THE IMMEDIATE AND REMOTE RE- 
SULTS OF SEVENTY-ONE ALEXAN- 
DER AND SEVENTY-ONE SUSPEN- 
SIO-UTERI OPERATIONS. 
BY 
W. L. BURRAGE, M.D., 
OF BOSTON. 
FROM 
THE MEDICA IT“TTE'W’S7 
October 8, 1 898. [Reprinted from The Medical News, Oct. 8, 1898.] 
THE IMMEDIATE AND REMOTE RESULTS OF 
SEVENTY-ON E ALEXANDER AN D SEV- 
ENTY-ONE SU SPENS/O-UTERI 
OPERA TIONS-1 
By W. L. BURRAGE, M.D., 
OF BOSTON. 
The paper here presented is based on 71 Alex- 
ander and 71 suspensio-uteri operations performed 
by the writer during the six years from 1891 to 1897, 
inclusive, the first Alexander having been done Au- 
gust 7, 1891, and the first suspension August 1, 
1893, so that a majority of the Alexanders were per- 
formed in the earlier years of this period and a ma- 
jority of the suspensions in the later years. The 
facts in this paper are from my private operation- 
records written by myself on the day of the opera- 
tion, with very few exceptions, and during the sub- 
sequent convalescence and whenever the patient 
again came under observation. With 3 exceptions, 
all of the 142 patients were examined by me per- 
sonally at the time of their discharge, two or 
three weeks after the operation, and notes made of 
the existing condition. These notes form the basis 
of the immediate results here chronicled. For the 
remote results the patients were examined at least 
three months after their operations, for the most part 
by the writer, but in several instances where the pa- 
tients were at a distance by their attending physi- 
i Candidate’s paper presented for admission to membership in 
the American Gynecological Society at its Twenty-third Annual 
Meeting, held at Boston, May aapssyaftd afv-iSgS.. 2 
dans, who kindly reported the results to me. Six- 
teen patients it was impossible to trace at all, and 7 
were reported as being free from uterine symptoms, 
or wrote me to that effect. Reliable statistics were 
obtained from 62 Alexander and 60 suspension cases, 
122 out of 142 cases. None of the patients died as 
a result of the operation. Three, upon whom the 
Alexander operation was performed, have since died, 
2 of pneumonia and the other of unknown causes. 
The Alexander Operation.—Sixty-four operations. 
Technic: Locate pubic spine by touch. Incision 
six centimeters long, nearly parallel with Poupart’s 
ligament, the lower end of the incision being at the 
pubic spine. Dissection of the subcutaneous fat 
layers until the glistening fibers of the aponeurosis 
of the external oblique are brought into view. All 
the structures in the external abdominal ring are 
seized with tissue-forceps and drawn up. Here it 
may be said in passing that the author has never 
failed to find the ligament. A small hook is passed 
under all the tissues and is then replaced by the 
operator’s finger. The nerve is separated from the 
ligament and drawn to one side. Traction is made 
on the ligament, and after it has. been pulled out to 
its uterine enlargement the same procedure is adopted 
with the ligament on the opposite side, the uterus is 
anteverted by bimanual touch, and the ligaments are 
anchored to the pillars of the ring by two ligatures 
of fine silk to each pillar. Silkworm gut, kangaroo 
tendon, and chromicised catgut were used in some 
instances, but fine silk as a general rule. If the 
ligament is much bruised it is cut off, otherwise it 
is left in the wound. The wounds are closed with 3 
interrupted sutures of silkworm gut passing through 
skin and fat, and catching up a few fibers of the 
aponeurosis of the external oblique so as to leave no 
dead space. Some of the wounds were closed with 
a continuous suture of either catgut or silkworm gut 
passed subcutaneously. The dressings consist of 
dry powder, aristol, or sterilized nosophen dusted on 
the wound, and dry gauze stuck to the skin with 
corrosive collodion to prevent contamination of the 
wound from the patient’s finger or the subsequent 
shifting of the dressing. 
