MECHANICAL OBSTRUCTION IN DISEASES OF 
THE UTERUS. 
BY 
GEORGE F. HULBERT, M.D., 
OF ST. LOUTSTSttr.' 
FROM 
THE MEDICAL NEWS, 
December 20, 1890. Reprinted from THE MEDICAL NEWS, December 20, 1890. 
MECHANICAL OBSTRUCTION IN DISEASES 
OF THE UTERUS.1 
BY GEORGE F. HULBERT, M.D., 
OF ST. LOUrS,'*MO. 
My observations of and experience with the dis- 
eases of the uterus in which mechanical obstruction, 
or its congener, stenosis of the canal, is considered 
to be the malady is so at variance with the consensus 
of medical opinion and practice, that I wish to make 
it a matter of record and open the door to criticism 
and correction, if such are deserved. 
It may be somewhat startling to many of those 
men whose reports of cases and operations relating 
to the subject under consideration so frequently 
appear in our medical journals, when we say that 
in more than ten thousand women coming under 
our care in hospital and private practice, a large 
proportion of whom suffered from uterine disease, 
we have not seen a single case which satisfied us 
that mechanical obstruction existed or was the dis- 
ease, although the phenomena supposedly attendant 
upon that condition were frequently observed; and 
that in over three hundred autopsies in which the 
1 Read at the sixteenth annual meeting of the Mississippi Val- 
ley Medical Association, Louisville, Kentucky, October 8, 9, and 
10, 1890. 2 
HULBERT, 
pelvic contents and conditions were carefully ex- 
amined, we have not found a single case which 
positively demonstrated that during life mechanical 
obstruction existed -that condition which has oc- 
cupied so much of the time and attention of gyne- 
cologists, and has been the fons et origo of so much 
operative procedure and instrumental paraphernalia. 
Such being our declaration, it becomes incum- 
bent upon us, in explanation, to present the reasons 
for " the faith that is in us." In doing so, we shall 
consider the subject under the following heads : 
1. The normal or natural order of things, as 
related to structure and function. 
2. The abnormal, pathological, or unnatural order 
of things, as related to structure, and the possibility 
or impossibility of, or interference with, the per- 
formance of function. 
3. The phenomena usually considered as due to 
"mechanical obstruction" and their accepted ex- 
planation. 
4. Our criticism and reconciliation of inconsis- 
tencies, based upon the facts and phenomena ob- 
served by us during life and in the dead-house. 
5. Conclusions. 
First. We may question if menstruation, as ob- 
served to-day, is a perfectly normal or natural 
phenomenon as far as it relates to the quantity of 
fluid discharged. Reasoning by analogy and from 
the purely physical standpoint, it certainly seems 
a strange straining of that universal uniformity of 
law and order in nature, that in the highest mam- 
malian this particular element in the functional 
phenomena should be so greatly and unnecessarily MECHANICAL OBSTRUCTION. 
3 
overdone. But it seems from the testimony at hand 
that such is the fact; that at the menstrual period 
in women we do have a more or less free discharge 
of fluid, instead of what seemingly should be a 
simple elimination or excretion. The conclusion, 
therefore, which we must reach, is that the organ 
which we are considering must be competent to 
discharge fluids. The reason that the uterus is 
composed of involuntary muscle is at once plain 
to any one who considers its other peculiar func- 
tion, gestation ; but the reason for its peculiar form, 
the arrangement of its cavities, the complicated in- 
terlacement of muscular fibres, the dual nervous 
supply, and the delicately-poised position in the 
body is not so evident. In our search for a reason 
for these things, it occurred to us that the uniformity 
of law and order in nature might be a possible ex- 
planation, and that in the physical laws and condi- 
tions governing the discharge of fluids would be 
found the answer to the query. Investigation in 
this direction led to the conviction that the appli- 
cation of the conic frusta to containers presented 
the most perfect conditions in order that the greatest 
velocity and quantity of discharge of fluids be 
attained. The laws and principles involved in this 
particular domain of physics presented a striking 
adaptation to the uterus, and seemed to offer a clear 
explanation. 
By reference to Fig. i this application may be seen. 
We have four apertures of exit, at D, E, C, and A. 
