| Reprinted from the American Gynaecological and Obstetrical Journal 
for December, 1896.] 
SHORTENING THE ROUND LIGAMENTS; 
INDICATIONS, TECHNICS, AND RESULTS* 
By George M. Edebohls, A. M., M. D., New York, 
Professor of Diseases of Women, New York Post-Graduate School; Gynaecologist, St, 
Francis Hospital; Consulting Gynaecologist, St. John's Hospital. 
HISTORICAL. 
Alquie, of Montpellier, France, appears to have been the genius 
who first conceived the idea and proposed a plan of shortening the 
round ligaments to correct downward and backward displacements 
of the uterus. In his historical memoir to the Academic de Mede- 
cine (i) he calls the operation utero-inguinoraphie. He had per- 
formed it only upon animals and the dead subject, never having 
operated upon the living woman. The proposition of Alquie was 
referred to a commission composed of Baudelocque, Berard, and 
Villeneuve, who, after wrestling with the problem for four years, 
finally reported to the Academic (2) in substance as follows: They 
condemned the proposal of Alquie in toto, both as regards the pos- 
sibility of permanently correcting uterine displacements by shorten- 
ing the round ligaments and as regards the practicability of the 
operation itself. They asked the Academic, however, to pass a vote 
of approbation of Alquie for his prudence in never having attempted: 
* Read before the Second International Congress of Gynaecology and Obstetrics,. 
Geneva, September, 1896. 
Copyright, 1896, bx. M. JL». George M. Edebohls, M. D. 
his operation upon a living woman. The report was received by 
the Academic and acted upon in the sense of the reporters. 
The first note of mild approbation comes from Aran (3), who, 
in advance of the time in which he lived, grasped the full signifi- 
cance of Alquie’s proposition that shortening the round ligaments 
will bring into position a uterus displaced downward or backward, 
or both, but was deterred by the difficulties of the operation, which 
he considered one next to impossible of successful execution. 
Denefife (22), with the courage of the recent graduate, was the 
first to attempt the operation upon the living woman at Ghent, Bel- 
gium, in June, 1864. During his student days he had frequently 
practiced the operation successfully upon the cadaver, and, immedi- 
ately upon obtaining his degree, requested of Burggraeve and 
Soupart an opportunity to shorten the round ligaments upon the 
living woman, avowing his confident belief that he would be able 
to carry the operation to a successful conclusion. His request was 
granted, and, in the presence of the masters, the operation was 
undertaken upon a patient suffering from prolapsus. Denefife, how- 
ever, failed to find either round ligament, although, following a 
suggestion of the great Burggraeve, he opened up the entire in- 
guinal canal on both sides. The patient recovered from the at- 
tempt, but Burggraeve was promptly called to account by the Com- 
mission des Hospices for permitting experiments upon patients 
committed to his care. 
Thereafter the idea seems to have slumbered in the medical 
mind, although Freund (4), and probably others, occasionally at- 
tempted the operation upon the cadaver, until William Alexander 
(S)» °f Liverpool, performed the first successful shortening of the 
round ligaments upon the living woman on December 14, 1881. 
Very soon after, in February, 1882, James A. Adams (6), who had 
for two years previously both practiced and taught the operation 
upon the cadaver, and recommended to his students its perform- 
ance in suitable cases upon the living woman, performed his first 
operation-—unsuccessful, however, on account of posterior adhe- 
sions of the uterus—upon a patient suffering from prolapse. 
Such are what are believed to be the correct data in relation 
to the early history of the operation under discussion. From these 
beginnings the operation, although viewed askance in its infancy, 
and in spite of the fact that its performance to the majority of sur- 
geons is not a congenial undertaking, has steadily, though slowly, Shortening the Round Ligaments. 
3 
gained favor and adherents as the ideal method of surgical pro- 
cedure in those cases to which experience has shown it to be 
adapted. In America, probably, earlier and to a wider extent than 
in any other country, has it found due recognition; there also does 
it count its most numerous and enthusiastic supporters. 
NOMENCLATURE. 
Alquie himself entitled the operation utero-inguinoraphie. Only 
one writer (29) seems to have followed him in the use of this desig- 
nation, which seems inappropriate in that neither the uterus nor 
the groin is sutured, but the essential of the operation is the resec- 
tion and suture of the round ligaments. Cittadini (137) calls it 
hysteropexie ligament air e. Abbreviatio ligamentorum rotundorum uteri, 
used by Riasentseff (50, 70, 71), itself needs abbreviation. It has 
been customary since 1882, when the first publications of Alexan- 
der and Adams called attention also to the original proposition of 
Alquie, to designate the operation variously, according to the 
writer’s conception of the relative share of honor due each of these 
three men. Patriotism possibly, in some instances, also had more 
or less to do with the matter. Thus it has been called the Alquie, 
the Alexander, and occasionally the Adams operation; and two, 
and even all three, of these names have been combined in designat- 
ing the procedure. Alquie was undoubtedly the genial originator 
of the idea. Alexander performed the first successful operation, 
and, in addition, deserves our thanks for the persistence with which 
he kept the operation before the profession by his frequent publica- 
tions. Adams was preceded by Alquie in the conception of the 
operation, by Deneffe in its unsuccessful attempt upon the living 
woman, and by Alexander in date of operation, in successful execu- 
tion, and in publication. The names of each of the three are in- 
delibly and impressively associated with the operation, and can 
never be obliterated from its history. While second to no one in 
his admiration of the genius which originated the idea of-this ideal 
operation, as well as of the courage which first attempted and the 
success which first attended its performance, the writer believes 
that the time has arrived when names should be dropped in the 
designation of the operation, and when, until some briefer and just 
as expressive term be proposed, the operation should be known as 
shortening the round ligaments. 4 
George M. Edebohls, M. D. 
INDICATIONS. 
From the outset the writer would have it clearly understood that 
the present paper deals exclusively with extraperitoneal or inguinal 
shortening of the round ligaments, as distinguished from intraperi- 
toneal shortening of the round ligaments after either coeliotomy 
or vaginal section. 
The superiority of shortening the round ligaments over its com- 
petitors, the various forms of ventral and vaginal fixation of the 
uterus, intra-abdominal shortening of the round ligaments, cysto- 
pexy of the uterus, and operative procedures on the utero-sacral 
ligaments, lies in the facts (a) that, while being equally successful 
and efficient, it is the most physiological of all these operations, both 
as regards its plan and the character of the results obtained, and 
(b) that it interferes to a less degree—indeed, not at all—with the 
functions proper of the uterus, childbearing and childbirth. 
Comparison of Anatomical Result with that obtained by Other 
Operations.—Ad (a). The writer is quite free to admit that an ana- 
tomical cure of retroversion can be obtained by each of the above- 
named operations in from ninety to one hundred per cent, of cases 
by proper technics and a capable operator. Mackenrodt figures 
ten per cent, of failures for vaginal fixation. Kellogg, who has 
probably had the largest individual experience in shortening the 
round ligaments, writes me: “ I have done the operation more than 
five hundred times, and have had failures in less than five per cent, 
of the cases.” In ventral fixation there is no reason why the aver- 
age operator should not obtain from ninety-five per cent, upward 
of anatomical cures. 
The quality of the cure, however, is an entirely different matter, 
especially to the patient. After a successful shortening of the round 
ligaments the physiological mobility of the uterus remains unim- 
paired, no peritoneal adhesions having been established. In future preg- 
nancies the shortened round ligaments undergo evolution and in- 
volution with the uterus. Essential to all of the rival operations is 
the establishment of a condition always pathological, never physio- 
logical, the deliberate creation, repugnant to every surgical instinct, 
of more or less extensive, more or less firm, peritoneal adhesions. 
On this score alone, I contend, shortening of the round ligaments, 
whenever applicable to the particular case, should receive the 
preference of the true surgeon. Shortening the Round Ligaments. 
5 
Comparison of the Course of Subsequent Pregnancies.—Ad (b). 
Their greater or less interference with the functions proper of the 
uterus—childbearing and childbirth—constitutes the higher stand- 
ard by which these various operations must now be judged. The 
writer (186) has recently gone somewhat extensively into this sub- 
ject, and will not reiterate details here. The record of disasters of 
pregnancy and parturition following the yet young operation of 
vaginal fixation of the uterus is already so appalling as to justify 
the dictum that it has no place, or rather is absolutely contra- 
indicated, in the case of any woman with the possibility of a future 
pregnancy before her. 
Milaender (Zeitschr. f. Geb. u. Gyn., vol. xxxiii, No. 3) and Noble 
(193) have collected a large number of cases of pregnancy following 
ventral fixation of the uterus. While the record of ventral fixation 
in this respect is not quite so bad as that of vaginal fixation, it is 
still bad enough to impose on us the duty of limiting to as great an 
extent as possible the field of ventral fixation of the uterus. 
Contrast with this the course of pregnancy and parturition after 
shortening the round ligaments. A slight drawing pain, beginning 
with the eighth month of pregnancy, and attributed, whether cor- 
rectly or not, to traction upon the shortened ligaments, has been 
reported in a few cases. Beyond this, disturbances of pregnancy or 
parturition, due in any way to the operation, have not been observed. 
This is all the more remarkable when we consider the length of time 
during which the operation has been before the profession and the 
numerous subsequent pregnancies which have been reported by 
many writers. Foreman (61), as long ago as 1887, reported seven- 
teen pregnancies in sixty-seven cases in which he had shortened 
the round ligaments, all of which terminated by easy deliveries at 
term. Gardner (41), Alexander (54), Batchelor (151), Johnson 
(188), and others too numerous to mention, testify to the uniformly 
smooth and normal course of subsequent pregnancies and labors, 
recording only very exceptional cases of abortion. The writer’s 
cases of pregnancy following shortening of the round ligaments 
will be detailed under the head of results. 
Broad General Indication and Corollaries.—l have dwelt thus 
long upon the distinguishing features of. the operation of shortening 
the round ligaments as compared with its rivals—viz., (a) preserva- 
tion of the physiological mobility of the uterus; (b) non-dependence 
for success upon the establishment of intraperitoneal adhesions; 6 
George M. Edebohh, M. D. 
(c) the equal permanence, as well as the better character, of its 
anatomical results; (d) non-interference with the course of future 
pregnancy and parturition—since a consideration of these features 
of superiority leads unavoidably to the establishment of one grand 
indication to which all other indications are subsidiary or corollary. 
This dominant law might be formulated as follows: Shortening of 
the round ligaments is indicated whenever and wherever it will meet 
the indications as well as or better than one of its rival procedures, i. e.: 
i. In all uncomplicated cases of retroversion, retroflexion, and 
excessive mobility of the uterus requiring operative treatment. 
2. In cases of aggravated anteflexion of the uterus, when the 
fundus is below the level of the internal inguinal ring—i. e., in all 
uncomplicated anteflexions worthy of the name. 
4. In simple prolapse of the ovaries without adhesions, when 
that condition calls for treatment. 
3. In cases of retroverted anteflexed uteri without adhesions. 
5. In cases of adherent retrodisplaced uteri, with or without ad- 
hesions of tubes and ovaries, these organs being otherwise in condi- 
tion to call for an attempt at their conservation. The adhesions 
in these cases are first to be separated, at the preference of the opera- 
tor, by means of anterior or posterior colpotomy, median ccelioto- 
my, or by an incision through the peritonaeum at the internal in- 
guinal ring, and enlargement of the latter to permit the introduction 
of one or two fingers. The writer has practiced each of these pro- 
cedures, the last of which he believes to be original with him. 
In two instances I have shortened the round ligaments in order 
to enable the patients to dispense with the use of pessaries, which 
they were compelled to wear to maintain the uterus in anteversion. 
Both ladies considered the wearing of a pessary and all that it im- 
plies a nuisance, deliverance from which was not purchased too 
dearly at the cost of an operation. 
Shortening the Round Ligaments not the best Prolapsus Operation. 
- -The above appear to the writer to be all absolutely indisputable 
indications for shortening the round ligaments. In addition, the 
operation has been practiced by its originators, and by nearly all 
of their followers, for the cure of prolapsus uteri. When practiced 
in these cases it should be clearly understood that shortening the 
round ligaments is but an adjuvant operation to the necessary plas- 
tic work upon uterus, vaginal walls, and perinseum called for by 
the conditions presenting in each case, and that, in order to secure Shortening the Round Ligaments. 
7 
the best results, all operations called for should be performed at 
the same sitting. Although among those who practiced this method 
with success, the writer early became convinced that the function 
of the round ligaments is not to sustain the uterus from dropping 
out of the pelvis, and that whatever success had been reached in 
the treatment of prolapsus uteri by the combination of shortening 
the round ligaments with plastic work, was due in greater part to 
the plastic work, and in a minor degree to the anteversion secured 
by shortening the round ligaments. Since December, 1890, in place 
of shortening the round ligaments, the writer has employed ventral 
fixation of the uterus, performed at the same sitting with the plastic 
work called for by each case, in the operative treatment of complete 
prolapsus uteri et vaginae. This combination of ventral fixation and 
plastic work was taken up some three years later by Kuestner. 
German writers, either overlooking or ignoring the author’s prior 
work and publication (Edebohls, The Operative Treatment of Com- 
plete Prolapsus Uteri et Vaginae, Am. Jour. Obst., vol. xxviii, No. 1, 
1893, and Combined Gynaecological Operations, Am. Jour. Med. 
Sciences, September, 1892), call it Kuestner’s method. 
Of the objections to the operation of shortening the round liga- 
ments the greater part, especially that relating to the alleged more 
or less frequent absence of the ligaments, are purely theoretical 
(Gehrung (12), Smith (52), Bird (152), and others), the more tangi- 
ble ones concerning themselves chiefly with the technics. These 
objections have been so frequently, so fully, and so ably answered 
by others—notably by Kellogg (161)—-that I will refrain from en- 
tering upon them here. The only serious objections that can be 
justly urged are the occasional occurrence of hernia and of pains 
in the region of the scar. How the risk of these occurrences may 
be minimized, or possibly entirely obviated, the writer will endeavor 
to show under the head of Technics. 
OBJECTIONS. 
Abnormal Course and Insertion of Round Ligaments.—Regarding 
the alleged more or less frequent absence of the round ligament, the 
writer would merely add his testimony to that of other competent 
observers that the round ligament is a structure constantly present. 
He failed to find it in one instance only (Case XVI), but the fault 
lay with his insufficient development as an operator upon the round George M. Edebohls, M. D. 
8 
ligaments. He hopes to have atoned in some measure for this 
shortcoming by subsequently finding four round ligaments (the 
right in Case LVI and Case XCVHI, and both ligaments in Case 
XCII) that were not in their normal place in the canal. So far as 
my reading and knowledge go these are the first and only instances 
in which the round ligaments have been demonstrated to be present 
in full development while at the same time absent from their normal 
place in the inguinal canal. The round ligament in each of these 
instances ran its usual course from the cornu of the uterus to the 
internal abdominal ring, but, immediately on leaving the latter, 
instead of running downward and inward in the inguinal canal, it 
turned abruptly to run upward and outward, behind the transversalis 
muscle, to be inserted into the outer half of Poupart’s ligament and 
the adjacent portions of the transversalis fascia. Three of the liga- 
ments were found only after tracing them, through a median inci- 
sion, from the cornu of the uterus to the internal ring, and thence 
onward in their erratic course to their abnormal insertion, none of 
the fibers, be it distinctly understood, running downward and in- 
ward along the canal. The fourth abnormal ligament was found 
and traced from the internal ring upward and outward by enlarging 
the external incision. Each of the four abnormal ligaments was 
cut away from its insertion above, shortened, brought down into 
its normal place in the canal, and sutured in the usual way (175). 
Since the above was written, my house surgeon at St. Francis Hos- 
pital, Dr. T. A. Lehmann, in shortening the round ligaments of one 
of my hospital patients, found the ligament of the right side taking 
the same abnormal course and having the same abnormal insertion 
as in the four cases just detailed. He successfully followed the same 
tactics in the management of this case that were employed in three 
of my operations. 
