- Email: [email protected]
ON THE NERVES OF THE UTERUS.
501
with, infiltrated with a serous-looking fluid, which rapidlyspire, I am of opinion that it would be mainly attributable to coagulates, and becomes like jelly, at a heat of 840 Fahr. the shock produced on the system by the disparity of temThis exists in enormous quantities, and requires to be removed, perature between the cold injection, and the blood, and the in order to proceed with the dissection. The muscles are cavity into which it was injected. Should the view now taken of this interesting and important found pale-looking, and rather atrophied, in some cases considerably so, and with much fat and cellular tissue around point be in any way tenable, all that we have to observe is, them. The veins, except the larger ones, are diminished in that the proposed injections can easily be made of an equal size, and appear less numerous, the superficial ones being temperature, and yet retain their properties. And it requires almost obliterated. The arteries are small, compared with but slight reflection to convince ourselves that the absence what might be expected from the abnormal hypertrophy of of success in the treatment of uterine haemorrhage, experienced the parts they supply. The nerves are somewhat flattened by by the use of vaginal injections, and the disparaging opinions compression. The outer skin is not at all mobile; it seems which have been expressed relatively thereto, will not deroglued to the part; the thickness becomes less marked towards gate in the slightest degree from an altogether different class the borders of the foot. When a. portion of the skin is re- of injections—i. e., uterine, as distinct from vaginal. moved, and sliced horizontally, it seems to be composed of Braunston, Northamptonshire, Sept. 1846. layers, and has the appearance of sheets of pasteboard, soaked and firmly compressed together. The epidermis is less affected than the cutis vera, which has the physical characters of ON THE NERVES OF THE UTERUS. marked hypertrophy, although the epithelia of the former are greatly enlarged, and present an appearance not unlike the BY T. SNOW BECK, ESQ., M.R.C.S., London.
i
scales of a fish.
THE opinions of Dr. Robert Lee, and of myself, upon this subject, having been so frequently quoted in opposition to each other, perhaps it may not be inappropriate to give a short account of the opinions of each, and that they may be more ON THE UTILITY OF compared, to place them in juxtaposition. Nor does INJECTIONS INTO THE UTERINE CAVITY readily it appear improper to add to this account the statements of IN THE TREATMENT OF the principal authors upon the same subject, and then to HÆMORRHAGE, & INACTION OF THE UTERUS, DURING PARTURITION. examine the points in which any difference of opinion exists. Georgetown, Demerara, June, 1846.
BY THOMAS CATTELL, M.D., Braunston. IN THE LANCET of December 6th, 1845,I drew the attention of the profession to the utility of injections into the cavity of the uterus in the treatment of inaction, and of haemorrhage occurring at the time of, and subsequently to, delivery. I requested, at the same time,after a trial had been made,that the experience of my professional brethren might be recorded on the subject. I had, however, not observed anything relatively thereto, until the appearance of the very excellent paper by John W. Tripe, Esq., in THE LANCET of August 1st. But in this communication, Mr. Tripe has not done me the honour of making the slightest reference-all I could possibly desirealthough I am not aware that any active uterine injection had been used in these cases prior to the time at which my paper appeared. I am, notwithstanding, greatly gratified that Mr. Tripe should have taken up the subject, and that he has been able to suggest another injection, capable of producing such favourable results. The considerations which induced me to adopt the injectional mode of treating uterine haemorrhage, and inaction of the uterus during parturition, were1. Because the local treatment which has been proposed by the most eminent men in this department of practical medicine is frequently found to be inefficient, opposed to the feelings of the patient, and often impossible of adoption. I refer, for example, to plugging the vagina with a silk handkerchief, or the use of ice; insertion of the hand into the uterus; dashing cold water over the abdomen, or allowing it to drop from a height; compression of the aorta, &c. 2. Because one of our most efficient internal remedies, ergot of rye, will not be always retained by the stomach; indeed, I have known the very smell of the decoction, or infusion, induce an intense degree of sickness, most unfavourable to the state of the patient. 3. Because uterine injections are generally more available, the issue of the case not being solely dependent on the state of the stomach to receive medicines, as is often experienced when the ordinary external means have failed. 4. Because, by the use of injections into the cavity of the uterus, we produce an immediate effect, which in many cases of uterine haemorrhage is absolutely necessary to the safety of the patient. 5. Hæmorrhage succeeding parturition is generally the consequence of atony of the uterus. The use of injections, then, which possess a stimulating action on that organ, at the same time that they influence the character of the effused and effusing blood, would appear to be peculiarly indicated. These pro-
will be found in the employment of those medicines, in the form of injection, proposed -by me in THE LANCET of Dec. 6th, 1845. It is well known that vaginal injections of cold water have been used in the suppression of uterine haemorrhage; but Dr. Ramsbotham thinks (no doubt rightly) that uterine phlebitis might ensue from their use. If such a result wereto tran-
perties
The chief new statements, which are found in Dr. Lee’s late papers, comprise assertions relative to the existence of large ganglia and plexuses, which completely cover the whole surface of the gravid uterus; the large size of the nerves which enter into the formation of those plexuses; the great increase which occurs in them during pregnancy, and their returning, after parturition, to the state in which they were previous to impregnation; and the large size of the ganglia at the neck of the uterus, and on the vagina. Each of these statements, however, will require a separate examination.
