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THE 
 
 Abdominal and Pelvic 
 
 Brain 
 
 With Automatic Visceral Ganglia 
 
 BYRON ROBINSON, B. S., M. D. 
 
 CHICAGO, ILLINOIS 
 
 Author of "Practical Intestinal Surgery," "Landmarks in Gynecology," "Life-size Chart of the 
 Sympathetic Nerve," "The Peritoneum, its Histology and Physiology'," "Colpoperi- 
 neorrhaphy and the Structures Involved," "The Mesogastrium;" Splanchnop- 
 tosis, Professor of Gynecology and Abdominal Surgery in the Illinois Medi- 
 cal College; Consulting Surgeon to the Mary Thompson Hospital 
 for Women and Children, and the Woman's Hospital of Chicago. 
 
 FRANK S. BETZ 
 
 HAMMOND, IND. 
 
Copyright, 1907, 
 
 BY 
 
 BYRON ROBINSON 
 
 no? 
 
CO I 
 
 en 
 
 
 THIS BOOK IS DEDICATED TO THE MEMORY 
 OF MY FATHER 
 
 WILLIAM ROBINSON 
 
 WHOSE LIFE-LONG PRECEPTS WERE INDUSTRY 
 AND HONESTY 
 
PREFACE. 
 
 Where a truth is wade out by one demonstration, there needs no further inquiry; 
 but in all probability where there wants demonstration to establish the truth 
 beyond doubt, then it is not enough to trace one argument to its source and 
 observe its strength and weakness, but all the arguments, after having bee 
 examined on both sides, must be laid in the balance, one against another; 
 and upon the whole the understanding determines its assent. — John Locke 
 on the Conduct of the Understanding. 
 
 The present volume contains views concerning the anatomy, physiology 
 and pathology of the abdominal and pelvic brain. The abdominal brain is 
 the solar or epigastric plexus. The pelvic brain is the cervico-uterine gang- 
 lion located on each side of the uterus. 
 
 A brain is an apparatus capable of reception, reorganization and emission 
 of nerve forces. It may be composed of one or more nerve or ganglion cells. 
 The book is partly based on the so-called "reflexes," as they are observed in 
 both health and disease. We understand by "reflexes" disturbances which 
 are produced in parts more or less remote from points of local irritation. 
 The reflex is the "referred disturbance" of modern writers. I have attempted 
 to show the extensive utility and dominating influence of the abdominal sym- 
 pathetic nerves upon the animal economy. The reflexes and rhythm con- 
 cerning organs under various conditions are discussed. The automatic 
 menstrual ganglia are presented as the peripheral ganglia of the uterus and 
 oviducts. No attempt has been made to divorce the cerebro-spinal and 
 sympathetic nervous systems from their exquisite mutual dependency. Yet, 
 notwithstanding this latter, the abdominal sympathetic nerve, under observed 
 conditions of defect of the cord and cerebrum, acts with a certain degree of 
 independence. I do not claim that deep-seated, grave diseases are caused 
 by reflex irritation, nor that these diseases are dispersed by removal of the 
 reflex or peripheral irritation. However, it may be stated that the chief 
 suffering is not due to deep-seated disease, but to superficial, reflex irritation, 
 which brings in its train innumerable disturbances capable of unbalancing 
 the complex abdominal visceral system. 
 
 The course of reflex irritation may be observed clinically as: (1), Per- 
 ipheral (reflex, infective) irritation; (2), indigestion; (3), malnutrition; (4), 
 anemia; (5), neurosis. The final stage is the irritation of the innumerable 
 abdominal sympathetic ganglia by waste-laden blood, which produces the 
 hysteria and neurasthenia. 
 
 This book is practically a treatise on the abdominal sympathetic nerves 
 (nervus vasomotorius abdominalis), a resume of views which I have dis- 
 cussed in current medical literature for a decade and a half. 
 
 The subject of gastro-duodenal dilatation, on which I have studied and 
 practiced since 1893, will be found discussed in detail. 
 
Splanchnoptosia is presented from a practical viewpoint. Its physiol- 
 ogy, anatomy, pathology, as well as its treatment — medical, mechanical and 
 surgical — are exposed for general practice. The views noted in this book on 
 splanchnoptosia are the result of observation in seven hundred personal 
 autopsic abdominal inspections and fifteen years devoted to special labors in 
 gynecologic and abdominal surgery. The comparison of the living clinical 
 features of splanchnoptosia and those observed in the dead is not omitted. I 
 have endeavored to present a practical view on the diagnosis and treatment 
 of constipation and sudden abdominal pain, which will be suggestive to the 
 general practitioner. Throughout the book will be observed the dominating 
 influence of the genital viscera over all other viscera, explained by the mag- 
 nitude of their nerve supply (pelvic brain). For ten years I have attempted 
 to emphasize and teach the importance of knowledge of pathologic physiol- 
 ogy. A short pioneer chapter on pathologic physiology of abdominal viscera 
 is introduced to emphasize its signification and practical value to general 
 physicians. This subject I have attempted to teach by word and pen 
 for a decade. The essay on diagnosis and treatment of reflex neurosis from 
 disturbed pelvic mechanism will suggest to the general practitioner rational 
 views of handling such cases. 
 
 In this book I wish to recommend vigorously, especially to the younger 
 members of the profession, what I term "visceral drainage." By its sys- 
 tematic, persistent employment the physician can accomplish vast benefit for 
 the patient and successfully establish a permanently increasing clientele on 
 rational treatment. 
 
 The chapter on shock has been ably and practically presented by Dr. 
 Lucy Waite, Head Surgeon of Mary Thompson Hospital of Chicago. 
 Neither time nor expense has been spared to produce accurate and original 
 illustrations of practical worth. A definition of a structure is of value, but a 
 picture does it a thousand times as well. I am aware that the present vol- 
 ume does not belong to the stereotyped, systematized text-books ; yet I am 
 confident that the thinking reader will find in its pages ample reward for its 
 perusal. It is also hoped that since it is chiefly the fruit of original labor it 
 will prove of interest alike to general practitioner and specialist. 
 
 A portion of this book, entitled "Abdominal Brain and Automatic 
 Visceral Ganglia," was published in 1899 by the Clinic Publishing Company, 
 the copies of which were exhausted in 1904. Numerous repetitions occur 
 in the book, arising from the fact that each chapter was written independent 
 of the others and is practically complete in itself. Fragments of this book 
 were published in medical journals such as the Medical Review of Revicn's, 
 Medical Age, Medical Brief, Milzvaukee Medical Journal, Medical Fort- 
 nightly, Medical Review, Medical Record, Medical Standard, Physician and 
 Surgeon, New York Medical Journal, Alabama Medical Journal, Medical 
 Times, Columbus Medical Journal, America)i Medical Compend, St. Paul 
 Medical Journal, Central States Medical Monitor and Mobile Medical and 
 Surgical Journal. Zan D. Klopper is the artist. Byron Robixsox. 
 
 Chicago, III., October, 1906. 
 
CONTENTS. 
 
 CHAPTER PAGE 
 
 I. A Historical Sketch of the Developmental Knowledge of the Sympathetic 
 
 Nerves 11 
 
 II. Classification of Diseases Which May Belong in the Domain of the Sympa- 
 thetic Nerve 28 
 
 III. Applied Anatomy and Physiology of the Abdominal Vasomotor Nerve 
 
 (Nervus Vasomotorius) 33 
 
 IV. The Trunk of the Sympathetic Nerves (Nervus Truncus Sympathicus) ... 39 
 V. Plexus Aorticus Abdominalis. (A), Anatomy; (B), Physiology 46 
 
 VI. The Vasomotor Iliac Plexus. Plexus Interiliacus Vasomotorius (Sympa- 
 thicus) 52 
 
 VII. The Nerves of the Tractus Intestinalis. Nervi Tractus Intestinalis. (A), 
 
 Anatomy ; (B), Physiology 62 
 
 VIII. The Nerves of the Tractus Urinarius. Nervi Tractus Urinarius 76 
 
 IX. The Nerves of the Genital Tract. Nervi Tractus Genitalis. (A), 
 
 Anatomy ; (B), Physiology 87 
 
 X. Nerves of the Blood-vessels. Nervi Tractus Vascularis. (A), Anatomy; 
 
 (B), Physiology 103 
 
 XL Nervus Tractus Lymphaticus ILL 
 
 XII. Abdominal Brain (Cerebrum Abdominale) /T12 
 
 XIII. Pelvic Brain (Cerebrum Pelvicum) \13L 
 
 XIV. General Considerations 162 
 
 XV. Independence of the Sympathetic Nerve 187 
 
 XVI. Anatomic and Physiologic Considerations 193 
 
 XVII. Physiology of the Abdominal and Pelvic Brain with Automatic Visceral 
 
 Ganglia 204 
 
 XVIII. Considerations of the Removal of Abdominal and Pelvic Tumors 208 
 
 XIX. The Abdominal and Pelvic Brain with Automatic Visceral Ganglia in Re- 
 gard to the Sexual Organs 227 
 
 XX. The Automatic Menstrual Ganglia 240 
 
 XXI. Menopause 253 
 
 XXII. General Visceral Neurosis 267 
 
 XXIII. Relation between Visceral (Sympathetic) and Cerebro-spinal Nerves. -The 
 
 Xerve Mechanism of Pelvic and Associated Regions 278 
 
 XXIV. Hyperesthesia of the Sympathetic 302 
 
 XXV. Motor Neurosis 318 
 
 XXVI. Gastro-Intestinal Secretion 329 
 
 XXVII. Secretion. Neurosis of the Colon 334 
 
 XXVIII. Reflex Neurosis from Disturbed Pelvic Mechanism 340 
 
 XXIX. Constipation — Its Pathologic Physiology and Its Treatment by Exercise, 
 
 Diet and "Visceral Drainage" 311 
 
 XXX. Shock 382 
 
 XXXI. Sudden Abdominal Pain — Its Significance 398 
 
 XXXII. General Pathologic Physiology 432 
 
 XXXIII. Pathologic Physiology of the Tractus Intestinalis 448 
 
 XXXIV. Pathologic Physiology of the Tractus Genitalis 460 
 
 XXXV. Pathologic Physiology of the Tractus Urinarius 479 
 
 XXXVI. Pathologic Physiology of the Tractus Nervosus (Abdominalis) 495 
 
 XXXVII. Pathologic Physiology of the Tractus Vascularis 502 
 
 XXXVIII. Pathologic Physiology of the Tractus Lympathicus 514 
 
 XXXIX. Splanchnoptos'ia 546 
 
 XL. Sympathetic Relation of the Genitalia to the Olfactory Organs 654 
 
THE 
 
 Abdominal and Pelvic Brain 
 
 WITH 
 
 AUTOMATIC VISCERAL GANGLIA. 
 
 PHYSIOLOGIC AND ANATOMIC CONSIDERATIONS. 
 
 CHAPTER I. 
 
 A historical sketch of the developmental knowl- 
 edge OF THE SYMPATHETIC NERVES. 
 
 The sympathetic nerve presides over rhythm, circulation, sensation, absorption, 
 secretion and respiration — nutrition. 
 
 "The cloud-capped towers, the gorgeous palaces, tlie solemn temples, the great 
 globe itself, yea all which it inherits shall dissolve and, like the baseless 
 fabric of a vision, leave not a wreck bcliind." — William Shakespeare's 
 epitaph, written by his own hand, placed on his statue in Westminster Abbey. 
 
 The sympathetic system of nerves was discovered by Claudius Galen, 
 who was born 131 and died in 201 to 210 A. D. He lived first at Pergamos, 
 and finally at Rome. Galen considered that the sympathetic nerves acted 
 as buttresses to strengthen themselves as they proceeded from their origin. 
 He studied them in animals and evidently did not know that the sympathetic 
 nerves were a part of the cerebro-spinal system. It appears that before his 
 time the sympathetic ganglionic system of nerves was entirely unknown as 
 to their function or nature. Yet doubtless Aristotle viewed them many 
 times in his dissections, and wondered what such white cords and nodules 
 signified. It appears that the Arabians had some ideas concerning the 
 sympathetic system. 
 
 Galen was the author of the dogma that the brain was the place of 
 origin of the nerves of sensation, and the spinal cord of those of motion. In 
 general medical literature he has the credit of discovering the sympathetic 
 nerve, and as Galen was a practical anatomist (learning his anatomy, how- 
 ever, almost exclusively from animals) he perhaps gave a quite accurate 
 account of the sympathetic, and this became quoted, until he was finally 
 announced to be its father and discoverer. Galen gave correct views of the 
 omentum and peritoneum. He seems to have been quite well acquainted 
 with the ganglia of the abdominal nerves. 
 
 li 
 
12 THE ABDOMIXAL AND PELVIC BRAIX 
 
 It is claimed that the sympathetic was known to the Hippocratic school. 
 Hippocrates (460 — 370 B. C. ), who practiced medicine at Athens, Greece, 
 doubtless saw the sympathetic many times, at least in animals, but did not 
 interpret its functions. Yet he was one of the first to cast aside tradition, 
 which, by the way, still lingers, and to practice medicine on a basis of 
 inductive reasoning, just as a carpenter takes careful measurements before 
 building a house, or as a physicist studies astronomy. 
 
 Erasistratus (340 — 280 B. C.) believed that all nerves arise from the 
 brain and cord, but doubtless did not recognize the sympathetic nerves as 
 such. It appears, however, that he separated nerves into those of motion 
 and sensation. He studied particularly the shape and structure of the brain. 
 
 Herophilus (300 B. C. ), it appears, dissected more than all his predeces- 
 sors, both in man and animals. He was the first to distinguish nerves from 
 tendons, which Aristotle confounded. Herophilus gave the duodenum its 
 name because it is twelve inches or finger breadths in length. He, like 
 Erasistratus, distinguished nerves of motion from those of sensation, and 
 added a careful study of the brain. We all remember his "Torcular 
 Herophili, " or wine-press. 
 
 Aristotle (384 B. C), who widely dissected animals while instructing 
 Alexander, the son of King Philip, no doubt saw the sympathetic system 
 frequently, yet did not interpret its significance, for he confounded tendons 
 and nerves. 
 
 B. Eustachius, an Italian anatomist, who died in 1574, considered that 
 the sympathetic nerves originated from the abducens or sixth cranial nerve. 
 It was not until the name of Thomas Willis (1622-1675), an English 
 physician, appeared in anatomical records that the proper significance of the 
 sympathetic nerves was recognized. Willis looked on the sympathetic 
 system of nerves as an appendage of the cerebrospinal system and repre- 
 sented them as growing from the cerebrospinal nerves. Many neurologists 
 hold the same opinion today as did the able Willis two hundred and fifty 
 years ago. He looked upon the sympathetic nerves as a kind of diverticula 
 for the animal spirits received from the brain. In 1660, while Sedleian 
 professor of philosophy at Oxford, he described the chief ganglia. 
 
 Rene Descartes (1569-1650) was one of the first to describe reflex move- 
 ments from ganglia. 
 
 R. Yieussens (1641-1716), a French anatomist, wrote a work entitled 
 
 Fig 1. It presents a general view. 1 and 2, abdominal brain. B represents the pelvic 
 brain or ganglion cervicale. Observe the profound and intimate connection between the 
 abdominal brain (1 and 2) and the pelvic brain (B) by means of the plexus aorticus (10 and 
 12) and plexus hypogastrics (H). Note the lateral chain of the sympathetic ganglia from the 
 cervical ganglia (1) to the last sacral ganglion (S G). 1 and 2, abdominal brain, is the major 
 assembling point of the plexuses of the abdomen. Observe the plexus aorticus with its mul- 
 tiple ganglia and two lateral cords extending from the abdominal brain (1 and 2) to the 
 bifurcation of the aorta. Next note the hypogastric plexus, beginning at the aortic bifurca- 
 tion and ending practically in the pelvic brain (B). H, the hypogastric ganglion is a coal- 
 esced, unpaired organ. The major sympathetic ganglia are located at the origin of arteries, 
 hence every abdominal visceral artery has at its origin a definite ganglion. In drawing the 
 pelvic brain suggestions of Frankenhauser were employed. The dissection was performed 
 under alcohol. 
 

 
 Fig. 1. AN ILLUSTRATION OF THE SYMPATHETIC NERVE 
 
14 THE ABDOMINAL AND PELVIC BRAIN 
 
 "Neurograph" in 1684, in which he adopted the views of Willis, that the gan- 
 glionic nerves were appendages of the cerebrospinal system. 
 Vieussens wrote of the ganglia of the solar plexus. 
 Prochaska described the reflex channels. 
 Duverney (1643-1730) discovered the ciliary ganglia. 
 J. M. Lancisus (1654-1720), an Italian anatomist, wrote a monograph on 
 the sympathetic nerves, agreeing with the keen Willis as regards structure. 
 His monograph was entitled "Opera Omnia." Lancisus looked upon the 
 sympathetic nerves as a kind of forcing pump adapted to propel the animal 
 spirits along the nerves. 
 
 The senior Johann Friedrich Meckel (1714-1774), in his "Memories de 
 Berlin," 1745, held views on the subject of the sympathetic nerves similar to 
 those of Willis, as did also Johann Gotfried Zinn (1727-1759) in a publica- 
 tion in 1753. 
 
 J. B. Winslow (1669-1760), a Dane, professor of anatomy in Paris, 
 insisted in his writings on the independence of the sympathetic nerves. 
 Since that time writers have wavered between the opinions of Winslow 
 (independence) and Willis (dependence) in regard to the sympathetic nervous 
 system. Yet up to one hundred years ago actual physiologic and experi- 
 mental data were quite limited. Bichat, who widely influenced the anatomic 
 world, vigorously proclaimed the independence of the sympathetic ganglia. 
 
 Hoare wrote a publication in 1772 on the sympathetic system entitled 
 "De Ganglia Nervorum." 
 
 Antoine Scarpa (1752-1832), the Italian anatomist of "Scarpa's Triangle" 
 fame, wrote an essay on the sympathetic system entitled "De Nerv. Gangl." 
 in 1779. This work of course contained the views of previous writers. 
 
 Alexander Monro (Monro secundus, 1733-1817), a Scotch anatomist of 
 Edinburgh University, published an essay "On the Structure and Function of 
 the Nervous Ganglia," in 1783. The later writers analyzed more in detail 
 and generalized in a manner superior to that of previous writers, yet all 
 agreed or disagreed with Willis or Winslow. 
 
 Johann Friedrich Blumenbach (1752-1840), a German anatomist, in 
 "Institutes of Physiology," published views on the sympathetic nerves in 
 1786. 
 
 Francois Chaussier (1746-1828), a French surgeon and anatomist, wrote 
 an "Exposition" of the sympathetic nerves in 1807. 
 
 In 1812 Le Gallois wrote "Sur le Principe de la Vie," containing views 
 on the sympathetic nerve. 
 
 In 1823 views of the sympathetic nerve appeared in Beclard's "El. 
 d'Anat. Gen." 
 
 Georges Cuvier (1769-1832), a famous French naturalist, espoused the 
 doctrine of the independence of the sympathetic nervous system as published 
 in his "Lecons d'Anat. Comp.," 1799. 
 
 Xavier Bichat (1771-1802), the master intellect of his day in Paris, 
 professor of anatomy and physiology, the associate and rival of the priestly 
 physician, Pinel, may be heard insisting with his accustomed eloquence 
 
DEVELOPMENTAL KNOWLEDGE OF SYMPATHETIC NERVES 15 
 
 upon the independence of the sympathetic nervous system, as noted in his 
 "Sur la Vie et la Mort.," 1802. Bichat represented all the ganglia of this 
 system as the particular centers of organic life, that not only were all the 
 ganglia collectively independent, but that each ganglion was independent of 
 rvery other ganglion, that each nerve proceeding from such a ganglion was 
 in a great measure independent from that ganglion, and even that each point 
 of such a nerve was independent of all the rest and consisted of a distinct 
 focus of nervous influence. Bichat's influence is distinctly traceable 
 through subsequent writings on the sympathetic system. 
 
 Wilson Philip wrote "On the Vital Functions," in 1817, analogous to the 
 grand center of animal life. He also held views referring to the sympathetic 
 system. 
 
 In Mason Good's work "On the Study of Medicine, " 1825, views are 
 expressed in regard to the sympathetic nervous system. 
 
 Writers on the sympathetic system became more numerous in the period 
 subsequent to 1800. 
 
 Richerand (Phys. 1804), and Gall (Anat. et Phys. du Syst. Nerv., 1810), 
 adopted tenets concerning the sympathetic nervous system similar to those of 
 Bichat. 
 
 Wurtzer in 1817 (De Corp. Hum. Gang.) further inculcated Bichat's, 
 Winslow's and Cuvier's views. 
 
 Broussais, whose name is indelibly connected with inflammation of the 
 peritoneum as Bichat's is with establishing the independence of the 
 sympathetic, describes a peculiar kind of sensibility or irritability belonging 
 to the sympathetic nerves with which it immediately endows all organs 
 destined for nutrition, secretion and the other organic functions, and, by 
 means of its repeated connections with the cerebrospinal system, all organs 
 of the body. 
 
 Brachet, in his "Sur les Fonctions du Syst. Nerv. Gang.," 1823, in an 
 especial manner, distinctly represents the ganglionic system of nerves as the 
 seat of "imperceptible sensation" and as presiding in an especial manner 
 over the several viscera of the body. The author, though not acquainted 
 with Richerand's and Bichat's views, worked out the same views from orig- 
 inal studies and experiments, but added the idea that the abdominal brain 
 (solar plexus) is the chief organizing center of the abdominal sympathetic. 
 
 The preceding views are simply some of the chief landmarks in the 
 progress of the evolutionary development of the knowledge of the sympa- 
 thetic nerves, in the direction of their function and signification. 
 
 The most significant names among the brilliant galaxy of students of 
 the sympathetic nerves are Willis, Bichat, Cuvier, Winslow and Brechet. 
 
 In 1835 articles on the sympathetic nerves began to appear from the pen 
 of James George Davy, of London, England, which study and writing on 
 the sympathetic he continued for about thirty years. In 1858 the same 
 author published a book "On the Ganglionic Nervous System." The work 
 is composed of 109 pages, is interestingly written and contains about all the 
 real knowledge of the subject up to that date (1858). Davy claimed that 
 
16 THE ABDOMINAL AND PELVIC BRAIN 
 
 much of his book was original, and doubtless this industrious worker produced 
 many new views in thirty years of labor. Yet Davy, as we view him forty 
 years past, appears very honest in that he credits the gifted Bichat with so 
 many original views and vast conceptions. The writer can only hope that 
 readers forty years hence will view this present little volume with similar 
 candor and charity. 
 
 Bichat's genius established in medical literature the sympathetic nerves 
 under the names "organic and vegetative" system, because he saw analogies 
 between the nerves which preside over viscera (and hence nutrition) and the 
 life of plants. He considered that the sympathetic nerves induce an animal 
 to live, assimilate and nourish, induce circulation and excretion — in short 
 to have an habitual succession of assimilation and excretion sufficient to 
 preserve life's integrity by a vital inherent process. No effort was required 
 of the animal — all was done in the so-called sub-conscious region, by what 
 we might call today unconscious or imperceptible sensation. It is especially 
 the sub-conscious, the imperceptible traumatic insults of pathologic processes 
 among viscera, which the writer will attempt to elucidate. 
 
 Bichat paved the way for a more ready appreciation of the physiology of 
 the sympathetic system. Dr. Grant, a writer of some sixty years ago, said 
 that "the sympathetic nerves, appropriated to the more slow and regular 
 movements of organic life, form a more isolated system" (than the cerebro- 
 spinal). It appears that Dr. John Fletcher wrote learnedly on the sympa- 
 thetic system in his "Rudiments of Physiology," published in 1837, for in 
 May, 1853, Dr. Davy read an essay "On the Physiologic Uses of the 
 Ganglionic Nervous System" before the London Medical Society, whereupon 
 M. Walford, of Reading, addressed a curt note to Dr. Davy informing him, 
 politely, that it was Dr. Fletcher who deserved the credit of "establishing 
 on an immutable basis the function of the great sympathetic nerves." Davy 
 very honestly relates how he sent a paper on the sympathetic nerve to the 
 Lancet, but the editor not only rejected it, but did not return the manuscript. 
 This was in 1836. The strife concerning priority in regard to views upon 
 the divisions of the nervous system was very active some sixty years ago. 
 Among the participants might be named Marshall Hall, Robert Reid, Davy, 
 Gall, Brechet, Blane, Mayo and others. However, one and all bowed 
 before the magnificent intellect of Bichat. Bichat located the passions in 
 the "epigastric center," and believed that they belong to the sympathetic 
 nerves. Bichat's opinion dominated medical ideas for three-quarters of a 
 century after his death. Buffon, Cabanis, Reil and Broussais, contem- 
 poraries of Bichat, located the passions in "the Viscera of the Chest and 
 Belly," or represented them as belonging to the ganglionic system of nerves. 
 
 The labors of Morgagni and Petit (1827) should be mentioned, as well as 
 those of Bergen (1731), Walter (1783), Huber (1774), Gerald (1754), Weber 
 (1831), Rudolphi (1818), Lobstein (1823) (nerve tables), Manee (1828), 
 Radcliff (1846), Hall (1847), Moses Gunn, inaugural thesis (1846), Robin 
 (1847), Wagner (1847), and Axmann (1847). Valentin, Kraus (1857), Bourgery 
 (1845), Arnold (1826), Andersch, Haller, Wrisberg, Sommering, Remak, 
 
DEVELOPMENTAL KNOWLEDGE OE SYMPATHETIC NERVES 17 
 
 Muller, Lee (Frankenhauser, 1867), and Baker are but some of the many 
 workers in the field of the sympathetic. 
 
 Todd and Bowman named the solar plexus 'the abdominal sympathetic 
 system" (1847). Solly called the solar plexus "the center of the cyclo- 
 ganglionic system" (1848). There is little doubt that to Bichat is due the 
 credit of originating the doctrine of the entirety and independence of the 
 sympathetic nervous system. Later writers, as Cuvier, Richerand, Gall, 
 Wurtzer, Broussais, Brechet, Solly and Fletcher, have taught similar views. 
 Many older neurologists divided the nervous system into three distinct 
 divisions, viz. : (a) cerebral, (b) spinal and (c) sympathetic. 
 
 Le Gallois, a noted neurologist, taught that the spinal cord was the 
 source of a part of the ganglionic nervous system, but Davy strenuously 
 denies Le Gallois' assertion and remarks that the medical profession never 
 acknowledged it. About 1840 no less distinguished a person than Marshall 
 Hall asserted that in the removal of the frog's viscera "every portion of the 
 ganglionic system" would also be removed. This showed lack of anatomical 
 knowledge. But by 1840 such writers as Cuvier, Solly, Bichat, Richerand, 
 Wurtzer, Gall and Broussais claimed that every ganglion of the sympathetic 
 was independent of the remainder and that each ganglion is a distinct focus 
 of nervous influence. It was Broussais (the founder of the idea of independ- 
 ent peritoneal inflammation) who claimed that the ganglia presided over the 
 viscera and their functions. 
 
 Prochaska and John Hunter asserted that the ganglia of the sympathetic 
 nervous system generate and control nervous power. Any one can witness 
 this fact by separating a frog from its heart. The heart will beat for hours 
 alone. The cerebrospinal nerves together perform the animal functions 
 which prove us to be feeling and thinking and willing beings. 
 
 The ganglionic system of nerves, with the abdominal brain as their 
 central organ, performs the vital functions, which are independent of mind 
 and present to us the idea of life. The sympathetic system of nerves 
 presides over the viscera — over secretion, nutrition, gestation, expulsion, 
 respiration and circulation; over sub-conscious phenomena. 
 
 Muller, Bayly, Rolando, Akermann, Blumenbach and Gall agreed to the 
 following views (by 1840), viz. : The sympathetic system of nerves of the 
 chest and abdomen are fully formed while the brain is yet a pulpy mass. 
 Now, these ganglia of the sympathetic would hardly be formed before the 
 brain and cord if it were not for the sake of the organs which they supply 
 and rule. Besides, it may be added that the sympathetic controls the 
 viscera, which are as perfect at birth as in the adult. But the mind and 
 brain are very slowly perfected. The priority of the sympathetic nerves over 
 the cerebrospinal is evident and signifies their import in the continuance of 
 the vital forces of life. Babies are born alive with no brains. Dr. Ball, of 
 Ohio, writes me that he found one baby fully formed without even a 
 medulla oblongata. Marshall Hall records that a fetus was born "without 
 either a brain or spinal marrow, without a particle of either of those organs, 
 yet perfectly developed." Blumenbach furnishes an equal example, when 
 
 2 
 
18 THE ABDOMINAL AND PELVIC BRA1X 
 
 he says, "In fetuses without brain or spinal marrow the circulation, nutrition, 
 secretion, etc., proceed equally as in others, who, besides spinal marrow, 
 nerves and ganglionic nervous system, possess a brain." 
 
 Children are born quite well developed without the vestige of a cerebro- 
 spinal system, — only possessing a sympathetic system. It might be argued 
 that often these children originally possessed a cerebrospinal system, but 
 that through pressure, as hydrocephalic conditions, the fluid had pressed 
 the nerve-cells out of existence. Yet this does not explain all the cases. 
 
 In 1872 there appeared one of the best and most reliable books on the 
 sympathetic system of nerves up to that date. The authors are Guttmann 
 and Eulenberg. It was translated from the German into the English in 1878 
 by Dr. C. Napier. This work was based on physiologic and pathologic 
 labors. It was for this essay of Eulenberg and Guttmann that the Astley 
 Cooper Prize for 1877 was originally awarded — a decision which was subse- 
 quently overthrown, however, on the technical ground that the essay was the 
 work of two authors and not one only, as the terms of Sir Astley Cooper 
 would seem to require. 
 
 In 1802 William Hunter presented the nerves of the uterus. The 
 Osianders, father and son, also did similar work in 1808-1818. Tiedemann 
 (1822) made valuable observations on uterine nerves. Lobstein, in 1823, 
 produced excellent views on the sympathetic. He carefully described the 
 various plexuses by the names we now give them. 
 
 In 1839 Robert Lee gave some good descriptions of the sympathetic 
 uterine nerves, as also Snow Beck (1845) with Clay, Goetz, Schlem, Swan 
 1846), Killian (1834) and Lambell (1841). 
 
 In 1867 a most excellent work was published by Dr. F. Frankenhauser, 
 entitled: "The Nerves of the Uterus." It contains finely executed tables of 
 the sympathetic nerves of the abdomen. 
 
 The sympathetic nervous system is shown to be supremely evident when 
 we note the body nourished, the viscera perfected and the bony structures 
 finished, without a brain or cord, and still more evident when we observe 
 the finely balanced circulation, delicate absorption and secretion, in full and 
 perfect operation for nearly a year without a cord or brain — only a sympa- 
 thetic nervous system to rule. Should the main-spring of life, the 
 abdominal brain, solar ganglion, cease its activity, then life itself disap- 
 pears. The sympathetic nerves carry on life's functions during sleep, like 
 the additional spring to a watch which enables it to go while being wound. 
 
 By 1850 the physician had not lost sight of the fact that the sympathetic 
 nerve, being so intimately associated with the vital action of every viscus, 
 could become involved in disease. For the past fifty years the pathology of 
 the sympathetic has been studied. In the work of Davy may be found 
 numerous diseases attributed to the sympathetic. Dr. Marshall Hall stated 
 that: "The ganglionic system is that power under which all formation, all 
 nutrition, all absorption and all secretions are performed; therefore, that 
 being affected may affect different acts." 
 
 The opinions of men famous, though dead, still prevail. Bidder produced 
 
developmhxt.il knowledge OFSYMPATHETIC NERVES 19 
 
 a celebrated article, in Midler's Archives for Physiology, in 1844, entitled: 
 "Experience over the Functional Independence of the Sympathetic as the 
 Center of Motion and Sensation for all the Vegetative Organs." Volkmann 
 assumed the same views as Bidder in his well-known article: "The Inde- 
 pendence of the Sympathetic Nervous System Demonstrated through 
 Anatomical Investigations" (1842). Prof. Albert V. Kolliker, of Wurtzburg, 
 who is now celebrating his fifty-year jubilee as a medical teacher, assumed 
 an intermediate ground between Bidder and Volkmann, when in 1845 he wrote 
 his article entitled, "The Independence and Dependence of the- Sympathetic 
 Nervous System Demonstrated by Anatomical Observation." Budge in 1864 
 gave some reliable data in regard to the nerves of the bladder, in Henle's 
 and Pfeufer's "Landschrift fur rational Medicin, " as did also Gianozzi in 
 1863. 
 
 The history of the developmental knowledge of the sympathetic is not 
 complete without the names of Schiff, Henle, Ludwig, Heffer and especially 
 the often-quoted experiments of Nasse found in his article: "Lecture on the 
 Physiology of Bowel Motion," Leipsic, 1866. Henle stated, in 1840, that 
 the peristalsis of the intestines was due to ganglia scattered among the 
 intestinal nerves. Brown-Sequard, Pickford, Remak (1864), Jastrowitz 
 (1857,) Rochefontaine, Tarchanoff, Pflueger, Bernard, Golz and Knoll aided 
 in the building of the present knowledge of the sympathetic. 
 
 In 1860 DuBois-Reymond inferred that migraine was due to the influence 
 of the cervical part of the sympathetic, i. e., it produced a kind of tetanic 
 contraction of the vessels, showing the influence of the sympathetic over 
 vessels. He styled it Hcmicrania sympathetica atonica. Cruveilhier and 
 Aran are credited with discovering muscular atrophy, but Charles Bell (1832) 
 gives several cases. Bell places muscular atrophy under the domain of the 
 sympathetic. Parry (1825) discovered a group of symptoms which we now 
 call exophthalmic goiter (Graves' or Basedow's disease) which many place in 
 the field of the sympathetic nerve. The three great symptoms are (a) 
 cardiac palpitation, (b) goiter and (c) finally exophthalmos. Basedow (1840) 
 claimed to have first described the disease, but the priority of Graves is now 
 universally known. 
 
 Angina Pectoris, described by Heberden in 1768, is considered by many 
 as caused by the sympathetic nerves, especially the three cervical ganglia 
 and the cardiac plexuses. Addison's disease is placed by some in the field of 
 the sympathetic. 
 
 In 1783 Walter presented the best tables of the sympathetic nerves up 
 to his day. It appears that Walter was the first who represented in his 
 cuts the cervico-uterine ganglia, i. e., lateral ganglia of the uterus. 
 
 The above authors discuss in a very instructive method the various 
 diseases of the sympathetic and attempt to establish, as far as possible, the 
 physiologic, anatomic and pathologic limits of the domain of the sympathetic 
 nerves. Especially interesting and valuable, though unfortunately limited, 
 are the discussions upon the abdominal parts of the sympathetic. 
 
 Eulenberg and Guttmann discuss as belonging to the domain of the 
 sympathetic system, the following diseases: 
 
20 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 1. Functional disturbances, especially those dae to irritation and paraly- 
 
 sis. 
 
 2. Unilateral Hyperidrosis (perspirat .:>n) 
 
 3. Hemicrania i neuralgia i. 
 
 4. Glaucoma (Nenro-retinitis, ophthalmia, neuro-paralytica). 
 
 5. Progressive Facial Hemiatrophy. 
 
 6. Progressive Muscular Atrophy. 
 
 7. Exophthalmic Goiter (Basedow's or Graves' disease). 
 
 8. Angina Pectoris (steno-cardi:. . 
 
 9. Addison's disease (bronzed skin). 
 
 10. Diabetes Mellitus. 
 
 11. Hyperesthesias of the sympathetic system: 
 
 (a) Enteralgia, enterodynia, colic. 
 
 (b) Neuralgia celiaca. 
 
 (c) Neuralgia hypergastrica. 
 
 (d) Neuralgia spermatica (ovarica). 
 
 12. Anesthesias of the sympathetic system ''not well established). 
 
 13. Sympathetic paralysis and spasmodic affections of voluntary muscles. 
 Reflex paralysis, diphtheritic paralysis, tabes dorsalis (.locomotor ataxia, 
 progressive . 
 
 The above thirteen classes of disease discussed as belonging to the 
 domain of the sympathetic nerves have remained a more cr less constant 
 quantity with writers on the sympathetic nerve. However, some writers 
 add, others subtract, while still others change the names of the above 
 diseases. The subject is in a state of progress. 
 
 In 1867 Griesinger began investigations on the "Pathology of the 
 Sympathetic." Griesinger's enthusiasm stimulated two physicians, Dr. Paul 
 Guttmann and Dr. Albert Eulenberg, to produce one of the best and most 
 reliable books on the pathology of the sympathetic based on physiologic 
 grounds ever published. Griesinger's good work and enthusiasm were 
 productive of practical results: for his remarkable words, that "our positive 
 knowledge of the pathology of the sympathetic should be again collected 
 by skilled hands," induced his scholars, Eulenberg and Guttmann, to study 
 and write their prize book on the sympathetic nerves. 
 
 In 1876 a very learned and a very instructive essay appeared from the 
 ^en of Dr. Sigmund Mayer, entitled, "Die Peripherische Nerven Zellen und 
 das Sympathetische Nerven System. " Dr. Mayer was full five years engaged 
 in the work in his microscopical laboratory and presented many interest- 
 ing ideas and some of the most suggestive drawings of the nerves and cells. 
 The essay represents many new views and vast labors. 
 
 In 1881 there appeared the "Fisk Fund Prize Essay," Rhode Island 
 Medical Society — "The Sympathetic Nerve; its Relation to Diseases," by 
 C. V. Chapin. M. D. This is a valuable essay, as it gives many authorities 
 and references which enable us to enlarge our knowledge of this nerve. Dr. 
 Chapin has sifted out the theoretical and practical knowledge of the nerve 
 quite well. Chapin has but little deviation from the classification of the 
 
DEVELOPMENTAL KNOWLEDGE OF SYMPATHETIC NERVES 21 
 
 diseases which belong to the sympathetic of Eulenberg and Guttmann. An 
 epitome of Chapin's book would be, that it is a record of opinions on the 
 sympathetic nerve skilfully collected and arranged in a scholarly manner. 
 
 In 1885 Dr. W. H. Gaskell published the results of some excellent labor 
 on the sympathetic system of nerves. One of the best was entitled: "The 
 Structure, Distribution and Function of Nerves which Innervate the V'^ceral 
 and Vascular Systems." Dr. Gaskell noted some of the following p-j.nts: 
 
 1. The visceral nerves issue from the central nervous system indefinite 
 sacral, thoracic and cervico-cranial regions. 
 
 2. From the above regions the visceral nerves pass through the ganglia 
 into the visceral system. 
 
 3. From the sacral region they pass in a single stream to the ganglia of 
 the collateral chain. 
 
 4. From the thoracic region they pass in a double stream, one to the 
 ganglia of the lateral chain, the other to the ganglia of the collateral chain. 
 
 5. From the upper cervical region they pass in a single stream to the 
 ganglia on the main stem of the vagus and glosso-pharyngeal nerves. 
 
 Gaskell's labors on the sympathetic are of far-reaching value and their 
 utility has been recognized by being copied very generally, and even in detail, 
 in the best modern works on physiology. 
 
 Rauber did some excellent work on the sympathetic, and his labor is 
 recognized by Quain's latest edition borrowing one of his cuts. 
 
 In 1885 Dr. Edward Long Fox published a well-written and very 
 instructive book on "The Influence of the Sympathetic on Disease." This 
 is the most comprehensive of late books on the sympathetic. He widens 
 the influence of the sympathetic in the domain of disease beyond that laid 
 down by Eulenberg and Guttmann. He includes insomnia, neurasthenia, 
 pigmentation, myxedema and neuroses of the extremities — symmetrical 
 gangrene. The writer can highly recommend Dr. Fox's book as instructive 
 and valuable. Articles of merit and value on the sympathetic nerves have 
 appeared with increasing frequency during the past ten years. 
 
 In 1877 Gubler described a morbid symptom of the peritoneum related 
 to the sympathetic system. He called it peritonismus. He included pain, 
 meteorismus in various degrees, hiccough, vomiting, rapid pulse, cyanosis, 
 lowering of the temperature, cerebral symptoms of great activity, depression 
 of mental powers and decrease of amount of urine. The nerves of the heart 
 are affected. This aggregate of symptoms Gubler designated by the word 
 peritonismus. The abdominal surgeon only too frequently sees this clinical 
 picture, but it is doubtful how much is gained by designating it as perito- 
 nismus. , 
 
 THE PELVIC BRAIN. 
 
 (A.) Macroscopic. 
 
 From the stately rhythm and periodic peristalsis of the uterus in labor, 
 the early observer must have been impressed with the nerves governing the 
 genitals. However, from the unfortunate dogma of the church, the light of 
 
22 THE ABDOMINAL AND PELVIC BRAIN 
 
 knowledge of anatomy and physiology was denied mankind by prohibiting 
 human dissection. So far as I have been able to note almost all observations 
 on the nerves of the genitals (uterus), previous to the fifteenth century, were 
 almost valueless. 
 
 Among the first names I find in literature referring to the nerves of 
 the uterus is that of A. Vesalius, a Belgian by birth, professor of anatomy 
 at the famous school of Padua, Italy. He was born in 1514 and died in 1564. 
 Vesalius made the general statement (partly false and partly true) that 
 the cervix was supplied by the sacral nerves (spinal) while the fundus was 
 supplied by the sympathetic. 
 
 This view of Vesalius generally prevailed for two centuries and was 
 practically confirmed by the following famed eponymic names on anatomy: 
 Eustachius (died 1574), Reignier de Graaf (1641-1673), Thomas Willis 
 (16-22-1675), Albert Haller (1708-1777), Johann G. Walter (1734-1818). With 
 investigation (anatomic and physiologic), and lapse of time, views changed. 
 especially among the French, English and Germans. Definite records of 
 dissection and observation on the nerves of the tractus genitalis (uterus) 
 begin to accumulate in literature. 
 
 Eustachius, an Italian anatomist of Eustachian tube fame, published at 
 Amsterdam in 1722 Tabula Anatomica. Eustachius described the nerves 
 connecting the lumbar ganglia with the hypogastric plexus, which in union 
 with branches from the sacral nerves arrived at the side of the uterus. 
 
 Reignier de Graaf, a Dutch anatomist of Graffian follicle fame, published 
 at Amsterdam in 1705 "Opera Omnia." He dissected and pursued the nerves 
 to the uterus, ovary, oviduct and ligamentum latum. The presentations are 
 schematic and description crude. 
 
 Thomas Willis, an English anatomist and philosopher of Circle of Willis 
 fame, published at Geneva in 1680 "Cerebri Nervorumque Descriptio." 
 Willis first described the course of the ovarian nerves, though defectively. 
 He styled the solar plexus, cerebrum abdominale. 
 
 Albert Haller, a Swiss anatomist of multiple eponymic fame, published 
 at Lausanne in 1778 Elementa Physiologiae. He limited the origin of the 
 ovarian nerves to the plexus renales and lateral sympathetic chain only. 
 This error was repeated by Tiedemann in his 1822 publication. He left no 
 illustration. 
 
 R. Vieussens (1641-1716), a French anatomist of multiple eponymic 
 fame (the ganglion of Vieussens — solar plexus), left a rough presentation of 
 the sympathetic. 
 
 Johann Gottlieb Walter, a German anatomist of "coccygeal ganglion" 
 fame, published at Berlin in 1783 talnilcc ncrv. Thoracis ct Abdominis. He 
 presents several excellent copper-plate tables of the thoracic and abdominal 
 nerves, which have become famous for accurateness and careful preparation. 
 To 1875 Walter's tables were the best presentation of the sympathetic, 
 especially the best and most accurate in their presentation of the sympathetic 
 nerves supplying the female tractus genitalis. Walter's tables are not 
 schematic but naturally correct, excelling the later much-lauded tables of 
 
DEVELOPMENTAL KNOWLEDGE OF SYMPATHETIC NERVES 23 
 
 Tudemann (1S22). It is the first presentation of the tractus genitalis in its 
 natural position and in connection with the pelvic and abdominal viscera. 
 Unfortunately the plexus aorticus and especially the plexus hypogastrics is 
 incompletely presented. Also the course of the nerves in the uterus and 
 ovary is not indicated. Walter was the first who presented a ganglion on 
 the lateral borders of the cervix uteri. Hence these nerve masses or nodes 
 should be known by the eponym "Walter's cervico-uterine ganglion." 
 Walter's plates of the sympathetic are superior to those of Tiedemann but 
 are not so well known. It is a rare book. 
 
 William Hunter (171^-1783), the celebrated English obstetrician, pub- 
 lished an atlas on the nerves of the pregnant human uterus which is a note- 
 worthy work. I could find no presentation of the uterine nerves originating 
 from the sacral nerves in the atlas. Hunter asserted that the uterine nerves 
 all rise from the intercostal, that they assume the same course as the blood- 
 vessels and that therefore on each side will occur a plexus spermaticus and 
 plexus hypogastrics A plexus springs from the ganglion semilunare and 
 while it passes to uterus is strengthened by branches from the intercostals. 
 The plexus aorticus emits nerves to the plexus renalis, which gives origin to 
 the plexus spermaticus. The plexus aorticus divides into two nervi hypogas- 
 tric!, distal to the aortic bifurcation. Each hypogastric nerve divides into 
 a dorsal branch supplying the rectum and a ventral branch which follows 
 the arteria uterina to supply the uterus. The greatest number of nerve 
 branches tend toward the cervix uteri, according to Hunter. He believed 
 that the uterine nerves increased in dimension during gestation, furnishing 
 no proof by specimen however. 
 
 John Hunter (1728-1793), the famous brother of William Hunter, asserted 
 that its nerves did not increase in dimension during gestation, also adding 
 no proof by specimen. William Hunter shows sympathetic nerves supplying 
 the cervix, corpus and fundus uteri. Previously and subsequently to 
 Hunter's time it was a widespread dogma that the sympathetic nerve 
 supplied corpus and fundus uteri only — not the cervix uteri. 
 
 Johann Friedrich Osiander (son, 1787-1855), obstetrician at Gottingen, 
 published a prize essay in 1808 on Nerves of the Uterus, noting that he 
 believed that nerves were present in the uterus but could not detect them. 
 
 Friedrich Benjamin Osiander (father, 1759-1822), obstetrician at 
 Gottingen, inventor of uterine traction forceps, asserted in his Handbook of 
 Obstetrics, 1818, that he doubted if any man had seen nerves in the uterus. 
 
 Friedricus Tiedemann (1781-1861), German professor of anatomy in 
 Heidelberg from 1816 to 1844, published in Heidelberg in 1822 Tabulae 
 Nervorum Uteri, which has become extensively and favorably known, many 
 times copied, and prized as the best presentation of the nerves of the uterus 
 in connection and with the natural position of the viscera. Tiedemann's 
 plates are schematic, defective and inferior to those of Walter — his predeces- 
 sor by thirty-seven years. Tiedemann's plates, like Walter's and Hunter's, 
 are the most imperfect in presenting the relations of the sacral nerves to 
 the hypogastric plexus and uterus. Tiedemann advocated that the nerves 
 of the uterus were enlarged during gestation and atrophied during senescence. 
 
24 THE ABDOMINAL AND PELVIC BRAIN 
 
 J. G. C. F. M. Lobstein (1777-1815), a French anatomist and obstetrician 
 at Strassburg published at Paris in 1823 nervi sympatJictici Humani Fabrici, 
 etc. Lobstein accentuated the plexus mesentericus superior and inferior. 
 He practically denied the existence of the plexus spermaticus. 
 
 My observation of Lobstein's book on the sympathetic induces me to 
 think that he obscured and retarded its knowledge rather than advanced it. 
 For fifty years, to 1875, no special work appeared on the nerves of the 
 tractus of the female. The general assertion for half a century, on whose 
 authority I know not, was that the sacral nerves supplied the cervix and 
 the sympathetic the body and fundus. In 1839, in an atlas to the book of 
 Frances Joseph Moreau (1789-1862) entitled Traite pratique des accoucJiemans, 
 appeared a new illustration of the nerves of the pregnant uterus after J. M. 
 Jacquemier (1806-1879). It is schematic, defective, imitates Tiedemann's 
 plates and their errors and adds practically nothing new. 
 
 From 1838 to 1846 occurred the fierce polemic on the nerves of the 
 uterus between Robert Lee and Snow Beck, chiefly found in the Philosophi- 
 cal Transactions. Robert Lee (1793-1877), an English obstetrician, physician 
 to the British Lying-in Hospital, published several papers on the nerves of 
 the uterus from 1838 to 1846. Lee claimed to find under the perimetrium 
 several nerve plexuses which were connected with the ovarian and hypogas- 
 tric plexuses as well as the sacral nerves. Since Lee produced no convincing 
 evidence, no microscopic demonstration as regards the cellular structure of 
 the claimed nervous ganglia, suspicion arose among his colleagues (especially 
 Snow Beck) that he had mistaken elastic fibres, connective or muscular 
 tissue of the uterus for nerve plexuses. Lee was an Englishman of typical 
 vigor, possessing the spirit of progress and was not easily turned aside by 
 adverse criticism of opposing colleagues. He said the processes which he 
 had held for nerves branched with the arteries of the uterus, a fact which, 
 according to Lee, occurred nowhere with elastic or muscular tissue. By an 
 industrious prosecution of his dissecting labors he rediscovered in 1841, 
 Walter's cervico-uterine ganglion (of 1783) and proved it a constant structure. 
 
