Ventrofixation and Alexander’s 
Operation Compared 
BY 
A. LAPTHORN SMITH 
B.A., M.D., M.R S.C.S. England 
Fellow of the. American Gynecological 
Society ; President of the American 
Electro-Therapeutic Association ; Sur- 
geon-in-Chief of the Samaritan Hospital 
for Women, Montreal; Gynecologist to 
the Western Hospital, Montreal, and to 
the Montreal Dispensary ; ex-Professor 
of Gynecology in Bishop’s University, 
Montreal 
RF.PRINTED FROM 
The American Journal op Obstetrics 
VoU XXXII. No. 2.1805. 
NEW VOBH 
WILIJaM WOOD & COMPANY, PUBLISHERS 
1895 VENTROFIXATION AND ALEXANDER’S OPERATION 
COMPARED.1 
Comparatively limited as my experience lias been with these 
two operations, yet it might be of interest to the Society to give 
that experience and the conclusions which I have drawn from 
having performed one or the other of them forty-nine times. 
I need not take up the time of such learned men as these 
around me in pointing out the necessity for this or any opera- 
tion for the cure of retroversion. When 1 say that I have only 
performed the Alexander operation twenty-one times and ven- 
trofixation twenty-eight times in the last five years, while during 
that time I must have attended many hundred cases of this dis- 
ease, it is evident that I only considered a small number of them 
as being subjects for operative treatment. Many cases have 
come before my notice in which the retroversion was discovered 
incidentally and caused no symptoms whatever. Others, suffer- 
ing from slight symptoms, were easily cured, simply by replac- 
ing the displaced organ and by removing the cause which 
brought the condition about. Others, again, failed to be cured 
by such simple measures and required the prolonged use of the 
tampon, and others of the pessary. It was only in those cases 
which were not benefited by these means that I resorted to the 
operation. If there are those who doubt the necessity of treat- 
ing this condition at all, as I believe there are a few, let me re- 
mind them that a woman with retroversion sometimes suffers 
so acutely and constantly as to be really an object of pity. Not 
only is the circulation of the uterus greatly interfered with by 
the kinking of the vessels in the broad ligaments and by the 
pressure of the fundus on the uterine veins, but also the bladder 
is frequently irritated by the pressure of the cervix on its neck, 
and the bowel also by the pressure of the heavy fundus on the 
rectum, which is in some cases sufficient to completely obstruct 
all passage through the bowel, the patient constantly experienc- 
1 Read before the American Gynecological Society at the meeting in Balti- 
more, May 28th, 1895. 2 
SMITH : VENTROFIXATION AND 
ing a feeling of tenesmus or bearing down, the obstacle to defeca- 
tion being present even when the bowels are in a liquid condi- 
tion. But the worst symptoms, perhaps, are the reflex ones 
caused by the pressure of the uterus on the branches of the 
great sympathetic nerve, leading to distention and sluggishness 
of the bowels, dyspepsia, palpitation of the heart, disorders of 
vision, and headaches. Neither must wTe forget that the retro- 
verted uterus and ovaries are often so painful as to offer an in- 
surmountable barrier to sexual intercourse. 
Of the many claims to our gratitude which Dr. Howard Kelly 
has won I think this the greatest, for of all the operations which 
I have ever performed the one which has afforded me the great- 
est satisfaction is ventrofixation of the uterus. The satisfaction 
comes from three distinct sources : first, from its effectiveness 
in accomplishing the object desired ; second, in accomplishing 
it with the smallest possible risk to the patient; and, third, in 
effecting it with the greatest possible ease to the operator. 
I shall now consider each of these points in detail. First, its 
efficiency. When a woman consults us for retroversion of the 
uterus, for prolapse, or even for procidentia—using this term to 
mean falling of the womb in which the organ projects more or 
less from the vulva—we may treat her in several different ways. 
