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EMMET’S OPERATION. 
WHEN SHALL IT, AND WHEN SHALL IT 
NOT BE PERFORMED? 
BY 
GUSTAVE ZINKE, M. I)., 
CINCINNATI, O. 
Read before the Section of Obstetrics and Diseases of Women of the American 
Medical Association, at New Orleans, La., April 1885. EMMET’S OPERATION. 
WHEN SHALL IT, AND WHEN SHALL 
IT NOT BE PERFORMED? 
By Gustav Zinke, M.D., Cincinnati, Ohio. 
[Read before Am. Medical Association, at New Orleans, La., April, 1885.] 
Mr. President: Trachelorrhaphy, or Emmet’s operation for 
the cure of laceration of the cervix uteri, and its consequences, 
is recognized by many, in this country at least, as a measure 
productive of much good, and a great advancement in gyne- 
cology. Though the English and the Germans are slow in 
accepting it, and although in Franee we find as yet not one who 
will openly endorse it, the operation seems to be, neverthe- 
less, a legitimate and permanently fixed resource for the relief 
of some lacerations of the cervix and their results. And how 
could it be otherwise? The injury is readily Hmgmmmf, and its 
mischievous influences easily appreciated and recognized as 
such by skillful men. What treatment could be more simple, 
more rational, and more effective ? There should not be any 
doubt upon this question. Still there are some, even in this 
country, who are disposed to look with disfavor upon the 
operation. So much has been said and written on this point 
by the ablest gynecologists of this country, that no argument 
of mine is needed here. Experience and time will accomplish 
what argument has so far failed to do. With the knowledge 
I have upon this subject, in my judgment there is but one 2 
point left to be discussed, and that is: When shall we, and 
ivhen shall we not perform this operation? Upon this there 
is great diversity of opinion. To aid in the removal of this 
dissension and establish greater harmony, is the object of this 
paper. For this purpose I have addressed to a large number 
of our most prominent gynecologists and surgeons of this 
country and abroad, a letter containing a number of questions, 
calculated to elicit their latest opinion regarding this subject. 
I sent it in printed form, with sufficient space after each ques- 
tion to allow a concise answer. I adopted this course to obtain 
an answer from all as nearly alike as possible, and to the point- 
I also took pains to send these questions to those known to be 
more or less opposed to the operation, or, if you please, “ not 
much impressed with the importance of trachelorrhaphy.’’ 
The following is' the letter which accompained the questions 
as seen in the record : 
Cincinnati, O., February, 1885. 
Dear Doctor: 
Owing to the great diversity of opinion respecting 
the beneficial effects and proper sphere of usefulness of Emmet’s 
Operation, I have concluded to write an essay upon this subject, 
which is to be read before the American Medical Association, con- 
vening at New Orleans, La., the latter part of April next. In order 
to make the paper complete and valuable, I have deemed it wise to 
obtain the latest opinion of those men in the profession, in this 
country and abroad, who, by reason of their position and professional at- 
tainments, are best (pinlifted to judge. Iam well aware that this subject 
has been discussed and written upon from every aspect by many; but 
it must also be admitted that it has never been fairly decided, indeed, 
that to-day it is shrouded in greater uncertainty than ever. It is my 
desire to put on record the statements of all who will be kind enough 
to answer and present the same in concentrated form, from which 
those interested in the matter now, and hereafter, may draw their 
own conclusions, which, I hope, will harmonize more than at present. 
Hoping that you will consider the importance of the subject, and 
favor me with an early reply, by answering briefly the questions in 
the accompanying blank, I remain, 
Yours fraternally, 
413 Elm, Cincinnati, O. Dr. Gustav Zinke. 3 
. The letter, as well as the questions, will need explanation 
in so far as they refer to the beneficial effects and proper 
sphere of usefulness of Emmet’s operation, and not directly 
to what the caption indicates. Any one looking over 
the questions and answers, however, as given in the tabu- 
lated record, will be convinced that I could not have adopted 
any other way to arrive at conclusions at once unbiased and 
free from the suspicion of being one-sided. I could not have 
asked simply and solely : When do you and when do you not 
operate ? The answers to the questions, as propounded, put 
each one on record fully, by giving his reasons why he would 
in one case, and not in another, or, perhaps, never perform the 
operation. (See Record.) 
Let us now consider these replies and see if from them we 
may gather sufficient evidence to decide when we should and 
when we should not operate. 
1 Question. Do you believe lacerations of the cervix uteri to 
be an important factor in uterine and pelvic disease? 
Twenty-two out of thirty-four answer with an unqualified 
“yes,” or “ I do;” while some modify an affirmative reply 
by “most emphatically, especially if there be eversion,” or 
“subinvolution,” or “chronic congestion,” or “when ex- 
tensively lacerated, ” or “only when a persistent focus of 
irritation,” etc. Only one replies with “no.” There does 
not seem to be much difference of opinion here, and one is 
safe to conclude that laceration of the cervix uteri constitutes 
an important factor in uterine pathology, notwithstanding 
that we have one dissenting voice. 
2 Q. Do you believe fissures of the cervix uteri a cause of 
uterine and pelvic disease? 
The majority answer “sometimes,” or to that effect; 
eleven, by “yes;” seven, “rarely;” two, “if deep;” four do 
not answer at all, and three with “no.” Judging from these 
answers, fissures of the cervix are apparently productive of 
evil results under certain conditions. 4 
3 Q. State your theory in what manner a lacerated cervix 
will or may cause disease of the uterus, its surrounding tissues, 
and in parts remote. 
The substance of these answers is about as follows: 
1. Septic poisoning at the time of its occurence. 
2. It causes pelvic cellulitis. 
3. “ “ “ peritonitis. 
4. “ prevents involution. 
5. “ acts as a point of irritation. 
6. “ causes pelvic congestion. 
7. “ “ cervical and corporeal endometritis. 
8. “ “ profuse leucorrheal discharge. 
9. “ “ displacements of the uterus. 
10. “ “ erosions and eversion. 
11. “ hyperemia 1 ofcervixaswe]lasbod 
12. “ “ hyperplasia ) 
13. “ “ cystic degeneration. 
14. “ “ numerous reflex symptoms, especially from irritating ci- 
catricial contraction. 
15. “ “ menorrhagia. 
16. “ “ sterility, by preventing conception, and by causing abor- 
tion. 
17. “ “ lays the foundation of epithelioma. 
No one present, familiar with this subject, will expect me to 
discuss the manner or the order in which one or all of these 
consequences may arise ; every one of them seems to 
be conceded as being a natural result of laceration of 
the cervix uteri, and have been discussed at length in 
the latest text-books (especially by Emmet & Thomas), in 
the American Journal of Obstetrics, and in the reports of the 
American Gynecological Society ; also numerous original arti- 
cles (read before the various societies all over the country) can 
be found together with the discussion that followed their read- 
ing. So profuse is the literature regarding the results of this 
accident that it would be imposing upon good nature to cite 
the names of all the authors, and therefore I chose simply to re- 
fer to the books and journals in which most of the writings on 
this matter can be found. 5 
4 Q. Do you believe laceration of cervix a cause of sterility? 
Seventeen answer with “yes,” and three with “no” simply, 
while the others qualify an affirmative reply by adding 
“if extensive,” “sometimes,” “if there is profuse catarrh 
or cicatricial contraction of the canal,” etc. Sterility as 
an effect of laceration, has been violently assailed and 
ridiculed by some, but V. A. Hardon, American Journal 
of Obstetrics, 1881, in an excellent paper, describes in 
a striking manner how a lacerated cervix may be the 
cause of disease and sterility, and require sewing up for a 
cure, and how a cervix slit open by the knife to cure sterility, 
remains inert as a factor in disease and accomplishes the end 
desired. There is no doubt that we see instances, occasionally, 
of even extensive lacerations of the cervix in which pregnancy 
occurs and is continued to the end of gestation; but these are,- 
seemingly, exceptional cases. I have seen such cases; they 
all had aborted before, however, and did abort again, though 
they used great care, during gestation. 
5 Q. Do you believe that Emmet's operation, if performed 
early and properly, will, to some extent or entirely, prevent uterine 
and pelvic disease? 
This question is responded to affirmatively by about twenty; 
one answers “it may do immense good; ” some, “to a great 
extent; ” some, “ in well chosen cases ; ” and others, “ if exist- 
ing complications have to a great extent been cured by pre- 
paratory treatment ; ” only one gives a positive, “ no.” 
These replies are sufficient to prove that the question could 
not have been put to greater advantage, for it simply forces 
one to the conclusion that they are nearly all agreed that 
when the operation is performed early and properly, in well 
selected cases, it will, and in many cases entirely, pre- 
vent such uterine and pelvic disease as usually arise there- 
from. 
