ORIGINAL ARTICLES.

laws of structure, form, relations, etc., toward the accomplishment of the special work de

VULSION OF THE CERVIX UTERI

CORRECT AND RATIONAL IN PRINCIPAL, JUSTIFIABLE IN

APPLICATION?

BY GEORGE F. HULBERT, M.D.

Read before the St. Louis Medical Society, Nov. 3, 1887.

The subject of divulsion of the cervix uteri being, in my opinion, one of pronounced import both to the patient and physician, I desire to make a more formal and extensive reply to the paper read before this society by our respected friend Dr. Y. H. Bond than I was prepared to do at the time of its presentation. In doing so I shall confine myself to the pathological conditions mentioned in the aforementioned paper, as follows: Flexions, conical cervix, strictures and dysmenorrhea, and answer the question propounded in the title of my paper.

In order that I may not be misunderstood, I desire to remark that I speak of the operation of divulsion, not dilatation carried only to the point of the existing physiological limit of the internal sphincter or cervix.

The object to be accomplished in all these pathological condititions I understand to be to overcome a supposed obstacle to the discharge of the menstrual flow, and not so especially to rectify the abnormal changes in form and structure. While this is the platform the divulsionist stands on primarily, he also claims that these changes in form and structure secondarily do, by some mysterious hidden process, disappear, and the natural order of things becomes re-established.

The principle involved in this declaration is that divulsion removes the offence to nature and restores the normal performance of her functions in the most efficient and effective manner possible.

In order that we may have a clear conception of nature and a natural order of things, as manifest in the uturus, as well as receive the full import and necessity of established

the wise provision which has been made to meet a possible environment that may become established, I desire to present some thoughts, facts and illustrations, which will remove, I think, our protest against divulsion out of the realm of mere theory.

A glance at the history of gynecology will convince the mind that delusions and vaga. ries have ruled and had their day only too often. The result of this has been discredit to the specialty and gross abuse of the patient on the part of the specialist. One of the chief reasons of this lamentable state of affairs is due to the fact of a want of any definite or well grounded principle of truth in the work done. We have reasoned from effect to cause rather than from cause to effect. We all of us speak of imitating nature in means of relief, but in practice hardly reach the goal. There was a time when slitting the cervix wide open was the operation; now we have divulsion as the operation. The truth or the fact as to whether any procedure applied as a means of relief is correct and right, ought to be established by study of the uniformity of law and phenomena in nature and the manner in which she works, her wonders to perform. When we understand these, we can intelligently make the application. If the application results in a restoration of the natural order of things, it is simply due to the fact that truth is applied, whether the user knows it or not. A study of the uterine body in the virgin state especially, has been to me a matter of great interest, and in its normal condition and performance of its functions, indicated the manner in which very largely, and what the means of relief from disease should be. How often has the question been asked, Of what use or benefit is the cervix of the uterus? What is its object and purpose in the economy? I am of the opinion that it has a purpose, a necessary one; that in the entire organ there are clear evidences of a design for certain objects, that in the

branching off from the original. This grooving results in elevations or ridges. None of these ridges or grooves save the central ones on the median ridge reach to or terminate at the outer margin of the internal os. These ridges and gooves, save the central ones on the median ridge, which start from the posterior wall of the cavity of the cervix, are continued up and outwards to the lateral walls, where they turn down and inwards to return to the same position on the opposite or anterior wall of the cervical cavity. These are the so-called palmæ plicatæ. This arrangement of the endocervical cavity gives us a state of affairs supposed to assist and promote the passage of the spermatozoids toward the cavity of the uterus.

FIG. 2. A, Grooves or depressions. B, Elevations or ridges, taken from the normal. As a matter of fact we find in this cervical

cavity as perfect an application of the principles of dynamics, as one could conceive. All these grooves and ridges tending to force outward any contents when the longitudinal and circular fibers are brought into play. The following cuts represent a posterior and lateral view of this arrangement.

With the above before us we are prepared to apply the knowledge given us in the department of hydrodynamics.'

"By use of Torricelli's theorem we find the velocity of efflux of liquids from containers, as being analogous to the object to which we

wish to make the application. Let us take a vessel containing water, make a hole in the bottom, and consider the case of a particle of liquid on the surface. If this particle fell freely it would have a velocity on reaching the orifice equal to that of any other body falling through the distance between the level of the liquid and the orifice. This, from the laws of falling bodies, is 2 g h, in which g is the acceleration in ft. per second, and h the height. If the liquid be maintained at the same level by a supply of water from above, the particles will follow one another with the same velocity. The law is as follows: The velocity of efflux is the velocity a freely falling body would have on reaching the orifice after having started from a state of rest at the surface. Thus it will be seen the velocity will depend upon the depth of the orifice from the surface, and further we are taught that with liquids of different density the velocity is the same, provided the liquid is of the same depth, and the orifice of the same size. It also follows that velocities of efflux are directly proportional to square roots of the depth of the orifice."

"Water would flow from an orifice 100 inches below the surface with ten times the velocity it would from one inch below."

Understanding the laws governing the velocity of efflux, let us examine the laws of quantity of efflux.

"If we suppose the bottom of the vessel containing the water to be thin, and the orifice to be a small circle whose area is a, we would suppose the quantity of water discharged would be represented by the formula av/2 gh, since each particle has on the average a velocity equal toy/2g h, and parti cles issue from each point in the area in the orifice. But this is by no means true."

