the ergotine mixes with the blood sufficiently
to excite the rythmic centres, but that being
done, the action is simply augmented, or else
occasionally it becomes so violent that the in-
tervals are obliterated, and one contraction
becomes merged in another, so that an inter-
mittent is converted into a continuous uterine
action.

But that which more certainly demonstrates
that the rate of the motions, whether rythmic
or constant, is dependent on the kind and ex-
tent of irritation, is the variation in the results
obtained by different modes of inducing pre-
mature labour. If, according to the method
of Kiwisch r water is injected simply against
the cervix, after several repetitions, rythmic
action is slowly excited. If the cervix is dis-
tended by the introduction of a sponge tent,
rythmic action ensues more quickly and cer-
tainly. But if the first proceeding is so varied
that the water, instead of being merely thrown
against the cervix, is introduced between the
membranes and the uterine walls for a very
short distance, so as gently to effect their sepa-
ration from the inner surface of the uterus,
labour is induced with greater certainty and
speed than in any other way ; but should the
separation be carried still further, some such
tumultuous form of labour results as ergot pro-
duces when acting in the manner just specified.
The uterus acting continuously and very ener-
getically rather than intermittingly.

Influence of the different nervous centres upon
the uterus in parturition. In the present un-
settled state of neural physiology, especially in

* Paget, Croonian Lecture ; Proceedings of Roy.
See. vol. viii. No. xxvi. 1857.
x x 2



67G



UTERUS AND ITS APPENDAGES.



relation to the powers of the different nerve
centres, it is scarcely possible to arrive at any
satisfactory conclusion regarding the relative
degrees of influence which these may be sup-
posed to exercise over the movements of the
uterus. The marked differences of opinion
still existing upon this subject * afford sufficient
evidence of the uncertainty of the data upon
which definite conclusions can be based. In
this uncertainty, however, all points of the
nervous system are not equally involved.

The amount of influence of the cerebrum
upon the act of parturition can be determined
with tolerable accuracy. That the uterus is
in communication with the brain is proved by
the fact that the woman is conscious of the
foetal movements, and that she suffers pain
when the uterus contracts. Emotion may
excite, and may also for a time delay, uterine
action. The will cannot operate directly upon
the uterus, either in the way of producing, or
of restraining its contractions, but a slight in-
direct influence may be occasionally perceived,
when by voluntary changes of posture, or by
the use of those muscles which assist labour,
the force of the uterus is slightly increased ;
or conversely, when, by carefully restraining all
such movements and* actions, this result is
avoided.

It is further shown by the occurrence of
labour in cases of complete paraplegia, and also
during states of unconsciousness, induced by
anaesthetics, that the uterus contracts while it
is withdrawn from all volitional and like cere-
bral influences.

These several examples serve to show to
what extent the contractions of the uterus
may be influenced by the cerebrum, and also
how that influence may be withdrawn. It is
obvious that psychical influences are neither
necessary nor accessory to the simple act of
labour. They may often be regarded as dis-
turbing, but not as regulating forces. Hence
the dominant power over the contractions of
the uterus, which is exercised during labour,
must have its seat in some of those nervous cen-
tres that are placed lower than the cerebrum.

We may therefore proceed next to inquire
what are the attributes which from direct ob-
servation and analogical reasoning the uterus
may be supposed to derive respectively from
the ganglionic and spinal systems, regarded as
separate sources of motor power. But here,
on account of the intimate manner in which
the nerves derived from each of these centres
are bound up together, great difficulty arises
in distinguishing between the operations of
each, and these difficulties can be only in part
surmounted.

The circumstances which point more par-
ticularly to the influence of the ganglionic
system will be first considered.

The uterus derives a greater proportionate

* See Tyler Smith, Parturition and the Principles
and Practice of Obstetrics; and Lancet, 1856.
Scanzoni, Lehrbuch der Geburtshilfe. Brown-
Stquard, Physiology and Pathology. Carpenter,
Principles of Human Physiology; and Todd, art.
NERVOUS SYSTEM, in this Cyclopedia.



supply of nerves from the ganglionic than from
the spinal system. This appears from the re-
searches of both Snow Beck and Kilian.
The actions therefore of those parts or organs
having like endowments, which are in other
respects also comparable with the uterus, may
be here examined.

