THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES
 
 M Y O M A T A 
 
 OF THE 
 
 UTERUS 
 
 HOWARD A. KELLY and THOMAS S. CULLEN 
 
 PROFESSOR OF (Gynecology in the johns associate professor of gynecology, johns 
 
 HOPKINS university; GYNECOLOGIST-IN- HOPKINS UNIVERSITY; ASSOCIATE CYNKCOLO- 
 
 CHIEF TO THE JOHNS HOPKINS HOSPITAL GIST TO THE JOHNS HOPKINS HOSPITAL 
 
 I LLU S r RATE D 
 
 AUGUST HORX mid HERMAXX HF.CKER 
 
 l'Illl.AI)i:i,rHIA AM) LONDON 
 
 W. B. SAUNDERS COMPANY 
 
 1909
 
 Copyright, 1909, by W. B. Saunders Company 
 
 PRINTED IN AMERICA
 
 / / 
 
 %J^ 
 
 TO THE MEMORY OF 
 
 Xeselic flDattbew Swectnam 
 
 OF THE UNIVERSITY OF TORONTO. 
 
 A MAN OF RARE SURGICAL JUDGMENT AND A TRUE FRIEND
 
 PREFACE 
 
 Ix 1S94 we commenced a careful study of uterine myomata and contemplated 
 publishing the results of our findings. A year later, however, the work was tem- 
 porarily laid aside, as it was deemed wiser to take up the subject of carcinoma of 
 the uterus. After the publication of that work in 1900 we again turned our atten- 
 tion to uterine myomata, and since that time we have been contuiually gathering 
 data on that subject. 
 
 Our material has been drawn from (1) the cases operated upon at the Johns 
 Hopkins Hospital from the opening of the institution in 1889 to January 1, 
 1909; (2) those that have come under the care of Dr. Kelly at his private hospi- 
 tal; and (3) those operated upon by me at the Church Home and Infirmary, at 
 the Caml^ridge (Maryland) Hospital, and at the Emergency Hospital in Fred- 
 erick. The total number of cases examined was 1674. After obtaining complete 
 abstracts of the histories, the tumors were again examined, and many new and 
 interesting changes were found that had been overlooked in the regular routine 
 lal)oratory examinations. Descri})tions of the gross and histological appearances 
 of the myomata were made, and these descriptions were then attached to their 
 respective histories. 
 
 After carefully surveying the great wealth of material, the question arose as 
 to the advisability of reviewing the vast amount of current literature on myo- 
 mata, and it was found that to adeciuately cover it, and at the same time fully 
 discuss our own material, would necessitate the ])ul)lication of three or more 
 volumes. Under these circumstances, we felt that no one would wish to read so 
 much on one subject, and that it would be wiser to confine our effoiis to a thor- 
 ough study of our own material, with which we were thoroughly familiar. The 
 present volum(\ therefore, deals almost exclusively with the work clone l)y those 
 connected with the gynecological department of the Johns Hopkins Hospital and 
 of the Johns Ilojjkins I'niversity. 
 
 it nia\' b(- of interest briefly to detail the method ado]ite(| in coi-relat ing tiie 
 many j)oints of interest contained in the large amount of material. WC starteil 
 off without any i)reconceived theories and determined to cai'efully analyze the 
 cases at our disposal. After several months of indecision as to the best method 
 of handling the subject, we finally adojjfed the card system. l''.\-ery history and 
 ))ath()l()gical desci'ii)tion was I'ead and each point of importance was underscored. 
 Then a card was made of each point. This card also had the case number and 
 the jiatliological nunibei-. Some cases contained little or nothing of interest; 
 
 V
 
 VI phi: FACE. 
 
 for other casos, from live to ten cards were necessary. As a result we had several 
 thousand cards. These naturally fell under certain main headings. This gave 
 us a more concrete idea of the material and clearly hidicated the chapter classi- 
 fication. The card-index was of the greatest assistance; in the first place, be- 
 cause it enahled us to get every jwint of interest, and, secondly, because when 
 a given subject was undcM' discussion it was only necessary to pick out the cards 
 of that grou|) and then select the ten or twenty histories, as the case might be, 
 instead of each time going through sixteen huiidi'ed histoi'ies, with a strong like- 
 lihood of overlooking several cases. We fully realize the im]X)rtant part played 
 by the many assistant residents and the residents of the Gynecological Depart- 
 ment shice the opening of the Hospital; had it not been for their careful and con- 
 scientious histories and descriptions of the various operations jjcrformed, this 
 work would have been impossible. 
 
 On account of the great im))ortance of sarcomatous changes occui'ring in or 
 associated with myomata and the by no means infrequent association of carci- 
 noma of the fundus with myomata, we have considered both of these subjects 
 at unusual length. 
 
 The chapter on adenomyoma I'eached such large projiortions that we found it 
 necessary to deal with the subject in a separate volume.* On the other hand, the 
 chapter on myoma and jjregnancy is rather fi'agmentary, as we do no obstetrical 
 work. 
 
 We ha\"e not discussed the histoiy of tlie development of the surgical proced- 
 ures appropriate to uterine myomata. This has been so well handled by Dr. 
 Charles P. Noblef that nothing would be gained by duplicating the account. 
 ( )nly the various operative procedures that we personally have used are described. 
 Dr. Kelly being out of the cit}', it devolved upon me to briefly outline the scope 
 of the book, and altliough 1 know he would be averse to any personal mention of 
 his work, I feel it my duty to say a few words relative to his share in the develop- 
 ment of oi)erations for myomata. It was iii}- good fortune to come to Haltimore 
 in 1891, shortly after the hospital opened. At that time many cases of nu'oma 
 were considered inoperable, and even when hysterectonn- was undertaken it 
 was only in the cases in which a stout rubber ligature could be temporarily tied 
 around the cervix: and when, as happened in some cases, this ligature slipped, 
 alarming liemorrhage follow(Ml. Then came the systematic controlhng of 
 each of the cardinal vessels; latei' the bisection, and finally the transverse sever- 
 ance of the cervix as a pi'eliminary feature of the opei'ation in exceptionally diffi- 
 cult cases, until at ])resent a myomatous uterus that cannot be removed is al- 
 most unheard of. 1 have watched the gradual simplifications of the surgical 
 procedures with the greatest interest. Many American surgeons have had much 
 to do with the wonderful adxance in this direction, but I know of no other man, 
 
 *T!ionui.s S. Cullen, Adenomyoma of the Uterus, W. B. Saviiidors Co., 190S. 
 fin Krlly-Xoble, (lynecology and .\bdoniinal Surgery, vol. i. p. 660. W. B. Saunders 
 Co.. HM)S.
 
 PREFACE. Vll 
 
 either here or abroad, who lias done as much toward this advancement as Howard 
 A. Kehv. 
 
 AVe have purposely laid much stress on the mistakes and mishaps that have 
 occurred, and have given our deaths in full, as we feel that much more can often 
 be learned from failures than from successes. Moreover, we felt that a frank 
 statement of our mishaps might help other surgeons to aA'oid the un])leasant 
 complications that we have occasionally encountered. 
 
 Our mortality, taking all the cases from 1889 to July 1, 190G, was rather 
 high — between 5 and 6 per cent. It included all the early cases, but also embraced 
 many of the desperate cases and also many cases of myoma associated with ma- 
 lignancy. Just before going to press we have gone over the histories from July 
 
 I, 1906, to January 1, 1909, and find that in 238 myoma operations the death- 
 rate has been less than 1 per cent. — an evidence of a continued improvement in 
 our operative technique. 
 
 The work would not have been complete without some reference to the au- 
 topsy findings m a large number of cases. Professor William H. Welch kindly 
 placed his valuable records at our disposal. We are also deeply mdebted to 
 him for the sympathetic co-operation he has always accorded us in the labora- 
 tory studies. 
 
 To the casual observer the preservation of myomatous material to the extent 
 of several tons would seem unnecessary, but Dr. Henry M. Hurd has assisted us 
 in every way. This foresight has been of the greatest value in many instances, 
 notably in those cases in which sarcoma had been overlooked at the first examina- 
 tion, or in which subsecjuently to a supposedly simple hysteromj'omectomy, a 
 sarcoma developed in the stump. We also owe much to Dr. Hurd for his advice. 
 
 The illustrations have been made with wonderful accuracy in detail l)y Mr. 
 August Horn and Mr. Hermann Becker. Further comment is unnecessary, as 
 the pictures speak for themselves. We are also fortunate in having several exam- 
 ples of Mr. Max Brodel's w^ork. "\Vhen it is said that a drawing has been reduced 
 one-half, linear measurement is intended. In rcalit}- llic flat surface of the 
 l)icture is only one-fourth the natural size. It is well to beai- lliis ])()iiit in mind, 
 otherwise the reader will not get an adequate concej)ti()n of the aclual size. 
 With few exceptions the ilhislrations are original. \\c wisli to thank Dr. (ieorge 
 
 II. Simmons for allowing us to use several of the illustrations which we have al- 
 ready })ublished in the "Journal of the American Medical Association."' 
 
 To .Mr. Harry Hall and Mr. Hardy, of the Surgeon-GeneraTs Library, we ai-e 
 indebted for tlicii- kind assistance rendered while we wvvr Nciifying llie literature. 
 
 Dr. Herbert I. Cole, of Mobile, Ala., rendered much assistance in the ])rei)ai-a- 
 tion of the cha])tcr dealing with tlie findings at autopsy. 
 
 .Ml'. P)eiijaiiiin 0. McCleai'V made most of the slides from which the histolog- 
 ical pictures ha\e l)een dfawn. lie also i-eiidered most \alual)le aid in con- 
 trolling the man}' nuiulx-i's scattere*! throughout the book and also in checking 
 off all measurements.
 
 VIU PKKFACE. 
 
 Our thanks are due Dr. l'"raiik H. Smith, not only fof his correction of the 
 proof-sheets, but also for his kind ciiticisni of their contents. In numerous 
 phices he has indicatetl that the original text, while satisfactory to the specialist, 
 miiiht not have conveyed the proj)er meanino; to the general practitioner. 
 
 Dr. lamest K. ("ulleii spent his entire time for over a year in locating former 
 jiatients, in lilling in mi.ssing data, and in analyzing the cases from numerous 
 standpoints, lie has also devoted much time to the book in the last two years, 
 and during the progress of the work has made many valuable suggestions. He 
 has carefully followed the proof-sheets through the press, paying especial attention 
 to the accuracy of the numbers. It is imj)ossible for us to adequately thank him 
 foi' the large shai'c lie has had in the making of this volume. 
 
 Miss ("ora Iveik has l)een of the greatest assistance to us in the gathering of 
 the histories and lal)oratory abstracts and in the pre))arati()n of the manuscript. 
 
 ( )ur thanks are also due to the W. B. Saunders Company, who have done all 
 ill their power to procure the best possible i-epioductions of the illustrations and 
 to facilitate the progress of the book through the press. 
 
 In conclusion we can only say that if the reader gets a tithe of the j)leasure 
 from the pcn'usal of this volume that we did in gathering the material its function 
 will ha\'e been fulfilled. 
 
 Thom.\s S. Cullex. 
 
 B.«LTIM()E<E, Ml).. 
 
 •lune. 1909.
 
 CONTENTS 
 
 Chaptkr Pa(;e 
 
 I. Uterine Myomata 1 
 
 II. Parasitic Uterine Myomata 13 
 
 III. Cervical Myomata ')3 
 
 IV. Submucous Myomata ')9 
 
 V. Dilatation of the Uterine Lymphatics Associated with Myomata 72 
 
 VI. Torsion of the Uterus 77 
 
 VII. Hyaline and Cystic Degeneration S3 
 
 VIII. Calcification of Uterine Myomata 12G 
 
 IX. Suppurating Uterine Myomata 134 
 
 X. Myomata Associated with Malformations of the Uterus 155 
 
 XI. Angiomy'Oma 158 
 
 XII. LiPOMYOMA OF THE UtERUS 162 
 
 XIII. Adenomyoma of the Uterus 167 
 
 XIV. Myosarcoma of the Uterus 169 
 
 XV. Carcinoma of the Cervix Associated with Uterine Myomata 262 
 
 XVI. Adenocarcinoma of the Body of the Uterus Associ.^ted with Uterine 
 
 Myomata 274 
 
 XVII. The Condition of the Uterine Mucosa in Cases of Myoma 297 
 
 XVIII. Conditions of the Tubes and Ovaries when Uterine Myomata are Present . . 337 
 
 XIX. Conditions Found in the Ligaments Passing to and from the Uterus in 
 
 Cases of Uterine Myomata 354 
 
 XX. The Bladder in Cases of Uterine Myomat.\ 365 
 
 XXI. The Ureters in Cases of Uterine Myomata 378 
 
 XXII. The Rectal Findings in Cases of Uterine Myomata 3S6 
 
 XXIII. Analysis of the Cases of Uterine Myomata Found at Aittopsy ln the Patho- 
 
 logical Laboratory of the Johns Hopkins Hospital from the Opening of 
 
 the Hospital in 1889 to July 1, 1906 394 
 
 XXIV. The Cause of Uterine Myomata 430 
 
 XXV. The Symptoms Associated with Uterine Myomata 434 
 
 XXVI. Other Pathologic Conditions in Some of our Myoma Cases 460 
 
 XXVII. Differential Diagnosis 467 
 
 XXVIII. The Effect of Removal of the Ovaries on I'terine Myomata 504 
 
 XXIX. Abdominal Myomectomy 506 
 
 XXX. Vaginal Myomectomy 571 
 
 XXXI. Abdominal Hysteromyomectomy 5SS 
 
 XXXII. Difficult Abdominal Hystehectomies (130 
 
 XXXIII. PrEG.VANCV AM) ri'KHINF. MvoM AlA 613 
 
 XXXIV. Complications Following Ahdominal Hysteromyomectomy 654 
 
 XXXV. Results of Operations for I^terine Myomata 671 
 
 Index oi' Casks .Arranged Accordim; to '1'hkik ( Ivn'Ecologicai, N'imhkrs. . . . 689 
 
 Patiiologicai, Xumheus 697 
 
 .Ai ■I'oi's'i .NiMHioiis 701 
 
 ]ni)i:\ 703
 
 LIST OF ILLUSTRATIONS 
 
 Fig. Page 
 
 1. Sessile and Pedunculated Myomata 2 
 
 2. Mulberry-shaped and Sessile Myxoma 2 
 
 3. An Ordinary Myomatous Uterus on Section 3 
 
 4. A General "My'omatous Tendency" 4 
 
 5. Injection of a My'omatous Uterus 6 
 
 6. Typical Myxomatous Tissue 7 
 
 7. The Line of Cleavage Between a Myoma and the Uterine Muscle 8 
 
 8. Blending of a Myoma with the Uterine Muscle 9 
 
 9. The Irregular Extension of a Myoima into the Uterine Muscle 10 
 
 10. A Transverse Section Through a Myomatous Uterus 11 
 
 11. The Myxomatous Uterus as Viewed on Transverse Section Through the Cervix ... 11 
 
 12. Omental Blood-vessels that are Keeping Alive the Outer Layers of a Myoma 
 
 which Shows Almost Total Hyaline Degeneration 15 
 
 13. A Partially Parasitic My'oma Receiving Most of its Blood-supply- fro.m the 
 
 Omentum 17 
 
 14. A Partially Parasitic My'oma Receiving a Large Blood-supply' from the 
 
 Omentum 17 
 
 15. A Large Pedunculated My'oma Receiving Nearly all of its Blood-supply from 
 
 THE Omentum 18 
 
 16. A Very' Large Subperitoneal and Pedunculated Myoma, Receiving Most of its 
 
 Nourishment from the Omentum 19 
 
 17. A Very Large Pedunculated and Partially Necrotic Myxoma Receiving a Rich 
 
 Blood-supply' from the Omentum 20 
 
 18. A Parasitic Myoma Receiving a Large Blood-supply' from the Omentum. Partial 
 
 Atrophy of the^Omental Fat 22 
 
 19. Marked Disappearance of the Fat in an Adherent Omentum 23 
 
 20. The Gradual Disappearance of Omental Fat when the Omentum sends many 
 
 Vessels to a Parasitic Myoma 25 
 
 21. A Large Parasitic Myoma with Huge Vessels Coming from the Omentum 26 
 
 22. Large Congeries of Omental Vessels Supplying Nourishment to a Myomatous 
 
 Uterus; also Vessels Passing up from the Bladder to the Tumor 28 
 
 23. A Large Myoma Entirely Separated from the Uterus and Lying Free ix the 
 
 Omentu.m 29 
 
 24. Omental Vessels Supplying a Subperitoneal Peduncul.vted Myoma, and Asso- 
 
 ciated with 7000 CO. of Ascitic Fluid 34 
 
 25. A Partially- Parasitic Uterine Myoma Associated with 51 Liters of Ascitic 
 
 Fluid 36 
 
 26. A Partially P.yrasitic Myo.ma Receiving P.vrt of its Nourishment from the 
 
 Fallopian Tubes 37 
 
 27. A Parasitic Myoma i.v no Way Connected with the Uterus 39 
 
 28. MULTI.NODULAR MYOMATOUS UtERUS WITH A LkFT Pus-TI'HE 40 
 
 29. A Myo.ma Receiving .much of its NornisiiMi:\i' fuom iiii; Ukcitm and .Vpi'vukntlv 
 
 FRO.M THE Right Ovary and Tube 42 
 
 .30. A Large Subperitoneal Pedunculated My'oma, Receiving much of its Noruisii- 
 
 me.nt from the Intp:stines 43 
 
 31 . A Spleen-shaped Myoma 45 
 
 32. A Suppurating Subpkhitonf.al Myom.v Co.m.munhating with thf, Tyumen of thk 
 
 Cecum 46
 
 XU LIST OF ILLT'STUATIOXS. 
 
 Fig. ' Page 
 
 33. A Myoma Rkceivixg its Xoukishmext fuo.m the Mesexteky ok the Small ]5owel 
 
 VXD COXTAIXIXG AX AbSCESS C.VVITY WHICH Co.NLMl.MCATEU WITH THE LlMEX OF 
 
 THE IXTESTIXE 47 
 
 34. Peduxcul.vted Myomata Receivixg a Lauge Part of theik N'ormsHMEXT kkom the 
 
 Bladdeh oO 
 
 3.). A .MiLriNoDiL \K .Myomatous Uterus with Vessels Passixg fkom ihk, HiciHT An- 
 
 Du.MiXAL Wall axu Appendix to a Large Pedunculated Myo.\lv 52 
 
 3(). Myoma of the Broad Lig.\ment and Cervix 53 
 
 37. A Myoma of the Broad Ligament and Cervix 54 
 
 38. A Cervical Myoma 55 
 
 39. Cervical Developmext of Myomata 56 
 
 40. A Very Large Cervical My'oma 57 
 
 4L E.\TEXsivE Cervical Developmext of a Myoma 58 
 
 42. A SuBMi'cous Myoma Fillixg the TTterine C.wity 59 
 
 43. -Marked Suh.mucous Development of Uterine Myomata 60 
 
 44. Extensive Sub.mucous Development of Uterine Myomata 60 
 
 45. A Large Pedunculated Submucous MyoiMA 61 
 
 46. A L.\.rge Pedunculated Sub.mucous Myoma 62 
 
 47. A Portion of a Large I.nterstitial Myoma i hat has Become Submucous and Shows 
 
 Early Signs of Breaking Down 63 
 
 48. A Large Pedunculated Submucous Myoma 64 
 
 49. A Lobul.\ted Submucous Myoma Pro.iecting Through the Cervix 64 
 
 50. A (Iaxgrexous Sub.mucous Myoma 64 
 
 51 . A Sloughixg Submucous Myoma 65 
 
 52. A Very L.vrge Submucous Myoma which had been Extruded from the Uterus 66 
 
 53. A Sloughing Submucous Myoma 67 
 
 54. The Surface of a Sloughing Sub.mucous Myoma 68 
 
 55. The Superficial Portions of a Sloughing Submucous Myoma 69 
 
 56. The Surface of a Sloughing Submucous Myoma 69 
 
 57. E.voR.MOus DiLAT.vno.N OF the Lymphatics on the Sitrface of a Myomatous Uterus. 73 
 
 58. DiL.vTED Ly.mph.\tic Sp.\ces i.v the Uterine Wall in the Neighborhood of the 
 
 Right Tube a.\d Ovary 74 
 
 59. DiL.\TED Lymph.\tic Ch.\nnels .\t the Left T'tk:ri.\e Hor.x hetweex the Tube 
 
 and Ovary and between the Tube and Left Round Ligament 75 
 
 60. Rot.vtion of a Myom.\tous Uterus on its Cervix 77 
 
 61 Atrophy of the Cervix Associated with a Large CJlobular Myomatous Uterus ... 78 
 
 62. Marked Torsion of a Myomatous Uterus 78 
 
 63. Torsion of .v L.\rge Globular My'om.\tous Uterus 79 
 
 64. Spont.\neous Amput.\tio.\ of a Myo.m.\tous Uterits 80 
 
 65. Torsion of a Subperitoneal Pedunculated Myo.ma 81 
 
 66. Sudden Torsion of a SuBPERrroNE.\L Pedunculated .Myo.ma with Complete Shut- 
 
 ting OFF OF its Blood-supply 82 
 
 67. Abrupt Tr.vnsformation of Myom.\tous into Hyaline Ti.ssue 84 
 
 68. Focal Hyaline Degeneration in Muscle-bundles 85 
 
 69. M.\rked Hyaline Degeneratio.x of the W.\lls of the Blood-Vessels in a Myo.ma. . 86 
 
 70. Hyaline Degeneration in the Ckntek of .vn iNTEusirriAL .Myoma 87 
 
 71 . Edema ok a Myo.m.\ 88 
 
 72. Hyaline Degeneratio.x with Cystic For.matiox in a Small Subperitoneal Pedun- 
 
 culated Myo.m.y 89 
 
 73. Extensive and Sharply Dekinkd Hyaline Degkxer.\tiox ix a Subperitoneal 
 
 Myoma 93 
 
 74. Marked Hyaline Degeneration with Liquef.vctiox ix .\x I.nterstitial .Myoma .... 95 
 
 75. Cystic Degeneration oka Portion of a Peduncul.vted Subperitoneal .Myoma .... 96 
 
 76. Cystic Degevkk xttov i\ \ I, \rge Subperitoneal Pedunculated Myoma 98
 
 LIST OF ILLUSTRATIOXS. XI 11 
 
 Fig. Page 
 
 77. Marked Proliferation of the Endothelium of the Capillaries Dividing the 
 
 Myomatous Tissue into Alveoli 99 
 
 78. Coagulation Necrosis and Hyaline Degeneration in an Interstitial Myoma 100 
 
 79. General and Diffuse Cystic Formation in a Myoma 101 
 
 80. The General Contour and Relations of the Myoma seen in Fig. 81 102 
 
 81. Complete Cystic Degeneration of Portions of a Myoma that had Undergone 
 
 Hyaline Degeneration 102-103 
 
 82. Gradual Liquefaction of a Myoma 103 
 
 83. Liquefied and Hyaline Areas in a Myoma 104 
 
 84. Liquefaction and Hyaline Areas in a Myoma 106 
 
 85. Hyaline Degeneration with Liquefaction of an Interstitial Uterine Myoma .... 107 
 
 86. Massive Hyaline Degener.\tion and Liquefaction of a Large Uterine Myoma .... 109 
 
 87. A Cystic Subperitoneal Pedunculated Myoma 110 
 
 88. A Multilocular Cystic Myo.ma Ill 
 
 89. A Large Cystic Myoma Growing fro.m the Posterior Sttrface of the Uterus 113 
 
 90. A Large Subperitoneal Cystic Myo.ma .• 114 
 
 91 . A Cystic Myoma 115 
 
 92. A Large Multicystic Myoma 117 
 
 93. A Cystic Myoma Weighing 39 Pounds and Closely Resembling \ Multilocular 
 
 Ovarian Cyst 119 
 
 94. A Cystic Uterine Myoma 120 
 
 95. A Cystic Myoma Occupying the Anterior Uterine Wall 121 
 
 96. A Cystic Myoma with a Cavity Resembling Somewhat the Interior of a Heart. 122 
 
 97. Irregular Cystic Spaces in a Myoma 123 
 
 98. A Uterine Myoma with Cystic Sp.\ces Containing Material Resembling Melted 
 
 Butter 124 
 
 99. A Degener,\ted Partly Calcified Myoma 126 
 
 100. Myomata Representing Various Stages of Degeneration 127 
 
 101. Partial Calcification of a Myoma 128 
 
 102. Calcareous Plates in the Wall of an Artery 129 
 
 103. A Completely Calcified Subperitoneal Myoma 131 
 
 104. A Suppurating Subperitoneal Myoma 136 
 
 105. An Intraligamentary Suppurating Myoma 138 
 
 106. A Suppurating Intralig.\.mentary Myoma 139 
 
 107. A Suppurating Subperitoneal Myoma 140 
 
 108. A Suppurating Subperitone.\l Myoma 141 
 
 109. A Suppurating Myo.m.\ Opening into the Colon 143 
 
 1 10. A Suppurating Interstitial Myoma 145 
 
 111. Slight Suppuration of an Interstitial Myoma with Perforation into the Uter- 
 
 ine Cavity 146 
 
 112. A Suppurating Interstitial Myoma Opening into the Uterine Cavity 14S 
 
 113. A Large Suppurating Interstitial Myoma Opening into and Infecting the 
 
 Peritoneal Cavity and .vlso Draining into the Cavity of the Uterus 151 
 
 114. A Double Uterus Containing Subperitoneal, Interstitial, .\nd Sub.mucous 
 
 .M VOMATA 156 
 
 1 1 5. .\ngiomyoma 1 59 
 
 116. Multiple Angio.myo.matois i'cx i in .\ .Mvo.ma l.")'.t Hid 
 
 117. .\ngtomy()ma 160 
 
 1 IS. Lii'()\iv()\i A , 162 
 
 1 I't. l.iroNnoM A 163 
 
 120. l,ii'()MM)\i.\ 164 
 
 121. LlI'O.MVO.MA 11)5 
 
 122. .\ Sarcomatous Nodii.k i\ .\ I.argk !'i:i,\ ic lii.oon-VEssEi 175 
 
 123. Sarcomatous Transform \i ion of a SrnPF.RiToNKAi, Myoma with Dknse Adhesions 
 
 TO THE ReCTU.M AND I'KI.VIC \\ AM.S ISl
 
 XIV LIST OF ILLUSTRATIONS. 
 
 Fig. Page 
 
 124. Transition' of Myo.matoi's into S.a.rco.\iatous Tissue 182 
 
 125. Sarcomatous Transformation of a Myoma with a SECoxnARY Growth on the 
 
 Posterior Surface of the Uterus 185 
 
 V2{\. My'osarcoma of the Body of the Uterus with a Secondary and Pure Sarcoma- 
 tous Cockscomb-like Growth on the Posterior Surface 186 
 
 127. The Lobul.\ted .\nd Myom.\tous Nodule Removed from the Left Broad Ligament 
 
 IN Fig. 125 187 
 
 128. COM.MENCING SARCOMATOUS Tr.\NSFOR.M.\TION OF MYOMATOUS TiSSUE 188 
 
 129. A Sarco.m.v th.\t has Developed from an Interstitial My'oma 189 
 
 130. Sarcom.\ Developing in the Cervical Stump 191 
 
 131. Sarcomatous Transformation of a Uterine Myoma. Supravaginal Amputation 
 
 WITH Return of the Growth in the Cervical Stump 193 
 
 132. Sarcoma of the Anterior Uterine Wall 197 
 
 133. A Large Sarcomatous Nodule Containing an Irregular, Smooth-walled Cavity' 
 
 IN ITS Center 198 
 
 134. Probable Sarcomatous Transformation of Bundles of Myomatous Tissue 199 
 
 135. Sarcoma Developing in the Center of a Subperitoneal My'oma 202 
 
 136. Sarcoma Developing, in Part at least, from a Submucous Myoma 205 
 
 137. A Myoma Situ.vted to the Right of the Cervix and Showing Early Sarcomatous 
 
 Changes 206 
 
 138. Sarcoma Developing in the Center of a Large Interstitial Uterine Myoma 209 
 
 139. Saucom.\ Developing in the Interior of a Myoma 211 
 
 140. Prob-A-ble Sarcomatous Transformation of a Myoma; also Discrete Myomatous 
 
 AND Sarcomatous Nodules in the Same Uterus 213 
 
 141. Association of Myoma and Sarcoma in the Same Uterus 214 
 
 142. A Sarcomatous Uterus Conforming in Contour to a Globular Myomatous 
 
 Uterus 216 
 
 143. Sarcoma and Myoma in the Same Uterus 217 
 
 144. Mixed-celled S.vrcoma of the Uterus Associated with Myomata of the Uterus. . . 218 
 
 145. S.^.RCO.MA OF the POSTERIOR UtERINE WaLL, ORIGINATING IN A My'OMA 220 
 
 146. Sarcomatous Transformation of a Multinodular Pedunculated, Subperitoneal 
 
 Myoma 224 
 
 147. Suspicious Cell Changes in a Myoma 225 
 
 148. Early Sarcomatous Changes in a Myoma 225 
 
 149. Sarcomatous Transformation of Myomatous Tissue 226 
 
 150. Gradual but Direct Transition of Myo.matous into Sarco.matous Tissue 227 
 
 151. Sarcomatous Transformation of Myom.vtous Tissue 228 
 
 152. Sarcom.\tous Transformation of Myom.\tous Tis.sue 228 
 
 153. Sarco.matous Transfor.mation of My'omatous Tissue 228 
 
 154. S.\RCOMATOus Transformation of Myomatous Tissue 228 
 
 155. Junction of Myomatous and Sarcomatous Tissue 229 
 
 156. A Rapidly Growing Subperitoneal Myoma w^ith Small Papill.e-like Outgrowths 
 
 Springing from its Surface 238 
 
 157. Diffuse Myomatous Thickening of the Uterine Wall. Discrete Submucous 
 
 My'o.ma and a SuBMUcoiTs Myoma Presenting an Appearance Suggestive of 
 Sarco.m.v 241 
 
 158. Suggestion of Sarco.ma in a S.mall Sub.mucous Myoma 242 
 
 159. Suspicious Cell Changes in a Small Submucous Myoma 243 
 
 160. Suspicious Cell Changes in a Sm.vll Submucous Myoma 243 
 
 161. Suspicious Cell Changes in a Sm.vll Submucous Myoma 243 
 
 162. Large Cells Occurring in a Simple Interstitial Myo.ma 248 
 
 163. Gl\nt-cells in an Edematous Myoma 250 
 
 164. Suspicious Cell Changes in an Edematous and Partly Subperitoneal Myoma .... 251 
 
 165. Giant-cells from an Edem.\tous Myoma 252 
 
 166. A Large Nucleus in a Myoma 253
 
 LIST OF ILLUSTRATIONS. XV 
 
 Fig. Page 
 
 167. Suspicious Cell Changes in a Sloughing Submucous Myoma 253 
 
 168. Cell Changes in a Myoma Undergoing Partial Coagulation Necrosis 256 
 
 169. Squamous-celled Carcinoma of the Cervix; Subperitoneal and Interstitial 
 
 Myomata; Double Pyosalpinx; Cyst of Left Ovary 263 
 
 170. Squamous-celled Carcinoma of the Cervix and Submucous Myoma of the Body 
 
 OF THE Uterus 265 
 
 171. Squamous-celled Carcinoma of the Cervix; Partially Calcified Interstitial 
 
 Myoma in the Body of the Uterus 268 
 
 172. Multiple Small Uterine Myomata; Primary Carcinoma of the Oa'ary; Primary' 
 
 Carcinoma of the Uterus 272 
 
 173. Adenocarcinoma of the Body of the Uterus Associated with Myomata 276 
 
 174. Carcinoma of the Lower Part of the Body and Upper Part of the Cervix; Uter- 
 
 ine Myomata 277 
 
 175. Myoma of the Cervix and Carcinoma of the Body' of the Uterus 278 
 
 176. Multiple Uterine Myomata; Carcinoma of the Lower Part of the Body and 
 
 Upper Portion of the Cervix 280 
 
 177. Multiple Uterine Myomata; Carcinoma of the Body of the Utertts 282 
 
 178. Adenocarcinoma of the Body of the Uterus Associated with Interstitial 
 
 Myomata 283 
 
 179. A Large Myomatous Uterus, Showing also an Adenocarcinoma of the Body 285 
 
 180. Multiple Uterine Myomata; Adenocarcinoma of the Body with Extension to 
 
 the Peritoneal Surface 286 
 
 181. Myomata and Adenocarcinoma of the Body of the Uterus 288 
 
 182. A Large Myoma of the Cervix; Adenocarcinoma of the Body of the Uterus 290 
 
 183. Subperitoneal, Interstitial and Submucous Myomata; Advanced Adenocar- 
 
 cinoma Involving Cervix and Body 292 
 
 184. An Adenocarcinoma of the Body of the Uterus, so Small that it Could not be 
 
 Recognized Except with the Aid of the Microscope 295 
 
 185. Marked Dilatation of the Cervical Glands, with a Tendency Toward the 
 
 Formation of a Polyp 298 
 
 186. A Cervical Polyp 299 
 
 187. A Cervical Polyp 299 
 
 188. A Rare Form of Cervical Polyp 300 
 
 189. A Rare Form of Cervical Polyp 301 
 
 190. Suspicious Epithelial Changes in a Gland from the Cervix, Associated with a 
 
 Large Myomatous Uterus 303 
 
 191 Suspicious Epithelial Changes in the Mucosa of the Cervix, from a Large Myo- 
 matous Uterus 304 
 
 192. Suspicious Proliferation of the Cylindric Surface Epithelium of the Cervix, 
 
 Associated with a Large Myomatous Uterus 305 
 
 193. A Slit-like Tortuous Uterine Cavity 3()<) 
 
 194. A Very Small Uterine Cavity with a Large Myoma of the Fundus 307 
 
 195. Partial Obliteration of the Uterine Cavity with Dis.\ppe.\r.\nce of the Mucosa . 3()S 
 
 196. Partial Obliteration of the Uterine Cavity Caused by a Submucous Myoma 309 
 
 197. A Large Clot in the Uterine Cavity 310 
 
 198. Thickening of the Uterine Mucosa 311 
 
 199. Thickening of the Mucosa in a Myomatous Uterus 312 
 
 200. Moderate Thinning-out of the Mucos.v over a Submucous Myoma 312 
 
 201. A Small Myoma Pushing through the Mucosa 3L3 
 
 202. Thinnixg-out of the Mucosa over a Submucous Myom.\ 313 
 
 203. Atrophy of the Mucosa over a Submucous Myoma 314 
 
 204. Marked Thinning-oi r ok the Mucosa over a Submucous Myoma 314 
 
 205. A Submucous Myoma almost Devoid of Mucosa 315 
 
 206. Marked Thickening of the Uterine Mucosa in a Depression between Myo.matous 
 
 Nodules 315
 
 XVI LIST OF Tl.LrSTKATIOXS. 
 
 Fi<:. Page 
 
 207. CJlaxi) Hypehtroi'hy ix a Clkkt hetweex Mvomakhs Nodiles 316 
 
 208. Marked Dilat.\tion of the Veins of the Uteium; .Micosa 318 
 
 209. He.mohuhage into the Utekine Mucosa 319 
 
 210. Hemorrh.wje into the Mucosa 319 
 
 211. Rupture with Subsequent Thromrosis of a Vein of the Tterixe Mucosa over 
 
 A Submucous Myo.m.v 319 
 
 212. Branching of a Uterine Gland 320 
 
 213. An Atypical Uterine Gland 320 
 
 214. An Unusual Uterine Gl.\nd 320 
 
 21o. Marked Branching of a Uterine (!land 321 
 
 •_M(i. M MiKi.i) Bkaxchi.vg of a Uterine Gland 321 
 
 _M 7. IIdk.ma of the Uterine Mucosa 322 
 
 2 15. Dilated Uterine Glands over a Submucous Myoma 323 
 
 219. Marked Dilatation ofthe Uterine Glands over a Submucous Myoma 323-324 
 
 220. Markedly Dil.vted Uterine Glands 324 
 
 221. A Moder.vte Grade of Dilatation of the Glaxds 325 
 
 222. Three Small Poylpi 326 
 
 223. Small Uterixe Polypi 326 
 
 224. Poly'pi Associated with Uterixe Myomata 327 
 
 225. A Very Early Stage of a Uterine Polyp 328 
 
 226. The Beginning of a Uterine Polyp 328 
 
 227. A Uterine Polyp 329 
 
 228. Cross-section of a L.\rge Uterine Polyp in a Case of Multiple Myomata 330 
 
 229. Cross-section of Very Large Uterine Polyp in a Case of Myo.ma 330 
 
 230. A Very LAR(iE Uterine Polyp 331 
 
 231. A Myoxlv Oricixatixg in the Uterine Mucosa 333 
 
 232. Polypoid Endometritis and Double Pus-tubes Associated with a My'oma of the 
 
 Fundus 334 
 
 233. TuBERcixosis OF the Exdometkh'm and Fallopian Tihes Associated with a 
 
 Myomatous Uterus 336 
 
 234. A Myomatous Uterus Associated with Pyosalpinx 338 
 
 235. A Tubo-ovarian Cyst Associated with a Myomatous Uterus 339 
 
 236. A Tubo-ovarian Cy'st and Dense Adhesions Complicating a Myomatois Utkhcs . 339 
 
 237. A My'o.ma of the Right Fallopian Tube 340 
 
 238. Ruptured Tubal Pregnancy Co.mplicating Uterine Myomata 341 
 
 239. The .Median End of a Fallopi.vn Tube App.\rently Terminating in a Myoma 343 
 
 240. A .MlLTILOCULAR OVARIAN CySTADENOMA ASSOCIATED WITH A MULTINODULAR MyO- 
 
 M.\Tous Uteri's 345 
 
 241. A Multiplicity' of Pathologic Coxditioxs 346 
 
 212. Ax Ovarian Cyst with I'.aki.v Pai'ii.i.ahv M.vsses Associated with ^Iultiplk Uter- 
 ixe Myo.mata 347 
 
 243. .\ Der.moid Cyst Associ.vted with a Myomatous Uterus 349 
 
 244. A Multinodular Myomatcjus Uterus with a Parovarian Cyst on the Right and a 
 
 Der.moid of the Left Ovary' 350 
 
 245. A Very Large Left Ovary Associated with a Myom.vtous Uterus 351 
 
 246. A Gre.\tly Lengthened-out Ovary A.ssociated with Uterlne Myom.vi'a 352 
 
 247. The Coalescence of a Subperito.neal Pedunculated Myoma with an Ovary 353 
 
 248. Cy.ST of the UtERO-OVARIAN LlCiA.MENT 356 
 
 249. Cysts in the Utero-ox' arian Li(l\ment 357 
 
 250. Myoma of the Utero-ovauiax Lig.vment 359 
 
 251. Myoma of the Right Utero-ov.\rian Ligament 360 
 
 252. Myoma of the Utero-ovariax Ligament 361 
 
 253. Myoalv of the Round Fkiamkni' 362 
 
 254. A Myoma Lying Free from the Uterus and Situated hetwee.v the Tube and 
 
 Ovary 363
 
 LIST OF ILLUSTRATIONS. XVll 
 
 Fig. Page 
 
 255. A SuBVE.sicAL Myo.ma 365 
 
 256. A Bladder Forced out of the Pelvis by .\n Incarcerated Myomatous Uterus. . . 365 
 
 257. A Bl.\dder Carried as High as the Umbilicus by a Large Mygm.ytous Uterus . . . 366 
 
 258. A Bladder Adherent to Two Myomatous Nodules 367 
 
 259. Adhesions between the Bladder and a My'om.\tous Uterus 367 
 
 260. Adhesions between the Bladder and the Myomatoi^s Uterus 368 
 
 261. M.vrked Upward Displace.ment of the Bladder 369 
 
 262. The Bladder Lifted High into the Abdomen by a Myomatous Uterus 369 
 
 263. Dislocation and Dilatation of a L^reter due to a Large Myomatous Uterus 378 
 
 264. Myoma in the Broad Ligament Displacing the Right Ureter Upward and For- 
 
 w.^rd 379 
 
 265. Dislocation Upward and Forward of the Left Ureter by a Myo.matous Uterus 379 
 
 266. Marked Dislocation of the Ureters where the Abdomen was Filled avith a 
 
 Myom.\tous Uterus 380 
 
 267. Hydroureter Due to Pressure 381 
 
 268. Displaced Right Ureter Mi.st,\ken for a Dilated Yei.\; Ligated and Cut; Suc- 
 
 CESSFi'L End-to-side Anastomosis 383 
 
 269. Dense Adhesions Between the Sigmoid and a Myxomatous Uterus 386 
 
 270. Dense Adhesions of the Sigmoid Flexure .\nd of a Loop of Small J^owel to a 
 
 X Tubo-ovarian Abscess 387 
 
 271. An Extensive Rectal Tear 388 
 
 272. A MXTLTINODULAR MYOMATOUS UtERUS, COMPLICATED BY AX OVARIAX CyST OX THE 
 
 Right and a Densely' Adherent Tubo-ovariax Abscess ox the Left 389 
 
 273. A Tubo-ovarian Abscess, Densely Adherext to the Sigmoid Flexi're 389 
 
 274. C.\RCIXOMA OF THE SiGMOID FlEXURE ASSOCIATED WITH A MYOMATOUS UtEIUS 393 
 
 275. Myomata IX Old Age 395 
 
 276. Squa.mous-celled Carcinoma of the Cervix Associated with Multiple Uterixe 
 
 Myomata 399 
 
 277. C.\RCixoMA of the Bl.\dder Secoxdary to Squamous-celled Carcinoma ok ihk 
 
 Cervix 401 
 
 278. IxvAsiox OF A Myoma by a Squamous-celled Carcixoma of the Cervix 403 
 
 279. Adexocarcixom.\ ix a Myoma, Secondary' to Adexocarci.noma of the I^ody of the 
 
 Uterus 407 
 
 280. A Large Myo.m.\tous Uterus Choking the Pelvis; Small Ovarian Cysts on Both 
 
 Sides; Thickening and Retr.\ction of the Omentum. Metastasf.s in the 
 Liver Second.\ry to an Adenocarcinoma in the Body' of the Uterus 409 
 
 281. An Enlarged MYOM.vrous Uterus. Adenocarcinoma of the Body of the Utkius. 
 
 P.VPILLOCYSTO.MAT.\ OF BoTH OvARIES, WITH KxTKXSION HV CoNllNiriY I'o IHF. 
 
 Inguinal Glands 11- 
 
 282. Calcification of tiik IIkakt Muscle Associated with Uterine Myomata 121 
 
 283. Hyaline Degeneration of Heart Muscle, As.sociatei) with riKuiNK .Myomata. . 425 
 281. A Very Early Myoma. 431 
 
 285. Ax Early Myoma 432 
 
 286. An Early Myoma 433 
 
 287. The Ahdo.mi.nal Contour Caused by a Globular Myomapoi-s U^terts 437 
 
 288. The Abdomi.val Contour Caused by a Miltinodilau Myomatois Utkrcs 438 
 
 2S!). ^Lvl{KKD F]lo.\(;atio.\ of the SuPRAVA(iiXAi. i'oiMioN oi I UK ('ki;\ l.\ 442 
 
 290. .\ Myomatous Uterus Closely Rkse.mblin(; a ruKiiNANi I'lKia s ix its General 
 
 CoNi'oru 468 
 
 291. .\ .M Yo\K\i()i's rTEUFs Hesk\iiu.i\<; a P'etus i\ its Contoku l(t<) 
 
 292. Till'; l'i;i!KOK.\ TKi) IMiK(;N.\Nr I'li.in s a.s Seen on 1\i:\io\ ai, 171 
 2'.)'A. A I'ltKcv \\t rrEUKs. wki ii i iik Fetus and Placent.v Intact 172 
 
 291. .\ni)0\nN.\I, I'RE(i.\AN(V OK I'oKK YeARS' Dl'UATIO.V 476 
 
 295. A Ri'PTi'RED CoRNi'Ai- Pkegnancy 479 
 
 296. Rupture of the Right Cornu of a Bicor.vate I'terus with Ivscape of the Fetus ... 481
 
 XVIU LIST OF ILLUSTRATIONS. 
 
 Fig. Page 
 
 297. A Small Fhag.mknt ok a H vdatidikohm .Molk 482 
 
 298. Chorio-epitheliom.\ 484 
 
 299. Carcixo.ma of the Cervix and Lower Part ok the Body of the Uterus Clinically 
 
 Resembling .\ Myom.\tous Organ 486 
 
 300. A SuBMUcors Myom.a. Cli.vically Suggesting C.vrctnoma of the Cervix 487 
 
 301. Adenocarcinoma of the Body of the Uterus with Subperitoneal Nodules 488 
 
 302. A Rare Form of Adenocarcino.ma of the Uterus 490 
 
 303. A Pkculiar Arrange.ment of Muscle-fibers Suggestive of Carcinoma 491 
 
 304. Sarcoma of the Body of the I'terus 492 
 
 305. Sarcom.v of the Body of the I'terus 493 
 
 306. Fibroma of the Ovary 494 
 
 307. A Myomatous I'terus Mistaken for an Ovarian Cyst 496 
 
 308. A MULTILOCULAR OVARI.\N CyST IN FoR.M RESEMBLING A CySTIC MyOMA 497 
 
 309. Bil.\teral Ovarian Cysts with Papillary Masses on their Surfaces 498 
 
 310. S.mall Uterine Myomata; Carcinoma of the Ovary with Very Large Omental 
 
 Met.\stases 499 
 
 311. Tumor of the Sigmoid Flexire Due to Rupture of Rectal Diverticula into 
 
 the Surrounding Adipose Tissue; Small Pelvic Abscess 501 
 
 .'^12. Retroperitoneal Sarcom.\ 502 
 
 313. A Pedunculated Subperitone.\l Myoma 508 
 
 314. A Large Subperitoneal Myoma 508 
 
 315. A Difficult Myomectomy' 511 
 
 316. Abdo.minal Enl.\rgement Due to a Cystic Myoma 513 
 
 317. Cross-section of a Cystic Myoma Weighing 89 Pounds 515 
 
 318. Multiple Myomectomy' 516 
 
 319. Myomectomy or Hysterectomy 519 
 
 320. The First Steps in Abdominal Myomectomy 520 
 
 321. Kelly-Cullen Myoma Enucle.\tor 521 
 
 322. Shelling the Tumor out of the Uterine Wall 522 
 
 323. Obliteration of the Sp.\ce in the Uterine Wall after Removal of the Myo.ma .... 523 
 
 324. Appe.\ran'ce of the Uterus after Abdominal Myomectomy' 524 
 
 325. Uterine Myo.ma Complicated by a Three and One-half Months' Pregnancy- 530 
 
 326. Multiple Myomectomy on a Woman Three Months Pregnant 530 
 
 327. A Subperitoneal Myoma Complicating Pregnancy 531 
 
 328. Myoma of the Cervix Ob.stkucting the Vagina and Complicating a Four Months' 
 
 Pregnancy 532 
 
 329. A Myom.\ of the Bro.vd Lig.\.ment 554 
 
 330. Pelvic Adhesions Following Abdomin.\l Myomectomy 557 
 
 331. Appearance of x Uterus Five Years after Removal of a Laiige Interstitial 
 
 Myom.v 562 
 
 332. Myomata Re.muveu by Abdominal Myo.mecto.my 563 
 
 333. A Uterus about Six Years after Abdo.minal Removal of a\a. .Mvom.vta that 
 
 could be Detected 564 
 
 334. A Large Submucous Myom.\ 573 
 
 335. A Submucous Myoma Gre.\tly Distendlng the Vagina 573 
 
 336. Vagi.n.\l Bisection of a Submucous Myom.\ 574 
 
 337. Method of Removing x Very Large Submucous My().\l\ 574 
 
 338. Method of Delivering .\ Very Large Submucous Myoma 575 
 
 339. vSuTl'RE OF THE CeRVI.X .\FTER REMOVAL OF A SUBMUCOUS MyOM.V 575 
 
 340. Appearance of the Cervix .\fter Removal of a Submucous Myoma that had been 
 
 Attached to the Vagin.\l Portion of the Cervix 576 
 
 341. A Very V.\scul.\r Sloughing Submucous Myoma 583 
 
 342. A Gauze Swab Found in the Cavity of a Myomatous Uterus 588 
 
 343. A Myomatous Uterus .\fter Years of Electric Tre.\tment 589 
 
 344. The Myo.matous Uterus Prior to Removal 591
 
 LIST OF ILLUSTRATIONS. XIX 
 
 Fig. Page 
 
 345. Amputation Through the Cervix 592 
 
 346. The Appearance of the Pelvis when all the Cardi.nai. \'f,sskls have heex 
 
 Clamped and the Tumor Removed 593 
 
 347. The Uterus as it Appears on Removal when all the Vessels have been Con- 
 
 trolled WITH Clamps and Cut 595 
 
 348. Appearance of the Pelvis after all the Cardinal Vessels have been Controlled 596 
 
 349. Drawing the Uterine Vessels into the Cervical Stump 597 
 
 350. Insertion of the End of the Round Ligament into the Cervical Stump 598 
 
 351. Appearance of the Pelvis after Supravaginal Hysterectomy 599 
 
 352. Appearance of the Pelvis after Insertion of the Round Ligament into the 
 
 Cervical Stump 600 
 
 353. Extensive Removal of the Cervical Mucosa where Supravaginal Hysterectomy 
 
 is Performed 601 
 
 354. Extensive Removal of Cervical Mucosa 602 
 
 355. A Diagrammatic Representation of the Left to Right Operation 606 
 
 356. Bisection of the Uterus 609 
 
 357. First Steps in Bisection of the Uterus 610 
 
 358. Bisection of the Uterus 611 
 
 359. Bisection of the Uterus 612 
 
 360. Bisection of the Uterus 613 
 
 361. Bisection where the LTterus Completely Fills the Pelvis 614 
 
 362. The Value of Bisection of the LTterus 615 
 
 363. Transverse Section of the Cervix as the First Step in Hystehomyomectomy 616 
 
 364. Abdominal Hysteromyomectomy "from Below Upward" 617 
 
 365. Appearance of the Pelvis after Complete Hysterectomy 618 
 
 366. A Large Raw Area Left after Removal of a Cystic Myoma 619 
 
 367. Method of Controlling a Bleeding Area where a Needle Cannot be Safely 
 
 Employed 620 
 
 368. Temporary Control of Bleeding from a Subperitoneal Pedunculated M voma .... 621 
 
 369. Method of Establishing Vaginal Drainage 624 
 
 370. An Indication for Abdominal Instead of Vaginal Hysteromyomectomy 628 
 
 371. A Myomatous LTterus Accurately Filling the Pelvis 630 
 
 372. An Incarcerated Myomatous Uterus 630 
 
 373. Retroperitoneal Development of Myomata 631 
 
 374. A Very Difficult Hysteromyomectomy 632 
 
 375. A Myomatous Uterus Blocking the Pelvis 633 
 
 376. A Myomatous Uterus that Tended to Sag Down and Completely Fill the Pelvis . . 634 
 
 377. Leaving the Outer Layers of the Myoma Attached to the Bowel 635 
 
 378. Method of Dealing with Extensive Intestinal Adhesions 635 
 
 379. A Large Abscess Lying Anterior to a Myomatous Uterus 636 
 
 380. Circumscribed Abscess in the Omentum Associated with a Densely Adheuf.nt 
 
 Myo.matous Cterus and an Ovarian Abscess G3S 
 
 381. A Longitudinal Section OF the Abdomen Showing an I'.mbilical Hernl\, a Lahgk, 
 
 De.nsely Adherent, Myomatous Ftekus, and an Ovarian Abscess (HO 
 
 382. A liARfJE Peuuncul-vted Subperitoneal Myo.ma Compmcatinc; I'regnancv 643 
 
 383. A. Normal Precjnancy A.s.sociated with a Large Subperitonkal .Myoma 644 
 
 384. A Pregnant Multinodular .Myomatous Uterus 645 
 
 385. Pregnancy in a Multinodular Uterus 647 
 
 386. An Early Prf:gnancy in a Myomatous Uterus 651 
 
 387. A PuRULE.NT Accumulation in the Cervical Stump Following Supravaginal 
 
 Hysterectomy 664 
 
 3SS. Dii.AiiNc; \ Cervix to Kkmove a.n AccuMri.ATinN of Frs between the Ckkvical 
 
 Stump a.nd the Pelvic I'euitonei'm ()64
 
 MYOMATA OF THE UTERUS. 
 
 CHAPTER I. 
 UTERINE MYOMATA.- 
 
 Uterine niyuiiiata in the beginning are usually interstitial, but in time tend to 
 force their way to the outer surface, becoming subperitoneal, or toward the 
 uterine cavity, eventually becoming submucous. Should they pass out between 
 the folds of the broad ligament, they develop into intraligamentary myomata, 
 and those starting near the cervix may l^ecome essentially cei-vical myomata. 
 
 When the nodule passes to the outer surface of theuterusit may remain firmly 
 fixed and is spoken of as a sessile myoma, in contradistinction to one that has 
 become pedunculated. In Fig. 1 is represented a sessile myoma projecting from 
 the right of the uterus, and attached to the fundus is a pedunculated myoma. 
 The pedicle of the myoma consists of utei'ine nuiscle and carries the blood-vessels 
 for the tumor. The myoma itself may be enveloped in a thin covering of uterine 
 muscle, or the normal muscle may cover it only in the vicinity of the pedicle. 
 
 The subperitoneal myomata may reach almost any size and maybe lobulated 
 or smooth. The smaller ones are usually smooth. Occasionally we find a 
 myoma presenting a particularly rough, volcanic-looking appearance and very 
 hard on pressure. Such a myoma has no outer capsule of normal muscle and is 
 very dense. Fig. 2 shows an excellent example of a niulbei-ry-shaped myoma. 
 It is pedunculated and very nodular, while the remaining myomata are sessile 
 and more or less spheric. 
 
 On section, the myomata are very firm. They an> glistening white oi' whitish 
 yellow in appeai'aiice, and ai'c conqxtscd of biintllcs of libei-s iHinning in all dii'ec- 
 tions. As a rule, they can be (>asily shellecl out from the surrounding muscle, a 
 fact that renders a myomectomy the operation of choice in suitable cases. The 
 myomata stand out in shai-p conti-ast to the surrouniling uterine muscle, as seen 
 in Fig. 'A. Tiie contrast between the myoma and the muscle is \-ei-y shai'p in the 
 cut sjH'cimeii, as the myoma remains the same, while the \iterine muscle con- 
 tracts, lea\iiig the luiiior standing out in relief. 
 
 * Myoiiiat.-i. (iliniinyi)m:il;i. Ill )n >in:il :i , ami lil)n)i(ls of I lie uterus an- used as syuoiiyiniius Icnus 
 ami nicau prccisriy llic same lliiiii;. ( »!' coiii-sc. in ^ninc inyninala tin- muscular lissuc prcdonii- 
 iiatc^. ill otiicis, t lie (iiirou.s tissue \\ r lia\i' iicscr seen a I rue lilinuiia n|' the uterus, tliat is, 
 a Uterine tumor consisting entirely of lil)rous tissue. l''roni tlie patiiolouist 's staml|ioiiit tlie 
 term myoma seems the ])referal)le one. Ciinicaiiy, eaeh of tliese terms i- so lirmly lixed that it 
 is hanlly m'ee--sary to m,-ike any eli.iiiL;!- in tlie designation. 
 1 1
 
 MVO.MATA OF THH ITKRUS. 
 
 Pedicle 
 
 
 
 Fig. 1.— Sessile and Pedunculated Myomata. (i nat. size.) 
 San. No. 1530. Path. No. 6479. The uterus has been amputated through the cervix. Toward the right, 
 at the junction of the cer%'ix and body, i.s a broad-based sessile myoma. Springing from the fundus near the 
 origin of the right tube is a pedunculated and slightly subperitoneal myoma. The appendages are normal. With 
 our present knowledge the ovaries would have been left. 
 
 ^"^'ivVf .* I'll i ,. 
 
 Vu;. 2. — Mulberry-shaped and Sessile My'o.ma. (3 nat. size.) 
 Gyn. No. 10403. Path. No. 6618. Occupying the fundus are several globular sessile nodules. Projecting 
 toward the |)03terior surface is a markedly nodular, mulberry-shaped myoma, which was devoid of muscular 
 covering and was excessively hard.
 
 /0^' 
 
 '^ 
 
 'l/i .- . fc' 1 , - 
 
 ml-"-'- ' h 
 
 
 ,^. 
 
 UTERIXE :\IYOMATA. 6 
 
 Usually nn'omata are discrete and sharply defined, Init in some instances we 
 have not only well-outlined nodules, but also a general myomatous tendency. 
 Such a condition is well shown in Fig. 4. The surface of the uterus is uneven, 
 owing to the presence of numerous small subperitoneal myomata. Near the 
 cervix, and also at the fundus, are discrete myomata, while the outer layers of 
 uterint^ muscle from cervix to fundus are composed of myomatous tissue only 
 impei-fectly divided into definite myomata. 
 
 Number of Myomata. — Before operation it is usually impossible to tell just 
 how many myomata the uterus contains. Sometimes it may be the seat of one 
 small or large tumor, but 
 very frequentl}' it contains 
 several, and in a few cases 
 the uterus may l^e literally 
 riddled with tiunors, as in 
 Gyn. No. 12849. 
 
 In Case 4903 the myo- 
 matous uterus filled the 
 lower two-thirds of the ab- 
 domen and 32 myomata were 
 counted. The uterus in Case 
 8354 contained l:)etween 30 
 and 40 nodules. Such large 
 numbers are the exception. 
 The uterus, as a rule, con- 
 tains less than ten myomata 
 and often only one or two. 
 
 Size of Myomata. — The 
 tumor may consist of the 
 uterus riddled with myo- 
 mata, or the enlargement 
 may be due to one or more 
 interstitial or subj)eritoneal 
 nodules.* 
 
 In afewof our cases the ulci'us was i-ciatix'cly small aiidoiieratioii was indicated 
 for the loss of blood, not for the size of the myoinata. Small subniucoiis tumors 
 at times give rise to alarming liciiioriiiagc. 
 
 In the vast majoritv of our cases the l uinoi' IiIKmI the |i('l\is and c\tcndc(l into 
 the lowci" aixloincn. During the early days of the hospital many myomata of 
 large jjroportions were cncountertMl. I'oi- example, in Case 3394 tlu> tumor 
 weighed 22 pounds; in Case ()41S, 2'.l pounds: and in Case 3440, 30 ])ounds. 
 The invomatous tumors ni;i\- not onl\' (ill the abdomen, but occasionallv are so 
 
 Fi 
 
 3. 
 
 .\n Ordinary Mvomatovs Utervs ox Section. 
 (J nat. size.) 
 CJyn. No. 3985. Path. No. 986. The uterine cavity is 
 relatively small and has been encroached upon. Occupying 
 the upijer part of the body are nuinemus myomata of various 
 sizes and sh.ipes. and with the muscle bundles arranged in 
 \vh<irls or passing in almost any direction. The myomata stand 
 (lut in sharp contrast to the normal muscle, which is much 
 darker iti color. 
 
 * In ;i fi'W cases the iiiyi)ii:;itiiiis iiicriis .ii)]!:!!!'!)! ly inci'cascs pfM'ccpl ii)ly in size at the men- 
 strual period. 'I'liis was |)articularly ni)iieeal)ie in Cases JlilT anil !)J'J1.
 
 MYO.MATA OF TllK ITKHIS. 
 
 large that tlioy extend ui)\var(l hciicath the costal inargiiis, as hi Cases 4285 and 
 6324. 
 
 Myoniata may reaeh tremendous projjortions, as in Case ]\IeA. (p. 512). This 
 j)ati('nt was operated uj)on by one of us* in 1906. The myoma was attached to 
 the uterus by a small pedicle, and weighed 89 pounds. It had received the 
 greater part of its iiouiishment from the omentum. As far as we can learn from 
 
 the literature, it was the largest 
 myoma ever successfully removed. 
 Shape of the Myomata. — A\']ien 
 we remember that myomata may 
 be single or nmltiple, that they 
 may be situated in any part of the 
 uterus, and may be small or reach 
 very large ])ro]i()rtions, it is clearly 
 evident that the uterus or the myo- 
 matous masses, as a result of the 
 a])normal enlargement, may as- 
 ■^ siune a great variety of shapes. 
 
 Pear-shaped Myomata. 
 — AMien the uterus contains one 
 large interstitial myoma it may be 
 pear-shaped, and resemble in con- 
 tour a pregnant uterus. (See p. 
 468.) Case 2881 (Path. No. 359) 
 offered a very good example of 
 such a condition. The uterus was 
 pear-shaped and measured 31 x 28 
 X 21 cm. The enlargement was 
 caused chiefly by an interstitial 
 myoma, 19 x 20 x 23 cm. Pear- 
 ^ ^ sha])ed enlargement of the uterus 
 
 'Myomatous Tkxukxcy." (Nat. . i ,• i 
 
 ^i^^^ IS relatively common. 
 
 Path. No. 3601. The uterus is not much enlarged, K i (1 U C y- S h a p C (1 111 y O - 
 
 but its surface is nodular, owing to the presence of numerous , ± ■ r i^ j. 
 
 small subperitoneal myomata. Nearly all the uterine HI a t a ai'C UOt lilt IVqUent ly mct 
 
 muscle is occupied by small myomata, or its fibers show a with' thcV are USUallv SUl)])eri- 
 definite diflfuse myomatous tendency, a is the uterine cavity. 
 
 toneal and pedunculated, and are 
 generally associated with interstitial and submucous nodules. In Case 3281 
 the uterus contained interstitial and subimieous myomata, while projecting from 
 the right side of the uterus was a kidney-shaped tumor, 9 x 10 x 18 cm. On the 
 left side of the uterus was an irregular, kidnc^y-shajied mass, 16 x 18 x 29 cm. 
 I'he concavity of this mass was directed toward the uterus. 
 
 * Thomas S. Cullcn, A Scries of Interesting Gynecologic and Obstetric Cases, Jour. A. M. 
 A., May 4, 1907. 
 
 Fi<;. 4. — A Gknkiial
 
 uterixp: myomata. 5 
 
 In Case 3340 (Path. No. 607) the uterus was 10 x 11 x 12 ciii. and studded with 
 small subperitoneal, interstitial, and sul)niucous niyoniata. In addition there 
 were three large pedunculated submucous nodules, a mulberry-shaped tumor 
 13 cm. in diameter, and two kidney-shaped masses, each averaging 13 cm. in 
 its longest diameter. One was situated to the left, the other to the right, of the 
 uterus. Kidney-shaped subperitoneal myomata are fairly common. 
 
 Heart-shaped myomata may be interstitial or subperitoneal. 
 In Case 3111 (Path. No. 479) th(> uterus was 9 x 9 x 10 cm., the enlargement 
 being caused by small myomata. Springing from the right cornu was a pedun- 
 culated myoma, 4.5 x 5 x 7 cm., and from the left cornu a heart-shaped, slightly 
 lobulated mass, 5.5 x 8 x 10 cm. 
 
 In Case 3199 (Path. No. 524) the uterus contained several myomata. The 
 anterior wall was occupied l)y a heart-shaped myoma, 11 x 12 x 14 cm. 
 
 The pelvic tumor in Case 3320 (Path. No. 589) was 13 x 21 x 28 cm. and heart- 
 shaped. Lying on its anterior surface were the uterus and appendages intact, 
 
 M u 1 b e r r y - s h a p e d m y o m a t a are subperitoneal and peduncu- 
 lated and may be small or large. They are easily recognized by their globular 
 form and rough nodular surface. They are not very common. 
 
 Projecting from the myomatous uterus in Case 2800 (Path. No. 312) was a 
 large, mulberry-like tumor, 12 x 19 x 19 cm. This was covered with dense 
 adhesions, and was attached by a pedicle 2 x 3 cm. 
 
 The uterus in Case 3340 (Path. No. 607) contained subperitoneal, interstitial, 
 and submucous myomata. One of the three pedunculated sub{)(>ritoneal myo- 
 mata had a mulberry-like surface and was 13 cm. in diameter. 
 
 In Case 3942 (Path. No. 964) the pedunculated, subperitoneal, mulberry- 
 like myoma, 8.5 x 11.5 x 12.5 cm., was removed and the uterus saved. 
 
 T h r e e - 1 e a f - c 1 o V e r - s h a p e d M y o m a t a. — In Case 2718 (Path. 
 No. 259) the uterus viewed from the front resembled in form an immense three- 
 leafed clover. The hilum corresponded to the sacrum. 
 
 Saddle-bag M y o m a t a. — Occasionally, when a myoma is pn^sent on 
 either side of the uterus, the picture suggests a saddle-bag. In Case 4845 there 
 were two large myomatous masses, one on either side of the uterus, "giving it a 
 saddle-bag appearance." Similar pictures were noted in Cases 3689 and 6542. 
 
 Sacral Ma r k i n g s. Occasionally, where the luiiior reaches lai'ge ])i'()- 
 portions and still lies in the i)elvis, it may rest firmly on the sacrum, ll will then 
 show a concavity where it has come in contact with the sacral promontory. 
 In Case 3130 (Path. No. 499) the uteinis contained a few small myomata. 
 Springing from the right side was a subperitoneal myoma. 14 x 18 x 25 cm. 
 Its posterior surface presented a deej) (lej)i-ession, corresponding to the jiromon- 
 tory of the sacrum. On either side of this depression were prominent lobu- 
 lations. 
 
 In Case 3440 (Path. No. 674) a myoma weighing 30 i)oun(ls was attached to 
 the small myomatous uterus by a pedicle 4 cm. in diameter. The under surface
 
 6 :MY()M ATA OF THK ITEIU'S. 
 
 of the tumor presented a (lej)ressi()ii whieli A\as an exact counterpart ot the 
 sacml prominence. 
 
 Pelvic Mollis. — Whei'e tiie tumors are Hrmly lixed in the jielvis and 
 continue to enlarge, they may finally become molded to the form of the j)elvis. 
 In Case 1767 the uterus contained at least 30 myoniata, anil filling the pelvis 
 was a tumor which was a "true cast of the pelvis." This myoma seemed to be 
 made up of a great mass of nodules pressed together. 
 
 This process of molding was also noted in Cases 8882 and F., C. H. I., August 
 10, 1902. 
 
 R e s e m b 1 i n g a F e t u s.— The resemblance of a myomatous utems to 
 a fetus is described on page 469. 
 
 (.Complete erosion of mucosa 
 vessels of capsule exposed.. 
 
 J"iG. 5. — IxJECTio.N' OF .\ Myom.\tous Uterus. (X 1? diam.) 
 The uterus after injection ha.s been cut in two. The uterine walls are very vascular, hut tlie niyoinafa in 
 this particular case show practically no blood-supply. The uterine mucosa i.s in places intact, but over a wide area 
 show.s a dpfinite ero.sion. l.Vftcr ,Tohn G. Clark.) 
 
 The Blood-supply of Myomata. — This sul)ject has been very satisfactorily 
 worked out by John (1. Clark,* who injected a large number of myomatous uteri. 
 He found that, taken as a whole, the uterine muscle was much more vascular 
 than the myoniata. 
 
 The blood-.supply of the myomata is, of course, derived from the uterine 
 muscle. If the nodules are small, the blood-vessels surrounding them are cor- 
 resjiondingly small, but where the myomata reach very large proportions, very 
 large blood-vessels are seen passing from the muscle and ramifying over the 
 surface of the tumor. The veins may reach 7 mm. or more in diameter. The 
 arteries are much less in evidence. 
 
 * John G. Clark, Tlie Cause and Significance of Uterine Heniorrliage.s in Ca.ses of Myoma 
 Uteri, Johns Hopkin.s Hosp. Bulletin, 1899, vol. x, page 11.
 
 UTERIXE MYOMATA. 7 
 
 If the myoma is a very large tumor with a thin outer covering of uterine 
 muscle, two definite vascular systems can at times be made out, the one supply- 
 ing the muscle, the other forming the network over the surface of the tumor. 
 
 A^'hen an injected myomatous uterus is cut in two, the contrast between the 
 uterine muscle and myomatous tissue is very sharply defined. In practically 
 all cases the uterine muscle is richly supplied with blood. In some the myomata 
 are almost devoid of vessels, as seen in Fig. 5, but not infrequently many vessels 
 are scattered throughout the tumors. 
 
 
 
 •.H-.i>-- 
 
 \^:!^- 
 
 "S^^SH^v '■ 
 
 A-'i 
 
 
 IT"--*' 
 
 -v^' 
 
 
 
 ^^m^-::r,^^ 
 
 ':. -:*«?_-: 
 
 -.1^ 
 
 -^^ 
 
 Fio. 6. — Typical Myomatous Tissue. (X 100 diam.) 
 Gyn. No. 2091. Path. No. 265§. Scattered throughout the fibrous-tissue matrix are bundles of non-striped 
 muscle-fibers cut longitudinally and transversely. The muscle bundles present a wavy appearance. The nviclei 
 of the muscle-fibers are sjjindle-shaped. 
 
 \\'li(ii the iiiN'omata arc very large, veins of (■x('('])ti()iial size may be seen 
 scattered tliioughoiit the tumor. In Case 2881 (Path. No. 359), the myoma 
 measured 19 .\ 20 .\ 23, and thin-walled veins fully 8 mm. in diameter were found 
 in the tumor. Again, in Case 3440 (Path. Xo. <)74). the tumor weighed 30 jKumds, 
 and there were slit-like openings, 5 to 7 mm. in diameter, in its substance. These 
 veins closel)'' resembled the veins of a livei-. 
 
 Histologic Appearances of Myomata. — Sections from myomata are remark- 
 abl}' uniform in their ajjijearaiiee. The tis.sue is made up of bundles of non-
 
 5 -MYO.MATA OF THE rTERUS. 
 
 striped iiiusclc-tihcrs cut Iciiiithwisc and transversely. These bundles may t'orni 
 graceful curves, be perfect!}' circular, or run in and out in all directions, ^\'hcn 
 the niyoniata are young, the circular arrangement is often very clearly seen, as 
 in Fig. 286 (p. 433). In the very small myomata the tumor consists almost 
 entirely of muscle, but when it reaches 1 cm. or more in diameter, there is an 
 admixture of muscle and fibrous tissue. Fig. 6 shows the characteristic myoma- 
 tous picture. II(>re longitudinal and cross-sections of non-striped muscle are 
 found scattered 'nreuularl\' t Inouii'liout a matrix of fibi'ous tissue. 
 
 
 
 h 
 
 ,if 
 
 a - b c 
 
 Fig. 7. — Thk Line or Clkavagk Between a Myoma and the Uterine Muscle. (X 55 diain.l 
 Gyn. No. 3008. Path. No. 435. a is myomatous tissue; b an outer and rough capsule also composed of 
 myomatous tissue; c is uterine muscle. At d is a definite point of cleavage, the myoma being separated from its 
 outer myomatous capsule b.v a well-defined space. At e the uterine muscle shows a definite inflammator.v 
 reaction. 
 
 In practically all myomata that reach any apj^reciable size hyaline degenera- 
 tion is noted in the librous tissue, in the muscle, or in both. As a rule, the 
 muscle-fibers in the myoma are closely packed together and stain somewhat 
 more deeply than the suirounding uterine muscle. 
 
 The line of junction l)etween the growth and the uterine muscle is usually 
 not only sharply defined, but there is a definite cleavage. In Fig. 7, for exam{)le, 
 there is a space sej)ara1ing the myoma from the uterine wall. There are, of 
 course, excei^tions to this rule. In Fig. S the myoma is sharply differentiated 
 from the muscle, and yet they are so insej)aral)ly united that it would be im- 
 possible to shell this tumor out. Occasionally the myoma, instead of forming a
 
 UTERINE MYOMATA. 
 
 9 
 
 globular nodule, may grow out irregularly into the surrounding muscle. Such 
 a picture is ])resented in Fig. 9. 
 
 Individual Cells. — The individual nmscle-fibers are spindle-shaped. The 
 nuclei are long and narrow. A\'hen the muscle-fiber is cut through at its center, 
 we see a small spherical mass of protoplasm and a central small round nucleus. 
 If the cell is cut obliquely, it may appear oval, and the nucleus also ovoid, in 
 shape. A cross-section of a muscle-fiber near the end will yield a small mass of 
 protoplasm, devoid at this point, of course, of a nucleus. Many such little masses 
 of protoplasm are seen in the nmscle bundles. When the muscle nuclei are very 
 closely packed together, the tissue naturally stains more deeply. Nuclear figures 
 are rarely, if ever, seen in the ordinary myoma stained in the routine manner. 
 
 
 '«., '••( V' •»/»(|f'>'-^' 
 
 Fr;. N. ULK.NUi.NO Ut A M\OMA W I 1 H Tilt UTliRINK MuiSCLK. (. X 1 00 clialU. ^ 
 
 Gyn. No. 2570. Path. No. 162. a is uterine muscle; b very cellular myomatous tissue. The line of junction 
 is very sharply defined, but there is no point of cleavage, the myoma merging directly into the uterine muscle, 
 c is a blood-vessel. 
 
 Professor Mallory,* of Harvartl University, in 1904 described several new 
 stains by means of which he was able, in api)r()])riately preserved material, to 
 bring out clearly the neuroglia, myoglia, and fibroglia of the various tumors. 
 In speaking of myoglia he says: '' The study of a series of leiomyomata obtained 
 chiefly from the uterus shows that while, in general, the sinooth-nmscle cells 
 closely resemble those found in normal tissues, they may vary considerably in 
 form from the normal tyjM'. For exanijile, a leiomyoma occasionally occurs in 
 which the cells are very long and thin and the nuclei are the slenderest of rods. 
 In still other cases the cells are shoiM and thick and the iniclei have a long or 
 short oval form. This difference in tiie shape of the cells (h'pends, in })art at 
 
 * F. B. Mallory, A Contribution to tiio Classification of Tumors, .Journal of Medical Re- 
 search, vol. xiii, January, 1905. See also F. B. Mallory, The Results of the Application of Special 
 Histological Methods to the Study of Tumors, .lour. Kxpcr. Medicine, vol. x. No. 5, September 
 .5, 1908.
 
 10 
 
 MYOMATA OF THE UTERUS. 
 
 least, on the raj)idity of firowth of the tiiinor. In general it niay ])e said thai th(> 
 slowest growing smooth-muscle cells are the most slender." 
 
 "The myoglia fibrils in the tumors vary somewhat in number and coarseness, 
 but always form a well-marked and characteristic feature of the cells. As in 
 iioiiiial tissue's, they remain closely applied to the cell columns; so far as can be 
 dclcrmincd. they do not leave the surface of cell protoplasm and mix with the 
 intercellular connective-tissue fibrils surrounding the smooth-muscle cells. 
 The iiiyogHa fibrils show a certain tendency to twine together, especially in tissue 
 
 
 Fig. 9. — The Irrkgular Extension ok a Myoma into the Utkrine Muscle. (X70diam.) 
 Gyn. No. 5010. Path. No. 1536. Projecting into the field from the left lower corner and occupying the 
 middle is myomatous ti-ssue, recognized by the dark stain. Its confines are indicated by a. At b are a few isolated 
 myomatous bundles. The remaining tissue, which stains palely, is uterine muscle. 
 
 which is somewhat edematous, so as to form what seem to be unusually coarse 
 fibrils. This appearance is most marked at the ends of cells, where they arc 
 drawn out thin, so that the fibrils running from one cell to the ne.xt are brought 
 into close a])p()sition." 
 
 In oi'der that the myoglia may be carefully studied, small ])ieces must be 
 immediately j)laced in Zenker's fluid. In the ordinary routine laboratory 
 examination, as u.sually carried out. it is im])ossible to detect the finer structures 
 of the mu.scle-fiber.
 
 utp:rixk my():\iata. 
 
 11 
 
 Fig. 10. — A Tr.^nsverse Section thuoigh 
 A Myom.vtous Uterus. 
 Gyn. No. 2881. The uterus was pear- 
 
 Position of the Body of the Uterus. — The position will (li'iu'iul iip(jii the size 
 and situation of the niyomata. If they are of .^^mall size and seattered uniformly 
 throughout it, the organ retains its 
 normal position (Fig. 10). If a myoma 
 develops from the upper part of the uterus, 
 the normal relations of the uterus may 
 still be maintamed. If a myoma develops 
 in the posterior wall, the fundus may be 
 pushed forward toward the symphysis; if 
 the myoma originates in the anterior wall, 
 the fundus may be forced back into Doug- 
 las' sac. 
 
 "When a myoma develops in the lateral 
 w'all and spreads out into the broad liga- 
 ment, the uterus will usually be forced to shap'dV'si x 28 xTl"cm. The transverse sec- 
 the ODDOSite side (Fis! 11) ^'""^ '^^^ been made just above the ovaries. 
 
 1 • 1 "^^^ uterine cavity is surrounded by myomatous 
 
 U hen the mVOmata are multiple and tissue. The greater part of the uterine muscle 
 reach large proportions, the uterus may j^^jread ou^t^over the surface of the myoma in the 
 
 rest like a cap on the top of the tumor, as 
 
 noted in Cases 3133 and 8344. Sometimes the uterus is so hidden between 
 
 myomata that it is difficult to find, as in Case 10403. In Case McA., in which 
 
 an S9-pound subperitoneal, pedunculated myoma 
 !^. ,broad Lig. ^^'^^ reiiioved, the utcrus lay behind the tumor and 
 
 near the liver. 
 
 Condition of the Uterine Muscle. — If the myo- 
 mata are small, or if the tumors are subperitoneal 
 and pedunculated, the uterus is usually normal 
 in size, but when it contains several myomata, 
 tliere is commonly an increase in size. This in- 
 
 FiG. 11.— The Myomatous Uterus d'casc Is Undoubtedly causcd by the iiiyoiiial :i , as 
 
 AS Viewed on Transverse Sec- • i i i j_i r , i i j i i i i ,• 
 
 evidenced by the tact that the enlarged uterus, alter 
 the myomata have been removed, gradually under- 
 goes involution until it becomes normal in size. 
 The following cases clearly ilhistrate the increase in 
 size of the uterus. 
 
 In Case 5021 a myoma, 7 \ 11 \ 11 cm., was 
 remoN'ed per alxlonicH fi-om the posterioi' wall. 
 The uterus, iinniedi.-ilcly alter reino\-aI of ihe 
 tumor, was two and one-half times its natural si/e. 
 The smooth-walled uterus in Case *.)'J21 reached 
 neaiiy to the unihilicus. .\n in t erst ilia I myoma, !) \ 10 cm., was renioNcd from the 
 right cormi. The utei'us, after ivmoxal of the tumor, was between two and three 
 tim(>sits natiu'al size. .\t the end of three weeks it was little Iai'i;ei- than normal. 
 
 TION THROUGH THE CeRVIX. 
 
 Gyn. No. 701. The cervix on 
 section looks normal. Attached to 
 it on the right is a portion of (he 
 myoma, which extends out into the 
 broad Hgament. From the sketch 
 it is seen that the myoma projected 
 deeper into the pelvis than did the 
 cervix. 
 
 With a myoma in this i)o.sitioii 
 the left to right oi)erution would \ iclil 
 the best results. Much care wouM 
 be necessary to avoid iiij\iry to the 
 right ureter.
 
 12 MVOMATA OF TIIK rTF.Rl'S. 
 
 \\'h('n the iii^'oiiiatous uterus is \-('r}' lar<2;(', the blood- vessels are naturally 
 much increased in size and tlie uterine nuiscle is very vascular. 
 
 Occasionally the uterine muscle may undergo partial hyaline degeneration, 
 as noted in Case 2S52. The globular utems was 13 x 13 x 14 cm., the chief 
 increase in size being due to the j)resence of a degentM'ated and interstitial myoma 
 12 cm. in diani(>ter. The uterine muscle was considerably altered. The muscle- 
 bundles were separated from one another l)y hyaline material containing only a 
 few nuclei. The individual muscle-fibei-s aj)peared to have undergone this 
 hyaline change. In other jjortions the muscle appeared normal.
 
 CHAPTER II. 
 PARASITIC UTERINE MYOMATA. 
 
 Myomata that have for some reason become ])artially or ahiiost eoiii- 
 pletely separated from the uterus and receive their main l:)loo(l-!?upp]y from 
 another source may be termed parasitic. 
 
 Uterine myomata at first obtain their entire nourishment from the uterus, 
 but may in time derive the greater part of it from (1) the omentum; (2) the 
 Fallopian tubes; (3) the mesenteric vessels; (4) the large or small intestine: 
 (5) the bladder; (6) the abdominal wall; (7) the broad ligament; (8) several of 
 these sources at the same time. 
 
 We are here chiefly interested in the role that the omentum plays when the 
 myoma gradually changes its source of blood-supply. Our own observations 
 have satisfied us that the omentum is the guardian of. the abdominal organs. 
 In many cases, when myomata exist, the omental adhesions are associated with 
 dense pelvic adhesions or with pus-tubes. Here it is perfectly natural that the 
 omentum should become firmly adherent. Of special interest is that grou]i of 
 cases in which the tubes and ovaries are comparatively normal and offer no 
 particular incentive for the omental adhesions, and yet in which, for some reason, 
 the omentum manifests a certain affinity for the subpc^-itoneal and usuall>- 
 pedunculated nodule, becomes adherent to it, and soon furnishes a large part of 
 its sustenance. Sometimes only a few vessels pass from the omentum to the 
 myoma, as in Fig. 24 (p. 34), where four vessels are seen entering a jkhIuiicu- 
 latccl nodule. As the jK'diclc of the tumor becomes small(>r and its original source 
 of nourishment diminishes, the omentum sends in more and more vessels, as 
 seen in Fig. 13 (p. 17), Fig. 14 (p. 17). Fig. 15 (p. 18), and Fig. Ki (p. 19). 
 These vessels may spread out over the siui'acc, divide into smaller brandies, and 
 then enter the tumor, as shown in Fig. 18 (p. 22) and Fig. 20 (j). 25); or they 
 may plunge at once into the depth, as is shown in Fig. 24 (ji. 34). .\s a nih'. 
 we have found large arteries accompanied by two veins. The Ncins in some 
 instances reach t i'enien<lous pi-o|»oilioiis. In Case C., Ilagerstow ii. toi' instance, 
 some of them were iiioi'e than 1 eiii. in diameter and looked lii\e sniaH snakes. 
 
 CHANGES IN THE OMENTUM. 
 The function of the onientuni can l)e most i)eautifully followed in these cases. 
 If it be called upon for a small l)lood-suiii)ly. a few \-essels are at once sent in 
 and but little change is noted in the oiiientuin. lint when the t unioi' is large and 
 
 i;;
 
 14 MYOMATA OF THE rTEHUS. 
 
 much is rc(|uir('(l of the oinciitiini, the vessels rajjidly increase in size and the 
 oiiiciital fat iiiathially disappears. This gradual absorption of fat is well fol- 
 lowed in Fig. 17 [\). 20), Fig. 18 (p. 22), Fig. 20 (p. 25), Fig. 21 (p. 26), 
 Fig. 23 (p. 29), and Fig. 24 (p. 34). The first change noted is that the vessels 
 in the vicinity of the tumor stand out clearly, and that the tissue between the 
 vessels is becoming rarefied. Later, the vessels near the tumor are mcn^y sup- 
 ported by the peritoneal folds of the omentum. The fat continues to be absorbed 
 until little or no trace of omentum remains, and the vessels are only recognized 
 as omental on account of their relation to the transverse colon. This is strik- 
 ingly well shown in Fig. 25 (p. 36), in which a small fringe of fat, 1 cm. broad 
 and lying against the transverse colon, was all that remained of the omental 
 adipose tissue. 
 
 The omental vessels seem to have an unlimited capacity, as in Case C. (p. 24), 
 in which a very large myoma with a small pedicle existed. Here not only was 
 there a liberal su))])ly of omental nourishment for the upper surface of the 
 tumor, but the omentum had sent down a bunch of vessels to its lower pole. 
 These vessels formed a cord 6 cm. in diameter. They were held together by 
 peritoneum, but wei'e free, the only fixed points being their points of origin at the 
 transverse colon and their disappearance into the lower end of the tumor. At 
 operation we lifted this cord up, completely encircling it with the hand. It 
 looked just like a bunch of small snakes. One isolated omental vessel lay ab- 
 solutely free for a distance of IS cm. The function of the omentum is certainly 
 marvelous, as can be seen on reference to Case McA. (p. 512). Here the subper- 
 itoneal tumor weighed 89 pounds and was attached to the uterus by a pedicle 
 1 X 1.5 cm. in diameter. The chief nourishment had come from the omentum. 
 
 In rare instances the myoma becomes completely separated from the uterus 
 and rc^ceives its entire nourishment from the omentum. Such an example is 
 furnished by Case 14709 (see Fig. 23, p. 29). 
 
 Lymphatics. — AMien large myomata exist, dilated hmphatics are often 
 found in the broad ligaments. It is but natural that with the increased activit}' 
 of the omentum its lymphatics also should be increased in size. 
 
 In Fig. 17 (p. 20) there is marked dilatation in the broad ligament lymphatics, 
 as is indicated at a, and coursing down the omentum, which is densely ad- 
 herent to the pedunculated myoma, are markedly dilated and tortuous lymph- 
 channels. 
 
 In Fig. 18 (p. 22) the omentum is rapidly losuig its fat, and its peritoneum 
 is disappearing, leaving oval clear spaces. At e is a very large tortuous lymph- 
 channel. As a rule, these large lymph-vessels collapse soon after remo\al and, 
 therefore, frecjuently escape observation in the laboratory. 
 
 Etiology. — The cause seems inherent in the myomata and not in the sur- 
 rounding organs. The uterus is naturally trying to get rid of its interstitial 
 nodules, and they conse(iuently become subnnicous and subperitoneal. Now, 
 when a myoma becomes subperitoneal, the continued uterine contraction grad-
 
 PARASITIC UTERIXE :MY()MATA. 
 
 15 
 
 iially renders it pcdunculatt'd, and finally the mere -weight of the nodule making 
 traction on the pedicle will still further attenuate it. Owing to the diminished 
 blood-supply, these nodules are usually prone to degenerate, and often show 
 hyaline degeneration or necrosis. The peritoneal surface develops a slight 
 roughening, and the omentum at once becomes adherent. 
 
 If this reasoning be true, we would naturally expect the part of the tumor 
 farthest away from the pedicle to sufTer first. A reference to Fig. 13 (p. 17), 
 Fig. 14 (p. 17), Fig. 15 (p. 18), Fig. 16 (p. 19), Fig. 17 (p. 20), Fig. 18 (p. 22), 
 Fig. 20 (p. 25), and Fig. 25 (p. 36) will show that in each of these cases 
 
 b-M'T 
 
 „ .' ;-"?-5,^'«*''7..-:",!.'.,,...v- ft-''; 
 
 
 
 v.^:*^. 
 
 » * 
 
 
 
 
 
 W^W^'"^'^ 
 
 5.^.'.Tr £" 
 
 '. Z'-^ ■ ■•.'■•■■■■ 
 
 
 ^^^ff:^' 
 
 Vic. 12. — Omkntal Blood-vksski.s that ark Keeping Alive the Outer Layers of a Myoma which Shows 
 ALMOST Total Hyaline Degeneration. (X 80 diameters.) 
 Gyn. No. 11S98. Path. No. 8284. The myoma was enveloped in omentum and was attached to the uterus 
 by a pedicle 1 cm. in diameter. The appendages were normal. Microscopically, the tumor showed marked hyaline 
 degeneration and coagulation necrosis, as well as areas of calcification (Fig. 101, p. 12S). a indicates the outer con- 
 fines of the hyaline degeneration; h, the remaining outer zone of myomatous tissue; and c, tlic limits of the 
 adherent omentum. To the left the omental fat is still seen, but toward the right it has been entirely replaced 
 by fibrous tissue and many new and relativelj- large blood-vessels. 
 
 the omental vessels entered the tiiiiior ai liie point most distant from ils 
 connection with the uterus. The omentum appears I o be fullilling its normal 
 useful function of guardiiiii; othei- abdominal organs from danger. If the 
 omentum does lu^t furnish the myoma with the necessary nourishment, the lat- 
 ter may develop an abscess in its interior and open into the intestine (as seen in 
 Fig. 32, p. 46), or else it may become a parasite U|)on the intestines or bhidder 
 for its sustenance. 
 
 Special Points in the Operative Treatment when Large Omental Adhesions Exist. 
 — Naturally, the firstthingtodoafter oi)ening the abtlomen will be to control the
 
 16 :myomata of the uterus. 
 
 omental vessels. We always make it a point to tie off the omental vessels twiee 
 on the proximal and once on the distal or tumor side. These vessels are so 
 delicate and tear so easily that we invariably tie instead of clamping and then 
 tying. The mere weight of the artery forceps is at times sufficient to tear them, 
 and serious hemorrhage may follow. 
 
 Since it is of the greatest im])ortance to always tie under sight, the incision 
 must he sufficiently long to enable the operator to see all the vessels clearly. 
 A\'hcii the omental adhesions extend over a wide area, the incision may be 
 gradually lengthened as is found necessary, but an attempt should never be made 
 to liberate adhesions far up under the abdominal wall, as they may contain large 
 veins or arteries. 
 
 In Case McA. (p. 512), in which the tumor weighed 89 pounds, these precau- 
 tions were strictly ol^served, and yet the tumor was everywhere so intimately 
 attached that, notwithstanding our care, a small piece of liver came away with 
 it. If a careful and methodic tying of the omental vessels be practised, even the 
 largest tumors may often be removed with a loss of not over two ounces of blood. 
 
 Fig. 22 (p. 28) gives a very good idea of the huge congeries of omental ves- 
 sels that the operator will occasionally encounter. 
 
 Cases in which the Omentum Affords Part of the Blood-supply to Parasitic 
 Myomata. — This condition is relatively common.* AVe have picked out a num- 
 ber of the more characteristic cases, so that the various and progressive changes 
 in the omentum can be clearly followed. 
 
 Gyn. No. 694. 
 
 A multinodular myomatous uterus with a partially 
 p a r a s i t i c m y o m a , receiving m u c h of its blood- s u p p 1 }- 
 from the o m e n t u m (Fig. 13) . 
 
 E. P.. white, single, aged thirty-six. Admitted April 23; discharged June 20, 
 1891. This tumor had grown rapidly and had almost completely filled the ab- 
 
 * All the following 37 cases showed verj- extensive omental adhesions. In the 25 designated 
 by an asterisk the myomata were partially parasitic. 
 Gyn. No. .51.5* Gyn. 
 
 '" " 660* 
 
 " 694* '' 
 
 " " 1.38.3^* 
 
 " " 2800* 
 
 " " ,3216 
 
 " " 3296* 
 
 " " 3.387* 
 
 " " .3440 
 
 " " 3.5.58* 
 
 " " 3842 
 
 " " 39.50* 
 
 Mo. ,3974* 
 
 Gyn. 
 
 No. 12139 
 
 '' 4293 
 
 
 " 121,5,5* 
 
 " 4869 
 
 
 " 12216 
 
 " ,5,392 
 
 
 " 12696* 
 
 " ,5784* 
 
 
 " 12738* 
 
 " 6367 
 
 
 " 12864 
 
 " 6432 
 
 
 " 13023* 
 
 " 7220 
 
 
 " 13039* 
 
 " 7549* 
 
 
 " C. H. I. (P.), 
 
 " 7739* 
 
 Hagerstown (C.).* 
 
 " 9027* 
 
 Frederick (B.).* 
 
 " 9078* 
 
 
 
 " 11898* 
 

 
 TARASITIC UTERINE MYOMATA, 
 
 17 
 
 (loiiicii after one year. It had been first noticed two years ])reviously. Opera- 
 tion, May 2, 1891. Supravaginal hysterectomy. The omental adhesions were 
 tied off and the uterus was removed. The patient made an uninterrupted recov- 
 ery. The chief interest centered in the large subperitoneal and pedunculated 
 myoma, which had several omental vessels entering through its upper surface. 
 
 Gyn. No. 3950. 
 
 Double h }' d r o s a 1 p i n X ; left ovarian abscess, ^^• i t h 
 d e n s e a d h e s i o n s . A p e d u n c u 1 a t e d a n d p a r t i a 1 1 y 
 p a r a s i t i c m y o m a , r e c e i v i n g most of its 1) 1 o o d - s u ]) - 
 ply from the omentum (Fig. 14). 
 
 Fig. 13. — A Partially Parasitic Myoma Receiving 
 MOST OF its Blood-supply from the Omentum. 
 Gyn. No. 694. This sketch represents the ap- 
 pearance at operation. The uterus is much enlarged. 
 Above the right tube is a globular tuuKjr, and above 
 and to the left is a pedunculated nodule receiving the 
 greater part of its nourishment from the omentum. 
 The parasitic vessels are relatively very large and the 
 omental fat has disappeared. 
 
 Fig. 14. — A Partially Parasitic Myoma Receiving 
 A Large Blood-supply from the Omentum. 
 Gyn. No. 3950. The uterus is relatively normal 
 in form, .\ttached to its posterior surface by a nar- 
 row pedicle is a globular calcified nodule. Its entire 
 upper surface is covered by omental vessels, which 
 spread out over its peritoneal covering. Both Fal- 
 lopian tubes are the seat of a hydrosalpinx and the 
 left ovary has been converted into a large abscess 
 which is densely adherent to the rectum. 
 
 M. E., colored, married, aged thirty-seven. Admitted Xovemhcr *.); dis- 
 charged December IS, IS!)."). The })atient has had two cliildreii, the youngest 
 seven, also one miscarriage. Five years ago she noticed a small luiiior in the 
 right inguinal region. Only for the })ast yar has it been })ainful and tender: 
 it was movable at first, but has been adherent for the last five months. She has 
 a constant dull aching pain at the umbilicus. 
 
 Operation, November 14. ISO,'). Hysteromyoniectoiny. There were general 
 pelvic adhesions. Attached to the ]-)0st(Mior snrtaee oi the uterus by a sniall 
 pedicle was a calcified myoma, receiving nmcli of its nut lit ion from l lie adherent 
 omeiituni (big. II). Faeli tube was the seat of a li\(lrosalpin\ and the left 
 ovary had been conN'erted into a lai'ge abscess. The patient made a satislaetoi'V 
 recovery.
 
 18 
 
 MVOMATA OF THK ITERUS. 
 
 Gyn. No. 3558. Path. No. 742. 
 A p a r t i a 1 1 y p a r a s i t i c 111 y o in a . r c c c i v i n o; most of its 
 n o II r i s h 111 e n t f r o 111 t h v o 111 c 11 t u 111 : n o r 111 a 1 u t c r u 8 a n d 
 a ]) J) (' 11 (I a g V .s (Fi^. 15). 
 
 1;. H., white, siiiiilc. a.iicd thirty-two. Aihnittcd June 3; discharged June 
 29, lS9o. Five years ago her menstrual How l)egan to be profuse and her phy- 
 sician told her that she had a tumor. The abdomen is tender and she has sharp 
 pains throughout it. 
 
 Operation, .lune 6, 1S95. Myomectomy. Attached to the right cornu by a 
 long slender jK'dicle was a myoma, 9x9 cm., movable, non-adherent except 
 posteriorly to tiie vermiform appendix, to which it was attached by light vela- 
 
 mentous adhesions, and anteriorly to 
 the onientuni, which sent in several 
 large vessels (Fig. 15). The patient 
 made an uninterrupted recovery. 
 
 Path. No. 742. The specimen con- 
 sists of an irregular globular tumor, 9 
 x 9 x 8 cm., covered over an area 
 measuring 7x7 cm. with adhesions. 
 Some of these contain fat and are un- 
 doubtedly omental. The large tumor 
 on section is pearly white in color and 
 is traversed by numerous yellowish- 
 white, slightly translucent areas. 
 Along one margin it contains an area 
 of degeneration 4x4 cm. The central 
 ])ortion of the growth is brownish-gray 
 
 Fig. 15. — A Large Pedunculated Myoma Rf> 
 
 CEIVING nearly ALL OF ITS BlOOD-SUPPLY 
 J-ROM the OmENTU.VI. 
 
 Gyn. No. 3558. The sketch represents the ap- 
 pearance as seen at operation. The uterus and appen- 
 dages are normal. Attached to the right cornu by an 
 unusually long and slender pedicle is a myoma which 
 has received nearly all its blood-supply from the omen- 
 tum. As seen from the history, the myoma showed i i • i 
 considerable degeneration. In a short time the tumor aiKi the lliarginS shOW^ an OrangC COlor. 
 would probably have entirely lost its connection with 
 the uterus. 
 
 fined from, and are much softer than. 
 
 The degenerated areas are sharply de- 
 fined from, and are much softe 
 the surrounding tis.sue. The pedicle of the tumor is 1.5 cm. in diameter. 
 
 Gyn, No, 3974. Path. No. 980. 
 
 S u ij ]) e r i t o n e a 1 a n d i 11 t e r s t i t i a 1 \i t e r i n e m y o m a t a ; 
 1 a r g e s u b p e r i t o n e a 1 n o d u 1 e , j) a r t i a 1 1 y p a r a s i t i c an d 
 receiving its main blood-supply from the omentum 
 (Fig. 16). 
 
 .M. \\'., colored, single, aged thirty. Adinitte*! Xoveniber 19; discharged 
 December 28, ]S<)5. Three years ago the j)atient noticed an al)doniinal enlarge- 
 ment, first on the left side. The tumor apparently disai)peared for six months, 
 evidently because it had been dislodged. It reappeared and gradually increased 
 
 m size
 
 PARASITIC ITKRIXE MVOMATA, 
 
 19 
 
 Operation, Novonihcr 20, 1895. Hystei'oiiiyonict'tomy. Through an in- 
 cision 20 cm. in length a lai'ge myoma, springing from the h'ft horn, was dehvered. 
 The highest post-oi)erative temperature was 101. o" on ihc second day. 
 Recovery was complete. 
 
 Path. No. 980. The specimen comprises the uterus with its ap])endages and 
 two large pedunculated tumors. The uterus is irregular and nodular, approxi- 
 mately 7 X 5.5 X 5 cm. Its surface is covered with a few vascular adhesions, 
 and presents numerous l^osses and pedun- 
 culated nodules, varying from 1 to 3 cm. in 
 diameter. Springing from the left cornu is a 
 pedunculated tumor 9 cm. in diameter, and 
 from the right side of the wall a tumor, 25 
 cm. in diameter, and attached by a pedicle 
 3 cm. broad (Fig. 16). The larger tumor for 
 the most part is smooth and glistening, but 
 presents an area of omental adhesions, 12 x 8 
 em. These adhesions consist of a large 
 number of blood-vessels surrounded by a 
 small amount of connective tissue. The 
 uterine walls are occupied by numerous firm 
 nodules, varying from 0.5 to 3 cm. in dia- 
 meter. All the nodules, both interstitial and 
 subperitoneal, present the typical myomatous 
 appearance. The uterine cavity is 6 cm. in F"-- i6.— a very large subperitoneal 
 
 , . , 1 (• 1 1 • ■'^^'^ Pedunculated Myoma, Receiv- 
 
 length, 3 cm. m breadth at the fundus, and is ing most of its nourishment from 
 
 THE Omentum. 
 
 Gyn. No. 3974. The sketch was made at 
 operation. The uterus contains several small 
 myomata, and the appendages are normal. 
 Attached to the fundus by a short pedicle is a 
 myoma 2.5 cm. in diameter. Over an area 
 12 X S cm. the omentum is densely atlherent. 
 The omental vessels are large and tortuous, 
 and are so intimately blended with the myoma 
 that they might readily be mistaken for nor- 
 mal instead of adviMititiDUs vessels. 
 
 distorted. The mucosa varies from 1 to 4 
 mm. in thickness. It is smooth and glisten- 
 ing, but shows some hemorrhage. 
 
 Gyn. No. 3296, Path. No. 580. 
 
 A large su b p c i' i t o n c a 1 jx'dun 
 C u 1 a t e d a n d p a r a s i f i c m y o in a 
 s h o w i 11 g 111 u (• h (1 e g e 11 e ]• a t i o n 
 
 an d re c e i v i n g m o s t of its n o u r i s h m c 11 t f ro m t h c o m e 11 t u 111 
 (Fig. 17). 
 
 M. W., white, married, aged forty-one Aihiiiltcd .lanuaiy 28; disch.irgcd 
 March 6, 1895. The ])atient has been inari'lcd liftccii ycai's, has had two childi'cn 
 and one miscan'iagc The menses began at eighteen and wei'e I'egiilar excry four 
 weeks until recently. .\o\\ the peiiods occur e\eiy two weeks. I'or two years 
 the abdomen has been steadily increasing in size, and al present a large hard mass 
 can be readily felt through the alxlominal walL 
 
 ()pei'atioii, .Ianuar\' 30, 1805. ilysteroniyoniectomy. ( )n section of the 
 abdomen a large sessih', subserous myoma with a ])edicle, (i \ I cm., was found.
 
 20 
 
 MYO.MATA OF THK ITF^RI'S. 
 
 The whole transverse breadth of the oiiiciituni was adherent to tlie tumor and 
 sent large vessels mto it (Fig. 17). The omentum was tied ofi' and the uterus 
 removed. For the first two days the patient ]3resented an almost typical picture 
 of hemorrhage, ah hough neither dressings nor incision showed any oozing. 
 The temperature rose to 102.0° on the second day, the j)ulse to IIS. She then 
 commenced to ini]irove, the temperature^ drop])iiig to normal. After removal 
 
 of the stitches for some vmac- 
 couiitable reason, the tem))er- 
 ature rose to 104.2° and the 
 l)ulse to 120, but on the fif- 
 teenth day the former dropped 
 to 100° and reached normal 
 on the twenty-second day. 
 
 Path. No. 580. The speci- 
 men consists of the uterus, 
 tubes, and ovaries and a large 
 mass springing from the pos- 
 terior surface. The tumor is 
 irregularly oval in shape, 
 27 X 23 X 16 cm. Its surface 
 is smooth and glistening, ex- 
 cept along its upper portion, 
 where the omentum is adher- 
 ent over an area measuring 
 16 X 8 cm. The tumor pre- 
 sents numerous bosses, is 
 pinkish in color, and along 
 
 Fk;. 17. — A \'kry Large Pedunculated AND Partially NKfRoTic •> <■ i • 
 
 .Myoma, Receiving A Rich Blood-supply FROM THE Omentum. ^tS SUrtaCC many large VCmS 
 
 Gyn. Xo. 3296. The sketch indicates the appearance at opera- Ml'e SCCU the largest of thcSG 
 tion. The uterus itself is normal. In the right broad ligament are 
 large and tortuous vessels (a), filled with clear or milky fluid. These 
 are markedly dilated lymph-channels. 
 
 The large pedunculated myoma attached to the posterior sur- 
 face of the uterus is 27 x 2.3 x 16 cm. in its various diameters. At- 
 tached to its entire upper surface is omentum which distributes 
 numerous blood-vessels to the tumor. The large tortuous and 
 white vessels (b) projecting from the transverse colon are dilated 
 lymph-channels. 
 
 being 6 mm. in diameter. 
 The tumor is firm, but some- 
 what yielding, and on section 
 is dirty grayish yellow in 
 color and has whitish bands 
 traversing it in all directions. 
 These divide the tissue up into large and small lobules. In a few places are 
 eircum.scribed masses of bright yellow material I'esembling fat, and in some por- 
 tions of the tumor are s))aces reaching 3x2 cm., wiiich are divided up into smaller 
 ones by delicate trabecuhe and contain a clear transparent fiuid. Scattered 
 thnjughout the tumor are many hlood-vessels AN'hich have \'erv delicate walls. 
 The uterus presents nothing of interest. On the right side the vessels of the 
 ])arovarium are greatly enlarged, and the parovarian tissue is edematous. The 
 ovary is normal. On the left side the appendages are unaltered.
 
 PAKASITIC UTERINE MYOMATA. 21 
 
 Histologic Examination. — The mucosa is edematous, and in some places the 
 glands can be traced a short distance into the muscle. The large tumor spring- 
 ing from the uterus is composed of non-striped muscle-fibers cut longitudinally 
 and transversely. It has a fairly abundant blood-supply, and scattered through- 
 out it are irregular patches of hyaline degeneration. The yellow patches seen 
 macroscopically are nothing more than large areas showing typical hyaline 
 change. In the vicinity of these the non-striped muscle-fibers often appear un- 
 altered or may stain deeply; they end abruptly, being replaced by finely fibril- 
 lated hyaline material. In other portions the tissue has undergone coagulation 
 necrosis and there is considerable nuclear fragmentation. At such points there 
 is hemorrhage into the tissue and rows of resistant muscle-fibers can still be 
 made out. There is a moderate polymorphonuclear infiltration. In this case 
 abscess formation would certainly have occurred in a short time. 
 
 Gyn. No. 7220. Path. No. 3476. 
 
 A large pedunculated parasitic and partially c 3' s t i c 
 myoma, deriving its b 1 o o d - s u p p 1 y a 1 m o s t e n t i r e 1 y 
 from the o m e n t u m (Fig. 18). 
 
 E. C, white, aged fifty, married. Admitted September 20; discharged 
 October 14, 1899. The patient has had four children and two miscarriages. 
 She ceased to menstruate one year ago. The abdomen is obliciuely distended. 
 The tumor takes up the entire right half and lower left half of the abdomen. 
 
 Operation, September 25, 1899. Myomectomy. After the omental adhe- 
 sions had been freed, the tumor was readily separated from the uterus. The 
 patient had a postoperative temperature of 102.8° on the sixth day. She 
 made a satisfactory recovery. 
 
 Path. No. 3476. The specimen consists of a large subi)eritoneal myoma, ovoid 
 in shape, 19 x 14 x 12 cm. Its surface for the most part is covered with ad- 
 hesions. The anterior and upper surface presents a large area of omental tid- 
 hesions, covering about half the anterior surface (Fig. 18). These adhesions 
 contain numerous large blood-vessels, which branch over the surface of tiie 
 tumor. There are also large lymph-vessels. One of these is dilated (7 mm. in 
 diameter), and filled with clear fluid. It is very tortuous, and resembles a 
 ground-worm in its convolutions. On ])ressure the tumor is in i)ai't lirni, l)iit 
 contains an area of fluctuation. On section, it is found tliat the entire mass has 
 undergone more or less cystic degeneration. In sonic parts small delicate 
 septa divide up the cystic spaces. The pedicle is 1.1 cm. in diameter, and con- 
 tains verv large vessels. The specimen is a typical example of a parasitic 
 myoma. 
 
 On histologic examination the myoma pi'esents lai'ge areas of niaii<ed cystic 
 change. In places there are muscle-fibers separating the alveoli. In other 
 places the tissue is structureless and is liciuefying.
 
 Fig. is. — A Parasitic Myoma REfF.ivixo a Largk Bi.ood-sipply from thk O mkntim. Partial .\trophv 
 
 OF THE O.MENTAL FaT 
 
 Gyn. No. 7220. The .sketch \va.s made immediately after operation. The uterus i.s normal in size, .\ttached 
 to the fundus by a short slender pedicle is a myoma 19 x 14 cm. Covering the entire upper surface of the tumor 
 are omental adhesion.'^, and, a« seen from the pathologic report, the greater part of the myoma has undergone 
 hyaline and cystic degeneration. 
 
 The picture well depicts the gradual atrophy of the adipose tis.sue that follows when many omental ves.sel.s 
 are connected with a tumor. .At a, normal omentum is seen; at b the blood-ves-sel has lost its adipo.se covering 
 and stands out clearly. In the lower part of the omentum all trace of fat has disappeared (c),and nothing but the 
 peritoneal layers of omentum and the vessels remain. At d the vessel is very clearly seen. At numerous points 
 even the peritoneum is giving way, clear spaces resulting. In one of these is a large tortuous vessel (e) filled with 
 clear fluid. It is a much dilated lymph-vessel.
 
 PARASITIC UTKRIXE .MYOMATA. 
 
 23 
 
 Gyn. No. 13039. Path. No. 10039. 
 
 S II 1) p e r i t o 11 I' a 1 , interstitial, a n d .s u 1) 111 u c o u s u t e r i n e 
 111 y m a t a ; 111 a r k c d a trophy of the o m e n t u 111 as a 
 r e s II 1 t o f t h e 11 o u r i s h 111 e 11 t i t h a s h a d t o s u p ply to the 
 uterus (Fig. 19). 
 
 H. H., colored, aged twenty-seven, married. Admitted June 24; discharged 
 July 17, 1906. 
 
 Operation, hysteromyomectomy; left salpingo-oophorectomy; right salpin- 
 gectomy. The highest postoperative temperature was 103.2°, twenty-four hours 
 after operation. The patient made a perfect recovery. 
 
 Fig. 19. — Marked Dis.\ppeara.\ce oe the Fat in an Adherent (Jmextum. (s nat. size.) 
 Gyn. No. 13039. Path. No. 10039. The left tube and ovary are normal. The omentum forms a mantle 
 over the posterior surface of the nodular myomatous uterus, between a and a'. In most places nothing but the 
 peritoneal folds of the omentum remain, giving the surface of the uterus a rather wrinkled appearance. Im- 
 mediately around the blood-vessels, however, the adipose tissue still persists, as is well seen at b. 
 
 Path. No. 10039. Tiic uterus has l)ccn aiiiputntcd tiirough the cervix. It is 
 9 cm. in lengtli, 7 cm. in hreadlh. and 7 cm. in ils anter()])()st(>ri()r diaincttM'. 
 It is everywhere covere*! wit h adhesions, and lias a lacework of oiiieiit uin attached 
 to it. The oiiientiini is atrophic to a certain extent . and the fat has ahnost en- 
 tirel\' disappeared, l)Ut still persists on the surface of the uterus, nlonii the course 
 of the blood-vessels (l''i,ii. 19). This fat would in time certainly disai)pear. 
 Scattered throu<ihout the uterus are numerous nodules, some of them not o\'er 
 2 mm. in diameter, others reaching 2..") cm. The uterine cavity is 4 cm. in length. 
 The inuco.sa is hei-e and tiiere gathered up into little domes: in other woi'ds. it 
 shows a tendenc}' toward ])olypoid formation. It vai'ies from 2 to 1 mm. in 
 thickness.
 
 24 MYOMATA OF THE I'TKRUS. 
 
 Histologic exaiiiiiiation shows that the mucosa is practicahy nornuU. In sec- 
 tions from one of the myomata a good deal of hyaline transformation is evident. 
 
 This case exemplifies how the omentum atrophies when it becomes adherent 
 to the uterus. We have the fat disappearing almost entirely except in the im- 
 mediate vicinity of the blood-vessels. 
 
 Path. No. 7925. 
 
 A p a r a s i t i c m y o m a receiving most of its blood- 
 s u J) p 1 y f r o m t li e o m e n t u m ; m a r k e d d i s a p p e a ranee of 
 the omental fat (Fig. 20). 
 
 Mrs. B., PVederick Emergency Hospital, October 30, 1004. The patient was 
 forty-five years of age, and had been under observation six months. On opening 
 the abdomen I found a subperitoneal myoma attached to the anterior surface 
 of the uterus. It had received the greater part of its blood-supply from the 
 omentum. After the omental vessels had been tied off the uterus, which con- 
 tained several myomata, was amputated through the cervix. The ])atient made 
 an uninterrupted recovery. 
 
 Path. No. 7925. The specimen consists of a myomatous uterus with a 
 pedunculated myoma attached to its anterior wall. The uterus is enlarged, 
 measuring 7.5 x 7 x 5 cm. Its outer siu'face is smooth. At the fundus is a sub- 
 peritoneal nodule, 6 nun. in diameter, and another on the posterior wall, 2.7 
 X 2 cm. Projecting from the anterior wall and attached by a delicate pedicle 
 is a large myoma. Attached to the upper surface of this, over a wide area, is 
 omentum. In places this is perfectly normal ; in other places it shows marked 
 diminution in the amount of fat, and at numerous points the omental vessels, 
 now al)solutely devoid of fat, are seen plunging into the tumor (Fig. 20). This 
 is one of the most interesting specimens that we have ever seen, as it clearly 
 shows the various stages of atrophy of the omental fat when the omentum 
 furnishes a parasitic myoma with nourishment. 
 
 Case C. (Hagerstown, Md.). 
 
 A large parasitic m }' o m a ^\■ i t h m a r k e d develop m e n t 
 of the omental ^' e s s e 1 s , some reaching 1 cm. in diame- 
 ter (Fig. 21).* 
 
 C, colored. Seen in consultation with Dr. Scheller at the Washington 
 County Hospital, Hagerstown, on August 4, 1906. The ])atient had had an ab- 
 dominal tumor for five years. The tumor rose al)ruptly, and projected fully 
 18 inches from the general abdominal contour. The vagina posteriorly was 
 greatly encroached upon. 
 
 Operation. On opening the abdomen the tumor encountered was every- 
 where adherent to the anterior abdominal wall and also laterally. Running into 
 
 * Thomas S. CuUen, A Series of Interesting CJynccologic and ()l)stetric Cases, Jour. Ainer. 
 Med. Assoc., May 4, 1907.
 
 PARASITIC UTERIXK .MYOMATA. 
 
 25 
 
 the anterior surface of the tumor from its upper end were blood-vessels, some of 
 them nearly 1 cm. in diameter. They were spread out over an area 16 cm. in 
 
 ■"■-•; — --'"^ 
 
 FlO. 20. — 'rUK (IhADI AI. OlSAIM'KAHANCK OF OmKNTAI, I'AT WhKN THK OmKNITM SkNDS MaNY \' KSSKl.S TO A 
 
 Parasitic Myoma. (Nat. size.) 
 Path. No. 792."). The uteru.-i is about twice the iiiitural size and cotitaiii.s several iiiyoiiiala. .Attached to its 
 anterior surface l)y a short slender pedicle is a sliKhfiy lohulated myoma, and attached to the myoma over a wide 
 area is omentum. .\t a the omental fat still i)resents the usual appearance. .\t b there is atrojjh.v of the fat and 
 the vessels stand out clearly. At c there is still further atro])hy of the omentum, as only immediatel.v around the 
 ves.sels does the fat still persist. At d all semblance of fat has disap|>eared and we see the omental vessels 
 spreading out over the surface of the tumor m- pluiiuinn dircctl\- inlu the depths. 
 
 breadth. Passing:; down the ritilit side of the tumor, and lyiiiii; beneath it, was a 
 regular rope of blood-vessels ( Fii^. 21, b'). These lay perfectly fi'ee from the sur-
 
 P'iG. 21.— A Larce Parasitic Myoma with Huge Vessels Comint; from the Omentum (i nat. size.) 
 The tumor weigher! 18 pounds, and wa.s attached to the uterus by a pedicle. 5mm.x3cm. .\t the top is a broad, 
 omental adhe.sion carrying ves.sels to the tumor. At b' i.s a cros.s-section of a portion of the " rope of omental vessels, " 
 which passed down beneath the tumor to b, and then turned upward again, plunging into the tumor, a rep- 
 resents one of the largest blood-ve.s.sels, which stand out prominently. Crossing these large vessels are numerous 
 adhesions, c is a portion of a vessel which passed down, perfectly free from the omentum, to the under surface 
 of the tumor. 
 
 26
 
 PARASITIC rT?:KIXE MYOMATA. 27 
 
 rounding .structure.^, could be liftt'd up, were covered with peritoneum, and were 
 evidently omental, but no fat was present. These vessels formed a mass 6 cm. 
 in diameter, and looked and felt like small snakes. They could be traced down 
 to the lower end of the tumor, where they spread out over its surface and jjlunged 
 into its substance. One of the vessels, 5 mm. in diameter, passed down by itself 
 and lay absolutely free (Fig. 21, c). It was isolated for a distance of 18 cm., 
 being devoid of any attachment whatsoever. It had originated in the omentum, 
 extended downward, and plunged into the tumor. 
 
 After liberating the vascular supply I found that the tumor was attached to 
 a small myomatous uterus. The pedicle was 3 cm. in breadth, o mm. in thick- 
 ness, and contained only one blood-vessel of any size. The pedicle was cut and 
 the tmiior delivered. Of the vessels passing from the omentum, as a rule there 
 was one artery to two veins. The artery was about one-third the size of the vein. 
 
 As the patient's condition became rather serious, although she had not lost 
 more than two ounces of blood, we stopped the operation, leaving the myomat- 
 ous uterus and a second myoma, fully 25 cm. across. This also had vessels 
 from the ouKnitum plunging into its uj^per part, and was attached to the uterus 
 by a pedicle 2 cm. in diameter. 
 
 The patie^nt promised to return to the hospital for removal of the uterus as 
 soon as she was in good condition. She kept putting it off, however, until 
 finally, at the end of onc^ and one-half years, she entered the hospital with the 
 abdomen as distended as when first seen. The abdominal scar had given way, 
 and purulent fluid was escaping from the abdominal cavity. There was marked 
 sepsis, and hysterectomy was out of the cjuestion. She got somewhat better, 
 but died after a few months. 
 
 The hardened specimen measured 23 cm. in length, 25 cm. in breadth, and 
 20 cm. in its anteroposterior chameter. It was markedly nodular, very hard, 
 and weighed IS pounds. ]']ven in the hardened s])e('imen some of the blood- 
 vessels were nearlv 1 cm. in diameter. 
 
 Gyn. No. 5784. 
 
 A V e r y 1 a )• g e m y o m a t o u s u t e r u s . w i t h 1 a r g e c o n - 
 g e r i e s of o m e 11 t a 1 a' c s s c 1 s c o \' c r i 11 g its s u i' I' ace: d c n s e 
 adhesions to the b I m d d c i' and numerous ^• e s s e 1 s from 
 t h e b 1 a il d e r s u p p 1 y i n g 11 o u r i s h 111 cut to t h c t u m o r 
 (Fig. 22). 
 
 .\. Jv., coloi-ed, aged foi'ty-li\c, iiiari'icd. Admilted .January 11: discliai'ged 
 Februai'v 1'.), 1S9S. The menses wei'e regular until a yeai' ago. Since then they 
 have been diminishing in amount, and ha\'e occuri'ed at longer inter\-als. ( )n 
 vaginal examination the cerN'ix is found to be small, pressed down by a hard 
 pelvic mass, e^■idently connected with a large tunioi-, which almost completely 
 fills the entii'c abdomen, extending upward to within two inches of the ej)igastri('
 
 28 
 
 -MYOMATA OF THK ITKRUS. 
 
 notch. The luiiior is firm, hard and iinniobilc, and tender only over the sym- 
 physis. 
 
 Ojx'ration, January 15, 189S. Hysteromyomectomy; right oophorectomy. 
 On making the incision I found a hirge tumor filhng the entire abdomen. The 
 uterus had rotated 180° from right to left. Attached to the entire anterior sur- 
 face of the tumor was the omentum, which sent in numerous vessels (Fig. 22). 
 There were also extensive adhesions to the bladder. These contained large 
 
 Fig. 22. — Large Coxgkries of Omental Vessels Supplying Nourishment to a Myomatous I'terus; also 
 N'essels Passing up from the Bladder to the Tumor. 
 Gyn. No. 5784. This picture demonstrates one of the difficult hysterectomies that frequently confront the 
 surgeon. In such a case the incision should be continued upward until free omentum is encountered, and then 
 the vessels should be tied twice on the proximal or colon side and once on the distal side. It is better not to use 
 artery forceps, as the vessels are so friable. In such cases the ureters are often drawn up in festoon fashion along 
 the sides of the tumor by adhesions, and may readily be tied accidentally or cut if extreme care is not exercised. 
 (After Howard A. Kelly.) 
 
 vessels. The uterus was amputated through the cervix. Convalescence was 
 interrupted by a mild attack of salivation after taking calomel. Her highest 
 postoiK'i'ative temperature was 100.8°. She maile a satisfactory recovery. 
 
 Fig. 23. — X Large Myoma E.ntirely Separated from the Uterus and Lying Free in the Omentu.m. 
 Gyn. No. 14709. Path. No. 12618. On opening the abdomen the large myoma, seen in the upper part of the 
 picture, presented. It measured 10 x 13 x 17 cm., and had large numbers of omental vessels coursing over its 
 surface. The omental fat had here to a great extent disappeared, allowing the blood-vessels to stand out sharply. 
 To the right is a long adhesion, to the lower end of which an elongated subperitoneal cyst is attached. Two similar 
 and smaller cysts are attached to the lower and anterior surface of the tumor. .Ml of them are in reality small 
 subperitoneal cysts, similar to those so frequently associated with pelvic adhesions. Protruding from the ab- 
 dominal incision is a small myomatous uterus. Partially enveloping the uterus and the right tube and ovary is 
 the omentum, which is continued upward and envelops the myoma. The large myoma has entirely lost its connec- 
 tion with the uterus.
 
 Ll 
 
 Tig. 2:?. 
 
 29
 
 30 MVOMATA OF THK UTERI'S. 
 
 Gyn. No. 14709. Path. No. 12618. 
 
 A myoma lying free in the omentum (Fig. 23). 
 
 One of the most interesting examples of a jxii-asitic myoma that we have ever 
 encountered was furnished by Case 147(M). The uterus contained several small 
 myoniata. while lying enveloped in omentum was a large myoma which had 
 entirely lost its connection with the uterus. 
 
 Gyn. No. 14709. A. C, colored, aged thirty-seven. Admitted A])ril 0; dis- 
 charged May 2, 1908. On opening the al)d(jmen one of us (Cullen) found a 
 large mvoma pi-esenting. On drawing this out he found it envelo])ed in omen- 
 tum and entirely separated from the uterus (Fig. 23). The tumor was removed 
 with th(! utmost care, the large omental vessels being doubly tied and cut. 
 The small and densely adherent myomatous uterus was then removed. 
 
 Path. No. 12618. The uterus measures 2x5.5x7 cm. and contains several 
 small myomata. The large parasitic myoma measures 10x13x17 cm. Its 
 surface is uneven and nodulai'. It is tii-m in consistency and covered over with 
 omentum. The central jwrtion of the myoma has undergone hyaline degenera- 
 tion, with some li([Uefaction, and there is extravasation of blood. 
 
 Ascitic Fluid Accompanying Uterine Myomata. 
 
 Ascitic fluid is fre(|iiently associated with fibroma of the ovary, but only 
 rarely is there any appreciable amount of free serous fluid accompanying uterine 
 myomata. In seven of our cases a considerable amount of ascitic fluid was 
 detected at operation.* 
 
 In Gyn. No. 978(), in which the rounded myomatous tumor reached to within 
 5 cm. of the umbilicus, the abdomen contained 200 c.c. of fr(>e fluid. A glance 
 at the history will show, however, that other factors were in all probability re- 
 sponsible for the ascites. The patient had a loud a})ical systolic murmur. There 
 was marked edema of the feet and ankles, and the hemoglobin on admission was 
 only 20 per cent., but reached 43 per cent, just before the operation. 
 
 In Case 6272 the uterus contained several subperitoneal myomata and was 
 densely adherent. About three months before operation 1550 c.c. of fluid had 
 been asj)irated from one ])lem-al cavity. About eleven days prior to the opera- 
 tion 8050 c.c. of ascitic fluid had been withdrawn from the abdomen. In this 
 case the cardiac lesion and the accompanying nephritis were probably respon- 
 sible for the accumulation of fluid. 
 
 The free fluid in the abdomen in Cases 641S, 3387, 1383^, 12155, and P., 
 C. H. I. was undoubtedly caused by the presence of the tumor and not by any 
 constitutional impaii'inent . 
 
 In Case 12155 a large jK-dunculated myoma had made a three-(|uarter turn 
 on itself, and the omentum was adherent over an area 14 cm. in extent. Some 
 
 * In Cases 12166, 1218.5, 12678, 12871, a small ainoimt of ascitic fluid was also found. In 
 Case 12)^48, as a result of a mild )>critonitis, tlie abdomen containetl a small amount of free 
 turbid fluid with flakes of fibrin.
 
 PARASITIC ITHHIXK MYOMATA. 31 
 
 of its vessels entering the tunioi' were only 1 mm. in diameter. The alxlomen 
 in this case contained two ounces of clear yellow serum. For a full description 
 of the case see p. 200. 
 
 In Case 6418 the subperitoneal pedunculated myoma weighed 29 pounds 
 and the abdomen contained about 500 c.c. of ascitic fhiid. 
 
 In Case 3387, in which a partially parasitic myoma existed (Fig. 24, p. 34), 
 marked ascites was present, 7000 c.c. of free fluid being found. 
 
 In Gyn. No. 1383^ the omentum was densely adherent to the tumor, and the 
 abdomen contained 14,500 c.c. of straw-colored fluid, and about 2000 c.c. of a 
 clear, jelly-like material, that was scooped out with thc^ hand. The urine con- 
 tained albumin, but no casts. After removal of the tumor the albumin dis- 
 appeared. 
 
 Undoubtedly one of the most remarkable cases of the intimate association of 
 uterine myomata and extensive ascites is furnished by case P. In this case 
 (p. 35) the subperitoneal myoma had been almost completely weaned away 
 from the uterus, and was receiving its chief blood-supply from the posterior 
 surface of the bladder and from huge omental vessels (Fig. 25). The abdomen 
 contained 51,000 c.c. of clear ascitic fluid. 
 
 Cause of the Ascites. — The fluid is clear, straw-colored, and usually limpid, 
 but may coagulate, forming a loose, clear, jelly-like mass. 
 
 As previously mentioned, fibromata of the ovary are usually accompanied 
 by ascites. In these cases the large vessels in the loose ])e(licle are undoubtedly 
 twisted, causing a transudation of serum. That the fibroma is undoubtedly 
 responsible for the fluid is clearly proved l:)y the total absence of free abdominal 
 fluid after removal of the tumor. 
 
 In four of our cases the condition has been an analogous one. The myomata 
 have been ])edunculated, and have received a large part of their blood-supply 
 from the omentum. Partial rotation of the tumor, with twisting of the 
 vessels, had from time to time undoubtedly occurred, and transudation of serum 
 into the abdomen was the natural I'esult. A I'eference to h'ig. 25 will show the 
 slender attachment of the pedunculated myoma, and any latei'al niovemeiit of 
 the patient was undoubtedly accompanied by a partial twisting of the tumoi", 
 shutting off the blood-su))ply of the huge omental Ncssels and favoring the 
 ])ouring out of serum. It is now four and one-half years since the tumor was 
 removed, and although the abdomen, prior to operation, contained 51 liters ot 
 fluid, there has never been any retui'ii of the ascites. 
 
 Cases in which the Myomata were Accompanied by Ascites, in the following 
 cases the i-eader can detei'inine for himself the probable cause ol the tree 
 abdominal fluid: 
 
 Gyn. No. 9786. 
 
 Ascitic fluid associated with a m y o m a tons u t e r >i s . 
 M. B., colored, agi'd forty. Admittetl .bily 15: disch;ii-ged Septembei- 20,
 
 32 MYOMATA OF THK ITERUS. 
 
 1902. The jwticnt coiiiplains of the jji'csciicc of an abdominal tumor and of 
 general weakness. For the last two years sh(> has suffered from weakness, and 
 has had numerous fahitino; sjh'IIs. shortness of breath, and swellino; of the feet. 
 Her weakness she attributes to a profuse menstrual flow. The tumor was first 
 noticed af)out a >'ear aii'o. M this time it was the size of a baseball. The 
 j)atient is exeeedingly anemic, and shows })uffiness around the eyes, a loud sys- 
 tolic mui'imu', marked edema of the feet and ankles, and a hemoglobin of 30 
 pel- cent. 
 
 She was at once ])ut to l)ed, given iron and strychnin, and kept as much as 
 possible in the open air. She im])roved rapidly. On August 14th she had her 
 usual ])eriod, which was profuse. At this time the edema of the ankles and 
 ])uffiness of the eyes had entirely disa])peai'ed. Her hemoglobin I'eached 43 
 per cent. 
 
 Operation, hysteromyomectomy, August 26, 1902. When the abdomen was 
 opened, about 200 c.c. of free fluid were foimd and a rounded soft tumor about 
 the size of a fetal head. Hysteromyomectomy was done, and the patient made 
 a satisfactory recovery. At the time of her discharge, on September 20, 1902, 
 her hemoglobin had reached 52 per cent. She had recovered almost entirely 
 from her weakness and had no further symptoms. 
 
 The ascitic fluid in this case was apparently due directly to the general 
 weakened condition and to the low hemoglobin. Of course, indirectly, the 
 weakness had been pi'oduced to a great extent by the continued loss of blood 
 occasioned In' tiie myoma. 
 
 Gyn. No. 6272. Path. No. 2530. 
 
 Ascitic fluid associated wit h u t e r i n e m y o m a t a . 
 C h r o n i c nephritis; in i t r a 1 i n s u fh c i e n c y. 
 
 B. S., colored, aged thirty-six, single. Admitted July 27; discharged August 
 2S, 189S. This patient was admitted to the gynecologic department from the 
 medical service on July 27th. In A))ril loot) c.c. had been withdrawn from the 
 pleural cavity, and on July 16th, 8050 c.c. of ascitic fluid from the abdomen. 
 The patient's last menstrual period had occurred in November, 1897. On 
 admission to the gynecologic service a diagnosis of uterine myomata, chronic 
 ne])hritis, and mitral insufhciency was made. 
 
 Operation, July 27, 1S9S. Hysteromyomectomy with I'emoval of the ai)})en- 
 dages. The posterior surface of the uterus was densely adherent to the l)i'oad 
 ligament and pelvic floor, and both tubes and ovaries were buried in adhesions. 
 The bladder on the left sitle was adherent to the uterus, and there was a con- 
 siderable amount of cystic pelvic peritonitis in t he cul-de-sac. The apjiendix was 
 adherent to the right ovary, lying under the tumor. The highest postoj^erative 
 temi)erature was 103.2°. The ])atient made a .satisfactory recovery. 
 
 Path. No. 2530. The specimen consists of the enlarged uterus, with 
 the tubes and ovaries intact. The uterus is aj)j)r()ximately 18x14x15 cm.
 
 PARASITIC I'TERIXK MVO.MATA. 33 
 
 The increase in size is due to tlie })i'esence of sul)|)eritoneal interstitial and sub- 
 niucous myomata. Coverinii the anterior and posterior surfaces are numerous 
 adhesions. The uterine cavity is 6 cm. in length and its mucosa is much atro- 
 phied. The chief interest in this specimen is centered in the subperitoneal 
 myoma, 7 cm. in diameter. This, on section, presents the usual myomatous 
 appearance, save over an area measuring 3.5x2.5 cm. Here large, irregular, 
 cyst-like spaces are present, the walls of which are very delicate. Extending 
 across them are fine tral^'cuhp. Clinging to the walls, and ])artly filling the 
 cavity, are quantities of l)lood. The appendages are covered with adhesions. 
 
 Histologic Examination. — The walls of the cyst-like spaces are composed of 
 hyaline myomatous tissue, totally devoid of nuclei. The inner surface of the 
 cysts have no lining. They are covered with blood. These cyst-like spaces, 
 therefore, are nothing more than areas in which the hyaline myomatous tissue 
 has undergone liquefaction, followed by hemorrhage. 
 
 In this case the myoma may have had a causal relation to the develo})ment 
 of ascitic fluid, but the nephritis and the mitral insufficiency were undoubtedly 
 directly responsible for the pouring out of the fluid into the abdominal and 
 pleural cavities. 
 
 Gyn. No. 6418. 
 
 Ascitic fl u i d associated with a uterine m y o m a . 
 
 M. W., colored, aged thirty-nine, married. Admitted October 9; discharged 
 November 7, 1898. The patient has never been pregnant. Her menses began at 
 seventeen, were regular, lasting five or six days, and associated with considerable 
 pain until the last three or four months. The tumor was noticed three years 
 ago. Latterly she has had shortness of breath. The abdomen is greatly and 
 irregularly distended. 
 
 Operation, October 12, 1S9S. Hysteromyomectomy. The large dense mass 
 was liberated and brought out. It was attached to the uterus by a pedicle 2 cm. 
 broad. As the tumor was draw out, aljout 500 c.c. of ascitic fluid escaped. The 
 tumor was liberated from left to right in the usual way. It weighed 29 pounds. 
 The free oozing in the pelvic floor was checked with numerous sutures. The 
 right ureter was about twice the natural size. The highest postoperative tem- 
 perature was 100.2°. The patient made a satisfactory recovery. 
 
 In this case the myoma seems to have been the cause of the ascitic fhiid. 
 
 Gyn. No. 3387. Path. No. 641. 
 
 Ascitic fl u i d a s s o c i a t e (I with a large 111 y o 111 a I o u s 
 uterus. One ]> e d u n c u 1 a 1 e (1 in y o ni a i' e c e i v e d p^rl ol its 
 n o u r i s h m e n t f r o m the o 111 e n I u in ( l-'ig. 21). 
 
 M. S., white, aged thirt>-t\vo, mnn-ied. .\(lmitte(l Maivli 20: discharged 
 April 27, 1S95. The patient has been ninrrieil Iwelve yeai's and has had two 
 children; no miscarriages. The menses wei-e i-egulai' until an attack of typhoid 
 3
 
 34 
 
 MYOMATA OF THE UTERUS. 
 
 fever, one year ag(3. Since then they have been somewhat irre<i;iihir and the 
 flow is free. 
 
 Soon after the birth of the youn<iest child, live years ago, she noticed a lump 
 the size of a hen's egg in the midline of th(> lower abdomen. About eighteen 
 months ago her abdomen began to increase in size, and has been gradually en- 
 larging up to the present time. When she turns, the mass seems to move from 
 side to sitle, and then^ is pres(mt a constant dragging sensation, with occasional 
 sharp })ains, especially on the right side. 
 
 The abdomen is distended by several distinctly palpable tumors. Some of 
 
 these give a definite ballottement 
 and there is marked distention of 
 the abdomen with ascitic fluid. The 
 ballottement is easily obtainable 
 with two large masses. The cervix 
 is jannned down to the pelvic floor 
 by the tumor. The urine is normal. 
 Operation, March 23, 1895. Hys- 
 teromyomectomy. After the inci- 
 sion, 7 liters of ascitic fluid were 
 evacuated. One of the large pe- 
 dunculated nodules had four large 
 omental vessels entering it (Fig. 24) . 
 These were tied and separated. The 
 highest postoperative temperature 
 was 100.3° on the second day. 
 
 Path. No. 641. The uterus 
 measures 14 x 17 cm. It is smooth 
 ^ „ ^ ,, ^ „ and glistening. Springing from its 
 
 Fig. 24. — Omental Vessels Supplying a Subperitoneal _ o i <-t l 
 
 Pedunculated Myoma, and Associated with 7000 autcrior SUrfaCe is a globular Uodule, 
 CO. OF Ascitic Fluid. n n o Tj- • 4-^ U i i 
 
 ^ ^, . , ., , 9x9x8 cm. It is attached by a 
 
 Gyn. No. .3387. Path. No. 041. The uterus measured ... . 
 
 14x17 cm. .\ttached to the fundus are two pedunculated ])edicle 1.5 CUl. ill length, 3 ClU. in 
 invomata, one of which has several omental vessels entering i i.i ^^ • ■ v ii r i 
 
 it." On palpation one of the vessels gave a definite bailotte- Ijl-^'^dth. Springing irolll the fuuduS 
 nient. The abdomen contained 7000 c.c. of clear fluid. ^g another IX'duilCulatC^d Uodule ir- 
 
 regularly oval, and measuring 10 x 8 
 x 6 cm. The entire left lateral wall of the uterus is occupied by a tumor 
 10 X 7.5 X 6 cm. It is oval in shape, regular in outline^, and has a secondary 
 nodule, 2 x 2 x 2.1 cm., springing fi'om its imder surface. The uterus, on sec- 
 tion, is found to contain numerous interstitial and some submucous nodules. 
 The uterine muco.sa is smooth and glistening, and apparently much atrophied. 
 The tubes and ovaries on both sides are normal. 
 
 Histologic Examination. — The uterine mucosa is atrophic, but otherwise 
 normal. All the tumors consist of fibers, most of which are cut transversely. 
 The tissue is rather lax and shows a slight amount of hyaline degeneration.
 
 PARASITIC UTERINE MYOMATA. 35 
 
 In tlii.s case the oiuciital vessels <i;i'()\viiig into the sul)])entoneal and peduncu- 
 lated niyonia were a})i)arently the source of the ascitic fluid. 
 
 Gyn. No. 1383^. 
 
 A 1 a r g e q u a n t i t y of ascitic fl u i d a s s o c i a t e d with 
 a }3 a r t i a 1 1 y p a r a s i t i c u t e r i n e ni y o ni a . 
 
 R. G., colored, aged thirty-four, married. Admitted May 12; discharged 
 July 5, 1892. The patient has been married eighteen years, but has never been 
 pregnant. For the j^ast two years she has had pain in the left ovarian region, 
 steadily growing worse. In December, 1891, her abdomen commenced to swell. 
 About two years ago she noticed that her feet and ankles were edematous. 
 The abdomen is uniformly distended. The urine contains albumin, but no 
 casts. 
 
 Operation, May 16, 1892. Hysteromyomectomy. When the abdomen was 
 opened, about 14,500 c.c. of clear straw-colored fluid escaped, and later about 
 2000 c.c. of clear, jelly-like material were removed with the hand. The myomat- 
 ous uterus rose from the pelvis and extended about 8 cm. above the umbilicus. 
 The omentum was intimately adherent to the upper and anterior s\u-face of the 
 tumor. Hysterectomy was performed. The temperature gradually rose to 
 102° by the tenth day, and then fell to normal. It again reached 102.6° by 
 the twenty-seventh day, when there w^as some pulmonic dulness. The albumin 
 disappeared entirely after operation. The patient left the hospital on July 
 8th, but she still had some fever. 
 
 P. C. H. I.* 
 
 A p a r t i a 1 1 y p a r a s i t i c myoma, a s s o c i a t e d ^^• i t li 51 
 liters of ascitic fluid (Fig. 25). 
 
 P., aged fifty-four, white, single. Admitted October 29, 1902, complaining 
 of marked abdominal enlargement. Her face was drawn and pinched. She 
 was exceedingly thin; the al)domen was tremendously and uniformly distended. 
 From the ])ubes to the sternum in the midline there was dulness. and on ]u'rcus- 
 sion a very distinct wave of fluctuation was easily detected. 
 
 A diagnosis of ovarian cyst was made, and after a delay of a few days on 
 account of a slight bronchitis, the abdomen was opened. The peiiloneum 
 was much thickened. The great distention was due to ascitic lluid, ")l liters being 
 removed. Attached to the fundus by a \-ery small ju'dicle was a myomatous 
 nodule 16 cm. long (Fig. 25). Plunging into llie upper or free surface of this 
 nodule, were numerous blood-vessels, each about ;^ (ir I iimi. in diameter, torluous, 
 and closely resembling angle-worms. On being ti'aced ujiward, they proved 
 to be the large omental vessels. The omentum as such was i-ecdgnized as a 
 fringe, not more than 5 mm. long, projecting from the iowei- edge ol the tran.s- 
 
 * Thomas S. Culicii, .J. A. .M. \.. XovcihIkt lit. 1<)()I, p. l.')l_'. .\ Partially I'arasitic Uterine 
 Myoma, Associated witli .'>! Liters of Aseitie Fluid.
 
 36 
 
 MYOMATA OF THK ITHRIS. 
 
 verse eoloii. The altei'ed omental \-essels were exceediiitily friable, and ruptured 
 on the sliiihtest manipulation. The pai'asitie myoma derived part of its hlood- 
 su])j)ly from the bladder, to which it had become inthnately attached. After 
 tying off the blood-supply of the myonui the growth was easily removed and 
 the patient made a satisfactory recovery. 
 
 Fig. 25. — A Partially Parasitic Uterine Myoma Associated with 51 Liters of Ascitic Fluiu. 
 .\ttached to the fundu.s by a narrow pedicle is a subperitoneal myoma. Plunging into the edge of the myoma 
 are the omental vessels. The omental fat has almost entirely disappeared. The myoma was intimately blended 
 with the posterior surface of the bladder, from which it received a good deal of nourishment. The abdomen is 
 markedly distended with a,scitic fluid. The small intestines were effectually held back by the tumor and the 
 omental vessels. (After Thomas S. Cullen.) 
 
 March 1, 1007: The patient is at the present time in good health, and there 
 has never been any return of the ascitic fluid. 
 
 In this case we had to rely entirely on the j)hysical signs, as the patient was of 
 
 Fig. 26. — A Partially Par.vsitic Myoma, Receiving Part of its Nourishment from the Fallopi.^n Tubes. 
 
 (i nat. size.) 
 C. H. I. No. 4'Jo. The uteru.s contains several interstitial inyomata. Attached to the posterior surface of 
 the uterus b.v a short pedicle is a l)road, lobulated myoma. On the left side an artery and vein pass from the 
 outer end of the tube to the anterior surface of the tumor. Tlie branches of the artery sjireatl out over the tumor 
 On the right side is what might be termed an unneces.sarily long adventitious artery, passing from the outer end 
 of the tube to the posterior surface of the tumor, where it plunges into the depth. The accompanying vein clings 
 like a vine to the artery, taking a very tortuous course. The fimbriated ends of both tubes are patent. The 
 left ovary is normal. The right was not removed. The cy.stic spaces near the outer ends of both tubes are 
 probal)ly dilated lynipli-spaces. There is no evidence of pelvic peritonitis.
 
 
 I'n; 26. 
 
 37
 
 38 MYOMATA OF THK ITKIUS. 
 
 unsoiiiul luiiul, and U]) to the day of operation no history could he oljtaincd. 
 The facial expression and the al)d()ininal signs tallied in every particular with 
 those referable to an ovarian cyst, and without the clinical history a correct 
 diagnosis was impossible. The tyni])any in the flanks is, on first thought, 
 ditiicult of exjilanation, but when we i-eiueinber that this myoma, with the omental 
 vessels attached, stretched almost the entir(> length of the al)domen, it is readily 
 seen that the small intestines were held l)ack and at the same time forced out 
 laterally. I'nder any circumstances there would have been dulness over the 
 entire antei'ior abdomen, as the intestines, even if not held back by th(> tumor 
 and omental vessels, could not have reached the surface, their mesentery not 
 being long enough. A\'e know of no instance in th(> literature in which such 
 a hirge ([uaiitity of ascitic fluid was ass(X'iated with a myoma. 
 
 A Partially Parasitic Myoma, Receiving Part of its Blood-supply 
 FROM the Fallopian Tubes. 
 
 In this case (Fig. 26) the uterus was slightly enlarged and contained several 
 small myomatous nodules. Projecting from the posterior surface was a broad, 
 lobulated subperitoneal myoma attached by a small pedicle (a). Passing 
 into the anterior surface of the myoma was a small artery from the left tube, 
 and into the posterior surface of the tumor a large artery from the right tub(\ 
 This artery was very long, and lay perfectly free in the abdomen. Coiled around 
 it was the accompanying vein. There were no omental adhesions. The fimbri- 
 ated ends of both tul)es were normal, hence it is at first glance difficult to explain 
 how the tul)al vessels ever reached the myoma. AVhile the myoma formed 
 an integral part of the uterus, delicate adhesions evidently formed between the 
 outer ends of the tubes and the myoma and, as the myoma became more and 
 more pedunculated, the uterine blood-supply diminished and the tubes gradually 
 sent in vessels to the myoma through the existing adhesions. 
 
 From a clinical standpoint, the case is interesting because if the jK'dicle had 
 become still more attenuated and had been finally severed, the myoma would have 
 been entirely supported by the large tubal vessels; then any sudden jolting might 
 readily have caused a rupture of one of the adventitious vessels and a fatal hemor- 
 rhage have followed. 
 
 C. H. I. No. 495. 
 
 L. C. B., aged thirty-six, married. Seen in consultation with Dr. P. B. 
 Norment, and admitted March 12; discharged April 2, 1905. The patient has 
 never been pregnant. For the past month there has been dull ])ain down the 
 right side of the abdomen. Otherwise the ])atient feels })erfectly well, and it 
 was not until eight days ago that she noticed the tumor. 
 
 Operation. March l.'Jth, hysteromyomectomy, with removal of the uterus, 
 both tubes, and the left oN'aiy. When the abdomen was opened, a most unusual 
 picture was seen (Fig. 2()). Several greatly twisted l)lood-vessels lay perfectly 
 free on the surface of the tumor and between the tubes and ovaries on both
 
 PARASITIC ITKRIXK MVO.MATA. 
 
 39 
 
 sides were cysts with very thin walls, which api)eared to be dilated lymphatics. 
 The uterus was renio\'ed in the usual way from left to right. The highest 
 postoperative temi)erature was 100.4° F. 
 
 A Parasitic Myoma Situated at the Pelvic Brim Fig. 27 and Receiving its Entire 
 
 Blood-supply from the Superior Mesenteric Vessels, from the 
 
 Peritoneum, and from Appendiceal Adhesions. 
 
 This is the second case in our series in which the myoma had become entirely 
 separated from the uterus. (See Fig. 23, p. 29.) It lay just above the pelvic brim, 
 
 Fig. 27. — A Parasitic Myoma in no way ("eNNi;c-Ti;i) with the Uterus. 
 Gyn. No. 9540. This myoma was attached to the peritoneum over the right ureter and the large ve-^sels. It 
 had received the greater part of its nourishment from vessels which appeared to be derived from the superior 
 mesenteric artery; it was also firmly adherent to the appenilix. For the appearance of the myomatous uterus 
 see Fig. 28. 
 
 and great care had to be exercised during its removal to avoid injury to the 
 ureter and the neighboring vessels. The nourishment appeared to lia\c come 
 from the arteries supplying the small bowel. 
 
 In this case the uterus was about three times the natural size (Fig. 2S) and 
 contained several myomata. All the appearances at operation indicated that 
 the myoma had originated in the uterus and hml latei- engrafted itself on to the 
 tissue at the ])elvic brim.
 
 40 
 
 :my()Mata of thk uterus. 
 
 Gyn. No. 9540. 
 A'. H.. coloivcl, aged f()i1y-()ii(\ Admitted Ai)ril 7: dischariicd May S. 1902. 
 The j)aticnt complains of pain in the abdomen toward the end of the menses, 
 and of an abdominal tumor. She has had two children, the youngest twenty-two 
 years of age. fifteen yc^ars ago she first began to have dysmenorrhea and 
 cramps. Two years ago a vaginal section was done for a douljle pyosalpinx 
 (Gyn. No. 6226). Further operation was advised, but refused. For six months 
 the ]iatient was free from pain, but after that the pain returned and during the 
 last two months has been very severe, so that the patient has been confined to 
 bed most of the time. For three weeks she has had difficulty in urination and 
 severe bearing-down pains at the same time. 
 
 Fig. 28. — Mui.tixodular Myomatous Uteris with a L?;ft Prs-TCBr:. {i nat. size.) 
 Gyn. No 9540. The specimen is of interest only as forming the key to Fig. 27. One of the myomatous nodules 
 had evidently become completely separated from the uterus and engrafted itself on to the peritoneum just above 
 the pelvic brim. 
 
 Ojx'ration. Hy.steromyomectomy and appendectomy. A\'hen the abdomen 
 was opened, a myoma was seen lying just above the pelvic brim, absolutely in- 
 de{)endent of the uterus, and attached to the mesentery at the inner side of the 
 cecum (Fig. 27). The uterus was irregularly nodular (Fig. 28) and about three 
 times its natural size. It was amputated through the cervix and removed. The 
 appendix was adherent to the parasitic myoma and was also removed. The 
 l)arasitic myoma had obtained most of its blood-supply from the superior 
 mesenteric ve.s.sels. It was entirely outside the pelvis and in no way con- 
 nected with the uterus. The jxitient made a rather tardy recovery. She was 
 extremely constipated and had vesical irritability. 
 
 On histologic examination the j)arasitic myoma showed extensive hyaline 
 changes, but there were no fui'thei- evidences of necrosis.
 
 pakasitic uterine myo.mata. 41 
 
 Adventitious Intestinal Vessels Furnishing Nourishment to Uterine Myomata. 
 
 Uterine niyonuita, whether coniphctited with ]);ith()l()o;ic lesions in the a])peiRl- 
 ages or not, are prone to develop adhesions, and naturally, where adhesions exist, 
 the intestines may be implicated. As a rule, these adhesions consist chiefly of 
 fibrous tissue, but should the uterine nourishment to the myoma diminish, 
 arteries will occasionally l)e sent from the intestines to the tumor along the 
 already existing adhesions. 
 
 In the accompanying grou}) we mention only the more pronounced cases. 
 
 In Case 6324 (Fig. 30) a large pedunculated myoma si)rang from the posterior 
 surface of the uterus and attached to over half of the anterior surface were dense 
 intestinal adhesions containing many blood-vessels. The intestines furnished a 
 liberal blood-supply to the myoma. 
 
 In Case 9027 a multinodular myomatous uterus received much nourishment 
 from the omental vessels. The intestines were adherent to on(> of the tumors. 
 These adhesions consisted almost entirely of blood-vess(>ls. The main tumor 
 in this case weighed 29 pounds. 
 
 The multinodular myomatous uterus in Case 6774 was wedg(>d in the pelvis 
 by adhesions. The sigmoid flexure was densely adherent to the uterus and 
 furnished the tumor with large adventitious vessels. 
 
 In Case 7226 the patient was in a precarious conditicjn, due to partial intes- 
 tinal obstiiiction caused by the adherent multinodular myomatous uterus. 
 One of the pedunculated myomata was becoming strangulated, through torsion 
 of the pedicle. On exposure the sigmoid flexure was fomid adherent to th(> 
 tumor and sending numerous well-developed vessels to the myoma. 
 
 In Fig. 29 we see numerous vessels passing from th(> rectum to the myoma. 
 The right tube and ovary also seem to furnish their (juota of blood to the tumor. 
 
 In some instances the relation between the pedunculated myoma and th<' 
 intestine becomes very close, and if the myoma undergoes degeneration, with 
 cavity formation, an opening may be established between the cavernous myoma 
 and the intestine. Such a condition existed in Case 9()7S (Fig. 32). The pedun- 
 culated myoma had received ])art of its nourishment fi'om tiie omentum, |>art 
 from the uterus, and the remainder from the cecum. A direct coininunicalion 
 existed between the interior of the degenei-ated myoma and the lumen of the 
 cecum. 
 
 An even more advanced case, somewhat siniihir in character, came undei- the 
 care of Dr. J. Mason Hundley, of the Fniversity of Maryland. The patient had 
 been luidei- the ob.^ervation of anolhei' jjliysician for over two yeai's and a diag- 
 nosis of uterine myoma had l»een made. At o|)eration a ulenis practically 
 normal in size was found. It containe(l a small subperitoneal myoma. Filling 
 the pelvis was tlie i)arasitic cystic myoma seen in l''ig. 33. It had i-eceived its 
 entire nourishment from the small bowel, and had a broken-down cavity in its 
 center. This communicated directlv with the hmien of the gut, allowing the
 
 42 
 
 MYOMATA OF TlIK ITKRUS. 
 
 free passage of fecal matter from the l)owel into the ])arasitic luxUde. The my- 
 oma was attached to the uterus by a few slender adhesions. 
 
 Such a condition is exceedingly rare, and yet the possibility of so serious a 
 complication should not be overlooked. 
 
 i,<Lj. iCrr-^ _ 
 
 Fit; 29. — .\ MvoM V Kkckivixg Mich of its Nourishment from the Rf.ctum and .Apparently from the Right 
 
 Ov.\RY .\ND Tube. (§ nat. size.) 
 C. H. I. No. 18-14. The uterus contained several m.vomata. The largest is posterior to the uterus and was 
 firmly fixed on the iielvic floor. From the fimbriated end of the right tulie and from the inner end of the right 
 ovary many vessels pass to the myoma. Numerous vessels are also seen e.xtending from the rectum to the tumor. 
 
 Gyn. No. 6324. 
 
 A large sub p e r i t o 11 e a 1 ]) e d u n c u 1 a t e d m y o m a , r e - 
 c e i V i n g m u c h of it s n o u r i s h m e n t f r o m the intestines 
 (Fig. 30). 
 
 N. R., colored, aged thirty-six, married. Admitte(l August 26; discharged 
 October 1, LSOS. The ])atient has had an abdominal enlargement for the past 
 six years. She lias had two children, but no miscarriages. 
 
 Operation, August 29, 1898. Hysteromyomectomy. An incision 15 cm. in 
 length was made through thick abdominal walls and a large pedunculated myo- 
 ma found. The upper portion of the tumor and part of its posterior surface were
 
 PARASITIC UTERIXK :\IYOMATA. 
 
 4:^ 
 
 donsoly adherent to the mtesthies. The large timior exteiRU d well iij) iiiuler the 
 costal margin. The enucleation was begun in the ])elvis, by tying oft' the pedicle 
 of the large tumor and of a smaller one on the left side. The tumor was next 
 lifted out of the abdomen, the intestines were covered with warm gauze, and the 
 separation of the tumor and intestines was effected. The intestinal adhesions 
 w^re very dense, and contained numerous quite large blood-vessels. The tumor 
 had evidently received a considerable part of its blood-supply from the adherent 
 intestines. The raw areas were brought together with catgut and the abdomen 
 ^^'as closed. The highest post- 
 operative temperature was 
 101.4° F. The patient made 
 a satisfactory recoverv. 
 
 ^c^ 
 
 ;Sifcs 
 
 & 
 
 Gyn. No. 9027. 
 
 A m u 1 t i n o d u 1 a r 
 m y o m a t u s u t e r u s 
 receiving part of 
 its blood- sup ply 
 from the intestines. 
 
 E. S., colored, aged thirty- 
 nine. Admitted August 30; 
 discharged October 5, 1901. 
 The patient has been married 
 twenty-two years and has 
 had one child. For ten years 
 she has thought that she had 
 an abdominal tumor, but this 
 was only definitely determined 
 three weeks ago. During the 
 last year it has grcnvn con- 
 siderably and she has lost a 
 good deal in weight. At 
 present she is rather pale, l)ut 
 fairly well nourished. 
 
 Operation. Hysteiomyo- 
 mectomy. When the aljd(jnien was opened, a multinodular myoma was im- 
 mediateh' seen. A large jjorlion of its surface was cox-ci'cd wilh adherent 
 omentum and many of llic oiiicnlal vessels cntci'cd directly inio ihc tumor. 
 instead of spreading out on the surface. The intestines wci-e adlieicnt in se^•eral 
 places, and these adhesions consisted niniost entirely of blood-vessels. After 
 the adhesions had been separated, the uterus was i-enioxcd without dilliculty. 
 It weighed 29 pounds. The p.-ilieni was dischai'^'eil in good condition. 
 
 
 Fig. 30. — A Large Suhi'eritonk.\l Peduncui-ated .Myoma, Re- 
 ceiving Much of its Nourishment from the Intestines. 
 Gyn. No. 6324. The large pedunculated subperitoneal nodule 
 .shows a raw area over its upi)er and anterior surface. Here it waa 
 completely covered by intestinal loojjs, which were densely adherent 
 to it. The intestines had sent large vessels into the luinor, as is seen 
 by the cross-sections of arteries and veins scattered throughout the 
 roughened raw area.
 
 44 MY()^[ATA OF Till-: UTERUS. 
 
 Gyn. No. 6774. 
 
 A m y o 111 a tons n t c r n s r c c i v i 11 s; a large adventitious 
 vessel fro ni the s i tj; ni o i d fl c x n r c . 
 
 H. II., white, agetl forty-two, .single. Admitted March 18; discharged 
 April 22, 1899. One sister had had uterine niyomata, another sister an ovarian 
 cyst. The i)atieiit had a soft systolic luurniur in the pulmonic area and at the 
 apex, which was jin^hably hemic. 
 
 Operation, March 20, 1899. A large tumor was found wedged in the pelvis. 
 The mass was gradually lifted and enucleation begun on the left side. There 
 was a hematoma containing 120 c.c. of thick, tarry fluid on that side. On 
 reaching the pelvic floor on th(^ left side dense adhesions were discovered between 
 the tumor and the sigmoid. These were freed with scissors. On cutting them 
 across ami rolling the tumor out it was found that a large vessel passed directly 
 from the sigmoid into the tumor. The o])eration was com])leted in the usual 
 way. The highest postoperative temperature was 100.5° F. 
 
 Gyn. No. 7226. 
 
 A m y o m a t o us u t e r u s v e c e i v i 11 g w e 1 1 - d e v e 1 o p e d 
 blood-vessels from the sigmoid fl e x u r e . 
 
 M. J., colored, aged thirty, single. Admitted September 22; discharged 
 November 4, 1899. 
 
 Operation. Hystero.salpingo-oophorectomy. The operation was complicated 
 by dense adhesions reciuiring a great deal of dissection. There was a cystic 
 myoma, the size of an orange, dark blackish green in color. This lay just in the 
 median line, above the l)rim, and was attached to the tumor propc^r by a pedicle 
 2 cm. long. It had become twisted on itself once and was evidently under- 
 going necrosis. Firmly adherent to this mass at its upper margin were two 
 separate coOs of intestine. The ileum everywhere else above the brim was per- 
 fectly free. The bladder was drawn high up over the nodule. The uterus was 
 removed from left to right. The adhesions from the sigmoid flexure to the 
 tumor contained large well-developed vessels. These were tied both ways and 
 separated. The tissues were exceedingly vascular. (Ireat difhcully was ex- 
 perienced in liberating the bladder, and the utmost care was exercised to avoid 
 injuring the ureters. In this case a second operation was necessary on accomit 
 of kinking of the ileum causing partial obstruction. The patient was in a very 
 weak condition. The tumor weighed 14 pounds. She gradually recovered. 
 
 Path. No. 348(). The specimen consists of the enlarged uterus, with 
 its appendages. The uterus is nodular, apjiroximately 13 cm. in diameter. 
 Attached to its surface are muuei-ous vascular adhesions. Springing fi'om it are 
 several pedunculated and sessile nodules. The largest pedunculated tumor, 
 both in shape and size, bears a strong resemblance to a spleen (Fig. 31). It 
 measures 12 x9 x 7 cm., and is attached to the surface of the utems by a delicate
 
 PARASITIC UTHRIXE MYO.MATA. 
 
 45 
 
 pedicle, 1.5 x 0.7 cm. On section, the s])leen-shaped nodule presents a dark, 
 reddish-brown, glistening appearance and is traversed by fibrous bands of a 
 pinkish color. The uterus contains interstitial nodules varying from a pea in 
 size to 5 cm. in diameter. The largest of these is undergoing necrosis. The 
 uterine cavity is 8.5 cm. in length. The mucosa is smooth and glistening, but 
 not more than 1 mm. in thickness. The right tube is normal. The left tube 
 and both ovaries are covered with adhesions. 
 
 Microscopically, the nodule described as resembling a spleen presents large 
 areas of coagulation necrosis accompanied by hemorrhage. In the degenerated 
 areas the blood-vessels are much dilated. It is only in the outlying portions of 
 the growth — in oth(>r words, in the capsular portion — that the typical myoma- 
 tous tissue is preservetl. It was this myoma that had 
 twisted and was undergoing degeneration. 
 
 Gyn. No. 9078. Path. No. 5234. 
 
 Multinodular myoma t o u s u t e r u s 
 \\- i t h a subperitoneal pedunculated 
 nodule, j) a r t i a 11 y parasitic, under- 
 going suppuration and communi- 
 cating with the cecum (Fig. 32). 
 
 E. C, white, aged thirty-six. Admitted Sep- 
 tember 21; discharged October 30, 1901. (For the 
 patient's former admissions to the hospital see Nos. 
 7315 and 8992.) Complaint: abdominal tumor and 
 uterine hemorrhage. The patient began to menstru- 
 ate at fifteen, was always regular, with a ])rofuse flow 
 lasting at least seven days. She had a miscarriage 
 nine weeks before admission, and since that time she 
 has had constant bleeding. She has been married 
 sixteen years and has had two children, fifteen and 
 ten years respectively. Two years ago she was 
 
 admitted to the hospital and an ether examination was made. At that time 
 three myomata w(>r(> detected. For some time before this the patient had shai p 
 pains in both groins. Following the ether examination the patient feh \-ei\- well 
 until she became pregnant in April. Since then slie has had bearing-down jtains, 
 aching and throl)bing. These pains became much more severe at the time of her 
 miscarriage and liave continued since. She has lost 30 pounds in weight during 
 the last six months. 
 
 On examination she is not very \k\\(\ despite the history of heniovriiages. 
 The hemoglobin is 50 percent. 
 
 Operation. Ilysteromyomectoiny, right o(")phorectomy, appendectomy, sului'e 
 of cecum. The patient during the o])eratioii was in such a pi'eearious condition 
 that ether had to be dis{'ontinue(l. The fundus was found nuslied somewhat to 
 
 Fig. 31. — A Si'lkkn-shai'kd My- 
 oma. 
 Gyn. No. 7226. Path. No. 34Sti. 
 This myoma had undergone tor- 
 sion. It showed areas of necrosis 
 and had become adherent to the 
 intestinal loops.
 
 46 
 
 MYOMATA OF TUK UTERUS. 
 
 the right l)y an intraligaiiicntary iiiyoina. To the right was a second myoma 
 rising from the cornii, covered by omentum and very adherent. From this 
 a thick fil)rous hand })assed to the small bowel. The myoma attached to the 
 right cornii had a rather pale gray color and looked necrotic. Its pedicle was 
 very long and was easily twisted oft' from the uterus without any bleeding, the 
 tumor api)arently having drawn its l;)lood-supi)ly from the omentum. It rested 
 on the head of the cecum but was not very adherent to it, and during the at- 
 tempt to separate the adhesions an opening, o mm. in diameter, was detected 
 
 
 -'^"^ 
 
 Fig. 32. — \ Suppurating Subperitonkal Myoma Communicating with the Lumen of the Cecum. 
 C'lyn. No. 9078. Path No. 52.34. The uterus is somewhat enlargeil, owing to the jiresenee of a myoma, 
 which projects into the left broad Hgameiit. Attached to the fundus near the right t\il)e is a i)e<lunculated myoma, 
 which mea-sured 7x5 cm. Plastered to its surface and furnishing considerable nourishment is the densely ad- 
 herent omentum. The center of the myoma contained an abscess cavity which opened directly into the cecum. 
 The myoma has been dissected free from the cecum, so that the opening is clearly seen at a. 
 
 reaching from th(> cecum to a cavity in the tumor (Fig. .32). The remaining 
 adhesions were freed and the myoma was removed. The right tube and ovary 
 and ajipendix were brought into view. The apjiendix was buried in more or 
 less necrotic tis.sue along the head of the cecum. It was gradually dissected out 
 and its stump cut off flu.^h with the wall of the cecum and then this and the 
 fistulous tract were turned in with nuiiierous buried silk sutures. Enucleation 
 of the uterus from left to right was rather easily carried out. A gauze drain was 
 left in and carried down to the head of the cecum. The ])atient gradually 
 recovered and left the hospital in good condition.
 
 PARASITIC UTERIXK MYoMATA, 
 
 47 
 
 Path. No. 523 4. The spcciincn consists of a suhjH'ntoneal myoma, 
 which was partially ])arasitic and ojjcncd into the cecum. The tumor is ovoid 
 in shape, 7 cm. long, 5 cm. in its broadest diameter. Its surface is rough, and 
 shows innumerable small tags of adhesions. At one ]X)int the old pedicle can 
 be made out. Attached to the tumor is a considerable amount of omentum, and 
 to the feel the tumor is yielding. On section a firm fibrous capsule, 3 mm. thick, 
 is evident. Inside this the tissue is less firm, yellowish in color, and apparently 
 undergoing degeneration. 
 
 Another portion of the specimen consists of the uterus and adherent tumor, 
 both tubes, and the right ovary. The mass measures 11 xS cm. The intraliga- 
 mentary myoma on the left 
 side measures 7x7x5 cm. 
 The left tube is uniform in 
 diameter, 13 cm. long, and at 
 its distal portion has been con- 
 verted into a small cyst . On the 
 right side the tube and ovary 
 are closely bound together. 
 
 Histologic Examination. — 
 The necrotic myoma whicli 
 communicated with the bowel 
 has broken down and is in- 
 filtrated with polymorpho- Fig. .33.— a Mvoma Reckivinc. its Nourishmknt from the 
 
 nuclear leukocytes and small mesexterv op the smal. bow^. and coktainikg an- abscess 
 
 •^ Cavity which Communicated with the Lumen of the 1n- 
 
 round cells. It shows evi- testine. 
 
 dence of chronic inflamma- ^'■':'^^'''^"'''''"'- -rt^lr^'-^^^t^J^ 
 
 myoma at one time was uterine. The uteru^^ wa.s nearlj normal in 
 
 tion. The appendix is the size and projecting from its surface was a small myomatous mxlule. 
 
 „ , . ]••<-• ^^'^ parasitic myoma measured 12 cm. in diameter and was at- 
 
 Seat of a chronic appendicitis. tached to the uterus by a few adhesions. It received nearly all of 
 
 its blood-supply from the mesentery of the small bowel. Its central 
 portion had been converted into an abscess cavity 10 cm. in diameter, 
 which communicated with the lumen of the bowel by an opening 
 2 cm. in diameter. The fecal matter passed freely into aii.l fmm the 
 myoma, as indicated Viy the arrows. 
 
 a 11 d () p e 11 1 11 g 
 
 into t li e 
 
 D r. J. Mason Hund- 
 ley's case of a pa r a - 
 s i t i c m y o m a u ii d e r- 
 going sup |) u rati o n 
 small bowel (Fig. 33). 
 
 M.E.C., white, aged thirty-nine, single. She was never robust, but had no 
 serious illness until July, 1900. In this year .she began to have irregular uteriiu" 
 hemorrhages, which were very jirofuse. She had a sinking s|)ell and from that 
 time gradually grew weak and lost flesh. In March, l'.)()3. she had a fall, and the 
 injuries sustained necessitated lier icni:iining in bnl I'oi' several weeks. While 
 in bed she passed a numbei' of large bloody stools, had fever aiul chills, ami 
 suffered with abdominal p;iin. 
 
 Adiagnosis of tuinoi- of the uterus had i)e<'n made in l'"el)ruar>-. VM)'!. and again 
 in 1004. An operation was not advised, as it was thought that the tumor would
 
 48 MVo.MATA OF THK ITKRUS. 
 
 cease to give trouhlc. Dr. Iluiullcv saw the ])ati('iil on Deceinlier 5, 1904, and 
 advised operation. 
 
 Operation. T)eeenil)er 12. 1904. The luiiior seemed to be adherent every- 
 where, Init in reahty it was attaehed to the uterus merely by a few slender 
 adhesions. It had a))pai'ently originated in tlie ])osteri()r wall of the uterus. 
 Its bloo(l-supi)ly was now derived from a portion of the ileum (Fig. 33), which 
 supplied vessels as large as the radial artery. The lumen of the adherent portion 
 of the bowel comnuniicated with the cavity in this tumor, and the cavity in the 
 myoma contained grape-seeds and fecal matter. About five inches of the bowel 
 were resected. The i)atieiit died thi-ee (la\'s later, but at autopsy there was no 
 evidence of infection. 
 
 The i)ai"asitic cyst is 12 cm. in diameter and the cavity in its longest diameter 
 is 10 cm. The cavity connnunicated with the lumen of the gut b}' an opening 
 2 cm. in diameter. Its walls are soft and ulcerated. The growth received 
 a rich blood-supj)ly from tlie intestine. Sections from numerous areas of 
 the abscess wall show that it is composed of very dense myomatous tissue. 
 It is va.scular and highly inflamed. There is no evidence of sarcomatous trans- 
 formation. The intestinal walls near the attachment of the growth show an 
 extensive inflammatory process and marked vascularity. 
 
 In this case it is difficult to say with absolute certainty how long the myoma 
 had connnunicated with the bowel, but the passage of a number of large bloody 
 stools in 1903, accompanied by the elevation of temperature and pulse, strongly 
 indicates that there was an opening between the two at this period. 
 
 ADVENTITIOUS VESSELS FROM THE BLADDER SUPPLYING NOURISHMENT TO 
 
 UTERINE MYOMATA. 
 
 One of the first questions the surgeon asks himself before making an abdominal 
 incision when a myomatovis uterus exists is, ''Is the bladder high up?" This 
 dislocation of the bladder is fully dealt with in another (•ha])ter, and here we are 
 chiefly interested in the l)lood-sup{)ly that the bladder or its arteries may furnish 
 to a neighb(iring myoma. In our series only seven myomata derived any 
 appreciable amount of nourishment from the bladder. 
 
 In Case 12194 a large multinodular uterus was present. The ovarian and 
 uterine blood-vessels were greatly distended. Rising from the anterior portion 
 of the uterus was a myoma with little or no uterine attachm(>nt. It apparently 
 derived its blood-.supply from the tissues surrounding the l)la(lder. 
 
 In Case 7739 a tumor filled almost the entire abdominal cavity. Much 
 nourishment was furnished by the omentum, but a portion was contributed by 
 very vascular adhesions from the bladder and from the anterior and left lateral 
 abdominal wall. 
 
 The bladder in Case 3842 was so intimately attached to the tumor that a 
 piece 1x6 cm. was excised with the growth. In this case omental and in- 
 testinal adhesions also existed.
 
 PARASITIC UTERIXE .MYOMATA. 49 
 
 Prolxil)lv the most extensive vesical ])l()()d-su|)])ly to a myoma that one is 
 likely to encounter was noted in Case P. (Fig. 25, p. o()). Here the bladder was 
 drawn high up into the abdomen, and from its posterior surface many large and 
 tortuous vessels passed to the tumor. 
 
 In Case 578-4 (Fig. 22, p. 28) the l)ladder supplied its (juota of blood to the 
 myomatous uterus. Here there were large tortuous vessels emerging from the 
 pelvis and entering the tumor. 
 
 In Case 6915 the bladder also apparently supplied many vessels to the en- 
 larged uterus. In one of our recent Hagersto^A7i cases (Fig. 34) numerous vessels 
 passed from the bladd(>r to two subperitoneal myomata. 
 
 Gyn. No. 12 194. Path. No. 8776. 
 
 A multinodular m y o m a t o u s u t e r u s with one of its 
 nodules d e r i a' i n g its chief b 1 o o d - s u p }) 1 y from the 
 tissues surrounding t h e b 1 a d d e r . 
 
 S. C, colored, aged thirty-nine, married. Admitted June 19; discharged 
 July 28, 1905. 
 
 Operation, June 21 , 1905. Hysterectomy, double salpingo-oophorectomy, and 
 appendectomy. The large myomatous uterus was easily delivered. One nodule 
 rose from the posterior part of the fundus and was about the size of an adult's 
 head; another had originated from the anterior part of the uterus low down 
 near the cervix. This had drawn the bladder reflection of the i)eritoneum high 
 up over the tumor mass. All the pelvic vessels were greatly distended. The 
 uterus was removed in the usual way. The tumor arising from the anterior 
 part of the uterus was nearly, if not entirely, parasitic. Its connection with the 
 uterus itself was very slight. It had derived its blood-supply a])})arently from 
 the tissue surrounding the bladder. 
 
 The highest postoperative temperature was 100° F. 
 
 Gyn. No. 7739. 
 
 A m u 1 t i n o d u 1 a r m y o m a t o u s uterus w i t h dense 
 omental a d h e s i o n s , also v e r y v a s c u 1 a r a d h e s i n s 
 fro m t h e b 1 a d d e r a n d f r o m t h e a 11 t e r i o r and left lat- 
 eral a b d o m i n a 1 w alls. 
 
 M. R., colored, aged twenty-nine. man-ic(l. ()i)erali()n. Hysterosalpingo- 
 oophorectomy and i-emo\al of tumor of the i-iglit ovaiy. The abdomen was 
 nearly filled with a large solid tumor. The omentum was everywhere adherent. 
 Some of the vessels were the size of a little linger and looked just like large worms. 
 The tumor was adhei'ent to the bladder, the antei'ior and left lateral alxlominal 
 walls. These adhesions were exceedingly vascular. The patient was well when 
 discharged.
 
 50 
 
 MYOMATA OF THE I'TKRUS. 
 
 Gyn. No. 3842. 
 
 D (.' 11 s (> :i (1 h (• s i n s b c t w e e n t he hi a d d c r a 11 d a in y o - 
 III a tons II t I' r II 8 . 
 
 ]■]. \\., colored, -dgcd lifty-two, inarricd. Admitted October 2; discharged 
 November <), 1S95. ()])erat ion October 10, 1895. Hysteromyomectoiiiy. The 
 hirge myomatous uterus liad drawn the bhulder almost to the umbilicus. The 
 adhesions between the tumor and the bladder were so dense that a piece of 
 bladder 1 x (5 cm. was excised, and the wound closed with four mattress sutures. 
 There were also adhesions to the omentum, intestines, and rectum. The patient 
 was Avell when discharged. 
 
 Fig. 34. — PEDr.NCUL.\TKi) Myomata Receiving a Large Part of Their Nourishment from the Bladder. 
 C. G., seen in consultation with Dis. Preston and Victor Miller at the Hagerstown Hospital, June 14, 1907. 
 Pa-ssing from the bladder to the two myomata, and hiding the fundus, were broad adhesions (a) carrying large 
 blood-vessels. Adhesions and blood-vessels (b) also passed from one tumor to the other. The tumors were 
 attached to the uterus by relatively small pedicles 
 
 C. G. (Hagerstown, Md.). 
 
 Ted u n c u 1 a t e d in y o m a t a r e c e i v i n g a large \) a r t of 
 t h e i r 1) 1 o o d - s u ]) p 1 y f r o m the b 1 a d d e r (Fig. 34). 
 
 C. ('.., coloretl, aged twenty-eight, seen with Drs. Preston and \'ictor Miller, 
 of Hagerstown, June 14, 1907. This patient had a large myomatous uterus. 
 ( )n opening the abdoiiicn we immediately encountered large vessels running 
 fi-oni the bladder into a subperitoneal myoma. In the adhesions there were at 
 least three or four arteries. The myoma itself was the size of a child's head. 
 Immediiitelv behind the uterus was a nodule similar in size, l^'roni this to the
 
 PARASITIC UTERINE MYOMATA. 51 
 
 other nodule passed an artery at least 5 nun. in diameter, also several smaller 
 ones. We liberated the bladder adhesions and did a complete hysterectomy. 
 The patient stood the operation well and made a good recovery 
 
 Vessels from the Abdominal "Wall Furnishing Abundant Nourishment to a 
 
 Partially Parasitic Myoma. 
 
 Myomata not infrequently become adherent to the lateral or anterior abdomi- 
 nal wall; it is, however, unusual to have blood-vessels of any appreciable size 
 passing between the abdominal parietes and the myoma. The following case 
 proves, however, that such a condition occasionally occurs. 
 
 Gyn. No. 15283. 
 
 C. B., colored, aged thirty. Admitted November 13, 1908. Four weeks 
 before entering the hospital she first noticed a tumor in the lower abdomen. 
 On admission her abdomen was found distended by an irregularly nodular 
 mass which reached 4 cm. above the umbilicus. The nodules seemed more or 
 less fixed, but there was no unusual abdominal tenderness on palpation. 
 
 On opening the abdomen, one of us (Kelly) found several very large peduncu- 
 lated myomata. One of them had large lymphatics coursing over its surface 
 and received much blood from the omentum. In addition, vessels passed from 
 the appendix to the large myoma and dense adhesions to the right anterior and 
 lateral abdominal walls furnished many vessels to the tumor (Fig. 35). These 
 vessels were very abundant and paralleled each other from the abdominal wall 
 to the tumor. 
 
 Myomata Extruded from the Uterus and Lying Free in the Broad Ligament. 
 In the foregoing pages we have described subperitoneal myomata that have 
 become partially or completely separated from the uterus. Occasionally a 
 myoma that has been extruded into the broad ligament loses its connection with 
 the uterus and receives a meager blood-supply from the tissue in whicli it lies. 
 The following case is a good example of such a condition. 
 
 Gyn. No. 9674. 
 
 M. McM., white, aged thiit>-seven. Admitted May 27; dischargetl June 
 20, 1902. Menstruation began at tiiirteen, was regular and modei-ate in amount, 
 l^ecently the periods have l^'come irregular, the ])atient sometimes going four 
 or hve months without any nieiislrunl flow. She has been niari'ied eight years, 
 l^ut has never been ])regnant. 
 
 Operation. Kemoval of a pai'asitie niyoinn, i-elense of .-idhesions, multiple 
 myomectomy, suspension of the uterus. When the alxloinen was opened the 
 uterus was found in ret roposition. Thei-e were a few adhesions about the left 
 appcnidages. Beneath the round ligament and in tiie broad ligament was a hard 
 tumor the size of a small egg. It was sligiilly movable. The peritoneum was
 
 52 
 
 MYOMATA OF THK ITKUr.S. 
 
 incised, the tumor shelled out, and the hole left behind closed with eatgut. 
 Two small mvomala of the fundus were shelled out and the incision was closed. 
 
 Vessel* from append 
 
 Tube' 
 
 Rouncl lig't. Ovary 
 
 K 
 
 Fig. 35. — A Multinodular Myomatois Uterus with Vessel.s Passing j-rom the Right Abdominal Wall 
 
 AND .\pPENDIX to A LaRGE PEDUNCULATED MyOMA. 
 
 Ciyn. No. 15283. Path. No. 13199. The multinodular myomatous uteru.s, with its attached pus-tubes, filled 
 the pelvis. The large globular pedunculated myoma was free from omental adhesions, hut was attached to the pa- 
 rietal abdominal wall by broad adhesions. Traversing these were many blood-vessels which passed from the 
 tumor to the abdominal wall. The smaller adhesions also contained vessels, but of less caliber. 
 
 The appendix was adherent, and numerous superficial ai)i)endiceal vessels i)a.ssed over to the myoma. Cover- 
 ing the surface of the ajjpendix were clusters of small, smooth-walled cysts, apparently dilated Ij-mphatics. They 
 were particularly abundant near the cecal junction. 
 
 The myoma in the hroad lifjament had no appai'ciit comicctioii with the ligament 
 itself or with the uterus. The i)atient recovered without incident.
 
 CHAPTER III. 
 
 CERVICAL MYOMATA. 
 
 In a few of our cases the myoniata developed low down in the l^ody of the 
 uterus or in the cervix. Such growths may spread out in front of or behind 
 the cervix,* but arc more prone to separate the folds of the broad ligament, thus 
 becoming in part intraligamentary.t 
 
 
 Fig. 36. — Mydma di- Tiih; Hhoau I,ii;ami:\i and Ckuvix. ( } iiat. size.) 
 Gyn. No. 5752. Path. No. 2055. The irregular myoiiia, 10 x 13 c-iii., fills the left broad liRainent and 
 is in part cervical. In such a case control of the left uterine ve.ssels is difficult. The cervical canal is consiiierably 
 distorted. The appendages are nninial. 
 
 Cervical myoniala arc of inlciTst cliiclly from a clinical stand|»oinl. Tlicy 
 mayso block Ihc pcb'is thai , wlici'c pregnancy exists. ;i normal labor is out of the 
 question and operati\-e measures nnist be undeilai^eii. Thus, in case (!., the 
 
 * Marked c'cr\'icai <l('\'('l()])iiH'nl ol iny(iiii;ii;i was rmicil in Cases '-'Kit. :-!'.l71. lO'JL'. .")7.'>-. 70.")'.). 
 7240, 88GG, 97S0, 979S, tOOod, lOL'IJ, aiul I IJl.i. 
 
 t Iiitraligamcntary (lovcloimiciil was |>ail iciilariy |iniiniiiriit in Cases .'i!t71. 117'-'. I.S7(). 
 4586, 5752, G915, 7181, and 9S2;i. 
 
 53
 
 54 
 
 MYOMATA OF THK ITKIUS. 
 
 pelvis was partly Ijloeked by a inyuiiia that had developed in the anterior wall of 
 the cervix (Fig. 328, p. 532). After abdominal removal of the myoma the 
 ])alieiit. who was four months pi-eti;naiit , proceeded to term and had a normal 
 labor. 
 
 Again, when hysterectomy is necessary, the uterus is often found firndy 
 wedged in the jx'lvis and its removal is fraught with much difficulty. During 
 the shelling out of these tumors exceptional care has to be exercised not to injure 
 or tic one or ))oth ureters, as they are so intimately connected with the tumor. 
 At times it is practically impossible to dislodge cervical myomata without first 
 
 Fig. 37. — A Myoma of the Broad Ligament and Cervix. (§ nat. size.) 
 Path. No. 6920. The uterus is somewhat enlarged, owing to the presence of small myomata. Extend- 
 ing far out into the left broad ligament is a globular myoma. Its lower half is cervical and extends quite a dis- 
 tance below the point at which the cervix wa-s amputated. In such a case it w^ould be best to control the right 
 ovarian vessels, the inght round ligament, and the right uterine vessels, cut through the cervix, and then catch 
 the left uterine vessels. 
 
 bisecting them. Tiie accompanying illustrations will give a clear conception 
 of the various forms (A cervical myomata encountered. 
 
 In Fig. 36 is represented a myoma which fills the left broad ligament and 
 whose lower portion is cervical. Th(> uterus has been distorted and pushed 
 toward the right. 
 
 Fig. 37 also represents a myoma Hlling the left broad ligament. The lower 
 part is cervical, and extends far l)elow the level at which the cervix has been 
 amputated. Naturally, much difficulty may be encountered in controllhig the 
 left uterine vessels in such a case. 
 
 The cervical myoma in Fig. 3S occupies the anterior wall and spreads out
 
 CKUVICAL MYOMATA. 
 
 55 
 
 slightly into both broad ligaments. The cervical mucosa over the anterior 
 wall had become somewhat atrophied as a result of the tension and it will be 
 readily seen that the cervical stump was much bigger than usual. 
 
 In Fig. 39 we have not only a myomatous condition of the fundus, but also 
 a general myomatous condition of the cervix. The various nodules completely 
 surround the small cervix. 
 
 Fig. 40 gives an example of the marked cervical development that may occa- 
 sionally be attained. This patient (Gyn. No. 9798) for a year had had i)ain in the 
 
 M y 
 
 Fk;. :5S. — A ("khvicai. Mvoma. (^ nat. size.) 
 Gyn. No. ;ii)71. I'lith. No. 977. The upper part of the liody of the uterus ami the ap|)ciiihiKe.s are imrmal. 
 Occupying the anterior portion of the cervix and liulRinR into the cervical canal is a myoma, I 1 cm. in diameter. 
 The cut surface of the cervix was naturally larger than usual, being 4.5 cm. in diameter. 
 
 lower abdomen and b;ick;iclic and her jx'fiods had been more profuse and of 
 longer duration than before. Thei'e was fretiueiicy of urination, with almost loss 
 (jf control. The N'aginal \auh w.is occu|)ied by a myomatous eeiAix and the 
 cervical canal was i-epreseiited by a small slit, .\nterioiiy and to the I'ight 
 the mass could be nio\'e(l about, but not ])ushed u|) out of the pebis. rpward, 
 the tumor extended almost to (he umbilicus. A glanci' at the })icturt' shows 
 that the fundus is enlarged, but the chief increase in size is due to an essentially 
 cervical myoma, which has originate(l in the posterior wall and literally un-
 
 56 
 
 MYO.MATA OF THK UTERUS. 
 
 folded t lie cxtcnial os. It wasncccssaiT not only to remove the uterus ('onij)letely, 
 but also to excise with it a portion of the x'a.irinal nuicosa. 
 
 Fiu'. 41 i-e])re.sents a myoma that was lirnily fixed in the pelvis and HMjuired 
 not only much ])atie!ice, hut also rapid work in its i'em()\-al. The tumor 
 had grown from the anterior surface of the uterus and cervix and filled Douglas' 
 sac almost eompletelw In this case the bladder occupied the lower angle of 
 
 Fig. 39. — Ckrvical Development of Myomata. (I nat. size.') 
 Ciyn. No. 97S0. Path. No. 5996. The body of the uterus contained several small myomata and was partially 
 covered with adhesions. The right tube and ovary are adherent. Occupying the lower part of the body, and 
 extending out into the left broad ligament and surrounding the cervix, are myomata. Those on the left siile ex- 
 tend below the point at which the cervix was amputated. The uterus was removed from right to left. The left 
 ureter was exposed for a distance of 5 cm. 
 
 the incision and extended Ki cm. above the symphysis. The blailder was 
 liberated and jmshed down. The left ovarian vessels were ligated, the left round 
 ligament was controlled and cut; the corresponding structures of the right 
 side were then dealt with in a similar manner. The right uterine artery was now 
 found and ligated on the .surface of the tumor. Th(> operator, not being able to 
 enucleate further, cut through la>'er after layer of the uterine tissue until the 
 tumor |)ropei' was readied, aflei' which completion of the enuck^ation was easy.
 
 CERVICAL MYOMATA. 
 
 Ot 
 
 Ce rv'i cat 
 Cft nal 
 
 Submuc ous 
 my ma 
 
 I Hi. 10. A N'l.iiv I. Mil ; I. Ci i<\ i( \i, M vi)\i \. 1 7 nut. sizi-. 1 
 ('■yii. Nil. !l7ilS. I'alh. N'n. tiOi:?. The IhhIn nf llic ulcnis i- (•(ui-iiliTahly enlnrtjcil. 'V]n- icrvix is occiipiod 
 by a very larRP ami a|)iir().\iiiiatcl.\- k1"1'IiIi"' iiias.s, wliicli occupies the atitcrinr wall and liulncs into the cervical 
 canal, literally uiifolilinK it. .\n irreRiilar ciitT of vaninal mucosa was removed with Ihe uterus. The uterine 
 vessels were tied hiiih up. 'Vhv vaKinal veins were carefully clamped a.s encountered and hence little bleeding 
 occurred during the operation.
 
 58 
 
 .MVdMATA OF THK ITKIU'S. 
 
 The va<iina was widely ()j)ciicd. Un the ciirlith day tlic patient had signs of 
 cardiac dilatation with ahnost complete anuria. Xeverthcless, she made a 
 irood recovery. 
 
 Cysts 
 
 Fig. 41. — Extensive Cervical Development of a Myoma. (? nat. size.) 
 Gyn. No. 7240. Path. No. 3502. The normal fundus and the practically normal appemlages are perched on the 
 upper surface of a large myoma, which occupies Douglas' pouch and extends out into the broad ligaments. The 
 left uterine vessels are clearly seen on the side of the tumor. Attached to the surface of the tubes are a few small 
 subperitoneal cysts. On the left side is a very small parovarian cyst. The operation wivs a very difficult one. 
 
 (For the description of hi.section of the uterus as [)ractised in some of these 
 cases see page 608.)
 
 CHAPTER IV. 
 
 SUBMUCOUS MYOMATA. 
 
 Nearly all iiiyomata arc primarily interstitial and are gradually forced 
 toward the outer or inner surface of the uterus. In some instances the uterus 
 contains only one myoma, in others the myomata are as abundant as potatoes 
 in a potato-hill. As a rule, only one myomatous nodule becomes submucous, 
 but sometimes the entire cavity may be greatly enlarged and literally paved 
 with them. 
 
 In Fig. 42 is shown an interstitial myoma which has grown into the uterine 
 cavity and fills it from fun- 
 dus to cervix. The uterus 
 contained this single myoma. 
 
 Fig. 43 shows an enlarged 
 uterus, which contains num- r^^^^^HP' "--^w^ ""^ftA 
 
 erous interstitial myomata, 
 while its cavity is literally 
 paved with small myomatous 
 nodules. In addition, a 
 mass of myomatous tissue 
 consisting of several smaller 
 myomata is pedunculated 
 and partly fills the cavity of ^la. 42.— a submucous myoma fim.ing thk riKniM; cavuv. 
 the uterus. 
 
 Tlic submucous develop- 
 ment of the myoma is strik- 
 ingly shown in Fig. 44. One 
 subj)eritoneal and several 
 
 smaller interstilial nodules are seen, but the great increase in the size of the 
 uterus is caused by se\'ei'al large sulnnueoiis myomata. One can readily see 
 how such an eiihii'ged utei'us might in tiinee\|)el nearly all its myomata. and 
 eventually show little evidence of its |)i-e\ious size. 
 
 Size. — The submucous myomata ina>' not reach oxer 1 em. in diameter. 
 On the other hand, they may assume very large pioixulions. In Case Kit)'.), 
 for example, the suhniucous tumoi' was so lai'ge that the uterine caNity was 
 24 cm. in length. 
 
 Pedunculated M y o m a t a. - Since the suhnnicous myomata act 
 as foi'eign bodies and ihe uterus manifests a decidecl tendency to e\])el them. 
 
 59 
 
 (5 nat. size.) 
 
 Gyn. No. ()S4;5. Path. No. .3080. The uterus was the size of 
 that of a four months' pregnancy, a represents the cervical portion. 
 The uterine walls are of the normal thickness. ProjectinR into the 
 cavity and filling it is a submucous myoma (b). A myoma in such 
 a po.sition invariably causes severe uterine hemorrhage.
 
 Fio. 43. — Marked Submucous Developmknt of I'tkrink Mvomata. (§ nat. size.) 
 Gyn. Nos. S0.36 and 9203. Path. No. 5378. One tube and ovary and a myoma had been removed per ab- 
 domen five years before. The uterus filled the pelvis and extended 6 cm. above the symphysis. Scattered through- 
 out the walls are numerous interstitial myomata. Lining the uterine cavity are many small round myomatous 
 nwlules; in fact, the cavity is literally paved with them, a is the upper i)art of the cavity. Projecting into and 
 partially filling the cavity is a conglomerate mass of small myomata. 
 
 When the patient entered the hospital, her hemoglobin was only 15 per cent. She was built up and a success- 
 ful hysterectomy performed when the hemoglobin had reached 46 per cent. 
 
 Fig. 44. — E.xtensivk Sub.mucois Dkvklopmk.nt of Uterine Myomat.\.. (5 nat. size.) 
 Gyn. No. 8495. Path. No. 4716. A vaginal myomectomy had been done three years previous to the hyster- 
 ectomy. Projecting from the fundus is a pedunculated subperitoneal myoma and scattered throughout the walls 
 are a few interstitial nodules. 
 
 Greatly distending and completely filling the uterine cavity are three submucous myomata. The largest one 
 is markedly lobulated and sharply outlined from the uterine walls. The two others are sessile and one of them 
 spreads out into the left liro.-ul ligament. 
 
 It is interesting to note that for the jjrevious four months the flow had been excessive and painful and that 
 between periods the patient had had severe labor-like pains lasting from three to four hours. Marked exertion 
 would bring on the pains. The largest myoma would have undoubtedly soon been expelled, provide 1 the patient 
 had not meanwhile succumbed as a result of the severe hemorrhages. 
 
 60
 
 srBMUcors myomata. 
 
 61 
 
 the myoma will 1)0 forced more and more into the cavity and li'radually become 
 pedunculated. As a result of the continued uterine contractions it ma}' be 
 forced completely out of the uterus, as seen in Fig. 49. Here the lobulated and 
 
 Fi(i. 45. — A I,AU(iK I'KDiNcri.ATKi) SiHMi I <irs MvoMA. c'l iiat. size.) 
 Gyn. No. fi43.3. Path. No. 2().5H. The nodular myoiiiatou- uI(mu> hhmsuicmI 10 \ 11 \ 1 :{ <in. I'rojoctiii); 
 through the cervix and attached by a broad-ba.sed ])ediclp is a lohulali'd >uliiiniicais ni.Mima. S \ U) \ 11 cm. I'hc 
 exact relations are iti<licated in the small sketch on the left. The m\oMia sliuucd a good deal of disintegration. 
 
 The patient was jjoorly nourished and very anemic; her face had a drawn e.xpressioii. She made a go<nl 
 recovery. 
 
 roughened myoma ])r()j('ct.^ from the cciA'ical canal and the cciAical li|).-< loi'iii 
 a collar ai'oimd il.'^ i)cijiclc. The pedicle ol' ,-;uch a iiiyoiiia may be .•<e\'eral centi- 
 meters in diameter, but is often atlenuated, as seen in I'ii::. •'>().
 
 62 
 
 :my()mata of the iterus. 
 
 l'"r()iii l-'iti. 4") we get a (jood idea of a lar^c iiiyoina which jn-ojccts from the 
 cervix and tills the vagina, and which is still very hrnily fixed as a result of its 
 broad basal attachment. Its pedicle would in tune, however, become so attenu- 
 ated that the sul)nuicous growth could be removed with the utmost ease. 
 
 In Case 909 the subnuicous myoma measured 7x8 cm., and the pedicle 
 was so delicate that the tumor easily rotated on its axis. In Case 4382 the pedicle 
 was even more attenuated, the myoma becoming completely detached during 
 the jJH'paratory vaginal wasiiing. 
 
 Fic. 4ti. — A Lakck Pkdunculatkd Submucous Myoma. (,^t nat. size.) 
 
 C. H. I. R., October 25, 1902. Path. No. 6226. Projecting through the cervix and completely filling the 
 
 vagina wa.s a large lohulateii submucous myoma. It bled so freely, anil the patient was so blanched, that o])eration 
 
 was at first deemed impossible. The dilated but otherwi.se normal cervix is clearly seen. The body of the uterus 
 
 contains numerous small myomata. The uterus was removed per abdomen and the patient made a good recovery. 
 
 In Fig. 46 we have an exam{)le of a submucous, ])('duiiculated myoma, 
 practically as large as the myomatous uterus with its a{)pendages combined. 
 This myoma comj)letely fillc(l the vagina: it bled profusely and was removed 
 with great difficulty. 
 
 A\ hen the uterus contains but one myoma and this becomes submucous and 
 pedunculated, as in Fig. 48, with the removal of this growth all trace of jx'lvic 
 disturbances usually disappears.
 
 SUBMUCOUS MYOMATA. 
 
 63 
 
 Sloughing Submucous Myomata. 
 (For the histologic appearances of the mucosa covering submucous myomata 
 
 see page 312.) 
 
 Many of the submucous nodules undergo i)artial and occasionally complete 
 
 Fii;. 47.— A PonxioN ok a Lauck Intkustiti ae. Mvi.mv that has lU.roMK Sihmicovs am) Shows Early Sujns 
 
 OF Hrkakinc Down. (J iiat. size.) 
 Cyn. No. «"<i9. I'aili. No. .'i982. The uterus is pear-.shai)e<l ami mea-sures 1.5 x IS x 20 cm. The K^neral 
 outlines are altered, a.-* the left tube and ovary are on a higher kvel than the right appendages. The uterine 
 cavity hiis heen split from cervix to fundus. FillinR the cavity is the sul)muc()us portion of the tumor, which is 
 lohulatcd and mottled in appearance. .\t h it shows commenciiiK dencneration. 
 
 (iisiiilctiratioii. This breaking down may occur while the Iiiiiior is still lying 
 ill th,. uterine cavity, or not manifest itself until the myoma has been forced 
 into the vagina or has e\-en emerged from the vauina.
 
 64 MYOMATA OF THK ITKIU'S. 
 
 Size. — SonictiiiR'S the tumors arc ywv small, not rcachiuti; ovvv 1 or 2 cm. 
 
 f^t^VanL/^i^t^ 
 
 Pedicle 
 
 Fig. 48. — A Laiuu: I'kdunc i latkd Submucous 
 Myoma. 
 
 Gyn No. 8410. Path. No. 4.59.3. The body of 
 the uteru-s is only .slightly enlarged. The cervix is 
 widely dilated and the vagina greatly distended by a 
 lobulated subuiucoii.s myoma. (For details of the 
 myoma see Fig. 49.) 
 
 Fig. 49. — A Lobulated Submucous Myo.m.\^ Pro- 
 jecting Through the Cervix. 
 Gyn. No. 8410. Path. No. 4593. The vaginal 
 discharge was extremely offen.sive and brownish in 
 color. Projecting through the cervix is a globular 
 myoma with a markedly lobulated surface. The 
 myoma was grayish in color and rather soft. It was 
 apparently sloughing. 
 
 ill diameter, but not infrt 
 Pedicle 
 
 ;?{•>*- 
 
 Fig. 50. — A Gangrenous Sub.mu- 
 cous Myoma. (Nat. size.) 
 Gyn. No. 7615. Path. No. 3879. 
 This lobulated myoma had a slender 
 pedicle, and measured 1.5 x .3.5 x 4.5 
 cm. It was mottled in appearance, 
 having dark green, gray, and reddish 
 areas .scattered over its surface. His- 
 tologic examination showed that the 
 surface was covered with fibrin and 
 polymorphonuclear leukocytes, be- 
 neath which was tyjiical graiuilation 
 tissue. The uterus contained another 
 similar liut smaller submucous my- 
 oma. 
 
 '([ueiitly are of goodly .size and may occasionally 
 reach the large proportions seen in Fig. 52. 
 
 The sloughing usually commences at the 
 most dependent part of the tumor, at some 
 point mo.st remote from the source of hkwd- 
 suj)ply and where the tumor is most likely to 
 l)e exposed to the air. In Case 2732 (Path. 
 No. 266) we have an example of the early 
 changes. The submucous tumor was conical 
 in .shape, measuring 2 x 3.5 x 7 cm. Near the 
 pedicle its .surface was pale pink, hut its lower 
 end was dark brown in color and soft, and here 
 and there the surface was eroded. In Case 7237 
 (Path. No. 3491) the ut(>rus was greatly enlarged, 
 measuring 14 .x 20 x 21 cm. Occupying the 
 cavity of the uterus and {)rojecting through the 
 cervix was a submucous myoma, 5x7x12 cm., 
 with a broad ba.sal attachment. Its .surface was 
 slight!}' lobulated, granular, and somewhat in- 
 jected. Histologically, the surface in places 
 showed necrosis and some j)olym()rphonuclear 
 infiltration. Fig. 47 represents a ])ortion of a
 
 SUBMUCOUS -M Y(J.M ATA . 
 
 65 
 
 large myoma of the fundus filling the uterine cavity, projecting through the 
 cervix, and showing early signs of disintegration. 
 
 AMien the mvoma is extruded into the vagina, it often forms a glol)ular 
 
 ca-vity 
 
 Cervjx- 
 
 I-"ii;. 51. — .\ Si.orciiiiNc Si i;\ii cdi s Mioma. ( ■; iiat. size.) 
 Gyn. No. 7.')40. rath. No. 3799 Tlie .•section repie.seiil.'S liiilf of the uteru.--. .Attached to the surface are a 
 few adhesions ami in the neighborhood are two small myoinata. OccupyiiiK the fundus and completely (illiiiR 
 the uterine cavity is a myoma, the lower ijortion <>i which has widely dilated the cervix and extendeil into 
 the vagina. The vaginal ijortion of the myoma had Lrckiii <li>\vn to a considerable extent, and the central part 
 of the tumor is necrotic. In time the greater part of llic niyoina would be extruded into thevadina if the patient 
 did not meanwhile succumb to sepsis. 
 
 mass with a I'ouglieiicd surface and iiailially cdNi'icd wiih a pyogenic nieinbrane, 
 as in Figs. I'.t and .')(). 
 
 In Case l')")l a siihmucous myoma had hccn i'cnio\-cd four yeais before.
 
 66 
 
 MVOMATA OF THE UTERUS. 
 
 On admission to the hospital the myonialous uterus reaelied the uiuhilicus, 
 while projecting from the vagina and directly continuous with the uterine tumor 
 was a gangrenous mass. 
 
 The gangrenous sul)mucous myoma in Case 4668 (Path. Xo. lo27) was IS cm. 
 long, and from 1 to 7 cm. in diameter. It was mottled in color, being green or red- 
 dish yellow, and necrotic. 
 
 The large submucous 
 myoma in Case 6433 pro- 
 jected through the cervix 
 and filled the vagina. It 
 measured S x 10 x 11 cm., 
 and was attached to the 
 uterine wall by a pedicle 
 4 cm. in diameter. This 
 myoma was covered with 
 blood and fibrin and its 
 surface consisted of a 
 greenish pyogenic mem- 
 brane. 
 
 The inflammatory pro- 
 cess gradually extends to 
 the imderlying myomatous 
 tissue and, if the submu- 
 cous myoma has a broad 
 basal attachment, portions 
 of the tumoi- may be 
 gradually sloughed off. In 
 Fig. 51 we have a good 
 illustration of .such a con- 
 dition. Filling the uterine 
 cavity and intimately 
 blended with the walls is a 
 large submucous myoma. 
 Its lower portion has un- 
 dergone a good d(>al of 
 disintegration and the 
 center is already necrotic. 
 When the process advances still further, we find a grayish, offensive, tough, 
 stringy ti.'^.'^ue projecting from the vagina, as in Case 6143. Probably the most 
 ])i-oii()unce(l instance of this kind, in our experience, was Xo. 11889, described in 
 detail on page 577. The ])atient was almo.st moribund. Her hemoglobin was 
 14 per cent.; the temperature was 104.2°. The myomatous uterus reached the 
 umbilicus. Projecting from the dilated cervix was a grayish-white .sloughing 
 
 Fig. 52. — X Vkry Large SiB.Micors Myoma which had bkkn Ex- 
 truded FRO.M THE Uterus. 
 H. .\ut. No. 2987. The patient entered the hospital in a desperate con- 
 dition. Operation was out of the question, and she died in a few days. 
 During the interim the submucous myoma, which protruded slightly, 
 was forced out of the vagina. The myomatous uterus still fills the pelvis, 
 but the tumor projecting from the vulva and attached by a broad pedicle 
 is larger than the uterus. This myoma had molded itself to the pelvis, 
 otherwise it could not possibly have escaped through the vagina.
 
 SUBMUCOUS M Y( )M ATA . 
 
 6< 
 
 ,Pe dicle 
 
 submucous myoma. The necrotic })ortion of the submucuus myoma \va>; n 
 moved, and the patient was in good health three years later. 
 
 It is astonishing what large myomata 
 may be expelled through the vagina. 
 In Fig. 52 the transverse diameter of the 
 myoma is greater than the distance from 
 the symphysis to the sacrum. The myoma 
 was soft and flabby and had readily ac- b 
 commodated itself to the jjelvis, again 
 assuming its former shape as soon as it 
 had emerged from the vagina. 
 
 In Fig. 53 we see the mottled appear- 
 ance and the engorgement freciuently 
 noted in sloughing submucous nodules. 
 The dark color is due to extravasation of 
 blood, and many of the blood-vessels are 
 dilated and filled with thrombi. 
 
 The sloughing subnmcous myoma in 
 Case 6185 lay between the thighs, and at 
 first suggested a prolapsed uterus. The 
 growth, however, was dark l)i-()wiiish green 
 in color and covered with a bloody, foul- 
 smelling discharge. It measured 15 cm. 
 in length and 8 cm. in diameter. The 
 finger entered the vagina readily, and 
 the pedicle of the tumor was found to 
 spring from within the cervix on the left 
 side. 
 
 The odor from a sloughing subnmcous 
 myoma is often almost unbeai'able; even 
 after the tumor has been in alcohol for 
 years, the disagreeal)le stiiell clings to the 
 hands for hours despite tlu^ most careful 
 washing and the use of deodorants. 
 
 The vaginal discharge is likewise 
 offensive. Its color naturally depends 
 upon the abundance of polymorphonu- 
 clear leukocytes, the aniounl of disintcgi'ation, and lln 
 watery, dark brown, or greenish in hue. 
 
 (For sloughing subix'riloneal and intcrstilial inyoniala see |)ag(' 134.) 
 
 It 
 
 Fig. 53. — A Si.oti;niM; SrHMrcois Myoma. 
 (I iiat. size.) 
 
 Gyn. No. 7313. Path. No. 3(>73. The luy- 
 oina was 15 cm. long and varied from 3 to 5 cm. 
 ill diameter. Us lower end appearetl RunKreii- 
 ous, and the tumor liad a very foul odor. The 
 liicliHi' rcprrsriil^ a lonniliuiinul section of the 
 {growth. The siuall pedicle is seen at the top. 
 At a is a small polypoid projection of the myoma. 
 The tumor presents a mottled api>earanee, and 
 many of its hlood-vessels are dilated U>). Hi.sto- 
 Idnic examination .showe<l that the surface of the 
 myoma wius entirely necrotic. 
 
 The uterus was removed shortly afterward 
 and sarcoma foimd U'- I'-'J*- '"'"' I':i'''"mI di^HJ of 
 pidmcinary metastases. 
 
 liciniilTlKme, being
 
 68 
 
 .MYO.MATA OF TIIK UTERUS. 
 
 fc^.., - 
 
 
 ?">, 
 
 
 «, 
 
 
 ';• • * 
 
 
 v.^*:? ■ 
 
 
 1* ^- 
 
 
 i^ '^ -^r 
 
 ', 
 
 ^.%f.y- 
 
 
 »«'\. .. 
 
 
 ;^/V' "^.. 
 
 , 
 
 .V V'.lVs* 
 
 ' 
 
 
 • 
 
 'C'. 
 
 
 tv' 
 
 Histologic Appearances of Sloughing Submucous Myomata. 
 As the niyuiiia is forced more and more into the uterine cavity, its pedicle 
 naturally becomes more attenuated; and when the tumor is extiuded into the 
 vagina, it is more liable to become bruised, so that the likelihood of infection be- 
 comes greater. The breaking down of the tumor usually starts on the surface 
 and graduallv ti'avels inward. The more prominent parts of th(> tumor 
 
 may have a thin covering of mucosa, 
 or this may have already entirely dis- 
 a{)))eared. First the tissue immedi- 
 ately beneath the surface shows 
 some small-round-celled and poly- 
 morphonuclear infiltration (Fig. 54). 
 Occasionally there may also be 
 edema, as in Case 2593 (Path. No. 
 17S). This, however, is uncommon, 
 as the tumor is subjected to pressure 
 from all sides. The number of poly- 
 morphonuclear leukocytes and small 
 round cells rapidly increases, and the 
 surface soon shows signs of disinte- 
 gration. The tissue in the vicmity 
 undergoes complete coagulation ne- 
 crosis, the colorless fibers still l)eing 
 visible. Occasionally there is frag- 
 mentation of nuclei, as noted particu- 
 larly in Cases 6143 (Path. No. 2413) 
 and Gyn. No. 7237 (Path. No. 3491). 
 The blood-vessels near the surface 
 may be much dilated, as in Case 
 2732 (Path. No. 266) and Case 3066 
 
 -The Surface of a SLOUCnixG Submucous , -.^ ,n,^\ t ^i f i 
 
 MvoMA. (xnodiam.) (P^th. No. 460). In the very foul 
 
 Gyn. No. 6855. Path. No. .3177. o i.< the .surface sloUgllillg grOWths tile blood-VeSScls 
 
 of the growth, con.si.sting of tis.sue which is partly necro- . , . , , ^|, > 
 
 tic. It contains a few distorted polymorphonuclear leu- Ul the UCCrotlC mUSClc UUiy bC hllcd 
 
 kocytes and small round cells. In the underlying tissue ^^.jjj-^ organislUS (Fig. 55), aS iu CaSB 
 a few muscle-fibers are still visible, and there is much 
 
 hemorrhage (6). In the depth are numerous caidllaries 2732 (Path. No. 266), CaSC 4663 
 
 (c). The tissue shows considerable small-round-celled , t-, ,i -^t i ootx t^.r. Kon/2 /"D^+U 
 
 and some polymorphonuclear infiltration. (^ ^th. No. 132/), CaSC o296 (Path. 
 
 No. 1750), Case 7313 (Path. Nos. 3576 
 and 3673), and Case 11889 (Path. No. 8297). 
 
 As the inflammation becomes more chronic the surface will be found covered 
 with fibrin, polymorphonuclear leukocytes, and blood, while the underlying part 
 consists essentially of granulation tissue (Fig. 56). The increased vascularity 
 diminishes and the vessels may show organizing thrombi, as in Case 6185 (Path. 
 No. 2441); or the vessels may be already obliterated, as in Case 7237. 
 
 Fig. 54.
 
 SUBMUCOUS :\IYOMATA. 
 
 69 
 
 Occasionally a niyoiiia that has already shown marked hyaline degeneration, 
 as it becomes submucous, will disintegrate very rai)idly without showing nuich 
 
 Necrotic,, surface 
 
 
 Fig. 55. — Thk Suhkkkicial Poktion.s of a Sloughinc; 
 Submucous Myoma. (X 140 diain.) 
 
 Gyn. No. 7549. Path. No. .3799. The myoma was 
 approximately 15 cm. in length, 9 cm. in breadth. The 
 lower portion was sloughing, anil projected through 
 the cervix. 
 
 The .surface i.-i entirely necrotic; then conies a ne- 
 crotic zone densely inhltrated with small round cells and 
 polymorphoiuiclear leukocytes; heneatli this the necrotic 
 character of the tissue is clearly seen, as indicated by the 
 area a. At 6 are blood-ve-ssels almost completely choked 
 with organisms. 
 
 «iA 
 
 v^:?^; 
 
 Fi(.. Oli. Till- SiiUAU "I \ Si ..I ..iiiN^. .•SUB- 
 MUCOUS MvoMA. (X 150 diam.) 
 Gyn. No. 7.383. Path. No. 3f.35. The .sub- 
 mucous myoma was cm. long, 4 cm. broad. 
 In protected places the mucosa was intact, but 
 :it some points had entirely .lisappeared. M a 
 the surface is covered with hbrin contaiiiiiig blood 
 ;iriil polymori>lii>nuclear leukocytes in its me-shes. 
 I he underlying tissue {!>) consists of typical granu- 
 lation ti.ssue. Scattered throughout this arc 
 numerous cai)illaries (H). r is the unaltered un- 
 derlving injcmialons tissue. 
 
 inflammatory ivactioii. This was ])articulaily noticeable in ( 
 No. 3491). 
 
 (Pat
 
 70 MVO.MATA OF THK UTKUUS. 
 
 A Sausage-shaped Sloughing Submucous Myoma, Three Feet in Length. 
 
 The accoiiipanyiiig case is unique, and dcnionstratcs the amount of ])r('ssure 
 that can he cxci'tcMl l)y the uterine muscle. For five years the patient had l)een 
 aware that a uteiine tumor existed. f)ut only towai'd the end of tliis period was 
 there evidence of a suhmucous growtli. AA'itli the rapid necrosis of the tvunor a 
 hirge portion of it was sj)eedily ex})ened l)y the uterus, being molded in its exit by 
 the cervix until it formed a sausage-like ma.ss over three feet in length. 
 
 I". .1. 11., aged thirty-eight, colored, admitted to the Cambridge Hospital. 
 Md,, January 13, 1907. The patient had always been well and strong, but five 
 years before had been told that she had an abdominal tumor. Three days before 
 admission to the hospital she was seen by Dr. ]']. ]■]. AA'olff, She had at that time 
 a temperature slightly over 101° F. A large nodular mass occupied tlie lower 
 part of the abdomen and there was some abdominal tenderness. The foul 
 vaginal discharge still continued. Filling the vagina was a rope-like structure 
 over thi-ee feet in length. This was attached within the uterine cavity. On its 
 lower end was a knob-like, lobulated mass, 3x5 inches. After the vagina had 
 been cleaned up as thcM'oughly as possible the uterus was removed from above by 
 Dr. Curtis Burnam. 
 
 After operation there was a good deal of vaginal discharge and some pelvic 
 inflammation. The patient improved greatly and was ready to leave the 
 hospital, when she suddenly dropped dead without any warning. 
 
 Path. No. 11044. The uterus measures approximately 8 x 9 x 10 cm. 
 Tt is everywhere covered with dense adhesions. Projecting from the right lateral 
 wall, l)Ut intimately connected with the fundus and filling the uterine cavity, is 
 a necrotic looking, foul-smelling, grayish-black tumor mass. It appears to be a 
 sloughing submucous myoma. On section, it is grayish or reddish-black in 
 color and soft in consistency. 
 
 At one or two points small interstitial nodules are seen scattered throughout 
 the uterine walls. Accompanying this specimen is a twisted rope of tissue, 
 about three feet in length, grayish-black in color, and on section j)resenting the 
 same apj)earance as the necrotic submucous myoma. 
 
 Histologic Examination. — Sections from the submucous myoma showed 
 thtit it was undergoing necrosis and that there was marked su])puration. A\ here 
 the tis.sue was preserved, it was rather cellular. Blood-vessels were numerous 
 and markedly engorged. Cross-sections of the vopr of tissue showed that it 
 likewise consisted of myomatous tissue. In most places it had undergone al- 
 most comj)lete necrosis. .\t a few points the necrotic muscle showed typical 
 calcareous de|)()sits. 
 
 We had in this case a submucous myoma, which had in part imdergone nec- 
 rosis and had l)een >:raduail\' extruded, formiiiii a tumor thi'ee feet in length.
 
 SX'BMUCOUS .M V( ).MATA. 
 
 Inversion of the Uterus Associated with Submucous Myomata. 
 
 In our series of uterine myoniata we have hatl four cases in which partial in- 
 version of the uterus was noted and in each of these the myoma was submucous. 
 When the uterus is the seat of a single tumor which l^ecomes submucous and 
 pedunculated and is being; o-radually extruded into the vagina, it is but natural 
 that the traction of the ])edicle on the uterine wall in a few cases will produce 
 partial inversion of the uterus. 
 
 In Case 1716 the vagina was filled with a round, fii'ni myomatous tumor, 
 about 11 cm. in diameter, and attached in the uterine cavity by a pedicle 2.5 cm. 
 in diameter. Bimanual examination revealed a slight cupping of the fundus. 
 
 The uterus in Case 7133 contained a submucous myoma. After the cervix 
 had been split and the tumor di\-ided into foiu' pieces it was removed. The 
 uterus was partially inverted on account of the traction of the myoma. 
 
 A smooth, glistening, pedunculated, subnmcous myoma protruded from the 
 enlarged and edematous cervix in Case 1610; at the site of the fundus was a cup- 
 shaped depression. 
 
 In Case 2873 the patient was very pale and had a very ra])id puls(\ A sul)- 
 mucous myoma, 11 x 15 cm., protruded fi'om the vulva. It was attached to the 
 uterus by a pedicle 4.5 cm. in diameter. The fundus was nodular, aljout the 
 size of that of a three months' pregnancy, and partially inverted. 
 
 After removal of the submucous growth the inversion, as a rule, can be 
 readily rectified. The dangers of vaginal myomectomy or vaginal hysterectomy 
 when partial inversion exists are considered on page 575.
 
 CHAPTER V. 
 
 DILATATION OF THE UTERINE LYMPHATICS ASSOCIATED 
 
 WITH MYOMATA. 
 
 For convenience two divisions may l)e made: (1) Dilatation of the snperficial 
 lymphatics; (2) dilatation of the deep lymphatics. 
 
 By the superficial lymphatics we mean those that are so near the surface that 
 they are readily seen as soon as the abdomen is o])ened. Naturally, the condi- 
 tion of the deej) lym])hatics cannot, as a rule, he made out until the tumor is 
 studied at leisui'e in the laboratory. 
 
 Dilatation of the Superficial Lymphatics. 
 
 In the chai)ter on Parasitic Myomata two cases are mentioned in which the 
 omentum furnished abundant nourishment to jxxlunculated myomata, and large 
 lymph-channels coursed down the omentum to the tumors. In one of these 
 cases (Gyn. No. 7220, Fig. 18, p. 22) a single large, tortuous, thin-walled lym- 
 ])hatic, several millimeters in diameter, is seen passing down the omentum to 
 the tumor. In Case 8296 (Fig. 17, p. 20) several large, tortuous, \)i\\v lym- 
 phatic vessels are seen extending down from the omentum to the tumor. 
 
 Probably one of tlie most striking examples of a large lymphatic coursing 
 over the surface of a myomatous uterus is found in (lyn. No. 13067 (Fig. 57). 
 iMuerging from the uterine muscle, several centimeters to the median side of the 
 uterine horn, is a markedly lobulated and tortuous lymjihatic vessel. This in 
 places reaches over 1 cm. in diameter and rises nearly 1 cm. from the surface of 
 the uterus. It passes downward and outward between the tube and ovary and 
 is lost near the hilum of the ovary. Anterior to the tube is a much dilated 
 lymphatic vessel. 
 
 Another remarkable example of dilatation of the lymphatics is furnished by 
 Gyn. No. 11224 (Path. No. 744Sj. At the origin of the Mt tube, between the 
 left tube and ovary and between the tube and the neighboring round ligament, 
 were cystic spaces. The}' varied from 1 to 2 cm. in diameter and their nmscular 
 covering was so attenuated that their clear fhiid contents were readily seen. 
 Some of the spaces on section were found to be made up of numerous smaller 
 ones. The spaces were filled with serous fluid. In sections they were lined in 
 jtlaces with one layer of flat cells; at other points no endothelial lining could be 
 detected. Similar spaces were present in the vicinity of the right uterine horn. 
 In neither of these cases were there adhesions, which sometimes give rise to 
 superficial, subperitoneal spaces — an encysted peritonitis.
 
 DILATATION OF THE UTKKIXK LY.MPHATICS. 
 
 dilated Ij/mpbat 
 
 Fig. 57. — E.NonMois Dilatation ok tiii. I.-, mimi \tii> on tiii: .SrHKAci; oi \ Mm>m\tois I'tkuis. (Nat. !<ize.) 
 Gyn. No. 18067. Path No. lOOTd. iMiiciKiiiK fnun tin' -iiif.uc nf ilir ul<>ni>. :i fi-w (•("iitiiiiotoi-s aliove ami 
 anterior to the left tul)e, i.s a tortuous lymphatic vcss.-l uhi.h \n plioc- i- ..v.-r 1..'. nu. in (iiamotor. It i)a.>*.>»e.s 
 over the tube down hetwecti tin- lulic ami ovary an. I i- lo~l in IIm> .Icplh. nc:ir the hiluni ..f 111.- ovary. Thi." 
 lymphatic ve.s.sel was fille.l with clear lluhl. Antcrinr to the lulic i~ a lar^'c lynipliatic vessi-l. On the surface 
 of the tube are a few .subperitoneal si)accs. Ihc lunmr i> free fn.ni a.lli.'M..n>, The Kreal increa.-e in size of the 
 ovary is clue in a large meii-sure to dilated l.\ niphaiic-. in p.iri. in iiian.\ c,\>ii<- follicle-.
 
 74 
 
 MVOMATA OF THE ITHHl'S. 
 
 Gyn. No. 13067. Path. No. 10076. 
 Enormous dilatation of the superficial lymphatics 
 
 a n (1 m u c h c d c m a o f the 1 e f t o v a r y , a s s o c i a t e d wit h 
 
 a 111 >■ o 111 a t o u s u t e 1' u s {V\^. 57). 
 
 S. (;., white, a.u'ed t'oi1\--()iie, inarried. Admit te(l .hily 9, 1906. Operation. 
 
 Hystei-omyoiiiectoiii}'. The specimen consists of a large myomatous uterus 
 
 with the a])pendages attached. The 
 uterus is soft and boggy, and on sec- 
 tion tlie increase in size is found to 
 he caused by a large degenerated and 
 cystic myoma, which arises from the 
 posterior wall and is partly sul)mu- 
 cous. The right ovary is ap))arently 
 normal. The left ovary measures 10 
 cm. ill length, is correspondingly 
 lii'oad, and very soft and edematous. 
 J'jiierging fi'om the uterus just to the 
 anterior and inner side of the left 
 uterine hoi'ii is a markedly dilated 
 and superhcial lymphatic, which in 
 ])]aces reaches nearly 2 cm. in di- 
 ameter. It passes down behind the 
 tube and is lost in the tissue between 
 it and the ovary (Fig. 57). There 
 are also dilated lymphatics l)etween 
 the left tube and the left round lig- 
 ament. 
 
 Microscopically, the uterine mus- 
 cle seems normal, l^ut there is a ten- 
 dency for the glands to extend into 
 the muscle. The tumor itself shows 
 marked hyaline degeneration. Sec- 
 tions through the dilated lymphatics 
 that were seen coiu'sing ovei' the sur- 
 face show tliat in ])laces they have a 
 distinct endotiielial lining. The in- 
 marked dilatation of the lymphatics. 
 11a noted iiiacroscopically. 
 
 Fig. 58. — Dilated Lymphatic Spaces in the Uterine 
 Wall in the Neighborhood ok the Right Tube 
 AND Ovary, (i nat. .size.) 
 
 Gyn. No. 11224. Path. No. 7448. Covering the 
 surface of a jjortion of the right tube are nuineroii?; 
 subperitoneal cysts. .\t the cornu is a raised eystic 
 area extending anteroposteriorly a' from to ii. This, on 
 section, was found to be made \i]> of numerous cystic 
 spaces, b and c are otlier dilated cystic spaces in the 
 uterine wall. .\ll were filled with clear fluid. In many 
 an endothelial lining could be made out. 
 
 ci'ease in size of the left ovary is due to 
 These have given rise to the apparent eilei 
 
 Gyn, No. 11224. Path. No. 7448. 
 
 .\ ill y o m a t o us u t e r u s wit h m a r k e d d i 1 a t a t i o n o f t h e 
 lymphatics in the region of both uterine horns ( l'"igs. 
 58 and 59). 
 
 C. II., white, agetl forty-six. married, .\dinitted April 25: discharged
 
 DILATATION' OF THK UTERIXK LYMTHATirS. 
 
 to 
 
 May 22, 1904. Hci- family history is not ^(hhI. Her mother (Hcd in (lial)etic 
 coma; a })at('rnal aunt also diet! of diabetes. Her father died of cai'diac asthma, 
 one brother of pericarditis, another brother of aneurysm, and a paternal aunt of 
 tuberculosis. The patient has been married twenty-six years and has had two 
 children, twenty-four and twenty-one years old respectively. Ten years ago she 
 began to have slight bleeding between her ])eriods. This has gradually increased. 
 and the periods have also 
 been getting longer and more 
 profuse. For the last two or 
 three years she has had con- 
 siderable weakness, and has 
 been bleeding almost contin- 
 uously. One year ago her 
 hemoglobin was 58 per cent. 
 
 Operation. Hysteromyo- 
 mectomy. The highest post- 
 operative temperature was 
 102.2°, on the fourth day. 
 
 Path. No. 7448. 
 The specimen consists of a 
 roughly spheric myomatous 
 uterus, 15 cm. in diameter. 
 It is free from adhesions. 
 The uterine cavity is much 
 dilated. Just where the right 
 tube joins the uterus is an 
 oval-shaped swelling, 3 cm. 
 X 1.5 cm. (Fig. 58). This is 
 lobulated, covered with peri- fk;. so.— dilated lymphatic channki.s at thk lkft i tkkink 
 
 1 • 1 .1 -• Horn Bktween the Tube and Ovary ani> Between the 
 
 toneum and evidently cystic. .,.^,„,, ^^^ i^„„. ^^^,^„ i.,«ament. c? ..at. size.) 
 
 It is composed of numerous C!yn. No. 11224. Path. No. 7448. At the uterine horn is an 
 
 , ,, , _ eloiiKate cystic dilatation, the anterior an<l posterior confines of whirh 
 
 SmOOtn-WalleCl spaces, vary- ^j.^ indicated by a and (('. This, on section, was found to be coni- 
 
 ino" from a l^inh("ld to neaiiv P"scd of numerous smaller spaces. At the inner end of the utero- 
 
 *^ ' ' _ ovarian ligament is another cystic space, seen at /». Between the 
 
 1 cm. in diameter. T^he tube and ovary and between the tube and round liKamenl are other 
 
 11 ,1 cystic spaces at ■. Soiiii' of ilu-iii had an eiiiioihclial liniiiK: in 
 
 walls are ai)parenl ly com- ^^^^^^^ .^ ^,^,,,,,, ,_,„ ,,,. _„^„,,. ,„„ ,,,,..^ ^^,..,.^. ,i„^.., „•„, ^.,,.,^,. „„i,,. 
 posed of muscle. On the left 
 
 side, near the point of origin of the left tube, there is a moiv diffuse swelling 
 (Fig. 59). This measures 4.5 x 2.5 cm. and pi-ojects about I cm. from the sur- 
 face. On section it also pi-esents a honev-eonilxMl ;i|ti>e;ii;inee. between the 
 inner cud of the tube and the utei'o-ovarian ligament is an o\al cNst, I eiii. in 
 diametei'. It has thin walls and on section is found to consist of two main cysts 
 and of nuniei'ous sniallei' ones. 
 
 On examination of the cystic area in the \-ieinit\- of the left uterine horn we
 
 76 MYOMATA OF TIIH UTERUS. 
 
 find a cross-section of the tube slightly dilated. The uterine muscle sumnuiding 
 this is perfectly normal. In the outlying portion the tissue is very edematous. 
 The large spaces in places show no definite lining, but at other ])oints have one 
 layei- of Hat endothelium. The nuclei of the endothelial cells are s])indle-sha]ied. 
 The s|)aces are partially (illed with a homogeneous material and take the eosin. 
 We aiv uiuloubteilly dealing with dilated lymphatic spaces. 
 
 Sections from the cystic areas near the left utero-ovarian ligament and from 
 the uterine horn on the right side show a similar picture. 
 
 Dilatation of the Deep Lymphatics. 
 
 In Gyn. No. 3133 (Path. No. 494) the uterus, as the result of the myomatous 
 de\-elopment. had been converted into a pear-shaped tumor, 36 x 32 x 32 cm. 
 The tumor, on section, presented a pearly-white, coarsely striated appearance 
 and had scattered throughout it homogeneous areas, l)rownish in color. Mi- 
 croscopically, the uterine muscle itself showed much hyaline degeneration and in 
 some places were small round or oval empty spaces which suggested lymph- 
 spaces. Confirmatory of this idea were many channels of a similar shape, filled 
 with hyaline material and lined with endothelium. Fully half of the large 
 tumor had undergone hyaline degeneration, but there was no breaking down of the 
 tumor substance. Its blood-supply was very ])oor. Surrounding nearly every 
 blood-vessel were round or oval spaces, similar to those seen in the uterine mu.^^cle. 
 These, from their arrangement, looked like lymph-si)aces. 
 
 The lymph-s])aces in the uterus in Case 4203 were markedly dilated. The 
 uterus was 9 cm. in diameter and very soft. 
 
 In Gyn. No. 3113 (Path. No. 4S7) the uterus had been converted into a multi- 
 nodular myomatous tumor, approximately 25 cm. in diameter. Large and small 
 smooth-walled sinu.ses were scattered everywhere throughout the myomatous 
 tissue. The largest of these was 1.2 cm. in diameter. Many of the larger com- 
 municated with the smaller ones. Most of them were filh^d with serous fluid and 
 a few contained blood. On histologic examination the myomata showed much 
 hyaline degeneration and some edema. The large sinuses that apj^eared to lie 
 lyiii])li-channels in many places showed an endothelial lining: at other points no 
 lining could be detected. As the blood in the arteries and veins had been well 
 preserved in Mueller's fluid and as these spaces were comparatively free from 
 blood, we are inclined to believe that they were lymph-\essels. 
 
 Unless careful histologic examinations luv made one can never be sure that 
 such spaces are lymphatics, as the majority of clear spaces found in myomata 
 result from the melting away of the tissue following hyaline degeneration. This 
 (luestion is discussed fully in the chapter dealing with hyaline changes in uterine 
 myomata (see p. 92).
 
 CHAPTER VI. 
 TORSION OF THE UTERUS. 
 
 Torsion of the uterus is occasionally met with in niyonia cases. It may, for 
 convenience, be divided into — (1) torsion of the cervix; (2) torsion of the body 
 of the uterus; and in addition we may have twisting of a |)eduncu]ate(l sub- 
 peritoneal myoma. 
 
 TORSION OF THE CERVIX. 
 
 In Case 4925 we have an excellent example of tor 
 globular myomatous uterus reached to within 8 cm. 
 free from adhesions, but had rotated 
 through an angle of 90 degrees to the 
 right. The left round ligament, tube, 
 and ovary, therefore, lay in front (Fig. 
 60). On referring to Fig. 61, it will l)e 
 noted that the upper ])art of the cervix 
 had been greatly thinned out. A\'hether 
 this was the cause or the effect of the 
 torsion it is impossible to accurately 
 determine, but as the cervix w^as evi- 
 dently put on the stretch by the ever- 
 increasing upward growth of the tumor, 
 there has, in all probability, been atro- 
 l)hy of the cervix, facilitating the tor- 
 sion. 
 
 si on of 
 of the 
 
 the cerv 
 xiphoid. 
 
 ix. The 
 It was 
 
 \) 
 
 Torsion of the Body of the Uterus in 
 Cases of Uterine Myomata. 
 
 As this condition is coniparativcly 
 rare, a brief description of the eight in- 
 stances in our series may be of intci-cst. 
 
 In Case 3.'^7 the lower abdomen was 
 filled with a niuhinodular myomatous 
 uterus. The uterus was twisted on its 
 
 I'k;. CpO. -Rotation of a Myomatoi's Utkhts on 
 ITS Ckuvix. 
 (ijii. No. 4012.5. 'I'lie )(l<>ljular inynmaliiiis \ilonis 
 is perfectly .smootli, l)Ut has rotufcd tlirmiKli an aiiulo 
 of !)0 ileRrees (o the riRht. The riRlit appeiKiiiKos 
 liavc l)fe II carried l)ack\varii; tlie left loiliul liKaiiieiit, 
 tiilie, and ovary lie just above the l)ladder. For tlie 
 unfol<led cervix see Vir. i\\ . A myoma, 12 x 21 x 27 
 cm., was reinoveil per iihdoriiiti. For the .sul)se(|uent 
 development of other myomata see Fig. 331, p. 562. 
 lAfl.T Howard A. Kelly.) 
 
 axis. 
 
 The irregularly globular inyoinatous uterus in Case V.\\\ was as large as that 
 of a six and one half months" |)regnan('y. it was twisted through an angle of 90
 
 78 
 
 .MYO.MATA OF THE UTKRUS. 
 
 degrees from left to right and the left ovary eontaiiicd a unilocular cyst 8 cm, 
 in (lianictcr. 
 
 In Case ")()44 a myoma, 12 x 12 cm., occupied the posterior uterine wall. 
 Tlici'c was torsion of the uterus through an angle of 90 degrees fi'oin i-ight to left. 
 
 Tile niyoinalous uterus in Case 5784 filled the entire abdomen. The omentum 
 was firmly attached to the tumor over its entire breadth and furnished enor- 
 mous vessels to the myoma. The uterus had rotated through an angle of 180 
 degrees from right to left. 
 
 The abdomen in Case 5946 was filled 
 with a synunetric and semifluctuant 
 myomatous tumoi". The uterus had ro- y^ 
 
 tated 90 degrees. 
 
 In Case 6570 the myomatous uterus 
 reaelie(l the umbilicus. Its pedicle con- 
 
 ,41/ 
 
 \Rrlig. 
 
 Fig. 61. — Atrophy of the Cervix Associated with a 
 Large Globiti.ar Myomatous Uterus. 
 Oyn. No. 4925. riie ui)i)er i)art of the cerv'i.x is 
 greatly attenuated, and at uperatidn the iiteru.s was 
 rotated to the right, giving the iiictuie seen in Fig. 60. 
 (After Howard A. Kelly.) 
 
 Fic. 62. — Marked Torsion of a Myomatous 
 Uterus. 
 
 (i.\M. No. fi.570. The great enlargement in 
 the iiiJiKT i)ait of the uterus was caused by a 
 .spheric myoma. Near the middle of the uterus 
 proper there is marked torsion from right to 
 left — so much so that the insertion of the right 
 round ligament is carried to the o|)posite side, 
 while the right tube and ovary lie in the median 
 line. .\t the i)oint of the twist the diameter of 
 the uterus had been reduced to 1 cm. 
 
 sisted of the middle ixjilion of the uter- 
 us. Here there was a definite twist from 
 right to left. The ])ortion of the uterus 
 
 forming the jx'dicle had become markedly attenuated, being only 1 cm. in 
 thickness (Fig. ()2). 
 
 Tn Case 7()9") the myomatous uterus reat 
 made a (|uarter turn from left to right, tin 
 The twist was near the cervix. 
 
 In Case 1 1()()7 the alxlomen was syn 
 been definite torsion of the uterus from left t 
 
 •lied the umbilicus. The cervix had 
 ■ left tube and ovary lying in front. 
 
 nmetrically distended. There had 
 to right (Fig. 68j.
 
 TORSION' OF THE ITHHUS. 
 
 rg 
 
 In none of these cases had the torsion <iiveii rise to any especial clinical 
 symptoms. A\'hile it is impossible to tell definilely why ttjrsion took place, it 
 seems probable that the twisting commenced as a result of the attempts of the 
 tumor to accommodate itself to its surroundings. When once twisting starts 
 it often, for some unknown reason, tends to increase in degree. 
 
 Torsion of the Uterus with Complete Severance of the Body from the Cervix. 
 
 Professor Raffaele Bastianelli, of Rome, when in J^altimore, related a most 
 
 interesting cas(> of this character that had come under his observation, and on 
 
 Fig. 63. — Torsio."< of a Large Globular Myomatous Utkuis. 
 Gyn. No. 11067. Path. No. 7285. There is marked tor.sion of the uterus from left to rinht, so that the in- 
 sertions of the left tube and ovary lie in front. The lower surface of the left ovary has hecomc lirndy plasleriNl 
 on to the surface of the myomatous uterus. The blood-vessels lyiriK between Ihi- tube and ovary are much 
 dilated. 
 
 his return to Italy he scnl us an explaiialor}- ilhisl ration ( !'"ig. (Ih. in llie 
 beginning there was evidciilly loi'sion of the utci-us. This grailu.-iily became 
 more marked until fiiiall\- tlie fundus was comiilelelN- se\-ere(j Iroiii llie eei-xix. 
 
 Miss E. J. C, aged lifty-lhive, seen !)>• Dr. HasliatieHi in iJoiiie in I'.KIl*. 
 The patient menstrualed last eiglil years piv\iously. i'or mtnv iliaii tweiily- 
 one yeai's a lumor has been iiolieecj in I he lower abdomen. Tliis at lirsl was not 
 painful, but in bSSl.j'or one da>-, she li;id sexciv pain throughout the entire
 
 so 
 
 .MYOMATA OF THK ITKIU'S. 
 
 abdomen. In 1890 she had what was siij)j)os(>d to be a severe attack of ])eri- 
 toniti.s, wliieh histed more than eifjht days ami was accompanied with nuxh'rate 
 fever. Tn ISOo slic had another attack, and two or three others at hiter 
 intervals. In l'.)01, after exercise, she had severe abdominal pain for three 
 days and since then, on mnnerous occasions, has had much abdominal discom- 
 fort after exercise. In March, 1902, she had sudden ])ain duriiiii; the night. 
 There was little vomiting, some diarrhea, and abdominal distention. She was 
 in bed for a month and suffered a good deal. From that time until the day 
 of opi'ration she has had numerous other attacks of abdominal ])ain. 
 
 May 25, 1902: Occupying the lower al)domen. and extending almost to the 
 umbilicus, is a tumor about the size of a child's head, hard, immovable, rather 
 
 Fig. 64. — Sfoxtaxkous A.mpltatiox of a Myomatous Uterus, (i nat. si7e.) 
 
 niustration sent by Professor R. Bastianelli, of Rome. To the riaht is a large myoma which had grown fa.st 
 
 to the abdominal wall. Toward the left is the small uterine cavity, which has been opened. At n is a twisted 
 
 pedicle consisting of the broad ligament, round ligament, and the tubes and ovaries much atrophied, c is the 
 
 fimbriated end of one of the tubes. The torsion had resulted in complete separation of the uterus from the cervix. 
 
 painful, and .situated somewhat to th(> left. On n-ctal examination the cervix is 
 easily felt. Xo connection can he made out i)etween the tumor and the cervix. 
 
 May 26: On section of the ahiloinen a myoma was found. This was round, 
 adherent to the abdominal wall on the left side, and was se})arated with diffi- 
 culty. The tumor was then freely movable, and was found to be attached to 
 the Hoor of the right iliac fossa by a large pedicle. This was cut between clamps 
 and the tumor then lay perfectly free in the hands of the operator. 
 
 The specimen consists of the body of the uterus, with a round myoma attached 
 to its anterior wall, and also includes l:)oth ovaries and tubes and round ligaments 
 twisted many times. In the jMcture (Fig. 64) one can see easily the cavity of 
 the uterus which has been opene(l. It is small and has an atrophic mucosa. It 
 ends in the twisted pedicle. Attached to the uterus are the tubes and ovaries.
 
 TORSION OF THE UTKKUS. 
 
 81 
 
 Professor Bastiaiielli ^ivcs the following explanation of the condition. The 
 body of the uterus was twisted first, and little by little completely severed from 
 the cervix. Then the tubes and broad ligaments became twisted, and finally 
 the tumor became adherent to the abdominal wall. The condition, then, rep- 
 resents a spontaneous sui)ravaginal amputation of the uterus, with secondary 
 twisting of the tubes and the ligaments. Professor Bastianelli thinks that if 
 the uterus had not been removed the twisting of the tubes and ligaments could 
 have advanced still further. The uterus would then have been completely 
 separated from them, and would have remained attached to the ])arietal peri- 
 toneum like a parasitic myoma. 
 
 Fig. 65. — Torsion of a Subperitonkal Pedunculated Myoma. (J nat. size.) 
 C. H. I. (C), August 12, 1902. The specimen consists of an irregular, fan-shaped, subperitoneal petluiiculate*! 
 myoma. At the pedicle the tumor has twisted from right to left. Near the center of the tumor many vessels 
 are ramifying over its surface. 
 
 Torsion of Subperitoneal Myomata. — In Case ('. the ])atient was admitted to 
 the Church Home and Infirmary Augnst 12, 1002. She had a small multinodnlar 
 uterus and a large subperitoneal pedunculated nodule, which had become twisted 
 through an angle of 90 degrees from right to left ( h'ig. (>,')) and was densely ad- 
 herent to the tissues at the jx-lvic brim. The |)ediclc was se\eivd. ami the ad- 
 hesions dealt with from the under side. The uterus was then reinoxed. 
 
 In Case 127(H), a colored woman, aged forty-two. had (•oiiii)lai!ied of sudden 
 cramp-like pains in the right lower abdomen six da>s bcl'oiv. Tliere was markeil 
 dysuria and a moderate elevation in leiii|)ei-ature. 
 
 On her admission to the hos|)ital \)v. II. T. llutchins found the lower abdo- 
 men tender and detected an indefinite mass in the left iliac fossa. There was a 
 (i
 
 82 
 
 MYOMATA OF TUE UTKRUS. 
 
 niodcratt' IcukoiTlical dischariic. The cervix was low down, and the uterus in 
 antt'-i)ositi()n and fixed. On both sides were wliat appeared to l)e definite tubo- 
 ovarian masses, wiiich were tender. 
 
 When tile abdomen was opened a myoma, 4.') x 5 x S em., immeiliately })re- 
 scnted. Tliis was ])ednneulate(l, and had made one (•omi)lete twist, so tiiat the 
 blood-sui)piy had been entirely shut off (Fig. (H)). The tumor was of a dark, 
 
 Fig. 66. — Suddkn Torsion of a Sibperitoxkal I'lcinNcuLATKi) Myoma with Complete Shl'ttino pKF of its 
 
 Blood-supply, 
 
 Gyn. No. 12709. I'ath. No. 9.545. The utenis was relatively iioniial in size. The right appeiulases were 
 densely adherent. The left tube was dilated, as seen in the drawing, and the ovary contained a cyst. 
 
 .Attached to the funihLs is a subperitoneal pedunculated myoma. This is very dark in color, and its vessels 
 are much ililated, owing to one complete turn of the myoma on its pedicle. The twist is clearly seen at a. 
 
 reddish-green color, hut had not as yet undergone^ necrosis. The omentum was 
 lightly adherent over its surface. The right apiK'iidages were densely adherent. 
 The left ovary contained a cyst, 7 cm. in diameter. 
 
 The uterus was removed and the cyst evacuated. The tem])erature reached 
 102° F. on the second day. but recovery was speedy. 
 
 Pat h . X o . 1) .') 4 .") . Sections from the tumor sliowed that the blood- 
 vessels just beneath the capsule of the st rangulat eil subiKiitoneal myoma were 
 very much dilated and the myomatous tissue itself had undergone slight cystic 
 change. Had this patient not been ])rom])tly ojierated u])oii gangrene of the 
 strangulated tumor would have soon taken |)lace ;md ])eritonitis followed. 
 