Seven operations by the Edebohls’ method. Slightly 
longer incision. Inguinal canal laid open by divid- 
ing the aponeurosis of the external oblique in the 
direction of Poupart’s ligament up to the internal 
abdominal ring. Isolation of the round ligament 
in the canal by means of hooks, and separation of 
the nerve. Drawing out of the round ligament up 
to its uterine enlargement and stripping back of the 
peritoneal investment. After the other ligament 
has been shortened the position of the fundus uteri 
is verified by the operator’s little finger passed 
through the internal ring. The edge of the internal 
oblique muscle is stitched to Poupart’s ligament by 
a continuous suture of chromicised catgut, No. 2, 
the needle passing through the round ligament with 
each stitch and thus securely anchoring it. The 
aponeurosis of the external oblique is closed with 
the same stitch, which is tied with its other end at 
the upper limit of the wound in the aponeurosis. By 
this procedure there is only one knot in the entire 
operation. The ligament is cut off at the external 
ring. The wounds are closed and the dressings 4 
are applied in the same way as in the other 
method. 
Although the Alexander operation was primarily 
intended for cases of retroversion without adhesions, 
its field has been amplified in my hands by perform- 
ing it in conjunction with posterior colpotomy in 
cases of moderate adhesions. This was done in nine 
of my cases with good results. The colpotomy 
proved especially useful where the uterosacral liga- 
ments were tight. Where the ovaries were pro- 
lapsed and free from adhesions the Alexander opera- 
tion, in certain cases, has restored them to a normal 
position, but when adherent, or when the ovarian 
ligaments have been long, it has not done so in a 
majority of cases even with the aid of colpotomy. 
A glance over the tabulated statistics of the 71 
Alexander operations, shows that 34 are cases of re- 
troversion free from adhesions, 7 of retroflexion free 
from adhesions, 28 of retroversion or retroflexion 
with some adhesions or with tight uterosacral liga- 
ments, and 2of procidentia. One or both ovaries 
were noted as being prolapsed in 16 cases. An in- 
guinal hernia existed on one side in two cases, and a 
radical cure was effected in the course of the Alex- 
ander operation in each case. Curetting of the 
uterine cavity was done in every case. Amputation 
of the cervix and the ligature operation for hemor- 
rhoids were each done once. Trachelorrhaphy and 
perineorrhaphy were performed together 7 times, 
perineorrhaphy alone 6 times, and trachelorrhaphy 
alone 9 times. 
The immediate results of the 71 Alexander opera- 
tions were good in all but 6, 92 per cent. Of these 5 
6, i only was a total failure, the other 5 being classed 
as fair. The cause of the failure is not plain as the 
ligaments were of good size, were anchored with 
silk, and the wounds healed by first intention. One 
ligament broke off in the course of the operation in 
five cases. As a result, the uterus was in the first 
degree of retroversion at the time of the patient’s 
discharge in 3, and later, completely retroverted in 
all except 1. This patient went through a normal 
labor one year and five months after the operation, 
and subsequently the uterus was in good position and 
well involuted. The first 4 cases, taken together 
with one case in which there was only one ligament 
to shorten because of a previous ovariotomy, and in 
which there was an ultimate failure, would argue 
against trusting to one ligament to hold the uterus in 
place. In one or two other cases the ligament broke 
during the operation and was recovered by opening 
the entire inguinal canal and fishing for the ligament 
through the internal ring. In the one Edebohls’ 
operation where the cord gave way at its uterine in- 
sertion, the fault was due to using too great force 
in pulling on a fatty cord in a fleshy patient through 
an error in not appreciating that the fundus uteri 
was already well up. 
Pregnancy has taken place in 12 cases, 19 per 
cent., following operation. The pregnancy and labor 
were both normal in 5 of these. Of the remaining 
7, 1 had a tedious labor terminated by forceps, and, 
following that, three miscarriages. Six years after 
the operation the uterus was found retroverted. It 
was noted in this case at the time of her discharge 
from the hospital after the Alexander operation that 6 
from the one-sided position of the uterus one liga- 
ment had probably given way. In another there 
was prolonged suppuration in the wounds and the 
silkworm-gut ligatures which had anchored the liga- 
ments came out. Here the uterus was found retro- 
verted in early pregnancy. Another patient mis- 
carried at seven months from overwork. The uterus 
was subsequently in good position. Another had 
pain in the left groin while pregnant, and her labor 
was slightly tedious. The uterus was in good posi- 
tion afterward. Another is now pregnant in the 
early months, while still another was eight-months’ 
pregnant when last seen and had had no unusual 
symptoms. Another had a normal pregnancy, but 
the labor was long and the placenta was adherent 
requiring manual extraction, which was followed by 
sepsis. Five weeks after labor the uterus was found 
introverted and adherent, a condition not to be won- 
dered at in the light of the sequelse of the confine- 
ment, but two months afterward it was small and in 
good position. To sum up: Pregnancy and labor were 
both normal in five cases; pregnancy was noted as 
being abnormal in the remaining cases three times; 
labor abnormal three times; pregnancy normal three 
times, and labor normal once. Abortion resulted 
from the operation in no case. The uterus was re- 
troverted following labor in 4 cases. 