At the aperture of the Fallopian tubes ; at the internal 
os or sphincter, extending down to the line B; and 
at the external os extending into the vagina, we 4 
HULBERT, 
see the principle of the conic frusta applied with 
peculiar perfection. As to form, we see this at the 
internal os, C. It is also to be observed that that 
Fig. i. 
part of the entire canal which approaches each 
aperture is more or less perfectly tubular in form, MECHANICAL OBSTRUCTION. 
5 
thereby assuring a column of liquid above and pres- 
sure in the axis of exit. We also find that each 
aperture is provided with a well-developed muscular 
sphincter, covered with a thin, closely-adherent 
mucous membrane, which insures the even closure 
of the lips of the apertures, save at the external os, 
where other principles come into play, namely, that 
of aspiration by the contact of the os with the 
vaginal mucous membrane, and the elastic play 
insured by the uterine ligaments, the movements 
of respiration, and the general movements of the 
body. 
In estimating the capacity of the normal uterus 
by means of the above principles of hydrodynamics, 
it was found that the uterus was capable, with one- 
fourth of an inch aperture at the point of exit and 
one inch depth of cavity, with the resultant pres- 
sure of the column of liquid contained therein, of 
discharging 0.64541 cubic inch per second, or 
38,624.4 ounces during the twenty-four hours. Re- 
ducing the diameter of the ap rture to one-thirty- 
second of an inch, we find a capacity equal to 
603.493 ounces for twenty-four hours. In men- 
struation the average flow for twenty-four hours is 
from three to five ounces of fluid with a temperature 
of ioo° Fahr, and a specific gravity of 1-055. This 
gives the uterus a capacity to discharge about 600 
ounces more than it is required to discharge, with 
an aperture of one-thirty-second of an inch. 
It is also necessary to recall the peculiar arrange- 
ment of the muscular elements of the uterus, namely, 
longitudinal, oblique, and transverse muscular fibres 
intimately interlaced, establishing conditions which, 6 
HULBERT, 
in the presence of proper innervation and nutrition, 
insure the certainty of play of force. With peculiar 
strength is the fact of the dual nerve-supply, namely, 
a direct spinal supply to the cervix and a ganglionic 
supply to the body of the uterus, brought to mind 
in our application of these principles. The cervix, 
responsive to immediate reflex influences at the in- 
ternal sphincter, especially concerned in permitting 
exit and entrance under proper conditions; the 
body, under ganglionic innervation, concerned in 
the wonderful phenomena of creative energy, in the 
to-and-fro play of its forces annuls sufficient of 
the necessary antagonism to establish equilibrium 
in the performance of function, and menstruation 
becomes an unconscious experience in the life of 
women, save to the sense of sight. 
In the circulatory arrangement we see a still fur- 
ther application of our principles, in that the quan- 
tity of fluid is governed by a power inherent in the 
organs, so that in the presence of equilibrium of all 
else the supply and discharge are under perfect con- 
trol. 
As a last point under this head, we will recall the 
rhythmical intermittent discharge of the fluid during' 
menstruation, dependent upon the physiological 
action of the uterine circulation. It may be well 
termed the evidence of a uterine respiration, so to 
speak, by which the life of function is maintained. 
Second. From a pathological point of view, the 
conditions accepted as being the cause of mechanical 
obstruction are those that produce narrowing or 
closure of the uterine canal. These so far as de- 
scribed are flexions, conical cervix, pinhole os, and MECHANICAL OBSTRUCTION. 
7 
congenital or acquired partial or complete stenosis, 
the latter being synonymous with atresia. Some 
consider displacements without distortion of the 
canal as mechanical obstruction, but the presence 
of the open canal makes such claims inconsistent. 
However, those who have taken the latter position 
have made progress, and, in reality, their inconsis- 
tency has brought them, nearer the truth. 
The condition of flexion of the uterus has gener- 
ally been considered the typical one for mechanical 
obstruction; and we are presented with the flexed 
rubber tube as illustrating the condition. But this 
fails to illustrate the conditions as they actually 
exist. 