 Torsion of the pedicle was also noted in Cases 4485 and 7220.
 
 CHAPTER MI. 
 HYALINE AND CYSTIC DEGENERATION. 
 
 Hyaline Degeneration of Uterine Myomata. 
 
 The majority of myomata show cithcu- gross or histologic pictures indicative 
 of hyahne degeneration. In order to exchide absohitely the presence of h3'ahne 
 changes it is, of course, necessary to carcfuhy cut each myoma and also to 
 make slides from innumerable portions of each tumor. In our consideration of 
 the sul)ject we have dt>alt with only those tumors in which the degeneration was 
 readily recognized. In 114 of our cas(>s early or advanced changes were easily 
 detected.* 
 
 A thorough knowledge of the early literature on the subject can be obtained 
 from a study of the comprehensive article on Fibromata and Cystofibromata of 
 the Ovary by H. C. Coe.f Although published more than twenty-five years 
 ago, it deals with the subject of degeneration of solid ovarian and uterine tumors 
 in a clear and succinct manner and is written in a very attractive style. 
 
 A careful study of the subject has led us to classify hyaline degeneration of 
 uterine myomata according to the following stages: 
 
 * List of Cases or Hyaline and Cystic Myomata. 
 
 Gyn. No. 
 
 Gyn. No. 
 
 Gyn. No. 
 
 Gyn. No. 
 
 
 659 
 
 3345 
 
 4193 
 
 11806 
 
 San. 1682 
 
 1628 
 
 3349 
 
 4293 
 
 11944 
 
 
 1672 
 
 3385 
 
 4415 
 
 11984 
 
 San. 1868 
 
 1909 
 
 3394 
 
 4441 
 
 11989 
 
 San. 1924 
 
 2606 
 
 3408 
 
 4485 
 
 12139 
 
 San. 1925 
 
 2672 
 
 3437 
 
 4635 
 
 121S5 
 
 San. 1973 
 
 2691 
 
 3440 
 
 4828 
 
 12225 
 
 F. Auji. 10. 1902. 
 
 2699 
 
 3445 
 
 4869 
 
 12234 
 
 C. H. I. 620 
 
 2718 
 
 3449 
 
 4894 
 
 12423 
 
 C. H. I. (i64 
 
 2746 
 
 3461 
 
 5021 
 
 12439 
 
 C. H. I. 7!)(i 
 
 2772 
 
 3475 
 
 5058 
 
 12453 
 
 C. 11. I. 1019 
 
 2777 
 
 3485 
 
 5141 
 
 12488 
 
 C. 11. I. 129() 
 
 2852 
 
 348S 
 
 5325 
 
 12522 
 
 
 2881 
 
 3491 
 
 5766 
 
 12591 
 
 
 3038 
 
 3493 
 
 6002 
 
 12696 
 
 
 3066 
 
 349S 
 
 6272 
 
 1273S 
 
 
 3107 
 
 3504^ 
 
 6432 
 
 1 2779 
 
 
 3113 
 
 3552' 
 
 7049 
 
 I2S39 
 
 
 3130 
 
 3522 
 
 7220 
 
 12SH 
 
 
 3199 
 
 3661 
 
 7511 
 
 12SI!) 
 
 
 3216 
 
 
 
 12S<il 
 
 
 3218 
 
 3SS2 
 
 8882 
 
 rjS77 
 
 
 3232 
 
 3960 
 
 ((0.30 
 
 13123 
 
 
 
 3971 
 
 •)l IS 
 
 1.3625 
 
 
 3296 
 
 3991 
 
 •t'.i-'l 
 
 II. A. K. I'd). 22, 
 
 , 1S96. 
 
 3320 
 
 
 lOl.^N 
 
 S:in. '.Ml 
 
 
 3338 
 
 1 1 7-' 
 
 1 1 ll'.l 
 
 Sail. Kll 1 
 
 
 Hm.I all 
 
 of our fascs Ik'cii ( 
 
 •aiclully cxainiiicd. 
 
 the huiiiIk T WKiild 1 
 
 Ki\c liccii matcri.-illy in 
 
 creased. 
 
 
 
 
 
 t AnifT. 
 
 Jour, of ( >l>st ('tries. 
 
 ISS'J. vol. \V. J). 5 
 S3 
 
 61. 

 
 84 
 
 MYOMATA OF THK ITKRUS. 
 
 1. Early hyaline changes recognizable only with the microscope. 
 
 2. Hyaline areas recognizable macroscopically. 
 
 'A. Advanced hyaline degeneration with liquefaction and the i'orniation of 
 small cysts. 
 
 4. Hyaline degeneration with the formation of large cysts in the myomata. 
 Naturally one stage gradually merges into the succeeding one. 
 
 c 
 
 Fig. 67. — Abrupt Transformation- of Myomatous into Hyaline Tissue. (X210 diameters.) 
 Gyn. No. 3107. Path. No. 472. In the left upper corner at a is typical myomatous tissue, but the greater 
 part of the field, as indicated by b, has undergone hyaline degeneration. This can be termed massive hyaline 
 degeneration, the muscle fibers ending abruptly and being almost entirely replaced by hyaline tissue. In a few jjlaces 
 colorless Hhers of connective tissue aie still in evidence. The majority of the free cells, as indicated by r, belong to 
 the endotheUum of the delicate capillaries. .\ few polymorphonuclear leukocytes are seen in the hyaline material. 
 
 Early Hyaline Changes Recognizable only with the Microscope.* — Only rarely 
 have we made a thorough examination of a myoma without finding areas of 
 hyaline changes. This degeneration is most easily recognized when the specimen 
 is stained with hematoxylin and eosin. The hyaline tissue takes the co.'^in stain, 
 and is usually recognized as a homogeneous tissue devoid of nuclei. The degenera- 
 tion may be scattered in patches throughout the field, but is generally sharply 
 
 * The following cases showed early histologic changes: 2606, 2672, 2691, 2699, 2746, 3107, 
 3218, 3338, .3385, 3408, 3437, 3493, 3552, 4441, 6002, 11984, 12139, 12185, 12225, 12423, 12439, 
 124.-)3, and 12849.
 
 HYALINE AND CYSTIC DEGEXEKATIOX. 85 
 
 circumscribed, as is well seen in Fig. 67. Here the muscle ends abruptly and is 
 rei)laced by hyaline tissue, with here and there a muscle-fiber or an endothelial 
 cell of a capillary still jK'rsisting. In other sections little masses of muscle- 
 fibers still survive as islands in the sea of hyaline tissue. This was noted in 
 Cases 2772 and 3349. Although the hyaline degeneration occurs frequently en 
 masse, it may show a predilection for the muscle-bundles, as in Fig. 68. In this 
 picture, although the stroma between the muscle-bundles shows hyaline degener- 
 ation, the muscle-bundles themselves show the most striking change, one 
 
 a trr 
 
 a 
 
 Fig. 68. — Focal Hyaline Degeneration in Muscle-bundle.s. (X120 diam.) 
 Cyn. No. 6002. Path. No. 2275. The tumor was a submucous myoma about 11 cm. in diameter. One is 
 instantly impressed with the small, delicate, discrete areas of hyaline degeneration indicated liy a, it. This is par- 
 ticularly well seen in the muscle-bundle indicated by b, nearly half of which has l)een converted into hyaline ma- 
 terial. The fibrous stroma (c) has also undergone some hyaline change. Such a distribution of the hyaline de- 
 generation is most unusual. 
 
 bundle containing at least five or si.\ large foci of hyaline degeneration. The 
 picture presented in P'ig. 68 is a most unusual one. 
 
 The blood-supply in the hynliiic area is usnall>- \cry liinitrd. but the sur- 
 rounding ti.ssue is often liberally studded with blood-vessels :iiid occasionally 
 there have been hemorrhages into the degenerated tissue. 
 
 In a few cases, as in (Jyn. Nos. 2772, 3()(;('). :521(), 12S77. San. \o. P.L'."). ('. II. I. 
 No. 1019, the hvaline degenernt ion is \i'i-y pi-oiuiunced ;ii-()U1h1 ihe Mdod-x-essels. 
 The vessels are usually small and, as shown in I'ig. (•'.», the eiidot lu'liuni of the 
 capillary still i)er.sists, but the \-essel-\v;ills ;ind the suiToiinding tissue have been
 
 86 
 
 MYO.MATA OK TIIK UTKHUS. 
 
 entirely eonveiled into hyaline inalefial. In only two cases (Nos. 3445 and 
 3488) (lid we find any small-round-eelled infill I'ation. 
 
 Hyaline Areas Recognized Macroscopically. — Tsually such changes are 
 not detecteil until the specimen has been cut o])en. 'i'hey may occur in sub- 
 peritoneal, interstitial, or submucous myomata, and may be limited to one 
 nodule or be ])resent simultaneously in several myomata. 
 
 Necrosis was noted 
 d 
 
 
 ,y^ 
 
 ^ 
 
 ■i*? 
 
 
 
 
 niacrosc()i)ically in cases 
 2881, 3199, 3296, 3991, 
 7511, 11461, and 12738. 
 
 Some of the tumors, 
 on palpation, are firm and 
 differ in no \\ay from an 
 ordinary myoma. Others 
 are soft and succulent and 
 occasionally the tumor 
 may give a soft, elusive 
 feel, suggesting a lipoma, 
 as was the case in No. 
 3294. 
 
 On cross-section the 
 area of degeneration is 
 usually sharply defined 
 and is whitish yellow in 
 color. In such an area 
 the muscle st nation is usu- 
 ally still clearly recogniz- 
 al)le. In Fig. 70 we have 
 
 Gyn. No. .3216. Path. No. 5.34. At a is the typical myomatous '^ "^ ^'O' gOOd exaini)le Ot 
 tissue. 6, h, b are transverse and longitudinal sections of blood-vessels tllC sliarp differentiation 
 surrounded by a broad zone of hyaline material. All that remains of the 
 normal vessel-wall is the endothelial lining. At c the myomatous 
 tissue has imdergone complete hyaline degeneration. The upper jiart 
 (if the field has been converted almost entirely into hyaline tissue. 
 The muscle-fibers that remain are gatheretl into little bunches that 
 stain very deeply at d, d, d. They are being gradually crushed out of 
 existence, owing to pressure exerted by a rapidly enlarging abscess in 
 the center of the myoma. 
 
 \iw- 'v- "**?■ *^ W i 
 
 
 .r.tf/- 
 
 mM^A 
 
 -^^j 
 
 Fi< 
 
 69. — Makkki) Hyaline Degeneration of the Walls of the 
 Blood-vessels in a Myoma. (X65 diam.) 
 
 from the surrounding my- 
 omatous tissue. The cen- 
 ter has undergone de- 
 generation. The fibrous 
 arrangement, although 
 somewhat alteix^d, is still 
 recognized, and in this case the degenerated area is separated from the sur- 
 rounding myomatous tissue by a zone of hyaline tissue from which all trace of 
 the fillers has disappeared. Fig. 73 (p. 93) represents the extreme hyaline 
 degeneration that may occur in a .subperitoneal myoma. Fully three-(iuarters 
 of the tumor has undergone hyaline transformation and the junction between 
 the unaltered myomatous tissue and the ai-ea of degeneration could hardly be 
 sharjH'r. The area of degeneration is in the i)art furthest from the bIood-su])ply.
 
 HYALIXK AM) CYSTIC DEGKXKRATION. 
 
 87 
 
 The area of hyaline degeneration is usually whitish yellow in color, but oc- 
 casionally we have seen it yellow. — bright yellow suggesting fat, — grayish blue, 
 grayish red, yellowish l)r()wn, pink, dark red. or a reddish blue. 
 
 Histologic examination shows that the hyaline areas are almost totally devoid 
 of cell elements. Here and there, however, a few muscle-fibers are still present. 
 
 Polyp 
 
 Polyp 
 
 Fk;. 70.— Hyaline Degenkration in the Center ok an Interstitial Myoma. (8 nat. 
 
 San. No. 941. I'ath. No. 411.3. The uterine cavity is con.si(leral>l.v clonKated; .situate.1 in 
 
 cervix are polypi. Occupying the anterior wall is an interstitial myoma aix.ut 1.5 cm. in <liamot 
 
 of this (a) has partially disintegrated. Separating this degenerated area fnim the ordinary myom 
 
 ribbon of h.\;iliiie material (b). 
 
 size.) 
 
 the funtlus 
 er. The ce 
 alous li.>isiH' 
 
 tiler 
 is a 
 
 The l)right yellow areas, as a rule, represent a simple liy.-iline degeiienition. but 
 occasionally the color is due to the large deposit of yellow pigment, the result of 
 old hemorrhage. 
 
 Where the areas are dark in coloi', vniying amounts of eoagulaiion neei-osis 
 are usually present. Here the tissue has undergone complete death. The out-
 
 88 
 
 .MVOMATA OF THK ITKIU'S. 
 
 lines of the iiiusclc-fihcrs and of the iiitci'vcning connective tissue still ])(Tsist. 
 The stain with hematoxylin and eosin is faint and rather indistinct and frag- 
 ments of nuclei are found. In a few instances a slight degree of infiltration with 
 polyinoi'phomiclear leukocytes can be noted. 
 
 Advanced Hyaline Degeneration with Liquefaction and the Formation of 
 Small Cysts. — The gradual merging of the hyaline myomatous tissue ])resents 
 
 the most delicate and 
 beautiful macrosco])ic and 
 microscopic pictures and 
 is readily followed in nearly 
 all the cases in which the 
 myoniata contain cystic 
 
 i*'^.' I S^-*^*K" • .• — ••^---^^- 
 
 ... ..-^s^v 
 
 
 . '^-s.- 
 
 :'j'^^ 
 
 de- 
 
 in 
 
 iefly 
 
 in 
 
 ■esent. 
 
 On palpation such a uterus, 
 after its removal, often 
 gives a sensation as if it 
 were Huctuant or semi- 
 fluctuant and at times is 
 so soft that the patholo- 
 gist may suspect a preg- 
 nancy if the uterus is 
 symmetrically enlarged. 
 So suspicious have we been 
 on several occasions that 
 we hesitated to cut into 
 the sjH'cimen fearing that 
 
 Fig. 71. — Edkma ok a Myoma. (X 120 diam.) 
 Gyn. No. 11989. Path. No. 8445. The entire picture presents a 
 loose appearance, in contrast to the compactness of an ordinary my- 
 oma. At a is a cross-section of a -swollen muscle-fiber. At fe is a fiber the OjX'ratol" had by UllS- 
 that has imbibed considerable fluid and the nucleus ha.s been pushed *" , 1 . .1 . i 
 
 the side of the cell. .\t c are two muscle-fibers which have appar- take I'einOVeU a UOrmal 
 cntly lost their nuclei. In the transverse sections the swollen muscle- nre^i'liailt Utcl'llS 
 fibers bear a striking resemblance to the e.xfoliated tubal epithelium 
 
 found in a hydrosalpinx. The apparently emiity spaces are filled with Oil SCCtlOll, tllC lliyoma 
 
 a serum of sufficient density to coagulate en masse instead of becoming rrivnif ^ tVir> 11 'ii'il 'ii-ii^ri'if 
 
 granular. 1 ' ' ^^ c ' 1 J "^ 
 
 ance, save for the fact that 
 it is very juicy and from the cut surface much serum runs off. This edema is 
 u.'^ually associated with hyaline degeneration, but may occur at points where 
 none exists. 
 
 Histologically, the usual jncture of edema is found (Fig. 71). The muscle- 
 bundles, and in some instances the muscle-hbers, are separated from one another 
 bv serum, recognized in the section as Hocculent or ti'raiiulai' matei'ial which takes
 
 hyalixp: and cystic degexeratiox. 
 
 89 
 
 the cosin stain faintly. Lying in this serum are isolated muscle-fibers cut either 
 transversely or longitudinally. These are much swollen and on cross-section 
 remind one of the swollen exfoliated epithelium often found in a hydrosalpinx. 
 Evidently, as a result of maceration, some of the muscle-fibers have lost their 
 nuclei. 
 
 Liquefaction of the Hyaline Tissue with Cyst Formation. — On section, the 
 myoma contains one or more translucent areas, which remind one of an apple 
 containing a ''water co¥e." Such areas are well seen in Fig. 74 (p. 95). As 
 the degeneration advances portions of these translucent areas become trans- 
 parent and are seen to be filled with 
 
 clear, serous-like fluid. Traversing " 
 
 them are delicate trabecukr. AMth the 
 continued degeneration the areas con- 
 taining clear fluid increase and one area 
 may merge gradually into another. 
 Thus in one myoma we may have the 
 ordinary myomatous tissue, translucent 
 areas, transparent areas, filled with 
 clear fluid, and the definite cystic 
 spaces. 
 
 This form of degeneration occurs 
 rarely in submucous myomata, more 
 commonly in interstitial nodules, and 
 most freciuently in subperitoneal tu- 
 mors. It may be limited to a small 
 area, as in Fig. 75 (p. 96), or involve 
 nearly half the tumor, as in Fig. 76 
 (p. 98) ; or it may be scattered through- 
 out the entire tumor (Fig. 116, p. 160). 
 In Fig. 79 (p. 101) large and small 
 cystic spaces are scattered every whcn-e 
 throughout the tumor and divided into 
 smaller spaces by trabecuke. Occa- 
 sionally the tumor may undergo almost 
 
 complete cystic transformation, as seen in Fig. M (p. lOL'i. in wliidi :i portion 
 of the tumor was like a ball of jelly having delicate trabecuhe rumiing thiMugii 
 and dividing it into large and small C()mj)artmeiits. 
 
 The cyst fluid is usually straw-colored, lim|)i(k and tiickles away fi'oin the 
 cut surface. In most cases it coagulates on exposuic to the air. but occasion- 
 ally remains liciuid. 
 
 Histologic A p |) e a 1' a n c e s of .M y o in a t a l' n d e r g o i n g 
 L i ([ u e f a c t i o n . — In I'ig. fi7 (j). SI) we liaA'e a good example of diffuse and 
 sharj)ly defined hyaline degeiieiat ion. .\fter a t inie t his hyaline t issue undergoes 
 
 Fig. 72. — Hyalixe Dkgeneratio.v with Cystic 
 Formation in a Small Scbperitoneal Ped- 
 unculated Myoma. (Nat. size.) 
 Gyn. No. 4415. Path. No. 1207. The upper 
 l)art of the myoma has undergone tyi)ical hyaline 
 degeneration, as seen at a; at b tliis has gone on to 
 cyst formation. Ct)vering the outer surface of the 
 cyst is a well-marked zone of myomatous tissue. 
 It will l)e noted that the degeneration is at a point 
 most remote from the source of lilnod-supply.
 
 90 MVO.MATA OF THE ITKHIS. 
 
 softening. The softening rcniinds one very much of the uneven melting of a largo 
 sea of ice on a hot sj)ring day. In some places it is still dense, in others fairly 
 thick yet rarefied: and where the heat has been most intense, the ice has almost 
 disapjM'ared. Tn the hyaline areas the tissue at first takes the eosin stain uni- 
 formly. A little later there ai'e certain areas whei-e the eosin stain has faded, 
 owing to the thinning out of the hyaline. Still later the hyaline has entirely dis- 
 aiJpeared in the rarefied areas, leaving them threadbare, so to speak, and showing 
 tile hbrillary arrangement of the remaining fibrous tissue: and finally there re- 
 main s])aces filled with a fine granular deposit — coagulated serum. 
 
 Some of these spaces are traversed by minute trabecuhe consisting of minute 
 capillaries, just sufficiently wide to allow one red blood-corpuscle to pass at a 
 time. 
 
 In Fig. 82 (p. 103) can be seen extensive hyaline degeneration, although 
 in })laces the muscle-bundles and individual muscle-fibers are still preserved. 
 Nearly all the hyaline material has vanished, only the fibrillatcd connective 
 tissue remaining, and at / even this has disap|)eai'ed, nothing luit li(iuid being 
 left. Fig. 83 (p. 104) is even more instructive. A few nmscle-fibers and bundles 
 still persist; the majority of the muscle-bundles have been converted into 
 hyaline tissue. They stain with eosin, stand out sharply, and are easily differen- 
 tiated from the stroma, which has also undergone hyaline degeneration. In the 
 center of the field the tissue has completely melted away and we have an 
 irregular cavity filled with coagulated serum, recognized as granular material. 
 
 Probably the most instructive picture in the series is Fig. 84 (p. 106). It is 
 from a degenerated myoma noted during pregnancy. In the upper part of the 
 field are a few bundles of swollen muscle-fibers. The great(>r part of the picture 
 consists of hyaline material that has undergone licjuefaction. The darker areas 
 indicate the amount of albumin held in the solution and all gradations in 
 density can be traced until we have areas in which the fluid contains practically 
 no albumin and the spaces are almost colorless. This process* of liquefaction 
 gradually advances until we have ninnerous small cysts, limited to one j)ortion 
 01-, as is frequently the case, scattered throughout various portions of the tumor. 
 
 Hyaline Degeneration with the Formation of Large Cysts in the Myomata. — 
 L'rom the |)i'eceding pages we have seen that the hyaline areas in the myomata 
 gradually undei'go li(|Uefaction and that ^uiixW cy.st-like spaces are developed. 
 It has further been noted that these are not true cyst sjxices, as they are merely 
 the reservoirs of the broken-down tissue and their walls are conqiosed of ragged 
 hyaline tissue. Naturally, such cavity formations have neither an epithelial 
 nor an endothelial lining. 
 
 With the gradual disintegration of the tumor it is only natural that \hr cystic 
 
 * In tlie following cases small cyst-like spaces were noted in the degenerated myomata: 
 Nos. 2718, 3107. 3113, 3488. .3498, 3622, 36G1, .3882. 3977, 3991, 4172. 441.5, 4635, 4894. .5021, 
 5058, 5141. 5325, 6272. 7511. 9924, 10573, 11806. 12194. 12779. 12864, C. H. I. Petli., San. 
 1011, San. 1924, C. H. I. \V., C. H. I. 1019
 
 HYALIXE AXD CYSTIC DEGF.XKUATIOX. 91 
 
 spaces should increase in size, first by the gradual crunibUng down of their own 
 walls and, secondly, by the merging into them of other cystic spaces, the 
 process in so far being analogous to that which occurs in a multilocular ()\;irian 
 cyst. 
 
 In Fig. 85 {]). 107) we have an excellent example of an interstitial inyoina 
 that has been converted into one hirge cavity and has trabecuhe extending from 
 side to side. Its walls were composed of friable hyaline tissue. It was filled 
 with a clear serous fluid. 
 
 The myoma in Fig. 86 (p. 109) measured 23 x 25 x 81 cm. It had been con- 
 vert (hI into one large cavity, the walls being composed of shaggy tissue, and con- 
 tained a central core of shaggy tissue held in place by trabecuhp extcMiding to the 
 cyst-walls. The core and the trabecular represented the more resistant portions of 
 the tumor which had not gone on to liquefaction. The cavity was filled with a 
 turbid, greenish-brown fluid. 
 
 In Fig. 87 (p. 110) the process has gone on more slowly, there being large and 
 small cyst spaces and much tissue that has undergone only partial disorganization. 
 
 In Fig. 89 (p. 113) we have a large subperitoneal myoma that presents a hone}-- 
 combed appearance and also contains several large cystic cavities. \\\'iv the 
 uterus hidden and the outer muscular covering obscured, the tumor might 
 readily be mistaken for a nmltilocular ovarian cyst. 
 
 The cystic tumor seen in Fig. 90 (p. 114) is evidently an old one. The hyaline 
 tissue to a great extent has become licjuefied, and there have be(>n numerous 
 secondary cavities, as indicated by the trabecuhe which carry blood-vessels (Fig. 
 91, p. 115). 
 
 The multilocular cystic tumor noted in Fig. 92 (p. 117) is a most unusual one 
 and, looking at it casually, one could very readily mistake it for an ovarian cx-st. 
 
 These tumors* may reach very large proportions. In No. 13025 the myo- 
 matous uterus weighed 39 pounds, the greater part of the tumor being made ui> 
 of one cyst (Fig. 93, p. 119). With the abdomen open we at hrst felt sure that 
 we were dealing with an ovarian cyst, and it was only when wo reached the jH'dicle 
 that the true nature of the mass was determined, (^ur largest cystic myoma 
 weighed 89 pounds. It is described in detail on ]). 512. 
 
 Fluid. — The cyst fluid is usually straw-colored. In the small(>r cysts it 
 usually coagulates on exj)osur(> to the air, but in the largei' ones olten ivinains 
 li(|uid. In No. 7049 the fluid was turbid and givenish brown in color. Willi 
 the disintegration of the tumor theic may be hemorrhage into the cavitw .and 
 then the fluid is red, reddish brown, oi' cliocol;ii<'-coloivd, .accoiding to the length 
 of time that has elapsed since the bleeding. In .No. 122:11 I he ca\ily was lilled 
 with |)ale clots. 
 
 The cystic myoma repivseiited in JMg. 90 (p. 122) is a most unusual one and 
 
 * In the t'ollowing cti.scs liyaliiie dogent'nitioii aiui larsic cystic spaces were noted: Nos. 0,39, 
 1628, 1672, I!)(H», :^ t tO, :?44."). 3.-)2.3, 3960, 1 IS."). t,S2S, M:i2. 70 19, .SSS2, 91 IS, 104GI, 12234, 12488, 
 1.3423, 1362.-), San. 192.-), ('. II. I. 1'., C 11. I. 1296.
 
 92 MYOMATA OF THE ITKRUS. 
 
 Ix'ars a striking rcsciiihlancc to the interior of a heart. It was lined with 
 myomatous muscle, had no endothelial lininiz:, and was fille(l with a clear Huid. 
 
 On histologic examination we have found that nearly all these cystic si)ace.s 
 are linetl with hyaline material. This occasionally bears evidence of an old 
 hemorrhage, as is indicated by the yellow pigment in San. No. 1925 and by the 
 deposit of brown granular pigment in Xo. 3960. 
 
 C a u s e of Cystic Degeneration of M y o m a t a . — In the vast 
 majority of the cases the hyaline degeneration is the primary factor. Dilatation 
 of the lymi)hatics. however, may occasionally be partly responsible for some of 
 the cystic spaces, as indicated by the two following cases: 
 
 In Xo. 3113 a tumor, 25 cm. in diameter, had sprung from the posterior wall 
 of the uterus. On section, it was whitish in color, and presented a finely striated 
 ai)i>eai-ance. Scattered everywhere throughout the tumor were sinuses, the 
 largest being 1.2 cm. in diameter. These sinuses had smooth walls and communi- 
 cated with numerous smaller ones. On histologic examination the tumor was 
 found to be edematous in i)laces. Some of the large and small spaces had an 
 endothelial lining. In others no lining could be found. As the blood in the 
 arteries and veins had been well preserved in Miiller's fluid, and since these 
 spaces were comparatively free from blood, we were inclined to believe that they 
 were lymph-channels. 
 
 In Xo. 4S2S a cystic myoma, 27 cm. in diameter, had s|)rung from the uterus. 
 There was one large cyst and numerous smaller on(>s. On histologic examination 
 the cystic spaces were found to be due in ])art to li(iuefaetion, luit others were 
 evidently dilated lymph-s])aces. as proved by the lining, which consisted of one 
 layer of endothelium. 
 
 Hyaline Degeneration of Myomata with Emulsified Fat in the Cystic Areas. — 
 Almost constantly we find that li(iuefaction of hyaline material yields spaces filled 
 with a clear yellowish Huid, but in two instances the resultant cavities have con- 
 taincl-d a material resembling melted butter. In Xo. 2852 the posterior wall was 
 occupied by a myoma, 12 cm. in diameter. This contained two caviti(>s, one 
 measuring 2 x 2.5 cm., the second 4.5 x 5 x 6 cm. (Fig. 98, p. 124). Both of these 
 spaces had convoluted and smooth walls and were lined with a smooth, butter- 
 like material, which was semisolid: both cavities were filled with a liquid which 
 closely resembled melted butter. Histologic examination showed that the my- 
 oma had undergone moderate hyaline degeneration and that the walls of the 
 cavities were composed of hyaline material. 
 
 Innnediate examination of the fluid from the cavities showed that it con- 
 tained many cholesterin crystals, large round cells filled with fat-globules, and 
 many muscle-fibers containing fat-droplets. There was much granular detritus. 
 In this case there had been first a hyaline degeneration and then emulsification, 
 or, in other words, fatty degeneration with li(|uefaction of the hyaline material. 
 
 In X'(j. 3475 a nodule, 4.5 cm. in diameter, springing from the right side of the 
 uterus, contained a soft, friable central portion of the consistence of casein. On
 
 HYALINE AND CYSTIC DEGEXKHATIOX. 
 
 93 
 
 histologic examination nearly the entire tumor was found to be necrotic. The 
 creamy material from the center of the myoma was composed of elongate cells 
 partly filled with fat-droplets. There was much free fat and here and there 
 masses of cholesterin crystals. The changes in this case were analogous to those 
 noted in the preceding one. 
 
 Relation of Hyaline Degeneration to Sarcoma. — Hyaline degeneration cer- 
 tainly seems to favor the development of sarcoma. The cells that resist the 
 hyaline change lie free in the hyaline tissue or in the serous fluid and occasionally 
 take on active development. This subject is discussed in detail in the cha})ter 
 on Sarcomatous Transformation of Myomata (p. 175). 
 
 Detailed Report of Cases Showing the Various Types of Hyaline Degeneration. 
 
 In our brief description it has been impossible to describe in detail the various 
 degenerative changes. ^\c, therefore, give in extenso the more characteristic 
 cases which portray accur- 
 ately the various steps in 
 the hyaline degeneration. 
 
 Gyn. No. 751 1. Path. No. 
 3757. 
 
 Extensive and 
 sharply d e fi n e d 
 
 hyaline d e g e n e r a - 
 t i n in a s u b p e r i t - 
 n e a 1 pedunculated 
 Myoma (Fig. 73). 
 
 A. D., aged thirty, mar- 
 ried, black. Admitted Janu- 
 ary 16; discharged February 
 9, 1900. 
 
 Path. No. 3757. The 
 specimen consists of a myo- 
 matous uterus with its a))- 
 
 pendao'eS. Th(^ bodv of the Fk;. 7.3. — ExxENgivE and Sharply Dkhnki) Hyai ink DniiKN-KWA- 
 
 TION IN A SUBPKRITONKAI- MyOMA. (J Iiat. .size.) 
 
 uterus measures cm. m ^^^ No. 7511. Path. No. 37r)7. The tumor n'presi'iil.s a 
 
 lenffth 4 5 cm in br('a(hll cross-section of a subperitoneal i)e<lunc'iiliit«'d in.VDma, 7 xStx 10 cm. 
 
 The fourth of the tumor nearest the ix-ilicle presents thej usual 
 and 3.5 cm. in its ailtcropOS- myomatoiis appearance, as seen at .;. I'ull.v ihree-f.uirllis of tlie 
 
 terior diameter. .Vntcriorly 
 it is smooth and glistening. 
 Posterioi'ly it is covei'ed 
 with numerous adhesions. 
 Studding the uterine walls and also pi-ojecling iVoni the surface are several 
 
 tumor is mucli hjihter in color and stands out in sharp eontnust 
 with the unaltered myomatous tissue. 'I'he line of demarcation 
 is well shown at h. In the larRe hyaline area the tihrousJarraiiKe- 
 iiKiit is still visilile. The center of the deRenerated area has broken 
 down and contains f;ranular material, as seen at r.
 
 94 MVOMATA OF THK UTERUS. 
 
 small iiiyoiiiata : posteriorly, near the cervix, is a suhpcritoiical nodule, 4.5 
 cm. in diameter, envelo|)ed in adhesions. Tt shows an area of hyaline de- 
 generation, 2.5 em. in diameter. The chief interest lies in a subperitoneal 
 myoma springinii' fi-om the left side (Fiji'. ~-^)- Tiiis is co^•ered with a few 
 omenta! adhesions, and ])oslcriorly is pushiiiii aside the folds of the hroad liga- 
 ment. It measures 7 x!) x 10 cm. On .section it j)resents a very unu.sual pic- 
 ture. One-fourth of its .substance consists of tyjVical myomatous tissue. The 
 remaining three-fourths is light in color and very shai'])ly defined. In this 
 light-colored aica the central i)ortion has melted away and left aji irregular, 
 ragged cavity. 
 
 Micro.scopically, the uterine nuicosa is normal. The light area in the sub- 
 peritoiu'al myoma consists in ])art of necrotic tissue entirely devoid of nuclei, 
 but containing large and small calcareous deposits. Other portions show some 
 hyaline degeneration. The appendages, apart from adhesions, are normal. 
 
 San. 1924. Path. No. 8824. 
 
 M a r k e d h y a line d e g e n e rati o n with 1 i q 11 e f a c t i o n 
 of an interstitial myoma (Fig. 74). 
 
 P.. aged fifty-two, married. Achnitted May S; discharged June 13, 1905. 
 
 Path. No. SS24. The tumor is irregularly heart-shaped. It is 12 cm. in 
 length. IS cm. in breadth, and 20 cm. in its anteroposterior diameter. Tt is 
 smooth and glistening. Attached to the side are the tubes and ovai'ies. The 
 great inci-ctise in size of the uterus is due to an interstitial notlule, 11 x 15 cm. 
 It is sharply circumscribed. In some ])laces the myoma is perfectly ))reserved, 
 but at least two-thirds of it has undergone degeneration (Fig. 74). The spaces 
 are filled with coagulated fluid. At a point most remote from the uterus there 
 has been a slight breaking down and the cystic si)aces -thus formed vary from 
 0.5 to 4 cm. in diameter. The.se have .smooth walls. The myoma presents the 
 typical ])icture of hyaline degeneration, with .subsecjiu^nt cystic formation. 
 
 Micr()sc()])icall_\' the myoma shows marked hyaline degeneration. Scattered 
 throughout this hyaline material are little bundles of muscle-fibers. 
 
 Gyn. No. 9924. Path. No. 61 18. 
 
 Cystic (1 e g e n e |- a t i o n o f a p o r t i o n of a ]) e d u n c u - 
 1 a t e d s u b ]} e r i t o n e a 1 m y o m a (Fig. 75). 
 
 E. S., aged forty-nine, married, white. Admitted September 23: di.<charged 
 October 18, 1902. 
 
 Path. No. (ills. The specimen con.sists of an irregular, nmltinodular, myo- 
 matous uterus, which is apjii'oximately 15 cm. in breadth and S cm. in its antero- 
 posterioi- diametei-. .Vtt.ached to it are the tubes and ovai'ies. 
 
 The utci'us contained pedunculated, sessile, interstitial, and subnuicous 
 nodules. ( )ne pedunculateil nodule s])ringing from the posterior sui'face is aj)- 
 ))i'o\imately (i cm. in diameter and nmlberry-shaped, there being litth' nodules
 
 HYALIXE AND CYSTIC DEGEXERATIOX. 
 
 95 
 
 projecting from its surface everywhere. Attached to the posterior surface of the 
 fundus by a pedicle, 2 cm. in diameter, is an oval subperitoneal nodule. 8 x 12 x 14 
 
 (. ■'- 
 
 Fig. 74. — .Mahkkd Hyaline DF;c;E.NKHAri(>N w nil Ln^i ki-aci io.n oi- an In tkhsti ii ki. M vo.m v. (■ nut. size.) 
 San. No. 1924. Path. No. 8824. The incUiie lepieseiits an ol)li(iii(> sectimi llimuuli llu- uterus; tlio ulctine 
 cavity has not been entered. 
 
 The interstitial myoma is 11 x 15 em. a indicates the outer eoveriiiK <>f uterine niuschs l> the juiu-linn 
 of the myoma with the muscle. The greater jiart of the myoma has underRnne iiyaline defeneration with liiiue- 
 faction, the litiuefied areas reminding one of the "water eore" occasionally seen in an ai>i)le. The liiiuefieil areas 
 are well seen at d. Scattered throughout the deKeiierated areas are irrcKular patches of typic.-d myomatous (issue, 
 the largest area being at r. In some jjlaces the licpiefied areas have gone on to cyst formation, as designatctl at t. 
 
 cm. (Fig. 75). It is partly solid, pjirlly cystic. < )ii section, the portion nearest 
 the uterus seems to be firm, but about one-sixth of the luiiioi-, at a jioiiit remote 
 from the pedicle, is soft and cystic and much jialei- in color. This cystic ])ortion
 
 96 
 
 MYOMATA OF TIIK UTKUrS. 
 
 is filled with clear Huid aiul tliffer.s markedly in eoloi' fr(»iii the ordinary inyomat- 
 
 ous tissue. The line of de- 
 marcation is exceedingly 
 sharp, the tumor pri'sent- 
 in<2; a ratlier porous ap- 
 pearance and being yel- 
 lowish white in color. 
 Where the degenerative 
 process is markedly ad- 
 vanced, the tissue is honey- 
 combed and we then have 
 irregular spaces, with deli- 
 cate trabecuhe running 
 
 Fig. 75. — Cystic Degeneration of a Portion of a Pedunculated, Subperitoneal Myoma. (? nat. size.) 
 
 Gyn. No. 9924. Path. No. 6118. The uterus contains numerous nodules. Springing from the right and 
 anterior a.spect of the fundus is a subperitoneal pedunculated myoma, 8 x 12 x 14 cm. The upper portion (a) has 
 undergone hyaline degeneration, with subse<iuent liciucfaction. Traversing the cavity everywhere are large and 
 small trabecula>, dividing the degenerated area into cystic spaces of different sizes. These were filled with a clear, 
 straw-colored fluid. 
 
 Histologic Examination. — The walls of the cystic spaces are composed entirely of hyaline tissue, and there is 
 no endothelial lining. 
 
 It is interesting to note that the degeneration has occurred at the point farthest removed from the source of 
 blood-supply — the pedicle. Projecting from the surface of the uterus, between the Fallopian tubes, is a small 
 nodule. The upper half is very pale, as indicated by b. The pallor is due to hyaline degeneration occurring in 
 this myoma also. 
 
 The Fallopian tubes are somewhat thickeiied. Bnth fimbriated extremities are free. The tubes were the seat 
 of tuberculosis. The endometrium also showe 1 an early tuberculous process. 
 
 acro.ss them, 
 liquefaction. 
 
 The picture is typical of hyaline degeneration with gradual
 
 HYALIXE AND CYSTIC DEGEXERATIOX. 97 
 
 Microscopically the area of degeneration consists entirely of hyaline tissue. 
 This tissue is devoid of nuclei except for a little rim on the outer surface. Here 
 the muscle-fibers are still preserved. The trabecuUe traversing the cavities con- 
 sist of hyaline tissue that stains a little deeper than that filling some of the spaces. 
 It contains some calcareous ])lates. Examination of the uterine mucosa shows 
 tuberculosis of the endometrium. There was also tuberculosis of both tubes, and 
 the adhesions around the uterus contained tubercular nodules. 
 
 Gyn. No. 12864. Path. No. 10311. 
 
 A large m u 1 t i n o d u 1 a r m y o m a t u s u t e r u s with a 
 huge s u b p e r i t o n e a 1 {) e d u n c u 1 a t e d m y o m a u n d e r - 
 going cystic degeneration (Figs. 76 and 77). 
 
 M. B., married, aged forty-four, black. Admitted April 21: discharged 
 May 23, 1906. In this case the enlargement of the abdomen was first noticed 
 fifteen years ago. The growth has been slow. Seven years later her physician 
 diagnosed a myoma, but advised against operation. The abdominal enlai'ge- 
 ment steadily increased. For the last five months there has been some jiain in 
 the lower part of the back and in the abdomen after exertion. For three months 
 there has been rapid growth of the tumor. The patient has not been incapaci- 
 tated or inconvenienced seriously until within the last three or four months. 
 During the last few days there has been considerable difficulty in mictui'ition. 
 
 At operation the omentum was found to be markedly adherent. Tlu^ omen- 
 tal vessels were greatly dilated. The tumor was very soft and strongly sugges- 
 tive of sarcoma. It bled with the utmost readiness. It was so densely adherent 
 that during its removal the left side of the bladder was opened. The patient 
 made a very satisfactory recovery. 
 
 Path. No. 10311. The specimen consists of a huge multinodular myomat- 
 ous uterus, 20x25x28 cm. The myomata have undergone hyaline degenera- 
 tion. Attached to the left side of the uterus is a large ])edunculated myoma 
 (Fig. 76). Its upper half presents the usual myomatous a])])earance. The 
 lower half has undergone marked degeneration, is dark in color, and contains 
 numerous cystic spaces. 
 
 Histologic Examination. — In the degenerated ])ortion of the myoma there is 
 coagulation necrosis and also a good deal of hyaline degeneration. The cystic 
 spaces are devoid of nuclei, showing neithei- eiidoihelial nni- ejiiihelial lining. 
 In certain parts of the myoma the en.lotheliiiin of the c.aiiillaries has piolilei-ated 
 to such an extent that the muscle-fiheis are di\ided up into ahcoli i l-'ig. 77t. 
 At hrst sight one might \'eiy I'eadily diagnose a malignant growth. .\t other 
 points there is a typical hyaline degeiieiation. 
 
 Gyn. No. 3991. Path. No. 990. 
 
 Disintegration o f t h e c e n t i' a 1 p o v I i o n o f a n i n t e r - 
 s t i t i a 1 m y o ma ( Fig. 78).
 
 Fig. 76, 
 98
 
 HYALIXE AND CYSTIC DEGEXEUATIOX. 
 
 99 
 
 L. N., single, aged forty-seven, white. Admitted November 29; discharged 
 December 30, 1895. 
 
 Path. No. 990. The specimen consists of the uterus with the appendages. 
 The uterus is globular in shape and approximately 10 em. in its various diam- 
 eters. Scattered over its surface are several small subi)eritoneal nodules, vary- 
 ing from 1 to 3 cm. in diameter. The uterus is covered with numerous adhesions, 
 
 Fig. 77. — Marked Proliferation of thf. Endothelium of the Capillaries Dividinc; the Mvomatois Tissue 
 
 INTO Alveoli. (X120diani.) 
 Gyn. No. 12864. Path. No. 10.311. The myomatous tissue presents the usu.al appearance, but ilividiug it 
 up into fairly regular alveoli are deeply staining bands of tissue. These dark-staining cells are proliferated and 
 deeply staining endothelial cells of the blood-capillaries. The picture is a most unusual one. 
 
 those on the posterior surface being rather dense. On pal])ati()ii it is rather solt 
 and yielding, giving an indistinct sensation of fluctuation. The uterine cavity 
 is 9 cm. in length, at the fundus 5.5 cm. in bn^adtii: the mucosa is rouglient'd and 
 corrugated in appearance. The portion covering the jxjsterior surlace near the 
 right cornu ])resents an area of thickening 1 cm. in diameter, and (■(•Mtains nu- 
 merous dilated glands, varying in size from a pin-|)oinl to 1 mm. Situated in the 
 anterior uterine wall are several firm white lu.dules. varying from 0.5 to 3 cm. and 
 
 Fig. 76. — Cystic Degeneration in a Laucje Si'ih-ekitonkal I'i.di n< i i.aii-.i> .M^omx. .,. "•"■ -i'< ■ 
 Gyn. No. 12864. Path. No. 10311. To the right is an enlarged inyoinaloua uterus, reoogniwible by the left 
 tube and ovary above and the rro.ss-section of the cervix below, n is the small pedicle ronnecting the large tumor 
 with the uterus. Attached to the lower end of the tumor i.s a broad omental adhesion. Hejow the line, between 
 b and //, the peritoneal covering is of a darker hue and tlie surface is smooth, suggesting .legcnerative changes in 
 this portion of the tumor. The ui)i)er part of the myoma, on section, presents the usual appearance. Near the 
 middle are small, .smooth-walled cysts. The lower lialf of the tumor is much darker in color, owing to the de- 
 generative change, and contains numerous cystic spaces. lliNlol.igii- c\Mniiii:ilioii -.|„,w> ihni (he chief changes are 
 due to hyaline degeneration of the tumor.
 
 100 
 
 MYO.MATA OF TIIK LTKHIS. 
 
 presenting the typical myomatous appearance. The posterior wall is occupied 
 by a tumor 8 cm. in diameter (Fig;. 78). This tumor is surrounded by a di.-<tinct 
 capsule of uterine muscle, varying; from 0.6 to 2.5 cm. in thickness. On section, 
 it is found to be composetl of bunches of fil)ers concentrically and irregularly 
 arrang;ed. Its entire central portion over an area 5 cm. in diameter has degen- 
 erated and contains a tenacious, semisolid material. 
 
 cav 
 
 Fol 
 
 ji.SecHeii 
 
 Fic. 78. — Co.'^GOL.vTioN Necrosis and Hyaline Degexer.\tiox ok ax Interstitial Myoma. ( ", iiat. size.) 
 Gyn. No. .3991. Path. No. 990. a is one of several small niyoinata occupying the anterior wall. In the 
 
 uterine cavity near the cervix is a small polyp. Occupying the posterior wall is a myoma S cm. in diameter. The 
 
 central portion ha.s broken down, forming an irregular cavity x^d) filled with a tenacious, semisoliil material. At c 
 
 is a colony of small cysts. 
 
 On histologic examination the degenerated area was found to consist partly of hyaline material and partly of 
 
 tis.sue that had undergone coagulation necrosis, with fragmentation of the nuclei. 
 
 Histologic Examination. — The nodules in the uterine walls present the usual 
 appearance, and the degenerated myoma occupying the posterior wall is likewise 
 compo.sed of non-striated mu.scle-fibers undergoing coagulation necrosis. The 
 central portion is represented Ijy a pale-staining fibrillated or almost homoge- 
 neous material from which the nuclei have disappeared, but in other ])ortions.
 
 HYAI.IXK AND CYSTIC DEGKXKHATIOX, 
 
 101 
 
 lurgc nunilx'r.s of l'ragim'iit('(l nuclei aiv seen. (_)n i)assing toward the uterine 
 muscle the degeneration becomes less marked. 
 
 San. No. loii. Path. No. 4508. 
 General a n d d i ft' u s e c y s t i c f o r m a t i o n i n a m y o m a 
 (Fig. 79). 
 
 ,ty 
 
 C e r V 1 
 Fig. 79. — General and Dikkusk Cystic Iohmation in a Myoma, {'i nat. size.) 
 
 San. No. 1011. Path. No. 4.508. o indicates the upper limit of the uterine cavity. The Rreiil incn-xM- in 
 size of the uterus is due to an interstitial and degenerated myoma. Inward it extends to the mucosa; outward il 
 is covered with a zone of normal uterine muscle. The line of junction lict ween the nuiscle and the myoma is sliarpiy 
 defined, as indicated by 6. The tissue jMcsents a diffuse, honeycomlicd appearance. The <-ysts are of different 
 forms and traversing them are broad and also delicate trabecuhc. 'I'he cyst-spaces were tilled with lliiiil. 
 
 In the solid portions of the tumor the typical myomatous tissue is still preserved, but shows abumlant Ijyalitie 
 degeneration. The walls of the cavities coiisi-l cliicdN of li.\ aline material. Tli.- cavities wereilevoid of any epithe- 
 lial or eniiothelial lining. 
 
 J. H. T., aged fift\'-thn'c, white, iiiaiTicd. .\iliiiille(l ()ct(ilier I."): discharged 
 November 22, 1900. In this case, at'tei- doing a liy.^tei-ectoiiiw tiie dperator 
 removed several gall-stdiies. 
 
 Path. No. -loOS. The speciineii consists of a large niyonialous uterus with
 
 102 .MVOMATA OF THF-: UTERUS. 
 
 the tul)rs and ovaries attaclu'd. The tumor incasurcs approximately IS em. in 
 diameter. It is everywhere soft and elastie, and is covered with perfeetly 
 smooth peritoneum. On section, the tumor is seen to consist of a thin wall, 1 cm. 
 in thickness, with an interior filled with a brain-like substance (Fig. 79). The 
 growth is really a cyst, with remnants of the muscular tissue occurring as a cen- 
 tral ma.ss, supported by delicate trabecuhe extending to the outer wall. The 
 spaces wen^ filled with a iluid,a))))arently serous in character, l)ut as the specimen 
 was hardened before being opened, no definite statement can be made. 
 
 Histologic Examination. — Sections through the capsule of the tumor show 
 that it is made up of fibrillated connective tissue and non-striped muscle-fibers. 
 Sections from the large cystic myoma show that it consists of myomatous tissue, 
 in most ])laces the seat of a considerable degree of hyaline degeneration. In 
 other j)laces, however, the muscle-bundles present the usual appearance. In 
 some portions of the tumor the tissue has absolutely lost its structure and 
 nothing remains except large, pale-staining areas, which have scattered through- 
 out them groups of large, swollen, spindle-shaped and round cells. These are 
 undoubtedly swollen muscle-fibers which have l)een cut longitudinally and 
 transversely. At first sight they .suggest sarcoma cells, but there is no evidence 
 of any activity. The cyst-spaces show no evidence of an}' endothelial lining. 
 
 Gyn. No. 3345. Path. No. 616. 
 
 M a r k e d c y s t i c d e g e n e ration of p o r t i n s o f a m y o - 
 m a that h a d u n d ergo n e h y a 1 i n e degeneration ( Figs. 
 SO and 81) . 
 
 E. Z., married, aged forty-three, colored. Admitted February 25; discharged 
 April 4, 1895. Three years ago the patient noticed a bearing-down feeling in 
 
 the abdomen and two and a half years later a lump 
 just below the umbilicus. This was approximatel)^ 
 4 X 4.5 X 5.5 cm. It has groAvn rapidly since its 
 ap})earance, but has not been associated with any 
 pain. 
 
 Path. No. 616. The s])ecimen comprises the en- 
 larged uterus, with a tumor springing from its right 
 side, and the appendages. The uterus is oval in con- 
 FiG. 80.— Gyn. \o. .3.34.5. tour, mcasuring 10 X 12 X 16 cm. Springing from its 
 
 Path. No. 616. The general con- , . i ^ • p i i ^•^ 
 
 tour and relations of the myoma antcHor aud postcnor surtaccs are several dome-like 
 seen in Fig. 81. iiodulcs, the largest of these being 4 cm. in dia- 
 
 meter. Projecting from the right side of the uterus is 
 a kidney-.'^haped tumor, 12x13x21 cm. (Figs. 80, 81). This is smooth and 
 glistening, and in many places traversed by numerous blood-vessels. It is at- 
 tached to the side of the uterus by a short pedicle, 4 cm. in diameter. On pal- 
 pation the tumor is soft and gives one the impression of being cystic. It has an 
 outer and firm rim, varving from 0.5 to 1 cm. in thickness, but the entire cen-
 
 Fig. 81. — Complete Cystic Degener.'VTIon of Portions of a Myoma that had UNi)KR<iONE Hyaline Oegenkr- 
 
 ATio.N. (Nat. size. 1 
 
 Gyn. No. 3345. Path. No. 616. The relation of the tumor to the uterus is iiulicuteii in Vig. SO. 1 In- st-ction 
 here depicted was obtained by cutting into one end of the peduncuhited noilule. 
 
 The outer covering consists of uterine muscle which is much congested. (Occupying the entire n-nter ..f the 
 field is a lemon-colored cystic mass. Dividing the tumor into large and small cysts wore delicate trabecuhr, many 
 of which carried delicate blood-vessels. On cutting into the mass clear, serous-like (lui.i escapiil iiikI soon coagu- 
 lated, forming a delicate, jelly-like ma.ss. Other portions of the tumor presente«i the characteristic hyaline changes. 
 
 Unless one has seen such tumors, he might .loubt the accuracy of the coloring, but Mr. Brudel was fortunately 
 on hand just as the specimen was cut and caught the various hues perfectly.
 
 HYAl.IXE AXI) CVSTIC DKCKX KUATK )\. 103 
 
 tral portion is soft and l)n'akinii; down. Traversing sonic ))ortion.s of the 
 center is an irregular core of solid tissue which is attached to the outer wall in 
 various places. One portion of the section, however, is entirely cystic; it is of a 
 lemon color and is traversed by delicate trabecula\ On cutting into it sei'ous 
 fluid escaped, which soon coagulated (Fig. 81). 
 
 Histologic Ivxaniination. — The large and degenei-ated nodule to the right of 
 the uterus is coniposetl of non-striped muscle-fibers. Between the Inmdles and 
 muscle-fibers are numerous homogeneous areas of hyaline degeneration in \\hich 
 remnants of muscle-fil)ers are still visible. This hyaline change becomes more 
 marked as one passes toward the center, \\hei-e the tissue appears as one mass of 
 hyaline material. .Scattered throughout it are occasionally small bundles of 
 muscle-fibers. The hyaline material in turn gradually dissolves and is lost, a 
 delicate reticulum remaining. This was the jucture obtained in the cystic areas. 
 
 Gyn. No. 12522. Path. No. 9233. 
 
 Mark e d h y aline d e g e n e r a t i o n o f a m y o m a w i t h 
 g r a dual 1 i ( | u e f a c t i o n of t h e h y aline t i s s u c (Fig. 82) . 
 
 
 
 
 M 
 
 iff'- 
 
 
 
 ^ ,:' v^-, / , ..;. ■>.- . ^ - ... • . - *• 
 
 T- i- ,1" •!-'>-.■.■> 
 
 •a 'ci b 
 
 Fiu. Sli. — GRADt'Ai, Lun'KiAcrio.\ oi- A Mvo.MA. (X S") ilisim.i 
 G.vn. No. 12.522. Path. No. 92.3.3. .■Vt the point.s inilirated li.v a the churuct«'riNli<- iii.viiiiiatinis livsiu- ^lill 
 persists; at 6 is a cross-section of a inuscle-Vxindle and al c a cross-swlion of an imlividual niiiscU'-lilnT. d is a 
 blood-vessel. At e all trace of the muscle has disappcareil, iiolhinK Ikmmk left l)Ut liyaline material and (lie outhiie 
 of hyaline connective tiss\ie. .\t /even the hxaline li:i> heen replaced li\ an irremil;ir space tilleil with coanuhdeil 
 fiviid. 
 
 S. M., aged thii-t\'-f()Ui'. admiltcd .XoNciiibci- 17, I'.X)."); discliiugcd on the 
 twenty-fifth day. The uterus is .•ipproxiiu.'ilcly I.'! cm. in diMiuctci- mikI is
 
 104 
 
 MYo.MATA OF THK ITKUIS. 
 
 tilohular: it has a cystic feel and contains a juicy-lookint;' myoma. It is free 
 from adhesions. The myoma is uniformly semisohd and is filled with small 
 cystic areas. Kroni the cut surface a straw-colored tluid esca])es. 
 
 Micro.scopically, the myoma shows marked hyaline d(\<>;eneration. AMiere 
 the cy.sts occur, there are clear spaces with only a few muscle-lihers remaining. 
 These stand out clearly. The picture is one of a myoma undero-oing hyaline 
 transformation, with gradual li(|Uefaction (Fig. 82). 
 
 Gyn. No. 3349. Path. No. 610. 
 
 L i"(| u e f a c t i o n o f a h y a 1 i n e m y o m a (Fig. <S8). 
 S. Pv.. married, aged forty-eight, white. Admitted February 26; discharged 
 March 2r). IS')."). 
 
 a 
 
 
 a - 
 
 -# 
 
 
 ■% 
 
 r; 
 
 ^i 
 
 /»': 
 
 -^ 
 
 (T^Vv^-i^ 
 
 Fig. 83. — Lhjukfikd and IIvaline Arkas in a Myoma. (X 95 diain.) 
 Gyn. No. 3349. Path. No. 610. At the points indicated by n transverse or longitudinal sections of muscle- 
 bundles are still visible. Scattered throughout the field are dark circular or irregular clumps of hyaline, particu- 
 larly well seen at b. These are muscle-bundles that have undergone complete hyaline transformation. The lighter 
 hyaline matrix, a.s seen at c, represents what remains of the filjrous structure. In the center of the picture is an 
 irregular cavity (d), lined with hyaline tissue, and filled with a granular material — coagulated serum. .\I e are 
 empty spaces from which all trace of the myoma has disappeared. 
 
 This picture gives in detail practically all stages that occur when a myoma undergoes hyaline degeneration. 
 
 Path. Xo. GIO. The specimen consists of an enlargetl uterus with both tubes 
 and ovaries. The uterus is jx'ar-shaped and nieasui'es lOx 12x10 cm. An- 
 teriorly, it i.s smooth and glistening; posteriorly, it is covered with a few iion-
 
 HYALIXE AXD CYSTIC DEGKXKRATlOX. 105 
 
 vuscular adhesions. On the anterior surface of the uterus is a subperitoneal 
 nodule, 1 cm. in diameter. Situated in the anterior uterine wall i.s a sharply 
 defined globular tumor, 9 cm. in diameter. In part this is made up of a delicate 
 meshwork of libers running in all directions, but th(> greater portion consists of 
 a jelly-like material, yellowish in color, translucent, and from the cut surface of 
 which a large quantity of clear fluid escapes. This fluid coagulates on exposure 
 to the air. The entire tumor might be likencHJ to a ball of ]o]\y everywhere 
 traversed by delicate fibrilhe. 
 
 Histologic Elxamination. — The large nodule in the tmterior uterine wall is 
 composed of non-striped muscle-fibers which have undergone diffuse hyaline 
 degeneration, the individual fibers being separated from one another by hyaline 
 material. Where the tissue appears jelly-like the field is almost colorless (Fig- 
 83), but a fine fibrillated meshwork can be made out, and scattered here and 
 there throughout this colorless material are little islands of muscle-fibers and 
 man}^ delicate blood-vessels. In other portions isolated nmscle-fibers can be 
 seen and the tissue also contains hyaline droplets. It looks as if the muscle- 
 fibers had first undergone hyaline degeneration, and that after this the hyaline 
 material had broken up into clumps and had disappeared, leaving a fibrillat(>d 
 network. 
 
 C. H. I. 620. Path. No. 8827. 
 
 Liquefaction of a myoma (Fig. 84) . 
 
 E. S., aged thirty-five, married, white. Admitted May 25; discharged 
 June 24, 1905. 
 
 Path. No. 8827. The specimen consists of a nodular myomatous uterus, 
 amputated through the cervix, and of a fetus at about the second month. The 
 uterus itself is nodular and is 8x8.5x16 cm. The largest myoma is apjiroxi- 
 mately 11 cm. in diameter. There is a diffuse myomatous thickening of the 
 uterine walls. 
 
 Histologic Examination. — Sections from the endometrium show the usual 
 appearance of pregnancy. Those from the myoma show typical and wide-spread 
 hyaline degeneration, a few fibers remaining here and there throughout the hya- 
 line tissue. Other portions have gone on to li([uefaetion (Fig. 84). \\ here such 
 changes have taken place almost the entire field is filled with coagulated serum. 
 The density of the eosin stain depends ui)on llic ainoimt of albumin that the 
 fluid contained. The fluid is di\idcd off into little comijartments by deli- 
 cate strands of either nuiscle-fibers oi- connective tissue. The walls of the cyst- 
 spaces are devoid of endothelium. 
 
 Gyn. No. 3504],. Path. No. 719. 
 
 M a r k e d h y a 1 i n e a n d c y s t i c d e g e n e r a t i o n o f a n 
 interstitial u t e i' i n e in y o in a (l''ig. N5). 
 
 M. 0., single, aged thirtw coloi-ed. .Vdmitted May 11: dischai'ged .luiie IS, 
 1895.
 
 106 
 
 MldMATA OK 'I'llI': ITKHl'S. 
 
 Path. No. 71*1. The s])c('iiii('n consists of the litems with the appendages 
 intact. 'Hie uterus measures 12 x 1(5x19 cm. and is iVee from adhesions. Pro- 
 jecting from the lower part of the anterioi' siu-face are two small pedunculated 
 nodules, the larger being 1x1.2x2 cm. Situated in the ])Osterior wall is a 
 tumor. !l X lo cm. ( l-'ig. So). This consists of one large cavit\' traversed by fi])rous 
 
 ^S'S^ 
 
 f; 
 
 
 e 
 
 ■x' 
 
 ^m 
 
 
 ^ 
 
 , d 
 
 / •. 
 
 y 
 
 space 
 
 ^ 
 
 Viv.. 84. — I.iiji'i'.i'ACTioN AND Hyai.ini: .Vhka^; in a .Myoma. (X 90 diam.) 
 
 C. H. 1. <)20. I'lith. N(i. S,S27. Tlie specimen i.s from a mynma diiriiiK the early months of pregnancy, n in- 
 dicates the usual myomatovis tissue. In the upijer part of the field are cross-sections of l)\iiidles of swollen muscle- 
 fibers ffc). r indicates blood-vessels. The rest of the field is comp(jse<l of albuminous fluid divided off into compart- 
 meats by delicate cai)illaries, as indicated at d. The coagulated fluid in the various comi)artments differs in density 
 of staining. This depends upon the amount of albmiiin contained in the fluid — the more albumin, the deeper 
 the stain. At e the albuminous contents are abundant, at / almost nil, a,s the fluid stains very faintly. The lower 
 border of the section is a small segment of a cyst-wall It is totally devtiid of an endothelial lining. 
 
 trabeciihe, which ))artially di\ide it into se\-eral smaller ca^■ities. filled with a 
 yellowish, transparent lluid. The walls of the ca\"ity are conqjosed of a yellow- 
 ish, cruml)ly material. The outer rim of the tumor is still intact and varies 
 from 1 to 'A cm. in thickness. The ajjix'iidages are normal.
 
 HVALIXK AXI) CYSTIC DKC.EXF.RATIOX. 
 
 10- 
 
 Histologic Examination. — The tumor is composed of noii-stripcd muscle- 
 fibers closely packed together. The tissue lining the cyst-like cavities has 
 undergone complete hyaline transformation. This hyaline material in some 
 places presents a homogeneous appearance, but in other places the colorless 
 
 Fig. 85. — Hyai.ink Dkgkxkration wriii Liquef.\ctio.\ ok an Intkri*titiai. I'tkhi.m; .Myoma. (J nut. siie.) 
 Gyn. No. .3.504^. Path. No. 71i). Occupying the fun(lu.< is a myoma 9 x I'.i cm. The conter of this consists 
 of one large cavity lined with a shaggy, crumbly material, and traversed with tr;jl)eciila'. It has ooiitniiie<i a clear 
 transparent Huid. The appendages are normal, and the uterine cavity hsis in no way l>een encroached upon. 
 Histologic examination shows that the inner lining of the dcgcncrale<l m\iima <-onsisls of hyahiie material. 
 
 mu.scle-fibcrs are still xisible. Here and tlicic unaltered niuscle-libers can still be 
 made out. The hyaline material graduallN" fades a\\a\' and on the inner surface 
 of the cavities almost entirely di.sa])])ears. The line of junction between the de- 
 generated and unaltered muscle-fibers is siimrplv defined, the one ending abruptly 
 where the other begins. The caxity foriiiatioii in this case is due to hyaline 
 degeneration with subse((uent lii(uefaction. At no |)oiiit does the ('a\ity show 
 any epithelial or endothelial lining.
 
 108 MYOMATA OF THE rTP:Rl"S. 
 
 Gyn. No. 7049. Path. No. 3318. 
 
 M a r k v cl li y a 1 i 11 v d e g c n c ration and 1 i (| 11 c f a e t i o n 
 of a large myoma (Fig. 86). 
 
 A. -M., married, white, aged fifty-one. Admitted July 6: discharged August 
 17. 1S09. 
 
 Path. No. :VA\s. The specimen consists of a large myomatous uterus, with 
 intact tubes and ovaries. The myomatous mass is markedly nodular, being 
 studded with mvriads of small and moderately large nodules. The tumor meas- 
 ures 23 X 25 X 31 cm., and situated in a cleft on its upper and anterior surface 
 is the verv small uterus. The myoma has conseciuently filled the ])elvis and 
 spread out the folds of the broad ligament. On section, it is found that almost 
 the entire myomatous mass has been converted into a huge cavity (Fig. 86), 
 the inner surface of which presents a shaggy appearance. Traver.sing the cavitj^ 
 in all directions ar(^ large and small trabecuhr that hold together large and firm 
 masses m the centei-, the trabecuhe .stretching from side to side. The shaggy 
 masses lining the walls of the cavity are whitish yellow in color. The general 
 impression gained is that the softened portions of the myoma have melted away, 
 leaving the more resistant ])ortions, which remain as trabecuhr. The Huid 
 filling the cavity is somewhat turl)id and of a greenish-brown color. 
 
 Histologic Examination. — The outer i)ortions of the walls of the large and 
 cystic myoma consist of typical myomatous tissue. The shaggy inner surface 
 and the trabecuhe re])resent nothing more than myomatous tissue that has 
 undergone complete hyaline degeneration. This ti.ssue is totally devoid of nuclei 
 of any kind. 
 
 San. 1925. Path. No. 8838. 
 
 A 1 a r g e m u 1 t i n o d u 1 a r m y m a t u s u t e r u s wit h a 
 h u g e subperitoneal and cystic m y o m a (Fig. 87). 
 
 G. S. W., aged thirty-eight, married, white. Admitted May 8; discharged 
 June 13, 1905. 
 
 Path. No. 8838. The specimen consists of the uterus, with many myomata, 
 and the appendages. The tiunor weighed twenty ])ounds. The uterus has been 
 crowded down between two myomata. One is irregularly kidney-shajx'd, 
 17 cm. in length: the other sj)rings from the ])osteri()r surface of the uterus, and 
 is 15 cm. in length. Scattered throughout the uterus are numerous peduncu- 
 lated, interstitial, and partially submucous myomata. The chief interest is 
 centered in the cystic pedunculated myoma, 30 cm. in its longest diameter 
 (Fig. 87). This is attached to the anterior and right side of the uterus by a short 
 pedicle, 6 cm. in breadth. This tumor is covered with omentum, which is 
 greatly thinned out . ( )n section, it is found to consist of myomatous tissue in the 
 outlying portion: in the central portion is a gelatinous-like tissue, with trabecuhe 
 running through and giving rise to many large and small cystic spaces. In the 
 center of the tumor is an oval cystic space, 8x10 cm. It has a .smooth lining
 
 Fig 86-M.ss,vk Hvaiin,: 1)k,;kn,:u m h.n an.. I.u„ ,:. a., .on .m- a 1.vu..k r.KU.s.: Mvoma. .iA nat. Mre. > 
 Gyn. No. 7049. Path. No. 331S. 11... ...„..m „K.u.suro.l 23 x W x 31 <•.... Situa..-! in u cU-f. .... ...s ,.,.,.cr 
 
 and anterior surface was .he ve,y .....all u,...us. Al .st .he en.ire ....nor ha.s ..o.-.. conv..,-..-.. ....o ••"«; >;j J" ;«; " 
 
 The walls are ,.o„.,„.se.l of typical ...vo.na.ous .i.ssue. well see., at a. Near .he walls are er..ss-..er... ...m of , ,>o- 
 
 n'ai:; ttsi.e that'has undergone hyaline change. This is elearly seen at /,. The ee...ral ,.or,...n of < J--; ^ '» 
 partly filled by a shaggy degenerated .na.erial. held in plaee l.y trabeeula. ex.e...l.ng to he """;■-'",. J; '^ , ^ 
 
 finer trabecular are seen at c. At d is a large space where con.ple.e d.s.n.egr... ha- aken place. I h ' > ' « 
 
 the tumor was somewhat turbid and gree.ush brown in color. TI.e shaggy .n..cr wall. a..d the .naxM s .n .lu . , n- 
 ter consisted of hyaline material totally devoid of nnclc. 
 
 10'.)
 
 110 MVO.MATA OF THK UTERUS. 
 
 aiul in sonic portions contains a clear fluitl: in others, chocolate-colored clots, 
 
 e-'ifJ^i. 
 
 Fig. 87. — A Cystic Subi-kritoxeai- Pkdlnculatku Myoma. (^ nat. size.) 
 San. No. 192.5. Path. No. 8838. To the right is the enlarged and myomatous uterus. To the left a large 
 and somewhat flattened cystic m.voma, .30 cm. in its longest diameter. This is attached to the uterus by a short 
 pedicle, 6 cm. in breadth. Over the greater part of its convexity it is covered with dense omental adhesions. 
 The tumor, to a great extent, has been converted into large and small cystic spaces. Between the points a and 
 a' the delicate cystic formation with fine trabecular is particularly well seen. Most of the smaller c.vsts were filled 
 with clear fluid. The largest cyst is 8 -x 10 cm. and has a smooth lining. It was partially filled with clear fluid, 
 I)artially with clots. The cyst c contained remnants of old blood. Sections from various parts of the tumor 
 show marked hyaline degeneration with liquefaction. Clinging to the large cysts are partly organized clots and 
 old blood-pigment. There is no evidence of entlothelium. 
 
 evidently the remains of old hemorrhages. There is also another oval cystic 
 space, 9 cm. in length and traversed l)y traljeciihe ]-)resenting a homogeneous
 
 HYALINE AND CYSTIC DEGKXHKATIOX. 
 
 Ill 
 
 Fig 88. -A Mn.iii.oci i.au Cvsrn 
 Cvn No 888" Path N.. 5072 The ut.-ru. is r.-lntivoly M..,,n:.l in size. Mot). t„l..-s un.l tl,.- l.-ft -vary :ire 
 
 no.JS';;^: p^^i.,;;:;::. t:;.t. ..v.. is .•>•- ..,.u. rn.... .... -;;;-•;;;:::; -;.:;^:r;;;;:Hi::: 
 
 .ovulated cystic tun..,-. This .k. ^^^^;^.^^^'^^y X:'::X^''v^^^^ ^^ 
 
 In such cases there is great (iaiiRer of injury to the ureters. lAen ii.ur ui. i 
 at first supposed to be an ovarian .-yst. Kor the tu.nor on .section .see !• .g. H.».
 
 112 MYOMATA OK THK ITKIU'S. 
 
 ai)])('amiK'('. It is evidently filled with a good deal of old blood. These two 
 cystic spaces arc very unusual. l)ut the outlying semisolid and cystic portion 
 is characteristic of any case of advanced hyaline transformation of a myoma. 
 
 Histologic I'^xamination. — The edematous, cystic areas are the i-esult of a 
 iiiai-ked h\-aline t raiistoi'iiiation, with sul)se((ueiil rK|uefaetion. The tissue im- 
 medialelv around the hlood- vessels has undergone almost complete hyaline trans- 
 formation. We have, also, large areas, absolutely devoid of cells and later this 
 hyaline material has become almost transparent and entirely disappears. The 
 line of hyaline transformation is in many places very sharply defined. In some 
 places throughout the hyaline material we have deposits of yellowish pigment, in 
 all probability the result of old hemorrhag(>s. Sections from one of the cystic 
 spaces partially filled witli blood show that we have here in the Avails also a great 
 deal of hyaline transformation. Clinging to the wall is fibrin, here and there 
 aggregations of small round cells, and occasionally polymorphonuclear leu- 
 kocvtes. Many of the leukocytes have a brownish tinge, showing that they are 
 rather old and have probably imbibed old blood- pigment. Clinging to the inner 
 surface of one of the cysts is blood, which is fairly well preserved. 
 
 Gyn. No. 8882. Path. No. 5072. 
 
 A large m u 1 t i 1 c u 1 a r cystic m y o m a d e v e 1 o p i n g 
 f r o m the p o s t e r i o r s u r f a c e o f t h e u t e r u s (Figs. 88 and 
 89). 
 
 A. B., aged thirty, white, married. Admitted June 25: discharged July 19, 
 1901. She has been married eleven years, has had three children, the youngest 
 now twenty months old. The labors were easy and there were no complications. 
 Fourteen years ago she first noticed a small tumor in the abdomen. This has 
 grown steadily since then, but has given rise to ncj symptoms. 
 
 Operation. Panhysterectomy. On section of the abdomen the uterus was 
 found resting on the top of a cystic mass. This mass was su])posed to be an 
 ovarian cyst and not until it ruptured was the true diagnosis arrived at. Enu- 
 cleation was carried out in the usual manner from left to right. The procedure 
 took a good deal of time, owing to the dense i)elvic adhesions and to free oozing 
 from the vaginal veins. Ther(> was a hydro-ureter on the right side. 
 
 Path. No. 5072. The specimen consists of the uterus, which is but little 
 altered, and of a large tumor, which has apparently developed in the posterior 
 wall. This tumor measures 9 x 20 x 31 cm., is lobulated, cystic, and is very sug- 
 
 Fi<;. 89. — A Lah<;k Cy.stic Myoma Growing from rm: Postkrior Surface of the Utkrus. 
 
 Gyn. No. 8882. Path. No. 5072. The picture represents a longitudinal section of the tumor seen in Fig. 88. 
 a indicates the uterine cavity, which is normal. Springing from the posterior wall of the uterus is the large multi- 
 cystic myoma, 9 x 20 x 31 cm. Covering the outer surface is a mantle of muscular tissue (6). The upper part of 
 the tumor contains large cystic spaces with secondary recesses opening into them. The lower half presents a 
 spongy appearance, due to the presence of many small cysts embedded in the rarefied tissue. 
 
 Histologic examination shows that nearly the entire central i^ortion of the tumor is devoid of nuclei. The solid 
 tissue is much r:iretied or "threadbare," and the cysts are spaces devoid of any epithelial or endothelial lining.
 
 
 
 ^^ X:., 
 
 / 
 
 ^:;; •^ 
 
 
 :^ 
 
 Fig. 89. 
 
 113
 
 114 
 
 ^n■().MA■l■A OK 11 IK UTKRIS. 
 
 gcstivc of an oRliiiary niultilocular ovarian cyst ( Fi*!;. SS). On section (Fig. 89) 
 the upper ])art of the tumor is foniul to he made uj) of hirgc cysts with numerous 
 recesses opcninu- into them. Tlicsc cysts appear to he filled with clear fluid. 
 
 Fig. 90. — A Large Slhi'erito.\k.\i. Cv.stic Myo.ma. (i nat. size.) 
 Gyn. No. 6432. Path. No. 2661 Springing from the fundus is a partially pedunculated cystic tumor, 16 x 27 
 X 30 cm. The fundus itself is somewhat enlarged, from the presence of myomatous nodules, lioth tubes and the 
 left ovary are normal. The right ovary contains a small dermoid cyst. For the appearance of the uterus on sec- 
 tion see Fig. 91. 
 
 The lower half of tlie tumor is made up of a s|)on<iy material containing numerous 
 small C3'8ts in it.s me.shes. Covering the entire outer surface is a mantle of myo- 
 matous tissue, in most places reaching 1 cm. in thickness.
 
 HYALINE AND CYSTIC D?:GENERATI0N. 
 
 115 
 
 Fig. fll. — A Cystic Myoma. 
 Gyn. No. 64.32. Path. No. 2001. (For the geiicrul appejinince of the tumor .sco FIr. ilO.I The M'ction has 
 been cut longitudinally through the tumor. The upper part of the tumor han heen converte.! into a large cystic 
 cavity with walls from 1 to .3 mm. thick. The inner surface is smooth an.l on the right are numerous traheculae. 
 pas.sing from the outer thin wall to the soli.l l.orlion of th<; tumor. lliese Iral.ecuhe .-arry hlu,..l-vessel8. A 
 large wedge of the solid portion of the tumor has undergone complete iiyahnc degeneration, hut in the lower part 
 the typical myomatous tissue still persists. 1 h.' uteiine cavity it.self is normal. There was no epithelial nor 
 endothelial lining to the cyst.
 
 116 MVOMATA OF TllH ITKUl'S. 
 
 Histologic Examination. — The outor portions of the tumor present the usual 
 myomatous appearance. The central ]X)rtion consists of tissue that has under- 
 gone hyaline degeneration or is entirely devoid of nuclei. It is gradually be- 
 coming rarefied and the empty spaces are totally devoid of any endothelial 
 linhig. This is the most remarkable cystic degeneration in a myoma that we 
 have ever noted. 
 
 Gyn. No. 6432. Path. No. 2661. 
 
 A 1 a r g e c y s t i c m y o m a s p r i n g i n g f r o m the f u n d u s 
 of t h (> u t e r u s (Figs. 90 and 91). 
 
 A. B., single, aged forty-four, white. Admitted October 18; discharged 
 November 17, 1898. 
 
 Path. No. 2601. The specimen consists of the uterus, attached to which is a 
 large tumor, lx)th tubes, the left ovary, and a dermoid cyst of the right ovary 
 (Fig. 90). The uterus proper is relatively small, measuring 5x6x6 cm. 
 Springing from the fundus is a large pedunculated tumor, 16 x 27 x 30 cm. 
 On the posterior surface of the tumor is a groove corresponding to the promi- 
 nence of the sacrum. The surface of the tumor is smooth and glistening, and 
 traversed by numerous blood-vessels. It is fluctuant and its walls are appar- 
 ently thin. The tumor is attached to the fundus by a broad pedicle, 6 cm. in 
 diameter. Springing from the posterior surface of the large tumor on the left 
 side are two nodules. The large myoma, on section, is found to be composed 
 of two portions, one cystic, the other solid (Fig. 91). The upper part forms 
 one large cavity, with numerous trabecukr extending to the wall of the solid 
 portion of the tumor. The wall itself is composed of myomatous tissue of 
 varying thickness. Fully one-third of the solid portion of the tumor has 
 undergone complete hyaline degeneration, as indicated in the figure. 
 
 Histologic Examination. — The walls of the large cystic tumor present smooth 
 inner and outer surfaces, the former having no special cell lining. The walls 
 consist of large spindle-shaped fibers that run more or less parallel to the circum- 
 ference, but in some places hiterlace. There is considerable fibrillation of the 
 tissue, which is poor in cells and is quite edematous. The picture is a very 
 unusual one. 
 
 Gyn. No. 4485. Path. No. 1245. 
 A m u 1 t i c y s t i c u t e r i n e m y o m a (Fig. 92). 
 
 Fig. 92. — A Large Multicystic Myoma. (;'. nat. size.) 
 Gyn. No. 4485. Path. No. 1245. This tumor measured 19 cm. in diameter, was lobulated, densely adherent, 
 and attached to the upper surface of the uterus by a twisted pedicle. Bulging from the surface are several large 
 cystic spaces. The cysts are large and small, and even the smallest have smooth walls. Clinging to the inner sur- 
 face of some of the cysts is old blof>d. The solid portion of the tumor consists of myomatous tissue, which has in 
 places undergone marked hyaline degeneration. The cysts are devoid of any epithelial or endothelial lining.
 
 Fig. 92. 
 
 117
 
 118 MVOMATA OF THE UTERTS. 
 
 A. .1.. married, ai^cd forty-seven, white. Admitted .Iviiie 25: discharged 
 August 2, 1S9(). The patient had one child, twenty-three years ago. She first 
 noticed an abdominal enlargement ahovU six months ago. The increase in size 
 has heen gradual. 
 
 At the operation the cystic myoma had a twisted ))edicl(> and there were dense 
 adhesions between the tumor and the anterior abdominal wall. The tubes and 
 ovaries were adherent to the ])elvic fioor. 
 
 Path. Xo. 1245. The specimen consists of the uterus with its appendages 
 and of a large tumor. The uterus is a])proxiniately globular, and averages 8 cm. 
 in diameter. It is covered with a few adhesions. The walls are thickened, and 
 contain two small myomatous nodules. Occupying the fundus is a tumor, 5 cm. 
 in diameter, which is becoming cystic. The large tumor (Fig. 92), springing 
 from the ii))per surface of the uterus where it joins the right tube, is irregular in 
 .shape ami avei'ages 19 cm. in diameter. Projecting from its surface are rmmer- 
 ous bosses and two pedunculated cysts, 8 and 9 cm. in diameter respectively. 
 The large cyst has delicate walls. These, OA'er an area 4 nun., have undergone 
 partial rupture, some of the layers having given way. The tumor is covered 
 with dense adhesions, some of which contain adipose tissue. The walls of the 
 tumor vary from 2 to 4 nun. in thickness. One smaller cyst is hemorrhagic and 
 there are numerous adhesions on the under surface of the tumoi-. The cysts 
 have smooth inner surfaces. 
 
 Histologic Examination. — The solid ])art of the large tumor consists of non- 
 striped muscle-fibers, and between the nmscle-bundles are wide bands of con- 
 nective tissue which have undergone hyaline degeneration. The tumor has an 
 abundant l)lood-sup])ly, but many of its vessels are becoming ol)literated and 
 others are filled with recent or partially organized thrombi. The walls of the 
 cyst projecting from the surface of the large tumor are likewise composed of non- 
 .striped muscl(>-fil)ers. There is no evidence at any jioint of an epithelial or en- 
 dothelial lining. 
 
 Gyn. No. 13625. Path. No. 11651. 
 
 A V e r y 1 a r g e c y s t i c m y o m a ( Fig. 93). 
 
 A. N., married, white, aged forty-eight. Admitted March 1; discharged 
 March 29, 1907. Four years ago the patient began to notice a uniform en- 
 largement in the abdomen. This increase in size has been gi'adual. The ])a- 
 tient states that the girth of the abdomen increases during her menstrual ju'riod. 
 
 The tumor was densely adherent to the omentum and from it the greater 
 part of the nourishment came. 
 
 Path. No. 11651. The specimen consists of the uterus, attached to which is 
 a large cy.stic myomatous mass, the whole measuring approximately 16 x 35 x 50 
 cm. (Fig. 93). The uterus, which has been am])utated through the'cervix, 
 measures ajjproximately 7x11 cm. It is multinodular, containing subperitoneal 
 and interstitial myomata. The main tumor springing from the fundus measures 
 approximately 16 x 35 x 39 cm. The surface of the tumor is moderately smooth,
 
 KiG. 93.— A Cystic Myoma \Vi:i<-..iin.; 39 Pounds anm, Cm.sii.v Hisimimin.. a Mi i.tii.o.ti.ar Ovarian I ^c 
 
 (J nat. size.) 
 Gyn No 13625. Path. No. 1 ItuA. In the Ul)|«-r part of the picliiro a cross-sort ion ..f the uterii.-* is seen. It 
 contains one interstitial and one snhperitoneal no.liile. .\tta<-h.Ml t.. the si.le ..f the viterus is a very larRe nnilti- 
 locular cystic myoma. At the points iiulicato.l hy <i tlie myomatous arranKemeiit is still clearly seen. I he small 
 cysts have smooth walls, and were filled with clear flui.l. The large cyst with its secomlary hernial project inn (/.) 
 has very thin walls, so thin that in the vicinity of r light was easily transmitte.1. The large cyst was also hlled 
 with clear fluid. The outer surface of the cyst was covered with many ..mental adhesions 
 
 119
 
 120 
 
 MVO.MATA OF TIIK I'TKHl'S. 
 
 but toward the iipjuT part anterior]}- is a hand of omentum approximately 10 
 cm. in length and o em. in width. At otliei' jxjint.s over it.s .surface there are also 
 omental adhesions. (.)ne large vein in the omental atlhesions is fully 8 mm. in 
 diameter and others noted at operation were at least o nmi. 
 
 On section, the large cj^stic mass is found to be filled with a moderately clear 
 straw-colored fluid. The large cystic space measures api)roximately 25 cm. in 
 diameter. The walls are perfectly smooth and about the thickness of parch- 
 ment. Large l)lood- vessels can be seen coursing in the walls in this cyst. Pro- 
 jecting from the large cyst is a secondary hernial cyst. The middle portion of 
 
 the tvmior is made up of moder- 
 ately firm whorls of myomatous 
 tissue, l)ut here also cystic 
 spaces are in evidence, the 
 largest cyst measuring l.o cm. 
 in diameter. All these spaces 
 have smooth imier linings and 
 contain clear fiuid. 
 
 Histologic Examination. — 
 Sections taken from the more 
 solid portions of the large tumor 
 show that it is made up of my- 
 omatous tissue, in places mod- 
 erately well preserved. In most 
 instances, however, there is 
 rather extensive hyaline degen- 
 eration. Sections taken from 
 those areas which macroscopi- 
 cally have a soft and gelatinous 
 appearance show tvpical lique- 
 
 Fio. 94. — A Cystic Utkrixk Myo.ma. "" 
 
 r. H. I. F. Path. No. 6046. In this case there was a factioU of the mUSClc-fiberS. 
 
 strang\ilated umbilical hernia. Filling the pelvis was the pro- Jjj^ SOlUC DlaCCS "X fcW Cclls are 
 jection a, and it was necessary to completely sever the cervix 
 
 before this could be dislodged. A large part of the main tumor Still modcratcly WCll prCSCrVCd. 
 
 M?n''.r^rHrr.'r'1°^r7*'r-'"^T'^'f'°^"'"""" Ii^ other places there has been 
 
 tion was found to be hned with hyaline material. t 
 
 complete disintegration, only a 
 few swollen cells or shadows of cells remaining. Sections taken through the 
 edge of the large cystic space show that it is lined with typical myomatous 
 tissue. No endothelial lining can be noted. This is one of the most pro- 
 nounced examples of a cystic myoma that we have ever encountered. 
 
 C. H. I. F. Path. No. 6046. 
 S t r a n g u 1 a t e d u m b i 1 i c a 1 h e r n i a and 
 m y o m a w i t h a ]> o r t i o n i n c a r c e rated 
 1)4). 
 
 (Fit 
 
 a large cystic 
 in the pelvis
 
 HYALIXE AND CYSTIC DKGEXKRATK )X. 
 
 121 
 
 F., about forty-five years of lu^v, was seen in consultation with Dr. A. Trego 
 Shertzer and admitted August 10, 1902. She had had an abdominal tumor for 
 a long period. She came to the hospital hurriedly on account of a strangulated 
 umbilical hcn-nia. The tissues in the hernial sac were almost bluish black. After 
 removal of a wide area at theuml)ilicusan attempt was made to deliver the tumor. 
 This was exceedingly difficult, because a large portion of it was wedged in the 
 pelvis. Finally, after using a good deal of traction, we were able to expose the 
 tumor and amputate through the cervix. It then became feasible to remove 
 the pelvic portion. The patient made an excellent recovery. 
 
 The uterine tumor measures 22.5 x 20 cm. Its central ])ortion over a wide 
 area, as indicated in Fig. 94, has undergone complete cystic transformation. 
 The cystic transformation on microscopic examination was found to be due to 
 hyaline transformation, with subsequent liquefaction. 
 
 Gyn. No. 13423. Path. No. 10677. 
 
 Extensive cystic degeneration of an interstitial 
 uterine myoma (Figs. 95 and 96). 
 
 H. M., aged forty-one, white, married. Admitted December 4, 190G; dis- 
 charged January 17, 1907. The patient made a perfect recovery. 
 
 Path. No. 10677. The specimen consists of a large myomatous uterus. The 
 uterus itself has been opened 
 posteriorly. It is 15 cm. in 
 length, 8 cm. in breadth (Fig. 
 95). The uterine walls show a 
 considerable thickening, reach- 
 ing 3 cm. in thickness in the 
 upper portion. Occupying the 
 anterior wall is a growth 11 cm. 
 in diameter. This, on section, 
 is cystic, and at first sight 
 bears a striking resemblance to 
 a heart (Fig. 96). Its walls 
 vary from 0.5 to 2.5 cm. in 
 liiickness. Its inner surface is 
 smooth and glistening. Its 
 walls contain numerous depres- 
 sions and smooth, dome-like section see Fig. ot;. 
 elevations; and stretching from 
 
 depression to depression are little smooth bands which are rounded imd Ix'ai- 
 considerable resemblance to th(> columnn' caniea'. 'I'he depressions soiiictiines 
 extend for at least 2 cm. into the ilcplli. At h. on the anterior surface, is a 
 cyst 2 cm. in diameter, with smooth walls. This cystic sj)ace was tillctl with 
 clear stra^v-colored fluid, which did not coagulate on exposure. 
 
 Fio. 95. — A Cystic Miu.\i.v. Ui:cLiii.\o the .\ntkhioii 
 
 Utkkine Wall. 
 
 Gyn. No. 13423. Path. No. 10)77. ProjectinR int.. ilu> 
 
 uterine cavity from the anterior wall i.s a glolnilar tuiimr. 'I"hi' 
 
 appendages are normal. Fur the appearance of (lie utniis on
 
 122 
 
 MYO.MATA OF THK ITKRl'S. 
 
 llistoloiiic I^xainiiiatioii. Sections tVoiu the uterine wall show undoubted 
 beginning adenoinyonia. Sections from the growth in the waU of the uterus 
 show that it is coin])osed of myomatous tissue. The musele-tibers are closely 
 packed together and at first sight strongly suggest sarcoma. The individual 
 cells. howe\-er. are perfect 1\' sinoot h and the muscle-fibers ai'e I'egulai'ly arnuiged. 
 Here and there are faint evidences of li(|Uefaction. The muscle ends aljruptly at 
 
 Fig. 96. — A Cystic Myoma with a Cavity Rkskmblix(; Somkwiiat thk Interior of a Heart. (? nat. size.) 
 Gyn. No. 1.342.3. Path. No. 10677. For the general relations of the pelvic organs see Fig. 95. Occupying 
 the anterior uterine wall is a myoma 11 cm. in diameter. Its line of junction with the uterine muscle is indicated 
 by a. The entire center of the tumor is cystic. The inner surface is smooth and glistening, but there are numerous 
 recesses corresponding to dome-like elevations, and stretching across the depressions are rounded trabeculsc resem- 
 bling columna; carnece. 6 is a small cyst with clear contents. The cyst was filled with a straw-colored fluid that co- 
 agulated on exposure to the air. The walls of the tumor show some hyaline degeneration, but the inner surface 
 is lined with muscle-fibers. There is no evidence of any endothelial lining. 
 
 the inner surface of the cyst. The inner .surface is also lined with muscle-fibers, 
 wiiich lie parallel to the cyst cavity and form a layer of cells at least three to six 
 deep. We expected to find a hyaline imiei' lining, but this is absent on the 
 inner surface, a most unusual picture where large cysts are associated with uterine 
 myomata. This is the only myoma in which we have found such an appearance 
 due to hyaline degeneration.
 
 hyalixp: and cystic degexeratiox. 
 
 123 
 
 i n Part 
 
 ,^ a p » g g*^^ 
 
 Gyn. No. 3 113. Path. No. 487. 
 
 Cystic 8 p a cos i n a Al y o ni a A p p a r cull y d u 
 to Dilatation of L y ni p h - c h a n n c 1 s (Fig. 97). 
 
 A. V. G., married, ag(d fifty-two. Admitted October 16; di.schargcd De- 
 cember 6, 1894. 
 
 Path. No. 487. The specimen con.sists of a large globular tumor, in the 
 upper portion of which the uterus is situated. Both tubes and ovaries were in- 
 tact. The tumor is approximately circular, 25 cm. in diameter. Along its lower 
 and anterior surface are five ill-defined bosses, the largest of which is 3.5 x 5 x S 
 cm. The tumor is whitish red in color, smooth, glistening and covered with 
 peritoneum. On the anterior surface of the tumor is a piece of l)la{lder mucosa, 
 3x6 cm. On palpation the tumor is firm tmd yielding, giving a faint sensation 
 of fluctuation. On section, it is whitish in color and 
 presents a finely striated appearance. Scattered 
 everywhere throughout the tumor are sinuses (Fig. 
 97), the largest of which is 1.2 cm. in diameter. 
 These have smooth walls and communicate Avith 
 numerous smaller ones. They contain a sercnis-like 
 fluid. Some, however, are filled with dark-red blood. 
 Most of these sinuses appear to be lymphatic in origin. 
 On section, the entire tumor mass, is found to spring 
 from the posterior uterine wall. It is interstitial 
 and has an outer covering of muscle averaging 2 
 mm. in thickness. The posterior wall of the uterus is 
 filled witli sinuses similar to those noted in the tumor. 
 
 Histologic Examination. — The uterine muscle 
 just beneath the mucosa appears to be perfectly 
 normal. In other placets it contains numerous small 
 empty spaces, some of which lia\'e an endothelial 
 lining. These are pr()l)al)ly lym])h-spaces. The 
 large tumor situated in the posterior wall is comj)()sed 
 
 of non-strij)ed muscle-fibers and shows diffuse^ hyaline degeneration. In some 
 places this hyaline degeneration is so mai-ked that the inuscle-l)undles ai)pear 
 as small islands in the hyaline material. Thei'e arc many recent hemorrhages, 
 which are chiefly confined to the hyaline aivas. In some places the tumor is 
 edematous. Tiie blood-vessels are moderate in numbei'. the veins pi-edominating. 
 Scattered everywhere throughout the tumoi' are huge and small empty s))aces. 
 some with, others without an endothelial lining. .\s the blood in the arteries 
 and veins has been well jHVserved in Miiller's Huid and as thes(> spaces are com- 
 paratively free fi'om bh)()d, we aiv incHiicd to believe that ihey are lymph- 
 channels. In this case, as noted on p. 2-17, there are some \-eiy l;ii-ge cells, 
 strongly suggesting a sarcomatous transformation of the myoma. 
 
 Fig. 97. — Irregular Cystic 
 Spacks IN' A Myoma. (Nat 
 size.) 
 
 Gyn. No. 3113. Path. No. 
 487. -At a are numerous small 
 cystic spaces, .some of which com- 
 municate with one another. In 
 this case there were edema and 
 hyaline degeneration. Some of 
 the spaces in the myoma had an 
 endothelial liniiiR and were ap- 
 parently dilate<l lymph-channels; 
 others api)eared to he due to dis- 
 integration of the hjaline ti.ssvie.
 
 124 
 
 M YUM ATA OF TIIK ITERl'S. 
 
 Gyn. No. 2852, Path. No. 347. 
 
 A u t (' r i 11 (' 111 y o m a w i I h c y s t i c s j) a c e s containing 
 a m a t c r i a 1 r c s c in h 1 i n ti in cite d butt c r (Fig. 98). 
 
 M. S. 1).. inairit'd. aged forty-three, white. Athnitted June IS; tliseharged 
 July .SO. 1S<)4. 
 
 Patli. Xo. 0-17. The spcciincn consists of an ciilargrd utciiis with its a|)pen- 
 dages intact (Fig. 98). The uterus is globular in form and measures 13 x 13 x 1-4 
 em. It is smooth, glistening, ])inkish in color, and eN'eiywhere covered with 
 
 ^" 
 
 Fig. 9S. — .\ Uterine Myoma with Cystic Spaces Containing Material Resemhiinc Mki.tkd Bitter. 
 
 (u nat. size.) 
 Gyn. No. 2852. Path. No. 347. The globular myoma contains two irregular spaces, the upper one having, 
 been cut in two. They are filled with butter-like material, which contains many fat-droplets and cholesterin crys- 
 tals. We have only had two such cases in a large series of degenerated niyomata. (.\fter Howard \. Kelly.) 
 
 peritoneum. Th(> posterior wall of the uterus is occupied by an a])])arently 
 rounded nodule 12 cm. in diameter. This is whitish in aj)i)earance, and is made 
 up of smaller nodules composed of concentrically striated fibers. The anterior 
 ])ortion of the tumor contains a cavity, 2 cm. broad and 2.5 cm. in de))th. The 
 walls of this are smooth and of a j^ellowish color. In the posterior })ortion of this 
 tumor is a second cavity. This measures 4.5 x 5 x 6 cm. and presents a convo- 
 luted appearance, has smooth walls and is lined with a yellow, semisolid, butter. 
 like material. Both cavities are filled with a liquid which closely resembles
 
 HYALINE AND CYSTIC DEGENERATION. 125 
 
 melted butter. Scattered throughout this material are grayish-red fioeculi or 
 streaks of blood. 
 
 Histologic Examination. — The large nodule situated in the posterior wall is 
 composed of a hyaline stroma with non-striped muscle-fibers scattered freely 
 throughout it. The muscle in the vicinity of the cavities shows patches of hy- 
 aline degeneration, associated with slight lymphoid infiltration, or ends abruptly 
 in a hyaline material. The inner walls of these cavities are composed entirely of 
 this hyaline substance, with a few muscle-fibers scattered here and there. A few 
 blood-vessels are still visil)le in the hyaline material. The ragged inner surfaces 
 of the cavities are also composed of hyaline material, but the individual fibers are 
 still faintly visible. In no place is there the slightest evidence of polymorphonu- 
 clear infiltration. The fresh fluid from the cavities contains many cholesterin 
 crystals, large round cells filled with fat-globules, also many muscle-fibers con- 
 taining fat-dro})lets. It also contains much granular debris. 
 
 The probable steps in the degeneration of the myoma have been as follows: 
 (1) Hyaline degeneration of the muscle-fibers; (2) emulsification or, in other 
 words, degeneration with liquefaction of the hyaline material. 
 
 The most striking point is the fact that the degeneration has occurred with- 
 out any reaction whatever.
 
 CHAPTER VTTT. 
 
 CALCIFICATION OF UTERINE MYOMATA. 
 
 It' one systciiKitically sections all iiiyoniata, he will ho surprised at the fre- 
 qiu'iK'V with which gritty ])articlos are found scattered throughout the tumors. 
 On the other hand, it is rare to find a myoma that has been completely trans- 
 t'ornied. into a calcified nodule. Calcified areas may be found in subperitoneal, 
 interstitial and submucous myomata; though in some cases limited to one 
 nodule, at othci- times they are pr(\sent in sevei'al myomata in the same uterus. 
 
 \Ct- -y i/tHrf-t^ 
 
 Fic. 99. — .\ Df.gknkkatki) and Partly Cai.cifikd Myoma. (Nat. size.) 
 Gyn. No. 3014. Path. No. 44.3. The uteru.s contains several myomata. Occupying the greater part of the 
 field is a degenerated interstitial myoma which has a covering of uterine muscle (a). In the outlying portions of 
 the myoma are many white calcareous areas, some of which are indicated by h. At c remnants of myomatous 
 tissue are still in evidence. The entire center was occupied by a pultaceous mass (rf), which to the examining finger 
 felt like ca.seous material. 
 
 The calcareous areas are usually first recognized when the myoma is cut — the 
 knife at once encountering areas that will not yield or that are gritty. The 
 myomatous tissue in such cases may be dark-red, yellowish-red, or gray, but 
 it is u.sually yellowish in color, friable, and very like a caseous lymph-gland. 
 Calcareous jxirticles ar(> at times so small that they are scarcely re('ogiiizal)le, but 
 
 l_'G
 
 CALCIFIC'ATIOX OF UTERINE MYOMATA. 
 
 12:; 
 
 can be readily detected by rubbing the tissue between the fingers. Where the 
 salts are liberally deposited, it may be necessary to saw jiortions of the myoma. 
 
 In Case 7819 (Fig. 171, p. 268) carcinoma of the cervix was present, and an 
 interstitial and slightly submucous myoma, about 5 cm. in diameter, had under- 
 gone necrosis. The entire outer surface of this myoma was encas(^d in a calcified 
 mantle. 
 
 Case 3014 (Fig. 99) shows a very good example of partial calcification of a 
 myoma. The central portion has to a great extent undergone softening, sug- 
 gesting a caseous gland. In the outlying portion the myomatous tissue is still 
 in part preserved, but in many places are found large and small deposits of cal- 
 careous material. Surrounding the 
 tumor is a mantle of uterine muscle. 
 
 Fig. 100 shows a good example of 
 the various stages in the process of de- 
 generation. The uterus contains three 
 small myomata — one is soft, a second 
 friable, the third calcified. 
 
 Histologic Examination. — In the 
 early stages the calcareous deposit may 
 be overlooked macroscopically, espe- 
 cially if the deposit of salts be very 
 scant. In such cases the nuclei of the 
 muscle-fibers have disappeared entirely, 
 but the fibers can still be made out. 
 Scattered throughout the tissue, are 
 splotches of dark-staining material, 
 sometimes forming one deeply staining 
 mass with hematoxylin, but oft(ni ar- 
 ranged in w^avy rows (Fig. 101). On 
 careful study this deeply stained mate- 
 rial is found to !)(' finely gi-anular and at numerous points refract iv(\ oblong, 
 or irregular crystals are sometimes seen. Occasionally calcareous plates ai'e 
 found in the outer coats of the bl()od-V(\ssels, as noted in Fig. 102. 
 
 When the calcification is far advanced, it is necessary to remove all the salts 
 before the section can be cut; we then have an essentially necrotic tissue, 
 totally devoid of nuclei, but still retaining its fibrous arrangement. 
 
 Fig. 100.- 
 
 Vauioi's 
 
 -Myomata Representing 
 Stages of Degeneration. 
 Gyn. No. 8270. In the cervix is a small myoma. 
 
 In the po.sterinr wall of the uterus is a soft myoma; 
 
 lying in Douglas' pouch is a friable, cheesy myoma, 
 
 which was 5 cm. in diameter; between the two is a 
 
 j)artly calcified myoma. 
 
 How Calcium Salts are Deposited. 
 It is a well-establisluMl fact that in ])ath()logic conditions (-ilciuin snits nie 
 never de})Osited in living tissue. The most ])olenl f:ictoi-s in llie (•;ius;ition ot 
 cell-death are the lack of blood-supjtl.x- and the iiijuiy ivsulling from the action 
 of toxic substances.
 
 128 
 
 MYOMATA OF TIIH UTERUS. 
 
 The iiitcrcstiiiii ('XjK'i'iliiciit of Littcii* was one of the first iiiij)ortant stejis in 
 deterniiniii,i;' llic conditions under which deposits of calcium saUs in the tissues 
 may occur. W'lien llie renal artei'v of a ral)bit was tied for a few hovu's and 
 
 ?U 
 
 ^. 
 
 \'\i... 101. — P.\RTiAi. Calcification of a Myoma. (X SO tliain.) 
 Gyn. No. 11898. Path. No. 8284. The specimen is from a pedunculated myoma which has undergone hyaline 
 degeneration and coagulation necrosis to a marked degree. In the field from which this picture was taken prac- 
 tically no trace of cells remained, the tissue presenting a fibrillated arrangement and staining a dirty pink with 
 hematoxylin and eosin. The dark wavy areas indicate where salts have been deposited in the necrotic tissue. 
 At numcrou.^ points small crystals of the chalky deposit stand out clearly, as is well seen at a. 
 
 the ligature was then removed and the blood again allowed to circulate, Litten 
 found that at the end of twent y-f(nir hours after such removal the kidney tubules 
 showed the presence of highly refractive granules, which microchemically were 
 
 * Litten, Zeit.'^clir. f. kliii. .Mod.. 1879, I, l.'U.
 
 CALCIFICATION OF UTERINE MYOMATA. 
 
 129 
 
 found to consist of calcium salts. He 
 and calcium phosphate and concluded 
 that these substances unite ^vith the 
 ground-substance of the cell to form 
 an insoluble calcium albuminate. By 
 injecting copper sulphate into the 
 circulation of rabbits he obtained 
 similar results. Since that time many 
 observers have found d{'i)osits of cal- 
 cium salts in various tissues following 
 the injection of many irritants, or- 
 ganic and inorganic. Although much 
 has l)een written on the deposition of 
 calcium salts in the tissues, com- 
 paratively little was added to our 
 knowledge of the chemical nature of 
 the process until the recent work of 
 Klotz appeared. The conclusions 
 reached by this observer may be 
 briefly summarized as follows: Pre- 
 ceding the deposit of these calcium 
 salts there are fatty changes in the 
 tissues involved. These in turn are 
 followed by the appearance of soaps 
 or soapy substances, which unite with 
 the albumins of the degenerating cells 
 to form soap albumins. These, with 
 the calcium derived from the blood, 
 form insoluble calcium curds or double 
 calcium soaps. These latter, by the 
 action of substances in the body fluids 
 containing carbonic and phos])horic 
 acids, are then decomposed into phos- 
 phate and carbonate of lime and re- 
 main as ins( )lub](' deposits in the tissue. 
 For further consideration of this 
 subject the reader is i-cfen-ed to the 
 paper of Klotz* and the ('oiii|)ivh('n- 
 sive review of the literature gi\-eii by 
 Aschoff.t 
 
 determined the presence of carbonic acid 
 
 Fic. 1(JL'. — Calcareous Platks in 'ihk W ai.i. ur an 
 AuTKRY. (X llOdiaiu.) 
 Gyn. No. 4364. Path. No. 1170. The uterus was 
 the seat of a tliffuse adeiminynina (see .\<lenoniyoma of 
 the Uterus, p. 97). The ve.ssel has been tortuous, as 
 the picture shows two cross-sections of the same lumen. 
 The various areas of calcHicalioii are iiidicateil liy <i. 
 This calcareous deposit stains .iceply with l\emato\yliii 
 and has a (iiii-ly (rranuhir appearance. The vessel is em- 
 betliled in mi.\ imumIdiis tissue. 
 
 The findings in one of our cases seem to indicate that electric treatments may 
 
 * Klotz. .lour. K\|). Mi'd.. li»(»."), vii. iV.V.i (17.'). 
 
 t Ascliotf, I.uharsch-Ostt'rta.ir, Krgebni.sse. I'.tdJ. Wi«-<l):i<lcn IHIH. viii. .")(>1 .")S0.
 
 130 MYOMATA OF THE ITKIU'S. 
 
 in some way favor the tlcjjositioii of calciuin salts. In (liis case the myomatous 
 tumor \v('i<!;h('(l over 40 poiiiuls. The ])atii'nt had been midcr electric treat- 
 ment for a loii.ti: period, the (>leetrodes having been ai)i)li(Hl to the opposite sides 
 of the abdomen. On llic outer surfaces of tlic tumor, at the points correspond- 
 ing to the places at which the electrodes had been applied, were irregular cal- 
 careous j)la(iues varying from 4 to 6 cm. in diameter and from 1 to 2 mm. in 
 thickness. 
 
 Total Calcification of Myomata. 
 
 We ha\'e had several cases in which the myomata formed solid calcareous 
 tumors. 
 
 In ("ase ()47") the uterus contained several myomata and there was an adeno- 
 carcinoma of the left ovary. Attached to the right uterine horn was a com- 
 pletely calcified myoma. 1 x 2 cm. 
 
 In Case 78.su one myoma luid been pai'tly transformed into a caseous material, 
 and projecting from the anterior uterine walb a little beneath the bladder, was a 
 solid calcified myoma, 6 cm. in diameter. 
 
 In Case 8732, in which the uterus contained a large sarcoma apparently spring- 
 ing from a myoma, an almost totally calcified myoma jii'ojected from the surface 
 of the uterus. 
 
 In Ca.se 4801^ a pedunculated myoma, 8 x 10 x IG cm., had to a great extent 
 undergone calcification. 
 
 The most interesting calcified myoma is described in Path. No. 5816 (Fig. 103). 
 The specimen was sent us by Dr. George E. Holtzapple, of York, Pa. It was as 
 hard as stone, markedly lobulated, and measured 9 xll x 15 cm. It had been 
 obtained at autopsy. At a is a depression which coi'resjionds to the site of 
 pedicle. 
 
 Uterine Stones. 
 
 Our attention was first directed to this sul)ject by a study of Path. No. 161. In 
 this case, during I'emoval of carcinomatous tissue from the uterine cavity, a cal- 
 culus was brought away. This concretion was about 1.5 cm. in diameter and re- 
 sernl)le(l t he lialf of a hollow sj)here. Its outer surface was rough and irregular and 
 at several j)oints presented a mulberry-like a])pearance. The iimer and concave 
 surface was covered with friable ti.ssue. A chij) of the concretion was (examined 
 by Profes.sor Welch, who failed to find any trace of bone-corj)iiscles. Chemically, 
 Professor Abel showed that it was compo.sed of CaX'03 and Ca3(P04)2. 
 
 It is difficult to explain the origin of the calcareous concretion. The most 
 plausible theory is that it is the remains of a ])ait ially calcified myoma. The case 
 is reported in full and illustrated in "Cancer of the Uteru.s, " p. 412. 
 
 Thorn.* who has made a statistical study of uterine calculi from the time of 
 
 * Thorn, .1., "Ziir Kasuistik dcr I'terussteine," Zeit. f. (!cl). u. Cyii.. 1S!)4, Ud. xxviii, S. 7;").
 
 CALCIFICATION OF UTERINE MYOMATA. 131 
 
 Hippocrates down, reports a similar case. If an interstitial calcified myoma 
 
 Fig. 103 — A Comim.ktki.y Cai.cikiki) Si;bi'kiiitom;ai, Myoma (|i iiiit. size.) 
 Path. No. 5816. This .specimen was removed at autop.sy by Dr. (ieorRe K. Holtzapple, of York, Pa., and 
 sent to us on May 18, 1902. a represents the jioint at wliicli the pediele was altaeiied. The pedicle did not be- 
 come calcified, but gradually alrnphiiil. leaving the eavii\ , Tlw tiiiMur presiMiled a niullM-rry-like surfaee. It was 
 perfectly .solid and, when dropin'il 'uj ilic door, fell wiili ilic ilnid of a ~,\,H\r 
 
 becomes siil^nuicous, it will iiMlur;illy in time he extruded tliiduii;!! the xa^ina 
 as a so-called uterine stone.
 
 132 MYOMATA OF THE UTERUS. 
 
 Tabulation of the Calcified Myomata Examined. 
 The accoiiii)anying table gives a fair idea of the mure important partly or 
 completely calcified myomata that have come under our observation. 
 
 OvN. No. Path. No. Uteris. Calcified Myomata. 
 
 2740 276 Multinodular. One nodule calcified. 
 
 :i()14 \i:\ Multinodular. Interstitial nodule, 5 cm. in diam.; 
 
 outer layers calcareous, center 
 caseous (Fig. 99, p. 126). 
 
 3130 499 Multinodular. Tumor, 2.5 x 18 x 14 cm. Calcareous 
 
 areas. 
 
 3340 607 .Multinodular. Rough, nudberry-shaped myoma, 13 
 
 cm. in diam. Area of calcifica- 
 tion 4.0 X 3 cm. on surface. Cen- 
 ter soft, grayi.sh yellow. 
 
 3778 872 Montinodidar. Several nodules containing calca- 
 
 reous deposits. 
 
 3844 910 Multinodular. Several nodules containing calca- 
 
 reous deposits. 
 
 3950 970 Subperitoneal peduncu- Dense omental adhesions. Calcified. 
 
 lated myoma. 
 
 3985 986 Multinodular. Nodule in front of cervix, yellow, 
 
 surrounded hy calcareous de- 
 posits. 
 
 4160 1084 Two subperitoneal nodides. Myoma, 7 x .") x 4.") cm.: pinkish 
 
 yellow or bluish ; small calcareous 
 deposits beneath peritoneum. 
 
 4341 IIO.) Sul)pentoneal myoma. Myoma, 6 x 4.5 cm., yellowish with 
 
 dark center; calcareous deposits 
 especially near capsule. 
 
 4364 1170 Diffuse adenomyoma. Calcified plates in vessel-walls of 
 
 uterus (Fig. 102). 
 
 4801 i 1392 .Mvdtinoilular. Pedunculated myoma, S x 10 x 16 cm.; 
 
 greater part calcareous. 
 
 4975 1.300 Multiiinihdar. Some small interstitial nodules, cal- 
 
 cified. 
 
 5.303 17.>5 Abdominal niyomoctumy Yellow patches; some contain cal- 
 
 (single). cified material. 
 
 6479 2700 .Mvdtinodvdar. Calcified myoma. 1x2 cm., at right 
 
 CDI-IIU. 
 
 6N33 3075^ Sul)mucous myoma. Mucli c:dcareous deposit. 
 
 7775 4043 .Multinodular. Two of nodules calcified. 
 
 7795 4055 .Multinodvdar. Large subperitoneal myoma, partly 
 
 calcified. i)artly soft and degener- 
 ated. 
 
 7889 4136 Multinodular. Calcified myoma. 6 cm. in diam., 
 
 under bladder; interfered with 
 bisection. 
 
 8270 44.33 -Multinodular. Large calcified myoma; near it a 
 
 chee.sy myoma, 5 cm. in diam. 
 (Fig. 100). 
 
 8732 4931 Multinodular with sarco- Subperitoneal calcified myoma (Fig. 
 
 matous degeneration. 143, p. 217).
 
 CALCIFICATION OF UTERIXE :MY()MATA. 133 
 
 Gyn. No. Path. No. Uterus. Calcified Myo.mata. 
 
 11792 811G Uterus normal in size. Subperitoneal myoma, 15 x 12 x 8 
 
 cm.; hyaline degeneration; areas 
 of complete necrosis; points of 
 calcification. 
 
 11898 8284 Subperitoneal myoma. Ad- Microscopic dark-purple areas of 
 
 herent omentum. calcification (Fig. 101, p. 128). 
 
 12779 9(542 Multinodular. Myomata show hyaline and cystic 
 
 changes and calcareous deposits. 
 
 San. 2189 1001.") Multinodular. Subperitoneal myoma, 1.5 cm.; small 
 
 areas of calcification. 
 
 Dr. Holtzapple . . 5816 Large subperitoneal myoma com- 
 pletely calcified (Fig. 103). 
 
 W.,C. H. T 6421 Large, globular. Interstitial myoma with sarcoma- 
 
 tous degeneration. Areas of cal- 
 cification (Fig. 131, p. 193). 
 
 Clinically, these calcified niyoniata are of little import. A degenerated my- 
 oma, when soft, may become infected, but when once calcified, usually gives little 
 or no trouble. It cannot be well diagnosed as calcified prior to operation. 
 
 To the surgeon the condition may offer certain obstacles, on account of the 
 difficulty in getting at the uterine vessels, or ^^■hen, as a result of adhesions, bi- 
 section is deemed necessary, since it may be impossible to cut through the cal- 
 cified nodule. This difficulty may be readily overcome by merely shelling the 
 tumor out and then completing the bisection. We have seen operators in re- 
 moving myomatous uteri by the vagina have untold difficulty with a large cal- 
 cified myoma. In fact, we have seen them resorting to the saw and removing 
 the calcified nodule piecemeal.
 
 ("I[apti:p. IX. 
 
 SUPPURATING UTERINE MYOMATA. 
 
 In this (*haj)t('r \vc iiu-liulc only those cases hi which the pus formation oc- 
 curreil in niyoniata situated on the outer surface of the uterus, or located in the 
 musculatui'e. Suppurating inyoniata are (li\isil)le into \hvvv definite classes: 
 (1) Suhj)eritoneal: (2) interstitial; (3) submucous. However, inasmuch, as the 
 subnuicous variety has certain characteristics totally different from those of the 
 other two classes, they will he discussed hi another j)lace. 
 
 SUPPURATING SUBPERITONEAL MYOMATA. 
 
 We have had five cases of this character, and two other interesting specimens 
 have been referred to us. In Case 12216 (Fig. 104), on section, a multinodular 
 uterus was found reaching to the umbilicus. The most prominent myoma was 
 densely adherent to the anterior abdominal wall, over an area 4x4 cm., and 
 there were also omental adhesions. As soon as the myoma was separated from 
 the abdominal wall, jnis trickled down its surface from a cavity situated ilirectly 
 beneath the point at which the abdominal adhesions had existed. This cavity 
 measured 7x5 cm. and was filled with pus. 
 
 In Case 3216 a myoma, 23 cm. in diameter, was attached to the left side of the 
 uterus (Figs. 105 and 106). On account of the septic temperature pus was sus- 
 pectetl. On tapping, 4700 c.c. of creamy pus were evacuated. The tumor was 
 released from the omental adhesions and the uterus and its a]ij)endages were 
 removed. 
 
 Case 15281 furnished one of the most interesting of our series. The ])atient, 
 some months prior to her labor, noticed a small abdominal tumor. Her labor 
 was uneventful, but a few weeks later she entered the hos])ital very ill. At opera- 
 tion a su]i])urating, pedunculated, subperitoneal myoma was found. This had 
 ru])tured and an absces^s sac had developed between the myoma, the omentum, 
 loops of small bowel, and the right lateral abdominal wall (Figs. 107 and 108). 
 
 In February, 1895, Dr. David A\'. Houston, of Troy, N. Y., sent us a portion 
 (jf a subperitoneal myoma which a woman, fifty-five years of age, had carried 
 for thirty years. The central portion of the tumor had been converted into an 
 abscess containing 10^ quarts of pus. 
 
 Suppurating s u b p e r i t o n e a 1 m y o m a t a co m m u n i c a t - 
 i n g w i t h the bo w e 1 . 
 
 In three of the seven cases of suppurating subperitoneal myoma the abscess 
 had opened into the bowel. In Case 7549 the whole abdonu^n was filled with a
 
 SUPPURATING ITHHIXE MYOMATA. 135 
 
 large myomatous uterus. In the upper part was a large irregular abscess com- 
 municating with the colon (Fig. 109). 
 
 In Case 9078 a partially ])arasitic myoma contained an abscess cavity. This 
 conmumicatecl freely with the cecum, fecal matter passing from the bowel to the 
 cavity in the mj^oma. This case is reported in detail on p. 45 (Fig. 32). 
 
 In Hundley's case the parasitic myoma had received its nourishment from 
 the small bowel. The interior had been converted into an abscess sac and fecal 
 matter passed directly from the bowel into the myoma and back again to the 
 bowel. This case is likewise reported in detail in the chapter on Parasitic 
 Myomata (p. 47, Fig. 33). 
 
 Cases of Suppurating Subperitoneal Uterine Myomata. 
 Gyn. No. 122 16. Path. No. 8825. 
 
 Cervical, i n t e r s t i t i a 1 , a n d s u Id p e r i t o 11 e a 1 m y o m a t a ; 
 necrosis of a large s u I3 p e r i t o n e a 1 m y o m a , ^^' i t h ab- 
 scess formation (Fig. 104); dense adhesions to the 
 abdominal wall and to the o m e n t u m . 
 
 M. H., colored, aged twenty, married. Admitted July 5; died July 15, 
 1905. She has never been pregnant. For about ten months she has had definite 
 pain of a sticking character in the right side of the abdomen. Early in the onset 
 of the present trouble she felt a small mass in the right side, which has gradually 
 increased in size. The pain has been associated at times with fever, more marked 
 at the menstrual period. Four months ago the patient had considerable diffi- 
 culty in getting the bowels to move; the abdomen was swollen for three or four 
 weeks, and there was some vomiting. For the last three weeks the patient has 
 had shortness of breath, dizziness, and night-sweats. 
 
 Operation, July <S, 1905. Hysterectomy was done in the usual manner. 
 There was, however, consideralile difficulty in liberating the most prominent 
 myoma from the anterior abdominal wall. After liberation of the adhesions, 
 pus commenced to trickle down from the surface of the myoma (Fig. 104). 
 Care was taken to cover in the raw peritoneal area as far as possible by bringing 
 the peritoneal surfaces together with catgut. On the sixth day after operation 
 the patient de\'e]o](e(l partial intestinal obstruction. The patient did fairly 
 well for two days, when she had a sudden attack of abdominal i)ain, colick\- in 
 character. The bowels had moved, and iier temj)erature was normal. The 
 bowels wer{> moved again two or three times, hut the distention increased. 
 The temperature remained ahout 99° l'\ 
 
 July 15th. lv\i)loratory laparotomy. When the ])atieiit was j)laced under 
 ether, vomiting commenced. This was decidedly fecal in ('liai'acter, although 
 there had been no vomiting in the ward. The ahdominal ca\ity contained a 
 moderate amount of clear .serum and the intestines were e\-ery\vhere distended. 
 In the right (|uadrant they were fastened to the anterior abdominal wall at the
 
 136 
 
 MYOMATA OF THE UTERUS. 
 
 point at which the sui)|)uratiiiti iiiyoina had lu'cn adhcroiit. The patient died 
 ahnost itnnicdiatcly. At autopsy it was found that the intestine at t\w site of 
 
 the adhesions was bent upon itself at 
 a sharp angle. The highest postopera- 
 tive temperature was 100.5° F. In 
 &dVv^K"^^^Hl this case it would have been wiser to 
 
 Fig. 104. — .\ Suppurating Subpkritonkai. Myoma. (« nat. size.) 
 Gyn. No. 12216. Path. No. S.S2.5. The uterus is seen from the side. The myoma to the left encroached on 
 the bladder. That on the right wa.s densely adherent. Occupying the upper part of the uterus is a large globular 
 myoma. Over the area indicated by a it was densely adherent to the anterior abdominal wall. \t b pus is welling 
 from the interior of the myoma. The omentum is adherent over a wide area
 
 SUPPURATING UTERIXI-: MYoMATA. 137 
 
 have done an explonitoiy opcraticjn caiiicr, when the patient was in good con- 
 dition; the chance of success would then have been much greater. 
 
 Path. No, 8825. The specimen consists of a myomatous uterus approxi- 
 mately 12x12 cm. Projecting from the cervix, and extending down into the 
 broad ligament, is a myoma 7 cm. in diameter. There is also one of smaller size, 
 springing from one horn, and scattered throughout the walls of the uterus arc 
 several smaller nodules. The chief interest is centered in the sul)peritoneal 
 nodule, 10 x8x8 cm. Attached to its surface is a large tag of omentum. Pus 
 flows from a rent in the myoma. On the surface, in the vicinity of the omental 
 adhesions, is a raw area 4x4 cm. At this point the growth was adherent to the 
 abdominal wall and had literally to be cut away. This subperitoneal myoma 
 is in part covered with numerous adhesions. On section, it is found to have 
 broken down over a considerable area. The myoma has evidently first under- 
 gone necrosis. AVe have an irregular cavity, 7x5 cm., filled with pus. 
 
 Histologic Examination. — Sections from the subperitoneal myoma which 
 contained a quantity of pus show that a large portion has undergone h3^alinc 
 degeneration and coagulation necrosis. Such areas are almost entirely devoid 
 of cell-elements. The inner surface of the abscess wall is bathed in polymor- 
 phonuclear leukocytes and necrotic material. The underlying myomatous 
 tissue, where hyaline degeneration has taken place, shows a good deal of small- 
 round-celled infiltration and the formation of many new connective-tissue cells 
 around the blood-vessels. There has, in this case, undoubtedly been a primary 
 necrosis followed by infection. 
 
 Gyn. No. 3216. Path. No. 534. 
 
 A s u p p u r a t i n g i n t r a 1 i g a m e n t a r y m y o m a ( Figs. 105, 
 106) ; slight p e r i - o (J p h o r i t i s on 1) o t h sides. 
 
 A. S.,white, aged forty-four, married. Admitted December 1, 1894;dischai'ged 
 January 1, 1895. The patient has had eight children and one miscarriage. Six 
 years ago she noticed an enlargement of the left lower abdomen and there was 
 some "sticking" pain. The tumor has gradualh' increased in size, both sides 
 being now involved, and she has a constant dragging ])ain, occasionally sharp and 
 bearing down in ehanicter. She is weak and has l)een having a se])tic teni])era- 
 ture. 
 
 Operation, Deceinbei' ;!, IS91. llysteroinyoinectoniy. A densely adherent 
 suppurating intraligamentary niyoina was found and tapped, 1700 v.v. of creamy 
 pus being removed. There were dense omental adhesions. The tempei'alui'e, 
 which was 100.6° F., rose a lit tie, and then tell loiiornial. It I'ose again to 103° !•'. 
 on tlu! nineteenlh day. williout ;i|)i)an'iit iv;ison, and al'ler lliat became iioinial. 
 
 Path. No. 534. The siK'cimen consists of llic uterus, with a large tumoi' 
 springing from its left side, and both tubes ami o\aries. The tunioi', which is 
 globular, is 23 cm. in diameter. It springs from the left side of the ulems. ap- 
 pai'ently arising fi'oin the left utei-ine eoi-iui. just beneath the tube (Figs. 105 and
 
 138 
 
 MVO.MATA OF THH ITKIUS. 
 
 106). It then jiasscs out Ix'twccu the layers of the hroad ligament, being covered 
 with ])eritoneuin. It is whitish yellow or pinkisli in color, is covered with 
 numerous adhesions, and is adherent to the omentum over an area 8x8 cm. 
 On pressure it is somewhat elastic. On section, the tumor is seen in places to be 
 covered with a layer of nmscle, 4 nun. in thickness. This covering gradually 
 disappears as the tumor passes toward the broad ligament. The tissue of the 
 tumor is grayish-pink in color and is ver}^ edematous. It is divided up into 
 large and small, irregular oval masses. These contain numerous Ijmiph-spaces, 
 the largest of which is ') inn 1. in diameter. In the center of the tumor is a cavity, 
 15 cm. in diameter, and having somewhat irregular and ragged walls. The inner 
 
 surface is covered with a yel- 
 lowish membrane, 1.5 mm. in 
 thickness. Attached to this 
 membrane are many whitish- 
 
 ■^If^^i- 
 
 J* 
 
 Fig. 105. — .\n Intrai.igamentary Suppurating Myoma. (,| nat. size.) 
 CJyn. No. 3216. Path. No. 534. Springing from the left of the uterus is a large globular myomatous tumor, 
 that shows dense adhesions on its upper and outer surfaces. The uterus and right appendages are normal. The 
 left tube is marketlly elongated, as the result of stretching by the tumor, and the left utero-ovarian ligament is 
 much lengthened. For the interior of the myoma see Fig. 106. 
 
 yellow flakes, resembling those found in a i)unilent jxTitonitis. The cavit}^ 
 contains 3000 c.c. of dirty, bluish-green ))us, which microscopically is found to 
 be composed of polynior]:)honuclear leukocytes and degenerat(^d cells containing 
 fat-droplets and debris. Numerous diplococci are also seen. Coursing over the 
 outer surface of the tumor is the left Fallopian tul)e. which takes a curve 
 directly outward, backward, and then inward. The uterus and th(> appendages 
 on the opposite side are of little interest. 
 
 Histologic Examination. — The large tumor everywhere shows moderate hya- 
 line degeneration. In the vicinity of the cavity the muscle is very rich in blood- 
 vessels, many of which have undergone complete hyaline degeneration. In 
 some places, however, the endothelium still persists. The muscle-fibers in this
 
 SUPPURATIXG utt<:rixk MYo.MATA. 
 
 139 
 
 region stain niucli more decpl}' than in the outer portion of tlie tumor. In many 
 places the muscle shows aggregat icons of newly formed connective-tissue cells. 
 Still farther inward the entire nmscular substance has undergone hyaline degen- 
 eration, and scattered throughout this hyaline material are a moderate number of 
 polymorphonuclear leukocytes. Just beneath the inner surface the tissue has 
 undergone coagulation necrosis. The inner surface of the cavit)^ at such points is 
 covered with polymorphonuclear leukocytes. In other places the tissue presents 
 a typical granulation surface. .Many polymorphonuclear leukocytes, both on the 
 surface and in the depth, are swollen and appear to contain fat-droplets. This 
 is a most striking example of a suppurating intraligamentary myoma. 
 
 Fig. lot). — A Suppuratinc; Intrai.icamkntauv Myoma. {!, nat. size.) 
 Gyn. No. 3216 Path. No. 534. This represents the posterior half of the tumor .seen in Fig. 105. The uterus 
 and right appendages are normal, a represents the outer covering of normal uterine muscle; 6, myomatous tissue. 
 Over half the tumor has l)e(>n converted into an abscess sac. 
 
 Gyn. No. 15281. Path. No. 13121. 
 
 A s u )) p u r a t i n g s u b p e r i t o n e a 1 p e d u n c u 1 a t e d m y o - 
 m a , w h i c h r u p t u r e d a 11 d f o r 111 e d a 11 a b .^ cess b c t w e e 11 
 the o m (■ n t u m , s m all bo w el, a n d right 1 a t e r a 1 ab- 
 dominal wall (Fig.^. 107. 108) . 
 
 A. W., married, aged I weiity-oiic, colored. .Vdmil ted XoNcmbci- io ; dischai'ged 
 December 17, lOOS. She complain.'^ of a "knot " in 1 he I'iglil side of t he abdomen. 
 The patient has been mari'ied ten niontlis ;in(l lias one cliild, a month old. In 
 March, 1908, sh(> experienced sliai-p bearing-down pain in the right .side of the 
 pelvis, and at that time noticed a luni|) which was apparently about (i cm. in
 
 140 
 
 MVO.MATA OF THK UTERUS. 
 
 diameter occup^inii the riiilit iliac fossa. The pain was dull, achiiiii in character 
 and constant. Since then the pain has increased more or less and has been 
 aggravated on many occasions by exertion. There was no increase in the size of 
 the tumor until the termination of pregnancy. She has complained of no back- 
 ache, but of much headache. Her labor, one month ago, was perfectly normal. 
 She states that during the early pregnancy there was occasionally fever and 
 during the last few days she has had considerable nausea and vomiting. 
 
 On admi.ssion she appears to be quite sick. The tongue is brownish in color 
 and coated. The ])ulse is of fail' 
 volume. lo() to the minute. 
 
 Jh. omertt-jm 
 
 Acl4eS-o 
 par etal pari 
 
 Fit;. 107. — A Suppurating Subperitoxk.al Myoma. 
 Oyn. No. 1.52S1. I'atli. No. 13121. The uterus is normal in size, .\ttacheil in the fundus is a peihiuoulated 
 myoma which had .sui)i)urated and ruiitured. On the outer side it wa-s adherent to the atxlominal wall, on the 
 inner side, to the omentum and small bowel. For the interior of the myoma see Fi?. 108. 
 
 Abdominal i^xamination : ( )\'er the lower two-tiiirds, on the right side of the 
 abdomen, is a distinct owil jjiomiiicnce. and on palpation this area is firm, 
 slightly tender, and has a brawny feel. No fluctuation can be made out, but there 
 is a slight yielding of the tumor. This mass is firmly fixed. On vaginal exam- 
 ination nothing can be detected. 
 
 Her hemoglobin was 80 percent.: leukoc3^tes, 24,000. An incision was made 
 through the right rectus and the mass immediately (>xpos(>d. Over its surface
 
 SUPPURATING UTEKIXK MYOMATA. 
 
 141 
 
 the oinontuni was firinl}' tulhen'iit. On its inner side were adherent intestinal 
 loops. On its outer side it was firmly fixed to the lateral abdominal wall. The 
 mass was carefully walled off on all sides and Ww omentum then o;radually with- 
 drawn. There was an innnediatc escape 
 of very fetid pus. This came from the 
 inner side of the mass and also from the 
 
 Suppurating' subperitoneal, 
 myoma 
 
 \ m 
 
 IH 
 
 I 
 
 ■ 
 
 
 
 N» 
 
 y 
 
 P 
 
 i 
 
 w 
 
 : r. tu]t>€ 
 r. ovary 
 
 ^aN^^' 
 
 .:?■' 
 
 
 Omeni 
 
 uni 
 
 adherent to tumor 
 
 
 
 Fk;. 108. A SUI'ITIIATINO SlUU'ERITONKAr. M\(IM\. 
 
 CJyii. No. 152.S1. I'alli.No. i;n21. The uteni.s was normal in size, !)Ut on paipiilinn a few .small m.\i>mala 
 could he felt. Attached to the fundus by a broad pediole was a suppuratiiiR myoma. DurinR pregnancy it had 
 been carried upward and lay above anil to the right of the umliilicus. Uere it had become fixed. Us center was 
 filled with pu.s and necrotic tissue. \X had ruiJlured. but was walled off on the median and anterior surfaces by 
 the omentum and small bowel; on the outer side, by the lateral abdominal walls. The api)cndaKes were normal 
 
 vicinity of the ahdominal wail. ( )ii l)ciiiu- .irfadually lod.^ciicd up it was found to 
 be a myoma which was attached to the uterus by a rathci' broad ])C(hch' (Fifj. 
 107). The tumor was freed abo\-e ;ui(l l;itei-;illv and then the uterus was (h'awn
 
 142 MYO.MATA OF THK UTKIU'S. 
 
 out. The Uterus, tuhcs. and ovaries were ])ert'eetly normal. The pedicle of 
 the luyonia was cut across, and the I'aw aiva closed. A small drain was laid in 
 the pelvis and also in the pocket from which tlie tumor had been removed. 
 The tissues in all directions were hanl and edematous, the omentum was 
 marke(llv thickened, and the ahdominal wall roughened. The intestines were 
 covered with a pN'ogenic meml)rane. 
 
 Xovemher 2()th: The j)atient is in excellent condition. Her temperature 
 and pul.se are normal. The abdominal wound has to a great extent closed, but 
 there is considerable discharge, which seems to be fecal in character. We are 
 not at all surj^ri.sed at this, on account of the implication of the intestinal loops 
 in the abscess wall. The wound closed completely, and the patient was discharged 
 well on December 17, H)OS. 
 
 Path. Xo. 1."!I2I. The specimen consists of a myoma a))proximately 8 cm. 
 in length and 7 cm. in diameter. This, on its outer surface, presents a rather 
 worm-eaten appearance, especially where it was adherent to the abdominal 
 wall (Fig. lOS). The raw area indicating the site of the pedicle is 4 cm. in length 
 and 2.0 cm. broad. The entire central portion of the tumor is irregular, 
 yello^^sh- white in a])))(vi ranee, and has trabecula' extending from side to side 
 over a consideralile aica. The walls vary from 2 cm. to not more than 1 mm. in 
 thickness and in some places have given way entii'ely. Occupying the central 
 portion are grayish-yellow necrotic masses. The largest of these measures 2.5 x 
 o cm. Filling in all the interstices of the center is grayish-yellow, offensive pus. 
 This had trickled out between the tumor and the lateral abdominal wall and 
 likewise between the bowel and the omentmn on the inner aspect. 
 
 Histologic Examinati(jn. — Sections from some portions of the growth show 
 the typical myomatous picture. At other points there is marked hyaline trans- 
 formation, with li(iuefaction. The walls of the abscess are composed of typical 
 granulation tissue, which is very va.scular and in })laces hemorrhagic. Scattered 
 throughout the walls ar(> many polymorphonuclear leukocytes and small round 
 cells. The growth is essentially a myoma which has undergone suppuration in 
 its central ))()rtion. 
 
 Gyn. No. 7549. Path. No. 3799. 
 
 Small subperitoneal and interstitial uterine my- 
 o m a t a : large si o u g h i 11 g s u b p e r i t o n e a 1 m y o m a c o m - 
 m u n i c a t i n g w i t h the c o 1 o n (Fig. 109). 
 
 K. H., aged thirty-Hve, white, single. Admitted February 1; discharged 
 March 22, 1900. Occupying the lower and median portions of the abdomen is a 
 large irregular mass. This is smooth, hard, freely movable from side to side, 
 and continuous with a large jK'lvic growth. 
 
 Operation, February .'^ 1900. Hysteromyomectomy. On section of the ab- 
 domen the transverse colon was found so fii-nily adherent to the tumor that sepa- 
 ration was imj)o.ssible. The cervix was at once located, cut across, and the 
 uterus turned out so that the adhesions were gotten at from the under surface.
 
 SUPPURATIXG UTERIXE MYOMATA. 
 
 143 
 
 The myoma contained an abscess cavity whicli coiiiiiiunicated witli the colon. 
 The operation is described in detail on p. 613. The patient had a fecal fistula 
 when she left the hosj)ital. Tliis is hardly to l^e wondered at, considering the 
 markedly indurated ojjening noted in the cecum at oj)eration. 
 
 Path. No. 3799. The greater part of the myoma lies above the utc^rus. In 
 its upper part is a iai'gc sloughing cavity which ojjcns on the surface and has 
 connnunicated directlv with the bowel. 
 
 \^^^^%:M 
 
 Fk;. 109. — A Si'i-i'i'RATixc M-iOMA Oi'km.ng into thk Colon. 
 Gyn. No. 7.')49. Path. No. .3799. Occupying more than half of the abdomen is a niyoniatovi.'s tumor. Rs 
 upper ijart contains an irregular al)sees.s cavity which empties into tlie colon. For a full description of the 
 operative difficulties in this case see p. 613. (.\fter Howard A. Kelly, i 
 
 ()ii histologic exainiiiation ])oiliotis of the iiiyoiiin litiing llie al)scess (•a\'ity 
 ar(> entirely iiecrolic. The surface is eo\-ei'e(l with many polyiiioiphoiiuelear 
 leukocytes, which also haxc infill caled the undeiiyiug tissue Idi' a ('onsideral)le 
 distance. Apart from this no lUK'lei aic anywhere demonstrable. Had we not 
 first cut across the cervix and then attacked the cecal adhesions from behind, 
 the case would ha\'e been ino|)erable.
 
 144 MYOMATA OF THK TTERUS. 
 
 Path. No. 605. 
 
 A s u p ]) u r a t i n g s u I3 p (> r i t o n v a 1 11 t v r i ii c m y o 111 a . 
 
 Patient of Dr. Houston, Troy, N. V. The tumor, a subperitoneal myoma 
 that contained 10^ quarts of ]ius. liad been obtained from a woman fifty-five 
 years of age, who had carried it foi' thirty years. The specimen received l)y us 
 for examination in February. J SO"), consisted of a ])()rtion of the wall of this 
 abscess. 
 
 Plistologic Examination. The tissue is composed of non-strijx'd nniscle- 
 fibers cut longitudinally and transversely. It has a fairly rich blood-supply. 
 Along the outer margins of the tumor the muscular tissue stains poorly. There 
 is a mod(n"ate nuclear fi'agmentation and marked ])olyniorphonuclear infiltra- 
 tion. The inner surface is entirely necrotic and devoid of nuclei. Scattered 
 throughout this necrotic material are masses of micro-organisms Avhich, when 
 stained. ])rove to be cocci. They are arranged singly oi" in short chains. 
 
 SUPPURATING INTERSTITIAL UTERINE MYOMATA. 
 
 In (iyn. \o. 8707 the globular uterus was LS cm. in diameter. The gi'eat in- 
 crease in size of the abdomen was due to an interstitial myoma, 17 cm. in di- 
 ameter, occupying the posterior wall. The uterine cavity was 15 cm. in length, 
 and its muco.sa scarcely 1 nun. in thickness. At one point in the posterior wall 
 the nmcosa over an area 7 x o cm. had entirely disappeared and the portion of 
 the myoma projecting through was brownish in color, roughened, and disinte- 
 grating (Fig. 111). The entire myoma was rather soft. 
 
 In Gyn. No. 5093, as soon as the cervix was cut at operation, a stream of 
 brownish, tenacious mucus poured out. The uterus had been converted into a 
 globular tunioi- 22 cm. in diameter. ()ccu{)ying the anterior wall was a large 
 myoma which was imdergoing necrosis. The uterine cavity was 16 cm. long 
 and at the fundus reached 5 cm. in breadth. At two points over the large myoma 
 the nmcosa had disap])eared and the underlying mA'omatous tissue was dark 
 l)luish red and necrotic. The larger area, 4 cm. in its longest diameter, had 
 sharply defined rounded margins (Fig. 112). 
 
 In Case 5617 the patient gave definite signs of sepsis. The uterus was 
 globular and averaged 22 cm. in diameter. The uterine ca\'ity was greatly en- 
 larged. Occupying the anterior wall was a myoma, 17 cm. in diameter, over 
 which the nuico.sa was atrophic. Near the center of the cavity the tumor was 
 devoid of mucosa over an area 10 cm. in diameter and here it had been trans- 
 formed into a ragged, sloughing mass. 
 
 In San. No. 1847 the patient, prior to operation, had had chills and fever. 
 The uterus mea.'^ured 10 x 9x S cm. There was a diffuse myomatous thickening 
 of the vUei'iis. a submucous myoma, 2.5 cm. in diametei', and an interstitial myo- 
 ma which had undergone almost complete hyaline transformation. The central 
 portion of this had broken down and opened into the uterine cavity. This
 
 SUPPURATING UTERINE MYOMATA. 
 
 145 
 
 cavity on histologic examination presented the typical appearance of an ab- 
 scess wall. 
 
 In Case 14942 an interstitial myoma had been detected three years previously. 
 Shortly before operation the patient lost 26 pounds. Fully one-fourth of the 
 interstitial myoma had been converted into an abscess sac (Fig. 110). 
 
 The supi3urative changes in Case 7158 were very extensive. The uterus was 
 apparently about the size of that of a five months' pregnancy. As the hand was 
 passed around to tlio right of the uml)ilicus there was an escape of several ounces 
 
 Fig. 110. — A Suppuratinc iNTicitsTniAi. Mvoma. (Vnat.size.) 
 Gyn. No. 14942. Path. No. 12963. The patient, admitted July 2, 1908, w.as thirty-six years old and had 
 noticed the tumor for three years. Recently she had had much pain in the lower abdomen and had lost 20 pounds. 
 At operation the omentum was densely adherent to the uterus. The myomatous uterus reached SJcm. above the 
 umbilicus. The enlargement was due chiefly to an interstitial and partly submucous myoma, 9 x 12 .x 12.5 cm., 
 occupying the anterior wall. Fully one-fourth of the myoma consisted of an abscess, the margins of which were 
 very irregular. The patient made a good recovery. 
 
 of thick green pus with a garlicky odor, 'i'lic uterus was a]iproximately M) \ H) x 
 12 cm. It was everywhere covered with vascular adhesions. On IIk^ anterior 
 surface was a necrotic area, 10x8 cm., greenish in color, and surrounded by 
 dense adhesions. Its edges were very irregular and tlu^ u(H'rotic surface was ul- 
 cerated to a depth of 5 inin. It was fioni this area that tlu> pus escaped. The 
 great increase in size of the uterus was dne to a large int(>rstitial myoma situated 
 in the anterior wall. This was dark blue in color, and at the jwint at which the 
 ulceration was noted had reacheil the peritoneal surface. Tlu^ tumor was soft 
 and pultaceous in character and eniille<l an olTeiisive odor. 'i1i(> uterine cavity 
 10
 
 146 
 
 MVOMATA OF THK UTFIRUS. 
 
 was 11 cm. in length. Tlie anterior wall was perforated over an area 5 x 4.5 cm. 
 (Fig. 113). The margins of this opening were sharply defined, and the floor 
 of the cavity was uneven ami co\-(M-ed with greenish-3Tllow pus. The necrotic 
 material had not only hi-oken through the ]ieritoneal surface, hut also into the 
 uterine cavity. 
 
 Gyn. No. 8767. Path. No. 4959. 
 An interstitial u t e r i n (> m y o m a a t one ji o i n t pro- 
 jecting into the uterine c a v i t y ( Fig. Ill), and u n d e r - 
 going il i s i n t e g r a t i o n ; slight p (^ 1 \- i c adhesions. 
 
 Fig. 111. — Slight Suppuration ok ax Ixtkrstitiai, Myoma with Pkrforatiox into the Uterixe Cavity. 
 
 a nat. size.) 
 Gyn No. S767. Path. No. 4959. Occujiying the posterior wall is a myoma 17 cm. in diameter, a ami a 
 indicate the extreme depth of the uterine cavity. At the ijoints indicated by b the mucosa had liisappeared and 
 here the underlying myomatous tissue was brownish in color, roughened and disintegrating. On microscopic ex- 
 amination this tumor was found to have undergone marked hyaline degeneration and there was consiiierable 
 polymorphonuclear infiltration. 
 
 1'^. P., aged forty-four, colored. .Vdmitteil Ma}' Ki; tlischarged June 15, 
 1901. Com])laint: An abdominal tumor and swelhng of the legs and ankles. 
 Her menses began at fourteen and were regular up to seven years ago. Since 
 then the periods have been too fre([uent. At present lileeding comes on three 
 or four times a month and varies from a small amount to a flow lasting from 
 eight to ten davs. She has had ten children and two miscarriages. For nine
 
 SUPPURATING TTEIUXK MYOMATA. 147 
 
 years there has been a white, non-irritatii\o; (Uscharge, more profuse after the 
 menses, and she has noticed that the abdomen has l)een enlarged. The patient 
 says the tumor at the present time is much smaller than it was two years ago. 
 During the past three months she has had frequent urination and painful defeca- 
 tion. For three years she has had edema of the legs, especially of the left. 
 Hemoglobin, 51 per cent. 
 
 Operation. Panhysterectomy. When the ])atient was discharged, the left 
 leg was still rather edematous and i)ainful. but the hem()glol)in had risen to 
 70 per cent. 
 
 Path. No. 4959. The specimen consists of a globular uterus, 18 cm. in di- 
 ameter, and also of the lateral structures. The great increase in size of the uter- 
 us is due to an interstitial myoma, approximateh^ 17 cm. in diameter, occui)ying 
 the posterior wall. The uterine cavity is 15 cm. in length and its mucosa is 
 scarcely 1 mm. in thickness. The chief point of interest in this case lies in the 
 fact that at one point in the posterior wall the mucosa over an area 7x5 cm. has 
 entirely disappeared (Fig. Ill), and the portion of the myoma projecting through 
 is brownish in color, somewhat roughened in appearance, and disintegrating. 
 The myoma itself is rather soft. The appendages offer nothing of interest. 
 
 Histologic Examination. — The mucosa lining the uterine cavity is perfectly 
 normal, save in the vicinity of the area, where the myoma projects through. As 
 we approach this the mucous membrane becomes thinner and thinner, until it 
 disappears and the myomatous tissue, which has undergone almost complete 
 hyaline degeneration, forms the floor of the cavity. Scattered throughout the 
 hj^aline material are quite a number of polyniorphonuclear leukocytes. It is 
 astonishing to see such a mild degree of inflanunation where so much loss of 
 substance has taken ])lace. 
 
 Gyn. No, 5093. Path. No. 1599. 
 
 A n i n t e r s t i t i a 1 u 1 e r i n e m y o m a s u ]> p u r a t i n g a n d 
 opening i n t o u t e r i n c c a v i t y (Fig. 1 12). 
 
 M. B., aged forty-three, white, single. Admitted March \'2: thscliarged 
 May 3, 1897. Tlie patient first noticed an abdominal tumor six years ago. 
 This has grown steadily. It is slightly soi-e during the meiisli'ual ])eiiod, and at 
 these times is inciH^aseil somewhat in si/,e. ( )ii examination under ethei' the lower 
 part of the alxloiiieii is Inund lilled with a liai'd. nodular. |)artly mobile luiuoi- 
 about the size of a utems in the se\-entli moiilh of |iregnancy. 
 
 Operation. Ilysteromyomectomy. The tunioi' was (leli\-ei'ed with gi'eat 
 difficulty and was exti-emely \'asculai'. ()ii section into th(> cerxical canal, a 
 sti'eam of bi'owii tenacious mucus poured oul. ()ne-lil'lli (if ihe let'l o\ar\' was 
 left behind. ( 'oiixalesceiice was interru| it ei j jiy the foi'nialioii of a ]iel\ic abscess, 
 ueeessitating drainage through the x'agina. 'I'liere was also slight suppuration 
 from the alxlominal incisidn. 
 
 Path. \o. i5!l9. The specimen consists of the eiilai'ged uterus to which the
 
 148 
 
 MVO.MATA OF THE UTERUS. 
 
 right tulx' is attached. The uterus has been converted into a globular tumor, 
 22 cm. in diameter. The posterior surface is covered with numerous vascular 
 adhesions — the anterior is smooth and glistening. Occupying the anterior uterine 
 wall is a large myoma, which is undergoing necrosis. The uterine cavity has lieen 
 drawn out by the tumor; it is 16 cm. in length and 5 cm. in breadth at the fundus. 
 The jiostcrior surface of the uterine cavity is smooth and glistening, but is 
 almost eiitiicly devoid of mucosa, the atrophy being evidently due to pressure. 
 On the autciior suiface of the uterine cavity are two oval areas with sharply 
 
 Fig. 112. — .\ Suppurating Interstitial Myoma Opening into the Uterine Cavity, (i nat. size.) 
 Gyn. No. 5093. Path. No. 1,599. The uterus had been converted into a globular tumor 22 cm. in diameter, 
 the increase in size being due chiefly to a large myoma occupying the anterior wall. At a and b the myoma, which 
 was partly necrotic, had broken through into the uterine cavity. The myomatous tissue forming the floor of these 
 cavities was dark bluish red and necrotic, c is a small polyp. 
 
 circumscribed, smooth margins, and a central portion consisting of dark, bluish- 
 red necrotic tissue (Fig. 112). The larger area is 4 cm. in its longest diameter. 
 The mucosa over the remaining portion of the anterior wall is smooth, but much 
 thinned out. 
 
 Gyn. No. 5617. Path. No. 1962. 
 
 A sup ]) u r a t i n g interstitial u t e r i n e m y o m a ; chronic 
 endometritis ; n o r m a 1 a \) p e n d a g e s . 
 
 II. .1., colored, aged forty, married. Admitted October IS; died October 
 21, ISUT. The patient has had two children. For the i)ast year she has had
 
 SUPPURATING UTERIXK MYOMATA. 149 
 
 an almost continuous hcinorrhage, at times oozing in character, at other times very 
 profuse, with severe pain. The flow has been offensive. Five years ago she began 
 to have pain in the left side and a year later noticed a tumor in the abdomen. 
 This has grown steadily. She is weak, has shortness of breath and occasionally 
 severe abdominal pains. 
 
 Operation, October 21, 1897. Hysteromyomectomy. The patient was very 
 weak, the pulse beuig 130 and feeble before operation. She had had bronchitis. 
 Chloroform was first used, and the respirations stopped. The patient was re- 
 suscitated and ether employed. The pulse rose to 168, grew weaker and weaker 
 and the patient died on the talkie. Her temperature before operation ranged 
 from 99.8° to 104.2° F. 
 
 Path. No. 1962. The specimen consists of the uterus and its appendages. The 
 uterus is globular, resembling the pregnant wom]3, and averages 22 cm. in 
 diameter. Posteriorly, it is covered with numerous vascular adhesions. The 
 under cut surface is 7 cm. in diameter. The uterine cavity is greatly enlarged, 
 being nearly 22 cm. long and 13 cm. broad at the fundus. The posterior wall 
 averages 3 cm. in thickness, but the anterior wall contains a tumor 17 cm. in 
 diameter. This is in part covered with mucous membrane which is thinned 
 out and hemorrhagic. About the center of the cavity the tumor has broken 
 through the mucosa over an area 10 cm. in diameter, and a large, ragged, sloughing 
 mass fills the cavity. The mucosa covering the posterior wall is also atrophic 
 and hemorrhagic. 
 
 Histologic Examination. — Cover-slips from the necrotic mass show a few 
 cocci arranged in rows, also short bacilli in clumps and two or three in a row. The 
 surface of the myoma where it projects into the uterine cavity shows disinte- 
 gration and is completely necrotic, consisting of homogeneous granular and jworly 
 stained material containing polymorphonuclear leukocytes and fragmented 
 nuclei. The deeper portion of the myoma contains areas of coagulation necro- 
 sis. The uterine mucosa presents none of the normal elements, but consists 
 of granulation tissue made up of young connective-tissue cells, young blood- 
 vessels, which rise to the surface, and a dense zone of small round cells. The 
 surface is covered with leukocytes embedded in fibrin. 
 
 San. No. 1847. Path. No. 8346. 
 
 Diffuse t li i c k (• u in g o f t li c u t c r i u c wall: s u p ]• u r a I i o n 
 o f a II i 11 t (' r s 1 it i a 1 111 >' d m a . 
 
 W. .!., white, iiianicd, agcil tliiiM y-t'our. A(linittc(l March 1 : discharged 
 April 12, 1905. The i)atient has had eleven children and has had i)rofus(> niiMi- 
 struation for the last year. She is very sallow in apju'arance and has a hemo- 
 globin of 50 jier cent. After hysterectomy the patient made a very satisfactory 
 recovery. 
 
 Path. No. 8316. Tlie specimen consists of the uterus, which is about twice 
 its natural size. This case is reported in full in '' A d e n o m y o m a o f the
 
 150 MVOMATA OK THK ITERUS. 
 
 Uterus," p. 230. Briefly, it consists of an interstitial myoma which has 
 undergone almost comi)l('t(> hyaline transformation and then sujipuration. 
 On histologic examination llic iimer surface of this contains many polymor- 
 ]>li()iuicl(';ir Icid^ocytes. The offensive (hscharge was ('videiitl}- (hie to the de- 
 generation. 
 
 Gyn. No. 7158. Path. No. 3431. 
 
 A 1 a r g e interstitial n e c r o t i c m y o m a ; [) e r f o r a t i o n 
 of t h e u t e r u s ant e r i o r 1 y , f o r m a t i o n o f a h s c e s s on 
 its s u r f a c e a n d u 1 c e rati o n i n t o the uterine cavity 
 ( F i g . 1 1 ."> ) , g i ^' i 1' g" 1" i •'^ ^' to a p u r u lent vagi n a 1 
 (1 i s c h a r g e. 
 
 0. S., aged twenty-three, white, married Admitted August 26; died 
 August 29, 1S90. The ])atient had had one child and no miscarriages. She was 
 profoundly emaciatecl and had a pulse of from 120 to 130; the temperature varied 
 from 100° to 103° F. She was in a desperate condition when put on the table. 
 
 Operation. The uterus was apparently about the size of that of a six months' 
 pregnancy. \\ hen the hand was jjassed around to the right of the umbilicus, 
 there was a free escape of several ounces of thick green ])us having a distinctly 
 garlicky odor. This was removed as fast as possible, to i)revent general infection. 
 The fundus was ch'awn out with considerable (hfficulty, and a large necrotic area 
 surrounded by adhesions was found on the anterior surface. The uterus was 
 removed in tiie usual way, the abdomen (h'ained, and an infusion of saline 
 sokition given. The patient, however, was in a desperate condition, showed 
 but little improvement, and died on the third day. 
 
 Path. No. 3431. Tlie sj)ecimen consists of a large globular myomatous 
 uterus with its tubes and ovaries. The uterus is approxhnately 19 x 16 x 12 
 cm. Over its entire surface it is injected and covered with vascular adhesions. 
 On the anterior surface is a necrotic area, 10 x 8 cm., greenish in color and sur- 
 rounded by dense adhesions. The edges are irregular and the necrotic surface 
 has ulcerated to a depth of 5 mm. The great increase in size of the uterus is due 
 to a large interstitial myoma situated in the anterior wall. This is dark blue 
 in color and at the jxjint at whicli ulceration was noted has reached the peritoneal 
 surface. It is soft and {)ultace()us in consistence and emits an offensive odor. 
 The myomatous arrangement is still visible. The uterine cavity is 11 cm. in 
 length and the mucosa, api)roximately 2 mm. thick, is deeply injected and in 
 places shows a yellowish-brown mottling. Situated in the anterioi' utei-ine wall 
 and opening directly into the cavity is a heart-shaped ])ei-f()ration, x 4.5 cm. 
 (Fig. 113). Its floor is uneven and covered with greenish-yellow jms. Its mar- 
 gins are slightly raised and sharjjly defined. The right tulx- is coNcred with 
 adhesions. Its fimbriat(Ml end is patent. The ovary, apart from adhesions, is 
 normal. The apjn'ndages on the left side are likewise co\-ered with adhesions, 
 but are otherwise unaltered. 
 
 Histologic Examination. — Sections from the uterine mucosa neai- the opening 
 in the anterior wall show that it is comjjosed almost entirely of granvdation
 
 Sri'PURATIXG UTERIXK MYOMATA. 
 
 151 
 
 tissue, which is weh oriiaiiizcd ami sliows very little !)()lyiii()ri)hoiuiclear infiltra- 
 tion. Here and there the surface ei)ithehuni is to a sli^iiht extent preserved, but 
 at such pomts has proliferated. A few glands are still visible, but in most of them 
 the gland contour is distorted and the cells stain palely and are swollen. At the 
 edge where the perforation has taken place the surface is covered with polymor- 
 phonuclear leukocytes, and the tissue consists essentially of granulation tissue 
 devoid of gland elements and containing many polymorphonuclear leukocytes. 
 The floor of the area of ulceration consists essentially of necrotic myomatous 
 
 Fu;. 113. — A Largk Suppurating Intkkstitial Myoma Upp:nin(; into and Infecting the Peritoneal Cavity 
 A.ND ALSO Drainini: INTO THE Cavity OF THE Uterus. (i nat. sizc") 
 
 Gyn. No. 7158. Path. No. 34.'U. The uterus was ai)i)roxiniately 19 x 16 x 12 cm. On the anterior surface 
 as seen from the history, was a foul necrotic area 10 x S cm., where tlie myoma had ulcerateil through to the surface. 
 
 At a the myoma had ulcerated through into the uterine cavity. Tliis cavity measured 4..") x r> cm. and its 
 floor was covered with greenish-yellow pus. The entire myoma was dark blue in color, soft and pultaceous in 
 character, and emitted an offensive odor. 
 
 tissue containing nothing but fragmentated polyiiKirithonuclear leukocytes. 
 Sections from the outer surface of the uterus, where the ulcerated area was noted, 
 show necrotic myomatous tissue coiitaiiiing (|uaiitities of polym()r|)honuclear 
 leukocytes. It is interesting to note thai iiunierous neci'otic muscle nuclei 
 contain calcareous pl.'ilcs. Sections from othci' ]ioilions <»f the myoma show 
 that it has undergone ahiiosl coinplcic coagulation necrosis, it is most exceptional 
 to And such a puncluMl-out area of ulceration comniunicating with the uterine 
 cavitv. In brief, we hnxc a laruje necrotic ni\-oni;i, with ulceration on its anterior
 
 152 MYOMATA OF THE UTERUS. 
 
 peritoneal surface and a corresponding area of ulceration on its posterior surface, 
 coinnuinicatino; witli the uterine cavity by the large opening above mentioned. 
 
 Cause of Suppuration in Uterine Myomata. 
 
 It will be seen that suj^puration in interstitial and subperitoneal myomata is 
 a rare occurrence. In the majoritv of the cases hyaline degeneration is present. 
 This is chie to a (hininishcd blood-supply. In the subperitoneal variety infection 
 from the intestine was evidently the cause in three of the cases. Here the de- 
 generated myomata had l)ecome adherent to the cecum or small bowel. As the 
 intestinal nourishment to the myoma l)ecame more and more abundant, the inter- 
 vening walls gradually became thinner and thinner until the cavity in the myoma 
 opened directly into the bowel. The constant passage of feces into and out of the 
 myoma cavity naturally converted it into an abscess-sac. 
 
 In those cases in which the myomata were entirely free from the intestine 
 hyaline degeneration had likewise evidently first taken ])lace, l)ut why they 
 became infected later it is difficult to say. 
 
 Interstitial myomata that impinge on the uterine cavity are easily infected 
 when there is focal necrosis or hyaline degeneration in portions of the myoma 
 near the uterine cavity and an infective agent in the uterine nmcosa. Infection 
 readily follows on account of the poor blood-sui)]oly of the average myoma. 
 
 Suppuration in a myoma must not be confused with the condition in such 
 cases as A. W. (Path. No. S932), wliere there were tubo-ovarian abscesses, 
 and as a result secondary and encysted abscesses developed in the spaces between 
 contiguous myomata. Here the purulent process was confined almost entirely 
 to the outer surfaces of the tumors and not to their interiors. 
 
 The ap])earance of the myoma that has undergone marked hyaline degener- 
 ation very often simulates abscess formation so closely that it is impossil)le to 
 render an absolute diagnosis without making sections. AMiere simple hyaline 
 degencM'ation is i)resent, no nuclei are visible, \\niere abscess formation has taken 
 place, the characteristic polymor])honuclear leukocytes are in evidence. 
 
 Symptoms of Suppurating Uterine Myomata. 
 
 With the advent of sui)purati()ii in the uterine myomata the symptoms 
 
 may undergo a marked change. A sticking or lancinating pain is noticed in the 
 
 lower abdomen, and the patient may have chills and fever, at times accompanied 
 
 by night-sweats. One of the inoi-e ini])or1ant late phenomena is the sallow color. 
 
 This differs entirely from the i)allor that is so fi-e(|uently noted where there has 
 
 been great loss of blood from submucous myomata. If such septic absorj)tion 
 
 has taken ]ilace, the patient often grows very weak and the tumoi- may a))j)arently 
 
 diminish somewhat in size.* With the septic absoi'ption renal changes may 
 
 * Leukocytosis in niyonia cases, it' there is no oft'ensivc uterine disciiarge, usually indicates 
 either a suppurating myoma or a purulent accumulation involving the tubes, the ovaries, or 
 both. .\n ordinurv nivomatous uterus does not give rise to a leukocytosis.
 
 SUPPURATIXG UTERINTE MYOMATA. 153 
 
 be induced, recognizable by the ])resence of alhumiii and casts in the urine. 
 "V\liere the suppurating myomata open into the uterine cavity, there is a pro- 
 fuse foul-snielhng vaginal discharge. 
 
 Treatment. 
 The patient's resistance is naturally much reduced, and the pulse, just before 
 operation, may be very rapid, as is so often the case when pus is present. Our 
 object should be to remove the uterus just as soon as feasible, as without operation 
 the condition will steadily grow worse. In these cases the purulent process is 
 usually very active, and consequently the dangers of infection are great. 
 
 RESULTS AFTER OPERATION FOR SUPPURATING INTERSTITIAL OR SUB- 
 PERITONEAL MYOMATA. 
 
 Gyn. No. 12216 Died of intestinal obstruction on sixth day 
 
 " " 3216 Recovered. 
 
 " " 7549 Recovered. 
 
 " " 8767 Recovered. 
 
 " " 509.3 Recovered (postoperative pelvic abscess). 
 
 " " 5617 Died on table (desperate condition before operation). 
 
 " S. 1847 Recovered. 
 
 " " 7158 Died on third day (peritonitis before operation). 
 
 " " 9078 Recovered. 
 
 " " 14942 Recovered. 
 
 " " 15281 Recovered. 
 
 We have given this table to show the high mortality in such cases. The result 
 in Case 12216 is open to criticism, as the abdomen should have been explored 
 earlier and the obstruction relieved. In Case 5617 the woman was in a desperate 
 condition before operation, and the fatal result in Case 7158 is what might 
 naturally have been expected. In the majority of such cases it is well to drahi 
 the pelvis through the vagina, and in some cases also from above, treating 
 the entire pelvic content as a most dangerous area of infection. 
 
 NECROTIC MYOMATA. 
 
 Necrosis is fairly common: it is liable to occur in sub]ieritoneal, interstitial, 
 or submucous myomata, but inorc esi)ecially in sloughing submucous nodules. 
 In a few instances we have noted it in very small myomata, but it is more prone to 
 develo|) in large tumors. 
 
 The necrotic areas are recognizerl as dirty gray, grayish-brown, or dark 
 reddish-blue patch(>s in the myoma. Such areas ar(> clearly outliiuMl. but the 
 contrast between the myomatous tissue and th(> degenerated j)ortion is not 
 nearly as clean cut as in the cases where hyaline degeneration exists. In the 
 necrotic areas the muscular striation is usually still visible, Init the tissue is softiM* 
 than usual. The necrosis is usuall\' in the ('(Mitral portion of the tumor, but is 
 occasionallv not(Ml near the surface, as in Case lOSSo (Path. \o. 7()S<)). It mav
 
 154 MVOMATA OF THE UTERUS. 
 
 be limited to one area, or the luyoiua may contain several foci of degeneration. 
 Hvaline d(>generation and neci-osis are often noted side by side in the same tumor. 
 
 Histologic Examination.— Where the necrotic area is present, the muscle- 
 fibers usually still persist, but fail to take the stain. As a rule, the fi(>ld is devoid 
 of any living cells, but occasionally a few muscle nuclei may still be visible around 
 the blood-vessels, as noted in Case 3199 (Path. No. 524). In a few cases frag- 
 mented nuclei have been tletected in the necrotic area. This was the case in 
 Gyn. No. ::;199 (Path. No. 524) and Gyn. No. 3296 (Path. No. 580). 
 
 As noted on page 127, lime salts may be (le])osited in the necrotic areas. 
 
 It is exceptional to note any inflannnatory reaction in the necrotic areas, 
 except in submucous myomata. Case 3199 (Path. No. 524), however, proved 
 an exception, as some polymorphonuclear leukocytes were noted. 
 
 The coagulation necrosis is undou])tedly caused by a partial cutting off of the 
 myoma's blood-supply.
 
 CHAPTER X. 
 MYOMATA ASSOCIATED WITH MALFORMATIONS OF THE UTERUS. 
 
 We have encountered three cases of myoma coming inukn- this category: 
 
 1. Numerous discrete myomata in a uterus containing two (hstinct uterine 
 cavities and two cervical canals. 
 
 2. A diffuse adenomyoma in one horn of a bicornate uterus. 
 
 3. A submucous adenomyoma developing in a uterus in which there was 
 apparently only one fundus, with a septum (Uviihiig the cervix into two canals, 
 and a double vagina. 
 
 Gyn. No. 11694. Path. No. 7953. 
 
 A large m 3^ o m a t o u s tumor, on s e c t i n s h o w i n g t w o 
 distinct uterine cavities (P'ig. 114). 
 
 y. H., aged thirty-seven, white, single. Admitted Noveml^er 16; discharged 
 December 10, 1904. The patient has always been nervous and subject to con- 
 stipation and headaches. One year ago she had an attack of vomiting and 
 sharp pain in the region of the appendix. She noticed a lump in the alxlomen 
 at that time. This has grown until it has reached its present size. On ex- 
 amination, the pelvis is filled with a large multinodular mass reaching 10 cm. 
 above the umbilicus. At operation dense adhesions were found about the 
 j)ylorus and gall-bladder and in the region of the ap])endix. Hysteromyomec- 
 tomy was performed. 
 
 Path. No. 7953. The uterus contains many nodules and measures approxi- 
 mately 15 X 17 cm. On section, two definite uterine cavities are disclosed, as 
 seen in Fig. 114. The mucosa lining each cavity shows little or no cliange. 
 
 Gyn. No. 10314. Path. No. 6531. 
 
 D u b 1 e (• e r v i x , d o u 1) 1 e vagi n a : s u b 111 u c o us adeno- 
 myoma. 
 
 E. K., white, aged fifty, married. Admitted March 7: (hscharged April 17, 
 1903. The operation consisted in si>littiiig the vagina and cervical sei)tum and 
 in the I'cinox'ul of a suiiinucous iiiyoiiia. 
 
 Path. Xo. ()5."!1. The myoma is appro.ximately 7\7\ 11 ciii. Scatt(Mvd 
 tln'oughout it arc iiunicroiis ii-i'cgular islands of mucosa : ;il olln'i' poiiils ai'e spaces, 
 I'uHy S X 2 mm., Wwcd wilh imicosa wliicli almost (•oiiiplclcly lills ilic (■;i\il\'. 
 These ai'c instaiillx' ivcognizrd as tiiiniaturf utci-iiic caxMtics. Sonic of these 
 spac(\s are pale ainl lillcd wilh (■hocoj.atc-coioi'cij contents cN'idcntly old 
 menstrual blood. 
 
 155
 
 156 
 
 MYOMATA OF THE UTERUS. 
 
 Fig. 114,
 
 MYOMATA ASSOCIATED WITH MALFOR.MATlUXS OF THE UTERUS. 157 
 
 The growth on histologic oxaniiiiation presents tlie typical adenoniyomatous 
 appearance. It is described m detail in " A d e n o ni y o m a of t h e U t e r u s," 
 p. 162 (Fig. 47). 
 
 Gyn. No. 11572. Path. No. 7800. 
 
 Diffuse a d e n o ni y o m a in one horn of a b i c r n a t e 
 uterus. 
 
 This case is also described in detail hi " Adenoniyonia of the Uterus," p. 238. 
 
 It is mteresting to note that in two out of the three cases in which myomata 
 were associated with an al)normal develoi)ment of the uterus the growths were 
 of the adenoniyomatous type. 
 
 Fig. 114. — A Double Uterus Containing Subperitoneal, Interstitial, and Submucous Mvomata. 
 
 (f nat. size.) 
 Gyn. No. 11694. Path. No. 79.53. This tumor reached 10 cm. above the umbilicus, and measured 15 x 17 cm. 
 Two distinct uterine cavities are seen and two separate cervical canals (a, b). Scattered throughout the uterus 
 are many interstitial nodules, and projecting slightly into the cavity is a submucous myoma. Several myomata 
 project from the outer surface of the uterus.
 
 CHAPTER XI. 
 ANGIOMYOMA. 
 
 The hlood-supply of a inyoina may be so copious that the tumor in reality 
 becomes an ano-iomyoma. This excessive vascularity is occasionally noted in 
 the dependent portions of subnmcous myomata; it may also occur when a sub- 
 peritoneal pedunculated myoma has become twisted. In a few cases we have 
 seen the angiomyomatous appearance totally independc^it of any interference 
 with the blood-supph\ 
 
 In Case 3449 (Path. Xo. 6S3) the uterus was irregularly lilobular and 
 measured 13 x 13 x 14 cm. Situated in the anterior wall was a dark-red and 
 very vascular myoma, 10.5 x 12 cm. Sections from this tumor showed that the 
 dark color was due to the angiomyomatous character of portions of the myoma. 
 
 In Case 3357 (Path. No. 618) the uterus contained a myoma 6.5 cm. in 
 diameter. On histologic examination it was found that the tumor had a very 
 rich ca})illary blood-supply. So abundant were the capillaries that the muscle 
 was everywhere divided up into small irregular squares by them. 
 
 In Case 7226 (Path. Xo. 34S6) the multinodular ut(>rus was approxhnately 
 13 cm. in diameter. The largest pedunculated tumor, both m shape and color, 
 bore a striking resemblance to a spleen. It was 7 x 9 x 12 cm. and attached 
 to the uterus by a delicate pedicle, 1.5x0.7 cm. On section, the nodule pre- 
 sented a dark, reddish-brown, glistening appearance. On histologic examination 
 it showed large areas of coagidation necrosis accom])anie(l l)y hemorrhage, and 
 in the degenerated areas the blood-vessels were much dilated (Fig. 115). It 
 was only in the outlyhig portions of tlie growth that typical myomatous tissue 
 was preserved. 
 
 In Case 3488 we have a remarkable example of a myoma showing numerous 
 large angiomyomatous foci. 
 
 Gyn. No. 3488. Path. No. 707. 
 
 A n g i o m y o m a o f t h e u t c r u s (Figs. 116 and 117). 
 
 A. D., married, aged forty-five, white. Admitted May 7; discharged June 
 3, 1895. Five years ago the ])atient noticed enlargement of the abdomen 
 accompanied by l)earing-(l()wn ])ain. The swelling has gradually increased. 
 The mass is movable, but not tender. The patient has a tlragging sensation 
 in the lower abdomen. A successful hysterectomy was done. 
 
 Path. Xo. 707. The uterus is 25x20x15 cm. It is smooth, and sj^ring- 
 ing from the under surface on the left side is a nodule, 5 x 3 cm. The uterine 
 
 1.58
 
 Fig. 116. — Mi-ltiple Angiomatous Fori in a Mvoma. (^ nat. size.) 
 
 Gyn. No. 3488. Path. No. 707. A section through an interstitial myoma, 15 x 20 x 22 cm. Scattered 
 
 throughout the tumor are groups of cysts originating in the melting of hyaline material. At numerous points are 
 
 sharply outlined dark-red or bluish porous areas. These consist almost entirely of blood-vessels, chiefly arteries. 
 
 This is the only myoma that we have ever seen presenting such pronounced and circumscribed angiomatous areas. 
 
 For the histologic appearance see Fig. 117. (After Howard A. Kelly.)
 
 AXGIU.MYU.MA. 
 
 159 
 
 cavity is 10 cm. in loiigtli; its walls average 2 cm. in thickness; the uterine 
 mucosa is whitish in color, smooth and glistening, and projecting into the 
 utenne cavity from the jKJsterior wall near the cervix is a sessile nodule. 
 2.5 X 1.5 X 1 cm. 
 
 Occupying the left uterine wall is a tumor approxhnately 15x20x22 cm. 
 On section this is whitish yellow in color and consists of fibers concentricalh* 
 arranged. Scattered throughout the tumor, especially in its central i)ortion, 
 ai-e numerous dark-blue vascular areas, comj^osed of l)lood-vessels (Fig. 116). 
 These vascular areas present a honeycombed api)earance and vary from 0.5 to 
 3.5 cm. in diameter. The individual vessels are closely packed together. Some 
 
 Fig. 115. — Angiomyoma. (X 120 diaiu.') 
 Gyii. No. 7226. Puth. No. .3486. The section is from a peduiicnilated, siilccn-.shaped, dark reddish-brown, sul)- 
 Ijeritoneal myoma. At a the muscle-fibers are still clearly seen. M b the tissue has become rarefied. Scattered 
 throughout the field are many dilated veins (c). 
 
 are not larger than a ])in-])oint, others reach 'A mm. in diameter. The vessel-walls 
 are smooth and glistening. The entire ))ictiire suggests an angioma. The tumor 
 has undergone a niodei-ate amount of cystic degenei'atioii. The cysts ;ii-e 
 scattei'cd iifegularly thi-oughout the tissue, and \ai-y from ().;; to .") cm. in 
 diameter, ha\-e ifivgular, shai-])ly detined edges, ;uid conlain a pale \-elIo\v 
 transj)arenl Ihiid which coagulates on e\posui-e to the air. The sm.aller c\sts 
 are commencing to merge one into the olhei-. and one of ilie lar^e (vn'ities 
 contains an ii'ivgulai', xcllowisli-white mass, .'! cm. in di.ameiei', in its center. 
 This is held ill |»osilioii by delicate bands which aic adhei-eiil lo the margin of 
 the ca\ity. '|"he walls of this ca\ily are smooth and glistening, and numerous 
 delicate blood-Ncssels c;in be seen raniif\in<2; beneath the surface.
 
 160 MVOMATA OY THE UTERI'S. 
 
 The outer surface of \\\v tumor has a delicate cai)sule, yellowish white in color, 
 and loosely connected with the uterine muscle, thus allowing the tumor to be 
 shelled out with ease. 
 
 Histologic J'^xamination.— The uterine mucosa has been imperfectly preserved, 
 but where present, the glands are oval on cross-section and have an intact 
 epithelial lining: some are considerably dilated. The stroma of the nmcosa 
 shows small-round-celled infiltration. 
 
 The lartre tumor situated in the uterine wall is composed of non-striped nmscle- 
 
 ■>:1'^^_ 
 
 'f!,_ 
 
 fe^':-. .... ::^--:-l;li . ' if' '"^MM 
 
 
 iV'i. 
 
 •..■\* 
 
 iMf^^f'' 
 
 i^ 
 
 ^ 
 
 M 
 
 Fig. 117. — Angiomyom.\. (X 13 diain.) 
 Gyn. No. 3488. Path. No. 707. The section is from one of the angiomatous areas in Fig. 116. The ground- 
 work consists of typical myomatous ti.ssue, well seen at a. Scattered throughout the field are masses of arteries, 
 some of them large (6). The tissue immediately surrounding them shows some hyaline degeneration. The 
 muscle is here and there undergoing liquefaction (c). 
 
 fibers arranged in bundles and cut lx)th longitudinally and transversely. The 
 tis.sue has a rich })lood-sui)})ly. The dark-blue angiomatous areas are com- 
 posed almost entirely of arteries irregular in contour (Fig. 117). They have 
 an endothelial lining and a thick layer of circular muscle surrounding them, 
 but the greater part of the circular layer has undergone hyaline degeneration, 
 contrasting sharply with the surrounding muscle. Most of the vessels are filled 
 with blood. Scattered throughout the tumor, frociuciitly in the vicinity of the 
 blood-vessels, are irregular areas of hyaline tlegeneration. In some of these
 
 AXGIOMYOMA, 161 
 
 hyaline areas an isolated small round cell is here and there visible and in a few 
 places aggregations of small round cells can be made out. In the area where the 
 softening has occurred the tissue has undergone practically complete hyaline 
 degeneration, but a muscle-fiber can here and there be seen in the hj^aline material. 
 We have here subperitoneal and submucous myomata and a very large 
 angiomyoma. 
 
 11
 
 CHAPTER XTT. 
 
 LIPOMYOMA OF THE UTERUS. 
 
 A tumor of this character, as the name implies, consists of myomatous muscle 
 interspersed with adipose tissue. Myomata of this nature are exceedingly 
 rare; in our entire series only one typical example was found. This case, San. 
 No. 8.')(). was reportcnl in detail by Dr. J. H. Mason Knox, .Ir..* who also reviewed 
 
 ^mucowi polyp 
 
 utexinc saviCy 
 
 Vi(.. 118. — LipoMYOMA. (J nat. size.) 
 San. No. Sl?ti. Path. No. 3703. Tlie uterus has been amputated through the cervix. OccuijyiiiK the poste- 
 rior wall and distorting the uterine cavity is an interstitial myoma. The coarse fibrillated arrangement of the 
 myomatous growth is easily seen, but the interspaces are darker in color and more homogeneous than usual. They 
 consist to a great extent of adipose tissue (Fig. 119). The uterine cavity is much lengthened; at the fundus is 
 a broa<l-ba.sed polyp. f.\fter .T. H. Ma-son Knox, .Jr.) 
 
 the inca<;cr literature on the subject. At first si^ht the iiiyoiua presented the 
 usual appearance, hut on careful sci'utiny it was found to iiave a yellowish tinge, 
 and although in many places the coarse fibrous arrangement of the myomatous 
 tissue could be readily seen, in the interspaces the tissue was more homogeneous 
 
 ♦Johns Hop! ins Hosp. Jiull., liHU, vol. \ii, p. .JIS. 
 I(i2
 
 LIPOMYOMA OF THK ITKUL'S. 
 
 163 
 
 than usual (Fig. 118) and from the cut surfaces many oil-globules could be 
 brought away with the knife-blade. On pressure the myoma felt very soft, 
 although it showed no areas of degeneration. 
 
 The histologic picture is characteristic. The many clear spaces represent 
 adipose tissue, and the framework of the tumor consists essentially of non-striped 
 muscle-fibers (Fig. 119). 
 
 In two other cases in which large myomata were present we also found areas 
 of adipose tissue distributed 
 throughout the tumor (Fig. a 
 
 120, J). 164: Fig. 121, p. 165). 
 
 Ji>i ^,^ ;.;• v. 
 
 -j::':-'W 
 
 San. No. 836. Path. No. 3703. 
 
 L i j)o m y o m a o f t h e 
 u t erus (Figs. 118, 119). 
 
 The patient was sixty-two 
 years of age and had had 
 thirteen children. The labors 
 were normal. The meno- 
 pause had occurred twelve 
 years previous to her admis- 
 sion. Three years later she ^' 
 had noticed a slight serous 
 vaginal discharge, which soon 
 disappeared, but returned 
 after an interval of eight 
 years, only lasting a short 
 time. I'oi- two weeks she 
 had been bleeding moderately 
 but continuously. 0})era- 
 tion, iiysteromyomectomy. 
 
 Path. No. 370:-;. Tile 
 
 •..v../ 
 
 1; 
 
 
 \A. 
 
 
 
 7>'-V 
 
 6^-b 
 
 
 
 K J:A)'i^,J'-~Jt-Sei!)^(^- 
 
 J 
 
 Fig. 119. — Lipomvoma. (X 48 diam.) 
 
 San. No. 836. Path. No. 3703. The section is from the 
 
 myoma .seen in Fig. 118. a indicates large and small l)lood-vessels. 
 
 The solid areiLs (()) consist of myomatous tissue, and the many clear 
 
 spaces (c) represent fat-cells. .\11 |)arts of the tumor that were pre- 
 
 SpeCimen consists ot the en- served presenteil a similar picture, i After .1. H. Ma,son Knox, .Jr.) 
 
 larged uterus, both F;ill()j)iaii 
 
 tubes, a ])()rti()n of the left ox-ary. and a cystic right (»\aiT. The utei-iis is 
 globular in form ( Mg. IJS), regular in oulline, M x b") x IS cm. in its various 
 diameters. It is peii'eetly smooth. The uteiine ea\it\- is I 1 cm. in length. The 
 muco.sa of the anterior wall is scarcely I mm. in thickness. That covering the 
 posterior wall is considerably alteicd: in some places minute sj)aces are .scattered 
 throughout the muco.sa, .some reaching 2 mm. in diameter. Over an area 4x1 
 cm. in the uppei" part of the cavity the muco.sa is e\cessi.vely thin and the tumor 
 lias extended almost thi-oughthe mucosa. Situated in the ui)|)ei- i)art of the cavity 
 is a .sessile |>ol\'|), ."> x 2..') cm. ()ccu|)ying the posteiior wall is ;i tumor mass, 
 10 \ 10 X 1.'! cm. ( )ii section, the luinoi' ;it (irst sight preseuts the usual
 
 164 
 
 MYO.MATA ()P^ THK UTERUS. 
 
 appearance of myoma, but on careful scrutiny is found to l)e markedly different. 
 Traversing it in all directions are <:;listcnint!; bands, between which are yellow, 
 soft-looking areas. A\'hen the cut surface is scraped, distinct oil-globules can be 
 brought away — which is never possible when an ordinary myoma is examined. 
 
 
 Fio. 120.— LiPOMYOMA. (X 140 diam.) 
 
 Gyn. No. 3133. Path. No. 494. o is a longitudinal section of a blood-vessel. Surrounding it, and embedded 
 in the myomatous tissue, are many fat-cells indicated by spaces. 
 
 It looks very much a,s if the vessel when it first entered the tumor carried a certain :unii\int of adipose tissue 
 with it. 
 
 The tumor presents no areas of breaking down. It is sharply dehned from the 
 surrounding uterine muscle. It varies from W to 5 mm. in thickness. 
 
 Ivight side: The Fallopian tube is considerably lengthened and covered 
 with adhesions. Its fimbriated extremity is adherent. The ovary has been
 
 LIPOMYOMA OF THE UTERUS. 
 
 165 
 
 converted into a lobulated, partly cystic, mass, wliich measures 8x5x4 cm. 
 The outer cystic portion consists of small multilocular cysts. 
 
 Left side: The tube presents the same appearance as the right. 
 
 Histologic Examination. — The uterine tumor is found to consist of large fat 
 cells inclosed in a supporting substance consisting of smooth muscle and con- 
 nective tissue in varying proportions (Fig. 119). The fat-cells are generally 
 round (c), oval, or irregular in outline from pressure. They vary in size from 
 five to fifteen times the diameter of a red blood-corpuscle and, after hardening 
 
 
 b 
 
 Fig. 121. — Lipomyoma. (X 140 diam.) 
 Gyn. No. .3320. Path. No. 589. The space a indicates an oblique section of a blood-vessel, h is ordinary 
 myomatous ti.ssue. .\t numerous points are aKKreRutions of fat-cells (,c). Surrounding the fat, and separating it 
 from the myomatous tissue, is a varyitiK ;inii>uiit of fibrous tissue (d). 
 
 by llic usual pi'occss in which the fat is dissohcd, apiw'ar as clear spaces. The 
 nuclei of these cells can fre(|ueiilly be made out as oxal or r()(l-sha|)ed bodies 
 pu.shed to the j)en])hery and often situated in an angle between other cells. 
 The tumor is traversed by numerous bands of firm fibrous ti.ssue which })roduce 
 the lobulated ap])earance notetl in the gro.-;s specimen. The tumor consists 
 esvsentially of non-striped muscle-fibers ;ind fat-cells e(|ually intermingled. There 
 is, of course, the ground-work of fibrous ti.ssue. Scatteivd thioughout the 
 tumor are large cells which clo.sejy resemble mast-cells.
 
 166 .MVOMATA OF THK UTERUS. 
 
 Gyn. No. 3133. Path. No. 494. 
 
 A r (• a s of a d i p u .< (,' l i .s .s u e i 11 a 111 y o in a (Fig- 1-Oj. 
 
 M. R., aged fifty, white. Admitted October 24; discharged November 24, 
 lcS94. The .specimen consists of a pear-shaped ntenis, 32 x 32 x 36 cm. The 
 great increase in size is caused by an interstitial myoma. The mucosa is atrophic 
 and projecthig nito the cavity is a deHcatc polyp. Numerous cystic areas are 
 scattered throughout the m3'0ma. 
 
 On histologic examination, in addition to much hyaline tissue, small areas 
 of adipose tissue are recognized. In one group may be anywhere from three to 
 eight or more fat-cells, chiefly found in close proximity to the blood-vessels 
 (Fig. 120), and reseml)ling ordinary adipose tissue. 
 
 Gyn. No. 3320. Path. No. 589. 
 
 Areas of adipose t i s s u e i n a m y o m a (Fig. 121). 
 
 M. I)., aged twenty-nine, white. Admitted February 8; discharged March 
 9, 1895. The uterus was large and nuiltinodular. The largest myoma was 
 13 X 21 X 28 cm. Some of the nodules show nmch hyaline degeneration and 
 liquefaction. In several sections small groups of fat-cells were found (Fig. 121).
 
 CHAPTER XIII. 
 ADENOMYOMA OF THE UTERUS. 
 
 In 1903, in a review of the literature published in a supplement to Orth's 
 Festschrift, one of us (Cullen) reported 22 cases of adenomyoma examined by us 
 up to that time. Sinee then we have paid especial attention to these growths 
 and have been astonished at the striking frequency with which they occin-. 
 Out of a total of 1283 cases of myomata examined from April 1, 1893, until 
 July 1, 1906, 73 (about 5.7 ])er cent.) were instances of adenomyoma. We have 
 included only interstitial, sub})eritoneal, and submucous adenomyomata and 
 large adenomyomata of the uterine horns. 
 
 Our cases have yielded many interesting histologic and clinical data. It 
 was found impossible to do the subject justice and at the same time keep the 
 present work within a reasonable size. To adenomyoma accordingly a sepa- 
 rate volume has been devoted, and we will here merely give the briefest sunmiary 
 of the findings which have l)een fully elaborated in that publication.* 
 
 Summary. — In cases of adenomyoma of the uterus we usualh' find a diffuse 
 myomatous thickening of the aterine muscle. This thickening may be confined 
 to the inner layers of the anterior, posterior, or lateral walls, but in other cases 
 the myomatous tissue completely encircles the uterine cavity. 
 
 This diffuse myomatous tissue contains large or small chinks, and into these 
 the noriii;il uterine mucosa flows. If the chinks are small, there is only room 
 for isolated gltmds, but wliei'e the spaces are of goodly size, large masses of 
 mucosa How into and fill them. We accordingly have a diffuse myomatous 
 growth with normal nnicosa flowing in all directions through it. The nuicosa 
 lining the uteiine ca^■ity is perf(>ctly noiinal. 
 
 After a time poitioiis of the diffuse myoma may be iii])|)ed off and be eai'iMed 
 toward either the outer or inner sui-faces of the uterus. It' they become sub- 
 !uuc()us growths, they are gradually expelled. If they i)ass toward the outer 
 sui'face, they become eithei' subperitoneal or int laliganientary. WC lia\"e 
 accordingly diNideil adeiioniyi iiiala into the following groups: 
 
 1. .Vdenoniyomala in which thenterus pi-eseixcs a relatixcly normal contour. 
 
 2. Suhpei'itoneal oi' int raliganienlary adenomyomata. 
 
 3. Snl)inucous adenomyomata. 
 
 ,\ dil'luse adenomyoma presents a \-ei-y coaise appearance, because the 
 myomatous musclc-bnndles nni in all dii-cctions. In the spaces between bim- 
 dles, and occasionally siu'roumled by circular rings of muscle, we find spaces 
 
 * .Adoiioinyonri nf tlic t ■|('rus. 'riioiiiMs Stc|)li(Mi ( 'iillcii. ]>. JTO. W. ]^. Sauiidcrs Co., 1908. 
 
 If ',7
 
 168 MYOMATA OF THE UTERUS. 
 
 filled Avith tran.slucoiit and slightly punctiform tissue — areas of uterine mucosa. 
 Sometimes its direct connection with the mucosa of the uterine cavity can be 
 traced. Not infrequently cyst-like spaces are scattered throughout the diffuse 
 myoma. These are filled with a chocolate-colored fluid and arc lined with a 
 definite membrane, often 1 to 2 mm, thick. They are miniature uterine cavities, 
 and the chocolate-colored fluid is old menstrual blood that has not been able to 
 escape. 
 
 "When an adcnoniyoiiialous nodule becomes subperitoneal, the menstrual 
 flow in the growth may gain the U}iper hand and the myoma become cystic, the 
 contents, of course, being formed from the accumulation of old menstrual blood. 
 
 Age. — Our youngest patient was nineteen, o»iu- oldest sixty. The disease 
 is most prevalent between the thirtieth and sixtieth years; it does not in any way 
 tend to sterility. 
 
 Symptoms. — Lengthened menstrual periods are the first symptoms. The 
 flow gradually assumes the proportions of hemorrhages and eventually the periods 
 may become continuous. 
 
 At the period there is often discomfort, and occasionally a grinding pain in the 
 uterus, evidently due to the increased tension, since all the islands of mucosa 
 scattered throughout the diffuse myoma naturally swell up at the menstrual 
 period and thus increase the size of the organ. 
 
 In over two-thirds of our cases there was no intermenstrual discharge. This 
 is perfectly natural, as in these cases the uterine mucosa is normal and no dis- 
 integration of tissue is going on. 
 
 Clinically, the diagnosis of diffuse adenomyoma is relatively easy, for the 
 following reasons : 
 
 1. The bleeding is usually confined to the period. 
 
 2. There is usually much })ain, referred to the uterus, at the period. 
 
 3. There is usually no intermenstrual discharge of any kind. 
 
 4. The uterine mucosa is perfectly normal, and may be rather thick. 
 
 No other pathologic condition of the uterus, as a rule, gives this characteristic 
 picture.* 
 
 Treatment. — The patient's health is often gradually undermined by the 
 uterine hemorrhages, and the only way to control them is to remove the uterus. 
 A supravaginal hysterectomy is all that is necessary. The ovaries should be 
 saved. 
 
 The prognosis is good, as the glands of the adenomyoma are perfectly normal 
 uterine glands and are surrounded by the characteristic stroma of the mucosa. 
 
 Origin. — The glands in the adenomyoma originate, in the vast majority of the 
 cases at least, from the uterine nmcosa. 
 
 Cause. — The cause of adenomyoma is still unsolved. 
 
 * Some submucous myomata are accompanied by a train of symptoms closely resembling 
 adenomyoma.
 
 CHAPTER XIV. 
 MYOSARCOMA OF THE UTERUS.* 
 
 That a primary sarcomatous change can take place in a myoma has long been 
 kno\Mi, and as early as 1863 Virchowf gave a very clear account of the gross and 
 histologic pictures. In 1872 ChrobakJ again drew attention to this class of 
 cases, and in 1887 Ritter§ gave a full abstract of the literature up to that date. 
 In 1894 the same question was fully discussed by Williams || and also by Schreher,^ 
 and in 1895 L. Pick** gave a very clear account of sarcomatous changes in 
 myomata. The article by Gessnerft published in 1899 is most exhaustive and 
 will well repay a thorough study. Among the still more recent and lucid articles 
 are those of Weir,Jf published in 1901, and of Jacobi and Wollstein,§§ which 
 appeared in 1902. 
 
 Frequency. — Although quite a number of isolated instances of sarcomatous 
 changes in myomata have been recorded, it would appear that the importance 
 of the subject has hardly been fully appreciated. Fehling, || || in 409 myomata, 
 found that 2 per cent, showed malignancy. In eight there was a sarcomatous 
 degeneration and in one case carcinoma was present in the same uterus. Martin*}^ 
 observed direct sarcomatous transformation four times in a series of 205 cases. 
 
 * The term myosarcoma may be objected to on the ground that in some cases it is impossible 
 to say whether the sarcoma has developed from the myomatous muscle or from its connective 
 tissue. We fully appreciate this objection, but since in the great majority of our cases the origin 
 of the. sarcoma from the muscle-fibers seemed evident, and as the term myosarcoma is definitely 
 fi.xed in the literature, and, furthermore, since it clearly indicates to the physician the clinical 
 picture, we have thought it much wiser to stick to this word. 
 
 t Virchow: Die Krankhaften Geschwiilste, Bd. iii, S. 201. 
 
 X Chrobak: Arch. f. Gynilk., 1872, Bd. iv, S. 549. 
 
 § Ritter: Dissert. Inaug. Ueber d. Myosarkom des Uterus, Berlin, 1887. 
 
 II Williams, . J. Wliifridge: Contributions to the Histology and Histogenesis of Sarcoma of 
 the Uterus, Am. Jour, of Obstet., 1894, vol. xxix, No. (i. 
 
 ^ Schreher: "Ueber d. Complikation von Utenisinyoiii init .sckiuidiircr sarkomatoser Degen- 
 eration," Diss. Inaug., Jena [Strassburg], 1894. 
 
 ** Pick, L.: Zur Histiogciiese und Classification tier ( iclnirMiutlcrsarcdnic, .Vrcli. f. (iviiiik., 
 189,"), xlviii, 8. 24. Arcli. f. (lyiuik., 189."), S. :V.i. Zur Lelire voin .Myoma sarcomatosum und 
 iiber die sogenannten Undotlu'lioinc dcr Ocbiirmvitter, .Vrcli. f. (lyniik., 1S9.">. xlix. S. 1. 
 
 ft Gessiior: N'cit's Han(ll)iich dcr ( lyniikolniric. 1S99. iii. Zwcitc Iliilftc, S. 9.')7. 
 
 tl Wt'ir, Wni. II.: Musc1c-<t11 Siircoriiata dl" (lie I'tcriis, .\iii. .I.iur. (if ( )l.stct.. 1901, vol. xliii, 
 618. 
 
 §§ Jacobi, .Mary I'utnain. and WOllstcin, .Martha: .\\u. .loiir. nf < »l)stct.. 1902. vol. xlv. p. 218. 
 
 nil Fehling: Centralb. f. Cyn.. ISOS. xxii, S. Ills. 
 
 •[^Martin, A.: Ueber Myoinc, NCrh. d. dculsch. ( k's. f. (lyii., ii. S. 12.). 
 
 169
 
 170 MVOMATA OK TIIK ITERUS. 
 
 In oui' scries, which now cinhniccs over 1400 cases. 17 sliowed undouhtcd sarco- 
 mata of the uterus occurring in or associated with niyoniata. In 17 other cases 
 suspicious gross or histologic pictures were present, but the changes in these 
 were not sufficient to warrant a positive diagnosis of sarcoma. Now, since 
 many of our cases were not examined histologically unless they jn-esented sus- 
 picious macr()scoj)ic ])ictures, and again, in view of tlie fact that it would be 
 almost ini])ossible to examine every portion of a myomatous uterus histo- 
 logically, without doubt some cases have been overlooked. During the last 
 decade hysterectomies and myomectomies for myoma have become much more 
 frecjuent, and careful clinical histories and pathologic records have been kept. 
 We feel confident that, as a result of these careful studies, in the next few years 
 many cases of sarcomata developing in myomata will be reported, and that this 
 malignant change will l)e found to be relatively connnon. 
 
 The Gross Appearances of Myosarcomata, — Uterine myomata are usually 
 multiple. Thus, in those cases in which a sarcomatous change takes place 
 several other myomata are almost invariably present. The nodules may be 
 subperitoneal, interstitial, or submucous. As a rule, only one nodule undergoes 
 a malignant change, but, as in von Kahlden'.s* case, sarcomatous foci may occur 
 simultaneously in several myomata. In the very early stages the macroscopic 
 changes may be totally wanting or, as has been pointed out by Chrobak, 
 they may be so slight as not to be recognized. This was clearly shown in 
 San. No. 1857 (Fig. 137, p. 206 ) . Here, lying to the side of the cervix, was a myoma 
 several centimeters in diameter. Macroscopically it differed in no way from the 
 oi'dinary myoma, and yet on histological examination the transition of muscle- 
 cells into sarcomatous tissue was pei'fectly evident. Where th(^ malignant change 
 is present, it is usually readily recognized. The ))inkish-white tissue with the 
 coarse fibrous arrangement has been in part re])laced by a yellowish-wliite, homo- 
 geneous tissue, almost totally devoid of fibrous elements, and l;)earing a striking 
 resemblance to raw \H)vk. The sarcomatous is usually sharply differentiated from 
 the myomatous tissue, but now and then gradually merges into it. Sometimes 
 the sarcoma presents a jjoious ap])earance, as noted in Fig. 138 (p. 209) and Fig. 
 
 131 (p. 193), or it may contain large and small cyst-like spaces, as seen in Fig. 
 
 132 (p. 197), Fig. 133 (p. 198), and Fig. 140 (j). 213). These were also noted in 
 Menge's case. They are probably dilated lymph-spaces. The sarcomatous tissue 
 is exceedingly soft, and from its surface a considerable amount of fluid can be 
 sfjueezed. As exemplified in Case 8732 (p. 215), the growth may be soft — so soft 
 that it rt^sembles brain tissue. With the advance of the sarcoma hemorrhages 
 take place, giving the cut surface a i( ddish-brown, mottled ajijx'arance. which 
 after a time is i-eplaced by a yellowish or yellowish-brown color, due to the de- 
 position of blood-pigment. In a short time the central portions of the tumor 
 undergo coagulation necrosis, followed by li(|uefacti()n (see Fig. 138, p. 209). 
 Th(> sarcomatous changes usually connneiice in t he central [joilions of the myoma, 
 
 * \'(jii Kahldcii: Zicdor's Hcitnigo ziir i)atli. Aiiatoiiiic uml allu;. Patliologie, 1.SS3. xiv. S. 174.
 
 MYOSARCOMA OF THE UTERUS. 171 
 
 but occasionally occur in the periphery. The latter seems to have been the 
 case in Fig. 143 (p. 217), in which the renmants of a myoma are entirely sur- 
 rounded by sarcomatous tissue. With the advance of the growth secondary 
 pure sarcomatous nodules become scattered throughout the uterine walls, as 
 is well seen in Fig. 140 (p. 213) and Fig. 143 (p. 217); or sarcomatous polypi may 
 project into the uterine canal, as shown in Fig. 138 at i. (p. 209). 
 
 In Figs. 125 (p. 1S5) and 126 (p. 186) is represented a most unusual secondary 
 nodule in Path. No. 7555. The uterus was small, and its interstitial myomatous 
 nodule showed marked hyaline changes and also sarcomatous transformation 
 of muscle-fibers. Attached to the posterior surface of the utems was a large, 
 cockscomh-likc secondary growth, which on histologic examination was found 
 to consist essentially of tissue that was of even a more pronounced sarcomatous 
 type than that of the primary tumor. 
 
 The older writers claimed that myomata that underwc^nt sarcomatous de- 
 generation were almost invariably submucous. Our experience, however, 
 goes to show that the malignant change may equally well start in a subperitoneal 
 or interstitial myoma. 
 
 The following table gives the location of the sarcomatous growths in our 
 cases : 
 
 Interstitial: Gyn. Nos. 11944. 6724, 7040. 7474. 8610, 8732.8836. S. 1879 (partly submu- 
 cous), Path. No. 6421 9 cases 
 
 Subperitoneal: Gyn. Nos. 6045, 7604. 9536, 12155 4 " 
 
 Intraligamentary: S. 1857 1 case 
 
 Submucous: Gyn. Nos. 7313. 10376 (uterus not removed). Path. No. 7555 3 cases 
 
 17 ca.ses 
 
 Uterine myomata are usually at first interstitial and eventually become 
 either submucous or subperitoneal. In former years when few abdominal 
 operations were performed naturalh' only the sul)nuicous sarcomatous nodules 
 were recognized clinically. From a study of our table it will be seen that over 
 half the cases were interstitial, and that the inter.stitial and .subperitoneal myo- 
 mata undergoing sarcomatous changes wei'e far in excess of those of the sub- 
 mucous group. In only three out of oui' se\-eiiteen cases wei'e the sarcomatous 
 myomata submucous. Of coiu'se, at a later date .some of these myomata would 
 have undoubtedly migrated into the uterine cavity and have become subnuicous. 
 
 Case 6045 and Case 9536 (Fig. 123, ]). ISl ) areexcellent examjiles of sarcomata 
 commencing in subperitoneal myoinata; I'ig. 1 3S (p. 209) shows a sarcoma de- 
 veloping in an intei'stitial myoma. In the latter case it seems more ])robal)le 
 that the growth in time would tend to extend more and more into the uterine 
 cavit>'. If a myosai'coma projects into the uterine (•;uial, it usually becomes 
 lobulated fi'oin liie I'apid character of the gi'owth. ;ind we h;i\'e the ex])ulsion 
 through the vagina of ;i tumor usually su|)|)ose(l to be a submucous myoma. 
 The original growth si ill coniinues. but after a short time further portions are 
 expelle(| in a similai' manner.
 
 172 MYOMATA OF THE UTERUS. 
 
 Histologic Appearances of Myosarcomata. — Sarcomata developing from 
 myomata are divisible into two varieties: (1) Sarcomata developing from the 
 connective tissue of the myomata; (2) sarcomata dc^veloping from the myomatous 
 muscle. 
 
 Of course, there are undoubted cases in which the sarcoma develops in part 
 from the connective tissue and in part from the transition and multiplication 
 of muscle-fibers. Macroscopically both these varieties present the same ap- 
 pearance and naturally require precisely the same operative interference. 
 
 1. Sarcomata Developing from the Connective Tissue of Myomata. — Virchow 
 was one of the first to describe this variety, and his description is so good that 
 we cannot do better than quote him directly: ''The degeneration, as I have 
 traced it, is as follows. At certain ])oints the intercellular substance commences 
 to grow, the cells increase through division. Thus more and more round cells 
 are formed, at first small, later larger and larger and with bigger nuclei. Mean- 
 while the intercellular substance becomes less and more rarefied and, while 
 the stroma increases, the muscle disappears entirely in many places. At other 
 points it still persists and even increases. In this manner the trabecular character 
 of the growth develops. The cells grow; many of them become angular and 
 develop processes and their nuclei reach the size of epithelial nuclei. They are, 
 however, usually arranged in rows or groups. With this increase in the cellular 
 elements the original stroma is in pari or entirely replaced by the new growth. 
 Such portions become soft, friable, and have a whitish or yellowish appearance. 
 Comparatively large blood-vessels penetrate the softer portions and give rise 
 to hemorrhagic infiltration. In this way a portion of the cyst-like spaces are 
 produced." 
 
 Every one nuist agree fully with Mrchow's description. In our own Case 
 7474 (Fig. 139, p. 211) we have an excellent example of the development of 
 small cells into larger ones. Side by side we have crops of the large and small 
 cells, while in the immediate neighborhood all intermediate sizes are demonstrable. 
 The increase in the cells is due, as A'irchow pointed out, to indirect division. 
 Sometimes the entire normal karyokinetic cycle can be traced and usually many 
 cells with atypical forms are ])resent. Now and then direct l)udding of nuclei is to 
 be seen. Fig. 144 (p. 21S) depicts clearly the many cell forms that may be found. 
 Here we have small and large, round or oval, vesicular nuclei; large and small, 
 deeply staining nuclei ; large and irregular and partly dividing nuclei, and tre- 
 mendous clumps of chromatin scattered throughout large ])laques of protoplasm, 
 (iiant cells are also ])resent, usually with their nuclei arranged in a imilbei'ry- 
 shaped form. Sarcomata originating from the connective-tissue elements of 
 myomata may be either spindle-celled or round-celled. These sarcomata may 
 be in part due to a proliferation of the endothelium of dilated. lymph-spaces, as 
 has been pointed out by Chrobak and Menge.* The stroma of this growth at 
 times shows distinct myxomatous degeneration. As the sarcoma iiicretises in 
 
 * Menge: Centralbl. f. Gynak., 1895, Bd. xix, S. 45.3.
 
 MYOSARCOMA OF THE UTRRUS. 173 
 
 size the central portions undergo necrosis, witli or without fragmentation of 
 nuclei, and often along the margin of the necrosed area there is a small-rouiul- 
 celled or polymorphonuclear infiltration. 
 
 2. Sarcomata Developing from the Muscular Elements of Myomata* — Myo- 
 sarcomata are usually tlior.ght to be derivatives of the connective-tissue portions 
 of myomata. Nevei-theless, recent investigations tend to show that a fair pro- 
 portion are due to a direct transformation of normal muscle-fibers into malignant 
 fibers. As far back as 1860, however, Virchow when describing those of connective- 
 tissue origin said: ''The muscle disappears entirely in many places; at other 
 ])oint8 it still persists, and is even increased," thus indicating that the muscle 
 might take part in the process. Von Kahldenf reported a case in which he was 
 sure he was able to trace the direct transition of myomatous muscle-cells into 
 sarcomatous cells. To Williams we are indebted for the most clear and con- 
 vincing proof that the muscle-fibers are actually capable of becoming malignant. 
 Similar and confirmatory evidence has been furnished by L. Pick, Morpurgo,:{: 
 Gessner,§ Veit,|| Gebhard,l[ Weir, and others. 
 
 In thirteen of our seventeen cases (S. 1857, S. 1879, Gyn. Nos. 6045, 6724, 
 7313, 7604, 8836, 9536, 10376, 11944, 12155, Path. Nos. 6421 and 7555) the sar- 
 coma was apparently the result of a transformation of the myomatous muscle- 
 fibers, and in one further case (Gyn. No. 8610) the sarcoma seemed also to have 
 resulted from an alteration in the muscle-fibers. But the proof in the last case, 
 although strongly suggestive, was not sufficient to enable us to make an absolute 
 statement. 
 
 Of the remaining cases, Gyn. No. 7474 (Fig. 139, p. 211) seemed to be a round- 
 celled sarcoma. Gyn. No. 7040 was a mixed-cell growth and Gyn. No. 8732 
 wasaveryunusual mixed-celled sarcoma (Fig. 144, p. 218), containing areas closely 
 resembling decidua, and others strongly suggestive of syncytium. From the 
 above it will be seen that out of the seventeen cases, in thirteen the sarcoma had 
 resulted aj)parently from an alteration in the muscle-fibers, and in the remaining 
 cases the ])resumptive evidence was in favor of a similar origin. 
 
 A reference to Case 6045 (p. 223), with its figures (146, 147. 14S. 14<). 150, 
 
 * Mallory has recently drawn attention to the fart that spccinicns of tliis cliaractcr iniisl lie 
 cut in small pieces and hardcncMJ within a few ininntcs after removal, otherwise the liner details 
 will be lost. Xearly all of our cases were operated u|)oii ix'foic his article appeared, and conse- 
 quently his technic could not be employed. In tiiis connection a thorough study of Mallory's 
 exhaustive and painstaking articles cannot fail to be jjrohtable. .Mallory, F. H.: A Contrilni- 
 tion to the Classification of Tumors, Jour. .Med. Research, vol. xiii, Jan., 19()">. Resvdts of 
 the Application of Histological .Methoils to the Stvidy of Tumors, Jour. Kxjier. .Med., vol. \, 
 No. 5, Sept. ;'), 1908. 
 
 t Von Kahlden: Ziegler's i^eilriige /.ur path. Analoniie und aU'j:. I'aihologie, ISiKi, xiv, !>. 171. 
 
 }: .Morjjurgo: Ueber sarkonialmlii-he und nialiy:ne I .eioinyonie. /tschr. f. Heilkunde, 1895, 
 It), S. 157. 
 
 § Gessner; XCilV ll.indl.iicli di'r ( iynakologie, IS'.l't, iii, Zweite llaifte, S. 957. 
 
 II Veit: llandbuch d. CyiiakoloLMc. 1S1»7, IM. ii. S. 191. 
 
 «!r.el)hard: \'cit 's iiandiiurli der ( Ivnakologie, 1S<.)7, ii.S. III.
 
 174 MVO.MATA OF THE UTKRUS. 
 
 151, 152, 153, 154, and 155). will give the reader a clear idea of the various 
 transition stages of the myoma into sarcoma. 
 
 In order to follow these ohanges satisfactorily it is always necessary to ob- 
 tain sections at the outer edge of the growth, because in the central portion all 
 trace of the myomatous muscle has disappeared and its i)lace is occupied by 
 spindle-celled sarcoma. In Case 6045 the change had been a very gradual one 
 antl many distinct foci could be traced near the border of the growth, indicating 
 that there was a gen(>ral tendency for the myoma to become malignant. In 
 Fig. 150 ()). '227) we see typical myomatous muscle-fibers. A short distance 
 further on are nuclei twice the size, then four or five times as long, correspond- 
 ingly broad, and containing a slight increase in chromatin; and finally we en- 
 counter bunches of very large nuclei containing great (juantities of chromatin. 
 In this picture, then, we have all gradations, from the normal to the unmistak- 
 able sarcomatous fib(>r. Fig. 148 (p. 225), taken from a hyaline area at some 
 distance from the unun growth, is even more easily followed, inasmuch as here 
 the cells are further apart. Here also the gradual and yet steady increase in the 
 size of the nuclei is easily followed. In Fig. 149 (p. 226) from the same case, 
 cross-sections and longitudinal sections of muscle-bundles are still clearly visible. 
 Nevertheless, in each of them all stages in the transition, from the slender, 
 spindle-shaiM'd, to the very large elongate and deeply staining nuclei, can be 
 followed. Figs. 151, 152, 153, 154 (p. 228), from the same case, are even more 
 convincing. In Fig. 151, at a we have a cross-section of a muscle-bundle with the 
 tips of muscle-fibers still pi-eserved, and yet sufficient changes have taken place in 
 the surrounding muscle-fibers to render a diagnosis of sarcoma certain. Other 
 portions of the same specimen show all transition forms. The cells in Figs. 152, 
 153, and 154 of the same case illustrate admirably the relatively huge dimensions 
 that these cells may attain, and also show^ clearly the presence of large numbers of 
 hvaline droplets in the giant nuclei. As w^e pass toward the center of the growth 
 the sarcoma is found to be composed of a sea of cells, chiefly spindle-shaped, and 
 usually so closely packed togeth(>r that the cell outlines are hard to differentiate. 
 Traversing the sarcoma are large and small blood-vessels almost totally devoid 
 of stroma. Case 9536 also shows clearly the gradual transition from the myoma- 
 tous nmscle-fibers into the sarcomatous growth. Fig. 124 (p. 182) is taken from 
 the growth seen in Fig. 123 (p. bSl) and is at the junction of the sarcoma with the 
 myoma. The left portion of the section contains nmscle-fibers slightly swollen 
 but otherwise unaltered. As we pass to the right, however, the nuck>i increase 
 rapidly in number, are more spherical, and are somewhat enlarged. Some of 
 them also contain an increased amount of chromatin. Near the right border 
 of the section the nuclei have become clumped together, forming giant-cells. 
 The tissue immediately beyond this was that of a typical sarcomatous growth. 
 The .subseciuent degeneration in this variety of sarcoma is similar to that occur- 
 ring in those arising from the connective-tissue ])ortions of myomata. 
 
 Thus we have sarcomata developing in uterine myomata. These nuiy be of
 
 MYOSARCOMA OF THK UTERUS. 
 
 175 
 
 connect ivo-t issue origin, and are cither si)in(lle-e('llc(l or round-celled. We also 
 have sarcomata developing from the nmseular dements of the myoma. These 
 are invariably spindle-celled. Of course, it is (juite possil)le that both stroma 
 and muscle may take part sinmltaneously. This division into the two varieties 
 is of purely pathologic interest, as it can be determined only on careful histologic 
 study. It is of no particular import to the surgeon. 
 
 In San. No. 1852. included among the adenomyoma eases (" Adenomyoma 
 of the Uterus," p. 225). we have a very interesting 
 example of adenocarcinoma of tlie l)ody of the 
 uterus developing in part from a preexisting 
 adenomyoma. Commencing sarcoma was also 
 present in the body of the uterus. 
 
 A careful study of the pathologic deseri])tioii 
 of the cases certainly suggests that in many in- 
 stances hyaline degeneration has been the fore- 
 rminer of the malignant change. The muscle- 
 fibers scattered throughout the hyaline and 
 partially liquefied material have a much more 
 fa^'orable opportunity for swelling up or for taking 
 ujjon themselves increased activity, not being 
 closely packed together, as in the ordinary myoma. 
 The more we study these tumors, the more 
 strongl}^ we become impressed with the apparenth' 
 predisposing tendency to sarcoma created by the 
 ])iMmaiy hyaline change. 
 
 Secondary Growths of Myosarcomata. — As has 
 been noted in the foregoing pages, with sar- 
 comatous degeneration of myomata there is a 
 sinniltaneous increase in the size of the myoma, 
 and secondary sarcomatous nodules fi-e(|uently 
 become scattered thi'ougiioul 1 he uterine walls. If 
 the nodule be .subperitoneal, we shall exj)ect the 
 .sircoma to soon reach the outer surface of the 
 myoma, and to then engraft itself u])on the sui- 
 roimding ti.ssues, as in Case 95.% (Fig. 123, j). ISl). 
 in which the large subperitoneal tumor has become 
 intimately attached to the rectum, .\gain. in Case 7 17 I there was a laige aica of 
 iieci'osis on t he anterior- s\n'face of I he t umor. l'"inlny* I'eporls an inlei-est ing case 
 of a woman. Hfly-eight years of age, who had had an abdominal tuinoi' foi- (ifieen 
 years. This had recent I\- increased niateiially in size. She died eight days after 
 admission with signs of peiilonil is. .\i aulopsy a tumor the size of a child's 
 head was tound .attached to the fundus. The u|)|ier porli(»n showed a breaking- 
 * I'iiiliiy: Iniiis. of tin- I'liili. .S,,c. of Londoii. lss;5. vol. \\\iv. p. 177. 
 
 Fin. 122. — .\ SARroM.\Tors Nodule 
 IX .\ L.\.RGK Pf.lvic Blood- 
 
 VKSSEL. (Nat. size.") 
 
 Path. No. 7903. The original 
 growth started in the uterus. It was 
 a -sarcoma that had apparently de- 
 veloped from a myoma. Dr. Hunner. 
 when removing the uterus, felt 
 one of the bloo<l-ves.«els to be firmer 
 than u.suul, and on further dissection 
 drew this ca-st of sarcomatous tissue 
 from the ve.-isel lumen, a represents 
 the main ve.s.sel: h, l>' , W . are secondar.v 
 branches. The sarcoma had grown 
 directly into the vein.
 
 176 MYOMATA OF THE UTERUS. 
 
 down. The lower portion had a firm consistence. The tumor proved to be a 
 spindle-celled sarcoma. In this case the growth had become adherent to and 
 had grown into the bladder, where it formed a fungating mass. Secondary 
 sarcomatous nodules were found in the skin, lungs, and heart muscle. Ritter* 
 reported an instance of myosarcoma with subsequent supravaginal hysterec- 
 tomy. The patient died six weeks after from a recurrent growth. In this case 
 metastases had taken place into the lymph-glands at the pelvic brim. These 
 glands broke down during enucleation and were found to contain brain-like 
 material. In this case so malignant was the growth that within six weeks 
 after the ojieration perforation of the anterior abdominal wall had taken place. 
 Schreherf points out that metastases in otherwise operable cases are rare. In 
 the late stages of the growth he mentions metastases in the liver, lungs, pericar- 
 dium, omentum, heai't muscle, and vertebra^. What we have most to fear is 
 the lightning rapidity with which the growth extends to the surrounding pelvic 
 structures rather than the danger of metastases. 
 
 In our cases coming to autopsy three showed metastases. In Case 7313 (p. 195) 
 in which a necrotic submucous myoma and a subperitoneal myoma were present, 
 a secondary nodule developed in the broad ligament, and later, as will be seen 
 from Dr. Osier's letter, the patient evidently had metastases in the glands of 
 the neck, in the lungs, and in the pleura^. 
 
 The growth in Gyn. No. 12,155 (p. 200) was exceedingly rapid, as within a 
 few months after operation a large secondary tumor was found in the right upper 
 abdominal cjuadrant. At autopsy this nodule was found to be in the liver. 
 There were also general abdominal metastases, and likewise numerous skin 
 metastases, which were readily recognized clinically. 
 
 The secondary growths in Gyn. No. 7604 (p. 220) were particularly interest- 
 ing, sarcomatous nodules being found in the chorda' tendinea^ of the tricuspid 
 valves as well as in the lungs. 
 
 Some of the sarcomatous growths show a decided tendency to remain local, 
 as noted in Path. No. 6421. In this case two years after the supravaginal 
 amputation of a myomatous uterus — the sarcoma being at the time com- 
 pletely overlooked — there was a local return in the cervical stump, and at the 
 second operation no metastases were apparent (Fig. 130, p. 191, and Fig. 131, 
 p. 193). 
 
 Condition of the Uterine Mucosa in Cases of Myosarcoma of the Uterus. — 
 In very few of the cases reported has any attention been paid to a description 
 of the mucosa. In those cases in which the interstitial nodules gradually become 
 submucous, as reported by Pick, the overlying mucosa becomes atrophic; 
 the glands are pushed aside or are obliterated, and the nodule soon lies directly 
 beneath the surface ei)ithelium. This soon yields, and eventually the submu- 
 
 * Hitter: Dissert. Inaug., Leber d. Myosarkom des Uterus, Berlin, 1887. 
 t Schreher: Ueber d. Complikation von Uterusinyoin niit sekuiidiirer, sarkoniatoser Degen- 
 eration, Inaug. Diss., Jena [Strassburg], 1894.
 
 MYOSARCOMA OF THE UTERUS. 177 
 
 cous myoma over its most prominent pc^rtion is not only devoid of a covering of 
 mucosa, but shows breaking-doA^Ti of its superficial portions. 
 
 In thirteen of our seventeen cases wc have definite data as to the condition 
 of the uterine mucosa. In Gyn. No. 7313 the mucosa here and there showed focal 
 endometritis, hut was on the whole normal. Projecting into the uterine cavity, 
 in Civn. Xos. 7474 and 12,155, were pohq)i. In a few cases minor changes, such 
 as dilatation of the veins in the mucosa, dilatation of the lymph-channels, or 
 dilatation of a few glands, were detected. In ten out of thirteen cases the mucosa 
 was, however, practically normal.* This is exactly what one might expect 
 when the tubes and ovaries are normal and when a sarcoma is either interstitial 
 or subperitoneal. When the growth becomes sul)mucous and sloughs, the 
 inflammatory process naturally extends to the surrounding mucosa. 
 
 Condition of the Tubes and Ovaries. — The appendages seem to be little affected 
 by the development of the sarcomatous growth. In fourteen out of our seven- 
 teen cases we have definite data as to the condition of the appendages. In 
 Case 7313 the right tube was the seat of a subacute salpingitis and there was 
 pelvic peritonitis. The left tube was normal. In this case a slight focal endo- 
 metritis existed. The outer end of the right tube in Case 6045 had become 
 lost on the surface of the tumor, while the ovary was adherent at its outer pole. 
 
 In Gyn. Nos. 7604, 8610, and 8836 adhesions were also noted; in the remain- 
 ing nine the' tubes and ovaries were perfectly normal. 
 
 On the whole, we can be reasonably certain that the growth exercises little 
 influence on the appendages. Of course, if pelvic adhesions have existed, wc 
 usually expect the tubes and ovaries to be implicated in this process. 
 
 Clinical History in Cases of Myosarcomata of the Uterus. — These patients usu- 
 ally come with a definite history of uterine myomata of several years' standing. 
 Gessner and Weir both report cases in which a myoma had been detected two 
 years previously; Ritter and Weir o!)served instances in which the myoma 
 had been recognized at least ten years before operation. Finlay's })atient had 
 had a distinct abdominal tumor for fifteen years, and in Langerhans' patient, who 
 was sixty years of age, the tumor had been demonstrable for twenty years. 
 In Case 7212 the myoma was detected four years before admission, and in 
 Case 7474 a period of twelve years had elapsed from the time the myoma was 
 first recognized until operation. In Cast^ 9536 the growth was detected only 
 six months before operation. Here the tumor was posterior to the uterus, 
 was situated low down in the pelvis, and had evidently escaped recognition for 
 a much longer period. Nearly all of th(> pati(>nts giv(> a history of a slow develop- 
 ment of the tumor for several years, with a marked increase in growth during 
 the last few months. 
 
 * Atropl)y of the mucosa is iiiorely a rclati\c tcriii. W'licrc tlic surface area is four times as 
 great as normal, owing to the presence of a myoma, a mucosa ()iic-(|uartrr i)\' tlic normal thickness, 
 although apparently atrophic, is in reality normal. 
 12
 
 178 MVOMATA OF THK ITKHUS. 
 
 Age. — -As seen from the aooonipanyiii^ table, the highest incidence in our 
 cases was between forty and fifty }'ears of age: 
 
 Gyn. No. 6,724 age 27 San. No. 1,857 age 46 
 
 Gyn. No 8,610 " 39 Gyn. No. 9,536 " 48 
 
 San. No. 1,879 " 41 Gyn. No. 8,836 " 48 
 
 Path. No. 6,421 " 42 Gyn. No. 12,155 " 48 
 
 Gyn. No. 7,604 " 44 Path. No. 7,.355 " 50 
 
 Gvn. No. 10,376* " 45 Gyn. No. I'^Jf^ ] " 50 
 
 Gyn. No. 7,313 " 45 Gyn. No. 7,474 " 52 
 
 Gyn. No. 8,732 " 46 Gyn. No. 6,045 " 56 
 
 Gyn. No. 11.944 " 46 
 
 thus indicating clearly that this malignant degeneration is most fre(|uent at the 
 age at which carcinoma also is prone to develoj). 
 
 We ha\'e seen that sarcomata may develop in sul)])erit()neal, interstitial, or 
 submucous niyoniata. H(>nce the clinical picture will vary according to the 
 location of the growth. Where the growth is subperitoneal, there will be a 
 rai)id increase in size of the tumor, with or without pressure symptoms, according 
 as the growth becomes jammed in the pelvis or not, and according as it does or 
 does not extend to the rectum (see Case {)o'M), p. ISO). Such cases usually come to 
 0])eration Ix'foi-e the disease advances further: otherwise the growth may extend 
 to the bladder, if that viscus has been drawn u))\var(l on the surface of the tumor, 
 and in a short time we shall have a growth projecting into the bladder, as was 
 noted in P'inlay's case. The subperitoneal tumor itself will rarely cause uterine 
 hemorrhage, and, if a bloody vaginal discharge is present, it will ]3e due to the 
 existence of intei'stitial or subnuicous myomata in the same uterus. AVhere 
 the sarcomatous myoma is interstitial, there may be a general enlargement of 
 the uterus with extension of a portion of the growth toward the peritoneal 
 surface or, as is more frequent, toward the uterine cavity. When the growth 
 enci'oachcs on the utei'ine cavity, the patient will have hemorrhages. This 
 portion of the gi-owth is forced more and more into the cavity of the uterus, 
 becomes pedunculated, and then often undergoes partial necrosis. The hemor- 
 rhages subsequently increase, and in the interim there is a foul-smelling watery 
 discharge due to disintegration of the sloughing growth. The intra-uterine growth 
 is after a time expelled, and the patient, who has become very anemic and 
 sallow as a result of continual loss of blood, ra))idly improves for a time. After 
 a \ai'iablc ])eri()d other poi'tions of the growth become subimicous and in turn 
 are exi)elled per vaginam. Hence arose the term, '" recurrent fibroids." Gessner 
 mentions well-known cases reported by Hutchinson, Callender, Paget, and 
 West, and fjuite recently many similar cases have been published. In Case 7313 
 (p. 195) a necrotic submucous n(»dul(' was expelled two weeks before the patient's 
 
 * The tumor in tliis ca.sc was a subnuicous sloughing niyonui. It is just in this class of cases 
 that the pathologist finds the greatest difhculty in differentiating between simple disintegration 
 of the myoma and sarcomatous transformation. The changes in this case were so prono\inced 
 that from the histologic picture we were forced to classify it among the sarcomata.
 
 MYOSARCOMA OF THK UTP^RUS. 179 
 
 admission, and others would doubtless have followed had the uterus not been 
 removed. Case o4<)() (p. 252) is a typical example of a "recurrent fibroid." 
 The patient was forty years of age. For three months there had been frequent 
 hemorrhages and a large, sloughing, cauliflower-shaped myoma, 10 cm. in diame- 
 ter, filled the vagina. This was removed and the uterus was packed with gauze. 
 Two months later a similar nodule was expelled into the vagina, and for another 
 tw^o months there was perfect relief. Three months after removal of the second 
 nodule, a third pedunculated myoma, 9 cm. in diameter, was removed per 
 vaginam. At the end of a year this patient was perfectly well. From these 
 cases it is evident that some of the "recurrent fibroids" are sarcomatous myo- 
 mata, others are simple and rapidly growing myomata. It is often exceedingly 
 difficult, and in fact impossible, to determine whether these submucous growths 
 are sarcomatous or simply edematous and necrotic myomata. We found no 
 absolute proof in our case of "recurrent fibroid" that it was malignant, and 
 clinically the patient remained well. Gessner says that Simpson removed 
 seven successive growths through the vagina, and that it was onh^n the seventh 
 that he was able to detect sarcoma. Of course, if such a nodule as that seen in 
 Fig. 138 (p. 209) were to be expelled from the cervix, the diagnosis would be clear. 
 This nodule, however, is not the primary growth, but a secondary one from 
 the sarcomatous portion of the large myoma. 
 
 Pregnancy may occur when myosarcoma exists. Schreher reports a case in 
 which the growth was situated laterally, suggesting an intraligamentary cyst, 
 and in the uterus was a four-months' fetus. 
 
 Color. — In the seventeen cases examined by us, fifteen of the patients were 
 white and two colored. 
 
 From the foregoing it is seen that sarcomatous myomata present few, if 
 any, distinct clinical features. Myomata which have incn^ased slowly for 
 years often take on a rapid development without becoming malignant, and (^vcn 
 when "ivcurrent fibroids" are present, a good many arc simply necrotic myo- 
 mata showing no malignant changes. Only in rare instances will it be possible 
 to obtain definite evidences of sarcoma from extruded subnnicous tumors. As 
 seen from a study of our cases, in some instances sarcoma was not for a moment 
 suspected until the uterus had been I'emoved to the laboratory, and even then 
 the gi'owth was occasionally overlooked. In those cases in which the ojH'ration 
 is not perfoi'ined, dc.'il h iiiny be due to \\\r coiilinuous hemorrhage j)roduciiig 
 exhaustion, but occasionall\' to ^\•ide-sj)read metastases. 
 
 Treatment. The only hope of sa\'ing these patients' li\-es lies in a complete 
 remo\'al of the uterus. In nearly all of the cases reported in the lilei'ature. and 
 in nearly all of our own, su])i'a\'aginal liyslereeioiny was jxTlorined, the o])eralor 
 not for a moment hax'ing suspected sarcoma e\'en alter the abdomen was opened. 
 In every case in which sarcoma is susjx'cted the entire oi'gan must be i-enio\-ed, 
 and also as nnich as possible of t he jtarainet rial tissue. Considering the mnnber 
 of cases showing sarcomatous t raiisfoi-niat ion of myomata, and the possibility
 
 180 :my()Mata of the uterus. 
 
 that carcinoma may coexist in a myomatous uterus, we strongly advise that in 
 every case in which a supravaginal hysterectomy is deemed preferable, the uterus 
 be opened immediately after removal, so that if by chance a malignant growth 
 be present, the cervix can be removed without delay.* 
 
 No better example of the necessity of carefully examining all myomata at 
 once could be foimd than in Path. No. 6421 (p. 190). In this case about two 
 years after a supravagintU hysterectomy, the patient had definite signs of intra- 
 abdominal hemorrhage. At operation a larg(> sarcoma was found developing 
 from the cervical stump. Its complete removal was impossible. On examination 
 of the original tumor, sarcoma was readily recognized, even macroscopically. 
 It had been overlooked in the laboratory. 
 
 For the various stej^s in a com{)lete a])dominal hysterectomy sec page 588. 
 ^^^lere the growth has not been entirely removed, operation evidently hastens 
 the end. In Ritter's case thirty days after supravaginal hysterectomy a return 
 of the growth was noted, and six weeks after operation the patient died, the 
 secondary tumor at the cervical stump having reached a diameter of 20 cm. 
 The growth had perforated the abdominal wall. In Case 7212 a movable mass, 
 the size of a walnut, was detected at the cervical stump tAventy-six days after 
 operation, and the patient died less than thr(>e months from the date of the 
 hysterectomy. 
 
 In Case 12,155 a few months after operation a large metastatic nodule de- 
 veloped in the liver, and the patient soon died of wide-spread disseminated 
 abdominal metastases. 
 
 It seems to us probable that, when the supravaginal hysterectomy is done, 
 the sarcomatous growth is transplanted in various directions by the knife, 
 and that it commences to grow with increased vigor. As will be seen from our 
 cases, the immediate results following hysterectomy for sarcoma are not very 
 gratifying. In all cases of myosarcoma there seems to be a great danger of 
 infection, and if the utmost care be not exercised, a local or general peritonitis 
 will develop from the necrotic and frequently sloughing sarcomatous growth. 
 
 Detailed Report of Cases in which Myomata Became Sarcomatous or were 
 Associated with Sarcoma of the Uterus. 
 
 This subject is of such practical importance tliat each of our cases is given 
 in detail. 
 
 Gyn. No. 9536. Path. No. 5730. 
 
 Small i 11 t e r s t i t i a 1 u t e r i 11 e m y o m a t a ; large sub- 
 peritoneal my 111 a densely adherent an d undergoing 
 sarcomatous transformation (Figs. 123 and 124); 
 normal appendages. 
 
 * Cullen, Thomas S.: Sarcomatous Transformation of Myomata, Jour. Am. Med. Assoc, 
 Oct. 2-1, 1903. Immediate Examination of Uterine Mucosa and Myomatous Nodules after 
 Hysterectomy, to Exclude Malignant Disease, Jour. Am. Med. Assoc, March 10, 1906.
 
 MYOSARCOMA OF THE UTERUS. 
 
 181 
 
 E. C , white, marnod, agcnl f()rty-oio;ht. Admitted A))ril 7, 1902, complaining 
 of pain in the lower abdomen. Her family and past history are negative. Her 
 menses commenced at fifteen, were regular, lasting four days. The flow was 
 moderate and unaccompanied by pain. There has been a slight leukorrhea. 
 She has been married thirty-two years and has had three children, the eldest 
 thirty, the youngest twenty-four. 
 
 Six months ago the patient began to suffer from pain in the lower abdomen, 
 back, and rectum, and shortly afterward noticed a tumor. There was increased 
 
 frequency of micturition, but no 
 other symptoms. On admission 
 the geneial condition was fair; 
 
 Fig. 123. — Sarcomatocs Transkormatio.n of a Suupkritonkai, Mvom<\. with Dkn.sk .\nnKsioNs to the Rectum 
 
 AND Piii.vic Walls. 
 Path. No. 5730. The drawing rei)re.sents the appearances as found at operation. The uterus is somewhat 
 enlarged. Situatetl in its anterior wall is an interstitial myoma; in the posterior wall a .smaller one. Attached to 
 the posterior surface of the uterus at h is a large subperitoneal myonui. This fills the entire pelvis and extends 
 aliovc the pelvic Ijrim. The outlying portions (a) itrescnt the typical myomatous appearance, l>ut the entire 
 central jjortion is broken down. At c the growth is iiitimatcl\ lilcndcd witli the rectum. From tiie text it will 
 be ijeen that the disintegration of the tumor was due to sarcom;itinLs iruiisfoniialion of the iiiMima. 
 
 llic tciii|icraliiiv was ii()nii;il. Tliciv was :i hard mass lilling the lower altdtniieii 
 and exteiidiiiii; to within ;i ciii. of the uinbiliciis. 
 
 r)|)e]-atioii. The iitei'iis was situated ;iiit ei'ioiiy and abox'e the tumor, which 
 hlled the ])el\-is and w.as densely adherent. ( )n account of the adhesions the 
 uterus and tumor w(av liisceleiL Ndt all of I he t uinoi- could he u'ol I en fi-om t he 
 jH'lvic llooi- and many bleeding ])()iiits were left. Two gau/e di'ains were carried 
 down to the pelvic lloor. The i)atieiit was in good condition on leaving the 
 table.
 
 182 
 
 MYOMATA OF THE UTERUS. 
 
 h 
 
 
 bj. 
 
 Diirinp; the next clay she had severe pain in the h'ft lower abdomen. Her pulse 
 was 110, the teniju'rature 101.5°. There were vomiting and distention. The 
 bowels iiio\-e(l on tlic second day and all the paeks were removed. She developed 
 
 signs of intestinal obstruetion, and 
 on the fourth day, the day of her 
 death, her temperature reached 
 105°. No autopsy was obtained. 
 ^4 I \ y ^ >^'7^^<*^^-^'; Path. No. 5730. The specimen 
 
 consists of the ut(M'us with a tumor 
 springing from its posterior sur- 
 face, and also of the appendages. 
 The uterus has been amputated 
 through the cervix. It is 6 cm. in 
 length and 6 cm. in its antero- 
 j)osterior diameter. This increase 
 in thickness is due to two myo- 
 matous nodules, one situated in the 
 ])()sterior, the other in the anterior, 
 wall. Attached to the left side of 
 the uterus near the cervix is a 
 tumor mass. a])proximately 15 cm. 
 in its longest diameter (Fig. 123). 
 This nodule ])i'esents a distinctly 
 myomatous appearance, and over a 
 wid(> area is covered with dense 
 adhesions. On section fully one- 
 half of the tumor ])resents a nodu- 
 lar myomatous picture. The re- 
 mainder is softer in character, 
 slightly homogeneous, and suggests 
 sarcoma. The centi'al ])ortion of 
 this suspicious area has midergone 
 degeneration. Here the tissue is 
 hemorrhagic and very friable and 
 in this ai'ea is an irregular cavity, 
 5 by 4 cm., which has a smooth 
 inner surface. The uterine cavity 
 is of normal length and its mucosa 
 appears to be unaltered. The ap- 
 pendages on both sides are normal. 
 Histologic Examination. — Sections from the uterine cavity show that the 
 mucosa is practically normal. The more solid portion of the larg(> nodule spring- 
 ing from the posterior wall on the left side consists of typical myomatous tissue. 
 
 
 
 ^i \ 
 
 I* ' 
 
 
 
 
 Fig. 124. — Transition ok Myomatous ixto Sarcomatoi's 
 Tissue. (X 180 diam.) 
 Path. No. 5730. The section is taken from Fig. 123, 
 where the myoma is undergoing "softening,"' or, in other 
 words, sarcomatous transformation. .\t a the myomatous 
 tissue with some hyaline degeneration is seen. At b the 
 nuclei, although still of the same shape, are arranging 
 themselves in a long row, each nucleus overlapijing its 
 neighbor. At c the tissue has already become sarcomatous. 
 There is an increased amount of chromatin at d, and at e, e, 
 are large, mulberry-shaped giant-cells. The nuclei com- 
 posing these giant-cells are similar in size to the isolated 
 ones, f is a blood-vessel; g, one of the irregular clear 
 spaces scattered throughout the tissue. This field is given 
 to show the transition of the myomatous into sarcomatous 
 tissue. Sections near the center of this tumor are the most 
 typical examples of a mixed-cell sarcoma that we have ever 
 seen developing from a myoma.
 
 MYOSARCOMA OF THE UTHKUS. 183 
 
 The softer porliun presents an entirely different picture. At the junction of the 
 myomatous tissue with the softer growth the niusch'-fil)er8 are increased in size 
 (Fig. 124) . Their nuclei are also larger and irregular and stain more dec^ply. The 
 softer growth consists of spindle-shaped cells closely packed together, and 
 scattered throughout this growth are many plaques of protoplasm containing 
 from two to ten or more large, deeply staining nuclei. These giant-cells are 
 everywhere in evidence. The l)lood-vessels in the areas above described have 
 very thin walls and lie in direct contact with the tumor cells. A considerable 
 degree of necrosis has taken place, large areas having undergone complete 
 coagulation changes. In such areas the blood-vessels remain intact. In some 
 of the large veins thrombosis has taken place, and cells of the new growth have 
 wandered in and arc replacing the blood. 
 
 We are dealing with a myoma showing undoubted transformation into sar- 
 coma. In other places we have a large myomatous nodule presenting the typical 
 appearance in many places, and scattered throughout it are softened areas which 
 are clearly sarcomatous. Moreover, the histologic examination shows that there 
 is direct transition from the myoma into sarcoma cells, all gradations being found. 
 
 Gyn. No. 10376. Path. No. 6596. 
 
 S 1 o u g h i n g sub ni n c o u s m y m a u n d e r g o i n g s a r c o in a t - 
 o u s t r a n s f o r m a t i o n . 
 
 M. S., white, married, aged forty-hve. Admitted April 1; discharged April 
 17, 1903. The patient complains of a })elvic tumor. She has always been 
 healthy until the present illness. The menstrual history for five years was pain- 
 ful, but after that she had no discomfort. The flow has been normal up to the 
 present illness. The patient has been married twentj'-eight years, has had 
 eight children, the eldest twenty-seven, the youngest five years old. For five 
 years she has had very severe backache and last year rather profuse hemorrhage 
 during the menses, and occasionally .some bleeding betwcM'u titnes. She has lost 
 a great deal of blood, and for the ])ast two months has been in bed practically all 
 the time. I ler si rengt li has greatly diiiiinished, her appetite is ])oor, and she 
 is much constipated. 
 
 The ])atient is lai'ge and fat. The heart is dihiled and extends fail her to the 
 left than \isual; there is a systolic munnur at the apex, which is transmitted to 
 the axilla: thei-e is also a systolic nnu'nnu' in the |)uhnonarv area and a double 
 murnnu" in the aoi'tic area. The pulse is typical of aortic insuliiciency. and thei'e 
 is j)robably both mitral and aortic disease, llei' hemoglobin is 30 pel" cent. 
 The vagina is lille(l with a dull red mass al)oul IL* em. in diameter. There is a 
 very |)rofuse, fi)ul-snieHing discharge. The |iel\ic landmarks are diliicull to 
 outline, but one can feel the edge of the cel'xix surrounding the pedicle o|' ihe 
 growth. 
 
 ( )|)eration. The tumor was renioNcd in fragments without much hemorrhage. 
 It apparently had a broad peilicle. which was thoroughly curetteil. l-"our pieces
 
 184 MYOMATA OF THE UTERUS. 
 
 of gauze were packed into the uterine cavity. The highest temperature after 
 operation was 101.8°; it droi)ped to normal by the fifth day. The convalescence 
 was uninterrupted. At the time of her discharge the uterus was considerably 
 enlarged and nodular. The symptoms, however, had been completely relieved. 
 
 Path. No. 6596. The specimen consists of fragments of a foul-smelling, 
 friable tissue, amounting in all to about 700 c.c; the largest piece measured 
 7x4x3 cm. 
 
 On histologic examination many sections are found to consist almost entirely 
 of blood-clots rich in fibrin and containing quantities of polymorphonuclear leu- 
 kocytes. In many places what at first sight appears to be blood consists of 
 numerous very much dilated blood-vessels. Further sections show areas of 
 myomatous tissue \-ery rich in cell elements and here and there showing hyaline 
 degeneration. The cells for the most part are fusiform in shape with moderately 
 dee])ly staining nuclei. Others have more or less oval nuclei. Scattered 
 throughout the tissue are several large, deeply staining, and irregular nuclei, 
 and still other cells containing quantities of coal-black pigment. One is able to 
 trace the transition between the ordinary muscle-fibers and the deeply staining 
 masses. The ])icture is one of typical sarcomatous transformation of a myoma. 
 
 August 27, 1908, more than five years after the operation, the patient's phy- 
 sician, Dr. James Cooi)er, writes, "She is quite well." 
 
 C. H. I. No. 78. Path. No. 7555. 
 
 Sarcomatous transformation of an interstitial 
 myoma; secondary and ]i u r e sarcomatous nodule on 
 the posterior surface of t h e u t e r us. M y o m a t o u s 
 n o d VI 1 e with sarcomatous invasion in t h e 1 c f t b r a d 
 ligament (Figs. 125, 126, 127, 128, and 129). 
 
 L. T., white, married, aged fifty. Seen in consultation with Dr. Lilian A\'elsh 
 and admitted May 30, 1904. For several years the patient has suffered from 
 uterme fibroids and also from a growth in the right breast. Recently the growth 
 in the pelvis has materially increased in size. There has been a great deal of 
 pain extending do^^^l the left leg. Examination under anesthesia shows the 
 uterus to be considerably enlarged, and extending off from it is a large mass in- 
 volving the left broad ligament. 
 
 Operation. On opening the abdomen we found the uterus considerably en- 
 larged, and attached to its posterior surface was a cockscomb-like growth fully 
 15 cm. in length (Figs. 125 and 126). To the left of the uterus and attached to 
 it was a mass filling the entire broad ligament (Fig. 127), and extending up to 
 the pelvic brim. This was thought to be malignant, and no attem})t was made 
 to remove it. A supravaginal hysterectomy seeming preferable as a palliative 
 procedure. 
 
 June 11, 1904. After having carefully examined the uterus macroscopically 
 we came to the conclusion that the growth was benign, and therefore determined
 
 MYOSARCOMA OF THK UTKRUS. 
 