The explanation of this anomaly is not so very clear, but the 
writer would hazard the surmise that its setiology is identical with 
that of non-descent of the testis and spermatic cord in the male, the 
round ligament being the analogue of the spermatic cord. 
The Operation not Congenial to Every Surgeon.—A contra-indica- 
tion to the operation of shortening the round ligaments that may 
be allowed by some is inability of the operator to perform the opera- 
tion. Others, again, will not admit this, and contend that in that 
case the surgeon should either learn how to do the operation or 
send his patient to some one who can perform it successfully. The Shortening the Round Ligaments. 
9 
operation is certainly one that is not congenial to every surgeon; 
the majority of operators will always find it easier to find the fundus 
uteri through an abdominal or vaginal incision and stitch it for- 
ward than to find, isolate, and shorten the round ligaments in the 
inguinal canal. It is this difficulty, relatively speaking, of the opera- 
tion of shortening the round ligaments which has stood in the way 
of its earlier and more general adoption. Yet, though Adams, one 
of the originators of the operation, said of it, “ The operation is one 
that all and sundry can not perform,” the writer is convinced that, 
with a knowledge of anatomy and a little practice upon the cadaver, 
any surgeon capable of doing a Bassini operation for the radical 
cure of inguinal hernia should be able to shorten the round liga- 
ments successfully. 
TECHNICS. 
General Considerations.—The essentials of shortening the round 
ligaments successfully are: i. To find the round ligaments. 2. To 
isolate, draw out, and sufficiently shorten them. 3. To properly 
anchor the external ends of the shortened ligaments. 
To begin with, operators have preferences as to which side of 
the patient to stand on while operating; a few even change sides 
during the course of the operation. An occasional one stands be- 
tween the thighs of the patient. The writer prefers to stand on the 
right side of his patient and to begin the operation upon the left 
ligament. Next, as to the external incision, the vast majority of 
operators prefer to incise parallel to Poupart’s ligament, the lower 
end of the incision generally corresponding to the external inguinal 
ring. The length of incision varies from the neat two- to four-centi- 
metre cuts of Alquie (2), Imlach (27), Kellogg (86), Newman (91), 
Cleveland (174), to the ghastly gash of Kocher (146), who lays open 
skin and fat from pubis to anterior superior spine of ilium. Foreman 
(61) makes a i_-shaped incision for sesthetical reasons; Duret (143), 
a curved incision, with the convexity downward, from one external 
ring to the other. Alquie, Kellogg, and Newman incise over the 
middle of Poupart’s ligament. 
Finding the Ligament.—ln searching for the ligament three prin- 
cipal methods have been adopted. The first is to seek and draw 
out the round ligament at the external ring. Alexander (5) oper- 
ated in this way upon his first case, and the great majority of all 
operators since have followed him in this method. The second George M. Edebohls, M. D. 
method, that originally proposed and practiced upon the cadaver 
by Alquie himself, is to incise or puncture the anterior wall of the 
inguinal canal higher up, near the internal ring, and through this 
small opening to hook up the ligament in the canal and draw it out. 
Kellogg (86) was the first to adopt this as a routine procedure. 
Newman (91), following a suggestion of Frank, punctured the an- 
terior wall of the canal a little higher up than Kellogg, and claimed 
priority. His method, as far as can be gathered from his very de- 
ficient and imperfect first description (91), differed in no essential 
or principle from that of Kellogg, except that Kellogg punctured 
the anterior wall of the canal near its middle, Newman a trifle higher 
up—a distinction without much of a difference. Newman’s (91) first 
case was operated upon some three months after Kellogg read a 
paper (106, page 17 of reprint) reporting a number of operations 
performed by his new method. 
The writer (123) was the first to propose incision of the entire 
length of the anterior wall of the canal as a routine procedure in the 
operation of shortening the round ligaments. Others before him 
had, for various reasons, in exceptional cases, incised the anterior 
wall of the canal to a greater or less extent. Deneffe (22), in the 
very first operation attempted upon the living woman, after failing 
to produce the round ligaments through the incision of Alquie, at 
the suggestion of Burggraeve opened the entire inguinal canal in 
the vain attempt to find them. Reid (15), after breaking a round 
ligament, incised the canal for half an inch to aid him in again find- 
ing it. Alexander (17) himself, in one of his later papers, refers to 
the occasional necessity of partially opening the canal. Roux (95) 
derived help from incising the arciform fibers to the extent of one 
centimetre. Blake (134) opened the canal on the left side, after 
experiencing great difficulty in finding the right round ligament 
at the external ring of the same patient. A number of operators— 
Chalot (136), Kocher (146), Werth (171), Kuestner (178), Fabricius 
(176)—have, in the course of years, followed the writer in advocat- 
ing incision of the entire length of the anterior wall of the canal. 
The name of Newman has, under misapprehension, been so often 
associated with the writer’s (123) modification of the operation of 
shortening the round ligaments, originally proposed in 1890, on 
account of the hasty, ill-considered, and baseless claim of Newman 
(132, 130), that this would appear to be the proper place to empha- Shortening the Round Ligaments. 
11 
size the fact that Newman’s technics come into competition with 
the prior method of Alquie-Kellogg (2, 85, 88, 106) rather than 
with those of the writer. In other words, there is nothing essentially 
original in the operation described by Newman (91). 
Isolating and drawing out the Round Ligament.—To find, isolate, 
and draw out the round ligament is not always an easy matter. 
The difficulties are materially increased when the ligament is sought 
and drawn out at the external ring instead of higher up in the in- 
guinal canal. This is due to the anatomical structure of the round 
ligament, which runs as a single cord from the cornu of the uterus 
to and through the internal ring and the upper portion of the in- 
guinal canal. It divides up and its anatomy becomes more com- 
plicated, however, just within and at the external ring. Adams 
(6, 183), himself an expert anatomist, quotes Rainey {Trans. Royal 
Soc., 1850) as giving the most complete and altogether reliable de- 
scription of the round ligament: “The so-called round ligaments 
of the uterus, regarded as a muscle, may be said to arise by three 
fasciculi of tendinous fibers—the inner from the tendon of the in- 
ternal oblique and the transversalis, near to the symphysis pubis; 
the middle, from the superior column of the external ring near to 
its upper part; and the external fasciculus from the inferior column 
of the ring just above Gimbernat’s ligament. From these attach- 
ments the fibers pass backward and outward, soon becoming fleshy. 
They then unite into a rounded cord, which crosses in front of the 
spermatic artery. ... It then gets between the two layers of the 
peritonaeum forming the broad ligament, along which it passes 
backward, downward, and inward to the anterior and superior part 
of the uterus, into which its fibers, after spreading out a little, may 
be said to be inserted.” From a most minute and brilliant practical 
demonstration of the anatomy of the round ligaments by Professor 
James E, Kelly, of New York, which I had the privilege and pleas- 
ure of witnessing, I am convinced that the above description is 
practically correct. When operating at the external ring the diffi- 
culties of collecting these scattered fibers of the round ligaments at 
and near the ring and tracing them upward to where they unite to 
form a single cord, are additional to those necessarily encountered 
in separating the round ligament from the ilio-inguinal nerve and 
fat, as well as from the muscular and tendinous fibers of the internal 
oblique, which—analogues of the cremaster muscle in the male— 
invest the round ligament in the canal. When, in addition to this. 12 
George M. Edebohls, M. D. 
it is considered that the round ligament becomes stronger, and is 
less likely to tear in manipulation, higher up in the canal than at or 
near the external ring, the advantages, apart from other considera- 
tions, of picking it up within the canal rather than at the external 
ring become apparent. 
In drawing out the round ligament the accompanying ilio- 
inguinal nerve should be carefully separated from the ligament and 
guarded against division. This will prevent the subsequent pains 
in and about the cicatrices which are frequently observed when this 
nerve is divided. The separation of nerve and ligament is difficult 
only in the canal, where they run side by side. At the upper end 
of the canal their courses diverge, the ligament penetrating the 
internal ring, while the nerve continues upward and outward be- 
tween the muscular layers of the abdominal wall. Werth (171) re- 
sects a portion of the nerve to prevent after-pains. With Kuestner 
(178), however, I have never met with subsequent pain when the 
nerve is stripped off and preserved. 
Another point, to which the writer believes he was the first to 
call attention, is the advisability of stripping back the investing 
peritonaeum of the broad ligament for a certain distance from off 
the round ligament in every case. This stripping back of the peri- 
tonaeum, which is accomplished by the fingers aided by the sense 
of sight, has two things to commend it. Firstly, it avoids the dan- 
ger, when drawing down the round ligament, of invagination of a 
peritoneal pouch or process into the canal, with the possible re- 
sultant invitation to descent of a hernia. Secondly, we are assured 
by this measure that the round ligament is really shortened in its 
intra-abdominal course between the cornu of the uterus and the 
internal ring, and not merely stretched in the canal, which, of 
course, would have no effect upon the position of the uterus. Neg- 
lect to shorten the round ligaments sufficiently, by stripping back 
the investing peritonaeum, explains many a case of failure or semi- 
failure of what otherwise would have been a successful operation, 
as well as the necessity for the use of pessaries after operations by 
some operators. The corrugated cuff of stripped-back peritonaeum, 
in addition, forms a very effective plug at the internal ring, an addi- 
tional safeguard against hernia. Newman (132) and Adams (183), 
in his last paper, also advocate this procedure. In practicing it the 
writer draws out the round ligament and strips back the perito- 
naeum until the finger passed down to the internal ring recognizes Shortening the Round Ligaments. 
the impact of the cornu uteri of the same side as it is drawn for- 
ward by the round ligament. 
The amount of shortening of the round ligaments necessary to 
be accomplished averages about ten centimetres, and, to make an 
assuredly successful operation, should not be less than seven centi- 
metres. Alexander (7) draws out the round ligament farther when 
operating for prolapsus than when dealing with retroversion. 
Anchoring the Shortened Round Ligaments.—ln no other part of 
the operation of shortening the round ligaments, or perhaps of any 
other operation, has the same amount of ingenuity and fertility of 
resource been displayed as in the attachment and suture of the 
shortened ligaments. Of those who operate upon and draw out 
the ligament at the external ring, nearly all stitch the shortened 
ligament to the pillars of the ring. Alexander (7), in addition, 
stitches the end of the ligament to the margins of the skin wound, 
Lee (87) to the periosteum, and Roux (95) to the spine of the pubis. 
Cleveland (174) brings the ligament out through a puncture of the 
skin at a little distance from the operation wound, and secures it 
there with a suture. Carpenter (120) cuts away the excess of liga- 
ment an inch or so outside of the ring, splits this inch of ligament 
longitudinally, and sews each half to the external fascia. In dis- 
posing of the excess of ligament the above-named operators, in 
the majority of instances, simply cut it away. Foreman (61), as a 
rule, and Adams (183), sometimes, stow away the slack in the wound. 
Abbe (New York Med. Jour., March 17, 1888) draws one ligament 
subcutaneously through the fat overlying the pubis across to the 
opposite side, and there ties it in a living knot with its fellow. Do- 
leris (102), Batchelor (151), and Martin (189) follow Abbe’s plan 
with insignificant modifications. Duret (143) also accepts the same 
principle, fastening the two ligaments to each other, however, at 
the bottom of a crescentic wound extending across from one ex- 
ternal ring to the other. 
Kellogg (67, 106), who, as already stated, draws out the liga- 
ment through a small opening in the anterior wall at the upper 
part of the canal, has varied his method of securing the ligament 
from time to time. Originally he secured the ends of the ligaments 
with silver wires, which he tied together over a hard-rubber plate 
placed on the skin between the wounds. Subsequently he tucked 
the excess of ligament down into the lower part of the canal. Still 
later, he drew out the slack of ligament through a separate small 14 
George M. Edebohls, M. D. 
puncture lower down in the aponeurosis of the external oblique, 
leaving the ligament attached at the external ring, and folding the 
excess in the fat of the external wound. 
Of those who prefer to open the inguinal canal along its entire 
length, Chalot (136), Kuestner (178), and the writer (123) in his 
first operations, fastened the shortened round ligaments within the 
canal just behind the aponeurosis of the external oblique, the cut 
margins of which were brought together by a series of sutures 
which also pierced and secured the ligament. Kocher (146) turns 
the drawn-out ligament upward at the upper and outer angle of 
the fascial wound, and sews it on to the outer surface of the external 
oblique aponeurosis in the direction of the anterior superior spine of 
the ilium. Fabricius (176) and the writer (186, 187), in his later 
cases, place and secure the shortened ligament in its natural habitat 
behind the lower border of the internal oblique. 
The Accident of tearing the Round Ligament.—When a round liga- 
ment tears in drawing it out, what shall we do? The answer to this 
will depend upon the site of the tear. If the ligament has parted 
within the canal, the retracted end should be sought for and recov- 
ered, if possible, at the internal ring. If this should prove impossi- 
ble, the peritonaeum should be incised at the internal ring and the 
ligament sought for and brought out of the abdomen with the aid 
of a finger or two, assisted, if necessary, by slender forceps. If the 
torn end of the ligament can not be readily found and grasped by 
the forceps, the finger should be hooked behind the broad ligament 
of the corresponding side and passed along the posterior surface 
of the latter until the cornu uteri is reached. The uterus, and with 
it the torn ligament, is then lifted forward and the round ligament 
traced from the cornu uteri outward to its torn end, which is then 
grasped by forceps, brought out, shortened to the requisite degree, 
and sutured in the usual manner. 
The same course may be successful if the round ligament should 
happen to tear just within the internal ring. In the only instance 
in which this happened to me I made a small incision in the median 
line of the abdomen, sought the ligament at its uterine end, traced 
it outward to the tear, pushed the torn end out of the abdomen 
through the internal ring, and successfully completed the opera- 
tion. 
When the round ligament tears out of the uterus, or so near 
the latter as to leave a stump too short to be drawn out and prop- Shortening ihe Round Ligaments. 
erly fastened, three courses are open to us. The first is to shorten 
the opposite ligament, and trust to one shortened ligament to keep 
the uterus forward. This course has been followed by success in 
a case reported by Ledyard (13), and the writer has learned of sev- 
eral other successes from personal communication with the opera- 
tors. Gottschalk (Ges. f. Geb. u. Gyn., Berlin, November 8, 1889) 
has reported bad effects resulting in a case in which only one round 
ligament was shortened. In this connection it is interesting to note 
that Blake (134) advocates operating on one ligament only at a 
time as a routine procedure, and that Brown (77) quotes Doleris 
as advising the same procedure in certain cases in order to allow 
the bladder room for expansion on the opposite side prior to short- 
ening the second ligament. 
The second alternative, originally suggested by the writer, but 
thus far practiced neither by himself nor by any one else to his 
knowledge, is to open the abdomen in the median line, unite the 
torn ends of the round ligament, or attach the pulled-out end to 
the uterus, by suture, and complete the operation in the usual way. 
Our third resource is to substitute immediately the next best retro- 
version operation. The writer followed this course in five instances 
in which the round ligament parted at or near the uterus, perform- 
ing ventral fixation at the same sitting, with resultant cure of the 
retroversion in each case. 
Strength of Round Ligament.—ln estimating the amount of trac- 
tion the round ligaments will bear without tearing, experience will 
probably prove to be our main help. In a large number of experi- 
ments made by the writer, both on the dead subject and with pieces 
of round ligament obtained at operation, the force necessary to tear 
the round ligament varied between the limits of three and fifteen 
kilogrammes. 
The Wearing of Pessaries after Operation.—There exists among 
operators some divergence of view, both as to the best method of 
anteverting the uterus before or during operation and as to the 
necessity of artificial support of the uterus after operation. Some 
recommend and some condemn the use of the sound to replace 
the uterus before shortening the round ligaments. Some consider 
the wearing of a pessary in cases of retroversion or of an intra- 
uterine stem in cases of retroflexion for a certain variable period 
after operation as well-nigh indispensable to success. My own 
practice in these regards has been as follows: After the patient George M. Edebohls, M. D. 
is under ether I satisfy myself that the retroverted uterus can be 
brought into pronounced anteversion by bimanual manipulation; 
that tubes and ovaries are normal in size and not adherent. I then 
curette the uterus, allow it to assume any position that it will, and 
proceed to shorten the round ligaments, lifting the fundus forward 
during the operation by traction on the ligaments. I have never 
had my patients wear any kind of support after operation. The 
positive shortening of the intra-abdominal portion of the round 
ligaments accomplished by the technics which I employ renders a 
pessary or support after operation entirely superfluous. 