The manner in which a flexion is brought about 
is, we believe, in perfect accord with mechanical 
laws. Given that vicious constitutional condition, 
of which the local expression is debility of the 
uterine tissue and its supporting ligaments, called 
softness by Graily Hewitt, without which the de- 
velopment of a flexion is impossible, the first step is 
an excessive amount of blood in the parenchyma of 
the organ and its adnexa. This means lack of mus- 
cular tone and increased weight, causing the uterus, 
as a whole, to rest on the posterior and lower part 
of the pelvic floor; or, if the conditions are so for- 
tunate, on the lower uterine ligaments. The descent 
persisting and increasing, owing to the angle at 
which the cervix meets resistance, or to pressure on 
the fundus, the cervix or body must move either 
forward or backward, and the result is a flexion. 
This is a matter of time ; there is not sudden violent 
bending of the uterus, as occurs in the rubber tube, 8 
HULBERT, 
and the degree of bending is determined by the con- 
ditions of the uterine tissue. This bent position 
having been produced, a process of atrophy at the 
At A is seen the indentation where the normal tissue has atrophied. 
B and C show the hypertrophy in the posterior wall! 
concavity of the angle, and of elongation and hyper- 
trophy at the convexity, at once begins, and /ar/ 
/axsvzwith the bending the atrophy and hypertrophy 
proceed, so that in the process, when completed, 
that factor which is the essential cause in producing 
closure in the rubber tube, namely, the V-shaped 
wedge of tissue at the convexity of the angle, is not 
'present. This is shown by the accompanying cut 
(Fig- 2). 
The hypertrophy of the posterior wall is due, no 
doubt, to the constant efforts exerted to accomplish 
the function of menstruation under the changed 
conditions, and also by the constant irritation pro- MECHANICAL OBSTRUCTION. 
9 
duced at the point of impact on the floor of the 
pelvis. 
The atrophy of the anterior wall at the angle is in 
accordance with the well known effects of pressure 
and interference with nutrition. The disappearance 
of this wedge of tissue in the anterior wall at the site 
of the angle, in the final rearrangement and adapta- 
tion for function, results in the longitudinal and 
oblique fibres, anteriorly, having instead of two points 
of departure in contracting, as at the fundus and 
extremity of cervix, three points, namely, from 
fundus to angle, and from the angle to the extremity 
of the cervix, the ultimate result being the same in 
either case-pulling forward of the anterior segment 
of the tissue at the site of the angle. The posterior 
segment would follow, as it does in the rubber tube, 
on the simultaneous contraction of the longitudinal 
and oblique fibres, but for the interposition of the lateral 
segments, which does not occur in the rubber tube. 
Thus it is seen that with a fairly coordinate action 
of all the fibres in any particular transverse plane 
of the uterine body closure of the canal is simply 
impossible. Any angle in the direction of the 
canal must be more or less straightened, this result 
being dependent upon the area of uterine tissue 
brought into action. A perfect en masse contrac- 
tion of the organ must produce more or less straight- 
ening and patency of the canal dependent upon the 
amount of force exerted. 
This is illustrated by Fig. 3. 
To this antagonism of forces we can attribute the 
fact that in the most acute flexions the canal is not 10 
HULBERT, 
bent at an angle, but maintains the direction of the 
segment of a circle. 
Extreme degree of flexion-450 : O, showing the atrophy in the 
anterior wall at the site of flexion ; M, O, A, points of departure on 
the contraction of longitudinal and oblique fibres in the anterior 
wall. The interposition of the lateral wall between the anterior 
segment at O and the posterior at B makes it impossible for the 
inner surfaces at A and B to come in apposition, save by a domi- 
nant contraction of the sphincter fibres. 
In our examinations to determine the degree of 
flexion we frequently deceive ourselves, and speak 
of acute angles. As a matter of fact, it is rare 
that we meet with a flexion more acute than a 
right angle, and in an acute-angled flexion during 
life we not only would be sure to find the fundus in 
the position of an anteversion, but the os would 
be toward the meatus urinarius. 
Fig. 4 illustrates what would be present in a right- 
angle flexion : 
If the central line, D B (Fig. 4), of the fundus 
was brought forward, and placed on the line C B, 
Fig. 3, we would have the fundus about in the 
normal position in the body. Now, moving the MECHANICAL OBSTRUCTION. 
11 
central line of the cervix forward so that it rests on 
B, F, we would find that the prolongation of this 
line would make its exit at the anterior edge of the 
anus. This would represent a flexion with a right 
angle. Now place D B on MB (Fig. 5> 12 
HULBERT, 
the central line of the cervix on B F, and we have 
an angle of 450. In this case a prolongation of the 
central line of the cervix would pass out through the 
posterior commissure of the vulva. 
