The Use of Traction and Morcellation 
in the Removal of Fibroids versus 
Hysterectomy. 
BY 
Thomas Addis Emmet, M. D., 
NEW YORK. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for June, 1895. [Reprinted from the American Gynaecological and Obstetrical Journal 
for June, 1895.] 
THE USE OF TRACTION AND MORCELLATION IN THE 
REMOVAL OF FIBROIDS VERSUS HYSTERECTOMY.* 
Thomas Addis Emmet, M. D., New York. 
The method to be described for treating fibrous growths of the 
uterus by traction and morcellation is one yet but little known to the 
profession, notwithstanding it has been practiced in this country by 
myself for many years. 
While the subject is limited as to a special mode of treatment, it 
is earnestly hoped that the discussion on it may be so directed 
as to determine within a reasonable limit the circumstances under 
which the uterus should be removed. I bring forward the method 
with the firm belief that, if properly practiced, it will be the means of 
greatly reducing the number where total extirpation would be resorted 
to if we could not have the benefit of such a procedure. We are yet 
in a transition state, when the tendency is always to run into one ex- 
treme or the other. But experience has long since taught me that the 
truth seldom lies in either extreme. Consequently I will no more ac- 
cept the view that the uterus should be removed, from the fact that a 
fibroid exists, than I will condemn the operation with the dictum that 
it should never be performed. 
Unfortunately the operation for removal of the uterus is not, under 
ordinary circumstances, a difficult one of execution ; were it other- 
wise it would not be so necessary, in attempting to check the abuse* 
that public opinion of the profession should not only be heard at this 
stage, but heeded. The abuse is due to the enterprising spirit of dif- 
ferent members in the profession seeking for what is thought by them 
* Read at the Twentieth Annual Meeting of the American Gynaecological Society, 
May 28, 1895. 
Copyright, 1895, by J. D. Emmet and A. H. Buckmaster, Thomas Addis Emmet, M. D. 
to be progress, but, owing to the extreme views so frequently held, the 
result is malpractice. In the name of such progress the uterus is 
being removed for procidentia, for different forms of prolapse of the 
vaginal walls, and it is but a few weeks since I saw a young woman, 
then a hopeless invalid, whose condition was caused, during the past 
winter, by the removal of the uterus, tubes and ovaries, for the reason 
that she had not been relieved after an attempted operation for lacera- 
tion of the cervix ! Further comment is unnecessary. 
Almost every operative procedure in surgery has within a limited 
space a legitimate place, and when needed it should be performed. 
If we grant this proposition to be true we must hold that when an 
operation is performed unnecessarily it is malpractice. 
To remove the uterus in consequence of the existence of a fibrous 
growth, from which the woman may have suffered but little, is not, in 
my judgment, justifiable. To extirpate the uterus before thoroughly 
exploring the uterine canal is equally reprehensible. Frequently a 
secondary growth projecting into the canal is the immediate cause of 
the loss of blood, and until an effort had been fairly made to aid the 
advance of the growth for its removal, it is impossible to decide as to 
what the exigencies of the case might require. And lastly, the most 
important point of all to determine, after locating a uterine tumor, is 
in reference to the rapidity of its growth. I exclude the tendency to 
loss of blood as the least urgent symptom or need for the operation of 
removal of the uterus, since it is possible, with the proper surround- 
ings, to hold this in check for an indefinite period. It is but reason- 
able that this delay should take place whenever the slightest prospect 
of a good result exists. We will not discuss the death-rate after re- 
moval of the uterus for a fibrous tumor, as this doubtless can be made 
more favorable, but we will consider the condition of those who sur- 
vive as offering the chief objection to the operation under any circum- 
stances but the most urgent. We have reached a stage in the history 
of this operation where the Testimony must be heard of those who 
have to take charge of the cases after the surgeon has already received 
full credit for a supposed successful operation. Their testimony 
would be that too large a proportion of these women remain invalids 
after the uterus has been removed. This has certainly been my ex- 
perience in having the patients of other operators under my care, and 
instances have occurred in my own practice where I had felt the op- 
eration was called for, but the result afterward has shaken my confi- 
dence. I have indeed seen remarkably good results, but with many 
I have been in doubt as to the gain in getting rid of one set of symp- Use of Traction and Mdrcollation in the Removal of Fibroids. 
3 
Toms by the substitution of others entirely new in character, and which 
are attended often with even a greater degree of invalidism. 
Sometimes as a cause of their suffering we may find among these 
women a certain proportion with more or less sagging of the roof of 
the pelvis, while others suffer from prolapse of the bladder, of the 
urethra, or of the whole vagina. So long as we are thus able to de- 
tect any abnormal condition we can at least be encouraged by the 
hope of being able to offer relief. But unfortunately there remains a 
number of women, after the uterus has been removed, who continue 
invalids from some unknown cause, as no special lesion can be de- 
tected. Under these circumstances, if the statement be true, and I 
think no one will charge me with having exaggerated the condition 
which does frequently exist, we must all ultimately reach the same 
conclusion. This will be that the operation for removing a uterus 
containing a fibrous growth should only be resorted to when abso- 
lutely necessary, and, I will add as the result of my own observation 
and personal experience, only to save life. My experience is not a 
recent one, as the length of time which has passed since my first 
operation for removing the uterus with a fibrous growth has been 
probably longer than that of any one within reach of my voice, and I 
can claim to have had some good results and some very unsatisfactory 
ones. For years past I have honestly striven to define, if possible, 
the limit of necessity for this operation, and have consequently been 
misrepresented as opposing it under all circumstances, which is an 
absurdity. 