 185 
 
 to rt'iiiuvc the large mass in the left broad ligament. A long incision was made 
 parallel to the left Poupart's ligament and extending up to the left flank. The 
 ])eritoneum was pushed upward and forward until we came in contact with the 
 mass. This was dissected out with little or no hemorrhage ; in fact, no ligatures 
 were necessary. As the pelvic cavity was accidentally opened low do\ra, a 
 small drain was carried to the bottom of the wound. The i)atient made a per- 
 fectly satisfactory recovery. She was advised to return in a few months to have 
 the breast amputated, but procrastinated, ^^'hen she came back in March, 1908, 
 there were inoperable car- 
 cinomata of both breasts. 
 
 Path. No. 7555. The 
 uterus is fully three times 
 the natural size and is 
 somewhat globular. The 
 portion present is 8 cm. in 
 length, 9 cm. in breadth, 
 and 9 cm. in its antero- 
 posterior diameter. Its 
 anterior surface is smooth. 
 Its ])osterior surface is 
 prominent, apparently ow- 
 ing to the presence of a tu- 
 mor in its walls. Attached 
 to th(> |X)sterior surface by 
 a narrow pedicle is a cocks- 
 comb-shaped growth, 15 
 cm. in length. It is sharply 
 diffci'cntiated from the 
 
 I'k;. 12.'). SARf'OMATOt'S TRANSFORMATION' OF A MvOMA WITH .\ 
 
 uterus. At its Up])er J)Ole Skcon-dary growth on thkPostkriorSurfack of thk uterus. 
 
 it is adherent and forms a Path. No. 755.5. The uterus is considerably enlarged and on its 
 
 jjosterior surface is a growth roughly resembling a cockscomb. Histo- 
 depreSSion on the fundus. logic examination showed it to be a pure .sarcoma (Fig. 129>. The 
 TVTnar ita tnuldlo if i • • 1 • <lotteil lines indicate the confines of a myosarcoma in the left broad 
 
 .Near us mUKUe n is aiSO ii^,.„„e„t. For the interior of the uterus, see Fig. 120. For the mass in 
 attached to lllC lltcl'US b\' the left broad ligament, see Fig. 127. 
 
 a broad |)c(liclc. Tlic lower 
 
 half is sc|)ai'atcd I'roiii llic ulciiis by an itilci\al of fully 5 iiiiii. The lower end 
 has lain decj) in Dtjuglas' pouch, and has molded itself to t he suiface of the sacrum 
 (Fig. 12()). This cocksconib-like growth \aries from ."! to 5 cm. in bi-eadth and 
 projects from 2 to .'^ cm. from the suii'ace of the uteiHis. It has a lobulated 
 a])i)earance. due to the coarse and Inie molding of the sui'face. ( )n section the 
 growth in places clo.sely resembles a myoma; at othei- ]»oiiits it is very homo- 
 geneous, showing little sti'iation, and has an appearance suggesting sarcoma. 
 On .section ol' the utei-us nearly ihe eiiliie ea\ily is I'ound lilleil with a gi'owlh 
 ■1.5 cm. in iliaineter and somewhat irregular. It is coinijosed of lobulations
 
 186 
 
 MVoMATA OF TllK ITKHUS. 
 
 \vliicli have smooth siu-faccs and vary from 1 to o mm. in diameter. On section 
 this growth mitiht he taken for a degenerating myoma or for a sarcoma. 
 
 On examination of the hardened uterus the walls are found everywhere in- 
 filtrated by the growth, which in some places suggests myomatous tissue, in 
 others the homogeneous appearance of .sarcoma. The a])i)endages offer nothing 
 of interest. 
 
 The mass from the left broad ligament, which was removed at the second 
 operation, is 1.3 cm. in length, 8 cm. in breadth, and approximately 8 cm. in 
 
 / 
 
 Myoma ^ sarcoma 
 
 Fig. 120. — Myosakcoma ok thk Body of thk I'tkris \viih a Skcondaky .\xd I'lre Sarcomatous Cockscomb- 
 like Growth on the Posterior Surface. (| nat. size.) 
 Path. No. 7555. The uterus has been opened anteriorly. Behind the uterus is the cockscomb-like 
 sarcoma. (See Fig. 125.) Occupying the body of the uterus is a rather diffuse myoma, which on histologic ex- 
 amination showed marked hyaline degeneration and definite sarcomatous transformation of the muscle-fibers 
 (Fig. 128). The cockscomVj-like growth is attached to the posterior surface of the uterus by a broad iiedicle, which 
 consists essentially of a pure sarcomatous growth (Fig. 129). 
 
 thickness. It presents a markedly lol)ulate(l ap]X'arance. These lobul(\s vary 
 from a j)in-])oint to \\ cm. in diameter; they have a mottled apix'ai'ance in places, 
 and are made up of secondary lobules not more than 1 mm. in diameter. On 
 section some portions of the growth ])resent the typical pictui'e of myoma; others 
 are homogeneous, mottled, and strongly suggest sarcoma. The center of the 
 growth contains much blood. At the upper end of the growth and lying over the 
 i)ifurcation of the pelvic vessels is a lobular nodule, 4 by ;U'm. (Fig. 127). This 
 on section aj)])ears to i)e a myoma, although at operation it was su])posed to bo 
 an enlarged and hardened lymph-gland.
 
 MYOSARCOMA OF THE UTERUS. 
 
 187 
 
 liistulogic Exaiiiinatioii. — Sections from the uterine niueosa siiow that the 
 cen-ical glands arc perfectly normal and that the surface epithelium of the 
 cervix is intact. In \hv body of the uterus the surface e])ithelium is still i)rc- 
 served. The glands are normal. 
 The stroma just beneath the surface 
 shows some edema and there is some 
 slight dilatation of the glands. The 
 uterine mucosa can be traced directly 
 up to the growth occupying the fun- 
 dus and encroaching on the cavity. 
 This growth in the hjwer portion pre- 
 sents a typical myomatous picture. 
 The greater part of the myoma has, 
 however, undergone hyaline degenera- 
 tion, only a few nuclei remaining. 
 
 Sections from the body of the 
 uterus, also through the growth, like- 
 wise show much hyaline degeneration. 
 We note, however, that the nuclei 
 that still remain in this hyaline ma- 
 terial, here and thei'e show an increase 
 in size, being two or three times as 
 large as normal and staining rather 
 deeply (Fig. 128). In other areas, 
 where the myomatous tissue is still 
 well preserved, we have a rather 
 active condition of the cells, although 
 the buntUes are still pei-fectly pre- 
 si'rved. The nuclei are here also two 
 or three times as lai'ge as normal and 
 stain deeply. Tli;il this ;ilterati()ii is 
 going on ill the bundles and cells is 
 perfectl}' clear, as the outline of the 
 bundles is in no wav distorted. In 
 
 127. I'm; Louui.atki) and .Myo.matous Nodui.f 
 Hi Mnvi;i> iKOM TiiK LEfT Broad Ligamknt in 
 i-'ii;. Hi'), li riat. size.) 
 
 Path. No. 7555. This nodule was shellcil >>iil of llii- 
 li'fl broad liKaineiit twelve days after removal of the 
 uterus. .\ii incision wtLs made parallel to ami just above 
 I'ouparf's ligament, 'riie peritoneum wa.s (cradually 
 )t her portions ol the !J,ro\\tll we lllld pushed medianward vnitil the nodule was perfectly free. 
 
 It was removed without it beiuK necessary to control any 
 bliKHl-ve-s-seU. The small and partially constricteil nodule 
 (I was at first thoUKht to he an eidarKed Klaiul, but in 
 reality it formeil part of the lurKC nodule. Histologic ex- 
 aTuiiialioii showe<l that the growth was a myonui with 
 marked liyalliu> ili'Reiieration. It also containeil tvpical 
 sarcomatous tissue. 
 
 a totally different ])icture. WC ha\-e 
 
 scattered throughout tin' muscle 
 
 masses of cells that at first sight look 
 
 like carcinoma nests. ( )n careful 
 
 scrutiny it is found, howexcr. that the 
 
 individual nuclei fonning these nests are unifoi'iii in si/e throughout, and that 
 
 they come out mucli more clearly than is iisu;il in carcinoma, each cell being 
 
 sharply circumscribed. The growth wduld undoubtedly be taken for carcinoma.
 
 188 
 
 MYOMATA OF THE UTERUS. 
 
 The true character is well shown in the cockscomb-like growth attached to 
 the posterior surface of the uterus. Here we have a homogeneous sea of cells 
 divided by a framework of connective tissue just sufhcient to carry capillaries 
 (Fig. 129). The individual cells have oval vesicular nuclei, and in the entire 
 field ])racticall>- all are of the same size and show the same staining properties. 
 The picture here is one of typical sarcoma. The character of the growth would 
 also indicate sarcoma. If we were dealing with carcinoma, we would not for a 
 moment expect the entire cockscomb-shaped growth to be firm in texture and 
 show at no point the slightest tendency to break down. This entire growth is 
 
 
 
 
 
 .-^^.^^ 
 
 
 ,5 ^^ 
 
 k 'a 
 
 Fig. 128. — Commencing Sarcomatous Transformation 01 Myomatous Tissue. (X 100 diam.) 
 C. H. I., No. 78. Path. No. 7555. The section is from the submucous myoma seen in Fig. 126. At a the 
 tissue has undergone ahnost complete hyaline degeneration. At b are cross-sections of muscle-fibers of the usual 
 size. Over the area indicated by c the nuclei of the muscle-fibers are two or three times as large as usual and 
 stain deeply. In the area indicated by d the nuclei are still larger, suggesting a rather active process. For the 
 typical sarcomatous develoi)rnent, see Fig. 129. 
 
 made ii]) of tvpical sarcomatous tissue. The differentiation is particularly 
 well l)r()Ught out by the van (iieson stain. 
 
 The nodular mass shelled out from the left broad ligament consists for the 
 most part of a myoma that has un(l(>rgone almost comi)lete hyaline degeneration. 
 Little tufts of muscle-fibers still persist, esix-cially around the blood-vessels. 
 About nine-tenths of the field consists of hyaline tissue. In these hyaline areas, 
 however, we find cells sometimes four or five times the usual size, the central 
 nuclei being surrounded l)y a broad zon(> of fine dark dots, looking very much 
 like ])lasma cells. Other ])ortions of this broad ligament growth are totally dif- 
 ferent. Here the cells have undergone ccjagulat ion necrosis, but one still makes 
 out areas of malignant cells similar to those in the cockscomb-like growth. In
 
 MYOSARCOMA OF THK I'TKRUS. 
 
 189 
 
 Still other portions of the growtli we iiiid the iiiu.scular elements in the hyaline 
 areas staining very sharply and showing a tendency to increase in size and to 
 augment their supply of chromatin. 
 
 The nodules situated in the bifurcation of the iliac vessel are composed of 
 fibrous tissue and of nests of sarcoma cells. In this specimen we have at certain 
 points a glandular arrangement. No lymphoid elements can be detected, con- 
 sequently it is not a lymphatic gland that has been invaded by the new growth. 
 
 "We have here, then, a uterus twice its natural size, and with the fundus oc- 
 cupied by a lobulated growth which penetrates the uterine wall and forms a 
 cockscomb-like giowth on 
 
 the outer surface. \\c t> 
 
 also have a large irregular 
 growth situated between 
 the folds of the left broad 
 ligament. The growth oc- 
 cupying the body of the 
 uterus is to a great extent 
 composed of a finely lobu- 
 lated myoma which has 
 undergone partial hyaline 
 degeneration. The fibers 
 of this myoma in certain 
 areas show a marked ten- 
 dency to proliferate and 
 become malignant, not- 
 withstanding the fact that 
 muscle-bundles are still 
 well preserved. The outer 
 portions of this growth 
 consist of tissue in no way 
 distinguishable fioni sai- 
 coma. The cockscoml)- 
 like growth is sarcomatous. 
 The left intraligamentary 
 nodule lias to a large extent nndei-gone hyaline t ransfonnation. but it also has 
 been invade(l by a new growtii wiiich started from the uterus. We have been 
 unal)le to find any similar case in the literature. In all probability the myoma 
 was the i)nmary factor. an<l this myoma is undergoing .sarcomatous transforma- 
 tion, and we believe, although we ai'e not in ;i |iosilion to prove il. thai the sar- 
 comatous cockscomb-like growth of the uterus is secondary to the sarcomatous 
 degeneration of the myoma, and that it is nothing more tiian an outgrowth of the 
 sarcoma in the uterus. i'Voin ;i clinic;il standpoint it is partieuiailv interesting 
 that this patient is perfectly well, as far as the pelvic lesion is concerned. 
 
 'm^^M 
 
 Fui. 129. — .\ Sarcoma that has Dkvki.oped from an Interstitial 
 Myoma. (X 125 diam.) 
 C. H. I. No. 78. Path. No. 7555. The section is taken from the 
 cockscomb-shaped sarcomatous growth on the posterior surface of the 
 uterus seen in Fig. 12<). The mahgnant changes first commenced in an 
 interstitial an<l partiall.v submucous myoma and tlie seci>ntlary growth 
 wa.s a pure sarcoma, a.s seen in tiiis i)icture. The cells are large and 
 remarkably uniform in size. This sea of cells has delicate strands of 
 stroma (a) scattere<l throughout it and dividing the growth into alveoli 
 of various sizes, as indicated by b. The picture is t.vpical of sarcoma.
 
 190 MYOMATA OF THE UTERUS. 
 
 C. H. I., W., Jan. 22, 1903. Path. Nos. 6421-8370. 
 
 S u j) r a V a <2; i n a 1 h y s t c r v c t o in y s u j) p o s e d 1 y for si m p 1 e 
 i n t (' r s t i t i a 1 and subperitoneal m y ni a t ti . Two y e a r s 
 later sudden collapse due to hemorrhage from a sar- 
 c o m a developing from 1 h c c e r v i c a 1 s t u m p (Fig. 130). 
 Reexamination of the o r i g i n a 1 t u m o r s h o w e d t y p i c a 1 
 sarcomatous t r a n s f o r m a t i o n of the myoma (Fig. 131). 
 L a t e r intestinal o h s t r u c t i o n ; a r t i fi c i a 1 a n u s wit h 
 e o m ]) 1 e t e control. Death e i g h t m o n t h s a f t e r the 
 second o ]) e r a t i o n .* 
 
 Mrs. V^'.. white, aged forty-two. Seen in consultation on January 22, 1903. 
 For several years the mcnsti-ual periods have been exceedingly free. From time 
 to time she has been treated for dyspepsia and for some cardiac lesion, but not 
 until recently has any abdominal enlargement been detected. She is well 
 nourished, but is exceedingly pale. The mucous membranes are blanched and 
 the hemoglobin is 30 per cent. On vaginal examination the cervix is found to l)e 
 normal, but filling the vaginal vault and extending half-way to the umbilicus is 
 an irregular myomatous uterus. Above and to the right is a globular mass the 
 size of a kidney. One of the most interesting phenomena is a thrill felt by the 
 examining finger along the course of the left uterine vessels. 
 
 0{)eration. The uterus was brought up without much difficulty, and the 
 large mass felt in the region of the liver proved to be a suliperitoneal and pedun- 
 culated myoma. The uterus was removed from left to right. The left tube and 
 ovary were not disturbed. The patient stood the operation well and lost very 
 little blood. Phlebitis developed some days after operation, but did not retard 
 her progress very nuich. Within a month her color had returned, and in less 
 than three months she appeared to be in perfect health. I saw her on January 21, 
 1905, and she was in excellent condition. 
 
 Second operation, February 17, 1905. The patient felt perfectly well and 
 went to mai'ket yesterday morning. About 1 p. m. she was taken with pain in 
 the lower abdomen, and a little later almost fainted while at stool. Dr. Nathan 
 11. Gorter was called to see her and advised immediate removal to the hospital. 
 
 On examination under anesthesia we found the pelvis partly filled with a 
 mass the size of a small cocoanut. This a|)])arently involved the left side more 
 than the right. The left ovary having been saved at the previous operation, we 
 thought that this tumor was certainly ovarian in origin. On opening the abdo- 
 men the left ovary was found to be ])erfectly normal, but projecting from the 
 stump of the cervix, and extending down between the cervix and the rectum, was 
 a definite sarcomatous nodule fully 10 cm. across (Fig. 130). This was somewhat 
 lobulated. It had been slightly lacerated and free bleeding had occurred. We 
 removed at least a quart and a half of free blood and clots from the alxlominal 
 
 * CiiUen, Thomas S.: riarcoiiiatous Traiisforinatiim of Myoinata, .lour. Am. Med. Assoc, 
 March 10, 1906.
 
 .\n()SAK(<).MA OV THK UTERUS. 
 
 191 
 
 cavity. Her sudden discoiiitort had evidently been due to partial tearing of the 
 growth. \\\' wei'e al)le to peel the growth out to a great extent. l)Ut it was im- 
 possible to remove it in its eiitiivty. 
 
 The left lobe of the liver was shar]). the right lobe very blunt and thickened. 
 We thought we were dealing with a hei)atic metastasis, but on contimiing the 
 
 Fifi. 130. S\i(r(iM\ 1)kvi;i.oi'1\(; in tiik Ckrvicai. Sump. 
 Path. .No. s:i7(). 'I'he pelvis i.s viewe<l from ntjove. RisitiR from the pelvi.'^ between the lihuliler uinl the rectum 
 i.s a smooth, h>l>iihite<l Rrowth pre.><eiitiii({ a somewhat 8"arreil appenraiiee. To the left is the intact and iiorinjil 
 left ovary. The riKlit appetiiiaRe.s were removeil at the first operation. 
 
 incision U|)ward, tound there was merely thickening of the lixcr. The omentum 
 was free. The ap|)endi\ was reinoxcd. 
 
 The condition is |>articulaiiy interesting when we i-cmcmbci- that the uterus 
 had been i'enio\-ed two years before ami that the patient had ri'inained j)erfectly 
 well. 
 
 Postopeiatix'e History. The patient was readmittetl to the ("hui'ch Home on 
 .\ugust 21, 1!)()."). j'or the )(receding foui- or ti\-e weeks she hail great ditlicultv
 
 192 MVOMATA OF THK I'TERUS. 
 
 in securing an evacuation of tiie bowels. On examination we found the pelvis 
 practically filled with a new o;i()\\tli, rendering necessary the making of an arti- 
 ficial aims. The bladder was definitely implicated by the growth and the urine 
 contained large quantities of blood. I made an incision through the left rectus, 
 brought out the sigmoid tiexure, cut it in two, closed the lower (>nd, brought the 
 upper end out through the rectus, passed it outward beneath the sheath of the 
 rectus for about an inch and a half, then made a longitudinal section through the 
 sheath of the rectus and through the fascia to the skin, attaching the bowel to 
 the skill. The bow(>l. therefore, was brought upward, then outward, and then 
 U])wartl again. The patient experienced a great deal of relief. Her bowels 
 moved once or twic(> a day, but she had practically alisolute control, as there was 
 no escape of fecal matter excejjt at stool. She improved considerably. Occa- 
 sionally there was some discomfort from the rectal tenesmus due to the ever-in- 
 creasing growth pressing on the remaining portion of the rectum; otherwise she 
 was comfortable. She remained in the hospital until October 1st. During the 
 last two weeks of her life she became much weaker and died October 30, 1905. 
 
 Path. X o . S o 7 . A s a r c o m a t o u s g r o \\- 1 h developing 
 fro m t h e c e r \' i c a 1 s t u m \) . The specimen (Fig. 130) consists of a 
 mass of tissue, 10 x 8 x 5 cm. It is somewhat lobulated, rather smooth, and 
 on its under surface has a basal attachment extending over an area 5x5 cm. 
 The tissue is of brain-like consistence, yellowish-white in color. It is very friable. 
 On section the mass is found to contain a large, irregular ar(>a of hemorrhage. 
 At one point is a cystic space 2 x 1.5 cm. This is divided by trabecuhe into 
 smaller spaces and is filled with blood-clots. The general character of the 
 growth is clearly evident without histologic examination. 
 
 Histologic Examination. — The tumor is found to be made up of a sea of cells. 
 Most of these have oval vesiculai- nuclei and bear a striking resemblance to those 
 of muscle-fibers. Th(^ cells themselves are spindle-shaped, with deeply staining 
 nuclei, two or three times the natural size. Others are irregular and also stain 
 deepl>'. In places we have masses of protoplasm containing five or six deeply 
 staining nuclei. At other points there are giant-cells in which the miclei are not 
 over one-third the usual size. In places are seen spindle-cells undergoing divi- 
 sion. There are large, irregular plaques of protoplasm containing fragmented 
 nuclei and cells showing typical miclear figures. The micleus itself is sometimes 
 divided into five or six young nuclei. The blood-vessels are large and abundant. 
 The majority of them appear to be veins. Some are filled with thrombi and the 
 tumor cells are gradually obliterating them. In fact, dividing tumor cells can be 
 demonstrated lying free in such blood-vessels. In some places the tissue is 
 much rarefied. In such areas giant-cells are })articularly abundant. The 
 growth is essentially a spindle-celled sarcoma which shows a marked tendency 
 toward giant-cell formation. 
 
 Path. No. 6421. Description of the original tumor. 
 
 The specimen (Fig. 131) consists of a globular uterus, approximately 18 cm.
 
 MYOSAIiCOMA OF THH UTKRUS. 
 
 193 
 
 ill diameter. It is smooth and <ilistening. On the surface one or two nodules 
 can be detected. Attached to the riijht coriiu is a ki(hiey-.shaped subperitoneal 
 nodule, 13 cm. in leiijith and s cm. in breadth. It is attached by a pedicle, 2.5 x 
 
 Fir;. l.'Jl. — SviicoMAToi's Tkanskokmation OF A Utkrink Myoma. Si'HRAVAcilSAi, .Xmi'ttatkin wnii IUtiks 
 OK THK (IhOWTII IN THK Ckkvicai, .STrMP. (J iiat. f<ize.') 
 Path. No. 0421. The picture represents a loiiKitiiiiinal seotinti throuRh the entire uterus, a is the upper 
 limit iif the uterine cavity; b, the lower or cervical portion. It is thus .seen that the inyonia occupyinR the poster- 
 ior wall i)rojpcte<l into the uterine cavity ami put the mucosa on tension. The myomatous niMlule is api)roximatcly 
 circular and in many places yielils the ustnil myomatous striation. ,\t c is an area of typical hyaline ileKoneration, 
 recoKnizeil liy its homogeneous appearance. .Vt numerous points inilicateil hy il we fiml sharply outlined jtranular 
 or spongy area.s, which are at once recognized lus sarcomatous. .Vt e along the outer margin of the myoma are 
 area.s of sarcoma, and the tissue lictwccn f aiicl f is partly myonnitous, partly sarcomatous; g is an area of calcifi- 
 cation. 
 
 1 ..") cm., and is freely iiio\able. The utei-ine cjiNily is 17 cm. in length, and is 
 markedly con\'ex, owint:; lo the fact that the tumor projects inward from the 
 posterior wall. The mucos;i on the whole looks noi'in.al. but is atrophic. Near 
 
 13
 
 194 MYO.MATA OF THK UTHUUS. 
 
 the fundus it has uiKlcrt^oiic in some i)l:u'cs ahnost (•()inj)h'te atrophy, the growth 
 in the posterior wall shining through. 
 
 The enlargement of the uterus is due chiefly to a circular nodule 13.5 cm. in 
 diameter, occupying the posterior wall. This nodule is almost spherical. The 
 central portion has in ]iart undergone typical hyaline degeneration, as is evi- 
 denced by large and small spaces traversed by delicate trabccuhr. On careful 
 examination there are several areas presenting a homogeneous spongy ap- 
 pearance (Fig. \:\\). These form a part of the myomatous tissue. They vary 
 from 1 to 4 cm. in iliameter, are irregular in their distriljution, and have un- 
 doubtedly develojx'd from the myomatous tissue. They give the characteristic 
 appearance of sarcoma and aic distributed throughout the solid portion of the 
 tumor, being also intermingled with areas of hyaline degeneration. Macroscopi- 
 cally one is able to (liagnos(> with absolute certainty a sarcoma developing from 
 the myoma. The uterine walls posterior to the tumor vary from 1 to 1.5 cm. in 
 thickne.><s, and in some places there is a covering of from 2 to 5 mm. of uterine 
 muscle separating the growth from the mucosa. 
 
 Histologic Examination. — The areas indicating hyaline degeneration are en- 
 tirely devoid of nuclei. Here the tissue has undergone the usual complete hya- 
 line transformation. Many sections have been taken from the areas suggesting 
 sarcoma. In the majority of these most of the elements have undergone com- 
 plete coagulalion necrosis. Here and there, however, in the vicinity of the 
 blood-vessels are a good many small round cells. In some of the sections in 
 which there is incomplete hyaline degeneration a good many muscle-fibers are 
 still preserved and there are quantities of mast cells. The nuclei of the muscle- 
 fibers show considerable variation in size and staining properties. One is in- 
 stantly remind(>d of a sarcomatous transformation. In the more characteristic 
 sarcomatous areas, where the cells are still preserved, we find similar histologic 
 changes. The miclei are four or five times the natural size, are irregular in out- 
 line, and stain very deei)ly. In other places we have very large, irregular cells 
 wnth protoplasm that takes the eosin stain deeply, and irregular nuclei situated 
 in the centers or at the margins of the cells. Again, some cells contain six 
 or .s(>veii nuclei. The picture instantly suggests sarcoma, but it is impossible to 
 tell with certainty whether the growth has really started in the muscle-fibers or 
 whether it has originated from th(^ connective tissue. On the whole, the evi- 
 dences of musck; origin appear to be the more reliable. In some of the hyaline 
 areas the blood-vessels still persist, the endothelium is present, and the cells 
 of the vessels are stained deeply and are irregular, suggesting that the connective 
 tissue of the vessel wall is also undergoing a malignant change. The deeply 
 staining cells stand out in sharj) contrast with the surrounding areas of hyaline 
 degeneration. Macroscojjically and microscopically areas of calcification are 
 evident. At no point do we find any evidence that the sarcoma extends beyond 
 the confines of the myoma. The specimen was examined in the laboratory 
 immediately after the first oi)eration and longitudinal sections were made. In
 
 MYOSARCOMA OF THE UTERUS. 195 
 
 these degenerative changes were noted, but through an unfortunate circum- 
 stance no further sections were made, and it was not until after the second opera- 
 tion, more than two years later, that we found the sarcoma springing from the 
 cervical stump. When the original tumor was again examined, even a casual 
 glance showed areas of hyaline degeneration in the myoma and also irregular 
 areas of typical sarcoma. 
 
 A consideration of this case might well raise the question whether a complete 
 hysterectomy would not be advisable in all cases. But the supravaginal opera- 
 tion is the easier one; it leaves better support to the pelvic floor, there is less 
 danger of tying the ureters, antl as the blood-supply of the bladder is but little 
 interfered with, there is less likelihood of a postoperative cystitis. The ad- 
 vantages of the supravaginal operation would appear to more than outweigh 
 the objection that there is an occasional occurrence of malignant changes in 
 or associated with myomata. This case, however, clearly indicates that we 
 should carefully examine not only the uterine mucosa for carcinoma, but also 
 the myomata for sarcomatous changes before the cervical stump is closed. 
 
 Gyn. No. 7313. Path. Nos. 3673 and 3576, 
 
 A sloughing submucous myoma; large spindle- 
 celled sarcoma occupying the anterior uterine wall, 
 and implicating the uterine cavity (Figs. 132, 133, 
 and 134). Formation of a secondary nodule in the 
 right broad ligament; small interstitial myomata; 
 localized endometritis. Later implication of the 
 cervical glands and j) r o b a b 1 y secondary growths in 
 the lungs and pleura^. 
 
 L. H., white, married, aged forty-five. Admitted October 25; discharged 
 November 29, 1899. Complaint, tumor of the uterus. The patient has been 
 married seventeen years, has had one child and one miscarriage. The child is 
 fourteen years old. The patient had an instrumental labor, was in bed twelve 
 weeks, and had chills and some fever. Her menses commenced at fourteen and 
 have been regular every four weeks until nine inouths ago. They have always 
 been profuse, and she has had a great deal of hemorrhage since the tumor was 
 first noticed. The hemorrhage began in April, 1899, and the loss of blood has 
 been almost continuous, l)ut more marked at the menstrual periods. Two 
 weeks ago she had a chill and a necrotic subnmcous myoma, 14 x 8 x S cm. in 
 diameter, was expelled. The tem))erature was 100.4°; the j)uls(> was 101. Three 
 days preceding this she had laboi-like pains. ( )n alxloininal examination a 
 tumor is found extending 9 cm. above the unihilicus. 
 
 Operation, November 1, 1S99. .Vbdoniiiial liNstei'eetomy. The omentum 
 was adherent to a subperitoneal nodule, 7x7 cm. It was tied off, and the 
 entire mass lifted out. Dense adhesions were cut , and the uterus was amputated 
 just above the vaginal vault. On the right side was a lai'ge abscess full of thick
 
 196 MVOMATA OK THE UTERUS. 
 
 jms. The al)sc'Oss was situated Ix'iieath the broad ligaiiicnt : it was attached to 
 the rectuin and had burrowed about 4 ciu. along the vagina on the right side. 
 The vaginal vault was opened, and an iodoform gauze drain carried into the 
 vagina. The cervix was covered over with peritoneum in the usual way, and 
 tile abdomen closed. The abscess originated in the tube. The maxinmm post- 
 oju'rative temperature was 100.6°. Tt reached normal on the eleventh day, and 
 the ))atient made a satisfactory recovery. 
 
 This j)aticnt had Ix'cn seen in .May, 1S91), and inunediate ojuTation was 
 advised, but she decided to wait until the fall, thinking that the tumor might 
 
 Path. No. 3673. The specimen consists of a submucous myoma, spontane- 
 ously exju'lled from the uterus. It is 1.3 cm. in length, and varies from 3 to 5 cm. 
 in breadth. The surface is comparatively smooth and of a Ijright red color. 
 At the lower end the tumor is jiartially subdivided by a cleft 2.5 cm. in depth. 
 The growth at its base, where attachetl to the uterus, is 3 cm. in diameter. On 
 pressure it is firm and tough. At its extremity it appears to be gangrenous 
 and has an exceedingly foul odor. On section, it does not present the charac- 
 teristic appearance of myoma. It has a very abundant blood-supply, some of 
 the vessels reaching 2.') mm. in diametei-. 
 
 Histologic Examination. — In sections tak(>n from various portions of the 
 tumor no trace of the mucosa is to be made out. The .surface is entirely necrotic. 
 The cell-outlines are no longer visible, but just Ix'ueath the surface are many 
 fragmented polymorphonuclear leukocytes. In the deeper portions a few 
 nuiscle-fibei's are stih visil)le. Here and there are large irregular and deeply 
 staining nuclei. Scattered throughout the necrotic ti.s.sue are myriads of cocci, 
 and .some of the blood-vessels are tilled with them. The deeper portions of the 
 tumor consist of non-striped mu.scle-fibers, showing much diffuse hyaline de- 
 generation and a high degree of vascularity. The a])pearances are typical of 
 a sloughing submucous myoma. 
 
 Path. Xo. 3576. The specimen consists of an enlarged and irregular uterus 
 with the ai)j)endages intact. The uterus, which has been amputated through the 
 cervix, is 15 cm. in length and 15 cm. broad. It has a smooth surface, and 
 anterioi'ly is covered with peritoneum. Posteriorly are numerous den.se ad- 
 hesions; attached to the fundus is a soft, friable mass, 6x4 cm. This can be torn 
 readily and seems to be arranged in long threads. On section, the great increase 
 in size of the uterus is found to be due to a growth occupying chiefly the anterior 
 wall. This growth reaches () eni. in thickness, is yellowish white in color, homo- 
 geneous in consistence, and divided into smaller lobules by glistening fibrous 
 trabecula- (Fig. 132). In some j^ortions this growth is honeycombed with 
 small, cyst-like spaces, varying from 1 to 7 mm. or more in diameter. The 
 tumor is sharply outlined from the uterine muscle, and in the middle of the 
 uterus extends to the mucosa. Near the internal os it is devoid of nmco.sa and 
 lies free in the cavity. It implicates the fundus, but does not encroach upon the
 
 MYOSARCOMA OF THE UTKHl'S. 
 
 197 
 
 post('ri(ji- wall. Situatcil in the posterior wall, however, is an interstitial myoma, 
 2 em. in diameter. The uterine eavity is 11 em. in length. The mucosa of the 
 cervical portion is thin, and that of the body is als(^ atrophic. Occupying the 
 right broad ligament, and intimately connected with the uterus, is a nodule, 
 10 X 9 X 8 cm. This, on section, consists of the same liomogeneous tissue that 
 formed the tumor occu})ying the anterior wall. The central portion contains 
 
 Fk;. 132. — Sarcoma of thk .Vntkhiou I ri;ni\i; W'ai.i.. (; luit. size.) 
 Path. No. .3.576. a i.s the outer coveritiK "f iioniial iiniscle; h, the smooth homogeneous sarcomatous tissue, 
 which is divided up into large and small islaiuls hy the haruls of stroma, c. This stroma is fihrillateil, and seems 
 to be composed of myomatous ti.ssue. Scattered thniii^rhinit ilic s;u<-iimki arc iiumv siiiDnih-wallcd. cyst-like siiaces 
 (d), varying from 1 to 10 mm. or more in diamcl<'i. 
 
 an ii'regular, cysl-likc ea\it\' ( i'^ig. \'.VA), api)io\imalel>' o x 3 cm., and scattered 
 throughout the growth -.Wi' minute e>'sts. 
 
 ( )n the right side ihctiilic is II cm. long, .and gradually inci'cascs in di.'imcter 
 from i) mm. t(j ^).o cm. at its distal cxti'cmity. It is coxcrcd with \ascular 
 adhesions. The o\'ai'y is bound to the tube and posici'ior surface of the uterus. 
 It measures o.o x 2 cm., and contains a small cyst. 
 
 On the left side the appendages arc api)ai'cntly noi'inal.
 
 198 
 
 MYOMATA OF THE ITHRUS. 
 
 Histologic Examination. — Sections from the uterine mucosa show that the 
 surface epithelium is intact, but that in a few places it is slightly thickened. 
 Here and there the surface is covered with iiolymorj^honuclear leukocytes, and 
 at such points the mucosa is ivpi-esciit cd by granulation tissue. In most places, 
 however, the uterine glands are normal, and the stroma, apart from localized 
 small-round-celled infiltration, shows little alteration. We have a fairly normal 
 nuicous membrane, with foci of endometritis. The growth occupying the 
 anterior uterine wall consists of laige ([uantities of spindle-cells ari'anged in 
 
 Flc. 1.33. — A I.AHi.h >AHi<)MATors Noiui.k Containinc an luRi.cri.AR, Smooth-wallei) Cavity in its Centkr. 
 
 (I nat. size.) 
 Path. No. 3576 a represents the uterine muscle, which i.s coarser than usual; h is the sarcomatous growth, 
 which, although showing some fibrillation and whorls, is fairly homogeneous. Scattered throughout the growth 
 are several small, irregular, cyst-like spaces, as indicated by c, and the center of the growth is made up of an ir- 
 regular, smooth-walled cavity, (d). Histologic examination failed to reveal any epithelial or endothelial lining to 
 this space. The sarcoma, while in places intimately blended with the muscle, at other points, as seen at e, is very 
 loosely connected At f the sarcoma has reached the peritoneal surface, forming a distinct prominence. 
 
 bundles. These ha\'e been cut lengthwise and transversely, and the j)icture at 
 first sight suggests a veiy cellular myoma. But on further examination it is 
 found that many of the nuclei ai'e two or three times the length and double the 
 breadth of those near them, and furthermore, that they stain intensely. Careful 
 scrutiny shows that even in a single field it is {)os.sible to detect six or more minute 
 nuclear figures in different stages of develo])ment. Other sections contain myriads 
 of deeply staining nuclei. So abundant are they in ])laces that they form fully 
 lialf the field. Large areas of the growth have undergone complete coagulation
 
 MYOSARCOMA OF THE UTERUS, 199 
 
 necrosis, and in the vicinity of such ])oints many of the cells of the growth con- 
 tain brown graiuilar ])i<z;nient. In the scanty amount of stroma numerous small 
 round cells are demonstrable. The nodule situated in the right broad ligament 
 is of the same character. The growth is, of course, malignant, and is a spindle- 
 celled sarcoma (Fig. 134) . At one point it is possible to trace the gradual transi- 
 tion of the muscle-fibers into the sarcomatous tissue. 
 
 In this case, from the general contour of the uterus on bimanual examination, 
 one would naturally render a diagnosis of myoma. So characteristic was the 
 growth in its outline that the assistant who wrote up the gross description before 
 the organ was opened spoke of it as a myomatous uterus. This assumption 
 naturally would be fully justified by the history of the submucous myoma. 
 
 The right tube is the seat of a subacute salpingitis; the left tube is normal. 
 
 a 
 
 
 
 
 
 a 
 
 
 
 
 d 
 
 -r-£C' 
 
 ^ 
 
 ^'-i:. 
 
 5 
 
 
 "-^^ 
 
 
 
 '•' .'P'- - 
 
 ~_5 
 
 ^ 
 
 ."— -L; 
 
 ;r.-^- 
 
 :'^_*^ 
 
 
 ;x^' 
 
 y.- 
 
 - V- 
 
 -'^— ^ 
 
 
 "" — ' 
 
 
 '-~^- ' ' 
 
 " " \~ >*"^ *•_-/ - . 
 
 y^^.- 
 
 i-i 
 
 ^i<ri- 
 
 
 ^^^',~yr^ 
 
 _— - - 
 
 ~^z~^-^ 
 
 ^^V.i^---' — 
 
 — -r— r 
 
 
 
 /•^■^>=-*t 
 
 ■T*.* <~~ 
 
 — 
 
 " ._ — '''^ — "'' 
 
 " '^ 
 
 ''Z--^ 
 
 ^/3> 
 
 '-''. 
 
 
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 >^^, 
 
 
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 ^yy 
 
 ■■'^-i' 
 
 b 
 Fig. 134. — Probabl?: Sarcomatous Transformation of Bundles of Myomatous Tissue. (X 80 diain.) 
 Path. No. 3576. The section is from the sarcoma seen in Fig. 132. The upper half of the field, as indicated 
 by a, is composed of myomatous tissue; the lower part (b), of sarcomatous tissue; c is also sarcomatous tissue, and 
 at d the muscle-bundles ajjpear gradually to merge into the sarcoma. Some of the muscle-bundles have undergone 
 necrosis. 
 
 The suhs('((U('iit clinical history of .Mrs. II. is of iiilci-cst . \"^\. ( )sI(T, in a letter 
 dated November 12, 1902, writes: " I saw her with Drs. iiuiiii-ichoiise and Scott, 
 of Hagerstown, on November 1, 1901. She iiad lost much in weigiit. There 
 was great pain in the left side, dysjniea, dulness on the left side of the chest, 
 uniform flatness, retained vocal fremitus, feeble, distant bi'eatliing, no disloca- 
 tion of the heart. The glands were involved abo\-e the clavicle. I think there 
 w^as no doubt of the correctness of the diagnosis made l)\- the doctors of secondary 
 growth in the lungs and ])leura'. Then we found out froiiiCullen that there was a 
 sarcomatous degeneration of a ni\-oma. She died w few weeks later."
 
 200 MVOMATA OF THH UTERUS. 
 
 Gyn. No. 12 155. Path. No. 8723. 
 
 S a r c o 111 a t o u s t r a n s t" o r in a t i o n o f t h c 111 u s c 1 c - fi b c r s 
 i n n (• 111 y o in a (Fig. 1 o ) o f a 1 a v 12; c in y o 111 a t on s 11 1 criis . 
 H y s t e roc t u 111 y . K c t u r n of patient with abdominal 
 ni t a s t a s e s . 
 
 L. Q., colored, aged forty-eight, married. Admitted May 29; discharged 
 June 24. 100"). The i)atient complain.s of pain in the left side of the abdomen 
 and also in the back. Many of her relatives died of tuberculosis. Her menses 
 l)egan at twelve, were always n^gular u]^ to two years ago, when the}' began 
 coming at shorter intervals and the flow lastetl fi-oiii eight to ten days; it was 
 free, but not painful. Two years ago they lasted as long as three weeks at a 
 time. The last period was three months before admission. There was excessive 
 bleeding, but there has been no hemorrhage since. The patient has been married 
 fourteen years, has had no childi'eii, but one miscarriage twenty-three years ago. 
 There has been a foul leukorrheal discharge at times for the ])ast year. 
 
 Three years ago the patient felt a small mass in the right lower abdomen. 
 It was about the size of a hen's egg. Two years ago this commenced to increase 
 in size and to be tender to the touch. It would swell up and then decrease again. 
 About this time she noticed a swelling in the feet, and was told by her physician 
 that .she had a tumor. 
 
 The tumor has aj^parently grown much more rapidly during the last few 
 months, but there were no marked symptoms until about three weeks ago, 
 when the patient began to conijilain of severe pain in the left lower abdomen, 
 radiating to the back and down the left leg. For two years she has had some 
 difficulty at times in voiding. There has been increased frec{uency, the amount of 
 urine has been scant, and it has been difficult to start the flow. The patient has 
 had a sev(>re cold during the ])ast winter. There are no marked heart or lung 
 sym]itoiiis. though the ])atieiit is troubled witli night-sweats. 
 She has been rapidly losing in weight. 
 
 On admi.ssion she is thin and pale. On abdominal examination a rounded 
 swelling is found extending from the symphysis to the ensiform cartilage. Res- 
 ])iiation is markedly limited. There is a small umbilical hernia. The ring 
 admits the tip of the index-finger, and through it the finger can be forced into 
 the abd(jniinal cavity and can readily palpate a hard tumor. On bimanual 
 examination it is ])0ssible to feel at least two large tumor masses. The diagiio.sis 
 lies between a multinodular myomatous uterus and an ovarian cy.st. 
 
 Operation. On opening the abdomen about two ounces of clear yellow serum 
 were found in the abdominal caxity. ( )('cupyiiig the up})er ])art of the abdomen 
 was a large tumor, attached by a pedicle. 'A cm. in diameter. The tumor has 
 made a three-fourths turn on itself. This readily accounts for the j)resence of 
 the free fluid. The omentum was adherent to the upper pole of the tumor for a 
 distance of 14 cm. Some of its vessels were from 1 to 2 mm. in diameter. There
 
 MYOSARCOMA OF THK ITERUS. 201 
 
 was one adhesion on the left side, between the anterior abdominal wall and the 
 tumor; this measured 2 x 0.5 cm. After some dittieulty the uterus was re- 
 moved. Little or no bleeding occurred. The highest postoperative temperature 
 was 100.6°. The patient made a satisfactory recovery. 
 
 Second admission: The patient entered the hospital again on February IS, 
 1906, complaining of pain in the arms and left side of the abdomen. When she 
 left the hospital in June she was in fair health, and remained so until October 1, 
 1905. She then began to feel a drawing, tingling sensation in the hands and 
 finger-tips, and on account of poor circulation had to wear three pairs of gloves 
 during the winter. About three weeks before admission she noticed her al)do- 
 men getting fuller, so that it was impossible for her to wear corsets. There was 
 a '' sticking pain" in the right side and also in the back. There was no fever and 
 no vomiting. On examination there was dulness in the right side, and continuous 
 with the liver and extending over as far as the left of the nipple. Occupying 
 the right upper abdominal quadrant was a large firm mass which had thick, 
 rounded margins. On its inner side was a notch resembling that between the lobes 
 of the liver or the hilum of the kidney. The mass was so large that it was only 
 slightly movable. It was very distinct posteriorly in the flank. A renal catheter 
 was introduced and the kidney injected. Injection of 9 c.c. of fluid brought on 
 pain, apparently located in the lower part of the tumor. A bladder examination 
 showed nothing aljnormal. At this time it was impossible to tell the exact 
 character of the tumor, as the changes in the myoma had been totally over- 
 looked in the laboratory. This was due to the fact that the tumor was supposed 
 to be nothing more than a simple myomatous uterus, so that instead of making 
 a systematic examination of each myomatous nodule, the pathologist had merely 
 0])en(Kl the uterine cavity and split the larger nodules. The patient shortly 
 aftei'ward left the hospital, although she had a temperature of 101° F. and had 
 been lying in bed in a listless condition. 
 
 March 2(S, 1906: The ])atient entered St. .Joseph's llosi)ital to be exaiiiiiied. 
 She had lost greatly in weight and strength since leaving the Johns Hopkins 
 II()S])ilnl. llei' face was much emaciated, the libs wei'e prominent, and the 
 abdomen was much distended with free fluid. Se^'eral irregular nodules were 
 felt in the abdomen. At this time some skin metastases were .seen in \\\v ab- 
 dominal wall. The patient was tappecl hiter, and a small amount of bloody 
 ascitic fluid withdrawn. She died on the following day. 
 
 Autopsy showed thai the kidneys were noi'niai. The alxloniinal timior was 
 apparently a sarcoma of the lixcr, two large nodules being found, one in the 
 right, the othei' in the left, lobe. There wci'e genei-;il niet.Mslnses ihi'oughout 
 the abdomen. 
 
 l^ath. No. S72.'). The specimen consists ol' the body of I he uterus, |);irl of the 
 right tul)e, and of large myomatous masses. The specimen is dJNided into two 
 masses, connectecl by a twisted pedicle. I cm. in diameter. The sniallei' mass 
 consists of the much distoi'ted bod\'of l he uteinis. w ith t hi-ee m\-omatous nodules.
 
 202 
 
 :\IY()MATA O?" THK UTERUS. 
 
 The Upper and lart^cr mass is composod of one large heart-shaped tumor that 
 measures 21 x 22 cm. The U))i)er mass is yellowish-white in color and has 
 
 Fig. 135. — Sarcoma D?;veloping in the Center of a Subperitoneal Myoma. (| nat. size.) 
 Gyn. No. 12155. Path. No. 8723. At the time of operation sarcoma was not suspected. This is a cross- 
 section of a flattened, subperitoneal myoma. The outer zone consists of typical myomatous tissue, but the central 
 portion has undergone degeneration. The line of demarcation is sharply defined, as seen at a. At b the tissue 
 is homogeneous and shows some disintegration. At this point there is also calcification. A cystic space is seen at 
 c, and in the area indicated by d the tissue has comjjletely lost its muscular striation and has been converted into 
 a characteristic homogeneous sarcomatous growth. As can be gathered from the history, the sarcoma was of 
 a most virulent type. 
 
 numerous bright-red injecled areas. Attached to the surface are omental ad- 
 hesions over an area 10 cm. across. The omentum is here densely adherent;
 
 MYOSARCOMA OF THE UTERUS. 203 
 
 it iy iiitimatclv hlciulcd with the tumor, and has ('vi(h'ntly furnished it a hberal 
 blood-sii])i)lv. The uterus is greatly distorted, and the normal tissue every- 
 where has been replaced by a myomatous growth. The anterior uterine wall 
 appears to be of normal thickness. The uterine cavity is enlarged and stretched. 
 It is 8 cm. in length and 4 cm. broad. From the upper inner and anterior wall 
 of the uterus projects a tumor showing polypoid masses that are smooth and 
 very soft. Projecting into the cavity from the fundus is a polyp 5 cm. in length, 
 3 cm. in breadth, and tapering dovm. to 1 cm. at the point. It resembles veiy 
 much a chicken's liver. It is long, narrow, and spongy, and apparently consists of 
 mucosa. On section, the large myoma shows in the center an oval area 9 cm. 
 in length and 7 cm. in breadth. It is sharply circumscribed, yellowish or whitish- 
 yellow, reddish, or brownish in color, and presents a very mottled appearance. 
 In many places it is homogeneous. In some places it looks friable (Fig. 135). 
 At numerous points the blood-vessels are injected and reach 1 mm. or more 
 in diameter. The picture macroscopically is most suggestive of sarcoma. It 
 was not until after the patient's death that this portion of the tumor was 
 examined, otherwise a definite clue to the subsequent clinical history would have 
 been obtainable. 
 
 On histologic examination the nuicosa shows considerable disintegration, 
 but, taken on the whole, apart from some dilatation of the glands, it is perfectly 
 normal. Sections from the uterine muscle show nuich hyaline degeneration. 
 Many sections were made from the suspicious looking areas in the myoma. . In 
 the outlying portions is typical, but somewhat dense, myomatous tissue. We then 
 come upon a zone where there is almost complete death or hyaline degeneration. 
 Then we encounter a growth not so rich in cells. In some places this growth is 
 somewhat homogeneous in character. In other ])laces it a})pears to bear a 
 definite relation to the blood-vessels. The luiclei of'the cells in many places are 
 of the natural size. At other points they are somewhat swollen and are vesicular. 
 Then we have large rounded or oval cells with masses of chromatin, irregular in 
 form, and showing that llir nuclear division has not been of the iioniial type. 
 At other points we ha\'e elongated cells with deeply staining luiclei. Then again 
 the cells contain two or three miclei. In .some jjlaces tlie bundles of nuiscle- 
 fibers are still preserved, but even here in the bundles are large and small nuclei. 
 At some points nuclear figures are to be made out. and their jticsence in the 
 specimen that has been hardened rather slowly certainly indicates that the growth 
 has been an active one. I'Acrywhere we have cells with small round nuclei. 
 These apjx'ar to be chiefly nmscle-fibers. They haxc been cut transversely, 
 and in any field it is easy to find several of the veiT large, irregular nuclei. Soin(> 
 portions of the growth show coagulation necrosis oxer large nicas. \\ lieic the 
 myoma has undergone almost coniplete li(|uefaction it is |»articulaily interesting. 
 as here the cells are se])arated from one another by (|uile an inter\al. At such 
 j)()ints large, irr(>gularly formed nuclei are clearly in exideiice. ()ther portions 
 of the growth show the typical appeai'ance of a s])indle-celle(l sarcoma. Some
 
 204 .MVOMATA OF THK ITIsltUS. 
 
 of the 1)1()(kI-V('ssc1s arc throiuboscd, others arc pcrt'cctly ])rcsci-vcd. In certain 
 
 sections wiicrc there is coagiihition necrosis wc have marked dihitation of the 
 
 l)lood-vessels and hemorrhage into the .surrounchng tissue. In such areas there 
 
 is some ])reservation of the cell elements around the blood-vessels, giving the 
 
 apjH'arance of an angiosarcoma. 
 
 \\'e have in this case a sarcoma developing in the interior of a very large 
 
 mvoma. which is undergoing hyaline transformation. The sarcoma is of the 
 
 spindle-celled variety, and must have originated from the muscle-fibers, as all 
 
 transition stages can be followed. From the histologic standpoint there is no 
 
 doubt as to the ])()sitive diagnosis of sarcoma with accompanying degeneration. 
 
 After making this diagnosis w(> learned that the ]iatient shortly after developed 
 
 metastases and died. 
 
 San. No. 1879. Path. No. 8458. 
 
 S a 1- c o m a t o u s t r a n s f o r m a t i o n in t h e interstitial 
 p o r t i n f a s u b m u c o u s m y o m a ( F i g . 1 3 6 ) . 
 
 F. D., white, aged forty-one, mai-ried. Admitted March 26; discharged 
 May 5, 1905. The patient has been married fifteen years and has had one child, 
 but no miscarriages. Her menses have been excessive and accom])anied by 
 some pain. At times there has been a ])i'ofuse vaginal discharge. Her family 
 and j)revious history are negative. She has lost no weight. For the last few 
 months she has suffered from an excessive flow, at times amounting almost to 
 Hooding. There has always been })ressure on the bladder and rectum, and a 
 bearing-down sensation in the lower abdomen. (\)ni])lete hysterectomy was 
 performed, and the ))atient made a satisfactory recovery. 
 
 Path. No. S4r>S. The s))ecimen consists of a uterus which has been com- 
 pletely removed. It is 12 cm. in length, 8 cm. in bn^adth, and 8 cm. in its antero- 
 posterior diameter. Attached to it are the tubes and ovaries. The uterus has 
 a smooth peritoneal covering. Projecting from the posterior surface are two 
 small myomatous nodules, the larger of which is 1 cm. in diameter. Where the 
 uterine cavity has been opened it is o cm. in length. The mucosa of the posterior 
 wall is 2 or 'A mm. in thickness. That of the anterior wall is exceedingly thin, 
 owhig to the presence of a growth which occupies the entire body and projects 
 into the uterine cavity. This growth, on section, is found to \m somewhat 
 irregular and reaches (> cm. in length. The lower portion, where it ])rojects into 
 the ca\'ity, consists of tyj)ical myomatous tissue, but in the upper portion this 
 gradually shades over into a growth that is smooth, whitish-yellow in a))])earance, 
 and homogeneous (Fig. 136). One is instantly i-eminded of .sarcoma. Further 
 sections of the tumor leave fit tie doubt that it is a malignant growth, and in 
 addition this nodule gradually slunles over into myomatous tissue. This can be 
 readily determined macroscopically. On retracing our ste))s to the myomatous 
 tissue we find that, in places, it has undergone a certain amount of ]i(iue- 
 faction, characteristic of that a.ssociated with hyaline transformation. The 
 tubes and ovaries on both sides appear to be normal.
 
 MYOSARCOMA OF THE UTERUS. 
 
 205 
 
 Histologic Examination. — Sections from tlic endometrium show that the 
 mucosa has an intact surface ei)itheHum. The glands look perfectly normal. 
 The mucosa in the wall over the submucous nodule is nnich atro])hied. The 
 surface epithelium is still intact, but the glands are to a great extent missing, 
 and we have spaces containing nothing but coagulated serum. They appear to 
 be dilated lymphatic channels. 
 
 The lower })art of the growth, which macroscopically resembled a myoma, 
 consists essentially of myomatous tissue which here and there has imdergone a 
 certain amount of liquefaction. As one passes into tlie depth the nuiscle- 
 fibers are more closely packed together. They vary considerably in shape and 
 
 size. A short distance farther 
 on we have a typical sarcomat- 
 ous growth. In this growth the 
 cells are very closely packed to- 
 gether. There are large areas of 
 
 Fig. 136. — Sarcoma Dkvki.opinc. in Part, at I.kast, irom a Submucous Myoma. (5 nat. size.) 
 San. No. 1879. Path. No. 8458. The section represents the anterior half of the uterus. The cervix is 
 normal. In one uterine wall are two small niyomata. Projecting into the uterine cavity is a submucous myoma. 
 In the lower i)art this presents the typical striated appearance, but in its upper portion it Rradually shades off 
 into a homogeneous growth — typical sarcomatous tissue. Macroscopically, the gradual merging of the myoma 
 into the sarcoma could be traced. The histologic cxainiiiation also ciemonstrate<l the transformation of muscle- 
 fibers into sarcoma cells. 
 
 cells, with here and there large oi- small blood-vessels. Here and ihei-e nurl(>ar 
 figures are demonstrable. The growth is a spiiKJIc-cclJcd sai'coiiia. The cells, 
 on the whole, ai'e very unifoi'm in size and do nol show any leiidcncx' lo form 
 large masses of chromatin. The transition from the myoma into the sai'coma 
 and the contour of the myoma and .sarcoma wouhl macro.scopically lea\-e little 
 doubt as to the origin of the sarcomatous gi-owth, e\('n though we had nol the 
 corroborative evidence as funiished by the microscope. 
 
 December 21, 190(): "Mrs. 1). has \\i-itten ivi»cal(Mily that she is in the best 
 of health" (H. A. Kelly).
 
 206 
 
 MYOMATA OF THE UTERUS. 
 
 This case had been overlooked in the routine histologic examination. The 
 uterus had been cut partially in two, and the section had gone through the 
 lower portion of the myoma, which presented the typical myomatous appearance. 
 It was only when we made a section entirely through the uterus that this growth, 
 which was clrarly sarcomatous, even macroscopically, was discovered. 
 
 H. A. K. San. No. 1857. Path. No. 8349. 
 
 C o m m e n c i n g s a r c o 111 a in an i n t r a 1 i g a 111 e n t a r y m y - 
 o m a (Fig. 137). 
 
 A. L., white, married, aged forty-six. Admitted March 8; discharged 
 April 16, 1905. The menstrual history has been normal, except for an offensive 
 
 Fig. 137. — .■^. Myom.\ Situated to tuk Right of the Cervix and Showing E.\rly SARcoMATors Changes. 
 
 (/j nat. size.) 
 Path. No. 8349. The section represents the posterior half of the uterus. Portions of the uterine cavity and 
 cervical canal are seen. The myoma to the right of the cervix macroscopically presents the usual appearance, 
 but on histologic examination sarcomatous transformation of muscle-fiber.s was ilemonstrable. 
 
 flow. Of late there has been a slight leukorrhea. The ])atient has a constant 
 feeling of pressure on the bladder and a continuous desire to urinate. There is 
 some bearing-doA\Ti pain in the rectum. She never has a natural movement. 
 
 Operation March 9, 1905. Hysteromyomectomy. The patient made a satis- 
 factory recovery, but was not very strong. Her highest jiostoperative tem])era- 
 ture was 101.2°. 
 
 Path. No. 8349. The s})ecimen consists of the uterus and of a growth spring- 
 ing from the right side of the cervix, and extending into the broad ligament. 
 The uterus itself, which has been amputated through the cervix, measures 11 x 
 9x8 cm. Posteriorly, it is covered with adhesions; anteriorly, it is smooth. 
 The uterine walls contain several myomata, chiefly interstitial. The largest of
 
 MYOSARCOMA OF THE UTERUS, 207 
 
 these is 2 cm. in diameter. Attached to the right side of the cervix is a myoma, 
 9x6x7 cm. This was evidently not covered with peritoneum, and extended 
 out into the right broad ligament. The right tube looks normal. The left tube 
 and ovary are normal. On section, the large nodule to the right of the cervix 
 resembles an ordinary myoma (Fig. 137), although at first sight its lobulated 
 appearance suggests a malignant growth. 
 
 Histologic Examination. — On examination of the large myomatous nodule 
 one instantly sees that something unusual exists. In the outlying portion 
 typical myomatous tissue is encountered. Then, with the low power, we see 
 that there is a decided picture of unrest. The nmscle nuclei become two or 
 three times the natural size. Some of them stain palely, others intensely. In 
 the individual muscle-bundles one sees an increase in the size of the nuclei. The 
 change is limited almost entirely to the muscle-fibers themselves. At other 
 points we have deeply staining masses of chromatin representing nuclei. At 
 still other places are irregular and deeply staining nuclei. The proliferation at 
 certain points is of such a character that it bears a slight resemblance to gland 
 formation, or might suggest that these large cells were in part due to proliferation 
 of the endothelium of the capillaries. In other places we find the protoi)lasm 
 of the muscle-fibers greatly increased in size, corresponding with the increase in 
 size of the nuclei. In some sections a very interesting picture is to be noted. 
 There is a good deal of edema and liquefaction of the myoma, and in such areas 
 we find the nuclei particularly prone to increase in size and to stain deeply. In 
 those areas we find the individual cells teased out from one another. There is a 
 marked tendency for the cells still remaining to swell up, and for the deeply 
 staining nuclei to nmltiply in number. 
 
 This specimen in particular leads one to think that the hj-aline degeneration 
 and the liquefaction of myomata are factors predisposing to the development of 
 sarcomatous growths. Several of our cases have emphasized this point, and it 
 is particularly well illustrated in Fig. 148 (p. 225). 
 
 In other places the cells are diminishing in nuinhci-. In the sections in 
 which they still persist they lie far apart. They have, therefore, an increased 
 stimulus to active division. Sections from other portions of the growth show 
 that, in certain areas, these large active cells are found in groups or colonies. 
 
 Although the myoma, as noted macr()S('()|)ically, is not very large, we haNc 
 undoubted evidence of commencing sarcomatous transformation. Inasmuch as 
 in none of the sections do \vi\ find these cells I'ight out at the margin, the prog- 
 nosis Tnight not be uiifa\'oi"able. Thei'e is little doubt, howevei", that had this 
 process gone nmch farther, metastases would ha\-e taken place. Sections I'loiii 
 the cervix show perfectly a normal cervical mucosa. The endomc^trium in the 
 depth has been poorly ])reserved, but looks noi-mal. 
 
 In a letter dated .lamiaiy 2*.), 1!)()7, Dr. Doiiehoo reports that the patient is 
 in excellent health.
 
 208 MVoMATA OF THK UTPmUS. 
 
 Gyn. No. 7474. Path. No. 3729. 
 
 S a r c o 111 a d c v c 1 o j) i 11 ^ in t h e cent c r o f a la r g u t e r - 
 i n V 111 y 111 a ( Figs. 1 3 S a 11 d 189). 
 
 T. B., white, aged fifty-two. married. Admitted January 1 : died February 5, 
 1000. ("(iiiiplaint. abdominal lunioi-. The patient has been married thirty-hve 
 years and has had .seven ehildreii, but no miscarriages. The eldest child is 
 thirty-five year.s of age. Her j)eriods commenced at fourteen, were regular, 
 lasting from six to seven days, and not \'erv jirofuse. About five years ago the 
 periods became less freciuent, and last year they cea.sed entirely. The tumor 
 was first noticed about twelve years ago. The abdomen is now filled with a 
 tumor which extends down into the pelvis. It reaches 14 cm. to the right of 
 the median line, and fills the entire left .side of the alxlomen. Hounded masses 
 as large as tenni.s-balls can be felt connected with the main tumor. These are 
 softer, especially at the costal margin on the left side. 
 
 On vaginal examinatic^n the outlet is considerably relaxed. There is a 
 slight bulging of both anterior and posterior walls. There is also a slight bluish 
 discoloration of the mucosa. The cervix is pushed up behind the symphysis, but 
 is of normal size and consistence. The external os admits the tip of the index- 
 finger. 
 
 Operation, January 8, 1900, supravaginal hysteromyomectomy. On section of 
 the abdomen a large white n(>crotic patch, fully 15 cm. in diameter, was found 
 on the front of the tumor. Coursing over the sides of the tumor were large 
 congeries of blood-vessels. The uterine arteries were fully as large as normal 
 femoral arteries, and pursued a tortuous course over the surface of the tumor. 
 On account of the difficulty in getting at the vessels the uterus was bisected. 
 The tumor was shelled out. after which the collapsed organ was easily removed. 
 
 January 27th : The malignant character of the growth having been established, 
 it was decided to excise the cervical stump. The cervix was grasped with 
 tenaculum forceps and drawn forcibly downward. There was considerable 
 oozing, which was checked by the fi'ee use of catgut .sutures. The removal of 
 the cervix was fraught with considerable difficulty. Th(> anterior and posterior 
 vaginal walls were a])pr()xiinate(l in the median line with two .sutures, and a 
 gauze drain was inti'odueed to the right and left side. 
 
 Feljruary 5th: The patient gradually developed signs of intestinal adhesions, 
 requiring an exploratory operation. A median incision was made. Loops of 
 small intestine were found adherent along the line of incision. These wen; 
 freed, but with some difficulty. The omentum was adhei'ent to the .scar, and 
 also to the intestines. It was ligated and cut awa3\ The small intestines were 
 quite distended, and in the pelvis the intestinal coils were flaccid. There did not 
 appear to be any peritonitis, and no fibrin was seen on the loops of gut. The 
 intestinal loops were adherent to one another, to the bladder, the broad ligament, 
 and the site of the drain in the pelvic floor. These adhesions were separated, at 
 times with the finger, but in some places were so den.se that scissors and knife
 
 MYOSARCOMA OF THE ITKHUS. 
 
 209 
 
 Fk;. 138. — Sarcoma Dkvki.opixc in tiik Ckntkii of a Fauck Intkustitiai, Ui-i;ki\i; Myoma. (| nat. size.) 
 
 Path. No. 3729. The picture represents the cut surface of a longitudinal section throuKh a greatly enlarKetl 
 uterus, a is the posterior uterine wall, which, consideriiiK the stretching of the walls, is of the usual thickne.ss. 
 b is the uterine cavity which has been greatly lengthened out. Had a uterinesouiid been pa,ssed, it would scarcely 
 have reached the top of the cavity. The uterine mucosa is scarcely 1 mm. in thickne.ss. Occupying the anterior 
 wall is a large interstitial myoma, very sharply ddiiicd fnun the muscle. .\t several points, especially at c and 
 d, are very dense myomatous foci, easily recognizeil liy their lighter hue. ."scattered througlmut tlie large myoma 
 are large and small sarcomatous masses. The sarcomatous growth le) is one of .several small ones. .Ml are homo- 
 geneous in structure and sharply outlined from the mu.scular growth. In the sarcomatous noilule cfHs an irregular 
 cystic cavity. The nodule (g) shows areas varying in color and consistence. This is due to a breaking-ilown of the 
 malignant growth. The largest sarcomatous; focus (h) has undergone almost complete necrosis, a.s is indicated by 
 the lighter central portion, only a small outer rim of solid tissue remaining. The variovis clefts in the center of this 
 nodule are due to the degenerative process, i indicates a sarcomatous nodule situated in the cervix near the 
 internal os. In this ca.se the growth was iirimary in the myoma, showing conclusively that it developed from the 
 myomatous tissue. Sarcoma was not suspecte<i until the specimen reached the laboratory. This case indicates 
 clearly the advisability of opening the uterus at once after removal. If the malignant jirocess be present, the 
 cervix can then be removed before the abdomen is closed, thus saving the patient a secoml oi)eration, an<l 
 
 avoiding the danger of leaving a possible sarcomatous cervix for a pciidd nf t\v • three weeks hmger. The large 
 
 myoma was shelled out of the uterus with ease. 
 14
 
 210 MVo.MATA OK THK ITKRl'S. 
 
 were RHiuired. At the \nnut at which constriction had taken ])lacc the adhesions 
 were extremely dense, and over an area two inches in leno;th, and ahnost sni- 
 rounding the circumference of the intestine, the peritoneum had been denuded 
 and some of the muscle-fibers were wanting.* A small rent, 1.5 cm. long, was 
 made in the lumen of the gut. This was brought out at the side, most of the 
 fecal matter and gas above was forced out, and the tear in the collapsed in- 
 testine was then closed with three mattress silk suturesand an additional layer of 
 Lembert sutures. All adhesions were separated except over a small area of the 
 sigmoid. The sutures and denuded areas were placed low down in the abdo- 
 men, next to the gauze drain, which was packed in the pelvis. This loop at the 
 point of stricture was straightened out so as to prevent reformation of the stric- 
 ture. The pulse was weak, and respiration rapid. The patient failed to react 
 to stimulation, and died on the following day. 
 
 I'ath. Xo. 3729. The specinu^n consists of a large myoma which has been 
 shelled out. and also of the uterus with the attached tubes and ovaries. The 
 tumor is ai)proxiiiiately gIol)ular, b(>ing 20 x 20 x IS cm. in its various diameters. 
 In part it is smooth and glistening and covered with peritoneum. At least 
 three-quarters of it, however, has a ragged appearance, owing to the presence of a 
 large myoma, Avhich has at least two lobulations due to clefts extending from 3 
 to ") em. into tlie de])th. These lobulations are further sul)(li\-ided l)y minor 
 clefts. The tumor, as a whole, is firm, Init one of the lobulated areas is rather 
 soft. On section, the tumor is found to consist of two distinct elements, the 
 outer enveloping portion made up of muscle and a central i)ortion consisting of 
 a soft growth (Fig. 138). This is yellow in color, does not show the striation 
 of muscle, but presents a porous appearance and, in fact, might be likened to 
 a very fine sponge. The central portion of this growth is slightly friable, and here 
 the ])orous a])pearance is more pronounced. It also shows numerous clefts. This 
 large new-growth makes up fully one-half of the myoma, and other similar but 
 smaller nodules, varying from 1 to 7 cm. in diameter, stud the outlying portion. 
 One of the largest lobulations noted on the outer surface consists essentially of this 
 peculiar new-growth, and here marked softening has taken place. In the cervix is 
 a nodule, 4 cm. in length, 3.5 cm. in breadth, and 1 cm. in thickness. It is at- 
 tached by a pedicle 2 cm. broad. The nodule is ))(M-fectly smooth and has an 
 intact surface. The uterine cavity is 13.5 cm. long and 11 em. broad at the 
 fundus. The surface of the mucosa has a pinkish-yellow color and is somewhat 
 wrinkled in appearance. Al)out the middle of the right lateral wall is a disc- 
 like projection, raised 1.5 mm. above the mucosa. Its margins are sharply 
 defined. At the fundus is a soft ])olyp, 2 cm. in diameter. 
 
 The right tube is 15 cm. long and fi'ee fi-oiii adhesions. The ovary is greatly 
 flattened and measures 6 x 2 x 0.5 cm. 
 
 The left tube is 11 cm. long. The ovary has the .same dimensions as that of 
 the opposite side, and is free from adhesions. 
 
 *\Vith our present knowledge we would, of course, merely do an enterostomy.
 
 MYOSARCOMA OF THE ITKRUS. 
 
 211 
 
 
 9 
 
 * ^d 
 
 '«, 
 
 « 
 
 1$ • 
 
 Histologic Exaiiiinatioii. — The large tumor that was shelled out from the 
 uterus consists of non-striped muscle-fibers cut in various directions, and pre- 
 senting the usual appearance of myoma. Here and there is much hyaline de- 
 generation, principally diffuse in character. The large porous tumor, occupymg 
 the center of the myoma, and diff'ering from it so widely macroscopically, shows 
 a still greater contrast on histologic examination. It consists of a sea of cells 
 all having the same genei-al 
 characteristics. Its tissue is 
 traversed in all directions by 
 the most delicate capillaries, 
 consisting merely of an endo- 
 thelial lining. The cells of 
 the growth are round and 
 have round, uniformly deeply 
 staining nuclei (Fig. 139). 
 They vary greatly in size, and 
 all gradations from minute 
 spheric nuclei to those ten or 
 twelve times larger are clearly 
 demonstrable. It looks very 
 nuich as if the small cells 
 were gradually developing 
 into the larger ones. Some of 
 the large nuclei are irregular 
 in outline and contain pale- 
 staining spheric dropk^ts. 
 Between the cells w(» occa- 
 
 
 \^ 
 
 ^^^J^g.% 
 
 «P 
 
 © © o * ^ 
 
 < 
 
 
 9 4 
 
 
 
 
 
 
 Fig. 139. — Sarcoma Developing in the Interior of a Myoma. 
 (X 360 diam.) 
 Path. No. 3729. The section is taken from the sarcoma seen 
 in Fig. 138. The deUcate-walled blood capiUary (a) divides the fiehi 
 into an upper half, composed of large cells, and a lower, of much 
 smaller cells. The cells are loosely arranged. In most places it is 
 Sionally see large blood- jmssible to clearly outline not only the nucleus, but its protoplasm. 
 
 In the upper half of the field, b may be taken to represent the aver- 
 age size of the cell. These nuclei and those indicateil by c are mod- 
 erately enlarged and irregular and stain more deeply. At d we have 
 a relatively much larger cell, and at e the nucleus of a cell is divided 
 into two, while a.s yet no cleavage has occurred in the protoplasm. 
 In the lower half of the field the cells iire fairly uniform. At f 
 a small cell contains two nuclei, anil at g is a l)udding nucleus. Froni 
 a careful study of many sections we gather the impression that the 
 cells were at first very small, ami that they have gradually devel- 
 oped into the large ones, 'riiis would account for the crops of small 
 and large cells foutid side by side and yet sharply defiiieil from one 
 another. 
 
 numerous points tiiere has 
 
 evidently been an old hemorrhage, as the tissue is studded with l»ro\\n pigment- 
 granules. The growth is a round-celled sarcoma. The other porous nodules 
 scattered throughout the myoma are also sai'comatous in origin. Scattered 
 throughout various |)ortioiis of the mycuiia .■we microsco])ic loci of sarcomatous 
 tissue. 
 
 The uterine mucosa is much atrophie(l, bui its sui'face e|)ithelium is intact. 
 The glands ai'e ati"o])hic, and in a Few places ai)iiarently dilated. The stroma 
 
 vessels, with practically no 
 connective-tissue framewoi'k. 
 Many areas show hemorrhage, 
 and at certain points there 
 is complete coagulation nec- 
 rosis, often accom])anied by 
 fragmentation of nuclei. .\t
 
 212 MVOMATA OF THK UTERUS. 
 
 of the iiuicosa consists of spiiullc-shujx'd cells, and hciv and there shows some 
 sinall-round-celled infiltration. The large nodule in the cervical canal is .sar- 
 comatous, as are also the polyj)i in the body. The smaller polyp in the body has 
 pushed the surface epithelium in front of it. This is well ]-ecoo;nized as a single 
 row of cul)oid cells lying directly on the .-sarcomatous tissue. The di.sc-like 
 nodule described in the cavity is a .small submucous myoma. 
 
 In this most instructive ca.se we have a large myoma, partially subperitoneal, 
 but to a great extent interstitial. In the center of this a sarcoma has develoixnl, 
 and has gradually gi\'en rise to secondary foci in the niNoma, and also to deposits 
 in the uterine wall and in the cavity of the uterus. That the growth is primarily 
 of myomatous origin we are practically .sure. In no other ]iart of the body was 
 there a primary malignant focus, and it is most exceptional to find a metastasis 
 in a m\'oma. The appendages are normal. 
 
 This case demonstrates very clearly the advisability of avoiding bisection of 
 the uterus whenever sarcoma is suspected. 
 
 Gyn, Nos. 7040 and 7212. Path. Nos. 3312 and 3472. 
 
 Subperitoneal, interstitial, a n d s u b m u c o u s u t e r - 
 i n e m y o m a t a ; large c i r c u m s c r i 1 ) e d s a r c o m a tons nod- 
 ule in the u t e r u s , a p p a r e n t 1 y originating in a 
 myoma (Figs. 140, 141); atrophy of t h e u t e r i n e m u - 
 c o s a : nor m a 1 a }> \) e n d a g e s . S u p r a v a g i n a 1 h y s t e r e c - 
 t o m y w i t h ret u r n o f t h e growth in t h e c e r v i x . 
 
 E. C. H., white, married, aged fifty. Admitted July 2; discharged July 
 28, 1899. Complaint, abdominal tumor. The patient has had two children 
 and one miscarriage. The first lal)or was normal; the .second was attended 
 with a great deal of Hooding. Her menses commenced at fourteen and were 
 regular until two years ago, lasting from five to six days. During the past two 
 years the flow has increased in amount, has been dark and clotted, and has 
 lasted from one to three Aveeks. 
 
 The presence of a tumor was first susp(>cted four years ago. It was .slow in 
 growth until six months ago. Since that time it has increased rajndly in size. 
 The bowels have l)een regular, and there has l)een a fre([uent desire to micturate. 
 On examination the outlet is found to be markedly relaxed. The cervix is low 
 down. Anteriorly, the entire vaginal vault is bulged out by a rounded, .smooth, 
 .somewhat soft, non-sensitive mass. This is wedged down in the jx'lvis, is im- 
 mol)ile. and is in direct connection with the abdominal nuiss, which extends up- 
 ward to the umbilicus. The right fornix is clear, exce))t at the ajX'X. where the 
 lateral structures are palpable. The left fornix is coni])letely obliterated. 
 
 Operation, July o. IS'.M). Hysteromyomectomy, the ut(>rus being aminitated 
 through the cervix. The maximum i)osto])erative tem])eratvn-e was 101.4° F. 
 The patient was discharged on July 2Sth. but there was a movable mass the size 
 of a walnut on the right side. She was readmitted to the hospital .shortly after- 
 ward, and died September 25, 1899.
 
 MYOSARCO.MA OF THE UTERUS. 
 
 213 
 
 Path. No. 3312. The specimen consists of an enlar<2;ed uterus, tunimtated 
 through the cervix, and of the ajipcndagcs. The uterus presents a somewhat 
 h)l)uhited aj)peai'ance, and measures 15 x 13 x 11 cm. At a few points there are 
 small sul)peritoneal nodules. The anterior uterine wall is fully 8 cm. in thick- 
 nt^ss, owing to its invasion by a new-growth. Near the cervix is a nodule 6 cm. 
 
 Fig. 140. — Phohahi.i-; Sarcomatous Traxskohmatiox of a Mvoma; also Discrkti: Myom^tol's and Sarco- 
 matous NoDui.ES IN THK SAME Uterus. (i nat. size.) 
 
 Path. No. .3312. The uterus, which is much enlarged, has been opened anteriorly. Tlie uterine nuiscle, aa 
 ndicated by a, is much thickened, owing to a general hypertrophy. At b is a small myoma which hius been cut in 
 two. c is one of many large and small areas of hDinogeneous tissue scattere<l throughout tlie uterine walls. It Is 
 lighter in color than the muscle, and is shari)ly imthned. It is sarcomatous tissue, d is also a sarconuitous nodule. 
 It contains several smooth cystic spaces, a.s indicated l)y e. This nodule at several points lacks the homogeneous 
 appearance, the tissue being fibrillary and resembling myoma. This is ijarticularly well seen at f. Here we have 
 the remnants of a myoma entirely surrounded by sarcomatous tissue. Situateti near the cervical canal is a small 
 sarcomatous nodule. The uterine cavity is mvich lengthetied. Its mucosa is atrophic, and situated i\ear the 
 fundus is a large, slightly lobulated submucous niyoma (g). Its texture is readily recognize*! from the cut surface. 
 
 The appearance noted in the nodule d suggests that in this particular nodule the sarcoma originate*.! from 
 the my(jma. 
 
 in diameter, irregular in contour, and consisting in part of myomatous tissue. 
 A portion of it, however, has lost its lihrillation ; it has hccomi' homogeneous and 
 is yellowish in color. This area is very suggestive of sarcoma, and on section is 
 found to contain irregulai', cyst-like spaces, some I'eaeliing '2 em. in diameter 
 (Figs. 140. 141). The t hiekeiiing in the anterior wall is due to the jiresenee of a
 
 214 
 
 MVOMATA OF THH ITKRUS. 
 
 similar ikkIuU-, 1) x () cm. This in a tVw places presents a myomatous ])icture, 
 hut at most points is light in color, homogeneous in consistence, and entirely 
 devoid of fibrous arrangement. The uterine nmscle shows isolated foci of this 
 soft growth. On section of the large nodule, a typical myoma, 3 cm. in diameter, 
 is found situated in the center of this peculiar and homogeneous mass. The 
 l)osterior uterine wall varies from o to T") cm. in thickness, the increase being 
 due to the ])resence in its walls of a sul)])eritoneal and partially interstitial 
 mvoma. It also contains a few small foci of the yellow and homogeneous 
 
 I'k;. 141. — .\ssoci.'VTiON of Myoma and Saucoma in thi-: hame Uterus. (,'1, nat. size.) 
 Path. No. 3312. This is a section through the tliickened uterine wall in Fig. 140. a represents the coarse 
 uterine mii.scle, which forms the general framework. .\t b is a group of five thin-walled cysts. At c and c are 
 sections of two myomata, easily recognized by their striation. At d is one of the many smooth, homogeneous, 
 sarcomatous nodules scattered throughout the uterine wall. 
 
 growth. Situated in the fundus ai'e several of these small growths; projecting 
 into the uterine cavity from the fundus is a submucous myoma, 7x4 cm. 
 
 The uterine cavity is \'S cm. in length. Its muco.sa is apparently unaltered, 
 and has nowhere been invaded by the soft and homogeneous growth. ()v(>r the 
 submucous myoma the mucosa is still intact, but quite atro])hic. The tubes 
 and ovaries are aj^parently normal. 
 
 Histologic I'^xamination. — The uterine mucosa is considerably atrophied. 
 The surface epithelium is intact, and the glands present the normal appearance.
 
 MYOSARCOMA OF THK UTERUS. 215 
 
 Over the subinucous niyonia it is possible to trace the surface epithelium, and 
 here and there a group of glands is still visible. The subnuicous myoma presents 
 the usual appearance and shows considerable diffuse hyaline degeneration. The 
 soft nodules scattered throughout the uterine wall consist of a homogeneous 
 tissue, made up of great (juantities of cells, in most places showing no definite 
 arrangement. This tissue is traversed in all directions by delicate blood capil- 
 laries. The individual cells have oval or round, deeply staining nuclei, and here 
 and there is a nucleus five or six times the size of its neighbor, and staining in- 
 tensely with hematoxylin. These cells are actively growing. Nuclear figures 
 are abundant, and all stages of karyokinesis are visible. We often find the 
 chromatin filaments delaying at the poles instead of passing along the achromatic 
 threads to the center. Here and there is a large mass of protoplasm, staining 
 deeply with eosin, antl containing several deeply staining nuclei, so arranged as to 
 form a mulberry-shaped mass. Large portions of this growth have undergone 
 complete coagulation necrosis, without any subsequent polymorphonuclear 
 infiltration. In some places, although coagulation necrosis has occurred, the 
 large blood-vessels in such areas are still surrounded by a zone of well-preserved 
 sarcoma-cells. The line of demarcation between the uterine muscle and the 
 new growth is sharply defined, and it is a common thing to see the sarcomatous 
 cells wandering in and separating the muscle-fibers from one another. The 
 growth is a spindle-celled sarcoma. 
 
 In this case we have an enlarged uterus implicated by a myomatous and at 
 the same time by a sarcomatous process. Macroscopically, one can see the 
 gradual merging of a myoma into a sarcoma, and in a large nodule a typical 
 myoma is surrounded by sarcomatous tissue. But histologically we are unable 
 to trace the transformation of myomatous tissue into sarcomatous tissue. From 
 the general arrangement, however, we believe that the sarcoma developed in the 
 myoma. 
 
 The Fallopian tubes are normal. The right ovary contains a few gland-like 
 spaces lined with cyliiKlric cj)!! helium. Both ovaries are, however, practically 
 normal. 
 
 Gyn. No. 8732. Path. No. 4931. 
 
 S u b p e r i t o n e a 1 and i n t e i- s t i t i a 1 u t e r i n c m y o ni a t a , 
 m i X e d - c e 1 1 e d s a r c o m a o f t h e a n t e r i o r u t c r i n c w all: 
 w i t h r e m n a n t s of the in y o in a in its i n t c r i o r ( !■' i g s . 
 14 2, 143, 144). Normal cervical in u c o s a : at r o p h y 
 of t h e u t e r i n e m u c o s a ; n o r in a 1 a p p e n d a g e s . 
 
 M. J. L., black, married, aged forty-six. Admitted .Ma\- •.): died May 1(), 
 1901. The patient had one miscarriage two years ago. Her menses began at 
 fifteen, were always regular, but profuse, and lasted from tour to six days. The 
 last ])eriod occurred four weeks ago. The |)ntient"s mind is not ^■erv clear, and 
 conse(iuently a coinj)lete history caimot be obtained. The cervix is in the 
 normal position, firmly fixed. Behind it is a large hard mass. Situated in the
 
 2I(i 
 
 MNd.MATA (»l" 
 
 ITKIUS. 
 
 suix'rior strait, and cxtciKliiiii' up into the alxldiiicii, is a large soft mass, the size 
 of an adult's head. 
 
 OjX'ration, May 9th. Panhysicrcctoiny. The largo ma.ss was vory soft and 
 Huc'tuating. and covered with vessels ruiuiing in all directions beneath the peri- 
 toneal surface. Tile tumor in the hollow of the sacrum is \-ei'v hard. As the 
 entile growth was thought to he myomatous, enucleation was begun with the 
 idea of cutting across the cer\ix and then t\"ing the left ox^arian vessels and 
 round ligament, and hegiiminu' t<> work down to the left uterine \"essels. A slight 
 
 Fio. 142. — -A Sarcomatous Uterus Conformixg in CoxTorn to a Globular Myomatous Uterus. (,5 nat. size.) 
 Path. No. 49.31. The uterus is much enlarged, globular in f<.im. and .«trongly suggests a myomatou.s con- 
 dition, especially a.s the majority of the nodules .seen springing from the posterior surface are myomata. The 
 ikmIuIc near the cervix is .seen on section to be a myoma, and the dark patches scattered throughout it are areas 
 of calcification. A glance at Fig. 143 shows that the greater part of the uterine enlargement is due to the presence 
 of a .sarcoma occu|)ying the anterior wall. 
 
 On bimanual examination the diagnosis of a myomatous uterus would naturally be the most rational one, 
 and even after the abdomen was f>pened, there would be little to suggest sarcoma except the rather flabby contour 
 of the organ. The left tube and both ovaries appear to be normal. The right tube is longer than usual. .Situatetl 
 between the left tube and ovary is a small parovarian cyst (a). 
 
 tear in the lai'ge t uiiioi- allowed a hi'ain-like substance to ooze out o\'er the uterine 
 vessels, showing almost conclusi\-ely that the large growth was sarcomatous. 
 Panhysterectomy was immediately decided upon. The large vessels were tied 
 ofT, the i)ladder was j)ushed down, and the vagina incised in front of the cervix, 
 w hich was <|uickly cut all around. The entire growth and the pelvic organs were 
 removed. A gauze drain was placed in the vagina. After operation the pulse 
 gradually became rapid and the patient died on .May Kith. 
 
 Path. No. 49.'U. The specimen consists of an enlarged uterus with its appen-
 
 .MVOSAHCD.MA OF THK I'TKIU'S. 
 
 217 
 
 dages intact. The uterus (Fig. 142) with its intact cervix is a))|)n^xiniately IS 
 cm. in length, lo cm. in l)rea(hh, and 15 cm. in its anter()j)Osterior diameter. It 
 
 Fu;. 14.3. — Sahcoma and Myo.ma i.v the Samk Uterus. (« iiat. size.) 
 Path. No. 4931. This is an anteroposterior section through tlie uterus seen in F\k. 142. a is the upper part 
 of the uterine cavity; a' is that of the cervical portion. The walls of the cervix are of the normal thickness, as 
 seen at b. The uterine mucosa is rather atrojihic, but at c two of the glands show cystic dilatation. Situateti in 
 the posterior wall are several small, ill-defined myomata, and the circuinscribe<l nodule, d. The dark |)atche9 in 
 the myoma, e, are areas of calcification. This is the myoma seen in F'ig. 142. Occupying the anterior wall of the 
 uterus is the large growth f. This is homogeneous in appearance and sharply outline<l from the uterine muscle. 
 It is partially subdivided into smaller ma,sses by septa of muscle. At g are the remains of a myoma easily recog- 
 nized by the arrangement of the muscle-bundles. At h this myoma gradually .shade.s off into sarcomatous tissue. 
 Scattered throughout the uterine muscle are numerous isolated sarcomatous foci, as seen at i. It looks very much 
 as if the myoma (g) had undergone sarcomatous transformation. If the sarcoma ha<l occurred independently, we 
 would expect to find the myoma either pushed to one side or surrounded by sarcoma, instead of merging im- 
 perceptibly into it. 
 
 is irregular and nodular, and project ing from its surface are se\-eral peilunculaletl 
 myomata, the largest of which is ."> cm. in diameter. Situated in the j)osteri()r
 
 218 
 
 MYO.MATA OF THE UTERUS. 
 
 
 
 U . Becker w, 
 
 e " d k c 
 
 Fig. 144. — Mixed-cei.i.?:!) Sahcoma ok tkk Utkhus .\ssoci.\tki) with Myomata ov the Uterus. (X 350 diam.) 
 Path. No. 4931. The .>iectii)ii is from the .sarcoma in Fig. 143. At first glance it bears some resemblance to 
 chorio-epithelioina. a i.s a large vein; b represents the average size of the nuclei. At numerous points indicated 
 by c the cells are greatly enlarged; they stain deeply, and their chromatin is gathered up into coarse granules. At 
 .several i)oitits, d. d, the large nuclei are somewhat constricted, showing a tendency toward cleavage. At e six 
 nuclei of variable size are contained in one ma.ss of protojjlasm, forming a giant-cell. A large and irregular mass 
 of chromatin with several projections is seen at f, and at g we have three large irregular and ragged masses of 
 chromatin contained in one ma.ss of protoplasm. Nearly filling the large vein a is a huge plaque of protoplasm (h) 
 containing many large and small irregular masses of chromatin, roughly resembling small lumps of coal. Scattered 
 throughout this protopla.sm are many small round cells and i>olymorphonuclear leukocytes. A similar mass of 
 protoplasm (i) fills the ui)per jiart of the vein. 1 represents one of the many vacuoles scattered throughout the 
 field, m is a zone of stroma which forms only a very small part of the tumor. It is impossible to determine with 
 certainty whether this stroma represents connective tissue or remnants of muscular tissue.
 
 MYOSARCOMA OF THE UTERUS. 219 
 
 wall is an interstitial myoma, fully G cm. in (liainctcr, and just beneath the 
 peritoneum of the anterior wall are several small, soft, and slightly raised growths. 
 These, however, are in no way suggestive of myomata. The chief increase in size 
 of the uterus is due to a growth fully 12 cm. in diameter, occupying the anterior 
 wall (Fig. 143). This is sharply circvmiscribed, yellowish-white, translucent, soft, 
 edematous, and bears a striking resemblance to the gray matter of the brain. 
 Scattered throughout it are bright yellow patches and others of a greenish hue. 
 At several points over the center of the tumor are areas slightly suggestive of 
 myomatous tissue. The large tumor has an outer covei-ing of muscle averaging 
 2 mm. in thickness. Its inner portion extends to the mucosa. The cervix yw- 
 sents the usual appearance. 
 
 The uterine cavity is 7 cm. in length, and at the fundus 7 cm. in breadth. 
 Its mucosa is not over 1 nun. in thickness. It is smooth and glistening. The 
 appendages are apparently normal. 
 
 Histologic Examination. — The cervical glands in places reach 3 to 4 nun. 
 in diameter; otherwise the mucosa in this portion is unaltered. The cells of 
 the new-growth are clinging to the surface. This appearance is certainly due to 
 the fact that the juice of the tumor has oozed out when pieces Avere being excised 
 for examination. Sections from the body of the uterus show marked atrophy 
 of the mucosa. The surface epithelium is intact, but consists of low cuboid or 
 almost flat cells. The glands are very small, but are normal except for occasional 
 dilatation. The stroma of the mucosa is very dense, and in places it is impossible 
 to differentiate between nmscle-bundles and altered stroma. 
 
 Situated in the uterine muscle are small typical myomata. The larger 
 nodule, occupying the anterior wall and consisting of soft tissue, is made up of a 
 framework of spindle-shaped connective-tissue cells and apparently of non- 
 striped muscle-fibers. Its stroma contains many large blood-vessels and, 
 roughly speaking, it would have made up one-cjuarter of the tissue. The major 
 portion of the tumor consists of solid masses of cells which vary greatly in size. 
 Some are rounded or polygonal in shape, have vesicular nuclei, and bear some 
 resemblance to decidual cells (Fig. 144). Others contain lai-ge vesicular nuclei, 
 ten or twenty times the size of those in the near vicinity. Scattered abundantly 
 throughout the section are large, deeply staining nuclei, and great irregular 
 masses of chromatin. Everywhere small round cells are to be .seen, and fre- 
 quently polymor{)honuclear leukocytes. Scattered throughout many portions 
 of the tumor are large and small vacuoles, lying between cells or in the cell- 
 protoplasm. Frequently masses of tumor-cells are found ])rojccting into oi- 
 lying free in veins or aiicrics. .Many pails of the tunioi' ha\f undci'gonc com- 
 plete necrosis or show marked fragmentation of uucKm. 
 
 As seen from the description, this large tumor is a sarcoma of the mixed-celled 
 variety. Whether or not it has originated from the myoma it is impossible to 
 say with absolute certainty. The appeai'ance of the gross specimen, howe\-er, 
 strongly suggests such an origin.
 
 220 
 
 MVOMATA OF THK UTKKrS. 
 
 Gyn. No. 7604. Path. No. 3865. 
 
 S a r {• 111 a o t' the j) o s t c r i o r wall of t h v u t c v us, o r i g - 
 i n a t i n ii i n a 111 y o 111 a ( F i ^i . 1 1 "> ) : metastases in t li c 1 u 11 i^s 
 and (' n (1 {' a r (I i u ni . 
 
 K. \l.. white, aficd fort y-t our. niarricd. Adinittcd Fchruaiy 27. liHK). She 
 has l)een married nineteen years, hut has had no children and no miscarriages. 
 The menses have usually been regular, of five days' duration, and accompanied 
 by con.siderable pain before the flow commenced. For the past five or six 
 months there has been a slight l)lood-stained, watery discharge. The bowels 
 have i)een consti|)ate(l. and there has been some bui'iiing and increased freciuencv 
 
 BUdier 
 
 Fk;. 145. — Sarcoma of thk Postkhior I'tkrink Wall, Oricinatixg in a Mvo.ma. 
 Path. No. :j86o. The uterus i.s much enlargeil. mainly from the presence of a growth in its posterior wall. 
 Histologic examination shows this to be a sarcoma <ieveloping in a myoma. It is firmly fixed in the pelvis, being 
 intimately blen(le<l with the rectum. The bladder is drawn high into the abdomen. 
 
 of micturition. At one time the ])atient had the cervix dilated for dysmenon-hea, 
 and a polyj) was removed from the uterus. She had definite signs of stone in the 
 left kidney, and thinks .she pa.^.^ed a stone into the bladder, after which the renal 
 svniiptoms di.sai)peared. For the past three or four months there has been pain 
 in the j)eK-ic region. I'adiating down the legs, and the patient has noticed the 
 abdomen increasing in size for two months. For the last three months there has 
 been considerable difficulty in voiding, and at times the flow of urine would 
 suddenly stop. There has always been great straining and (jl)stinate constipation. 
 She has been in bed for eight weeks, and has been taking large quantities of 
 morphin. For the ])ast w(>ek .she has b(>en unable to void at all, catheterization 
 being necessary.
 
 MYOSARCOMA OF thp: uti-:rus. 221 
 
 Operation, March 3, 1900. The vagina was encroached upon post(U-iorly b}^ a 
 cystic tumor filHng the cul-de-sac. The cervix was small and soft, and pushed 
 above the symphysis. The urethra was jammed against the symphysis, and the 
 bladder reached to the uml)ilicus. As a great deal of difficulty was experienced on 
 account of the dense adhesions (Fig. 145), the uterus was bisected. As soon as the 
 uterus was split there was a gush of blood-stained serous fluid from the cavity. 
 The lower portion of the uterus was occupied by a soft, stringy substance, re- 
 sembling striated muscle, much softer and darker in color than usual, and very 
 vascular. There was alarming hemorrhage wherever it was cut. An opening 
 was made into the l)ladder, and urine escaped into the peritoneal cavity. The 
 patient at the time of operation was exceedingly weak, and there was a good deal 
 of shock. She grew weaker, had much abdominal pain and nausea, and died 
 on March 14th, eleven days after the operation. 
 
 Path. No. 3865. The specimen consists of the uterus, together with both 
 tubes and ovaries. The uterus has been divided into two portions and is con- 
 siderably enlarged, being twice the size of a man's fist. Accurate measurements 
 cannot be given on account of the mutilation of the specimcni. The tubes and 
 ovaries are bound together by dense adhesions, and so greatly distorted as to be 
 scarcely recognized. Both ovaries have been converted into cysts, and are 
 almost completely embedded in adhesions. One is approximately the size of a 
 small orange. The cyst on the left is apparently the size of a hen's egg: it 
 presents numerous partitions and trabecukr, which show that it was multilocular. 
 The posterior portion of the ovary is occupied by a mass of tissue com])osed of 
 stroma, in which are masses of tissue irregular in shape. The posterior wall of 
 the uterus and the anterior half of the uterus present numerous dense adhesions. 
 
 Histologic Examination. — The surface of the mucosa has to a great extent 
 been mechanically removed, but in a few places is fairly well pr(>served, antl 
 here the surface is smooth. The uterine glands are of the usual numbei- and are 
 normal. Others are considerably dilated. The stroma is dense. The muscular 
 tissue innnediately beneath the mucosa is normal. In the uterine wall the 
 nuiscle-cells end abruptly; in some places they ai'e abundant and stain intensely; 
 they vary somewhat in size. In thecentei'of the tuinoi' the arrangement of cells 
 in bunches is less evident and the cells are less distinct, until finally there is a 
 mass of oval or elongate cells having no definite arrangemcMit. and traversing it 
 are numerous bunches of blood-vessels. Many of the cells aiv inimUe. Hunches 
 of fibers still persist in the tumor mass, and weiv it not foi' the ])i-esence of ir- 
 regular masses of cells, the diagnosis would be myoma. In some places the c{>l]s 
 are small; in othei- ])lac(>s the nuclei are se\-eral times iheir usual size. The 
 picture is one of t \'pical sarcoma de\-elo|)ing in t he intei'ioi- of a myoma, although 
 the cell changes are not so marked as are usua.ll>- found. 
 
 A u t o p s y No. 1 5 3 , M a r c h 11, 1 <) . .\ n a t o m i c 
 diagnosis: Pv e c e n t s u i' g i c a 1 incision, w i t h d r a i n r e a c h - 
 i n g into t h e p e 1 \'i c c a \' i t >' : i' e c e n t a m p u t a I i o n o f t h e
 
 222 MYOMATA OF TlIK UTKRUS. 
 
 II t (M- u s : I) 1 () () (1 - (• 1 () t fi 1 1 i 11 g J) e 1 V i s ; g e n e r a 1 a n e ni i a of 
 all () r g a n s . 1^ o t h h r a ii c h o s of o v a r i a n v c ins t h r o in - 
 b o s e (1 ; ^ a n ti r c n e o f left o v a r y ; involve m e n t o f 1 u m - 
 bar <!; 1 a 11 1 1 s by s a r e o m a t o u s metastases. M e t a s t a s e s 
 in the 1 u n 2: s . \' c g e t a t i o n s on the e h o r d [c t e n d i n e ffi 
 of the t r i c u s p i d v a 1 v i' a 11 d o n t h v c o 1 u ui 11 a' e a r n e ve, 
 o f t h (' r i ^' h t \- (' II t ]■ i {■ 1 (■ : b r o n e h o ]> 11 c 11 in o n i a ; el o u d y 
 swelling of t h V V i s c c r a : f o e a 1 a r e a s o f 11 e c r o s i s i n 
 the liver: cholelithiasis: <:; a 1 1 - s t o 11 e in the diver- 
 t i (' u 1 u 111 f \' a t e r . 
 
 On ()])enini!; the abdominal cavity the jieritoneiim is found to be smooth and 
 glistening;. The intestinal loops are somewhat distended with gas. At the site 
 of the wound there are firm adhe.-tions between intestinal loops and the per- 
 itoneum. I'^xcept for these adhesions the intestinal coils are quite free. Filling 
 the entire pelvis is a large blood-clot which appears to be several days old. 
 
 The left ovary is dark, firm, tense, and on section is found to be filled with a 
 blood-clot and necrotic material. There is no rupture, and nothing can be 
 found in the ))elvis to account for the (juantity of blood present. 
 
 Intestines: The rectum and greater part of the colon aj)pear practically 
 normal. The cecum, however, is considerably distended. On examination, 
 the mucosa is found to be injected but intact. 
 
 Lungs: The metastases in the lungs are rather extensive. 
 
 The hemorrhage in this case was apparently not the result of bleeding from 
 vessels of any size, but of a general oozing. There is little wonder that the patient 
 in her weakened condition did not sur\i\'e the operation. 
 
 Gyn. No. 6724. Path. No. 2946. 
 
 r t e r i 11 e m y o 111 a u 11 d e i' g o i 11 g c y s t i c s a r c o m a t o u s 
 d e g e n e rati o n . 
 
 Al. F., white, aged t weiity-.'^even, single. Admitted February 26: dis- 
 charged A])ril 1, 1S99. The family hi.^tory is not important. The patient as 
 a girl was always healthy. The menses commenced at fifteen, were regular, 
 painful, but not especially copious. The patient, about four weeks, ago, noticed 
 pain and swelling of her ankles, associated with some discomfort in the back and 
 lower ])art of the abdomen. During the last four years her periods have been 
 regular except for the last seven months. Hince August, seven months ago, 
 the periods have occurred every two weeks and have been profuse and painful. 
 The last menses ceased about ten days ago. On abdominal examination a smooth, 
 firm, spheric, immobile tumor mass can be felt rising from above the symphysis 
 and extending to the umbilicus; a little to the left of the median line a second, 
 but smaller, mass, apparently continuous with the first, crosses the median line 
 to the right. 
 
 O])eratioii, February 27, 1899. Abdominal myomectomv. For nearlv two
 
 MYOSARCOMA OF THK ITRRUS. 223 
 
 days after operation the patient had a great deal of abdominal ))ain and a feel)le 
 and rapid pulse; there was also a considerable degree of abdominal distention. 
 Nervous symptoms were prominent during convalescence, but gradually abated, 
 and she was discharged on April 1, 1899. Her highest postoperative temperature 
 was 102.5° F., on the day following the operation. The pulse on that day was 
 very feeble, rising to 140. From this time on there was a gradual drop to 82. 
 
 Path. No. 2946. The specimen consists of several myomata, the largest 11 
 cm. in diameter, a smaller one, 5 cm. in diameter, and a third still smaller one, 
 to which is attached a piece of the uterine wall. These myomata are apparently 
 edematous. Situated just below and to the right of the tube is a small nodule. 
 9x6x4 mm. Its surface is slightly lobulated, and a))])arently consists of fibrous 
 tissue. The large myoma presents a different picture from those usually seen. 
 It is made up chiefly of coarse fibers forming bundles, which sometimes present 
 a whorl-like arrangement, while in other places they interlace in various direc- 
 tions. The nuclei vary greatly in size and shape. They are, for the most part, 
 oval or fusiform, but may be spheric. Many are several times the usual size, 
 and frequently large, deeply staining masses of chromatin are seen, or several 
 cells seem to have bunchetl together and to have coalesced, while the nuclei have 
 remained distinct. Some of the nuclei stain palely and show a few rather 
 coarse granules of chromatin, while others take an intense homogeneous stain. 
 No definite division of the cells is to be seen. In some areas the fibrillated 
 tissue has been replaced by a homogeneous or granular, (^osin-stained substance 
 containing a few degenerated cells. In some parts of the tumor the cells are verv 
 abundant and closely packed together, while at other ]K)ints they are f(nv in 
 number. Near the periphery of the myoma typical myomatous tissue is present. 
 There is moderate vascularity of the tumor. The growth is undoubtedly an 
 early sarcoma, occurring in the interior of a myoma. 
 
 The patient was in good health when heai'd from on January 1, 1907, 
 about eight years later. 
 
 Gyn. No. 6045. Path. Nos. 231 1 and 2314. Autopsy No. 1085. 
 
 Multiple an d s u b j) e r i t o n e a 1 u t e r i n e m y o m a t a , w i t h 
 S a r c o m a t o u s d e v e 1 o p m e n 1 in t h e i n t c r i o r o f a m y o 111 a 
 (Figs. 146-155). 
 
 E. F. M., white, aged fifty-six. single. A.imittcd April 21; dicl Aj.ril 23. 
 1898. The patient complains of tightness in I he abdoincii. acc(iiii])ani('il by 
 abdominal swelling. Her menses began at foiii'lccn and were regular, lasting 
 from one to one and one-half days. The How was scanly. The inrns(>s (-(^ascd 
 six years ago. Micturition has been more iVciiui'iil tli.aii iionnal tni-tlic ))ast two 
 or three months. The bowels arc conslipatcd. The abdomen is much disleinled, 
 and on j)al])ation several nodulai' and tendci" masses can be felt. There is shght 
 edema of the labia. 
 
 Operation, A])ril 23. l']\ploratory hii)arotoiny was pcrfoi'nied. but nothing 
 was removed. The patient died on Apiil 23, bSilS.
 
 224 
 
 MVOMATA OF THK ITKIU'S. 
 
 A u t o {) s y No. 1 s 5 . A ii ti t o in i c d i a ^ n o sis : U t o r i ii o 
 m y o 111 a t a ii ii d c r g o i n o; s a r o o in a tons d v g v n c rati o n ; 
 gene r a 1 a n cm i a o f t h v o r «: a ii s . 
 
 Fig. 146. — Sarco.matous Transformation of a Multinodular Pkounculatkd, Sl-bim;kitonkal Myoma. 
 Gyn. No. 604.5. Path. Nos. 2.311 and 2314. The specimen was obtained at autopsy, .\ttached to the fumiu.s 
 by a rather broad pedicle is a multinodular, lobulated myomatou.s tumor. Dr. Louis Livingood, who made the 
 autopsy, noted that the tumor as a whole was softer than a myoma and that it tore readily. The central portion 
 of the lobulations showed degeneration, but in the outer portions typical myomatous tissue was still visible. For 
 the histologic pictures showing that the sarcoma iiriginatpd frmn a nuiligiKint metamorijhosis of the muscle-fibers 
 see Figs. 147-155. 
 
 Tiic cdiics of the al)d(»iiiinal wound arc well approximated. 'Hie intestinal coils 
 occupy the uppci' poi'tion of the ca\'it\', the lower part being filled with a large 
 tumor s|)riiiging from the uterus. The lowei' intestinal coils and the tumor
 
 MYOSARCOMA OF THE UTERUS. 
 
 225 
 
 mass are coveivcl with blood, which is tni versed hy shreds of tissue suggestino; 
 siiiah blood-vessels. The appearance resembles that seen in an organizing 
 blood-clot. The intestinal coils are loosely attached to the U])iX'r part of the 
 tmnor, and at first completely hid it from view. 
 
 Dr. Livingood kindly placed the ]x4vic organs at the disposal of the gyneco- 
 logical department. 
 
 Path. No. 2311 and 2314. The specimen consists of the uterus, with a large 
 tumor springing from the fundus, and also of the intact tubes and ovaries. The 
 uterus is distorted by the presence 
 of a tumor. The uterus is 8 cm. 
 long, 5.5 cm. broad, and 2 cm. in 
 its anteroposterior diameter. The 
 
 
 V '*<^ 
 
 -X 
 
 
 Fig. 147. — Suspicious Cell Changes in a 
 Myoma. (X 460 diam.) 
 Path. No. 2314. a represents approximately 
 the usual size of the nucleus in a muscle-fiber. 
 -•Vt b one cell is overlapping another. Both are 
 much enlarged. At c we have a giant-cell con- 
 taining six nuclei, all of which are larger than 
 those of normal muscle-fibers. There is some 
 Ijolymorphonuclear and small-round-celled in- 
 filtration, as indicated by d. The presence of 
 the large nuclei at b and c is somewhat sug- 
 gestive of sarcoma, but these are occasionally- 
 found in benign myomata. 
 
 Fig. 148. — Early Sarcomatous Changes in a Myoma 
 CX 225 diam.) 
 Path. No. 2314. Much of the tissue has undergone 
 hyaline degeneration, as indicated by a. At b we have 
 muscle-fibers of the usual size; at b' is a nucleus twice a.s 
 large as normal, and at b" the nuclei are not only much 
 larger, but also contain an increased amount of chromatin, 
 c, c', c" also depict the gradual transformation of muscle 
 nuclei into very large ones, so suggestive of a malignant 
 change. The nucleus d is enlarged, stain.s deeply, and 
 has an irregular outline. The cell e is particularly well out- 
 lined, lying free in the hyaline tissue. It is greatly en- 
 larged, and the nucleus is fully five times the normal size, 
 contains much chromatin, and two hyaline droplets. From 
 this field alone we would strongly suspect sarcoma, but could 
 not venture a positive diagnosis. 
 
 cervical canal is 6 cm. in length and its mucosa is slightly granular. The 
 uterine cavity is 4.3 cm. long and 1.5 cm. broad at the fuiulus. The mucosa 
 lining the uterine cavity averag(>s 2 mm. in thickness and has a .smooth surface, 
 but a few of the glands are dilated, .some reaching 1 mm. in diametei-. 
 
 S])ringing from the fundus by ;i pedicle. 3.5 em. in diameter, is a large lobu- 
 lated tumor, about I he size of ;iii adiiH 's he;id, ineasuiiiig iM \ Hi \ 11 cm. (l''ig. 
 14()). This is the large mass that fihed the lowef ;ibd(iMien. It is irregularly 
 rtnighened, ])inkish in color, and on section a))]ieai's librillated. Some ol the 
 fibers present a i)arallel aiiangeineiil : others are grouped concentrically. At 
 many points the tissue ap])ears to ha\(' undei'gone degeneration. Taken as a 
 1.")
 
 22() 
 
 MYOMATA OF THK I'TFJU'S. 
 
 whole, tile tumor is softer than an oi'(hiiar\' inyoiua. and tears more readily. 
 The portion of the tumor which shows the least degeneration, however, presents 
 the typical myomatous appearance. Situated in the j)osterior wall of the uterus 
 is a small myoma, 2 cm. in diameter. 
 
 Ivijiht side: The tul)e on passiniz; out ward 10 cm. is lost on tlie .surface of the 
 tumor. It averages 5 cm. in thickness. The ovary measures o x 2 x cm. 
 Its outer j)ole is adherent to the tumor. 
 
 
 l'"i<;. 149. — Sar< o.MATOLS Transformation- of Myomatov.s Tissue. (X 215 diam.) 
 Path. No. 2314. At a the nuclei of the muscle-fibere are pale-.staining and comparatively normal in .size. 
 In the area indicated by b. and including about one-.sixth of the field, the muscle-bundles have been cut trans- 
 versely. The majority of the fibers are normal, but here and there (ci the nuclei are enlarged, slightly irregular, 
 and stain deeply. In the area d. where the fibers have been cut longitudinally, the grarlual transition of normal 
 nuclei into the large, irregular, and deeply staining ones can be followeil. In the area e the same gradual transi- 
 tion of average-.sized nuclei into large and deeply staining ones can be outlinetl. 
 
 Left side: The ajjjx'ndages are normal. 
 
 The glands along the aorta are slightly enlarged: no nieta.stases are to be 
 detected in them or in any of the organs. The right lung shows a good deal 
 of con.solidation in the lower lobe, and cultures re\'eal a lanceolate di})lococcus, 
 probatily M. laneeolatus. 
 
 Heart : The coronary arteries are diffusely thickened. The heart valves are 
 normal. 
 
 Histologic Examination. — Sections from the denser poititjiis oi the tumor
 
 MYOSARCOMA OF THH ITKRUS. 
 
 227 
 
 show non-striped muscle-fibors closely packed tof^ether. Sometimes these are 
 cut ti-ansversely, but in many places lono;itudinally ; or they run in and out in 
 ev(>rv dirc^ction. The ])icture is that of an oi'dinary iiix'oma. Here and there 
 are foci of hyaline degen(>ration, sharply tlehned from the surrountling muscle 
 and frequently entirely devoid of muscle-fibers. Occasionally the degeneraticMi 
 is more diffuse, isolated Inmdles of 
 nuiscle undergoing hyaline trans- 
 formation. In other portions of the 
 tumor the picture is difl'erent. 
 Here dark-staining areas can be 
 detected with the low ])ower. On 
 careful examination they ai'e found 
 to consist of enlarged nuclei (Figs. 
 147, 148, 149, 150, 151, 152, 153, 
 154, and 155). Some of these are 
 spindle-shaped and four or five times 
 the size of those surrounding them ; 
 they stain very deeply, and their 
 chromatin is finely granular. All 
 gradations from the ordinary muscle 
 nuclei to these enlarged and deeply 
 staining ones are demonstrable. In 
 the neighborhood of these there are 
 also very large and irregular, deeply 
 staining masses of chromatin, at 
 least twenty times the size of an 
 ordinary nucleus. Many of these 
 enlarged cells are found scattered 
 throughout tlie tissue. ( )n examina- 
 tion of still other portions of the 
 tumor a very unusual |)icture is 
 noted. The miclei of the cells 
 become about twice the size of 
 those of an oi'diuai'v muscle-fiber. 
 There is, h()we\'ei\ no alteration in 
 the ai"i-angement of the (ibei's. 'i'liis 
 ai'ea is undoubtedl}' malignant in 
 
 character, and there is a direct I ranslonnat ion fi'oni the myomatous into sai'- 
 coinatous tissue, characteri/etl pi'iinai'ily by ;ni increase in size of the nuclei 
 and the tendency to become iri-egulai' in (Uitline, and by a considei'able augmen- 
 tation in the chromatin. l'"rom some poitions of the t unioi- all t I'aces of myoma 
 ha\'e di.sa])))eared, and the cells liaxc o\al, \"esiculai' miclei. .\ numbei' of them 
 contain miclear figures. The nuclei are very closely packed together, and the 
 
 
 
 Fig. 150. — Gradual but Direct Transitiox of Myo- 
 matous into Sarcomatous Tissue. (X 210 (liam.) 
 Path. No. 'I'.WA. a i.s tlie normal .size of the nucleu.s of 
 the iinisclc-fiher. .\t h we see the gradual transition into 
 nuclei fvill.v five or six times a.s large. At c the nuclei are 
 al.so normal, hut at d considerably enlarged and more ileeply 
 staining. .\t e they are grouped and still more enlarged, 
 and at f are of such a size as to very strongly s\iggest a sar- 
 comatous change. \\\ the vicinity of g the same gradual 
 transition from normal musde-fihers into enlargeil anil 
 suspicious ones is seen. The groups of very large, irregu- 
 lar, and deeply staining nuclei at h and i leave absolutely 
 no doul)t as to the malignant character of the proce.ss. 
 .•-ionic of these nuclc'i i-oiitaiii hyaline droplets. The 
 tissue shows yjitjhl >ni:ill-iouiiil celled intiltralion, iis 
 iiidieaii'il li.\ U. I'liis |iiel\ire liemonsl rates clearl.v the 
 iriaihiMl I raii-iticiii of mu>c-le'lil>er> into sarcomatous cells.
 
 228 
 
 .MYOMATA OF THK ITERUS. 
 
 entire })ieture is that of .sarcuiiia. This sareuiuatuus tissue does not show a 
 tendency to hyahne degeneration, but where the tissue dies, it undergoes 
 
 
 V 
 
 V 
 
 I'.g. 1-. 
 
 Sarcomatous Trax!- 
 
 Fig. 1.-,: 
 
 ■(formatiox OF Myom\tous Tissue. (X SSOdiani.) Figs, lol , 152, 1.51J, ami 1.54 are from the 
 same .specimen (Path. No. 2314); all are enlarged the same number of time.s. 
 
 Via. 151. — a represents a cross-section of a myomatous bundle of mu.scle-fib3rs. At b are cross-sections of 
 the tips of muscle-fibers too near their ends to include portions of the nuclei, c is a cell containing two nuclei, 
 an<l at d we have a cell containing three large, deeply staining nuclei. In this mu.scle-bundle all transitions from 
 normal fibers to those containing very large and suspicious nuclei can be traced, e is the nucleus of a comparatively 
 normal muscle-fiber. At e' the nucleus is fully twice the usual size, e" is much enlarged, contains a good deal of 
 chromatin and several hyaline droplets, e'" shows a still further nuclear enlargement, together with a tendency 
 toward the formation of giant-cells. At f there is a distinct giant-cell formation. 
 
 In this specimen we can trace the gradual transition of muscle-fibers into sarcoma cells, not only where the 
 fibers have been cut longitudinally, but also where they have been cut transversely. 
 
 Fig. 152. — a .shows the average size of a myomatous muscle-fiber; b, c, and d represent the various stages 
 in the enlargement of the mu.scle-fibers. e is a very much enlarged cell containing an abundance of chromatin 
 and many hyaline droplets. 
 
 Fig. 153. — a repre.sents the average size of the nucleus of the myomatous muscle-cell, b shows considerable 
 enlargement, but the nucleus still stains palely, c is much enlarged, contains an abundance of chromatin, and 
 one hyaline droplet, d is a greatly enlarged and somewhat irregular nucleus, containiiiK iiuich chroniatin and 
 many hyaline droplets. 
 
 Fig. 154. — No muscle-fibers of normal size are to be seen. At a the nuclei are fully twice the average size, 
 and quite a number of cell-shadows are .seen where the nucleus is wanting, b indicates the group of five very 
 large nuclei, containing quantities of chromatin and many large and small hyaline droplets, as indicated by c. 
 (Figs. 152 and 1,53 are in themselves very suggestive of .sarcoma. Figs. 151 and 154 indicate beyond doubt the 
 sarcomatous character of the growth.) 
 
 coaguh\ti()n necrosis. Traversing the sarcomatous areas are numerous delicate 
 l)l()o(l-\-e.ssels.
 
 MYOSARCOMA OF THP: UTERUS. 
 
 229 
 
 This is a most instructive case. On the one hand, we have typical myoma- 
 tous tissue; on the other hand, a most pronounced example of sarcoma, both 
 situated in the subperitoneal myoma, and almost isolated from the uterus. 
 Fortunately, we are able to trace the direct transition of the myomatous muscle 
 into the sarcomatous tissue. For those who are ske])tical as to the sarcomatous 
 
 
 Fig. 155. — Junction of Myom.a.tous and Sarcom.\tous Tissuk. (X 150 diaiu. > 
 Path. No. 2314. A line between a and a divides the field into an upper one, compo.sed of myomatous tis.sue, 
 and a lower, made up of sarcoma-cells. At b the bundles of mu.scle-fibers have been cut transversely, and tho 
 nuclei accordingly appear round. They are uniform in size. In the vicinity of c the fibers have been cut leiiRth- 
 wise. The sarcomatous tissue commencing at a and extending to the lower border of the field shows no definite 
 arrangement, but consists of a homogeneous .sea of cells. The nuclei of these cells are. for the most part, oval and 
 vesicular; they are much larger than those of the muscle-fibers. The line of jum-lioii between the niyotnatous and 
 sarcomatous tissue is not well defined. 
 
 transformation ol' iiiusclc-fiber.^ \\c think thai the hist()h»i^ic picture, as .seen in 
 the accompaiiyiiiii; di'awiiigs, will t<iul to i-('iiio\-e all doulit. 
 
 Gyn. No. 8836. Path. No. 5032. 
 
 S a r c o 111 a o f t h c u t c i' u s ;i )» ]) a i- cull y o r i .ii i 11 a t i n i: i 11 a 
 111 y o 111 a . (J 1 i II i c a 1 d i a [^ n o sis, d c 11; c n c r a t c il 111 >' o ni a . 
 
 J. \\., white, a^cd roiiy-citiht , niai'ricd. .\diiiittcd .luiic IM: died ,Iune IT), 
 1905. The patient cntcrctl coinplainiii':; of uterine heniorrhai2;e. Her menses
 
 230 M^OMATA OF THK UTERUS. 
 
 began at sixteen, and wvvv rcmilar, usually lasting throe days. She has been 
 niarriod twenty-five years, has had two children (twins), but no miscarriages. 
 Following the labor she had a severe attack of puerperal sep.sis, the fever lasting 
 for three weeks. Her last inensti-ual period was three weeks ago, and since then 
 she has had a slight but constant bleeding, although not severe enough to cause 
 any marked syinj)toms. She is well nourished. The abdomen is rounded and 
 synnnetric. On vaginal examination a free hemorrhagic discharge is noted. 
 The cervix is high up. pointing posteriorly. In front of the cervix, and between 
 it and the symphysis, is a large, i-ounded mass, reaching half-way to the um- 
 bilicus. This a)i]iears to be fluctuating, and is apparently continuous with a 
 hard mass poslerioi'ly, and resting more or le.ss on the .sacral promontory. 
 
 Operation. Panhysterectomy. It was found necessary to do a bisection on 
 account of adhesions. Both the bladder and rectum were injured and were im- 
 mediately re])aire(l. Two j)el\-ic drains were introduced, and also a retention 
 catheter. The j)ulse was thready and weak throughout the entire operation, 
 being hardly perceptible when the o])eration was started. The l)ladder anteriorly 
 had been cai'i'ied well up above the symphysis by adhesions, and posteriorly 
 there were many adluvsions to the bowel, some of which were very dense. The 
 ))atient on her I'eturn to the ward was nnich collapsed, notwithstanding the 
 ra])idity with which the operation was performed. Her pulse was b30, very 
 weak and irregular, and the extremities were cold. In spite of stimulation she 
 gradually grew worse, and died the same afternoon. 
 
 Path. No. 5032. The specimen consists of a bisected uterus with the lateral 
 appendages. The whole mass measures 14 x 10 x 10 cm. The outer surface is 
 everywhere rough and covered with adhesions. The uterus is more or less 
 symniet rically enlarged, on accoimt of the soft, fluctuant tumor which has 
 develo])ed in the posterior wall. The anterior wall is o cm. in thickness and of 
 normal appearance. The uterine cavity is 10 cm. in length. The nuicosa 
 appears normal. On cross-section the myoma presents a somewhat edematous 
 a])pearance. The lateral structures are adherent, but not much eidarged. The 
 specimen is mutilated, making a more accurate de.scri])ti()n imj)o.ssible. Macro- 
 scopically, the diagnosis is interstitial myoma with adhei'ent apj)endages. Scat- 
 tered throughout the walls of the uterus are several small myoniata, but the 
 main growth is exceedingly soft, and gradually l)lends with the surrounding 
 muscle, being in no way so sharply circumscribed as an ordinary myoma. 
 
 Histologic Examination. — Tlie growth apparently arises from the nm.scle. 
 -Vll t ransition stages from muscle-fibers to those of a malignant type can be traced. 
 The nuclei gradually become larger; they stain more deej)ly, and finally all evi- 
 dence of nniscle structure di-sappears. In .some j)laces the ai'rangement is that 
 of a myoma: in other places there is no definite ari'angenient . \o cell division 
 is evident. The blood-N'essels are well foi'nied. The diagnosis of sarcoma is 
 certain. 
 
 This case demonstrates the danger in the routine atloption of bisection of
 
 MYOSARCOMA OF THE UTKRUS. 231 
 
 the uterus. It is impossible to tell whether the sarcoma is really due to a break- 
 ing-down of a myoma, but the evidence is strongly in favor of it. At any rate, 
 we have a sarcoma associated \\ith a myoma. 
 
 Gyn. No. 8610. Path. No. 4823. 
 
 Sarcoma of the uterus apparently originating 
 from a myoma. 
 
 M. G., white, aged thirty-nine, married. Admitted March 27: discharged 
 April 23, 1901. Clinical diagnosis: Uterine myoma with sarcomatous degenera- 
 tion. The patient entered complaining of painful menstruation and constant 
 backache. Her menses began at fourteen and were usually regular, lasting three 
 or four days. In August, 1900, the patient had a slight bleeding after her 
 regular period was over. In February, 1901, she had two periods, and for the 
 last month the bleeding has been constant. The patient has been married 
 seventeen years and had one child, sixteen years ago. She has had much 
 pain in the lower abdomen for ten months, and backache for years. The abdo- 
 men is full, rounded, everywhere soft except in the hypogastric region, where 
 there is considerable resistance on deep palpation. On vaginal examination the 
 cervix is found low^ dowm, lying to the left side. Springing from the cervix and 
 filling the superior strait is a smooth, hard, rounded mass, apparently extending 
 two-thirds of the w'ay to the umbilicus. This mass is somewhat fixed. 
 
 Operation. On opening the abdomen a purplish tumor mass was found 
 choking the pelvis. This resembled a cystic ovarian tumor, and was so firmly 
 wedged in the pelvis that it could not be pushed up. It was verj^ adherent on the 
 left to the pelvic brim, and also somewhat friable, suggesting malignancy. Bi- 
 section was followed by very little hemorrhage. The cervix was split for drainage, 
 as there was considerable persistent oozing. For the first day after operation the 
 patient had considerable oozing from the vagina. She gained rapidly and was 
 discharged in good condition. 
 
 Path. No. 4823. The specimen consists of a large uterus with the tubes and 
 ovaries attached. The portion of the uterus present measures 12 x 14 cm. 
 Occupying the anterior portion of the cavity is a nodular growth. The nodules 
 vary from 0.5 to 3.5 cm. in diameter. At first sight they apj)ear to l)e cystic, 
 but on careful examination the majority are found to be solid. 'Vhr smaller arc 
 smooth, and on palpation are found to be soft. The larger ones |)resent a mottled 
 appearance, being pink, dark red, or red in color, as a result of the appearance of 
 the blood-vessels, which at certain points vary considerably in number. The 
 larger nodules arc very soft , and hci-c and there apjx'ai' to be cystic. On section, 
 the growth occupying the antei'ior wall seems to consist of one dilTuse mass. In 
 the central portion it resembles m\'omat()Us tissue, and numerous strands of 
 tissue can be seen running in all directions. In o\'er one-hall oi the specimen. 
 particularly in the outlying i)ortions, a very homogeneous appearance is present. 
 These areas are very translucent, and stand out in sharp contrast to what ap-
 
 232 MVoMATA OF THE VTERUS. 
 
 pears to Ix' inyoniatoiis tissue. It is tiiis homogeneous and translucent growth 
 tiiat forms the bosses or ncxhdes on the surface. 
 
 liight side: The tube is 7 em. long and has a patent fimbriated extremity. 
 The ovary is apparently intact. The utero-ovarian ligament contains a sub- 
 peritoneal nodule, 1.5 cm. in diameter. This, on section, is perfectly white in 
 color and homogeneous in structure. The ovary measures 3x2x2 cm.; it is 
 covered with delicate adhesions, and contains a dilated corpus luteum. Between 
 the tube and ovary is a lobulated mass, 2 cm. in length, 1.5 cm. in breadth, and 
 approximately 1 cm. in thickness. On section, it is found to be made up of 
 distinct foci of a homogeneous growth. They ar(> without doul^t extensions 
 from the uterine growth. 
 
 Left side: The tube is 7 cm. in length, and is small throughout its course. 
 At its proximal end, for a distance of 2 cm., it is represented by a flattened band, 
 1 cm. in thickness. The fimbriated extremity is free, but at several points are 
 milky-white areas in the folds of the fimbria', and on palpation small nodules can 
 be felt. The nodulai' growth has evidently involved the fimbria' of the tube. 
 The tube measures 4.5 x 3 x 2 cm. It is covered with a few adhesions. Be- 
 tween the tube and ovary is a nodule 8 mm. in diameter. This is sharply cir- 
 cumscribed, pearly white, and translucent, being evidently secondary to the old 
 growth. Between the end of the tube and the ovary is a smaller nodule, 7 mm. 
 in diameter. 
 
 Histologic examination shows that the growth is a sarcoma, and there ap- 
 pears to be a transition between the muscle-fibers and the sarcoma. It is im- 
 possible to determine with certainty whether it was primary sarcoma of the 
 uterus or whether it was secondary to the myoma. 
 
 Gyn. No. 11944. Path. No. 8350. 
 
 Large interstitial a ii d p a r t i a 1 1 y s u b m u c o us myoma. 
 M a r k e d h y a 1 i n e t r a n s f o r m a t i o n , with 1 i (| u e f a c t i o n , 
 and u n d e r going s a r c o m a t o u s t r a n s f o r m a t i n . N r - 
 m a 1 t u 1) e a n d o v a r y . 
 
 R. A., white, aged forty-six, married. Admitted March 7: discharged 
 March 29, 1905. The patient complains of an abdominal tumor. She has had 
 two children and no miscai'riages. The oldest child is thirteen, the youngest, ten. 
 The menses began at sixteen, and at first were regular and normal in amount. 
 Since the birth of the last child, ten years ago, the flow has been excessive, lasting 
 as long as eight or nine days, until two years ago: since that time it has been very 
 scant, and tlie periods have i)een irregular. At times she has had no flow for 
 four or five months. The last period was two months ago. This one was so ex- 
 cessive that the uterus had to l)e jiacked. The doctor at the time the child was 
 born, ten years ago, noticed a tumor, and thought at first that it was a second 
 child. This tumor increased in size, and six years later she was treated with 
 electricity and the tumor ajiparently became smaller. Since ihv hemorrhage two
 
 MYOSARCOMA OF THE UTERUS. 233 
 
 months ago the patient has remained in bed on account of weakness. The left 
 leg began to swell. There was difhcult and j)ainful urination. 
 
 The abdomen was distended to the size belonging to a full-term pregnancy. 
 The tumor was rather soft in consistence. It rose to the costal border. The 
 uterine vessels were very large, some of them reaching 1 cm. in diameter. The 
 uterus was amputated through the cervix. The ])atient stood the operation well. 
 She made an excellent recovery, and was discharged March 29, 1905. 
 
 Path. No. 8350. The specimen consists of a greatly enlarged uterus, which 
 has been amputated through the cervix. It is 25 cm. in length, 17 cm. in l)readth, 
 and 16 cm. in its anteroposterior diameter. It is perfectly smooth and glistening. 
 The great increase in size of the uterus is due to the presence of a myoma, 20 cm. 
 in its greatest diameter. This myoma on section is edematous, and here anfl there 
 shows a certain amount of breaking down, presenting a tyi)ical picture of a myoma 
 undergoing diffuse hyaline degeneration with moderate licjuefaction. At one 
 point is an irregular cystic space, 3x2 cm. Its walls are rather ragged, and the 
 appearance suggests a breaking down of myomatous tissue. At several points are 
 little whitish nodules, rather hard. Such areas have undergone calcification. The 
 uterine cavity is 15 cm. in length. The nnicosa is smooth and glistening, but 
 exceedingly thin. 
 
 On histologic examination the mucosa of the liody of the uterus is intact. 
 The surface epithelium is ])erfectly preserved. The glands are normal. The 
 mucosa is exceedingly thin. The stroma is normal. The veins in the mucosa are 
 here and there much dilated. The muscle inmiediately beneath the mucosals 
 normal. Then, as we pass directly to the myoma, a marked chang(» is noted. 
 The muscle has a wild appearance, and under the low ])Ower the nuclei are en- 
 larged and stain deeply. These deeply staining nuclei sometimes are isolated; 
 in other places there are rows of three or four. The nuclei also occur in bunches 
 of four or five, presenting a mulberry-shaped ai)pearance. These nuclei are 
 three or four times the normal size, and stain deeply. Nearly the entire central 
 portion of the myoma has undergone C()m])lete hyaline transformation, and there 
 is also liquefaction, partial or c()ni{)lete. In ])lac("s wlicre the luusclc-huiidlcs are 
 intact one also notes an irregularity in the size of the iniclei, many of whicii are 
 becoming larger. Far out in the hyaline tissue the nmscle-bundles here and 
 there are still ])reserved. Some of these present the usual ajipearance; oth(>rs 
 show an increase in size of the iniclei, and auii'iueiitalion in amount of chroiiKitin. 
 together with deep staining. At one j)oint in the hyahne tissue one sees an ex- 
 (juisite picture, a few nmscle-fibers ix'ing ])reserve(l aroimd an artery. The lumen 
 of the artery is still intact, and a few of the muscle-lihei-s preseiU ihe iioiinal 
 appearance, but those a short distance away show mni'keil .•icti\ity. Secti(tns 
 were cut from various areas cori'espotuhng to on'ci- h;ilf I he surhice (»I a longitudinal 
 section of thiMiiyoma. The same |)icl ui'e is note(l in neaily :ill ot ihem. Sections 
 through other portions of the niyoni;i show absolute hy:iline t I'ansfoi'ination. 
 
 \\v have hei'e an intersiiiinl and pari iall\' submucous ni\-oma, which has
 
 234 MYOMATA OF THE TTKRUS. 
 
 undergone almost conipk'te hyaline triinsfoniiation. The myoma, at its junc- 
 tion with the normal muscle, has undergone sarcomatous transformation. The 
 islands of myomatous tissue that have been preserved in the hyaline areas also 
 show similar changes. There is not the .slightest doubt that the sarcoma is 
 dev('l()|)iiig from a myoma. This is another exam]:)le of the predisposition of 
 myomala that liavc uiKicrgoiic marked hyaline changes and li(|U('faction to 
 
 beeonn' sarcomatous. 
 
 Gyn. No. 1558. Autopsy No. 353. 
 
 .Multiple uterine m y o m a t a with marked sarcomat- 
 ous implication of the a b d o m i n a 1 viscera an d 
 1 y m ]> h - g 1 a n d s . 
 
 In this case the uterus was enormously enlarged, and possibly bore a causal 
 relation to the wide distribution of sarcomatous nodules. Being in no position, 
 however, to prove this, we have placed the case in a class by itself. 
 
 M. B., colored, aged thirty-eight, married. Admitted September 10; died 
 October 1, 1892. The patient has never been pregnant. Her menses com- 
 menced at fourteen and were regular, the flow lasting from five to six days, and 
 accompanied l\v cram{>-like pains. The flow has l)een very profuse and abun- 
 dant. In 1S91 her fri(>nds noticed that her abdomen was larger than usual, 
 but the increase in size had been painless. She has lost in weight since March of 
 this year, and is very short of breath. The abdomen is distended from the 
 symphysis to the xiphoid, and from flank to flank. It is globular in shape. There 
 is an umbilical hernia, 3.5 x 3.5 cm.; through the h(>mial opening hard nodular 
 masses can be felt, and the lower ribs are lifted up. 
 
 The patient was not operated upon, l)ut sank ra{)idly during the two or three 
 days preceding her death, suffering but little from pain, but markedly from 
 dyspnea. The temperature for the first two weeks varied between normal and 
 100.7° F. for two days prior to her death, later between 95° and 96.4° F. 
 
 A u t o [) s y N o . 3 5 3 . Anatomic diagnosis : M u 1 1 i p 1 (^ u t e r - 
 i n e m y o m a t a : m y o m a in vaginal wall; c o m p r e s s i o n 
 of the iliac veins: sarcoma of the p e r i p a n c r e a t i c and 
 mesenteric 1 y m }i h - g 1 a n d s . Secondary sarcoma of the 
 peritoneum, o m e n t u m , mesentery, intestine, stomach, 
 liver, p 1 e u r x , a n tl lungs. 
 
 Peritoneal cavity; Several hundred cubic centimeters of yellow fluid were 
 present. When the abdomen was opened, a large mass was found occupying 
 the entire jielvis and reaching to the umbilicus. It was nodular, hard, and had a 
 .sulcus corres])onding to the median line. Smaller nodules were distributed over 
 the surface of the tumor. The parietal peritonemn was studded with nodules 
 varying from 1 to 6 nun. or more in size. Some of them were coalescing. Snn- 
 ilar nodules \ver(> ])resent on the intestines and the mesentery. The omentum 
 was greatly distorted and thickened, and extended to the lower l)order of the 
 umbilicus. It was studded with similar nodules, grayish white in color. The
 
 MYOSAECOMA OF THK ITKRUS. 235 
 
 smaller ones were somewhat translucent. The omental vessels everywhere were 
 dilated and showed extravasations. The liver was adherent to the intestine 
 and to the abdominal wall in the median line, and extended 8 cm. below the 
 ensiform cartilage. The whole of the small intestine was located in the right 
 hypogastric region, and coagulated serum was present between the intestinal 
 loops. In the left hypogastric region was a large firm mass, adherent to the 
 adjacent structures. 
 
 The spleen was adherent and high up. At the site of the left kidney was a 
 large firm nodular mass. The lungs were not adherent, but nodules could be 
 felt beneath the pleura^. The uterus was enormously and symmetrically en- 
 larged. The left side was more prominent than the right. The ])eritoneal 
 surfaces were studded with nodules, similar to those above mentioned. Large 
 confluent nodular masses covered the floor and sides of the cul-de-sac. On the 
 right side and anterior to the uterus was a globular mass, about the size of an 
 orange, markedly constricted at its point of attachment. On section, it was 
 dense and presented the usual myomatous picture. Above and to the right of 
 it a second and similar tumor, the size of a walnut, was present. On the left, 
 over the posterior surface, were some six or eight other subperitoneal nodules, 
 the smaller ones measuring about a centimeter, the larger the size of a walnut. 
 On section, the walls of the uterus, which was greatly hypertrophied, were found 
 to contain numerous myomata of various sizes. Submucous myomata were 
 also present. 
 
 Vaginal myoma: In the posterior wall of the vagina, embedded in loose tissue 
 and not adherent to the wall, was a myoma, 4x2 cm. This tumor was shelled 
 out without difficulty. 
 
 Mesenteric tumor: A tumor, weighing 2800 gm. and measuring 23 x 9 x 13 
 cm., occu])ied the left up])er abdominal quadrant and was ])ressing down upon 
 the left kidney. It was separated from the surrounding structures with ditliculty. 
 It appeared to be retroperitoneal. It was firmly attached behind, and sprang 
 apparently from glands about the pancreas. It was encased in a thin capsule, 
 from which it could be stripped. It was irregularly nodular, and on its outer 
 surface were grayish trabecuhe. On section, it appeared homogeneous, ex- 
 cepting where large areas of coagulation necrosis and hemorrhage^ were present. 
 Firmly adherent to the upj)er suii'ace of this tunioi- was a second (Hic. measuring 
 22 x 12.5 X 10 cm., and weighing 1200 gm. It i»fcscnte(l ;in appcai-ance simiiai' 
 to that of the tumor described. 
 
 Metastases were found in the walls of the stomach and intestines, in the 
 liver, pleura', hmgs, and mesentery. 
 
 Histologic examinaticjn showed that t he ret roperitoneal growth was a sarcoma. 
 There is no mention as to the probable origin of this retroperitoneal growth. ( )n 
 microscopic e.xamination of the uterus it looked \-ery much as if we had two in- 
 dependent processes, a retroperitoneal sarcoma ami mnnerous subperitoneal, 
 interstitial, and sul)nuicous uterine rn\-omata.
 
 236 MVO.MATA OF THK UTERUS. 
 
 Myomat A Presenting Gross or Histologic Appearances Suggestive of Sarcomatous 
 
 Degeneration. 
 
 In the foregoing ])ag('s we have dealt with inyoiiiata sliowing iindouhted 
 sarcomatous changes, ^^'e will now review several cases in which the inyoinata 
 show alterations somewhat suggestive of sarcomata, changes, however, that are 
 not sufHciently conclusive to wari'ant a positive diagnosis of malignancy. Some- 
 times the gross appearance of the myoma suggests a sarcomatous change, hut in 
 the majority of these the growth will present the typical myomatous picture, and 
 only on careful histologic study will any evidence of sarcoma be found. 
 
 Sometimes it is particularly difficult to determine whether a given specimen 
 really shows sarcomatous changes or not. We have had seventeen cases in which 
 the growth, either in the gross or microscopically, ])resented alterations that 
 strongly suggested a malignant condition, but in which the changes were not 
 sufficiently marked to enable us to say with certainty that they were sarcomatous. 
 These border-line cases are of especial interest to the ])athologist, and we ac- 
 cordingly give the salient features in each case. 
 
 For convenience these cases can be divided into two groups: 
 
 (1) Those showing gross appearances strongly suspicious of .sarcoma. 
 
 (2) Those in which the histologic picture is suggestive of sarcoma. 
 
 Of course, some of the cases show both gross and histologic changes strongly 
 indicative of malignancy. 
 
 Cases in which the Gross Appearances of the Tumor Suggested Sarcoma. 
 
 The myoma in Case 127S8, although small, was markedly lobulated, pre- 
 sented a mottled a])])earance, and might have been readily mistaken for sarcoma. 
 As soon as it was touched, however, all doubt was dispelled, as the character- 
 istic density of myomatous tissue was everywhere in evidence. 
 
 In Case 8477 a nodule, 2 cm. in diameter, projecting from a large myoma, 
 was so soft that sarcoma was at once suspected. So firmly convinced was the 
 operator that he was dealing with a sarcoma that a comjilete hysterectomy was 
 performed. 
 
 In Ca.se 12864 the tumor at ojK'ration was found to l)e very soft; moreover, 
 it bled easily and felt like sarcoma. This softening was due chiefly to cystic and 
 hyaline changes. In certain areas the ca))illaries were so abundant, and their 
 endothelium had so proliferated, that the tissue was divided up into myriads of 
 alveoli, at first glance strongly suggesting a malignant growth. 
 
 In Fig. 156 (p. 238) we have a large subperitoneal myoma springing from the 
 I)osterior surface of the uterus, and attached to it by a Inroad pedicle. One is 
 instantly struck by the unu.sual ap))earance, the growth ])resenting a mark(>dly lob- 
 ulated form, welling uj), as it were, on all sid(>s of the j)edicle. Agani,at c and d are 
 represented clumps of small flat papillary outgrowths. From the pathologic 
 re))ort we learn that the surface of the growth was verv vascular. Thus far the
 
 MYOSARCOMA OF THE ITKRUS. 237 
 
 growth bears a striking resemblance to a malignant growth, as only exceptionally 
 do we find such a welling-out of tissue on all sides; and, further, in benign myo- 
 mata such papillary masses as are seen at c and d are rarely ev(u- noted. On 
 section, the growth was found to be in part solid, in part cystic. Its cut surface 
 resembled that of a myoma. On histologic examination, in general it presented 
 the appearance of a simple myoma, but in places the cells were very abundant 
 and closely packed together. Furthermore, a few nuclear figures were found. 
 Both these findings suggest to a slight degree sarcoma, but there was marked 
 uniformity in the size of the nuclei. In this case, although sarcomatous degenera- 
 tion cannot be positively excluded, the weight of evidence is in favor of a rapidly 
 growing but benign myoma. Fig. 157 (p. 241) represents half of a uterus which 
 shows a diffuse myomatous thickening. At c we have a small, well-defined sub- 
 mucous myoma; at d, two minute myomata, and at e a partially pedunculated 
 submucous myoma. This pedunculated submucous nodule is the one of chief 
 interest. The mucosa over it is everywhere intact. The nodule near its base 
 shows remains of the muscle-bundles, but in the upper portion and near the tip 
 the tissue presents a homogeneous appearance, all trace of fibers having disa])- 
 peared. This homogeneity, coupled with the softness of the growth, instantly 
 arouses one's suspicions of a malignant growth, and as the mucosa covering it is 
 intact and somewhat atrophic, the most natural supposition is that the myoma 
 is undergoing sarcomatous changes, which, however, are very early. 
 
 The histologic appearances of this submucous nodule, as seen in Fig. 158 
 (p. 242) and Fig. 159 (p. 243), are even more suggestive of sarcoma. In Fig. 158 
 the appearance of ''unrest" is manifest. Here in places the cells are more 
 closely packed ; in another place one cell may contain two nuclei, while in the 
 neighborhood may be a cell containing five or six nuclei. Some of the nuclei 
 contain an increased amount of chromatin. In Figs. 159 and 161 the changes 
 are still more marked. Here we have ill-defined giant-cells and large, iiTcgulai-. 
 deeply staining nuclei, containing hyaline droplets. Polym()r])h()nuclear leu- 
 kocytes and small round cells are also scattered throughout the field. In fig. 
 160, while the same changes are to be noted, v(mt large and irregular clumps of 
 chromatin are seen lying in hyaline tissue. In this case both the gross ar.d 
 histologic pictures are very suggestive of sarcomatous degeneration of the myoma. 
 If a malignant change is present, it is still in its infancy, as the growth is small. 
 well defined, and has not pushcnl its way thi-ough the thin ovei'lying layer of 
 mucosa. We can i-eadily understand how a sarcoma may develop in such a 
 snail myoma, and how, in the course of a few months, all trace of the originrd 
 myomatous tissue may be obliterated. 
 
 Gyn. No. 91 18. Path. No. 5274. 
 
 A large in y o m a t o u s u I e r u s w i t h m y o in a t o u s t i s s u e 
 w e 1 1 i n g out f r o 111 t h e u t e r u s , a 11 d p r e s e n t i n g a p i c t u r e 
 m a c r s c o p i c a 1 1 y suggest i v v of sarcoma ( I''ig. 156).
 
 238 
 
 .MYO.MATA Ul" THE ITKRl'S. 
 
 E. S., white, aged r()rty-('i<i;ht. Admitted O.-'tohcr 10; discharged Novem- 
 ber 8, 1901. The patient eotiiplains of an aixloniirial tuiiinr. The menses com- 
 menced at eh'X'en and were I'eu'ular: the flow was scanty in amount. Since the 
 onset of the present tiouhle the How has histe<l one week, hut tliere has been no 
 excessive bU'cchng. There has been a (Hscharge with a \'er\- offensive odor. 
 
 Fig. 156. — .\ Rapidly Gkowi.ng SrBPEniTo.\E.\L Myo.m.\ with S.mam,, 1'apill.e-Likk Ovtgrowths Spri.n(;ixg 
 
 FROM iT.s SuRFACK. (1 nat..size.) 
 Path. No. .5274. The uterus i.s relatively normal in .size, and the tube.s and ovarie.s pre.sent the ii<ual appear- 
 ance. Springing from the fundus by a broad pedicle, a, i.s a very large subperitoneal myoma. This tuiuor, instead 
 of being smooth and globular, wells up on all sides of the pedicle, leaving here and there deep clefts where the 
 connective ti.ssue has been particularly dense, b is a flattened myomatous nodule lying on the surface of the 
 large growth. At c, d, and e are flatteneil, pai)ill;o-likc outgrowtlis of myoniatous ti.ssue. A myoma presenting 
 such a picture is rarely seen. 
 
 The patient has been married twenty-eight years and has liad two chiMreii. She 
 first noticed a mass in the ligiit side .seven years ago. This has grown stea(hly 
 hirger and caused pain in the right si<le; otherwise she feels well. Hemoglobin, 
 75 per cent. 
 
 Operation. The pedicle attaching the tumor to the uterus was fii-st cut. the 
 tumor being then se])arate(l from the uterus. The tumor having been bisected,
 
 MYOSARCOMA OF THE UTKRUS. 239 
 
 the left half was removed, and later the right. This bisection was done on ac- 
 count of adhesions. The patient made a very satisfactory recovery. 
 
 Path. No. 5274. The tumor is oval in shape, and measures 22 x 10 x 16 cm. 
 It was attached to the posterior part of the left side of the uterus. It was densely 
 adherent to the rectum and to surrounding tissue. The tumor as a whole is 
 bluish gray in color, and on first inspection reminds one of an ovarian cyst. 
 It is irregularly lobulated, and springing from the surface are numerous papillae- 
 like outgrowths. Their presence is explained by the fact that the tumor sub- 
 stance has grown too rapidly for the capsule, and hence has welled out, produc- 
 ing these papillary masses (Fig. 156). They vary from the size of a pea to 4 cm. 
 in diameter. The outer surface of the tumor is very vascular. On section, the 
 portion nearest the pedicle has the appearance of a soft myoma. The remaining 
 half has been converted into a thin- walled cyst. Traversing this cyst are numer- 
 ous trabecuke stretching from side to side. The cyst contents are l)lo()(ly in 
 character. 
 
 Histologic Examination. — The growth in general presents the appearance 
 of a myoma. In many places, however, there is nuich hyaline degeneration. 
 At other points the entire field is filled with muscle-cells lying in such close re- 
 lationship to one another as to give an indefinite suggestion of sarcoma. A few 
 nuclear figures are here and there seen, but there is a marked unifornnty in the 
 size of the nuclei. The large, irregular, cyst-like spaces are due to a breaking- 
 do^^Tl of the tumor, as its walls have no epithelial lining, but are composed of 
 hyaline tissue. There are also other smaller areas of liquefaction. The growth 
 is a myoma undergoing hyaline degeneration. We do not think that thcTe is 
 any sarcomatous change, although the possiljility cannot be excluded in view 
 of the fact that nuclear figures are scattered throughout the myoma, a condition 
 that is most unusual. 
 
 Sub.sequent history, Nov(>mber 24, 1902: Dr. Alexander Hannah writes that 
 the patient feels quite well — better than she has been for twenty years, and is 
 able to do all her own housework. 
 
 January, 1907: This y:)atient is in excellent health five years and four months 
 after operation. 
 
 Gyn. No, 12864. Path. No. 10311. 
 
 A V e r y large m u 1 t i n o d u 1 a r m y o m a I o u s u t e r u s w h i c li 
 a t o p e r a t i o n w as so soft and b 1 e il so f r e e 1 y that t h e 
 c o n d i t i o n w a s s t r o n g 1 y suggestive of s a r c o m a . 
 
 M. B., colored, aged forty-four, married. Admitted A))ril 21 : discharged 
 May 23, 1906. Her menses commenced at thirteen, occurred every four weeks, 
 and were usually ratlier ])rofuse. The last period caine on one month befoic 
 admission. She has been man-ieil t\venty-se\'en \('ars. luul one child twenty- 
 six years ago, and no miseai-riages. Swelling of the abdomen was first noticed 
 fifteen years ago. The patient thought she was pregnant, but the menses did 
 not cease, and there was no ])ain. The growth increased slowly, and scn'en
 
 240 MVO.MATA OK THK ITKRIS. 
 
 yenirs later her physician told her she had a niyuiiia, but advised against opera- 
 tion. The swelling has steadily increased in size. For the past five months 
 there has been pain in the lower i)ack, and bearing-down pains in the abdomen 
 after exertion. For the last three months the tumor has grown ([uite rapidly, 
 and the ))ain in the abdomen and l)ack has been severe at times. For the last 
 four oi" five days she has had diliiculty in micturition. 
 
 Operation. The omentum was densely adherent to the tumor. In lifting 
 up the tumor it was found firmly adherent in the pelvis. It was very soft, bled 
 easily, contained cystic areas, and was very suggestive of sarcoma. It was 
 impossil)le to get a .satisfactory e\{)osure, and in dissecting on the left side an 
 opening was made into the bladder, which had l)een lifted high up and pushed 
 forward by a retrovesical nodule. After considerable difficulty the tumor was 
 entirely removed. The patient was catheterized in all o<S times. She made a 
 very satisfactory recovery. 
 
 Path. No. 10311. The specimen consists of a large multinodular myomatous 
 uterus, 28 x 25 x 20 cm. The omentum is densely adherent to one of the large 
 nodules. The myomata have undergone hyaline degeneratioji. and several 
 contain areas of calcification along their edges. The uterine cavity is distorted, 
 and the mucosa is scant in amount. The tubes and ovaries are normal save 
 for a small cyst, 6x4x4 cm. 
 
 Histologic examination shows a myomatous uterus with definite hyaline 
 areas. Along certain parts of the myoma the entlothelium (jf the capillaries has 
 proliferated to such an extent that the nmscle-fibers are divided off into alveoli 
 which one might very I'eadily think l)elonged to a malignant growth. 
 
 San. No. 471. Path. No. 1815. 
 
 A s u b m u c o u s m y o m a p r e s e n t i n g a h o m o g e n e o u s 
 a p p e a r a n c e and suggesting s a r c o m a (Fig. 157). His- 
 tologic changes suggestive o f s a r c o m a (Figs. 158, 159, 
 160, 161). 
 
 D. C. ('., white, aged forty-four, mai'ried. Admitted May 22; discharged 
 June 30, 1897. Complaint, uterine hemorrhages. The patient has been married 
 ten years, has had one child and no mi.scarriages. A year ago the periods be- 
 came prolonged, lasting eight days, and the flow was more profuse. The patient 
 has lost a great deal of blood. Opei'ation, May 25. 1S97. Alxlominal hyster- 
 ectomy. The highest p()sto])erative lempei-ature was 101°. The patient 
 made a good recovery. 
 
 Path. No. 1815. The specimen com])i'is('s the uterus, tubes, and ovaries 
 intact. The uterus measures 11 cm. in length. S cm. in bi-cadth, and 5 cm. in 
 its anteroposterior diameter (Fig. 157). Its peritoneal surface is smooth. The 
 cervix presents a nodular appearance when viewed from below, but the mucosa 
 lining the canal has mimUe piickles s))ringing from its surface. The uterine 
 cavity is 4.5 cm. in length. Its mucosa is vcrv thin, but has a .smooth, intact
 
 MYOSARCOMA OF THK UTKRUS, 
 
 241 
 
 surface. The anterior uterine wall varies from 2 to 3 cm. in thickness, the pos- 
 terior from 2.5 to 4 cm. Occupying the fundus and projecting into the uterine 
 cavity are two myomata. One is circular, 2.5 cm. in diameter, and ])resents the 
 typical myomatous picture. The second nodule is somewhat ])ear-shaped, and 
 
 Fig. 157. — Diffuse Myomatous Thickenixo of the Uterine Wall. Discrete Submitous Myoma axd a 
 Submucous Myoma PRKSENTiNt; an Appearance Suggestive of Sarcoma. (Nat. size.) 
 Path. No. 1815. The ijictuie represents a longitudinal section through the uterus. The uterine cavity, as 
 seen at a, is slightly enlarged. The mucosa is somewhat atroi)hic. At a' the upper part of the uterine cavity 
 is seen, b is the diffusely thickened uterine wall. At c is a typical submucous myoma, d also indicates two 
 similar, but much smaller, nodules, e is a pedunculated submucous myoma. Near its bivse the strands of muscle 
 are clearly in evidence, but toward the tip the tissue is homogeneous and the fibrillation is lacking. This homo- 
 geneity is most unusual, and makes one instantly suspicious of a malignant change. For the histologic apjiear- 
 ances see Figs. 1.58, 159, IGO, and ItU. 
 
 measures 3 cm. in Iciigtli and 2 cm. in hrc.-idlli. il is pcdunciilntcil niid pi-ojccts 
 far down into the uterine caN'ity. Il hcni's some rrscniMancc to ;i myoma, hut 
 the coarse striation is ladling and the tissnc apjx'ars sonicwliat lioiiiogciicous. 
 This nodule is covered with an intact mucosa, wiiicli is, liowcxcr. not more than 
 0.5 mm. in thickness. The tuhcs and ox'arics arc normal. 
 H)
 
 242 
 
 MVO.MATA OF TIIK ITKIU'S. 
 
 
 
 C 
 
 
 
 Histologic Exauiiniition. — Sections from the cervix show that the vaginal 
 portion is normal, and that the cylindric epithelium of the cervix, as well as 
 that of the cervical glands, presents the usual appearance. The delicate out- 
 growths seen springing from the surface of the cervix are papillary masses of 
 stroma covered by a layer of cylindric epithelium continuous with that of the 
 mucosa proper. They are in no way suspicious. The mucosa of the body of the 
 uterus has an intact surface epithelium. Its glands in a few places show hyper- 
 trophy, l)Ut, as a rule, are little altered. The stroma of the nmcosa in the super- 
 ficial jiortion contains a few small round cells scattered between the stroma cells. 
 The pedunculated, submucous nodule springing from the fundus consists 
 in part of typical myomatous tissue, which here and there has undergone 
 
 complete hyaline degeneration. Along the 
 margins of such hyaline areas there is fre- 
 ([uently a deposition of orange-yellow pig- 
 ment droplets, presumably the remains of 
 old hemorrhages. In other portions of this 
 small submucous myoma the tissue is rarefied 
 or contains large areas of hemorrhage. At 
 still other points all trace of the myomatous 
 tissue is lost, and the nuclei, instead of being 
 elongated, oval and regular in size, are 
 plumper and vary greatly in diameter. .Some 
 of them contain round or oval tran.slucent 
 Path. No. 181.5. The section is from the l)odies, and uuclci fivc or six times the usual 
 
 suspicious nodule e in Fig. 157. On glancing . . 
 
 at the picture one is instantly impressed with SlZC, SOUlCWhat HTegular lU OUtlUie, aud 
 the appearance of unrest, and is reminded of ^^.^ij^jj^p. j-^ther dccplv. Again, foUr Or flvC 
 sarcoma. At a is a cell containing two nuclei; '-' i .^ o ' 
 at b is an aggregation of nuclei forming an nUclci may fomi OnC cluiUp, Jll'oducing ill- 
 ill-defined giant-cell. Scattered throughout i /• i • , ii tt i j.u 
 
 the field are several deeply staining nuclei, dehued giant-cclls. Here and thcrc IS an 
 
 The tissue is freely infiltrated with .mall r.mnd inVgular, VCrV dccplv Staiuiug nUcleUS. Such 
 cells. o .. I . 
 
 areas as the ones just described bear a striking 
 resemblance to those seen in sarcoma. Given such a picture alone, we would 
 not hesitate to make a diagnosis of sarcoma. Having the gross specimen before 
 us, however, with its still well-defined outline, we hesitate to speak of it as a 
 malignant growth. We are, however, inclined to believe that there is a com- 
 mencing sarcomatous degeneration. 
 
 The histologic changes are well depicted in Figs. 158, 159, 160, and 161. 
 
 Subsecjuent History. — The patient writes in 1902, that is, about five years 
 after operation: ''The year immediately following the operation I was in fairly 
 good condition, but at the expiration of that year I began to lose strength and 
 flesh, and for three years was in a most horribly nervous condition, unable to 
 sleep most of the time without trional, and suffering constantly from intestinal 
 indigestion. I am seemingly better this fall than I have been at any time since 
 the operation." 
 
 Fig. 158. — Suggestion ok S.\rcoma in . 
 S.MALL Submucous Myom.\. (X 145 diain.)
 
 MYOSARCOMA OF THE UTKRUS. 243 
 
 Gyn. No. 12788. Path. No. 9662. 
 
 Interstitial and s vi Ij ni u c o u s u t c r i n c ni y o ni a t a . One 
 of the ni y o ni a t a on section present s a n a }) p e a r a n c e 
 that might readily be mistaken for s a r c o m a . 
 
 J. D., white, aged forty, married. Admitted March 21; discharged April 26, 
 1906. Her mother died at the age of fifty-two, supposedly from uterine myo- 
 mata, and two sisters were operated upon for myomata; both recovered. The 
 patient at times has swelling of the feet and also shortness of breath. A year ago 
 (Gyn. No. 11700) she entered the hospital and was treated for cystitis. Her 
 menses began at sixteen, were profuse, and lasted from six to seven days. There 
 
 
 
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 Fig. 159 Fig. 160. Vi<:. Itil. 
 
 Suspicious Cell Changes in a Small Submucous Myoma. (X 150 diam.) 
 
 Fig. 159. — Path. No. 1815. The section is from the suspicious submucous myoma (e) in Fig. 157. a is a 
 small giant-cell. At b the nuclei of the muscle-fibers show a tendency to cluniping; at c are two large, irregular, 
 and rather deeply staining nuclei, suspicious in character. There is considerable sniall-round-celled infiltration, 
 as indicated by d. 
 
 Fig. 160. — Path. No. 1815. This field is from the nodule (e) in Fig. 157, and shows hyaline degeneration, pro- 
 nounced at (a). The two large, irregular, and deeply staining nuclei at b are most suggestive of a malignant 
 change. The nuclei tend to form clumps (c). Scattered throughout the field are numerous small round cells. 
 
 Fig. 161. — Path. No. 1815. This section is also from the submucous nodule in Fig. 157. a and b show 
 clumping of the nuclei, which correspond exactly in size and shape with tho.se of the surrounding muscle-fibers, 
 c is a very large irregular and deeply staining nucleus, containing two hyaline droplets and very suggestive of a 
 commencing sarcomatous change. The tissue shows some small- round-celled infiltration. 
 
 never has been any interinenstrual bleeding until four week.-; ago. The jKiticnt 
 has been married twenty-two years, but has never been pregnant. The prc.-^cnt 
 trouble began four weeks ago, when she had profuse bleeding, with severe pain 
 in both sides and in the back. The bleeding was exc(>ssive, and large clots came 
 away. She first noticed swelling of the abdomen one month ago, and thought 
 that she was getting stout . llcinoglobin, 70 percent. 
 
 Operation. Hysteromyomectomy with removal of adherent appendages. 
 The patient made a satisfactory recovery. Her highest postoperative tenijH'r- 
 ature was 101.5° F., on the second day. 
 
 Path. No. 9662. The speeimen consists of the uterus amputated through the 
 cervix. It is ajiproximatc^ly 9 em. in Icmgtii, S em. in l)readth, and 7 em. in its
 
 244 :\IY().MATA OF THK UTERUS. 
 
 anteroposterior diaiiu'tcr. Posteriorly it is eovt-rrd by a few adhesions. Sit- 
 uated in the fundus is a markedly lohulatcd myoma, 3 cm. in diameter. This, 
 on section, has a mottled ai)i)earance, due to the presence of large and small 
 bundles, and might very readily be mistaken for sarcoma. It proves, however, 
 to be exceedingly hanl. Occu))ying the ))osterior wall and jjrojecting markedly 
 into the cavity is a submucous myoma, 3.5 cm. in diameter. The uterine mucosa 
 is very atrophic throughout the entire cavity. The right tube is covered with 
 a few delicate adhesions. The ovary is exceedingly small. The left tube is 
 thickened and has a patent fiml)riated extremity. The ovary has apparently 
 been slightly adherent. 
 
 Histologic Examination. — The endometrium is to a great extent devoid of 
 an epithelial covering. The glands are few and far between. The stroma of the 
 mucosa shows considerable small-round-celled infiltration. There has evidently 
 been a mild grade of endometritis. Over the submucous myoma the mucosa has 
 almost entirely disa])peared, and we have a zone of marked small-round-celled 
 infiltration. 
 
 The gross appearance in this case was at first very suggestive of sarcoma. 
 From a clinical standpoint the case is particularly interesting, as the patient's 
 mother presumably died of myoma and as the patient's two sisters were operated 
 upon for uterine myomata. 
 
 Gyn. No. 8477. Path. No. 4672. 
 
 P a n h y s t e r e c t o m y instead of supravaginal h y s t e r - 
 e c t o m y o n ace o u n t of a suspicious s u b peritoneal 
 m y o m a . 
 
 E. L., white, agetl forty-nine. Admitted .January 26: discharged February 
 21. 1001. Complaint, soreness and sharp pain in the lower abdomen. Her 
 menses Ix'gan at fourteen and were perfectly regular. The menopause occurred 
 thirteen months ago. She has had no hemorrhage since then. She has been 
 married thirty-one yeai's, has had eight children and two miscarriages. Two 
 weeks ago the patient was suddenly taken with pain and burning in the bladder 
 region, and for a short time had marked frequenc}^ of urination accompanied by 
 nuich ])ain. After seventy-two hours the dysuria practically disa])peared, and 
 the day following the ))atient had some soreness in the up])er right side. Her 
 temjH'rature at this time rose to 101.')° F. 
 
 Operation. Hysteromyomectomy performed in the usual manner; the 
 perineum was also repaired. An abdominal incision having been made and the 
 uterus brought up, a conical sub])eritoneal myoma was felt. On the tip of this 
 myoma, which was the size of an orange, was a rounded i)rojection 2 cm. in 
 diameter, and .softer in consistence than the myoma. This apparently was a 
 small sarcoma, and on this account comjjlete hysterectomy was performed. 
 The patient made an uninterrui)ted recovery. 
 
 Path. No. 4672. The specimen consists of the uterus. From the posterior
 
 MYOSARCOMA OF THF: UTERUS. 245 
 
 surface a myoma has developed. The uterus measures 6x7x4 cm., and is of 
 the normal consistence. Developing from the upper ]iosterior wall of the fundus 
 is a tumor 6x6. It is soft and almost fluctuatino;. It is covered with smooth 
 peritoneum. The cut surface is succulent and resembles a soft myoma. The 
 uterine cavity is 4 cm. in length and 4 cm. in breadth at the fundus. The mucosa 
 is smooth and normal in appearance. In the median line of the fundus is a 
 sessile polyp measuring 5 by 10 mm. The uterine wall is everywhere thicker 
 than normal, averaging 2.5 cm. 
 
 In this case it is readily seen that, although the ajjpcarance at operation was 
 ver}' suggestive, the tumor on section bore no resemblance whatever to sarcoma. 
 
 Myomata Macroscopic ally Presenting the Usual Appearance, but Histologi- 
 cally Containing Areas Suggestive of Sarcomatous Degeneration. 
 
 The literature contains very little on this subject. l)ut we are certain that if 
 a systematic examination of all myomata were made early, sarcomatous changes 
 or at least suspicious pictures would occasionally be detected. In the course of 
 our investigation at least twelve tumors, which macroscopically presented little 
 of interest, on histologic examination yielded pictures more or less suggestive 
 of sarcoma. In Case 3113, although the myoma as a whole showed little that 
 was unusual, nevertheless at several points the muscle nuclei were very large 
 and contained correspondingly large oval or almost round nuclei (Fig. 162, 
 p. 248). 
 
 The cell alterations in Case 3295 are very instructive. A lobulated sub- 
 mucous myoma had been removed, and on histologic study at the junction of 
 two lobulations marked cell changes were noted. At this point some of the 
 nuclei were normal in size; others were four to five times the usual size, and 
 stained deeph^ Some nuclei appeared as long threads, being three or four 
 times the normal length, and others cells contained three or four luielei Inmched 
 together. Such a field is strongly suggestive of sarcoma. A rather odd co- 
 incidence in this case is the fact that, more than five years later, the uterus was 
 removed on account of an adenocarcinoma which had meanwhile developed just 
 above the internal os. 
 
 Case 3461 is also a good example of changes strongly suggest iv(> of (>arly 
 sarcoma in the myoma. The tumor was composed of non-strijx'd muscle-fibers 
 which were markedly separated from one another, tiie entire tissue appearing to 
 be edematous. Many of the muscle-fibers were normal, but numerous unusual 
 pictures were seen. Here and \hrvv were spindle-shaped cells at least five times 
 the usual length and four times the breadth. These contained five or six oval 
 nuclei, which stained iiioi'e deeply than those in the \ieinily. In (»lh('r |)la('es 
 four or five nuclei were joined end to end. The picture instantly suggests sar- 
 comatous transformation of muscle-fibers. Such cell changes were found 
 sparsely scattered throughout the tumor, but were most abundant near the 
 peritoneal surface.
 
 246 MVO.MATA OF THE UTKRUS. 
 
 In San. No. 577 wo have another instructive example of suspicious cell changes 
 in niyoinata. The myoma was situated in the ])()sterior uterine Avail and was 
 (Mlciuatous. .Maci'oscopically, there was not the faintest suspicion of a malignant 
 change. A reference to the patiiologic report shows that the solid portions of 
 the tumor presented a typical myomatous picture. Occasionally, however, the 
 muscle nucleus was irr(»gular in outline, stained somewhat deeply, and was five 
 or six times the usual size. At other points the muscle-fibers had luiclei varying 
 markedly in diameter. On careful study of such fields the following were noted: 
 some of the nuclei were small, oval, and vesicular; others were twice the normal 
 dimensions, while (]uite a number were four or five times larger than normal and 
 had irregular outlines. All gradations between those of normal size and the 
 larger ones were demonstrable. Occasionally large masses of protoplasm stain- 
 ing deeply with eosin and containing four or five large nuclei bunched in their 
 centers were noted. Such cells are depicted in Figs. 163 (p. 250) and 165 
 (p. 252). At other points long fusiform masses of protoplasm, fully twelve times 
 the length of normal muscle-fibers, were demonstrable^, and some of these con- 
 tained two or three (enlarged nuclei bunched in their centers. One of these large 
 fusiform cells is seen in Fig. 164 (p. 251), extending almost the entire length of 
 the field. In sections from the softened areas of the myoma all trace of the 
 myomatous arrangement had entirely disappeared. The tissue was rarefied, 
 and many giant-cells were found. Xowhere, however, were nuclear figures 
 demonstrable, nor was there much excess of chromatin. In this case the entire 
 histologic picture was most suggestive of sarcoma. 
 
 Tlie histologic ])icture seen in Fig. 166 (p. 253) represents a large giant-cell 
 containing many small nuclei scattered regularly throughout it. This was the 
 only unusual cell found in the myoma. Fig. 167 (p. 253) is from Case 5496, in 
 which the ])atient suffered from ''recurrent fibroids." These submucous myo- 
 mata wei'e, for the most part, necrotic: in many places no cell elements remained, 
 but at other ])oints were fragments of nuclei and nmch small-round-celled and 
 polymorphonuclear infiltration. In the figure we see two very large nmscle- 
 fibers with correspondingly large and irregular miclei. As noted in the history, 
 this patient is now perfectly well. In some cases in which the myoma is under- 
 going necrosis much inflanmiatory reaction has taken })lace. We occasionally 
 encounter rather large and deejily staining nuclei, as seen in Fig. 168 (p. 256). 
 They suggest slightly a malignant change, but are evidently degeneratiA'c phe- 
 nomena. While in nearly all these cases evidences of sarcoma were ])rominent, 
 in none of them were we justified in making a positive diagnosis of malignancy. 
 As is well known, early carcinomata may often be recognized by commencing 
 changes in the epithelial elements, but the benign alterations in coimective- 
 tissue growths are .so manifold and fre([uently resemble to so remarkal)Ie a degree 
 malignant growths that one is often at a loss to detei'tnine whether a given case 
 is l)enign or malignant, and must await the subse(|ueiU clinical history of the 
 case or be ai)le to detect metastases befoi'c savinu; that the tumor is I'callv sar-
 
 myosarco:ma of the uterus. 247 
 
 comatous. On the other hand, the growth may appear benign in character, and 
 yet the chnical history may show that it is mahgnant. This is especially true of 
 some spindle-celled sarcomata. 
 
 Gyn. No. 31 13. Path. No. 487, 
 
 Interstitial uterine m y o m a t a with cell changes 
 somewhat suggestive of sarcoma (Fig. 162). Very 
 early carcinoma of the body of the uterus (Fig. 
 18 4, p. 2 95). 
 
 A. V. G., white, aged fifty-two, married. Admitted October 16; dis- 
 charged December 6, 1894. The abdominal veins were greatly distended. 
 
 Operation, October 24th. Hysteromyomectomy. There was excessive vas- 
 cularity of the uterus and of the tumors, and extensive subperitoneal myomatous 
 development. The bladder was high up in the abdomen. During removal of 
 the tumor a portion of the bladder wall was accidentally removed. The ureters 
 were catheterized. After removal of the uterus the bladder was sewed up 
 with interrupted sutures. The patient made an uninterrupted recover}-. 
 
 Path. No. 487. The specimen consists of a large globular tumor, in tlii; 
 upper part of which the uterus is situated. Both tubes and ovaries are intact. 
 The tumor is approximately circular, 25 cm. in diameter. On its lower and 
 anterior surface are five ill-defined bosses, the largest of which measures 8 x 5 x 3.5 
 cm. The tumor is whitish red in color, smooth and glistening, and covered with 
 peritoneum. The under cut surface presents a denuded area, 25 x 15 cm. On 
 the anterior surface of the tumor is a piece of bladder mucosa, 6x3 cm. The 
 tumor on pressure is firm but yielding, and gives a faint sensation of fluctuation. 
 On section it is whitish in color and presents a finely striated appearance. Scat- 
 tered throughout the tumor are sinuses, the largest of which is 1.2 cm. in diam- 
 eter. They are smooth-walled and communicate with one another. They 
 contain a serous-like fluid. Some, however, are filled with dark-red blood. 
 Most of these sinuses appear to be lymphatic in origin. 
 
 On section, it is found that the entire tumor mass springs from the posterior 
 uterine wall. It is int(U'stitial, having an outer covering of nniscle, averaging 
 2 mm. in thickness. The ])osterior uterine wall is also filled with sinuses smaller 
 than those found in the tumor. 
 
 Histologic Examination. — The glands of the cci'vix in i)lac("s arc dilated. 
 The uterine mucosa is very atrojihic. 'Hie suifacc cpitiicliuiu is intact. The 
 glands ar(! few in munbei-, and are small and cii'cular on cross-si^ction. The 
 stroma of the mucosa shows consi(lei';ii)le lymphoid infilt I'ation. and non-st i-ijicd 
 muscle-fibers are seen passing uj) into the stroma of the mucosa nearly as far as 
 the uterine cavity. Spi-inging fi-oin the mucosa are three ])olypi, one situated 
 near the internal os and ha\"ing a broad base; the second is 1.5 cm. from the 
 fundus and pedunculated; a third is situated at the fimdus. These ]> :)l>'iti are 
 covered with cylindric epithelium, h;i\e numerous inlands scattei'ed throuLrhout
 
 248 
 
 MViiMATA OF TIIK rTERI'S. 
 
 thcin, some of which arc (Hinted, others empty. Some of the glands coiitam 
 polymorphoiUK'h'ar leukocytes and desquamated epithelium, blood, or hyaline 
 casts. At one ]X)int is a very early carcinoma (Fig. 184, p. 295). 
 
 The uterine muscle just l)eneath the mucosa appears to be perfectly normal. 
 Ill other places it contains numerous small empty s])aces, some of which have an 
 endothelial lining. These are probably lymph-spaces. The large tumor sit- 
 uated in the ])osterior wall is com{)osed of non-striped muscle-fibers which show 
 diffuse hyaline degeneration. In some places this degeneration is so marked 
 that the muscle-bundles appear as small cells in hyaline material. There 
 
 arc many recent hemorrhages which arc chiefly 
 found in hyaline areas. In some places the tumor 
 is edematous. In no place can polymorphonuclear 
 leukocytes l)e detected. The blood-vessels of the 
 tumor are moderate in number, the veins pre- 
 dominating. Scattered everywhere throughout the 
 tumor are large and small empty spaces, some with, 
 others without, an endothelial lining. As the blood 
 in the arteries and veins has been well preserved 
 in Miiller's fluid, and since these spaces are com- 
 paratively free from blood, we are inclined to 
 
 9 
 
 
 
 
 
 Fig. 162. — Large Cells Occur- 
 ring IN A Simple Intersti- 
 tial Myo.ma. (X 450diani.) 
 
 Path. No. 487. a represents bclievc that they are lymph-channels. Passing 
 
 the average size of the nuclei of , . 
 
 the muscle-fibers. At b are two across souic of the suiallcr spaccs are delicate capil- 
 
 nuclei, approximately spheric and 
 much enlarged. Their chromatin 
 is, however, only slightly in- 
 creased. Above and below the 
 center many of the nuclei tend 
 to overlap one another and to 
 arrange themselves in rows, c 
 indicates some small-round-celled 
 infiltration. After detecting the 
 large nuclei (b) further sections 
 should be examined to see if more 
 definite signs of sarcoma are i)res- 
 ent. From these nuclei alone we 
 would not be warranted in saying 
 that the growth was malignant. 
 
 laries, just large enough to admit the passage of 
 one red blood-corpuscle at a time. In one of the 
 large arteries a hyalin(> thrombus is seen. The tubes 
 and ovaries are normal. 
 
 The chief interest in the case centers in the pres- 
 ence of some very large cells containing equally large 
 oval or almost round vesicular nuclei (Fig. 162). 
 These suggest to a slight degree commencing .sar- 
 comatous transformation, but are by no means 
 conclusive. 
 
 After the opei'atioii the patient did j)erfectly well, but she could not retain 
 ler water long without some pain. 
 
 Gyn. No. 3295. Path. Nos. 582 and 3948. 
 
 S u b 111 u c o u s m y o m a s h o w i n g cell changes very sug- 
 gestive of s a r c o m a . Y i v (> y e a r s 1 a t r c o m p 1 e t e h 3' s - 
 t c r e c t o m y f o r a n ad e n o c a r c i n o m a apparently orig- 
 inating in the body of the uterus. 
 
 R. B., white, aged forty-five, married. Admitted January 24; discharged 
 February 23, 1895. She has l)een married twenty-three years, but has had no 
 children and no miscarriages. Eighteen years ago, when suffering from uterine
 
 MYOSARCOMA OF THE UTERUS. 249 
 
 hemorrhages, the patient was told that she had a tuinor. and eight years ago 
 noticed what seemed to be a tumor })rotruding fi'om tlic vulva. She was re- 
 Heved somewhat by wearing a pessary. For the jxist two years, at intervals 
 of a few days to two weeks, she has had a hemorrhage from the vagina, usually 
 appearing as large dark clots. 
 
 Operation, January 30, 1895. Vaginal myomectomy. The ])atient made a 
 satisfactory recovery. 
 
 Path. No. 582. The specimen consists of an irregular and globular mass, 
 10 cm. in diameter. This is coarsely lobulated, pinkish in color, and covered 
 with numerous adhesions. At one extremity is a raw surface, 6.5 x 5 cm. This 
 corresponds to the pedicle. The tumor is firm and non-yielding; on section it 
 is whitish pink in color, and consists of concentrically arranged striie. 
 
 Histologic Examination.— The outer surface of the tumor is covered with 
 several layers of cells, from nearly all of which the nuclei have disajiiK-ared. 
 There is no evidence of nuicosa. The tumor is composed of non-striped muscle- 
 fibers cut both longitudinally and transversely, and the tissue shows much 
 hyaline degeneration. These degenerated areas are scattered irregularly through- 
 out the muscle, and in such places a few isolated muscle-fibers are still visible. 
 The tissue just beneath the outer surface has a rich blood-supply. At one point, 
 where one lobulation joins another, the nmscle-cells are markedly altered. 
 Some of their nuclei are normal in size, others are four times as large as usual and 
 stain deeply. Some of the nuclei appear as long threads, three times the normal 
 length, and other cells contain three or four nuclei bunched together. The 
 picture is a very unusual one and, were only such a field in question, one might 
 be warranted in making a diagnosis of sarcoma. But the gross appearance of 
 this area is identical with that of an ordinary myoma, and, as seen from the 
 description, the surrounding muscle-fibers are of the ty])e so constant in myoma. 
 It is possible that there is a commencing sarcomatous degeneration, but if so, 
 it is in an exceedingly early stage. 
 
 Path. No. 3948. The specimen consists of the entii'e uterus. The upper 
 part of the cervix and lower part of the bod\' are in\()l\'ed in a cancei-ous grow th 
 which, on histologic examination, ))roved to be an adenoeaicinoiiia. Theiv is 
 also a small interstitial myoma. 
 
 In October, 1902, the patient retui'iied with ;iii inoperable ivcuireiice in the 
 vagina. 
 
 This case is particularly interesting on account of the clianges th;il took place 
 in the subnmcous myoma, and IVom the fad that li\-e years later carciiioniM de- 
 velojK'd. The coincidence of these two is certainly an accideiilal occuri'eiice, 
 the one ap])earing indeixMideiil ly ol' the other. 
 
 San. No. 577. Path. No. 2402. 
 
 An edematous s u b |) e i' i t o 11 e a 1 111 y o m ;i ])resenting 
 histologic c h a n g e s s t r o n g 1 y s u g g est i \- e o I' s a r c o m a 
 ( F i g s . 1 6 3 , 16 4,165).
 
 250 
 
 MYO.MATA OK THK UTERUS. 
 
 11 K., white, afi'cd fifty, siniilc. Admitted March 15; discharged April 19, 
 ISOS. Coiiiplaint, a constant flow for the last three months. 
 
 Operation, March 17, 1898. Hysterectomy. The ])atient made a satisfac- 
 tory recover}. 
 
 Path. No. 2402. The specimen consists of an enlarged uterus which has 
 heen coin-erted into a glohuhir tumor, 12 x 11 x 11 cm. Its surface is free from 
 adhesions. The increase in size of the uterus is due to the presence of a tumor 
 that occupies its posterior wall. The anterior wall is of the normal thickness. 
 The uterine cavity is 5.5 cm. long and 3 cm. broad at the fumhis. The mucous 
 membrane has an un(hilating surface. The tumor occupying the posterior wall 
 
 is approximately 10 cm. in dia- 
 
 c Tj meter. At some points it presents 
 
 m a typical myomatous appearance, 
 
 (^ -d' ^'^^^' '^^ niany places between 
 nuiscle-bundles are less dense areas, 
 presenting a homogeneous surface 
 and entirely devoid of a myomat- 
 ous arrangement. These closely 
 resemble edematous areas. Here 
 and there are small irregular empty 
 sj^aces, so often seen where a 
 myoma is breaking down. The 
 most j)rominent portion of the 
 specimen contains an irregular 
 hemorrhagic area, 4 cm. in dia- 
 meter. This has in part broken 
 down, and clinging to the walls of 
 the cavity are small blood-vessels. 
 There is a second area of hemor- 
 rhage, but here no dissolution has 
 taken place. Tn the neighborhood 
 of the uterus the tumor has a 
 covering of muscle varying from 1 to 8 mm. in thickness. But at the point 
 most distant from the organ the growth is pi'actically devoid of nmscular 
 covering, and the fibers of the tumor are clearly visible. From the foregoing 
 description it will be seen that the tumor appears to be an ortUnary myoma 
 in which some degeneration has taken ])lace. The gross appearance in no way 
 suggests a malignant })rocess. 
 
 Histologic Examination. — The uterine cavity appears to be normal. Sections 
 from the solid portion of the tumor in many places 3'ield typical myomatous 
 tissue. Occasionally, however, we find a nucleus five or six times the usual 
 .size, irregular in shape, and staining fairly deeply. This tis.sue also contains 
 small round cells, freely interspersed between nuiscle-bundles, but apparentiv 
 
 lt)3. — (JiAXT-CKLLS i\ AN' Edematois Mvoma. (X 420 
 
 diain.) 
 Path. No. 2402. a represents the average size of a 
 muscle nucleus; b is a shade larger and stains a little more 
 intensely; c shows partial subdivision; d, d', d", d'", and 
 d"" depict various stages in the development of giant-cells. 
 Note that all of the nuclei of the giant-cells, although in- 
 creased in size, show little or no increase in chromatin. The 
 tissue is sparsely infiltrated with small round cells, as 
 indicated by e. This field, while slightly suggestive of sar- 
 coma, is almost too cjuiet to make one very suspicioas.
 
 MYOSARCOMA OF THE UTERUS. 
 
 251 
 
 no polyinorphoiuK'lear leukocytes. At other points the niuscle-tibers have 
 nuclei varying markedly in size. Careful scrutiny of such fields shows that some 
 of the nuclei are small, oval, and 
 vesicular; that others are twice the 
 natural size, while a number are four 
 or five times the normal size, are 
 irregular in shape, but do not stain 
 deeply. All gradations between the 
 normal nuclei and the large ones are 
 demonstrable. Occasionally we note 
 a large mass of protoplasm staining 
 deeply with eosin and containing four 
 or five of these large nuclei bunched 
 in its center (Figs. 163 and 165). At 
 other points are long, fusiform masses 
 of protoplasm, sharply defined from 
 the fact that they take the eosin 
 stain so deeply. These are sometimes 
 twelve times as long as the normal 
 muscle-fibers (Fig. 164). The giant 
 fibers occasionally contain two or 
 three somewhat enlarged nuclei, 
 bunched in their centers. There is 
 one cell of this character which con- 
 tains three nuclei — one of the normal 
 size, the second about three times, 
 and a third about ten times, the usual 
 diameter. This largest nucleus has 
 a distinctly hyaline droplet in its 
 center. Sections from the softened 
 areas are still more startling. The 
 typical arrangement of the myoma 
 has entirely disappeared. The cells 
 vary greatly in size, and there are 
 many large plaques of protoplasm, 
 varying in diameter, staining deeply, 
 and containing anywhere from one 
 to four or five nuclei. The more 
 rai'efied the tissue, the moi'c abund- 
 ant these giant-cells. In I he areas 
 in which the hemorrhage has taken place we (iik 
 \() nuclear figures can be detected in the tuinoi'. 
 
 I'^roni the foregoing description one is instantly reinin(le(l of sai'coni; 
 
 Fin. 164. — Su.spicious Ckll Changes ix ax Edematous 
 AND Partly Subperitoneal Myoma. (X 350diam.) 
 
 Path. No. 2402. a shows the average size of the 
 muscle nuclei on cross-section. At h we have a spindle- 
 shaped cell cut longitudinally. c represents one of 
 several large nuclei, c' is also a large nucleus, but its 
 chromatin is diminished instead of being augmenteil. 
 The nuclei tend to form dumps at d. .\t e the nuclei are 
 much larger, and the same tendency toward clumping is 
 noted. Here the largest nucleus contains the hyaline 
 droplet f. g is the pnjtoiila-sm of a cell that can be traceti 
 nearly the entire length of the held. Near its lower por- 
 tion it contains the clump of nuclei (h). M its middle 
 is a group of nuclei ihM, and in the upper portion a 
 small nucleus (h"). There is some small-round-cclleii 
 infiltratiim, as indicated by i. 
 
 The presence of the gigantic cell g, with its clumps 
 of nuclei, liigctlicr with the large nuclei scattered through- 
 out the field, make one mindful of sarcoma. The knowl- 
 edge, however, that we are dealing with an edematous 
 myoma should deter us from making a positive diagnosis 
 ■ if malignancy. See Figs. 1():{ and Iti.") for sections from 
 I lie same m>oma. 
 
 nuniliers dl' I hese gi;int-eells. 
 \t no
 
 252 MVOMATA OF THE UTERUS. 
 
 point, however, do we find typical sarcomatous tissue, nor do we find a very 
 marked tendency to an increase in amount of nuclear chromatin. Furthermore, 
 it will be noticed that the most pronounced changes are found in th(^ rarehed areas. 
 At no point in the gross specimen were we able to detect a solid and circumscribed 
 homogeneous area, so characteristic of sarcoma. It is inipossil)le to render a 
 positive diagnosis, but the probability is that no sarcoma is ])resent. From a 
 clinical standpoint, however, should we find tissue of such a character in a 
 myoma, it is incumbent on the pathologist to advise immediate and complete 
 removal of the uterus. 
 
 November 27, 1902, four years and a half after the oi)eration, the patient 
 writes that she is in good health. 
 
 Gyn. No. 5635. Path. No. 1973. 
 October, 1897. The specimen consists of a small myoma from the right 
 horn. This measures 5x4x2 cm. On histologic examination it presents the 
 typical myomatous picture. It contains one suspicious area, as depicted in 
 Fig. 166. 
 
 i£&'W >*; £!_. 
 
 A 
 
 Fig. 165. — Giant-cells from an Edem.vtous Myoma. (X .320diaiii.) 
 
 A. Path. No. 2402. The nuclei are, on the whole, more oval than spindle-shaped, but are of the usual size, 
 a is a very large mass of protoplasm containing four nuclei of various sizes. 
 
 B. a is a very large irregular plaque of protoplasm surrounded by nuclei of muscle-fibers. It contains five 
 goodly sized nuclei and several smaller ones (b). Their chromatin is slightly increased; c is a small round cell. 
 
 These two giant-cells are somewhat suspicious of sarcomatous changes, and should stimulate further ex- 
 amination of the tumor. 
 
 Gyn. Nos. 5496 and 5907. Path. Nos. 1899 and 2222. 
 
 ''Recurrent fi 1) r o i d ' ' ^^■ i t h histologic a }) p e a r a n c e 
 s t r o n g 1 5' suggestive of sarcoma (Fig. 167). 
 
 M. D., white, married, aged thirty-eight. Admitted September 3: discharged 
 September 30, 1897. The patient has l)een married fourteen years; she has had 
 no children, but two miscarriages. The menses began at thirteen and were 
 regular until six months ago, when the flow became scant. Three months ago 
 she had a hemorrhage, and since then has had frequent bleetling. For three 
 years there has been a thick, offensive leukorrheal discharge, and for the past 
 three months constant ])ain in the lower abdomen. During this time she has 
 become very weak. 
 
 Operation, September 4, 1897. Vaginal myomectomy. A large, cauliflowtT- 
 like myoma projected into the vagina. It was about 10 cm. in diameter, very
 
 MYOSARCOMA OF THK ITKRUS. 
 
 25." 
 
 friable, and bled profu«ely. The uterine cavity was packed. Her temperature 
 on admission was 101.5° F. After operation it rose to 103.6°, and on the third 
 day gradually fell to normal. The i)atient rapidly gained fiesh and strength and 
 was discharged feeling well. 
 
 Path. No. 1899. The specimen consists of numerous fragments of tissue 
 from the uterine cavity. 
 
 Histologic Examination. — The tissue has to a great extent undergone de- 
 generation, but at some points, especially around the blood-vessels, the cells are 
 still preserved. They are spindle-shaped, closely packed together, and form 
 
 
 Fig. 166. — A Large Nucleus in a Myoma. (X 320 
 diam.) 
 Path. No. 1973. a represents the average size of 
 the nuclei. .\t b is a nucleus somewhat enlarged, c 
 is a much elongated, oval-shaped giant-cell contain- 
 ing more than twenty nuclei, which stain more deeply 
 than those in the surrounding tissues. Apart from the 
 one giant-cell, nothing unusual was noted in the 
 myoma, and this large cell alone would scarcely sug- 
 gest a malignant change. 
 
 whorl.-; or run in various directions. 
 The picture instantly reminds one of 
 myomatous tissue. At some distance 
 from the vessels the tissue is found to 
 
 
 i. 
 
 & a 
 
 ' "r-e 
 
 W 
 
 -aWSK 
 
 (# 
 
 jr.JS. 
 
 Fig. 167. — Suspicious Cell Changes in a Sloughing 
 Submucous Myoma. (X 315 diam.) 
 
 Path. No. 1899. The nuclei are few and far be- 
 tween, much of the tissue having undergone hyaline 
 change, a represents the average .size of the nuclei 
 of the muscle-fibers. At b are a few red corpuscles; at 
 c a polymorphonuclear leukocyte, d is a large plaque 
 of protoplasm containing two enlarged nuclei, over- 
 lapping one another, e is also a mass of protoplasm 
 containing two very large and deeply staining nuclei. 
 Below this cell is another clump of protoplasm devoid 
 of nuclei. 
 
 The two large cells, d and e, make one very suspi- 
 cious of malignancy, and further tissues should be 
 examined. Such pictures are occasionally found in 
 edematous myomata. From this field alone one 
 would not be justified in saying that the growth is 
 malignant. 
 
 show marked hyaline degeneration. 
 Other ])()rtions of the tumor have undergone complete necro.^i.^;, not a nucleus 
 being visible. Here and there a few large, suspicious-looking muscle-libers are 
 seen (Fig. 167). Where the necrosis has taken place, the l)l()(>(l-vess('ls are 
 exceedingly numerous and arc much dilated. Some of them coniaiii tliroiiibi. 
 
 Gyn. No. 5907. The ])atient was readmit led on Mairh 2. JSilS. and di.<- 
 charg(>d on March 30, 189S. 
 
 In November, 1S97, about two months after her o])ei'alion at the hospital, a 
 sloughing sul)iiiu('ous myoma was reiiioxcd by her family |)hysician. For two 
 months she was relie\-ed, but then eoiiinieiiced to lose Hesh and had chills and
 
 254 MVo.MATA OF THE UTERUS. 
 
 fever. Fur tlie past two week.s she has had pain and tenderness in the lower left 
 abdomen. 
 
 Operation, March 4, 1898. A'aginal myomectomy. A pedunculated slough- 
 ing submucous myoma. 9 cm. in diameter, was removed from the vagina. 
 There was a consiilerahle degree of inversion of the uterus. Her temperature 
 after the ojx'ration reached I()o.4°, but after the fiftli day gradually dropjK'd 
 to normal, and she was discharged, feeling well. 
 
 l^ith. No. 2222. The specimen consists of many pieces of tissue, the largest 
 5 cm. ill diameter. It is very firm, and on section is yellowish white in color, 
 and apparently consists of bands of fibrous tissue running in all directions. 
 Other ]iortions show marked dilatation of the blood-vessels. Many of these are 
 surrounded by a zone of hemorrhage, and some portions of the tumor are hemor- 
 rhagic throughout. Along the edges of some of the })ieces the tissue is very 
 friable, looks necrotic, and has an exceedingly offensive odor. 
 
 Plistologic Examination. — The solid portion is composed of bunches of cells 
 cut longitudinally and transversely. The nuclei are oval, elongate-oval, or in 
 some places spindle-shaped. They are fairly uniform in size, and take the stain 
 evenly. Occasionally a nucleus is two or three times as large as an adjoining 
 one, and now and th(>n one sees a large mass of chromatin, somewhat granular 
 and ap])arently divided up into several smaller nuclei. The tissue bears much 
 reseml)lance to a myoma, but the connective tissue is conspicuous by its absence. 
 The blood-vessels are fairly abundant. In other sections in which the tissue was 
 softer the same spindle-shaped cells are present, but are to a great extent sepa- 
 rated from one another by blood-corpuscles. Scattered throughout the hyaline 
 tissue are ]X)lymori)honuclear leukocytes. The surface of the offensive ])()rtions 
 is composed almost entirely of leukocytes. From the macroscopic examination 
 one would naturally make a diagnosis of sui)purating myoma, but the presence 
 of the few large cells noted histologically, and the fact that there is little connec- 
 tive tissue, make the presence of sarcoma quite ])robable. From a histologic 
 standpoint it is not advisable to make a positive diagnosis. One must be guided 
 entirely by the clinical history. 
 
 November 14, 1902, the patient writes that she has been ])erfectly well since 
 the last operation, and that her weight, which was formerly 90 pounds, is now 
 143 pounds. It is over four and a half years since the last operation. 
 
 Gyn. No. 3461. Path. No. 682. 
 
 S u b m u c o u s , interstitial, a 11 d s u b p e r i t o n e a 1 m y o- 
 m a t a . S 11 b p e r i t o n e a 1 m y o 111 a s h o w i n g m a r k e d v a s- 
 c u 1 a r i t y and a p j) a r e 11 t 1 \' u 11 d e r g o i n g s a r c o 111 a t o u s 
 transformation. 
 
 M. C, white, aged forty-nine, married. Admitted April 2o; discharged 
 May 18, 1895. The patient has had no children and no miscarriages. One year 
 ago she had a severe attack of yimu in the lower abdomen, and now has constant
 
 MYOSARCOMA OF THE TTHRI'S. 2oo 
 
 pain, worse on the left side, and extending down to the limbs and l)aek. The 
 abdomen is somewhat tender; micturition is frequent and painful. Defecation 
 is painful. 
 
 Operation, May 24, 1895. H^^steromyomectomy and herniotomy for incar- 
 cerated femoral hernia. The patient made a satisfactoiy recovery. 
 
 Path. No. 682. The specimen comprises the uterus and a large myoma 
 springing from its left side. The appendages are also present. The uterus is 
 somewhat irregular in outline, and measures 9x6x6 cm. It is smooth and 
 glistening, but springing from its anterior wall is a pedunculated nodule, 1 cm. 
 in diameter, and a sessile nodule, 2 cm. in diameter. A small nodule projects 
 from the fundus. All these are firm and non-yielding. Situated in the fundus 
 is an interstitial nodule, 4 cm. in diameter. This is yellowish- white in color, antl 
 presents a striated appearance; it is firm and non-yielding. The uterine cavity 
 is 4 cm. in length. Its mucosa is grayish-white in color and presents a slightly 
 granular appearance. That covering the anterior wall contains small cysts. 
 Springing from the middle of the left side of the uterus is a globular tumor, 
 12 X 11 X 10 cm. This is connected with the uterus by a round pedicle, 4.5 cm. 
 in diameter, 4.5 cm. in length. It is bluish-white in color, and contains many 
 superficial vessels which spring from the uterus and ramify over the tumor. 
 Over its upper portion the tumor is bright red, but in the dependent i)ortions 
 bluish red. It is everywhere covered with peritoneum, is soft and somewhat 
 yielding, and where pressure is exerted, the tissue becomes blanched, but is very 
 vascular. The appendages are normal. 
 
 Histologic Examination. — The uterine mucosa is, on the whole, normal. 
 Projecting into the uterine cavity is a polyp consisting of nuicosa. The sub- 
 nmcous myoma is composed of non-striped nmscle-fibers cut longitudinally and 
 transversely. They are closely packed together, and stain nmch more deeply 
 than do those of the uterine muscle. The myoma is intimately connected with 
 the uterine niuscl(\ Sections through the i)edicle of the tumor springing from 
 the left side show that it is quite vascular. The tumor is comix)sed of non- 
 striped muscle-fibers which are markedly se])arated from one another, the ciitiiv 
 tissue appearing to be edematous. Many of the muscle-fibers are normal, but 
 numerous unusual forms are seen. Here and there ar(> sjiindle-shaped cells 
 at least five times the usual length and four times th(> normal breadth. These 
 contain five or six oval nuclei, which stain more deeply than those neai" them. 
 In other places four or five nuclei are joini'd end to end. One is immediately 
 rennnded of sarcomatous tran.sformation of the inuscle-libers. Such cells are 
 found sparsely scattered throughout the tumor, but they are most abun<l;uit 
 near the ])eritoneal surface. Toward the center of the tumor are homogeneous 
 areas which stain ])ink with eosin, and sprinkled throughout these ai'eas are a 
 few nmscle-fibers. It looks as if the tissue weiv becoming li(iuefied. The outer 
 portions of the tumor are exceedingly \asculai-, i)olh the arteries and veins 
 being very abundant, and it is in the \icinily of these blood-vesst>ls that the
 
 256 .MYOMATA OF THK UTERUS. 
 
 atyj)ical cells ai'c most niinierous. The vessels arc so numerous that the tumor 
 might be justly called an angioma. 
 
 We must coiisidei' the tumor ))iimarily as a myoma which has such a rich 
 l)lo()(l-supi)ly that it might he called an angiomyoma. Secondly, from the 
 aty))ical cells we nuist strongly susjx'ct .sarcoma or, to say the least, an exceed- 
 ingly rajMcUy growing myoma. 
 
 November 13, 1902, the patient writes that she is not feeling very well, but 
 her description of her condition is not definite. The length of time since opera- 
 tion—seven and a half years— demonstrates clearly that even if, by any chance, 
 the piocess was malignant, the sarcoma had been completely removed. 
 
 
 
 
 
 
 ^ 
 
 
 
 ••« 
 
 
 
 
 
 »• 
 
 
 -^ii 
 
 Fic. 168. — Ckll Chancks in a Myoma Undergoi.m; Partial Coagulation Necrosis. (X 130 diam.) 
 Path. No. 2372. The section is from the neighborhood of an area which has undergone coagulation necrosis. 
 The area indicated by (a) consists of hyaline myomatous tissue. Many of the nuclei, as shown at b, have lost their 
 outlines and consist merely of fine granular cliromatin. .A.t c is a nucleus slightly enlarged and staining deeply, 
 and at several points we have small aggrogatioiis of nuclei tending to form giant-cells. This is well seen at d. 
 Scattered throughout the field are many small round cells and a moderate number of polymorphonuclear levikocytes. 
 Such an infiltration is very common in the tissvie surrounding an area of coagulation necrosis. The giant-cells 
 impress one as being the result of a breaking up of the cells, with the subsetiuent coalescence of the surviving nuclei. 
 .\lthough at first sight the cell changes suggest to a slight degree sarcoma, a careful an.alysis of the cells clearly 
 shows that there is no evidence of m.alignancy. 
 
 San. No. 581. Path. No. 2372. 
 
 Degenerative change in a myoma that might be 
 mist a k e n f o r s a r c o m a (Fig. 168). 
 
 M. Operation March 22, 189S. Myomectomy. The specimen consists of 
 five myomata. The largest is lobulated, and measures 9x8x7 cm. The 
 others are much smaller. The large nodule is very friable, tears easily, and 
 shows marked degeneration. 
 
 Hi.stologic Examination. — Sections from the undegenerated portion of the
 
 MYOSARCOMA OF THE UTERUS, 257 
 
 nodule present the usual myomatous picture. The greater part of the tumor 
 consists of hyaline material, but separating this from the outer and still well- 
 preserved tissue is a zone of coagulation necrosis, for the most part consisting of 
 granular material that stains with eosin, and of nuclear detritus. Scattered 
 throughout the outer portion of the necrotic zone are cells containing deeply 
 staining nuclei of various sizes (Fig. 168). Many of the cells contam several 
 such nuclei. One gathers the impression that such pictures are due to the fact 
 that adjoining cells have fused with one another. 
 
 Gyn. Nos. 6407 and 12 139. Path. No. 8750. 
 
 Large m u 1 1 i n o d u 1 a r m y o m a t o u s u t c r u s ^^■ i t h g c n - 
 e r a 1 p civic a d h e s i o n s ; marked hyaline degeneration 
 of the m y o m a , jm- e s e n t i n g a picture at fi r s t suggestive 
 of sarcoma, but on further examination 1) e a r i n g no 
 d e fi n i t e resemblance to such a condition. 
 
 M. R., colored, aged forty-two, single. Admitted May 20; discharged 
 June 17, 1905. The patient was in the hospital (Gyn. No. 6407) in October, 
 1898, with a right pyosalpinx and an encysted peritonitis, which was opened 
 through the vaginal vault and drained. One month after leaving the hospital 
 she had an attack of pain which commenced in the lower abdomen and extended 
 down the thighs. Since then she has had four more d(>finite attacks of severe 
 pain. 
 
 Operation, May 27, 1905. Hysteromyomectomy and appendectomy. On 
 opening the abdomen the omentum was found everywhere adherent to the pelvic 
 organs. It was tucked down behind the uterus and adnexa to the bottom of 
 the cul-de-sac. After releasing the omentum Ave found that we were dealing 
 with a large multinodular myomatous uterus. On the right side there was a 
 chronic salpingitis. The tube and ovary were j)lastered down to the back of 
 the broad ligament. On the left side there was an adherent ovarian cyst. 6 cm. 
 in diameter. A supravaginal amputation was pcrfornied, and the i)atieiit iiiaile 
 a very satisfactory recovery. 
 
 Path. No. 8750. The specimen consists of a lobulatcd myomatous uterus 
 to which the omentum is densely adherent. The uterus with its nodul(> is 
 10 cm. in length, 12 cm. in breadth, and S cm. in its antt-roiiosterior diameter. 
 Projecting from the surface are pedunculated and sessile myomata, the largest 
 reaching 5 cm. in diameter. Covering the surface, and intimately blended witii 
 the myomata, is the omentum. Scattered throughout tiie uteiine walls are 
 smaller myomata, some of them subnuicous. Attached to one side is a cystic 
 mass, 7 cm. in diameter, also covered by adhesions. It appears to be composed 
 of the tube and ovary, but the exact relations are dilficult to establish. 
 
 Histologic Exaininalioii. Sections IVoni the myomata show hyaline tissue 
 with dee}) patches scatteivd throughout it. At first sight it reminds one of a 
 malignant growth, but on careful study we find deeply staining bunches of 
 17
 
 258 :\IV().MATA OK THK ITHIU.S. 
 
 iiuisclc-lihcis lyiiiii: in the hyaline tissue. In fact, we have a most typical example 
 of diffuse iiyaline t i-ansformation of a myoma. Sections from the endometrium 
 show that the surface is covered with polymorphonuclear leukocytes, that the 
 surface e))itheliiim is fiattened, and that the underlying stroma shows a great 
 deal of small-round-celled infiltration. W'e have here a chronic inflammation 
 of the cervix with dilatation of the capillai'ies. One of the tubes shows a 
 typical follicular hydrosalpinx. 
 
 Gyn. No. 11949. Path. No. 8351. 
 
 A 1 a r ti e interstitial m y m a showing cell changes 
 strongly suggestive of sarcomatous transformation. 
 
 M. S. K., white, aged thirty-nine, married. Admitted March 8, 1905; dis- 
 charged six weeks later. The menses have always been regular. 
 
 Operation. Hysteromyomectomy, double salpingectomy, right oophorec- 
 tomy. The uterus is considerably enlarged, owing to the presence of a large 
 myoma that springs from its posterior surface. The rectum is adherent to the 
 ])(3Sterior smface of the uterus near the cervix. It is easily freed. Hysterec- 
 tomy was performed without any difficulty. The patient made a very satisfac- 
 tory recovery. The highest i)ostoperative temperature was 100° F. 
 
 Path. No. 8351. The specimen consists of the uterus, the right tube and 
 ovar\', and the left tube. The uterus is approximately 21 cm. from before back- 
 ward, 17 cm. in length, and 12 cm. in breadth. The great increase in size is due 
 to the ])resence of a myoma, 15 x 11 cm., situated in the posterior wall. The 
 anterior uterine A\-all varies from 1.5 to 2.5 cm. in thickness. It shows diffuse 
 myomatous thickening. The uterine cavity is 5 cm. in length. The mucosa 
 in the thicker portions reaches 5 mm. in thickness. The appendages show 
 nothing of interest. 
 
 Histologic examination shows that some of the cervical glands are enlarged, 
 but otherwise are normal. The surface epithelium is intact. The glands are 
 more convoluted than usual: they show a slight tendency toward hypertrophy, 
 and here and there can be traced for some distance into the muscle. Sections 
 from the myoma show diffuse hyaline degeneration. In some places, how- 
 ever, the nuclei are five or six times the natural size; they are irregular and stain 
 deeply. At one point we may have two or three miclei bunched together, while 
 at other places the nuclei are of the usual type, and about twice the natural 
 length and breadth, and stain deeply. In a few areas the cells seem to have a 
 very wild look: in other woi-ds, they are more active than usual. In others 
 the nuclei are twice the normal length and three tim(>s the normal breadth, and 
 appear irregular. In some ])laces the nuclei are irregularly triangular, stain 
 deeply, and are fully tour oi- five times larger than those that surround them. 
 
 In this case we have an atypical myomatous growth. The cell changes are 
 most suspicious of a commencing sarcoma developing from the nuiscle. Were it 
 possible clinically to remove a section of a myoma without taking out the entire
 
 MYOSARCOMA OF THE UTERUS. 259 
 
 growth, and had wc found such suspicious clianges, we would certainly have 
 advised immediate removal of the uterus in its entirety. In this case, of course, 
 the uterus with the myoma has been removed, and if the growth is actually 
 commencing sarcoma, we have in all probability eliminated the process, as it 
 seems too early for metastases. 
 
 San. No. 1973. Path. No. 9129. 
 
 8 u b p e r i t o n e a 1 and interstitial u t e r i n e m y o m a t a , 
 suspicious altera t ions in the m u s c 1 e - fi b e r s of the 
 myoma strongly suggesting sarcomatous t r a n s f o r m a - 
 t i n . 
 
 E. H. S., white, aged twenty-nine, married. Admitted October 17: dis- 
 charged December 1, 1905. The patient has had no children and no miscar- 
 riages. She is a frail woman: the hemoglobin is 75 per cent. 
 
 Operation. Supravaginal hysteromyomectomy. The highest temperature 
 was 100.4° F. Recovery was uninterrupted. 
 
 Path. No. 9129. The specimen consists of an enlarged uterus, with the 
 tubes and ovaries attached. The uterus, which is multinodular, is 15 cm. in 
 length, 11 cm. from side to side, 12 cm. in its anteroposterior diameter. It is 
 riddled with nodules, subperitoneal, interstitial, and submucous. The uterine 
 mucosa varies from 2 to 6 mm. in thickness. The appendages are normal. On 
 section, the largest myoma shows a moderate amount of disintegration. 
 
 Histologic Examination. — Sections from the endometrium show that the 
 mucosa is greatly thickened. The glands themselves are perfectly normal, 
 although they show a slight tendency toward hypertrophy. The superficial 
 portions of the mucosa show marked edema. Sections from the large myoma 
 show marked hyaline degeneration and considerable li([uefaction. Here and 
 there throughout the liquefied areas are deeply staining nuclei and nuclei two or 
 three times the natural size. On examination of further sections we note the 
 appearance of unrest in the myomatous tissue. On careful examination of the 
 muscle-cells the majority are found to be swollen endothelial cells of the capillaries, 
 w^hich stain rather deeply. There arc, however, nuclei that are twic(> the natural 
 size and stain intensely. Then, here and there, are bunches of two or three 
 nuclei, also staining rather deeply, antl masses of jjrotoplasm containing six 
 or seven nuclei in a row. The {)icture is, on the whole, rather susjjicious, but 
 the cell alterations are not suthciently marked to enable us to say i>ositively 
 that there is any malignant change. Furthermore, at no point do we find evi- 
 dence (jf nuclear diN'ision. "We should l)e inclin('(l to look upon this as a benign 
 myoma, but from a clinical stan(li)oint would adxisc removal of the uterus. 
 The appearance in this case is another link in the chain that suggests to us most 
 strongly the I'ole a])])ai'entl\' played !)>■ hyaline transformation and liiiuefaction 
 in a sarcoma develoj)ing in a myoma. The muscle-libers are sepai'ated fi'oni each 
 other and are loosened up, the.^e changes affording them an increased chance 
 of undergoing further development, in other words, of becoming larger.
 
 260 AIYOMATA OF THE ITERUS. 
 
 Gyn. No. 12297. Path. No. 8887. 
 
 Suspicious histologic changes in a subperitoneal 
 myoma which has been shelled out of the uterus. 
 
 y. McC, white, aged thirty-two, married. The patient's menstrual periods 
 have been perfectly regular, and she has had eleven children, but no miscarriages. 
 Urination has been increased in frequency for the last four months. About two 
 months ago she noticed some abdominal enhirgement, but has had no marked 
 discomfort, except pain in the lower abdomen at night. There has been slight 
 fever, but no nausea or vomiting. 
 
 Operation. Myomectomy and appendectomy. There were five myomata; 
 the large one was pedunculated; all were removed without difficulty. The 
 patient made a very satisfactory recovery. 
 
 Path. No. 8887. The specimen consists of five myomata, the largest 15 x 9 x 6 
 cm. It is markedly lobulated, but is smooth and glistening. At one point there 
 is a raw area, 4 x 2.5 cm., corresponding to the uterine attachment. On section, 
 this myoma, over an area 3 cm. in diameter, presents a dark-mottled appearance. 
 There is considerable softening; in fact, the tissue is porous-like. This shows 
 how difficult it is to tell at operation whether or not the myoma is undergoing 
 degeneration, although in this case the area of degeneration reaches to within 
 2 mm. of the surface. In a very short time the omentum would have become 
 adherent, and l)efore long the uterine attachment would have been very small. 
 The other nodules are quite small, the largest one being 2.5 cm. in diameter; they 
 offer nothing of interest. 
 
 Histologic Examination. — Certain portions of the large tumor show distinct 
 hyaline degeneration. There are also areas of coagulation necrosis, with here 
 and there quite a number of pohmorphonuclear leukocytes. Some areas of the 
 myomatous muscle are strikingly well ])reserved, considering the degeneration. 
 There is no definite clue as to any marked sarcomatous changes, but one gets the 
 general impression that there is a slight tendency toward malignancy, 
 
 C. H. I. No. 686. Path. No. 8829. 
 
 Interstitial and sub 111 u c o us u t c r i n e m y o m a t a ; s u b - 
 m u c o u s m y o m a u 11 d c i' g o i n g hyaline changes and d i s - 
 i n t (' g r a t i n , a n tl p r e s e n t i n g a j) i c t u r e t h a t m i g h t 
 readily b e mist a k e n f o r s a r c o m a . 
 
 H. ^^'., white, aged forty-two, married. Admitted July 3; discharged 
 July 30. 1905. 
 
 Operation, alxlominal hysterectomy and appendectomy. The patient made 
 an uninterrupted recovery. Her highest postoperative temperature was 101.4° 
 F., twent^'-four hours after operation. 
 
 Path. Xo. SS29. The six'ciiiicn consists of a myomatous uterus and of the 
 apjx'iidix. The uterus is Ki cm. l)road, 12 cm. in length, and 16 cm. in its antero- 
 posterior diameter. The increase in size is due to the presence of a myoma, 8 cm.
 
 MYOSARCOMA OF THP: UTERUS. 261 
 
 in diameter, occupying the posterior wall, and also of numerous smaller nodules. 
 The uterine cavity is distorted b}^ a myoma which projects into it and com- 
 pletely fills it. The mucosa covering this myoma varies from 2 to 3 nun. in 
 thickness. 
 
 Histologic Examination. — In sections from the endometrium the cervical 
 glands are somewhat dilated. The epithelium lining the body of the uterus is 
 intact, the glands are normal, and show some tendency to extend into the depth. 
 
 The myoma projecting into the uterine cavity shows a great deal of hyaline 
 degeneration, especially in its superficial portion, and the degeneration is of such 
 a character that one might readily mistake the remaining fibers for an infiltra- 
 tion by a new-growth. Portions of the myoma have undergone complete 
 coagulation necrosis. In the suspicious areas there is a great deal of fibrous 
 tissue, and then swollen islands of muscle-fibers which stand out sharply in the 
 tissue and give a suspicious appearance. The changes are due entirely to hyaline 
 degeneration and disintegration, and we do not for a moment think thiit there 
 is any sarcoma.
 
 CHAPTER X\'. 
 CARCINOMA OF THE CERVIX ASSOCIATED WITH UTERINE MYOMATA. 
 
 Myomatous growths suj)i)ly about one-eighth of the pathologic conditions in 
 gynecologic work, and carcinoma of the cervix is by no means rare. Hence 
 it is perfectly natural that the two conditions should occasionally be met with in 
 the sani(> individual. In discussing the association of the two diseases, it is not 
 our intention to include the cases in which only very small myomata existed, but 
 chiefly those in which the presence of the myomata* caused a material increase 
 in the size of the uterus. 
 
 In " Adenomyoma of the I'terus" (p. 206) six cases of squamous-celled car- 
 cinoma of the cervix associated with adenomyoma of the body are described. 
 In Chapter XXTII two autopsies on patients suffering from carcinoma of the 
 cervix and uterine myomata are given in detail. 
 
 In addition to these 8 cases, we have had 10 others — making 18 in all — in 
 which the myomatous uterus was also the seat of carcinoma of the cervix. 
 
 In Case 4007, in which the carcinoma of the cervix was well marked (Fig. 
 170, ]). 2()5), there was a subnmcous myoma 4 cm. in diameter. 
 
 The uterus in Case 1135 was densely adherent and contained a myoma 5 cm. 
 in diameter. A carcinoma of the cervix had extended to both broad ligaments. 
 
 In Case 7086 the uterus was the seat of far-advanced carcinoma of the cervix, 
 and the fundus contained an interstitial myoma 5 cm. in diameter. A successful 
 abdominal hysterectomy was performed. 
 
 In Case 9004 the cervix was occupied by a fungating carcinomatous mass. 
 The body of the uterus, owing to the presence of myomata, was four times its 
 natvu'al size. It was densely adherent. A successful panhystcrectomv was 
 performed. 
 
 In (!yn. No. 112Uo a hard, movable myoma, the size of a child's head, rose 
 from the pelvis and extended almost to th(^ umbilicus. The cervix had been 
 replaced by a fi-iable growth which involved the vagina on all sides and extended 
 to the broad ligaments. The di.-;ease was too far advanced to warrant operative 
 interference. 
 
 In Case 7819 (Fig. 171, p. 2()S) the cervix was occupied by a far-advanced 
 carcinomatous tumor. The uterus C(jntained an interstitial and pai'tly sub- 
 mucous myoma, nearly 5 cm. in diameter. Its outer surface had undergone 
 
 * In Ca.ses 5498, 6062, 7428, 7.304, 7N4U, 12:313, 12()1(), in which carcinoma of the cervix was 
 found, myomata varying from the size of a pea to that of a walnut w^re also present. In these 
 cases the myomata were too small to have much clinical significance. 
 
 262
 
 CARCINOMA OF THE CERVIX ASSOCIATED WITH UTERINE MYOMATA. 263 
 
 Fui. 169.— Squamous-celled Carcinoma of the Cervix; SuBPERiTONEAt, am. Imiusthmi. M^.imm \, l)orni.E 
 PyosAi.i'iNx; Cyst ok Left Ovary, (i ilhiiii.) 
 
 Gyn. No. 13050. I'ath. No. 10077. The piitieiit \v:i.s colored, aged forty-lhree, aiil h:i.l ii.-vcr lic.-n i.rcKiiuiit . 
 Abdominal hysteiectoiuy was porfortued. She made a .satisfactory recovery. 
 
 The cervix is occupied by a ty|.ical carciiiomatovis urowth, and surroundiiiK it is a cutT of vaginal mucosa. 
 The body of the uterus is studded with myomala, the Wirgest of which is C. x 7 cm. .Mtached to one of the nodules 
 is an omental adhesion which carries .several vessels to the tumor. Itxli l:ill..i.ian i.flM- an- (died with pus. and 
 the left ovary contains a small cyst.
 
 264 MYOMATA OF THE UTERUS. 
 
 coini)lete calcification, tlic calcareous material foniiiiig a mantle averaging 1 to 
 2 nun. in thickness. 
 
 In the following cases onlv the salient features are detailed. 
 
 Gyn. No. 1135. 
 
 Carcinoma of the cervix, myoma in the body of 
 the uterus. 
 
 H. W.. wliitc. married, aged forty-seven. Admitted December IS, 1891; 
 discharged January 20. 1892. The patient has been married twenty-four 
 years ami has had four children. The menses commenced at thirteen, were 
 regular, lasting three tlays, and accompanied by some pain. She has had quite 
 a profuse leukorrhea for one year. 
 
 On vaginal examination the outlet was found to be relaxed ; the cervix was the 
 seat of a carcinomatous growth. There was induration in both broad ligaments. 
 
 Operation, December. 13, 1891. Vaginal hystero myomectomy. 
 
 A myoma, 5 cm. in diameter, was found in the ])ody. Con.siderable diffi- 
 culty was experienced in removing the uterus on account of dense adhesions. 
 The temperature rose to 100.3° F. on the first and second days, after which 
 it fell to normal. The patient was discharged apparently well. Later, however, 
 she had a recurrence, and died in February, 1893. 
 
 Gyn. No. 7086. Path. Nos. 3373 and 3390. 
 
 S q u a m o u s - c (' 1 1 c d carcinoma of the cervix; inter- 
 stitial m y o m a of the bo d }' o f t h c u t e r u s . 
 
 C. H., white, married, aged sixty. Admitted July 20; discharged August 
 31, 1899. The patient has had three children. The menopause occurred at 
 forty-nine. For six months the patient has had a bloody discharge, moderate 
 in amount, occurring every few days. On ether examination the outlet is found 
 to ])(' decidedly relaxed. The vagina is fined \nth a dark, necrotic looking, 
 foul-smelling material. l''rom the cerxdx projects a mushroom-like growth, which 
 is dark brown, mottled in ai)pearance, and somewhat necrotic. It breaks down 
 readily under the examining finger. 
 
 The cer\dcal growth was first curetted away on August 31. 1899, and a pan- 
 hysterectomy with enucleation of the glands was done. The disease extended 
 on the left side out into the broad ligament. The patient made a very satisfactory 
 recovery. 
 
 Path. No. 3373. Examination of the tissue removed from the cervix shows 
 that it is a typical squamous-celled carcinoma. 
 
 Path. No. 3390. The .specimen consists of the uterus, tubes, ovaries, and 
 several lymph-glands. The uteius is 11 x G x (3 cm. The cer\'ix is dense and 
 brawny, and to the touch feels like a hard, twisted rope. The os pre.sents a 
 funnel-.shaped depression, which implicates the entire cerxdx. The fundus is
 
 CARCINOMA OF THE CERVIX ASSOCIATED AVITH UTERINE ^lYOMATA. 
 
 265 
 
 irregular and globular in form, anil on section an interstitial myoma, 5 cm. in 
 diameter, is found, which has distorted the uterine cavity considerably. The 
 uterine cavity is approximately 7 cm. in length; at the fundus, 3 cm. in breadth. 
 The lymph-glands removed show no microscopic evidence of carcinoma. 
 
 Gyn. No. 4607. Path. No. 1304. 
 
 Early s c| u a in o u s - c e 1 1 e d carcinoma of the cervix 
 and s u 1^ m u c o u s m y o m a o f the body of the u t e r u s 
 (Fig. 170) . 
 
 L. D., married, white, aged forty-five. Admitted August 20; died Sep- 
 
 c a re 1 n o ma 
 
 Fig. 170. — Squamois-cki.i.ki) C.mici.nom v ok tiii: Ckrvix and SuHMrrors Myoma ok tiik Hodv ok tiik riKius. 
 
 (0 nat. size.) 
 Gyn. No. 4607. The cervix is the seat of an early carcinoma, wliicli nii^;lil li.ni' ln'cn iT:i.iil\ nviMln.ikcil at 
 operation. Projecting into the uterine cavity is a myoma, 4 cm. in iliamctcr; a >iiliinu<'iius mynma is iniiicalcii 
 by M. 
 
 tember 1, bSOG. The patient has l)een married (wenty-onc yc:iis, and lias had 
 six children and one miscarriage. The meii.^es were icuuImi- until the last two 
 years. Since then they have been profuse, ahnost coiitinuous. and offensive 
 in odor. About a year and a Imlf ;igo she had an attack of a|)|)('ii(licitis.
 
 266 MYO.MATA OF THE UTKRUS. 
 
 Oi)eniti()n. August 31, 1S96. Panhysterectomy. Vagiual* hysterectomy 
 was exceed iii.uly didicuh on account of the hip-joint (Usease from which the 
 l)atient was suffering. At the end of the opei-ation the patient's pulse could 
 scarcely be felt. There had been considerable loss of blood during the opera- 
 tion. She never rallied, and died twelve hours later. 
 
 Path. No. 1304. The sjx'ciincn consists of the uterus with its left appendages 
 intact. The uterus is 1()- cm. long, 8 cm. broad, and 8 cm. in its anteroposterior 
 diameter (Fig. 170). Its surface is covered with dense vascular adhesions. 
 On tlic anterior surface is a small myoma, 7 mm. indiameter. The cervix is 3 cm. 
 in diameter, and is exceedingly firm and resistant. The jjosterior cervical lip 
 is somewhat everted. The vaginal portion is smooth, but the cervical ])orti()n 
 presents a roughened and granular surface. The anterior lip has an ulceratetl 
 area in its left side, from the floor of which stand out many delicate papillary 
 projections. The uterine cavity is 5.5. x 4.5 cm. Projecting into the cavity is a 
 subnuicous myoma, 4 cm. in diameter. Over this the nmcosa is markedly 
 atrophied. .Microsco})ically, sections from the cervix show the typical picture 
 of s([uam()us-celled carcinoma. The uterine mucosa over the submucous myoma 
 is much thinned out, but is otherwise normal. 
 
 Gyn. No. 9004. Path. Nos. 5176 and 5223. 
 
 S ( I u a m o u s - c e 1 1 e d carcinoma of t h e c e r v i x ; m y o m a t a 
 of the body of the uterus; pelvic adhesions. 
 
 M. W., aged forty-nine, black. Admitted August 22; discharged October 
 15, 1901. Complaint, uterine hemorrhages. The menses began at fourteen and 
 were perfectly regular, lasting from five to six days, until thirteen months ago. 
 Since then the patient has had a slight continuous Ijleeding ])ractically every day. 
 Occa.sionally the discharge is rather free and contains numerous clots. On two 
 occasions she has had a sudden sharp hemorrhage, losing a pint or more. She 
 has had three children, the youngest nine years of age. Recently the patient 
 has lost from fifty to sixty pounds. For two weeks she has been so weak that she 
 has been unal)le to do any work. She is very anemic; the hemogloinn is 34 
 per cent. On vaginal examination the cervix is nodular and hard, one of the 
 nodules l)eing fully 3 cm. in diameter. The uterus is in the midline, the size 
 of that of a four months' pregnancy, and very adherent. 
 
 Operation. The cervix was first curetted. Several days later a vaginal 
 hysterectomy was performed. The patient rapidly recovered, and left the 
 hospital in good condition. 
 
 Path. No. 5176. The growth is a sfpiamous-celled carcinoma of the cervix. 
 
 Gyn, No. 11 293. 
 Carcinoma of the cervix; large myoma of the body 
 of the u t e r u s . 
 
 * Vaginal hysterectomy for carcinoina is now never employed by us wiien tlie alxlominal 
 route can be adopted.
 
 CARCINOMA OF THE CP]RVIX ASSOCIATED AVITH UTERINE MYOMATA. 267 
 
 L. D., colored, aged fifty-five, married. Admitted May 17; discharged 
 May 27, 1904. The patient has had four children, the youngest thirty years of age. 
 The menopause occurred at forty. For the past thrive months the patient has 
 noticed a profuse discharge from the vagina. This at first was whitish in color, 
 but lately has become bloody and foul-smelling. During the past two months 
 she has complained of a dull aching pain in the lower abdomen, more pronounced 
 in the left side. This has gradually increased in severity. The bowels have been 
 constipated. The abdomen is very lax, and extending up from the pehds to 
 tlie uml:)ilicus is a hard, movable tumor mass as large as a child's head. The 
 cervix has been replaced by a friable growth, which involves the vagina on all 
 sides and extends out into both broad ligaments. Filling the pelvis is a large 
 multinodular mass which was detected through the abdomen. The disease 
 was too far advanced to w^arrant operation. 
 
 Gyn. No. 7819. Path. No. 4074. 
 
 S c} u a m o u s - c e 1 1 e d c a r c i n o m a of the cervix ; s u b - 
 peritoneal and interstitial uterine m y o m a t a ; sub- 
 acute salpingitis and peri-oophoritis ( Fig. 171) . 
 
 8. B., white, aged forty, married. Admitted May 15; discharged June 12, 
 1900. Her father died of cancer of the throat; otherwise the family history 
 is unimportant. The patient has been married twenty years and has had two 
 children, the youngest seventeen. The labors were normal. Several weeks 
 ago she noticed a slight reddish discharge and complained of sharp pain in the 
 lower part of the abdomen. This pain has now become localized on the right 
 side. The attack was accompanied by nausea and vomiting and a feeling of 
 faintness. The discharge has gradually increased in (juantity up to the present 
 time, and has assumed a sanguino-purulent character. The patient is pale and 
 poorly nourished. Hemoglobin, 35 per cent. 
 
 Operation, May 17, 1900. Panhysterectomy. The ])atient made a fairly 
 satisfactory recovery, and was discharged June 12, 1900. 
 
 Path. No. 4074. The specimen consists of the uterus, tubes, and ()^■aries. 
 The uterus measui'es 12 x 8 x S cm. The ])ostei'i()r siu'face is covered with ad- 
 hesions, and on the anterior surface is a very small myoma. Posteriorly, the 
 uterus presents a large rounded boss, very htird, which on section ))roves t(^ be an 
 interstitial myoma 6 cm. in diameter (Fig. 171). The peripheral portion has 
 undergone calcification, and the center shows coagulation necrosis. The cer\ix 
 is also enlarged and resistant; it feels nodular, and is a})proximately cm. in 
 diameter. The vaginal ])ortion on the right sitle is irregular in out Hue, but is 
 co^•ere(l with smooth mucosa. The eerxix to the left side ])reseiits a lai'ge. ci-atei- 
 like area, 3 to 5 cm. in diameter, and about .'! cm. in depth. The base of tiiis 
 presents a roughened, granular surface, with here and there masses of delicate, 
 friable-looking papilhe. It is, for t he most part, surrounded by a band of smooth 
 vaginal nuicosa, but at one {)oint, for a distance of I cm., tlie growth ap{)arently
 
 268 
 
 MVO.MATA OF THK UTERUS. 
 
 extends to the cut Illal•,^■in. The cervieal canal is 3 cm. long, and posteriorly is 
 lined with smooth nuicosa. Anteriorly, however, the walls are composed of 
 a new-growth, and the entire inner surface is ulcerated. The cervical walls 
 average 1.5 cm. in thickness, and are penetrated by the growth to within less 
 than 1 mm. of the outer surface. The cut surface of the growth consists of a 
 y(41owish-white, gramilar material, traversed by delicate fibrous bands. The 
 gi'owth has extcMulcd to the internal os. The uterine mucosa is injected, but 
 
 Fig. 171. — SijUAMors-rKLLKD Carcinoma of the Cervix; Partially Calcifip;i) iNTr.itsrniAh Mvoma in the 
 
 Body of the Uterus. (| nat. size.) 
 Gyn. No. 7819. Path. No. 4074. The cervical growth i.s far advanced, and has extended almost to the cut 
 surface. The interstitial and partially submucous myoma is surrounded by a calcareous mantle (a), easily recog- 
 nized by its white, jagged contour. 
 
 otherwise noi'inal. < >n the right side the tube and ovary ai'e bound together by 
 adhesions. ( )ii the left side the a])})endages are also coN'ered with dense adhe- 
 sions. 
 
 Microscopically, the growth proves to be a ,s(|uamous-celled carcinoma of the 
 cervix. 
 
 Ill the above cases the diagnosis of carcinoma was perfectly clear on digital 
 examination, but if the physician had known that myomata had existed for a
 
 CARCINOMA OF THE CERVIX ASSOCIATED WITH UTERINE MYOMATA. 269 
 
 long time, he might readily have supposed that the hemorrhage and offensive 
 discharge came from one of the nodules that had become submucous and was 
 sloughing. In all myoma cases in which no operation is deemed necessary it is 
 advisable to make a vaginal examination from time to time to determine if, by 
 any chance, a carcinoma of the cervix is developing. 
 
 Cases of Early Carcinoma of the Cervix Associated with Myomata. 
 
 In such cases the malignant growth of the cervix might readily be overlooked. 
 Case 12725 affords a striking example of such a condition. The external os was 
 slightly patulous. The surface of the cervix was a little roughened, but ''not 
 suggestive of malignancy." The body of the uterus was somewhat enlarged, 
 and slightly irregular in outline. Vaginal hysterectomy was performed. An 
 interstitial myoma, 3x3x2 cm., was found in the fundus. On removal, the 
 cervix macroscopically looked normal, but was slightly indurated. 
 
 On histologic examination we found the cervix the seat of the earliest scjua- 
 mous-celled carcinoma we have ever encountered. Had an abdominal supra- 
 vaginal hysterectomy been done instead of total vaginal hysterectomy, we 
 would ere long have had a well-marked carcinoma of the cervix, and would 
 have classed it as a carcinoma developing in the cervix after removal of the myo- 
 matous uterus, whereas the growth, though clearly present at the time of the 
 operation, would have been overlooked. 
 
 In Case 2432 the patient was in a weakened condition. The pelvis was filled 
 with a large myomatous uterus, to which the omentum and bowel were adherent. 
 Had hysterectomy been attempted, the patient would have undoubtedly died 
 on the table. Examination of the cervix showed adenocarcinoma. 
 
 In Case 6330 the position of the cervix, which was jammed uj) behind the 
 symphysis, rendered the detection of the cancer very difficult. The uterus 
 seemed much enlarged. On examination under ether, however, the true character 
 of the condition was readily ascertained. In the vagina were several indurated 
 areas, one of which was apparently about to ulcerate. The cervix was nuich 
 thickened and friable, and I'eadily bi'oke down uiulcr the finger. Tiie body of 
 the uterus was the size of a three months' pregnancy, owing to th(> presence 
 of a myoma. Histologic examination showed that the cervical growth was 
 a squamous-celled carcinoma. 
 
 In Case 13015, in which a multii)licity of pathologic })rocesses existed, and 
 in which a supravaginal hysterectomy was done, a very small carcinoma occupying 
 the upper part of the cervix and lower i^art of the body (Fig. 172. j). 272) was 
 totally overlooked until cxainiiicd in the laboi'alory. Ibid the opcratoc known 
 carcinoma of the cervix was {)resent, however, it wonld have made little differ- 
 ence, as the independent and primary carcinoma of the ovary had already 
 given rise to many metastases throughout the abdominal cavity, and the op- 
 eration was therefore merely palliative, not radical. In this case the uterus 
 contained numerous small myomata. subperitoneal, interstitial, and submucous.
 
 270 MYOMATA OF THK TTERIS. 
 
 Gyn. No. 12725. Path. Nos. 9502 and 9546. 
 
 Interstitial 111 y u 111 a in t h c 1) o d y o f t li c u t c r 11 s ; v r y 
 early s q u a ni u u s - c e 1 1 e d carcinoma of t h e c e r ^' i x . 
 
 S. C. E., white, aged thirty-seven, married. Admitted February 24; 
 discharged March 21,1906. This patient was admitted to the hospital several 
 years ago (Gyn. No. 5864) with a diagnosis of extra-uterine pregnancy. After 
 operation she made an uninterrupted recovery. The ])atient has been bleeding 
 steadily for the ])ast two months and has had almost constant ))ain in the lower 
 abdomen on both sides. On vaginal examination the cervix was found to 
 present a peculiar hardness, although there was practically no breaking down 
 and although, as mentioned in the history, there was no suggestion of malignancy. 
 The body of the uterus was considerably enlarged. 
 
 Operation, Febiiiary 28, 1906. A'aginal hysterectomy. Convalescence un- 
 eventful. 
 
 Path. No. 9546. The uterus is 12 cm. li)ng. The cervix looks normal. 
 Occupying the fundus is an interstitial myoma 3x3x2 cm. 
 
 Histologic Examination. — Sections from the cervix show just a few cells 
 beginning to proliferate and to invade the stroma. Had it not been for the scrap- 
 ing ])rior to operation, it would have been very difficult for us to have said with 
 ab.solute certainty that we were dealing with a malignant growth. The combined 
 picture, however, leaves no doubt whatever that we have an early squamous- 
 cellcd cai'cinoma. 
 
 Gyn. No. 2432. Path. Nos. loi and 119. 
 
 A m y o m a tons u t e r u s ; c a r c i n o m a o f the c e r v i x . 
 
 S. B.. white, aged thirty-three, single. Admitted November 28; died 
 December 26, 1893. Seven months before admission the patient first noticed 
 a tumor in the lower abdomen in the left side, and for the past three weeks she 
 has been complaining of severe pain in the pelvis and has been confined to bed. 
 During the last few months the periods have increased in duration and the flow 
 has been excessive. Menstruation has l)eeii iiTegular. The cervix was found 
 to be the seat of a carcinomatous growth. 
 
 Operation, December 2. 1893. On section, the pelvis was found filled with 
 a myomatous uterus to which the omentum and bowel were adherent. It was 
 impossible to attempt enucleation on account of the weak condition of the patient. 
 As a palliative mea.sure the uterine arteries were clamped on both sides and the 
 vagina was packed with gauze. The i)atient improved for a time, t hen lost ground 
 and died DecemlxT 26th. The enlargement of the body of the utems was caused 
 by nmltiple myomata. The growth of the ceiA'ix on histologic examination 
 proved to be a carcinoma. 
 
 Gyn. No. 6330. Path. No. 2584. 
 
 S q u a m o u s - c e 1 1 e d c a r c i n o m a o f t h e c e r \- i x ; m y o m a 
 in t h {' b o d v of t h e u t e r u s .
 
 CARCINOMA OF THE CERVIX ASSOCIATED WITH UTERINE MYOMATA. 271 
 
 M. M., colored, aged fort3'-.seven, married. Admitted August 30: dis- 
 charged September 20, 1898. Complaint, pain in the lower abdomen and pain- 
 ful micturition. For the last four months the patient has had a profuse yellowish, 
 offensive leukorrheal discharge, and for a month has noticed a dull aching pain 
 in the back and radiating down the legs. The ])ain at times has been cramp-like 
 in character. ^Micturition has increased in frequenc}', and has been attended 
 with considerable pain. During this period she has also lost much weight. On 
 vaginal examination the outlet is found to be relaxed. The cervix is jannned 
 up behind the symphysis, and the uterus is apparently much enlarged, retroflexed, 
 and immovable. On ether examination the exact condition of affairs is readily 
 ascertained. The vagina is very large. At the junction of the anterior and 
 lateral wall on one side is a thickened area, irregular and roimded. about 2.5 cm. 
 in diameter, rising above the surrounding tissue. The mucous membrane 
 over this is reddened and apparently about to ulcerate. There is a similar 
 thickened area low down in the vagina on the left side, and several smaller thicken- 
 ings on the posterior wall. The surface of the cervix is roughened and readily 
 breaks down under the examining finger. The body of the uterus is irregular, 
 large, and nodular, the size of a three months' pregnancy, and markedly adherent 
 posteriorly. The clinical diagnosis is carcinoma of the cervix, myomatous 
 uterus incarcerated in the pelvis, secondary carcinoma of the vaginal ^^•all. On 
 September 2 the upper part of the cervix was curetted away. The ai)doinen 
 was opened, the incarcerated myomatous uterus freed, but the carcinomatous 
 process in the cervix had extended too far to permit of removal of the uterus. 
 
 Path. No. 2584. Histologic examination showed the growth to l)e a typical 
 squamous-celled carcinoma of the cervix. 
 
 Gyn. No. 13015. Path. No. 10033. 
 
 Multiple a n d s m a 11 u t e r i n e m y o m a t a ; p r i m a r y c a r - 
 c i n o m a o f the up p e r part of the cervix and 1 o w e r p a r t 
 of the b o d y ; p r i 111 a i- y c a r e i n o m a o f t h e o v a r y , wit h 
 w i d e - s p r e a d m e t a s t a s e s (Fig. 172). 
 
 S. G., white, married, aged fifty-one. Admitted .hiiie 16; discharged 
 July 14,1906. Complaint, a tumor in the abdomen. The mciioiiause occurred 
 five or six years ago. Since then there has been no bleediiii;-. {•'ifteen nioiiths 
 ago \hv. ])atieiit consulted her j)hysi('ian on account of grij)ing pain in the abdomen. 
 Although the pain was general in character, it was more marked in the rigiit side. 
 At this time she found that she had a tumor tiie size of a list. Since then there 
 has been a gradual abdominal enlargement. She lias noticeil some swelling of 
 the feet and also enlargement of the veins on the light side. 
 
 On section, several fjuarts of daik-brownish fluid escaped fioin the aiidoinen. 
 An ovarian cyst was found in the right side. The small intestines e\-erywhere 
 were covered with nodules ] to 2 mm. in diametei', and t he a])])en(lix had siniilai' 
 nodules on its surface. No tlelinile metastases wei'e found in the oineiituni, al-
 
 272 
 
 MYOMATA OF THE UTERUS. 
 
 though it was thifkciiccl and its vessels were dihited. Numerous small vessels 
 were attached to the left ovary. kSupravaginal hysterectomy was performed. 
 The patient was discharged twenty-three days after operation. 
 
 Path. No. 10033. Th(» uterus has been amputated through the cervix. It 
 is 4.5 cm. ill length, 5 cm. in breadth, and 4 cm. in its anteroposterior diameter. 
 It is covered with adhesions. On the surface are several small })edunculated 
 myomata, the largest 1 cm. in diameter. There is also a small submucous myoma 
 2 cm. in tliameter, situated in the ])osterior wall. The upper part of the cervix 
 and the lower part of th(> body are occupied by a growth apparently 2 cm. in 
 length. This is porous in ap]iearance and sugg(^sts carcinoma. Occupying what 
 
 ova 
 
 r > 
 
 ""' c i n o m a. of 
 
 Fig. 172. — Multipi.k Small Uterine Myomata; Primary Carcixoma of thk Ovary; Primary Carcinoma 
 
 OF the Uterus. (| nat. size.) 
 Gyn. No. 13015. Path. No. 10033. The specimen is seen from the front. The uterus contains several myo- 
 mata — subperitoneal, interstitial, and submucous. Occupying the upper part of the cervix and the lower part 
 of the body is an early carcinoma. This has been cut through and a portion left behind. The right ovary has 
 been converted into a cystic tumor filled with papillary masses, which have at one point perforated the cyst-wall 
 and reached the peritoneal surface. As mentioned in the history, wide-spread metastases were found in the abdom- 
 inal cavity, a is a corpus luteum which has not ruptured. 
 
 corresponds to the right ovary is a tumor 14 cm. in diameter. This is covered 
 with adhesions, is pearly white in appearance, but has areas of mottling. On 
 section, the cyst is found to be partly cystic, with little masses projecting from 
 the surface. To a great extent, however, it is solid, having cauliflower-like 
 masses projecting into the cavity. Some of these masses resemble ])rain tissue. 
 The solid portion is 5 cm. in thickness. 
 
 Histologic Examination. — The tumor of tlu^ right ovary consists of masses 
 of papillary outgrowths of all kinds. In sonu^ places the glands are large, in 
 others exceedingly small. The gland epithelium here and there has prohferated, 
 but, as a rule, is well preserved. We have a characteristic picture of adeno- 
 carcinoma. The nuclei of the cells, on the whole, are very uniform.
 
 CARCINOMA OF THE CERVIX ASSOCIATED WITH UTERINE MYOMATA. 273 
 
 The friable area in the cervix, suggesting niahgiiancy, proves to be carcinoma. 
 We have glantl-Hke spaces hned with one layer of very high cylindric epithelium. 
 In some places the glands are completely filled with young secondary glands, 
 and at other points the epithcliuni of these secondary glands lias so proliferated 
 that we have masses of cells which, under the low power, closely resemble epi- 
 thelial pearls. The individual epithelial cells are fairly uniform in size. Here 
 and there, however, are large vesicular nuclei, irregular nuclei, and a great 
 numl)er of nuclear figures. There is a certain amount of disintegration. The 
 growth is an adenocarcinoma and is apparently independent of the carcinoma 
 of the ovaiy. Along its advancing margins there is considerable small-round- 
 celled infiltration. 
 
 In this case we have multiple uterine myomata, two malignant processes, 
 one commencing in the ovary and forming metastases over the surface of the 
 intestines, the other a primary carcinoma originating in the cervix and lower 
 part of the body of the uterus. 
 
 IS
 
 CHAPTER XVI. 
 
 ADENOCARCINOMA OF THE BODY OF THE UTERUS ASSOCIATED 
 WITH UTERINE MYOMATA. 
 