The tables show that out of 62 cases examined the 
ultimate results were good in 48, 77 per cent., and 
failures in 14, 23 per cent. The other 9 cases were 
classed as unknown. It is to be remembered that of 
the 14 failures, 6 were immediate partial or com- 
plete failures also, leaving 8 cases in which the uterus 7 
became retroverted subsequent to the discharge of 
the patient. Four of these became retroverted, as 
already stated, after a subsequent labor. It is notice- 
able also that all of the immediate partial or com- 
plete failures were afterward traced and the results 
appear again in the list of ultimate failures. The 
large percentage of ultimate failures is to be attrib- 
uted to lack of skill on the part of the operator, most 
of the failures being among the earlier cases, and to 
the fact that the operation was sometimes performed 
in unsuitable cases. 
A left inguinal hernia followed the Alexander 
operation in two instances. In one the cords were 
slender and the rings normal in size, while in the 
other the cords were very large and the rings 
large. The ligaments were anchored with catgut in 
both cases. In both the uterus was in good position 
ultimately. Pain in the scars followed the earlier 
operations where the nerves were not carefully sepa- 
rated from the cords, but not in the later operations. 
No bladder symptoms as resulting from the operation 
have been noted in any of the cases. 
The Suspensio-uteri Operation.—Technic: For 
convenience of description the 71 cases may be 
divided into (1) those in which the uterus was sus- 
pended by attaching the fundus uteri to the parietal 
peritoneum, and (2) those in which suspension was 
accomplished by sewing the round or ovarian liga- 
ments to the parietal peritoneum. 
1. Of this class there were 58 cases, divided into 
11 for the posterior face of the fundus, 11 for the 
top of the fundus, and 36 for the anterior face of the 
fundus. Permanent ligatures of silk or silkworm gut passing through muscle and fascia as well as perito- 
neum and constituting ventral fixation, were em- 
ployed only seven times. Both ovaries and tubes 
were removed in two of these and one or both ova- 
ries resected in the others. It is interesting to note 
here that only one of these patients has since become 
pregnant, and she was reported by her physician as 
having had pain during early pregnancy, but later to 
be entirely free from it. This was a case of extensive 
suppuration following pelvic abscess, where the ad- 
hesions between the fundus and the parietes must 
have been very dense. 
The usual method of operating is as follows: Un- 
less there is much work to do in the pelvis in the 
way of operating on the ovaries and tubes, the in- 
cision is short, six centimeters, in the median line, 
with its lower end not nearer than three centimeters 
to the symphysis pubis. The uterus is brought up 
to the abdominal wound by two fingers of the opera- 
tor’s left hand. A slender, full-curved needle with 
a round point, and threaded with a carrying thread, 
is passed through the transversalis fascia and peri- 
toneum at a distance of one centimeter from the right 
edge of the incision, then through a deep bite of the 
fundus uteri, and finally through the peritoneum and 
transversalis fascia on the left edge of the incision. 
The carrying thread is used to draw through a strand 
of No. 2 or No. 3 chromicised catgut. Two or three 
stitches are inserted, that through the top of the 
fundus being quite superficial in the uterine tissue. 
Care is observed in not interfering with the uterine 
ends of the tubes and in not attaching the fundus too 
close to the pubes. Tying the uterine sutures closes 9 
the peritoneum except for a short space in the upper 
part of the wound, which is closed with a continuous 
stitch of fine catgut. The linea alba is dissected out 
and the bellies of the recti are approximated by two 
or three interrupted stitches of No. 2 chromicised 
catgut, each stitch catching up the underlying peri- 
toneum so as to leave no dead space. The fascia is 
closed by a continuous suture of the same material 
and the skin by a subcutaneous right-angled silk- 
worm-gut suture. Dressings of dry powder on the 
line of the wound and dry sterile gauze stuck to the 
surrounding skin by corrosive collodion. 
