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Diagnosis of
Endometrial Biopsies
and Curettings
A Practical Approach
Tricia A. Murdock
Emanuela F. T. Veras
Robert J. Kurman
Michael T. Mazur
Third Edition
123
Diagnosis of Endometrial Biopsies
and Curettings
Tricia A. Murdock • Emanuela F. T. Veras
Robert J. Kurman • Michael T. Mazur
Diagnosis of
Endometrial Biopsies
and Curettings
A Practical Approach
Third Edition
Tricia A. Murdock Emanuela F. T. Veras
Department of Pathology Department of Pathology
The Johns Hopkins Hospital The Johns Hopkins Hospital
Baltimore, MD Baltimore, MD
USA USA
Robert J. Kurman Michael T. Mazur

Department of Pathology Department of Pathology and
The Johns Hopkins Hospital Laboratory Medicine, State University
Baltimore, MD of New York Upstate Medical University
USA Syracuse, NY
USA
ISBN 978-3-319-98607-4 ISBN 978-3-319-98608-1 (eBook)

https://doi.org/10.1007/978-3-319-98608-1
Library of Congress Control Number: 2018960871
© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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Preface
The third edition of Diagnosis of Endometrial Biopsies and Curettings: A

Practical Approach developed from positive comments received from the
second edition and recognition that several topics have advanced since the
last publication. The emphasis of this book is to provide a foundation for a
daily, pragmatic approach for common entities found in endometrial samples.
Our understanding of endometrial pathology has evolved, and clinical termi-
nology accompanying these specimens also has changed. Therefore, the
entire text has been updated; all illustrations are now in color.
As with the first two editions, the focus of this book is to assist the patholo-
gist in the routine evaluation of endometrial tissue specimens. The book is not
intended to be an all-encompassing text of endometrial pathology but to
guide the pathologist through the more common diagnoses such as artifacts,
benign entities, precursor lesions, and neoplasia. We recognize that for cer-
tain areas, such as precursors of endometrial cancer, there is ongoing debate
and study regarding the terminology for these lesions. Different investigators
and practitioners prefer different terminologies (hyperplasia/atypical hyper-
plasia versus hyperplasia/endometrial intraepithelial neoplasia [EIN]), and
we therefore attempt to provide a balanced discussion of both so readers can
decide which they prefer. For the majority of the text, the terminology and
classification schemes mirror the most recent edition (2014) of the WHO
Classification of Tumors of Female Reproductive Organs in an effort to pro-
mote uniform and comprehensive communication with our clinical col-
leagues as ultimately this is the most important role of the diagnostic surgical
pathologist.
In the second edition, immunohistochemistry (IHC) was largely discussed
in the final chapter on methodology, but as its use in diagnosis has greatly
expanded, the current edition incorporates IHC into each of the individual
chapters. Furthermore, IHC now has an important role as a surrogate marker
of genetic aberrations, knowledge of which is becoming increasingly impor-
tant for diagnostic and therapeutic purposes. For example, the use of fumarate
hydratase staining to detect fumarate hydratase-deficient leiomyomas can
lead to the recognition of the hereditary leiomyomatosis and renal cell carci-
noma syndrome.
Although molecular diagnostics currently are infrequently used in routine
evaluation of endometrial specimens, pathologists need to be familiar with
the advances in molecular genetics as this is transforming our understanding
of many of the pathologic conditions that can be found in endometrial
v
vi Preface
s amples. For example, the classification of endometrial stromal tumors has

been modified based on fluorescence in situ hybridization and targeted RNA
sequencing that have demonstrated different types of high-grade endometrial
stromal sarcomas depending on their molecular genetic features. Another
example is that through molecular genotyping, we are now able to defini-
tively diagnose partial hydatidiform moles, whereas in the past morphologi-
cal, immunohistochemical, and cytogenetic studies were insufficiently
reliable to make a definitive diagnosis.
In summary, we hope that this new edition continues to be a foundation for
the diagnosis of endometrial specimens with a strong emphasis on the impor-
tant morphologic features and that this will be useful to pathologists and
gynecologists.
Baltimore, MD, USA Tricia A. Murdock

Baltimore, MD, USA Emanuela F. T. Veras
Baltimore, MD, USA Robert J. Kurman
Syracuse, NY, USA Michael T. Mazur
Acknowledgments
We are grateful to Norman Barker, a friend and colleague, who provided his
expertise in the field of medical illustration and tirelessly assisted us with the
images depicted in this edition. We are also grateful to Dr. Lora Ellenson,
another good friend and esteemed colleague, for generously supplying
updated information that helped enrich the contents of this book.
vii
Contents
1 Introduction�� 1
Indications for Biopsy�� 1
Clinical History and Biopsy Interpretation�� 2
Abnormal Uterine Bleeding�� 2
Infertility Biopsy�� 4
Products of Conception�� 4
Hormone Therapy�� 4
Other Considerations �� 5
Clinical Queries and Reporting�� 5
References�� 6
2 The Normal Endometrium�� 9
General Considerations in Histologic Evaluation�� 10
Histologic Features of Normal Cycling Endometrium�� 13
Proliferative Phase �� 13
Secretory Phase�� 16
Menstrual Endometrium�� 20
Pitfalls in The Histologic Assessment
of The Normal Endometrium�� 21
Sample Adequacy and Standardized Reporting �� 24
Artifacts and Contaminants�� 27
Irregular Secretory Endometrium�� 31
References�� 35
3 Pregnancy, Abortion, and Ectopic Pregnancy�� 39
Endometrial Glands and Stroma in Pregnancy�� 40
Early Gestational Endometrium (1–3 Weeks
Postfertilization)�� 40
Endometrium in Later Pregnancy (4 or More Weeks
Postfertilization)�� 41
Arias-Stella Reaction �� 45
Other Glandular Changes in Pregnancy�� 47
Trophoblast and Villi�� 49
Trophoblastic Cells�� 49
Immunohistochemistry of Trophoblastic Cells�� 51
Placental Implantation Site�� 53
Chorionic Villi and Villous Trophoblast in the First Trimester�� 57
ix
x Contents
Hydropic Change and Other Pathologic Changes

in Abortions�� 59
Chorionic Villi and Villous Trophoblast After
the First Trimester�� 62
Placental Polyps �� 63
Placenta Accreta�� 63
Endometrium Associated with Ectopic Pregnancy�� 64
References�� 71
4 Gestational Trophoblastic Disease�� 75
Hydatidiform Mole�� 76
General Features�� 76
Complete Hydatidiform Mole�� 76
Partial Hydatidiform Mole�� 81
Cytogenetics�� 83
Differential Diagnosis�� 85
Abnormal (Non-molar) Villous Lesions�� 90
Other Considerations �� 91
Persistent Postmolar Gestational Trophoblastic Disease
and Invasive Hydatidiform Mole �� 91
Clinical Queries and Reporting of Hydatidiform Mole �� 93
Gestational Trophoblastic Neoplasms�� 94
Choriocarcinoma�� 94
Placental Site Trophoblastic Tumor �� 100
Epithelioid Trophoblastic Tumor �� 107
Nonneoplastic Lesions �� 110
Exaggerated Placental Site�� 110
Placental Site Nodule and Plaque�� 111
Clinical Queries and Reporting of Trophoblastic Neoplasms�� 112
References�� 113
5 Abnormal Uterine Bleeding�� 121
Morphologic Features of Glandular and Stromal Breakdown
in Menstrual and Abnormal Bleeding�� 122
Abnormal Uterine Bleeding: Nonstructural Causes�� 126
Estrogen-Related Bleeding�� 129
Proliferative Endometrium with Glandular
and Stromal Breakdown�� 129
Disordered Proliferative Endometrium
and Persistent Proliferative Phase�� 132
Atrophy�� 133
Progesterone-Related Bleeding�� 135
Irregular Secretory Endometrium�� 136
Irregular Shedding �� 137
Abnormal Secretory Endometrium with Breakdown
of Unknown Etiology�� 138
Contents xi
6 Effects of Hormones�� 145

Estrogenic Hormones�� 146
Progestins, Oral Contraceptives, and Selective
Progesterone Receptor Modulators�� 146
Patterns of Response�� 148
Decidual Pattern�� 148
Secretory Pattern�� 149
Inactive Pattern�� 150
Other Stromal Changes�� 151
Combined Estrogen and Progestin as Replacement Therapy
for Menopausal Women �� 153
Progestin-Like Effects with No Hormone Use�� 154
Effects of Other Hormones�� 155
Selective Progesterone Receptor Modulators�� 155
Tamoxifen�� 156
Raloxifene�� 160
Clomiphene Citrate�� 160
Danazol�� 161
Human Menopausal Gonadotropins/Human
Chorionic Gonadotropin�� 162
Gonadotropin-Releasing Hormone Agonists �� 162
Antiprogestin RU486 �� 162
Postmenopausal Hormone Replacement�� 163
Abnormal Uterine Bleeding�� 163
Treatment of Hyperplasia and Endometrioid Carcinoma�� 164
Infertility Therapy�� 165
7 Endometritis �� 173
Nonspecific Endometritis�� 174
Inflammatory Cells�� 174
Stromal Changes�� 177
Abnormal Glandular Development�� 178
Epithelial Changes �� 178
Glandular and Stromal Breakdown�� 179
Specific Infections�� 179
Granulomatous Inflammation�� 180
Actinomycosis�� 182
Cytomegalovirus�� 183
Herpesvirus�� 184
Mycoplasma�� 185
8 Polyps�� 199
Classification and Histologic Features�� 200
Common Polyps�� 205
xii Contents
Proliferative/Hyperplastic Pattern�� 205