 In our examination of over 1400 cases of myomatous uteri adenocarcinoma 
 was detected in the body of the uterus in 25 cases (about 1.7 per cent.) : Adeno- 
 myomata associated with adenocarcinoma of the body (see "Adenomyoma 
 of the Uterus/' p. 218), 3 cases. Myoma and adenocarcinoma of the uterus 
 seen at autopsy, 6 cases (see p. 404). Myoma and adenocarcinoma of the 
 body of the uterus, operated upon, 16 cases.* 
 
 Clinical History. — The accompanying histories demonstrate that in 
 most of the cases myomata had been present for several years, that for 
 some months or a year before admission uterine hemorrhages had been noted, 
 and that between periods there had been a watery and offensive vaginal discharge. 
 
 Color. — In 15 out of the 17 cases in which definite d'dta. could be obtained 
 the patients were white. 
 
 Age. — In 17 cases we have data as to the patient's age. The periotl at 
 which the carcinoma has l)een detected corresponds to the decade of hfe 
 during which carcinoma of the body of the uterus is usually found. The 
 youngest |)atient was thirty: the oldest, sixty-four. 
 
 Between thirty and forty — 2 cases. 
 Between forty and fifty — 5 cases. 
 Between fifty and sixty — S cases. 
 Between sixty and seventy — 2 cases. 
 
 17 cases. 
 
 The association of sterility with the development of carcinoma of the 
 body of the uterus was emjjhasized by us scn'eral years ago.f Our previous 
 experience is strikingly supported by the table on p. 275. 
 
 Out of the 17 patients, 6 were single and o more had never been pregnant. 
 Of the remaining 8 patients, 3 had had one miscarriage each, but had never born 
 full-term children. Thus, 12 out of the 17 had never been delivered of a child at 
 term. The remaining 5 women had given birth to 12 children. Sterility cer- 
 tainly seems to be in some way closely associates 1 with the development of adeno- 
 carcinoma of the body of the uterus. 
 
 * In Cases 2832, 32.>S, and 12771 myomata ami adcnocarfinoma of the body of the uterus 
 were found in the same uterus. The myomata were, however, too .small to be of any clinical 
 significance, and these ca.se.s have, accordingh'. been omitted from the tal)le. 
 
 t Thomas S. CuUen, Cancer of the Uterus, page 474. 
 
 274
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 2 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 ADENOCARCINOMA OF THE BODY OF THE UTERUS. 275 
 
 Number of 
 Gyn. No. Married Children Miscarriages 
 
 San. No. 1852 Yes 4 
 
 10220 Yes 4 1 
 
 10085 No 
 
 9141 No 
 
 1069 No 
 
 1691 No 
 
 4262 Yes 1 
 
 5858 No 
 
 5957 Yes 
 
 3295 Yes 
 
 10462 Yes 
 
 10997 No 
 
 9443 Yes 
 
 9012 Yes 
 
 9934 Yes 
 
 K. C. H. I. Nov. 8, 1900 Yes 
 
 3113 Yes 
 
 12 4 
 
 Gross Appearances of the Uterus. — ^The myomata may be situated in 
 any part of the uterus. Most frecjuently they are found in the body, but 
 in some cases are located low down in the cervix. For example in Fig. 175 
 (p. 278) we see a myomatous nodule several centimeters in diameter, situated 
 to the side of the cervix. In Fig. 182 (p. 290) the cervix is much distorted by a 
 large myoma, rendering it as large as the body, which is also much increased in 
 size as a result of the carcinoma combined with interstitial myomatous nodules. 
 
 In Fig. 183 (p. 292) the uterus is several times its natural size. Studding 
 the surface are numerous small myomata, and scattered throughout the walls 
 are several myomatous growths. The chief increase in size is due, however, 
 to a most extensive carcinoma occupying every part of the uterine cavity. 
 
 The uterus shown in Fig. 180 (p. 286) was several times the usual size, ami 
 presented the characteristic myomatous appearance, but there was a peculiar 
 volcanic api:)earance of the outer surface at a. Here, as shown later, the carcinoma 
 had penetrated the entire thickne.'^s of the uterine wall and lay just beneath the 
 peritoneum. 
 
 Occasionally, as in Case 1091, in wliich the enlarged uterus extended four 
 inches above the pubes, a submucous myoma was associated with the carcinoma. 
 
 It must he borne in mind that in nearly e\'ery case tlic myomatous condition 
 partly or conij)ietely obscures the ))res(Mice of the carcinoma. Histologically, 
 these adcnocarcinomata difTer in no way whatever from uncomijlicated adeno- 
 carcinoma of the body of the uterus. 
 
 Diagnosis of Adenocarcinoma. — A glance through the histories of the accom- 
 panying cases will show that in most of them carcinoma was not suspected until 
 after removal of the uterus. Clinically, uterine hemorrhages can be causetl by 
 uterine myomata, and when the iKMhiles become sulnnucous and undergo disin- 
 tegration, a foul and at times watery discharge is the natural accompaniment.
 
 276 
 
 .MYO.MATA OF THK UTKIUS. 
 
 Ill such cases the cervix is iionual and the enlarged and ii're^ular iitcn'us jjresents 
 the chanicteristic luuhilatinu' contour of a tiiultiiio(hihir uterus. As a rule, no 
 niahgnant chanj^c will he found in the uterine mucosa, althou<j;h in a certain 
 percentage carcinoma of the hcdy exists. Tinie, in a goodly number of cases cu- 
 rettage would reveal tlu^ cai'cinoma, hut if we followed these \mv^, (Hux^ting would 
 be clone in many cases in which no carcinoma exists, and in some instances, as, for 
 exani])le, Case 9141 (Fig. 1S2, p. 290), in which there was a very large cervical 
 myoma, the uterus was so distorted that 
 it would be almost imp()ssil)le to reach 
 all parts of the uterine ca\ity with the 
 curet. 
 
 ' Care. 
 
 Fig. 173. — Adenoc.\rci.noma of thk Body of thk Utkri:s, Associ.a^ted with Mvom.\t.\. (J nat. size.) 
 Path. No. 6811. This specimen was sent us by Dr. Paul Owsley, of Chicago, on January 25, 1903. It is not 
 included in our statistics, but is such an excellent example that we have had it drawn. Near the cervix is a small 
 .submucous myoma. Occupying the upi)er part of the body is an early carcinomatous growth which as yet has 
 not broken down. The myoma, occupying the left upper uterine wall, measured S cm. in diameter. The uterus 
 also contained several other nodules. 
 
 Treatment. The association of adeiujcarcinoma of the bod}' of the uterus 
 with myoma in about 1.7 per cent, of the cases would naturally suggest total ab- 
 dominal hysterectomy as a routine proceduic. We know by experience, however, 
 that the supravaginal am])utation is not only the easier operation, but that 
 whei-e the uterus is nuich enlarged and distorted, it is often the only on(> feasible. 
 We feel that in this o])ei-ation there is much h'ss danger of injuring the ureters. 
 If the presence of carcinoma of the body can l)e definitely established or is 
 relatively certain, total hysterectomy .should certainh' be performed. We are
 
 ADEXOCARCIXOMA OF THE BODY OF THF I'TERUS. 
 
 277 
 
 still in favor of the routine supravaginal hysterectomy, with the usual precaution- 
 ary control measures* — opening the uterus to determine if carcinoma exists 
 and cutting open any suspicious ni}-()mata to see if l)y chance sarcomatous changes 
 are present. If malignancy is detected, the cervix is at once removed, ^^^len 
 carcinoma of the body exists, the chances of infection and death are consider- 
 ably increased as a result of the foul vaginal discharge. 
 
 Cases in which Adenocarcinoma of the Body of the Uterus was Associated 
 
 WITH Uterine Myomata. 
 
 Gyn. No. 9443. Path. No. 5671. 
 
 S u b p e r i t o n (> a 1 and interstitial m y o m a t a : a d e n o - 
 c a r c i n o m a o f t h c f u n d u s , p r o b a 1) 1 >• o i' i g i n a t i n g n e a r 
 the internal o s . (Fig. 
 174) . 
 
 D. S., aged sixty-four, white, 
 married. Admitted March 4; dis- 
 charged April 12, 1902. The meno- 
 pause occurred ten years ago. The 
 patient has had two children; no 
 miscarriages. For ten years she has 
 had some pain over the bladder, 
 especially on lying down, and more 
 recently has had constant pain, more 
 marked on exertion. Operation, 
 March 15th. l^anhysterectomy. Re- 
 covery. 
 
 Path. No. 5671. The specimen 
 consists of the entire uterus with the 
 appendages. The uterus is 10 cm. in 
 length, 7 cm. in brcadlh. and 5 cm. in 
 its anteroposterior diameter (Fig. 
 174). The appendages ai'e slightly 
 adherent. Springing from the right 
 uterine horn is a myomatous nodule, 
 3.5 cm. in diameter. The cervix ap- 
 pears normal. The uterine walls 
 vary from 2 to 2.5 cm. in thickness, 
 show diffuse myomatous thickening, 
 and contain some discrete myomatous nodules. The mucosn of the cei'vix in 
 the lower })art looks normal. ()ccuj)ying the upjxT p;irt (if the eei-\i\, and also 
 
 * Thomas S. CuUen, PJxainiiKition of L'teriiie .Mucos i ami .Myniiiatotis Xodulos after Hystcro- 
 myonieotomy to Exclude Malignant Disease, Jour. A. M. A., Marcli 10, 1906. 
 
 Caret aoma 
 
 Fic. 174. — <"arcinoma iwkk 1'aht ok the 
 
 HoDV AND Fl'I'KR I'Mll IH IHK CkKVIX; I'tKRINK 
 
 Myomata. (i iiat. size.) 
 
 Ciyii. No. 944.3. Path. No. 'itul. Tl»e Rreater part 
 of the uterine cavity was the seal of a carcinomatous 
 growth. The uterine walls siioweii <iiffuse myomatous 
 thickeninji an<l conlaineil small discrete myomata. Tlie 
 subperitoneal myoma was '.i.'i cm. in (liameter.
 
 975 
 
 MYOMATA OP^ THK UTKRUS. 
 
 Care. 
 
 the greater ])art of the uterine cavity, is a shaggy growth. In some places this 
 projects fully 1 cm. from the surface. The shagginess in places consists of fine 
 outgrowths, but at other points there are little tongue-like projections. 
 
 On histologic examination the growth in the body of the uterus is found to 
 consist of typical adenocarcinoma, ai)parently of the type that originates in the 
 body. 
 
 Hiiiiaiiual examination of such a uterus would show that the body is con- 
 siderably enlarged and that, 
 on the surface, is a nodular 
 growth. One would at first 
 suppose that he was deal- 
 ing with a myomatous 
 ^^' '' " uterus, but curettage would 
 
 instantly give a pro])er clue 
 as to the diagnosis. 
 
 Gyn. No. 10220. Path. No. 
 6418. 
 
 C e r V i c a 1 m y o m a 
 a s s o c i a t e d ^^■ i t h 
 
 a d e n o c a r c i n o m a o f 
 t h e b o d y of the 
 u t e r u s (Fig. 175). 
 
 N. S., white, married, 
 aged fifty-eight. Admitted 
 January 28: discharged 
 March -S, 1903. 
 
 The periods conunenced 
 at foui'teen and w(>re regu- 
 lar, every four weeks, last- 
 ing four or five days. The 
 
 1. in diameter, and situated in the anterior wall meUOpaUSC OCCUrrcd SeVeU 
 odule 2. .5 cm. in diameter. There is some ilif- r^i, . . , 
 
 Fig. 175. — Midma of thk Ckrvix and CARrixoMA of tiif. Body 
 OF THK Utkrus. (Nat. size.) 
 Gyn. No. 10220. Path. No. 6418. The myoma to the left of 
 the cervi.x wa.s 4 cm. 
 
 was an interstitial nodule -..j ^••,. ^.i i..,v.wcic. . inc.c .=> .lumc mi- rpi • ■ i 
 
 fuse thickening of the uterine walls, and cross-sections of the ycaiS agO. lUC paiieni naS 
 blood-vessels stand out prominently. The carcinomatous growth J^.,,] four children and OUC 
 
 She has had 
 
 uniformly occupies the iipijer part of the cavity and is sharply defineil. 
 
 nad 
 
 miscarriage. 
 
 a leukorrheal discharge for the ])ast year and a half. This at first was yellowish 
 in color, but later assumed a reddish tinge. 
 
 Operation, supravaginal hysterectomy. After removal of the uterus it was 
 split open, and in the fundus was found a ))olypoid friable growth. The rest of 
 the cervix was now removed. The i)atieiit made a satisfactory recovery. 
 
 Path. No. 641S. This specimen consists of the uterus, left tube and ovary, 
 and the remaining portion of the cervix. The jjortion of the uterus measures 
 8 X fi X () cm., and is considcrablv distorted. Proiectinii from the anteriorwall
 
 ADENOCARCINOMA OF THE BODY OF THE UTERUS. 279 
 
 is an interstitial nodule approximately 2.5 cm. in diameter, and from the side 
 of the cervix a myoma 4 cm. in diameter. The cervical canal forms a semilunar 
 slit. The nmcosa lining the cervix is apparently normal. Occupying the body 
 of the uterus is a growth which in places reaches 1 cm. in thickness (Fig. 175). 
 It has a shaggy surface and here and there forms little polypoid masses. It has 
 penetrated the uterine wall for a considerable distance, and has apparently 
 involved the mucosa throughout the greater part of the cavity. The left tube 
 and ovary show nothing of interest. 
 
 Microscopically, the myoma in the anterior wall shows considerable hyaline 
 change. The growth in the body of the uterus is an adenocarcinoma. In most 
 places the gland epithelium has i)roliferated to such an extent, however, that it 
 forms solid masses, and here and there suggests a s([uamous-celled growth. 
 
 From a clinical standpoint the condition might very readily be mistaken 
 
 for a simple myomatous uterus. We have to the left of the cervix a hard nodule, 
 
 a typical myoma, and in the anterior wall just above this a myomatous nodule. 
 
 One would naturally suppose that the hemorrhage had come from the submucous 
 
 myoma. 
 
 Gyn. No. 10462. Path. Nos. 6685 and 6730. 
 
 Carcinoma of the body of the u t e r u s , a p p a r e n t 1 y 
 originating n e a r t h e i n t e r n a 1 o s ; s u b p e r i t o n e a 1 
 m y o m a t a ; pelvic adhesions; sub a c u t e s a 1 ]) i n g i t i s 
 (Fig. 176). 
 
 K. S., white, aged fifty-one, married. Admitted May 5; discharged June 1, 
 1903. The pati(^nt has been married twenty-five years but has never been 
 pregnant. Seven weeks ago she noticed a yellowish vaginal discharge. Six 
 weeks ago hemorrhage began and has continued ever since. The i)atient is 
 rather emaciated and w(>ak. Hemoglobin, 50 \wr cent. 
 
 Operation. The uterus was the size of a four months' pregnancy and was 
 lifted upward with a great deal of difficulty on account of nunici'ous adhesions. 
 On pressure it sutldenly collapsed and a large amount of necrotic material escaj)ed 
 from the cervix, suggesting a pyometra. Two myomatous nodules on the right 
 side were adherent to the pelvic wall, apparentl>' causing a hydroiiretc^r on the 
 right side. On account of the subse(|uent pathologic findings the cervix was 
 removed two weeks later per nKjiiKni). The patient was disehai'ged t went\'-fiN'e 
 days after the first operation. 
 
 Path. Nos. 6()<S5 and (ITMO. The specimen consists of a inyoinatous utei'us am- 
 putated through the cer\-ix and (tf the tubes and ovaries. The utcius measures 
 6 x 5 X 5 cm. Antei'iorly, it is smooth; posterioi'ly, co\-erc(| with adhesions. 
 Projecting from its surface are two peihuicuJated niyoniala, one (i \ .") cm., the 
 other somewhat smaller (Fig. 176). These ai'e hkewise eoxcrecl witli adhe- 
 sions. On section, it is found that nearly the entire cervical jiortion of the 
 uterus and the greater portion of \hv body is o('cu])ied by a shaggy growth, 
 which in the cervix extends downward almost to the line of incision, and has
 
 280 
 
 -MYo.MATA OF THK ITKRI'S. 
 
 apparently not been entirely reniox-ed. The uterine wall above the point of in- 
 vasion varies from 1 to 2 cm. in thiekness. 
 
 Microscopic sections show that the i^i-owlh in the uteiiis is of a glandular 
 type. In many places the epithelium has so proliferated that we have solid 
 
 masses of cells closely resemblinc: squamous 
 epithelium. The superficial jjortions show 
 considerable disintegration. The o;rowth is 
 
 Fig. 176. — Mli.tipi.k Uterim; Mvomata; Carcinoma of the Lower Part oe the Body and Upper Portion 
 
 OF THE Cervix. (4 nat. size.) 
 Gyn. No. 10462. Path. Nos. 6685 & 6730. Before the drawing was made the cervix, which was removed 
 later, was added to the upper part of the uterus. Three subperitoneal myomata are seen. The largest of these 
 was 6x5 cm. The external os is normal but the upper part of the cervix and lower part of the body are occupied 
 by a shaggy papillary adenocarcinomatous growth. 
 
 an adenocarcinoma. Sections fr(.)m the left tube near its middle show a 
 moderate degree of subacute salpingitis. 
 
 This case is interesting from a clinical standpoint. The general contour of 
 the uteruS; with its accom])anying nodules, strongly suggests a myomatous 
 uterus. The growth is seen extending down to the internal os, and might very 
 readily be oN'erlooked: in fact, carcinoma was not susjx'cted until the uterus 
 had been removed. 
 
 San. No. 1852. Path. No. 8347. 
 
 S u 1) a c u t e i n fl a m m a t i o n o f t h e c e r \- i x : a d e n o c a r c i - 
 n o m a of t h e b o d y o f t h c u t e r u s : a d r n o 111 y o m a o f t h e 
 1) d y o f t h e u t e r u s , a 11 d a n a p p a r e 11 t 1 y i n d e {) e n d e n t 
 r o u n d - c e 1 1 e d s a r c o m a o f 1 h c b o d y o f t h e u t e r u s . 
 
 This case is reported in detail in " Adciioiiiyoma of the rterus." j). 225. 
 
 Gyn. Nos. 3295 and 7699. Path. Nos. 582 and 3948. 
 
 S u 1) m u c o II s 111 y o in a . wit h a r e as strongly suggest- 
 ing s a r c o m a tons d e g e n e ration. Five years la t e r
 
 ADEXOCARCIXU.MA UF THE BODY OF THE UTERUS. 281 
 
 complete h y s t e r e c t o in y for c a r c i ii o m a of t h e 1) o d y o f 
 the u t e r ii s . 
 
 R. B., aged forty-five, married, white. Admitted January 24, 1895. At 
 that time the vagina was filled with a smooth, hard, conical mass. A myomec- 
 tomy was performed, and the patient discharged on February 23, 1895. 
 
 Histologic examination of the myoma showed changes very suggestive of 
 sarcoma. 
 
 The patient was admitted again in April, 1900, more than five years later, and 
 the uterus removed on account of a carcinomatous growth, which occupied the 
 body. 
 
 Path. No. 3948. The specimen consists of the uterus with its appendages. 
 The uterus is somewhat enlarged, measuring 13 cm. in length, 8 cm. in breadth, 
 and 6 cm. in its anteroposterior diameter. Occupying the right cornu is a 
 nodule 3 cm. in diameter, which proves to I)e a myoma. The cervix has been 
 converted into a mere shell, measuring 7 cm. in length and 5 cm. in its antero- 
 posterior diameter. The internal os is 1.7 cm. wide. The lower 2.5 cm. of the 
 cervical canal presents the usual appearances, but the remaining portion has been 
 liollowed out with a curet. Here the surface is rough and covered with a layer 
 of friable tissue and blood-clots. Occasionally long, finger-like, papillary out- 
 growths are seen, and where the growth joins the uterine cavity and has not been 
 injured by the curet, definite yellowish-white, very friable papillary masses an* 
 present. The Avails of the excavated portion of the cervix vary from 3 to 4 mm. 
 in thickness, are indurated, but jjreak down readily. The uterine cavity is 3 cm. 
 long. The mucosa in the upper portion is slightly injected, but smooth. In the 
 lower half of the cavity it is gathered up into papillary masses continuous with 
 those of the cervical growth. Projecting into the uterine cavity are two small 
 polypi. The tubes and ovaries are slightly adherent, but otherwise normal. 
 
 On histologic examination the growth in the uterus proved to be an adcnio- 
 carcinoma, and probably originated just above the internal os. The uterus, 
 besides containing the subjjcritoneal nodule, also had sinall interstitial niyoniata 
 scattered throughout it. 
 
 In October, 1902, the patient returned \\\{\\ an in()i)('ial)le growth in the 
 vagina. This case is intei'csting because the myoma which was removed li\-e 
 yeai's before showed changes most suggestix'e of sarcoma. (See j). 248.) 
 
 Gyn. No. 10997. Path. No. 7246. 
 
 M u 1 t i |) 1 e u t e r i 11 e m y o tn a 1 a , s u b ni u c o u s, i 11 t e i' s t i - 
 t i a 1 , and s u 1) p e i' i t o 11 e a I : a d e n o c a r c i 11 o 111 a i 11 \' o 1 \' i 11 g 
 f u n d u s and c e i' \- i \ ( l''ig. 1 77). 
 
 B. A., aged hfty-four, white, single. .Vdinilled .laiiuai'v IS; discharged 
 February 27, 1904. One sistei- was operated ui)on in this hospital for myoma 
 some years ago. For seven years the patient has noticed an abdominal tumor. 
 Two years ago there was considerable abdominal pain. I'or the last year there
 
 282 
 
 MYOMATA OF THK ITERUS. 
 
 has been a ooiitinuous vaginal discharge, usually watery m character, often 
 stained with blood. 
 
 Operation. Hysteroniyoinectoniy with aiiijHitatioii through the cervix. 
 The endometrium looked cai-cinomatcnis, and in conse(iuence the entire cervix 
 was removed. The patient made a ])erfect recovery. 
 
 Path. No. 724(). The specimen consists of a multinochilar myomatous uterus, 
 16x14x10 cm. This has been amputated through the cervix. Anteriorly, the 
 growth is free from adhesions; po.steriorly, these are numerous. Occupying the 
 anterior wall is a myomatous nodule 8 cm. in diameter (Fig. 177). There is a 
 subperitoneal myoma 2 cm. in diameter, and several others scattered throughout 
 
 "^^^f-"' 
 
 Larc- 
 
 Fig. 177. — Mri.iii'i.i: I iihim; Mvdmm^; Carcixoma of the Body of thb Utkru.s. (5 nat. size.) 
 Gyn. No. 10997. Path. No. 7246. The uterus contained several interstitial myomata, the large.st of which 
 was 8 cm. in diameter. Lining the entire uterine cavity was a carcinomatous growth that extended to the i>i>int 
 of amputation. This fact having been discovered at the time of operation, the remainder of the cervix w:is at 
 once renifivpfi. 
 
 the walls. The aj){)endages are apparently normal. ()a section, the cavity of 
 the uterus is found to be irregular in shape and 7 cm. in length. iSurrounding the 
 entire cavity from cei'vix to fundus is a fine ])npillar\' or tree-like growth. In the 
 cervical portion it is very well outlined and ])reserved, but in the body it has in 
 ))laces become necrotic. M no i)oint is there any evidence of normal mucosa. 
 The growth in certain places imolves the wall foi' a distance of l.o cm. It is 
 sharply outlined fi-oni the uterine muscle. 
 
 Microscopically, no trace of normal mucosa of the cervix or of the body is 
 found. The cavity of the uterus is lined with an irregular growth of glands, 
 that in some places show a distinct papillai-y arrangement. The growth is a 
 ty])ical adenocarcinoma.
 
 ADENOCARCIXOMA O?^ THK BODY OF THK UTERUS. 
 
 283 
 
 Gyn. No, 5858. Path. No. 2146. 
 
 A d e II o c a r c i 11 o in a o f t h b o d }' o f t h c uterus, as- 
 sociated with i n t e r s t i t i a 1 m y o in a t a ; c h r o n i e e 11 d o in e - 
 t r i t i s both of body and cervix (Fig. 17S) . 
 
 K. H., aged forty-seven, white, single. Admitted February 8, 1898, com- 
 plaining of pain ill the left lower abdomen and also of uterine hemorrhage. For 
 two years she has had severe hemorrhages and some vaginal discharge, watery in 
 
 Fi(i. 178. — Adenocarcinoma of t:ik Boi)v of thk Uterus Associated with Interstitim. Myomata. 
 
 ( } iKit. size. ) 
 
 Ciyii. No. .'JS.'JS. I'adi. No. 2\M>. The uterus is nearly twice its natural size and is ijear-shaped. Siluateil in 
 the anterior wall near the fundus is a typieal myoma, and .iust below it a s:naller one, of the interstitial variety. 
 The cervix is much thickened, hut retains its normal contour. The vaKinal portion is intact. In the gro.ss .speci- 
 men the cervical canal appears unaltered, although a severe endometritis was present. The mucosa in the lower 
 part of the uterine cavity likewise presents the usual appearance, although here alsa there was a most e.vtensive 
 endometritis. Occupying the upper part of the cavity is a new-growth, roughly divided into parallel rows. These 
 vary in size and have smooth surfaces, in contradistinction to the delicate, finger-like outgrowths usually present. 
 In a few of the crevices between the polypi, however, some of the finger-like processes are noted. 'IMie growth 
 averages 1 cm. in thickness, and has invaded the greatly thickened muscular walls to a slight extent. .Macro- 
 scopically, the api)endages on both sides apj>ear to be normal, but the tube on the right side was found to be the 
 seat of an acute s.alpingitis, although the fimbriated extremity was palenl. It is almost certain that the strepto- 
 coccic peritonitis develoix'ii from the discharges caused by the profuse cndoinetritis. (.-\ft<'r Thomas S. Cullen.) 
 
 character, and frciiucnt ly blood-tiugcd ;iiid ort'ciisiNc. ( )ii examination of 
 s:'raj)iiigs the j)resence of adcnorarcinoma (»!' I lie boily \\;is (IclccttMl. 
 
 ()j)eration, February 1L\ 1N*.)S. Panhysterecldiiiy. The .adlicicnt omentum 
 having been released, the uterus was removed in the usual way. The ))atient 
 developed a general peritonitis and (hed within twenty-four hours. .V pure 
 culture of Streptococcus pyogenes was obtained fi-om the abdominal cavity.
 
 284 MYOMATA OF THE I'TERl'S. 
 
 rath. No. 1214(). The spccinicu consists of the uIltus, tubes, and ovaries. 
 The uterus is 11 cm. in length, 7 cm. broad, and 8 cm. in its anteroposterior 
 diameter. It is free from adhesions. Projecting fi-om the anterior surface is a 
 rounded boss 5 cm. in diameter. It is firm in consistence, and on section pre- 
 sents the u.sual myomatous appearance. The vaginal portion of the cervix 
 a])pears to be normal. The cervical portion is 'A.') cm. long, and averages 9 mm. 
 in diameter. The muco.sa is smooth, but somewhat injected. The uterine 
 cavity is 5 cm. in length, and at the fundus reaches 5 cm. in breadth. Occupy- 
 ing nearly the entire cavity is a new-growth, grayish in color (Fig. 178). It is 
 for the most part divided uj) into .several longitudinal ridges, separated by deep 
 furrows. The tissue comj^osing the ridges has a smooth surface, but at several 
 points along the advancing margin of the growth delicate, finger-like processes are 
 visible. The downward extension of the tumor is sharply defined, the growth 
 overlapping the mucous membrane. On an average it is 1 cm. in thickness and 
 has extended for about 3 or 4 mm. into the depth. On section, the tis.sue of the 
 new-growth is seen to be somewhat friable. 
 
 Histologic Examination. — The muco.sa of the cervix and that of the body 
 not invaded by the cancer has Ix'en converted almost entirely into granulation 
 tissue, evidently as a result of a long-standing infection. The patient was un- 
 doubtedly infected from the uterine discharge, the general peritonitis which so 
 soon caused her death being readily accounted for. 
 
 This case is described in detail in Cullen's '" Cancer of the Uterus." p. 452. 
 
 Gyn. No. 5957. Path. No. 2238. 
 
 A large m y o m a t o u s u t e r u s w i t h a d e n o c a r c i n o m a 
 of the body; general pelvic peritonitis (Fig. 179). 
 
 8. B., colored, aged forty-seven, married. Admitted March 16; discharged 
 April 22, 1898. Complaint, al)dominal tumor. Her menses commenced at 
 thirteen and were always regular until six years ago. She had a mi.scarriage at 
 twenty-three. Six years ago .she had a fairly constant bloody uterine discharge, 
 alternating with a leukorrheal flow, and about three years later first felt a small 
 lump in the abdomen, which has increa.sed slowly in size. During the last nine 
 months she has had a dull, aching sensation in the lower part of the abdomen. 
 
 Operation, March 21, 1898. Abdominal hysten^ctomy. The uterus was 
 amputated through the cervix, cai'cinoma not being suspected imtil after the 
 operation was coni]:)lete(l. 
 
 Path. No. 2288. The sjiecimeii consists of the uterus, which has been con- 
 verted into a globular tiunoi- 1 1 cm. in diameter, covered with numerous vascular 
 adhesions. Springing from it are several myomata, some of which are sessile, 
 others pedunculated. The ])ortion of the ceivix jire.sent is 2 cm. in length; its 
 nmco.sa presents the usual a))pearance. The uterine walls vary from 4 to 8 cm. 
 in thickness, and contain several myomatous nodules, the largest being 6 cm. in 
 diameter. The uterine cavitv is (] cm. long and 4.5 cm. broad at the fundus
 
 ADENOCARCIXO.MA OF THE BODY OF THE UTERUS. 
 
 285 
 
 (Fig. 179j. The mucosa covering the posterior wall is smooth and glistening and 
 slightly injected. Tt varies from 1 to 2 mm. in thickness. The ])ortion cover- 
 ing the anterior wall is profoundly altered, and now consists of a new-growth 
 averaging 1 cm. in thickness. The surface, for the most part, is smooth, but 
 occasionally ])roj(>cting from it is a minute, hnger-like process, while at several 
 
 ■'#^^ 
 
 x-m 
 
 4^ 
 
 »^ K 
 
 Fig. 179. — A Large Myomatous Uterus Sho\vi.\g .\i.so .\n .\i)e.\ocarcinom.\ of the Body, (i nat. size.) 
 Gyn. No. 5957. Path. No. 22.38. The uterus is much enlarged and has subperitoneal nodules projecting; from 
 its surface. Situated in the anterior wall are one large and several smaller interstitial myomata. The uterus has been 
 amputated through the cervi.x. The mucosa in the lower part of the uterine cavity is normal, but on being traced 
 upward several centimeters on the anterior wall it is replaced by a new-growth, which in places is smooth, but at 
 most points is covered with delicate, finger-like oiitgrowths. The growth reaches 1 cm. in thickne.ss, and 
 stands out in sharp contrast to the uterine muscle, which it has invaded to a slight extent. Upward it reaches to 
 the to)) of the uterine cavity, its advancing margin being irregular. The mucosa covering tlie posterior wall is 
 slightly mottled, but otherwise ajjpears normal. The stumps of both Fallopian tubes are visible in the upper 
 part of the picture. All the symptoms in this case might readily have been caused by the myomata, and without 
 curettage it would have been impossible to diagnose the carcinoma. Had we known that the carcinoma was i)resent 
 in this case, the uterus would have been cntiicly rciiKivcc! inslcud n! licin^ nnipul.'ili'il llirnugh the (-('rvix. 
 (After Thomas S. Cullen.) 
 
 points the surface ])resents a shaggy appearance, due to aggregations of myriads 
 of these finger-like ])rojections. At one point these delicate outgrowths form a 
 hunch projecting fully 1 cm. from the surface. The growth, on .section, presents 
 a waxy appearance, and stands out in sh;irp coiit last to the muscle which it has 
 invaded for a short distance.
 
 286 
 
 MYOMATA OF THE UTERUS. 
 
 On histologic exaniiuation the growth in the body is found to be a typical 
 adenocarcinoma. 
 
 This case is describ(Ml in detail in Cullen's ''Cancer of the Uterus," p. 449. 
 
 K ., C. H. I. Path. No. 4479. 
 S u b p e r i t o n e a 1 . interstitial, an d s u b in u c o u s myoma- 
 
 t a : e X t e n s i \' e adenocarcinoma of the body of the 
 
 ut erus (Fig. 180). 
 
 E. P. K., white, aged thirty-eight, married. Admitted to the Church Home 
 
 and Infirmary November 8: died November 17, 1900. She had one miscarriage 
 
 nine years ago. In March, 
 1900. she had three hemor- 
 rhages, which were severe and 
 showed large clots. Since then 
 there has been frequent bleed- 
 ing, and lately a profuse leukor- 
 rheal discharge. 
 
 The uterus reached a point 
 midway between the pubes and 
 umbilicus, and on examination 
 presented a peculiar appear- 
 ance. The mass suggested a 
 myoma, and yet there was an 
 un e^'ennessof the surface — what 
 might be termed a volcanic ap- 
 pearance, the growth welling out 
 on all sides and having an um- 
 bilicated center. The left tube 
 and ovary were tied off, the 
 round ligament was controlled, 
 and a myoma 5 cm. in diameter 
 was then detected lying in the 
 broad ligament. After opera- 
 tion the uterus was opened and 
 the malignant growth detected, 
 and we exjjeeted to remove the 
 cervix at a later date. 
 For the first day after operation the patient did comparatively well, but then 
 
 commenced to show definite signs of ))eritonitis and died in a few days. This case 
 
 shows the absolute neces.sity of opening the uterus the minute it is removed. 
 
 Had we followed out this rule, the cervix would have been taken out at once: we 
 
 would have ])lace(l a liberal gauze drain in the ju'jvis, and })rol)ably have avoided 
 
 Fig. 180. — Multiple Uterine Myomata; Adknocarcixoma of 
 
 THE Body, with Extension- to thk PfiRiToxEAL Surface. 
 
 (i nat. size. ) 
 
 K., C.H.I. Path. \o. 4479. The uterus ha.s been amputated 
 through the cervix, aiifi to the left is a myoma. The body of 
 the uterus contains several myomatous nodules. Over a large 
 area (a) the tissue presents a volcanic appearance, due to a well- 
 ing-out of the growth. On section, carcinoma of the body was 
 found, the unusual appearance of the surface being due to ex- 
 tension of the growth by continuity t<} the peritoneal surface. 
 
 Had the carcinoma been suspected at operation, the cervix 
 would, of course, have been removed at once. The cervical 
 myoma, together with the general contoiir of the uterus, 
 would naturally suggest to the operator that he was dealing 
 with an ordinary myomatous uterus.
 
 ADENOCARCINOMA OF THE BODY OF THE UTERUS. 287 
 
 infection, which so frequently follows where such a foul carcinomatous growth 
 exists. 
 
 Path. No. 4479. The specimen consists of a large multinodular myomatous 
 uterus (Fig. 180). The fundus is occupied by a large tumor mass, 12 x 13 cm., 
 developed more posteriorly than anteriorly. The surface is generally smooth. 
 On section of the uterus the cavity is found to be filled with a carcinoma of the 
 body, associated with numerous myomatous nodules. 
 
 G5m. No. 4262, Path. No. 1137. 
 
 Subperitoneal, interstitial, and submucous myo- 
 mata; adenocarcinoma of the body of the uterus 
 (Fig. 181). 
 
 E. P., aged thirty, colored, married. Admitted March 30; discharged April 
 30, 1896. The patient has had one child and no miscarriages. 
 
 Operation, April 6, 1896. Abdominal hysteromyomectomy with amputation 
 through the cervix. The patient made an uninterrupted recovery. 
 
 Path. No. 1137. The specimen consists of the uterus with its appendages. 
 The uterus is approximately globular, measuring 15 x 13 x 13 cm. Both ante- 
 riorly and posteriorly it is smooth and glistening. The portion of the cervix 
 present is 4 cm. in diameter. The posterior uterine wall varies from 2.5 to 3 cm. 
 in thickness, and scattered throughout it are several myomata, some of which 
 are interstitial, others sessile. The anterior wall varies from 2 to 9 cm. in thick- 
 ness; besides containing several small myomata, it is occupied l)y a sul)mucous 
 myoma 8 cm. in diameter. The uterine cavity is 8 cm. in length, and at the 
 fundus 7.5 cm. in breadth. The mucosa at the fundus varies from 2 to 3 mm. in 
 thickness, but the greater part of that covering the anterior wall and also that 
 on the posterior wall presents a markedly altered appearance, being gathcMx^l up 
 into large and small tongue-like folds, varying from 0.3 to 1.5 cm. in breadth 
 (Fig. 181). Some of these reach 7 mm. in thickness, but where subjected to 
 pressure, they are flattened. The small tongue-like masses are smooth and 
 glistening, and cannot be subdivided into smaller ones, as is usually the case in 
 adenocarcinoma of the body. After hardening in Miiller's fluid it is jxjssible 
 to make out in a few places a delicate branching or tree-like arrangement. 
 The larger eminences are traversed by shallow depressions, which to a slight ex- 
 tent subdivide them into smaller ones. They also have delicate cajnllaries 
 ramifying over them in all directions. Near the fundus the nuicosa readies 2 
 cm. in thickness, and only its superficial portions tend to become polypoid. 
 The mucosa in its (lee])er j)oi'tioii is sharply defined, being well iiiarkeil ni]' from 
 the nuiscle, which it a])])arently has not penetrated. The jxisterioi- wail over 
 a limited area has been entii'ely denuded of nmcosa by the curet. 
 
 Microscopically, the growth proved to be an exceptionally interesting adeno- 
 carcinoma. (The histologic findings are gi\-en in detail in Cullen's "Cancer of 
 the Uterus," p. 440.)
 
 288 
 
 MVO.MATA OF THH I'TKRUS. 
 
 Gyn. Nos. 1069 and 1782. 
 
 r t (' r i 11 {' 111 y 111 a I a : c a r c i 11 o in a o f t h c h o d y o f the 
 u t V u s . 
 
 L. W., single, white, aged forty-four. Admitted Xovciiihcr Hi: discharged 
 Decenihcr 17, ISOl. The iiKiistruatioii has hccii profuse for the last three or 
 four years; lately a.ss(jeiated with pain in the lower abdomen. Operation, No- 
 vember 23, 1891, removal of both ovaries. 
 
 Fig. 181. — Myomata and Adknocarci.noma of thk Body of thk Utkrus. (f nat. size.) 
 Gyn. No. 4262. Path. No. ll.'i?. The much enlarged uterus has been opened posteriorly. Projecting from 
 the posterior surface is a small subperitoneal myoma. Scattered throughout the walls, which are increased in 
 thickness, are a few interstitial myomata. The cervical canal is imaltered. The uterine cavity is much eidarged. 
 Projecting into it from the anterior wall is a large submucous myoma. Occupying the anterior wall and extending 
 over the posterior wall is a new-growth, in some parts forming a homogeneous and slightly lobulated mass, but in 
 some places consisting of polypi of various sizes and with fairly sharp edges. In a few places delicate, finger-like 
 outgrowths spring from the surface of the polypi or from the depre.ssions between them. The new-growth stands 
 out sharply from the normal mucosa covering the pi)steri)r wall, (.\fter Thomas S. Cullen.) 
 
 She was again admitted on January 29, and discharged on February 27, 
 1893 (Gyn. No. 17S2). Operation, February 1, 1S93, hysteromyomectomy; 
 amputation through the eervix. ( )n removal of the large, irregular myomatous 
 uterus carcinoma of the body was found. The jjatieiit made a ])erfect recovery. 
 \o histologic examination was made. 
 
 Gyn. No. 1691, 
 
 A s 1 o u g li i n g s u b m u c o u s m y o m a associate d w i t h 
 carcinoma of the body. 
 
 Pi. A., white, sinuie. aired fol■t^■-(i^•e. .\dniitte(l Xovember 23: discharged
 
 ADENOCARCIXOMA OF THE BODY OF THE UTERUS. 289 
 
 December 29, 1892. The menses were regular until seven years ago, after whicli 
 the flow appeared every two weeks and was very })rofuse. During the past year 
 it has been almost continuous. The bleeding at times has been so profuse that 
 the patient has fainted. 
 
 Operation, November 28, 1892. Hysteromyomectomy with amputation 
 through the cervix. When the uterus was opened, a sloughing subnmcous myo- 
 ma was found, and also a carcinoma of the body. A note was made on August 
 13, 1895, that the patient was well and growing fat; her only complaint was of 
 slight backache. No histologic examination was made. 
 
 Gyn. No. 9141. Path. No. 5312. 
 
 A large cervical m y o m a ; subperitoneal and intersti- 
 tial uterine m y o m a t a ; advanced adenocarcinoma of 
 the body (Fig. 182). 
 
 S. T., single, white, aged sixty-one. Admitted October 17, 1901. The 
 menopause occurred at fifty-four. For the past six years there has been a slight 
 yellowish discharge, and five years ago this became blood-tinged ; for the ])ast year 
 it has been offensive. 
 
 Operation, October 21,1901. Panhysterectomy. A large mass above the 
 symphysis was found to be the fundus ])ushed up from below by a myoma 
 situated near the cervix. On the surface of the uterus, near the right cornu, 
 was an elevation, 2 cm. in diameter; this differed entirely from an ordinary 
 myoma, and was evidently an area of carcinoma from an extension of the 
 growth through the uterine wall. Complete hysterectomy was performed. The 
 patient was discharged on November 16, 1901. 
 
 Path. No. 5312. The specimen consists of an enlarged uterus, \\ith its 
 appendages intact. The uterus is approximately 14 x 10 x 10 cm. in its various 
 diameters. The surface is smooth and glistening, but nodular. Over the right 
 cornu is an irregular, slightly raised, whitish area, with puckered margins. Tt is 
 about 2 cm. in diameter, and closely resembles an area of lupus where healing has 
 taken place. Scattered throughout the uterine walls are myomata, the chief in- 
 crease in size being due to a globular myoma, 7 cm. in diameter (Fig. 1S2). This 
 is situated directly l)ehind the cervix, and has evidently ])r()jected down beneath 
 the peritoneum into Douglas' cul-de-sac. The uterine cavity is about 10 cm. in 
 length. Th(> nuicosa of the cervix presents the usual apjx'arance, but the cavity 
 of the uterus is considerably distended, and is everywhere lined with a friable 
 material of brain-like consistence. The superficial ])oitions of this consist of 
 small, delicate, finger-like ])r()jections, and c()\-ering the surface is neci-otic 
 tissue. The growth reaches a thickness of 2 cm. or nioi-e, and is everywhere 
 penetrating the uterine walls. At the right uteiine horn, where the puckering 
 was noticed on the surface, it has extended to the peritoneum. The tubes and 
 ovaries on both sides are apparently normal. 
 
 On histologic examination the growth is found to he an adenocarcinoma with 
 19
 
 290 
 
 MYOMATA OF THK UTERUS. 
 
 a (Icfiiiitf tciulcncy to form ])a{)illary out (growths. Along its advancing margin 
 there is a great tlcal of round-celled infilt I'ation. 
 
 Fig. 182. — A I.arck Mvoma ok thk Cehvix; .\Di:xorARriN<)MA of the Body of thk I^teru!?. (J nat. size.l 
 Gyn. No. 9141. Path. No. 5312. Behind the cervix is a globular myomatous nodule, 7 cm. in diameter. 
 Smaller subperitoneal and interstitial myomata are also seen. The uterine cavity is filled with a carcinomatous 
 growth which, in places, reaches 2 cm. in thickness. Over the right uterine horn was an irregular, slightly raised, 
 whitish area, with puckered margins, and closely resembling a patch of lupus where healing had taken place. This 
 represented an extension of the carciiinnia Id the peritoneal surface of the uterus by <'cintiiiuity. 
 
 Gyn. No. 9012. Path. No. 5180. 
 
 M y o m a tons u t e i' u s : a d e n o c a r c i n o m a of t li v body; 
 d o II b 1 e h \' d r o s a 1 j) i n x ; o v a r i a n c y s t on the right side; 
 t u 1) o - o V a r i a n abscess o 11 the 1 e ft si d e .
 
 ADEXOCAKCIXO.MA OF THE BODY OF THK UTERUS. 291 
 
 M. 8., white, aged fifty, iiiaiTicd. Admitted August 26; discharged Octo- 
 ber 10, 1901. During the last eighteen months the menses have been irregular 
 and profuse; Recently there has been bleeding for six or seven weeks at a time. 
 During this ])eriod the patient passed a hard body, probably a submucous 
 myoma. She has had one miscarriage. Six years ago she was told that her 
 uteiiis was enlarged. She can feel something shifting about in the al;)domen ; this 
 is particularly noticeable when she moves around. 
 
 Operation. Hysteromyomectomy; radical cure of hernia; drainage of tubo- 
 ovarian abscess through the abdomen. 
 
 A long abdominal incision was made, and a small umbilical hernia excised. 
 Much difficulty was experienced on account of a tubo-ovarian abscess on the left 
 side, which had to l:)e drained. The left tubo-ovarian mass was very closely 
 associated with the intestines, and the omentum was thickened, pale, and bled 
 very freely. Resting upon the ovarian cyst was a large myomatous uterus. 
 Later, the perineum was repaired, and the patient left the hospital very much 
 improved. 
 
 Path. No. 5180. The specimen comprises an enlarged uterus, a cyst of the 
 ovary, and a portion of a small ovarian abscess. The uterus, which is irregular 
 and pear-shaped, measures 16 x 10 x 11 cm. Its surface presents irregular prom- 
 inences, corresponding to interstitial myomata. On section, a large, partially 
 subperitoneal myoma, 9 cm. in diameter, is found occupying the fundus, and to 
 one side of this is an interstitial nodule 6 cm. in diameter. This, on section, ap- 
 pears to be cystic, consisting of fibrillated material with translucent areas in its 
 meshes. The uterine cavity is 5 x 5.4 x 3.5 cm. The lower portion is lined with 
 a slightly injected, fairly normal looking mucosa. The upper portion, however, 
 is occupied by an exceedingly friable pajiillary growth, the papillip of which are 
 long and finger-like. The advancing margin of the growth is fairly well defined; 
 it shows a rounded but somewhat irregular outline. 
 
 The right ovary has been converted into a thin-walled cyst, 18 x 15 x 15 cm., 
 covered with numerous tags of adhesions. It is pale nnldish in color, and by 
 transmitted light is found to be unilocular; it contains a pale yellowish fluid. .\n 
 ovarian al)scess is present on the left side. 
 
 Sections from the body of the uterus show that the growth is an adenocarcin- 
 oma of the fundus. 
 
 Gyn, No. 10085. Path. No. 6275. 
 
 S u I) ]) e r i t n e a I , interstitial, a n d s u I) m u c o u s ni y o - 
 m a t a ; a d v a n c e d a d e n o c a i" c i n o ni a , i n \' o 1 \" i n g b o t h 
 the body and the c e i' v i x (l*'ig. 18;^). 
 
 P. I)., white, single, aged fifty-two. Admitted No\-einber bS; discharg(>(l 
 December 17, 1902. The ])atient first noticed, about two yeai's ago. that her 
 periods, instead of gradually sto))ping, were so fi('(|uent that she could not tell 
 whether she was having a contiinious flow or when the next ])eiiod began. 
 Hemoglobin, 55 per c(>nt.
 
 292 
 
 MYOMATA OF THE I'TERUS. 
 
 Operation, hysterectomy. The lower abdonieii is distended with a nmlti- 
 nodular hard mass which reaches one-third of the distance from tlie symphysis 
 to the umbihcus; it is somewhat movable. 
 
 November 17, 1902: .\n incision exposed what was a])parently a myoma. 
 
 Fig. 183. — SuBi'Kr.iToNKAi., IxTKRsTniAL, and SrnMrrous Myomata; Advanced Adenocarcinoma Involving 
 
 Cervix and Body. ((; nat. size.) 
 
 Oyn. No. 10085. Path. No. 6275. The uterus is much enlarged, measuring 15 cm. in length, 12 em. in breadth 
 and 11 cm. in its anteroposterior diameter. Scattered throughout it are numerous myomata, subperitoneal, 
 interstitial, and submucous (M). The cervix is intact, as seen at c, where there is a cystic gland. The entire 
 uterine cavity is lined with a carcinomatous growth. The tree-like projections are in evidence near the cervi.x, but 
 in the ujjper part of the cavity the growth is more pol.vpoid in form. At 6 is a delicate stem of the growth several 
 centimeters in length, and terminating in a club-like e.xtremity. a indicates the normal musculature of the uterus. 
 
 Simple bimanual examinaticm in this case was strongly stiggestive of a normal myomatous uterus. Had 
 carcinoma been susi)ected, under no <'ircumstances would bisection have been commenced. 
 
 Bisection was bci^un. After the first cut there was a p;iisli of a])pareiitly car- 
 cinomatous material from the anterior wall of the uterus. The uterus was re- 
 moved in its entirety at once. The patient made an uneventful recovery and 
 was discharged on the thirty-second day.
 
 ADENOCARCINOMA OF THE BODY OF THE UTERUS. 293 
 
 Path. No. 6275. The specimen consists of the uterus and normal appendages. 
 The uterus is globular, about 15 x 12 x 11 cm. Anteriorly and posteriorly it is 
 smooth. On the anterior surface is a smooth myoma, 1.5 cm. in diameter. 
 On the posterior surface several smaller ones are seen. The vaginal portion of 
 the cervix looks normal. On section, it is found that portions of the cervix and 
 body have been replaced by a new-growth (Fig. 183). The cavity of the uterus 
 is 12 cm. in length. The growth presents a very shaggy appearance, and consists 
 of many tree-like processes, little buds, or of small papillary projections. The 
 individual projections vary from 1 to 8 mm. in diameter. The growth projects 
 into the cavity for from 2 to 5 cm. The uterine walls are only slightly en- 
 croached upon. Projecting a little way into the cavity from the posterior wall 
 is a submucous myoma fully 3 cm. in diameter. Numerous other myomata 
 are scattered throughout the uterine walls, which are considerably thickened. 
 
 Histologic examination shows that the growth is essentially of a glandular 
 character, and that it is an adenocarcinoma. 
 
 The general contour of the growth strongly suggests myoma. This view is 
 supported by the fact that there are somewhat isolated myomatous nodules, and 
 one might very readily, as was done here, make a diagnosis of myoma. Even 
 with the abdomen open the operator felt sure that he was dealing with a myo- 
 matous uterus. Examination of scrapings in this case would, however, render 
 the diagnosis easy. 
 
 Gyn. No, 9934. Path. No. 6127. 
 
 Uterine myomata; a d e n o c a r c i n o m a o f t h e body. 
 
 J. S. B., white, aged fifty, married. Admitted September 29; discharged 
 November 1, 1902. One aunt died of a uterine tumor, aged fifty-five. There is 
 tuberculosis on the paternal side. The patient has been married twenty-eigiit 
 years, but has never been pregnant. During the past two years the nuMistrual 
 flow has gradually increased; it has been very copious and frecjuent for the last 
 six weeks, and the patient has had severe hemorrhages. Apart from a pro- 
 gressive weakness due to loss of blood, her health has been normal. Hemo- 
 globin, 55 per cent. 
 
 Operation. Hysteromyomectomy with am])uta(i()ii through the cci-vix. The 
 patient was discharged November 1, 1902. 
 
 Path. No. 6127. The specimen consists of an enlarged uterus, amputated 
 through the cervix. The ap])endages arc intact. Extending from the posterior 
 wall close to the cervix is a subperitoneal myoma, 7 cm. in diameter. On section, 
 it shows a typical hyaline change. The body of the uterus is considerably en- 
 larged, and on section is found to be occupied by a moderately lai-ge, caulillower- 
 like growth which extends into the cavity and involves the uterine wall for about 
 one-half its thickness. The endometrium lining the lowei- portion of th(> utin'ine 
 cavity is quite smooth. 
 
 The growth on histologic examination proves to be a typical adenoeareinonia.
 
 204 MYO.MATA OF THK I'TERUS. 
 
 An Exceptionally Early Adenocarcinoma of the Body of the Uterus, Associ- 
 ated WITH A Large Myomatous Uterus. 
 
 The foUowinii; ease is only one exain])le of the inten'sting conditions that may 
 he (Ictcctcd by a cai'cful and routine examination of all s])eeimens coming from 
 the operating-room. The multinodular myomatous uterus measured 25 cm. in 
 diameter. 
 
 0]i histologic examination we detected one of the earliest carcinomata of the 
 body of the uterus on record (Fig. 184). The growth could not ])ossibly be seen 
 macroscopically on account of its small size, and because it was flush with the 
 surface of the nuicosa, not jirojecting from the surface. It had not yet penetrated 
 the muscle, and was surrounded on all sides by normal mucosa. The general 
 pattern of the glands left absolutely no doubt that we were dealing with a com- 
 mencing carcinoma of the body. 
 
 Gyn. No. 31 13. Path. No. 487. 
 
 A. y. G., white, aged fifty-two. Admitted October 16; discharged De- 
 cember 6, 1894. The other interesting features in this case are reported in the 
 chapter on Sarcoma (p. 247). 
 
 Path. No. 487. The spt^imen consists of a large globular tumor involving 
 the ui)per portion of the uterus. It is approximately circular, and has a diameter 
 of 25 cm. The uterine cavity itself is 6 cm. long, and about 1 cm. in diameter. 
 The mucosa is yellowish in color, and at the cervix is somewhat hemorrhagic. 
 It is 1 mm. in thickness. 
 
 Histologic Examination. — Some of the cervical glands are dilated. The 
 uterine mucosa in most places is atrophic. The surface epithelium is intact, the 
 glands are few in number, dilated, small, and circular on cross-section; some of 
 them run ])arallel to the surface. The surface of the mucosa shows considerable 
 i"()un(l-celled infiltration, and non-stripetl muscle-filiers are seen ])assing up into 
 the nnicosa nearly as far as the uterine cavity. Springing from the mucosa are 
 three polypi, one situated near the internal os, and having a broad base, a second 
 1.5 cm. from the fundus, presenting a pedunculated appearance, a third situated 
 at the fundus. These polypi are covered with cylindric epithelium and have 
 numerous glands scattered thi'oughout them. A section taken at one point in the 
 region of the ])()lypi gave the picture seen in Fig. 184. Here we have normal 
 mucosa on l)oth sides, and over a very small area. i)robably not more than 1 to 2 
 mm. in diameter, the glands ai'e so changed that they leave no doubt as to the 
 malignancy of the growth. The surface epithelium is becoming thicker; the 
 cells stain more palely. The epithelium is several layers in thickness, and the 
 glands present the typical ))icture of a mucosa undergoing a carcinomatous 
 change. 
 
 It is particularly interesting in this case to note that there were also very 
 suspicious changes in the cells of the myomata. The muscle-fibers contained
 
 ADENOCARCINOMA OF THK BODY O?^ THE UTERUS. 
 
 295 
 
 large oval and round, vesicular nuclei (Fig. 102, j), 248), suggestive in a slight 
 degree of a sarcomatous transformation of the myoma. 
 
 Fio. 184. — Ax Adknocarcinoma of the Body of the Uterus, so Small that it could not be Recognized 
 EXCEPT WITH THE Aid OF THE Microscope. (X 145diam.) 
 Gyn. No. .3113. Path. No. 487. This picture was accidentally discovered during our routine examination of 
 the mucosa. The mucosa to the left and right of the field is normal. The surface epithelium between « and a' 
 and between 6 and b' is also normal, but between a' and 6' it is several layers in thickness and stains more faintly. 
 The general gland pattern in the central area, extending from c to c', is totally different from that of the normal and 
 surrounding glands, and the epithelium has proliferated to a marked degree. The epithelium at a' also shows signs 
 of proliferation and sends out a small bud. d is the normal uterine muscle. This is the earliest carcinoma of the 
 body of the uterus we have ever seen, or of which we can find any record in the literature. 
 
 Secondary Carcinoma of the Uterus, Associated with Uterine Myomata. 
 
 Two cases of this character haN'e come undei- oui' ol)S('r\ali(»n, and in hoth 
 instances the i^rimarv carcinoma was of ()\-ai'ian origin. 
 
 In Case 7992 hotli oN'ai'ies were carcinomatous and mdastases were I'ound in 
 the Fallopian tubes and uterus. 'V\\v utci-us contaiiuMl two small sul))>('iiloncal 
 and several small interstitial myomata. 
 
 In Cas(^ 5528, five months al'tci' removal of both oNai'ics, on account of a 
 carcinoma, a com])lete hysterectomy became ncccssarw Flic uterus was 1 1 .\ 12 
 X 8 cm., and contained myomatous nodules, ^•al■ying from 1 to () cm. in diameter. 
 Attached to the right side of the uterus was a ragged, fi'iable carcinomatous mass,
 
 296 MYOMATA OF THE UTERUS. 
 
 8 cm. ill (liaiiieter. Occupying the anterior uterine wall was a carcinomatous 
 mass 2x4 cm. This was directly continuous with the uterine mucosa and was 
 soft and slightly friable. The mucosa itself was perfectly smooth. It is evident 
 that in this case the carcinomatous nature of the ovarian growth was not clear, 
 otherwise the uterus would haN'e b(>en removed with the ovarian growths at the 
 first operation.
 
 CHAPTER X\U. 
 THE CONDITION OF THE UTERINE MUCOSA IN CASES OF MYOMA. 
 
 In most of our cases when the uterus has been removed, supravaginal am- 
 putation has been employed. As a result, only rarely have we been able to as- 
 certain the histologic appearances of the vaginal portion of the cervix. 
 
 In nearly all the cases in which the uterus was removed we carefully opened 
 the uterine cavity and studied the appearances macroscopically and histologically. 
 Pieces of mucosa were removed from various portions of the cavity, especial 
 attention being given to any area suggesting the least pathologic change. It 
 will readily be understood that a histologic examination of the mucosa from all 
 parts of the cavity in over 1000 cases would be out of the question, and, therefore, 
 the pathologic changes in a few cases have undoubtedly been overlooked. The 
 findings, on the whole, however, are relatively accurate. 
 
 The mucosa of the uterus is naturally divided into two main kinds — that 
 from the cervix and that lining the uterine cavity. They will, therefore, be 
 considered separately. 
 
 CHANGES IN THE CERVICAL MUCOSA. 
 
 Edema. 
 
 Hypertrophy. 
 
 Atrophy. 
 
 Dilatation of the cervical glands. 
 
 Cervical polypi. 
 
 Unfolding of the cervical glands. 
 
 Cervical endometritis. 
 
 Suspicious changes in the cervical mucosa. 
 
 Carcinoma of the cervix. 
 
 Edema. — In only one case was edema of the mucosa noted, llci'c the uterus 
 had been partially inverted by a submucous iiiyoiiia. 
 
 Hypertrophy. — Marked increase in size of the cervix was noted four times, 
 and on i-cfcrring to p. 441 it will be seen that in each of these cases there was 
 ])rolapse of the uterus. The nuicosa usually showed marked thickening of the 
 S((uanious epithelium of the vaginal portion of the cerxix. and the papilhe ])ro- 
 j(>cting into the s([uamous (>pitheliuin were much longer than usual and showed 
 marked branching. 
 
 Atrophy. — Where j)artiall>' submucous ceiAieal niNoniata exist, the cervix 
 is occasionally so unfolde(| that little of it I'emains. The eei-xieal nuicosa is put 
 
 297
 
 298 
 
 MVOMATA OF THK UTKUrS. 
 
 oil marked tension and, on account of the stn^tching, ])ecoines much thinner than 
 usuaL The atropliy is iiioi-e ai)i)arent than real, the appearance being duo to a 
 thiiiniiiij: out of the mucosa, which now has to cover a wider area. 
 
 Dilatation of the Cervical Glands. — Enlarged glands arc very coinmon in the 
 cervix, and are often recognized as slightly raised, circular, translucent areas. 
 In our experience dilated glands are not more freiiiieiit in myoma cases than in 
 those in which no tumor exists. 
 
 In Case 3349 some of the cervical glands reached 5 mm. in diameter. 
 
 In Case 3038 thev reached (i mm. in diameter, and in Case 3493 there was a 
 
 
 V^/^ ^''f 
 
 
 ^ / ^T 'V"! '^^ r 
 
 Fio. 185. — Markkd Dilatation ok thk Ckrvical Glands, with a Tendkncy Toward thk Formation of a 
 
 Polyp. (X 5 diam.) 
 Gyn. No. .349.3. Path. No. 715. The myomatous uterus was 16 x 16 x 22 em. The section is from the cervix. 
 On the right, at a, the glands are normal, and on the left, at b, the mucosa is of the usual thickness, but between 
 these two points the glands are markedly dilated, some being spheric, others oblong and very irregular. The 
 gland epithelium is in places normal, at other points slightly flattened. 
 
 marked tendency toward dilatation of the glands (Fig. 185). One gland reached 
 0.5 X 1.5 cm. 
 
 41ie dilated glands ai'e usually spheric, hut ma>' he ii'reguiar. 'Hie gland 
 contents, as a rule, are viscid and semitranslucent; occasionally they are whitish 
 yellow or opacjue, owing to an abundance of exfoliated epithelium. Their 
 epithelium may be high eylindric, or considerably flattened. 
 
 Cervical Polypi. — Polypi of the cervical mucosa, in our ex])ericnec, have been 
 comparatively rare in myoma cases. In some cases they were found near the 
 internal os; in others they were near the external os, or projected slightly into
 
 THE COXDITIOX OF THE CERVICAL MUCOSA IX CASES OF MYOMA. 299 
 
 the vagina. They wort' u.>^ually single, Init occasionally several were present, as 
 in C. H. I. Xo. 768. 
 
 ..-'VJ^JtJ^^tS 
 
 
 Fig. 186. — A Ckrvical Polyp. (X 8 diam.) 
 
 Gyn. No 6169. Path. No. 2426. The uterus contained a small submucous myoma. The endometrium pre- 
 sented a wavy, polypoid appearance, and polypi were found in the cervix. 
 
 At a and a' we have a normal mucosa. Projecting from the mucosa is a polyp attached by a broad base, 
 the confines of which are indicated by 6 and b'. The polyp consists of normal cervical mucosa. A dilated gland 
 is seen at c. rf is a very small polyp. At e, a dilated gland is seen deep in the stroma of the cer\'ix. 
 
 The size of the uterus or the situation of the myomata seemed to have little 
 or no influence on the development of the polypi, as they occurred just as fre- 
 quently when the myomata were small and when no submucous nodules existed. 
 
 ^'^^.■- 
 
 
 .liA 
 
 
 -r't^^^V-; /^b 
 
 cj /'•^■i .,^>s-r\^ 
 
 
 Fig. 187. — A Ckhvuai, Poi.vp. (X 6 diam.) 
 
 Gyn. No. 6169. Path. No. 2426. The uterus contained a small .submucous myoma. Tho cervix C(»ntaiiied 
 the polyp (le|)ict{'d in Fig. 186. 
 
 This polyp is made up chiefly of long, finger-hke outgrowths of cervical mucosa. The struma reseml>les tliat 
 of a normal cervix, and the projections are covered with the chararlcrislic liigh cyhndric epithelium of the cervix. 
 The iJolyp was attached to the cervical mucosa by a delicate i)edicle, indicated on the left. 
 
 On histologic examination some of the i»oly)ii closely reseiiiMed the noniial 
 cervical mucosa (Fig. ISfi) and wci-e in realit\- nothing more than small areas
 
 300 MYOMATA OF THE UTERUS. 
 
 of iiiueou.s iiienibranc that had been extruded and partiahy nipped off. In other 
 polypi the process of extrusion had advanced further. The polypi were com- 
 ))()sed of long narrow tongues of mucosa (Fig. 187), and the attachment to the 
 j)arent nmcosa was very slender. 
 
 In San. No. 1872 (Path. No. 8433) the glands of the polypi were uniformly 
 and markedly dilated, and the picture resembled closely that of a thyroid gland. 
 
 A II a !• e 1' () r m of Cervical Polyp . — In the following case, in which 
 a small submucous myoma was removed, a large cervical polyp was also taken 
 
 ■'•. , 
 
 
 ti?"' 
 
 -<r - 
 
 ", 
 
 - ^ ' T- 
 
 
 
 ^ L> 
 
 c 
 
 
 jft ■ *^-»^-j* 
 
 
 
 " 
 
 
 i.f^ -^ ^ ^ 
 
 
 
 •^ ' r '^ » '^ 
 
 
 
 
 
 
 '^W,X"''> V -' " 'S " 
 
 • 
 
 ^'- - 
 
 "^ . -• ' .„ 
 
 "' 
 
 ■%/ ' . -^ J'i'K 
 
 M- K^' 
 
 
 Fig. 188. — A Rare Form of Cervical Poi.yp. (X Otliani.) 
 Gyn. No. 7615. Path. No. 3879. This is a small portion of a cervical polyp, 1.5 x 3.5 x 4.5 cm. The polyp 
 
 was mottled in appearance and contained cyst-like spaces, some minute, others reaching 3 mm. in size. The glands 
 
 are indicated by a. Some are of the normal size, others much tlilated and spheric. 
 
 Scattered throughout the polyp are many pale-staining anil solid areas (6), which, under the lower power 
 
 bore some resemblance to cartilage. For the finer details of the.se areas see Fig. 1S9, in which the area indicated 
 
 by c is magnified. 
 
 away. The histologic api)earances of the polyp are .so unusual that we give 
 them in detail. 
 
 Gyn. No. 7615. Path. No. 3879. The i)atieiit was fifty-one years of age, and 
 the operation consisted in the removal of two polypoid masses from the cavity 
 of the uterus. The specimen com])rises two small tumor masses. The larger 
 of these is 4.5 x 3.5 x 1 .5 cm., {)resents a lobulated apjiearaiice, and has a mottled 
 surface, with areas of dark green, gray, or bright red. On section, it is found to 
 contain cyst-like spaces, varying from a pinj)oint to 2 or 3 mm. in diameter.
 
 THE CONDITION OF THE CERVICAL MUCOSA IN CASES OF MYOMA. 301 
 
 This growth is a polyp. The small tumor measures 1.5 x 2.5 cm., and consists of 
 myomatous tissue. 
 
 Sections from the large and cystic polyp show that the surface is devoid of 
 epithelium, and that, to a great extent, the superficial portion consists of granu- 
 lation tissue on the surface of which is fibrin containing polymorphonuclear 
 leukocytes in its meshes. The tissue immediately beneath the granulation zone 
 shows much small-round-celled infiltration. The stroma of the polyp resembles 
 that ordinarily found in the cervical mucosa, and penetrating it in all directions 
 jire cervical glands. These are more convoluted than usual, and contain many 
 delicate, teat-like ingrowths. The epithelium lining most of these glands still 
 preserves its normal type, and in some places the cells are flattened and the 
 nuclei stain deeply. Occasionally there is proliferation of the gland epithelium. 
 
 *-. f^.//?'^i--- 
 
 ^^^^^^^4^*cVr^^ 
 
 Fig. 189. — A Rare Form ok Cervical Polyp. (X 120di:iin.,) 
 Gyn. No. 7615. Path. No. 3879. The picture represents an enlargement of the area c in Fig. 18S. The 
 stroma of the polyp consists of ordinary cervical stroma, but scattered throughout it is much blood. The cells of 
 the pale-staining area, the confines of which are indicated by a and 6, consist of polygonal cells having round or 
 oval nuclei. The protoplasm of these cells took the hematoxylin stain faintly. 
 
 several layers of cells being present. Some of the glands are much (lilat(Hl. jii'o- 
 ducing the cysts noted macro.scopically. The ei)ithelium of the dilated glands 
 is much flatten(>d, and at some jjoints has disa})j)eare(l. Scattered throughdut 
 the stroma are large oval or ii'regulai', deeply staining areas, under the low power 
 strongly suggesting cartilage (Fig. 188), but when examined with the high power, 
 differing much therefrom (Fig. 189). The individual cells of these areas are 
 polygonal in shape, ha\-e o\'a] or roiiiid. unifoniily staining nuclei, and a ])ro- 
 toplasm that takes the hematoxylin stain faintly. These areas were at first 
 sight thought to I'ejiresent broken-down cervical glands, but on closei- examina- 
 tion they resemble more a mucoid t ransfonnation of the stroma, although it is 
 difficult to explain the sharj) line of demarcation between them and the stroma. 
 We have never seen another ))oly)) jirescMiting these ]i(>culiarities.
 
 302 MYO.MATA OF THE UTERUS. 
 
 Unfolding of the Cervical Glands. — In those cases in which the cervical canal 
 is much drawn out or the mucosa of the cervix is put on great tension by a large 
 submucous myoma, the glands may literally unfold. The gland epithelium then 
 forms part of the lining of the cervical canal. Although the scjuamous epithelium 
 usually ends at or ik :w the external os, it may extend far up into the canal. If 
 such is the case, when the unfolding of the glands takes place, the epithelial 
 hning will consist of two ty])es — squamous e])ithelium, alternating with the high 
 cvlindric varietv. Such a con(Hti()n we have noted on several occasions. 
 
 Cervical Endometritis. — InHannnation of the cervical mucosa is relatively 
 freiiuent when a sloughing submucous myoma or a carcinoma of the uterus 
 exists, but is rarely found under other circumstances, even if there be an old 
 inflammatory process in the adnexa. 
 
 Tn Case 3199, in which the cervical glands showed ])rolif(>ration, there was a 
 marked small-round-celled infiltration, but the surface ejnthelium was intact. 
 
 In Case 12221 there was likewise new gland-formation in the cervix. In 
 places the surface epithelium was intact, but at other jjoints it had l)e(>n rejilaced 
 by granulation tissue. 
 
 In Case 2800 (Path. No. 312) the omentum was adherent to the large multi- 
 nodular uterus over a wide area, and the ai)pendages were bound u\) in adhesions. 
 The cervical mucosa presented a branching, arl)orescent ai)pearance. The 
 sm-face epithelium was intact, and covered with polymorphonuclear leukocytes, 
 while the underlying stroma showed marked small-round-celled and polymor- 
 phonuclear infiltration. 
 
 In Case 12139 the woman had been in the hospital seven years before, a 
 pelvic abscess being evacuated through the vagina at that time. When the 
 abdomen was ojjcned, the omentum was found glued to the myomatous uterus, 
 and general ])elvic adhesions were encountered. Sections from the cervix showed 
 that the .surface was covered with ])olymorphonuclear leukocytes. The surface 
 e])ithelium was intact, but the underlying stroma showed much small-round- 
 celled infiltration. 
 
 Suspicious Changes in the Cervical Mucosa. — In at least five of our mj'oma 
 cases sections fioin the cervix have yielded rather .suspicious histologic pictures 
 when macroscoj)ically nothing abnoi-mal could be detected. 
 
 The uterus in Case 341S (Path. Xo. (ifil ) was the seat of a diffuse adeno- 
 myoma of the ])osterior wall. The cervical glands wer(> in some places normal, 
 but here and there had ))rolif crated. 'Hie epithelium lining the cervical canal 
 was intact. 
 
 In Case 3199 (Path. No. 524) the nuiltinodular myomatous uterus reached to 
 the umbilicus. The cervical epithelium was intact, but the glands were smaller 
 than usual, and appeared to have i)r()liferated. The newly formed glands were 
 small and had a lining of cuboid epithelium. They did not ajipear to extend far 
 into the stroma, but the latter .showed marked infiltration, with small round 
 cells.
 
 THE COXDITIOX OF THE CERVICAL MUCOSA IX CASES OF .MYOMA. 
 
 303 
 
 '^& 
 
 In Case 3349 (Path. No. ()10) the nodular myomatous uterus measured 10 x 
 12 X 16 cm. Some of the cervical glands were dilated. In close proximity to 
 one of the glands was an aggregation of minute glands, some of which were 
 branching. They were lined with culwid ciliated epithelium, and had round or 
 oval nuclei situated near the center of the cells. The picture instantly suggested 
 commencing adenocarcinoma. 
 
 The myomatous uterus in Case 12221 (Path. No. 8832) measured 6 x 7 x 10 
 cm. The cervical glantls had proliferated, forming many new and smaller ones. 
 The cell proliferation had in places ad- 
 vanced so far that solid nests had been 
 formed. These resembled masses of 
 squamous epithelium. At other points the 
 surface epithelium had been replaced by 
 typical granulation tissue. 
 
 In one of our cases we found very sus- 
 picious changes in the uterine mucosa, 
 changes which strongly indicated that a 
 malignant growth was starting in the 
 mucosa. In Case 3133 the abdomen was 
 filled with a myomatous tumor, 36 x 32 x 
 32 cm. On histologic examination some 
 very interesting changes were found. Fig. 
 190 represents a portion of a gland 
 in the cervix. The epithelium on one 
 side is normal; on the other side the 
 
 ... . Gyn. No. .3133. Path. No. 494. The sec- 
 
 nuclei are mcreasmg m size, and there is tion shows a portion of a gland; a and a 
 a large circular nucleus projecting into the 
 lumen. A section from the same region 
 shows more marked changes (Fig. 191). 
 Here and there through the surface are 
 large masses of i)roto])lasm which ai'c 
 totally devoid of nuclei, and near the cen- 
 ter of the field is a nucleus at least ten 
 times as large as the suiTounding ones, 
 staining more deei)ly, and showing many hyaline dro})lets. That this largi 
 cell is distinctly abnormal is cleai'ly indicated by the zone of small round 
 cells which partially wall it off fi'om the uterine tissue. ()thei- sections show 
 that the surface ej)ithelium has a decided tendency to torin finger-like out- 
 growths (Fig. 192) or slender pi-ojections comjjosed eiilii-ely of e))ilhehuiii. 
 At d the nucleus of the epithelial cell is becoming larger mid slnins more deeply. 
 The entire picture stnjiigly suggests a comiiieiiciiig c;ii-ciiioMi;i of ihe utems. 
 
 Fig. 190. — Sispinous Epithelial Changes ix a 
 Gland from the Cervix, Associated with a 
 Large Myomatous Uterus. (X 360diam.) 
 
 dicate opposite walls; h and c represent irregular 
 nuclei, lioth of which, however, are of normal 
 size. The nuclei d and e are much enlarged, 
 and the nucleus / even more so. Normally, nuclei 
 of such a size anil character never exist in the 
 epithelium, and their presence strongly .suggests 
 a malignant tendency in the uterine mucosa. 
 (For other changes see Figs. 191 and 192.) .\t 
 several points cilia are demonstrable; they are 
 particularly well seen at Q. The luulerlying 
 stroma is practicidly normal, hut a few small 
 round cells are wandering in at h.
 
 304 
 
 MYOMATA OF THE UTERUS, 
 
 Gyn. No. 3133. Path. No. 494. 
 
 A large m y o m a t o u s uterus, ^^• i t h changes in the 
 m II c o s a V c r v suggestive of a commencing c a r c i n o m a . 
 
 M. J]. K.. aged fifty, white, married. A(hnitted October 24; discharged 
 Xovemhcr 24, 1S94. A supravaginal hysterectomy was ])erformed. Recovery 
 was uninterrujjted. 
 
 Path. No. 494. The specimen consists of a greatly enlarged uterus, with 
 the tubes and ovaries intact. The uterus is ])ear-sha])cd and measures 36 x 32 
 X 32 cm. Th(> upper surface of the tumor is covered with j^eritoneum and is 
 smooth and glistening. The lower two-thirds, both anteriorly and posteriorly, 
 are denuded of peritoneum. Projecting through the cervical canal is a small 
 uterine jiolyi). The portion of the uterine cavity present is 31 cm. long, and 
 
 Fig. 191. — Srspiciors Epituki ial Changks in tiik, Mlcosa of thk Cervix, kro.m a Larcf. Myomatous Uterls. 
 
 (X 390 diam.) 
 
 Gyn. No. .313.3. Path. No. 494. a represents the normal thickness of the surface epitheHvun, ami b shows a 
 nucleus of normal size, c, d, and e are Rranular masses of protoitlasiu of various sizes. They resemble miniature 
 ■■ ijuff balls," and are devoid of nuclei. 
 
 / is an exceptionally large nucleus containing aggregations of chromatin and large and small hyaline droplets. 
 This nucleus is strongly suggestive of an early malignant change. Nature evidently fears trouble, as she is partially 
 walling it off with many small round cells (a). 
 
 varies from 9 to 14 cm. in breadth. I'he mucosa is whitish yellow in color, 
 smooth and glistening, and apparently ver}' thin. Sixteen centimeters from the 
 fundus is a polyp 3.5 cm. long, 1 cm. broad at the base, and 2 mm. in thickness; it 
 is attached by a very delicate pedicl(\ In the posterior wall, about 12 cm. 
 from the fundus, is a yellowish area, 3 cm. in diameter. From this mucus mixed 
 with l)lood oozes into the uterine caNity. The cavity from which the mucus can 
 l)e sf[ueezed has .smooth walls. 
 
 On histologic examination the entire uterine mucosa is markedly ati"ophied, 
 and seems to consist of one layer of epithelium, resting almost directly upon the 
 uterine muscle. The surface of th(» muco.sa in the cervical ])ortion is compara- 
 tively smooth, but near the fundus it becomes somewhat convoluted. The
 
 THE CONDITIOX OF THE UTERINE MUCOSA IX CASES OF MYOMA. 305 
 
 epithelium lining the lower part of the uterus is alternating, for a certain area 
 being of the cervical type, then of the body type, and then again of the cervical. 
 The chief interest centers in the suspicious pictures noted in Figs. 190, 191, 
 and 192. 
 
 It will be noted that in each of these five cases the picture was suggestive 
 
 Fig. 192. — Suspicious Proliferation of the Cylindric Surface Epithelium of the Cervix, Associated 
 WITH A Large Myomatous Uterus. (X lOOdiam.) 
 Gyn. No. 3133. Path. No. 494. a and a' indicate normal surface epithelium, .-it b the epithelium is several 
 layers thick, and at c forms distinct outgrowths, totally devoid of a supporting stroma. This condition in itself is 
 strongly suggestive of a malignant change. At d is an enlarged and more deeply staining nucleus. Scattered 
 among the epithelial cells, and also in the stroma, are small round cells and polymorphonuclear leukocytes. 
 
 of a beginning carcinoma, but in no instance was the evidence conclusiv(\ In 
 two of the five cases an inflammation of the cervix was present. 
 
 Carcinoma of the Cervix. — From p. 262 it will be seen that in eighteen cases 
 carcinoma of the cervix was associated with uterine myomata. As each of the 
 cases is described in detail in another portion of the book, further reference to 
 them here is unnecessary. 
 
 THE UTERINE CAVITY IN MYOMA CASES. 
 Size and shape of the uterine cavity. 
 Partial obliteration of the uterine <'avity. 
 Blood in the uterine cavity. 
 Pus in the uterine cavity. 
 
 Size and Shape of the Uterine Cavity when Myomata are Present. 
 
 The size and shape of the uterine cavity dejM'iid in a great measure on the size 
 and situation of the uterine tumors. If a myoma develops in the u))]H'r part of 
 the fundus, the cavity may remain normal in size or be very small (Fig. 194). 
 If the tumor is intraligamentary, it may reach veiy large proportions without 
 causing the cavity to increase in size. On the other hand, when a myoma 
 remains interstitial and reaches large proportions, with tlie graihial enlargement 
 of the tumor there is a corresponding lengthening and often broadening of the 
 20
 
 306 
 
 .MVOMATA OF THE ITEHUS. 
 
 Uterine cavitw The caxity may retain its normal shajx', hut if invaded l)v 
 suhniucous myomata, it heoomes greatly distorted and may he very tortuous. 
 In Fig. 198 we have an example of a large myomatous uterus with a tortuous 
 hut slit-like cavity. 
 
 The following cases give a fail' idea of the various shapes and siz(^s that the 
 uterine cavity may assume. 
 
 In Case 2919 (Path. No. 8S()) the multinodular myomatous uterus measured 
 11 X 18 X 14 cm. The myomata were interstitial and suhpei'itoneal. The 
 cavity of the uterus was scarcely more than 1 cm. in length. It is diHicult to 
 account for .such a small cavity in a patient only thirty-four years of age. The 
 mucosa, however, was fully 1 cm. thick. 
 
 Fig. 193. — .A. .Siit-iikk Torti ors rTKiiixi; Cavity. (J nat. size.) 
 
 Path. No. 2.53S. Scattered throughout the uterine walls are many interstitial myomata, and projecting from 
 the surface are several others. The upper part of the cervix is readily recognized in the lower i)art of tlie picture. 
 The upper part of the uterine cavity appears a.s the narrow chink a. 
 
 In Case 12086 (Path. No. 8727) the myomatous uterus was 22 cm. in breadth 
 and 12 cm. in its anteroposterior diameter. The uterine cavity formed a caver- 
 nous space, 5 x (> cm. Its walls could not dro]) together, as in Fig. 198, ])ecause 
 the uterine cavity was literally paved with ni\-omata, whose ])resence rendered 
 it a non-collapsible space. 
 
 The uterus in Case 5784 (Path. Xo. 2084) was much enlarged, being converted 
 into a lobulated tumor 14 x 19 x 27 cm. Thegretit increase in size was due chieHy 
 to the presence of three subperitoneal myomata, averaging 11 cm. in diameter. 
 The uterine cavity was narrow and tortuous, approximately 10 cm. long, and 
 averaging l.o cm. in diameter.
 
 THE COXDITIOX OF THE UTERIXE :\irCOSA IX CASES OF MYO.MA. 
 
 ]o: 
 
 In Case 3491 (Path. No. 713) tho globular uterus inoasured 16 cm. in diameter. 
 Occupying the posterior wall, and projecting into the cavity, was a myoma 12 
 cin. in diameter. The uterine cavity was 13 cm. long and 9 cm. broad in its 
 upper portion. 
 
 The globular uterus in Case 5617 (Path. No. 1962) was 22 cm. in diameter, 
 and reseml^led a pregnant organ. Situated in the anterior wall was a myoma 
 17 cm. in diameter. The uterine cavity was 22 cm. in length and 13 cm. broad 
 at the fundus. 
 
 One of the largest uterine cavities we have ever seen was furnished by Case 
 3133 (Path. No. 494). The uterus was pear-shaped, measuring 32 x 32 x 36 cm. 
 
 Fii;. 194. — A Very Small Uterink Cavity with a Large Myoma ok the Fundus, (f iiat. size.') 
 
 Gyn. No. 1()9U). Path. No. 7162. The globular myoma, which was 11 cm. in diameter, ha.s been split in two 
 
 The uterine cavity was not over 2 cm. in length. The mucosa presented the usual appearance. 
 
 The great increase in size was due to the j)i'('sence of a myoma occupying the 
 anterior wall. The uterine cavity was 31 cm. long, and varied from 9 to 14 cm. 
 in breadth. Situated in the posterior wall, about 12 cin. from the fundus, was a 
 yellowish-area, 3 cm. in diameter. From this nmcus mixed with blood escaped 
 into the uterine cavity. This secondary cavity, on histologic examination, was 
 tound to ))e lined with one layer of e])il helium, and seemed to be a markedly 
 dilated gland. 
 
 The f(M"egoiiig exam])les are sullieieiil to show ihal the uleiiiie caxity may 
 assume almost any size and sha|)e, and, furthei', that the alteralion is dependent 
 entirely on the size and position of the niyomata.
 
 308 
 
 MYOMATA OF THE UTERUS. 
 
 a< 
 
 Kgtr-^VP 
 
 c -^-.. 
 
 
 Partial Obliteration of the Uterine Cavity. 
 In a few of the ctises of suhimicous niyoniata the mucosa from the anterior wall 
 isso firmly jjressed aiiaiiist that of the posterior wall that the walls become adherent 
 
 and the mucosa disappears from this area. 
 Thus in Case 300S (Path. No. 435), in which 
 the multinodular myomatous uterus filled 
 the pelvis, the uterine cavity, which was 6 
 em. in length, had become partially obliter- 
 ated by a submucous nodule, situated in the 
 anterior wall, becoming adherent to a similar 
 nodule in the posterior wall, thus giving the 
 cavity an X-shaped contour. The uterine 
 mucosa, on the whole, is normal, but toward 
 the point at which the uterine cavity is par- 
 tially obliterated the mucosa becomes some- 
 what atrophic, and that of the anterior fuses 
 with that of the posterior wall. The glands 
 gradually diminish in number, and then en- 
 tirely disappear, leaving only a small amount 
 of stroma (Fig. 195). This finally disaj)- 
 pears, and the muscle from the anterior wall 
 becomes continuous with that from the pos- 
 terior wall. At the point of junction arc 
 numerous blood-vessels, and the muscle 
 shows small-round-celled infiltration. On 
 })assing still further toward the upper part 
 of the cavity the mucosa gradually reap- 
 pears, and near the toj) of the ca\'ity has 
 regained its normal ai)])earance. 
 
 In Case 3111 (Path. No. 479), the multi- 
 
 the anterior wall, becoming adherent to a 
 
 similar nodule in the posterior wall, thus Uodular myomatOUS UtcrUS WaS 9 X 10 X 9 Clll. 
 
 giving the cavity an x-shaped contour. ^j^^. ^,j^,,-j^,^ ^..^^,j^ ^^..^^ 5 p„, j,, j^.j^^^^ 
 Ihe section i.s taken from the point of ' <^ 
 
 The mucosa covering the small submucous 
 myoma in the anterior wall had become ad- 
 herent to the corresponding mucosa of the 
 ))osterioi- wall, thus partially ol)literating the 
 cavity. On histologic examination it was 
 found that where the nodule projected into 
 the uterine cavity the mucosa siuklenly be- 
 came compresscHJ (Fig. 196), that from the anterior wall being directly con- 
 tinuous with that from the posterior wall. The mucosa became still more 
 atrophic, and o\<i- the most prominent part of the nodule entirely disappeared. 
 
 .r- 
 
 1 
 
 Fig. 195. — Partial Obliteration of thk 
 Uterine Cavity with Disappearance 
 OF THE Mucosa. (X4diam.) 
 Gyn. No. 300S. Path. No. 4.35. In this 
 case the uterine cavity was partially oblit- 
 erated by a submucous nodule, situated in 
 
 coalescence. Pres.-^iiig in from either side are 
 myomata, the edges of which are indicated 
 by m. a, is the normal mucosa from the up- 
 per part of the cavity. At c, where most 
 pressure ha-s been exerted, all trace of mucosa 
 has disappeared. In the lower part of the 
 field, as indicated by b, the mucous membrane 
 is again present, but is markedly compressed. 
 The clear, elongate, and irregular si)aces are 
 blood-vessels.
 
 THE CONDITION' OF THE UTERINE MUCOSA IN CASES OF MYOMA. 
 
 309 
 
 Here the muscle from the posterior wall was directly continuous with that 
 covering the submucous myoma. The line of fusion could still be recognized 
 by a moderate infiltration with small round cells.* 
 
 
 ^.v^^ 
 
 A Ho f, 
 
 Fig. 196.— Partial Obliteration ok the Utiorink Cavity Calskd h\ a Suumucols Myoma. (X 6 diam.) 
 
 Gyn. No. 3111. Path. No. 479. The uterus mea.sured 9x10x9 cm., and contained interstitial and subperitoneal 
 myomata. Situated in the anterior wall, just beneath the mucosa, was a myoma, 1.5 cm. in diameter. The 
 myoma had become adherent to the muscle of the jjosterior wall, thus partially obliterating the uterine cavity. 
 
 At a the uterine mucosa is normal. IX gradually becomes thinner, and at b entirely disappears. This is due 
 to the fact that the subnmcous myoma of the anterior wall has pressed so firmly on the posterior wall that the two 
 have unite<i. At c, where little or no pressure has existed, the nornuil mucosa is again found. 
 
 Coalescence of the uterine walls rarely occurs, but is not infretjuently simu- 
 lated when submucous myomata gre>atly narrow the hmicn of the cavity. In 
 such cases, however, ihcy have iiici'cly pushed the mucosa in fronl of them 
 without causing fusion with the nnicosa of the opposite wahs. 
 
 Blood in the Uterine Cavity . 
 
 As a rule, when the cavity of the uterus is opened, litth' or no blood is found, 
 but occasionally, as in Case 8738, the cavity will be found partially or completely 
 filled with l)lood. In this case it was full of tarry masses and recently coagu- 
 lated blood. 
 
 In Fig. 197 we have a large submucous myoma filling the entire uterine cavity 
 
 ♦Partial obliteration of the uterine cavity, due to foale.scence of tlie uterine waits, was also 
 noted in Cases 2G06 (Path. No. 19G), 27i:? (Path. No. _>.-)()), J. 'H 4 (Palli. No. ll.VJ), and 3319 
 (Path. No. 592). In the last case, however, tlicrc was tulxTculosis of the endometrium.
 
 310 
 
 :\IYU.MATA OF THK UTF.RUS. 
 
 aiul also clilatinji the cervical canal. In the ni)j)cr })art of the cavity the surface 
 is covered Avitii a large clot. 
 
 If blood is })resent in the cavity, the amount will depend upon the copiousness 
 of the flow and the ease or dilliculty with which it can escape from the cervix. 
 
 Pus IN THE Uterine Cavity in Cases of Myoma. 
 
 A definite ])y()metra is rarely associated with myomata, but occasionally at 
 operation a small amount of pus is found in the uterine cavity. In Case 2098, 
 for example, the lower abdomen was filled with a myomatous uterus, and a 
 .small quantity of ])us was found in the cavity. 
 
 In Case 12430 the lai'o;e multinodulai- uterus was adhei'ent in the j^'lvis, and 
 
 Fic;. 197. — A LARot; Ci.ot ix the L'terixe C.wity. Kh nat- si^e.) 
 Gyn. No. 14.37.3. Path. No. 12090. The anterior uterine wall is of normal thickness. Filling the uterus 
 is a pear-shaped submucous myoma. Covering the surface of the myoma, in the upper part of the cavity, is 
 a large clot. The small connections passing from the uterine wall to the myoma are drawn nut and rather 
 elastic threads, composefl of fibrin, with red blood-corpuscles in the meshes. 
 
 also liniily fixed to a looj) of small bowel. Hoth tubes were tilled with ])us. 
 The cavity of the uterus contained |)us. The uterine cavity had evidently long 
 l)een the seat of an inflammation, as the mucosa had been rej)laced by granula- 
 tion ti.s.sue. 
 
 In all cases in which there is a foul discharge from the uterus, any alxlominal 
 operation should be postponed until the discharge has been eliminated, otherwise 
 there will be great danger of infection. Of course, in some ca.ses immediate 
 operation is im})erative, irrespective of such risks. 
 
 CONDITION OF THE MUCOSA LINING THE UTERINE CAVITY IN CASES OF 
 
 MYOMATA. 
 
 (Hands running paralh'l to the surface of the mucosa. 
 
 Extension of the muscle into the mucosa.
 
 THE COXDITIOX OF THK UTKRIXK MUCOSA IX CASES OF .MYO.MA. 
 
 311 
 
 Alterations in the l)lood- vessels of the mucosa. 
 
 Thrombosis of the veins in the mucosa. 
 
 Unusual gland shaj^es. 
 
 Edema. 
 
 Dilatation of the uterine glands. 
 
 Gland hypcrtroi)hy. 
 
 Uterine polyj)i. 
 
 Atypical changes in the epithelium lining the uterine cavity. 
 
 Adenocarcinoma. 
 
 A small myoma developing in th(> uterine nni- 
 cosa. 
 
 Endometritis. 
 
 Tuberculosis of the endometrium. 
 
 If the myomata are so situated that the uterine 
 cavity is not encroached upon nor enlarged, and 
 provided the tubes are normal, as a rule it may be 
 assumed that the uterine mucosa is normal. Oc- 
 casionally, however, it is thicker than usual, as 
 appears in Fig. 19(S, or in rare instances it is gath- 
 ered up into ii-regular mounds forming localized 
 areas of very thick nmcosa, as seen in Fig. 199. 
 
 When an interstitial myoma reaches large di- 
 mensions, it usually produces a corresponding 
 lengthening and broadening of the uterine cavity. 
 Under these circumstances the normal amount of 
 mucosa has to cover an area sometimes twice, or 
 in other instances four or more times as great as 
 before, and naturally will then ]w only one-foui'th 
 the usual thickness. Fig. 200 shows a small seg- 
 ment of normal mucosa from an enlarged uterine 
 cavity. If the myoma is small or of moderate 
 size, it will almost always become subpei-itoneal 
 or submucous. If it })asses toward the cavity of 
 the uterus, the overlying nuicosa gradually becomes 
 thinner, as is well seen in l''ig. 1202. This mechanical 
 
 thinning out becomes more and iiioi-e marked, until Hnally little or no mucosa 
 can be detected over the more jjroniinent part of the tuiiioi-. and sometimes it 
 is clearly evident, even macroscopically, that this portion is toiahy dcNoid of 
 a mucosa, ^^'hen the myoma is small, the tension on the mucosa is naturaUy 
 not as great, and the tumor, even though subnuicous and |)edunculated, may 
 still have a lilieral covering of mucosa. In Fig. 201 we have an example of 
 a young myoma foi'cing its way through the mucosa into the uterine cavity. 
 The myoma is \'irtually plowing through the nmcosa, i)ushing it to either side. 
 
 Fig. 198. — Thickeni.vg ok thk 
 Uterine Mucosa. (X 8 diam.) 
 Gyn. No. 2706. Path. No. 
 245. The uterus contained small 
 interstitial and subperitoneal myo- 
 mata. The uterine cavity was 4.5 
 cm. long. The mucosa is consider- 
 ably thickened, and consequently 
 tlic glands are much lengthened. 
 They are normal, a indicates the 
 surface ei)itheliuni, and li the irregu- 
 lar line of jimcliiin lictween the 
 inuciisa and the muscle.
 
 312 
 
 MVOMATA OF THE UTf:RUS. 
 
 and also causing atrophy over the most prominent portion of the nodule, 
 whereas the mucosa at the sides is much thicker than usual. 
 
 '■■cyo\ „ _v>> 
 
 r- ■.%. 
 
 k 0--; ,^.^ ... 
 
 
 
 
 
 ^7-V. 
 
 f)_^.. 
 
 a 
 
 Fig. 199. — Thickening of the Mucosa in a Myomatous Uterus. (X 8 diam.) 
 Gyn. No. .3614. Path. No. 788. The uterus was 11x9x9 em., and covered with den.se adhesions. Its walls 
 showed diffuse myomatous thickening, in places reaching 5 cm. .An interstitial myoita, 9 cm. in diameter, was 
 also present. The uterine cavity was 6 cm. in length, and the mucosa in the upper part of the cavity wa.s gathered 
 up into mounds, varjing from 1 to 3 cm. in diameter, and projecting from 1 to 8 mm. into the cavity. The section 
 is from one of these elevations, a and a' indicate the line of junction between the mucosa and the myoma. The 
 surface epithelium is intact. Many of the glands, especially in their deeper portions, are dilated. The stroma in 
 the superficial portion is somewhat rarefied. It also contains many capillaries, one of which is seen at b. Near 
 the muscle are numerous vacuoles, indicated by c. 
 
 ^^'ith the continued inward progress of the myoma the mucosa becomes 
 thinner and thinner, until all trace of the glands disa)i)»ears and merely the surface 
 
 
 ^m^^'^ 
 
 Fig. 200. — Moderate Thinning-out of the Mucosa Over a Submucou.s M vo.ma. ( X ^i diam.) 
 
 Path. No. 591. The globular uterus measured 17 x 17x12 cm. The uterine cavity was 15 cm. in length, 11 cm. 
 
 in breadth, and projecting into it from the posterior wall was a submucous myoma, 13 x 11 cm. The section is from 
 
 the surface of this large submucous tumor, a is the mucosa, which is much thinner than usual, but otherwise 
 
 normal, b is a thin layer of uterine muscle separating the mucosa from the underlying myomatous tissue (m). 
 
 epithelium and a zone of underlying stroma are left, .separating the myoma from 
 the uterine cavitv. This is clearlv shown in Fig. 203. The stroma becomes more
 
 THE COXDITIOX OP^ THE UTERIXE MUCOSA IX CASES OF MYOMA. 313 
 
 and more thinned out, until only a few layers of stroma cells are interposed be- 
 tween the myoma and the surface epithehum (Fig. 204). Finally, when the 
 myoma projects far into the cavity, the mucosa may be represented merely by 
 
 ■-^ 
 
 
 Fig. 201. — A Small Myoma Pushing Through thp: Mucosa. (X 12 diam.) 
 Path. No. 5.33. a is the surface epithehum. The myoma is pushing the mucosa to either side and is causing 
 a thinning-out of the mucosa over the most prominent portion of the tumor. The mucosa is thicker on the sides of 
 the myoma than it is elsewhere. 
 
 a layer of somewhat flattened epithelium, resting directly on the myoma. Such 
 a condition is presented in Fig. 205. 
 
 The next stage is so well exemplified in Case 8767 (Path. No. 4959) that a 
 
 '/Ki--^*«»-?tj. 
 
 ^ ■ '^^^^ 
 
 
 - y 
 
 MOL. 
 
 ^U-li^'!'K>-7l '"^CL'ZW.Ji -.Vi'".'.-^-' 
 
 Fig. 202. — Thi.\nin<; out of the Mucosa Over a Submucous Myoma. (X iij diam.) 
 Oyn. No. 3008. Path. No. 43.'). a indicates the normal thickness of the mucosa, and b the layer of muscle 
 separating the submucous myoma from the mucosa. Toward the left the myoma becomes more prominent, and 
 the muscle and mucosa gradually become thinner until at a' all traces of the glands have liisappcaicd. and the 
 mucosa is represented merely by the surface epithelium and a certain amount of underlying stroma. 
 
 detailed description will b(; given. The specimen consisted of a globular uterus, 
 averaging 18 em. in diameter. The great increa.^e in size was due to the pres- 
 ence of an interstitial myoma, approximately 17 cm. in diameter, and occupying 
 the posterior wall. The uterine cavity was 15 cm. in length, and its mucosa
 
 314 
 
 MVOMATA OF THK UTERI'S. 
 
 avcragecl about 1 iimi. in tliickncss. At one point oviT the suhimicous myoma 
 the mucosa had entirely (lisa|)])eare(l tVoni an area measurinii 7x5 cm. The 
 myoma here was dark l)ro\vn in cohjr and somewhat roughened. On histologic 
 examination, the mucosa hning the uterine cavity was found to be perfectly 
 
 >?-■• :^ - -.-^^.t -^-V-- •■-'"' 1,*^ -^ 
 
 
 3 •f^AK*-.<ihP/i.-. 
 
 
 Fig. 203. — Atrophy of the Mucos.v Over a Submucous Mvoma. (X 140 diam.) 
 Gyn. No. .3218. Path. No. .539. The surface epithelium (a) is normal, b is the zone of underlying stroma, 
 devoid of glands; c is the muscle. The myomatous tissue lies immediately beneath this. A few strands of muscle 
 are passing up into the stroma at d. 
 
 normal, but near the denuded area it had become thinner and thnmer, until 
 nothing but surface epithelium remained. This finally disappeared, and the 
 myomatous tissue which had undergone hyaline transformation now formed the 
 surface. Scattered throughout the hyaline material were numerous polymor- 
 phonuclear leukocytes. The next step 
 would be breaking down of the degen- 
 erated myomatous tissue, with a speedy 
 formation of a sloughing submucous 
 myoma. 
 
 In some cases the myoinata are very 
 abundant, and literally pave the uterine 
 cavity. In .such cases the walls suggest 
 a mosaic. Over the myomata the mu- 
 cosa is very thin, whereas the spaces Fig. 204.— marked thi.nm.ng-out of the mucosa 
 
 . Over a Submucous Myoma. (X 140 diam.) 
 
 between myomata arc hlled with mu- ^^^ ^^ 3^49 p^^j, j^„ ggs. a is the 
 
 COSa, which is often injected and much normal surface epithelium. It is separated from the 
 
 myomatous muscle (c) merely by (a) narrow zone of 
 thickened. stroma (b). 
 
 Case No. 2658 (Path. Xo. 213) 
 afforded an excellent example of such a condition. The uterus was ajjproxi- 
 mately globular, being 13 x 11 x 11 cm. Scattered throughout the walls 
 were many .small myomata. The uterine cavity was 5 cm. in length, and 
 projecting into it from the top were two pedunculated myomata, the 
 
 C{5 
 

 
 THE COXDITIOX OK THK UTERINE MUCOSA IN CASES OF MYO.MA. 315 
 
 larger Ix'ing o cm. in (lianieter. The entire inner surface of the uterus was 
 
 H.^r^.it' 
 
 Jiu. 20o. — A Submucous JIvoma Almost Dkvoid ok Mucosa. (X 41 diam.) 
 Gyn. No. 329.3. Path. No. 583. The surface epithelium (a) is all that remains of the mucosa. It rests directly on 
 
 the myomatous tissue. 
 
 '■^i'J' ?' 
 
 "'l*^' ".'(V" 
 
 ^fM 
 
 ^-^~S>-«l0><Si-.y.^.^ ,-,, . 
 
 fc 
 
 '■■X-. 
 
 Fici. 20G. — Marked Thickkninc ok tiik Utkrink Mucosa in a I)KrnKssioN Hi;r\vi;i;.\ .Myomatous Nodi'lks. 
 
 (X 5 (liam.) 
 
 Gyn No. 2658. Path. No. 213. 'I'he uterus \va-< enlarged, measuring 13 x 11 \ 11 cm. Scattered Ihrnugli- 
 out its walls were myomata, varying from 0.5 to 5 cm. in diameter. 
 
 The uterine cavity was S'cni. in length. Projecting into it from llic lop were two pciluiiculalcd suhnmcous 
 myomata. The whole inner surface of tlie uterus was paved with small, pearly while m.\ onial.-i, v:u\ing frum 
 3 mm. to 3 cm. in diameter, the intervening si)accs being occupied l)y iii.iected mucosa. 
 
 The i)icture represents the cleft between myomata, where the nuicosa readied 8 nun. in thickness. Scattered 
 everywhere throughout the muscle are myomata of various sizes. To the left the nuicosa is fairly well preserved. 
 In the cleft it is very thick, but otherwise normal. At « a young )>olyp is developing. .\t b the mucosa is repre- 
 sented by one layer of cyiiridric cpithcliuni which rests directly im the m,\(imatons muscle. 
 
 paved witii small, pearly' white myomata, N'aiA'iiig from ().'.] to .'5 cm. in diameter. 
 The inteiA'eniiig sj)a('es wei'e occupied hy injected imicosa, which in one ch'ft
 
 316 MYOMATA OF THK UTERUS. 
 
 reached 8 mm. in thickness. Histologic examination showed that the mucosa 
 was in phices virtually al)sent, but at other points reached 8 mm. in thickness 
 (Fig. 206). That covering the submucous nodules over their most prominent 
 {)ortion was represent etl 
 by one layer of cylindric 
 epithelium resting almost 
 
 5^5- 
 
 
 Fi<;. 207. — Gland Hypertrophy in a Cleft Between Myomatous Nodules. (X 7 diam.) 
 J. ( H. A. K., DecemberO, ISQOV Path. No. 3674. The slightly irregular myomatous uterus measured 13 x 10 x 10 
 cm. Scattered throughout its walls were myomata, the largest 7 cm. in diameter. The uterine cavity was ap- 
 proximately 10 cm. in length, but much distorted and narrowed by submucous nodules. The mucosa was smooth. 
 Over the submucous nodules it wa,s as thin as parchment, but where not subjected to pressure, reached from 2 to 
 3 mm. in thickness. 
 
 On histologic examination, the mucosa presents an undulating surface and an intact surface epithelium. 
 Over the prominent portion of the submucous myomata it consists merely of a narrow layer of stroma covered with 
 epithelium, but devoid of glands. In the protected areas the mucosa was thickened. The picture represents such 
 an area. At c and c' the surface epitheUum rests directly on the muscle, but in the cleft becomes even thicker than 
 normal. It shows tj-pical gland hypertrophy, especially well seen at a. Some of the glands, as at b, are dilated. 
 m is a small myoma. 
 
 directly on the muscular tissue. Some distance from the most prominent por- 
 tion of these tumors the mucosa had regained its normal thickness. 
 
 In a few cases the thickened mucosa in the crevices between myomata showed 
 typical gland hyjieitrophy, as seen in Fig. 207. 
 
 Glands Running Parallel to the Surface of the Mucosa. 
 It is no uncommon thing to see the deeper portions of a gland running parallel 
 with, instead of at right angles to, the surface. This is especially prone to occur 
 over the less prominent portions of a submucous myoma. In such cases it
 
 THE COXDITIOX OF THE UTERINE MUCOSA IX CASES OF MYOMA. 317 
 
 would seem that, with the ingrowth of the myoma, the deeper portions of the 
 glands are pressed upward until they are at right angles to their superficial por- 
 tions. This explanation will apply only to a certain percentage of cases, as we 
 have not infrequently seen this deflection of the glands in the absence of sub- 
 mucous myomata. 
 
 Extension of the Muscle into the Mucosa. 
 
 It is a common occurrence to find one or more uterine glands extending a 
 short distance into the muscle, especially if there be an adenomyomatous ten- 
 dency, but the extension of muscle-bundles into the mucosa is relatively rare. 
 
 In Case 2852 (Path. No. 347) some of the uterine glands were much dilated, 
 the stroma of the mucosa showed moderate hemorrhage in its sui:)erficial portion, 
 and here and there bundles of muscle-fibers had extended into it. 
 
 The picture in Case 3113 (Path. No. 487) was even more striking. The 
 mucosa was very atrophic. The surface epithelium was intact, the glands were 
 few in number, small, and round on cross-section. The stroma of the mucosa 
 showed a considerable amount of infiltration with small round cells, and non- 
 striped muscle-fibers were seen passing up into the stroma of the mucosa nearly 
 as far as the surface epithelium. 
 
 Alterations in the Blood-vessels of the Uterine Mucosa in Myoma Cases. 
 
 As a rule, the mucosa will jjresent the usual appearance if the tumors do not 
 encroach upon it, and even if there is a marked projection of the tumor into the; 
 cavity, little or no change in the mucosa may be noted. 
 
 In a moderate number of the cases the mucosa is uniformly bright red, ap- 
 parently owing to an injection of the capillaries. More common than this are 
 foci of ecchymosis. These ecchymotic spots, if recent, are bright red in color, and 
 appear as splotches of red. They are irregular in outline, and sharply difTeren- 
 tiated from the surrounding and normal mucosa. Sometimes they are found 
 in a mucosa of the normal thickness, l)ut are more likely to l)e noted over the 
 prominent surface of a large submucous myoma. As the hemorrhagic areas be- 
 come older, they change in color, being in turn dark red and tlien almost black. 
 
 ^Miere the mucosa is exceedingly thin, dilated veins beneath it are often 
 clearly visible. These veins are often greatly increased in size when large myo- 
 mata are present. 
 
 On histologic examination one Imiuently notes an abuiidaiice and much 
 dilatation of the capillaries in the superficial portions of the mucosa. In I'ig. 208 
 we have an example of a mucosa showing mark(>(l dilatation of the larg(>r veins. 
 This mucous membrane is otherwise unaltered. 
 
 In the cases in which ecchymosis is noted, there is usually nnich free blood in 
 the stroma of the mucosa. This may be fresh, as in I-'igs. 20*1 and 210, or show a 
 moderate degree of disintegration, in most cases all trace of the hemorrhage 
 eventually disappears, but occasionally l)lo()(l-i)iginent remains. In Case 3960
 
 318 
 
 MVOMATA OF THK UTERUS. 
 
 (Path. Xo. 971), for cxaiiiplc the uterine cavity was 3 cin. in length, 3 cm. in 
 l)rea(lth. and its smooth mucosa presented numerous fine ecchymoses. In sec- 
 tions from these areas the surface epitheUum was intact and the glantls were 
 
 
 ^ D ^ 
 
 '--^.< ^*^ 
 
 Fn;. 208. — Marked Dil.vtation of the Vei.ns of the Uterine Mucos.\. (X 11 diaiu.) 
 Path. No. ,524. a is the mucosa, b, the underlying muscle. The surface epithelium and the glands are normal 
 
 but the veins (c) are greatly dilated. 
 
 normal. The stroma of the mucosa showed slight small-rouiid-ccllcd infiltra- 
 tion, and there were deposits of yellowish-l)rown, granular pigment. 
 
 In Case 3492 (Path. No. 711) a myoma, 10 cm. in diameter, projected into the 
 uterine cavity. Scattered throughout the mucosa were numerous patches of 
 
 ..,va^'JC:;?i& <£ ^i > 
 
 I'll.. _'it'.i. lliMoKuiiAGE INTO THE Uterine Micn-v. ■ 130 diam.) 
 Gyn. No. 3038. Path. No. 452. The surface epithelium a is normal. .\t b it ha.s been cut on the bevel, and 
 thus appears several layers thick. The uterine glands are normal, but scattered throughout the stroma are quan- 
 tities of fresh blood, and in places the stroma-cells lie totally isolated from one another. 
 
 ecchymosis. Histologic examination showed the mucosa co\'enng the sub- 
 mucous myoma to be atrophic, and there was al.so edema, ^^'here the ecchy- 
 motic patches were noted, large quantities of an almost l)lack pigment were found 
 in the stroma. This pigment occurred in irregular clumps or as minute
 
 THE COXDITIOX OF THE UTERINE MUCOSA IX CASES OF MYOMA. 
 
 !19 
 
 specks. AMiether or not it was coiitainod in the cells it was difficult to deter- 
 mine. 
 
 
 
 
 
 »t';r 
 
 
 
 
 
 i-^ 
 V""?-*---:'' 
 
 -.^.^.t..... »l 
 
 Fig. 210. — Hkmohhiiac;i; inio rm. Mrcus v. ( ■ 'JOdiam.i 
 Gyn. No. 3281. Path. No. 573. The surface epithelium (a) is intact, and the glands are normal. The 
 stroma of the mucosa shows marked hemorrhage (b). The large, irregular, empty areas were also filled with 
 blood. This has clrr)])i)e(l out, owing to its crumbling character. The veins of the mucosa are mucli dilated (c). 
 
 
 
 
 Fig. 211. — Rup'riiu-. vmih SiJbcik.>.iUK.M Thhombosis ok a V'i.in ut iuk I ii.niM-, .Mitn.-A o\ i-,u v SrnMi'oous 
 
 Myoma. (X 100 diam.) 
 Gyn. No. 8354. Path. No. 4539. a represents the remnant of the atrophic uterine mucosa covering the large 
 submucous myoma; b is the underlying muscle. Occui)ying the tiitper pail of the field is a large vein. This, at 
 c, still contains normal blootl, but at d is filled with a thrombus which reaches to and opens on tl\e sinface. There 
 has undoubtedly been a recent hemorrhage from this vein. 
 
 It is most exceptional to find any e\ideiu'e of a deliiiite l)leedin<i \'essel in the
 
 320 
 
 MYOMATA OF THE UTERUS. 
 
 mucosa. The surface epithelium is invariably intact, and the bleeding seems to 
 be just a general oozing from the vessels in the mucosa, without any especial 
 injury to their walls. In all the cases just described the hemorrhage was into the 
 mucosa, and the surface was smooth. In Case 7688, however, in which the cavity 
 of the uterus was di.^torted by interstitial and submucous myomata, the mucosa 
 showed large heuiorrhagic areas which, to a great extent, were covered with fibrin 
 and blood. 
 
 
 -d 
 
 
 
 
 i-f^ 
 
 Tig. 212. — Hkam HIM. oi- a 
 Uterine Gland. (X 50 
 diam.) 
 
 Gyn. No. 3008. Path. 
 No. 435. The uterus con- 
 tained subperitoneal, inter- 
 stitial, and submucous myo- 
 mata. a is the point at which 
 the tubular gland divides into 
 secondary glands, b and c. 
 The gland c, after passing a 
 short distance, divides into d 
 and d'. The glandular ei)ithe- 
 lium is everywhere normal, 
 and the surrounding glands 
 and stroma present the usual 
 appearance. 
 
 Fig. 213. — An Atypical Uter- 
 ine Gland. (X 50 diam.) 
 
 Gyn. No. 3216. Path. 
 No. 534. The uterine cavity 
 in this case was not encroached 
 upon, but situated in the 
 right broad ligament was a 
 suppurating myoma (Fig. 
 105, p. 138). The surface 
 epithelium is intact. In the 
 depth is a slightly ililated 
 gland (a). This continues 
 downward, but also sends off 
 two secondary branches, b and 
 c. The epithelium of all the 
 uterine glands is normal, and 
 the surrounding stroma is un- 
 altered. 
 
 6 
 
 Fig. 214. — An Unusual Uterine Gland. 
 (X 50 diam.) 
 
 Gyn. No. 3385. Path. No. 634. The multinod- 
 ular inyomatous uterus measured 14 x 1.5 x 11 cm. 
 The nodules were chiefly interstitial and subperitoneal. 
 
 The surface of the mucosa is smooth, and the 
 glands near the surface are normal. The gland (a^ 
 can be traced downward and to the right. Us ap- 
 parently solid character is due to the fact that the 
 section ha,s been cut through the margin, instead of 
 through the center of the gland. At b it spreads out. 
 It is continued downward and also to the left, where 
 it gives off the terminal branches c and d. Although 
 the picture is a most unusual one, there is not the 
 slightest suspicion of malignancy. The surrounding 
 glands and their intervening stroma are normal. 
 
 Thrombosis of Veins in the Mucosa. 
 
 In Ca.se 6667 (Path. No. 29U0) there was a history of a sudden hemorrhage 
 four years before, and profuse bleeding each month after that. The cavity of 
 the uterus was occujiicd by one large and two small myomata. On histologic 
 examination several large thin-walltHl veins of the atrophic mucosa were found 
 thrombosed. 
 
 In Case 8354 (Path. Xo. 4.^39) the uterus was greatly enlarged as a result of
 
 THE CONDITION OF THK UTERINE MUCOSA IN CASES OF MYOMA. 
 
 321 
 
 siihpci'itonoal, interstitial, and subinucoiis inyoinata, and the uterus contained a 
 very large polyp (Fig. 230, j). 331). The mucosa lining the uterine cavity was 
 very thin. Its surface epithelium was intact, but flattened. The glands were 
 small. The stroma showed slight infiltration, and occasionally a thrombosed 
 vessel simulating to a liinit(>d extent a young tubercle. At one point at least 
 (Fig. 211) the walls of a superficial A'(Mn had given way, but the leak had been 
 partially controlled b}' a thrombus. 
 
 b 1) b" 
 
 Branching of a 
 (X 50 diam.) 
 Path. No. (>M. 
 
 Fig. 215. — Marked 
 Uterine Gland 
 Gyn. No. 3385. 
 The gland a in its upper portion is nor- 
 mal, but on passing toward the mus- 
 cle, divides into the .six terminal 
 branches a', a', a', a', a', a'. Its epithe- 
 lium is normal. The surrounding ghinds 
 present the usual appearance, and the 
 stroma of the mucosa is unaltered. 
 
 
 Fig. 216. — Marked Branching of a Uter- 
 ine Gland. (X 50 diam.) 
 Gyn. No. 3038. Path. No. 452. The 
 gland a in the lower part of the field is 
 slightly dilated. That in the upper part is 
 greatly dilated and partially filled with blood 
 and granular detritus. The gland sends off 
 the terminal branches /), //, and h", while the 
 gland between b and b' is jirobably a l)ranch 
 cut at another level. To the right the gland 
 spreads out into a large bay. .\11 the glands 
 are lined with normal cylindric epithelium 
 and the surrounding stroma is unaltered. 
 
 Unusual Shapes of the Glands Associated with Uterine Myomata. 
 
 As has been said, when the myomata do not encroach u))()n the uterine cavity, 
 the latter is usually of the nonnal size: the mucosa is noniial in appearance, and 
 the uterine glands are of the usual type, l^ven if a sul)inucous myoma is ])i'esent , 
 the only change in the niucosa will be a ihinning-out . 
 
 In a few instances we ha\'e found unusu;il |)alleiMs in I he gl;in(f'^; some of the 
 more interesting of these ai'e shown in Figs. 212, 2I."!, 211, 21."), and 21(). 
 
 In Fig. 212 we see a dichot onions branching, ;ind one of the secoiidai'y branches 
 again divides. 
 
 21
 
 322 MVOMATA OF THK ITKHIS. 
 
 In Fig. 213 wc have a slightly dilated gland in the d(']ith of the mucosa send- 
 ing off two lateral branches. 
 
 In Fig. 214 a tubular gland can be followed from near the surface into the 
 depth, where it sends off branches to the i-jglit and left. One of these again 
 subdivides. 
 
 In Fig. 21 ") a gland in its suj)erficial portion is normal, l)ut in the depth spreads 
 out and apparently ends in six terminal branches. 
 
 The large ghuul in Fig. 21G is considerably dilated, and spreads out into three 
 terminal branches. 
 
 The glands in each case are lined with normal cylindric epithelium, and are 
 
 d 
 
 Fiii. 217. — Ki)i-.MA OK THE Utkrink MicosA. (X 130 diam.) 
 Gyn. No. 3209. Path. No. 540. Separating the surface epithelium from the mucosa at a and b is coagulated 
 serous fiuid. The uterine glands are normal in appearance. The stroma is very edematous, as is particularly well 
 seen at c. Scattered throughout the coagulated serum are many small vacuoles, one of which is indicated by d. 
 .\t e the stroma-cells are arranged aroimd a vacuole resembling a small gland. 
 
 surrounded by the chai'acteristic stroma of the muco.sa. In none of them is there 
 the slightest suspicion of malignancy. 
 
 Edema of the Uterine Mucosa. 
 
 Edema is usually rec(jgnized by the succulent character of the tissue in which 
 it is found, and by the escape of serous fluid from the cut surfaces. The uterine 
 mucosa has a glistening, ti-anslueent appearance, so that edema might very 
 readily be thought to lie jjresent, when in reality none exists. Hie diagno.sis, as 
 a rule, can be made only on histologic examination. 
 
 Fdema of the muco.sa is rare and, when met with, is usually limited to the 
 superficial portions, and is not found neai- the muscle. It may be localized or
 
 THE COXDITIOX OF THE UTERIXE MUCOSA IX CASES OF MYOMA. 
 
 323 
 
 uniform throughout the cavity. It occurs irrcs})ective of the presence or ab- 
 sence of submucous myomata. 
 
 The surface epithehum is intact, and the glands are usually normal. The 
 stroma cells are separated from one another by a granular material which takes 
 the eosin stain. Scattered throughout it are large or small vacuoles. The 
 granular material is undoul)tedly c()agulate(l scrum. A certain amount of fibrin 
 can also be demonstrated in some cases bv means of Weitjert's stain. Oc- 
 
 rn XL c o ^ 
 
 Fig. 218.— Dilated Uterine Glands Over a Submucous Myoma, (i; nat. size.) 
 Gyn. No. 12490. Path. No. 9186. As soon as the uterus was opened, its muscular walls contracted, leaviiiR 
 the submucous myoma standing out prominently. The mucosa over the submucous nodule is very thin, and 
 standing out shaqily from this, are the cystic glands (a). The mucosa (h) at the ba-se of the myoma is consideralily 
 thickened. That lining the opposite wall is gathered up into folds, owing to the marked contraction of the walls liS 
 soon a.s the uterus was opened. 
 
 casionally the exudate is exceptionalh' rich in albuiiiiii. It ihcii forms a hoiiic- 
 geneous mass that takes tlic eosin stain. When the cdcina is \('i-y pronounced, 
 as in Fig. 217, much serum is j)oure(l out not only into the stroma, but also into 
 the glands, and the surface epithelium may be separated from the stroma by 
 scnmi. ()ccasionally the lyniith-N'csscls in the underlying nniscle are dilated, 
 as in Case 4203 (Patii. No. UK;). 
 
 Dilatation of the Uterine Glands. 
 In a moderate luimber of inyonia cases we li;i\"e found slight dilatation of 
 some of the uterine glands. The dilate(l glands may be present in an\' part of
 
 324 
 
 MYU.MATA OF THE UTERUS. 
 
 the cavity, and are more j)r()iie to occur when submucous myomata exist. 
 The smaller ones are recognized as spheric cysts, O.o to 1 mm. or more in diam- 
 eter, and filled with a translucent or transparent content. If the mucosa is 
 atroj)hic. these small cysts .stand out prominently. They are also especially 
 noticeable in uterine i)()l\-pi. 
 
 In rare instances the cysts become relatively large, as in Fig. 218, in which we 
 see numerous cysts, .several millimeters in diameter, ])rojecting from the atrophic 
 muco.'^a covering the submucous myoma. Another striking examj)le of cystic 
 glands is furnished by Fig. 219. Here the uterine cavity is much increased in 
 size, and the muco.sa over a large submucous nwoma has numerous cysts or 
 blebs projecting from its surface. These cysts tend to arrange themselves in 
 rows; they have exceedingly fine walls, and ramifying over their surfaces arc; 
 delicate traceries of blood-vessels. They are filled with a clear. linij)id fluid. 
 
 
 
 Fic. 220. — Makkkdly Dilated Uterine Glands, v ,\ '> .liam. - 
 Gyn. No. 3232. Path. No. 543. The section embraces one of the dilated glands in Fig. 219. a is the normal 
 mucosa. .\t b the glands show cystic changes. The smaller cysts are irregular, the larger spherical, c is one of 
 the markeilly dilated glands. The surface epithelium is continued over it. .\11 trace of an epithelial lining has 
 disappeared from the inner walls of the greatly dilateti glands, although still present in those showing only moderate 
 dilatation. 
 
 Occasionally the (iilated glands contain small yellow bodies that float around 
 in the clear fluid. These bodies usuall>- consist of exfoliated epithelial cells. 
 
 On histologic examination the glands sho\ATng moderate dilatation have an 
 intact cylindric epithelium. They may be empty, as in Fig. 221, or contain a 
 granular detritus or a .solid coagulum resembling a hyaline cast. When the 
 glands l)ecome still more dilated, the epithelium .sometimes retains its normal 
 form, but is usually flattened. In a few in.stances, as in Case 3437, the epithelium 
 may show ])roliferation, being several layers in thickness. 
 
 Where marked dilatation occurs, the epithelium may entirely disappear. 
 In Fig. 220 .some glands .show slight dilatation and are irregular in contour. 
 Tho.se moderately dilated are spheric, whereas the one .showing great dilatation 
 is irregularly oval. 
 
 An example of gland dilatation of a marked degree is furnished by Case 3133 
 (Path. No. 494). The uterus was pear-.sha|)e(l, and measured 36 x 32 x 32 cm 
 The uterine cavdty was 31 cm. long, and varied from to 14 cm. in breadth. Its
 
 Fig. 219. — Marked Dilatation of the Uterine Glands Over a Submucous Myoma. (J? nat. size.) 
 Gyn. No. 3232. Path. No. 543. Mr. Bnidel painted this picture within a few minutes after the uterus was 
 opened, and was fortunate in getting the exact colors of the mucosa. 
 
 Occupying the posterior uterine wall, and seen in hazy outline, is a myoma 15 cm. in diameter. The uterine 
 cavity is much increased in size. The mucosa has a yellowish tinge, and scattered over the anterior and posterior 
 walla are a few irregular patches of ecchymosis. Scattered over the posterior walls are numerous cysts varying 
 from 1 to 7 mm. in diameter, and apparently arranged in definite rows. The larger cysts have elevated margins, 
 are sharply defined, and project fully 1 mm. from the surface. They are covered with a delicate membrane, which 
 is everjT^'here traversed by a fine network of blood-vessels. The blood-supply of these cysts reminds one somewhat 
 of the vascular arrangement of the fundus of the eye. 
 
 For the histologic appearances of the cysts see Fig. 220.
 
 THE CONDITION OF THE UTERINE MUCOSA IN CASES OF MYOMA. 325 
 
 mucosa was atrophic, and j)rojc'('ting into the cavity from the upper part were 
 three large polypi. Situated in the posterior wall, about 12 cm. from the top of 
 the cavity, was a yellowish area, 3 cm. in diameter. From this mucus mixed 
 with blood escaped into the uterine cavity. This cavity had smooth walls. 
 
 On histologic examinatioii marked atrophy of the mucosa was found, and 
 most of the glands had disappeared. The cyst-like cavity seen near the middle 
 of the uterus, and communicating with the uterine ca\dty, was lined with one 
 layer of epithelium similar to that covering the surface of the mucosa. This 
 cavity was in all probability a dilated uterine gland. The fact that it secreted 
 mucus, however, suggests the possibility of a cervical origin. 
 
 Gland Hypertrophy. 
 
 This was noted in several cases. \Mien present, it was usually associated 
 with submucous myomata, and even macroscopically the mucosa was thicker than 
 
 Fk;. 221. — A MoDKRATE Grade of Dilatatiox of the Glands. (X 8 diam.) 
 Gyn. No. 2852. Path. No. 347. The mucosa on the right and left is normal. The glands in the central 
 portion are more convoluted and show slight dilatation. Just beneath the surface is a markedly dilated and 
 irregular gland. The dilatation has produced a decided elevation of the surface of the mucosa at this p;>int. 
 
 usual (Fig. 207, p. 316). The hy])('rtr()])hic changes were almost invariably 
 limited to the su])erficial layers of the mucosa. The cause of the gland hyjx'r- 
 tropliy is unknown. In Case 7795 (Path. No. 4055), in which a right tubal 
 pregnancy existed, the exciting factor was evident. 
 
 Uterine Polypi Associated with Myomata. 
 
 On opening the cavity of a myomatous uterus one oi' more jxilypi arc not 
 infrequently found. These may he situated in any i)ait of the cavity, i)ut are 
 more prone to occur in the u])per part. .\ii cxaiiiiiiation of It cases in which 
 uterine poly))i were present showed that in 34 tlici-c was I p()ly[): in 5 there 
 were 2, and in 5 cases 3 polypi; thus it is evident that the polypi usually occur 
 singly. 
 
 The polypi were found in large and small myomatous utci-i, the size of the 
 organ seeming to have little or no influence (Jii their development. 
 
 Some of the polyjn were very small, as in Fig. 222. and a))peared as little Hat 
 and yet sharply outlined ele\-atioiis from the sui-faee of the mucosa. 'Ilie relation
 
 326 
 
 .MVO.MATA OF THK ITKRUS. 
 
 of such small polyj)! to the nuicosa is clcaHy seen in Fig. 225, where the polyp is 
 evidontlv iiothinu- iiioic than a heaping up of the mucosa at a given point. 
 
 My oma 
 
 '^%i.X, 
 
 Fig. 222. — Three Small Polypi. (I! nat. size.) 
 Gyn. No. 91.'?2. Path. No. 5286. The picture represents the right half of the uterus. The right tube is much 
 thickened near the cornu. In the anterior wall is a myoma, several centimeters in diameter. In the posterior 
 wall are a few minute tumors. In the uterine cavity are three small flat polypi, as indicated by a. Two are in the 
 upper part of the cavity; one is near the internal os. 
 
 Fig. 223. — Small Uterine Polypi, d'o nat. size.) 
 .'^ut. No. 869. Path. No. 1.3S2. The cervix is normal. The anterior uterine wall is thickened, and contains 
 a small myoma. Projecting into the uterine cavity are two small pedunculated polyi)i, and between them and to 
 one side are the faint outlines of a smaller one. 
 
 As the poly])i get larger they become somewhat ixMlunculated, as seen in
 
 THE CONDITION OF THK ITKHINE MUCOSA IN CASES OF MYOMA. 327 
 
 Figs. 223 and 224. The majority have broad bases, and are relatively thin, 
 being not over 1 to 2 mm. in thickness. Nearly all of them point downward. 
 The polyp in Case 3038 (Path. No. 452) is on(> of the rare exceptions. This polyp 
 was 1.5 cm. long and 4 mm. broad; it was attached near the internal os and 
 pointed upward. 
 
 The polypi are usually smooth, and consist of a whitish-yellow, semi-trans- 
 lucent substance — uterine mucosa. Scattered throughout it are often seen 
 small cystic spaces — dilated glands. The lower and free margins of the polypi 
 are often deeply injected, as a result of hemorrhage into their dependent portions. 
 
 Fig. 224. — Polypi Associatki) with Utkkink Myomata. (.^ aat. size.) 
 Gyn. No. 9707. Path. No. 5912. The appendages are normal. The uterus had been opened posteriorly. 
 Springing from its surface, and studding its walls, are myomata of various sizes. Occupying the greater part of 
 the cavity is a long and partially submucous myoma. Springing from the left side of tiie fundus, near the coriui, 
 and attached by a delicate iiedide, is a sligiitly lobulated i)olyp, several centimeters long. Hanging down from the 
 top of the cavity is a second but smaller pnlyp, which has been cut in two. 
 
 The uterine mucosa surrounding the polypi ma\' be (.)f the normal thicknes.s, 
 atrophic, or even show an increase in thickness. 
 
 In a few cases the mucosa had shown a marked tendency to gathei' into 
 ridges or folds, but no definite poly|»i had developed. In Case I*,)").') (Path. No. 
 1484), the globuhir uterus had a caNity bl cm. long and 7 cm. broad. The nnicosa 
 covering the j)ostei'i()i' wall was pale, smooth, and a\'eraged 2 mm. in thickne.ss. 
 This surface was concave, having been subjected to pressure extorted by a tumor 
 occupying the anterior wall. Near the fundus, the nmcosa was gathered u]) into 
 a broad flat mound, 3 cm. in diametei- and I cm. thick. Its mai'gins wen* 
 slightlv injected.
 
 328 
 
 MVOMATA OF THK UTERUS. 
 
 H i s t () 1 () g i (• a j) p I' a r a ii c e .s o f p o 1 y jm f v o in t h e b o d y o f 
 the uterus. 
 
 Fk;. 225. — A Very Eakly Stage of a Uterine Polyp, (i nat. size.) 
 Gyn. No. 8368. Path. No. 4554. The appendages are normal. The uterus has been opened from the front. 
 Growing from its walls are subperitoneal, interstitial, and submucous myomata. The mucosa of the posterior 
 wall is atrophic; that of the anterior wall is of the normal thickness, except at a, where it forms a distinct area of 
 thickening, producing a cystic, sessile polj-p. The small cj'st in the polyp is a dilated gland. 
 
 Uterine polypi are nothing more than portions of the mucosa that have been 
 partiall}' extruded, and with the succeeding and frequent contractions of the 
 
 6 f 
 
 
 ^^ 
 
 /i/y. 
 
 Fig. 226. — The Beginm.ng of a Uterine Polyp. CX 12 diam.) 
 (Jyn. No. 3130. Path. No. 499. The section is from the body. To the right and left is normal mucosa. 
 In the center the mucosa is thicker, and forms a dome-like elevation from the surface. Here the glands are very 
 abundant. In time this elevated portion would be forced more into the cavity, until it became a pedunculated 
 polyp. 
 
 uterus have been forced out into the cavity. P'ig. 226 is an excellent examjile 
 of the earliest stage. The muco.si on either side is relativclv normal, whereas in
 
 THE COXDITIOX OF THK I'TERIX?: MUCOSA IX CASES OF MYOMA. 
 
 320 
 
 the center it is Ix'iii*;' heaixnl up into a dome-like ele\'ation. This area would, 
 in time, be pushed farther into the cavity and would form a definite polyp. 
 
 If the uterine mucosa from which the polyp is nipped off is normal, we should 
 expect the polyp to consist of normal mueosa. The surface of the polyp is usually 
 smooth, as in Fig. 226, hut may be wavy in outline. The majoritv of the glands 
 present the usual appearance, but as a result of ()l)struetion, some of them 
 tend to become cystic, and their epithelium flattened. In the stroma of the pedicle 
 of the polyp non-striated nmscle is not infrequently found. This is due to the 
 fact that some of the muscle is drawn out with the mucosa as it is being extruded. 
 
 The mucosa near the tip of the ))olypi often shows a good deal of hemor- 
 rhage. A few of the ])olypi show slight disintegration: the gland e{)ithelium 
 
 
 Muscle 
 
 Polyp 
 
 
 Sjf >^ > 
 
 
 Fiii. 227. — A Utkrine Poi.yp. (X 7 diain.) 
 Gyri. No. 7t)99. Path. No. 3948. The character of the polyp shows that it is from the body of the uterus. To 
 the left is uterine mucosa, which, apart from slight gland dilatation, is normal, a indicates the to)) of the uterine 
 cavity. Attached by a narrow pedicle is an oblong polyp with a rounded end. Its surface e|>ithelium is contiiuious 
 with that lining the uterine cavity, and represents uterine mueosa. Many of its glanils are dilated, some reach- 
 ing large proportions. Where marked dilatation has occurred, the partitions between glands have in places 
 disappeared. 
 
 ends to drop off, and the gland cavities are (illcd with hyalin(--lik(' casts, as was 
 noted in Case 3113 (Path. No. 4S7). 
 
 When the uterine mucosa is the seat of gland hypeil r()])liy, the poly])i, as a 
 rule, will also show hypertrophy of the glands. This was especially noticeable 
 in (;ise 12021 (Path. No. 8002). 
 
 Very Large Polypi. — That uterine |)oly|ti may reach \-ery Jai'ge |)i'op()rtions is 
 clearly demonstrated by the following cases: 
 
 In Case 5940 (Path. No. 2212) the uterus was convtM-fed into a nodular 
 tumor, ai)i)r()ximately 24 .\ 10 cm. The uterine ca\'ity \\;is 1 I cm. in ItMigth and 
 7 cm. in breadth. 4'he ni)per two-thirds was hllcd with three I'emarkably large 
 polypi (I"'igs. 22S and 229). The lai'ger of the^c nieasui'cil 7\ 1 x 2..") cm. 41ie
 
 330 
 
 .\n(».MATA OF THK ITHRUS. 
 
 surfaces dt' the polyj)! were injected, traversed by branching blood-vessels, and 
 studdcil with niiiuite cysts, avera^ng 1 mm. in diameter. Sections from these 
 ])(>ly])i showed cyst-like s))aces scattennl everywhere througliout their substance, 
 some of them i-caching .") nun. in diameter. 
 
 The uterine nuicosa was smooth, ])ut markedly hemorrhagic. The myomata 
 showed lit lie tendency to enci'oach on the uterine cavity. 
 
 Un histologic examination all the ))oly])i ])resented the same j)icture. Their 
 sui'faces were compai'atively smooth, and in many places were covered with one 
 layer of epithelium. Scattered 
 tliroughout the stroma of the 
 ))()ly])i weic man\' ty])ical uter- 
 ine glands. The cyst-like 
 s|)aces were dilated glands. In 
 the majoi'ity of them the (^pi- 
 
 H B^'^-s.^r.M 
 
 Fig. 229. — Cross-section of a Very Large Uterine Polyp 
 IN A Case of Myoma. (Nat. size.) 
 (jyn. No. 5946. Path. No. 2242. The section is taken 
 from the neighborhood of the uterine horn, and shows a small 
 part of the uterine cavity filled with polypi, a is normal 
 uterine muscle; b, a small sessile subperitoneal myoma; c, 
 the edge of a large myoma; d indicates blood-vessels, which, 
 judging from their thin walls, are probably veins; e, f, and g 
 are cross-sections of polypi. Scattered throughout the sub- 
 stance of the polypi are large and small cyst-like spaces — dil.ated 
 uterine glands, h is the smooth inner surface of the uterine 
 cavity, (.\fter Thomas Culleii.) 
 
 I'k:. 22S. — Cuoss-sEfTiox OK a Large 
 
 Uterine Polyp i.n a Case ok Multiple 
 
 Myomata. (Nat. size.) 
 
 Gyn. No. 5946. Path. No. 2242. The 
 section is taken from the fundus, a is nor- 
 mal uterine muscle; b, the edge of a large 
 myoma; c, dilated veins; d shows a cross- 
 section of a large polyp. Its surface, al- 
 though undulating, is perfectly smooth, but 
 on section it presents a cystic appearance, 
 due to the many dilated glands, one of 
 which reaches at least 5 mm. in diameter. 
 The polyp has a broad ba.se, and shows lu) 
 tendency to penetrate the muscle. Histologic 
 examination shows it to consist of practically 
 normal mucosa, e is normal mucosa (.\fter 
 Thomas CuUen.) 
 
 thelium was still well preserved. In not a few ))laces, however, it had dropped 
 off in ril)bons, forming irregular skeins in the gland-spaces, and at first sight 
 offering a suggestion of malignancy. The ai)])earanc(\ howcwer, was due to 
 faulty hardening. The stroma of the mucosa corr(>sponded to that of the uter- 
 ine mucosa. 
 
 In Case 8354 (Path. No. 4.j;!i)) the myomatous uterus was 24 x 20 x lo cm. 
 The uterine cavity was 13 cm. long and 7 cm. broad in its upi)er portion. The 
 
 Fig. 230. — A Very Large Uterine Polyp (j nat. size.) 
 Gyn. No. 8354. Path. No. 45.39. The myomatous uterus extended to the umbilicus, and was 24 x 20 x 15 cm. 
 It is literally riddled with subperitoneal, interstitial, and submucous myomata. Filling the upper part of the 
 uterine cavity is a lobulatetl polyp with a delicate granular surface, strongly suggestive of carcinoma. This polyp 
 was 7 cm. long, 5 cm. broad, and 3 cm. in thickness. On histologic examination it was found to be composed of 
 uterine mucosa, showing areas of gland liypertrophy. It is the largest uterine polyj) that we have ever seen.
 
 THE CUXDITIOX OF THE UTERINE MUCOSA IX CASES OF MYOMA. 331
 
 332 MVOMATA ()K THK UTERUS. 
 
 mucosa was N-crv thin. Tlic cliiof interest centered in a mass which was attached 
 to the uterine wall l»y a deUcate pedicle, and filled almost the entire cavity. 
 This mass was irreu;ular in shape, somewhat lobulated, and had a fine granular 
 surface (Fig. 230). It measured 7x5x3 cm. Its granular appearance strongly 
 suggested carcinoma, hut it showed no areas of disintegration. On section, the 
 growth was fairly homogeneous and cut like cheese. Scattercnl throughout it 
 were numerous hemorrhagic areas and many dilated blood-vessels. 
 
 On histologic examination the growth filling the uterine cavity was found to 
 consist essentially of mucosa. Its surface was covered with one layei- of ej)itheli- 
 um. Its glands in ))laces were normal; at other jjoints they branched a great 
 deal or show(>d dilatation. Some areas showetl tyi)ical gland hypertrophy. The 
 stroma of the polyp was, to a considerable extent, infiltrated with small roimd 
 cells. The growth was nothing more than an exceptionally large uterine polyp. 
 
 In Oyn. No. 12155 (Path. No. 8723) a very large myoma sprang from the sur- 
 face of the uterus, whose walls were studded. with smaller nodules. The uterine 
 cavity was S cm. long and 4 cm. broad. Projecting into the cavity from the toj) 
 was a polyp 5 cm. in length, 3 cm. in breadth, and tapering to 1 cm. at the jxjint. 
 It bore a strong resemblance to a long and narrow chicken's liver, was spongy, 
 and apparently con.sisted of mucosa. Histologic examination proved it to be a 
 simple uterine polyp. Some of its glands had l)een imperfectly preserved, 
 and the epithelium had dropped off in ribbons, forming a skein-like arrangement. 
 
 Large poly}H were also noted in Case 1223-4 (Path. No. 88-14). The uterus 
 was ii'regularly nodular and measured 25 x 21 x 15 cm. The uterine cavity was 
 balloon-shaped, and j^rojecting into it were several m^'omata and three polypi, 
 the largest of which was 5.5 x 4 x 3 cm. This large polyp, on histologic examina- 
 tion, showed typical gland hypertrophy. Such large polypi as have just been 
 described are, of course, exceptionally rare. 
 
 Atypical Changes in the Epithelium Lining the Uterine Cavity. 
 
 In addition to the cell-changes found in endometritis and in cancer, we have 
 also noted in a few cases a definite tendency in \hv surface epithelium to pro- 
 liferate. In Case 3320 (Path. No. 589), in which the uterus was greatly enlarged 
 from the presence of sub})eritoneal and interstitial nn^omata, the epithelium 
 covering the surface of the mucosa showed a slight tendency to i)roliferate, being 
 two or three layers in thickness at several points. 
 
 Proliferation of the surface e])itheliuin was aW) noted in Case 3408 (Path. 
 No. 659) and in Case 6479 (Path. No. 2700). Occasionally small papillary 
 outgrowths may be detected arising from the surface of the mucosa. In Case 
 3133 (Path. No. 494) the uterus was tremendously enlarged from the presence 
 of an interstitial myoma. The uterine cavity was also greatly increased in .size, 
 being 31 cm. long, and varying from 9 to 14 cm. in diameter. The mucosa was 
 naturally greatly thinned out. About the middle of the cavity were delicate 
 papillary outgrowths from the surface epithelium.
 
 THE COXDITIOX OF THE UTERINE MUCOSA IX CASES OF MYOMA. 333 
 
 In Case 3340 (Path. No. GOT) the uterus was the seat of subperitoneal, inter- 
 stitial, and suhnuu'ous niyomata and the uterine cavity was (i em. long. The 
 mucosa was somewhat atro]:)hic. The surface e))itlielium was everywhere intact, 
 and in most places normal, ))ut near the submucous myomata were three finger- 
 Hke outgrowths of epithelium, and not far distant from these the surface ej)ithe- 
 lium had proliferated, being three or four layers in thickness. The newly formed 
 cells stained much more faintly than normal epithelial cells, and they were 
 separated from each other by a moderate number of polymorphonuclear leuko- 
 cytes. The uterine glands were normal. 
 
 Were the mucosa lining all portions of the uterine cavity systematically 
 examined histologically, we feel sure that such alterations in the surface epithe- 
 lium as we have noted would be much more frequently found. Some of them 
 undoubtedly indicate a commencing malignant change; others, however, would 
 advance no further. 
 
 Adenocarcinoma. 
 
 This subject is dealt with fully on ])]). 274 and 404. 
 
 A Small Myoma Developing in the Uterine Mucosa. 
 Tn Fig. 231 we have a definite example of a small myoma originating in the 
 uterine mucosa. It is the only picture of this kind that we have ever encountered . 
 The uterus formed a glo])ular tumor, 14 cm. in diameter. The anterior wall 
 contained an interstitial and slightly submucous myoma, 12 cm. in diameter. 
 The uterine cavity was 12 cm. long, 1 1 cm. in l)readtli. Its mucosa was atroj)hic, 
 
 
 
 Fk;. '2'M. — A Myoma Oni(iiNATi\(; in thk I'tkhink Mrcosv. iX 4 ilium.) 
 Gyn. No. .5808. Path. No. 2101. The uterus eoulaiueil a suli|>eriloiieal and irit<Mslitial niy<iina. an.! two 
 polypi lay in the uterine cavity. 
 
 The muco.sa at a and a' is perfectly normal, e.xcept for slight ulaml dilatation, hut hetween these points and 
 projecting slightly from the surface is a small flat myoma. This is confineil entirely to the mucosa, hivs pushed the 
 glands to either side, and is covered over with the surfiice epithelium, h. This myoma hail undoulitedly originated 
 in the nuu-osa, probably from some preexisting muscle-fibers that were located there. In the lower part of the 
 picture a small i)ortion of a large interstitial myoma is seen. 
 
 and some of its glands were dilated. I'lojccting into its ca\-ity was a tongue- 
 sha])ed polyp, 3.5 cm. long and !.;> cm. broail. A second and smaller one lay 
 near the internal os. 
 
 On histologic examination the muco.sa, aj)art from atroj)hy and gland dilata- 
 tion and the presence of the myoma, as seen in Fig. 231, was little altered.
 
 334 
 
 MVo.MATA OF THH ITKRUS. 
 
 Endometritis. 
 
 Inflaiiiinatioii of the (■iKlonictriuni has, in our experience, l)een very rare. 
 
 One of us (Ciillcn) in 1898* re])orte(l that in tiie routine examination of the 
 
 specimens from the »z:}'necol()gic o])eratinf2;-room of the Johns Hopkins Hospital 
 
 for a period of four years endometritis had been found only 48 times; in other 
 
 Fig. 232. — Polypoid Endometritis and Doubi.k Pus-tibes .\ssociatki) with a Myoma of the Fi'.s'dis. 
 
 (t3 nat. size.) 
 
 Gyn. No. 869.3. Path. No. 4898. The uterus wa-s pyriforin in shape, and iiieasureil 1 1 x 7 x (> cm. In the 
 fundus wa-s a myoma 5 cm. in diameter. The uterine mucosa varied from 2 to 4 mm. in thickness, and presented 
 a granular appearance, due to flattened projections varying from 1 to 1 .5 mm. in diameter. The tubes and ovaries 
 were bound up in a<lhe.sions. Both tubes were filled with pu.s. On histologic examination it was found that the 
 surface of the mucosa was in many places greatly altered, the cylindric epithelium having been replaced by many 
 layers of cells resembling squamous epithelium. Lying beneath the epithelial cells were myriads of polymorpho- 
 nuclear leukocytes. The knob-like outgrowths were composed of newly formed connective tissue containing 
 many blood-vessels, and covered externally with cylindric epithelium or with many layers of cells of the squamous 
 type. The uterine glands showed some hypertrophv- in the superficial portions, but in the depth most of them 
 were normal. 
 
 words, on an averajie of only once each month. \\r were astonished at the lack 
 of fre(iuency with which it was encountered, and were still further surj)ri.sed to 
 find that even when the I'alloiiian tuhes sho\\('(l dcliiiitc (■\-ideiices of inflamma- 
 tion, the endometrium was often unaltered. If. however, an inflammation of 
 the uterine muccsa exists, the excessive vascularity, together with the excellent 
 * Thomas S. CuUen, Endometritis, Md. Med. J., 189S, p. r^7l.
 
 THE COXDITIOX OF THE UTERIXE MUCOSA IX CASES OF MYOMA. 335 
 
 drainage afforded 1)}' the more or less perpendicular position of the uterus, favors 
 the speedy restoration to normal. 
 
 What applies to the endometrium in general is equalh' applicable in myoma 
 cases. In our experience the mucosa rarely shows any inflammation when the 
 uterus contains myomata. After carefully tabulating the cases in which there 
 was an endometritis, — usually of a very mild grade, — we have found that \A-ith 
 one or two exceptions either the uterus contained a submucous mj'oma, usually 
 disintegrating, or the tul)es showed definite evidences of a recent or old inflam- 
 mation. 
 
 These findings are of importance to the surgeon in that he can with alnujst 
 certainty say that if the patient has no vaginal discharge, and if the appendages 
 are normal, the uterine mucosa is unaltered. Knowing this, he can open the 
 uterine cavity, if necessary, with relative certainty that there is no danger of 
 infection lurking there. 
 
 In Fig. 232 we have an examj^le of a small myomatous uterus with a fine 
 ]X)lypoi(l endometritis, associated with double pus-tubes. 
 
 Tuberculosis of the Endometrium Associated with Uterine Myomata. 
 
 From the accompanying table it will be seen that we have had 7 cases* in 
 which, in addition to the myoma, tuberculosis of the endometrium was noted. 
 In 6 of the cases the uterus was relatively small: only in Case 3319 did it reach 
 fairly large proportions. In 2 of the cases minute tubercles were recognized on 
 the surface of the uterus. 
 
 In some of the cases the implication of the endometrium was quite recent; in 
 others, nearly the entire mucosa had been replaced by tuberculous tissue, and in 
 Case 4965 the small uterine cavity was filled with creamy fluid. 
 
 In Case 3319 the tuberculosis had extended to the muscle l)eneath the mu- 
 cosa. In none of our cases, however, had the tuberculous ])rocess involved a 
 myoma. In April, 1901, Dr. Homer (Jage, of \\'orcester, Mass., sent us a myo- 
 matous uterus showing definite tuberculous implication of a myoma. The 
 interstitial myoma was ap])roximately globular and 7 cm. in diameter. On 
 section, it ])resented a i)utty-like appearance and was very soft, fully three- 
 fourths of the myoma showing this degeneration. Snieai's made by Dr. ( lage 
 yielded tubercle bacilli in moderate numb''i-s. 
 
 On making sections from the eiidoniet riuni we found nonn;il imieosa in ])laces, 
 but at other points the stroma showed small- lound-cel led inliliialion, and at one 
 point in the mucosa a definite tubercle was found. 
 
 The myoma was everywhere riddled with areas of caseation showing sur- 
 I'ounding zones of tubcTculous tissue. All stages in the tui)ereulous ])rocess 
 were demonstrable. Scattered throughout the myoma were a few islands of 
 uterine mucosa. In other words, it was in pai1 an interstitial adeiioniyoma. 
 
 * The ciidometrium was also tubcirulous in Aut. Xo. SO'J (Path. No. 1382).
 
 336 
 
 MYOMATA OF THE UTERI'S. 
 
 Both tubes wciv tlu' scat of advanced tulx'i'ciilosis. , 
 
 It is well known that tiil)ereulosis of the tubes is usually ])resent when tuber- 
 culosis of the endometrium is found, and, as seen from the table, our cases closely 
 
 Fig. 2.3.3. — TrBERCULOSis of the Endometrium and Fallopian Tubes Associated with a Myomatous Uterus. 
 
 (V nat. .size.) 
 Gyn. No. 3319. Path. No. 592. The myomatous uteru.s mea,sured 15 x 17 ,x 20 cm. Situated in the posterior 
 wall is a large myoma; in the anterior wall, a second; while just posterior to the cervi.x is a third. The endome- 
 trium is roughened, as indicated by a. This is due to a loss of substance caused by the tuberculosis. The left 
 tube is thickened and tuberculous. The left ovary contains a corpus-luteum cyst. 
 
 follow this rule. In five, both tubes were involved: in a sixth ease, one tube. 
 In only one ease was there no e\'ideii('e of tubal tuberculosis. 
 
 The a.ssociation of tuberculosis of the endometrium with uterine myomata 
 must be regarded as a mere coincidence. 
 
 TUBERCULOSIS OF THE ENDOMETRIUM ASSOCIATED WITH UTERINE MYOMATA. 
 
 Gyn. No. 
 
 Path. No. 
 
 Size of Uterus. 
 
 Conditions of Tubes. 
 
 Endometrium. 
 
 3319 
 
 592 
 
 15 X 17x20 cm. (Fig. 233). 
 
 Tuberculosis of both 
 
 tuljcs. 
 
 Advanced tuberculo- 
 sis. Commencing 
 involvement of un- 
 derlying nuisde. 
 
 496.5 
 
 1499 
 
 4 x 3.8 X 3 cm. Largest 
 
 Hotii tui)es em- 
 
 Early tul)erculo.si.s of 
 
 
 
 myoma on surface, 5 cm. 
 
 bedtled in adhe- 
 
 endom(>trium. 
 
 
 
 Cavity small, filled with 
 
 sions, but not tu- 
 
 
 
 
 creamy fluid. 
 
 IxTcuious. 
 
 
 6991 
 
 3277 
 
 6 X 6.5 x6 cm. .Mimite tu- 
 
 Tul)erculosis of one 
 
 Early tuberculosis of 
 
 
 
 bercles over surface 
 
 tube. 
 
 endometrium. 
 
 8220 
 
 4403 
 
 Slightly enlarged. 
 
 Tuberculosis of botli 
 tubes. 
 
 I'^arly tuberculosis of 
 endometrium. 
 
 9636 
 
 5825 
 
 Myoma, 8 cm., in posterifjr 
 
 Tuberculosis of both 
 
 Early tuberculosis of 
 
 
 
 wall. 
 
 tubes. 
 
 endometrium. 
 
 12119 
 
 8714 
 
 7x8x7 cm. Several my- 
 
 Tul)erculosisof l)otli 
 
 Tuberculosis of en- 
 
 
 
 omata from surface; lar- 
 
 tubes. 
 
 ilometrium. 
 
 
 
 gest, 14 X 11 X 11 cm.; 
 
 
 
 
 
 minute tubercles on sur- 
 
 
 
 
 
 face. 
 
 
 
 12860 
 
 97.55 
 
 7x8x8 cm. 
 
 Tul)ercul()sis of both 
 tubes. 
 
 Tuberculosis of endo- 
 metrium.
 
 CHAPTER XVIII. 
 
 CONDITIONS OF THE TUBES AND OVARIES WHEN UTERINE 
 MYOMATA ARE PRESENT, =^= 
 
 Although our investigations arc based on over 1400 cases coming under oiu' 
 observation, many of the cases operated upon in the smaller hospitals could not 
 be as carefully tabulated from a clinical and ])athologic standpoint as were those 
 observed in the Johns Hopkins Hospital. ( onsecjuently, in discussing the con- 
 dition of the tubes and ovaries, we have utihzed only those cases admitted to 
 this institution. 
 
 A SUMMARY OF THE CONDITION OF THE TUBES IN 934 CASES OF UTERINE MYOMA 
 WHERE IT WAS NECESSARY TO REMOVE THE UTERUS. 
 
 Free from adhesions 511 cases 
 
 Free from adhesions, but showing some other pathologic change 29 " 
 
 Total number in which normal tubes were present 482 cases 
 
 Adhesions. 
 
 Both tubes adherent 364 cases 
 
 One tube adherent 59 " 
 
 Total number in which one or both tubes were adherent 423 cases 
 
 Dense tubal adhesions were present in 94 of these cases 
 
 Hydrosalpinx 88 cases: 
 
 Hematosalpinx 12 cases: 
 
 ^, ■ 1 • •,. ,o / 43 bilateral. 
 
 Chronic salpmgitis 48 cases: < - •■ . i 
 
 ' ^ I •» unilateral. 
 
 / 19 unilateral. 
 
 \ 22 bilateral. 
 
 / 1 right side. 
 
 \ 4 left side. 
 
 n^ , • i. ij r f 3 riglit side, 
 
 lubo-ovarian mass 5 cases: < ., • ?, ,• • 
 
 f 4 right sitle. 
 
 Tubo-ovarian abscess 14 cases: -i 9 left side. 
 
 [ 1 bilateral. 
 
 Tubercidosis 14 cases: both tubes involved. 
 
 Q. , „„ r 51 unilateral. 
 
 ^™P^« '' \ 26 bilateral. 
 
 n, ,,• 1 in f 6 unilateral. 
 
 F°ll'^^'l^^»- ^S 4 bilateral. 
 
 1 pn^P ^ "S'lt, follicular. 
 
 ^ '^'^^^ \ left, simple. 
 / 9 unilateral. 
 \ 3 bilateral. 
 
 Pyosalpinx 41 cases: 
 
 Tubo-ovarian cyst 5 cases: 
 
 Tul)al ))regnancy 6 cases: 
 
 / 5 ruptured. 
 \ 1 intact. 
 
 Rudimentary left tube, 1 case (Oyn. No. 10917). 
 Myoma of the tube. 1 case ((lyn. No. 10237). 
 
 * In the tabulation of the condition of the tubes and ovaries we have exerci.sed great care, 
 but as in some cases one or both appendages were not removed, and only a con.servative opera- 
 tion was performed, we have occasionally been compelled to rely entirely on the notes made at 
 operation. In some cases these are naturally incomplete. Accordingly, it will Ix' safer to make 
 an allowance for possible error in the statistics of about 1 per cent. 
 22 337
 
 338 
 
 :\IYOMATA OF THE UTERUS. 
 
 Adherent Tubes. -From tlie suinmary it is seen that one or both tiihcs were 
 adherent in 42;j out of 934 cases. This is a hirge percentage. In many of the 
 cases the adhesions were shght; in others sufficient to occlude the tu])e and j^ro- 
 duce a hyth-osalpinx, while in a good many cases the tu])es were densely adheicnt 
 as a result of a pyo.salpinx or pelvic abscess. 
 
 The friction between the tumor and the pelvic ix'ritoneum naturally tends to 
 cause irritation of the .surfaces, with the occasional formation of .shght adhesions. 
 Again, the myomata, as they grow, may ])artially l)l()ck the uterine cavity and 
 force the uterine secretions or menstrual How out through the tubes. A mild 
 inflammation may thus be set up. Sloughing submucous myomata also are 
 
 resi)onsibh' for infhunmatory changes. 
 In other cases the infection is im- 
 (loul)ledly introduced from without. 
 
 Being at a loss to explain the 
 large [percentage of cases in which 
 adhesions existed, the histories were 
 carefully examined to see how many 
 patients were colored, as the per- 
 centage of tubal lesions is known to 
 be much larger in the negress: 
 
 Total luunljer of whites 60<S 
 
 Adherent appendages in 216 cases (.35.0 per 
 cent.). 
 
 Total number of colored 326 
 
 Adherent appendages in 207 cases (6.3 per 
 cent.). 
 
 The result shows tliat in the colored 
 adherent ajjpendages were nearly 
 twice as fre(nient as in the white 
 women. 
 
 Hydrosalpinx. — Hydrosali)inx was 
 noteil ill SS of the ca.ses. In 77 of 
 these it was of the simj)le variety; 
 in 11, follicular hydrosalpinx was 
 present. A very mild grade of inflammation is often sufficient to occlude the 
 fimbriated end of the tube, and a hydrosalpinx is the natural secjuence. We 
 have frecpiently .seen the occluded tube lying free in the pelvis, being nowhere 
 adherent. 
 
 Hematosalpinx. — In 12 cases a hemato.salpinx was noted. As a rule, a hema- 
 tosalpinx is a hydro.salpinx into which a hemorrhage has taken place. If we 
 include these two varieties, in one grou]) we have 100 cases out of 934 showing a 
 non-))urulent accumulation of fluid in the Fall()])ian tube. 
 
 Salpingitis. Salpingitis and pyosalpinx have been emi)loye(l really as synony- 
 mous terms. In our cases the inflammatorv changes in the tubes in the main 
 
 Fic. 234. — A Myomatous Uterus .-V.s.sociated with 
 Pyosalpinx. 
 (iyn. No. 6381. The omentum \va.< adherent to the 
 abdominal wall and bladder. Situated in the anterior 
 uterine wall, and lying partially beneath the bladder, is 
 a myoma several centimeters in diameter. In the pos- 
 terior wall is a smaller one. Lying behind the uterus and 
 adherent to it is the right tube, which is distended with 
 pus. n reached 2.5 cm. in diameter. The left tube 
 also contained a purulent accumulation.
 
 CONDITIONS OF THK TIHKS AM) ()\ARIES. 
 
 339 
 
 were chronic at the time of ojx'i-atioii. \Mien the tube was small, hard, and in- 
 durated, we usually term(Nl the condition a salpin.uitis, hut when enlarged, 
 
 Fig. 2.35. — A Tuho-ovariax Cyst Associated with a Myomatous Uterus. (j\ nat. size.) 
 San. No. 2368. Path. No. 11191. The large myomatous uterus is pear-shaped, and projecting from its sur- 
 face is a small pedunculated myoma. The right tube is occluded and is the seat of a hydrosalpinx, a is a corpus 
 luteum. The left tube, for the most part, is normal. The outer end, however, is distended and lobulated; it 
 communicates with the ovarian cyst. The fluid filling the tube and cyst was clear and limpid. 
 
 
 Fig. 2.36. — A Tuho-ovarian Cvst and Dense Adhesions Co.mpi.icatinc a Myomatous I'tekus. (5 nat. size.) 
 San. No. S.'xS. I'ath. No. 3706. I'lilly one-half of the posterior surface of the uterus \va.s covered with ilense 
 adhesions. The uterus contained a inyiiina, .5. .5 cm. in diameter. The left tulie and ovary were somewhat ad- 
 herent, but the fimbriated end of the tube was initent. The rlglit tulie in its outer i)(>rtion wa.s nuich dilated, and 
 at its outer end reached 5 cm. in diameter. The longitudiiuil ridges on its inner surface indicate the tubal folds. 
 The ovary had been converted into a simple cyst which mea.'<ure<l 7 cm. in diameter. The <lilated tube and the cyst 
 communicate at a. Both were lilleil with clciir llui.l. I li-tnli.;;ic exaiiiiiiatioM nf ilic cNst indicated that it was 
 a dilated Graafian follicle. 
 
 hard, and filled with an apprcciahlc (|uantity of pus. we put it down as a pus-tuhe 
 (Fig. X\\) or a pyo.salpiux. 
 
 In 4<S cases salpingitis was found, and it is iiUci-csiing to note that in 4.") out 
 of the 48 the condition was liilatcral.
 
 340 
 
 MYo.MATA OF TllK ITHIUS. 
 
 In 41 cases pyosaljjiiix was found. Thus, in 89 out of the 934 cases a definite 
 inflammatory process existed in one or both tubes. 
 
 It is very difficult to discuss i)urulent chan,ii;es in the tubes without the coin- 
 cident consithM'ation of infianunatory lesions in the ovaries so intimately associ- 
 ated with them. 
 
 In ") cases " tul)0-ovarian masses" were found. This clinical term indicates 
 a firm inflannnatory mass without macroscojiic evidence of pus. In 14 other 
 cases tubo-ovarian abscesses were ])resent. It will thus b(> seen that in over 
 10 j)er cent, of the cases the a|)])endages wei-e the seat of ))urulent changes. 
 In such cases the ])atient had usually suffered more pain than falls to the 
 lot of one affected with a simple myoma. Moreover, the operative measm'es 
 required are naturally more radical, and at the same time more difhcult, 
 than th(\v would be if the aj)i)endages were free from adhesions. 
 
 The same factors 
 that produce hydrosal- 
 pinx cause pyosalpinx, 
 the only difference being 
 tliat in the latter the 
 inflammatory reaction is 
 more se^'ere. 
 
 Tubo-ovarian Cysts. 
 — In 5 cases of our 
 series tubo-ovarian cysts 
 were found. In these 
 cases the tube is the 
 seat of a hydrosalpinx 
 and is intimately 
 blended with the ovar}-, 
 which is usually con- 
 verted into a single cyst. 
 On section, it is found that the distended tube connnunicates by a large or 
 small opening with the ovarian cyst. The fluid filling the cavities is usually 
 clear and limpid. In these cases there has evidently been a mild inflammation; 
 the tube has become glued to the ovary, and a hy(lr()sali)inx has developed. 
 At a later date a matured Graafian follicle at the point of adhesions has been 
 unable to empty itself, and has developetl into a (Jraafian follicle cyst. The 
 cyst and the hydrosalpinx have eventually opened into one another.* In Fig. 
 235 we have a very good example of a tubo-ovarian cyst associated with a 
 myomatous uterus. Fig. 236 shows a somewhat similar tubo-ovarian cyst on 
 section. 
 
 A Rudimentary Fallopian Tube. — In Gyn. No. 10917 the omentum was 
 firmly adherent to the uterus, which contained several small myomata. The 
 
 * Thoma.s S. Cullen, Hydrosalpinx. .lolins Hopkins Reports. 1S9.5, Vol. 4. 
 
 Fig. 237. — A Mvoma of the Right F.\llopi.\n Tube, (i nat. size.) 
 Gyn. No. 10237. Path. No. 6430. To the right was a parovarian 
 cyst, 20 cm. in diameter; to the left, an ovary containing several large 
 cystic follicles. 
 
 Springing from the anterior surface of the uterus near the left 
 round ligament is a small pedunculated myoma. The uterine cavity is 
 almost completely filled with polypi. Projecting from the upper surface 
 of the right tube at a is a pedunculated myoma, which measured 7 x 8 x 
 10 mm.
 
 COXDITIO.XS OF THE TrBp:S AXD OVARIES. 
 
 341 
 
 right tube and ovary wc^rc iionnal. Tlic left ovary was ahsont, and llic left lul)0 
 was represented l)y a mere remnant of a noi'nial tulx". It had evidentlv never 
 fully d(>vel()i)ed. 
 
 Myoma of the Fallopian Tube. — The tul)al muscle is similar to tliat of tlie 
 uterus, and as myoniata are so eonnnon in the uterus, we would consequently 
 not be surprised if, at times, myoniata should develop from the tube. 
 
 Case 10237 is, however, the only one in which any tendency toward a tubal 
 myoma was found. In this case the patient was seventy years of age. The uterus 
 measured 2.5x3 x() cm., had a small {)edun('ulated myoma springing from its 
 outer surface, and contained several polypi. On the right side was a parovarian 
 cyst, 20 cm. in diameter. On the left, the ovary measured 3x3.5x6 cm., the 
 increase in size being caused 
 by several umisually large 
 Graafian follicles. Arising 
 from the upper surface of 
 the light tube near the 
 uterus was a well-defined 
 myoma, 7 x 8 x 10 nun. 
 (Fig. 237). 
 
 Tuberculosis of the Fal- 
 lopian Tubes. — In 14* of 
 the 934 cases the Fallopian 
 tubes were the seat of tu- 
 berculosis, and in all these 
 cases the disease was bilat- 
 eral. In 6 of the cases the 
 tuberculous character of the 
 process was recognized only 
 on microscopic examination. 
 
 Ill 2 of the 6 a distinct infiammatory process was preseiil, but no lubei-cles 
 were detected maeroscopically. and in another of the cases (1142S), although a 
 tubo-ovarian abscess was present on the left side, no macroscopic evidence of 
 tuberculosis was found. In the remaining 7 cases tubercles were e\ideiit, 
 and the cHagnosis was readily established when the abdomen was opened. 
 
 The presence of a thickened nodular tub(> with a patent (inibriated exti-eiiiity 
 is always strong pi'esumi)tive evidence of tubei'culosis in this situation. 
 
 In Case 4732 there was a wide-sj)read tuberculous jx'ritonitis. 
 
 Fi'om the (Tmical histories it is eN'ident that in only one of the II cases would 
 the ])hysician ha\'e suspected tubercailosis prioi- to oix'i'alion. the symptoms of 
 th(> myoma in each case ox'ersliadowing those of the tuberculosis. The e\ce])tion 
 was Case 12866. This patient, three years ])re\i()usly, had been admitted to 
 
 *(;yn. Nos. ;«li», K)22, 17;52. (l!»i)l, 7J41, S22(). <)():5(i. '.».S'J3. lOlTJ. 1():>S7, 1 1 IJS, 117(W, 
 1211!), 12><(ifi. 
 
 C e r V 
 Fig. 238. — Ruptured Tubal Prkgnancy Complicating Uterine 
 MyoMAT.\. (S nat. size.) 
 (iyn. No. 8985. Path. No. 5159. The uterus is iiioderatel.v 
 enlarged, owing to the presence of several myomata. The left tube 
 was adherent. The right ovary aj^pears normal, but the tube near 
 its middle is considerably dilated, and at a placental tissue and 
 clotted blf)oil project through a rent in the aniciidr wall.
 
 342 
 
 .MVOMATA OF THK ITKIUS. 
 
 Dr. Halstt'd'.s service suffei-iiiji; from tiilierculosis of the hip. \\'heii she entered 
 the gynecological dcpartiiK'Hl there weiv definite signs of tuberculosis of the right 
 kidney, the right ureter, anil of an early tuberculosis of the bladder. The ])ains 
 in the right iliac fossa naturally suggested the possible development of an early 
 tuberculous ])rocess in this location. Thus in 13 out of 14 ca.ses in which tuber- 
 culosis of the tubes was associated with uterine myomata, the chie as to the 
 tubal complication clinically was absolutely wanting. 
 
 In some of the cases examination of the eiidoiiietrium would have shown 
 tuberculosis, as evidenced by the .subsequent pathologic findings, but, as a rule, 
 the operator refrains from cuivtting v/hen the diagnosis of myoma is perfectly 
 clear. 
 
 Tubal Pregnancy. — In O.'U of our ca.ses 6 tubal pregnancies were detected. 
 P'rom the accompanying table it will be seen that "> were ru))ture(l and 1 was 
 intact. 
 
 The left tube in Case 12380 .showed a globular thickening, 4 em. in diameter, 
 near the uterus, but the fimbriated end was intact. \\'hen the tul)e was opened, 
 the tyjjieal picture of tul)al {)regnancy was noted. 
 
 TABLE OF TUBAL PREGNANCIES ASSOCIATED WITH UTERINE MYOMATA. 
 
 Gyx. No. 
 
 Nu.MBER OF 
 
 Ye.^rs Number ok 
 
 Married. Children. 
 
 7795 
 7849 
 8985 
 8990 
 
 924:i 
 12380 
 
 5 
 10 
 10 
 12 (col) 
 
 11 
 
 14 
 
 
 
 
 
 
 
 1 
 (twenty-one 
 years ago). 
 
 
 
 
 
 Number 
 of Mis- 
 carriages. 
 
 Symptoms Suggesting 
 TuB.\L Pregn.^ncy. 
 
 Of no value. 
 Of no value. 
 Of no value. 
 Definite .'^ign.s of prej 
 nancy. 
 
 Of little value. 
 
 R. or L. Tub. Preg. 
 Intact or Ruptured. 
 
 R., rupt. 
 
 L., partly ruptured. 
 R., rupt (Fig. 238). 
 L., five months rup- 
 tured. 
 
 ' R., rupt. (niyoMiec- 
 tomy). 
 History slightly sug- L., ruptured (.see 
 gestive ("velvety "Adenomyoma of 
 
 feel"). the I'terus," Fig. 
 
 , 66, p. 247). 
 I 
 
 This table shows that 5 of the 6 ])atients had never l)een delivered of a child 
 at term, and 3 of the 6 had never been pregnant before. 
 
 From a clinical stan(l])()int it is interesting to note that in 4 of the eases the 
 sym))toms attributable to tlie myoma completely overshadowed those of the 
 tubal pregnancy. Conseciuently the surgeon was totally unaware of the condi- 
 tion imtil the abdomen was o])ene(l. 
 
 In Case 123S() the uterus was the .seat of .several myomatous notlules, and a 
 hrm tumor was felt to the left of the uterus. This, on pali»atioii, difi'ered ma- 
 terially from the myoniata. On gentle ])ali)ati()n it felt soft, but when firm 
 pressure was exerted, hard. It reminded one of a hai'd ball covered with velvet.* 
 
 ♦Thomas S. Cu Hen, The Velvety Feel of an Unrui)tur(Ml rul)al Pregnancy, Johns Hopkins 
 Hosp. Bull., 1906. p. 1.54. 
 
 See Cullen, Adenomyoina of the Uterus, Fig. 66, p. 247, W. B. Savuiders Co., 19t)8.
 
 COXDITIOXS OF THI-: TURKS AXI) r)VAI{IF-:S. 
 
 343 
 
 The soft feel was due to the ])r(\mi;uit sphere heiii^' surrounded by soft tubal 
 muscle and numerous dilated bIo()d-\'essels. This sifjn is natui-ally obsciu'cd if 
 the tube mptures. 
 
 Mechanical Alterations in the Tubal Relations. — In the majority of the cases 
 in which no infianunatory clian<2;es in the appendages are present the tubes pre- 
 sent a normal a))pearance. When the myoma extends far out into the l)road 
 
 _^ ^^ ;i-V 
 
 Ut, cavity 
 
 Fig. 239. — The Median End of a Fallopian Tuuk Apparently Terminating in a Myoma. (S nat. size.) 
 Gyn. No. 7063. Path. No. 3354. Scattered throughout the uterus were subperitoneal and interstitial my- 
 omata. The right tube and ovary were covered with a few delicate adhesions, but were practically normal. The 
 left tube looked normal, but at the median end it apparently passed directly into the myoma. Even in serial 
 sections it was impossible Ui trace (he tube after it reached the myoma. 
 
 ligament, the tube may be greatly stretched, reaching 17 cm. or more in length. 
 Occasionally a greatly elongated tube may be associated wilh a large oxary, as 
 in Fig. 245 (p. 351). 
 
 I'ig. 231) represents a multinodulai' utei'us with a large nodule projecting 
 directly Uj)ward from the left coi'iui. The left tube is normal, but a]ii)arently 
 passes directly into the myoma. 
 
 CONDITION OF THE OVARIES IN CASES OF UTERINE MYOMATA. 
 
 I'Vom the tabulation we found that in the (l.'!l c.'ises the o\ai'ies were normal 
 in 43S. In the remainder, comprising oxci' h;df, I he o\"ai'ies were either a dhei'eiit 
 or showed some pathologic lesion.
 
 344 MVOMATA OF THK UTKRUS. 
 
 Free from ailhesions 508 cases 
 
 Free from adhesions, but showing some pathologic changes 70 
 
 Both ovaries normal -138 cases 
 
 Adhesions. 
 
 Both ovaries adherent 370 cases 
 
 One ovary adherent 56 
 
 Total iiuinhcr in which one or i)oth ovaries were adherent 426 cases 
 
 In 05 of these cases the adhesions were dense. (For ovarian abscess and tiibo- 
 ovarian abscess see tabulation of diseases of the tubes, p. 337.) 
 
 Ovarian abscess a])])arently not associated with ])yosalpinx, 6 cases. Pelvic 
 pci'itonitis with abscess formation apparently independent of ])yosali)inx or def- 
 inite ovarian abscess, 6 cases. Tiil)erculosis, 3 cases (tubes |)i-iniarily involved). 
 
 Cysts. 
 
 ,, . . 1 •£• 1 II / 37 unilateral. 
 
 Mnall ovarian cvsts not classined 44 cases: { _ , ., , 
 
 \ I l)ilateral. 
 
 ,. ,,. , , ro i .")6 unilateral. 
 
 Graafian iolhcle cvsts 68 cases: < , , ., , 
 
 >. 12 bilateral. 
 
 ,. , „ , r 32 unilateral. 
 
 Corpus luteum cvsts 34 cases: < 
 
 12 bilateral. 
 
 Multilocular cystadenomata 9 cases 
 
 „ .,, , 1.-, j 10 unilateral. 
 
 PapiUocystomata 12 cases: < 
 
 ^ -^ I •_' l)dateral. 
 
 Adenocarcinoma (primary) 8 cases 
 
 Dermoid cyst 17 
 
 Fibromata 3 
 
 Very large ovaries 2 
 
 Merging of a myoma and an ovary 1 case 
 
 „ . , io f IS unilateral. 
 
 Parovarian cyst 19 cases: \ ^ , ., 
 
 •' I 1 bilateral. 
 
 Tubo-ovarian abscesses and ovarian abscesses are, for obvious reasons, con- 
 sidered with inflannnatory conditions of the tubes. 
 
 In 6 case.s* there was an ovarian abscess apparently not acconij)anied by a 
 pyosaljjinx. In each case tiic abscess was unilatei'al. 
 
 Pelvic ])eritonitis with ab.scess formation apparently independent of any 
 tubal or ovarian ab.sce.ss was noted in 5 cases.! 
 
 In 184 cases cysts of \-arious sizes were noted. ( )f t his number, 44 wer(> small, 
 unclassified ovarian cysts; 68 Graafian follicle cysts; 34 corjnis hiteum cysts; 
 9 multilocular adenocystomata; 12 papillocystomata; and 17 dermoid cysts. 
 In addition to this number there were also 8 adenocarcinomata of the ovary, 
 nearly all of which were cystic. 
 
 Graafian Follicle Cysts. We know that ovarian adhesions tend to jM'event the 
 normal cycle of the (Iraafian follicle, and as the ovaries were adherent in 426 of 
 the 934 cases, it is but natural that this vaiiety of cyst should be conmion. 
 
 * (lyn. Xos. 2973, 3395, 5123, 5302, 9013, 12209. 
 t Gyn. Xos. .")010, 6199. 7320. 8008. 9678.
 
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 346 
 
 MVOMATA OF THK i:Ti:iU'S. 
 
 \A'c tuuiid ill all ()S instances of Graafian follicle cysts. The smallest was 2.5 cm. 
 in diameter, the largest, 22 cm. 
 
 Corpus Luteum Cysts. — These are also more prone to occur when pelvic ad- 
 hesions exist. They wer(> noted in 34 of the 934 cases. The smallest was 2.5 
 cm. in diameter, the largest, 3 x 5 x 10 cm. 
 
 Multilocular Cystadenomata. — In 9* of the 934 cases mnltilocular ovarian 
 cvsts were found. In 5 of these the myoma was the chief factor. In the re- 
 maining 4 the symptoms caused by the cyst completely overshadowed those duo 
 to the myomata. In Case 7775 (Fig. 240), the myomatous uterus measured 
 10x10x13 cm., the cyst, 15x20x25 cm. The iiedicle of the cyst had 
 formed a complete rotation from right to left. 
 
 When the cyst is relatively small, its simultaneous occurrence with the myo- 
 mata should occasion few additional symptoms, 
 but when it has reached large ])ro portions (Fig. 
 241), dense adhesions are liable to give rise to 
 very serious complications. 
 
 Case 9030 affords a striking example of 
 such com])lications. The patient, aged fifty- 
 one, at the time of operation was very weak and 
 anemic. On opening the abdomen, in addition 
 to the myomatous uterus, 20 cm. in diameter, 
 we found the abdomen nearly filled with a 
 nuiltilocular ovarian cyst. This was every- 
 where very adherent to the intestines, and was 
 tumor which extends slightly above the Separated iu nuuiy placcs by Sacrificing the 
 
 umbilicus. To the right is a hematoma. . 11 t^ • -^ 1 j.i i. 
 
 To the left is a large ovarian cyst. CVSt-Wall. Dui'ing itS reillOVal the Cyst ni\)- 
 
 tured and a large amount of foul-smelling 
 purulent material escaped. This was at once carefully wiped out, and the 
 myomatous uterus ciuiekly removed. At the end of the operation the patient 
 was i)roioimdly collapsed, and she died a few hours later. In this case un- 
 doubtedly the multilocular cyst and not the myoma was primarily responsible 
 for the patient's death. 
 
 Papillocystoma of the Ovary. — In 12t of th(> 934 cases i)apilloma of the ovary 
 was associated with uterine myomata. In 10 of the cases the process was uni- 
 lateral, in 2, bilateral. In Case 10875 the left ovary had been converted into a 
 l)ai)illocystoma, 7 x 10 x 12 cm. The right ovary was not of abnormal size, but 
 histologic examination revealed a small cystic space containing a j)aj)illomatous 
 mass in this ovary. The })rocess here was an excei)tionally early one. 
 
 In Cases 1455, 2172, 12034, 12912, the ])ai)illary growth had penetrated the 
 cyst-wall and extended to the peritoneum of the .^surrounding structures. In 
 Case 12034 there was also fi'ee ascitic fluid in the general ju'ritoneal cavity. 
 
 *Gyn. Nos. 6201, 7377. 777.3, 7971, 8227, 8266, 9030, 110.>0. 12764. 
 
 tr.yn. Nos. 14.1.-), 2172, 3898, 6344, 6439, 8738, 10867, 10875, 12034, 12848, 12849, 12912. 
 
 Fig. 241. — A Mi:ltipi,icity ok I'atho 
 LOGIC Conditions. 
 Gyn. No. 2172. The uterus is con 
 verteJ into a multinodular myomatous
 
 CONDITIONS OF THE TUBES AXD OVARIES. 
 
 347 
 
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 348 
 
 MVO.MATA OF THK ITKRUS. 
 
 In most of tlic cases tlic inyoniata were ivlativcly small, and dui-ini:; the few 
 months pi-i(ir to operation the syni])t()ms referable to the ])apillary <:;r()\vth ecinaled 
 or overshadowetl those of the myoniata. 
 
 Tn Case (VMA (Fii:;. 242), however, the cyst was still small, and the lendeiiey 
 towai'd pai)illar_\- foi'iiiation markedly limited. 
 
 The presence of i)apillary masses on the outer surface of the ovary naturally 
 handicaps the surgeon's endeavors. He wishes to he as conservative as possible, 
 but realizes that where one ovary is extensively involved, the opposite one is 
 ])rone to i)i('k up and nurture epithelial cells that drop off from the pai)illary 
 growth. If it is thought that the opposite ovary is still normal and a myomec- 
 tomy is contem])lated in the ho])e of i)reserving the menstrual function, the 
 surgeon is in a (juandary as to whether scattered tumor-cells may not engraft 
 themselves upon the uterus at the point from which the myoma has been shelled 
 out. Should both ovaries be involved, however, hysteromyomectomy with 
 complete remo\al of the appendages is clearly indicated. 
 
 ADENOCARCINOMA OF THE OVARY OCCURRING WITH UTERINE MYOMATA. 
 
 No. 
 
 Utkrus. 
 
 RiClIT OVAHY. 
 
 Left Ovary. 
 
 Path. 99 t'tcnis contains luunei- 
 uus myonuita. the largest 
 4 X 4.r>\ .").") em. 
 
 (!yii. 11)37 .Moderately small myoma 
 lo left of cervix not re- 
 nui\'eil. 
 
 (Jyn. 10'_'() Mullinixhilai- myomatons 
 uterus. \'}\ 19 \ 21 cm. 
 
 (lyn. ').V2S .Multinodular myomatous 
 uterus, S X 11 x 12 cm.: 
 later extension of ovarian 
 carcinoma to body of 
 uterus. 
 
 (Jyn. (i479 Uterus contains .several 
 myomata, the lariiest '].r> 
 cm. 
 
 (lyn. !)4.")7 Uterus, 9x11 cm., con- 
 tains two myomata. the 
 larger S x 9 cm., also dis- 
 crete adenomyoma. 
 
 (lyn. 8G7.') .Midlinoduhir myomatous 
 uterus, 6x 8x 11 cm. 
 Largest myoma, 3x5 cm. 
 
 Cyn. 12011 Uterus 7xScin. Several 
 myomata, the largest 
 1 cm. 
 
 Springing from a portion 
 of the ovary is an adeno- 
 carcinomatouscyst 10 cm. 
 in diameter. 
 
 Adenocarcinomatous cyst 
 contained S.IOO c.c. of 
 chocolate-colored fluid. 
 Adenocarcinoma of right 
 ovary. ,")..■) x (i x 7..") cm. 
 Secondary in\ol\cnient 
 of right tube. 
 Adenocarcinoma. 
 
 Api)an'ntly not impli- 
 cated. 
 
 .-Adenocarcinomatous cyst, 
 20 cm. in diam. 
 
 Contained |) a p i 1 1 a r y 
 adenocarcinomatous mass. 
 1.5 cm. in il i a m e t e r . 
 Met astases in omentum 
 wide-spread. 
 
 A few ]>apilltiry masses. 
 C a r c i n o m a t o u s moss 
 springing from slightly 
 eidarged ovary. 
 Ovarv normal. 
 
 Multicystic pai)illary car- 
 cinomatous masses on sur- 
 face. 
 
 Adenocarcinoma. 
 
 Semisolid adenocarcin- 
 oma, 7 X S X 9 cm. 
 
 Adhesions, otiierwise nor- 
 mal. 
 
 Two ])etlunculated hud- 
 ding papillomatous masses 
 on upper border; adeno- 
 carcinomatotis on histo- 
 logic extimination. 
 Adenocarcinomatous; tvi- 
 mor small and den.sely 
 adherent. 
 
 Adenocarcinoma of the Ovary, — In <S of the O.'U cas(>s adenocarcinoma of the 
 ovary was present. ^hicrosco})ically, it is often imjKJssible to distinguish between 
 papilJocystomata and adenocarcinomata, and even on histologic examination one
 
 CONDITION'S OF THE TUBKS AND OVARIES. 
 
 349 
 
 is frequently unable to say with certainty whether or not the given specimen is 
 really malignant. 
 
 In half of the cases the carcinoma was bilateral. From the tal)le it will be 
 seen that some of the carcinomata were very small and solid. Others had be- 
 come cystic, and in at least two cases (Gyn. Nos. 1637 and 9457) the malignant 
 tumors were relatively large. 
 
 In several of the cases the disease had extended to other structures. In Case 
 8675 the omentum was studded with secondary growths. 
 
 The uterus, in most of the cases, contained a few myomata of moderate size. 
 Only in Case 4020 did the myomata reach large proportions. 
 
 Where carcinoma of the ovary and myomata exist, the better plan seems to be 
 complete removal of the tubes, ovaries, and uterus. Seven of our patients w^ere 
 operated upon and all recovered temporarily. 
 
 Fig. 243. — A Dkrmoiu Cyst Associated with a Myomatous Uteri's. (A nat. size.) 
 Gyn. No. 3960. Path. No. 971. The specimen is seen from behind. The increase in the size of the uterus i< 
 caused by subperitoneal and interstitial myomata. The right tube and ovary are normal. The specimen has been 
 hardened, and the left ovary cut in two. The solidified sebaceous material fills the greater part of the cyst. Pro- 
 jecting from the lower part of the cyst cavity are numerous black hairs. 
 
 Dermoid Cysts. — In 17* of the 934 cases dermoid cysts wei-e encountered. 
 They were u.'^ually unilateral, and fairly evenly distributed between the right 
 and left ovaries. 
 
 The smallest dermoid was 3 em. in diametei-, the largest, 17 em. The largest 
 cyst (Case 3232) was multilocular, and nearly all the cysts were deiinoids. It is 
 a well-known fact that dermoid cysts tend to become adherent, and in fully two- 
 thirds of our cases dense adhesions existed. In Fig. 243 we have an example of a 
 small dermoid cyst associated with a myomatous uterus, and in i''ig. 211 a multi- 
 nodular uterus with a paro\'arian cyst on the I'ight and a dei-nioid cyst of the 
 ovary on the left. 
 
 In two of our cases ((Jyn. Nos. 300S and l()()95). the patients died. In the 
 first case the enucleation of the jx'lvic organs was exceedingly ditlicuh, and the 
 patient died with signs strongly suggestive of infection oi' ol)sti'uetion. Death 
 in the second case was suj)])ose(l to be due to a myocarditis. 
 
 *Gyn. Nos. ;WOS, .32:52. 3.')(K). :5<)()(), 1S7;5, 01:52. Till. 7.')()S. 771 I. 771i;. SS7S. lOOI),-). ]()SS:5, 
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 350
 
 CONDITIONS OF THE TUBES AND OVARIES. 
 
 351 
 
 Fibroma of the Ovary. — In 3 out of 934 cases fibromata of the ovar}- were 
 encountered and in each case the fibroma was unilateral. In Case 9090 the 
 uterus contained several small myomata and the left ovary had been transformed 
 into a fibroma 12 x 14 x 16 cm. 
 
 Attached to the uterus in Case 3294 was a pedunculated myoma 7 x 9 x 13 cm.; 
 the left ovarv had been converted into an enormous ftbroma, 16 x 24 x 30 cm. 
 
 Fig. 245. — A Very' Largk Lkkt Ovarv Assot-iATEu with a Myomatous Utkrus. (Nut. size.^ 
 Gyn. No. 57.34. Path. No. 2034. The tube is much leiiRtlieiied, and near its center is covere*! with a few 
 bands of adhesions. The ovary measures 2.5 .x 4 x 9 cm. The increase in .size is in part due to the Oraatian follicle, 
 but the solid portion of the ovary is very coarse in texture and much increa.sed in amount. (After Howard .\. 
 Kelly.) 
 
 The multinodular uterus in Case 10491 measured 10 \ 17\2()('ni.; dcNclopiutj; 
 from the rif2;ht ovary was a fibroma '> .\ 10 \ 10 cm. 
 
 The occasional association of (ibroina of the o\'ary with ulcriiic inyoinata is 
 of interest only to the pathologist and has no cnnical ini|)orl. If both are 
 present, it is almost impossible to make a (hagiiosis before o])('ration. and cN-en 
 with the sy'XTimen before him the sur.ucon at times mistakes the libroniM for a 
 myoma and only after seeiii.ti its rclat ions to 1 he I nbc or on incisino- it docs he 
 realize the exact nature of the <j^'o\\th.
 
 352 
 
 MY(MATA OK THE UTKRUS. 
 
 Alterations in the Location of the Ovaries. — Willi the t'i('(|iu'nt great increase 
 in the size of the uterus, due to the continued growth of the niyoinata, the ovaries 
 arc gradually tlrawn away fi'oni tlu^r usual location, l-'or exani])le, in Case 4771 
 the left ovary and the sigmoid fiexiu'e were drawn high uj) on the surface of the 
 tumor. 
 
 With the migration of the ovary there is naturally an altered relation of the 
 ovarian vessels, and they may be found high up on the side of the tumor, as noted 
 in Case 4022. 
 
 When the ovarian vessels su])ply a great deal of the nourishment to the tumor, 
 they may reach large proportions, the veins in some cases being 1.5 cm. in diam- 
 eter, as in Case 9767. 
 
 Fig. 
 
 Gyn. 
 The tube 
 
 The< 
 it is not I 
 ovary wa: 
 
 246. — A Greatly Lexcithened-out Ovary .Associated with Uterine Myomata. (i nat. size.) 
 No. 10102. Path. No. 6299. The tube and ovary are wedged in between large myomatous ma-sses. 
 has been converted into a large hydrosalpinx and is adherent to one of the myomata. 
 
 )vary was markedly increased in size, being 3 x 13 cm. Even when i)ictiired about half its natural length 
 inly much longer than normal, but also much thicker. There is one small Graafian follicle cyst. The 
 s slightly edematous. 
 
 In some cases the gi'eat increase in size of the veins is e\i(lently due to com- 
 pression of the uterine veins between the tumor and the peh-ic walls. The 
 ovarian veins then return more venous blood than is theii- wont. The alterations 
 relative to the pelvic structures must be most carefully borne in mind by the 
 surgeon, otherwise the rectum or ureters may suffer serious injury. 
 
 Very Large Ovaries. — In two cases what might be termed gigantic ovaries were 
 found. In Case 57o4 the utems had been converted into a nodular tumor. 14 x 
 19 X 27 cm. The right ovary was rej)resented by a cyst, 6 x S cm. The left tube 
 was 14 cm. long, and the ovary w-as much enlarged, being 2.5 x 4 x 9 cm. (Fig. 
 245). Part of the increase in size was due to a cystic Graafian follicle, but the 
 ovary itself was much enlarged. In Case 10102 the abdomen, to within S cm. of
 
 CONDITION'S OF THE TUBES AND OVARIES. 
 
 353 
 
 the costal margin, was filled with a hard myomatous tumor. The right ovary 
 was greatly enlarged, measuring 3 x 10 cm. (Fig. 246). It contained a cystic 
 follicle, but the great increase in size was due in ])art to edema. 
 
 The Merging of a Myoma into an Ovary. — This condition is exceptional. In 
 Path. No. 4090 the uterus was 16 cm. in diameter and irregular in outline, owing 
 to the presence of numerous myomata. The chief interest in the specimen is 
 centered in the left ovary, which was apparently 7 cm. in length, and vari(Hl from 
 3 to 4 cm. in breadth. The outer end presents the characteristic lobulated ap- 
 pearance, but the inner end is exceedingly dense and nodular (Fig. 247). On 
 splitting this supposedly large ovary, we found that the outer third Avas com- 
 
 FiG. 247. — The Coalescence of a Subperitoneal Peuunculated Myoma with an Ovary, (g nat. size.) 
 Path. No. 4090. The sketch shows a small portion of a multinodular uterus, 16 cm. in diameter. The left 
 tube is normal. Springing from the surface of the uterus, just behind the insertion of the left tube, is a pedun- 
 culated myoma, the outer pole of which has grown into and become continuous with the ovary. 
 
 posed of ovarian tissue, which, save for a (Graafian follicle 1.") cm. in diameter, 
 presented the usual apjx'arance. The inner two-thirds consisted of a sul)i)eri- 
 toneal myoma, which, on account of its jjroximity to the ovary, had bui'i-owed 
 into it in the manner that a ball would fit into a socket. 
 
 Parovarian Cysts. — Parovarian cysts were noted 1!) times in the WM cases of 
 uterine myomata. In one case they were bilateral. The.sc cysts varied from 
 1 cm. to 20 cm. in diameter. Fig. 244 is an excellent illustration of a parovarian 
 cyst, as it shows cleai'ly the relation of the cyst to the tube and ovary, and also 
 the charticteristic t rniislucency. The opposite ox'ary is the seat of a dermoid 
 cyst. 
 
 23
 
 CHAPTER XIX. 
 
 CONDITIONS FOUND IN THE LIGAMENTS PASSING TO AND FROM 
 THE UTERUS IN CASES OF UTERINE MYOMATA. 
 
 T. Alterations in the broad ligaincnts. 
 II. Changes in the utcro-ovarian ligaments. 
 III. Changes in the round hgaments. 
 
 I. Alterations in the Broad Ligaments Associated ^x^ITH Uterine Myomata. 
 As a rule, the broad ligaments show no alterations, but in a few instances we 
 have noted marked changes. The following are those of especial interest: 
 
 1 . A myoma separating the folds of the broad ligament. 
 
 2. A myoma densely adherent to the posterior surface of the ])road ligament. 
 8. Great tlilatation of the veins of the broad ligament. 
 
 4. Dilatecl lymph-spaces in the broad ligament. 
 
 o. Cireat thickening of the broad ligament, usually due to edema. 
 
 G. Al)scess in the broad ligament secondary to a tubo-ovarian al)scess. 
 
 Myomata of the broad ligament and adhesions to the broad ligament are dis- 
 cussed in the chapter on Treatment (p. 630). 
 
 Dilatation of the Vessels of the Broad Ligament. — As a rule, after s})litting the 
 jH'ritoneum of the broad ligament the oj)ei-ator can readily free a .myoma in 
 this region, but in some cases great congeries of blood-vessels — chiefly veins 
 — occupy the bi'oad ligament and, if not gently handled, ruptiuv and a 
 troublesome, if not alarming, hemorrhage may ensue. 
 
 In Gyn. Xo. 77 the abdomen was filled with a nmltinodular myomatous 
 uterus. The \-eins in both broad ligaments were enormously distended. 
 
 In Gyn. .\o. 0129 the myomatous uterus extended almost to the umbilicus. 
 The surface of the tumor was covered with numerous vessels, and vovy large 
 veins course»d over the bi'oad ligament. Many ligatures were required to com- 
 pletely cont rol the bleeding from these vessels. 
 
 In Gyn. No. 7237 the fundus was the size of a cocoanut and smooth. Cours- 
 ing over its surface were large tortuous vessels. The broad ligaments with the 
 greatly engorged tortuous vessels were di'awn well upon each side of the tumor. 
 When the broad ligaments were split, these veins looked like large earth-worms. 
 
 The large myoma in Case S526 had d(>veloped chieHy in the right broad 
 ligament, and the vessels on this side were much dilated. 
 
 The increase in size of the vessels of the broad ligament in these cases did not 
 appear to be due in any measui-e to obstruction, but rathei' to the great vascu- 
 larity of the tumor. 
 
 354
 
 CONDITIONS FOUND IN THE LIGAMENTS. 355 
 
 Parovarium. — In some cases the vessels passing between the tube and 
 ovary are greatly enlarged. This is prone to occur when the tumor is of large 
 proportions and requires nuich nourishment, or when the return of the venous 
 flow from the uterus is retarded as a result of ])ressure. 
 
 Occasionally the parovarian tissue is nuich thickened and translucent. This 
 may be due to edema, as in Case 3296, or to marked dilatation of the lymphatics, 
 as in C. H. I., Case B., operated upon March 13, 1905. 
 
 Dilated Lymph-spaces in the Broad Ligament. — On p. 14 we discussed dilated 
 lymphatics in the omentum associated with parasitic myomata, and on p. 72 
 dilated uterine lymphatics. If such conditions occur in the uterus, it is but 
 natural that we should find them in the broad ligaments. A reference to Fig. 
 57, p. 73, will show greatly dilated lymph-vessels coursing over the surface of 
 the uterus, and becoming lost between the tube and ovary. 
 
 In Case 5141,* in which the myomatous uterus extended far above the um- 
 bilicus, it was found that the myoma had developed to a large extent in the left 
 broad ligament. In both broad ligaments were many dilated lymph-spaces. 
 
 The dilated lymphatics at operation stand out sharply, but after operation 
 collai)se and are readily overlooked. 
 
 Thickening of the Broad Ligament in Cases of Uterine Myomata. — Occasion- 
 ally the Inroad ligaments are not only thickened, but also drawn upward to a 
 considerable extent by the myoma. The thickening is usually due to edema. 
 
 In Case 6190 the uterus was enlarged and adherent, and on both sides were 
 cystic appendages. The right broad ligament was thickened and edematous. 
 
 In Case 7528 the myomatous uterus extended 9 cm. above the umbilicus. 
 There were broad adhesions between the ileum and broad ligament. There was 
 extensive edema in both broad ligaments. 
 
 In Case 6863 the uterus contained several myomata and there were adhesions. 
 Both broad ligaments were very edematous and thickened, and were di-aA\'n up 
 over the fundus. 
 
 The myomatous uterus in Case 7064 was ])artially eiiNcloped in adhesions. 
 The left broad ligament was swollen and edematous; it contained mai'kedly 
 dilated veins, and was drawn up ()\-er and adherent to the fundus. 
 
 It will be noted that in each of these four cases in which edema of one or 
 both broad ligaments existed, ]'eni;iins of peKic in(l;iniiiiatioii wci'e present. 
 
 Abscess in the Broad Ligament. This condil ion, so connnon after a post j)uer- 
 peial infection, is i-;ii'ely associated with inyoni;i. In Case 7313 the nmltino(hilar 
 myomatous uterus contained sarcoiuatous nodules. The I'ight tul)o-o\"ai'ian 
 abscess h;id opened into l he blond huMnielil. It li;iil iheli i)UI'rowe(l hack to the 
 rectum, and extended to the tissue (hreclly beneath the xaginal mucosa. This 
 case is reported in detail in the chaptei' ou Sarcoui.a (p. I!).")). 
 
 M>oiiiata thenise|\-es rarely, if e\-er, gi\-e rise to an .abscess in the broad 
 ligament. 
 
 * Tiii.s case \v;is rc|>()rt('(l in detail l)y Tliomas S. Ciillrn, in llic .loliii^ Il()i)kins Hiillctiii, Octo- 
 l)cr, 1S97.
 
 356 
 
 MVOMATA OF THK UTKRUS. 
 
 II. Changes in the Utero-ovarian Ligaments. 
 In sonic eases the altei-ations are minor in character. For example, as a 
 resuh of pressure from the ciihn;tietl uterus, the utero-ovarian ligaments may be 
 much flattened, as in San. ^io. 1924. In other eases in which the uterus is much 
 enlarged and there is hypertro])hy of the uterine muscle the ligaments may be 
 abnormally de^•el()j)e(l. This was particularly noticeable in Case 8866. The 
 uterus measured 26x25x12 cm., the chief development being in the cervical 
 jiortion; the utero-ovarian ligaments were unusually well developed. 
 
 In our experience tumors of the utero-ovai'ian ligaments have been of four 
 varieties : 
 
 (1) Cysts. (2) Myomata. (3) Adenomyomata. (4) Sarcoma (primary 
 
 growth in the uterus). 
 
 Cysts of the Utero-ovarian Liga- 
 ments. — We have had two in- 
 stances. In Case 2763 a the myo- 
 matous uterus measured 6xl4x 
 20 em. in its various diameters. 
 Ill the right utero-ovarian liga- 
 ment was an oval cyst, 4.5 by 3 
 cm. (Fig. 24S). Unfortunately, 
 the specimen was lost, and no 
 j histologic examination could be 
 made. 
 
 In Case 6667 the myomatous 
 uterus was 18x15x12 cm. The 
 right tube was normal. The ovary 
 was drawn out, l)(>ing 2x5x7 cm. 
 The increase in size was caused 
 by several large follicles. Situated 
 in the utero-ovarian ligament 
 were several small cysts containing a clear fluid (Fig. 249). Microscopically, 
 these cysts were evidently dilated (Ii'aafian follicles. This is the only instance 
 in which we have ever found the ovarian elements in the utero-ovarian ligament. 
 \\'hen one examines the drawing carefully, it is seen that the ovary is dis{)laced 
 unusually far out, thus making the ligament abnormally long. Had the ovary 
 been in its normal ])Osition, these apparently aberrant ovarian structures would 
 in all ])robability have been included in the ovary. 
 
 Fig. 248. — Cyst of the Utero-ovarian Ligament. 
 
 (i nat. size.) 
 Gyn. No. 2763 a. Path. No. 286. .\ttached to a large 
 myomatous uterus is an occluded right tube, on the surface 
 of which are a few small subperitoneal cysts. The ovary is 
 considerably drawn out. Incorporated in the right utero- 
 ovarian ligament is an oval, thin-walled cyst with two small 
 secondary cysts on its inner side. The cyst measured 4.5 by 
 .3 cm. 
 
 Gyn. No. 2763 a. Path. No. 286. 
 
 M y o 111 a t o u s u t e r u s w i t ii a d h c r e 11 t a j) p c 11 d a g e s a n d a 
 cyst in the right utero-ovarian ligament ( Fig. 248). 
 
 J. R., white, aged forty-four, married. Admitted May 4; discharged June
 
 CONDITIONS FOUND IN THE LIGAMKXTS. 
 
 357 
 
 19, 1894. The myomatous uterus was large, irregulai', and filled the pelvis and 
 lower part of the al)donien. 
 
 Operation, May 7, 1894. Hysteromyomectomy. The chief interest in the 
 case is centered in the appendages on the right side (Fig. 248). The tube is the 
 seat of a hydrosalpinx and the ovary is drawn out. Situated in the right utero- 
 ovarian ligament is a cyst 4.5 x 3 cm. No histologic examination was made. 
 
 G3ni. No. 6667. Path. No. 2900. 
 
 e m y o m a t a ; 
 n e a 1 , inter- 
 a n d s u b m u c - 
 a fi a n follicle 
 he right side; 
 y s t s in the 
 a r i a n 1 i g a - 
 
 249). 
 
 Fii;. 249. — CvsTS in tuk Utkro-ovaiuan Li(iAMi;NT. (1 nat. size.) 
 Gyn. No. 6667. I'ath. No. 2900. Attached to the large imiltinodular inyoinatous uterus are the right tube 
 and ovary. The ovary contains two dilated follicles. In the right iitero-ovarian ligament are three cysts. On 
 histologic examination they are found to be typical (iraafiaii fnllicli--. 
 
 A. \'.. colored, ngcd tlii i-ty-ciglit , mairiccl. Adtiiillcd .laniiary 27: dis- 
 charged February 27, bSi)!). 
 
 ( )peral ion, hystcromyoiiiect oiiiy. 
 
 I'alli. Xo. 2!)()(). The specimen coiisisis of the utefus, tul)es. and o\ai'ies. 
 'Hie uteiiis is a no(hila!' luiiioi', JN \ 1") \ 12 cm. S])ringing from its surface, 
 chieliy from the fuiuhis, are numerous ))e(hiiicuhit<'(l and sessile myomata, \'arv- 
 ing from 1 to cm. in diameter, 'i'he ulei'ine ca\ity is oc(aipied b\- a large 
 submucous myoma and two smaller ones. This large myoma is j)ear-sha))ed 
 and 11 cm. in diameter. Our chief interest centers in the iii:iit utero-oN'arian
 
 358 MVO.MATA OF THK LTKRIS. 
 
 ligaiuciit. The tube is iiornial, the ovary is much di-awii out, and situated in 
 the utcro-ovariaii liiiaincnt is an oval cyst, 2 x 1 cm. (Fig. 249.) Near the 
 uterus is a small cyst, 7 x ') mm. There are no adhesions. The left tube is 
 normal. The left ovary contains a thin-walled cyst. 
 
 Microscopic sections from the small cysts in the rigiit utero-ovai'ian ligament 
 show that they are typical (!i-aatian follicles, and that they are essentially ovarian 
 elem('nt>. 
 
 Myomata of the Utero-ovarian Ligaments. — W v have had five cases of this 
 character, ami all were associated with uterine myomata. They varied from 1 
 to 4.5 cm. in diameter. Tn Case 4609 there was a nuiltinodular uterus, 12 cm. 
 in diameter. Situated in the upper border of the right ovarian ligament was a 
 myoma, 1 x 0.7 x 0.7 cm. In Case 4869 an irregularly globular myomatous uterus 
 averaged 16 cm. in diameter. Springing from the left utero-ovarian ligament, 
 about its middle, was a myoma about 2 x 2.3 cm. (Fig. 250). 
 
 In Case 7859 the uterus had been converted into a nodular tumor, a))proxi- 
 mately 12 x 10 x 10 cm. Histologic examination showed that the uterus was the 
 seat of a diffuse myoma. Situated in the right utero-ovarian ligament was a 
 myoma 2.5 cm. in diameter. 
 
 In Case 4252 the myomatous uterus was adherent to the pelvic floor and to 
 the rectum. In the right utero-ovarian ligament was a myoma 2.5 x 2.5 cm. 
 (Fig. 251). 
 
 In Case 9()/5 the myomatous uterus was free from adhesions. Sj)ringing 
 from the anterior aspect of the right utero-ovarian ligament was a globular 
 myomatous nodule. 4.5 cm. in diameter (Fig. 252). The right tube and ovary 
 were normal. 
 
 On histologic examination these myomata all j)roved to l)e identical in struc- 
 ture, as they naturally would be, with those developing in the uterus. 
 
 Gyn. No. 4609. Path. Nos. 1307 and 1318. 
 
 S u b p e r i t o n e a 1 a n d interstitial u t e r i n e m y o m a t a , 
 s u )) p u rati n g s u b m u c o u s m y o m a ; small m y o m a o f t h e 
 right o V a r i a 11 1 i g a m cut ; g o n o r r h e a 1 salpingitis. 
 
 M. T., white, married, aged fifty-two. .\dinitt(>d August 31; died Sep- 
 tembei- 19. 1S9(). When the ])atient was ojK'rated upon she was in a very weak- 
 ened condition; the urine contained albumin and casts. 
 
 Operation, September 14, 1896. Hysteromyomectomy. 
 
 Path. No. 1318. The uterus is irregularly globular, measuring approxi- 
 mately 12 cm. in diameter. Springing from its surface are several hrm, flattened 
 bosses and two subperitoneal nodules, 3 cm. in diameter. The uterine walls 
 contain numeidus myomatous nodules, varying from 0.5 to S cm. in dianu^ter. 
 Tile largest of these is situated ill the posterior wall : the central portion has been 
 converted into two large cavities lined with a greenish yellow, exceedingly friable 
 material. There are several submucous myomata, one greenish yellow and
 
 COXDITIOXS P^OUXD l.\ THE LIGAMENTS. 
 
 359 
 
 suppurating. On the left side the appendages are normal. On the right side the 
 ovary is covered with a few delicate adhesions. Situated in the upper border of 
 the right utero-ovarian ligament is a firm myomatous nodule, 1 x 0.7 x 0.7 
 cm. This presents a glistening white surface and is composed of fibers con- 
 centrically arranged. 
 
 Gyn. No. 4869. Path. No. 1434. 
 
 Interstitial uterine m y o m a t a ; slight j) e 1 v i c a d - 
 h e s i n s ; small m y o m a in the left u t e r o - o v a i- i a n 
 ligament (Fig. 250) . 
 
 E. G., colored, married, aged thirty-four. Admitted December 9, 1896; 
 discharged January 17, 1897. 
 
 Operation. HysteromA'omectomy. 
 
 Path. No. 1434. The uterus is irregularly globular, averaging 16 cm. in 
 diameter. Occupying the 
 posterior wall, and extend- 
 ing do^^'n below the cervix, 
 is a tumor 17 x 16 cm., 
 presenting the usual myo- 
 matous appearance. On 
 the right side the append- 
 ages are covered with a 
 few adhesions. On the 
 left side the tube is sev- 
 eral centimeters long, and 
 the fimbriae are slightly 
 adherent to one another. 
 The ovary is covered with 
 a few vascular adhesions. 
 
 Springing fi'oin the left utero-ovarian ligament altout lis middle is a tii}-o!iia. 2 
 X 2.:] cm. (Fig. 250 ). 
 
 Gyn. No. 7859. Path. No. 4122. 
 
 M u I t i )i o d 11 I a V III y o m a t o u s u I v v u s : d i tT u s v a d e n o - 
 m y o m a of t li f bo d y : n u m e r o u s a d h e s i o n s ; rig h t 
 li y d r o s a 1 |) i n \ . 
 
 S|)riiiging from the right utero-ovarian ligament is a small myoma, 2.5 cm. in 
 diameter. Tiiis case is reported in detail in " .\denomyoma of the Uterus,'" p. 109. 
 
 Gyn. No. 4252. 
 
 -M y o III a t o 11 s u I (' r u s w i 1 h a 111 \- o m a i 11 I li c r i g h t 
 u t (' r o- o V a r i a 11 1 i g a 111 cut ( i'ig. 25! ). 
 
 .\. ('.. aged forty, iiiarricd. .Vdmittcd Maicli 2S: dischai-gcd May 9. 1S<)(). 
 Operation. ilystcroiiiy(»nicctoiiiy. Tlic niyoiiiatoiis uterus was ret rollexed 
 
 Fig. 250. — Myoma of the Utkro-o% arian LKiAMKxr. (V nat. size.) 
 Gyn. No. 4869. Path. No. 1434. Situated ou the posterior surface 
 of the left utero-ovarian ligament near its middle is a myoma (a). 
 This measures 2 x 2.3 cm.
 
 360 
 
 MVOMATA OF THE UTERUS. 
 
 and adherent to the jx'lvie iUmv. Situated in the right utero-ovarian Hganient 
 was a niyoina, 'A.n by 2.5 em. (P'ig. 251). 
 
 r i "; h t ii t e r o 
 
 Gyn. No. 9675. Path. No. 5870. 
 U t e r i n e ni y o ni a t a ; m y o ni a of t h e 
 ovarian 1 i g a ni n t (Fig. 252). 
 
 N. B., aged forty-three, -white, single. Admitted Ahiy 27; died June 3, 
 1902. 
 
 On admission she was suffering from chronic nephritis. 
 
 Operation. Hysteromyomectoniy. The uterus extended as high as the um- 
 l)iHeu8. Situated in the right utc^'o-ovarian ligament was a myoma, 4.5 cm. in 
 diameter. In this ease the fatal result was due to the nc-jjhritis. 
 
 Adenomyoma of the Utero-ovarian Ligament, — This condition is an exceed- 
 ingly rare one, and we have had only one 
 example (San. No. 1872). The uterus was 
 14 cm. in length and 13 cm. broad. Pro- 
 jecting from its surface were myomata 
 varying from 2 to 9 cm. in diameter. His- 
 tologic examination showed that the 
 mucosa manifested a definite tendency to 
 extend into the nmscle. 
 
 Lying perfectly free from the uterus, 
 and attached to the utero-ovarian liga- 
 ment, was a pear-shaped myoma, 6 cm. in 
 length, and varying from 3 to 4 cm. in 
 thickness. Projecting slightly from its 
 surface were cysts, one of which reached 1 
 cm. in diameter. On section, numerous 
 cystic spaces were found scattered 
 throughout the myoma. Some of these 
 were filled with old coagulated l)lood and had a brown lining. Scattered here 
 and there throughout the ti.ssue were light-brown, porous areas, suggesting mu- 
 cosa. Even macroscopically the diagnosis of adenomyoma was easy. 
 
 On histologic examination some of the cysts were found to be dilated glands; 
 others were distended miniature uterine cavities. The jjorous areas were masses 
 of typical uterine mucosa. 
 
 The case is described in detail in "Adenomyoma of the Uterus,'' p. 140 (Figs. 
 41 and 42). 
 
 Secondary Sarcomatous Nodule in the Utero-ovarian Ligament. — In Case 8610 
 (described in detail in the chapter on Sarcoma, j). 231) the uterus was approxi- 
 mately 12 x 14 cm., and was studded with sarcomatous nodules. Histologic ex- 
 amination strongly indicated that the sarcoma had resulted from a malignant 
 change in the myomata. Situated in the right utero-ovarian ligament was a 
 
 Fig. 251. — Myoma of thk Right Utkro-ova- 
 KiAN" Ligamf;nt. 
 Gyn. No. 4252. To the left is a small por- 
 tion of the myomatous uterus. Occupying the 
 central portion of the right utero-ovarian liga- 
 ment is a myoma which measured 2.5 x 3.5 cm.
 
 CONDITIONS FOUND IN THE LIGAMENTS. 
 
 361 
 
 sarcomatous nodule, 1.5 cm. in diameter. This on section was perfectly white 
 in color, homogeneous in consistence, and resembled the sarcomatous uterine 
 nodules. 
 
 III. Changes in the Round Ligaments in Cases of Uterine Myomata. 
 With the increased size of the uterus it is but natural that alterations in one 
 or both round ligaments should be met with. We have found the following in- 
 teresting conditions in our scries: 
 
 1. An altered relation of one round ligament to the opposite one. 
 
 2. The round ligament as a tense band. 
 
 3. Great lengthening of the round ligament. 
 
 4. Hypertrophy of the round ligament. 
 
 I'm. 252. — MyoM\ of the Utkko-ovakian I,i<;ami:nt. (V nat. size.) 
 
 Gyn. No. 967,5. Path. No. 5870. The right tube and ovary are normal. GrowiniB; from the anterior aspect 
 
 of the right utero-ovarian hgameiit, and free from the uterus, is a globular myoma, 4.5 cm. in diameter. 
 
 5. Myoma of the round ligamciil. 
 
 6. Adenomyoma of the round ligaiin'iil . 
 
 Altered Relations of One Round Ligament to its Fellow. The iclarKtii of the 
 ends of the I'ouiid ligaments to one aiiothci- is often an imporlanl jtoinl in the 
 diagnosis between j)regnancy and inyoina. In some cases, on opening the ab- 
 domen, the surgeon, from t he geiieial eonioui' of t he ntems, cannot exclude preg- 
 nancy, although the clinical hisloiy in no \\.a\' suggests it. ()ften a glance at the 
 uterine insei'tion ot llie rouml liuaiiients will show that the\' are not over a few
 
 362 
 
 MVUMATA OF TMK LTHIUS. 
 
 C'ciitinictcrs ;i));u-t. altliou^'li the iitcnis is as largo as that of a six months' prog- 
 nancy. This will usually indicate that the onlargemcnt is duo to a tumor sit- 
 uatod in tho posterior wall. In other cases when a myoma is developing in one 
 side of th{^ uterus the corros])onding round ligament is drawn far up and is ap- 
 ])arenlly inserted at a higher level than its fellow opposite. When pregnancy 
 exists, there is usually an equable enlargement of the uterus, and although the 
 distance between the round ligaments increases, their points of uterine attach- 
 ment remain on the same level. 
 
 In Case 8371, when the abdomen was opened, we at first suspected pregnancy, 
 but a glance at the round ligament at once solved tho problem. 
 
 The Round Ligament as a Tense Band. — As a rul(\ bimanual examination 
 will enable one to get only a general idea of the contour of the myomatous uterus 
 and to determine whether the tumor is fi'eely movable or fixed. Occasionally, 
 as in Case 13025, the ligament may be outlined as a tense cord. In this case the 
 tumor had developcnl from the fundus on the right side, and had drawn the right 
 cornu high up into the abdomen. The right round ligament was 6 inches in 
 
 V 3<2<^^<S^. 
 
 Fig. 2.53. — Mvoma of the Rorxn Ligamk.xt. (Nat. size.) 
 B. H., December 5, 1908. The uterus is normal in size, but the left tube is .slightly thicker than usual. SpriiiK- 
 ing from the upper border of the left round ligament, about 2 cm. from the uterus, is a myoma over 1 cm. in di- 
 ameter, n was freely movablf. 
 
 length, and on bimanual examination, with the ])atient under ether, it was felt as 
 a tense band running from the right inguinal ring to a point near the summit 
 of the tumor. 
 
 Great Lengthening of the Round Ligaments. — As one end of the round liga- 
 ment emerges fi-om the inguinal canal and the other merges into the lateral and 
 anterior aspect of the uterus, it is but natural that any uterine tumor that en- 
 larges or draws up the uterus .should at the same time cause a lengthening of the 
 round ligament. In our experience increased lengthening of the round ligaments 
 has not caused a corresjxmding diminution in their diameters. 
 
 Tn Ca.se 6915 the left round ligament was enormously lengthened out and 
 almost lo.st in the tumor. 
 
 In C. H. I. (McA.) an S!)-])()und sub[)ei-itoneal myoma filled the alxlomeii.
 
 CONDITIONS FOUND IX TH H IJCAMENTS. 
 
 363 
 
 The uterus lay near the hver, and the round ligaments were greatly length- 
 ened. 
 
 Hypertrophy of the Round Ligaments. — As a rule, the round ligaments are of 
 the usual diameters, even when myomata exist. Occasionally, however, they are 
 greatly hypertrophied. 
 
 In Case 8024 the uterus was about the size of that of a six months' pregnancy. 
 Both round ligaments were greatly hypertro))hied. 
 
 Both round ligaments were greatly lengthened and thickened in Case 5103, 
 in which the lower half of the abdomen was filled with a multinodular myo- 
 matous uterus. 
 
 From an operative standpoint, it is always wise to be particularly careful that 
 the round ligament is properly 
 ligated. On several occasions 
 we have seen the round liga- 
 ment slip away from its ligature 
 during the course of the opera- 
 tion, and considerable oozing 
 follow. When there is much 
 hypertrophy, the vessels are 
 often of goodly size, and if not 
 carefully tied, may later give 
 rise to alarming bleeding. 
 
 Myoma of the Round Liga- 
 ment. — Four of our myomatous 
 uteri have been associated with 
 myoma of the round ligament. 
 In Case 8713 the multinodular 
 myomatous uterus was the size 
 of a child's head, and situated 
 in the right round ligament was 
 a myomatous nodule. 
 
 In Case 10()()9, Path. No. 
 6908, the nodular uterus was 
 10 X 6 X 6 cm. Situated in 
 the right round ligament was a iiiyoma 7 cm. in diameter. 
 
 Quite recently another myoma of the I'ouiid ligament was found: this is 
 shown in Fig. 253. 
 
 The myomatous uterus ill San. .\o. l()5S(Pa!li. .Xo. KiKl) was 20 \ 20 \ 12 em. 
 Situated in the right round ligaiiieiit was a inyoiiia. 6 x 3 \ 3 em., separated from 
 the uterus by at least 1 em. of iioniial round ngaineiit. 
 
 The nmscle of the round hganieiil is identical in characler with that compo.s- 
 ing the uterus, and myomata of the round hgaiiieiit accordingly present the same 
 gross and histologic jiictures. 
 
 254. — .\ MvoMA LviMi Fhkk kko.m the I'tkrus .\xi) 
 
 .SlTU.\TED BeTWKK.N THE TuBE AND OvARV. (Nat. size.) 
 
 Path. No. 8432. The tube is thickened, owing to a sac- 
 cvilated salpingitis, n is rare to have the fimbriated end open 
 when such a condition exists. The ovary has been converted 
 into a corpus luteuni cyst, a is a small corpus hiteum. Sit- 
 uated between the tube and ovary, and lying near the inner 
 end of the tube, is a small inMhilar nudiua.
 
 364 MYOMATA OF THK ITKRUS. 
 
 Adenomyomata of the Round Ligament. — This condition is exceedingly rare. 
 It fell to our lot to record the first case of this character.* 
 
 \'aginal examination did not indicate any increase in size of the uterus. Oc- 
 cu{)yin<i; the uj)per ])art of the I'iiiht labium was an irregular mass, about 2 cm. in 
 diameter. On removal it ])ro\cd to be an adenomyoma of the round ligament. 
 About eighteen months later another myoma was removed from the left round 
 ligament in the inguinal region. This case is reported in detail in '' Adenomyoma 
 of the Uterus," p. 2o(). 
 
 Small Myoma Unattached to the Uterus and Situated between the Tube and 
 Ovary. — In Path. No. 8432 we have a tul)e that is the seat of a mild inflannnation, 
 l)ut nevertheless has a patent fimbriated end. The ovary contains a corpus 
 luteum cyst. At the inner end of the tube, and lying between it and the enlarged 
 ovary, is a small myoma (Fig. 254). It is entirely free from the uterus. 
 
 * Thomas S. ('ullen, Adenomyoma of the Round Ligament, Johns Hopkins Hospital Bulletin, 
 May and June, 1S96. Further Remarks on Adenomyoma of tiie Round Ligament, Johns Hop- 
 kins Hospital Bulletin. .Tune, 1898.
 
 CPIAPTKR XX. 
 
 THE BLADDER IN CASES OF UTERINE MYOMATA. 
 
 Position of the Bladder. 
 
 In the majority of our cases the blacUler had retained its normal position; 
 nevertheless, not infrequently* it had been carried up into the abdomen. This 
 displacement of the bladder is dependent upon two main factors: (1) Upward 
 pressure by subvesical myomata. (2) The gradual ascent of the bladder ^^^th 
 the continued growth of the myomatous uterus. 
 
 The Upward Pressure of Subvesical and Intraligamentary Myomata. — ^^'hen 
 a myomatous nodule develops in the lower segment of the uterus and spreads 
 
 Fir:. 255. — A Subvesical Myoma. 
 
 Gyn. No. 4.340. Projecting from the ante- 
 rior surface of the uterus and encroaching on the 
 bladder is a subvesical myoma which meiusureil 
 4x4.5x8.5 cm. A myomectomy was done. 
 
 Although the nodule greatly tliminished the 
 mobility of the bladder, there were no local 
 symptoms. 
 
 Fig. 256. — A Bladder Forced out ok the Pelvis by 
 AX Incarcerated Myomatous Uterus. 
 
 Gyn. No. 7630. Occupying the posterior wall of the 
 uterus is a large myomatous nodule. The uterus is firmly 
 fixed in the pelvis by rectal adhesions, as indicated by a. 
 
 The bladder, even when emptied, extends to within 
 4 cm. of the umbilicus. Its walls are much thickened. 
 
 out beneath the l)ladder, the latter is naturally caiTicd upward on its suii'ai'c .\ 
 similar condition may also be pnxhiccd by a large inyoinatous uterus becoming 
 impacted in the pelvis; much j)ressure is then exercised in all directions and the 
 bladder is forced into the abdomen. 
 
 * Displacement upward of the bladder wa.s noted in Ca.ses HiSL', 1703. 17.')2, 2777, 2X22. 8113, 
 3133, 3218, 3340, 3445, 3H42, 3882, 4020, 4022. 4285, 4293. 4340, 4771. 4801 J. 4832, 4002, 5086, 
 5332, 6178, 6206, 6376, ()582, 6628, 6863, 6015, 7049, 70()4, 722(), 7237, 7240, 7597, 7()30, 7832, 
 8008,8368,8866,10778, 10969, lllSO, 11792, 12194, 12520, 12841 . 12864, and 13016. Displace- 
 ment was un(ioul)te(lly present in oilier eases in wiiidi no note was in;idc at openilion. 
 
 365
 
 366 
 
 MVO.MATA OF THK UTERUS. 
 
 Ill l"i^-. 2').') wv have an example of a sul)V('sical inyouia encroaching on the 
 bladder and greatly diiuiiiishing its power of e<iual)le distention. As it fills, it 
 must naturally dilate in its upjx'r jjortion. 
 
 fig. 2")() shows a bladder that is becoming mainly an alxlominal organ, as 
 Douglas' sac is tilled with a large myomatous notlule that has become incarcerated 
 and has grown fast to the rectum. 
 
 A distinct subvesical myoma is not very connnon. In Ca.se 2822 the myo- 
 matous uterus measuretl 23 x 25 cm. There was also a subvesical myoma, 8 x 
 12 cm. 
 
 In Case 4832 there was extensive subve.sical development and several myo- 
 matous nodules. 
 
 In Ca.se 7226 the bladder was <lrawn 
 high uj) over the surface of a myoma, 
 about 7 cm. in diameter, which had de- 
 veloped on the anterior surface of the 
 uterus at the junction of the cervix and 
 l)ody. 
 
 In Case lllSO a nodule about 6 cm. in 
 diameter projected into the ])ladder-wall. 
 
 It will thus be seen that the develop- 
 ment luider or the projection into the 
 bladder b}' a myomatous nodule will 
 materially alter the shape and position of 
 this viscus. 
 
 The Gradual Ascent of the Bladder 
 with the Continued Growth of the Myo- 
 matous Uterus. — When the myomatous 
 development is in the upper part of the 
 uterus, the bladder usually remains in its 
 normal jjositioii, but if the growth in- 
 volves the greater part of the uterus, with 
 the growth of the tumor the entire mass 
 is forced out of the pelvis, owing to the 
 limited .space, aii<l naturally carries the bladder with it. 
 
 Fig. 257 affords a good illustration. The entire i)osterior wall of the uterus 
 is implicated in the myomatous growth. The upper ])art of the tumor has out- 
 grown the pelvic confines and stretches high into the abdomen. The bladder 
 has been carried upwai'd on tli(> surfac(» of the inyoiiia uiilil it reaches the um- 
 bilicus. In such a case, if the operator attemi)te(l to open the abdomen below 
 the umbilicus, he would at once enter the bladder. In some of these cases the 
 lower limit of the abdomen is practically the uiiibilicus— the peritoneum from 
 the abdominal wall being reflecte(l b.ack on to the tumor at this point. 
 
 The Role Played by Vesical Adhesions. — For marked displacement upward of 
 the bladder it is usually necessary to have extensive development of the tumor. 
 
 Fig. 257. — \ Hi.addkr Carrikd as High as 
 
 THE Umbilicus hy a Largk Myomatois 
 
 Uterus. 
 
 Gyn. No. 16S2. The fundus is recognizetl 
 as a .slight prominence high in the abdomen. 
 The posterior wall is involved in a large myo- 
 matou.s growth, and the uterine cavity is greatly 
 lengthenefl. The bladder is firmly pressed 
 against the anterior abdominal wall, and has 
 been carried upward on the surface of the tumor 
 as far as the umbilicus. 
 
 The peritoneal reflection anteriorly only 
 reached the umbilicus; posteriorly, the .sacral 
 prominence. The pelvic portion of the tumor 
 was in reality extraperitoneal. 
 
 In such a case the abdominal incision should 
 be commenced well above the umbilicus, as 
 there is great danger of injuring the bladder.
 
 THK BLADDER IX CASES OF UTEHIXE MYOMATA. 
 
 36i 
 
 Init if the l)la(l(ler has bccoinc adherent to the uterus early, it may be carried 
 upward with it. 
 
 ^.- 
 
 
 
 i ^ 
 
 Fig. 258. — A Bl.\dder .\dhkrent to Two Myomatous Nodules. 
 Gyn. No. 6667. The body of the uterus is occupied by numerous myomatous nodules, and the round liga- 
 ments are taut. The bladder presents a festooned appearance, being drawn up at two points where it has 
 become adherent to small myomatous nodules. 
 
 Fio. 259. — .\dhe8ions Bktweex the Bi.adoer a.nd a Myomatous Uterus. 
 Gyn. No. 2777. The uterus contains several myomata and, just al)(>ve a larRC siii)vesical imdulo which 
 presses the bladder against the symphysis, the bla<lder has become u<lhercnt. .Na(urall\-, willi the increase in 
 the size of the tumor, the bladder would be lifted higher and highcM-. 
 
 Fi^. 2r)S shows a freely iiio\"al)le iiiiih iiio(hilMr iiiyotnalous utei-iis. 'Hie Mad- 
 der has become adliei'eiit to two small myoiiiala. ;iiid w illi I he uiow ili nf th(>se i.s 
 bein^ ^■radually lifteil up inio llie al)d()iii('ii.
 
 368 
 
 MYOMATA OF THE UTERUS, 
 
 In Fig. 259 a sliglitly more advanced condition is seen. In the cleft just 
 above a subvesical myoma the bladder has become firmly adherent to the myo- 
 matous uterus, and, as the tumor grows, will be carried higher and higher. 
 
 Fig. 2(U) shows another example of the effect of vesical adhesions. Here 
 almost the entire anterior surface has become fixed to the uterus. 
 
 In Case 4020 (Fig. 201) the l)ladder lies ]:>lastered on the anterior surface of 
 the tumor, and can be lifted well out of the abdomen. 
 
 In Cases 6863 and 7064 the bladder formed a complete mantle over the 
 anterior surface of the uterus. 
 
 In Case 4022 (Fig. 262) the bladder was spread out on the lower half of a 
 large myomatous uterus, antl large vesical branches passed to the tumor. When 
 
 Fig. 260. — Adhksions Between the Bladder and the Myomatous Uterus. 
 Gyn. No. 1.3629. The bladder peritoneum is firmly fixed to the anterior surface of the large myomatous 
 uterus. At one point is a sickle-shaped opening where no adhesions existed. The ureters in this case were also 
 displaceii. 
 
 the bladder is intimately adherent to the tumor, the utmost care must be exercised 
 in freeing it. and .sometimes it is necessary to litci'ally dissect it away. In such 
 cases if the bladder be peeled down with tlH> stalk sponge tluTe is great danger of 
 injuring it. 
 
 Downward Displacement of the Bladder, \\hen, as a result of a myomatous 
 growth, the bladtler is displaced, it is usually carried ujjward, but occasionally 
 it may be displaced downward into the vagina. In Case 4761 the entire pelvis 
 was choked with a hard globular myomatous uterus. A submucous myoma, 
 approximately 12 x 1") cm., was removed through the vagina. In this case the 
 bladder was displaced downward into th(> vagina, and micturition and defecation 
 were interfered with.
 
 THE BLADDER IX CASES OF UTERINE MYOMATA. 
 
 369 
 
 Fig. 261. — Marked Upward Displacement of the Bl.^ddkr. 
 Gyn. No. 4020. Path. No. 1009. The large globular myomatous uterus extended to within 8 cm. of the 
 xiphoid. The bladder was adherent to the tumor, and with the increase in size of the uterus hail been lifted high 
 into the abdomen. (After H. A. Kelly.) 
 
 Fig. 262.— The Bladder l.iiii i> High into the .\bdomk.\ hv a Myomatovh I'tkhvs. 
 Gyn. No. 4022. Path. No. 1012. Ttie nodular myomatous uterus extemls upward to the umbihcus. The 
 bladder has been lifted high into the abdomen. Its upper limits are clearly indicatinl at the point at which the en- 
 larged and tortuoiis vesical vessels end. For nine months i)rior to operation the patient hsu) difficult micturition. 
 At times there wa,s stoppage of urine, as if the bladder was being jiressc.l upon by the tumor. (After H. A. 
 Kelly.) 
 
 24
 
 370 MYOMATA OF TfiK ITKRUS. 
 
 Condition of the Bladder "Wall when the Viscus is Drawn Upward by the 
 
 Myomatous Uterus. 
 
 In nearly all the eases the walls of the bladder, apart from adhesions on 
 the outer surface, were perfeeth' normal. In five of our cases, however, some 
 alteration was noted. 
 
 lIyi)ertroi)hy of the Uladder wall, 4 cases. 
 
 Hypertrophy with sacculation, 1 case. 
 
 In Case 3445 the patient had frecpieiit mietuiitioii, and once it was necessary 
 to catheterize. At operation the bladder reached to within 3 cm. of the umbili- 
 cus. Its walls were much hypertrophied, thick, and rigid. After operation, 
 on account of the residual urine, it was necessary to catheterize almost until the 
 time the patient left the hospital. 
 
 In Case (UTS a myomatous uterus extended almost to the umbilicus. Mic- 
 turition was difficult at night, Ijut after the patient had been up and about during 
 the morning, she could void with ease. At operation the bladder was found to 
 extend 14 cm. above the symphysis. Its walls were much thickened and its 
 vessels large. "\Mien em])tied, it fell into folds instead of contracting uniformly. 
 For four days after ojoeratioii it was necessary to catheterize. 
 
 In Case 6582 the ])eKis was filled with a retroflexed myomatous uterus. For 
 some time the patient had had frequent micturition, and on three different oc- 
 casions during the previous six months it had been necessary to catheterize on 
 account of retention. The bladder extended half-way to the umbilicus and 
 had greatly thickened walls. 
 
 In Case 7630 a myomatous uterus was incarcerated and adherent in Douglas' 
 cul-de-sac. For nine months the patient had had frequent micturition and 
 marked constipation for some time. The bladdei' was hypertrophied and felt 
 and looked like the body of a large uterus, but was more flabby. When emptied, 
 it extended to within 4 cm. of the umbilicus. 
 
 In Case 11422 there was a small myomatous uterus. For two months there 
 had been difficulty in starting the flow of urine. When catheterized prior to 
 ojx^ration, the bladder contained 1400 c.c. The j^atient was watched for several 
 (lavs, and on no occasion did she com])letely emj)ty the bladder. At operation 
 the bladder was found well uj) in the abdomen and was sacculated. Three 
 uterine nodules, the largest 5 cm. in diameter, were enucleated, and the round 
 ligaments shortened. After the operation a severe cystitis developed. A 
 vesicovaginal fistula was accordingly matle, and after the inflammation had 
 subsided, the bladder opening was closed. 
 
 In some of the cases the myomatous uteruf; undoubtedly pressed upon the 
 bladder and rendered micturition difhcult ; the bladder had to exert more force 
 than usual and hypertrophy natuially followed. Jn other cases the liyix'itrophy 
 was an accidental accompaniment of the myomata. Thus, in Case 11422, the 
 l)ladder condition com])letely overshadow(^d the few symptoms due to the 
 relativelv small uterine mvomata.
 
 THE BLADDER IX CASES OF UTERIXE MYO.MATA. 371 
 
 Encysted Peritonitis Suggesting a Full Bladder. 
 In Case o()97 there were a densely adherent and rather small myomatous 
 uterus and double pus-tubes. So firmly fixed were the pelvic structures that a 
 I)oint of cleavage was obtained with the greatest difficulty. L3dng nearly where 
 the bladder should have been was a pocket that resembled a full bladder. It was 
 noted, however, that the peritoneum at one ])oint was especially thin, and clear 
 fluid could be seen immechately beneath it. It proved to be a pocket due to an 
 encysted ix'i'itoiiitis. 
 
 Injury to the Bladder During Operation for Removal of Uterine Myomata. 
 
 The injury usually consists in an accidental opening into the bladder. In 
 many cases the bladder has been displaced ujj into the abdomen, and as a result 
 the operator may cut through into this viscus, thinking he is opening up the ab- 
 dominal cavity. In other cases the bladder has become intimately adherent to 
 the myomatous uterus, and as it is pushed down prior to the hysterectomy, it may 
 be torn. In a few cases the usual landmarks are lost and during dissection the 
 bladder may be accidentally cut into. 
 
 Accidental Opening into the Bladder. — Case 1579 belongs to the early days of 
 the hospital. The pelvis was filled Anth a globular mass, 12 cm. in diameter. 
 During an exi)loratory operation an incision one inch long was accidentally made 
 into the bladder. As the myomatous uterus was firmly fixed, hysterectomy was 
 not attempted. The bladder opening was closed, and the patient recovered with 
 no untoward symi)toins. Xo ui'inary symptoms developed as a result of the 
 injury. 
 
 In Case 8437 the uterus contained agloljular myoma, about If cm. in diameter; 
 the bladder was drawn far up, and as the abdominal incision was made, it was 
 accidentally cut. The opening was closed without difficulty, and hyst(M-ectomy 
 performed. The l)ladder injury in no way retarded the recovery. 
 
 Injury to the Bladder During Hysterectomy. — In Case 3113 there was a mvo- 
 matous uterus, a])proxiniately 2") cm. in diaiiielei'. ami tlie bladder was drawn 
 high into the alxlomen. During the removal of llie lumor a ])iece of bladder. 
 3 X (■) cm., was accidentally bi'ought away with the tumor. The ureters were at 
 once catlieterized thiough the bladder opening, and this alone saved ihein. The 
 bladder was sewed up immediately with inteii'upted sutures an< I the abdomen 
 (lraine(l. '{'here wei'e no untowaid bladder symptoms during convalescc'iice. 
 
 'i'he inxoinatous uterus in Case ;;;;i!l was approximately !,") x 17 x 20 ciil. and 
 choked the pelvis. Dui-ing its reinoxal the MaddiT was acci< lenlalK' incised. 
 'I'he opening was clo.sed with catgut, ami the patient made a good recovery. 
 
 In Case 3.")',)() the patient was lifly-nine years of age and colored. The lower 
 abilomen was markedly distended with a iiodulai- tuinoi- which icached the 
 umbilicus. An exj)loratory section was done, and on account of the den<e ;u\- 
 hesions hysterectomy was ab.'indoned. .\ secdiid at tempt was made a few months
 
 372 MVOMATA OF THP: UTERUS. 
 
 later. Although adhesions were everywhere present and the heart was inter- 
 mittent, hysterectomy was deemed advisable. During the enucleation dense ad- 
 hesions were encountered and the bladder was accidentally torn for a distance of 
 12 cm. As one ureter lay near the tear it was cathcterized and the l)la(l(ler wound 
 then sewn ui). The pelvis was drained, anil a retention catheter left in the 
 bladder. The temperature reached 103.8° F. on the third day. ^^'hen heard 
 from nearly two years later the patient said she had been in perfect health since 
 the operation, and that she had no discomfort of any kind. 
 
 In Case 3842 there was a densely adherent myomatous uterus and the bladder 
 reached almost to the umbilicus. Dense adhesions existed between the uterus 
 and the bladder, and during the separation of the bladder a piece, 1 x G cm., was 
 excised \nth the tumor. The opening was closed with mattress sutures of silk. 
 Intestinal and rectal adhesions were also present. The pelvis was drained. The 
 patient was discharged on the thirtieth day. 
 
 During the removal of a myomatous uterus (12 x 14 x 19 cm.) and double pus- 
 tubes in Case 5647 the bladder was accidentally opened. It was at once sutured, 
 and a retention catheter introduced. The patient made a good recovery. 
 
 In Case 6915 the patient was forty-nine years of age and had a very large 
 intraligamentary myoma on the left side. The body of the uterus was on a level 
 with the umbilicus, and the bladder was likewise pushed up until it nearly reached 
 this point. Enucleation was begun on the right side, and the large mass of 
 ovarian veins lifted and tied ^Aith difficulty in the narrow space between the 
 tumor and the ])elvi(' brim. After section of the right round ligament the bladder 
 was dissected off on the right side, revealing a large mass of knotted veins going 
 from the bladder to the uterus. The right uterine vessels were tied, and the 
 cervix was cut across. As the uterus was carefully Ufted up there was suddenly 
 an almost uncontrollable hemorrhage. Nothing remained but to enucleate as 
 rapidly as possible in spite of the tremendous bleeding. With the uterus partly 
 rolled out on the left side a large spurting vessel was caught and ligated. During 
 the rapid dissection the bladder was torn from the trigonum to the symphysis. 
 The opening in the bladder was at once closed with intei-ru])ted catgut sutures, 
 going down to but not catching the mucosa. The highest postoperative tem- 
 perature was 99.8° F. On the twenty-third day a mild phlebitis developed in the 
 left leg; otherwise convalescence was perfect. 
 
 In Case 7049 a white woman, aged fifty-one, had an enormous myomatous 
 uterus, 23 x 25 x 31 cm., with extensive subvesical development. The bladder 
 peritoneum reached almost to the innbilicus. The incision was continued down- 
 ward to the symj)hysis, but great care was exercised to avoid injuring the l)la(lder. 
 After much difficulty the left ovarian vessels were found and ligated. An attempt 
 was then made to get a point of cleavage between the tumor and the bladder, 
 but in doing so the bladder was accidentally opened for a distance of 12 cm. on 
 the right side. The dissection was continued; the right uterine vessels were 
 controlled on the outer side of the ureter, which was firmly adherent to the tumor
 
 THE BLADDER IX CASES OF UTERIXE MYOMATA. 373 
 
 for a distance of 6 cm. It was now possible to pass a finger beneath the bladder, 
 and the posterior surface was thus gradually separated from the tumor. After 
 removal of the uterus the rent in the bladder was closed with twelve interrupted 
 catgut sutures, extending to but not including the mucosa. These were rein- 
 forced with a second row of catgut. The highest postoperative temperature 
 was 101° F. on the fourth day. She had a "heat-stroke" on the twelfth day, 
 the temperature reaching 105.8° F. She was discharged well. 
 
 In Case 8836 bisection of the uterus was resorted to on account of the ad- 
 hesions, and as the patient was in an alarming condition. During bisection the 
 bladder and rectum were purposely opened. They were at once closed as soon as 
 the uterus had been removed, but the patient never rallied, dying a few hours 
 later. The tumor proved to be sarcomatous. The case is reported in full on 
 p. 229. 
 
 In Case 10204, while gently pushing the bladder down from the myomatous 
 uterus prior to doing a hysterectomy, we opened the bladder for a distance of 3 
 cm. It was at once sutured. Subsequently the patient developed a broncho- 
 pneumonia. She was discharged well on the forty-first day. 
 