Of all organs the heart is that which most
nearly resembles the uterus. It constitutes,
after the uterus, the largest hollow muscle.
Like the uterus, it acts with rhythm, and, in a
certain degree, peristaltically. It continues its
contractions, with little, if any, interruption,
for a long time after its principal cerebro-spinal
connections have been destroyed, as by tying
the pneumogastric nerves. It continues to
contract rhythmically in many animals for a
variable time after death, or when cut out of
the body Its contractions are regulated mainly
by sympathetic ganglia, while the cerebro-spinal
fibres which it receives serve to establish rela-
tions between it and other parts.

The uterus exhibits many like peculiarities.
It acts with rhythm and peristaltically. It
continues these actions, in numerous species
of animals, for a variable time after death.
Even in the human subject, a post-mortem
power of contraction seems to be occasionally
retained, as in the case of women whose spon-
taneous delivery has taken place some time
after all evidences of somatic life have ceased.*
In these several offices we may conclude that
the uterus also, so far as its operations are
under the dominion of the nervous system, is,
like the heart, chiefly influenced by sympathetic
ganglia and nerves.

That this is the case is also further shown
by the occurrence of delivery under circum-
stances in which all spinal influence appears
to be abrogated. The following is an ex-
ample.f

A woman was attacked with paraplegia in
the eighth month of pregnancy. JShe had
neither sensation nor motion in any part below
the umbilicus. No reflex movements what-
ever could be produced by tickling the soles
of the feet. The faeces passed involuntarily,
and the urine was drawn off daily. About the
ninth month, her medical attendant, when
about to pass the catheter, found a full-grown
foetus in the bed (dead). The uterus was con-
tracted, and the placenta in the vagina. The

* A large number of these cases has been col-
lected by Dr. W. H. Wittlinger, " Von der nach
dem Tode der Mutter von selbst erfolgenden
Geburt," in the Analekten fur die Geburtshulfe,
Bd. I. 1849. All cases of post-partum delivery are
probably due to one of three causes, viz., to a con-
tractile power or irritability remaining in the utems
after death, and comparable to that which in vo-
luntary muscles produces the now well-known
post-mortem cholera movements ; to rigor mortis ;
or to the development of gases within the abdo-
men or uterus, causing the expulsion of the child
by pressure. The first is probably the cause of
birth within a few hours, and the last several days,
after the death of the mother, and the second of
the expulsion of the foetus before decomposition has
set in, yet at a later period than can be accounted
for upon the first hypothesis.

f For this case I am indebted to Mr. Paget.



UTERUS (FUNCTIONS).



woman was entirely ignorant of what had
occurred. Scanzoni andChaussier relate simi-
lar examples of birth taking place notwith-
standing complete paralysis of the sensitive
and motor functions of the lower half of the
body. In Chaussier's case the pressure was
occasioned by a hydatid cyst which involved
the chord on a level with the first dorsal
vertebra.*

On the other hand, that the uterine move-
ments are also capable of being influenced by
spinal fibres, appears from the following con-
siderations. Uterine contractions may be ex-
cited by the application of cold to the general
surface of the body, or by placing the child at
the breast; by injecting warm and stimulating
fluids into the rectum, and in other like modes.

Again : the uterus, under various circum-
stances of health and disease, is observed to

* Cases of paraplegia have sometimes occurred in
which artificial aid appears to have been needed to
complete the delivery, as in a case cited by Brachet
(Fonctions du Systeme nerveux ganglionaire, p. 266.
1830). By thos"e who contend for a preponderance
of spinal influence over labour, such cases are cited
in proof. It is said that notwithstanding the com-
plete loss of sensation and motion in the extremities,
independent reflex operations may still be preserved
in the uninjured portion of the chord. But the
motions which may be occasionally excited by irri-
tating paralysed limbs are " disorderly and pur-
poseless," and are in no way comparable with those
co-ordinated actions that characterise natural la-
bour. Moreover, the argument is entirely inappli-
cable to the case cited in the text, in which no
reflex action whatever could be produced. It has
also been supposed that an essential distinction may
be drawn between cases in which the disease is
situated high up, and those in which it occupies a
lower situation: in the latter cases the portion of
chord supposed to furnish spinal nerves to the
uterus being involved in the disease, and in the
former not. But such conclusions can be of little
value until the precise limits of the chord, whence,
spinal fibres can be derived to the uterus, have been
anatomically determined. (See the account of the
origin of these nerves at p. 641.)

