[Reprinted from the American Gynecological and Obstetrical Journal 
for February, 1896.] 
INDICATIONS OF TREATMENT IN THE CASE OF 
UTERINE MYOMATA.* 
George T. Harrison, M. D., New York. 
It is my purpose in this introductory paper to define, with as much 
precision as possible, the indications of treatment for uterine myomata 
under the varying conditions which they present. In order to this 
I would propound the following queries : 
1. In the case of uterine myomata, when is a symptomatic and ex- 
pectant plan of treatment indicated ? 
2. What are the conditions that demand radical therapeutical 
measures—in other words, surgical intervention ? 
3. The indication being a radical operation, when should vaginal 
total extirpation be the method adopted, and when abdominal ? 
4. Under what circumstances is supravaginal amputation to be 
preferred to total extirpation ? 
5. When is enucleation, morcellement, or Emmet’s traction method 
per vaginam demanded ? 
In dealing with this morbid condition surgically, the operative 
technique has, in the past few years, been so greatly improved that 
the tendency is to embrace within the scope of surgical intervention a 
continually increasing number of cases which were formerly excluded 
from this domain. This tendency, too, appears to have reason on its 
side ; for it must be borne in mind that every uterine myoma is a 
neoplasm, and why should it not be removed, it may be argued, just 
as we do elsewhere in the body—as we do the ovary, for example, 
when the seat of a new formation. In the first place, it may be 
urged, How can we be absolutely sure that our diagnosis is correct 
What is diagnosed as a myoma may prove to be a sarcoma. Again, 
no one can say beforehand, with any degree of certainty, thal a 
myoma will not grow to greater proportions and become a source 
of danger to its possessor; it is easy to understand, then, that an 
operation performed in the early stages of its development might be 
* Read before the New York Obstetrical Society, December 3, 1895. 
Copyright, 1896, by J. D. Emmet, M. D. 2 
George T. Harrison, M. D. 
an easy matter, but later on exceedingly hazardous. We know also 
that degenerative processes occur at times in myomata, such as cal- 
cification, suppuration, gangrene, etc., which may bring great risk to 
the patient. One such degenerative change, which greatly in- 
creases the difficulty of diagnosis and may involve serious con- 
sequences, is general oedematous infiltration. The oedema is 
the consequence of stasis occasioned by the formation of thrombi, 
originating spontaneously in anaemic subjects or following upon 
therapeutical procedures. It has been observed repeatedly, after 
the Apostoli treatment, it may be remarked in passing. After 
a wound, infection may take place with-putrefactive bacteria, or with 
staphylococci, or with streptococci, resulting in thro?nbosis, oedematous 
infiltration, suppuration, necrosis, or pycemia. The endometrium, as is 
well known, exhibits a condition of chronic inflammation or hyper- 
trophy, especially in the case of intramural tumors. Menorrhagia or 
metrorrhagia are consequent upon this condition, and in the event of 
invasion of staphylococci, pus tubes may complicate the case. When 
the growing tumor is detained in the pelvis it may cause from pressure 
disturbances in the functions of the neighboring organs, especially the 
bladder. When it develops between the folds of the broad ligament it 
may dislocate the ureter of the corresponding side and so obstruct it 
as to cause hydronephrosis. Lastly, the degeneration into sarcoma has 
been observed, and even rarely into carcinoina. In view of these pos- 
sibilities, unfavorably affecting the prognosis, it would seem that a 
strict logical deduction from the premises would demand the ablation 
of the offending organ. As Kiistner, * however, justly remarks, “this 
radical standpoint to subject all myomata to operative treatment will, 
at all events, never find place in a science which makes it a problem 
to help the suffering organism as much as possible according to the 
standard of its individuality.” Virchow f admirably expresses it when 
he says “ the myomata in itself is a benignant entirely local formation, 
which brings no other danger to the body than that which is produced 
by its effects and changes.” It can not be denied that the preponder 
ating majority of women affected with myomata, if subjected to a 
symptomatic treatment, attain to the menopause, when the dangerous 
symptoms disappear gradually, as a rule. To a large degree the en- 
vironments of the patient must be taken into consideration in discuss- 
ing the question of a radical operation. A woman who has to earn 
her bread by daily toil can not afford to submit to a long continued 
* Grundzuge der Gyncekologie. 
f Die Krankhaften Geschwulste. Indications of Treatment in the Case of Uterine Myomata. 