Atrophic Pattern �� 206
Functional Pattern�� 206
Mixed Endometrial–Endocervical Pattern �� 206
Adenomyomatous Pattern�� 207
Atypical Polypoid Adenomyoma (APA)�� 207
Adhesions�� 215
9 Precursors of Endometrial Carcinoma�� 225
Endometrial Hyperplasia/Atypical Hyperplasia�� 225
Behavior �� 240
Epithelial Cytoplasmic Change (Metaplasia)�� 241
Serous Endometrial Intraepithelial Carcinoma�� 251
Behavior �� 254
10 Endometrial Carcinoma�� 261
Classification of Endometrial Carcinoma�� 262
Important Issues in Interpretation of Biopsies �� 264
Criteria for the Diagnosis of Well-Differentiated
Endometrioid Carcinoma �� 264
Confluent Gland Pattern�� 264
Altered Fibrous or Desmoplastic Stroma�� 265
Extensive Papillary Pattern�� 265
Malignant Neoplasms: Classification, Grading, and Staging
of the Tumor�� 267
Classification�� 267
Grading�� 269
Clinically Important Histologic Subtypes�� 274
Typical (Endometrioid) Carcinoma �� 274
Carcinoma with Squamous Differentiation�� 278
Mucinous Carcinoma �� 281
Microglandular (Endocervical-Like)
Endometrial Carcinoma �� 283
Hereditary Syndromes �� 285
Hereditary Nonpolyposis Colorectal Cancer
(Lynch Syndrome) �� 285
Cowden Syndrome�� 288
Histologic Effects After Progestin Therapy �� 289
Serous Carcinoma�� 290
Clear Cell Carcinoma�� 295
Rare Histologic Subtypes�� 297
Contents xiii
Carcinosarcoma�� 301
Differential Diagnosis of Carcinosarcoma�� 305
Staging �� 309
Endometrial Versus Endocervical Carcinoma�� 310
Metastatic Carcinoma�� 317
Carcinoma Mimics�� 318
11 Mesenchymal Tumors and Other Rare Neoplasms�� 333
Smooth Muscle Tumors �� 333
Leiomyomas�� 333
Variants of Leiomyoma�� 334
Smooth Muscle Tumor of Uncertain Malignant Potential�� 335
Leiomyosarcoma�� 336
Tumorlets �� 337
Miscellaneous Mesenchymal Tumors�� 339
Perivascular Epithelioid Cell Tumor�� 339
Stromal Tumors�� 340
Endometrial Stromal Nodule and Low-Grade Endometrial
Stromal Sarcoma�� 341
High-Grade Endometrial Stromal Sarcoma �� 344
Undifferentiated Uterine Sarcoma �� 345
Uterine Tumors Resembling Ovarian Sex Cord Tumors �� 347
Mixed Epithelial and Mesenchymal Tumors �� 347
Adenofibroma and Adenosarcoma�� 347
Pathologic Features�� 347
Immunohistochemical Analysis �� 349
Molecular Analysis�� 350
Rare Neoplasms �� 351
Inflammatory Myofibroblastic Tumor�� 351
Lymphoma and Leukemia�� 351
Miscellaneous Tumors �� 352
Other Lesions and Tumor-Like Conditions �� 353
12 Methods of Endometrial Evaluation�� 363
Endometrial Sampling Techniques�� 363
Endometrial Biopsy �� 363
Dilation and Curettage �� 364
Hysteroscopy and Curettage�� 364
Other Aspiration Devices �� 365
Endometrial Imaging Studies�� 365
xiv Contents
Ultrasound�� 365
Magnetic Resonance Imaging�� 366
Histologic Techniques�� 366
Frozen Section �� 367
Index�� 373
Introduction
1
Contents
Indications for Biopsy 1
Clinical History and Biopsy Interpretation 2
Clinical Queries and Reporting 5
References 6
Endometrial biopsies and curettings are among the tion of any pathologic specimen, proper
most common tissue specimens received in the interpretation requires appropriate fixation, pro-
pathology laboratory. In several respects, these cessing, and sectioning of the tissue.
specimens present a unique challenge for the sur-
gical pathologist. The normal endometrium under-
goes a variety of morphologic changes, especially Indications for Biopsy
during the reproductive years, when cyclical hor-
monal influences and pregnancy affect uterine There are four main indications for endometrial
growth. Biopsy-induced artifacts confound this biopsy or curettage [5–9]:
heterogeneous group of morphologic changes.
Endometrial sampling techniques can vary from 1. Determination of the cause of abnormal uter-
hysteroscopy with curettage, which is considered ine bleeding
the “gold standard” [1–4], to a “blind” biopsy with 2. Evaluation of the status of the endometrium in
no visualization of the tissue sampled. The final infertile patients
specimen contains multiple, irregularly oriented 3. Evacuation of products of conception, either
tissue fragments mixed with blood and contami- spontaneous abortions, termination of preg-
nating cervical tissue and mucus. nancy, or retained tissue
Interpreting the biopsy material demands a 4. Assessment of the response of the endome-
logical approach that takes into account many trium to hormonal therapy, especially estrogen
factors, including patient history, the specific replacement in perimenopausal and postmeno-
requests of the clinician performing the biopsy, pausal women, progestin therapy in reproduc-
and an appreciation of the limitations, potential tive age women for treatment of endometrial
pitfalls, and complex array of patterns encoun- hyperplasia or endometrioid carcinoma, and
tered in the microscopic sections. As in evalua- tamoxifen therapy for breast cancer
© Springer Nature Switzerland AG 2019 1

T. A. Murdock et al., Diagnosis of Endometrial Biopsies and Curettings,
https://doi.org/10.1007/978-3-319-98608-1_1
2 1 Introduction
Other indications for biopsy may arise. An linical History and Biopsy
C
occasional patient will have atypical or abnor- Interpretation
mal glandular cells of undetermined signifi-
cance (AGUS) in a cervical–vaginal cytologic Abnormal Uterine Bleeding
specimen that requires endometrial sampling to
exclude hyperplasia or carcinoma. Uterine The most common reason for performing an
screening with transvaginal ultrasound can endometrial biopsy is abnormal uterine bleeding
show a thickened endometrial stripe in post- (AUB). Because of the inconsistent nomenclature
menopausal patients, and a biopsy can be per- used to describe variations of abnormal bleed-
formed to exclude significant pathology ing, the International Federation of Gynecology
[10–12]. Some clinicians sample the endome- and Obstetrics (FIGO) developed a classification
trium prior to hysterectomy to exclude signifi- system. Categorization is based on the acronym
cant pathology, although this procedure reveals PALM-COEIN (polyps, adenomyosis, leiomy-
little pathology in the absence of a history of oma, malignancy and hyperplasia – coagulopathy,
abnormal bleeding [13, 14]. Likewise, endome- ovulatory dysfunction, endometrial, iatrogenic,
trial biopsy for screening of endometrial cancer and not yet specified) and is used for AUB in non-
or precursor lesions in asymptomatic perimeno- gravid women of reproductive age. The first four
pausal and postmenopausal patients has a very terms are structural lesions, i.e., specific lesions.
low yield of significant abnormalities and is not The latter five (COEIN) are used to describe causes
cost-effective [15–17]. that are not defined by imaging or histopathology
At times, these indications for endometrial and were previously under the term dysfunctional
sampling overlap. For example, some compli- uterine bleeding (DUB) [18]. Abnormal uterine
cations of pregnancy, such as a missed abor- bleeding can be a sign of one or multiple uterine
tion or trophoblastic disease, are accompanied disorders ranging from nonstructural abnormalities
by abnormal uterine bleeding. Nonetheless, to structural lesions such as polyps, hyperplasia, or
these broad categories provide a clinicopatho- carcinoma [8, 11, 18–22]. For the FIGO classifica-
logic framework for approaching the micro- tion system, if the AUB is attributed to polyps, the
scopic analysis of endometrial biopsy patient chart would then read “AUB-P”; if a patient
specimens. The text has therefore been divided had multiple causes, such as a submucosal leiomy-
into chapters that correspond to these clinical oma and a coagulopathy, AUB-L(SM), C would be
indications. an acceptable term (Table 1.1).
Table 1.1 Clinical terms for abnormal uterine bleeding (AUB)

Abnormal uterine bleeding Abnormal uterine bleeding caused by structural lesions
(AUB) (PALM) Polyps (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Malignancy and hyperplasia (AUB-M)
Abnormal uterine bleeding Abnormal uterine bleeding with no structural cause
(AUB) (COEIN) Coagulopathies (AUB-C)
Abnormalities in ovulation (AUB-O)
Primary disorders of the endometrium (AUB-E)
Iatrogenic (AUB-I)
Other causes not yet specified (AUB-N)
Acute AUB Nongravid, reproductive-aged women with bleeding of sufficient quantity to
require immediate intervention to prevent further blood loss [18, 23]
Chronic AUB Bleeding that is abnormal in duration, volume, and/or frequency and has been
present for the majority of the last 6 months [18, 23]
Clinical History and Biopsy Interpretation 3
Age and menstrual/menopausal status are Table 1.3 Causes of abnormal uterine bleeding in peri-
menopausal years
especially important data to include in the pathol-
ogy requisition, as causes of abnormal uterine Common Uncommon
bleeding vary significantly according to parame- Ovulatory dysfunction Coagulopathies
Structural lesions Endometritis
ters, as discussed later. The prevalence of the
Hyperplasia Sarcoma
various abnormalities that lead to abnormal
Polyps (endometrial, Complications of
bleeding is difficult to determine precisely, vary- endocervical) pregnancya
ing with the patient population and the previous Iatrogenic
terms used by investigators [5–7]. The nomencla- Birth control
ture to describe menstrual bleeding related to Estrogen replacement
regularity or frequency of onset, duration, and Progestin therapy
heaviness (volume) of menstrual flow has been See Chap. 3 (Complications of pregnancy)
a
reclassified as well, and terms such as menorrha-

