TREATMENT AND REMOVAL 
OF 
FIBROIDS FROM THE UTERUS 
BY 
TRACTION. 
By THOMAS ADDIS EMMET, M. D., 
Surgeon of tlie Woman’s Hospital of the State of New York. 
NEW YORK: 
G. P. PUTNAM’S SONS, 
Fourth Ave. and Twenty-Third St. 
1875. TREATMENT AND REMOVAL 
OF 
FIBROIDS FROM THE UTERUS 
BY 
TRACTION. 
By THOMAS ADDIS EMMET, M. D., 
Surgeon of the Woman’s Hospital of the State of New York. 
NEW YORK: 
G. P. PUTNAM’S SONS, 
Fourth Avr. and 23d St. 
1875. TREATMENT AND REMOVAL 
OF 
FIBROIDS FROM THE UTERUS 
TRACTION. 
By Thomas Addis Emmet, M.D., Surgeon to the Woman’s Hospital of the State of 
New York. 
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 fibres of the uterus to contraction. I have 
also noted that the muscular fibres th: oughout the whole organ do 
not contract equally. 
From some change of structure, due to the long-continued pres- 
ence of the tumor, the fibres forming the outer wall of the uterus 
and covering these growths lose to a great extent their contractile 
power. In corroboration it has been noted when marked uterine 
contraction is exerted an apparent sinking in of the sub-peritoneal 
surface takes place, corresponding in extent to the interstitial tumor 
beneath. If the contraction is prolonged, the extent of the de- 
pression will lessen just in proportion as the tumor may be forced 
into the uterine canal. About the circumference of this neutral 
space of uterine tissue, forming the outer wall of the tumor, the 
muscular action is more marked than at any other point—a natural 
result that the greatest action should be in proximity to the seat 
of irritation. This neutral surface, when thus encircled by a con- 
tracting band, continues to be crowded in upon as rapidly as the 
space below becomes vacated, and the tumor pedunculated in pro- 
portion to its advance into the uterine canal. 
This depression I have felt distinctly when the uterus was in a 
state of active contraction ; but it has been a question in my mind 
if any real displacement of this neutral space takes place. I am 
rather inclined to the opinion that a ridge is formed around by the 
damming up, as it were, of the contracting muscular tissue about 
this surface, which acts as an obstruction. 4 
THOMAS ADDIS EMMET. 
When a tumor is situated at or near the fundus we can hasten 
the termination of the case by exciting the muscular fibers with 
the use of ergot, as is the accepted practice; or we may aid the 
action of gravity by dilatation of the outlet, or by incising the 
cervix. 
But there are many eases 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 sub- 
stance would be sufficient to close in behind, as the advance was 
made, and obliterate the canal 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 stand-point 
has been very gradual. But I cannot demonstrate this progress 
better than to present somewhat in detail several prominent cases, 
which have stood by the way as so many sign-posts. 
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 por- 
tion 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 applied 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 Gouch’s canula, 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 slip-knot and strangulated 
the mass to control the hemorrhage which I anticipated. Steady 
traction was made on the cord by an assistant, for fear that hemor- 
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, I was surprised that the vagina continued to be occu- 
pied by about the same sized mass as at the beginning. But I was so REMOVAL OF FIBROIDS FROM THE UTERUS. 
5 
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. 
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 hemorrhage, for this case taught me 
that it could be controlled in the manner I have described. 
A few years after this case I assisted a physician in Newark, N. J.T 
to remove a large tumor from the uterus. A portion of the growth 
presented through a well-dilated os, and the lower portion of the at- 
tachment was within reach on the anterior wall, some two inches 
within the canal. I passed the chain around the growth, but as it 
was being attached to the instrument it slipped from the fingers, and 
it became necessary to re-apply it. The chain was again adjusted by 
her physician, and finally attached to the ecraseur, after great diffi- 
culty, from the fact that it seemed to include a much larger portion 
of the mass than before. The hemorrhage was excessive from the 
beginning, and increased to such an extent tha. it became necessary 
to remove the mass as rapidly as possible. To control the bleeding, 
ice-water was injected into the uterine cavity to excite contraction. 
