THE 
Operation of Shortening the 
Round Ligaments, 
WITH TWO CASES. 
J BY 
F. B. HARRINGTON, M.D., 
Surgeon to Out-Patients at the Massachusetts General Hospital. 
{Reprintedfrom the Boston Medical and Surgical Journal, 
of April 2Q, 1886.] 
BOSTON : 
CUPPLES, UPHAAT & CO., Publishers, 
©ID Corner Book Store. 
188G. THE OPERATION OF SHORTENING THE 
ROUND LIGAMENTS, WITH TWO CASES.* 
Carolus Stepiianus, an anatomist of the sixteenth 
century, is said to have discovered the round ligaments 
of the uterus. 
Gray 2 says : “ The round ligaments are two rounded 
cords, between four and five inches in length, situated 
between the layers of the broad ligament in front of 
and below the Fallopian tube. Commencing on each 
side at the superior angle of the uterus, this ligament 
passes forward and outward through the internal abdo- 
minal ring, along the inguinal canal to the labia majo- 
ra in which it becomes lost. The round ligament con- 
sists of areolor tissues, vessels and nerves, besides a 
dense bundle of fibrous tissue and muscular fibres pro- 
longed from the uterus, inclosed in a duplicature of the 
peritoneum, which, in the foetus, is prolonged' in the 
form of a tubular process for a short distance into the 
inguinal canal.” 
Rainey 3 believes that the principal function of these 
ligaments is to draw the uterus towards the symphysis 
pubis during sexual intercourse, and thus favor the 
ascent of the semen. He says, “ The so-called round 
ligaments of the uterus, regarded as a muscle, may be 
said to arise by three fasciculi of tendinous fibres, the 
inner from the tendon of the internal oblique and the 
transversalis is near to the symphisis pubis; the mid- 
dle (fasciculus) from the superior column of the exter- 
nal ring near to its upper part, and the external fasci- 
BY F. B. HARRINGTON, M.D. 
1 Read before the Suffolk District Medical Society, Surgical Section, 
April 7, 1886. 
- Anatomy, Descriptive and Surgical. 
8 On the Structure and Use of the Ligamentum Rotundum Uteri. 
Loud., Phil., Tr. 1880. 2 
cuius from the inferior column of the ring, just above 
Gimbernat’s ligament. From these attachments the 
fibres pass backwards and outwards, soon becoming 
fleshy. They then unite in a rounded cord, which 
passes through in front of the spermatic artery. It 
then gets between the two layers of the peritoneum, 
forming the broad ligament, along which it passes 
backwards, downwards, and inwards to the anterior and 
superior part of the uterus, into which its fibres, after 
spreading out a little, may be said to be inserted. 
Dr. James A. Adams 4 says, ** Besides muscular tissue 
there isan abundance of fibro-areolar tissue intermixed.” 
Adams believes that the round ligaments are active 
during parturition, fixing and maintaining the uterus 
in due relation to the {telvis. 
During pregnancy, as is well-known, the round liga- 
ments are much enlarged, and there is an increase of 
muscular development. 
Alqui6, a French surgeon, in 1840, proposed and 
discussed with details the operation of shortening the 
round ligaments. The proposition was condemned, 
and attracted little or no favorable attention. There 
were no operations on living subjects. Aran, Deneffo, 
Sou part, Burggroeve, Revington, Freund, Schultze, 
and Adams subsequently projtosed the same operation.6 
Dr. William Alexander, on December 14, 1881, 
successfully operated on a case of prolapsus uteri by 
pulling out and shortening the round ligaments. Since 
that time he has operated upon a large numl>er of 
cases with good results. Dr. Alexander, although not 
the originator of the operation, is the surgeon to whom 
the credit of its first repeated and successful perform- 
ance is due. 
The result of drawing out the round ligaments 
through the external abdominal rings is to lift the ute- 
rus aud broad ligament upward and forward. With a 
4 A New Operation for Uterine Displacement*. Glasgow Med. 
Jour.. June, ts*2. 
sDol6ri*. Nouvelle* Archive* d’ObstStrique et de Gynecologic, 
January, 1SS6. 3 
movable uterus this cau, almost without exception, be 
accomplished. Backward displacements and prolapse 
of the uterus can thus be corrected. What now is 
needed is the testimony of operators regarding the diffi- 
culties, the dangers and the final results of the operation. 
After considering the statistics, and from a limited 
personal experience, I should say that the operation 
was one of great merit in appropriate cases. 
I have been able to find reports of one hundred and 
forty cases by twenty-one operators. Sixteen of these 
twenty-one operators, who operated upon one hundred 
and twenty-six of the cases, look upon the operation 
with favor. Four operators, who have had nine cases, 
are in doubt as to the value of the operation, or ex- 
press no opinion. Two operators, who have had five 
cases, look upon the operation with disfavor because 
of the difficulties, the dangers, or the poor results. 
