TRANSACTIONS OF THE AMERICAN ASSOCIATION

ought to be accepted by this body. We might differ upon points of technic.

Dr. Goldspohn laid down principles many years ago and taught us a certain method of extension of the Alexander operation, which was very much of an improvement over the Alexander operation because of the cases that needed correction of complications, but he found complications extensive enough to give up the operation. We now have a method presented in Dr. Stark's paper that has all the objections of Dr. Goldspohn's method with a few added. I did the Goldspohn procedure for a number of years, and I much prefer it to the technic offered by Dr. Stark. I should feel that if I went back to the technic presented by Dr. Stark according to the description given, I would be going backward fifteen years. This talk about the round ligament not holding the uterus because they are not on tension is not tenable. Nothing is on absolute tension in the abdomen. We cannot say the mesentery does not hold the intestines because it is not drawn taut. guy-rope of a tent does not exert traction because we do not find it We cannot say that the drawn absolutely taut. There are other forces at work. There is the force of gravity of the rope, and the wind blowing the rope, and that may carry it in one direction or another. Nature says that these ligaments have an influence. Nature said it over again, so that finally animals that get somewhat in the upright position develop a little of the round ligament. In the human being, in whom the upright position is maintained, we have the greatest development of the round ligament. Nature said it was necessary that the uterus be anteverted and developed this ligament, which is the development of the upright position to drag the uterus forward, and it does that regardless of the fact that we do not find it in an absolutely taut position.

DR. GOLDSPOHN (closing). To add a few things I forgot in reading my paper. It is very important that the anchorage you make of the round ligaments is not over 3 centimeters above the upper border of the symphysis pubis. In my earlier years I did not know that and some of the cases are not so satisfactory. There is no retroversion, but the uterus will not stand so well anteverted.

I will say in regard to the primitive Alexander operation, which professed not to invade the peritoneal cavity, I have never had any use for that ideal of superficiality; and I condemn it now. outside of the limits of all thorough ideas of work. But I will do a It is thorough bi-inguinal laparotomy via the inguinal canals without cutting anything else than skin and superficial tissues in patients. who also have either a hernia or a disposition to one, either inguinal or femoral; because in closing that incision correctly I can cure these hernias at the same time. I can see no advantage in Dr. Stark's technic over my bi-inguinal operation; because, like the latter, it does not enable him to remove the appendix and to explore the general abdominal cavity. For that reason I do the bi-inguinal operation only rather exceptionally gall-bladder, common duct, pylorus or the kidneys, in addition I often want to explore the

to the routine removal of the appendix vermiformis in cases of this kind. We can do all this if we have a median incision. I have done a number of these operations by the transverse Pfannenstiel incision and anchored the round ligaments at the ends, but I do not like it. In the first place, the Pfannenstiel incision must be made quite low down if good anteversion of the uterus is to be secured, and then it does not provide good access to the appendix, unless the latter hangs down into the pelvis. In most cases it is an inconvenient if not an unsafe approach; and occasionally the appendix is found high up. I have had three cases where I removed the appendix from a point as high up as the normal position of the hepatic flexure of the colon, where the normal evolutionary migration of the colon had not been completed and the appendix had been left up at a high point. I had to extend the abdominal incision considerably in order to reach it.

The argument of Dr. Rosenthal strikes me forcibly as being such as I have heard in court. When an attorney has a bad case and has no logical argument to advance, he will put up a theory, and with a good deal of oratory will endeavor to make an impression, but the thing does not count in the end. I have never spoken of the round ligament as normally holding the uterus forward. I have never declared that I believed that the round ligament has either this or that function physiologically; but there is no reason under the sun why we should not give it a function when we have so good a reason for doing it harmlessly and changing its course from a lateral one to an anteroposterior one.

DR. STARK (closing the discussion).-I would like to go on a little bit where the previous speaker left off. I would consider it an imposition upon the intelligence of this audience were I to think anybody present believed that the round ligament had anything to do with the suspension of the uterus. I consider it entirely superfluous to discuss that phase of the subject but as the previous speaker has said, that is no reason why it should not be used as a guy rope to hold the uterus in proper position. If we were so placed as an engineer whose engine is out of order and could definitely locate the site of trouble, and remedy the same by correcting the obvious fault that would be a different matter, but you all know that we have not arrived at a definite conclusion as to what the physiological supports of the uterus are. The three commonly accepted factors are intraabdominal pressure, the ligamentous structures and the pelvic outlet. I believe that most of us are satisfied that intraabdominal pressure has nothing to do with the maintenance of the uterus in normal anteversion and flexion. We have retroversion of the uterus in women who have perfectly normal intraabdominal pressure.