2. By the round or ovarian ligaments, 13 cases, 8 
of the former and sof the latter. The incision into 
the peritoneal cavity is the same as in suspension of 
the fundus. If by the round ligaments, the liga- 
ment on one side is pierced at a point three centi- 
meters from the uterus by a round-pointed, full- 
curved needle carrying fine silk. The needle is then 
made to pierce the peritoneum and overlying trans- 
versalis fascia at a point two centimeters outside of 
the line of the abdominal incision and five centi- 
meters from the symphysis pubis. Another stitch is 
placed on this side and two similar stitches on the 
opposite ligament and all are tied. In cases where 
the ovarian ligaments are very long, allowing com- 
plete prolapse of the ovaries, the same procedure is 
carried out with the ovarian ligaments as with the 
round ligaments, two fine silk stitches to each liga- 
ment being used. The abdominal wound is closed 
and dressed as in the other form of suspension. 
Glancing over the tables it appears that in 40 
cases suspension was done for retroversion, retro- flexion, or retroposition accompanied by more or less 
extensive adhesions; in 19 cases for retroversion, re- 
troflexion, or retroposition without adhesions; in 6 
cases for prolapse; and in 6 cases to prevent ovarian 
prolapse, or, after the removal of severe grades of 
inflammatory affections of the ovaries and tubes, to 
prevent retroversion of the uterus into the raw sur- 
face left by their removal. Both tubes and ovaries 
were removed in 13 cases, one ovary in 34 cases, 
the ovaries and tubes were resected in 17 cases, and 
nothing was done to the ovaries or tubes in 15 cases. 
Every effort was made to preserve some healthy 
ovarian tissue and, considering the severity of many 
of the cases, the number in which both ovaries and 
tubes were removed is a small one. 
The immediate results were good in every one 
of the 71 patients except that 5 had mural ab- 
scesses. As far as the uterus was concerned it was 
suspended in good position at the time of the pa- 
tient’s discharge. As regards symptoms, the pain 
immediately following was inconsiderable in al- 
most all. A few patients complained of a drawing 
feeling in the uterine region on coughing and sneez- 
ing during the first days after being up and about. 
In no case was there interference with micturition. 
Subsequent pregnancy has resulted in 7 cases, or 12 
per cent. Of these, 5 women have had normal preg- 
nancies and normal labors, and one of them is now 
five-months’ pregnant for the second time, and is not 
having pain. The remaining 2of the 7 are now preg- 
nant. One, four months along, is having no special 
symptoms to mark this pregnancy from her former 
ones; the other, six months along, has already been 11 
referred to as having had pains but as now free from 
them. 
In the 5 cases in which normal pregnancy and 
labor has taken place the uterus was found in good 
position two months after labor in one, a case of 
suspension by the anterior face of the fundus, and 
in another, a case of suspension by the round liga- 
ments, the uterus was found retroverted two years 
later. One of the remaining three is now pregnant 
again, and of the other two it has been impossible to 
obtain the facts because the patients live at a dis- 
tance. 
When we take into account the fact that a major- 
ity of the suspension operations have been done dur- 
ing the past year and a half, it is not surprising that 
fewer of these women have become pregnant than 
has been the case with those upon whom the Alex- 
ander operation was performed, to say nothing of the 
suspension operation having been accompanied by 
the removal of one or both ovaries in 66 per cent, of 
the cases as against the Alexander, in which, with one 
exception, the ovaries and tubes were not operated 
upon. 
Of the 60 patients examined as to ultimate results, 
the results were good in 56 and bad in 4. Four 
of the 12 patients counted as unknown, wrote that 
they were relieved of their symptoms. Not in- 
cluding these we have 93 per cent, of good results 
and 7 per cent, of failures. Only one of the failures 
followed pregnancy, and that one was a case of sus- 
pension by means of the round ligaments. In an- 
other, also a suspension by means of the round liga- 
ments, the ligaments gave way ultimately. The other two suspensions were by the anterior and top 
of the fundus. In one there was suppuration in the 
wound, while in the other, the union was by first in- 
tention, but there was a question as to the patient 
having had an abortion not long after the operation. 
