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Distribution of Pelvic and Abdominal Adenomyomas

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Abstract

By 1920, Cullen accepted three models for the pathogenesis of extrauterine adenomyomas: (1) from embryonic müllerian rests, (2) “springing from” the posterior wall of the cervix or body of the uterus and invading the rectum, and (3) from overflow of uterine mucosa – shed from an adenomyoma of the rectovaginal septum onto tube and ovary – the same flowing metaphor that he used to explain the pathogenesis of diffuse uterine adenomyomas. Cullen came tantalizingly close to – and yet so far from – Sampson’s later observations when he wrote: “One gathers the impression that the uterine mucosa from the diffuse adenomyoma on the posterior surface of the cervix and uterus has overflowed upon the adherent tube [and ovary].”1 Cullen had the implantation pathogenesis in reverse.

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Notes

  1. 1.

    Cullen, TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283: 244.

  2. 2.

    Cullen TS. Archives of Surgery 1920;1:215–283.

  3. 3.

    Scholars with a deep interest in this subject may wish to read this chapter with a copy of Cullen’s 1920 article in hand so they can compare the illustrations in the article with the text of this chapter.

  4. 4.

    Cullen TS. Archives of Surgery 1920;1:215–283;217. Fig. 1.

  5. 5.

    Cullen TS. The distribution of adenomyomata containing uterine mucosa. American Journal of Obstetrics and Diseases of Women and Children. 1919;180:130–138:136. “Figure 1. The abnormal distribution of uterine mucosa. 1. In the wall of the uterus and at the uterine horn. 2. I the rectovaginal septum. 3. In the round ligament. 4. In the ovary. 5. In the utero-ovarian ligament. 6. In the uterosacral ligament. 7. At the umbilicus.”

  6. 6.

    Cullen, Thomas S. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283.

  7. 7.

    Cuthbert Lockyer, Fibroids and Allied Tumours (Myoma and Adenomyoma): Their Pathology, Clinical Features and Surgical Treatment [London: Macmillan and Company, 1918].

  8. 8.

    Cullen, TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283:217.

  9. 9.

    Cullen, Thomas S. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283: 217, Fig. 1. The illustration shows extensive “diffuse adenomyoma” or adenomyosis of the uterus involving not only the anterior and posterior walls but also the fundus of the uterus. Young, RH. Dusting of old books: Comments on classic gynecologic pathology books of yesteryear. International Journal of Gynecological Pathology. 2000;19:67–84. As Robert H. Young pointed out, Cullen used the term adenomyoma of the uterus to include both “diffuse adenomyoma” (adenomyosis) and “discrete adenomyoma” (adenomyoma). This lesion was treated exhaustively in a separate monograph. Thomas Stephen Cullen, Adenomyoma of the Uterus [Philadelphia: WB Saunders, 1908].

  10. 10.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283: 217, Fig. 1. Note the discrepancy between terminology and illustration: the lesion labeled adenomyoma of the rectovaginal septum is shown in a retrocervical location involving the tissue between the posterior vaginal fornix and anterior portion of the rectovaginal pouch of Douglas.

  11. 11.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283: 222 Cullen noted: “We have in this tube an adenomyoma of the uterine type, and I am totally at a loss to explain its mode of origin.”

  12. 12.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283: 243, Fig. 21. The legend reads: “Uterine mucosa on the surface of the ovary in a case of adenomyoma of the rectovaginal septum…The miniature uterine cavity on the surface of e the right ovary is represented by a. The lining mucosa resembles in every particular that of the body of the uterus. Some of the glands show hypertrophy. The mucosa of the adenomyoma of the rectovaginal septum seems to have overflowed to the surface of the adherent ovary. The same condition was noted on the surface of the corresponding tube.” This is an important addition to his classification and the first evidence of his attention directed to the ovary, other than a prior acknowledgement of the case of WW Russell published in 1899.

  13. 13.

    This lesion was treated exhaustively in a separate monograph. Thomas S. Cullen. Embryology, Anatomy, and Diseases of the Umbilicus [Philadelphia: W. B. Saunders, 1916].