gia and menometrorrhagia have been largely patients [25, 32–34]. One consistent observation
abandoned. A practical approach to the possible in studies of postmenopausal patients is that atro-
diagnoses associated with abnormal bleeding phy is a common cause of abnormal bleeding,
takes age into account (Tables 1.2 and 1.3). In being found in 25% or more of cases [25, 26, 28,
adolescence, AUB may be secondary to ovula- 31, 33, 35, 36].
tory dysfunction, pregnancy, exogenous hormone There are a few exceptions where younger, pre-
administration, or coagulopathies. Pregnancy- menopausal women are at higher risk for endome-
related and nonstructural entities are more com- trial hyperplasia and carcinoma. Premenopausal
mon in younger patients, whereas atrophy and women (<45 years of age) with AUB and a body
structural lesions become more frequent in older mass index >30 kg/m2 are four times more likely
individuals [24]. Polyps in perimenopausal and to develop endometrial hyperplasia or carcinoma
postmenopausal patients have been found in than premenopausal women with a normal body
2–26% of patients [25–33] with a mean age of mass index [37]. Hereditary cancer syndromes
45.8 [34]. Hyperplasia is found in up to 16% of including Lynch, Cowden, Peutz-Jeghers, and
postmenopausal patients undergoing biopsy and Li-Fraumeni all have an elevated risk for endome-
endometrial carcinoma in fewer than 10% of trial cancer [38–41]. For Lynch syndrome, one
surveillance strategy is for annual transvaginal
ultrasound and/or endometrial sampling, followed
Table 1.2 Causes of abnormal uterine bleeding in the by risk-reducing hysterectomy upon completion
reproductive years
of childbearing [42]. In women aged 30–35 years
Common Uncommon
with Cowden syndrome, consideration for annual
Endometritis Neoplasia
transvaginal ultrasound and endometrial sampling
Complications of Endometrial
pregnancya carcinoma with a discussion of hysterectomy following
Ovulatory dysfunction Cervical carcinoma childbearing is a potential surveillance and risk
Anovulatory cycles Hyperplasia reduction strategy, respectively [42]. In addition
Inadequate luteal phase Coagulopathies to endometrial cancer, women with Peutz-Jeghers
Irregular shedding syndrome have a risk of developing sex cord

Structural lesions tumor with annular tubules (SCTAT) of the ovary
Leiomyomas and minimal deviation adenocarcinoma of the
Polyps (endometrial,
cervix [41]. Because of the additional ovarian and
endocervical)
Adenomyosis cervical cancer risk, an annual pelvic exam with
Iatrogenic Pap smear starting at age 18–20 years and consid-
Birth control eration of an annual transvaginal ultrasound is a
Progestin therapy reasonable surveillance approach. There are no
a
See Chap. 3 (Complications of pregnancy) clear surveillance recommendations for
4 1 Introduction
Table 1.4 Causes of abnormal uterine bleeding in post- Infertility Biopsy

menopausal years
Common Uncommon When a patient undergoes biopsy for evaluation of
Atrophy Endometritis infertility, the clinical information often is limited,
Structural lesions Sarcoma
but here, too, the history should include the date of
Hyperplasia Coagulopathies
the last menstrual period (LMP) to place an approx-
Polyps (endometrial)
Neoplasia imate time in the menstrual cycle. This information
Endometrial carcinoma is useful but not precise for determining the actual
Exogenous hormones day of the cycle, as ovulatory frequency and length
Estrogen replacement of the follicular phase are highly variable among
Progestin therapy patients. Usually the main objective of biopsies for
infertility is to determine whether there is morpho-
logic evidence of ovulation, i.e., secretory change
Li-Fraumeni syndrome and no clear risk reduc- (see Chap. 2). The gynecologist may seek other
tion strategies for Peutz-Jeghers or Li-Fraumeni specific information, such as response to hormone
syndromes [42]. therapy, so it is important that the pathologist be
Even among perimenopausal and postmeno- given any additional history that may be necessary
pausal patients, the proportion of cases attributable for the interpretation.
to any of the aforementioned conditions is age
dependent (Table 1.4). Atrophy and carcinoma
occur more frequently in patients older than Products of Conception
60 years of age, while polyps and hyperplasia are
more common in patients who are perimenopausal When endometrial sampling is performed to remove
or more recently postmenopausal. In addition to products of conception, clinical information often is
these uterine causes of bleeding, other abnormali- sparse, as the main goal of the p rocedure is simply
ties, such as genitourinary syndrome of menopause, to remove the placental and fetal tissue. Significant
can cause vaginal bleeding, and this may be difficult pathologic changes are rare. Nonetheless, it is help-
to distinguish from uterine bleeding until the patient ful to know if pregnancy is suspected, and, if so, the
undergoes thorough clinical evaluation. approximate gestational age of the pregnancy. If
A history of anovulation, obesity, hyperten- there is a suspicion of trophoblastic disease, this
sion, diabetes, and exogenous estrogen use should be stated. In such instances, the serum
should alert the pathologist that the patient is at human chorionic gonadotropin (hCG) titer is very
increased risk for hyperplasia and endometrioid important. If an ectopic pregnancy is suspected,
carcinoma, but this information is rarely included alerting the pathologist can ensure rapid processing
on the requisition. Typically, there is little and interpretation of the specimen.
accompanying clinical data except the patient’s
age and a short history of abnormal bleeding.
Consequently, hyperplasia and adenocarcinoma Hormone Therapy
must be diagnostic considerations for most
endometrial specimens received in the labora- Because the endometrium is responsive to hor-
tory. On rare occasions, hyperplasia or even ade- mones, the history of hormone use is important
nocarcinoma is found in biopsies performed information. Clinical uses of steroid hormones
during an infertility workup [28]. It should be (estrogens, progestins, or both) include oral, subcu-
kept in mind that women with unexplained infer- taneous or vaginal contraception methods, proges-
tility or diagnosed with polycystic ovarian syn- tin-releasing intrauterine devices, postmenopausal
drome (PCOS) at a young age are at risk of replacement therapy, and therapy for endometrio-
endometrial cancer [43, 44]. sis, infertility, hyperplasia, and endometrial endo-
metrioid or breast carcinoma. As with other facets
of the clinical data, this information may be absent Clinical Queries and Reporting
or, if present, unreadable on the requisition (in
which case the gynecologist should be contacted). Diagnostic terms such as “no pathologic diagno-
Consequently, the pathologist must be prepared to sis” or “no significant pathologic findings” are
recognize hormonal effects in the absence of his- unacceptable as there is a wide range of normal
tory indicating the use of hormones (see Chap. 6 – histology. When the tissue lacks abnormalities,
Effects of Hormones). stating the normal phase of the endometrium, for
example, menstrual, proliferative, or secretory,
provides useful information for the clinician.
Other Considerations In biopsies for abnormal uterine bleeding, the
pathologic information sought varies with the
Pregnancy history is useful, especially in pre- patient’s age and clinical history. The gynecolo-
menopausal patients, regardless of the indication gist wishes to know the following:
for biopsy, as recent and remote effects of preg-
nancy, such as a placental site nodule or gesta- 1. Is there an organic or structural lesion, such as
tional trophoblastic disease, may be encountered a complication of pregnancy, inflammation, or
in biopsy material. The history of recent or past a polyp?
pregnancies is expressed as gravidity and parity. 2. Is there evidence of active or old breakdown
The letter G (gravidity) followed by a number and bleeding?
(G1, G2, etc.) indicates the number of pregnan- 3. Is there evidence to suggest abnormalities in
cies, and the letter P (parity) followed by a num- ovulation?
ber indicates the number of deliveries. For 4. Is there evidence of hyperplasia or carcinoma?
example, G4, P2 indicates that a woman has had
four pregnancies and two deliveries. Further For example, in young premenopausal patients
information on parity often is designated by four with a normal BMI, the possibility of pregnancy
numbers indicating full-term pregnancies, prema- and related bleeding is a frequent question. In a
ture pregnancies (>20 but <37 weeks’ gestation), perimenopausal patient, the concern shifts to
abortions (<20 weeks’ gestation), and living chil- hyperplasia and carcinoma, and in postmeno-
dren. Thus a patient who is G5, P3013 is currently pausal patients, the importance of ruling out car-
pregnant and has had three previous full-term cinoma becomes paramount. In any of these
pregnancies and one abortion, and the three chil- conditions, glandular and stromal breakdown
dren from the term pregnancies are alive. may be present either focally or diffusely. It is the
The type of procedure, that is, biopsy versus underlying disorder that is most important to
curettage, is important for deciding whether focal report. The changes of breakdown and bleeding
changes represent significant abnormalities or are secondary and do not indicate a primary dis-
whether small specimens are adequate (see Chap. order by themselves. Nonetheless, when there is
12 Methods of Endometrial Evaluation). Although a history of abnormal bleeding, it can be helpful
office-based biopsies generally provide a repre- to note whether there is histologic evidence of
sentative sample, they may not contain sufficient glandular and stromal breakdown (see Chap. 5),
tissue to ensure that the endometrium has been especially if the tissue lacks evidence of an
adequately sampled. For example, the irregular organic process such as hyperplasia or carci-
glands of hyperplasia may resemble patterns seen noma. This information serves to document to
in some polyps, low-grade adenocarcinomas, and the gynecologist that bleeding is, in fact, endo-
even artifactually distorted normal endometrium. metrial in origin. Even when there is no evidence
Furthermore, atypia can be focal in hyperplasia; of active bleeding, foci of stromal foam cells or
therefore, biopsy specimens may preclude a defin- hemosiderin, sometimes with fibrosis, indicate
itive diagnosis. In these cases, a more thorough that abnormal bleeding has taken place and
biopsy or curettage is necessary. deserve comment.
6 1 Introduction
Besides reporting the morphologic changes tematic review and meta-analysis. Obstet Gynecol.
2017;130:803–13.
present, noting significant negative findings can 3. Gkrozou F, Dimakopoulos G, Vrekoussis T,
be helpful to the clinician. As an example, the Lavasidis L, Koutlas A, Navrozoglou I, Stefos T,
diagnosis of chronic endometritis is more helpful Paschopoulos M. Hysteroscopy in women with
if it includes a comment regarding the presence abnormal uterine bleeding: a meta-analysis on four
major endometrial pathologies. Arch Gynecol Obstet.
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evidence of a recent pregnancy. Likewise, if an 4. Svirsky R, Smorgick N, Rozowski U, Sagiv R,
structural lesion such as a polyp is present, it is Feingold M, Halperin R, Pansky M. Can we rely
helpful to indicate whether noninvolved tissue is on blind endometrial biopsy for detection of focal
intrauterine pathology? Am J Obstet Gynecol.
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cologist indicates a specific concern regarding findings in 3,600 biopsies from selected patients. Am
the presence of hyperplasia, atypia, or carcinoma, J Clin Pathol. 1975;63:9–15.
6. Nickelsen C. Diagnostic and curative value of
then a statement noting the absence of these uterine curettage. Acta Obstet Gynecol Scand.
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eration, but this needs to be specifically addressed biopsy interpretation. Shortcomings and problems
in current gynecologic practice. Obstet Gynecol.
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not clear-cut. Scant tissue obtained by an office- 8. Galle PC, McRae MA. Abnormal uterine bleed-
based biopsy may be insufficient to allow thor- ing. Finding and treating the cause. Postgrad Med.
ough assessment of the status of the endometrium. 1993;93:73–6. 80–81
9. Merrill JA. The interpretation of endometrial biop-
In these cases, the pathologist should indicate in sies. Clin Obstet Gynecol. 1991;34:211–21.
the report that the specimen is scant. For instance, 10. Goldstein RB, Bree RL, Benson CB, Benacerraf BR,
small samples may reveal hyperplastic glands, Bloss JD, Carlos R, Fleischer AC, Goldstein SR, Hunt
but it may be difficult to determine whether the RB, Kurman RJ, Kurtz AB, Laing FC, Parsons AK,
Smith-Bindman R, Walker J. Evaluation of the woman
abnormality represents a localized polyp with a with postmenopausal bleeding: society of Radiologists
proliferative/hyperplastic pattern (see Chap. 8) or in ultrasound-sponsored consensus conference state-
a diffuse hyperplasia. Some assessment of the ment. J Ultrasound Med. 2001;20:1025–36.
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J, Rush D. Endometrial thickness as measured
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endometrium is proliferative or secretory phase. ing histopathologic diagnosis in women with
Atrophic endometrium typically yields a very postmenopausal bleeding. Int J Gynecol Pathol.
small amount of tissue, yet these specimens 2017;36:348–55.
12. Fleischer A, Abramowicz J, Goncalves L, Manning F,
should not be regarded as inadequate (see Chap. Monteagudo A, Timor I, Toy E, editors. Sonographic
5). The subsequent chapters consider in greater techniques for early detection of ovarian and endo-
detail the queries likely to arise in various cir- metrial cancers. Fleischer’s sonography in obstetrics
cumstances and the information that the patholo- and gynecology. 8th ed. New York: McGraw Hill
Education; 2018.
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sampling prior to hysterectomy. Obstet Gynecol.
1989;73:405–9.
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The Normal Endometrium
2
Contents
General Considerations in Histologic Evaluation 10
Histologic Features of Normal Cycling Endometrium 13
Pitfalls in The Histologic Assessment of The Normal Endometrium 21
Sample Adequacy and Standardized Reporting 24
Artifacts and Contaminants 27
Irregular Secretory Endometrium 31
References 35
The histologic features of what constitutes “nor- under sampling. These examples emphasize the
mal” endometrium change with a woman’s age, importance of clinical information including
through the premenarchal, reproductive, peri- patient’s age and hormonal status. In biopsy
menopausal, and postmenopausal years [1–3]. specimens, the combination of these cyclical
Throughout the reproductive years, the cyclical changes along with potential processing arti-
hormonal changes of the menstrual cycle pro- facts, limited sampling, or the presence of mim-
vide a continuously changing morphologic spec- ics can make normal patterns difficult to
trum from proliferative to secretory to menstrual interpret. Deviations from normal, either in his-
phenotypes which is considered “normal.” Once tologic pattern or in temporal relationship to
menopause is reached, the presence of only rare ovulation, often indicate underlying abnormali-
strips of atrophic epithelium in biopsy/curettage ties that may contribute to female infertility and
sampling becomes the new “normal.” The same abnormal uterine bleeding.
“normal” in a postmenopausal woman would be Over the past 6 decades, pathologists have used
deemed “abnormal” in a premenopausal woman the histologic criteria originally described by Noyes
or, alternatively, would raise the possibility of et al. [1, 4] to date secretory phase endometrial biop-
exogenous hormonal effect. Likewise, finding sies (Table 2.1), as part of an infertility workup. The
only cervical or lower uterine segment tissue in a original study by Noyes et al. described discrete
woman known to have an ultrasonographic changes that varied daily following ovulation, cul-
lesion such as thickened endometrium supports minating with menstruation. Over the last decades,
© Springer Nature Switzerland AG 2019 9

