THE uterus is the organ of gestation in which the fecundated ovum is received, nourished and supported till the proper period of its expulsion at parturition. In its virgin state the uterus constitutes the pivot around which play all the physical and nervous energies of the female organism; and its functional perfection exercises a powerfully controlling influence upon the physical health and social and moral happiness. The generative organs constitute the grand centre of the female economy. All the other organisms and functions of the woman are more or less in sympathy with these. And from the full, healthy, and harmonious development of the sexual system come the ruddy cheek, the elastic step, the buoyant, womanly spirit, and all that constancy of love and affection which so pre-eminently characterize, beauty and ennoble the female sex. And the impregnated uterus becomes at once one of the largest and certainly the most important organ in the body of the female in her highest state of physical development, -it being then the true physiological centre of the most exalted vital activity, the reproductive seat of life within life.
This distinction of the virgin from the impregnated uterus, not only underlies the whole character and constitution and function of the organ; but affects also the entire physiological, social, moral and even spiritual nature and condition of the female herself. Both the organ and the individual, in the one case are totally different in structure, function and being, from the organ and the individual in the other. The virgin or unimpregnated uterus has a structure and functions and disorders peculiar to itself. The impregnated uterus also has structure, functions, disorders, difficulties and dangers peculiar to its condition.
The virgin uterus is to be regarded then as a very different organ from the impregnated uterus; even as the virgin female is an entirely different person from one expecting to become a mother. We give then, in the first instance, an account of the virgin uterus; describing its shape, size, structure, position, relations, appendages, functions, and the principal disorders to which it is liable. And subsequently pursue a similar course with reference to the gravid or impregnated uterus; tracing its natural history, both normal and abnormal, from conception to parturition; detailing the various disturbances and dangers incident to the pregnant condition; and reciting the chief characteristic indications for the principal remedies required in their treatment.
THE VIRGIN OR UNIMPREGNATED UTERUS-Is a hollow, pearshaped conoid organ, with its base or larger part turned upwards and forwards, and its apex or smaller extremity looking downwards and backwards. The great importance of this organ and the consequent minuteness of description requisite for its thorough study, have caused it to be divided, nominally and externally at least, into five parts. Of these, the base or upper third is called the fundus; the middle portion or that part between the fundus and the cervix is called the body; the lower third is called the cervix or neck; the lower extremity of the cervix is called the apex; and the orifice or opening of the cervix is called the os externum, os uteri, or mouth of the womb.
The womb has also, externally, an anterior and a posterior face; the anterior being more flat and looking towards the bladder and symphysis pubis while the posterior face is more extensively covered by the peritoneum, more convex, and looks towards the rectum and promontory of the sacrum. There are also three borders or margins; one superior border, which bounds the summit of the fundus; and one right and one left lateral border. To the two latter are attached the broad and round ligaments of the corresponding sides. And finally, the cervix and body of the womb have also an internal surface, composed of mucous membranes and supplied with numerous muciparous follicles and glands.
A. The uterus, seen on its anterior face. B. The intra-vaginal portion of the neck of the uterus. C.C. The Fallopian tubes. D. The pavilion or fimbriated extremity of the tube E.E. The ovaries. F. The ligaments of the ovary G.G. The round ligaments H. The vagina laid open.
On the right, the fimbriated extremity of the tube is seen applied to the ovary.
The fundus or base of the womb is convex, looking upwards and forwards, ordinarily inclining towards the arch of the pubis, its summit never rising above the margin of the superior strait; while the superior two -thirds of its anterior and the whole of its posterior surface is covered by the reflected folds of the peritoneum. Some authors distinguish three angles on the external surface of the uterus; two superior,-one on each lateral border, marking the insertion of the Fallopian tubes, -and one inferior, at the point of union of the cervix with the body of the uterus.
The cervix uteri extends about half an inch into the vagina; and at its apex or free extremity is found the os uteri, -sometimes called os tincae, from its fancied resemblance to the mouth of the tenth, a species of small fish. The apex itself at its margin is divided into anterior and posterior lips,-the former, on account of the inclination of this part to the sacrum, being apparently longer than the latter. The occasional and still greater, abnormal length of the anterior lip, by entirely foreclosing the os uteri, has sometimes been the efficient cause of sterility, which can only be obviated by the female, in coition, assuming the prone position on the face and abdomen.