At the present time it is in accord with my judgment that the 
more rapid the growth of a uterine tumor, the more urgent the ne- 
cessity for total extirpation, and I hold this view without reference to 
the tendency to haemorrhage. The rapid growth is either indicative 
of sarcoma, or of a condition where the tumor seldom becomes pe- 
dunculated, as the uterine tissues and those of the tumor are so blended 
as a rule, that it is impossible to enucleate the mass without great 
danger of perforating the uterine wall. 
Under these circumstances, where an operation has been attempted 
and could be only partially done, and the patient has been weakened 
by a great loss of blood, death frequently results from blood poison- 
ing. The necessity may arise for removal of the uterus where the 
tumor has become so large, or is so situated, that the proper examina- 
tion can not be made, or the loss of blood controlled. But the dan- 
ger from an operation is greatly increased with the size, so that a 
reasonable delay is warranted to ascertain if the limit has not been 4 
Thomas Addis Emmet, M. D. 
reached in its growth, when the loss of blood may become modified. 
The age of the patient should have some bearing in determining the 
necessity for removal of the uterus. The existence of a rapidly de- 
veloping fibrous growth in the uterus of a woman of twenty is a far 
more serious circumstance than it would be in one at forty years of 
age, if we are able to exclude the existence of sarcoma. 
I have seen it stated by some recent writer, who was an advocate 
for removing the uterus under almost all circumstances, that a woman 
suffering from a fibrous growth could have nothing to look forward 
to after reaching the menopause, and he made the additional asser- 
tion that no change ever took place at that time. This is simply a 
haphazard statement. It is my belief that no one in the profession, 
at home or abroad, has given more attention than I have to this sub- 
ject, during the past thirty years. lam justified, on this experience, 
in making the statement that with a large proportion of cases, who 
have suffered from fibrous growths of the uterus great changes do oc- 
cur at the time of the menopause or after that time—in what propor- 
tion it is impossible to ascertain, but the numbers are certainly suffi- 
cient to anticipate for many some amelioration at that time in their 
condition. I certainly have seen tumors of fair size disappear at this 
period of life, others have decreased in size, many have remained 
stationary for years after, while I can recall but a few instances where 
the tumor increased rapidly in size after a change of life had taken 
place. It must also be borne in mind that these growths sometimes 
disappear as the result of pregnancy, and not infrequently their 
growth becomes self-limited in consequence of the pressure exerted 
on their blood vessels, and these have Deen known to frequently dis- 
appear, or their development to become arrested from the same cause. 
As these facts are in accord with my experience I cannot in justice to 
my own judgment accept without question the teaching advocated 
by those who favor an indiscriminate removal of the uterus for fibrous 
growths. I have stated that this subject has occupied much of my 
attention during the past thirty years, and I may add it is my honest 
belief that no one has succeeded in removing a greater number of 
fibroids from the uterine canal than I have done in the same period. 
It is from an intimate knowledge as to how much good can be ac- 
complished that I have been induced to present this subject for your 
consideration and have done so notwithstanding it necessitates fre- 
quent reference to my own work. Nothing is more distasteful, but 
in justice to myself I must do so, as I originated the method lam to 
treat of and have continuously practiced it for over thirty years. Yet Use of Traction and Morcellation i?i the Removal of Fibroids. 
5 
it is now coming back to us from abroad as an original method, with 
a foreign indorsement and title of “ Treatment by Morcellement.” 
Velpeau and Araussat were the first to enucleate, or, by force tear 
these growths from their bed, and Dr. Sims at an early period of his 
professional life forcibly separated a fibroid with a stout steel instru- 
ment and afterward Dr. Thomas introduced the serrated scoop. But 
by all these means more or less damage was done to the surrounding 
uterine tissues, and a cavity was left with a roughened surface which 
sloughed more or less before the space could become obliterated. 
The procedure I originated is entirely different, and consists in firmly 
seizing a growth with a large tenaculum or double hook and by trac- 
tion to excite sufficient uterine contraction to displace the mass, and 
at the same time by the contraction excited to close up the space 
which had been occupied. Elsewhere I have stated; “ This action 
may be illustrated by the removal of a body from a mass of India 
rubber. If the rubber were stationary and sufficient traction was 
made with a tenaculum, on the body buried in the mass, the process 
would be similar to that by which a tumor becomes pedunculated. 
We have substituted force for the action of gravity, and the natural 
elasticity of the rubber may be likened to the muscular action of the 
uterus. Now, when the body is drawn out from the mass it brings 
with it a portion of the rubber in the shape of a pedicle, and no cavity 
will remain, since the elasticity of the rubber is sufficient to cause it 
to close in behind, pari passu with the advance. And so when trac- 
tion is made on a tumor, with the effect of exciting sufficient muscu- 
lar action, the space which was filled by the growth will immediately 
become obliterated, or at least, there never will remain more than a 
small and unimportant cavity. Great care is taken to do as little 
damage as possible to the tumor until it is evident that the uterus is 
contracting sufficiently to aid in displacing the mass and at the same 
time to obliterate the cavity.” 
Unfortunately the case books for the first six years of my service 
as surgeon in chief of the Woman’s Hospital were lost, or rather 
stolen, some years ago. These six years included much of interest 
in connection with the development of gynsecological surgery, and 
this period covered the most active portion in original work during 
my professional life. In consequence of this loss I can not state 
positively when I began the method of making traction and of remov- 
ing these growths piece by piece as the mass was displaced into the 
canal. But my recollection is very clear in reference to one fact, that 
it was in such an operation that I made the earliest use of the differ- 6 
Thomas Addis Emmet, M. D. 
ent curved scissors I had devised. I hope I may be excused for the 
digression, but while I am substantiating my claims I may well place 
on record in this connection that the profession is indebted to me for 
the introduction and general use of scissors in surgery. With the use 
of different curved scissors many operations in plastic surgery were 
rendered comparatively simple of execution, which would have been 
almost impossible with the knife. But in no class of operations have 
these scissors been of more practical service than within the uterine 
canal for the removal of fibrous growths. My impression is that dur- 
ing the winter of 1861 and 1862 I first employed traction for the pur- 
pose of removing fibroids and shortly after used the scissors. How- 
ever, I will quote from a paper termed “ Treatment and Removal of 
Fibroids from the Uterus by Traction,” which was read by me before 
the Medical Society of the State of New York in February, 1875, and 
was published in the volume of Transactions of the Society for that 
year. 