 Lee's Monograph, the anatomy of the nerves of the uterus, 1841, lies 
 before me. It is an excellent labor by an earnest investigator. It contains 
 two plates some 10x10 inches illustrating the dissected nerves and ganglia 
 of two pregnant uteri, one in the sixth and the other in the ninth months of 
 gestation. Lee said, in short, that his dissections prove that the uterus 
 possesses a great system of nerves, that they enlarge with gestation and 
 return to the original condition subsequent to parturition. 
 
 Also, if the nerves of the uterus could not be demonstrated to exist, its 
 physiology and pathology would be completely inexplicable. Lee repeatedly 
 demonstrated the cervico-uterine ganglion in the pregnant and non-pregnant 
 uterus. He showed that the plexus hypogastrics ended in the great cervico- 
 uterine ganglion, which he claimed was composed of six or seven smaller 
 unifed by nerve strands and located on the lateral border of the cervix uteri. 
 He noted that the branches of the second and third sacral nerves entered the 
 cervical ganglion. Lee located a ganglion at the junction of the uterus and 
 
DEVELOPMENTAL KNOWLEDGE OE SYMPATHETIC NERVES 25 
 
 the oviduct. He also located a subperitoneal ganglion on the dorsum of the 
 corpus uteri and one on the ventrum of the corpus uteri of the extensive 
 surface dimension. These subperitoneal ganglia, according to Lee's illus- 
 trations, extend over large surface areas of the corpus uteri and stand in 
 connection with the hypogastric plexus and cervico-uterine ganglion. 
 
 Modern investigations, especially by the aid of the microscope, demon- 
 strate that Lee's extensive subperitoneal ganglion do not exist. Later in 
 Lee's dissecting labors he had Dalrymple make microscopic sections of the 
 nerve plexuses which confirmed their nervous structure, but no mention is 
 made of a microscopic examination to confirm the nervous structure of the 
 uterine ganglia. Robert Lee located three vesical ganglia, viz: (a), external 
 vesical ganglia; (b), middle and (c), external vesical ganglia. Later he 
 described but two internal and external vesical ganglia. Dr. Robert Lee made 
 valuable additions to the literature of the nerves of the uterus. His labors 
 aroused vigorous opponents and valuable polemics by which was instigated 
 extensive additional researches. He rediscovered Walter's cervico-uterine 
 ganglion, hence, the memory of this earnest investigation should be entitled 
 to the eponym, "Lee's cervico-uterine ganglion." 
 
 T. Snow Beck, an English anatomist, published in 1846 in the Philo- 
 sophical Transactions, several investigations concerning the nerves of the 
 uterus, which were almost a complete negation of Lee's views. Snow Beck 
 claimed that Lee's cervico-uterine ganglion was merely a mass of connective 
 tissue containing a few small ganglion cells, that it was due to the union of 
 the branches of the sacral nerves and hypogastric plexus. He similarly 
 disposed of Lee's other uterine ganglia. Snow Beck gave detailed descrip- 
 tions of the uterine nerves, adding some illustrations which contain 
 numerous errors. He, like Lee, had prepared the specimens on the extir- 
 pated genitals — not while they were in situ. This insured confusion in 
 non-accuracy and supposed schematism. 
 
 In 1894 I advocated that the ganglionated mass located at the lateral 
 border of the uterus should be termed the pelvic brain (cerebrium pelvicum). 
 
 T. Snow Beck introduced the term pelvic plexus, which is the result of 
 the union of the branches of the sacral nerves second, third and fourth with 
 the distal end of the hypogastric plexus. Secondary to Snow Beck the 
 second sacral nerve sends one branch to the pelvic plexus, the third sends 
 12 or 13, the fourth, 5 or 6. Small ganglia are distributed over the pelvic 
 plexus, which sends nerves to the bladder, vagina (10 to 12) and rectum but 
 not to the uterus. T. Snow Beck indicates that many of the uterine nerves 
 are very fine, threadlike and without plexiform character. T. Snow Beck's 
 illustrations are obscure, the descriptions contradictory, and doubtless 
 prepared after being extirpated from the body, which increased the errors. 
 He denied the claim of Robert Lee that the uterine nerves enlarged in 
 dimensions during gestation. T. Snow Beck's iconoclastic negation of 
 Lee's conclusions in regard to the nerves and ganglia of the female genitals 
 served rather as a sample of medical polemic of those times than to enhance 
 knowledge. The work of Clay, 1845, and that of Swann, 1846, The Physiol- 
 
26 THE ABDOMINAL AXD PELVIC BRAIN 
 
 ogy of the Nerves of the Uterus, were not to me accessible, but since I find 
 nowhere citations from them perhaps they contain nothing new. 
 
 Antoine Joseph Jobert (de Lamballe) (1799-1867), a French anatomist 
 and surgeon, published in 1841 in Comptes Rendus de Science de V Academic, 
 T XII, No. 20, his Researches stir la Disposition dcs Nerfs de V uteres. His 
 illustrations are faulty and his work adds little new data. Jobert announces 
 that no nerves penetrate the portia vaginalis uteri. 
 
 Ludwig Moritz Hirschfield (1804-1876), professor of anatomy at Paris 
 and Warsaw, and Jean Baptiste Francoise, Leville (1769-1829), French 
 anatomist, published in 1853 Neurologic des Cript et Icongraphic du System 
 Nerveaux. The same illustrations are employed in the Atlas of Savage, 
 1863. The illustrations are not clear and visceral positions with nerve 
 relations are incorrect. 
 
 Ferdinand Frankenhauser (died 1894), a German obstetrician, published 
 at Jena in 1867 Die nerven der Gebaermntter. This book is excellent, 
 accurate, comprehensive, unique and instructive. Though a book of 82 pages 
 only, it is a monument of industry for all time. His descriptions are 
 accurate, his illustrations are according to Nature. I am indebted to Dr. 
 Frankenhauser for his labors in the sympathetic nerves, especially those of 
 the tractus genitalis. His honor is admirable in crediting justly to every 
 author his share in the developmental knowledge of the sympathetic nerves. 
 Other authors have labored in the microscopical field of the sympathetic 
 nerve but space forbids further mention. 
 
 (B.) Microscopic. 
 
 Reliable microscopical examinations of the nerves of the tractus genitalis 
 are limited in number and separated by long intervals. Microscopic anatomy 
 began about 1850. W. M. Hunter (1805), Robert Lee (1846) and Fr. 
 Tiedemann (1822) claimed that the uterine nerves increased in dimension 
 during gestation. John Hunter, the brother of William Hunter, denied 
 that the nerves enlarge during gestation, that the thickening was due to 
 multiplication of the connective tissue. 
 
 Herman Friedrich Kilian (1800-1863), a German obstetrician, published 
 in 1851 in the ZeitscJirifi fur rationclle mcdicin, a work Die Nerven des 
 Uterus, which founded for all time the microscopic structure of the uterine 
 nerves. Kilian attempted to determine which part of the uterus was sup- 
 plied by sympathetic and which by spinal nerves by the aid of the micro- 
 scope. He claimed that both sympathetic and spinal nerves supplied all 
 parts of the uterus, but sympathetic nerves only were found in ovarian 
 plexuses. He claimed that the cervix is richer in nerves than the body. 
 Ganglion cells lie nowhere in the uterus. Kilian announced an age 
 relation of uterine nerves. During pueritas the nerves were limited in 
 number and dimension. During adolescence the number increased. During 
 gestation the number and dimension were marked. During senescence the 
 nerves became lessened in number and dimension. Kilian concerned himself 
 with: (a) the origin of the uterine nerves; (b) the changes experienced by a 
 
DEVELOPMENTAL KNOWLEDGE OF SYMPATHETIC NERVES 27 
 
 nerve passing through the uterus; (c) the age relations. Frankenhauser of 
 Jena in lsiU, Koerner of Breslau in 1864, Kehrer of Giessen in 1864, Polle 
 of Gottingen in 1805, Frey, 1867, and Kolliker (1817 — living) and Koch (1843 — 
 living,) in 1865 published accounts of ganglia on the uterine nerves (in 
 addition to the cervico-uterine ganglion). To 18(37 little was added to the 
 great work of Kilian except ganglia on the uterine nerves and special nerve 
 ending in the uterus. 
 
 We have thus finished a very limited and meager sketch of the sympa- 
 thetic nerve. Vast numbers of worthy names and workers have not been 
 mentioned for want of space. However, a few of the landmarks in the 
 development of the knowledge of the sympathetic nerves have been noted, 
 from Galen, its discoverer, to the present time. The sympathetic nerve has 
 long been an unknown field as to facts. Our knowledge of the nerve is still 
 incomplete and will be for some time to come. 
 
 To the scholar and investigator the steps by which knowledge is gained 
 are not only interesting but of value for further progress. 
 
CHAPTER II. 
 
 A CLASSIFICATION OF DISEASES WHICH MAY BELONG IN 
 THE DOMAIN OF THE SYMPATHETIC NERVES. 
 
 The sympathetic nerve concerns itself with the life of the viscera. It presides 
 ■■■ the visceral economy. 
 
 "A man's poller is hedged in by necessity, which, by mat ments, he 
 
 touches on every side, until he learns its art." 
 
 — Ralph Waldo Emerson. 
 
 We here present the classification of diseases considered to belong to 
 the domain of the sympathetic nerve by various writers. The classification 
 has no hard or fast lines, but we present it for the purpose of securing a 
 general or bird's-eye view of the field of the sympathetic. The field of definite 
 action, physiologic, anatomic or pathologic, of the cerebrospinal and 
 sympathetic nerves, is not yet settled. The pathology of the sympathetic 
 must rest on its physiologic paths. Physiology, with our present limited 
 anatomical means of tracing nerve fibers, is surer than anatomy. It is 
 difficult to make a satisfactory classification of diseases of the sympathetic, 
 for a multitude of symptoms, which may reasonably be supposed to depend 
 upon the sympathetic nerves, are encountered without our being able, by 
 minute examination, to recognize the morbid process upon which they 
 depend. Their chief manifestation is through reflex action, referred 
 disturbance. 
 
 Again, many sympathetic nerves, and especially ganglia, are found at 
 the autopsy sclerosed, pigmented or possessed of increased connective tissue, 
 yet the patient left no records of physical complaints during life. Hence, it 
 is difficult to retrace, in such cases, the interpretations of Nature's physio- 
 logic experiment. Also, one is not always able to decide whether the 
 pathologic findings at the autopsy are not secondary. No doubt there is a 
 special pathology of the sympathetic nerve, or rather ganglia; but it may 
 not be a recognized pathology. In normal and pathological states the 
 sympathetic nerve is constantly affected by reflex irritations. The pathology 
 of the sympathetic is chiefly observed in the cervical and abdominal ganglia, 
 and is characterized by vascularity, deposit of excessive connective tissue, 
 pigmentation, atrophy, hypertrophy, sclerosis, fatty infiltration, accumu- 
 lation of microbes and leucocytes in the ganglia, amyloid or fatty degenera- 
 tion. Sometimes the blood-vessels of the ganglia are found dilated and 
 engorged with white blood corpuscles. 
 
 Classification of diseases which are certainly, or probably, connected 
 with the sympathetic nervous system : 
 1. Functional disturbances: 
 
 (a) Irritation (hyperesthesia). 
 
 (b) Paralysis (anesthesia). 
 
 28 
 
hkMm 
 
 r :-rt 
 
 n& i kc, 
 
 
 
 Wr 
 
 It 
 
 mm 
 
 rail 
 
 d&i 
 
 m 
 
 m 
 
 AN ILLUSTRATION OF THE ABDOMINAL SYMPATHETIC NERVE OF 
 
 THE MALE 
 
 Fig. 2. It is accompanied by ureteral dilatation. 
 
 Drawn from a specimen under alcohol which I secured at an autopsy through the 
 courtesv of Dr. W. A. Evans and Dr. C. O' Byrne. 1 and 2, abdominal brain ; 1" and 12 
 represent the spermatic ganglia emitting their plexuses along the spermatic artery; H 
 represents the coalesced hypogastric ganglia. 11. inferior mesenteric ganglia. Note the 
 network of nerves ensheathingthe ureters and also the anastomosis of the plexus spermaticus 
 with the plexus ureteris. hence, the testicular pain is explained in ureteral calculus. Observe 
 the numerous and marked dimensions of the ganglia renalia. 
 
30 THE aBDOMIXAL AXD PELVIC BRAIX 
 
 2. Hyperesthesia of the sympathetic (reflex irritation) : 
 
 (a; The abdominal brain (neuralgia celiaca). 
 
 (b) The mesenteric plexus (enteralgia, enterodynia, colic). 
 
 (c) Hypogastric plexus (neuralgia hypogastrica). 
 
 (d) Gastric plexus (gastralgia, gastrodynia). 
 
 (e) Spermatic or ovarian plexus (ovarian neuralgia). 
 
 (f) Splenic plexus (splenic neuralgia). 
 
 (g) Hepatic plexus (hepatic neuralgia), 
 (h) Renal plexus (nephralgia). 
 
 (i) Pelvic brain or cervico-uterine ganglia (irritable uterus, 
 
 uterine neuralgia), 
 (j) Aortic plexus. 
 (k) Diaphragmatic plexus. 
 (1) The cervical ganglia. 
 
 (m) The cardiac ganglia fcardialgia, angina pectoris). 
 (n) Trigeminus (facial neuralgia). 
 
 3. Anesthesia of the sympathetic. 
 
 4. Paralysis or spasmodic affections of voluntary muscles: 
 
 (a) Locomotor ataxia. 
 
 (b) Epilepsy. 
 
 (c) Diphtheritic paralysis. 
 
 5. Progressive muscular atrophy : 
 
 (a) Pseudo-muscular atrophy. 
 
 (b) Progressive facial hemiatrophy. 
 
 6. Visceral neuroses: 
 
 (a) Hysteria. 
 
 (b) Gastralgia. 
 
 (c) Gastrodynia. 
 
 (d) Insomnia. 
 
 (e) Pleurodynia. 
 
 (f) Peritonismus. 
 
 (g) Mastodynia. 
 
 7. Neurasthenia. 
 
 8. Pigmentation: 
 
 (a) Spleen. 
 
 (b) Liver. 
 
 (c) Uterus. 
 
 (d) Adrenals. 
 
 9. Addison's disease (bronzed skin), 
 
 10. Hemicrania (.headache). 
 
 11. Trigeminal neuralgia (facial neuralgia). 
 
 12. Exophthalmic goiter, Pavy's (1825), Graves' (1635), or Basedow's 
 
 - 10) disease. 
 
 13. Angina pectoris or stenocardia (Heberden's disease (1768). 
 
 14. Diabetes mellitus ^hepatic neuralgia). 
 
 15. Diabetes insipidus (renal neuralgia). 
 
DISEASES IX DOM, II X OF SYMPATHETIC NERVES 31 
 
 16. Unilateral hyperidrosis (sweating). 
 
 17. Edema. 
 
 L8. Diarrhea. 
 
 19. Glaucoma. 
 
 20. Myxedema (sterodema). 
 
 21. Symmetrical gangrene of the extremities. 
 
 22. Pathologic changes in the sympathetic in other diseases: 
 
 (a) In syphilis. 
 
 (b) In old age. 
 
 (c) Leukemia. 
 
 (d) Sunstroke. 
 
 (e) Infectious diseases. 
 
 (f) Cardiac diseases. 
 
 (g) Malignant diseases, 
 (h) Pigmentation. 
 
 23. Splanchnoptosia. 
 
 The above table records diseases which are certainly or probably 
 connected with the sympathetic nervous system. However, some of them 
 ere much more doubtfully connected than others. 
 
 We will here consider briefly the hyperesthesias (neuralgias) of the 
 abdominal brain and its closely related plexuses of nerves. In regard to 
 the functional disturbances, or reflex irritation, we have hyperesthesia or 
 exalted irritability of the sensory nerves. The hyperesthetic nerve manifests 
 itself first by pain, secondly by a reflex act on a motor apparatus. Hyperes- 
 thesia, or exalted irritability of the sympathetic nerves, is liable to manifest 
 pain irregularity, periodically, paroxysmally, and yet retain some irritability 
 during the intervals. The symptoms of hyperesthesia are generally uniform 
 and persistent throughout the duration of the disease. Early life is very free 
 from hyperesthesia of nerves and it does not endanger life. Anatomically, 
 we know little of the characteristic changes in structure in hyperesthesia. 
 The etiology of hyperesthesia is obscure; however, malnutrition is perhaps a 
 bottom factor. The presence of certain substances, such as lead, will induce 
 hyperesthesia or lead colic (neuralgia saturnina). Climate, sex and age 
 play a role, as does anemia or plethora. Checking of secretions induces 
 hyperesthesia, as does rheumatism or congestion. Hyperesthesia generally 
 runs a chronic course, is periodic, is seldom completely recovered from, is 
 often a forerunner of organic disease, is very persistent individually, and is 
 doubtless accompanied by tonic spasm of vessels. 
 
 Hyperesthesia of the nerves of special sense is manifested by phantasms. 
 One of the objects of this little volume is to attempt to show anatomically 
 and physiologically how reflex irritation in one diseased viscus will unbalance 
 the rest. For example, what gynecologist has not personally observed that a 
 tender, irritable uterus will unbalance the other viscera (abdominal and 
 thoracic) year after year. From some form of malnutrition or other morbid 
 process the uterus has become chronically hyperesthetic, and the result is 
 that the secretions and excretions, visceral rhythm and circulation, are 
 
32 THE ABDOMINAL AND PELVIC BRAIN 
 
 disturbed, while malnutrition results with an accompanying neuroses, which 
 is due to the nerve apparatus being bathed in waste-laden blood. 
 
 It is not easy, practical or even useful to discriminate between hyperes- 
 thesia and a visceral neurosis, as one may blend into and become identical 
 with the other. The active hyperesthesias of the great ganglia of the 
 sympathetic system are characterized by an overpowering sense of prostra- 
 tion, a sense of impending dissolution, as if the center of life itself would be 
 destroyed. This is the essential and common story of neurotic women. A 
 blow on the pit of the stomach makes one stand with overwhelming awe of 
 a coming danger, a sense of death-like anxiety and annihilation. These 
 profound impressive sensations are characteristic of the sympathetic nerve. 
 He who has once fainted need not be told of profound sensations. It may 
 be stated here that the indefiniteness of the symptoms and findings in the 
 sympathetic tracts have induced theoretical writers to offer placebos to the 
 profession in the form of a profusion of terms, such as gastralgia, gastrodynia, 
 gastric neuroses, and gastric neuralgia, terms some of which mean nothing 
 to the diagnostician, and are confusing to physicians. 
 
 From a careful study of visceral neuralgia it is evident that it is a second- 
 ary disease. It consists of a peculiar malnutrition of a sensitive nerve 
 apparatus. The treatment of visceral neuralgia consists in improving nutri- 
 tion, relieving present distress by harmless means and removing all depressing 
 causes. The cause producing the reflex irritation of different viscera must 
 be discovered and the appropriate remedial agent employed. 
 
CHAPTER III. 
 
 APPLIED ANATOMY AND PHYSIOLOGY OF THE ABDOMINAL 
 VASOMOTOR NERVE (NERVUS VASOMOTORIUS). 
 
 A complete nervous apparatus consists of nerve or ganglion cell (c. g. cerebrum), 
 a conducting cord (e. g. spinal cord, peripheral nerve), a periphery (e. g. 
 Touch corpuscle). 
 
 "Defeated o'er and o'er but ne'er disgraces."— From the London Times and placed 
 on a monument to Lord Bcaconsfield. 
 
 The sympathetic system of nerves (nervus vasomotorius) has experi- 
 enced a variety of names. Synonyms: The vasomotor nerve (nervus 
 vasomotorius) (Benedict Stilling, 1840 — German anatomist and surgeon, 
 1810-1879). The sympathetic nervous system (systema nervorum sympath- 
 icum). The vegetative nervous system (systema nervorum vegetatorum). 
 The ganglionic nervous system (systema nervorum ganglionicum). The 
 nervous system of organic life (systema nervorum vitse organicae.) The 
 nerve system of nutritive life (systema nervorum vitas nutritiae). The great 
 sympathetic nerve (nervus sympathicus magnus). The intercostal nerves 
 (nervus intercostalis, Thomas Willis, 1622-1674, English anatomist). The 
 great intercostal nerve (nervus intercostalis magnus). The trisplanchnic 
 nerve (nervus trisplanchnicus, Francois Chaussier, 1746-1828, French 
 anatomist). The ganglionic nerves (nervus gangliosus). The visceral 
 nervous system (systema nervorum visceralis). The trunk nervous system 
 (systema nervorum trunci) (Rumpf nerven system, K. F. Burdach, German 
 anatomist, 1776-1847). Grand sympathetic. Since this system of nerves 
 rules the motion of the heart and blood-vessels I shall assume with Stilling 
 that the most appropriate term is the vasomotor nerve (nervus vasomo- 
 torius). The term "sympathetic" nerve is without signification and hence 
 should be discarded for a term significant of function; therefore, nervus 
 vasomotorius, since the blood carries nutrition to all organs, the term"nerves 
 of nutritive life" is included in the term nervus vasomotorius. 
 
 The Vasomotor Nerve 
 
 (nervus vasomotorius) or unfortunately the meaningless term sympathetic 
 nerve consists of: I, nerve ganglia, II, nerve cords, III, nerve plexuses. 
 I. The nerve ganglia, for practical purposes, present three grand 
 divisions, viz. : (1) the bilateral chain of trunk ganglia (trunci nervi sympath- 
 ici) extending from the base of the skull (ganglion of Francois Ribes, 
 1800-1864— French professor of hygiene in Mont Pieler) to the distal end 
 of the coccyx or coccygeal ganglion. (2) Three great ganglionated plexuses 
 or aggregations of ganglia known as {prevertebral plexuses) the prevertebral 
 plexuses of the thorax, abdomen and pelvis. (3) Automatic visceral ganglia 
 
 3 33 
 
34 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 or peripheral ganglia located in relation with the thoracic, abdominal and 
 pelvic viscera. The ganglia composed of nerve cells receive, reorganize 
 and emit nerve forces. II. {Afferent and efferent apparatus.} The nerve 
 cords composed of nerve fibers consist of conducting, communicating or 
 distributing apparatus. III. The vasomotor nerve possesses peculiar 
 ganglionated plexuses and nonganglionated plexuses. The vasomotor nerve 
 is connected to the spinal cord through the (a) rami communicantes; (b) 
 nervi sacralia and (c) to the cerebrum by the vagi. 
 
 Fig. 3. A diagram of the nervus vasomotorius (sympathetic) from the proximal end 
 (ganglion of Ribes) to the distal end (coccygeal ganglion of Luschka) presenting a lateral view 
 of the truncus vasomotorius (lateral chain) and the three prevertebral ganglia (cardiac, 
 coeliac and pelvic plexuses). Observe the exit of the three cardiac nerves, the three abdom- 
 inal splanchnics and the 3 (or more) pelvic splanchnics (after Flower). 
 
 GENERAL VIEW OF THE VASOMOTOR SYSTEM. 
 
 The vasomotor nerves or nervus vasomotorius originate in the cere- 
 brospinal. The bilateral halves of the vasomotor nerves (sympathetic) 
 anastomose at the proximal and distal ends in the medium plexuses, 
 especially through the cardiac plexus, the abdominal brain and pelvic brain, 
 thus solidly and compactly anastomosing, connecting all viscera into a 
 balanced system. The vasomotor or sympathetic nerves are practically the 
 visceral branches of the spinal nerves. At the origin of the visceral vessels 
 from the aorta, vasomotor ganglia as a rule exist according in size with that 
 of the vessel, e. g., at the origin of the aorta from the heart is located the 
 
ABDOMINAL VASOMOTOR NERVE 
 
 35 
 
 cardiac ganglia or plexus of Wrisberg (German anatomist [1739-1808], professor 
 at Gottingen). At the origin of the coeliac axis is located the abdominal 
 brain. At the origin of the common iliacs originally existed the pelvic brain. 
 As a rule large vasomotor or sympathetic ganglia are located at the origin 
 of large visceral vessels from the aorta. 
 
 Fig. 4 (Jacob Henle, 1809—1885). Represents the abdominal brain, the lumbar lateral 
 chain, the inferior mesenteric ganglion and the hypogastric plexus ; 2, abdominal brain; 
 3 great splanchnic ; 4, small splanchnic ; 5, superior mesenteric artery; 6, renal ganglion ; 7, 
 renal artery with its ganglionic plexus surrounding it; 8, superior mesenteric ganglion; 9, 
 ramus communicans; 10, lumbar lateral chain; 11, inferior mesenteric artery surrounded by 
 its plexus; 12, 13, sacro-iliac point; 14, innominate vein; 15, innominate artery; 16, ramus 
 communicans to inferior mesenteric ganglion; 17, ramus communicans; 18, lateral chain ; 
 19, right renal artery; 20, splanchnic minor; 21, renal ganglion; 22, splanchnic ganglion; 
 23, splanchnic major; 24 ad-renal; 25, ganglion phrenicum. 
 
36 THE ABDOMINAL AND PELVIC BRAIN 
 
 The chief manifestation of the vasomotor nerve is that it is endowed 
 with a peculiar rhythmical phenomenon. The ganglia of the nervus 
 vasomotorius alone possess rhythm. (Some advocate that muscle 
 possesses inherent power of rhythm, however, so far it is found in muscle 
 supplied by the sympathetic nerve, e. g., muscles of the various visceral 
 tracts.) 
 
 The vasomotor nerve is particularly connected to the cerebrum through 
 the vagi (proximal end) and to the spinal cord by the sacral nerves (distal 
 end). 
 
 The vasomotor nerves may pass directly from the bilateral chain of 
 ganglia to the viscera without passing through intervening ganglia or 
 plexuses, viz.: (a) pharyngeal plexuses located at the bifurcation of the 
 carotids; (b) the cardiac plexus — located at the origin of the aorta from 
 the heart; (c) the cceliac plexus (abdominal brain) located at the origin of 
 the cceliac axis from the aorta; (d) the pelvic plexus (pelvic brain) located 
 originally at the bifurcation of the aorta. These four great ganglionated 
 nerve plexuses are located intermediary between the bilateral vasomotor 
 ganglionic chain and the automatic visceral ganglion located in relation with 
 the organs. The vasomotor ganglia are originating centers for nerve fibers, 
 hence there is no relation between the number of nerve fibers which enter 
 (afferent) and the number of nerves which depart (efferent) from a ganglion. 
 The ganglia of the vasomotor nerve (composed of ganglion cells) may be 
 viewed as nervous centers, i. e., receive, reorganize and emit nerve forces — 
 to which all the physiologic and pathologic phenomena of the viscera may be 
 referred. The three prominent systems or series of ganglia constituting the 
 vasomotor nerve, for convenience of description and practical purposes, may 
 be termed: (a) primary ganglia (the vasomotor bilateral chain). They appear 
 assomatic or segmental in location on the lateral borders of the vertebra; (b) 
 secondary ganglia (the four great prevertebral plexuses). They appear to be 
 located in relation to major blood-vessels, ventral to the vertebra; (c) 
 tertiary ganglia (automatic visceral ganglia). They appear to be located in 
 relation to viscera ; in or on visceral wall. The vasomotor visceral plexuses 
 differ as much in arrangement from the vasomotor bilateral chain as the 
 latter does from the spinal cord. 
 
 The prevertebral plexuses form a kind of fusion between the cerebro- 
 spinal and vasomotor nervous systems; also they solidly and compactly 
 anastomose, unite the bilateral ganglionic vasomotor chain and the automatic 
 visceral ganglia as well as fuse the lateral halves of the nervus vasomotorius. 
 The signification of the vagi nerves may be observed when it was noted that 
 they assist in the formation of three of the four great prevertebral vasomotor 
 plexuses (see a, b, c, above). 
 
 There is a peculiar balanced relation between the vagi and vasomotor 
 nerves. In animals especially, but also in man, there is a tendency to fusion 
 of the vagi and vasomotor nerves. They act vicariously for each other. 
 The greater the dimensions of the vasomotor nerves the less the dimensions 
 of the vagi and vice versa. The vagi are practically visceral nerves supplying, 
 
ABD0MIX.1L VASOMOTOR NERVE 
 
 37 
 
 viz. : larynx, lung, heart, gastrium, liver, pancrea. The vasomotor plexuses 
 differ essentially from nerve plexuses formed by the cerebrospinal nerves. In 
 cerebrospinal nerve plexuses the afferent and efferent nerves are identical, 
 however the afferent and efferent cords may be differently combined 
 previous to entrance and subsequent to the formation of the plexus. 
 
 The efferent branches departing from the plexus are precisely the same 
 as the afferent branches that entered it. On. the contrary, in the vasomotor 
 
 .9 
 
 .1 
 
 15 
 
 LUMBAR AND SACRAL PORTIONS OF THE SYMPATHETIC 
 
 Fig. 5. 1, incised edge of diaphragm; 2, lower end of oesophagus; 3, left half of stom- 
 ach; 4, small intestine; 5, sigmoid flexure of the colon; 6, rectum; 7, bladder; 8, prostate; 
 9, lower end of left vagus ; 10, lower end of right vagus; 11, solar plexus; 12, lower end of 
 great splanchnic nerve; 13, lower end of lesser splanchnic nerve ; 14, 14, two last thoracic 
 ganglia ; 15, 15, the four lumbar vertebra? ; 16, 16, 17, 17, branches from the lumbar ganglia ; 
 18, superior mesenteric plexus; 19 21, 22, 23, aortic lumbar plexus; 20, inferior mesenteric 
 plexus ; 24, 24, sacral portion of the sympathetic ; 25, 25, 26, 26, 27, 27, hypogastric plexus ; 28, 
 29, 30, tenth, eleventh and twelfth dorsal nerves ; 31, 32, 33, 34. 35, 36, 37, 38, 39, lumbar and 
 sacral nerves. (Sappey, 1810.) 
 
38 THE ABDOMIXAL AXD PELVIC BRA IX 
 
 nerve plexuses there is no relation in dimension, number and structure of 
 the afferent and efferent nerves with each other and the vasomotor nerve 
 plexus itself. The mode of distribution of the cerebrospinal and vasomotor 
 nerves differ. 
 
 The cerebrospinal nerves practically follow blood vessels; however, they 
 divide by acute angles and do not form plexiform sheaths around blood 
 vessels. 
 
 The vasomotor nerves are generally distributed in the plexiform network 
 ensheathing vessels and entering with them into the parenchyma of viscera. 
 From the reason that the vasomotor nerves are distributed in a plexiform 
 gangliated network intimately ensheathing vessels (especially arteries) con- 
 tinuously to their destination, i. e., to the viscera, it has long originated 
 the idea that the nervus vasomotorius belongs exclusively to the vascular 
 system (blood, lymph vessels). This view was especially promulgated 
 by Claude Bernard, a French physiologist in 1K51 (1813-1873). The vaso- 
 motor nerves accompany the arteries not the veins, the trunk of the vena 
 porta forming the exception to the rule. In this chapter of applied anatomy 
 and physiology of the nervus vasomotorius abdominalis I shall mention 
 essential features only for practical reasons. I shall consider in order 
 regardless of any exact system the following subjects: Chapter IV, truncus 
 sympathicus; Chapter V, nervus plexus aorticus abdominalis; Chapter VI, 
 nervus plexus interiliacus; Chapter VII, nervi tractus intestinalis; Chapter 
 VIII, nervi tractus urinarius; Chapter IX, nervi tractus genitalis; Chapter X, 
 nervi tractus vascularius; Chapter XI, nervi tractus lymphaticus; Chapter 
 XII, the abdominal brain (cerebrum abdominale) ; Chapter XIII, pelvic brain 
 (cerebrum pelvicum). 
 
CHAPTER IV. 
 
 THE TRUNK OF THE SYMPATHETIC NERVE— (NERVUS 
 TRUNCUS SYMPATHICUS). 
 
 "One glorious hour of conquering strife is worth an age of quiet peace." 
 
 — Shakespeare. 
 
 We do well what we do automatically. 
 
 The trunk of the vaso-motor (sympathetic) nerve has experienced a 
 variety of names: 
 
 Synonyms: The lateral cords of the sympathetic; the principal cords of 
 the sympathetic; the lateral ganglionic chain of the sympathetic; the 
 nodular cords of the sympathetic. 
 
 German: Grenzstrang, Hauptstrang, Knotenstrang. 
 
 The nerve strands connecting the ganglia of the sympathetic trunk are 
 termed commissural cords. The trunk of the sympathetic nerve presents 
 the form of an elongated elipse enclosing the vertebral column, united at th e 
 proximal and distal ends by unpaired ganglia. The trunk consists of a 
 vertical, symmetrical, bilateral ganglionated cord with indefinite union at the 
 proximal end (ganglion of Ribes) and distal ends (Ganglion Coccygeum). 
 The number of ganglia and roots correspond in general to the number of 
 spinal nerves. Exceptions occur in which the ganglia coalesce, as in the 
 reduction of the seven cervical to the usual number of three. The total 
 number of trunk ganglia (3, cervical), (11, dorsal), (4, lumbar) and (4, sacral) 
 vary from 20 to 25. The form of the trunk ganglia varies and may be 
 elongated, olive, spindle, triangle, pyramidal, irregular shaped. The 
 ganglia in general are located ventral to the transverse processes and on the 
 lateral surfaces of the vertebrae. However, the relation of the ganglia in 
 each segment to the vertebra varies. The trunk ganglia vary in dimension 
 from Y\ of an inch long (inferior cervical ganglion) to less than the size of 
 a grain of wheat. The terminations, both proximally and distally, of the 
 elongated elliptical ganglionated trunk are obscurely united by ganglia or 
 commissura, cords. 
 
 A ganglion is composed of a larger or smaller number of multipolar nerve 
 cells enclosed in a capsule of connective tissue. 
 
 RAMI COMMUNICANTES. 
 
 The bilateral symmetrical vertical ganglionated trunk of the sympa- 
 thetic is connected to the spinal cord by means of the rami communicantes, 
 which are two bands of nerves extending from the spinal nerves to the 
 ganglia of the trunk of the sympathetic. These central communicating 
 branches are known as gray (sympathetic) and white (visceral) rami com- 
 municantes. The ganglionated trunk of the sympathetic nerve emits 
 
 89 
 
40 THE ABDOMINAL AND PELVIC BRAIN 
 
 important visceral branches from its different segments (cervical, dorsal, 
 lumbar and sacral) to the viscera of the thoracic, abdominal and pelvic 
 cavities. The following table will present a bird's-eye view of the segments 
 of the trunk of the sympathetic nerve with their important branches. 
 
 SUPERIOR MEDIAN GANGLION (RIBES) (GANGLION SUPERIOR MEDIUS). 
 
 fl. Superior cervical ganglion (ganglion cerv- 
 
 I. Trunk of the cervical sympathetic j 2 Middle 'c^rvica^'ganglion (ganglion cervi- 
 
 (Truncus Sympathies Cervicales). \ cale medium). 
 
 1 wo to three. 3^ i n f er j or cervical ganglion (ganglion cervi- 
 
 (. cale inferior). 
 
 II. Trunk of the dorsal sympathetic. \ EmitsVplalTchnic nerves. 
 
 (Truncus Sympathies Dorsahs). ] (Coeliac Plexus). 
 
 III. Trunk of the lumbar sympathetic. Four to five. 
 
 (Truncus Sympathies Lumbalis). | Emits lumbar branches to plexus aorticus. 
 
 IV. Trunk of the pelvic sympathetic. fp , ~ 
 
 (Truncus Sympathies Pelvinus). ] _ . . , 
 
 v J ^ Emits visceral nerves. 
 
 INFERIOR MEDIAL GANGLION (GANGLION COCCYGEUm). 
 
 I. Branches of the Cervical Trunk of the Sympathetic. 
 
 The cervical sympathetic trunk is a projection proximalward (toward 
 the cranium) along the great cervical vessels. 
 
 The branches of the three cervical ganglia and commissural cord are 
 distributed to structures of the head, neck and thorax and consist of: 
 
 (a) Motor fibres to involuntary muscles (pupil dilators). 
 
 (b) Vaso-motor fibres to head, neck and proximal limbs. 
 
 (c) Pilo-motor fibres along cervical spinal nerves. 
 
 (d) Cardiomotor fibres. 
 
 (e) Secretory fibres. 
 
 The trunk cervical ganglia are located on the prevertebral muscles 
 dorsal to the carotid artery. It extends from the first rib to the base of the 
 skull. 
 
 The cervical sympathetic trunk is characterized by the absence of the 
 white rami communicantes. The cervical ganglia, usually coalesced, from 
 seven to three in number, are important on account of the emitting of the 
 pharyngeal plexus and cardiac nerves. 
 
 A. Superior Cervical Ganglion (Ganglion Cervicale Superius). 
 
 Synonyms: Supreme cervical ganglion (ganglion cervicale supremum); 
 
 Fig. 6. The trunk of the vasomotor nerve here presented was dissected under alcohol 
 with care as regards connexions and relations. The ellipse formed by the two lateral 
 trunks is evident. The ellipse extends from the cranium to the coccyx. The two nerve 
 trunks are especially united at the cranium (cervical part) at the coeliac axis (abdominal 
 part) and the distal end (pelvic part). Between the two lateral trunks of the nervus vasomo- 
 torius lies the plexus aorticus, thoracicus, cerebrum abdominale, plexus aorticus abdominalis, 
 intenliac nerve disc, plexus interiliacus, cerebrum pelvicum. 
 
Fig 6. TRUNK OF THE VASOMOTOR NERVE (Truncus Vasomotorius). 
 
42 THE ABDOMINAL AND PELVIC BRAIN 
 
 the great cervical ganglion (ganglion cervicale magnum); the fusiform 
 cervical ganglion (ganglion cervicale fusiforme); the olive-shaped cervical 
 ganglion (ganglion cervicale olive). 
 
 The superior cervical ganglion, % of an inch in length is the largest of 
 the sympathetic trunk ganglia. It is located at the base of the skull between 
 the internal jugular vein and internal carotid artery. It is irregular in form, 
 however, chiefly spindle-shaped. The commissural cord connects it to the 
 middle cervical ganglion. 
 
 The main branches of the superior cervical ganglion are: 
 
 Cpntral rnmmnnicatin? branches \ L Gray rami communicantes (no white). 
 
 Central communicating branches j 2 Communicantes w i t h cranial nerves. 
 
 ( 3. Emits branches to pharynx. 
 Peripheral branches of the distribution, -j 4. Emits superior cervical cardiac nerves. 
 
 ( 5. Branches to vessels (controlling lumen). 
 
 B. Middle Cervical Ganglion (Ganglion Cervicale Medium). 
 Synonyms: The thyroid ganglia (Ganglion Thyroideum). 
 The middle cervical ganglion sends branches: 
 
 1. (Central Communicating Branches) gray rami communicantes (no 
 white). 
 
 2. The subclavian loop (Ansa Vieusseni. French anatomist, 1641-1716) 
 enclosing the subclavian artery and joining the middle and inferior cervical 
 ganglia. 
 
 3. Peripheral branches of distribution, the middle cervical cardiac nerve. 
 
 4. Branches to the thyroid body. 
 
 C. Inferior Cervical Ganglion (Ganglion Cervicale Inferius). 
 Synonyms: The first thoracic ganglion (Ganglion Thoracicum primum) ; 
 
 the vertebral ganglion (Ganglion Vertebrale) ; the stellate ganglion 
 (Ganglion Stellatum). 
 
 The inferior cervical ganglion is irregular in dimension, form, location 
 and branches. The inferior cervical nerve emits: 
 
 1. (Central Communicating Branches) gray rami communicantes 
 (no white). 
 
 2. Subclavian loop. 
 
 3. Communications with larynx. 
 
 4. (Peripheral branches of distribution). The inferior cervical cardiac 
 
 nerve. 
 
 - -d u 4. i i (a) Vertebral plexus, 
 
 o. Branches to vessels \ >, \ c , i • Jf , 
 
 ( (b; Subclavian plexus. 
 
 The bilateral trunks of the cervical sympathetic are not directly united 
 
 by transverse nerve strands. 
 
 II. Branches of the thoracic or dorsal trunk of the Sympathetic. 
 
 The dorsal or thoracic ganglia composing the dorsal or thoracic trunk of 
 the sympathetic generally consists of eleven ganglia of varied form and 
 dimension connected by commissural cords of marked dimension. The 
 important feature of the thoracic sympathetic trunk is that the distal five or 
 six ganglia give origin to the three splanchnic or visceral nerves which richly 
 
Branches of the thoracic sympathetic 
 trunk. 
 
 THE TRUNK OF THE SYMPATHETIC NERVE 43 
 
 supply the abdominal viscera. The branches forming the ganglionated 
 thoracic cord may be divided into two kinds (a) central branches connecting 
 with other nerves; (b) peripheral branches distributed in a plexiform 
 manner to the thoracic and abdominal viscera. The significant feature of 
 the thoracic trunk of the sympathetic is the presence of the white rami 
 communicantes (visceral nerves). The central communicating branches are 
 (both) the white and gray rami communicantes. The peripheral branches of 
 distribution of the thoracic trunk arise both from the ganglia and the 
 commissural cord. The important distributing branches in the practice of 
 medicine for the abdominal viscera are the three splanchnic nerves; the distal 
 ends of the splanchnic nerves practically form the abdominal brain — the 
 visceral ruler of the peritoneal organs. The splanchnic nerves are the 
 abdominal visceral nerves. The following table presents a bird's eye view 
 of the branches of the thoracic sympathetic trunk: 
 
 fl. (Central communicating branches) white 
 rami communicantes. 
 
 2. Gray rami communicantes. 
 
 3. (Peripheral branches of distribution). 
 Pulmonary (from II, III and IV ganglia) 
 
 to form the pulmonary plexus. 
 
 4. Aortic (from proximal 5 ganglia) to supply 
 aorta. 
 
 5. The three splanchnic nerves (from the 
 distal 7 thoracic ganglia and commissural 
 cords) to supply the abdominal viscera. 
 
 A. The Great Splanchnic Nerve (Nervus Splanchnicus Major). 
 
 arises from the thoracic trunk between the fifth and ninth ganglia. By the 
 coalescence of several irregular strands a nerve of marked dimension is 
 formed which passes distalward in the dorsal mediastinum and perforating 
 the crus of the diaphragm terminates as the principal mass of the abdominal 
 brain (semilunar ganglion). The great splanchnic ganglion (ganglion 
 splanchnicum maxium) is found on the trunk of the great splanchnic nerve 
 within the thoracic cavity. 
 
 B. The Small Splanchnic Nerve (Nervus Splanchnicus Minor). 
 
 The small splanchnic nerve arises from the trunk of the thoracic sympa- 
 thetic in the region of the ninth and tenth ganglia. It courses adjacent to 
 the bodies of the distal thoracic vertebrae, perforates the crus of the dia- 
 phragm adjacent to or with the great splanchnic and terminates irregularly 
 in the abdominal brain, (and occasionally in the so-called aortic-renal 
 ganglion). 
 
 C. The Least Splanchnic Nerve (Nervus Splanchnicus Minimus 
 
 (inferior or tertius). 
 
 The least splanchnic nerve arises from the last thoracic ganglion in the 
 sympathetic trunk (or from the small splanchnic). It perforates the 
 diaphragm and terminates in the plexus renalis. The bilateral thoracic 
 trunks of the sympathetic are not directly united by the transverse nerve 
 strands similar to the lumbar and sacral trunks. 
 
44 THE ABDOMINAL AND PELVIC BRAIN 
 
 III. Branches of the Lumbar Sympathetic Trunk. 
 
 The lumbar trunk of the sympathetic consists usually of four ganglia 
 joined by commissural cords. It is continuous proximally with the thoracic 
 and distally with the sacral trunk of the sympathetic. The lumbar trunk is 
 located on the bodies of the lumbar vertebrae internal to the origin of the 
 psoas muscle and ventral to the lumbar vessels. The lumbar ganglia are not 
 always bilaterally symmetrical in dimension, location, distance from each 
 other and form. The ganglia are larger than those of the dorsal or sacral 
 trunk. The commissural cords of the lumbar sympathetic trunk are longer, 
 stronger and more irregular in number than the dorsal or sacral. The 
 branches from the lumbar gangliated trunk consist of two sets, viz. : 
 
 A. Central Communicating Branches. 
 
 1. The first two or three lumbar spinal nerves possess visceral branches 
 which form white rami commnnicantes joining the proximal lumbar ganglia 
 or commissural cord. 
 
 These white rami communicantes comprise vaso-motor fibres for the 
 tractus genitalis and motor fibres for the uterus and bladder. 
 
 2. Gray Rami Communicantes which pass to the ventral primary 
 divisions of the lumbar nerves. The rami communicantes (white and gray) 
 are irregular in length, dimension and location. 
 
 B. Peripheral Branches of Distribution from the lumbar ganglia and 
 commissural cord arises and pass to the plexus aorticus and aorta. The 
 lumbar sympathetic trunk sends branches to the plexus ureteris. The 
 branches are irregular in length, dimension, number and location. The 
 bilateral sympathetic trunk is directly united by several transverse nerve 
 strands, chiefly extending from ganglion on one side to that on the other. 
 
 IV. Branches of the Sacral Sympathetic Trunk. 
 
 The sacral trunk of the sympathetic is a continuation of the lumbar 
 trunk. It terminates in a plexiform coalescence over the coccyx with the 
 trunk of the opposite side. The distal termination of the sacral sympa- 
 thetic trunks are known as the ganglion impar or coccygeal ganglion. There 
 are usually four ganglia which united by a commissural cord decrease in 
 dimension from sacral promontory to coccyx. The ganglia are generally not 
 bilaterally symmetrical in location, dimension or equidistant from each 
 other. The usual location is on the ventral surfcae of the sacrum on the 
 internal border of the sacral foramina. The ganglia scralia vary in number, 
 dimension, location and form. The bilateral sacral sympathetic trunks are 
 united directly by numerous transverse nerve cords which are arranged in a 
 plexiform manner (which I have termed plexus intertrunci sacralis). The 
 middle sacral trunk of the sympathetics, like that of the cervical and distal 
 lumbar receives no white rami communicantes from the spinal nerves. 
 
 The visceral branches (Pelvic Splanchnic) of the II, III and IV sacral 
 nerves join the pelvic plexus (pelvic brain) without being directly connected 
 with the sacral sympathetic trunk. These nerves, however, are to be con- 
 sidered homologous with the white rami communicantes of the thoracic and 
 lumbar (abdominal splanchnics). 
 
THE TRUNK OF THE SYMPATHETIC NERVE r, 
 
 The II, III and IV sacral nerves transmit to the tractus genitalis (uterus) 
 tractus intestinalis (rectum) and tractus urinarius (bladder) motor and inhib- 
 itory nerves, and also vaso-dilator fibres for the tractus genitalis. 
 
 The branches of the sacral sympathetic trunk are of two kinds, viz. : 
 
 A. Central Communicating Branches. 
 
 I. Gray rami communicantes arise from the ganglia and join the ventral 
 primary division of the sacral and coccygeal nerves. There are no white rami 
 communicantes. 
 
 B. Peripheral Branches of Distribution are: 
 
 1. Visceral branches of limited dimension which arise mainly from the 
 proximal ganglia of the trunk and commissural cord and pass medianward to 
 join the interiliac plexus and pelvic brain as well as the three kinds of pelvic 
 viscera and adjacent vessels. 
 
 2. Parietal branches limited in dimension which ramify on the ventral 
 surface of the sacrum, especially in relation with the sacral artery, forming 
 what I have termed the plexus intertrunci sacralis. 
 
 The four segments of the trunk of the sympathetic nerve, cervical, 
 dorsal, lumbar and sacral, differ according to location and environment. 
 
 The white rami communicantes (visceral nerves abdominal splanchnics) 
 stream from the dorsal and proximal lumbar ganglia. 
 
 The visceral nerves of the pelvic sympathetic trunk (pelvic splanchnics) 
 do not pass through the sacral ganglia but through the II, III and IV 
 sacral nerves. 
 
 The distributing branches of the pelvic sympathetic trunk are the least 
 important of any segmental trunk. The bilateral cervical and dorsal sympa- 
 thetic trunks are practically not directly united by transverse nerve cords, 
 the bilateral lumbar and pelvic trunks are united by numerous transverse 
 nerve cords (and plexuses). 
 
 The bilateral cervical sympathetic trunks are united by two localized 
 prevertebral plexuses, the pharyngeal and cardiac. 
 
 The bilateral dorsal sympathetic trunks are united by a single prever- 
 tebral colossal pelvus — abdominal brain. 
 