This was promptly established, but the bleeding was not arrested, 
and the condition of the patient became critical. As soon as the 
ecraseur had cut through and had been withdrawn, I passed my 
hands within the uterus, and found its cavity occupied by two tu- 6 
THOMAS ADDIS KM MET. 
mors, the one above overlapping the other. When I applied the 
chain it passed between them and encircled the lower one, but a 
portion of both had been included in the last adjustment. Passing 
my hand over the abdomen, I felt a sub-peritoneal fibroid, as large 
as a hen’s egg, on the anterior wall near the fundus and to the left. 
I was satisfied the uterus could not contract sufficiently to control 
the hemorrhage with so large a mass attached to its wall and filling 
its cavity. I therefore attempted to break down and tear away with 
my fingers the remains of the tumors. This brought on violent 
uterine contraction, but irregular in course, so that the organ as- 
sumed somewhat of the hour-glass form. I felt the canal suddenly 
encroached upon, and on placing my hand over the abdomen found 
the external tumor had disappeared. Involuntarily I attempted to 
enucleate the presenting mass, by opening the capsule with my 
thumb-nail, when it split, and the tumor escaped so suddenly from 
its bed that my first impression was that rupture of the uterine wall 
had occurred. The uterus now contracted uniformly and rapidly, 
so that the remaining masses were soon removed, and the hemor- 
rhage arrested. This patient convalesced slowly from the great loss 
of blood, but ultimately recovered under the close watching of her 
physician. 
February, 1867, a patient was admitted to the Woman’s Hospital 
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. Abroad attachment could now 
be felt just above the vaginal junction, somewhat less in width 
than the portion of tumor occupying the canal, while previous to 
leaving the hospital merely a uniform projection existed. June 3, 
I operated by passing well up into the cant1l a large tenaculum, 
and by steady traction 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 portion, 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 REMOVAL OF FIBROIDS FROM THE UTERUS. 
7 
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 pre- 
vious 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 possible, 
and away from the lower portion of the base. I excited muscular 
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 
contracted on the diminishing size of its contents. The portions 
of this tumor weighed together four pounds and a half. 
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 afterward drew down the tumor as I have described, and re- 
moved it piecemeal. The pedicel 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 re- 
moved weighed a little over five pounds. 
March, 1874, I received from Dr. D. E. Kissam, of Brooklyn, 
a patient in my private hospital who had long suffered from exces- 
sive hemorrhage. She was so antemic that for nearly a month I 
carefully controlled the loss of blood, and directed my attention to 
improving her general condition before I deemed it safe to attempt 
any operative procedure. The uterus was very much anteverted, 
enlarged at the fundus, and somewhat pear-shaped. The sound 
passed five inches posteriorly to the base of the tumor and three 
inches in front of it. When the condition of the patient admitted 
I dilated the uterine canal fully, and reached the lower portion of a 8 
THOMAS ADDIS EMMET. 
tumor with a base below of some three inches. Every other day I 
dilated the canal and passed high up within it an ergot suppository.. 