I shall make an extract at some length from this article and cite 
several of the cases which are equally as well fitted now for illustrat- 
ing the subject, as they were when selected for the purpose over 
twenty years ago. 
<l It is my belief, as the result of observation, that fibrous tumors 
become pedunculated only when situated at a point where the force 
of gravity can be exerted. This force acts as a source of irritation to 
excite the muscular fibers of the uterus to contraction. I have also 
noted that the muscular fibers throughout the whole organ do not 
contract equally. 
“ But there are many cases where the tumor is not so favorably 
situated, where the action of gravity can not be exerted, and where 
uterine contraction, if excited, is lost and inert in displacing the 
tumor from its bed. 
“ For the relief of a large number of these cases it has been my 
practice to excite uterine contraction by making traction on the 
growth. This action I have continued until the tumor becomes 
pedunculated from being crowded out of its bed by muscular con- 
traction closing in around and behind the mass. As an illustration 
of this action we may imagine the removal of a body by traction 
from a mass of India rubber, where the contractility of the substance 
would be sufficient to close in behind, as the advance was made, and 
obliterate the cavity on the withdrawal. 
“ My attention has been directed to this subject for a number of 
years, but the development of my views to the present standpoint Use of Traction and Morcellation in the Removal of Fibroids. 
7 
has been very gradual. But I can not demonstrate this progress 
better than to present somewhat in detail several prominent cases, 
which have stood by the way as so many signposts. 
“In 1863 a patient was admitted to the Woman’s Hospital with a 
fibrous tumor, distending the uterus to the size of full term, a portion 
of which filled the vagina and had already begun to slough. I could 
form no idea by a digital examination as to its attachments. I ap- 
plied a pair of forceps, with the view of delivering the mass until I 
could reach the base, around which I intended to have applied the 
chain of the ecraseur. My efforts, however, were fruitless, as the 
tumor was too large above to enter the pelvis. Fearing to leave the 
patient in this condition, I passed, with the aid of Couch’s cannula, a 
stout twine around the mass, as high up as I could, within the uterine 
cavity. To the end of the cord I made a slipknot and strangulated 
the mass to control the haemorrhage which I anticipated. Steady 
traction was made on the cord by an assistant, for fear that haemor- 
rhage would occur should the noose become relaxed. I proceeded 
to remove the mass, piece by piece, with the aid of a large tenaculum 
and a pair of properly curved scissors. After I had taken away a 
large portion, 1 was surprised that the vagina continued to be occu- 
pied by about the same-sized mass as at the beginning. But I was so 
much occupied with the work immediately before me, that I did not 
notice the gradual decrease in the size of the uterus until near the 
close of the operation. As I advanced the cord was cut by accident. 
There was no bleeding, so I introduced my hand within the vagina 
and proceeded with the operation by pulling down, with the tenacu- 
lum, portion after portion, until the pedicle was reached. I thus re- 
moved the whole tumor with scarcely the loss of an ounce of blood 
after the traction had been commenced. I noted the blanched ap- 
pearance of the mass remained the same after cutting the cord as 
the strangulated portion did after the blood which it contained had 
escaped. It was a matter of the greatest surprise to me, for which I 
could offer no explanation, that the pedicle for such a mass should 
not have been larger in diameter than the index finger. Previous to 
the operation I had supposed the greater portion of the tumor was 
buried within the uterine tissue. At the termination of the operation 
the uterine canal was barely five inches in depth. The mass con- 
tained a number of cysts of various sizes, and the quantity of fluid 
which escaped could not be estimated, but the pieces of the tumor 
weighed together nearly seven pounds. The patient recovered with- 
out a bad symptom. 8 
Thomas Addis Emmet, M. D. 
“ From this time I have seldom used the ecraseur, but have removed 
with scissors any growth within the uterine canal which I could 
reach. I have had no fear of haemorrhage, for this case taught me 
that it could be controlled in the manner I have described. 
“ In February, 1867, a patient was admitted to the Woman’s Hospi- 
tal with a large fibrous tumor imbedded in the greater portion of the 
anterior wall of the uterus. The tumor encroached on the uterine 
cavity, but only so far as to give a marked curve to the canal, as 
nearly the whole was interstitial. The case was under the care of 
Dr. John G. Perry, then one of the assistant surgeons, who, by my 
advice, continued the use of sponge-tents for some two months or 
more. After an absence of several weeks she returned to the hospital 
in consequence of continued pain from uterine contraction. The os 
was found dilated to some four inches in diameter, with the tumor 
presenting as a child’s head. A broad attachment could now be felt 
just above the vaginal junction, somewhat less in width than the por- 
tion of tumor occupying the canal, while previous to leaving the hos- 
pital merely a uniform projection existed. June 3d, I operated by 
passing well up into the canal a large tenaculum, and by steady trac- 
tion drew down or rolled out into the vagina a large portion of the 
mass. I took out with a pair of scissors a large wedge-shaped por- 
tion, and as the traction had already excited uterine action, I removed 
piece after piece, as the tumor could be drawn down, until the uterus 
had been emptied. When the pedicle was divided it was less than 
half an inch in diameter, and was formed by the capsule covering that 
portion of the base of the tumor which was nearest to the uterine 
outlet at the beginning of the operation. The location of the pedicle 
at this point, I have noticed, has been without an exception. I have 
referred to the recorded history of the case, and find that the depth 
of the uterus was not noted, but my impression is that it was eight 
inches previous to the operation. The lower portion of the base was 
felt just within the cervix, and the attachment of the tumor extended 
from that point to the fundus. The base therefore could not have 
been less than seven inches in length, with a width of from three to 
four inches. I purposely commenced the traction as high up as pos- 
sible, and away from the lower portion of the base. I excited muscu- 
lar action at the fundus, where it seems always to be greater than in 
any other part of the organ. As I rolled out the tumor from above, 
its separation advanced from this point downward as the uterus con- 
tracted cn the diminishing size of its contents. The portions of this 
tumor weighed together four pounds and a half. Use of Tractio?i and Morcellation in the Removal of Fibroids. 