 Ganglionic coalescence occurs chiefly in the cervical trunk. The 
 ganglia are the most irregular in the pelvic trunk, the largest in the cervical 
 and lumbar trunks. 
 
 The commissural cords are multiple supernumerary in the lumbra and 
 sacral trunks only. 
 
 The cervical sympathetic trunk and pelvic brain are the only segments 
 so far subject to surgical intervention (extirpation). 
 
CHAPTER V. 
 
 PLEXUS AORTICUS ABDOMINALIS.— (A) ANATOMY, 
 (B) PHYSIOLOGY. 
 
 One's rainbow of desires changes color with the passing years. 
 
 "Instead of condemning me to death the city (Athens) should grant me a pen- 
 sion." The defense presented by Socrates in his trial. 
 
 (a) ANATOMY. 
 
 The plexus of the abdominal aorta extends from the coeliac artery to 
 the aortic bifurcation. It extends from the abdominal brain to the hypo- 
 gastric ganglion or disc. At the proximal end of the aortic plexus is located 
 the abdominal brain, at the distal end is located the hypogastric ganglion or 
 disc. It consists of a wide meshed network of anastomosing nerve bundles 
 and ganglia. The main nerve cords, two in number, course parallel to the 
 lateral borders of the abdominal aorta, constituting the aortic plexus, anas- 
 tomosing with each other by means of nerve strands coursing obliquely or 
 transversely ventral or dorsal to the aorta, and also with the lateral chain of 
 lumbar ganglia by means of short nerve cords. The plexus aorticus 
 practically ensheaths the aorta, especially ventrally, with a wide meshed 
 network of nerves and ganglia. 
 
 (a) The Ganglia of the Plexus Aorticus. 
 
 The ganglia of the aortic plexus are numerous and important, being 
 located practically at the origin of visceral vessels from the aorta. They 
 consist of multiple bordered, irregularly flattened bodies located mainly on the 
 ventral and lateral borders of the aorta. Originally the aortic plexus consisted 
 of a bilateral gangliated cord located along the lateral aortic border, each 
 ganglion representing the origin and mission of a visceral vessel. By 
 evolutionary processes and change of attitude the ganglia become removed, 
 changed from this original site which was at the origin of the arterial vessels. 
 In general the ganglia of the plexus of the abdominal aorta are located at the 
 exit of the visceral vessels from the aorta abdominalis, viz. : (a) ganglion 
 diaphragamaticum (paired), located on the proximal border of the abdominal 
 
 Fig. 7. This illustration is from a dissection made under alcohol. It is a drawing 
 from a subject possessing a typical large abdominal brain with the ureter, bladder and 
 urethra dilated into a single channel without sphincters intact. 1 and 2, abdominal brain ; 
 3 and 4, renal plexuses ; 5, plexus adrenalis ; 6 and 7, the two vagi ; 8 and 9, the three splan- 
 chnics on each side; 10, two spermatic ganglia; 11 inferior mesenteric ganglia; 12 and 13 
 lumbar lateral chain of ganglia; 14 and 15, dilated ureters wrapped by nerve plexuses; 16 
 arterio-ureteral crossing ; 17, hypograstic plexuses ; 18, and 19, lateral chain of sacred gang- 
 lia; A and B, Patulous ureteral orifices. The Plexus aorticus extends from the abdominal 
 brain (1 and 2) to the aortic bifurcation, whence the Plexus interiliacus (hypogastricus) 
 begins and extends to the Pelvic brain. I consider the Plexus Aorticus in this subject as a 
 typical one. 
 
 46 
 

 Fig. 7. PLEXUS AORTICUS ABDOMINALIS 
 
48 THE ABDOMINAL AND PELVIC BRAIN 
 
 brain in the form of a conical projection simulating the olfactory bulbs of 
 the cranial brain; (b) ganglion coeliacum (unpaired), located at the origin of 
 the coeliac, superior and inferior mesenteric and renal arteries; (c) Ganglion 
 renalis, located at the origin of the arteria renalia; (d) ganglion ovaricum 
 (paired), located at the origin of the arteria ovarica; (e) ganglion mesenteri- 
 cus inferior (unpaired), located at the origin of the arteria mesenterica infe- 
 rior; (f) ganglion hypogastricum (unpaired), a coalesced disc located at the 
 origin of the arteria iliacacommunicus at the aortic bifurcation. The 
 hypogastric ganglion, or disc, arises at the bifurcation of the abdominal 
 aorta. Its existence is according to the rule (modified by environments and 
 erect attitude) that a sympathetic ganglion occurs at the exit of the 
 abdominal visceral arteries from the aorta abdominalis. 
 
 The position of the ganglia appears to have experienced changes with 
 evolutionary development as they become transported by detachment from 
 the base of the visceral artery toward the corresponding viscus or along 
 bones and muscles. Some visceral arteries, like the renal, possess a wealth 
 of separate ganglia. The ganglia are located in general: (a) at the origin 
 of the visceral artery from the aorta ; (b) along the lateral borders ; (c) on 
 the ventral surface of the vessel. The ganglia mainly surround the root of 
 the visceral vessel like a collar or fenestrated sheath and encase it towards 
 its viscus with a plexiform network of nerves. 
 
 The dimension of the ganglia in the aortic plexus practically correspond 
 with the volume of the corresponding visceral artery. The longest ganglion 
 is that of the arteria coeliaca. The smallest constant ganglion is perhaps 
 that at the base of the arteria diaphragmatic. 
 
 The form of the ganglia are oval, triangular or multiple bordered 
 flattened bodies. The surface of the ganglia are uneven, with irregular, 
 fenestrated spaces and occasionally perforated by blood vessels. 
 
 (b) The Nerve Trunks and Cords of the Plexus Aorticus. 
 
 The ganglia of the aortic plexus are united or anastomosed into a wide 
 meshed plexus by two general methods: (1) By two trunk cords extending 
 along the lateral borders of the aorta from the ganglion coeliacum to the 
 ganglion hypogastricum or hypogastric discs; (2) by cords of smaller and 
 larger caliber coursing irregularly from ganglion to ganglion, from cord to 
 cord and from one lateral trunk to the other. The plexus aorticus is solidly 
 and compactly united to the bilateral chain of lumbar ganglia by short, 
 strong strands and to all visceral nerve plexuses of the abdomen. 
 
 The plexus aorticus practically ensheaths the abdominal aorta (especially 
 lateral, and ventrally) with a plexiform network of nerve cords and ganglia. 
 From the plexus aorticus abdominalis arise: (a) the plexus diaphragmaticus 
 (paired), which accompanies and ensheaths the arteria diaphragmatica (the 
 right possesses a ganglion) ; (b) plexus coeliacus (unpaired), which accompanies 
 and ensheaths the arteria gastrica (supplying the stomach), hepatica (supply- 
 ing the liver) and lienalis (supplying the spleen) ; (c) the plexus mesentericus 
 superior (unpaired), which accompanies and ensheaths the arteria mesenterica 
 
PLEXUS AORTICUS ABDOMINALIS 49 
 
 superior with a network of nerve cords and ganglia to supply the enteron, 
 right colon and right half of transverse colon; (d) plexus renalis (paired), 
 which accompanies and ensheaths the arteria renalis with a network of nerve 
 cords and wealth of ganglia to supply the kidney and proximal ureter; (e) 
 plexus ovaricus (paired), which accompanies and ensheaths the arteria 
 ovarica with a network of nerve cords and ganglia to supply the ovary, 
 oviduct and ligament a lata; (f) plexus mesentericus inferior (unpaired), 
 which accompanies and ensheaths the arteria mesenterica inferior with a 
 mesh-work of nerves and ganglia to supply the right half of the transverse 
 colon, right colon, sigmoid and rectum; (g) plexus hypogastrics (unpaired 
 coalesced) which originally accompanied and ensheathed the arteria hypogas- 
 trica with a network of nerve cords and ganglia to supply tractus genitalis 
 (especially the uterus and vagina) and distal segment of the tractus urinarius 
 (especially the bladder and distal segment of the ureter). The plexus 
 aorticus abdominalis includes the abdominal aorta from the coeliac axis to 
 its bifurcation on the sacral promontory, hence its profound connection to 
 every abdominal visceral tract through the arteries. The vital signification 
 of the plexus aorticus abdominalis is at once evident when it is observed 
 that from it issues practically nine great visceral arteries (the coeliac, two 
 mesenteric, two renals, two ovarian and two iliacs) accompanied by great 
 nerve plexuses and having at least one marked sympathetic ganglion at their 
 origin. Each of the eight nerve plexuses of the plexus aorticus are solidly 
 and compactly anastomosed with every other plexus and connected with all 
 other abdominal plexuses, making a compact network of abdominal sympa- 
 thetic nerves perfectly planned to report functions to the ruling potentate, 
 the abdominal brain. 
 
 (b) physiology. 
 
 The physiology of the plexus aorticus abdominalis comprises the 
 function of the viscera to which it supplies nerves viz. : tractus intestinalis, 
 urinarius, genitalis, vascularis and lymphaticus. The three great common 
 functions of the abdominal viscera are: (a) Peristalsis, absorption, sensation 
 and secretion. To the common functions must be added for the tractus geni- 
 talis, (d) ovulation; (e) menstruation ; (f) gestation. We unconsciously employ 
 the physiology of the aortic plexus in the practice of obstetrics for uterine 
 haemorrhage. When, after parturition, there is undue bleeding the physician 
 attempts to check it by compressing the aorta. He is in error for what the 
 practitioner really performs is to irritate the aortic plexus and this results 
 in exciting uterine contraction, the uterine muscular and elastic bundles act 
 like living ligatures which limits the lumen of the vessels. In irritating the 
 aortic plexus no trauma or roughness need be employed. Simple, light 
 stroking of the abdomen or gentle kneading will quickly stimulate the aortic 
 plexus which sends branches to supply the uterus through the pelvic brain, 
 inducing it to contract and check haemorrhage. The peristalsis of labor may 
 be hastened by administering hot drinks to the patient. The heat in the 
 stomach stimulates the aortic plexus through the gastric plexus and conse- 
 
 4 
 
50 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 quently the nerves which supply the uterus inducing more vigorous and 
 frequent uterine rhythm. Friction on the nipple or massage of the breasts 
 will induce more frequent and vigorous uterine rhythm during labor. The 
 stimulation from the mammae travels to the abdominal brain (and conse- 
 quently to the aortic plexus and uterus) over the nerve plexus accompanying 
 the mammary, intercostal, inferior epigastric arteries. In abdominal 
 massage we apply practical physiology to the various abdominal visceral 
 tracts. For example in constipation one or all the great visceral functions 
 (peristalsis, absorption, sensation and secretion) are defective. By stimulating 
 the aortic plexus through massage intestinal peristalsis, secretion and absorp- 
 tion are enhanced as the irritation passes over the gastric plexus to the stom- 
 ach over the superior mesenteric plexus to the enteron and over the inferior 
 
 PLEXUS AORTICUS ABDOMINALIS 
 
 Fig. 8. This illustration represents a typical aortic plexus, which I dissected under 
 alcohol from a specimen taken from a subject of about fifty years of age. 1 and 2 abdominal 
 brain lying at the foot of the great abdominal visceral arteries. P. O. S. ganglia located at 
 the other visceral arteries. HP, represents the fenestrated interiliac nerve disc. 
 
PLEXUS AORTIC IS ABDOMINALIS 51 
 
 mesenteric plexus to the colon. Constipation may be cured by massage of 
 the abdomen. Massaging the abdominal brain induces more active renal 
 peristalsis, absorption and secretion. The physiology of the sympathetic 
 presents a vast field for future therapeutics, especially in the direction of 
 visceral massage. The massage of the abdominal sympathetic (plexus 
 aorticus) will assume three directions of physiologic utility, viz. : (a) The 
 great ganglia of the plexus aorticus will be stimulated, that is, the ganglion 
 at the root of each visceral artery will be stimulated, which will excite the 
 pulsating vessel (and the heart), supplying more blood to its corresponding 
 viscus and consequently individual and collective visceral peristalsis, absorp- 
 tion and secretion is enhanced — this is administering a vascular tonic. It 
 also aids visceral drainage which consists in elimination of waste laden blood 
 and lymph products. In short, massage of the plexus aorticus abdominalis 
 enhances visceral function (rhythm) and visceral drainage (elimination) ; (b) 
 massage of the plexus aorticus enables the operator to manipulate each, 
 individual, viscus which not only excites the capsule or muscularis of the 
 organ to enhance peristalsis, but the parenchyma of each viscus receives a 
 direct stimulus for increased absorption and secretion. This is again admin- 
 istering a natural tonic for the massage of a viscus enhances its function and 
 drainage. Visceral stimulation and visceral drainage must be complements 
 and compensatories of each other; (c) in performing massage of the plexus 
 aorticus abdominalis, the voluntary abdominal muscles are invigorated in 
 function and usefulness. The active contraction and relaxation of the 
 abdominal muscles on the viscera is a necessity for their normal function 
 (rhythm, absorption, secretion) and support, e. g., splanchnoptotics possess 
 relaxed abdominal walls and consequent distalward movements of viscera 
 and elongated mesenteries — resulting in disturbed, compromised, visceral 
 peristalsis, absorption and secretion as constipation, indigestion and neuras- 
 thenia. Every organ has its rhythm. In the rhythm or peristalsis of an 
 organ undoubtedly lies the physiologic secret of correlated secretion and 
 absorption. Hence one of the essential duties of a physician is to aid in 
 maintaining a normal visceral rhythm. In conditions of acute inflammation 
 or irritation of viscera, the abnormally active rhythm is best treated by 
 anatomic (quietude of voluntary muscles) and physiologic rest (prohibition 
 or control of fluid and foods). In conditions of defective rhythm of organs 
 as in constipation, splanchmoptosia, the best means to stimulate normal 
 rhythm is systematic abdominal massage and vigorous visceral drainage. A 
 rational method to stimulate visceral rhythm is to administer coarse foods 
 (cereals and vegetables) that leaves a large fecal residue which irritates the 
 intestines into vigorous peristalsis or rhythm. 
 
CHAPTER VI. 
 
 THE VASOMOTOR INTERILIAC PLEXUS (PLEXUS INTER- 
 ILIACUS VASOMOTORIUS— SYMPATHICUS). 
 
 Immaterial, irrelevant, incompetent. — Attorney's objection to evidence in law 
 trials. 
 
 Industry wins living, honesty wins respect. 
 
 Extending from the abdominal brain (the coeliac axis) to the pelvic 
 brain (cervico-uterine junction) there exist two rich and mighty nerve 
 plexuses, plexus aorticus and plexus interiliacus. 
 
 For convenience of description and significance in practice I will divide 
 this plexus into two grand divisions, viz. : 
 
 (a) The plexus aorticus extending from the coeliac axis to the aortic 
 bifurcation; (b) the plexus hypogastricus or more significantly plexus 
 interiliacus, which extends from the bifurcation of the aorta (sacral promon- 
 tory) to the junction of uterus and vagina. The plexus interiliacus is 
 important because it is the great highway of travel for afferent (initiative 
 or spontaneous) and efferent (reflex peripheral) genital nerve forces. I 
 shall view the plexus interiliacus as originally belonging and accompanying 
 the common iliac vessels. However, by erect attitude, distalward movements 
 of the tractus genitalis and increasing dimensions (especially lateralward) to 
 the pelvis, coalescence of the proximal extremities of the two branches of 
 the plexus interiliacus arose. That is, the original nerve plexuses accompany- 
 ing the common iliac arteries gradually moved medianward from them. 
 Hence the term plexus interiliacus is particularly appropriate. The plexus 
 interiliacus has experienced a variety of names during the past two centuries. 
 Synonyms: Superior hypogastric plexus (plexus hypogastricus superior, 
 Tiedemann, 1822). Medial hypogastric plexus (plexus hypogastricus 
 medius). Impar (odd, single, impaired) hypogastric plexus (plexus hypo- 
 gastric impar). Interiliacal plexus (plexus interiliacus, Waldeyer, living). 
 The great uterine plexus (plexus uterinus magnus, Tiedemann, 1822). 
 Pelvic plexus (plexus pelvicus, Thomas Snow Beck, 1845, 1814, 1847). The 
 hypogastric ganglion, i. e., layer (lamina gangliosa hypogastrica, Gabriel 
 Gustave Valentine, German anatomist, 1810-1883). The common uterine 
 plexus (plexus uterinus communis, Tiedemann, 1822). Iliac plexus (plexus 
 iliacus — anatomica nomina, Basel). Distal part of the aortic plexus (plexus 
 aorticus distal, Henle — Fred Gustav Jacob Henle, German anatomist, 
 1809-1885). 
 
 The plexus interiliacus I shall consider under three distinct headlines, 
 viz.: (a) interiliacal nerve disc (proximal end); (b) trunk of the plexus 
 interiliacus (central segment) ; (c) pelvic brain (distal end or ganglion 
 cervicale). 
 
 52 
 
THE I'ASOMOTOR INTERILIAC PLEXUS 
 
 53 
 
 PLEXUS INTERILIACUS 
 
 Fig. 9 This illustration presents the sympathetic nerves following the arteries. I 
 dissected this specimen (man 40) with care, and the artist, Mr. Klopper, sketched exactly 
 from the model. 1 and 2, abdominal brain. Pn, Pneumogastric nerve; sp. Nervus 
 Splanchnicus major. Ad, adrenal ; Dg, ganglion diaphragmaticum ; Adn, 10 adrenal 
 nerves (right), (left), 7. G. R. arteria renalis (right and left partially duplicate). N. 
 Ganglia renalia (left). Ur, ureteral nerves. S. G. and 5 upper ganglia spermatica. I, gang- 
 lion mesentericum inferior; X, ganglionic coalescence of nerves at the vasa spermatica and 
 ureteral crossing. 5 ganglionic coalescence of the nerves at the crossing of the ureter and 
 vasa iliaca communis. IB, Plexus interiliacus (hypogastricus) surrounding the rectum. 
 ID is the fenestrated nerve disc of the sacral promontory. V, Vena cava emitting the 
 vena ovarica on which is ensheathed the plexus ovaricus. 
 
54 THE ABDOUIXAL AXD PELVIC BRAIN 
 
 (a) INTERILIAC NERVE DISC. 
 
 The proximal end of the plexus interiliacus, which I shall term the 
 interiliacal nerve disc of the sacral promontory, is practically a plexus of 
 nerve cords compressed or flattened dorso-ventrally. The interiliacal disc is 
 the result of coalescence of the distal end of the plexus aorticus, located at 
 the aortic bifurcation, practically on the sacral promontory and the distal- 
 ward movements of the tractus genitalis producing traction and extension 
 on the nerve disc of the sacral promontory. The interiliac nerve disc is 
 practically a plexiform nerve mass located at the proximal end of the plexus 
 interiliacus. The arrangement of the interiliacal disc consists in the coal- 
 escence on the same promontory of the afferent nerve — plexus aorticus and 
 branches from the distal bilateral lumbar ganglia — and the emission of efferent 
 nerves: (a) two bilateral large plexuses to the pelvic brain; (b) branches to 
 the tractus intestinalis (rectum haemorrhoidal) ; (c) branches to the tractus 
 genitalis (uterus, vagina, oviduct); (d) branches to the tractus urinarius 
 (ureter, bladder). 
 
 POSITION. 
 
 I. Holotopy (relation to general body). The interiliac nerve disc is 
 located on the median line in the space between the major bifurcation and 
 the distal end of the abdominal end cavity immediately proximal to the lesser 
 pelvis. It is a coalesced unpaired organ situated extraperitoneally on the 
 sacral promontory, dorsal to the peritoneum. It is strongly ensconced in 
 connective tissue at the most accessible portion of the abdomen for palpa- 
 tion. 
 
 II. Skeletopy (relation to osseous system). The interiliac nerve disc 
 lies on the ventral surface of the distal lumbar and proximal sacral vertebrae. 
 It lies practically on the brain of the inner osseous pelvis. 
 
 III. Syntopy (relation to adjacent viscera). The interiliac nerve disc, 
 coalesced (unpaired), is located centrally in the space between the major 
 aortic bifurcations which practically includes the ventral surface of the two 
 distal lumbar and two proximal sacral vertebras. It is securely ensconced in 
 strong dorsal subperitoneal connective tissue. It is situated between the 
 peritoneum and pelvic fascia. The interiliac nerve disc is limited to the 
 space between the coalescence of the plexus aorticus (aortic bifurcation) and 
 the emission or divergence of the plexus interiliacus (second sacral verte- 
 bras). The interiliac nerve disc lies dorsal to certain changeable mobile 
 loops of the enteron and mesenteron and possess variable relations to the 
 sigmoid and mesosigmoid. In peritonotomy, in spare subjects, the inter- 
 iliac nerve disc may be observed shimmering whitish through the dorsal 
 peritoneum. 
 
 IV. Idiotopy (relation of the component segments). The interiliac 
 nerve disc consists of a nerve plexus compressed, flattened, dorso-ventrally, 
 and interspersed with fenestra of varying number and dimension. The 
 fenestra increase in number and dimension from proximal to distal borders. 
 Dimensions. The interiliacal disc is some two inches in length and three- 
 
THE VASOMOTOR INTERILIAC PLEXUS 
 
 55 
 
 fourths of an inch in width. Form. The form is that of truncated cone. 
 The lateral borders are bounded by nerve cords. The proximal border fuses 
 with the plexus aorticus. The distal border coalesces with the emerging 
 efferent lateral interiliacal plexuses. 
 
 GENERAL REMARKS IN REGARD TO THE INTERILIAC NERVE DISC. 
 
 It consists of a flattened, band-like nerve plexus in a sheath of firm , 
 dense, connective tissue, located in the interval between the two common 
 iliac arteries. It is formed by a continuation of the plexus aorticus plus 
 prolongations from the ganglia lumbales. It is a flat plexiform nerve mass 
 
 PIC. 6. — PELVIC I1RAIN. 
 
 PLEXUS INTERILIACUS OF ADULT 
 
 Fig. 10. This specimen I dissected with care under alcohol. The plexus interiliacus 
 extends from the discus interiliacus (D) to the pelvic brain (A). Observe: (1) Two 
 nerve strands are emitted from the interiliac plexus to the uterus previous to passing 
 through the pelvic brain (A). (2) Note the contribution of the lateral sacral chain of gang- 
 lia and II and III sacral nerves to the plexus interiliacus. (3) Bear in mind the intimate 
 relation of the plexus interiliacus to the rectum proximalward and distalward. 
 
 at the junction of the distal lumbar and proximal sacral vertebrae. I have 
 termed it the interiliac nerve disc, as it contains no constant distinct ganglia. 
 Some authors claim it contains no ganglia, while others claim it contains 
 some ganglia, the latter being the more probable. The interiliac disc is 
 significant as it emits (efferent nerves) from its distal border, the two nerve 
 
5G THE ABDOMINAL AND PELVIC BRAIN 
 
 plexuses which rule the pelvic viscera. The interiliac nerve disc is an 
 example of the principle elsewhere noted that at every emission of a major 
 (visceral) artery from the abdominal aorta there exists a ganglion (or nerve 
 disc). Practically there should be two ganglia at the aortic bifurcation. 
 However, coalescence occurred and one ganglion or disc resulted — the 
 interiliac nerve disc (or ganglion). Efferent nerve branches from the 
 interiliac disc not only accompany the two common iliac, ovarian, superior 
 haemmorhoidal and sacral arteries but emit the two great interiliac plexuses 
 (for the pelvic viscera) as well as branches to the ureters, left colon and 
 sigmoid. The interiliac nerve disc is important in, practice because it is 
 practically accessible to manipulation, massage. By gentle irritation or 
 massage of the interiliac disc in post partum haemorrhage the plexus 
 interiliacus will be stimulated, which, supplying the uterus, will induce the 
 elastic and muscular bundles of the myometrium to act like living ligatures, 
 limiting the uterine vessels, and checking haemorrhage. It is not the 
 supposed constriction of the aorta that checks the haemorrhage. 
 
 (b) TRUNCUS PLEXUS INTERILIACUS SYMPATHICUS. 
 
 The trunk or central segment of the interiliac plexus (paired) extends 
 from the interiliac nerve disc to the pelvic brain. The plexus interiliacus 
 consists not merely of nerve strands, for it is composed of nerve plexuses 
 the commissures and cords of which are band or ribbon-like in character 
 surrounding apertures or fenestra of various dimensions which increase in 
 area toward the distal end. The plexus interiliacus increases in breadth 
 from proximal to distal end, i. e., from interiliac nerve disc to pelvic brain. 
 The proximal end is relatively small and composed of a few nerve cords, the 
 distal end is broad and divides into numerous branches. The course of the 
 interiliac plexus is proximally along the internal side of the pelvic vessels 
 while distally it courses along the dorsal and rectal wall with which it is 
 intimately connected by connective tissue and, when it again resumes inti- 
 mate association with the pelvic vessels the length of the trunk of the 
 plexus interiliacus averages some 3/4 inches. Numerous nerve branches 
 from the V lumbar ganglion and from the I, II, III and IV sacral ganglia 
 join the external border of the plexus interiliacus. From the internal 
 border of the plexus interiliacus numerous branches pass to the rectum, 
 ureter, uterus, vagina, bladder. From the plexus pass numerous nerves to 
 the pelvic vessels. The trunk of the plexus interiliacus is profoundly 
 associated with the rectal wall, sharing in its movements or contraction of 
 and dilatation. The intimate and profound connections of the trunk of 
 the plexus interiliacus with the rectal wall explains the favorable therapeutic 
 value of the rectal enema due to stimulation of the plexus. The rectum is 
 practically surrounded, ensheathed by two great bilateral interiliac plexuses, 
 i. e., the rectum lies in the boot-jack angle produced by the divergence of 
 the plexuses. The plexus interiliacus possesses a remarkable anatomic 
 feature, which is that it sends some two strong nerves directly to the uterus 
 without first passing through the pelvic brain (demonstrated with very 
 extraordinary facility in infant cadavers). 
 
THE VASOMOTOR IXTER1LIAC PLEXUS 
 
 57 
 
 PLEXUS INTERILIACUS (with interiliac nerve disc, 115). 
 
 Fig. 11. I dissected this specimen in 1894 from a spare subject having enormously 
 large vasomotor nerves' The aorta divided into the iliacs at the junction of the III and IV 
 lumbar vertebrae. 112, genital ganglion ; 173, third lumbar ganglion (R) ; 114, genito-rectal 
 ganglion; 103, lumbar lateral chain of ganglia; 173, third lumbar nerve (R) ; 90, lumbar 
 nerve ; 91, lumbar nerve ; 179, fourth lumbar ganglion (R) ; 104, lateral chain of ganglia ; 
 181 com. iliac artery arising in this case at third lumbar vertebra; 188, inferior renal gang- 
 lia; 174, fourth lumbar nerve (R) ; 189, fifth lumbar ganglion (R) ; 93, lumbar nerves ; 114, 
 genital ganglion ; 115, hypogastric plexus ; 134, first sacral ganglion (L) ; 179, fourth lumbar 
 ganglion (R) ; 116 hypogastric plexus ; 125, lumbo-sacral cord ; 135, first sacral ganglion (K) ; 
 136, genital ganglion; 118, hypogastric plexus; 126, first sacral nerve (L) ; 1/0, lumbar 
 sacral cord; 130, first sacral nerve (R) ; 158, right sacral plexus; 137 second sacral gang- 
 lion ; 117, hypogastric plexus; 156, rectum; 127, second sacral nerve (L). trom authors 
 life-size chart on the sympathetic nerve. 
 
58 THE ABDOMINAL AND PELVIC BRAIN 
 
 (c) DISTAL END OF THE PLEXUS INTERILIACUS OR PELVIC BRAIN. 
 
 The broad distal end of the plexus interiliacus, a plexiform fenestrated 
 nerve mass, unites with the branches of the II, III and IV sacral nerves to 
 form the pelvic brain (ganglion cervicale). The resulting union of the distal 
 end of the plexus interiliacus and sacral nerves — a plexiform ganglionated 
 mass, the pelvic brain — rules the physiology of the pelvic viscera, especially 
 the vascularity of the genitals. The pelvic brain is elsewhere described in 
 detail. 
 
 GENERAL REMARKS ON THE PLEXUS INTERILIACUS. 
 
 The plexus interiliacus, like the plexus aorticus, is one of the great and 
 important nerve plexuses of the abdomen. It practically supplies the 
 tractus genitalis; distal end of tractus intestinalis (rectal, sigmoid) ; and 
 distal end of tractus urinarius (ureter, bladder). The plexus interiliacus is 
 double, bilateral, presenting practically no anastomosis. It is accessible to 
 manipulation through the abdominal wall as well as per rectum and per 
 vaginam. Dilatation of the rectum produces its favorable therapeutic 
 effects through the plexus interiliacus by flushing the capillaries and stimu- 
 lating visceral function, especially respiration. The plexus interiliacus is 
 the dominating plexus of the pelvis. It is the great assembling nerve center 
 of the pelvic organs and is solidly and compactly bound and anastomosed to 
 all other pelvic sympathetic nerves as well as the I, II, III and IV sacral 
 spinal nerves. The following table presents an idea of the vast extent 
 and richness of distribution of the branches of the plexus interiliacus. It 
 should be remembered that the vast majority of the branches of the plexus 
 interiliacus first pass through the pelvic brain before supplying the pelvic 
 viscera (especially those to the tractus genitalis). 
 
 { (Hemorrhoidal) 
 
 . ^ T , .. r J a, colon (left) 
 
 b, sigmoid 
 
 c, rectum 
 ovary 
 oviduct 
 
 ligamentum latum 
 uterus 
 vagina 
 
 ^pelvic subserosium 
 
 ! ureter 
 bladder 
 urethra 
 . ™ Tr , . \ arterial plexuses accompanying 
 
 4. Tractus Vascularis { all pelv £ arte ries 
 
 5. Tractus lymphaticus (all pelvic lymphatic glands are richly supplied), 
 A peculiar character of the plexus interiliacus is that it is considerably 
 disassociated from arterial vessels — unlike the plexus aorticus. The pelvic 
 visceral plexus or branches of the plexus interiliacus possess similar features. 
 On the contrary, the visceral plexuses or branches of the abdominal brain 
 notably accompanying the visceral arteries. 
 
 2. Tractus Genitalis 
 
THE VASOMOTOR INTERILIAC PLEXUS 
 
 59 
 
 AGE RELATION OF THE PLEXUS INTERILIACUS. 
 
 The plexus interiliacus experiences an age relation according to the 
 sexual phases as presented by the utero-ovarian artery in: (a) pueritas, 
 (childhood), a quiescent, undeveloped state with limited blood, ganglion cells 
 and neurilemma ; (b) pubcrtas, a developmental state (of congestion) of 
 multiplication of ganglion cells and increased neurilemma; (c) menstrual 
 phase, a functional state of engorgement (of the vaso uterina), which 
 
 fiO- 3- — PELVIC BRAIN OF ADULT. 
 
 PLEXUS INTERILIACUS OF ADULT 
 
 Fig. 12. This specimen I dissected under alcohol. D, interiliac nerve disc. Interiliac 
 plexus extending from the interiliac nerve disc (D) to the pelvic brain (A). Observe : (1) 
 That two large nerve strands are emitted from the interiliac plexus to the uterus without 
 first passing through the pelvic brain. (2) The plexus interiliacus is intimately associated 
 with the rectum. (3) The lateral sacral chain of ganglia and sacral nerves contributes 
 branches to the interiliac plexus. 
 
 The II, III, IV, and V sacral nerves contribute to form the pelvic brain, while in some 
 specimens the I sacral nerve contributes a branch or branches. 
 
 further increases the neurilemma if not the ganglion cells; (c) gestation, a 
 state of complete development of the tractus genitalis (continuous maximum 
 engorgement of the utero-ovarian artery) with the multiplication of ganglion 
 
CO THE ABDOMINAL AND PELVIC BRAIN 
 
 cells and periganglionic tissue with neurilemma; (d) puerperium. The 
 elastic and muscular bundle of the myometrium having contracted like living 
 ligatures, the enormous volume of blood passing through the utero-ovarian 
 artery is checked, maximum engorgement suddenly ceases, the ganglion cells 
 perhaps remain the same in number, however, decreasing in dimension; while 
 the periganglionic tissue, the neurilemma and associated connective tissue 
 decrease, degenerate ; (e) climacterium. This phase of sexual life represents 
 beginning atrophy from lessening of blood volume in the utero-ovarian 
 artery. The ganglion cells diminish in size and number as well as the 
 periganglionic tissue, while the associated connective tissue multiply; (f), 
 senescence. This is the atrophic sexual phase — death of parenchymatous and 
 increase of connective tissue framework of viscera. The muscularis and 
 elastic fibres of the myometrium and oviduct decrease while the connective 
 tissue increases. The wall of the utero-ovarian artery increases in thickness 
 while the lumen decreases in dimension. The ganglion cells of the plexus 
 interiliacus decrease in number and dimension while the ganglion cell, 
 nucleus and body cell outlines become less distinct. 
 
 The periganglionic connective tissue and neurilemma decrease while 
 the associated connective multiplies. In senescence the plexus interiliacus, 
 which was originally destined for the tractus genitalis, gradually fades from 
 its maximum dignity of structure and function. Senescence has returned 
 the plexus interiliacus to its primitive phase of pueritas or quiescent existence. 
 
 UTILITY OF THE PLEXUS INTERILIACUS IN PRACTICE. 
 
 It is accessible to manipulation from proximal to distal end through me 
 abdomen, per rectum or per vaginam. Massaging or stimulating the plexus 
 interiliacus induces the muscular and elastic bundles of the organ which it 
 supplies to contract by controlling the blood volume. The most typical 
 example for the employment of therapeutics on the plexus interiliacus is 
 during post-partum haemorrhage. It is the irritation, massage of the plexus 
 interiliacus, that induces muscular and elastic bundles of the myometrium to 
 contract and consequently control the haemorrhages. It is not the obstruc- 
 tion produced in the aorta by the pressure, the technique of which is 
 almost impossible, for the two ovarian arteries would still continue to force 
 large volumes of blood to the uterus. Light abdominal stroking, digital 
 manipulation of the uterus in post-partum haemorrhage irritates, massages 
 the plexus interiliacus and its branches, which induce the elastic and mus- 
 cular bundles of the uterus to contract like living ligatures on the blood 
 vessels, checking haemorrhage. The so-called uterine inertia of long, 
 tedious labor may be due to paresis of the plexus interiliacus from trauma by 
 the child's head. Sudden cessation of parturient peristalsis— arrest of labor- 
 is doubtless due to trauma by the child's head on the plexus interiliacus, 
 a sudden paresis. Vaginal or rectal injections (hot or medicated) stimulate 
 the plexus interiliacus, hastening labor. Electricity will accomplish similar 
 effects. The flat, band-like form of the plexus interiliacus protects it from 
 trauma during parturition. Massage of the plexus interiliacus will end all 
 
THE VASOMOTOR INTERILIAC PLEXUS <;i 
 
 alleviating constipation by stimulating active peristalsis and secretion of the 
 left colon, sigmoid and rectum. The plexus interiliacus may be stimulated 
 by means of hot fluid or food taken, in the stomach. The irritation passes 
 from the stomach over the plexus gastricus to the abdominal brain, whence 
 it is reorganized and emitted over the plexus interiliacus, inducing more 
 vigorous uterine contractions. By appropriate systematic massage of the 
 plexus interiliacus stimulation of the pelvic viscera may be effected, resulting 
 in a vigorous circulation. 
 
CHAPTER VII. 
 
 THE NERVES OF THE TRACTUS INTESTINALIS (NERVI TRAC- 
 TUS INTESTINALIS).— (A) ANATOMY, (B) PHYSIOLOGY. 
 
 "To be or not to be, that is the question." — Shakespeare. 
 
 "I came, I saw, I conquered." — Ccesar's report to the Roman senate. 
 
 (a.) ANATOMY. 
 
 The abdominal sympathetic emits the great nerve plexuses to the tractus 
 intestinalis (accompanying corresponding named arteries), viz.: (1) plexus 
 coeliacus (unpaired) consisting of: (a) plexus gastricus; (b) plexus hepaticus; 
 (c) plexus lienalis. (2) Plexus mesentericus superior (unpaired); (3) plexus 
 mesentericus inferior (unpaired); (4) plexus haemorrhoidalis medius et 
 superior (paired). The above five nerve plexuses are not only solidly and 
 compactly anastomosed, united with each other but are anastomosed, con- 
 nected with all other abdominal plexuses. The nerves of the tractus 
 intestinalis are motor (rhythm, peristalsis — Auerbach's plexuses), secretory 
 (tubular visceral glands Meissner's plexus and glandular appendages) and 
 sensory (peripheral reporters to the abdominal brain). The nerves of the 
 tractus intestinalis are preponderatingly sympathetic, however, the cranial 
 (vagi) share in supplying the proximal segment. 
 
 The spinal (second, third and fourth sacral) share in supplying the distal 
 segment. 
 
 While the rami communicantes (spinal) share in supplying the medial 
 segment, the abdominal brain was doubtless a" primitive brain for the 
 tractus vascularis and secondarily for the tractus intestinalis. 
 
 (1) Plextis Coeliacus (Unpaired). 
 
 The coeliac plexus arising from the abdominal brain is about one- 
 half inch in length, encases the coeliac artery in a dense plexi-form net- 
 work of nerves, cords, commissures and ganglia. It is the largest and most 
 luxuriant sympathetic plexus surrounding the arteria <:oeliaca with a 
 rich, closely fenestrated nerve sheath, solidly united by connective tissue. 
 The origin of the coeliac plexus is the ganglion coeliacum located in the 
 region of the emission of the great visceral arteries including three sources 
 of nerves, viz. : (a) vagus, right (cranial) ; (b) splanchnic, the most important 
 (spinal cord, rami communicantes) ; (c) sympathetic. The plexus coeliacus 
 is one of the great assembling plexuses of the abdomen. It divides into 
 three branches of vast importance in medical practice, viz. : (a) plexus 
 gastricus; (b) plexus hepaticus; (c) plexus lienalis. 
 (a) Plexus Gastricus (Unpaired). 
 
 62 
 
THE NERVES UP' THE TRACTUS INTESTINALJS 
 
 03 
 
 H St? 
 
 
 
 1: " % til ! 
 
 Eft* 
 
 
 
 ^v 
 
 SS, 
 
 >i 
 
 '^V 
 
 ABDOMINAL BRAIN AND CCELIAC PLEXUS 
 
 Fig. 13. This figure presents the nerves of the proximal part of the tractus intestinal^ 
 that is, the nerve plexuses accompanying the branches of arteria coeliaca. 1 and 2 abdominal 
 brain surrounding the cceliac axis drawn from dissected specimen. H. Hepatic plexus on 
 hepatic artery. S. Splenic plexus on splenic artery. Gt. Gastric plexus on gastric artery 
 Rn. Renal artery (left). R. Right renal artery in the dissection was rich in ganglia. Dg. 
 diaphragmatic artery with its ganglion. G. S. Great splanchnic nerve. Ad. Adrenal. K. 
 Kidney. Pn. Pneumogastric (Lt. left). Ep. right and Eps. left epiploica artery. St. Stom- 
 ach Py, Pyloric artery. C. cholecyst. Co. chole-dochus, N, adrenal nerves (right, 10, left 10). 
 The arterial branches and loops of the cceliac tripod (as well as that of the renals) with the: r 
 corresponding nerve plexuses demonstrate how solidly and compactly the viscera of the 
 proximal abdomen are anastomosed, connected into single delicately poised system with the 
 abdominal brain as a center. Hence local reflexes, as hepatic or renal calculus, disturb the 
 accurate physiologic balance in stomach, kidney, spleen, liver and pancreas. 
 
64 THE ABDOMINAL AXD PELVIC BRAIX 
 
 I. Plexus Gas trims Superior. — It is recognized as the plexus coro- 
 narius ventriculis superior. The accompanying table illustrates a scheme of 
 gastric nerve supply. 
 
 I. Plexus gastricus superior (sympathetic) (plexus coronarius ventriculi 
 superior). 
 
 (a) Plexus ramus dexter. 
 
 (b) Plexus ramus sinister. 
 
 (2) Plexus gastricus inferior (sympathetic) (plexus coronarius ventriculi 
 inferior). 
 
 (a) Plexus ramus dexter (arteria hepatica). 
 
 (b) Plexus ramus sinister from (arteria lienalis). 
 3. Vagi plexuses (cranial). 
 
 Dorsal, ventral (cranial). 
 
 The gastric or superior coronary plexus consists of a fine plexiform net- 
 work which ensheathes and accompanies the curved gastric artery along the 
 lesser gastric curvature. It lies between (however, proximalward) to the two 
 gastric plexuses of the vagi (cranial) dorsal and ventral anastomosing with 
 both, hence solidly and compactly connecting, uniting the gastric plexuses 
 (cranial) with the gastric plexuses (sympathetic). 
 
 II. Plexus Gastricus Inferior. (Unpaired). This is recognized as plexus 
 coronarius ventriculi inferior. (The inferior gastric or coronary plexus 
 supplying the greater curvature is mainly from the hepatic and splenic 
 plexuses accompanying the arteria gastro-epiploica dextra et sinistra). The 
 stomach is supplied by the cranial (vagus), right phrenic (spinal) and the 
 sympathetic nerves from the plexus coeliacus. However, since the sympa- 
 thetic nerves dominate in supply to the stomach it possesses a rhythm or 
 peristalsis. The nerves of the sympathetic plexuses at first course beneath 
 the peritoneum and finally penetrate the gastric muscularis, becoming 
 Auerbach's plexus, destined to rule the gastric rhythm. The ultimate 
 + ermination of the gastric sympathetic nerves becomes the Meissner-Bilroth 
 plexus destined to rule the gastric secretion and absorption. The gastric 
 rhythm is modified by the vagi (cranial) and spinal (ramus communicantes 
 and phrenic). The location of the gastric nerves is important by reason of 
 the diagnosis of gastric disease from pain and reflexes. 
 
 (b) Plexus Hcpaticus (Unpaired). 
 
 The hepatic plexus (sympathetic) arises from the coeliac plexus and 
 joining with the hepatic plexus (cranial) from the right (and left) vagus 
 accompanies the arteria hepatica as a coarse plexiform sheathed network 
 of nerves and ganglion (ganglia hepatica). 
 
 The hepatic plexus consists of strong flattened nerves arranged in the 
 form of a closely fenestrated meshwork, surrounding the hepatic, artery 
 on its journey through the liver. A peculiarity of the hepatic plexus is that 
 it emits plexuses to ramify on the vena porta and its branches in their course 
 through the liver. The hepatic plexus is the largest and coarsest of the three 
 branches of the coeliac plexus. The sympathetic nerves preponderate in the 
 
THE NERVES OE THE TRACTUS INTESTINALIS G5 
 
 liver, hence it possesses a rhythm (through its elastic capsule, parenchy- 
 matous cells, vessels, biliary ducts). 
 
 The following plexuses, important in modern practice, are branches of 
 the hepatic plexus: 
 
 PLEXUS HEPATICUS. 
 
 1. Plexus arteriae hepaticae. 
 
 (a) Plexus ramus communis. 
 
 (b) Plexus ramus dexter. 
 
 (c) Plexus ramus sinister. 
 
 (d) Plexus arteriae pylori. 
 
 (e) Plexus arterias gastricae epiploicae dextra. 
 
 2. Plexus ductus bilis. 
 
 (f) Plexus ductus choledochi. 
 
 (g) Plexus ductus cystici. 
 (h) Plexus cholecysticus. 
 (i) Plexus ductus hepatici. 
 
 3. Plexus vena? portae. 
 
 (j) Plexus ramus communis, 
 (k) Plexus ramus dexter. 
 (1) Plexus ramus sinister. 
 
 The hepatic nerve plexus accompanies the three important apparatus 
 of the liver, viz.: (a) artery; (b) biliary channels; (c) portal vein; (d) the 
 liver is supplied by nerves directly and indirectly from the abdominal brain. 
 
 (a) Plexus arteries Jiepaticce consists of numerous strong gray nerve 
 fibres arranged in a plexiform network ensheathing the hepatic artery. At 
 the points of nerve crossing or anastomosis occur flat enlargements — ganglia 
 hepatica. The plexiform network is a closely fenestrated sheath. 
 
 The branches of the hepatic plexus accompanies richly the branches 
 of the hepatic artery through the five liver lobes; they accompany the pyloric 
 artery to the lesser gastric curvature; they ensheath the arteria gastro 
 epiploica dextra to the greater gastric curvature; they supply the duodenum 
 and caput pancreatica and encase the two arteries which supply the lateral 
 borders of the cholecyst. In short, the nerve plexuses accompany the* 
 hepatic artery and all its branches. 
 
 (b) Plexus ductus bilis. Nerves of the biliary channels consist of a 
 rich plexiform network which accompanies and ensheaths each segment of 
 the biliary passages, viz.: (1) ductus choledochus communis; (2) ductus 
 cysticus; (3) cholecyst ; (4) ductus hepaticus. Each of the segments of the 
 biliary channels possess a fine meshed, grayish red, nongangliated nerve 
 plexus. The localization of the nerve plexuses of the biliary passages, the 
 direction of their reflexes with the position of reorganized focal symptoms 
 are extremely important in the modern practice of cholelithiasis and inflam- 
 matory processes in the segments of the ductus bilis. In dissecting with a 
 magnifying lens it is evident that the ductus bilis is rich in nerve plexuses. 
 The nerve plexuses of the biliary channels are chiefly derived from the 
 
66 THE ABDOMIXAL AND PELVIC BRAIN 
 
 plexus arteriae hepaticae; however, large numbers of nerves pass to the biliary 
 channels independent from the abdominal brain. Especially rich and 
 abundant nerve plexuses are found accompanying the ductus choledochus 
 communis, ductus cysticus and cholecyst, which explains the severity of 
 the pain from infection of any of its segments inducing disordered, wild, 
 violent peristalsis of the bile channels. Recent advances in surgery of the 
 biliary passages have directed attention to the nerve supply of the bile chan- 
 nels. Dissection demonstrates that they are richly supplied with numerous 
 nerve strands and ganglia which accounts for the terrible pain in cholecystitis 
 calculosa. The different segments of the biliary passages are so abundantly 
 supplied with nerves that they have assumed the name plexuses. The sig- 
 nificance of the nerves of the biliary channels is evident in pain during 
 the passage of a calculus or in pain from localized infection of any segment 
 of the bile channels. 
 
 (c) Plexus vena porta consists of a strong plexiform network of nerves 
 surrounding and accompanying the portal vein and its branches through the 
 liver parenchyma. The portal vein is a voluminous tube with extensive 
 ramifications in the liver and hence possesses an enormous nerve supply. 
 The sympathetic nerve is destined for the arteries; however, the portal vein 
 is a marked exception, as it receives an abundant sympathetic nerve supply. 
 (I have traced large sympathetic nerve supplies to the vena cava distal). 
 
 The liver is supplied directly from the abdominal brain (sympathetic): 
 (a) by nerves accompanying the arteria hepatica ; (b) by nerves originating 
 from the abdominal brain and passing directly to the liver; (c) by nerves- 
 originating in the abdominal brain and accompanying the venae portae ; (d) 
 (cranial) vagi, right (and left) ; (e) (spinal) right phrenic. 
 
 (c) Plexus Licnalis (Unpaired). 
 
 Plexus lienalis, a branch of the coeliac plexus, a fine and wide-meshed 
 network of nerves accompanying the spiral splenic artery as a sheath to the 
 spleen. The accompanying table presents the nerve supply of the spleen: 
 
 PLEXUS LIENALIS. 
 
 (a) Plexus arteriae lienalis. 
 
 (b) Plexus ramus gastricus. 
 
 (c) Plexus ramus pancreaticus. 
 
 The plexus lienalis is less in dimension than the plexus hepaticus. The 
 splenci plexus is joined by branches from the right vagus, which modifies 
 the splenic rhythm. It furnishes a branch plexus to the arteria gastrica 
 epiploica sinistra which courses along the major curvature of the stomach to 
 meet the right artery of corresponding name. It emits branch plexuses to 
 the pancreas. The splenic plexus emits branches from the omentum majus. 
 The splenic plexus anastomoses with the plexus suprarenalis. Practically 
 the splenic plexus supplies the left half of the stomach, the spleen, and 
 the pancreas. 
 
 The main nerves of the plexus lienalis, much diminished from omission 
 
THE NERVES OF THE TRACTUS INTESTINALIS 
 
 G7 
 
 of branches, enters the hilum of the spleen with the sheath of the splenic 
 artery to be distributed to the splenic parenchyma to the Malpigian bodies. 
 
 (2.) Plexus Mesentericus Superior (Unpaired). 
 