3 
course of symptomatic treatment which her sister, in better circum- 
stances, could choose without inconvenience. In a word, it is the in- 
dividual that must be subjected to treatment, and not merely the dis- 
ease. The question might be thus put in each individual case : Are the 
dangers and annoyances incident to the myoma of such a grave char- 
acter as to outweigh the dangers arising from operative intervention, 
together with such drawbacks as appertain to the mutilation ? It is a 
well-attested fact that the removal of the uterus and the annexa, in 
young women is at times attended by such psychical disturbance as 
to make it a question if it had not been better to have let the patient 
remain as she was. Under these circumstances it might be well to re- 
move the uterus when the operation seems imperatively indicated and 
leave the ovaries intact. I have now under my care a patient affected 
with uterine myoma who may be considered a type of a large class. 
I have observed the case for seventeen years. Within this period I 
have seen the tumor take its origin in small beginnings, grow after 
emerging from the pelvis, assume huge proportions, ascending above 
the umbilicus, and then, after the menopause had been attained, gradu- 
ally undergo retrogressive changes, until now it is an insignificant en- 
largement. Meanwhile the physical condition of the patient is excel- 
lent, her fine complexion and robust appearance impressing one strong- 
ly with the exuberance of her health. The chief symptoms which 
called for treatment from time to time in this case were menorrhagia 
and metrorrhagia, and they were controlled by dilatation with lami- 
naria tents followed by injections with iodine. 1 have had excellent 
results with this mode of treatment for such conditions. Latterly I 
have employed dilatation, curettage, and packing with iodoform gauze 
with gratifying results, as a rule. It is doubtful if the patient would 
be as well if I had performed a radical operation, as at one time I 
thought of doing, when the symptoms seemed to demand it. 
Myomectomy I believe to be indicated under the following condi- 
tions : i. The persistent growth of a tumor, if certainly demonstrated 
and occurring in a woman rather young, unconditionally demands a 
radical operation. In the case of subserous myomata, even if they 
begin to grow when the patient is near the menopause, the indication 
is still a radical surgical procedure, as it may be assumed that they 
are nourished by their adhesions, and consequently that they will 
continue to grow during and after the climacteric. If the myoma oc- 
cupies the pelvis, and by its growth causes phenomena of incarceratipn 
on the part of the bladder, its removal is indicated if it can not be 
replaced. George T. Harrison, M. D. 
4 
2. Profuse haemorrhages, which cause intense anaemia and per- 
ceptibly exhaust the patient, furnish an indication especially when 
ordinary therapeutical measures prove inefficient. 
3. A radical operation is indicated when the pains and annoy- 
ances that accompany the growing tumor destroy all pleasure in ex- 
istence and render the patient incapable of doing any work. 
4. In a certain class of cases, in consequence of the presence of 
the myoma, ascites is evoked, which can only be relieved by the ex- 
tirpation of the growth. In these circumstances myomectomy is uncon- 
ditionally indicated. 
For the method of vaginal total extirpation, cases of subserous and 
intramural myomata not exceeding a child’s head in size should be 
reserved. For larger myomata, laparo-myomectomy is indicated. The 
fact that the after-treatment is so much more simple after total ex- 
tirpation than after supravaginal amputation, and that the patient’s 
condition is so much better, and further that the healing process pro- 
ceeds more smoothly and with so few complications, makes it the 
preferable operation. Only when the portio and cervix are very 
small, or it is important to save time, is amputation the preferable 
operation. When submucous myomata have passed through the cer- 
vix and attained the vagina, the removal by scissors, using Emmet’s 
method of traction, is usually not difficult, as the tumor is already 
more or less pedunculated. The same thing happens when the myo- 
ma is still in the cervix. When the tumor is quite large and has a 
broad base, it may be necessary to employ enucleation, morcedement> 
and traction. A necessary condition is that the cervix should be well 
dilated. Instead of the slow method of dilatation by laminaria or 
tupelo tents, it is better to incise the cervix, preferably after the man- 
ner of Fritsch, by incising the posterior lip up to the internal os. In 
this way the entire cavity may be felt, and our manipulations much 
facilitated. These methods are contraindicated in interstitial tumors 
of large size, and even in submucous myomata when the base is very 
broad.