  14. 14.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives Surgery 1920;1:215–283. In Figure 1, Cullen labeled the various sites at which he had found uterine mucosa, (1) was the body of the uterus; (2) rectovaginal septum, (3) uterine horn or fallopian tube, (4) round ligament, (5) hilum of the ovary, (6) utero-ovarian ligament, (7) uterosacral ligament, (8) sigmoid colon, (9) rectus muscle, and (10) umbilicus.

  15. 15.

    Cullen TS. Archives of Surgery 1920;1:215–283;217. Figure. 1. As evidence that Cullen valued this contribution, he had it published as a hard cover sixty-nine page monograph in 1920. Thomas S. Cullen. The Distribution of Adenomyomas Containing Uterine Mucosa. Chicago, IL: American Medical Association Press, 1920. The author has a copy in his library, thanks to Dr. Ronald Cyr.

  16. 16.

    E. Stewart Taylor, Essentials of Gynecology [Philadelphia: Lea & Febiger, 1958], 256. Figure 194. “The usual locations for endometriosis. (Cullen, courtesy of Arch. Surg.)”

  17. 17.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives Surgery 1920;1:215–283:269. Figure 42 (Case 16, rectovaginal septum Case 19). See also Figure 1, page 217; sagittal view of the female pelvis and abdomen.

  18. 18.

    Cullen TS. Archives Surgery 1920;1:215–283:271, Figure 43 (Case 16, rectovaginal septum Case 19).

  19. 19.

    Cullen TS. Archives Surgery 1920;1:215–283:269. Figure 42 (Case 16, rectovaginal septum case 19) inset showing “independent adenomyoma of the sigmoid almost completely blocking the lumen of the bowel.” This beautiful illustration depicts deeply invasive endometriosis (adenomyoma) of the rectovaginal pouch of Douglas that has penetrated the posterior fornix of the vagina. It also purports to show an adenomyoma partially obstructing the sigmoid colon.

  20. 20.

    In the illustration the mucosa – though distended over the intraluminal spherical polyp – is normal.

  21. 21.

    Kellogg FS. Adenomyoma of the recto-vaginal septum. Boston Medical and Surgical Journal 1917; 176 or 177: 22–24:24. Puckering and gathering of bowel serosa is a universally recognized phenotypic feature of advanced bowel adenomyomas that surgeons routinely observe with adenomyomas of the rectum, sigmoid colon, descending colon, ascending colon, and ileum. On numerous occasions of partial to complete obstruction of the sigmoid colon or the ileum, the author has observed an “Omega deformation of the bowel segment” where the adenomyoma (endometriosis) has invaded.

  22. 22.

    Cullen TS Archives Surgery 1920;1:215–283:269. Figure 42 (Case 16) inset showing “independent adenomyoma of the sigmoid almost completely blocking the lumen of the bowel.” This illustration depicts deeply invasive adenomyoma (endometriosis) that has penetrated through the anterior rectovaginal pouch of Douglas into the posterior fornix of the vagina. It also purports to show an adenomyoma obstructing the sigmoid colon.

  23. 23.

    Stacey E. Mills, ed., Sternberg’s Diagnostic Surgical Pathology, 4th ed., vol. 2. [Philadelphia: Lippincott Williams & Wilkins, 2004], 1589–1591. Juan Rosai, ed., Ackerman’s Surgical Pathology, 8th ed., vol. 1. [St. Louis: Mosby, 1996], 645–647:645. “Gastrointestinal stromal tumors, (GISTs) constitute the largest category of primary nonepithelial neoplasms of the stomach and small intestine.” Dr. Salvador Udagawa, my colo-rectal surgical colleague with whom I have worked closely for 25 years has removed gastrointestinal stromal tumors from the large intestine including the sigmoid colon; the largest GIST he removed was obstructing the distal transverse colon. See also Ancel Blaustein, “Pelvic endometriosis,” in Pathology of the Female Genital Tract, ed. Ancel Blaustein [New York: Springer-Verlag, 1977], 404–419. See figure 22.29, page 416. “Napkin-ringlike constriction of the [bowel] wall, intramural endometriosis present.” See figure 22.30, page 417. “Sigmoid colon. Endometrial implants in the smooth muscle layer. There is a hypertrophy of muscle about the implants.” See Figure 22.31 “Sigmoid colon. Lesions of endometriosis that on gross inspection have a high index of suspicion for carcinoma. There is a raised submucosal lesion and puckering on the serosal surface.”