6 Q. Do you believe that Emmet's operation is absolutely 
necessary in certain cases? If so, specify the class of cases. 6 
The sum total to all replies received on this inquiry, is that 
the operation should be carefully and perfectly performed : 
1. When pathological changes exist which depend upon 
the laceration, and which can not be disposed of by other treat- 
ment. 
2. When the laceration is deep, bilateral or stellate with a 
history of cancer, even before secondary changes occur. 
3. When in advanced age it prevents senile involution. 
4. Where subinvolution and cervical disease exists. 
5. Where there are large gaping rents. 
6. When there is villous degeneration of endometrium. 
7. In menorrhagia. 
8. In habitual abortion. 
9. To lessen the danger of cancer after child-bearing period. 
10. Where there is cicatricial tissue in the rents, causing re- 
flex symptoms. 
7 Q. Do you believe that every lacerated (not fissured) cer- 
vix will cause, eventually, uterine and pelvic disease? 
The greater number answer “no,” or “ not necessarily.” A 
few believe that the majority of lacerations will. One states 
that “some escape by reason of unimpared ligaments;” an- 
other that “ some will heal over and never produce any symp- 
toms whatever.” Only 2 answer with “yes;” and some with 
“ only when extensive.” 
This seems positive evidence that we have exceptions, and 
that all lacerations do not contribute to uterine and pelvic 
pathology. Those who have observed the greatest number 
of cases, and who have practiced longest and most skill- 
fully in this department, are found among those who believe 
that not every laceration produces diseases of the uterus and 
its surroundings. 
8 Q. If not, state approximately how many such cases you 
have observed? 
The answer from about five is, “ quite a number, but by far 7 
the minority not a few have, “ kept no statistics, but have seen 
quite a number;” three, ‘‘never one, “6;” two, “ioo or more” 
each; another, “about’40 ; ” one, “over 50; ” one, “impossible to 
do so;” four do not answer; and one “has seen many hun- 
dreds.” 
This is one of the most important questions, and yet one 
which has been replied to very unsatisfactorily. A certain 
degree of uncertainty is manifest; most of my correspondents 
guess at it, only one or two make exact statements. Yet it 
must be considered that in the practice of nearly every one, 
numerous cases have occured, in which a lacerated cervix ex- 
cited none of the affections that usually are said to arise there- 
from. 
9 Q. State approximately or exactly, if you can, how many 
times you have performed the operation? 
To know about how many operations have been made by 
those who favored me with an answer, would give, I thought, 
weight and strength to their opinion. Unfortunately, some 
who have had a very large experience, and who are known to 
have operated hundreds of times, can not, even approximately, 
state the number of their operations. Dr. Emmet refers me 
to his last edition, and there I find that up to the time of its 
publication, he has apparently operated over 600 times. It is 
safe to presume that Dr. Gaillard Thomas has probably per- 
formed the operation an equal number of times. Lyman, of 
Boston, simply states that he operated on a considerable num- 
ber. Byford, of Chicago, and Taylor, of Cincinnati, do not 
respond to this question at all. Not willing to be accused of 
exaggeration, I have rated the combined experience (although 
I am satisfied it is too low an estimate) of— 
Emmet, 'l 
Thomas, 
Lyman, } as comprising about 1500 Cases. 
Byford and 
W. H. Taylor, of Cincinnati. , 
G. T. Engelmann about (40-50) 45 “ 8 
A. Reeves Jackson about 200 Cases. 
Ellwood Wilson exactly 128 “ 
C. M. Wilson “ “ 12 “ 
Herbert M. Nash “ 22 “ 
R. S. Sutton “ 100 
Paul F. Munde “ 200 “ 
Ely Van DeWarker “ 120 “ 
Jos. Taber Johnson “ 30 “ 
Janies B. Hunter at least 200 “ 
David Prince “ (6-8) 7 “ 
Willis P. King exactly 7 “ 
C. D. Palmer “ (35-40) 37 “ 
Wm. Goodell exactly 263 “ 
M. D. Mann “ 90 “ 
W. H. Baker “ 400 u 
E. W. Jenks “ 200 “ 
Thad. Reainy “ 324 “ 
T. B. Harvey “ 200 “ 
P. J. Murphy “ 50 “ 
J. Byrne “ 200 “ 
W. T. Lusk “ 300 “ 
Chrobak “ 10 “ 
W. T. Howard “ 100 “ 
A. H. T. Barbour “ 0 “ 
J. Mathew Duncan “ 0 “ 
Tf 'c v. . u / o 
/ 4,f45 
Here we have, then, in condensed form, the experience of 
31 operators, nearly all of whom have a reputation through- 
out the country, some over the whole civilized world, men 
who are known to be conscientious, active and zealous work- 
ers in the profession ; all of which, I think, will go far to sub- 
stantiate the conclusions given at the end of this paper. 
9a Q. How oftenfor the restoration of the cervix simply? 
This question I asked for the purpose of ascertaining how 
many there are who believe in restoring a lacerated os, be- 
fore pathological changes have occurred, and about how many 
times the operation has been performed for that purpose 
alone. 
Nine answer “never;” one, “can not separate causes;” 9 
one, “often as a prevention;” one, “3 times;” one, “ 1 
time;” one, “25 times;” one, “50 times;” one, “1 time 
after delivery, for hemorrhage from circular artery ; six do 
not answer the question at all; and others, from various 
reasons, can not state how many times. 
9b Q. IIow often for the relief of pathological changes and 
reflex disturbances depending thereon f 
This, of course, includes all the other operations, with the 
exception of those that may be contained among those who 
did not answer questions 9 and 9a. 
Dr. Emmet and Dr. Thomas have confessed, on more than 
one occasion, that to-day they do not operate as frequently as 
formerly, because experience has taught them that oftentimes 
the operation had been performed unnecessarily (of Byford, 
and Lyman, and Taylor, Cincinnati, I have no knowledge re- 
garding this point); but whether by that they mean to say that 
they operated in cases of laceration without complication, as 
well as in cases in which the complications were looked upon 
as following a torn cervix, can only be conjectured. For 
this reason I wish they had answered at least question 9a. 
Since I have estimated the number of their operations so low 
already, I will permit them to stand, and count them with those 
cases in which the operation was performed only for the 
relief of pathological changes, local as well as general; and if 
afterwards it is discovered that some of them were performed 
in cases of uncomplicated lacerations, let them be counted 
with those for which they were not credited. 
10 Q. What have been your immediate results respecting 
union and relief? 
Most of my correspondents answer “ good;” one had 
union fail four times; one failed to obtain union in his early 
practice, occasionally; another mentions failure of union in 
five per cent., but that he had always good results when the 
cicatricial tissue was thoroughly removed; in one instance 
failure of union occurred five times out of 200 cases ; and the 10 
same author makes the statement that relief followed, not im- 
mediately after the operation, but about three months there- 
after; one states that he always secured union, but not always 
relief; one speaks of cellulitis following in one instance; an- 
other mentions one death from septo-pyemia, and one from 
phlebitis. 
From this we learn that, as a rule, good will follow the oper- 
ation ; not always immediately, yet oftentimes in the course 
of three to six months thereafter; that union but rarely fails, 
and that it is more apt to be obtained when the cicatricial 
tissue has been well taken out, or the parts have been effect- 
ually treated for the relief of certain diseased conditions prior 
to the operation. The answers to this question also furnish 
evidence that the operation is accompanied by some danger, 
since in one instance death occurred from septo-pyemia, and 
in one from phlebitis. 
11 Q. What have been your remote results respecting union, 
relief and sterility? 
One answers “ Pregnancy occurred in 20 per cent.” 
“ “ “ Pregnancy occurred in 5 per cent.” 
“ “ “ Pregnancy occurred in 25 per cent.” 
“ “ “ Pregnancy occurred in some.” 
“ “ “ Believe it cures instead of causing sterility.” 
“ “ “ 12 confinements out of 128 cases, one twice 'with re- 
currence of tear.” 
“ “ “ Sterility cured in small number.” 
“ “ “ Conception frequently followed.” 
“ “ “ Relieved large number of sterility.” 
“ “ Conception usually followed successful operation.” 
“ “ “ Not positive.” 
“ “ “ Highljr satisfactory.” 
“ “ “ Impossible to say.” 
“ “ “ Very generally good.” 
“ “ “ Good.” 
“ “ “ Largely beneficial.” 
“ “ “ Can not say.” 
“ “ “ Good in early, failure in old cases.” 
“ “ “ Remote results better than immediate.” 
“ “ “Excellent; conception quickly followed.” 11 
One answers “ Saw 10 cases in which sterility lasting several years 
seemed to have been cured.” 
“ “ “Good.” 
“ “ “Not been able to follow all my cases, some have 
become pregnant.” 
“ “ “ Relieved a large number of sterility.” 