 The superior or proximal mesenteric plexus consists of large, coarse, 
 dense, whitish gray nerve fibres which arise in the abdominal brain at the 
 
 THE SOLID AND COMPACTLY ANASTOMOSING ARTERIES OF THE 
 TRACTUS INTESTINALIS 
 
 Fig. 14. This illustration demonstrates that the arteries of the tractus intestinalis are 
 solidly and compactly anastomosed by vascular circles, arcs and arcades. To recad the 
 plexus vasomotorius abdominalis one need to remember the arteriae abdominalis only. The 
 circles, arcs and arcades of the abdominal arteries are richly ensheathed with a nodular 
 plexus of nerves. 10 arteria coeliaca emitting the arterial tripod (tripus Halleri), hepatic, 
 splenic and gastric, presenting circles, arcs and arcades. 5 arteria mesenterica superior 
 with its circles, arcs and arcades. 7, arteria mesenterica inferior with its circles, arcs and 
 arcades. 2-10, gastro-hepatic vascular circle (of author) anastomosed to the circles, arcs and 
 arcades of the superior mesenteric arteries with their circles, arcs and arcades by means of 
 the arteria pancreati co-duodenalis superior (a branch of the hepatic) and arteria duodenalis 
 inferior (a branch of the superior mesenteric artery). 
 
68 THE ABDOMINAL AND PELVIC BRAIN 
 
 root of the arteria mesenterica superior, which it accompanies as a plexiform 
 network of nerves and ganglia. Branches of right vagus joins the plexus. The 
 superior mesenteric plexus is composed of thick, flat, ganglionated masses 
 (ganglia mesenterica superior) of oval, crescentic or stellate form, which, 
 woven into thick sheath, surrounds the superior mesenteric artery and 
 accompanies it to the enteron (with the exception of the duodenum) and colon 
 (with the exception of the left colon, sigmoid and rectum). The plexus 
 mesentericus superior not only arises from the entire abdominal brain but 
 from the plexus renalis, bilateral. It also arises by several cords from the 
 plexus aorticus abdominalis. 
 
 The plexus mesentericus superior contains ganglia relatively less in 
 number and dimension than the plexus coeliacus. 
 
 A smaller portion of the plexus mesentericus superior accompanies the 
 arteria pancreatico-duodenalis inferior proximalward to the duodenum and 
 caput pancreatica (rami pancreatici duodenales). 
 
 The greater portion courses on the arteria mesenterica superior distal- 
 ward in the form of a long white closely fenestrated plexiform sheath to the 
 enteron, coecum, right and transverse colon (rami enteron and rami colici). 
 
 The nerves course between the blades of the mesenteron and mesocolon 
 partly closely adjacent to the artery and partly at a distance from the same. 
 The nerves anastomose here and there more irregularly than the arteries as 
 curved arches. The termination of the plexus mesentericus superior is: (a) 
 between the longitudinal and circular muscles of the enteron and colon — 
 ruling rhythm — (plexus myentericus externus — Auerbach's, Leopold Auer- 
 bach, German Anatomist Prof, at Breslau, 1823-1897) ; (b) in the intestinal 
 submucosa — ruling secretion — (plexus myentericus internus — Meissner-Bil- 
 roth, George Meissner, 1829-1905, German Anatomist Prof, in Goettongen. 
 Theodor Bilroth, German— Prof, surgery in Vienna, 1829-1894, German 
 Surgeon Prof, in Vienna). The meshwork of the plexus myentericus internus 
 is not so regular nor the ganglia so large or numerous as that of the plexus 
 myentericus externus. On the nerve plexuses which accompany the vasa 
 intestini tennis and on the nerve plexuses more distantly removed from the 
 vessels, may be found diminutive plexuses and ganglia. The nerves end in 
 the wall of the tractus intestinalis as automatic visceral ganglia. Ganglia 
 exist at the origin of the arteria mesenterica superior which endow the 
 enteron with several, three or four rhythms, daily (three meals). There may 
 be more or less. The superior mesenteric plexus is fan-formed, is the largest 
 plexus in the abdomen. It accompanies the mesenteric artery coursing 
 dorsal to the pancreas. The mesenteric nerves are remarkable for strength, 
 number, length and thickness of their neuri lemma. They are placed in 
 contact with the vessels and also at variable distances from the same. 
 They course toward the intestine in straight lines without emitting branches. 
 At a limited distance from the concave intestinal border they pass directly 
 toward the enteron and colon, or they anastomose with an adjacent nerve at 
 an angle or in an arch. From the convexity of the anastomotic arches the 
 branches pass directly to supply the enteron and part of the colon. There 
 
THE NERVES OF THE TRACTUS INTESTINALIS 69 
 
 is only one series, row, of nerve arches in the plexus mesentericus superior 
 regardless of the number of series, rows, of arterial arches (in the vasa 
 intestini tennis). • The simple nerve arch corresponds to the vascular arch, 
 the most adjacent to the intestine. The superior mesenteric plexus anas- 
 tomoses with the renal ganglia, plexus mesentericus inferior and ovarica. 
 Practically it is a continuation of the plexus coeliacus and aorticus abdominis. 
 
 (3) Plexus Mesentericus Inferior (Unpaired.) 
 
 The inferior mesenteric plexus consists of a rich plexiform network of 
 nerves and ganglia ensheathing and accompanying the inferior mesenteric 
 artery to the left colon, sigmoid and rectum (as nervi colici sinistri et 
 
 NERVES OF THE HEPATIC ARTERY AND BILIARY DUCT 
 
 Fig. 15. Presents the copy of an X-ray of the hepatic artery, biliary and pancreatic ducts 
 which are each richly ensheathed by a nodular, plexiform web of nerves. The quantity of 
 nerves may be estimated by the number of arteries and ducts in the liver and pancreas. I, 
 Vater's papilla at duodenal end of ductus chcledochus communis. II, junction of 
 ductus hepaticus (III) and ductus cysticus (IV). C, cholcyst, P, ductus pancreaticus, Sa, 
 ductus pancreaticus accessorius. The black conduit coursing parallel to the biliary ducts is 
 the hepatic artery. 
 
 haemorrhoidales superiores). It arises from the aortic plexus and especially 
 from the ganglion located at the origin of the arteria mesenterica inferior 
 (ganglion mesenteric inferior) as well as from the lumbar lateral ganglionic 
 chain (plexus lumbales aorticus). The fenestra or meshwork of the inferior 
 mesenteric plexus are not so compact or close as that of the superior mesen- 
 teric plexus. The nerves of this plexus form in its course subordinate 
 plexuses, accompanying or lying between the arterial branches, and produce 
 
70 THE ABDOMINAL AND PELVIC BRAIN 
 
 curved, arc anastomoses. They terminate the colonic muscularis as Auer- 
 bach's plexus (rhythm) and the colonic submucosa as Meissner-Bilroth plexus 
 (secretion and absorption). 
 
 The plexus mesentericus inferior arises from: (a) abdominal brain 
 (plexus mesentericus superior); (b) plexus aorticus; (c) ganglion mesenter- 
 icum inferior. 
 
 The plexus mesentericus inferior is not only solidly and compactly 
 anastomosed in all its branches, but solidly and compactly with all other 
 abdominal sympathetic plexuses. There exist nerve nodes — ganglia mesen- 
 terica inferior — along the course of the plexus. At the origin of the arteria 
 mesenterica inferior there is located a mass of nerve tissue — ganglion mesen- 
 tericum inferior — which doubtless endows the faecal reservoir (left colon, 
 sigmoid and rectum) with a daily rhythm for faecal evacuation. The inferior 
 mesenteric plexus anastomoses or is connected with: (a) second lumbar 
 ganglion in the lateral chain; (b) plexus aorticus abdominalis; (c) plexus 
 mesentericus superior; (d) plexus ovaricus; (e) plexus hypogastrics; (f) 
 plexus haemorrhoidalis (medius and inferior) from the arteria pudendalis. 
 The plexus mesentericus inferior ends in the colonic wall as automatic 
 visceral ganglia, Auerbach's (plexus myenteric externus) and Bilroth- 
 Meissner's (plexus myentericus internus). The nerves of the inferior 
 mesenteric plexus are remarkable for their tennity, length and general non- 
 branching state. The nerves of the inferior mesenteric plexus are not the 
 most numerous in the mesosigmoid. The plexus mesentericus inferior 
 terminates, like the inferior mesenteric artery, by bifurcating the two divi- 
 sions of this bifurcation are called the haemorrhoidal plexus superior. 
 They course bilaterally cistalward on the rectal wall accompanying two 
 lateral superior haemorrhoidal, terminating partly in the rectum and partly 
 in the plexus hypogastrics. 
 
 (4) Plexus Hcemorrhoidalis Medius ct Inferior (Paired). 
 
 The sources of the median and inferior haemorrhoidal plexuses are: (1) 
 from the dorsal part of the plexus hypogastrics; (2) the nerves accompany- 
 ing the middle (vaginal) and inferior haemorrhoidal artery ; (3) from the 
 pelvic brain (ganglion cervicale). The numerous nerves course bilaterally 
 through the mesorectum to the rectum. The proximal portion of the two 
 haemorrhoidal plexuses curve proximalward to anastomose with the plexus 
 haemorrhoidalis superior. The distal portion passes distalward to supply the 
 rectum and vagina. Small swellings may occur at the nerve crossings or 
 anastomoses, however, ganglia haemorrhoidalia are doubtful nervus haemor- 
 rhoidalis medius and inferior are branches of the plexus pudendus. The 
 nerves of the tractus intestinalis are not an independent system as it is 
 solidly and compactly anastomosed with all other abnormal systems. How- 
 ever the haemorrhoidal nerves are a spur which complicates the distal end 
 of the intestinal tract and separates the great partially independent nerves 
 of the tractus intestinalis for the rectum. The change is due to the 
 distalward movement of parts of the tractus genitalis and tractus urinarius 
 
THE NERVES OF THE TRACTUS INTESTINALIS 
 
 71 
 
 and their function with the rectum. In general I think the older anato- 
 mists with the exception especially of Henle represented the nerves and 
 ganglia supplying the tractus intestinalis rather too rich, too abundant. 
 Tedious dissection will lessen the number of nerve strands by eliminating 
 white fibrous connective tissue. 
 
 (b) Physiology of the Nerves of the Tractus Intestinalis. 
 
 The physiology of the nerve plexus supplying the tractus intestinalis is 
 important both theoretic and practical. The sympathetic nerves dominate, 
 
 v/- 
 
 ARTERIES OF CECUM AND APPENDIX 
 
 Fig. 16. The nerves in the important appendiculo-csecal region may be estimated by 
 observing an illustration of the arteries of this segment of the tractus intestinalis. The 
 nervus vasomotorius richly ensheaths the artery in a plexiform network. 
 
 rule, the intestinal tract, hence it possesses a rhythm, peristalsis — only 
 sympathetic ganglia possess the power of rhythm. In the physiology of 
 organs the course of nerves must be considered. First, the vagus (as cranial 
 nerve) supplies the proximal end of the tractus intestinalis as well as its 
 appendage; especially the liver with numerous fibres. The vagus aids to 
 
72 THE ABDOMINAL AXD PELVIC BRAIN 
 
 check rhythm, especially of the stomach. Second, the spinal nerves at the 
 distal end of the tractus intestinalis particularly the middle and inferior 
 hemorrhoidal nerves supplying the rectum and interfering with its rhythm 
 or peristalsis. The spinal nerve attending the rectum places it partially 
 under the will in controlling to some extent the evacuation of faeces or gas. 
 Third, there is the great splanchnic nerves, chief delegates in the function, 
 rhythm or peristalsis of the tractus intestinalis (median) especially in the 
 enteron or business segment. The splanchnic nerves though preponder- 
 atingly sympathetic possess a rich source in the spinal cord. Therefore 
 though the tractus intestinalis is preponderatingly supplied with sympathetic 
 nerves (hence rhythmic) it is supplied at its proximal end by cranial nerves 
 (vagi) and at its distal end by spinal nerves (hemorrhoidal). The general 
 function of the tractus intestinalis under the sympathetic nerve is: (a) 
 peristalsis (rhythm); (b) absorption; (c) secretion. Its object is digestion. 
 The business of a physician is chiefly to aid in maintaining normal functions, 
 i. e., peristalsis, absorption and secretion in the intestinal tract. In the 
 general application of the physiology of the nerves of the tractus intestinalis 
 for practical purposes there should be considered: (a) those of the proximal 
 end, stomach and appendages; (b) the nerves supplying the medial region 
 (enteron) and (c) the nerves supplying the distal end (colon). The great 
 sympathetic nerve plexuses accompany the arteries. 
 
 (a) The Physiology of the Nerves of the Proximal End of the Tractus Intes- 
 tinalis (Stomach, Liver, Spleen and Pancreas). 
 
 Since the arterial branches of the coeliac axis (hepatic, gastric and 
 splentic) are solidly and compactly anastomosed at their peripheries by means 
 of circles and arcs the three branches of the coeliac plexus which accompany 
 the hepatic, gastric and splenic arteries are solidly and compactly anas- 
 tomosed on the arterial circles and arcs. This anatomic fact solidly and 
 compactly anastomoses the nerve plexuses of the liver, stomach, pancreas 
 and spleen as well as that of the duodenum and pancreas forming a single 
 apparatus thus inducing the nerve arrangement of the liver, stomach, 
 duodenum, pancreas and spleen to act as a unit or single apparatus with 
 the abdominal brain as a reflex, focal or reorganizing center. In practice 
 this is found true, e. g., the irritation of a calculus in a segment of the 
 biliary passages from inflammation or irritation will be transmitted to the 
 abdominal brain as a focal center, become reorganized and emitted over the 
 gastric plexus, inducing nausea or vomiting, thus disordering the gastric 
 rhythm. Irritating food or liquid (alcohol) in the stomach quickly disorders 
 the hepatic rhythm and if gall stone be present hepatic colic is liable to arise. 
 Again, the introduction of food and fluid into the stomach incites the rhythm, 
 peristalsis and secretion of the stomach, liver, duodenum and pancreas, 
 demonstrating the anatomic and consequently the physiologic connection 
 and anastomoses of the nerve plexus apparatus of the stomach, liver, duo- 
 denum, pancreas (and spleen). The nerve apparatus of the viscera in the 
 proximal abdomen is a finely balanced structure with the abdominal brain 
 
THE NERVES OF THE TRACTUS INTESTINALIS 
 
 73 
 
 as a reorganizing, focal, center. Subjects with hepatic calculus are ample 
 evidence of the solid and compact anastomoses of the nerves of the stomach 
 and liver, for they avoid many kinds of food, as their experience has taught 
 that stimulating foods in the stomach will excite hepatic colic. The 
 rhythm of the proximal end of the tractus intestinalis (stomach) being 
 supplied by two powerful cranial nerves (vagi) is the most irregular of any 
 segment of the intestinal tract. 
 
 (b) Physiology of the Nerves Supplying the Middle Region of the Tractus 
 
 Intestinalis {Enteron). 
 
 The superior mesenteric plexus is the largest and richest sympathetic 
 plexus in the body. It has an extensive and an enormous surface area (a 
 
 AN X-RAY OF THE DUCTUS PANCREATICUS AND PART OF THE DUCTUS BILIS 
 
 Fig. 17. This illustration represents the ductus pancreaticus with its lateral ducts, all of 
 which are richly ensheathed in a plexiform, nodular meshwork of nerves. It is an X-ray of 
 part of the ductus bilis and ductus pancreaticus of a girl of 11 years old. I to II, ductus chole- 
 dochus communis. II to III, ductus hepaticus. II to IV, ductus cysticus. C, cholecyst. It is 
 easy to observe the segments of the pancreas, viz. : — caput, collum, corpus, cauda. In fact, this 
 beautiful accurate illustration establishes final anatomy. Sa, ductus Santorini functionated 
 as the celloidin projected from its exit duct during the injecting of it. The proper eponym 
 for the pancreatic secretory channel is the Hofman-Wirsung duct. The liver of this patient 
 was advanced in sarcomatous disease but the pancreas appeared healthy. P, ductus pan- 
 creaticus. 
 
 truncate cone, the base of which is twenty-one feet; apex six inches; 
 height six inches — covering an area of many square feet). The superior 
 mesenteric plexus consists of a closely fenestrated meshwork of powerful 
 nerves and ganglia ensheathing in a plexiform manner the superior mesen- 
 teric artery which practically supplies the digestive portion of the tractus 
 intestinalis. 
 
74 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 The first factor in the physiology of the superior mesenteric plexus is 
 that it controls the volume of blood-supply of the enteron. It is nervus 
 vasomotorius of the enteron. Stimulation of the splanchnics (which con- 
 stitutes the major portion of the superior mesenteric plexus) produces 
 hyperemia of the enteron. The function of the enteron depends on its blood 
 supply. The stimulus which induces necessary blood supply to the enteron 
 for digestion is the irritation that the food produces on its mucosa. A full 
 enteron is hyperaemic, active one. An empty, evacuated enteron is an anaemic, 
 quiet one. The three great manifest functions of the superior mesenteric 
 plexus is to produce in the enteron rhythm, peristalsis, secretion and absorp- 
 tion. There can be little doubt that included in the rhythm of the enteron 
 (dependent on hyperemia) is the factors of secretion and absorption. So 
 long as enteronic rhythm is not interfered or especially the enteronic (foecal) 
 current is not obstructed the enteron performs its function (rhymth, secretion 
 and absorption.) However, as soon as mechanical obstruction to the enter- 
 onic (food) current occurs (as flexion, volvulus stricture) the nondrainage 
 induces residual deposits resulting in accumulation of bacteria and consequent 
 infection. The enteron possesses a periodioc rhythm about every six hours 
 (ingested meals and fluids) which enables absorption and secretion to com- 
 plete itself and the rhythm to transport the residual debris to the colon. 
 
 (c) TJw PJiysiology of the Nerves at the Distal End of the Tractiis 
 
 Intestinalis. 
 
 The physiology of the sympathetic nerve at the distal end of the tractus 
 intestinalis is interfered, complicated by the addition of the spinal nerves 
 (as the proximal end is complicated by the addition of the cranial nerves — 
 vagi). The physiology of the distal end of the tractus intestinalis (left 
 colon, sigmoid and rectum) is chiefly included in the so-called hemorrhoidal 
 nerves — a developmental addition, an imposition on the original markedly 
 independent sympathetic nervous system of the intestinal tract, through the 
 coalesce of the tractus intestinalis, tractus genitalis and tractus urinarius — 
 the coloaca has disappeared and its place is supplied by a rectal, vaginal and 
 urethral sphincter. The haemorrhoidal nerves are a spur which complicates 
 anatomically and physiologically the distal end of the intestinal tract and 
 separates the great practically independent nerves (plexus mesentericus in- 
 ferior) of the tractus intestinalis from the rectum. The hemorrhoidal nerves 
 can not manifest definite action on the tractus intestinalis (left colon, sigmoid 
 and rectum) which I shall term the faecal reservoir, which has a daily rhythm. 
 It is practically, for local purpose, under the rule of the inferior mesenteric 
 ganglion. Numerous phenomena of the rectum in disease, in pain, do not 
 belong to the sympathetic nerve but to the spinal nerves accompanying it, as 
 the sharp pains in the anal fissure. 
 
 The expiratory moan resembling the bray of an ass in rectal dilatation is 
 explained by the irritation being transmitted over the haemorrhoidal plexuses 
 (inferior medius and superior) to the abdominal brain, whence it may pass: 
 first, over the diaphragmatic plexus (right side) to the right phrenic nerve 
 
THE NERVES OF THE TRACTUS INTESTINALIS 
 
 75 
 
 (contracting the diaphragm); second, over the splanchnics to the inferior 
 cervical ganglion, which is connected to the phrenic by a nerve cord, whence 
 the route is direct to the diaphragm (inducing the diaphragm to contract) ; 
 third, the irritation from the rectal dilatation may pass over the third and 
 fourth sacral nerves, proximalward of the spinal cord to the cranial cerebrum 
 where reorganization and emission occurs over the cord and phrenic nerve- 
 to the diaphragm, inducing contraction and an expiratory moan or bray. The 
 disordered functions of the digestive canal are chiefly excessive (diarrhoea, 
 colic), deficient (constipation), or disproportionate (fermentation). In the 
 excessive rhythm (colic) or secretion of the tractus intestinalis, we possess 
 effective remedies, as anatomic and physiologic rest; with the holding of food 
 and fluids and the administration of anodynes (opiates). The treatment 
 consists in securing normal rhythm, peristalsis, absorption and secretion. 
 In deficient rhythm (constipation) and secretion in the tractus intestinalis we 
 possess effective remedies in the restoration of the normal rhythm and secre- 
 tion as diet. Coarse food, as cereals and vegetables, leave ample faecal residue 
 to stimulate the colon, intestine to vigorous peristalsis; the evacuation of 
 the colon at regular intervals; exercise and massage of the abdomen; 
 electricity. It is a known physiologic principle that regular habits of bowel 
 evacuation daily will maintain the rhythm normal, but that neglect of regu- 
 lar evacuation will destroy the rhythm; in fact, induce constipation. The 
 normal rhythm of bowel evacuation is a delicate matter and mental disturb- 
 ance, change of habits, different environments, may viciate the rhythm of the 
 faecal reservoir (left colon, sigmoid and rectum). In disproportionate peris- 
 talsis (colic) and secretion (fermentation), the effective remedy is to regu- 
 late the diet and fluid to restore normal rhythm and secretion; to introduce 
 disinfectants to check fermentation, as sulphocarbolates. It will be observed 
 that the sympathetic system of the entire tractus intestinalis, consisting of 
 six great plexuses (nerve cords and ganglia), viz.: (a) gastric; (b) hepatic; 
 (c) splenic; (d) superior mesenteric; (e) inferior mesenteric; (f) haemor- 
 rhoidal, is not only profoundly connected with the coeliac plexus or abdomi- 
 nal brain, but the five plexuses are all solidly and compactly anastomosed, 
 bound together and also anastomosed (connected) with all other plexuses of 
 the abdominal visceral tracts, in order that the chief potentate — the 
 abdominal brain — may rule as a single unit of power. No conflict of power 
 arises, as all ganglia of the tractus intestinalis are subordinate to the abdom- 
 inal brain — however, local rulers, as the ganglion mesentericum inferior, are 
 allowed to rule, to dominate, with a daily rhythm, the faecal reservoir (left 
 colon, sigmoid and rectum). The nerve plexuses of the various abdominal 
 visceral tracts are anastomosed, connected, solidly and compactly, in order 
 to maintain a balanced system and for local and general physiologic reports 
 to the abdominal brain. 
 
CHAPTER VIII. 
 
 NERVES OF THE TRACTUS URINARIUS (NERVI TRACTUS 
 URINARIUS).— (A) ANATOMY, (B) PHYSIOLOGY. 
 
 These are times which try men's souls. — Thomas Paine. 
 
 The object of research is not to know the truth merely but to discover something 
 that will benefit some one — relieve suffering and prolong life. 
 
 (a) ANATOMY. 
 
 To the urinary tract pass nerves from: (1) plexus suprarenalis, (2) plexus 
 renalis, (3) plexus ureteris, (4) plexus ovaricus, (5) ganglia lumbales, (6) 
 plexus communis arteriae iliacus, (7) ganglia sacrales, (8) plexus hypogastricus 
 (9) plexus vesicalis, (10) plexus urethralis, (11) plexus mesentericus superior, 
 (12) plexus mesentericus inferior, (13) plexus arteriae uterinae, (14) plexus 
 sacralis (spinal). The above nerve plexuses solidly and compactly anasto- 
 mose with each other and with all abdominal sympathetic plexuses, thus con- 
 necting the tractus urinarius intimately and profoundly through the nerve 
 plexuses with all other abdominal viscera. 
 
 (l) The Plexus Suprarenalis (Paired). 
 
 Bilaterally from the external border and proximal angle of the abdominal 
 brain depart from five to eight coarser and finer nerves to supply the adrenals. 
 These nerves are remarkably developed in infancy. The strands of the 
 suprarenal plexus possess many small ganglionic masses in their course, and 
 at the points of division. For the small adrenal the nerve supply is enor- 
 mous. In the plexus suprarenalis may be found the ganglion suprarenale or 
 nervus splanchnicus minores. The plexus suprarenalis sends branches to 
 the plexus renalis and on the right side also branches to the plexus 
 diaphragmaticus. 
 
 (2) Plexus Renalis {Paired). 
 
 Bilaterally from the external border and distal lateral angle of the 
 abdominal brain departs a wide meshed plexus of nerves along the renal 
 arteries to the kidneys. The renal plexus is composed of larger and smaller 
 ganglia with larger and smaller strands and it is extensively fenestrated. 
 Nerve branches from the renal ganglia course distalward on the ureter and 
 obliquely medianward to join the plexus aorticus. The renal plexus is one 
 of the richest in ganglia and strands. In fact, the renal plexus frequently 
 appears as a continuation of the cceliac ganglion. There is a profound and 
 solid connection between kidney and abdominal brain. The renal plexus 
 ensheathes the renal artery with a network of ganglia and cords arriving at 
 the kidney through the hilum. The plexus renalis receives strands from the 
 second and third ganglia of the lumbar lateral chain. The renal plexus is 
 connected with the plexus mesentericus superior and inferior. The renal 
 plexus arises from: (a), the major splanchnic; (b), the minor splanchnic; (c). 
 
 76 
 
NERVES OF THE TRACT US UR1XARIUS 
 
 77 
 
 .IV. 
 
 -AS.V 
 
 ARTERIAL SUPPLY OF THE TRACTUS URINARIUS 
 
 Fig. 18. The proximal part of the figure is from corrosion anatomy The nerve supply 
 to the tractus urinarius is perhaps best remembered by recalling its blood supply, for the 
 sympathetic nerves accompany the vessels, especially the arteries. The. artenes to the 
 tractus urinarius are : (a) the arteria adrenalis ; arteria renalis ; arteria ovarica (spermatica) 
 to arteria media ureteris, (y) arteria uterina, (z) the three vesical arteries observe each of 
 which is accompanied by its plexus of nerves The tractus urinarius is "^ly Jeset wtjivaso. 
 motor nerves. This anatomic fact is evident from the violent symptoms induced by an ure- 
 teral calculus. See also Fig. %, for rich ganglia renalia. 
 
78 THE ABDOMIXAL AXD PELVIC BRA IX 
 
 the first lumbar ganglion; (d), the cceliac ganglion; (e), plexus mesentericus 
 superior; (f) plexus aorticus — six sources. Each renal plexus contains four 
 to six ganglia. A profound connection, anastomosis, exists between the renal 
 plexus and plexus aorticus, hypogastricus and ovaricus — i. e., the kidney and 
 genitals are profoundly and solidly connected or anastomosed, by nerve cords 
 and ganglia. 
 
 The renal plexus is practically all sympathetic. Certain nerve nodes — 
 ganglia renalia — remarkable for number and dimension — are distributed in the 
 plexus renalis. The largest renal ganglia lie on the ventral surface of the 
 renal artery, while several smaller ones lie in the bifurcations of the arteria 
 renalis and on the distal and proximal border of the renal artery. 
 
 The plexus renalis receives some branches from the plexus adrenalis and 
 the plexus mesentericus superior. The nervus splanchnicus minor supplies 
 a branch to the plexus renalis which is frequently strengthened by branches 
 from the two proximal ganglia of the lateral lumbar chain. 
 
 (-3) Plexus Ureteris {Paired). 
 The ureter is supplied by a rich plexus of nerves from many sources, as 
 may be observed from its vigorous and brusque rhythm, resembling cardiac 
 contraction. The ureter consists of calcyces, pelvis and ureter proper, and 
 each segment is supplied in a degree from different areas of the abdominal 
 sympathetic, and lumbar and sacral chain of ganglia, however, united into 
 one unit of power in order that the ureteral rhythm may be periodic and 
 orderly from proximal to distal end. The ureter is supplied by: — (a), plexus 
 renalis; (b), plexus aorticus; (c), plexus ovaricus (spermaticus); (d), lumbar 
 lateral chain; (e), sacral lateral chain; (f), plexus hypogastricus; (g), plexus 
 arteria?; (h), plexus mesentericus superior; (i), plexus mesentericus inferior; 
 (j), sacral nerves — ten sources. By the silver method on fresh ureters of ani- 
 mals we could demonstrate rich plexuses or networks of nerves on the walls 
 of the ureter, with ganglia at the union of junction of the anastomosing 
 nerves. Three strong and important points of rich anastomoses of the plexus 
 ovaricus and plexus uterinus with the plexus ureteris occurs at (a), where the 
 ureteris is crossed ventrally by the vasa ovarica (spermatica^ which solidly 
 unites the ureteral and ovarian (spermatic.) nerve plexuses. This explains the 
 reflex pain of ureteral irritation {e. g. calculus) on the ovary or testicle — 
 (retraction), (b), Where the ureter crosses dorsally to the arteria uterina a 
 strong and solid anastomosis occurs between the plexus ureteris and plexus 
 arteriae uterinae. Ureteral irritation (e. g. calculus) may be transmitted to 
 the uterus (genitals) and bladder, (c), The plexus ureteris and plexus com- 
 munis arteriaeiliacus solidly anastomose at the point where the ureter crosses 
 ventrally to the iliac arteries. This explains the reflex pain in the thigh dur- 
 ing ureteral irritation, e. g. % ureteral calculus. 
 
 (4) Plexus Ovaricus {Spermaticus — Paired). 
 The ovarian plexus arises from the plexus aorticus, extending from the 
 ganglion cceliacum, located at the arteria cceliaca, to the ganglion hypogastri- 
 cum, located on the promontorium. Its chief origin is from the ganglion 
 
NERVES OF THE TRACTUS URINARIUS 
 
 79 
 
 ovaricum. Immediately subsequent to its origin from the plexus aorticus it 
 presents about a dozen nerve strands which gradually coalesce and converge 
 into three main nerves trunks, studded with ganglia, and accompany the vasa 
 ovarica to the ovary. At the point where the vasa ovarica crosses ventral to 
 the ureter the accompanying plexus ovaricus forms a rich anastamosis with 
 the plexus ureteris. This anastamosis of the plexus ovaricus with the plexus 
 ureteris explains the reflex pains of the irritated ureter (ureteritis, calculus) in 
 
 NERVES OF THE TRACTUS URINARIUS— CORROSION ANATOMY 
 
 Fig. 19. This specimen presents quite faithfully the circulation, the kidney, calyces and 
 pelvis. The two renal vascular blades I present opened like a book. The corrosion was on 
 the left kidney and the larger vascular blade is the ventral one. The vasomotor nerves 
 accompanying the urinary tract may be estimated by the fact that a rich plexiform network 
 of nerves ensheath the arteries, the calyces, pelvis and ureter proper. When the renal vas- 
 cular blades are shut like a book their thin edges come in contact, but do not anastomose. 
 The edges of the vascular blades are what I term the exsanguinated renal zone of Hyrtl, who 
 discovered it in 1868, and we, at present, employ it for incising the kidney to gain entrance 
 to the interior of the calyces and pelvis with minimum haemorrhage. 
 
 the ovary and uterus (testicle retraction). The anastomosis of the plexus 
 ovaricus with the plexus ureteris solidly and compactly connects the ureter 
 with the entire length of the plexus aorticus. 
 
 (5) Ganglia Lnmbalcs {Paired). 
 The two proximal lumbar ganglia send branches to the proximal plexus 
 ureteris, as well as branches to the plexus renalis and plexus ovaricus, thus 
 supplying the proximal end of the ureter. 
 
80 THE ABDOMINAL AND PELVIC BRAIN 
 
 {6) Plexus Iliacus Communis Arteries {Paired). 
 
 A small artery springs from the common iliac and supplies the lumbar 
 spindle of the ureter. This solidly connects the plexus ureteris with the 
 plexus of nerves that accompanies the iliac and femoral vessels, accounting 
 for the pain in the thigh during attacks from ureteral calculus and ureteritis. 
 
 (7) Ganglia Sacrales {Paired). 
 
 The proximal sacral ganglia send branches to and anastomose with the 
 plexus ureteris, thus intimately connecting the pelvic ureter with all other 
 sympathetic pelvic plexuses. 
 
 {8) Plexus Hypogastricus {Paired). 
 
 This powerful plexus sends several branches to the pelvic ureter, solidly 
 anastomosing the ureter with the genital tract. 
 
 {9) Plexus Vesicalis {Paired). 
 
 The vesical plexus consists of a wide meshed network of nerves supply- 
 ing the bladder with greater and smaller ganglia studding the plexus at the 
 junction of the anastomosing nerves. The vesical plexus arises from: (a), 
 plexus hypogastricus; (b), ganglion cervicis uteri; (c), nervi sacrales; (d), 
 lateral sacral chain; (e), nerve plexuses following the course of the three 
 vesical arteries (superior, middle and inferior) derived from the hypogastric 
 plexus, (a large spinal nerve supplies the bladder from the third sacral, thus 
 making a mixed nerve supply to the bladder). The rhythm of the bladder 
 (systole and diastole) is not so apparent as that of some other organs, as the 
 ureter, heart, uterus or enteron, being modified by the interference of the 
 spinal nerves. 
 
 The vesical plexus is a leash of nerves which supplies the distal ureter 
 and bladder. So far as I can learn from dissection, it originates in the pelvic 
 brain (ganglion cervicale). The plexus vesicalis solidly anastomoses with all 
 other sympathetic plexuses in the pelvis. 
 
 {10) Plexus Mesentericus Superior {Unpaired). 
 Sends some branches to the proximal end of the ureter. 
 {ll) Plexus Mesentericus Inferior {Unpaired). 
 
 Sends several branches to the ureter. Nos. 10 and 11 anastomose the 
 ureter with the tractus intestinalis, and hence when ureteral pain arises it 
 will be diffused through the intestines, and will confuse ureteral and intes- 
 tinal colic. 
 
 {12) Plexus Arteries Uterincz {Paired). 
 
 The uterine artery is accompanied by a strong nerve plexus ensheathing 
 it. At the point where the uterine artery crosses ventrally to the uterer the 
 nerve plexuses of the artery and ureter anastomose with each other. This 
 explains the uterine reflex pain during attacks of ureteral calculus and 
 ureteritis. 
 
NERVES OF THE TRACTUS URINARIUS 
 
 81 
 
 (IS) Plexus Urethralis (Paired). 
 
 The urethral plexus is a continuation of the vesical plexus accompanied 
 by the sympathetic nerves which arrive at the urethra on the supplying 
 blood vessels. 
 
 The above thirteen plexuses are sympathetic, hence it is evident that the 
 tractus urinarius is dominated by the sympathetic nerve in its function 
 (rhythm). 
 
 CORROSION ANATOMY (Hyrtl's exsanguinated renal zone) 
 
 Fig. 20. In this specimen of corrosion anatomy the renal vascular blades (ventral and 
 dorsal) are closed like a book. It presents (left kidney) on the margin of the dorsal lateral 
 surface the exsanguinated zone of Hyrtl — the line of minimal haemorrhage for cortical renal 
 incision. A rational method to estimate the quantity of nerves of the tractus urinarius is 
 to expose the number and dimension of the arteries and other tubular ducts which are 
 ensheathed in a plexiform network — a fenestrated, nodular, neural vagina of nerves. 
 
 (14) Plexus Sacralis (Spinal). 
 
 The sacral spinal plexus sends nerves to the bladder, and hence gives rise 
 to a mixed nerve supply. However, the sympathetic dominates, as it compels 
 the bladder to assume rhythm (diastole and systole). The chief spinal nerve 
 to the bladder arises from the III sacral, and supplies the body of the bladder. 
 
82 THE ABDOMINAL AND PELVIC BRAIN 
 
 (b) physiology. 
 
 The establishment of the nerve supply to the tractus urinarius serves as a 
 foundation to an understanding of its physiology. A complete nervous sys- 
 tem comprises (a) a peripheral apparatus, (b) a conducting cord, and (c) a 
 ganglion cell. The object of the nervous system is that the peripheral 
 apparatus shall collect data (sensation), the conducting cord shall transport 
 it, and the nerve ganglion shall reorganize and utilize the nerve forces. 
 
 The collection, transportation, and utilization of nerve forces from and 
 to the tractus urinarius is a matter of vast importance in diagnosis and 
 practice. 
 
 The function of the tractus urinarius is practically comprised in four acts, 
 viz. : — peristalsis (rhythm) secretion, sensation and absorption. All visceral 
 muscles, being under the sympathetic nerves, must execute rhythm, contract 
 and relax, or atrophy. The object of the kidney is to secrete fluid while the 
 object of the urinary tract (ureter, bladder and urethra) is to conduct a 
 stream of fluid to the external body by means of periodic rhythmical move- 
 ments. From ureteral sensibility, i. e., from urine flowing on the sensitive 
 ureteral mucosa, every three to five minutes a brusque, peristaltic wave 
 passes from the proximal to the distal end of the ureter. The vesical and 
 urethral waves are more irregular, as the bladder is practically a reservoir. 
 The periodic ureteral peristalsis is due to the sympathetic ganglia located 
 within the ureteral wall. So long as the ureteral peristalisis is not interfered 
 and especially the ureteral stream is not obstructed, the ureters perform their 
 periodic rhythm. However, as soon as mechanical obstruction to the ureteral 
 stream arises (as from flexion, calculus, ureteritis or stricture) the non-drain- 
 age induces residual deposits with resulting accumulations of bacteria, 
 whence the vicious circle occurs in the tractus urinarius exactly similar to 
 the vicious circles arising from obstruction in the pylorus or the biliary ducts. 
 The urinary ducts are independent organs conducting the urine to the 
 external body by means of rhythmic, periodic waves, regardless of the bodily 
 attitude or force of gravity. The kidney is a composite organ, consisting of 
 numerous secretory organs — malpigian corpuscles and tubuli uriniferi — and 
 no doubt these secrete rhythmically, periodically, though the urine exists 
 constantly in the ureteral calcyces and pelvis — that being the accumulative 
 results of secretion. The sympathetic nerve, however, is a silent, ceaseless, 
 painless agent, unconsciously increasing its function — rhythm, secretion and 
 absorption — as food and fluid are offered. 
 
 It should be remembered that nerve forces travel in the direction of least 
 resistance, i.e., a nerve plexus containing the greatest number, of nerve 
 strands. It is not multiplication of ganglion cells that increases intelligence, 
 it is multiplication of nerve connecting cords that facilitates transmission. 
 Hence in diseases of the channels of the tractus urinarius, as calculus, stric- 
 ture, ureteral flexion, or ureteritis, the organs connected with the tractus 
 urinarius by the greatest number of nerve strands will suffer the most 
 trauma. For example, in ureteral calculus the pathologic irritation from 
 
NERVES OF THE TRACTUS Uh'l.X.lh'WS 
 
 83 
 
 NERVES OF THE TRACTUS URINARIUS 
 
 Fig. 21. The nerves of the urinary tract were dissected in this specimen under alcohol. 
 The ureters, which I term swan-shaped, were irregularly dilated and contained valves (V), 
 SP, abdominal brain, D, ganglia renalis distributed over the dilated ureteral pelvis. C. 
 plexus adrenalis. The plexus ureteris is rich in plexiform network. B, great splanchnic, 
 Observe that the proximal ureteral isthmus (neck) lying in a groove in the renal pole is not 
 dilated. 
 
84 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 the ureter passes over the giant renal plexus to the abdominal brain, whence 
 reorganization and emission occurs on the plexus gastricus to the stomach, 
 inducing nausea or vomiting. Again, the plexus ureteris is profoundly con- 
 nected or anastomosed with the plexus ovaricus (spermaticus) ; hence during 
 attacks of calculus the testicle suffers pain and is retracted, also the ovary 
 suffers pain. In short, an irritation in the tractus urinarius will induce the 
 most pain in the viscera possessing the plexuses with the greatest number of 
 nerve strands. 
 
 The influence of the plexus ureteris is patent when micturition is so 
 urgent and irregular in the presence of calculus or ureteritis. The plexus 
 
 CORROSION ANATOMY 
 
 Fig. 22. This specimen of corrosion anatomy presents the ureteral calyces, ureteral 
 pelvis, and proximal end of ureter proper together with the arteria and vena renalis. All 
 segments except the vein are ensheathed in a rich plexiform network of the nerves govern- 
 ing peristalsis, absorption, secretion, sensation. When a ureteral calculus becomes mobile 
 in the ureter, peristalsis (violent) and sensation (pain) become evident. 
 
 vesicalis is influential in indicating the line of pain in calculus, and the plexus 
 urethralis is a continuation of it, localizing the pain in the glans penis (male) 
 and the pudendum and clitoris (female). Hence, as regards pain in the 
 tractus urinarius, it aids in diagnosis by manifesting the most prominent 
 symptoms along the nerve plexus containing the greatest number of nerve 
 strands, such as the plexis renalis (stomach — vomiting), plexus ovaricus or 
 spermaticus (retraction of the testicle). 
 
 Since the nerve plexuses of the tractus urinarius are solidly and compactly 
 anastomosed with all the other nerve plexuses of the abdominal sympathetic, 
 the pain from ureteral disturbances is rather diffuse. However, since the 
 nerve plexuses of the tractus urinarius are extensively and profoundly con- 
 
NERVES OF THE TR ACTUS URINARIUS 
 
 85 
 
 nected with the plexuses of the tractus genitalis, ureteral disturbances are 
 more intensely reflected over the plexuses of the tractus genitalis, c. g. % in 
 the nerve plexus of the ovary, pudendum, clitoris (female), and of the 
 testicle, perineum, penis (male). 
 
 As regards lithiasis, the chief manifestation from the tractus urinarius 
 is pathologic physiology, that is, disordered function, rhythm, absorption. 
 
 RELATION OF SPINAL NERVES TO TRACTUS URINARIUS 
 
 Fig. 23. Illustrates the relation of the spinal nerves to the ureter, especially its plexus 
 lumbalis. The ureter is intimately connected with the genito-crural nerve (A), hence the 
 pain reflected in the thigh and scrotum in ureteral colic and other ureteral diseases. (2) 
 Ileo-inguinal nerve. For illustration of ureteral nerves and legend of same, See fig. 24 
 
 or secretion. Hence the clue to the local disorder must be sought in the 
 nerve plexuses suffering most intensely, associated with the tractus urinarius. 
 For example, in calculus there may be the reno-uterine reflex, the reno- 
 testicular reflex, all indicating intense pain along the above-indicated nerve 
 plexuses. 
 
 The stamping pain of Clement Lucas is where one afflicted with a 
 ureteral calculus stands on one foot and stamps, which places the psoas 
 muscle on a violent tension, and traumatizes, massages the ureter, which, if 
 
86 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 it possesses a calculus, will induce vigorous ureteral peristalsis and consequent 
 ureteral pain, colic. Jordan Lloyd's method of inducing pain in the ureter 
 with calculus, by a blow on the erector spinas muscles, is simply another 
 process by which the lumbar muscles (especially the psoas) massages the 
 ureter, exciting vigorous ureteral peristalsis and consequent pain and colic. 
 
 The explanation of pain intensified in different regions of the body 
 during attacks of calculus or other diseases of the tractus urinarius must be 
 sought in the line of the nerve plexuses and their anastomoses with other 
 nerve plexuses. For example, ureteral calculus produces pain in the plexus 
 spermaticus (pain and retraction of the testicle) because the plexus ureteris 
 anastomoses with the plexus spermaticus where the ureter is crossed ven- 
 trally by it (vasa spermatica). A useful suggestion for remembering the 
 nerve plexus of the tractus urinarius is to recall the arterial supply, as the 
 ureteral nerve plexuses accompany the arteries of the tractus urinarius. 
 
 The function of the tractus urinarius is rhythm (peristalsis), absorption, 
 sensation, and secretion. The rhythm keeps its tract always full. It is a 
 perfect system of waterworks whose stop-cocks or sphincters are always in 
 order and on guard. 
 
CHAPTER IX. 
 
 THE NERVES OF THE GENITAL TRACT (NERVI TRACTUS 
 GENITALIS)-(A) ANATOMY, (B) PHYSIOLOGY. 
 
 The American government is not in any sense founded upon the Christian 
 religion.— Treaty with Tripoli signed by President George Washington. 
 
 The appointive power of a political party vitalizes its energy and locates its re- 
 sponsibility. 
 
 (a) anatomy. 
 
 The origin of genital nerves are: I, nervus vasomotorius (sympathetic- 
 abdominal brain); II, spinal cord (medulla spinalis), through rami commun- 
 icantes and rami nervorum sacralium (II, III, IV), cerebrum (vagi). 
 
 The three major nerve streams to the tractus genitalis are (a) the plexus 
 interiliacus (which is a continuation of the plexus aorticus) originating in the 
 abdominal brain; (b) the plexus ovaricus originating from the whole plexus 
 aorticus; (c) plexus sacralis spinalis (rami nervorum sacralium — II, III, IV). 
 The minor nerve streams to the tractus genitalis are: (d) lateral lumbar gan- 
 glia (truncus nervus lumbales vasomotorius) ; (e) lateral pelvic ganglia (trun- 
 cus nervus pelvis vasomotorius); (f) nerves of the uterine artery (nervi 
 arteriae uterinae) ; (g) nerves of the hypogastric artery (nervi arterise hypo- 
 gastrics) richly demonstrated in infant cadavers. Also nerves of the round 
 ligament and hemorrhoridal arteries. 
 
 Practically the nerves supplying the tractus genitalis are solidly and 
 compactly anastomosed connected with the whole abdominal vasomotor 
 nerves (sympathetic), especially with the giant ganglion coeliacum— the 
 abdominal brain — the great assembling center of the vasomotorius abdominale 
 or sympathetic nerve plexus. The anastomosis or connection of the genital 
 nerves to the nervus vasomotorius (sympathetic) and cerebro-spinal is vast 
 and profound. The order of solidarity or compactness of anastomosis or pro- 
 fundity of connection of the vasomotor nerves (sympathetic) to the abdom- 
 inal viscera is the following, viz. : (A) nervus vasomotorius to the tract js 
 vascularis (blood and lymph vessels); (B) nervus vasomotorius to tractus 
 intestinalis; (C) nervus vasomotorius to tractus genitalis; (D) nervus 
 vasomotorius to tractus urinarius. However, all the abdominal viscera are 
 solidly and compactly anastomosed, connected to the central abdominal 
 sympathetic or vasomotor nerve that no one visceral system can become dis- 
 turbed, deranged, without affecting profoundly all other visceral systems. 
 The derangement arising in the several abdominal visceral systems caused by 
 irritation or disease in any one abdominal visceral system is produced by 
 reflexes, resulting in the disturbed common visceral function — peristalsis, 
 secretion, absorption, sensation. So far as I am able to observe, the reflexes, 
 or irritation in the tractus genitalis produces the most profound and vast 
 
 87 
 
88 THE ABDOMINAL AXD PELVIC BRAIN 
 
 derangement of function in other abdominal viscera of any single visceral 
 system, e.g., irritation, disease in the tractus genitalis, passes to the abdom- 
 inal brain (over the plexus interiliacus and plexus aorticus) where it is reor- 
 ganized and emitted to the tractus intestinalis or tractus urinarius, deranging 
 the common function of peristalsis (rhythm), secretion, sensation and absorp- 
 tion — causing deficient, excessive or disproportionate peristalsis, secretion or 
 absorption. The older anatomists, like the philosophic Willis (1622-1675), 
 who was the Sedlian professor in Cambridge, claimed that the nerves supplying 
 the tractus genitalis arose from the intercostal nerves, that is, by means of the 
 rami communicantes, truncus vasomotorius — lateral ganglionic chain and 
 nervi splanchnici. This is as true today as in the days of the ever-memor- 
 able Willis ; however, we ascribe today more to independent, more differen- 
 tiation to the vasomotor nerves (sympathetic) than did Willis. These 
 so-called intercostal nerves (rami communicantes) form a nervous center — 
 the abdominal brain — secondary to the cranial brain, which has differentiated 
 functions of the first magnitude as regards existence of life itself. Hence, 
 today we are inclined to believe from experimentation and clinical data that 
 the chief origin of the nerves of the tractus genitalis is the abdominal brain 
 — cerebrum abdominale, and since this giant ganglion controls the vascular 
 supply of the abdominal viscera it should be termed cerebrum vasculare ab- 
 dominale. In the consideration of the nerve supply of the tractus genitalis it 
 is favorable for convenience of description and practical purposes to present 
 a major and minor nerve stream. The following table presents in a bird's- 
 eye view the major and minor nerve supply to the genital tract: 
 
 Ma joy Nerve Supply. 
 