 In Case 10916 the pelvis and lower abdomen were filled with, a myomatous 
 uterus. During the separation of many adhesions a large vein in the meso- 
 sigmoid was torn and profuse bleeding followed. As the bladder was pushed 
 down it was torn for two inches. After removal of the uterus the tear in the 
 bladder was closed with catgut and a vaginal drain introduced. The pulse rose 
 steadily, and forty-eight hours after operation was 148. The highest postopera- 
 tive temperature was 101.4° F. For four days there was a profuse vaginal dis- 
 charge and bloody urine. After that the convalescence was normal. 
 
 In Case 11013 the patient, aged forty-nine, white, had first noticed her ab- 
 dominal tumor fourteen years before admission. She had had severe and pro- 
 longed uterine bleeding, for two years had suffered from freciuent urination, and 
 during the last six months there had been an almost constant dribble. The urine 
 had a foul odor, and at times contained pus. On admission she was in a state of 
 chronic invalidism. The pelvis and abdomen as far as the ensiform cartilage 
 were occupied by a multinodular myomatous uterus. During separation of the 
 l)ladd('r from the surface of tlie tumor it was accidentally opened in two ))laces. 
 the ciTor being due to not getting the propel" layer of cleavage, .\fter I'einoxal of 
 the uterus the bladder openings were closed, and an extraperitoneal drain in- 
 troduced down to the bladdei'. The highest postojx'rat ive temperature was 
 1(X).5° F. The |)atient was si lipid and rat hei- inat ional toi- se\-ei'al da\'s al'tei' the 
 opei'ation. She insisted on going home on the thirtieth day, aithoiigh still weak. 
 In ( "ase I'JSC)! there was a \cry large myomatous ulei'us (see p. 239). 
 .\ttei" libei'ation of omental adhesions liie tumor was lifted up and found to l)e 
 lirnily adherent in the pel\is. ( )n ac<-ount of its soft iiess sai'coina was suspected. 
 Satisfactory exposure was impossible, and during an at tempt to dissect the tumor 
 free on the left side the l)ladder was aceideiitally opened. It had been lifted
 
 374 MYO^FATA OF THH X-TERUS. 
 
 hi^h uj) and Ix'cii jjiishcd fonvanl by a retrovesical nodule. After removal of 
 the uterus the l)ladder was controlled with continuous catgut and the pelvis 
 drained. Th(> ])atient was catheterized at first every hour. She was improving 
 rapidly when discharged on the thirty-first day. 
 
 In San. Xn. 1049 the i)atient was sixty-five years of age and white. The 
 large myomatous uterus, which exteniled almost to the costal margin, was firmly 
 anchored behind to the rectum, in front, to the bladder and anterior abdominal 
 wall. The tumor was bisected transversely, and the dense bladder and ab- 
 dominal adhesions were attacke(l from the under surface. .Many raw and 
 bleeding surfaces were left, and a hole 2 cm. in diameter was found at the apex 
 of the bladder. This was closed with catgut. The large raw area on the ab- 
 dominal wall was ai)proximated as far as possible. The patient made a good 
 recovery. It is of interest to note that an exploratory oi)erati(>n had been done 
 thirty years before and the case pronounced inoperable. 
 
 In the chapter on Treatment it has been noted that few vaginal hysterec- 
 tomies have been performed, and hence the bladder injuries complicating vaginal 
 hysterectomy have been correspondingly limited. In only one cas(> was the 
 bladder accidentally opened. 
 
 In Case 2754, during reiii()\-al of a small myomatous uterus, the l)aseof the 
 bladder was o])ened for 4 cm. It was at once sutured. The patient comi)lained 
 of pain in the bladder for several days after operation, but made a good recovery. 
 
 From our study of the relation of the bladdei" to the uterus and th(^ various 
 accidents that ha\'e occurred to it during hysterectomy some ^•aluabl(■ data may 
 be derived : 
 
 (a) The bladfler should always be carefully ))ali)ated with a catheter while 
 the urine is being withdrawn on the operating table, to determine if it is of normal 
 size ()!■ not. If it reaches up into the abdomen, the incision should be made up 
 near the umbilicus. After section, a finger in the abdomen serves as a guide as to 
 the location of the bladder. 
 
 (h) In freeing the bladdei' from tlie uterus very little force should be used 
 with the stalk sponge, and if it seems fixed, it is better to carry out the dissection 
 with the knife, the cutting edge being, of course, directed toward the tumor and 
 not toward the bladder. 
 
 (c) After all hysteromyomectomies it is imj)oi-tant to carefully examine the 
 bladder and rectum to see if they have been injui'ed. 
 
 (d) If the bladdei' is accidentally opened, the tear iiia>" be closed with inter- 
 rupted or continuous catgut sutures, catching uj) all but the mucosa. This row 
 of sutures should be coxcrcd in with a continuous line Pagenstecher or silk suture. 
 The greatest care imist be exercised not to pierce the vesical mucosa, as the 
 suture might form the nidus for a sul)se(jueiit calculus. If the tear be near the 
 ureter, it is wise to outline clearly the ureter by means of a ureteral catheter while 
 the sutures are being introduced; and if the ureteral orifice is too close to the 
 incision, a slit 1 cm. long may be made in it.
 
 THE BLADDER IX CASES OF UTERINE MYOMATA. 375 
 
 (e) As injuries of the blatlder ure usually associated with dense pehic ad- 
 hesions, it is frequently advisable to drain through the vagina. 
 
 (/) We realize the shortcomings of a retention catheter, hut notwithstanding 
 its tlrawl)acks, we unhesitatingly reconnnend its use for the fii'st two or three 
 days in cases in which the bladder has l)een accidentally opened. 
 
 {(J) Injury to the bladder, if recognized and attended to, does not materially 
 increase the risks. In only one of our cases did death follow, and here the fatal 
 issue was due to innnediate shock. 
 
 Injuries to the bladder are bound to occur, es])ecially in the presence of 
 dense adhesions, where the viscus is displaced, and we deem ourselves fortunate 
 that this accident has not befallen us more freciuently. In desperate cases, when 
 the patient is exceedingly weak or when alarming hemorrhage is going on, the 
 speedy removal of the uterus is infinitely more important, even if the bladder is 
 injured, than a careful dissection of the bladder with the collapse and probable 
 death of the patient before the operation is completed. As our class of myoma 
 cases is becoming more and more difficult each year, we nnist naturall}^ expect 
 a continuance of a certain number of injuries to the l)ladder. 
 
 Hysteromyomectomy with the Subsequent Passage of a Silk Ligature from a 
 Uterine Artery into the Bladder. 
 
 Case F., seen in consultation with Dr. A. Trego Shertzer at the Church Home 
 and Infirmary, August 10, 1902. The operation was very difficult. Thei-e was 
 a very large strangulated umbilical hernia and a huge myomatous uterus with its 
 lower portion molded to the pelvis (Fig. 94, p. 120). The patient made a good 
 recovery. 
 
 Months after she l)rought to one of us fCullen) a small loop of thread which 
 she had just passed from the bladder. It was a silk ligature from one of the 
 uterine art(Ties. The loop was perfect, and the two ends of the ligature were 
 intact. The ligature had e\idently lain in the bladder some little time, as it was 
 partly incrusted. The stunij) of one of the uterine arteries had evidently lain 
 in contact with the bladder, and the ligature had gradu;dly worked its way 
 through. It had occasioned the patient little or no incon\-enieiice. 
 
 A Vesical Calculus Associated with Uterine Myomata. 
 
 Vesical calculus was noted in only one instance. In Case .")9I() tlie patient, 
 aged fifty-two, white, had a lai'ge myomatous uterus whidi almost lillc(l the ab.- 
 domen. For the ])revious year she had had attacks of pain in the bladder and 
 fre(|uent mict ui'ition, licniat ui'ia, tenesmus, and sudden slo|i|)age ot urine. The 
 vesical symjitoms had been almost continuous for the nine weeks pi'ioi- to opei'a- 
 tion. 
 
 A catheter introduced into the blaijdei' at once came in contact with a cal- 
 culus. An attempt was made to reinoxc the stone tlii-ough the urelhia, but it
 
 376 MYOMATA OF THK ITKRIS. 
 
 was foiiiul necessary to extract it throujili a vesicovaginal incision. The opening 
 was at once closed, and a retention catheter introduced. Recovery was satis- 
 factory. 
 
 Bladder Symptoms Attributable to the Myomata. 
 In the u;reater nuniher of the cases the patient gives no history suggestive of 
 bladder disturbance. In a certain small percentage, however, definite vesical 
 symptoms are present. These and theii- older of frequency may be stated as 
 follows : 
 
 1. Frecjuent urination. 
 
 2. Frequent and painful uiination. 
 
 3. Retention of urine. 
 
 4. Loss of control. 
 
 Frequent urination is the most common bladder sym])tonL It is evidently 
 due, in many instances, to the encroachment of the myomatous uterus upon the 
 bladder, which necessitates the more frecpient emj)tyiiig of this viscus. This 
 increased frequency in micturition differs entirely from that due to cystitis. In 
 many cases there is absolutely no pain, and getting up at night to void is most 
 uncommon. Out of 109 cases in which there was frequent and painful micturi- 
 tion, only f) of the patients had to rise at night. 
 
 Frequent and Painful Urination. — There is often a feeling of discomfort or 
 weight, rather than ))ain, in the bladder during micturition. Some patients, 
 however, have definite vesical pain and tenesmus when voiding. The pain is 
 evidently due to the fact that the tumor pushes the two bladder-walls together, 
 and in those cases in which the bladder has become adherent to the tumor and 
 has been draw^n far up into the abdomen, it is impossible for it to contract prop- 
 erly and satisfactorily empty itself. This naturally tends to produce tenesmus. 
 
 Retention of Urine. — In 20 cases* partial or complete stoppage of urine was 
 noted. Sometimes there was difficulty in starting the flow, as in Case 10991; 
 in others .sudden obstruction, as in Case 12293. In Case 13016 there was acute 
 obstruction for twenty-four hours. In Case 2073 catheterization was also neces- 
 sary. The retention is undoubtedly due to the tumor shifting in such a manner 
 that the urethra or bladder is so jammed against the symphysis that escape of 
 urine is impossible. The stoj^page of urine rarely lasts over twenty-four hours. 
 It may be periodic, as in Cases oK) and 9057. When the tumor has passed high 
 into the abdomen, the tendency to retention is diminished. 
 
 Loss of Control. — In Cases 7063, 7583, 979S the patients had a feeling of pres- 
 sure on the bladder or had frecpient micturition, and at times great difficulty in 
 preventing the urine from dribbling out. 
 
 In Cases 1039, 3133, 5421, and 11587 there was at times complete loss of 
 control. In each of the 7 cases the ))ressure of the tumor on the bladder seemed 
 to be the cause of the disturbance. 
 
 ♦Retention was noted in Cases 516, 149.5, 1499, 1716, 2073. 3038, 4022, 4168, 5332, 5987, 6854, 
 6992. 9057, 9612, 10969. 10:)ni, 121.')4. 122.")7. 12293. and 13016.
 
 THE BLADDER IK CASES OF UTERINE MYOMATA. 377 
 
 Cystitis Associated with Uterine Myomata. 
 
 Despite the fact that the liladder may l)e displaced and altered in its shape by 
 the myomata, vesical inflanunation is rarely found. In only two of our cases 
 was it particularly prominent. 
 
 In Case 4599 there was a marked cystitis on admission, and in Case 11013 a 
 constant dribble of offensive urine. 
 
 The fact that the bladder mucosa is usually normal in myoma cases has a 
 definite surgical import. If the bladder be accidentally opened, we know that 
 if it be properly sutured the accident has in no way increased the tendency 
 toward infection.
 
 CHAPTER XXI. 
 THE URETERS IN CASES OF UTERINE MYOMATA. 
 
 1. Position. 
 
 2. Double urctci". 
 
 3. Pressure on the ureters. 
 
 4. Accidental liti'ation. 
 
 5. Injury to the ureter (lurin.ii- operation. 
 
 6. Removal of a tubei-culous kidney and ureter shortly after hysteromyo- 
 niectoniy. 
 
 7. Locating th(^ ureters during operation. 
 
 Position of the Ureters in Cases of Uterine Myomata. 
 When uterine myomata spread out from the surface of the uterus and lie free 
 
 in the abdominal cavity, as a rule, little anxiety need be felt about the ureters, 
 
 l)ut if an interstitial myoma spreads 
 out between the folds of the broad 
 ligament, the ureter may be dis- 
 lodged, and at times lie on the sur- 
 face of the tumor. A similar con- 
 dition is occasionally noted when 
 cerx'ical myomata reach large pro- 
 portions. 
 
 Fig. 203 shows a splendid example 
 of a dilated ureter which has been 
 lifted up with the pelvic peritoneum 
 and lies on the side of the tumor. 
 Were the operator not on his guard, 
 the vessel might very readily be mis- 
 taken for a lymphatic and clamped 
 and tied. In this case (Gyn. No. 
 2809) the whole abdomen was filled 
 with a nuiltinotlular myomatous 
 uterus. The tubes and ovaries were 
 drawn up high on either side. Both 
 ureters were lifteil high out of the 
 
 pelvis. The left ureter was ligated, but not cut. Later, the mistake was 
 
 recognized and the ureter liberated. The ureter on the right .side was detected 
 
 early in the enucleation and was not injured. 
 
 378 
 
 Fig. 263. — Dislocation and Dilatation of a Ukktkr 
 DUE TO A Large Myomatous Uterus. 
 
 Gyn. No. 2899. Only a small part of the uterus, 
 which filled the entire abdomen, is seen. To the right 
 is the right round ligament. The right ureter is much 
 filiated, and was displaced so high that a portion of it was 
 brought out of the abdomen with the tumor. It might 
 readily have been mistaken for a dilated lymi)hatic vessel 
 (see Fig. .57, p. 7.3) and severed. The congeries of 
 vessels just above the loop of the ureter are the ovarian 
 vessels. 
 
 Both ovaries and the left ureter were also lifted high 
 into the abdomen.
 
 THE URETERS IX CASES OF UTERIXK MYo.MATA. 
 
 379 
 
 lifted upward and forward, and crosses just at the point 
 where one would naturally tie the right ovarian vessels. 
 
 In Case 3133 the abdomen was tilled with a myomatous uterus. The fundus 
 lay near the ribs in the median liiu\ 
 The l^ladder rose S cm. above the 
 symphysis, and the ovarian veins 
 were greatly distended. The sig- 
 moid was adherent to the tumor, 
 about S cm. above the pelvic brim. 
 After this had been freed, the left 
 ovarian vessels were ligated. The 
 left ureter was found adherent to 
 the posterior surface of the tumor, fig. 264.— a m^..ma in ihk bkoau li(;amknt displac- 
 and was freed. The left uterine ves- ^'^^ '^^'^ ^^^"'^ ^'^^''™ ^^'^•'^" -'^^ fobward. 
 
 Gyn. No. 3971. Occupying the right broad ligament 
 Sels were then ligated. The right is a laVge myomatous nodule. The right ureter has been 
 
 ureter as it entered the broad liga- 
 ment was compressed, and its upper 
 portion was about 2 cm. in diameter. It was dissected down to the bladder. 
 Fig. 2(34 shows the altered position of the ureter due to a broad-ligament 
 
 myoma. In this case (Gyn. 
 No. 3971) it was so situated 
 that it might readily have 
 been tied with the right 
 ovarian vessels. 
 
 In Fig. 265 (Case 6017) 
 we see the bladder and left 
 ureter lifted high up by a 
 myoma which filled the 
 p(>l\'is and rcachcil to the 
 umbilicus. I'lic ureter was 
 recognized and carefully 
 freed. 
 
 In Case 9 I." the uterus 
 was the s(v\t of ;i diffuse^ 
 ;ideiiomyoiii:i and the right 
 o\'ary was i-ejilaeeil by a 
 large cyst eoiit.'iiniiig can- 
 cerous ai'eas. l".;ieh ureter, 
 aftei' i>assiiig o\-ei' the |)el\ic 
 bi'iiii. r.aii almost a str.aight 
 course to a i)oiiil near the 
 coi'respondiiig uterine horn. 
 Both urelei's were dissected 
 le I'einowd of the litems 
 
 Fig. 265. — Dislocation Upward and Forward of tiik Lkit Urk- 
 TKR BY a Myomatous Utkrus. 
 
 Gyn. No. 6017. The myomatous uterus reaches the uinhiliciis, 
 and the greatly lengthened-out uterine cavity can be traced by tlir 
 dottefl lines to the vagina. 
 
 The left ureter pa.sses over the surface of the tmnor at the level 
 of the pelvic lirim, and is inserted into the bl.adder, which is lifted high 
 up into the abdomen. In reality it docs not enter the ix'lvi- al all. 
 
 free for a distance 
 was bemm. 
 
 S to 10 cm. before ll
 
 380 
 
 MYOMATA OF THE UTERUS. 
 
 Fig. 266 shows a ureter j^assing directly across from the pelvic brim to the 
 bladder without di{)ping into the pelvis. 
 
 Dislocated ureters were also iiottxl in Cases 3281, 4168, and 8391. This by 
 no means represents the total number, but only those especially mentioned in 
 the notes made at operation. 
 
 Dr. J. H. Mason Knox,* in 1000, ))ublished an excellent article on the effect of 
 
 Fund ul. 
 
 r TopofWadd 
 
 ^ <-^ /" Lpening of ureter 
 Cervix 
 
 Fig. 266. — Marked Di.si.oc.vtiox ok the Ureters Where the .\bdomen was Filled with a Myomatous 
 
 Uterus. 
 
 The fundus is situated high in the abdomen, and the right ureter is seen plastered on the surface of the tumor. 
 Starting near the fimbriated end of the tube is the peritoneal reflection. This can be followed backward to a 
 point a short distance above the sacral prominence, .\nteriorly, it reaches a little below the umbilicus; thus more 
 than half of the tumor is extraiieritoneal. 
 
 The blatlder is raised high up, and the right ureter passes directly across the pelvic brim to the bhadder. The 
 left ureter is seen at a slightly higher level, as indicated by the dotted lines. 
 
 This operation was rendered more difficult from the fact that the lower portion of the myoma filled the pelvis 
 so snugly. (After Howard A. Kelly.) 
 
 pressure of myomata on the ureters, and discu.ssed fully most of those cases that 
 had been observed in the g}'necological department of the Johns Hopkins Hos- 
 pital prior to that date. 
 
 * J. H. Mason Knox, Compression of the Ureters by Myomata Uteri, Amer. Jour. Obst., 1900. 
 vol. xlii, No. 4.
 
 THE URETERS IX CASES OF UTERINE MYOMATA. 
 
 381 
 
 Double Ureter. 
 In case C. H. I. 949, while dissecting out the left ureter, we found two ureters 
 instead of one. They ran side by side to within about 1.5 cm. from the bladder, 
 and then entered the bladder as a single ureter. It is well to bear in mind the 
 possible existence of a double ureter. If there is a double ureter and one is 
 ligated, the portion of the kidney connected with the ligated ureter will naturally 
 be thrown out of function. 
 
 Pressure on the Ureters Exerted by Uterine Myomata. 
 
 In Chapter XXIII (p. 396) we have described the condition of the ure- 
 ters in cases of uterine myomata coming to autopsy. Here we will briefly refer 
 to the deviations from the normal noted at operation. 
 
 Before performing an abdominal hysteromyomectomy the urine is carefully 
 examined, and if any marked evidence of renal infection exists, when possible, 
 operation is avoided. Consequently, we would not expect to find any serious 
 alterations in the ureters in the 
 operable cases. 
 
 As a result of the pressure of the 
 myoma, one or both ureters may be 
 so flattened or kinked that above 
 the point of obstruction a hydro- 
 ureter develops.* In our experience 
 the right ureter is more frequently 
 implicated than the left. In a few 
 cases, as in No. 2899 (Fig. 267) and 
 8391, both ureters were dilated. 
 
 The obstruction may be in the 
 pelvis or just at the pelvic brim. 
 The size of the ureter will depend, 
 of course, on the degree of obstruc- 
 tion. It may be twice its natural 
 size, as in Case 6418; it may reach 
 1.3 cm. in diameter, as in Case 7597, 
 or 1.8 cm., as in Case 8391. Occa- 
 sionally the size may be enormous, 
 as in Case 10204, in which the left 
 
 ureter above the jx'h'ic bi'iiii foniicd a sac 4 ciii. in (liaiiictci-. Sudi a large 
 ureter may at first be mistaken for a loop of small liowcl, l)ul il has no mesen- 
 tery, has thin walls, and contains transparent fluid. 
 
 Fig. 267. — Hydroureter Due to Pressure. 
 
 Gyn. No. 2899. The abdomen was, to within 4 or 5 
 cm. of the ensiform cartihiRe, lille<l with a hard myoma- 
 tous uterus. Botli ureters were lifted high out of the 
 pelvi.s. The left was accidentally tied, but later discov- 
 ered and released. 
 
 The sketch shows the pelvis after removal of the 
 uterus. The right ureter is markedly dilated; the left 
 also to a limited degree. 
 
 * Hydroureter was noted in Cases 2708, 2899, 3426, 4020. (ills, T.y.V, 
 and 10462. 
 
 'M7. 7s;v2, s;iin. 10204.
 
 382 MVOMATA OF THE UTERUS. 
 
 Accidental Ligation of the Ureter During Hysteromyomectomy. 
 
 A\'c liave recoiils of several cases in which one ureter was accidentally tied, 
 oitiicr when the utorino artery was being controlled at the side of the cervix or 
 when, owing to marked (lisj)laceinent, the ureter lay close to the point at which 
 the ovarian ve-^sels were ligated. 
 
 In Case 659 a large, densely adherent cystic myoma filled the abdomen. It 
 was impossible to remove the growth, but the ovarian and uterine vessels on both 
 sides wereligatefl. The patient did fairly well after the operation, but died sud- 
 denly on the eighth day. Aut. No. 188 showed a very large cystic myoma and 
 general anemia; one kidney was the seat of hydronejjhro.^is, the other of pyelo- 
 nephi-osis with renal abscesses. The left uretcn- was occluded by a ligature. The 
 abdominal condition was in itself suHicieiit to cause the fatal issue. l)ut death was 
 undoubtedly hastened by tlie accidental ligation of the ureter. 
 
 In Case 2899 the entire abdomen was filled with a myomatous uterus. The 
 tubes, ovaries, and ureters were lifted high out of the pelvis. Both ureters were 
 dilated. The left was acci(l(>ntally ligated. but the error was later discovered, 
 and the ureter was rc^leased. The jiatient recovereih 
 
 In Case 3272 a globular myomatous uterus filled the i)elvis. The right ureter 
 was tied. Later, the .mistake was discovered and the ureter released. The 
 patient recovered. 
 
 During the removal of a large myomatous uterus complicated by an ovarian 
 cyst in Case 6344 (Fig. 242, )). 347) the left ureter was accidentally included in the 
 ligature controlling the left uterine vessels. After I'emoval of the uterus the left 
 ureter was located at the pelvic brim, and followed down to the cervix. After 
 the ureter had been freed, the uterine vessels were retied. The i^atient recovered. 
 
 In Case 8321 the myomatous uterus, which filled the jielvis, was removed 
 from left to right. During ligation of the right uterine artery the ureter was 
 included. The error was discovered and rectified. The patient recovered. 
 
 In C. H. I. R.. ()ctol)er 24, 1902, the patient was very anemic. The pelvis 
 was filled with a inultino(hilar myomatous uterus, and ()ccuj)ying the vagina was 
 a large gloljular submucous nodule. On the right side the ovarian vessels were 
 controlled with the utmost difficulty on account of their distorted position. After 
 removal of the uterus the right ovarian .'^tump was examined and the ureter found 
 included in the ligature. It was released without much (HHicu.lty, and the j)atient 
 made a perfect recovery. 
 
 From the forc^going we see that in only one case did we fail to discover the 
 ligated ureter before the abdomen was closed. In this case death followed. 
 Temporary ligation does not seem to matei'ially injure the ureter. 
 
 Injury to the Ureter During Hysteromyomectomy. 
 In two of our cases the ureter was accidentally cut during the hysteromyo- 
 mectomy. In both cases a uretero-ureteral anastomosis was done, in one case 
 with failure, in the other with success.
 
 THE I'RETEKS IX CASES OF UTERINE .MVOMATA. 
 
 383 
 
 Gyn. No. 11989. 
 
 H y s t e r m y o 111 c t o m y ; accidental e u t t i n ,«; o f t li e 
 left ureter; u r e t e r o - u r e t e r a 1 a 11 a s t o 111 o s i s ; failure; 
 subsequent r e ni o \' a 1 of the left k i d n c 3^ ; recovery. 
 
 R. R., wliite. aged thirty-five. Admitted March 23, 1905. For several 
 years she had had frequent urination and had Ijeen forced to get uj) several times 
 at night to void. There had been pain and pressure over the bladder. 
 
 During the I'emoval of the myomatous uterus, which reached to tlie um- 
 bilicus, the left ureter was cut. The ureter was at once anastomosed into itself, 
 and an extraperitoneal drain carried down to the ureter. 
 
 On the day following it was evident that the urine from the left kidney was not 
 reaching the l)lad(ler. and as none escaped along the extraperitoneal drain, the 
 vaginal vault was opened, nitrous cxid anesthesia being emijioyed. A small 
 
 Fig. 2fiS. — Displaced Ricnr I'rktkr Mistaken for a Dit.ated Vein; Ligated and Cut; Successful Enu-to- 
 
 siDE Anastomosis. 
 
 Gyn. No. 1946. The dotted line indicates the course of the uterine cavity. The right ureter had been lifted 
 high on the .side of a myomatous nodule, and being mistaken for a vein, was ligated and cut. 
 
 a indicates one of the two traction sutures by means of which the upper end of the ureter was drawn down 
 into the slit on the side of the lower end of the ureter and held in place until the ten approximation sutures had been 
 introduced and tied. The traction sutures were then removed as they entered the lumen of the ureter, and later 
 might have become incrusted. 
 
 amount of blood-tinged fluid escaped. The jiatient gradually improved. An 
 (ether) examination revealed the fact that the fistulous tract leading from the 
 previous ureteral anastomosis had made its way down and out through the 
 stiim|) of the cervix. 
 
 It was thought that it might be possil)le to go in extraperitoneally and 
 reanastomose the uretei'. There was, howe\'er. too much jxTi-iireteritis lo 
 warrant such a j^rocedure. The urine from the hl.-idder and fi'oiii the ih'ainage 
 tract had been carefully exainine(l for urea. Il was found that ihe ligiit ki(hie>" 
 was secreting from 1000 to ]2()() c.c. with about 10 gm. of urea lo the htei-. This 
 was thought sufhcient to allow the i-eiiio\al of ihe lel'l ki(hie\-. and as the |»alient 
 refused to go home and wait for two oi- thi-ee months to see if the listulous tract 
 would close of its own accoi'd, remo\al of the h'ft kidney was uuih'i'takeii. The 
 highest postoperative temperature was 100° V.. ;ind the patient made a good 
 recovery.
 
 384 MYO.MATA OF THE UTERUS. 
 
 Gyn. No. 1946. 
 
 A cci dental severance of the displaced right ure- 
 ter during h y s t e r o ni y o m e c t o m y . Successful u r e t e r o - 
 ureteral anastomosis (Fig. 268). 
 
 F. M., aged twenty-five, colored. Admitted April 26; discharged June 
 13, 1893. During the removal of a large myomatous uterus what appeared to 
 be a large vein on the right side was ligatetl and cut, when it was found to be the 
 ureter. The upper end of the ureter was invaginated into the opening made in 
 the side of the lower portion, the invagination being accomplished by means of 
 two temporary sutures (Fig. 268). Accurate approximation was now obtained 
 with ten tine silk sutures. A gauze drain was inserted in the pelvis and the 
 patient made an uiiintcrrujjted recover}'. 
 
 Removal of a Tuberculous Right Kidney Shortly after a Hysteromyomectomy. 
 The following case .shows clearh' what extensive operations even a weak 
 patient may be able to stand. 
 
 Gyn. No. 12866. Path. No. 9755. 
 
 L. T.. aged thirty-nine, white, married. Admitted April 23; discharged 
 July 26, 1 *)()(). The ])atient entered the hospital complaining of pain in the 
 bladder, rectum, and back. 
 
 Three years before she had been under treatment on the surgical side of the 
 hospital for tuberculosis of the right hip. At that time the joint was aspirated 
 and a cast was put on. She remained in the hospital for three months. 
 
 Urination had been very fre([uent and painful for the last year, and there was 
 much vesical tenesmus after voiding. 
 
 Cystosco])ic examination revealed extensive ulceration of the vertex pos- 
 teriorly, and also on the right side. The right ureteral orifice was nmch reddened. 
 The left ureteral orifice w^as retracted, and from it pus was exuding. 
 
 On jx'lvic examination the right ureter was palpable, hard, and {prominent. 
 A hrmly fixed myomatous uterus filled the pelvis. 
 
 On section of the abdomen the omentum was found adherent. Many ad- 
 hesions were found in the region of the cecum, and several small tubercles were 
 detected on the cecum and scattered over the loops of small bowel in the vicinity. 
 The appendix was not seen. After much difficulty the adluTcnt uterus with its 
 appendages was removed. 
 
 The right ureter was much thickened and indurated. The right kidney was 
 movable, and about twice its natiu'al size. The liver was fixed to the anterior 
 abdominal wall. The left kidney was normal in size. The tuberculous process 
 in the abdomen seemed to be limited to the right iliac fossa. 
 
 Path. No. 9755. Examination of the pelvic contents revealed interstitial 
 and submucous uterine myomata, tuberculosis of the endometrium, tuberculosis 
 of both tubes, and general pelvic peritonitis.
 
 THE URETERS IX CASES OF UTERIXE MYOMATA. 385 
 
 Right Nephrectomy , — Thirty-six days after the hysteromyomectomy 
 the right kichiey was removed, the sufficiency of the excretion from the left 
 kidney in the meantime having been fully established. 
 
 When the patient left the hospital, the okl sinus at the hip had not yet en- 
 tirely healed. The bladder mucosa, although still red and showing many tu- 
 bercles and some areas of superficial necrosis, was considerably improved. 
 
 Location of the Ureters During Hysteromyomectomy. 
 
 The one question that haunts the operator most after difficult hystero- 
 inyomectomies is: Have I tied one or both ureters? With the gradual develop- 
 ment in the operative technic the operation has become not only easier, but also 
 more simple, and if the operator is in the least worried, he can answer his question 
 at once before the abdomen is closed. We now make it a rule to examine care- 
 fully the ureters in any case in which there is the slightest possibifity that they 
 have been injured. 
 
 In some of our early cases the ureters were catheterized prior to operation. 
 In the first place this is a doubtful procedure, since a foreign body in the 
 ureter for a half to an hour or more may cause injury to it, and, in the second 
 place, because in the very cases in which we most desire to outline the course of 
 the ureters, they are so displaced and distorted by the myomata that catheteriza- 
 tion of them is almost impossible. 
 
 One of us (Kelly) years ago noticed the vermicular contraction of the ureters 
 on manipulation. We accordingly gently stroke the peritoneum at the pelvic 
 brim, just where the ureter should be, with a pair of blunt forceps, and the ureter 
 will usually be seen to begin its snake-like contraction. It is then dissected out 
 down to the cervix, care l)eing taken not to loosen it from its j)eritoneal cover- 
 ing, as its blood-supply might be interfered with. This point has been very 
 clearly brought out by Sampson.* 
 
 The opposite ureter is then exposed in the same way. 
 
 One of us (Cullen) found it necessary to isolate the ureters in this maimer in 
 three cases in a single moining. 
 
 Occasionally, a fold of pei'itoneum may simulate a ureter, but it lacks the 
 vermicular contraction and is not covei'ed with the delicate tracery of \'e.ssels so 
 characteristic of the ureter. 
 
 Sometimes the peritoneum of the jx'lvis over the ureter has become densely 
 adherent to the myoma, as in Case 7()4!>, oi' to an accoui]ianying cyst, as in Case 
 71S1. It is then liable to be much tliickeiieil. and detection of the ureter is luucli 
 more difficult. 
 
 If the operator is unable to locate the ureter and feels i-el;iti\-el\- sure that it 
 has been tied, as a last resort he can split the M.adiler ;tud iuti-oduce a renal 
 catheter through the ureteral orilice. This will not lengthen the oju'ration over 
 fifteen or twenty minutes, and may be a life-saving procc'dure. The ureters were 
 located in this maimer in Cases 3113 and 3.")!)(). 
 
 *J. Sampson, .Inliiis Hopkins llosp. liriU., I'.tOl, xv. p. .10. 
 25
 
 CHAPTKR XXII. 
 
 THE RECTAL FINDINGS IN CASES OF UTERINE MYOMATA. 
 
 Adhesions hctwccii the utci'us and rectum. 
 Upward di.<ii)la('eni('nt of the rectum. 
 Injury to the rectum durinii; o|)eration. 
 Resection of a portion of the sigmoid. 
 Perforation of the rectum found at autopsy. 
 Passage of an enema into the abdominal cavity. 
 Rectal prolapsus^ 
 Perirectal abscess. 
 Carcinoma of the sigmoid. 
 
 Adhesions Between the Myomatous Uterus and the Rectum. 
 In a moderate number* of the cases slight or dense adhesions are found between 
 
 the tumor and the rectum. 
 
 Fig. 269. — Densk Adhesions Between the 
 Sigmoid \sd a Myomatous UTERts. 
 Gyn. No. 1499. The sigmoid is lifteil 
 up and densely adherent to the posterior 
 surface of the uterus. The appendix is also 
 firmly glued to the posterior surface of the 
 tumor. 
 
 riiese adhesions may occur when the appendages 
 are normal, Init are usually associated with 
 general pelvic adhesions and are particularly 
 jn'oiie to occur when a pelvic abscess exists. 
 The rectal adhesions may be low down near 
 the cervix or may l)e limited to the sigmoid 
 flexure. Fig. 269 is a good example of a sig- 
 moid densely adherent to the posterior sur- 
 face of the myomatous uterus Fig. 270 
 shows dense adhesions of the sigmoid and 
 also of the small l)owel to a tubo-ovarian 
 abscess complicating a myomatous uterus. 
 For adventitious vessels passing from the 
 rectum to the myomatous uterus .see p. 42. 
 
 Upward Displacement of the Rectum by Uterine Myomata. 
 If the myoma pushes out beneath the me.so.sigmoid, with the continued growth 
 of the tumor the sigmoid will be carried up on the surface of the myoma. This 
 was the ca.se in (lyn. No. 1499 (Fig. 2(39j. In Case 4S2S the redundant portion 
 of the sigmoid was carried uj)ward beyond the umbilicus. In some cases it seems 
 as if the jjelvic structure were di-agged upward en ///a.s.se by the myomatous uterus. 
 
 ♦Rectal ndhesions were noted in Gyn. Nos. 2207, 2638, 2706, 2800, 3107, 33.37, So.Vi. 3661. 
 3844. 4097, 4334. 4370, 5014. 5325. 6607. 6863. 7266. 7511, 7.")97, 8115, 9118, 9694, 9769, 10749A, 
 11647, 12520, 12779, 12841, C. H. I. 382. 
 
 386
 
 THE RECTAL FINDINGS IN CASES OF UTERINE .MYOMATA. 
 
 38^ 
 
 For example, in Case 4097 l)oth the bladder and rectum were carried high into 
 the abdomen. In Case 1682 the bladder reached 15 cm. above the symphysis, 
 while the sigmoid flexure had been carried out of the pelvis and lay over the 
 surface of the tumor. In Case 3133 the condition was even more pronounced. 
 Xot only had the bladder and the rectum been carried upward, but oik; ureter 
 was adherent to the posterior surface of the tumor. 
 
 Injury to the Rectum During Operation. 
 
 Injury to the rectum during operation has occurred in several cases. In all of 
 them the myomatous uterus 
 has been firmly adherent to 
 the rectum, and during the 
 liberation the bowel has been 
 torn. 
 
 The rectal tears are natur- 
 ally divisible into two groujjs: 
 
 1. Tears involving the 
 muscular coats only. 
 
 2. Tears extending into 
 the lumen of the rectum. 
 
 Tears Implicating the Cir- 
 cular Coats. — Tears of the 
 longitudinal and in some in- 
 stances also of the circular 
 coats were noted in Cases 
 2706, 4097, 4370, 5325, 6607, 
 SI 15, and 12841. Some were 
 very slight in extcMit, others 
 5 cm. long and 4 cm. broad. 
 
 Tears into the Rectal 
 Lumen. — In (i\c cases the 
 lumen of the bowel was e\- 
 |)ose(l (liiriiit!; relii()\-al of the 
 tumor — four times accident- 
 ally, and once when it was deenn'd neeessai'v to i-eino\e a piece of the bowel. 
 
 In Case 9694, after bisection and i'emo\al of the densely adherent myomatous 
 uterus, a hole 1.5 cm. in dianietei' was torn in the rectum dui-iim the libeiation of 
 adherent right ap|)endages. 
 
 In Case 12520 the myomatous utei'us was en\'elo])ed in dense jiehic ad- 
 hesions and there was a |)elvic abscess. In libei-ating tlie inllamed left append- 
 ages a teai\ two inches long, was made in the rectinn. 
 
 The injury to the bowel in Case 501 I was veiy extensive ( l''ig. 271 ). During 
 
 I'lG. 270. — Dknmk .\i)Hksions of thk Sicmoik Fi.kxi rk and ok a 
 Loop ok Small Howkl to a Tubo-ovariax .\b8ck8.s. 
 (lyi). No. 4.370. The uterus contains several myomatous nod- 
 ules. On the left is a large tubo-ovarian abscess, to the upper por- 
 tion of which the sigmoiil and a loop of small bowel are a<lherent. 
 I'he chief difficulty in these cases consists, however, in libeniting the 
 lower part of the rectum from the abscess wall.
 
 388 
 
 .MYOMATA OF THK T'TKRUS. 
 
 removal of the iiiiivcisally adherent iiiyoinatous uterus the l)Owel wa.s torn for two- 
 thirds of its circuinferenee. The (ipeiiiiiii; was at once chjsed with fine silk sutures. 
 The operation in Case 12779 was exeeedin<i-ly ditheult as a result of the ad- 
 hesions. On the left side was a tubo-ovarian abscess, the lining of which closely 
 resembled bowel mucosa. Dui-ing libei'atioii of the ri^ht appendages the rectum 
 was opened for H inches. It was impossible to free the rectum from the cervix, 
 owing to the dense adhesions. A flap of the cervix, attached to which was a torn 
 piece of the bowel, was dissected free and turned back on the bowel to close the 
 rectal deficiency. 
 
 At ojM'i'ation in Case 11047 the ])elvic growth was thought to be carcinoma- 
 tous. Complete hysterectomy was per- 
 formed and, as the rectum was densely 
 adherent to the cervix and the tissue 
 much indurated, an elliptic piece of the 
 rc^ctum was removed with the uterus, 
 and the opening closed with a row of silk 
 sutures first, and then with a row of cat- 
 gut sutures. 
 
 Whenever feasible, it is well to get at 
 the rectal adhesions from the under side. 
 This may be accomplished by bisecting 
 the uterus (Fig. 357, p. 610), or by first 
 dissecting back the bladder and amputat- 
 ing through the cervix (Fig. 363, p. 616), 
 before tying off the broad ligaments. In 
 this way the partially ol^literated Doug- 
 las' sac is at once exposed. When it is 
 necessary to liberate the rectum and it is 
 impossil)le to dissect it free, a thin shell of 
 the tumor should be left attached to the 
 rectum. This raw area is then turned in on itself and sutured, leaving a per- 
 fectly smooth surface. This procedure was successfully carried out in Case 6607. 
 Where only the outer coats of the l)owel ar(> torn, one or more continuous cat- 
 gut sutures are all that are necessary to bring the raw surfaces together. But 
 if the lumen of the bowel is entered, the opening should be closed with fine silk or 
 Pagenstecher sutures, and then reinforced with a second continuous suture of 
 catgut. A vaginal drain should then be introduced for safety. It should be 
 very small, and so placed that it does not lie on the sutiu'e line, as it may h^ad to 
 suppuration and the development of a fecal fistula. 
 
 Under no circumstances should rectal enemata be oi-dered where an incom- 
 plete or coni))lete rectal tear exists. 
 
 In all of these cases the rectal wounds healed pei'fectly, and the ])atients 
 made a good recovery. 
 
 Fig. 271 .^An Extensive Rectal Tear. 
 
 Gyn. No. 5014. During the removal of a very 
 adherent myomatous uterus the bowel was torn 
 for two-thirds of its circumference. The opening 
 in the rectum was sutured, and the cervix carefully 
 covered over with peritoneum The patient re- 
 covered satisfactorily.
 
 THE KKCTAL FINDINGS IN CASES OF UTERINE MYOMATA. 
 
 389 
 
 Resection of a Portion of the Sigmoid and Removal of a Myomatous Uterus. 
 The nuiltinodular iiiyoniatous uterus (Fig. 272) was of moderate size. On the 
 right side was an ovarian cyst; on the left, a tuho-ovarian abscess, adherent to 
 
 Tubo- ova rian 
 abscess 
 
 Fig. 272. — A Multixodulak Myomatous Uterus, Complicated by an Ovarian Cyst on the Right and a 
 Densely Adherent Tubo-ovarian Abscess on the Left. 
 
 Gyn. No. 8738. Path. No. 49.35. The uterus contains several myomatous nodules; it measures 8 x 10 x 12 
 cm. The cyst on the right was 16 cm. in diameter, and had a twisted pedicle. It was multilocular and had 
 papillary masses springing into its cavity. 
 
 On the left side is a t\ibo-ovarian abscess, densely adherent to the small bowel, and jilastered down to the 
 rectum. For the intimate relation between this inflammatory mass and the sigmoid see Fig. 273. 
 
 Tub 
 
 Fk;. 273. — .\ Tiito-dVMd \N ,\hm 
 
 /Sigmoid 
 
 IV AimiKKNT to thi: Sii;m()II( I'i.kxirk. 
 
 Gyn. No. 8738. Path. No. 4!K{.'i. For the Reneral relations of the absees.s see Fig. 
 
 The absccis sac 
 
 has been cut in two. To the left is a cros.'s-section of the greatly thickened tube. The two large irregular 
 cavities are loculi of the ab.scess and are lined with granulation tissue. a is a snudi abscess surrounded by 
 dense new connective tissue. The bowel at this point is .so intinuitely blended with the abscess-wall that it 
 would bo absiiliitel.N- iiii|>o»iblr In di>sccl il ofT. 
 
 tlie small howcl and sigmoid (lexiirc So dense were I he adhesions of the 
 
 moid
 
 390 MVO.MATA OF THE UTERUS. 
 
 (Fig. 273) that a n'scction of a ixiition was necessary. The recovery was nat- 
 urally slow. 
 
 Gyn. No. 8738. Path. No. 4935. 
 
 A. H., single, aged thirty-seven, white. Admitted May 10; discharged 
 August 6, 1901. 
 
 Three years ago the patient had an attack of abdominal pain, which was 
 supposed to be (hie to api)endicitis. Six months later she had a similar attack, 
 accompanied l)y an inability to void. About this time a small tumor was noted 
 in the left side. 
 
 Operation, May 11, 1901. Hysteromyomectomy; resection of a portion of the 
 sigmoid flexure. The uterus was synunetrically enlai'ged. This, together with 
 the ovarian cyst on the left side, was removed. In order to enucleate the tubo- 
 ovarian mass on the left side it was necessary to resect about 12 cm. of the sig- 
 moid flexure. A gauze drain was carried down through the inguinal incision to 
 the ]K)int of resection. The j)atient was much shocked. After the operation the 
 patient hiccoughed a good deal and had much nausea and abdominal pain. It 
 was impossible to move the bowels. On the sixth day an inguinal colostomy 
 was done in order to relieve the obstruction. The patient improved rapidly. 
 Several days later an attempt was made to close the fistulous opening under 
 cocain. but the stitches tore out. The patient made a slow recovery. 
 
 Perforation of the Rectum Found at Autopsy, Nine Days After Hysterectomy 
 
 FOR A Densely Adherent Myomatous Uterus, Associated with 
 
 Pyosalpinx and an Ovarian Abscess. 
 
 The accomi)anying history does not render it clear whether the rectal per- 
 foration was a result of the operation or merely a ])art of the ulcerative process 
 found in other portions of the bowel. Had it been due to the operation, the acute 
 manifestations would in all probabihty have developed earher. 
 
 Gyn. No. 5302. Aut. No. 954. 
 
 E. H., single, aged forty-six, colored. Admitted May 29; died June 19, 
 1897. 
 
 The lower two-thirds of the abdomen was filled with a solid tumor, irregular in 
 outline. Hysteromyomectomy was performed. The appendix was involved 
 in an abscess. Th(>re were dense adhesions to the pelvic floor, rectum, colon, and 
 anterior abdominal wall. The operation was a very diflicult one. 
 
 After operation the urine showed many casts — an exacerbation of an old 
 nephritis. Saline infusions were given twice daily. There were nausea and 
 vomiting, the feces began to pass involuntarily, and the patient died in a coma- 
 tose condition on the ninth day. Her highest postoperative temperature was 
 102° F. on the day of her death. 
 
 Aut. No. 954. On section of the abdomen perforation of the sigmoid flexure 
 was found. There were a localized purulent ])eritonitis and an acute general
 
 THE RECTAL FINDINGS IX ("ASES OF UTERINE MYOMATA, 391 
 
 peritonitis, arteriosclerosis, chronic diffuse nephritis, chronic adhesive pleuritis, 
 and ulceration of the large intestine. 
 
 The Passage of an Enema into the Abdominal Cavity. 
 In Case 10749J, described in detail on p. 675, the patient suddenly collapsed 
 on the third day after a simple enema had been given. At autopsy on the follow- 
 ing day it was found that there was a hole 3 cm. long in the rectum, and through 
 this the enema had passed into the general cavity, at once setting uj) a peritonitis. 
 
 Rectal Prolapsus. 
 
 This would naturally seem to be a frequent accompaniment of uterine myo- 
 mata, but it was noted only twice in our series. 
 
 In Case 5987, in which the uterus had been converted into a nodular tumor, 
 11 X 12 X 17 cm., a small mass had protruded from the anus for a year. 
 
 In Case 5249 the patient had consulted her physician five years before opera- 
 tion, on account of prolapsus of the rectum, and was then told that she had a 
 uterine tumor. 
 
 Perirectal Abscesses. 
 
 Pelvic abscesses are not infrequently associated with uterine myomata, and 
 the rectum under such conditions is often implicated in the general process. The 
 two following cases are, however, very unusual. 
 
 In Case 5697, after removal of a small, densely adherent myomatous uterus, 
 which was associated with chronic salpingitis on both sides, and with a small 
 pelvic abscess, another abscess was accidentally discovered behind the rectum, 
 just as the abdomen was about to be closed. This sac was wiped out and drained 
 through the vagina. Had this abscess not lieen (Hscovered, recovery might have 
 been greatly retarded. 
 
 In Case 6199 a small myomatous uterus was associated with peh'ic inllamiua- 
 tion. The infection had exteii(h'd to the rectovaginal septum, which was fully 
 3 cm. in thickness. 
 
 In Case 8264, shoi'tly after abdominal uiyoiiicctomy. the patient underwent 
 three successive oj)eratioiis for ischiorectal abscess. The i-ectal conditioii in this 
 case must be considered merely as a coinci(UMice. 
 
 Carcinoma of the Sigmoid Flexure Associated with Uterine Myomata. 
 
 ( )ii p. 117, in the autopsy chapl (T, arc d('scril)c(l tw(» cases of cancer ol the 
 lowci" bowel associated with ulci'inc myomata. in the liisl the carcinoma was 
 situaied in the signioiil (lexure; in the second, within 1 cm. of the anal oi'ifice. 
 in iieithei' case was operation feasible. 
 
 In the following case the patient entered with signs of obst I'uction. After 
 a lar<r<' invomatous utei'us had been renio\'e(l, ;i carciiioina of the si<j:moid (lexure
 
 392 MYOMATA OF THK UTERUS. 
 
 was discovered (Fig. 274). This was at once excised, and the patient enjoyed 
 fair health for several weeks. On her return to the hospital wide-spread 
 abdominal metastases were found. 
 
 Gyn. No. 12000. Path. No. 8447. 
 
 Acute intestinal obstruction; a large myomatous 
 uterus wedged in the j) e 1 v i s ; unsuspected a d e n o c a r - 
 c i n o m a o f t h e s i g m o i d flexure. Hysterectomy; re- 
 section of the diseased 1) o w e 1 ; t e m ]) o r a r y r e c o v e r y.* 
 
 E. S., colored, aged forty. Admitted .March 26; discharged June 9, 1905. 
 One of us (C.) saw this patient in consultation with Dr. Clement A. Penrose. 
 On admission she was suffering from intestinal o])st ruction. This was thought to 
 be caused by a myoma which had Ix'en known to exist for hfteen years. Twelve 
 years before she had had a severe attack of abdominal pain. This was sharp 
 and shooting in character, but there was no intestinal ol)struction. For the past 
 six weeks she had noticed sharp shooting pains in the al)domen, intermittent in 
 character, and limited to the left side. The bowels had not moved for several 
 days. There had been no blood noted in the stools prior to the obstruction. 
 
 The abdomen was at once opened. After removal of the myomatous uterus 
 (Fig. 274) the rectum was found to contain what appeared to be a malignant 
 growtli. The rectal tumor was loosened as carefully as possible from the cervix. 
 It lay entirely below the ])elvic brim, was approximately 7 cm. in diameter, and 
 about 8 cm. in length. The tumor was removed, and an end-to-end anastomosis 
 done. In order to give the anastomosis complete rest, a left inguinal colostomy 
 was done. The patient was very weak when r(>turned to the ward, but in fairly 
 good condition, considering the severity (;f the operation. She gradually im- 
 proved, and was discharged on June 9th. 
 
 Path. No. 8447. The myomatous uterus has l^een amputated through the 
 cervix. It is approximately 11 x 12 x 16 cm. (Fig. 274). 
 
 Our chief interest is centere(l in the growth of the sigmoid flexure. The piece 
 of tissue is 9 cm. in length. The outer covering of the bowel looks fairly normal, 
 except for some slight whitish elevations. Occupying the entire thickness of 
 the bowel near the center is a hard, light-colored growth (Fig. 274, c). This is 4 
 cm. in length, and extends throughout the entire thickness of the bowel. The 
 growth itself, with the induratetj adipose tissue sun'ounding it, is fully ;■) cm. in 
 thickness. 
 
 Histologic examination shows that the tumor of the bowel is a typical adeno- 
 carcinoma. 
 
 Gyn. No. 12204. The patient was r(>admitted on June 24, 1905. Until a Aveek 
 previous she had be(>n in good condition. The bowels, however, became con- 
 stipated: there were fre<|ueiit attacks of pain in 1 he abdomen, and during the last 
 
 *Thi.s ca.se is reported in detail in " .\ Scries of Intestinal Anastomoses," Thoinas S. Ciillen, 
 Canadian Jour, of Med. and .Siui;., .July, 190().
 
 THE KKCTAL FINDINGS IX CASES OF UTERIXE MYO.MATA. 
 
 393 
 
 seven days there had hcen no niovement. For the last two or three days the 
 abdoniinal |)ain had inci'cascd in severity, but tlicrc had been no vomiting. 
 The patient gradiudly grew weaker, and died .July 3, IIH)."). 
 
 Aut. No. 2558. The autopsy revealed a recurrenee of the careinonia at the 
 
 Fig. 274. — Cakcinoma ok the Siumoio Flexurk -Associatki) with a Myomatous Uthrvs. 
 
 Gyn. No. 12000. Path. No. 8447. After sketching a longitudinal section of the pelvis, the artist ilrew the 
 uterus and growth in the bowel from nature. The uterus measures 11 .x 12 x 16 cm., and almost completely fills 
 the pelvis, leaving little room for the hhwkler or rectum. It contains numerous interstitial and a few submucous 
 myomata. The uterine cavity is slit-like, hut at a is slinlillx- dilatril. Tlic linht palches. h, in the myoma art- 
 areas of calcification. 
 
 Occupying the sigmoid is the carcinomatous growth, c, whicli ahucsi (•iiinpl<'ii'l,\ lilN the limuMi of ihc bowel. 
 Its confines are indicated by d and d'. (After Thomas S. ('ullcn. i 
 
 point of anastomosis. Tiici'c \\'as also some ii;in'o\\ iim ol' ilic bowel ;ii this 
 point. There were mct.-istasrs in llic iicritoiiciiiii ;iiid :\ liliiiiio|iurulciii peri- 
 tonitis, apparently nrisinti in the u|)|)<'i- riiiiil MlMloniiiiMl (|ii;idr:int , :it a [joint 
 far removed from the site of the ;iii;isloniosis.
 
 CHAPTER XXIII. 
 
 ANALYSIS OF THE CASES OF UTERINE MYOMATA FOUND AT AUTOPSY 
 IN THE PATHOLOGICAL LABORATORY OF THE JOHNS HOPKINS 
 HOSPITAL FROM THE OPENING OF THE HOSPITAL, IN 1889, TO 
 JULY I, 1906. 
 
 Through the kindness of Professor W'ilhani H. Weh'h the autopsy records 
 of the Johns Hopkins Hospital have been {)hiced at our disposal From the open- 
 ing of th(> hospital, in 1889, to July 1, 1006, there have been 2740 autopsies. 
 In 2729 cases complete data are availal)le. The accompanying tabulation gives 
 the relative number of males and females, and also the ratio of white and blacks: 
 
 Males, white 1102 
 
 Males, black 659 
 
 Females, white 537 
 
 Females, black 431 
 
 It will be seen that the number of males nearly doubles that of females, and 
 that the ratio of l)lack to white women is 1 to 1.25. 
 
 As myomata are rarely present in women under twenty years of age, we have 
 only inclutled autopsies upon women of twenty or over. Of these, there were in 
 all:' 
 
 ( )n white female.s of twenty years of age or over 431 
 
 On black females of twenty years of age or over 311 
 
 Total 742 
 
 In 14S of these cases the uterus contained one or more myomata; in other 
 words, in about 20 per cent, of the autopsies in women of twenty years of age 
 or over the uterus was the seat of a myomatous growth. This is certainly a 
 remarkable showing. 
 
 The following table gives the number of eases according to decades: 
 
 In patients between 20 and ;•>() years of age myomata were found in 14 cases. 
 
 .■•iO •• 40 " •' •' ' 38 " 
 
 " " " 40 " .50 " " " " " " " 52 " 
 
 .iO " (iO " " " " " " " 29 " 
 
 (SO ■' 70 " " " " " " " 10 " 
 
 70 " 80 " " " " " " " 4 " 
 
 " 80 " 90 " " " " " " " 1 case. 
 
 Of the 14.S patients, 4'A were white and lOo black. In other words, 33.7 
 per cent, of all the black women twenty years of age or over coming to autopsy 
 had uterine myomata, wliile only 10 ])er cent, of the white ])atients were 
 affected in this way. 
 
 394
 
 AUTOPSY FINDINGS, 
 
 395 
 
 Themyoniata varictl from 0.5 to 27 x 17 x 13 cm. in diameter, the largest 
 being found at autopsy No. 1969. In some of the cases only one myoma was 
 present. Usually the uterus contained several nodules, and in one case fifteen 
 were noted. 
 
 Fig. 275 shows a small myomatous uterus removed at auto])sy from a 
 patient ninety years of age. 
 
 Site of the Tumors. — In 30.4 per cent, only subperitoneal nodules were found. 
 
 In 2().3 per cent, only interstitial nodules were noted. 
 
 In 15 per cent, subperitoneal and interstitial nodules were found. 
 
 In only a few were submucous nodules detected. Subperitoneal or inter- 
 stitial myomata, when not 
 large enough to occasion any 
 pressure symptoms, in the 
 majority of cases cause little 
 trouble and consequently the 
 patient rarely comes to the 
 surgeon for treatment. 
 
 Adhesions. — In 48.6 per 
 cent, old pelvic adhesions 
 were found. 
 
 In 7.6 per cent, pelvic 
 and abdominal adhesions 
 were noted. 
 
 In all, 56.2 per cent, of 
 the cases were complicatetl 
 by adhesions of some char- 
 acter. 
 
 Degeneration. — In 12.2 per cent, portions of the myomata were necrotic* 
 
 In 15.5 per cent, calcareous deposits were present. f 
 
 Of course, in these cases showing calcareous (.lei)osits areas of necrosis had 
 preceded ihe deposition of the calciiun salts, so that at one time or another 
 in 25 per cent, of the cases necrosis was present in one or more of the myomata. 
 
 Cystic or hyaline changes were detected in 8 cases (about 5.5 per cent.) — 
 Nos. 288, 54, 85, 188, 1113, 1206, 1969, 2080. 
 
 Fig. 275. — Myomata in Old Age. (| nat. size.) 
 M. S. Aut. No. 1823. Path. No. 5471. This uterus was re- 
 moved from a patient ninety years of age, dead of an intercurrent 
 affection. The organ is enlarged only slightly. Occupying the 
 fundus are a few small interstitial nodules; projecting from the fun- 
 dus are three small, irregular, nodular myomata, all of which appear 
 to have undergone some atrophy. 
 
 Condition of the Tubes and Ovaries noted in Myoma Cases at Autopsy. 
 
 In 5().2 per cent, of all the myctma cases pelvic or abdominal adhesions were 
 found. Naturally, tlieii, we should expect to liiul numerous minor i)athologic 
 lesions in the tubes ami o\'aries. 
 
 * .\ut. .\()K. (19, \:u], iss, 277. ;rJL', 474, .");v_'. mo. (;.■>:•;, (iso, (is't. 7(io. 7i.'l'. los.",. i7.")4. -Joso, 2()sr, 
 
 2202. 
 
 t .\ut. Xos. 2:i. (>(t. 1 17, .')!<). .")7i», (iS2, 700, 722. (101. OOS. \:\H). ]:VA7 . I'.UV.';. l.")!);<. KiOd 17(,o, 
 lS2;i l,S(i!», 1S9S, 20SS, 22;<0, 2 10 1. 2r2().
 
 396 .MVo.MATA OF TIIK ITKUrS. 
 
 Hydrosalpinx, unilateral ^ oases 
 
 Hydrosalpinx, liilatcral 5 
 
 Hematosalpinx 1 case 
 
 Pyosalpinx 4 cases 
 
 Tuberculosis of the tu!)e (Aut. No. 1898) 1 case 
 
 Carcinoma of tlic Fallopian tuhc (Aut. No. 810), .secondary to carcinoma of 
 
 the uterus, 1 
 
 Small cyst "in the broad ligament " 6 cases 
 
 Multilocular cystadenoma of l)oth ovaries 1 case 
 
 Dermoid cyst 2 cases 
 
 Ovarian abscess 4 
 
 Tubo-ovarian abscess 1 case 
 
 Primary carcinoma of the ovary (Aut. Nos. 474 and \'M\) 2 cases 
 
 Carcinoma of the ovary associated with carcinoma of the stomach* 2 " 
 
 The snuill cysts noted in tlie brojul ligament are cliiefi}^ intlannnatory in 
 origin, l)eing due to accumulations of peritoneal fluid. 
 
 From a study of this table it will be seen that in two of the cases there were 
 ])rimary malignant changes in the ovaries, and in one case tuberculosis of the 
 Fallopian tub(\ 
 
 Changes in the Ureter Associated with Myomata.! 
 The following table shows that in these cases one or both ureters were dilated, 
 o'ivin"; rise to lix'di'oui'eter: 
 
 
 
 
 Right or Left 
 
 
 Aut. No 
 
 SlZK OF UtKUUS. 
 
 Adherent. 
 
 Hydroureter. 
 
 Cause. 
 
 288 
 
 Large, filling pelvis. 
 
 Yes. 
 
 Double. 
 
 Myoma. 
 
 451 
 
 3 myomata, 5 cm. in 
 diameter. 
 
 
 Right. 
 
 Was associated 
 with diffuse 
 nephritis and 
 cardiac hy- 
 pertrophy. 
 
 Myoma. 
 
 653 
 
 Pelvis filled. 
 
 Yes. 
 
 Double. 
 
 Myoma. 
 
 908 
 
 9x7 cm. 
 
 — 
 
 Double. 
 
 Myoma 
 (jammed), 
 
 994 
 
 Ri.ses i:! cm. above 
 
 
 liight. 
 
 Myoma. 
 
 pelvic hriiii. — 
 
 The situation and the size of the tumor are to a great extent responsible for 
 pressure upon the ureter sufficient to caus(> dilatation. A myoma just large 
 enough to fill the pelvis and snugly tied down by adhesions can very readily 
 produce sufhcient j)ressun' to cause hydrourelci-, while a very hirge tumor may 
 be so .situated as to exert liltle or no effect upon the ureter. 
 
 In the removal of an S<.)-])()und tumor in the week during which we were 
 gathering this data we did not find the slightest cNidcnce of any interference with 
 
 *The intimate relat ion>liip between ])riinary carcinoma of the stomach and secondary growths 
 in the ovaries was made clear by Professor Welch several years ago (Pepper's System of Med., 
 vol. ii, p. 533). 
 
 fin several other cases ureteral and renal changes were fount!, but as they were evidently 
 caused by other pathologic conditions, these cases have been omitted.
 
 AUTOPSY FINDINGS. 397 
 
 the ureter. About the only way in which llie myoma can ])riiig about the nec- 
 essary pressure on the ureter is to get it hrmly wedged against the ])ony wah 
 of the pelvis. As a rule, the larger the myoma becomes, the more room it requires, 
 and hence its ascent into the general cavity. 
 
 In Aut. No. 451 the combined myomatous masses with the associated adhesions 
 seem to have been the causative factor. 
 
 In Aut. Nos. 653, 908, and 994 the evidence is in favor of the myomata as the 
 distinct cause of the hydroureter. 
 
 There was one more case in which hydroureter was found at autopsy (No. 
 188). Here the ureter had been accidentally tied during operation, and had 
 remained so until several days later, when it was discovered at autopsy. This 
 case is described in full on p. 382. 
 
 In one case (Aut. No. 69) there was a double pyoureter associated with 
 an ascending infection and implication of both kidneys. The large myomatous 
 tumor was sufficient to cause dilatation of the ureters, but the accompanying 
 infection could not be directly attributed to the uterine tumor. 
 
 Changes in the Kidney Associated with Uterine Myomata. 
 
 Aut. No. 288, double hydronephrosis. 
 
 Aut. No. 653, double hydronephrosis. 
 
 Aut. No. 994, dilatation of the right pelvis. 
 
 Aut. No. 1745, dilatation of the right pelvis. 
 
 Aut. No. 69, double pyelonephrosis. 
 
 Aut. No. 1112, miliary abscesses of the kidney (Staphylococcus aureus, 
 sloughing submucous myoma). 
 
 In Aut. Nos. 288 and 994 the dilatation of the ureter seemed to have l)een 
 caused by pressure exerted by the myomata, which was likewise ])i'()l)ably re- 
 sponsible for the dilatation of the renal pelves. 
 
 In Aut. No. 1745 the coexistence of the myoma witli dilatation of the right 
 kidney w'as a mere coincidence. 
 
 The dilatation of the kidney in Aut. Xo. 69 was ])i-ini;irily due to ])ressure 
 exerted by the tumor, but the .subsecpient infection cainiot be attiibiited to the 
 presence of the myomatous uterus. 
 
 The general picture in Aut. No. 1112 strongly suggests that the sloughing 
 submucous myoma was responsible for the acute endocarditis, with the secondaiy 
 manifestations, as seen in the miliary ab.sce.sses in the kidney. 
 
 Taken as a whole, the alterations in tluMUvters and kidneys c;iused by myomata 
 are chiefly lueclianical, and may to a gi'cat extent be i'elie\('d by o|ieralioii. ( )iily 
 in those cases in which there is a sloughing sul»niucous myoina oi- necrotic and 
 sloughing interstitial oi' sul)i)eritoneal myotnata need i)urulent changes be looked 
 for in the ureter or the kidney.
 
 398 MYOMATA OF THE rTKRUS. 
 
 Autopsies Showing Carcinoma and Myomata in the Same Uterus. 
 
 In 8 cases this conditioii was found at aut()i)sy. In 2 cases the carcinoma 
 was situated in tlie cervix : in 6 cases, in the body of the uterus. 
 
 Carcinoma of the Cervix and Uterine Myomata.* — In Aut. No. 689 (Case 
 3490) the cervix had been inva(h'd with cancer, which had extended not only to 
 the lateral structures. l)ut also to the vag:ina. Situated in the l)ody of the uterus 
 was a sloughing submucous myoma, 6.5 x 4.5 x 2 cm. 
 
 The uterus in Aut. No. 926 (Case 5092) presented a striking picture. The 
 cervix had lieen entirely eaten away by the carcinomatous growth, and the body 
 of the uterus was markedly encroached uixni. Scattered throughout the uterus 
 were subperitoneal, interstitial, and submucous nodules, and the carcinoma had 
 riddled the contiguous ])ortion of the myomata (Fig. 278, p. 403). It is little 
 wonder that the large carcinomatous surface gave rise to a fatal hemorrhage. 
 
 The cases operated ui)on in which carcinoma of the cervix was associated with 
 myomata will be found on p. 262. 
 
 Gyn, No. 3490. Aut. No. 689. 
 
 Extensive c a r c i 11 o in a o f the cervix; sloughing 
 s u b m u c o u s m y o m a . 
 
 Aut. No. 689. K. Pv.. white, aged forty-four. .Vdniitted May 7: died July 
 18, 1895. Anatomic diagnosis: general infection with the gas bacillus; carci- 
 noma of the cervix extending to the vagina and lateral structures; metastases 
 in the liver, both layers of peritoneum, and inguinal and retroperitoneal lymph- 
 glands; arteriosclerosis; chronic diffuse nephritis; chronic perisplenitis; chronic 
 adhesive and acute peritonitis; sloughing myomata in the uterine cavity. 
 
 On opening the abdomen 900 c.c. of greenish, foul-smelling fluid were found 
 free in the peritoneal cavity. The cervix had almost entirely disappeared, 
 its site in the upper part of the vaginal wall being infiltrated by the carcinoma, 
 which laterally extended to the pelvic wall. The growth was sloughing and 
 necrotic. In the uterine cavity was a hard nodule, 6.5 x 4.5 x 2 cm., which showed 
 a necrotic surface. This was a sloughing subimicous myoma. Both Fallopian 
 tubes were thickened and adherent to the posterior surface of the uterus. 
 
 Histologic examination showed that the growth and the metastases were 
 com])osed of carcinomatous tissue. The records, however, do not say whether 
 it was a squamous-celled growth or an adenocarcinoma. 
 
 Gyn. No. 5092. Aut. No. 926. Path. No. 1631. 
 Umbilical hernia; s r ( u a m o u s - c e 1 1 e d c a r c i n o m a of 
 the c e r v i X ( F i g . 2 7 6 ) extending to the \' a g i n a , bod y 
 
 *In Aut. No. 810 (Ca.se 4;i74) the cervix wa.s extensively invaded by the carcinomatous tissue, 
 which was also wide-spread in the lateral structures. Two small interstitial myomata were pres- 
 ent in the body of the uterus. These nodules were too small, however, to justify the inclusion of 
 this case in the group.
 
 AUTOPSY FINDINGS. 
 
 399 
 
 of the II t e r us, bladder (Fig. 277), r e c t u in , 1) r o a d liga- 
 ment, t u 1) e s a n d o ^• a r i e s , a n d f o v m i n g ni e t a s t a s e s i n 
 the pelvic, inguinal, retro p e r i t o n e a 1 , ni e s e n t e r i c . 
 and bronchial g 1 a n tl s ; a 1 s o i n t h e lung s , p 1 e u ra? , and 
 
 Fk;. 276. — Squamous-cki.i.ed CAnri.\OM.\ ui iiii; C'i:kvi.\. .V.-smx iai i.d with Mri.Tipi.i-: Utkrink Myomata. 
 
 (7 nat. .size.) 
 Path. No. 1631. The uterus i.s much enlarged. Projecting from its surface are numerous large anil small 
 bosses, which on section are seen to consist of subperitoneal, interstitial, and subnmcous myomata. Note how- 
 prominent the myomatous nodules are on section, owing to the rec«'ssion of the uterine muscle. The lower part 
 of the vagina presents the normal appearance. l)ut occupying the upper part of the vagina, llie site of tlie cervix, ami 
 also the greater part of the uterus is a ragged and friable looking growth, composed of smootli, dome-like elevations, 
 varying from a pin's head to 2 cm. in diameter. The larger ones are slightly lobulated. Over the smooth inner 
 surface the tissue is almost entirely necrotic. The uterine walls have been invaded nearly to the peritoneal surface, 
 and present a very ragged outline. The small nodules in the nmscle of the fundus are myomata. The growth on 
 microscopic examination is found to have jienetnited the muscle between them, and ha.s invaded a snuill myoma- 
 tous nodule, as seen in Fig. '27H. (.\fter 11. A. Ki-ll\, i 
 
 the s e r o s a o I' the i ii t c s t i n c s. I n l c i- s i i i i ;i 1 ;i n d s u b - 
 
 p (' r i t () 11 e a 1 ii 1 c r i n c iii y o iii ;i t ;i ; il o u b I c li y d i' i» ii i- c I c r ; 
 
 a 11 (■ III i a of all I li c o r g ;i ii s : I' o c ;i I I' ;i I I y d c g c n v r a ! i o n 
 
 o 1 the 1 i \- (• r : i n t c r s 1 i t i a I n c |) li r i t i .s ; .s u d tl e n d e a t h 
 foil o \v i n ii uteri n e h c in o i' r h a ir e s .
 
 4()0 MYOMATA OF THK UTERUS. 
 
 L. S., aged fifty-four, colored. Admitted March 11, 1897. Complaint, 
 frequent uterine hemorrhages and an offensive discharge. 
 
 The patient ha.s been married twenty years, and has liad two children and 
 one miscarriage. Her menses commenced at thirteen, were regular and profuse, 
 lasting three or four days, and very painful. Seven years ago the periods 
 diminished in frequency, occurring once in every three or four months, though 
 there was frequently a bloody discharge. In August, 1895, the bloody discharge 
 reappeared and became constant, but not excessive; it continued until January, 
 1896. Since then she has had copious hemorrhages, and after one in January, 
 1896, she fainted. The last sev(n-e hemorrhage ])rior to her admission occurred 
 in September. 1896. Since then at times she has had a bloody discharge, slight 
 in amount, and accompanied by no pain, but very offensive and irritating. 
 
 On admission the discharge is yellowish white and profuse. The family 
 history is negative. 
 
 The only noteworthy fact in her ])revious history was that in the sunmier 
 of 1896 she had no stool for two weeks. 
 
 Pres(»nt sickness: The ])atient did not know that she had an abdominal 
 tumor until so informed by her ])hysician; she thinks that the growth has dimin- 
 ished in size. There has been little pain in the abdomen, except for the ac- 
 cumulation of flatus. Enlargement of the inguinal glands was first noticed 
 in June, 1896. These, she says, have not increased in size, but during the last 
 four weeks have been very painful. She has lost much in weight, although she 
 has a very good ap})etite. The l)owels are costive, and defecation is accompanied 
 by much pain and occasionally by bleeding from hemorrhoids. The urine is 
 sometimes scalding and occasionally blood-tinged. 
 
 Abdominal Elxamination. — The abdomen is dome-.shaped, the most prominent 
 point being the umbilicus. The patient has an umbilical hernia, the pouch 
 being 3 cm. in diameter, and ])rojecting 3.5 cm. from the surface. The hernial 
 ring easily admits tlie end of the index-finger. 
 
 The abdominal tenderness is most marked below and to the left of the um- 
 bilicus. Over an area about 5 cm. in diameter in this vicinity the tissue is very 
 edematous, and pits readily on pressure. Owing to the tenderness it is diflficult 
 to outline the al)tlominal tumor, which, however, is very smooth and does not 
 extend above the umbilicus in the median line. In both inguinal regions the glands 
 are as large as walnuts and are movable. Those on the right side are tender. 
 
 The right leg is much swollen and pits on pressure, especially below the knee. 
 The left leg also is swollen. The glands of the neck and the epitrochlears are 
 palpable. 
 
 Vaginal Examination. — The outlet is considerably relaxed, and the ui)per 
 ))art of the vagina is occuj)ied by a necrotic, offensive tissue which rapidly breaks 
 down under the examining finger. 
 
 Further examination is imjKJssible on account of the extreme tenderness. 
 
 On the moi'ning of Mai'ch 27, 1906, the })atient had a jn'ofuse uterine hemor-
 
 AUTOPSY FINDINGS. 
 
 401 
 
 rhage, and, as nearly as could be estimated, lost about one pint of blood. So far 
 as the pulse and respiration were concerned, the loss of blood caused little change, 
 but there was a slight tendency to drowsiness. At 3.30 p. m. she had a second 
 hemorrhage, more profuse than the first, was restless, complained of severe pain 
 in the back, and had a pulse of 136. The mucous membranes were quite pale. 
 The respirations were not increased. Morphin was given with good effect. 
 At 11.15 p.m. she had a third hemorrhage, much more severe than the two 
 
 .-i^°wuTa. 
 
 ^ydro " ilr^tej' 
 
 Corn n o - 
 
 'Carri/T 
 
 Caret o ■ 
 nodule.!, 
 
 L c/'t ur. 
 
 ort'f/'cc 
 
 '^'^t ureteral orcfi 
 
 Fig. 277. — Carcinoma of the Bladdkr Secondary to Sijuamous-celled Carcinoma of the Cervix. 
 Path. No. 1631. Scattered over the peritoneal surface of the bladder are many small white, flat, isolated 
 carcinomatous nodules. Some also have united to form conglomerate masses. The bladder-walls are of the usual 
 thickness. Just within the inner urethral orifice is an elongated nodule, about 1 cm. in length, which rises abruptly 
 from the surface, is sharply defined, and presents slight lobulation. The left ureteral orifice is normal, but the right 
 is situated in the center of a lobulated carcinomatous nodule, nearly 2 cm. in length. Behind this are several other 
 carcinomatous outgrowths, some of which are not more than 1 mm. in diameter. The bladder mucosa, except 
 where it is involved in carcinomatous nodules, is normal, .\bove the bladder is the enlarged myomatous uterus, 
 with two myomata on its surface and numerous small, flat carcinomatous nodules covering the peritoneum. To 
 the right is the dilate<i right ureter. The left ureter is also distended, being constricted below by carcinomatous 
 infiltration. (After Thoiiuis S. rulleii.i 
 
 preceding. The pul.sc was 110, and at 1 a. m. the patient wa.s uncuii.scious and 
 gasping for breath. She died at 2.10 a. m. 
 
 Aut. No. 926. The body is that of a colored woman, small in statui'e, and 
 somewhat emaciated. In both inguinal regions ai'e prominent nodnlar swellings, 
 the largest about the size of a hen's egg: all ai-e IVeely mowible. and tiie 
 largest gives a slight fluctuation, l^xteiiding upward to the inguinal rings 
 tire indurated ma.sses. .Just below the unibilicus is a firm, nio\able mas.s, 
 about the size of a child's head. 
 26
 
 402 MYOMATA OF THE UTERUS. 
 
 The right lung is hound ))y fibrous adhesions to the chest-wall at about the 
 middle third, and again posteriorly near the base. The parietal pleura on the right 
 side shows a grayish-white nodule, 6 mm. in diameter, and there are small groups 
 of similar nodules on the surface of the diaphragm. Where the lung is bound 
 down at its base posteriorly there is marked induration, due to superficial meta- 
 static tvnnor deposits. Thes(> form a conglomerate mass of small round nodules, 
 which are beginning to undergo .softening in their centers. On section, they are 
 of a uniformly pale yellow color. The surface is dry, but the central portions 
 are soft, and can be readily scjueezed out. There are also five similar nodules 
 scattered over the surface of the lung. 
 
 The left lung has several nodules, each about 1 cm. in diameter, scattered 
 over its surface. 
 
 The anterior mediastinal glands are not enlarged, but the bronchial glands 
 are nuich increased in size, owdng to metastatic deposits. 
 
 Spleen negative. 
 
 The liver contains no metastases. 
 
 The kidneys are of moderate size; the capsules strip off reatlily; scattered 
 over the surface of each kidney are minute clear cysts. 
 
 Both ureters are dilated, especially the left, which along its lower third is 
 nearly 1 cm. in diameter; at the junction of the lower and middle third is a kink, 
 above which the dilatation is not so marked. 
 
 On opening the abdomen a portion of the somewhat fatty omentum was found 
 in the small hernial orifice at the umbilicus ; it was readily withdrawn by gentle 
 traction. The orifice was 1.5 cm. in diameter. 
 
 Both la\-ers of peritoneum are smooth in the upper abdomen, save for nodules 
 about the size of peas, which here and there stud the surface of the intestines. 
 
 The ]:)rominent and enlarged fundus is slightlv adherent to the parietal 
 peritoneum in the median line below the umbilicus. The peritoneum in the lower 
 part of the abdomen is studded with single or grouped whitish nodules, some of 
 which are as large as ])eans; the tissue on both sides of the pelvic brim is nuich 
 thickened, and has nodules over its entire surface. 
 
 The iliac glands are enlarged, one on the left side reaching about 4 cm. in 
 diaiiictcr, and in its center c(mtaining a clear, odorless, straw-colored fluid look- 
 ing much like urine. The smaller glands are softened in their central portions. 
 The largest inguinal gland on the left side contains a fluid material resembling 
 creamy-white pus. The glands at the bifurcation of the aorta are 4 cm. in diam- 
 eter and necrotic. The mesenteric glands are enlarged and necrotic, as are 
 also the retroperitoneal glands. The stomach and the large intestines have 
 small white nodules scattered over their peritoneal surfaces. 
 
 Frozen sections from llie small nodule in the ])osterior inediastimun show 
 it to consist of dense fibrous tissue infiltrated with broad, irregular plugs of e\)\- 
 thelial cells. These plugs show a tendency to l)reak down in their central 
 portions.
 
 AUTOPSY FINDINGS. 
 
 403 
 
 1. 
 
 f'A .W^^ '^!& 
 
 
 
 m 
 
 The \\\QY shows consklerable fatty degeneration, especially about the periph- 
 ery of the nodules. 
 
 Examination of the Pelvic Organs. — Path. No. 1631. The uterus is con- 
 verted into a large, nodulated tumor mass, approximately 21 x 17 x 15 cm. 
 Projecting from the fundus anteriorly is a large rounded boss, 8 cm. in diameter. 
 Both the anterior and posterior surfaces also present similar but less prominent 
 elevations. On pressure, these nodules are firm and resistant. Studding the 
 surface of the uterus are small flattened tumors or confluent masses of whitish, 
 soft material. Covering the large 
 nodules are tags of adhesions. On 
 cutting open the uterus a large 
 sloughing cavity is found (Fig. 
 276); this is 14 cm. in length, 8 
 cm. in its greatest diameter, and 
 includes the upper part of the 
 vagina, the broken-down cervical 
 canal, and the greatly enlarged 
 uterine cavity. The cervix is 
 represented by a deep excavation, 
 whose walls consist of a greenish, 
 necrotic material, but in a few 
 places, where the degenerative 
 process is not so advanced, a pap- 
 illary arrangement of the tissue 
 can be easily recognized. The 
 new-growth, which has evidently 
 originated in the cervix, has ex- 
 tended to the vaginal vault, antl 
 has involved to a moderate degree 
 the rectum and bladder. Project- 
 ing into the uterine cavity are sev- 
 eral irregular, dome-shaped nod- 
 ules, varying from 1 to o cin. in 
 diameter. The entire cavity is 
 lined with necrotic tissue, but here 
 and there, as in the (■or\i\. line |)a|)illary outgrowths are occasionally visible. 
 
 The broad ligaments, mesosalpinx, lub(>s, ;uid ovaries are studded with 
 isolated or condiiciit masses, wliicli hit w I litis! i in color and soft ; tlicv coi-i-cspoiid 
 with those covering the surface of the uterus. Tlic ovai'ics ai'c ncarh- twice the 
 natural size. The bladder mucosa is evei-ywhei-e sinootli. hut in the i-egion of the 
 trigonum is a whitish elevation, '1 cm. in dianietei-. to the left of which is a second 
 but smaller one. Both of these are tunioi- ^I'owths (fig. 277). 
 
 Histologic I'^xaniination. Sections IVoin the oi-i<i:inal tumor and from 
 
 Fig. 278. — Inv.\sion of k Myom.\ by \ Squamous-cellkd 
 Carcinoma of the Cervix. (X 90 diam.') 
 Gyn. Path. No. 16.31. The section is composed of 
 typical myomatous tissue and bunches of muscle-fibers cut 
 longitudinally and transversely, and separated from one 
 another by connective tissue which is poor in nuclei. .\t a 
 the muscle-fibers are cut obliquely. At b, b, and b typ- 
 ical nests are seen, composed of cells that, as a rule, are 
 uniform in size and contain vesicular nuclei. At c is a row 
 of cancer-cells lying isolated in the stroma between muscle- 
 bundles. .\ cross-section of such a row gives the picture 
 seen at d and e, where single cancer-cells are visible. The 
 growth also forms giant-cells, as seen at f. where there is a 
 large irregular phujue of protoplasm containing a lobulated, 
 deeply staining mass of chromatin. The extension to the 
 myoma ha.s been by continuity. (.After Thomas S. Cullen.)
 
 404 MYOMATA OF THE UTERUS. 
 
 various points show tyijical s(iuanious-('('llo(l carcinoina. They also show quanti- 
 ties of ^•('l•y large cells and plaques of irregular, deeply staining chromatin lying 
 loose in the tissue or surrounded by large masses of protoplasm. 
 
 Definite nests arc to be made out in the tubes and ovaries. 
 
 Sections from the myomata show that the carcinomatous process has ex- 
 tended by continuity into them, anil that various portions of the myoma are 
 being replaced by nests of epithelial cells (Fig. 278). 
 
 The complete histologic findings in this case are given in "Cancer of the 
 Uterus," p. 139. 
 
 Uterine Myomata Associated with Carcinoma of the Body of the Uterus 
 
 Detected at Autopsy. 
 
 All these patients entered the hospital too late for any extensive operative 
 ]-)roc('dure; in fact, some of them died shortly after admission. 
 
 In Aut. No. 1605 the anterior uterine wall contained a myoma, 6x4x4 cm., 
 while tlie l)ody of the ut(>rus was the seat of a far-advanced carcinomatous 
 process that had been widely disseminated through the lymph-channels. In 
 this case the myoma played an important role in the differential diagnosis, 
 as judged by the bimanual examination. 
 
 The uterine enlargement in Aut. No. 117 was due chiefly to the presence of 
 the myomata, — a calcified nodule, 3.5 cm. in diameter, and on the left side a 
 myoma 19 x 15 cm., — the carcinoma being relatively small. It is just in this 
 class of cases that the malignant growths escape detection. 
 
 In Aut. No. 505 the uterus contained several myomata, the largest the size 
 of a hen's egg. In this case, as a result of the exploratory laparotomy, metastatic 
 nodules were found in the omentum and the peritoneum of the abdominal wall. 
 The growth in the uterus, as the metastases would indicate, was far advanced. 
 
 The clinical ])icture in Aut. No. 1407 was confusing. There Avere not only 
 several myomata and a carcinoma of the body of the uterus, but also a slough- 
 ing submucous myoma and a pyometra. Clinically, the sloughing myoma, 
 the carcinoma, and the pyometra each might give the same symptoms, and only 
 on an examination of the curettings could a positive diagnosis be established. 
 
 Aut. No. 1220 was given in detail in Cullen's "Cancer of the Uterus," p. 466. 
 When I saw the patient in consultation, 1 diagnosed uterine myomata and ad- 
 vised hysterectomy. When the ])atient entered the hos])ital a few days later it 
 was found that the inguinal glands had suddenly enlarged, and as the possibility 
 of malignancy was thought of, I advised the removal of an inguinal gland for ex- 
 amination, not wishing to subject the patient to an alxlominal operation if the 
 growth should prove to be malignant. As will be noted from the history. Dr. 
 Stokes found the inguinal gland the s(>at of cysts containing papillomatous 
 masses identical with those fomid developing in tlie ovary. Tiie ])atient raj^dly 
 lost weight and soon died. 
 
 Not until autopsy did we suspect carcinoma of the l)ody of the uterus.
 
 AUTOPSY FINDINGS. 405 
 
 although it was far advanced and had caused wide-spread metastases. This is 
 another example of the manifold pathologic processes that may be present in the 
 pelvic organs of the same women. 
 
 Undoubtedly, the most instructive in our series is Aut. No. 277. In the early 
 days of our myomectomy operations we did not hesitate to remove myomata, 
 even though the uterus might be bound down by adhesions. In this case a 
 myoma the size of an orange was removed from the anterior wall, but a nodule, 
 5 cm. in diameter, in the posterior wall could not be enucleated on account of ad- 
 hesions. The patient died on the sixth day of peritonitis. The source of infection 
 in all probability was the adenocarcinoma in the body of the uterus, which was 
 unsuspected and which was not detected until the autopsy. 
 
 The uterus also contained a small subnmcous myoma. This case emphasizes 
 the extreme care that must be exercised to determine the probable condition 
 of the uterine mucosa, and also that of the tubes when myomectomy is con- 
 templated. It also demonstrated the fact that a submucous myoma, 1.5 cm. in 
 diameter, cannot always be palpated, even when the uterus is carefully (examined 
 by the operator after the al)domen has been opened. 
 
 Report of Cases of Uterine Myomata Complicated by Carcinoma of the Body 
 OF THE Uterus as Found at Autopsy. 
 
 Gyn. No. 2634. Aut. No. 505. Path. Nos. 204 and 222. 
 
 A d e n o c a r c i n o m a o f the b d y o f the u t e r u s , with ex- 
 tension of the g r o w t h t o the uterine myomata (Fig. 
 2 7 9); secondary involve m e n t of t h e p (m- i t o n e u m , 
 the inguinal, j) e r i c a r d i a 1 , bronchial, a n d c e r ^' i c ti 1 
 1 y m p h - g 1 a n d s ; c a r c i n o m a o f the o m e n t u m ; c h r o n i c 
 endocarditis of the mitral, a o r tic, a n d t r i c u s p i d 
 valves, and acute e n d o c a r d i t i s of the mitral valves. 
 G i a n t - c e 1 1 s in the c a r c i 11 o m a tons g 1 a n d s . 
 
 E. S., ag(*d fifty ; colored. Admitted March (>, 1SU4. Coiiiplaiut . abdominal 
 enlargement, with soreness in the region of the umbilicus. 
 
 The ])atieiit had one miscarriage ten years ago, but has had no children. 
 Her family history is not important, and with the exception of an attack of 
 rheumatism a year ago she has always been well. The menstrual history is 
 normal; the last period conimeiiced I'Vbruai'y 22. 
 
 In the lattei" part of Decern be i', I S!);!, she began to complain of some abdominal 
 pain, and on })Utting her hand (»n her abdomen discoN'ered a luni]) about the size 
 of the end of the finger jusl aboxe the innbilicus. This nodule, which was at 
 first hard and non-seiisit i\'e, has gradual!}' become lai'ger, mihI is now (|uite tender. 
 The patient on admission is faii'ly well nourished, and apart from the abdominal 
 enlargement, feels well. 
 
 Operation, March 10, 1S!)4. h^xplorator}- celiotomy. On opening tiie abdo-
 
 406 my():mata of the uterus. 
 
 men the peritont'iiin was fouiul covered with numerous small nodules; similar 
 tumors were also attached to the intestines, tubes, ovaries, and to the posterior 
 surface of the uterus. The omentum was rolled up, forming a firm, nodular 
 mass just beneath tiie costal margin. The peritoneal cavity contained about 
 2000 c.c. of turbid fluid. For .several days after the oj)eration the patient did 
 well, but died on March 23. 
 
 I'ath. No. 204. A large amount of dark-yellow, nuiddy-looking Huid from 
 the abdominal cavity, and two .small, papillary-like masses from the omentum, 
 each mea.suring 1x1 cm., were sent for examination. A note was made that 
 similar masses were attached to the abdominal wall, intestines, pelvic organs, 
 and mesentery, and, in fact, to the peritoneum everywhere. 
 
 On microscopic examination these small nodules are found embedded in 
 adi])ose tissue. They consist of glands lined with one layer of low cylindric 
 epithelium. 
 
 In many of the cells nuclear figures are visible, and the gland epithelium has 
 proliferated so as to completely fill the cavity. The stroma between the glands 
 is moderate in amoimt and poor in cellular elements. The picture is that of an 
 adenocarcinoma. 
 
 Aut. No. oOo. Path. Xo. 222. An abstract from the protocol is as follows: 
 The abdomen is somewhat distended, and in the peritoneal cavity is a considerable 
 accumulation of yelhjwish serum. Extending completely acro.ss the abdominal 
 cavity, in the I'egion of the umbilicus, is a large tumor mass which covers the 
 anterior surface of the transverse colon. This tumor is lobulated, light in color, 
 and opacjue. It corresponds to the greater part of the omentum. The right 
 eihfi^v of the omentum is thicker than the left ; the gastrocolic portion is relatively 
 free from tumor involvement. In the jjeritoneum. at the hilum of the s))leen. are 
 several small white nodules; the lymphatics around the jjortal vein also contain 
 small nodules. All these appear to Ijc metastatic. Covering the peritoneum 
 and the large intestine are numerous metastases, varying from a millet seed to a 
 pea in size. The}- cover the peritoneum everywhere, and are especially abundant 
 in the pelvis. The lymi)h-glands beneath the pericardium are enlarged and con- 
 tain tumor metastases. The vagina and cervix are apparently normal. The 
 utei'us contains several myomata, the largest of which is sul)mucous and 
 pedunculated, being the .size of a hen's egg. 
 
 The muco.sa covering one-half of the surface of this nodule is congested and 
 hemorrhagic; it presents a mottled ajjpearance and suggests carcinoma. The 
 second myoma is subperitoneal, antl also appears to have been invaded by the 
 tumor occupjdng the uterus. The inner surface of the uterus is grayish in the 
 upper portion, and in places presents a yellowish mottling. The muco.sa ap- 
 pears to extend foi' some depth into the muscle. The ovaries do not show any 
 involvement. 
 
 Histologic Examination. — Sections from the uterus show that the nmscular 
 coat has been invaded by bunches of glands which are small, circular, and have
 
 AUTOPSY FIXDIXGS. 407 
 
 a lining of cylindric epithelium. In some of the cells two or more nuclei appear. 
 A few of the glands contain giant-cells. At many points the gland epithelium 
 has proliferated so that, instead of a bunch of glands, there is merely a large 
 mass of cells having no definite arrangement. The centers of such masses often 
 show nuclear fragmentation, but no inflammatory reaction. The myoma, 
 which is involved in the new-growth, to a great extent has undergone hyaline 
 changes. The principal part consists of hyaline tissue, with here and there 
 
 Fig. 279. — .\dknocarcinoma ix a Myoma, Skcondary to .^dknocarcixoma oi tiik Body ok thk Utkrts. 
 
 (X 125diam.) 
 Path. No. 222. Aut. No. 505. The section consi-st.s of tyi)ical iiiyomatoiis tissue. The majority of the 
 muscle-fibers have been cut longitudinally, and wind in and out in all directions, not .showing the regular arrange- 
 ment so characteristic of normal uterine muscle. Moreover, there is an excess of connective ti.ssue. Scaftere<l 
 abundantly throughout the myoma are groups of carcinoma cells. In the majority of i)laces they appear ij.s glands 
 lined with one layer of cuboidal epithelium (a), but in a few i)laces the glands have become filled, as at b, or the cells 
 form large solid masses as .seen at c. d is an irregular mass of cells showing a tendency to branch. On the whole, 
 the nuclei of the epithelial cells are fairly uniform in size, but at c are seen a few large nuclei. The growth has 
 extended by continviity. (After Thomas S. Cullen.) 
 
 tufts of non-striped nnisclc-iibci's. ( Itlici- ])oitioiis of tlic iiiyoiiin coiil.'iiii glanils 
 arranged singly or in bunches. Sonic show a single lumen, while othei-s are com- 
 pletely filled with cells (Fig. 279). This growth is merely a continuation of that 
 in the uterine muscle. Portions of the myoma haxc undergone coagulation 
 necrosis. Just beneath the capsule of the lixcr, and attached t(» the surface of 
 the kidneys, are small tumor masses. The glands of the neck show marked 
 carcinomatous involvement, the typical glandular type being here well preserved.
 
 408 MYOMATA OF THE UTP:Rr.S. 
 
 The complete histologic descriiitioii of this case is given in "Cancer of the Uterus/' 
 
 p. 434. 
 
 Gyn. No. 6439. Aut. No. 1220. Path. No. 2808. 
 
 S u 1) )) e r i t o n e a 1 ami interstitial u t c r i 11 e ni y o ni a t a 
 (Figs. 280 and 281); a d c n o c a r c i n o in a o f t h e h o d y 
 of t h e u t e i' u s . with s e c o n d a r y g r o \v t h s in the p c r i - 
 tone u in . o in c n t u ni , in e s e n t c r y , 1 i v e r . ]) a n c r e a s , left 
 adrenal 1 > o d >• , p 1 e n r av, and lungs; ) ) a p i 1 1 o c y s t o - 
 m a t a of 1) o t h o \' a r i e s . with extension h y c o n t i n u i t y 
 to the c r r e s J) o n d i n g inguinal glands; h y d r o s a 1 - 
 J) i n X in the inner part of the left tube, due to a 
 kink, t h e fimbriated e x t r e in i t y h e i n g ]) a tent. 
 
 M. 11., aged fifty, colored. Admitted October 14. 189S. Complaint, an 
 abdominal tumor accomjianied by general weakness. 
 
 The i)atient has been inarrie(l twenty-seven years, has had no children and no 
 miscarriages. Menstruation conunenced at twelve years, and was usuall}' regu- 
 lar, lasting from three to seven days, ])ut always excessive. At forty-one the 
 flow ceased. One year ago a hemorrhagic discharge commenced, and has been 
 ))racti('ally continuous. For many years there has been an irritating leukorrheal 
 discharge. The family history and pre\'ious history are unimportant. 
 
 About ten years ago the ]iatient noticed a luni]). about the size of an egg, in 
 the left lower abdomen. This was not painful and caused no inconvenience. 
 In August, 1897, the same nodule, although not enlarged, became quite tender, 
 and the patient noticed that the abdomen at times was somewhat distended. 
 As above noticed, the uterine hemorrhage began at this time. The abdominal 
 pain has been more or less constant of late, sometimes dull and aching in character. 
 at other times sharp and crainj)-like. There has been considerable swelling 
 of the lower extremities and also shortness of breath. At present .she is ap- 
 parently a strong, well-nourished woman; her temperature is 100.3° F., the 
 pulse is 116. The bowels are constipated, and defecation and micturition are 
 painful. The lungs and heart are apparently normal. 
 
 October 10th. The abdomen is much enlarged, and just above the umbilicus 
 measures 115 cm. in circumference. The most prominent point lies midway 
 between the umbilicus antl the ensiform cartilage. The abdominal wall just 
 above the pubes is much thickened and j)endulous. The distance from the umbili- 
 cus to the pubes is 18 cm. ; from the umbilicus to the ensiform cartilage, 27 cm. ; 
 from the right anterior superior spine to the umbilicus. 32 cm.; from the left 
 anterior superior spine to the uml^ilicus, 32 cm. 
 
 ^'aginal i^xamination. — The labia are large and flabby. The vaginal outlet 
 admits two fingers, and it is just j)ossil)le to touch the tip of the cervix, which 
 lies far back and is apparently continuous with the tumor hlling the abdomen. 
 Occupying the left groin is an immovable mass, 6x3 cm. This has a somewhat 
 elastic feel, and suggests a metastasis.
 
 AUTOPSY FIXDIXGS. 
 
 409 
 
 tint 
 
 Fig. 280. — A Lar(;e Myomatous Utkuis t'lioKiNc nu: Pki.vis; Small Ovaiuan Cv.sls on Both Sidks; Thick- 
 ening AND RkTRATTION OF THK OmKNTUM. MkTASTASKS IN THE LiVKR SKCONnARV TO AN .\l)ENOCARCINOMA 
 
 IN THK Body of thk Uterus. 
 
 Path. No. 2808. .\ut. No. 1220. Tlic fiKUrc sIidws tlii' appcurancc nf llu> ;ilicl<iiiiiri:il (Mvily a.s .seen at 
 autop.sy. Filling thei^elvis, ami projectinR into tlie Kt'm'i'al cavity, is a laiKc iricKular niyitniatoiis uterus i PiR. 281 V 
 Springing from the .surface of the organ are large and .small .sulii>eritoneal myomata. The right ttihe is seen i)a.s.sing 
 outward in a depre.ssion between .several of the largest myomata. On the right side, the edge of a small ovarian 
 cyst is .seen. On the left are two cysts springing from the left ovary. The lower otie ha.s very thin walls and is 
 translucent. On the left a loop of .small intestine ha.s dropped down, and hecome firmly a<lherent to the growth 
 in the inguinal region. Stuililing the nie.sentery of the small intestine are ininurc uliitish noilules, which are 
 secondary growths from the adenocarcinoma in the body of the uterus. The lip nf ilie vermiform appendix is 
 also embedded in carcinomatous nodules. As a result of cancerous infiltration the omentum is drawn up and forms 
 a dense ma.ss between the stomach antl tran.sverse colon, arul just l)elow the gall-blailder the ailipose tissue is also 
 greatly involved. Studding the right lobe of the liver are five carcinomatous nodules, one of which, even in the 
 reduced drawing, is nearly 1 cm. in diameter. .Ml are sharply <iclined, whitish in color, and are slightly um- 
 bilicated. There were also minute nodules, both in the sul)stance and on the surface of the organ. The hei)atic 
 nodules were secondary to the carcinoma of the uterus. i.\fter Thomas .S. CuUen.)
 
 410 MYOMATA OF TH?: UTERUS. 
 
 Operation, October 17. 1898. Partial excision of the glands in the left in- 
 guinal region. Before ()i)ening the abdomen Dr. I'h-nest Stokes thought it ad- 
 visable to explore the mass in the left inguinal region. As soon as an incision 
 had been made through the skin over the most })romiiu'ut ])ortion of the tumor, 
 a thin watery flukl escaped. Small cysts, lined with a pale, glistening membrane, 
 were found in the deeper portions. Many of these contained papillomatous 
 masses. In the face of such findings, associated with an abdominal tumor, 
 it was deemed advisable to abandon any furthci' ()])eration. A small drain having 
 been placed in the lower angle of the wound, the latter was closed. The patient 
 recovered satisfactorily from the effects of the slight operation, so that on 
 October 29th she sat uj) in a wheel-chair. The lower extremities, however, 
 gradually became edematous; she grew weaker, and died on December 17, 1898. 
 
 Aut. No. 1220. The body is 163 cm. long; rigor mortis is not marked. There 
 is an extreme degree of edema of the lower extremities, and of the trunk as far 
 as the shoulders. The al)domen is markedly distended, and fluctuation can be 
 elicited. Filling the lower part of the alxlomen is a large tumor mass, while 
 an oval, deeply seated tumor is found in the left inguinal region (Fig. 280). 
 The body i)resents an anemic appearance; the muscles are very pale, but an 
 abundance of adipose tissue is present. The peritoneal ca\dty contains about 
 3000 c.c. of a fairly translucent, yellow fluid. The parietal peritoneum has lost 
 its glistening appearance, and over a large area is covered with rough, irregular, 
 translucent deposits. This condition is especially marked over the diaphragm 
 and over the right side. The lx)wels are very nmch contracted throughout 
 their entire extent, and the small intestines average from 1.5 to 2 cm. in diameter. 
 Studding the mesentery of the small intestines are many small white tumor 
 metastases; the mesentery itself varies from 5 to 6 mm. in thickness. On the 
 left side a loop of ileum is adherent to the large tumor filhng the lower part of the 
 abdomen. The omentum is drawn up and contracted into a firm mass between 
 the stomach and transverse colon. Everywhere it contains tumor deposits. 
 Attached to the rolled-uj:) omentum is a part of the ileum, which makes it appear 
 as if the transverse colon ])asse;l through a canal. The ascending as well as 
 the descending colon is firmly adherent to the posterior abdominal wall, being 
 bound down ])}• tumor inctastases. Studding the intestine at various jx)ints 
 arc small tumor nodules. 
 
 The pericardial cavity contains a slight excess of cleai' yellow fluid, but there 
 are no adhesions. The outer muscle is rather pale and soft: its vessels are tor- 
 tuous. The coronary arteries contain yellow patches of atheroma. The 
 pleural cavities, each of which contains 400 c.c. of clear yellow fluid, are free from 
 adhesions. Small, translucent, carcinomatous nodules are found on the costal 
 pleura'. 
 
 Both lungs are emj)hyseniatous, and at their bases show marked edema. 
 Scattered throughout both lungs are yellowish-white tumor masses, some reach- 
 ing 1 cm. in dianietei-. The arteries of the rijiht lunij contain several definite
 
 AUTOPSY FIXDIXGS. 411 
 
 organizing thrombi. Tlic spleen weighs 70 grams; attached to its surface arc a 
 few translucent tumor masses; its substance shows nothing of interest. 
 
 The liver is rather small, measuring approximately 25x16x9 cm. It is 
 pale; the surface is fairly smooth, whitish in color, translucent, and somewhat 
 umbilicated (Fig. 280). Several of the nodules are cystic, and the cyst-spaces 
 contain a clear reddish fluid. Numerous nodules and cyst-like spaces, having 
 corrugated walls, are scattered through the substance of the organ. There are 
 numerous minute nodules on the surface and in the substance of the liver. On 
 the under aspect of the liver the nodules are surrounded by areas of congestion. 
 
 The periportal glands apparently contain metastases. The gall-bladder is 
 distended, evidently owing to pressure at its neck, resulting from implication of 
 the adjacent lymph-glands. 
 
 Both kidneys present the usual appearance, but on the surface of the right 
 kidney is a small tumor nodule, 2 mm. in diameter. The ovaries are normal in 
 size. The right adrenal is apparently normal, but the left about its middle 
 portion contains a definite tumor nodule, 1 cm. in diameter. The pancreas is 
 enveloped in adhesions, and at its tail contains a small tumor nodule. The 
 stomach at the pyloric orifice is surrounded and compressed by a mass of enlarged 
 glands; the greater curvature is intimately adherent to the tumor mass, lying 
 between it and the transverse colon. The vermiform appendix in its last 2 cm. is 
 entirely occluded by secondary growths. The external iliac vein on the left 
 side shows a partial thrombosis. Many of the veins below Poupart's ligament 
 are also thrombosed. The right femoral vein is completely occluded l^y a firm 
 thrombus, ])ale brown in color. 
 
 In the inguinal regions the large tumor masses are intimatel}' connected with 
 the veins; the mass on the left side is the larger, and is composed of many cysts 
 of considerable size, from which a slightly turbid fluid escapes. The mass on 
 the right side is much firmer. The thyroid gland on both sides of the median line 
 is much enlarged. A lymph-gland in the anterior axillary line, 10 cm. below 
 the axilla, contains a cystic tumor. The boiic-maiTow of the fciiiur is dark red 
 in color, but fairly firm. The brain and cord are apparently normal. 
 
 Path. No. 2.S0S. The siH'ciinen consists of the jx'lvic contents and of tissue 
 from the inguinal region. The vagina presents the usual appearance, and the 
 vaginal portion of the cervix is unaltered. The utei'us measui'es IS \ \i\ \ i;> cm. 
 (Fig. 281). The anterior surface of the finidusand the post ei'ior wall are studded 
 with myomatous nodules, varying in size fi'om that of a pea to 7 cm. in diameter. 
 Nearly all tlie nodules ai'c sessile. Attached to the ])ostcrioi- surface of tlic utci'us 
 are several broad, fan-like a<lhesions. The uterine walls \ai-y fi'oiii .") to (> cm. 
 in thickness, owing to the presence of inyoinatous nodules, which are sharply 
 circumscribed and can be shelled out readily. ( >iie of iheni encroaches to a 
 slight extent on the utei'ine ca\-ity. The cer\'ical canal is rathei' shoil , but the 
 mucosa ])resents the usual appeai'ance. The uterine ca\ity is 12 cm. in length, 
 and the nuicosa in the lower part has a slightly granular appeai'ance, due to the
 
 412 
 
 MYOMATA OF THK I'TERUS. 
 
 Fig. 281. — .\n Enlarged .Myomatous Uteris. Adenocarcinoma of the Body of the Uterus. Papillo- 
 
 CYSTOMATA OF BoTH OvARIES, WITH EXTENSION BY CONTINUITY TO THE InGUI.N'AI. GlANDS. (g nat. size.) 
 
 Path. No. 2808. Aut. No. 1220. The bladder is contracted but normal. The uterus is much enlarged, irreg- 
 ularly pear-shaped, and has springing from its surface numerous subperitoneal myomata, some of which are cal- 
 cified. The uterine walls are greatly thickened. They contain many small interstitial myomata. The vaginal 
 mucosa is normal, and the vaginal jjortion of the cervix presents the usual appearance. The cervical mucosa in 
 the lower part is unaltered, but near the internal os the mucosa covering the posterior wall is uneven and ro\ighened, 
 owing to the n\any minute, finger-like processes springing from the surface. In the body of the uterus the normal 
 mucosa is no longer recognizable, being replaced by a ragged looking gnjwth, from the surface of which spring 
 myriads of delicate, finger-like processes. The growth is whitish in cohjr, friable in appearance, and ha-s invaded 
 the uterine muscle to a marked degree; in jilaces it c<)mi)letely encircles the myomatous nodules. .\t another level 
 it was found penetrating some of the myomata, and had extended almost to the iieritoneal surface, a distance of 
 fully 5 cm. On the right side a small portion of an ovarian cyst can be seen. Springing from the outer and inner 
 surfaces of these cysts are papillary ma.sses, the papillary growth extending by continuity into the inguinal glands. 
 On the left side is a small, nuiltilocular ovarian cyst, from the inner surface of which arise papillary growths. 
 The marked thickening and infiltration of the left inguinal region are due to papillary growths in the left ovary. 
 A section through the thickened area would show large and small cyst-like spaces containing tree-like ingrowths. 
 (After Thomas S. Cullen.J
 
 AUTOPSY FINDINGS. 413 
 
 .short, finger-like outgrowths. In its upper })ortion the cavity shows no normal 
 mucosa. The walls are somewhat ragged, and are implicated in a new-growth 
 which in places infiltrates the tissue to a depth of at least 5 cm., penetrating the 
 entire thickness of the uterine wall. The growth consists of delicate trabeculse, 
 in the meshes of which is a fine, crumbly material. 
 
 The right tube is 9 cm. long, considerably curved, and throughout the greater 
 part of its course lies in a depression between the myomatous nodules. It aver- 
 ages 1 cm. in diameter, and has a patent fimbriated extremity. The ovary is 
 converted into a semicystic tumor, 6 cm. in diameter. Its outer surface is in 
 places covered by adhesions, but springing from it at several points are delicate 
 papillary projections or warty outgrowths. On section, the tumor is seen to be 
 made up to a great extent of large and small thin- walled cysts. The semisolid 
 portion consists for the most part of a somew^hat friable papillary growth, which 
 projects into the cyst cavities. The contents of the smaller cysts are gelatinous. 
 
 The left tube is 8 cm. in length, averages 6 mm. in diameter, and terminates 
 in an occluded fimbriated extremity. Its outer surface is covered with dense 
 adhesions that bind it to the posterior surface of the uterus. On more careful 
 examination it is found that the point of occlusion is situated a short distance 
 from the fimbriated extremity of the tube, and that the fimbriae are free; then 
 w^e have a hydrosalpinx, and at the same time a patent outer extremity. The 
 occlusion is due to dense adhesions. 
 
 Springing from the outer pole of the ovary is a smooth-walled cyst, 5 cm. in 
 diameter. Its walls vary from 1 to 2 nmi. in thickness; its anterior surface is, 
 for the most part, smooth, but over an area 2.5 x 2 cm., and corresponding to the 
 ovarian attachment, large clusters of papillomatous masses project into the 
 cavity. Springing from the small portion of the ovary that remains are similar 
 outgrowths. 
 
 The bladder mucosa presents the usual appearance, and no changes can be 
 noted in the rectum. Both broad ligaments are markedly thickened, and areas of 
 induration can be traced down to and are directly continuous with the growths 
 in the inguinal region. On pressure they are somewhat elastic. The entire 
 inguinal growth on the left side on section is found to consist of cyst-like s])aces, 
 some fully 5 cm. in diameter, which contain a gelatinous material. Springing 
 from the partitions between the cysts are complicated i)apillary outgrowths. 
 Such sections remind one very much of a ])apillocystoma of the ovary. 
 
 Histologic examination demonstrated that the growth involving the iinicr 
 walls of the uterus was a typical adenocarcinoma, and that this had given rise to 
 wide-spread metastases especially prominent in the liver. The tumors on either 
 side of the uterus were ])apillocystoniata, ovarian in origin. The growth on the 
 left side had extended by continuity to the inguinal glands. For the complete 
 histologic picture in this case sec "Cancer of the Uterus," p. 468. 
 
 This case is of importance on account of the intimate I'elal ioiishij) between 
 the mvomata and the ;u lei loearci noma. Im'oiii I he clinical e\a mi nation ah )iie the
 
 414 MYOMATA OF THK ITKRUS. 
 
 case would have been considered as one of niyomata. Still more interesting is 
 the coexistence of the carcinoma of the body of the uterus and of papillocystomata 
 of both ovaries. When an incision was made over the prominence in the left 
 inguinal region, the papillary nature of that growth was clearly perceptible to the 
 naked eye; and even if one had previously thouglit of the possibility of an adeno- 
 carcinoma of the uterus, the mintl would have been entirely set at rest on that 
 point, inasmuch as uterine carcinomata originating in the cervix or body never 
 give rise to such metastases. The combination of the uterine myomata, the ad- 
 enocarcinoma of the body of the uterus, and the papillocystomata of both ovaries 
 is, of course, merely a coincidence. It may be well, however, to remember, when 
 considering the advisability of removing an ill-defined pelvic tumor, that inde- 
 pendent malignant growths may exist in the uterus and ovaries at the same time. 
 
 Gyn. No. 8147. Aut. No. 1605. 
 
 Anatomic Diagnosis. — M y m a and a d e n o c a r c i n o m a 
 of the bod}- of the uterus; metastases in the lymph- 
 glands and adjacent peritoneum, p 1 e u r se , medi- 
 astinal glands, and s j) 1 e e n ; extension into the b r o a tl 
 ligament; chronic endocarditis of the aortic and 
 mitral v a 1 \' e s ; cardiac hypertrophy; edema and con- 
 gestion of both lungs; infarction of right kidney; 
 d o u 1) 1 e h \' ( I r o u r e t e r ; general arteriosclerosis; 
 perisplenitis. 
 
 The peritoneal cavity contains about 600 c.c. of a deep red fluid, mostly blood. 
 The surface of the peritoneum is smooth. The uterus is markedly enlarged. 
 Occupying the anterior wall of the uterus is a rounded myoma, 6x4x4 cm., 
 which distorts considerably the shape of the organ. Projecting from the fundus 
 behind the first tumor is a second smaller mass, which merges gradually with the 
 body of the uterus. Situated upon the anterior surface, and also upon the ad- 
 jacent surface of the bladder, are small, firm, grayish-white masses, with irregular 
 and slightly nodular surfaces. Similar nodules arc present in the posterior cul- 
 de-sac and in the wall of the rectum. The uterus is 9 cm. in length, and on section 
 the tumor in the anterior wall proves to be a typical myoma. The cavity of the 
 uterus is 7 cm. in length and 1.5 cm. in width. It contains freshly coagulated 
 blood, and the walls, es])e('ially the posterior portions, are irregular and ragged. 
 Extending from the cavity and occupying the entire fundus and greater portion 
 of the posterior wall is a soft, grayish-white tumor mass, in many places studded 
 with o])aque yellowish areas. There is marked thickening of the broad ligament, 
 and the tubes and o^'aries are densely adherent to the uterus, but there are no 
 adhesions to the wall of the pelvis. Both ureters are embedded in the thick- 
 ened broad ligament and show some slight dilatation. Examination of the wall 
 of the rectum shows that the tumor masses nuMitioiied alxive have invaded only 
 the serous and nmscular coats.
 
 AUTOPSY FIXDIXGS. 415 
 
 Microscopic examination of the tumor mass in the funtlus shows it to be an 
 adenocarcinoma. 
 
 Gyn. No. 7102. Aut. No. 1407. 
 
 Adenocarcinoma of the Ij o d y of the uterus associ- 
 ated with subperitoneal and s u 1) m u c o u s uterine m y o - 
 m a t a . 
 
 L. R., aged fifty-three. Autopsy, August 18, 1899. Anatomic diagnosis: 
 adenocarcinoma of the uterus; sloughing submucous myoma ; pyometra; suppu- 
 rating parametrium; vaginal implantation with carcinoma; extension to the peri- 
 toneum and the surface of pleura; thrombosis of the femoral veins; embolic 
 plugging of both pulmonary arteries; infarction of the right lung ; thrombosis of 
 the vesical veins; cardiac hypertrophy and dilatation; chronic diffuse nephritis 
 (small granular kidney) ; cholelithiasis. 
 
 The abdominal cavity contained a large amount of fluid. The intestines were 
 slightly matted together, the coils being studded with small tumor nodules. The 
 uterus was globular, extended 12 cm. above the symphysis, and was adherent to 
 the abdominal wall. The tubes and ovaries were buried in adhesions. The 
 uterus was pear-shaped, measuring 18 x 14 cm. The bladder was adherent to it. 
 Attached to the uterus at the cornu was a ])edunculated myoma, 3 cm. in diam- 
 eter. Similar but smaller nodules were found on the posterior surface of the 
 uterus. The uterine cavity was full of grayish-looking pus. The mucous mem- 
 brane was 2.5 cm. in thickness, and apparently had grown into the uterine wall. 
 The appearance strongly suggested carcinoma. Scattered throughout the uter- 
 ine wall were numerous submucous myomata, the largest 6 cm. in diameter, and 
 sloughing. 
 
 Histologic examination showed the growth to be a typical adenocarcinoma. 
 
 Gyn. No. 278, Aut, No. 117. 
 
 C a r c i n o m a o f t h c bod y o f t li c u t e r us a s s o c i a t e d 
 w i t h large an d s m a 1 1 u t e r i n c in y o m a t a . 
 
 M. L. K., white, aged sixty-five. Admitted .July 13, 1890. The i)atient has 
 had no children and no miscarriages. The iii('n()])ause was passed about fifte(Mi 
 yearsago. For the last year she has complained of aconstant bloody vaginal How 
 and of pain in the back, and during the last four months of ])ain in the right groin. 
 She has noticed swelling of the feet and ankles for the last we(>k. l-'illing the 
 lower part of the abdomen is an oblong mass, apiinrcntiy adiicicnt lo the ab- 
 dominal wall, ^riic umbilicus is slightly rctiactcd. The \aginal outlet is in- 
 tact; the cervix is small. The pelvis is full of small nodules. The patient has 
 been delirious for the last few days. The urine contains a considerable amount 
 of albumin. 
 
 Aut. No. 117 (July 27, 1890). On the anterior wall of the uterus is a partly 
 calcified myoma, 3.5 cm. in dianuMer, and on the lel'l side a inyoina. l!»x I.") cm.,
 
 416 MVOMATA OF THK ITHRUS. 
 
 grayish in color. Tiiis tiiinor is easily shelled out from the uterus. The left tube 
 is dilated and elongated. It is 4 cm. in diameter and 24 cm. in length. The 
 right tube is likewise closet! ; it is 2 cm. in diameter and 18 cm. in length. The 
 body of the uterus contains several fungus-like, friable masses, and the upper 
 part of the cavity is filled with ])rojections resembling villi over an area 5 cm. in 
 diameter. 
 
 Histologic examination shows the growth to be a tyijical carcinoma of the 
 body of the uterus. The autopsy was an incomplete one, but sufficiently thor- 
 ough to show that there were a chronic diffuse nej)hi-itis and hypertrophy of the 
 left ventricle of the heart. 
 
 Gyn.N0.1173. Aut. No. 277. 
 
 I n c o m p 1 e t e m y o m e c t o m y , o n e n o d u 1 e having been 
 removed, others left behind on account of dense ad- 
 hesions. Death resulted f r o m general peritonitis. 
 Unsuspected carcinoma of the body of the uterus 
 was found at a u t o j) s y . 
 
 A. B., single, aged forty-three, colored. Admitted January 26, 1892. Men- 
 struation began at fourteen, was regular. ])ainful. ])r()fuse, and lasted from three 
 to four days. Three and one-half weeks ago the i)atient noticed a lump in the 
 left iliac region. For a few months previous she had had some pain. In No- 
 vember, 1891, in New York, she had two small myomata removed by the vagina. 
 At the present time tliert^ is a growth down in the right ovarian region, and the 
 patient has a slimy, wat(>ry vaginal discharge, with occasional burning. She 
 is very anemic. 
 
 Vaginal Examination. — The outlet is relaxed. The cervix is near the outlet 
 and is intact. Filling the entire pelvic cavity is a hard and innnovable mass, 
 a nodular portion, the size of two fists, occupying the left side of the pelvis. 
 
 Operation, February 13, 1892. Myomectomy. 
 
 The uterus apparently contained two myomatous masses, the anterior one the 
 size of an orange, the jjosterior one a little larger. After the release of a few 
 intestinal and omental adhesions the anterior myoma was enucleated. The 
 posterior one could not be shelled out on account of the dense adhesions. 
 
 The patient vomited a great deal after the operation. The abdomen soon 
 became distended; the pulse grew ra])i(l, and the tem])(>rature rose to 103° F. on 
 the fifth day, but (Iropi)e(l to 101..")° F. on the sixth. The patient at this time 
 was covered with a cold, clammy sweat; .>^he voided her urine involuntarily, 
 and died on the same day. She had definite signs of peritonitis. 
 
 Aut. No. 277. Anatomic diagno.sis: Acute ))urulent ))eritonitis following 
 abdominal myomectomy; subpci'itoncal and sul)inucous utei'ine myomata; un- 
 suspected carcinoma of the body of the uterus; general arteriosclerosis; cardiac 
 hypertrophy; chronic diffuse nei)hritis; emphysema of both lungs; bronchopneu- 
 monia of the right lung.
 
 AUTOPSY FIXDIXGS. 417 
 
 In the peritoneal cavity is a considerable accinnulation of tiirljid fluid that 
 has a decidedly fecal odor. There are slight intestinal adhesions. In the pelvic 
 cavity is a sloughino; area correspomUng to the point of niyoniectoniy. The tubes 
 and ovaries are bound down by adhesions. The uterine cavity is fihed with 
 sloughing tumor masses, which seem to be infiltrating the uterine wall. The 
 cervix is free. Scattered throughout the uterus are several small myomata. 
 Sections from the uterine wall revealed adenocarcinoma of the body. Cultures 
 from the peritoneal cavity showed a pure growth of Staphylococcus pyogenes 
 aureus. 
 
 Carcinoma of the Rectum Associated with Uterine Myomata. 
 
 In one of these cases the carcinoma was situated in the sigmoitl flexure. 
 Both ovaries were the seat of C3'stic tumors, and the uterus contained myomata. 
 In this case fatal peritonitis developed. On p. 392 is described in detail a case 
 in which a carcinoma of the sigmoid was accidentally discovered after the re- 
 moval of a large m^^omatous uterus. A portion of the bowel w'as resected, 
 and the patient lived for several months. 
 
 In the second case here tlescriljed the myomatous uterus was large. One 
 ovary was the seat of an abscess, and all the tissues were densely matted together 
 by pelvic adhesions. Examination of the rectum revealed a carcinoma involving 
 the entire lumen of the bowel, situated 1 cm. from the anal orifice. In neither of 
 these cases was an operation feasilile. 
 
 Gyn, No. 12656. Aut, No. 2671. 
 
 Carcinoma of t h e s i g m o id flex u r e , u t e i' i n e m y o - 
 m a t a , b i 1 a t e r a 1 a d e n o c y s t o m a t a o f t h e o \' a r }• ; sec- 
 ondary p e r i t o n i t i s . 
 
 E. C, colored, single, aged thirty. Admitted January 25; died February 
 8, 1906. The patient has com|)lained of ))ain in th(> abdonuMi for the past three 
 years. At present she has four or five stools daily, which show the ])resence of 
 blood. This sym])t()m has been noted for nearly a year, although the patient 
 has no hemorrhoids. She appears to be very ill, and is extremely emaciated. 
 
 A week after admission to the hospital there was considerable abdominal 
 distention, and a rather definite tumor mass could be felt in the i-ight hypo- 
 gastrium. She died fi\-e days later. On account of the extreme weakness a 
 satisfactory examination could not be made. 
 
 Aut. No. 2()71. Anatomic diagnosis: l^ilateral o\arian adenoe\-stoniata ; 
 multiple utei'ine myomata : carcinoma of the sigmoid flexure: ])erl oral ion ol the 
 bowel; gangrenous peritonitis. 
 
 The contents of the abdominal cavity are ci-owded high up into the cavity 
 by two large tumor masses which extend upwai'd from the peb'is: one lying 
 in the median line extends to l.o cm. above the synii)hysis ])ubes: the second 
 lies in the left flank an<l extends to the costal border. Between the two masses
 
 418 MYO.MATA OF THE UTERUS. 
 
 is a cavity containing a tarry, iirccnish-hlack material, with a mixture of blood 
 and havino; a distinctly gangrenous odor. The tumor masses are covcMvd with a 
 thick fi]:)rous membrane outside the capsule, which apparently represents a 
 reflected peritoneal fold. The intestines are bound down to the tumor masses 
 by fibrous adhesions, and to each other by a firm fibrinopurulent exudate. 
 The diai)hragm reaches to the third rib on tlu' right side, and to the fourth inter- 
 space on the left. The ])elvic viscera and tumor masses were removed in one 
 mass. On section, the uterus seems normal in size; it has been pushed forward 
 and to the left by the tumor. Rising from its fundus is a pedunculated tumor, 
 7.5 X 4 cm. in diameter. This tumor is slightly lobulated; it is firm, and on 
 section shows interlacing l:)undles of tissue in a somewhat translucent back- 
 gi-()vmd. A similar but smaller tumor, measuring 2.5 x 1.5 x 1 cm., lies just 
 beneath the serosa. In the anterior surface of the uterus a third tumor, 8.5 cm. 
 in diameter, is ])resent. They all })resent the typical myomatous a])pearance. 
 The large tumor masses described earlier are attached to the uterus l)y an ovarian 
 ligament; one occupies the position of the right ovary, the other the left. The 
 mass corresponding to the right ovary measures 19 x 12 x 12 cm. It is firm, 
 and on section has a light yellowish-pink color, and on close inspection is seen 
 to have a honey-combed structure, the surface showing many small cavities, 
 1 to o mm. in diameter, containing colloid material. The cut surface is some- 
 what uniform in appearance. The capsule has Ix^en in no way invaded by the 
 growth. The mass in the position of the left ovary measures 15 x 10.5 x 10 cm.; 
 in the upjx'r part of the tumor it abuts on the gangrenous peritoneal cavity 
 mentioned. This cavity, which appears as a deep ragged space, is filled with 
 foul-smelling, softened, grayish-black material. Except for this and a somewhat 
 general greater degree of softness, this tumor resembles that found in the sigmoid 
 flexure. There is a fungating tumor mass in the bowel, 16 cm. from the anal 
 opening. This mass is made up of numerous large nodules of irregular shape, 
 ])rojecting into the lumen — at one })oint for a distance of 2.5 cm. These masses 
 surround a crater-like depression where there has been a perforation of the in- 
 testinal wall. The pcM'foration leads ui)ward between the tumor masses into the 
 cavity above described. On section of the tumor mass the muscular coat of the 
 intestine is foimd to be invaded by a somewhat opa(|ue growth. Al)ove the ulcer- 
 ation the intestine is dilated and its mucosa shows numerous ulcers. Its wall 
 is hypertrophied. 
 
 Microscopic examination of the uterine nodules shows them to be typical 
 myomata without degeneration. Sections from the solid portions of the ovarian 
 cysts show the tumors to be made up of alveoli containing a colloid material. 
 The alveoli are lined with a singli' layer of uniformly staining epithelial cells. 
 Portions of the section show some necrosis, but no signs of malignancy are 
 present. In one necrotic area there is leukocytic invasion. Sections from the 
 tumor in the sigmoid flexure show the growth to consist of large alveoli lined with
 
 AUTOPSY FIXDIN'G.S. 419 
 
 irregularly shaped and stained cells, lying usually in a single row. The growth 
 has invaded the muscular coat as far as the peritoneum. 
 
 This case is very interesting on account of the multiplicity of the pathologic 
 processes detected in the pelvis. Not only are thtnv the myomatous uterus, 
 and the large ovarian cysts, but also the carcinoma of the sigmoid flexure, 
 which in itself would have been suflficient to cause death. 
 
 Gyn. No. 562. Aut. No. 172. 
 
 Carcinoma of the r e c t u m ; uteri n e m y o m a t a . 
 
 J. Z., white, admitted February 3; died February 17, 1891. The patient 
 is forty-eight years of age. She has been married twenty years, but has never 
 been pregnant. The menstrual periods have been regular during the past year. 
 The patient complains of pain in the left flank, with alternating attacks of con- 
 stipation and diarrhea, with occasional bloody stools. She has lost considerably 
 in weight during the past two years. During this same time she has suffered con- 
 siderably from pain and diarrhea, but these symptoms have been especially 
 troublesome during the past three months. During the past six months blood 
 has frequently been found in the stools. In the past three months there has 
 been pain in the left iliac region, and also in the lower abdominal zone. Palpation 
 in this region elicits consideral)le tenderness. On vaginal examination the uterus 
 is found to be markedly enlarged, hard, and fixed; it fills up the whole lower 
 portion of the pelvic cavity. On manipulation a free bloody discharge comes 
 from the uterus. Owing to marked tenderness, examination is exceedingly difli- 
 cult. 
 
 Aut. No. 172. The pelvic viscera were removed en ina.sse. Douglas' pouch 
 was obliterated by fibrous adhesions between the rectum and the uterus. The 
 inner wall of the rectum, 1 cm. from the anus, is occupied by an ulcerated new- 
 growth which implicates the entire circumference of the bowel and is 7 cm. long. 
 The ulcerated surface of the growth is whitish ; its margins are ele\-ated and of a 
 soft, grayish appearance; intermingled are areas of henu^rrhage. The whole 
 presents a crater-like appearance. The wall of the rectum has been entirely 
 destroyed. Over the central ulcerated area it measures 5 cm. in iliamclri-. The 
 muscular wall of the rectum is hy))ertro))hied al)ove the growth. 
 
 The posterior wall of the uterus is hrmly emheddcd in adhe.^ions to the 
 cancerous part of the bowel, and is the seat of s('\-eral intci-stitial myomata. The 
 largest on th(> right side is 5 cm. in diameter. There is a soft, pedunculated sui)- 
 mucous myoma, 1.") cm. long, and in the right lateral vaginal wall a cyst. 4 cm. 
 in diametei'. The left ovar}- contains an abscess 7 x S cm., and tVom it esca])es 
 green, foul-smelling pus. 
 
 Cultures from the abscess of the ovary show a colon-like b.-u-ilhis, and sections 
 from the rectal tumor prove that it is an adenocarcinoma of the bowel.
 
 420 .MYUMATA OF THE UTERUS. 
 
 Sarcomatous Transformation of Myomata Detected at Autopsy. 
 In only one case was a j)riniary sarcoma (Ictcctcd in a myoma at autopsy. 
 (Gyn. No. OO-io. Aut. No. lOSo.) This case was carefully described by the late 
 Dr. J>ouis I.ivin^ood. and is given in detail (page 224) with a series of similar 
 growths detected at ojx'ration. 
 
 Sarcoma of the Bladder Associated with Uterine Myomata. 
 As this condition is exceetlingly rare, a short history of the case is given. 
 
 Gyn. No. 832. Aut. No. 211. 
 
 L. G., aged forty, coloi'ed. Admitted to the Johns Hopkins Hosi)ital June 
 24; died July 12, LS91. She had been married twent^'-five years and had 
 had four children and one miscarriage. For the previous month she had been 
 complaining of incontinence and painful micturition. The urine was very strong 
 in odor and of a dirty, muddy color, and material resembling grit had been passed. 
 These pieces at times were as large as beans. She had complained of pain in 
 the lower part of the abdomen for the last two months, and said that it burned 
 like fire. She had had fever and chills, and had lost in weight. 
 
 The patient on admission appeared anemic and had a worn expression. The 
 abdomen was slightly swollen, and she complained of sudden attacks of pain. 
 On examination the outlet was found to be relaxed, th(> anterior vaginal wall 
 was tense and sensitive, and there was a mass the size of a closed fist just behind 
 the symphy.sis. It moved up and down in the pelvis and had a markedly solid 
 feeling. The uteru-^ was retroflexed. The patient gradually lost ground, and 
 died July 12, 1891. 
 
 Aut. Xo. 211, July 1.3th. Anatomic diagnosis: Sarcoma of the bladder, no 
 metastases; extensive diphtheric cystitis, pyehtis, some pyelonephrosis, espe- 
 cially of the left kidney, chronic diffuse nephritis, apparently limited to the left 
 kidney, moderate atheroma, slight cardiac hypertrophy, moderate i)ulmonary 
 emphysema, uterine myomata. 
 
 The l)la(lder-walls are much thickened, measuring on an avcTage 0.8 to 1 cm. 
 in thickness. The muscular coats are hypertrophied. The nnicous membrane 
 of the bladder has been almost entirely rejjlaced by exten.-^ive dij^htheric u1c(t- 
 ation. From the inner surface of the bladder j^roject several soft, grayish-white 
 masses. The free surface in some places is covered with a slight opacjue grayish- 
 white necrotic tissue, and the tissue beneath is almost homogeneous, appearing 
 like mucous membrane. The growths vary in size from O.'A to 1 .5 cm. in diameter, 
 and project in places as far as 1 cm. into the bladder. 11iey have broad basal 
 attachments, and arc most ;diuiidaiit in the jiosterior wall of the bladder, near 
 its middle portion. The vaginal mucosa is ('(mted, over a large part of its extent, 
 with a grayish, coherent false membrane, which in ))laces can be scraped off without
 
 AUTOPSY FIXDIXGS. 421 
 
 loss of substance, while in other places the mucosa itself seems to be nothing more 
 than necrotic membrane. 
 
 The uterus is 7 cm. long antl contains in its walls myomata, the largest of 
 which is 2 cm. in diameter. The myomata are submucous, interstitial, and sub- 
 peritoneal. The left ovary and tube are surrounded by old adhesions. 
 
 Histologic Examination. — The free surface of the bladder growth is covered 
 with a necrotic layer containing many bacilli and some chromatin particles. The 
 new-growth is composed of closely packed cells, varying in size and shape. 
 In general they are large and somewhat fusiform, not mistakable for smooth 
 muscle-fibers. In other places there are epithelioid cells, round, oval, or poly- 
 gonal in shape. There are also cells with large, well-staining vesicular nuclei, 
 and a protoplasm that is somewhat granular. The cells in the growth are 
 separated from one another by a scant amount of a finely hbrillated sul^stance. 
 Sometimes the cells occur in clumps, apparently in lymph-spaces, but there is no 
 regular alveolar arrangement. Strands of the same kind of tissue extend out 
 between the bundles of smooth muscle tissue, or they often spread out into 
 the layers. This invasion of the muscle extends in places throughout the entire 
 thickness of the bladder-wall, but the main mass of the tumor lies inside of the 
 muscular coat, in the situation of the mucosa or submucous coats, which are not 
 to be recognized. 
 
 The tumor is a mixed large-celled sarcoma, with a predominance of large 
 fusiform cells, often arranged in bundles, especially along the blood-vessels. 
 The presence of the uterine myomata in association with sarcoma of the 
 bladder is, of course, a mere coincidence. 
 
 Tuberculosis of the Uterus Associated with Myomata. 
 There was only one case in which tuberculo.sis of the uterus coexisted with 
 uterine myomata. In Aut. No. 136 on a patient thirty-two years of age i)ul- 
 monary tuberculosis was found. The mcscnlci'ic glands were implicated. In 
 the left uterine cornu was a myoma, 3 cm. in diameter, that showed areas of 
 degeneration. The Ixjdy of the uterus was occujjied by a gi'ayish mass which 
 projected into the canal, and scattered throughout it were tubercles. In this case 
 the tuberculous j)rocess in the uterus was undoubtedly secondary to the pulmon- 
 ary lesion. 
 
 Autopsies in which Heart Lesions were Found, possibly Attributable to 
 
 Uterine Myomata. 
 
 We have two cases in which it seeiiKnl that the niyomata directly or indirectly 
 had been responsible for the cardiac lesion. In the one case tlieic wcic \-ege- 
 tations on the heart-valves; in the oilier. (legenerati\-e changes wei-e found in 
 the heart muscle.
 
 422 ]\IY<)MATA OF THE UTERUS. 
 
 Gyn. No. 6185. Aut. No. 11 12. Path. No. 2441. 
 
 M u 1 t i )) 1 (' 111 y 111 a t a o f the u t e r u s , wit li one large 
 sloughing s u h 111 u c o u s n o d 11 1 e . A c u t e vegetative 
 a o r t i e and mitral endocarditis; septic infarction 
 of the left lung, acute localized j) 1 e u r i s y , old 
 [) 1 e u r i t i c adhesions, chronic interstitial splenitis, 
 subacute glomerular nephritis, recent miliary ab- 
 scesses in the renal pyramids, chronic adhesive 
 pelvic J) e r i t o n i t i s . 
 
 The j)atient was fifty-four years of age, colored. Admitted June 21; 
 died June 2o, 1898. She was in a precarious condition, and had to be operated 
 u])on at once. On examination under ether an ovoid tumor was found pro- 
 jecting from the vulva. It was yellowish l)rown or greenish in color, and cystic. 
 It had a ])edicle 2. 5 cm. in diameter, and sprang from the cervix on the left side. 
 A smaller and similar mass was also seen projecting from the cervix. The uterus 
 was the size of that of a four months' pregnancy, hard, and fixed in the pelvis. 
 The pulse was very rapid, and the temperature 101.8° F. The submucous 
 nodules were removed in the usual way, but the j^atient steadily grew worse. 
 Her maximum temperature on the day of her death was 106.2° F. 
 
 Aut. No. 1112. The myomatous uterus was found firmly bound down 
 in the pelvis by numerous adhesions. The aortic and mitral valves were the seat 
 of fresh vegetations. Septic infarction was found in the left lung, and there were 
 evidences of old adhesions in the pleural cavity. 
 
 The kidneys were the seat of a subacute inflammation, and as evidences of 
 the recent infection miliary abscesses were found in the pyramids of the left 
 kidney. The offending organism was Staphylococcus pyogenes. 
 
 Path. No. 2441 . The submucous nodule removed from the uterus at operation 
 was 12 cm. long and 7 cm. in diameter. Its surface was slightly roughened; 
 otherwise it presented the typical myomatous appearance. Sections from the 
 surface of the tumor showed no trace of mucosa. The surface was covered with 
 polymorphonuclear leukocytes and necrotic tissue. Beneath was a very vascular 
 zone, comjiosed of large and small blood-vessels. So abundant were these blood- 
 vessels that in j)laces they occupied half the field. Some of the vessels contained 
 organizing thronil)i. The surrounding stroma showed considerable hemorrhage, 
 but was covered with many polymorj^honuclear leukocytes. The tumor was 
 composed of non-striated muscle-fibers running in various directions. It was an 
 ordinary siihmucous myoma, the surface of which had become necrotic and had 
 gradually disintegrated. In this case a general infection had ])r()bably developed 
 ironi the sloughing submucous myoma, and might account for the vegetations on 
 the cardiac valves and for the recent miliary abscesses in the kidney.
 
 AUTOPSY FIXDIXGS. 423 
 
 Gyn. No. 77. Aut. No. 69. 
 
 M y 111 a of the uterus with central 11 e c r o s i s , p y o - 
 nephrosis due to \)Y e s sure on the ureters. Chronic 
 passive congestion of the lungs, d i s ji 1 a c e m e n t of t he 
 diaphragm and a b d o 111 i n a 1 viscera b }' pressure of the 
 tumor, hypertrophy and hyaline degeneration of the 
 heart (Figs. 282 and 283). 
 
 An abstract of the case reported by Dr. Ernest K. Cullen in the Johns 
 Hopkins Bulletin, 1906, vol. xvii, p. 267, is quoted here: 
 
 The patient was admitted January 6, 1890. No satisfactory history could 
 be obtained on account of her condition. She, however, first noticed a tumor 
 in the abdomen about four years ago. This had gradually increased in size. The 
 abdominal wall was uniformly distended by a large tumor, which on palpation 
 presented two smaller nodules in the lower abdominal zone. The patient had a 
 slight but exceedingly fetid vaginal discharge. She was examined by Dr. 
 Osier, who, apart from the pressure symptoms due to the tumor, found nothing 
 abnormal. The patient gradually grew weaker and died on January 31st. 
 
 Aut. No. 69. The uterus is 19 cm. in length, anteflexed, and occupies 
 the anterior portion of the tumor. The tumor is nodular, and divided into two 
 distinct lobes. On section, it presents a triangular cavity, which at its base 
 measures 11 cm. It is filled with a slightly blood-stained fluid, and dense masses 
 of firm Avhite elastic tissue. The lymphatics in the lower abdomen are greatly 
 dilated and contain a brownish colored fluid. 
 
 The left kidney is enormously dilated and turned toward the front. The cap- 
 sule is adherent. The surface is irregular and lobulated. Beneath the capsule 
 are numerous whitish areas, while surrounding the kidney are jiurulent foci. 
 The pyramids are flattened. The pelvis is generally smooth and hard, and 
 covered with a fibrinopurulent exudate. The ureters are dilated and closely ail- 
 herent to the posterior surface of the tumor. The right kidney is about th(> 
 same size as the left, and presents essentially the same features. 
 
 The liladder mucosa shows ecchymoses, is dee})ly injected, and contains a 
 small amount of turbid urine. 
 
 The heart is slightly enlarged, and weighs 245 grams. The pericardial surfaces 
 are smooth. With the exce))ti()n of a slight contraction of the mitral orifices, 
 the valves appear to be normal. .\ few i)ale ])atches are seen scattcicd throughout 
 the cndocardiuiii. The wall of the left vent i-icic iiicasurcs 17 1111 11., and that of the 
 right 4 mm. in thickness. The heart muscle is tolenibly lii'iii and dark brown 
 in color. On section of the left ventricular wall, small foci arc visible immediately 
 beneath the endocardium. The orifices of the coi-onary Mitci'ics aic dihitcd. 
 
 Histologic appearances of the heart iiiusch'. Scattered throughout the wall 
 of the left ventricle, especially near tiie endocardium, ai'e numerous isolated 
 groups of opaque, deeply staining fibers, which ajipear to have undergone calci-
 
 424 
 
 MYOMATA OF THE UTERUS. 
 
 fication (Fig. 282). These areas are composed of adjacent fibers ranging in 
 nunibc^r usually from three to twelve. Such fibers in most instances are well 
 defined, but occasionally appear irregular in outline, as if disintegrating. They 
 have lost both t heir cross and longitudinal striations, and appear rather homogene- 
 
 .^.7 - -i- ^ 
 
 
 ^•^•,.., 
 
 
 
 •y^^.'i^SLikS 
 
 Fig. 282. — C.\i.t iii. vi lus ut hik IIi-.aki Musci.k As>im iai kd uiki L ilium-. Myomata. (X 125 diam.) 
 
 Aut. No. 69. The dark areas represent calcifietl muscle-fibers. The most characteristic of these are indicated 
 
 by a. The stroma between the muscle-fibers shows some small-cellefl infiltration, (.\fter Ernest K. Cullen.) 
 
 ous and opa(iue, staining deeply with iiiethylene-blue and hematoxylin. No 
 nucleus is discernible within the fiber, but fine, small, oval or round nuclei are situ- 
 ated about it. In the interventricular septum the process appears to be much 
 less extensive. Single fibers (Fig. 283) are observed, which present a homogeneous, 
 granular tippearance, and with the cosiii stain ai'c differentiated fn^m the sur-
 
 AUTOPSY FINDINGS. 425 
 
 rounding fibers. Sucii fihci's ai'c stained faintly hi'own in color, and the nucleus 
 is absent. Definite calcification is observed in small groups of fibers which, 
 in general appearance, resemble those in the wall of the left ventricle. In sections 
 taken from other parts of the heart no alteration of the fibers was visible. 
 
 At the time of the autopsy Professor Welch studied the microchemical 
 reaction of these altered fibers in the fresh specimen, and found, on the addition 
 of glacial acetic acid to those fibers which contained a highly refractive substance, 
 a slow dissolution of this material without the evolution of gas. This refractive 
 material dissolved I'apidly in hydrochloric and nitric acid, also without the 
 evolution of gas. As it dissolved the fibers sw(>]1(h1 and lost their refractive 
 
 *3» 
 
 
 
 "<C> 
 
 ^ 
 
 
 I .^v a :.^ 
 
 Vv 
 
 '■^p 
 
 - r -- ' V 
 
 \ I 
 a 
 
 Fig. 283. — Hyaline Degeneration of Heart Muscle, .'Associated with Uterine Myomata. (X 650 diam.") 
 Aut. No. 69. The section is from the interventricular septum. Some of the muscle-fibers (a) have imdergone 
 typical hyaline degeneration, and the stroma surrounding them shows some small-round-celled infiltration, (.\fter 
 Ernest K. CuUen.) 
 
 property and appeared h\'aliiu'. This suljstancc was insoluble in strong caustic 
 ])otash and ammonia. In the frozen section left onci- night in an atiucous 
 solution of potassium dichromate the refract i\c iiiatci-ial dissolved slowly. The 
 most interesting reaction was obscixcd in the spccinicn treated with strong 
 sulphuric acid. The refracti\'e matei'ial changed without the eNolution of gas 
 into beautiful clumj^s and rosettes of naiiow, I'hombic crystals of calcium sul- 
 phate. Smaller crystals, usually single, ap|)eai'ed in the fluid close by, but no 
 such reaction was ex'ideiiced in specimens fi-oiii otliei' ]>ai1s ot the heai't. 
 
 Ernest Culleii says fuiiher: "The etiolog\" of the cell neeiosis in this case 
 cannot be definitely determined, but it is possible that the etiologic factor con- 
 cerned in the })roduction of the existing pyoiiephi-osis may also be responsible
 
 426 MYOMATA OF THE UTERUS. 
 
 for the lesion in the inyocardiuni. The pressure exerted upon the heart by 
 the large abdominal tumor may also have entered into the causation." 
 
 As noted in the history, no definite account of previous illness could be 
 obtained. The myoma caused pressure on the ureters, infection followed, and 
 then necrosis in the heart muscle, with subsequent deposit of calcium salts. It 
 it ([uite iH)ssil)le that if no myoma had existed no pyonephrosis would have 
 developed, and consequently no cardiac lesion would have followed. In any 
 event the presence of the myoma was a predisposing factor. 
 
 In neither of these cases is there clear presumptive evidence that the myomata 
 were responsible for the cardiac lesion, but the clinician will certainly gather 
 the impression that if the myoma had been removed several years before, the 
 danger of cardiac lesion would have been materially less. 
 
 Death Due Directly to Myomata. 
 
 All surgeons are familiar with the marked pallor seen in patients suffering 
 from continued and severe hemorrhages when submucous myomata are present, 
 and also with the elevation of temperature and other septic phenomena which 
 accompany foul-smelling and sloughing submucous myomata. 
 
 In Clyn. No. 11337 the jxitient entered the hospital complaining of weakness 
 and loss of blood. Her hemoglobin was only 12 per cent., and she died within 
 four (lays. The autopsy findings were those that might have been expected 
 aftci- excessive hemorrhage. 
 
 In Gyn. No. 6185 the symptoms were those of exhaustion from hemor- 
 rhage, combined with sepsis due to absorption from the foul, sloughing submucous 
 myoma: the secondary cardiac and pulmonary foci were a natural sequence to 
 the local necrotic and sloughing myoma. 
 
 A study of Gyn. No. 10337 shows that the j)atient was suffering from 
 emaciation and marked toxemia, evidently in large measure due to a slough- 
 ing submucous nodule. Both kidneys contained retention cysts. These probably 
 hastened the patient's d(>ath, but the changes may lik(>wise have been primarily 
 due to the myoma. 
 
 In the fourth ca.se, Gyn. No. 77, there were a fetid discharge from the 
 vaginti and central necrosis of one of the myomata. The abdominal contents 
 had been nmch displaced by the tumor, and the ureteral dilatation was caused 
 by pressure exerted by the tumor. In this case the death was in all prol)al)ility 
 itiimcdiatcly due to the pus kidney, but primarily to the tumor. 
 
 A careful ])erusal of these cases will certainly convince the reader that if th(i 
 myomata had not been present, or if they had been removed before the nodules 
 had become submucous, the outlook for the patients would have been greatly 
 inqjroved.
 
 autopsy p^ixdixgs. 427 
 
 Cases in which Myomata Caused Death. 
 
 Gyn. No. 11337. Aut. No. 2319. 
 
 Intramural myoma; hemorrhage from the uterus; 
 extreme secondary anemia; fatty degeneration of 
 the heart and other organs; focal necroses in the 
 liver; double hydrosalpinx; ovarian cysts; healed 
 infarct of spleen. 
 
 B. H., colored, aged thirty-eight. Admitted June 6; died June 10, 1904. 
 She complained of weakness and bleeding. 
 
 She was married ten years ago, but has had no children. Six months ago she 
 began to have hemorrhages. The flow lasted about three weeks. From that 
 date there has been almost constant bleeding, and she has been in bed for three 
 months. WTien the bleeding is not present, there is a very foul discharge. The 
 patient is very weak and short of breath. There is considerable nausea and 
 vomiting. The mucous membranes are ver}' pale ; the hemoglobin is 12 per cent. 
 Red blood-corpuscles, 1,828,000. In making a blood examination the patient 
 bled so much from the prick in her ear that compresses had to be put on to 
 stop the bleeding. Adrenalin had no effect. 
 
 Vaginal Examination. — A mass is felt extending a hand 's-breadth above the 
 symphysis. The cervix is smooth and normal. There is a mass the size of a 
 cocoanut occupying the fundus. 
 
 The patient gradually lost ground, and died the fourth da}^ after her admission. 
 Her temperature varied between 102° F. on admission and 103° F. on the second 
 day; on the fourth day, the day of her death, it reached normal. The uterine 
 cavity was irrigated and packed with gauze, but this procedure did not in any 
 way check the bleeding. 
 
 At autopsy it was found that the uterus contained three myomata. The 
 chief bleeding had come from the submucous myoma, and there were marked 
 anemia of the various organs, fatty degeneration of the heart, and focal necroses 
 in the liver. 
 
 In this case the death seems to have Ix'cn due primarily to the excessive 
 uterine hemorrhages. 
 
 Gyn. No. 10337. Aut. No. 2088. 
 
 L' t e r i n e m y o m a t a with a s 1 o u g h i 11 g sub m u c o u s 
 n o d u 1 e ; m a r k e d e m a c i a t i o n a n d p r o t' o u 11 d t o x c m i a . 
 R e t e n t i o n cysts in the k i d 11 c y s . 
 
 J. McC, aged forty, colored. Admitted March 17: dic.l Marcii 22. I<)03. 
 Her history was obtained from her sister-in-law, as the jinliciit was unconscious. 
 Fifteen years ago she had an attack of tyi)liniil U'vrv ;iMd was insane. Re- 
 covery took place after two montiis. Since then she has been a little <|ueer at 
 times. Ten years ago an abdominal tumor was first noticed. This has grown
 
 428 MYOMATA OF THE FTKRUS. 
 
 slowly. Tlirt'e weeks ago she was taken ill, Init no further history could be 
 ehcited. 
 
 On admission she was very irrational and much emaciated. The temperature 
 was 96° F. ; the pulse, 100. She was di-owsy most of the time, apparently pro- 
 foundly toxemic. The hmg-sounds were normal. There was a loud systolic 
 murmur at the apex, transmitted to the axilla and over the entire chest. The 
 abdomen was .'symmetrically enlarged below the umbilicus, and on the upper 
 surface of the tumor were three nodules. The patient's condition gradually 
 grew worse, and she died five days after admis.sion. 
 
 At autopsy a sloughing subnuicous myoma was found, and the uterus also 
 contained numerous nodules. In both kidneys retention cysts were encountered. 
 There were marks of old rachitis, and apparently nmcoid degeneration of the sul)- 
 epicardial fat. 
 
 Grayish opaque flecks were found in the myocardium. 
 
 In this case the cause of death seems to have been the sloughing sul)mucous 
 myoma, a.ssociated with the results of pressure. 
 
 Tor the details of Gyn. No. 6185 (Aut. No. 1112) seep. 422, and for the findings 
 in Gyn. No. 77 (Aut. No. 69) see p. 423. 
 
 Summary of the Autopsy findings in which Uterine Myomata were Present. 
 The following tabulation gives the more essential autopsy findings as viewed 
 from the surgeon's standpoint: 
 
 Tuberculosis of the Fallopian tube associated with uterine myomata (Aut. No. 
 
 189S) 1 case. 
 
 Carcinoma of the ovarj' (primary) associated with uterine mj'omata (Aut. Nos. 
 
 474 and 1.371) 2 cases. 
 
 Sarcoma of the bladder associated with uterine myomata (Aut. No. 211) 1 case. 
 
 Carcinoma of the sigmoid flexure associated with uterine myomata (Aut. Nos. 
 
 172 and 2671) 2 cases. 
 
 Tuberculosis of the uterus associated with uterine myomata (Aut. No. 136) 1 case. 
 
 Carcinoma of the cervix associated with uterine myomata (Aut. Nos. 689, 926) .... 2 cases. 
 Carcinoma of the body of the uterus associated with myomata (Aut. Nos. 117, 277, 
 
 505, 1220. 1407, 1605) 6 cases. 
 
 Sarcomatous transformation of uterine myomata (Aut. No. 1085) 1 case. 
 
 Cases in which sloughing myomata were directly the cause of death (Aut. Nos. 69, 
 
 1112, 2088, 2319) 4 cases. 
 
 According to this table, in S cases carcinoma of the uterus complicated the 
 myomata. In all but one of these cas(>s the myomata were of sufficient size to 
 obscure the diagnosis. In one case the myomata had become sarcomatous. 
 Thus, out of 148 autopsies, in (> jx'r cent, the myomata were associated with 
 malignant changes in the uterus. 
 
 In two cases the ovaries were the seat of primary carcinoma. In one instance 
 primary sarcoma of the bladder existed, and in two j)rimary carcinoma of the
 
 AUTOPSY FIXDIXGS. 429 
 
 sigmoid flexure was found. Thus in 14 out of 148 cases primary malignant 
 changes were present either in the uterus or in one or other of the pelvic organs. 
 
 In 4 cases death was directly attributable to the uterine hemorrhage, and as 
 a result of the necrosis and sloughing of the myoma. Accordingly, in 18 cases 
 out of 148, death was primarily due to changes in the pelvic oi'gans. In this 
 connection we have purposely excluded one case in which tuberculosis of the 
 body of the uterus existed; one case of tuberculosis of the tube, and those cases 
 in which the myomata by pressure caused changes in the ureters and kidneys. 
 
 The diagnosis of uncomplicated uterine myomata is, as a rule, simple, but 
 when other pathologic processes develop in the adnexa, bladder, or rectum, it 
 becomes impossible for the operator to determine the exact condition until he 
 carefully dissects the tumor in the laboratory. We do not wish to make any 
 deduction from this large percentage of cases in which changes in the pelvic 
 organs were the primary cause of death, but would suggest that the reader care- 
 fully review the data, in order to determine in what percentage of cases he thinks 
 he would have been likely to have made an accurate diagnosis, and then decide 
 for himself whether it is wise to let myomata alone or to remove them.
 
 CHAPTiai XXR'. 
 
 THE CAUSE OF UTERINE MYOMATA. 
 
 In searching* for a clue as to the origin of uterine inyoniata we have 
 approached the sul)je('t from three main avenues: 
 
 1. Heredity. 
 
 2. The clinical course of myomata. 
 
 'A. The microscopic appearance of very early myomata. 
 
 Heredity, — In the accompanying tabulation are embodied the findings rela- 
 tive to the family history in 1245 cases. Naturally, it is often im])ossible to 
 determine the exact nature of the growths, hence it has been thought advisable 
 to give all the available data concerning tumors of every kind mentioned as 
 having occurred in relatives. 
 
 It will be noted that in 11 cases one or more of the patient's sisters had had 
 uterine myomata. In 3 of these, two of the patient's sisters had had myomata. 
 
 Family History in 1245 Cases of Uterine Myomata.* 
 
 Grandmother: Carcinoma, 9 cases (.uterine in 1 case). 
 
 Mother: Carcinoma, 20 cases (uterine in 6 cases). 
 
 Sarcoma of jaw, 1 case. 
 
 "Ovarian tumors," 2 cases. 
 
 "Abdominal tumors," 10 cases (1 myoma). Death was due to the tumor in 
 
 7 of the 10 cases. 
 
 Aunt: Carcinoma, 21 cases. 
 
 Abdominal tumor, 5 cases. 
 
 ^ Uterus 2 
 
 o- , o • o I Breast 1 
 
 bister: Carcinoma. 8 cases: i ^^ , 
 
 Stomach 1 
 
 I- "Cancer" 1 
 
 "Tumor of \vo!iib," 4 cases. 
 "Abdominal tumor," 3 cases. 
 Ovarian tumor, 1 case 
 
 ' 2 sisters (besides patient) 3 cases 
 
 Myomata, 1 1 cases: \ 1 sister 7 " 
 
 I 1 half-si.ster 1 case 
 
 11 cases 
 Grandfatiier: Carcinoma, 4 cases. 
 Father: " 24 " (11 gastric). 
 
 I'ncle: " 11 " 
 
 I5rother: " 4 " (2 gastric). 
 
 *In the majority of the cases of carcinoma in relatives it was not mentioned whether the 
 patient came from the maternal or paternal side. 
 
 430
 
 THE CAUSE OF UTERINE MYOMATA 
 
 431 
 
 A glance at the foregoing table must at once impress the reader with the fact 
 that heredity plays little or no role in the development of uterine myomata, 
 although in a few cases one or more of the patient's sisters may have had myo- 
 mata of the uterus. 
 
 The Clinical Course of Myomata. — From the table on p. 434 we learn that 
 myomata are most conmion during the child-bearing period, and from p. 457 that 
 of 1149 w^omen, 584 were sterile. Of the sterile patients, 295 were marrietl 
 women and 289 single. The impression gained by us after a critical examina- 
 tion of the histories was that the uterus must have something to do, and that if 
 it is not kept relatively l)usy as a result of frequent pregnancies, it may tend to 
 show its activity in another direction, namely, in the formation of myomata. 
 
 Fig. 284. — A Very Early Myoma. (X 13.5 diam.) 
 Gyn. No. 33S.5. Path. No. 634. The myomatous uterus filled the pelvis. Occupying the center of the 
 field is an oval-shaped myoma. The muscle-fibers in the myoma as yet show no tendency to form whorls. M 
 a the nuclei of the myoma gradually merge with those of the surrounding muscle. 
 
 On the oth(T hand, it may be possible that the unknown factor which stimu- 
 lates the development of myomata may in itself tend to cause the sterility. 
 
 The Microscopic Appearance of Very Early Myomata. Where large iiiNoiiiat- 
 ous tumors e.xist, it woulil naturally be iin))().s.>^ible lo detenniiie the .source of 
 origin, and only from an examination of the niiiiule niyoinala can we hojie to 
 gain any definite clue as to their mode of (le\-eloi)iiient . 
 
 It has been claimed that t he myomata ])riniai'ily dexclop around bloo(l-\-e.>^.seLs, 
 and we have carefully examined many small nodules to see if the \-essels realh' 
 bore any causal relation. 
 
 In Fig. 284 we have a \-ery earl\' myoma, ll forms an o\al nodule and i.s 
 sharply defined from the surrounding nmscle. Its nuclei are closely packed 
 together, and thus the myoma ap])areMtly stains more deeply than does the
 
 432 
 
 MYOMATA OF THK ITHRUS. 
 
 surrounding muscle. At one ]M)int the nodule gradually shades off into the sur- 
 rounding tissue. There is nothing in the ])ieture to in any way suggest an origin 
 from l)lood-vessel8. 
 
 In Fig. 2S5 we have a myoma slightly larger in size. The muscle-fibers in 
 the myomatous area show a marked tendency to cui-l up in bands or to assume 
 irregular forms. Otherwise there is no deviation in a])i)earance from the sur- 
 
 
 
 
 
 ■' •-. '^-^Ci-X- .■ -.VA..*^-:'- ^■^'^'^•. ' „•.>i^'W^■ 
 
 -Vic ■<*• ■ ■• •' 
 
 
 \!^B^'^"°' 
 
 Fig. 285. — .\n E.\rly Myom.\. (X 35 diam.) 
 Gyn. No. 2699. Path. No. 246. The large multinodular myomatous uteru.s was 11 x 16 x 17 cm. Occupy- 
 ing the greater part of the field is a myoma, recognized by the wavy arrangement of its muscle-bundles. Its con- 
 fines are not sharp, but can be definitely made out at a. -•Vt b the myomatous tissue blends imperceptibly with 
 the surrounding muscle. No blood-vessels are to be seen in the tumor. 
 
 rounding muscle. In this myoma also there is not the .slightest evidence of the 
 tumor having developed around blood-vessels. 
 
 Fig. 286 represents an early myoma from a ])regnaiit uterus. Here, as a 
 result of the pregnancy, the contrast between the uterine muscle and the nodule 
 comes out sharply. The nodule is approximately spheiic. and composed of in- 
 terlacing bundles of muscle-fibers. It has no blood-vessels of any apprecial)le 
 size. At some points it gradually blends into the surrounding muscle.
 
 THE CAUSE OF UTERINE MYOMATA. 
 
 433 
 
 In none of the myoniata thus far studied have we ever seen any conclusive 
 evidence that the tumor had developed around blood-vessels. 
 
 
 * ';' I '.' ■ * ',> •• ."■■ '-"■-■ '\' ■■ - ■'v'.m':!-"^ 
 
 
 &"'\''.' ''^'^1 
 
 lilip:; 
 
 
 
 
 ^ft'\\ 
 
 
 ..^"-^ 
 
 ^^■^ 
 
 ^i'.yycr?^ 
 
 ^■•'^;;;; /■%>,;■■ 
 
 
 
 .^^!r 
 
 ' ^^K- 
 
 -'•'■»» ,^''' 
 
 
 Fig. 286.— An Eaki.v Myom.\. (X tlO diam ) 
 
 Gyn. No. 2434. Path. No. 186. In this case Cesarean section fi)ll(iwc(l l)y iiysterectoiny wa.*; done at term on 
 account of a large pelvic myoma. 
 
 An early spheric myoma occupies the center of the field. It consists of closely packed muscle-bundles cut 
 lengthwise and transver.sely. It is sharply defined from the surrounding muscle. The muscle-fibers of the uterus 
 (a) are swollen as a result of the pregnancy. .At b tlie myoma is separateil from tlie muscle by a definite cleft, 
 c is a blood-vessel. 
 
 We still k n o w p r a c t i c a 1 I y not h i ii ^ ;i s t o I h v o r i g i ii 
 of uterine in \' o in a t a . 
 
 28
 
 CHAPTER XXY. 
 THE SYMPTOMS ASSOCIATED WITH UTERINE MYOMATA. 
 
 In this fhajitci- the clinical phenomena (jccvn'i'ing in our cases have been care- 
 fully analyzed, hut a conii)lete survey of the literature has not been attempted. 
 
 Age. — In b'>()7 of our cases we have definite data us to the age of the patient 
 on admission to the hospital. Of course, this is no index as to the length of time 
 the tumors had existed. 
 
 The greater number had been de\'eloping for several years, l)ut had not 
 been detected until they hatl reached goodly proportions. 
 
 From the table it will be noted that the youngest patient (Gyn. No. 9637) was 
 only nineteen years of age, and that 26 patients were under twenty-five years. 
 The oldest j)atient coming for operation was seventy-one. In our experience the 
 great pre])onderance of the cases came to oi)eration l)etween twenty-eight and 
 fifty-two years of age. 
 
 TABILATIOX OF AGES OF 1307 CASES OF UTERINE MYOMA ON ADMISSION 
 
 TO THE HOSPITAL. 
 
 Age (in Years) Number of Cases. Age (in Years) Number of Cases. 
 
 19 1 46 52 
 
 20 3 47 34 
 
 22 2 48 43 
 
 23 6 49 33 
 
 24 14 50 34 
 
 25 12 51 20 
 
 26 14 52 21 
 
 27 15 53 10 
 
 28 28 54 15 
 
 29 28 55 4 
 
 30 31 56 11 
 
 31 21 57 4 
 
 32 47 58 4 
 
 33 46 59 8 
 
 34 50 60 4 
 
 35 61 61 3 
 
 36 62 62 1 
 
 37 47 63 1 
 
 38 77 64 2 
 
 39 65 65 2 
 
 40 93 66 1 
 
 41 49 67 1 
 
 42 53 6S 
 
 43 60 69 
 
 44 50 70 1 
 
 45 62 71 1 
 
 Total 1307 
 
 434
 
 THE SYMPTOMS ASSOCIATED WITH TTEIUXK MYOMATA. 435 
 
 In Case 9637 the patient, a mulatto, was only nineteen years old. She had 
 married early, had had one child and one miscarriage. On admission to the 
 hospital a small myoma, 2.5 cm. in diameter, was removed from the right uterine 
 horn. 
 
 In Case 12216, a colored woman, twenty years old. married, entered com- 
 plaining of abdominal pain. At operation a multinodular uterus, 12 x 12 cm., 
 was found, and a subperitoneal pedunculated myoma, 8 x 8 x 10 cm. This was 
 adherent to the anterior abdominal wall and had suppurated (Fig. 104, p. 136). 
 
 In Case 9652, a white woman, also twenty years old, had a myomatous 
 uterus about 11 cm. in diameter, and reaching to the umljilicus. In Case 4382 
 the patient, a white woman, was twenty years old. Slie had married early and 
 had had one child. For one month there had been profuse uterine hemorrhages. 
 At operation a submucous myoma, about 6x7 cm., was removed. 
 
 In Gyn. No. 2042 the patient, a white woman, was twenty-two years old. 
 The uterus was the size of that of a five months' pregnancy, o\Wng to the presence 
 of a large interstitial nodule in the posterior wall. This was removed, and 
 fourteen years later the patient was in good health and had had four children 
 since the operation. 
 
 In Case 11927 the colored patient was twenty-two years old. She had had a 
 child at eighteen. On pelvic examination the appendages were found adherent, 
 and what appeared to be a myomatous mass, 7 cm. in diameter, was situated to 
 one side of the cervix. As the patient developed measles she was transferred to 
 the medical side and no operation was performed. 
 
 We have sketched the histories of those cases in which uterine myomata were 
 recognized at an early age in order that the reader may get an idea as to the size 
 and location of the tumors. It \^^ll be noted that several of the patients were 
 colored. In these cases there is always an element of uncertainty as to the correct 
 age. Such a mistake is. however, less likely to occur in the young colored women 
 than in the old. In the case of a white woman therc^ is less room for doubting the 
 accuracy of the patient's statement as to her age 
 
 From the findings at operation it is evident that some of the tumors had 
 existed for several 3^ears prior to operation. Accordingly, in a few of tiie cases 
 the patient's uterus must have been the seat of myomata when she was still in 
 her teens. 
 
 Duration of Uterine Myomata before Operation. It is \-ery dillieult to (h-t er- 
 mine with any degree of accuracy just how long it has taken a given tumor to 
 develoj), unless, perchance, at a pre\ious abdominal opei'ation a small nodule lias 
 been discovere(l in the uterus, but foi' some I'eason has not been eiuicle.ated. 
 Patients fre(|uentiy consult the surgeon foi' some ill-ileliiied abdominal discom- 
 fort, while they are totally unaware that the pehis is filled with ;i nodular myo- 
 matous uterus. ( )n the other hand, if a patient is thin, and the myoma springs 
 from the fundus, it is often felt by the woman herself. In some ca.ses the tumor 
 is detected an<l then cannot be found for some months, as in Case 3974. This
 
 436 MYOMATA OF THP] UTERUS. 
 
 is due to an alteration in the position of the uterus. When once the patient is 
 under the physician's care, the data as to the grachial or rapid increase in the 
 tumor's dimensions become more accurate. 
 
 In r. H. I., H.. Ai)ril 2S. 1<)()4, we have a good example of the gradual increase 
 in size of the myomata. the uterus having reached half-way to the uml)ilicus at 
 the end of five years. 
 
 Many patients give a history of an abdominal tumor of several years' standing. 
 Some develop gradually, and later increase rapidly in size; others grow \\-ith great 
 raj)idity when first noticed, and then later become (piiescent. 
 
 In Case ()94 the tumor had a])])arently entirely filled the abdomen by the end 
 of one year; in Case 1628 the growth had trebled in size in twelve months. 
 
 In Case 1682 the tiunor had a})parently been increasing in size for twenty- 
 seven months, but during the three months before the patient's admission ap- 
 parently had been cjuiescent. 
 
 In Cases 1664, 2800, 3449, the increase in size had been marked during the 
 few weeks or months ])revi()us to o])eration. 
 
 Many of the i)atients gave a history indicating that the uterine enlargement 
 had commenced from one to ten or more years before surgical intervention was 
 sought, and in a few^ cases the tumor had existed for a period varying from ten 
 to thirty or more years. For example, in Cases 2899 and 3426 the tumor had 
 been recognized twelve years; in Cases 3340, 3440, and 3774, fourteen years; 
 in Cases 4(;i7 and 12864, fifteen years; in Cases 3281, 3394, and 5946, twenty 
 years before. 
 
 Examples of long-standing tumors are furnished l)y the three following cases: 
 In Case 7460 the tumor had been recognized twenty-two years before; in San. 
 No. 1049, for over thirty years; and in Case 10969, for thirty-six years. 
 
 San. No. 1049 is particularly interesting, as in this case an exploratory opera- 
 tion had been performed thirty years before. The surgeon pronounced the case 
 inoperable, and said that the tumor sat right down flat on the womb, without even 
 a particle of a pedicle. 
 
 When the tumor reaches very large proportions, it usually remains Cjuiescent 
 unless a malignant process is developing, but in C. H. I., McA., the tumor had 
 existed for over twenty years, and had kept on increasing in size until it had 
 reached a weight of 89 pounds. 
 
 The Abdominal Contour, The general abdominal outlines, when uterine 
 myomata exist, are (le])endeiit upon several factors: 
 
 1. The location of the tumor. 
 
 2. Its size. 
 
 3. The abuii(hiii(*e or sj)arsity of the adij)ose tissue. A tumor may com- 
 pletely fill the pelvis and yet not project into the general cavity; in such a case 
 the contour of the abdomen is little altered. 
 
 When the myoma emerges into the abdomen, the general symmetric lines are 
 changed. The shape of the abdomen will depend upon the size and location of
 
 THE SY:MPT0MS associated AVITH UTKKIXK MYOMATA. 
 
 43^ 
 
 the tumor. If it be uninodiilar and globular, there may be a dome-like eleva- 
 tion, as in rig. 2S7. where the tumor stands out .sharply on all sides. In some 
 cases, for example. Case 7220, the abdomen may be "obliciuely" distended, the 
 tumor occupying the entire right upper half and the lower left portion. 
 
 AMien the abdomen is uniformly distended by a myomatous tumor, as in 
 Fig. 316 (p. 513), and the ribs are pushed far outward, the appearance strongly 
 suggests the presence of an ovarian cyst. 
 
 In those cases in which j^arasitic myomata are i)resent and ascitic fluid has 
 been pour(>d out, the flanks also are distended, and the abdominal contour bears 
 a marked resemblance to that found in cases of fibroma of the o^'ary with ascitic 
 fluid or a malignant ovarian tumor with free abdominal fluid. 
 
 Fig. 287. — The .•Vudominal Contour Caused bv a Globular Mvo.matous Uterus. 
 The patient is stouter than in Fig. 288. The tumor produces a dome-like elevation. The ascent from the 
 symphysis to the umbilicus is gradual; the descent from the umbilicus toward the xiphoid more abrupt. There 
 8 no sagging in the flank. The only other abdominal tumor likely to give such a contour would be an ovarian 
 cyst In the latter case percussion would, in most instances, yield fluctuation, (.\fter Howard .\. Kelly.) 
 
 In some cases from the abdominal contour it is difficult to get a clear idea of 
 the condition, but in others a glance at the al)d()men will warrant the diagnosis 
 of a myomatous condition. Such an abdomen is i)ictured in big. 2SS. The 
 growth is cleaiix' niiiltiiioduiar, has "|)recipitoiis edges," as was noted in (i\n. 
 No. 90o7, and tliei-e is no bulging in the Hanks. When the patient is \-ery thin, 
 as in this case, the outlines of the tumor are iiiucii more in e\ideiice. .\ thick 
 mantle of adipose tissue, as found in so ni.any cases, naturally obscures the sliarj) 
 outlines of the t unior. 
 
 Enlargement of the Abdominal Veins Associated with Uterine Myomata. — 
 Dilated x'eins ;ire irei|U('iiI ly noted when o\ai'iaii cysts or malignant o\arian 
 tumors exist. If, in addilion lo the o\aiian growth, ascites is found, marked 
 enlargement of the veins may be looked for.
 
 438 
 
 -MYOMATA OF THE ITERUS. 
 
 On the other hand, an increase in the size of the abdominal veins, associated 
 with niyoniata. is rare. Tlie \'enous dilatation, when ])resent, is due chiefly to 
 an interference with the usual avenues of circulation, and the myoma, as a rule, 
 does not exert much pressure on the abdominal vessels. In a fe\v cases, however, 
 the abdominal veins are enlarged. This was noted in Case 3113; the myomatous 
 uterus extended above the umbilicus, and was densely adherent: the abdominal 
 veins were dist ended. 
 
 The Condition of the Vagina in Cases of Uterine Myomata. — Some of the patho- 
 
 FiG. 288. — The Abdominal Contodr Caused by a Multinodular Myomatous Uterus. 
 (Jyn. No. 1.3626. The patient is very thin, the outlines of tlie ribs being quite prominent. The tumor rises 
 abruptly from the abdomen, is markedly lobulated. aritl there is no sagging in the flank. In this case the clue 
 furnished by the abdominal contour alone would almost warrant a definite diagnosis of myoma. 
 
 logic conditions found are dependent Ujjon the myoinatous condition, liut the 
 majority, as will be noted, must i)e considered merely coincidental. 
 
 1. Labial cyst. 
 
 2. Shallow vagina. 
 
 3. Bluish mucosa. 
 
 4. \'aginal cyst. 
 
 o. \'aginal myoma. 
 
 6. Vaginal phlcboliihs. 
 
 7. Ulceration of the vagina. 
 
 <S. Induration of the vaginal vault. 
 
 Labial (" y s t . — Only one labial cyst has come under our ol)servation. 
 In Case 12681 the uterus was the seat of a diffuse adeiioiiiyonia. Lying in the 
 left labial fold, and nearly on a level with the clitoris, was a cy.st 2 cm. in diam- 
 eter. It was firmly attached to the skin, but was freely movable on the under- 
 lying structures. Projecting into the cyst cavity was a pedunculated papilloma- 
 tous mass made up of smaller masses. 
 
 Path. No. 9473. Microscopically, the papillomatous masses are seen to be
 
 THE SYMPTOMS ASSOCIATED WITH ITKI^IXE MYOMATA. 439 
 
 covered with one layer of eylindric epithelium which, in places, tends to form 
 glands. There is nothing suggestive of malignancy. 
 
 Alterations in the Size and Shape of the \' a g i n a . — If 
 a submucous myoma is expelled, the vagina must neetls dilate sufficiently to 
 accommodate the tumor, which is sometimes large enough to almost completely 
 fill the pelvis. 
 
 A large intraligamentary or submucous myoma wedged in the pelvis may 
 render the vagina so shallow that the finger cannot be carried over 1 or 2 cm. 
 straight inward, but in such cases it can be introduced backward toward Douglas' 
 sac or forward toward the l)ladder. C. H. I. No. 1205 affords an example of 
 complete occlusion of the upper part of the vagina. This patient was forty-two 
 years old and single. The myomatous uterus extended as high as the umbilicus. 
 The vagina was greatly narrowed, and half-way up there was complete occlusion. 
 With the finger it was possible to separate the vaginal walls from one another, 
 and the cervix was then encountered. 
 
 With the advent of old age the vagina naturally contracts considerably. 
 In Case 12681 the contraction was very marked. This patient, although the 
 mother of eight children, had a vagina that would not admit two fingers. 
 
 The Bluish Color of the Vaginal Mucosa. — The vaginal 
 mucosa usually takes on a bluish tinge in pregnancy. The same color is often 
 presented when the patient is under the influence of nitrous oxid gas, or if the 
 ether or chloroform has been pushed too far. In the unanesthetised patient this 
 blueness always suggests pregnancy. 
 
 In Case 7361 the myomatous uterus reached almost to the umbilicus; the 
 outlet was markedly relaxed, and there was slight protrusion of the anterior and 
 posterior vaginal walls. The mucosa of the anterior wall was bluish in color. 
 When pregnancy exists, the bluish tinge is found over all parts of the vaginal 
 mucosa, and is not rniiile(l \n a certain area, as in this case. 
 
 In Case (S0()8, a negress, married, aged forty-one, had a myomatous uterus 
 that filled the ])elvis. There was mark(>d blueness of the vaginal mucosa. In 
 this case there was nlso a peb'ic abscess which was possibly i-esponsible foi- the 
 bluish color, although, as a I'ule. a pel\"ic abscess does not cause such a discolora- 
 tion of the nuicosa. 
 
 \ a g i n a 1 C y s t s . — The association of \'aginal cysts with utei-ine inyo- 
 mata is merely a coincidence, in Case ')SW) a small c>"st was detected in the 
 posterior vaginal wall, close to a scar in the sulcus. 
 
 In Case ()S,")r) a cyst, 3 X 1 . 1 cm., was found in the left lateral wall, just within 
 the hymen. 
 
 The cyst in Case SS | | was 2.') cm. \ I..") cm., oxoid in shape, and situated in 
 the anterior vaginal wall under the lu'ethra. 
 
 All these cases wei'e rejxirted in detail in the .Johns Hopkins Hospital Bulletin 
 for 1905.* 
 
 * Tliomas S. CulU'ii, Wi-inal Cy^ls, .1. II. II.isp. Hull.. UM).-,, vnl. \vi, i\ '-'07.
 
 440 MVOMATA OF THE UTERUS. 
 
 A \' a g i n a 1 M y <> in a . — Myoniata in this situation are rare, and we 
 have only found one case in which a ^•a<;■inal myoma was associated with uterine 
 myoniata. 
 
 In Case 155S the uterus contained nunu'rous myoniata, and wide-s})read sar- 
 comatous metastases were detected in the mesenteric and peripancreatic lymph- 
 glands, in the pei-itoneum, omentum, mesenteiy. intestine, stomach, liver, lungs, 
 and pleura*. The original source of the sarcoma could n(Jt be detected. 
 
 Situated in th(> j:)osterior vaginal wall, and loosely embedded in the tissue, 
 was a myoma 2x4 cm. This was shelled out with ease. 
 
 P h 1 e b o 1 i t h s in the \' a g i n a 1 Wall. — In Case 7600 the uterus 
 contained several small myoniata. Situated in the left vaginal wall were several 
 })hleboliths. The uterus was cureted and the ])hleboliths were readil}^ dissected 
 out. The pi-esence of "vein stones" in the vagina is excei)tional, as evidenced 
 by the fact that we detected the condition only once in between 1400 and loOO 
 cases. 
 
 Ulceration of the \' a g i n a . — In Case 12036 a small flat myoma 
 was removed from the |)osterior surface of the uterus near the cervix. Histologic 
 examination of this (Path. No. 8579) showed that it was a typical subperitoneal 
 adenoinyoma. Several interstitial myoniata were also shelled out. A right 
 inguinal hernia was then repaired. 
 
 Situated in the posterior \aginal vault, two inches from the outlet, was a 
 granulating area, 8 mm. in diameter. As the vaginal ulcer was not excised, but 
 treated locally, we cannot be sure of its exact nature. The Fallopian tubes 
 wei'e normal. 
 
 Induration of the ^' a g i n a 1 \' a u 1 t Associated with 
 U t e r i n e .M }• o m a t a . — This condition can usually be easily differentiated 
 from myoniata projecting into the vagina. \Miei-e myoniata encroach on the 
 vagina, the mucosa covering them is perfectly smooth, stretched, and gives the 
 sensation of being relatively thin. Where there is marked induration, the 
 sharply curved outlines ai'e lost, and the vault has a dense, board-like feel; 
 and where abscess foi'ination is fai' advanced, there may l)e areas of softening 
 or fluctuation scattered throughout the board-like tissue. The differences are 
 analogous to the contrast between the sharply (uit lined ]iicture {)resente<l by a 
 fibroma of the skin and the hard. i)i-awny . and I'ather indistinct ccntcurof aboil. 
 
 A reference to Chapter X\'I1I (p. 337) will show that inflanunation of the 
 tubes is a very common accompaniment of uterine myoniata, and that the in- 
 flammation not infrequently goes on to abscess formation. 
 
 The Condition of the Cervix as Detected by Digital Examination. 
 
 1. Normal cervix. {<i) In the usual position. (/■) Carried up. 
 
 2. Cervix almost obliterate(l or llu-^h with the vaginal \ault. 
 
 3. Cervix jammed down on the perineum or up behind the symj)hysis. 
 
 4. Edema.
 
 THE SYMPTOMS ASSOCIATf]D WITH ITKRIXE MVOMATA. 441 
 
 5. Elongation and hypertroj)hy of the vaginal portion of the cervix. 
 
 6. Dilatation of the cervix caused by suljnuicous niyomata. 
 
 7. Carcinoma of the cervix. 
 
 Normal Cervix. — The shape and position of the cer\ix will to a great 
 extent depentl on the size and situation of the myomata. If the myoma has 
 developed in such a manner that the uterus is not encroached upon, the cervix 
 will usually be of the normal size and in its proper ])lace; but when the uterus is 
 uniformly enlarged, it gradually rises into the abdomen and carries the cervix up 
 with it. 
 
 Again, when many myomata are growing at the same time, the uterus is 
 occasionally found completely surrounded by the tumor. In such cases also it 
 may be carried high into the abdomen, and the cervix can with difficulty be 
 palpated by the finger in the vagina. 
 
 Cervix Almost Obliterate d . — When the myomatous develo])- 
 ment has been particularly pronounced in the cervical region, the cervix may be 
 encroached upon to such an extent that it is almost completely unfolded, the 
 edges merging almost imperceptibly into the vaginal walls (Fig. 40, \). 57). 
 
 In Case 6198 the cervix was flush with the vaginal vault. In Case 3498 it 
 was almost obliterated, antl in Case 8106 represented by a small pit. The en- 
 croachment of the myoma on the cervix in Case 4370 was so pronounced that the 
 "cervix shaded off into a large abdominal mass wedged tightly in the i)elvis.'' 
 
 Cervix Jammed Down on the P e r i n e u m o r up Be- 
 hind the S y m j) h y s i s . — When, as a result of adhesions or of subperi- 
 toneal develo])ment, the u])ward course of the myomatous growth is iiitcifenMl 
 with, the tmnor pushes its way downward. In such cases the vagina may be 
 greatly shortened; the cervix may ])ress down upon the perineum or be carried 
 upward and forward, and be jannned against the symphysis. In such cases it 
 may l)e difficult to reach with the examining fing(>r, and can be recognizc^d as a 
 slightly altered cervix, a hnlf-moon-sha))e(l slit (as in Case oUl), or as a mere 
 button (Case 4731). 
 
 1"] d e m a of the Cervical Lips. In Case 1(110 the ulciiis was 
 jmrtially inverted as a result of the li'actioii of a submucous myoma, and the 
 cervical lips wer(^ edematous. 
 
 K 1 o n g a t i o n o f t h e \' a g i n a 1 Portion of the ( " c i- \ i x . — 
 In four cases we have I'ccoi'ds of inai'kcd liypciirophy of the ccrNix associated w iih 
 uterine myomata. In Case r)<S4."> there was |)rolapsus, clongalion ol' llic cci-\i\. 
 and a small adhei-ent myomatous utei'us. 
 
 In Case 444 I the adherent myomatous uterus measured (1 \ '.) \ II cm. Tlieiu' 
 was ))rolaj)sus of the uterus and liypei'ti'opliic eloiigal ion of the cer\i\. with slight 
 cervical ulceration. 
 
 In Case 7441 the))aiieid, although mai'ried eight years, iiad ne\-ei- been pi'eg- 
 nant. Th(> vaginal portion of the cei'X'ix was 7..") cui. in leni;th, and piotruded 
 3.5 cm. fi-om the \-ul\'a. The uteiais containeil a ni\-onia about 7 cm. in di.a meter.
 
 442 
 
 MYO.MATA OF THE UTERUS. 
 
 The most reniarkal)le liyi)('rtroj)hy of the cervix we have ever encountered 
 was in Case 6240. There was marked prolapsus and enlargement of the cervix; 
 the body of tlie uterus was correspondingly enlarged as a result of a (Hffuse adeno- 
 
 mvouia. 
 
 It will he seen that in each of these cases there was j)r()la))sus of the uterus, 
 and further that the myomatous condition was apparently in no way responsible 
 for the hypertrophy of the cervix. 
 
 Dilatation of the cervix due to submucous myomata is described on p. 61; 
 
 carcinoma of the cervix associated with uterine 
 myomata on p. 202. 
 
 A Thrill Felt on Vaginal Examination. — In C. 
 II. I. \V. (Path. Xo. 6421) a large globular myo- 
 matous uterus was present. A definite thrill was 
 felt along the course of the left uterine artery. 
 The same sensation was transmitted to the finger 
 each time a vaginal examination was made. 
 
 Elongation of the Supravaginal Portion of the 
 Cervix Associated with Uterine Myomata. — In Cape 
 12590 the uterus was considerably thickened, owing 
 to the presence of a diffuse adenomyoma. The 
 cervix was lengthened to such an extent that a 
 total hysterectomy would have been exceedingly 
 ditlicult. As .soon as malignancy was excluded, 
 the uterus was amputated through the cervix. 
 
 The uterus in Case 11944 was several times the 
 natural size, being 15 cm. in diameter. The cer- 
 vix, which was 10 cm. long, was at first mi.staken 
 for a senile uterus. 
 
 Excessive elongation of the cervix is illustrated 
 in Fig. 2S9. Here the fundus is ()ccui)ied by an 
 irregular globular myomatous tumor, while the 
 cervix is drawn out until it is as long as a normal 
 uterus. 
 
 Character of the Uterine Discharge. — As a pre- 
 liminary to the study of the character of the men- 
 strual flow and the intermenstrual discharge, a 
 brief ref(M"ence may l)e made to Cha])ter I, which 
 deals with the general distribution of uterine myomata, and to Chapter XVH, in 
 which the condition of the uterine nuico.sa in myoma cases is dealt with in detail. 
 Uterine discharges are naturally divisible into two main groups: 
 1. Menstrual. 2. Intermenstrual. 
 
 Fig. 289. — Marked Eloxgatio.n 
 OF THE Supravaginal Por- 
 tion OF THE Cervix. 
 .\ut. No. 1689. The fundus of 
 the uterus is Rreatly enlarged and 
 rather irregular in outline, owing to 
 the presence of myomata. Passing 
 off from the lower and anterior 
 surface of the uterus are the round 
 ligaments. The cervix is greatly 
 lengthened out, extending from the 
 external os to a, where it is much 
 attenuated. 
 
 It is in just such a case as this 
 that torsion of the cervix might be 
 expected. 
 
 * This case is reported in detail in "Adenomyoma of tlie Uterus." and tl 
 trated in Fig. 56 (p. 201) of that publication. 
 
 condition is illus-
 
 THE SYMPTOMS ASSOCIATED WITH I'TEKIXE MYOMATA. 443 
 
 M e n s t r u a t i o 11 . — In the vast majority of cases the menstrual function 
 is in no way influenced ])y the ]:)resence of myomata, and the flow may even be 
 diminished. In carefully tabulating the cases in which the menstrual flow was 
 excessive, and often associated with an intermenstrual discharge, we have been 
 struck l:)y the great regularity with which the myomata were of the submucous 
 variety. In the more pronounced cases these submucous tumors were recog- 
 nized before operation; in other cases only after the uterus had been oj^ened. 
 
 After carefully weighing the clinical and pathologic findings, we have not the 
 slightest hesitancy in saying that in nearly every ease the uterine bleeding is due 
 to the encroachment of one or more myomata on the uterine mucosa. The 
 mucosa is ])ut on tension, there is an increased blood-pressure, and the large veins, 
 which naturally once a month pour out their quota of menstrual l)lood, are now 
 Hkely to yield a moderate cjuantity between periods and an excessive amount 
 during the period. No matter how large the myomatous uterus, providetl the 
 contour of the uterine cavity is unaltered and the mucosa in no way impinged upon 
 by the myomata, there will rarely be any disturbance in the menstrual function. 
 
 If it is possible to exclude the presence of uterine polyjH, which frccpiently 
 cause hemorrhage, of diffuse adenomyomata, which are associated with profuse 
 menstruation but little or no intermenstrual bleeding, ami adenocarcinoma,* 
 which occasionall}^ accompanies uterine myomata, one can sa}' with almost ab- 
 solute certainty that the uterine hemorrhage which occurs in association with the 
 myomatous uterus is due to a tumor of the submucous variety. 
 
 Menstrual H i s t o r y . — In these cases the patient usually gi\-es the 
 history of a gradual increase in the loss of blood at the i)erio(ls. In some, menor- 
 rhagia has been noticed for only a few months, and in others for ten years or more. 
 The length of time usually varies inversely with the rapidity with which the 
 myoma has become submucous and with whicli the uterus has exjx'lhMl it into 
 the vagina. The increase in amount may be so unexpected or sudden that tlic 
 flow really amounts to a hemorrhage, as ha])])ened in Case 27(M).V. It may be 
 continuous or come in gushes, as was noted in Case H154. In some instances it 
 is so excessive and persistent that the patient has to remain in Ix'd to prevent 
 flooding, and even this precaution may not stay the bleeding. For example, 
 in Case 11944 the hemorrhage was so excessive that it became necessary to j)a('k 
 the uterine cavity. Any increase in blood j)ressure may bi'ing on a hcinoi-i'hage. 
 
 Where bleeding was free, little pain was e\|)eiienced, but if the blood came 
 away in clots, or if it was teinjioi-arily dainine(l back, the disconifoii was usually 
 severe. 
 
 When the myomata do not imj)inge on the utei'ine nnicosa. the menopause 
 will usually occur at the normal time, but if at a later date the myomata be- 
 come submucous, bleeding is likely to occui". 
 
 * Of course, in such a case as No. 1()91, in wliidi tlie submucous myoma was associated willi 
 adenocarcinoma of the body, a satisfactory deduction could not \)c drawn. This case is reporte 1 
 in detail on p. 288,
 
 444 MVO.MATA OK THK UTERUS. 
 
 lute r 111 e 11 s t r u a 1 H 1 e c d i ii g . — In some cases the j)eno(ls are so 
 long that tlie intermenstrual interval is very short or almost wanting. In other 
 cases there is a continuous slight hemorrhage, or oozing of blood, and the periods 
 are recognized as exacerl)ations of the flow. In some of the cases this continuous 
 flow had cxistiMl for a few months, in othcM-s it had been present for three or four 
 years. 
 
 A\'hen the intermenstrual i)eri()d is of some (hn'ation, there is liable to be a 
 leukorrheal discharge. This is whitish or yellowish in color, and is often l)lood- 
 tinged just before and after the jjeriod. In some cases the discharge is watery 
 and may hv irritating. 
 
 If the submucous myoma is undergoing disintegration, the discharge tends to 
 be more profuse, and at times is fetid. This watery discharge associated with 
 some of the submucous myomata is almost nauseating, and cannot be distin- 
 guished from that accompanying a far-advancc\l carcinoma of the cervi.x. 
 
 Pruritus Vulvae. — ^This distressing symptom is rarely caused by uterine 
 myomata, even those of the sloughing submucous variety. In only one of our 
 cases was it in any way j^ronounced. In Case 2606 the patient entered the 
 hos])ital com))lainiiig chieHy of pruritus vulva\ The external genitals showed 
 excoi'iatioiis and a few raw areas. The uterus contained a myoma, 11 cm. in 
 diameter. A hysterectomy was performed, and the patient was at once com- 
 pletely I'elieved of the pruritus. The itching in this case was undoubtedh' due 
 to the irritating discharge. The myoma was of the submucous variety, but on 
 histologic examination the mucosa covering it. aside from some thinning out, 
 appeared perfectl}' noi'inal. 
 
 Bleeding into the Abdominal Cavity after Bimanual Examination of Sub- 
 peritoneal Pedunculated Myomata. — The surgeon is often impresseil by the ease 
 with which a subperitoneal ])edunculated myoma can be torn away from the 
 uterus. When severance takes place, there is natvu-ally free hemorrhage. 
 This tendency for the myoma to tear away should always be borne in mind 
 when making a bimanual examination. 
 
 Some years ago one of us (L'uUen) was demonstrating a case of multinodular 
 uterus, and several students examined the patient. The abdomen was o])ened 
 about ten minutes later for removal of the uterus. One of the examining grouj) 
 had evidently used too much forc(\ as a subperitoneal nodule, about 10 cm. in 
 diameter, had been partially torn away from the uterus, and even in a few 
 minutes se\-ei'al liuiidi-e(l cubic centimeters of blood had escaped into the 
 abdomen. In this case the outcome was perfectly satisfactory, but if this 
 examinaticjii had been made in a j)rivate Ikjusc and not just prior to ojx'ra- 
 tion, the hemorrhage might have proved fatal. 
 
 In Chapter II it has been pointed out that, when i)arasitic myomata exist, 
 large free vessels plunge into the tumor. In such cases also the bimanual ex- 
 amination must be made most gently. 
 
 Mobility. — In estimating the mobility of the tumor in any given case the
 
 THE SYMPTOMS ASSOCIATED WITH I'TERIXE MYOMATA. 445 
 
 variety of myoma with wliich we are dealing must naturally be taken into con- 
 sideration. If the myoma is subnmcous, the degree of mobility will depend 
 upon that of the uterus. When the myoma is large, the round ligaments are 
 pulled taut, and only a limited excursus of the uterus is possible. If the tumor 
 is interstitial and not very large, less traction will be exerted on the ligaments 
 and the uterus will be more movable. Subperitoneal nodules, if pedunculated, 
 can often be pushed from one side of the abdomen to the other, and in thin 
 individuals can sometimes be Hfted up in the hands. 
 
 When the patient has had children, the broad ligaments and the vagina are 
 naturally more lax, and the degree of mobility is consequently greater than in the 
 nullipara. 
 
 The following cases exemplify the marked degree of mobility that may exist 
 in some instances. In Case 2005, in which the multinodular uterus extended to 
 the umbilicus, the patient noticed that the tumor changed its position with 
 any alteration of her own. Case 9953 was that of a very intelligent physician, 
 thirty-tw^o years of age. The uterus was hard and nodular, and on pelvic ex- 
 amination was found to extend half-way to the umbilicus. She noticed that 
 the tumor moved about the abdomen; in the morning it would be well up to- 
 ward the umbilicus, but after she had walked about for some time it settled more 
 into the pelvis. A myomectomy was performed, and the patient, writing from 
 India five years later, reported herself as feeling perfectly well. In Case 10555, 
 a subperitoneal tumor, 10 cm. in diameter, sprang from the posterior surface of 
 the utenis. The enlarged uterus "could be displaced to any part of the ab- 
 domen"; in fact, so mobile was it that it was thought to be an ovarian 
 cyst. 
 
 WTien pelvic adhesions exist, the mobility of the uterus is usually much 
 restricted. 
 
 A bimanual examination with the patient anesthetized often proves of the 
 greatest assistance to the surgeon. He at once learns the relative degree of 
 mobility of the lumoi', and can dctcrniinc with sonic accuracy whether the 
 operation will be easy or diflicult. The discovery of a lai'ge cervical myoma 
 that has unfolded the cervical canal, or a jx'lvis packed with myomata and 
 a marked narrowing of the vagina, usually indicates that einicleation will prove 
 difficult. On the other hand, when, with the finger in the vagina and the hand 
 over the abdomen, one is able to lift th( entire mass well up into the abdomen, 
 the pelvic portion of the operation, at least, is likely to be easy. Occasionally, 
 however, even with dense j)el\'ic adhesions, the pel\ic cdntents can be nio\cd 
 upwai'd and downward en masse. 
 
 Constipation. — Constipation is frc(|ucnlly associatccl with uterine nivdniata. 
 Many of the patients give a history of constipation daling fi'oni a few nionlhs 
 to two or three years prior to tlieii' a<lniission to the hospital, although bctorc 
 that time the bowels had been regulai'. Other patients have been constijjated 
 for many years, but during the last six months or a yeai' the constipation has
 
 446 MYOMATA OF THE UTERUS. 
 
 l)ecn more obstinate. In Case 6381 the patient at times went for two weeks 
 without a movement. 
 
 In many instances the myomata are the direct cause of the constipation. 
 Patients freciuently c()mi)lain of severe pressure in the rectum (Case 4959), or 
 that the constipation is due to something coming down when they go to stool. 
 
 Myomata of moderate size that accurately fill the pelvis often exert a very 
 firm pressure on the rectum, and more frequently cause constipation than do the 
 larger tumors, which, on account of their size, are carried uj) out of the pelvis. 
 
 When the tumors not only fill the pelvis, but are also firmly fixed by ad- 
 hesions, the tendency to constipation is naturally increased. 
 
 With the shifting of the tumor in the pelvis or its outgrowth from the confines 
 of the pelvis and extension to the general abdominal cavity the existing con- 
 stipation may cease. In Case 6441 the pati(»nt had been constipated until 
 four months before her admission. This change is to be explained by the fact 
 that the tumor altered its relations, which allowed the bowels again to become 
 regular. 
 
 In some cases constipation is evidently due to ])artial intestinal obstruction. 
 In Case 12811 the bowels were j^rone to be constipated, "especially when the 
 tumor swelled," the swelling evidently indicating distention of the bowel due 
 to its inability to empty itself. 
 
 Hemorrhoids, — Constipation is frequently associated with uterine myomata, 
 the sluggish bowel action in large measure being due to pressure of the tumor 
 upon the rectum. This obstructive condition naturally retards the return 
 flow in the rectal veins, and might favor the development of hemorrhoids. 
 Nevertheless, only rarely are these associated with myomata. 
 
 ^^'h(■Il a cervical myoma is fixed in the pelvis, as in Case 11243, hemorrhoids 
 are almost certain to develop. If the myoma that has previously caused dila- 
 tation of the rectal veins alters its position, the hemorrhoids may disappear, as 
 was noted in Case 6376, in which they vanished one year before the patient's 
 admission to the hospital. 
 
 If hemorrhoids are present at the time a hysterectomy is performed, but are 
 of a relatively mild grade, nature will usually take care of them, and they will 
 disappear spontaneously after the obstruction is removed. If, however, the}' are 
 of an aggravated type, removal at once is the wiser procedure, {provided the 
 patient is in good condition after the abdominal operation. 
 
 Painful Defecation. — This is usually associated with constipation, and ma}' be 
 intermittent or accoinpaii}' each stool. When hemon-hoids exist, the cause 
 of the pain is clear. In most cases it seems to be due to the pressure of the 
 tumor on the rectum, ami any pelvic adhesions that may be present are apt 
 to aggravate the discomfort. We have noted a certain constancy with which 
 frequent and painful iiiicturition and painful defecation occur together. 
 
 Pruritus Ani. — The occurrence of this sym})tom with uterine myomata 
 appears to be most unusual, as only one patient in our entire series conq)lained
 
 THE sy:mptoms associated with UTERIXK MYOMATA. 447 
 
 of it. In Case 8462 the patient, aged forty-one, for two years prior to admission 
 had noticed a persistent and annoying itching in and around the anal orifice. 
 So severe was it that her hands were tied each night to prevent her scratching 
 the parts. 
 
 On visual examination nothing could be detected. Pelvic examination 
 revealed a multinodular myomatous uterus (Fig. 318, p. 516). Thirteen myomata 
 were enucleated. The pruritus ceased innnediately after o[)eration and never 
 returned. Over six and one-half years have now elapsed since the operation. 
 In this case the pressure of the enlarged uterus was evidently responsible for 
 the pruritus. 
 
 Nausea and Vomiting. — As is well known, in the early months of })regnancy, 
 when the uterus is undergoing a gradual dilatation, nausea and vomiting are 
 not infrt>ciuent. and since the rapid development of myomata sometimes greatly 
 alters the shape and size of the uterus, a certain amount of reflex nausea 
 and vomiting might be expected. In only two of our cases, however, was there 
 a history of nausea. 
 
 In Case 4203 the uterus was about the size of that of a three months' preg- 
 nancy and free from adhesions. The patient suffered from nausea and back- 
 ache, more pronounced at the menstrual period. In Case 1787 the uterus filled 
 the lower abdomen and the patient complained of irregular attacks of nausea 
 and vomiting. 
 
 On the whole, then, myomata have little or no tendency to cause nausea 
 or vomiting. Of course, when the small bowel becomes densely adherent to the 
 enlarged uterus, kinking may follow and vomiting may occur as a result of 
 intestinal obstruction. 
 
 Partial Intestinal Obstruction Prior to Operation. — In view of the nunuuous 
 cases in which intestinal adhesions are present (see p. 633) it is hardly a matter 
 of surprise to find that in a certain proportion partial intestinal ()l)structi()n has 
 existed i)rior to operation. 
 
 In Case 6521, a negress, aged forty-three, had had definite signs of j)artial 
 obstruction before coming to the hospital. At operation the adherent myomatous 
 uterus, an ovarian cyst, and an adherent appendix were removed. The intestines 
 were greatly distended and everywhere adherent. The patient was exceetlingly 
 weak before operation. The intestinal obstruction increased after opei'ation 
 and she died on the eight li day. 
 
 In Case 8()1)S a white woman, aged thirty-eight, had noticed a ccrlain degree 
 of obstruction of the bowels for two years. At opei-ation scNcral niyouiata were 
 removed. There were no intestinal adhesions. Tiu' obstruction had probal)ly 
 been due to pressure of the myomatous uterus on the bowel. 
 
 In Case 12216, a negr(>ss, aged twenty, four inonlhs before admission hail 
 partial obstruction. The abdomen was swollen for thi'ce or four weeks. Sjie 
 had some vomiting, and experienced dilliculty in se(an-ing a movement. \\ 
 operation a loop of small bowel was found adherent to the anterior abdominal
 
 448 MYO.MATA OF THE UTERUS, 
 
 wall at the jjoint at which a suppurating suhjK'ritoiical inyoina had become 
 adherent. The patient died of intestinal obstruction a few days after operation. 
 This case is re]X)rted in detail on p. 135. 
 
 In Case I'iOOO tiie woman entered the hospital as an emei-gency patient on 
 account of acute intestinal obstruction. It was thought that the pressui'e of the 
 myomatous uterus, which was firmly wedged in the pelvis, had caused the ob- 
 struction. At operation the narrowing of the bowel was found to be due to a 
 coexisting carcinoma of the sigmoid (Fig. 274, p. 393). 
 
 Pain. — In the majority of cases of uterine myomata little (jr no jmin is ex- 
 perienced by the patient. 
 
 When the tumor is adherent, the adhesions naturally often give rise to a good 
 deal of distress, i)ut at the i)r(>sent time we are chiefly interested in those cases 
 in which the discomfoi't is due mainly to the tumor itself. 
 
 Our histories go to show that tumors of moderate size cause the most pain. 
 Sometimes very small myomata located in the pelvis give rise to a good deal of 
 discomfort, but very large ones are forced into the general abdominal cavity 
 and cause relatively little i)ain. 
 
 A patient will often consult her physician without any idea that she has a 
 tumor, although complaining of a heavy weight in the lower alxlomen, as in 
 Case 4526; or she may be suffering from a severe bearing-down sensation in 
 the lower abdomen after exertion. In Case 337 the patient experienced much 
 abdominal pain on stooj^ing over. Other patients suffer from a constant sore- 
 ness in the lower abdomen, as was noted in Case 1)013. Others have par- 
 oxysmal {jain in the lower abdomen, or a sharp ])ain may radiate throughout the 
 entire abdomen, as in Case 1151. Coitus may cause pain, as was noted in Case 
 2772. 
 
 Pain referable to uterine myomata may be divided into two classes: 
 
 1 . Pain in the uterus itself. 
 
 2. Pain as a result of pressure on the surrounding j)elvic structures. 
 Pain in the T t e r u s Itself . — The uterine pain may be intermittent 
 
 or continuous, and is usually most severe at, or just before, the menstrual period. 
 
 In Case 4972 the uterus was excpiisitely tender, and in Cases 4975 and 6133 
 it was painful at or near the menstrual ])eriod. 
 
 Labor-like pains were ex])erienced in Cases b551, 1966, 2052, 3066, 3111, 
 416S, 52S9. In Case 52(S9 they occurred when the hemorrhage was severe. 
 In Case 4168 the ])atient said that when the j)ains came on she felt "just as if 
 the child's head was about to be boi-n." 
 
 Pressure Pains . — In addition to an ill-defined abdominal discomfort 
 and general abdominal pain, we may find many definite pressure symptoms. Pain 
 in the back and hips is frequent. AMiere there is much pressure, there is liable 
 to be localized pain, as in Cases 21 58 and 2838. in which the patients experienced 
 severe pain in the region of the left thigh and hip. The )\ain may be dull and 
 boring in character, as in Case 5014, or sharp and lancinating.
 
 THE SYMPTOMS ASSOCIATED WITH ITEKIXE MYOMATA. 449 
 
 C'oiitiiiiied pressure on the pehic nerves causes discomfort in one and some- 
 times in both legs. For example, in Case 4016 there were cramp-like pains in 
 the legs and feet ; in Case 13016 there was aching in both legs. In Case 9924 
 the pain in the right leg was so severe that the patient at times was forced to 
 remain in bed. 
 
 The pain in the leg and foot has been mistaken for rheumatism, as in Case 
 8943. 
 
 In other cases the pressure interferes with the sensation of the extremities. 
 Thus in Case 3583 the patient complained of numbness in the right leg; in case 
 8266 in the outer side of the left leg, and in Case 1329 in both legs. In Case 
 694 the pressure was so severe that there was loss of sensation in the left leg. 
 
 Only in rare instances does the pressure of the tumor ])eeome excessive, but in 
 Case 3199 the pelvic pain was so severe that the patient was comjielled to give 
 up work and remain in bed for eleven days, and in Case 1212 the patient was con- 
 fined to her bed for five months. 
 
 In Case 3338 the paroxysms of pain were so severe that the patient had con- 
 vulsive attacks, and in Cases 3353 and 4828 there was loss of consciousness 
 also. 
 
 The effects of pressure on the Idadder and on the rectum will be discussed 
 under ^licturition and Defecation. 
 
 In only one instance (Case 12369) was there pain in the breasts. 
 
 Condition of the Breasts in Cases of Uterine Myoma. — In the vast m.ajority 
 of cases the breasts show no change, and the myomata seem to have little or no 
 influence on these organs. 
 
 The following changes have been noted : 
 
 1. Colostrum in the breasts. 
 
 2. Small benign breast nodules. 
 
 3. Carcinoma of the breasts. 
 
 Colostrum in the Breasts . — In two of our cases the breasts 
 contained fluid. ai){)arently colostrum. 
 
 In Case 1 1392 a n egress, aged thirty-foui', had liccn iiiai-ricd tlii'cc years but had 
 riev^er been pregnant. The myomatous uterus was ihc si/c of that of a sc\('ii 
 months' pregnancy ; tlie ccrN'ix was hard. The l)r('asts were hard, but contained 
 colostrum. 
 
 In Case 12154, a negress aged thirty -sexcii. although mai'iMcd se\-ei'al years, 
 had never l)een pregnant. A multimxhihii' myomatous uterus i-eached -I cni. 
 above the umbilicus. The cei-vix was very soft and (lisphu'(>(l downward and 
 backward. The breasts contained colostriun. 
 
 We are at a loss to account foi- the colosl lann, ;is in neithei- ease (hd jifegnaney 
 exist. The diagnosis between a unifoi'inly enlarged and soft niyoiuatous uterus 
 and pregnancy is often (lillicuh, and the presence of eolostrum in the breasts is 
 strong presunipti\'e exidence of pi-egnancy. Xe\-ertheless. in rai'e instances 
 colostrum may be present when no pregnancy exists. 
 29
 
 450 MVOMATA OF THE UTERUS. 
 
 S m a 11 Benign Breast T u in o r s . — In Case 1558 a small, semi- 
 fluctuant, and apparently l^enign tumor was found in the left breast. The 
 uterus contained numerous myomata, antl there was sarcoma of the peripan- 
 creatic lymph-glands (Aut. Xo. 353). Xo operation was performed on account 
 of the debilitatetl condition of the patient. 
 
 In Case 1637 there was a small myomatous uterus and a large ovarian cyst 
 shoeing irregular carcinomatous changes. The patient had had a small tumor 
 in one breast for twenty years. 
 
 C a r (• 1 n <) m a o f t h e B r east . — In Case 3426 the patient entered 
 the hospital with a sloughing submucous myoma. This was removed, but the 
 patient died on the .seventh day. Autop.sy showed that death was due to 
 rupture of a preexisting pus-tube. Eighteen months j)rior to her admission 
 one breast had been removed for carcinoma. 
 
 In Case C. H. I. Xo. 78 the patient entered the hospital on account of the 
 pressure symptoms produced l)y a i)elvic tumor which proved to be a myoma 
 undergoing sarcomatous transformation fp. 184). 
 
 She also had carcinoma of one breast, but refused to have it removed. 
 Four years later she returned with inoperable growths in both breasts. 
 
 Carcinoma of the breast must be looked upon as an accidental accompaniment 
 of uterine myomata, the one being in no way responsible for the other. 
 
 Effect of the Tumor on Respiration. — With the increase in the size of the tumor 
 the patient often notices thai her clothes are getting tight. Later, the tumor 
 may interfere with walking, and when the myomatous uterus almost fills the 
 abdomen, the abdominal organs so impinge on the diaphragm that the lungs 
 are partialh' compressed and the patient complains of shortness of breath.* 
 
 In Case C. H. I. McA., in which the myoma weighed more than the patient 
 (Fig. 316. p. 513), it was impossible for her to he on her ])ack. If by chance 
 she got over on her back, she had at once to call for assistance on account of 
 almost complete suffocation. \Mien the interference with breathing is due 
 to the tumor, respiration becomes n()fni:d as soon as the growth is removed. 
 
 The shortness of breath may also be due to the excessively low hemoglobin, 
 caused by great loss of blood from the myomatous uterus. (See p. 453.) 
 
 Edema of the Lower Extremities. — In 45 cases edema was noted. Sometimes 
 it involved one ff)ot or ankle, and in severe cases the knee; in other cases both legs 
 were swollen. The edema ai)j)eared to be due chiefly to the following factors: 
 
 1. Pressure exerted by the tumor upon the pelvic veins. 
 
 2. A low hemoglol)in percentage, with a w'eak heart's action. 
 
 3. Renal insufhcienc^^ 
 
 Pressure. — ^^Tlen the edema of the legs was due to pressure by the 
 tumor upon the pelvic veins, the swelling was sometimes unilateral; in other cases 
 both legs were involved. In Case 8542 the edema was confined to the right 
 
 *Shortness of breath was noted in Cases 121. 6.39. 1(372. 1.S62. 207.3. 2713, 2S22, 3111, i314, 
 4828, 5617, 5987, 6418, 9786, and 9915.
 
 THE SYMPTOMS ASSOCIATED WITH UTERINE MYOMATA. 451 
 
 leg. In Case 4599, at first the right leg alone was edematous, but with the in- 
 crease in size of the tumor the swelhng came to involve both legs. In Cases 83G8, 
 9138, 9928, and 11944 the edema was hmited to the left leg. 
 
 Myomata often move about to a limited extent, and as a consequence the 
 pressure upon the pelvic veins may be temporarily or permanently relieved, and 
 the edema disappear. In one case edema of the ankles had been noted seven 
 3'ears before the patient's admission, but with the increase in the growth of the 
 tumor the edema had disappeared permanently. 
 
 In Cases 6441 and 10199 the edema also completely disappeared with the 
 alteration in position of the tumor. 
 
 The relief of the pelvic veins from pressure may be intermittent — hence the 
 occasional edema noted in Cases 1685 and 3444. 
 
 A Low Hemoglobin Percentage. — Submucous myomata often 
 cause alarming uterine hemorrhages, and as a result the percentage of hemoglobin 
 rapidly diminishes. In Case 12234 the hemoglobin was 25 per cent. ; in Case 
 9678, 23 per cent. ; in Case 9707, 22 per cent. ; in Case 9786, 20 per cent., and in 
 Case 9593, 10 per cent. With a very low hemoglobin the heart muscle cannot 
 receive the necessary nourishment, and a more or less marked grade of cardiac 
 dilatation, wdth edema in the extremities, is the natural consequence. That the 
 cardiac murmurs due to the dilatation are merely functional is clearly shown by 
 the rapid recovery of patients after the removal of the cause of the hemorrhage. 
 Thus, in the absence of organic cardiac disease, after a few weeks the change in 
 the patient is marvelous, and in the course of a month or two the cardiac area 
 becomes normal in extent, the heart's action regular, and all the murmurs 
 vanish. In Cases 6017, 9593, 9678, and 12154, in addition to a low hemoglobin 
 percentage, there were definite cardiac symptoms. 
 
 When the edema is the result of a lack of hemoglobin, Ijotli legs are usually 
 enlarged. 
 
 Renal Insufficiency. — In three of our cases the edema was ap- 
 parently attributable to renal insufficiency. In Case 1383^- the urine contained 
 albumin, but no casts were detected. Edema was present, and the abdominal 
 cavity contained ox'cr 14,000 c.c of ascitic fluid. 
 
 In Case 2713 the abdominal walls wci'c cdeniatous. and (he ui'ino contained 
 hyaline and (^j)ithelial casts. 
 
 In Case (Hebrew Hospital, .hily 11. 1!)02) the i)ali(Mit"s legs for several 
 days had been greatly swollen and had turned pui'ple. The ui'ine contained 
 <|uantities of albumin and was loaded with casts. 
 
 The Condition of the Heart. — Much has been said about the \ai"ious cardiac 
 changes that at'c due to oi" associated with ul<'i-iiic myomata, ;iii(l ;i great deal of 
 confusion exists as to the roh' |)layed li\' luyoiuata in the ile\'elopinent of he.art 
 lesions. 
 
 In 92 of our cases we haxc data iiiihcating iiiip.aii'eil cardiac action. 
 
 Varietv of Cardiac Sounds. The abnormal cardiac sounds
 
 452 MYO.MATA OF TIIK UTERUS. 
 
 have been manifold and varied. In Case TSoO, for instance, a soft systolic 
 niurnmr could i)0 heard over the entire precordial area. In Case 7G8S the first 
 sound over the entire heart had a rather snapi)ing, hollow, tympanitic quahty. 
 In Case 13039 a soft, blowing murmur was heard all over the base of the heart. 
 The murmur was very intense in the second left intercostal space, and was 
 probably diastohc. A diastolic ruinl)le was noted in Case 7240. Soft, systolic, 
 pulmonic nun-murs were noted in Cases 6722, 7266, and 7295, and a loud, sys- 
 tolic, pulmonic murmur in Case 9769. 
 
 Systolic murmurs at the base were also found in Cases 6843, 7630, 12165, 
 12234, 12293, and 12964. 
 
 Reduplication of the first sound over the jnilmonic area was detected in Case 
 7216, and at the apex in Case 7014. 
 
 In Case 13025 the heart was enlarged, no thrill could be detected, but there 
 was a prolonged, blo\Aing, systohc murmur at the apex. 
 
 We have cited a few cases to d(>monstrate the great variety in the character 
 and location of the heart-murmurs. 
 
 In the majority of the cases, however, an a{)ical svstohc murmur was 
 all that could ])e detected. This nmrmur was usually very soft in character. 
 In some it was limited to the apex, but in others could be traced to the axilla, 
 and in some patients to the base of the heart. 
 
 In a few cases the murmur was harsh. In Case 8495 the prominent systolic 
 nnuMuur at the apex was associated with a goiter. This patient comj)lained of 
 l)alj)itation and shortness of breath. 
 
 In Case C. H. I. 392 and Gyn. No. 7569 presystolic nuu'niurs were present at 
 the apex. 
 
 Cause of -M u r m u r s . — Among the first writers to mention the as- 
 sociation of mycjinata and cardiac lesions were Hofmeier* and Fehling.f 
 
 In many of the cases studied by them there was cardiac dilatation, espt'cially 
 of the right auricle, while the heart muscle showed brown atro|)hy antl fatty 
 degeneration. 
 
 On referring to the chai)ter on Autopsies (p. 394), it will be sec^n that in two 
 of our cases myocarditis was present, but that in neither of them was it clear that 
 the myoma had been the causative factor. Our clinical material, however, 
 sheds nmcli light on the subject. In nearly all the cases in which cardiac lesions 
 were present the patient gave a history of menorrhagia, often associated with 
 intermenstrual l)leeding. These patients, as a rule, stood the anesthetic and 
 the operation well, and in a comparatively short time they had gained much 
 in strength, and their cardiac murmurs had disappeared. Some authorities 
 claim that tlic myoma in itself brings about cardiac changes. If such were the 
 
 *"Zur Lehre vom Shock," Zeitsch. f. (Icl)., 1885, xi, S. 366. 
 
 f'Beitrage zur operativen Behandlunjj; d. Utenismyome," Wiirtcnihurg. med. Correspond- 
 enzbl., 1887.
 
 THE SYMPTOMS ASSOCIATED WITH UTEHIXE MVOMATA. 453 
 
 case, then the larger the myoma, the more pronomiced .should be the cardiac 
 murmurs. This has not been our experience. The largest tumors have not 
 been associated with any cardiac symptoms, but the heart complications have 
 almost invariably been associated with copious bleeding from the uterus. 
 
 Most of the murmurs noted in our cases were, at the time, considered to be 
 functional. With the continued loss of blood the ])atient's vitality is lowered, 
 and the amount of hemoglobin materially decreased. The coronary vessels ac- 
 cordingly furnish the heart muscle with an inferior quality of blood, and, as a 
 result, the heart is not able properly to cope with the situation, and there is, in 
 consequence, a slight dilatation of the chamber, causing the murmurs. After 
 operation there is naturally no more hemorrhage. A relatively normal per- 
 centage of hemoglobin is soon reached, and the heart muscle once more receives 
 a healthy blood-supply. The heart contracts to its normal size, and the hemic 
 or functional murmurs disappear. 
 
 Our experience coincides with the view expressed by Leopold,* that the cardiac 
 changes are usually functional and are a direct result of the anemia caused 
 by the uterine hemorrhage. 
 
 There are, of course, a certain number of cardiac lesions that are in no way 
 caused by myomata. These still persist after operation. 
 
 In Cases 7569 and 13039 the previous history of ''acute rheumatic fever" was 
 given, and in Case 6272 the cardiac lesion was associated with nephritis and as- 
 cites. In Case 5010 there was a chronic pericarditis. This patient was in a 
 precarious condition on entering the hospital. An attempt was made to build 
 her up, but she grew rapidly worse. Operation was undertaken as a last resort, 
 but the patient died on the table. 
 
 In only a few cases has a cardiac lesion been so severe that operation could 
 not be undertaken with safety. 
 
 A Low Hemoglobin Percentage Associated with Uterine Myomata. — In the 
 accompanying table we have given 22 cases in which the hemoglobin was 40 \)cr 
 cent, or less at the time of admission to the hospital. The loss of hemoglobin 
 in nearly all the cases is due directly to the frecjuenl iu\d often contimious 
 uterine hcniorrhages caused by tlic myomata. 
 
 .\n()MA CASIIS SHOWIXC. A VERY I.OW i'i:i!('i;.\ rA( ;!■; Ol' Uli.MOCl.oI^l.X. 
 
 GvN. No. 
 
 Presence of Sub- 
 
 UlvMOULUHlN. MlTfOlS MyOMATA. 
 
 OpKiiAiKiN. Hi:sri.T. 
 
 11 yst erect (Ciiy. l\ecn\ery. 
 
 N'ai^iiin! inyninec i!ec()\-ery. 
 
 tomy. 
 I lystei-ectiiiny. Ivccdxcry. 
 Ilystcrtcluiiiy. Uecu\ ery. 
 
 1 
 
 l{ IM MIkS. 
 
 27 1 1 
 
 3()()6 
 
 661") 
 
 7438 
 
 39 |)('r cent. Multiple myo- 
 ni;it:i. .\(l(Mi()- 
 
 IllVDIlKl. 
 
 24 " Suhiimcous. 
 
 30 
 
 19 " Sul)iinic(nis. 
 
 _ 
 
 
 * Areliiv f. (Ivn., IS<)I), I'-d. wwiii. S. 1.
 
 454 MYOM.\T.\ OF THK UTERUS. 
 
 Myoma Cases Showixg a \'eky Low Pekcext.^ge of Hemoglobin. — {Continued.) 
 
 Gtn. No. 
 
 Hemoglobin. 
 
 39 per cent. 
 
 Presence of Sub- 
 mucous Myomata. 
 
 Oper.^tion. 
 
 Result. 
 Recovery. 
 
 Remarks. 
 
 7615 
 
 Submucous. 
 
 Vaginal myomec- 
 
 
 
 
 
 tomy. 
 
 
 
 8804 
 
 20 
 
 Submucous, fever 
 
 Evacuation of 
 
 Died eigh- 
 
 In desperate 
 
 
 
 for two weeks; 
 
 uterine con- 
 
 teen hours 
 
 cone i t i on 
 
 
 
 later clotted 
 
 tents. 
 
 later. 
 
 when brought 
 
 
 
 blood in uterine 
 
 
 
 to hospital. 
 
 
 
 cavity. 
 
 
 
 
 8936. 1 .. 
 
 i:> 
 
 
 
 
 
 9203. J .. 
 
 Returneil with 
 hemoglobin 
 46 per cent. 
 
 Submucous. 
 
 Hysterectomy. 
 
 Recovery. 
 
 
 8951 
 
 3') per cent. 
 
 
 Hysterectomy. 
 
 Recovery. 
 
 
 9593 
 
 10 per cent.; 
 after iron 
 and arsenic. 
 21 per cent. 
 
 Submucous. 
 
 Hysterectomy. 
 
 Recovery. 
 
 Hemoglobin 48 
 per cent, on 
 discharge. 
 
 9678 
 
 23 per cent. 
 
 Submucous. 
 
 Hysterectomy. 
 Evacuation of 
 tubo - ovarian 
 abscess. 
 
 Recovery. 
 
 
 9707 
 
 22 
 
 Submucous. 
 
 Hysterectomy. 
 
 Recovery. 
 
 Hemoglobin 45 
 per cent, on 
 discharge. 
 
 9786 
 
 20 per cent, on 
 admission: 
 before opera- 
 tion, 43 per 
 cent. 
 
 Submucous. 
 
 Hysterectomy. 
 
 Recovery. 
 
 Hemoglobin 52 
 per cent, on 
 discharge. 
 
 10172 
 
 29 per cent.; 
 tonics, rest in 
 bed ; 44 per 
 cent, before 
 operation. 
 
 Submucous. 
 
 Hysterectomy. 
 
 Recover^'. 
 
 Hemoglobin 53 
 per cent, on 
 discharge. 
 
 11139 
 
 28 per cent. 
 
 
 Hysterectomy. 
 
 Recover}'. 
 
 
 11337 
 
 12 per cent. 
 Severe bleed- 
 ing from nee- 
 dle-prick. 
 
 
 No operation. 
 
 Died in ten 
 days. 
 
 
 11889 
 
 14 per cent. 
 
 Submucous, in- 
 
 Partial removal 
 
 Recover^'. 
 
 
 
 Delirium; 
 
 fected. 
 
 of submucous 
 
 
 
 
 temperature 
 
 
 tumor. 
 
 
 
 
 104°; respir- 
 
 
 
 
 
 
 ations, 40 : 
 
 
 
 
 
 
 seemed mori- 
 
 
 
 
 
 
 bund. 
 
 
 
 
 
 12234 
 
 25 per cent. 
 
 Multinodular, al- 
 so submucous. 
 
 Hysterectomy. 
 
 Recovery. 
 
 
 12890 
 
 25 
 
 Submucous. 
 
 Hysterectomy. 
 
 Recovery. 
 
 Hemoglobin 55 
 per cent, on 
 discharge. 
 
 San. 1837 . 
 
 30 
 
 Interstitial. 
 
 Hysterectomy. 
 
 Died on fifth 
 day. Par- 
 alysis of 
 small bow- 
 el. 
 
 Recovery. 
 
 
 San. 1868 . 
 
 30 
 
 Multinodular, al- 
 
 Hysterectomy. 
 
 
 
 
 so submucous. 
 
 
 
 
 San. 1944 . 
 
 40 
 
 Adenomyoma. 
 
 Hysterectomy. 
 
 Recovery. 
 
 
 Path. 6421 
 
 30 " 
 
 Sul)mucous. .sar- 
 comatous de- 
 generation. 
 
 Hy.st erect omy. 
 
 Recovery; 
 well for two 
 years. 

 
 THE SYMPTOMS ASSOCIATED WITH UTERINE MYOMATA. 455 
 
 One cannot safely rely on the patient's general appearance for an index of the 
 anemia. For example, in C. H. I. 728 the patient was very thin, pale, anemic, 
 and apparently had a hemoglobin of approximately 40 percent. Tests, how- 
 ever, showed it to he 79 per cent. 
 
 In 14 of the tabulated cases the hemoglobin (taken with the Dare instmment), 
 on admission to the hospital, was under 30 per cent., and in 4 of this number 
 15 per cent, or under. For example, in Case 8936 it was 15 per cent. : in 11889, 
 14 per cent. ; in 11337, 12 per cent., and in 9593, only 10 per cent. 
 
 Dr. Henry T. Hutchins, formerly Resident Gynecologist in the Johns Hopkins 
 Hospital, has gone very carefully into the subject of the ''Clinical Effects of Sur- 
 gical Anesthesia and Operation upon Anemic Patients,"* and by his tabulation 
 has shown clearly how by rest, fresh air, and careful nourishment, supplemented 
 by Blaud's pills. Fowler's solution, tincture of nux vomica, etc., the patient's 
 hemoglobin may be much increased in the course of a few weeks or months. 
 
 In Case 9593. although the hemoglobin on admission was only 10 per cent., 
 by the above methods it was increased to 21 per cent, before operation. Simi- 
 larly, in Case 8936 it was increased from 15 per cent, to 46 per cent., in Case 9786, 
 from 20 per cent, to 43 per cent., and in Case 10172, from 29 per cent, to 44 per 
 cent. 
 
 All such patients need especial care on the part of the surgeon. Some enter 
 the hospital just after a ])ei'iod which has been exhausting, and an operation 
 would be fraught with great danger. With the appropriate treatment there is'a 
 steady increase in the hemoglobin, but if the operation is too long delayed, the 
 next period may be so excessive that the patient may be even weaker than when 
 admitted to the hospital. 
 
 In some cases immediate operation oftc^n affords the only chance for saving 
 the patient's life. In Case 11889, for example, reported in full on p. 577, the 
 patient entered the hospital almost moribund. There was marketl delirium, a 
 temperature of 104.2° F.. with a pulse of 140 and respirations of 40. The 
 hemoglobin was 14 per cent., and the heart showed marked signs of iusuthciency. 
 She was stimulated for a few hours, and the necrotic and ofl'cnsivc ))()rtions of 
 a submucous myoma were then removed. Two years later the patient wrote: 
 "My health is better than ever." This cas(> demonstrates what brilliant results 
 may occasionally be obtained even imder most adverse circumstances. 
 
 In Ca.se 11337 we have an example of the ))rofound anemia that sometimes 
 results when an intact or sloughing submucous myoma is present. Six months 
 before the patient's admission uterine hemorrhages had commenced and had been 
 almost contimious, and foi' the last thice months she liad been I'oiccd to icniain 
 in bed. On admission the inucous nienihraiies wei'e very pale, ihc hemoglobin 
 was 12 per cent., and the red coi'puscles were l.S2S,()0(); there were functional 
 cardiac murmurs and a temperature of 102° 1'. When blood was drawn from 
 the ear for making the blood count, the needle-piick lih'd so ))rofusely that a 
 
 * Henry T. Hutcliins. .1. 11. 11. Hull.. MMll. vol. xv, p. :^')*t.
 
 456 MYOMATA OF THE UTERUS. 
 
 compress had to be applied, and vwn adrenalin did not .>^top the How. Opera- 
 tion was impossible, and the patient died on the I'onrth day. Autopsy revealed 
 fatty degeneration of the heart and othei- organs, focal necroses in the liver, and 
 a healed infarct of the spleen. 
 
 In Case 8804 for nearly four years the j)atient had had fre([uent uterine 
 hemorrhages, and for thri'e weeks prior to admission contiiuious l)!eeding. Since 
 that time she had grown ])rogressively weaker, antl for the last two weeks had 
 had fever. On admission she looked des])erately ill, the respirations were shallow, 
 and there was a blowing systolic nuu-mur over the apex; hemoglobin, 20 per cent. 
 The abdomen was greatly distended by the myomatous ut(>rus. The uterine 
 discharge was so offensive and free that under light anesthesia the cavity was 
 irrigated, and about a liter of foul clots brought away. Toward evening the pulse 
 became weaker and weaker, and the respirations shallow and labored. Death 
 soon followed. 
 
 In San. No. 18o7 the patient liad a mitral systolic murmur, a hemoglobin of 
 30 per cent., and a temperature of 100° F. A simple abdominal hysterectomy 
 was performed. The patient did not do well frtjm the first, and died on the fifth 
 day. At autopsy the intestines were nuich distended, but there was no evidence 
 of infection. For some unaccountable reason there had evidently been a paraly- 
 sis of the bowels. 
 
 From the above it will be seen that, as a rule, the sim])le lowering of the 
 amount of the hemoglobin in itself need not deter the surgeon, especially as by 
 operation he is going to completely remove the cause of the hemorrhage, which, if 
 it persists, may speedily cause a fatal issue. When infection is associated with 
 a very low hemoglobin, the outlook is very gloomy. 
 
 Loss of Weight. — The ])resence of myomata, as a rule, has little or no in- 
 fluence on the general ai)j)earance. Some i)atients are very thin because they 
 have always been of a frail l)uild. Others are very stout and have been so for 
 years. Still others put on flesh while the tumor is developing. 
 
 A few patients give a history of a gradual or rapid loss of weight in the few 
 months or years prior to applying for treatment . For exam})le, in Case 9593 the 
 patient said she was losing weight and growing weak. In Case 4903 there had 
 been a loss of 15 ])()un(ls in weight in the ])revious four months, and in Case 4S77, 
 oi thirty-fi\-e pounds in two years. An iii(|uiry into the history of such cases will 
 almost invariably show that the loss of weight has been due to the (>xcessive 
 uterine bleeding, and th;it the hemorrhage has been caused by one or Tuore 
 submucous myomata. The loss of weight in Case TloS was due to a sloughing 
 submucous myoma, and in ( 'asc 9078, in which the ])atient had lost ;>() pounds in 
 six months, it was fovuid that a suppurating subjx'ritoneal myoma had oi)ened 
 into the cecum. With the rem(n-al of the tumor the patient's health was again 
 restored to the noruiah 
 
 When sarcoma or carcinoma is associated with th(> myoma, it is only natural 
 that the vitality .should be i-apidly und(>rmined.
 
 THE SYMPTOMS ASSOCIATED WITH UTERIXE MYOMATA. 457 
 
 Profound Weakness. — When there is great weakness associated with uterine 
 niyoniata. it may he assumed that either a sul)mueous myoma is giving rise to 
 profuse uterine bleeding, or that some other independent process is sapping the 
 patient's vitahty. In Cases 1879, 2902, and 3437 the patients complained of 
 excessive weakness, and in Cases 4285, 9786, and 10618, in addition to the weak- 
 ness there w^ere fainting spells. These were especially prone to occur at or just 
 after the excessive period. 
 
 In Case 9707 the menorrhagia was so ])rofuse that the hemoglobin was re- 
 duced to 22 per cent., and the patient had blurred vision following the periods. 
 
 In all the cases in which we found such marked lowering of the vitality the 
 asthenia was due to excessive bleeding. 
 
 The loss of blood may be so marked that the patient suffers from air-hunger, 
 as w^as noted in Case 9786. In a few of the cases the patient, on account of the 
 continuous foul discharge and of the continuous dribbling, may become bed- 
 ridden. Such a condition existed in Case 11013, and the patient had taken 
 large quantities of morphin. 
 
 Temperature, — UncompHcated myomata are rarely accompanied by any 
 rise in temperature. When fever exists, it is usually due to absorption from a 
 necrotic submucous myoma or a suppurating myoma, to an infection from an 
 accompanying accunmlation involving the adnexa, or to some complicating 
 intercurrent affection. 
 
 The Fertility of Women Who Develop Uterine Myomata. — In 1149 cases we have 
 definite data as to marriage and pregnancy. Of this number, 757 were white 
 women and 392 colored. 
 
 X. , • 1 Q.o ' White 530 
 
 Number married, <S4i: \ r^ ^ ^ oio 
 
 ( Lolored 312 
 
 ^^ , . , .,,,_ /White 227 
 
 Number single. 30.: (colored 80 
 
 All but five of the married j)atients were marricvl bc^fore they wcM'e foi'ty 
 years of age. 
 
 Out of the tfttal number of cases — 
 
 584 were sterile. 
 
 7.5 had had miscarriages, l>ut no tuli-tcrm labor. 
 490 iiad lia.i cliihh-en. 
 
 Total 1149 
 
 Sterile Patients. Of tlie-^e, 2<)r) weiv mai-ried (1S7 white: lOS 
 colored); 2S9 wei-e single. 
 
 Length of mai'i'ieil life of the 29.") sterile patients: 
 
 Less than six montlis ■"> cases 
 
 Six montlis lo (jne year 10 
 
 ( )ne to five years .').') 
 
 Six to ten years 70 
 
 Eleven to twenty years 94 
 
 Twenty years or over 1.3 
 
 Data n"i)t (.btain.-iblc 1,S " 
 
 29.") "
 
 458 :\IYOMATA OF THK ITKRUS. 
 
 Miscarriages. — In addition to the 7") patients that had miscarried 
 but had never been dehvered of a full-term child there were 165 others that, 
 besides going to term, had also miscarried, thus making a total of 240 patients 
 who hat! had miscarriages. 
 
 Tainilation of the numi)er of miscarriages jkt j)atient: 
 
 1 miscarriage in eatli of 1 oS cases 
 
 2 miscarriages ' 51 
 
 3 •• " " " 15 
 
 4 •• " " " 8 
 
 5 •• " " " 6 
 
 6 or more miscarriages " " " 6 
 
 Several miscarriages " " " 1 case 
 
 Total, 240 cases 
 
 In the great preponderance of the eases there was only one or at most two 
 miscarriages, demonstrating that there was no decided tendency to abort, except 
 in a few of the cases. 
 
 Tabulation of the approximate age of the fetus at the time of the miscarriage: 
 
 Miscarriages occurring during the first month 3 
 
 " " " " second " 41 
 
 " third " 45 
 
 " fourth " 18 
 
 " fifth " 7 
 
 " sixth " 11 
 
 " " " " seventh " 5 
 
 130 
 
 In 1 10 cases the montli was not gi\en 110 
 
 240 
 
 As seen from the tabulation, the greater numl)er of miscarriages aj)parently 
 occurred tluring the .second and third months. 
 
 In order to study the effect of myomata on conce})tion we have made a 
 tabulation of the length of time l)etweeii the miscarriage and the patient's en- 
 trance to the hospital for operation. 
 
 Miscarriages occurring within five months of the operation 13 cases 
 
 " " " six to eleven " " " " 10 " 
 
 " " " one vear before " 4 " 
 
 " twoVears " " 10 " 
 
 " three " " " 10 " 
 
 " four " " " 9 " 
 
 " " " five to ten years before " 56 " 
 
 " " " eleven to twenty years before operation 59 " 
 
 " " " twenty years before operation 26 " 
 
 Data not given 43 " 
 
 240 " 
 
 In only .six of these was any cau.se as.signed for the miscarriage. In three of 
 these it was instrumentally induced, and in the remaining three was ascribed 
 to a fall. 
 
 The table seems to indicate that, as the myoma increased in .size, the tendency 
 to conception lessened.
 
 THE SYMPTOMS ASSOCIATED WITH ITEKIXE MYOMATA. 
 
 459 
 
 PATIF.XTS WHO HAD BORNE CHILDREN PREVIOUS TO OPERATION FOR 
 
 UTERINE MYOMATA. 
 
 1 child 
 
 2 children 
 3 
 
 4 
 5 
 6 
 More than 6 
 
 Table of the Number of Childkex. 
 each in 184 cases 
 
 104 
 59 
 
 . 51 
 26 
 
 . 15 
 51 
 
 490 
 
 In only seven out of the 490 cases was a child born within a year prior to 
 operation. 
 
 In Case 12725 the patient had had two children, one miscarriage, and an 
 extra-uterine pregnancy. 
 
 The foregoing statistics are interesting in a general way, demonstrating that 
 over half of all the patients had never been pregnant. After excluding the 
 307 who on account of their being single were of necessity sterile, we still have 
 277 out of a total number of 842 who were married and yet remained sterile. 
 We have seen on p. 337 that in myoma cases the appendages are adherent in a 
 large percentage of cases, and as this in itself would account for the sterility, 
 we are still unable to say with any degree of certainty that the myoma per se 
 was the direct cause of the sterility.
 
 CHAlTKPv XXVT. 
 OTHER PATHOLOGIC CONDITIONS IN SOME OF OUR MYOMA CASES. 
 
 Goiter Associated with Uterine Myomata. — In one of our cases (No. 8306) 
 there was a sH^lit enlargement of the thyroid, and in five other cases* one or 
 both sides of the thyroid showed a considerable increase in size. In only one 
 case was there any definite sign of exophthalmos. 
 
 In four of the cases abdominal hysterectomy was performed, and in one case 
 a sloughing submucous myoma was removed by the vagina. 
 
 In one case (No. 4801^) the patient had a large goiter on the right side. Hys- 
 terectomy was performed on account of the myomatous uterus, which filled the 
 lower half of the abdomen. The pulse on the second day was 148; on the third 
 day it ranged i)etween 13{) and 144, and on the fourth day between 118 and 
 132. A maximum temperature of 101° F. was noted on the third day. 
 
 In Case 8495 the patient had lost much blood from the vagina. She was 
 anemic, had a slight j^rotrusion of the eyeballs, palpitation of the heart, short- 
 ness of breath, and bilateral enlargement of the thyroid gland. A soft systolic 
 murnuir was heard at the apex. This replaced the first sound and was trans- 
 mitted to the axilla. The lower al)domen was filletl with a myomatous tumor. 
 
 On account of the j)atient's condition s|)inal anesthesia with cocain was 
 attempted, but ether had to be resorted to. The hysterectomy was a simple 
 one, but the patient on leaving the table had a very rapid pulse and shallow 
 respiration. The pulse the same evening and the next day ranged between 180 
 and 200, and then gradually came down. Later a severe diarrhea appeared. 
 Convalescence was considerably retarded, but the patient was discharged after 
 four weeks in a better condition than before operation. 
 
 The acceleration of the pulse in both of these cases seems to have ])een in 
 a large measure due to the goiter, but the final results were satisfactory. 
 
 Prolapsus of the Uterus Associated with Uterine Myomata. — It is l)ut natural 
 that prolaj)sus and myoma should l)e associated in a certain number of the cases. t 
 The descensus may be slight, moderate, or com])lete. With the increase in size 
 of the uterus the organ often is carried out of the ))elvis into the abdomen, and 
 as a consequence the {)rolapsus may disappear in part or com])letely unless there 
 be marked elongation of the cervix. The pr()lai)sus is usually associated with 
 small myomatous uteri. 
 
 In Case 12452 there was an irr(>ducible ]irola])sus. The cervix ])iT)je('ted (> cm. 
 
 *Gyn. No. 4801^, 8495, 1U5G.J. 12079. 12.V)7. 
 
 t Prolapsus was noted in Cases 362, 1852. 3172. 4:341. 4.337. 5248 G577, 9335, 11169, 12003, 
 and 124,32 
 
 4(30
 
 OTHER PATHULCKUC CCJXDITIOXS IX SOMH OF OUR .MV(JMA CASES. 461 
 
 from the vagina, and the pelvis was filled with a hard globular mass. At oper- 
 ation this mass was found to be densely adherent posteriorly, and irreducible. 
 
 Lipoma of the Abdominal Wall Associated with Uterine Myomata. — In Case 
 7460 the pelvis was filled with a myomatous uterus. The abdominal walls 
 were so thin that the intestinal movements could be seen readily. In the left 
 abdominal wall was a tumor which extended from the costal margin to the level 
 of the umbilicus. It was 22 cm. long, 12 cm. broad, and on removal proved to 
 be a lipoma. 
 
 The Condition of the Umbilicus in Cases of Uterine Myomata. — If the myoma- 
 tous uterus does not reach above the pelvic brim, it should have little or no effect 
 on the umbilicus. But when the tumor assumes large proportions, the abdominal 
 wall is stretched, and its weakest point, namely, the umbilicus, is likely to yield. 
 
 Obliteration of the Umbilical Depression . — This 
 condition was noted in Cases 362 and 659. 
 
 In Case 362 a subperitoneal myoma, 17 x 17 cm., was adherent to the abdomi- 
 nal wall, and also to the surrounding structures. It is probable that in this 
 case the tugging of the abdominal adhesions had gradually unfolded the navel. 
 
 The abdomen in Case 659 was greatly distended by an inoperable cystic 
 myoma. There was marked bulging in the flanks, and total effacement of the 
 umbilical depression. 
 
 Retraction of the Umbilicus . — Only once in our series was 
 this phenomenon noted. In Case 7549 the pelvis and lower two-thirds of the 
 abdomen were occupied by a myomatous growth. The tumor was apparently 
 freely movable, but on moving the patient from side to side the umbilicus would 
 retract to the side to which the tumor moved. When the abdomen was 0])(>ned. 
 dense adhesions were encountered, and the upper part of the tumor had become 
 infected and had opened into the tran.sverse colon. 
 
 Umbilical Hernia . — Small umbilical hernia'* are not infr(M|ueiilly 
 associated with uterine myomata. The opening is usually small, sometimes just 
 admitting the tip of a finger, but may reach larg(^ pi'oportions. as in Cases 
 5123, 8354, and C. H. I. F. 
 
 As a rule, the hernial sac is not very sensitive, but if the oincntuin is incar- 
 cerated, manij)ulation will occasion considerable ))ain. 
 
 Occasionally the incarcerated omentum may become si i-aiigulale(l and under- 
 go necrosis. In C. H. I., F., described on ]>. 120. and shown in Fig. 94, the abdo- 
 men was markedly distended by a large niyoinalous uterus. The umbilicus 
 was the seat of a large hernial sac. The central poUion of this was (lai"k I'ed, 
 and the surrounding tissue very edematous. 
 
 When the abdominal wall is rather s))are and llie hernial I'in^ iiol i)lngge(l 
 with omentum, a flnger can be carried thi-ongh the opening and the surface of 
 the myoma palpated over a con.sideral)le area. This procedure was carried 
 out in Cases 5092 and 12155. 
 