These were made by Dr. Squibb of gelatine, glycerine, and the 
aqueous extract, in equivalent to one hundred grains of the pow- 
der. At night one was introduced into the rectum, and on the 
intervening day, in the morning and at night, they were adminis- 
tered by the bowel. Marked uterine contraction followed the use- 
of these suppositories, but the effect was more decided when intro- 
duced directly within the uterine canal. A practical point has been 
overlooked in the treatment of these cases, should it be proved that 
the absorbing power of the uterine mucous membrane is always as 
active as it seemed to be in this instance. Iodine, for example, as we 
all know, is taken up so as to be detected by the taste of the patient 
almost instantaneously. This is the only case in which I have- 
used these suppositories within the uterus, but do not think they 
could have acted merely as a foreign body from the rapidity with 
which they were dissolved. The uterus became broader at the 
fundus, from before backward, and altered in shape so much that 
a projection was formed on the posterior wall as the tumor was 
crowded in that direction; but no advance was made toward the 
uterine outlet, nor did the base lessen in diameter. At the end of 
some ten days I felt satisfied that nothing more could be gained by 
delay. Although the os below was kept fully dilated, the expul- 
sive power was lost, as in a shoulder presentation. No advance 
could be made, as, from the situation of the uterus and the tumor, 
the action of gravity could not be exerted. I decided to remove- 
the tumor with scissors, and placed the patient under ether; but 
at the end of an hour I was obliged to abandon the attempt. I 
could barely reach the most depending portion of the tumor with 
my finger, and failed in getting a loop or any contrivance around 
the growth by which I could draw it down. March 3d. a week 
after, in the presence of Drs. Kissam, George T. Harrison, and Bache- 
Emmet, I again made the attempt. I first retroverted the uterus, 
and then gradually drew it down to the vaginal outlet. When ne- 
cessary the uterus may be thus with safety brought within reach, if 
no cellulitis has existed, and if it is done by gradual traction without 
jerking. The uterus was held in this position by a stout tenaculum 
in the hands of an assistant. I then passed the index linger within 
the uterine cavity as a guide, and seized with a double tenaculum 
the fibroid high up posteriorly. By steady traction in the course 
of half an hour I succeeded in drawing a portion of the tumor REMOVAL OF FIBROIDS FROM THE UTERUS. 
9 
through the os, and for the first time was able to pass my finger 
around the base. The tumor was a half spheroid in shape, situ- 
ated near the fundus in the anterior wall, about three inches in 
diameter at the base, and unusually dense in structure. To give more 
room I removed with the scissors the portion which had been drawn 
out from the os. I introduced my hand within the vagina and the 
fingers into the uterine cavity, gnd made traction on the mass with 
a tenaculum in the other hand. I requested Dr. Kissam to place 
his hand over the fundus to steady the organ and press it down 
into the pelvis. The uterus was'now contracting with great force, 
and as I crowded my fingers in around the base to aid the process 
of pedunculation, if I may use the term, I could feel the con- 
tracting wave passing in a spiral or an oblique direction around 
the uterine, walls. The muscular contraction was more marked 
immediately around the base, as it seemed to crowd up on the 
tumor. Suddenly Dr. Kissam informed me that the uterus was 
becoming inverted, and I noticed at the same time that the base of 
the tumor was lessening in diameter. I passed my hand over the 
abdomen, and as the uterus contracted I could feel the cup-like 
depression distinctly through the relaxed abdominal wall. I was 
pleased at the prospect of the inversion, for I felt satisfied after 
enucleating the tumor I could easily replace the uterus. I there- 
fore redoubled my efforts to bring about this condition, but noticed 
the size of the depression diminished as the base of the tumor 
became smaller. This depression may have been accidental, 
or it may have been more marked in consequence of the violent 
uterine contraction, and in extent would necessarily bear a relation 
to the size of the tumor imbedded beneath. These are points 
which must be settled by future observation. But in watching 
this case, with my fingers encircling the base of the tumor, while 
the uterine tissue was contracting around it, I realized for the first 
time the manner in which a growth becomes gradually peduncu- 
lated as the force of gravity comes into play. It was now evident 
to me that the traction which I had practised for years, without 
appreciating cause and effect, had produced the same result. T 
also appreciated that the uniformly attenuated pedicel, which T 
had always noticed had been a natural result of the traction I had 
employed, and not accidental. Early in the operation I called the 
attention of the gentlemen present to the appearance of the portion 
of the tumor which I had drawn out beyond the labia. As I 
made traction to excite the muscular action of the uterus, the 10 
THOMAS ADDIS EMMET. 
mass became blanched, and remained so as long as the action was 
kept up. After the uterus, however, had begun to force the tumor 
out of its bed, this bloodless appearance became permanent. In 
this case, as is the rule, 'the pedicle was formed at the lowest point 
of the base nearest to the uterine outlet. It was unusually small, 
and when divided was not larger than an ordinary lead pencil, and 
yet the base was about three inches in diameter at the beginning. 