“ “ “ Two out of my seven cases have again borne chil- 
dren.” 
“ “ “ Sterility cured in small number.” 
“ “ “ Can not state definitely.” 
“ “ “ Good in overcoming steiility.” 
“ “ “ Good, so far as a check upon tendency to abort.” 
Two “ “ Unable to answer.” 
The answers to this question must of necessity be more or 
less indefinite, from the fact that most of my correspondents 
devote themselves entirely to gynecology, and receive many 
patients from different and very distant parts of the country. 
They know not what the remote results have been, in prob- 
ably the majority of cases; on the other hand, one can easily 
observe that the answers from those whose practice is more 
limited, or rather local, are much more definite. In general, 
the replies are favorable respecting relief of symptoms, cure 
of sterilit)7 or unfruitfulness, as Dr. Wm. Goodell prefers to call 
it, and will aid considerably in permanently establishing 
Emmet’s operation. 
12 Q. When, in your opinion, is Emmet's operation contra- 
indicated? 
The answers to this may be summed up as follows : 
1 “ In acute and sub-acute inflammations.” 
2 “ In pelvic cellulitis.” 
3 “In pelvic peritonitis.” 
4 “ In lymphadenites.” 
5 “When ovaries and tubes are diseased.” 
6 “ When uterus is very irritable.” 
7 “ Never the rent, eo ipso.” 
8 “Pregnancy.” 
9 “ After menopause, if no eversion or hypertrophy exi3t.” 
10 “ Manifest hydro or pyo salpinx.” 
11 “ Where there is no ectropion.” 12 
12 “ Where there are no Nabothian bodies apparent.” 
13 “ When there are no symptoms of uterine origin.” 
14 “Not needed in limited lacerations, anemia or fissures.” 
15 “ When local treatment gives relief.” 
16 “When peri-uterine adhesions exist.” 
17 “ When uterus is immobile.” 
18 “When there is neither eversion, local congestion nor reflex 
disturbance.” 
19 “ When there is cancer of neck or body of the uterus.” 
20 “ When patient is suffering of pulmonary consumption or other 
fatal malady.” 
The summing up and condensing of all the answers to these 
questions has been a laborious yet interesting work. I might 
here abandon my inquiry and rest content with what can be 
learned from it, and leave my audience, as well as those who 
may chance to read it in the future, to draw their own infer- 
ences ; but I feel that my effort to create more harmony 
will have been in vain, if, after studying the different views of the 
various operators, I should not attempt to answer the ques- 
tion that has called forth this essay. I do not flatter myself 
that my views of this subject, gained from the above, will 
agree with all of you, nor with '.those who will read it here- 
after, but I present them with the hope that they may aid to 
clear the way to a better understanding. The above inquiries 
certainly furnish abundant proof of a great difference of opinion 
among gynecologists as to when it would and when it 
would not be proper to perform the operation. They may be 
divided into three classes : those who advocate operative 
interference in every lacerated cervix; those who do not 
endorse the operation at all; and those who deem it a ne- 
cessity in some “ well selected cases ” only. 
That the operation is too often performed; that cases are oper- 
ated upon in which no indications for it exist; that as a con- 
sequence the results looked for are not obtained ; that the 
patients, so far from being relieved, are subjected unneces- 
sarily to procedures not free from danger, and are occasionally 
even followed by unfavorable results, rendering the patient 13 
worse instead of better, is the opinion of many. The abuse, 
not the use of the operation, has done the mischief. In the 
heat of debate many will defend the grounds they have taken, 
and fortify their position by apparently plausible arguments. 
But the quiet looker on—the unprejudiced and diligent 
student of this question—will come to the conclusion that the 
charges made are only too true. The accompanying tabulated 
record, as well as Dr. Emmet’s letter, will testify to this state- 
ment ; and I do believe that many of the gentlemen who 
have performed this operation are willing to admit the same. 
Like any other new remedy, this operation has been resorted 
to because of its evident utility, and too much has been ex- 
pected from it. That, however, might have been looked for 
from its first announcement. The same fate has followed 
every newly invented operation. But while this is no reason 
that the operation should be abandoned, as some, especially 
from abroad, would have us to do, there is certainly to-day 
no longer any excuse for performing this operation for 
every laceration we find. We all have heard the remark, 
and probably have made it ourselves, I know I have, 
that if a lacerated cervix is the cause of all the ills text-books 
and authors attribute to it, then every rent in that portion of 
the womb ought to be sewed up. 
Here it is that we must pause and reflect upon the ex- 
perience of others as well as our own; and when we do 
so, one is compelled to admit that it is not true that every 
tear in the cervix is productive of evil, and that it is not 
good practice to stitch up every os, simply and solely because 
it sustains a slit; nor is it fair to assume that because 
of certain diseased conditions co-existing in, around, or near 
the cervix or uterus and its appendages, an operation is neces- 
sary to a cure. 
To be better understood, I have drawn two diagrams to 
illustrate the various degrees of lacerations as we observe 
them in practice. Figs, i and 2 almost explain themselves. 14 
Fissures are, indeed, lacerations—lacerations which, in my 
opinion, have been more or less extensive, but have failed to 
heal perfectly, leaving a depression or gutter in the cervical 
Fig. 1. 
Fig. 2. 
canal, to which the name fissure has been applied, a (Fig. i) 
represents my idea of a fissure. From a to b constitutes a lacer- 
ation of the first; from b to c a laceration of the second ; and 
c to d a laceration of the third degree. Lacerations extending 
through and beyond the cervico-vaginal junction, if not 
amounting to a rupture of the uterus, may be considered lacer- 
ations of the fourth degree. 
The following are my conclusions, drawn from the above 
tabulated record, from text-books, from the numerous articles 
referred to, and my own clinical experience, extending over a 
period of seven years as assistant of Prof. C. D. Palmer’s 
Clinic, at the Medical College of Ohio : 15 
1. It is evident that the operation has been performed un- 
necessarily for symptoms similar to but other than those arising 
from lacerations of the cervix. Further, that it has been done 
imperfectly, even without preliminary treatment, in many more ; 
and the failure to give relief, as reported by several, is due 
to these two causes. 
2. That from our present knowledge we can not, at this 
time, arrive at any definite conclusion, from the fact that 
many of the so-called consequences of lacerations of the 
cervix uteri are not settled beyond doubt. 
3. That every one engaged in this department should care- 
fully select his cases, and try every known means to give relief 
before resource is had to an operation. 
4. The operation should never be performed eo ipso in cases 
of simple fissures or lacerations of first and second degree. 
5. In cases of eversion and disease of the cervical or cor- 
poreal cavity, or both, although attended by hyperplasia and 
displacement, it has been observed that all the symptoms 
abated and the parts returned to their natural condition, and 
that no laceration was discoverable after alleviative measures 
were instituted first, which alone caused the parts to return to 
a normal condition. 
6. That there are some cases of extensive lacerations of 
cervix that seldom give rise to any inconvenience, and that, 
therefore, an operation should be deferred until symptoms 
arise that will call for its performance. 
7. The operation, although indicated, should never be 
performed until, by preparatory treatment, the parts have 
been brought into a healthy condition. 
8. Near, and during, the climacteric period the operation 
should be postponed as long as possible, and the patient not 
exposed to any risks, since in many cases all the symptoms 
subside under proper treatment, and never return on account 
of senile involution. 
9. The operation is justifiable in cases of lacerations of the 16 
third and fourth degree, without complications, yif there is a 
history of malignant disease in the family. 
10. The operation may be performed with perfect propriety 
in young women, as a preventive, if the laceration is bilateral 
and extends up to the cervico-vaginal junction, or beyond it, 
even though there are no pathological changes; indeed, it 
seems to be the duty of every one, who observes a lesion to 
that extent, to urge the operation. 
11. The operation is justifiable in any degree of laceration, 
and in rare instances even in fissures, when there exists cica- 
tricial tissues, productive of reflex disturbances, annoying in 
character, and not tractable to any other treatment. 
12. The operation is absolutely indicated in all extensive 
tears of the os, in which the cervix is everted, its mucous 
membrane and Nabothian follicles diseased, and especially if 
there be granular or cystic degeneration present, provided, the 
parts have first been restored to a healthy condition by pallia- 
tive treatment. This letter received too late for insertion with the others: 
Dr. Gustav Zinke:—I have the highest regard for Emmet, and have 
learned much from his works. But “Emmet’s operation” I look upon as en- 
tirely unnecessary. I perform the same only when, by retroflexions, the 
laceration of the cervix interferes with orthopaedic, treatment. I can fur- 
nish many cases in which women, in spite of extensive tears, were and re- 
mained perfectly well, that pregnancy was not interfered with, and that 
the rents caused absolutely no complaint. For this reason I do not per- 
form this operation, and I am firmly convinced that in a few decades it 
will be forgotten. 