9 
“ A case similar to the first one given was admitted to the hospital 
in 1869, in the service of Dr. George T. Harrison. The vagina was 
filled by a portion of the tumor, which had begun to slough, and the 
patient already presented the symptoms of blood-poisoning. I used 
a cord for the purpose of making traction in the beginning, but after- 
ward drew down the tumor as I have described, and removed it piece- 
meal. The pedicle was not larger than the index finger, yet previous 
to the operation I am certain that fully one third of the tumor was 
interstitial. This seemed to be the case, at least so far as the opinion 
could be based on the passage of the sound as an indication of the 
depth of the uterine canal. This tumor was also filled with cysts and 
their contents lost, but the portions removed weighed a little over five 
pounds. 
“ December 8, 1874, as I was about to commence my clinic at the 
Woman’s Hospital, Dr. Whitwell, the house surgeon, informed me 
that he had been obliged to substitute a patient just admitted, for 
operation, whom I had not examined. While she was being etherized 
I learned that during her last labor, three years previous to admission, 
her physician had been obliged to remove a large growth from the 
uterine cavity, which had obstructed the delivery. Menstruation had 
been free, lasting a week; and for a profuse leucorrhoea, with a con- 
stant bearing down and a backache, she had sought relief. The 
doctor had examined the case and reported the existence of a large 
mucous polypus projecting from the os uteri. The speculum exposed 
a soft vascular growth as large as an English walnut, with an attach- 
ment to the posterior lip almost as great. There had been double 
lateral laceration of the cervix, and although this growth was outside 
of the uterine cavity, it really sprang from a surface which formed a 
part of the cervical canal before the accident. The appearance of the 
tumor was unusual and led to further examination. I found the uterus 
very wide from before backward for its apparent depth, and from the 
rectum detected a deep depression near the fundus, as if from inver- 
sion. But the passage of the sound forward five inches indicated the 
presence of a fibrous tumor in the posterior wall, extending nearly to 
the fundus without encroaching on the uterine canal. The growth 
was very soft, and bled profusely in consequence of the tenaculum 
tearing out on making the slightest traction. I therefore resorted to 
my favorite means for the purpose—a cord with a slipknot. The 
tissue of the pedicle, which had been drawn out, was dense, and I 
soon discovered that it was inclosed within a sheath having an origin 
beyond the submucous surface. I divided with the scissors the sheath Thomas Addis Emmet, M. D. 
around the supposed pedicle, close to the uterine surface, and pro- 
ceeded to make traction as I separated the tissues with my index 
finger. I was soon satisfied that it was a portion of the fibrous tumor 
occupying the posterior wall of the uterus, and having advanced so 
far I had no alternative but to enucleate the whole tumor. In the 
course of half an hour I succeeded in drawing out from its capsule a 
mass some four inches in length, round, and of nearly uniform thick- 
ness throughout of an inch and a half in diameter. In the beginning, 
while making steady traction, I confined myself to separating the 
tumor from its capsule as it presented itself at the opening. The 
haemorrhage was profuse and increased so rapidly when I had with- 
drawn about half of the tumor that I hastened the operation by intro 
ducing my finger and breaking up its attachment in advance. After 
the mass had been removed I found the cavity was two inches and a 
half in depth, with the remaining posterior wall of the uterus so thin 
that I was surprised it had not been ruptured. An equally thin sep- 
tum existed in front, between the cavity and the uterine canal, which 
had not been entered. The traction had excited the muscular uterine 
tissue to action, and the size of the organ had materially lessened ; 
but the posterior wall being so thin, the contractile force seemed lost 
in that direction. Notwithstanding the depth of the cavity had been 
shortened an inch and a half, it was my impression its capacity had 
been but little diminished, since its width was greater than that of the 
tumor after its removal. A portion of the capsule presented at the 
opening, which I seized with a tenaculum, and drawing down all 
which was loose, removed it with the scissors. The patient was now 
placed on the back, over a bedpan, and the cavity washed out with 
a quantity of very hot water, by means of a Davidson’s syringe. She 
was afterward replaced on the left side, and Sims’ speculum intro- 
duced, as at the time of the operation. The cavity was dried by a 
large sponge probang, and as soon as it was withdrawn twro drachms 
of Churchill’s tincture of iodine were injected. By use of the hot 
water the size of the cavity was greatly reduced and the bleeding 
diminished, but the iodine contiacted it still more, and entirely 
arrested the haemorrhage. Some pledgets of cotton saturated with 
glycerin were introduced into the cavity, now about an inch and a 
half in depth, and the vagina was moderately tamponed with cotton 
dampened with a solution of alum. On the second day after the 
operation all dressings were removed and the cavity carefully syringed 
out with warm water, to which had been added some carbolic acid- 
This treatment was continued from day to day without a bad symp- Use of Traction and Morcellation in the Removal of Fibroids. 