Fig. 5 shows an extreme degree of flexion, which 
is found only in the minority of cases. The proof 
of the disappearance of the tissue at the concavity 
of the angle of flexion is found in autopsies, and is 
demonstrated by straightening the bend and com- 
paring the anterior and posterior walls. We have 
seen some specimens in which the healthy tissue at 
the concavity was only one line in thickness. 
In order that the rubber tube should accord with 
the existing conditions, it is necessary to select one 
corresponding in the thickness of its walls and in its 
calibre with the normal uterus at the internal sphinc- 
ter, one which is elastic, one in which there is some 
means of producing the effects of the longitudinal 
and oblique fibres, and, lastly, one in which a suffi- 
cient amount of the wall at the concavity of the angle 
shall be removed corresponding to the absorbed and 
atrophied tissue at the site of the angle in the de- 
formed uterus. This done, the bent rubber tube 
will in a fair degree illustrate what takes place at 
menstruation in a flexed uterus. 
The action of the longitudinal fibres, as far as the 
anterior wall is concerned, can be produced by 
passing a few threads through the calibre of the tube, 
fixing it in the angle desired, which is usually not 
more acute than a right angle, and making traction 
on the threads in the line of each arm of the bent 
tube. It will be found that the obstruction even MECHANICAL OBSTRUCTION. 
13 
with this imperfect arrangement will be overcome, 
and that water will flow through the tube. 
This is illustrated by Fig. 6 : 
Fig. 6. 
The upper illustration shows the prepared tube ; at A, V-shaped 
wedge of the anterior wall removed. The lower illustration re- 
presents the same tube, bent at a right angle, and the effect pro- 
duced by traction on the threads in the line of each arm of the 
bent tube. The arms are firmly fixed in position in any sustain- 
ing apparatus, as a glass tube is slipped over and held by an 
assistant. 
Fig. 7. 
The closure on bending at B is readily understood, and the 
effect of removing the wedge-shaped piece of the anterior wall at 
A, as well as the influence of the longitudinal threads, is possibly 
better appreciated by the comparison. 14 
HULBERT, 
Fig. 7 illustrates the usual faulty method, save 
that the tube is of the proper dimensions to use 
in the above experiment. 
From the foregoing we conclude that in the 
abnormal deviations of direction which are found 
in flexions, nature in her conservatism still utilizes 
the principles and agencies present in the normal 
state, and thereby perpetuates the operation of 
natural laws and insures the performance of func- 
tion. 
Only by this conception are we able to account 
for the phenomena of normal menstruation so fre- 
quently found, certainly in fifty per cent, of women 
who have well-marked flexions. We have frequently 
seen women in whom it was possible to pass into 
the uterus only a small wire probe, who had at no 
time suffered from inconvenience during the men- 
strual flow. 
Upon the other conditions productive of mechan- 
ical obstruction there is this observation to make, 
namely, that at times there exists the capacity to dis- 
charge fluid blood, save in only one condition- 
atresia. All that the uterine canal can justly be 
called upon to permit to pass through it is fluid 
blood. If the passage of clots, mucous plugs, shreds 
of membranes, etc., are the evidences needed to 
establish the conditions for mechanical obstruction, 
then we are, indeed, undone. We respectfully sub- 
mit that such a demand is unreasonable, illogical, 
and unscientific. We conclude, therefore, that the 
passage of fluid blood is positive proof that there 
exists a capacity in all the above conditions, save 
that of atresia, for the performance of function. MECHANICAL OBSTRUCTION. 
15 
Third and fourth. Such being our conclusion, 
how do we account for the symptoms usually ascribed 
to mechanical obstructions, namely, pain, intermit- 
tent and scanty flow, relief from pain when the 
flow is present, and inability to pass the uterine 
sound ? The most radical of those who claim that 
flexions produce mechanical obstruction, freely ad- 
mit that where menstruation is normal and painless 
obstruction is not present. Stenosis being the con- 
dition considered necessary, by the "obstruction 
philosophy," in the absence of the diagnostic symp- 
toms mentioned above, there is, consequently, no 
stenosis; hence these diagnostic symptoms must be 
explained. 