This was fully appreciated by the gentlemen who assisted me, for 
on making the examination but a slight pit or depression could be 
detected with the finger to mark the point of attachment. The 
operation lasted an hour and a half, and when completed the 
uterus was three inches and a half in depth. After the operation 
I carefully replaced the uterus with the finger to its normal position 
in the pelvis. This patient made a rapid recovery, and within a 
week has visited me in perfect health. 
December 8, 1874, as I was about to commence myelinic 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 ether- 
ized 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. Men- 
struation had been free, lasting a week ; and for a profuse leucor- 
rhoea, with a constant bearing down and a backache, she had sought 
relief. The doctor had examined the case and reported the exist- 
ence 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 attachment 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 acci- 
dent. The appearance of the tumor was unusual and led to far- 
ther examination. I found the uterus very wide from before back- 
ward for its apparent depth, and from the rectum detected a dee}) 
depression near the fundus, as if from inversion. 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 with- 
out 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 
rpeans for the purpose—a cord with a slip-knot. The tissue of the REMOVAL OF FIBROIDS FROM THE UTERUS- 
11 
pedicle, which had been drawn out, was dense, and I soon discov- 
ered that it was inclosed within a sheath having an origin beyond 
the submucous surface. I divided with the scissors the sheath 
around the supposed pedicel, 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 ad- 
v meed so far I had no alternative but to enucleate the whole tu- 
mor. In the.course of half an hour I succeeded in drawing out 
fVom its capsule a mass some four inches in length, round, and of 
nearly uniform thickness throughout of an inch and a half in di- 
ameter. In the beginning, while making steady traction, I con- 
fined myself to separating the tumor from its capsule as it present- 
ed itself at the opening. The hemorrhage was profuse and in- 
creased so rapidly when I had withdrawn about half of the tumor 
that I hastened the operation by introducing my finger and break- 
ing up its attachment in advance. After the mass had been re- 
moved 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 sur- 
prised it had not been ruptured. An equally thin septum 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 capac- 
ity had been but little diminished, since its width was greater than 
that of the tumor after its removal. A portion of the capsule pre- 
sented at the opening, which 1 seized with a tenaculum, and draw 
ing down all which was loose, removed it with the scissors. The 
patient was now placed on the back, over a bed-pan, and the cavity 
washed out with a quantity of very hot water, by means of a Da- 
vidson’s s}rringe. She was afterwards replaced on the left side, 
and Sim's speculum introduced, as at the time of the operation. 
The cavity was dried by a large sponge probang, and as soon as it 
was withdrawn two drachms of Churchill’s tincture of iodine was 
injected. By use of the hot water the size of the cavity was great" 
ly reduced and the bleeding diminished, but the iodine contracted 
it still more, and entirely arrested the hemorrhage. Some pledgets 
of cotton saturated with glycerine were introduced into the cavity, 
now about an inch and a half in depth, and the vagina was moder- 12 
THOMAS ADDIS KMMET. 
ately 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 today without a bad symptom 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 speculum examination was 
made, and a sloughing mass exposed, which at first glance appear- 
ed to be the posterior lip. I found that it was a portion of th# 
capsule protruding, behind which a cyst had formed, containing 
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 pair of forceps. There was 
some bleeding, 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 lent 
it out from its bed with a pair of curved scissors. The uterus con- 
tracted promptlj* on its removal, and it was beyond question due 
t<4 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 [ 
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 pathologists teach us that these growths have a uniform 
origin and a similarity of structure, into which the uterine tissue 
becomes incorporated. Yet from observation I had become im- 
pressed with the belief that so soft and vascular a growth, as in 
this instance, had always its origin and extent limited to the sub- 
mucous tissues. I have met with but one other instance where 
this condition was an outgrowth from the dense tissue of a true 
fibrous tumor. I did. no: recognize the connection at the time, 
and although the case has no bearing strictly on the mode of treat- 
ment under consideration, yet its teaching is of great practical value 
to the subject at large. 