T. A. Murdock et al., Diagnosis of Endometrial Biopsies and Curettings,
https://doi.org/10.1007/978-3-319-98608-1_2
10 2 The Normal Endometrium
multiple studies critically evaluating the Noyes dat- use of terms such as “early,” “mid,” and “late” secre-
ing criteria have shown that they are not reproduc- tory endometrium suffices [13]. Nonetheless, an
ible and that the criteria themselves are seriously appreciation of the various morphologic changes
flawed [5–12]. More importantly, gynecologists that occur in the secretory phase of the cycle is
appear to be less inclined to utilize this information important for pathologists so that normal phases of
in the evaluation of infertility. For these reasons, the secretory endometrium are not misinterpreted as
traditional dating schema is not discussed in detail in abnormal (Table 2.1).
this chapter but is briefly outlined in Table 2.1. Of
interest, the Gynecologic Pathology Interest Group
of the Canadian Association of Pathologists (GPIG- General Considerations
CAP) published a guideline for pathologists stan- in Histologic Evaluation
dardizing terminology to assist in communicating
with our clinical colleagues. One recommendation Histologic evaluation begins with identification
was that formal “dating” of secretory endometrium of surface epithelium, a prerequisite for orient-
is optional but that it should be provided if specifi- ing the underlying glands and stroma. The sur-
cally requested by the clinician. Consequently, the face epithelium is less responsive to sex steroid
Table 2.1 Secretory phase endometrial changes

Interval phase, 14–15d.a No datable histologic changes for 36–48 h after ovulation
Early secretory phase, 16–20d. Glandular changes predominate
Early Histologic features
16 Subnuclear, irregular vacuoles
17 Regular vacuolation—nuclei lined up with subnuclear vacuoles
18 Vacuoles decreased in size
18 Early secretions in lumen
18 Nucleus approaches base of cell with supranuclear vacuoles
19 Few vacuoles remain
19 Intraluminal secretion
19 No pseudostratification, no mitoses
20 Peak of intraluminal secretions
Mid- to late secretory phase, 21–27d. Stromal changes predominate, variable secretory exhaustion
Mid
21 Marked stromal edema
22 Peak of stromal edema—cells have “naked nuclei”
23 Periarteriolar predecidual change
23 Prominent spiral arteries
24 More prominent predecidual change
24 Stromal mitoses recur
25 Predecidual differentiation begins under surface epithelium
Late
25 Increased numbers of granular lymphocytes
26 Predecidua starts to become confluent
27 More numerous granular lymphocytes
27 Confluent sheets of predecidua
27 Focal necrosis
24–27 Secretory exhaustion of glands—tortuous with intraluminal tufts (saw-toothed), ragged luminal borders,
variable cytoplasmic vacuolization, and luminal secretions
d. = day of ideal 28-day menstrual cycle
a
General Considerations in Histologic Evaluation 11
hormones than the underlying glands, but it epithelial cells are important features in the histo-
often shows alteration in pathologic conditions, logic evaluation. Under normal conditions, the
especially when the abnormalities are subtle or glands should be regularly spaced and have a per-
focal. For example, during the proliferative pendicular arrangement from the basalis to the
phase, estrogenic stimulation results in ciliated surface epithelium. In the secretory phase, the
cells along the surface [10, 14]. Ciliated surface endometrium also shows a stratum compactum, a
epithelial cells are, however, far more frequent thin region beneath the surface epithelium. In the
in pathologic conditions, particularly those stratum compactum, the stroma is dense, and the
associated with unopposed estrogen stimula- glands are straight and narrow, even when the
tion, such as hyperplasia and metaplasia (see glands in the functionalis are tortuous. The basa-
Chap. 9) [2, 3, 15–17]. lis adjoins the myometrium, serving to regenerate
The subsurface endometrium is divided into the functionalis and surface epithelium following
two regions, the functionalis (stratum spongio- shedding during menses. The endometrium of the
sum) and the basalis (stratum basalis) (Fig. 2.1). basalis is less responsive to steroid hormones and
The functionalis is situated between the surface typically shows irregularly shaped, inactive-
epithelium and is important to evaluate because it appearing glands, dense stroma, and aggregates
shows the greatest degree of hormonal respon- of spiral arteries. The spiral arteries of the basalis
siveness. The size and distribution of glands as (basal arteries) have thicker muscular walls than
well as the cytologic features of the glandular those in the functionalis. In biopsies, tissue
Fig. 2.1 Normal secretory phase endometrium. Surface epi- blood vessels demonstrate the typical patterns of maturation
thelium orients the tissue (far right). The midportion of the through the menstrual cycle. The stratum compactum is com-
tissue consists of functionalis where glands, stroma, and posed of the surface-type epithelium and a subjacent thin
layer of dense stroma
fragments that contain basalis often do not have mal cells with minimal cytoplasm seen in the
surface epithelium. The glands and stroma of the corpus.
basalis are unresponsive to steroid hormones. Tangential orientation of the functionalis in
Lower uterine segment/isthmus is another biopsies and the tortuosity of the glands, partic-
region of the endometrium that is less responsive ularly in the late proliferative and secretory
to steroid hormones. In the lower uterine seg- phases, often lead to irregular cross sections of
ment, the endometrium has shorter, poorly devel- the tissue. In this instance, gland development
oped, inactive glands dispersed in a distinctive can be difficult to assess. Furthermore, not all
stroma (Figs. 2.2 and 2.3). The columnar cells fragments of tissue in a biopsy or curettage
lining the glands resemble those of the corpus. include surface epithelium, which helps to
Some glands near the junction with the endocer- orient the glands. Nonetheless, at least focally,
vix show a transition to mucinous endocervical- portions of better-oriented glands usually can be
type epithelium. The stromal cells in the lower traced through the functionalis to the surface
uterine segment are elongate and resemble fibro- epithelium, and these foci are critical for
blasts with more abundant eosinophilic assessing appropriate glandular and stromal

cytoplasm, in contrast to the oval to rounded stro- development.
Fig. 2.2 Lower uterine segment in curettage specimen. which are juxtaposed to hormonally responsive endome-
At the right side of the image, lower uterine segment trium (left)
shows inactive glands embedded in a fibrotic stroma
Fig. 2.3 Lower uterine segment. Small, poorly developed glands are seen in nonreactive stroma. Tissue from the lower
uterine segment cannot be dated
istologic Features of Normal