With many respects, Fritsch. 
Breslau, March 27, 1885. I>r. I. K. Taylor. 
New York, March 10, 1885. 
Dear Doctor: I hart not forgotten the circular you addressed to me on the important 
subject you contemplate writing—a paper for the American Medical Association. | could 
not answer your questions categorically—in the manner you have put the questions— 
from the standpoint of my own experience, for over forty-five years, having given close 
attention to the dieases of the cervix uteri, as you will perceive from the monographs I 
have sent you. I had therefore to enlarge somewhat on some questions as explanatory of 
the views I held, so diametrically different from those of Emmet on this single point of 
his experience. I hope you will be able to extract from the information I have attempted 
to communicate to you an expression of the views I hold on this important subject. I do 
not know your views, and they may be entirely opposed to my own. What I have written, 
and given utterance to long before Emmet’s views, and I believe his views will in a few 
years demonstrate the error of the frequency of the operation. I hop : you will pardon the 
seeming neglect, and that you will see that I had not forgotten you. Believe me, my 
dear sir, Yours very truly, 
I. E. TAYI.OR. 
1 Question.—Not necessarily. By removing the pathological condition of the cervix 
uteri, whatever that may be, by the treatment your own judgment and experience may 
dictate, the laceration will be either perfectly overcome, or so much so that the lacera- 
tion will not sustain the pathological state previously existing, and the laceration, 
whether it is a deep unilateral one or not, will be restored, and the length of the os 
tine® will be diminished so much as to present almost a natural appearance. 
2 Question.—The same as above. 
3 Question.—Laceration of the cervix uteri, when treated by closure before attending 
to the treatment of the pathological condition, unless it is directly after the laceration, 
an acute laceration will not succeed; and even then I have my doubts whether it will 
not produce more trouble then than when the operation is deferred till after convalescence. 
If the laceration is severe, as to produce a secondary hemorrhage—which I should 
consider as exceptionally rare, then a closure may be attempted. If not, then the oper- 
ation should not be performed, for in very many cases if there has been a slight laceration 
the patients have perfectly recovered, especially if proper treatment is adopted. 
4 Question.—By no means. I have several cases at present in my private practice 
whom I have attended in severe confinements, and who had partial laceration, and a 
few up to the vaginal junction have had children, and one of them every fifteen months. 
They were safely delivered, and no further laceration occurred. In some of the patients 
who became widows, and others not having any more children, the laceration has 
healed and the cervix presented a more natural appearance. In a few the cervix has 
1 
2 
3 
4 
5 
6 
7 
8 
9 
9 a 
9 b 
10 
11 
12 
Name. 
Do you believe lacer- 
ations of cervix uteri 
to be an important 
factor in uterine and 
pelvic disease? 
Do you believe fis- 
sures of the cervix 
uteri a cause of the 
same? 
State your theory in what manner a lacerated 
cervix* will or may cause disease of the uterus, 
its surrounding tissues, and in parts remote. 
Do you believe la- 
ceration of cer- 
vix a cause of 
sterility? 
Do you believe that Emmet’s 
operation, if performed early 
and properly, will, to some ex- 
tent or entirely prevent 
uterine and pelvic disease? 
Do you believe that Emmet’s 
operation is absolutely neces- 
sary in certain cases? If so, 
specify the class of cases. 
Do you believe that every 
lacerated, (not fissured) 
cervix will cause event- 
ually uterine and pelvic 
disease? 
If not,state approx- 
imately how many 
such cases you 
have observed. 
State approximately, 
ur exactly, if you can, 
how many times you 
have performed the 
operation. 
How many times 
for the restora- 
tion of the cervix 
simply? 
How often for re- 
lief of pathologi- 
cal changes and 
reflex disturban- 
ces depending 
thereon? 
W’hat have been your immedi- 
ate results respecting union 
and relief? 
' 
What have been your remote 
results respecting union, re- 
lief and sterility? 
When, in your opinion, ia 
Emmi t’s operation contraindi- 
cated? 
T. Gaillard Thomas, 
New York, N. Y. 
Yes, decidedly so. 
Yes, but to a less 
degree. 
By creating local hypertrophy and glandular 
disease and by reflex influence. 
Sometimes, un- 
questionably. 
In most cases. 
Yes, in hll of great lacera- 
tion. 
No. 
gi 
Impossible to do 
so. 
Can not do so even 
approximately. 
Almost uniform success. 
Very generally good. 
In cases of subacute pelvic 
peritonitis and cellulitis which 
may be excited into acuity 
during pregnancy, and after 
the menopause if no eversion 
and hypertrophy exists. 
Geo. T. Enbelmann, 
St. Louis, Mo. 
It is one of the con- 
ditions which facili- 
tates and assists the 
development of cer- 
tain diseases directly 
leading to other. 
Karely. 
Destruction of sphincter muscle leads to subin- 
volution—the open surface—exquisitely sensi- 
tive and irritable—leads to reflex symptoms by 
reason of friction—and inflammation by absorp- 
tion. 
Frequently. 
It will certainly prevent such 
diseases as are dependent on 
laceration. 
It is necessary in all cases in 
which symptoms—which can 
not he allayed—depend upon 
the laceration. 
No. 
1 have seen quite 
a number of such 
cases, but by far the 
minority incases of 
laceration. 
40-50 times. 
Never. 
Always. 
First intention. 
Excellent ;conception rapidly 
followed. 
Acute and subacute inflamma- 
tion or exacerbation of chronic 
trouble. 
A. Reeves Jackson, 
Chicago, 111. 
When sufficiently 
extensive, yes. 
Yes. 
The exposure of the intra-cervical structures to 
the vaginal secretion excites inflammation, first 
of the endometrium, secondly of the par- 
enchyma. 
Yes. 
Yes. 
Yes. Cases in which the lacera- 
tion extends beyond the crown 
of the cervix so as to permit 
eversion of the lining mem- 
brane. In laceration of less ex- 
tent after childbearing has 
ceased, in order to lessen dan- 
ger of malignant disease. 
Not necessarily. 
In many cases 
could not* believe 
the symptoms were 
dependent upon 
the laceration. 
About 200 times. 
About 20 or 30 
times. 
/ » 
All the others. 
Only know of 4 cases of non- 
union. Relief of symptoms 
did not always follow the other 
cases. 
In a few cases (perhaps 10) 
sterility lasting several years 
seemed to have been cured by 
1 the operation. 
When there are present evi- 
dences of pelvic inflammation 
W. H. Byford, 
Chicago, 111. 
I do when attend’d by 
chronic subinvolut’n 
or chronic conges- 
tion, not otherwise. 
I believe it perpetuates subinvolution and its 
consequences. 
Only when at- 
tended with the 
morbid conditions 
mentioned before. 
Y’es. After its complications 
have to a great extent been 
cured by preparatory treat- 
ment. 
Not always, but often. 
/ 
Ellwood Wilson, 
Philadelphia, Pa. 
Y’es. 
Sometimes. 
By allowing the uterus to sag downward in the 
pelvis and by the ectropion of the cervical mu- 
cous membrane it acts as a constant source of ir- 
ritation,preventing involutionThe genetal reflex 
symptoms are more marked than the local ones 
Yes, if extensive. 
Yes, usually. 
Yes, where the rent is more 
than a quarter of an inch in 
length and when hypertrophy 
of tlie cervix exists with ectro 
pion. 
As a r ule. 
J. 
Six. 
128. 
About 20 per 
cent. 
About 80 per 
cent. 
Always good, non-union in 
only one case Never have had 
serious results follow. 
Excellent, have delivered 
12 women on whom I had prev- 
iously operated,one twice. Re- 
currence of tear in 2 cases. 
Where peri-uterine adhesions 
exist, and when the general 
health of the patient militates 
against the operation. 
Charles Meios Wilson, 
Philadelphia, Pa. 
Yes. 
Yes. 
By preventing involution, acting as a constant 
source of irritation, and causing disturbances of 
general health, as manifested by the gravity of 
reflex symptoms. 
Yes. 
Yes 
Yes, if the rent is extensive, 
and if the symptoms, local or 
reflex, are of a serious nature. 
As arule. 
None. 
12 times. 
1 time. 
11 times. 
Good. 
Good. 
In cases where other surgical 
procedures are contra-indicat- 
ed, and where the uterus is 
immobile. 
Herbert M. Nash, 
Norfolk, Ya. 
My observations in 
the past 20 years force 
me to the confirmed 
opinion that lacera- 
tion of the cervix 
uteri is frequently a 
most important fac- 
tor in both. 
May he a cause. 