 * Umbilical hernite was noted in Cases 1920, 4869. 5092. rA23 (F\^. :W1, p. (ilO). ,-)94(;, 7:3.30. 
 7460, 7508, 7583, 8270, 8354, 94.57. 11006. 121.55. 12696. nnd ('. H, I. F. (Fii?. 94. p. 120).
 
 462 
 
 MYOMATA OF THK ITHIU'S. 
 
 When an umbilical hernia complicates a myomatous uterus, it is well to begin 
 the incision in the median line above the hernia. With the finger in the abdomen 
 as a guide the entire hernial sac can be dissected out rapidly and without risk 
 of cutting any incarcerated omentum. With the sac lying free it can be readily 
 cut away from the omc^ntum, and the hysterectomy completed in the usual 
 manner. 
 
 A S m all C y s t at t h c V m b i 1 i c u s . — In Case 7688 the lower part 
 of the abdomen was filled with a myomatous uterus. At the umbilicus 
 was a small cyst which, at first sight, suggested an incarcerated hernia. As 
 the specimen was lost we are, unfortunately, not able to give its histologic 
 jX'culiarities. 
 
 Femoral Hernia Associated with Uterine Myomata. — In only three of our 
 myoma cases have we records of a femoral hernia. In two it was on the left 
 side, in one, on the right. 
 
 In Case 3416 the incarcerated myomatous uterus did not rise out of the pelvis. 
 In Case 6129 the uterus reached almost to the umbilicus, and in Case 11984 
 the uterus was as large as that of a six months" pregnancy. It will thus be seen 
 that in none of the cases was the uterus large enough to cause any great tension 
 on the abdominal walls. The hernia in each case must be looked upon as an 
 accidental accompaniment. 
 
 Inguinal Herniae Associated with Uterine Myomata. — The accompanying 
 table gives the records of 7 cases in which, in addition to uterine myomata, 
 an inguinal hernia was found. In two it was on the right, in two on the left, 
 and in three cases hernia' were present on l)oth sides. In none of the cases 
 did the myomata reach large proportions. 
 
 It is clearly evident that the association of the myomatous uterus and the 
 hernia in each of these cases was purely accidental. 
 
 INGUINAL HERNIA ASSOCIATED WITH UTERINE MYOMATA. 
 
 GyN. No. 
 
 Myomatous Uterus. 
 
 Herni.\. 
 
 Operation. 
 
 2763a 
 
 Size of that of a six 
 months' pregnancy. 
 
 Left inguinal. 
 
 Abdominal hysteromyomectomy. 
 
 2772 
 
 Myoma, 6.5 x 5 x 4 cm. 
 
 Left inguinal. 
 
 Abdominal myomectomy: re- 
 moval of appendages. 
 
 4967 
 
 Uterus adherent, globular. 
 
 Right and left 
 
 Abdominal hvsteromyomectomy, 
 
 
 approximately 15 cm. 
 
 inguinal. 
 
 double herniotomv. 
 
 
 in diameter. 
 
 
 
 5871 
 
 Reached umbilicus. 
 
 Right and left, 
 apparently in- 
 guinal. 
 
 .\bdominal hysteromyomectomy. 
 
 9457 
 
 Small adenomyoma of 
 
 Right and loft in- 
 
 .\l)d()ininal hvsterectomy, also 
 
 
 uterus; large cyst of 
 
 guinal, also um- 
 
 cvstectomy. obliteration of her- 
 
 
 ovary, probably carcin- 
 
 bilical hernia. 
 
 nia from within. Radical cure 
 
 
 omatous. 
 
 
 of umbilical hernia. 
 
 11067. 
 
 .Myoma, 1 1 cm. 
 
 Riglit inguinal. 
 
 Abdominal liysteromyomectomy; 
 modified Hassini operation. 
 
 12036 
 
 Small uterus with several 
 
 Right inguinal. 
 
 .\bdominal mvomectomv; radi- 
 
 
 very small myomata. 
 
 1 
 
 ! 
 
 cal cure of iiernia.
 
 OTHER PATHOLOGIC CONDITIONS IN SOME OF OUR MYOMA CASES. 463 
 
 Strangulated Inguinal Hernia . — In Case 1852 there was 
 complete eversion of the anterior vaginal wall; the fundus of the uterus was 
 enlarged, and posterior to it was an ovoid myomatous mass, 6x7 cm. Vaginal 
 hysterectomy was performed. 
 
 On the nineteenth day a radical operation for a strangulated inguinal hernia 
 was performed. 
 
 A Myomatous Nodule Filling a Postoperative Hernial Sac. — One patient 
 (Case 662S) entered the hospital giving a history of a previous exploratory 
 abdominal operation. The entire lower abdomen was filled with a multinodular 
 myomatous mass. The abdominal scar was 20 cm. long, and in one place reached 
 5 cm. in width. The walls had given way at some points, and there were several 
 hernial protrusions in the scar. On excising the scar many omental adhesions 
 were encountered, and one subperitoneal myoma was found to be extra- 
 abdominal and occupying one of the hernial sacs. 
 
 Notwithstanding the universal adhesions, a successful hysterectomy was 
 accompUshed. 
 
 Cysts of the Urachus Associated with Uterine Myomata. — In two of our cases 
 cysts of the urachus were encountered during operation for myomata. In Case 
 6722 the cyst was very small — only 3 mm. in diameter. 
 
 The bladder in Case 7295 reached 4 cm. above the symphysis. In this case 
 also a small cyst of the urachus was found. It was situated just above the 
 bladder. 
 
 Descensus of the transverse colon was found in Case 11251. This con:lition 
 may occasionally be successfully overcome by looping up this portion of the bow(»l, 
 but the chances for permanent relief are slight. 
 
 Appendicitis. — In the cases operated upon in the early nineties mention 
 of the condition of the appendix was rare, but in recent years the appendix 
 has been systematically examined in nearly all the cases. 
 
 The appendix was removed in at least 83 cases. In only one instance 
 (Case 12369), was there an acute appendicitis. In three a subacute inflammation 
 was noted. 
 
 In Case 2129 the appendix was adherent to the right tube. In Case 2S0() 
 it was adherent to the posterior surface of the uterus, and in Cases 9078 and 
 11392 it had grown fast to the myoma. 
 
 In several other cases tlie appendix had grown fast to Ihc right a|)p(Mi(higes, 
 where there was a tubo-ovarian cy.st, a sal|)ingitis, or a jx'lvic ahsccv'^.s. 
 
 In C. H. I. 793, in adchtion to the a{)j)endi('itis there was a marked chronic 
 cohtis, hmited chiefly to the transverse and descending colon. 
 
 The myomatous uterus does not seem in any way to predispose to the develop- 
 ment of an appendicitis. In fact, it really looks as if an acute and well-defined 
 appendicitis is a very rare occurrence whvu myomata exist. 
 
 The question the surgeon naturally asks himself is, "Shall 1 remove the 
 appendix or not?'' If little or no (n'idence of a definite inllarnination is pn^sent,
 
 464 MYOMATA OF THE UTERUS. 
 
 our opinion is that, when myomectomy is performed, it is wiser not to remove 
 the api)en(Ux, as (les{)ite all precautions the danger of infection in myomectomies 
 is great. 
 
 When hysterectomy is j)erforme(l, api)en(lectomy is indicated if there is the 
 slightest eviilence of inflammation, and if the hysterectomy has been a simple 
 one, even a normal appendix is better out. We have had at least one case 
 (C. H. I., A.) in which, several years after hysterectomy, it became necessary to 
 oj)erate ujKin the patient for an acute appendicitis. 
 
 Tuberculous Peritonitis and Uterine Myomata. — The association of tuberculous 
 peritonitis and uterine myomata has, in our experience, been rare. In Case 6991 
 the uterus contained several small myomata. It was densely adherent, and 
 tubercles were widely disseminated throughout the abdominal cavity and also 
 implicated the adnexa. The uterus with the appendages and the appendix 
 were removed. 
 
 Findings in the Mesentery in Myoma Cases. — C alcareous Nodules . — 
 In Case 7011, after removal of the multinodular myomatous uterus, a calcareous 
 nodule, 2 x 2.5 x 3 cm., was carefully shelled out of the mesentery of the ileum, 
 about 10 cm. from the ileocecal valve. Two similar but smaller ones were 
 removed from the mesentery a short distance further on. The three openings 
 were closed with catgut, great care being exercised to avoid injury to the blood- 
 vessels. 
 
 An Abnormally Long Mesentery . — In Case 69 the woman 
 died five days after the hysteromyomectomy. The mesentery of the ileum 
 was very long. X'olvulus had taken ])lace. with the subsecjuent development 
 of f)eritonitis. 
 
 Abnormal Conditions of the Liver and Gall-bladder. — T h i c k o n i n g of 
 the Left Lobe . — In Case C. H. I., W. ( Lath. No. 6421), a secondary operation 
 was performed on account of sarcoma in the cervical stump two years after the 
 primary operation (Fig. 130, p. 191). We examined the liver to see if it con- 
 tained metastases. The edge of the left lobe was sharp and clean cut, but the 
 right lolje was thickened and had blunt edges. We at first thought we were 
 dealing with hepatic metastases, but on inspection none were found. 
 
 Adhesions Let w e e n the Liver and the T u m o r . — In 
 Case 3440, in which the tumor weighed 30 pounds, a subj)eritoneal ni}'onia was 
 adherent to the abdominal walls, to the omentum, and to the suspensory ligament 
 of the liver. 
 
 In Case C. H. I.,McA., in which an SO-pound myoma was removed, the tumor 
 was so intimately adherent to the liver that a jjiece of hepatic tissue came away 
 with it. 
 
 Gall-bladder . — In Case 6432 the myomatous uterus iill(Ml the entire 
 abdomen. The tumor was adherent to the omentum, mesocolon, to the hepatic 
 flexure of the colon, and also to the gall-bladder.
 
 OTHER PATHOLOGIC CONDITIONS IN SOME OF OUR MYOMA CASES. 465 
 
 In Cases 6792, 8514, 8667. and s71o. after removal of the myomatous uterus, 
 the gall-bladder was opened on account of gall-stones. 
 
 Glycosuria. — In only two of our cases of uterine myomata was glycosuria 
 noted prior to operation. In Case 12291 there was a multinodular myomatous 
 uterus which reached 3 cm. above the umbilicus. On account of the large 
 amount of sugar contained in the urine, operative interference was considered 
 inadvisable. 
 
 In Case 2108 the patient had a multinodular myomatous uterus which ex- 
 tended almost to the costal margins. She had profuse uterine hemorrhages and 
 suffered from constant pain in the right flank and down the right leg. The urine 
 at first contained much sugar, but after the patient had been kept under observa- 
 tion for two and a half weeks the sugar disappeared completely. Three weeks 
 later the abdomen was opened; the intestines were densely adherent to the 
 uterus and to one another, and bled freely on liberation. The appendages were 
 also inflamed and adherent. On account of the condition of the patient and the 
 desperate chances attending a hysterectomy, the abdomen was closed. The 
 patient made a satisfactory recovery. 
 
 Shortly after the operation the glycosuria reappeared, lasted several days, 
 and then again disappeared. Had the symptoms been distressing and the uterus 
 free from adhesions, we would certainly have removed it, inasmuch as patients 
 suffering from diabetes often stand operations remarkal)ly well. 
 
 Misplaced Kidneys in Cases of Uterine Myomata. — Prolapsus of the kidney is 
 very common, and we should not be surprised to find it frequently associated with 
 uterine myomata. When the myomata reach any considerable size, the abdom- 
 inal capacity is naturally diminished, and there is not the same chance for a 
 general enteroptosis ; consequently in very few of our cases has prolapsus of the 
 kidney been noted where the myomatous uterus has been large. 
 
 In Case 8197 the myomatous uterus was small and the lower pole of the right 
 kidney reached to the level of the umbilicus. 
 
 The dislocation of the kidney in Case 891 was most marked, and naturally 
 led to confusion on bimanual examination. The uterus was studded with small 
 myomata, and what was suj)posed to be a pedunculated sul)peritoneal nodule was 
 felt behind and to the right of the uterus. This supposed jx-dunciilated myoma 
 proved to be the right kidney, which lay within the jx-lvis. being entirely below 
 the sacral promontory. 
 
 Nodules Studding the Left Kidney. — In Case 7438, a white woman, aged 
 forty-three, had a myomatous uterus which filled the jx'lvis. After its removal 
 the kidneys were examined. Both were much enlarged, and the left was 
 studded with nodules varying from 2 to 5 mm. in diameter. They were confined 
 chiefly to the lower half of the kidney. .\o en!arge(l lynii»h-giands could be 
 found, nor was there any evidence of growths elsewhere in the abdominal cavity. 
 Of course, no microscopic examination of the nodules could be made, and we
 
 '*"" MYOMATA OF THE UTERUS. 
 
 are in the dark as to their nature. The patient made a i^ood recovery. Her 
 hemop^Iobin at the time of operation was 19 jjer cent. 
 
 Renal Colic— In onl}- one case did a patient with uterine myomata give a 
 history suggestive of renal colic. In Case 3113, the woman, aged fifty-two, had 
 had what appeared to be definite symptoms of renal colic once or twice a'year 
 for twelve years before operation. She had violent pain, commencing in the 
 left kidney and passing dovra the course of the ureter. No calculus was detected, 
 but the urine at these times was tinged with blood. The wax-tipped catheter 
 and the .r-rays at that time had never been employed.
 
 CHAPTER XXVII. 
 
 DIFFERENTIAL DIAGNOSIS. 
 
 To describe ade(|uately the various pathologic conditions that might have to 
 be differentiated from uterine myomata would necessitate a careful considera- 
 tion of nearly every pelvic lesion that can occur in women, and many abdominal 
 lesions would also require a detailed description. In the limited space at our 
 disposal we shall merely describe those cases in which we have personally found 
 difficulty in arriving at a correct diagnosis. 
 
 Pregnancy 
 
 At times the differentiation between myoma and pregnancy is clinically 
 almost impossible, and even after the abdomen has been opened, it is often diffi- 
 cult to decide whether the uterine enlargement is due to a myoma or pregnancy. 
 The difficulty is especially apt to occur when the uterus is uniformly enlarged. 
 
 Menstruation. — In myoma cases the menstrual period is usually 
 regular; for pregnancy, cessation of the period affords strong presumptive evi- 
 dence. In some cases, however, the flow may be perfectly regular throughout 
 the period of gestation. 
 
 Breasts. — In pregnancy the breasts afford signs that are characteristic 
 and that are usually wanting in myoma cases. But, as noted on p. 449, the 
 breasts in some instances are enlarged and contain fluid. In all these cases the 
 possibility of a pregnancy with an associated myomatous condition must be 
 remembered. 
 
 The Cervix. — The characteristic softness of the cervix in pregnancy is 
 usually sufficient to establish the diagnosis, but in a few cases the cervix may be 
 hard and firm, and lead one to infer that no pn^gnancy exists. 
 
 The flail-like manner in which the body of the uterus can be moved back- 
 ward and forward on the cerv'ix is most characteristic of pregnancy, but in rare 
 instances this may be simulated in the case of a myomatous uterus when the 
 cervix has been greatly lengthened out and attenuated (.see p. 442). 
 
 Inspection of the Uterus. — Prior to opening the abdomen the operator has care- 
 fufiy considered all these possibilities, and yet on .seeing tiic uterus its regularity 
 may be so pronounced that he is .'^till suspicious of j)r(>gnancy.* Where pr(>g- 
 nancy exists, the uterus is usually of a hhiisii hue, due to the marked vascularity, 
 and very different from the pinkish color usually seen in the luyoniatous uterus. 
 
 *In the following additional cases the myomatous litems strongly suggested a pregnancy. 
 Gyn. Nos. 1579, 4203, 5687, 7059. 72.37 8247, and 9G7S. 
 
 467
 
 468 
 
 MYOMATA OF THK UTERUS. 
 
 In pregnancy also the vessels passing to and from the uterus are greatly enlarged 
 and engorged. 
 
 When pregnancy exists, the insertions of the tubes and round ligaments bear 
 their normal relations to the uterus. This may or may not be the case if the en- 
 largement is due to a myoma. 
 
 Where the cervix is rather broad and hard and the tubes and round ligaments 
 are inserted closer to the center than they would ordinarily be in cases of preg- 
 nancy (Fig. 290), myoma will usually be found. On the other hand, if the in- 
 sertions be at the relatively normal site considering th(> size of the uterus, it may 
 be necessar\% as a last resort, to split the uterus to determine the cause of the 
 
 :^0Sy. 
 
 ¥m^ 
 
 Fig. 290. — .\ Myonhtocs Uteru.s Closely RESE.Mi>i,iN<. \ Viit.<.s.\sr Uteri-s in its Ge.ner.\l Contour. 
 
 (fs nat. size.) 
 -Although the uterus resemble.? a pregnant organ, the right tube and right round ligaments are inserted at a 
 higher level than are the left tube and round ligament. On the other hand, the ovary is attac'.ied at a lower 
 level than the ovary on the left. The enlargement wa.s due to an interstitial myoma in the posterior wall. 
 (.\fter Howard A. Kelly.) 
 
 enlargement. This we did in .several instances, and in each case found the myo- 
 matous tumor. 
 
 In Ca.se S., C. H. I. (June 0, 1903), the uterus on inspection strongly suggested 
 a four months' pregnancy, although the history in no way indicated it. On the 
 one hand, we did not want to disturl) a normal gestation, and, on the other hand, 
 did not deem it fair to close the abdomen when another operation would in all 
 probability be necessary a few weeks later. We accordingly carefully split the 
 uterine wall and at once encountered a cystic myoma, 10 cm. in (haineter. This 
 projected .slightly into the uterine cavity. A myomectomy was done and the 
 uterus saved.
 
 DIFFEHKXTIAL DIAGNOSIS. 
 
 469 
 
 In Case M., C. H. T. f.Iaiuuiry IS, 1900), the uterus reached to the unil^iHcus 
 and strongly reseinl)l('(l a pi'cjinant organ, althougli there was no history sugges- 
 tive of it. The uterus was carefully cut into, and the enlargement found to he 
 due to a ])artially submucous myoma. The myoma was removed, hut the 
 organ left. 
 
 On several occasions when examining the enlarged utems in the laboratory 
 we have opened the organ with fear and trepidation that the op(>rator had pos- 
 sibly removed a pregnant uterus. In each case, however, the softness was due to 
 the fact that the myoma was edematous or had undergone cystic changes. 
 
 A Myomatous Uterus in Contour Resembling a Fetus. 
 Occasionally, the myomata may l:)e so arranged that they resenil)le a fetus. 
 This was the case in Gyn. No. 3198. The clinical history in no way suggested 
 ))regnancy, neither did the uterus look like a pregnant organ, but in its general 
 outlines the tumor bore a strong resemblance to a child (Fig. 291). 
 
 lie. '2!)1. — A Myom.\tous Uterus Reskmbi.i.ng a Fetis in its Contouk. 
 Oyii. No. ;5I'JS. Path. No. .533. The greatly enlarged uterus niea.sureti U x 13 x 21 cm. Tlic iKulule just 
 beliiiKJ the left ovary might readily have been mi.staken for the head on palpation, and the large one l)ehind the 
 right ovary for the Ijuttocks. The appendages were normal. The right tube apparently emerges from a small 
 myoma. (.After Ilnward .\. Kelly.) 
 
 The nodule to the left might readilv !>(' mistaken for the liead. the one to tlie 
 right for the buttocks, and the central i)ortioii. consisting of tlie uterus and 
 several smaller nodules, Un' the trunk with the hands and feet. 
 
 Definite Ballottement with Uterine Myomata. 
 This sign is most exceptional apart from pi-egnancy, in Case '.VAST. howcNcr. 
 it was clearly made out. The uterus cdiUaineil se\-ei-al myomata of go( dl\- si/e. 
 and attached to its sui'I'ace were 1 wo |)edunculaled niyoniat.a, the lai'ger b x S x 10 
 cm. One of the tlwee nodules had four large omental Ncssels entering it (Fig. 
 24, J). ;') I ), anil the abdomen containe(l 7()()0 c.c. of ascitic lluid. Sex'eral of the 
 nodules gave a distinct ballottement on bimanual palpation. This was undoubt-
 
 470 MYOMATA OF THE ITERUS. 
 
 edly due to the fact that they were iJinhuiculated and floated easily in the ascitic 
 fluid. The ballottenient was the only sign that in any way suggested pregnancy. 
 
 Death of Fetus with Suppuration: Perforation of Uterine "Walls: Supravaginal 
 
 hysterectomy: recovery.* 
 
 This case demonstrated how nature, if left alone, may successfully ward off 
 an attack of general peritonitis. Here there were suppuration in the uterine 
 cavity, numerous perforations of the uterus, — fortunately situated entirely in 
 the anteridr wall, — and then a successful walling off by the abdominal wall be- 
 coming adherent to the uterus. 
 
 A. P., colored, aged twenty-one, was admitted to the Cambridge Hospital 
 March 4, 1906. The patient had been thought to be pregnant one year before. 
 She had been carefully watched for some time, but no further development had 
 taken place. She had had some slight fever, but nothing more definite could be 
 learned. When one of us (Cullen) examined her the cervix was soft; the uterus 
 was globular, and lay half-way between the umbihcus and the xiphoid. The 
 growth was apparently somewhat movable. 
 
 Operation: I made an incision over the growth and immediately came in 
 contact with what looked like grumous material, w^hich suggested a suppurating 
 ovarian cyst. As the tissues were densely adherent, the incision was continued 
 upward and the general ])eritoneal cavity opened. On loosening the other ad- 
 hesions we found the omentum adherent. This was clamped and cut. The 
 tumor was intimately blended with the thickened abdominal j)eritoneuin. It 
 was shelled out as rapidly as [)ossible, but pus oozed from the surface in various 
 directions (Fig. 292). I thought that I w^as deahng wdth an ovarian cyst, but 
 was surprised to find that it w^as the enlarged and globular uterus. I amputated 
 through the cervix. The tubes and ovaries were covered with a few shght ad- 
 hesions, l)Ut were otherwise normal and were left behind. It was with the 
 greatest difficulty that enough jjeritoneum was oljtained to close the abdomen, 
 as so many raw areas had been left where the uterus had been adherent to the 
 abdominal wall. A gauze drain was introduced into the low^r part of the in- 
 cision. The patient im[)roved rapidly, and left the hospital feeling perfectly 
 well. 
 
 Description of the Uterus. — Path. No. 9810. The specimen consisted of an 
 irregular and globular mass, approximately 18 x 17 x 15 cm. Its surface was 
 everywhere covered with adhe.-ions, and at numerous points were openings irreg- 
 ular in shape, and varying from 3 to 5 mm. or moi'e in diameter. Through these 
 openings quantities of pus welled out during the operation. The pedicle or cut 
 surface was 4 cm. in breadth, 3 cm. across, and in the central portion of this was 
 the cervical canal. On opening the specimen after it had been hardened we 
 
 * Thomas 8. Cullen, A Series of Interesting (iynecologic and Obstetric Cases, Jour. A. M. A., 
 May 4, 1907.
 
 DIFFERENTIAL DIAGNOSIS. 
 
 471 
 
 found that this tumor was the uterus (Fig. 293). The wahs varied from 1.5 to 
 4 mm. in thickness. 
 
 Fetus. — Snugly filhng the entire cavity was a fetus. Its length from elbow 
 to axilla was 7 cm., from elbow to shoulder, 8 cm. Its breadth in the axillary 
 line was 13 cm. Other measurements could not be made on account of the dis- 
 tortion of the child, but it appeared to be an eighth-month fetus. The skin was 
 somewhat macerated. The child was evidently a mulatto, as in many places the 
 
 • I 
 
 Fig. 292. — The Pekkok.\ted Pkegn.\nt Uteru.s as Seen on Re.\iov.\l. 
 
 Path. No. 9810. The surface is everywliere rough and covered with ailhesions. In the lower part of the field 
 
 i.i the stump of one tube. At a, a, are perforations of the uterus, whence pus was seen oozing out; at b, the 
 
 walls are very thin; there have been many adhesions, and pus is lying on the surface. One would not for a 
 
 moment take this to be the uterus, except for the presence of the tube. For the interior of the uterus see Fig. 293. 
 
 mottled appearance was still present. At oiIhm- points, however, the outer skin 
 had been rubbed off, and the surface li;itl die \):\\r .'ipix-araiicc of a wliitt' child. 
 The hair, which was matted up again-<l the uleriiie \\;ill, was curly and black and 
 several centimeters in length. 
 
 Placenta. — The ])lacenta occupie.l the lowei- (luulraiit of the uterus, and 
 projected over the cervi.x ; there had been a partial placenta pra'via. The 
 placenta at the thickest j)ortion was '2 cm. in thi<'kness. .Vttached to the surface
 
 472 
 
 MYOMATA OF THK ITERUS. 
 
 Fig. 293. — A Puegnant Lii.ui-, wiiii ihe Fetus asd Pl.\cent.\ Int.\ct. (Nat. size.) 
 Path. No. 9810. F"or the exterior of the uterus see Fig. 292. After the uterus had been well hardened, the 
 anterior surface was removed. The cervi.x presents the usual appearance, and the uterus is firmly contracted 
 around the fetus. The head lies in the upper portion. The left arm is firmly adherent to the left side of the chest, 
 and the skin is macerated to some extent. Situated in the lower part is the placenta, which extends slightly over 
 the internal os.
 
 DIFFEHKXTIAL DIAGNOSIS. 473 
 
 of the child, especially in the vicinity of the hair, was nuich friable, yellowish 
 material that looked veiy much like ins])issated ])iis. It was from the surface 
 of the uterus at the points of perforation that the jjurulent discharge came 
 during the operation. 
 
 Sections from the uterine wall showed that the outer surface, at certain jioints. 
 particularly where it was adherent to the abdominal wall, was covered with 
 numerous adhesions. On the protected sitle cuboid cells were visible. The 
 muscle in such areas showed a great <leal of small-round-celled infiltration. The 
 inner lining of the uterus was much altered. There were areas of canalized fibrin, 
 and also regular ribbons of hyaline and canahzed fibrin. Just beneath the sur- 
 face, and on both sides of this, were numerous small round cells and polymorpho- 
 nuclear leukocytes. At a few points calcified vilH could be made out. Decidual 
 cells were still in evidence, but they had become smaller. There had evidently 
 been a chronic inflammation of the inner surface of the uterus, cou})led with an 
 inflammatory process on the outer surface at the points where the utems was 
 adherent to the abdominal w^all. 
 
 In this case there had been death of the fetus from some unknown cau.se, and 
 discharge or absorption of the liquor anmii. Suppuration had taken ])lace in 
 the uterine cavity. At some points the uterine walls had become jxn-forated. 
 and the pus had trickled out over the surface. Fortunately no intestines lay in 
 the way, and the pus had glued the uterus to the anterior abdominal wall. 
 This is certainly one of the rarest conditions met with in the literature. 
 
 A Dead Fetus Resembling a Myomatous Uterus. 
 Occasionally the patient may be totally unaware that she has been pregnant. 
 If the fetus dies, the cervix becomes hard, the uterus contracts materially, and 
 there is often a slight bloody discharge. In such cases, if no definite history is 
 obtainable, myoma may be suspected. A feeling of malaise and chilly sensations, 
 however, suggests a dead fetus, and dilatation and curettage will settle the tliag- 
 nosis. 
 
 Abdominal Pregnancy and Uterine Myomata.* 
 In the following case there was a typical history of a pregnancy gding on 
 apparently to term. Labor i)ains developed and soon ceased, and the patient 
 retained the tumor for nearly four years without any marked discomfort. Little 
 credence was given to her statements, as it ap|)eare(l doubtful if .she knew exactly 
 what had ha[)pene(l. On bimanual examination the diagnosis lay b(>tween a 
 myomatous uterus and a dcnnoid cN-st. and cNcn when one of us r('in(»\('d the 
 tumor, we thought that it was a dermoid cyst. It was only when the hardened 
 specimen was cjpened in the laboratory that pregnancy was detected. .V glance^ 
 
 ♦Thomas S. Culleii. \ Series of Intere.slii)<; ( lynecoloiiir ;iii(i Ohstclric Cases, Jour. A. .M. .\., 
 May 4, 1907.
 
 474 .MYUMATA OF THE UTERUS. 
 
 at the contour of the tumor, as soon in Fi^. 204. will show that it closely simulated 
 a nn'oma in its general outlines. 
 
 Gyn. No. 13272, Path. No. 10417. 
 
 Abdominal 1' r e g n a n c \- o f 1"' our \' e a r s ' Duration. — 
 J. A., colored, married, aged twenty-eight, was admitted to the Johns Hop- 
 kins Hospital September 27, 1906, complaining of j)ain and sweUing in the 
 abdomen. 
 
 Her general health had always been good, and she had never consulted a 
 physician before. Her menstrual history was unimportant. She had been 
 married fifteen years and had had four children, the eldest nearly fifteen years 
 old. The second child was deficient mentally, but lived five years. The third 
 was ten, and the youngest eight, years of age. Her labors had all been normal ; 
 there had never been any miscarriages. For some years she had had a slight 
 amount of thick, white, foul-smelling discharge, more marked before and after 
 her menstrual periods than at any other time. For several years she had been 
 constipated, the bowels not moving for two or three days at a time. She had 
 passed no blood or mucus. 
 
 Present illness: About four years ago she noticed a small lump, the size of a 
 baseball, situated below and to the left of the umbilicus. The tumor increased 
 in size at a uniform rate, and the patient thought she was pregnant. At the end 
 of nine months the tumor reached above the umbilicus. The breasts were en- 
 larged and contained colostrum. The patient had had no nausea or vomiting. 
 Her menstrual periods had been regular, although she had had a very scanty flow. 
 She was certain that she had felt movements of the child. About the time that 
 labor should have come on she had bearing-down pains, beginning in the evening 
 and lasting until early morning. The pains then ceased and never returned. 
 The patient thinks that she has never had any other signs or symptoms since that 
 night. The breasts gradually become soft and dried up. The tumor seemed to 
 decrease slightly in size. No movements were felt, and the patient suffered no 
 discomfort. She became convinced that she had a tumor. 
 
 Until about a year ago she could go about her work without difficulty, but 
 then she noticed a little soreness, and the tumor "began bothering her.'' In 
 the few months previous to admission she had felt an increase in the amount 
 of soreness. She had had headaches at times, her tongue had been coated, she 
 had frequently felt nauseated, but had not vomited. After walking a good deal 
 there was a burning sen.sation in the lower part of the abdomen, and during the 
 last two months the headaches had been quite severe. The patient had to stop 
 work on account of the burning pain that would come and go, but was eased by 
 lying down. She slept well, but her appetite was poor, and she said she did not 
 gain in weight. There was no pain or burning on defecation or urination. 
 
 Examination. — Dr. Hutchins, the resident gynecologist, found the patient 
 rather emaciated. The abdomen was distended rather more on the left than on
 
 DIFFERENTIAL DIAGNOSIS. 475 
 
 the right side by a tumor which rose from the pelvis and reached 4 cm. above 
 the umbihcus in the median hne. The tumor felt cj^stic; it was movable, dull 
 everywhere on percussion, and no fluid wave was noted. On vaginal examina- 
 tion no evidence of infection could ])e found. The cervix was firm. There was 
 slight bilateral laceration. The uterus was in anteposition, normal in size, and 
 apparently in no way connected wdth the abdominal tumor. Movement of the 
 tumor did not draw the cervix upward. Clinically, the tumor was thought to 
 be an ovarian cyst or a myoma, but no definite diagnosis could be made. 
 
 Operation. One of us (CuUen), after making a long abdominal incision, found 
 that the abdominal cavity was occupied by a large ''tumor of the left ovary," to 
 which were adherent the omentum, the entire transverse colon, a portion of the 
 sigmoid, and the ascending colon. The uterus was densely adherent on the 
 right side. The omentum was tied and cut, a portion being left attached to the 
 tumor, the proximal ]X)rtion being reflected backward with the ti-ansverse colon. 
 In doing this the thin wall of the tumor was ruptured, and an ounce or two of 
 thick, creamy, yellowish material escaped. This was rapidly sponged up, and 
 further escape controlled by pressure with gauze. In order to avoid infection, 
 as far as possible, the right tube, which had been converted into a pus sac and 
 was adherent to the cystic tumor, was liberated. The broad ligament on the 
 left side was clamped and cut, so that the tumor could be shelled out of the pelvis 
 and tipped over to the left side. In this way the grumous contents of the cyst 
 were prevented to a great extent from escaping into the abdominal cavity. 
 After the tumor was shelled out there was a great deal of bleeding from the 
 mesocolon. This was checked as far as possible by sutures, and the transverse 
 colon was then curved in on itself, so that the mesocolon formed a funnel. A 
 gauze drain was introduced into this as it dropped down on the pelvic brim 
 and was brought out through the vagina. In this way we were able to check 
 the bleeding almost completely. The abdomen was closed without di-ainagc 
 from above. The patient made a very satisfactory recovery and was dis- 
 charged October 21, 19()(). 
 
 Path. No. 10417. The specimen consists of an abdominal tumor which was 
 connected with the left bi'oad ligament and the left lube and ovary. It was 
 absolutely free from the uterus, which was not removed. The specimiMi in the 
 hardened state measures 21 cm. in length, IS cm. in breadth, and Ki cm. in its 
 anteroposterior diameter, .\ttaehed to its right side are a pus-tube and the 
 right ovary. To its left are the lube and ovary, which are plastered down on 
 it. Covering almost the entire upper suiface of the tumor is omentum, wliich is 
 densely adherent to I he mass and I'ui-nishes a lai'ge pari of its i)h)od-su|)|>ly. The 
 walls of this lunior \-ary from ihe lhickiies< i»l' paper lo Iwo or ihive iiiilhnielei-s. 
 From this tumor grumous malerial, like I'al iiii\e<l uilh pus. esc;ipes, ;itid at 
 several points hair can be seen. When a w indow is eul oul ( big. 2!l 1 ), I he inlei-ior 
 is found to be (IHed with a felus. which is of at least seven oi- eight months' 
 irrowth. On account of the disloiled condition it isdillicult to get the exact age.
 
 476 
 
 .MVO.MATA OF THK ITKUCS. 
 
 Foot 
 
 Fig. 294. — Abdomin.^l Pkegxancy ok P'our Ye.\rs' Dur.\tio.n. 
 Gyn. No. 13272. Path. No. lOilT. The ilhistration i.s an exact reprothietion of the alxloiniiKil conteiit.s, uiid 
 ha.s been drawn from the specimen. Attaclied to it.s ri^ht side is a large pus-tuhe. which is ilensely adherent to 
 the sac. On the left side tlie structures are not clearly outlined, as the broad ligament was intimately attaclied to 
 the pregnant sac. Fa.ssing over the anterior surface of the sac in its upper portion, and considerably flattened, is 
 the transverse colon. Densely matted to the .surface of the sac is the omentum. In the upper part of the sac a 
 window has been cut out, and to the left a hand, at the top a foot, an<i lietween these two, and lying in the vicinity, 
 numerous tufts of hair represented in black may be seen. The sac passes down and almost completely fills Douglas' 
 pouch. This tumor had lain in the abdomen about four years. Apart from the adhesions to the transverse 
 colon, the intestines were perfectly free.
 
 DIFFERENTIAL DIAGNOSIS. 4/< 
 
 Imt the sole of the font iiicasurcs ().5 cm. in Icii.mh and looks matiirc. The other 
 parts arc corrcspondin^iy lar(2;('. The liair of the child is black and curly. There 
 are several points where slight ulceration of the surface has taken place. These 
 correspond to the very thin areas noted in the outer covering. The right tube, 
 which was so firmly glued down that it was thought necessary to remove it, in 
 the hardened state measures 10 cm. in length. It is entirely covered with ad- 
 hesions, and at its fimbriated end reaches 2.5 cm. in diameter. The ovary is 
 also covered with adhesions, but is not enlarged. 
 
 The left ovary is very much flattened and covered with adhesions. The tul)e 
 runs over into the tumor mass and is lost. It is flattened out, and at one point 
 measures 8 mm. in diameter. The placenta is attached to the left side of the 
 mass. 
 
 Histologic Examination. — The sac inclosing the fetus shows that where the 
 omentum has becni adh(>rent it has been transformed almost entirely into new 
 and old connective tissue; even the outer adhesions, which contain islands of 
 adipo.se tissue, are for the most part made up of dense fibrous tissue. Passing 
 inward the fibrous tissue looks older, and then hyaline areas are seen which in 
 size and form closely resemble placental villi. Between these are many small 
 round-cells and spindle-cells. The inner portion is composed of similar hyaline 
 areas, surrounded by a zone of brown pigment that has evidently resulted from 
 an old hemorrhage. The inner surface is lined with necrotic tissue which is 
 especially rich in canalized fibrin, containing chiefly polymorphonuclear leuko- 
 cytes. In no place is there evidence of muscle-fibers, and it looks as if the case 
 was one of an abdominal pregnancy in which the sac, which was partly supported 
 by the omentum, had gone on to new connective-tissue formation. 
 
 Extra-uterine Pregnancy. 
 In several instances we have found it impossible to differentiate between an 
 adherent myomatous uterus and a tubal pregnancy that has IxM^n ru|)turetl for 
 several weeks. The ru|)tiii"('d tube is not onl\' enlarged and suri'ounded by 
 partly organizing clots, but is likewise adherent to the adjacent strudui'es. 
 Where definite nniltiple myomatous nodules can be fell on the surface of the 
 uterus, or where a submucous myoma can be felt oi" has been passed, the diagnosis 
 of myoma can be made with a fair degi-ee of certainty, but it nnist be remembei'ed 
 that tubal pregnancy occasi()nail\- accompanies a myomatous utei-us. as noted 
 on p. .'^42. The cessation of the jiericul for one or two months, followed by con- 
 tinuous bleeding and definite ))ains on one side of the uterus, is, of coui'se. 
 strong i)resumpti\(' exidence of tubal pregnancy. 
 
 A Ruptured Cornual or Interstitial Pregnancy Simulating a Myomatous 
 
 Uterus. 
 
 Several years ago Di'. T. A. I!rck. of riiiladelphiti. sent us a specimen from a 
 
 patient that had had a jielvic tumor. It .somewhat closely sinuilati'd a myoma.
 
 478 MYOMATA OF THK UTERUS.. 
 
 Mrs. G. ,]., ajicil twciity-thrcc, married six years. Had one child three years 
 ago. The hihor was normal. Her last period began December 22, 1903, and 
 continued four days. On Ahireh 7. 1904. she lifted a heavy wash-boiler and was 
 taken with sudden abdominal ])ain, vomiting, and a bloody vaginal discharge. 
 She went to bed. continueil to have intermittent pain, and the next day i)asse(l 
 a clot as large as a fist. Thinking .she had miscarried, she remained in bed a 
 week and then resumed her household duties. Two weeks later she again had 
 much pain in the hy])ogastrium and frequent vomiting s]iells. She dragged along 
 for several weeks without medical attention, but was finally admitted to one of the 
 Philadelphia lio.sj)itals on June 19, 1904. The surgeon, on making an examina- 
 tion, diagnosed ])regnancy, with ])r()bably a large cystic adherent ovary. The 
 patient was discharged on June 22(1. In a .short time there was recurrence of 
 her pain and vomiting and .she was admitted to another hospital, where .she 
 remained in bed four weeks but refused operation. 
 
 On August 8, 1904, she reentered the hospital, and at this time had nuich pain 
 and frequent vomiting. Her aljdomen was distended. A hard irregular mass 
 cotild l)e felt extending from the pelvis to a point above the umbilicus, ^'aginal 
 examination disclosed a soft cervix. The uterus was fixed and crowded to the 
 left side by a mass occupying the right. The temperature was 99° F., the pulse 
 116. 
 
 August 10, 1904; The abdomen was opened and omental adhesions to the 
 parietal ])eritoneum were separated. The omentum covered the pelvic organs 
 and was adherent to the bladder, the inner surface of the broad ligament, and 
 the ma.ss in Douglas' cul-de-sac. After the adhesions had been freed, a fetus was 
 found enveloped in omentum and intestines to the left of the umbilicus. The 
 pelvis was now cleared of a large amount of old blood-clot, and the placental sac 
 was found to project from the right cornu of the uterus (Fig. 295). Both tubes 
 and ovaries were intact. The right tube continued into the mass without any 
 point of rupture. The ovarian artery was ligated on the pelvic side and cut. 
 The ma.ss was then removed from the uterine wall, and the raw area in the 
 uterus closed with a continuous silk suture. The uterus after operation looked 
 one-.sided. The patient made an uneventful recovery. 
 
 The specimen consists of the right uterine cornu, greatly distended, rup- 
 tured, and containing a partially extruded placenta, to which a fetus is attached. 
 Chnging to the side of the cornu are the right tube and ovary. The ]wrtion of 
 the cornu present is 8 cm. in its antero))osterior diameter, 5 cm. from right to 
 left, and 7 cm. in length. The cornu has been attached to the uterus ])y a 
 mu.scular band, o cm. broad and 2 cm. in its antero))osterior diameter. 
 
 The placenta is 12x7 cm. and two-thirds of it has escaped from the cornu 
 through a rent approximately 7 cm. in diameter. The wall of the cornu varies 
 from 1 to 3 nun. in thickness. The tube is cm. in length, and where attached 
 to the cornu is exceedingly small. It is covered with a few adhesions. The 
 ovary is 4.5x2.5x2 cm. It is likewise covered with a few adhesions. The
 
 DIFFERENTIAL DIAGNOSIS. 
 
 479 
 
 fetus, doubled on itself, is 13 cm. in Icniith, with the tlii^^h flexed upon the 
 abdomen (Fig. 296). It is partially covered with adherent membrane. There 
 is malformation of the hand and foot on the right side, and also of the left 
 foot. The left hand is adherent to the membrane and is also distorted. 
 
 On histologic examination at the site of amj)utation a definite portion of the 
 uterine cavity is found. The mucosa here is 1 nnn. in thickness. The gland 
 elements are perfecth' normal. The surrounding nmscle shows a good deal of 
 
 uterine 
 att achmerxt 
 
 Fig. 295.— a Ruptured Cornu.'^l Pregnancy. 
 The right tube is normal. The ovary is sligiitly adherent. The ri«ht cortiu is considerably eniarKed. and 
 attached to its inner aspect is a distorted fetus. Its extremities have become adiierent to tiie t>i>dy, and it is still 
 partially covered witli the fetal nieml)ranes. The [)lacenta has peen partially extruded. (Specimen sent by Dr. 
 T. A. Erck. of Philadeii)hia.,i 
 
 proliferation of tiic ciidothcnuni of the capillaries, and the musclc-ct'lls them- 
 selves are considerably swollen. The outer wall of the sac is (•omj)osed of uterine 
 muscle, and in the outer muscular layers there is dilatation of the capillaries, 
 with some edema of the mu.^cle. The sac contains a ( plant it y of plactMital tissue. 
 That lying close to the iim.scle lias to a great extent iiiidergoiie necrosis. We are. 
 no doubt, dealing with a corniial |»i-egnaiicv. Sections through the l'allopi;in 
 tube and through the uterine horn show that they are perfectly normal.
 
 480 mvomata of thk iterus. 
 
 Hydatidiform Mole.* 
 
 The fulluwing ease illustrates very well how a hydatid mole ^'ivinfi; I'ise to a 
 uterine enlargement may he mistaken for a myoma. Whenever a hydatid 
 mole is detected, however, there has been the history of a recent cessation of 
 the period and, on dilatino; the uterus and curetting, the characteristic small 
 cystic dilatations of the placental villi, as seen in Fig. 297, at once clinch the 
 diagnosis. 
 
 The j)atient was referred to me by Dr. ICrnest Johnston, of Berkeley Springs, 
 W. \'a., on April S, 1901. On admission to the Church Home and Infirmar}^ it 
 was learned that five months previous to the examination she had missed her 
 period for two months, and since then there had been a continuous, very dark- 
 red vaginal discharge. The uterus was uniformly enlarged, and the size of that 
 of a three or four months' pregnancy, but the cervix was very hard and the os 
 small. .Myoma was first .suspected, but we decide(l to explore the uterine cavity, 
 as the tem])orary cessation of menstruation, followed by the very dark discharge, 
 was strongly suggestive^ of a dead fetus. On dilatation of the cervix and intro- 
 duction of the curet fully half a liter of cyst-like bodies was removed. These 
 varied from 1 mm. to 2 cm. or more in diameter. The patient made a prompt 
 recovery. 
 
 Path. No. 4S')l. The s])ecimen consists of about half a liter of small trans- 
 parent cysts, varying from 1 mm. to 2 cm. in diameter. They have thin walls 
 and immediately remind one of small .subperitoneal cysts. They are traversed 
 by a delicate network of blood-vessels. The exact relation of the majority of the 
 cysts cannot be determined, as they were brought away with the cvn-et. Here 
 and there, however, we have been foi'tunate enough to obtain large pieces of the 
 growth. At such points we find shreds of membrane, and attached to these by 
 delicate ])edicles, varying from 1 mm. to 2 cm. in length, are these small cysts 
 (Fig. 297). On further examination of these cysts some of them are found 
 to be jwar-shaped instead of round. Accompanying the cysts are large and 
 small shreds of solid tissue, ncj doubt portions of the decidua. 
 
 Histologic Examination. — Sections from the cVvSt show that the outer sur- 
 faces in places have a covering of syncytium, veiy scant in amount. At most 
 ])oints, however, this is wanting. The walls consist of spindle-shajM'd cells, 
 and the inner surface has clinging to it coagulated fluid. There is no layer of 
 
 * Thomas S. Culleii. .Johns Hopkins Hospital Hulk-tin, 1902, vol. xiii. 
 
 Fig. 233. — Ruituke of the Right (\)knl' ok a IJicornate Uterus with Escape of the F"etus. (^ nat. si;!e.) 
 The fetal membrane seen in Fig. 29.t lias been severeil. .so that the relations can be more readily followed. 
 The cornu had partially ruptured, and the fetus was held in contact with the uterus only by the membrane. 
 More than half of the placenta has been e.xtruded from the ruptured wall, and the muscle at this point is 
 greatly thinned out. The fetus is macerated. The left leg is flexed and has grown fast to the thigh. The left 
 arm is adherent to the chest, an<l has become firmly attached to the membranes. Tlie right arm and leg al.so 
 showed marked distortion. (Specimen sent by Dr. T. A Erck. of Philadelphia.;
 
 31 
 
 481
 
 482 
 
 MYOMATA OF THP] UTERUS. 
 
 cells liiiiiiii the imiiT surface of the cyst. These small tumors are due to cystic 
 dilatation of the stroma of the villi, and hence are not true cysts. In some places 
 typical villi are demonstrable. Covering the outer surface of some of the villi, 
 and in close proximity to the cysts, are masses of cells somewhat resembling 
 
 decidual cells. They are. however, much larger than 
 ordinary decidual cells. The miclei are also larger, 
 iri'egular, and stain deeply. All gradations, from those 
 of normal size to the large and irregular ones, can be 
 followed. While the majority of these cells are prob- 
 ably decidual in origin, some of them are undoubtedly 
 altered syncytial cells, as the direct transition can be 
 traced. 
 
 The patient was perfectly well six years after 
 ojieration. 
 
 Chorio-epithelioma. 
 
 In the following case* a chorio-epithelioma on 
 bimanual examination suggested a large myomatous 
 uterus, and not until the abdomen was opened were 
 we aware of the exact condition. 
 
 In all such cases, however, if an accurate history is 
 obtainable, it Mill be found that the patient has either 
 recently had a miscari'riage or a normal labor, and in 
 all these ca.ses a curettage will yield the characteristic 
 growth, or at least necrotic material which would at 
 
 Fig. 297. — A .Small Fkagment 
 OF A Hydatidifoum .Mdlk. 
 (§ nat. size.) 
 Path. No. 4S.51. The specimen 
 
 has been floated out in water, in OUCC put the OpCratOr OU llis gUard. 
 ortler tiiat the ramifications may 
 
 be followed, a corresponds to the 
 basal attachment, and b is a large 
 cystic dilatation of a villus. .At 
 c we have rows of small oblong 
 cysts. The main stem continues 
 downward, anil spreads out into 
 the conglomerate mass of cysts 
 (d), but just above this point it 
 gives off a small stem of stroma 
 which ends in a cystic terminal (e) 
 after having given off two terminal 
 
 Gyn. No. 13204. Path. No. 10278. 
 
 Chorio-epithelioma with the uterus 
 the s i z e o f t li a t o f a five m o n t h s ' 
 j) r e g n a n c y ; h y s t e r e c t o m y ; t e m p o - 
 r a r y r e c o v e r y . 
 
 The patient was admitted August 31, and was 
 twigs (e') with cystic ends. At f discharged September 2."). 190(3. On examination, 
 
 is a cystic dilatation in the con- t^ t-« i r i i i i i ^ i- ^ i i 
 
 tinuityof a villus, a short distance Di'. Kushmore touiid thealxlomen somewhat distemled 
 
 further on followed by the termi- ^ ^ ^j.,^j „j,^^^_ ^^.l,;,.], ,.,,^,, ,,^u ,,j' jj^^. pc\y\H and CX- 
 nal bunch of cysts, g. (After • ... 
 
 Thomas s. Cuiien.) tended as high as the umbilicus, rather more pronii- 
 
 neiilly on the left than on the right side. The mass 
 was .slightly moval)le, and not tender, e\cej)t just above Poupart's ligament on 
 the left .side. It was regular in outline, and on deep inspiration its ui)per border 
 
 * Thomas S. Cullcn, .\ ."Series of Iiitcrcstinj; (lyiiecolo.iiic ami Olj.'^ti'trio Ca.ses, .Jour. A. M. A., 
 Mav 4, 1907, vol. xlviii.
 
 DIFFER KXTIAL DIAGNOSIS. 483 
 
 was obliterated by the suiToimding intestines. The vaginal outlet was moder- 
 ately relaxed, the cervix was high in the vaginal vault, lying far back and pointing 
 downward. The cei-vical lips were not hypertrophied ; the os was slightly 
 patulous. There was no iiuluration suggestive of a new-growth. The mass in 
 the pelvis was uniformly fixed. On examination under ether the tumor was 
 freely movable, but suggested a myoma about six inches in diametei'. with a 
 cystic mass on the left. The l)reasts contained colostrum. 
 
 On exposure of the enlarged uterus the appearance suggested pregnancy very 
 .stronglv. The ves.sels were much dilated. No definite nodules could be made 
 out in the fundus, but on the i)Osterior surface was a slight prominence, with a 
 curious yellowish discoloration of the tissue beneath, and there were numerous 
 dilated ve.s.sels suggestive of a malignant new-growth. As a definite diagno.sis 
 could not be made from palpation, we decided to incise the uterus over the 
 prominence, at the same time carefully walling it off so that the general cavity 
 would be jjrotected. On incision, a vascular new-gi-owth was immediately seen. 
 This had a spongy appearance, and immediately suggested a malignant growth, 
 differing entirely from carcinoma and sarcoma. Dr. Cuthbert Lockyer, of 
 London, Eng., a man who has contributed largely to our knowledge of this sub- 
 ject, was with me (Cullen) at the time, and corroborated the diagnosis of chorio- 
 ei)ithelioma. The incision was immediately closed, and the uterus removed. 
 The liver was carefully examined for metastases, but none could be detected. 
 
 In this case there was no positive history of a recent miscarriage, although 
 the possibility cannot be excluded. The contour of the uterus on pelvic ex- 
 amination strongly suggested a myomatous uterus, and with the abdomen 
 opened it was impossible for one to exclude pregnancy. 
 
 Path. No. 10278. The specimen consists of a greatly and uniformly en- 
 larged uterus, measuring 20 cm. in length, 13 cm. in breadth, and 12 ciii. in 
 thickness. The anterior surface is smooth and glistening; the jjoslci-ior is 
 covered with many adhesions, thin and fan-like. Attacheil neai' the lel't rdi'nu 
 is a tag of onuMituni. ( )n set-tioii, the utei'ine (-n'ity is found to be 1.")..") cm. in 
 length. The uterine walls wiry from 3 to (> cm. in thickness. The outer jiort ion 
 of the wall consist-^ of inu-;cle, \-ai'}'ing from 1 to I ..") cm. in thickness. I.ininu-the 
 entire uterine cavity is a s])ongv, j)oi-ous growth ( l"'ig. 21)S). The utei-ine nuicosa as 
 such is not I'ccognized, but is repi'esented by hills and hollows. The j)i-ojections 
 into the ca\'ity are dome-shapeil, and \ary fi'om ()..') to 2 cm. in depth. I Jereand 
 there on the suii'ace are cyst-like de|)i-e-<sions, with nai'i'owcil bands of tissue 
 sti'etching from side to side. Tliei'e are also innnerou< caxcnious spaces, bi'idged 
 oN'er by bands of the growth. This gi'dwih inx'oKcs the entire uterine wall, 
 both antefiofly and posteiiorly. The ureal thickness in the wall is due to the 
 j)resence of the gi'owt h, which \aiie< fi'oni 1 to (1 cm. in I hickness. .\t the fundus 
 it extends almost to the peritoneal i-o\-eiing. The grow ih in no way resembles 
 either a carcinoma oi" a sai'coma. ( )ne is instant \v I'emiiiileil of the irrowth that
 
 484 
 
 .MYOMATA OF THK ITEUrS. 
 
 occasionally occurs after a miscarriage. The cervix is somewhat flattened, 
 is 6 cm. in breadth, and its lips ajjpear to be normal. 
 
 Fig. 298. — Chorio-epithelioma. (5 nat. size.) 
 Gyn. No. 13204. Path. No. 10278. The specimen consists of a uniformly en arged uterus. The cervix is 
 normal; the body is as large as that of a five months' pregnancy. Occupying tiie entire body of the uterus is a 
 new-growth with many depressions and cystic spaces extending into the wall. The growth itself presents a pecu- 
 liar porous appearance (b), and the finger-like processes so characteristic of carcinoma are absent. In the lower 
 part of the uterus the outer muscular walls are still clearly seen, but in the upper part of the cavity the growth 
 has extended almost to the peritoneal surface. The growth coidd hardly be mistaken for anytliing else. It is 
 remarkable to see so uniform an involvement of the entire uterine wall, a indicates clearly the sharp line of 
 demarcation between the malignant growth and the outer musctdar covering. 
 
 Histologic examination sliows the gi'owth to be a tyj)i('al chorio-cpithelioma. 
 After some months the i)atieiit commenced to lose ground, and soon died with 
 metastases.
 
 DIFFERENTIAL DIAGNOSIS. 485 
 
 Enlargement of the Uterus Due to a Retained Menstrual Flow. 
 
 In 190() we^ received word from one of the most, cai-eful practitioners in the 
 State saying that he was going to send a patient with a uniformly enlarged and 
 globular uterus for operation, and that the enlargement was apparently caused 
 by a nwoma. During the long railroad ride the patient lost nnich blood, and 
 when one of us examined her at the hospital the uterus showed little enlarge- 
 ment. From the history, it will be seen that as the result of an endometritis 
 the vaginal walls had become irritated and later agglutinated. Successive 
 menstrual flows had thus been retained, and the uterus had become distended. 
 The jolting over a poorly ])allastcd railroad had been sufficient to partially 
 separate the adherent vaginal walls; the fluid contained in the upper part of the 
 vagina and distending the uterus had escaped, and the suj^posed uterine tumor 
 disappeared. 
 
 P., admitted to the Church Home and Infirmary June 17, 1906. The patient 
 was fifty years of age. For several months she had had no periods, but recently 
 there had been an excessive amount of pain in the lower abflomen. The en- 
 largement was apparently due to a myoma. Her i^hysician found a glo])ular 
 and enlarged uterus. During a long railroad journey she had had a profuse 
 bloody discharge, and the abdominal pain hatl to a great extent disappeared. 
 We examined the patient under ether, and found the vagina closed half-way up, 
 but there was just a small opening. This could readily be dilated with the finger, 
 and there was an immediate escape of old blood, rojiy in character. The cer\-ix 
 was considerably dilated. Pressure on the uterus increased the flow. We 
 stretched the cervix and curetted the uterus, but obtained little mucosa. 
 
 On histologic examination of the mucosa we found that it was the seat of 
 acute inflammation. In this case there had been an acute endometritis. The 
 vaginal surfaces had l)ecome glued together, and complete occlusion had taken 
 place. There hud l)een an accumulation of secretion in the uterine cavity, 
 gi\'ing rise to the supposedly globulai' myomatous uterus, and at the same time 
 causing a great deal of disconifoi't from the distent ion. 
 
 Carcinoma of the Uterus. 
 
 Hcfoi'c considci'ing the (Hfficulties in diagnosing carcinoma of the uterus from 
 myoma, it may be well to glance at Chapter X\'l, ]>. 274, in whicli many cases 
 of carcinoma of tiie body associatcnl with lUeiine myoma are described. 
 
 When the carcinoma commences in the vaginal portion of the cer\i\, the 
 dilTerential diagnosis between a malignant gi-o\\lli and a niyonia is usuall\" easy, 
 but in some cases, when a sloughing sul)iiiuco\is luxdnia pi'ot rudes Irom the 
 cervix aii<l ])aitiall\' (ills the \agina, it may he mistaken for a cauliflower-like 
 carcinomatous mass. The |)e(licle of the myoma is usually attached high up 
 in the cer\'ical canal oi- in the IxkIv of the uterus, and the linger can lie cari'ied 
 around it on all sides. When carcinoma of the cer\i\ is pi'esent, the gi'owth
 
 486 
 
 .MVo.MATA OF TlIK ITKRUS. 
 
 * ^. / ' I 
 
 Fig. 299. — C.\rci.som.\ of the Ckkvi.k .\sd Lower P.-irt of the Hodv ok the Uterus Ci.inicai.i.v .Sicckstixg 
 
 A .Myo.m.\tous Organ. (Nat. size.) 
 Gyn. No. 10490. Path. No. 6727. The uterus was globular and about the size of that of a four months' 
 pregnancy. The vaginal portion of the cervi.x was normal. The greater part of the cervix and tlie lower portion of 
 the body of the uterus were occupied by carcinomatous tissue. Mas.ses of it are seen projecting into the uterine 
 cavity at a, a, a. The cervical canal had been blocked, and the body of the uterus had become much distended and 
 was filled with pus. The mucosa has been replaced by granulation tissue, as recognized by the undulating surface 
 so often noted where a suppurating membrane exists. From the normal appearance of the cervix, the uniform 
 contour of the body and the firmness of the tissue, myoma was naturally diagnosed. Had carcinoma l)een sus- 
 pectetl, curettage would have at once established the true diagnosis.
 
 ])IFFf:rextial diagxosis. 
 
 487 
 
 springs from the ccrN-ix ilscif, is cxcccdingiy triahlc, ami l)U'C(ls \-cr\- much mure 
 freely on manipulation than the suhnnieous myoma. If the diagnosis cannot 
 be established, histologic examination of the tissue may at once afford the 
 proper diagnosis. 
 
 If the carcinoma be far up in the cervical canal or in the body of the uterus, 
 con.siderable confusion may arise. 
 
 The following cases are very good examples of the difliculty in deciding be- 
 tween mvomata and carcinoma of the uterus. 
 
 '' V L X 
 
 Fig. 300. — A Submucous Myo.ma Clinic.\lly Suggesting Carcinoma of thk Cervix, d", luit. size.) 
 Gyn. No. 1.3498. Path. No. 10776. The clinical hi.story stroiijtly suftKe-sted carcinoma of tlie uteiu.s. On 
 examination the vaginal portion of tiie cervix was found to be normal, hut the greater part of tiie cer\ix was much 
 enlarned an<l hard. So sure was the operator of tiie malignancy of tlie growtii that he did a complete hysterec- 
 tomy. In the illustration the small vaginal portion of the cervix is intact. The uterine cavity has heen opened 
 and unfoldccl. With the uterus closed, points a and a' would come together. The great harilne.ss in the lower part 
 of the uterus was due to the peduticulated submucous myoma b. Thi.s also gave rise to the suspicious discharge, 
 c is a small polyp. Scattered throughout the uterine wall.s are a few small ititerstitial myt)mata. 
 
 The uterus in Ciyn. No. 1()4()() (Path. No. ()727) formed a glol)ular ma.ss, 
 about the size of that of a four months" pregnancy. .Myoma was diagiutscd. 
 ( )n opening the su|)|)ose(||y myomatous utenis. the eerx'ix and lowci' pai't nf the 
 hinW were found (illeil with carciiionialous tissue ( f'ig. 2!)'.)); the cax'ity of the 
 uterus was full of jtiis. .\ glance at the cei-\-i\ will show that on \'aginal ex- 
 amination it a|)|)eai'ed pei'jeelly iiomial. ('ui'eltage in this case would ha\'e 
 cleared uj) I he diiigiiosis at (ince, but , a^ a rule, w hei'e t he condil i( )n is sup])osedl^• 
 one of simple myoma, one hardly deems it wisetocuret unless some important
 
 488 
 
 MVOMATA OF THK rTKRUS. 
 
 "^f/1 
 
 iiit'urinatiuii scciiis to be proiiiised. Wht'iicver carciiioiiui is .suspected, scrapings 
 should by all means be examined prior to attempting the hysterectomy. 
 
 On the other hand, a myoma may simulate a carcinoma, as was noted in 
 Case 13498 (Fig. 300). The operator found a .small external os and an apparently 
 much enlarged and densely hard cemx. So sure was he that the growth was 
 carcinomatous, that he made a rather extensiveand complete ahdomiiial hv.ster- 
 ectomy. The enlargement and denseness of the cervix were due to a .subnuicous 
 and pedunculated myoma (6). 
 
 In Gyn. No. 10440 the patient was exceedingly stout, and had a relatively 
 
 small uterus. One of us,* on 
 thorough bimanual examination, 
 clearly felt nodules on the surface 
 of the uterus, and accordingly 
 made a diagno.sis of nmltiple myo- 
 mata. A glance at the accom- 
 panying history of the case will 
 show that the gi-owth was prim- 
 arily a carcinoma of the body, 
 with extension by continuity to 
 the peritoneal surface. 
 
 Gyn. No. 10440 ; Path. No. 6644. 
 Diagnosis; Myoma- 
 tous uterus. Act u a 1 
 condition : a d e n o c a r - 
 c i n o ni a of the I) o d y o f 
 the uterus, ^^• i t h s e c - 
 o n d a r y s u b p e r i t o n e a 1 
 nodules (Fig. 301). 
 
 ^1. C, aged fifty-eight, white. 
 Admitted April 22, 1903. The 
 ])atient has had three children. 
 The menses stoj)ped at forty-nine. Four years ago uterine hemorrhages com- 
 menced and lasted several months. Since then they have been irregular. There 
 is a coiitimial leukori'heal discharge, with .some odor. 
 
 On vaginal examination we found the uterus about twice its natural size. 
 Scattered over its surfac(> were numerous nodules. As the patient was in good 
 condition and had a nodular uterus, which in general contour closely resembled 
 a myomatous uterus, we made a diagnosis of myoma (Fig. 301), especially as the 
 hemorrhages could readily be accounted for by the presence of myomata and 
 the vaginal discharge was but slightly offensive. 
 
 * Thomas S. CXillen, A Series of Mistaken Gynecologic Diagnoses, J. A. M. A., November 
 19, 1904. 
 
 Fig. 301.— Adenocarcinoma of the Body of the Uterus 
 WITH Subperitoneal Nodules. (| nat. size.) 
 Gyn. No. 10440. Path. No. 6644. The specimen is viewed 
 from the front. The right round ligament is drawn upward by 
 a cancerous nodule situated at its junction with the uterus. 
 Scattered over the surface of the uterus are cancerous nodules, 
 varying from a few millimeters to 2 cm. or more in diameter. 
 The insertion of the left round ligament is at a much lower 
 level than is that of the right. The general contour of the en- 
 larged and nodular uterus closely resembles that of a myoma- 
 tous organ. (.After Thomas S. Cullen.)
 
 DIFFERENTIAL DIAGNOSIS. 489 
 
 At operation we found the uterus as I have deseribed it, but the supposedly 
 myomatous nodules represented points at which the cancer of the body of the 
 uterus had extended to the peritoneal surface. They were raised nodules beneath 
 the surface, and at several points had become attached to the intestines. Com- 
 plete hy.sterectomy was performed. The patient made a good recovery, and was 
 in perfect condition five years later. In this case curettage, even without a 
 microscopic examination, would have been sufficient to establish the diagnosis. 
 
 In Path. No. 4479 (Fig. 180, p. 286) we did a supravaginal hysteromyomec- 
 toniy. Myomatous nodules were scattered over the surface of the uterus, and 
 the entire growth seemed to be myomatous in character. On examination of the 
 specimen in the laboratory the greater part of the enlargement was found to l)e 
 due to a carcmoma of the body of the uterus. If the operator, with the alxlo- 
 men open, sometimes fails to differentiate between carcinoma and myoma, there 
 is certainly abundant excuse for the general practitioner, who has to rely on 
 the bimanual examination. 
 
 In Case 3693 we have another example of the difficulties in deciding between 
 myoma and carcinoma. On referring to Fig. 302 it will be noted that the uterus 
 is nodular and several times its natural size. The cervix is enlarged, but intact; 
 the cavity is lined with nodular masses that bear some resemblance to the 
 myomata which sometimes pave the uterine cavity. Further, it will be noted 
 that although the patient had had a profuse leukorrheal discharge, there was no 
 hemorrhage. Scrai)ings in such a case would at once yield carcinomatous 
 tissue. 
 
 Gyn. No. 3693 ; Path. No. 828. 
 
 A n II n u s u a 1 c a r c i n o m a t o u s uterus, bearing c n - 
 side r a b 1 e r e s e m b 1 a n c e t a m y o m a t o u s organ* (Fig. 
 30 2). 
 
 N. G., aged seventy-six, white. Admitted July 30; {lischarg(Hl September 
 8, 1895. The menses ceased twenty-five years ago. The patient has always 
 been healthy. One grandfather died of cancel', and several i-clatives of tuber- 
 culosis. For the last year she has had a profu.se bloody vaginal discharge, and 
 has experienced sharp shooting })ains all through the abdomen. Vov the relict ot 
 these during the last six months she has taken a good deal of opium. At no time 
 has she had uterine lieinonliages. Her genei'al condition is \hh)v: she eats x-eiy 
 little; her tongue is red and fissured; the bowels are constii)ated. On vaginal 
 examination tiie cervix is found to be intact, lait enlarged: the uteinis is about 
 the size of that of a three months" ])regnanc}-, and somewhat nodulni'. A com- 
 plete hysterectomy was done. 
 
 Path. No. S'JS. The specimen consists of the utci-usand appendages intact. 
 J^oth anteriorly and postci-ioily the oi'gan is smooth ;md glistening. Projecting 
 
 *Thiscasc was nimitcii in lull in C'oiiliiliuliniis to llic Sc-ifiict' of .Mi'diciiic, l)y the Pupils of 
 Wiliiiiiii H. Welch, KtOO, p.'^e 101.
 
 490 
 
 .MVO.MATA OF THK UTERUS. 
 
 from the anterior surface, about 2.5 cm. from the fundus, are two sul)|)eritoneal 
 lujilulcs. These are irreguhir in contour, whitish yellow, and covered with 
 peritoneuni (Fig:. 302). Tliey do not project more than 2 mm. from the .surface. 
 Just posterior to the i-i^iht cormi is a similar elevation, 2.5 cm. in diameter. 
 
 Fig. 302.— a Rare Form of .\de.noc.^rcinoma of the Uterus. (Nat. size.) 
 Path. Xo. 828. The uterus is nearly three times its natural size; it presents a nodular surface, as noted at a 
 and a'. The cervix is greatiy thickened, but the vaginal portion and the external os are still intact. The organ, 
 from the external os to the fundus, is occupied hy a new-growth which entirely obliterates the normal landmarks. 
 The uterine cavity is linetl with large and small dome-like mas.ses. consisting almost entirely of necrotic tissue. 
 The new-growth has invailed the cervix and body unifonnly, extending in most places to within 5 mm. of the 
 peritoneal covering, and at a and a' reaching the outer surface. The growth is whitish in color, very friable, and 
 stands out in sharp contrast to the uterine muscle. (After Thomas S. Culien.) 
 
 On palj)ation the uterus seems to contain many areas which present a stony 
 hardness. The cervix is 'A.o cm. in diameter, and is intact. It feels somewhat 
 soft to the touch, but at the same time one obtains the im])ressi()n that there are 
 deeper areas which are vei'v dense.
 
 DIFFERENTIAL DIAGXOSIS. 401 
 
 Oil section, the ('crvical niucosa presents the usual ap))earaiice for a distance 
 of 5 mm., hut aboNc this point it is ])ractically impossible to distinguish bctwet^n 
 the cavity of the cervix and that of the body, both being of equal breadth. The 
 combined cavity is 10 cm. in length. Almost from the external os to the fundus 
 the walls are composed of necrotic-like tissue, which is gathered up into large 
 and small dome-like masses. Covering the inner surface is a dirty greenish 
 or reddish material. The uterine walls from cervix to fundus have been in- 
 vaded by a new-growth which penetrates the niusch^ to within from S to 2 mm. 
 of the surface; the wall has ))een invaded throughout its entire thickness, these 
 areas being nothing more than a continuation of the growth. 
 
 The cervix and body are almost uniformly im])licated, although the former, 
 perhaps, has suffered a little more extensively. 
 
 Histologic examination shows this growth to be a carcinoma of a most un- 
 usual type. It is described and pictured in detail in ''Cancer of the Uterus," 
 p. 588.' 
 
 Histologic Changes in Myoma suggesting Carcinoma. 
 Sarcomatous changes in myomata are by no means rare. (See Chapter XI\', 
 p. 169.) For the primary development of a carcinoma in a myoma it is absolutely 
 
 Fic. 30:5. — A l'i;ci!i,i\i{ Arraxgemext of Mu.scle-fiberh Suocsestive m Caui inom \. ( \ 1 10 iliam. < 
 Gyii. No. 12.j'.)l. I'alli. No. 9349. The specimen i.s from the center of ii .siil>nuu'inis ni.Nonia. The pah' areas 
 are due to hyahne ilejjieneration. Tlie remaining muscle-fibers are urrunKcd in struiiclit, irrenular or curved groups, 
 as indicated l)y a. .M 1) are capillaries, .some of Ihein surroutuled l>y a zone of hyaline. The picture at first sug- 
 gests carcinoma, Imt all the niuscli'-niicli'i arc of tlio usual si/.c and there is no epithelium.
 
 492 
 
 MVO.MATA OF THK UTERUS. 
 
 necessary to have had })n'(''xistinti: <2;lan(ls, and these are found only in an adeno- 
 niyonia. Nevertheless, we may hav(» the niiisele-fibers arranged in such a way 
 that they closely resemble alveoli. In Case 12591, for example, a submucous 
 myoma, 6 cm. in diameter, was removed through the vagina. Histologically 
 (Path. No. 9349), the surface of the myoma was covered with squamous epi- 
 thelium, and the muscular tissue had undergone marked hyaline degeneration 
 and liquefaction. The remaining nuisclc-hbers were arranged in single, straight 
 or curved, rows (Fig. 303) and at first sight strongly suggestetl carcinoma, but 
 on careful study of the nuiscle nuclei they were found to be of a uniform size, 
 and there was no doubt that the u'rowth was benign. 
 
 Sarcoma of the Uterus. 
 Sarcoma of the uterus, in our experience, has in the majority of cases devel- 
 oped in or been associated with uterine myomata. (See Chapter XR', p. 169.) 
 In such cases the only clinical clue to the malignant growth is the fact that the 
 tumor has of late grown very rapidly. 
 
 
 
 Fii;. 304. — Sahcoma ok the Body of the Uterus. {\ nat. size.) 
 Path. 10494. The body of the uterus is irregularly enlarged, and at a is the volcanic welling-out of a growth 
 which occupies the interior of the organ. The cervix and appendages are normal. For the appearance of the 
 growth on section see Fig. 305. 
 
 When the growth from the beginning is a .sarcoma, it may imj)licate the uterus 
 uniformly, or produce numerous nodular elevations. If the major {jortion of the 
 tumor is subperitoneal, it may possibly be I'ecognized by the soft feel; if sub- 
 mucous, portions can be curetted away and the diagnosis established.
 
 DIFFERENTIAL DIAGNOSIS. 
 
 493 
 
 In Fig. 304 we have an example of an enlargcnl uterus which, from its contour, 
 suggested an irregular 
 myomatous growth. 
 Dr. James Bosley, under 
 whose care the patient 
 had come, had, how- 
 ever, recognized the 
 malignant character of 
 the growth from scraj)- 
 ings obtained a few 
 weeks before. In Fig. 
 305 we see the appear- 
 ance of the sarcoma on 
 section. The cervix is 
 normal, and would yield 
 no clue on vaginal ex- 
 amination. The ]:)ody 
 of the uterus is occu- 
 pied by a homogeneous 
 growth which has ex- 
 tended to the peritoneal 
 surface at several points. 
 It shows considerable 
 hemorrhage and degen- 
 eration in the area in- 
 dicated by b. 
 
 The diagnosis be- 
 tween sarcoma and my- 
 oma is in some cases 
 absolutely impossible 
 prior to operation. 
 
 Fibroma of the Ovary. 
 The diagnosis be- 
 tween filiroina of the 
 ovary and myoma ot 
 the uterus may be faii-ly 
 easy, provided it is pos- 
 sible to outline a per- 
 fectly normal uterus. If, on the other hand, the utems contains inyomata. the 
 differentiation between the solid ovarian tunioi- and the tnyoinata is well-nigh 
 imjjossible. The following cases illustrate tins dilllcullv: 
 
 I X 
 
 Fig. 305. — Sarcoma ok tin-; Body oi- tiik riKitus. (.Nut. size.) 
 Path. No. 10494. For (lie Keiieral appeiiriiiice of the uterus see Fig. 
 301. A few cervical glands are ililateil. otherwi.se (he cervix is normal, a 
 is the (listorteil u(erine cavi(y. Occup.virig the fundus is a homogeneous 
 growth siiowing little structure. .\t 1) it is hemorrhagic and is disintegrating. 
 At (• the growih forms a iiodiil.ir pnijcctidii frnin llic peritoneal surface. The 
 p(islcipci-ali\i' hisldiN- iriilicali'il u iili-spiiM,! I\ inph:il ic iin'olvement in a few 
 months.
 
 494 
 
 MYn.MATA OF Tlii: ITKHUS. 
 
 Gyn. No. 9090. Path. No. 5247. 
 F i 1) r o 111 a o f t h c o v a r y ; s 111 all uteri 11 c 111 y o m a t a . 
 C. C, H'^inl sixty-two, white. Admitted Sei)teinl)ei- 27; discharged October 
 20, lllOl. I'illiiiu' the lower al)(loiiieii. and exteiidiiiii almost to the umbilicus, 
 
 Fig. 306. — Fibrom.v ok the Ov.\ry. (i Nat. size.) 
 Gyn. No. 9090. Path. No. .5247. The irregular Klobular mass measured 12 x 14 .\ 16 cm., and was wliitish in 
 appearance. KamifyinK over its surface were numerous blood-vessels. At several points were small subperitoneal 
 cysts. A colony of them is seen at a. When lyinK on the table, the tumor bore a striking resemblance to a sub- 
 peritoneal myoma. The pedicle was .") mm. broad and l.o cm. long. 
 
 was an irregular and freely mo\-al)le nodular ma.ss. The ceiA-ix was normal, 
 but the bod}' of the uterus could not be ()Utliiie(l. 
 
 On section of the alxlomen a fibroma of the ovary, 12 x 14 x l()cm., was found 
 fFig. 306). Three small subj)eritoneal myomata, not over 1 cm. in diameter, 
 and another 2 cm. in diameter and i)edunculate(l. were removed from the uterus 
 and the ))atient made a good recovery.
 
 DIFFERENTIAL DIAtiXOSIS. 495 
 
 A glance at Fig. 3UG will show that the tibruiiui of the ovary bore a striking 
 resemblance to a myoma, and the further fact that the uterus contained small 
 myomata would influence the physician in making a diagnosis of uterine myomata 
 instead of fil)roma of the ovary. A suljperitoneal myoma may be just as freely 
 movaljle as was this ovarian tumor. 
 
 Gyn. No. 10491, Path. No. 6712. 
 
 Fibroma of the o v a r y ; m u 1 t i j) 1 e u ferine m y o m a t a . 
 
 R. B., aged twent3^-nine, colored. Admitted May 14; discharged June 8, 
 1903. The cervix was high up, soft, and normal in size. Filling Douglas' 
 pouch was a very hartl mass. Occupying the lower abdomen, and extending as 
 high as the umbilicus, was what appeared to be a myomatous uterus. "When 
 the abdomen was opened, the tumor filling the cul-de-sac proved to be a fibroma 
 of the ovary. The myomatous uterus and the ovarian tumor were removed. 
 
 Path. No. 6712. The uterus contained submucous, interstitial, and subperi- 
 toneal myomata. It measured 10 x 17 x 20 cm., and was free from atlhesions. 
 The fibroma of the ovary measurc^d 5 x 10 x 10 cm. 
 
 Uterine myomata are very common. Fibroma of the ovary is relatively rare. 
 
 Ascitic fluid is a common accompaniment of fibroma of the ovary, excep- 
 tional with myoma, although it may occur as noted on p. 30. Accordingly, if 
 we have a solid pelvic tumor and also ascites, w^e may strongly susj^ect a fibroma 
 of the ovary. This assumption becomes almost a certainty if the uterus is normal 
 in size and free from myomata. 
 
 ^^^lat has been said concerning ovarian fil)romata applies equally well to the 
 slow-growing sarcomata of the ovary. 
 
 Ovarian Cysts. 
 
 As a rule, the diagnosis betwe(Mi uterine myomata and ovarian cysts is easily 
 established, but there are certain cases in which it is exceedingly difficult to de- 
 cide whethci- the gi'owth springs from the ox'ary oi' uterus. The following 
 cases illustrate this point \-("ry well. 
 
 M y o m a t a H c s c m b 1 i n g ( ) \- a r i a 11 Cyst s . -In (".-isc lOo.").") the 
 abdominal walls were xrvy lax. A smoolli i-ouiid('(l mnss, aboiii 10 cm. in dia- 
 metei', lay in the pch'is. It could be displaced lo aii}' part of the abdomen. 
 The vaginal outlet was markedly relaxed; the fimdus was in retroposition. It 
 was impossible to detei'inine whether or not the alxlominal tumor had any con- 
 nection with the uterus. ( )n account of its excessi\-e mobility, the tunioi' was 
 thought to be an owiiian cyst . When the nb(lomeii w;is o|)eiied. it pro\'ed to be 
 a pedunculated subperitoneal myomn. 
 
 In Case !()!)'.l the pelxis was lilled with a i-ounded, sliuhlly m<i\able. and a])- 
 parently lluctUMUt tumor. .\t o|ier;ition the eiil;ii-g("nient was found to be due 
 to an interstitial m\'oma.
 
 496 
 
 MVOMATA OF THK ITKHUS. 
 
 In Case 10204. in whicli llie entire abdomen was greatly clisteniled, the clinical 
 signs, even under ether, strongly suggested an ovarian cyst, and yet the tumor 
 proved to be a niyointitoiis uterus. 
 
 In Case 7'2iV-\ the soft and irregular boggy feel of the enlarged uterus strongly 
 suggested a dermoid cyst glued to the surface of the uterus. At operation an 
 iiitei'stitial m\'oina was found. 
 
 Fk;. Ij()7. — A Myomatous Utekus Mistake.n fok an* Ovakian Cyst. 
 
 Ciyii. No. 97.36. On section of the abdomen the tumor was found to have a double set of blood-ve.ssel,s. .\n 
 attempt was made to puncture it. on the supposition that it was an ovarian cyst. No fluid was obtained, and on 
 enlarginK the incision it was found tliat the tumor was a .soft, boggy, myomatous uterus, with tlie ovaries plastered 
 on its posterior surface. 
 
 The right round ligament is clearly seen in the drawing. The rectum was also firmly adherent to the tumor. 
 Removal of the uterus was difficult on account of iiifl.ammatory tissue. 
 
 In Case 9730 (i'ig. -'A)!) the myomatous uteinis simulated an o\"arian 
 cyst so closely that e\'en after the abdomen wasopem^d an attemi)t was made to 
 evacuate it. 
 
 A cystic myoma may .sometimes be felt on digital examination as a boggy 
 mass. This was noted in Case 9030. Occasionally on abdominal palpation a 
 doughy sensation was noted, as in Case 8251.
 
 DIFFER KXTIAL DIACXOSIS. 
 
 -19- 
 
 A Parasitic .M y o in a w i t h Ascites.* — On p. 35 Case P. is 
 reported in full. This ])atient had a tremendous al)dominal enlargement and a 
 drawn facial expression. Dulness in front, tympany in the flanks, and marked 
 fluctuation were elicited. From the physical signs we were sure that the patient 
 had a very large ovarian cyst. It was imi)ossil)le to get the previous history from 
 the patient, as she was weak mentally. CJuided solely by our findings, we made 
 a diagnosis of ovarian cyst, 
 but in this the famih'- phy- 
 sician, Dr. I]. H. Hoi)kins, 
 did not concur. He in- 
 sisted that the patient had 
 a myoma with ascites, be- 
 cause he was sure that the 
 patient had hatl a solid 
 uterine tumor for several 
 years before the appear- 
 ance of any fluid. On 
 opening the abdomen we 
 found a pedunculated my- 
 oma which received nearly 
 all its nourishment from 
 the omentum and bladder 
 (Fig. 25, p. 36). In the 
 abdomen were 51,000 c.c. 
 of ascitic fluid. The tym- 
 pany in the flanks was due 
 to the fact that the intes- 
 tines were held back by the 
 tumor and the omental ^'^^- sos. 
 vessels, and even if they 
 had Ijeen free, the abdom- 
 inal distention was so great 
 that the mesentery of the 
 small bowel would not 
 have allowed the intestine 
 been present over the anterior abdoiniii;d wall. 
 
 S i m pie v a r i a n (' y s t s P e s e in b 
 the ovarian cyst is irregulai' in shape, fills the pehis, and spi-eads out into the 
 broad ligament, it may closely resemble a cystic myoma. W'e have such an 
 example in I'^ig. .'JOS. The jumoi- is vei-y iiM'egulai' in shape and lobulated: the 
 uterus rests in a depi-ession neai- the u])i)er ami anterioi- surface of the cyst. It 
 
 * Thomas S. ('ullcii. .\ Scries of .Mislaivcn (iynccoloiiic I liaiitinscs. .loiir. .\. .M. .\.. .\()\rinljer 
 19, 1901. 
 
 A Mi'LTii.ix ri.Aii 0\AniA\ CvsT in Fokm Kksk.muling a 
 Cystic Myoma. (J nat. size.) 
 tiyii. No. 11133. Path. No. 7364. The mult ilocular ovarian c.vst 
 arising from the right ovary is markedly lolnilateil ami irregular in form. 
 It has evidently filled the pelvis completely, and been held firmly in 
 l)lace by the uterine attachments. In form anii in its relation to the 
 uterus it bears a close reseml)lance to the cystic myoma seen in Fig. 
 8S, p. 111. 
 
 lo reach the surface, and dulness would still ha\'e 
 i n "■ .M \" o in a t a . \\ here
 
 498 
 
 MYOMATA OF THK UTERUS. 
 
 i.s clearly evident that this tumor was hnuly wedged in the })elvis. (In referring 
 to Fig. SS f J). Ill), where a xrvy large eystie inyonia was present, it will be seen 
 that both tumors l)ear a striking resemblance to each other in form and also in 
 the relation of the uterus to the tumor, lioth of them naturally yielded a cystic 
 feel on bimanual examination. 
 
 Bilateral Ovarian Cysts with Papillary Masses on Their Surfaces and also on 
 THE Peritoneum of the Uterus. 
 
 Occasionally the uterus may be wedged in between cystic tumors of both 
 
 ovaries. If these are \-ery tense and covered with papillary masses, myoma may 
 
 be strongly suspected. In Fig. 309 we have an example of such a condition. 
 
 Both ovaries have been converted into multilocular ovarian cysts, the left being 
 
 Fig. 309. — Bilater.\l Ovari.\.n Cysts with P.\pillary Masses ox Their Surfaces. (§ nat. size.) 
 Gyn. No. 9608. Path. No. 5799. Both ovaries have been converted into multilocular cysts, and on their 
 outer surfaces are papillary mas.ses. The left lay deeper in the pelvis. .Vttaehed to the surface of the uterus are 
 several small papillary masses, indicated by a From the general contour of the pelvic mass it might be mistaken 
 for a uterus with multiple myomata. 
 
 the larger. Hoth are covered with shaggy papilloiiialous growths. The cyst 
 on the left side has been firmly held in Douglas" sac by the uterus. In such a case 
 the growths might readily be mistaken for soft myomata with secondary nodules 
 on their .surfaces. Where the cysts have very thin walls, however, little cUfficulty 
 should be encountert-d.
 
 DIFFERENTIAL DIAGNOSIS. 
 
 499 
 
 Omental Metastases. 
 Where one or hotli ovaries arc oairinoiiiatous and ])ortions of the growth are 
 seen on the surface of the tumor, it is not unusual to find a secondary 
 
 Carci noma / 
 of Ovar\ 
 
 Fig. 310. — Small Utekine Mvomata; Cahcinoma ok tmk Ovahy with \'ery Lau<!e Omentai, Metastase.s. 
 
 Path. No. 4878. The uterus contains two small interstitial ami one subperitoneal niyoinata. The left ovary 
 is small, but carcinomatous nodules jirojcct from its surface. The lower part of the omentum contains a larpc 
 metastatic carcinomatous growth. This is lohiilatcd, lias a definite framework of connective tissue, and the inter- 
 vening lobules consist of carcinomatous tissue of the .same type as that of the primary growth in the ovary. Bi- 
 manual examination in such a case reveals a small myoma on the surface of llie uterus, and iho natural assumption 
 would be that the omental >;rowlh was merely a subperitoneal nodule. 
 
 carciiioiiiatous iiniilical ion of llie onieiiluni. Tiiis may he limited (o llic 
 h)\vcr end of the omenlum. or occur as mimerous foci. The nodules may he 
 small or reach xcry lai'ii'e ])ro|»ort i(dis. W'iici-e, on himanual examinalion. the
 
 500 MYOMATA OF THK ITERUS. 
 
 Uterus is found lo Ix- soiiicwliat cnlarpMl, and where one or more small myomata 
 are detected on its surface, as in V\ii. olO. the natural infen^nee is that the abdomi- 
 nal growth is also myomatous. Some of the omental metastases, however, are 
 not rounded, hut have sharp, clean-cut edges, reminding one of the lower 
 margin of the liver. In such cases no confusion should exist. 
 
 Ruptured Rectal Diverticula. 
 Tile following ca.se clearly illustrates the great difiieulty sometimes encount- 
 ered in making a positive diagnosis between uterine myomata and other pelvic 
 lesions. Not until the abdomen was opened were we sure that the enlargement 
 was not uterine in origin. 
 
 S., C. H. I. (February, 1904), Path. No. 7276. 
 
 Diagnosis: P e 1 \- i c abscess w i t h r e t r o v e r t e d m y o - 
 m a t o u s uterus. A c t u a 1 c o n d i t i o n : Rectal diverti- 
 cula with r u p t u 1' e i n t o the s u r r o u n d i n g fat. produc- 
 ing a d e f i n i t e t u m o r : s m all abscess b e t w e e n the t u m or 
 and the pelvic floor (Fig. 311). 
 
 This patient was sixty years of age. For s(jme time she had experienced 
 slight difficulty in defecation. The stools, however, were perfectly normal in 
 caliber. For several days she had had a temperature of from 100° to 103° F. 
 
 On vaginal examination the uterus was somewhat enlarged. Posterior to it, 
 and apparently continuous with it, was a glolmlar mass. This was very hard, 
 and resemi)led a myoma in contoui'. There was, howcN'er, a hard ridge ()\'er its 
 lower portion, as is so often noted where a jx'lvic abscess exists. 
 
 A small incision was made in the vaginal vault, just posterior to the cervix. 
 and aftei- the mucosa had been peeled back, Douglas' pouch was entered with a 
 pair of blunt artery forceps. A small amount of pus and a few flakes of fibrin 
 escajK'd, but th(> mass was in no way diminished in size. Pvealizing the presence 
 of an unusual condition, the opening in the vault was packed and the abdomen 
 immediately entei'ed fi-om above. Filling Douglas' sac almost completely was a 
 tumor mass, evidently sjwinging from the sigmoid flexure. This mass had rotated 
 through an angle of 90 degrees and had become firmly embedded in the ])elvis. 
 It closely resembled a rectal cancer. It w^as carefully brought out, and an end- 
 to-end anastomosis done. A portion of the descending colon was brought up into 
 a small incision in the left inguinal region and made fast. It was necessary to 
 make an artificial opening at this point on the fourth day. The patient made a 
 satisfactory i-ecovery. 
 
 Path. No. 7276. On laying the tumor open we found two rectal diverticula 
 passing out into the adipose tissue and comnmnicating with the lumen of the gut 
 by openings not more than 1 mm. in diameter (Fig. 311). The larger diverticu- 
 
 * Thomas S. Cullen, A Series of Mistaken (Jynecologic Diagnoses, Jour. A. M. A., November 
 19, 1904.
 
 differp:xtial diagnosis. 
 
 50 1 
 
 lum was 1 cm. in clianiotcr and filled with a fecal mass. Its fioor had given way, 
 and the surroundin'i; fat was everywhere infiltrated with inflammatory })r()ducts. 
 The excessive hardness of the tumor was due to rej)lacement of the fat in many 
 places by recent connective tissue. The small abscess between the tumor and 
 the pelvic floor was due to the extension of the inflammatory process to the peri- 
 toneum of Doufilas' pouch. The diverticula were lined with atrophic mucosa. 
 A rectal cxainiiiation in this case would have yielded little beyond some narrow- 
 ing of the lumen of the bowel, which is often present in cases of jK'lvic al)scess. 
 
 Fig. 311. — Tumor of the Sigmoid Flexure Due to Rupture of Rect,\l Diverticui..\ into the SuRHOUxniNG 
 
 Adipose Ti.ssue; Small Pelvic .\b.scess. 
 Path. No. 7276 Tlie lumen of the bowel below the promontory of the sacrum i.s con.-^iderably nurnnveii. At 
 this point is a definite tumor made up of adipose tissue. Projecting into it are two diverticula, one seen in longi- 
 tudinal, the other in cross-section. At the point indicated by the three arrows the diverticulum has given way. and 
 its contents have percolated through the fat. This fat on histologic e.xamination shows evidence of acute and 
 chronic inflammation, which acct)unts for the denseness of the tumor, lietween the tumor and the pelvic floor is 
 a small abscess. The tumor was at first thought to be a myoma, (.\fter Thomas S. ("ulleii.") 
 
 Retroperitoneal Sarcoma. 
 
 Het r(i))crit()iii';il abdoiiiiiial lumoi's arc not comiiKni. ImiI dcc-isioiially one 
 is encounl ci'cd whicli, in situalioii and lonii, siiiiulalcs a iiivoina. In Mg. -WI 
 is represented a large, lobulalctl growili, which oc(ai|>ic(l ilic lowci' abdomen, 
 aiul which in geiici'al contour bore sonic I'cscmbhiiicc lo a niyoiiia. The growth, 
 however, was cystic, and the utci-us was not ciihii'gcd. Tlic jtaticnt uiidcislood 
 English poorly, and consc(|uciitly could not gi\'c a clear history of the de\"elop- 
 ment of the tuiiiof.
 
 502 
 
 .MVOMATA OF TIIK ITKRI'S. 
 
 Gyn. No. 9107. Path, No. 5265. 
 A. K., white. Admitted October 7; discharged Xoveiiiher *), 1901. The 
 patient first noticed a tumor in the abdomen a few months afjo. It has increased 
 rapidly in size. For the i)ast five weeks she has had severe pain in the left side 
 of the abilomen. The patient is rather anemic and poorly nourished. The 
 abdomen is f2;reatly distended by a tumor, which is most ])rominent in the umbi- 
 lical reijion and ap])ears to be semicystic. It is irreiiularly nodular, and very 
 
 
 Fig. 312. — Retroperitonkal S.\Hfu.MA. (» nat. size.) 
 Gyn. No. !(107. Path. No. 526.T. The tumor was of rapid growth, and had developed l)ehiiid the transverse 
 colon, to which it was intimately adherent. U measured 1.5 .\ 23 x 2.5 cm. .\bove the transverse colon were large, 
 sharply outlined, loljulated portions of the growth. The general contour of the tumor strongly suggested myoma, 
 but its position and consistency excluded the possibility of a uterine origin. 
 
 freely movable. On vaginal examinatioii no communication between the tumor 
 and the uterus could be determined. 
 
 Operation (Dr. Iluniicn: The tumor proved to be a ret roixi'ltoneal sarcoma 
 (Fig. .312) that lay beneath the transverse colon. It was neces.sary to resect 
 a large portion of the colon with the tumor. The patient made a satisfactory 
 recovery. 
 
 Path. No. 5205. The specimen consists of an o\'al-shaped tumor, 25 x 23 
 X 25 cm. To the hnver bordei' of the tumor is attached the omentum, and
 
 DIFFERENTIAL DIAGXOSIS. 503 
 
 across the surface of the tuiiior are '22 em. of the transverse colon. On clo.'^e 
 inspection the tumor is .seen to he between two hirers of the omentum, and is 
 covered with peritoneum, except along the upper hfth, where it has been attached 
 to the stomach. The tumor presents a dirty yellowish color, somewhat suggesting 
 omental fat. Scattered throughout the omentum are numerous nodules. Some 
 of these near the lower edge of the omentum are 1 cm. or more in diameter. 
 On palpation the tumor is semifluctuant and apjx'ars partly cystic, but when cut 
 into, the tissue seems for the most part to be homogeneous and resistant. 
 
 Histologically, the tumor consists of cells crowded together, with no definite 
 arrangement. The shape and size of the nuclei vary considerably. Many giant - 
 cells are present. Numerous thin-walled blood-vessels are scattered throughout 
 the tissue. The tumor is a retroperitoneal sarcoma with omental metastases. 
 
 In the foregoing we have given merely a few examples of the difficulties 
 occasionally encountered in making an accurate diagnosis. We have in one in- 
 stance opened the abdomen on the supposition that the patient had a small 
 and adherent myomatous uterus. A primary carcinoma of the right tube was 
 found* with extension to contiguous parts. In another case a mass to the right 
 of the uterus, and apparently continuous with it, seemed to be a myoma. At 
 operationf it proved to be an inoperable carcinoma of the ovary which had spread 
 out into the broad ligament and had apparently implicated the small bowel. On 
 the other hand, we have on several occasions opened Douglas' pouch per vagi- 
 nam, on the assumption that a pelvic abscess existed, only to find no abscess, 
 but an adherent retroverted myomatous uterus. 
 
 The diagnosis of uterine myomata is, as a rule, easy; nevertheless, in a certain 
 number of cases the real condition cannot be definitely established until the 
 abdomen is opened. 
 
 * Thomas S. CuUen, Primary Carcinoma of the Right Fallopian Tnhe, Johns Hopkins 
 Hosp. Bull., 1905, vol. xvi, p. 397. 
 
 t Thomas S. CuUen, A Series of Mistaken Gynecologic Diagnoses, Jour. A. M. A., November 
 19. 1904.
 
 CHAPTEE XXMIT. 
 THE EFFECT OF REMOVAL OF THE OVARIES ON UTERINE MYOMATA. 
 
 In the early clays of the hospital hysterectomy wtis a more formidaljle oper- 
 ation than it now is. and when removal of the uterus was especially difficult, 
 the ovaries were taken away in the hope that the tumor would gradually decrease 
 in size, or at least remain dormant. In 25 cases only the tubes and ovaries were 
 removed, and in 12 of these we have been successful in learning the subsequent 
 history. From the accompanying table of the cases (page 505) we get some very 
 interesting data. 
 
 In 4 of the cases no uterine bleeding was noted after operation. In Cases 
 1373 and 1405 it appeared once, and in Cases 182 and 516 three times. In Case 
 143 it was regular for a year, and in Case 213 bleeding occurred at irregular 
 inter\-als for a year. In Ca.se 1949 bleeding persisted at irregular intervals until 
 the uterus was removed four }'eai's later. These figures tend to show that 
 removal of the ovaries caused ces.sation of the bleetiing, either at once or in the 
 course of a year. It will be noted from the table, however, that in no case had 
 the myomatous uterus reached large proportions. 
 
 In 10 of the cases the ])atients were completely relieved of their former pelvic 
 symj^toms. In Case 891 the patient's health five years later was "very bad." 
 She had pain on defecation and micturition, and was exceedingly nervous. One 
 patient (Case 1949) was reachnitted to the hosjntal four years later, and the 
 densely adherent myomatous uterus, which choked the pelvis, was removed. 
 
 We have from time to time heard of uterine myomata spontaneously dis- 
 appearing or \anishing after renio\-al of the ovaries, but have looked uj)on such 
 rejjorts with considerable incredulity. We have one case, however, where such a 
 change evidently took j)lace. On section of the abdomen in Case 143 the myoma- 
 tous utei'us completely filled the ]»elvis; both tubes and ovaries were removed. 
 Two and a half years later the patient was examined. She had gained 40 pounds. 
 The uterus was small, antejjosed, and no trace of the myoma remained. 
 
 We now remove the myomatous uterus, wherever necessary, saving the 
 ovaries if normal. The knowledge gained from the.se cases, however, certainly 
 suggests the adN'isability of removing the ovai'ies, where feasible, in those cases 
 in which hysterectomy is impos.^ible. 
 
 504
 
 EFFKCTS t)F U(JrHORECTO.MY OX UTKKIXE .MYCJMATA. 
 
 505 
 
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 7: 
 
 
 
 
 
 
 
 
 
 
 
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 o 
 
 o 
 
 >i 
 
 •3 
 
 
 j£_ 
 
 
 c > 
 
 _^ 
 
 
 
 
 micturition freq 
 
 ((Jyn. No. T) 
 
 and choking | 
 
 ). Subperitoneal 
 
 Muucous myomat 
 
 f. 
 
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 CO 
 
 o 
 
 p 
 
 o 
 
 
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 CIIAPTKIJ XXIX. 
 ABDOMINAL MYOMECTOMY. 
 
 Any operation that has for its aim the conservation of tho uterus instead of its 
 removal must always be of particular interest to l)otli suigeon and patient. 
 We have carefully examined the cases admitted to the Johns Ho])kins Hospital 
 fi-oin the time it ojx'ncd, in ISSi), until July 1, I'.KHi. In our considei'ation of 
 the suhjet-t we have also included cases of i)atients operated u])on at the Church 
 Home and Infirmary, the Caml)ridu;e (Md.) Hosi)ital, and the Frederick Emer- 
 gency Hospital. In that period we have had 296 cases of uterine myomata 
 in which the conservative method was adopted. In the following pages we shall 
 give Ijriclly the salient features, and then discuss fnlly the various complications 
 accom))anying or following inmiediately after operation. Those cases in which 
 death occurred are i-eported in detail. 
 
 Letters have been sent to nearly all the patients, and it is interesting to 
 learn the condition years after th(> myomectomy. 
 
 .M}'omectomy naturall}- falls into two main sul)(livisions: 
 1. Abdominal myomectomy. 
 -. \'aginal myomectomy. 
 
 Before j)roceeding to a detailed description of the oj)ei'ation and its various 
 (■onij)licalions. we will partially outline the salient clinical features in cases re- 
 ([uiring abdominal mycjuiectomy. 
 
 Color. — Of the 21)() patients, 2.50 were white and 4(1 were colored. 
 Naturally, the whites outnumber the blacks, but the marked i)reponderance of 
 white patients coming to abdominal myomectomy is due, in part at least, to the 
 fact that in the colored the tubes are more fre([uently the seat of inflanunatory 
 troul)l(\ wliich usually necessitates a hysterectomy instead of a myomectomy. 
 
 Age. In all but 1.") cases we have I'ecoi'ds of the age at the time of 
 operation. 
 
 ABDOMINAL MYOMECTOMIES. 
 
 1 9 years of age 1 case 
 
 Between 20 and 30 years of age 43 cases 
 
 Between 30 and 40 years of age 137 " 
 
 Between 40 and 4o years of age 62 " 
 
 Between 4.") and oO years of age 19 " 
 
 Between ,50 and 60 years of age 17 " 
 
 Between 60 and 70 years of age 2 " 
 
 Ages not recorded 15 " 
 
 Total 296 " 
 
 506
 
 ABUU-MIXAL MYO.MKCTU.MY. 5U7 
 
 The youngost ])atioiit, wlio was nineteen jTars of age (Case 9037). had a 
 small adenoniyonia. 2.') <'iii. in diameter, removed from the right uterine horn. 
 
 It wall further be noteil that at least 38 out of a total of 296 patients were over 
 forty-five years of age, the oldest being sixty-six. This patient (C'asc^ o279) 
 had an intraligamentary myoma, 6 x 8 x 10 cm. 
 
 It is generally conceded that myomectomy is more dangerous than hyster- 
 cctomv. and conse(|uently, after the menopause, it is usually wiser to remove the 
 uterus than to enucleate the myomata. There are, however, some excejjtions. 
 When there is only one myoma and this is attached to the uterus by a narrow 
 pedicle, as in Case 9118, myomectomy is naturally the easier and safer operation. 
 In looking back, it is always easy to see where one might have shown l)etter 
 judgment in the selection of the safer operation. For example, in Cases 1422. 
 5279, and 6047, myomata were enucleated from the broad ligament. In such 
 cases we now know that it is very difficult to obhterate the resultant space, and 
 hysterectomy is much safer. Again, in patients who have passed the climac- 
 teric no possiljility of pregnancy or the preservation of the menstrual fvuiction 
 exists to compensate for the increased risk. 
 
 Furthermore, we know that when many incisions are made into the uterus, 
 the risk is materially increased, and yet in Case 5153 we removed 11 myomata 
 through 7 incisions, and in Case 6395, 15 myomata were enucleated. Little is to 
 be gained in saving such organs after the menopause. 
 
 In Case 5493 the nodule was a submucous myoma, and during its removal 
 the uterine cavity was opened throughout its entire length. Here, hkewise, 
 the increased risk was in no way compensated for by the ultimate results. 
 
 Although myomectomy is always attended with an increased risk over 
 hysterectomy, after the menopause the l)lood-supply of the uterus is nuich 
 diminished, and the i)ower of absorption from this organ lessened. This is 
 shown ])y our results: every one of the 38 patients oj)erated upon after the 
 menopause recovered from the operation, and the greater number wci'e pci'fectly 
 well years aftei'. 
 
 Single or Married.— Of the 29() patients that underwent alMlomiiial iiiyoiiiec- 
 tom\', 101 were single; ISO were niai-ried; in 6, data were lacking. 
 
 These figures are of only I'elative value, as the morals of some of the white 
 as well as the colored patients were not above (piestion. 
 
 The Relation of Uterine Myomata to Pregnancy. In 00 of the myomectomy 
 cases in married women during the child-bearing ju'i'iod we have dehnite data as 
 to pregnancy. Of this number, 59 have had children. A few have been the 
 mothers of large families, but in a large projiortion onl\- one oi- two chilihcn have 
 been boi'n. In .■■)2 (35.1 pel' cent . ) the ])al ient had ne\'ei- been pi'egnant up to t he 
 time of entering the hos))itah Our figures, thercfoi-e, faxdi' the \-iew tliat myo- 
 mata ma}' possibly cause stei'ihty. 
 
 The Location of Myomata Removed by the Abdominal Route. IVom a surgi- 
 cal standpoint, it seems advisal)le to divide the myoinat.a into the following geo- 
 gra])hic groups:
 
 oOS 
 
 MYOMATA OF THK UTP:RUS. 
 
 Fig. 313. — .\ Peduncul-'^ted Subperitoneal 
 Myom.^. 
 Gyn. No. 19.50. The patient was forty 
 years old. The uterus had been rotated to the 
 left to accommodate the myoma, which was at- 
 tached to the posterior surface of the uterus by 
 
 1. Subperitoneal i)e(liiiR'ulatetl inyoniata. 
 
 2. Interstitial (ineliuling those that are partly sul)peritoneal). 
 
 3. Submucous (inehuling those partly 
 interstitial. 
 
 4. Myoniata of the broad ligament or 
 int raligamentary mj'omata. 
 
 5. Subvesical m3'omata. 
 (i. Cervical myomata. 
 7. Adenomyomata. 
 In all but 25 of the 296 cases we have 
 
 definite data as to the location of the my- 
 omata. In some instances subperitoneal 
 pedunculated nodules, interstitial tumors, 
 and submucous myomata were removed 
 from the same organ. 
 
 Subperitoneal Fed u n c u - 
 1 a t e d M y o m a t a . — In 49 cases 
 
 a narrow pedicle. Abdominal myomectomy was peduUCUlated UlVOUiata WCrC rcmOVCd, and 
 
 performed. The patient made a good recovery. ' - . . . , 
 
 Fourteen years later she writes, "Health not in at Icast 8 of thcSO CaSCS mtcrstltUll myO- 
 
 cood. Trouble not connected with operation," , PnUclpatcd 
 
 showing that no new myomata have developed. Ul'ita ^^C1C aibO enUCiedlLU. 
 
 This is a case in which myomectomy is less J^l CaSC 7220 the UiyOUia meaSUrod 14 
 
 dangerous than hysterectomy. -r i i ' i • i- i 
 
 X 19 cm. It had rotated on its pedicle 
 from right to left through an angle of 180 degrees, and was covered with 
 dense vascular omental adhesions. (See Fig. 18, p. 22.) 
 
 The myoma in Case 8310 was nearly as 
 large as a uterus at full term. Its pedicle 
 consisted of the fundus and cenax, and was 
 2 cm. in length. The cervix itself had been 
 ))ulled high u]j toward the jx'lvic brim. 
 
 The myoma in Case 67S1 was approxi- 
 mately 9 cm. in diameter, and almost 
 completely enveloped in very vascular 
 omental adhesions. The greater number 
 of ju'dunculated myomata were fi'eely 
 movable. 
 
 In Fig. 313 we have an example of a 
 large subperitoneal myoma that was easy 
 of removal. The myoma represented in 
 
 Fig. 314, on the other hand, was attached Abdominal myomectomy was performed, and the 
 
 ' patient reported that she was in very good health 
 
 to the uterus over a broad area. It was .sixteen years later, 
 difficult to decide whether the myoma alone 
 
 should be removed, or whether a hy.sterectomy would be the .'^afer procedure. 
 
 Myomectomy was done, and the patient was in good condition sixteen years later. 
 
 Interstitial Myomata. — The majority of myomata are intersti- 
 
 FlG. 314. A L.\RGE SuBPERITOXE.\L MyOM.\. 
 
 Gyn. No. 1112. The myoma rises high 
 out of the pelvis and is attached to the posterior 
 surface of the uterus by a rather broad pedicle.
 
 ABDOMINAL .M V( )MK('T()M V 
 
 509 
 
 tial ill their iiicipiciic}' and linulually ht'coiiie subperitoneal or suhinufous. 
 Consequently, we should expect the greater nuniher operated u]jon to he of the 
 interstitial variety, and such proved to be the case. All partially subperitoneal 
 niyomata are, to a great extent, interstitial, and as the operative procedure in 
 both instances is the same, Ave find it wiser to include them in the same group. 
 In 202 of the 296 cases, that is, in about 70 ])er cent., interstitial niyomata were 
 removed. 
 
 Sub m u c o u s M y o m a t a . — In 20 cases submucous niyomata were 
 removed. Sometimes it is possiljle to remove the myoma without opening the 
 uterine cavity, but in others the myoma encroaches so upon the cavity that its 
 removal is impossible without entering the cavity to some extent. The accom- 
 panying table gives the essential features in all the cases in which submucous 
 myoma t a were found. 
 
 SUBMUCOUS MYOMATA REMOVED PER ABDOMEN. 
 T.^.BLE Showing Whether Uterine Cavity was Opened or not During Oper.^tion.
 
 510 MYo.MATA OF THH UTKRUS. 
 
 Ill 'A casrs it was possible to cmiclcatc the j)artly subiiiucoiis myoiiiata with- 
 out o])('iiiiii: the uterine (•a^■ity. In 4 cases the uterine ea\'ity was only slightly 
 or moderately oi)ene(l, and in 7 cases the cavity was explored for nearly its entire 
 length. Tn 'A cases the utei-us was deliberately split open to see if myomata were 
 present, ami in 2 out of the M myomata were detected. 
 
 Hysterotomy, or sj^litting of the uterus, has been frequently employed by our 
 colleague. Dr. W. W. Kus.sell, with excellent results. In Case 10351, however, a 
 very large uterus was bisected, and 28 nn'omata were removed from various parts 
 of the wall. The utei'us was then sewn together again. The patient died. 
 Complete tletails of her case are foimd in on page 537. 
 
 In C. H. I., B., one-third of the uterine cavity was saved, and the i)atient 
 menstruates regularly. In C. H. I., 1019, in which a partially submucous myo- 
 ma, 10 X 10 X 12 cm., was ])resent, half of the uterine cavity was saved. The 
 menses ceased about six months later, jiossibly partly as the result of a marked 
 cardiac lesion. 
 
 -M y o m a t a o f t h e B r o a d L i g a m e n t . — Seven out of 296 ab- 
 dominal myomectomies wei'e for myomata of the broad ligament, which some- 
 times occurred alone, and in other cases associated with interstitial or peduncu- 
 lated nodules. The intraligamentary myoma is usually easily removed, but if 
 there is much oozing, there is great danger of an accunmlation of l)lood between 
 the peritoneal folds, and this later may become infected, giving rise to a l)road- 
 ligament abscess, as ha))])ene(l in Case 5359 (p. 553). 
 
 S u b V e s i c a 1 .M y o m a t a . - Subvesical myomata are not uncommon, 
 but are usually associated with other myomata, and in such cases hysterectomy 
 is the safer operation. Two of our abdominal myomectomies were done for the 
 removal of subvesical nodules. 
 
 In Case 5332 a subx-esical myoma, S cm. in diametei', was removed, and the 
 l^atient was perfectly well ten years later. 
 
 In Case 6762 a subvesical nodule, 6x6x7.5 cm., was removed. Iletention of 
 tu-ine i-e(|uire(l catheterization up to the twenty-third day. An annoying cystitis 
 ju'i'sisted for ovei- two years, and now, eight years after operation, is much better, 
 but apparently the patient has tabes dorsalis. 
 
 Cervical M y o m a t a . — Cervical myomata that caimot b(> enucleated 
 per vaginam are usually so hard to get at from above on account of their proxi- 
 mity to the uterine artery and ureter, and from the difficulty of obliterating the 
 resultant space, that hysterectomy is generally (he (>asier procedure. In two 
 of our cases single cervical myomata have been removed per abdomen. 
 
 In Fig. 315 we have an exam])le of a myoma that was attached to the uterus 
 so low down in the cervical region that its removal occasioned much difficult}-. 
 
 In Case 1033 a small cervical myoma, 1.5x2 cm., was icmoved from (he 
 posterior surface of the cervix. Nine years later (No. S415) the uterus was 
 removed on account of multiple myomata. 
 
 Case G., in which a large cervical myoma with part of the vaginal mucosa
 
 ABDOMINAL MYOMECTOMY. 
 
 511 
 
 Tubf 
 
 T'^a. 
 
 was reniovccl per ahdoincii without iiitcrniptin^ the four months' pregnancy, is 
 reported in detail on p. 531. 
 
 In one of our early cases (No. 1329) a myoma, 5 cm. in diameter, was re- 
 moved from the fundus, but instead of attempting to enucleate a cervical myoma, 
 8 cm. in diameter, we removed the ovaries. Of course, with our present knowl- 
 edge we would do a hysterectomy and save the ovaries. 
 
 A d e n o m y o m a t a . — In five cases diffuse or discrete adenomyomata 
 were removed from the uterine wall. We have made a separate division of this 
 variety, because in the majority of these cases the myoma is so intimately con- 
 nected with the uterine wall that it cannot be peeled out and must be cut away. 
 In Cases 3600, 4415, and 12036, it 
 was necessary to cut out a wedge of ^^-'-- ~~~-,^ 
 
 the uterine wall to remove the ^^"^ '"^ -- 
 
 growth. In cases 9024 and 12585 
 the myomata were more circum- 
 scribed and could be dissected out. 
 All these cases are dealt with in 
 detail in "Adenomyoma of the 
 Uterus." 
 
 Size of the Myomata Removed. 
 — In the 296 cases we have in- 
 cluded practically every case in 
 which myomata were removed, no 
 matter how small or how large. 
 As seen from the records of the 
 deaths, the removal of even small 
 nodules may prove fatal. 
 
 P e d u n (• u 1 a t e d Myo- 
 mata. — 111 the following cases 
 large pedunculated myomata were 
 removed: in Case 911S a subperi- 
 toneal nodule. 16 x Ki \ 22 ciii. ; 
 in Case 5826, a myoma 15 x IS x 20 
 cm.; ill Case 5086, a myoma 17x2*)x29 ciii., and in Case 1(172 a sub|tciit(»iieal 
 nodule, 30x34 cm. In all probability the largest subix-iitoiieal nodule ever re- 
 moved was from Case McA. (see Fig. 317, p. 514). Th(> t umor weighed 89 j)ounds. 
 and was attached to the uterus by a pedicle only a few centimeters in diameter. 
 
 Interstitial .M y o in a t a . — The iiiterstitiat t uiiiors. of course, do not 
 reach such large projKJilions. In Case lo.").") an interstitial iiiyoiiia, 10 \ 10x21 
 cm., was removed; in Case 1 JL'.")!') one 15 cm. in diameter, hi (". 11. 1.. \\ ., the 
 tumor measured K) cm., and in Cas(> 4!)25, 12x21 x 27 cm. hi tiie last case 
 hysterectomy followed a few years latei- on account of the ap|)earance of other 
 myomata. (See Fig. 331, p. 562.) 
 
 \ 
 
 Fig. 315. — A Difkicult .Myo.mecio.my. 
 Oyn. No. S389. Path. No. 4576. At the junction of 
 the cervix and fundus was a myoma about 7.5 cm. long, 
 n was exposed with tlifliculty ami removed, .\fter opera- 
 tion the patient developeil a severe cystitis. Six years 
 later she was perfectly well.
 
 512 MYOMATA OF THE UTERUS. 
 
 S u I) 111 u c- o II s M y () 111 a t a . — Myoniata of this variety are relatively 
 small. In our tirouj) they varied from 1 to 10 cm. in diameter, the average 
 ])eing about o cm. In ('a.-;e 5447 the myoma reached about 9 cm. in diameter 
 and in C. H. I.. S.. 10 cm. 
 Successful Removal of a Pedunculated Eighty-nine Pound Cystic Myoma Intact.* 
 
 As will be noted from the following history, this j)atient was cognizant of the 
 fact that the tumor had existed for over twenty years. At that time she was 
 under the care of Dr. James Bosley. Further, it will l)e seen that this large 
 growth did not prevent her from looking after her household duties until a short 
 while before admission, and less than three months before the operation she 
 had taken a ISO-mile trip with no ill effects. This, so far as we can learn, is the 
 largest myoma of the uterus that has been successfully removed. The patient 
 is now, two and one-half years after the operation, in perfect health. 
 
 McA. Path. No. 10382. 
 
 Mrs. McA.. aged fifty-eight, was seen by one of us (CuUen) in consultation 
 with Dr. Marshall Smith, June 25, 1906. 
 
 History. — Twenty years ago she noticed a tumor in the lower abdomen, and 
 later was seen in consultation with Dr. W. T. Howard, who at that time advised 
 an operation. Some time after this she was delivered of a healthy child, now 
 eighteen years of age. Tliis patient, although suffering from a large alxlominal 
 tumor, was able to go around and to do her work until three weeks before T saw 
 her. Her chief inconvenience had been her inability to lie on her Imck in Ijed. 
 And sometimes when she would get ''stalled," it was necessary for her husband 
 to turn her over quickly, otherwise she would have suffocated. For two weeks 
 before admis.sion she had a temperature sometimes reaching as high as 103°. 
 She was admitted to the Church Home and Infirmary July 27, 1906. There was 
 consid(>rable edema of the lower part of the abdomen and some edema of the legs. 
 On admission to the hospital her temperature was 100° F. ; pulse, 105. On the 
 morning of operation the temperature was 100° F. ; pulse, 100; respiration, normal. 
 
 Operation, July 'AO. 1906: Prior to receiving the anesthetic the patient was 
 thoroughly washed and all preparations for operation were made, so that she 
 might remain as .short a time as i)ossible under ether. It was impossible for her 
 to lie down, conse<iueiitly she was o|)erated on in the sitting posture. An incision 
 was made over the most prominent part of the tumor, and I attempted to punc- 
 ture it; the growth, however, started to bleed, and no cyst fluid escaped. I 
 continued the inci.sion upward, for the reason that many large veins projected 
 into the tumor from .some structure above. The incision was gradually con- 
 tinued ui)ward until the xii)hoid process was reached (Fig. 316). We found 
 that the large vessels going to the tumor were omental in origin, and were si)rea(l 
 out over the entire upper surface. Some of them were fully 7 or S mm. in diam- 
 
 * Thomas S. Cullen, A Series of Interesting Gynecologic and Obst etric Cases. Jour. A. M. 
 A., vol. xlviii, May 4, 1907.
 
 ABDOMINAL M YOM KCTO.M Y 
 
 513 
 
 eter. The tumor was densely adherent to the anterior and to the lateral ab- 
 dominal walls. These adhesions were gradually shelled off with the hand, but I 
 had to use the utmost care and do all liberating under sight, as the rupture of 
 one large vein might have caused death before the hemorrhage could have been 
 checked. Accessory vessels also passed from the stomach and the liver to the 
 tumor. The pedicle of the tumor was not more than 1.5 cm. in diameter, and 
 was situated directly beneath the ribs. On removal of the tumor I found that 
 I had brought away a piece of liver tissue 3 cm. in diameter. We had no liver 
 needles handy, so I used sharp Hagedorn needles, running the eye through instead 
 of the sharp end. This device answered admirably, and the liver bleeding was 
 
 Fig. 316. — Abdominal Enlargement Due to a Cystic Myoma. 
 The abdomen is markedly and uniformly distended, and the growth extends down almost to the knees. 
 It will be noted that there is no saKging in the flanks. Coursing over the surface were very large vessels. When 
 it is realized that the abdominal incision extended fom the xiphoid cartilage down over the entire length of the 
 tumor, and then back to the symphysis, it is readily seen that the wound was nearly 4 feet in length, (.\fter 
 Thomas S. Cullen.) 
 
 easily checked with four catgut sutures, llie uterus and the right tube and 
 ovary lay under the surface of the liver. Anticipating the possibility of great 
 difficulty in controlliiig the tumor, wo had. jjrior to operation, sterilized a large 
 foot-bath and covered it over with a sterile sheet. The foot-bath held about 
 one-third of the tumor, and the p(>rson who took charge of it was able to guide 
 the tumor in the desired direction without allowing it to slip from his grasp. 
 The tumor was drawn downward and outward, and finally dcliNcrcil from the 
 abdomen. In the lower part it was extraperitoneal. I closed the abdo- 
 men, but left a small cigarette drain in the extraperitoneal pouch just over the 
 symphysis. 
 
 Postoperative history: The patient stood the ojK'ration wt^U. but was com- 
 
 33
 
 514 MYOMATA OF THE UTERUS. 
 
 nioncing to collapse by the time we finished. She was under ether for one hour 
 and twenty minutes; 200 gi'anis were used. The operation, from the incision to 
 complete closure, took fifty-five minutes; a much longer time would have been 
 consumed had it not been for the combined assistance of both the Johns Hopkins 
 and Church Home staffs. The patient's temperature rose to 102.2° F., within 
 eight hours after operation, but had dropped to 100° F. by evening. The highest 
 pulse-rate was 130. There was no postoperative vomiting. The legs were 
 bandaged on account of the edema. The patient voided urine on the evening 
 of the day of operation. She was catheterized only once. The usual after-treat- 
 ment was employed. On the fourteenth day she had considerable discomfort 
 from frequent stools. The diarrhea persisted off and on for a couple of weeks. 
 At this time, however, tlie weather was excessively hot, and diarrhea was general 
 throughout the hosjjital. It affected chiefly those patients who were somewhat 
 weak. The patient, on admission to the hospital, weighed 174 pounds. 
 Twenty-three days after operation she weighed 80^ pounds. The condition of 
 the abdomen in this case was particularly interesting. I did not even resect a 
 portion of the abdominal wall, because we had to save as much time as possible 
 during operation. At the first dressing it was noted that the ribs extended out 
 fully 6 inches from the abdomen, and that the recti muscles lay on the bed on 
 either side, while there was a good deal of loose and wrinkled skin covering the 
 abdomen. Another interesting point was that the gauze, which drained the ex- 
 traperitoneal pocket just at the symphysis, now lay in the middle of the abdomen, 
 as the tissues were gradually contracting. After the lapse of two weeks the recti 
 muscles could be felt gradually contracting and coming in, and the costal arch 
 was flattened down to some extent. When I examined her six weeks after opera- 
 tion the recti muscles were well up in the abdomen, being not over 10 cm. apart. 
 The skin had contracted down wonderfully. The pendulous skin over the sym- 
 physis had retracted to a marked extent, and the ribs were almost in their normal 
 position. At the time of operation there was a good deal of edema of the ab- 
 dominal walls. There was also edema of the legs and of the buttocks. Although 
 the utmost care was used, a bedsore developed several days after the operation, 
 there being a black slough 6 cm. in diameter over the sacrum, and surrounded 
 by a faint red halo. It had resulted from pressure on the table. The patient 
 had had marked edema of the Ijack, but was forced to sit u\) during almost the 
 entire operation. After she went home she ra[)idly regained her strength. The 
 bedsore gradually diminished, and in time entirely healed. It is astonishing 
 that she had so little inconvenience after the operation. 
 
 Fio. 317. — Cross-section op a Cystic Myoma Weighing 89 Poonds. (1% nat. size.) 
 The pedicle is clearly seen, and in the fresh specimen was not over 1.5 cm. in diameter. Attached to the top 
 over the pedicle are the tube and ovary, and near the tube is a piece of liver substance. The tumor has been 
 converted into one large cavity, the walls of which consist of muscle. In the walls are numerous cystic spaces, 
 particularly well shown at the points indicated by a. There are several large cystic dilatations in the wall. The 
 largest is indicated by b. The myomatous walls vary from 5 cm. to 1 or 2 mm. in thickness. At the point c. 
 ■where the tumor lay over the vertebral column, the wall is exceedingly thin. The entire inner surface is lined 
 with partly organized blood-clots, which give the growth a very shaggy appearance. The entire tumor was filled 
 with blood. The outer surface is in many places covered with adhesions containing large vessels.
 
 li(.. .il7. 
 
 515
 
 516 
 
 .MVOMATA OF THI-: UTERUS. 
 
 Description of Tumor. — Path. No. 103S2. Miss X. Ellicott, sii|H'rint('ii(leiit 
 of imrst's, weighed the tumor iiuniediately after its removal; the net weight, 
 after deducting that of the vessel in which it lay, was exactly 89 pounds. The 
 thin part lay posteriorly, otherwise we might have evacuated the tumor. Had 
 we done so, however, it would have been much more difficult to have gotten at 
 the large vessels, which we cncouutci'ed at almost every point. Had this condi- 
 tion jK'rsisted much loiiuci-. the jjosterioi" wall of the tumor would certainly have 
 
 gi^en way, and then 
 operation would have been 
 almost out of the question. 
 As it was, the hardened 
 specimen collapsed of itself 
 wh(^n placed on the table. 
 Macroscopic Examina- 
 tion. — The hardened speci- 
 men is about 50 cm. in 
 length, 45 cm. in breadth, 
 and approximately 25 cm. 
 in thickness. Over the 
 entire anterior surface and 
 laterally are numerous ad- 
 hesions. Attached to the 
 upper border is an area of 
 omentum 20 cm. in 
 breadth, and the hardened 
 vessels range from 5 to 6 
 nun. in diameter. The 
 pedicle of the tumor is 1.5 
 cm. in breadth, 1 cm. in 
 thickness, and the portion 
 removed is 1.5 cm. in 
 length. Situated just be- 
 
 FiG- 318. — Multiple Myomectomy. 
 
 Gyn. No. S462. From this uterus 13 myomata were enucleated. 
 
 The large kidney-shaped tumor on the rijiht measured 7x7x14 cm. 
 
 Practically all the myomata seen were removed, with little injury to 
 
 the uterus. Six years later the patient reported that her general health 
 
 could not have been better. Prior to the operation she had frequent UCatll the ])edicle, and at- 
 tached to the surface of 
 th( 
 
 micturition and a troublesome pruritus ani, which had persisted over 
 two years, but was completely relieved by operation. 
 
 ovary, is a piece of 
 liver substance 3 by 2 cm. (Fig. 317). On pressure the tumor in part seems 
 to be solid, in part cystic. At operation, when I attempted to puncture 
 the tumor, nothing but blood was encountered. Th(> growth is, however, evi- 
 dently made up of one large cystic space and numerous smaller ones, together 
 with the semisolid area. Over the part that is cystic the muscle-fib(>rs have been 
 greatly stretched and thinned out, and there are little hernial })r()jections, the 
 picture being analogous to that foimd in a slightly sacculated urinary bladder. 
 On section the greater part of the tumor is found to con.sist of one cavity, which
 
 ABDOMINAL MYOMECTOMY. 517 
 
 is approximately 42 by 35 cm. The walls vary from 2 mm. to 5 cm. in thickness. 
 Only at one point is the wall very thin, namely, on the under surface, where it 
 lay over the vertebral column. The greater part of the wall consists of simple 
 myomatous tissue, but at numerous points small cystic areas are visible, and the 
 tissue has undergone the characteristic hyaline tra,nsformation. One of the cysts 
 measures 2 by 3 cm. The inner surface is covered with blood, and the greater 
 part of the tumor is filled with Ijlood which has undergone coagulation during 
 the hardening. 
 
 Microscopic Examination. — On histologic examination the growth is seen to 
 be made up of typical myomatous tissue. In many areas hyaline transforma- 
 tion has taken place and at some points there is typical liquefaction. The inner 
 surface of the cyst has no epithelial lining; it is covered with blood which is faintly 
 organized. 
 
 Number of Myomata Removed by Abdominal Myomectomy. — In the greater 
 number of the cases the uterus contained only one myoma, and that was inter- 
 stitial. In several instances, however, several tumors were enucleated. For 
 example, in U. P. I., S., and C. H. I., H., 9 myomata were removed. In Case 
 4365, 10 myomata; in Cases 5153 and 10300, 11 myomata, and in Cases 8773, 
 6395, and 5452, 13, 15, and 17 myomata, respectively, were shelled out. In 
 Case 8462 (Fig. 318) 13 myomata were removed. The patient six years later 
 was well. The greatest numl^er removed in any one of our cases was furnished 
 by Case 10351. The uterus was split, and 28 myomata, varying from 1 to 1.5 cm., 
 were removed. The patient developed marked abdominal distention, and on 
 exploration free blood and clots were found in the abdomen. Death occurred 
 on the fifth day. The case is reported fully on p. 537. 
 
 After adding up all the myomata removed and then striking an average, 
 we find that if they had been evenly distributed, each uterus would have con- 
 tained a fraction over two m3'omata. 
 
 Contraindications to Myomectomy. 
 
 Low Hemoglobin. — In three of our cases in which abddiiiinnl myoUHM'toiiiy 
 was performed the hemoglobin was very low, and it is interesting to follow 
 the progi-ess of the individual cases. 
 
 In Case 9629 the ])atient was twenty-seven years old and had a hemoglobin 
 of 23 per cent. A large interstitial myoma nec(>ssilat(Ml an incision into the 
 uterus 13 cm. long. The patient made a slow convalescence, owing to liei- ;iiieinia, 
 but there were no com})lications. 
 
 In Case 10573 the patient, aged twenty-seven, had a i-ougli apical systolic 
 murmur transmitted laintly to the axilla. There was also a marked systolic 
 murmur over the pulmonic area; hemogl()])in, 3S per cent. A myoma, 10 cm 
 in diameter, and several smaller ones, were emich^ateil. '{'he patient develojxnl 
 phlebitis of the left saphenous vein on the s(>venleenth day. It did not retard
 
 518 MVOMATA OF THK UTKRUS. 
 
 her progress niatcriall}-. liowever, as she was diseharged on the twenty-fourth 
 day. 
 
 In Case 10257 the i)atient was twenty-three years old. and the hemoglobin 47 
 per cent. Prior to suspension of the uterus an interstitial myoma, 1 cm. in 
 diameter, and another smaller one, were removed. Convalescence was normal, 
 and since then the patient has had two normal la})ors. 
 
 Syphilis. — When syphilis exists, the question naturally asked is, Will the 
 wound heal if an abdominal operation is jierformed? In Case 111G9 a colored 
 woman, aged fortj'-six, had marked relaxation of the outlet, prolajisus of the 
 uterus and a myoma, and also a syphilitic ulcer of the leg. The cervix was 
 amputated, the perineum repaired, a myoma 4 cm. in diameter shelled out of 
 the fundus, and the uterus suspended. The patient matle a perfect recovery, 
 and was transferred to the surgical department, where the ulcer was skin-grafted. 
 She left the hospital on the forty-seventh day. The syphilitic taint in this case 
 certainlv in no wav retarded convalescence. 
 
 Abdominal Myomectomy. 
 
 General Considerations. — Before undertaking an abdominal operation for 
 uterine myomata several points should be thoroughly weighed. In the first place, 
 it is generally agreed that, as a rule, hysterectomy is safer than myomectomy. 
 On the other hand, it is the surgeon's duty to save the pelvic organs whenever 
 feasible. 
 
 Age. — If the patient is under forty-five years of age, the possibility of a 
 subsequent pregnancy should always be borne in mind. 
 
 Condition of the Patient . — ^^Tl(>n the })atient is very anemic 
 and otherwise frail, as a rule, a myomectomy is hazardous, antl the possible gain 
 by saving the uterus w^ould be more than balanced by the liability to a fatal out- 
 come. In every case the advantages and disadvantages of each operation should 
 be thoroughly discussed, and explained to the patient or some responsible relative. 
 
 Under no circumstances should the surgeon undertake the operation unless 
 the patient freely consents that the operator shall do exactly what he deems 
 wise when the abdomen is opened, as it is usually impossible to tell with absolute 
 certainty just what should be done until the uterus is exposed. One patient 
 coming for operation was so strenuous in her opposition to hysterectomy that 
 she exacted a promise from one of us (Cullen) that nothing more than a myo- 
 mectomy should be done. On opening the abdomen we saw clearly that hyster- 
 ectomy would be the safer operation, but our hands were tieil by the promise, 
 and many myomata were enucleated. This jjatient (Case 10588), within twenty- 
 four hours, developed fever and died at the end of forty-eight hours. There 
 was no hemorrhage into the abdominal cavity, ami the cultures were negative. 
 Since then we have absolutely refused to operate unless the matter is left to the 
 best judgment of the operator.
 
 ABDOMIXAL .MY( )M KCTi ).MY 
 
 519 
 
 Points to be Considered after the Abdomen has been Opened. — As soon as the 
 uterus is exposed, the appendages sliould 1)0 carefully examined. Should pus- 
 tubes be present, it will be necessary to remove them at once, and if this can be 
 accomplished without the escape of any pus, myomectomy may be considered. 
 Should pus escape, however, there is always a risk of infecting the cavities 
 made in the uterus if myomectomy be done. 
 
 Next, the location and number of the mj^omata are of importance. Sub- 
 peritoneal and pedunculated nodules are eas}^ of removal. Interstitial myomata, 
 if of small size and few in number, are also enucleated without nuich difficulty. 
 
 Fig. 319. — Myo.mectomy or Hysterectomy. 
 In such a case it may be possible to shell out the large myoma occupying the posterior wall and the several 
 smaller ones, saving the uterus. The myoma has, however, extended so far downward towartl the cervi.x that 
 it would have been very difficult to accurately close the myomectomy wound. Unless the patient were very 
 young and the necessity for children of the utmost importance, hysterectomy would be the wiser operative pro- 
 cedure, as it offers the patient much greater cliances of recovery. 
 
 It has Ix'cn our experience thai the more the uterus is niulilatccl, the ui'catcr 
 the danger to the palicul. Where many interstitial myoiiuita are removed, 
 the uterus is lacerated in all directions, and it is not only diflicult to completely 
 check oozing', but the area I'oi' infection is xci-y ureat. 
 
 The same applies when a xcry lai'iie intei'stitial myoma is enucleateil. [''or 
 example, in Case 4*)25 aji interstitial myoma, 12 x 21 x 27 cm., was removed, 
 and .")() catgut sutures were re(|uii-e(l to obliterate the cavity and a]iproxlmate 
 th(> uterine surfaces. Notwitlistaiidinu,' the lad that our patient m.ade a ii;ood 
 recovery, in future we would liatilly ad\'ise such an ojx'i'ation unless the j)()s-
 
 520 
 
 MYO.MATA OF THE UTERUS. 
 
 sibility of issue was of the ^n-eatest importance. We have removed myomata 
 when as many as 70 sutures were required to ol)hterate the cavity. 
 
 If the cHnical signs strongly 
 the operator should be exceedingly 
 dominal myomectomy. Opening up 
 occasions no trouble, as noted in 
 
 My oma In 
 post, wall 
 
 point to submucous myomata, 
 cautious in recommending ab- 
 the uterine cavity sometimes 
 Cases 5447 and 5493, in which 
 
 Fig. 320. — The First Steps i.\ .\i:i..j.\u\ai, Mvomectomy. 
 
 The uterus has been lifted out of the abdomen ami is surrounded with gauze. The tubes and ovarie.s are normal 
 
 The myoma m the posterior wall has been exposed and incised for a short distance. 
 
 the cavity was opened up for its entire length. It is sometimes almost impos- 
 sible for the operator, however, to tell with certainty whether the endome-
 
 ABDOMINAL MVU.MECTOMY. 
 
 521 
 
 /^l 
 
 trium is normal or infected, and if infected, there is a great danger that the 
 infection may spread to the wound in the uterine wall. 
 
 ^^llen large interstitial myomata are present or when many small nodules 
 are found, the uterus itself, after the myomectomy, is occasionally fully tw(j or 
 three times its natural size; consequently the tendency to aljsorption is maikcdly 
 increased. 
 
 In Fig. 319 we have an example of a border-line case — a case where it is 
 difficult to determine whether a myomectomy or a hysterectomy should be 
 performed. The uterus contains but one large myoma, and this does not ap- 
 parently encroach u[)ou the uterine cavity. On the other 
 hand, it extends far down into Douglas' pouch, and after 
 myomectomy it would be difficult to effectually obliterate the 
 resultant space. In this case, while myomectomy was feasible, 
 hysterectomy as carried out was undoul^tedly the safer proce- 
 dure. 
 
 Removal of Pedunculated Myomata. — If the pedicle is ver}' 
 small, it is only necessary to cut it in such a way that in the 
 uterus a wedge-shaped cavity is left. If there are any large 
 blood-vessels, they can be picked up free hand and tied with 
 catgut and the shallow cavity obliterated with catgut. 
 
 Subperitoneal, jiedunculated myomata are occasionally en- 
 veloped in omentum. If the omental adhesions are limited to 
 the anterior surface of the myoma, the omentum should be tied 
 and cut. Care should be exercised because such omental vessels 
 are often very large and friable, and if torn, bleed tremend- 
 ously. When the nodule is enveloped in adhesions, it is 
 often wiser to cut the pedicle and attack the adhesions from 
 the under surface. 
 
 When the myoma is densely adherent to the sigmoid, as in 
 Case 7978, it is wise to sacrifice the outer layers of the tumor, i,, 
 leaving them attached to the bowel. In (he case in question a 
 thin layer of tumor, 10 cm. in length, was left on the bowel. 
 After removal of the tumor this raw ai'ea was turned in on itself ;uid sutured, 
 a smooth surface resulting. 
 
 Removal of Interstitial Myomata, — The removal of small interstitial myomata 
 is easy. An incision is made over them (Fig. 320), tiiey are grasped with the 
 mesoforceps, and peeled out with a knife-handle or some other l)lunt instrumtMit 
 (Fig. 321). Should two or three be near one aiiothei-, they can often be Ijrought 
 out through the same incision, thus miniiiii/ing the possibility of sul)se(|uent ad- 
 hesions. 
 
 When a large interstitial myoma is |)i'esenl . an o\'al or ellii)lic incision is 
 usually made over tiie tumoi-. It is alwavs better to be on tiie safe side and 
 not remove too large an area of the uterine wall with the mvoina, as after removal 
 
 C'i-i,ij:n' Myoma 
 Enucleator.
 
 522 .MYOMATA OF THE UTERUS. 
 
 of the iiiyonia the uterine muscle frequently ivtracts to such an extent that it is 
 
 Fig. 322. — Shelling the Tumor Out or the Uterine W.\ll. 
 The myoma is firmly grasped. with the mesoforceps and strong traction made. The tumor is being shelled out by 
 
 means of the myoma enucleator. 
 
 difficult to bring the tissues together and obliterate the dead space. On the 
 other hand, it is easy to cut away the excess from redundant uterine flaps.
 
 ABDOMINAL .MYUMECTO.M V. 
 
 523 
 
 The myoma is grasped with a strong mesoforccps and gradually shelled out 
 with a myoma enucleater (Fig. 322), a pair of curved artery forceps, a knife- 
 handle, or a bhiut periosteal elevator. Care should be taken to avoid getting 
 
 Fig. 8 5titch closing wound 
 
 Fig. 323.— Dbliteuation ok the Space in the Uteiu.ne Wall ai ii,k Ixi-nka al ok the .Mm>ma. 
 One figure-of-8 catgut suture has been introduceil and tied. The second has just been inserted. It is impor- 
 tant to accurately coapt the surfaces, leaving no dead spaces. Whon llic cavity is large, two or throe tiers of 
 sutures may be necessary in aildition to tying any large vessels. 
 
 into the uterine cavity, it' po.s'^ihle; hut , wliei'e neces.siiy, il may he fully ()pene(l 
 up. 
 
 Submucous Myomata. .Many large inteistilial niyoin.ala are partly submucous, 
 and then it may be necessarx' to hi-ing away a iai'ge area of llie muco.sa covering 
 the mvoma. This should he cut awav boldly but eai-efully with the knife.
 
 524 
 
 .MYOMATA OF THE ITERUS. 
 
 Sometimes where there is marked utei'ine hemorrhage but a small uterus, hyster-- 
 otomy is done, the first incision going directly into the uterine cavity. This is 
 then explored for small myomatous nodules, which often give rise to alarming 
 hemorrhage. 
 
 If the uterine cavity is oi)ened, after the removal of large nodules it is usually 
 wise to dilate tiie cervix from al)ove to allow for free drainasje for several davs 
 
 Fig. 324. — Appe.\r.\nce of the Uterus after Abdomix.m. Myomectomy. 
 The uterus is still considerably enlarged. Accurate approximation has been accomplished. By employ- 
 ing a figure-of-8 suture, only half as many knots are necessary, and thus there is a diminished liability to ad- 
 hesion. 
 
 at least. Whether a small <raii/.e drain should he left in tiie uterus with its low 
 end projecting from the cervix is still a mooted question. We have em])loyed 
 it in several cases. 
 
 The sutures are now introduced into the depth of the wound. They extend 
 to, but do not ])ierce, the mucosa. When these are tied the uterine cavity is 
 closed.
 
 ABDOMINAL MYOMF.CTOMY. o2a 
 
 In the early days we employed silk, but now catgut is used in all niyoniecto- 
 niies. The cavity in the uterine wall is gradually obliterated with tier after tier 
 of figure-of-eight catgut sutures (Fig. 323) introduced with a curved needle with 
 rounded edges, and finally the surfaces of the uterus are approxiinate(l as ac- 
 curately as possible, and yet with just sufficient pressure to check bleeding (Fig. 
 324). Ochsner lays special stress on not tying the sutures too tight, as the 
 tissues may be so blanched that they become incapable of resisting the slightest 
 infection. One must, however, completely obliterate the spaces formerly occu- 
 pied by the myomata. 
 
 Tearing of the Uterine A r t e r y d u r i n g A b d o ni i n a 1 
 Myomectomy . — In Case 6773 both ovaries were released from light ad- 
 hesions, and two interstitial myomata, each about 4 cm. in diameter, removed. 
 One of the tumors lay very close to the uterine artery. This vessel was torn 
 during the enucleation and ligated near the cervix. The uterus was then sus- 
 pended. 
 
 Suspension of the Uterus after Myomectomy. — One of the greatest drawbacks 
 to a myomectomy is the fact that one or several lines of sutures are bristling 
 from the surface of the uterus and, so to speak, are inviting the omentum or 
 intestine to become adherent. If the suture line be in the anterior wall of the 
 fundus, it can be effectually hidden by attaching the uterus to the anterior 
 abdominal wall. If fastened to the anterior wall, firmer union is liable to take 
 place than if no myomectomy had been performed, and a subserjucnt pregnancy 
 may lead to serious trouble, as in Case 4856 (p. 567). If the uterus is suspended 
 with catgut instead of silk, the union, as a rule, is not so firm. In any event we 
 would infinitely rather take the chances of dystocia than of intestinal obstruction 
 from adhesions, especially when, at any time during the course of a subsequent 
 pregnancy, by a very simple exploratory laparotomy, the adherent uterus 
 may be readily freed, as has recently been pointed out by Dr. Elizalx'th Ilurdon* 
 and others. 
 
 Covering o v e r t h e 1 ]i c i s i o n i n the It c r u s w i t h the 
 Broad L i g a lu c ii t . When the tissues are lax, it may be possible, as was 
 done in Case 12852, to draw portions of the bi'oad ligaiiicnt o\-ci- the fundus, 
 thus completely hiding the suture line. 
 
 Preservation of a Portion of the Fundus. W hen the niyonia occupies nearly 
 the entire fundus, )-endering an enucleaiioii dillicuh, it may still be possible, by 
 am{)utation, to save a portion of the nuicosa. This plan was adopted in cases 
 C. H. 1. 930 and in C. 11. I. 1019. 
 
 In Case C. H. I. 1019 the patient was ihiity-nine yeai's old. The ni(>nses 
 continued for six months and then ceased. Since then ihe patient has been 
 in bed nearly all the time, suffering from mnikeil cnidiac dilalalion. 
 
 In Cas(> C. H. I. 930 the I'esults have been much more salislactoiy. The up])ei' 
 part ot the fundus was amputated on accouni of a subnnicous myoma, 7 cm. 
 
 * Aiiifricaii Joiir. of Ohst dries, .Julv, I'.IOT.
 
 526 
 
 MYOMATA OF THE UTERUS. 
 
 in diameter. Tiie i)atieiit, fifteen months later, was in good health and menstru- 
 ating regular!}'. 
 
 This method of atteni])ting to save as much of the mucosa of the body as 
 feasible has received a great deal of attention from Spinelli, of Naples, and 
 others, and deserves the most careful consideration. 
 
 Other Operations Performed in Conjunction with an Abdominal Myomectomy. 
 When the patient is under the anesthetic, other pathologic pelvic conditions 
 requiring attention are often detected. The accompanying data will give a fair 
 idea of the various other operations that were performed in the 296 abdominal 
 mvonicctomv cases: 
 
 Removal of both tul)es and ovaries 13 cases 
 
 Removal of rijjht tube and ovary 11 " 
 
 Removal of left tube and ovary 12 " 
 
 Removal of one or both tubes 18 " 
 
 Plastic operations on the tube 3 " (Nos. 
 
 Release of pelvic adhesions 17 " 
 
 Removal of ovarian cysts 20 " 
 
 Graafian follicle cysts: Cases 4765, 8698, C. H. I. Peth., 5493 and 12848. 
 Corpus luteum cysts: Cases 5588, C. H. I. Cuth., C. H. I. 930, San. 1628. 
 Papillocystoma of ovary: Cases 1455, 12034 (double). 
 Dermoid cyst: Case 12852 (left twisted pedicle), San. 2142. 
 
 Resection of corpus fibrosum 1 case 
 
 Repair of perineum 37 cases 
 
 Repair of complete perineal tear 2 " 
 
 Anterior colporrhaphy 5 " 
 
 Removal of vaginal cysts 2 " (Nos, 
 
 Dilatation and curetting 28 " 
 
 Amputation of cervix 10 " 
 
 Suspension of uterus 71 " 
 
 Shortening of the round ligaments 6 " 
 
 Appendectomy 15 " 
 
 Cure of left inguinal hernia 1 case 
 
 Cure of ventral hernia 1 " 
 
 Cholecystotomy (for gall-stones) 2 cases(Nos. 
 
 Fixation of kidney 2 " 
 
 Opening of ischiorectal abscess 1 case 
 
 Removal of hemorrhoids 3 cases 
 
 Removal of clitoris 1 case (No. 
 
 Omphalopexy 1 " (San. 
 
 4016 
 
 4471 
 
 12165). 
 
 5846 
 
 8844). 
 
 6854 
 8310). 
 
 9304). 
 1545). 
 
 Tubes and Ovaries. — The removal of the tubes and ovaries was indicated in 
 most instances by dense adhesions, hydrosalpinx, hematosalpinx, or pus tubes. 
 
 In Case 9243 the right tube was the seat of a tubal ]iregnancy, and in Case 
 10587 the mucosa of both tubes was tuberculous.
 
 ABDOMINAL MYOMIXTOM Y. o2i 
 
 Plastic opt' rat ions were dune uii the left tube in Case 4471, and on the right 
 tube in Case 4016, artificial fimbriated ends being made. 
 
 In Case 12165 a myoma occupied the cornii, and after removal of the tumor 
 the tube was anastomosed into the uterine wall with success. 
 
 Ovarian C y s t s . — Where feasible, small ovarian cysts were merely 
 punctured or resected, as much of the ovary as possible being saved. 
 
 It will be noted that in two instances (Cases 1455 and 12034) secondary 
 papillary masses were scattered throughout the abdomen. 
 
 Gyn. No. 1455. 
 
 A b d o m i n a 1 I\I y o m e c t o m y a n d Removal of P a p i 1 1 o - 
 c y s t o m a o f the Ovary. 
 
 H. J., married, aged fifty-seven, white. Admitted June 27; discharged 
 August 8, 1892. Operation: When the abdomen was opened, a large cyst was 
 tapped. It had developed from the right ovar}^, and contained, besides 2000 c.c. 
 of chocolate-colored fluid, many dense papillary masses. The peritoneum was 
 also studded with ])apillary masses. A pedunculated myoma attached to the 
 left uterine cornu was enucleated. The patient made a satisfactory recov(>ry. 
 On June 10, 1907, we received a communication from the patient's husband 
 saying that she had died on September 11, 1903; in other words, she had li\('d 
 eleven years, notwithstanding the fact that papillary masses were i)resent at 
 the time of operation. 
 
 Gyn. No. 12034. 
 
 Bilateral P a p i 1 1 c y s t o m a t a of the v a r y w i t h m u 1 - 
 t i p 1 e Metastases in the Peritoneum and Bowel. A b d o - 
 m i n a 1 M y o m e c t o m y . 
 
 This patient was admitted April 8, and discharged May 5. 1905. At 
 operation about 2000 c.c. of ascitic fluid were evacuated, and both ovaries were 
 found to be the seat of papilkuy cysts. The one on the Ict'l side was a])i)roxi- 
 mately 13 cm. in (liaiuclci'; the one on the i-Juht . sdiiicwhat smaller. Projecting 
 from the surface were delicate, tree-like .outgrowths. These covennl over half 
 the surface area of the cyst. The cysts and a myoma. 2.5 cm. in diameter. 
 were removed. The patient's health a year and a half later was "tairly good." 
 
 in both of these cases, after removal of the o\arian tumors a myomectomy 
 was done. Under ordinary circumstances one would prefer hysterectomy, but 
 in both of these cases, as intlicated ])y the history, myomectomy under existing 
 circumstances was a simpler operation, ll is remarkable that in Case 1455 
 the patient lived over ten years after th(> oj)eration. notwithstanding the wide 
 distribution of ihe |i;i|iill;iry ,u-r((\\tli. 
 
 Repair of the Perineum. 4'lie large number of jierineal o])erations was in- 
 dicated mainly by the numerous cases of jn'olapsus a.'^sociated with myomata.
 
 528 MYOMATA OF THE UTERUS. 
 
 Suspension of the Uterus. It will be seen from the t;il)k' that in 71, or nearly 
 25 per cent, of the cases, the uterus was suspended. This was clone partly for the 
 correction of a retrodisplacenient, but more often on account of the necessity 
 of bringino; the myomectomy suture line in contact with the anterior abdominal 
 wall, thus minimizing the possibility of the omentum or intestines becoming 
 adherent to the catgut sutures ])rojecting from the surface of the uterus. 
 
 Abdominal Myomectomy During Pregnancy. 
 
 ^^'hen a myoma complicates pregnancy, no operation is performed until after 
 delivery, providetl the myoma in no way obstructs the pelvis, so as to prevent 
 delivery by the vagina. In six of our cases, for various reasons, it was deemed 
 necessary to do a single or nuiltiple enucleation during the puerperium. In 
 Case 4990 the patient had had four miscarriages, but no children at term, during 
 her seven years of married life. On her admission she was three and one half 
 months pregnant. An interstitial and partly submucous myoma, 7 x 7 x 10 cm., 
 was removed (Fig. 325), but one in the cervical region could not be dislodged 
 without much handling and the certainty that a miscarriage would be caused. 
 Xotwithstanding the extreme care the fetus came away on the tenth day. 
 About seven weeks after the first operation the cervical nodule, which measured 
 10 cm. in diameter, was shelled out. 
 
 Case 5081 affords another example of a miscarriage following myomectomy. 
 The patient was three mouths pregnant (Fig. 326). An interstitial myoma, 
 8 X 9.5 x 12 cm., was removed. Within twenty hours the patient complained 
 of sudden uterine pain, and the fetal head was found projecting from the vulva. 
 
 The results in the three succeeding cases were much more satisfactory, the 
 pregnancy in each of these cases going on to term. In Case 1249 the patient was 
 three months pregnant. A sessile subperitoneal myoma, about 6x7x8 cm., 
 was removed from the posterior surface of the uterus (Fig. 327) and recovery 
 was uninterrupted. 
 
 The patient in Case 8897 had been pregnant over three months. A pedun- 
 culated myoma, 8 x 8 x 12 cm., was removed from the left side of the uterus, and 
 two interstitial nodules, each 2 cm. in diameter, were shelled out. The preg- 
 nancy went to term. 
 
 Mrs. G. (Path. No. 7895) was brought to the Emergency Hospital, Frederick, 
 complaining of uterine hemorrhages. A cystic mass could be felt rising out of the 
 pelvis. Pregnancy w-as suspected, but the operator w^as assured that none ex- 
 isted. As will be noted from Fig. 328, a myomatous tumor occupied the anterior 
 lip of the cervix and encroached markedly on the anterior vaginal wall. On 
 opening the abdomen a four months' pregnancy was found. The myoma was 
 shelled out from above, and an area of vaginal mucosa, 6x5 cm., removed with it, 
 as the myoma was very adherent to the vagina. The patient })romptly recovered.
 
 ABDOMINAL M YO.M KCTo.M V. 529 
 
 and was (l('li\-ci-('(l at tcnii of a tt'ti-pouiid cliilil. In this case the inyonia so 
 obstnictcil tlic ])('l\is that a iioi'inal labor would hardly havo been possil)le. 
 
 ^^\' had oiu' (^('asc 11110) death following niyomectoniy during pregnancy. 
 This patient had been married eleven years and had never Ijeen jjregnant. A\'hcn 
 the abdomen was ojx'iied a large, soft, four months' pregnancy was found. 
 Scattered over the surface were many small myomatous nodules. The largest, 
 7 cm. in diameter, was removed. Considerable difficulty was experienced in 
 controlling the hemorrhage. After the operation the bowels would not move. 
 On the fifth day the fetus was expelled, and the placenta had to be removed with 
 the curet. On account of an intestinal obstruction enterostomy was performed, 
 on the sixth day. There was much bloody fluid in the abdomen, Init the intestines, 
 apart from the distention, looked normal. The patient died on the follo^^ing 
 day. This case is reported in full on p. 530, und(>r " Deaths following abdominal 
 myomectomy." 
 
 In Oase 650S al)dominal myomectomy was attempted during pregnancy, 
 but on account of the excessive hemorrhage, an immediate Porro operation 
 seemed imjierative. 
 
 Detailed Report of Cases in which Abdominal Myomectomy was Performed 
 
 DURING Pregnancy. 
 
 Gyn. No. 4990. Path. Nos. 1521 and 1628. 
 
 U t e r i n e M y o m a t a Complicating a t h r e e a n d a h a 1 f 
 m o n t h s ' pregnancy (Fig. 325). 
 
 M. S., married, aged thirty-five, white. Admitted February 3; discharged 
 April 24, 1897. The patient has been married seven years, has had no children, 
 l)ut four miscarriages, the last two years ago. In December, 1S9G, she discoveretl 
 a small hard lump in the right side of the abdomen, low down. 
 
 Operation, myomectomy. To the right of the three and one half months' 
 pregnant uterus was a dense, hard myoma, which was lii-mly attached to the 
 uterus (Fig. 325). There was also a large myoma, situated low down in the broad 
 ligament, to the left of the cervix. The one on the right side was removed, 
 but it was impossible to remove the one in the Nroad ligament without iiUer- 
 fering with the pi-cgnancy. Ten days later the paliciU miscarried, and it was 
 necessaiy to i-emo\-e the I'emains of the placenta with the curet. 
 
 March 15, 1S97: An attem]>1 was made to i)artially obliterate the Moo.l- 
 supply of the utei-us by clamping Uic left utei-iiie vessels; but this had little el'fect. 
 
 March 27, bS97: Myomectomy per abdomeiu The lai'ge inyonia situated to 
 the left of the cervix was renioveil. The ))atient made an unintci-i-uptcd i-ecoNcrv. 
 It is intei-esting to note that the site of the lli'sl niyonii'cNuny was almost uiu'cc- 
 Ognizable at the second operatioiL llierr heing praci jcalK' no seal'. 
 
 Path. .\o. 1521. The myoma situated ncai' ihc right lulie nicasure(l 7x7 
 X 10 cm. 
 34
 
 530 
 
 MYOMATA OF THE UTERUS. 
 
 Fig. 325. — Uterine Myomata Complicated 
 BY A Three .\nd one-h.\lf Months' 
 Pregnancy. 
 Gyn. No. 4990. The interstitial myoma 
 
 near the right tube was enucleated. A mis- 
 
 Path. \(). 1()2S. The iiiyonia situated to the left of the cervix was 10 cm. 
 in (liaineter. 
 
 Jaiuiarv 1, 1007. T]\v patient 's jreneral health at present, nearly ten years 
 
 after operation, is ijood. She has no hemor- 
 rhages. .Menstruation is normal. There has 
 been no {jregnancy since the operation. 
 
 Gyn. No. 5081. 
 
 V t (' r i n (■ -M y o in a t a C o m p 1 i - 
 c a t i n o; P r e g n a n c y ( Fig. 826). 
 
 R. H., nian-ied seven months, aged 
 twenty-five, white. Admitted March 9: 
 discharged May 2."). 1S97. Operation. An 
 interstitial myoma, 8x9.5x12 cm., was 
 removed (Fig. .326). The incision into the 
 uterus was 14.5 cm. long, and the hemor- 
 rhage was excessive. Two other small myo- 
 mata were also remo\'ed. The patient was 
 kept under mor])hin after operation, l)ut 
 within twenty hours c()m])lained of sudden 
 
 carriage followed on the tenth day. The large p.^^jj^ .^^^^\ ^^j^. fV^.^J \-^^..^^\ ^y^g fouud l)rojeCt- 
 nodule to the left of the cervix was removed _ 
 
 several weeks later. iug fi'om the vulva. She was anesthetized 
 
 and a three months' fetus and })lacenta were 
 removed. The subsequent history was uneventful. 
 
 A letter from the patient, dated January 1. 1907, nine and one-half years 
 after operation, states that she has 
 been under a physician's care for 
 uterine trouble for four years. She 
 has no hemorrhages. There is no 
 vaginal discharge, but there is some 
 bladder irritation. Her menses are 
 normal. 
 
 Gyn. No. 1249. 
 
 M y o m e c t 111 y Without 
 I n t e r f e r e n c e w i t h the 
 Pregnane y ( Fig. 327). 
 
 M. S., married, aged twenty-five. 
 Admitted March 7: discharged April 
 6, 1S92. The i)atient has b(>en mar- 
 ried one year, and has had 110 chil- 
 dren and no miscarriages. Operation, myomectomy. .\n incision, 8 cm. in 
 length, was made into the uterus, and the .subperitoneal noelule projecting from 
 
 Fu;. 326. — .Mlltipi.k .M vu.MKtioMY on a Wo.man Three 
 Mo\TH.s Pregn.^nt. 
 Cjyn. No. .5081 The large interstitial myoma pro- 
 jected from the posterior surface of the uterus. It was 
 enucleated, and several smaller nodules were also re- 
 moved. .\ miscMTiage followed within twenty-four 
 hours.
 
 AHDO.MINAL MYOMECTOMY. 
 
 531 
 
 the posterior surface removed (Fig. 327J. Tliis luyoiiia was ap])roxiinately 
 7x6x8 em. The temperature never rose above 99.5° F. The patient made 
 a perfect recovery, and tlie pregnancy went on to term. 
 
 January 1, 1907. about fourteen and one-half years after operation : A h'tter 
 from Dr. Edwin II. MiUer. of Philad('l))hia. states that the patient's general 
 heahh is not good. She has no hciiion-hagcs; there is no (hscharge; no bladder 
 disturbance, and her menstruation is normal. 
 
 Gyn. No. 8897. 
 
 U t e ]• i n e M y o m a C o m ]> 1 i c a ting P r e g n a n c y . 
 
 K. S.. aged twenty-nine, white, marrieti. Admitted July o: discharged Julv 
 ;>(), 1901. The ])atient has been mar- 
 ried six months. ()n bimanual exam- 
 ination definite myomatous nodules 
 can be made out. Operation, nuiltiple 
 niyomectoni}'. A median incision 
 exposed one large myoma springing 
 from the wall of the fundus an- 
 teriorly, a smaller one beside this 
 on the anterior wall, and a third on 
 the left posterior wall. The pedicle 
 of the large myoma was cut across, 
 and the resultant raw surface obliter- 
 ated with catgut sutures. The other 
 two myomata were shelled out. The 
 uterus itself was about the size of a 
 fourmonths' pregnancy. The patient 
 recovered raj)i(lly. the pregnancy be- 
 ing in no way interfered with. The large myoma measured S x S \ 12 cm.: the 
 two smaller ones, each 2 cm. in diameter. 
 
 Case G., Path. No. 7895. 
 
 •^ <■ "1 o \ a 1 of a Large Cervical Myoma per Abdomen 
 f r o m a P :i t i e 11 t I-' o u r .M o n t h s P r e n; n ;i n t ( l-'iti;. M2S). 
 
 This p;itii'nt \v;is I hli-ly-foui' \'e;irs of .me. ( )ne of us (('.) saw her in coiisuMa- 
 tionwith Dr. Lamar, of .Middletown. on .May 17. P.IOI. She was o|)er;ited U|)on in 
 tile Frederick I'lmergency Ilospitnl. She h;id been hieeding profusely for several 
 weeks. When 1 saw liei-, the pulse \v:is j.'lO. The eiit ire anterior lijt of the cervix 
 was greatly thickened ( |''i<r. :\2Sr. the |)osterior was noi-m.-ij. The ihickening in 
 the anterior cervic:il lip w.-is c;iused by ;i h.-ird nodule, approximately '.) cm. in 
 diameter, .\bove this was \\h;it ;ippe;ired lo be a cystic tumor. Despite care- 
 lul in(|uiries there was nothing in the histor\- in any way suggesting pregnancy. 
 On opening the abdomen we found ;i foui- months' pregn.'incy and the ni\-oma of 
 
 Fig. 327. — A Subpekito.ne.^l .My(j.\i.\ Complicating 
 
 PrEGN'.'VNCY. 
 
 Gyn. No. 1219. The subperitoneal nodule (m) was enu- 
 cleated and the patient went on to temi.
 
 532 
 
 MVU.MATA OF THK ITKRUS. 
 
 the anterior lip. This almost completely filled the })elvis. Not having per- 
 mission to do a hysterectomy, we determined to shell out the myoma, but this 
 was so intimately hlcndcd with the vaiiina that a jiortion of the vagina, a])out 
 6x5 cm., had to he ri'moved with the tumor. The o])eiiing into the vagina was 
 dosed, but there was nmch oozing, and in places the bleeding was checked with 
 the greatest difficulty. The patient made a good recovery, went on to term, 
 and after a normal labor was delivered of a ten-pound child. 
 
 Fig. 328. — Myoma of the Cervix Obstkucting the Vagina and Complicating a Four Months' Pregnancy. 
 G., Frederick Emergency Hospital, Path. No. 7895. The myoma had developed in the outer portion of the 
 anterior lip of the cervix. It ha<l not only grown upward, but also had encroached markedly on the vagina. It 
 was so intimately blended with the vaginal mucosa that over a wide area it was necessary to remove the mucosa 
 with the myoma. The pregnancy proceeded to term. 
 
 On -May 2!), l',)()7, three years after the operation, I received a letter from the 
 patient in which she stated she was al)Solutely well. 
 
 Immediate Death Following Abdominal Myomectomy. 
 In our 29(3 al)(lominal myomectomies 2<S() ])atients recovered and 1(3 died — a 
 mortality of 5.4 jK-r cent. From the clinical course of the fatal cases and from 
 the autopsy findings in .^ome of tliem we can. with a fair degree of accuracy, 
 divide the probable causes of death into the following grouj)s:
 
 ABDOMINAL M YO.M i;( T( ).M Y. 533 
 
 Intestinal obstruction, peritonitis, or hotli 8 cases 
 
 (Cases 57, 65, 4S2, 1862, 563S, 7560, 10351. S; Toronto case.) 
 
 Possible cerebral embolus with hyperpyrexia 1 case 
 
 Myomectomy during pregnancy 1 " 
 
 Probable infection from an unsuspected carcinoma of tlie body (Case 1173) 1 " 
 
 Probable death from faulty catgut (Case 1752) 1 " 
 
 Probable infection from Fallopian tube (Cases 5124 and 11296) 2 cases 
 
 Almost moribund condition of patient before operation, deatli on table 
 
 (Case 1672) , 1 case 
 
 Possible myocarditis (C. H. I., W.) 1 " 
 
 16 cases 
 
 Intestinal Obstruction, Peritonitis, or Both. 
 
 In the majority of our fatal cases death was due either to intestinal obstruc- 
 tion or peritonitis or to obstruction followed by peritonitis. In some instances 
 the cause of death is perfectly clear, as in Case 7560, in w^hich the patient un- 
 doubtedly died of a streptococcus peritonitis. In other cases, however, the 
 patients had first shown signs of intestinal obstruction, and later mild manifesta- 
 tions of peritonitis. It is well known that obstruction may, in a few days, lead 
 to peritonitis, and, further, that where peritonitis is the primary factor, intestinal 
 paralysis with signs of ol^struction is among the earliest manifestations of i)eri- 
 tonitis. We are inclined to think that in our cases intestinal obstruction was the 
 dominant factor in most instances, and that the peritonitis was secondaiy. 
 
 As we all learn more ])y our failures than by our successes, we have concluded 
 to report each of the fatal cases in some detail, so that the reader may draw his 
 own conclusions as to the cause of death. 
 
 Gyn. No. 57. 
 
 Abdominal M y o m e c t o m y ; Obstruction; Death. 
 
 S. R., married, aged thirty-three, colored. Admitted November L\') ; died 
 December 6, 1889. Oi)eration, uiyoincctoiny ; double sal|)iii,u()-()(')jtli()rectomy. 
 A myoma, 3.5 cm. in diameter, was removed from the fundus. Both tubes and 
 ovaries were excised on account of adhesions, .\fter operation the abdomen was 
 not distended or tynii)anitic. X'omiting connneneed on the tliii'd day. There 
 was inabihty to evacuate the bowels after the sixth day. The |)atient die(l on 
 the eleventh day. Iler |)ulse at that time reached HIS; hei- temperature was not 
 over 100.5° F. Just |)i'ioi' to death there was .some delii'iuiiL 
 
 Aut. No. 48. ^riie ])ei-iloiieum is red and injected. The intestines are ad- 
 herent, and bound down in the peKis. The heait and lungs ai'e normal. Cul- 
 tures from the peritoneal caNil)'. kidne\s, and sjileeii gixc negatixc I'esults. 
 
 Gyn. No. 65. 
 
 Intestinal ( ) b s t i- u c t i o n !•' o 1 I o w i n g .\ b d o m i 11 a 1 .M y - 
 o m e c t o 111 \- . Death.
 
 534 MYOMATA OF THK UTERUS. 
 
 V. K. H., inarricil. :i<i;(>(l tliirty-thrco. ^vhito. Admitted ])ec-cniber 10, 1889; 
 died Jamiarv 2. ]8!)(). Operation. December 30th. The pelvis was filltMl with 
 the tumor mass, which was intimately adherent. After li!)eration of adhesions, 
 which was accom])anied by considerable hemorrhage, a myoma was enucleated, 
 the uterine cavit}' beinij; o])ened. 
 
 8ul)se{iuent History. — The pulse became more rapid. The abdomen was 
 opened on the thinl day. There was no evidence of inflammation. The pulse 
 soon rose to 152, and the temperature was 101.6° F. on the following day, when 
 she died. 
 
 Aut. No. 52. The intestines are distended, and there is some bloody Huid in 
 the abdomen. Anatomic diagnosis: jjeritonitis, general anemia, fatty degenera- 
 tion of the heart and kidneys. Cultures from the abdominal wound, from the 
 ])elvis, and from the bloody fluid in the alxlominal cavity gave a growth of 
 Staphylococcus ])yogenes aureus. 
 
 It will be noted that when the abdomen was o{)ened on the third da}' there 
 was no evidence of inflammation. When the drain is placed in the abdomen, 
 cultures later on usually yield one of the jnis-organisms. In this case it looks 
 as if death was due to obstruction rather than to peritonitis. 
 
 S. (Toronto), June, 1903. 
 
 Probable General Peritonitis. Death. 
 
 Mrs. S. was seen in consultation in Toronto June 8, 1903. She gave a history 
 of bleeding for a short time. On examination the uterus was found to be the 
 size of that of a four and one-half months' ))regnancy, but freely movable. On 
 section of the alxlomen the growth was found situated in the anterior wall. On 
 cutting through a thin layer of muscle we encountered a partially degenerated 
 myoma, fully 12 cm. in diameter. This was readily shelled out. The cavity was 
 obliterated with catgut, and a few silk sutures were used as the catgut gave out. 
 The patient stood the operation well, but died three days later. The pulse from 
 the time of o))erati()n was never lower than 135, and shortly before her death 
 reached 1()5. The tem])erature varied from 101° to 104° F. She had no vomit- 
 ing or distention, and the bowels moved freely. It is impossible to state the exact 
 cause of death, as no autoji.sy was allowed. The diagnosis lay between peritoni- 
 tis or the unaccountal)le al)sori)tion that takes place even when no infection 
 occurs. 
 
 Gyn. No. 482. 
 
 Abdominal Myomectomy. Death f i' o in Suppura- 
 tive P e r i t o n i t i s . 
 
 A. W., single, aged twenty-three, colored. Admitted December 20, 1S90; 
 die(l .lamiary 7, 1891. Operation, December 22d. The ovaries on both sides 
 contained Graafian-foUicle cysts. The tubes and ovaries were released from 
 adhesions and removed. A small myoma in the ]iosterior wall of the fundus 
 was transfixed beneath its base and removed.
 
 ADBOMIXAL MYOMECTOMY. 535 
 
 Subsequent History. — On the fifth chiy the temperature rose to ]()1.S° V., 
 and examination revealed a tender, semifiuctuant spot in the left l)r()ad lijiament. 
 On the sixth day the temperature reached 103.2° F., the pulse IGO, and the 
 patient had an attack of vomiting. The abdomen was not especially sensitive 
 and not distended. The incision was thoroughly cleansed with l)ichloride, and 
 the lower portion opened. On the introduction of the index-finger a small 
 amount of blood escaped. The omentum and intestines were adherent to the 
 myomectomy wound in the uterus, and also at the i)oints from which the tubes 
 and ovaries had been removed. These adhesions were separated, and about 
 30 c.c. of ])lood escaped. A drainage-tube was inserted behind the uterus. 
 
 The patient seemed to improve slightly at first, but later became gradually 
 weaker. The abdomen became more tympanitic and the pulse became moic 
 rapid and poor in vohime. She complained of severe thirst, had several in\(>l- 
 untary stools, and died in a semiconscious state on the twelfth day. The tem- 
 perature ranged between 99° and 102° F. The pulse just prior to death was 156. 
 
 Cultures after the second operation showed Staphylococcus aureus. In this 
 case the trouble was undoubtedly primarily an obstruction due to adhesions, and 
 following the second ojieration peritonitis developed. 
 
 Gyn. 1862. 
 
 Abdominal Myomectomy; Intestinal 1) s t ruction 
 Followed by Peritonitis. Death. 
 
 L. J., single, aged thirty-eight, colored. Admitted March 15; died A))ril 
 10, 1893. Operation, March 22d. A sessile tumor, 10 x 12 cm., was enucleated 
 from the anterior surface of the fundus, and a smaller myoma, 2x3 cm., from 
 the posterior surface. 
 
 The patient subsecpiently developed some tenderness and swelling, with 
 marked constipation. She w^as anesthetized, and a hand, introduced into the 
 rectum, broke up adhesions by which some of the loops of the small intestine 
 had become adherent to the pelvis. Later the patient Noniiteil soiue fecal 
 matter, and a s(M*ond ()])ei-ation was ])erformed. The abdomen, which was di.s- 
 tinctly distended, was opened, and the intestines wer(> found greatly inliamed 
 and somewhat adherent. In releasing the intestines the jx-i-itoneal coat was torn 
 in several places — in one j)lace so badlyas to necessitate a resection of the l)o\vel. 
 Some fecal matter escaped. A drain was introduced into the |)elvis and to the 
 j)oint of the intestinal resection. 
 
 The tem))eratui"e after the first operation was behiw 100" !•"., niid iliij not go 
 much higher until the (ifteeiith day, the day after llie second operation. It 
 then rose to 102.2° F.. and the pulse to 150. The patient died of ]terilonitis on 
 the twentieth day. 
 
 With oiu' ])resent knowledge of intestinal ol)sl i-uci ion we would not lliink of 
 loosening up adhesions thi'ough llie rectum without knowing the exact condition 
 in the pelvis. Adhesions are now ne\-ei- liUeraled except luidei' sight. The
 
 536 MYO.MATA OF THE UTERUS. 
 
 primary cause of death in this case was un(loul:)te(lly the adhesions, which pro- 
 duced intestinal obstruction. Such a case would now call for an enterostomy. 
 
 Gyn. No. 5638. 
 
 Intestinal ( ) 1 > s t r u c t i o n Following A b d o m i n a 1 M y - 
 o m e c t o m y . J) v a t h . 
 
 M. K., single, aged thirty-seven, white. Admitted October 26; died Nov- 
 ember 4, 1897. Oi)eration, myomectomy and suspension. A large myoma 
 was enucleated from the posterior wall of the uterus, and five smaller nodules 
 from the anterior surface. 
 
 After operation all attempts to move the bowels were fruitless. The patient 
 vomitetl continually, the vomitus later having a fecal odor. The temperature 
 varied between 98.4° and 100° F. The pulse became gradually more rapid and 
 weaker, reaching 132 on November 3d. 
 
 Second operation: release of adhesions; release of suspended uterus. The 
 intestines were distended with gas. Adhesions of omentum and small intestines 
 to the utcM'us obstructed a looj) of small IxjwcI. A gauze drain was introduced. 
 
 The temperature rose to 103°P\, the pulse reached 144, and was very thready 
 in character. There was much nausea and vomiting, and the patient died 
 about twenty-four hours after the second operation. 
 
 Gyn. No. 7560. 
 
 A 1) d o ni i n a 1 M y o m e c t o ni y. Streptococcus Peritoni- 
 tis. Death. 
 
 J. B. C, aged forty-four, white. Admitted February 7; died February 15, 
 1900. Operation, February 12th, abdominal myomectomy: suspension of the 
 uterus. A myoma, al)out 4.5 cm. in diameter, was removed from beneath the 
 left round ligament. The tubes and ovaries were normal. At the time it was 
 noted that the colon was much distended with gas. 
 
 In the peritoneum over the bladder there aj)peared a slightly elevated area, 
 1x2 cm. This .^eemed to be a thickening of the bladder-wall, which did not, 
 however, a])pear inflamed. After the operation the patient suffered from 
 nausea and vomiting. The vomitus was dark brown in color, and suggested an 
 admixture of clotted blootl. Her first night was fairly comfortable. She voided 
 a small quantity of urine. The pulse ranged between 80 and 104, the tempera- 
 ture between 98° and 100.5° F. The nausea grew worse. At the end of twenty- 
 four hours the tongue was very dry and the abdomen was distended, but at first 
 there was no tenderness. The bowels did not move until several enemata had 
 been given. On the third day the tempeiature reached 104.8° F. A diagnosis 
 of general peritonitis was made. 
 
 Operation, February 14th. At the u))))er angle of the wound some creamy 
 white pus was noted along the sutures. The incision was opened, the peritoneal 
 sutures were cut, and a seropurul(>nt fluid, slightly l-)lood-tinged, welled up.
 
 ABDOMINAL MYOMECTOMY. 537 
 
 Cover-slips from this showed streptococci. The intestines were injected and 
 covered with a fibrinous deposit. The omentum was injected. There were no 
 adhesions. The alxlominal cavity was Hushed out. The patient (Ued the fol- 
 lowing day. 
 
 Gyn. No, 1035 1. 
 
 Abdominal ^I y m e c t o m y F o 11 w e d by Intestinal 
 Obstruction. Death. 
 
 L. B. D., aged thirt^'-five, colored, married. Admitted March 24; died 
 March 29, 1903. At operation a multinodular myomatous uterus was found 
 filling the pelvis, and extending to within 5 cm. of the umbilicus. The uterine 
 vessels were controlled by a rubber tube drawn around the cer\-ix. The uterus 
 was then bisected, and 28 myomata of various sizes were shelled out. The cervix 
 was dilated, an iodoform pack put in the uterine canal, and the uterus .sewn up 
 with two layers of catgut sutures. The bleeding was ap])arently successfully 
 controlled. There was, however, slight oozing, and several stri})s of iodoform 
 gauze were left in the lower end of the abdominal incision. The patient left the 
 table in excellent condition. 
 
 Four hours after operation the tem])erature reached 101° F., the i)ulse was 
 100. Twenty-four hours later the ])ulse was 130. The temperature never was 
 higher than 101° F. Her pulse became gradually higher until the fifth day at 
 9 A. M., when she died. Eight hours after the operation the l)in(ler was stained 
 through with l)lood. Her bowels refused to move and she had (juite marked 
 abdominal distention, which began twenty-four hours after the operation. The 
 restlessness increased shortly after the operation. 
 
 On the fourth day she was removed to the operating room, and under gas an 
 enterostomy was done. When the abdominal cavity was()])ened, a large amount 
 of tarry blood escaped, together with some clots. The intestines were modi'rately 
 distended. A loop of small intestine was brought out and opened. There was 
 an escape of gas, but no fecal matter. After this second operation there was no 
 imjirovement , and the ])a(ient gradually grew weakei' and died. She liail what 
 ajijK'ared to be fecal vomiting before death. 
 
 The myomata varied from 1 to 1.5 cm. in diameter. 
 
 In this case it would have been iinieh wiser to have done a hysterectomy in- 
 stead of a myomectomy, especially when so iiiany myomata were i)resent. After 
 splitting almost entii'cly thi'ough the uterus it is exceedingly diflicult to apjiroxi- 
 mate the two halves, and at the same time absolutely to check bleeding. 
 
 Possible Cerebral Embolus with Hyperpyrexia. 
 
 In Case 105SS, in which a nniltiple niyoinectomy was done, the pulse soon 
 
 rose to 140, and gradually became ]tooi-ei' in (|uality. The abdomen showed 
 
 slight distention, and the patient became drowsy. Ilei- lem|)ei-alui-e suddenly 
 
 rose to 107° F. shortly befoi'e her death on the third dav. 41ie abdominal inci-
 
 538 MYo.MATA OF THK UTKRl'S. 
 
 sioii was opened after death. Not over an ounce of blood-stained fluid was 
 found. There were no e\idenees of ])eritonit is. and euH ures were negative. In 
 this ease the symptoms suggesteil a cerelji'al embolus. 
 
 Gyn. No. 10588. 
 
 M u 1 t i p 1 e A b d o m i n a 1 M y o m e c t o ni y . D e a t h w i t h 
 Indefinite Signs. 
 
 I>. II.. single, aged forty, white. Admitted .hily o: died .luly S, 1903. The 
 patient was well noui'ished and had a good color. The heart and lungs were 
 apparentlv nonnal. The utei'us contained .•<evei-al myomata. varying from 0.5 
 to 5 cm. in diameter. 
 
 The operation was ])erfectly sim])le, and the patient was returned to the ward 
 in good condition. Soon after her pulse rose to 140, but remained of good 
 volume for twenty-four hours. Th(> second night she was quite uncomfortable. 
 She was given calomel on the second day, followed by Epsom salts and enemata, 
 wliicli were not effectual. On the third day her ])ulse was 120; her tem])erature, 
 100° F. She was comfortable, and slept well during the night. About 11 a. m. 
 there was a sudden collapse. Tn the afternoon her tem])erature rose to 107° F. 
 There was no pallor and no symptoms except the tem])erature were present to 
 indicate ])erit()nitis. l^]verything pointed strongly to ;ui end)olus involving a 
 thermic centei-. She gradually grew weaker, and died at 7 p. M. We had per- 
 mission to open the abdominal incision and found the intestines perfectly smooth. 
 There was not an ounce of blood in the alxlomen. The stitches had held every- 
 where in the uterine wall, and on o])ening the uterus we found that none had 
 entered the uterine cavity. Furthermore, there were no dead spaces containing 
 blood. 
 
 This is one of those cases in which the patient dies and yet no definite assign- 
 able cause can be detected without the most thorough autopsy. The probability, 
 however, is that .she had an embolus. Cultures from the peritoneal cavity were 
 negative. 
 
 .\ few years later we learned that this patient shortly before entering the 
 hospital had told several fi'iends that she w\as sure she was going to die. In all 
 cases in which the patient has a |)ersistent premonition of death, ojieration, if 
 not immediatel\' imperative, should be deferred until the chances of success 
 have been so thoi'oughly impressed ui:)on th(^ patient that her mental attitude 
 is changed and she promisees to do all she can toward getting well. 
 
 In this case, as is said elsewhei'e. we wished to do a hysterectomy, but were 
 ham])ere(l by our jiromise to the patient to sa\'e the uteinis. 
 
 Fatal Myomectomy During Pregnancy. 
 The patient had been mai'i'ied eleven years and had never been ])regnant 
 before. At operation a four months" pregnancy was detected. Numerous
 
 ABDOMINAL MYOMECTOMY. 539 
 
 nodules stiulded the uterus. A myoma 7 cm. in diameter was removed and 
 some difficulty was experienced in controlling the bleeding. 
 
 Intestinal atony developed, undoubtedly favored by the pregnancy. Mis- 
 carriage followed, and the patient soon died. Infection certainly played a very 
 minor role in this case. 
 
 For the successful abdominal myomectomies during ])regnanc5^ see p. 52.S. 
 
 With our present knowledge we would not think of doing a myomectomy in 
 such a case. The abdomen would be closed at once, the pregnancy being al- 
 lowed to go on to term, after which, if necessary, hysterectomy or myomectomy 
 would be performed. 
 
 Gyn. II 1 10. 
 
 A b d o m i n a 1 M y o m e c t o m y D u ring P r e g n a n c y . 1) e a t h . 
 
 C. S., aged thirty-three, colored. Admitted March 9; died March 20. 1904. 
 This patient had been married ek^ven years and had never been pregnant. Opera- 
 tion, March 14, 1904. When the abdominal cavity was opened, a large, soft, 
 pregnant uterus was found. The pregnancy had probably run about four 
 months. Many small nodules were scattered over the surface of the uterus, 
 and one of the larger tumors, about 7 cm. in diameter, was removed. Ther(> was 
 some difficulty in controlling the bleeding. 
 
 Postoperative History. — After the operation morphin was given rather 
 freely during the first forty-eight hours, to prevent, if possible, miscarriage. On 
 the evening of the second day the temperature was 101.6° F., and at noon of the 
 next day it was again normal. Cathartics were given on the second day, but 
 neither these nor enemata had any effect, and the intestinal distention increased 
 rapidly. On the night of the third day she was quite ill: her pulse was 118, and 
 the al)domen considerably distended. Leukocytes, 3(3,000. The distention 
 became somewhat less, and her leukocytes dropped to 11,000. The bowels did 
 not move, however. There were no signs of bleeding from the vagina until the 
 night of the fifth day, when she suddenly passed a small fetus. The placenta 
 had to be I'emoved manually. 
 
 The distention was becoming greater, the pulse had become moi-e rapid, and 
 on the sixth day an enterostomy was done under cocain. Her jnilse at this time 
 was 130 and weak. The incision was made through the outer l)()rder of the right 
 rectus nuiscle and the ])eritoiieal cavity openetl. Thei-e was much free blood: 
 the intestinal coils wei'e much distended, but otherwise noi'iiial. A loop ol large 
 bowel was brought int(j the wound and sulured with catgut. 
 
 Cultui'es taken from the bloody fluid al the lime of the second ojiei-ation 
 yielded St aphylo('oC(ais albus. The temperat ui'e steadily I'ose to 10."!. T)" !■.. and 
 she died on \\\o followiiiir afternoon.
 
 540 MVO.MATA OF THE LTERUS. 
 
 Probable Infection of the Uterus from an Undetected Carcinoma of the Body 
 
 OF THE Uterus. 
 
 In looking over the history of Case 1173 it will be noted that the patient had 
 a slimy, watery, vaginal discharge. This is very significant in connection with 
 the subsequent history, but at the time was cncrlooked. In this case the uterus 
 was bound down by adhesions and contained two myomata. One of these, 
 about 7 cm. in diameter, was enucleated. The other could not be shelled 
 out on account of adhe.-^ions. The patient died on the sixth day of acute purulent 
 peritonitis. 
 
 This operation was performed in 1892, when the technic of myomectomy had 
 not been fully developed. Now we would not think of tr3'ingto save the uterus 
 in such a case, but would perform hysteromyomectomy. The finding of a 
 carcinoma of the body of the uterus at autopsy gives us a very valuable surgical 
 hint. In all cases in which we advise abdominal myomectomy, as far as possil:)le 
 we exclude the presence of a carcinoma of the body. In the chapter on Carcinoma 
 of the Body and Myoma, it was clearly demonstrated tliat in numerous cases 
 carcinoma was not suspected until the uterus was opened up after its removal. 
 
 ^lyomectomy in the presence of an adenocarcinoma of the body is naturally 
 almost certain to give rise to infection. 
 
 Gyn. No. 1173. Aut. 277. 
 
 A b (1 o 111 i n a 1 M y o 111 e c t o in y C o m plicated 1) y an U n - 
 s u s p e c t (■ d A (1 (' II o c a r <• i n o ni a o f t h e B o d }• o f t h e U t e r u s . 
 
 A. B., single, aged forty-three, colored. Admitted January 2(i; died Feb- 
 ruary IS. 1802. In Xovenil)er. 1801. two small myomata were removed per 
 vaginam in New York. Three and a half months ago the i)atient noticed a lump 
 in the left iliac regicjii. She has a slimy, watery, vaginal discharge, with occa- 
 sional clots, is very anemic, and has a double apical heart murniur. 
 
 Operation, February 13, 1892. The uterus was distended by two myomatous 
 masses; the anterior, about 7 cm. in diameter, was removed. The ])osterior, 
 which was slightly larger, was bound down by adhesions, which prccliuh'd its 
 enucleation. 
 
 The i)atieiil Nonntcd many times after operation. The abdomen l)ecaine 
 distended, the pulse rai)id, and the tein])erature rose to 103° F. on the fifth 
 day, dropping to 101.5° F. on the sixth day. the day of her death. That day 
 the patient was covered with a cold, clammy sweat and voided urine involuntarily. 
 
 Aut. No. 277. Anatomic diagnosis: Acute j)uriileiit peritonitis. Myoma 
 and carcinoma of the uterus; general arteriosclerosis; cardiac hy))ertrophy; 
 chronic difl'use nei)hritis; broncho])neuinonia (right lung). The peritoneal 
 c;)\ify showed \nu-c Stai)hylococcus pyogenes aureus.
 
 ABDOMINAL MYOMECTOMY. 541 
 
 A Death Probably from Faulty Catgut. 
 
 Bet^veen January IS and 25, 1S93, five laparotoniies were performed in the 
 Gynecological Department of the Johns Hopkins Hospital and four of these 
 patients died.* In all the fatal cases the operation \vas a simple one, and the 
 abdomen at the time of operation was apparently perfectly clean. In the fifth 
 ease — one of pyosalpinx — the patient recovered. 
 
 In all the cases Staphylococcus aureus was found. The source of infection 
 appeared to be some old catgut, but it was impossible to determine with certainty, 
 as all the catgut had been used, none remaining for bacteriologic examination. 
 
 This case was one of the four fatal cases. 
 
 Gyn. No. 1752. 
 
 Abdominal Myomectomy; General Peritonitis Ap- 
 parently Due to Fault}" Catgut. D e a t li . 
 
 E. H., aged thirty-four, white. Admitted January 12; died January 20, 
 1893. Operation, January 23, 1893. Two symmetric myomata were discovered, 
 one in the anterior wall, 8.5 cm., and one in the jxjsterior wall. 8 cm. in diameter. 
 Both of these were enucleated, as were also four other smaller ones. 
 
 On the night of the second day the patient complained of severe stabbing 
 pain over the area of the lower lobe of the left lung. The pain was increased on 
 deep inspiration. The tongue was moist and slightly coated; the abdomen was 
 not distended. On the following day the pulse was 120. Her expression was 
 bad. She had been nauseated at intervals during the entire day. The abdo- 
 men was prominent, distentled, tympanitic, and sensitive. On opening the 
 lower angle of the wound the operator was unable to find any evidence of pus. 
 The temperature was 104.4° F. On January 26th it rose to 107.8° F., and tleath 
 quickly followed. The patient was conscious to the last. 
 
 Autopsy. Anatomic diagnosis: Purulent hemorrhagic peritonitis following 
 abdominal myomectomy; stitch-hole al)scesses; acute s])lenic tumor; emliolic 
 lung abscess; congestion of ihc lungs; infection witli Streptococcus ])yogenes 
 and Staphylococcus pyogenes aureus. (The auto))sy findings are given in full 
 in the Johns Plopkins Hospital Peports, 1895, vol. iv, j). 412.) 
 
 Probable Infection from Fluid Liberated from the Fallopian Tubes. 
 In Case 5124 the uterus not only contained mnnerous myomata, but was also 
 denselv adherent. \Mien the al)doinen was opened, the right tube and a myoma. 
 4 cm. in diameter, were removed, and an artilicial linilnialeil end was made for 
 the left tube. After many ui)s and downs this patient dieil about six wi-eks 
 after ojjeration. 
 
 * Thoinus S. C'lilleii, rostoperative Septic roritonitis, 'I'ho ,I.>lins lloiikins Hosp. Reports, 
 voL iv, 1S9.3, p. 411.
 
 542 MVO.MATA OF THK rTHRfS. 
 
 In Case 11296 a myoma, 6 cm. in diameter, was shelled out of the posterior wall, 
 and both tubes, which were filled with clear fluid, were ])unctured. the fluid 
 escaping into the abdominal cavity. 
 
 The surgical ti-catnicnt in both of these cases is o])en to criticism. 
 
 In ( ase 5124 we (CuUen) would have shown nuich better judgment had we 
 done a hysterectomy. In Case ]129() both tubes should have been removed 
 and no lluid allowed to escajx' into the abdominal cavity. The occlusion of the 
 tube was primarily due to an infection, and we can never tell when all the 
 organisms are dead. 
 
 Gyn. No. 5124. 
 
 A b d o in i n a 1 M y o in e c t o 111 y ; Release of Adhesions ; 
 t h e .M a king o f a n A r t i fi c i a 1 I'' i m b r i a t e d }■] x t r e m i t y 
 f o r On e T u be . 1) ea t h . 
 
 A. M. H., aged forty, married, colored. Admitted .March 2.'5 ; died May o. 
 1807. Ojjeration. March 2()th. vaginal section with release of adhesions. Second 
 operation, April lOth. Fehic adhesions were liljerated from above, the right 
 tube was remo\'ed. a niN'oma 4 cm. in diameter enucleated from the uterine wall, 
 and an artificial oix'iiing made in the left tube. Other myomata were seen, but 
 were not disturbed. 
 
 The abdominal inci.sion broke down for its entire length, necessitating di-ainage. 
 SuV)se(|ueiUly on two occasions i)eh-ic drainage was reestablished from below. 
 The ))atient. however, gradually grew weak(M'. the pulse more raj)id, and she died 
 on May o, 1X97. 
 
 In this case the fact that the abdominal incision hrokedown notwithstanding 
 the careful technic, indicates a very low vitality. At the time of oj^eration it 
 would ha\'e been much wiser to remove the ut(M'us with the appendages, instead 
 of trying to do a conservative oj:)eration. 
 
 Path. No. !()()."). Th(> right tulx" is S cm. in length, firmly covered by dense 
 adhesions. It contains a yellowish, cheesy-like material. 
 
 Histologic examination shows the tube to be the seat of a chronic .salpingitis. 
 
 Gyn. No. 11296. 
 
 A 1) d o in i n a 1 .M y o in e c t o in y , 1'] v a c u a t i o n o f S e r o u s 
 F 1 u i d f r o m B o t h V a 1 1 o p i a n Tubes. 1) e a t h . 
 
 \'. S., aged thirty-four, white, mai-ried. Admitted May 19th; died May 28, 
 1904. The patient was intensely neurotic and rather anemic. She was fairly 
 well iiom-ished and well built. ()peratioii, May 21, 1904. A myoma, 6 cm. 
 in diameter, was enucleated fi'om the posterior wall. Both tubes were the seat 
 of a hydro.salpinx. They were punctured, fluid escaping into the abdominal 
 cavity.
 
 ABDO.MIXAL .MV(XMi:CT(J.M Y. 543 
 
 Postoperative History. — For four days she diel fairly well. Her temperature 
 was 101.2° F. on the second day; the third day it reached 100° F.; the fourth 
 day it was down to 99° F., but she began to vomit. Enemata had no effect. On 
 the fifth day she was nauseated nearly all day, took but little nourishment, but had 
 no abdominal pain. There were six small offensive fluid stools. Her tem- 
 perature on the fifth day varied from 99° to 102° F. Her pulse, however, at one 
 time reached 130, and her general condition was not satisfactory. The nausea 
 continued. The wound was inspected and found to be clean. Lavage relieved 
 her gastric symptoms a good deal. 
 
 On the seventh day she began to have diarrhea, and the same afternoon her 
 condition suddenly became worse: she grew very weak, restless, and slightly 
 irrational; her pulse reached 140, and she died on the eighth day. Just before 
 her death the cheeks were flushed, the eyes were bright, and the intellect was 
 active; there was no pain or rigidity. She was intensely restless. No autopsy 
 was allowed, but we diagnosed a general peritonitis. Shortly before death 
 the temperature was 106.5° F. 
 
 The Patient in an Almost Moribund Condition before Operation. 
 Many an ai)parently forlorn hope yields a brilliant surgical triumph, and as long 
 as there is a possiljility of saving the patient, it is the surgeon's duty to take 
 that chance. In the following case the patient was in a desperate condition and 
 succumbed on the table. The death, of course, cannot be in any way attributed 
 to the abdominal myomectomy, but it is, nevertheless, included among our fatal 
 cases. 
 
 Gyn. No. 1672. 
 
 R e m o V a 1 o f a L a r g e C y s t i c M y o m a f r o m a Patient i n 
 a n A 1 m o s t Moribund (' o n d i t i o n . 1) e a t h on the T a b 1 e . 
 
 P., .single, white. Admitted November 12; died November 13, 1892. 
 The patient, on admission, was suffering with extreme dyspnea and was unable 
 to lie down. The abdomen was much distended, fluctuant, and dull on 
 percussion e\'erywhere, except at the center of the upper abdominal zone. The 
 circmnference at the umbilicus was 52 inches. The urine contained a motlerate 
 amount of albiiiiiiii, but 110 casts. 
 
 Operation November 13th. The anesthetic was administered with the patient 
 in the sitting ])ostui"e, on account of the extreme dys])nea. 
 
 A small incision was made near the (lepeiideiu portion of the abdomen, 
 a trocai- was inserted, and from four to six pints of fluid deeply stained with blood 
 came away. The almost moribund j)atient was then placed on the operating 
 table. The incision was increased in length, and a iai'ge (juantity of blood- 
 stained fluid flowed out. The iai'ge flbrocyslic tumoi" was shelled out of its ad- 
 hesions, which wei'e flbrous and oiiienlal in chai'actei". The pulse and i-es))iration 
 stopped. The patient was in\-ei1e(l, and artificial I'espirat ion resorted to, but to
 
 544 MYOMATA OF THE ITERUS. 
 
 no i)urposc. The pulse before opemtion was 160. The tumor was a cystic 
 myoma, 30 x 34 cm., the inner portion hcins:; composed of one large cyst filled with 
 chocolate-colored contents. The base of the tumor measured 14x16 cm. and 
 was composed of typical iiiN'omatous tissue. 
 
 Myocarditis as a Possible Cause of Death Following Abdominal Myomectomy. 
 In (". II. I. ease W'., the patient gave a history of cardiac weakness, and at the 
 end of twenty-four hours after operation became weak and had fainting spells. 
 None of her symptoms except vomiting in any way suggested peritonitis. Un- 
 fortunately, no autopsy could hv obtained. Her postoperative condition strongly 
 suijtrested a mvocardial lesion. 
 
 '&o^ 
 
 C. H. I., W. 
 
 W'.. white, aged thirty-eight years, was admitted to the Church Home and In- 
 firmary ( )ct()l)er lOth, and died October 12, 1899. She had noticed an abdominal 
 eniai'geiiient about a year before. The tumoi' had grown considerably since she 
 was examined, six months before. A myoma, 16 cm. in diameter, was removed 
 from the ))()sterior wall, and several small ones from both the anterior and poste- 
 rior walls. The patient was weak, but did fairly well for twenty-four hours. 
 She had fainting spells on the afternoon of October 12th, vomited a good deal, 
 and died suddenly the .same evening. There was no abdominal distention, no 
 hemorrhage. Her temperatui'e had been normal throughout. No autopsy 
 was obtainal)le. 
 
 Dr. W. V. Hines, of Chesterto\Mi, ^Id., her family physician, informed me 
 t hat on several occasions .she had suddenly collapsed, and that he thought she had 
 a myocardial infection. W'v are unable to say with absolute certainty whether 
 or not such was the condition. 
 
 Immediate Postoperative Complications in Non-fatal Cases of Abdominal 
 
 Myomectomy. 
 
 By immediate we mean those occurring during the patient's sojourn in 
 the hospital. <')f the 280 i)atients, ([uite a mimber had mild or serious com})li- 
 cations. These are of suthcient practical importance to warrant a thorough 
 consideration. 
 
 The postoperative complications encountered were: 
 
 High temperature. 
 
 Ka])id ])ulse. 
 
 Ilystei'ieal manifestations. 
 
 Excessive nausea and vomiting. 
 
 Postoperative hemorrhage. 
 
 Great abdominal pain. 
 
 Cystitis.
 
 ABDOMINAL MYOMECTOMY. 5-45 
 
 Nephritis. 
 
 Escape of pus from the urethra. 
 
 A foul uterine discharge. 
 
 Sloughing of the anterior uterine wall. 
 
 Pelvic peritonitis. 
 
 Intestinal obstruction. 
 
 A high leukocytosis. 
 
 Abscess in the broad ligament, with spontaneous evacuation into the bladder. 
 
 Tonsilhtis. 
 
 Bronchitis. 
 
 Pleurisy. 
 
 Bronchopneumonia. 
 
 Lobar pneumonia. 
 
 Phlebitis. 
 
 B(Hlsore. 
 
 Temperature and Pulse after Abdominal Myomectomy. — Elevation of tem])cr- 
 ature Avith an acceleration of the pulse is a connnon occurrence after an al)dominal 
 myomectomy, and causes the surgeon much anxiety. As a rule, both temperature 
 and pulse drop gradually, reaching normal several days after operation. Of the 
 cause of the increased temperature we know little or nothing. On reopening the 
 abdomen in some of the severer cases we have found no hemorrhage nor infection. 
 It is quite possible that in many cases, notwithstanding the surgeon's care, 
 there exist small accumulations of blood in spaces that have not been totally 
 obliterated, and that the disintegration and absorption of this l)lood may in some 
 way be responsible for the increased temperature. No other class of abdominal 
 operations has given us as much anxiety during the first week following operative 
 interference. 
 
 In 242 of the cases we have com})lete data as to the postoperative temperature 
 and juilse. 
 
 That the findings ma}' be ])resented as concisely as possible, tables haA'e been 
 pi'epared. In these are included the postoperative tein])erature and pulse-rate 
 during the first week, as abnormalities after this period, with a few exceptions, 
 were associated with posto]X'rative complications and are considered in the discus- 
 sion of that su])ject. Only the highest teni])erature and pulse-rate are considered, 
 and the grouping of the cases is arranged accordingly, as seen in TaJjles 1 and 111. 
 In Table II ai'e included cases showing a tenn)erature abovi' 102° F.. the 
 striking feature being the absence of any clear cause for such iis(>. Similarly, 
 in Table R'cases showing a high pulse-rate are considered, and hei-e too. in the 
 majority, no satisfactory cause can be assigned. In 1 1 eases the pulse-rate re- 
 maine(l high during the greater part of convalescence. 
 
 Temperature. — From a consideration of Table! it will i)e seen that in 7S per 
 cent, of the cases the inaxinmni postopei'at i\'e tenipei'al ure during the lii'st week 
 was over 100° F. 
 35
 
 546 
 
 :myo.m.\ta of the uterus. 
 
 TABLE I. 
 Maximum Postoper.vtive Temperature During First Week. 
 
 98.8°, 1 case ( 0.4 per cent.) 
 
 99°— 100°, 53 cases (21.7 per cent.) 
 
 100°— 101°, 127 cases (52.9 percent.) 
 
 101°— 102°, 43 " (17.9 per cent.) 
 
 102°— 103°, 10 " ( 4.2 per cent.) 
 
 103°— 104.5° 8 " ( 2.9 per cent.) 
 Total, 242 cases 
 
 Til 17 cases the tctiiperaturc was al)ovo 102° F. These cases are shown in 
 
 1'al)l(' II. ill only 4 out of the 17 cases could any definite cause l)e assigned for 
 
 tills elevation. 
 
 TABLE II. 
 C-4SE.S Showing a Maximal Postoperative Temperature of Over 102° F. in the 
 
 First Week. 
 
 Gyn. No. 
 
 Temperature. 
 
 Day after Operation. 
 
 .\ppARENT Cause. 
 
 121 
 
 362 
 
 6724 
 9304 
 1489 
 8844 
 
 102.2° 
 103.4° 
 
 102.4° 
 l(r2.4° 
 102 .-)° 
 102.6° 
 
 Seventh. 
 Seventh. 
 
 Second. 
 Fourth. 
 Tliird. 
 Sixtli. 
 
 7220 
 
 102.8° 
 
 Sixth. 
 
 8476 
 
 102.8° 
 
 Second. 
 
 4055 
 
 103.0° 
 
 Sixth. 
 
 0059 
 
 103.0° 
 
 Second. 
 
 0394 
 
 103.0° 
 
 Tliird. 
 
 5452 
 
 103.2° 
 
 Filth. 
 
 4929 
 
 103.4° 
 
 Sixth. 
 
 858 
 
 103.8° 
 
 Filtii. 
 
 2039 
 
 104.2° 
 
 Fourth. 
 
 5359 
 
 104.5° 
 
 Fourth. 
 
 Not clear. 
 Lung involvement (no definite consoli- 
 dation). 
 
 Lung involvement. 
 
 Tenderness and muscle spasm in right 
 iliac fossa following appendectomy and 
 myomectomy. 
 
 Not clear. 
 
 IIO.VJ 
 
 Pulse. 
 
 nieetoniy 
 
 niaxiniun 
 
 104..-)° 
 
 S(M'()iid. 
 
 Too early discontinuance 
 
 di'ainage. 
 Bronchopneumonia. 
 
 of vasrinal 
 
 111 Ji; 
 
 onU' .") of 
 
 That the piilse-i'ate is inaterially increased after abdominal myo- 
 is evidenced hy the fact that in about 67 per cent, of 241 cases the 
 1 diirin.u' llie first week was over 100, as is shown in Talile TIT. 
 
 TABLE III. 
 
 Maximal rosin i-kuative Pulse-rate Dnu.XG the First Week. 
 
 70— 80 1 case ( 0.4 per cent.) 
 
 80— 90 12 ca.ses ( 5.0 per cent.) 
 
 90—100 06 " (27.5 percent.) 
 
 100 110 69 " (28.3 percent.) 
 
 110 I -'(J 54 " (22.5 percent.) 
 
 120 130 23 " ( 9.75 per cent.) 
 
 130—140 11 " ( 4.57 per cent.) 
 
 Above 140 5 " ( 2.08 per cent.) 
 
 Total, 241 cases 
 
 cases the niaxiiiiuin i)ul^e-i'ate durin<;' the (irst week was over loO. Tn 
 these could a satisfactor\' cause he assigned.
 
 ABDOMIXAL MYOMECTOMY. 
 
 547 
 
 TABLE IV. 
 Cases Showing a Ma.ximal Postoperative Pulse-rate of Above 130 During First Week. 
 
 Gyn. No. 
 
 Pulse-rate. 
 
 Day. 
 
 .•\ppARENT Cause. 
 
 5588 
 
 132 
 
 Second. 
 
 Not clear. 
 
 10059 
 
 132 
 
 Sixth. 
 
 (( (( 
 
 10587 
 
 1.32 
 
 Second. 
 
 (< u 
 
 10394 
 
 132 
 
 Third. 
 
 " " 
 
 11052 
 
 132 
 
 Second. 
 
 Bronchopneumonia. 
 
 2500 
 
 136 
 
 Third. 
 
 Not clear. 
 
 8476 
 
 136 
 
 Second. 
 
 " " 
 
 9221 
 
 136 
 
 Third. 
 
 " " 
 
 858 
 
 140 
 
 Fifth. 
 
 (( it 
 
 6724 
 
 140 
 
 Second. 
 
 a i( 
 
 8089 
 
 140 
 
 Fifth 
 
 " " 
 
 12583 
 
 144 
 
 Third. 
 
 Intestinal obstruction; beginning post- 
 operative peritonitis. 
 
 1212 
 
 148 
 
 Third. 
 
 Not clear. 
 
 10983 
 
 160 
 
 Second. 
 
 Pulse before operation 160; almost im- 
 perceptible after operation. Rapid and 
 irregular during convalescence. 
 
 2772 
 
 152 
 
 Third. 
 
 Not clear. 
 
 10300 
 
 170 
 
 First. 
 
 Not clear. 
 
 Ill 11 case.s the pulse-rate remained high (hiring convalescence, and in only 
 2 of these (Gyn. No. 10983 and 12583) could a satisfactory cause be assigned. 
 
 In Gyn. No. 3980, 5588, 6585 and 7073 the pulse-rate was above 100 for several 
 days. 
 
 In Gyn. No. 2598 and 7810 the i)ulse was irregularly rai)id, reaching 110 
 on several occasions. 
 
 In Gyn. No. 11111 convalescence was slow, and the pulse during the last 
 nineteen days ranged between 112 and 84. 
 
 In Gyn. No. 6760 the pulse rose to 130 on the second day. and during con 
 valescence ranged loetween 110 and 90. 
 
 In Gyn. No. 10300 the pulse innnodialcly before ojx'i'ation was 90. The 
 evening following opei-ation it rose to 162. During the next nin(^ days it gradu- 
 ally drop))ed to 100, and from tliis time until t lie date of discharge ranged between 
 100 and 90. 
 
 The two cases in which a definite cause for the accelei'ation couM be ;issigned 
 were (Jyn. No. 10983 and 12583. In the former (he i)ulse immediately lollowing 
 oi)eration rose to 160. It eontimied high and ii'regular, ranging between 116 
 and 104 from the .sixth to the thirty-second day. In this case there was a rather 
 se\'ere postopei'alix'e hemorrhage, the details of which are coiisidci-ed on p. 51!). 
 
 In Gyn. No. 12583 the continucMl r<apid pulse was undouhledly due lo the 
 intestinal obstruction and conunencing i)ostoper;iti\-e pei-itoiiilis. 
 
 Hysterical Manifestations. In Case 2710 a myoma, 5 x 5 cm., .and the left 
 lube and ox'ary were i'emo\'ed. ( )n hei- admission to the hospital it was noted 
 that the jjatienl. who was forty yeai's old, was very nerN'ous .and hyslei-ical. 
 During her con\-alescence she had s(n'eral hystei'ical att.acks, but these in no 
 way retarded her recoveiy.
 
 548 MYOMATA OF THE UTERUS. 
 
 The patient in Case 7880 was also forty years old. On adirdssion she com- 
 plained of general nervousness. Several myoniata were removed. Her con- 
 valescence was complicated by nervousness of an extreme type. 
 
 In Case 8250 the jnitient was forty-two years old and comi)laincd of marked 
 nervousness. A myoma, altout 7 cm. in diameter, was removed. Her nervous 
 condition is now (six years after operation) even worse, and her own life and that 
 of her family are renderetl miserable by her morbitl imaginations. 
 
 It will be noted that in each of these three cases the nervous phenomena 
 antedated operation, and that the extra strain of operative interference merely 
 served to accentuate them. 
 
 Excessive Nausea and Vomiting. — In Case 20.39 there was nuich nausea, but 
 no vomiting. In Case 10300, 11 myomata were removed; the .same night the 
 pulse reached 170, and nausea persisted until the seventh day. 
 
 The nausea in Case 10497 persisted for four days, although only two small 
 myomata had been enucleated. 
 
 In Case 4878 two large interstitial myomata were removed, and a dermoid 
 cyst was resected from the right ovary. Xau.^ea and vomiting were present 
 for five days. 
 
 In Case 5801 several myomata were enucleated. During convalescence 
 there were two attacks of nausea and vomiting. The patient vomited a blood- 
 stained fluid each time. 
 
 In Case 0., operated upon at the Ilebrcnv Hos]ntal, continuous vomiting per- 
 sisted for several days, the Nomitus sometimes being of a dark chocolate color. 
 Such vomiting is usually followed by death. As seen on p. ,551, this patient had 
 acute nei:)hritis and extensive sloughing of the anterior uterine wall. She re- 
 covered and now, five years later, is perfectly well. 
 
 Stercoraceous vomiting is usually indicative of obstruction, and is always 
 a grave sym])tom. In Case 2598 a myoma of the right cornu, together with the 
 corresponding tube and ovary, was removed. The patient had persistent vomit- 
 ing for .'^ix days. At this time the stomach was washed out and a large quantity 
 of stercoraceous matter came away. The jiatient recovered. 
 
 A reference to p. 533 will give a tlescription of the excessive vomiting noted 
 in fatal cases. 
 
 Postoperative Hemorrhage. — We include here only those cases in which, 
 notwithstanding the hemorrhage, the patient recovered. In two cases (Nos. 62 
 and 10983) secondary hemorrhage occurred. In the first case the bleeding was 
 slight in amount; in the second, \-ei-v extensive. 
 
 Gyn. No. 62. 
 H e m o r r h a g e V olio w i n g A b d o m i n a 1 M y o m (> c t o m y . 
 M. S. L., single, white, aged thirty-three. Admitted November 28, 1889; 
 discharged February 1, 1890. Operation. A myoma, approximately 7 cm.
 
 ABDOMINAL MYOMECTOMY. 549 
 
 in (lianiotor, was removed, as well as the right tube and ovary. On the second 
 day there was slight oozing, necessitating another hgature al^out the deep sutures 
 in the uterus. The patient then made an uneventful recovery. 
 
 Gyn. No. 10983. Path. 7192. 
 
 Hemorrhage Foil o ^^' i n g Removal of a M y o m a . 
 
 C. B., colored, aged thirty-two. Admitted January 9; discharged Febru- 
 ary 11, 1904. Operation, removal of an intraligamentary myoma, about 12 cm. 
 in diameter, and enucleation of several nodules from the posterior wall. After 
 the patient reached the ward it was noticed that the abdominal dressings were 
 markedly stained. Her jnilse rose from 116 to 130. An hour later it was 140. 
 and the dressings were soaked ^ith bright-red blood. On removal of one stitch 
 a quantity of blood filled the incision. As rapidly as possil)le it was sponged out. 
 She was at once taken to the operating room, and the incision was opened. The 
 abdominal cavity was filletl with blood. As no bleeding point calling for control 
 could be found in the uterus, gauze packs were placed in the cul-de-sac about the 
 uterus. These apparently checked the oozing. She did well for twelve hours, Init 
 then her pulse again rose to 140, and the oozing was very free. The abdominal 
 incision was again opened, two sutures were taken in the top of the uterus, whence 
 the myoma had ])een removed, and ten minims of adrenalin 1 : 1000 were ad- 
 ministered hypodermically. The bleeding was entirely checked, and from this 
 time on she made a normal convalescence. Her highest postoperative temper- 
 ature was 100.8° F.; the highest pulse w^as 160, on the second day. She was dis- 
 charged on the thirty-first day. 
 
 Intense Abdominal Pain Following Abdominal Myomectomy. — Abdominal 
 pain is a natural accomjjaniment of abdominal operations, l)ut unless intestinal 
 obstruction is present or peritonitis is developing, the pain is usually readily 
 amenable to treatment. In only one of our cases was it excessive. In Case 
 11256, the patient, forty-two years of age, had a myomatous uterus ext(>nding 
 almost to the umbilicus, and also comi)lained of nervousness. An interstitial 
 myoma, 15 cm. in diameter, was removed at the patient's recjuest. Iler liiglu'st 
 postoperative temperature was 100° F., and from a i)Iiysical standixiiiit she rallied 
 reatUly, but for nearly a week she complained of the most intense agony. The 
 pain was relieved by various simj)le remedies. It was with the greatest dithculty 
 that she could be ])ei'suaded to leave h(M- bed. She (iiially left tlie lios]>ilal oil the 
 thirty-seventh day. Three years later she was still e.\('essi\-ely nervous, and 
 said that her health was not good. 
 
 Such a case might \-ery readily mislead the operatoi- into reopening the 
 abdomen, on the sup|)osition that obsti'uction existed oi- th;it peritonitis was 
 commencing. 
 
 Postoperative Cystitis. — This not iiirfe(|uent coniplicatioii following ;in 
 abdominal operation is sometimes undonbtedly dne to carelessness, but in other 
 instances occurs without any appreciable cause.
 
 550 MYOMATA OF THK UTERUS. 
 
 In Case 8389 an intorstitial niyoina. about cm. in dianioter, was found at the 
 junction of \\w cervix and corj)us on the left. The nodule was removed. The 
 patient developed a severe cystitis, although she was never catheterized in the 
 ward. It had not entirely subsided when she left the hospital, and although her 
 health was good six years later, she still suffered from "b(»aring-(lown ])ains" 
 in the vesical region. 
 
 In Case S4()2 many myomata, the largest 7x7x14 cm., were removed. 
 Convalescence was complicated by a cystitis. The ])atient was well six years 
 later. 
 
 In Ca.se ()7()2 a myoma, G x 6 x 7.5 cm., lay between the vesical reflection and 
 the uterus. Catheterization was necessary up to the twenty-third day on 
 account of retention. A cystitis develo])ed and lasted for two years. At present, 
 eight years later, there is no bladder disturl)ance, but the ])atient has tabes 
 dorsal is. 
 
 In this case the jx-rsistent retention was an undoubted factor in the causation 
 of the cystitis, and in the removal of the myoma from beneath the bladder the 
 ve.sical blood-supply may ])ossibly have been injured. 
 
 Nephritis Aggravated by Abdominal Myomectomy. — In Case 7753 a myoma, 
 3 cm. in diameter, was shelled out, a hysterotomy done for a {polypoid condition 
 of the endometrium, and the j)erineum repaired. Later the jmtient was trans- 
 ferred to the medical side for treatnuMit for a chronic nejjhritis. The ne])hritis 
 had been i)i-es(Mit before the operation, and it is interesting to see how much a 
 patient can sometimes stand even when the kidney function is impaired. 
 
 The acute ne|)hritis in Case 0. operated uj)on at the Hebrew Hospital, was 
 e\i(h'ntly ilue in pai1 to the acute infection following the sloughing of the anterior 
 uterine walL With removal of the necrotic tissue the renal symptoms subsiih^d, 
 and the patient i'^ well fi\-e years later. 
 
 Free Escape of Pus from the Urethra. — In Case 0474, in wliich the uterus ex- 
 tended foi- two-thirds the distance fi'om the i)ul)es to the umbilicus, a large inter- 
 stitial myoma was removed ])er abdomen. The temperature reached 103.2° F. 
 on the eighteenth day, and a persistent phlebitis developed in the left leg. 
 Sixty cubic centimeters of pus escaped from the urethra. Its source could 
 not be definitely ascertained, but possibly it came from a small peh'ic abscess 
 that may have opened into the bladder. Such an evacuation of an abscess is 
 well instanced in Case 5350, described on page 553. 
 
 A Foul Uterine Discharge Following Abdominal Myomectomy. — In Case 10394 
 the patient, thirty-four years old, had a submucous myoma, 2.5x5x9 cm. 
 A drain was carried down through the ulei-us to the vagina, and a small drain left 
 in the lower end of the abdominal incision. On the third day the temperature 
 reached 10;!° I"'., and on the i-enio\al of the uterine driiin a foul discharge came 
 away. ( )ii the nineteenth day the |)atient had a chill, and the temperature was 
 104° \'\ 
 
 The tumor, on removal, was found to be lobulated, dii-fy gray in color, and
 
 ABDO.MIXAL MYOMECTOMY. 551 
 
 had a foul smell. Histologic examination showed an acute infiannnation. 
 There was much degeneration of the tissue, and infiltration with ])olymorphonu- 
 clear leukocytes. The infection from the degenerated submucous myoma 
 readily accounts for the offensive discharge. The patient was well three and 
 one-half years later. 
 
 In CaseC. H.I. S., admitted June 9, 1903, a soft, cystic, submucous myoma, 
 10 cm. in diameter, was removed. On the sixth day the tem))erature reached 
 103.6° F., but then dropped to normal. There was a most offensive uterine dis- 
 charge. The patient's health was fair four years later. 
 
 In Case 0., operated upon in the Hebrew Hospital, nearly all the anterior 
 uterine wall came away, and there was natui'ally a most offensive and abundant 
 uterine discharge. 
 
 In each of these cases the uterine cavity was 0])ened up at operation, and in 
 the first and third cases the cause of the oft'ensive discharge was readily explained. 
 
 Sloughing of the Anterior Uterine Wall After Removal of a Large Interstitial 
 Myoma. — In this case, although the patient's urine contained much albumin, we 
 were forced to operate on account of the pressure symptoms. The gloljular 
 uterus extended almost tothe umbilicus. During removal of the tumorthe uterine 
 cavity was slightly opened. Persistent nausea and vomiting followed the opera- 
 tion, the vomited material at times being of a chocolate color. The urine con- 
 tained much more albumin and many casts after operation. A vaginal dis- 
 charge having appeared, the cervix was split and quantities of the necrotic anterior 
 uterine wall were removed. Had it not been for this evacuation of the uterine 
 contents, the patient would undoubtedly have died of infection. 
 
 Why the anterior wall sloughed it is, of course, impossil)le to determine with 
 certainty. Opening into the uterine cavity during operation naturally ])rovides 
 an avenue of infection if the uterine cavity contains pus-organisms. In this 
 case also the nephritis naturally reduced the patient's resistance. 
 
 Had it not been for the fact that the suture line in the uterus was brought into 
 intimate contact with the anterior abdominal wall as the result of the fixation 
 (the patient being near the menopause and single), the thin and rotten shell of 
 the anterior uterine wall would certainly have perforated and the j)atient died 
 of peritonitis. 
 
 0., Hebrew Hospital. 
 
 Sloughing of the Anterior l' t e r i ii e W a II 1'" o 1 1 o w i ng 
 A b d o m i n a 1 M y o ni e c t o m y . 
 
 0., admitted to the Hebrew Hospital .lul>- II, l'.t()2. The |.aliriit had been 
 suffering for several years with a myomatous uterus, mid toi- the last lour or five 
 days her legs had been iiiai'kedly swollen and she liail been t'orced to i-emain in 
 bed. The urine contaiiuMl much albumin and many easts. ( )])eration, howe\'ei\ 
 could not be a\'oided, as there wci-e distinct jii-essure synij)Ioins. W hen the ab- 
 domen was ojx'iied, a myoma was found extending almost to the umbilicus, and
 
 552 MYOMATA OF THE UTKRUS. 
 
 situated in the anterior wall. It was peeled out without difRculty. Tt was 
 fully 11 cm. in diameter, and there was a good deal of bleeding. At two points 
 the uterine cavity was opened. The cavity was clo.sed with catgut sutures, and 
 the uterus firmly fastt'iu'd to the anterior abdominal wall. The appendages were 
 normal. 
 
 July 17th: Ever since operation the patient has l)een vomiting. The vomi- 
 tus has a chocolate color. The stomach has been washed out, and since then 
 the nausea has been much less marked. To-day the |)ulse is better, and the 
 ])atient shows some improvement. The urine still contains many casts. 
 
 July 20th: The urine contains quantities of albumin and casts. She has 
 improved very little antl for the last few days has been delirious. There has been 
 a most offensive uterine discharge for several days. On examination under anes- 
 thesia we found fetid pus escaping from the cervix. On stretching the cervix 
 and curetting, only a slight amount of tissue came away, but on careful examina- 
 tion of the anterior uterine wall where the myoma was situated, and on making 
 a little traction, masses of necrotic uterine tissue were brought away. We re- 
 moved in all fully a large handful of the necrotic uterine wall, without, however, 
 causing any hemorrhage. To insure free drainage we split the cervix posteriorly 
 back as far as the internal os, and controlled all bleeding points with catgut. 
 The uterine cavity was then irrigated thoroughly and packed with iodoform 
 gauze. The })atient made a gradual recovery. 
 
 July 1, 1907: The patient is in excellent health five years after operation. 
 
 Pelvic Peritonitis Following Abdominal Myomectomy. — Where there have been 
 pelvic adhesions associated with a myomatous uterus there is liable to be slight 
 pelvic peritonitis following operation if all oozing is not checked and no vaginal 
 drainage is ])rovided for. 
 
 In Gyn. No. 5826 two large myomata were removed from the uterus. One 
 of the.se was partially cov(>red with omental adhesions. After the operation the 
 patient had a slight bronchitis, and her temj)erature reached 101° F. At the 
 time of her discharge there was some slight induration and tenderness in the 
 po.sterior vaginal fornix. The ])atient was well nine years after operation. 
 Such thickenings often disap])ear spontaneously in a short time. 
 
 In Case 4537 a colored woman, forty-two years of age, had an interstitial 
 myoma, 5 x6 cm., and a tubo-ovarian cyst, which was densely adherent to the 
 posterioi- .surface of the uterus. Both were renun'ed. A month later the pvW'is 
 was o])ened through the vagina and about 300 c.c. of encysted sero-hemorrhagic 
 fluid came away. On account of i^rolapsus the cervix was removed and the ))ei-i- 
 neum repaii'ed. The ]iatient was in fair health nine and one-half years later. 
 
 Intestinal Obstruction Following Abdominal Myomectomy. — In only one of 
 our 280 abdominal m\-()mectoinies in which rec()\-ery took |)lace did we have 
 intestinal obstruction. In (a.^e 125S3 the patient was thirty-.seven years old. 
 At operation the left appendages were liberated from adhesions, and the right 
 ai)pendages removed on account of a corpus-luteum cyst; two interstitial myo-
 
 ABDOMINAL MYOMECTOMY. 553 
 
 mata, the larger 2.5 cm. in diameter, and the appendix, which was sHghtly con- 
 stricted near its base, were also removed. On the third day signs of intestinal 
 obstruction developed. When the abdomen was opened, no evidence of general 
 peritonitis could be found, but a loop of gut had become adherent to the posterior 
 surface of the uterus. The intestine at this point was thickly coated with fibrin. 
 Recovery after the second operation was uneventful. The patient is well 
 eighteen months later. 
 
 Where obstruction can be definitely diagnosed there should not be anv delay 
 in opening the abdomen. 
 
 For the fatal cases of obstruction see p. 533. 
 
 Leukocytosis Following Abdominal Myomectomy. — Wien a purulent accumu- 
 lation is present, one naturally expects to find an increase in the number of leu- 
 kocytes. We have had one case in our series, however, in which the leukoc^^to- 
 sis developed and subsided without our being able at any time to detect the i)uru- 
 lent focus. In Case 8773 the patient was thirty-eight years old and single. 
 Many myomata were present, thirteen separate incisions being made through 
 which to remove them. The patient, who was extremely nervous and had had 
 fits of tlepression prior to operation, did well for a few days after operation, but 
 from the eleventh to the twenty-first she ran a temperature, reaching 102.8° F. 
 on the fifteenth. On the nineteenth day the leukocytosis reached 18,000. She 
 rapidly imjjroved, and left the hospital on the twenty-fifth day in excellent con- 
 dition, and with the nervous dejiression seemingly relieved. 
 
 Abscess in the Broad Ligament Developing After Removal of a Myoma. 
 Spontaneous Evacuation into the Bladder. — In the following case a large intra- 
 ligamentary myoma lay partly in front of the uterus, but chiefly to the left, be- 
 tween the peritoneal folds. Enucleation was easy, but closure of the resultant 
 space difficult. Several days after operation an abscess develo})e(l in the space 
 formerly occupied by the myoma, and soon opened into the bladder. 
 
 In this case it would have been ^\^ser at the time of oi)eration to have carried 
 a small retroperitoneal drain from a point just above Poupart's ligament down 
 to the point at which the myoma had been removed. 
 
 Vaginal drainage was not attempted earlier on account of the danger i^f in- 
 juring the left ureter or the uterine artery. The patient was well ten years later. 
 
 Gyn. Nos. 5359 and 5560. 
 
 Abscess of the broad ligament d e v e 1 o p i n g after 
 removal of a myoma (Fig. 329). 
 
 L. W., single, aged thirty-five. Admitted .lunr 27. 1S!)7: discliargetl Septem- 
 ber 6, 1897. Operation, June 28, 1897, myoniedoniy and suspension of the 
 uterus. A myoma, 7x9x12 cm., was shelled out of the left broad ligament 
 (Fig. 329). The temperature rose steadily after operation, reaching 104. (5° F. 
 on the fourth day. It then fell slowly, reaching 100° !•". on the ."sixteenth, and 
 becoming normal on th(> forty-eighth day. Several days after operation there
 
 554 
 
 MYOMATA OF THK UTERUS. 
 
 ^-^_ ^^^^ZU'* 
 
 was a sudden escajje of pin from the liladder, with an iin))rovenient in the con- 
 (Ution. The uriiu* contained (luantities of ])us for a consi(lera])le time. Shortly 
 afterward the jx'lvis was drained throutrh the vaf^ina, and on November 22, 1897, 
 it a<]i;ain became necessary to opiMi the pel\-is through the vagina, about 60 c.c. 
 of thin grayish pus escaping. On January 14, 1898, the vaginal opening was 
 again (Hlated. but no pus came away. Tn Xovember, 1900, all vestige of the 
 former trouble liad disappeared, and the pelvis was absolutely free from any 
 thickening. The patient was perfectly well ten years after oj)eration. 
 
 Tonsillitis. This complication is a by no means rare one. j)articularly in old 
 
 institutions, and the sudden rise of temj)erature, especially after an abdominal 
 
 myomectomy, ma}' alarm the surgeon until the cause of the fever is ascertained. 
 
 In only one ca.se (5873) did tonsillitis de\-el())). In this case five small my- 
 
 oniata and the appendix had Ixh'ii removed, and a radical cure for left inguinal 
 
 hernia had been done a month later. Re- 
 covery was .satisfactory. 
 
 Bronchitis. — The anesthetic employed 
 in the early years of the tlepartment was 
 chloi'oform, but since 1894 ether alone or 
 l)receded by nitrous oxid or ethyl chlorid 
 has been the anesthetic in conniion use. 
 
 In two out of the 280 succes.sful cases 
 a bi-oiicliitis de\-elope(l. In Case 8389 an 
 interstitial myoma, about 6 cm. in diameter, 
 was removed. The patient developed a 
 .severe cystitis and a slight bronchitis, 
 neilliei-of which was absolutely cured when 
 she left thehos|)ital. 
 
 In Case o82() two fairly large myomata 
 were removed. The patient developed a 
 marked bronchitis that lasted several days. 
 Pleurisy. In 3 of our 280 succes.sful cases pleurisy occurred during convales- 
 cence. 
 
 In Case 4415 a wedge of adenomyomatous tissue, 2x5 cm., was excised from 
 the posterior uterine wall. During convalescence the patient had phlebitis and 
 pleurisy with effusion. With the develo])ment of the pleurisy the temjjerature 
 rose to 102° F. The patient remained well for two years, after which the uter- 
 ine hemorrhages recurred. 
 
 In Case 8704 four myomata were removeil. ( )n the twelfth day the j)atient 
 complained of a sharp pain at the lower angle of th(> right scapula. At this 
 point there were im))aired resonance and a slight friction rub. The ))ulmonary 
 dullness disappeared comi)letely in five days. 
 
 In Case 1570 seven myomata were i-emoved. Convalescence was intei-rui)ted 
 by a definite attack of pleurisy, with effusion in the right chest, accomj)anied by 
 
 Fig. 329. — \ .Myo.m.\ of thk Bkoad Ligament. 
 Gyn. No. .5.3.59. The myoma lay partly be- 
 tween the bladder and uterus, but chiefly in the 
 left broad listameiit. .\fter removal of the my- 
 oma per abdomen an ab.scess developed in the 
 left broad ligament and opened into the bladder.
 
 A BDOM I X AL M YOIM ECTOM Y , 
 
 555 
 
 a cough, fulness of that si(k> of the chest, and a temperature of 102.2° F. l^leven 
 years later the patient ''died very suddenly from hemorrhages — she vomited 
 blood." The letter strongly suggested death from ])ulmonary tuberculosis. 
 
 Bronchopneumonia, — Tn Case 11052 the patient was twenty-seven years old. 
 A myoma, o cm. in diameter, was removed from the fundus. She develojjed 
 bronchopneumonia; the temperature rose to 104.5° F. on the second day, and 
 slowly dropped, reaching normal on the eleventh day. The subse<iuent course 
 was uneventful. 
 
 Lobar Pneumonia. — In Case 660 a large i)edunculated myoma and the left 
 tube and ovary were removed from a woman thirty-six years old. The myoma 
 was enveloped in many omental adhesions. The temj)eratur(' on tlie s(H-on(l 
 day was 101.4° F., but below 101° until the fourteenth day, when she had a 
 chill, a cough, and a temperature of 105.2° F. A few days later a consolidation 
 in the right lower lobe was made out. Finally she made a perfect recovery. 
 
 In Case 8764 several myomata were removed and the uterus was suspended. 
 The patient, a white woman, aged thirty, on the thirteenth day complained of 
 .sharp pains at the lower angle of the right sca])ula. Resonance was imi)aii-ed, 
 the respiratory sounds were harsh, a shght friction-rub was detected, and later a 
 distinct area of consolidation. This entirely cleared up before she left the 
 hospital. 
 
 Phlebitis Following Successful Abdominal Myomectomy. — From the accom- 
 panying table it will be seen that in six out of 280 cases a phlebitis develoix'd. 
 In five of these the thrombosis was situated in the left leg. In Case 4415 the 
 history note does not mention which leg was involved. 
 
 PHLEBITIS FOLLOWING SUCCESSFUL ABDOMINAL MYOMECTOMIES. 
 
 Cases. 
 
 Size of Myomata. 
 
 Onset. 
 
 Location. 
 
 12.504 
 
 Four niyf)inata, Uirfz;est 4 cm. in 
 diameter. 
 
 Seventeenth day. 
 
 L. .sa]>li("n(His vein. 
 
 12028 
 
 Several small myomata. 
 
 
 L. femoral vein. 
 
 10573 
 
 Multiple myomata, largest about 
 7 cm. in diameter. (Hemo- 
 globin, 38 per cent.) 
 
 Seventeenth day. 
 
 L. saphenous vein. 
 
 9.329 
 
 Myoma, 3 cm. in diameter. Re- 
 
 
 
 
 pair of complete perineal tear. 
 
 
 Slight phlebitis in left leg. 
 
 6474 
 
 Myoma. 10 cm. 
 
 
 Phlebitis in left leg obstinate. 
 
 4415 
 
 Adenomyoma; remoxal of wedge 
 
 
 Phk'i)itis (side not noted). 
 
 
 2 X 5 cm. 
 
 
 Pleurisy. 
 
 Bedsore Following Abdominal Myomectomy. — In Case Mc.V. (p. 512). in \vhi(di 
 an 89-p()Uiid myoma was rciiiovcd, the i)aruiit had rdciiia of the bullocks and 
 legs. On account of marked dyspnea the o|»('i'alioii was pcrfoinicd willi the 
 jjaticnt in the sitting posture. Notwithstanding the givalcsl caiv a bedsore 
 developed a few daN's after operation, it ictai'detl her recoNcry only very 
 slightly.
 
 556 MYOMATA OF TMK TTHRUS. 
 
 Abdominal Operations Necessary Subsequent to Abdominal Myomectomy. 
 As a result of the many letters sent out we have information eoncernini!; the 
 greater number of the 'iSO myomectomy ])atients. with the followinii; results: 
 
 Cask. 
 
 rj.')04. Hi'lease of vesical, intestinal, and ovarian ailhesions 1 
 
 7.')()(). Kelief of intestinal obstruction 1 
 
 2709i + .")t)8."). Hei)eated niyoniectomy 1 
 
 4517 7073. Removal of ovaries 2 
 
 5359 + 5560. Evacuation of pelvic abscess 1 
 
 706.4329,4925, 5076, 5846, 6760, 7779, 7886, 8220, 8936. U. P. I. + C. H. I.. San. No. 
 
 1582, Hysterectomy, 12 
 
 Total 18 
 
 Release of Vesical, Intestinal, and Ovarian Adhesions. — In Case 12504 a myo- 
 ma. 4 X 4 X o cm., was removed from the right uterine comu, and several other 
 very small nodules were .shelled out. The appendages were normal. Sixteen 
 months later the alxlomen was opened on account of pelvic pain. Fig. 330 shows 
 the findings. The Madder was adherent to the anterior surface of the uterus. 
 A loop of small bowel was partially kinked and firmly fixed to the posterior sur- 
 face of the utei-us on the I'ight side, and also firmly glued down to the inner edge 
 of the right ovary. 
 
 This case demonstrates clearly the danger of postoperative adhesions. It 
 is imj)o.s.siJ)le to i)revent the intestines from adhering to the suture line in the 
 utems if the myoma is situated in the ])osterior wall of the utcu'us. When 
 located in the anterior wall, suspension of the uterus will often cover in the raw 
 area completely. 
 
 Gyn. No. 12504. 
 
 A b d o m i n a 1 m y o m e c t o m y . S 11 b s e ([ u e n t o ]> e rati o n 
 for release of vesical, intestinal, and o v a r i a n a d - 
 h e s i o n s (Fig. 330). 
 
 A. 8., single, aged thirty-eight, white. Admitted November 10, 1905; dis- 
 charged thirty-two days latei'. A myoma, 4 cm. in diameter, was removed from 
 the vicinity of the right uterine horn, and the opening closed with through-and- 
 through sutures of plain catgut: other small niN'omata were also enucleated. 
 On the seventeenth day the ])atient complained of ])ain in the left leg, with some 
 swelling. On November 1(5. 1007, the abdomen was again opened. We re- 
 moved the appendix, which was enlarged and injected. There were numerous 
 adhesions to the a.scending colon. The bladder was drawn up o\-er the anterior 
 surface of the uterus (Fig. 330). The.se adhesions were easily liberated. A loop 
 of small bowel was adherent to the ])()stei"ior surface of the uterus by numerous 
 exceedingly va.scular adhesions, which were also easily se})arated. and the same 
 loop was adherent to the right ovary over an ar(>a 1.5 cm. in diameter. Th(> re- 
 lation between the ovary and the bowel was an exceedingly intimate one. After
 
 ABDOMINAL MYOMECTOMY, 
 
 557 
 
 loosening up adhesions we found that the outer coat of the bowel had ])een sac- 
 rificed to a slight extent. The raw surfaces w^re approximated with Pagen- 
 stecher sutures. 
 
 This complication is of great interest. At the previous operation the uterus 
 was free from adhesions and the appendages were normal. The intestine had 
 undoubtedly become adherent to the uterus over the area of the myomectomy, 
 probably as the result of the irritation produced by the ends of the catgut su- 
 tures. Whv the intestine became adherent to the ovary it is im])ossible to say. 
 
 Fig. 330. — Pelvic Adhesions Following Abdomin.\l Mvomecto.mv. 
 Gyn. No. 12504. This was the condition found sixteen months after a myoma, 4 cm. in diameter, had lieen 
 removed from the vicinity of the right uterine cornu. Several other small nodules were also enucleated. The 
 bladder is adherent to the anterior surface of the uterus. A loop of small bowel was firmly fixeil to the posterior 
 surface of the uterus, and also to the riglit ovary. 
 
 Intestinal Obstruction Following Years After Abdominal Myomectomy. —\\'(> 
 
 have had one case of this character. In 1SS() a conscrvntivc \)r]\\r oitci-atioii, of 
 the nature of which we know nothing, was |)ert'oniic(L i'ouilccti ycais lalcrthe 
 patient entereil the .hihiis lIo])kins llosi)ital aiul a iiiyoni.-i, thivc times the size 
 of the uterus, was removed. Intestinal adhesions wei'e reh'.-ised, ;m(l the uleius 
 was sus])eiide(L The follow ing year another surgeon ivmoxcd the ;i|)])en(li\, and 
 subseciiiently had to ojK'ii the abdomen for obst ruction, releasing nian\- adhesions, 
 and resecting a portion of the small bowel. .\ lew months ag(» the patient had 
 typhoid fever. Jn .lanuaiy, lUO", she reporte(l th.it hei- health was not good.
 
 558 MYOMATA OF THE UTERUS. 
 
 Ill this case tho iiiyoiiicctoiuy was in no way responsible for the adhesions, as 
 these were present hct'orc the ojieration. 
 
 Gyn, No. 7566. 
 
 A 1) (1 (I 111 i n a 1 ni y o ni e c t o ni y w i t h sub s e (j u e n t r e ni oval 
 of the appendix: later d e n s e a d h e s i o n s producing 
 intestinal obstruction and requiring resection of 
 t h e 1) o w (■ 1 . H e c o v e r y . 
 
 -M. F., white, single, aged forty. Admitted February 10 ; discharged March 
 10, 1900. She said that a conservative abdominal operation had been done four- 
 teen years before, the nature of which we do not know. At operation various 
 intestinal adhesions were released, a myoma was removed from the uterus, and 
 the uterus .suspended. The uterine tumor was about the size of a two months 
 pregnant organ. The tubes and ovaries were not diseased. In a letter re- 
 ceived from hci' seven years later she states that in the following year her appen- 
 dix w-as i-emoved, and that later on, on account of dense adhesions and intestinal 
 obstruction, it was necessary to open the abdomen again and remove a portion 
 of the small intestine. In 1906 she had typhoid fever. 
 
 Repeated Myomectomy. — In one case in which a myoma was situated in the 
 left cornu, the cornu and the left appendages were removed after liberation of 
 many adhesions. Three and a half years later, after release of adhesions, two 
 small myomata were removed from the anterior Avail of the uterus. 
 
 Gyn. Nos. 2'jog\ and 5635. 
 
 C. B.. aged fifty-six, white, widow. Admitted April 9; discharged .May 5, 
 1S94. A myoma, o x x 7.5 cm., was removed from the left cornu. Pelvic 
 adhesions were liberated, and the left tul)e and ovary were removed. 
 
 The patient returned to the hospital (No. 5635) on October 27, 1897, and was 
 discharged November 24th of the same year. The operation this time consisted 
 of a myomectomy with removal of the right tube and ovary. Adhesions were 
 present between the uterus and omentum, .small intestine, and bladder. Two 
 small myomata were removed from the anterior wall of the uterus near the cervix. 
 The patient made a good recovery. 
 
 Removal of Ovaries Subsequent to Myomectomy. — In Case 4517 four small 
 niyomata were removed and the ulerus was suspended. The appendages were 
 normal. About ten years later she had another abdominal operation, of the 
 character of W'hich .she knows nothing. A few inoiitlis later she had her oN'aries 
 I'emoved, for what reason we do not know. 
 
 In Case 7073, after release of the adherent ajjpendages, an inteistitial myoma, 
 / cm. in diameter, was removed. A few months latei' she came under the care 
 ol another ])hysician. and her ovaries wei'e iviuovimI, with tempoi-ary benefit.
 
 ABDOMINAL MYOMECTOMY. 559 
 
 Gyn. No. 4517. 
 
 R e m o \' a 1 o f o \' a r i v s a f t c r m y o 111 c c t o 111 y . 
 
 E. T., single, aged thirty-nine. Admitted July 17; discharged August 16, 
 1896. Operation, July 18th. Myomectomy and suspension of the uterus. Four 
 small myomata were enucleated. The appendages were normal. On June 10, 
 1907, we received a communication from the patient saying: ''The operation did 
 but little good. It only patched me up for about a year. From then on I have 
 been a great sufferer." Last year she had an o])eration ])erf()rmed at another 
 hospital, and in April of this year had her ovaries removed. Thcnr condition we 
 do not know. Of course, in this case it is quite possible that the adhesions of 
 the ovary were in no way the result of the previous operation, especially as the 
 patient remained well for the first year. 
 
 Gyn. No. 7073. 
 
 M y o m e c t o in y \\- i t h s u b s e ci u e n t removal of t h e 
 ovaries. 
 
 M. S. H., aged thirty-six, white, married. Admitted July 13: discharged 
 August 22, 1899. Operation, myomectomy with release of adherent tubes and 
 ovaries; suspension of the uterus. The myoma was subvesical. After its re- 
 moval a good many sutures were necessary on account of the bleeding from the 
 stitch holes. 
 
 April 29, 1907: A letter from Dr. A. F. Brant, of Heathsville, ^'a., says 
 that the patient experienced little relief from the operation. She returned to 
 another hospital within a few months and had both ovaries removed. 
 
 Of course, in this case the adhesions in the pelvis already existed. An at- 
 tem])t was made to rectify matters without sacrificing the organs. 
 
 Evacuation of a Pelvic Abscess Months After a Myomectomy. — In C asc 5359. 
 in which a broad ligament myoiiia was rem()\'c(l, an abscess developed. This 
 ()])(Mied into the bladder. Hcfoi'c the ])atieiit left the hospital it was n(>c(>ssary to 
 drain the peU'is thi'oiigh the \'agina, and on se\-ei-;il occasions after she lett the 
 hospital it was found expedient to reestablish the peUic ch'ainage. This case is 
 repoi-te(l in full on p. ^)^)'.]. 
 