We have seen from what has been presented the 
importance of that harmonious, perfect, involuntary, 
and unconscious rhythm of circulatory, muscular, 
and nutritive action found in health. As the dom- 
inant energizing factor we must look to the inherent 
quality of nutritive and nervous capability, and to 
this alone; and in grasping the full meaning of this 
we must go back to the quality of protoplasm before 
our position becomes rational. This is a universal 
principle so frequently lost sight of by us as gyne- 
cologists, that it is no surprise to see so much error 
and disappointment in our therapeutics, be they 
surgical or otherwise. 
We must go to the nervous system, especially the 
sympathetic, for the all-governing factor: to nutri- 
tion, as a whole, we must go for stability of function. 
The nerve-tone coupled with the resultant nutritive 
activity and power, both impressed, under favorable 
environment, with the capacity for a higher stand- 16 
HULBERT, 
ard, determines what shall be the future of every 
organism or part thereof. 
A woman born with and maintaining a standard 
degree of health will never be cursed with any of 
the conditions we are considering. But in those 
who are born without the standard, or who, by the 
vicissitudes and accidents of life, depart from per- 
fect health, in proportion to the deviation we will 
find the liability to and acquisition of these condi- 
tions. In these deviations from the standard degree 
of health we find lowered nerve and nutritive tone, 
manifested by irregular and erratic innervation, re- 
sulting in irregu'ar, incoordinate action, increased 
irritability, irregular circulation and muscular action, 
pain, spasm, and relaxation, alterations of secretion, 
rapid exhaustion, slow recuperation, imperfect re 
pair, insuring debility, fatigue, pain, and disorder in 
the accomplishment of function. These are the real 
factors in the dysmenorrhoea of so-called mechanical 
obstruction. These, and not stenosis, are the disease. 
In the functional antagonism between the cervix 
and the body of the uterus we find the immediate 
cause of all the symptoms attendant upon mechanical 
dysmenorrhoea. Irritation or dilatation of the cer- 
vix produces contraction of the cervix. This physi- 
ologically and anatomically demonstrable fact, 
which, if sought for, is always found antedating and 
associated with mechanical dysmenorrhoea, when 
followed to its reasonable and logical conclusion, 
proves that mechanical obstruction, as at present 
generally accepted, does not exist save in that con- 
dition termed atresia. 
The constitutional condition means increased MECHANICAL OBSTRUCTION. 
17 
local irritability and lowered nutrition. This begets 
irreg-ular and spasmodic muscular and circulatory 
action, with altered excessive or scanty secretion 
and excretion. The excessive flow, the blood-clots, 
the membranes, and the mucous plugs are due to the 
influences mentioned, and their expulsion produces 
severe suffering. Such cases are used by some as 
an argument in support of the idea of mechanical 
dysmenorrhoea, especially when a flexion is present. 
It is unnecessary to answer such arguments. It 
would be perfectly consistent for these men to as- 
sume mechanical obstruction as a disease, in the 
delivery of a foetus. But given menstruation with 
fluid blood as the substance to be expelled in a 
woman who presents the symptoms of mechanical 
dysmenorrhoea, what facts will aid us in the present 
discussion? Excluding atresia, it matters not what 
the local condition is, we find the general devia- 
tion from the standard degree of health. A fat 
and apparently well-nourished woman may present 
symptoms at her menstrual period similar to those 
presented by another woman in the opposite condi- 
tion of general health. In the first instance, inner- 
vation, motor power, is at fault; in the second, the 
fault is in both innervation and nutrition. In both 
the local conditions are alike. Now, take either of 
these women and place her under methods of treat- 
ment that will allay irritation, produce coordinate 
action, and improve the general health, and we find 
that without any local treatment all the symptoms 
indicative of mechanical dysmenorrhoea disappear, 
and still the flexion, pinhole os, elongated cervix 
or stenosis, remains. Let the woman return to 18 
HULBERT, 
the original diseased condition, and the symptoms 
of mechanical dysmenorrhoea again appear. Further- 
more, in the worst cases, in which the flow is usually 
very scanty, we find that in spite of the persistent 
stenosis, as they approach the standard degree of 
health the flow increases and the suffering decreases 
and eventually disappears. Manifestly, we must look 
elsewhere for the cause of the symptoms, and we 
find it in lowered nutrition and increased irrita- 
bility, expressed by hypersesthesia and erratic mus- 
cular and circulatory action. It is nerve-ache, 
muscle-ache, nerve tire, muscle-tire. It is the cry 
for quietude, harmony, and rest from the ceaseless 
and persistent wants of the physiological rhythm of 
forces. That the local condition in its development 
has no influence on the systemic we do not affirm. 