"In figure three let A B represent the opening in the bottom of the vessel. Every particle above A B endeavors to pass out of the vessel, and in doing so exerts a pressure on those near it. Those that issue near A and B exert pressure in the directions M M and N N, those near the centre of the orifice in the direction R O, those in the intermediate parts

in the directions P O and P O. In consequence the water within the space P O P is unable to escape and that which does escape, instead of assuming a cylindrical form, at first contracts, and takes the form of a truncated cone. It is found that the escaping jet continues to contract, until at a distance from the orifice about equal to the diameter of the orifice. This part of the jet is called the vena contracta."

It is found that the area of its smallest section is about 0.62 of that of the orifice. The true value of the efflux per second is therefore about 0.62 a 1/2 gh. or about 0.62 of the theoretical amount. This result is in the case of an orifice of a thin wall. If a cylindrical or conical efflux tube or ajutage is fitted to the aperture, the amount of the efflux is materi

the jet within the ajutage causes a vacuum, as can be readily shown by the contractions in the figure. If an aperture is made in the ajutage, near the point of greatest contraction, and is fitted with a vertical tube, the other end of which dips into water, it is found that the water rises in the vertical tube, thus proving the fact.

If the ajutage has the form of a conic frustum with the larger end at the aperture, provided the dimensions are properly chosen, the efflux in a second may be raised to 0.92 a

2 gh. If the smaller end is at the aperture the efflux may be still further increased and fall very little short of the theoretical amount, in both cases probably dependent on the influence of the vacuum in the ajutage. With

FIG. 3. A, Cast or mould (Schematic) of uterine and cervical cavities. B, Lateral surface of cervical cavity, showing the form of grooves and ridges.

ally increased, and in some cases falls but little short of the theoretical amount. A short cylindrical ajutage whose length is two to three times its diameter has been found to increase the efflux per second to about 0.82 a v/2 gh. In this case the water on entering the ajutage forms a contracted vein (see fig. 5) just as it would do on entering the air, but afterwards expands, and, in consequence of the adhesion of the liquid to the tube has on leaving the ajutage a section greater than that of the contracted vein. The contraction of

FIG. 4.

the above facts before us what lesson is rationally taught, in the form of the unimpregnated uterus, virgin or otherwise. Certainly a very striking one. We see first of all that the arrangement of the conic frusta has a meaning, that is to produce such a condition, that efflux of liquids is accomplished accordto fixed laws, that the operation of these laws is brought to the highest degree of efficiency possible. Every part of conformation is in perfect order for the work to be accomplished. See the sloping converging sides of the cavity to the internal os; thereby obviating the lateral pressure at the aperture seen in square bottomed containers, and concentrating the pressure more nearly in the form of a

column of the section of the aperture; the application of the smaller end of the conic frusta to the outer side of the orifice of cavities to be emptied, as at the opening of the Fallopian tubes, cavity of the uterus, and cavity of the cervix. Another advantage gained is the temperature of the liquid to flow out, it being well known that liquids of higher temperature flow with less friction, than those of lower. Another advantage produced by the projection of the cervix into the vagina, is the aspirating effect brought about by the application of the mucous membrane of the vagina to the external os in the movements of the body. The effect can be very readily illustrated by taking a tube of small caliber, closed at one end, filling it with water; now

A

FIG. 5. Vena contracta.

hold it upright and apply the surface of the finger to the lower end; break the contact, and liquid that would not come out, does so, repeat the procedure and the tube can be emp. tied. The normal position of the cervix is not one of contact against the posterior vaginal wall, but the movements of the body project the cervix against it, and every time contact is made this emptying of the os would be

favored.

The above is dependent upon the cohesive property in fluids. All these advantages coupled with the power of expulsion by muscular contraction inherent in the uterus as a whole,

blood pressure and gravity, certainly present an arrangement that is perfect. The limits of this paper will estop any extended notice of the other advantages and objects of a uterine cervix. I will only mention a few. The observed antagonism existing between the cervix and the body due to differences in nervous supply, is worthy of attention and serves to demonstrate the wise provision of two cavities. Opening in a forcible way the external cervix or irritation of the cervical cavity immediately produces a contraction at the body and internal os. This phenomenon is frequently manifest at unskilled and rough efforts in passing the sound. In some women it is so palpable that a diagnosis of stenosis is made. In this antagonism the purpose is manifest.

The cervical cavity is the antechamber, where passengers of all descriptions are examined, and, if found obnoxious, the effort is made to prevent further advance. What a beautiful arrangement to enter a protest against the rough, unskilled and unnecessary use of the uterine sound. Again the cervix is the fulcrum of support for the entire organ, and he who uses pessaries or supporting tampons should treat it with great consideration.

A study of the muscular structure of the cervix plainly shows the value of an intact cervix in promoting the ability of the body to serve as an erectile organ, and keep intact and in equilibrium the circulation. This fact we have seen established by the after results of incisions, or splitting of the cervical walls, and also in the results following lacerations at labor.

In the mucous membrane is another lesson taught. Observe the richness of power toward growth, and ability and care for the proper inhabitant of the cavity; examine the manner in which these characteristics are lost at the internal os; here we find only mucous tissue in its simplicity, few glands; the membrane intimately adherent to the underlying muscular tissues, smooth, everything tending toward a free exit or inlet, as far as this structure is concerned. The same is largely true at at the external os. In the cavity of the cer