lion and plexzc,ses.-A structure figured as one inch and three quarters in length, and described as numerous large and nervous large ganglia of nerves which explexuses, which are named as branches tend up the left side of the follows:uterus from the cervix to the The anterior subperitonœal fundus. ganglia and plexuses, which The right subperitonœal gaxzgcover the whole anterior surlion and plexuses.—Structures face of the uterus as high as of similar extent and situation the fundus.-These structures as those on the left side of the are firmly adherent to the organ. peritonæum and muscular coat The left spermatic ganglion.of the uterus at the upper as three quarters of Figured part, but are separated from an inch in breadth, by an inthe muscular coat at the lower definite length, and situated in part by a thick soft layer of the vicinity of the principal cellular tissue. The middle spermatic artery and vein. part of the ganglion is more The spermatic ganglion. than two lines in thickness, - Thatright there is a similar strucbut it becomes everywhere ture on the right side " does thinner towards the circum- not admit of doubt." ference, and particularly at the 31r.. BECK’S VIEWS. inferior border. Large, broad, These various ganglia and flat, and innumerable nerves are sent off from these strucplexuses described on the body
LEE’S VIEWS. The whole surface of the gravid uterus is covered with DR.
tures to the uterus.
of the uterus
are
not
nervous
posterior subperitonœal structures, but a layer of organglia and ptexzcsss, -which ganic muscular fibres, which, in many parts, adheres to the cover the whole posterior surface of the gravid uterus, and under surface of the peritoThe
of similar structure and næum, and extends from thence to the proper muscular as those on the anterior surface.-The nerves are de- tissue of the uterus, in the scribed as equally large, broad, form of broad, flat, fasciculated bands. and innumerable. The left subperitonœal gargDR. LEE’S VIEWS. MR. BECK’S VIEWS. The great ti-ci?.,svej,.3e plexuses, The transverse plexuses are which extend across the bodv a band of -fibre-cellular tissue, of the uterus, and are described which extends across the body as a " white, pearly, fascicuof the uterus. This has only lated membrane, about one been seen in the gravid uterus. quarter of an inch in breadth." are
extent
502 The amount and size of the going to the uterus.—The amount of nerves which is believed to be supplied to the uterus may be inferred from the previous description of the different ganglia and plexuses.
The nerves which supply subsequent examinations, however, he was more successful. the uterus are very small, and Osiander, in 1829, says, (I quote from Dr. Lee’s folio, " On the Anatomy of the Nerves of the Uterus,")" Although it is measure from t4e 150th to the 200th of an inch in diameter. very probable that the uterus possesses nerves, still, hitherto, They are numerous, from 20 they have been very unsatisfactorily demonstrated, either as to 30 in number, and come off regards their number or their nature. I myself, like others, as distinct branches from the deceived by the authority of more scientific persons, formerly Various terms are used-as, hypogastric plexus. stated that nerves were spread over the whole of the human " numerous large nerves," uterus, since I believed that more skilful anatomists than " large flat nerves," " layers myself had really seen them; for example, Walter, who of broad nerves," " sheath speaks so confidently of nerves which accompany the larger of nerves," " innumerable arteries. But I know now that they have not been seen by others any more than by myself; and I can only assume that nerves," "superficial and deep the uterus, as an irritable organ, must possess nerves. But I plexuses of nerves," &e. &c. These ganglia and plexuses, The special nervous system. have not seen, and it certainly does not possess, any nerves are easily demonstrable by the scalpel, and still less any together with the utero-cer- - No special nervous system that vical ganglion, constitute "the for the uterus exists. The large branches." It would be easy to add many more authorities, all expressgreat and special nervous nerves do not differ in any the same opinions, but these appear sufficient to show the system of the uterus," and respect from those sent to the ing universal belief which prevails upon the subject. And when "are formed for the purpose stomach, intestines, liver, &c.; of supplying the uterus with and, consequently, there is no we consider that the authors already quoted rank amongst, that nervous power which it evidence to show that the the most celebrated anatomists and the most accurate obuterus receives any supply of servers, we cannot avoid asking the question, Have they requires during labour." overlooked these structures described by Dr. Lee? or have nerves which can be supposed to especially influence or pre- they seen them, and not believed them to be nerves? Had it been one or two small branches of nerves, or one or two small side over gestation. : ganglia, we might have considered they had been overlooked, The sources of the nerves supThe uterus is supplied from !and were now brought to light by our improved methods of plying the uterus.—The nerves the hypogastric plexus, which dissecting. But it exceeds the possibility of belief, to suppose are derived from the hypo- plexus is a continuation from that John Hunter, William Hunter, Tiedemann, Lobstein, and gastric plexus, and branches the superior aortic plexus, and Osiander, should have carefully dissected the gravid uterus, from the sacral nerves. consists of gelatinous nervous and not discovered structures which cover the whole anterior fibres, partially derived from and posterior surface of the uterus; which pass up the sides of the ganglia in the aortic the organ as large broad nerves, and which form large ganglia,, plexus, and tubular nervous more than two lines in thickness. We are, then, forced to fibres, derived from the lumbar the conclusion, that they must have seen these structures, but spinal nerves. The branches did not consider them nerves. Dr. Lee describes them as from the sacral nerves are not " presenting the appearance of a layer of dense structure, supplied to the uterus, but are composed of fibres strongly interlaced together, and having a distributed to the bladder, yellowish-brown colour;" " as a dense, reddish-brown coloured vagina, perinæum, and some mass, consisting of fibres firmly interlaced together;" as. to the lower part of the "thick and solid, and consisting of a yellowish-brown subrectum. stance." And, I would ask, what anatomist of the present The enlargement of the nerves The nerves of the gravid day will have the hardihood to affirm, that tissues having during pregnancy. - As the uterus are of the same