Three deaths, as the result of the operation, have 
been reported. One of these occurred in the practice 
of Dr. Alexander. The patient died with signs of 
pyaemia, due, he thinks, to a lack of care and cleanli- 
ness. Dr. Coe 6 reported an autopsy in which death 
followed an operation on the round ligaments. There 
had been sloughing of the round ligaments and pyaemia. 
There was no peritonitis. A third death occurred in 
the hands of a Liverpool surgeon, and is referred to 
by Dr. Alexander as the result of pyaemia. 
Doleris (loc. cit.) thinks that Alexander 7 makes too 
little of the difficulties and dangers of the operation. 
Munde failed to find the ligaments in three out of six 
cases. Alexander has never failed to find them. In 
one case, a ligament which he could not find was after- 
wards discovered at a later operation. Dr. Indach 
never failed to find the ligaments in thirty-six cases. 
Alexander, before the British Gynaecological Society,8 
said : “The operation is a delicate one, and quite dif- 
American Journal Obstetrics, November, 1S85. 
7 •' Shortening the Round Ligaments,” London, l>t4. 
* British Gynaecological Journal, November, 1sk5. Operator. 
No. of 
Cases. 
Results 
Good, 
Results 
Bad. 
Pro- 
lapse, 
Retro- 
version. 
Retro- 
flexion. 
Not 
Given 
Remarks. 
Opinion 
of the 
Operator. 
Reference. 
Alexander, Wm. 
40 
37 
3 
11 
6 
5 
18 
One Death. 
Excellent 
Brit, Gvn. Jour., Nov., 188.5. 
jinlach, 
*; 
36 
- 
4 
- 
- 
32 
“ 
“ “ Nov.. 18*5. 
Lediard, H. 
4 
4 
- 
4 
* 
- 
«< 
Brit. Med. Jour., Feb. 23, 1884. 
Burton, 
13 
13 
- 
2 
11 
- 
- 
Good. 
“ “ “ Nov., 18 84. 
l*olk, 
10 
ID 
- 
1 
- 
- 
9 
44 
Amer. Jour. Obs., Feb., 1886. 
Maud*1, 
6 
•> 
4 
- 
- 
• 
6 
See Note. 
Doubtful. 
“ “ “ Feb.. 1886. 
Campbell, W, M. 
4 
4 
- 
2 
2 
- 
- 
Excellent Liv. Med.Chir. Jour., duly, ’*3. 
Uarduer, W. 
9 
9 
• 
2 
- 
7 
- 
Good. 
Austral. Med. Jour.. Sept., ’84. 
Held, Win. L. 
2 
2 
• 
- 
1 
1 
- 
“ 
Brit. Med. Jour.. Nov. 15. 1884. 
Tait, Lawson 
1 
- 
1 
- 
« 
* 
1 
Nearly died. 
Bad. 
Brit. Gvn. Jour., Nov.. 1885. 
Duncan, Win. A. 
4 
1 (?) 
3 
- 
4 
- 
- 
Was no re lief. 
“ 
Brit. Med. Jour., July, 1*85. 
lVrrish, W. 11. 
1 
- 
1 
- 
1 
- 
Doubtful 
N. Y. Med. Jour.. Va'y, 1885. 
Allan, J. 
1 
1 
- 
1 
• 
- 
- 
Good. 
Ijtncet, June 7. 1885. 
Zeiss, 
1 
1 
- 
- 
1 
- 
44 
Centralblatt fiir Gynic., 44, H5. 
Nanorede, C. B. 
1 
- 
- 
1 
- 
• 
“ Phil. Med. Sur. Rep.. Dec., ’85. 
Sinclair, A. J. 
1 
1 
• 
1 
- 
- 
Doubtful. 
Tr. Edin. Obs. Soc.. 1884-85. 
Elder, G. 
1 
1 
- 
- 
1 
- 
. 
Excellent Brit. Med. Jour., Nov.. 1884. 
Winslow, R. 
1 
1 
- 
1 
- 
— 
Good. 
Phil. Med. News, XLY.. 18K5. 
Miller, K. 
2 
2 
- 
2 
- 
- 
- 
44 
Glasg. Med. Jour., XXII., 1884. 
Adauis. J. A. 
1 
- 
1 
- 
- 
- 
1 
44 
.... 
Smith, .1. B. 
1 
- 
1 
• 
• 
1 
- 
Doubtful. 
Bristol Me«1. Chir. Jour., No. 1. 
Harrington,F. B. 
2 
2 (V) - 
** 
1 
1 
* 
Good. 
142 
127 
14 
32 
26 
17 
67 
Noth.— The operator failed to Hml Ligaments in three cases. 5 
ferent from nearly all the ordinary operations. It re- 
sembles most ligature of arteries or neurotomies, but 
from both it differs in many essential particulars. In 
the ligature of arteries, the pulsation of the vessel 
guides us to the spot, and assures us that we have 
reached the structure we seek. In looking for a nerve, 
we have a characteristic white structure to find, and 
twitching often shows us when we have found it. The 
round ligament does not pulsate, and is of a pale flesh 
color when first seen. It lies imbedded in other tissues, 
that, by the inexperienced, might easily be mistaken 
for it. Its white sheen only appears when pulled out.” 