For like reasons it does not appear that in the
present state of neural physiology in relation to the
uterus, satisfactory conclusions can always be drawn
from experiments upon animals. For "although it
might seem probable that in a case of mixed nerves,
by destroying the centre or origin of one of the
sets, the functions of the other might be left unim-
paired ; or by stimulating one of the nerve centres
alone, their actions would be exclusivelv called
forth, while the rest would remain passive; still,
absolute conclusions cannot always be arrived at,
even in these ways. For in the latter case, on ac-
count of this very intermixture of nerves, whenever
w y e attempt to stimulate ganglionic centres, or
plexuses, we are dealing at the same time with the
spinal fibres which pass through them. Or con-
trariwise, when we endeavour to destroy extensive
tracks of spinal centres, we do not know if the
arrest of labour that may follow is not due to the
violence which, in most "of these experiments, has
caused the death also of the animal within a few
hours or days after, rather than to the destruction
only of the portion of spine whence uterine fibres
are supposed to be derived. In this way, perhaps,
we can explain those discordant results of experi-
ments, in some of which labour has been arrested,
and in others has not apparently been interfered
with, so far as uterine action alone is concerned,
after greater or less injury or destruction of the
chord.



677
or several of the parts just



react upon
named.

Hence it appears that a mutual relationship
is established, by virtue of which the uterus
may be either the excitor of actions in these
parts, or may through them be itself excited
to action. And there can be no doubt that
the spinal cord is the 'agent through whose
reflex operations these several effects are pro-
duced.

From this evidence it may be concluded
that the double supply of nerves answers dif-
ferent purposes. That the spinal system fur-
nishes nerves for the purpose of bringing into
harmonious relations all those organs whose
cooperation with the uterus is essential or ac-
cessory to various steps of the reproductive
process. While the organ deriving also a simi-
lar or even larger supply from the ganglionic
system, these nerves serve to regulate the
functions which the uterus itself is capable of
discharging without cooperative aid. In this
view the offices of the spinal system, as a
system of relations, and of the ganglionic, as a
system presiding over the direct acts of the
parts which it supplies, may be separately ex-
hibited. It is doubtless also a chief office of
the ganglionic system to regulate and control
the action of the blood-vessels with which the
uterus is so largely supplied.

What is the exciting cause of labour ? This
question carries us only one stage further in
the preceding course of inquiry : and the reply
to it will be nearly found in the facts already
stated. For if these serve to throw light upon
the causes of the rhythmic and peristaltic
movements of the uterus, then the conditions
which determine the first rhythm and first
peristalsis, or, in other words, the beginning
of labour, cannot lie very remote from these.

Many circumstances may evoke the first
rhythm, which being followed by others, labour
becomes established. Thus, irritation of in-
cident nerves in various parts and organs may
so force those sympathies with the uterus
which, for other uses, are established by the
spinal system of nerves, as to bring on an un-
natural and premature form of labour ; but
this is not the present question.

The determining causes of natural labour
can be only satisfactorily sought among that
class of phenomena which causes the separa-
tion of the ripe fruit from the stem which
bears it : in a perfecting, namely, of the fruit
or product of conception, so that it becomes
fitted for an independent existence, and as a
step preparatory to this, in a gradual meta-
morphosis of those tissues which, having
served for a time the purpose of connecting
the two together, are now no longer required
by either. This connecting medium in the
human subject is the decidua, which lines the
whole uterus. Its metamorphoses during preg-
nancy have been described. Already as early
as the middle of that period, the preparation
has begun for a new tissue, which, after labour,
is to reconstruct the lining membrane. The
old attenuating and perishing decidua, now no
longer needed, except at the spot where it
x x 3



678



UTERUS AND ITS APPENDAGES.



covers the placenta, loses by degrees the cha-
racter of active vitality, and its tissues are con-
verted into molecular fat.