Tom presenting, and the cavity rapidly decreased in size. December 
19th, eleven days after the operation, the temperature suddenly rose 
to 103°, and symptoms of blood-poisoning were detected. A specu- 
lum examination was made, and a sloughing mass exposed, which at 
first glance appeared to be the posterior lip. I found that it was a por- 
tion of the capsule protruding, behind which a cyst had formed, con- 
taining about two ounces of a thick gelatinous fluid. After puncturing 
the cyst I removed the remains of the capsule by means of scissors 
and by tearing it away with a strong forceps. There was some bleed- 
ing, but the quantity was not excessive. Curiosity prompted me to 
pass my finger to the bottom of the cavity, when I detected another 
fibroid, a little smaller than a pigeon’s egg, just projecting sufficiently 
to map out its size. This I seized with a strong tenaculum, and as 
traction was made by Dr. Whitwell I cut it out from its bed with a 
pair of curved scissors. The uterus contracted promptly on its re- 
moval, and it was beyond question due to the presence and position 
of this little fibroid that the cavity had not been more reduced in size 
at the time of the first operation. I again injected the iodine, and as 
it excited the uterus to further contraction the bleeding was entirely 
arrested. January 7th I found the cavity from which this tumor had 
been removed now obliterated, and the uterus three inches deep. On 
the 12th instant she was discharged cured from the hospital.” 
The histories of other successful cases are to be found in my work 
on the Theory and Practice of Gyncecology, and examples also are given 
showing the cause of failure and of death in other instances. 
I have frequently seen where the removal of a single fibroid from 
its bed by traction has accomplished a radical cure. But occasion- 
ally the removal of such a tumor seems but to make room for others 
which develop rapidly, and have then to be removed one after the 
other. 
The history of the following patient is of interest in showing how 
it is possible to hold these growths in check, and that a woman afflicted 
with them may be carried through a series of years, even to an im- 
provement in her condition, with a very fair prospect of final restora- 
tion to health if she be able to resist, as I fear this patient will not, 
the urgency of some of her friends for extirpation : 
Mrs. C. came under my observation for the first time early in 1882, 
when I saw her in consultation. She was then suffering from an en- 
largement of the uterus with some pelvic inflammation. I did not see 
her again until December 30, 1887, when she applied for admission to 
my private hospital, and the following history was then obtained : 12 
Thomas Addis Emmet, M. D. 
Her age was thirty-two. She had menstruated for the first time 
at fifteen, was regular from the first, and continued in good health 
until she had reached nineteen years of age, when menstruation began 
to be painful. But, according to her statement, she took no care of 
herself, and committed every excess within her power by overexercise 
in dancing and horseback riding. After she had reached the age of 
twenty-one menstruation became very irregular, as well as painful, 
and she was frequently six months at a time without its appearance. 
She married at twenty-five and was sterile. For some time previous 
to marriage she had become again regular, with a flow lasting five days, 
and her general health was apparently fully established.. But the first 
menstrual flow after marriage was too free, and with it she had con- 
stant pain behind the left hip which continued for eight days, accom- 
panied by irritability of the bladder. She became an invalid from 
the time of this menstrual period. I found her local condition some- 
what changed from what it had been five years before. The uterus 
was still enlarged but rather irregular in shape, and on the anterior 
wall, close to the junction with the bladder, a subperitoneal fibroid, 
as large as an almond, projected toward the bladder in the shape of a 
spur. The uterus had but little mobility in consequence of an exten- 
sive pelvic inflammation which existed on both sides and behind the 
uterus, a condition which had been caused, or had been greatly aggra- 
vated, by an ill-fitting pessary which she had worn for over a year with- 
out having had it looked to. 
Mrs. C. remained an inmate of my private hospital for a year be- 
fore her condition admitted of dilating the uterine canal with safety, 
and in that time the uterus had nearly doubled itself in size, notwith- 
standing the surrounding inflammatory condition had been removed 
by treatment. 
December 12, 1888.—The uterus was dilated with a large sponge 
tent; this was removed on the following day, and the vagina and 
uterine canal was washed out with a strong solution of the bichloride 
of mercury. Then by the use of graduated and large dilators the ca- 
nal was sufficiently opened to form a diagnosis and for the removal 
by traction and scissors of two fibrous growths. One of these was as 
large as a hen’s egg, and was almost entirely buried in the posterior 
wall ; the other was situated in the fundus, and was as large as a 
pigeon’s egg. I suspected from the shape of the uterus that another 
growth was developing in the fundus, but was unable to detect its 
situation. In this operation I was assisted by my son, Dr. J. Duncan 
Emmet, and by Dr. Buckmaster. Use of Traction and Morcellation in the Removal of Fibroids. 