 Hysterectomy Subsequent to Abdominal Myomectomy. 
 In the following pages several cases are desci'ibed in which remo\-al of the 
 uterus became necessary later. These cases natui'ally fall into two delinite 
 gi'oujjs: 
 
 1. Hysterectomy on account of pehic adhesions. 
 
 2. Hysterectomy on account of tiie de\-elo])ment of other myomata. 
 Hysterectomy on Account of Postoperative Adhesions. — Cases 5076, oSKl, aiul
 
 560 MVOMATA OF THE UTERUS. 
 
 San. 1582 bi'loii-j; to this iiroup.* In Case 5()7() an interstitial myoma, 6 x 7.5 x 9 
 cm., was removed, antl portion.s of both ovaries were resected on account of an 
 ovaritm cyst. Two years hiter Dr. George Ben Johnston, of Richmond, found it 
 necessary to i-ciiiove the uterus and appendix. 
 
 In Case 5S4() a reference to tlie history shows that a myoma, 2 cm. in diameter, 
 was removed, and jx-lvic adliesions were reh-ased. Five years hiter hysterectomy 
 was done for pelvic adhesions. 
 
 The uterus in San. 1582 contained a myoma, 4 cm. in diameter; this and the 
 appendix wei-e removed. Later a hysterectomy was reijuired on account of 
 tlense ix'lvic adhesions, probably gonorrheal in origin. 
 
 Adhesions may be due to so many diffen^nt causes and are so freciuently 
 associated with myomata before o|)eration that it is difficult to attribute pelvic 
 adhesions to the myomectomy unless the adhesions are chiefly around the uter- 
 ine incisions from which the tumors have been enucleated, and even then, where 
 adhesions have once existed, there seems to be a marked tendency for them to 
 reform. 
 
 Gyn. No. 5076. 
 
 A b d o m i n a 1 m y o meet o m y w i t h s u 1) s c q u c n t h y s t e - 
 recto m y o n a c c o u n t of pelvic adhesions. 
 
 M. ('., white, married, aged forty-five. Admitted March 7; discharged 
 April 20, 1897. Ui)(Tation, March Sth, myomectomy ; cystectomy. An elliptic 
 incision, 6 cm. long, was made in the anterior wall of the uterus, and an interstitial 
 myoma, 6 x 7.5 x 9 cm., enucleated. A Graafian-follicle cyst of the right ovary 
 was dissected out. On February 21, 1907, w^e received the following letter from 
 the patient: "My health was not improved by my stay in the Johns Hopkins 
 Hospital. Two years later I went to Dr. Ben Johnston, of Richmond, who re- 
 moved the uterus and api)en(lix." 
 
 Gyn. Nos. 5846 and 10183. 
 
 A 1) d o m i n a 1 m }• o m e c t o ni y w i t h s u b sequent li y s t e r - 
 e c t o m y on a c c o u n t o f a d h e s i o n s . 
 
 1^. F. A., white, aged thirty-three, married. Admitted Fe])ruary 4; dis- 
 charged .March 4, 1898. Operation, February 5, 1898. Two small vaginal cysts 
 were removed, a subperitoneal myoma 2 cm. in diameter was enucleated, 
 pelvic adhesions were freed. an<l the uterus was suspended. 
 
 Gyn. No. 10183. For two years after leaving the hospital the patient was in 
 very good health, ])ut during the last three years there has been a gradual in- 
 crease in the menstrual discluirge. Now the jiatient is in bed most of the time. 
 She has a great deal of pain, especially in the left side. 
 
 * In Gyn. No. S220, after liberation of the adhesions, two small myomata were removed from 
 the uterus. Examination of the scrapings (Path. No. 440.3) showed tuberculosis. Four months 
 later the uterus was removed on account of the tulxTculosis. The hysterectomy was in no way 
 rendered necessary by the myomata.
 
 ABDOMINAL MYOMECTOMY. 561 
 
 January 14, 19Uo: Abcloniiiial In-.sterecloiny on account of somewhat dense 
 adhesions. 
 
 Hysterectomy on Account of the Development of Other Myomata. — The 
 following cases are of some interest, inasmuch as they not only show the num- 
 ber of myomata that may develop after a myomectomy, but also enable us to 
 determine with relative accuracy the rate of growth of some of the in}-(jmata. 
 
 Often during a myomectomy minute white specks are seen either on the sur- 
 face or in the musculature of the uterus. These are usually myomata, not 
 over 0.5 or 1 nmi. in diameter, and may be readily overlooked. 
 
 Fortunately, relatively few of our patients have required a secondai-y liyster- 
 ectom}'. 
 
 In Case 706 (also 1033 and S41o) a small subperitoneal myoma situated near 
 the cervix was removed in 1S91. Ten j^ears later the uterus was (everywhere 
 studded with small myomata and filled the pelvis. Hysterectoni}' was per- 
 formed. 
 
 In Case 4925 (also 9439) an interstitial nodule, 12 x 21 x 27 cm., was removed. 
 Fifty catgut sutures were necessary to close the resultant space. Five years 
 later the uterus seen in Fig. 331 (p. 562) was removed. 
 
 Case 7779 (also 12689) affords a very interesting example of the sub- 
 sequent development of large myomata. A subperitoneal myoma, 9 x 10 x 12 
 cm., and several smaller ones, were removed in 1900 (Fig. 332). A little less 
 than six years later the uterus was again enlarged, measured 12 x 13 x 16 cm., 
 and contained numerous myomata. These were subperitoneal, interstitial, 
 and subnuicous, the last of large size (Fig. 333 p. 564). Hysterectomy was 
 performed. 
 
 In Case 7886 a pedunculated myoma, aljout 7 cm. in diameter, and several 
 small interstitial nodules were removed in 1900. About six years later hyster- 
 ectomy was performed, chiefly on account of dense adhesions between the uterus 
 and surrounding structures. The uterus contained three small myonuita, the 
 largest 1 cm. in diameter. There was also some diffuse thickening of the inner 
 muscular layers of the uterus, with early adenomyoma. 
 
 The left ovary and a myoma were removed in Case 8936 in 1896. Five 
 years later hysterectomy was performed on account of dense i)elvic lesions and 
 interstitial and subiimcous myomata. 
 
 In U. P. I. Case (!., fiNc inlcrstilial iiiyoiiiala, the largest 5 cm. in diameter. 
 were removed. Seven and a h;df years later (C. H. 1. Case G.) tiie uterus was 
 densely adherent antl contained several myomata. Hysterectomy was per- 
 formed. 
 
 Judging from these cases only, one w'oukl doubt the wisdom of doing a myo- 
 mectomy, but the cases recpiiring a second o))ei\'ition foi'ni a small percentage 
 of the total number. 
 3G
 
 562 
 
 MVO.MATA OF THE UTERUS. 
 
 Case 706 (1033 and 8415). 
 
 A b d m i II a 1 111 y o 111 c c t o 111 y w i t li s u b s q 11 e n t h y s t c r o - 
 111 y o 111 c c t 111 y . 
 
 This patient entered the liosjutal on April 2S, bS<)l, when a (Ulatation and 
 curettage was done. She returned to the hospital (1033) oil October 2Sth of the 
 same year, when a cervical myoma. 2x 1.5 cm., was removed from the uterus 
 throup;h an abdominal incision. 
 
 Gyn. No. S415. A^ain admitted December 29, 1900. On vaginal examin- 
 ation the cervix was found to be normal in size and in good position. Numerous 
 nodules tilled the j)elvis. The uterus Inilged forward. ])ushing outward the an- 
 terior vaginal wall. .\ hysterectomy was done. The j)atient made a jjcrfectly 
 satisfactorv reco\-erv. 
 
 Fio. 331. — .-Vppearaxce of a Uterus Five Years after Removal df a I.akce Interstitial Myoma, if; nat. 
 
 size.) 
 Gyn. No. 9439. Path. No. .5640. Five years ago an interstitial myoma, 12 x 21 x 27 cm., was removed. 
 The appendages and the cervix are normal. The scar on the anterior surface of the uterus shows clearly some 
 of the transverse suture lines, and at the upper end of the scar is an oval area showing where the uterus was at- 
 tached to the anterior abdominal wall. The enlargement in the fundu.s is caused by several myomata, and pro- 
 jecting from the fundus, near the right tube, is a large myomatous nodule. See Fig. 60. p. 77. for the appearance 
 f)f the uterus at the first oi)eration. 
 
 Path. No. 4595. The sjx'ciinen consists of tiie uterus, which is aj)proximately 
 13 X 10 X 11 cm. Surrounding it on all .sides are myomata, se.ssile and })eduncu- 
 lated. It also contains interstitial and submucous nodules. 
 
 Gyn. Nos. 4925 and 9439. 
 
 ^I }• o in e c t o 111 y w i t li h }• s t e r o m }• o 111 e c t o m y five y e a r s 
 later (Fig. 331). 
 
 S.J. L., white, sinde, anoil fortv-thr(M'. .Xdmitteil Januarvfj; discharged
 
 ABDOMINAL MYOMECTOMY. 
 
 563 
 
 January 28, 1897. Oi)eration, January 9, 1897, niyoniectoniy. The uterus was 
 twisted to an ano;le of 90 degrees (Fig. 60, p. 77). It contained one myoma 
 12x21 X 27 cm., in the anterior wall. The resultant space was closed witli .')() 
 catgut sutures. 
 
 Gyn. No. 9439. The jjatient was readmitted March 3, 1902, and operated 
 upon on March 5th, a complete hysterectomy and appendectomy being per- 
 formed. As soon as the abdomen was opened the scar of the old myomectomy 
 was seen on the left anterior surface of the fundus (Fig. 331). The fundus itself 
 was greatly enlarged, especially to the right, and there was a rounded tumor 
 in the right cornu. The first glance at the specimen suggested a uniformly en- 
 larged bicornate uterus. The patient made a perfectly satisfactory recovery. 
 
 Path. No. 5640. The specimen consists of the entire uterus with the 
 appendages. Its general form is 
 seen in Fig. 331. 
 
 Gyn. Nos. 7779 and 12689. 
 
 A b d o m i n a 1 m }■ o m e c - 
 t o m y with h y s t e r o m y o - 
 m e c t o m y nearly s i x y e a r s 
 later (Figs. 332 and 333). 
 
 R. W., aged thirty-one, white, 
 single. Admitted April 30; dis- 
 charged May 26, 1900. Operation, 
 May 3, 1900, myomectomy. The 
 largest tumor was situated in the 
 posterior wall of the uterus, and 
 was very offensive, apparently under- 
 going degeneration. Several other 
 
 smaller myomata were removed peritoneal nodule projecting from the posterior i 
 
 tlie uterus measured 1) X 10 X 12 cm. ProjectiiiK 
 from various portions of the uterus fundus, and also from the anterior surface, are other 
 (Fig. 332). The l);lti("llt made an «'"'^" ""d"l«s. For the appearance of the uterus aU.ut 
 ^ " 1 SIX years later see r IR. m3- 
 
 uninterrupted recovery. 
 
 Path. No. 4038. The large myoma measures 9 x 10 x 12 cm. Its surface is 
 rough and shaggy, and on section presents an area of degeneration consisting 
 of a soft disintegraliiig mass. 
 
 Gyn. No. 12689. Readmitted February 10, 1906. The i)atient had some 
 discomfort for a year following the previous operation, but remained perfectly 
 well for four years. A few months ago she began to have pain in the iliac fossa 
 and in the hip, aching in character. ( )ne month ago the menstruation lasted 
 nearly thirty days. 
 
 Operation, panhysterectomy. The peritoneal surface of the uterus was 
 everywhere smooth. There was one small band of adhesions from the pelvic 
 wall to the region of the left ovary. On superhcial examination there were no 
 signs whatever of the previous operation. The patient made a perfect recovery. 
 
 Fig. 332. — Myom.\t.\ REiViovED by Abdo.minai. Myo- 
 mectomy. 
 Gyn. No. 7779. Path. No. 4038. The large sub- 
 surface of 
 from the
 
 564 
 
 MYOMATA (IF TIIK ("TKIU'S. 
 
 l\ith. No. OooS. The iitciiis is 1") ciii. in lentil li. \'.\ cm. in hi'cadth, and 112 cm. 
 in its anteropostci-ior diainoter (Fig. 333). Attaclicd to one \)o\u\ is a small 
 tag of omentum. Pi-ojectiiig from the posterior surface is a pedunculated 
 myoma. 2..') \ 1 .."> em. Tlie enlargement in the uterus is due chieHy to one large 
 and several smaller suhmucous myomata. The large myoma is 9 cm. across. 
 
 This case is particularly interesting, as it shows the possible developments in 
 the course of six years. 
 
 ut Cavity ^(((^•A\' 
 
 Fig. 333. — A Utekus .\noL t Six \'k.\k.s .Vi-tkh Audo.minal Kkmh\ al of all Mv().\l\ta that Could be Detecfed. 
 
 (| nat. size.) 
 Ciyn. No 126S9. Patli. No. 'Joi>!S. The uterus measures lo x 13 x 12 rni. The cliief increase in size is 
 caused by submucous myomata. The appendages are normaL For ihc appcar;ince of the uterus when myomec- 
 tomy was performed nearly six years before see Fig. 332. 
 
 Gyn. No. 7886. San. No. 2178. 
 
 A lid o m i n a 1 m y o m e c t o m y foil o \v e d six y e a r s 1 a t e r h y 
 h y s t e V o m y o m e c t o m y . 
 
 C. S., aged forty, white, married. Admitted June 0: discharged July 7, 
 1900. Operation, inulti])le myomectomy. .\ myoma 7 cm. in diameter was re- 
 moved from the ])osterior surface of the uterus, and several smaller scattered 
 ones were also enucleated. Com-alescence was complicated by ner\-ousness 
 of an extreme type. 
 
 San. No. 2178. The jjatient was readmitted on May 2, 190G. In addition
 
 ABuu.MixAL :myu.mkctumy. 565 
 
 to the myomatous uterus, there were marked adhesions around the left tube 
 and ovary and to the surrounding structures. The rectum and intestines were 
 slightly adherent on the right side. 
 
 Path. No. 9803. The uterus, both antei-ioi'Iy and posteriorly, is enveloped 
 in adhesions. It is very little increased in size, and contains three myomata, 
 the largest 1 cm. in diameter. The right tube is bound down to the uterus. Its 
 fimbriated end, however, is free. The ovary is Httle altered. The left tube 
 and ovary show few adhesions, but the fimbriated end of tiie tube is normal. 
 Microscopic examination in this case shows commencing adenomyomatous 
 formation in the body of the uterus. 
 
 Gyn. Nos. 8936 and 9203. 
 
 M y o m e c t o m y foil o \v e d b y a b d o m i n a 1 h y s t e r e c - 
 t o m y . 
 
 S. B., aged thirty-six, white. Admitted July 22, 1901. Five years before 
 the patient had been operated on for sterility, and at that time a myoma was 
 removed from the body of the uterus, and the left ovary also extirpated. The 
 patient on admission was extremely pale; the hemoglobin was 15 per cent. 
 She remained in the hospital for some time, and was sent home to recuperate. 
 
 She was readmitted on November 9, 1901, and discharged on December 7, 
 1901. Her hemoglobin had risen to 46 per cent. In the lower part of the 
 abdomen, on the left side, was a hard mass made up of two distinct nodules 
 that reached half-way to the umbilicus. This was very movable and tender. 
 Operation, November 11, 1901, hysteromyomectomy; removal of th(> right tube 
 and ovary; cure of ventral hernia. The sigmoid was densely adherent to the 
 posterior wall of the fundus. This was cut free by leaving the outer sheath of 
 the myoma and round ligament against the intestines. On the right side the 
 pus-tube and cystic ovary were gradually pulled out of their l)ed of adhesions. 
 The patient, on her discharge, had a hemoglobin of 75 per cent. 
 
 U. P. I., G., also C. H. I., G. 
 
 M y o m e c t o m y w i t li sub s e (j u e n t d e a' e 1 o )) ni e n t of 
 other m y o m a t a . 
 
 This patient was seen in consultation with Dr. Thomas bintliicuni. Sa\age. 
 Md., on February 19, iS'.IS. She was forty years old, and complained of |)i()fus(> 
 and frecjuent nuMistruation. < *n bel»ru;ny L'.'id a niyoinecidiiiy was ilone. The 
 uterus was the size of that of a three and one-hall' months" preunaiicy. noihilai", 
 and contained (i\-e interstitial myomata. which were I'diioNcd through three in- 
 cisions. The largest m\'oma was 5 cm. in iliametei'. ( )n .Mai'cli '_'."!. 1S9<I, the 
 uterus was only slightly enlai'ged and fi-eely mo\ai)le. 
 
 On Decembei' 11, 1902, the i)atient was admitted to the Church Home and
 
 566 MYOMATA OF THE UTKKUS. 
 
 Iiiliruiarv. On cxaininatioii we found a nodule, fully 10 em. in diameter, on 
 the left side. The adhesions were broken up and the uterus was removed. 
 The ])atient's health five years after the seeond o))eration was "tolerably <;ood." 
 
 Immediate Return to the Hospital on Account of Adhesions. 
 In Case 6760 a partially submucous myoma. 1.") cm. in diameter, was removed 
 per abdomen. The patient made a fair recovery, but two days after her discharge 
 returned to the hosi)ital. The al)domen w^as reopened and dense adhesions 
 were found between the ileum and fundus along the myomectomy hne. During 
 their liberation the ileum was torn. Hysterectomy was performed, but the 
 patient never reacted satisfactorily and soon died. Examination of the mucosa 
 showed a marked endometritis, and it is quite probable that the pelvic infection 
 was due to the wide opening up of the uterine cavity to permit the enucleation 
 of the myoma. 
 
 Gyn. Nos. 6760 and 7036. Path. Nos. 3052 and 3315. 
 
 Intestinal o I) s t r u c t i o n foil o w i n g shortly after 
 abdominal m y o m e c t o m y . 
 
 Mrs. L., admitted March 13, 1899. At this time abdominal myomectomy 
 was performctl and an interstitial myoma, encroaching upon the uterine cavity 
 and measuring about 15 cm. in diameter, removed. The jmtient improved fairly 
 i"ai)idly, and was discharged April 23d. Two days after leaving the hospital 
 she had a return of the uterine hemorrhage. There was constant oozing, and 
 the uterus was increased in size. At the second operation it was found that 
 the fundus was twice the normal size. The appendages were bound down and 
 the ileum was adherent to the fundus along the line of the former incision. During 
 the separation of these adhesions the ileum was ru|)tured. The sigmoid and rectum 
 were also densely adherent to the floor of the pelvis and the j)osterior surface of the 
 fundus. Complete hysterectomy was done, and the rent in the bowel sutured. 
 The patient died on July 6, 1899. 
 
 Path. No. 3315. Histologic examination of the mucosa shows a marked 
 endometritis. 
 
 Pregnancy Following Myomectomy. 
 
 Letters were sent to all patients upon wImhii an abdominal myomectomy had 
 been performed, in order to learn not only about their subse(iuent health. l)ut also 
 whether they had borne children after the operation. A large number of answers 
 were received. 
 
 After ruling out those that died immediately after operation, unmarried 
 patients, widows, women oxvv forty-hve, and those ]iatients ujion whom a sub-
 
 ABDChMIXAL MYUMICCTOMY. 567 
 
 sequent hysterectomy was ])erforine(l, we still have 04 patients in whom 
 pregnancy was possil)le. 
 
 As we all know, the menopause occurs early in some and late in others, con- 
 sequently we took a middle ground in assuming forty-five as the arbitrary age 
 at which the menses should cease; otherwise it would have been impossible to 
 obtain an even approximate basis for our calculation. The accompanying table 
 shows that 13 of the 94 patients have been pregnant — 12 proceeding to term, and 
 one miscarrying. In 8 of the cases there has l)een only one pregnancy, but in 
 Case 10257 two chiklren, and in Case 7109 three chiklren, were Ijorn. In Case 
 2042 the patient, who was single at the time of operation, is now the mother of 
 four. The patient in Case 4856 was single when operated upon. Over three 
 years later she became pregnant ; the labor was long and tedious, and finally 
 Cesarean section was performed, with delivery of twins. The patient died 
 apparently of shock. It will be noted that in this case susix'iision of tlie uterus 
 had been performed. 
 
 \Mien a long suture-line is left in the uterus after removal of a myoma, the 
 chance of omental, intestinal, and other adhesions is great; on the other hand, 
 if a suspension is done, the union with the anterior abdominal wall is liable to be 
 very firm. In either case there is considerable danger. After carefully weighing 
 the advantages and the disadvantages, we have decided that in those cases where 
 it has been impossible to draw the round or broad ligaments up over the suture- 
 line it is, as a rule, wiser to suspend the uterus after the myomectomy, provided the 
 suture-Hne is in the upper part of the fundus or situated anteriorly. If far down 
 posteriorly, the uterus is dropped back. True, there are numerous disadvantages 
 associated with the suspension, but when we remember that in the majority of 
 cases the i)atients do well, and further that, if mal{)osition of the pregnant 
 uterus should by chance exist, we can readily and i)romi)tly release it with 
 httle danger, we shall not hesitate to choose the lesser of the two dangers, and 
 suspend the uterus in suitable cases. 
 
 In the accompanying table the size and situation of the myomata are given. 
 Some of them were small and removed when the abdomen had been opened for 
 other causes. The majority of the tumors were interstitial. It is particularly 
 interesting to note that in Case 7159, in which a subnuicous myoma about 8 cm. in 
 diameter was present and the uterine cavity was widel>' ojx'ned. the patient 
 subse(iuently had three children. Of the 13 women that bccaiiH" picgnnnt sub- 
 sequent to operation, 7 had previously l)een pi-egnaut. 3 sterile, and 3 were 
 single at the time of opei'ation.
 
 568 
 
 MYOMATA OF THE UTKRUS. 
 CASES OF PREGNAxXCY AFTi:!! .M^'()^Il:(•T().MY. 
 
 No. 
 
 Nami.. 
 
 1260 
 
 H. 
 
 1489 
 
 W. 
 
 2042 
 
 K. 
 
 4856 
 
 |H. 
 
 
 |P. 
 
 Number of 
 Datk ok Opkration. Pregnanciks 
 
 BEFORK OpER- 
 
 5303 
 
 H. 
 
 30 March, 1892. 
 
 :i') 
 
 .luly. lSi)2. 
 June, 1S93. 
 
 One. 
 
 None. 
 
 28 December, ISlMi. 
 
 40 May, 1S97. 
 
 Single, since 
 married. 
 
 Siiiiile. since 
 iuarri(Ml. 
 
 Size of Myo.mata. 
 
 One myoma, 2 cm. 
 in (liam. (suspen- 
 sion of uterus). 
 
 One interstitial, 
 about (i cm. 
 
 Sul>j)eritoneal pe- 
 dunculated my- 
 oma, 16 cm. in 
 diameter. 
 
 Myoma, 4x8 cm. 
 (Uterus s u s - 
 l)ended). 
 
 Number of Children 
 SINX'E Operatio.n. 
 
 One. 
 
 Two. 
 
 5826 
 
 F. 
 
 34 
 
 7 1 .">9 
 
 ,s. 
 
 31 
 
 9243 
 
 N. 
 
 28 
 
 9329 
 
 F. 
 
 38 
 
 1()2.")7 
 
 B. 
 
 23 
 
 10179 
 
 W. 
 
 33 
 
 IIOOO 
 
 S. 
 
 30 
 
 San. 
 
 
 
 lo4.-) 
 
 H. 
 
 32 
 
 January. 1S9,S. Onemis.(?) 
 
 Septemi)er, 1S99. 
 November. 1901 . 
 
 .January, 1902. 
 
 Fel)ruary, 190;^. 
 Mav, 1903. 
 
 Three. 
 None. 
 
 Tliree. 
 
 Single; since 
 
 married. 
 Two. 
 
 January. H)04. None. 
 
 Marcli. 1903. 
 
 ( )ne. 
 
 Sul)j)eritoneal mj-- 
 oma, 3x5 cm. 
 (suspension of 
 uterus, repair of 
 perineum). 
 
 Two nodvdes, sub- One. 
 peritoneal and pe- 
 dunculated, 15 X 
 IS X 20 cm.; inter- 
 stitial, 2.5 X 3.5 X 
 5 cm. 
 
 Partly submucous. Three, 
 about 8 cm. Cav- 
 ity widely opened. 
 
 Two small intersti- One. 
 tial myomata (re- 
 lease of adhesions, 
 removal of right 
 tube and ovary). 
 
 Myoma, 4 cm., in One 
 right cornu (repair 
 of complete peri- 
 neal tear; su.spen- 
 sion of uterus). 
 
 Se\'eral small inter- Two 
 stitial myomata. 
 
 (a) Subnuicous my- One. 
 oma, 2 cm.; (b) 
 interstitial, 1 cm. 
 
 Three myomata: (a) One. 
 2 cm., (^)3 cm., (c) 
 4 cm. Remo\al of 
 left liydrosalpinx. 
 
 Interstitial, 5 x (5 x One. 
 7 cm. 
 
 One. 
 
 Four. 
 
 Died about four years 
 later in twin labor. 
 Cesarean section per- 
 formed in a distant 
 city after "a pro- 
 longed and exhaust- 
 ing labor." 
 
 One miscarriage, nine 
 years later. 
 
 Present Condition of Patients after an Abdominal Myomectomy. 
 Letters were scut out to all ])ati('nts, and from many rcplie.s were rccoivod. 
 Where no response was forthcominu- il,,. family jdiysician often kindly fiu'iiislied 
 the necessary data. Finally, in a ^ood many cases the |)ati('nts were visited 
 in their homes and their present condition was ascertained.
 
 ABDU.MIXAL .MYOMECTOMY. 569 
 
 Out of the 280 siiocossful cases, we have accurate (hita of tlie sul^sefjuent 
 history in 216. 
 
 137 patients are well at periods varying from a few months to sixteen years. 
 48 are in only fair condition. Some are suffering from pelvic trouble, but 
 
 the large majority from lesions remote from tlic pelvis. 
 13 reciuired sul)se(iuent operation for various troubles. 
 18 died chiefly from intercurrent affections. 
 
 216 
 
 Patients Remaining Well Years After an Abdominal 
 M y m e c t o m y . — We have endeavored to be as unbiased as possible in the 
 grouping of these cases. In a few of the cases in the following table the patients 
 were not absolutely well, but said that they were greatly benefited, and that their 
 general health had been much better since operation, or that the operation had 
 been the means of saving their lives. 
 
 Patients well 10 years after oiaeration 3 cases 
 
 " 15 " " " 2 " 
 
 " " 14 " " " 1 case 
 
 " 13 " " " 2 cases 
 
 II << 1 9 u a a 9 ii 
 
 " 11 " " " 3 " 
 
 " 10 " " " 16 " 
 
 " 9 " " " 9 " 
 
 " 8 " " " 11 " 
 
 " 7 " " " 7 " 
 
 " 6 " " " 19 " 
 
 " 5 " " " 10 " 
 
 tl U ^ << U (I J.^ u 
 
 " 3 " " " 18 " 
 
 " 2 " " " 6 " 
 
 1 year " " 14 " 
 
 " " less than a year after operation 1 case 
 
 137 cases 
 
 The reason that there are so few between the tenth and the sixteenth year is 
 because at that time hysterectomy was jx'rformcd much more frecpiently than 
 myomectomy. 
 
 Patients in F a i r (' o n d i t i o n .V f 1 c r a n A b d o m i n a 1 
 Myomectomy. — In this group we haxc indinh'd those i)atients that are 
 at present not well. 
 
 In Cases 9024 and 9329 there isa persistent cystitis; in Cases ■)9():). \)\:{). 11111, 
 excessive menstrual bleeding, and in ( ases ()773, I2()2S. and <". 11. !., I'etli., from 
 thcdata received, we would not be sui'])rised if the uteruscontained more myomata. 
 Thus in only 8 of 48 cases in which the patieiU i> not well is the trouble definitely 
 attributable to the peK'ic organs. ( )!' the iciuaining 10 jialieiits, in Case (1070
 
 570 MVO.MATA OF THK UTERUS. 
 
 there were syini^toins of some spinal lesion, and in Case 69o0 of asthma and em- 
 physema. In Case 7218 there was a renal lesion, and in Case 7872 a gastric ulcer. 
 The rest of the patients were either below {)ar or complained of indefinite symp- 
 toms. 
 
 Causes of Death in Patients Succumbing after Leaving the Hospital. 
 Eiw'hteen of the 21() jiaticnts concorniiiii- whom we ha^■o late records are dead. 
 
 Xo assigned cause (Cases 515, 1455,* and 7721) 3 cases 
 
 Typlioid fever, three years later (Case 9215) 1 case 
 
 Spinal meningitis, five months after operation (Case 4055) 1 " 
 
 Liver abscess, several j^ears later (Case 4160) 1 '' 
 
 Pneumonia. Ovaries removed in another hospital several months later. Died next year 
 
 of pneumonia (Case 7073) 1 " 
 
 Pulmonary tuberculosis, four years later suddenly (Case 1576) 
 
 eleven years later (Case 1821) 
 
 several years later (Case 1916) 
 
 five years later (Case 21S9) I 
 
 ten years later (Case 2500) l 
 
 two years later (Case 6145) J 
 
 Operation for release of adhesions (dense intestinal adhesions following shortly after 
 
 patient left hospital; ileum torn during operation (Case 6760) 1 case 
 
 Intussusception. Well after operation, sudden intussusception three years later (Case 
 
 8698) 1 " 
 
 Cesarean section for twins several years after abdominal myomectomy (Case 4856) 1 " 
 
 Obscure uterine lesions. "Died from uterine trouble" seven vears later (Case 1685). "i 
 Died apparently from some pelvic lesion six years later (Case 4814) / 
 
 18 cases 
 * Died suddenly eleven years after operation, aged sixty-four.
 
 CHAPTER XXX. 
 VAGINAL MYOMECTOMY. 
 
 In 84 of our cases vaginal myomectomy was performed. Tn several other 
 cases a submucous myoma was enucleated preparatory to an alxloniiiuil hyster- 
 ectomy. The latter cases are describetl elsewhere. 
 
 Age. — Submucous myoinata. in our experience, are most coniiiion during 
 the child-bearing period, as is indicated by the acconiiJanying tal)le. deaUng 
 with the age in SO of the cases: 
 
 Between 20 and 30 years of age 8 cases 
 
 " 30 and 40 " " " 29 " 
 
 40 and 50 " " " 32 " 
 
 " 50 and 55 " " " U " 
 
 80 cases 
 
 The youngest patient (Case 4382) was twenty years of age. Three years 
 previously she had borne a child. On admission, the uterus was found to be 
 soft and thin. Projecting from the cervical canal, and filling the upper part of 
 the vagina, was a sloughing mass, approximately 6 cm. in diameter. The ]iatient 
 made a good recovery. 
 
 Our oldest patient (Case 8159) was fifty-four years of age. A submucous 
 myoma, 6 cm. in diameter, was twisted off, and the ])atient was well six years 
 later. 
 
 Color. — In 83 cases we have data as to the color of \hc j)atient. ( )1" this 
 number, 64 were white and 19 colored. 
 
 Symptoms of Submucous Uterine Myomata. — The cliief symptoms are Ikmu- 
 orrhages and its sequences, and those (hie to ])ressui'e. 
 
 Vaginal Discharge. — If we bear in mind the \arious foi-ms of sub- 
 mucous myomata, the various positions of subnuicous noihiles. and the graihial 
 disintegration of tlie myomata, the character of the uterine (Hscharge will be 
 readily understood. 
 
 Profuse menstruation is, as a I'ule, the first sign of a submucous nodule; the 
 periods are also jn-olonged. Menorrhagia, as a rule, develops gi-adually, but. as 
 in Case 7050, may be co])ious fi-om the first. In some cases \hr liemon-hage iua\- 
 assume alarming propoi-tions, as in Case I'J.V.ll. in wiiicli llie patient estimated 
 a loss of from thi'ee to foui' pints. 4'lie How ina>- be ln-iglil red in coloi', dark, or 
 even brownish; when excessixc. it ni.ay be clotted, llie jiatient passing pieces of 
 tissue resembling liver. 
 
 In the majority of the cases bleeding is the most pi-ominent sym])tom; 
 
 571
 
 572 MYOMATA OF TIIK ITKRUS. 
 
 ii('\-('rth('l('ss, ill a few, this pliciiotiKiioii is cntii-cly wanting'. In Cases 10872 
 and 11010 no excessive flow was noted, and in Case 12257 the last period had 
 occurred forty-six days before the patient's admission. In Case 1489 the flow- 
 was scant. 
 
 L e u k () r r h c a . In several (\ases (2291, 5687, 9875, and 11243) the dis- 
 charge was l('ui<(irrh('al in cliaractei'. in some of the cases being very offen.sive. 
 
 P r () fuse \' (• 1 lo w i s h Disc h a r g e . — In ([uite a number of cases the 
 flow was yellowish in color, thick or thin, and most ()tTensi\-e. 
 
 W a 1 (• 1- y 1) i s (• h a r g e . — In Cases 7383 and 10872 the discharge was 
 watery in character, and in Case 11. ')0 it was watery and blood-tinged. 
 
 The h e in o r r h a g e nsuall\' indicates that a large area of uterine mucosa 
 has been put on tension by the submucous myoma which acts as a foreign body. 
 The offensive yellowish oi- wateiy discharge means that the tumor is undergoing 
 necrosis and disintegration. 41ie odor in some of these cases is so oft'ensive that 
 it takes hoiu's to remove it fi'om the hands. 
 
 With the loss of l)lood, secondary manifestations are noted. In Case 10370 
 the patient, on account of excessive hemorrhages, was compelled to remain in 
 bed ah the time. II(>r hemogloltin was only 30 per cent. 
 
 In Case 9()3S the loss of blood was so great that the ])atient's vision was 
 l)lurred and she was dizzy. Her hemogloljin was reduced to 21 per cent. 
 
 In Case 1 1SS9 the bleeding was severe, many clots being passed. Functional 
 heart iiiurmurs were heard, and the hemoglobin had fallen to 14 per cent. 
 
 Loss of Wei g h t . — When the patient has had a constant loss of blood 
 for years, there is likely to be a marked loss in weight, but when the symptoms, 
 although severe, are of short (Uu-ation, the patient may still be stout, although 
 suffering from anemia. 
 
 F e V e r and Chills. — When a sloughing submucous myoma is present, 
 it is but natural that ;d)sorption .should occasionally follow, with a subsecjuent 
 rise of temperature and acceleration of the pulse. We have .seen the tempera- 
 ture reach 100° F. 
 
 P r e s s u r e S y m p t o m s . — Submucous myomata must of neces.sity be 
 or become much smaller than tlie pelvic cavity, in order that exi)ulsi()n may 
 take i)lace through the vagina. Occasionally they reach the size of a "child's 
 head,'' as in Case 1317. In Case 4663 the myoma was 18 cm. long, but nuich 
 smaller in its other dimensions, ^^'hen pressure symptoms are present, they are 
 (hie either to large interstitial or siibj)eritoneal nodules, or to a large tumor mass 
 cau.sed by a multiplicity of smaller nodules. Pressure symptoms are fully de- 
 scril)ed on ]). 448. 
 
 Vaginal Myomectomy. 
 It is only necessary for us to remember that we are usually dealing with a 
 tumor partially or completely fllling the vagina, and attached somewhere in the
 
 V AGIX AL .M YU.MECTO.M Y . 
 
 573 
 
 uterine cavity })y a pedicle varyin<j from 1 to 3 cm. in diameter, to at once tliink 
 of the appropriate sm-^cal i)rocedure. The cases naturally fall into two main 
 groups. 
 
 1. Non-infected .sul)mucous myomata. 
 
 2. Infected and disinteiirating subnuicous myomata. 
 
 Non-infected Submucous Myomata. — If the vagina is large and the myoma of 
 moderate size, it is often possi])le to place a curved clamp on the pedicle, and at 
 once cut the myoma off. The pechcle is then \vliii)])ed over with two or more 
 
 Fig. 334. — A Large Submucous Myoma. 
 Gyn. No. 2873. The patient had lo.st a great 
 deal of blood, and for one week before admission 
 a submucous myoma had protruded from the 
 vulva. It measured 11x1.5 cm. The patient 
 was very pale, cacliectic, had a rapid and ex- 
 tremely weak pulse, and accelerated respiration, 
 but an operation afforded the only hope. Va- 
 ginal myomectomy was done, the pedicle beinK 
 -severed at the point indicated by the dotted 
 lines. The pulse soon rose to 172, and the tem- 
 perature to 102.9° F. She died within twelve 
 hours after the operation, apparently from 
 shock. 
 
 Fig. 335. — A Submucous Myoma Greatly Distending the 
 Vagina. 
 Gyn. No. 2593. The uterus contained a single myoma. 
 This had become submucous, and finally pedunculated. It had 
 been forced out of the uterus, and markedly di-stended the vagina. 
 The only way to remove such a tumor satisfactorily is to grasp 
 it firmly with me.soforceps and remove successive wedges until the 
 ina.ss is .so diminished in size that it can be delivered. The 
 pedicle then can be easily clainpeil, and the tumor removed. 
 The pedicle is then conl nillcd willi ciitgut sutures. 
 
 catgut sutures. When the niyoina is still largtM", it may he grasped wilh iiicso- 
 forceps and delivered, a finger in the rectum materially assisting in its expulsion, 
 or it may be po.ssihle to deliver the tumor with o1)stetric forceps as in Ca.st^ 3()()(). 
 In Case 2873 (Fig. 334) the large niyoina already protruded from the 
 vagina. 
 
 When the tumor is too large (Fig. 335) and the vagina relatively small, the 
 tumor may he seized with two nie.soforce]:)s and bisected to the pediele ( j-'ig. 33()). 
 If half of the tumor is now cut off, the other half will still serve to steady the ped-
 
 574 
 
 MVO.MATA OF THE UTERUS. 
 
 -Vaginal Uisectiox of a Sub- 
 mucous MVOMA. 
 The myoma is firmly grasped with meso- 
 forceps on either side, and cut in two, as 
 indicated by the arrow. Half is then re- 
 
 iclo and prevent it from slipping. After halt' 
 the pedicle has been sutured, the other half 
 of the tumor is removetl and the rest of the 
 pedicle sutured. 
 
 \\'hen bisection is not feasible, a wedge 
 of the myoma may be removed (Fig. 337). 
 If the tumor is still not sufficiently reduced in 
 size, successive wedges are taken out (Fig. 
 338) until it can be delivered and the pedicle 
 controlled with catgut. 
 
 In a virgin the vagina is often so small 
 that r(Miio\-al of the myoma by any of the 
 methods suggested is not feasil)le. In such 
 cases the perineum may be incised, as was 
 done in Cases 1610 and 1716. After the 
 necessary room has been obtained, the my- 
 oma is removed in the usual wa}'. 
 
 In Case 3066 the patient was a widow, 
 moved, and the corresponding half of the agctl tliirty-five aud had ucvcr bccu prcg- 
 
 pedicle controlled with catgut. The other " . x^ii i • i 
 
 half is then removed, and its vessels are con- UaUt. 1 hc VaglUa WaS hllcd With a Sul)- 
 
 trolled, the sutures already introduced mean- j^^^.^^^^ mvoma, 6 X 11 X 11 CUl. The 
 while serving as a tractor. 
 
 perineum on the right side was incisetl 
 down to the rectum and the tumor delivered with obstetric forceps. 
 
 When the myoma has not been completely expelled into the vagina or lies 
 partly in the cervical canal, it may be necessary 
 to s))lit the cervical lij)s both anteriorly and pos- 
 teriorly or laterally until the pedicle is reached. 
 The remainder of the o])eration is then relatively 
 easy. This method was employed in Cases 5242 
 and 5296. 
 
 Sometimes, notwithstanding the care used, the 
 l)edicl(> is so friable that the stitches will not hold 
 or it may slip through the artery forcej)s. It im- 
 mediately retracts, and its subse(iuent control is 
 impossible. In such cases, as a I'ule, it suffices to 
 pack the uterine cavity tightly with iodoform gauze, 
 which is remo\'ed after twenty-four oi' forty-eight 
 hours. 
 
 Occasional!}' the pedicle of the iiiyoma is at- 
 tached to the cei-\-ical lips instead of projecting 
 through the cervical canal. In such a case a 
 wedge-.shaped incision is made in the cervix, the 
 myoma withdrawn and the resultant space closed as indicated in Figs. 339 and 340. 
 
 Fic;. .337 — ^h^THOI> ok Rkmoving a 
 \khv Lauge Submucous Myoma 
 When the submucous myoma 
 greatly distends the vagina, as in 
 tliis case, a wedge may be removed, 
 as indicated by the dotted lines. If 
 the remaining portion is still too 
 large, succe.ssive segments are cut 
 away, as indicated in Fig. 33S.
 
 VAGIXAL MYOMKCTOMV. 
 
 575 
 
 Fig. 338. — Mkthod of Deliver- 
 ing A Very Large Scbmu- 
 COU.S Myoma. 
 
 Years ago it was the custom to remove suhmucous myomata ])y means of an 
 ecraseur, and then it was very important for the 
 operator to determine with absolute certainty whether 
 partial inversion of the uterus was present. Several 
 3' ears ago I saw a surgeon remove a su})nuu'()us my- 
 oma with the wire. To his great astonishment, after 
 removal of the tumor, he found, wdiere the pedicle 
 should have been, a hole fully 2.5 cm. in diameter, 
 communicating directly with the abdominal cavity. 
 The weight of the su1)nmc()us nodule, together with 
 the usual expulsive movenient. had occasioned pai'- 
 tial inversion of the uterus. He had removed fully 
 half of the fundus. Fortunately, no intestines had 
 dropped into the cup4ike depression, otherwise these 
 also would have been severed by the ecraseur. 
 
 With the abandonment of the wire and the cm- "^^^ *"'""'" '^ altogether too 
 
 large to be removed intact from 
 
 ployment of the simple method of operating imdcr the vagina, it is grasped with 
 
 • 1, 1 Ti.- Ill 11 1 forceps, and successive wedges are 
 
 Sight, such a complication could hardly be encoun- .amoved in the order indicated. 
 
 tered. ^'^ *^'^ ^^y ^^^ pedicle is finally 
 
 clearly exposed and controlled 
 
 In four of our cases (1610, 1^16,2873, and 7133) with catgut, 
 slight inversion of the uterus was noted at operation. 
 
 In some instances, as in (Aise 4967, in which a submucous myoma projected 
 
 from a large multinodular uterus, it may 
 be possible to do a vaginal myomectomy 
 and then immediate removal of the 
 uterus from above. 
 
 Removal of Infected and Disintegrat- 
 ing Submucous Myomata. — A reference 
 to p. 572 will show how foul a condition 
 of the vagina may be caused by infected 
 and disintegrating myomata, and it will 
 l)e readily seen that no nniount of j)re- 
 ])arat()rv cleansing will gi\'e the ojx'rator 
 a clean field for operation. He must ac- 
 cordingly opci'ntc ill such ;i way thai the 
 vagina or cciAix is in no way injured, 
 otherwise a serious general infection may 
 result. When 1 heiiiyomaisfirm, it may be 
 bisected and iciiioxed, or its size may he 
 materially reduced by lirst taking away 
 one or more wedges of tissue. Inder no 
 (■ir(MiMistanees, how-e\-er, should the peri- 
 lieiilii be incised or the celA'ix split. 
 
 Fig. 339. — Suture of the Cervix After Rkmovai. 
 OF A Submucous Myo.ma. 
 The pedicle of a submucous myoma is usually 
 attached high up in the cervical canal or in the uter- 
 ine cavity, but occasionally sijrings from the cervix. 
 In such cases it is removed as a wedge from the cer- 
 vix, and the resultant space closed with formalin and 
 plain catgut. If the incision has extended high iij) 
 laterally, care must he exercised not to pierce the 
 uterine arterv with tlie needle.
 
 •6 
 
 ]MYOMATA OF THK ITKRUS. 
 
 lii many cases a degenerated myoma resemhles a toiiiih piece of beef that 
 has lain in water for a longtime. Such tissue is very soft and boggy. It cannot, 
 however, be easily torn, but can l)e readily cut away with the scissors. When 
 the tissue is very friable, it can be brought away piecemeal with placental forceps. 
 Sometimes it is possible to control the stiunj) with catgut, l)ut when this will not 
 hold and when bleeding occui's. the thermocautery may be employed. After 
 
 removal of these myomata it is 
 well to give a vaginal douche of 
 bichlorid solution and to j^ack 
 lightly with iodoform gauze. 
 
 y 
 
 ^ r 
 
 Complications Occurring During 
 Vaginal Myomectomy. 
 
 1. rncoiitrollable hiiMMling 
 from the pedicle. 
 
 2. Rupture of the uterus. 
 Hemorrhage. — In Case 6604 the 
 
 patient was thirty-four years of age 
 and single. A wedge was removed 
 fiom the submucous myoma which 
 filled the vagina. Suddenly, the 
 tumor tore away from its pedicle 
 and was delivered. The pedicle 
 was far uj) in th(> cervical canal. 
 As there was steady l)leeding from 
 the uterus and as it was impossible 
 to draw the cervix down so that the 
 bleeding area could be exposed, the 
 uterine cavity was tightly packed 
 with gauze, but the bleeding still 
 continued. The abdomen was then opene<l, and l)oth of the uterine arteries were 
 tied. On the right side tliis ])ro(M'dui'e was didicult on account of dense adhe- 
 sions, which bound the tube and (A'ary and the uterus to the pelvic floor. The 
 patient eight years later wrote that .^he was in good health. 
 
 This case is anothei- st riking example of the necessity of always being prepared 
 to do an abdominal operation whenever any important vaginal work is under- 
 taken. We always make it a point to have the abdomen cleancnl in such cases 
 s(j that no delay will be necessary if its exploration should .suddenly be found 
 imperative. 
 
 Rupture of the Uterus. — In Case \)]'A7 the woman was forty-eight years of 
 age. The outlet was small, and a liai'd oval mass, (i x 10 cm., hlled the vagina. 
 The cervical canal was fully 1 cm. in diameter, and the pedicle could be felt 
 
 Fig. .340. — Appearance of the Cervix After Removai, 
 OF A Submucous Myoma that Had Been Attached 
 TO the Vagixal Portion ok the Cervix.
 
 VAGINAL MYOMECTUMY. 577 
 
 extending up into the uterine cavity. The tumor was partially bisected and 
 twisted off. A sound passed up into the cavity at the ]X)int of the pedicle went 
 directly into the abdominal cavity. A small gauze di'aiti was carried into the 
 uterus, but nothing further was done. The patient, in wi'iting five years later, 
 stated that she was well. 
 
 In such a case it would, of course, be much wiser to clamp and cut the pedicle 
 instead of twisting it off. 
 
 In this connection it may be interesting to mention Case 12323. The patient 
 was thirty-two years of age and com])lained of amenorrhea. Although th(^ ut- 
 most care was used in curettage, the instnunent suddenly ])assed into the abdom- 
 inal cavity. Anterior vaginal section was done, and a small perforation found 
 just on the edge of the subperitoneal myoma, not over 3 nun. in diameter. The 
 minute nodule was removed, and the rupture closed. The patient suff'ercd no 
 ill effects from the mishap. 
 
 Vaginal Myomectomy on a Patient Almost Moribund. Recovery. — The follow- 
 ing case demonstrates that even when the patient has ])n)found toxemia as a 
 result of a sloughing gangrenous myoma, she may rally if the tumor is removed. 
 Dr. Gerry R. Holden, of Jacksonville, Fla., who was resident gjmecologist at the 
 time, felt almost certain that the patient would succumb, but took the only 
 chance. The speedy recovery was little short of marvelous, and the patient 
 wrote, two years later, that her health was better than ever. 
 
 Gyn. No. 11889. Path. No. 8297. 
 
 L. V. G., colored, aged thirty-two, admitted February 13, 1905. She had had 
 one child, and no miscarriages. During the last year she had experienced a 
 great deal of pelvic pain at the menstrual period, and had had to remain in bed 
 frequently during the flow, which had been excessive. For the last three weeks 
 she had been in Ijed. Ten days before her ])h3'sician packed the uterus with 
 iodoform gauze, and gave ergot to control the hemorrhage. The patient be- 
 came very weak and anemic from the repeated hemorrhages, and had a high 
 fever and one severe chill. 
 
 On admission she seemed to be in an almost moribund condition. She was 
 markedly delirious, suffered great ])ain, and had a rectal temperature of 104.2° F. 
 The pulse was weak, irregulai', 140 to the minute, and could not be felt in the 
 right wrist. The respirations were 40, and a loud systolic murmur could be 
 heard at the apex and was transmitted to the midaxillary line. II(>r hemoglobin 
 was 14 per cent. She was stimulated at night, and in the morning the tempera- 
 ture was somewhat lower and the pulse better. ( )n alidDininal examination it 
 was found thai a I'oun ded tumor fille(l ihc |)el\is and extended as fai' as ilir um- 
 bilicus. Th(! abdomen was very sensiti\-e. ( >n \aginal examinalion llie cervix 
 was found to l)e dilated, the external os Ix'ing 1 cm. in diameter. I'l'ojecting 
 from the cervix was a nasty, grayish-while, neci'olic, submucous myoma. The 
 37
 
 578 MYOMATA OF THE UTERUS. 
 
 hand introduced within the cervix palpated a mj'onia which reached high into 
 the abdomen. 
 
 Operation under nitrous oxid anesthesia. The cervix was well exposed. 
 The tumor was seized with a heavy mesoforceps and an effort made to take it out 
 piecemeal. Over one-quarter of the tumor was gotten away in this manner. 
 The tissue was foul-smelling and necrotic. An iodoform gauze pack was in- 
 troduced into the uterus. The prognosis was exceedingly grave. Recovery was 
 slow, owing to thrombosis of the right femoral vein and also to nephritis. On her 
 discharge, one month and twenty-five days after o])eration, her hemoglobin was 
 60 per cent., her general condition good. She refused further operation. 
 
 Path. Xo. 8297. The largest piece of tissue was 2x6x9 cm. Even after the 
 specimen had been in alcohol for a year and a half the odor was most disgusting, 
 and sections showed that the tissue was necrotic. The surface was covered with 
 polymorphonuclear leukocytes, and in the blood-vessels were what appeared to 
 be myriads of micro-organisms. 
 
 January 9, 1907: We are just in receipt of a letter from the patient in which 
 she says : ''My health is better than ever. I am healthier than ever and stouter." 
 Of course, in this case a large portion of the submucous myoma is still in the 
 uterus. 
 
 Other Operations. — In the majority of our cases the vaginal myomectomy 
 was the only oi)eration performed. In Case 6855, however, after removal of 
 a submucous myoma, 3.5 x 4 x 8 cm., a vaginal cyst, 2x3 cm., was excised from 
 the left side and a tubo-ovarian abscess containing about 80 c.c. of non-fetid pus 
 evacuated. The pus from the pelvic abscess might very readily have infected 
 the wound from which the vaginal cyst had been removed. 
 
 In Case 10314 a submucous adenomyoma, approximately 7x7x11 cm., 
 was removed from a patient having a double vagina and a double cervix. The 
 vaginal septum was removed. This case is repoited at length in "Adenomyoma 
 of the Uterus," p. 161. 
 
 Complications Following Vaginal Operations for Uterine Myomata. 
 
 1. Elevation of temperature and pulse. 
 
 2. Phlebitis. 
 
 3. Erysipelas. 
 
 4. Delirium. 
 
 Elevation of Temperature and Pulse. — In 57 of our successful vaginal myo- 
 mectomies we have accurate data as to the postoperative temperature. From 
 the accompanying table it will be seen that 21 of the patients had a tempera- 
 ture of 101° F. or over, after the operation. It will be further noted that in 
 nearly all these cases the myoma removed was disintegrating and naturally, 
 therefore, was infected.
 
 VAGINAL MYOMECTOMY. 
 
 579 
 
 The highest temperature (105.5°) was noted in Case 4382. The patient had 
 suffered from fever and chills ])efore the operation. 
 
 The maximum temperature was usually present on the second or thii-(l day. 
 With the rise in temi)erature there was naturally a coincident rise in the pulse- 
 rate. 
 
 CASES OF VAGINAL MYOMECTOMY WITH A POSTOPERATIVE TExMPERATURE OF 
 
 OVER 101° F. 
 
 Case No. 
 
 Highest Temperature. 
 
 Day .\fter Operation. 
 
 Character of 
 
 .Myoma. 
 
 301 
 
 101.6° 
 
 Third. 
 
 Blackish red. 
 
 
 1317 
 
 104° 
 
 Third. 
 
 Strangidated. 
 
 
 1489 
 
 102.2° 
 
 Third. 
 
 
 
 1551 
 
 102.2° 
 (Restless, delirious.) 
 
 Third. 
 
 Sloughing. 
 
 
 1610 
 
 102.6° 
 
 Second. 
 
 Smooth. 
 
 
 1716 
 
 102° 
 
 Second. 
 
 
 
 4382 
 
 105.5° 
 
 Chills and fever before operation: 
 
 Temp, reached normal 29th day. 
 
 First. 
 
 Sloughing. 
 
 
 4794 
 
 101.9° 
 
 First. 
 
 Sloughing. 
 
 
 5296 
 
 102.6° 
 
 First. 
 
 Sloughing. 
 
 
 5496 
 
 103.6° 
 
 Third. 
 
 Sloughing. 
 
 
 5622 
 
 101.4°. 
 
 Sixteenth. 
 
 Smooth. 
 
 
 587 U 
 
 105° 
 
 Fifth. 
 
 Smooth. 
 
 
 6441 
 
 101.2° 
 
 Second. 
 
 Necrotic. 
 
 
 6604 
 
 101.2° 
 
 Second. 
 
 
 
 6833 
 
 102° 
 
 Fifth. 
 
 Sloughing. 
 
 
 7050 
 
 102° 
 
 First. 
 
 Sloughing. 
 
 
 10376 
 
 101.8° 
 
 Second. 
 
 Sloughing. 
 
 
 10618 
 
 105° 
 
 Second. 
 
 Sloughing. 
 
 
 10635 
 
 102° 
 
 Second . 
 
 Smooth. 
 
 
 12257 
 
 102.2° 
 
 Third. 
 
 Sloughing. 
 
 
 13014 
 
 101.4° 
 
 First. 
 
 Sloughing. 
 
 
 Phlebitis. — In Case 10314, after removal of a submucous adenomyoma, the 
 patient developed a phlebitis in the left leg on the twenty-first day. Her highest 
 temperature was 100° F. Tt is interesting to note that in none of the 21 cases 
 in which the postoperative temperature exceeded 101° F., did ])hlebitis develop. 
 
 In Case 11889 the patient entered the hospital with a large sloughing sul)- 
 mucous myoma. Her hemogio])in was only 14 per cent. Despite the fact that 
 she was almost moribund, vaginal myomectomy was undertaken and she made 
 a good recovery. The case is re])ort(Hl in detail on \). 577. I )uring convalescence 
 she had thrombosis of the i-ight femoral vein, and also of the superlicial veins of 
 the neck. 
 
 Erysipelas. — In Case 12079 the patient, forty-six years of age. had a sloughing 
 submucous myoma. \'aginal myomectomy was jierformed, and the uterus was 
 dilated and curetted. ( )n the eighth da>' foll(t\\ing the second anesthesia there 
 was a sudden rise of tempei'ature, and erysipelas develoiieij ;ii the jxiiiit at which 
 a subcutaneous infusion had been given. 
 
 The pathologic report (8655) showed that the surface of the myoma was 
 composed of typical gramilation tissue, and lh;it many of the blood-ve.ssels were
 
 580 MYOMATA OF THE UTERUS. 
 
 filled with organisms. It is possible that the infection canic from the uterine 
 tumor. The patient, however, had had an attack of erysipelas four years before 
 her operation, at a time when no uterine tumor had been detected. 
 
 Delirium. — In Case 1551 the patient, aged forty-seven, white, gave a history 
 of a vaginal myomectomy foui- years before admission. On examination a myo- 
 matous uterus was found filling the i)elvis and extending almost to the umbilicus. 
 A very offensive gangrenous mass filled the vagina. The ))atient was noisy, 
 restless, and had a ra])id jnilse on admission. As nuich as p()ssil)]e of the slough- 
 ing myoma was removed, and an iodoform pack introduced. After operation 
 the patient was still restless, delirious, and noisy at times. The maxinmm tem- 
 perature was 102.2° F., on the third day. Twelve days later more of the sub- 
 mucous myoma had been forced into the vagina, and this was twisted off. With 
 the removal of the sul)nuicous nodule the jwtient si)eedily I'ecovered, although 
 the uterus contained other myomata. The restlessness, delirium, and tempera- 
 ture were undoubtedly due to .'^e))tic absorption from the sloughing submucous 
 mvoma. 
 
 Immediate Death Following Vaginal Myomectomy. 
 
 In 84 cases submucous myomata were removed through the vagina; 79 
 patients recovered and 5 died. 
 
 On referring to the history of Case 1441 it will be seen that the operation was 
 a simple one, and that, under ordinary circumstances, we should have expected 
 recovery. The woman died in a state of profound asthenia on the thirteenth 
 day. We are not clear as to the cause of death, but infection may possiljly have 
 been spread from a primary focus in the myoma. 
 
 In Case 2873 the woman was in a desperate condition on admission, not only 
 on account of the great loss of blood, but also from septic absorption. Operative 
 interference offered the only possible chance of relief. Although the operation 
 itself was a simple one, she died in profound shock twelve liours later. 
 
 In Case 3426 the condition was a most complicated one. Not only was there 
 infection in the vagina, but an ovarian abscess was also present. It is little 
 wonder that the patient died of general ])entonitis. With our present knowledge 
 of these cases we never do an exploratory abdominal operation when a sloughing 
 siibnmcous myoma is present. The necrotic submucous growth is removed 
 through the vagina. After several weeks, when the vaginal discharge has ceased 
 and when the dangers of infection are greatly reduced, an abdominal hysterec- 
 tomy is done if necessary. In the case under discussion any o])erative measure 
 would have been accompanied ])y the greatest danger. 
 
 In Case 3508 death occurred six weeks after operation. The })atient, on 
 admission, was nuich mn down, and recently had been vomiting. The operation 
 was not responsible for her death, but failed to tide her over, her vitality having 
 become too low.
 
 VAGIXAL MYOMECTOMY. 581 
 
 The history of Case 6185 reveals the desperate condition of the patient on 
 admission. She had a moderate fever, a rapid pulse, and a foul, slougliing, 
 brownish-green, myomatous mass projecting down beneath the thighs. There 
 is little wonder that she succumbed on the fourth day. 
 
 In this case it might have been wiser to leave the clamps attached to the pedi- 
 cle instead of attempting to suture the stump. 
 
 Gyn. No. 1441. 
 
 "\^ a g i n a 1 m y m e c t m y . Death. 
 
 S. L., white, married thirty-two years. Admitted June 20; died July 3, 
 1892. Operation, June 21, 1892; removal of a suljmucous myoma by mor- 
 cellation. The uterus was packed ^\ith gauze to control hemorrhage. After 
 the operation the patient had a considerable quantity of seropurulent discharge, 
 interspersed \\itli a few hemorrhages of small amount. Toward the end there 
 were vomiting and periods of extreme restlessness, usually followed by uncon- 
 sciousness and feebleness of the pulse and respiration. The patient died in a 
 state of profound asthenia on the thirteenth da3\ Her temperature reached 
 102.8° F. on the third day, but was below 99.5° F. after the ninth day. 
 
 Gyn. No. 2873. 
 Vaginal myomectomy. Death. 
 C. D., aged forty-nine, white, married. Admitted June 23; died June 23, 
 
 1894. The patient, on admission, gave a history of having had a submucous 
 myoma removed a week before admission. She had lost a great deal of l^lood 
 recently, and was very cachectic and weak. On admission she was found to be 
 poorly nourished and very j)ale; she had a rapid and extremely weak pulse and 
 a rapid respiration. A large myomatous tumor, 11 x 15 cm., projected from the 
 vulva. It was attached by a pedicle 4x5 cm., and the uterus was partly in- 
 verted. Vaginal myomectomy was done, and a second nodule, 2x3 cm., was 
 removed from \nthin the cervix. Thirty catgut ligatures were rccjuircd to con- 
 trol the oozing. The cavity of the uterus was packed with gauz(\ The patient 's 
 pulse rapidly rose to 172, her temperature to 102.9° F., and she died within 
 twelve hours after operation in a ('()n(Hti()n of markc^d shock. 
 
 Gyn. No. 3426. 
 Vaginal m y m e c t o m y f o r a si o u g h i n g s u b m u c o u s 
 myoma. Death from general p c i- i t o n i t i s . 
 
 A. S., single, aged forty-five, colored. Ailmil tctl April 7; died April 17. 
 
 1895. For the ])ast year the menses have been less regular and scant. Her lasi 
 ])eriod comnuMiced four weeks ago, and the (low since then has been contimious. 
 Twelve years ago the patient noticed a small lump in tlu^ right side. This has 
 grown gradually larger. Four weeks ago she began to ha\'e severe pain accom- 
 panying the coi)ious discharge.
 
 582 MYOMATA OF THK UTERUS. 
 
 Operation, April 11, 1895, exploratory celiotoiiiy; inyoiiiectoniy through the 
 vagina. AVhen the abdomen was opened, a large myomatous uterus was found 
 densely atlherent to the pelvic floor. The abdomen was at once closed. The 
 cervix was distended by a sloughing submucous myoma, which had been partly 
 expelled thi'ough the vagina and was removed as far as |)ossible with the ecraseur 
 and curet; the uterus was then i)acked. 
 
 The ))atient develo])ed signs of general peritonitis — constant abdominal pain, 
 nausea, and xoniiting. The temperature gradually rose to 103.7° F. on the sixth 
 day, falling suddenly to normal just before her death on the sevcMith day. 
 
 Aut. No. ()5o. Anatomic (Hagnosis: Sloughing uterine myoma, infection 
 of the vagina, cavity of the uterus and Fallopian tubes. The right ovary was the 
 seat of an ovarian abscess, and there was wide-spread fil)rinopurulent i)ei'itonitis. 
 Both ureters were dilated. At autopsy cultures yielded Streptococcus from 
 the peritoneal cavity and also from the vagina. 
 
 Gyn. No. 3508. 
 
 A' a g i n a 1 m y o m e c t o m }- f o r a sloughing s u b m u c u s 
 m y o m a . Death six weeks 1 a t e r . 
 
 L. M., aged thirty-five, colored, married. Admitted ^lay 13; died July 
 30, 1895. For three weeks prior to admission the patient has had an offensive 
 bloody discharge containing shreds of broken-down tissue. Eighteen months 
 ago she first noticed an abdominal tumor. It has been gradually getting larger, 
 and for the two months there has been some abdominal })ain. Recently the 
 jiatient has been vomiting considerably. 
 
 Oi)eration, May 15, 1895. A sloughing sulmmcous myoma was removed, 
 and the uterus dilated, curetted, and washed out. The patient's highest tem- 
 perature was 103.2° F., on the third day. She gradually grew weaker and died 
 six weeks after operation. 
 
 Gyn. No. 6185. Path. No. 2441. 
 
 Removal of a G a n g r e n o us Sub m u c o u s ^l y o m a (Fig. 
 341). Death. 
 
 A. W., aged fifty-four, colored, married. Admitted June 21 ; died June 25, 
 1898. The patient was admitted as an emergency case. Between the thighs 
 was a large ovoid tumor, dark brownish-green in color. This was covered with 
 a bloody, foul-smelling discharge, and measured 8 x 15 cm. It projected from 
 the cervix, the jx-diclc being 2.5 cm. in diameter. 
 
 Operation, June 22, 1898. It was impossijjle to clean the vagina thoroughly. 
 The pedicle of the tumor was clampetl, and the sloughing growth removed. 
 Several sutures were passed through the cervix to stop the oozing, as it was 
 impos.sible to satisfactorily control the pedicle. A smaller myoma was also 
 grasped with mesoforeeps and twisted off. The uterine cavity was then tightly 
 packed with iodoform gauze. The uterus itself after removal of the tumor
 
 VAGINAL MYOMECTOMY. 
 
 583 
 
 Mt 
 
 W^: 
 
 '^^^ 
 
 was about 11 cm. in diameter. The patient did not do well after operation. 
 Her temperature on admission was 99° F. ; after tlie operation it rose to 101.8° F. ; 
 on the second day it dr()i)ped to 99.5° F.; on the third day it rose to 103° F., 
 and on the fourth day it reached 106.2° F. shortly before death. The pulse on 
 her admission was 115; shortly before death it rose to 158. 
 
 Path. No. 2441. The specimen consists of a pear-shaped submucous nodule, 
 approximately 7 x 12 cm. Its surface is slightly roughened, and on section it 
 presents the typical myomatous appearance. Sections from the surface of the 
 tumor show no trace of mucosa. The surface is covered with myriads of poly- 
 morphonuclear leukocytes and necrotic tissue. Beneath this is a very vascular 
 zone, composed of large 
 and small blood-vessels 
 (Fig. 341). So abundant 
 are the vessels that in 
 places they occupy half 
 the field. Some of these 
 vessels contain organizing 
 thrombi. The surround- 
 ing stroma shows a con- 
 siderable amount of hem- 
 orrhage, or is infiltrated 
 with many polymorpho- 
 nuclear leukocytes. The 
 tumor consists of non- 
 striped muscle-fibers cut 
 in various directions, and 
 presenting the characteris- 
 tic myomatous appear- 
 ance. In some places there 
 is hyaline degeneration, 
 with a gradual melting 
 away of the myoma, noth- 
 ing but a dchcate reticulum 
 being left. We are dealing 
 
 with an ordinary submucous myoma, tlic surfac(> of wliidi ha 
 and disintegrated. It is exceptional to find so many Mood-vi 
 They readily account for the free hemorrhage noted. 
 
 Aut. No. 1112. Anatomic diagnosis. (Jangrcnous sui)inu('ous myoma; 
 acute vegetative aortic and milral endocarditis; septic infarction of the left hmg: 
 acute locahzed pleurisy; old pleui'itic adliesions; ehi^Miic interstitial splenitis; 
 subacute glomerular nephritis; miliary abscess in the left kidney. Chronic 
 adhesive pelvic peritonitis. 
 
 In this case the weakened condition of the patient was cei-tainly caused by 
 
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 Fig 
 
 341. — A Vp:Ry Vascular Si.ou(;hing Submucous Myoma. 
 (X lOOdiam.) 
 Gyn. No. 6185. Path. No. 2441. The .surface of the myoma 
 consisted of necrotic tissue covered and infiltrated witli ijoiynior- 
 phonuclear leultoeytes. Beneath this was an exceedingly vascular 
 zone. As seen from the ))icture, nearly half the field is made up of 
 large and small markedly dilated veins. The muscular elements have 
 to a great extent disappeared, and the tissue is infiltrated with small 
 niund cells and fragmented niiiU'l. There has also been much hemor- 
 rhage into the tissue. 
 
 hecoiiie necrotic 
 els in ;i niN'om.a.
 
 584 MYOMATA OF THE UTERUS. 
 
 the profuse liciiiorrhages; the acute endocarditis and the niiUary abscesses can 
 Uke\A'ise easily be accounted for by infection from the foul sloughing and infected 
 myoma. The death can certainly be attributed to the submucous myoma in 
 this case. 
 
 A Fatal Case in which Vaginal Myomectomy was Impossible. 
 Gyn. No. 8804. 
 
 From the following history it is seen that the patient was suffering from a 
 most profound anemia and from absorption from a large sloughing myoma. 
 Vaginal myomectomy was impossible, and only a palliative operation was ven- 
 tured upon. 
 
 M. P., aged forty-five, white. Oi)eration, June 1, 1901 ; death on the same day. 
 This })aticnt had had frequent hemorrhages for three and one-half years before 
 her admission. On May 8, 1901, her last period began, and continued until her 
 admission to the hospital. She had grown very weak, and had been losing 
 ground. For the previous two weeks she had had symptoms of fever. She was 
 a very large, fleshy woman. Her lips and mucous membranes were markedly 
 blanched; the respirations were shallow, and she looked very ill. There was 
 a blowing systolic murmur at the apex. The hemoglobin was 20 per cent. On 
 palpation a rounded tumor was found filling the entire abdomen. The cir- 
 cumference of the abdomen measured 115 cm. On vaginal examination the out- 
 let was found greatly relaxed. There was a free bloody discharge. The cervix 
 was, in the normal position. The external os was greatly dilated. Palpation 
 through the external os revealed a necrotic mass near the anterior surface. Under 
 light anesthesia thorough curettage was done, and fully a liter of foul blood-clots 
 removed from the uterine cavity. The cavity was then irrigated with salt 
 solution and lightly packed. The patient was returned to the ward in fairly 
 good condition. Toward evening the pulse became irregular, the respirations 
 shallow, and she soon died. 
 
 Final Results after Vaginal Myomectomy. 
 Letters were sent out to all patients that recovered from the original operation, 
 and in 48 of the 79 cases we have data as to the subsequent history: 
 
 Suljseiiucnt hysterectomy necessary 2 cases 
 
 Subsequent operation, nature not known 1 case 
 
 Development of carcinoma of the body five years hiter 1 " 
 
 Recurrent fibroids 1 " 
 
 Deatli from intercurrent affection fourteen and fifteen years later 2 cases 
 
 Patients not well S " 
 
 Patif iits well at periods varying from a few months to fifteen years 33 " 
 
 48 cases 
 Subsequent pregnancy 2 cases
 
 VAGINAL MYOMECTOMY. 585 
 
 Hysterectomy Subsequent to Vaginal Myomectomy. — In Case 1317 the ])ationt 
 was thirty-tlircc years of age. On Apfil 11, 1S92, a blackish-red, strangulated 
 myoma, about 11 cm. in diameter, was found filling the vagina. This mass was so 
 friable that the greater portion was easily broken do\Mi with the finger. On the 
 third day the temperature reached 104° F., but she left the hospital after a month, 
 feeling well. 
 
 When the patient reentered the hospital eighteen months later (Gyn. Xo. 
 2183) the vagina was filled with a large, sloughing, offensive mass, which pro- 
 truded from the cervix. This was removed, and twenty days later the large 
 myomatous uterus, which extended as high as the umbilicus, was taken away 
 through an abdominal incision. The patient left the hospital very much 
 improved. 
 
 Fifteen years after the first operation she wrote: ''My health is very bad." 
 She was very weak and nervous, and often had attacks in which she fell. The 
 nervous phenomena, however, had been prominent l^efore her first admission 
 to the hospital. 
 
 In Case 9196 the patient was forty-seven years of age and entered the hospital 
 on November 5, 1900. Projecting from the cervical canal was a pedunculated, 
 smooth, submucous myoma. This was readil}^ removed, and with the curet a 
 large amount of mucosa was brought away. Recovery was without incident. 
 Several months later the patient entered a hospital in Staunton, Yii., and was 
 curetted on account of uterine hemorrhage. This gave relief for a few weeks. 
 She then returned to Baltimore and had her uterus removed. 
 
 Path. No. 6319 demonstrates clearly the cause of the persistent bleeding. 
 The uterus was the seat of a typical diffuse adenomyoma. The complete details 
 of the gross and histologic examination of the uterus are found in " Adenomyoma 
 of the Uterus." p. 99. 
 
 Other Operations Subsequent to Vaginal Myomectomy. — In Case 5133 the 
 patient was forty-eight years of age. She entered the hosi)ital on March 26. 1897. 
 Projecting from the cervical canal, and attached by a [H'dicle 1 cm. in diameter, 
 was a submucous myoma 3x5 cm. This was readily removed, and tlic patient 
 made a good recovery. In a letter from her ten years later siie said that she iiad 
 since had two other operations, ])ut further imiuiiy faih-d to elicit their nature. 
 Her general health was fair. 
 
 Vaginal Myomectomy ; Hysterectomy Five Years Later on Account of Adeno- 
 carcinoma of the Body of the Uterus. — Gyn. No. 3295. Aged forty-five. Fnteivd 
 the hospital on January 24, 1S95. The vagina was filled with a smooth, hard 
 conical mass. This was readily removed and the patient discharged on 
 February 23d. 
 
 Gyn. No. 7699. On April 4, 1900. a complele alxlominal hysterectomy 
 was done for adenocarcinoma of tlie body, wliich ai)pari'ntly had originated just 
 above the internal os. Situated near the right cornu was an interstitial myoma,
 
 586 
 
 MYOMATA OF THE UTERUS. 
 
 3 cm. in diameter. This case is reported in detail in the chapter on Adeno- 
 carcinoma of the Body of the Uterus, p. 280. 
 
 "Recurrent Fibroids." On p. 585 we mentioned Case 1317, in which, after 
 the removal of a large submucous mj'-oma, the patient reentered the hospital 
 eighteen months later and had a second suhiiiueous myoma excised. A few 
 weeks later hysterectomy was })erformed. 
 
 In Case 5496 the patient, aged forty, hrst entered the hosjiital on September 
 3, 1897. Filling the vagina was a large, cauliflower-shaped, sloughing and friable 
 submucous m^'oma. The removal of this was complicated by excessive hemor- 
 rhage. The patient rapidly gain(>d strength and left the hospital on September 
 30, 1897. On several subsecjuent occasions other submucous myomata were 
 removed. The case is described in detail in the chapter on iSarcoma (p. 252). 
 
 The patient wrote on January 9, 1907, more than nine years later, that her 
 general health was good, but that she had a constant uterine discharge. 
 
 Late Deaths Following Vaginal Myomectomy. — Two of the 48 patients con- 
 cerning whom the subseciuent history has been learned are dead. One (Case 909) 
 died fifteen years after operation, of some unknown cause. The other (Case 
 1551) died fourteen years after operation, of cerebral hemorrhage. Neither 
 of these deaths can be in any way attributed to the operation. 
 
 Patients Alive, but not well After Vaginal Myomectomy. — From the accom- 
 panying table it will be seen that S of the patients are not well, but in only 2 of 
 these (No. 12079 and San. No. 1593) is there evidence of pelvic disease. In 
 San. No. 1593 it looks verv much as if the uterus contained other mvomata. 
 
 No. 
 
 Years Since Oper- 
 ation. 
 
 Pelvic Disease. 
 
 Cause of Illness. 
 
 
 4663 
 
 Ten. 
 
 No. 
 
 
 
 5242 
 
 Ten. 
 
 No. 
 
 Pain in chest and knees. 
 
 
 8410 
 
 Six. 
 
 No. 
 
 
 
 10376 
 
 Four. 
 
 No. 
 
 
 
 10872 
 
 Three. 
 
 No. 
 
 Nervousness. 
 
 
 12079 
 
 One. 
 
 Yes. 
 
 Pain in left side of pelvis. 
 
 
 12591 
 
 One. 
 
 No. 
 
 
 
 San. 1593 
 
 Three. 
 
 Yes. 
 
 Still menstruating at fifty-four; 
 weak and dizzy. 
 
 IS 
 
 Patients Remaining Well After Vaginal Myomectomy. — Of the 48 patients 
 al)out whom we have been able to obtain the necessary data, 33 are well at 
 periods varying from six months to fifteen years. This demonstrates conclusively 
 that in many cases the uterus contains only one myoma, and that after its 
 removal the patient may have no further uterine trotible.
 
 VAGINAL MYOMECTOMY 
 
 587 
 
 TABLE OF VAGINAL MYOMECTOMIES— PATIENTS REMAINING WELL. 
 
 Case No. 
 1150 
 1489 
 1610 
 
 Years After 
 Operation-. 
 
 Fifteen. 
 Fifteen. 
 Fourteen. 
 
 1716 (Weight at operation 70 Fourteen. 
 
 pounds, now 160.) 
 
 2182 Thirteen. 
 
 2593 Thirteen. 
 
 2666 Thirteen. 
 
 4165 Eleven. 
 
 5296 . Ten. 
 
 5687 Nine. 
 
 6002 Nine. 
 
 614.3 Nine. 
 
 6441 
 6604 
 6833 
 6855 
 7010 
 8159 
 8517 
 
 Eight. 
 
 Eight. 
 
 Eight. 
 
 Eight. 
 
 Seven. 
 
 Six. 
 
 Six. 
 
 
 Years .Xfter 
 
 Case No. 
 
 
 QPERATIO.N'. 
 
 8600 
 
 
 Six. 
 
 8831 (Now a 
 
 myoma 
 
 Six. 
 
 1 cm. at 
 
 junction 
 
 
 of cervix and 
 
 
 body.) 
 
 
 
 9137 
 
 
 Five. 
 
 9875 
 
 
 Three. 
 
 10618 
 
 
 Four. 
 
 San. 1497 
 
 
 Three. 
 
 10635 
 
 
 Four. 
 
 11243 
 
 
 Three. 
 
 C.H.I. J. 
 
 
 Three. 
 
 C.H.I. 409 
 
 
 Two. 
 
 11889 (Almost 
 
 
 Two. 
 
 moribund.) 
 
 
 
 12257 
 
 
 One. 
 
 13014 
 
 
 One-half. 
 
 C.H.I. 1201 
 
 
 One-half. 
 
 Pregnancy Following Removal of a Submucous Myoma. — In two of our 48 
 patients pregnancy has occurred. One (Case 1489), aged thirty-live, was ad- 
 mitted on July 23, 1892. Her menses had been irregular, occurring at intervals 
 of from four to nine weeks. Six weeks previous to her admission she noticed 
 a tumor in the left ovarian region. This was not tender. l)ut apparently in- 
 creased rapidly in size. On vaginal examination a small submucous myoma 
 was found. The uterus was the seat of an early pregnancy. The myoma 
 was readily removed. On the third day the temperature readied 102.2° V.. l)ut 
 dropped to normal ])y the tenth day. The pregnancy was in no way inlerfei-ed 
 with. 
 
 The patient, wi'iting fifteen years later, state(l that her health was good, 
 and that she had been deliN'ered of the one child. The conception in this case, 
 or course, antedated tlie operation. 
 
 In Gyn. No. 6002 the patient was thirty-four years of age. She entei-ed the 
 hospital on April 5, 1898, complaining of a moi'e of less contimious bloody 
 vaginal discharge, which she had had U)V thi'ee years, '['he \agina was tilled 
 with a large, hard, firm, rounded mass, about 11 cm. in diameter. The uterus, 
 which was small, was })erched on the toj) of the mass. The tninor was remo\"ed 
 chiefly by morcellation and the piMhcie conlriilleij with catgut. l\ec()\-ei-_\- was 
 prompt, although the |)atient was anemic 
 
 Nine years later the |)atient wrote that she had had perfect health e\-er since. 
 She also said that since the operation she had had one child, and that the birth 
 was an easv one.
 
 CHAPTER XXXI. 
 ABDOMINAL HYSTEROMYOMECTOMY. 
 
 Local Applications as a Means of Checking Hemorrhage. — A few 3'ears ago it 
 was custoniary to apply astringents to the uterine mucosa, with, the idea of check- 
 ing the bleeding, \\lien the uterine cavity was small and 
 readily accessible, this doubtless had some temporary value, 
 but in the majority of the cases it is impossible to reach all 
 portions of the uterine cavity with any instrument, and then 
 there is always the danger of losing the cotton pledget of the 
 applicator, as in Fig. 342, or of setting up a pelvic inflamma- 
 tion. With the splendid technic as now perfected, operation 
 certainly gives the patient a much better prospect of recovery 
 than does any method of local treatment. When the uterus 
 is freely movable, the operative mortality is ver}- low. Where 
 pus-tubes are associated with myomata, local ai)j)lications are 
 contraindicated. 
 
 Electrical Treatment for Myoma Cases. — Our e.\i)erience in 
 this field has been practically nil. It is supposed that electric 
 applications check hemorrhage and in some instances diminish 
 the size of the tumor. A glance at the various hgures showing 
 the sizes and sliapes of the uterus and the distorted uterine 
 canals that are tluis so frequently found in myoma cases wiW 
 convince the reader that, even if electricity has a beneficial 
 effect, in many cases it would be impossible for the })hysician 
 to reach any appreciable i)ortion of the uterine cavit}- with 
 his instrument. 
 
 The following case that was under Apostoli's care for a 
 considerable period is of interest, l^lectricity certainly had 
 a temporary effect, but it \nll be noted that after cessation of 
 the treatment the bleeding recurred and he finally advised 
 hysterectomy. 
 
 Our examination of this uterus after removal showed little 
 or no alteration in the myomata, and tlic mucosa was i)racti- 
 call}' normal. 
 
 Fig. 342.— .\ Gacze 
 Swab Found in 
 THE Cavity of a 
 Myomatous Ute- 
 rus. (Nat. size.) 
 S.. C. H. I. De- 
 cember 15, 1906. .\t 
 operation we found a 
 foul, offensive uterine 
 discharge and an ir- 
 regular, greenish mass, 
 about 1.5 cm. in dia- 
 meter, lying free in the 
 uterine cavity. The 
 artist in sketching 
 the hardened specimen 
 chipped off the outer 
 layer and detected the 
 gauze network as seen 
 at a. At b the coagu- 
 lated blood is still 
 present. 
 
 The consultant 
 who had attempted 
 to check the uterine 
 hemorrhage had ap- 
 plied chromic acid to 
 the uterine mucosa, 
 and the pledget had 
 evidently dropped off 
 the probe. The foul 
 discharge greatly in- 
 creased the dangers of 
 the operation. 
 
 J. Path. No. 3674 
 
 J. J., seen December *), 180'.). In 188.3 the patient suffered 
 from a severe degree of prostration and had fever for sixty days. She had constant 
 
 588
 
 ABDOMINAL HYSTEROMYO.MKCTOMY. 
 
 589 
 
 alxloimnal pain aiitl i)rofuso monstruation. The bleeding shortly after this l)ecanie 
 excessive, and she had almost total loss of memory. Dr. Ajwstoli gave her electric 
 treatment, and she returned much improved. In 1SS7 she went back to Paris 
 for more electric treatment, and again experienced relief, but later, at Carlsbad, 
 she had profuse menstruation. This was again checked by electric treatment. 
 
 In 1891 Dr. Apostoli found her very ill, and did not expect her to recover. 
 In 1897 electric treatment was again started and tlie bleeding ceased during the 
 treatment, but recommenced and continued when the electricity was stopi)ed. 
 Apostoli advised operation, but the patient refused. When she camc^ under our 
 care the patient had constant headache and profuse hemorrhages, and liml l)een 
 in bed one week of each 
 month. The uterus was 
 removed by one of us 
 (Kelly) December 9, 1899, 
 and the patient recovered. 
 
 Path. No. 3674. The 
 specimen consists of a myo- 
 matous uterus, slightly ir- 
 regular in shape, measuring 
 10 X 10x13 cm. (Fig. 343). 
 The outer surface is smooth 
 and glistening, and some- 
 what roughened. Scat- 
 tered throughout the uter- 
 ine wall are numerous 
 myomata, the largest 7 
 cm. in diameter. 
 
 The uterine cavity is 
 approximately 10 cm. in 
 length, and in places, es- 
 pecially in the neighljor- 
 hood of the cervix, is almost 
 
 obliterated, as well as much distorted by the submucous nodules. To introduce 
 a stiff catheter or an instrument far u]) into such a uterine cavity would be 
 almost an impossibihty. The uterine nuicosa is smooth. Over the submucous 
 nodules it is as thin as ])archment, but where not subjected to pressure, reaches 
 2 or 3 nun. in thickness. None of the myomata gives any macroscoj-tic evidence 
 of disintegration. 
 
 Histologic Examination.— The uteiine mucosa pi'esenlsa wavy and tuuhilating 
 appearance, and has an intact surface epithelium. ( )\-er the prominent portion 
 of the submucous myomata the mucosa is thiiuied out and consists merely of a 
 narrow layer of stroma covered witii epillieiiiun. but dexoid of glands. In the 
 protected areas betw(>en nodules ilie mucosa is slightly tliickened; the glands 
 
 Fig. 343. — A Myomatous Utervs after Years ok Electric Treat- 
 ment. 
 
 Path. No. 3674. This patient was given intra-uferine electric treat- 
 ment by Apostoli in 1885 with relief, and again in 1887, 1891 . and 1897 
 respectively. Hysterectomy was performed iby Kelly) in 1899. 
 
 As seen from the history, the electric treatment temporarily checked 
 the bleedings, but they recurred. The uterus, on removal, was 10 x 10x13 
 cm. From the contour of the uterine cavity it is evident that no local 
 api)lications could possibly have reached all jiortions of the interior of 
 the uterus. It must be admitted that the growth was a slow one, as it 
 had been under observatinn fur fourlci'ii \cars.
 
 590 MYOIMATA OF THE UTERUS. 
 
 are numerous, convoluted, and in ])laces moderately increased in caliber. The 
 gland epithelium is intact, slightly swollen, but somewhat flattened. These en- 
 larged glands have little tufts of stroma projecting into their cavities, and these 
 tufts are also covered with epithelium. The picture is one of gland hypertrophy. 
 The stroma of the nmcosa is sparsely sprinkled with small round cells, and in 
 the superficial ])ortions there is some hemorrhage. The mucosa, taken as a whole, 
 is normal. The myoniata show a few areas of hyaline degeneration, but are other- 
 wise unaltered. 
 
 It will be seen from the foregoing that the electric treatment had caused no 
 I)ermanent alteration in either the mucosa or the myomata. Gland hypertrophy 
 is a common accompaniment of uterine myomata, and hyaline degeneration 
 of the tumor is invariably found. 
 
 Indications for Operative Interference. — Long experience has taught that 
 myomata, if let alone, may reach large proportions and give rise to pressure 
 symptoms, and that if they become submucous, alarming and occasionally 
 fatal hemorrhage may ensue. In some of our cases the subperitoneal or intra- 
 ligamentary myomata had suppurated and opened into the intestines or caused 
 a peritonitis. Submucous tumors occasionallj^ undergo disintegration that in 
 some instances leads to a fatal issue; hyaline and cystic changes have been 
 frequently noted. In over 1 per cent, of the cases sarcoma had either de- 
 veloped in or been associated with the myomatous growth, and in nearly 2 per 
 cent, of our cases, carcinoma of the body of the uterus in addition to the 
 myomata was found. 
 
 Judging from these findings, the surgeon would naturally infer that all 
 myomata should be removed. It must be remembered, however, that many 
 patients have small myomata that occasion no discomfort whatsoever, and are 
 detected only during the routine examination made when the woman is being 
 treated for .some intercurrent affection. 
 
 If a patient has a small myomatous uterus that is apparently ciuiescent 
 and occasioning no discomfort, it is wise to let well enough alone; but should 
 the periods be increasing in duration and be very free, submucous myomata are 
 probably present, and the advisability of a myomectomy or hysterectomy should 
 be carefully considered while the patient is still in good condition. Again, 
 whenever the tumor ajjjx'ars to be growing rapidly, it should be removed. The 
 presence of a myomatous uterus two or three times its natural size, when un- 
 accompanied by any discomfort, is no indication for operation. The patient 
 should, how^ever, be kept under observation, reporting to the physician at least 
 four times a year. 
 
 The Anesthetic— In nearly all our cases at the present time ether, preceded 
 by gas or ethyl chloride, is the anesthetic used, the ether being administered 
 by the drop method. Since doing away with the cone we have been surprised 
 at the marked diminution in the amount of postoperative vomiting.
 
 ABDO-AIIXAL HYSTEROMYOMECTOMY. 
 
 591 
 
 Occasionally when the patient has bronchitis or an old })k'urisy chloroform 
 is used. 
 
 In Case 11944 the abdomen was opened with the patient under t lie influence 
 of Schleich's solution, the incision extending from the ensiform to the pubes. 
 
 r 
 
 «> 
 
 Fig. 344. — The Myomatous Utkris riiioR to Kkmoval. 
 A liberal incision gives good exposure, facilitates the operation, and prevents the bruising of tissues that may 
 occur where very strong traction is necessary. Where it is advisable to remove the aijpendages with the tumor, 
 the round ligaments are first clamped and cut, and then the ovarian vessels are doubly clamped, as indicated, 
 and cut between the clamps The uterus can thon bo liftcil fartlicr u|i\vard, and tlic uterine vessels located 
 after the bladder has been pushed down.
 
 592 
 
 .MVOMATA OF THH UTERUS, 
 
 After the tumor was delivered, the patient eoiiiphiined bitterly of an indes- 
 cribable feeling of unrest and ainioyance, although there was no pain. The oper- 
 ation was conijileted untler general anesthesia. 
 
 In San. No. 2142 the patient had a mitral insuffieieney. The entire o})eration, 
 
 Fig. 345. — Amputatio.v Through the Cervix. 
 The left round ligament, the left ovarian vessels, and the left uterine vessels have been cut between clamps. 
 The right round ligament and the ovarian vessels have likewise been controlleil. The cervix is being drawn 
 strongly upward and to the right with mesoforceps, and is being severed. When the amputation is completed, 
 it will only be necessary to clami) the right uterine vesse s and the tumor can be removed.
 
 ABDU.MIXAL HYSTEROMYOMIXTO.M Y, 
 
 593 
 
 which histed an hour, ^vas pcrfoniiod with nitrous oxide gas as the anesthetic, 
 with thorough satisfaction. 
 
 Taking all in all, we have found ether the safest and most satisfactory anes- 
 thetic. 
 
 .'(An Eav 
 
 Fig. 346. — Tm: Api'i.akance of thk Pki.vis Wiikn vi.i. tiii; ("audiwi. Vksski.s havk bi:i:>J Clampkd and tiik 
 
 TU.MOK ReMOVKI). 
 
 The anterior lip of the cervix is gra.specl with Jacob's forceps, and the uterine ves.sels \vitl> Wcrtheini's'chinipN, 
 the ovarian vessels with Kocher-Ochsner clamps, and the round ligaments with curved artery forceps. For the 
 appearance of the tuiimr with its attached clamps see Fig. 347. 
 
 Supravaginal Hysterectomy and Panhysterectomy in Myoma Cases. — Con- 
 siderable diffcivncc of (.pinion exists as to whether supravaginal hysterectomy 
 or total removal of the uteinis should he cniM-iiMl out when niyoiii;ita exist. .Viter 
 38
 
 594 MYOMATA OF THE UTERUS. 
 
 carefully weighing the advantages and the disadvantages of each operation, we 
 have adoi)ted 8ui)ravagiiial hysterectomy as the usual procedure. 
 
 Su[)ravaginal aiiiinitation is the easier operation, especially in difficult cases, 
 where it is almost iin])()ssil)l(' to expose the cervix and the uterine vessels. In 
 this operation there is nuich less danger of injuring th(> ureters, and less tendency 
 to the production of cystitis. When a portion of the cervix is saved, the ends 
 of the round ligaments may be inserted into it, and a good buttress for the pelvic 
 contents is thus formed, which diminishes the tendency to prolapse of the pelvic 
 contents. Panhysterectomy is much safer whenever sarcomatous degeneration 
 of the uterus is suspected (p. 195) or when carcinoma of the body of the uterus 
 complicates uteiine myomata (p. 276).* 
 
 When, as in Case 8114, the cervix is so small that no stump can be left, com- 
 plete hysterectomy is not only a wise procedure, but the only possible one. In 
 other cases the cervix may be unfolded by a large submucous cervical myoma, 
 as in Case 9798 (Fig. 40, {). 57). Here it was necessary to completely remove 
 the uterus. 
 
 In some cases large subnuicous myomata filling the vagina distend it and lift 
 the uterus up. In such cases the vagina is easily opened up, and it is manifestly 
 simpler to do a complete hysterectomy. Cases 10995 and C. H. I., R. are good 
 examples of such a condition. 
 
 Taking all in all, and making due allowance for the possibility of occasionally 
 encountering sarcoma or carcinoma, we feel that supravaginal hysterectomy 
 is the better operation to adopt in the majority of the cases.f 
 
 Simple Abdominal Hysteromyomectomy with Preservation of the Tubes 
 
 AND Ovaries. 
 
 Where abdominal hysterectomy is deemed advisable in patients before the 
 menopause, and where the appendages are normal, it is our duty to save the 
 ovaries on both sides if possible. If the uterus is relatively movable, it may be 
 removed in one of two ways: 
 
 1. By first tying the cardinal vessels as they are encountered and then re- 
 moving the uterus. 
 
 * Inspection of the Uterine Cavity for Carcinomd and the Myomata for Sarcoma before Suturing 
 the Cervix. — We have elsewhere strongly emphasized the necessity for opening up the uterine 
 cavity just as soon as the tumor is removed, to exclude the presence of carcinoma of the body, 
 as it has been associated with myomata in 25 of our cases (see p. 277). 
 
 On p. 190 is described in detail a case in which we had amputated through the cervix and a 
 typical sarcoma was present in the myoma. Section of this myoma would have instantly demon- 
 strated the malignant growth. It was overlooked, and the patient, two years later, had an in- 
 operable growth in the cervix. Whenever a malignant growth is found, the cervix should be 
 excised at once. 
 
 t GVowp Operations. — On p. 526 we have coiisiden'd the various other operations that were 
 performed in addition to a myomectomy. In quite a number of our hysterectomy cases other 
 disorders required surgical interference. The necessarj' procedures were undertaken at the same 
 time, or. when the patient was too weak, after an interval of several weeks.
 
 ABr)( )MIXAL HYSTEROMYOMECTOMY. 
 
 595 
 
 2. By clamping ihc canlinal vessels as they are encountered, removing the 
 uterus, and then applying the ligatures. 
 
 Fig. 347. — The Uterus as it Ai'i>t:.\HS on JIemovai^ When all the Vessels have ueen Oontuolled with 
 
 Clamps and Cut. 
 
 The cervix is grasped with mesoforceps, the uterine vessels with Wertheini clamps, the round liKanients with 
 
 curved artery forceps, and the ovarian vessels with Kocher-Ochsner forceps. 
 
 Tying the Cardinal Vessels as They are Encountered and Then Removing the 
 Uterus. — The usual steps arc: 
 
 1. Tying the left round liiiaiiicnt nii the tlistal ami claiiipiii^ on ihe proxi- 
 mal side and severiii";.
 
 596 
 
 MVO.MATA OF THK UTERUS. 
 
 2. Ligating the left ovarian and tubal vessels on the pelvic side near the 
 uterus, clamping on the uterine side, and cutting between the clamps. 
 
 3. Separating the vesical peritoneal fold from the anterior surface of the 
 uterus, from the round ligament on the left to the round ligament on the right. 
 
 4. Separating the folds of the left l)road ligament until the left uterine 
 vessels are seen or felt. Ligating the uterine vessels on the pelvic side, clamping 
 on the uterine side. Severing the uterine vessels between the clamps and ligating. 
 
 5. Ligating and suturing the right round ligament. 
 
 6. Ligating the right ovarian and tubal ve-ssels near the uterine horn and 
 cuttiiiir th(> tube and ovarv from the uterine cornu. 
 
 Fig. 348. — Appkarance of the Pelvis after all the Cardinal Vessels have been Controlled. 
 The ovarian and uterine vessels on both sides have been tied, and the anterior and posterior lips of the 
 cervix are being approximated by a figure-of-8 suture of catgut, which has not yet been tied. The round 
 ligaments are temporarily clamped i)rior to their insertion into the cervical stump. 
 
 7. Separating the right broad ligament and exposing the uterine vessels, 
 ligating and then cutting these vessels. 
 
 8. Amputating through the cervix. 
 
 9. Closing the cervical flaps.* 
 
 10. The final toilet of the pelvis includes bringing the ends of the round 
 ligaments to the cervical stump and covering in the cervical stump with the 
 redundant vesical peritoneum, thus leaving a perfectly smooth pelvic cavity. 
 
 * The cervical flaps are nearly always brought together with catgut. In a few of the early 
 cases silver wire or silk was used. As a rule, the cervical stump is not over 3 or 4 cm. in diameter, 
 but in a small number of cases the raw area to be approximated may be very large.
 
 ABDOMINAL HYSTEIIOM YO.M i:( 'TOM V 
 
 597 
 
 By tying and sovorino; the left round ligament the broad ligament is at once 
 opened up, and the uterus ean be lifted still further out of the abdomen. The 
 "clear space" beneath the tubal vessels is well exjxjsed, and a ligature is at once 
 carried through it, the ovarian and tubal vessels being controlled a short dis- 
 tance from the uterine horn. In this ligature are included the inner end of the 
 tube and the utero-ovarian ligament, in addition to the vessels. The combined 
 mass is, however, relatively small. Some emijloy only catgut for this ligature, 
 but it is safer to use, for all cardinal vessels, a fine Pagenstecher reinforced by a 
 second consisting of catgut. Clamps are now applied to the uterine horn, and 
 the tube and ovary severed from their uterine attachment It is necessary to 
 have forceps that, when once applied, will remain //; s{(i( and not s])riiig off or 
 
 Ov. vess. V 
 
 Fig. 349. — Drawinc; thk Utkrixk Vessels into the C'ekvical Silmt. 
 The uterine and ovarian vessels on both sides have been ligated, and the round ligaments are controlled 
 with forceps. The left uterine vessels have been drawn over and included in the last cervical ligature on that 
 side. The right uterine vessels are being drawn over preparatory to including them in the last suture on the 
 right side. This method is frequently adopted, and offers ailditioiial security- against hemorrhage from the 
 uterine vessels. 
 
 slip. Ochsner's modification of Koehei-'s force))s answers this ret'iuirement 
 perfectly. 
 
 In opening up the left l)road Hgameiit only a scant amount of connective 
 tissue is encountered. This is rapidly snipped with the scissors, or can be readily 
 dissi])ated by gently sej)arating with the two index-fingers drawn away from 
 each other. If the posterior peritoneal layer of the broad ligament is cut down- 
 ward toward the cervix for ai»out half an inch, ihe ulerus can be bi'ought still 
 further upward, and the uterine \'essels are bellei' e\|)osed. During this dis- 
 section it is atlvantageous I ha! a lighl he placed on I he opposil e side of t he broatl 
 ligament, so that, if any impoitaiit si iiicluicsare in danger, they can be seen by the 
 transmitted light. \\ hen cutting the ])ostei'ior peritoneal llap, it is well to keep
 
 598 
 
 MVOMATA OF THE ITKRUS. 
 
 close to the uterus and not to cut too far down, as the ureter might be severed. 
 The left uterine artery with its accompanying veins is now exposed and can l)e 
 readily tied. A round curved needle is used. It is inserted close to the cervix, 
 so that the vessels are not punctured; in fact, it may pass through the outer 
 margin of the cervix. After both ligatures have been tied, a clamp is applied 
 about an inch above, and the vessels severed between the clamj) and the liga- 
 tures. 
 
 The steps on the opposite side are similar to these already described. 
 
 Prior to cutting across the cervix, the abdominal incision and the surrounding 
 pelvic contents are carefully walled off with gauze. The operator makes strong 
 traction on the uterus and cuts across the cervix with a knife, or preferably with 
 a Kelly spud (Fig. 345). As he does this, he cups out the cervix slightly or leaves 
 
 Fig. 350. — Insertion of thk End of the Round Ligament into the Cervical Stump. 
 The central part of the cervical stump has been approximated. On the right the round ligament has been 
 brought into the angle of the cervix. On the left, the suture which accomplishes this has been introduced, 
 but not drawn taut and tied. The remaining raw areas are then approximated, as shown in Fig. 352. The 
 stumps of the ovarian vessels are seen 
 
 a concave surface, so that it really forms the anterior and j)()sterior flaps, which 
 can be approximated. There should be very little bleeding, as all the main 
 vessels have already been controlled. The cervical stump is grasped with a 
 Jacob's forceps and drawn upward. If the remaining cervical mucosa shows 
 any signs of inflammation, it is advisable to dilate the cervical canal well, so that 
 there may be good drainage, or, still better, remove most of the cervical mucosa 
 with the uterus, as advocated by one of us (Kelly), and as sho^^^l in Figs. 
 353, 354. 
 
 The anterior and posterior surfaces of the cervical stump are now approxi- 
 mated with catgut. The last suture on the right and that on the left includes
 
 ABDO:\IIXAL H YSTEKOM VO.MECTOM Y. 
 
 599 
 
 the stump of the coiTospoiidino; uterine artery (Fig. 349), thus (lou])ly minimizing 
 the chance of secondary hemorrhage from these vessels. 
 
 The round ligaments are now, if of sufficient length, brought do\Mi and fastened 
 to each other and to the cervical stump (Figs. 350, 351, 352). The stumps 
 comprising the inner ends of the tubes and the utero-ovarian ligaments with the 
 vessels are covered over with broad ligament i)erit()neum, and the cervix is 
 
 A^ 
 
 ^^^^ 
 
 4-- 
 
 
 in 
 
 ^ 
 
 ^VM 
 
 Htm- 
 
 M^ 
 
 ■ H 
 
 ■L' w^H 
 
 
 
 W% 
 
 
 I^HB^^^^^^^^^ 
 
 
 
 
 
 ^ -^^^ 
 
 
 
 
 &t ...v..^-**- 
 
 
 .tfSaH^ 
 
 i^ii 
 
 
 Ik., ool. Al'PEARANCE OF THE FsLVIS AFTKR Sf HHWAUINAL H YSTKBKCTOM Y. 
 
 The cervical suture line is usually from left to rifcht, but here it has been in the anteroposterior direction 
 The ends of the round ligaments are brought together behind the cervix, to minimize the danger of prohipsus, 
 and the iimer ends of the ovaries have been apiiroxiinated. All raw areas have Ijeen controlled, so that there L* 
 little danger of postoperative intestinal adhcsi(nis. (For the usual methoil of closure sec I'ig. '.i^y'2.) 
 
 covered over with vesical ])erit()neum. Tn this final covering over of the areas 
 with peritoneum fine needles and line catgut arc necessary, on account of the 
 delicate character of the peritoni'uui, and care imisi be cxci-ciscd not to pierce 
 any artery with the iicc(llc-|)oiiit or to ])!-ick t lie ui-ctci- or iiicliidc it in one ot t lie 
 peritoneal flaps. 
 
 Prior to closing the cervix, the operator has, of course, re(iuested an assistant 
 to open the uterine cavity to exclude the possibility of c;nicer of the body. The
 
 600 
 
 :VIYOMATA OF THE UTERUS. 
 
 uterine myomata have also been examined to see if, ])ert'luince, a sarcomatous 
 degeneration can be found. If either early process should happen to be present, 
 the cervix should be removed at once. For a full discussion of this point see 
 p. 179. 
 
 The appendix is now examined and the abdomen closed. 
 
 Clamping of the Cardinal Vessels, Removal of the Uterus, and the Apphcation 
 of the Ligatures. — If the surgeon has had little experience in abdominal hysterec- 
 tomies, it is advisable to tie the vessels as he encounters them, l)ut one who is 
 
 Bladder-perit.covering 
 e e r V. stump 
 
 Biiried stump of ov. vess.- 
 
 Fig. 352. — Appearance of thk Pelvis after Insertion of the Round Ligament into the Cervical Stump. 
 The round ligaments have been brought into the angles of the cervix, as indicated in Fig. 350. The bladder 
 peritoneum is then drawn over the cer\-ix and snugly sutured to its posterior surface. The stump of the ovarian 
 vessels and the remaining raw areas are covered in with peritoneum by means of continuous sutures. 
 
 doing hysterectomies frccjuently can save much time by temporarily clamping 
 the vessels and tying them after the uterus has been removed. 
 
 Where clamps alone are used, it is absolutely necessary to employ those that 
 will not slip, otherwise alarming hemorrhage may result. Figs. 344, 345, 346 
 show the most satisfactory kinds of artery forceps. The various steps in the 
 operation are: 
 
 1. Clamping the left round ligament on the outer side and clamping on the 
 inner side, severing the round ligament and then opening up the left broad liga- 
 ment.
 
 ABDOMINAL HYSTKllU.MYO.MIXTU.MV, 
 
 GOl 
 
 2. Clamping:; the left ovarian and tnl)nl vessels near the uterus, separating 
 the tube and ovary from the uterus. 
 
 3. Opening uj) the left broad ligament and freeing tlie bladder from the 
 uterus. 
 
 4. Doubly clamping and cutting the left ulerine vessels. 
 
 5. Clamping and severing the right round ligament. 
 
 Fio. 353. — ExTENSivK Removal of the Cervical Mucosa where Supravaginal Hystkr^ci-omv is 1'krkorxied. 
 When the clinical findings strongly suggest an infection of the cervical mucosa, it is advisable to remove as 
 much of this as is feasible. The uterus is freed on all sides, and the cervix severed circularly almost to the mucosa. 
 The dissection is continued downward until most of the mucosa lining the canal has been freed, as indicate^!. Two 
 provisional sutures held in the directions of the arrows prevent retraction of the cervix. A clamp across the cervix 
 prevents any escape of the uterine contents. The uterus, which is held merely by the cervical mucosa, is liberateti 
 by means of the thermocautery. The operation is finished in the usual manner. One of us (Kelly) has been 
 using this method with much satisfaction for several years. 
 
 6. Clamping and se\'ei-iiig the i-jght tulie;iiid owiry fit»iii the uterus at the 
 cornu. 
 
 7. Spreading the right bi'oad hgaiiieiit and ehimpiiig the iitei'ine \"esse]s. 
 
 8. Amputating the uterus at the cervix. 
 
 9. Ligating the left ovarian, h'I't uterine, riglit utei'ine, and lighi (i\arian 
 vessels in the order mentioned. 
 
 10. Closing the cervical stump, luinging I he ends ol' the round hgaineiit into 
 the suture line if possible.
 
 602 
 
 -MVOMATA OF THH ITKKUS. 
 
 11. Covering over all raw areas with jjeriloiieiim. 
 
 It is always well to elaini) aiul cut the round ligaments at once, as cutting 
 them permits the operator to lift the uterus still further out of the alKlomen and, 
 furthermore, the clear space in the broad ligament is at once seen. One l)lade of 
 the artery forceps may be at once push(Ml through this, and the ovarian and tubal 
 vessels controlled. A clamp is now applied to the uterine cornu, and the uterus 
 is severed from its tubal and ovarian attachments. The bladder reflection is 
 now picked up and easily separated by sli])ping the scissor blade beneath the 
 itladdcr pei-itoneum. and severing it from left to right or the reverse. The peri- 
 
 M u <" s a 
 
 drawn/ 
 
 Fici. 3o4.— Extensive Removal of Cervical Mucosa. 
 Where there seems to be danger of infection from the cervical mucosa, the mucous membrane is sometimes dis- 
 sected out, in the manner indicated, and removed prior to closure of the cervical lijjs. 
 
 t(jneum is very thin and translucent, and if it cari'ies blood-vessels of any appreci- 
 able size, these are seen at once. 
 
 The left broad ligament is now widely opened, and the uterine vessels, after a 
 little blunt dissection, are readily seen or felt. They are now doubly clamped 
 with Wertheim parametrial forceps, and the vessels cut between the clamps 
 (Fig. 345). The structures on the right side are handled in the same order, and 
 the cervix can then be cut acro.ss with little or no hemorrhage. 
 
 The clamps cent nulling the vessels are now replaced by ligatures. For each 
 group of vessels we usually employ one Pagenstecher reinforced by one catgut 
 ligature. 
 
 Wherever there is the slightest danger of infection fr(jm the cervical canal, the 
 abdominal incision and the pelvic contents should be most carefully walled off 
 before the cervix is severed. The cervical flaps are now brought together, 
 and, where possible, the ends of the round ligaments sutured into the cervical
 
 ABDOMIXAL HYSTERDM Y( )M i:(T( ).M V 
 
 603 
 
 stump. All raw areas are now covered over with peritoneum, and after careful 
 sponging of the pelvis the abdomen is closed. 
 
 The Employment of the Round Ligaments in the 
 Suspension of the Cervical Stump . — In those cases in which the 
 cervix tended to sag down into the vagina, after bringing the cervical flaps to- 
 gether we have drawn the ends of the round ligaments down to the cervix and 
 sutured them there, as indicated in Figs. 350, 351, 352. The peritoneum has then 
 been sutured over the cervix. By this means the cervix has been held well up 
 in the vaginal vault. This method is similar to that advocated by other surgeons. 
 
 The Preservation of One or Both Ovaries in Cases of Hysteromyomectomy. — In 
 at least 125 of our cases one or both ovaries were saved. Tiial we might ascer- 
 tain the effect of such preservation upon the general health, letters were sent out 
 to these patients. Fifty-six (37 white and 19 colored) replied, giving fairly 
 complete answers. The chief object was to ascertain in what percentage of the 
 cases an artificial menopause had been avoided, special attention being paid to 
 the presence or absence of hot flushes. In order to absolutely exclude any al> 
 normally early appearance of the menopause we have included only those cases 
 in which the patients were not over forty-one years of age. A study of the 
 accompanying table will show the essential data obtained. 
 
 
 
 
 
 Hot Flushes. 
 
 
 
 Age at 
 Opera- 
 tion. 
 
 Present 
 Age. 
 
 48 
 
 
 
 
 Case No. 
 
 Present or 
 Absent. 
 
 Earliest Appearance 
 After Operation. 
 
 Duration. 
 
 Present 
 Health. 
 
 3340 
 
 36 
 
 Present . 
 
 Fourteen 
 
 Ft)ur years. 
 
 (lood. 
 
 
 
 
 
 months. 
 
 
 
 4635 
 
 37 
 
 48 
 
 " 
 
 Not mentioned. 
 
 Still persist. 
 
 \'ery good. 
 
 4832 
 
 28 
 
 39 
 
 ti 
 
 Several years. 
 
 Still persist 
 ( e \' e r y two 
 weeks). 
 
 \'ariable. 
 
 5239 
 
 39 
 
 49 
 
 " 
 
 A few months. 
 
 Still oreasionally 
 present . 
 
 I'^xeellent. 
 
 5277 
 
 31 
 
 41 
 
 It 
 
 
 
 (lOOtl. 
 
 5325 
 
 35 
 
 45 
 
 " 
 
 Several months. 
 
 Several months. 
 
 Poor. 
 
 6372 
 
 40 
 
 49 
 
 
 Eight years. 
 
 Oeeasionally pres- 
 ent. 
 
 ( lOod. 
 
 6972 
 
 38 
 
 4() 
 
 " 
 
 P'ive years. 
 
 One year. 
 
 Poor. 
 
 7696 
 
 30 
 
 ■M 
 
 Absent. 
 
 
 
 \ Cry gootl. 
 
 7703 
 
 29 
 
 •M\ 
 
 Present. 
 
 Two years. 
 
 Still occasioiiiilly 
 present . 
 
 \ ery good. 
 
 8306 
 
 36 
 
 42 
 
 Absent. 
 
 
 
 |-;.ir. 
 
 8705 
 
 39 
 
 45 
 
 " 
 
 
 
 \'ery good. 
 
 9029 
 
 38 
 
 44 
 
 Present . 
 
 Sniin alter. 
 
 Still persist. 
 
 (Jood. 
 
 9078 
 
 36 
 
 42 
 
 Absent. 
 
 
 
 Ciood exi('i)t for 
 ovarian |)ain 
 at period. 
 
 9286 
 
 37 
 
 43 
 
 li 
 
 
 
 I'.Tfe.-l. 
 
 9527 
 
 36 
 
 41 
 
 " 
 
 
 
 I''airlv i:ood. 
 
 9788 
 
 32 
 
 37 
 
 Present. 
 
 Iniinciliatcly al'- 
 Irr (i|>it:iI ion. 
 
 Six months. 
 
 Poor! 
 
 9818 
 
 40 
 
 45 
 
 Ab.senl. 
 
 
 
 (iood. 
 
 9843 
 
 29 
 
 34 
 
 " 
 
 
 
 ( lood. 
 
 9928 
 
 40 
 
 45 
 
 Present . 
 
 Six inoiit lis. 
 
 Ilirrc to lour 
 <l;.y>. 
 
 ( iood.
 
 604 
 
 MYOMATA OF THE UTERUS. 
 
 
 .\gk .\t 
 
 
 Hot Flcshes. 
 
 
 Case No. 
 
 Opkr.\- 
 
 Present 
 
 
 
 
 Present 
 He.\lth. 
 
 
 TION. 
 
 Age. 
 
 Present or 
 
 Earliest Appearance 
 
 Duration. 
 
 
 38 
 
 42 
 
 Absent. 
 
 After Operation. 
 
 
 10357 
 
 Prp.sent . 
 
 F'oiir years. 
 
 Still persist. 
 
 Good. 
 
 10453 
 
 36 
 
 40 
 
 Absent . 
 
 
 
 Good. 
 
 10558 
 
 38 
 
 42 
 
 Present . 
 
 A few weeks. 
 
 Still persist. 
 
 Fair. 
 
 10580 
 
 27 
 
 31 
 
 Absent. 
 
 
 
 (iood. 
 
 l()(i<>7 
 
 3S 
 
 42 
 
 " 
 
 
 
 Poor. 
 
 hjk; 
 
 • )- 
 
 .SO 
 
 Pre.sent. 
 
 Two months. 
 
 Still persist. 
 
 Poor. 
 
 11217 
 
 41 
 
 44 
 
 Ab.sent. 
 
 
 
 Very good. 
 
 11392 
 
 34 
 
 37 
 
 Present . 
 
 Three weeks. 
 
 Still persist. 
 
 Poor. 
 
 1 1472 
 
 3S 
 
 41 
 
 
 One year. 
 
 Still oceasionally 
 present. 
 
 Good. 
 
 11681 
 
 33 
 
 36 
 
 Ab.sent. 
 
 
 
 Fairly good. 
 
 11688 
 
 39 
 
 42 
 
 Present. 
 
 Two montlis. 
 
 Still occasionally 
 present. 
 
 Good. 
 
 11722 
 
 33 
 
 36 
 
 Absent . 
 
 
 
 Fairly good. 
 
 11984 
 
 41 
 
 43 
 
 '' 
 
 
 
 \'ery good. 
 
 12086 
 
 37 
 
 38 
 
 '' 
 
 
 
 Ciood. 
 
 12185 
 
 38 
 
 40 
 
 " 
 
 
 
 (lOOtl. 
 
 12301 
 
 24 
 
 26 
 
 Present. 
 
 Not mentioned. 
 
 Not mentioned. 
 
 Fair. 
 
 12369 
 
 27 
 
 29 
 
 Absent . 
 
 
 
 Good. 
 
 12488 
 
 41 
 
 43 
 
 Pre.sent. 
 
 One montli. 
 
 Four months. 
 
 Perfect. 
 
 12522 
 
 34 
 
 36 
 
 
 Sixteen months. 
 
 Still occasionally 
 present . 
 
 Fair. 
 
 12525 
 
 28 
 
 30 
 
 " 
 
 One month. 
 
 Still persist. 
 
 Good. 
 
 12696 
 
 28 
 
 30 
 
 Ab.sent. 
 
 
 
 Ciood. 
 
 12764 
 
 24 
 
 25 
 
 
 
 
 Gootl. 
 
 12937 
 
 41 
 
 42 
 
 " 
 
 
 
 (iood. 
 
 12944 
 
 43 
 
 44 
 
 Present . 
 
 .\ few weeks. 
 
 Still persist. 
 
 Ciood. 
 
 13039 
 
 27 
 
 28 
 
 " 
 
 Six months. 
 
 Still persist. 
 
 Fair. 
 
 C. H. I., 
 
 
 
 
 
 
 
 382 
 
 37 
 
 40 
 
 u 
 
 Three mf)nths. 
 
 Four months. 
 
 Good. 
 
 C. H. I., 
 
 
 
 
 
 
 
 392 
 
 32 
 
 35 
 
 Ab.-<ent. 
 
 
 
 Good. 
 
 C. H. I., 
 
 
 
 
 
 
 
 620 
 
 35 
 
 37 
 
 " 
 
 
 
 Perfect . 
 
 C. H. I.. 
 
 
 
 
 
 
 
 673 
 
 36 
 
 38 
 
 Present. 
 
 One month. 
 
 Still persist. 
 
 Fair. 
 
 C. H. I., 
 
 
 
 
 
 
 
 949 
 
 39 
 
 41 
 
 Al)sent. 
 
 
 
 Fair. 
 
 C. H. I., 
 
 
 
 
 
 
 
 1095 
 
 29 
 
 30 
 
 Present. 
 
 ( )nc inontli. 
 
 Still persist. 
 
 Ciood. 
 
 San., 
 
 
 
 
 
 
 
 1691 
 
 40 
 
 43 
 
 Absent . 
 
 
 
 Ciooil. 
 
 San.. 
 
 
 
 
 
 
 
 1702 
 
 40 
 
 43 
 
 " 
 
 
 
 Ciood. 
 
 San., 
 
 
 
 
 
 
 
 1773 
 
 37 
 
 40 
 
 Present. 
 
 .After operation. 
 
 Six months. 
 
 \'ery good. 
 
 San.. 
 
 
 
 
 
 
 
 2144 
 
 39 
 
 40 
 
 " 
 
 Sevenil months. 
 
 Still persist. 
 
 Good. 
 
 San., 
 
 
 
 
 
 
 
 2Hi4 
 
 38 
 
 39 
 
 .\l>sent. 
 
 
 
 Fair. 
 
 H o t !•' 1 u s h e s . — Twcnty-niiic, cjr 51.8 per cent., of the })ati('iits .suffered 
 from hot flushes of varying severity and duration. These in most instances 
 appeared at the time the menstrual flow would normally have been present. In 
 4 of the 29 cases (4832, 6372, 6972, and 10357) the hot flushes did not appear for 
 several years after operation. Of \hrsr patients, 2 were forty-nine and forty- 
 seven years old respectively when the iiot fhi.^iies occurred. This was un- 
 rloul)tedly the period when, under normal conditions, their menopause would
 
 ABUO.MIXAL HYSTEROMYOMECTO.MY. 605 
 
 have been reached. In Cases 6972 and 10357 the women were forty-three and 
 forty-two years old respectively when the hot flushes appeared, and although 
 they were still under forty-five years of age, the phenomena strongly suggested 
 the onset of the normal menopause. By excluding these 4 cases from our tabu- 
 lation we find that in only 25, or 44.6 per cent., of the 56 were hot flushes or indi- 
 cations of the menopause present. 
 
 In Case 9928 the patient was forty years old. Hot flushes appeared six 
 months after operation and lasted only a few days. She is now forty-five years 
 old, and has had no reappearance of symptoms suggestive of the menopause. 
 
 In 3 cases hot flushes appeared only occasionally. In 6 cases hot flushes 
 occurred after operation, but continued only for a few months. 
 
 In several cases, however, the hot flushes occurred more frequently and were 
 of much longer duration. In Case 3340 the woman was thirty-six years old. Hot 
 flushes appeared fourteen months after operation, and were present each month 
 for four years In Cases 9029 and 10558 hot flushes appeared soon after operation 
 and still persisted six and four years later respectively. In 12 cases hot flushes 
 appeared during periods of from one to three years after operation, and still 
 persisted. Thus in only 15 of the 56 cases were there hot flushes of motlerate 
 severity which persisted for a long period. 
 
 Even if we exclude the 4 cases in which no hot flushes were present for se^•eral 
 years and were not noted before what appeared to be the normal menopaus(\ we 
 still have 27 cases, or 48.1 per cent., in which no hot flushes have ever been noted. 
 This, to our mind, demonstrates conclusively that the surgeon should, wherever 
 possible, save every normal ovary. In some instances, of course, when the 
 ovaries are h^ing high in the abdomen, although it might be surgicalh' feasible to 
 spare them, their retention might materially increase the risk. 
 
 Vicarious Menstruation. — Efforts were also made to ascertain 
 if in any way the menstrual function was retaincxl. In 2 cases (8705 and 9527) 
 bleeding from the nose w^as noted at the time inciistiuntioii would normally 
 have been ])resent. Both of thes(> jiaticuts prior to operation had not been 
 subject to bleeding from the nose. In one of these cases (8705) bleeding oc- 
 curred at the second month after operation, hut lU'X'er rea|)peai"ed. in Ca.se 
 9527 bleeding from the nose a{)peare(l each month for several months. In 
 neither of these cases, however, is mention made of tiie duration or th(> amount 
 of bleeding. 
 
 In 4 cases vaginal bleeding wasjjresent. Cndoubtedly in these cases there 
 had been a high amputation of the uterus, a small jjortion of tlie uterine mucosa 
 remaining, which at the menstrual jn-riod continued to pei'form its normal func- 
 tion. In 3 of these cases the vaginal bleeding was ii'i'egular and lasted but a 
 short time. The fourth case (9286) is most inteivsiing. Three years after 
 operation menstruation reappeared, and has continueil each nioiuh for the j)ast 
 two years. The quantity of flow is slight. 
 
 Present Health of Patients. In 36 of the ca.ses the health
 
 606 
 
 MYOMATA OF THE UTERUS. 
 
 is ''good"; in 13, "fair"; and in 7, "poor." In only 4 cases were the symptoms 
 directly rcfcraMc tn the |»cl\is 
 
 Simple Left to Right Abdominal Hysterectomy with Removal of the Appen- 
 dages.— When it is deemed advisable to remove the tubes and ovaries with the 
 uterus, the technic carried out may be similar to that described on p. 600, the 
 only difference being that the ligatures or clamps applied to the ovarian and 
 tubal vessels control these vessels to the outer or pelvic side of the ovary, instead 
 of near the uterine horn. 
 
 Fig. 355. — .\ Diagrammatic Representation of the Left to Right Operation. 
 
 This represents a hysterectomy after the menopause, otherwise the ovaries would not have been removed. 
 First the left ovarian vessels are controlled and cut, then the left round ligament. The bladder is now freed, 
 and the left uterine vessels are controlled. The cervix is cut across, the right uterine vessels are clamped and 
 severed, and the uterus is rolled out. The right round ligament is clamped and cut. The right ovarian vessels 
 are controlled, and the uterus is removed. 
 
 The numbers and arrows indicate clearly the line of procedure, (.\fter n(nvard A. Kelly.) 
 
 Several years ago one of us (Kelly*) described a method which materially 
 simplifies hysteromyomectomy. It is usually spoken of as the "left to right," 
 or "right to left," operation (Fig. 355). 
 
 The usual steps in the operation are the following: 
 
 1. Suturing and severing the left round ligament. 
 
 2. Doubly clamping and cutting the left ovarian vessels (Fig. 344). 
 
 3. Freeing the bladder from the uterus. 
 
 4. Blunt dissection of the left broad ligament and double clamping of the 
 left uterine vessels. 
 
 * H. A. Kolly, .lohiis Hopkins Hosp. Bull., Kcl)ni;iry, 1896.
 
 ABDOMINAL HYSTKHOM YOMKCTO.M Y. 607 
 
 5. Aiin)iitati()n of the uterus through the cervix (Fig. 345j. 
 
 6. Champing the right uterine vessels and severing these vessels. 
 
 7. Clamping the right round ligament and right ovarian vessels, severing 
 them, and removing the uterus. 
 
 8. Tying all cardinal vessels (Fig. 348). 
 
 9. Closure of the cervix, with insertion of the round ligaments into the 
 cervical stump (Fig. 350). 
 
 10. Covering over all raw areas with peritoneum (Figs. 3.")! and 3o2j. 
 
 In this operation the aim is literally to roll the tumor out of the abdomen. 
 When the left round ligament is severed and the left ovarian vessels are ligated 
 and cut, the bladder is freed from the uterus; the uterus is then drawn strongly 
 to the right, and with gentle dissection the left uterine vessels are seen or felt, 
 and must be controlled l)y the most trustworthy clamp.s — preferably Wertheim's. 
 When the cervix is cut across, the uterus can be drawn still further outward. 
 The lower part of the cervix is meanwhile firmly grasped with mesoforceps by an 
 assistant to prevent it from receding. As the knife severs the final cervical 
 fibers on the right, great traction is exerted and a certain amount of stretching 
 of the tissues enables the operator to grasp the uterine vessels at a higher level. 
 These once severed, the uterus can be rolled out, and after the round ligament 
 and the ovarian vessels have been clamped, the uterus is free. All cardinal 
 vessels are now controlled, the cervix is closed, and all raw areas are covered 
 over with peritoneum. 
 
 In each case some minor modifications may be necessary. For instance, in 
 some cases when there is not room to apply two forceps to the left ovarian vessels, 
 it may be necessary to ligate the vessels and then cut, the vessels on the uterine 
 side being grasped as they are cut. Again, when the operation is likely to be 
 a long one or when it may be necessary for the operator to witluh-aw without 
 doing a complete operation, it is often wise to tie all vessels as they are encoun- 
 tered. WTiere it is very difficult to get a point of cleavage on the left side, the 
 removal may be started on the right and carried to the left. In this operation 
 the more difficult side is always left until the last, and in the end it really 
 becomes the easier side, as after severance of the cervix tli(> uterus can l)e rohed 
 out without difficulty. 
 
 Hysteromyomectomy Followed by Immediate Removal of the Appendages. 
 
 In certain cases the appendages are so ghieil ilown to the sun-ouniHng struc- 
 tures that their removal is not only liaught with much .langer. but it is ahnost 
 imi)ossible to get a point of cleavage. Where such a condition exists, the uterus, 
 as a rule, is not very large. This is nvidily understood, because if the uterus had 
 reached large })rop()rtions, the appendages would liaM' Iteeii lit'led high into the 
 abdomen, and then control would have been easier. 
 
 In such cases two m(>thods of treat nieiil are available:
 
 608 MYO.MATA OF THK ITERUS. 
 
 1. Hysterectomy with iiimicdiato iiMiioval of the appendages. 
 
 2. Bisection of the utci'us. 
 
 Wherever possible, hysterectomy is preferable, bisection being reserved for 
 those cases in which hysterectomy is otherwise impossible. 
 
 Hysterectomy with Immediate Removal of the Appendages.— The uterus is 
 firmly grasped with strong mes()forcei)s. and any vantage once gained by the 
 traction is never yielded. The following steps are then taken: 
 
 1. ('lami)ing and cutting of the left ai)pendages at the uterine horn. 
 
 2. Tying and severing the left round ligament. 
 
 3. Separating the bladder reflection. 
 
 4. Exjiosing, clamping, and severing the left uterine vessels. 
 
 5. Cutting across the cervix. 
 
 G. ('lami)ing and severing the right uterine vessels. 
 
 7. Clamping and severing the right round ligament, the right appendages 
 at the uterine horn and removing the uterus. 
 
 8. Liberating the left ai)])endages from Ix-low upward, clamping the ovarian 
 vessels, and removing. 
 
 9. Liberation of the right ajjpcndages. Clamping of the ovarian vessels; 
 removal. 
 
 10. Tying all the cardinal vessels. 
 
 11. Closure of the cervix, with insertion of the round ligaments into the 
 stump if feasible. 
 
 12. Closure of all raw areas. 
 
 13. Drainage through the vagina if raw areas cannot ho covered, or if there is 
 much danger of infection. 
 
 By removing the uterus first, the adherent ai^pendages can be gotten at from 
 the under side and dissection carried on under sight. Before this procedure was 
 adopted the rectum was much more fretiuently injured. Naturally, clamping 
 the vessels instead of tying them during removal of the uterus is preferable, as in 
 the later steps of the operation the tying of the vessels fvu'ther out would make 
 the first ligatures superfluous. 
 
 Recently one of us (Kelly) has cupped out the cervix to a marked degree in 
 those cases in which infiammation of the cervical nuicosa is susi)ected. From 
 Figs. 353 and 354 it will be noted that the cervical mucosa is dissected free almost 
 to the external os. It is then clamped, so that none of the cervical contents can 
 escape to contaminate the cervical stump, and then cut across below the clamp. 
 
 Bisection of the Uterus. 
 
 In a certain number of cases the o))erator, on opening the abdomen, feels 
 
 completely baffled to find the uterus sitting on the top of a myoma, 
 
 which fills the pelvis (Fig. 356), or that the uterine tumor fits the pelvis so 
 
 accurately and is so fixed by adhesions that the usual operative pro-
 
 ABDOMIX AL II YSTEHOM VO.M Kl TOM Y. 
 
 009 
 
 cedures are futile. Or, as in Case 9G78, a large jielvic al)scess may add to 
 the difficulty. 
 
 In such cases l)isection, as described Ijy one of us (Kelly),* in 1900, enables 
 the operator in a few minutes to overcome the chief obstacles, and enucleation 
 can then be effected. 
 
 As seen on p. 683, the mortality in this operation is high. In myoma ca.ses 
 it is never to be resorted to when the utcn-us can be removed intact, and is to be 
 studiously avoided whenever the chance of sarcomatous degeneration of a myoma 
 exists, or when there is a possibility of carcinoma of the body being present. 
 
 It is but natural that the mortality should he high, as it is only in desperate 
 and otherwise inoperable cases that the 
 operation is to be performed. The steps 
 of the operation are as follows : 
 
 1. Grasp each side of the fundus with 
 strong mesoforceps and make firm traction 
 upward (Fig. 357). 
 
 2. Cut directly through the center of 
 the tumor until the vesical reflection is 
 reached. 
 
 3. Dissect down the vesical reflection, 
 the assistant meanwhile keei)ing up the 
 strong traction. 
 
 4. Continue the bisection imtil the cer- 
 vix is reached (Fig. 358). 
 
 5. Cut to the left until the uterine 
 vessels are nearly exposed, meantime 
 making very strong traction on the left 
 
 half of the uterus (Fig. 359). Doubly chimp the left uterine vessels and cut 
 between forceps. 
 
 6. Roll out the left half, clamping in succession the left round ligaments and 
 the left ovarian vessels (Fig. 300). 
 
 7. Cut across the right half of the ceiA'ix until the t uinor is nearly fre(\ Clainj) 
 the right uterine vessels and cut. 
 
 8. Clamp the right round ligament and the right ovarian vessels in succession 
 and deliver the right half of the uterus. 
 
 9. Ligate the cardinal \'essels. 
 
 10. Clos(^ th(> cervical flaps. 
 
 11. C()\-er all raw areas with peritoneum, and diaiii ihiough the \'agina 
 if it be deeineil necessary. 
 
 It is a well-known fact that strong traction greatly diininish(\'< hemoi-rhage, 
 
 * Howard A. Kelly, A Preliminary Report on tlie Surgical Treatment of Complicateil 
 Fibroid Tumors of the Womb, with a Description of Two^Iethods of Operating, Johns Hopkins 
 Hosp. Bull., 1900, vol. xi, p. 56. 
 39 
 
 Fig. 3.56. — Bisection ok the Uterus. 
 The arrow indicates the Une of bisection.
 
 610 
 
 MYOMATA OF THE UTERUS. 
 
 SO there should Ix' lui let up on the mcsoforceps from the time bisection is com- 
 menced until the two halves of the uterus have been delivered. 
 
 Sometimes it is onl}- necessar}' to continue the incision until a large myoma 
 has been bisected and .shelled out (Fig. 361). In such cases the uterus may then 
 collapse, and the operation is converted into a simple one (Fig. 362), the uterus 
 being easilv removed in the usual way from left to right. 
 
 -• %. 
 
 % 
 
 / 
 
 Fig. 357. — First Steps in Biskction of the Uterus 
 The fundus has been firmly grasped on the right and left with mesoforceps. The bladder is being 
 dissected free and pushed down preparatory to bisection of the organ. The myomatous uterus has purposely 
 been drawn small, so that the various steps can be more readily followed. 
 
 In other cases, even after bisection and shelling out of the uterus, dense ad- 
 hesions are found fixing it to the pelvic floor. These adhesions are now carefully 
 dissected free from liclow upward under sight. 
 
 As a rule, the ojKTation is not accomi)anied by much hemorrhage, but if in the 
 bisection the knife cuts too far to one .side, large venous .'minuses or big branches 
 of one or other uterine artery may l)e cut, and alarming hemorrhage follow.
 
 ABDOMINAL HYSTEROMVCJ.MIX'TO.M Y. 
 
 Oil 
 
 We cannot be too emphatic in sayinfj that this operation should be employed 
 only where no other method is feasible. 
 
 On the other hand, l)isection is of the greatest assistance to the surgeon in 
 
 tmiMWT'vr^ 4 
 
 lit,. 358. BiSKCTION OK THK UtKRDS. 
 
 The uterus has been bisected almost to the cervix. The ine«of«rceps now Kra>|is caoh li.-ilf of tin- iilorus 
 about its middle. A pair of artery forceiJS in the uterine cavity insures culling in llie iiiidhnc, thus avoiilinK 
 either uterine artery. The appendages are embedded in adhesions. 
 
 cases in which hysterectomy is necessary, on account of densely adherent jius- 
 tubes. In such cases there is. as a rule, lillle dnn.^er from s|)lilling the uterus. 
 The adlu^sioiis ai'e then ;il t;icke(| fioni thcii' under side, and a x'ei'y dillicult 
 or impossil)le removal of the ulei'us is rendered conipai'.'iliNcly easy, j-'or such
 
 612 
 
 .MYO.MATA OF THK UTERUS. 
 
 cases bisection is uiul()ul)l('(lly the easiest operation, and yields the lowest 
 mortality. 
 
 Abdominal Hysteromyomectomy from Below Upward, Transverse Section 
 of the Cervix being the First Step. — One of us (Kelly*) when o{)erating upon 
 a very coinplicated myomatous uterus, found it so firmly fixed that its removal by 
 
 Fio. 359. — Bisection of the Uterus. 
 The left half of the uterus has been amputated through the cervix. This portion of the cervix is drawn 
 strongly upward with mesoforceps. and the left uterine vessels are damped. 'I'he left half of the uterus is now 
 rolled completely out, clamped at the uterine horn, and removed 
 
 any of tiie usual methods, or even by biseetion, was out of the (juestion. A 
 novel plan was then adojjted. Fortunately, the eervix was fairly accessible. 
 The bladder reflection was at once separated, and the cervix firmly grasped with 
 mesoforceps (Fig. 863). It was then severed transversely, and the uterine 
 
 * Howard A. Kelly, A Prcliininary Report on the Surgical Treatmoiit of Complicated Fil)roid 
 Tumors of the Womb, with a Description of Two Metliods of Operatiiis;. Jolms llopUins Hosp. 
 Bull., 1900, vol. xi, p. 56.
 
 ABDOMIXAL HYSTERO.MYOMECTO.MY 
 
 613 
 
 vessels were grasped on either side (Fig. 364). The cervix lKiviii<r l)eeii cut 
 through and the broad ligaments opened, the round ligaments were next cut, the 
 ovarian vessels clamped and cut and the densely adherent tumor wtis then freed 
 from its pelvic attachments. The abdominal com])lications were then readily 
 dealt with, first because they could be studied both from in front and also from 
 behind, and — equally important — because there was now little bleeding, the 
 cardinal vessels of the tumor having been tied. 
 
 (Tube an.l 
 u t , o V. t i q 
 
 a.^ >■...., 
 
 Fid. ,300. Bi.section' or tiik L'tluus. 
 Tlie left luilf of the uterus has Ijeen removed. The left uterine vessels have Ix-eii lit-il. Tlie h-fl muiiil Hki«- 
 ment and the left tubal and ovarian vessels are controlled with forceps. The riRhl half of the uterus is reniovetl 
 in the same manner. The adherent appendages are now carefully dissected free under sight, and removed if nec- 
 essary. 
 
 We cannot better .show the value of this ()|)erati(m tlinii by giving in detail 
 the first case that l(>d to its em])l()ynient . 
 
 In Case 7549 the ])atient, when ])l;ice(l on the t;il)h'. had a small, rapitl pulse 
 which soon reached 140. .M'lcr ihc i-elease of some omental adhesions a large 
 myomatous tumor was found glued down by extensive adhesions. The trans- 
 verse colon was so intimately attached to it (Fig. !()*.), j). W'M that it soon l)ecame 
 evident that continued di-ssection would finallv necessitate an extensive resection
 
 614 
 
 MYOMATA OF THE UTERUS. 
 
 of the bowel. An alteinj)t was then made to leave a thin layer of the tumor 
 attached to the l)owel, as had been successfully earned out in the previous case.* 
 The bleeding became so profuse that this plan of procedure had to be abandoned. 
 The operator then turned to the lower pelvic pole of the tumor. The cervix 
 was grasped with strong mesoforceps and pulled up within reach. The vesical 
 reflection was dissected back, and the cervix grasped low down with a second pair 
 of mesoforcejis. The cervix was now cut transversely from before backward, con- 
 
 FiG. 3tU — Bisection where the Uterus Completely Fills the Pelvis. 
 The myomatous uterus filled the pelvis so accurately that it would have been absolutely impossible to get 
 at the uterine vessels. The vessels at the uterine horns have been controlled temporarily to partially check the 
 blood-supply to the tumor. The bliulder peritoneum is being pushed down jjrior to bisection of the body of the 
 uterus, in the line indicated by the arrow The bisection with reiuoval of the large myoma is shown in Fig. 
 362. (After Howard A. Kelly.) 
 
 tinued traction being made on both portions. The cellular ti-ssue to the left 
 of the cervix was then exposed, and the uterine vessels, although not yet seen, 
 were doubly claiiij)e(l and severed. The uterine vessels on the right side were 
 next controlled in the same way. 
 
 When these important vascular trunks had thus been secured, the larger 
 forceps were used to forcibly drag up the tumor and the uterine body, rotating 
 them on a transverse axis, exposing first the round ligament, then the ovarian 
 vessels on the left, and then those on the right side. These structures were 
 
 ♦Howard A. Kelly. .Jolms Hopkins Hosp. Bull., IS'Jl, vol. ii, p. 46.
 
 ABDOMIXAL HYSTERO.MYOMECTOMY. 
 
 G15 
 
 clamped, and the whole mass was disconnected from its pelvic attachment. 
 The tumor now remained fixed only by dense adhesions at its upper pole. 
 
 The next occurrence was the rupture of a large abscess lying behind and ex- 
 tending from the center of the tumor into a sac, bordered posteriorly by t he luiuhar 
 vertebrae, and above by the mesocolon, and discharging through a large opening 
 into the transverse colon. 
 
 The specimen examined showed that the abscess was in reality a suppurating 
 
 I'll.. oG:.'. Till, Value OF Bi.si.iiiii.N (.n iiii. Lii^iu>. 
 Fig. 361 shows the appearance of the uterus before the bisection. We now see the uterus split in two. The 
 large myoma which occupied the anterior wall and blocked the pelvis has been shelled out, leavinK plenty of room. 
 The cardinal vessels can now be controlled with ease, and the hysterectomy conipletetl in the usual manner. 
 (After Howard A. Kelly.) 
 
 myoma, which had become adherent ;ind had discliarged into \]\o large bowel. 
 The tumor was now shelled out and emiclealed I'ldin beliiud ui)\vard without any 
 injury to the bowel. The containiiialcd alidomiiial caxily and t lie abscess ('a\-ity, 
 which contained at least a liter of lliiek yellow \)\i^. wei'e closeil. The opening 
 in the bowel was sutured. An abdominal drain of iodoform gauz(> was carried 
 down to the point of this sac and th(^ abdomen closed. The patient made an 
 excellent recovery, and only a small, rapiilly closing (istulous tract remained.
 
 616 
 
 .MYO.MATA OF THK ITKRUS. 
 
 Had the operator not hit upon this method of first amputating through the 
 cervix and then working from below upward, any radical procedure would have 
 been out of the question, and the ]xiticnt's death would at have been a 
 matter of only a short thne. 
 
 Fig. 363. — Tkansverse Sectio.v of the Cervix .\s the First Step i.v Hysteromyomectomy. 
 It was impossible to separate the myomatous uterus from the omentum and transverse colon •nnthout great 
 danger of losing the patient on the table. Fortunately, the cervix was accessible. The overlying bladder peri- 
 toneum was severed, the cervix grasped with two pairs of mesoforceps, and severed transversely. The complete 
 separation of the cervix is seen in Fig. 364. (After Howard A Kelly.) 
 
 Panhysterectomy. 
 When complete removal of I lie uterus is tlceided ii])on, we have found it wiser 
 to control all vessels as thev are encountered. We will describe the method
 
 ABDOMINAL HYSTEROMYO.MKCTOMY, 
 
 617 
 
 of hysterectomy where it has been found lulvisable to remove both ovaries with 
 the uterus. 
 
 1. The left round hgainent is tied with eat^ut and cut. 
 
 # 
 
 Fig. 364. — Ahdominai, HYSTEROMYOMiicroMY "from Bki.ow Ui-wahd. " 
 The cervix wa.s separated transversely. The uterine vessels were cliiinped and cut and the ovarian ves-xels 
 clamped. The uterus wa.s then liberated from its iielvic attachment in the manner indicate*! hy the arrows. 
 It wa.s then rolled out, walled off from the ahdominai contents with Rauze, and the adhesions to the transverse 
 colon were attacke.i from their posterior an<i easier side. Ha<l the al)sccss opciiiiiK into ihc l.owcl {Vig. 10«, p. 
 143) ruptured before the uterus ha<l been freed from the pelvis, the daiiKcrs of a fatal termination wonl.l have 
 been infinitely greater. (After Howard A. Kelly.) 
 
 2. If the left ovarian ves.«^els are accessible, llicy an- tied with ra^ciistcciicr 
 thread, reinforced with catijut and cut. 
 
 3. The right round li^aiucnt is tied and cut.
 
 618 
 
 MYU.MATA OF THK I'TERUS. 
 
 4. The right ovarian vessels are tied aiul cut. 
 
 5. The l)hidder reflection is dissected free and pushed down. 
 
 6. The left uterine vessels are tied and cut. 
 
 7. The right uterine vessels are tied and cut. 
 
 Fig. 365. — Appearance of the Pelvis after Complete Hysterectomy. 
 The vagina is walled off with a piece of gauze; the vaginal walls are held taut by provisional sutures (or artery 
 forceps) to prevent infection from the vagina. The ligated stumps of the ovarian and uterine vessels and the 
 round ligaments are seen. In some cases, as indicated in the drawing, the ureters are also clearly visible. The 
 vaginal walls are whipped over to check bleeding, and the vagina is eitlier drained or closed. The raw areas are 
 then covered over. 
 
 8. The cervix is gradually dissected free until the vaginal wall is seen on all 
 sides. 
 
 9. The cervix is freed from the vagina on all sides and the uterus removed 
 (Fig. 365). 
 
 10. The vaginal margins are whipped over with fine catgut to control all 
 bleeding, and if it is deemed safe to close the vagina, the anterior and posterior 
 raw vaginal surfaces are approximated.
 
 ABDOMINAL HYSTEROMYOMECTOMY. 
 
 619 
 
 11. The raw areas in the pelvis arc; covered over with peritoneum. 
 
 The plan of operation differs little from that employed in the supravaginal 
 hysterectomy, until the cervix is reached. The uterine vessels are ligated by 
 passing a needle threaded with Pagenstecher thread close to the cervix, so as to 
 avoid piercing the vessels. A second suture of catgut is then introduced in the 
 same way. 
 
 After the uterine vessels have been cut, the dissection is carefully carried 
 do^^^lward until the vagina is encountered. Here one frequently finds vaginal 
 veins which may cause troublesome bleed- 
 ing. In catching these vessels great care 
 must be taken to avoid the ureters. 
 
 After the right uterine vessels have been 
 controlled and the dissection has been 
 carried do^^m to the vagina, little difficulty 
 is usually encountered in severing the cer- 
 vix from the vagina, but, should there be 
 any, a pair of artery forceps pushed up 
 into the vagina from below may be cut 
 down upon and the vagina thus easily 
 opened (Fig. 369). 
 
 It is wise to drain the pelvis in all cases 
 where there is likelihood that the uterine 
 cavity has been infected. 
 
 Raw Areas. — The surgeon aims to pro- 
 duce as few raw areas as possible, and 
 when finishing the operation, if feasible, 
 leaves everything covered with perito- 
 neum (Fig. 352). This minimizes the 
 possibility of intestinal loops becoming 
 adherent, kinking, and causing intestinal 
 obstruction. 
 
 Raw areas after an abdominal liystcro- 
 myomectomy are usually (hie to an accom- 
 panying pelvic infection. Thus, in Case 619S the uterus was lirmly li\e<l to the 
 rectum. After operation it was found impossible to cox-er the cervical stump, 
 and it was left bare. In Cases 8690 and 12139 the law areas were so extensive 
 that it was impossil)le to cover them. 
 
 Sometimes the capillary oozing from the roughened peritoneum, whence an 
 adherent tube or ovary has been liberated, is persistent. This oo/.iii^ iiia\- be 
 controlled with hot gauze left on for a few miimtes while tlie operator is engaged 
 in liberating or tying other structures. If tin* bleeding is not checked, a suture 
 which puckers up the peritoneum may control it jjerfectly. as in Case 7739. 
 
 Fig. 366. — A Large Raw Area Leii .Vftkr Re- 
 moval OF a Cystic Mvoma. 
 
 Gyn. No. 4828. The abdomen was filled with 
 a cystic myoma which had carried (he siRinoid 
 Uexure above the umbilicus. The sigmoid, as now 
 seen, has dropjied back into the pelvis. 
 
 In closing such a raw area the large vessels 
 or the left ureter might bo very easily prickeil 
 with the needle.
 
 620 
 
 .MVO.MATA OF THK UTERUS. 
 
 ^^^^en the bleeding area is small ami the needle prick causes much oozing, the 
 ])()iiit may be lifted up and tied, as indicated in Fig. 367. 
 
 A large raw area in Case 7064 was completel}' covered in by drawing the 
 broad hgament over it. The l)ladder may also be pressed into a similar service, 
 especially where, as a resuh of an extensive myomectomy, the surface of the 
 uterus is much roughened. In some of these cases we have drawn the bladder 
 over such an area and sutured it, thus completely hiding the suture line. Oc- 
 casionally we have drawn the bladder peritoneum back, and attached it to the 
 peritoneum of the rectum. 
 
 In suturing the peritoneum (Fig. 366) delicate needles and fine catgut should 
 be employed, and great care exercised to avoid piercing blood-vessels or one or 
 other ureter. 
 
 Where thickened and indurated areas are felt, as after the evacuation of a 
 [X'lvic abscess, it is not only impossible, but unwise, 
 to attempt to cover them over with peritoneum. In 
 such cases a gauze drain laid in the pelvis and brought 
 out through the vagina will yield the best results. 
 
 Irrigation of the Abdominal Cavity. — In many of 
 the myoma cases operated upon in the early days of 
 the hospital the abdomen was irrigated with salt sol- 
 ution just prior to closure. Sometimes this was done 
 to wash out any blood that might have escaped into 
 the abdominal cavity; in other cases to cleanse the 
 intestines when i)us had escaped during the hyster- 
 ectomy. 
 
 With our more careful technic in walling off the 
 tumor from the general cavity with gauze, the abdom- 
 inal contents are rarely soiled, and if contaminated, 
 they are carefully wiped off with gauze slightly moist- 
 ened with salt solution. When it is impossible to 
 cleanse the pelvis, the infected area is lightly packed with gauze, the low^r end of 
 wiiich is brought down into the vagina. The patient is then put to bed, and is 
 kept in Fowier's position for several days. 
 
 She is permitted to drink all the water she desires from the moment she 
 recovers from the anesthetic. 
 
 We have entirely given up abdominal irrigations after hysterectomies for 
 myomata. 
 
 Hemorrhage During Abdominal Hysteromyomectomy. — When the uterus is 
 small and uniform, the ovarian and uterine vessels are easily gotten at and 
 controlled ; but when the tumor has reached large proportions, not only are the 
 vessels displaced, but of necessity they are also much larger. Sometimes the 
 uterine artery on one side may be carried up into the abdomen, wiiile on the 
 opposite side it is deep in the pelvis. The vessels may reach tremendous pro- 
 
 FiG. 367. — Method of Controll- 
 ing A Bleeding Are.\ W'here 
 A Needle Cannot be Safely 
 Employed. 
 
 Sometimes a bleeding point 
 lies directly over a ureter or a large 
 vessel, and any attempt to suture 
 the area might entail injury to the 
 vessel from the point of the needle. 
 By lifting up such an area with a 
 pair of curved forceps the operator 
 can effectually control the bleed- 
 ing without using the needle.
 
 ABDOMIXAL HYSTKROMYOMFX'TOMY 
 
 621 
 
 portions. In Case 7474, for example, the uterine arteries were fully as lar-ic 
 as the femorals. A corresponding augmentation in the diameters of the veins 
 has also been noted. 
 
 The great increase in the size of the ovarian vessels is described on p. 352. 
 
 Hemorrhage from the Pedicle of a Subperitoneal 
 Myoma. — During a hysterectomy nmch traction is naturally employed, 
 and sometimes subperitoneal, pedunculated nodules are partially or completely 
 pulled away from the uterus (Fig. 368). In such cases free hemorrhage follows 
 unless the pedicle is quickly clamped. This condition was present in Case II.. 
 admitted to the Church Home and Infirmary, ]\Iarcli Ki, 1903. 
 
 Hemorrhage Due to General Oozing. W'licii the myoma- 
 tous uterus is adherent to the surrounding structures, free hemorrhage often 
 accompanies the liberation of the tumor. This is due chiefly to capillary ooz- 
 ing, and not to bleeding from vessels of any appreciable size. The more recent 
 the adhesions, the more marked 
 is the tendency to bleed. — """^ ^ 
 
 Tearing of the 
 
 Ovarian Vessels . — In 
 Case 7276, during the release of 
 adhesions, one of the ovarian 
 vessels was torn. Free hemor- 
 rhage followed, but was quickly 
 controlled with forceps. 
 
 In Case 7064 the hvsterec- 
 
 FiG. 368. 
 
 -Temporary Control of Bleeding fro.m a Sub- 
 peritoneal Pedunculated Myom.\. 
 During an abdominal hysteromyomectomy a subperitoneal 
 myoma may be partially torn away from the uterus, and trouble- 
 some oozing follow. If the operation is a long one, a mattress 
 suture will effectually check the bleeding. iJ is a side view 
 tomy was a most difhcult one, showing the suture securely tied. 
 
 owing to dense vascular adhe- 
 sions, and because the tumor so accurate!}' filled the jieKis. The v(>ssels were 
 clani])ed as eiicouiitei'ed and tieil later. The right oNarian \-essels were tied and 
 the clamps reiiioN'ed. Tiie ligature was not tight enough, the artery retracted, and 
 the free bleeding innnediately jiroduced a wide-s])read heni.-itoma, obscuring the 
 situation of the artery. It was necessary to tie the \-essel high al»o\'e the brim 
 of tlie peh'is, at the point at which it ci'ossed the lU'etei'. The hematoma was 
 then shelled out, and the peritoneal surfaces were approximated. 
 
 Hemorrhage from tiie ovarian ves.^els is usually a minor complication, as these 
 vessels are easily accessible. 
 
 Hemorrhage from the I'terine \' e s s e 1 s . In ("ase()722, 
 after the left uterine vessels had been tieil and sexcreil. the ceixix was cut 
 across. Suddenly the right uterine artery was torn, .and thei-e w;is excessive 
 and almost uncont I'ollalile bleeding h)r half a minute. :ifter which the ai'lei-y 
 was successfully clampecl. 
 
 The myomatous uterus in Case Tl'tiii w.as densely adhereiil .and wedged in the 
 pelvis. During the operation the let'l uterine arleiy w.as torn. ;ind free hemor- 
 rhage followed before it could be controlleil.
 
 622 MYOMATA OF THE UTERUS. 
 
 After tying off the omental adhesions in Case 6206 the operator deUvered 
 the myomatous uterus and then began enucleation on the left side. The left 
 ovarian vessels and the left round ligament were controlled and severed, and the 
 bladder, which was high up on the surface of the tumor, was freed. As the tumor 
 was being pulled up to get at the left uterine artery, this vessel, together with 
 several large veins, was suddenly torn, and there was a tremendous gush of 
 blood. The bleeding was, however, quickly checked. 
 
 During removal of the densely adherent myomatous uterus in Case 11634 
 the left uterine artery ruptured at a point just external to the ureter. In this 
 ease, on account of the oozing, it was necessary to drain through the vagina. 
 
 During removal of a small densely adherent myomatous uterus in Case 7120 
 the uterine artery was torn while the bladder was being liberated. The tear was 
 in such close proximity to the ureter that it was necessary to carefully dissect 
 out the ureter to avoid injury to it. The artery was then ligated near the pelvic 
 floor. 
 
 Alarming Hemorrhage from "\' e s s e 1 s on the Pelvic 
 Floor . — In Case 6792 the uterus was found perched on the top of a large 
 myoma. The normal appendages on each side and both round ligaments were 
 tied and severed. The bladder was then freed and pushed dowTi, and the uterine 
 arteries on both sides were controlled. The uterus with the appendages was 
 then removed. The tumor was then shelled out of the loose cellular pelvic 
 tissue. It came out easily, but with tremendous hemorrhage, the blood almost 
 filling the pehis. After much difficulty it was found that the hemorrhage came 
 from a large vessel on the pelvic floor. This was ligated, but the general oozing 
 was still so profuse that the anterior branch of the internal iliac artery was tied. 
 The raw area was now covered in, care being taken not to injure th(^ urc^ter, 
 which was placed toward the median line. 
 
 After all bleeding had ])ecn checked, several gall-stones were removed. The 
 patient left the hospital well. 
 
 The myomatous uterus in Case 6915 was as large as that of an eight months' 
 pregnancy, and the abdominal walls were very thick. The bladder reached al- 
 most to the umbilicus. 
 
 i'jiucleation was begun from right to left, and large masses of ovarian 
 vessels were raised with difficulty and tied off, in a narrow space between the 
 tumor and the pelvic brim. After section of the round ligament the bladder was 
 dissected free on the right side and a large mass of knotted veins passing from 
 the uterus to the bladder was revealed. These were ligated and cut. The right 
 uterine vessels were exposed and tied without difficulty; the cervix was cut 
 across, and the left uterine vessels controlled. As the uterus was being care- 
 fully drawn up there was a sudden uncontrollable limiorrhage. The l)loe(Hng 
 point could not be gotten at, and nothing remained but to remove the uterus with 
 the utmost speed, notwithstanding the bleeding. The tumor, which still held 
 by its ovarian attachment, was rolled out of the abdomen, the l)lood rai)idly
 
 abdo:mixal hysteromyo.mectomy. 023 
 
 ladled out of the pehis, and a large spurting vessel caught on the jielvic floor. 
 During the necessarily speedy removal of the uterus the hladdei- was torn from 
 the trigonum to the symphysis. The rent was closed, and the ..pcrat ion (•(.iiii)l('t('d 
 in the usual way. The patient was discharged well on the thirty-third day. 
 
 Hemorrhage Due to Slipping of a Ligature .—In Case 
 6178 the ligature around the left uterine artery slipped and free hemorrhage 
 followed for several minutes. The vessel was caught and retied. 
 
 Just as the abdomen was being closed in Case 5734 free blood was noted in 
 the pelvis; the ligature controlhng the left uterine artery had shj)j)ed. The 
 vessel was retied. 
 
 Hematoma in the Broad Ligament .—In Case 5193. at the 
 close of the operation a hematoma, 4x5 cm., was noted in the left Inroad ligament. 
 The clot was turned out and the bleeding vessels were controlled. 
 
 Hematoma Under the Sigmoid Flexure .—After removal 
 of a large myomatous uterus in Case 7583 a hematoma, 3x5 cm., was detected 
 under the sigmoid flexure. It was opened and the bleeding ve.'^sels were con- 
 trolled. 
 
 Almost Fatal Bleeding from an Accessory Branch 
 of the Uterine Artery .—The myomatous uterus in Case 4731 filled 
 the entire lower abdomen. The cervix was represented as a mere button. 
 Abdominal hysterectomy was performed without difficulty, notwithstaiitiiiig 
 intestinal adhesions and the marked vascularity of the tissues. Just as tiie 
 patient was ready to leave the table she became pulseless and markedly blanched ; 
 a large clot was found filling the vagina. 
 
 On account of the collapse, internal hemorrhage w^s suspected, and the 
 abdomen was at once explored. No blood being found, the cervical stumj) was 
 reopened, and an accessory branch of the uterine ai'tery found spurting. The 
 blood from this I'ouiul its way into the vagina through the cervical canal. Al- 
 though the patient was ])ulseless at the wfist. she soon rallied and left ilir hos- 
 pital well at the end of iWo wec^ks. 
 
 The above cases yield some yvry important practical suggestions: 
 
 1. In cases in which much difficulty is exjx'cteil. tie vessels and cut as you 
 go. When the emergency ai'ises, the field will not lie entirely obstructed by 
 artery forceps. 
 
 2. Doubly ligate all the caidinal vessels. 
 
 3. If a hematoma forms, shell it out and catch the x'cssels. 
 
 4. Inspect all st umps carefully to see if bleeding has been effect nally checked. 
 
 5. Whenever there is dangei' of including the uretei- in a ligature, dissect it 
 out to be sure that it is intact. 
 
 6. In whi))])ing over the pelvic ))eritoneum he careful not to puncture a 
 vessel, as a hematoma will result. 
 
 Vaginal Drainage. \\'hei'e, on account of I'.aw areas in the jichis that cannot 
 be satisfactorily covered, or whei'e, as a result of |)el\ic infection, it is deemed
 
 624 
 
 MYOMATA OF THK ITKRUS. 
 
 advisable to drain tlie pelvis, va^-inal is iialurally |)refei-al)le to abdominal drain- 
 age. 
 
 The easiest way to accomplish this is to liaNcaii assistant carry a pair of artery 
 forceps high up into the vagina. The operator then cuts down ui)on the 
 
 forceps from above (Fig. 369). The opening 
 thus made is stretched with the forceps, the 
 pelvis is quickly wiped out, and one or more 
 long pieces of iodoform gauze are introduced. 
 The ends of the gauze are grasped with the 
 forceps and drawn tlown imtil they are seen 
 at the vaginal outlet. The jx'lvic portion of 
 the drain is snugly applied to the raw area, 
 and the rectum allowed to drop down over it, 
 so that no small bowel can become adherent 
 t(j the gauze. A ]Mece of rubber tissue around 
 the drains, at their exit from the pelvis, will 
 facilitate their removal later. 
 
 In introducing the forceps the assistant 
 must push them up directly behind the cervix. 
 If introduced to one or other side, the vessels 
 of the broad ligament may be cut or the ureter 
 injured. Sometimes the rectum is adherent 
 to the postei'ior surface of the cervix. Tn 
 such a case, if it is not previously lil)erated, 
 when the forcei)s are cut down upon, the in- 
 cision will first open uj) a fold of the Ixnvel, 
 and then the vagina. 
 
 The artery forcej)s should be introduced 
 into the vagina under sight. In one case 
 (C. H. I., 949), in which a small uterus was 
 studded with myomata, a pelvic inflammation 
 was also present. On account of the pelvic 
 inflammation it was decided to drain through 
 the vagina, but not remove the uterus. The 
 assistant experienced much difhculty in ])ush- 
 ing the artery forcej)s up into the vagina direct- 
 ly behind the cervix. Finally, however, the 
 maneuver was accomplished, and the operator 
 cut down upon the forceps from above. He 
 remarked that the vagina had not been cai'efully wiped out . as a small amount of 
 clear fluid escaped. After two ))ieces of 3-inch iodoform gauze had been laid in the 
 pelvis and their lower ends brought out below, the abdomen was closed. To our 
 astonishment the end of the gauze was found emerging from the urethra, and not 
 
 Fig. 369. — Method of Establishing 
 V.\GiN.\L Drainage. 
 Wlieii, on account of raw areas or 
 continued oozing, it is deemed advisable 
 to drain the pel\ns through the vagina, the 
 latter is carefully wiped out and any .secre- 
 tions that may have escaped from the 
 uterus during operation are in this way 
 removed. A long curved artery forceps 
 is then introduced into the vagina under 
 sight, and pushed up directly behind the 
 cervix, as indicated by a. At this point 
 the forceps is cut down upon and then 
 pushed up into Douglas' pouch. The 
 opening is then enlarged by separating the 
 forceps blades or with a dilator from above. 
 The ends of the necessary drain or drain.s 
 are now caught wth the forcejis and 
 drawn down into the vagina, care being 
 exercised not to include the rectum or 
 any ligatures in the forceps. The upper 
 end of the drain is held taut until the pelvi.s 
 has again been wiped dry, and is then snugly 
 api)lied to the pelvis. The rectum and 
 bladder usually drop down and completely 
 cover over the gauze, eflfectually preventing 
 any loops of small bowel from adhering 
 to it.
 
 ABDOMINAL HYSTEROMYO.MECTOMY. (Vi') 
 
 from the vagina. Naturally, the assistant had had much difficuhy in bringing 
 the tip of the forceps up behind the cervix, but hnally had done .so by greatly 
 stretching and distorting the bladder. The abdomen was at once opened, the 
 gauze was drawn out from below, and a complete hy.sterectomy performed, 
 the ureters being at the .same time carefully dis.sected out, as it was impo.ssil)Ie 
 to tell whether they had also Ix'en injured. They were found intact; the hole 
 in the base of the bladder was closed, and the patient made a perfect recovery. 
 
 A similar example is furnished by Case ('. IT. T.. 1552, Decend^er 31, 1000. 
 In this case, after removal of a densely adherent ovaiian cy.st, an artery forceps 
 was introduced from l)elow and cut down u])()n from above. Next morning 
 the ends of the two pelvic drains were found emerging from the rectum instead 
 of from the vagina. The abdomen was at once opened, and the drains with- 
 dra^^•n from the rectum. Only with great difficulty was the opening in the l)oweI 
 closed, as the hole in the rectal nmco.sa was at a point 4 cm. below that in the 
 outer or peritoneal coat. Finally, we reproduced the conditions ])resent when the 
 bowel was injured, by carrying the index-finger of the left hand up in the rectum 
 to the hole, and then pushing it up until it was opposite the hole in the peri- 
 toneum. The opening was thus closed from above, and a drain introduced. 
 The pati(Mit Tnade an uninterrupted recovery. 
 
 Successful Hysterectomy in a Constitutional Bleeder. — In ( ase 1 1019 the patient 
 was forty-seven years old. She gave a history of nejihi-itis. was weak and 
 anemic, and had a hemoglobin of 40 per cent. Ever since a chikl she had bled 
 profusely from the slightest scratch or cut. Her sisters also had a marked pre- 
 disposition to hemorrhage. She entered the hospital on account of a myomatous 
 uterus, which reached to the umbilicus. There was severe utei-ine bleeding. 
 After her hemoglobin had risen to 60 per cent, hvsterectomy was performed, 
 and the patient made a good recovery. The tendency to bleeding in no way 
 retarded her convalescence. 
 
 Abdominal Hysterectomy in a Syphilitic Patient. — In Case ()791 a woman, 
 aged forty, was the mother of two children. She had had .syphilis for several 
 years. On admi.ssion .she was very weak, and had a .soft .systolic murmur al the 
 apex. 
 
 The myomatous uterus was removed thi'ough the abdomen. The rr- 
 moN'al was rendered difficult on account of chronically inflamed and adherent 
 adnexa and dense vesical, intestinal, and ai)pendiculai- .ulhesions. .Not wit h- 
 .standing these complications, the luetic taint did not .-ipp.arently retard the 
 ]iati(>nt's |)i'()gi'ess and she made a good i'eco\'ery. 
 
 Hysteromyomectomy in Patients with Renal Lesions. WC shall here discuss 
 only those cases in which ihe jjatients i-ecovei'ed. 'i'he othei's ai'e dealt with 
 in e.iienso in their appropi'iate chaplers. 
 
 In Ca.ses 10()9, 13<S;>.^, and 1()7l'. aliiumin without casts was iiotnl licfore 
 operation. After removal of the uleius the ;ill>uniin disajjpeared. 
 
 In Case 1946 albumin was noted before opera lion. I m media ti'ly alter remoxal 
 40
 
 026 MYOMATA OF TIIK I TFJUS. 
 
 of the uterus it incivascd in amount aiul then disappcaivd. In these cases we 
 cannot say definitely that the kichieys were chseased, hut the albumin certainly 
 indicated an abnormal condition. 
 
 When a hysterectomy is comem])lated and the urine found to contain al- 
 bmiiin and casts, we have to consider whether the patient can successfully 
 withstand the ojx'ration. It is a well-known fact that any patient having neph- 
 ritis has a lowered resistance, and that the dangers accom])anying any o{)eration 
 are much inci-eased. ( )n the other hand, the local ])eb-ic condition in some cases 
 is becoming so serious that the patient will in all likelihood succumb if operative 
 relief is not given. 
 
 The following cases show what may be accomplished: In Case olO.S, a white 
 woman, aged fifty-four, had for foui' years been losing a good deal of blood. 
 The last hemorrhage, she claimed, amounted to two or three quarts. The lower 
 abdomen was filled with a globular uterus. The urine contained albumin and 
 casts. After an abdominal hysterectomy tlie urine diminished in amount, while 
 the albumin increased and hyaline and granular casts were very abundant. 
 Convalescence was otherwise uneventful. The bleeding was due to a sub- 
 mucous myoma 6 cm. in dianu'ter. 
 
 In (a.se ()272, a colored woman, age(l thirty-six, entered Dr. Osier's service 
 suffering from nephritis and mitral insufficiency. Later she was transferred 
 to the gynecological department on account of a myomatous uterus. When the 
 abdomen was opened, a considerable amount of ascitic fluid was found. The 
 nmltinodular uterus filled the lower abdomen and was firmly fixed in the pelvis. 
 After removal of the uterus the appendix was amjuitated. The patient recovered 
 perfectly from the operation, and was returned to the medical side for further 
 treatment. 
 
 The.se two ca.ses demonstrate cletirly that much may be accomplished even 
 in most unfavorable subjects. 
 
 General Hints in Operations for the Removal of Uterine Myomata. 
 
 The following procedures we have found of especial value. l)efore, during, 
 and after hysteromyomectomy. 
 
 Before Op e rati o n . — A\'hen the j)atient is very anemic we build her 
 Uj) with rest, good food, iron, strychnin and ])lenty of fresh air, and ojx'rate before 
 the next period, if this is likely to be profuse. 
 
 Inoperable cases may later h(>come operable. 
 
 Remember that almost moi'ibund patients may recover if operated u])on. 
 
 Never operate without full pei-mission to do all that is necessary, and then 
 be as conservative as possible. 
 
 Never tell the ])atient that there is no danger in the operation. 
 
 Have the bowels well emptied befoi-e operation.
 
 ABDU.MIXAL HYSTERO:\I YOMECTOM Y, ■ ()27 
 
 During Operation . — Always determine the upper limit of the bladder 
 with the cathetcn- before opening the abdomen. 
 
 When a pelvic abscess exists, drain through the vagina and do a hysterectomy, 
 if necessary, two or three months later. 
 
 A good long abdominal incision saves time in the end. Cut down almost to the 
 symphj^sis. 
 
 Employ the operation offering the quickest and easiest removal of the uterus, 
 and involving the least danger of loss of blood and of infection. 
 
 A tumor wedged in the pelvis can sometimes be pushed up by the hand in 
 the vagina. 
 
 Rotate or "lateralize" a tumor to facilitate its delivery from the abdomen. 
 A corkscrew introduced into the tumor answers as a good tractor in some 
 cases, but should not be used where malignancy is suspected. 
 
 Get at dense adhesions from the under surface if possible. 
 
 Where dense intestinal adhesions are present, sacrifice the outer coats of the 
 tumor (Fig. 377, p. 635). Do not injure the bowel. 
 
 When large omental vessels enter a myoma, ligate and tie distally and 
 proximally. These vessels are very friable, and may tear if clamped. 
 
 The ovarian and uterine vessels in difficult cases may be more easily exposed 
 by rotating the uterus. 
 
 Treat the cervical canal as if it were an infected area. 
 
 When the tumor involves the cervix, do a complete hysterectomy. 
 
 Cover in all raw areas when feasible. 
 
 If a large raw area involves several inches of small bowel, short circuit by 
 means of a lateral anastomosis, and then roll in the raw area (Fig. 378, p. 635). 
 
 After-treatment . — Give enough morphin to relieve pain during 
 the first twenty-four hours. 
 
 Let the patient (h'iiik all the water she desires from the time of operation, 
 provided there are no especial contraindications. If she vomits, the stomach 
 will be thoroughly washed out. If she retains the water, the excess of mucus 
 will be carried into the bowel. 
 
 Get the patient on the back-rest in two or thnn' days after operation, if 
 feasible. 
 
 Use little catharsis — rely chiefiy on enemata. 
 
 If there is the slightest sign of intestinal obstruction, give no cathartic l)y 
 mouth, as it may increase tiie kink. Coax the intestinal contents down with 
 enemata. 
 
 Alow enema of two ounces each of glycei'in ami watei' will almost inxariably 
 relieve abdominal distention if not due to obstruction. 
 
 Open the abdomen at once if thei'e are dehnile signs of jx-ritonitis or 
 obstruction.
 
 628 
 
 MYOMATA OF THK UTERUS. 
 
 Ome nt um/ 
 
 Bladder- attachment 
 
 Fit;. 370. — An Indication van Ahhominai. I.\sTK.\r) oi- \'a(iinm. H vstkuomvomkctom v. (J? nat. size.) 
 Path. No. 1990. Some suiKeoiis aiivocule vaginal removal of the msomatims uterus as a routine procedure, 
 but in our experience the enlarged uterus is often adherent to the omentum or to the bowel, and removal from 
 below would prove a hazardous procedure. In this case we have a large left pus-tube which did not lie in the 
 pelvis, but high in the abdomen. Its removal from below, even in the absence of the large myoma in the 
 left broad ligament, would have been fraught with grave danger. As we are never absolutely sure what we will 
 find on exploring the abdomen in these cases, it certainly seems that aljdominal hysteromyomectomy is, as a rule, 
 the more surgical procedure.
 
 ABDOMINAL HYSTEROMYOMECTOMY, 629 
 
 Vaginal Hysteromyomectomy. 
 
 Vaginal removal of the uterus is easily carried out provided the myomata 
 are fe\Y in number and of small size, and provided there is a certain amount of 
 prolapsus. 
 
 In about one-half of the cases the appendages were adherent (see p. 337) 
 the adhesions adding materially to the difhculty of removal through the vagina. 
 
 The uterus may be removed intact by the usual method; Init, if too large, 
 may be drawn down, l)isected, and removed, as has l)een so brilliantly done bv 
 Doderlein, Segond, Kronig, Wertheim, and others. 
 
 Our findings at operation have only served to strengthen our opinion that 
 when the uterine myomata are of sufficient size to cause trouble, it is wiser to re- 
 move the uterus from above, especially as in some instances there are other and 
 unsuspected pathologic conditions in the abdomen reciuiring treatment (Fig. 
 370), lesions that might be totally overlooked unless the abdomen were opened. 
 
 We must admit that the recovery after vaginal hysterectomy is a more 
 speedy one, and that the immediate discomforts are infinitely less, but in the end 
 we feel that the patient's condition is much better after the abdominal operation. 
 
 Out of the total of 993 hysteromyomectomies only 24 were by the vaginal 
 route.
 
 CIIAPTl-li XXXII. 
 
 DIFFICULT ABDOMINAL HYSTERECTOMIES. 
 
 Thick Abdominal Walls. The thickness of the alxloiniiial wall plays an iin- 
 j)()i-tant rule in all dilHcult abdominal operations for niyoiiiata. If the walls 
 are thin ami lax, exposure of the abdominal contents is easy, but. when much 
 adipose tissue is )iresent, removal of th(> uterus is often frau<2;ht with the greatest 
 difficulty. The thickened abdominal walls naturally increase the distance to the 
 jx'lvis. and in these cases there is liable to be much subperitoneal ix'lvic fat, and 
 also much fat in the omentum. Moi-eover, these patients usually breathe l)adly. 
 
 Fig 372. — An I.vc.\rcerated Myomatous Uterus. 
 Gyn. No. 3119. The pressure symptoms were so 
 severe just prior to operation that the patient, aged 
 thirty-four, could not work. In order to get at the cardi- 
 nal vessels and to deliver the tumor it was necessary to 
 have an a.ssistant press up from below. Even then de- 
 livery of the uterus would have been exceedingly difficult 
 had not one of the myomata been soft as the result of 
 degeneration. 
 
 Fig. 371.— .-V Myo.matous Uterus Accu- 
 rately Filling the Pelvis. 
 Gyn. No. 33.38. The enlargement was 
 due to a myoma in the posterior wall. If 
 the myoma is soft, as in this case, the car- 
 dinal vessels are easily controlled, but when 
 the tumor is very dense, it may be impossible 
 to reach the ovarian or uterine arteries. 
 In the latter case myomectomy, with subse- 
 quent hysterectomy or bisection, would have 
 to be resorted to. This uterus could not be 
 dislodged from the jielvis jjrior to ojjeration. 
 
 The amount of adipose tissue may be marked. Thus in Case 271.3 the ab- 
 <loniinal walls were (5 cm. in thickness. 
 
 Uterine Myomata Adherent to the Abdominal Wall. When the myomata 
 are undergoing- sujipui'ation. they natui-ally become adherent to the sui-roundino 
 structures, and, if near the abdominal wall, the nodule may become tlensely 
 adherent to the peritoneum of the lateral or anterior wall, as was pointed 
 
 630
 
 DIFF^ICFLT ABDOMINAL HYSTKUECTOMIF.S. 
 
 631 
 
 out in Chapter IX. Pelvic adhesions are veiy fre(|ueiit. If the inflaniniatoi-v 
 reaction has been marked, adhesions between the abdominal wall and the 
 mj^oma will be found in a few eases. In the following cases, in which the my- 
 oma had not undergone suppuration, adhesions to the abdominal wall were 
 noted— Gyn. Nos. 2091, 3440, 4870, 7237, 7739, and San. No. 1049. 
 
 Raw areas on the alxlominal peritoneum naturally cause the surgeon much 
 concern. His aim is to draw over the peritoneum and complete!}^ cover them, 
 but if the process has been a recent one, there is liable to be considerable indu- 
 ration, and the peritoneum is brittle in- 
 stead of elastic and pliable. In such a 
 case it is almost imj)ossible satisfactorily 
 to eliminate the formation of intestinal ad- 
 hesions at these ])oints. 
 
 Myomata Snugly Filling the Pelvis. — 
 Fig. 371 represents the type of a myoma 
 that is often difficult to remove. It fills 
 the pelvis snugly and cannot be dislodged 
 upward into the abdominal cavity. Con- 
 trol of one or other uterine vessel is diffi- 
 cult, but when one side has l^een tied and 
 cut, the cervix can be cut across and the 
 tumor rolled out. If this plan is not feas- 
 ible, it may become necessary to shell out 
 the large tumor and do a hysterectomy, or 
 bisection may be resorted to. 
 
 In Fig. 372 we have a very large un- 
 n-ieldv tumor, which not onlv completely ''"*^"''' ^'''^T '^^ '''^'''^*"' '"^fl«'^*'°" f^''^^^^'^ *" 
 
 " ^ I ,7 the surface of the tumor, far above the level of 
 
 fills the lower abdomen, but also the pel- 
 vis. In such a case shelling out of the 
 myoma or bisection is out of the question. 
 The only chance of removing the uterus 
 lies in so rotating the tumor that the uter- 
 ine vessels on one side can be controlled. 
 The cervix is then cut across and the uttMuis removed. 
 
 Fig. 373 shows a rather unusual conditioii. The chief myomatous develoj)- 
 ment having taken })lace between the folds of the broad ligaiiieiit. it has become 
 necessary to split the broad ligament on each side and carefully stii]) it off. 
 Moreover, when the iiiyoiuata develop in sncli a niannei', the mctei-s mav be 
 displaced foi'ward, ontwai'd, or down \\a I'd, and I lieii- local ion n nisi be ascerlaiiied 
 most carefnll)-. In this case llie lunioi- was loosely adlieivni io ihe bladdei- and 
 rectum. 
 
 Fig. 374 represents one of the most dillicnlt cases the surgeon can eiicounlei-. 
 The operation was begun from '■ right to left."' Large ma.sses of ovarian veins 
 having been with dillicully lied and cut, ami the bladdei- freed bv dissection 
 
 Fig. .37-3. — Retroperitoneal Development of 
 Myomata. 
 Gyn. No. 4097. The myomatous uterus 
 reached above the brim. The greater part of 
 the myomatous development had been retroperi- 
 toneal. The rectal peritoneal reflection passed 
 over to the myoma at the pelvic brim. Over the 
 
 the symphysis. Both the bladder and the rec- 
 tum were displaced high into the abdomen, and 
 during the liberation of the rectum a tear, 2 cm. 
 broad antl 12 cm. long, was matle in its outer 
 coats. 
 
 In such a case there is great danger of injur- 
 ing the ureters, which, as might besui)posed, 
 are displaced by the tumor.
 
 632 
 
 MYO.MATA OF THK UTERUS. 
 
 a large mass of knotted veins was revealed passing from the bladder to the uterus. 
 All these were tied, and the right uterine vessels were then exposed and ligated 
 with nnioh diffleulty. The cervix was cut across. The uterus was drawn up 
 carefuUv. hut a sudden and uncontrollable hemorrhage immediately followed. 
 
 Ov. -\ essels 
 
 Fig. 374. — .\. Vkry Difficult H^sihiomiomi < i(>\n '_ iiat. size.) 
 Gyn. No. 691.5. Path. No. 3170. The body of the uterus reached the level of the umbilicus and lay sur- 
 rounded by myomatous nodules. The bladder had been drawn upward almost to the umbilicus. The letters 
 a indicate the limits of the peritoneal covering of the tumor. 
 
 It now became necessary to enucleate with the utmost speed. The tumor was 
 liberated on the left side and shelled out. Bh)od was literally ladled out of 
 the pelvis, and all spurting vessels were caught. The tumor was cut away en- 
 tirely and removed. The bladder was torn from the trigonum to the symphysis 
 and drawn out in a long thin fhij). It was sutured, and the raw pelvic areas
 
 DIFFICULT ABDOMINAL HYSTKIIKCTOMIES. 
 
 633 
 
 were covered over. Apart from a mild phlebitis in the left le<z; on the twenty- 
 third day, the patient made a jx'rfect recovery. If the uterus had not been re- 
 moved with the utmost speed, the patient in a few minutes would have bled to 
 death on the table. 
 
 In Fig. 375 the myomatous uterus accurately fills the pelvis and. viewed 
 from the abdominal incision, would seem difficult of removal. A j^revious care- 
 ful bimanual examination, however, would hav(> demonstrated that the uterus 
 
 Fig. 375. — A Myomatous UTKiiua Blockixg the Pelvis. 
 Autopsy specimen, January 15, 1897. The uterus fills the pelvis snugly and has ciowdeil the greater part of 
 the bladder above the symphysis. Viewed from the abdominal cavity, it seems almost impossible to lift the uterus 
 out of the pelvis, but from Fig. .376 we see that it could be readily dislodged either liy upward pressure from 
 below or by means of a corkscrew from above. (After Howard A. Kelly.) 
 
 could be readily dislodged into the abdomen (Fig. 376), and myomectomy or 
 hysterectomy, according to the age of the patient, rai)idly carried out. 
 
 Intestinal Adhesions. \\ lieii we consider in how many castas the apjx'ndages 
 are adherent (see p. 337) and, referring to the ehaplers dealing with parasitic 
 myoma and sui)purating myomata, follow the details of those cas(\s in which the 
 myomata were densely adherent to the I'ectum, or wher(> hyst(M'ectoiii\- was 
 rendered exceedingly dinicult on account of the uterus being bound down, we can 
 readily understand why intestinal adhesions are commonly found. ''= 
 
 * Proiioiiiiced iiitcstiiKil udlicsioiis were notctl in the t'ollowing cases: (iyn. No. ,'Ao, 1151, 
 2108, 2691, ;«94, ;W12, 3921, 4370, 4731, 4732, 4S7(), 4917, r)123, "V2(i0, ■)392, 6133, 6324. 6432, 
 6521,6791,70(>4,71Sl,7226,7."')t9,.SO()S,9()27.9O7S.9312.9(i7S.9736. KM;.")!, II 172, 12209. t2lSS.
 
 684 
 
 MYOMATA OF THK VTERVS. 
 
 The bowel may become adherent to th(> myomatous uterus, to one or both 
 ap])emlages, or to the abdominal wall; or, as a result of a general peritoneal 
 infection, the intestinal loops may become adherent to one another. 
 
 If the peritonitis has been of recent date, tiie involved intestinal looj^s are 
 much injected, freiiuently edematous, and are easily parted, but their separation 
 is followed by very jjrofuse bleeding from capillary oozing. 
 
 Where the intestines have been long adherent, if loosely attached ])y fan-hke 
 adhesions, these can be I'cadily cut without any hemorrhage. Tn some instances, 
 
 Fig. 376. — A Myomatous Uterus that Tk.nded to Sag Down a.nd Completely Fill the Pelvis. 
 Autopsy, January 15, 1897. For the uterus before being dislodged from the pelvis see Fig. 375. (After Howard 
 
 A. Kelly.) 
 
 however, the intestine is so glueil to the tumor that it is necessary literally to cut 
 it away. In such a case the wiser i)rocedure is carefully to dissect through the 
 outer layers of the tumor, leaving them attached to the intact bowel (Fig. 377). 
 AMien a large raw area is left on the intestine, it is usually advisable to short- 
 circuit the gut just l)cyoiid and turn the raw areas in upon themselves, as 
 indicated in Fig. 378. The treatment necessary when supi)urating myomata 
 oj)en into the bow'el is de.scribed on p. 612.
 
 DIFFICULT ABDOMINAL HYSTKRKCT( )MIKS. 
 
 635 
 
 the 
 
 on 
 
 Myomatous Uteri Associated with Pelvic Abscess. — In .sonic of the cases 
 operator can definitely outline the myomatous uterus from above, while 
 vaginal examination induration 
 of the vault can be detected. 
 This board-like thickening can 
 usually be readily distinguished 
 from the globular bulging of a 
 myoma in Douglas' sac. When 
 such an induration is present, 
 hysterectomy is for the time 
 being contraindicated. An in- 
 cision should be made behind 
 the cervix, and Douglas' pouch 
 drained. Usually the patient 
 will improve rapidly, and the fig. 377.- 
 vaginal tissue .soften materially. 
 She may be sent home for a few 
 months, and then return for the 
 hysterectomy. It is astonishing 
 to note how much the nodular 
 uterus loo.sens up as a result of the drainage, and wluit would have been a for 
 midable and dangerous operation now becomes relatively easy. The following 
 case illustrates .such a plan of treatment. 
 
 Leaving the Outer Layers of the Myom.a At- 
 tached TO the Bowel. 
 In some cases when the bowel is densely adherent to the 
 myoma, as at A, the outer layers of the tumor can be left 
 attached to the intestine, as indicated by the dotted line a-h. 
 The freed bowel then presents the picture B. The bowel-wall 
 is thus preserved intact, and the lumen is encroached upon 
 only .ilightly. 
 
 Fig. 378. — Method of Dealing with Extensive Intestinal Adhesions. 
 A indicates three raw areas — points at which the bowel has been ailherent to the myoma. To c 
 in successfully necessitates much narrowing of the lumen of the bowel, with the danger of postoperativ 
 tion. One of us (Cullen) in such Ciuses does a lateral amistomosis as a routine j)roceilure In Fig. u, 
 line of the anastomosis is indicated. The raw areas of the bowel are then turned in upon ihemsclves, 
 perfectly smooth, tongue-shaped i>rojection, c. The results have been most Katisfactor.\-. 
 
 1' r (■ 1 i Ml i II a r y c \' a c u a t i o 11 o f a |i c 1 \' i 
 s e ({ u e n t h y s t e r o 111 y o 111 c c t o in y . 
 
 a I) s (' e s s ; 
 
 over them 
 
 e obstruc- 
 
 at a, the 
 
 leaving a 
 
 ub-
 
 636 
 
 MYOMATA OF THK UTERUS. 
 
 Mrs. H., thirty-ciiilit years of age, was adniittod to the Church Home and 
 Infinnary on March :\\. 1<K)4. She had for a lonji time comphiined of a pain in 
 the lower abdomen. Occupyinir tlie entire lower abdomen was a hard mass 
 which reached almost to the umbilicus. Throu.uh the rectum a distinct buljiin^-, 
 irregular in character, could be detected. 
 
 On opening Douglas' sac through the vagina we encountered a smooth jxx'ket, 
 <» cm. in diameter. On the left side was a pus-cavity containing 500 c.c. of 
 grayish-yellow, non-odorous ))us. Both cavities were drained. The patient 
 left the hosi)ital with instructions to return later for hysterectomy. 
 
 July 26. 1004: She had improved greatly in health. l)ut the i)ain in the left 
 
 side had been ])ersistent. On opening the 
 abdomen we found many adhesions, and a 
 myoma (i cm. in diameter. The right tube 
 and ovary wer(> much enlarged and densely 
 adherent. The left tube and ovary formed 
 a mass (S cm. in diameter. We amj^utated 
 from right to left with nuich difficulty, but 
 were able to control the vessels perfectly. 
 \'aginal drainage was employed, and the 
 patient made a good recovery. 
 
 While it is, as a rule, advisable to drain 
 an al:)scess and do a hysterectomy later, 
 Fig. 379.— a Large ag.scess Lyi.ng .a.ntekior thcrc are ccrtaiu cascs ill wliich this is not 
 
 TO A Myomatous Uterus. „ -i , t j^- n-r\ f • j. ii i 
 
 ^ X- onnc Tu .• . f . feasible. In hm'. .^<0, for instance, the pel- 
 
 Gyn. !No. 8008. The patient wa.s forty-one ' 
 
 years of age and colored. Three weeks before vic absCCSS la\' autel'lor tO tllC UtcrUS, aiul 
 
 admission, while washing clothes, she had severe -.i . i i • i j.- i i j. 
 
 pain in the lower abdomen, an.l on the follow- WltllOUt ail alxlominal OpCratlOll COUld HOt 
 
 ing day noted some abdominal swelling. She ]y^y(. )jeen illtelligeutlv handled. Ill thlS 
 was in bed for two weeks before admission. 
 
 At operation the bia.i.ier was found ex- casc it was wiscr to (lo a livsterectomy at 
 
 tending half-way to the umbilicus, and the intes- ,i _ • 
 
 tines were everywhere adherent. Anterior to L'te .clllll llIUl. 
 
 the globular myomatoas uterus lay the large ab- fjjg Treatment Of Apparently InOpet- 
 
 scess indicated by the shaded area. Both tubes 
 
 were filled with clear fluid. Hysterectomy was able Uterine Myomata.— Great diiiiculties 
 
 perfonned and the abscess drained through the .^^.^^ oCCasloUallv eilCOUlltered whcll tile ill- 
 vagma. Kecovery. 
 
 testines have been imperfectl}' emptied, or 
 when the abdominal organs are so loaded with fat that exposure of the field 
 of operation is almost im])os.sible. In a few instances the pelvis has been so 
 deep that great difficulties were exjn'rieiuHMl in removing the uterus. 
 
 We are here chiefly interested in those cases in which, on account of dense 
 adhesions or the coexistence of a purulent collection in the pelvis, hysterectomy is 
 almost impossible. 
 
 Case 71SI is an example of that class of cases in which the oijcrator, on (){)ening 
 the abdomen, feels almost hopeless. Everything is so glue<l down and covered 
 with adhesions that few, if any, of the familiar landmarks are visible. Finally, 
 he finds one point of vantage, and after loosening up this area, another is exposed, 
 until in the end the uterus can be removed.
 
 DlFf^ICULT ABDOMIXAL HYSTERECTOMIES. 637 
 
 Gyn. No. 7181. 
 
 A (1 e n s (> 1 y a d h r e 11 t 111 y o 111 a t o u s u terns. 
 
 A. II. L., inaiTied, white, aged forty-two. Admitted September 4; dis- 
 charged October 1, 1S99. On section of the abdomen the omentum was found 
 drawn out into a cord-hke mass, 9 cm. broad. This was spread out over the 
 surface of the tumor and had become adherent to the bhidder. The tvinKjr was 
 wedged in the pelvis and inmiobile; a nodule, about 1 1 cm. in diameter, extended 
 upward and lay against the right costal margin. A hand was j)assed under the 
 mass, and by rotation the nodule was brought out of the abdomen. The main tumor 
 mass was then partially raised out of the pelvis. The uterus was everywhere 
 surrounded by adhesions, and posteriorly no opening could be found on the left 
 side. The left tube and ovary were densely adherent and were plastered on the 
 side of the tumor; the left broad ligament lay spread out over the surface. 
 Posteriorly, the small intestines were everywhere densely adherent to the tumor. 
 and it was impossible to pass a hand beneath the tumor on account of adhesions 
 to the large bowel. 
 
 On the right side everything was glued down. The ileum and a|)pendix were 
 adherent to the infundibulopelvic ligament. The right broad ligament was very 
 much thickened, and was drawn up over the mass; beneath it, in the angle be- 
 tween the pelvic wall and the fundus, was a small cystic tumor. The bladder 
 was drawn high up over the tumor and covered a myomatous nodule. 
 
 Operation. The omentum was ligated and released, the small gut freed along 
 the posterior border. The left tube and ovary were dissected free with scissors. 
 It was still impossible to budge the tumor. Finally, an opening was made and 
 the ovarian vessels were caught about 3 cm. above and under the sigmoid, which 
 also had to be dissected back. The right round ligament was next caught and 
 severed, and now, for the first time, the tumor connnenced to yield. The bhidder 
 was most carefully outlined and j)ushed down with a sponge. The engorged 
 left uterine artery was exposed, caught, and ligated with heavy silk. Even 
 then the tumor was so immobile and so densely adherent posteriorly that it 
 was deemed best to control the vessels on the right side. This was accomplished 
 with the greatest difhculty. The right ovarian \-essels were cont rolled after the 
 most careful dissection. An attempt was made to control the rigiu uterine 
 vessels, but they could not be exjiosed. The subvesical vessels were large and 
 bled a('ti\'ely. The cervix was amputated: free hemoiThage l'olli)we(!, but llir 
 right uterine vessels were then caught with clamps and the right broad ligament 
 was clamped and cut. After removal of the uterus the light tube and ovary 
 were gradually dissected loos(>. The reiiiaiiuler of the opei-ali(tii was canied out 
 in the usual maimer. The patient made a x'ery satisfactory reco\-ery. 
 
 C. H. I., Case K. March 14, 1903. 
 
 r t e r i II e m y o m a t a a s s o c i a t e d w i l h a n o \' a r i a n a b - 
 s c e s s , an a b s c e s s in t h e o m e n t u m ( I''ig. 3<S0), partial
 
 638 
 
 MYOMATA OF THE UTERUS. 
 
 obstruction. relict" h y e x ]) 1 o r a t o r y o p c rati o n . 
 H y s t e r c c t o 111 y two w c v k s 1 a t c r . 
 
 Case K., seen in consultation with Dr. A. Harr Snively, of Waynesboro, Pa., 
 on March 14, 1903, is an excellent example of what may be accomplished by 
 completing the operation in two stages. When the patient Avas first seen, there 
 were sym]itoiiis of obstruction. These were relieved, and the abdomen was 
 
 Fig. 380. — Circdmscribed Abscess in the Omentum Associated with a Densely Adherent Myomatous 
 
 Uterus and an Ovarian Abscess. 
 C. H. I., K., March 26, 1903. The uterus reached to the pelvic brim. In the longitudinal section of the uterus 
 three niyomata are seen. It also contained others. Projecting into the uterine cavity is a i)olyp. The posterior 
 surface of the uterus is densel.v adherent to the rectum. One ovarj- had been converted into an abscess sac. This 
 is not, however, visible at this level. The omentum is markedly thickened and contains an abscess. 
 
 drained. After a delay of nearly two weeks it was possible to do a complete 
 hysterectomy. Had we attempted a radical operation when the patient was first 
 seen, she would have undoubtedly died on the table. 
 
 This patient had been ill for about a year, and several months before had 
 had an attack of pelvic pain, very severe in character. For the previous two 
 days the temperature had been from 100° to 101° F., and the i)ulse had been
 
 DIFFICULT ABDOMIXAL HYSTERECT* ).M1KS. 639 
 
 rapid. On the night before I saw her she colhijjsed, and her jjulse was ahnost 
 imper('e|)til)le. .She was too weak to be removed to the hospital, and ()j)eration 
 was imperative. A median incision was made, and the uterus found extending 
 shghtly above the pelvic brim. It was everywhere wedged in the pelvis and 
 covered with dense adhesions. Over the surface of the tumor the omentum and 
 several loops of small bowel had grown fast. To relie\-e the jiain, we loosened 
 up the intestinal loops and then closed the abdomen. 
 
 March 26, 1903: The uterus contained several myomata; both tubes were 
 filled with pus and glued to the pelvic floor. On the left side was an ovarian 
 abscess containing a considerable quantity of very fetid pus. Enucleation was 
 commenced from the left side, and was found to be impracticable. The right side 
 was gradually liberated, the uterus cut from right to left, and also pulled away. 
 The walls of the abscess still remained, and there was consideral)le l)lee(ling from 
 the peh'ic floor. A pelvic drain ^^■as carried down through the x'agina. 
 
 Preparatory to closing the abdomen we carefully examined the omentum and 
 found that it contained a mass about 10 cm. in diameter. The omentum was 
 very hard, and the condition suggested a foreign body. In order that there might 
 be as little escape of pus as possible we incised the left rectus, continuing the in- 
 cision five inches to the left. The omentum w^as tied off and removed. The 
 thickening was found to be due to an isolated omental abscess (Fig. 380). At one 
 point the abscess reached the peritoneum, and here, over an area 1 x 2.5 cm., 
 the surface had become necrotic. The patient made a very satisfactory recovery. 
 
 There are other cases in which the operator, once he has commenced the oper- 
 ation, from the character of the condition, is forced to complete it, not being able 
 to abandon it at any stage. One patient came with a large umbilical hernia, 
 densely adherent omentum, and a large myomatous uterus fllling the greater 
 part of the abdomen, and associated with a large ovarian abscess connnunicating 
 with the bowel. This is a typical example of such a group of cases. This pat lent 
 was, fortunately, in good condition, and made an excellent recovery. In many 
 of these cases, however, the surgeon is in a quandary as to what should be done, 
 realizing, on the one hand, that the patient is continually losing ground, ami. on 
 the other, that operation is fraught with great danger. As a rule, the operation 
 offers the only j)()ssibility of relief. 
 
 Gyn. No. 5123.* 
 
 Um b i 1 i e a 1 h e r n i a ; m u 1 t i n o d u I a i' m y o 111 a t o u s u t e i' u s ; 
 large o v a r i a 11 a b s c e s s c o m 111 u n i eating w i l h the s m a 1 1 
 bowel; h y s t e r e c t o m y ; r e c o v e i' y . (Fig. 38 1 . ) 
 
 R. L., colored, aged forty. Admitted March 23, 1S97. The patieiil had 
 first noticed a tuiiioi- ten years before. At times she had had a great de;d of 
 abdominal pain, and on one occasion had been (•(inCnied to bed tor t hree months. 
 
 * Tlioinas S. Cullcn, .Joliiis Hi)i)kiiis llos]). Kuil., S. IMtT. \<>i. \iii. ]>. '_M7.
 
 640 
 
 MYOMATA OF THK UTP:RUS. 
 
 On account of the ii'r('<2;ul:ir licrnial jjrotrusion th(> nhdoininal incision was com- 
 menced at a point midway between the xi])h()i(l and the unil)ihcus, and continued 
 downward to within a short distance of the pulx's, the hernial sac being encircled 
 and r(>ni()ved. At the umbilicus the omentum was firmly adherent. Presenting 
 at the incision were several suhpei-itoiieal iiiyomata. To these the omentum was 
 also firmly ailherent. After these adhesions had been loosened up the nodular 
 myomatous uterus, 21 \ 2S em., was delivered (Fig. 381). 
 
 Fig. 381. — A Longitl-dinal Skction of the Abdomen showing an Umhilical Uernia, a Lakge, Densely 
 Adherent Myomatous Uterus, and an Ovarian Abscess. 
 Gyn. No. .5123. The section shows, from above downward, an umbilical hernia, a large niultincMlular myoma- 
 tous uterus, on the upper and anterior surface of which the omentum is adherent, a pus-tube, an<l an unusually 
 large ovarian abscess, which communicated with a loop of small intestine. The abscess was more on the right 
 side of the body, but has been drawn on the same level to bring it out more clearly. (After Thomas S. Cullen.) 
 
 Occupying the posterior pari of the ])clvi(' cavily was an elastic tumor, 17 cm. 
 in diam(>ter. This looked like an ovarian cyst, and was intimately adherent 
 to two loops of the small intestine. I)iiriiii2; an attempt to shell off the outer 
 layers of the cyst. leaviii,ti them attached to the intestine, the cyst ruj)tured and 
 was found to contain about <)()() c.c. of grayish, fetid jnis. After removal of the 
 uterus the ovarian abscess was freed; it was necessary, however, to leave a small 
 part of the sac attached to the intestine, and on careful examination an opening.
 
 DIFFIdLT ABDOMINAL HYSTERECTOMIES. 641 
 
 1 cm. in (liaiiictcr, was found hctwccn the intestine and the abscess sac. The 
 margins of the intestinal opening were ahnost as dense as cartihige, but very 
 friable. After a good deal of dissection it was possible to turn in the edges, and the 
 opening was closed with fine silk sut ures. These were now su])ported with a second 
 and a third row. Tlie alxlomen was closed without drainage, and the patient 
 made a good I'ecovery. 
 
 The Gradual Absorption of Adhesions after Abdominal Sections. — The mere 
 opt^ning of the abdomen is in some cases followed by |)artial absorption of dense 
 adhesions. Case W. affords a striking example of siicli an amelioration of the 
 condition. On opening the abdomen we found dense adhesions everywhere, 
 and the operation had to be abandoned at once on account of the patient's 
 precarious state. She gradually inipnjved, and on several occasions, in the 
 course of the next few months, she was brought to the operating-room, but 
 each time to no avail. Finally we were alile to open the abdomen, and were 
 greatly surprised to note how the tumor had loosened up. Hysterectomy was 
 performed, and the patient was well several years after. In this case she would 
 certainly have succumbed on the table had we attempted a radical operation 
 when the abdomen was first opened. 
 
 A. W. Path. No. 8932. 
 
 S u c c e s s f u 1 h y s t e r e c t o m y a f t e r s e \' e r a 1 u n s u c c e s s - 
 f u 1 attempts. 
 
 A. W., aged forty-five, colored, seen in consultation with Dr. Brice Golds- 
 borough, at the Cambridge, Md., Hospital, May 24, 1905. For four years her 
 physician had been endeavoring to have her submit to an operation for a large 
 myoma, but she had persistently refused. When I saw hei' there was a great 
 deal of alxlominal distention; her pulse was weak and i-apid. The history 
 was strongly indicative of an accom]Kuiying peritonitis. 
 
 On o])ening the abdomen we found what ap])eared to l)e a lobuhited myoma, 
 everywhere adherent to the abdominal wall and also in the pelvis. The tumor 
 bled on the slightest touch. As her condition was desperate, we thought it 
 wiser to close the abdomen, hoping that at a later day we might i-einove the 
 uterus. 
 
 On several sul)se(|uent occasions she was bi'ouglit to the opei-ating-room. 
 but as soon as the anesthetic was started her pulse would run uj) to between 120 
 and 150. and become veiy weak. I'^inally, on August 17, 1!)05, .she was again 
 bi'ought to the operating-i'ooiu. Since the prex'ious o])(Tation she had impi'o\'ed 
 markedly, and the tuiiioi' showed much mobility. ( )ii o])eiiiiig I he abdomen we 
 foimd we wei'e dealing wit li a multinodular myomatous uterus; one lai'ge nodule, 
 fully II cm. in diameter, pi'esented at the incision, and was adherent to the 
 abdominal wall. It was shelled out, claui])e(l, and reinoNcd. .\ secoiul nodule 
 aj)peared on the left side. It was treated in a similar maimei', and a third was 
 removed from the pelvis. Durhig liberation of the first large tumor we encountered 
 41
 
 642 :myomata of tiik uterus. 
 
 an abscess which lay along the edge of and in a cleft of the tumor. The left tube 
 contained a quantity of milky pus. We amputated through the cervix, removing 
 the entire growth. The pelvis was tlrain(;d, and the patient made a slow but 
 iminterrui)ted recovery, and in the course of a few months was able to resume 
 her work. 
 
 The histologic examination sliowed that the abscess cavity noted in the cleft 
 of the large myoma was lined with typical granulation tissue. 
 
 February 20, 1907. The patient's condition is excellent.
 
 CHAPTER XXXIIT. 
 PREGNANCY AND UTERINE MYOMATA. 
 
 In the cha])t(T on abdominal niyonicctoiny we liave considcnxl those cases 
 in which a niyonicctoniy was performed (hirinij; the course of pregnancy, and on 
 p. 528 we have given data rehitive to the numl)er of pregnancies or miscarri- 
 ages the patients had had before being opc^'ated upon. 
 
 In five other cases we encountered myomata and pregnancy at operation. 
 In Case C. H. I., 620, the woman was thirtv-hve vears old, and during fifteen 
 
 Fio. 382. — A Larc:?; Pkduncui ated Subpkritonkat, Myoma Cumiiii ahm; ritKiiNANCY. (J iiat. size.) 
 Path. No. 740. (Specimen sent by the late Dr. Stansbury Sutton, of PittsburR.) The uterus measures 9.5 
 X 11 X 12 cm., the increase in size being due to the pregnancy. The tubes ami ovaries are normal. .Vttached 
 to the posterior surface of the uterus by a very l)road base is a markedly inMiular in\ oiiiatous mass, which meas- 
 ures 9x11x12 cm. For the interior of the uterus see Fig. 383. 
 
 years of married life had iie\'ei- been j)regnant, but had missed her last two 
 periods. l''or months she iiad been aware of a nodular gi'owth in the lower 
 abdomen. When the abdomen was opened, a large subpei-itoneal nodule was 
 noted, 'i'he uterus was slightly enlarged and rather .soft, so that a j)regnancy 
 was suspected. As the cervix, however, was very hard, and as the patient 
 had remained sterile throughout fifteen years of her married life, W(> excluded
 
 644 
 
 MYOMATA OF TUK UTKRUS. 
 
 a pregnancy and performed a hysterectomy. As will be seen from the accom- 
 panying history, the uterus contained a small fetus. 
 
 In ( a.se 650S the pregnancy was recognized clinically, and an attem))t was 
 made to rcmox-c the large myomata witlio\it distui-l»ing gestation. The bleeding 
 was so alarming, however, that complete removal of the uterus was deemed 
 necessary in order to save the patient's life. 
 
 In Case 12902 a widow, forty-four years of age, gave a history of having missed 
 her jx'riod li\c months before admission and of some distention of the alxlomen. 
 A large nuiltinodular uterus was detected, and the breasts were full of colostrum. 
 After carefully weighing the contlition, the operator decided to remove the uterus, 
 
 Fig. 383. — A Normal PREOXANfv Asso<iatkd with a Largk Sibi'kkiionkai. .Myoma, (i nat size.) 
 Path. No. 740. (Specimen sent by the late Dr. R. Stan^bury Sutton, i The picture represents the uterus 
 in Fig. 382 after being oijcned. The uterine walls ajjpear normal. The placental attachment presents the usu; 1 
 appearance, and the fetus, which measures 0..t cm. in length in its doubled-up i)<;sition, is perfectly normal. 
 
 The myoma did not appear in any way to he impeding the growth of the fetus. The only suspicion of a myoma 
 s furnished by a small subperitoneal nodule on the left 
 
 feeling that, from the ])osition of the tumors. deli\cry of a normal child would 
 be im])o.ssiblc. 
 
 'i1ic pathologic rc])ort shows that the largest myoma was 12 cm. in diameter. 
 and that there were also several .submucous nodules. 
 
 Fig. 38(5 shows the enlarged uterus in Case 12r)S7. Tlie patient had mi.s.sed 
 two periods, but on admission the breasts contained no colostrum, and there was 
 a brownish vaginal discharge. The cervix was larger than normal, but firm. 
 Hy.sterectomy was performed, but when the uterus was oj)ene(l a small fetus 
 was found. In this case a continuation of the j)regnancy would hai'dly have been 
 possible.
 
 PREOXAXrY AXI) I li:!;! .\ K MVdMATA. 
 
 ()4o 
 
 In Case 2434 the patient was over seven months j)retz;nant. In the fun(his 
 were several myomata, and l)h)okino; the pelvis was a eei-A-ieal myoiiia, 10 cm. in 
 diameter. The patient eomijlained of constant ])aiii in the lower alxloiiieii. 
 Normal lahoi' was out of the ((uestion. The ])reii-nan('y was allowed to advance 
 as far as possible, and Cesarean section, followed by supi'avaginal hysterecti^my. 
 
 Fici. 384. — A Prkgnant Mui.tinoullak .NUum \ i m s l-nurs. (^ nat. sizp.l 
 Path. No. 8325. (Specimen .sent liy Hr. GeorKe Ben Johnstcn. nf Kicliiunn.l. Vii.) This pear-shiiix'il uteni.s 
 measured 16x16x25 em. Scattererl over its entire surface are larKe ami small suhperiloneal m.voniatu. The 
 api)en<lages on both siile« are normal, but the left tube i.s inserteil on a liidher level than is that on the rijtht. 
 For the ai)poarance of the iiitericjr of tlu' uterus see l"\ir, ;\Sr>. 
 
 was ])ei"fornied. 'Hie niolher made a i^ood recoxci'y. but the child ilieil siiddeidy 
 without aj)pareiit cause twenty hours after o])eralioii. 
 
 The specimen shown in i'^igs. 3S2 and '.\s:\ was seiil to us by the hite Dr. 1\. 
 Stansbury Sutton, of Pit Isbiirti, I'a.; and ih.al in l'"i,iis. .'>S 1 ami .'IS,") by |)i-. 
 (leoriic Hen Johnston, of llichnioiid, \ a. 
 
 Changes in the Myomatous Uterus Due to Pregnancy. — ( 1 r o s s (' h a ii iz; e s . 
 — The ceiA'ix is usualU' nnich softer, but in some of our cases it was \-er\- hard.
 
 646 .MYOMATA OF TH K ITERUS. 
 
 On opening the abduuicn one i>; instantly iiii|)ivss('d by the niarkccl increase 
 in vascularity, as noted in Case 6508, in which, on account of the ahirming 
 bleeding, niyoniectoniy had to l)e abandoned and hysterectomy ])erformed. 
 The tremendously increased blood-sui)|)ly may give the uterus a dark, purplish- 
 red color, as was seen in Case 125S7. 
 
 Whether the jjrcgnancy is in any A\ay mccliaiiically interfered with will 
 depend, of course, on the position of the tumors. In Fig. 3S2 we see an enlarged 
 pregnant uterus, with a l)road-based, lobulated, subperitoneal myoma attached 
 to its posterior surface From Fig. 383 we see, however, that the tumor in no 
 way had encroached upon the uterine cavity, and the development of the child 
 was ])roceeding normally. 
 
 Fig. 384 shows a uterus fairly riddled with myomata, small and large nodules 
 projecting forward from the surface. The interior of this uterus, as seen in Fig. 
 385, shows that there were also interstitial and submucous myomata, and that, 
 where the myomata were subnuicous, the placenta was atrophic or missing. 
 Nevertheless, pregnancy was ])roceeding in an orderly fashion. 
 
 I''ig. ."JSO. from Case 12587, shows a dense, multinodular uterus, with one small 
 submucous myoma and an early pregnancy. A full-term pregnancy was almost 
 out of the question in this case, and the premonitory signs of miscarriage were 
 already present. If the child had become viable, the cervical myoma (a) would 
 have prevented delivery by the normal channel. 
 
 Nature has, however, the happy faculty of sometimes accomplishing what 
 seems most improbable. Case 7549 affords a brilliant example. Seven weeks 
 after a normal laboi- a large, densely adliei'ent myomatous uterus was removed. 
 Pilling U]) the entire uterine cavity was a .sloughing submucous myoma, 9 x 15 cm. 
 This case is illustrated on p. 65. 
 
 Histologic Changes . — The indi\idual muscle-fibers are considerably 
 swollen, and the nuclei are usually more vesicular. They may, however, stain 
 more deeply and be irregular in outline, as was noted in Case 12587. 
 
 In addition to th(> changes in the muscle-fibers, th(re is usually swelling of the 
 stroma cells between the muscle-l)undles. 
 
 Hyaline areas in the myomata seem to show an increased tendency to melt 
 away when associated with pregnancy. This is strikingly seen in Fig. 84 (p. 
 106). 
 
 Disappearance of Myomata after Pregnancy. — It is claimed that in a few 
 instances myomata that were clearly palj^able before and during pi'cgnancy dis- 
 ap])eared shortly after labor. We have never .seen any evidence su))porting this 
 view, but our experience with pregnancy associated with myomata has been 
 too limited to enable us to speak with any degre(> of certainty on this point. 
 
 Fig. 38.5. — Pregnancy in a Multinoijui.ar Myomatous Uterus. 
 Path. No. 8325. (Specimen sent by Dr. George Ben Johnston, of Richmond, Va.) For the appearance of 
 the intact uterus see Fig. 384. Scattered throughout the walls are interstitial and submucous myomata. The 
 fetus looks normal, and from the head to the buttocks mea.sures 16 cm. in length. Where the myomata pro- 
 ject into the uterine cavity the phicenta is very thin or entirely wanting. 'I'his is i)artioularly well seen at a anil a\
 
 PREGXAN'CY AXD UTElil.XE .MYo.MATA. 
 
 647 
 
 Vu:. :',s.->
 
 048 myo.mata uf tiik itkhus. 
 
 Myomata associated with Pregnancy. 
 
 Gyn. No. 6508. 
 
 I'^ a 1- 1 y P ]■ (' <2; n a 11 c y i n a M >' o 111 a t o ii s V t c r u s ; M y o m e c - 
 t 111 y w a s a t t c 111 p ted. h u t II y s t c r c c t o 111 y h a d t o h c j) e r- 
 foi'iiicd oil account of t li alarining h c 111 o i' i- h a g e . 
 
 A. (".. iiiari-i('(l, aged thiily-foiir, while. Admitted November 14; dis- 
 charged Decemher 20, 1S*)S. There has been no How for the hist six weeks. 
 The entire i-ighl sith' of the abdomen is on a higher level than the left. 
 
 I'^xamination under Ether. — An irregular tumor, apjiroximately 11 x 12 cm., 
 is felt low down on the right side of the abdomen. The mass is veiy hard, 
 and appears to be made up of a number of superficial l)osses with shallow sulci 
 between them. The tumor is freely movable, and can easily be ])ushe(l over 
 to the left side. On vaginal examination the outlet is found to be slightly 
 relaxed. The cervix is well back, is soft and flabby, and instantly suggests 
 pregnancy. In the anterior fornix is a small, liard nodule. The uterus itself 
 aj)p;irently contains a three or four months' ])regnancy. ()))eration, hystero- 
 myomectomy. 
 
 On section of the abdomen, the fundus is found to be dark purple in color, 
 much enlarged, and ti'av(>rsed by greatly distended vessels. Springing from the 
 uj)j)er anterior surface of the fundus is a pedunculated myoma, about 12 cm. in 
 diani(>ter. Pi'oj(>cting from t he anterior surface of the uterus is a smaller myoma, 
 about S cm. in diameter. .Myomectomy was decided upon, and the small myoma 
 was reiiKA'cd through a circuhw incision. lvemo\al was instantly followed l)y a 
 profuse hemorrhage, which was at once controlled l)y gras])ing the incision with 
 the fingers. Attempts wei'e made to control the l)leeding with sutures; but 
 there was much oozing from the needle j)unctures. Bleeding ])oints were grasped 
 with artery forceps, but a broad, deep sinus was opened, and a teriific hemorrhage 
 foIIow(Ml. The uterine muscle tore wherev(M" th(> force])s were applied. It was 
 lound that the only hope of sa\'ing the patient was to remove the uterus. 
 .\n assistant grasped the cei'vix tightly with his hand, and thus controlled the 
 bleeding. The uterus was remo\-e(l in the usual manner. The ))atient made 
 a satisfactory recovery. 
 
 Gyn. No. 12587. Path. No. 9348. 
 
 II y s t e r o m y o m e c t o 111 y . T h e V t e r us (' o n t a i n e d a T wo 
 Months' Fetus (Fig. ;-5S()). Death on the Fifth Day, 
 f r o m H r o n c h o p n e u m o n i a . 
 
 S. .)., married, aged thiily-nine. .\dmitt{Ml December oO, H)0o; died Janu- 
 ary 7, 1906. 
 
 For the last year and a hall' the periods ha\'e been increasing in length, 
 sometimes lasting thirteen days. Seven months ago a tumor was noticed in the 
 hnver abdomen. Her last period was two months before admission, but two
 
 PRKGXAXrV AXD UTKRIXI-: MYOMATA. 649 
 
 weeks ago there was a bloody discharge foi" two or three days. For the hist two 
 weeks she has been losing her a])i)('tit(\ and has had some nausea and vomiting. 
 She has been forced to remain in bed for the last ten days. The breasts contain 
 no colostrum. The lower |)art of the abdomen, as fai' as the umbilicus, is filled 
 with a firm, nodular mass. A brownish, mucous discharge escapes from the 
 vagina. The cervix is larger than normal and is firm. The history is suggestive 
 of pregnane}' with myoma, but the examination is not conclusive. 
 
 Operation. — On section of the abdomen a dark, purplish-red, myomatous 
 uterus was encountered. The uterus was boggy and suggested pregnancy. 
 The vessels of the ovarian ligaments were greatly distended. 
 
 Hysterectomy was carried out in the usual maimer, the uterus being am- 
 putated through the cervix. 
 
 The operation was a very difficult one. The j)atient left the table in a poor 
 condition. On the following day her leukocytes were 80,600; the temperature 
 was 102.6° F. She developed a pneumonia and died on the fifth day. 
 
 The autopsy showed, however, that a general peritonitis was the immediate 
 cause of death. There was an acute fibrinous pelvic peritonitis ; thrombosis of the 
 uterine and vesical veins, thromV)oses in the |)ulm()iiary arteries, jjulmonary 
 abscesses, bronchopnevmionia, acute bronchiectasis and bronchitis, acute 
 fibrinous pleuritis, acute diphtheric colitis, cloudy swelling of the viscera. 
 
 Path. No. 934S. The uterus (Fig. 386) measures 16x13x14 cm., and is 
 markedly nodular. Covering the posterior surface are many adhesions, and 
 springing from the fundus is a sessile, mulbeny-shaped nodule, 4xo cm. 
 There are also numerous other nodules springing from the anterior and jios- 
 terior walls. Scattered throughout the uterus are nodules of various sizes. The 
 uterine cavity contains a small fetus, which lies just beneath the small sub- 
 mucous myoma (rl). The myoma projects a short distance into the sac. 
 
 Histologically, the uterine mucosa presents the tyjMcal i)icture of pregnancy. 
 Over the submucous nodule, which ])i()jected into the uterine caN"ity, there is 
 considerable decidual formation, l)ut no glands. It is interesting to see tlu> 
 swelling of the nmscle-fil)ers and the stroma cells between the nniscle-bundles. 
 
 In this case signs of mi.scarriage had ah'ead>' appeai'ed, and had the chiM 
 come to term, the myoma (a), as seen in Fig. 386, would haxc preveiiteil deh\-ery 
 through the natural passages. 
 
 Gyn. No. 12902. Path. No. 9840. 
 
 A Multinodular Myomatous F t e f u s ('(tntaining a 
 V Y e g n a n c y B e t w e e n T w o a n d T h r e e M n n t h s . 
 
 F L. P., white, widow, aged forty-four. .\dniitti'd May o; disehai'ged May 
 27, 1906. 
 
 The ])atient has had no menstrua! distui'bance imtil a few months ago, wIkmi 
 the flow began to increase. I*'oui' months ago the peiiods ceased, and it was 
 thought the men 01 la use was fomimi: on. I )uiini:; the lasi h\-e nidiit lis the abdomen
 
 650 MYO.MATA OF THE UTERUS. 
 
 has rapidly increased in size. She experienced no pain until a month ago, when 
 she was confined to bed for ten days. The pain was ''jumping and gnawing" 
 ill character. The breasts were large and full of colostrum. On examination 
 under ether the tumor is found to extend two inches above the umbilicus, and on 
 the left side reaches the umbilicus. There is some blueness of the mucosa. The 
 cervix is firm, the os slightly ])atulous. The fundus cannot be made out dis- 
 tinctly, but it appears to be continuous with the abdominal mass. 
 
 The history and the examination pointed to pregnancy at about the fourth 
 month, but on account of the markedly myomatous condition of the uterus, 
 it was thought that the patient would not be al)le to go to term. 
 
 Operation. On section of the abdomen the irregular and myomatous uterus 
 showed at least fifteen myomata scattered over its surface. .-Vll the uterine 
 vessels seemed dilated, and the body of the uterus was rather l^oggy. All the 
 tissue was so vascular that even the smallest bleeding point had to be tied. 
 The patient stood the operation well and made a good recovery. 
 
 Path. No. 9840. The uterus has been amputated through the cervix. It 
 measures api)i-()ximately 10 cm. in breadth, 24 cm. in length, and 13 cm. in its 
 anteroj)osterior diameter. The great increase in size is due to the presence of 
 many myomatous nodules, the largest of which is approximately 12 cm. in di- 
 ameter and subperitoneal. There are also numerous small ones, some of which 
 are subnmcous. The uterus contains a fetus which is between three and four 
 months old. 
 
 Sections from the endometrium show typical decidua, and we have here 
 and there in it areas of coagulation necrosis and infiltration with small round 
 cells — an indication that a miscarriage would s(xjn have occurred. The muscle- 
 fibers in the myoma show a slight increase in size. 
 
 C. H. I. 620. Path. No. 8827. 
 
 A n K a r 1 y P r e g 11 a 11 c y D i s c o v e r e d a f t e r Re m oval of 
 t h e I' t e r u s . 
 
 E. S., married, aged thirty-five, white. Admitted May 29: discharged 
 June 24, 1905. 
 
 The patient had been married for fifteen years. Init had nc\Tr been thought 
 to be j)regnant. She had missed two periods, however, just before admi.ssion. 
 Upon pelvic examination a myomatous uterus was diagnosed and an operation 
 advised, as there had been a great deal of abdominal pain. On ojiening the 
 abdomen we found what appeared to be a large myomatous nodule. The uterus 
 was slightly enlarged and rather soft. We considered the po.s.sibility of preg- 
 
 FiG. 386. — An Early Pregnancy in a Myomatous Uterus. (« nat. size.) 
 Gyn. No. 12587. Path. No. 9348. The entire specimen measured 13x14x16 cm. There are numerous 
 subperitoneal and interstitial myomata. The specimen has been opened from the front, a is a cervical myoma 
 that would have certainly prevented a normal labor; b is a shaggy placental covering of the fetal sac; c, a blood- 
 clot; d is a -small submucous m.voma that encroaches on the embryonic sac; e is the thickened uterine mucosa. 
 In the right lower corner is a sketch shf)\vinK the relation of the submucous myoma to the amniotic sac.
 
 Fic. :«r). 
 
 651
 
 652 MYOMATA OF THE UTERUS. 
 
 nancy, hut the cervix was very hard. The uterus was removed, and the patient 
 speedily recovered. 
 
 Path. Xo. 8827. The specimen consists of a myomatous uterus, amputated 
 through the cervix. The uterus contains a small fetus, 1.5 cm. in length. The 
 uterus itself is nodulai', and is 16.5 cm. broad, 8 cm. in length, and 8.5 cm. in 
 its anterojjosterior diameter. The largest myoma is approximately 11 cm. 
 in diameter, and there is a diffu.se myomatous thickening in the other ]K)rtions of 
 the wall. 
 
 Sections from the endometrium show the typical ])icture of pregnancy. The 
 muscle-fibers, ])articularly beneath the mucosa, show some thickening. 
 
 S(>ctions from the myoma show typical and wide-spread hyaline degenera- 
 tion, only a few fibers remaining here and there. The interspaces are divided 
 by ;i substance that is granular (Fig. 84, p. 106). In ])laces it stains slightly, 
 at other points, deeply, the intensity of the stain indicating the density of the 
 fluid filling the spaces. 
 
 Diagnosis: interstitial uterine myomata, complicated by a pregnancy of 
 Ix'tween two and three months. 
 
 Gyn. No. 2434. Path. No. 186. 
 
 Pre g n a n c y i n a M y o m a t o u s Uterus. Cesarean Sec- 
 tion followed by S u ]) r a v a g i n a 1 H y s t e r e c t o m y. 
 
 Mrs. 1). S., aged thirty-six, white, admitted November 28, 1893; discharged 
 April 2, 1894. The jxdient had had one child and one miscarriage. Fetal 
 movemeiUs were first noticed on October 16th. The patient was not positive 
 when the menses had cea.sed. She complained of constant pain in the lower 
 abdomen. After waiting nearly two months. Cesarean section was performed, 
 as a large cervical myoma, 10x8x8 cm., choked the pelvis. After delivery 
 of the child the uterus was amputated at the cervix. The patient made an 
 uninterrupted convalescence. The child died twenty-four hours after operation, 
 without any apparent cause. 
 
 Path. Xo. 186. The contracted uterus is 16x16x18 cm. In addition to 
 the large cervical myoma there are several others scattered throughout the uterine 
 walls. The largest of these is 5 cm. in diameter. A])art from the numerous 
 myomata the uterus presented the usual appearance. 
 
 After studying the histories the reader may feel that j)oor surgical jutlgment 
 was shown in some of the cases. In one case the myomatous uterus reached 
 large ))roporlions, and in the cervix was a myoma that would have effectually 
 blocked normal delivery. In other cases there were already premonitory signs 
 of miscarriage. It is easy to look l)ack and see where im])rovements might have 
 been made. In some instances it is difficult accurately to determine the con- 
 dition until the abdomen is opened. With the exact condition before him the 
 operator, on the one hand, wishes to l)e c(jnservative and not interfere with
 
 PREGXAXCY AXD UTKRIXH MYOMATA. 653 
 
 gestation, Init, on tlic other liand, he rcalizos that there is a ju'cuhar proneness 
 for these patients to niiseaiTV. and lie also knows tliat if snhmueous myoniata 
 exist, they are liai)le to become infected. Furthermore, he cannot lose sight of 
 the fact that, if radical ])rocediires are deferred, in the near future it will become 
 necessary to again subject the ])atient to an abdominal operation. In one 
 or two of our cases it would have been wiser hail we watched thej)atient, for 
 a few months at least. 
 
 The aim in each case should be to effect a normal delivery at term, if that be 
 possible, after which, if it be deemed necessary, the myomata or the utei-us 
 can be removed. 
 
 Recenth' Bland-Sutton has drawn attention to what he terms red degenera- 
 tion of myomata occurring during pregnancy. Our exj)erience with myomata 
 in pregnancy has been so limited that we have had little opixirtunity of study- 
 ing this form of degeneration.
 
 CIIAPTEl^ XXXI\\ 
 COMPLICATIONS FOLLOWING ABDOMINAL HYSTEROMYOMECTOMY. 
 
 Hemorrhage. — Scooiularv hcinorrha^r after alxloniinal hystorcctomy has, 
 fortunately, l)eeii coiiij)aratively rare in our series. In recent years we have 
 made it a rule to tie all the cardinal vessels twice, so that if, by any chance, 
 one ligature is not tight enough, the second will effectually prevent bleeding. 
 
 In Case 3997 a densely adherent myomatous uterus, 18 x8 x 10 cm., was re- 
 moved through the abdomen. After operation the pulse become very weak 
 and rapid. Hemorrhage was suspected, although no other signs of bleeding 
 were noted. The abdomen was reopened twenty-four hours after the o])eration, 
 and a large quantity of free and clotted blood was found. The bleeding was from 
 the left ovarian artery. This was reticd securely. At the end of the operation 
 the j)ulse was 160. A liter of saline solution was introduced under the breast. 
 The patient was discharged well. 
 
 In Case 7330 the multinodular uterus extended half-way to the umbilicus. 
 One of the nodules had encroached markedly on the anterior vaginal wall. On 
 the tenth day a hematoma was detected, which lay in front of the cervix and 
 filled both broad ligaments as far as the ])elvic brim. Through a vaginal o])ening 
 the clot was removed and the cavity lightly packed. The patient was discharged 
 well on the twenty-seventh day. In this case the bleeding was in all probability 
 due to a continuous ooze from small vess(^ls, and did not come from an artery 
 or vein of any appreciable size. 
 
 In Case 9736 a boggy, adherent, myomatous uterus was removed, together 
 with the adherent a])pcndages. The abdominal wound bi'oke down. In the 
 pelvis was an accumulation of lilood, and in both broad ligaments, clots. 
 The thickening was more marked on the right side. V'aginal section was done, 
 the pelvis drained, and the clots were removed. Rapid recovery followed. In 
 this case also the bleeding was a])])arently due to oozing rather than to any free 
 hemorrhage. 
 
 In Case 3977 the catgut ligature controlling the left uterine^ artery absorbed 
 too ra])idly, and the ])atient died fi-oiii hemorrhage on the eighth day. This case 
 is described in detail on p. 681. 
 
 S y m p t o m s Suggesting 11 e m o r r h a g e . — In Case 3492 hystero- 
 myomectomy was done and the patient had a sudden fainting spell on the 
 nineteenth day; the pulse rose to 130, the res{)irations became rapid, the hands 
 were clanmiy, and she presented th(> ])icture of hemorrhage. The abdomen 
 was opened with negative results. The case was later su{)posed to be one of 
 pulmonary embolism. It is rej)()rted in detail on p. ()()9. 
 
 (554
 
 COMPLICATIONS FOLLOWING ABDOMINAL HYSTEHOMYOMECTOMY. 655 
 
 In such cases as this it is usually much hcttcr to explore the abdomen at once. 
 Naturally, the already existing depression is intensified to some extent ijy the 
 anesthetic and the exploration, but through a very small opening one can at once 
 determine whether the abdomen contains free blood or not. If there is hemor- 
 rhage and prompt action is deferred, the patient may be too weak to stand 
 any operation when the diagnosis becomes certain. Where there are definite 
 signs of hemorrhage, the abdomen should be opened at once. 
 
 Elevation of Temperature. — In reading the postoperative histories of patients 
 from whom a myomatous uterus had been removed through the abdomen, we 
 have often been surprised to see it stated that the patient had absolutely no 
 elevation of temperature. This has not been our experience. From the ac- 
 companying tabulation of 100 uncomplicated abdominal hysteromyomectomies, 
 taken in their regular sequence, it will be seen that in only 15 per cent, did the 
 temperature remain below 100° F. In over half of the cases it at one time 
 reached some point between 100.2° and 101° F., and in five cases it was over 
 102° F. 
 
 From the statistics, as frecjuently published, the operator would be alarmed 
 if the temperature reached 101° F., but, as seen from the table, it is of common 
 occurrence, and in the absence of complications should occasion little uneasiness. 
 
 TABLE SHOWING MAXIMUM TEMPERATURE IN 100 CASES AFTER AN UNCOMPLI- 
 CATED HYSTEROMYOMECTOMY. 
 99 to 100 in 15 per cent, of the cases 
 100.2 to 101 in 61 per cent. " " 
 101.2 to 102 in 19 per cent. " " " 
 102.2 to 103.8 in 5 per cent. " " " 
 
 100 per cent. " " " 
 
 The maximum temperature usually occui's within four da^^s after operation. 
 It was present on the second day in 52 per cent, of the cases, as seen from the 
 second table. 
 
 DAY OF MAXIMUM 
 
 POSTOPE 
 
 HATIVE TE.MPERATUHE 
 
 First 
 
 day 
 
 after 
 
 operation in 1,") jx-r cciif. 
 
 of tlie 
 
 cases. 
 
 Second 
 
 
 
 " 
 
 .')2 per cent. 
 
 
 " 
 
 Third 
 
 
 
 " 
 
 1.) per cent. 
 
 
 " 
 
 Fourth 
 
 
 
 " " 
 
 4 per cent. 
 
 
 " 
 
 Fiftli 
 
 
 
 " " 
 
 6 per cent. 
 
 
 " 
 
 Sixth 
 
 
 
 '' " 
 
 3 per cent. 
 
 
 
 Seventh 
 
 
 
 " " 
 
 2 per cent. 
 
 
 
 Eighth 
 
 
 
 
 2 per cent. 
 
 
 
 Ninth 
 
 
 
 
 1 per cent. 
 
 
 
 Total l(»() per cent. 
 
 Hot W e a t h e r a s a Can s e o f P o < i o p c r ;i live K 1 <• v a t ion 
 of Temperature. We have occasionally noted an uiuisual postoperative 
 rise of temperature in patients operated upon in excessively warm weather.
 
 656 MYOMATA OF THK UTRRrS. 
 
 Whether this rise is depemlcnt 111)011 the atmospheric condition or not it is impos- 
 sible to say. but the re])eated coexistence of these two phenomena strongly sug- 
 gests that hot weather predisposes to a postoperative elevation of temperature. 
 
 Pulse. — With the elevation of temperatui'e that u.sually follows an abdominal 
 hysteromyomectomy, thei'e is naturally an acceleration in the pulse-rate. 
 
 KAXC.E OF THK MAXIMIM P()S'1( )1'KHATI\ K PILSK-HATE IN 100 SIMPLE AxND SUC- 
 
 CESSFl'L AHI)( )MIXAL HVSTEROMYOMECTOMIES. 
 
 •10 to 100 in 32 per cent, of tlie cases 
 
 lU'i " 1-U " 55 per cent. " " " 
 
 122 " 130 " 7 per cent. " " 
 
 132 •' 140 " 6 per cent. " " " 
 
 Total 100 per cent. " " 
 
 Tn nearly 6S per cent, the pulse reached 102 or over .shortly after operation. 
 Tlif tai)le giving the day of most rapid |)ul.'^e-rate shows that it occurred most 
 fre(|uently on the second and third days after operation. 
 
 DAY OF .MAXLMI'M POSTOPERATIVE PULSE-RATE. 
 First (lay after operation in 13 per cent, of the cases. 
 
 Second " " " " 41 per cent. " " " 
 
 Third " " " " 2(1 per cent. " " " 
 
 Fourth " " " "11 per cent. " " 
 
 Fifth " " " " 5 per cent. " " " 
 
 Sixth " " " " 1 per cent. " " " 
 
 Seventh " " " " 1 per cent. ■' " " 
 
 Eisihth " " " " 1 per cent. " " " 
 
 Eleventh " " " " 1 per cent. " " " 
 
 Total 100 per cent. " " 
 
 A Ik a pi d Pu 1 se. — When the myoma has been complicated l)y i)Us-tubes 
 or a pelx'ic abscess, it is perfectly natural tliat tlie pulse-rate should be rai)id not 
 only during, but also after, operation. A (|uickened pulse is likewise usually 
 noted when jjeritonitis is de\'elo])ing. 
 
 In Case <S495 the ])atient had pal])itation of the heart and shortness of breath, 
 a.'^sociated with, and ])i-obably dependent on, an eiilai'ged tliyroid. Spinal 
 cocain anesthesia was employed, and the abdomen oi)ened. The i)ain was so 
 .•severe that ether had to be substituted. Ilvsterectoiny was then iierformed. On 
 leax'ing the table the patient had a very rapid pulse and rapitl and sh;dlow re.s- 
 ])irations. The jnilse \-ai'ie(l from ISO to 200 for the Hi'st tweiUy-four hours, 
 and then gi'adually became slower. 
 
 It is difhcult to determine whether the sjjinal anesthesia, the goiter, or l)oth 
 wei'e in any way responsible for the rapid pulse. 
 
 These figures will naturally vary somewhat in diffei'ent clinics, but it is 
 readily seen that, e\-eii in the sim|)le uncom])licated abdominal hysteromyo- 
 mectomies, there is usually a definite rise of temperatiu'c and pulse at some jx'riod 
 during the convalescence.
 
 COMPLICATIONS FOLLOWING ABDOMIXAL HVSTEHO.M VOMECTOMY. 657 
 
 Postoperative Retention. — Pvctcntion of lu-inc folluwino; the avemge hystero- 
 inyoniectomy has not been very conmion in our cxporiencc. Where the bladder 
 has been drawn high up on the surface of the tumor, it may l)c several days be- 
 fore it regains its normal power of contractility, and temporary retention may 
 occur. When the bladder-walls are greatly hypertrophied, retention may occur, 
 as was noted in Case 3445. 
 
 As a result of the removal of the uterus, the position of the bladder is naturally 
 altered, and this tends to produce retention for a short period. Supravaginal 
 hysterectomy causes much less alteration in the location of the bladder than does 
 a panhysterectomy, and hence the tardy vesical evacuation is less frequent after 
 the supravaginal operation. 
 
 When the patient finds it very difficult to void, a hot-water l)ag may be 
 applied over the bladder, and hot douches given. Contractions of the bladder 
 may also be favored by making the patient sit up, if it is deemed .safe. Catheteri- 
 zation should Ije avoided whenever possible. 
 
 Partial Suppression of Urine. — In Case 7240 a large myomatous uterus was 
 removed from a white woman aged thirty-eight. Prior to operation she had had 
 frequent and profuse uterine hemorrhages. She had a mitral stenosis, with an 
 accompanying hypertrophy. Her hemoglobin was 60 per cent. She did well 
 until the tenth day, when slight dyspnea was noted. There was some edema 
 of the face and legs, and a rapid pulse. During th(^ twenty-four hours she voided 
 only 300 c.c. The cardiac dulness had increased, and the heart's action resembled 
 the fetal type. Digitalis and Epsom salts were administered, and the patient 
 drank freely of cream of tartar water. She was discharg(Hl on the twenty-fifth 
 day in excellent condition. 
 
 The partial suppression was imdoubtedly secondary to the cardiac lesion. 
 
 Cystitis. — Inflammation of the bladdc^r very frequently follows abtloniinal 
 hysterectomy for carcinoma of the cervix. This is primarily due to the fact that 
 it is impossible to perfectly sterilize the carcinomatous growth, and, secondly, 
 because the extensive dissection not only necessitates free handling of l he bladder, 
 but often also the cutting off of a ])ortion of the vesical blood-supj)ly. 
 
 Where the myomatous uterus is removed sui)ravaginall\'. the bladder is 
 usually little disturbed, and ])rovided there has been no previous abnormality 
 in this viscus, no trouble follows. \\v ha\'e had i-elati\'ely few cases of cystitis 
 after hysteromyomectomy. 
 
 Nephritis. — We shall consider here only those cases in which i-eco\'ery took 
 place. Definite signs of renal insufficiency were noted in sevei-al of the i)aliciUs 
 who (lied of general peritonitis. These cases are discussed a! length on |>. (173. 
 
 In Case 4S()<), after removal of a lai'ge myomatous uterus, a I I'ace of albumin 
 and some hyaline casts were noted. The convalescence, howexci-. was not in any 
 way disturbed. 
 
 In Case 10101 the urine was normal befoi'e o))eration. .\fter reinowil of a 
 nmltinodular uterus, which i-eached the umbilicus, the urine contained a trace 
 42
 
 658 MYOMATA OF THE UTERUS. 
 
 of allKiniin, and some hyaline and granular casts. The temperature reached 
 102.5° F. twenty-four hours after operation, and on th(> eleventh day reached 
 103° F. The patient was discharged in good condition. 
 
 Case 77()o, in which a severe postoperative nei)hi-itis was associated with a 
 large Ix'd-sore and acute mania, is rejxjrted in detail on p. (Hil. 
 
 Edema of the Legs. — Tn Case 7240 hysterectomy was {x-rformed for a very 
 large cervical niyotna, Ki x 17 x IS cm. The i)atient was anemic, and the cardiac 
 dulness was increased. The heart -sounds also suggested dilatation. The patient 
 did well until the tenth day, when the pulse became weak, intermittent, and rapid. 
 There was slight dys))nea, and some edema of the face and legs. 
 
 Tinctui'e of digitalis and Fpsom salts were adniinistei'ed, and cream of tartar 
 water was given lihei'ally. The patient im))i-oved ra{)idly and left the hos])ital 
 twenty-five days after ojH'ration. The edema in this case was evidently due 
 to the cardiac insulliciency. 
 
 Nausea and Vomiting, -Formerly nausea and \'omiting were l(j(jke(l for after 
 nearly all serious abdominal operations, but since the introduction of the drop 
 method of administering ether, the giving of large quantities of water to the 
 patient as soon as siie desires it after operation, and the raising of the patient's 
 head on pillows, thereby tending to carry the gastric contents downward in- 
 stead of U]nvard. our experience with nausea and vomiting has been remarkably 
 diminished. 
 
 Some patients, ho\ve\-ei', show a peculiar tendency toward nausea and vom- 
 iting. In Case 2()*)i), in which the operation was sim})le, the patient had almost 
 constant nausea for forty-eight hours. In Case 2129 there was nausea for ten 
 days, but only slight vomiting. Tn Case 2919 there were obstinate nausea and 
 vomiting for the first six days. 
 
 S t e r c o r a c e o u s \' o m i t i n g . — Fecal vomiting is relatively connnon 
 in cases of intestinal obstruction and in peritonitis, l)ut not very often met with 
 in patients that i'eco\-er. 
 
 In Case 9971 the patient had carcinoma of the cervix and adenomyoma of 
 the body of the uterus. For several days after the necessarily extensive hyster- 
 ectomy she had excessive naus(>a, vomiting, and diai'i-hea, and also fecal vomiting. 
 For the first ten days after operation her life hung in the balance, l)ut after that 
 the convalescence was raj)id. 
 
 Stercoraceous material was washed from the stomach in Case 2598, several 
 days after an ai)doniinal myoinectomy. This case is reported in detail on p. 548. 
 
 D a r k - b r o w n \' o in i t u s . — In very ill ])atients small or large quanti- 
 ties of a dark-brown material are frequently ejected from the stomach. This 
 fluid resembles coffee-grounds to a certain extent. The coloring is in part due 
 to partly digested blood. \Mienever such vomit us is noted, a grave prognosis 
 should be given, as neai'ly all these patients die. 
 
 Case 7560, in which an aljdominal niyoniectoniy, and Case 5858, in which
 
 COMPLICATIONS FOLLOWING ABDOMINAL HYSTKHOMYOMECTOMY. Go9 
 
 an al)doniinal hystcroctoniy, had been performed afford typieal examples; 
 both patients died. 
 
 Intestinal Worms. — In two of our cases lumbrieoid worms were detected after 
 operation. In Case 7460 the myomatous uterus nearly filled the abdomen. 
 Hysteromyomectomy was performed, and the patient made an uneventful re- 
 covery. On the eleventh day she passed a lumbrieoid worm,' 35 cm. long. 
 Ten da3^s later santonin was administered, with the result that a large number 
 of round wonns and many eggs came away. 
 
 The convalescence in Case 2706 was not quite so smooth. After a hystero 
 myomectomy the patient had persistent nausea and vomiting until the fourth 
 day, when, after an ascaris lumbricoides, 14 cm. long, had been vomited, the 
 nausea and vomiting ceased. 
 
 In 1894 Stavely * gave an interesting account of the symptoms produced by 
 lumbrieoid worms after abdominal operations. He found that the most con- 
 stant and alarming feature in such cases was a peculiarly persistent nausea and 
 severe vomiting, accompanied by colicky pains, disturbed breathing, an anxious 
 expression, palpitation of the heart, and a general feeling of malaise — a complex 
 of S3aiiptoms quite different from the simple persistent nausea and discomfort 
 frequently ol^served after anesthesia. 
 
 Occasionally, in our abdominal work, when we have detected worms at 
 operation, they were squeezed between the fingers, later a cathartic was given, 
 and the parasites usually came away dead and somewhat macerated. 
 
 Obstipation. — With the patient in the recumbent position it is often diflicult 
 to secure a proper evacuation. We usually rely on enemata for the first few 
 days, followed later by some mild laxative. The tendency to obstinate con- 
 stipation is especially noticeable in very stout individuals. 
 
 In some cases the tardy bowel evacuation amounts almost to intestinal 
 obstruction. This was especially noticeable in Case 4172. If there are signs 
 of obstruction, cathartics are contraindicated absolutely. A harmless but efii- 
 cient laxative is castor oil. The safest plan is to rely entirely on enemata. 
 