H [1]. Five of these features affect the glands,
Cycling Endometrium namely, tortuosity, gland mitoses, orientation of
nuclei (pseudostratified versus basal), basal sub-
The endometrium displays two distinct phases in nuclear cytoplasmic vacuoles, and glandular ser-
ovulatory cycles. The first is the proliferative rations with increased luminal secretions and
(follicular or preovulatory) phase which is secretory exhaustion. Four features relate to the
characterized by growth of glands, stroma, and stroma: edema, mitoses, predecidual change, and
vessels that is influenced by estradiol produced infiltration of granular lymphocytes. Practically,
mainly by granulosa cells in the ovarian follicles. the most important glandular features are orienta-
Following ovulation, the secretory (luteal or tion of nuclei, subnuclear cytoplasmic vacuoles,
postovulatory) phase reflects the effect of the and luminal secretions with secretory exhaustion,
combined production of progesterone and estra- and the most important stromal features are
diol by luteinized granulosa and theca cells of the edema, predecidual change, and granular lym-
corpus luteum [18]. phocytic infiltration (Table 2.1).
The day 1 of the menstrual cycle was arbi-
trarily defined as the first day of bleeding in a
“normal” cycle of 28 days [1]. Proliferative phase Proliferative Phase
changes are not as discrete as those in the secre-
tory phase; the latter can be roughly divided into During the proliferative phase, the endometrium
early, mid-, and late secretory phases. grows from about 0.5 mm up to 4.0–5.0 mm in
There are nine histologic features of the glands thickness, so by the late proliferative phase, a
and stroma that determine the phase of the cycle biopsy obtains a moderate amount of tissue.
Proliferative endometrium has three phases: small nucleoli and dense basophilic cytoplasm.
early, mid, and late [2]. There is considerable The pseudostratified nuclei remain oriented to
overlap between these phases so the diagnosis of the basement membrane, but some nuclei are
proliferative phase alone is sufficient, indicating raised above the basement membrane, giving a
that the endometrium is growing and shows a two-dimensional layering of the nuclei. The
normal glandular distribution and evidence of pseudostratification of the nuclei and the pres-
ovulation is not present. ence of mitotic activity in the glands and stroma
Growth of endometrium is the main charac- are two constant features of the proliferative
teristic of the proliferative phase (Figs. 2.4, 2.5, phase.
2.6, and 2.7). Glands and stroma show brisk In the proliferative phase, the stromal cells are
mitotic activity. In early proliferative endome- widely separated in the functionalis. They are
trium, the functionalis contains small, tubular small and oval, with dense nuclei, scant wisps of
glands. The glands progressively elongate and cytoplasm, and ill-defined cell borders. Some
become tortuous from the mid- to the late pro- stromal edema is normal at mid-proliferative
liferative phase because the gland growth is dis- phase. A few lymphocytes also are scattered
proportionate to the stromal growth. Despite throughout the stroma, being most prominent
the tortuosity, the glands maintain a relatively around the vessels. Small spiral arteries and thin-
regular spacing between each other. Throughout walled venules are present.
the proliferative phase, the epithelium lining The orientation and outline of proliferative
the glands has pseudostratified, oval nuclei with phase glands and their relationship to intact stroma
Fig. 2.4 Proliferative endometrium. Focal hemorrhage beneath the surface epithelium is a result of the biopsy and does
not represent a pathologic change
Fig. 2.5 Proliferative endometrium. Glands are tubular and dispersed in abundant stroma
Fig. 2.6 Proliferative endometrium. In this tangential section, the glands are regularly spaced. The gland to stroma ratio is 1:1
Fig. 2.7 Proliferative endometrium. The proliferative phase gland shows pseudostratified nuclei with mitotic activity.
The stromal cells have oval nuclei and indistinct cytoplasm. Scattered lymphocytes are normally present
are important features for recognizing this normal gests another diagnosis. Also, proliferative
pattern, as hyperplastic glands or glands in a polyp phase glands frequently show the telescoping
can have cytologic features identical to those of artifact (see below).
glands in the proliferative phase. The regular spac-
ing and uniform shape of the glands are character-
istics of normal proliferative endometrium. Secretory Phase
Assessing gland orientation can be complicated,
however, by biopsy-induced fragmentation, an In the secretory phase, the glands and stroma
especially common artifact in early to mid-prolif- develop in a somewhat orderly sequence, dis-
erative phase biopsies when the mucosa is still playing histologic features of (post-ovulation)
thin. Detached and disrupted glands may appear secretory activity. The endometrium attains a
abnormally crowded or irregular. thickness of up to 7.0–8.0 mm. Unlike the prolif-
To distinguish fragmentation artifact from erative phase, the changes in the glands and
true abnormalities, it is important to assess the stroma are relatively discrete, changing more
integrity of the stroma as well as the glands and abruptly from one day to the next. The first half
to use surface epithelium to help orient the tis- of the secretory phase is characterized primarily
sue fragments. Detached and poorly oriented by glandular changes, whereas in the second half,
glands that show pseudostratified nuclei and stromal alterations become more prominent.
mitotic activity usually represent proliferative The morphologic changes of the secretory
endometrium unless better-oriented tissue sug- phase begin within 48 hours after ovulation;
Fig. 2.8 Interval endometrium. The glands maintain proliferative phase characteristics and show scattered subnuclear
vacuoles. The extent of cytoplasmic vacuolization is not sufficient to be certain ovulation has occurred
however, that interval varies among women and c ulminating with a peak in luminal secretions
from cycle to cycle in the same woman. During (Figs. 2.12 and 2.13).
this interval, the glands become more tortuous During the mid-luteal phase, edema, the first
and begin to show subnuclear vacuoles (Fig. 2.8). noticeable stromal change, is most prominent.
The first diagnostic evidence of ovulation, how- Because of the edema, the stromal cells take on
ever, is the presence of abundant subnuclear gly- the so-called “naked nucleus” appearance. With
cogen vacuoles in the undulating, tortuous glands this change, the stromal cells are widely dis-
(Fig. 2.9a, b). At this time, the stroma is indistin- persed and have small nuclei with scant, imper-
guishable from that of the late proliferative phase. ceptible cytoplasm. This phase of pure stromal
If confirmation of ovulation is a requirement, edema is brief, and the subsequent predecidual
substantial amounts of glands with conspicuous transformation of the stroma becomes the main
vacuoles should be present. feature in the late secretory phase. Edema may
During the early secretory endometrium, occur in the earlier portion of the secretory phase
subnuclear vacuoles are abundant, progressively which does not connote an irregularity of matura-
moving from the basal to a supranuclear posi- tion. The glands show increasing tortuosity, and
tion (Figs. 2.10 and 2.11). Concurrently, the variable amounts of luminal secretions persist
nuclei become basally oriented and line up in a until just before menses.
single layer perpendicular to the basement Finally, during the late secretory phase, secre-
membrane. The cytoplasmic contents then form tory exhaustion is achieved (Figs. 2.14, 2.15).
mucin that is expelled into the gland lumen, Secretory exhaustion is characterized by the
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timely refreshment, and the sail up the river, with the sunrise, was
ample compensation for our effort. At five o’clock we landed at Bath,
and Jerry’s friend harnessed him for us, saying courteously, as he
handed us the reins, “Whenever you come this way again call for the
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The drive through the main street of Bath at that early hour was a
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our table we recognized the faces of the bride and bridegroom,
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we time to delay. The Kennebec runs close by the main street, and
the large covered bridge is opposite the hotel. We walked to the
middle of the bridge to watch the sunset clouds, and feast our eyes
on the view up the river. As the light faded we strolled down the main
street, which is overarched by old willows. We measured the largest,
walking around it with a handkerchief, just twenty-four lengths,
twenty-three feet and four inches, a grand old trunk.
The wife of the proprietor brought some pictures of the town to our
room in the evening, and promised us a drive in the morning.
We rested well in our pretty blue room, and were ready for the drive,
after leaving Jerry with the blacksmith. We were taken to the river’s
edge for one view, and to Sunset Rock for another. All the places we
wished to see, and others we did not know of were pointed out to us,
and we were sure if people only knew about it, the Quinnebassett
House would be full of those who like a quiet, comfortable resting
place.
We spend only one night in a place, and are usually ready to go on,
but we left Norridgewock reluctantly, and were only consoled for
turning away from the lovely Kennebec, by promising ourselves to
drive to Norridgewock again some time, and follow still farther up the
river. Maine cannot be exhausted in many trips, and we have some
fine ones growing in our mind. Every journey makes a better one
possible.
We must now face about for this time, and we aimed next for the
Androscoggin, driving first to Farmington, then turning south,
crossing the Androscoggin on one of those scow ferries run along a
wire, that old Charlie disliked so much. He was not a good sailor, like
Jerry, who can hardly wait for the scow to touch the shore, before he
leaps on.
We should have told you, before crossing the ferry, about our quiet
Sunday at a farm house. The man was reading his paper as we
drove up, and it seemed almost too bad to disturb their Sunday rest,
but his wife said we could stay if we would take them “as they were.”
We were soon settled in a cosy parlor with bedroom adjoining, away
from all sights and sounds of the busy world. We felt as if we were
miles from everywhere, and you can imagine our surprise when the
man said that he came down from Boston on the boat with us, and
recognized us when we drove to the door.
Monday morning we left our kind host and hostess, with directions
for Strickland’s ferry. We have already taken you across, but we did
not mention our ferryman. We do not remember now just what he
said, but we set him down for a philosopher. All that ride and
philosophy for ten cents! We thought it worth twenty-five at least, but
he said some grumbled at ten.
Now we renewed our acquaintance with the Androscoggin, which we
followed so many miles on one journey farther north. We wondered
where all the logs were, and found out all about it from a boy who
brought us milk, and entertained us while we had our first and only
wayside camp at noon day. Our Sunday hostess had put up
luncheon for us, as we were not to pass through any village on our