The Question of Hernia following Operation.—From the very be- 
ginning the possibility of hernia following the operation of shorten- 
ing the round ligaments has been ever present in the minds of op- 
erators and measures of precaution against this accident have en- 
tered into the technics of most surgeons. Previous to the advent 
or just appreciation of the value of the Bassini operation for the 
radical cure of inguinal hernia these precautionary measures were 
of a nature as unsatisfying as were the then known operative pro- 
cedures against hernia themselves. Not that hernia in any con- 
siderable degree of frequency followed the operation of shortening 
the round ligaments; yet the slight risk of its occurrence formed 
the chief and perhaps only well-founded objection to the operation. 
Among others, Foreman (61) early included the deep abdominal 
muscles in his sutures, burying the latter. Fry (124) mistakenly 
advocated open treatment of the wound to prevent hernia. Kocher 
(146), after drawing out the ligament and securing it as already 
described, closed the canal by a row of sutures embracing the entire 
thickness of the muscles of the abdominal wall, and tied upon the 
fascia of the external oblique. Yet these measures were all more 
or less crude, and not up to the standard of modern surgery, until 
Fabricius (176) and the writer (186, 187), each in his own way, cor- 
rectly applied the essential principle of the Bassini operation—the 
sewing of the lower edge of the internal oblique and transversalis 
muscles to Poupart’s ligament, and the obliteration of the inguinal 
canal—to the technics of shortening the round ligaments. To 
Fabricius (176), between us, belongs priority both of execution and 
of publication. Fie unites the internal oblique and transversalis to 
Poupart’s ligament by a row of interrupted buried-silk sutures, each 
of which also pierces the round ligament. Over this he closes the 
anterior wall of the canal by a second row of interrupted silk sutures. Shortening the Round Ligaments. 
The technics employed by the writer will be described in detail in its 
proper place. The question of hernia will be again referred to in 
the analysis of the author’s statistics. 
Suture Material and Drainage.—ln the matter of suture material 
and drainage the same latitude of opinion and practice obtain as in 
other departments of operative surgery. The writer has tried every 
form of suture material, but now uses exclusively the buried run- 
ning suture of forty-day catgut for the deep parts and a subcutane- 
ous catgut suture to unite the skin. In the first half of my cases I 
drained the deep parts of the wound with a few strands of silkworm 
gut; the last sixty or so have, with a rare exception now and then, 
not been drained. 
Anaesthesia.—Shortening the round ligaments can be performed, 
if necessary, without general anaesthesia. Kellogg (106) operates 
quite frequently under local cocaine anaesthesia. Ether has been 
the anaesthetic in nearly all of my cases; I have, however, operated 
under cocaine, with Schleich’s infiltration anaesthesia, and without 
any anaesthetic whatsoever. 
Comparison of Different Methods of shortening the Round Liga- 
ments.—Before entering upon the description of my present method 
of shortening the round ligaments, it is but proper to state that I 
have had personal experience with each of the three principal meth- 
ods under discussion—that of operating at the external ring (Alex- 
ander), that of hooking up the ligament through a puncture of the 
anterior wall of the canal near the internal ring (Alquie-Kellogg), 
and that of laying open the canal along its entire length (Edebohls). 
After operating upon seventy-four cases after his (123) original 
method, the writer, in September, 1894, during a visit to Battle 
Creek, Mich., saw Dr. Kellogg shorten the round ligaments of two 
patients. I was so fascinated by the smallness of the incision re- 
quired, by the neatness of the entire operative technics, by the dex- 
terity and celerity (nine minutes exactly) with which Dr. Kellogg 
performed his operation, that I at once discarded my own method 
and adopted Kellogg’s. I succeeded with it quite satisfactorily, in 
a few instances, however, having to open the canal along its entire 
length to find, draw out, and secure the ligament. In the twenty- 
six cases in which I practiced Kellogg’s method three ligaments 
(Cases XCII and XCVIII) were unfortunately not present in the 
canal. In some of the other cases other tissues—in one instance 
even the femoral artery—were hooked up and drawn out before George M. Edebohis, M. D. 
the ligament was found. I should have persisted in a further trial 
of the method, however, and perhaps have adopted it permanently, 
had I not missed too greatly the ease and certainty with which the 
ligament could be found and isolated after opening the canal, as 
well as the welcome test of the proper amount of shortening af- 
forded by passing the finger to the bottom of the canal and feeling 
the cornu uteri at the internal ring when the ligament was drawn 
taut. The only thing I did not quite like in my old operation was 
the method of securing the ligament just behind the aponeurosis of 
the external oblique. With the modification, however, of closing 
the wound by a typical Bassini and of suturing the ligament in 
its natural habitat, this objection, together with that of the risk 
of hernia, seemed to be overcome. Since January, 1896, when he 
first adopted it, the writer has practiced his present method in four- 
teen cases. 
To compare once more and briefly the three methods of short- 
ening the round ligaments, let us see how each of them meets the 
three requirements of a successful operation: (1) To find the liga- 
ments, (2) to isolate and draw them out sufficiently, (3) to properly 
anchor the shortened ligaments. It is self-evident that the round 
ligaments can be more readily found and more easily, directly, and 
gently separated from their surroundings after the entire canal is 
opened than by fishing for and drawing them out either at the 
external ring or through a small opening in the anterior wall of the 
canal near the internal ring. Moreover, in cases of abnormal course 
and insertion of the round ligament, five instances of which have 
been detailed above, the real condition present could be known with 
certainty only after opening the entire canal. 
In regard to the third postulate—the proper anchorage of the 
shortened round ligaments—none of the many methods already re- 
ferred to compares in directness and naturalness with that of anchor- 
ing the round ligaments in their normal situation in the canal. This 
can be done properly in but one way—i. e., with the canal widely 
open. 
author’s present method of shortening the round 
LIGAMENTS. 
On the day preceding operation the bowels are emptied by a laxa- 
tive, the pubis and external genitalia are shaved, and a cleansing 
bath is given. Eight to twelve hours preceding operation an oint- Shortening the Round Ligaments. 
ment, composed of creolin (ten parts) and mollin (ninety parts), is 
rubbed into the skin of the lower abdomen, pubes, and adjacent 
surfaces of the thighs. The parts are then covered with sterile 
gauze and left undisturbed until the patient is upon the table and 
anaesthetized. 
Just prior to shortening the round ligaments the uterus is al- 
ways curetted, and whatever plastic work upon cervix, vagina, and 
perinseum the conditions presenting in each case call for is per- 
formed. If adhesions of the uterus and annexa exist, and the 
operator prefers to sever these adhesions by anterior or posterior 
colpotomy rather than by an incision from above, this is the proper 
time to do so. At all events, the operator must satisfy himself that 
the uterus can be well anteverted by bimanual manipulation before 
proceeding with the operation of shortening the round ligaments. 
The uterus is then allowed to assume any position it may please,, 
generally dropping backward, to be brought into position at a later 
stage of the operation by traction on the round ligaments. A little 
iodoform gauze is loosely placed in the vagina, not to sustain the 
uterus, but as an antiseptic precaution in view of the preceding 
curettage. The field of operation is lathered and scrubbed with 
more ten-per-cent, creolin-mollin, rinsed clean with sublimate solu- 
tion (i to 3,000), and the patient is ready for operation. In shorten- 
ing the round ligaments I prefer to have the pelvis slightly elevated 
and to stand at the right side of my patient, beginning the opera- 
tion upon the left ligament. 
An incision five to six centimetres long, and nearly parallel to 
Poupart’s ligament, is carried from the site of the internal inguinal 
ring downward and inward, terminating just within the spine of the 
pubis. Careful location of the pubic spine, from the time of begin- 
ning the operation until the anterior wall of the inguinal canal is 
opened, is absolutely essential to success. The subcutaneous fat 
is divided until the glistening aponeurosis of the external oblique 
muscle is exposed. The superficial epigastric artery is frequently 
divided, and if so should be ligated in this stage of the operation. 
The external inguinal ring is now either exposed to view or located 
by the touch. A grooved director is inserted through the external 
ring and passed along the inguinal canal, directly behind the apo- 
neurosis of the external oblique, until its point is over the site of 
the internal ring. Cutting upon the director exactly in the direc- 
tion of the fibers of the external oblique aponeurosis, one sweep of 20 
George M. Edebohis, M. D. 
the knife lays open the anterior wall of the inguinal canal along its 
whole length (Fig. i). 
Fig. i. 
Fig. 2. 
Fig. I.—lncision, 5 centimetres long, through aponeurosis of external oblique, laying 
open inguinal canal from external to internal ring and exposing internal oblique 
muscle and round ligament. The ligament is more or less concealed according 
to greater or less development of internal oblique. S., skin ;s. c. f., subcutane- 
ous fat; a. e. 0., aponeurosis of external oblique ; i. 0., internal oblique ; r. /., 
round ligament. 
Fig. 2.—lsolating round ligament from its attachments in inguinal canal. S., skin ; 
s. c. f., subcutaneous fat; i. 0., internal oblique ;a. e. 0., aponeurosis of external 
oblique ;r. round ligament. 
It is very desirable that all haemorrhage should be controlled 
before opening the inguinal canal, otherwise the flow of blood into 
the latter may render differentiation of the round ligament from 
the other contents of the canal exceedingly difficult. An assistant 
exposes the contents of the canal by drawing apart the lips of the 
incision through the external oblique aponeurosis, with the aid of 
tenacula, blunt hooks, or clamp forceps. The lower fibers of the 
internal oblique muscle are seen crossing the upper half of the 
canal, filling it more or less, according to the greater or less mus- 
cular development of the individual. 
In a fair proportion of cases the lower end of the round liga- 
ment is at once exposed to view, emerging from beneath the lower 
border of the internal oblique; more generally, the round ligament 
is well covered and entirely hidden from view by the internal oblique 
muscle and an investment of fatty, areolar, and fibrous tissue. Quite 
frequently some of the fibers of the round ligament are so closely 
interlaced with those of the internal oblique muscle that differentia- 
tion and separation of the ligament from bundles of muscular fiber 
becomes difficult. It is this part of the operation which generally Shortening the Round Ligaments. 
21 
trips the beginner; he fails to find the ligament, and can not, of 
course, proceed. Experience has taught me that the best method 
of procedure at this stage, if the ligaments are not at once exposed 
to view and recognized, is to search for them in the following man- 
ner (Fig. 2): Retract the internal oblique muscle upward and in- 
ward by a blunt hook passed beneath its lowermost fibers, and hand 
this hook to your assistant. Take two small blunt hooks, one in 
either hand, and sweep one of them, point downward and outward, 
along the posterior and outer walls of the canal from the depths of 
the wound skinward, hooking up the entire contents of the canal. 
By teasing these contents apart more or less, as required, by means 
of the two blunt hooks, the round ligament, surrounded by fat and 
muscular and tendinous fibers from the internal oblique, and ac- 
companied by the ilio-inguinal nerve, will soon be recognized, and 
can be followed along the canal to the internal ring. There the 
round ligament is always strong, however weak, thin, and frayed- 
out it may have been found lower down in the canal or at the ex- 
ternal ring. 
The ligament is next separated from its investments in the canal, 
leaving, however, the pubic end attached for the present. In this 
part of the operation great care should be exercised not to divide 
or tear the ilio-inguinal nerve which accompanies the ligament, 
and division of which is the cause of the various dyssesthesise in the 
vicinity of the scar sometimes complained of by patients after opera- 
tion. In the canal itself the ilio-inguinal nerve and the round liga- 
ment are very intimately connected; at the upper end of the canal 
they diverge, the nerve to pass between the muscular layers and the 
ligament to enter the internal ring. 
The ligament, freed from its surroundings in the canal, is next 
grasped by the thumb and forefinger of the right hand and cau- 
tiously drawn out at the internal ring (Fig. 3), The line of traction 
should be more or less perpendicular to the surface of the abdomen 
at that point, approximately in the direction of the intra-abdominal 
portion of the ligament. As the round ligament emerges at the 
internal ring it is seen to carry with it, in the form of an inverted 
cone, the investing peritonaeum of the broad ligament, the point 
of reflection of the latter being marked by a distinct white line sur- 
rounding the round ligament. With the thumb and forefinger of 
the left hand the investing peritonaeum is stripped or milked back 
into the abdomen as the round ligament emerges farther and farther 22 
George M. Edebohls, M. D. 
from the internal ring. Occasionally the peritonaeum tears in strip- 
ping it back; this is a matter of no consequence provided the asep- 
sis is all it should be. 
Fig. 3.—Drawing round ligament out of abdomen and stripping back investing peri- 
tonseum of broad ligament, i. 0., internal oblique ; s. c. f., subcutaneous fat; P., 
peritonaeum ;r. round ligament; a. e. 0., aponeurosis of external oblique ; S.r 
skin. 
Should the ligament not run freely out of the abdomen, it will 
be wise, before employing the limit of safe traction force, to ascer- 
tain the cause by incising the peritonaeum at the internal ring, 
bluntly dilating the latter, and passing a finger into the abdomen. 
If posterior adhesions prevent the uterus, tubes, and ovaries from 
coming freely forward, these may be separated by a finger or two 
hooked behind the broad ligament; or if the infundibulo-pelvic 
ligament, as obtained in one of the writer’s cases, be shortened and 
thickened as the result of previous inflammation, this ligament may 
be stretched. The round ligaments will then be found to run freely, 
and the process of stripping back the peritonaeum is continued until 
the index finger, passed down to the bottom of the wound, recog- 
nizes the impact of the cornu uteri at the internal ring when trac- 
tion is made upon the round ligament. This constitutes the writer’s 
index to the proper amount of shortening, which, expressed in fig- 
ures, will average about ten centimetres. 
The opposite round ligament is now sought, isolated, and drawn 
out in the same way. When free play of both ligaments has been Shortening the Hound Ligaments. 
23 
secured, the anteposed fundus of the uterus may be drawn from 
side to side by alternating traction upon the ligaments, the move- 
ments of the fundus being recognized by the operator’s fingers 
placed on the abdomen immediately above the pubis. In thin per- 
sons the transits of the uterus are frequently visible to the eye. 
The proper course to pursue in case the round ligament should 
tear either in the canal or within the abdomen, as well as in cases 
of absence of the round ligament from the canal, has already been 
indicated. 
Our next care is to properly reanchor the ligaments and close 
the wound. Thus far the ligaments have remained attached at their 
outer or pubic ends. These attachments are now cut for conven- 
ience in further manipulation, without, however, amputating any 
part of the ligament at present. After securing the desired position 
of the uterus by traction upon the round ligaments, and adjusting 
the latter nicely along the bottom of the canal, suture of the wound 
is in order. 
The writer’s suture material for the deep parts consists of catgut 
No. o, chromicized to resist absorption for about six weeks. Those 
who may be interested in the method of preparation and sterilization 
of forty-day catgut are referred to an article by the writer in the 
American Gyn. and Obst. Jour., May, 1896, entitled What is the Best 
Method of making and of closing the Coeliotomy Incision? A half- 
metre length of this forty-day catgut is threaded upon a full-curved 
Hagedorn needle of medium size or under. An assistant, with two 
tenacula, holds wide open the lips of the incision through the apo- 
neurosis of the external oblique, so as to clearly expose the deep 
parts of the canal, and especially the clean-cut projecting shelf of 
Poupart’s ligament. 