We may advise her to wear a tight T or perineal bandage ; this 
of course is the poorest kind of a makeshift and one which few 
women would be content with. We may replace it and keep it 
up by means of cotton or woollen pads, which are, however, very 
unsatisfactory for the reason that the vulva in many cases is large 
and relaxed; the tampon will only remain in for a short time, 
dropping out either while she is walking or at the next effort at 
defecation. Even if the tampon, when accompanied by the 
perineal pad which keeps the tampon in, were effective, there 
would still be the great objection that its use necessitated the 
spending of much of the unhappy woman’s time in journeying 
to and fro to the dispensary or consulting room. This method 
never cures, and the patient sooner or later becomes tired of it 
and abandons it altogether. The next best treatment is the 
pessary, but this has been abandoned by most specialists, al- 
though practised still bv some general practitioners. The pes- 
sary hasqnany objections. First of all, if the ovaries and tubes 
are inflamed and bound down by adhesions the pessary cannot 
be borne, and as a rule the patient returns in a few hours or in Alexander’s operation compared. 
3 
a few days, stating that she cannot bear the pain of it, and she 
will with good reason blame us for making her worse. Second, 
even if there were no inflammation or adhesions and the uterus 
and appendages were freely movable, the vaginal outlet, as a 
rule, is too large to prevent the pessary from coming out, or, if 
not already so, the pressure exercised by the pessary will distend 
it until it drops out, and then larger and larger ones must be 
introduced. Even when the vulva is small, as in virgins, and 
the pessary can be worn by the patient, she must come at regular 
intervals to the physician’s office to have it cleansed and reintro- 
duced; it is more or less a constant source of irritation and is 
apt to cause leucorrliea, which in many cases I have seen be- 
come purulent; in other cases it becomes encrusted with phos- 
phatic deposits, rendering it exceedingly irritating ; cases are 
even on record in which the pessary, when not regularly attended 
to, has ulcerated through the vaginal wall until malignant dis- 
ease has been set up, and in other cases it has worked its way 
clear through the vagina to the abdominal cavity, whence it has 
been removed by abdominal section. Third, the pessary inter- 
feres more or less with sexual intercourse, while most women 
feel uncomfortable at the very idea of having an instrument in- 
side of them and are always glad to dispense with it as soon as 
possible. To give the pessary its due, however, we must admit 
that a few cases of retroversion and prolapse are cured after 
three months’ toayear’s useof it, but in the meantime, of course, 
the uterus comes down again when the pessary is removed. It 
is most useful in temporary cases, such as when the womb falls 
because it has become pregnant and heavy ; in such cases the 
pessary is useful to hold the womb up until the end of the 
third month, after which by its size it will be prevented from 
falling backward or descending. One of the objections to the 
pessary can be remedied by reducing the size of the vaginal outlet 
by performing anterior and posterior colporrliaphy, or, in other 
words, sewing up the lacerated perineum and reducing the area 
of the anterior vaginal wall by means of Stoltz’s operation. 
Some have thought to cure the prolapse by this operation alone, 
but now all operators agree, especially Martin of Berlin, that no 
matter how much the vagina may be narrowed, even to the 
extent of closing it up altogether, as by Lefort’s operation— 
which, of course, is only applicable to old widows—the uterus 
will still come down and present at the vulva, By at the same 4 
SMITH : VENTROFIXATION AND 
time dilating, curetting, and repairing a lacerated cervix, or 
amputating it if there is much cystic disease, the weight of the 
organ is reduced so much that the weak and relaxed ligaments 
are sometimes able to hold it up, but more often it drops again 
in spite of everything. 
There remain three other procedures which are effective and 
which I shall mention in the order of their gravity—first, re- 
moval of the uterus by the abdomen or by the vagina ; second, 
Alexander’s operation ; and, third, ventrofixation. 