 A. Plexus interiliacus (sympathicus). 
 
 B. Plexus ovaricus. 
 
 C. Plexus sacralis spinalis (rami nervorum sacralium). 
 
 Minor Nerve Supply- 
 
 D. Lateral lumbar ganglia (truncus nervus sympathicus lumbales). 
 
 E. Lateral pelvic ganglia (truncus sympathicus sacrales). 
 
 F. Nerves of the uterine artery (nervi arteriae uterinae). 
 
 G. Nerves of the hypogastric artery (nervi arteriae hypogastrics). 
 
 H. Nerves of the round ligament artery (nervi arteriae ligamenti 
 rotundi). 
 
 Fig. 24. An illustration of the pelvic brain (B) and the nerve supply in the pelvis, uterus 
 and bladder and rectum. Ut, uterus (with its plexus uterinus) ; Vs, bladder (with its plexus 
 vesicalis) ; Ov, ovary (with its plexus ovarica) ; Od, oviduct (with its plexus oviductus) ; R, 
 rectum (with its plexus rectalis) ; GS, great sciatic nerve; 5L, last lumbar nerve; I, II, III, 
 IV, sacral nerves. The nerves supplying the ureter are from (a) the I sacral ganglia (see u 
 on ureter) ; (b), hypogastric plexus (at P) ; (c) the III sacral nerve (at X) ; (d), pelvic brain 
 (at B). The pelvic brain (B) originates the plexus uterinus, plexus vaginalis, plexus rectal- 
 is. Suggestions for this drawing were employed from Frankenhauser. H, interiliac nerve 
 disc (the original visceral ganglion located at the aortic bifurcation — at present a dorso- 
 ventrally flattened nerve disc with limited number of ganglion cells). S. G., the five sacral 
 ganglia. 16 (a), right ureter at junction with vasa ovarica. Note anastomosis of plexus 
 ureteris and plexus ovarica explaining pain of ureteral calculus in testicle and in ovary. 16, 
 some relations on left side. For illustrations of the nerves of the tractus genitalis see 
 previous figures. 
 
90 THE ABDOMINAL AND PELVIC BRAIN 
 
 I. Nerves of the hemorrhoidal artery superior et medius (nerv» arterise 
 hemorrhoidalis superior et medius). 
 
 The major nerve supply consists of (A) plexus ovaricus; ( B) plexus 
 interiliacus (vasomotorius); (C) plexus sacralis spinalis rami nervorum sacra- 
 lium (II, III, IV). 
 
 (A) Plexus Ovaricus. 
 
 Origin. -According to my dissection the main origin of the ovarian 
 nerves is from the ganglion ovaricum proximal, a definite ganglion of irregu- 
 lar form and dimension located at the origin of the arteria ovarica on the 
 aorta. However, the plexus ovaricus arises also from the adjacent regions 
 in the plexus aorticus both proximal and distal to the ovarian ganglion, 
 especially it may be noted that the renal ganglia contribute ovarian nerves. 
 Frankenhauser (1867) in one of his tables marks the origin of the ovarian 
 nerves extending from the root of the arteria renalis to the interiliac nerve 
 disc located on the sacral promontory. He notes the ovarian nerve com- 
 posed at the origin of some twelve separate strands, and as they pass 
 distalward on the vasa ovarica coalesce into three main trunks, studded with 
 ganglia. In dissecting it will be observed that the ganglia renalia and 
 ganglia ovarica are closely associated in a solidly fenestrated network 
 indicating identical origin from the Wolffian body. I could not discover 
 such an abundant ovarian nerve supply neither from such an extensive area 
 of the plexus aorticus, as reported by Frankenhauser. However, the 
 explanation may lie in the fact that Frankenhauser dissections were from 
 non-pregnant and infant genitals. The sections disclosed large numbers of 
 nerve fibres originating in various regions from the plexus aorticus, especially 
 the ganglia renalia and ganglia ovarica proximal and directing themselves 
 toward the vasa ovarica coalesce into some three nerve trunks. The ovarian 
 nerves coerce with the ovarian vessels, forming an elongated wide network 
 studded with nerve ganglia limited in number and dimension and located at 
 the crossing, junction of the nerve strands. 
 
 The ovarian nerves arise from the ganglion ovaricum proximal in the 
 form of a plexus or a leash which accompanies and ensheaths the arteria 
 ovarica to the union with the vena, ovarica, where both the vein and artery 
 share more equally the attention of the ovarian nerves. The plexus ovaricus 
 in general arises from the following ganglia, viz. : (a) ganglion ovaricum 
 (proximal); (b) ganglia renalia; (c) ganglion mesentericum inferior; (d) 
 ganglia lumbalis. The above ganglia are solidly and compactly connected 
 with the ganglion cceliacum. 
 
 {Note. — It should be remembered that the numerous pains of which 
 woman complains as being in the ovaries are not located in the ovaries, but 
 reside in the cutaneous distribution of the ileo inguinal and ileo hypogastric 
 nerves. It is hyperesthesia of the skin). 
 
 The plexus ovaricus arises from the following plexuses: (a) plexus 
 aorticus; (b) plexus renalis; (c) plexus mesentericus superior; (d) plexus 
 mesentericus inferior; (e) plexus ureteris (where the vasa ovarica cross 
 
NERVES OF TRACTUS GENITALIS PREGNANT ABOUT THREE MONTHS 
 
 Fig 25 This illustration presents the nerves on its genital vascular circle at about three 
 months gestation. The fundus of the uterus is drawn distalward, exposing its dorsal surface. 
 A, abdominal brain. The pelvic brain is faintly represented. The plexus ovancus is care- 
 fully presented. 
 
92 THE ABDOMINAL AND PELVIC BRAIN 
 
 ventral to the ureter the plexus ovaricus becomes anastomosed with the 
 plexus ureteris, further solidly anastomosing the plexus ovaricus with the 
 plexus renalis); (f) plexus interiliacus ; (g) the plexus ovaricus receives 
 branches from the genito-crural nerve, again solidly anastomosing the plexus 
 lumbalis (spinal) with the plexus ovaricus (sympathetic). 
 
 Course. — The plexus ovaricus accompanies the vasa ovarica in their 
 extended journey to the pelvis in erect animals in the form of sheathed net- 
 work of nerves with extremely elongated fenestra. The plexus ovaricus in 
 its course is studded with spare ganglia of various size. The nerves of the 
 plexus, like many other sympathetic plexuses, are cylindrical — not flat like 
 those of the plexus uterinus — and retain their caliber throughout their course. 
 Toward the distal end of the vasa ovarica the vein and artery become more 
 branched, occupying more space, whence the plexus ovaricus divides its 
 branches to accompany the additional vessels. The distal end of the plexus 
 ovaricus divides and supplies: (a) the ovary; (b) the oviduct; (c) liga- 
 mentum latum; (d) the lateral border of the uterus; (e) it anastomoses with 
 branches of the plexus interiliacus. 
 
 (B) Plexus Interiliacus ( Vasomotorius). 
 
 The interiliac plexus extends from the interialic nerve disc to its union 
 with the sacral nerves of the cervico-vaginal junction. It is the major nerve- 
 supply of the genitals. It is elsewhere described in detail. 
 
 (C) Plexus Sacralis Spinalis (Rami Nervorum Sacralium). 
 
 The second, third and fourth sacral, spinal nerves emit branches (pelvic 
 splanchnics) which join, coalesce, with the distal branches of the interiliac 
 plexus to form the pelvic brain (ganglion cervicale — which issues the white 
 rami communicantes) practically the plexus uterinus, plexus vesicalis, plexus 
 rectalis, plexus vaginalis, plexus clitoridis, plexus pudendalis. The spinal 
 sacral nerves passing to the pelvic brain gave rise to the idea that they 
 supplied the cervix uteri, and that they are sensory nerves of the uterus. So 
 far as I have been able to observe, all branches of the sacral spinal nerves 
 first enter the pelvic brain before passing to the uterus and vagina. One 
 nerve from the second sacral passes directly to the bladder without first pass- 
 ing through the pelvic brain. The branches of the sacral nerve passing to 
 the pelvic brain vary in number, origin, arrangement, length, and dimension. 
 They are the most accurately demonstrated in infant cadavers preserved in 
 alcohol. The blending or coalescence of the branches of the sacral nerves 
 (pelvic splanchnics) ( I to IV) with the distal branches of the plexus 
 interiliacus (vasomotorius) results in the pelvic brain — a plexiform, multiple, 
 nodular ganglionic nerve mass located where the rectum joins the cervico- 
 vaginal junction, and being of irregular form, dimension, weight. The pelvic 
 brain is practically the source of the genital nerves. The minor nerve 
 supply of the tractus genitalis consists of D, E, F, G, H, I. 
 
 (D). The lateral lumbar trunk ganglia send nerves to the plexus 
 aorticus and plexus interiliacus. 
 
THE NERVES OF THE GENITAL TRACT 
 
 93 
 
 (E). The lateral pelvic trunk ganglia send nerves to the genitals by 
 way of the pelvic brain. It sends nerves to the distal ureter. 
 
 (F). The nerves accompanying the internal iliac artery continue their 
 course over the arteria uterina as the nervi arteriae uterinae. 
 
 (G). The nerves of the hypogastric artery (nervi arteriae hypogastricae) 
 carries larger numbers of nerves to the genitals in the infant. It also emits 
 branches to the ureter and bladder. With atrophy of the hypogastric artery 
 many nerves fade with the artery. 
 
 (H). Nerves of the round ligament artery (nervi arteriae ligamenti 
 
 F1C. I. — PELVIC BRAIN OF AN INFANT. 
 
 GENITAL NERVES OF INFANT 
 
 Fig. 26. The plexus interiliacus in this infant extends from the discus interiliacus (D) 
 to the pelvic brain. (A) A segment of the ureter (Ur) is removed in order to expose the 
 interiliac plexus as it is in relation with the rectum (R). Observe first that the interiliac 
 plexus receives contributing nerves from the I, II and III sacral nerves. Second observe 
 that the interiliac plexus emits three nerve strands to the uterus (Ut), which do not first 
 pass through the pelvic brain. (A) Third, note the large nerve supply that the rectum 
 receives from the plexus inieriliacus. This illustration I dissected under alcohol and it was 
 drawn by the aid of a highly magnifying lens. A non-developed pelvic brain. The plexuses 
 of the pelvic brain-uterine, vaginal, vesical and rectal — are distinct 
 
94 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 rotundi) pass from the external common iliac artery to join with the plexus 
 ovaricus and plexus uterinus. 
 
 (I). Nerves of the hemorrhoidal artery superior and medial (nervi 
 arteriae hemorrhoidalis superior et medius) emit nerves to the genitals. It 
 will be observed that the major and minor nerve supply of the genitals is so 
 extensive, so solidly and compactly anastomosed that severing the genital 
 nerves for experimentation is incompatible with life, and consequently 
 reports of such experiments are of limited value only. 
 
 The Plexuses of the Pelvic Brain. 
 
 The pelvic brain practically emits the nerves to the pelvic viscera, but 
 especially the plexuses of the genital tract. The table represents the scheme : 
 
 Plexuses of the Pelvic Brain. — 1. Plexus uterinus. 2. Plexus vaginalis. 
 3. Plexus vesicalis. 4. Plexus rectalis. 
 
 1. Plexus uterinus is emitted to the uterus from the pelvic brain. 
 In infant cadavers I have counted as many as eight different strands of nerves 
 passing from the pelvic brain to the uterus. In the infant cadavers one can 
 observe several nerves passing from the pelvic brain over the external border 
 of the ureter to penetrate finally the myometrium. The first proposition to 
 assert is that the uterus is practically supplied by two plexuses, viz. : (a) 
 the plexus interiliacus (hypogastricus) sends one (two or three) branches 
 directly to the uterus without first entering the pelvic brain ; (b) the plexus 
 uterinus, which passes directly from the pelvic brain to the uterus, where it 
 anastomoses with the branches of the plexus interiliacus. Hence the uterus 
 is supplied by branches of the plexus interiliacus directly from the abdom- 
 inal brain and the plexus uterinus directly from the pelvic brain — leaving 
 the abdominal brain as the chief ruling potentate of the abdominal viscera, 
 while the pelvic brain is a subordinate, local, ruler of the pelvic viscera. 
 The plexus uterinus accompanies the uterine vessels in general only — not in 
 particular like the intimate relation of the plexuses of the abdominal brain 
 to its visceral vessels. The plexus uterinus presents large, strong branches 
 to the cervix uteri, which is unusually rich in nerve supply. The order of 
 richness of nerve supply to the uterus is (a) cervix, luxuriant; (b) corpus, 
 rich ; (c) fundus uteri, abundant. The form of the nerve supply to the uterus 
 imitates it, viz. : fan-shaped. In the illustrations of the nerves of the uterus 
 what is presented is the main superficial branches of the plexus interiliacus 
 and plexus uterinus which accompany the major uterine arteries the most 
 intimately along the lateral uterine borders (see figure 3). 
 
 The branches from the plexus interiliacus (one to three) are distributed on 
 the dorsal wall of the cervix, becoming distributed on the dorso-lateral 
 border of the fundus uteri, where they anastomose with the branches of the 
 plexus ovaricus at the junction of the uterus and oviduct, where is located 
 (especially marked in infants) a ganglion. The dorsal surface of the fundus 
 also receives numerous branches from the branches of the plexus interiliacus. 
 Finally the branches directly from the plexus interiliacus (which is directly 
 from the abdominal brain through the plexus aorticus) supply strong, large 
 
THE NERVES OF THE GENITAL TRACT 
 
 95 
 
 nerves which are richly distributed to the cervix, corpus, fundus, and oviduct. 
 They anastomose solidly and compactly with the plexus ovaricus and pl< 
 uterinus from the pelvic brain. The plexus uterinus — major nerve supply to 
 the uterus — originates in the pelvic brain. The plexus uterinus, like the 
 plexus interiliacus, approaches the uterus from the neck and lateral border. 
 This leash of ganglionated uterine nerves from the cervico-uterine ganglion 
 in contradistinction to the branches of the plexus interiliacus, supplies the 
 
 EIC 6. — PELVIC I1RAIN. 
 
 GENITAL NERVES OF ADULT 
 
 Fig. 27. This specimen I dissected with care under alcohol. The plexus interiliacus 
 extends from the discus interiliacus (1) to the pelvic brain (A). Observe: (1) Three 
 nerve strands are emitted from the interiliac plexus to the uterus previous to passing 
 through the pelvic brain (A). (2) Note the contribution of the lateral sacral chain of ganglia 
 and II, III and IV sacral nerves to the plexus interiliacus. (3) Bear in mind the intimate 
 relation of the plexus interiliacus to the rectum proximahvard and distahvard. Observe 
 the ganglionated plexuses from the pelvic brain — uterine, vaginal, vesical, rectal. 
 
 ventro-lateral border of the uterus, and courses more intimately in relation 
 with the uterine segment of the utero-ovarian artery. Many of the large 
 nerves of this plexus are superficial, simulating the superficial position of the 
 artery. As the branches of the plexus interiliacus (direct from the abdom- 
 inal brain) richly supply the dorsal surface of the corpus and fundus 
 uteri so that the plexus uterinus (directly from the pelvic brain) luxuriantly 
 supplies the ventral surface of the cervix, corpus and fundus uteri. Branches 
 
96 THE ABDOMINAL AXD PELVIC BRAIN 
 
 from the vesical ganglia pass to the plexus uterinus, thus aiding to make the 
 uterus and bladder act clinically as one organ. The solidly anastomosed 
 plexuses of the uterine nerves continually increasing their area of distribu- 
 tion and their number of multiplying peripheral branches as they proceed 
 toward the fundus, finally sends branches to anastomose with the plexus 
 ovaricus, especially at the oviductal junction, where lies a marked ganglion. 
 This utero-oviductal ganglion appears to be the nerve center from which 
 radiate nerves to the fundus uteri and distal oviduct as well as to the 
 muscular plates lying in the ligamentum latum. The entire uterus is sur- 
 rounded and traversed by a closely woven network of ganglionated nerve 
 plexuses. The microscopic ganglia are most numerous in the region of the 
 cervix, especially adjacent to the pelvic brain. The uterus is abundantly 
 and luxuriantly supplied by vasomotor sympathetic nerves from which, could 
 we dissolve the substance of the uterus, leaving the network, they would 
 appear like a spider's web. It must be remembered that the uterus is a 
 coalesced organ, and hence the adult nerve supply is a complex affair 
 resembling the adult circulation, which is most extraordinarily demonstrated 
 by corrosion anatomy. 
 
 2. Plexus vaginalis is emitted from the pelvic brain to the vagina. 
 The vaginal plexus is a rich leash or ganglionated plexus of nerves which 
 surround the vagina like a network of cords surrounding a rubber ball. The 
 vaginal nerve plexus and vaginal vein plexus, both rich, complicated and 
 abundant, intertwine and interweave with each other. The rich vaginal 
 plexus is bedecked with numerous ganglia at the points of nerve convergence. 
 The meshes of the vaginal plexus, being occupied by fatty tissue, connective 
 tissue, lymph and blood vessels, its dissection is accompanied with difficulty. 
 Infant cadavers should be chosen to facilitate correct exposure of the finer 
 constituents of the vaginal plexus. As the bladder is supplied by a large 
 branch from the third sacral nerve, so the vagina is supplied from a large 
 branch of the fourth sacral nerve. The ganglionated nerve cords from the 
 pelvic brain surround the vagina like a mighty network, ventrally and 
 dorsally. The vaginal plexus also emits many large nerves to the rectum 
 and bladder. The ventral vaginal nerve leashes course proximalward and 
 distalward. The larger ganglia of the vaginal leash or plexus occur at the 
 proximal ventral vaginal fornix, while on the distal ventral end of the vagina 
 the ganglia are numerous, but more limited in dimensions. The ganglia of 
 the dorsal vaginal wall is limited in number. The entire vagina is com- 
 pletely surrounded by a closely woven ganglionated nerve network. These 
 perivaginal and paravaginal plexuses stand in intimate relation with the 
 pelvic brain. 
 
 Toward the central longitudinal axis of the uterus and vagina the genital 
 plexuses diminish, simulating exactly the genital blood and lymph supply. 
 
 3. Plexus vesicalis is emitted from the pelvic brain to the bladder. 
 The vesical plexus is of the powerful, rich, ganglionated plexuses or leashes 
 of the pelvic brain. It is solidly and compactly anastomosed to the plexus 
 rectalis, but especially to the plexus uterinus, inducing the rectum, uterus 
 
TIUl NERVES OF THE GENITAL TRACT 
 
 97 
 
 and bladder to act clinically or symptomatically as one apparatus. For 
 description see nerves of tractus urinarius. 
 
 4. Plexus rectalis is emitted from the pelvic brain to the rectum as rich 
 network of nerves bedecked with ganglia limited in number and dimension. 
 The rectal plexus emitted by the pelvic brain is a fine plexiform leash 
 of nerves which passes distalward on the lateral borders of the rectum, 
 intimately blending with the tissues of the rectal wall. The rectum has not 
 only a rich and complicated nerve supply, but it has a mixed nerve supply. 
 The following table presents a general view of a rectal nerve supply: 
 
 Recta! Nerve Supply. 
 
 1. Plexus hemorrhoidalis superior (from the arteria mesenterica 
 superior). 
 
 THE NERVES OF THE TRACTUS GENITALIS 
 
 Fig. 28. This illustration is a dissection I made ten years ago from a spare subject 
 The trunk of the cadaver I preserved in alcohol for six months. The vesical, rectal, uterine 
 and vaginal plexuses are evident as they issue from the pelvic brain, which is an elongated 
 ganglionic mass. 
 
 2. Plexus interiliacus (from the abdominal brain). 
 
 3. Plexus hemorrhoidalis medius (accompanying the arteria hemor- 
 rhoidalis media). 
 
 4. Plexus hemorrhoidalis inferior (from the arteria hemorrhoidalis 
 inferior and plexus pudendalis sacralis — mixed vasomotor and spinal nerves). 
 
 5. Plexus rectalis (from pelvic brain — a powerful, rich nerve plexus 
 solidly anastomosed to the plexus uterinus and vesicalis). 
 
98 THE ABDOMINAL AXD PELVIC BRAIN 
 
 6. Plexus sacralis spinalis (branches from the second, third and fourth 
 sacral nerves). 
 
 7. Truncus pelvis sympathicus (lateral sacral ganglia). 
 
 The three great hemorrhoidal plexuses arriving at the rectum via the 
 three hemorrhoidal arteries invest it with a network of rich nerve plexuses. 
 A rich leash of nerves passes to the rectum from the plexus interiliacus. Part 
 of the branches of the plexus pass proximalward on the rectum to anastomose 
 with the plexus hemorrhoidalis inferior (from the inferior mesenteric 
 plexus) while part passes distalward on the rectum, penetrating its coats. 
 Some of the branches of the hemorrhoidal plexus supply the bladder and 
 genitals. From this anatomic distribution of the hemorrhoidal plexus — to 
 genitals, rectum and bladder — it is obvious that the genitals, rectum and 
 bladder are solidly and compactly anastomosed. Clinical work demonstrates 
 this balanced union of organs in the pelvis through nerve connection, as 
 rectal or genital operations will induce inability to micturate. The plexus 
 heemorrhoidalis medius (and inferior) corresponds to the plexus pudendalis 
 on the arteria pudenda. For further description of the rectal nerve supply, 
 seetractus intestinalis. The nervous apparatus ventral, lateral and dorsal to 
 the vagina, that supplying the ureter, that coursing through the paramet- 
 rium and perimetrium, that supplying the bladder, rectum and ureter, are 
 solidly and compactly anastomosed. They form an inseparable nerve plexus 
 bedecked with ganglia of greater and lesser dimensions surrounding the cer- 
 vico-vaginal junction. The vast plexuses of the pelvic brain, rich in ganglia, 
 extend from the cervico-vaginal junction distalward to the pelvic floor sur- 
 rounding with a luxuriant closely woven network, uterus and vagina (tractus 
 genitalis), the rectum (distal tractus intestinalis), the bladder and ureter 
 (distal tractus urinarius). 
 
 (b) physiology. 
 
 The physiology of the nerves of the tractus genitalis comprises the 
 function of the genital organs, which are in order of origin: 1, ovulation; 
 2, absorption; 3, secretion; 4, peristalsis (rhythm); 5, menstruation; 6, 
 gestation; 7, sensation. 
 
 First it should be observed that the abdominal brain originates the 
 plexus aorticus, and the plexus aorticus gives origin to two great nerve 
 plexuses, viz., plexus interiliacus and plexus ovaricus. The plexus inter- 
 iliacus, so far as the genital tract is concerned, divides into two, i.e., one, the 
 larger branch, terminates in the pelvic brain, while the smaller branch 
 terminates directly in the uterus without first passing through the pelvic 
 brain. The plexus ovaricus arises from the plexus aorticus and terminates 
 practically at the ovary; this plexus, however, proceeds to anastomose with 
 the plexus uterinus in the ligamentum latum. Hence, a larger portion of 
 the nerves which supply the genital tract arise in the abdominal brain and 
 pass to it directly through the plexus interiliacus and plexus ovaricus. On 
 the other hand, a massive plexus (the uterine modified by the sacral spinal 
 nerves) passes through the pelvic brain before it arrives at the genital 
 
Spiral segment (utcro-ovarian artery), i, 2, 3, 4, 5, 6, 7-9, 6-8, 9, 10, n, 12, ij, 14, 15. 
 Straight segment abdominal aorta, 16. Common iliac, 17, and internal iliac, 18 
 
 DIVISIONS OF THE SPIRAL SEGMENT. 
 
 Pelvic floor sapert, I, 2, 3, 4. 
 
 Uterine segment, 4, 5, 6. 
 
 Otiducal segment, 
 
 6, 7-9, 6-8, 9, 
 
 Ovarian ssgrr-sr.!. 
 
 9, 10, II, 12. 
 
 Round ligament 
 segment, 13, 14, 15 
 Urster. 20, 19 
 Vaginal Ar- 
 teries. 25 
 
 .^U 
 
 IMPORTANT LOCATIONS IN THE SPIRAL SEGMENT 
 Arterio-ureteral loop, 2. Cervical 
 loop, 2, 3, 4 Distal arte- 
 rio-ureteral crossing, 2. 
 Rami cervicis, 22. 
 Rami corporis, 23. 
 Rami fundi, 24. Rami 
 oviductus, 31, 32, 33. 
 
 Eisanguinated utetim 
 lones •*• central longi- 
 tudinal axis, <b, lateral 
 cervical border, 'cj fun- 
 dus, and <</> temcj- 
 corporeai. 
 
 Chicago, 1902, 
 
 
 At the post mortem ths uterus was 
 injected in situ, also the ureters with 
 red lead and starch. The specimen 
 was X-rayed in Dr. Harry Pratt's I- 
 Ray and Electro-Therapeutic Labora- 
 tory, doubly magnified by Or. Wm. E. 
 Holland, and followed as a model by 
 Mr. Zan, 0. Klopper, the artist. 
 
 Arterial Circulation of the Puerperal Uterus. 
 
 Four Hours Post Partum?*-Life Size. 
 
 Illustrating the Utero-Ovarian Vascular CircleTthe Circle of Byron Robinson) 
 
 CIRCULATION OF THE PUERPERAL UTERUS 
 Fig 29. A reasonable estimate of the richness of the vasomotor nerves (sympathetic) 
 to an organ is made through the number and dimensions of the arteries which are 
 ensheathed by a plexiform, nodular, nervous web. The quantity of nerve supply to the ute- 
 rus is vast 
 
100 THE ABDOMINAL AND PELVIC BRAIN 
 
 tract. These anatomicr-.l facts demonstrate how solidly and compactly the 
 tractus genitalis is anastoi losed to the whole abdominal sympathetic. 
 Besides this must be hel 1 in view the modifying influence on the genital tract 
 of the sacral (spinal) ne; . es 1 hrough their coalescence with the distal end of 
 the plexus interiliacus, i. c, I hrough the pelvic brain. 
 
 Peristalsis -Rhythm of the Tractus Genitalis. 
 
 Peristalsis, or rhythm, of the genitals, though one of the common func- 
 tions of all abdominal viscera (under control of the abdominal brain), is 
 particularly specialized in the tractus genitalis— uterus and oviducts— to a 
 degree of popular demonstration. Rhythm of the uterus to the ordinary 
 observer is its chief characteristic phenomenon. The rhythm, or peristalsis, 
 of the uterus under the direct command of the sympathetic nerve, differs 
 not, except in degree, from the rhythm of other viscera under direct com- 
 mand of the sympathetic, such as the enteron, colon, ureter, spleen, liver, 
 pancreas. Such organs as the lungs, heart, stomach, and bladder, though 
 dominated by the sympathetic, yet are so powerfully supplied by the cranial 
 nerves (vagi) and the spinal nerves (sacral) that their rhythm is modified. 
 The periodic rhythm and stately peristalsis of the uterus has induced 
 observers of all time to enquire and wonder as to its cause. That irritation 
 of the plexus interiliacus and of the plexus uterinus is followed by the rhyth- 
 mical movements of the uterus, is the main testimony of a vast majority of 
 investigators. The myometrium, the complicated muscle of the uterus in 
 general, is maintained and completely developed by menstruation and 
 gestation, otherwise it would atrophy. In the uterus are located nerve 
 ganglia, little brains, smaller ganglia— extended or transported from the 
 pelvic brain to the uterus, which I termed fifteen years ago automatic men- 
 strual ganglia. They are local rulers of muscle or myometrial rhythm. 
 When the automatic menstrual ganglia are periodically bathed in extra blood 
 (which is a stimulant or excitant) they explode rhythmically, the uterine 
 muscle or myometrium assumes an active, vermicular movement; thus the 
 myometrium or uterine muscle is preserved from atrophic death. Extra 
 absorption of the uterine glandular apparatus is due to the extra trauma of 
 the muscular bundles on the utricular glands. The myometrium thrashes, 
 massages, and whips the glands to extra secretory labors. Myometrial 
 activity and glandular activity are concomitant — cause and effect. The 
 chain of events is: extra blood to the automatic menstrual ganglia induces 
 extra myometrial rhythm. Extra uterine peristalsis induces extra massage, 
 excitation, to the uterine glands, which results in extra secretion. Therefore, 
 be it observed the dominating nerve of the uterus— the sympathetic— 
 functionates as a unit— no conflict, in rhythm which develops the myome- 
 trium. During gestation the automatic menstrual ganglia become bathed 
 with continual extra blood. Profound congestion, progressive exalted 
 engorgement, produce extra nourishment and multiply elements until the 
 gestating uterus is perhaps fifty times the dimension of the resting uterus. 
 The gestating uterus is always in motion — rhythm. One curious feature I 
 
THE NERVES OF THE GENITAL TRACT 101 
 
 have noted in the arteries of gestating uteri of animals and man, and that is, 
 that the uterine artery was enlarged, hypertrophied, exactly from its origin in 
 the internal iliac. No part of the iliac was enlarged. Hence gestation 
 belongs entirely to the tractus genitalis, to the utero-ovarian artery. The 
 function is distinct, does not glide into any other visceral tract. The 
 sympathetic nerve has through aeons of ages become differentiated to per- 
 form separately and distinctly the important functions of the tractus genitalis. 
 The sympathetic nerve, nervus vasomotorius, originally belonged to the 
 arterial system. It is differentiated at present to control some veins and also 
 the gradually added tractus lymphaticus. Great importance lies in the 
 tractus vascularis and its ruler, nervus vasomotorius. The future problems, 
 especially as regards shock, must be solved in the wide field of the sympa- 
 thetic nerve and circulatory system. 
 
 Besides rhythm or peristalsis the nerves of the uterus preside over the 
 functions of absorption, secretion, menstruation, gestation, and sensation of 
 the uterus, a description of the physiology of which space forbids. The 
 physiology of the oviduct is under the control of the sympathetic nerve and 
 we may note the following points in its functional activity: 
 
 The object of the oviduct is transportation — export and import service 
 — of spermatozoa proximalward and of ova distalward, forcing the impreg- 
 nated ovum distalward to the uterine cavity. The following are the main 
 physiologic factors in oviductal transportation: 
 
 1. The periodic congestion of the genitals, stimulation of the automatic 
 menstrual ganglia by extra blood. 
 
 2. The cilia of the oviductal mucosa whip continually toward the 
 uterus distalward, not only forcing the ova distalward, but also creating a 
 fluid current. 
 
 3. The congestion induces the endosalpinx to secrete a fluid which 
 makes the oviduct a canal to float the ovum distalward: 
 
 4. Congestion induces continual oviductal peristalsis, which forces the 
 ova distalward. 
 
 5. The contraction of the muscular processes in the ligamentum latum 
 enhances the peristalsis. 
 
 6. The shortening of the fimbria ovarica which induces the infundibulum 
 to apply its mucous surface to the ovary, capturing the ovum. 
 
 7. The congestion induces the secretion of mucus and glues the infun- 
 dibulum on the surface of the ovary. 
 
 8. Intra-abdominal pressure aids the distal progress of the ova. 
 
 9. The enlarging of the ovum approaching the infundibulum aids. 
 
 10. Secretion of the endosalpinx produces a fluid medium adjacent to 
 the proximal oviductal end and the cilia of the fimbriae induce a current 
 toward the abdominal ostium. 
 
 11. The oviduct has an import (spermatozoa) and an export (ova) ser- 
 vice. It is analogous to the vas deferens in the male. The spermatozoa 
 pass through the oviduct proximalward, while the ova pass through it 
 distalward. 
 
102 THE ABDOMINAL AND PELVIC BRAIN 
 
 12. The oviduct is a temporary (or pathologic permanent) depot for 
 conception. The oviduct (ampulla) is a physiologic sporting ground for ova 
 and spermatozoa. It has three general physiologic offices to fulfill, viz. : (a) 
 to secure and transport the ovum (distalward) to the cavity of the uterus; 
 (b) to conduct spermatozoa proximalward; (c) to serve as physiologic tem- 
 porary (or pathologic permanent) depot of conception. All the physiologic 
 statements in regard to the ovary will be, that the rich plexus ovaricus rules 
 ovulation, but also, perhaps, some form of internal ovarian secretion is 
 necessary for the best normal corporeal existence. The physiology of the 
 tractus genitalis is vigorous, as it is supplied by a luxuriant system of sympa- 
 thetic nerves. With the higher forms of differentiated animals the 
 magnitude and influence of the genitalis increases. The higher the animal 
 the more thought is applied to the genitals, the more periodic congestion 
 and permaent increase of nerve and blood supply. The intense attention 
 paid to sex in higher animals, such as monkey and man, is a remarkable 
 phenomenon, and attention induces blood flow, congestion. At the bottom 
 of the sex lie ambition, hope, and much of the pride of life. Man's life 
 and thoughts are arranged around sex as a center. Hence the genital nerve 
 and blood supply and consequent genital physiology will remain an increas- 
 ing maximum. For the detailed physiology noted in the subjects "Abdominal 
 Brain" and "Pelvic Brain" the reader is referred to the Medical Age for 
 July, 1905, and the Medical Review of Reviews for November, 1905. 
 

 CHAPTER X. 
 
 NERVES OF THE BLOOD VESSELS (NERVI TRACTUS VASCU- 
 LARIS).— (A) ANATOMY, (B) PHYSIOLOGY. 
 
 Our most cherished hopes are frequently maintained in silence. 
 
 Tin- curfew tolls the knell of parting day— Thomas Gray (1116-1111), professor of 
 modern history in the University of Cambridge, England. 
 
 (a) anatomy. 
 
 The proper nomenclature to apply to the sympathetic nerves is the 
 nervus vasomotorius. Practically it is a nerve belonging to the arteries. In 
 the anatomy of the nerves of the blood vessels two factors should be consid- 
 ered, viz. : (a) that nerves tend to course with blood vessels as the intercostals, 
 nerves in the extremities, nerve coursing with the aorta and its branches. 
 However, cerebro-spinal nerves course mainly parallel with the vessels and 
 divide mainly as acute angles, while vasomotor (sympathetic) nerves form a 
 plexiform network, a neural meshwork, on the walls of the blood vessel, 
 and are not confined to acute-angled dichotomy but divide and anastomose 
 by angles of all dimensions; (b) the cerebro-spinal nerves in general do not 
 form ganglia in their course along blood vessels. The vasomotor nerve 
 (sympathetic) forms ganglia, plexiform nodular meshwork on the walls of the 
 arterial vessels especially at the bifurcation or point of exit of the arterial 
 divisions. The nervus vasomotorius courses along with the blood vessel as 
 a nodular plexus, a leash woven like a web on the vessel wall. The coarser 
 or finer web-like anastomotic meshwork of nerves surrounding a vessel is 
 characteristic of the nervus vasomotorius (sympathetic). With the develop- 
 ment and differentiation of the animal life the nervus vasomotorius becomes 
 distributed in its relation to blood vessels, dislocated, removed, transported 
 along projecting lateral vessels from its direct contact with the original trunk 
 vessel. Excellent examples of removal — dislocation of the vasomotor nerve 
 from contact with its original vessel — may be observed in the plexus aorticus, 
 and especially in the instance of the plexus interiliacus where it is dislocated 
 toward the median line from arteria iliacus communis. The second signifi- 
 cant characteristic of the nervus vasomotorius is its numerous nerve ganglia 
 found attached to the vessel wall and the location of marked ganglia at the 
 bifurcation of trunk arteries as at the aortic bifurcations. Ganglia of dimen- 
 sion also exist at the origin or exit of visceral arteries from the great 
 arterial trunk as ganglion cceliacum (abdominal brain) ganglion spermaticum, 
 ganglion renalis, ganglion arteriae phrenicae, ganglion mesentericum superior 
 et inferior, ganglion cervicale (pelvic brain). These significant ganglia 
 located on the aorta at the origin or exit of visceral vessels, I shall term the 
 aortic viscerel ganglia — ganglia aorticse viscerales. The visceral aortic 
 
 103 
 
104 THE ABDOMINAL AND PELVIC BRAIN 
 
 ganglion may have become dislocated from its vascular course during devel- 
 opment, the most typical example of which is the ganglion cervicale, which 
 was dislocated, transported medianward from the arteria iliaca communis to 
 the lateral border of the uterus. In the region of the origin of the cceliac axis, 
 the arterial tripod, the ganglia have become dislocated, fragmented and 
 removed, transported along adjacently developed arteries as the renal, mes- 
 enteric superior and inferior. From fragmentation and transportation along 
 arteries the renal arteries possess multiple ganglia. In localities of the tractus 
 vascularis where the vascular parietes are of maximum thickness, as the myo- 
 cardium the ganglion cells collect in masses, known as cardiac ganglia. We 
 thus have the well-known cardiac ganglia of Ludwig (1816-1895), Bidder 
 (1810-1892), Schmidt (1831-1894), Remak (1815-1865). The nervus vasomo- 
 toria is an automatic nerve. Ganglia located at the anastomosing points of 
 nerves accompany its network of conducting coils throughout the entire 
 course of the artery, thus automatically controlling each arterial segment. 
 The intimate relations of the nervus vasomotorius with the great arterial 
 vessels may be sufficiently observed in the plexus aorticus thoracicus, plexus 
 cceliacus (abdominal brain) plexus aorticus abdominalis, plexus interiliacus, 
 plexus pelvicus (pelvic brain). Ganglia of maximum dimension are located 
 in intimate relation with the entire course of the aorta. The nervus vas- 
 omotorius was originally essentially a vascular nerve, hence its name, 
 nervus vasomotorius. The nervus vasomotorius, vascular nerve plexuses, 
 begin in ganglia (aortic visceral ganglion — ganglion coeliacum, spermaticum, 
 mesentericum, renalis, cervicale), accompanies the arterial vessels as a plexi- 
 form nodular meshwork, a neural anastomosed vascular sheath, and ends in 
 automatic visceral ganglia (Auerbach's, Meissner's, automatic menstrual, 
 renal ureteral, vesical, etc., etc.), located in the parenchyma of organs. 
 
 In general the dimensions of the ganglia on the arterial plexuses corre- 
 spond with the dimensions of the vascular channel. However, the renal 
 arterial plexus is supplied with numerous ganglia of maximum dimension, 
 relatively greater in proportion than that of the segments of the arterial 
 channels as the myocardium. The ganglia located on the arteries of the 
 tractus genitalis are relatively numerous and of large dimension. The original 
 great abdominal vascular ganglion is that of the coeliac axis, from which 
 doubtless many adjacent vascular ganglia have become fragmented, and 
 transported on the vessels toward the viscera. Perhaps the most typical 
 example of this transportation of ganglia is the renal artery, on which is dis- 
 tributed relatively numerous small and large ganglia throughout its entire 
 course. A peculiar degenerative developmental process has occurred at the 
 bifurcation of the aorta near the sacral promontory. According to the general 
 rule there should be a ganglion of large dimension located at the bifurcation 
 of the aorta. However, the nervous ganglion located in this region (which 
 I term the interiliac nerve disc) has not only few ganglion cells (some deny 
 the existence of any ganglion cell) but is dislocated distalward from the aortic 
 bifurcation to the promontory of the sacrum. It is mainly a dorso-ventrally 
 flattened nerve disc with disappearing ganglion cells. 
 
NERVES OF THE BLOOD VESSELS 
 
 105 
 
 The vascular nerve plexuses vary in dimension and fenestration. The 
 meshwork of nerves may be coarse or fine, wide or narrow. The plexus 
 aorticus abdominalis possesses ganglia, cords and fenestra of maximum 
 dimensions. The fenestra are extensive, elongated, formed by nerve cords 
 of maximum dimension, on the anastomosing points of which are distributed 
 ganglia of maximum dimension. The plexus renalis is a wide-meshed net- 
 work richly beset by large ganglia. It is a plexus nervus vasomotorius 
 possessing ganglia, cords and fenestra of maximum dimension. The plexus 
 mesentericus superior possesses numerous fine white cords with relatively 
 large fenestra and ganglia limited in number and dimension. This plexus 
 possesses the peculiarity of the meshes or fenestra deviating considerably 
 from the course of the artery. The plexus hepaticus, composed of branches 
 from the nervus vagus dexter and plexus cceliacus, surrounds the hepatic 
 artery with strong, flat cords in the form of a narrow-meshed network. The 
 
 /\ 
 
 CIRCLES, ARCS AND ARCADES OF THE ABDOMINAL ARTERIES 
 
 Fig. 30. This illustration presents two views, viz. : (a) The arterial trunks, arcs, arcades 
 and circles of the tractus intestinalis are solidly and compactly anastomosed, connected 
 through blood currents and channels, (b) The sympathetic nerve (nervus vasomotorius) 
 accompanies the arteries as a plexiform network, as a nerve vascular sheath. This cut 
 demonstrates that the nerves of the tractus intestinalis are solidly and compactly anasto- 
 mosed ; hence irritation on any sympathetic plexus of the tractus intestinalis will affect, 
 reflexly, all others. 10, arcs and arcades of the cceliac axis. 6, 7, 8 arcs and arcades of the 
 superior and inferior mesenteric arteries, all of which are anastomosed united by (4), the 
 pancreatico-duodenalis superior and inferior. The arterial arcs, arcades and circles of the 
 hand and utero-ovarian artery resemble those of the tractus intestinalis. The number and 
 dimensions of the arteries furnish a clue to the quantity of nerve supply. 
 
106 THE ABDOMINAL AND PELVIC BRAIN 
 
 plexus lienalis ensheath the arteria renalis and is bedecked with numerous 
 ganglia of varied dimension. Microscopic and macroscopic ganglia occur in 
 the vascular plexuses. Some macroscopic ones are constant, as the ganglion 
 located on the external carotid artery. Wrisberg's ganglion is situated in 
 the cardiac plexus, notably the renal ganglia (macroscopic) are found on the 
 plexus renalis. In general the vasomotor nerves, sympathetic, form a plexi- 
 form nodular sheath around the blood vessels and enter with it into the sub- 
 stance of parenchyma of the organs. This arrangement of the nervus 
 vasomotorius induces many physicians to adopt the idea that the nervus 
 vasomotorius originally and essentially belonged to the vascular system, and 
 is lost on the coats of the arteries. The nervus vasomotorius invariably 
 accompanies the arteries — not the veins — the trunk of the vena portae being 
 the only exception. The ganglia of the nervus vasomotorius (sympathetic) 
 are connected with the anterior primary divisions of the spinal by short 
 nerve cords known as rami communicantes, which are gray and white in color. 
 
 The gray rami communicantes arise in the ganglia of the nervus vasomo- 
 torius (sympathetic) and pass to the spinal cord. 
 
 The zvhite rami communicantes arise in the spinal cord and pass to the 
 cords and ganglia of the nervus vasomotorius (sympathetic). Hence the 
 cerebro-spinal nerves and nervus vasomotorius (sympathetic) are distinctly 
 and firmly anastomosed; however, like the federal, state, county and city 
 government, possess many independent functions* 
 
 (b) physiology. 
 
 The nervus vasomotorius consists of — (a) the lateral chain and its 
 ganglia; (b) the nerve plexuses and their ganglia accompanying the blood 
 vessels from the aortic ganglia to the viscera; (c) the automatic visceral 
 ganglia. Hence the nervus vasomotorius of the abdomen consists of gang- 
 lion cells and nerve cords. It must be remembered that it is not the number 
 of ganglion cells that designates the power of a nervous system to accomplish 
 maximum labor, but it is particularly the number of conducting cords asso- 
 ciating and connecting the ganglion cells which decides the superiority of 
 nervous executive ability. The nervus vasomotorius is peculiarly rich in 
 conducting cords, establishing rapid and frequent communication between its 
 ganglion cells — governing every particular segment of the arterial channel. 
 The ganglion cells of the nervus vasomotorius are well informed from the 
 rich association of connecting fiber transmitting news over many lines. To 
 illustrate the eternal vigilance of the nervus vasomotorius it need only to 
 indicate the fact that the artery is always on tension, that the nerve is always 
 on guard — awake or asleep. A ganglion cell at each end of a conducting 
 cord can accomplish more work than the single cord can transmit. A depot 
 at each end of a railroad line can handle more freight than a single road can 
 transmit. Increased number of conducting cords transmit increased informa- 
 tion to the ganglion cells. The nervus vasomotorius is partially indepen- 
 dent, automatic in action. If a frog's brain and cord be removed or destroyed 
 the visceral functions will proceed for a time. Circulation, respiration, 
 
NERVES OF THE BLOOD VESSELS 
 
 107 
 
 NERVES ACCOMPANY THE ARTERIES 
 
 Fig. 31. This illustration presents the sympathetic nerves following the arteries. I 
 dissected this specimen (man 40) with care, and the artist, Mr. Klopper, sketched exactly 
 from the model. 1 and 2, abdominal brain. Pn, Pneumogastric nerve; sp. Nervus 
 Splanchnicus major. Ad, adrenal ; Dg, ganglion diaphragmaticum ; Adn, 10 adrenal nerves, 
 (right), (left), 7. G. R. arteria renalis (right and left partially duplicate). R. G. Ganglia 
 renalia (left). Ur ureteral nerves. S. G. and 5 upper ganglia spermatica. I, ganglion 
 mesentericum inferior; X, ganglionic coalescence of nerves at the vasa spermatica and 
 ureteral crossing. 5 (Lower) ganglionic coalescence of the nerves at the crossing of the 
 ureter and vasa iliaca communis. ID, Plexus interiliacus (hypogastricus). ID, is the n e1 " ve 
 disc of the sacral promontory. The arteries are accompanied by a plexiform nodular 
 neural sheath encasing the vessel. 
 
108 THE ABDOMINAL AND PELVIC BRAIN 
 
 digestion, which indicates that absorption, secretion and peristalsis, sensation 
 remain intact. The functions manifested by the blood vessels are: (a) 
 peristalsis (rhythm) ; (b) absorption ; (c) secretion ; (d) sensation. The 
 plexiform nodular anastomosing neural network ensheathing the artery con- 
 trols the above four functions. The tractus vascularis contracts and relaxes 
 with clock-like regularity. Sensation is important from the fact that fluid in 
 the vascular channel is required to produce normal vascular peristalsis. 
 Hence the rational idea in "visceral drainage" is to maintain sufficient volume 
 of fluid in the vascular channel to stimulate and insure contraction. It is the 
 functions of the vascular plexiform neural sheath that is of peculiar interest 
 to us. From the fact that the heart will continue its peristalsis some time 
 after removal indicates that the intramural cardiac ganglia are automatic. 
 That the ganglia are located in the myocardium would indicate that the 
 nervus vasomotorius terminates in the arterial parietes, and hence the con- 
 traction and dilatation of the heart are analogous to the contractions and 
 dilatations of the arteries, being due to ganglia located in the vascular wall. 
 There is an intimate relation of the blood vessels within the substance of 
 organs and the automatic visceral ganglia. In general the origin of the 
 nervus vasomotorius is the spinal cord — as there lies the vasomotor center, 
 yet ganglia located on the aorta {e. g., abdominal brain) possess controlling 
 influence. 
 
 Aortic Visceral Ganglia — Ganglia Aortica; Viscerales- 
 
 I wish to call attention in the function of the nervus vasomotorius to 
 the ganglia located on the aorta at the exit of the visceral vessels. I have 
 termed them aortic visceral ganglia — ganglia aorticas viscerales — because 
 they appear not only to influence visceral vessels, but the function 
 of viscera, and to become, with differentiation and developmental processes, 
 definitely associated with distinct individual visceral function, e. g./\i one 
 examines systematically in man and animals the arteria uterina ovarica 
 during gestation, and in the resting state, a peculiar phenomenon will be 
 observed. The uterine artery will be enlarged, hypertrophied, exactly from 
 its origin in the internal iliac, and the ovarian will be enlarged, hypertro- 
 phied exactly from its origin in the aorta, i. e., both uterine and ovarian arteries 
 are enlarged, hypertrophied, from their exact origin in the arterial trunk. 
 Now the arteria uterina ovarica possesses distinct ganglia belonging to itself 
 and the genitals. In this case it consists of ganglion cervicale, or cervical 
 ganglion (pelvic brain) dislocated from its original position located at the 
 origin of the uterine artery. In other words, through eons of ages the ganglia 
 at the origin of the arteria uterina ovarica have become differentiated, 
 developed into the power of endowing the artery supplying the genitals with 
 function — gestation and menstruation — which requires a certain amount of 
 blood. Again, at the origin of the arteria mesenterica inferior is located a 
 ganglion which irritates peristalsis in the left half of the colon — the faecal 
 reservoir (left half of the transverse colon, left colon, sigmoid, and rectum) 
 — peristalsis sufficient for a daily evacuation. 
 
NERVES OE THE BLOOD VESSELS 
 
 109 
 
 In the tractus nervosus accompanying the tractus vascularis there are 
 differentiations of nerve functions as, e.g., vasomotor dilator nerves and 
 vasomotor constrictor nerves. If vasomotor dilator nerves be stimulated 
 relaxation and rest of the vessels of occur. Hence these nerves have been 
 termed vaso-inhibatory nerves, e.g., stimulation of the nervi eregentes pro- 
 
 NERVES OF THE BLOOD VESSELS 
 
 Fig. 32 represents typical Vascular Plexuses, which I dissected from a specimen taken 
 from a subject of about fifty years of age. 1 and 2 abdominal brain lying at the foot of 
 the great abdominal visceral arteries. P. O . S. ganglia located at the other visceral 
 arteries. The nervus vasomotorius (sympathetic) accompanies the arteries in the form of 
 a plexiform, fenestrated, neural sheath. 
 
 ceeding from the plexus sacralis (due to accidental trauma of the spinal cord) 
 will induce dilatation of the arteries of the penis with congestion of the 
 corpora cavernosa and consequent partial erection. Stimulation of the 
 spinal cord induces priapism, i.e., pathologic conditions of the spinal cord 
 may produce erection from stimulation. The vasomotor constrictor nerves 
 
110 THE ABDOMINAL AND PELVIC BRAIN 
 
 are in evidence when the surface of the body from fright or other cause 
 become blanched, pale. 
 