In the majority of cases it seems to be the cause 
of irritation followed by both cervical and cor- 
poreal endometritis, erosions, profuse leucor- 
rhoeal discharge, and in my opinion these con- 
ditions forerun or may distinctly cause cellulitis 
and even pelvic peritonitis. Displacements are 
common, and they are sometimes attended by 
numerous and annoying reflex symptoms. 
I do, in some 
cases I have known 
abortions to occur 
from this cause. 
I do, hence advocate an early 
operation, though my case's 
have all been operated on for 
the relief of distressing re- 
sults. 
Y’es, especially those accom- 
panied by eversion and endo- 
metritis, which if cured or im- 
proved invariably return un- 
less the operation is made; 
those accompanied by menor- 
rhagia, displacements, etc. It 
is especially useful in ahyper- 
plastic condition of the organ, 
favoring complete involution. 
The great majority, 
Some may escape liy rea- 
son of unimpaired uter- 
ine ligaments and strict 
cleanliness, but very 
few. 
\ t. 
About 40 cases. 
22 cases, about one- 
half for bilateral lacer- 
ation. 
Never. 
Always. In five 
cases operation 
for lacerated per- 
ineum was done 
at same sitting. 
They have all been successful 
in union, and were relieved 
of the symptoms for which the 
operation was done One in- 
valid eight years could not 
walk 200 yards, relief entire. 
I am not able to report posi- 
tively on this matter. 10 of my 
patients in the childbearing 
age are now under observation 
as to the bearing of the ques- 
tion. 
In active inflammation ofthe 
aterus and itsjsurroundings. I 
have almost invariably used 
local treatment to relieve all 
active disease before operating. 
G. H. Lyman, 
Boston, Mass. 
I do most emphati- 
cally, especially if 
there be eversion. 
I do, but to a less 
degree than the 
former. 
Local congestion of the body and mucous lin- 
ing of the uterus, with neuralgic pains, hvstero- 
neurosis, by reflex action on distant parts, etc. 
I believe all such should be repaired, if only as 
a safeguard against epithelioma. 
Not necessarily, 
but often so. 
I know it will prevent such 
diseases as would supervene if 
left untouched, and in conse- 
quence of the laceration itself 
See answer 1. 
In cases of reflex disorder, in- 
tense local congestion of womb 
and ovaries, leucorrhcea and 
general nervous derangement. 
Perhaps not universally, 
but in the great majority 
of cases. 
Very doubtful, 
certainly a small 
number. 
Have kept no record, 
but a very considerable 
number. 
Often, as pre- 
vention of im- 
pending trouble. 
More often for 
this class. 
Have been very rarely obliged 
to repeat the operation. The 
relief has in every instance 
been satisfactory. 
Impossible to say, as a large 
number have been hospital 
cases. 
When there is neither ever- 
sion, local congestion or reflex 
disturbance. In such cases the 
only excuse for it would be the 
possibility of growth, and of 
this the patient should decide 
for herself. 
R. S. Sutton, 
Pittsburg, Pa. 
It is very fre- 
quently so. It is 
often the prime 
factor. 
If deep. 
It arrests involution, causes catarrh of 
the canal, prolapse of the lining of the ca- 
nal of the cervix, congestion of the entire 
cervix, prolapse of the uterus, retrover- 
sion, drag upon the round ligaments, con- 
gestion of the cellular pelvic tissue, consti- 
pation. nervous phenomena, vesical irrita- 
tion, indigestion, backache, pains in the 
groins, etc. 
Yes. 
It may do immense good. 
Y’es, in cases where sub- 
involution and cervical dis- 
ease exists. 
Y es. 
’' ! 
None. 
About 100. 
Never. 
Always. 
In mv early cases I had 
union of both sides fail oc- 
casional! v. In the last two 
vearsfailure to make union 
has occurred only once. 
I have not been able to 
follow many of the cases. 
Some have become preg- 
nant. 
When the ovaries or 
tubes are diseased ; when 
the uterus is very irritable; 
when the laceration is not 
accompanied with symp- 
toms of uterine disease. 
Paul F. Munde, 
New York, N. Y. 
Most decidedly. 
None more so in 
certain selected 
cases. 
The smaller 
the rent or fls’ure 
the less.as a rule, 
its pathological 
significance. 
First, subinvolution of the uterus, then 
hyperaemia, then menorrhagia; or, first, 
subinvolution, then hyperplasia; or, at- 
tendant on subinvolution and hyperplasia, 
chronic eversion, hyperaemia and hyper- 
plasia; or, immediate or remote pelvic 
cellulitis, peritonitis or lymphangitis. 
Finally, epithelioma of eroded lips. 
Yes, if there is 
profuse cervical 
catarrh(as usual) 
or cicatricial con- 
traction of cer- 
vical canal. 
Without doubt, in well 
chosen and proper cases. 
Yes, absolutely’ necessary’ 
in large gaping rents with 
everted and eroded lips, 
and freely’ secreting cer- 
vical canal; in subinvolu- 
tion and areolar hyper- 
plasia, with villous degen- 
eration of endometrium 
and menorrhagia, depend- 
ent on the laceration; in 
habitual abortion and con- 
ditions given under ques- 
tion 3. 
No. Many a case, 
even of lqrge lacera- 
tion, will heal over 
and never produce 
any symptom what- 
ever. 
100 or more. I 
have no positive 
notes on this par- 
ticular point, but 
have o;ften de- 
clined to operate. 
About 200 times. 
— 
- 
Much more 
often than for 
question 9a. 
About 92 per cjjnt. union, 
certainlv 75 per cent, relief 
from symptoms for which 
operation was done. Suc- 
cess dej muds on following 
properhitional indications. 
25 Per cent, of cases under 
my knowledge conceived 
after the operation; un- 
doubtedly many more did 
so but were not reported. 
When not indicated, i. e., 
not the rent eo ipso, but the 
sy’mptoms produced by the 
rent, call for the operation. 
Acute and chronic pelvic 
inflammation. 
Ely Van de Warker, 
Syracuse. N. Y. 
-Only when of 
such extent as to 
become a persist- 
ent focus of irrita- 
tion. 
I have rarely 
seen mere fiss- 
ures cause pelvic 
symptoms. 
— | 
By acting as a persistent focus of local 
irritation, thus inducing a morbid degree 
of uterine and pelvic hyperfemia. 
I do. 
Where the operation is 
indicated, I believe it to be 
curable. 
Y’es, when it results in 
conditions stated in ques- 
tion 3, and when in ad- 
vanced age it prevents 
senile involution. 
Only when of the 
extent named in 3d 
question. 
A very large 
number in which 
I did not believe 
the ope ration 
called for. 
About 120. 
— 
Never for the 
cervix simply. 
Always. 
Union lias never failed. 
Sometimes have been dis- 
appointed in general re- 
sults. 
And large number of 
cases relieved of sterility. 
In lymphadenitis 
in pelvic inflammation and 
its products, phlegmon and 
ulcers. 
Jas. Taber Johnson, 
Washington, D. C. 
I do. 
I think the 
pathological and 
reflex disturb- 
ances are large 
in proportion to 
the extent of lac- 
eration, but not 
always. 
It causes endometritis, chronic cellulitis, 
favors subinvolution and all its evil effects. 
Displacements on account of increased 
weight and size, and relaxed supports. 
Leucorrhcea. cervical and uterine catarrh. 
Increases quantity and frequency of 
menses. By irritation and congestion fav- 
ors abortion; predisposes to epithelioma, 
and causes many reflex nervous disturb- 
ances. 
In many cases 
by producing 
conditions nam’d 
in answer to 3d 
question. In 
some cases no 
effect seems to 
follow. 
I believe it will to some 
extent, or entirely prevent 
such uterine or pelvic dis- 
eases as are often sure to 
follow its occurrence. We 
see, however, all the above 
named and other uterine 
and pelvic diseases w’here 
no laceration exists. 
I do. In cases where the 
above named (question 3) 
and other pathological con- 
ditions follow its occur- 
rence, and are not curable 
by other means. If local 
treatment would cure,don’t 
operate. 
No 
. I have seen 
many’ cases 
where no symp- 
toms were com- 
plained of. 
About 30 times. ] 
j 
Never for the 
sake of operat- 
ing, only for 
the cure of 
symptoms. 
About 30 times. 
Good. 1 had one case of 
acute cellluitis follow, and 
in ouecase sutures all tore 
out. I operated again and 
cured the case so far as I 
know. 
My remote results have 
been good. I believe it 
cures sterility’ instead of 
producing it. 
When no symptoms ex- 
ist which demand it, and 
where any’’cellulitis exists. 
• 
James B. Hunter, 
New York, N. Y. 
I do—one of the 
most important. 
Not necessarily 
—unless there is 
cicatricial tissue. 
By impairing the circulation. By keep- 
ing* up engorgement of uterus, and thus 
causing displacements, etcj. 