size as these characters are nervous structures ? But we might still various subperitonaeal ganglia those of the unimpregnated have been left in uncertainty and doubt, had not Lobstein and plexuses do not exist, or uterus, and, consequently, out these structures, and cautioned anatoespecially pointed but very imperfectly, in the either no increase has taken mists from falling into the error of supposing them to be unimpregnated uterus, the place during pregnancy, or no nerves. After mentioning the examination of two gravid enlargement which is supposed decrease has occurred after uteri which he performed, he observes, (Additamenta, p. 169,) to take place must be very parturition. " On this occasion, I am led to observe, that when the external The nerves of the virgin tunic of the uterus is taken great indeed, and equal to away, there occurs many fibres’ that of the other structures. uterus are of the same size as which decussate in various ways with themselves, and are This enlargement has been those of the gravid uterus, united by loose cellular tissue, both with each other, and with considered by John Hunter and, consequently, they do the denser and deeper substance of the uterus. These fibres,, to be "probably fifty times." not enlarge during pregnancy, of whose I am ignorant, may be readily taken for the growth Also, the nerves " return, after nor do they undergo any continuation of nervous branches, yet they differ from them, parturition, to their original change after parturition. not only in their direction and greater thickness, but also by condition before conception the greater flatness of their figure. Wheresoever the nerves takes place." of the uterus are finally distributed, it appears certain to me,. they do not interlace with each other in the substance of Opposed to these views of Dr. Robert Lee, we have the that the uterus." authors who of all the have directed their previous opinions In making these remarks, I have endeavoured to place the attention to this subject. Waiter, in 1783, figured the nerves of the uterus, and described them as very fine, and going to question upon the " common sense" view, and to give the the neck of the organ and os uteri. Haller, in 1763, gives a opinions of authors who wrote prior to the publication of Dr. Dr. William Lee’s papers. But I may now add, the improvements which very similar description to that by Walter. Hunter, in 1794, to whom the previous descriptions were have taken place in microscopes and in microscopical anatomy,, since the time that Lobstein wrote, enable us to determine, unsatisfactory, carefully dissected a female subject for the that the layer of fibres, of the nature of which he was ignorant, purpose of describing the nerves. He describes them as the continuation of the hypogastric plexus, and says-" They are, in fact, a layer of organic muscular fibres. I am aware, in consequence of hasty and imperfect observations, some spread out in branches, like the portio dura of the seventh that difference of opinion has existed between microscopical obpair." No mention is made of large nerves or ganglia. John servers upon this subject. But I am also aware, that the difHunter, about the same time, also speaks of the uterine nerves ference has not been nearly so great as some have endeavoured the and small. in nerves, being Tiedemann, 1822, figures describes them as fine, soft, and slightly red.* Lobstein, in to make it; for words and opinions have been attributed to who neither spoke the one nor entertained the 1823, says that branches of nerves are very rarely seen to gentlemen enter the substance of the uterus, either in the unimpregnated other. is the condition of the nerves or in the gravid state, and mentions that he could not find The next question at issue pregnancy. Upon this subject John Hunter remarks, any nerves in the uterus of a woman who died twelve hours " The uterus, in the time of pregnancy, increases in substance after parturition, although he carefully looked for them. In and size, probably fifty times beyond what it naturally is; and * Dr. Robert Lee remarks- From Professor Tiedemann’s work it this increase is made up of living animal matter, which is might justly be inferred, that the human gravid uterus is more sparingly capable of action within itself. I think we may suppose its, supplied with nerves than any other organ in the body." Dr. Lee has also quoted all the authorities in the first part of his folio brochure, with tte action more than double; for the action of every individual apparent intention, of showing how much they differ from his own views, part of this viscus, at this period, is much increased, even.
nerves
Ii
during
503 of size, and yet we find that the nerves of this part are not in the smallest degree increased. This shows that the nerves and the brain have nothing to do with the actions of the part, while the vessels, whose uses are evident, increase in proportion to the increased size; if the same had taken place with the nerves, we should have reasoned from analogy :’ Dr. William Hunter observes, 111cannot take upon me to say what change happens to the system of uterine from utero-gestation, but I suspect them to be enlarged nerves in some proportion, as the vessels are. Whilst Tiedemann states that the nerves increase both in number and magnitude during pregnancy. Although Tiedemann mentions this enthe largement, yet he is far from believing that they undergo " enormous increase which Dr. Lee mentions, or that a great and special nervous system" springs up in the gravid uterus, and is" formed for the purpose of supplying the uterus with that nervous power which is required during labour." In these opinions, Dr. Lee stands alone; and when we remember that his views and opinions have been formed whilst tracing the gradual development of a layer of muscular fibres, which, as it were, springs into existence as the uterus increases in size, we have a ready explanation of the singular errors into which he has fallen. Had Dr. Lee but paid attention to Lobstein’s caution he would have saved much time and much unpleasant-
beyond its increase
matter, like other ganglia:’ Whilst Dr. Lee has applied the term, " nervous ganglia and plexuses" to muscular tissue on the body of the uterus, he has descended lower down, and called
of fibro-cellular tissue a" nervous ganglion," and, still further, he has described the fibro-cellular tissues on the side of the vagina as " large flat ganglia." Much confusion has thus arisen from the profuse mode of describing all tissues as nervous; but the real error lies in Dr. Lee not distinguishing one tissue from another. Upper Marylebone-street, Oct. 1846. a mass
descending
INSTANCE OF
FRACTURE OF THE CRANIUM, SUBSEQUENT HERNIA CEREBRI. BY GEORGE HARVEY, ESQ., Surgeon, Castle
WITH DEPRESSION, AND
Hedingham.