The parts are brought together after the principle of Bassini’s 
operation for the radical cure of inguinal hernia, with the exception 
that, instead of the interrupted suture, the buried running suture 
of forty-day catgut, applied according to the following technics, is 
used: Beginning at the upper angle and inner side of the right 
wound, the first sweep of the needle pierces the aponeurosis of the 
external oblique, the underlying internal oblique and transversalis 
muscles, the margins of the internal ring, the round ligament as it 
emerges between them, and the projecting shelf of Poupart’s liga- 
ment. The succeeding loops of the deep tier of sutures, three or 
four in number, pierce the internal oblique and transversalis mus- 24 
George M. Edebohls, M. D. 
cles, the round ligament, and Poupart’s ligament. The last loop, 
in addition, penetrates the outer pillar of the external ring, and 
emerges upon the outer surface of the external oblique aponeurosis 
Fig. 4.—Deep tier of buried running suture of forty-day catgut, embracing internal 
oblique and transversalis muscles, round ligament and Poupart’s ligament. Deep 
part of uppermost loop of suture (not showing in cut) passes at level of and em- 
braces margins of internal ring. S., skin ;s.c. f, subcutaneous fat; a. e. 0., apo- 
neurosis of external oblique ; i. 0., internal oblique ; r. /., round ligament; P. /., 
Poupart’s ligament. 
Fig. 4. 
Fig. 5. 
Fig. 5.—Deep tier of suture drawn home, obliterating inguinal canal. S., skin ; 
.f. c. f., subcutaneous fat; a. e. 0., apeneurosis of external oblique ; i. 0., internal 
oblique ;P. Poupart’s ligament. 
at the lower end and outer side of the fascial wound (Figs. 4 and 5). 
A stitch is then taken, with still the same strand of catgut, piercing 
the internal pillar of external ring, round ligament, and external 
pillar. The excess of round ligatnent is now cut away just outside 
of the external ring, leaving the stump to plug the ring (Fig. 6). 
After thus obliterating the inguinal canal and closing both in- 
ternal and external rings, the same strand of catgut is continued 
upward as a running suture, uniting the lips of the incision in the 
external oblique aponeurosis and closing the anterior wall of the 
canal. At the upper end of the wound the two free ends of catgut 
emerging upon the aponeurosis of the external oblique are tied 
together, forming the only buried knot. This knot, if carefully and 
tightly tied after the manner depicted in the cut—a single turn in Shortening the Round Ligaments. 
25 
the first half and a double turn in the second half of the knot—can 
be depended upon not to slip. The skin is nicely approximated 
over all by a subcutaneous suture of ordinary catgut and the wound 
closed without drainage. Sterilized dressings applied over the 
wounds, and held in place by adhesive plaster and a double spica 
bandage, complete the operation. 
The dressing is changed, for the sake of cleanliness, at the end 
of a week. This second dressing is removed a week later, and the 
patient allowed to sit up. No pessary or support of any kind is 
worn at any time after operation. 
Interference with the function of the bladder as a result of the 
operation has not been observed in the writer’s cases. The urine 
is generally drawn for two days, after which it is voided on the 
bed-pan. 
Fig. 6.—Superficial tier of buried suture of forty-day catgut closing incision through 
aponeurosis of external oblique, restoring anterior wall of canal. The excess of 
round ligament has been cut away just outside of external ring. The part pro- 
truding through ring together with pillars of external ring pierced by lowest loop 
of superficial suture. Loose knot at upper end shows proper way of tying buried 
catgut knot to prevent slipping. Skin and fat to be closed over all by a subcu- 
taneous catgut suture. 
Primary union has been the rule, except during a brief period 
•of repeated deep suppuration from infected silkworm gut, which 
material we were using at the time in the form of buried sutures. 
In cases of primary union the scar becomes practically invisible 
after six months to a year. 
In three of my last cases an attempt was made to complete the 
operation rapidly. The time required for these three operations, 
from the first incision to the completed closure of both wounds, was 
nineteen, twenty-one, and twenty minutes respectively. 26 
George M. Edebohls, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
I 
M. A. 
20 
Single. 
Retroversion of uterus. 
Prolapse of left ovary. 
29-XU-89 
i5-viii-g3 ; Curettage 
of uterus. 
25-vii-g6 ; Uterus in normal anteversion. 
No prolapse of ovaries. Patient remains 
perfectly well. 
2 
-L. K. 
22 
Single. 
Retroversion of uterus. 
3I-XU-89 
vi-g3 ; Uterus in excellent anteversion. 
3 
B. S. 
45 
Married. 
3 
Complete prolapsus uteri 
et vaginae. 
I-ii-90 
ly-iii-go: Anterior 
colporrhaphy. Col- 
po-perineorrhaphy. 
21-iv-go : Uterus well up in pelvis and an- 
teverted. No prolapsus vaginae. 
4 
L. IS. 
30 
Married. 
2 
Retroversion of uterus. 
Movable right kidney. 
3-11-9° 
vii-92: Nephropexy. 
27-vii-g6 : Uterus in normal anteversion. 
5 
K. W. 
43 
Married. 
2 
Complete prolapsus uteri 
et vaginae. Laceration 
and hypertrophy of cer- 
vix. 
ig-ii-90 
At same sitting: Am- 
putation of cervix. 
Colpo - perineorrha- 
phy. 
ig-iv-gs ; Uterus well up in pelvis and an- 
teverted. Perfectly well with exception 
of moderate cystocele. 
6 
B. W. 
29 
Single. 
Retroversion of ante- 
flexed uterus. 
24-ii-gO 
24-ii-g2: Uterus in normal anteversion, 
the angle of flexion having disappeared. 
7 
M. P. 
44 
Married. 
8 
Complete prolapsus uteri 
et vaginae. Laceration 
and hypertrophy of cer- 
vix. 
5-111-gO 
At same sitting: Am- 
putation of cervix. 
Colpo - perineorrha- 
phy. 
28-iv-g6 : Has remained perfectly cured of 
prolapsus. Uterus well up in pelvis and 
anteverted. 
8 
A. B. 
4i 
Widow. 
4 
Prolapsus uteri, first de- 
gree, with retroversion. 
Laceration of cervix 
and perinseum. Cysto- 
cele and rectocele. 
24-iii-go 
3-xii-8g : Trachelor- 
rhaphy. Anterior 
colporrhaphy. Col- 
po-perineorrhaphy. 
7-V-90 : Prolapsus of vaginal walls cured. 
Uterus well up in pelvis and anteverted. 
9 
L. H. 
57 
Married. 
3 
Prolapsus and retrover- 
sion of uterus, both 
first degree. Moderate 
cystocele and rectocele. 
g-v-go 
28-vi-g3 : Uterus well up in pelvis and 
anteverted. N 0 increase of cystocele 
and rectocele. 
IO 
A. Le B. 
37 
Married. 
5 
Laceration of cervix. 
Retroversion of uterus. 
Movable right kidney. 
ig-v-go 
At same sitting; Tra- 
chelorrhaphy. 12- 
vi-90: Nephropexy. 
12-vii-go : Uterus in normal anteversion. 
Table of* Author’s Operations for shortening the Round Ligaments. Shortening the Round Ligaments. 
27 
II 
J. M. 
38 
Married. 
4 
Laceration of cervix and 
perinaeum. Rectocele. 
Retroversion of uterus. 
Haemorrhoids. 
21-V-90 
At same sitting; Tra- 
chelorrhaphy. Col- 
po-perineorrhaphy. 
Delivered, n-ii-92, of full-grown child. 
Delivered, i2-i-g4, of full-grown child. 
Uterus in normal ant eversion after both 
deliveries. Normal labors. 
vii-96: Pregnant seven months; third 
pregnancy since operation. 
12 
M. S. 
24 
Married. 
2 
Chronic metritis. Lacer- 
ation of cervix and 
perinaeum. Retrover- 
sion of uterus. 
& 
1 
CO 
At same sitting; Tra- 
chelorrhaphy. Peri- 
neorrhaphy. 
28-vii-go : Uterus in normal anteversion. 
13 
S. K. 
20 
Single. 
Retroversion of uterus. 
Endometritis. 
12-vi-go 
g-v-92 : Normal delivery of living child at 
term, without complications. Develop- 
ment of right inguinal hernia during fifth 
month of this pregnancy, and of left in- 
guinal hernia soon after delivery. 
Jan., 1896: Double inguinal hernia. Uterus 
in anteversion. 
July, 1896 : Pregnant six months. 
14 
A. Q. 
33 
Married. 
5 
Retroversion of uterus. 
Laceration of cervix 
and perinaeum. 
19-ix-go 
At same sitting: Tra- 
chelorrhaphy. g-x- 
90; Perineorrhaphy. 
Uterus in normal anteversion six months 
after operation. 
15 
M. D. 
25 
Married. 
2 
Retroversion of uterus. 
Chronic metritis. 
6-xi-go 
At same sitting: Am- 
putation of cervix. 
Uterus in normal anteversion on discharge 
one month after operation. 
i6 
C. A. 
44 
Married. 
10 
Prolapsus and retrover- 
sion of uterus, first de- 
gree. Prolapsus va- 
ginas. 
i8-xi-go 
At same sitting: Tra- 
chelorrhaphy. An- 
terior colporrhaphy. 
Colpo - perineorrha- 
phy. 
Failure to find ligament on left side. Not 
attempted on right. Failure of operation 
to cure, the retroversion and prolapse re- 
turning promptly after patient left bed. 
17 
S. McM. 
52 
Widow. 
1 
Retroversion of uterus. 
Laceration of perinae- 
um. Cystocele. 
19-xii-go 
20-xi-go: Anterior 
colporrhaphy. Col- 
po-perineorrhaphy. 
Uterus well anteverted on leaving hospital 
one month after operation. No prolapsus 
of vaginal walls. 
18 
N. H. 
23 
Single. 
Retroflexion of uterus. 
Chronic metritis. 
xg-xii-go 
27—vi—93: Uterus in normal anteversion. 
Perfectly well ever since operation. 
19 
M. K. 
32 
Single. 
Retroversion of uterus. 
Chronic endometritis. 
7-iii-gi 
28-vi-g3: Uterus in normal anteversion, 
limited in mobility. Patient not better 
than before operation owing to develop- 
ment of bilateral salpingo-oophoritis since 
operation. 28 
George M. Edebohls, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
20 
A. M. 
31 
Married. 
I 
Subinvolution and retro- 
flexion of uterus. 
n-iv-gi 
Curettage of uterus. 
i-vii-92 : Delivered of a child at term, 
without complications. 
3-viii-g3 : Uterus in normal anteversion. 
No pelvic symptoms. Patient died of 
pulmonary phthisis in 1894. 
21 
M. G. 
17 
Single. 
Retroversion of uterus. 
Endometritis. Pro- 
lapse of ovaries. 
i3-v-gi 
Curettage of uterus. 
22-VU-95: Uterus in anteversion. Left 
ovarian cystoma and movable right kid- 
neyliave developed since operation. Pa- 
tient no better than before operation. 
22 
P. K. 
22 
Single. 
Retroversion of uterus. 
20-V-91 
On discharge, one month after operation 
uterus in normal anteversion. Not seen 
since. 
23 
A. K. 
20 
Single. 
Retroversion of uterus. 
Endometritis. Catar- 
rhal salpingitis. 
17-vi-gi 
27-ii-p3 : Curettage of 
uterus. 
Salpingitis and movable right kidney devel- 
oped subsequently to shortening of round 
ligaments and nullified therapeutic results. 
27-v-g3 : Uterus in normal anteversion. 
24 
D. N. 
25 
Widow. 
Retroversion of uterus. 
Laceration of cervix. 
g-ix-91 
At same sitting: Tra- 
chelorrhaphy. 
Uterus in normal anteversion one month 
after operation. Not seen since. 
25 
A. F, 
31 
Married. 
Retroversio uteri fixati. 
Pelvi-peritonitis chron- 
ica. 
17-X-91 
12-X-91 : Curettage of 
uterus and separation 
of adhesions in nar- 
cosis after Schuitze. 
Patient writes that according to a state- 
ment of her physician, in July, 1895, her 
womb remains in anteversion. 
26 
J. M. 
23 
Single. 
Retroversio of uterus. 
Prolapse of ovaries. 
i8-xi-gi 
Curettage of uterus at 
same sitting. 3-v- 
92 : Salpingo-obpho- 
rectomy for uterine 
fibroma, and curet- 
tage of uterus. 
Fibromata uteri developed after operation. 
Uterus remained continuously in normal 
anteversion until last seen, ig-iii-gs. 
27 
C. V. 
29 
Married. 
2 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. Catar- 
rhal salpingitis. 
30-xi-gi 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
Patient remained well for some six months 
after operation. Then acute prolapsus 
uteri, cured by tampons and supports. 
Later left chronic salpingo-odphoritis 
nullified therapeutic results. 
xo-vii-g6 : Uterus in excellent anteversion. 
Descensus of first degree on straining. Shortening the Round Ligaments. 
29 
28 
M. W. 
28 
Married. 
3 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. 
u-xii-gi 
At same sitting; Cu- 
rettage of uterus. 
Amputation of cer- 
vix. i3-iii-g6: Right 
Felt well for several years after operation ; 
then symptoms of movable right kidney, 
ty-vi-gb: Uterus remains in normal ante- 
version. 
nephropexy. 
Therapeutic results nullified by the pro- 
29 
M. S. 
23 
Single. 
Retroversion of uterus. 
22-xii-gi 
Curettage of uterus. 
Prolapse of ovaries. 
Catarrhal salpingitis. 
Lues acquisita. 
gressive development of extensive syph- 
ilitic visceral lesions within a year after 
operation. The uterus remained in nor- 
mal anteversion until her death, ig-xi-gs. 
30 
C. R. 
28 
Married. 
3 
Subinvolution and retro- 
15-1-92 
At same sitting: Cu- 
Uterus in normal anteversion six weeks 
version of uterus. 
rettage of uterus. 
Amputation of cer- 
after operation. Not seen since. 
3i 
M. S. 
25 
Married. 
1 
Retroversion and subin- 
volution of uterus. 
Laceration of cervix. 
Laceration of perinse- 
ig-i-g2 
At same sitting; Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Perineorrha- 
Right round ligament in final pull thereon 
drawn out of uterus as demonstrated at 
the immediately added ventral fixation. 
No operation upon left side. Ventral 
um through sphincter. 
phy. Ventral fixa- 
fixation holds uterus anteverted four and 
tion of uterus. 
a half years after operation. 
32 
M. B. 
23 
Widow. 
1 
Retroversion of uterus, 
second degree. Pro- 
22-i-g2 
At same sitting, with- 
Shortening of round ligaments under local 
out anaesthesia: Cu- 
cocaine anaesthesia. 
lapse of uterus, first de- 
rettage of uterus. 
28-iv-g2: Uterus in normal anteversion 
gree. Chronic metritis. 
Amputation of cer- 
and at proper height in pelvis. Thera- 
Mitral insufficiency 
vix. 
peutic results impaired by progressive 
and aortic stenosis. 
left salpingo-oophoritis. 
33 
K. S. 
26 
Married. 
Retroversion of uterus. 
2-U-92 
Curettage of uterus. 
Ether pneumonia after operation. 
Endometritis. Pro- 
8-vii-g6: Uterus in normal anteversion. 
lapsed and adherent 
Chronic metritis and adhesion of right 
right ovary. 
ovary impair somewhat the therapeutic 
result. 
34 
C. H. 
30 
Married. 
4 
Retroversion of uterus. 
5-ii-92 
At same sitting; Cu- 
3-V-94: Uterus in normal anteversion. 
Laceration of cervix. 
rettage of uterus. 
Amputation of cer- 
vix. 
Perfect anatomical and therapeutic re- 
sults. George M. Edebohls, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
35 
M. F. 
30 
Married. 
3 
Retroversion of uterus. 
Laceration of cervix 
and perinseum. 
22-iii-g2 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Perineorrhaphy. 
3-vii~95 : Curettage 
with drainage of 
uterus. 
2g-x-gs : Uterus in normal anteversion. 
Felt perfectly well until three years after 
operation, when endometritis, salpingitis, 
and movable right kidney impaired thera- 
peutic results. 
36 
A. H. 
27 
Married. 
I 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. Pro- 
lapse of ovaries. 
ig-iv-92 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
26-VU-92 : Uterus in normal anteversion. 
37 
A. B. 
25 
Single. 
Retroversion of uterus. 
Endometritis. Catarrh- 
al salpingitis. Movable 
right kidney. 
10—v—92 
At same sitting: Cu- 
rettage of uterus. 