Often a cause 
of miscarriage. 
Most emphatically. 
When there is much 
hypertrophied and cicatri- 
cial tissue. 
Not necessarily. 
At least 200 times. 
About 25 per 
cent. 
About 75 per 
cent. 
Very’sa t i sfactory. Non- 
union rare exception. Re- 
lief comes later, six months 
to a year. 
Highly satisfactory. 
Chiefly in cases of recent 
cellulitis. 
David Prince, 
Jacksonville, 111. 
Y’es. 
Yes. 
By constant irritation inducing local 
chronic inflammation, and by reflex action, 
hyperaemia and hypertesthesia of near 
and sometimes distant parts through 
reflex action. 
J- 
Sometimes. 
Yes. 
/ 
Y’es, when the conditions 
in question 3 exist. 
No. 
Have not kept 
statistics, but I 
have seen nu- 
merous lacera- 
tions unattended 
with inconven- 
ience. 
6-8 times. 
Never. 
Always. 
Benefit. 
Can’t say. 
Never, only it may not 
always be necessary. 
Willis P. King, 
Sedalia, Mo. 
Y’es. 
Not necessari- 
ly, but in some 
cases I h a ve 
known a small 
fissure with 
granular ero- 
sion to cause 
severe reflex 
pains. 
1st. By causing septic poisoning when re- 
cent. 2d. By acting as a pqint of irritation, 
causing pelvic congestion. 3d. Granular 
erosions, by failure to heal. 4th. Laying 
the foundation for epithelioma by degen- 
eration of granular tissue. 
Y’es. 
Yes, excepting when 
disease of the pelvic organs 
immediately follows the 
laceration. 
Y’es. In any case where 
disease of the pelvic organs 
or tissue is directly trace- 
able to this as a cause. 
No. 
Not many. I 
believe that 95 
per cent, of real 
laceration will, 
ultimately, cause 
disease of some 
kind. 
7 times. 
None. 
Seven. 
Had perfect union in all, 
and all gave relief. 
Two out of seven have 
borne children, one of 
them two since the opera- 
tion. 
When reflex troubles are 
traceable to other causes, 
with manifest hydro or 
pyro salpinx, it should not 
be done. That is, Emmet’s 
operation is contra-indicat- 
ed, when Tait’s opera- 
tion Is manifestly In- 
dicated. 
Chaucey D. Palmer, 
Cincinnati, O. 
I most certainly 
do. 
Y’es. 
By delaying and preventing complete 
involution, creating erosions, granular de- 
generation of the cervix, and eversion of 
the cervical lips; and finally, hyperplasia, 
cystic degeneration, uterine displacement, 
and it may be epithelioma. 
Y’es. 
Yes, in properly selected 
cases. 
Absolutely necessary’, in 
most cases of deep seated, 
bilateral or stellate lacera- 
tions. even before second- 
ary’ changes have taken 
place. Also, in less marked 
laceration, if these changes 
are present as results. 
Not necessarily’. 
But such re- 
sults (mentioned 
before) are so 
constant as to 
form the rule. 
The proportion 
upon results is 
very small and 
exceptional. 
Some 35-40 times. 
To restore 
cervix before 
pathological 
changes have 
occured —3 
times. 
Some 35 times 
In the great majority of 
cases the immediate * re- 
sults have been satisfac- 
tory as to union and local 
relief. 
Largely, very beneficial. 
When there Is co-existant 
or inter-current chronic 
peri or para-metritis. The 
granular condition may 
forbid, but the para-metn- 
tic complication is the 
chief contra-indication. 
Wm. Goodell, 
Philadelphia, Pa. 
I do. 
Fissures, if 
skinned over, do 
but little harm, 
and I rarely 
touch them. 
By its keeping up an irritation of the 
uterine organs, and by an afflux of blood to 
them; causing growth, hypertrophy, etc. 
I do. 
I think it will, to a great 
extent, do so. 
Cases of ectropion; cases 
of tender and neuralgic 
cicatrix; cases of hy’pertro- 
phy; cases in which cancer 
is hereditary in the family. 
I do not think that 
every- tear will, but I 
think that the great 
majority do cause 
nel vie troubles of some 
kind. 
263. 
I have very rarely failed 
to secure union ; but I have 
sometimes failed to get re- 
lief. 
On the whole, I think 
that operation does not 
cause unfruitfulness, as I 
used to think, and the re- 
mote results have been 
better than the Immediate 
ones. 
In fissures of no great 
magnitude; and In all cases 
in which the ectropion Is 
slight, and yields to local 
treatment. 
M. D. Mann, 
Buffalo, N, Y. 
Very important 
and common. 
If by fissures 
you mean slight 
lacerations, I do 
not. May be only 
slight laceration, 
showing but 
much deep scar 
tissue which will 
do great harm. 
In several ways, by causing cellulitis, 
subinvolution, endomitrfcfs. hypertrophy 
of neck, reflex action on distant organs, 
displacements, etc. Believe it to be a 
common cause of cancer of cervix. 
Most certainly. 
Yes, unless cellulitis has 
occurred in child-bed. 
In all cases where symp- 
toms are serious enough to 
demand it, and where there 
is hereditary cancer. 
No. by no means. 
Many cases seem to 
suffervery little from 
it, or not at all. 
Can not tell— 
quite a number. 
About 90 times. 
Can not sepa- 
rate causes. 
Can not sepa- 
rate causes. 
Have only failed of 
luiionV’ines. None lately. 
Relief in at least 95 per 
cent, of cases. 
Sterility cured in small 
number, but liave not been 
able to tollow cases. 
When pelvic cellulitis 
and peritonitis are not 
well cured, or cancer is 
developed. 
J. Matthews Duncan, 
London, Eng. 
No. 
No. 
It may be the seat of local irritation—so 
called ulceration. 
No. 
No. 
No. 
No. 
Never observed 
(except immedi- 
ately—not event- 
ually’). 
Never. 
Never. 
Never. 
Almost always. 
\ 
Wm. H. Taylor. 
Cincinnati, O. 
Yes. 
By “ fissure” I 
understand less 
than "lacera- 
ti o n,” therefore 
less important. 
Keeping up engorgement, irritation, or 
pressure upon nerves, exhausting dis- 
charges. 
Only if exten- 
sive. 
To some extent. 
In extensive lacerations. 
No. 
Can not answer 
definitely. 
Can not answer 
definitely. 
Can not answer 
definitely. 
Can not answer 
definitely. 
Can not answer definitely’. 
Can not state definitely’. 
Not needed in limited la- 
ceration. 
W. H. Baker, 
Boston, Mass. 
Yes. 
If sufficiently 
extensive I do. 
By occasioning pelvic cellulitis, subinvo- 
lution of the uterus, hyperplasia of cervix, 
and increasing the tendency to the devel- 
opment of cancer of the cervix uteri. 
Yes. 
Yes. 
Y’es. In extensive lacer- 
ation. with eversion and 
ey’stic degeneration. 
Not necessarily. 
I 
Can not state 
number of such 
cases which have 
been observed. 
About 400 — four 
hundred times. 
Can not divide 
them without 
weeks of work 
in going over 
records of cases. 
Can not divide 
them without 
weeks of work 
in going over 
recordsof cases. 
Almost universally’good. 
Union by first intention in 
nearly e’very'case, and no 
complication save pelvic 
cellulitis in one case, death 
by septo-py’semia in one, 
and phlebitis in one. 
Good in overcoming ster- 
ility. 
When there is any acute, 
or sub-acute inflammatory 
action of cellulitis tissue or 
peritoneum around the pel- 
vis. 
E. W. Jenks, 
Detroit, Mich. 
Y’es. 
Yes. 
Ectropion and attention of the everted 
lips furnish a constant source of irritation, 
causing congestion, connective tissue 
growth, and retarding involution and re- 
flex symptoms, immediate and remote. A 
laceration which has healed wholly or in 
part, may cause symptoms like the above 
on account of cicatricial tissue in which 
nerves are involved. 
Y’es. 
Y’es. 
Y’es. In cases where local 
and constitutional symp- 
toms indicate uterine or 
pelvic disorder, and exami- 
nation reveals the exist- 
ence of cicatricial tissue, 
with more or less connect- 
ing tissue growth, the neck 
enlarged, and particularly 
if the nabothian glands are 
notably developed. 
No. 
Unable to say 
how man y’. I 
have seen hun- 
dreds. 
Can not state ex- 
actly. About 200. 
\ 
Can recall to 
mind but one, 
and that was a 
month alter 
childbirth. In 
this instance 
there was al- 
most constant 
hemorrh age 
from laceration 
of circular art- 
ery. 
Have alwa5rs 
operated on ac- 
count of patho- 
logical changes 
In the uterus, 
or reflex dis- 
turbances de- 
pending there- 
on. 