In the progress of every case the time arrives when 
the local condition, by reflex influences, becomes a 
very important element in the process: first, from 
general to local ; second, from local to general, 
until the poor sufferer cries out in agony, afraid to 
move, afraid to laugh, afraid to lie down ; tenderness 
and pain in all parts of her body, and in constant 
fear of the monthly onslaught of what should be to 
her an unconscious relief. This is not enough, it 
seems, but she must be further accused of carrying 
around with her a disease called "mechanical ob- 
struction," and be subjected to sponge-tents, and 
incision and divulsion of the cervix, followed by the 
use of a stem-pessary. 
Especially bearing upon the interpretation of the 
pain in conditions of supposed mechanical obstruc- 
tion, we desire to direct attention to a condition in MECHANICAL OBSTRUCTION 
19 
which the pain is of the same character and in 
which mechanical obstruction cannot be present, 
namely, the "after-pains" of parturition. We are 
of the opinion that as far as the location, character, 
and manner of onset of the pain are concerned, there 
are no differential features between the pain of 
mechanical dysmenorrhoea and the "after-pains" 
of labor, yet in the presence of only fluid blood 
severe "after-pains" frequently occur. There being 
no stenosis after a parturition, the severity of " after- 
pains " in the absence of blood-clots is considered 
dependent upon nervous, nutritive, circulatory, or 
muscular influences, even by the most radical sup- 
porters of mechanical obstruction in menstruation. 
In considering the question of spasm of the inter- 
nal sphincter as a factor in producing the phe- 
nomena of mechanical obstruction, we are impressed 
with the desperation of many in striving to retain 
the mechanical idea of dysmenorrhoea. Correctly 
understood, this frequent and ever-ready action of 
the internal sphincter serves but to establish our 
position in antagonizing the mechanical idea. The 
presence of the spasmodic element is proof positive 
of unnatural and incoordinate muscular action, as 
well as increased local irritability. This, coupled 
with the antagonism existing between the cervix 
and body of the uterus,-readily explains why during 
menstruation, rhe spasmodic action should occur, 
and also why there is no flow until the spasm is 
relieved. In spasmodic or neuralgic dysmenorrhoea 
the menstrual flow is almost ml. This is not due to 
a damming back by the spasmodic closure at the 
sphincter, but is due to the fact that there is no 20 
HULBERT, 
menstrual fluid in the cavity of the uterus, and it is 
only when coordinate action is accomplished that 
blood exudes from the endometrium. This is readily 
proven by the introduction of a tube into the uterine 
canal during the menstrual period, insuring beyond 
a doubt patency of the canal. 
The diminution or disappearance of pain when 
the flow is established is now readily understood, 
when we say that it is due to the rhythm of forces 
finally accomplished, to nervous, muscular, and cir- 
culatory factors, within the tissues, and not to the 
forcible expulsion of retained fluid. The failure to 
pass the probe or sound is a mere matter of diagnosis 
and dependent upon the hand that manipulates it. 
Finally, we appeal to post-mortem investigations. 
Any one who has labored in the dead-house, inves- 
tigating the pathology of those conditions which 
are considered active factors in the production of 
mechanical obstruction will meet with one stub- 
born fact, namely, that the conditions found after 
death are far different from those that would be 
expected from the severity of the symptoms during 
life. Consider, for instance, endometritis, and in 
the dead-house the specimen, macroscopically, is 
hardly distinguishable from one obtained from a 
subject who had never during life suffered from 
such a disorder. Microscopically we find the dif- 
ference, and in the vast majority of cases are forced 
to conclude that this difference is more a func- 
tional than organic one. Take also any speci 
men and study the subject of stenosis of ihe canal, 
and how often, unless there is stenosis from scar- 
tissue in the mucous tissue lining the canal or MECHANICAL OBSTRUCTION. 