ON Tuesday, June 30th, at about midnight, I was summoned to William C-, an agricultural labourer, aged thirty years, who had been kicked by a horse. I found him stupidly drunk, and I considered the stupor to arise from intoxicating liquors, because he replied to questions unwillingly, and in a, sulky manner, and made great objections to his hair being cut ness. close, which was necessary, in order to permit an examination In addition to these structures upon the body of the uterus, of a small wound of the scalp, about half an inch long, just large ganglia have been described as situated at the neck of above the left ear. As the injury did not appear to penetrate the uterus, and on the vagina. through the scalp, and he was in a very sulky mood, I merely DR. LEE’S VIEWS. MR. BECK’S VIEWS. applied a superficial dressing, and sent him to bed. He very The utero-cervical ganglia.At the junction of the hypo- methodically took off his shoes, and, with the assistance of a At this junction of the hy- gastric plexus and branches man to lead him, walked up stairs. July Ist.—Slept pretty well, answers questions readily, and pogastric plexus with the from the sacral nerves, several branches from the sacral small ganglia exist. The lar- complains of pain on the left side of the head. Being in an dark room, I requested to have him removed: nerves, is situated a large gest measure about the one- inconvenient, and walked into a front room, but staghe arose, directly "It of an inch in diameter. ganglion: appears to con- eighth gered a good deal. Pulse 70; pupils natural; bowels consist of six or seven smaller These ganglia, together ; was sick last night. On examining the head, I found ganglia, which are united to- the plexus in which they are fined the swollen, and a coagulum filling up the wound. On scalp "It are surrounded with a found, gether by nervous cords." this with a sponge, a small quantity of brain escaped. is nearly two inches in breadth, thick layer of fibro-cellular removing exceeds in size the semilunar tissue. This tissue is of con- I immediately made an incision down to the bone, in the inverted T, and exposed a fracture extending ganglia of the great sympa- siderable firmness, in conse- form of an anterior inferior angle of the parietal bone, and thetic, and constitutes only a quence of the nerves and through the small portion of the nervous ganglia being, in this situation, depressed to the full extent of the thickness of the bone; but as he was the pupils being natural, and the pulse system of the human uterus." much exposed to injury. None firm and sensible, I hesitated about trephining. My partner, regular, This ganglia is considered "as of the nerves from these ganthe centre of nervous supply glia are sent to the uterus, nor Mr. Seymour, being from home, I requested the assistance of to the uterus." (THE 1,AN- does it undergo any increase my friends, Mr. Mason, of Sudbury, and Mr. Fitch, of Sible Hedingham. In consultation, we resolved to do no more than CET, p. 457.) It enlarges dur- in size in pregnancy, nor any take twenty or thirty ounces of blood from the arm, and give and returns after change parturition. ing pregnancy, of calomel immediately, repeating it at bedtime; five grains the to oriafter parturition and tea diet, gruel; to be kept still, and the chamber to be ginal condition in which it was darkened; wet lint to the wound. before conception takes place. 2nd.-Very comfortable; bowels freely moved by the From the plexus formed by calomel. The vesical ganglia, called Ordered, solution of acetate of ammonia, an ounce; " the external, middle, and in- the junction of the hypogastric of nitric ether, two drachms; camphor mixture, six spirit and branches from the " Several plexus ternal ganglia." ounces: mix: two tablespoonfuls to be taken four hours. large, flat ganglia are situated sacral nerves, branches pass off To take five grains of calomel at bedtime. every about midway between the os to the bladder, vagina, and 3rd and 4th.-The case progressed comfortably, and the uteri and ostium vaginæ." rectum. Those to the bladder same remedies were continued. " From this great web of gan- and vagina are about the one5th.-Had passed a restless night., a considerable quantity glia and nerves on the sides of sixtieth of an inch in diameter, of brain protruding; still sensible, but articulates with diffithe vagina, by which it is com- those to the rectum being culty, and very indistinctly; pulse slow; pupil of left eye pletely covered, numerous much smaller. Several mi- dilated, and nearly insensible to light-that of the right more branches are sent to the sides nute ganglia are formed on natural; bowels not moved since yesterday morning. I now of the bladder :’ The nerves these nerves. determined to raise the depressed bone, and with the trephine to the vagina are described as removed a small piece of the edge of the parietal bone, which " many large, broad nerves." enabled me to get an elevator under the depressed portion, a The plexus on the side of the vagina has been known since large irregular-shaped piece, the corner of which was driven the time of Walter, who figured it in 1783. Tiedemann, in through the dura mater. The whole of this I easily removed, 1822, has also given a representation of it, and calls it a also several small splinters, laid down the flaps, and dressed "plexus gangliosus ;" whilst Dr. Lee differs from these authors the wound with wet lint as before. Ordered, calomel, five in the very large size which he gives to this " nervous grains; jalap, ten grains: mix for a powder at bed-time. The ganglionic plexus," or " utero-cervical ganglion," and in the left pupil immediately contracted. Head to be covered with wet rags. very large size of the nerves which pass from it. In this instance, as in the preceding one, we are asked to 6th.—Much better than I expected; has passed a comfortbelieve that the distinguished anatomists, whose names I have able night; bowels relieved three times; pulse 78; mouth already quoted, could carefully dissect these parts, and yet fail affected with the calomel. He is quite sensible, and answers to discover a structure " nearly two inches in breadth, and questions with "yes" or "no" correctly; but cannot pronounce which exceeds in size the semilunar ganglia of the great sym- longer words intelligibly, although he endeavours to do so: pathetic." Had they committed so great a piece of inatten- a portion of brain, about the size of a chesnut, protrudes tion, we might, with great reason, have questioned the accuracy through the wound. Ordered to omit the calomel, but to conof the whole of their works. But it fortunately happens that tinue the mixture. Wet lint to the wound. the error lies with Dr. Robert Lee, who mistook a mass of 7th.-Passed a restless night; bowels not moved; takes tea fibro-cellular tissue, enclosing in its centre some small ganglia, and gruel; wound looks well; pulse 80. Repeat the calomel for a true ganglion, consisting of " cineritious and white and jalap at bedtime; continue the mixture.