  24. 24.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives Surgery 1920;1:215–283:269–270. See caption under Figure 42 (Case 16, rectovaginal septum Case 19), page 269 that is titled “Adenomyoma of the rectovaginal septum, independent adenomyoma of the sigmoid almost completely blocking the lumen of the bowel.”

  25. 25.

    Cullen labeled the specimen rectal mucosa instead of mucosa of sigmoid colon.

  26. 26.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives Surgery 1920;1:215–283:271. See caption under Figure 43 (Case 16, rectovaginal septum Case 19) labeled “Adenomyoma of the sigmoid flexure totally independent of a coexisting adenomyoma of the rectovaginal septum.”

  27. 27.

    Judith Robinson, Tom Cullen of Baltimore [London, Toronto, New York: Oxford University Press, 1949], 330.

  28. 28.

    Judith Robinson, Tom Cullen, 280, 282.

  29. 29.

    Judith Robinson, Tom Cullen, 279–80.

  30. 30.

    John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History. [New York: Penguin Books, 2005], 258.

  31. 31.

    Martzloff KA. Thomas Stephen Cullen. Am J Obstet Gynecol 1960;80:833–843:837. “The artistry of Max Broedel was a priceless adjunct to the books written by Kelly and by Cullen; Broedel was, in fact, an indispensable collaborator. While it was his judgment that frequently decided the type and form of illustration to be used in a given situation, of equal importance were some of his dissections and microscopic studies.”

  32. 32.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives Surgery 1920;1:215–283:269. Figure 42 (Case 16, rectovaginal case 19).

  33. 33.

    Ancel Blaustein, “Pelvic endometriosis,” in Pathology of the Female Genital Tract, ed. Ancel Blaustein [New York: Springer-Verlag, 1977], 404–419. See Blaustein illustration 22.2, on page 405, labeled “Pelvic and abdominal sites of endometriosis.” It is a reproduction of Broedel’s sagittal illustration of abdomen and pelvis, showing all ten anatomic locations where Cullen had personally observed misplaced uterine mucosa: Cullen TS. The distribution of adenomyomata containing uterine mucosa. Archives of Surgery 1920;1:215–283;217. However, it was not attributed to Cullen. Instead it was reprinted in Blaustein by permission from C. Javert, Pathogenesis of endometriosis, Cancer 1949;2:399. In other words, Broedel’s sagittal illustration of abdomen and pelvis showing the sites of misplaced uterine mucosa had taken on a life of its own; the original reference to Cullen was not mentioned, another “disconnect” helped to perpetuate the error.

  34. 34.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:216.

  35. 35.

    Cullen TS. Archives of Surgery 1920;1:215–283:216.

  36. 36.

    Cullen TS. Archives of Surgery 1920;1:215–283:216.

  37. 37.

    Cullen TS. Archives of Surgery 1920;1:215–283:216–17.

  38. 38.

    Cullen TS. Archives of Surgery 1920;1:215–283:221. Figure 4 (Case 1). Adenomyoma of the right uterine horn.

  39. 39.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:221.

  40. 40.

    Cullen TS. Archives of Surgery 1920;1:215–283:222.

  41. 41.

    Cullen TS. Archives of Surgery 1920;1:215–283:224. See Figure 6, Case I. Adenomyoma of the left fallopian tube.

  42. 42.

    Cullen TS. Archives of Surgery 1920;1:215–283:222.

  43. 43.

    Chiari H. Zur pathologischen Anatomie des Eileiter-Catarrhs. Pager Ztschr. Heilkunde 1887;8:457–473. That same year, Martin reported cases similar to Chiari. Martin. Uber Tubenkrankung. Zeitschr für Geb und Gynak 1887;13. S. 299. Martin cited by: Cuthbert Lockyer, Fibroids and Allied Tumours (Myoma and Adenomyoma): Their Pathology, Clinical Features and Surgical Treatment [London: Macmillan and Company, 1918], 284.

  44. 44.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:223–224.

  45. 45.

    Cullen TS. Archives of Surgery 1920;1:215–283:222.

  46. 46.