Although the removal of the retroverted or prolapsed uterus 
by the vagina is a much safer operation than when it is per- 
formed for a cancer or fibroids, owing to the facility with which 
it may be brought dowm and all bleeding points seen and secured, 
and also to the greater certainty of accomplishing asepsis, yet we 
are hardly justified in resorting to it or to any operation in which 
the danger is so much greater than is the simple fastening of the 
uterus to the abdominal wall; while, when the appendages are 
diseased and the uterus is firmly attached with them to the sacrum 
or rectum, I have no hesitation in saying that the abdominal route 
is much more rational than the vaginal one. Even the authors 
of the latter method—Segond, Richelot, and Pean—admit that 
they are frequently obliged to leave portions of the diseased 
structures adherent to the intestines. But even when there are 
no adhesions, is removal of the uterus and appendages always 
effective for curing prolapse of the pelvic contents? True, the 
uterus when removed can no longer prolapse, but the uterus is 
not the only organ there ; even after its removal the woman may 
have prolapse of the pelvic floor, unless care is taken to sew the 
broad ligaments together, which is seldom done, although for 
my own part I make a practice of doing so when I remove the 
entire uterus by the vagina. But with ventrofixation not only 
is the entire uterus preserved and held up, but also the bladder, 
vagina, and small intestines are equally supported. 
When we compare ventrofixation with Alexander’s operation 
as regards efficiency, ventrofixation has one great advantage. 
Alexander’s operation is a complete failure in all cases in which 
the uterus, or even the ovaries and tubes, are adherent. True, 
Alexander’s operation was never meant for such cases, and no 
one would knowingly do it when the uterus is fixed. But some- 
times the uterus appears movable and yet the mobility is very 
limited, and when we attempt to draw the fundus up to the Alexander’s operation compared. 
5 
abdominal wall by means of the round ligaments the latter will 
break sooner than the adhesions will. These adhesions which 
anchor the uterus explain some of the frequent failures of Alex- 
ander’s operation ; when there were no adhesions I have found 
Alexander’s operation very effective in holding up the uterus. 
I have never had hernia after it, and I have only known of one 
relapse out of twenty-one cases. 
One objection to Alexander’s operation is that the round mus- 
cles, when they have not contracted for a long time, become 
fatty and break when pulled upon. There is another objection 
to Alexander’s operation which does not apply to ventrofixation, 
and that is the pain and numbness of the groins and labia due to 
the severing of the nerve running along the round ligaments, of 
which several of my patients have complained. 
Now, if we look at the two operations of ventrofixation and 
Alexander’s from the standpoint of the risk to the patient, one 
might think at first sight that in this one respect, at least, the 
odds were in favor of Alexander’s operation. But this is not the 
case. If there are no adhesions of the uterus, and the ovaries 
and tubes are not attached, the mere opening of the abdomen 
and fixation of the uterus under the rigorous aseptic precautions 
which we now employ is absolutely devoid of danger; while if 
there are adhesions it is ever so much safer to detach them with 
the fingers in the abdomen than to replace the uterus with the 
sound. At least one case has come to my knowledge of death 
from this procedure. Neither is Alexander’s operation entirely 
devoid of risk, if not to the patient’s life, at least to her comfort. 
A number of cases have come to my knowledge in which single 
or double inguinal hernia has followed—this, of course, should 
never happen, but the fact remains that it has happened ; and a 
great many cases have been followed by suppuration, this having 
occurred in one of my own cases, while in a case under the care 
of a colleague the suppuration spread down between the folds of 
the broad ligaments, causing a true pelvic abscess. A few cases 
of death even have been recorded as having followed Alexander’s 
operation; but it is only fair to say that since writing this paper 
I have heard of a case of death in Baltimore following ventro- 
fixation from bleeding from the needleholes into the uterus, 
although I cannot understand how that accident could have 
happened. It must be distinctly understood that when ventro- 
fixation is performed, for removal of pus tubes or tearing away 6 
SMITH : VENTROFIXATION AND 
of adherent ovaries, it then assumes the mortality of the larger 
operation, which is greater or less according to who the ope- 
rator is. 