In its embryonic state, the uterus is not to be distinguished in shape and appearance from the vagina, into which it is inserted at the middle of the cervix, and with which it is apparently homologous and continuous. But during childhood the body or upper portion of the uterus gradually increases in size, till at the full period of puberty its shape is pyriform instead of being cylindrical.
The cervix uteri is about one inch in length and constricted at its point of union with the body of the uterus. At this point, which is also called the inferior angle, takes place the in flexion which results from change of position of the fundus and body of the womb. In these cases of anteflexion, retroflexion and lateroflexion, the body of the uterus forms nearly a right angle with the neck. The usual position of the virgin uterus is with the fundus strongly inclined towards the symphysis pubis. This causes the cervix (see Figure of Section of Pelvis on page 36) to incline towards the superior portion of the coccyx, and the os uteri to look posteriorly towards the rectum, instead of looking directly downward in the axis of the inferior strait. The mouth of the womb in young females is often quite small, sometimes almost undiscoverable. But where it thus seems closed up, gentle pressure of the finger will detect a slight depression which will indicate its exact situation.
The vagina embraces the cervix at its upper third. Thus the larger portion of the cervix appears as a free extremity inserted into the vagina; the anterior face of this free extremity being a little shorter than its posterior, face, on account of the oblique manner in which the vagina surrounds the cervix.
The canal of the cervix is about three-fourths of an inch long. In its course from the os tincae or os externum uteri, it first widens, then grows narrower at its entrance into the cavity of the uterus,-this point of entrance being known as the os internum uteri. The mucous lining membrane of the canal of the cervix is arranged in radiating folds, or rugae on either side,- the united radiations of both sides having an appearance very similar to that of a cedar tree ( Thuya occidentalis); hence the name arbor vitae (Fig. 124. O, and Fig. 16, A.) A similar appearance, – to which also the same named is applied,- is seen in the cerebellum, on cutting it longitudinally. The glands of the canal of the cervix will be described in connection with the mucous coat, which lines the inner surface of both the cervix and body of the womb.
From the inner surface of the cervix, we naturally come to the description of that of the body of the womb itself. Thus internal surface of the womb into which that of the cervix leads, and with which it is continuous, is covered with mucous membrane, and abundantly supplied with muciparous follicles, -although these are far less numerous in the body than in the cervix. In the virgin.
A. Superior border or fundus of the womb. B. Cavity of the womb. C. Cavity of the neck of the uterus. D. The canal of the Fallopian tube cut open. E. The fimbriated extremity or pavilion, likewise laid open. F.F,. The ovaries, one-half of which has been removed so as to bring into views several of the Graafian vesicles. G. The cavity of the vagina. H.H. The ligaments of the ovaries. G.G. The round ligaments. womb the walls are nearly in apposition; there being ordinarily but little cavity in the empty womb. At the same time the walls are much more vascular and so of a more rosy hue than the parietes of the canal of the cervix. Still the cavity of the womb, such as it is,
This profile view gives an exact idea of the dimensions of the cavity of the body and of the neck of the womb in a state of vacuity. A Mucous membrane. B. Tissue proper C. Cavity of the body. D. Cavity of the neck.
(Fig. 14 B.) is triangular in shape; its inferior angle corresponding to the os internum,- the two superior and lateral angles being situated at the orifices of the Fallopian tubes. IN Fig. 15 appears a profile view, which conveys a more correct idea of the manner in which the walls of the virgin uterus are approximated in their ordinary condition. At the times of the menstrual excitement, they are somewhat more distended.
The external dimensions of the uterus vary in different persons- being larger or smaller, to correspond with the totality of their physical constitution. We give what may be considered the average ad measurements of the fully developed uterus at puberty. The entire length of the uterus, from the inferior margin of the cervix to the superior border of the fundus, is about two inches and a half; its greatest breadth is about one inch and a half; and its thickness from the anterior to the posterior face is one inch. As the uterus increases in size from childhood to puberty, -so from the cessation of the menses it begins to diminish the volume, till it becomes more or less atrophied in the second childhood of advanced age. And as in the impregnated condition, the womb becomes very greatly and permanently enlarged, that is, during the continuance of the pregnancy, so at the accession of each of the monthly periods, in many females, it becomes temporarily enlarged to twice its natural size. The weight of the virgin uterus may be set down as about eight drachms; but after child-bearing it remains two or three times as heavy.