    Judith Robinson, Tom Cullen of Baltimore [London, Toronto, New York: Oxford University Press, 1949], 125. Quotation of Cullen: “Popsy had read von Recklinghausen and he wanted to pull me out. ‘You’re wrong in your interpretation, Cullen,’ he told me, ‘von Recklinghausen says…’ But I had brought the evidence with me, sectioned and mounted for examination. ‘I don’t care a hoot what von Recklinghausen says,’ I said, ‘Look down the barrel of that microscope.’ ”

  47. 47.

    Cullen TS. Adenomyoma of the rectovaginal septum. JAMA 1914;62:835–839.

  48. 48.

    Cullen TS. Adenomyoma of the rectovaginal septum. JAMA 1916;LXVII:401–406.

  49. 49.

    Cullen TS. The distribution of adenomyomata containing uterine mucosa. Am J Obstetrics Diseases Women and Children 1919;180:130–138.

  50. 50.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:225.

  51. 51.

    Cullen TS. Adenomyoma of the recto-vaginal septum. Johns Hopkins Hospital Bulletin 1917;28:343–349:348.

  52. 52.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283.

  53. 53.

    Cullen’s total personal experience with adenomyomas of the rectovaginal septum at the time his 1920 paper went to press: 1913 – 2 cases, 1915–1 case, 1916–2 cases, 1917 – 4 cases, 1920 – 10 cases for total of 19 personal cases of adenomyoma of the rectovaginal septum.

  54. 54.

    Mahle AE, MacCarty WC. Ectopic adenomyoma of uterine type (A report of ten cases). J Lab & Clin Med 1920;5:218–228:226.

  55. 55.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283. Figure 7, labeled “Adenomyoma of the rectovaginal wall as seen on vaginal inspection.”

  56. 56.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283: Figure 8, labeled “Adenomyoma of the rectovaginal septum. This is a longitudinal section of the uterus and vaginal cuff seen in Figure 7.”

  57. 57.

    Cullen TS. Archives of Surgery. 1920;1:215–283.

  58. 58.

    Cullen TS. Archives of Surgery. 1920;1:215–283. Page 227, Fig. 8 (case 2). Denonvilliers, CPD. Bull Soc Anatomy of Paris (Series 3) 1836:20:105.

  59. 59.

    Denonvilliers, CPD. Bull Soc Anatomy of Paris (Series 3) 1836:20:105. This basic anatomic problem was clarified by the research of Nichols and Milley. Nevertheless, the misnomer perpetuated by Cullen, has persisted into the twenty-first century and has created much confusion as has the persistence of Cullen’s controversial theory of pathogenesis of these invasive lesions from müllerian embryonic rests.

  60. 60.

    Cullen TS. Archives of Surgery. 1920;1:215–283:223.

  61. 61.

    Cullen TS. Archives of Surgery. 1920;1:215–283:223.

  62. 62.

    Cullen TS. Archives of Surgery. 1920;1:215–283:223.

  63. 63.

    Cullen TS. Archives of Surgery. 1920;1:215–283:225.

  64. 64.

    Cullen TS. Archives of Surgery. 1920;1:215–283:227. Figure 8.

  65. 65.

    Cullen TS. Archives of Surgery. 1920;1:215–283:229.

  66. 66.

    Cullen TS. Archives of Surgery. 1920;1:215–283:233.

  67. 67.

    Cullen TS. Archives of Surgery. 1920;1:215–283:235.

  68. 68.

    Cullen TS. Archives of Surgery. 1920;1:215–283:223.

  69. 69.

    Cullen TS. Archives of Surgery 1920;1:215–283:223.

  70. 70.

    Cullen TS. Archives of Surgery. 1920;1:215–283:250. Figure 27 (Case 10).

  71. 71.

    Cullen TS. Three cases of subperitoneal pedunculated adenomyoma. Archives Surgery 1921;2:443–454. In this one article alone, Cullen employed the term “springing from” 13 times and “which sprang from” three times. In 1920, he had used the terms 20 times.

  72. 72.

    Cullen, Thomas S. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283:252. Figure 29 (Case 10).

  73. 73.

    Cullen TS. Adenomyoma of the rectovaginal septum. JAMA 1916;LXVII:401–406:405.

  74. 74.

    Cullen TS. JAMA 1916;LXVII:401–406:404.

  75. 75.

    Cullen TS. JAMA 1916;LXVII:401–406:404. Thomas Stephen Cullen, Adenomyoma of the Uterus [Philadelphia: WB Saunders, 1908], 169, Figure 49.