 Anatomically the cerebro-spinal nerves and nervus vasomotorius is dis- 
 tinctly and firmly anastomosed, connected, by the rami communicantes, 
 however, like the federal, state, county and city government, the two systems 
 of nerves perform many independent local functions. Long ages of habitat 
 established this function. 
 
CHAPTER XL 
 
 NERVES OF THE LYMPHATIC TRACT (NERVI TRACTUS 
 
 LYMPHATICUS). 
 
 Since the lymphatic vascular apparatus is an appendage of the blood 
 vascular apparatus it will be supplied and governed by the nervus vasomo- 
 torius similarly to that of the blood vascular system, hence its discussion will 
 be omitted. See Chapter XXXVIII, Pathologic Physiology of the Tractus 
 Lymphaticus. 
 
 ill 
 
CHAPTER XII. 
 
 ABDOMINAL BRAIN— CEREBRUM ABDOMINALE— (A) ANATOMY; 
 
 (B) PHYSIOLOGY. 
 
 O, gentle sleep, Nature's soft nurse. 
 
 —Shakespeare (156^-1616). 
 
 Embrouded u-as he, as it were a mede. 
 All full of freshe flour cs white and rede; 
 Singing he was, or floyting all the day; 
 He was as freshe as is tire moneth of May. 
 
 — Description of the Squire in Geoffrey Chaucer (13b0-U00). 
 
 (a) anatomy. 
 
 The abdominal brain or ganglion coeliacum has experienced multiple 
 names during the past three centuries. 
 
 Synonyms. — Celiac ganglion (ganglion cceliacum); solar plexus (plexus 
 Solaris, Todd and Bowman, 1847); semilunar ganglion (ganglion semilunare); 
 the great abdominal ganglion (ganglion abdominale maximum); abdom- 
 inal brain (cerebrum abdominale, Wrisberg, 1780 [1739-1808]); the nervous 
 center of Willis (centrum nervosum Willisii, 1622-1675); epigastric nervous 
 center (centrum nervosum epigastricum); splanchnic ganglion (ganglion 
 splanchnicum) ; vascular abdominal brain (cerebrum abdominale vasculare); 
 epigastric plexus (plexus epigastricus) ; celiac plexus (plexus cceliacum). 
 
 Some authors have viewed the abdominal brain or celiac ganglion as 
 composed of two parts, right and left, bilateral and paired. I shall consider 
 it as practically one sympathetic ganglion or plexus anatomically and phys- 
 iologically, and term it the abdominal brain — the celiac ganglion, a 
 coalesced, vascular, visceral brain, unpaired, existing at the origin of the 
 celiac, superior mesenteric, and renal arteries (major visceral arteries). 
 
 The arrangement of the abdominal brain consists of: (a) afferent or 
 centripetal nerves (entering or contributing nerves from the cerebrum, 
 spinal cord, or sympathetic) ; (b) efferent or centrifugal nerves (distributing 
 or visceral). The afferent nerves enter chiefly on the proximal and lateral 
 borders, while the efferent nerves radiate from all regions of the abdominal 
 brain — hence solar plexus. There is no relation between the number and 
 dimension of afferent and efferent nerves of the abdominal brain. 
 
 Fig. 33. An illustration of the sympathetic nerve with abdominal brain. In this 
 specimen the ureters (calyces, pelvis, and ureter proper) were dilated to the dimensions of 
 an index-finger, the channel of the tractus urinarius presenting no sphincters intact. This 
 subject possessed a typical abdominal brain (1 and 2) as well as a well-marked pelvic brain 
 (B). The ganglion hypogastricum (H) is well marked. This illustration presents fairly well 
 the abdominal sympathetic with their varied anastomoses. The great ganglionic masses of 
 the abdomen (1 and 2) and pelvis (B) are evident. It presents a general outline of its 
 nervous vasomotorius. I secured this specimen from an autopsy through the courtesy of 
 Drs. W. A. Evans and O'Byrne. 
 
 112 
 
ill 
 
 m 
 
 «4fllP 
 
 ^^Jit^S^ 
 
 Fig. 33. ABDOMINAL BRAIN. 
 
114 THE ABDOMINAL AND PELVIC BRAIN 
 
 (a) Afferent nerves. The afferent or contributing nerves composing the 
 abdominal brain are: (sympathetic), (1) plexus aorticus thoracicus 
 (unpaired); (2) nervus splanchnicus (paired), constituting the most essential 
 portion of the abdominal brain ; (3) branches from the two proximal lumbar 
 ganglia (paired): (cerebrospinal) I, nervus vagus (paired), especially the 
 right; II, nervus phrenicus (paired), especially the right. The abdominal 
 brain consists of the coalesced termination of the above (1, 2, 3, I, II) five 
 nerve apparatus. The abdominal brain is the major assembling center of 
 the abdominal sympathetic. 
 
 (b) The efferent nerves. The efferent, visceral, or distributing nerves of 
 the abdominal brain of various caliber radiate in a plexiform arterial sheath 
 to every abdominal viscus, viz., to the tractus intestinalis and its appendages: 
 plexus hepaticus, lienalis, gastricus, mesentericus superior, mesentericus 
 inferior, haemorrhoidalis; to the tractus urinarius : plexus suprarenalis, 
 renalis, ureteris, vesicalis, urethralis; to the tractus genitalis: plexus 
 ovaricus, hypogastricus (pelvic brain), plexus uterinus pudendalis vaginalis; 
 to the tractus vascularis and tractus lymphaticus. The abdominal brain 
 emits plexiform nerves and ganglia fixed in connective tissue sheaths which 
 intimately encase the vascular tubes. The nerves emitted from the abdo- 
 minal brain are gray or white in color, limited in diameter, plexiform in 
 arrangement, resist tension on account of the thick fibrous neurilemma, and 
 ganglia are liable to occur at their points of crossing or anastomosis. The 
 radiating, efferent nerves of the abdominal brain accompany the arteries 
 arranged in a plexiform sheath or network. They do not accompany the 
 veins — the trunk of the vena portas being the only exception. 
 
 I. Position: Holotopy (relation to general body). 
 
 The abdominal brain is located at the proximal end of the abdominal 
 cavity immediately distal to the diaphragm. It is situated medially, extra- 
 peritoneally, and is practically bilaterally symmetrical. 
 
 II. Skeletopy (relation to osseous skeleton). 
 
 The abdominal brain corresponds to the level of the first lumbar verte- 
 bra, on its ventral surface. 
 
 III. Syntopy (relation to adjacent organs). 
 
 The syntopic relations of the abdominal brain are intimate and profound 
 connections with vascular and visceral organs. It surrounds the roots of 
 the celiac, superior mesenteric, and renal arteries like a collar or fenestrated 
 sheath. It is located extraperitoneally, on the ventral surface of the aorta 
 and crura of the diaphragm. It is situated immediately distal to the hiatus 
 aorticus of the diaphragm. It lies between the diaphragmatic and renal 
 arteries. Right and left it projects against the capsules of the adrenals. It 
 is located between the proximal renal poles. It lies partly dorsal to the 
 corpus pancreaticus and stomach. Its right half lies between the right 
 crus of the diaphragm and the vena cava. Practically the abdominal brain 
 is lodged in the space bounded bilaterally by the adrenals and proximal renal 
 poles; proximally by a line drawn transversely from the proximal point of 
 one adrenal to that of the other; distally by the renal arteries. The situa- 
 
THE ABDOMINAL BRAIN 115 
 
 tion of the abdominal brain is included within the space of origin of the celiac 
 and renal arteries— some two inches. 
 
 IV. Idiotopy (relation of component segments). 
 
 The component parts of the abdominal brain are from proximal to distal 
 end in order, viz.: (a) The projecting ganglia of the origin of the diaphrag- 
 matic nerves located on the proximal border — conical elevations or bulb of 
 the brain itself; (b) the semilunar ganglia, the essential material in form 
 and dimension of the abdominal brain, constituting its major central segment; 
 (c) the renal ganglia, located generally at the origin of the renal arteries, are 
 practically constant, however varying in location, form, and dimension. 
 The segments proximodistally are compactly and solidly united by ganglionic 
 masses, flattened commissures, and nerve cords along the lateral borders of 
 the aorta. The segments laterally, i.e., the right half and left half, are 
 united transversely around the roots of the celiac, superior mesenteric, and 
 renal arteries by ganglionic arches, flattened commissures, and nerve cords 
 extending transversely from the right to left half of the brain. 
 
 Dimensions. — The abdominal brain or celiac ganglion is the largest and 
 richest ganglion of the sympathetic nerve. Hence from a preponderating 
 aggregation of nerve cells it becomes the ruling potentate of the viscera. 
 The left half is more compact, greater in dorsoventral diameter, thicker, less 
 fenestrated, and possesses more definite regular borders than the right; 
 however, the right half is greater in surface area. Its diameters are: (a) 
 transverse about V/2 inches; (b) proximodistal V/i inches; (c) dorsoventral 
 about \ inch. The dimensions of the abdominal brain practically correspond 
 with the space bounded bilaterally by the two adrenals and the two proximal 
 renal poles; distally by the two renal arteries; proximally by the diaphrag- 
 matic arteries, or a line drawn transversely from the proximal end of one 
 adrenal to that of the other. Its surface dimensions vary extremely on 
 account of the indefinite coalescence, interpolation, distribution, dislocation 
 of ganglion or by transportation along visceral vessels. 
 
 The Form. — The form of the abdominal brain is variable; however, in 
 general it is quadrilateral. It may present a half-moon or horseshoe shape, 
 or a ring surrounding the celiac axis and superior mesenteric artery. It may 
 also be represented by a single broad fenestrated ganglionated plate which 
 covers the ventral surface of the aorta adjacent to the celiac axis, and 
 occupies the space between the adrenals and proximal renal poles. The 
 left half may resemble a bean, a retort in compact form, while the right half 
 is more quadrilateral, flattened (from compression of the vena cava), and 
 irregular in contour. The form has changed by development from coales- 
 cence, interpolation, isolation, and transportation of ganglia along visceral 
 vessels, the vertebral column and ribs. 
 
 The Borders. —The borders of the abdominal brain (margo cerebri 
 abdominalis) are four, viz. : proximal, distal, and two lateral, (a) The 
 proximal border presents three factors of interest. The first is the concave 
 horseshoe-like depression made in it by the celiac axis and the surrounding 
 of the vessel like a collar by nerve cords and ganglia in a connective tissue 
 
116 THE ABDOMINAL AND PELVIC BRAIN 
 
 sheath. The other two factors are the cone-like projections of a portion of 
 the brain which emits bilaterally the nervus (plexus) diaphragmaticus. The 
 proximal border receives the continuation of the nerves of plexus aorticus 
 thoracalis as well as the termination of the right vagus (cranial), and also 
 communication may occur with the right nervus phrenicus. The proximal 
 border is generally blunt and rounded. Practically the plexus gastricus is 
 emitted from its proximal border. (b) The lateral border (left) presents 
 quite an uneven line, with irregular projections for efferent nerves, chiefly 
 destined to the adrenals and kidneys, and for afferent nerves, especially 
 the major splanchnic. The main projections along its border are those pro- 
 duced by the ganglion splanchnicum and ganglia renalia. (c) (right). The 
 lateral border is generally an irregular line caused by the irregular size and 
 location of the ganglion splanchnicum and ganglion adrenalis. The lateral 
 borders receive (afferent) nerves (splanchnic major) and emit (efferent) nerves 
 (plexus adrenalis and plexus renalis). (d) The distal border is bounded by 
 the arteria renalia — practically an even line. It emits or distributes efferent 
 nerves of various caliber to the abdominal visceral tracts. 
 
 Fenestra;. — The compact left half of the abdominal brain may be 
 limitedly perforated, while the widely meshed right half is considerably 
 fenestrated with larger and smaller, irregular-shaped apertures adding 
 unevenness to the surface. The fenestras possess sloping, smooth, irregular 
 contoured edges and are occupied with connective tissue, blood and lymph 
 vessels, glands, and areolar tissue. The chief central fenestras are produced 
 by the celiac axis and superior mesenteric artery. The left half of the brain 
 generally has one major fenestra due to a blood-vessel springing from the 
 aorta. The right half of the brain possesses some three definite apertures, 
 or fenestras, and several irregular large ones. In general the right half 
 possesses two kinds of fenestras, viz. : (smaller) those in the more solid 
 median division of the brain, and (larger) those in the lateral, more widely 
 meshed portion. The splanchnic ganglia, located at the termination of the 
 splanchnic nerves, are situated in the middle of the celiac plexus and 
 represent the major ganglionic masses. 
 
 The Surfaces. — The surfaces of the abdominal brain (facies cerebri 
 abdominis) consist of two, viz. : (a) the ventral, (b) the dorsal. The ven- 
 tral surface is uneven, from coalescence of smaller and larger ganglia, 
 irregular coalescence, compression of adjacent viscera (as the inferior vena 
 cava), or dislocation of ganglia by transportation along vessels. The 
 ventral surface is convex from the dorsal compression of the aorta and crura 
 diaphragmatica. The ventral surface receives (afferent) and emits (efferent) 
 nerves; also may be observed nerve loops which originate and insert them- 
 selves on the ventral surface. From the ventral surface pass the nerves to 
 the adrenal, pancreas, and plexus renalis — in fact, the nerve plexuses 
 accompanying the branches of the celiac axis and many of the plexus mesen- 
 tericus superior from the ventral surface. The surface is solidly bound by 
 connective tissue to adjacent structures. The ventral surface of the left 
 half of the abdominal brain is concave from the contact pressure of the 
 cylindrical aorta and crura diaphragmatica. 
 
ABDOMINAL BRAIN. 
 
 Fig. 34. This illustration is drawn from a specimen I secured at an autopsy through the 
 courtesy of Drs. Evans and O'Byrne. The right kidney was dislocated, resting on the right 
 common iliac artery, with its pelvis (P) and hilum facing ventralward. The adrenal (Ad.) 
 remained in situ. It was a congenital renal dislocation, and was accompanied with con- 
 genital malformations in the sympathetic nerve, or nervus vasomotorius. 1 and 2 is the 
 abdominal brain. It sends five branches to the adrenal from the right half (2). Though 
 the sympathetic system is malformed, yet the principal rules as regards the sympathetic 
 ganglia still prevail, viz., ganglia exist at the origin of abdominal visceral vessels, e.g., 3, 
 at the origin of the inferior mesenteric artery ; at the root of the renal vessels, HP is no 
 doubt the ganglion originally at the root of the common iliacs (coalesced). In this 
 specimen the right ureter was 5 inches in length, while the left was 11^4. This specimen 
 demonstrates that the abdominal brain is located at the origin of the renal, celiac, and 
 superior mesenteric vessels — i.e., it is a vascular brain (cerebrum vasomotorius). 
 
118 THE ABDOMINAL AND PELVIC BRAIN 
 
 The fenestra: or perforations of the dorsal surface correspond with those 
 of the ventral. Strong, fine white strands of connective tissue, blood, 
 nerves, and lymph vessels bind the dorsal surface of tne abdominal brain 
 solidly to the crura diaphragmatica, but especially strong to the aortic. 
 Nerves originate and depart from the dorsal surface. From the dorsal 
 surface nerves depart to the aorta and diaphragm and the splanchnicus 
 major, bilaterally, arrives on the dorsal surface. 
 
 Ganglia. — There are usually six constant ganglia in the abdominal brain, 
 viz.: (a) Ganglia diaphragmatic (paired); (b) ganglia splanchnica (paired); 
 (c) ganglia renalia (paired). They are solidly and compactly united into 
 one anatomic and physiologic nerve center — a brain. In general the ganglia 
 do not agree in form or dimension bilaterally. Practically the ganglia 
 agree in position bilaterally. However, the left semilunar ganglion is nearer 
 the median line than the right, and the left mainly lies on the aorta, while 
 the right chiefly rests on the crus of the diaphragm. The ganglia may rest 
 in an even transverse plane, or lie in superimposed layers in a dorsoventral 
 plane. The ganglia constituting the abdominal brain are as irregular and 
 variable as the plexus in which they are located. The ganglia consist of 
 large, swollen cords, or ganglionic arches or circles arranged in a network. 
 The dimension, form, and number of the ganglia may vary from coalescence, 
 isolation, interpolation, or transportation of ganglia along vessels, bones, 
 and muscles. The coalescence of the ganglia may proceed to such an 
 extent that the abdominal brain will present the appearance of several 
 nodes, or the two semilunar ganglia may coalesce and lie between the celiac 
 and superior mesenteric arteries. 
 
 The ganglia may coalesce proximally and distally in the form of a 
 ganglionic ring surrounding the origin of the celiac and mesenteric arteries. 
 The ganglia of the abdominal brain may be flat or elevated, single or mul- 
 tiple, united by gangliated commissures or flattened nerve strands. The 
 nervus splanchnicus major, the essential segment, terminates bilaterally in 
 the abdominal brain in a large semilunar or quadrilateral-shaped nodule — 
 ganglion splanchnicum (paired). The splanchnic ganglia may assume the 
 shape of the letter C. I have seen two splanchnic ganglia on each side of 
 almost equal dimensions formed by the splanchnic major and minor nerves. 
 
 1. The left semilunar ganglion has a more definite border, is nearer to 
 the median line, greater in dorsoventral diameter, more compact, yet smaller 
 and less fenestrated than the right. It lies transversely on the side of the 
 aorta between the renal and diaphragmatic arteries. Its average diameters 
 are: proximodistal, V2 inch; transverse, 1 inch; dorsoventral, \ inch. Its 
 thickest border is the left, its thinnest' is the right. Its ventral surface is 
 uneven, convex; the dorsal, concave. It is flask or quadrilateral in form. 
 The right proximal angle is elongated into a horn-like process to join its 
 opposite fellow. Afferent nerves arrive and efferent nerves depart from all 
 surfaces and borders except part of the left. Proximally it is connected with 
 the diaphragmatic ganglion— externally with the splanchnic nerve, medially 
 with the opposite fellow (right half of brain). 
 
ABDOMINAL BRAIN (S. P.). 
 Fig. 35. This illustration was drawn from a specimen I secured at .autopsy f through the 
 courtesy of Dr. W. A. Evans. It is not a typical abdominal brain on account of the peculiar 
 
 trophied The ureters present a network of nerves surrounding them. Observe the large 
 renal ganglion on the ventral surface of the renal artery at U. 
 
120 THE ABDOMINAL AND PELVIC BRAIN 
 
 2. The right semilunar ganglion is more flattened, greater in surface 
 area, more extensively fenestrated, and less in dorsoventral diameter than 
 the left. It lies between the vena cava (ventral) and right crus of the 
 draphragm (dorsal), and between the renal and diaphragmatic arteries. 
 Afferent nerves arrive and efferent nerves depart from its surfaces and 
 borders. The left, proximal, angle is prolonged into a horn-like process to 
 join its opposite fellow. Proximally it is connected with the diaphragmatic 
 ganglion ; distally with the renal ganglion ; externally with the splanchnic 
 nerve; and medially with the opposite fellow (left half of the brain). 
 
 Ganglion of the Phrenic Artery {Ganglion Arterial Phrenicce). — In this 
 brief note I wish to present a sympathetic ganglion (bilateral) which I have 
 not found described in literature. 
 
 This ganglion consists of a constant pyramidal, or cone-shaped projec- 
 tion on the proximal border of the abdominal brain in the course of the 
 phrenic artery. 
 
 In Fig. 1 on the right side it is located by a hook at the figure 2 in the 
 abdominal brain. On the left side it is located between the splenic and 
 phrenic artery. 
 
 The phrenic ganglion projects bulb-like from the proximal border of the 
 cerebrum abdominale similar to that of the olfactory nerve from the cranial 
 cerebrum. It is a part and parcel of it. By a general observation in dis- 
 secting the sympathetic nerve (nervus vasomotorius) it will be evident that 
 sympathetic ganglia are located at the origin of the vessels from the aorta, 
 as at the foot of the celiac axis (ganglion semilunare) at the origin of the 
 renal artery (ganglion renale) at the origin of the arteria mesenterica inferior 
 (ganglion mesentericum inferius) at the origin of the two common iliacs 
 from the aorta (the interiliac nerve disc), and so forth. Hence it is in 
 accordance with this rule that the ganglion arterias phrenicae is found in the 
 course of the phrenic artery (bilateral). If the phrenic artery has an 
 anomalous origin and course the phrenic ganglion tends to follow its origin 
 and course, and it was this anatomic relation that called my attention to 
 this heretofore undescribed constant ganglion. I do not refer to the 
 diaphragmatic ganglion (ganglion diaphragmaticum) located on the dia- 
 phragm on the right side (only) about two inches from the abdominal brain. 
 The abdominal brain consists practically of three ganglia (bilateral). They 
 are: 1. Ganglion semilunare (bilateral), located on the middle part of the 
 lateral border of the abdominal brain at the termination of the major splanch- 
 nic nerve (Sp. in figures). This ganglion is related to the origin of the 
 celiac artery. 2. Ganglion renale (bilateral), located at the distal lateral 
 border of the abdominal brain, and belongs to the origin of the arteria 
 renalis. 3. Ganglion arteria; phrenicae (bilateral), located at the proximal 
 border of the abdominal brain in the course of the phrenic artery. 
 
 In certain subjects the ganglion of the phrenic artery is located exactly 
 at the origin of the phrenic artery from the aorta. However, the origin of 
 the phrenic artery varies considerably, and this alters to some extent the 
 relations of the phrenic ganglion from physical facts. 
 
THE ABDOMINAL BRAIN 
 
 121 
 
 The phrenic ganglia are constant structures, constantly located in relation 
 to the course of the phrenic arteries so f;ir as I can determine by dissection. 
 The importance of the abdominal brain, with its ganglia, will sooner or 
 later be realized by the general profession. 
 
 The diaphragmatic ganglia are practically bilaterally symmetrical in 
 location, form, and dimension. They project as pyramids or cones from the 
 proximal border of the semilunar ganglia, at the origin of the diaphragmatic 
 arteries, giving origin in the diaphragmatic nerve. They project from the 
 
 ABDOMINAL BRAIN— CEREBRUM ABDOMINALE. 
 
 Fig. 36. This illustration was drawn from a carefully dissected abdominal brain. 1 
 dissected the tissue under alcohol. The relations and proportions are those of life, being 
 drawn by accurate measurements. 1 and 2, abdominal brain. Observe the nerves which 
 the adrenals receive: Sp, splanchnic major ; DG, ganglion diaphragmaticum ; GR, renal 
 ganglia; Ad, adrenals ; LS, lesser splanchnics ; RA, arteria renalis ; H, hepatic ; G, gastric; 
 and Sp, splenic artery. The hook fixes the ganglion of the phrenic artery which I term 
 ganglion arteris phrenicae. 
 
 abdominal brain as the olfactory projects from the cranial brain — being a 
 part of it. The diaphragmatic nerve possesses a small ganglion some 2 l A 
 inches from its origin, and it anastomoses with the right phrenic. 
 
 5 and 6. The primary renal ganglia are practically bilaterally symmet- 
 rical in form, location, and dimension. Their location is generally at the 
 origin of the renal arteries. 
 
 I. The ganglia of uncertain dimension, location, and form associated 
 with the abdominal brain are: (a) The nervus splanchnicus minor terminates 
 
122 THE ABDOMINAL AXD PELVIC BRAIN 
 
 bilaterally more distahvard generally on the renal arteries; (b) the ganglion 
 suprarenale supermini, which I have occasionally found chiefly on the right 
 suprarenal nerves. The color of the abdominal brain is grayish-red ; the 
 consistence is moderately dense, due to the presence of abundant connective 
 tissue; the composition consists of an aggregation of nerve ganglia, ensconced 
 in dense connective tissue, varying in dimension, number, and form. Each 
 ganglion is composed of oval-shaped nerve cells of various form and dimen- 
 sion. 
 
 Relations. — The relations of the abdominal brain well encased in fibrous 
 and connective tissue consist in intimate connection with the abdominal aorta 
 at the origin of the celiac axis, superior mesenteric and renal arteries. It 
 has also intimate but less solid connections with the vena cava and renal 
 veins. It is a vascular brain of the abdomen. The abdominal brain lies in 
 the square formed by the proximal renal poles with adrenals and the renal 
 arteries. It is in relation to the dorsal surface of the body of the pancreas, 
 peritoneum, and stomach. The abdominal brain in general occupies the 
 space including the origin of the major visceral arteries, viz. : (a) arteria 
 cceliaca; (b) arteria mesenterica superior; (c) arteria renalis — three mighty 
 visceral arteries originating from the aorta within the space of an inch and 
 a half. Hence practically the term abdominal brain should include the 
 aggregated or coalesced ganglia located at the origin of the major visceral 
 vessels. With development of viscera and elongation of visceral arteries, 
 the ganglia become isolated from the original abdominal brain and trans- 
 ported along the vessels toward the viscera. 
 
 The two best examples are the renal and aortic arteries with their 
 numerous transported large ganglia — ganglia renalia and ganglia aortica. 
 Development has sometimes separated the cord and ganglion of the nervus 
 splanchnicus minor from the abdominal brain by placing it more distalward 
 and lateralward toward the region of the origin of the arteria renalis, thus 
 altering the form and contour of the abdominal brain. The nerve plexuses 
 and ganglia of the abdominal brain, firmly bound in sheaths by strong white 
 connective and elastic tissue, encase the visceral vessels and accompany 
 them to the viscera. The abdominal brain is solidly and compactly anas- 
 tomosed, connected by nerves of various caliber with all the abdominal 
 viscera, viz., tractus intestinalis, urinarius, genitalis, vascularis, lymphaticus. 
 It is evident from its location at the origin of the celiac axis and superior 
 mesenteric arteries that the abdominal brain in its origin was a primitive brain 
 for the tractus vascularis. With development of viscera and elongation of 
 visceral arteries, dislocation, multiplication, distribution, coalescence or 
 transportation of ganglia, other viscera have acquired local ganglionic rulers, 
 e.g., the pelvic brain — ganglion cervicale. However, present conditions 
 allow the origin of the abdominal brain to remain at the exit of the major 
 visceral vessel. It should be denominated a vascular brain. 
 
 From the abdominal brain radiate plexuses of various caliber, chiefly in 
 vessels, to all the abdominal viscera, viz., tractus intestinalis, genitalis, 
 urinarius, vascularis, and lymphaticus. The abdominal brain emits more 
 
THE ABDOMINAL BRAIN 123 
 
 nerves than it receives, and hence is a creating, producing center, a source 
 for new and increased nerves. Nerve reception occurs chielly at the 
 proximal (plexus aorticus thoracalis, vagi) and lateral borders (splanchnics, 
 major, medius, minor). Nerve emission occurs mainly at the distal (plexus 
 aorticus abdominalis) and lateral borders (plexus renalis, adrenalis). From 
 the dorsal and ventral surface, from the bilateral proximal and distal borders 
 of the abdominal brain, nerves arrive and depart. Bilaterally radiate the 
 renal and adrenal nerves, and arrive the splanchnicus; proximally radiate a 
 few to the aorta, and arrives the plexus aorticus thoracalis and vagi; dorsally 
 many nerves pass to the aorta and diaphragm, and arrive the branches from 
 the splanchnics; ventrally a number of nerves radiate to the adrenals and 
 pancreas; distally are emitted nerve plexuses of vast importance on visceral 
 arteries of corresponding names, viz. : 
 
 I. Tractus intestinalis: (1) Plexus cceliacus, emitting (a) plexus 
 gastriticus accompanying the arteria gastrica; (b) plexus hepaticus accom- 
 panying the arteria hepatica; (c) plexus lienalis accompanying the arteria 
 lienalis. (2) Plexus mesentericus superior accompanying the arteria mes- 
 enterica superior (to the enteron — except the duodenum, and colon, except 
 the cacum, right colon and right half of transverse colon). (3) Plexus 
 mesentericus inferior accompanying the arteria mesenterica inferior (to the 
 left half of the transverse colon, left colon, sigmoid flexure, and rectum). 
 
 II. Tractus urinarius: (1) Plexus adrenalis accompanying the arteria 
 adrenalis. (2) Plexus renalis accompanying the arteria renalis. (3) Plexus 
 ureteris accompanying: (a) rami arteria: renales; (b) arteria ovarica; (c) 
 arteria ureteris media (from common iliac) ; (d) arteria uterina. (4) Plexus 
 hsemorrhoidalis accompanying the arteria hgemorrhoidalia. (5) Plexus 
 hypogastrics accompanying the arteria hypogastrica. (6) Pelvic brain 
 (ganglion cervicale) emits nerves which pass directly to the ureter without 
 accompanying blood-vessels as well as the plexus vesicalis. (7) Plexus 
 vesicalis accompanying the arteria vesicalis superior, media, and inferior 
 (hemorrhoidal). (8) Plexus urethralis (a continuation of the plexus vesi- 
 calis) accompanying arteria pudenda. 
 
 III. Tractus genitalis: (1) Plexus aorticus accompanying the arteria 
 aortica abdominis. (2) Plexus hypogastricus (a continuation of the plexus 
 aorticus) accompanying the arteria iliaca communis and arteria hypogastrica. 
 (3) Plexus ovaricus accompanying the arteria ovarica. (4) Plexus arteriae 
 uterinse accompanying the arteria uterina. (5) Cerebrum pelvicum (pelvic 
 brain), which emits the plexus uterinus without accompanying vessels as well 
 as the plexus vaginalis. The sympathetic nerve cords and ganglia accom- 
 panying vessels (blood, particularly arteries and lymph) arranged as a network 
 in a connective tissue sheath which encases the vessel. 
 
 (b) physiology of the abdominal brain. 
 
 In mammals there exist two brains of almost equal importance to the 
 individual and race. One is the cranial brain, the instrument of volitions 
 of mental progress and physical protection. The other is the abdominal 
 
124 THE ABDOMINAL AND PELVIC BRAIN 
 
 brain, the instrument of vascular and visceral function. It is the automatic, 
 vegetative, the subconscious brain of physical existence. In the cranial 
 brain resides the consciousness of right and wrong. Here is the seat of all 
 progress, mental and moral, and in it lies the instinct to protect life and the 
 fear of death. However, in the abdomen there exists a brain of wonderful 
 power maintaining eternal, restless viligance over its viscera. It presides 
 over organic life. It dominates the rhythmical function of viscera. It is an 
 automatic nerve center, a physiologic and an anatomic brain. Being located 
 at the origin of the celiac, superior mesenteric, and renal arteries — the major 
 abdominal visceral arteries — it is a primary vascular brain of the abdomen 
 and a secondary brain for visceral rhythm. The abdominal brain presides as 
 the central potentate, over the physiology of the abdominal viscera. The 
 common functions of these viscera are rhythm, secretion, and absorption, 
 and to preside over this triple office is the chief duty of the abdominal brain. 
 To the common functions of the abdominal viscera must be added the special 
 functions of the tractus genitalis — ovulation, menstruation, gestation; 
 however, many of the functions of the visceral tract are delegated to the 
 subordinate local ruler — the pelvic brain. The abdominal brain is a receiver, 
 a reorganizer, an emitter of nerve forces. It has the powers of a brain. It 
 is a reflex center in health and disease. The sympathetic abdominal nerve 
 alone possesses the power of rhythm. Every organ possesses rhythm. In 
 this rhythm of involuntary visceral muscles is doubtless included the factors 
 of initiation, maintenance, and conclusion of visceral absorption and secre- 
 tion. The rhythmic, peristaltic muscles massage the glands, inciting their 
 function of secretion and absorption. 
 
 The individual functions of the abdominal brain are numerous and 
 important, viz. : (1) It is the source of new nerves, as it possesses more 
 efferent than afferent nerves. (2) it demedullates nerves; nerves, enter 
 sheathed and depart unsheathed. (3) It presides over the rhythm, peristalsis, 
 of visceral muscles. (4) It presides over the absorption and secretion of 
 visceral glands — e.g., the glands lining tubular viscera and those denominated 
 glandular appendages. (5) The abdominal brain is a giant vasomotor center, 
 controlling the caliber of the abdominal vessels (blood and lymph) ; it should 
 be termed ncrvus vasomotorius. (6) It possesses nutritive powers over the 
 nerves passing from it to the periphery. (7) It is the major abdominal 
 reflex center. 
 
 The abdominal brain is not a mere agent of the brain and cord; it 
 receives and generates nerve forces itself; it presides over nutrition. It is 
 the center of life itself. In it are repeated all the physiologic and pathologic 
 manifestations of visceral function (rhythm, absorption, secretion, and 
 nutrition). The abdominal brain can live without the cranial brain, which 
 is demonstrated by living children being born without cerebrospinal axis. 
 On the contrary the cranial brain can not live without the abdominal brain. 
 The central idea founded in the abdominal brain should entitle it, in my 
 opinion, to the name vascular or vasomotor brain of the abdomen (cerebrum 
 vasculare abdominale). It initiates, sustains, and concludes visceral rhythm 
 
THE ABDOMINAL BRAIN 
 
 l-j- 
 
 (the peristalsis of involuntary, visceral muscles) — e.g., in the tractus 
 vascularis, intestinalis, genitalis, and urinarius. It presides over the absorp- 
 tion and secretion of the viscera — e. g. t the mucous glands of the tubular 
 viscera and visceral glandular appendages. It is evident from the great 
 volume of blood occasionally found in the vastly distended abdominal veins 
 at autopsy that a subject could bleed to death in his own abdominal vessels. 
 The abdominal brain, the vascular cerebrum, is responsible for this condition, 
 
 ABDOMINAL BRAIN. 
 
 Fig. 37. This illustration drawn from a cadaver, illustrates the location, relation, and 
 radiating plexuses jof the solar plexus, or abdominal brain (71 and 72), which is built 
 around the major visceral arteries, the celiac (73, 74, 75), superior mesenteric (106), and 
 renal (88) arteries ; hence it dominates the visceral function as to vascularity (blood and 
 lymph), peristalsis, absorption, and secretion. The clinical manifestations of theabdominat 
 brain are coextensive with that of the abdominal viscera. This ganglion of the firsl 
 magnitude presents radiating plexuses to all the abdominal viscera, presenting an exquisitely 
 balanced and poised nervous mechanism, controlling vascularity (blood and lymph), 
 peristalsis, absorption, and secretion. 76 and 185, splanchnic major; 110, 111, ganglia 
 ovarica. The body from which this dissection was drawn possessed wide, flat nerves, as 
 is noted by the majestic ganglion — the abdominal brain or cerebrum vasomotorius ; 69 is 
 the left vagus. 
 
126 THE ABDOMINAL AND PELVIC BRAIN 
 
 having forgotten, from paralysis, to control the lumen of the vessels. From 
 the anatomic vascular connection it is impossible to extirpate the abdominal 
 brain from living animals, hence the reports of experimentation accompanied 
 with its extirpation are unreliable. The abdominal brain is the nervous 
 executive of the abdominal vessels and viscera, the duties of which are to see 
 that the functions of the viscera (rhythm, secretion, and absorption) are 
 faithfully executed. The abdominal brain assumes practically an indepen- 
 dent existence; however, the cerebrospinal axis asserts a controlling 
 influence over it. For example, in children whose cerebrospinal axis is not 
 completely developed, and at death of adults, when the cerebrospinal axis 
 has lost its complete control, the intestines will mutiny, assuming a wild, 
 disordered, violent peristalsis, resulting in intestinal invagination. 
 
 The utility of the abdominal brain in practice is important — for example, 
 in postpartum hemorrhage the older practitioners taught that by compression 
 of the aorta the hemorrhage was checked. This, of course, is an error, as 
 the technique, if it were possible to execute, would not materially affect the 
 bleeding, as ovarian blood-supply would continue. The physiologic expla- 
 nation of checking postpartum hemorrhage by pressure over the abdominal 
 aorta is that the manipulation stimulates the plexus aorticus and plexus 
 hypogastrics, which is transmitted to the pelvic brain, where it is reor- 
 ganized and transmitted over the plexus uterinus to the myometrium, the 
 elastic and muscular bundles of which being excited, contract like living 
 ligatures, checking the postpartum hemorrhage by diminishing the lumen of 
 the vessels. The irritation, pressure, or trauma of the head of the child on 
 the expanding cervix uteri during the last month of gestation precipitates 
 labor by its effect on the pelvic brain (and consequently on the abdominal 
 brain), by inducing vigorous, persistent uterine contractions. In feeble 
 labor pains, during uterine inertia, vigorous uterine contractions may be 
 excited by the finger per rectum or per vaginam, irritating or massaging the 
 pelvic brain. The pelvic brain is palpated with facility, as it is located on 
 the lateral vaginal fornix. Again, the pelvic brain is subordinate to the 
 abdominal brain ; however, the pelvic brain must be intact to allow physio- 
 logic orders to pass from the abdominal brain through the pelvic brain to the 
 uterus. For example, during labor sudden cessation of uterine peristalsis 
 may occur — uterine inertia. The probable explanation is that as the head 
 passes through the pelvis it traumatizes the pelvic brain, producing temporary 
 paresis from pressure, and partially checks the uterine rhythm. With the 
 progress of labor the pelvic brain recovers and its dynamics resume. 
 
 The temporary paresis of the pelvic brain does not produce complete 
 paralysis, because a few of the nerves of the plexus hypogastricus (directly 
 from the abdominal brain) pass to the uterus without first entering the pelvic 
 brain. The abdominal brain rules the physiology of the abdominal visceral 
 tracts. The methods to utilize the physiology of the abdominal brain in 
 practice are varied. For example, the mammary gland is connected to the 
 abdominal brain by at least three distinct routes, viz. : (a) via the nerve 
 plexuses accompanying the arteria mammaria and arteria subclavia, whence 
 
THE ABDOMINAL BRAIN 
 
 127 
 
 the route is direct to the abdominal brain; (b) via the nerve plexuses 
 accompanying the arteriae intercostales to the aorta and its plexus, whence 
 the route is direct to the abdominal brain; (c) via the nerve plexuses accom- 
 panying the arteria epigastrica superior and inferior to the common iliac, 
 whence the route (plexus) continues on the artery of the round ligament to 
 the plexus uterina, whence the route is direct to the pelvic brain or abdominal 
 brain. Therefore, by stimulating or irritating the nipple with light friction 
 or massaging the mammary gland, the abdominal brain is reached by the 
 above three routes, and consequently the uterus is induced to contract more 
 frequently, and if the experiments be not repeated too rapidly, the uterine 
 contraction will be more vigorous. Again, the uterus may be incited to more 
 frequent and vigorous contractions by administering a tablespoonful of hot 
 
 GANGLION CELLS IN THE ABDOMINAL BRAIN. 
 
 Fig. 38. Drawn from a microscopic section of the abdominal brain. Observe that 
 the cells lie in connective tissue nests, i. e., the ganglion cells are ensconced in separate 
 chambers of connective tissue. The prolongations of the cells, i. <?., the conducting cords, 
 pass hither and yon, forming a network. 
 
 fluid, which first emits the stimulation over the plexus gastricus to the 
 abdominal brain, where it is reorganized and sent directly to the plexus 
 uterinus, which incites the uterus to increased peristalsis. The reverse 
 physiology of the influence of visceral tumors or pregnant genitals stimu- 
 lating the mammary gland (over the above three routes) is evident. The 
 tumor or fetus in the genitals rapidly induces the mammary gland to mani- 
 fest objective disturbances of dimension, circulation, color, palpation, as 
 well as sensory disturbances. 
 
 Practically the uterine nerves originate in the abdominal brain and 
 possess a relative independent existence. Children are born, expelled, from 
 the uterus after the death of the mother. Hyrtl, the celebrated Viennese 
 anatomist, reports that during a war with Spain some bandits hanged a 
 pregnant woman. After she had hung on the gallows for four hours, and con- 
 sequently was long dead, she gave birth to a living child. I have observed the 
 giant uterus of slaughtered pregnant cows executing with wondrous precision 
 
128 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 its rhythm hours subsequent to death and evacuation of uterine contents. If 
 one will extirpate an oviduct from a human and place it in warm normal salt 
 solution, oviductal rhythm may be maintained by physical stimulus — e.g. % 
 tapping with the scalpel — for some three-quarters of an hour. If one will 
 chloroform a dog to death and incise the abdominal wall, exposing the intes- 
 tines, in a room of 70°, the intestines will perform their rhythm, on being 
 tapped with the scalpel, for an hour and a half. The large urinary vesical 
 apparatus of steers will perform rhythmical movements for half a dozen 
 hours after death in summer temperature. 
 
 The anatomic location and the physiologic function of the abdominal 
 brain dignify it into a basic factor in diagnosis from pain. For example, 
 practically all acute inflammatory pain (localized peritonitis, visceral perfor- 
 ation) or violent visceral irritation (calculus, volvulus, invagination, acute 
 strangulation, obstruction) is first experienced in the epigastric region — i.e., 
 reorganization occurs in the abdominal brain. This means that all visceral 
 pain, irritation, is first transmitted to the abdominal brain, where it is 
 reorganized and emitted to the abdominal viscera, diffusing the wild, 
 disordered, violent peristalsis (colic) universally in the abdomen, which 
 prevents the localizing of the pain by the diagnostician. With the progress 
 of the disease the abdominal brain and associated nerve apparatus become 
 accustomed to the new experience and the pain becomes intensified, local- 
 ized on definite nerve plexuses, whence the pain, tenderness, can be diagnosed 
 by distinct circumscribed localization. The best example of this view is 
 appendicitis. 
 
 The abdominal brain is the seat of shock. A blow over the epigastrium, 
 violent trauma to the abdominal brain, may cause immediate shock, 
 collapse, or death. I performed an autopsy on a subject where invagination 
 of the uterus had killed the patient in two and a half hours. Death was due 
 to shock in the abdominal brain, transmitted to it over the hypogastric plexus 
 from the traumatized (invaginated) uterus. 
 
 CONCLUSIONS AS REGARDS THE ABDOMINAL BRAIX. 
 
 The abdominal brain is a nervous center — i.e., it receives, reorganizes, 
 and emits nerve forces. 
 
 The abdominal brain is the nervous executive for the common functions 
 of the abdominal viscera, as rhythm, absorption, and secretion. 
 
 The abdominal brain was originally in function and location a vascular 
 brain — cerebrum vasculare. Though complicated functions have been 
 added, yet it is still a primary vasomotor center controlling the caliber of the 
 blood-vessels and consequently the volume of blood to viscera, which 
 determines visceral function. 
 
 The abdominal brain is a reflex center in health and disease. 
 
 It is the major assembling center of the abdominal sympathetic. 
 
 The abdominal brain is the seat of shock. A blow or trauma on it may 
 cause shock, collapse, or death. 
 
 It is the automatic, vegetative, the subconscious brain of physical 
 existence. It is the center of life itself. 
 
THE ABDOMINAL BRAIN 129 
 
 In the abdominal brain are repeated all the physiologic and pathologic- 
 manifestations of visceral function — rhythm, absorption, secretion, men- 
 struation, gestation, ovulation. 
 
 The abdominal brain can live without the cranial brain (and spinal 
 cord), for children have been born alive with no cerebrospinal axis. Chil- 
 dren have been born alive hours after the mother was dead. 
 
 The abdominal brain may be the agent of valuable therapeutics — e.g. y 
 in postpartum hemorrhage massage of the aortic plexus will stimulate the 
 abdominal brain to control the blood-vessels of the uterus. Massage of the 
 aortic plexus will stimulate the abdominal brain to send blood to the viscera, 
 enhancing rhythm, secretion, and absorption, improving constipation and 
 increasing visceral drainage. 
 
 The abdominal brain is the primary agent of rhythmic visceral motion. 
 A wide office of the physician is to maintain regular visceral rhythm by 
 means of rational therapeutics, as regular habits and exercise, wholesome 
 coarse food, ample fluids, and proper rest. 
 
CHAPTER XIII. 
 
 THE PELVIC BRAIN (CEREBRUM PELVICUM). 
 
 We do automatically what we do well. 
 
 "La Duma est morte! vive la Duma!" — ("The Russian parliament is dead! 
 Long live the Russian parliament!" ) — Remark of Sir Henry Campbell-Ban- 
 ' nerman. Prime Minister of England during the Inter-Parliamentary Congress 
 Session at London. July 24, 1906. 
 
 (a) anatomy, (b) PHYSIOLOGY, (c) PATHOLOGY. 
 
 Prologue. — With the term cervical ganglion the names of Johann Gotlieb 
 Walther (1734-1818), Robert Lee (1793-1877) and Ferdinand Frankenhauser 
 (died in 1894) will be forever connected. Thomas Snow Beck (1814-1847,) 
 will be remembered, in the brilliant polemics only, from 1840 to 1*46, with 
 Robert Lee. Walter's book appeared in 1783. Lee's in 1841 and Franken- 
 hauser's in 1867 — all with illustrations of the cervical ganglion. The first 
 two books are pioneer works executed in the premicroscopical days; the 
 last work, that of Frankenhauser, is a work of scientific merit, and will stand 
 the test of time. I have designated the plexiform ganglionic mass, located on 
 the lateral border of the cervix and vagina, as the pelvic brain. The gang- 
 lionated mass located at the cervico-vaginal function has experienced a 
 variety of terms during the past two centuries. 
 
 Synonyms. — The pelvic sympathetic plexus (plexus sympathicus); 
 Cervio-cuterine ganglion (ganglion cervicis uterinum — Walther, 1783). 
 Hypogastric plexus (plexus hypogastricus — Walter, 1783). The lateral 
 hypogastric plexus (plexus hypogastricus lateralis — Friedrich Tiedemann, 
 1822) (1781-1861). The ganglionated plexus (plexus gangliosus — Tiedemann, 
 1822). The inferior uterine plexus (plexus uterinus inferior — Tiedemann, 
 1822). The hypogastric ganglion (ganglion hypogastrium — Lee, 1841). The 
 uterocervical ganglion (ganglion uterium cervicale — Lee, 1841). The vesico- 
 rectal plexus (plexus vesicis rectalis — J. M. Bourgery, 1840) (1797-1845), and 
 Claude Bernard (1813-1878). The ganglion of the cervix (ganglion cervicis — 
 Lee, 1841). The pelvic plexus (plexus pelvicus — Thomas Snow Beck, 1845) 
 (1814-1847). The cervical ganglion (ganglion cervicale — Frankenhauser, 
 1867). The fundamental nerve plexuses of the uterus (plexus nervosus fun- 
 damental uteri — G. Rein, 1892), Pelvic brain (cerebrum pelvicum — Byron 
 Robinson, 1894). The lateral cervical plexus (plexus lateralis cervicis). The 
 utero-vaginal plexus (plexus uterinus vaginalis). 
 
 Practically three views have been entertained in regard to Lie nature 
 and character of the pelvic brain; viz. : 
 
 (a) It is a more or less solid, composite, ganglionic mass — Walter (1783), 
 Lee (1841), Frankenhauser (1867), Freund (1885), Byron Robinson (1894), 
 Knupffer (1892). 
 
 (b) It is a ganglionated plexus or group of connected ganglia — Tiedemann 
 
 130 
 
ANATOMY 131 
 
 (1822), Moreau (1789-1862), Jastreboff (1881), Rein (1902), Sabura Hashimoto 
 (1892), Pessimski (l< s( -»->, Jung (1905). 
 
 (c) Jobert (de Lomalle) (1799-1867), 1841, and Thomas Snow Beck, 1845 
 (1814-1877), are the only authors known to me who have viewed the pelvic 
 brain as a nongangliated nerve plexus. 
 
 (A) Anatomy and Topography of the Pelvic Brain. 
 
 Position. — I. Holotopy (relation to general body). The pelvic brain is 
 located in the distal end of the abdominal cavity. It is a bilaterally located 
 organ (paired) residing in the lesser pelvic between the cervic uteri and 
 pelvic wall. It is situated extraperitoneally at the base of the ligamentum 
 latum, proximal to the pelvic floor, ensconced in the pelvic subserous 
 connective tissue. The pelvic brain is completely accessible to digital 
 palpation. 
 
 II. Skeletopy (relation to the osseous system). The pelvic brain lies 
 in the lesser bony pelvis, located bilaterally closely adjacent to the ischial 
 spine in the planum interspinosum. It lies on a level with the II sacral 
 vertebra and the proximal border of the symphysis pubis. By distention 
 and contraction of rectum, bladder, vagina and uterus the skeletopic relation 
 of the pelvic brain becomes altered. The pelvic brain lies practically midway 
 between the inlet and outlet of the minor osseous pelvis. The skeletopic 
 relation of the pelvic brain has been modified by erect attitude. 
 