June, 1871, I dilated the uterus of a patient in the Woman’s 
Hospital, and detected near the fundus a soft tumor, about an inch REMOVAL OF FIBROIDS FROM THE UTERUS. 
13 
in diameter, which I considered a mucous polypus partially pedun- 
culated, and the cause of hemorrhage. On the anterior wall, near 
the fundus to the right, was felt through the abdominal wall a sub- 
peritoneal fibroid a little smaller than a hen’s egg. This tumor 
seemed to one side, and accidental in its connection with the growth 
within the canal. Dr. T. G. Thomas, a member then of the con- 
sulting board, was present, and examined the case at my request. 
From its shape and position it was impossible to encircle it with 
the chain of the ecraseur, and too soft to be drawn down with a ten- 
aculum sufficiently within reach of the finger as a guide for its re- 
moval. I therefore decided to destroy it by cutting open with a 
pair of scissors the portion protruding, and I believe the procedure 
met with Dr. Thomas’s approval. The operation was easily done, 
and by the injection of iodine the slight bleeding was promptly 
arrested. The discharge was very profuse after the third day. To 
guard against blood-poisoning I directed the nurse to introduce the 
nozzle of the syringe just within the patulous os, and gently wash 
out the uterine cavity at the time of administering the usual vag- 
inal injections. This was done for a week or ten days, and the 
patient was apparently doing well. One morning, during the ad- 
ministration of the injection, the patient suddenly complained of 
great pain and discomfort. On removing a nearly-empty bed-pan 
the nurse realized that some serious accident had occurred, and I 
was sent for. The patient died in a few days from a violent attack 
of peritonitis. The post-mortem disclosed the fact that the sub- 
peritoneal fibroid had become displaced, leaving a smooth opening, 
as if made with an inch-augur, from the uterine canal through the 
fundus into the peritoneal cavity. The tumor was found lying 
behind the uterus in a bed of lymph. It was soft, and the portion 
which had been imbedded in the uterine tissues was ragged and 
sloughing. Over the opening through the fundus the intestines 
had become adherent in the attempt to repair the injury. At the 
time I supposed two distinct growths had existed, and in their de- 
velopment the intervening uterine tissue became absorbed, so that 
they lay in contact. It was thought, as the growth within the 
uterine cavity disintegrated, the capsule of the outer tumor became 
involved and loosened from its attachment, so that it was at length 
easily displaced by the injection. 
Now it is evident to my mind, in connection with the growth of 
the previous case, that there existed but a single tumor. I am also 
satisfied that in the Newark case the supposed subperitoneal fibroid 14 
THOMAS ADDIS KMMKT. 
was imbedded in the uterine tissue nearly to the mucous membrane 
of its cavity. Fortunately by the uterine contractions which were 
excited the tissues crowded up upon the tumor so as to force it in 
the direction of the canal, and, although leaving so thin a septum 
of uterine tissue beneath the peritoneum, the cavity was soon 
closed up by the rapid decrease in the size of the uterus. 
The practical bearing is obvious that in addition to the risk from 
blood-poisoning the practice is not a safe one to remove, as is fre- 
quently done, a projecting mass within the cavity without any 
knowledge as to its depth within the uterine tissue. When we can 
make traction it matters little how thin the outer wall of the uterus 
may be, provided we are able to excite the muscular tissue to con- 
traction, since the space will be closed up as rapidly as the mass is 
withdrawn. This will surely be the case where we have a single 
tumor, especially if it be situated near the lundus, or even in the 
lateral wall, if its size be not so large as to have replaced the greater 
portion of the true uterine tissue. There is certainly a limit to the 
procedure, but it is safer and is appreciable to every case where a 
prudent operator would feel justifiable in attempting enucleation 
by any method. I deprecate the practice of separating the tumor 
from its capsule before withdrawing it, where muscular action is 
not excited, or to so limited an extent that a large cavity is left 
from which the patient is exposed to the danger of blood-poisoning, 
if she does not sink from the loss of blood beforehand. 