Nephropexy. 
io-vii-g2 ; Uterus in normal anteversion. 
i2-vii-g3; Has remained perfectly well 
since operation. Pelvic examination not 
made. 
38 
P. K. 
30 
Married. 
Retroversion of uterus. 
Endometritis. 
io-v-92 
Curettage of uterus. 
Delivered of a full-grown boy at term in 
March, 1895. 
23-vii-gb: Uterus in normal anteversion. 
Patient enjoying perfect health. 
39 
M. K. 
35 
Married. 
3 
Adherent retroverted 
uterus. Laceration of 
cervix and perinseum. 
Chronic metritis. Cys- 
toma of right ovary. 
Movable right kidney. 
Mitral insufficiency. 
17-V-92 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Ovariotomy. 
Ventral fixation of 
uterus. i8-xi-g2: 
Nephropexy. Peri- 
neorrhaphy. 
After isolating and drawing out both round 
ligaments, the right ligament, at the final 
pull, tore out of uterus as verified at the 
immediately following ventral fixation. 
Cause of the accident, a small, unrecog- 
nized, adherent right ovarian cystoma. 
28-ii-g4: Sudden death, while at work, 
from valvular disease of heart, on the eve 
of confinement at term. 
(Case reported in full, Ttans. New York 
Obst. Soc., Nov. 21, 1893, and April 17, 
1894.) Shortening the Round Ligaments. 
31 
40 
A. M. 
28 
Married. 
2 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. Mov- 
able right kidney. 
3-vi-q2 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
Uterus in normal anteversion one month 
after operation. Not seen since. 
4i 
A. B. 
24 
Single. 
Retroversion of uterus. 
Endometritis. 
I7~vi-g2 
Curettage of uterus. 
Passed through a severe attack of typhus 
abdominalis beginning two weeks after 
operation. 
22-vi-g3 : Uterus in normal anteversion. 
42 
A. H. 
17 
Single. 
Retroversion of uterus. 
Endometritis. 
22-vii-g2 
Curettage of uterus. 
n-vii-g3: Right 
nephropexy. 15-iv- 
g5 : Right femoral 
herniotomy. 6-xii- 
g5 : Coeliotomy for 
acute gangrenous ap- 
pendicitis. Right 
salpingo-oophorecto- 
my. y-i-gb : Left 
nephropexy. 
Typhoid fever during convalescence. 
Movable right and left kidneys followed the 
typhoid fever. 
Acute strangulated right femoral hernia, 
April, i8g3 
Acute appendicitis with perforation, periap- 
pendicular abscess and serious involve- 
ment of right tube and ovary, Dec., i8g5. 
22-vii-g6: Uterus in normal anteversion. 
Patient perfectly well. 
43 
M. S. 
35 
Married. 
4 
Retroversion of uterus. 
Laceration of cervix 
and perinaeum. Rec- 
tocele. 
28-x-g2 
At same sitting: Cu- 
rettage of uterus. 
Trachelorrhaphy. 
Colpo - perineorrha- 
phy. 
28-vi-g3 : Uterus in anteversion. 
44 
L. S. 
32 
Married. 
1 
Adherent retroverted 
uterus. Laceration of 
cervix. Endometritis. 
8-xi-g2 
At same sitting : Sepa- 
ration of uterine ad- 
hesions in narcosis 
after Schultze. Cu- 
rettage of uterus. 
T rachelorrhaphy. 
Uterus in normal anteversion three months 
after operation. Not seen since. 
45 
R. S. 
36 
Married. 
6 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. 
8-xi-g2 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. i6-xii-g2: Hys- 
tero-salpingo-oopho- 
rectomy by com- 
bined perineotomy 
and coeliotomy for 
sarcoma of left broad 
ligament. 
Uterus remained in normal anteversion un- 
til removed together with the tubes, 
ovaries, and entire left broad ligament 
by combined perineotomy and coeliotomy 
for sarcoma of left broad ligament, 16- 
xii-g2. 
(Case reported in detail, Trans. New York 
Obst. Soc., March 21, i8g3, and March 
17, i8g6.) George M. Edebohls, M. £>. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
46 
A. W. 
25 
Married. 
3 
Retroversio uteri. Lac- 
eration of cervix and 
perinseum. Left in- 
guinal hernia. 
25-X-92 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Anterior col- 
porrhaphy. Perine- 
orrhaphy. Radical 
inguinal herniotomy. 
2i-vi-g3: Miscarriage at end of third 
month. Thereafter uterus in normal an- 
teversion. 
2o-ii-g4 : Pregnant sdven months. 
47 
A. H. 
19 
Single. 
Retroversion of uterus. 
Endometritis. 
29-X-92 
Curettage of uterus. 
9-xii-g3 : Uterus in normal anteversion. 
Endometritis for past two months. 
48 
A. W. 
28 
Married. 
I 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. 
!3-xii-g2 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
2-VU-96: U terus in normal anteversion. 
Perfectly well for three years after oper- 
ation, when mobility of both kidneys de- 
veloped, from the symptoms of which she 
now suffers. 
49 
A. B. 
25 
Married. 
2 
Retroversion of uterus. 
Laceration of cervix 
and perinseum. Endo- 
metritis. Cystocele. 
3-i-93 
At same sitting: Cu- 
rettage of uterus. 
Anterior colporrha- 
phy. Perineorrha- 
phy. Ventral fixa- 
tion of uterus. 
Right round ligament pulled out of uterus 
after both ligaments had been found and 
drawn out. Ventral fixation immediately 
added. Three pregnancies since opera- 
tion. 
Delivery at term, without complications. 
n-xii-93. Abortus, xo-vii-g5. Now, 
vii-96, pregnant eight months. 
(Case detailed in Trans. New York Obst. 
Soc., April 17, 1894.) 
50 
J. D. 
20 
Married. 
I 
Retroversion and subin- 
volution of uterus. Lac- 
eration of cervix and 
perinseum. Endome- 
tritis. Urethral polypi. 
I7-I-93 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Perineorrha- 
phy. Excision of 
urethral polypi. 
One month after operation uterus in normal 
anteversion. Not seen since. 
5i 
S. H. 
22 
Single. 
I 
Retroversion of uterus. 
Endometritis. 
io-ii-93 
Curettage of uterus. 
Uterus in normal anteversion one month 
after operation. Not seen since. Shortening the Round Ligaments. 
33 
52 
A. V. 
21 
Married. 
I 
Retroversion of 
uterus. 
io-iii-93 
At same sitting; Cu- 
Uterus in normal anteversion when last 
Laceration of 
cervix. 
rettage of uterus. 
seen, three months after operation. 
Endometritis. 
Trachelorrhaphy. 
i2-vii-g3 ; Feels perfectly well. Uterus in 
53 
L. S. 
33 
Widow. 
5 
Retroversion of 
uterus. 
i4-iii-93 
At same sitting: Cu- 
Laceration of 
and perimeum. 
cervix 
Endo- 
rettage of uterus. 
T rachel orrhaphy. 
normal anteversion. 
metritis. 
Perineorrhaphy. 
Uterus in normal anteversion six weeks 
after operation. Not seen since. 
54 
M. B. 
22 
Single. 
Retroversion of 
Endometritis. 
uterus. 
2i-iv-g3 
Curettage of uterus. 
55 
T. W. 
37 
Widow. 
i 
Retroversion of 
uterus. 
25-iv-93 
Curettage of uterus. 
Uterus in normal anteversion one month 
Endometritis. 
after operation. Not seen since. 
5& 
M. H. 
22 
Single. 
Retroversion of 
uterus. 
28-iv~93 
Curettage of uterus. 
Right round ligament, after leaving the in- 
Endometritis. 
ternal ring, ran upward and outward to 
be inserted into outer half of Poupart’s 
ligament. 
24-iv~94: Uterus in normal anteversion. 
Therapeutic result excellent until two 
weeks ago, since when acute oophoritis 
sinistra. 
57 
M. K. 
34 
Married. 
5 
Retroflexion of 
uterus. 
23-V-93 
2i-iv-g3 : Curettage of 
Uterus in normal anteversion ten weeks 
Laceration of 
and perinseum. 
cervix 
Mitral 
uterus. Amputation 
of cervix. Perineor- 
after operation, when last seen. 
insufficiency. 
rhaphy. 
Felt perfectly well until fifteen months 
58 
D. M. 
17 
Single. 
Retroversion of 
uterus. 
13-VL93 
Curettage of uterus. 
Endometritis. 
after operation. Then acute articular 
rheumatism and endocarditis. 
14-X-94 : Uterus in normal anteversion. 
59 
M. M. 
24 
Married. 
i 
Retroversion of 
uterus. 
20-vi-g3 
At same sitting: Cu- 
io-vii-g6 : Uterus in normal anteversion. 
Laceration of 
cervix. 
rettage of uterus. 
Therapeutic result good until recently, 
Endometritis. 
T rachelorrhaphy. 
when impaired by development of mova- 
ble right kidney and recurrence of en- 
dometritis. 
6o 
B. W. 
21 
Single. 
Retroversion of 
uterus. 
27-VL93 
Curettage of uterus. 
g-vii-g6: Patient has “felt splendid” ever 
Endometritis. 
since operation. Uterus in normal ante- 
version. George M. tdebohls, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
61 
J. B. 
25 
Single. 
Retroversion of nterus. 
Endometritis. Bilat- 
eral inguinal hernia. 
i8-vii-g3 
At same sitting: Cu- 
rettage of uterus. 
Double radical in- 
guinal herniotomy. 
Patient irresponsible mentally ; repeatedly 
removed her wound dressing. Suppura- 
tion and sloughing in both wounds. 
26-iv-Q4: U terus in normal anteversion. 
Left hernia recurred six months after op- 
eration. Right hernia remains cured. 
62 
M. D. 
25 
Married. 
3 
Retroversion of uterus. 
Laceration of cervix 
and pennseum. Endo- 
metritis. Cystocele. 
i5-viii-93 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Anterior col- 
porrhaphy. Perine- 
orrhaphy. 
25-vii-g6: Uterus in normal anteversion. 
Patient well except for symptoms due to 
mobility of both kidneys existing before 
operation. Bilateral nephropexy advised. 
63 
M. H. 
23 
Single. 
Retroversion of uterus. 
Endometritis. 
7-xi-93 
Curettage of uterus. 
30-vi-g6: Uterus in normal anteversion. 
Therapeutic results excellent until within 
three months past, since which time de- 
velopment of movable right kidney. 
64 
C. L. 
27 
Married. 
Retroversion of uterus. 
Endometritis. 
23-xi-g3 
Curettage of uterus. 
i-vii-96 ; Anatomical and therapeutical re- 
sults excellent. Uterus in normal ante- 
version. 
65 
A. E. 
31 
Married. 
I 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. 
9-1-94 
At same sitting: Cu- 
rettage of uterus. 
T rachelorrhaphy. 
Patient widowed one month after operation. 
io-vii-g6 : Anatomical and therapeutic re- 
sults excellent. Uterus in normal ante- 
version. 
66 
L. H. 
21 
Married. 
I 
Retroversion of uterus. 
Endometritis. 
17-1-94 
Curettage of uterus. 
Uterus in normal anteversion one month 
after operation. Not seen since. 
67 
N. T. 
29 
Single. 
Retroversion of uterus. 
Endometritis. Pro- 
lapse of ovaries. Oo- 
phoritis dextra. 
22—i—94 
Curettage of uterus. 
Delivery at term, without difficulty, 2-xi-g5. 
27-vii-g6 : Uterus in normal anteversion. 
Both ovaries and all pelvic contents nor- 
mal. Patient perfectly well. 
68 
M. A. 
28 
Widow. 
I 
Retroversion of uterus. 
Laceration of cervix 
and perinseum. Endo 
metritis. Rectocele. 
23-1-94 
At same sitting; Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Perineorrhaphy. 
Uterus in normal anteversion seven weeks 
after operation, when patient was last 
seen. Shortening the Round Ligaments. 
35 
6g 
A. M. 
23 
Single. 
Anteflexion of uterus. 
Chronic endometritis 
of cervix. Movable 
right kidney. 
9-iii-94 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. i5-vi~94 : Ne- 
phropexy. 
28-vi-96: Anteflexion has entirely disap- 
peared, the uterus lying in normal ante- 
version. Patient perfectly well. 
70 
E. S. 
26 
Married. 
Retroversio uteri. En- 
dometritis. Catarrhal 
salpingitis. Tubercu- 
losis of appendix vermi- 
formis. 
30-iii-g4 
At same sitting: Cu- 
rettage of uterus. 
Appendectomy. 
Ligaments sloughed in both wounds. Six 
weeks after operation position of uterus 
unsatisfactory, not sufficiently well ante- 
verted, rather vertical in body. - 
Very hysterical before operation. Insanity 
(hereditary taint) followed operation. 
Sudden death from fatty heart, 22-viii- 
94, nearly five months after operation. 
Autopsy showed the uterus again fully ret- 
reverted. 
7i 
A. B. 
29 
Married. 
4 
Retroversion of uterus. 
Laceration of cervix. 
Chronic metritis. Mov- 
able right kidney. 
Right inguinal hernia. 
Right femoral hernia. 
4-V-94 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. Radical femoral 
herniotomy. Radical 
inguinal herniotomy. 
23-L96 : Patient pregnant two months. 
Right inguinal hernia has returned. 
Femoral hernia remains cured. Uterus in 
normal anteversion. 
x-vii-g6: Patient eight months pregnant 
without inconvenience. 
72 
L. M. 
33 
Married. 
3 
Retroversion of uterus. 
Laceration of cervix. 
Prolapse of ovaries. 
Endometritis. Salpin- 
gitis. 
8-V-94 
2G-vii-g3: Curettage 
of uterus. Amputa- 
tion of cervix. 
Therapeutic success nil. Dr. H. J. Boldt 
subsequently performed vaginal bilateral 
salpingo-oophorectomy, after which pa- 
tient reports herself well. 
20-vii-g4 : Dr. Boldt writes me that the 
uterus remains anteverted and well up in 
pelvis. 
73 
S. R. 
20 
Single. 
Imperfect development 
of internal genitalia. 
Retroversion of uterus. 
Endometritis. 
12-VL94 
12-1-92 : Curettage of 
uterus. Bilateral dis- 
cission of cervix. 12- 
vi-94: Curettage of 
uterus. Amputation 
of cervix. 
Uterus in normal anteversion one month 
after operation, when last seen. 36 
George M. Edebohls, M. D 
No. 
Name, 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
74 
A. H. 
26 
Single. 
I 
Movable right kidney. 
Retroversion of uterus. 
Laceration of cervix. 
Endometritis. Right 
and left inguinal her- 
nia. 
i3-vi-94 
17-1-94: Nephropexy. 
l3-vii-g4; Curettage 
of uterus. Trachelor- 
rhaphy. Bilateral 
radical inguinal her- 
niotomy. 
14-iv 96: Uterus in normal anteversion. 
No return of either inguinal hernia. Pa- 
tient perfectly well. 
75 
J. McP. 
21 
Single. 
I 
Retroversion of uterus. 
Laceration of uterus. 
Chronic metritis. Mov- 
able right and left kid- 
neys. Chronic appen- 
dicitis. 
2-x-Q4 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 2i-xii-94 : Bi- 
lateral nephropexy. 
i5-ii-gs ; Inversion 
of appendix. 
28-vi-g6: Uterus in normal anteversion, 
still enlarged about 50 per cent, from 
persistence of chronic metritis. 
76 
S. M. 
31 
Married. 
5 
Retroversion of uterus. 
. Laceration of cervix. 
Endometritis. 
n-x-94 
25~i~94: Curettage of 
uterus. Amputation 
of cervix. 
28-L95 : Uterus in normal anteversion. 
Malaria and the development of movable 
right kidney since operation impair the 
therapeutic result. 
77 
E. F. 
23 
Single. 
Movable right kidney. 
Retroversion of uterus. 
Endometritis. Catar- 
rhal salpingitis. Ap- 
pendicitis. Mitral in- 
sufficiency. 
i6-x~94 
3-viii-94: Nephro- 
pexy. At same sit- 
ting : Curettage of 
uterus. Appendec- 
tomy. 