 III. Syntopy (relation to adjacent organs). The pelvic brain (paired) 
 is located bilaterally to the cervix uteri and vaginal fornix. It is situated in 
 the connective tissue of the parametrium, on a level with the middle of the 
 cervix uteri and about one inch lateralward from the cervix uteri. The 
 pelvic brain is located in the base of the ligamentum latum at the distal end 
 of the plexus interiliacus (hypogastrics). Practically the pelvic brain is 
 located at the crossing of the ureter and pelvic floor segment of the vasa 
 uterina. It lies on the internal border of the ureter midway between the 
 dorsal and ventral blades of the ligamentum latum in the loose connective 
 tissue. It is situated at the junction of the plexus interiliacus, hypogastrics, 
 with the branches of the II, III, and IV sacral nerves (spinal). It is lodged 
 practically at the junction of the cervix uteri with the vaginal fornix. A 
 major portion of it may lodge in the groove or fossa, between the rectum 
 and vagina. It is surrounded and interwoven with dense, subperitoneal, 
 pelvic connective tissue, presenting difficulties in exposition by dissection 
 because of its simulation to adjacent tissue. The pelvic brain has profound 
 and extensive connection with the uterus, vagina, and rectum, ureter and 
 bladder. In the majority of subjects the chief segment of the pelvic brain 
 lies adjacent to the lateral vagina fornix. From erect attitude the pelvic 
 brain has changed its position, having approached more adjacent to the cer- 
 vico-vaginal junction in the center of the pelvis. From the distalward and 
 ventralward movements of the genitals (in higher forms of life and erect 
 attitude) the plexus interilicus (hypogastricus) has been dragged, forced 
 medianward, isolating it from the arteria iliaca communis and arteria 
 
132 
 
 THE ABDGMLXAL AND. PELVIC DRAIN 
 
 PELVIC BRAIN OF AX INFANT 
 
 Fig. 39. A, pelvic brain; B, plexus vesicalis ; V, plexus vaginalis; I, II, III, IV, V, 
 sacral nerves with the sacral ganglia (N), plexus (hypogastricus) ; P. I. Ur., ureter; Ut., 
 uterus; B, bladder; v, vagina; R, rectum; O, oviduct 5 L V, lumbar nerve; D : interiliac 
 nerve disc. 
 
 The pelvic brain in this infant, viewed with a lens, presents the afferent nerves arriving 
 from the plexus interiliacus (P. I.), nervi sacrales, ganglia sacralia, mainly as single nerve 
 cords, at most slightly plexiform at the distal end of the plexus interiliacus. With a magni- 
 fying lens the efferent nerves of this pelvic brain (plexus , rectalis, vaginalis, vesicalis, 
 uterinus) resemble luxuriant leashes (cat o' nine tails) or richly ganglionated plexuses. 
 The pelvic brain in this subject has the following efferent leashes : (a) the plexus rectalis 
 presents some seven emissions of large nerves, coursing distalward on the rectal wall, richly 
 supplying the rectum. It has the most limited number of nerve trunks and ganglia of any 
 of the efferent leashes of the pelvic brain ; {b) plexus vaginalis presents some eight emissions 
 
ANATOMY 1 
 
 hypogastrica, and the sacral nerve branches which unite with the distal end 
 of the plexus interiliacus (to form the pelvic brain) have become elongated, 
 hence the pelvic brain is not intimately and profoundly associated with its 
 original great blood-vessels, resembling the profound connection of the 
 abdominal brain with its blood-vessels. Yet the pelvic brain is still a vas- 
 cular brain (cerebrum vasculare) associated with blood-vessels or a 
 vasomotor brain (cerebrum vasomotorius), for, by controlling the blood 
 supply of the uterus, it controls its rhythm and secretion. The ganglia of 
 the pelvic brain are interspersed with fenestra, interwoven with rich con- 
 nective tissue, intertwined with many arteries and numerous veins. The 
 pelvic brain is a ganglionated plexiform apparatus intimately associated with 
 the uterus. Distention and contraction of pelvic organs, with consequent 
 change of visceral location, alters to a relative degree the syntopic relations 
 of the pelvic brain. 
 
 IV. Idiotopy (relation of component segments). The pelvic brain 
 is practically a triangle, frequently a quadrangle in form with its apex 
 proximalward. Its base is essentially on a level with the IV sacral nerve. 
 At its proximal end and lateral border it receives (afferent) nerves in the 
 form of cords slightly plexiform. At its distal end (base) and medial border 
 it emits (efferent) nerves in the form of leashes and complicated plexuses. 
 Practically its medial border is divided by two septa; viz., (a) the septum 
 rectale and (b) septum vaginale, which divide the ventral and dorsal nerve 
 branches and leashes supplying the dorsal and ventral surfaces of the 
 respective organs. There is no segmental or other practical division of the 
 component segment of the pelvic brain ; it is a single, composite, gang- 
 lionated mass — a unit. As to function, the ganglia of the pelvic brain are 
 not differentiated in function similar to those of the ganglia of the cranial 
 brain. 
 
 Dimension. — The average dimensions of the adult pelvic brain in the 
 resting uterus are: Length (proximo-distal), three-quarters of an inch; 
 width, one-half inch, and thickness, one-sixth inch. Practically the average 
 
 of large, strong nerves for the vagina. The nerve supply to the vagina (plexus vaginalis), 
 a richly ganglionated plexus appears more luxuriant, enormous, profound, than that of the 
 uterus, because it is more on the surface, more apparent to the lens and unaided eye. The 
 ganglionated plexus vaginalis surrounds the vagina from the proximal to the distal end 
 with a mighty netwoik, which in its richness resembles the network of cords surrounding a 
 rubber ball. The proximal end and ventral vaginal wall are the most richly supplied ; (c) 
 the plexus vesicalis presents some six emissions of large strong nerves for the bladder 
 (besides a large strong nerve which arises from the II sacral and passes directly to the 
 bladder. The bladder is richly supplied by an extensive ganglionated plexus ; (d) the 
 plexus uterinus presents some twelve emissions of large nerves passing from the pelvic 
 brain to the uterus. With a lens one can count five of the trunks of the plexus uterinus 
 coursing to the uterus external to the ureter, and about seven trunks pass to the uterus 
 median to the ureter. Also one large or two small strands of nerves pass directly from the 
 plexus interiliacus (hypogastricus) to the uterus without first entering the pelvic brain. 
 
 The nerve supply (in this subject) to the uterus (plexus uterinus), a richly ganglionated 
 plexus, is luxuriant, enormous, profound. This infant's uterus and vagina demonstrate t?:at 
 they are profoundly supplied by a richly ganglionated fine nerve plexus which is intimately 
 woven on their surfaces and richly distributed through their parenchyma. The uterus, 
 like the heart, appears to possess single ganglia to rule its functions should the local ruler, 
 the pelvic brain, become incompetent 
 
134 THE ABDOMINAL AND PELVIC BRAIN 
 
 dimensions of the pelvic brain remain permanent, though the diameters 
 vary. If the major diameter decreases the minor diameter increases, and 
 vice-versa. Solid coalescence or plexiform distribution of the ganglia per- 
 haps alters inappreciably the general number of ganglion cells. The 
 thinnest or most membranous portion is its proximal segment. The thickest 
 or most ganglionic portion of the abdominal brain lies on the lateral vaginal 
 fornix. The pelvic brain (paired), next to the abdominal brain, is the largest 
 and richest ganglion of the sympathetic and combined; the two are almost 
 equal in dimension and number of ganglion cells to the abdominal brain 
 (unpaired). The longest diameter of the pelvic brain courses parallel to the 
 rectum and vagina. Proximalward its dimensions decrease, and when it 
 meets the entering efferent nerves from the hypogastric plexus it is mem- 
 branous. The largest ganglia are located in the central portion and dim- 
 inishes from center to circumference. The diameter of the nerves and 
 nerve commissures also decrease from centre to borders. Its plexiform 
 network increases in the dimensions of its fenestra from centre to circum- 
 ference. Ganglia of various dimensions and form, macroscopic and micro- 
 scopic, are located adjacent to the abdominal brain. Seldom does one meet 
 in dissection a pelvic brain of the extensive dimensions, definite contour, 
 solidarity and compactness of Frankenhauser's illustration (1867). I think 
 Lee's illustration (1841) is more natural in dimension and form. The 
 macroscopic dimensions of the pelvic brain depends, doubtless, much on the 
 dissector— deficient or excessive removal of connective tissue are frequent 
 errors. The microscope demonstrates enormous numbers of ganglion cells 
 in the pelvic brain, which, combined with periganglionic and connective 
 tissue, produces an organ of significant and marked dimension. Does the 
 pelvic brain increase in dimension during pregnancy? Whether its ganglion 
 cells increase in number, multiply, I am unable to answer. Perhaps, how- 
 ever, I have satisfied myself by careful dissection that the pelvic brain during 
 gestation macroscopically increases its dimension, whether it be from 
 hypertrophy, or hyperplasia increase in vessels, connective tissue, neuri- 
 lemma or muscle. In the gestating uterus the pelvic brain measures 1/4 
 inches in length, in width 1 inch, thickness \. 
 
 Form. — The pelvic brain is in general triangular, trowel-shaped, fre- 
 quently quadrangular in outline. It is a more or less solid, compact, com- 
 posite or compound ganglion, and not merely a nerve-meshed network. If 
 the surface dimension, contour, increases, the thickness decreases, and vice- 
 versa, presenting a widely varied form, resembling in this respect the 
 abdominal brain. With more recent repeated dissection of the pelvic brain, 
 especially on infant cadavers, I am inclined to believe the ganglionated 
 plexiform arrangement, the composite, compound ganglion within its 
 usual signification, prevails in the majority of subjects, explaining the 
 numerous irregular and individual forms. The form is modified by coales- 
 cence or separation of ganglia by the dimension of the fenestra and diameter 
 of the nerve cords and commissures. 
 
 The borders (margo cerebri pelvis). — The countour or borders of the 
 
ANATOMY 135 
 
 pelvic brain are not well denned and irregular.' They possess projecting 
 lobes for (afferent) nerve reception and serrated processes for (efferent) 
 nerve emission. The thinnest borders are the proximal and lateral, the 
 thickest are distal and medial; the vast majority of nerves arrive and depart 
 from its borders. Some arise and depart from its surface. Nerve loops may 
 arise and insert themselves in the same surface as the abdominal brain. 
 The nerves are chiefly received (afferent) on the proximal and lateral borders 
 and depart (efferent) from the median and distal borders. Practically, how- 
 ever, afferent and efferent nerves arrive and depart from both surfaces 
 and borders of the pelvic brain. For convenience, the pelvic brain 
 may be described with four borders; viz., proximal, distal, median 
 and external. The proximal (afferent) border is of interest as receiv- 
 ing the plexus interiliacus (hypogastricus). The external border is important 
 as it receives (afferent) the sacral (spinal) nerve. The median border is 
 notable for its emission (efferent) of the significant plexus utcrinus, plexus 
 vaginalis and plexus vesicalis. The distal border deserves consideration from 
 its emission (efferent) of the plexus rectalis. The afferent nerves arrive 
 generally in the form of single cords slightly plexiform or ganglionated, 
 but especially the efferent nerves depart from the borders of the pelvic brain 
 in the form of leashes or closely meshed ganglionated plexuses. 
 
 The arrangement of the pelvic brain consists of (a) afferent or centrip- 
 etal nerves (entering or contributing nerves) from the plexus interiliacus 
 (sympathicus), from the ganglia sacralia, from the sacral (spinal) nerves 
 (uterine, ovarian and round ligament arteries); (b) efferent or centrifugal 
 (distributing or visceral nerves), known as plexuses. The afferent nerves 
 enter chiefly on the proximal and external borders as single, slightly plexi- 
 form, cords, while the efferent nerves radiate mainly from the distal 
 and median border of the pelvic brain as luxuriant leashes or richly gang- 
 lionated plexuses. There is no relation between number and dimension of 
 the afferent and efferent nerves of the pelvic brain. It is a creating nerve 
 center; however, vastly greater numbers of nerves are efferent (exit) than 
 afferent (arrivals). The afferent nerves are mostly extended, slightly plexi- 
 form or ganglionated. The efferent nerves are in the form of leashes, highly 
 plexiform and rich in ganglia. Although the pelvic brain is the major 
 assembling centre for the pelvic vasomotor (sympathetic) nerves — practically 
 the source of the genital nerves — however, nerves (one or more) pass directly 
 from the plexus interiliacus (hypogastricus) to the uterus. This is demon- 
 strated with facility in infant cadavers. Hence, all the nerves supplying the 
 uterus do not first pass through the pelvic brain. The pelvic brain consists 
 of the coalesced termination of the vast majority of (a) plexus interiliacus 
 (hypogastricus); (b) nerves from the ganglia sacralia; (c) nerves from the 
 ii., iii., iv. nervi sacralia; (d) plexus arteriae uterinae; (e) plexus arteriae 
 ovaricae; (f) plexus arteriae ligamenti rotundi. The efferent nerves consist 
 of nerve plexuses and leashes emitted to each pelvic viscus. The following 
 table represents the arrangement of afferent and efferent nerves of the pelvic 
 brain. 
 
136 THE ABDOMINAL AND PELVIC BRAIN 
 
 Afferent Nerves. 
 
 1. Plexus interiliacus (hypogastricus). 
 
 2. Rami ganglionum sacralium. 
 
 3. Rami nervorum sacralium. 
 
 4. Plexus arterise ovaricae. 
 
 5. Plexus arteriae uterinae. 
 
 6. Plexus arteriae ligamenti rotundi. 
 
 Efferent Nerves. 
 
 1. Plexus uterinus. 
 
 2. Plexus ureteris. 
 
 3. Plexus vesicalis. 
 
 4. Plexus urethralis. 
 
 5. Plexus clitoridis. 
 
 6. Plexus vaginalis. 
 
 7. Plexus rectalis. 
 
 The plexuses of the pelvic brain radiate to the tractus genitalis (ovary, 
 oviduct, uterus, vagina, clitoris); to the tractus urinarius (bladder, urethra); 
 to the tractus intestinalis (rectum). The efferent ganglionated plexuses and 
 leashes of the pelvic brain, of varied caliber, ensheathe and accompany 
 arteries as the nerve emissions from the abdominal brain, but pass to the 
 pelvic viscera and weave through and around them a luxuriant, profound, 
 ganglionated, plexiform network, the major part of which is destined for the 
 tractus genitalis (uterus and vagina). The nerves emitted by the pelvic 
 brain are white in color, limited in diameter, plexiform in arrangement, 
 resist tension on account of the powerful fibrous neurilemma and are richly 
 bedecked with ganglia at the points of nerve crossing or anastomosis. The 
 arrangement of the pelvic brain produces a structure consisting of composite 
 or an aggregation of ganglia with nerve commissures or cords. 
 
 The Surface. — The surface of the pelvic brain is more smooth even than 
 that of the abdominal brain, as the ganglia and fenestra are less in dimension. 
 One may observe on its surface numerous depressions, fenestra of irregular 
 form and dimension occupied by strong connective tissue, blood and lymph 
 vessels. Some vessels centrally located may present, emerging through 
 perforation of the ganglion. The blood-vessels fix and bind it to vagina. 
 Thin strands or loops of nerves may be observed arising and inserting 
 themselves on the same surface of the pelvic brain, resembling the chordae 
 tendinae of the heart. Some smaller nerve strands arrive (afferent) and 
 depart (efferent) from the surface. 
 
 Fenestra. — The fenestra of the pelvic brain, irregular in dimension and 
 contour, depend for number and dimension on the coalescence or separation 
 of the ganglia. 
 
 The dimensions of the fenestra increase from center to periphery. The 
 fenestra are occupied by connective tissue vessels — arteries, veins and 
 lymph. Lymph glands may also be found in them. 
 
ANATOMY 137 
 
 The color is whitish-gray, brown; a liberal admixture of white conectiven 
 tissue. 
 
 The consistence is moderately dense from association of abundant con- 
 nective tissue. 
 
 PELVIC BRAIN 
 
 Fig. 40. An illustration of the pelvic brain, drawn from my own dissection. The plexus 
 interiliacus (hypogastricus) is distinct, presenting two terminations — viz. : (a) one part (P) 
 terminates in the uterus without first passing through the pelvic brain (B). The other 
 portion of the plexus interiliacus terminates in the pelvic brain (B). The source of the 
 nerves which compose the pelvic are (a) interiliac plexus; (b) the sacral plexus; (c) the 
 sacral ganglia. It may be observed that there are small ganglia on the rectum, bladder 
 and vagina and uterus. The pelvic brain rules the physiology of the tractus genitalis ; it 
 is a brain, it is a receiver, a reorganizer and an emitter of nerve force. The pelvic brain 
 includes in its dynamics the initiation, maintenance and conclusion of labor. G. S., great 
 sciatic. Pu., pudic nerve. S. G., sacral ganglia. R., rectum. V., vagina. X represents the 
 nerve which arises from the III sacral and ends in the bladder. H., interiliac disc. U., ureter. 
 C. I., common iliac artery. 16, vasa, ovarica crossing the ureter. Ov., ovary. O. D., oviduct. 
 Observe the solid ganglionic mass (A) as a pelvic brain. Note the peculiar origin from 
 the sacral nerves and the tailed division. The pelvic brain is but slightly fenestrated. 
 
THE ABDOMINAL AXD PELVIC BRAIX 
 
 The Ganglia. — The ganglia of the pelvic brain vary in location, number, 
 dimension, coalescence, separation and form. Each ganglion is composed 
 of oval or spherical-shaped ganglionic nerve cells, ensconced in abundant and 
 fine strand white connective tissue. Does the pelvic brain, the cervical 
 ganglion, exist as a constant structure in every subject? The answer is a 
 positive affirmative. However, the pelvic brain does not exist with such 
 definitely located and constantly formed ganglia as that of the abdominal 
 brain. The ganglion at the distal end of the major splanchnic nerve cannot 
 be confused in constant dimension and location. It is a constant, permanent 
 ganglionated apparatus, demonstrable in every subject. The macroscopic 
 ganglia are especially numerous adjacent to the cervix uteri. In the pelvic 
 brain the dissector does not find a single definitely located constant ganglion 
 with exact dimensions. What is found in most subjects is an apparatus 
 consisting of composite ganglia and nerve commissures and ganglionated 
 plexus of irregular form and uncertain dimension, but practically constant in 
 location. The ganglia and their commissures vary in dimension, form, 
 location and number. It is a difficult task and time-robbing process to 
 dissect and expose accurately the ganglia and commissures of the pelvic 
 brain. The pelvic brain (the pelvic nerve apparatus), like the plexus inter- 
 iliacus (hypogastricus) and ganglion interiliacum or interiliac nerve disc, has 
 become dislocated from the vascular route (arteria hypogastrica), due to 
 erect attitude and distalward movements of the tractus genitalis. A nerve 
 ganglion may consist of (a) a single ganglionated nerve cell, surrounded by 
 periganglionic connective tissue; (b) a group of ganglion cells, compound 
 or composite, surrounded by periganglionic connective tissue; (c) it may 
 consist of a plexiform ganglionic mass surrounded by periganglionic tissue. 
 Whether the nerve ganglion (apparatus) be of a single ganglionic cell, com- 
 posite ganglionic cells or a plexiform ganglionic mass matters not; its 
 function is identical in the histologic sense (viz., reception, reorganization 
 and emission of nerve force). In the composite ganglionic mass of the pelvic 
 brain the function of the ganglia are not differentiated like the composite 
 ganglia of the cranial brain. The pelvic brain is a composite ganglion. It 
 consists of central ganglia of larger dimension surrounded by numerous 
 adjacent ganglia of lesser dimension. The smaller ganglia may possess 
 single afferent and efferent nerves. The pelvic brain, an aggregation of 
 ganglia, is surrounded with periganglionic tissue only, and connective tissue 
 enters with the nerve tissue. The ganglia of the pelvic brain coalesce to a 
 central more or less solid mass and gradually decrease in dimension toward 
 the periphery, while the dimension of the fenestrated network increase and the 
 nerve commissures become elongated and more limited in diameter. 
 
 The Ganglionic Cells. — The ganglionic cells lie in oval or spherical 
 spaces of periganglionic tissue. The nerve trunk of a ganglion will divide 
 and reunite between the ganglion cells. The connective tissue, septa, divide 
 the ganglion in departments of oval or spherical form which contain units or 
 groups of ganglion cells. The cell body is generally granular and has a well- 
 defined central nucleus. The nucleus seldom is located against the cell wall 
 
A\AT< ).MV 
 
 — extra central. The dimensions of the ganglion cells vary. The number of 
 ganglion cells in the pelvic brain is enormous. 
 
 GENERAL REMARKS ON THE PELVIC BRAIN. 
 
 The relations of the pelvic brain is that it was primarily an executive 
 ganglionic nerve apparatus for the vascularity of the tractus genitalis; 
 secondarily, for the distal end of the tractus urinarius (ureter, bladder, 
 urethra) ; thirdly, for the distal end of the tractus intestinalis (rectum). 
 At present in man it is a local executive ganglionic nerve apparatus for the 
 general pelvic viscera. Cloacal differentiation has resulted in the more 
 intimate relations of the distal end of the tractus genitalis, intestinalis and 
 urinarius, with consequent solid and compact nerve anastomosis. 
 
 The relations of the pelvic brain well ensconced in connective tissue 
 are in intimate connection with the cervix uteri, lateral vaginal fornix, 
 lateral borders of rectum, distal ureter, vasa uterina, plexus sacralis spinalis, 
 plexus interiliacus (hypogastrics) bladder. The pelvic brain is located at 
 the distal end of the plexus interiliacus. It lies ensconced in the dense para- 
 metria! tissue perforated and benetted by blood-vessels and offers difficulties 
 for complete exposures by dissection. Nerves arrive (afferent) in the pelvic 
 brain as a rule at the proximal and lateral borders as simple cords chiefly and 
 depart (efferent) mainly from the distal and medial borders as leashes and plex- 
 uses. More nerves depart than are received by the ganglion cervicale; hence, 
 it is an originating, a creating center, a source of new nerve strands. The 
 pelvic brain is a constant structure. It is always a multiple or composite 
 ganglionic apparatus. It receives both spinal and sympathetic nerves. The 
 origin of the nerves contributed to the pelvic brain; the afferent are: (1) 
 plexus interiliacus (hypogastrics) ; (2) ganglia lumbalis; (3) plexus hemor- 
 rhoidals; (4) ganglia sacralia; (5) i, ii, iii, iv nervi sacralis spinales. The 
 converging nerves which coalesce to form the pelvic brain, a composite 
 ganglion, are both sympathetic (dominating) and spinal (subordinate). All 
 efferent nerves of the pelvic brain are vasomotor (sympathetic). The 
 cervical ganglion demedullates the spinal nerves, hence all exit efferent 
 nerves are sympathetic. The vast majority of the nerves enter the borders 
 of the ganglion cervicale; some enter its surface. The efferent nerves of the 
 pelvic brain compose (1) plexus uterinus, the main rich ganglionated nerve 
 supply of the uterus — the plexus interiliacus (hypogastrics) sends some 
 nerves to the uterus which do not first pass through the pelvic brain (see 
 Fig. 1) ; (2) plexus vesicalis, a rich plexiform network studded with ganglia 
 (the iii spinal sacral nerve emits a large branch which courses on the lateral 
 border of the rectum and vagina to supply the bladder; thus, the vesical 
 nerve supply is a mixed spinal and sympathetic, hence obscuring the vesical 
 peristalsis) ; (3) plexus vaginalis, supplying the vagina with an abundant, 
 mighty, woven nervous network studded with ganglia; (-4) plexus rectalis, a 
 network of nerves vastly less rich than either the plexus vesicalis or plexus 
 vaginalis with ganglionated masses at the points of nerve strand coalescence ; 
 (5) plexus clitoridis, a rich and luxuriant ganglionated plexus supplying the 
 
140 THE ABDOMINAL AND PELVIC BRAIN 
 
 clitoris with an enormous quantity of nerves. The additional discoveries of 
 increased numbers of microscopic nerve in the uterus (Jung, Koch, Kerner) 
 only further established the principle which I advocated fifteen years ago — 
 viz., that "automatic visceral ganglia exist in every organ — e.g., I advocated 
 a decade and a half past this principle and introduced the terms automatic 
 menstrual ganglia, automatic vesical ganglia, automatic renal, splenic and 
 hepatic ganglia. The composite compound ganglia of the pelvic brain are all 
 identical in function (rhythm) — unlike the differentiated function of the com- 
 posite ganglia of the cranial brain. No parts of the pelvic cellular tissue 
 remains free from traversing nerves and ganglia. It is not only the subser- 
 osium paracervicale and paravaginale immediately adjacent to the uterus 
 and vagina that is richly traversed with gangliated nerves, but also the 
 distant lateral subserous pelvic cellular tissue is abundantly supplied with 
 the same nerve apparatus, however attenuated. The central pelvic visceral 
 apparatus (tractus genitalis) ovary, uterus, oviducts and vagina, is richly and 
 luxuriantly surrounded with a ganglionate nerve plexus resembling the net- 
 work enclosing a rubber bulb. This wonderful wealth of ganglionated 
 genital sympathetic nerves I have so far been enabled to observe on infant 
 cadavers only and by the aid of a magnifying lens. Gross dissection of 
 adults baffles observation. My dissections have convinced me that the 
 pelvic brain in general subjects is not so compact a ganglion nor so pro- 
 nounced in contour as claimed by Frankenhauser in his illustration of 1867, 
 which I think is exaggerated in dimension, compactness or solidarity and in 
 its definiteness of contour or borders. The pelvic brain is difficult of prep- 
 aration because of its resemblance to adjacent connective tissue in structure 
 and color. It is whiter than the abdominal brain. To observe correct rela- 
 tions the pelvic brain must be dissected in situ. The most complete observa- 
 tions of the pelvic brain is obtained from infant cadavers preserved in alcohol, 
 in which little dissecting preparation is required and the cellular tissue is 
 transparent whence the nerves, together with their branches and ganglia, the 
 pelvic brain, are distinctly visible and extraordinarily instructive. This 
 method avoids the errors arising during gross dissection of the pelvic brain 
 in adults. The pelvic brain (ganglion cervicale) is a constant ganglionated 
 anatomic structure. It is practically complete in the infant as to form and 
 location, however; its ganglia and periganglionic tissue develops with the 
 development of the arteria uterina and genital functions (menstruation and 
 gestation). Its dimensions and form varies within wide limits. The pelvic 
 brain represents the major ganglionic assembling center of the pelvic 
 (genital) nerves. It is particularly the coalescing termination of the nerves 
 of the tractus genitalis. Investigators agree as to the pelvic brain being a 
 ganglion in animals, but opinions diverge as to whether it is a ganglion or 
 plexus in man. Remak demonstrated in the pig (1841) the presence of 
 ganglia on the nerve trunks which course to either side of the uterus. I 
 have found it a slight task to dissect and definitely expose the pelvic brain in 
 animals in which it is more distinctly an isolated single ganglion. The rela- 
 tions of the pelvic brain to the abdominal brain is subordinate in function 
 
A.\.\T()\!Y 111 
 
 and location, similar to the relations of the cerebellum to the cranial cere- 
 brum ; hence, it might be termed the cerebellum sympathicum. The pelvic 
 brain is the nerve executive apparatus of the pelvic organs — especially the 
 tractus genitalis. The pelvic brain is always a ganglionate plexus. The 
 degree of ganglionic coalescence or isolation decides its unity or multiplicity 
 — its ganglionic or plexiform state. Through the pelvic brain the nerves of 
 the distal end of the tractus urinarius, genitalis, intestinalis are solidly and 
 compactly anastomosed, connected. Hence, irritation of one of the three 
 tracts will irritate, induce reflexes in the other two (as in operation). The 
 pelvic brain is the ganglionic automatic nerve apparatus of the uterus. 
 Together with the ganglia located in the uterus it is the automatic nerve 
 center of the uterus. It is a composite ganglionic apparatus interpolated 
 between the cerebrospinal center and the myometrium — the uterus. About 
 the year 1863 microscopic ganglia were discovered in the walls of the uterus 
 and vagina by Keher, Koerner and Frankenhauser — which I termed automatic 
 visceral ganglia fifteen years ago. The ganglionic theory of an automatic 
 nerve center in the uterus, similar to that of the heart, intestine, bladder, 
 ureter, has a rational anatomic base. Experiments first demonstrated that 
 the muscle of the uterus (myometrium) was irritable — would contract and 
 relax, was rhythmic — after death. Observation demonstrated that children 
 were born, expelled, after the death of the cerebrospinal axis. In short, the 
 uterus is subject to rhythmic movements a certain length of time subsequent 
 to death or extirpation precisely similar to that of the other visceral tracts; 
 viz., tractus intestinalis (gastrium, enteron colon); tractus urinarius (ureter, 
 bladder); tractus vascularis (heart, aorta); tractus genitalis (oviduct, uterus). 
 It is well known that segments of the involuntary muscles of the visceral 
 tracts dominated by the sympathetic may persist in rhythmic movements, 
 accompanied or not by artificial stimulation. It is, doubtless, due to a local- 
 ized peripheral nerve apparatus — automatic visceral ganglia — located in the 
 parenchyma of the organs possessing a partially independent and more per- 
 sistent life than that of the cerebrospinal apparatus. The pelvic brain is the 
 ganglionic automatic nerve apparatus for the uterus, subordinate in number 
 of ganglion cells to the abdominal brain, and consequently subordinate in 
 power. There is a genital center in the lumbar cord which, being irritated, 
 induces uterine contraction. This center is of limited importance and sub- 
 ordinate to the sympathetic peripheral center. The lumbar center is not 
 absolutely necessary for conception, gestation and parturition, as these proc- 
 esses will occur when the sacral nerves which supply the uterus are severed. 
 To say that the pelvic brain is the automatic nerve center for the uterine 
 vessels simply is to beg the question, for it is the blood that stimulates the 
 myometrium (or any other organ) to contraction. The peripheral gangli- 
 onic nerve apparatus of the uterus (including the pelvic brain), macro- 
 scopic and microscopic, is the principal nerve center for its innervation. 
 The pelvic brain (paired) located bilaterally at the cervico-vaginal junction 
 is solidly and compactly anatomosed, connected, by a profoundly rich gan- 
 glionated network of nerve plexuses. The pelvic brain is the localized, sub- 
 
142 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 conscious, vegetative, sympathetic, automatic nerve apparatus for the 
 organic life of the pelvic viscera, particularly of the tractus genitalis. 
 
 The pelvic brain is located closely adjacent to the point of crossing of 
 the ureter by the pelvic floor segment of the utero-ovarian artery, hence in 
 hysterectomy the cervical ganglion is extensively traumatized and damaged. 
 
 A curious feature in regard to the pelvic brain is that, however, origin- 
 ally it was a vascular brain, located intimately with the common iliac arteries, 
 at present in man from erect attitude and distalward movements of the 
 tractus genitalis, it is practically removed from great arteries and lies 
 ensconced in a woven web of rich veins. The largest ganglia of the pelvic 
 brain lie in the center, while extending to widely adjacent distances on the 
 viscera are located smaller ganglia, separated by gradually increasing 
 fenestrated areas. 
 
 The nerve plexuses and accompanying ganglia of the pelvic brain firmly 
 bound in connective and elastic tissue richly surround the tractus genitalis 
 like a net on a rubber ball and traverse its parenchyma like a spider's web. 
 
 In the rich ganglionated plexuses issuing from the pelvic brain to the 
 tractus genitalis, i.e. the periuterine and parauterine plexuses, as well as the 
 perivaginal and paravaginal plexuses, the nerves assume an arrangement 
 similar to the arterial blood-vessels, i.e. they decrease in dimension in the 
 median plane. The entire uterus is luxuriantly surrounded and its paren- 
 chyma richly traversed by abundantly gangliated nerve networks. 
 
 The vagina from proximal to distal ends is interwoven with a fine 
 network of nerve fibers interspersed with ganglia to a remarkable degree. 
 (Best observed with a magnifying lens in infant cadavers.) 
 
 The pelvic brain receives, reorganizes and emits nerve forces and hence 
 is not a mere agent of the spinal cord. In it are repeated physiologic and 
 pathologic manifestations of general visceral functions (rhythm, absorption 
 and secretion) and special visceral function of the tractus genitalis (ovulation, 
 menstruation and gestation). 
 
 The pelvic brain is subordinate in function to the abdominal brain 
 because of less number of cells only, while it is superior in specialized 
 function (as ovulation, menstruation and gestation). The subordination of 
 the pelvic brain to the abdominal brain is evident from the fact that 
 animals and men can live well with the pelvic brain extirpated {i.e. with 
 absent genital function or genitals) while life will not continue, or at least 
 under disturbance and for short duration, with the abdominal brain extir- 
 pated. (The extirpation of the abdominal brain is practically an anatomic 
 inaccessibility during life.) 
 
 It must be admitted from anatomic facts that the abdominal brain partly 
 rules the physiology of the tractus genitalis, one (or several) strong nerves 
 from the plexus interiliacus (directly from the abdominal brain) passes 
 directly to the uterus without first passing through the pelvic brain. How- 
 ever, the plexus uterinus, the major nerve supply of the uterus — passes 
 directly from the pelvic brain to the uterus. It is a large, powerful 
 ganglionated nerve plexus and no doubt accounts chiefly for the wonderful 
 
ANATOMY 
 
 143 
 
 periodic rhythm, the stately peristalsis of the uterus. In short, the individual 
 functions of the pelvic brain are: 
 
 (1) It demedullates nerves; nerves enter it (afferent) sheathed and 
 depart (efferent) unsheathed. 
 
 (2) It is a source of new nerves; it has more efferent than afferent 
 nerves. 
 
 (3) The pelvic brain is a giant vasomotor center for the pelvic viscera 
 — especially the tractus genitalis. 
 
 (4) It shares in executing the six functions of the tractus genitalis— 
 ovulation, secretion, absorption, peristalsis, menstruation and gestation. 
 
 (5) It is the major pelvic reflex center. 
 
 FIG. 3. — PELVIC BRAIN OF ADULT. 
 
 PELVIC BRAIN OF AN ADULT 
 
 Fig. 41. Drawn from my own dissection. A., pelvic brain. In this case it is a 
 ganglionated plexus possessing a wide meshwork. Also the pelvic brain is located well 
 on the vagina, and the visceral sacral nerves (pelvic splanchnics) are markedly elongated. 
 V., vagina. B., bladder. O., oviduct. I't., uterus. Ur., ureter. R., rectum. P. L.. plexus 
 interiliacus (left). P. R.. plexus interiliacus (right). N., sacral ganglia. Ur., ureter severed 
 ro expose the pelvic brain. 5 L, last lumbar nerve. I, II, III, IV, sacral nerves. 5, coccyg- 
 eal nerve. Observe that the great vesical nerve (P) arises from a loop between the II and 
 III sacral nerves. G. S., great sciatic nerve. 
 
144 THE ABDOMINAL AND PELVIC BRAIN 
 
 (6) It possesses nutritive powers over its peripheral nerves. It presides, 
 though subordinately, over the rhythm, peristalsis, of involuntary, visceral 
 muscles of the pelvis. It controls secretion and absorption of the glands in 
 tubular viscera (pelvic). The parametrium and entire pelvic subperitoneal 
 tissue is richly traversed by nerves radiating to and from the pelvic brain. 
 An accurate and comprehensive knowledge of the anatomy of the nerve 
 supply of the tractus genitalis (especially the pelvic brain) will enable the 
 gynaecologist to interpret symptoms of disease and to form a correct diag- 
 nosis which is the basis of rational treatment. It will aid to extend so-called 
 medical gynaecology which is constructive, and limit so-called surgical 
 gynaecology frequently destructive. 
 
 A general view of the pelvic brain is that it is an intermediary agent 
 to receive and modify the spinal and sympathetic nerve forces for utilization 
 in the tractus genitalis. It is a plenary envoy, an ambassador plenipoten- 
 tiary to reconcile the spinal and sympathetic forces for appropriate use in 
 the genital tract and associated viscera. 
 
 (i>) Physiology of the Pelvic Brain. 
 
 The function of the ganglion cervicale — pelvic brain — is practically (a) 
 to rule the physiology of the tractus genitalis (uterus, oviduct, ovary, 
 vagina); (b) part of the tractus urinarius (bladder, distal ureter); (c) part 
 of the tractus intestinalis (rectum). The pelvic brain, subordinate to the 
 abdominal brain, dominates the function of the tractus genitalis, which is 
 under the command of the sympathetic. The dynamics of the pelvic brain 
 comprise the physiology of the tractus genitalis, which is: — (a) ovulation; 
 (b) secretion; (c) absorption ; (d) peristalsis; (e) menstruation; (f) gestation 
 (post-natal). It is claimed that the pelvic brain demedullates, unsheaths, 
 the spinal nerves and that all efferent or exit nerves of the ganglion cervicale 
 are sympathetic. The pelvic brain dominates the pelvic viscera as the 
 abdominal brain dominates the abdominal viscera. It assumes the dignity 
 of a brain from its power of reception, reorganization and emission of nerve 
 force. The dynamics of the pelvic brain includes the initiation, maintenance 
 and conclusion of rhythm (peristalsis, labor) in the tractus genitalis as well 
 as the domination of secretion and absorption. The pelvic brain presides 
 over the monthly explosions, monthly rhythm of menstruation, controlling or 
 modifying the automatic menstrual ganglia. The pelvic brain is a giant vaso- 
 motor center (cerebrum vasculare) for the tractus genitalis ruling the vast 
 and varying phases of circulation (congestion and anaemia during sexual life, 
 as pueritas, pubertas, menstruation, gestation, puerperium, climacterium and 
 senescence). It presides over the lymphatic circulation and nourishment of 
 the genital tract. The pelvic brain rules the manifest stately, periodic 
 rhythm of the uterus during labor. It is the rhythmic center for the tractus 
 genitalis. The pelvic brain dominates the bladder sufficiently to impose on 
 it a rhythm (diastole and systole), however, powerful spinal nerves are amply 
 present to modify the vesical rhythm. The plexus rectalis emitted from the 
 pelvic brain to the rectum to a limited degree influences the rhythm, secretion 
 
PHYSIOLOGY 115 
 
 and absorption of the rectum. Cerebrum pelvicum — the ganglion cervicale 
 —is an automatic nerve center, a brain, as it has the power of reception, 
 reorganization and emission of nerve force. 
 
 The pelvic brain is the local central potentate of visceral rule in the 
 lesser pelvis. 
 
 The initiation, maintenance and conclusion of parturition should be 
 referred to the pelvic brain. The stately rhythm and measured peristalsis of 
 the uterus in the evacuation of its contents has excited the wonder and stirred 
 the profound amazement of all observers in all time. The rhythm of the 
 uterus is its protest 'against all occupants. The gestating uterus is always 
 in a state of rhythm— the most active when most distended. The uterus 
 (corpus and fundus) is always ready for an abortion. Were it not for the 
 guarding, resting cervix, the sentinel of the uterine portals, the continuous 
 myometrial rhythm would expel all uterine contents without regard to time. 
 In the resting uterus the cervical ganglion or pelvic brain is free from 
 pressure, not subject to trauma. In the gestating uterus, since the cervix is 
 not practically involved in the enlargement, distention, the cervical ganglion 
 is free from pressure or trauma because the gestating corpus and fundus pass 
 proximalward in the abdomen in the direction of the least resistance, for 
 ample space, leaving the lesser pelvis free from compromising pressure or 
 trauma as in the resting uterus. During the last month of gestation the 
 fetus (especially the head or perhaps the pelvis) passes distalward into the 
 lesser pelvis and gradually the cervix becomes distended, obliterated from 
 pressure, allowing the fetal parts (head or pelvis) to press, traumatize, 
 mechanically irritate the pelvic brain with gradually increasing intensity, 
 which initiates labor (uterine rhythm). 
 
 Pressure or trauma of the cervical ganglion incites the vigor and fre- 
 quency of the uterine rhythm which is practically painless, however, the 
 traumatism or stretching of the spinal nerves supplying the cervix, vagina 
 and pudendum makes labor painful. Practically the vast majority of the 
 plexus uterinus or uterine nerves originate in the pelvic brain; hence, for 
 the control of uterine haemorrhage the cervical ganglion must be consulted. 
 In certain cases of postpartum haemorrhage the older obstetricians claimed 
 that by compressing the aorta the haemorrhage was checked. This, of 
 course, was an error, as its effective technical execution is practically 
 impossible. The vasa ovarica are not affected by the method. The manip- 
 ulation on the walls of the abdomen stimulated the plexus aorticus and 
 plexus hypogastricus which transmitted the stimulus to the pelvic brain 
 where it was reorganized and emitted over the plexus uterinus to the 
 myometrium — the elastic and muscular bundles of which under its control 
 act like living ligatures — checking the bleeding. Again, certain cases of 
 post-partum haemorrhage are fatal. The explanation may be that the 
 trauma of labor, especially the child's head, may have partially paralyzed the 
 pelvic brain (and interiliac plexus), whence the control of the muscular and 
 elastic bundles in the myometrium is lost — they become relaxed and fail to 
 contract the vascular lumen. In post-partum haemorrhage four procedures 
 
146 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 are indicated: — First, rapid, light stroking of the abdomen parallel to the 
 plexus aorticus and plexus interiliacus, the effect of which is to stimulate 
 both abdominal and pelvic brain. Second, seize the uterine fundus through 
 the abdominal wall and massage it, whence irritation of the myometrium 
 induces its peripheral ganglia (automatic menstrual ganglia located in the 
 myometrium and the pelvic brain located at the cervico-vaginal junction) to 
 contract the vascular walls, lessening the blood currents. Third, introduce 
 the finger into the vagina at the lateral fornix and excite the pelvic 
 brain, which will emit a stimulus over the plexus uterinus to the myometrium 
 resulting in the contraction of its elastic and muscular bundles. Fourth, 
 intra-uterine digital irritation stimulates the pelvic brain through the peri- 
 pheral ganglionated nerve plexuses which limits the vascular lumen. 
 
 The pelvic brain initiates, sustains and concludes parturition (peristalsis, 
 labor). Alexander Keilmann's theory of the introduction of labor (1881) 
 through mechanical irritation, pressure, or trauma of the pelvic brain is the 
 most rational as it is supported by anatomic and physiologic data. The 
 more mechanical irritation by the fetal pressure the greater the number of 
 ganglia of the pelvic brain are excited, traumatized; hence, with distal ward 
 movement of the child the labor is intensified in a geometrical ratio. 
 
 The more distahvard the child passes the more nerve elements are 
 traumatized. When the head of the child rests on the pelvic floor, it 
 practically presses, traumatizes or mechanically irritates all the pelvic nerve 
 elements (ganglia), hence parturient peristaltic pains are vigorous. 
 
 The finger introduced in the rectum can irritate the pelvic brain with 
 facility, which jeopardizes the patient less as regards infection. Hot 
 vaginal douches stimulate uterine peristalsis in labor. The uterus itself 
 may be considered a center with an automatic nerve apparatus (as I 
 advocated in 1^90, automatic menstrual ganglia). This idea of partial 
 automatic nerve apparatus being located in the uterus itself is heightened 
 by observation that the uterus is the most vigorously rhythmic in the begin- 
 ning and ending of gestation. Goltz claims that a genital center is located 
 in the lumbar cord, which has practically demontsrated itself as true on 
 humans from injuries to the spinal cord. Goltz severed the spinal cord at 
 the level of the tenth and eleventh dorsal vertebra on a dog and witnessed 
 normal conception and parturition, hence he concluded that a genital center 
 is located in the lumbar cord. The confusion would here lie in the influenc- 
 ing connection of the vagi with the abdominal brain. Does Goltz's genital 
 center in the lumbar cord explain the common pain in the back in disease of 
 the female genitals? Rein severed the sympathetic system and sacral nerves 
 supplying the uterus, but subsequently normal conception and paturition 
 occurred in the dog. Finally Rein claimed that he severed all the sympa- 
 thetic nerves to the uterus as well as the sacral nerves and extirpated the 
 pelvic brain (bilaterally) and still a normal parturition occurred in a dog four 
 days post operation. Hence he concluded the uterus possessed a central 
 nerve apparatus which controls its own function (especially peristalsis). 
 This experiment is defective and the consequent conclusion erroneous for 
 
PHYSIOLOGY 117 
 
 one can neither sever all the sympathetic nerves to the uterus nor extirpate 
 all the pelvic brain in the living as the ganglionated plexiform network is too 
 extensive. It is an anatomic impossibility. Besides Rein denies the 
 existence of a ganglion cervicale, placing in its stead plexus nervosus 
 fundamentalis uteri. Also Rein overlooked the extensive ganglionated 
 nerve connection — plexus ovaricus — through the ligamentum latum from the 
 ganglion ovaricum. He who has once observed with a magnifying lens the 
 wealthy labyrinth of luxuriant ganglionated nerve plexuses supplying the 
 tractus genitalis (in the infant) knows how futile it would be to attempt to 
 sever all the nerves of the uterus. Many authors (Ellinger, Rein, Dembo, 
 Cohnstein, Byron Robinson) have assumed a central nerve apparatus located 
 in the pelvic brain or in the uterus. (Similar to the automatic visceral 
 ganglia located in the tractus intestinalis, urinarius, heart, etc., etc.) The 
 extirpated uterus placed in warm normal salt solution will perform its 
 rhythm for some time similar to the extirpated oviduct, ureter, heart, 
 intestine — each has a partial independent nerve center — automatic visceral 
 ganglia. The so-called uterine inertia, or sudden cessation of uterine 
 peristalsis during a long, slow journey of the head through the pelvis may 
 be caused by a partial paralysis of the myometrium due to the temporary 
 impinging of the head on the plexus interiliacus (hypogastricus) or pelvic 
 brain. I observed once during the reduction of an invaginated puerperal 
 uterus of twenty hours' duration that immediately after reduction the 
 blood oozed abundantly from the uterine mucosa although I held my hand 
 within the uterine cavity. Gradually as I irritated the endometrium the 
 haemorrhage lessened and finally in fifteen minutes ceased. The explanation 
 was the trauma or constriction at the neck of the uterus had partially 
 paralyzed the pelvic brain and its plexuses, and it required some time to 
 recover their power over the elastic and muscular bundles of the myome- 
 trium. In slow labors accompanied by uterine inertia the pelvic brain could 
 be stimulated digitally per rectum or by rectal clysters or electricity, induc- 
 ing more frequent and vigorous contractions of the myometrium. The same 
 physiologic principle is involved in the observation that violent diarrhoea is 
 frequently followed by premature parturition or abortion. Drastic cathar- 
 tics will produce violent uterine peristalsis sufficient to cause premature 
 parturition or abortion — the pelvic brain is irritated per rectum. This 
 clinical fact demonstrated that the nerves of the tractus genitalis and 
 intestinalis are solidly and compactly anastomosed. The methods to utilize 
 the physiology of the pelvic brain in practice are varied. For example, the 
 mammary gland is connected to the pelvic brain by at least three distinct 
 routes, viz. : (1) via the nerve plexuses accompanying the arteria mammaria 
 and arteria subclavia, whence the route is direct along the aorta and its 
 plexuses to the pelvic brain ; (2) via the nerve plexuses accompanying the 
 arteriae intercostales to the aorta, whence the route is direct over the aorta 
 and its nerve plexuses to the pelvic brain; (3) via the nerve plexuses accom- 
 panying the arteria epigastrica superior and inferior to the common iliac 
 artery, whence the route continues on the plexuses accompanying the arteria 
 
148 THE ABDOMINAL AND PELVIC BRAIN 
 
 rotundi ligamenti to the plexus uterinus (and to the pelvic brain). There- 
 fore, by stimulating or irritating the nipple with light friction or massaging 
 the mammary gland (especially the nipple), the uterus can be reached by the 
 above routes and induced to contract more frequently and if the experiment 
 be not too rapidly repeated the uterine contractions become more vigorous. 
 I have experimented on this physiologic phenomenon during labor so frequent 
 with such constant results that no doubt exists as to its correctness. The 
 reverse physiology of the stimulation of the genitals influencing the mammae 
 through the sympathetic routes from the genitals to the mammas are still 
 more evident and frequent. If the tractus genitalis be stimulated by preg- 
 nancy, uterine myoma or other genital irritation, the mammary glands 
 rapidly manifest disturbance in dimension, circulation, color, sensation, 
 palpation. The sensations in the tractus genitalis have been reorganized 
 in the pelvic brain and emitted over the several nerve routes to the mammary 
 glands. Again the uterus may be incited to more vigorous and frequent 
 contraction during labor by the administration of a tablespoonful of hot 
 water which first emits the stimulation over the plexus gastricus to the 
 abdominal brain, where it is reorganized and transmitted over the plexus 
 aorticus and plexus interiliacus (hypogastricus) to the pelvic brain, whence 
 reorganization and emission over the plexus uterinus occurs with consequent 
 contraction of the myometrium. The pelvic brain must explain the 
 normal and abnormal pains of the uterus as its dominating nerve center. A 
 knowledge of the pelvic brain with its multiple radiating nerve leashes and 
 plexuses is not only valuable for the science alone of obstetrics and gynae- 
 cology, but it is important for successful practice. The independence of 
 the pelvic brain is evident when children are born, expelled, from the uterus 
 after the death of the mother. Joseph Hyrtl, the celebrated Viennese 
 anatomist, reports that during a war in Spain some bandits hanged a preg- 
 nant woman. After she had hung on the gallows for four hours, and 
 consequently was long dead, she gave birth to a living child. I have 
 observed the giant uterus of slaughtered pregnant cows executing with won- 
 drous precision its stately rhythm and measured peristalsis hours subsequent 
 to death and evacuation of the uterine contents. If one extirpate an 
 oviduct from a human patient and place it in warm normal salt solution 
 oviductal rhythm may be maintained by physical stimulus for some three- 
 quarters of an hour. Labor should be painless, as normal visceral rhythm is 
 painless. Scanzoni reports a woman paralyzed from the dorsal vertebra 
 distalward as having had a painless labor — the spinal nerve of the tractus 
 genitalis was paralyzed — hence, painless dilatation of the cervix occurred, 
 with expulsion of uterine contents. The signification of the cervical ganglion 
 in practice is evident when observed that trauma or shock on the pelvic brain 
 will kill in a few hours. For example, I performed an autopsy on the body 
 of a woman after her first child who had ventral hysteropexy performed on 
 her four years previously and in whom, immediately subsequent to labor, the 
 uterus invaginated, killing her in about two and a half hours. She died 
 from shock, which went swiftly onward and swiftly downward. The pelvic 
 
PHYSIOL* )<;V 
 
 149 
 
 brain dominates the rhythm of the corpus and fundus (uterus). That the 
 uterus is supplied by sympathetic nerves and cervix by spinal is significant in 
 practice. For example, the uterus (corpus and fundus) is always ready for 
 an abortion, because it is always in rhythm. The cervix is never ready for 
 an abortion, because it is not in rhythm, being dominated by sacral spinal 
 nerve. The pelvic brain is intimately and profoundly connected to the 
 abdominal brain by a direct nerve route of vast nerve plexuses and ganglia — 
 viz., by the plexus interiliacus (hypogastricus) and plexus aorticus. Any 
 disturbance in the pelvic brain is flashed with telegraphic rapidity to the 
 abdominal brain, and most of the consequent pathologic physiology is mani- 
 fest from the stomach by disordered rhythm (vomiting or nausea), absorption 
 and secretion. 
 