Other and corresponding changes, of which
an account will be hereafter given (see PLA-
CENTA), occur in those structures in which
the foetal blood circulates. The profusely de-
veloped capillaries which ramify within the
villi during the early and middle periods of
gestation begin to suffer retrogression as the
time of separation approaches, and the foetal
blood flows in more simple and relatively fewer
channels, while, not (infrequently, entire villi
become obliterated by calcification.

While these changes are proceeding in the
temporary structures that serve to connect the
fetus with the uterus, structures which begin
in part, at least, to become effete, even before
the offices for which they are formed have
been fully carried out, the tissues which are
to be employed in the process of expulsion
are as yet only ripening into full strength,
although they also, in turn, are about to suf-
fer a like retrogression, but not until the ob-
ject of their formation has been accomplished.
The contractile fibre, which constitutes the
principal portion of the uterine tissue, has
gradually, during pregnancy, advanced to that
more complete form which is reached com-
monly about the sixth month. From this pe-
riod probably no new development of muscular
fibre takes place, although that which is already
formed appears to increase somewhat in size
and power. It constitutes now a contractile
tissue, capable of exerting great expulsive
force. How easily, and in how many ways,
the contractile power may be evoked, has been
already shown. It is probable that by the
series of metamorphoses already enumerated
as occurring in the parts which connect the
foetus with the uterus, the entire ovum becomes
gradually placed in the position of a foreign
body within that organ ; a position which may
be compared to that of the food within the
alimentary canal. And just as the food is
propelled onwards, peristaltically, by irritation
of successive portions of the containing sur-
faces, until, with the subsequent cooperation
of muscles acting under the dominion of the
spinal cord, it becomes finally ejected ; so the
ovum is itself apparently the excitor of those
first peristalses in the uterus which initiate
labour. How these become coordinated and
established, and how the rhythmic periods are
probably determined, has been already con-
sidered, as well as the means by which, during
the further advances of the child over succes-
sive portions of the generative track, other
nerve and motor forces are added to those
with which the process commenced.

ABiNORMAL ANATOMY OF THE UTERUS.

A. Defective development. Imperfect or
defective development of the uterus may oc-
cur under two circumstances. There may be
either an original defect in its organisation,
arising from a failure of growth or imperfect
formation of those portions of the generative



canal out of which the uterus is developed ;
or else the organ, having been regularly
formed during embryonic and foetal life, may
not have proceeded in its development, but
may have retained the infantile character after
the usual age of puberty has arrived and



1st Class. Congenital defects. Defects of
this class may affect the uterus alone, or may
be conjoined with corresponding imperfections
of other organs. In order that their nature
and origin, as well as the possibility of their
occurrence, independently of any malforma-
tions of the other reproductive organs, may be
clearly understood, it is necessary to remem-
ber the mode in which the uterus is originally
constructed. Formed by the coalescence of

Fig. 460.




The entire internal generative organs, from a foetus of

three months. (After J. Midler x 8.)
a, uterus ; b, round ligaments ; c, Fallopian tubes;
d, ovaries ; e, remains of Wolffian bodies.

the inferior extremities of the ducts of Miil-
ler*, the uterus will be materially modified in
its construction according to the degree of
perfection of those ducts, as well as by the
amount of union which has taken place at
their lower terminations.

Taking these particulars as affording a basis
for classification the malformations of the
uterus which are dependent upon original
vices of formation may be arranged in four
groups, viz. :

Group 1 . The ducts of Miiller being both
imperfect or undeveloped, there results a
more or less complete absence of the uterus.
The examples of total absence of the uterus
which have been recorded are probably cases
in which the rudiments exist, but have been
overlooked, on account of their slight deve-
lopment ; for generally there may be traced
a more or less distinct fold of peritoneum ly-
ing behind the bladder and representing the
broad ligament, within which are found some
indications of a uterus. These rudiments
consist of two uterine cornua, either conjoined
at their lower extremities, or remaining sepa-
rate in their whole course. They usually oc-
cur under the form of two hollow rounded
cords or bands of uterine tissue, extending
upwards towards the ovaries, and united per-
haps at the usual seat of the uterus by cellu-
lar tissue, with which some uterine fibres are
intermixed. Sometimes one or two little
masses of uterine tissue are found. These
are either solid, or they contain a small cavity

* See p. 642.