It is even more hazardous to cut into the mass or excite inflam- 
mation within its structure, by the use of the cautery or other 
agents, with the view of bringing about disintegration ; for no man 
possesses the means of limiting, to the tumor, the inflammatory 
process which he will establish by this mode of treatment. Where 
the sloughing has stopped short of breaking down with the tumor, 
the outer uterine wall covering it, the progress has been stayed in 
every instance by a special interposition of Providence. Were we as 
familiar with the death record as we are with the result where the 
treatment has been survived, no conscientious man would ever at- 
tempt to destroy a uterine tumor by disintegration. 
A few words in relation to the after-treatment. When the tumor 
has been removed, and all shreds or loose portions within reach, it 
is important to wash out the cavity thoroughly. It is best to use 
very hot water; for not only is it a prompt exciter of uterine ac- 
tion, but by prolonging the injection we thoroughly empty the 
capillaries within reach of its direct influence. After the injection REMOVAL OF FIBROIDS FROM THE UTERUS. 
15 
we' possess no better means of increasing the contraction, and of 
maintaining this condition, than by the free application of Church- 
ill’s strong tincture of iodine. Should there be any oozing of blood 
after the hot-water injection, the application of iodine is certain to 
arrest it, without there exists some impediment to the proper con- 
traction of the uterus. It is an agent I have employed for this 
purpose more than ten years, and it is also a most valuable anti- 
septic. I am confident that we possess no better means as a pro- 
phylactic, when used as I have employed it. 
Under no consideration would I introduce the persulphate of iron 
into a cavity to arrest hemorrhage. It possesses in itself no styptic 
properties, and only coagulates a mass of blood, which then acts 
mechanically. The blood is so destroyed in character by contact 
with the persulphate that it undergoes decomposition within a few 
hours. From this source the patient frequently becomes blood- 
poisoned before any septic element has been generated elsewhere. 
It acts as a local irritant, and it is impossible to get rid of it until 
removed by suppuration. After injecting the iodine I sometimes 
pack in a little cotton saturated with glycerine. If more than this 
is needed, it is better to use damp cotton, which has been saturated 
with a strong solution of alum, and tampon the vagina with the 
same material. On the second day I carefully remove the cotton ; 
and if there is no bleeding after washing out the cavity, I dispense 
with all dressings. It is necessary to devote the utmost care to 
cleanliness by frequent injections of warm water. To these injec- 
tions may be added a little brewer's yeast as a stimulant and dis- 
infectant, or carbolic acid, if there is any tissue undergoing decom- 
position. Finally I keep, the patient in bed until the cavity has 
filled up, if a tumor has been enucleated, or until all discharge 
ceases from the uterine canal, if a polypus has been removed. 
My experience in this mode of operating would recommend it on 
the score of safety. I have not lost a single patient, after the removal 
of growths from the uterus, in over eight years, during which time 
I have regularly employed the method. The only case during this 
period in which I deviated from my practice, by cutting into the 
growth and leaving it to break down, died. The details of the 
case I have already presented. I must state, however, that I have 
never enucleated so large a fibrous tumor before as the case I have 
presented, for I have not been favorably impressed with the results 
following the usual methods of operating which have passed under 
my own observation in the practice of others; but I have safely 16 
THOMAS ADDIS EMMET. 
removed a number of small fibroids, where death has frequently 
occurred under other circumstances. I have also operated manv 
by traction in pedunculating tumors which have begun to 
project into the canal. Formerly, when I have operated under like 
ejrcumstances, I have lost patients from blood-poisoning in the 
breaking down of the portion left imbedded in the uterine wall. 
It has been my practice, when the growth was larger than a pigeon’s 
egg, to confine my efforts entirely to controlling the hemorrhage, 
and aiding the action of the uterus in forcing the tumor from its 
bed toward the canal. When it had projected sufficiently I then 
removed it by traction. I have always been very conservative in 
my views regarding any surgical interference with large fibrous 
tuniors involving a greater portion of the uterine wall. While I 
am likely still to hold these views to a great extent, my recent ex- 
perience may justify me in extending the field to a larger number 
of cases than formerly.