The control which the ligaments have over the posi- 
tion of the uterus, when not fixed by adhesions or 
by other means, is demonstrable on any female cadaver. 
The uterus may be drawn into the position desired, and 
the shortened ligaments made fast to the tissues about 
the external ring. If care in the after-treatment be 
used, it seems to be demonstrated that the shortened 
ligaments have the power to retain the uterus in its 
corrected position. 
Dr. Alexander reports cases which have stood the 
test for three and four years. The operation is not 
without difficulties and dangers, nor is any operation. 
In the description of the following cases, the writer 
will endeavor to give an idea of the method of 
operating. 
Case I. Mrs. "VV , twenty-eight years of age, 
has suffered, since the birth of her child, seven years 
ago, with backache and dragging pains, which have, at 
times, incapacitated her for work. The uterus was' 
retroverted and prolapsed in the first degree. For a 
year and a half she had obtained partial relief by wear- 
ing a pessary. Owing to the sensitive condition of 
the parts, it was necessary to frequently remove the 
pessary, when the old displacement and suffering 
would return. Being dependent upon her exertion for 
support, she became anxious to avoid the repeated loss 
of time, and the suffering incident to the wearing of 6 
a pessary, and asked to he relieved by operation, if 
possible. She eagerly accepted the chance for relief 
which shortening the ligaments afforded. With the 
assistance of I)rs. Strong and Monks, the ligaments 
were shortened about two and one-half inches. The 
pubes having been shaved, an incision in a line with 
Poupart’s ligament was made from the spine of the 
pubes, extending outward from two to two and one- 
half inches. Having cut through the superficial tissues, 
the tendon of the external oblique soon appeared. 
When the tip of the finger was inserted into the wound, 
the pillars of the ring could lx; felt near the spine of 
the pubes. These being exposed, a mass consisting 
largely of fat was seen filling the canal. This mass 
was raised upon a director until it could he seized by 
the fingers. Gentle and interrupted traction brought 
out various bands adherent to the sides of the canal. 
These were cut as they appeared. Gradually the mass 
lost its yellow, fatty character. As more and more 
was drawn into view, it became larger, round, and 
glistening white, with here and there a streak of mus- 
cular tissue. 
The operation was repeated on the other ligament, 
with a like result. It was found, on examination, that 
the ligaments controlled the position of the uterus. 
They were drawn out until the uterus was held in a 
position in which it was placed by the uterine sound. 
On each Ride, the ligament was made fast to the 
pillars of the ring and to the fascia about the pubes, 
by means of fine silk sutures. The redundant liga- 
ments were carefully handled and packed in the 
wounds. Careful antiseptic precautions were observed. 
The canal was made dry and free from blood. The 
wounds were closed with catgut, and covered with a 
tightly-fitting iodoform dressing. The dressings were 
attached to an elastic band about the body, which en- 
sured close approximation to the wounds. 
When the sound was removed from the uterus, a 
pessary was placed in the vagina to remove all strain 7 
from the ligaments. The recovery from the operation, 
and the healing of the wounds were perfect. 
There was no rise of temperature or of pulse follow- 
ing the operation. On the tenth day the dressings 
were removed. Complete union had taken place. The 
patient was kept in bed for three weeks. Six weeks 
after the operation, the uterus remained in its corrected 
position. 
Case II. Mrs G , thirty years of age, has suf- 
fered for three years with constant backache and pel- 
vic pain. There was some prolapse of the uterus, and 
a sharp retroflexion of the body. The uterus measured 
three and one-fourth inches in depth. The retroflexion 
could be corrected, but when the repositor was re- 
moved, the uterus immediately returned to its old posi- 
tion. Having obtained no relief after many months of 
treatment, she was advised to try shortening of the 
round ligaments. With the assistance of Drs. Strong, 
Elliot, and Vickery, the ligaments were secured, as in 
the previous operation. The left ligament was much 
larger than the right, being nearly double its size. 
When the ligaments were drawn the uterus was 
lifted, but the retroflexion was wholly uneffected. 
Following the plan of Alexander, a large stem-pessary 
was inserted into the uterine canal, which corrected 
the retroflexion. The ligaments were then shortened 
two and three-fourths inches, and attached as before. 
Severe ether-sickness, lasting thirty-six hours, followed, 
but the recovery was perfect. The dressings were re- 
moved on the ninth day. Four weeks after the opera- 
tion, the position of the uterus was good, and the 
patient more comfortable than she had been for many 
months. 
It is too early to determine positively the success of 
the operation in these two cases, but the prognosis is 
very favorable. THE BOSTON 
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