way to Lewiston. Our boy friend took us down to a little beach on the
river, and showed us where the river drivers had been for a week,
but they were then at work half a mile below. We had often seen a
river full of logs, and heard much about the river drivers, when in
Maine and northern New Hampshire, but this was our first
opportunity to see them at work. They were just coming from their
tents after dinner, as we drove along. One of them tied Jerry for us,
and conducted us to a nice place on the rocks. We watched them
nearly an hour, and concluded it took brains to untangle the snarls of
logs. It was quite exciting to see them jump from log to log with their
spiked boots, and when the last of a snarl was started, leap into a
boat and paddle off for another tangle. The river was low, and it was
slow work getting them over the rocks.
The drive to Lewiston was over a sandy road. We met two boys
puffing along on their wheels, who asked us if it was sandy all the
way up. We were sorry we could not cheer their hearts, by telling
them the road was level and hard before them. We spent the night at
Auburn, across the river from Lewiston, as the Elm House looked
attractive. At the suggestion of the proprietor we took a horse car
ride in the evening around the figure 8, one loop being in Lewiston
and the other in Auburn. The horses must have been electrified, for
we never rode so fast except by electricity, and we returned to our
room quite refreshed.
Poland Springs was our next point of interest, and we were well
repaid for our drive to the top of the hill, where the immense hotel
when filled must be a little world in itself, for all sorts and conditions
of men are attracted there. We met Boston friends who invited us to
the morning concert, in the music room. After dinner we climbed to
the cupola for the view, then ordered Jerry and were off again.
Sabbath Day Pond, which lay along our way, is fittingly named. It has
no look of a weekday pond, but is a crystal, clear, peaceful
perfection, that is indescribable. The Parker House at Gray Corner
afforded us every needful comfort, even to a hammock in the side
yard through the twilight.
Now we began to lay aside—not forget—the things that were behind,
and to strain our eyes for the first glimpse of the ocean. Portland was
only sixteen miles away, and as we had left the sand, it did not seem
long before we drove to the Portland post office and got home
letters, always so welcome, then to the Preble House for dinner.
There was one place on the coast, that we skipped before, and now
we proposed to explore Prouts Neck—nine miles from Portland; but
we did not leave the city until we had seen the good friends who
entertained us so hospitably when we attended a meeting there. A
storm cloud was over us, but we got only the last drops of a shower,
that laid the dust all the way to Prouts Neck.
We were glad this lovely spot had been reserved for us until then, for
we could not have seen it under a finer sky. We walked to the Rocks,
piloted by a young lady, who knew all the paths through the woods,
and we were fascinated with the path near the Rocks, over which the
wild roses and low evergreens closed as soon as we passed
through. We sat on the piazza watching Mt. Washington in the
distance until the sunset sky grew gray, and finished up the pleasant
evening in the cosy room of friends from Boston.
We saw them off in the morning for a day at Old Orchard, and then
went on our way, through Saco and Biddeford to Kennebunkport,
which also has its Rocks and many attractions. Spouting Rock was
not spouting, but we saw where it would spout sixty feet in the air,
when spouting time came.
The next morning we saw once again the friends we never pass by,
at Kennebunk, and visited the old elm under which Lafayette is said
to have taken lunch, when on a visit here after the Revolution. Night
found us at another favorite resort, York Harbor, and the charms and
comforts of the Albracca made us forget the heat and dust which a
land breeze had made very oppressive during the day.
While we were at dinner at the Rockingham, Portsmouth, the next
day, a black cloud spent its wild fury in a few terrific gusts of wind. All
was over when we started on our afternoon drive, but when half way
to Hampton, the clouds grew black again, and we had barely time to
drop the back curtain, put on the sides and unfasten the boot, before
a tempest was upon us; a tempest of wind and rain—not a common
rain, but pelting drops with thunder and lightning. We read
afterwards that a buggy was blown over not many miles from us, but
ours withstood the gale, and Jerry did well, although it seemed
almost impossible at times for him to go on against the storm. We
drove away from the shower and all was calm when we got to the
Whittier House, Hampton, one of our homelike stopping places.
We followed along the coast to Newburyport, and then the Merrimac
River enticed us inland. The experience of the afternoon previous
was repeated on our way from Haverhill to Andover. We were
scarcely prepared, before another tempest burst upon us, the rain
this time driving straight in our faces. It was soon over, however, and
we reached Andover unharmed.
We were now only a day’s drive from home, but Boston is only
twenty miles from Andover and as our mail reported all well, we
could not resist going the longest way round to do another errand or
two in Boston, and call on our friends in Reading and Maplewood on
the way.
The drive from Malden to Boston is distracting, with little that is
pleasant to offset the turmoil of the streets. We thought we could
leave Jerry at the old stable in Mason street, while we went
shopping, but like everything else in these days, the stable had
“moved on.” When we found a place for him it was late. We did not
idle this time, for it was so near five o’clock that gates were half
closed, and a man stood at every door as if to say, “You can come
out, but you cannot go in.”
The drive next morning was very fine. We went out on Beacon street
to Chestnut Hill Reservoir, then drove on the new Commonwealth
avenue as far as we could on our way to Allston. Whatever Scripture
may say about the “broad way,” we shall surely risk our lives on that
one as often as we have opportunity.
From Allston we retraced our first two days’ driving, making our
journey like a circle with a handle. We called on the same friends
along the way, spent the night at Wayland Inn, dined with the same
friends at the Lancaster House, and called on the campers at
Spectacle Pond. There was a slight variation in the return trip,
however, in the form of a tornado, which passed over South
Lancaster. We might have been “in it” if we had not stopped twenty
minutes or more to sketch a very peculiar tree trunk, between
Sudbury and Stow. There were nine huge oaks in a row, and every
one showed signs of having been strangely perverted in its early
growth, as if bent down to make a fence, perhaps; but later in life
showed its innate goodness by growing an upright and shapely tree
out of its horizontal trunk.
We called one journey a cemetery journey because we visited so
many cemeteries, and another a ministerial journey because we met
so many ministers. Trees were a marked feature of this journey. We
saw many beautiful trees beside the big willow in Norridgewock, the
Lafayette Elm in Kennebunk, and now sketching the curious oak had
possibly saved us harm from a beautiful maple, for we had not driven
many miles before we struck the track of the gale, where large trees
were torn apart, or uprooted. We had driven through the thunder
shower, or rather it seemed to sweep quickly past us, the pelting rain
lasting only a few moments, but as our direction turned we found a
large maple across the road. We were obliged to go two miles farther
round to reach the Lancaster House, and we had not driven far
before the road was obstructed by another large tree. This time we
could drive round through a field, and a third time, a large fallen
branch had been cut and the way cleared. We rejoiced that the
Great Elm stood unharmed, though mutilated trees were on each
side of it.
Giant willows, historic elms, upright oaks from horizontal trunks,
glorious maples and elms laid low, and scores of noble though not
distinguished trees, that we admired and shall remember as we do
pleasant people we meet, together with the fact that the greater part
of our driving was in the grand old Pine Tree state, warrants us in
calling this most delightful journey our Tree Journey.
CHAPTER XV.
ON HIGHWAYS AND BYWAYS. 1894 to 1904.
In response to many requests to share this journey with our friends
as we used, the spirit has moved us to give you first an inkling of our
annual trips for the ten years since our last report.
This is easily done, for we have a book in which is recorded the
name given to each journey, the name of every town we pass
through, with distance from place to place, and the sum total of time,
distance and expense of each journey. This goes with us, and is a
valuable book of reference. The revolver still goes with us, too, the
one thing we take but never use. Our electric hand-lamp, on the
contrary, is very useful. The Kennebec journey was followed by our
first visit to Nantucket, leaving our horse at New Bedford, and once
again prolonging the return trip to Leominster by driving to Boston.
This journey had a memorable postscript: We drove to Boston for a
day or two in the autumn and were detained eleven days by that
terrific November snow storm, and even then the last thirty miles of
the return trip it was good sleighing!
A September mountain trip, “The Figure 8” we named it, comes next
in order, followed by a Jefferson and Jackson trip, and then a
Massachusetts journey, which is always delightful.
The three ranges of the Green Mountains, with their “gulf” roads,
was a journey unsurpassed, and from Cape Ann to Mt. Tom was
another interesting journey in our own state, followed by a Cape Cod
trip, which completed the coast for us from New Haven to Bar
Harbor.
By this time we were ready for another journey to Lake George,
Saratoga, and the Berkshires, and the next trip through the
mountains was exceptionally fine, as we returned via Sebago Lake,
Portland and the coast, being just in time for the September surf.
The following journey “capped the climax,” seemingly, when we
crossed the Green Mountains, ferried Lake Champlain to
Ticonderoga, and drove to Eagle, Paradox and Schroon Lakes in the
Adirondack region, returning to Lake George, thence to the
Berkshire towns and as far south as Hartford, Connecticut, a superb
drive of five hundred miles.
Most of our journeys have covered more than four hundred miles,
and we are frequently asked if we have done all this with one horse.
No, there was handsome black Charlie, Old Nick, who liked to lie
down in harness now and then, bay Charlie, who had the longest
record—ten years—and was best loved and least trusted, faithful,
serious Jerry, whose long strides took us so easily through the
country, saucy and exasperatingly lazy Bess, who could do so well,
and altogether worthy Nan, whose two journeys have not revealed a
fault.
“Do you plan your journeys?” is another question often asked. Never,
except the Cape Cod trip, and we observed the innovation by having
a letter party. Imagine the pleasure of receiving thirty or more letters
at the tip end of Cape Cod, and of mailing an answer to the last one
at Plymouth on the way home! We have many times driven from
home to the post office packed for a three or four weeks’ journey,
without the faintest idea where we should go, and even sat there in