with
with, infiltrated with a serous-looking fluid, which rapidlyspire, I am of opinion that it would be mainly attributable to coagulates, and becomes like jelly, at a heat of 840 Fahr. the shock produced on the system by the disparity of temThis exists in enormous quantities, and requires to be removed, perature between the cold injection, and the blood, and the in order to proceed with the dissection. The muscles are cavity into which it was injected. Should the view now taken of this interesting and important found pale-looking, and rather atrophied, in some cases considerably so, and with much fat and cellular tissue around point be in any way tenable, all that we have to observe is, them. The veins, except the larger ones, are diminished in that the proposed injections can easily be made of an equal size, and appear less numerous, the superficial ones being temperature, and yet retain their properties. And it requires almost obliterated. The arteries are small, compared with but slight reflection to convince ourselves that the absence what might be expected from the abnormal hypertrophy of of success in the treatment of uterine haemorrhage, experienced the parts they supply. The nerves are somewhat flattened by by the use of vaginal injections, and the disparaging opinions compression. The outer skin is not at all mobile; it seems which have been expressed relatively thereto, will not deroglued to the part; the thickness becomes less marked towards gate in the slightest degree from an altogether different class the borders of the foot. When a. portion of the skin is re- of injections—i. e., uterine, as distinct from vaginal. moved, and sliced horizontally, it seems to be composed of Braunston, Northamptonshire, Sept. 1846. layers, and has the appearance of sheets of pasteboard, soaked and firmly compressed together. The epidermis is less affected than the cutis vera, which has the physical characters of ON THE NERVES OF THE UTERUS. marked hypertrophy, although the epithelia of the former are greatly enlarged, and present an appearance not unlike the BY T. SNOW BECK, ESQ., M.R.C.S., London.
i
scales of a fish.
THE opinions of Dr. Robert Lee, and of myself, upon this subject, having been so frequently quoted in opposition to each other, perhaps it may not be inappropriate to give a short account of the opinions of each, and that they may be more ON THE UTILITY OF compared, to place them in juxtaposition. Nor does INJECTIONS INTO THE UTERINE CAVITY readily it appear improper to add to this account the statements of IN THE TREATMENT OF the principal authors upon the same subject, and then to HÆMORRHAGE, & INACTION OF THE UTERUS, DURING PARTURITION. examine the points in which any difference of opinion exists. Georgetown, Demerara, June, 1846.
BY THOMAS CATTELL, M.D., Braunston. IN THE LANCET of December 6th, 1845,I drew the attention of the profession to the utility of injections into the cavity of the uterus in the treatment of inaction, and of haemorrhage occurring at the time of, and subsequently to, delivery. I requested, at the same time,after a trial had been made,that the experience of my professional brethren might be recorded on the subject. I had, however, not observed anything relatively thereto, until the appearance of the very excellent paper by John W. Tripe, Esq., in THE LANCET of August 1st. But in this communication, Mr. Tripe has not done me the honour of making the slightest reference-all I could possibly desirealthough I am not aware that any active uterine injection had been used in these cases prior to the time at which my paper appeared. I am, notwithstanding, greatly gratified that Mr. Tripe should have taken up the subject, and that he has been able to suggest another injection, capable of producing such favourable results. The considerations which induced me to adopt the injectional mode of treating uterine haemorrhage, and inaction of the uterus during parturition, were1. Because the local treatment which has been proposed by the most eminent men in this department of practical medicine is frequently found to be inefficient, opposed to the feelings of the patient, and often impossible of adoption. I refer, for example, to plugging the vagina with a silk handkerchief, or the use of ice; insertion of the hand into the uterus; dashing cold water over the abdomen, or allowing it to drop from a height; compression of the aorta, &c. 2. Because one of our most efficient internal remedies, ergot of rye, will not be always retained by the stomach; indeed, I have known the very smell of the decoction, or infusion, induce an intense degree of sickness, most unfavourable to the state of the patient. 3. Because uterine injections are generally more available, the issue of the case not being solely dependent on the state of the stomach to receive medicines, as is often experienced when the ordinary external means have failed. 4. Because, by the use of injections into the cavity of the uterus, we produce an immediate effect, which in many cases of uterine haemorrhage is absolutely necessary to the safety of the patient. 5. Hæmorrhage succeeding parturition is generally the consequence of atony of the uterus. The use of injections, then, which possess a stimulating action on that organ, at the same time that they influence the character of the effused and effusing blood, would appear to be peculiarly indicated. These pro-
will be found in the employment of those medicines, in the form of injection, proposed -by me in THE LANCET of Dec. 6th, 1845. It is well known that vaginal injections of cold water have been used in the suppression of uterine haemorrhage; but Dr. Ramsbotham thinks (no doubt rightly) that uterine phlebitis might ensue from their use. If such a result wereto tran-
perties
The chief new statements, which are found in Dr. Lee’s late papers, comprise assertions relative to the existence of large ganglia and plexuses, which completely cover the whole surface of the gravid uterus; the large size of the nerves which enter into the formation of those plexuses; the great increase which occurs in them during pregnancy, and their returning, after parturition, to the state in which they were previous to impregnation; and the large size of the ganglia at the neck of the uterus, and on the vagina. Each of these statements, however, will require a separate examination.
