[Reprinted from the American Gynecological and Obstetrical Journal 
for June, 1896.] 
ANTERIOR SUSPENSION OF THE UTERUS AND 
SHORTENING OF THE ROUND LIGAMENTS 
BY VAGINAL SECTION* 
By Henry T. Byford, M. D., Chicago. 
Since Dtihrssen and Mackenrodt first published their methods of 
vaginal fixation of the uterus, the medical periodicals have been so 
full of these operations and their modifications that it would be super- 
fluous for me to give to the members of this Society a historical re- 
view of the subject. Presuming, therefore, upon your familiarity with 
what has been accomplished, I will briefly describe an operation de- 
vised by me, which is practically a development from these pro- 
cedures. It consists, briefly, in (i) anterior colporrhaphy ; (2) suture 
of the fundus uteri to the peritoneal covering of the upper portion of 
the bladder ; (3) suture of the round ligament to the uterus above its 
normal uterine insertion at a point as far toward the pubic end as can 
be grasped; and (4) closure of the vaginal wound in such a way 
that the bladder regains its vaginal and uterine attachments, and the 
connective tissue from either side of the anterior fornix is drawn to- 
gether in front of the uterus and forces the cervix backward. 
The steps of the operation are as follows : Dorsal position. 
Thorough disinfection of the shaved vulva and perinaeum and the 
vagina with soft soap and scrubbing brush or gauze, then with alcohol, 
and finally with corrosive-sublimate solution. Curettage of the uterus, 
and disinfection of the endometrium (corporeal and cervical) with 
ninety-five-per-cent, carbolic acid. A strong silk thread is then 
passed through both lips of the cervix, which is used to draw the uterus 
toward the vulva, the vaginal walls being held apart by retractors. A 
transverse vaginal incision three centimetres long is made immedi- 
ately in front of the cervix, and the bladder is separated from the 
uterus by the finger. A median incision is made from the middle of 
* Read before the Chicago Gynaecological Society, April 17, i8g6. 
Copyright, 1896, by J. D. Emmet, M. D 2 
Henry T. By ford, M. D. 
the transverse incision, forward along the anterior vaginal wall for 
five centimetres, and the bladder separated from the vagina one or 
two centimetres on either side. The finger then tears through the 
peritonaeum at its junction with the uterus, and examines the append- 
ages. If the latter are adherent, they can usually be released, and 
if badly diseased, they can be drawn into the vagina and treated or 
removed, and small fibroids, if present, can be removed from the 
uterine walls. 
After drawing down the cervix and retracting the anterior vaginal 
wall and bladder with a long retractor, the anterior uterine wall is 
exposed to sight and grasped with tenaculum forceps. A curved 
haemostatic forceps is then passed up behind the bladder, under 
guidance of the finger, and made to grasp the bladder peritonaeum 
and pull it down into view, and another forceps applied higher up 
to gently pull the parts down, and so on until the peritonaeum, 
which was over the top of the bladder and behind the upper portion 
of the symphysis pubis, can be seen. Two long sutures of chro- 
micized catgut are passed through the peritonaeum at this point as 
high as possible and about a centimetre and a half to either side 
of the median line, and the bladder released, except as it is held by 
the long catgut sutures. The anterior wall of the uterus, already 
grasped by tenaculum forceps, is pulled into the vaginal opening, 
and the sutures are passed through the fundus uteri about the same 
distance on either side of the median line as they have been passed 
through the bladder peritonaeum. This is easily done by the aid of 
a curved needle on a handle. All blood is now sponged out of the 
pelvis and the sutures tied and cut off, bringing the fundus uteri 
firmly up against and over the bladder about an inch behind the 
pubic bones. 
The suspended uterus is now exposed by the vaginal retractors, 
whereupon the origin of the round ligaments can be seen. The in- 
dex finger or a haemostatic forceps pulls a loop of the left round liga- 
ment out into the vagina and draws it down until it is taut. Then a 
chromicized catgut suture is passed through it as near the inguinal 
end as practicable, and also through the anterior uterine wall directly 
above the visible place of origin of the ligament, and is tied. This 
draws the parts together, and the shortened ligament acquires an 
attachment a trifle nearer the fundus than before. The same is done 
on the right side, and thus both round ligaments are shortened and 
the general peritoneal cavity practically shut off. 
In closing the wound, the sutures, which should include the con- Anterior Suspension of the Uterus. 
3 
nective tissue under the bladder, are passed transversely, beginning 
at the end nearest the vulva, and restore the bladder to its original 
relation with the vagina. The transverse incision in front of the cer- 
vix is now closed by sutures so placed as to draw the two ends, which 
were three centimetres apart, together in the median line, thus not 
only drawing the connective tissue together in front of the cervix 
but also lengthening the anterior vaginal wall and pushing the lower 
end of the cervix backward. A few inches of a narrow strip of 
iodoform gauze are pushed into the wound and the end left hanging 
out near the cervix. It is removed in twenty-four hours. The pa- 
tient is kept in bed for three weeks. No pessary is required. 
After the operation bimanual examination shows the cervix to be 
eight or ten centimetres from the subpubic ligament, and the fundus 
to be over the bladder and behind but not over the pubes—that isr 
the uterus is in a normal position. In my first case I sutured the 
uterus to the bladder but did not shorten the round ligament, and 
bad occasion to immediately open the abdomen from above to re- 
move some omental tumors discovered during the operation. I saw 
the fundus uteri behind the pubes in about normal position and at- 
tached to the upper portion of the bladder, the sutures being con- 
cealed. I put in another suture from above, but the knot of this one, 
unlike the others, was exposed in the peritoneal cavity and demon- 
strated the advantage of introducing the sutures from below. 