21 
congenital atresia, will you find a contraction that 
fluid blood would not find its way through; certain 
it is that fluid blood will travel through the capil- 
lary system, and the uterine canal, save in atresia, 
has a diameter equal to at least several capillary 
vessels. We also find in post mortem examinations 
that the uterine canal, even in the presence of great 
deviations in surrounding structures, or extreme dis- 
tortion and displacement of the organ, is free from 
acute angles, and that the cavity is tubular, especi- 
ally at the site of the internal sphincter. These 
facts are readily proved by sections in any direction, 
and are readily accounted for if we accept the in- 
fluence of the muscular elements and correctly 
interpret the mechanical laws at work in the form 
and structure of the uterus in their relation to the 
performance of function. 
In the attempted demonstrations of the existence 
of mechanical obstruction by its supporters, the fact 
that they were dealing with a dead organ seems to 
have been lost sight of; for in no other way can we 
explain the usual methods of attempting to prove 
mechanical obstruction during life by forcing a life- 
less flexed uterus into a greater degree of flexion, 
for even dead as it is it will not remain in the 
forced position. It would seem unnecessary to 
remark that pickled specimens are not suitable for 
demonstration, either affirmative or negative, yet 
they are frequently presented as showing the state 
during life. 
The therapeutic measures which are successful 
in relieving and curing mechanical dysmenorrhoea 
demonstrate beyond all doubt the correctness of 22 
HULBERT, 
our position. And in using the expression thera- 
peutic measures, we wish it distinctly understood 
that we exclude all local, surgical, or mechanical 
treatment to relieve the supposed stenosis of the 
canal. The use of reconstructives, such as good, 
palatable food, the elegant gluten and malt prepar- 
ations, and the hypophosphites and bitter tonics, 
for the purpose of restoring the standard nutri- 
tion ; the employment of narcotics, anodynes, anti- 
spasmodics, such as opium, compound spirit of ether, 
antipyrine, viburnum opulus and viburnum prunifo- 
lium, alaetris farinosa, helonias dioica, cimicifuga, 
Scutellaria, laterifolia, and gelsemium; the valuable 
anti-congestive drug, hydrastis; the coordinating 
muscular tonics, ustilago maydis and quinine; and 
last but not least, electricity, are attended with results 
eminently successful. The intelligent and persistent 
use of these means will, in the absence of atresia, cause 
all the phenomena of mechanical obstruction to dis- 
appear, while the local deviation, as far as form and 
displacement are concerned, may remain. The local 
state, as far as secretion and function are concerned, 
will be restored to a normal condition. 
Furthermore, it is a matter of daily observation, 
that all surgical and mechanical methods of treating 
dysmenorrhcea which are not assisted by pronounced 
improvement in the systemic, nervous, and nutritive 
forces of the patient are ineffectual. 
We respectfully submit the following conclusions: 
i. That in the natural order of things we find the 
uterus in form and structure endowed with a capacity 
for the performance of the function, menstruation, 
so far in excess of any legitimate demand, that with MECHANICAL OBSTRUCTION. 
23 
a diameter of the canal of one-fourth of an inch at 
the sphincters the excess is 7724.8 times the de- 
mand, and with a diameter of one-thirty-second of 
an inch the excess equals 120.7 times the requirement. 
2. That in the pathological conditions considered 
essential for mechanical obstruction we find that 
the conservation of force so regulates the condi- 
tions that this capacity is not abolished, but persists 
in an eminent degree, so that in the presence of the 
normal physiological energy the function is accom- 
plished, unless there is atresia. 
3. That the phenomena considered as dependent 
upon mechanical obstruction are not due to the 
forcible expulsion of retained fluids through the 
uterine canal, but are produced within the tissues, 
and are dependent upon disturbed rhythm of physi- 
ological forces evolved by abnormal innervation, 
muscular action, and circulation. 
4. That the demand upon the uterus for the 
passage of blood-clots, membranes, mucous plugs, 
uterine sounds, sponge-tents, uterine dilators, etc., 
in order that the diagnosis of mechanical obstruc- 
tion may be made, is not only vicious in the extreme, 
but irrational, illogical, and unscientific. 
5. That the correct and rational interpretation 
of the testimony offered by symptomatology, path- 
ology, and therapeutics, removes mechanical ob- 
struction from the domain of gynecology as a 
demonstrable fact, save in atresia uteri. 
3026 Pine Street. THE MEDICAL NEWS. 
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