 Rectal Tenesmus. — In Case 3320 the multinodular myomatous uterus extended 
 above the uml)ilicus. For the first thirty-six hours after operation there were 
 pronounced sym{)toms of shock, and the patient had marked nrtal tenesmus. 
 
 Intestinal Obstruction. — For the fatal cases of obsti-uction following hystero- 
 myomectomy see p. ()77. 
 
 In Case 109()9 the patient had noticed a small abdoiiiinal tumor for o\-er 
 thirty years before admission. At the time of operation tlie utei'us icaehed to 
 the umbilicus. On the sixth day after operation a loop of siunll i)owel was 
 brought out and oix'iied on account of intestinal obst iiiclion. An unsuccessful 
 attempt was mack; to close this opening foui' days lalei-. I'inall\, however, it 
 
 * Altjert L. Stascly. liilcsliiiMl Wdrriis :is ;i Cornplic:!! iini in .Muloiniiial Surg(>ry, .lolins 
 H()})kins IIosp. I^cpDrts. IS'.H. \iil. iii, ]>, :?71.
 
 660 MVOMATA OF THE UTKUrS. 
 
 was cloi^ied two nionths after operation, and the patient dischai'ged ])erfectly 
 well. 
 
 In Case 12439 the hirac multinoduhir uterus was adiierent to the bowel in 
 Douglas' cul-de-sac. Durinji' liberation of adhesions })urulent accunnilations in 
 the appendaii'es on both sides were opened up. The surrounding structures 
 were walled off as carefully as possil)le, to minimize the danger of infection. Dur- 
 ing the operation just prior to closure of the abdomen the pelvis was drained 
 through the vagina. 
 
 On the third day tlie ])atient vomited and hiccoughed a good deal. Her 
 general condition was worse, and she had a spot of marked tenderness near the 
 umbilicus. In the abdominal incision was a small amount of slightly blood- 
 tinged turbid fluid. The intestines were moderately distended, and had lost 
 their glistening appearance. A loop of distended small bowel was brought out, 
 suturcnl to the abdominal wall, and opened S(>veral hours later. The fecal 
 fistula jM'i'sisted for over two months. Finally the patient was discharged in 
 good condition. 
 
 Both of these patii'uts would in all ])robability have died had not the enter- 
 ostomy been done. In all cases in which there are definite signs of obstruction 
 the safer ])rocedure is to at once ex])lore the abdomen and. if necessary, do an 
 enterostomy. 
 
 Fistula in Ano. — In Case 7859, the patient, aged fifty-two, white, as a result 
 of the excessive menstrual How, had become \-erv weak. Her hemoglobin was 
 30 ])er cent, and a soft systolic tmirmur was audi!)le over the entire precordial 
 region. A huge nmltinodular and adherent myomatous uterus was removed. 
 At the time of her discharge from the hospital her hemoglobin had risen to 
 59 per cent. One inch to the right of the anus was a small fistulous opening 
 from which a dark gra>ish material was discharging. The surrounding tissues 
 wei"e indurated. 
 
 Cardiac Complications. — We shall include here only those cases in which re- 
 covery took place. As noted on ]). 453, many of our patients have had a very 
 low hemoglol)in, and it is remarka!)le that so few manifested abnormal cardiac 
 symptoms following ojx'ration. 
 
 In Case 7240 there was a gra\'e anemia. The heart was enlarged, and a 
 diastolic rumble was lieard. A very diHicult hysterectomy was ])erform(>d. 
 The patient did well until the eighth day, when she manifested a slight (lysj)nea. 
 There was some edema of the face and legs, and a rapid and weak pulse. The 
 area of heart dulness was considerably larger than on admission, but on auscul- 
 tation no nuuTuurs could be heard. The heart's action was rajiid and approached 
 the fetal type. She was given liquid diet, Epsom salts, cream of tartar water, 
 and tincture of digitalis. She was discharged in excellent condition. 
 
 In Case 10164 what aj)i)eared to be a pseudo-angina developed on the sixteenth 
 day. The pulse became rapid, small, and weak, and there was considerable 
 precordial pain. The attack lasted only a few hours.
 
 COMPLICATIONS I^OLLUWI.XG ABJ)(),M1\AL HVSTKKo.M YU.MKCTU.M Y. 001 
 
 In Case 12764 an attack of syncope occuitccI on the third day. It was thoup;ht 
 to be hysterical in character. 
 
 In Case 12696 faintiii,u' occurred on tlie second day (hirinu' the removal of a 
 pelvic drain. 
 
 Nervous Phenomena. — In a few of the cases the patients manifested marked 
 mental depression or excessive ner\'ousness prior to operation, but after removal 
 of the uterus these phenomena usuallj' disaj)peared. .Marked nervous symptoms 
 following hysteromyomectomy are rare. They are divisible into two main groups: 
 
 1. Nervous symptoms a])])arently dependent upon local causes. 
 
 2. Nervous symptoms without any definite assignable cause. 
 Nervous Symptoms Dependent upon Local Causes. — 
 
 In Case 2070 a simple hysteromyomectomy was performed. The patient, a white 
 woman, aged thirty-four, did well until the third day, when her pallor became 
 more marked; the pulse rose to 130, and the temperature to 102.4° F. There 
 were al)dominal distention and restlessness. The ])atient was delirious and 
 nauseated, but on the seventh day a decided improvement was noted, and she 
 made a good recovery. In this case there was probably intestinal atony or a 
 partial obstruction, with absorption from the stagnant intestinal contents. 
 
 Nervous S y in p t o m s without any Assignable Cause . — 
 On p. 547 it was noted that in Cases 2710, 78S6, and 8259, marked hysterical 
 manifestations developed after an abdominal myomectomy. In Cases 3449, 
 3535, and 3918 intense nervousness followed the abdominal hysteromyomectomy. 
 
 In Case 2806 the nervousness was so severe that it at times bordered on 
 delirium. 
 
 Hallucinations . — In Case 11294, the patient, aged fifty, white, 
 had a definite systolic inunnur at the apex. As soon as the abdomen was o))ened, 
 the condition became precarious, and a speedy hysterectoin}- was imj)erative. 
 The patient lost a considerable amount of blood and was nuich shocked after 
 operation. 
 
 On the fourth da}' she began to ha\'e hallucinations. These gradually in- 
 creased in intensity until she became practically insane. Her tem|)erature 
 nevcn' I'ose above 100.5° l'\, and her general condilion was good. 
 
 On the fourteenth day after operation she was ti'ansfei'red to the isolation 
 ward. Eleven days later hei' me!ital condition was again clear, and she was dis- 
 charged ap|)arently well. Ten months later her |)hysician reported that she 
 was p(>rfectly well. 
 
 This ])atient was naturally hysterical, exceedingly dexout . hypersensitix'e. and 
 petulant. The loss of mental control was in no wa\' due to an intoxication, l)ut 
 must be at t ri but ed to a weak II lent a Iha I a lice. 
 
 Acute .Mania. In Case 77()3 an abdominal hysterectomy was per- 
 formed for a myoiiialous utei'us of moderate size. Prior to operation the 
 patient, a white woman, aged twenty-nine, had hail gical dilliciilty in kee])ing 
 her mind on the suhiect under consideration, and liaxc irrational answers.
 
 662 MVOMATA OF THK UTERUS. 
 
 After operation she eoniplained a great deal and showed hysterical symptoms. 
 On the sixtli day restraint was neeessaiy. Dr. Henry M. Hurd saw her in con- 
 sultation and diagnosed acute mania. For some days after this she voided and 
 defecated unconsciously, and as a result a very extensive bcd-.sore develo})ed, not- 
 withstanding all the precautions exercised. She also developed an intense 
 nephritis. She was placed in a continuous bath, and gradually improved mentally 
 and i)hysically. During convalescence she fully appreciated her condition, and 
 referred to the periods of excitement as '' bad dreams." When discharged on the 
 forty-fourth day, she seemed ([uite rational. 
 
 In this case also there was a lack of mental poise before operation. We have 
 seen patients go violently insane after minor operations, such as perineal repair, 
 and it is rather remarkable that we have encountered so few postoperative 
 mental disturbances in such a large number of severe abdominal operations when 
 the ]iatient's reser^■(' force is so fully taxed. 
 
 Suppuration of the Abdominal Wound. — Infection of the alxlominal wall may 
 be limited to a small area or may involve the entire length of the incision. In 
 some cases it is superficial; in a few it involves the entire adipose tissue and ex- 
 tends to the fascia. It is more ])rone to occur in stout than in thin individuals. 
 
 In some cases, in addition to a myomatous uterus, there are pus-tubes or 
 a jx'lvic abscess. In othei' instances a sul)mucous myoma has commenced to 
 ulcerate, or there is an endometritis. In all such cases there is a danger of in- 
 fection of the abdominal wall from the already existing pelvic focus. To avoid 
 such infection the abdominal incision is cai'efully protected with gauze, and the 
 instruments that have been employed in the ])elvis are discarded during the 
 closure of the abdominal incision. 
 
 Breaking down of the incision is in some cases undoubtedly due to injury 
 of the tissues by strong ti'action with the reti'actors, too small an abdominal 
 incision having been made. Our experience coincides with that of other clinics 
 in that we occasionally have an incision break down when we can find no adequate 
 reason for the infection. 
 
 On ]). 673 a case is reported in which, on the fifth day, the entire abdominal 
 incision gave way and the omentum was exposcHl. The patient died a few hours 
 later. 
 
 Bed-sore. —In Case 7703, after renioN'al of the uterus, the patient developed 
 acute mania on the sixth day and restraint was necessary. She subseciuently 
 voided and defecated unconsciously, and as a result an extensive bed-sore de- 
 veloped. She finally made a good recovery. 
 
 Pelvic Infection. — In Chapter X\TII it is recorded that in many of our cases the 
 tubes and ovaries were the seat of an acute or chronic inflammation, and it is 
 little wonder that, after a .supravaginal hysterectomy, there should occasionally 
 l)e a subsequent pelvic accunuilation. In the greater nund)er of these cases we 
 guai'd against a subs(H|uent pelvic abscess by di-aining thi'ough the vagina before 
 closing the abdomen. 
 
 We shall here consider oidv those cases in which no e\"i(lence of a recent in-
 
 COMPLICATIONS FOLLOWING ABDOMINAL H VSTEROMYOMECTOMY. 
 
 663 
 
 fection was noted at the time of opc^nition. Jii all these cases it is, of course, 
 necessary to cut across the cervix, and if, ])erchancc, the uterine cavity is infected, 
 there is great danger that the cervical stump or the surrouncHiig jx'lvic tissue will 
 become implicated. Again, if a myoma extends far out in the broad ligament 
 and impinges on the lower pelvic wall, it is at times difhcult completely to obliter- 
 ate the resultant cavity, and if there is any oozing into this cavity, the contents 
 are prone to become infected. Such a condition existed in Case 5093, and it was 
 subsequently necessary to drain the abscess through the vagina. In Case 5359 
 a myoma in the left broad ligament was shelled out : an abscess developed in the 
 broad ligament and oj)ened into the bladder. This case is described on p. 553. 
 
 CASES OF PELVIC INFECTION FOLLOWING ABDOMINAL IIYSTEPvOMYOMKCTONn' 
 
 Gvx. No. 
 
 
 HiGHKST 
 
 
 
 
 
 
 Temp. 
 101.0° 
 
 
 
 
 3614 
 
 Diffuse myomatous 
 
 Inflammat i o n 
 
 Cervix di- 
 
 Recovery. 
 
 
 thickening of uter- 
 
 
 of cervical 
 
 lated; 70 c.c. 
 
 
 1 
 
 ine wall. Septic 
 
 
 .stump. 
 
 of pus es- 
 
 
 
 temperature. 
 
 
 
 caped ( Figs. 
 387and3S8). 
 
 
 4193 
 
 Large, densely ad- 
 
 105.0° 
 
 Inflammatory 
 
 No operation. 
 
 Kxudategrad- 
 
 
 herent myomatous 
 
 
 exudate on 
 
 
 ually disap- 
 
 
 uterus. Septic tem- 
 
 
 right side of 
 
 
 peared. 
 
 
 perature noted on 
 
 
 pelvis. 
 
 
 
 
 twentieth day. 
 
 
 
 
 
 o093 
 
 Myomatous uterus 
 
 101.2° 
 
 Pelvic abscess. 
 
 Opened per 
 
 Patient per- 
 
 
 size of a six months' 
 
 
 
 vaginam on 
 
 fectly well 
 
 
 pregnancy. Tumor 
 
 
 
 twenty- sixth 
 
 eleven years 
 
 
 spread out in left 
 
 
 
 day. 
 
 later. 
 
 
 broad ligament. Mild 
 
 
 
 
 
 
 septic temperature. 
 
 
 
 
 
 6030 
 
 Uterus about 11 cm. 
 
 102.0° 
 
 Encysted pel- 
 
 Opened per 
 
 Recovery. 
 
 
 in diameter. Cer- 
 
 
 vic perito- 
 
 vaginam on 
 
 
 
 vical myoma shelletl 
 
 
 nitis. 
 
 f ou rt ecu t h 
 
 
 
 out. Septic temper- 
 
 
 
 day. 
 
 
 
 ature. 
 
 
 
 
 
 6039 
 
 Uterus extended 3 
 
 103.5° 
 
 Inflammatory 
 
 Opened }ht 
 
 Recovery. 
 
 
 cm. above umbili- 
 
 
 mass, 4.5 cm. 
 
 vaginam on 
 
 
 
 cus. Hroad cervix. 
 
 
 in diameter, 
 to left ol 
 cervix. 
 
 f ou rt ec n 1 li 
 ilay. 
 
 
 7237 
 
 Densely adherent niy- 
 
 103.6° 
 
 Abscess in cer- 
 
 Cervix dilated; 
 
 Reco\ cry. 
 
 
 1 omatous uterus. .\d- 
 
 
 vical stuin|> 
 
 90 c.c. of pus 
 
 
 
 nexa unusually ad- 
 
 
 
 escape d 
 
 
 
 herent. 
 
 
 
 through ex- 
 ternal OS. 
 
 
 10555 
 
 Myomatous uterus; 
 
 101. 0° 
 
 On eiglitecniii 
 
 No ()|)erat ion. 
 
 Di^appea red 
 
 
 subperitoneal nod- 
 
 
 (Imv indura- 
 
 
 in ten days 
 
 
 ule 10 cm. Adhe- 
 
 
 tion on riglit 
 
 
 after fre- 
 
 
 sions; slight te;ir 
 
 
 side of pelvis, 
 
 
 (|U('nt use 
 
 
 in outer coat ol 
 
 
 e X t e n ding 
 
 
 of hot 
 
 
 rcctuin. 
 
 
 from cer\i\ 
 to pel\ic\\;dl. 
 Tenderness. 
 
 
 douches. 
 
 San. No. 1944 
 
 MyoiiiMtoiis ulerii--, 
 Sx 12 X 12 cm. 
 
 100.1^' 
 
 Til ic k e ti i ng 
 around cer- 
 
 .\() ii|)('rat ion. 
 
 Kcco\(Ty. 
 
 vix for thir- 
 teen (lavs.
 
 664 
 
 MYOMATA OF THK UTERUS. 
 
 Treatment. — In some cases it is marvelous how the induration will 
 literally fade away under frequent hot douches. This was well exemplified in 
 Cases 4198 and lOooo. From the surgeon's point of view these cases should be 
 
 divided into two main groups: 
 
 1. Infection rmiilcd to the cervix. 
 
 2. Infection invoh-ing the hroad liga- 
 ment or extending to Douglas' pouch. 
 
 Infection Limit e d to the 
 C e r V i X . — If the area of induration is in 
 the cei-vix and not marked in the broad 
 ligament, it is ])robable that the infection 
 has come from the cervical canal, as in 
 
 Fio. .387.— A Purulent Accumulation in thk Fig. 387. lu SUch a CaSC it is Ouly UeCeS- 
 Ckrvic.l Stump Following Suprav.v.u- ^^^ carcfullv dilate the CCrvix and pUS 
 
 NAL Hysterectomy. - j ^ i 
 
 Gyn. No. 3614. After supnivugiiial removal CSCapCS (Fig. 388). This Ulcthod WES 
 
 of an adherent myomatous "tems the patient .^^l, |^.^| J,^ (^.^g^g ^QU and 7237. 
 
 had a temperature rangmg from 100 to 101" ' 
 
 for several days. On the fifteenth day the cer- Drainage of DoUglas' pOUch lu either of 
 
 vix was dilated (Fig. .388) and about 70 c.c. of , i i i i c i-i.i.i 
 
 pus escaped. The abscess developed between thcSC CaSCS WOUld liaVC bCCn Ot llttic Or HO 
 
 the cervical stump and the overlying pelvic vdue * 
 
 peritoneum. (After Thomas S. CuUen.) 
 
 Infection Involving the 
 B r o a d L i g a m e ii t or Douglas' S a c . — In these cases vaginal 
 drainage, as described on p. ()23, should be carried out. 
 
 Multiple Abscesses. — (Case H.) The })atient was admitted to the Church 
 Home and Infirmary in June, 1903. On 
 opening the alxlomen one of us (Cullen) 
 found a ghjlmlar myomatous uterus 
 wedged in the ])elvis. It was removed in ] 
 the usual way from left to right, but with 
 considerable difficulty on account of the 
 dense jidhesions and the thickened and 
 adhei-eiit Fall()])iaii tubes. At tlle time of 
 operation the j)atient had a very bad va- 
 ginal discharge. 
 
 Shortly after operation the temperature 
 
 rose, and on the elcN'enth day it reached 
 
 103° F. On ]X'lvic examination a definite 
 
 iiKhirated mass, about 8 cm. in diameter, 
 
 was felt on the left side. .\ small trans\'erse incision was made through 
 
 the vaginal mucosa, just behind the cer\'ix, and blunt dissection continued 
 
 upward and to the left with the finger. A blunt uterine dilator was in- 
 
 * Infection Limited to the Cervix. — In Case 1499. during convalescence the patient had several 
 attacks of pain in the lower abdomen, with a rise in temperature. Following this there was a 
 profuse discharge of pus from the vagina. There had evidently Ix-cii a purulent accumidation 
 in or near the cervical canal. 
 
 Fic. 388. — Dii.ATiNi; a Cervix to Re.move an 
 Accumulation of Pus Between the 
 Cervical Stu.mp .\nd the Pelvic Peri- 
 toneum. (.\fter Thomas S. CuUen.)
 
 COMPLICATION'S FOLLOWING AUI)()ML\AL II VSTKIJO.M V().MK( TOM V. 6(l5 
 
 troduccd, and a considerable amount of bloody fluid and pus csca])!')!. During 
 the afternoon there was a good deal of oozing, and when I returned to the citv. 
 after a few hours' absence, the jAilse was 1.30 and tht' ])atient had lost a gi-eat deal 
 of blood. She was immediately anesthetized. The oozing was fcnmd to come 
 from the left side of the cervix, ju.st at the normal site of the uterine vessels. 
 It was impossible to check the bleeding without j)la('ing ligatures in verv close 
 proximity to the ureter. The abscess cavity was accordingly quickly packed 
 with iodoform gauze which was se^ATi in place with catgut, the vaginal walls 
 being drawn over it as far as possible. The pulse after operation varied from 
 150 to 160. Saline infusions and strychnin were employed. ( )n I hi' loHowing 
 day the pulse had droppetl to 120 and was of good volume. A few da}-s later 
 an area of induration was noted just posterior to the anus. This gradually in- 
 creased in size. The overlying skin, although pale, was somewhat edematous. 
 An incision was made, and a pocket of pus containing at least 100 c.c. was found 
 deep in the adipose tissue. The temperature steadily drojiped after the abscess 
 had been opened and soon became normal. 
 
 A few days later there was pain in the right forearm. The jtatient had 
 frequently had rheumatism, and her husband, a physician, thought that the pain 
 was similar to that she had previously experienced. We were, however, sus- 
 picious of an abscess. The temperature again rose. We made an incision in 
 the right forearm and let out a considerable (juantity of pus. Four years later 
 the patient was in excellent condition. We had done our best i)rior to operation 
 to check the offensive vaginal discharge, but had be(»n unable to do so. The 
 original infection noted in the pelvis at the time of operation and during the 
 hysterectomy had evidently become disseminated. 
 
 Phlebitis. — In the accompanying table are the records of 27 cases of phlel)itis 
 following abdominal hysteromyomectomy. In 17 the left leg was involved: 
 in 6, the right leg, and in .3 there was thrombosis on both sides. In one case the 
 records are not cleai'. 
 
 In some cases only the saphenous \'ein was inq^licated; in others there,' was 
 definite thrombosis in the femoral \'ein. 
 
 In Case 49.55 the myomatous uterus was densely adherent . Dui'ing convales- 
 cence the abdominal incision broke down almost completely, and on (he sixteenth 
 day a very severe j)hlebitis de\('loped in both legs. The j)atient finally made a 
 good recovery. 
 
 In Case 12154 the myomatous uteinis extended nboxc the umbilicus ;nid 
 was \'ery adherent. Phlebitis (lexclojx'd in the Idl leg on ihc ninlh day: 
 in the I'ight on the Iwenly-third day. The ])atieiil made ;i good I'ecoxcry. 
 
 In two of these cases I hi'onibosis had been not rd jtr'nir lo opei';it ion. 
 
 In Case 75()0 a phlebitis ha<l (lc\clo))cd in llie Idl leg al'lcr ihe birlh of the 
 second child. During convalescence, nfl cr ii'iiio\;il of a small luyoiualous ulcrus 
 and the re])aii" of a lefl ureteroxnginal llslula, phlebitis de\-elo|)ed in the i'ight 
 leg.
 
 666 
 
 MYOMATA OF THE UTERUS. 
 
 In Case 12199 an ovarian tumor had been removed eight year.s before ad- 
 mission, and during convalescence there had been thrombosis of both femoral 
 veins. After the removal, by abdominal section, of a myomatous uterus the 
 size of that of a four months' pregnancy, thrombosis in l)oth femoral veins again 
 (level()i)ed. 
 
 PH I.I'.IUriS F( )LL( )WIXG HYSTEROMYOMECTOMY. 
 
 Cask No. 
 
 1666 
 
 209S 
 
 344.") 
 4369 
 4372 
 
 4617 
 
 Size of Uterus. 
 
 HEMO.-.I.OBIN. Day AFTER 
 
 Operatio.n'. 
 
 Vein Thro.m- 
 
 BOSED. 
 
 Remark.s. 
 
 Nearly filled ab- 
 
 16th 
 
 Left saphenous 
 
 Swelling of glands in 
 
 domen. 
 
 
 vein. 
 
 groin. Edema of foot 
 and leg. 
 
 Abdomen liidf 
 
 .\neniic. 22(1 
 
 In left leg and 
 
 Pus in uterine cavity at 
 
 filled. 
 
 
 thigh. 
 
 operation; evidently 
 slight infection after 
 operation. Temper- 
 ature 99.6° to 103.6°. 
 
 Large. 
 
 Reached uinl)ili- 
 
 loth 
 
 \'erv"anemic. 16th 
 
 lOtii 
 
 In left leg. 
 Left .saphenous. 
 In left leg. 
 
 \'ery difficult operation. 
 
 cus. 
 Reached uinhili- 
 
 
 In right leg. 
 
 Discharge of foul-smell- 
 
 CII.S. 
 
 
 
 ing pus from vagina 
 for a long time after 
 
 Filled large part 
 
 1.5th 
 
 Right femoral 
 
 operation. 
 Pleurisy on right side 
 
 of alxlomen. 
 
 
 vein. 
 
 during convalescence. 
 
 4902 
 
 Filled large part 
 
 
 of alxlomen. 
 
 4903 
 
 Filled two-thirds 
 
 
 of abdomen. 
 
 49.5.5 
 
 Moderate size, 
 
 
 densely ad- 
 
 
 herent. 
 
 .5766 
 
 .Size of six and one- 
 
 
 half months' 
 
 
 pregnancy. 
 
 6372 
 
 Fills pelvis. 
 
 nth 
 
 16th 
 20th 
 
 691.5 
 7.569 
 
 Size of eight 
 months' preg- 
 nancy. 
 
 .Small. (.\deno- 
 myoma.) 
 
 
 
 23d 
 
 832 1 
 
 Fills pelvis. 
 
 
 
 14th 
 
 10199 
 
 (Small pehic 
 
 9.5 
 
 per cent. 
 
 .Stli 
 
 ]()211 
 10229 
 
 myoma . ) 
 
 Contained myo- 
 ma about 7 cm. 
 in diameter. 
 
 Reached uini)ili- 
 
 70 
 7.5 
 
 per cent. 
 j)er cent. 
 
 lOtli 
 22d 
 
 10281 
 
 cus. 
 Half-way to um- 
 bilicus. 
 
 77 
 
 per cent. 
 
 10th 
 
 10323 
 103.57 
 
 Half-way to um- 
 bilicus. 
 
 Reached to with- 
 in 4 cm. of um- 
 bilicus. 
 
 49 
 
 per cent. 
 
 .5th 
 6th 
 
 In right leg. 
 
 Severe in both 
 legs. 
 
 Left internal 
 saphenous. 
 
 Slight phlebi- 
 tis in left 
 groin, thigh, 
 leg. and foot. 
 
 In left lesr. 
 
 .\l)ilominal incision 
 
 broke down almost 
 completely. 
 
 Desperate operation. 
 
 In right leg. Had had phlebitis in 
 
 left leg after liirth ot 
 second child. 
 .*>liglit swelling 
 in lower right i 
 leg. ^ ' 
 
 Lett saphenous. Temperature rose to 
 102° on twelfth day. 
 Right saphe- 
 nous. 
 
 Right saphe- 
 nous. 
 Left femoral. 
 
 Left rciuornl. 
 Left femoral. 
 
 Temperature 100-103.-5° 
 from thirteenth to 
 twcntv-first (lav.
 
 COMPLICATION'S F0LL0\^■1^■G ABDOMIXAL H VS'l'KHO.M Vo.MKCToM V. i'iiu 
 
 Phlebitis Following HysTEROMvoMEfTOMY. — {Contimied.) 
 
 Cask No. 
 10778 
 10875 
 
 12154 
 12199 
 
 12811 
 C. H. I. 
 
 (W) 
 
 C. H. I. 
 
 (A) 
 
 SiZK OF UtKULS. HEMO.n.OIUN. ,V^'*' •^••'•'KR ^EI^' THROM- 
 
 (JPKRATION. B08ED. 
 
 Rkmakks. 
 
 Reaches 5 cm. 
 above umbili- 
 cus. 
 
 Several small 
 myomata; bi- 
 lateral ovari- 
 an cysts. 
 
 4 cm. above um- 
 bilicus. 
 
 Size of four and 
 one-half months' 
 pregnancy. 
 
 Fills pelvis. 
 Size of four and 
 
 one-half months' 
 
 pregnancy. 
 Fills pelvis. 
 
 60 per cent. 
 
 2Ist i.cft femoral. 
 20th Left femoral. 
 
 9th 1 
 
 2;ki / 
 
 In both legs. 
 
 Bt)tli feinorals. After rcinoval nf ()\arian 
 I tumor eiglit years be- 
 I fore she had luul phle- 
 bitis on both sides. 
 14th Left femoral. 
 11th Left femoral. 
 
 Few days 
 after op- 
 eration. 
 
 In Case 3492 symptoiii8 .suggestive of puliiiuiiary enibolisni (lcvcl()])c(l, and 
 subsequently there were signs of phlebitis in both legs and the left ai'iii. On 
 account of the lack of clearness in the diagnosis, this case is not iueludcd in the 
 tabulation. 
 
 As will be seen from the table, thrombosis occurred as early a.^ the fifth 
 day and as late as the twenty-third day. The most common periotl was between 
 the tenth and the twenty-third days. 
 
 In Cases 2098, 4617, and 4955 the phlebitis was associated with infection, and 
 in Case 4902 with ])leurisy. In a few of the cases faint hemic imirinuis were noted, 
 but in only one case (1032.3) was there any organic lesion — a mitral insullicicncy. 
 
 It was impossible to determine the cause of the thrombosis in the above cases. 
 It seemed to develo]) in certain cases irrespective of whether the tumors were hirge 
 or small, free or adhei-ent , and whether infection was presenl oi- not nl o|H'r:ition. 
 It is particularly interesting, however, to note that the greater inimber of cases 
 of phlebitis developed in four isolated and distinct jx-riods in the histoiy of the 
 hosi)ital. For instance, the table shows that they were most pi'e\alent in the 
 fifth, seventh, eleventh, and thirteenth thousands. .Ml of the patients i-ecovered. 
 
 For j)hlebitis following abdominal niN'oniectomies see p. o.")."). l-'or those 
 cases complicating vaginal myomectomy see ]>. ,")7!l. ami tho.se occurring Mn 
 the fatal cases, p. 675. 
 
 Treat ment . -The leg was wrapiied in absorbent cotton and ele\'ated. 
 and every precaution taken to aNoid much ino\-en)enl of the ))ai1. .Massage, 
 of course, was prohibited. 
 
 Pleurisy. — Three of our patients showed definite sigiL-^ of pleurisy after the 
 operation.
 
 668 .MYU.MATA OF THE UTERUS. 
 
 In Case 3492 a wliitc woman, aged thirty-nine, had a myomatous uterus 
 filhng the lower alxlonien. For eight days after oi)cration the temperature 
 varied from 99° to 101° F. It then rose to 103.5°, and a thy {pleurisy was de- 
 tected. Suddenly, on the eighteenth day, the patient had a fainting spell and 
 showed symptoms suggestive of intra-abdominal hemorrhage. None was. 
 however, found, and the gcnci'al consensus of opinion afterward was that the 
 patient had had a pulnionar}- cmholism. After the exploratory section the 
 patient developed phlebitis in both legs and tlie left arm. She finally made a 
 good recovery. 
 
 In Case 4902, during convalescence after removal of a large myomatous uterus, 
 a dry pleurisv developed on the right side, and on the fifteenth day a mild phlebi- 
 tis of the right femoral vein. Recovery was otherwise uneventful. 
 
 In Case 8294 the patient was forty-five years of age and white. The myo- 
 matous uterus, which extended 3 cm. above the umbilicus, was easily removed. 
 Gas and ether anesthesia was employed. The same evening the patient com- 
 plained of ])ain on the right side. Her temjx'ratiu'e was 101° F.. and a distinct 
 friction-rub could be made out in the right lower axilla. By the tenth day the 
 temjjerature had reached normal, but a faint rul) could still be heard. 
 
 In Cases 3492 and 4902 the pleuris}' may possibly ha\'e aiisen from a secondary 
 infection. In Case 8294, however, it came on too early, and was evidently an 
 entirely inde))endent process. 
 
 Bronchitis. — In three in.stances we encountered a bronchial inflammation 
 during convalescence. In Case 4022 the uterus filled tlie lower abdomen and 
 the bladder was displaced ui)ward. For eleven days after the operation the 
 temperature ranged from 99° to 101.2° F. On the twenty-first day it rose again, 
 reaching 103.6° F. This ri.se was appai-ently due to a bi'onchitis. The patient 
 was well when she left the hospital. 
 
 The myomatous uterus in Case 4894 reached 8 cm. above the umbilicus. 
 On the seventeenth day after the operation the temperature rose to 102° F. 
 A hai'd. indurated mass was detected in the ])elvis. and the patient had a definite 
 bronchitis. The temperature soon fell, the bronchitis disappeareil. and the 
 patient made a good recovery. 
 
 In Case 12738 a myomatous uterus filled three-fourths of the abdomen. 
 Hysterectomy was rendered difficult on account of intestinal adhesions. On the 
 second day the patient had a temperature of 103° F., due to an acute bronchitis. 
 She was discharged well twenty-eight days after operation. 
 
 ^^ hethei' the bi'onchitis in the last case was due to the anesthetic or was merely 
 an accidental accompaniment we are unal)le to .say. 
 
 Bronchopneumonia. — In the following table are given the cases in which 
 a bronchopneumonia complicated convalescence. In two of the cases the oper- 
 ation had been very difficult, and in a third the patient's heart was dilated and 
 the hemoglobin was only 35 per cent. In the two remaining cases the oper- 
 ation was relatively easy. All these patients recovered.
 
 COMPLICATIONS FOLLOWIXd ABIX ).MIXAL HYSTKHC )MYO.M]:CT( )MY. 
 
 669 
 
 In Case 11 ISO there was a l)ronch()])iiciini()nia jtrohably seeondarv to a 
 pulnioiiaiy abscess. This ease is ineiitioiicd on p. (iSl. 
 
 CASES OF BRONCHOPNEUMONIA AFTl'H AHDOMINAL liYSTERO.MYOMECTO.MY. 
 
 
 Case No. 
 
 Operation. 
 
 Bronchopneumonia. 
 
 Result. 
 
 
 6792 
 
 Difficult; severe hemorrhage. 
 
 Bronchopneumonia and 
 
 right pleurisy. 
 
 Recovery. 
 
 
 10204 
 
 Easy. 
 
 Developed on eighteenth 
 day. 
 
 Recoverj\ 
 
 
 10287 
 
 Easy. 
 
 Developeil on sixth dav. 
 
 Recoverv. 
 
 
 10426 
 
 Heart dilated; heniojilobin. 
 35 per cent. Operation diffi- 
 cult on account of intestinal 
 adhesions. Hemoglobin, 60 
 per cent. 
 
 Developed on second day. 
 
 Recovery. 
 
 
 11869 
 
 Easy; double pyosalpinx. 
 
 Bronchopneumonia. 
 
 Recovery. 
 
 Pneumonia after Hysteromyomectomy. — Tn addition to the two cases in 
 which recovery took phice are Cases 7381, in which the patient (hed of lobar 
 pneumonia on the seventeenth day, and Case 6997, in which an intercurrent 
 double basal pneumonia developed during convalescence and death from dysen- 
 tery took place in the eleventh week. These cases are recorded on j). 681. 
 
 Case No. 
 
 Operation. 
 
 Part Involved. 
 
 Day ,\fter Highest Tem- 
 Operation. perature. 
 
 Result. 
 
 934 
 12194 
 
 Easy. Upper left lobe. 
 Easy. Posterior part of 
 right lower lobe. 
 
 3d 104.8° 
 17th 100° 
 
 Recovery. 
 Recover3^ 
 
 Pulmonary Abscess. — In Case 6933 the patient was thirty-nine years old ami 
 wliite. The greatly enlarged myomatous uterus was removed without difiicuhy. 
 On the fifteenth day the patient complained of pain at the lower angle of the 
 scapula on the right side. On the seventeenth day there was an clex'ation of tem- 
 perature and ])ulse, slight moaning on deep ins])iration, and a congh. On 
 the twenty-eighth day she coughed forcibly onc(\ and ihcic was an innncdiatc 
 escape of sevei'al ounces of jjui'ulcnl material which consisted of pus-cells, 'i'lie 
 patient was much relieved after expectorating the fhiid. She h'ft the hospital 
 two days later, still weak, l)ut free from pain. 
 
 For pulmonary abscess occui'ring in the fatal cases see |). 682. 
 
 Symptoms Suggesting Abdominal Hemorrhage, but Probably Due to a Pul- 
 monary Embolus. — In Case .'MO'J the ])alieiit, aired thirty-nine, white, had 
 ])r()fuse uterine bleeding due to a submucous niNoina. 10 cm. in di.aiuetei". The 
 multinodular myomatous uterus was i-eniox'ed ])er abdomen, ller tempei'atui'e 
 varied from 99° to 101° V. toi' eight days, when it rose to 103.")° 1*\ and a "dry 
 ]i)eurisy" was dectecteil. Suddenly, on the eighteenth day, she had a fainting
 
 670 ^lYOMATA OF THK ITERUS. 
 
 spell. The pulse rose to 130, the respirations became rapid, the hands were 
 clammy, and the ])atient presented a typical picture of hemorrhage. The 
 abdomen was at once opened, Init the area of ojM'ration was in a ])erfect condition. 
 The t('m])erature vai-jcd from 99° to 101..')° I'\ for the next ten days, when it again 
 rose to 10o.2° with .symptoms of phlebitis in both legs and the left arm. She 
 was discharged well. Pulmonary embolism was probably the cause of the sudden 
 collapse. 
 
 The fatal cases of {juliiioiiary embolism arc described on ]). 680. 
 
 Complications following Vaginal Hysterectomy. 
 
 Transitory Lack of Recognition. — In Case 8951 a small myomatous uterus 
 was bisected and removed tln-ough the vagina. The patient, aged forty-eight, 
 recovered slowly on account of weakness and anemia. 
 
 On the twenty-second day she was irrational, had tingling pains in the right 
 arm, and did not recognize the nurses. This condition lasted for a day or two 
 and gradually disap})eared. ^^'hen discharged, she was in good condition ex- 
 cept for the weakness. 
 
 Tn this case we can only surmise as to the sudden and temporary clouding 
 of the intellect. 
 
 Delusional Insanity. — In Case 1852, the })atient, aged forty-seven, white, had 
 a small retroflexed adherent myomatous uterus removed through the vagina. 
 Two and a half weeks later a strangulated inguinal hernia was reduced and the 
 opening closed. 
 
 After the operation the ])atient developed delusional insanity. Before 
 operation she was weak mentally.
 
 CHAPTKPv XXW. 
 
 RESULTS OF OPERATIONS FOR UTERINE MYOMATA. 
 
 Our material consists of the patients operated upon at the .Johns Ilojjkius 
 Hospital u}) to July I, 1 '.)()(), those coming under the care of Howard A. Kelly 
 at his sanatorium, and those o})erated upon by Thomas S. Cullen at the Church 
 Home and Infirmary, the Cambridge (Md.) Hospital, and a few at the Emerg- 
 ency Hospital, l"'re(lei'i('k, Md. 
 
 Cases admitted to the gynecological (le])ai1ineiit of the .lohus Hopkins 
 Hospital fi'om the o])ening of the hospital in 1SS<), to .lulv 1. 
 
 1006 " ...1207 
 
 Sanitarium ( Kelly) 64 
 
 Chiu'ch Home and Infirmary, Cambridge, and Frederick (Cullen) .... 97 
 
 Total 1428* 
 
 In 55 of the cases no radical operation was attempted on account of the 
 weakened condition, or on account of refusal on the part of the patient. In some 
 cases a simple exploratory operation was done, and the hopeless character of the 
 case determined. In some cases no operation was deemed advisable. 
 
 Among these 55 cases 21 deaths occurred in the hospital. 
 
 In 7 cases death followed an exploratory abdominal section. 
 
 In 2 cases death followed a vaginal section. 
 
 In 1 case death followed a combined vaginal and abdominal exj)loration. 
 
 In 11 cases no operation was performed. 
 
 Total, 21 cases. 
 
 When we deduct those cases in which no radical operation could ])e performed. 
 we still have 1373, t in each of which one or more uterine myomata were renio\-ed. 
 
 IMMEDIATE RESULTS IN OPERATIONS FOR UTERINE MYOMATA. + 
 
 Abdominal inyomectorny. .. . 296 cases, 280 recoveries, 16 deaths. Deafli-rate, .">. 1 i)erct'iit. 
 
 Vaginal myomectomy 84 " 79 " 5 " " 6 
 
 Abdominal hysteromyomec- 
 
 tomy 901 " S,")I " .'>() '• ■• .-)..-,.-) 
 
 Abdominal hysteromyomec- 
 
 tomy with bisection of 
 
 uterus 68 " (iO " 8 " " 11. 7(1 • •• 
 
 Vaginal hysteromynmoctorny 24 " 24 " " " .... 
 
 i;57.S 1294 79 r^.7r^ + 
 
 *In addition to liiis nuinixT (iiiitc a iiuinix'i' ol nl iicr cases arc mentioned in tiic l)()ok. 'i'liese 
 are all interesting, and either occurred since July 1, 19()(), or have been o|)erated u|)on liy others. 
 Two hundred and forty-.six cases entered tlie.Ioims IIo])l<ins Hospital iict ween July 1 , 19(16. an<l .Ian. 
 1, 1909, tlius making a total ol' 1671 myoma cases th.it lia\e come under our |)crsonal observation. 
 
 t At least 13 patients were admitted to the hospital more than once, but in the total miml)er 
 of cases only the first hospital Tuimber was considered. Each mimi)er thus stands for a diffcnMit 
 individual. 
 
 JTlie deatii-rate in the last two and a half years has been less than one per cent, (.see p. 687). 
 
 671
 
 672 MYO.MATA OF THE ITERUS. 
 
 In the remaining 55 cases, no radical operation was performed. 
 
 Of these patients, 10 (hed as the I'esult of the exploratory operation. 
 
 Eleven died iij)on whom no operation was performed. 
 
 From the above table we see that, of 1373 patients operated upon, 1294 
 recovered and 79 died — an average death-rate of over 5.75 per cent. 
 
 Immediate Results in Abdominal Myomectomy Cases. — Out of 296 patients, 
 280 recovered and 16 died, a death-rate of 5.4 per cent. Naturally, abdominal 
 myomectomy is pci'formetl only in suitable cases; in other words, in cases in 
 which there is a strong chance of preserving a normal uterus. Under these 
 circumstances we would naturally expect a lower death-rate than in the group of 
 abdominal hysteromyomectomies, which included many desperate cases. The 
 rate is slightly lower, but the difference is less than one might expect. We are 
 all aware of the fact that myomectomy offends nmch more chance for subsequent 
 infection than does hysteromyomectomy. 
 
 Abdominal myomectomy is considered in detail in Chapter XXIX. Here also 
 are given in extenso the postoperative complications, the causes of death in the 
 fatal cases, and a list of the ])atients that have subsequently borne children. 
 
 Immediate Results Following Vaginal Myomectomy. — From the tabulation 
 it is seen that of 84 cases, 79 patients recovered and 5 died — a death-rate of 6 
 percent. In Chapter XXX these fatal cases are recorded in detail, and it will be 
 seen that in 4 out of thc^ 5 cases the patients were in a desperate condition and 
 opei'ation ga\'(' the only hope of even tempoi'ary salvation. In only one case 
 were we surprised at the fatal issue. This ])atient had a small submucous myoma 
 twisted from the ulterior of the uterus. She did well for a short time, and then 
 rapidly grew weaker and died. This case is described in detail on p. 580. 
 
 Results after Abdominal Hysteromyomectomies. — In 901 cases an abdominal 
 hysteromyomectomy was ])erformed: 851 patients recovered and 50 died — a 
 mortality of 5.55 per cent. In the majority of the cases the uterus was ampu- 
 tated thi'ough the cervix. In only 50 cases was a j)anhysterectoniy done. 
 
 Causes of Death following Abdominal Hysteromyomectomy. 
 
 This table is as accurate as we can make it. l)ut every surgeon will realize 
 that there arc numci'ous chances for error. In some cas(\s we have been forced 
 to rely on the posto))erativc history for the probable cause of death, no autopsy 
 having been granted. In other cases the patients died of peritonitis, but whether 
 the se])tic factor was pj-imary or secondary to an obstruction it was difficult to 
 determine. 
 
 Probable cause : 
 
 General peritonitis in 22 cases 
 
 Intestinal obstruction in 5 " 
 
 Shock " 7 " 
 
 Pulmonary embolism " 4 " 
 
 Other causes " 12 " 
 
 Total 50 cases
 
 RESULTS OF OPEHATIOXS FOR UTFRIXK MYOMATA. 673 
 
 Deaths due to Peritonitis Following Abdominal Hysteromyomectomy. — 
 The tabulation of deaths due to peritonitis after al)dominal hysteromyomectomy 
 shows that in quite ti nunil)er of cases it was impossible to trace the source of 
 infection, but in the majority the operation was either complicated by very 
 dense adhesions, sometimes leading to injury of the bowel during the operation, 
 or was associated with an infected uterus, a suppurating myoma or a purulent 
 collection in the adnexa. 
 
 In Case 1767 death seemed to be due to separation of the abdominal wound. 
 Removal of the uterus, which reached the umbilicus and contained thirty 
 myomata, was difficult. On the fifth day the abdominal incision was widely 
 separated, and the omentum was bulging up into the incision. Studding the 
 margins of the incision were little foci of pus. The patient, before operation, 
 had many sonorous and whistling rales and severe paroxysms of coughing which 
 continued after the operation and may have been the cause of the giving way of the 
 abdominal sutures. iShe died with definite signs of peritonitis on the eighth day. 
 In this case it would ha^'e been much wiser to have delayed operation until the 
 pulmonary symptoms had entirely subsided. 
 
 Infection from a sloughing submucous myoma was noted in Case 4609. The 
 uterus was the size of that of a five months' pregnancy. Examination of the 
 specimen after removal showed, in addition to su])pentoneaI and interstitial 
 mj^omata, several submucous nodules. The largest of these was 4 cm. in diam- 
 eter, and its surface had been converted into a greenish-yellow suppurating tissue. 
 The uterine mucosa near the internal os was hemorrhagic and covered with 
 necrotic material from the suppurating myoma. In addition to the compli- 
 cations already mentioned the urine contained albumin and casts. In this case 
 operation was delayed for eleven days in the hope that the discharge might be 
 lessened and the abdominal operation rendered less dangerous, but the di.s- 
 charge did not abate, and hysterectomy was undertaken. 
 
 In such cases the operator is often confronted, on the one liand. by the abso- 
 lute certainty of the patient's speedy death if she is not rene\'ed. and. on the other 
 hand, by the great risk of infection if any operative interference is attempted. 
 
 In Case 7158 the fatal ])erit()nitis was due to a sloughing subperitoiu^al myoma. 
 The patient at operation was markedly emaciated and was in a most critical 
 condition. Her pulse varied from 120 to loO. The tumor was about the size 
 of a five months' pregnant uterus. When the hand was passed around to the 
 right of the uml)ilicus, several ounces of thick green fetid ]ius which had a gailicky 
 odor escaped. It was (|iiickly s]X)nged uj). On I'ciiioxal of the uterus t his large 
 abscess was found to be (hie lo ( lie hreakiiig-dowu of a sui)|)uratiiig subpei'iloiieal 
 myoma. The ])atieiit was in a des|)ei-ate condition when she left the table, and 
 died on the third day. In such a case the surgeon has no alternative but to 
 operate. This case is reported in detail in the chapter mi Su|i])Ui-ating Myomata 
 (see J). 1 ")()). 
 
 43
 
 674 
 
 MYOMATA OF THE UTERUS . 
 
 DEATHS Dl'E TO PERITOXmS FOLLOWING AN ABDOMINAL 
 HYSTEROMYOMECTOMY. 
 
 Gyn. No. 
 
 Autopsy Su. 
 
 Day after 
 
 Cultures. 
 
 Source of Infections and Compli- 
 
 
 'm 
 
 Operation. 
 
 
 cations. 
 
 69 
 
 5th 
 
 Staphylococcus 
 
 ^'ol^'ulus of ileum. 
 
 
 
 
 aureus. 
 
 
 701 
 
 
 4th 
 
 
 
 729 
 
 i98 
 
 5th 
 
 General B. coli. 
 
 Diphtheritic enteritis, sHglit peri- 
 tonitis. 
 
 963 
 
 237 
 
 3d 
 
 Cultures from 
 abd. cavity neg- 
 ative. 
 
 
 1767 
 
 385 
 
 8th 
 
 Staphylococcus 
 aureus. 
 
 Separation of abdominal wound, 
 and omentum seen. Cough con- 
 tinuous before and after opera- 
 tion. 
 
 2713 
 
 
 (itli 
 
 
 
 3008 
 
 561 
 
 4tli 
 
 Cultures nega- 
 tive. 
 
 Dense pelvic adhesions. 
 
 3198 
 
 595 
 
 2(1 
 
 Streptococcus. 
 
 Abdomen reopened. 
 
 3493 
 
 666 
 
 17tli 
 
 Staph, aureus. 
 
 
 3882 
 
 
 14tli 
 
 
 Slow general infection. 
 
 3898 
 
 
 6tli 
 
 
 Den.se adhesions, tear in external 
 coat of ileum, with .subsetiuent 
 perforation. 
 
 4609 
 
 
 6th 
 
 
 Sloughing submucous myoma. 
 
 5302 
 
 954 
 
 lOtli 
 
 B. coH. 
 
 Dense adliesions with perforation 
 of sigmoid. 
 
 5858 
 
 
 2,1 
 
 Streptococcus. 
 
 Carcinoma of body of uterus. (See 
 Cullen's "Cancer of the Litems, " 
 p. 454, Fig. 237.) 
 
 7158 
 
 
 3d 
 
 
 Suppurating myoma. 
 
 7863 
 
 
 8th 
 
 
 Slow general infection. 
 
 8732 
 
 1734 
 
 7th 
 
 Streptococcus. 
 
 Sarcomatous degeneration of my- 
 oma. 
 
 10669 
 
 2162 
 
 4th 
 
 
 General peritonitis. Rent in rec- 
 tum. 
 
 10749^ 
 
 
 4th 
 
 
 
 12209 
 
 
 7th 
 
 
 Dense intestinal and pelvic adhe- 
 sions and rupture of an ovarian 
 abscess. 
 
 12587 
 
 2651 
 
 5th 
 
 
 
 C. H. I. K. 
 
 
 10th 
 
 
 Advanced carcinoma of bodv (Fig. 
 
 
 
 
 
 180, p. 286). 
 
 Ca.scs oS5s and ('. H. I. K. isvv p. 2S()) afford ty])ical cxaniplcs of peritonitis 
 d('\-('!o})in(z; when a supravaginal hysterectomy has been i)erfornuMl in cases of 
 supposedly simj^le inyoina, hut where carcinoma of the body was also present. 
 The foul discharge is very prone to infect the field of operation, and peritonitis 
 speedily follows. Death in Case 5858 occurred on \hv second day and was due 
 to a streptococcic infection. This case is reported in detail in ("ullen's "( ancer 
 of the Uterus," j). 454 (Fig. 237). In Case 8732 jx'ritonitis resulted from acci- 
 dental soiling of the peritoncnim with sarcomatous tissue. After we had tied 
 the left ovarian vessels and round ligament and liad begun to work down to 
 the left uterine vessels a slight tear in the large tumor allowed a brain-like 
 material to ooze out near the uterine vessels. Sarcoma was at once diagnosed, 
 and complete, instead of supravaginal, hysterectomy performed. The patient,
 
 RESULTS OF OPKKATIOXS FOR UTKRIXF MYOMATA. 675 
 
 howevLT, died of (general pcritijiiitis on the sc\ciith day. Large sarconialous 
 areas are especially imnw to undergo coagulation necrosis and become infected. 
 The case is reported in detail on p. 215. 
 
 In Case 12209 the death was certainly due to infection from a large ovarian 
 abscess. The pulse before operation was between 150 and 160. Filling the en- 
 tire right lower alxloinen was a tumor. .\l)ove this the intestines and omentum 
 were everywhere adherent. On gradually hxjsening uj) the mass we found it to 
 be composed of a myomatous uterus with a densely adherent ovarian al^scess 
 on the right. The abscess was firmly adherent to the intestinal loops. Its walls 
 ruptured, and about ten ounces of greenish-yellow pus were evacuated, with little 
 soiling. Abdominal hysterectomy was performed. The ])atient"s condition 
 was desperate, and that night her temperature reached 105° F. On the fifth 
 day she developed phlebitis in the left leg. She died on the scA'cnth day. In such 
 a case little else could have been done. Where there are signs of an abscess low 
 down in the pelvis, however, the better plan is to attempt evacuation through 
 the vagina, and it is astonishing to see how the densely adherent pelvic structures 
 loosen up and the tumors that at the first operation were so firmly fixed that tlieir 
 enucleation would have been impossible can now be removed with relatively 
 little difficulty. The disappearance of the induration is often as striking as that 
 noted when evacuation of an appendix abscess is followed months latei' by the 
 easy removal of the appendix. In the case just cited, however, the abscess was 
 too high up to l)e readily attacked from below, and immediate ()p(>ration was 
 imperative. 
 
 In Cases 3898 and 5302 the peritonitis was, in a large measure at least, due 
 to injury of the bowel at operation. In Case 3898 the omentum, rectum, and 
 loops of small bowel were densely adherent to the enlarged uterus. During the 
 liberation of adhesions the outer coat of the small bowel was injured at one point. 
 This tear was closed with three sutures. The temperature and ])ulsc rose gradu- 
 ally after operation, and on the second day the patient c()ni])lained of excruci- 
 ating pain on the right side, over the site of the intestinal sutiu'e. This j)ain 
 became so intense that the abdomen was opened, and |)ei-foi'ation of the bowel 
 found at the point of sutui'e. Death soon followed. It looks \-ci-y much as if 
 the injury at the time of ojx'ration had involved nol merely the outer, but also 
 the middle and inn(>r, intestinal coats. We ha\'e nole(l that where dense intesti- 
 nal adhesions exist , the lumen of the bowel may be di'awn out as a liliform lube 
 for a considerable distance into the abdomen. Such adhesions should be as 
 carefully turned in as an appendix stum|), otherwise thei'e in.ay be danger of 
 general peritoneal infection. 
 
 In Case 10749^ a coloi-ed woman, aged forty-three, had mai-ked pain in the 
 lower abdomen. The myomatous utei-us reached to the costal margin on the 
 right side. The pelvic j)ortion of the tumor was embedded in adhesions. \v- 
 cordingly, the hysterectomy was very dilliiailt. Two vaginal and two abdominal 
 drains wei'e emj)loyed. ( )n the ex'ening of the third day an enema consisting ol
 
 676 MYOMATA OF THE UTERUS. 
 
 500 c.c. of soapsuds was given. This was expelled clear. Just at this time 
 the jjaticnt conijjlained of acute j)ain in the lower abdomen, Hanks, and also 
 beneath the ng\\\ costal mar<j;in. The pulse rose to 140, but the temjx'rature 
 remained at 99.")°. The ])atient vomited much clear fluid and was in a profuse 
 perspii'ation. Two liours later she was lyinij; with the legs drawn up: the res- 
 pirations were rapid. She became delirious, the pulse gradually grew weaker, 
 and she died early on the following morning. The autopsy showed a general 
 fibrinous p(>ritonitis, and at the junction of the sigmoid with the lower portion 
 of the rectiun an opening in the bowel o cm. long. Through this the enema had 
 been injected into the abdominal cavity. 
 
 At times the ])elvis presents such a ragged appearance as a result of the 
 dense adhesions that a hole in the bowel may be readily overlooked. In every 
 case in which thei-e had been the slightest possibility of injury the most careful 
 inspection should l)e made. 
 
 In Case 5302 the lower two-thirds of the abdomen was filled with a myomatous 
 growth. At operation dense adhesions were encountered. There was an ap- 
 pendix abscess, a right pyosalpinx, and an al)scess of the right ovary. The 
 tumor was firmly fixcnl to the ])elvic floor, rectum, colon, sigmoid flexure, and 
 anterior abdominal wall. The urine before operation contained a moderate 
 amount of albumin and some hyaline casts. After operation it showed many 
 casts. The patient died on the tenth day. At autopsy perforation of the sig- 
 moid flexui-e was found. This had first giv(>n rise to a localized peritonitis, and 
 latei' the geiiei-al peritoneal cavity had become involved. 
 
 The ))atients who succumbed to peritonitis usually die(l within the first 
 six days, but in some cases the infection was a slower one: in Case 3882, for in- 
 stance, the i)atieiit li\-ed until the fourteenth day, and in Case 3493, until the 
 seventeenth day. Where the infection is stre])tococcic, as in Case 5858, the 
 termination may be appallingly i-apid, this patient dying on the second day. 
 
 We regret that our bacteriologic examinations are not complete. In those 
 cases in which the second ojx'ration was undertaken the patient was usually 
 in such a desperate condition that all eflorts wei-e directed to doing what was 
 necessary and getting the patient off the table at the earliest possible moment. 
 
 In the i-apid streptococcic peritonitis cases o{)eration avails little unless per- 
 loi'ined within the first few houi's, before the infection has become general. Care- 
 lul wiping off of the ])elvic walls and the intestinal loops in the vicinity, with 
 wide-sj)read drainage of the pelvis with gauze, occasionally yields good results. 
 In the slow peritoneal infections wide-spread drainage is jwactically all that can 
 be accomplished. Where it is necessary to I'eopen the abdomen, we have found 
 it wiser to make a new incision instead of opening up the old abdominal wound. 
 
 From the foi'egoing it will Ix- seen ihal in many of the cases peritonitis un- 
 doubtedly (le\'elo))e(I fiom an ahcady existing pelx'ic infection, and in neai'ly 
 every case the hvsterectomv was a verv diflicult one.
 
 RESULTS OF OPERATIONS FOR UTFRIXK MV(J.MATA. 677 
 
 Deaths from Intestinal Obstruction Following Abdominal Hysteromyomectomy. 
 — In Case 6217 great diffieulty was experienced in covering in the raw areas on 
 account of the marked distention of the intestines. Finally, it was necessary 
 partly to eviscerate the patient before the parts could be properly approximated. 
 This maneuver was probably responsible for the subsequent obstruction, as in 
 replacing the intestine some kinking might have taken place, and, as was pointed 
 out at a recent meeting of the American Medical Association, nmch handling 
 of the bowel is often followed by prolonged atony. There are certain patients 
 that have marked distention of the intestine notwithstanding the most careful 
 preliminary preparations. 
 
 In Case 10486 the patient k'ft the operating tal)le in good condition, l)ut on the 
 third day the temperature rose to 101.6° F, and the pulse to 104. On the fourth 
 day an enterostomy was done. The intestines were enormously distended, owing 
 to the presence of a stricture in the small bowel, 10 cm. from the ileocecal valve, 
 a loop of bowel having become adherent to a raw area near the pelvic brim. 
 This case again emphasizes the great importance of covering over any raw areas 
 with peritoneum, thus leaving no point at which intestines may adhere. 
 
 In Case 12216 we were dealing with a large myomatous uterus. A sul)perito- 
 neal nodule had suppurated (Fig. 104, p. 136) and become adherent to the anterior 
 abdominal wall. Our attempts to draw the peritoneum over the raw area left 
 on the anterior abdominal wall were not very successful on account of the indurated 
 condition of the surrounding tissue. Partial obstruction developed on the sixth 
 day. On the eighth day the gut was found adherent to the anterior abdominal 
 wall, and kinked at this point. Death followed the .same day. In this case 
 we are certainly open to criticism, as, knowing the dangers at operation, we 
 should have opened the abdomen as soon as the obstruction commenced. Our 
 reason for delay, however, arose from the fact that the bowels had been thoroughly 
 moved a few days after operation. 
 
 DEATHS DUE TO INTESTINAL OH.STRITCTION FOLLOWIXC A.X AliDO.MIXAI, 
 
 HYSTEROMYOMECTOMY. 
 
 „ ,, .XT I^AV .\kter Secondary Oper- ^, 
 
 (jyn. No. Aut. No. Operation. ation. Co.mplications. 
 
 None. Great dilliculty in i^cttiiig a proixT 
 
 (■\j)osur(' on account of ilisttMuled 
 intcsl incs. 
 
 Mxploralory. I'arlial olislruclion lictorc liystcr- 
 
 cctoniy. 
 
 lioleaso of ob- Ileum adluTcnt to I'di:*- of pelvis 
 struetion. after operation. 
 
 lOxploratoiy. Siipiiuratinji myoma adherent to 
 anterior abdominal wall. I'o.st- 
 operative intestinal adhesions at 
 that point. 
 S. 1566 8th. None.
 
 678 
 
 MVOMATA OF THK ITERUS. 
 
 Deaths from Shock Following Abdominal Hysteromyomectomy. — The cause 
 of death in Case 1703 is not clear. After removal of the uterus, which extended 
 up to the ribs, a Mikulicz drain was introduced and the abdomen closed. The 
 patient never rallied .'Satisfactorily after the operation, notwithstanding the fact 
 that little blood was lost. The pulse rapidly rose to 16S and the resj)irations 
 to 40. She died fourteen hours after operation. 
 
 Case 4607 was one of carcinoma of the cervix associated with a sul)mucous 
 myoma. When the necessary extensive hysterectomy had l)een completed, the 
 pulse was hardly perceptible. In this case the tuberculosis of the hip prevented 
 the necessary flexion of the thigh, and rendered the proper exposure of the pelvic 
 structures difficult. Much blood was lost. Th(^ yxitient never recovered from the 
 effects of the operation and died twc]\'e liours after Icax'ing the table. 
 
 In Case 5010 the patient entered tlie liospital in a precarious condition. 
 Operation was delayetl in the hope that there might be some improvement, but 
 she steadily lost in strength. The abdomen having been opened and the omentum 
 drawn gently back, free pus welled up out of the pelvis. The condition present 
 was exactly as if one had poured half a liter or more of pus into a pelvis partially 
 filled with a multinodular and firmly adherent myomatous uterus. It was 
 impossible projx'rly to drain the various pockets. Hysterectomy was attempted, 
 but the tissues were everywhere almost like cartilage. The pulse, which was 120 
 and weak, rapidly increased as the operation progressed, and the patient died 
 just as the abdomen was being closed. Had we known of the l)isection method 
 at this time the operation could have been performed iinich more speedily, 
 and it is possible that the patient might have been .saved. 
 
 DE.\THS DUE TO SHOCK FOLLOWING ABDOMINAI> HYSTEROMYOMECTOMY. 
 
 Gyn. No. 
 
 Autopsy No. 
 
 Time after Opi 
 
 TION. 
 
 1703 
 
 
 14 liours. 
 
 4607 
 
 
 12 hours. 
 
 .")()1() 
 
 908 
 
 On taliie. 
 
 .')617 
 
 
 On table. 
 
 6017 
 
 
 Secondary 
 
 6760 1^ 
 
 13.S7 
 
 On table. 
 
 rose/ 
 
 9030 
 
 Complications. 
 
 Carfinonia of cervix: tulxTcu- 
 losis of iiip. 
 
 Abscess in niyonui: chronic ad- 
 hesive pericarditis; fatty de- 
 generation of liver. 
 
 Bronchitis, "weak heart." 
 
 Sii)U,a;hin,ii; submucous myoma. 
 
 Aixlominal myomectomy two 
 months before: later profu.se 
 lieniorrhajxe: intestinal adhe- 
 sions to titeriiie wound. 
 
 Rupture of large infected ovarian 
 cyst into abdominal cavity. 
 
 In Case 5617 there was weakness and .shortness of breath. The pulse was 130 
 and feeble. On account of bronchitis, chloroform was first used, but the respir- 
 ations ceased. After resuscitation ether was administered. The pulse rose to 168,
 
 KKSILTS OF OI'KHATIOXS FOR I'TERIXE MVo.MATA. 679 
 
 boconiing weaker and iri'e;u:;ular, and the ])atient died on the tal)U'. The hirge 
 myomatous tun Kir had supjiurated and hi'oken througli into the uterine cavity. 
 The wisdom of ojxTating on such a case may be ([uestioned, but it is perfectly 
 clear that without operation death was certain, and in other apparently more 
 desperate cases patients have survived the operation and have been restored 
 to perfect health. 
 
 In Case 6017 there were great weakness, shortness of breath, and swelling of 
 both legs. The vagina was filled with a large, rounded mass, slightly gangrenous 
 in several places. This tumor was continuous with t he myomatous uterus, which 
 extended to the umbilicus. At operation vaginal myomectomy was done and the 
 uterus removed from above. The hystertrtomy was very difficult, the growth 
 being to a great extent behind the bladder. The entire operation occupicnl three 
 hours. After infusion the jxitient steadily ini|»i-o\-ed until 4 a.m. on the next 
 morning, when she .suddenly felt faint. The pulse and respirations became very 
 rapid, and she presented the typical symptoms of hemorrhage. The abdomen 
 was opened, but there was no sign of bleeding. She died just as the abdomen 
 was closed. 
 
 We are certainly open to criticism in this case. When a sloughing submucous 
 myoma is present, this should be completely, or as far as po.s.sible, removed. 
 Under no circumstances should the hysterectomy be undertaken until the dangers 
 of infection from the necrotic submucous growth are past. 
 
 The operation in Case 7036 was secondary to a myomectomy done two months 
 before. The patient was so weak as a result of the intestinal obstruction that she 
 died on the table. For the full details of this case see j). ofiti. 
 
 In Case 9030 the ])atient was .so weak and anemic on admission that ojM-ration 
 was deferred. Later a large myomatous uterus was exposed, and filling the right 
 lumbar region and extending to the right side of the uterine mass as far as the 
 costal margin was a large cystic accunmlation with walls varying in thickness. 
 This was everywhere adherent to the intestines. During its liberation the cyst 
 ruptured, and a large amoimt of foul-snieliing puruleiil material was scattere(l 
 throughout the abdominal cax'ity. This was immedialely Hushed out wit h a large 
 amount of salt solution, and the uterus (juickly I'emovi'd. Immediately after the 
 operation the patient was in a state of colla])se. She soon rallied, and a few hours 
 later the pulse was easily counted. Toward excning there wei-e signs of collapse. 
 The pulse could not be counted. The patient was gasping foi- aii" and was xcry 
 cyanotic. She died eight hours after o|)erati()n. 
 
 In this case also ojiei'ation offered the only hope. With oiu' pi'eseiit know ledge 
 of the ojx'i'ative technie we would wipe out the pus that had escaped, and under 
 no circumstance I'un the I'isk of spreading it by llu>hing tln' abdominal ca\'ity. 
 
 I'rom 1 he al)o\(' it is seen t hat in six of I he siacii deat lis from shock following 
 abdouiiiial hystei'omyoiuectomy the fatal leruiinatioii was not unlooke(| foi". all 
 being despei-ale cases. In ( 'ase 17().") we are at a loss to account for the death.
 
 680 
 
 MYOMATA OF THF. UTERUS. 
 
 Fatal Pulmonary Embolism, Following Abdominal Hysteromyomectomy. — - 
 In four of the 901 abdominal hystcroinyoniectoniies tho patients died of pul- 
 monary embolism. 
 
 In Case 7361 thei'c was a simple, uncomplicated, su{)ra vaginal hysteromyo- 
 mectomy. The appendages, which were normal, were left in sitx. The patient 
 did well until the fourteenth day, when, while talking to another patient, she com- 
 plained of feeling ill, grew pale, and suffered from dyspnea and suffocation. The 
 face was covered with beads of perspiration. She responded to questions and 
 comj)lained of a "weight" on the chest. The pulse was slow and full, but 
 irregular. About an hour later dilatation of the left pujiil was noted, and the 
 patient responded to questions by nodding the head. There seemed to be paraly- 
 sis of the left arm and the right side of the face. The breathing was now very 
 stridulous. The condition imj)roved somewhat during the day, but toward 
 evening the pulse l)ecame irregular and dropped a beat freciuently. .Shortly 
 after midnight, just fifteen hours after the onset, the patient gave a gasp and 
 died. Autopsy showed embolism and thromboses in the pulmonary arteries, 
 and old tuberculous lesions in both lungs. 
 
 DEATHS FROM PULMONARY EMBOLISM FOLLOWING AN ABDOMINAL 
 HYSTEROMYOMECTOMY.* 
 
 GvN. No. 
 
 Autopsy No. 
 
 Character of 
 Operation. 
 
 Postoperative 
 conditio.v. 
 
 
 Day of Death 
 
 7361 
 9675 
 
 S. 1682 
 S. 1872 
 
 1445 
 1936 
 
 Simple. 
 Simple. 
 
 Simple. 
 Simple. 
 
 Good. 
 
 Thrombosis of 
 
 ovarian vein. 
 
 Good. 
 
 Good. 
 
 left 
 
 Fifteenth. 
 Fifth. 
 
 Twelfth. 
 Fourth. 
 
 In Case 9675 the patient was a stout, rather weak woman. She had a chronic 
 ncjihritis. The uterus was free from adhesions, and could have been easily 
 removed had it not been for the difficulty in obtaining the necessary exposure. 
 The ])atient did fairly well for two days, but grew weak on the fffth day, and 
 died apparently as th(^ I'esult of ])rofound asthenia. At autopsy thrombosis of the 
 left ovarian vein was found. The left pulmonary artery was normal, but on open- 
 ing the right a large thrombosed mass was found lying in the branch to the lower 
 lobe. This thrombus did not conqjlctely fill the vessel. It was rough, of agrayish 
 color, and had other clots attached to it. Its central jiortion was aj)))arently 
 undergoing softening. 
 
 In San. No. 1()S2 the uterus was easily removed, and the a{)pendages were 
 normal. The patient dieil suddenly, apparently of jHilmonary embolism, on the 
 twelfth day. 
 
 * In Case 12587 death was due primarily to a general peritonitis. At autopsy, in addition 
 to thrombosis of the uterine and vesical veins, pulmonary embolism was noted. The lungs were 
 also the seat of abscesses, bronchopneumonia, acute bronchiectasis and broncliitis, and there 
 was an acute fibrinous pleuritis.
 
 RESULTS OF OPERATIONS FOR UTERINE MYOMATA. 
 
 681 
 
 In San. No. 1872 the patient was a very IVail woman, fifty-one years old, with a 
 hemoglobin of 50 ])er cent. The myomatous uterus was removed without diffi- 
 culty. On the fourth day she was as bright as usual, when suddenly she screamed, 
 became unconscious, and died within a few minutes. Embolism was probably 
 the cause of death. 
 
 In not one of the four cases in which the patient died of pulmonary embolism 
 had we any evidence of the embolus Ix'ing due to pelvic infection. In each case 
 the operation was a simple uncomplicated one and the convalescence was normal 
 until the symptoms of embolism developed. 
 
 Other Causes of Death Following an Abdominal Hysteromyomectomy. 
 In addition to the deaths following abdominal hysteromyomectomy and due 
 to general peritonitis, intestinal obstruction, shock, and puhnonary embolism, 
 there were 12 other cases. The cause of the death in these cases is shown in 
 the following; table: 
 
 OTHER CAUSES OF DEATH FOLLOWING AN ABDOMINAL HYSTEROMYOMECTOMY. 
 Gyn. No. AnTOPSY No. Cause of Death. 
 
 10095 
 13016 
 
 Fatal hemorrhage from a uterine artery on the eighth day 
 due to too early absorption of the catgut Hgature. 
 
 Lobar pneumonia on seventeenth day. 
 
 Abscess of lung and bronchopneumonia. Death on twen- 
 tieth day. 
 
 Convalescence interrupted by double basal pneumonia. 
 Symptoms suggestive of gastric carcinoma. Death from 
 acute dysentery in eleventh week. 
 
 Did well till twenty-first day, then developed severe diar- 
 rhea and died on twenty-eighth day. 
 
 Persistent nausea. Abdomen opened on fourteenth ilay. 
 No signs of obstruction or peritonitis. Deatii the same 
 evening. 
 
 Persistent nausea; abdomen reopened, no signs of obstruc- 
 tion or peritonitis. Death on third day. 
 
 Chronic diffuse neplu'itis. Death on hfth day. Abtlomen 
 reopened; no peritonitis or obstruction. 
 
 Acute suppression of urine, due to a chronic ditTuse neph- 
 ritis. Death on the .second day. Operation: comiilete 
 removal of uterus by tlic Wertlieim method for carcinoma 
 of the cervix. The diffuse adenomyoma of the l)ody was 
 discovered only in the laboratorj'. (Kei)orie(l in full in 
 ■' Atlenomyoma of the Uterus," p. 211.) 
 
 Found dead in i)ed on t wciity-fiftli day. Had had |in'vi- 
 ous attacks of syncope. 
 
 Probable myocai-ditis; dcatli on fourlli day. No autops}-. 
 
 Myocarditis; death on twclftli day. 
 
 Fatal Secondary Hemorrhage. In Case .S977, as a result of too early ;ibsorp- 
 tion of the catgut ligature conti'oHing the left uterine ;irtery, the patient died of 
 sudden and fatal hemorrhage from this vessel on the eighth day. 
 
 In this case the ])el\'is was lilieil with ;i large globular mass about the size 
 of a fetal head and the cervix was drawn ui) hiuii. The mvomatous uterus
 
 682 MYOMATA OF THK UTERUS. 
 
 reached the uinhihcus. The operation proved to be rehitively simple. On the 
 eighth day the j)atient eallcd a nurse, saying that she felt faint. Her pulse 
 rapidly became impercej)tibl(', she was gasping for breath, her face was cyan- 
 otic, the extremities were cold; death resulted in a few minutes. At auto])sy 
 a considerable amount of fluid, especially clotted blood, was found in the ab- 
 dominal cavity. The hemorrhage appeared to have come from the left uterine 
 artery, proliably as i'(^sult of too early an absorption of the catgut ligatures. 
 TluM'e was slight atheroma of the coronary arteries and faint evidences of a 
 myocarditis. Death was undoubtedly due to the hemorrhage. 
 
 Pulmonary Abscess. — Tn Case lllSO a large nuiltinodular myomatous uterus 
 was removed. On the fourth day an area of dulness could be detected in the 
 right lung. It was demonstrable both in front and behind. The temperature 
 varied from 102° to 104.5° F. for a week, and when the patient was transferred 
 to the nuHlical ward on the sixteenth day, it was about 100.5° F. The pulse 
 was rapid and the general condition unfavoral)le. She died eighteen days 
 after operation. Auto))sy revealed a bronchopneumonia of the left lung, with 
 a large encapsulated gangrenous abscess in the lower lobe. There is no evidence 
 that the operation was in any way responsible for the pneumonia or for the pul- 
 monary abscess. 
 
 In Case 12587 the ])atient was a negress, thirty-nine years of age. After 
 removal of a large myomatous uterus she developed a l)ronchopneumonia and 
 died on the fourth day. At auto])sy acute fibrinous pelvic ])eritonitis, thrombo- 
 sis of the uterine and vesical veins, embolism of the pulmonary arteries, pulmo- 
 nary abscesses, bronchoj-jueumonia, acute bronchiectasis and bronchitis, acute 
 fibrinous pleuritis, and acute <liphtheric colitis were found. The pulmonary 
 abscesses were probably secondary to the emboli. This case is included among 
 the deaths from pei-itoiiitis on p. 074. 
 
 Acute Suppression of Urine. — The death in case V. H. T. 511, from acute sup- 
 pression, followed a Wertheim operation for carcinoma of the cervix in a patient 
 with chronic nephritis. The exact conditions and dangers were explained to the 
 patient before, and she chose operation. 
 
 The adenomyoma was not recognized until after removal of the uterus. This 
 case in a sense should not be inchided under deaths following operations for myo- 
 mata, but, as it foi-ms one of (jur total number of myoma cases, it hardly seems 
 fair to include il in one place and omit it in another. In order, therefore, to 
 remove even the slightest ])ossible suggestion of bias and to be on the safe side 
 we have included it. The same may be said of Case 8183, in which the carci- 
 noma of the c(>rvix was the dominant lesion and the myoma was not large. 
 
 Myocarditis. — The clinical picture in Case 10095 suggested myocarditis, 
 but the exact condition could not be ascertained, as no autopsy was obtainable. 
 
 In Case 18016, a negress, thirty years old, was well nourished and healthy 
 looking. There was marked pulsation in the arteries on the right side of the 
 neck. There was a faint, blowing, systolic murmur heard most distinctly in the
 
 RESULTS OF OPKKATIOXS FOR ITKRIXK MVOMATA. HS3 
 
 second left intercostal space. It was traceable to the vessels of llir neck. Killing 
 the lower abdomen was a niyoinatous uterus. This was removed without 
 difficulty, and uj) to within five minutes of her death, on the twelfth day, the 
 patient had improved steadily. Two hours before she had complained of pain in 
 the right leg. This, however, was not severe. The patient suddenly gasped f(jr 
 breath, became semiconscious, and died in five minutes. The coincident j)ain 
 in the right leg and the sudden death naturally suggested pulmonary embolism, 
 but at autopsy acute myocarditis (degenerative), chronic fibrous myocarditis, 
 and cardiac dilatation, together with lymphatic hyperplasia, were found. 
 
 Death Following Bisection of the Uterus. 
 In 68 of the abdominal hysterectomy cases, prior to removal of the utei'us. 
 it was bisected. On account of the newness of this operation, we have considered 
 these cases by themselves. Eight of the patients died, an exceedingly high 
 mortality, namely, 11.76 per cent. 
 
 Causes of Death. Nu.mber of Cases. 
 
 General peritonitis .3 
 
 Intestinal obstruction 1 
 
 Shock 2 
 
 Pulmonary embolism 1 
 
 Bronchopneumonia (wide-spread metastases from sarcomatous degeneration of a 
 
 myoma) 1 
 
 8 
 
 Peritonitis. — The death in Case 7474 was due to the fact that necrotic sar- 
 coma t (jus tissue in the center of a large myoma was set free by the bisection. 
 The case is reported in detail on p. 208. 
 
 In Case 8598 a negress, twenty-nine years old, had a hemoglol)in of 24 per 
 cent. On section of the abdomen dense adhesions were found between the tumor, 
 the pelvic walls and I'eetum. The right side was first free<l and (hiring tiie 
 manipulations an abscess ru])tui'e(l and a considerable aniounl of ci-eamy pus 
 escajx'd. The outer coat of the rectum was slightly toriL Hisection was at 
 once resorted to to save time. The two halves of the uterus were i-emoved, and 
 the pelvis was i)acke(l. The j)atient was mai'kedly shocked. She slowly rallied, 
 but two weeks after operation gi'ew weakei', and died on the sixteenth da\' with 
 signs of general peritonitis. 
 
 In Case 9182 a negi'ess, forty-two years old, hail a weak ;ind ra|)id pulse during 
 o])eration. ( )n account of intestinal and genei'al pehie adhesions the utei'us 
 was bisected. She I'allied slightly aftei- operalioii, but on the third day grew 
 weaker and died (jii the f(jllowing day. Aut . No. 1809 revealed a geiiei'al ))ui'ule!it 
 peritonitis. 
 
 Intestinal Obstruction. In Case 9.5.36 the opei-ator found the tunioi' filling 
 the |)eh'is and (irmly fixed by dens(> adhesions. Bisection olTeicd the best
 
 684 MYOMATA OF THE UTKItUS. 
 
 prospect.s. Posteriorly, the tumor was so densely adherent to the reetiini that 
 a portion of it had to be left attached to the bowel. The pelvis was packed with 
 gauze, and the patient left the table in good condition. During the n(>xt day 
 she had severe pain in the left side of the pelvis; the pulse was 110, the temper- 
 ature 101.5° F. Vomiting and distention developed, and the patient died on the 
 fourth day with definite signs of obstruction. This case is reported in detail 
 on p. ISO. Here it will be seen that the entire central portion of a large sub- 
 pei'itoneal myoma had undergone sarcomatous transformation, and that the 
 center of the malignant growth had l)ecome necrotic. Local infection naturally 
 followed, with kinking of the bowel. 
 
 Death from Shock Following Bisection. — In Case 8836 the patient was a 
 white woman, forty-eight years of age. Filling the pelvis, and extending half- 
 way to the um[)ilicus, was a myomatous uterus. On account of numerous dense 
 adhesions bisection was carried out. In order to free adhesions as rapidly as 
 possible the bladder and I'ectum were both opened, l)ut later accurately closed. 
 The patient, on leaving the table, was in a desperate condition; the pulse was 
 loO, very weak, and irregular; the extremities were very cold. In spite of stimu- 
 lation she died within a few hours. In this case the subsequent steps of the 
 operation clearly demonstrate that we had shown very poor judgment in opening 
 the l)ladder and rectum, as the time saved by opening them was more than lost 
 during the subsequent closui'e. 
 
 In Case 8872 the patient was a white woman, fifty-two years of age, and well 
 nourished. After a long median incision through very thick walls had been 
 made, a large multinodular uterus was exposed. This tumor was not adherent, 
 but had developed mainly in the cervical region. Enucleation was carried out 
 by first clamping the ovarian vessels on both sides and then bisecting. The 
 hemorrhage was very profuse. After splitting down to the cervix, the operator 
 pulled the tumor from its capsule, but the Ijleetling still persisted. Both halves 
 of the uterus were then removed. The patient was almost pulseless on leaving 
 the table. Toward midnight she became delirious, and died at 6 a. m. Ex- 
 tensive development of a tumor usually renders the hysterectomy difficult, 
 but with slow and patient traction we would probably have been able to 
 remove the uterus intact and to save our patient. Death was clearly due to the 
 great amount of blood lost during the operation. 
 
 Death from Pulmonary Embolism Following Bisection. — In Case S71o the 
 patient was a negress, forty years of age. On section of the abdomen the pelvis 
 was found fille(l with a multinodular myomatous uterus. Bisection was easily 
 done, and the riglit structures were removed without difficulty. The left ap- 
 pendages were very adherent. The gall-bladder was openc^l, and several stones 
 removed. Convalescence was normal until the sixth day. The night mu'se 
 heard her cough and gasp, and by the time she reached the bed the patient was 
 dead. Aut. No. 1733 showed a perfectly smooth peritoneal cavity, but throm- 
 bosis of the left common iliac vein. Unfortunately, the pathologist was unaware
 
 RESULTS OF OPERATIONS FOR VTHHIXK MYOMATA. 685 
 
 of the apparent eaiise of death, and the kinj2;s were removed in the ordhiary way 
 and no eniboHsni was detected. Both hnigs showed some petechial subpleural 
 hemorrhages. 
 
 The cHnieal ])ieture, coupled with the thrombosis of th(^ iliac vein, leaves 
 little doubt that the patient died of ])ulmonary embolism. 
 
 Bronchopneumonia Causing Death after Bisection. — In Ca.'^e 7604 the patient 
 was a white woman, aged forty-four. The enlarged uterus extended above the 
 umbilicus, and the bladder was drawn up as far as the umbilicus. The tumor 
 was adherent to the rectum, and each tube was the seat of a hydrosalpinx. The 
 uterus was l)iseeted. From the cavity blood-stained serous fluid escaped, 
 and from the lower part of the uterus a soft stringy substance, softer, darker, 
 and more vascular than ordinary muscle tissue. From an accidental rent in 
 the bladder infected urine escaped into the pelvis. The patient (i;i:i(hially grew 
 weaker and died on the twelfth day. Aut. No. 1503 revealed gangrene of the left 
 ovary, sarcomatous metastases in the lungs, bronchopneumonia, metastases in the 
 chorda^ tendinea^, on the tricusj)id valves, and acute endocarditis. This case is 
 rejxjrted in detail on p. 220. 
 
 The majority of the cases in which death followed bisection were most diffi- 
 cult, and in some instances impossible of accomplishment by any other method. 
 A study of the cases, however, shows that wherever there is inf(>ction of the uterine 
 cavity or malignant degeneration in the myomata, the danger of immediate general 
 peritonitis is great. In some cases, also, great loss of blood follows the liisection. 
 This o])eration should never be performed in myoma cases, when the uterus can 
 be removed intact. In a certain group of otherwise inoperal)le cases the pro- 
 cedure, however, is of the greatest value to the surgeon. 
 
 Results in Vaginal Hysteromyomectomy. 
 
 As seen from the table, we had 24 vaginal hysteromyoiiiectomies with no 
 deaths. In jjractically all these cases the uterus was small and mobile and was 
 taken out readily from below. In many of the ca.ses these myomata were 
 associated with prolajjsus of the uterus, and the operation was for the prolapse 
 rather than for the myoma. 
 
 In nearly all cases in whleh the myomata are of niodeiale or hii'ge size we 
 prefer o|)eniiig the abdomen and I'emoving the uterus from alio\e. We nre thus 
 enal)le<l to see cleai'lN' each step in the opei'ation. and to cope successfull\' with 
 the vaiious and unexpected complicating conditions that are .so fre(|uently met 
 with. 
 
 Final Results after Operations for Uterine Myomata. 
 After abdominal myomectomy the results ai'e, on the \\hole, \'ery salist'actoi'y 
 (Chapter XXIX, )). ')()(')). The di'agging sensations in the lower abdomen and 
 the backache, so fre((uenlly noted, disaiijx'ar, .and the palieiil teds ))ei'lectly
 
 686 MYOMATA OF THE Ul KRIS. 
 
 well. In a few installers, as noted on p. oGl, a sul)se(niciit liystereetoiiiy may 
 be necessary on account of the development of other myomatous nodules. 
 
 In cases in which a simple supravaginal hysterectomy has been performed 
 and the ovaries ha\'e been saved, the final results are also very satisfactory, 
 and in many cases the unpleasant phenomena of the ])i-emature menopause have 
 been avoided. (See p. 603.) 
 
 In cases in which there has been much hemorrha<ie, the rapidity with which 
 the patients improve after ojx'ration is often little sliort of marvelous, and the 
 hemoglobin, whicli piioi- to operation has been below 80 per cent., rapidly rises 
 to 60 or 70 per cent ., and in the course of a few we(>ks is nearly normal. In Case 
 M., seen in consultation with Dr. K. W. Meiseiiheldci', at York, Pa., on January 
 2, 1903, affords an excellent example of such improvement. The patient at 
 operation was almost colorless, and during the o{)ei-ation the blood on the sponge 
 left no deeper stain than if di])ped in port wine. There had been excessive 
 hemorrhages, due to a very large submucous myoma. At the end of ten weeks 
 the patient had improved markedly and had a good color. The improvement 
 was so great that her intimate friends, meeting her on the street, did not recognize 
 her. 
 
 Our death-rate, on the wliole, has been relatively large, but it must be remem- 
 bered that the series includes the cases from the time the liosj)ital opened in 1SS9 
 until .July 1. 1906. In the early days the operative technic for the removal of 
 myomata was still in the transition stages and many cases that called for an 
 operation, at that time formidable and attended with grave dangers, are now 
 relatively easy and can be pro])erly cared for with but little risk. Furthermore, 
 many of the patients had passed from clinic to clinic, the condition having been 
 regarded as inoperable, so that, so far as we were concerned, removal of the 
 tumor was attempted as a last resort. Such patients would now be operated 
 upon before atlhesions, suppuration, or marked degenerative changes had taken 
 place. A glance at the results of the last two and a half years will show that our 
 operative mortality has been less than one })er cent. 
 
 The remarkal)le improvement that can often be obtained by removing slough- 
 ing submucous myomata fi'om ])atients who, as a I'esult of the septic absorption, 
 have a high tcnipcratui'c, a i'a])i(l and weak pulse, and iWi- npparcntly almost 
 moribund, is simply astonishing. (See ]>. 'u7.) 
 
 Naturally, the removal of any tumor of ccjiisiderable size and weight affords 
 physical relief, which in some cases is almost indescribable. 
 
 Taken as a whole, few ojjcrations in surgery give as nuieh i)ermaiient satis- 
 faction as those for the removal of uterine mvomata.
 
 KKSILTS OF Ol'KKATIOXS FOK ITKHIXK MVoMATA. 687 
 
 RESULTS IN MYOMA CASES AT THE .loHXS Hol'KIXS HOSPITAL I'lloM JILY 1 
 
 1906, TO JAXl'AItY 1, 1909. 
 
 Casks. Dkaths. Pkrckxtagk. 
 
 Abdominal myomectomy 38 
 
 Vaginal myomectomy 6 
 
 Abdominal hysteromyomectomy 192 2 1 + 
 
 Vaginal hystcroniyoniectoiny 2 
 
 'lOtai operations 238 2 .85 
 
 Not treated 8 
 
 In the series of 246* euses there were ;! deaths, two tollowiiii;; ahdoininal 
 hysteromyomectomy, and on(> in wliich no opci-atioii had hccii pci'toi-mcd. 
 This gives a mortahty of .85, or less than 1 ])er cent. 
 
 In the 194 hysteromyomectomies all but two of the jjatients ((ivn. Xos. 
 14662 and 15252) recovered — a mortality of a little over 1 per cent. In Case 
 14662 the patient died of postoperative intestinal obstruction on the twenty- 
 second day. In case 15252 the w^oman was forty-four years of age. At o})eration 
 complicating the myomatous condition of the uterus a general jx'ritoneal 
 carcinosis was found. The origin of these j)a])illary carcinomatous masses 
 could not l:)e determined. 
 
 In case 15477 the patient was admitted to the hospital in a state of exti-enie 
 asthenia and was markedly anemic. She died in a state of shock on the following 
 day. In this case, of course, operation was out of the ([uestion. 
 
 The reduction of the operative mortality in the last two and one-half yeai's 
 to less than 1 per cent, is particularly gratifying. It is due in part to the fact 
 that many j)atients came to the operation befoi'e serious comjiliealions de\-elo]ied, 
 but in a large measure to the improved methods which naturally follow where 
 many cases of the same kind are ojxM-ated upon in the .^ame clinic. 
 
 * A number of cases have been omitted, as the myomata were too small and as the operation 
 was performed for somf other cause.
 
 NDEX OF CASES ARRANGED ACCORDING TO THEIR 
 GYNECOLOGICAL NUMBERS. 
 
 This list does not include all the cases operated upon, but merely those that arc more or 
 less fully described in the text. The pathological and autopsy numbers are given in the accom- 
 panying lists. 
 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 
 No. 57 
 
 No. 62 
 
 No. 65 509, 
 
 No. 69 464, 
 
 No. 77 354,42.3, 
 
 No. 121 
 
 No. 143 504, 
 
 No. 182 504, 
 
 No. 213 504, 
 
 No. 278 
 
 No. 288 
 
 No. 301 
 
 No. 337 77, 
 
 No. 362 461, 
 
 No. 482 
 
 No. 515 
 
 No. 516 ....376,504, 
 
 No. 562 
 
 No. 615 
 
 No. 659 382, 
 
 No. 660 
 
 No. 694 16,436, 
 
 No. 701 11, 
 
 No. 706 
 
 No. 729 
 
 No. 832 
 
 No. 858 546, 
 
 No. 891 ....465,504, 
 
 No. 909 
 
 No. 934 
 
 No. 939 
 
 No. 963 
 
 No. 1033 510, 
 
 No. 1039 
 
 No. 1049 
 
 No. 1069 288, 
 
 No. 1112 
 
 No. 1135 
 
 No. 1150 572, 
 
 No. 1151 
 
 No. 1173 410, 
 
 No. 1212 449, 
 
 44 
 
 533 
 
 548 
 533 
 674 
 426 
 546 
 505 
 505 
 505 
 415 
 505 
 579 
 448 
 540 
 534 
 570 
 505 
 419 
 505 
 461 
 555 
 449 
 674 
 562 
 674 
 420 
 547 
 505 
 586 
 669 
 505 
 674 
 562 
 376 
 436 
 625 
 508 
 264 
 587 
 448 
 540 
 547 
 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 
 Gyn. No. 
 Gyn. No. 
 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 CJyn. No. 
 Gyn. No. 
 Gyn. No. 
 Gyn. No. 
 
 1249 
 
 1258 
 
 1260 
 
 13 17.. 572, .-)79, 
 
 PAGE 
 
 530 
 505 
 568 
 585, 
 586 
 
 1329 449,511 
 
 1373 504,505 
 
 1379 505 
 
 1383i ...35,451,625 
 
 1405 504,505 
 
 1422 507 
 
 1441 581 
 
 1455 ...346,527,570 
 
 1489 ..546,568, 572, 
 
 579, 587 
 
 1499 386,664 
 
 1551 ..448,579, 580, 
 586 
 
 1558 234,440 
 
 1576 554, 570 
 
 1579 371 
 
 1593 586 
 
 1610 ...71,441, 574, 
 575, 579, 587 
 
 1628 436 
 
 1637 348,349 
 
 1664 436 
 
 1666 666 
 
 1672 ...511.543,625 
 1682 ...366,387,436 
 
 1685 451,570 
 
 1691 288 
 
 1703 678,679 
 
 171(5 . . . 71 , 574, 575, 
 579, 587 
 
 1752 541 I 
 
 1767 673,674 
 
 1782 288 
 
 17S7 4 47 
 
 1,S21 .")7() 
 
 1852 J63,(i7() 
 
 1862 535 
 
 689 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 Gyn. 
 
 (iyn. 
 I G 
 i ( 
 
 ( 
 
 ( 
 
 ( 
 , ( 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 No. 
 
 N( 
 
 N( 
 
 N( 
 
 N( 
 
 N 
 
 N( 
 
 No 
 
 N( 
 
 N( 
 
 Xi 
 
 N( 
 
 X( 
 
 N. 
 
 X( 
 
 Xt 
 
 1872 681 
 
 1879 457 
 
 191() 570 
 
 1946 384,625 
 
 1949 504,505 
 
 1966 448 
 
 2005 445 
 
 2039 546,548 
 
 2042 435.568 
 
 448 
 
 661 
 
 376 
 
 666 
 
 465 
 
 2129 463,658 
 
 2052. 
 2070. 
 2073. 
 2098. 
 2108. 
 
 2142... 
 2158... 
 2172... 
 2182... 
 2183... 
 2189... 
 2291 . . . 
 2432. . . 
 2434... 
 2500... 
 2570. . . 
 2593... 
 259S... 
 2()()().. . 
 2634... 
 
 592 
 448 
 346 
 
 587 
 585 
 570 
 
 . . . . 270 
 .433,652 
 .547, 570 
 9 
 .573,587 
 .548.658 
 . . . . 444 
 405 
 
 2658 314.315 
 
 2666 587 
 
 2691 7,631 
 
 2699 432,658 
 
 2706 ...311,387,659 
 
 2709.^ 443,558 
 
 2710 .■)17.()()1 
 
 2713 ...451,630,671 
 
 27-14 l.')3 
 
 2746 132 
 
 2754 374 
 
 2763a 356,462
 
 ()<)() 
 
 IXDKX OF GYXECOLOCICAI. XIMBKRS. 
 
 PA<:i; 
 Gyn. No. IITI . 1 tS, 4()_'. 547 
 
 Gyn. No. 2777 367 
 
 Gyn. No. 2800 302, 436 
 
 Gyn. No. 2806 463, 661 
 
 Gyn. No. 2822 366 
 
 Gyn. No. 2838 448 
 
 Gyn. No. 2852 ... 1 24 . 3 1 7 . 32.-> 
 Gyn. No. 2873 71..")73. 
 
 575. 581 
 
 Gyn. No. 2SS1 11 
 
 Gyn. No. 2899 378. 381, 
 
 382.436 
 
 Gyn. No. 2902 457 
 
 Gyn. No. 2919 306.658 
 
 Gyn. No. 3008 8, 308, 313, 
 
 320.349,674 
 
 Gyn, No, 3014 12(1, 132 
 
 Gyn, No, 303S . . .318,321.327 
 Gyn, No, 3066 448, 453, 
 
 573 , 574 
 
 Gyn, No. 3107 84 
 
 Gyn. No. 3111 308,448 
 
 Gyn. No. 3113 . . .76, 123, 247, 
 
 294.317.329,371,385,438, 
 
 466 
 
 (iyn. No, 3119 630 
 
 (iyn. No. 3130 132, 328 
 
 Gyn. No. 3133 . . 76, 164, 166, 
 
 304,307,324.332.376,379, 
 
 387 
 
 (Jyn, No. 3154 443 
 
 Gyn. No. 3198 469,674 
 
 Gyn. No. 3199 ...154,302,449 
 
 Gyn. No. 3209 322 
 
 Gyn. No. 3216 . . . .86. 137,320 
 
 Gyn. No. 3218 314 
 
 Gyn. No. 3232 323.324 
 
 Gyn. No. 3272 382 
 
 Gyn. No. 3281 . . .319, 380, 436 
 
 Gyn. No. 3293 315 
 
 Gyn. No. 3294 351 
 
 Gyn. No. 3295 . . .248. 280, 585 
 Gyn. No. 3296 .... 19. 154. 355 
 Gyn. No. 3319 . . 335,336.371 
 Gyn. Xo. .3320 165. 166, 
 
 332,659 
 
 Gyn. No. 3338 449,6.30 
 
 Gyn, No. 3340 132, 333, 
 
 136,603 
 
 Gyn, No. 3345 102 
 
 Gyn. No. 3349 104,303 
 
 Gyn, No, 3353 449 
 
 Gyn, No, 3357 158 
 
 Gyn. No. 3385. . .320, 321, 431 
 Gyn, No, 3387 33,469 
 
 P.\GE 
 
 (Jyn. No. 3394 436 
 
 Gyn. No. 3408 332 
 
 Gyn. No. 3416 462 
 
 Gyn. No. 3418 302 
 
 Gyn. No. 3426 436,581 
 
 Gyn. No. 3437 324,457 
 
 Gyn. No. 3440 . . .436.464,631 
 
 Gyn. No. 3444 451 
 
 Gyn. No. .3445 . . .370.657,666 
 Gyn. No. 3449 158. 314, 
 
 4.36.661 
 
 Gyn. No. 3461 254 
 
 Gyn. No. 3488 158 
 
 Gyn. No. 3490 398 
 
 Gyn. No. 3491 307 
 
 Gyn. Xo. 3492 31S, 654, 
 
 (i()S,669 
 Gyn, No, 3493 298, 441> 
 
 674,676 
 
 Gyn, No, 3504A 105 
 
 Gyn. No. 3508 582 
 
 Gyn. No. 3535 661 
 
 Gyn. No. 3558 18 
 
 Gyn. No. 3583 449 
 
 Gyn. No. 3590 371,385 
 
 Gyn. No. 3600 511 
 
 Gyn. No. 3614 . . .312, 663, 664 
 
 Gyn, No, 3693 489 
 
 Gyn. No. 3774 436 
 
 Gyn. No. 3778 132 
 
 Gyn. No. 3842 50,372 
 
 Gyn. No. 3844 132 
 
 Gyn. No. 3882 674, 676 
 
 Gyn. No. 3985 132 
 
 Gyn. No. 3898 674, 675 
 
 Gyn. No. 3918 661 
 
 Gyn. No. 3950 17.132 
 
 Gyn. Xo. 3960 317.349 
 
 Gyn. No. 3971 55. 379 
 
 Gyn. No. 3974 18 
 
 Gyn. No. 3977 654. 681 
 
 Gyn. No. 3985 3 
 
 Gyn. No. 3991 97 
 
 Gyn. No. 3997 654 
 
 Gyn. No. 4016 449.527 
 
 Gyn. No. 4020 348. 349, 
 
 .368.. 369 
 Gyn. Xo. 4022 352. 36S, 
 
 369.668 
 (iyn. No. 4055 ...511, 546, 570 
 
 Gyn. No. 4097 387, (531 
 
 Gyn. No. 4160 132, .570 
 
 Gyn, No, 4165 587 
 
 Gyn, No, 4168 380.448 
 
 Gyn. No. 4172 659 
 
 P.^GE 
 
 Gyn. No. 4193.. ......663,664 
 
 Gyn. No. 4203 323, 447 
 
 Gyn. No. 4252 359 
 
 Gyn. No. 4262 287 
 
 Gyn. No. 4285 457 
 
 Gyn. No. 4297 509 
 
 Gyn. No. 4314 77 
 
 Gyn. No. 4340 365 
 
 Gyn. No. 434L 1.32 
 
 Gyn. No. 4364 129.132 
 
 Gyn. No. 4365 517 
 
 Gyn. No. 4369 666 
 
 Gyn. No. 4370 387,441 
 
 Gyn. No. 4372 666 
 
 Gyn. No. 4,382 . . .435. 571, 579 
 Gyn. Xo. 4415 . S9, 511, 554, 
 
 555 
 
 Gyn. No. 4441 441 
 
 Gyn. No. 4471 527 
 
 Gyn. No. 4485 116 
 
 Gyn. No. 4517 559 
 
 Gyn. No. 4526 448 
 
 Gyn. No. 4537 552 
 
 Gyn. No. 4599 377,451 
 
 Gyn. No. 4607 265 
 
 Gyn. No. 4609 . . .358, 673, 674 
 
 Gyn. No. 4607 678 
 
 Gyn. No. 4617 436. 666 
 
 Gyn. No. 4635 ()03 
 
 Gyn. No. 4663 572, 586 
 
 Gyn. No. 4699 495 
 
 Gyn. No. 4731 441,623 
 
 Gyn. No. 4732 341 
 
 Gyn. No. 4761 368 
 
 Gyn. No. 4771 352 
 
 Gyn. No. 4794 579 
 
 Gyn. No. 480 U . . 130. 132.460 
 
 Gyn. Xo. 4814 570 
 
 (iyn. Xo. 4828 . . .386. 449,619 
 
 Gyn. No. 4832 366,603 
 
 (iyn. Xo. 4844 . . . 509, 568, 570 
 
 ( iyn. Xo. 4856 525 
 
 (iyn. No. 4869 359, 657 
 
 Gyn. No. 4870 631 
 
 Gyn. No. 4873 548 
 
 Gyn. No. 4877 456 
 
 (iyn. No. 4894 668 
 
 (iyn. No. 4902 666,668 
 
 Gyn. No'. 4903 456, 666 
 
 Gyn. No. 4925 .77, 511, 519, 
 
 562 
 
 (iyn. No. 4929 546 
 
 (Jyn. No. 4955 . . .327, (565, 666 
 
 Gyn. No. 4959 446 
 
 Gyn. No. 4965 335, 336
 
 INDEX OF GYNECOLOGICAL NIMBEKS. 
 
 691 
 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 Gyn. 
 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 
 No. 
 No. 
 No. 
 No. 
 
 No. 
 
 . 461 
 
 PAGE 
 ',075 
 
 448 
 
 132 
 
 529 
 
 . .10.453,678 
 .387,388,448 
 
 560 
 
 530 
 
 511 
 
 4967. 
 4972. 
 4975. 
 4990. 
 5010 
 5014 
 5076. 
 5081 . 
 5086. 
 
 5092 398,461 
 
 5093 663 
 
 5103 363,626 
 
 5123 461,639 
 
 5124 542 
 
 5133 585 
 
 5141 355,441 
 
 5153 507,517 
 
 5193 623 
 
 5239 603 
 
 5242 574,586 
 
 5249 391 
 
 5277 603 
 
 5279 507 
 
 5289 448 
 
 5296 ...574,579,587 
 5302 ...390,674,676 
 
 5303 132,568 
 
 5325 387,603 
 
 5332 510 
 
 5359 510, 546, 
 
 550, 553 
 
 5421 376 
 
 5447 ...509,512,520 
 5452 . ..509,517,546 
 5493 ...507,509,520 
 5496 ...252,579,586 
 
 5528 295,348 
 
 5560 553 
 
 5588 547 
 
 5614 509 
 
 5617 ...148,307,678 
 5622 579 
 
 558 
 536 
 78 
 372 
 587 
 5697 371,391 
 
 5635. 
 5638. 
 5644. 
 5647. 
 5687. 
 
 .orA 
 
 5734. 
 
 5752. 
 5766. 
 5784 . 
 5801 . 
 5808. 
 
 .306, 351, 
 352,623 
 
 53 
 
 666 
 
 . .. .27,78 
 
 548 
 
 333 
 
 PAGE ' 
 
 Gyn. No. 5826 511, 552, Gyn. No. 
 
 554,568 Gyn. No. 
 
 Gyn. No. 5843 441 Gyn. No. 
 
 Gyn. No. 5846 439, 560 Gyn. No. 
 
 Gyn. No. 5858 283, 658, Gyn. No. 
 
 674,676 Gyn. No. 
 
 Gyn. No. 5871 462 Gyn. No. 
 
 Gyn. No. 5871^ 579 Gyn. No. 
 
 Gyn. No. 5873 554 Gyn. No. 
 
 Gyn. No. 5907 252 Gyn. No. 
 
 Gyn. No. 5943. 441 Gyn. No. 
 
 Gyn. No. 5946 . .78,329, 330, i Gyn. No. 
 
 375, 436 I Gyn. No. 
 
 Gyn. No. 5957 284 Gyn. No. 
 
 Gyn. No. 5965 569 Gyn. No. 
 
 Gyn. No. 5987 391 Gyn. No. 
 
 Gyn. No. 5993 147 Gyn. No. 
 
 Gyn. No. 6002 85, 587 Gyn. No. 
 
 Gyn. No. 6017 . . .379,451,679 Gyn. No. 
 
 Gyn. No. 6036 663 | Gyn. No. 
 
 Gyn. No. 6039 663 Gyn. No. 
 
 Gyn. No. 6045 223 
 
 Gyn. No. 6047 507 Gyn. No. 
 
 Gyn. No. 6070 569 Gyn. No. 
 
 Gyn. No. 6129 354,462 
 
 Gyn. No. 6143 587 I Gyn. No. 
 
 Gyn. No. 6145 570 i Gyn. No. 
 
 Gyn. No. 6169 299 Gyn. No. 
 
 Gyn. No. 6178 370,623 Gyn. No. 
 
 Gyn. No. 6185 . . .422, 426. 582 Gyn. No. 
 
 Gyn. No. 6190 355 I Gyn. No. 
 
 Gyn. No. 6198 441,619 Gyn. No. 
 
 Gyn. No. 6199 391 Gyn. No. 
 
 Gyn. No. 6206 622 Gyn. No. 
 
 Gyn. No. 6217 677 I Gyn. No. 
 
 Gyn. No. 6240 442 Gyn. No. 
 
 Gyn. No. 6272 . . . .32, 4.")3. 626 Gyn. Xo. 
 
 Gyn. No. 6324 42 (lyn. No. 
 
 Gyn. No. 6330 270 Gyn. No. 
 
 Gyn. No. 6344 . . .347, 348, 382 Gyn. No. 
 
 Gyn. No. 6372 (i()3, ()66 Gyn. No. 
 
 Gyn. No. 6376 446 
 
 Gyn. No. 6381 .338, 446 ( lyii. No. 
 
 Gyn. No. 6395 507. 51 7 ( iyii. .NO. 
 
 Gyn. No. 6407 257 ( \\\\. No. 
 
 Gyn. No. 6418 33,381 (iyii. N.i. 
 
 Gyn. No. 6432 116, 464 (lyn. Xo. 
 
 Gyn. No. 6433 61 | Gyn. Xo. 
 
 Gyn. No. 6439 408 | 
 
 Gyn. No. 6441 146. 151 . Gyn. No. 
 
 579, .')S7 Gyn. No. 
 
 Gyn. No. 6474 550. 555 Gyn. Xo. 
 
 (;yn. No. 6479 1.30, 132, Gyn. No. 
 
 332.348 Gyn. No. 
 
 Gyn. No. 6.")0S 648 | 
 
 PAGE 
 
 6521 447.677 
 
 6570 78 
 
 6582 370 
 
 6604 ....576,579,587 
 
 6607 .387,388 
 
 6610 388 
 
 6615 453 
 
 6628 463 
 
 6667 ...320,3.57,367 
 6722 ...452,463,621 
 6724 ...222, ,546, 547 
 
 6760 566,570 
 
 6762 510,550 
 
 6773 525,569 
 
 6774 44 
 
 6781 508 
 
 6791 625 
 
 6792 ...465,622.669 
 6833 ...132,579,587 
 
 6843 59,452 
 
 6855 .. .68,439, 578, 
 587 
 
 6863 3.-)5,368 
 
 6915 . .362.372, 622, 
 632.666 
 
 6933 669 
 
 6950 570 
 
 6972 603 
 
 6991 .336,464 
 
 6997 669,681 
 
 010 587 
 
 Oil 464 
 
 014 452 
 
 025 509 
 
 029 509 
 
 036 .")66.679 
 
 010 212 
 
 049 . . .1(),S.;^72,385 
 
 O.')0 .")7 1,579 
 
 063 343.376 
 
 064. 
 
 ()7:> 
 O.SC) 
 1 ( )•_' 
 120. 
 133. 
 1 58 . 
 
 l.")9 
 ISl 
 2 1 2 
 216. 
 218. 
 
 355. .368, 
 620,621 
 .■>.')9.."0 
 
 ■_'(•. I 
 
 115 
 
 . 622 
 
 l.")0. 15(i. 
 
 673.674 
 
 .509,. 568 
 
 3X5.6.36.637 
 212 
 
 4.52 
 
 570
 
 692 
 
 LXDKX OF GYNECOLOGICAL NUMBERS. 
 
 PAGE 
 
 Gyn. Xo. 7220 21 , 437, Gyn 
 
 508, 546 Gyn 
 
 Gyn. Xo. 7226 .... 44, 158, 366 Gyn, 
 
 Gyn. Xo. 7237 354. 631, Gyn. 
 
 663,664 Gyn. 
 
 Ciyn. Xo. 7240 58, 452, CJyn. 
 
 657,658,660 Gyn. 
 
 Gyn. Xo. 7263 496 Ciyn. 
 
 Gyn. Xo. 7266 452, 621 Gyn. 
 
 Gyn. X^o. 7276 621 Gyn. 
 
 Gyn. Xo. 7295 452, 463 Gyn. 
 
 Gyn. Xo. 7313 .... 67, 195, 355 Gyn. 
 
 Gyn. Xo. 7330 654 Gyn. 
 
 Gyn. Xo. 7361 439, 680 Gyn. 
 
 Gyn. Xo. 7381 669, 681 Gyn. 
 
 Gyn. Xo. 7383 69, 572 ' Gyn. 
 
 Gyn. Xo. 7438 453 , 465 Gyn. 
 
 Gyn. Xo. 7441 441 Gyn. 
 
 Gyn. Xo. 7460. . .436,461,659 Gyn. 
 
 Gyn. Xo. 7474 . . .208, 621, 683 Gyn. 
 
 Gyn. Xo. 7511 93 Gyn. 
 
 Gyn. Xo. 7528 355 
 
 Gyn. Xo. 7549 . . . .65, 69, 142, Gyn. 
 
 461,613 , Gyn. 
 
 Gyn. Xo. 7560 536, 658 Gyn. 
 
 Gyn. X"o. 7566 558 Gyn. 
 
 Gyn. Xo. 7.")69 452. 453, Gyn. 
 
 665.666 Gyn. 
 
 Gyn. Xo. 7583 376,623 Gyn. 
 
 Gyn. Xo. 7597 381 Gyn. 
 
 Gyn. Xo. 7600 440 
 
 Gyn. Xo. 7604 220, 685 Gyn. 
 
 Gyn. Xo. 7615 .... 64, 300. 4,">4 Ciyn. 
 
 Gyn. Xo. 7630 . . .365, 370, 452 Gyn. 
 
 Gyn. Xo. 7688 452, 462 
 
 Gyn. Xo. 7695 78 Gyn. 
 
 Gyn. Xo. 7696 603 Gyn. 
 
 Gyn. Xo. 7699 . . . 280, 329, 585 Gyn. 
 
 Gyn. Xo. 7703 603, 658, Gyn. 
 
 661,662 Gyn. 
 
 Gyn. Xo. 7721 570 Gyn. 
 
 Gyn. Xo. 7739 . . . .49, 619, 631 Gyn. 
 
 Gyn. Xo. 7753 550 Gyn. 
 
 Gyn. Xo. 7775 . . . 132, 345, 346 Gyn. 
 
 Gyn. Xo. 7779 563 Gyn. 
 
 Gyn. Xo. 7795 . . . 132, 325, 342 Gyn. 
 
 Gyn. Xo. 7819 267 Gyn. 
 
 Gyn. Xo. 7849 342 Gyn. 
 
 Gyn. Xo. 7859 . . . 359, 452, 660 Gyn. 
 
 Gyn. Xo. 7863 674 Gyn. 
 
 Gyn. Xo. 7872 570 
 
 Gyn. Xo. 7886 ... 548, 564, 661 Gyn. 
 
 Gyn. Xo. 7889 130, 132 Gyn. 
 
 Gyn. Xo. 7978 521 Gyn. 
 
 Gyn. Xo. 7992 295 Gyn. 
 
 PAGE 
 
 Xo. 8008 439,636 
 
 Xo. 8024 363,681 
 
 Xo. 8089 547 
 
 Xo. 8106 441 
 
 Xo. 8114 594 
 
 Xo. 8115 387 
 
 Xo. 8147 414 
 
 Xo. 8159 571,587 
 
 Xo. 8183 681 
 
 Xo. 8197 465 
 
 Xo. 8220 336 
 
 Xo. 8251 496 
 
 Xo. 8259 548,661 
 
 Xo. 8264 391 
 
 Xo. 8266 449 
 
 Xo. 8270 127,132 
 
 Xo. 8294 668 
 
 Xo. 8306 460,603 
 
 Xo. 8310 508 
 
 No. 8321 382,666 
 
 Xo. 8354 319, 320, 
 
 330, 461 
 
 Xo. 8368 328,451 
 
 Xo. 8371 362 
 
 Xo. 8389 ...511,550,554 
 
 Xo. 8391 380,381 
 
 Xo. 8410 64,586 
 
 Xo. 8415 510,562 
 
 Xo. 8437 371 
 
 Xo. 8462 447, 516, 
 
 517, 550 
 
 Xo. 8476 546,547 
 
 Xo. 8477 244 
 
 Xo. 8495 60, 452, 
 
 460,656 
 
 Xo. 8514 465 
 
 Xo. 8517 587 
 
 Xo. 8526 354 
 
 Xo. 8593 683 
 
 Xo. 8600 587 
 
 Xo. 8610 231,360 
 
 Xo. 8667 465 
 
 Xo. 8675 348 
 
 Xo. 8690 619 
 
 Xo. 8693 334 
 
 Xo. 8698 447,570 
 
 No. 8705 603 
 
 Xo. 8713 ...363,465,684 
 
 Xo. 8726 509 
 
 Xo. 8732 1.30. 132, 
 
 215,674 
 
 Xo. 8738 309,390 
 
 Xo. 8764 554, 555 
 
 Xo. 8767 146 
 
 Xo. 8773 517,553 
 
 Gyn 
 
 Xo 
 
 Gyn 
 
 Xo 
 
 Gyn 
 
 Xo 
 
 Gyn 
 
 No 
 
 Gyn 
 
 Xo 
 
 Gyn 
 
 No 
 
 Gyn 
 
 Xo 
 
 Gyn. 
 
 Xo. 
 
 Gyn 
 
 Xo 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 xXo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 No. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 Gyn. 
 
 Xo. 
 
 P.^GE 
 
 . 8804 ...454,456,584 
 
 , 8831 587 
 
 , 8836... 229, 373, 684 
 8844 ...439,509,546 
 
 ,8866 356 
 
 8872 684 
 
 8882 112 
 
 8897 531 
 
 8936 60, 454, 
 
 455, 565 
 
 8943 449 
 
 8951 454,670 
 
 8963 455 
 
 8985 341.342 
 
 8990 342 
 
 9004 266 
 
 9012 290 
 
 9013 448 
 
 9024 511,569 
 
 9027 43 
 
 9029 603 
 
 9030 ...346,496,679 
 
 9057 376,437 
 
 9078 45, 456 
 
 463.603 
 
 9090 351,494 
 
 9107 502 
 
 9118 ...237,507,511 
 
 9132 326,683 
 
 9137 576,587 
 
 9138 451 
 
 9141 289 
 
 9196 585 
 
 9197 509 
 
 9203 ....60,454,565 
 
 9215 570 
 
 9221 547 
 
 9243 ...342,526,568 
 
 9286 603 
 
 9304 546. 
 
 9329... 555, 568,569 
 
 9439 562 
 
 9443 277 
 
 9457 348,349, 
 
 379,462 
 
 9470 569 
 
 9527 603 
 
 9536 180,683 
 
 9540 40 
 
 9593 451, 454,. 
 
 455, 456 
 
 9608 498 
 
 9629 517 
 
 96.36 336 
 
 9637 ...434,435.507
 
 IXDKX OF GYXKCOLOGICAL NTMRKRS. 
 
 693 
 
 PAGE 
 
 Gyn. No. 9638 572 
 
 Gyn. No. 9652 435,681 
 
 Gyn. No. 9674 51 
 
 Gyn. No. 9675 360, 680 
 
 Gyn. No. 9678 . . .451,454,609 
 
 Gyn. No. 9694 387 
 
 Gyn. No. 9707 327, 451, 
 
 454, 457 
 
 Gyn. No. 9736 496, 654 
 
 Gyn. No. 9767 352 
 
 Gyn. No. 9769 63,452 
 
 Gyn. No. 9780 56 
 
 Gyn. No. 9786 . . .31, 451, 454, 
 
 455, 457 
 
 Gyn. No. 9788 603 
 
 Gyn. No. 9798 .... 57, 376, 594 
 
 Gyn. No. 9818 603 
 
 Gyn. No. 9843 603 
 
 Gyn. No. 9875 572, 587 
 
 Gyn. No. 9924 94,449 
 
 Gyn. No. 9928 451,603 
 
 Gyn. No. 9934 293 
 
 Gyn. No. 9953 445 
 
 Gyn. No. 9971 658 
 
 Gyn. No. 10059 546, 547 
 
 Gyn. No. 10085 291 
 
 Gyn. No. 10095 . .349, 681,682 
 
 Gyn. No. 10102 352 
 
 Gyn. No. 10164 660 
 
 Gyn. No. 10172 454, 455 
 
 Gyn. No. 10183 560 
 
 Gyn. No. 10194 657 
 
 Gyn. No. 10199 451 , 666 
 
 Gyn. No. 10204 373, 381, 
 
 496,669 
 
 Gyn. No. 10211 666 
 
 Gyn. No. 10220 278 
 
 Gyn. No. 10229 666 
 
 Gyn. No. 10237 340, 341 
 
 Gyn. No. 10257 518, 568 
 
 Gyn. No. 10281 666 
 
 Gyn. No. 10287 669 
 
 Gyn. No. 10300 . .517, 547, 548 
 Gyn. No. 10314 . . 155, 578, 579 
 
 Gyn. No. 10323 666 
 
 Gyn. No. 10337 426, 427 
 
 Gyn. No. 10351 509, 510, 
 
 517,537 
 
 Gyn. No. 10357 604, 666 
 
 Gyn. No. 10376 183, 572, 
 
 579, 586 
 Gyn. No. 10394 509. 546, 
 
 .')47,5.")0 
 
 Gyn. No. 10103 2 
 
 Gyn. No. 10426 669 
 
 PAGE 
 
 Gyn. No. 10440 488 
 
 Gyn. No. 10453 604 
 
 Gyn. No. 10462 279 
 
 Gyn. No. 10479 509, 568 
 
 Gyn. No. 10486 677 
 
 Gyn. No. 10490 486, 487 
 
 Gyn. No. 10491 351,495 
 
 Gyn. No. 10497 548 
 
 Gyn. No. 10555 445, 495, 
 
 663,664 
 
 Gyn. No. 10558; 604 
 
 Gyn. No. 10573 517, 555 
 
 Gyn. No. 10580 604 
 
 Gyn. No. 10587 526, 547 
 
 Gyn. No. 10588 . .518, 537, 538 
 
 Gyn. No. 10593 681 
 
 Gyn. No. 10618 . .457, 579, 589 
 
 Gyn. No. 10635 579, 587 
 
 Gyn. No. 10667 604 
 
 Gyn. No. 10669 363,674 
 
 Gyn. No. 10749i .391,674,675 
 
 Gyn. No. 10778 667 
 
 Gyn. No. 10872 572, 586 
 
 Gyn. No. 10875 346, 667 
 
 Gyn. No. 10916 307,373 
 
 Gyn. No. 10917 340 
 
 Gyn. No. 10969 436, 659 
 
 Gyn. No. 10983 547, 549 
 
 Gyn. No. 10991 376 
 
 Gyn. No. 10995 594 
 
 Gyn. No. 10997 281 
 
 Gyn. No. 11000 568 
 
 Gyn. No. 11010 572 
 
 Gyn. No. 11013 . .373,377,457 
 Gyn. No. 1 1052 . . 546, 547, 555 
 
 Gyn. No. 11067 78, 462 
 
 Gyn. No. 11110 539 
 
 Gyn. No. 11111 569 
 
 Gyn. No. 11133 497 
 
 Gyn. No. 11139 454 
 
 Gyn. No. 11169 518 
 
 Gyn. No. 11180 366, 669, 
 
 681 , 682 
 
 Gyn. No. 11216 604 
 
 Gyn. No. 11217 604 
 
 Gyn. No. 11224 74 
 
 Gyn. No. 11243 . .446, 572, 587 
 
 Gyn. No. 11251 463 
 
 Gyn. No. 11256 511,549 
 
 Gyn. No. 11293 266 
 
 Gyn. No. 11294 661 
 
 Gyn. No. 11296 542 
 
 Gyn. \(). 11337 426. 427, 
 
 454, 455 
 Gyn. No. 1 1392 . .419, 463. 601 
 
 PAGE 
 
 Gyn. No. 11422 370 
 
 Gyn. No. 11428 341 
 
 Gyn. No. 11472 604 
 
 Gyn. No. 11572 157 
 
 Gyn. No. 11587 376 
 
 Gyn. No. 11630 350 
 
 Gyn. No. 11634 622 
 
 Gyn. No. 11647 388 
 
 Gyn. No. 11681 604 
 
 Gyn. No. 11688 604 
 
 Gyn. No. 11694 155 
 
 Gyn. No. 11722 604 
 
 Gyn. No. 11792 133 
 
 Gyn. No. 11869 669 
 
 Gyn. No. 11889. .454,455, 572, 
 
 577, 579, 587 
 
 Gyn. No. 11898 ..15,128,133 
 
 Gyn. No. 11919 625 
 
 Gyn. No. 11927 435 
 
 Gyn. No. 11944 232, 442, 
 
 443,451,591 
 
 Gyn. No. 11949 258 
 
 Gyn. No. 11984 462, 604 
 
 Gyn. No. 11989 88,383 
 
 Gyn. No. 12000 392, 448 
 
 Gyn. No. 12021 329 
 
 Gyn. No. 12028 ^o^^, 569 
 
 Gyn. No. 12034 346, 527 
 
 Gyn. No. 12036. .440, 462. ;511 
 
 Gyn. No. 12041 348 
 
 Gyn. No. 12056 263 
 
 Gyn. No. 12079 579,586 
 
 Gyn. No. 12086 306, 604 
 
 Gyn. No. 12119 336 
 
 Gyn. No. 12139 . . 257, 302, 619 
 Gyn. No. 12154 449. 451, 
 
 665,667 
 Gyn. No. 121.-)5 . .200,332,461 
 
 Gyn. No. 12165 452, 527 
 
 Gyn. No. 12185 604 
 
 Gyn. No. 12194 49.669 
 
 Gyn. No. 12199 666, 667 
 
 Gyn. No. 12209 674. 675 
 
 Gyn. No. 122ir) 135, 435, 
 
 447.677 
 
 Gyn. No. 12221 302,303 
 
 Gyn. No. 12234 332. 451, 
 
 4.V2.454 
 Gyn. No. 12257 ..572,579,587 
 
 Gyn. No. 12291 465 
 
 Gyn. No. 12293 376, 452 
 
 Gyn. No. 12297 260 
 
 Gyn. No. 12301 604 
 
 Gyn. No. 12.323 577 
 
 (ivn. No. 12369 . .449. I(i3. 604
 
 694 
 
 IXDKX OF OYXKCOLOCICAL NUMBERS. 
 
 Gyn. No. 123S0 842 
 
 Gyn. No. 12439 (iOO 
 
 Gyn. No. 12452 UiU 
 
 Gyn. No. 12488 604 
 
 Gyn. No. 12490 323 
 
 Gyn. No. 12504 555, 556 
 
 Gyn. No. 1 2520 387 
 
 Gyn. No. 12522 103, 604 
 
 Gyn. No. 12525 604 
 
 Gyn. No. 12583 547, 552 
 
 Gyn. No. 12585 511 
 
 Gyn. No. 12587 648, 674, 
 
 680,682 
 Gyn. No. 12591 .491,571,586 
 
 Gyn. No. 12611 681 
 
 Gyn. No. 12656 417 
 
 Gyn. No. 12681 438,439 
 
 Gyn. No. 12689 563 
 
 Gyn. No. 12696 604,661 
 
 Gyn. No. 12709 81 
 
 Gyn. No. 12725 270, 459 
 
 Gyn. No. 12738 668 
 
 Gyn. No. 12764 604,661 
 
 Gyn. No. 12779 133,388 
 
 Gyn. No. 12788 243 
 
 Gyn. No. 12811 446,667 
 
 Gyn. No. 12841 387 
 
 Gyn. No. 12852 509, 525 
 
 Gyn. No. 12864 , .97, 239,373, 
 
 436 
 
 Gyn. No. 12866 . .336, 341 , 384 
 
 Gyn. No. 12890 454 
 
 Gyn. No. 12902 649 
 
 Gyn. No. 12912 346 
 
 Gyn. No. 12937 604 
 
 Gyn. No. 12944 604 
 
 Gyn. No. 12964 452 
 
 Gyn. No. 13014 579,587 
 
 Gyn. No. 1.3015 271 
 
 Gyn. No. I.'^OIC. 376, 449, 
 
 681 , 682 
 
 Gyn. No. 1.3025 362,452 
 
 Gyn. No. 13039 23, 452, 
 
 4.>3,601 
 
 Gyn. No. 13056 263 
 
 Gyn. No. 1.3067 74 
 
 Gyn. No. 13204 4S2 
 
 Gyn. No. 13272 474 
 
 Gyn. No. 13423 121 
 
 Gyn. No. 13498 487, 488 
 
 Gyn. No. 13625 118 
 
 Gyn. No. 1,3626 438 
 
 Gyn. No. 13629 368 
 
 Gyn. No. 14373 310 
 
 Gyn. No. 14662 687 
 
 P.\GE 
 
 (lyn. No. 14709 30 
 
 Gyn. No. 14942 145 
 
 Gyn. No. 15252 687 
 
 i Gyn. No. 15281 139 
 
 Gyn. No. 15283 51 
 
 Gyn. No. 15477 687 
 
 B. H., Dec. 5, 1908 362 
 
 San. No. 471 240 
 
 San. No. 581 2.56 
 
 San. No. 577 249 
 
 San. No. 836 163 
 
 San. No. 858 339 
 
 San. No. 941 87 
 
 San. No. 1011 101 
 
 San. No. 1049. . . .374,436,631 
 
 San. No. 1058 363 
 
 San. No. 1497 587 
 
 San. No. 1530 2 
 
 San. No. 1545 568 
 
 San. No. 1566 677 
 
 San. No. 1593 586 
 
 San. No. 1682 680 
 
 San. No. 1691 604 
 
 San. No. 1702 604 
 
 San. No. 1773 604 
 
 San. No. 1837 4.54, 456 
 
 San. No. 1847 149 ; 
 
 San. No. 1852 280 | 
 
 San. No. 1857 206 
 
 San. No. 1868 454 
 
 San. No. 1872. . . .300,360,681 
 
 San. No. 1879 204 
 
 San. No. 1924 94,356 
 
 San. No. 1925 108 
 
 San. No. 1944 454,663 
 
 San. No. 1973 259 
 
 San. No. 2142 592 
 
 San. No. 2144 604 
 
 San. No. 2164 604 
 
 San. No 217S .564 
 
 San. No. 2189 133 
 
 San. No. 2368 339 
 
 r. H. I., P ,35 
 
 (". II. I.. R. Oct. 25. 1902 62 
 
 C. H. I., C. Aujjc. 12, 1902 81 
 
 (". H. I., W.Jan. 22, 1903 190, 
 
 442,464,511 
 
 ('. II. I., K 286 
 
 C. H. I., B 355 
 
 C. H. I., McA., .362, 4.36, 512, 
 
 C. H. I.. F. Auii. 10. 1902 120, 
 
 375 
 
 ('. H. I.. R.Oct. 24, 1902. 382 
 
 C. H. I., B.April 28, 1904 436 
 
 vw.r. 
 
 C. H. I., F 461 
 
 C. H. I., A 464 
 
 C. H. I., S 468 
 
 C. H. I.. M 469 
 
 C. H. I., Dr. Ernest .John- 
 ston's Case 480 
 
 C. H. I., P. June 17. 1906. 485 
 
 C. H. I., S. Feb. 1904 500 
 
 C. H. I., B 509 
 
 C. H. I.. S 509 
 
 C. H. I., B 510 
 
 C. H. I.,S 512 
 
 C. H. I., H 517 
 
 C. H. I., W 544 
 
 C. H. I., 8. June 9, 1903. . 551 
 
 C. H. I., G 565 
 
 C. H. I., Peth 569 
 
 C. H. I.. J .587 
 
 C. H. I., S. Dec. 15, 1906 .588 
 
 C. H. I., R ,-,94 
 
 C. H. I., H. Mar. 16. 1903 621 
 C. H. I., K. Mar. 14. 1903 637 
 
 C. H. I., H 6.36 
 
 C. H. I.. H.June, 1903. . . 664 
 
 C. H. I., A 667 
 
 C. H. I., W 667 
 
 C. H. I.. K 674 
 
 C. H. I., No. 78 184 
 
 C. H. I.. No. .382 604 
 
 C. H. I., No. 392 452.604 
 
 C. H. I., No. 409 .587 
 
 C. H. I., No. 495 38 
 
 C. H. I., No. 511 681,682 
 
 C. H. I.. No. 620 . . .105, 604, 
 650 
 
 C. H. I., No. 673 604 
 
 C. H. I., No. 686 260 
 
 C. H. I., No. 728 455 
 
 C. H. I., No. 793 463 
 
 C. H. I., No. 930 .525 
 
 C. H. I.. No. 949 .381, 604, 
 
 (524 
 
 C. H. I., B. No. 1019 ... . .-)09, 
 
 510.. 525 
 
 ('. H. I., No. 1095 604 
 
 ('. H. I., No. 1201 .-)87 
 
 ('. H. I., No. 1205 439 
 
 C. H. I., No. 1.3.->2 625 
 
 Ca.se C, Hagerstown, Md. . 24 
 Mrs. B., Frederick Emer- 
 gency Ho.spital, Oct. 30, 
 
 1904 24 
 
 Dr. J. Mason HinuUey's 
 
 case 47 
 
 C. G., Hagerstown. Mil. ... .50
 
 INDKX OF GYXKCOLOGirAL XU.MRKUS. 
 
 ()9o 
 
 Dr. Curtis Burnani's case. 70 
 Professor Raffaele Bas- 
 
 tianelli's case 79 
 
 Dr. George E. Holtz- 
 
 apple's case 1.30 
 
 Dr. Houston. Troy. N. Y., 
 
 case 144 
 
 Dr. Hunner's case 175 
 
 Dr. Paul Owsley's case . . 276 
 Dr. Homer Gage's case. . . 335 
 
 P.\ < i K 
 
 Ca.se O.. Hebrew Hospital. 451 
 A. P., Cambridge Hospital, 
 
 March 4. 1906 470 
 
 Dr. T. A. Erck's ca.se 
 
 (Philadelphia) 477 
 
 Dr. James Bosley's case . . 493 
 
 U. P. I " 517 
 
 S. (Toronto). June. 1903. . 534 
 
 Case G., Frederick 531 
 
 O., Hebrew Hospital 551 
 
 r. P. I.. G 
 
 J. I Kelly), Dec. 9. 1899... 
 A. \V.. Cambridge. Md., 
 
 Hospital. May 24. 1905 
 Dr. E. A\'. Meisenhelder, 
 
 York. Pa.. Jan. 2,1903. 
 Dr. Stansbury Sutton .... 
 
 Dr. Geo. Ben Johnston. . . 
 
 P.\GE 
 
 565 
 
 588 
 
 641 
 
 686 
 643, 
 
 644 
 645, 
 
 646
 
 PATHOLOGICAL NUMBERS. 
 
 This list includes only those cases that are more or less fully discussed in the text, 
 gynecological numbers and the autopsy numbers are given in the accompanying lists. 
 
 The 
 
 Path. No. 101 
 
 Path. No. 119 
 
 Path. No. 162 
 
 Path. No. 178 
 
 Path. No. 186 433 
 
 Path. No. 196 
 
 Path. No. 204 
 
 Path. No. 213 314 
 
 Path. No. 222 
 
 Path. No. 245 
 
 Path. No. 246 
 
 Path. No. 256 
 
 Path. No. 2.59 
 
 Path. No. 265* 
 
 Path. No. 266 
 
 Path. No. 276 
 
 Path. No. 286 
 
 Path. No. 312 5 
 
 Path. No. 347.... 124, 317 
 
 Path. No. 359 
 
 Path. No. 380 
 
 Path. No. 435.. 8,. 308, 313 
 
 Path. No. 443 126 
 
 Path. No. 452 .. .318,321 
 
 Path. No. 460 
 
 Path. No. 472 
 
 Path. No. 479 5,. 308 
 
 Path. No. 487.... 76, 123, 
 
 329, 247 
 
 Path. No. 494.... 76, 164, 
 
 303..304,305,307,324 
 
 Path. No. 499 5,132 
 
 Path. No. .524.. 5, 154,302 
 
 Path. No. 5.33 313 
 
 Path. No. 534 86,137 
 
 Path. No. 539 
 
 Path. No. 540 
 
 Path. No. .543 323 
 
 Path. No. 573 
 
 Path. No. ,580 
 
 Path. No. 582 248 
 
 Path. No. 583 
 
 Path. No. 589 .5,165,166 
 
 P.'V.GE 
 
 270 
 
 270 
 
 9 
 
 68 
 
 ,652 
 
 309 
 
 405 
 
 ,315 
 
 405 
 
 311 
 
 432 
 
 309 
 
 5 
 
 7 
 
 68 
 
 132 
 
 356 
 
 ,302 
 
 ,325 
 
 4,7 
 
 306 
 
 ,320 
 
 ,132 
 
 ,327 
 
 68 
 
 84 
 
 ,309 
 
 317, 
 
 ,294 
 
 166, 
 
 , .332 
 
 , 328 
 
 ,318 
 
 ,469 
 
 ,320 
 
 314 
 
 322 
 
 ,324 
 
 319 
 
 19 
 
 , 280 
 
 315 
 
 ,332 
 
 PAGE 
 
 Path. No. 591 312 
 
 Path. No. 592 309,336 
 
 Path. No. 605 144 
 
 Path. No. 607 5,132,333 
 
 Path. No. 610 104,303 
 
 Path. No. 616 102 
 
 Path. No. 618 158 
 
 Path. No. 6.34 . . .320,321,431 
 
 Path. No. 641 33 
 
 Path. No. 659 .332 
 
 Path. No. 661 302 
 
 Path. No. 674 5,7 
 
 Path. No. 682 254 
 
 Path. No. 683 158,314 
 
 Path. No. 707 158 
 
 Path. No. 711 318 
 
 Path. No. 713 307 
 
 Path. No. 715 298 
 
 Path. No. 719 105 
 
 Path. No. 740 643, 644 
 
 Path. No. 742 18 
 
 Path. No. 788 312 
 
 Path. No. 828 489 
 
 Path. No. 872 132 
 
 Path. No. 910 132 
 
 Path. No. 964 5 
 
 Path. No. 970 132 
 
 Path. No. 971 318,349 
 
 Path. No. 977 55 
 
 Path. No. 980 18 
 
 Path. No. 986 3,132 
 
 Path. No. 990 97 
 
 Path. No. 1009 369 
 
 Path. No. 1012 369 
 
 Path. No. 1084 132 
 
 Path. No. 1116 323 
 
 Path. No. 1137 287 
 
 Path. No. 1152 309 
 
 Path. No. 1165 132 
 
 Path. No. 1170 129,132 
 
 Path. No. 1207 89 
 
 Path. No. 1245 116 
 
 Path. No. 1304 2C)5 
 
 697 
 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 I'atli. 
 
 P.\GE 
 
 No. 1307 358 
 
 No. 1318 358 
 
 No. 1327 66,68 
 
 No. 1382 326 
 
 No. 1392 132 
 
 No. 1434 359 
 
 No. 1484 327 
 
 No. 1499 3.36 
 
 No. 1500 132 
 
 No. 1521 529 
 
 No. 1536 10 
 
 No. 1599 147 
 
 No. 1628 529 
 
 No. 1631 398 
 
 No. 1750 68 
 
 No. 1755 132 
 
 No. 1815 240 
 
 No. 1899 252 
 
 No. 1962 148,307 
 
 No. 1973 252 
 
 No. 1990 628 
 
 No. 2034 306,351 
 
 No. 2055 53 
 
 No. 2101 333 
 
 No. 2146 283 
 
 No. 2222 252 
 
 No. 22.38 284 
 
 No. 2242 329,330 
 
 No. 2275 85 
 
 No. 2311 223 
 
 No. 2314 223 
 
 No. 2372 256 
 
 No. 2402, 
 No. 2413. 
 No. 2426. 
 No. 2441. 
 No. 2.530. 
 No. 25.38. 
 
 249 
 
 6S 
 
 299 
 
 .(58,422..-)82 
 
 32 
 
 306 
 
 No. 2.584 270 
 
 No. 2.-)92 347 
 
 No. 2().-)3 61 
 
 No. 2()()1 116 
 
 No. 2700 132.332
 
 698 
 
 PATHOLOGICAL XrMHKRS. 
 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Patli. 
 Patli. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 Path. 
 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 No. 
 
 2808, 
 
 2900. 
 
 2946. 
 
 30 -)2 
 
 307.')^ 
 
 3080 
 
 411 
 
 .320,3.-)7 
 
 r>m 
 
 132 
 
 ,')<) 
 
 3170 632 
 
 3177. 
 3277. 
 3312 
 .331.') 
 3318. 
 3354. 
 3373. 
 3390. 
 3431. 
 3472. 
 3476. 
 3486 
 
 6S 
 
 33() 
 
 212 
 
 56() 
 
 108 
 
 343 
 
 264 
 
 2(i4 
 
 loO 
 
 212 
 
 21 
 
 ,44.158.159 
 
 3491 68,69 
 
 3502 58 
 
 3576 68, 195 
 
 3601 4 
 
 3635 69 
 
 3673 67.68,195 
 
 3674 316,588 
 
 3703 162,163 
 
 3706 339 
 
 3729 208 
 
 3757 93 
 
 3799 65,69,142 
 
 3865 220 
 
 3879 64,300 
 
 3948 , .248,280,329 
 
 4043 132,345 
 
 4055 132,325 
 
 4074 267 
 
 4090 353 
 
 4113 87 
 
 4122 359 
 
 4136 132 
 
 4252 35!» 
 
 4403 336 
 
 4453 132 
 
 4479 2X6 
 
 4508 101 
 
 4539 , ,319,320.330 
 
 4554, 
 4576, 
 4593, 
 4616, 
 4672, 
 4716, 
 4823 , 
 
 328 
 
 511 
 
 (i 1 
 
 363 
 
 244 
 
 60 
 
 231 
 
 4851 480, 482 
 
 
 
 
 PA HE 
 
 
 Path 
 
 No. 
 
 4878 
 
 , , , , 499 
 
 Path. 
 
 Patli 
 
 No. 
 
 489S 
 
 , , 334 
 
 Path. 
 
 Path 
 
 No. 
 
 4931 
 
 .132,215 
 
 Path. 
 
 Path 
 
 No. 
 
 4935 
 
 ,389,390 
 
 Path. 
 
 Path 
 
 No. 
 
 4959 
 
 ,146,313 
 
 Path. 
 
 Path 
 
 No. 
 
 5032 
 
 , , , , 229 
 
 Path. 
 
 Path 
 
 No. 
 
 5072 
 
 ,111,112 
 
 Path. 
 
 Patli 
 
 No. 
 
 5159 
 
 , , . , 3 11 
 
 Path. 
 
 Path 
 
 No. 
 
 5176 
 
 266 
 
 Path. 
 
 Path 
 
 No. 
 
 5180 
 
 , , . . 290 
 
 Path. 
 
 Path 
 
 No. 
 
 5223 
 
 . , . , 266 
 
 Path. 
 
 Path 
 
 No. 
 
 5234 
 
 . , ,45,47 
 
 Path. 
 
 Path 
 
 No. 
 
 5247 
 
 , , , . 494 
 
 Path. 
 
 Path 
 
 No. 
 
 5265 
 
 ... 502 
 
 Path. 
 
 Path 
 
 No. 
 
 5274 
 
 , , , . 237 
 
 Path. 
 
 Path 
 
 No. 
 
 5286 
 
 .... 326 
 
 Path. 
 
 Path 
 
 No. 
 
 5312 
 
 .... 289 
 
 Path. 
 
 Path. 
 
 No. 
 
 5378 
 
 .... 60 
 
 Path. 
 
 Path 
 
 No. 
 
 5471 
 
 .... 395 
 
 Path. 
 
 Path. 
 
 No. 
 
 5671 
 
 .... 277 
 
 Path. 
 
 Path. 
 
 No. 
 
 5730 
 
 , , . . 180 
 
 Path. 
 
 Path 
 
 No. 
 
 5799 
 
 , , , , 498 
 
 Path. 
 
 Path. 
 
 No. 
 
 5816 
 
 ,131,133 
 
 Path. 
 
 Path. 
 
 No. 
 
 5825 
 
 , . . , 336 
 
 Path. 
 
 Path. 
 
 No. 
 
 5870 
 
 .360,361 
 
 Path. 
 
 Path. 
 
 No. 
 
 5912 
 
 ... 327 
 
 Path. 
 
 Path. 
 
 No. 
 
 5982 
 
 , , . . 63 
 
 Path. 
 
 Path. 
 
 No. 
 
 5996 
 
 , . . . 56 
 
 Path. 
 
 Path. 
 
 No. 
 
 6013 
 
 .... 57 
 
 Path. 
 
 Path. 
 
 No. 
 
 6046 
 
 .... 120 
 
 Path. 
 
 Path. 
 
 No. 
 
 6118 
 
 ,..94,96 
 
 Path. 
 
 Path. 
 
 No. 
 No. 
 
 No. 
 
 6127 
 
 ... 293 
 
 Path. 
 
 Pnth 
 
 6226 
 
 , , . . 62 
 
 Path. 
 
 Path. 
 
 6275 
 
 .... 291 
 
 Path. 
 
 Path. 
 
 No. 
 
 6299 
 
 .... 352 
 
 Path. 
 
 Path. 
 
 No. 
 
 6418 
 
 , , . , 278 
 
 Path. 
 
 Path. 
 
 No. 
 
 6421 ,133, 
 
 190, 442, 
 464 
 
 Path. 
 Path. 
 
 Patli. 
 
 No. 
 
 6430 
 
 , . . . 340 
 
 Path. 
 
 Path. 
 
 No. 
 
 6479 
 
 2 
 
 Path. 
 
 Path. 
 
 No. 
 
 6531 
 
 , , . , 155 
 
 Path. 
 
 Palli. 
 
 No. 
 No. 
 
 6596 
 
 , , , . 183 
 
 Path. 
 
 Path. 
 
 6618 
 
 2 
 
 Path. 
 
 Path. 
 
 No. 
 
 6644 
 
 488 
 
 Path. 
 
 P;itli 
 
 No. 
 No. 
 
 6685 
 
 279 
 
 Path. 
 
 P.ilh. 
 
 6712 
 
 .... 495 
 
 Path. 
 
 Path. 
 
 No. 
 
 6727 
 
 . , . . 486 
 
 Path. 
 
 Path. 
 
 No. 
 
 6730 
 
 , , . . 279 
 
 Path. 
 
 Path, 
 
 No. 
 
 6811 
 
 , , , , 276 
 
 Path. 
 
 Path. 
 
 No. 
 
 6908 
 
 , , . 363 
 
 Path. 
 
 Path. 
 
 No. 
 No. 
 
 6920 
 
 54 
 
 P.-ith, 
 
 Path. 
 
 7089 
 
 1 53 
 
 Path. 
 
 Path. 
 
 No. 
 
 7162 
 
 307 
 
 Path. 
 
 Path. 
 
 No. 
 
 7192 
 
 549 
 
 Path. 
 
 Path. 
 
 No. 
 
 7246 
 
 .... 281 
 
 Path. 
 
 PAGE 
 
 No. 7276 500 
 
 No. 7364 497 
 
 No. 7448 72,74,75 
 
 No. 7555 184 
 
 No. 7800 157 
 
 No. 7867 350 
 
 No. 7895 528,531 
 
 No. 7903 175 
 
 No. 7925 24,25 
 
 No. 7953 155 
 
 No. 8116 133 
 
 No. 8284 . , ,15,128,133 
 
 No. 8297 68,577 
 
 No. 8325 645,646 
 
 No. 8346 149 
 
 No. 8347 280 
 
 No. 8349 206 
 
 No. 8350 232 
 
 No. 8351 258 
 
 No. 8370 190 
 
 No. 8432 363,364 
 
 No. 8445 88 
 
 No. 8447 392 
 
 No. 8458 204 
 
 No. 8502 329 
 
 No. 8579 440 
 
 No. 8655 579 
 
 No. 8714 336 
 
 No. 8723 200,332 
 
 No. 8727 306 
 
 No. 8750 257 
 
 No. 8776 49 
 
 No. 8824 94,95 
 
 No. 8825 135 
 
 No. 8827 105,650 
 
 No. 8829 260 
 
 No. 8832 303 
 
 No. 8838 108 
 
 No. 8844 332 
 
 No. 8887 260 
 
 No. 8932 152,641 
 
 No. 9129 259 
 
 No. 9186 323 
 
 No. 9233 103 
 
 No. 9348 648 
 
 No. 9349 491 
 
 No. 9473 438 
 
 No. 9502 270 
 
 No. 9545 82 
 
 No. 9546 270 
 
 No. 9558 564 
 
 No. 9642 133 
 
 No. 9662 243 
 
 No. 9755 336,384 
 
 No. 9810 470
 
 rATHOLOGICAL XIMJJKRS. 699 
 
 PACJE PACK PAGE 
 
 Path. No. 9840 649 Path. No. 10311. . . .97,99.239 Path. No. 11191 339 
 
 Path. No. 10015. ......... 133 Path. No. 10382 -)12 Path. No. 11651 118 
 
 Path. No. 10033 271 Path. No. 10417 474 Path. No. 12090 310 
 
 Path. No. 10039 23 Path. No. 10494 492. 493 Path. No. 12618 28, 30 
 
 Path. No. 10076 73, 74 Path. No. 10677 121 Path. No. 12963 145 
 
 Path. No. 10077 263 Path. No. 10776 487 Path. No. 13121 139 
 
 Path. No. 10278 482 Path. No. 11044 70 Path. No. 13199 52
 
 AUTOPSY NUMBERS. 
 
 PAGE I PAGE PAGE 
 
 Aut. No. 23 395 Aut. No. 610 395 Aut. No. 1503 221, 685 
 
 Aut. No. 48 533 I Aut. No. 653 395, 396, 397 Aut. No. 1593 395 
 
 Aut. No. 52 534 Aut. No. 666 674 Aut. No. 1605 414, 428 
 
 Aut. No. 55 674 Aut. No. 680 395 Aut. No. 1666 395 
 
 Aut. No. 69 .395,397,423,428 Aut. No. 682 395 Aut. No. 1689 442 
 
 Aut. No. 117 395,415,428 ! Aut. No. 689 395,398,428 Aut. No. 1703 395 
 
 Aut. No. 118 677 Aut. No. 700 395 Aut. No. 1734 674 
 
 Aut. No. 136 395,421,428 Aut. No. 722 395 Aut. No. 1745 397 
 
 Aut. No. 172 419,428 Aut. No. 742 681 Aut. No. 1754 395 
 
 Aut. No. 188 382,395,397 Aut. No. 810 398,428 Aut. No. 1809 683 
 
 Aut. No. 198 674 Aut. No. 901 395 Aut. No. 1823 395 
 
 Aut. No. 211 420,428 | Aut. No. 908. . . .395, 396, 397, Aut. No. 1869 395 
 
 Aut. No. 237 674 [ 678 Aut. No. 1898 395, 428 
 
 Aut. No. 277 . . .395, 416, 428, ' Aut. No. 926 398, 428 Aut. No. 1936 680 
 
 540 Aut. No. 954 390, 674 Aut. No. 2080 395 
 
 Aut. No. 288 396,397 Aut. No. 994 396,397 Aut. No. 2088 . . .395,427,428 
 
 Aut. No. 322 395 Aut. No. 1085 . . . 223, 395, 428 Aut. No. 2162 674 
 
 Aut. No. 353 234 Aut. No. 1112 . .397, 422, 428, Aut. No. 2202 395 
 
 Aut. No. 385 674 583 Aut. No. 2230 395 
 
 Aut. No. 474 395,428 j Aut. No. 1220 408,428 Aut. No. 2293 681 
 
 Aut. No. 451 396,397 Aut. No. 1310 395 Aut. No. 2319 427,428 
 
 Aut. No. 505 405, 428 Aut. No. 1337 395 Aut. No. 2404 395 
 
 Aut. No. 519 395 Aut. No. 1363 395 | Aut. No. 2426 395 
 
 Aut. No. 532 395 Aut. No. 1371 428 ' Aut. No. 2558 393 
 
 Aut. No. 561 674 ; Aut. No. 1387 678 Aut. No. 2651 674 
 
 Aut. No. 579 395 Aut. No. 1407 415,428 Aut. No. 2671 417,428 
 
 Aut. No. 595 674 Aut. No. 1445 6S0 Aut. No. 2987 66 
 
 701
 
 INDEX 
 
 Abdominal cavity, bleeding into, after bi- 
 manual examination for .subperitoneal 
 pedunculated myoma, 444 
 irrigation of, after abdominal hystero- 
 
 myomectomy, 620 
 passage of enema into, after hystero- 
 myomectomy, 391 
 Abdominal contour in myoma cases, 436 
 
 hemorrhage, symptoms suggesting, after 
 
 abdominal hysteromyomectomy, 669 
 hysteromyomectomy, 588. See also Hys- 
 teromyomectomy, abdominal. 
 metastases with myosarcoma, 200 
 Abdominal myomectomy, 506. See also Myo- 
 m,ectomy, abdominal. 
 operations necessary subsequent to, 556 
 pain after, 549 
 Abdominal pregnancy, myoma and, difTerenti- 
 ation, 473-477 
 veins, enlargement of, 437 
 Abdominal walls, lipoma of, associated with 
 myoma, 461 
 perforation of, by myosarcoma of uterus, 
 
 176 
 thick, rendering hysteromyomectomy diffi- 
 cult, 630 
 vessels from, supplying nourishment to 
 parasitic myoma, 51 
 Abdominal wound, suppuration of, after 
 
 hysteromyomectomy, 662 
 Abscess beneath broad ligament in myosar- 
 coma of utenis, 196 
 between intestines and omentum due to 
 
 suppurating myoma, 139 
 burrowing along vagina, 196 
 of broatl ligament after abdominal myomec- 
 tomy, 553 
 with myoma, 355 
 of kidney with uterine myoiiiata, 397, 122 
 of lung after hysteromyomectomy, 682 
 of ovary with myoma, 344, 396, 637, 639 
 omental, with uterine myoma. 637 
 on .surface of uterus due to perforation ol 
 suppurating interstitial myoma, 150 
 Abscess, pelvic, anterior to myomatous uterus. 
 636 
 
 Aljscess, pelvic, evacuation of, after abdominal 
 myomectomy, 559, 635 
 myoma a.ssociated with, aijdominal liy- 
 
 sterectomy in, 635 
 with myomata of uterus, 635 
 perirectal, 391 
 pulmonary, after abdominal hj-steromyo- 
 
 mectomy, 669, 682 
 tubo-ovarian, a.ssociate(l with myoma, 344, 
 396 
 with carcinoma of body and myoma, 290 
 Abscesses, multiple, after abdominal hystero- 
 myomectomy, 664 
 Acces.sory uterine artery, almost fatal bleeding 
 
 from, 623 
 Adenocarcinoma of ovary, associated with my- 
 oma, 348 
 of uterus, associated witli myoma, 274, 275, 
 276, 278 
 early, associated with myoma, 294, 295 
 
 with .suspicious changes in myoma, 248 
 extensive, overlooked at operation. 286 
 following submucous myoma, 248 
 growing into myoma, 405 
 inspection of cavity for, 594 
 myomectomy in case of, 416 
 rare form of, 489 
 
 with metasta.ses, in lym])h-glan(l.s 405, 
 414 
 in left adrenal body. 108 
 in liver, 408 
 in lungs, 408 
 in mesentery, lOS 
 in omentum, 105, lO.S 
 in pancreas, 408 
 in peritoneiim, 105, 108 
 in pleura, Kl.S 
 in s])le(Mi, 1 1 I 
 Adcntx'arcinonia of utcius with tubo-ovarian 
 
 abscess, 290 
 Adenocystoma of o\ary with uterine myoma, 
 
 346, 39(), 117 
 .\(_lenomyoma of round liganicnts w itii myoma, 
 364 
 of uteio-ovarian ligament with myoma, 360 
 of utcius, 167, 16S 
 
 ro3
 
 704 
 
 INDEX, 
 
 Adeiiomyoma of uterus, alxloiniual niyoniec- 
 tomy for, oil 
 diffuse, in one lioru of hiconiatc uterus, 
 
 157 
 removal of, per aI)tloineii, .311 
 witli apparently independent round-celled 
 
 sarcoma of uterus. 2S() 
 with double cervix and (i()ul)Ie vagina, 
 
 155 
 with squamous-celled carcinoma of cervix, 
 262 
 Adhesions, appendiceal, affording hlood-supjily 
 to parasitic myoma, 39 
 between liver and myoma, 464 
 between myoma and rectum, 386 
 gradual absorption of, after abdominal 
 
 hysteromyomectomy, 641 
 in myoma cases, found at autopsy, 395 
 intestinal, (')33 
 
 after abdominal myomectomy, 566 
 extensive, method of dealing with, 635 
 of bladder in myoma cases, role played by, 
 
 3()(i 
 ovarian, release of, after alidoniinal myo- 
 mectomy, 556 
 to broad ligaments in myoma cases, 354 
 vesical, release of. after abdominal myo- 
 mectomy, n.'yC) 
 Adipose tissue in myoma, 162, KiO 
 Adrenal body, metastases in. from adenocar- 
 cinoma of uterus, 40S 
 Anastomosis, uretero-ureteral. 383 
 
 intestinal, 635 
 Anesthesia in abddminai liysteromyomectoniy, 
 
 590 
 Angiomyoma of uterus, 158 
 Anus, artificial, with complete control, 190 
 Appendicitis a.ssociated with myoma. 463 
 Appendix, removal of, in myoma cases, 
 
 463 
 Areas, raw. with abdoiiiiiiai liysteromyomec- 
 
 tomy, 619 
 Artery, uterine, almost fatal bleeding from 
 accessory branch, during abdominal 
 hysteromyomectomy, 623 
 fatal hemorrhage from, due to absorption 
 
 of catgut, 681 
 pa.ssage of silk ligature from, into bladder, 
 
 375 
 tearing of. during abdominal myomec- 
 tomy, 525 
 Ascites associated witii myoma, 30 
 Autopsy, carcinoma of body of utenis and 
 myoma found at, 404 
 of cervix with uterine myoma 
 found at, 398 
 
 Autopsy changes found in ureter associated 
 with myoma, 396 
 condition of Fallopian tubes in cases of 
 uterine myoma, 395 
 of ovaries in myoma cases, 395 
 findings in myoma cases, 394, 428 
 myosarcoma and mj'oma found at, 420 
 perforation of rectum found at , after hystero- 
 myomectomy, 390 
 
 Ballottemext with uterine myoma, 469 
 Bastianelli, Raffaele, 79 
 
 Bed-sore following abdominal hysteromyomec- 
 tomy, 662 
 abdominal myomectomy, 55') 
 Bicornate uterus, diffuse adenomyoma in one 
 
 horn of, 157 
 Bimanual examination of a subperitoneal 
 pedunculated myoma, bleeding into ab- 
 dominal cavity after, 444 
 Bisection of uterus, 608. See also under Hys- 
 teromyomectomxj. 
 dangers of, 181, 609 
 death after, 683 
 
 followed by intestinal obstruction, 683 
 for submucous myoma, 574 
 Bladder, adhesions of, after abdominal myo- 
 mectomy, 556 
 role played by, in myoma cases, 366 
 adventitious vessels furnished by, 48 
 ascent of. with growth of myoma, 366 
 blood supply from, to ])arasitic myoma, 50 
 calculus in, associated with uterine myoma, 
 
 375 
 carcinoma of, .secondary to cervical carcin- 
 oma, 401 
 displacement of, by myoma, 365, 368 
 full, simulated by encysted peritonitis, 371 
 in myoma cases, 365-377 
 inflammation of. after alxlominal myomec- 
 tomy. 549 
 in myoma cases, 377 
 injurj^ of, during removal of uterine myoma, 
 
 371 
 loss of control of, 37() 
 
 manipulation of, in abdominal hysteromyo- 
 mectomy, 374 
 passage of silk ligatvire from uterine artery 
 
 into, 375 
 pres.sure on, by myoma, 365 
 retention of urine, 376 
 sacculation of, in myoma cases, 370 
 sarcoma of, with uterine myoma, 420 
 spontaneous evacuation of broad ligament 
 
 abscess into, 553 
 symptoms attributable to myoma, 376
 
 INDEX. 
 
 roo 
 
 Bladder wall, condition of, in myoma cases, 
 
 370 
 Bleeder, constitvitioiial, sncccssfui liystero- 
 
 niyomectomy on, 625 
 Bleeding. See Himorrhaqe. 
 Bleeding;, intermenstrual, in myoma cases, 
 444 
 into abdominal cavity on bimanual examina- 
 tion of subperitoneal pedunculated my- 
 oma, 444 
 Blood in uterine cavity in myoma ca.ses, 309 
 Blood .supply of myomata, 6 
 
 of parasitic myoma, 16, 38, 39, 41, 48 
 Blood-vessels of broad ligament, dilatation of, 
 with myoma, 354 
 of uterine mucosa, alterations in, witii 
 myoma, 317 
 Bluish color of vaginal mucosa with myoma , 
 
 439 
 Breasts, carcinoma of, associated with myoma, 
 450 
 colostrum in, with uterine myoma, 449 
 condition of, with uterine myoma, 449 
 in differential diagnosis of myoma and preg- 
 nancy, 467 
 tumors of, benign, with myoma, 450 
 Broad ligament, abscess beneath, associated 
 with myosarcoma of uterus, 196 
 abscess in, after removal of myoma, 553 
 
 associated with uterine myoma, 355 
 adhesions to, in myoma ca.ses, 354 
 alterations in, as.sociated with uterine 
 
 myoma, 354 
 cyst in, 396 
 dilatation of blood-vessels of, witli uterine 
 
 myoma, 354 
 dilated lymph-spaces in, witli myoma, 355 
 hematoma in, during alidominal liystero- 
 
 myomectomy, 623 
 infection of, after abdominal liysteromyo- 
 
 mectomy, 664 
 myoma of, 51, 53, 354, 510 
 
 abdominal myomectomy for, 510 
 secondary nodule in, from myo.sarcoma 
 
 of uterus, 195 
 thickening of, witli uterine myoma, 1555 
 I'niiicliial lymph-glands, metastases in, from 
 adenocarcinoma of uterus, 405 
 from .squamous-cellcd carcinoma of cei- 
 vix, .399 
 Broiicliitis after alidDiiiiiial liy^lciniiiyDiiK <■- 
 tomy, ()()S 
 myomectomy, 554 
 Bronchopneumonia after aijdominal hystero- 
 myomectomy, 668, 685 
 myomectomy, '^iyo 
 45 
 
 C.\LC.\HEOu.s nodules in me.sentery, 464 
 
 plates in an arterial wall, 129 
 Calcification of lieart muscle a.ssociated with 
 uterine myoma, 424 
 of myoma, 126, 130, 132, 133, 268 
 Calcium salts, how deposited, in myoma, 127 
 Calculus, uterine, with myoma, 130 
 
 vesical, associated with myoma, 375 
 Capillaries, marked proliferation of endothe- 
 lium of, in myoma, 99 
 Carcin(jma of body of uterus, un.suspected 
 during abdominal myomectomy, 540 
 with myoma, detected at autop.sy, 404 
 of l:)reast, a.ssociated with myoma, 450 
 of cervix, associated with myoma, 262 
 found at autopsy, 398 
 early, with myoma, 269 
 simulated by .submucous myoma, 487 
 suspicion of, with myoma, 304 
 with primary carcinoma of ovary and 
 
 myoma, 271 
 with sloughing submucous myoma, 398 
 Carcinoma of P'allojiian tube, secondary, witli 
 myoma, 396 
 of omentum, myoma and. differentiation. 499 
 of ovary, primary, with carcinoma of cervi.x 
 and myoma, 271 
 witli myoma, 396 
 with carcinoma of stomach, 396 
 of rectum, a.ssociated with uterine myoma, 
 
 391, 417 
 of uterus, a.ssociated with myoma, found at 
 autopsy, 404 
 histological changes in myoma suggesting, 
 
 491 
 myoma and, differentiation, 485 
 secondary, witii uterine myoma, 295 
 Cardiac hyaline ilegeneration, witii necrotic 
 uterine myoma, 423 
 hypertrophy, with uterine myoma, 414. 423 
 lesions, possil)ly attributable to uterine 
 
 myoma, 421 
 .sounds in myoma cases, 451 
 Cardinal vessels, clamping and apjilicalion of 
 
 ligatures later, 600 
 Catgut, dealli following use of, in ai)tli>minal 
 myomectomy, 541 
 too early ab.sorption of, wilii fatal liemor 
 rhage, after hysteromyomectomy, 681 
 Cecum, sujipurating myoma opening into. 46 
 Cells in myoiii;i. 9 
 
 Cerebral emliolus following abdominal myo- 
 mectomy, .")37 
 Cervical endomelrilis with myoma. 302 
 glands, dilatation of, with myoma. 29S 
 unfolding of, with mvoma 302
 
 706 
 
 INDEX. 
 
 CerA'ical lips, edema of, with myoma, 441 
 lyniph-glands, metastases in from adeno- 
 carcinoma of body of utenis, 405 
 Cervical mucosa, changes in, with myoma, 297, 
 302 
 extensive removal of, during supravaginal 
 
 hysteromyomectomy, 601 
 polypi of, with myoma . 29S, 300 
 Cervical myoma, 53 
 
 abdominal myonieotomy for, 510 
 associated witii atlenocarcinoma of uterus, 
 
 278 
 extensive, hysterectomy for, ditiicult, 58 
 large, with adenocarcinoma of body, 289 
 removal of, through abdomen, 510 
 Cervical stum]), appearance of, after abdom- 
 inal hysteromyomectomy, 599 
 hemorrliage from secondary sarcoma in, 
 
 190 
 return of myosarcoma in. 17(), 190 
 Cervix, almost obliterated, witli myoma, 441 
 atrophj^ of, associated with myoma. 78, 297 
 carcinoma of, a.ssociatetl with myoma, 262, 
 305, 398 
 simulated by sul)nmcous nwoma, 487 
 with myoma and primary carcinoma of 
 
 ovarj^ 271 
 with slovighing subnuicous myoma, 398 
 Cervix, closure of, after hysteromyomectomy, 
 596 
 condition of, in cases of myoma, 440 
 double, associated witli submucous adeno- 
 
 myoma, 155 
 elongation of, with myoma, 441 . 442 
 hypertrophy of, with myoma, 297, 441 
 in differential diagnosis of myoma and preg- 
 nancy. 467 
 infection of. following abdominal hystero- 
 myomectomy, 664 
 involvement of. l)y mycMua. 57 
 jammed down on jxTincum in myoma cases, 
 
 411 
 normal, with myoma. 441 
 pushed u]i Ix'liind sym])liysis in myoma 
 
 cases, 4 11 
 return of .sarcoma in. 212 
 torsion of, 77, 79 
 
 transverse .section of, as preliminary step 
 in abdominal hysteromyomectomy, 612 
 Ce.sarean .section with death four years after 
 
 abdominal myomectomy, 568 
 Chills with submucous uterine myoma, 572 
 Cholestorin in liroken down hyaline material. 
 
 125 
 Chorda' tendine:r, metastases in, from sarcoma 
 of uterus, 222 
 
 Chorio-epithelioma simulating myomatous 
 
 uterus, 482 
 Cockscomb sarcoma on surface of uterus, 184 
 Colic, renal, with myoma, 466 
 Colon, suppurating subperitoneal myoma open- 
 ing into, 142 
 transverse, descent of, with myoma, 463 
 Colostrum in breasts with myoma, 449 
 ColunuKC carneie of -right ventricle, metastases 
 
 in. following .sarcoma of uterus, 222 
 Constipation after abflominal hysteromyomec- 
 tomy, 659 
 with uterine myoma, 445 
 Cornual jiregnancy, ruptured, simulating my- 
 oma. 177 
 Cor[Mis liitcum cysts with myoma. 346 
 CuUen. Ciiurcli Home ca.ses, 671 
 Cystadenoma. multilocular, of ovaries, with 
 
 myoma, 346, 396, 417 
 Cystic areas containing enndsified fat, 92, 
 124 
 degeneration of myoma, 83, 92, 102, 111 
 myoma, 112 
 
 abdominal myomectomy for, 512 
 character of fluid in, 91 
 resembling heart cavity, 122 
 resembhng ovarian cy.st, 111 
 Cj'stitis, associated with myoma, 377 
 
 following abdominal hysteromyomectomy, 
 
 657 
 following myomectomy. 549 
 Cysts, corpus luteum, with uterine myoma, 
 346 
 dermoid, of ovaries, with uterine myoma, 
 
 349 
 formation, early, in myoma. 96 
 Graafian follicle, with uterine myoma, 344 
 in myosarcoma, 197. 198 
 labial, with uterine myoma. 438 
 large, due to hyaline degeneration in myoma, 
 
 90 
 of ovary, bilateral, ami myoma, ilil'ferentia- 
 tion, 498 
 in myoma cases. 344 
 myoma and. differentiation, 495 
 papillo-cystomatous, 498 
 removal of, during abdominal myomec- 
 tomy, 527 
 of umbilicus with myoma, 462 
 of urachus associated with myoma, 463 
 of utero-ovarian ligaments in myoma cases, 
 
 356 
 parovarian, with uterine myoma, 353 
 retention, in kidney, with myoma, 427 
 tubo-ovarian, with myoma, 340 
 vaginal, with mvoma, 439
 
 INDEX. 
 
 ro- 
 
 Death after abdominal inyomcctoiny probably 
 due to infection from Falloj)ian tubes, 541 
 apparently from diarrhea following ab- 
 dominal hysteromyomectomy, 681 
 causes of, in patients succumbing years 
 
 after abdominal myomectomy, 570 
 due directly to myoma, 426, 427 
 due to bronchopneumonia after bisection, 685 
 due to peritonitis following abdominal 
 
 hysteromyomectomy, (573 
 following abdominal hysteromyomectomy, 
 672, 677, 678, 680, 681, 682, 684 
 myomectomy, 532, 533, 538, 541, 543, 
 544, 672 
 bisection of uterus, 683 
 Cesarean section four years after ab- 
 dominal myomectomy, 568 
 uterine hemorrhage, 399 
 vaginal myomectomy, 672 
 Death from submucous myoma, no operation 
 performed, 584 
 immediate, following abdominal myomec- 
 tomy, 532 
 vaginal myomectomy, 580 
 myocarditis probable cause of, after ab- 
 dominal myomectomy, 544 
 on table, 543 
 
 years after vaginal myomectomy, 586 
 Death-rate, marked reduction in, in last two 
 
 years, 687 
 Decidua simulated by sarcoma, 218 
 Defecation, painful, with myoma, 446 
 Degeneration, cystic, of myoma, 83. See also 
 
 Degeneration, hyaline. 
 Degeneration, hyaline, of myoma, 8, 83-125, 
 
 .395 
 Delirium aftei' vaginal myomectomy, 580 
 Delusional insanity after vaginal hysteromyo- 
 mectomy, 670 
 Dermoid cysts of ovaries witli myoma, 349 
 Diagnosis of myoma, 467-503 
 Discharge. See Vaginal discharge. 
 Discrete myoma, 3 
 
 Dislocation of ureters witii myoma, 378 
 Displacement of bladder, by myoma, 365, 368 
 
 of rectum, upward, by myoma, 386 
 Diverticula, ruptured, rectal, .")()() 
 Double ureter with myoma. 3Sl 
 Drainage, vaginal, following alxlomiiiMl liys- 
 toromvomcctomv, (')23, ()2 1 
 
 Edkma of cervical lips witii myoma, 111 
 mucosa with myoma, 297 
 of legs after abdominal liysteromyomectomy, 
 658 
 
 Edema of lower extremities associated with 
 myoma, 4.)0 
 
 of myoma, 88 
 
 of uterine mucosa with myoma, 322 
 Edematous myoma, giant-cells in, 2.50 
 Electrical treatment for myoma, 588 
 Embolism, pulmonary, fatal, following ab- 
 dominal hysteromyomectomy, 680 
 following bisection, 684 
 Embolus, cerebral, following abdominal myo- 
 mectomy, ,")37 
 Emulsification of hyaline myomatous tissue, 
 
 92, 124 
 Encysted peritonitis suggesting full bladder, 
 
 with myoma, 371 
 Endocarditis, acute vegetative, with sloughing 
 suVimucous uterine myoma, 422 
 
 chronic, with myoma, 414 
 Endocardium, metastases in, froin myosarcoma 
 
 of uterus, 220 
 Endometritis, cervical, with myoma, 302 
 
 chronic, associated with suppurating inter- 
 stitial myoma, 148 
 
 with myoma, 148, 302, 334 
 Endometrium, inflammation of, witli myoma, 
 334 
 
 tuberculosis of, with myoma, 335 
 Epithelium lining uterine cavity, atypical 
 
 changes in, with myoma, 332 
 Erysipelas following vaginal operations for 
 
 myoma, 579 
 Exophthalmic goiter associated with myoma, 
 
 460 
 Extra-uterine pregnancy and myoma, differ- 
 entiation, 477 
 
 Fai-LoI'Iax tulx's. adherent , with myoma, 338 
 affording blood-supply to parasitic myoma, 
 
 38 
 carcinoma of, .secondary, 396 
 condition of, at autopsy, in myoma cases, 
 395 
 
 witli myoma, 337 
 
 with myosarcoma of uterus, 177 
 li('iii:iti»s:ilpin\. witli myom.-i, ."viS. ,39(1 
 hydrosalpinx, witli myoma, ;}.3S, 396 
 infection from lluid liberated from, 5-11 
 inflammation of. in inyoma cases, 338 
 mc(li;ini(;il .illcrations in relations of, with 
 
 inynnia cases. '.\ \',\ 
 niyonia ol . W 1 1 
 
 nourishing i)artially parasitic myoma, 38 
 ()])('rations on, during abdominal myo- 
 
 mcctonn', 526
 
 ro8 
 
 IXDKX. 
 
 Fallopian tubes, pyosalpinx, with myoma. 396 
 
 nulimciitary, with myoma, 340 
 
 salpingitis, with myoma, 338 
 
 tuberculosis of, with myoma, 341, 396 
 
 Family history in cases of uterine myoma, 430 
 
 Fat, emulsificil. witli cystic areas, in myoma, 92, 
 
 124 
 Fecal fistula, temporary, following removal 
 
 of ruptured suppurating myoma, 142 
 Femoral hernia associated with myoma, 462 
 Fertility in cases of uterine myoma, 457 
 Fetus, dead, resembling myomatous uterus, 473 
 death of, with suppuration and jierforation 
 
 of uterine wall, 470 
 myoma resembling, in contour, 4(59 
 rescml)led by myoma, (i 
 Fever with submucous uterine myoma, 'u'2 
 Fibroids of uterus, 1. See also Myoma. 
 recurrent, 178, 179, 252, 586 
 
 operation for, after vaginal myomectomy. 
 5X6 
 Fibroma of ovary, 493 
 
 and myoma, differentiation, 493-495 
 with myoma, 351 
 of uterus, 1. See also Mijoma. 
 Fibromyoma of uterus. 1. vSee also Myoma. 
 Fistula in ano following abdominal hy.stero- 
 
 myomectomy, 660 
 Fluid in cystic myoma, 91 
 
 Flushes, hot, after hysteromyomectomy, 603. 
 604 
 
 Gall-bladder, adhesions to, with myoma, 464 
 Gangrene of ovary after hysteromyomectomy. 
 222 
 
 Gangrenous .submucous myoma, 66 
 
 Giant cells in suspicious myoma, 250 
 
 Glanfls. See Lymph-(flnntl.'<. 
 
 (ilands, cervical, dilatation of. with myoma, 298 
 
 unfolding of. with myoma, 302 
 
 hypertrophy of. witli myoma. 316. 325 
 Glands, running parallel to .surface of uterine 
 
 mucosa, 316 
 unusual shapes of, associated with uterine 
 
 myoma, 321 
 Glands, uterine, dilatation of. witli myoma, 323 
 
 hypertrophy of, with myoma, 325 
 Glycosuria with uterine myoma, 465 
 (loiter with uterine myoma, 460 
 (Iraafian follicle cysts with uterine myoma, 344 
 Gritty particles in myoma, 126 
 
 HALLrciNATlONS following abdominal hystero- 
 myomectomy, 661 
 He;irt (vivity, cystic myoma resembling, 122 
 
 Heart complications after abdominal hystero- 
 myomectomy, 660 
 hypertrophy of, with necrotic myoma, 423 
 in myoma cases, 451 
 
 lesions, po.ssibly attril>iit able to myoma, 421 
 muscle, calcification of, witii myoma, 424 
 hyaline degeneration of, with necrotic 
 
 myoma, 423 
 metasta.ses in, from myosarcoma of uterus, 
 176 
 sounds in myoma cases, 451 
 Heart-shaped myoma, 5 
 
 Hematoma tluring abdominal hysteromyomec- 
 tomy, 623 
 Hematosalpinx with myoma, 338, 396 
 Hemoglobin in cases of myoma, 451, 4.")3, 455, 
 
 517 
 Hemorrliage, abiloiiiiiial. from sarcoma of 
 cervical stump. 190 
 symptoms .suggesting, after abdomina 
 hysteromyomectomy, 669 
 due to general oozing from pelvis, 621 
 due to slipping of ligature during abdominal 
 
 hysteromyomectomy, 623 
 during abdominal iiysteromyomectomy, 620, 
 
 621, 622 
 during vaginal myomectomy, 576 
 rnliowing abdominal hysteromyomectomj-, 
 654, 681 
 abdominal myomectomy, 548 
 in cases of .submucous myoma, 572 
 local applications as means of checking, 588 
 method of controlling, where needle cannot 
 
 be employed, 620 
 .secondary, as cause of death after abdominal 
 hysteromyomectomy, 681 
 Hemorrhoids with uterine myoma, 446 
 Heredity as cau.se of myoma, 430 
 Hernia, femoral, with myoma. 4()2 
 inguinal, witli myoma. 462 
 umbilical, strangulated. 120 
 
 with carcinoma of cervix and myoma, 398 
 with myoma, 120, 461. 639 
 Hernial sac, po.stoperative, containing my- 
 omatous nodule, 4()3 
 Histologic appearance of e.iriy iiiyoiiia. 431 
 
 of myosarcoma . 1 72 
 Hot fhi.shes after ai)dominal hysteromyomec- 
 tomy. 604 
 Hot weather as cau.se of poslopciativeelevation 
 
 of temperature, 655 
 Hyaline degeneration. adNaiiced. witii liiiue- 
 faction and formation of small cysts, 88 
 bright yellow areas of, 87 
 ca.ses showing various types of, 93 
 giving water-core appearance, 95
 
 IXDKX. 
 
 7()<) 
 
 llyaliiu' degeiiCM'atioii in muscle l)Uiulle.s of 
 myoma, 85 
 of blood-vessel walls in myoma, 86 
 of heart muscle with necrotic myoma, 423 
 of myoma, 8, 12, 83-125 
 
 relation to sarcomatous transformation. 
 
 93, 232 
 with formation of larfje cysts in myoma, 
 
 90 
 with litjuefaction and cyst formation. 
 88, 89 
 Hyaline material degenerated and containing 
 cholesterin crystals, 92, 124, 125 
 tissue, gradual liquefaction of, 103 
 Hydatidiform mole resembling myomatous 
 
 uterus. 480 
 Hydronephrosis with myoma. 397 
 Hydrosalpinx in myoma cases. 338. 396 
 Hydroureter with uterine myoma, 381, 396, 
 
 399, 414 
 Hypertrophy, cardiac, with myoma, 414 
 of bladder wall, 370 
 of cervical mucosa in myoma cases, 297 
 of cervix in myoma cisss, 441 
 of round ligaments in myoma cases. 363 
 of uterine glands with myoma, 316, 325 
 of uterus, with myoma, 11 
 Hysterectomy for myoma. See HyHkromyu- 
 
 mectomy. 
 Hysterical manifestations following abdominal 
 
 myomectomy, 547 
 Hy.steromyomectomy, abdominal. 588, 626, 641 
 accidental ligation of ureter during. 382 
 acute mania after, 661 
 adenocarcinoma of body of uterus over- 
 looked at. 2S(i 
 after abdominal myomectomy, 559 
 
 on account of development of 
 otlier myoma. 561 
 after-treatment, 627 
 almost fatal bleeding from acces.sory 
 
 braucli of uterine artery in. 623 
 anesthetic in, 590 
 
 appearance of cervic.i! stiinip after, 599 
 bed-sore after, 662 
 bisection of uterus in. 608, 683, 684, 685. 
 
 See also Bisection of uterus. 
 bronchitis after. ()()8 
 liniiiclinpneiiiiionia aftei'. 668 
 cardiac complications after, 6()() 
 clam])ing of cardinal ves.selsand applicat Idii 
 
 of ligatures. 600 
 closure of cervix in. 596 
 complicatiiins fullnwiim, 65 1. (iliS 
 constipation aftei-. (i59 
 cystitis after. 657 
 
 Hysteromyomectomy, alxloniinal, dark-brown 
 
 vomit us after, 658 
 death after, causes of, 672, 673, 681, 682, 
 
 683, 684, 685 
 difficult, 58, 630 
 edema of legs after, 658 
 employment of round ligaments in suspen- 
 sion of cervical stump in, 603 
 extensive removal of cervical mucosa 
 
 during. 601 
 fistula in :uio after, 660 
 from below upward, 612 
 gangrene of ovary and. 222 
 gradual ab.sorption of adliesions after. 641 
 hallucinations after. 661 
 heart complications after. 660 
 hematoma during. 623 
 hemorrhage after. 654, 681 
 
 during. 620-623 
 
 local applications as means of check- 
 ing, 588 
 hot flushes after. 603 
 immediate removal of appendages in. 607 
 
 results from, 672 
 in apparently inoperable myoma case, 636 
 in constitutional bleeder, 625 
 in intestinal adhesions, 633 
 in kidney diseases, 625 
 in myoma adherent to abdominal wall, 630 
 
 associated with pelvic ai)scess, 635 
 
 filling pelvis, 631 
 in syphilis, 625 
 indications for, 590 
 infection of cervix after, 664 
 injury of bladder during. 371, 374 
 
 to rectum during. 387 
 
 to ureter during, 382 
 inspection of uterine cavity for cancer and 
 
 myoma for .sarcoma in. 591 
 intestinal obstruction after. 6.')!t, 677 
 
 worms after. 659 
 irrigation of ai)dominal ca\ily after. 620 
 left to riglit . w itii I'cniowd nf appen(|ages. 
 
 location ol' ureters during. 385 
 nudliple abscesses after. 664 
 myocarditis as cau.se of dcaili .ifii-r. 6S2 
 nausea after, (').')>< 
 ncplirccl oiiiy .'iftci', .'{SI. HS.') 
 iiei)lirilis after. 657 
 nerxous phenonicna .ifter. 661 
 ol)stipati()n after, 659 
 operatixc com|)lications. (530 
 partial su|)])ression of urine after. 657 
 passage of enema into aixiominal ca\ily 
 after. 391
 
 710 
 
 INDEX. 
 
 Hystcromyomectomy, abdominal, pelvic infec- 
 tion after, G()2, 003, 004 
 involving broad ligament or Douglas' 
 
 sac after, 004 
 limited to cervix after, 004 
 perforation of rectum after, 390 
 on account of adhesions after abdominal 
 
 myomectomy, 559 
 peritonitis as cause of death after, 073 
 phlebitis after, 005, 007 
 pleurisy after, 007 
 pneumonia after, 009 
 preliminary treatment. 020 
 present health after. 005 
 preservation of ovaries in. 594. 003 
 pulmonary abscess after, ()09, 082 
 
 embolism as cause of deatli after, OSO 
 pulse after, 650 
 raw areas after, 019 
 rectal tears in, 387 
 
 tenesmus after, 059 
 removal of tulx-rculous kidney after. 
 
 384 
 resection of sigmoid flexure during, 389 
 results, 072 
 right to left, with removal of appendages, 
 
 600 
 secondary hcinorrliage as cause of death 
 
 after, 081 
 shock as cause of death after, 078 
 silk ligature from uterine artery passed 
 
 into bladder after, 375 
 subsequent to abdominal myomectomy, 
 559 
 
 vaginal myomectomy, 585 
 suppuration of abdominal wound after. 
 
 662 
 tearing of ovarian vessels during, 621 
 temperature after. 655 
 thrombosis of ovarian veins and, 222 
 transverse section of cervix in, 012 
 tying cardinal vessels and removing uterus 
 
 in, 595 
 urine, partial suppression after, 057 
 
 retention after, 657 
 vaginal drainage after, 623 
 vermicular contraction of ureters during. 
 
 385 
 vicarious menstruation after. ()05 
 vomiting after, 058 
 when abdominal walls are thick, 630 
 when pelvic abscess exists, 035 
 Hysteromyomectomy, supravaginal, for my- 
 oma, 593 
 myosarcoma overlooked during, 190 
 vaginal, 629 
 
 Hystei'omyomectomy, vaginal, compHcat i<jns 
 after, 070 
 
 delusional insanity after, 070 
 
 results after, 085 
 
 transitory lack of recognition after, 670 
 Hysterotomy, 509, 510 
 
 Iliac veins, compression of, by tumor, 234 
 Incarcerated myoma, 305 
 Incontinence of urine with myoma cases, 370 
 Indviration of vaginal vault with myoma, 440 
 Inflammation of bladder after abdominal myo- 
 mectomy, 549 
 with myoma, 377 
 of cervical mucosa in mj'oma cases, 302 
 of endometrium in myoma cases, 334 
 of Fallopian tubes in myoma cases, 338 
 Inguinal glands, metastases in, from squamous- 
 celled carcinoma of cervix, 399 
 hernia associated with myoma, 402, 403 
 lymi)li-glantls, carcinoma of, secondary to 
 adenocarcinoma of body of uterus, 405 
 Insanity following vaginal hysterectomy, 070 
 Intermenstrual bleeding with myoma, 444 
 Interstitial myoma, 1 
 
 abdominal myomectomy for, 508, 521 
 invaded by squamous-celled carcinoma of 
 
 cervix, 403 
 suppurating, 144 
 
 results after operation for, 153 
 Interstitial myosarcoma of uterus, 171 
 
 pregnancy simulating myomatous uterus, 477 
 Intestinal adhesions, 550, 033, 035 
 
 abdominal hysteromyomectomy and, 033 
 Intestinal obstruction after abdominal hystero- 
 myomectomy, 659, 677 
 myomectomy, 533, 552, 566 
 after bisection of uterus for myoma 
 683 
 years after jdxlominal myomectomj', 557 
 vessels furnishing nourishment to myoma, 41 
 worms following abdominal hysteromyomec- 
 tomy, 659 
 Intestine, sarcoma of, secondarj- to uterine 
 sarcoma, 234 
 small, nourishing parasitic myoma, 47 
 ovarian abscess opening into, 639 
 suppurating myoma opening into, 47 
 Intraligamentary myoma, 1, 187 
 suppurating, 137 
 upward pressure of, 305 
 Intraligamentary myosarcoma of uterus, 171 
 Inversion of uterus with submucous myoma, 71 
 Irrigation of abdominal cavity after hystero- 
 Tiivomectomv, 020
 
 INDEX. 
 
 11 
 
 Johns Hopkins Hospital autopsy records, 39-4 
 cases, 671 
 
 Kelly sanitarium cases, 671 
 Kidney, changes in, at autopsy, in myoma cases, 
 397 
 complications following; abdominal hystero- 
 
 myomectomy, 657 
 dilatation of pelvis of, with myoma. 397 
 diseases of, alidominal hysteromyomectomy 
 
 in, 625 
 miliary abscesses of, with myoma, 397, 422 
 misplaced, Avitli myoma, 465 
 nodules in, with myoma, 465 
 removal of, subsequent to injury of ureter, 
 
 383 
 retention cysts in, 427 
 
 tuberculous, removal of, after hysteromyo- 
 mectomy, 384 
 Kidney-shaped myoma, 4 
 
 Labial cyst with myoma, 438 
 
 Lateral anastomosis where extensive intestinal 
 
 adhesions exist, 635 
 Left to right abdominal hysteromyomectomy, 
 
 606 
 Legs, edema of, with myoma, 450; after ab- 
 dominal hysteromyomectomy, 658 
 Leukocytosis following abdominal myomec- 
 tomy, 553 
 in myoma cases, 152 
 Leukorrhea with submucous myoma, 571 
 Ligament, broad, abscass in, after abdominal 
 myomectomy, 553 
 adhesions to, with myoma, 354 
 alterations in, associated with myoma, 354 
 dilatation of vessels of, with myoma, 354 
 dilated lymph-spaces in, with myoma, 355 
 hematoma in, during abdominal hystero- 
 myomectomy, 623 
 myoma of, 354, 510 
 sarcoma in, secondary to myosarcoma of 
 
 uterus, 195 
 thickening of, witli myoma, 355 
 used to cover over myomectomy incision, 
 525 
 Ligaments, round, adenomyoma of. in myoma 
 cases, 364 
 alterations in, witli myoiiia, 3(')1 , 3('2 
 employment of, in sus])ension of cervical 
 stump in abdominal hysteromyomec- 
 tomy, 598, 603 
 hypertrophy of, witii myoma, 363 
 myoma of, 363 
 
 Ligaments, utero-ovarian, adenomj'oma of, in 
 myoma cases, 360 
 changes in, with myoma, 356 
 cysts of, with myoma, 356 
 myoma of, 358 
 
 secondary sarcomatous nodules in, with 
 myoma, 360 
 Ligation of ureters, accidental, during hystero- 
 myomectomy, 382 
 Ligature, passage of, from cervical stump into 
 bladder, 375 
 slipping of, with hemorrhage, during abdom- 
 inal hysteromyomectomy, 623 
 Lipoma of abdominal wall associated witli 
 
 myoma, 461 
 Lipomyoma of uterus, 162 
 Lips, cervical, edema of, with myoma. 441 
 Liquefaction of hyaline myoma, 88, 89, 103, 
 
 104 
 Liver, and myoma, adhesions between, 464 
 condition of, with myoma, 464 
 metastases in, from adenocarcinoma of 
 uterus, 408 
 myosarcoma of uterus, 176, 201 
 sarcoma of, secondary to sarcoma of uterus, 
 
 234 
 thickening of, associated with myoma, 464 
 Lobar pneumonia after abdominal hysteromyo- 
 mectomy, 669 
 myomectomy, 555 
 Lumbar glands, metastases in, from sarcoma 
 
 of uterus, 222 
 Lungs, abscess of, and bronchopneumonia, 
 after hysteromyomectomy, 682 
 metastases in, from adenocarcinoma of 
 uterus, 408 
 from myo.sarcoma of uterus, 176. 195, 220, 
 
 234 
 from s(iuamous-ce]lcd carcinoma of cervix. 
 399 
 septic infarction of, with sloughing suli- 
 mucous myoma, 422 
 Lym]>iiatic activity in jiarasitic myoma, 14 
 Lymphatics, omental, dilatation of, 14, 20, 22 
 uterine, dilatation of, associated with myoma, 
 72, 7C) 
 Lymiili-ciiaiuu'ls, (iiiatccl. in myoma cases, 123 
 Lymph-glands, l)roncliiai, metastases in, from 
 adenocarcinoma of uterus, 405 
 from sciuamoiis-ccllcd carcinoma of 
 cervix. 3i)9 
 cervical, metastases in, from ailenocarciii- 
 oma of uterus, 405 
 I ruin myo.sarcoma of uterus, 195 
 inguinal, metasta.ses in, from adenocarci- 
 noma of body of uterus, 405
 
 712 
 
 INDEX. 
 
 Lyiiipli-gUinds, iiifiuiiuil, metastases in, from Metastases from sarcoma of uterus to peri- 
 
 squamous-celled carfinoma of cervix, 
 399 
 
 lumbar, metastases in. from sarcoma of 
 uterus, 222 
 
 mediastinal, metastases in, fiom ailenocarcin- 
 oma of uterus, 414 
 
 mesenteric, metastases in, from squamous- 
 celled carcinoma of cervix, 399 
 sarcoma of, secondary to sarcoma of 
 uterus, 234 
 
 ])('lvic, metastases in. from s(iuamou.s-celled 
 carcinoma of cervix, 399 
 
 pericardial, metastases in. from adeno- 
 carcinoma of uterus, 40') 
 
 pcripancreatic, sarcoma of, 234 
 Lymph-spaces, (jilatcd. in hioad liiranient. in 
 
 myoma, 3.").') 
 
 .Malkokmatiox.s of uterus, myoma associated 
 
 with. 1,55, 157 
 Mania, acute, after alxiominal hysteromyo- 
 
 niectomy. G()l 
 .Mediastinal lymph-glands, meta.sta.ses in, from 
 
 adenocarcinoma of uterus, 414 
 Menstrual flow, retained, enlargement of 
 uterus due to, 485 
 history in myoma cases, 443 
 .Menstrual inn in differential diagnosis of 
 myoma and pregnancy. 4(J7 
 influence of myoma on, 443 
 vicarious, after altdoininal liysteromyo- 
 mectomy. f)()5 
 Mesenteric lymph-glanils,. sarcoma of, secondary 
 to sarcoma of uterus, 234 
 vessels affording blood-sup))iy to parasitic 
 myoma. 39 
 Me.senterj% ahnDnu.dly long, in myoma cases, 
 4G4 
 calcareous nodules in, witli myoma. 4(54 
 metastases in. from adi-nocarcinoma of 
 utenis. lOS 
 from .-(luamous-cellcd carcinoma of cervix. 
 399 
 .sarcoma of, secondary to sarcoma of uterus. 
 234 
 
 pancreatic lymph-glands, 234 
 in adrenal body from adenocarcinoma of 
 
 utenis, 4()S 
 in broncliial lynii)li-glands from s^iuamous- 
 
 celled carcinoma of cervi.x, 399 
 in inguinal lymph-glands from s(iuamou.s- 
 
 celled carcinoma of cervix, 399 
 in intestine, secondary to sarcoma of uterus, 
 
 234 
 in liver from adenocarcinoma of uterus, 234, 
 
 408 
 in lumbar glands from .sarcoma of uterus, 222 
 in lungs from adenocarcinoma of body of 
 uterus, 408 
 
 from sf|Uamous-c('lic(l carcinoma of cervix 
 399 
 
 .secondary to sarcoma of uterus, 195, 234 
 in mediastinal lymph-glands from adeno- 
 carcinoma of uterus. 414 
 in mesenteric lymph-glands, from squamous- 
 celled carcinoma of cervix, 399 
 seconflary to sarcoma of uterus, 234 
 in mesentery, from adenocarcinoma of uterus, 
 408 
 
 .secondary to sarcoma of uterus. 234 
 in omentum, 499 
 
 from adenocarcinoma of uterus, 408 
 
 secondary to sarcoma of uterus, 234 
 in pancreas, from adenocarcinoma of uterus, 
 
 408 
 in peritoneum, from adenocarcinoma of 
 uterus, 408 
 
 from s(:[uamous-celled carcinoma of cervix, 
 399 
 
 secondary to sarcoma of uterus. 195, 234 
 in pleura, from adenocarcinoma of uterus, 
 408, 414 
 
 from squamous-celled carcinoma of cervix, 
 399 
 
 secondary to sarcoma of uterus. 234 
 in spleen, from adcnocai'cinoma of body of 
 
 uterus. 41 t 
 in stomach, secondary to sarconui of uterus, 
 
 234 
 of chorda; tendineae of tricuspid valve follow- 
 ing sarcoma of uterus. 222 
 
 Metastases, alxiominal. with myo.sarcoma of Miscarriages in myoma cas3s, 458 
 
 uterus. 200 
 
 Mobility of myomata, 444 
 
 from adenocarcinoma of uterus to bronchial importance of determining, before opera- 
 
 lymph-glands, 405 
 to cervical lymph-glands, 405 
 to inguinal lymph-glands, 405 
 to omentum, 405 
 to pericardial lymph-glands. 405 
 to peritoneum, 405 
 
 tion, 445 
 Mole, hydatid, myoma and. dificrentiation, 
 
 480 
 Mortality. See Dcdih. 
 Mucosa, cervical, changes in, in myoma cases, 
 
 297, 298, 302
 
 INDEX. 
 
 13 
 
 Mucosa, cervical, extensive removal of, during 
 
 supravaginal hysteromyomectomy, 601 
 Mucosa, uterine, blood-vessels of, alterations 
 in. in myoma casss, 317 
 condition of, with myoma, '297. 310, 310, 
 317, 322, 334 
 in myosarcoma of uterus, 17G 
 small myoma developing in, 333 
 thrombosis of veins in, with myoma, 320 
 unusual gland shapes in, associated with 
 myoma, 321 
 Mucosa, vaginal, bluish color of. in myoma 
 
 cases, 439 
 Mulberry-shaped myoma, 1, 2, .5 
 Multilocular cystadenoma of ovary with niy- 
 
 oma, 346, 396, 417 
 Muscle bundles, hyaline degeneration in, 85 
 extension of, into uterine muco,sa, 317 
 heart, ca,lcification of. with myoma, 424 
 uterine, and myoma, line of junction be- 
 tween. S 
 condition of, with myoma, 11 
 myoma extending into, 9 
 Myocarditis as probable cause of death after nb- 
 dominal hysteromyomectomy, 682 
 myomectomy, 544 
 Myoglia in myoma, 9 
 Myoma, 1 
 
 abdominal contour in, 436 
 
 hysterectomy for, 588. See also Hystero- 
 myomectomy, abdominal. 
 myomectomy for, 506. 8ee also Myo- 
 mectomy. abdominal. 
 abdominal pregnancy and, differentiation. 
 
 473 
 abdominal veins, enlargement of, with, 437 
 abnormally long mesentery with, 464 
 abscess of broad ligaments witli, 355 
 of omentum with, 637 
 of ovary witli, 344. 39(5, 637, 639 
 adenocarcinoma of ovary and, 34S 
 
 of uterus a.ssociated witii, 271. See also 
 Adenocarcinoma of uterus. 
 adenocystomata of ovary with, 346, 396, 
 
 117 
 adenomyoiiiM nl round ligameut.s witli, 3()4 
 
 of utero-ovaiiaii ligament with, 360 
 adherent F;illi)pian tubes with. 33S 
 
 ti) ali(l()inin;il \\;ill, .-il idnniiiml hysterec- 
 tomy foi-. (■):',() 
 adhesions wit li. found at autopsy, 395 
 of bladder in, role ])layed liy, 3()6 
 to broad lig.aments \\ith,35l 
 to ir.'dl liliiddcr with. 161 
 
 to ii\cr with, n; I 
 
 to rcctiirii with .3X6 
 
 Myoma, advanced hyaline degeneration of, with 
 
 liquefaction and formation of small 
 
 cysts, 88 
 age of incidence of, 434 
 alveolar appearance of, due to proliferation 
 
 of endothelium of blood capillaries, 99 
 apparently inoperable, abdominal hysterec- 
 tomy for, 636 
 appendicitis as.sociated with, 4()3 
 areas of adipose tissue in, 162, 166 
 a.scites associated with, 30 
 autop.sy findings in ca.ses of, 394, 397, 428 
 ballot tement with, 469 
 bilateral ovarian cysts and, difTerentiation, 
 
 498 
 bisection of uterus for, 608 
 bladder and. 365, 370, 377 
 blood in uterine cavity with, 309 
 blood-supply of. 6 
 
 bluLsh color of vaginal mucosa with. 439 
 breasts in cases of, 449, 450 
 calcareous nodules in mesentery in. 464 
 
 plates in walls of artery in. 129 
 calcification of, 126, 268 
 carcinoma extending into. 405 
 
 of brea.st a.s.sociated with, 450 
 
 of cervix a.ssociated with, 262, 398 
 
 of Fallopian tube with, 396 
 
 of ovary with, 396 
 
 of rectum with, 391, 417 
 
 of stomach and oxarv with. 396 
 
 of uterus with, 404, 485 
 
 a.ssociated with, cases of, 274 
 cardiac hypertrophy with, 11 1 
 cau.se of, 430 
 cells of. 9 
 
 changes in, .suggesting .sarcoma. 238, 242, 
 243 
 
 transition into sarcoma cells. 188, 225, 
 226. 227. 228 
 Myoma, cervical, .")3 
 
 abdominal myomectomy for. 510 
 
 adenocarcinoma of uterus ami. 27*<. 
 
 endometritis with. 302 
 
 poly|(i with. 29S 
 (•(■r\i\ .-ilniost obliterated with. 111 
 
 januucd down on perineum with. 
 \\\) Ix'hind symphysis with. 111 
 choiio-epithelioma and. IS2 
 chronic endocarditis with, 11 1 
 cleavage from utei'ine muscle with. 8 
 clinical course of. 431 
 clinically o\'ershadow ing adenocarcinoma of 
 
 uterus. 275 
 colostiMini of breasts wit h. 1 19 
 constipation associ.ated with, 145 
 
 2S9 
 
 1 11
 
 714 
 
 INDEX. 
 
 Myoma, corpus luteum cysts with, 346 
 cystic, abdominal myomectomy for, 512 
 cystic degeneration of, S3. See also Hyaline 
 
 degeneration. 
 cystitis witli, 877 
 cysts of ovary witli, 344 
 
 of uraclms with, 403 
 
 of utero-ovarian ligaments with, 356 
 dead fetus resembling, 473 
 death due directly to, 426 
 degeneration in, found at autopsy, 395 
 dermoid cyst with, 349, 396 
 diagnosis of, differential, 467-503 
 dilatation of cervical glands with, 298 
 
 of deeji uterine lympliatics associatetl with, 
 76 
 
 of renal pelvis with, 397 
 
 of superficial uterine lymphatics asso- 
 ciated witli. 72 
 
 of ureters witli, 378 
 
 of uterine glands with, 323 
 
 of vessels of broad ligaments with, 354 
 dilated lymph-channels in, 123 
 
 lymph-spaces in broad ligament with, 355 
 dis:i])pearance of, after jiregnancy, 646 
 discrete, 3 
 
 duration of, before operation, 435 
 edema of, 88 
 
 effect of removal of ovaries on, 5U4 
 electrical treatment of, 588 
 elongation of sujiravaginal ]^ortion of cer\ix 
 with, 442 
 
 of vaginal portion of cervix with, 441 
 enudsification of hyaline material in, 92, 124 
 encysted peritonitis suggesting a full bladder 
 
 witli, 371 
 endometritis with, 334 
 extending into uterine muscle, 9 
 extra-uterine pregnancy and, 477 
 Fallopian tubes and, 338, 340 
 family history and, 430 
 femortd hernia a.ssociated with, 462 
 fertility and, 457 
 fibroma of ovary and, 351, 493 
 free in broad ligament, 51, 187 
 gall-bladder with, 464 
 giant cells in, 250 
 
 gland hypertropliy of mucosa with, 316,325 
 glands, unusual shapes of, associated with. 
 321 
 
 running parallel to surface of uterine 
 mucosa with, 316 
 glycosuria with, 465 
 goiter with, 460 
 Graafian follicle cysts with, 344 
 gritty particles in, 126 
 
 Myoma, heart in cases of, 421, 451 
 heart-shaped, 5 
 hematosalpinx with, 338, 396 
 hemoglobin percentage with, 451, 453, 455, 
 
 517 
 hemorrhoids associated with, 446 
 heredity and, 430 
 histologic appearances of, 7 
 
 changes in, suggesting carcinoma, 491 
 hyaline degeneration of, 83. See also 
 
 Hyaline degeneration. 
 hydatid mole and, 480 
 hydronephrosis with, 397 
 hydrosalpinx with, 338, 396 
 hydroureter with, 381, 396. 399, 414 
 hypertrophy of bladder wall with, 370 
 
 of cervical mucosa with, 297 
 
 of cervix uteri wuth, 441 
 
 of round ligaments with, 363 
 
 of uterine glands with, 325 
 hysterectomy for. See Hysteromyomectomy. 
 in contour resembling a fetus, 469 
 in old age, 395 
 incarcerated, 365 
 incontinence of urine with, 376 
 induration of vaginal vault with, 440 
 inguinal hernia associated with, 462 
 inoperable, treatment of, 636 
 Myoma, interstitial, 1 
 
 abdominal myomectomy for, 508 
 intestinal obstruction associated with, 447 
 intraligamentary, 1, 365 
 irregvdar growth of, 10 
 kidney, miliary abscesses in, complicating,397 
 
 misplaced, with, 465 
 
 nodules in, a.ssociated with, 465 
 kidney-shaped, 4 
 labial cyst with, 438 
 large ovary with, 352 
 leukocytosis with, 152 
 lipoma of abdominal wall with, 461 
 li([uefaction of, 88, 89 
 liver and, 464 
 
 loss of weight with, 456, 572 
 macroscopic appearances of, 1 
 malformation of uterus with, 155 
 menstrual history in cases of, 443 
 merging of, into an ovary, 353 
 mesentery, findings in, associated with,'^464 
 microscopic appearances of, early, 431 
 miscarriages with, 458 
 mobility of, 444 
 nndberry-shaped, 1, 2, 5 
 nndticystic, 112 
 myoglia in, 9 
 nausea associated with, 447
 
 INDEX, 
 
 15 
 
 Myoma, necrotic, 153 
 
 with cardiac hypertrophy, 423 
 
 with hyaline degeneration of heart muscle, 
 423 
 
 with pyonephrosis, 423 
 Myoma, number of, 3 
 
 removetl by abdominal myomectomy, .')17 
 obliteration of cervix with, 441 
 
 of umbilical depression with, 461 
 of broad hgament, 51, 53, 354, 510 
 
 abdominal myomectomy for, 510 
 of Fallopian tubes, 341 
 of round ligaments of uterus, 363 
 of utero-ovarian ligaments, 358 
 omental carcinoma and. 499 
 origin of, 433 
 
 ovarian cysts and, 344, 495 
 pain with, 448, 449 
 painful defecation associated with, 446 
 
 urination with, 376 
 panhysterectomy for, 593, 616 
 papillocystoma of ovaries and adenocar- 
 cinoma of uterus with, 408 
 
 of ovary with, 346 
 Myoma, parasitic, 13. See also Parasitic 
 
 myoma. 
 parovarian cysts with, 353 
 pear-shaped, 4 
 pedunculated, 1, 2 
 pelvic abscess with, 635, 636 
 
 molds and, 6 
 
 peritonitis with abscess formation and, 344 
 perirectal absce.ss with, 391 
 phleboliths in vaginal wall with, 440 
 polypi of cervical mucosa with, 298 
 
 of uterus associated with, 325, 328, 329 
 pregnancy and, 467, 473, 477, 507, 643 
 pres.sure of, on bladder, 365 
 
 on iliac veins, 234 
 
 on ureters, 381 
 
 pains with, 44S 
 prolap.se of rectum with, 391 
 
 of uterus with, 460 
 pruritus ani associated with, 446 
 
 vulva? with, 444 
 pyelonephrosis with, 397 
 pyometra as.sociated with, 310 
 pyo.salpinx with, 338, 340, 396 
 rectal diverticula, rupture of, and, .')()() 
 rectum and, 386 
 removal of, in apimrcnlly iiiopcraljic cases, 
 
 636 
 renal colic with. Kid 
 reseml)lanc(' of. to Ictus, (5 
 respiration and, 4.')() 
 results of operations for, 671 
 
 Myoma, retention cj-sts in kidney with, 427 
 
 of urine witii, 376 
 retraction of umbilicus with, 461 
 retroperitoneal, development of, 631 
 
 sarcoma anrl, 501 
 sacculation of bladder with, 370 
 sacral markings with, 5 
 saddle-liag appearance of uterus with, 5 
 salpingitis with, 338 
 
 sarcoma developing from, 169, 172, 173, ISO, 
 208, 420 
 
 of bladder a.ssociated with, 420 
 
 of uterus and, 492 
 secondary carcinoma of uterus with, 295 
 Myoma, sessile, 1, 2 
 shape of, 4 
 simulated by chorio-epithelioma, 482 
 
 by extra-uterine pregnancy, 477 
 
 by hydatidiform mole, 480 
 
 by omental metastases, 499 
 
 by retained menstrual flow, 485 
 
 by retroperitoneal sarcoma, 501 
 
 by simple ovarian cysts, 497 
 size of, 3 
 small developing in uterine mucosa, 333 
 
 unattached to uterus and situated between 
 tube and ovary, 364 
 snugly filling pelvis, rendering abdominal 
 
 hysteromyomectomy difficult, 631 
 sterility associated with, 457 
 Myoma, submucous, 1, 59, 571. See also Sufi- 
 
 mucoiis myoma. 
 Myoma, subperitoneal, 1, 45, 81, 134, 249, 444, 
 
 508 
 Myoma, subvesical, 365, 510 
 Myoma, suppurating, 134-153 
 
 cause of, 152 
 
 interstitial, 144 
 
 intraligamentary, 137 
 
 opening into cecum, 45 
 into colon, 142 
 into small bowel, 47 
 
 subperitoneal, 134, 135. 139 
 conununicating with bowel, 134 
 su.spicion of carcinoma of cervix with. 302, 
 
 304 
 .symjitoms of, 434-4.')9 
 t('m])erature with, 457 
 tliickening of broad ligaments with, '.^bo 
 
 of left lobe of liver with, 464 
 t hi((-i('af-clover-.'<haped, 5 
 tiirill felt on vaginal exann'nation with, 442 
 thrombosis of veins in muco.sa with, 320 
 torsion of ccrxix with. 77 
 
 of uterus witli. 77. 79 
 t I'.-msitioii of, into sarroiiia, 1S2
 
 716 
 
 IXDKX. 
 
 Myoma, transverse colon, descent of, with, 463 
 troiitmont of, 504, 506, 571, 58.S, 629, 630, 
 
 (171 
 tubal i)regiianoy with, 342 
 tuberculosis of endoinetriuiu with, 335 
 
 of Fallopian tubes with, 341, 396 
 
 of uterus associated witli, 421 
 tuberculous jieritonitis associated with, 464 
 tubo-ovarian abscess witli. 290, 344, 396 
 
 cysts with, 340 
 ulceration of vagina with, 440 
 umbilical cyst as.sociated witii, 462 
 
 licrnia associated witli. 461, (539 
 umbilicus and, 461 
 uiifohUnii of cervical ylands with, 302 
 unrecognized sarcomatous degeneration in, 
 
 193 
 ureters in cases of. 37S-3S5 
 urination and. 376 
 uterine cavity and, 305 
 
 polypi associated with. 325 
 
 .stones in, 130 
 vagina, size of, with, 439 
 
 vaginal, associatecl with uterine myoma, 234, 
 440 
 
 cy.sts with, 439 
 
 hysterectomy for, ()29. 
 hysterom yomectom ;/ . 
 
 myoma a.ssociated witl 
 
 myomectomy for, 571. See also Myo- 
 mectomy, vagindl. 
 
 stones in, 440 
 Myoma, varieties of. 1 
 
 vein stones in vagina witii, 440 
 vesical adiiesions with, 366 
 
 calculus witli. 375 
 vomiting as.sociated with, 447 
 weakness with, 457 
 weight of, 119. 512 
 Myomatous tendency, 4 
 Mj'omectomy, abdominal, .")06 
 
 abscess in broad ligament after, 553 
 
 age of patients in cases of, .506, 518 
 
 and hysterectomy on account of develo])- 
 ment of other myomata. 561 
 
 bed-sores after, 'in'y 
 
 bronchitis after, 554 
 
 bronchopneumonia after, 555 
 
 carcinoma of uterus not disco\-ored during, 
 lUi 
 
 cystitis after, 549 
 
 death after, 532, 533, 537, 538, 540. 541. 
 543, 544, 568 
 
 (hiring pregnancy, 528, 529, 538 
 
 evacuation of pelvic abscess after, 559 
 
 for adcMioinvoma of uterus. 511 
 
 See also Vaginal 
 
 440 
 See 
 
 Myomectomy, abdominal, for cervical myoma, 
 
 510 
 for cystic myoma. 512 
 for interstitial myoma, 508, 521 
 for niyonia of iiroad ligament, 510 
 for petlunculated myoma, 521 
 for submucous myoma, 509, 523 
 for subperitoneal pedunculated myoma, 
 
 508 
 for sub vesical myoma. 510 
 for suppurating subperitoneal myoma, 
 
 fecal fistula after. 142 
 foul discharge from uteru.'^ after. 5.50 
 hemoglobin, low, as contraindication to. 517 
 hemorrhage after, 548 
 hysterectomy after, 559, 560 
 hysterical manifestations after, .547 
 
 results after, 568, 569, 570, 672 
 in syphilitic patient, 518 
 intestinal adhesions after, .566 
 
 ob.struction after, 533, .5.V2, 557 
 leukocytosis after, 553 
 lobar pneumonia after, 555 
 location of myoma and. .")07 
 myocartlitis with, 544 
 nau.sea after, 548 
 nephritis after, 550 
 number of myomata removed by, 517 
 operations on tubes and ovaries during, 526 
 
 performed in conjunction with. 526 
 
 subsequent to, 556, 570 
 pain after, 549 
 peritonitis after, .")33, 552 
 phlebitis after, '>')') 
 pleurisy after. 5.54 
 
 postoperative complications and. 54 4 
 pregnancy following. 566 
 preservation of portion of fundus in. 525 
 pul.se after, .545, 546 
 pus from urethra after, 550 
 release of adhesions after, 5.56 
 removal of ovarian cysts during, 527 
 
 of ovaries after, 5.58 
 
 of tvil)es or ovaries during, .326 
 
 of \ermiforin ;ippendix and, 463, 557, 5.58 
 repair of perineum duiing, 527 
 repeated, 5.38 
 
 size of myomata removed, 5! 1 
 sloughing of uterine wall after, 551 
 suspension of uterus during, .328 
 .■syphilis as contraindication to, 518 
 tearing of uterine artery during, .325 
 teclinic of, .321, 523 
 temperature after, 545, 546 
 tonsillitis after, 5.34 
 vomiting after, 548
 
 IXDKX, 
 
 T 
 
 Myomectomy, vaginal, 571, .")77 
 bisection of myoma in, HH 
 complications after, 578 
 
 during, 576 
 death after, 580-583, 586 
 delirium after, 580 
 erysipelas after, 579 
 for infect etl and disintegrating submucous 
 
 myoma, 575 
 for non-infected submucous myoma, 573 
 hemorrhage during, 576 
 hysterectomy subsequent to, 585 
 operation for recurrent fibroids after, 586 
 operations subsequent to, 585 
 other operations during, 578 
 phlebitis after, 579 
 pregnancy after, 587 
 pulse after, 578 
 
 results after, 584, 586, 587, 672 
 rupture of uterus during, 576 
 temperature after, 578, 579 
 Myosarcoma of uterus, 169-261 
 
 abscess in broad ligament with, 196 
 
 age of incidence, 178 
 
 cervical stump, return in, 176, 190 
 
 clinical history, 177-179 
 
 condition of Fallopian tulies witli, 177 
 
 of ovaries with, 177 
 
 of viterine mucosa with, 176, 190 
 cysts in, 197, 198 
 
 developing from comiective tissue of 
 myoma, 172 
 
 from degenerated myoma, 188 
 
 from muscular elements of myoma, 173 
 
 in center of myoma, 208 
 gross appearances of, 170 
 
 suggesting, 236-245 
 histologic appearances, 172 
 incidence of, suggesting, 245-261 
 Myosarcoma of uterus, interstitial, 171 
 Myosarcoma of uterus, intraliganientary, 171 
 metastases in abdomen from, 200 
 
 in cervical lymph-glands from, 195 
 
 in chordir tendinea' of tricuspid \alvc 
 fnini, 222 
 
 in colunuKi' carncu' uf right Ncntricjc 
 from, 222 
 
 in cndocanlium from, 220 
 
 ill iii'art iniisclc IVoin, 171) 
 
 in liver from, 17(1, 201 
 
 in limgs rioin. 17(1. 1'.)."., •_'_'() 
 
 in lyni])h-glands fidiii. 17(1 
 
 ill (iinciitum fnim, 17(1 
 
 in |ili'iir;i IVoni, 195 
 
 ill skill frnin, 17(1 
 
 in \'ert('br;r iVdin, 17(1 
 
 Myosarcoma of uterus, o^•(■rl()()ked at opera- 
 tion, 190 
 in laboratory, 193, 2(J{). 204 
 perforation of abdominal wall with. 176 
 rapidity in growth of, 176 
 recurrence of, 17(1 
 relation of hyaline degeneration to, 232 
 
 of recurrent fibroids to, 178 
 secondary growths of, 175 
 
 nodules of , in right broad ligament, 195 
 Myosarcoma of uterus, submucous, 171 
 Myosarcoma of uteru<, subperitoneal, 171 
 
 transition of muscle fibers into sarcoma 
 
 cells in, 225, 226, 227, 228 
 treatment of, 179 
 
 Nausea after abdominal hysfcromyomectomy. 
 658 
 myomectomy, 548 
 associated with myoma, 447 
 Necrotic myoma, 153 
 Nephrectomy after hysteromytjmectomy, 384, 
 
 385 
 Nephritis after abdominal hysteromyomec- 
 tomy, 657, 681 
 myomectomy, 550 
 Nervous phenomena after abdominal hystero- 
 
 myomectomy, 661 
 Number of myomata, 3 
 
 OnsTiPATioN after abdominal hystcromyo- 
 
 mectomy, 659 
 Omental adhesions with iiai'asitic inyonia, 15 
 carcinoma, myoma and, differentiation, 499 
 metastases, 499 
 
 from adenocarcinoma of iitcrns, 405, 108 
 from myosarcoma of uterus, 176 
 vessels, friability of, 16 
 Omentum, abscess in, with myoma. 637 
 
 affording part of blood-sujiply to parasitic 
 
 myoma, 16-30 
 (•h:inges in, witli parasitic myoma. 13 
 dilated lymphatics of, I I. 20, 22 
 gradual disappearance of fat in, with 
 
 parasitic myoma, 22, 23, 25, 2S 
 greatly dilated vessels of, with jiarasitic 
 
 myoma, 24 
 secondary sarcoma of, 234 
 Ovarian adhesions, rt4eas(' of, after abdominal 
 myomectomy, 556 
 cysts, myoma and, different iat ion. 195,498 
 lia|iilloinatous, I9S 
 
 reiiioxal of, during alidoiniiial iiiyoinec- 
 tomv, 527
 
 718 
 
 INDEX. 
 
 Ovarian cysts, simple, resembling myoma, 497 
 simulated by myoma, 111, 119, 495 
 
 veins, thrombosed, after hysteromyomec- 
 tomy, 222 
 
 vessels, tearing of, during aljdoininal hystero- 
 myomec'tomy, 621 
 Ovary, abscess of , witli myoma, 344, 637, 390, 
 639 
 
 adenocarcinoma of, with myoma, 348 
 
 adenocystoma of, with uterine myoma, 346, 
 396, 417 
 
 alterations in Inctition of, with myoma, 352 
 
 carcinoma of, carcinoma of cervix with, 271 
 of stomach with, 396 
 primary, with myoma, 396 
 
 condition of, witii myoma, 337, 343, 395 
 with mj-osarcoma of uterus, 177 
 
 corpvis luteum cyst of. with myoma, 346 
 
 cysts of, with myoma, 344 
 
 dermoid cyst of, 349, 396 
 
 effect of removal of, on myoma, 504, 505 
 
 fibroma of, 351, 493 
 
 gangrene of, following hysteromyomectomy, 
 222 
 
 Graafian follicle cysts of, with myoma, 344 
 
 largo, with myoma, 352 
 
 merging of myoma into, 353 
 
 muitilocular cystadcnoma of, witii myoma, 
 346,396, 417 
 
 operations on, ilurinu alxloininal myomec- 
 tomy, 526 
 
 papillf)cystoma of, 346, 408, 498 
 
 preservation of, in abdominal hysteromyo- 
 mectomy, 594, 603 
 
 removal of, after abdominal myomectomj', 
 558 
 during aljdoniiiKil niyoni(>ctomy, 526 
 
 Pa IX, al^dominal, after myomectomy, 549 
 
 with myoma, 376, 446, 448 
 Pancreas, metastases in, from adenocarcinoma 
 
 of uterus, 408 
 Panhysterectomy for myoma, 593, 616 
 
 for suspected myosarcoma, ISO 
 Papillocystoma of ovary with myoma, 346 
 
 with myoma and adenocarcinoma of 
 uterus, 408 
 Parasitic myoma, 13 
 
 abdominal walls affording blood-supply 
 
 to, 51 
 ascites associated with, 30, 31, 497 
 l)ladder affording blood-supply to, 48, 49, 50 
 etiology of, 14 
 
 extruded from uterus ami lying free in 
 broad ligament, 39, 51 
 
 Parasitic myoma, Fallopian tubes affording 
 blood-supply to, 38 
 free from uterus, 29, 39 
 intestinal vessels affording l)lood-supply 
 
 to, 41 
 lymphatic activity in, 14 
 mesenteric vessels, peritoneum, and ap- 
 pendiceal adhesions affording blood- 
 supply to, 39 
 omental adhesions with, 15 
 omental changes with, 13 
 omentum affording part of blood-supply 
 
 to, 10-30 
 opening into bowel, 47 
 into cecum, 45 
 Parovarian cysts with mj'oma, 353 
 Parovariutn, alterations in, with myoma, 355 
 Pear-shaped myoma, 4 
 Pedunculated myoma, 1, 2, 521 
 
 subperitoneal, abdominal myomectomy 
 for, 508 
 submucous myoma, 59, 61 
 suppurating subperitoneal myoma, 139 
 Pelvic abscess, anterior to myoma, 636 
 
 evacuation of, after abdominal myomec- 
 tomy. 559 
 myoma associated with, 635 
 floor, hemorrhage from vessels of, during 
 
 abdominal hysteromyomectomy, 622 
 infection after abdominal hysteromyomec- 
 tomy, 662, 663, 664 
 Pelvic lymph-glands, metastases in, from scjua- 
 mous-celled carcinoma of cervix, 399 
 molds and myoma, 
 
 peritonitis after abdominal myomectomy, 
 552 
 with abscess formation in myoma cases, 
 344 
 Pelvis, myoma filling, abdominal liysterectomy 
 for, 031 
 of kidney, dilatation of. with myoma, 397 
 Pericardial lymph-glands, metastases in, from 
 
 adenocarcinoma of uterus, 405 
 Pericardium, metastases in, from myosarcoma 
 
 of uterus, 170 
 Perineum, repair of, during alidominal myo- 
 mectomy, 527 
 Peripancreatic lymph-glands, .secondary sar- 
 coma of, 234 
 Perirectal abscess with myoma, 391 
 Peritoneal cavity, large suppurating interstitial 
 
 myoma opeiung into, 151 
 Peritoneum affording l)lood-supply to para- 
 sitic myoma, 39 
 carcinoma of, secondtiry to adenocarcinoma 
 of uterus, 405
 
 INDEX. 
 
 719 
 
 Peritoneum, metastases in, from adenocarcin- 
 oma of uterus, 408 
 from squanaous-celled carcinoma of cervix, 
 399 
 secondary sarcoma of, 23-4 
 Peritonitis as cause of death after abdominal 
 hysteromyomectomy, G73-G7() 
 myomectomy, 533 
 bisection of uterus for myoma, G83 
 encysted, suggesting a full bkulder with 
 myoma, 371 
 Peritonitis, pelvic, after abdominal myomec- 
 tomy, 552 
 with abscess formation, with myoma, 344 
 tuberculous, associated with myoma, 464 
 Phlebitis after abdominal hysteromyomectomy, 
 665, 666, 667 
 myomectomy, 555 
 vaginal myomectomy, 579 
 Phleboliths in vaginal wall with myoma, 440 
 Pleura, metastases in, from adenocarcinoma of 
 uterus, 408, 414 
 from squamous-celled carcinoma of cervix, 
 399 
 probable metastases in, from myosarcoma of 
 uterus, 195, 234 
 Pleurisy, acute, with sloughing submucous 
 myoma, 422 
 after abdominal hysteromyomectomy, 667 
 myomectomy, 554 
 Pneumonia after abdominal hysteromyomec- 
 tomy, 669, 682 
 myomectomy, 555 
 Polypi of cervical mucosa with myoma, 298 
 
 uterine, associated with myoma, 325, 328, 329 
 Pregnancy, abdominal, myoma antl, differen- 
 tiation, 473-477 
 myomectomy during, 528, 529, 530, 531, 
 538 
 after abdominal myomectomy, 566-568 
 after vaginal myomectomy, 587 
 changes in myoma due to, 645 
 complicated l»y large cervical myoma, 532 
 Pregnancy, cornual, ruptvu'e of, myoma and, 
 differentiation, 477 
 disai)])earance of myoma after, MV> 
 extra-uterine, niy(ini;i and.differcntiat ion, 177 
 fatal abdominal myomectomy in case of, .')3S 
 interstitial, rupture of, myoma and, 477 
 myoma and, 459, 467, 507, 643, 648 
 ruptured cornual or interstitial, simulating 
 
 myoma, 477 
 tubal, and myoma, 342 
 Pressure on ureters by myomata, 381 
 pains with myoma. 448 
 symptoms with snlnnncons niyoniii, 572 
 
 Prolajjse of rectum \\itli myoma, 391 
 
 of uterus associated with myoma, 460 
 Pruritus ani associated with myoma, 446 
 
 vulvae associated with myoma, 444 
 Pulmonary abscess after abdominal hystero- 
 myomectomy, 669, 682 
 embolism as cause of death after abdominal 
 hysteromyomectomy, 680, 684 
 Pulse after abdominal hysteromyomectomy, 
 656 
 myomectomy, 545, 546 
 vaginal myomectomy, 578 
 Pus, escape of, from urethra, after abdominal 
 myomectomy, 550 
 in uterine cavity with myoma, 310 
 Pyelonephrosis with myoma, 397 
 Pyometra associated with myoma, 310 
 Pyonephrosis with necrotic myoma, 423 
 Pyosalpinx associated with myoma, 338, 340, 
 396 
 
 Raw areas, covering of, after abdominal 
 
 hysteromyomectomy, 619 
 Rectal diverticula, rupture of, myoma antl, 
 500 
 tears, 387 
 
 tenesmus after abdominal hysteromyomec- 
 tomy, 659 
 Rectum and myoma, adhesions between, 386 
 carcinoma of, associated with myoma, 417 
 displacement of, upward, by myoma, 386 
 injury to, during hysteromyomectomy, 387, 
 
 390 
 perforation of, after hysterectomy for 
 
 myoma, 390 
 ))rolapse of, with myoma, 391 
 Recurrent fibroids, 178, 179, 252, 586 
 relation of, to myosarcoma, 178 
 Renal colic with myoma, 466 
 insufficiency, 451 
 
 lesions, abdominal hysteromyomectomy in 
 patients suffering from, ()25 
 Resection of sigmoid flexure and removal of 
 
 myoma, 389 
 Respiration, ei'fect of myoma on, l.'iO 
 Retention cysts in kidney, 127 
 
 of urine after abdominal hysteromyomec- 
 tomy, 657 
 with myoma, .376 
 Hetraelion of uinbiliens with myoma. Kil 
 Retroi)eritoneal development of myoma, 631 
 
 sarcoma, myoma and, dilferent iation, .")01 
 I^ound ligaments, atieiiomyoma of, 3()4 
 altered relations of, 361 
 as tense b;inds with myoma, 362
 
 720 
 
 ixnKX. 
 
 Rdund ligaments, changes in, with myoma, '.HM 
 hypertrophy of, with myoma, 363 
 inserted in cervical stump, 596, 603 
 lengthening of, with myoma, 36"2 
 myoma of, 363 
 Rudimentary Fallopian tube witli myoma, 340 
 Rupture of rectal diverticula, myoma and, 
 differentiation, 500 
 of uterus during vaginal myomectomy, 576 
 
 Sachai, markings on myoma, 5 
 
 Saddle-bag appearance of uterus with myoma, 5 
 
 Salpingitis with myoma, 338 
 
 Salts, calcium, deposit of, in myoma, 127 
 
 Sarcoma and myoma, 169-261 
 
 colony development of cells in, 21 1 
 developing from (•()rui('cti\(' tissue of myoma, 
 
 172, 173 
 inspecting myonui for, tluring operation, 594 
 of bladder associated with myoma, 420 
 of cervical stinni), al)d()niinal lunnorrhage 
 
 from, 190 
 of liver secondary from uterus, 234 
 of omentum sccoiulary to sarcoma of 
 uterus, 234 
 Sarcoma of uterus, 169, 492 
 
 metastases from, 222, 234, iiOO 
 myoma and, 492 
 resembling myoma, 21(i 
 relation of hyaline degeneration to, 93 
 resembling decidua, 218 
 
 retroperitoneal, myoma and, differentia- 
 tion, .501 
 return of, in cerxix, 190,212 
 suggested by cell changes in myoma, 242, 
 
 243, 245 
 unusual, on surface of uterus, 184 
 with fading of myoma, 217 
 Sarcomatous change in myoma, 169, 420. See 
 
 also Mjfo.stnToniti oj ufcrufi. 
 Sausage-shapi'd sloughing sul)mucous myoma, 
 
 70 
 Sessile myoma, 1 , 2 
 Shapes of myomata, 4 
 
 Shock as cause of death after alKloininal 
 hysteromyomectomy, 678 
 bisection of uterus for myoma, 684 
 Sigmoiil flexure, careinoina of, with myoma, 
 389,391 
 furnishing ves.scls to myoma, 44 
 hematoma of, during abdominal hystero- 
 myomectomy, 623 
 resection of, and removal of myoma, 389 
 Skin metastases from myosarcoma of uterus, 176 
 Slipping of ligature with hemorrhage during 
 abilominal hysteromyomectomy, 623 
 
 Sloughing of uterine wall after abdominal 
 
 myomectomy, .551 
 Slougliing submucous myoma, 63, 64, 67, 68, 70, 
 
 398 
 Spleen, metastases in, from adenocarcinoma of 
 
 uterus, 414 
 Squamous-celled careinoina of cervix, invading 
 myoma, 403 
 metastas(>s from, 399, 401 
 with adenomyoma of uterus, 262 
 with fatal hemorrhage, 399 
 with myoma, 2f)2 
 Stercoraceous vomiting after al)tlominal hy.s- 
 teromyomectomy, 658 
 myomectomy, 548 
 Sterility associated with adenocarcinoma of 
 uterus, 274 
 with myoma, 457 
 Stomach, carcinoma of, with carcinoma of 
 ovary, 396 
 sarcoma of, secondary to sarcoma of uterus, 
 234 
 Stones, uterine, with myoma, 130 
 Strangulated umbilical hernia, 120 
 
 inguinal hernia associated with myonui, 463 
 Sul^nucous myoma, 1, 59, 571 
 
 abdominal myomectomy for, 509 
 
 technic of, 523 
 age of incideTice, 571 
 death without operation in, 584 
 fever and chills with, 572 
 gangrenous, 66 
 hemorrhage from. 572 
 hysterotomy for, 510 
 
 infected and disintegrating, vaginal myo- 
 mectomy for, 575 
 inversion of uterus associated with. 71 
 leukorrhea with, 571 
 loss of weight with, .572 
 myomectomy for, 571. See also Mi/o- 
 
 DKctomy, raginol. 
 pedimculated, 59, 61 
 pressure symptoms from, 572 
 removal of, 509, 523 
 siimdating carcinoma of cervix, 487 
 size of, .59 
 sloughing, f)3 
 
 abscesses, miliary, in left kidney with, 
 
 422 
 carcinoma of cervix with, 398 
 causing toxemia, 427 
 histologic appearances of, 68 
 lung, septic infarction of, cnniplieating, 
 
 422 
 odor from, t)7 
 pleuri-sy with, 422
 
 INDEX. 
 
 721 
 
 Submucous myoma, sloughing, sausage-shaped, 
 70 
 size of, 64 
 
 vaginal discharge from, (17 
 vegetative endocarditis witli, 422 
 suspicious changes in, 248, 281 
 symptoms of, 571 
 thrombi of vessels with, ()7 
 vaginal discharge with, 571 
 Submucous myosarcoma of uterus, 171 
 Subperitoneal myoma, 1, 185-144 
 edema in, 249 
 
 hemorrhage from jjcdicle of, 621 
 suppurating, 134, l.':i9 
 
 adherent to abdominal wall, 1.36 
 communicating with bowel, 134 
 torsion of, 81 
 Subperitoneal myosarcoma of uterus, 171 
 pedunculated myoma, abdominal myo- 
 mectomy for, 508 
 bleeding into abdominal cavity after 
 bimanual examination of, 444 
 Subvesical myoma, 365, 510 
 Suppression of urine after hysteroniyomectomy, 
 
 657, 682 
 Suppurating interstitial myoma, 144, 146-152 
 results after operation for, 153 
 with perforation of uterus, 150 
 intra-ligamentary myoma, 137 
 Suppurating myoma, 134-154 
 cause of, 152 
 opening into cecum, 45 
 into small bowel, 47 
 results after operation for, 153 
 symptoms of, 152 
 treatment of, 153 
 subperitoneal myoma, 134-144 
 
 adherent to abdominal wall, 136 
 communicating with bowel, 134 
 pedunculated, 139 
 results after operation, 153 
 rupture of, 139 
 Suppuration of abdominal wound after abdom- 
 inal hysteroniyomectomy, ()62 
 of uterine wall after death of fetus, 170 
 Supravaginal hysterectomy for inyoma, 593> 
 portion of cervix, elongat ion nf, with inyoinn, 
 442 
 Suspension of uterus iil'lcr alulniiiin.Ml inyn- 
 
 mectomy, 525, 528 
 Syphilis, abdominal hysteroniyoinccloiny in, 625 
 as contraindication to al>d(iininal niyn- 
 mectomy, 518 
 
 TiOAUS into I'cctal lunicri duiing iiystcroniyo- 
 mectomy, 387 
 46 
 
 Temperature after abdominal hysteromyomcc- 
 tomy, 655 
 after abdominal myomectomy, 545, 546 
 after vaginal myomectomy, 578, 579 
 in myoma cases, 457 
 
 Tenesmus, rectal, after abdominal hystero- 
 niyomectomy, 659 
 
 Three-leaf-clover-shaped myoma, 5 
 
 Thrill felt on vaginal examination witli my- 
 oma, 442 
 
 Thrombosed ovarian veins after hysteroniyo- 
 mectomy, 222 
 
 Thrombosis of blood-vessels in sloughing sub- 
 mucous myoma, 67 
 of veins in uterine mucosa with myoma, 320 
 
 Tonsillitis after abdominal myomectomy, 554 
 
 Torsion of cervix uteri with myoma, 77 
 of subperitoneal myoma, 81 
 of uterus with myoma, 77, 79 
 
 Toxemia from sloughing submucous myoma, 427 
 
 Treatment of myoma, 504, 506, 571, 588, 629, 
 630, 654, 671 
 
 Tubal pregnancy with myoma, 342 
 
 Tuberculosis of endometrium with myoma, 335 
 of Fallopian tubes with myoma, 341, 396 
 of uterus associated with myoma, 421 
 
 Tuberculous kidney, removal of, after hystero- 
 myomectomy, 384, 385 
 peritonitis associated with myoma, 464 
 
 Tubo-ovarian abscess with myoma, 344 
 
 and adenocarcinoma of uterus, 290 
 cysts with myoma, 340 
 
 Tumors of breast, benign, with myoma, 450 
 
 Ulceration of vagina with myoma, 440 
 Umbilical cyst associatinl with myoma, 462 
 depression, obliteration of, associated with 
 
 myoma, 461 
 hernia, strangulated, 120 
 
 with carcinoma of cervix ami myoma, 398 
 with myoma, 461, 639 
 rml)ilicus, condition of, with myoma, 461 
 rrachus, cysts of. associated with myoma, 4()3 
 I'l'eter, accidental cutting of, iluiinu iiystero- 
 iiiyDUiectoiuy, 'AS'.i 
 and niynuKi, 378-385 
 cDiidit ion of, in myoma cases, 396 
 (hlatatioii t)l, in myoma cases, 378 
 dislocation of, in myoma cases, 378 
 (loul)le, in myoma cases, 381 
 injury to, during hysteroniy<iniect(iniy, 382, 
 :;.s:;, 3si 
 
 ligation of, accidental, during hysteroniyo- 
 
 niectoiiiy. 3S2 
 loc.'it ioii of, <luring liysteroniyoiiiectoniy, 385
 
 722 
 
 INDEX. 
 
 Ureter, position of, in myoma cases, 378 
 pressure on, by myoma, 381 
 vermicular contraction of, 385 
 rretero-ureteral anastomosis, with subsequent 
 
 removal of kidney, 383 
 Urethra, escape of pus from, after abdominal 
 
 myomectomy, 550 
 Urination in myoma cases, 370 
 Urine, retention of, after abdominal hystero- 
 myomectomy, 657 
 suppression of, after alxlominal hystero- 
 myomectomy, ()57, 682 
 Uterine artery', bleeding from accessory branch 
 of, during abdominal hysteromyomec- 
 tomy, 623 
 fatal hemorrhage from, due to catgut 
 
 absorption, 681 
 passage of silk ligature from, into bladder, 
 
 375 
 tearing of, dm-iiig abdominal myomec- 
 tomy. 525 
 Uterine cavity, blood in, in myoma cases, 309 
 epithelium lining, atypical changes in, 
 
 in myoma cases, 332 
 obliteration of, partial, in myoma cases, 308 
 opening of suppui-ating interstitial myoma 
 
 info, 1 K; 
 pus in, in inyonia cases, .310 
 size and shape of, in myoma cases, 305 
 Uterine discharge, character of, in myoma, 442 
 foul, following al)dotniii;d myomectomy, 
 550 
 glands associated witli myoma, unusual 
 shapes of, 321 
 dilatation of, 323 
 hypertrophy of, 325 
 
 running parallel to surface of uterine 
 mucosa, 316 
 iiorii, diffuse adcnoniyoma of, in liicornate 
 uterus, l.')7 
 dilatation of lympliatics of, 74 
 lymphatics, dilatation of, associated with 
 myoma, 72, 76 
 Uterine mucosa, blood-vessels of, alterations 
 in, in myoma cases, 317 
 condition of, in myoma cases, 297, 310 
 
 in myosarcoma of uterus, 176 
 edema of, in myoma cases, 322 
 extension of nuiscle info, in myoma cases, 
 
 317 
 glands running parallel to surface of, in 
 
 myoma cases, 316 
 small myoma developing in, 333 
 thrombosis of veins in, with myoma, 320 
 unusual gland shapes associated with 
 myoma in, 321 
 
 Uterine muscle and mj-oma, line of junction 
 between, 8, 9, 10 
 condition of, with myoma, 11 
 Uterine polypi associated with myoma, 325, 
 
 328, 329 
 Uterine stones with myoma, 130 
 Uterine vessels, hemorrhage from, during 
 
 abdominal hysteromyomectomy, 621 
 U teiine wall, perforation of, after death of 
 fetus, 470 
 .sloughing of, after abdonunal myomec- 
 tomy, 551 
 after removal of large interstitial my- 
 oma, 551 
 L'tero-ovarian ligaments, adenomyoma of, 360 
 changes in, with myoma, 356 
 cysts of, with myoma, 350, 357 
 myoma of, 358, 360 
 
 secondary sarcomatous nodule in, with 
 myoma, 360 
 Uterus, adenocarcinoma of, associated with 
 myoma, 274. See also Adcunrnrcinomd of 
 vteruf!. 
 adenomyoma of, 167, 168, 511 
 angiomyoma of, 158-161 
 Uterus bicornate, diffuse adenomyoma in one 
 
 horn of, 157 
 Uterus, bisection of, for myoma, 60S, 683,684, 
 685 
 broad ligaments of, ab.scess of , and myoma, 
 354, 3.55, 510 
 Uterus, carcinoma of, 485 
 
 associated with myoma, 295, 296. 404, 
 405-416, 485 
 enlargement of, due to retained menstrual 
 
 flow, 485 
 fibroids of, 1. See also Myoma. 
 fil)roma of, 1. See also Myovta. 
 filjromyoma of, 1. iiee a\so M ynwa. 
 hypcrtropliy of, in myoma ca.ses, 1 1 
 infection of, from carcinoma of uterus, after 
 
 abdominal myomectomy, 540 
 inspection of, in differential diagnosis of 
 
 myoma and pregnancy, 467 
 interstitial myosarcoma of, 171 
 intraligamentary myosarcoma of, 171 
 inversion of, associated with sulimucous 
 
 myoma, 71 
 large suppurating myoma oj^'ning into cavity 
 
 of, 151 
 lipomyoma of, 162-166 
 malformations of, associated with myoma, 
 
 I.").")-157 
 myoma of, 1. See al.so Myoma. 
 myosarcoma of, 169-261 
 pain in, with myoma, 448
 
 INDEX. 
 
 '23 
 
 Uterus, perforation of, due to suppurating 
 interstitial myoma, 150 
 position of, with myoma, 11 
 prolapse of, associated with myoma, 400 
 rerurroiit fibroids of, 178, 179 
 round ligamonts of, with myoma. 361, o6'2, 
 
 363, 364, 603 
 rupture of, during vaginal niyomertomy, 
 
 576 
 saddle-bag appearance of, in myoma cases, o 
 sarcoma of, myoma and, 492 
 
 relation of hyaline degeneration of myoma 
 to, 93 
 
 resembling myoma, 216 
 submucous myosarcoma of, 171 
 subperitoneal myosarcoma of, 171 
 suspension of, during abdominal myomec- 
 tomy, 525 
 torsion of, in myoma cases, 77 
 
 with complete severance of body from 
 cervix, with myoma, 79 
 tuberculosis of, associated with myoma, 
 
 421 
 unusual sarcoma on surface of, 184 
 with dead fetus resembling myoma, 473 
 
 Vagina, abscess burrowing along, 196 
 
 alterations in size and shape of, with myoma, 
 
 439 
 bluish color of, with myoma, 439 
 condition of, with myoma, 438 
 double, with sul)mucous adenomyoma, 155 
 expulsion of large submucous myoma 
 
 through, 67 
 ulceration of, with myoma, 440 
 vein stones in, with myoma, 440 
 Vaginal cysts with myoma, 439 
 
 discharge with submucous myoma, 67, 571 
 drainage after alxloiniiial hystcromyoniec- 
 
 tomy, 623, 624 
 examination, thiili felt on, witli myoma, 
 442 
 Vaginal hystcromyomcctomy, (529, (570, (572, 
 685 
 
 Vaginal mucosa, bluish color of, in myoma, 439 
 Vaginal myoma, 234, 440 
 
 Vaginal myomectomy, 571. See also Myomec- 
 tomy, vaginal. 
 portion of cervix, elongation of, with myoma, 
 
 441 
 vault, induration of, with myoma, 440 
 wall, ))hleboliths in, with myoma, 440 
 Veins, abdominal, enlargement of, with myoma, 
 437 
 iliac, compression of, by tumor, 234 
 ovarian, thrombosis of, after hystcromyo- 
 mcctomy, 222 
 thromliosisof, in utci'inennicosa,witli myoma, 
 320 
 Vermicular contraction of ureters during 
 
 hystcromyomcctomy, 385 
 Vermiform appendix, removal of, after ab- 
 dominal myomectomy, 557, 558 
 Vertebrae, metastases in, from myosarcoma of 
 
 uterus, 176 
 Vesical adhesions, release of, subsequent to 
 abdominal myomectomy, 556 
 role played by, in myoma cases, 366 
 calculus associated with myoma, 375 
 Vicarious menstruation after abdominal hys- 
 
 teromyomectomy, 605 
 Vomiting after abdominal hystcromyomcc- 
 tomy, 658 
 myomectomy, 548 
 associated with myoma, 447 
 stercoraceous, after abdominal hystcro- 
 myomcctomy, 658 
 myomectomy, 548 
 N'ulva, pruritus of, in myoma cases, 444 
 
 Water-core appearance in areas of hyaline 
 degeneration. 95 
 
 Weakness, profound, in myoma cases, 4.")7 
 
 Weather, hot, as cause of postoperative ele- 
 vation of temperature, 655 
 
 Weight, loss of, in myoma ca.scs, 456,572 
 of myomata, 119, 512 
 
 Worms, intestinal, after alidomiiiai liystero- 
 myomectomy, 659
 
 
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