There was a small hernia in the cicatrix in one case 
two years after the operation. There had been sup- 
puration in this wound while the patient was in the 
hospital. In no case were there symptoms pointing 
to strangulation of a loop or loops of intestine due 
to the suspending ligaments or bands. 
In contrasting the Alexander with the suspension 
operation as to immediate and remote results one is 
impressed at the outset with the fallacy of statistics. 
Knowing as we do that many of the Alexander oper- 
ations have been performed on patients upon whom, 
in the light of a larger experience, we should elect 
to do the suspension operation, and also that the 
Alexander operations on my list having been begun 
so much before the suspensions that there has been 
with the former a longer period of time in which to 
allow of pregnancy to occur and of late results to be 
gathered, we are prepared to have the Alexander 
operations make a poorer showing. The immediate 
results of the Alexander operations were 92 per cent, 
good, as against xoo per cent, good for the suspen- 
sions. The remote results of the Alexander opera- 
tions were 77 per cent, good, as against 93 
per cent, good for the suspensions. Hernia fol- 
lowed the Alexander operation in 3 per cent., 
and the suspensio uteri in 1.7 per cent. Twen- 
ty-five per cent, of the subjects upon whom the 
Alexander operation was done who became pregnant had tedious labors. No tedious labors after the sus- 
pensio-uteri operation have been noted. One of 
each class of patients had excessive pains during the 
early months of a subsequent pregnancy. One-third 
of the Alexander subjects had the uterus retroverted 
after labor. In the suspension cases the statistics as 
to this fact are defective. Only one patient was 
known to have had retroversion following labor. 
Pains in the scars have been noted after certain of 
the earlier Alexander operations, and rarely these 
pains have persisted a considerable length of time. 
These may be contrasted with the drawing sensation 
noted after some of the suspension operations, but the 
drawing sensation has never been of more than tem- 
porary duration. After neither operation was there 
interference with micturition, and neither operation 
was the cause of abortion or miscarriage. 
General conclusions: (i) The Alexander opera- 
tion is preferable to the suspensio-uteri operation 
because it seeks to support the uterus by its natural 
ligaments. (2) The Alexander operation is indi- 
cated in retroversion, retroflexion, and retroposition 
without ovarian disease. (3) In retroposition with 
tight uterosacral ligaments posterior colpotomy for 
the purpose of dividing the tight ligaments may be 
performed with advantage, together with the Alex- 
ander operation. (4) In ovarian prolapse, espe- 
cially if the ovarian ligaments are long, the Alexan- 
der operation cannot be depended on to raise the 
ovaries into a normal position. (5) One round liga- 
ment is not sufficent to maintain the uterus in place. 
(6) The Edebohls’ operation, although requiring a 
longer time for its performance than the operation at 14 
the external ring, is the preferable operation because 
by it the round ligament, being uncovered in the en- 
tire length of the inguinal canal is less liable to be 
broken; also, because this method does away with 
the need of anteverting the uterus bimanually in 
the course of the operation; and finally, because of 
the secure manner in which the ligament is anchored 
and the inguinal canal closed, making subsequent 
hernia impossible. (7) Although the Alexander 
operation leaves two scars on the abdomen, they are 
so situated as to be covered by the pubic hair and 
are subsequently less of a disfigurement than is one 
scar in the median line. (8) The suspensio-uteri 
operation is indicated in retroversion, retroflexion, 
and retroposition with ovarian or tubal disease, 
whether inflammatory affections or prolapse. (9) 
The best method of performing the suspension is by 
means of absorbable ligatures passed through the 
anterior and upper portions of the fundus uteri and 
through the parietal peritoneum and transversalis 
fascia only. Thus an elastic band is created between 
the parietes and the uterus which maintains the 
uterus in place and does not cause interference with 
the enlargement of the anterior fundus during subse- 
quent pregnancy. (10) Suspensio uteri leaves but 
one weak spot in the abdominal parietes predispos- 
ing to hernia, instead of two, as in the Alexander 
operation, (n) In the great majority of cases, 
neither operation is the cause of complications in 
subsequent pregnancy. Whatever complications do 
occur are not of a serious nature. (12) In all cases 
of doubtful diagnosis in which the condition of the 
ovaries and tubes cannot be determined accurately the suspensio-uteri operation is to be preferred to 
the Alexander operation. The Medical News. 
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