Uterus in normal anteversion one month 
after operation, since which patient not 
seen. 
78 
B. C. 
25 
Single. 
Retroversion of uterus. 
Endometritis. Left sal- 
pingo-oophoritis. 
18-X-94 
Curettage of uterus. 
2y-vi-g6 : Uterus in normal anteversion. 
No trace of former salpingo-oophoritis. 
Patient perfectly well. 
79 
M. McC. 
27 
Married. 
4 
Laceration of cervix and 
perinseum. Endome- 
tritis. Retroversion of 
uterus. 
19-X-94 
3-viii-g4: Curettage of 
uterus. Trachelor- 
rhaphy. Perineor- 
rhaphy. 
Left ligament tore on final pull, one centi- 
metre from uterine insertion. Ventral 
fixation immediately added. Right groin 
not opened. 
23—vi-g6 : Two pregnancies since opera- 
tion. First terminated in abortion in 
fourth month. Now pregnant in eighth 
month, Shortening the Round Ligaments. 
37 
8o 
R. S. 
18 
Single. 
Movable right kidney. 
Chronic appendicitis. 
Endometritis. Retro- 
version of uterus. 
23-X-94 
ry-iv-94 : Nephro- 
pexy. 23-vi-g4: Ap- 
pendectomy. At 
same sitting. Dila- 
tation of sphincter 
Uterus in normal anteversion and patient 
perfectly well when last seen, five months 
after operation. 
81 
M. D. 
18 
Single. 
Retroversion of uterus. 
Endometritis. Urethral 
polypi. Adherent pre- 
puce of clitoris. Haem- 
orrhoids. 
2-xi~94 
At same sitting: Cu- 
rettage of uterus. 
Ablation of urethral 
polypi. Dilatation 
of sphincter ani. 
27~xi-94; Slitting of 
prepuce and separa- 
tion of preputial ad- 
hesions. Excision of 
haemorrhoids. 
2i-vii-g6 : Patient made a new woman by 
the operations. Subsequently slight re- 
lapse due to development of movable 
right kidney and recurrence of endome- 
tritis. Uterus in normal anteversion. 
82 
B. H. 
20 
Single. 
Retroflexion of uterus. 
Endometritis. Chronic 
appendicitis. Incipient 
pneumo-phthisis. 
i6-xi-Q4 
At same sitting: Cu- 
rettage of uterus. 
Appendectomy. 
25-VU-96: Patient remains well. Uterus 
in normal anteversion. 
83 
A. M. 
25 
Single. 
Adherent retroverted 
uterus. Endometritis. 
25-xi-p4 
At same sitting: Cu- 
rettage of uterus. 
Coeliotomy for liber- 
ation of uterine ad- 
hesions. Attempted 
ventral fixation 01 
uterus. 25-iii-g5 : 
Vaginal fixation of 
uterus. 
Ventral fixation of uterus, after liberation 
of adhesions, was the operation proposed. 
It failed on account of inability to bring 
tire fundus against anterior abdominal 
wall, due to thickening and inelasticity 
of parametria. Shortening of round lig- 
aments immediately added. Severe acute 
croupous pneumonia and pneumococcus 
infection of three wounds. Sloughing of 
round ligaments and immediate anatom- 
ical failure. Four months later vaginal 
fixation of uterus with resultant imper- 
fect anatomical but perfect therapeutic 
success. (Case detailed in N. Y. Med. 
Monatsschiift, July, 1896, p. 285.) George M. Edebohis, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
84 
B. K. 
26 
Married. 
I 
Retroversion of uterus. 
Laceration of cervix 
and perinseum. Endo- 
metritis. 
18-xii-g4 
At same sitting; Cu- 
rettage of uterus. T ra- 
chelorrhaphy. Peri- 
neorrhaphy. Ventral 
fixation of uterus. 
Left round ligament torn out of uterus at 
final pull. Ventral fixation. 
io-vii-96 : Patient has been perfectly well 
since operation. Fundus attached to an- 
terior abdominal wall. 
85 
A. W. 
24 
Single. 
Retroversion of uterus. 
Endometritis. 
8-xi-95 
Curettage of uterus. 
Uterus in normal anteversion when last 
seen, one month after operation. 
86 
L. McK. 
20 
Single. 
Retroversion of uterus. 
Endometritis. Leftsal- 
pingo-oophoritis' with 
adhesions. 
i2-iii-55 
At same sitting: Cu- 
rettage of uterus. 
Posterior colpotomy 
to liberate adherent 
left tube and ovary. 
Uterus in normal anteversion, six weeks 
after operation, when last seen. 
87 
L. H. 
22 
Single. 
Retroversio uteri. En- 
dometritis. 
26-iii-g5 
Curettage of uterus. 
Uterus in normal anteversion two months 
after operation, when last seen. 
88 
M. T. 
39 
Single. 
Retroversio uteri. En- 
dometritis. 
2g-iii-95 
Curettage of uterus. 
Right ligament tore just within internal 
ring. 
Sma 1 median incision made, and by pass- 
ing finger through it into abdomen the 
uterus was lifted forward and the uterine 
half of round ligament was pushed out 
through right internal ring and sutured 
in the canal in the usual way. 
Uterus in normal anteversion when last 
seen, one month after operation. 
89 
L. K. 
28 
Married. 
3 
Retroversion of uterus. 
Laceration of cervix. 
Chronic metritis. 
2-iv-gs 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
7-vii-g6: Uterus in normal anteversion, 
still very heavy. Therapeutic result 
marred by subsequent development of 
movable right kidney and chronic appen- 
dicitis 
90 
J. K. 
25 
Single. 
Retroversion of uterus. 
Endometritis. Catarrh- 
al salpingitis. Movable 
right kidney. Proctitis 
catarrhalis, 
i8-iv-gs 
Curettage of uterus. 
24-ii-g6: Nephro- 
pexy. Dilatation of 
sphincter ani. 
June, 1896; Uterus in normal anteversion. 
Therapeutic results excellent. Shortening the Round Ligaments. 
39 
9i 
A. K. 
22 
Married. 
I 
Retroversion of uterus. 
30-iv-g5 
At same sitting: Cu- 
Uterus ixi normal anteversion when last 
Laceration of cervix. 
rettage of uterus. 
seen, six weeks after operation. 
Endometritis. 
Amputation of cer- 
vix. 
At same sitting: Cu- 
Q2 
E. H. 
24 
Married. 
i 
Retroversion of uterus. 
7-v-95 
Neither ligament being found in canal, an 
Laceration of cervix. 
Endometritis. Catar- 
rettage of uterus. 
Amputation of cer- 
incision was made in the median line 
and the ligaments traced from either 
rhal salpingitis. 
vix. 
cornu uteri outward. After passing 
through the internal inguinal ring each 
ligament ran upward and outward be- 
tween the internal oblique and the trans- 
versalis to be inserted into the outer half 
of Poupart’s ligament and the transver- 
salis fascia as far outward as the anterior 
superior spine of the ilium. Both liga- 
ments cut away above, brought down 
into canal and fastened in usual way. 
Uterus in normal anteversion when last 
seen, one month after operation. 
93 
S. G. 
29 
Single. 
Retroversion of uterus. 
2i-vi-95 
Curettage of uterus. 
15-ii-gC: Uterus in normal anteversion. 
Endometritis. 
Patient perfectly well. 
94 
M. C. 
28 
Single. 
Retroversion of uterus. 
25-X-95 
At same sitting: Cu- 
Uterus in normal anteversion, one month 
Laceration of cervix. 
Endometritis. 
rettage of uterus. 
Amputation of cer- 
after operation, when last seen. July. 
1896, writes that she is well. 
95 
C. G. 
33 
Married. 
I 
Retroversion of uterus. 
6-xi-95 
ry-x-gs; Curettage of 
Uterus in normal anteversion at last exam- 
Endometritis. Catar- 
uterus. Nephropexy, 
ination two months after operation. July, 
rhal salpingitis. Mov- 
1896, writes that she remains perfectly 
able right kidney 
well. 
96 
M. W. 
23 
Married. 
I 
Retroversion of uterus. 
22-xi-g5 
At same sitting: Cu- 
y-v-g6: Uterus in normal anteversion. 
Laceration of cervix. 
Endometritis. 
rettage of uterus. 
Amputation of cer- 
vix. 
Therapeutic result marred by develop- 
ment of movable right and left kidneys 
since operation. 
97 
L. K. 
32 
Married. 
I 
Retroversion of uterus. 
lo-xii-gs 
At same sitting: Cu- 
Twin pregnancy immediately after return- 
Laceration of cervix. 
Endometritis. Mov- 
able right and left kid- 
rettage of uterus. 
Amputation of cer- 
vix. 
ing home. Abortion at end of third 
month, 3~iv-g6. 
x_vii-g6: Uterus in normal anteversion. 
neys. 
Patient well with exception of symptoms 
due to movable kidneys. George M. Edebohls, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
98 
M. K. 
31 
Single. 
Retroversion of uterus. 
Chronic metritis. 
17-XU-95 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
Left round ligament normal in every way. 
Right round ligament not found in canal. 
Through a small median incision of the ab- 
domen the right ligament was traced 
from the cornu of uterus outward, where, 
after passing through the internal in- 
guinal ring, it ran upward and outward 
to be inserted into outer half of Poupart’s 
ligament. It was cut away from its ab- 
normal attachments, brought down and 
sutured in the inguinal canal in the usual 
way. 
Anatomical result perfect after one month, 
when patient was last seen. 
99 
A. C. 
30 
Married. 
4 
Retroversion of uterus. 
Chronic metritis. Bi- 
lateral salpingo-oopho- 
ritis, with adhesions. 
24-xii-gs 
At same sitting ; Cu- 
rettage of uterus. 
Amputation of cer- 
vix. ly-i-pd : Right 
salpingectomy. Left 
salpingostomy. Ven- 
tral fixation of uter- 
us. 
Primary union of both wounds. Patient 
sat up in bed on eleventh day. Two 
weeks after operation uterus was found 
again retroverted. 
17-1-96. Cceliotomy. Chronic salpingo- 
oophoritis with universal adhesions of ap- 
pendages posteriorly in pelvis. Uterus 
not adherent. 
Tubes and ovaries not enlarged except 
outer ends of tubes which were occluded. 
Left ligament remained securely fastened 
in canal. Right round ligament retracted 
within abdomen; stump thereof con- 
tracted to four centimetres in length. 
Failure due to firm adhesions of tubes 
and ovaries. After liberation of these, 
right salpingectomy, left salpingostomy 
and ventral fixation of uterus; neither 
ovary removed. 30-vi-g6: Patient re- 
mains well. Fundus forward, attached 
to abdomina wall. Shortening the Round Ligaments. 
100 
M. M. 
38 
Married. 
2 
Retroversio uteri. Chron- 
ic metritis. Dementia. 
3i-xii-95 
At same sitting: Cu- 
rettage of uterus. 
Amputation of cer- 
vix. 
Patient neither before nor after operation, 
while under our care, passed water volun- 
tarily, requiring the constant use of cathe- 
ter. Notwithstanding several severe over- 
distentions of bladder, uterus in normal 
anteversion on discharge a month after 
operation, since which time not seen. 
IOI 
M. McC. 
19 
Single. 
Retroversion of uterus. 
Endometritis. 
6-i-g6 
Curettage of uterus. 
2-vii-g6: Uterus in normal anteversion. 
Patient well. 
IC2 
E. K. 
45 
Single. 
1 
Retroversion of uterus. 
Chronic metritis and 
perimetritis. 
1 y-i-gb 
At same sitting: Cu- 
rettage of uterus. 
Posterior colpotomy 
for separation of 
tubal and ovarian 
adhesions. 
Ovaries, tubes, and uterus adherent; other- 
wise normal. Adhesions separated 
through an incision of the posterior cul- 
de-sac, which was then closed. 
8-vii-g6: Uterus in normal anteversion. 
Tubes and ovaries normal. Patient well. 
103 
M. C. 
20 
Single. 
1 
Retroversion of uterus. 
Endometritis. Lacera- 
tion of cervix, vagina, 
and perinteum. 
y-ii-gb 
At same sitting : Cu- 
rettage of uterus. 
Trachelorrhaphy. 
Median coeliotomy. 
Difficulty in identifying ligaments in canal. 
Small median abdominal incision, through 
which ligaments were traced from uterine 
cornua outward to canals and there iden- 
tified. Uterus in normal anteversion one 
month after operation, when last seen. 
104 
E. S. 
3i 
Single. 
1 
Retroversion of uterus. 
Chronic metritis. 
Chronic parenchyma- 
tous nephritis. 
n-ii-96 
14-VU-96 : Uterus in normal anteversion. 
Patient relieved of pelvic symptoms. 
Nephritis persists. 
105 
J. McG. 
18 
Single. 
Anteflexion of uterus. 
Endometritis. - 
14-U-96 
Curettage of uterus. 
One month after operation uterus in normal 
anteversion, the angle of flexion having 
disappeared. Not seen since. 
106 
M. B. 
22 
Single. 
Retroflexion of uterus. 
Endometritis. Small 
cystic degeneration of 
right ovary. 
i8-ii-g6 
At same sitting: Me- 
dian coeliotomy. 
Puncture of ovarian 
cysts. 
Right ligament would not run out on trac- 
tion. Small median abdominal incision 
made to ascertain cause, which was found 
to consist in abnormal shortening of right 
infundibulo-pelvic ligament. This liga- 
ment stretched, few small cysts of right 
ovary punctured and the round ligaments 
shortened in usual way. 
14-vii-gb: Uterus in normal anteversion. 
Patient well in every way. George M. Edebohls, M. D. 
No. 
Name. 
Age. 
Condi- 
tion. 
No. of 
children. 
Pathological conditions. 
Date of 
operation. 
Additional operations. 
Result and remarks. 
107 
A. L. 
24 
Single. 
Retroversio uteri. Endo- 
3-iii-g6 
Curettage of uterus. 
Uterus in normal ante version one month 
metritis. 
after operation. Not seen since. 
108 
F. K. 
33 
Married. 
7 
Retroversion of uterus. 
io-iii-g6 
At same sitting: Cu- 
30-vi-g6 : Uterus in normal anteversion. 
Laceration of cervix. 
rettage of uterus. 
Patient perfectly well. 
Endometritis. 
Amputation of cer- 
vix. 
Curettage of uterus. 
log 
M. J. 
36 
Married. 
2 
Retroversion of uterus. 
io-iv-96 
Uterus in normal anteversion ten weeks 
Laceration of cervix. 
after operation, when last seen. 
Endometritis. 
no 
M. McK. 
32 
VV idow. 
3 
Retroversion of uterus. 
Laceration of cervix. 
i4-iv-g6 
At same sitting : Cu- 
rettage of uterus. 
Uterus in normal anteversion and patient 
perfectly well ten weeks after operation, 
Endometritis. 
Amputation of cer- 
vix. 
Curettage of uterus. 
when last seen. 
III 
L. P. 
42 
Married. 
T 
Retroversion of uterus. 
Chronic metritis. Right 
Bartholinitis. 
25-iv-g6 
Two months after operation, when last 
seen, uterus in normal anteversion and 
patient well. 
112 
E. D. 
30 
Married. 
3 
Retroversion of uterus. 
28-iv-g6 
At same sitting: Cu- 
Two months after operation, uterus in nor- 
Laceration of cervix. 
rettage of uterus. 
mal anteversion. 
Endometritis. Mitral 
Amputation of cer- 
Shortening of round ligaments performed 
and aortic insuffi- 
vix. 
under infiltration anaesthesia (Schleich). 
Single. 
ciency. 
113 
A. A. 
22 
1 
Retroversion of uterus. 
8-V-96 
At same sitting: Cu- 
Uterus in normal anteversion and patient 
Laceration of cervix. 
Chronic metritis. 
rettage of uterus. 
Amputation of cer- 
well when last seen, six weeks after op- 
eration. 
114 
A.J. 
23 
Married. 
Retroversion of uterus. 
15-V-96 
Curettage of uterus. 