the buggy fifteen or twenty minutes trying to decide which way we
would leave town.
Our journeys make themselves and we thought this summer’s
journey was not going to be worthy of mention, but would simply
preserve the record unbroken. We could spare but two weeks, and
we were never more at a loss what to do with it. Maine came to mind
most frequently, and we finally faced in that direction, spending the
first night at the Groton Inn. Of course, facing Maineward the Isles of
Shoals lay in our way as a side attraction, and as it was many years
since we had been there, we left our horse at Portsmouth, and took
the boat to Appledore, where we found the friends we hoped to
meet. After dinner and a walk to Celia Thaxter’s resting place, we
returned on the afternoon boat to Portsmouth. Our horse was waiting
for us at the wharf, and we drove on to Eliot, Me., where Green-Acre
attracted us.
A visit to Green-Acre alone would be enough for a summer’s outing,
even if one were limited to the exoteric interests of life—this beautiful
acre of green on the banks of the Piscataqua River, the finely located
Inn, with its hospitality, and the glorious sunsets—what more could
one desire? But if you have chanced to be, or wish to be, initiated
into the esoteric mysteries, what a feast!
Unfortunately Miss Farmer, the organizer and secretary of Green-
Acre, was away for a few days, but we had a brief sunset meeting
sitting on the river bank, a very fine reading in the parlor in the
evening, from Longfellow and Lowell, an early morning gathering on
the piazza of the Eirenion—House of Peace—when Browning and
Emerson were beautifully read and interpreted, and a later session
under Lysekloster Pines, a half mile away through the fields, where
the meetings of the Monsalvat School are held. This was a novel
experience, sitting on the dry brown needles, under the low, broad-
spreading branches of a mammoth pine, listening to the wisdom of
an Indian teacher.
We were loth to leave the tempting program, “The Oneness of
Mankind,” by Mirza Abul Fazl, and Mirza Ali Kuli Khan, next morning
in the Pines, and later “Man, the Master of His Own Destiny,” by
Swami Rami; in truth a whole summer’s feast of reason and music,
but our journey was waiting.
We had scarcely left the Inn after dinner, before muttering thunder
gave us warning, and a shower came up so quickly we barely had
time to drive under a shed back of the village church before the
floods came down. The shower was violent, but did not last very
long, and when the rain was over, we drove on. We were utterly in
doubt where we were being led until at the first glimpse of a distant
mountain peak our entire journey was revealed to us—a trip through
Sebago Lake, then on to Jefferson Highlands, and home through
Crawford Notch and Lake Winnipiseogee! We had not a doubt or
misgiving after the revelation. We had at last struck our trail!
According to the revelation, Sebago Lake was the first point of note,
but the incidents along the way, the pretty woodsy roads, the ponds
and brooks, the camping near a farmhouse at noon, and the small
country hotels, with their hospitable hosts, make up by far the larger
part of a carriage journey. When we answered our host, who asked
where we had driven from that day, he said, “Green-Acre? That’s the
place where Buddhists confirm people in their error,” adding “there’s
only one kind of good people—good Christian men and women.”
We were packing up wraps and waterproofs after a shower, when a
white-haired farmer came from the field and asked if we were in
trouble. We told him we were “clearing up” so as to look better. “Oh,
pride, is it?” he said, and asked where we came from. He seemed so
much interested that we also told him where we were going—it was
just after the “revelation.” He was very appreciative and wished us a
hearty Godspeed. The incident was suggestive of the universal
brotherhood to be, in the millennium. At a point on the Saco we saw
logs leaping a dam like a lot of jubilant divers—singly, and by twos
and threes.
We had an early drive of eight miles to meet the boat at Sebago
Lake, and on the way there was a slight break in the harness. We
drove back a short distance, hoping to find the rosette lost from the
head band, and finally tied it up with a string. This delayed us more
than we realized and when we drove to a hotel near the wharf and
were waiting for the proprietor, we asked a guest of the house what
time the boat was to leave. He answered quickly, “Now! run! I will
take care of your horse!” We ran, and not until we were fairly on
board did it occur to us that we had not told him who we were, where
we came from, or when we should return. It did not matter, however,
as the names on whip and writing tablet would give all that was
needful in case of necessity or curiosity.
The day was perfect, there was a pleasant company on board the
Longfellow, Sebago Lake was all one could wish for a morning’s sail,
and the Songo River, with its twenty-seven turns in six miles,
although only two and a half miles “as the bird flies,” fascinating
beyond all anticipation. Passing through the locks was a novelty and
the Bay of Naples as lovely as its name suggests. Then came the
sail through Long Lake to Harrison, the terminus, where the boat
stayed long enough for us to stroll up the street and go to the post
office, and then we had all this over again, enjoying the afternoon
sail even more than that of the morning.
This was a round trip of seventy miles, and it was too late when we
returned to drive farther, as we had planned, but we were off early
next morning, the buggy scrupulously clean, and with a new head
band and rosette. We hoped Nan’s pride was not hurt by wearing a
plain A on one side of her head, and an old English S on the other!
We drove up the east side of Sebago Lake, passed the Bay of
Naples, and on through the various towns on Long Lake, and at
night found ourselves at the Songo House, North Bridgton, just a
mile and a half across the end of the lake from Harrison, where we
posted cards the day before at noon.
The following day we turned our thoughts from lakes, bays and
rivers, and faced the mountains, which are never more enjoyable
than when approaching them. We retraced our route of two years
ago, but there is a great difference between driving towards the
mountains and away from them. As we drove on through the
Waterfords, Albany, West Bethel and Gilead, the views were finer
every hour, and at Shelburne we had a most beautiful sunset, and
watched the after-glow a long time from a high bluff.
The rain clouds of the night vanished after a few sprinkles, leaving
only delicate misty caps on the highest peaks, and the day was
perfect for the famous drive from Gorham to Jefferson, so close to
the mountains of the Presidential range, along through Randolph.
The afternoon drive over Cherry Mountain to Fabyan’s was never
more lovely. We feasted on wild strawberries as we walked up and
down the long hills through the woods.
That this was the tenth time we had driven through the White
Mountains did not in the least diminish their charm for us. On the
contrary, they have become like old friends. To walk up and down the
steep pitches through Crawford Notch, leading the horse, listening at
every turnout for mountain wagons, and this year for automobiles,
would be a delight every year. Our youthful impression of a notch as
a level pass between two mountains was so strong, the steep
pitches are a lovely surprise every time.
The old Willey House was one of our favorite resting places. We are
glad the driveway and barn were spared when the house was
burned, and we still stop there to give our horse her noon rest.
After the “pitches,” the rest at old Willey, and a snap shot at the
ruins, come the miles and miles of driving through the dense woods,
with high mountains on either side, the way made cheery by the
sunlight glimmering through the treetops, and the music of the
babbling brooks.
At Bartlett we received a large forwarded mail, the first for ten days,
which we read as we drove on to North Conway, and we were
grateful for the good news which came from every direction.
After leaving North Conway and getting our first glimpse of
Chocorua’s rugged peak, there was no more regretful looking
backward. Chocorua in its lofty loneliness is all-absorbing. We had
an ideal mid-day camp on the shores of the beautiful Chocorua lake
at the base of the mountain.
After two hours of concentrated admiration of the rocky peak, what
wonder we were hypnotized, and that on leaving the lake with one
mind we confidently took the turn that would have led us to the
summit in time! Having driven a distance which we knew should
have brought us to the next village, we began to suspect something
was wrong. There was nothing to do but to go on, for there was not a
turn to right or left, and not a house in sight. We were surely on a
main road to somewhere, so we kept on, until we met a farmer
driving, who brought us to our senses. We were miles out of our way,
but by following his directions in the course of the afternoon we
arrived safely at our destination for the night.
Immediately we took our books and writing-tablet, and climbed to a
summer house on a knoll just above the hotel, commanding a
magnificent view of Chocorua, also Passaconaway, White Face,
Sandwich Dome, and several others of the range. After supper we
returned to the knoll for the sunset, and later were interested in what
was thought to be a bonfire at the Appalachian camp on the summit
of Passaconaway, lingering until the outlines were lost in the
darkness.
We were up before six o’clock and went to the hammock in the
summer house before breakfast, and if it had not been such a
beautiful day for the sail through Lake Winnipiseogee, we would
have been strongly tempted to stay over at this homelike place, the
Swift River House, Tamworth Village, New Hampshire, opened only
last year, and already attracting lovers of fishing and hunting.
A drive of seventeen miles with Chocorua in the background, and
raspberries in abundance by the wayside, brought us to Centre
Harbor, where we took the boat for Alton Bay. A trip through Lake
Winnipiseogee sitting in the buggy in the bow of the Mt. Washington,
is an indescribable pleasure, and even our horse seemed to enjoy it,
after she became accustomed to the new experience. On the way
we had our parting glimpses of Mt. Washington and Chocorua.
With this glorious sail the “revelation” was fulfilled, and the one
hundred miles—or nearly that—between us and home was like the
quiet evening after an eventful day.
For more than two hundred and fifty miles we had been away from
the trolleys, and the busy world, among the mountains and lakes,
and recreation lovers everywhere, from the tent on the river bank to
the large mountain houses. Now came the familiar ways through the
country towns and villages, the gathering and pressing wild flowers
for Christmas cards, catching a pretty picture with the camera, and a
drive along the Merrimac in the cool of the morning, the atmosphere
clear as crystal after another dry shower, when clouds threatened
but gave no rain.
Then there were the lovely camping places at noon, the hospitable
farmers, and the pleasant chats in the kitchen while our spoons were
being washed—the souvenir spoons that were presented to us with
a poem after our twenty-fifth journey. One bright young woman
discovered the silver we left when we returned the milk pitcher and
glasses, and came after us, forcing it into our hands, telling us not to