On January 28, 1889, with Dr. Frederick Whiting to administer 
the ether, and with the assistance of Drs. J. D. Emmet and Buck- 
master, I proceeded to remove the subperitoneal fibroid from the an- 
terior wall of the uterus, which had by this time grown as large as an 
English walnut. With a pair of scissors I carefully separated the 
bladder from the uterus, while steady traction toward the vaginal out- 
let was exerted on the vesico-vaginal flap until the bladder had been 
sufficiently separated and the tumor reached. Then, with a strong 
tenaculum, the growth was seized and drawn well down into the 
wound, fully in view, and so held until I had succeeded in separating 
the peritonaeum, which was attached over the upper portion. Having 
done this without rupture the tumor was then twisted on itself by 
means of the tenaculum, which was deeply buried into the mass. The 
twisting was made with traction in one direction and then in the oppo- 
site one, while at the same time the mass was being separated from 
the uterine tissue with the finger nail as the parts presented at the sur- 
face. In a few moments the separation was accomplished, and not- 
withstanding the mass was apparently about one half buried in the 
uterine tissue, when it was drawn out the muscular tissue had con- 
tracted so promptly as to leave no cavity, and only a slightly depressed 
surface about an inch in diameter. The circular artery, which was 
very large on the right side, was pushed out of the way, but I felt it 
pulsating against my finger while working. 1 only regret that it did 
not occur to me to ligate it. which could have been done without the 
slightest difficulty. With a partially curved needle armed with the 
silk loop and silver wire I introduced seven silver sutures to unite 
again the bladder to the uterine wall. The first suture included more 
tissue than the others, and brought up the bladder in contact with the 
uterus, so as to close the wound from the peritonaeum. As the angle 
of the wound was drawn by a tenaculum toward the vaginal outlet 
and the sides put on the stretch, each suture was passed from the 
vaginal surface through the connective tissue into the uterine wall so 
as to catch up a portion of the denuded surface, through the connect- 
ive tissue on the other side and out into the vagina. Each suture in- 
cluded less tissue than the preceding one, until at length the bladder 
and anterior wall of the uterus were drawn together and restored to 
their original relation. She made a more rapid convalescence than 
she had done before, and her health became greatly improved after- 
ward. 
Early in 1893 the uterus began again to increase in size and the 
flow became more profuse. March 10th I concluded that the uterus 14 
Thomas Addis Emmet, M. D. 
was being overnourished by an increased supply of blood which 
reached it through the old peritoneal adhesions, and I decided to open 
the abdomen, separate these adhesions, and, if possible, to remove the 
ovaries. I succeeded in breaking up a large number of these adhe- 
sions attached to the uterus, and which doubtless furnished it with a 
large blood supply, but was not able to find the ovaries or do more, as 
she suffered from shock. Her convalescence was very tedious, and 
for several days her condition was not promising ; but she wonder- 
fully improved after the operation and ceased to have any loss of 
blood, but at the menstrual period—in fact, when she could be in- 
duced to take care of herself the period would last but a week, and 
the quantity would not be excessive. 
When I saw her last, toward the close of April, the uterus had be- 
come reduced at least one third in size, but in the shrinkage three sub- 
peritoneal fibroids had become more prominent. She is now over 
forty-two years of age, in good general health, and had passed six 
weeks without a period. Yet I found her nervous system upset through 
the influence of some friend who had been urging that she should 
have the uterus removed “to make a well woman of her.” The object 
of her visit was to ask that I would operate, as her confidence was as 
great in me, but I declined doing so for the several reasons just men- 
tioned. 
The use of ergot is, in my opinion, of doubtful efficacy unless it be 
employed under very favorable circumstances. It is certainly of no 
value for the purpose of expulsion if the tumor be so situated that 
gravity can not act, and unless the uterine canal be kept fully dilated 
at the time it is being administered. The injudicious use of ergot has 
done a great deal of harm by cutting off the proper supply of blood, 
with the consequent death of the tumor and blood poisoning after- 
ward. The action of ergot is, I believe, exerted not directly on the 
muscular tissue of the uterus itself, but upon the muscular structure of 
the blood-vessels, and especially on those distributed to erectile tissue. 
Its action, therefore, is only an indirect one on the uterus, by causing 
the vessels to contract. By thus diminishing the supply of blood to 
the organ, its muscular tissue will contract upon itself to fill the space 
which would be otherwise occupied were the usual circulation main- 
tained. I have known of a number of deaths from blood poisoning 
which resulted directly from the empirical use of ergot, and I can re- 
call two instances of pyaemia with the difficulty increased by abscess 
in the parotids and of one in the liver. 
The following case had been treated by large doses of ergot for Use of Traction and Morcellation in the Removal of Fibroids. 
months before she came under my observation, and the treatment had 
been continued apparently without the slightest idea as to the pelvic 
condition, beyond supposing, from the loss of blood, that she had a 
fibrous tumor : 
December 25, 1893, I was requested by Dr. Robert Milbank, of 
New York, to see Mrs. H. in consultation at one of the hotels. As a 
result of the consultation, and by his advice, she was admitted to my 
private hospital on the next day. I then obtained the following 
history : 
Mrs. H., of North Dakota, aged forty-three, had menstruated for 
the first time at sixteen, with no trouble. Married at seventeen and 
had had one child fifteen years before by a natural labor. From the 
first menstrual period after this labor the flow had been too free, and 
for several years it came on every three weeks, flowing always very 
freely but with uncertain duration. She stated that she had been tak- 
ing a preparation of ergot daily for some months, and as well as she 
could recollect there had been a tendency for weeks to fever every 
afternoon, with sometimes sweating after, and she had been steadily 
getting weaker during this period, but had suffered no pain. Her 
appearance was indicative of having suffered from loss of blood and 
very suggestive of malignant disease. At the same time her mental 
faculties seemed greatly blunted, in so much that it was difficult to 
elicit from her a very clear statement as to her previous history, and 
the greater portion had to be obtained from her husband. 
The uterus was found enlarged, lying forward and not very mov- 
able, as there had been at a comparatively recent period an extensive 
pelvic peritonitis. 
January 1, 1894, I operated, Dr. Milbank being present, Dr. Buck- 
master administering the ether, and Dr. J. D. Emmet assisting me. 