Cases. 
I have done this operation eight times, although in my first opera- 
tion I did not shorten the round ligaments, and in the last only I 
closed the transverse incision so as to approximate the ends instead 
of the sides. The operations were done on the following dates of 
this year : February 5th and nth, March nth (two cases), 12th, 17th, 
24th, and 28th. 
Case I.—Mrs. C. had retroversion ; had been almost bedridden 
for two years, and was unable to come to my office for examination. 
I removed an enlarged ovary with a large corpus luteum hoematoma, 
and then some small fibroid tumors of the omentum, by an abdom- 
inal incision. I found a trace of blood on either side of the bladder 
that came from the raw surfaces on the anterior wall of the cervix 
uteri. This would have been prevented had I shut off the peritoneal 
cavity laterally by shortening the round ligaments, as in my later 
cases. The patient now has no abnormal symptoms and is growing 
strong. 4 
Henry T. By ford, M. H. 
Case II.—Mrs. C. Retroversion ; enlargement of both ovaries ; 
prolapse of the left ovary. Unable to come to my office. Attacks of 
intense pelvic pains requiring opiates for their relief, and deterioration 
of health. Came to my office two months after operation. No attacks 
of pelvic pain since operation.4 Uterus in normal position. This pa- 
tient had a temperature of 102° during the second week. Fearing 
an abscess, I forced my finger into the tissues above the cervix for 
half an inch at the end of the second week, but found very strong 
union of the parts and no pus, although she complained of pain and 
tenderness in the bladder. Both pain and temperature subsided 
upon the administration the same night of one full dose of morphine. 
Whether the catgut became infected or not I can not tell, but no pus 
was found. The disturbance was probably due in a great measure to 
the restlessness following the sudden stopping of the opiate which 
she had previously taken for pain. Bladder symptoms have disap- 
peared. 
Case III.—Miss McC., virgin. Retroversion, endometritis, and 
enlarged ovaries. Hysterical. Chronic sufferer in spite of treatment. 
Normal temperature from time of operation. A slight pain in left 
iliac region similar to that before operation was felt during the first 
week she was allowed out of bed, but it has since disappeared. No 
bladder symptoms. 
Case IV.—Miss W. Retroversion, endometritis, and enlarged 
ovaries. Patient had suffered a long time, and was obliged to give up 
her position in a store. Vaginal entrance was so small that a specu- 
lum examination was impossible. No unusual difficulty experienced 
in performing the operation. No elevation of temperature after op- 
eration. All symptoms have so far disappeared, except a feeling of 
general weakness. 
Case V.—Miss Jennie M., virgin. Unable to work. Neuras- 
thenia, pelvic pains, etc. Operation performed in public hospital. 
Temperature during third week ioi° to 102° F. Shallow pit at site 
of gauze drainage probably due to catgut infection. Uterus normal 
in position. An old pain in the left leg is all she complains of. 
Case VI.—Miss Y., virgin. Retroversion, endometritis, and en- 
larged ovaries ; right ovary size of large egg and cystic. Invalidism 
for years. Removed right ovary. Patient got up out of bed during 
the second week. No symptoms referable to operation except slight 
infection of bladder from prolonged use of catheter. 
Case VII.—Mrs. O. Prolapse of uterus, cervix appearing at the 
vulva, with anterior and posterior colpocele. This was the first case Anterior Suspension of the Uterus. 
5 
in which I drew the ends of the transverse incision together in the 
median line. I also removed a longitudinal strip of vaginal tissue on 
either side of the median-line incision so as to narrow the vagina. 
Emmet’s perinseorrhaphy. This case presented more difficulty in 
suturing the uterus and ligaments than the virgin cases, on account of 
the redundancy of tissue. 
The uterus has, so far, remained in position in every case. 
This method of operating possesses, I think, the following recom- 
mendations : 
1. It is not a dangerous method in competent hands. 
2. It is efficient. 
3. It possesses an advantage over vaginal fixation in that the po- 
sition of the uterus is normal, the bladder resumes its normal relation 
to the uterus and vagina, and there is only slight liability to compli- 
cation in childbirth. The attachment of the fundus is peritoneal and 
less firm than that from ordinary ventral fixation, and will undoubt- 
edly stretch during pregnancy. 
4. It is more easily performed than Alexander’s operation, and 
there is greater certainty of its successful completion. 
5. It gives access to the peritoneal cavity and thus affords an op- 
portunity for accurate diagnosis, for the separation of adhesions, and 
for the treatment or removal of diseased tissues. 
6. Patients prefer it to Alexander’s operation with its two external 
incisions, or to ventral fixation with its abdominal wound. They 
feel less inconvenience after it, and never see or feel their wound. 
7. There is no danger of hernia. 
The above-described operation resembles in some respects the 
operations described by Wertheim a month later than my first opera- 
tion (Centralblatt fur Gynakologie, March 7, 1896), and by Bode 
(Centralblatt fur Gynakologie, March 28, 1896), but is essentially dif- 
ferent. Drawing down the peritonaeum from behind the pubes into 
the vagina and stitching it to the fundus is entirely new so far as I 
know. Stitching the shortened round ligament to a higher place on 
the uterus is also different from Wertheim’s methods of stitching the 
round ligament to the vaginal edges, or to the bladder at the reflec- 
tion of the peritonaeum, or of taking a reef in the ligament by sewing 
together a fold of it. 
I prefer to combine the suspension over the bladder with shorten- 
ing of the ligaments, because I do not think that the peritoneal at- 
tachment alone should be made to hold the fundus forward, and be- 
cause the round ligaments alone might not prove sufficient. 
34 Washington Street.