  76. 76.

    Cullen TS. JAMA 1916;LXVII:401–406:405.

  77. 77.

    Cullen TS. Adenomyoma of the rectovaginal septum. JAMA 1916;LXVII:401–406. In an abstract of the discussion to Cullen’s paper, Dr. Carey Culbertson stated: “It is not difficult to understand how inflammatory pressure might produce such a squeezing out of the mucosa into the wall of the tube; but in the case of the rectovaginal septum or postcervical space, the distance from the uterine cavity is too great to admit of the presence here of typical uterine mucosa as the result of inflammatory pressure.”

  78. 78.

    Cullen TS. JAMA 1916;LXVII:401–406:403.

  79. 79.

    Cullen TS. JAMA 1916;LXVII:401–406:401–2.

  80. 80.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283.

  81. 81.

    Cullen TS. Archives of Surgery 1920;1:215–283:236. See: Cullen’s septum case 14, illustrated in Fig. 16 (Case 6) on page 238. Cullen described this case as “This is the most widespread distribution of an adenomyoma of the rectovaginal septum that I have ever seen.” On page 240, Cullen stated this supravaginal (subtotal hysterectomy) “was one of the most difficult hysterectomies I ever attempted.”

  82. 82.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:225. See also pages 229, 230, 236, 239–40 etc. under operation for each case.

  83. 83.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283:225.

  84. 84.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:265. See Case 16, page 272: Septum Case 19; Gyn. No. 23764; Gyn. Path. No. 23891.

  85. 85.

    Cullen TS. Archives of Surgery 1920;1:215–283. Surgery was performed on 4 April 1918. Analysis of this paper is somewhat frustrating because the illustrations are out of sequence with the text they illustrate. That it was an article in the first volume of a new journal may explain the situation.

  86. 86.

    Casler DB. A unique, diffuse uterine tumor, really an adenomyoma, with stroma, but no glands. Menstruation after complete hysterectomy due to uterine mucosa in remaining ovary. Transactions of the American Gynecological Society. 1919;44:69–84:76–7. Casler’s patient was operated 3 January 1917 with Gyn. Path. No. 22897 ½. Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:272–3. Cullen’s patient was operated 4 April 1918 with Gyn. Path. No. 23891.

  87. 87.

    Lockyer, Cuthbert. Fibroids and Allied Tumours. New York: Macmillan Company, 1918.

  88. 88.

    Meyer, Robert. Ueber entzündliche heterotope Epithelwucherungen im weiblichen Genitalgebiete und uber eine bis in die Wurzel des Mesocolon ausgedehnte benigne Wucherung des Darmepithels. Virchows Arch. f. path Anat. 1919:195:487.

  89. 89.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:276.

  90. 90.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:276.

  91. 91.

    Mahle AE, MacCarty WC. Ectopic adenomyoma of uterine type (A report of ten cases). J Lab & Clin Med 1920;5:218–228:221–225. Leitch A. Migratory adenomyomata f the uterus. Proc Roy Soc Med 1913;vii, Pt. ii, Obst and Gynec Sec: 393–398,

  92. 92.

    Mahle AE, MacCarty WC. J Lab & Clin

    Med 1920;5:218–228:221.

  93. 93.

    Mahle AE, MacCarty WC. J Lab & Clin Med 1920;5:218–228:221.

  94. 94.

    Had this been a cancer originating in the mucosa of the sigmoid colon, the proctosigmoidoscopy would have been diagnostic, and probably the barium enema study also. However, adenomyomas originate on the serosal or outer surface of the sigmoid colon. While the adenomyomatous mass within the wall of the sigmoid colon might have indented the lumen, the bowel mucosa overlying the adenomyoma would have been smooth and normal appearing.

  95. 95.

    Mahle AE, MacCarty WC. J Lab. & Clin Med. 1920;5:221. The authors referred to a similar case of adenomyoma of the sigmoid colon observed by Leitch.

  96. 96.

    Mahle AE, MacCarty WC. Ectopic adenomyoma of uterine type (A report of ten cases). J Lab & Clin Med 1920;5:218–228:221.

  97. 97.