Uterus in normal anteversion six weeks 
Endometritis. 
after operation. 
US 
L. P. 
23 
Married. 
1 
Retroversion of uterus. 
15~v-g6 
At same sitting: Cu- 
Uterus in normal anteversion when last 
Laceration of cervix. 
rettage of uterus. 
seen, six weeks after operation. 
Chronic metritis. 
Amputation of cer- 
vix. Shortening the Round Ligaments. 
43 
RESULTS AND ANALYSIS OF AUTHOR’S OPERATIONS FOR SHORTEN- 
ING THE ROUND LIGAMENTS. 
I have attempted the operation of shortening the round liga- 
ments upon one hundred and twenty-three women all told. My first 
five cases were operated upon in 1889, and were patterned upon 
the operation as performed by Alexander. The records of these 
cases have been lost. The histories of two further patients, operated 
upon in other cities for the purpose of demonstrating the operation, 
were never obtained. The records of these seven patients and that 
of the only patient who died—eight cases in all—are not included 
in the appended table of operations. 
Mortality.—Of the one hundred and twenty-three patients op- 
erated upon, one died within a week after operation of acute septic 
peritonitis, which, until the autopsy proved the contrary, was at- 
tributed to the operation. The necropsy showed acute gangrenous 
appendicitis, with perforation and purulent general peritonitis, the 
death being in no wise attributable to the operation. The mortality 
may therefore be fairly stated as nil. This is the more remarkable 
when the large number of additional operations, many of them of 
a serious character, performed upon the same patients, and the 
formidable list of diseases complicating convalescence, are taken 
into account. 
Methods of Operation.—Of the one hundred and fifteen cases 
tabulated, Nos. 1 to 74 were operated upon after the writer’s origi- 
nal method (123), except that the buried silkworm-gut suture was 
used in the last thirty-eight. In Nos. 75 to 101 the method of 
Alquie-Kellogg was followed. Nos. 102 to 115, finally, were oper- 
ated upon with my present improved technics. 
Age.—The youngest patient was seventeen, the oldest fifty-seven 
years of age. The average age of the one hundred and fifteen 
women was twenty-eight years. Fifty-nine patients were married, 
forty-eight single, eight widows. 
Indication for Operation.— 
Retroversion and excessive mobility of the uterus, un- 
complicated, or complicated only by changes lim- 
ited to the uterus itself, as endometritis, chronic 
metritis, laceration of cervix, subinvolution 87 
Retroversion, with adhesions of the uterus 4 44 
George M. Edebohls, M. D. 
Retroversion of the uterus, with adhesions of one tube 
and ovary 2 
Retroversion of uterus, with bilateral salpingo-oopho- 
ritis and adhesions of uterus and appendages 1 
Retroflexion of the uterus, uncomplicated 4 
Retroflexion of uterus, with adhesions 1 
Retroversion of anteflexed uterus 1 
Anteflexion of uterus 2 
Prolapse of ovaries 5 
Prolapse of ovaries, with oophoritis dextra i 
Retroversion and incomplete prolapse of uterus 4 
Complete prolapsus uteri et vaginae 3 
Total number of cases 115 
This list of indications for shortening the round ligaments is 
believed to sufficiently explain itself, except perhaps as regards the 
use of the term “ prolapse of ovaries.” The ovaries are practically 
found more or less prolapsed in every case of movable retroversion 
of the uterus. The case has been classified as prolapse of the ovaries, 
instead of under retroversion of the uterus, whenever the two ova- 
ries prolapsed completely, so as to lie side by side, in contact with 
each other, in the deepest part of Douglas’ sac, beneath the retro- 
verted fundus uteri. Whenever the fundus uteri occupied the lowest 
part of Douglas’ sac, with an ovary on either side, the case was 
classed under the heading retroversion of the uterus. 
The relative rarity of cases of retroflexion, as compared with 
those of retroversion, is due to the fact that those cases only were 
classed as retroflexion in which the retrodeviated fundus was at 
least as low in the pelvis as the cervix, and in which, at the same 
time, the angle of flexion was so acute that the posterior surfaces 
of corpus and cervix were practically in juxtaposition. 
In the cases of retrodeviations of the uterus with adhesions of 
that organ or of its adnexa, or of both, the adhesions, except in 
two cases where existing adhesions of the right ovary were not 
recognized, were first separated either by bimanual divulsion after 
Schultze, by posterior colpotomy, by median coeliotomy, or by in- 
cision of the peritonaeum at the internal inguinal ring. 
Additional Operations.—ln addition to shortening the round liga- 
ments, or attempting to shorten them, the writer performed upon Shortening the Round Ligaments. 
45 
these one hundred and fifteen patients, at the same or additional 
sittings, the following operations: 
Slitting of prseputium clitoridis and separation of pre- 
putial adhesions I 
Excision of urethral polypus 2 
Stretching of sphincter ani 3 
Excision of haemorrhoids 1 
Perineorrhaphy 14 
Colpo-perineorrhaphy 8 
Anterior colporrhaphy 7 
Bilateral discission of cervix 1 
Trachelorrhaphy 17 
Amputation of cervix 40 
Curettage of uterus 96 
Posterior colpotomy 2 
Vaginal fixation of uterus 1 
Separation of adhesions in narcosis (Schultze) 2 
Coeliotomy for separation of adhesions 3 
Ventral fixation of uterus 5 
Left salpingostomy 1 
Right salpingectomy 1 
Salpingo-oophorectomy for fibroma uteri I 
Coeliotomy and puncture of ovarian small cysts 1 
Ovariotomy 1 
Hystero-salpingo-oophorectomy, by combined perine- 
otomy and coeliotomy, for sarcoma of left broad 
ligament 1 
Inversion of vermiform appendix I 
Appendectomy for chronic appendicitis 3 
Appendectomy for tuberculosis of appendix 1 
Coeliotomy for acute gangrenous appendicitis 1 
Radical left inguinal herniotomy 1 
Radical right inguinal herniotomy 1 
Bilateral radical inguinal herniotomy 2 
Right femoral herniotomy 2 
Nephropexy, for movable kidney 11 
Bilateral nephropexy 2 
Including the shortening of the round ligaments, three hun- 
dred and forty-nine operations were performed upon these one 46 
George M. Edebohls, M. D. 
hundred and fifteen patients. All of the patients made good recov- 
eries from all the operations performed upon them. 
Technical Difficulties encountered in the Operation of shortening 
the Round Ligaments.—The writer has noted, at the time of their 
occurrence, all the various technical difficulties encountered in these 
one hundred and fifteen operations for shortening the round liga- 
ments. His experience in this direction he believes to have been 
unusually large and varied, and a resume of these difficulties and 
the way in which they were met may possibly prove of service to 
younger operators. 
First, as regards finding the ligaments. In one instance only 
(Case XVI) was the round ligament not found, search for it being 
made on the left side only. The writer feels convinced that the 
ligament was present, and that the failure to find it was entirely 
chargeable to his lack of resources and development as an operator 
upon the round ligaments. 
In a second instance (Case CIII), after failure to find in the 
inguinal canal the round ligament there present, the abdomen was 
opened in the median line by a small incision, through which the 
round ligaments were traced from the cornu uteri to the internal 
ring and into the inguinal canal, where they were then readily 
identified. 
In searching for the round ligament the right deep epigastric 
artery was divided and doubly ligated in Case XXII. In Case 
LVI, in searching for a round ligament not present in the canal, 
the right internal iliac vein was drawn out by the hook, recognized, 
and dropped without injuring the vessel. In Case XCVI, in fishing 
for the ligament, the right internal iliac artery was hooked up, rec- 
ognized as such, and dropped without injury or bad result. 
The abnormal course and insertion of the right round ligament 
in Cases LVI and XCVIII, and of both round ligaments in Case 
XCII, necessitating their absence from the canal, have already been 
described. In similar cases, upon not finding the round ligament 
in the canal, I would propose, as the best plan to follow, to open 
the peritonaeum at the internal ring. The round ligament would 
then either be recognized running between the folds of the broad 
ligament or could be readily traced outward from the cornu uteri. 
The round ligament may tear, either in the canal or between 
the internal ring and the cornu uteri, in the attempt to isolate it 
or in drawing it out of the abdomen. Shortening the Round Ligaments. 
47 
Three times the round ligament (the left in Case L, and the 
right in Cases LXX and CVIII) is recorded as being torn within 
the canal, the uterine end retracting through the internal ring into 
the abdomen. In one case the torn uterine end was easily recov- 
ered just within the internal ring. In a second case the ligament 
was found, and its torn end pushed out through the internal ring 
by the aid of a small incision in the median line of the abdomen. 
In a third instance, a tear of the left round ligament, the perito- 
naeum was incised at the right internal inguinal ring, and by means 
of a finger passed through the latter into the abdomen the uterine 
end of the torn ligament was pushed through the left internal ring 
into the canal. In all three cases the recovered ligament was se- 
cured in the canal in the usual way. 
No less than six times the round ligament (the right in Cases 
XXXI, XXXIX, XLIX, LXXXVIII, and the left in Cases 
LXXIX, LXXXIV) tore within the abdomen in the attempt to 
draw it out. In four of these cases the ligament was pulled clean 
out of the uterus, leaving a depression or hole at the cornu to mark 
the site of its former insertion. In the fifth case the ligament parted 
at a distance of one centimetre from the uterine, cornu. In each of 
these five cases median coeliotomy and ventral fixation of the uterus 
were performed immediately on the occurrence of the accident. In 
the sixth case (Case LXXXVIII) the round ligament tore just 
within the internal inguinal ring, leaving the uterine end long 
enough for purposes of shortening. This uterine end was found 
through a small median incision, pushed out through the internal 
ring into the canal, and there secured in the usual way. 
In one of the six cases an unrecognized, adherent, small ovarian 
cystoma was the cause of the tear. The other five must be explained 
either by diminished strength of the round ligament, due to fatty 
degeneration or other causes, or to undue force exercised by the 
operator. The methods of meeting the accident of tear of the round 
ligament have already been considered. 
In developing or drawing out the round ligament its central 
fibers, or core, as it were, have sometimes been drawn out instead 
of the entire ligament, the outer or peripheral fibers being held 
by their attachments in the canal. In such cases the cone of perito- 
naeum accompanying the round ligament should be incised, if neces- 
sary, to secure the entire ligament. 
The peritonaeum incasing the round ligament can generally be 48 
George M. Fdebohls, M. D. 
stripped back with great facility. Occasionally, however, the peri- 
toneal investment has been found so firmly attached as to resist 
blunt dissection. No hesitation need be felt by an operator sure 
of his asepsis in using the scissors or knife, even though the peri- 
tonaeum should be opened. In one instance (Case XIII), where the 
peritonaeum was opened, the uterine end of the Fallopian tube was 
drawn out of the internal ring with the round ligament. The 
two structures were bluntly separated, the tube replaced within 
the abdomen, the ligament shortened and anchored in the usual 
way. 
On three or four occasions the writer has had the opportunity 
at subsequent coeliotomies of observing the condition of the short- 
ened round ligaments. They have always been encountered as 
short cords running in an almost straight line from cornu uteri to 
internal inguinal ring, and projecting on the anterior face of the 
broad ligaments in such a manner as to form a shallow peritoneal 
depression or pouch between the bladder anteriorly, the fundus 
uteri posteriorly, and the projecting round ligaments on either 
side. 
Behavior of Operation Wounds.—Ninety-three per cent, of the 
wounds healed by primary union; in seven per cent, wound infec- 
tion and more or less extensive suppuration are noted. In one 
case of acute croupous pneumonia immediately following operation 
(Case LXXXIII), infection of both inguinal wounds, as well as of 
a median abdominal incision made at the same time, followed. The 
three abscesses were opened on the tenth day after operation, and 
the pus from each of them furnished a practically pure culture of 
the pneumococcus. The majority of the other cases of infection 
occurred during a brief reign of sepsis, due to the use of infected 
silkworm gut in the form of buried sutures. In about one half of 
the cases the suppuration was deep; in the other half superficial in 
character. A permanent good result, as far as the position of the 
uterus is concerned, was obtained in all but two of the suppurative 
cases—Case LXX and the case of pneumococcus infection men- 
tioned above. In three patients (Cases I, XL, CXI) in whom exten- 
sive deep suppuration, with sloughing of the round ligaments and 
fascial edges, occurred in both wounds, the uterus remained in 
normal anteversion when last seen six years and a half, one month, 
and two months, respectively, after operation. Shortening the Round Ligaments. 
49 
Diseases complicating Convalescence.—During convalescence, or, 
more accurately stated, during the first four weeks after operation, 
the following complications were noted: 
Cases 
Typhus abdominalis 2 
Malaria 10 
Acute articular rheumatism 1 
Acute articular rheumatism and pericarditis 1 
Tertiary syphilis 1 
Diphtheria 2 
Acute croupous pneumonia 1 
Acute catarrhal (ether) pneumonia 4 
Acute right pleuritis 1 
Taenia solium 1 
Acute appendicitis 2 
Acute cystitis from catheter infection 1 
Sarcoma of left broad ligament 1 
The patient who developed tertiary syphilis died of cerebral 
tumor three years and eleven months after operation. The rest all 
made good recoveries from their complications. 
Failures.—Of the one hundred and fifteen cases tabulated, four 
were absolute and total failures. In one (Case XVI) the author 
failed to find the round ligament on the left side, no search being 
made for it on the right. Failures two and three (Cases LXX and 
LXXXIII) were due to sloughing of the round ligaments and of 
the edges of the fascial wound to which they were united. Failure 
four (Case XCIX) was the result of firm adhesions of the right 
tube and ovary, not recognized before operation, which pulled back 
the right round ligament into the abdomen within a month after 
operation. Two of these patients were subsequently cured, Case 
LXXXIII by vaginal, and Case XCIX by ventral fixation of the 
uterus. 
ULTIMATE RESULTS. 
There were five relative failures, due to giving way of one round 
ligament within the abdomen, the ligament in four cases being torn 
directly out of the uterus, in the fifth tearing at a distance of one 
centimetre from the uterus. In each of these five patients ventral 
fixation of the uterus was immediately substituted for the proposed George M. Edebohls, M. 1). 
shortening of the round ligaments, with resultant cure of the retro- 
version. 
It will thus be seen that only two of the one hundred and fifteen 
patients were not cured of the conditions, in one prolapsus, in the 
other retroversion, for which operation was undertaken. One (Case 
XVI) declined a proposed ventral fixation; the second (Case LXX) 
died a sudden death from fatty degeneration of the heart five months 
after having the round ligaments shortened. 
In speaking of ultimate results in the remaining one hundred 
and six cases, differentiation must be made between the anatomical 
result and the therapeutic result. To maintain the uterus in proper 
position is one thing, to cure your patient of her complaints quite 
another. 
Anatomical Results.—The anatomical result in these one hundred 
and six cases was invariably all that could be desired, the uterus in 
each case remaining in normal anteversion at the date of the last 
obtainable examination. The appended table indicates the period 
of time after operation at which this final physical examination was 
made: 29 cases were last examined 1 month after operation; 
12 in 2 months; 6 in 3 months; 1 in 4 months; 3 in 5 months; 5 
in 6 months; 1 in 7 months; 2 in 8 months; 2 in 9 months; 2 in 
12 months; 1 in 13 months; I in 14 months; I in 15 months; I in 
16 months; 3 in 20 months; 1 in 21 months; 1 in 22 months; 1 in 
23 months; 1 in 24 months; 1 in 26 months; 3 in 27 months; 1 
in 28 months; 3 in 30 months; 2 in 31 months; 1 in 35 months; 
2 in 36 months; 1 in 37 months; 1 in 38 months; 1 in 41 months; 
2 in 42 months; 2 in 43 months; 1 in 47 months; 1 in 48 months; 1 
in 50 months; 2 in 53 months; I in 55 months; 1 in 62 months; 1 
in 66 months; 1 in 72 months; 1 in 73 months; I in 77 months; 
I in 79 months. 