The same is true of the pelvic outlet. We commonly find the uterus in normal position with a complete tear at the outlet. The probability is, that the factor that is responsible for the maintenance of the normal position of the uterus is the proper balance in the connective tissue plane of the uterus, the so-called retinaculum uterinum of Martin which surrounds the cervicouterine junction and ex

tends forward, backward and laterally to constitute the pelvic fascial plane. My belief is that posterior displacement of the uterus is principally due to a congenital or traumatic deficiency of the posterior fasciculi of the pelvic fascia. About a year and a half ago Reynolds directed our attention to the influence exerted by a defective anterior fascial plane upon the cervix, displacing it forward and thus favoring posterior rotation of the fundus, which I have also frequently been able to verify.

I am sorry, gentlemen, you cannot see the purpose of this modification of the Goldspohn operation. I am sorry, too, that Dr. Goldspohn departed from his operation, because he introduced one of the most valuable surgical innovations that any member of this Association has brought before us, and some day posterity will recognize it.

THE PATHOLOGY OF THE MAJOR VESTIBULAR DUCTS AND GLANDS.*

Historical.

BY

JAMES E. DAVIS, A. M., M. D.,

Detroit, Mich.

(With twenty-six illustrations.)

The earliest reference to the secretions of the vestibular glands was made perhaps by the old Greeks, Pythagoras, Hippocrates and Galen, who wrote of the outpouring or ejaculation of seminal secretion by many erotic women.

As early as 1621 Plazzoni had observed the openings of the ducts of the major vestibular glands. In 1627 Spigelius made a similar observation. Rhodius, in 1661, Rolfine in 1664, and de Graaf in 1672, also made similar observations of the duct outlets. Some of these authors described or observed the emptying of a clear fluid from the ducts.

Guichard Duverney was the first to successfully demonstrate a particular similarity of openings from the ducts of the right and left. glands. This observation, however, was made in the cow. He shared his find with his friend and student, Casper or Caspard Bartholinus (Bartholinus II) of Copenhagen, who was then stopping in Paris. There were three Bartholini of Copenhagen, all of whom were celebrated anatomists, and all were liberal contributors to medical literature. They were Caspard I, Thomas his son, Caspard II, son of Thomas and grandson of Caspard I. They were Danes by birth but Cosmopolites in their residence, studies and knowledge of languages, being fond of travel and quite at home in Germany, Italy and France. Gaspard II was born in Copenhagen in 1655.

*Read before the Twenty-ninth Annual Meeting of the American Association of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916.

In 1674, when but nineteen years old, he received from the king the honorary appointment as Professor of Philosophy at the University. For the next three years, he studied physics and anatomy at various universities in Europe, and in 1677 began to lecture on these subjects in Copenhagen. He was led by the celebrity of Duverney of Paris to go to that city and complete his medical education, but especially to enjoy the advantages afforded for the study of anatomy under this celebrated teacher who had graduated at Avignon when only nineteen and was, at this time, under twenty-eight years of age. Here, Bartholinus graduated with the degree of Doctor of Medicine in 1678. But before obtaining his degree he published at Rome in 1677 his little book, "De Ovariis Mulierum et Generatonius Historia," in which appears the first account of the racemose glands which bear his name. This work was republished in Amsterdam in 1678, in Neurbaum in 1679, and in Lyons in 1696, but is at the present time one of the rare many works of the three Bartholini. In 1680, Bartholin, while studying in Firenze Osp. S Maria Nuova, found a corresponding gland in a female corpse and observed there the sticky, slimy nature of the secretion. For nearly a quarter of a century he continued his studies in anatomy, lecturing regularly on this subject and on physics at the university, but in 1701, he practically retired from professional work having become greatly interested in politics. He died in 1738. Caspar Bartholin described the duct, also called ductus major Rivini and the gland (glandula vestibularis major) which is called by his name. The discovery of these structures is sometimes, however, erroneously credited to his father or grandfather. Duverney, himself in 1701, Haller, and others confirmed the correctness of Bartholin's contribution. In 1706, Morgagni contributed new knowledge of the structure of the glands and in 1775 Santorini pictured the gland apparatus. In 1745, Haller entirely denied the existence of these ducts and glands for he could find only the openings of the ducts which he plausibly considered from the mucous glands. Upon Haller's authority these glands were soon forgotten, but Sabatier in 1791, Guthrie in 1834, and Taylor in 1838, revived them again. But it was really Tiedmann's thorough work in 1840, done at the instigation of Fricke, which again reestablished the glands and their meaning. In 1842, J. Heiberg made a very careful research of the glands and their very dilatable excretory ducts. In 1840 Boys de Loury, and in 1841 Vidal, made surgical mention of cysts and abscesses of the labia majora, but they did not clearly differentiate the cases so as to make their records of value. There had been some cases of vulvovaginal gland disease