lion and plexzc,ses.-A structure figured as one inch and three quarters in length, and described as numerous large and nervous large ganglia of nerves which explexuses, which are named as branches tend up the left side of the follows:uterus from the cervix to the The anterior subperitonœal fundus. ganglia and plexuses, which The right subperitonœal gaxzgcover the whole anterior surlion and plexuses.—Structures face of the uterus as high as of similar extent and situation the fundus.-These structures as those on the left side of the are firmly adherent to the organ. peritonæum and muscular coat The left spermatic ganglion.of the uterus at the upper as three quarters of Figured part, but are separated from an inch in breadth, by an inthe muscular coat at the lower definite length, and situated in part by a thick soft layer of the vicinity of the principal cellular tissue. The middle spermatic artery and vein. part of the ganglion is more The spermatic ganglion. than two lines in thickness, - Thatright there is a similar strucbut it becomes everywhere ture on the right side " does thinner towards the circum- not admit of doubt." ference, and particularly at the 31r.. BECK’S VIEWS. inferior border. Large, broad, These various ganglia and flat, and innumerable nerves are sent off from these strucplexuses described on the body
LEE’S VIEWS. The whole surface of the gravid uterus is covered with DR.
tures to the uterus.
of the uterus
are
not
nervous
posterior subperitonœal structures, but a layer of organglia and ptexzcsss, -which ganic muscular fibres, which, in many parts, adheres to the cover the whole posterior surface of the gravid uterus, and under surface of the peritoThe
of similar structure and næum, and extends from thence to the proper muscular as those on the anterior surface.-The nerves are de- tissue of the uterus, in the scribed as equally large, broad, form of broad, flat, fasciculated bands. and innumerable. The left subperitonœal gargDR. LEE’S VIEWS. MR. BECK’S VIEWS. The great ti-ci?.,svej,.3e plexuses, The transverse plexuses are which extend across the bodv a band of -fibre-cellular tissue, of the uterus, and are described which extends across the body as a " white, pearly, fascicuof the uterus. This has only lated membrane, about one been seen in the gravid uterus. quarter of an inch in breadth." are
extent
502 The amount and size of the going to the uterus.—The amount of nerves which is believed to be supplied to the uterus may be inferred from the previous description of the different ganglia and plexuses.
The nerves which supply subsequent examinations, however, he was more successful. the uterus are very small, and Osiander, in 1829, says, (I quote from Dr. Lee’s folio, " On the Anatomy of the Nerves of the Uterus,")" Although it is measure from t4e 150th to the 200th of an inch in diameter. very probable that the uterus possesses nerves, still, hitherto, They are numerous, from 20 they have been very unsatisfactorily demonstrated, either as to 30 in number, and come off regards their number or their nature. I myself, like others, as distinct branches from the deceived by the authority of more scientific persons, formerly Various terms are used-as, hypogastric plexus. stated that nerves were spread over the whole of the human " numerous large nerves," uterus, since I believed that more skilful anatomists than " large flat nerves," " layers myself had really seen them; for example, Walter, who of broad nerves," " sheath speaks so confidently of nerves which accompany the larger of nerves," " innumerable arteries. But I know now that they have not been seen by others any more than by myself; and I can only assume that nerves," "superficial and deep the uterus, as an irritable organ, must possess nerves. But I plexuses of nerves," &e. &c. These ganglia and plexuses, The special nervous system. have not seen, and it certainly does not possess, any nerves are easily demonstrable by the scalpel, and still less any together with the utero-cer- - No special nervous system that vical ganglion, constitute "the for the uterus exists. The large branches." It would be easy to add many more authorities, all expressgreat and special nervous nerves do not differ in any the same opinions, but these appear sufficient to show the system of the uterus," and respect from those sent to the ing universal belief which prevails upon the subject. And when "are formed for the purpose stomach, intestines, liver, &c.; of supplying the uterus with and, consequently, there is no we consider that the authors already quoted rank amongst, that nervous power which it evidence to show that the the most celebrated anatomists and the most accurate obuterus receives any supply of servers, we cannot avoid asking the question, Have they requires during labour." overlooked these structures described by Dr. Lee? or have nerves which can be supposed to especially influence or pre- they seen them, and not believed them to be nerves? Had it been one or two small branches of nerves, or one or two small side over gestation. : ganglia, we might have considered they had been overlooked, The sources of the nerves supThe uterus is supplied from !and were now brought to light by our improved methods of plying the uterus.—The nerves the hypogastric plexus, which dissecting. But it exceeds the possibility of belief, to suppose are derived from the hypo- plexus is a continuation from that John Hunter, William Hunter, Tiedemann, Lobstein, and gastric plexus, and branches the superior aortic plexus, and Osiander, should have carefully dissected the gravid uterus, from the sacral nerves. consists of gelatinous nervous and not discovered structures which cover the whole anterior fibres, partially derived from and posterior surface of the uterus; which pass up the sides of the ganglia in the aortic the organ as large broad nerves, and which form large ganglia,, plexus, and tubular nervous more than two lines in thickness. We are, then, forced to fibres, derived from the lumbar the conclusion, that they must have seen these structures, but spinal nerves. The branches did not consider them nerves. Dr. Lee describes them as from the sacral nerves are not " presenting the appearance of a layer of dense structure, supplied to the uterus, but are composed of fibres strongly interlaced together, and having a distributed to the bladder, yellowish-brown colour;" " as a dense, reddish-brown coloured vagina, perinæum, and some mass, consisting of fibres firmly interlaced together;" as. to the lower part of the "thick and solid, and consisting of a yellowish-brown subrectum. stance." And, I would ask, what anatomist of the present The enlargement of the nerves The nerves of the gravid day will have the hardihood to affirm, that tissues having during pregnancy. - As the uterus are of the same