UTERUS (ABNORMAL ANATOMY).



679



lined by mucous membrane. This constitutes
the condition designated by Mayer the uterus
bipartltus. The concomitants of this condition
may be a short vaginal cul-de-sac, together
with rudimental Fallopian tubes, and perhaps
well developed ovaries. In the latter case
the external organs may be well formed, and
there may be no deficiency of sexual cnarac-
ter, or the vagina may be entirely wanting.

The coexistence of this rudimental uterus
with ovaries well developed is easily ex-
plained. For the ovary is formed out of a
separate portion of blastema from that from
which the Wolffian bodies and excretory duct
of the generative apparatus are developed, jig.
400. and 416., so that the failure in growth
o the one does not necessarily involve a cor-
responding defect in the other.

Group II. If one uterine cornu retains the
imperfect condition last described, while the
second undergoes development, the one-
horned uterus or uterus unicornis is produced.
So that the organ here consists of a developed
and an undeveloped half combined.

The developed uterine horn may be either
the left or the right. It then consists of a
cylindrical or fusiform canal or body, curved
outwardly in the form of an arch which ex-
hibits various degrees of deflection from the
meridian. To its upper extremity is usually
attached a tube leading to the seat of a well-
formed ovary.

The second or undeveloped cornu, with its
tube, is not always entirely deficient ; but
there often exists a rudiment in connexion
with the developed horn, which, according to
the degree of malformation, is either solid or
hollow, or is traversed by a canal opening
into the cervix of the developed half.

In the case of the uterus unicornis, notwith-
standing the imperfection of one uterine half,
both ovaries may be found alike developed.

The type of this condition of uterus exists
as a normal formation in the class aves, where
one side only of the generative apparatus
proceeds in its growth, and the other remains
undeveloped from an early period of foetal
life.*

Group III. If, instead of an unsymmetrical
growth of the two uterine cornua, such as
occurs in the last example, both sides are
alike developed, yet without any, or with
only an imperfect, junction of their lateral
borders there is produced a uterus bicornis,
falsely termed a double uterus (uterus du-
plex). Here however there is no evidence of
plurality, or true duplicity of the uterus, but
only a deficiency of that union of the two
separately formed halves by whose subsequent
conjunction the organ is normally constituted.

This conjunction should naturally com-
mence from the level of the point of attach-
ment of the round ligaments, and the varia-
tions in the degree of malformation will be
according to the height at which the union of
the uterine halves stops short of that point.

The highest degree of malformation in this



group, or the greatest departure from the
normal form, is that in which the two uterine
halves do not coalesce at all, but remain com-
pletely divided in their whole extent. This
happens very rarely, and is co-existent with
other malformations, such as fissure of the
abdominal and pelvic walls. The division is
here so complete that certain of the pelvic or
abdominal viscera may occupy the space be-
tween the two uterine halves.

In the next degree of this kind of deformity
a horizontal commissure occupies the angle
in which the two uterine halves meet, and
serves to unite them together (fig. 46 1 .). The

Fig. 461.




The body of the uterus divided into two halves, which
are united at the cervix by a horizontal commissure
representing the fundus. The os uteri and vagina
are double. (After Busch.}

horizontal commissure is composed, like the
cornua, of uterine tissue, and represents the
fundus uteri. According to the height at
which it is placed, the external form of the
uterus approaches or recedes from the normal
type. Kokitansky* has pointed out how the
situation of this commissure affects the angle
in which the two cornua meet, and conse-

Fig. 462.




The vagina, os uteri, and cervix, single. (After
Busch.)

The body of the uterus forming two cornua,
which are still nearly horizontal, but are united by
a commissure at a higher point than in fig. 401.

quently the relative mutual position of the two
uterine halves. The nearer the point of co-