The structure of the uterus forms a very important element in studying its nature and functions. Three distinct tissues, coats or tunics,- each possessing a different constitution, and performing totally different functions,- make up this complicated structure. These are the external or peritoneal coat; the middle or muscular coat; and the internal or mucous coat.
The external or peritoneal coat.- This membrane is reflected from the posterior surface of the bladder upon the anterior face of the uterus; extends upwards, and covering the fundus, is continued down upon the vagina a short distance below the cervix; and is then finally reflected upon the rectum. The peritoneal membrane, or serous tissue, is thus seen to be identical and continuous with the common lining membrane of the abdomen. Processes from this membrane are reflected from each lateral border of the fundus to the corresponding side of the pelvis, near to the sacro-iliac symphysis. These processes form what are called the broad ligaments of the uterus; and contain the Fallopian tubes, the ovaries and the round ligaments.
The middle or muscular coat forms the principal part of the substance of the uterus. This tissue is dense, firm, and grayish in color. It is thickest upon the middle of the body and fundus; thinnest at the orifices of the Fallopian tubes. It consists of bundles of involuntary muscular fibres disposed in three layers intermingled with areolar tissue, blood-vessels, lymphatics and nerves. The external layer principally upon the anterior and posterior surface; its fibres, converging at each superior angle of the uterus, are continued upon the Fallopian tubes, the round ligament and ligament of the ovary,-some few running backwards from the cervix uteri to connect with the recto-uterine ligaments. The middle layer of this coat is composed of longitudinal, oblique and transverse muscular fibres. The internal layer consists of circular fibres arranged in the form of hollow cones, whose apices surround the orifices of the Fallopian tubes, their bases meeting and intermingling at the middle of the body of the uterus. The fibres of this layer are disposed transversely, or circularly, in the cervix uteri. The womb is a muscular organ of very great power; and a thorough knowledge of the nature and arrangement of its muscular fibres in the cervix, and especially in the fundus, and in their relation to the broad and other ligaments, is essential to a correct understanding of its wonderful action in parturition.
This figure represents the arrangement of the mucous membrane, and the tissue proper of the uterus, as also their relative dimensions. A Cavity of the neck and arbor vitae. B. Cavity of the body. C. Mucous membrane. D. Intervening membrane. E. Represents the marked thinning off the mucous membrane towards the neck.
The mucous coat of the uterus is so closely adherent to the subjacent tissue, that from the difficulty of separating and demonstrating its existence has been denied by many authors. But by the aid of the microscope this mucous coat has not only been clearly distinguished, but shown also to consist of epithelium, basement membrane, fibrous tissue, blood -vessels and nerves, like other mucous membranes. This internal mucous coat of the uterus is continuous with that of the vagina beneath, and also with the peritoneum above through the fimbriated extremity of the Fallopian tubes. It abounds in follicles, whose secretion lubricates the interior surface of the uterus. And the abnormal, catarrhal and leucorrhoeal secretions and other morbid products, to be subsequently considered as disorders of the cervix and even of the fundus, conclusively show the mucous character of this innermost tissue of the uterus. Numerous follicles, glands and papillae appear in the mucous lining membrane of the cervix; the secretions from which serve to maintain the mouth of the virgin uterus in a healthy condition, and to seal it when impregnated. Much the larger portion of the mucous secretion from the womb, is in reality the product of the innumerable glands of the cervix. This secretion in its normal state is whitish, very viscid, almost transparent, and gives an alkaline reaction. It adheres to the crypt and rugae of the cervix and occupies its canal.
The circulatory system of the uterus forms a most important part of its study. The blood vessels of the virgin womb are numerous and largely developed in comparison with the size of the organ. This has reference not only to the nutrition of the womb in its ordinary condition, and to its congested state at the periods of menstrual excitement, but is provisional also for the necessities of that impregnated condition for which its designed. The arteries, which supply the womb, form two distinct systems, according to the sources from which they are derived, and to the parts to which they are finally distributed. The first or superior system, is composed of the spermatics, or ovarian arteries, which arise from the aorta or emulgent arteries, and, descending along the sides of the womb in a serpentine course, are distributed to its upper part, to the Fallopian tubes, and to the ovaries. The second, or inferior system, is composed of the uterine arteries,- which are derived from the internal iliac or hypogastric arteries. These arteries also pass along the sides of the womb, to be finally distributed to the cervix and upper part of the vagina. These arteries pursue a remarkably tortuous course in the substance of the uterus; thus provision is made for their great elongation without danger of rupture in the advanced stages of pregnancy. The numerous branches of these two systems freely anastomose with each other.