    Judith Robinson, Tom Cullen of Baltimore [London, Toronto, New York: Oxford University Press, 1949], 122–23. The Gynecological Service lost four of five patients from postoperative septic peritonitis in 1 week; one patient was infected before surgery and survived, the four clean cases did not. At the weekly staff meeting in January 1895, Cullen recommended the cases be reported in detail. Kelly assigned the task to Cullen. See Cullen TS. Post-operative septic peritonitis. Johns Hopkins Hospital Reports 1895;IV:411.

  98. 98.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:272. See Figure 44, on page 272 an anatomical illustration labeled: “Adenomyoma in the left rectus muscle.” See also Figures 45, on page 273, a histologic section labeled: “The nodule consisted of nonstriped muscle and fibrous tissue, and scattered throughout it were areas of typical uterine mucosa.” Figure 46, on page 274 (also a microscopic section) shows islands of normal uterine mucosa “scattered throughout the myoma.”

  99. 99.

    Cullen TS. Archives of Surgery 1920;1:215–283:278. Subsequently the patient had a normal pregnancy, normal labor and delivery at term. However, a hematoma of the left broad ligament and left vaginal wall developed postpartum. It was successfully drained vaginally.

  100. 100.

    Cullen TS. Archives of Surgery 1920;1:215–283:272. Figure 44, Adenomyoma of the left rectus muscle. See Figure 45 on page 273 and Figure 46 on page 274 for the histology.

  101. 101.

    Cullen TS. Archives of Surgery 1920;1:215–283:272. Figure 44, Adenomyoma of the left rectus muscle. See Figure 45 on page 273 and Figure 46 on page 274 for the histology.

  102. 102.

    Mahle AE, MacCarty WC. Ectopic adenomyoma of uterine type (A report of ten cases). J Lab. & Clin Med. 1920;5:221.

  103. 103.

    Cullen TS, Broedel M. Lesions of the rectus abdominis muscle simulating an acute intra-abdominal emergency. Bulletin Johns Hopkins Hospital 1937;lxi:295–315.

  104. 104.

    Cullen, Thomas S. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283:258. William Wood Russell was the same man who reconsidered his withdrawal and accepted the residency position that Kelly had offered to Cullen in the interim. This resulted in Cullen spending three precious years in the pathology laboratory.

  105. 105.

    Russell WW. Aberrant portions of the müllerian duct found in an ovary. Johns Hopkins Hospital Bulletin. 1899;8–10 with an additional three pages labeled Plate I, Plate II, and Plate III each with illustrations of whole-ovary microscopic sections drawn by Max Broedel.

  106. 106.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283:260, 262.

  107. 107.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283:260, 263, Figure 36 (Case 13).

  108. 108.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283:259–60.

  109. 109.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283:259.

  110. 110.

    Cullen, Thomas S. Archives of Surgery. 1920;1:215–283:250–60.

  111. 111.

    Casler DB. A unique, diffuse uterine tumor, really an adenomyoma, with stroma, but no glands. Menstruation after complete hysterectomy due to uterine mucosa in remaining ovary. Transactions of the American Gynecological Society. 1919;44:69–84. See Fig. 5.

  112. 112.

    The glands were atypical only in the sense of being dilated, they resembling Swiss cheese hyperplasia of the uterine endometrium.

  113. 113.

    Casler DB. Transactions of the American Gynecological Society. 1919;44:69–84.

  114. 114.

    Casler DB. Transactions of the American Gynecological Society. 1919;44:69–84. See Figure 7.

  115. 115.

    Casler DB. Transactions of the American Gynecological Society. 1919;44:69–84:69.

  116. 116.

    Casler DB. Transactions of the American Gynecological Society. 1919;44:69–84:70.

  117. 117.

    Casler DB. Transactions of the American Gynecological Society. 1919;44:69–84:74. “The pathological process beginning in the polyp is really an orderly overgrowth of the stroma, which has gradually exterminated the uterine glands by strangulation, and then in the same manner has attacked the uterine musculature.”

  118. 118.

    Cullen, Thomas S. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery. 1920;1:215–283:259–60:258.

  119. 119.

    Cullen TS. Archives of Surgery 1920;1:215–283:259–260. Figures 33 and 34.

  120. 120.

    Cullen TS. Archives of Surgery 1920;1:215–283:237.

  121. 121.