size as these characters are nervous structures ? But we might still various subperitonaeal ganglia those of the unimpregnated have been left in uncertainty and doubt, had not Lobstein and plexuses do not exist, or uterus, and, consequently, out these structures, and cautioned anatoespecially pointed but very imperfectly, in the either no increase has taken mists from falling into the error of supposing them to be unimpregnated uterus, the place during pregnancy, or no nerves. After mentioning the examination of two gravid enlargement which is supposed decrease has occurred after uteri which he performed, he observes, (Additamenta, p. 169,) to take place must be very parturition. " On this occasion, I am led to observe, that when the external The nerves of the virgin tunic of the uterus is taken great indeed, and equal to away, there occurs many fibres’ that of the other structures. uterus are of the same size as which decussate in various ways with themselves, and are This enlargement has been those of the gravid uterus, united by loose cellular tissue, both with each other, and with considered by John Hunter and, consequently, they do the denser and deeper substance of the uterus. These fibres,, to be "probably fifty times." not enlarge during pregnancy, of whose I am ignorant, may be readily taken for the growth Also, the nerves " return, after nor do they undergo any continuation of nervous branches, yet they differ from them, parturition, to their original change after parturition. not only in their direction and greater thickness, but also by condition before conception the greater flatness of their figure. Wheresoever the nerves takes place." of the uterus are finally distributed, it appears certain to me,. they do not interlace with each other in the substance of Opposed to these views of Dr. Robert Lee, we have the that the uterus." authors who of all the have directed their previous opinions In making these remarks, I have endeavoured to place the attention to this subject. Waiter, in 1783, figured the nerves of the uterus, and described them as very fine, and going to question upon the " common sense" view, and to give the the neck of the organ and os uteri. Haller, in 1763, gives a opinions of authors who wrote prior to the publication of Dr. Dr. William Lee’s papers. But I may now add, the improvements which very similar description to that by Walter. Hunter, in 1794, to whom the previous descriptions were have taken place in microscopes and in microscopical anatomy,, since the time that Lobstein wrote, enable us to determine, unsatisfactory, carefully dissected a female subject for the that the layer of fibres, of the nature of which he was ignorant, purpose of describing the nerves. He describes them as the continuation of the hypogastric plexus, and says-" They are, in fact, a layer of organic muscular fibres. I am aware, in consequence of hasty and imperfect observations, some spread out in branches, like the portio dura of the seventh that difference of opinion has existed between microscopical obpair." No mention is made of large nerves or ganglia. John servers upon this subject. But I am also aware, that the difHunter, about the same time, also speaks of the uterine nerves ference has not been nearly so great as some have endeavoured the and small. in nerves, being Tiedemann, 1822, figures describes them as fine, soft, and slightly red.* Lobstein, in to make it; for words and opinions have been attributed to who neither spoke the one nor entertained the 1823, says that branches of nerves are very rarely seen to gentlemen enter the substance of the uterus, either in the unimpregnated other. is the condition of the nerves or in the gravid state, and mentions that he could not find The next question at issue pregnancy. Upon this subject John Hunter remarks, any nerves in the uterus of a woman who died twelve hours " The uterus, in the time of pregnancy, increases in substance after parturition, although he carefully looked for them. In and size, probably fifty times beyond what it naturally is; and * Dr. Robert Lee remarks- From Professor Tiedemann’s work it this increase is made up of living animal matter, which is might justly be inferred, that the human gravid uterus is more sparingly capable of action within itself. I think we may suppose its, supplied with nerves than any other organ in the body." Dr. Lee has also quoted all the authorities in the first part of his folio brochure, with tte action more than double; for the action of every individual apparent intention, of showing how much they differ from his own views, part of this viscus, at this period, is much increased, even.
nerves
Ii
during
503 of size, and yet we find that the nerves of this part are not in the smallest degree increased. This shows that the nerves and the brain have nothing to do with the actions of the part, while the vessels, whose uses are evident, increase in proportion to the increased size; if the same had taken place with the nerves, we should have reasoned from analogy :’ Dr. William Hunter observes, 111cannot take upon me to say what change happens to the system of uterine from utero-gestation, but I suspect them to be enlarged nerves in some proportion, as the vessels are. Whilst Tiedemann states that the nerves increase both in number and magnitude during pregnancy. Although Tiedemann mentions this enthe largement, yet he is far from believing that they undergo " enormous increase which Dr. Lee mentions, or that a great and special nervous system" springs up in the gravid uterus, and is" formed for the purpose of supplying the uterus with that nervous power which is required during labour." In these opinions, Dr. Lee stands alone; and when we remember that his views and opinions have been formed whilst tracing the gradual development of a layer of muscular fibres, which, as it were, springs into existence as the uterus increases in size, we have a ready explanation of the singular errors into which he has fallen. Had Dr. Lee but paid attention to Lobstein’s caution he would have saved much time and much unpleasant-
beyond its increase
matter, like other ganglia:’ Whilst Dr. Lee has applied the term, " nervous ganglia and plexuses" to muscular tissue on the body of the uterus, he has descended lower down, and called
of fibro-cellular tissue a" nervous ganglion," and, still further, he has described the fibro-cellular tissues on the side of the vagina as " large flat ganglia." Much confusion has thus arisen from the profuse mode of describing all tissues as nervous; but the real error lies in Dr. Lee not distinguishing one tissue from another. Upper Marylebone-street, Oct. 1846. a mass
descending
INSTANCE OF
FRACTURE OF THE CRANIUM, SUBSEQUENT HERNIA CEREBRI. BY GEORGE HARVEY, ESQ., Surgeon, Castle
WITH DEPRESSION, AND
Hedingham.