The uterine canal had been packed two days before with iodoform 
gauze and this was first removed. With great difficulty the index fin- 
ger was gradually advanced toward the fundus. The presence of a 
fibroid was easily detected at the fundus, in front and to the left side, 
and but partially projecting into the canal. With the finger in the 
canal and one hand over the abdomen it was estimated that the tumor 
was as large as the closed fist. By means of a stout tenaculum the 
mass was gradually dragged down, and out of its bed, through the slit 
which had been made with a pair of scissors into the uterine tissues 
covering it. The tumor was slowly separated from the uterine tissue 
by stripping it back in the opposite direction with the finger and scis- 
sors as the mass passed into the canal. When the tumor by this means Thomas Addis Emmet, M. D. 
had been about half delivered from its bed, a portion of the mass was 
cut out in a cone shape from around the tenaculum with a pair of 
sharp-pointed scissors. It was then made evident that the center of 
the tumor had begun to break down, and the pus, although not more 
than a drachm or two, was very offensive. As the central portion was 
too soft to make traction upon it, the efforts tor removal were limited 
to that part of the tumor nearest to the fundus, and the separation 
was made from above downward. In an hour 1 succeeded in remov- 
ing, piece by piece, fully two thirds of the mass, and with apparently 
all of the central portion which had begun to break down. But her 
general condition had been most unpromising from the beginning, 
with every indication of a collapse at an early stage. At length I was 
obliged to desist after hastily washing out the canal with a weak solu- 
tion of the bichloride of mercury and repacking it with strips of gauze, 
she remained in a critical state for fully twenty-four hours after the 
operation, and it was moreover exceedingly difficult to rouse her ; the 
pulse became rapid and weak, wilh some rise of temperature, occa- 
sional sweating, and with every indication that she was still suffering 
from blood poisoning. On the following day 1 removed the gauze, 
washed out the uterine canal, and with great difficulty replaced the 
uterine tampon. After an interval of twenty-four hours longer it be- 
came most evident that to save her life it was necessary to remove 
without further delay from the uterus the cause of the blood poisoning. 
Ether was carefully administered and at length I succeeded in 
getting away the remaining portion of the tumor, which it was found 
had also begun to slough. It was noted that the uterus had decreased 
in size fully one half from what its bulk was before the operation. A 
strong application was made to the fundus and over the site of the 
tumor with carbolic acid and glycerin, and the canal was repacked 
with gauze The pieces of this fibroid after removal weighed together 
three quarters of a pound. 
After twenty-four hours the gauze was taken away and the uterine 
canal for several days was thoroughly washed out from time to time. 
Fully a week passed after the last operation before the dullness of her 
mind cleared up. The convalescence was tedious, but in four weeks 
she was well enough to return home, at which time the uterus had re- 
gained its normal size and she had one natural period. 
Just one year after the operation this woman walked into my office 
in perfect health to thank me and so changed was she that I did not 
know her. She was most grateful and stated that she had never been 
in such perfect health. While she was an inmate of my hospital I Use of Traction and Morcellation in the Removal of Fibroids. 
had learned how careless she had always been in taking care of her- 
self, and on this occasion I scolded her for being so lightly clad for 
the season and her answer was that she never took cold. Within a 
few hours after she was on her way to Washington and was exposed 
during a sudden change in the weather. Eighteen hours after, pneu- 
monia developed and in three days from her visit to me she was dead. 
I feel that it is not necessary to offer the histories of any addi- 
tional cases to illustrate the subject. Great dexterity for removing 
these fibroids by traction and in section can only be acquired by 
practice. Not only does this experience afford the greater facility 
for working in so confined a space, but greater judgment is acquired 
in avoiding perforation of the uterine wall and in doing the least 
amount of injury to the tissues not immediately involved with the 
fibrous growth. But there are several points which should be fully 
appreciated and borne in mind beforehand, rather than that the 
knowledge of the necessity should have to be acquired by experience. 
As the portion, or pedicle, which is divided in making the final 
separation must always be situated at the lowest part of the growth, 
namely, that nearest to the mouth of the uterus, it is necessary always 
to begin the traction as far off as possible at the upper portion. 
The strong hook buried in the tumor should be twisted on itself 
so as to keep the point as much as possible toward the canal and 
away from the direction of the uterine wall. And for the same reason 
the points of the scissors also when in use should always be made to 
cut toward the center and upon the finger, which must be kept in the 
uterine canal, and thus the operator will be able to judge of the prog- 
ress made. 
As soon as the upper portion of the tumor is displaced, and the 
uterus responds by contracting, it is better as far as possible to con- 
tinue the separation above, and by working from above downward, 
stripping the uterine tissue with the finger nail back from the tumor 
as it projects into the canal. It is better never to attempt to dig, as 
it were, the tumor out of its bed, unless there should be some special 
reason for doing so. Nor should any portion of the tumor be cut off 
until it begins to block tlie way, and only when the uterus is contract- 
ing. When a part is cut away a sufficient portion should always be 
left, projecting into the canal, with which to make traction for the 
purpose of displacing the remaining part of the tumor. 
The traction exerted on the tumor is not to be made by dragging 
the uterus in the axis of the vagina down toward the outlet. But it 
is to be exercised by a twisting movement laterally in one direction Thomas Addis Emmet, M. D. 
and another, and when made downward the uterus must be steadied 
by means of a counter pressure made by the finger in the uterine 
canal against some part of the tumor, or in its neighborhood, as the 
mass is being separated with the finger nail or scissors. 
Whenever there is a marked difference in the density of the 
tissues it will be possible to separate the tumor rapidly from its bed 
and with this condition the uterus generally contracts promptly. 
Under these circumstances the operation is almost a bloodless one, 
but when the tumor has grown rapidly, and its structure and density 
is'about the same as that of the uterine tissue, the bleeding is often 
excessive. It becomes then often an impossibility to separate such a 
growth with “ clean delivery.” In the effort to remove it a large por- 
tion of the mass will become frayed out or in shreds, a condition 
likely to end in blood poisoning, as these shreds not being properly 
nourished soon begin to slough. It is better to desist at an early 
stage and as soon as the condition can be recognized, then wash out 
the canal and pack with gauze. If in twelve hours, on removing 
the packing, it be evident that the uterus has made no progress in 
expelling the growth by contraction and if there should be any evi- 
dence that sloughing had begun, then, with our present experience, 
the proper practice is to remove the uterus without delay or the pa- 
tient will ultimately die from blood poisoning. Yet I have known of 
several instances where the patient in time made a good recovery and 
under apparently the most unfavorable circumstances of exposure to 
blood poisoning, as the mass slowly sloughed away. 
