Reprinted from the New Yorlc Medical Journal, 
for March 17. 1888. 
NEW YORK CLINICAL SOCIETY. 
Meeting of January 27, 1888. 
The President, Dr. Robert Abbe, in the Chair. 
Alexander’s Operation.—In a discussion on this subject 
the President said that he had had an experience with Alex- 
ander’s operation wTiich had developed in him some enthu- 
siasm for it. He had performed it eight times, with, as far 
as could be judged at present, marked success. The earliest 
operation, however, dated back only a year and a half. In 
four cases the operation was done for extreme procidentia, 
in three for moderate procidentia, and in one for retrover- 
sion. 
The case of retroversion was the first. The uterus was tilted 
completely backward on to the rectum, and gave the usual 
symptoms in great severity. The patient was practically dis 
abled. The ligaments were very easily found, and the uterus 
was dragged up by pulling them out three inches and a half 
on one side and four inches on the other. Then one liga- 
ment was pulled through the subcutaneous cellular tissue 
over the pubes to the opposite side, and there tied in a knot 
with the opposite ligament so as to make it perfectly secure 
against retraction. The wounds healed primarily and the 
womb was held up against the pubes. The patient remained 
perfectly well five or six months, when pains developed in 
the pelvic cavity of a different character from those which 
had existed there formerly. It was found necessary to re- 
move the ovaries, and during the operation he had an oppor 
tunity to examine the condition of the uterus. It was being 
held up in its normal position without the slightest retrover- 
sion. The round ligaments wTere firm, but not in a state of 
marked tension, showing that they were in the position that 
they had been placed in a year before. The uterus when 
Copyright, 1888, by D. Appleton and Company. 2 
ALEXANDER’S OPERATION. 
first replaced was in a state of hyperplasia; the fundus was 
large and heavy, and the cavity measured three inches and a 
half. At the time of the laparotomy the uterus was still 
Fig. 1.—The usual method of securing the round ligament and cutting oil the 
end. 
large, yet it was being held in position. The removal of the 
ovaries led to marked atrophy of the womb. 
The next case was one of procidentia uteri. While it was 
Fig. 2.—Subcutaneous looping and stitching of the ligaments together, a small 
incision being made. 
not an extreme case, yet the womb was outside the body. 
Alexander’s operation was performed in the same way as in ALEXANDER’S OPERATION. 
3 
the first case, except that the ligaments were pulled out a 
distance of four inches on either side. A small incision was 
made over the symphysis, through which both ligaments were 
drawn, one from either side, when they were looped together 
and the two ends stitched to one another to retain them 
firmly in place. Primary union took place and the patient 
made a good recovery. The patient married a second hus- 
band soon after the operation, and there has not since been 
the slightest indication of recurrence of the procidentia. The 
operation was done eighteen months ago. 
In another case the procidentia existed in the third de- 
gree, and cystocele was well marked. In this case he tied a 
knot in the round ligaments over one inguinal ring. Primary 
union occurred. The uterus was retained well up in posi- 
tion. This patient had had the womb outside of the vulva 
three or four years, and had suffered much in consequence. 
Fig. 3.—Knotting of the ligaments together subcutaneously. 
In one other case he resorted to a different method, which 
he thought well illustrated the manner in which success was 
obtained in holding the uterus in position by the round liga- 
ments. The ordinary method of cutting off the redundant 
portion of the ligaments after pulling them out, and stitching 
the remaining portion at -the inguinal ring, it seemed to him, 
gave a chance for the ligament to slip back. He had prac- 
tised three different methods in order to avoid this accident. 
The first consisted in looping the ligaments together, the sec- 
ond in tying them together in a knot, and the third in using 
them as a suture to close the wound made while searching for 
them. He had resorted to the latter method in three or four 4 
ALEXANDER’S OPERATION. 
cases. Primary union had followed, the ligament could not 
possibly slip hack, and the result had been uniformly good. 
In one case he had been able to find hut one ligament, which 
Fig. 4.—Suture of the inguinal ring with the round ligament. 
he used as a suture in the manner described, and it held the 
womb well in place. 
Regarding stretching, it did not seem very probable that 
the round ligament would stretch much. He had had an op- 
portunity to examine the conditions of the womb and ligaments 
after laparotomy performed some time subsequent to Alex- 
ander’s operation in one other case. Dr. McBurney had per- 
formed Alexander’s operation on the patient with the result 
of the round ligaments holding the uterus well in place, and 
the speaker had occasion to perform laparotomy for a circum- 
rectal growth some months later.