ON Tuesday, June 30th, at about midnight, I was summoned to William C-, an agricultural labourer, aged thirty years, who had been kicked by a horse. I found him stupidly drunk, and I considered the stupor to arise from intoxicating liquors, because he replied to questions unwillingly, and in a, sulky manner, and made great objections to his hair being cut ness. close, which was necessary, in order to permit an examination In addition to these structures upon the body of the uterus, of a small wound of the scalp, about half an inch long, just large ganglia have been described as situated at the neck of above the left ear. As the injury did not appear to penetrate the uterus, and on the vagina. through the scalp, and he was in a very sulky mood, I merely DR. LEE’S VIEWS. MR. BECK’S VIEWS. applied a superficial dressing, and sent him to bed. He very The utero-cervical ganglia.At the junction of the hypo- methodically took off his shoes, and, with the assistance of a At this junction of the hy- gastric plexus and branches man to lead him, walked up stairs. July Ist.—Slept pretty well, answers questions readily, and pogastric plexus with the from the sacral nerves, several branches from the sacral small ganglia exist. The lar- complains of pain on the left side of the head. Being in an dark room, I requested to have him removed: nerves, is situated a large gest measure about the one- inconvenient, and walked into a front room, but staghe arose, directly "It of an inch in diameter. ganglion: appears to con- eighth gered a good deal. Pulse 70; pupils natural; bowels consist of six or seven smaller These ganglia, together ; was sick last night. On examining the head, I found ganglia, which are united to- the plexus in which they are fined the swollen, and a coagulum filling up the wound. On scalp "It are surrounded with a found, gether by nervous cords." this with a sponge, a small quantity of brain escaped. is nearly two inches in breadth, thick layer of fibro-cellular removing exceeds in size the semilunar tissue. This tissue is of con- I immediately made an incision down to the bone, in the inverted T, and exposed a fracture extending ganglia of the great sympa- siderable firmness, in conse- form of an anterior inferior angle of the parietal bone, and thetic, and constitutes only a quence of the nerves and through the small portion of the nervous ganglia being, in this situation, depressed to the full extent of the thickness of the bone; but as he was the pupils being natural, and the pulse system of the human uterus." much exposed to injury. None firm and sensible, I hesitated about trephining. My partner, regular, This ganglia is considered "as of the nerves from these ganthe centre of nervous supply glia are sent to the uterus, nor Mr. Seymour, being from home, I requested the assistance of to the uterus." (THE 1,AN- does it undergo any increase my friends, Mr. Mason, of Sudbury, and Mr. Fitch, of Sible Hedingham. In consultation, we resolved to do no more than CET, p. 457.) It enlarges dur- in size in pregnancy, nor any take twenty or thirty ounces of blood from the arm, and give and returns after change parturition. ing pregnancy, of calomel immediately, repeating it at bedtime; five grains the to oriafter parturition and tea diet, gruel; to be kept still, and the chamber to be ginal condition in which it was darkened; wet lint to the wound. before conception takes place. 2nd.-Very comfortable; bowels freely moved by the From the plexus formed by calomel. The vesical ganglia, called Ordered, solution of acetate of ammonia, an ounce; " the external, middle, and in- the junction of the hypogastric of nitric ether, two drachms; camphor mixture, six spirit and branches from the " Several plexus ternal ganglia." ounces: mix: two tablespoonfuls to be taken four hours. large, flat ganglia are situated sacral nerves, branches pass off To take five grains of calomel at bedtime. every about midway between the os to the bladder, vagina, and 3rd and 4th.-The case progressed comfortably, and the uteri and ostium vaginæ." rectum. Those to the bladder same remedies were continued. " From this great web of gan- and vagina are about the one5th.-Had passed a restless night., a considerable quantity glia and nerves on the sides of sixtieth of an inch in diameter, of brain protruding; still sensible, but articulates with diffithe vagina, by which it is com- those to the rectum being culty, and very indistinctly; pulse slow; pupil of left eye pletely covered, numerous much smaller. Several mi- dilated, and nearly insensible to light-that of the right more branches are sent to the sides nute ganglia are formed on natural; bowels not moved since yesterday morning. I now of the bladder :’ The nerves these nerves. determined to raise the depressed bone, and with the trephine to the vagina are described as removed a small piece of the edge of the parietal bone, which " many large, broad nerves." enabled me to get an elevator under the depressed portion, a The plexus on the side of the vagina has been known since large irregular-shaped piece, the corner of which was driven the time of Walter, who figured it in 1783. Tiedemann, in through the dura mater. The whole of this I easily removed, 1822, has also given a representation of it, and calls it a also several small splinters, laid down the flaps, and dressed "plexus gangliosus ;" whilst Dr. Lee differs from these authors the wound with wet lint as before. Ordered, calomel, five in the very large size which he gives to this " nervous grains; jalap, ten grains: mix for a powder at bed-time. The ganglionic plexus," or " utero-cervical ganglion," and in the left pupil immediately contracted. Head to be covered with wet rags. very large size of the nerves which pass from it. In this instance, as in the preceding one, we are asked to 6th.—Much better than I expected; has passed a comfortbelieve that the distinguished anatomists, whose names I have able night; bowels relieved three times; pulse 78; mouth already quoted, could carefully dissect these parts, and yet fail affected with the calomel. He is quite sensible, and answers to discover a structure " nearly two inches in breadth, and questions with "yes" or "no" correctly; but cannot pronounce which exceeds in size the semilunar ganglia of the great sym- longer words intelligibly, although he endeavours to do so: pathetic." Had they committed so great a piece of inatten- a portion of brain, about the size of a chesnut, protrudes tion, we might, with great reason, have questioned the accuracy through the wound. Ordered to omit the calomel, but to conof the whole of their works. But it fortunately happens that tinue the mixture. Wet lint to the wound. the error lies with Dr. Robert Lee, who mistook a mass of 7th.-Passed a restless night; bowels not moved; takes tea fibro-cellular tissue, enclosing in its centre some small ganglia, and gruel; wound looks well; pulse 80. Repeat the calomel for a true ganglion, consisting of " cineritious and white and jalap at bedtime; continue the mixture.
with