The means at our command for fully dilating the uterine canal are 
still defective and unsatisfactory. Nothing which has yet been em- 
ployed for the purpose has proved so effective as the sponge tent, 
and our future advance will rest greatly upon some improved method 
for preparing these so that they may be used with safety. I have 
yielded to the feeling of prejudice generally held by the profession 
against the use of sponge tents, and have not had the courage to 
employ them for some years past. But at the same time I believe 
that if they were properly prepared and the patient was properly 
cared for at the time of their use, little danger would be incurred. 
This does not seem to be an unreasonable expectation, for if a sponge 
can be made innocuous to the peritonaeum, certainly its use might 
be rendered safe in the uterine cavity. Our individual experience 
must necessarily carry a certain amount of weight in forming an 
opinion and the views I have expressed have been so influenced. 
During a number of years I used sponge tents fearlessly and they Use of Traction and Morcellation in the Removal of Fibroids. 
were prepared specially by a nurse who had no idea of the necessity 
for any aseptic precaution beyond perfect cleanliness and the free 
use of turpentine-soap and water. I can scarcely recall an instance 
of any trouble after the use of tents prepared by this woman, cer- 
tainly I never had any serious difficulty. It was then my practice 
to employ sponge tents several times a week, and often for months 
consecutively, in special cases when dilating the uterus for the descent 
of fibrous growths. Frequently I used then at that time with cases 
of subinvolution, before I had learned the close relation of this lesion 
to a laceration of the cervix. I then employed the tents, as I wished 
to excite by their use both pressure and drainage, leaving them in- 
frequently for two days before removal, and would then irrigate the 
canal with a stream of hot water until it had contracted. 
This nurse at length married and left my service ; I then purchased 
the tents I needed from Mary Smith, the old nurse who had served in 
the Woman’s Hospital, It was supposed that she had learned the 
art from Margaret Brennen, the head nurse, who had been as careful 
and trustworthy in preparing these tents as the nurse in my private 
hospital. For a time Mary Smith did a good business, as her tents 
were beautifully made, but I, in common with every one who used 
them, soon began to have not only inflammatory trouble set up, but 
had every now and then an unaccountable death. It was at length 
found that this woman carried off all the sponges used in the laparot- 
omies done at the Woman’s Hospital, which had been intrusted to 
her to burn after each operation. As she supplied the instrument 
makers, as well as most of the gynaecologists in New York at that time, 
the consequences of her devilish work were soon widespread through- 
out the country. 
After getting the sponges surgically clean, I believe the remaining 
difficulty would consist in being able to sterilize the saturated solution 
of gum arabic which is needed to stiffen the sponge and render it the 
easier of introduction. Possibty this can never be accomplished with- 
out destroying its peculiar properties and compressed sponge may 
have to be employed at times as a substitute for the gauze. While it 
is quite possible with the use of gauze to dilate sufficiently the uterine 
canal previous to an operation for removing some growth, it is not so 
effective as the sponge tent for dilating week after week for the grad- 
ual projection of the fibrous growth into the canal. Moreover, the 
sponge tent is of easy introduccion comparatively, while placing the 
gauze is often painful and necessitates the frequent use of ether. 
It is more necessary than for any other operation in gynsecology 20 
Thomas Addis Emmet, M. D. 
to observe, with the minutest detail, every known aseptic precaution 
in preparing both the patient and the materials needed for an exami- 
nation or operation within the uterine canal. As my remarks are ad- 
dressed to experts it is not necessary for me to enter into detail as to 
how these measures are to be carried out. I would urge that in all 
cases of fibrous growths of the uterus the operation for removal of the 
uterus should be delayed for a reasonable time, unless there should 
be some urgent and special reason for doing otherwise. This delay 
is urged that dilatation might be honestly tried since my experience 
has clearly shown that it is not possible beforehand to form the slight- 
est opinion as to what can be accomplished in any individual case 
from continued dilatation. 
Where a large fibroid develops, with several smaller ones in the 
neighborhood, it frequently happens that the larger growth is crowded 
outward and becomes subperitoneal as a result of uterine contraction, 
the force of which is always lost, or broken up, in the direction of the 
uterine canal from the presence of the smaller growths. In several 
instances I have recognized this condition and after having removed 
by traction the smaller tumors, the larger one has eventually become 
pedunculated, as soon as the uterine contraction, with the aid of 
gravity, could act together in forcing it out in the direction of the 
least resistance. 
Finally, as to the origin of these growths I am led to believe, as the 
result of my observation, that nearly all fibrous growths have their 
beginning, not only in muscular tissue but near to the uterine canal, 
where the functional activity is the greatest and where they would be 
better nourished. I, moreover, believe the natural tendency for such 
a growth is to advance toward and finally to project into the uterine 
canal. 
I believe the time may come when it will be found that the origin 
of these growths, from the tissues surrounding the uterine canal, is 
always due to perverted nutrition. And they seem to have some close 
connection in their genesis with the changes following menstruation 
in anticipation of pregnancy. Hence their origin, as a result of per- 
verted nutrition, would occur with those women in which the true 
function of the uterus had been sacrificed through want of the needed 
stimulus of pregnancy. This view would seem to be substantiated 
by the well-known fact that child-bearing women rarely suffer from 
these growths, and when they do exist with pregnancy they so fre- 
quently disappear before involution occurs, that their removal can not 
be attributed to an accidental cause.