Have usually had union, 
but not immediate relief ; 
look for the latter in about 
three months. I have been 
unable to follow up all of 
my cases. Have failed to 
obtain union in five cases. 
I desire to add as a partial 
answer, that I deem it of 
great importance to secure 
union in plastic operation 
about the generative or- 
gans of women, that a con- 
dition of health must be at- 
tained. This is done in 
many’ cases only’ by’ local 
and constitutional treat- 
ment. 
I am unable to answer, 
except as above, as the pa- 
tients have been from vari- 
ous parts of the country’. 
Where there is no ectro- 
pion, few or no cicatrices, 
no particular enlargement 
of the uterus, no Nabothian 
bodies apparent. Also where 
there are no s.vmTttoms that 
can be considered of uterine 
origin. 
Thad. Reamy, 
Cincinnati, O. 
Yes, without 
doubt. 
Yes, to some 
extent. 
Arrests involution by two or more pro- 
cesses, viz: Disturbs normal nervous 
function. 2d, the processes of repair of 
the injury which nature has to set up de- 
mands so much blood in the tissues as to 
prevent the fatty degeneration essential 
to involution. 
In many cases. 
In many cases prevent, 
in some cases cure. Will 
always do good in properly 
selected cases, properly 
done. But the most ex- 
perienced gynecologist 
may now and then be de- 
ceived as to which are pro- 
per cases. 
Whenever the laceration 
has left marked deformity’, 
as ectropion, or when hard 
cicatricial tissue is in the 
field of repair, whether the 
tissue causes pain or reflex 
irritation or not, I consider 
the removal of it necessary 
in order to guard against 
cancer. 
No. Anterior lacer- 
ation frequently heals 
without operation, 
leaving scarcely’ a 
trace, and in other 
forms of moderate de- 
gree no evil is mani- 
fest. 
Quite a number; 
can not say how 
many. 
324. 
N e V’ e r, be- 
cause have al- 
ways had in 
view this and 
its present and 
ultimate conse- 
quences. 
Union in almost every 
case. 
Properly’ done does not 
cause but often cures ster- 
ility. Good in large per cent 
of cases. Have had failures 
as to relief of reflex and 
other sy’mptoms. It Is not a 
‘■cure all." The lesion does 
not cause all, nor will the 
operation cure all pelvic 
disease nor yet all reflex 
nervous symptoms. 
All cases where lacera- 
tion slight, and has been 
followed by’ no sy’mptoms 
referable to it—during preg- 
nancy, during presence of 
acute or subacute metritis, 
peritonitis or pelvic cellu- 
litis. cancer of neck or body 
of uterus. When patient 
is suffering of pulmonary 
consumption, or any other 
fatal malady. 
T. B. Harvey, 
Indianapolis, Ind. 
I do. 
I do so far as 
pain and nervous 
disturbance are 
concerned, but 
not attended 
with so much dis- 
placement. 
i 
Fissures and slight lacerations cause in- 
flammation with exacerbations at the 
menstrual epoch. More extensive lacera- 
tions cause cystic degeneration, hyper- 
trophy, induration, displacements, and all 
kinds, cause cellulitis, reflex irritation, in 
remote parts, and predispose to epithe- 
lioma. 
I do, although 
many conceive. 
I do, where no other 
causes supervene, and I be- 
lieve that slight lacera- 
tions in time produce the 
so called “ Cervical Metri- 
tis ” ulceration and subin- 
volution and that the ear- 
lier the operation, the 
greater the success. 
In all cases w’here uterine 
sy’mntoms cause thewoman 
to consult a physician. 
I do. 
If upon exam- 
ination of a case 
laceration is 
found, I know of 
no means of ex- 
plaining it away 
as a factor In the 
etiology. 
I can not state ex- 
actly, as I take no 
note of hospital cas- 
es, over 290. 
In about one- 
fourth the 
cases. 
\ 
Probably one 
hundred and 
fifty. 
Good as to union in most 
cases, failure in 
about five per cent. Good 
in most all where all cica- 
tricial tissue was cut away. 
Not good when this was 
not done. 
Very encouraging and 
successful in recent cases, 
and where there has not 
been too great a degree of 
induration. Some failures 
where the opposite con- 
ditions exist. 
I can not see why it should 
not be tried in all cases 
where laceration or fissures 
exist, provided epithelioma 
has not invaded the parts 
so deeply’ that we can not 
hope for union. 
P. J. Murphy, 
Washington, D. C. 
The deeper lacer- 
ations owing to 
impeded circula- 
tion may be the 
cause of pelvic di- 
sease. 
No. 
A deep laceration of the cervix uteri in- 
terferes with the circulation of that organ, 
gives rise to hyperplasia, prevents involu- 
tion, and by these means will induce 
hypertrophy, and may give rise to any one 
of the displacements frequently accom- 
panying a lacerated cervix. 
No. 
I believe that uterine and 
pelvic disease always ac- 
company a lacerated cer- 
vix, and ought to be re- 
lieved before the operation 
is performed. 
It is necessary in deep 
lacerations of the cervix 
uteri, and ought to be per- 
formed for the reasons 
above stated. 
No,because as above 
stated pelvic and uter- 
ine disease usually ac- 
company a lacerated 
cerytx. 
About 50. 
About 50 times. 
Union by first intention 
has followed in almost all 
cases, i;, 
My observations have been 
few, theoretically I believe 
it induces sterility. 
/ 
It is contr a-i n d i c a t e d 
when the lacerated cervix 
is accompanied by uterine 
and pelvic disease, and 
ought not to be performed 
unless in the graver lesions 
of the cervix. 
J. Byrne, 
Brooklyn, N. Y. 
I do. 
Not invariably 
but frequently. 
Directly by its retarding involution, and 
more remotely as a cause (frequent) of 
abortion. 
Y’es. 
Y’es. 
Only’ in cases where the in- 
jury’ has been considerable, 
and where eversion of the 
cervical membrane exists, 
or dense cicatricial tissue 
occupies the seat of injury’. 
I do not. 
Y’ery many- 
perhaps hun- 
dreds. 
Probably two hun- 
dred times. 
Can not say, 
hut not a majo- 
rity. 
In most cases 
operated upon. 
Almost universally suc- 
cessful. 
In cases of sterility from 
this cause, conception has 
usually followed a success- 
ful operation. 
In chronic pelvic celluli- 
tis and anaemia or other 
depraved state of the sys- 
tem. 
William T. Lusk, 
New York City. 
In certain cases. 
Y’es. 
No. 
By leading to disease of cervical and often 
corporeal mucous membrane. Hence 
catarrhs, hemorrhages, uterine enlarge- 
ment,etc. Many patients .after from forms 
of remote reflex neuralgias, but these are 
not constant. 
Not as a rule. 
May lead to abor- 
tions. 
Don’t know—Many pa- 
tientswith lacerations have 
no disturbances resulting. 
I have only operated when 
symptoms made it neces- 
sary’. 
Y’es. In prolonged cer- 
vical catarrh, in hemor- 
rhage, from uterine cavity, 
and in reflex neuralgias, in 
constant backache, and 
where walking without un- 
usual fatigue is impossible. 
No. 
r -r 
About 300 times. 
Always. 
Failure to unite has oc- 
cureil perhaps a half dozen 
times. Amount of relief 
vaT’.ivhio -often complete 
and /always sufficient to 
repay for the operation. 
Good, so far as a check 
upon tendency to abort. 
Chrobak, 
Vienna, Austria. 
Ya. 
YTa, aber in an- 
derer Weise. 
Die Wirkung der Lacerktion bestehtso- 
wohlin der Zerrung, als in Entzuendung 
des param. bei hochstehendem Risse, als 
auch in den Veraenderungen, welche die 
dem Vaginalsecrete und den Insulten 
ausgesetzte Cervix schleifnhaut erleidet. 
Ya, doch haupt- 
saecblich durch 
die Compile a- 
tionen. 
Ich halte die Emmet’sche 
operation fuer eine der bes- 
ten und sichersten Uterus- 
krankheiten vorzubeugen. 
In einigen Faellen, hoch- 
gradigen Ectropiums und 
schweren Sy’mptomen un- 
bedingt noethig 
Verhaeltnissmaesig 
wenige Lacerationen 
m a c h e n so schwere 
Sy’niptome, dass Oper- 
ation unbedingt 
noethig ist. 
% 
Die reine Emmet’ 
sche Operation etwa 
10 mal. 
Injedem Falle, absolute 
prima intentio und vollen 
Erfolg. 
Kann ich nicht beantwor- 
ten. 
Halte die Operation fuer 
seltener noethig, als sle ge- 
woehnlich gemacht wird; 
contra-indicirt ist sie nur— 
von allgemeinen contra- 
indicationen abgesehen— 
bei bestehender frischer 
Entzuendung. 