dare leave it, but come again and she would give us a gallon. At
another place where we asked permission to stop in a little grove,
the farmer came out and set up a table for us, and gave us use of a
hammock. We prolonged our stay to the utmost limit—nearly three
hours—reading in the buggy and hammock under the fragrant pines,
our horse tied close by, nodding and “swishing” the flies. We have an
amusing reminder of that camp, for we had posed Nan for the
camera, and just as it snapped she dashed her nose into one of the
paper bags on the table.
A notable experience in the latter part of every journey is a visit to
the blacksmith, and it came, as often before, unexpectedly on the
way. The chatting that goes with the shoeing would be good material
for Mary Wilkins.
At last came a rainy day, without which no journey is quite complete.
We had a leisure morning with our books, and after an early dinner
enjoyed an easy, comfortable drive in the rain, which ended our
journey of more than four hundred miles in two weeks and two days.
CHAPTER XVI.
LAKE MEMPHREMAGOG.
We did not think to give you a report of this journey, but the day
before we left home little books called Wheeling Notes were given
us, with pages for day, route, time, distance and expense, and pages
opposite for remarks.
These little books we packed in our writing tablet, and Friday
afternoon, June 30th, we began our journey. Besides the note-books
we had an odometer and a carriage clock, in addition to our usual
equipment. Naturally we were much absorbed in our new
possessions, and the remarks, in diary form have become so
interesting to us that we gladly share them.
July 2—Rainy. Dropped in a back seat in a village church; only
nineteen present. The little minister is a Bulgarian, and inquired for
two classmates in Leominster. We practiced all day on pronouncing
his name, and could say it quite glibly by time for evening service.
He is very loyal to his adopted country, and urged all to make as
much noise as possible all day on the Fourth. Not a boy or girl was
there to hear such welcome advice, and we wondered if the parents
would tell them.
July 3—Drove all day. Mr. Radoslavoff’s advice must have sped on
wings, for the noise began early, and kept up all night. Three huge
bonfires in front of the hotel at midnight made our room look as if on
fire.
July 4—Somewhere between the southern and northern boundary of
New Hampshire there is a park, the fame of which reached us
several years ago, and we have had in mind to visit it some time.
This year seemed to be the time, as, by our map, it was right on our
way north. On making inquiries, we found it would give us five or six
miles extra driving to go through the park, and the day being hot it
took considerable wise arguing to make the vote unanimous.
Importunity, however, will sometimes bring about at least
acquiescent unanimity.
Suffice to say, we went through the park and now we are truly
unanimous, and will give you the benefit of our experience. There is
probably no town in New England that has not attractions enough,
within reach of a walk or short drive, to last all summer for those who
go to one place for recreation and change. But if you are driving the
length of New Hampshire, Vermont or any other state, do not be
beguiled by accounts of pretty by-roads, cascades, water-falls,
whirlpools or parks, even one of 30,000 acres, with 26 miles of wire
fence, 180 buffaloes, 200 elks, 1000 wild hogs, moose, and deer
beyond counting. You may do as we did, drive miles by the park
before and after driving five miles inside, and see only twelve
buffaloes, one fox, a tiny squirrel and a bird—yes, and drive over a
mountain beside, the park trip having turned us from the main
highway. For a few miles the grass-grown road was very fascinating,
but when we found we were actually crossing a mountain spur and
the road was mainly rocks, with deep mud holes filled in with bushes,
we began to realize the folly of leaving our good main road for a
park. To be sure, we might not see buffaloes, but we do see
partridge, woodchucks, wild rabbits, snakes, golden robins and
crows, and once, three deer were right in our path! And really we
think we would prefer meeting a drove of cattle on the main road, to
having a big moose follow us through the park, as has occurred, and
might have again, if it had not been at mid-day, when they go into the
woods.
Finally, our advice is, in extended driving, keep to the main highway,
with miles of woodsy driving every day, as fascinating as any Lovers’
Lane, with ponds and lakes innumerable, and occasional cascades
so near that the roaring keeps one awake all night. Then we have a
day’s drive, perhaps, of unsurpassed beauty, which no wire fence
can enclose, as along the Connecticut River valley on the Vermont
side with an unbroken view of New Hampshire hills, Moosilauke in
full view, and the tip of Lafayette in the distance, the silvery, leisurely
Connecticut dividing the two states and the green and yellow fields in
the foreground completing the picture. No State Reservation or Park
System can compete with it.
July 5—We were in a small country hotel, kept by an elderly couple,
without much “help,” and our hostess served us at supper. When she
came in with a cup of tea in each hand, we expressed our regret that
we did not tell her neither of us drink tea. She looked surprised and
said she supposed she was the only old lady who did not take tea.
“O wad some power the giftie gie us
To see oursels as others see us!”
July 6—Received our first mail at Wells River, Vt., and as all was
well at home, we began to plan our journey. For a week we had
simply faced north day after day. If we kept right on we would come
to Newport and Lake Memphremagog, which to us means the
Barrows camp, but we need a month for that trip. A bright idea
solved the problem. We drove north until we reached St. Johnsbury,
left our horse there and took a morning train for Newport, where we
connect with the Lady of the Lake for Georgeville, P. Q.
At the boat landing at Newport we met Mr. and Mrs. Barrows just
starting for Europe. They insisted that we must go on to Cedar
Lodge for the night, and make a wedding call on their daughter,
recently married in camp, and forthwith put us in the charge of camp
friends, who were there to see them off. The sail to Georgeville was
very delightful. We were then driven two miles to the camp in the
forest of cedars, and presented to the hostess, a niece of Mrs.
Barrows, who gave us a friendly welcome.
The attractions of Cedar Lodge are bewildering. The one small log
cabin we reveled in a few years ago is supplanted by a cabin which
must be sixty or seventy feet in length, with a broad piazza still
wearing the wedding decorations of cedar. Near the center is a wide
entrance to a hallway, with a fireplace, bookcase, and hand loom,
the fruits of which are on the floors, tables, couches, and in the
doorways. At the right is the camp parlor, called the Flag room,
draped with colors of all nations. It is spacious, with a fireplace,
center reading table, book shelves, pictures, writing desk, typewriter,
comfortable chairs, and a seat with cushions, the entire length of the
glass front facing the piazza and lake.
On the left is the Blue China or dining room. Here is a very large
round table, the center of which revolves for convenience in serving,
a fireplace with cranes and kettles, and a hospitable inscription on a
large wooden panel above. The telephone, too, has found its way to
camp since we were there.
Not least in interest, by any means, is the culinary department.
Instead of a cooking tent, where Mrs. Barrows used to read Greek or
Spanish while preparing the cereal for breakfast, and a brook
running through the camp for a refrigerator, there is a piazza partially
enclosed back of the Blue China room, with tables, shelves,
kerosene stoves, and three large tanks filled with cold spring water,
continually running, one of which served as refrigerator, tin pails
being suspended in it. The waste water is conveyed in a rustic
trough some distance from the cabin and drips twenty feet or more
into a mossy dell, where forget-me-nots grow in abundance.
Just outside the end door of the Flag room are flights of stairs to the
Lookout on the roof. This stairway separates the main cabin from a
row of smaller cabins, designated Faith, Hope, and Charity, in rustic
letters. (We were assigned to Hope, and hope we can go again
some time.)
These cabins are connected by piazzas with several others, one
being Mrs. Barrows’ Wee-bit-housie. A winding path through the
woods leads to Mr. Barrows’ Hermitage, or study, close by the lake,
and another path up the slope back of the cabins leads to a group of
tents called The Elfin Circle.
We went to the bath wharf, followed the brook walk through the
cedars, strolled to the hill-top cabin to see the friends who escorted
us from Newport, and then we all met at supper, on the broad
piazza, seventeen of us. The last of the wedding guests had left that
morning. After supper we descended the steps to the boat landing,
and our hostess and the best man rowed us to Birchbay for the
wedding call. Though unexpected we were most cordially received,
served with ice cream, and shown the many improvements in the
camp we first visited years ago. We walked to the tennis court and
garden, where the college professor and manager of Greek plays
were working when no response came from the repeated telephone
calls to tell them we were coming. We rowed back by moonlight.
We cannot half tell you of the charms of Cedar Lodge, but when we
were driven from Georgeville a bundle of papers was tucked under
the seat, which proved to be Boston Transcripts, containing an
account of the wedding. A copy was given us and it is such an
exquisite pen picture we pass it along to you:
_From the Transcript, July 6, 1905._
A CAMP WEDDING.
On the last Wednesday of June Miss Mabel Hay Barrows, the
daughter of Hon. Samuel J. Barrows and Mrs. Isabel C. Barrows,
two very well-known figures in the intellectual life of Boston and New
York, was married to Mr. Henry Raymond Mussey, a young professor
at Bryn Mawr. And the ceremony, which took place at Cedar Lodge,
her mother’s summer camp, was one of the most original and
picturesque which it is possible to imagine. Miss Barrows herself is a
girl with a refreshingly individual outlook upon life, and with a great
variety of interests, as well as a strong dramatic instinct, and every
one who knew her well looked forward to this wedding as promising
to be an occasion at once unique and beautiful. And they were not
disappointed, those eighty odd guests, who traveled so far, from
east, west, north and south, to the little camp snuggled away among
the sympathetic trees bordering the Indian Lake, beyond the
Canadian border.
Cedar Lodge, the Barrows’ camp, crowns a beautiful wooded slope
above the lake, a steep climb by a winding path bringing one to the
log cabin, with its broad piazza facing the sunset and overlooking the
lake, through misty tree tops which still wear the tender freshness of
hymeneal June. At either end of this ample balcony the guests were

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Diagnosis of Endometrial Biopsies and

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The third edition of Diagnosis of Endometrial Biopsies and Curettings: A

s­ amples. For example, the classification of endometrial stromal tumors has

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Hydropic Change and Other Pathologic Changes

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