    Cullen TS. Archives of Surgery 1920;1:215–283:238–240. See supra-vaginal hysterectomy specimen, amputated through the cervix: Cullen’s septum case #14, Figure 16, page 238.

  122. 122.

    Cullen TS. Archives of Surgery 1920;1:215–283:242. Cullen’s septum case #14 See: Fig. 20, page 242. Here, Cullen extended the use of his “flow” metaphor for describing adenomyoma of the tube.

  123. 123.

    Cullen TS. Archives of Surgery 1920;1:215–283:243. Cullen’s septum case #14. Fig. 21, page 243. The legend reads: “Uterine mucosa on the surface of the ovary in a case of adenomyoma of the rectovaginal septum…The miniature uterine cavity on the surface of the right ovary is represented by a. The lining mucosa resembles in every particular that of the body of the uterus. Some of the glands show hypertrophy. The mucosa of the adenomyoma of the rectovaginal septum seems to have overflowed to the surface of the adherent ovary. The same condition was noted on the surface of the corresponding tube.”

  124. 124.

    Cullen TS. Archives of Surgery. 1920;1:215–283: 242.

  125. 125.

    Cullen TS. Archives of Surgery 1920;1:215–283:262. See Cullen’s septum case 14 (Gyn.-Path. No. 25003) on page 237 and endometriosis of the tube: Figure 20 on page 242. See also endometriosis of the ovary: Figure 21 on page 243.

  126. 126.

    Cullen TS. Archives of Surgery. 1920;1:215–283: 244.

  127. 127.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283:264,

  128. 128.

    Cullen TS. The distribution of adenomyomata containing uterine mucosa. American Journal of Obstetrics and Diseases of Women and Children 1919;180:130–138.

  129. 129.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives Surgery 1920;1:215–283.

  130. 130.

    Cullen TS. Thomas S. Cullen, Henry Mills Hurd, the First Superintendent of the Johns Hopkins Hospital [Baltimore, MD: Johns Hopkins Press, 1920]. In 1920, Cullen published a small biography honoring Henry Mills Hurd, the first superintendent of the Johns Hopkins Hospital, the man who had so encouraged publication by members of the faculty. Three cases of subperitoneal, pedunculated adenomyoma. Arch Surgery 1921;2:443–454. Cullen TS. Further remarks on diseases of the umbilicus Surg Gynecol Obstet 1922;35:257–283. Cullen TS, Broedel M. Lesions of the rectus abdominis muscle simulating an acute intra-abdominal condition. Bull Johns Hopkins Hospital, November, 1937.

  131. 131.

    Cullen TS. Archives Surgery 1920;1:215–283:215.

  132. 132.

    Judith Robinson, Tom Cullen of Baltimore [London, Toronto, New York: Oxford University Press, 1949], 117.

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    Cullen TS. The distribution of adenomyomata containing uterine mucosa. Am J Obstetrics Diseases Women and Children 1919;180:130–138.

  134. 134.

    Cullen TS. The distribution of adenomyomas containing uterine mucosa. Archives of Surgery 1920;1:215–283.

  135. 135.

    Cullen TS. Archives of Surgery 1920;1:215–283. Cullen began his classification of adenomyomata with adenomyoma of the body of the uterus and ended with adenomyoma of the umbilicus, subjects on which he had written books.

  136. 136.

    Cullen TS. Archives of Surgery 1920;1:215–283:250. Figure 27 (Case 10). Cullen illustrated an adenomyoma [springing from the cervix] that invaded the broad ligament and compressed the right ureter causing partial ureteral obstruction.

  137. 137.

    Cullen TS. Three cases of subperitoneal pedunculated adenomyoma. Archives Surgery 1921;2:443–454:454. Mahle AE, MacCarty WC. Ectopic adenomyoma of uterine type (A report of ten cases). J Lab & Clin Med 1920;5:218–228:218. Cogently, Mahle and MacCarty from the Mayo Clinic had observed in 1920: “It is evident, regardless of the amount of literature which has been written on the subject, that the importance of adenomyoma has not been recognized either clinically or surgically.”

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    Ronald E. Batt M.D., Ph.D. (Professor of Gynecology)

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Batt, R.E. (2011). Distribution of Pelvic and Abdominal Adenomyomas. In: A History of Endometriosis. Springer, London. https://doi.org/10.1007/978-0-85729-585-9_7

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