The veins of the virgin uterus are of large size, possess no valves, correspond in name with the arteries, and follow their course. The right spermatic vein terminates in the inferior vena cava, the left in the renal vein; the uterine veins empty into the internal iliacs. They are capable of very great increase in pregnancy and are then known as uterine sinuses.
The lymphatic vessels of the uterus, invested by delicate coverings of peritoneum, are distributed upon all the external surfaces of that organ. They are very numerous and, in the virgin uterus, very small. Some of these ascend, in a serpentine course, from the cervix to the body and fundus of the uterus. Others pass less tortuously, in various directions over both these surfaces, communicating with branches ascending from the vagina and with those from the Fallopian tubes and ovaries. The internal as well as the external surfaces of the uterus, Fallopian tubes and ovaries, are abundantly supplied with these absorbent vessels. Those of the former, from the interior structure of these organs, communicate with the lumbar ganglia; those of the latter, from the external surfaces of the uterus, Fallopian tubes and ovaries, are abundantly supplied with these absorbent vessels. Those of the former, from the interior structure of these organs, communicate with the lumbar ganglia; those of the latter, from the external surfaces of these genital organs, communicate with the pelvic or inguinal ganglia. This latter circumstances is important to be borne in mind, since this anatomical and physiological connection is frequently the index to pathological appearances. In addition to the general division of the lymphatics of these organs, to correspond to their external and their internal surfaces,-the mode in which they are originally disturbed, to follow the course of the spermatic and iliac arteries, arrange them all in two distinct systems of lymphatic circulation. With the exception of the proper menstrual secretion, there is no discharge from the interior of the female organs of generation, in their normal condition; the lymphatics sufficing to reabsorb the natural secretions of their internal surfaces, so that no accumulation occurs.
The nerves of the uterus and its connecting structures of the generative system, are derived, either directly or indirectly, from all three of the great nervous centres of the body; and by their union and concentration serve to render the sexual system of the female the great physiological centre of her entire organism. The nerves which are distributed to the uterus are, in part, derived from the great sympathetic, and partly from the spinal nervous system. But these latter, as branches of the third and fourth sacral nerves, given off from the cerebro-spinal axis, are, indirectly at least, derived also from the cerebral nervous centre, as well as from the spinal; although they are not under the immediate control of the will.
The nerves which are distributed to the uterus from the sympathetic system, are derived from the aortic, and from the hypogastric plexus. The former, -variously named, as the renal, the spermatic or ovarian plexuses, according to their more immediate relations are all derived from the great solar or epigastric plexus; and are intimately connected with all the other pelvic, abdominal and thoracic nervous centres. Hence the powerful sympathy which exists between the womb itself and all the other great organs of the female. Hence, too the intense pain felt at the pit of the stomach in cases of uterine neuralgia; and the nausea and vomiting which are so often associated with peculiar conditions of the impregnated womb.
The nerves which are distributed to the uterus from the hypogastric plexus, come directly from the pelvic portion of the sympathetic; and have associated with themselves the filaments from the third and fourth sacral nerves, which connect the womb with the general muscular apparatus of the body. The former class of nerves having especial relation to the two great functions of nutrition and reproduction, as in the growth of the womb itself, and of the ovum which it may contain in the impregnated state:- the latter having relation to those muscular powers of the womb by which it is enabled to exert itself so wonderfully to expel the product of conception at full term, and to combine with its own efforts the muscular powers of all other parts of the body.
Unlike other muscular structures, the nervous filaments penetrate into the substance of the womb; and during the period of uterogestation all the uterine nerves are very greatly enlarged.
The virgin uterus is situated in the centre of the pelvis, just above the vagina, between the bladder in front and the rectum behind. In connection with the vagina, it describes a curve similar to that of the general axis of the pelvis. Thus it appears supported or suspended in the midst of the pelvis; and in this position it is sustained by ligaments, which are processes given off from its own substance, or from the enveloping peritoneal membrane. These are arranged in four pairs, and are known as the anterior, the posterior, the round and the broad ligaments. In addition to these, which serve rather to steady the womb in its position, the peritoneum itself appears to afford the principal direct support to the uterus.