This makes an average period of observation of nearly seven- 
teen months for each of the one hundred and six cases, a period 
long enough to warrant definite conclusions as to the permanency 
of the anatomical results of shortening the round ligaments. These 
perfect and lasting anatomical results are perhaps the more remark- 
able when it is considered that the majority of the women belong 
to the working classes, many of them being compelled to do house- 
work of the hardest kind. In one patient (Case XXVII) the opera- 
tion successfully stood the severe test of a subsequent complete 
acute prolapse of the uterus and vagina. Shortening the Round Ligaments. 
Therapeutic Results.—While the anatomical results may be thus 
readily and succinctly stated, an accurate report upon the thera- 
peutic results becomes a much more complicated matter. The less 
searchingly we cross-question our patients, the more superficially we 
go into their after-histories, and the less thoroughly we examine 
them in the endeavor to obtain evidence to the contrary, the more 
likely are we to record a large number of therapeutic successes. 
But closer investigation often reveals one or more stumbling blocks 
to perfect satisfaction in the shape of complicating diseases present 
at the time of operation or developing soon thereafter, which com- 
plications more or less fully, more or less permanently, mar the 
therapeutic result. 
The writer has considered it his duty to himself and to his 
patients to specifically and carefully investigate each case in which 
the anatomical result was perfect, while at the same time the thera- 
peutic result was not all that could be desired. This was done 
with a view to finding, if possible, the explanation of the discrep- 
ancy. 
Among conditions of disease present in patients at the time 
of operation, which shortening of the round ligaments and other 
operations combined at the same sitting could not be expected to 
relieve, and which persisted and caused their own symptoms after 
operation, the following were noted: 
Cases 
Mild insanity 2 
Chronic nephritis 2 
Valvular lesions of the heart 6 
Chronic appendicitis ' 1 
Movable right kidney 13 
Movable left kidney ' 1 
Movable right and left kidneys 2 
Bilateral salpingo-oophoritis 1 
Chronic metritis and right obphoritis, with adhesions 
of ovary 1 
Five of the cases of movable kidney were subsequently cured 
by nephropexy. In a sixth case nephropexy and shortening of the 
round ligaments were performed simultaneously. The case of 
chronic metritis and right oophoritis with adhesions was cured by 
a subsequent pregnancy, which liberated the imprisoned ovary by 52 
George M. Edehohls, M. D. 
carrying it out of the pelvis. The case of bilateral salpingo-oopho- 
ritis was later radically cured by a vaginal bilateral salpingo-oopho- 
rectomy performed by another surgeon. The remainder of these 
patients continued to suffer from the symptoms due to their re- 
spective complicating diseases. The complications, however, having 
been diagnosticated before operation, and the prognosis shaped ac- 
cordingly, left no real ground for disappointment in these cases, 
the symptoms due to the retroversion being relieved in each of 
them. 
In quite a number of cases, however, the development after 
operation of new morbid conditions caused disappointment, and 
called for repeated careful and critical analysis of the situation. 
Questioning and physical examination of the patient showed that 
the following diseases, developing after convalescence from the 
operation of shortening the round ligaments, had to a greater or 
less degree marred the therapeutic result: 
Cases 
Progressive tertiary syphilis i 
Acute articular rheumatism I 
Chronic rheumatic endocarditis I 
Plumbism i 
Malaria 12 
Acute dementia 1 
Movable right kidney 7 
Movable left kidney 1 
Movable right and left kidneys 1 
Chronic appendicitis 1 
Acute perforative appendicitis 1 
Endometritis 2 
Salpingitis I 
Salpingo-oophoritis 8 
Fibromata uteri I 
Sarcoma of left broad ligament 1 
Of these conditions developing after operation the following 
were surgically treated by the writer, all of them successfully: 
Four of the movable kidneys by nephropexy. 
The case of acute perforative appendicitis by removal of the 
appendix and drainage of abscess. 
One case of endometritis and the case of salpingitis by curettage 
of the uterus. Shortening the Round Ligaments. 
53 
One of the cases of salpingo-oophoritis by unilateral and one 
by bilateral coelio-salpingo-oophorectomy. 
The fibromata uteri case by bilateral salpingo-oophorectomy. 
The sarcoma of left broad ligament by extirpation of uterus, 
tubes, ovaries, and entire left broad ligament. 
Among the conditions existing at the time of operation or de- 
veloping thereafter, the various inflammatory conditions affecting 
tubes and ovaries, and movable kidney or kidneys, play so large 
and so important a role as to call for separate consideration. 
Salpingo-oophoritis in its Relations to Retro deviations of the Uterus. 
—More or less endometritis exists in every case of retrodeviation of 
the uterus of some standing. This endometritis is not always, per- 
haps not even generally, cured by simply correcting the position of 
the uterus. Hence the rule to curette the uterus preliminary to any 
operation for the correction of the retrodisplacement. Endometritis 
predisposes to—indeed, tends directly—to the development of sal- 
pingitis, and, by continuation, of salpingo-oophoritis. We have 
observed no less than eleven cases of the gradual development of 
endometritis, salpingitis, and salpingo-oophoritis months after short- 
ening the round ligaments, with resultant nullification or decided 
impairment of the therapeutic result of the operation. 
Movable Kidney in its Relations to Retrodeviations of the Uterus.— 
The frequent association of movable kidney or kidneys and retro- 
deviations of the uterus has been observed by the writer since 1890, 
and is drastically illustrated by the recorded observations made 
upon the one hundred and fifteen cases tabulated. No less than 
twenty-five patients are noted as suffering from movable kidney or 
kidneys, either existing at the time the round ligaments were short- 
ened or developed after the operation. Of these twenty-five pa- 
tients with movable kidney or kidneys, eleven were cured by right 
nephropexy and two by bilateral nephropexy. In three of these 
patients the nephropexy preceded the operation on the ligaments 
in point of time; in one case the two operations were performed 
simultaneously; while in nine instances nephropexy followed short- 
ening of the round ligaments. 
The therapeutic results may be summed up in the statement 
that the symptoms due to the positional deviations of the uterus 
and ovaries, for the correction of which shortening the round liga- 
ments was undertaken, were permanently relieved in one hundred 
and eleven cases, the remaining four cases being complete failures. 54 
George M. Edebohls, M. D. 
The symptoms due to other pathological conditions coexisting in 
the patient were, except in a certain proportion of cases of endo- 
metritis and catarrhal salpingitis, not influenced by the operation. 
In other words, shortening of the round ligaments accomplishes 
therapeutically all that can logically be expected of it. 
Hernia in Connection with shortening the Round Ligaments.—Only 
one patient (Case XIII) acquired hernia as the result of shortening 
the round ligaments. Both wounds of this patient healed by pri- 
mary union. During the fifth month of her first pregnancy, nine- 
teen months after shortening the round ligaments, right inguinal 
hernia developed. Soon after delivery, or about two years after 
operation, left inguinal hernia also appeared. Both hernise are to 
be operated upon for radical cure after the termination of her pres- 
ent pregnancy, the second since operation. 
Case XLII suddenly developed an acute strangulated right 
femoral hernia two years and nine months after, but certainly not 
as a result of, shortening the round ligaments. The hernia was suc- 
cessfully operated upon on the day of its occurrence, and remains 
radically cured to date. 
Case XLVI had left inguinal hernia and retroversion of the 
uterus. Radical herniotomy was performed in conjunction with 
shortening the round ligaments. The patient remained cured of 
the hernia when last seen, sixteen months after operation. 
Case LXI had retroversion and bilateral inguinal hernia, and 
double herniotomy was added to shortening the round ligaments. 
Suppuration and sloughing in both wounds was the result of re- 
peated removal of her dressings by the mentally irresponsible pa- 
tient. The left hernia recurred six months after operation; the 
right remained cured when last seen, nine months after operation. 
Case LXXI presented a right inguinal and a right femoral 
hernia at the time of shortening the round ligaments. Both hernise 
were operated upon with a view to radical cure at the same sitting 
with the ligament operation. When last seen, seventeen months 
after operation and two months after delivery at term, the inguinal 
hernia had returned, a new left femoral hernia had developed, while 
the original right femoral hernia remained cured. 
In Case LXXIV two inguinal hernise were operated upon for 
radical cure while shortening the round ligaments. Both hernise 
remained cured when the patient was last seen, twenty-one months 
after operation. Shortening the Round Ligaments. 
55 
To summarize: Two inguinal hernise developed in one patient 
as a result of the operation; two femoral hernise developed after, 
but not as a result of, the operation. Of seven hernise existing at 
the time of operation, and operated upon for radical cure while 
shortening the round ligaments, four inguinal hernise and one 
femoral remain cured; two inguinal hernise have recurred. Four 
inguinal and two femoral hernise are now present as against six in- 
guinal and one femoral existing at the time of shortening the round 
ligaments. The two femoral hernise stand in the relation of post 
hoc, but not propter hoc, to the operation of shortening the round 
ligaments. Two inguinal hernise, both in the same patient, were 
produced, and four inguinal hernise in four patients were cured by 
the operation of shortening the round ligaments. These hernia 
experiences all belong to the period at which the entire canal was 
opened and the round ligament was placed immediately behind the 
lips of the fascial wound, to which it was sutured. With the present 
improved technics, closing by a Bassini, the occurrence of an in- 
guinal hernia after operation ought to prove a very great rarity, 
while the cure of hernise existing at the time of shortening the round 
ligaments should become an almost absolute certainty. The in- 
guinal canal can be much more securely closed in women than in 
men, owing to the necessity of providing for the spermatic cord 
in the latter. 
Cases of Pregnancy following shortening of Round Ligaments.— 
Eighteen pregnancies have been observed, occurring in eleven of 
the one hundred and fifteen tabulated cases. 
Of these eighteen pregnancies no less than six occurred in three 
of the five patients whose round ligaments parted within the abdo- 
men during operation, and in whom ventral fixation of the uterus 
was substituted for shortening the round ligaments. 
These six, therefore, are cases of pregnancy following ventral 
fixation of the uterus. One mother (Case XXXIX) died suddenly, 
from valvular disease of the heart, on the eve of confinement at 
term. Case XLIX had one miscarriage and two living children at 
term, both born without complications. The third patient (Case 
LXXIX) had one abortion at the fourth month and one difficult 
and disastrous labor at term—transverse presentation, inability to 
deliver, on account of high posterior position of cervix and ob- 
struction formed by thickened anterior wall of uterus; rupture of 
uterus; coelio-panhysterectomy; death from sepsis. 56 
George M. Edebohls, M. D. 
The records of the twelve pregnancies following shortening of 
the round ligaments are carried up to date of going to press: 
Case XI: Three pregnancies, three living children at term. 
Case XIII: Two pregnancies, two living children at term. 
Case XX: One pregnancy, one living child at term. 
Case XXXVIII: One pregnancy, one living child at term. 
Case LXVII: One pregnancy, one living child at term. 
Case LXXI: One pregnancy, one living child at term. 
Case XLVI: Two pregnancies, one miscarriage at third month; 
pregnant seven months, without complications, when last seen. 
Case XCVII: One twin pregnancy; miscarriage at third 
month. 
There were thus ascertained twelve pregnancies in eight women 
whose round ligaments had been shortened. Of these twelve preg- 
nancies two terminated in abortion, one was lost sight of after the 
seventh month, and nine ended with the safe delivery at term of 
living children. All the labors were easy and natural with one ex- 
ception: Case LXXI had a transverse presentation, necessitating 
version and forceps to the after-coming head; mother well, child 
alive. In the seven patients whom it was possible to follow after 
each pregnancy, the uterus remains in anteversion. 
SUMMARY. 
Shortening the round ligaments is the only operation by which 
the retrodisplaced uterus can be brought into normal and physio- 
logical anteversion without establishing always pathological perito- 
neal adhesions. All other retroversion operations depend for their 
success upon more or less extensive, more or less firm, peritoneal 
adhesions. 
Shortening the round ligaments, in capable hands, is as safe and 
as successful as the other retroversion operations. 
Shortening the round ligaments is absolutely free from the dis- 
turbances and disasters of future pregnancy and parturition which 
are on record as having followed vaginal and ventral fixation of 
the uterus, its chief rivals. 
Shortening the round ligaments is therefore indicated, and 
should be the operation of choice whenever and wherever it will 
meet the indications as well as, or better than, one of the rival pro- 
cedures. Shortening the Round Ligaments. 
57 
Shortening the round ligaments is indicated— 
(a) In all uncomplicated cases of retroversion, retroflexion, and 
excessive mobility of the uterus requiring operative treatment. 
(b) In extreme and aggravated cases of anteflexion of the 
uterus. 
(c) In cases of retroverted, anteflexed uteri without adhesions. 
(.d) In simple prolapse of the ovaries when that condition calls 
for treatment. 
(c) In cases of adherent retrodisplaced uteri, with or without 
adhesions of tubes and ovaries, these organs being otherwise in con- 
dition to call for their conservation. The adhesions are first to be 
severed by colpotomy, median coeliotomy, or an incision through 
the peritonaeum at the internal ring. 
Shortening the round ligaments does not compare in efficiency 
with ventral fixation of the uterus as a prolapsus operation. 
Shortening the round ligaments should always be immediately 
preceded by curettage of the uterus. Other operations may be 
associated according to the indications in the particular case. 
The round ligament is never absent. It may, however, after 
emerging from the internal inguinal ring, run an erratic course to 
an abnormal insertion (in the writer’s experience in four per cent, 
of round ligaments). 
Shortening the round ligament is best performed by opening 
the whole length of the anterior wall of the inguinal canal, draw- 
ing the ligament out at the internal ring, really shortening the intra- 
abdominal portion by stripping back the investing peritonaeum 
and closing the wound after the manner of the Bassini operation 
for the radical cure of inguinal hernia, leaving and securing the 
shortened ligament in its natural habitat behind the lower edge of 
the internal oblique. 
Of the author’s one hundred and sixteen cases, four were abso- 
lute failures. In one of these the operator failed to find the round 
ligament on one side; failures two and three were due to sloughing 
of the ligaments; failure four to unrecognized adhesions of one 
ovary, which pulled back the round ligament of that side into the 
abdomen within a month. Two of these four patients were subse- 
quently cured, one by vaginal and one by ventral fixation of the 
uterus. There were five relative failures, due to giving way of one 
round ligament within the abdomen. In each of the five patients 
ventral fixation was immediately substituted, with resultant cure 58 
George M. Edebohls, M. D. 
of the retroversion. The writer preferred this course to trusting to 
one shortened ligament to hold up the uterus. One patient died 
within a week after operation of acute gangrenous appendicitis with 
septic peritonitis. 
In the remaining one hundred and six patients the uterus re- 
mained in normal anteversion when last examined, the period of 
observation varying from one month to six years and a half after 
operation, and averaging over sixteen months for each of the one 
hundred and six cases. 
The writer is convinced that these results can be improved 
upon. 
Two inguinal hernise, both in the same patient, occurred as a re- 
sult of shortening the round ligaments. Six inguinal and one fem- 
oral hernia were operated upon simultaneously with shortening of 
the round ligaments. Of these two, inguinal hernias recurred; the 
femoral and four inguinal hernias remain cured. 
Twelve pregnancies are known to have followed in eight of the 
successful cases. Of these, two terminated in abortion, one was 
lost sight of after the seventh month, and nine ended with the safe 
delivery at term of living children. In the seven patients whom it 
was possible to follow after each delivery, the uterus remains in 
anteversion. 
The appended bibliography is as complete as the resources of 
the library of the New York Academy of Medicine enabled us to 
make it. The writer is deeply indebted to Dr. T. Alexander Leh- 
man for valued aid in its preparation and in abstracting the litera- 
ture. 
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2. Alquie ; Nouvelle methode pour traiter les divers deplacements de la matrice 
(Rap. de Villeneuve). Bull. Acad, de med., Par., 1844-45, x. 192-195. 
3. Aran : Maladies de I’uterus. 1858, p. 1039. 
4. FrixSCH, IT.: Lageveraenderungen der Gebarmutter. Stuttgart, 1881, p. 
136. 
5. Alexander, W.: A New Method of treating Inveterate and Troublesome 
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1882. Shortening the Round Ligaments. 
59 
7. Alexander, W.: A New Method of treating Displacements of the Uterus. 
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