W. T. Howard. 
Baltimore, M. D. 
I do. 
As distinct from 
lacerations, only 
exceptionally. 
When a laceration is accompanied by 
catarrhal ectropion of the cervical mucosa 
this is increased by the attrition of the in- 
flamed surfaces during respiration and 
locomotion ; and this constant source of 
irritation creates reflex disturbance. 
In some cases, 
certainly, but not 
in all. 
I do. But if done too early’ 
it is apt to fail,andmay even 
increase the mischief ;while 
if badly done, it had better 
not be done at all. No 
operation is more abused, 
or oftener badly’ done. 
I have fully given my 
views under this head in 
the report I send you. See 
pages, 8. 9 and 10. (See his 
report.) 
I db not. 
I can give no 
acurate idea o f 
the number of 
cases I have seen 
not requiring 
ope ration; but 
they are not in- 
frequent. 
I have kept no re- 
cord ; but I must 
have operated 100 
times. 
I can not say. 
I can not say 
After I gained experience 
almost always good. 
I have not followed up 
many’ cases, as they were 
generally from a distance, 
and I have long curtailed 
obstetric practice. 
Y’ou will find this answer- 
ed in my report. (See his 
report.) 
TABULATED RECORD OF OPINIONS ON EMMET’S OPERATION. 
a-TTST-A-TT zinsnsiE, :lv£-:d-, o. 
become in form and appearance natural. This morning two cases were seen,and it would 
be a question with some whether the women had a child from the appearance of the 
cervix. The os tine* has either assumed the round, small opening, or a small trans- 
verse slit. 
5 Question. — If it is in a recent case, I do not. If the laceration is bilateral or 
tripod, without overcoming the diseased condition of the cervix, to some extent, or 
completely, then the operation for closure I do not believe will prove as suc- 
cessful, and as beneficial till the pathological condition is treated and restored. 
When this is accomplished, the laceration will be reduced in size, if it had been deep long, 
a more just estimate could be formed whether the bilateral should be treated 
by closure or not, and the tripod in the same manner. If the lacerations, bilateral or tripod, 
should have reached the vaginal junction, which is very rare, I believe, and the diseased 
condition of the mucous membrane not heal perfectly, and there is an eversion of the 
labia of the cervix, which is most generally the case, although eversion may occur from 
a positive or relaxed condition of the cervix, without laceration. In that class of cases 
I have preferred amputating the anterior and posterior labia, or the three points of the 
cervix (the tripod). Believing that this surgical method is far better, and more simple 
than the attempt at closure for the bilateral or tripod lacerations. After the removal of the 
parts the cervix heals up, and leaves a perfectly natural appearance of the cervix, 
cleanliness being only resorted to, and not covering the amputated stump as Syme has 
done. I will not enlarge on this point, but refer you to my monograph in Beilview and 
Charity Hospital Reports for 1876, on amputation of the cervix uteri in procidentia 
. uteri, and complete eversion of the cervix uterialso, Vol. 1 American Gynecological 
Society, for remarks “on Emmet’s Paper on Flexions. Emmet himself was much opposed 
toamputation of the cervix, except in special pathological conditions, and adopted Syme’s 
method of covering the stump by the mucous membrane. In a clinical lecture reported by 
Coe in the American Journal of Obstetrics,February number,1885,page 174, he says, in refer- 
ence to the treatment of lacerated cervix: “I desire to say here that I have been greatly 
misunderstood concerning amputation of the cervix. I find about twelve or fifteen cases of 
laceration every year, in which the injury has been so extensive that it would be bad 
surgery not to amputate. It should be only thought of in the case of women 
who are pretty well advanced in life. “ His objections have always been directed against 
the removal of an apparently elongated cervix, when the real condition has been not an 
elongation but a prolapse.” Now, my friend Emmet has not considered the subject 
on this point —see my paper on Physiological lengthening of the cervix uteri, etc. 
I have been present at operations for laceration of the cervix uteri which I must confess 
I should never have considered of this nature. Emmet himself does not perform the 
operation as often as he has done. The very proposition to repair a laceration for 
rent by the delivery of the child, has won many and many a professional gentleman to 
consider that was the correct and true and proper treatment. My own experience 
with the views I entertain and for long experience and a large practice is that this is only 
justifiable in a few cases. The frequency of the operation is to be condemned. The oper- 
ation will, I believe, in a few years not be performed as many times as it has, and possibly 
in only a few cases. It will be delegated to the same tomb that the posterior division 
of the cervix, or the bilateral incision of the cervix uteri, for they are things of a day. 
Any new operation on the cervix or uteri must run the gauntlet and be tested by time. 
But,' alas, these important and vital organs have been cut and sewed up so much 
and in such great numbers that it is, from the injury it has undergone, not to be 
considered an organ that conservatism is required, but must always be treated surgically, 
as one author has said, “ It is only to be treated surgically.” 
6 Question.—1This has been answered above. 
7 Question.—By no means. Too many cases have been seen to adopt that view. 
8 Question.—Answered above. 
96 Question.—Not by closure, but by amputation as above referred to. 
12 Question.—It is contra-indicated in a large number of cases, and only necessary in 
the class of cases I have referred to as above. 
March 1,1885. 
Dr. Zinkk.—Dear Sir: I regret that I have no statistics to aid you in your very 
valuable inquiry as to the merits of Emmet’s “ op.” I have operated very little. My 
patients do not come to me from abroad, and consequently will not submit to ulterior 
measures, as those will who go to men of more reputation. I have seen some cases in 
which I thought it desirable—many where it would have been done by others, I think. 
I have too few data to feel satisfied in my own mind, but my impression is that there are 
cases of unhealed laceration (ectropion) demanding the operation, and for those cases it is 
a gfqut improvement. 
As to the cicatricial tissue doctrine, I felt very doubtful, and so expressed myself in re- 
view of 1st edition of Emmet’s work (Am. Jour. Med. Soc.) Yet in last edition he brings 
many facts in support. I operated in a case week before last—repaired cervix and periton- 
eum at same time. I had exhausted local and general treatment in the case, and nearly 
two years ago advised the operation which she then refused. Three days after operation, 
she was free of backache for the first time in months. Of course I am waiting with great 
interest the ultimate result, for the ache had returned somewhat when I last saw her. 
There has been a wonderful change of doctrine by Emmet as to the operation to 
which I call attention in review of 3d edition, to appear in April No. American Journal. 
If you use this, please use no name. 
I am very truly yours, 
89 Madison Ave., N. Y., March 5, 1885. 
Dr. Gustav Zinke, Cincinnati, O.—Dear Doctor: I have so recently gone over the 
whole subject of laceration of the cervix in the 3d edition of my book, just published, 
that I have nothing more to add. I have there answered all the objections that have 
been brought against the operation. Little more is to be said on the subject until the pro- 
fession has carefully carried out my directions as based upon over-twenty years of ex- 
perience and close study. Where there has been failure to gain the results I have claimed, 
the burden must rest on the operator to show the cause. 
The operation has long since pased out of my hands, and so fully endorsed that I 
have no fear for its future. The great point is to check the abuse, which is tearful. Every- 
one feels competent to perform it; it is done without the proper perparatory treatment, 
and with no special purpose. I believe in nine cases out of ten, where it is done, or at- 
tempted, the execution of the operation is defective and without any benefit to the 
patient. You have here a most fruitful field for your paper, but to discuss the merits of 
the operation within its proper range, is futile. 
Yours truly, T. A. Emmet. 
Rome, CJa. , March 2, 1885. 
Dr. Gustav Zinke, Cincinnati, O. 
Dear Doctor: I have not as yet been impressed with the great importance of lacer- 
ations of the cervix—excepting where they are extensive. My operations have been con- 
fined to the latter class, and the results have been satisfactory. 
Respectfully, Robert Battey. 
Edinburgh, March 17,1885. 
Dr. Gustav Zinke, Cincinnati, O. 
Dear Sir: As I have had no occasion myself yet to perform Emmet’s operation, I 
feel scarcely justified in giving an opinion, and am not in a position to answer the queries 
in the form which accompanies your letter. My experience is drawn only from a few 
cases ih which I have seen Prof. Simpson operate, and would watch the progress of the 
There is no evidence that a lacerated cervix is in itself a condition of much import- 
ance i in its relation to cervical catarrh and cellulitis it is of importance. I fancy1 that the 
cellulitis we often see, especially in the left broad ligament, is due to slow septic absorp- 
tion from the laceration ; so also the ectropion will keep up, if not cause cervical catarrh. 
On the other hand, lacerations are so frequent that we must look on them almost as a 
physiological occurrence, just as we do a slight perineal laceration. 
Yours faithfully, A. H. Freeland Barbour.