When we compare the operation from the point of view of 
the ease with which it can be performed, Alexander’s operation 
is hors de combat. I was so fortunate at first in quickly finding 
the round ligaments and drawing them out that I could hardly 
believe that any skilled operator could have any difficulty in 
doing so; but after coming across two or three cases in succes- 
sion in which the ligament broke on the slightest traction, I was 
compelled to open the abdomen and complete the Alexander 
operation by doing ventrofixation. I have also spent as much 
as one hour in finding the two ligaments, and I have seen other 
operators spend even more time and yet fail to get the uterus 
forward, the incision having to be closed without curing the re- 
troversion. I have, indeed, heard one quite well-known surgeon 
say, after searching for the ligaments for one hour and a half in 
vain, that he had tried it for the last time. 
If the uterus wrere alw7ays free from adhesions when it appears 
so, and the round muscles always healthy, red, fleshy, and fairly 
strong bodies, there would be no difficulty in finding them and 
draw'ing them out. But, as a rule, in chronic cases of retrover- 
sion the muscle has not contracted for weeks, months, or years; 
the inevitable result is, of course, fatty degeneration. Ventro- 
fixation, on the contrary, I have always found extremely easy. 
It can frequently be performed in from ten to fifteen minutes 
with an expenditure of less than an ounce of A. C. E. mixture. 
There is never any doubt about finding the uterus, and, when 
found, never any difficulty about drawing it up ; when performed 
in the Trendelenburg posture it affords us an opportunity of 
examining the tubes and ovaries and of repairing them when 
necessary. 
I cannot reconcile myself to the belief that so serious a muti- 
lation as total extirpation for retroversion or prolapse is justi- 
fiable when such serious results may be avoided by the operation 
which I have just pointed out. My own course has been, when 
the case requires it, to perform, first, rapid dilatation ; second, 
curetting, with the application of pure carbolic acid and tincture 
of iodine to every part of the endometrium; third, repair of the 
lacerated cervix; fourth, closure or narrowing of the anterior 
and posterior vaginal wall; fifth, opening the abdomen and libe- Alexander’s operation compared. 
7 
rating the uterus from its adhesion, and at the same time remov- 
ing the appendages or as much, of them as are diseased ; and, 
sixth, fastening the uterus to the abdominal wall—all of which 
can be done in a little over an hour. My results in such cases, 
as I stated at the outset, have been most gratifying. 
The objection is sometimes made that the uterus is a movable 
organ and should not be fixed in an immovable position. While 
this may be admitted, I am in a position to state that ventrofixa- 
tion does not put the uterus in an immovable position, for in the 
one and only case of failure, which a year later necessitated my 
reopening the abdomen, I had an opportunity to see that the 
uterus was hanging by a cord as thick as a lead pencil, extending 
exactly from the place where I had fastened it behind the pubis 
to the anterior surface of the uterus. Tn many cases, on exam- 
ining the patient with the Sims speculum I could see the nor- 
mal amount of to-and-fro movement of the organ taking place. 
The union allows free movement to the uterus and in no way 
interferes with pregnancy. 
• Just a few words now as to the method of operating. After 
the usual aseptic precautions a small opening is made in the 
abdomen, about one and a half or two inches being sufficient to 
admit two fingers, with which the uterus is lifted up, the adhe- 
sions torn away, if there are any, and the ovaries and tubes ex- 
amined. While held up by the fingers the fundus is caught by 
the bullet forceps just in the centre and held in the incision, 
while a space of a square inch is scarified with the point of the 
scalpel. It is then lowered for a moment while the correspond- 
ing surface of the abdominal peritoneum is treated in the same 
manner, thus insuring broad and strong adhering surfaces. It is 
then drawn up again, while two well-sterilized silk ligatures are 
passed through the fascia, then through the anterior wall of the 
uterus, and then through the fascia of the other side, tied and 
cut short to be left in permanently. In two cases I used silk- 
worm gut for this purpose, but this caused trouble and I aban- 
doned it; in more than half the cases I did not leave any perma- 
nent ligatures in, and it was in one of these that the failure 
occurred. The abdominal wall is then closed according to the 
taste of the operator, my preference being given to the through- 
and-through silkworm-gut sutures, which I invariably leave in 
one month, by which time the exudation tissue has formed and 
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