 PELVIC BRAIN 
 
 Fig. 42. Drawn from my own dissection. Woman about thirty years of age. In this 
 subject the dissection was rather deficient than excessive, hence, the pelvic brain presents 
 more of a solid ganglion than a fenestrated ganglion, or ganglionated plexus. 1 and 2, 
 pelvic ganglion. 3, rectum. 4, uterus. 5, bladder. 6 and 7, sacral ganglia. 8, last lumbar 
 nerve. 9, IV sacral nerve. In this subject the pelvic brain results from the union of the 
 plexus interiliacus (1) and branches from II, III and IV sacral nerves. 
 
 The detailed dissection was not continued sufficiently to demonstrate that the plexus 
 interiliacus emitted separate strands directly to the uterus without first entering the pelvic 
 brain. In this subject the pelvic brain was one inch in length, one-half inch in width, and 
 one-fifth inch in thickness. Such a majestic ganglion must be endowed with giant power. 
 
150 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Age Relations. — In contra-distinction to the abdominal brain, a life-long 
 functionating organ, the pelvic brain possesses age relations concomitant with 
 the age relations of the tractus genitalis. The age relations of the pelvic 
 brain, similar to those of the tractus genitalis, depend upon the volume of 
 blood irrigating it at the different phases of sexual life, as pueritas, pubertas, 
 menstruation, gestation, puerperium, climacterium, senescence. The pelvic 
 brain, present at birth, experiences multiplication of its ganglion cells, max- 
 imum completion and minimum atrophy during postnatal life. Its function 
 rises and falls with that of the genitalis. 
 
 I. Pueritas. — In childhood the pelvic brain is present; however, the 
 ganglion cells are few and small. The cell body is small, slightly granular. 
 Cell nucleus is distinct. Cell nucleolus, small and indistinct. The ganglion 
 cells grow, increase gradually with the years. At six years of age the cell 
 nucleus is marked and the nucleolus is distinct. 
 
 II. Pubertas. — At puberty the ganglion cells are completely developed 
 (simulating the arteria uterina). 
 
 III. Menstruation. — At the menstrual period the hyperaemia, congestion, 
 may aid in increasing the connective tissue cells. 
 
 IV. Gestation. — During pregnancy the profound and continuous hyper- 
 aemia, the permanent, exalted engorgement, produces an increase, a multipli- 
 cation of interganglionic cellular nerve and connective tissue, which force the 
 ganglion cells asunder. This lends to the pelvic brain an evident increase in 
 its gross dimension (not positively a multiplication cf ganglion cells). The 
 vast majority of investigators admit that the pelvic brain hypertrophies in 
 its nerve and connective tissue department during gestation (not in ganglion 
 cells). However, it is a very difficult problem to solve, as we are not 
 familiar with the number of ganglion cells present at any one epoch of sexual 
 life. Besides, inflammatory processes in the tractus genitalis modify or 
 destroy the ganglion cells. Also individual variations confuse. Connective 
 tissue develops in the pelvic brain during the active function of the genitals, 
 in maximum sexual life (menstruation and gestation). S. Pessimski, in his 
 able production (1903), asserts that the character of the plexus (pelvic brain) 
 and the dimensions of the ganglia are identically the same in gravid and non- 
 gravid subjects. 
 
 V. Puerperium. — In the devascularization of the puerperal stage cel- 
 lular elements will perhaps degenerate, atrophy, disappear. 
 
 VI. Climacterium. — In the climacteric stage the blood supply begins to 
 diminish, increasing the interganglionic cellular elements, which forces the 
 ganglion cells asunder, and the parenchyma (ganglion cells) begins its final 
 long night of atrophy and disappearance. 
 
 VII. Senescenee. — In senescence the arteria uterina loses its spirality, 
 becoming extended, its lumen becomes diminished, its walls become hyper- 
 trophied and the volume of blood supplying the pelvic brain (and genitals) 
 gradually decreases with consequent atrophy. The interganglionic connec- 
 tive and nerve tissue increases, multiplies, while the parenchyma (ganglion 
 cells) becomes atrophied, compressed to death by cicatrization and lack of 
 
PATHOLOGY 151 
 
 blood. By progressive interganglionic nerve and connective tissue multipli- 
 cation the ganglion cells are separated and compressed, gradually losing 
 their nucleolus, and later their nucleus, and finally the granulation of the 
 ganglion cell body disappears and the ganglion cells become reduced to 
 a homogeneous mass — atrophic death. They have ceased to command the 
 rhythmic uterus. The senescent decadent process of the pelvic brain is 
 identical with that of the tractus genitalis (/. e. % for the segment supplied 
 by the arteria uterina). 
 
 (O Remarks on the Pathology of the Pelvic Brain. 
 
 The pelvic brain is subject to disease similar to other abdominal viscera. 
 
 Are diseases of the pelvic brain accompanied by a range of recognizable 
 symptoms? In some 700 personal autopsic inspections of the abdominal 
 viscera I observed that in 80 per cent, of female subjects the tractus genitalis 
 presented disease — inflammation. The majority of these inflammatory 
 processes are practically peritoneal only, and would hence not materially 
 interfere with the pelvic brain in structure or function. However, there are 
 two other classes of subjects in which peritoneal inflammatory processes 
 traumatize the structure and compromise the function of the pelvic brain, 
 viz. : (a) Peritonitis, with extensive adhesions, contracting in subjects where 
 the peritoneal adhesions by contraction dislocate the viscera, compromising 
 the circulation (blood and lymph) and function while the traumatism of the 
 peritoneal contractions on the pelvic brain compromises its circulation, 
 function, structure and nourishment, (b) In subjects where the inflamma- 
 tory process penetrates to various degrees in the pelvic subserosum with 
 resulting round-cell infiltration and subsequent contraction of cellular tissue. 
 In cellulitis the cicatricial contraction is more profound on the pelvic brain, 
 with consequently more profound impression in compromising its circulation 
 (blood and lymph) and traumatizing its ganglion cells, nerve cords and 
 commissures ending in degeneration. Pelvic peritoneal adhesions and 
 pelvic cellulitis are the chief diseases which attack the integrity of structure 
 and function of the pelvic brain. The advance of malignant disease in the 
 organs adjacent to the pelvic brain is so profound in its traumatism and 
 compromisation of structure and function that practically paresis, paralysis 
 or death of its structure and function rapidly ensues. 
 
 W. A. Freund's essay on parametritis chronica atrophicans is well 
 known. Inflammation frequently attacks the pelvic brain, and the resulting 
 hypertrophy and atrophy will inevitably damage its delicate structure and 
 function. No abdominal organs present more palpable macroscopic devia- 
 tion from inflammatory consequences than the tractus genitalis. The 
 inflammations in the uterus (myometritis) and ligamentum latum, with 
 resulting hypertrophy and atrophy, are common observations. These 
 inflammatory processes are accompanied by atrophy and compromisation of 
 blood and lymph vessels. Reflexes of various kinds and degrees follow in 
 the inflamed genitals— from both acute and chronic states. Cicatrization, 
 sclerosis, contracting peritoneal adhesions in the pelvis compromise the 
 
15.2 THE ABDOMINAL AXD PELVIC BRAIX 
 
 function of the pelvic brain and traumatize its structure. The observing 
 gynaecologist notes far more reflexes, hysteria, neuroses from atrophic 
 (genitals) chronic myometritis than from hypertrophic (genitals) myo- 
 metritis. The rational explanation is that atrophic states in the uterus and 
 parauterine peritoneal and cellular tissue (consequent on inflammation) are 
 accompanied by profound compromisation of function and traumatization of 
 structure in the pelvic brain and its adjacent delicate nerve fibres. As 
 common proof one can cite the neurotic hysterical patient with atrophic 
 pelvic organs. 
 
 The pelvic brain will present anatomico-pathologic reactions from toxic 
 agents similar to other viscera-degeneration. The more rapid or intense 
 the toxic agent the more profound the reaction. The toxic infectious 
 changes in the pelvic brain may be parenchymatous and degenerative in the 
 acute forms, nodular in the less acute and sclerotic in the chronic forms. 
 The toxic infections may leave sequels in the pelvic brain as in other viscera. 
 
 Laignel Lavastine has made a study of the abdominal sympathetic, and 
 has attempted to demonstrate that some of the neuroses subsequent to 
 infectious disease, as typhoid, scarlet fever, diphtheria, etc., may be due to 
 the changes effected in the sympathetic ganglia. 
 
 Some of the numerous neuroses accompanying genital disease may have 
 an anatomic substratum in the pelvic brain. We have noted that the 
 rational explanation of the sudden cessation of labor for a time is doubtless 
 due to trauma, shock on the plexus interiliacus or pelvic brain, which has 
 become paretic by the impinging of the harder parts of the child on the 
 interiliac plexus as it journeys through the pelvis. Though the stately 
 rhythm and measured peristalsis of the uterus during labor presents a 
 wonderfully established phenomenon, yet by trauma of the child's head 
 on the pelvic brain it is quickly deranged. The gynaecologist may claim 
 that, from the frequency with which neuroses, hysteria, visceral reflexes 
 follow pelvic inflammations, with consequent sclerosis atrophy in the 
 tractus genitalis (especially myometritis and inflammations of the ligamen- 
 tum latum), the neuroses hysteria reflexes are symptoms of diseases in the 
 pelvic brain. 
 
 CONCLUSIONS AS REGARDS THE PELVIC BRAIN. 
 
 (A) Anatomy. — The pelvic brain, a constant structure, is practically 
 formed by the union of the visceral branches (pelvic splanchnics II, III and 
 IV) of the sacral plexus with the interiliac (hypogastric) plexus. It is a 
 composite or compound ganglion, paired and practically symmetrical in 
 dimension, form, position and weight. The pelvic brain is located bilat- 
 erally at the cervico-vaginal junction, where the latter is in contact with the 
 rectum. It is situated extraperitoneally in the parametrium at the base of 
 the ligamentum latum, on a level with internal os uteri well concealed in 
 connective tissue. Practically the position of the pelvic brain is at the 
 point of crossing of the ureter with the uterine artery. It is the major 
 assembling center for the pelvic sympathetic. It is surrounded and inter- 
 
:'\TII<)LOGY 
 
 153 
 
 woven with dense subperitoneal pelvic connective tissue, presenting difficul- 
 ties of exposition by dissection on account of its simulation to adjacent 
 tissue. The pelvic brain has extensive and profound connection with the 
 uterus, vagina, ureter, bladder and rectum. The composite, compound 
 ganglia of the pelvic brain are composed of multipolar ganglionic nerve cells 
 ensconced in periganglionic tissue. From erect attitude the pelvic brain has 
 
 Fig. 43. (A) Drawn from the pelvic brain of a girl seventeen years of age. The 
 ganglion cells are completely developed. (B) Drawn from the pelvic brain of a three 
 months' normal gestation. The gangl : on cells are completely developed. Observe the 
 enormous mass of connective tissue present. (C) Child l l / 2 years old. A nerve process 
 courses within the ganglion. Few and small ganglion cells incompletely developed. (D) 
 Girl l l / 2 years old. A nerve process branches and reunites itself with the intercellular sub- 
 stance. (E) Girl 6 years old. The ganglion cells are presenting development (Redrawn 
 after Dr. Sabura Hashimoto.) 
 
 changed position, moving more distalward into the lesser pelvis and 
 approaching more the median plane. The average dimensions of the adult 
 pelvic brain, with resting uterus, are: Length (proximadistal), one inch; 
 width, three-quarters of an inch; thickness, one-sixth of an inch. In the 
 gestating uterus the average dimensions of the pelvic brain are: Length, 
 
154 THE ABDOMINAL AND PELVIC BRAIN 
 
 one and one-half inches; width, one inch, and thickness, one-fifth of an inch. 
 The form is triangular, quadrangular. The borders, or contour, are irregu- 
 lar and not well defined. The arrangement of the pelvic brain consists of 
 (a) afferent or centripetal nerves (entering or contributing nerves) from the 
 plexus interiliacus (sympathetic) and plexus sacralis (spinal); (b) efferent 
 or centrifugal nerves (distributing or visceral nerves). 
 
 The afferent nerves enter the pelvic brain mainly on the proximal and 
 external borders as single, slightly plexiform cords. 
 
 The efferent nerves radiate mainly from the median and distal borders 
 as luxuriant leashes or richly ganglionated plexuses. 
 
 There is no relation in number or dimension between the afferent 
 and efferent nerves. The pelvic brain is a fenestrated ganglionic mass. Its 
 consistence is moderately dense from association of abundant periganglionic 
 tissue. The ganglia of the pelvic brain vary in dimension, location, form, 
 coalescence, separat'on. 
 
 To expose the pelvic brain by dissection the most perfectly, the cadavers 
 of infants preserved in alcohol are absolutely necessary — superior to that of 
 adults. 
 
 The pelvic brain resembles the abdominal brain in that it receives the 
 visceral nerves (pelvic splanchnics) from the II, III, IV, sacral nerves, 
 while the abdominal brain receives the visceral nerves (abdominal splanch- 
 nics) from the VII dorsal to the II lumbar (thoracico-lumbar). The pelvic 
 brain is accessible to palpation per vaginam and per rectum. 
 
 Practically, the genitals are supplied from two sources, viz. : (a) directly 
 from the plexuses of the pelvic brain; (b) from one (to several) strands 
 issuing directly from the plexus interiliacus (which does not first pass through 
 the pelvic brain). 
 
 The plexuses of the pelvic brain (uterine, ureteral, vaginal, vesical and 
 rectal) anastomose, connect, solidly and compactly, the tractus genitalis, 
 part of the tractus urinarius (ureter, bladder), part of the tractus intestinalis 
 (rectum), which induces them to act clinically as a joint organ — injury or 
 disease in any one tract produces reflex effects in the other two, and vice 
 versa. 
 
 {B) Physiology. — The function of the pelvic brain is practically to rule 
 the physiology of (a) the TRACTUS GENITALIS; (b) part of the tractus 
 uriiiarius (ureter, bladder); (c) part of the tractus intestinalis (rectum). 
 
 The physiology of the tractus genitalis is (a) ovulation ; (b) secretion ; 
 (c) absorption; (d) peristalsis (prenatal and common with functions of the 
 abdominal brain) ; (e) menstruation ; (f) gestation (special functions of the 
 pelvic brain), and (g) sensation. 
 
 The pelvic brain is a nervous center — i.e., it receives, reorganizes and 
 emits nerve forces. The pelvic brain is a local nervous executive for the 
 common functions of the pelvic viscera (peristalsis, absorption and secretion) 
 and for the special function of the tractus genitalis (ovulation, menstruation 
 and gestation.) The pelvic brain was originally in function and location a 
 vascular brain — cerebrum pelvicum vasculare. 
 
I'ATIIOLOGY 155 
 
 The dynamics of the pelvic brain include the initiation, maintenance 
 and conclusion of parturient peristalsis (labor). 
 
 The ganglion cervicale assumes the dignity of a brain from its power of 
 reception, reorganization and emission of nerve impulses. 
 
 Parturient peristalsis (labor) is initiated by the distalward movement of 
 the child and the consequent mechanical irritation, pressure, excitement on 
 the pelvic brain. The greater the distalward movement of the child in the 
 pelvis the more mechanical irritation from the fcetal head occurs on the 
 pelvic brain, and consequently the greater number of nerve elements 
 (ganglia) are excited. 
 
 The pelvic brain functionates as a unit, possessing no segmental gan- 
 glionic differentiation as in the cranial brain. It is a source of new nerves, a 
 creating center, as it possesses more efferent than afferent nerves. The 
 pelvic brain is subordinate to the abdominal brain in total number of gan- 
 glion cells — not in specific functions (as ovulation, menstruation, gestation). 
 It demedullates nerves — i.e., medullated nerves enter (afferent) sheathed and 
 depart (efferent) demedullated, unsheathed. The pelvic brain is a giant 
 vasomotor center for the pelvic viscera, especially for the tractus genitalis. 
 It shares in the execution of the six functions of the genital tract — viz., ovula- 
 tion, secretion, absorption, peristalsis, menstruation, gestation. The pelvic 
 brain is the major pelvic reflex center. It is the minor abdominal reflex 
 center, the abdominal brain being the major reflex center. It possesses 
 nutritive power over its peripheral nerves. The pelvic brain arrives at its 
 adult maximum dimensions and functionating power after a complete gesta- 
 tion. The pelvic brain is an intermediary agent to receive and modify the 
 spinal and sympathetic nerve forces for utilization in the tractus genitalis. 
 
 The pelvic brain experiences an age relation concomitant with that of 
 the tractus genitalis — i.e., with the utero-ovarian artery. The age relations 
 of the pelvic brain depend on the volume of blood irrigating it at different 
 phases of sexual life. 
 
 (a) In pueritas the ganglion cells are few and small. 
 
 (b) In pubertas the ganglion cells are completely developed. 
 
 (c) In menstruation the hyperemia, congestion, increases the connective 
 tissue. 
 
 (d) In gestation the profound and constant hyperemia, exalted engorge- 
 ment, produces a multiplication of ganglion cells and an increase of connec- 
 tive tissue. 
 
 (e) In puerperium the devascularization of the ganglionic cell elements 
 may produce degeneration, atrophy. 
 
 (f) In climacterium the blood supply decreases, the ganglionic cells 
 atrophy and the connective tissue increases. 
 
 (g) In senescence the ganglion cells atrophy and disappear, while the 
 connective tissue multiplies, increases. The pelvic brain begins its long 
 night of atrophic death. 
 
 (O Pathology. — The pelvic brain is subject to disease similar to other 
 abdominal viscera. As the tractus genitalis is frequently subject to infection 
 
156 THE ABDOMINAL AND PELVIC BRAIX 
 
 and, consequently, inflammatory processes during its maximum activity, the 
 pelvic brain, no doubt, becomes diseased and manifests symptoms. Periton- 
 itis, cellulitis and infectious processes will affect the pelvic brain and induce a 
 series of neurotic symptoms. Atrophic genitals following inflammatory 
 processes are frequently accompanied by neuroses. The most typical disease 
 is that known from W. A. Freund as 
 
 Parametritis Chronica Atrophicans.— The anatomic substratum of reflex 
 neuroses, hysteria, may be found in disease of the pelvic brain; cicatricial 
 contraction traumatizes the pelvic brain. The pelvic brain may be the agent 
 of valuable therapeutics— e.g., in post-partum haemorrhage massage of the 
 pelvic brain may be accomplished per rectum, per vaginam, manipulation 
 of the uterus or light stroking of the plexus interiliacus inducing the elastic 
 and muscular bundles of the myometrium to contract like living ligatures, 
 controlling vessel lumen. 
 
 BIBLIOGRAPHY OF THE PELVIC BRAIN (GANGLION CERVICALe). 
 
 Eustachius, B. (died 1574). Tabulae Anatomicae, Amsterdam, 1722. 
 
 de Graaf, Regner (1641-1673). Opera omnia, Amsterdam, 1705. 
 
 Willis, Thomas (1622-1675). Cerebri nervorumque descriptio, Geneva, 
 1680. 
 
 Haller, Albertus (1708-1777). Elementa physiologiae. Laus, 1778. 
 
 Vieussens, R. (1641-1716). 
 
 Walter, J. G. (1734-1818). Tabulae nerv. thoracis et abdominis. Ber- 
 olini, 1783. 
 
 Hunter, William (1718-1783). Anatomic description of the pregnant 
 uterus. 1802. 
 
 Osiander, F. B. (father) (1757-1822). Handbuch der Entbindungskunst, 
 1818. 
 
 Osiander, J. F. (son) (1787-1855). Literario a mediocrum ordine praemio 
 Commentatio-physiologica quae disserata uterum nervos habere in certamine. 
 Literario a mediocrum ordine praemiornat. Goettingen, 1808. 
 
 Bourgery. J. M. (1797-1845), 1840, and Claude Bernard (1813-1778), 1840. 
 
 Tiedemann, Friedricus (1781-1861). Tabulae nervorum uteri. Heidel- 
 berg, 1822. 
 
 Lobstein, J. G. C. F. (1777-1815). De nervi sympathici humani fabrica, 
 etc. Paribsii, 1823. 
 
 Kilian, F. (1800-1864). Die Nerven des Uterus. Zeitschrift f 
 
 rationelle Med. 1851. Burns' Handbuch der Geburtshuelfe, herausgegeben 
 von Kilian. Bonn, 1834. 
 
 Boivin. Handbuch der Geburtshuelfe, uebersetzt von Robert Kassel. 
 1829. 
 
 Lee, Robert (1798-1878). Philosophical transactions. 1842. Also the 
 anatomy of the nerves of the uterus. 1841. 
 
 Beck, Thomas Snow (1814-1847). Philosophical transactions, 1846. 
 
 Clay. Nerves of the uterus. 1845. 
 
 Swan. The physiology of the nerves of the uterus. 1846. 
 
PELVIC BRAIN OF ADULT 
 
 Fig. 44. B represents the pelvic brain. The plexus aorticus extends from the abdominal 
 brain to the aortic bifurcation or interiliac disc (H). The plexus interiliacus (hypogastri- 
 cus) extends from the interiliac disc (H) to the pelvic brain (B). It is evident that the 
 pelvic brain is the result of the coalescence of the plexus interiliacus and sacral nerves II, 
 III and IV. Note that part of the plexus interiliacus sends nerve cords directly to the 
 uterus. 16a and 16 is the arterio-ureteral crossing. The ureters were dilated. Note the 
 great vesical nerve extending from III to X. In this drawing suggestions from Franken- 
 hauser were employed. 
 
158 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Jobert de Lamballe (1779-1867 . Comptes des science de L'Academie, 
 T. XII.. Xo. 20, Mai 17. Recherches sur la disposition des nerfs de l'uterus, 
 etc. 
 
 Langenbeck's Atlas. Tafel 11 and 12. Fasc. iii. Neurologic 
 
 Louget. Anatomie und Physiologie des Xerven-System. Bonn, 1819. 
 
 Hirschfeld and Laville. Neurologie descript. et iconographie du 
 systeme nerveux. Paris, 1853. 
 
 Frankenhauser, Ferdinand (died 1894). Die Nerven de Gebaermutter. 
 Jena, 1867. 
 
 Koerner, Thomas. De nervi uteri. 1865. 
 
 Polle. Preisschrift (Thesis). Goettingen, 1875. 
 
 Koch, Robert. Ganglia of the uterus. 1^65. 
 
 Keilman, Alexander, Dorpat. Zeitschrift f. Geb. und Gyn. Bd. 22. 
 Ursache des Geburtseintritts. 1881. 
 
 Goltz. Pflueger's Arch. Bd. 9. 
 
 Rohrig. Virch. Arch. Bd. 76. 1679. 
 
 Jostreboff. These St. Petersburg, 1881. Anatomie normal et patho- 
 logique du ganglion cervicale de l'uterus. 
 
 Freund. W. H. Verh. der Xat. Vers. Strassburg, 1885. 
 
 Cohnstein. Arch. f. Gyn. Bd. 18. 1881. 
 
 Historical study of the methods of experiments to determine the nerves 
 of the uterus. 
 
 Robinson, Byron. 1894 to 1899. A series of articles on the sympathetic 
 nervous system (abdominal and pelvic brain) published in a number of 
 journals. Book on "Abdominal Brain and Automatic Visceral Ganglia," 
 published in 1^99. 
 
 Mayer. R. Virch. Arch. Bd. 85. 
 
 Franz. Centralblatt f. Gynecol., Xo. "24. 1904. 
 
 Freund, W. A. Festschrift fur Chrobak. 1903. 
 
 von Herff, Munchen. Medicin. Wochensch., Xo. 4. 1^92. 
 
 Gawronsky. Arch. f. Gyn. Bd. 47. 1^94. Nerve endings in the uterus. 
 
 Knupffer. Wegen der Ursache des Geburtseintritts. Inaugural desser- 
 tation. Dorpat, 1892. 
 
 "Waldeyer, Wm. Das Becken. Bonn, 1^99. 
 
 Pissemski, S. Monatsschrift f. Gehurtshulfe und Gynakologie, Bd. 17. 
 1903. Zur Anatomie des Plexus fundamentalis uteri beim Weibe und 
 gewissen Thieren. 
 
 Ph. Jung. Untersuchung ueber die Innervation der weiblichen Genital- 
 Organe. Monatsschrift fiir Geburtshiilfe und Gynakologie, Bd. 21. Heft I, 
 Jan.. 1905. 
 
 Hashimoto, Sabura. Beitrage zur Geburt und Gynakol. Bd. 8. Heft 
 I, 1894. (Anatomy and histology of the cervical ganglion). 
 
 Freund. W. A. Verhand. d. 76. Xat. Vers. Breslau, 1904. 
 
 
CHAPTER XIV. 
 
 GENERAL CONSIDERATIONS. 
 
 Every thoracic and abdominal organ has its own rhythm (peristalsis). 
 A little knowledge is a dangerous thing. — Lord Bacon. 
 
 The original investigations of the sympathetic nervous system, in both 
 humans and animals, upon which this work is founded, were begun in 1887, 
 and have been carried on quite steadily since. The works of Fox, Chapin, 
 Gaskell, Eulenberg and Guttmann, Patterson, Robert Lee, Lobstein, Snow- 
 Beck, Rauber and Frankenhauser have been carefully studied. A number of 
 physiologies, as well as some fifty anatomies, were searched. One hundred 
 human cadavers have been dissected with reference to the sympathetic 
 system and also among the lower animals, those of the rodents and solipeds — 
 cow, calf, pig, dog, fish, bird, frog, rabbit, rat and sheep. The dissections 
 have comprised in addition a considerable number of embryos, human and 
 animal. The results of this work demonstrate that the ganglia of the sym- 
 pathetic nerve are much larger in the lower animals than in man. That is, 
 as the scale of animal life ascends, the sympathetic system proportionately 
 decreases, while the cerebro-spinal system proportionately enlarges. In short 
 the higher the life the more dominant the cerebro-spinal system, 'and the lower 
 the life the more dominant the sympathetic system. 
 
 In mammals there exist two brains of almost equal importance to the 
 individual and also to the race: One is the cranial brain, the instrument of 
 mental progress and physical protection ; the other is the abdominal brain, 
 the instrument of nutrition and visceral rhythm. To the casual observer 
 the cranial cerebrum seems to overshadow all other nervous centers. The 
 anterior brain of mammals, situated in the skull, is so manifest to the 
 practitioner that it seems to do all the business of the nervous system. It 
 is true that the knot of life is situated at the base of the cranial brain, and 
 by one prick of a bodkin in the medulla, life may be quickly extinguished. 
 Yet a derangement of the abdominal brain destroys life as effectually, 
 though not so quickly. A study of the abdominal brain brings to light 
 views which are both important and practical. In the cranial brain resides 
 the consciousness of right and wrong. Here is the seat of all progress 
 mental or moral, and in it lies the instinct to protect life and the fear ot 
 death. But in the abdomen there exists a brain of wonderful powers. It 
 presides over organic life. Its great functions are two — nutrition and 
 visceral rhythm. In this abdominal brain are repeated all the physiological 
 and pathological manifestations of nutrition and rhythm of viscera. It 
 controls nourishment and secretion. It initiates, sustains and prohibits 
 rhythm. It receives sensations and transmits motion. It is an automatic 
 
 169 
 
100 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 nervous center. It is a physiological and anatomical brain. In short, it is 
 a nervous ganglion; only a ganglion possesses rhythmical power. 
 
 The abdominal brain is situated around the root of the celiac axis and 
 superior mesenteric artery. It lies just behind the stomach, consists of a 
 blended meshvvork of nervous ganglia, and is made up of the union of the 
 splanchnics, the two pneumogastrics and the right phrenic. 
 
 There is a difference between the right and left abdominal brain. The 
 left is more closely packed together; it is retort-shaped, chiefly consists of a 
 large, solid ganglion and is apparently an expansion of the lower end of the 
 left splanchnic nerve and is larger than the right. The right half of the 
 abdominal brain is more of a meshwork than the left ; it is perforated with 
 numerous apertures, in short, is flatter and wider than its fellow. I am 
 convinced that its flatness is due to the pressure of the inferior vena cava. 
 
 The abdominal brain really consists of two ganglia. These two ganglia 
 are sometimes called semilunar, but I never saw one of such shape. The 
 two ganglia are united by cords at the foot of the celiac axis and are known 
 as the solar or epigastric plexus. This abdominal brain lying along the 
 aorta just behind the stomach is a silent power in assimilation and rhythmical 
 movements, unless some organ is deranged. Observations of the disturbance 
 of visceral functions in women who were the subjects of pelvic disease led 
 me to follow the work. 
 
 Disease of the viscera is likely to disturb the two great functions of the 
 abdominal brain: nutrition and rhythm. The abdominal brain distributes its 
 branches to all the vascular system — artery, vein and lymphatic. The 
 branches of nerves will sometimes surround the artery like a sheath or pass 
 along its parallel strands. In short, the branches of the sympathetic nerves 
 are carried to all parts of the economy on the walls of the blood-vessels. 
 The caliber of the blood-vessels, especially the smaller ones, is controlled 
 by these fine strands of nerves. They may produce by their'action the scarlet 
 flush (capillary dilatation) of the cheek, or the marble paleness (capillary 
 contraction) of fright. Several years ago, from experiments on the pregnant 
 uterus of slaughtered cows, I became thoroughly convinced that the sympa- 
 thetic nerve is the cause of rhythm, while the cerebro-spinal nerves prohibit 
 rhythm. It is evident that the rhythmical waves in the fundus and body of 
 the uterus are entirely due to the sympathetic, which almost alone supplies 
 it. The sober stillness and non-rhythmical motion of the uterine neck is 
 due to the excessive supply of spinal nerves. The order from the cranial 
 brain for motion is active, direct and reflex, subsiding after action. But 
 the order from the abdominal brain is rhythmical, and the rhythmical 
 movements play on all vessels and hollow organs, on the circulatory appa- 
 ratus and the viscera. 
 
 The abdominal brain presides likewise over the glandular system. Here 
 it holds the balance of power between normal blood-tissues and substances to 
 be excreted. The abdominal brain controls secretion. The orders which it 
 sends out to each gland, however, must be reorganized in each separate 
 viscus, i. c, in the periphery of the nerves. The orders to the liver are 
 
GENERAL CONSIDERATIONS 161 
 
 manifest in the products of bile, glycogen and urea. The forces sent to 
 the digestive tract from the abdominal brain are obvious from the secretion of 
 the digestive fluids, from the mouth to the rectum. The sympathetic system 
 holds the glandular system as a unit, e. g., when the ovarian gland is injured 
 or removed, inflammation may arise in the parotid gland. And mumps and 
 parotitis may be accompanied by orchitis. The rhythm of glands, such as 
 the liver and spleen, is possible from their elastic capsules. The orders 
 from the abdominal brain to the digestive glands may become so violent that 
 Auerbach's plexus throws the muscle of the intestine into rigid contraction, 
 and Meissner's plexus may secrete so rapidly that an active diarrhea may 
 arise in a few minutes. It has been observed that herds of cattle on a ship 
 have been attacked with diarrhea five minutes after the boat was put in 
 motion. The abdominal brain was suddenly disturbed. The sweat-glands 
 may be irritated so violently that the entire body becomes suddenly bathed 
 in perspiration. Much execution may be done by inhibiting the sweat- 
 centers. 
 
 Excessive or deficient gland secretion, then, depends on the abdominal 
 brain and its principal machines. The gynecologist sees wonderful rhyth- 
 mical movement in the generative apparatus, and he must refe^this to the 
 orders of the abdominal brain. The oviducts and ovaries pass through 
 rhythmical circles due to nervous bulbs situated in their walls. I named and 
 wrote of these as "automatic menstrual ganglia," several years ago. The 
 ganglia of the oviduct and uterus which cause the monthly rhythm are 
 entitled to due respect, as well as the peripheral digestive and cardiac ganglia. 
 Again, there is a mechanism called the vasomotor center, which distributes 
 itself in the medulla and along the spinal cord. If the abdominal brain is 
 disturbed the vasomotor center becomes deranged and the skin will be waxy 
 pale or scarlet red. Under this category come the cold, white hands and 
 feet of women, and the flushes and flashes at the menopause. In some 
 patients I have seen the neck and face show variations of color like that in a 
 revolving electric light. The wave of redness will gradually pass over one 
 side of the face and neck, and as it slowly disappears (two to four minutes), 
 the paleness which follows is of a marble whiteness. Then the other side of 
 the face shows that its capillaries go through a slow rhythm of dilatation and 
 contraction. In ten minutes all the rhythm is over and the nervous, pale 
 face again appears. 
 
 Uterine hemorrhage from a myoma is reflex and accomplished by the 
 sympathetic system. The bleeding is due to loss of tone in the vessels of 
 the endometrium. The irritation starts in the mucous membrane of the 
 uterus and passes up to the abdominal brain, where the force is reorganized 
 and sent to the vasomotor centers of the medulla and cord. Now, a con- 
 tinuous irritation soon disarranges a center and the vasomotors sooner or 
 later lose the power to control the blood .vessels of the endometrium and 
 become deficient in tone. It may be frequently observed that in a myoma- 
 tous condition the tone of the vessels in the endometrium is restored and the 
 bleeding ceases for a time, only to be renewed on exhausting irritation. 
 
162 
 
 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 CARDIAC NERVES 
 
 Fig. 45 represents the vaso-motor nerves supplying the heart. The heart is the typical 
 organ of popular demonstration of rhythm or peristalsis in the body. It is enormously 
 supplied with nervus vaso-motorius besides by the ganglia of Bidder, Schmidt, Remak, 
 Ludwig, Wrisburg, all but one located in the cardise parietes. 
 
GENERAL CONSIDERATIONS 163 
 
 Hence, we consider hemorrhage from a myomatous uterus as reflex. It con- 
 sists in irritation followed, through reflex action, by vasomotor paralysis, 
 which harbors congestion. We note, then, that the abdominal brain presides 
 over significant organs in man. It controls the forces which hold man's 
 body intact. It has a very subtle way of enforcing chemistry to subserve its 
 ends. 
 
 A general summary of the abdominal brain is that (a) it presides over 
 nutrition; (b) it controls circulation; (c) it controls gland secretion; (d) it 
 presides over the organs of generation ; (e) it influences in a dominant, though 
 not an absolute, control its peripheral visceral automatic ganglia. 
 
 Each of the above will again be discussed. 
 
 The ideal nervous system is: (1) a ganglion cell; (2) a conducting cord; 
 (3) a periphery. The sympathetic nervous system possesses all three in an 
 eminent degree. The abdominal brain represents the central ganglion cell. 
 Its thousands of distributing and communicating fibers represent the conduct- 
 ing cord. The various ganglionic machines located in each viscus represent 
 the periphery. 
 
 In regard to the independence of the sympathetic nerve we wish to say 
 that it is not entirely independent in action, but it maybe insisted that it has 
 certain amount of independence which is very manifest in rhythmical 
 motion. The dependence and independence of the (a) cerebro-spinal axis; 
 (b) the abdominal brain and (c) the automatic visceral ganglia may be 
 illustrated by (1) the federal government; (2) the state government and (3) 
 the city or county government. 
 
 The cerebro-spinal axis typifies the federal government, and is endowed 
 with the chief rule of the animal. It is the central power and all others must 
 submit to it. It is, moreover, to a large extent, under the will as far as 
 motion is concerned. 
 
 The abdominal brain is the state government. In fact, it exercises many 
 functions almost entirely independent. The abdominal brain sends its 
 physiologic orders to all the visceral ganglia. If healthy, all obey, but dis- 
 turbing pathologic changes cause some to stop, or act irregularly. 
 
 The automatic visceral ganglia situated in each organ represent the county 
 or city government. The city, or count)', government, is free from neither 
 state nor federal government, but still it has normal independence which it 
 freely exercises. The same views may be illustrated by society and labor in 
 general where division of labor exists, and where certain sections exercise 
 almost independent rights. Thus the sympathetic nervous system may be 
 considered to be independent to a certain degree. 
 
 After a large number of dissections on man and animals I find that the 
 ganglionic system of the female is larger and more marked than that of the 
 male. Females seem to have more distinct ganglia and more marked con- 
 ducting cords. I have not investigated the peripheral nerve supply suffici- 
 ently, so far, to render any opinion. I have found the abdominal brain and 
 ganglia relatively larger in animals than in man. The abdominal brain is 
 very large in the dog, in proportion to his cranial brain. Man's cranial 
 
164 THE ABDOMINAL AND PELVIC BRAIN 
 
 brain Las grown relatively faster than his abdominal brain, and I think man 
 suffers more from malnutrition than do the animals, so that he pays dearly 
 for his superior cranial brain power. Besides, it appears that man's 
 abdominal brain (and superior cervical ganglion) is very liable to deteriorate 
 with age. Disease is very apt to arise in the above ganglia after forty years 
 of age. Perhaps no animal suffers so much from indigestion as man and so 
 far as I know he has not only the smallest abdominal brain, but it is attacked 
 the most severely with disease. The latest researches seem to show that the 
 sympathetic nervous system originates by sprouting from the ganglia on the 
 posterior roots of the spinal nerves. Some believe that the sympathetic 
 nerve originated from the adrenal. Some points relative to the sympathetic 
 nerve and the suprarenal capsules are quite obscure. 
 
 The distribution of the sympathetic nerve is peculiar. It consists of 
 three great parts: 
 
 1. There exists a double lateral chain of ganglia lying on each side of 
 the vertebral column and extending from the skull to the coccyx. The 
 ganglia correspond generally in number to the vertebras, except in the neck, 
 where the seven are blended into three. The ganglia, no doubt, represent 
 the original segmentation of the body. Now, the lateral chain of sympa- 
 thetic ganglia is connected with the cranial nerves, and with the spinal 
 nerves. It is strongly connected with the cranial nerves, and also very 
 intimately connected to each side of the vertebral columns, out of the way 
 of pressure. A notable feature in regard to the lateral chain of the sympa- 
 thetic is that it is very intimately connected with the cranial nerves, and 
 also very intimately connected with the sacral nerves. In other words, it 
 blends at the ends very closely with spinal and cranial nerves, but is less 
 intimately associated in the middle with the spinal nerves. The best way to 
 demonstrate the sympathetic system in the human is to place an embryo or 
 fetus in alcohol and then open the thoracic and abdominal cavities, when 
 the chain can be easily observed through the pleura and peritoneum. The 
 sympathetic nervous system is relatively much larger in the fetus than in 
 the adult. In a dog just killed one can see the sympathetic nerves through 
 the pleura very easily and they can be observed also through the peritoneum. 
 
 2. The second part of the sympathetic consists of four great plexuses 
 of nerves, situated anterior to the vertebras, called prevertebral plexuses. 
 One of the pharyngeal, situated around the larynx. Another is the cardiac 
 and pulmonary plexus. A third is the solar or epigastric plexus, situated 
 around the coeliac axis and superior mesenteric artery. The ganglia in the 
 solar plexus are what I am calling the abdominal brain. A fourth plexus lies 
 in the pelvis, and is distributed to the generative and urinary organs and 
 rectum. 
 
 3. The third part of the sympathetic consists of the peculiar mechanism 
 at the ends of the nerves situated in each viscus. It is termed the peripheral 
 apparatus. In a diagnostic sense the peripheral apparatus is the most 
 important to the physician, as he can often only make his diagnosis by the 
 manifestation of the disturbances of the periphery of a nerve in a viscus: 
 
GENERAL CONSIDERATIONS 165 
 
 c. g., in dyspepsia, Auerbach's and Meissner's plexus may be wrong; in 
 jaundice the automatic hepatic plexus may be wrong, and bile, glycogen and 
 urea fail in proper quantity. It is well to remember that there are three 
 more or less distinct splanchnics distributed in the viscera. 
 
 TIic- splanchnics are the inhibitory nerves of the viscera, e.g., of sensa- 
 tion, motion and vasomotor action. We note the following distribution: 
 
 1. There are the cervical splanchnics, which arise in the cord from the 
 first cervical to the fourth dorsal. These splanchnic nerves mainly reach the 
 viscera (heart, stomach, etc.) by traveling up the cervical portion of the 
 spinal accessory and then passing down the vagus (especially the right). 
 
 2. The second splanchnics arise in the cord from the second dorsal to 
 the second lumbar and pass through the rami communicantes to the three or 
 four abdominal splanchnics, whence they pass to the abdominal brain. 
 These govern the vascular area of the intestines, etc. 
 
 3. There is also a third set of these nerves, called the pelvic splanch- 
 nics. They pass from the cord by way of the second and third sacral nerves 
 and do not enter the lateral chain, but pass to the hypogastric and thus 
 supply the genitals. 
 
 From the origin of these three great splanchnics (cervical, abdominal 
 and pelvic), it is clear why irritation or a blister on the lower part of the 
 back of the neck is so effective in dispelling visceral disturbances The 
 blister inhibits the vasomotor centers and thus soon rights the vascular 
 disturbances in the viscera. 
 
 The three splanchnics control the vasomotor region of the viscera. It 
 may be considered that the sympathetic nerve is endowed with sensation and 
 motion. But the sensation is dull in the sympathetic, and its motion is 
 rhythmical. But the utility of the sympathetic in the animal economy is not 
 fully settled. The reason is, that experiments on this nerve are not per- 
 fectly decisive, and also because it is so intimately blended with the cerebro- 
 spinal nerves. But some study has convinced me that it plays a large role 
 in chronic or remote uterine disease, and that is what has called out this 
 paper. The sympathetic nerve produces involuntary movements. It is 
 called the ganglionic nerve, from the tendency to the formation of ganglia, 
 or knots along its course. In using the term, "abdominal brain," I mean to 
 convey the idea that it is endowed with the high powers and phenomena of 
 a great nervous center; that it can organize, multiply and diminish forces. 
 The views which I wish to bring forward concern the periphery of the 
 abdominal brain, or the mechanism found in each viscus. I mean by viscera 
 those organs contained in the chest and abdomen. 
 
 During the investigation of the sympathetic I selected a spare female 
 cadaver, that of a woman about thirty years of age, amputated the thighs 
 close to the body, and then placed it in full strength alcohol. For nearly 
 two years I dissected on this cadaver, as I found time, and finally, after 
 tedious labor, dissected out all the visible sympathetic nerves which lay on 
 the dorsal region, in both chest and abdomen, returning the cadaver to the 
 alcohol when not using it. I then secured a skilled artist, who worked on 
 
166 
 
 THE ABDOMIXAL AXD PELVIC BRA1X 
 
 the drawing of the sympathetic nerve about five weeks, sketching it as 
 nearly according to nature as it was possible, and exactly life size. The 
 most important portions of the nerve are represented in the cuts accompany- 
 ing this work. 
 
 Before discussing other subjects I wish to make a few remarks on three 
 exaggerated ganglia of the sympathetic nerve, viz. : the cervical, the abdomi- 
 
 ABDOMIXAL BRAIN AND CCELIAC AXIS 
 
 Fig. 46. This cut represents the vaso-motor nervo supply to : (a) liver; (b) spleen; (c) 
 stomach ; (d) kidney. 
 
 nal and the pelvic. It is easy to dissect out the cervical, and especially the 
 large upper cervical, which is about one and one-half inches long. It is 
 very variable and appears to shrink a little with age, after forty. The 
 middle cervical is often so small that it is difficult to expose. The lower 
 
GENERAL CONSIDERATIONS 167 
 
 cervical is often difficult to dissect and isolate on account of complicated 
 relations, and also because it is so widely spread out, so fenestrated and 
 because its parts vary so much. The abdominal brain is quite easy to isolate, 
 especially in a fresh cadaver. The best way to dissect and expose it well, 
 without mutilating the body badly, is to tear through the ligamentum gastro- 
 coelicum and pass to the cceliac axis. Then, with a forceps, clear away the 
 tissue just above the middle of the upper border of the pancreas, i.e., at the 
 right and left of the coeliac axis. 
 
 In searching for the abdominal brain it is best to strike for the entering 
 great splanchnic nerve and then follow it to the side of each ganglion. On 
 the left will be found a large retort-shaped solid ganglion of a pinkish gray 
 color. On the right of the cceliac axis is found a wide, flattened, much 
 fenestrated ganglion. Both are well supplied with blood The most 
 difficult great ganglion to isolate and expose in a natural condition is the 
 uterine ganglion or pelvic brain. It is very large, much fenestrated, quite 
 flattened and richly attached to the second and third sacral (spinal) nerves. 
 It is situated close to the neck of the uterus and sends numerous nerves to 
 this organ and the bladder. It requires much uninterrupted leisure to isolate 
 the pelvic brain and such efforts are almost always a failure in tat subjects. 
 The cause of this difficulty in isolating the pelvic brain lies in the fact that 
 it is whiter than the other great ganglia and more like the surrounding 
 connective tissue, with which it is intimately blended and in which it is 
 imbedded; also because it is so much flattened out. Probably more disputes 
 have arisen over the cervico-uterine ganglion than any other in the body. 
 However, the cut of the pelvic brain, here presented, the author considers 
 quite close to nature. 
 
 In each of the viscera are found small nervous ganglia scattered through 
 the organ, or the nervous bulbs are gathered in distinct localities of the 
 viscus, as in the heart or digestive tract. Now it may be understood that 
 these little ganglia found in the organs have the power to maintain move- 
 ments to some extent. These peripheral ganglia may be looked upon as 
 little brains which are capable of developing nerve force and communicating 
 it to the organs without the aid of the cerebro-spinal axis. They can multiply 
 or diminish nerve force, which is sent to a viscus where they exist. Diseases 
 of any viscus or disturbance of its rhythm must be due to them or to 
 abnormal forces passing through them, arising from the abdominal brain. 
 Again, the rhythm and function of a viscus are involuntary, i.e., beyond 
 control of the will. They are automatic nerve centers placed in the viscus 
 in order to isolate it from the control of man's mind. These little brains 
 induce the viscera to perform their functions independent of the state of 
 mind. They exclude the mind from speculating on the viscus so far as 
 regards function. The will cannot induce the ganglia to do two years' work 
 in one, or one year's work in two. The peripheral ganglia of every viscus 
 assumes its own time of rhythm. The ganglia of each viscus rise to a 
 maximum and sink to a minimum according to their own law of existence. 
 They go through a rhythmical movement, ar peculiar cycle. There are 
 
168 THE ABDOMINAL AND PELVIC BRAIN 
 
 explosions of nervous energy from the ganglia during regular periods of time. 
 For example, the heart ganglia thus explode a little oftener than once a 
 second, while those of the oviducts and uterus explode once a month. They 
 are automatic visceral ganglia. 
 
 We will consider the peripheral apparatus of the heart, lungs, uterus 
 and oviducts, liver, spleen, kidneys, bladder and digestive tract. A study of 
 the ganglia in each organ will enable one to diagnose disease in the said 
 viscus. 
 
 1. The peripheral ganglia have been well studied and some of the 
 more important ganglia of the heart substance have received definite names. 
 The little brains in the heart are called automatic cardiac ganglia. They 
 are named the automatic centers of Remak, Bidder, Ludwig and Schmidt. 
 These are simply some of the more important automatic motor centers of 
 the heart. In many experiments on dogs I have repeatedly satisfied myself 
 that the automatic cardiac ganglia are mainly aggregated in the auricles and 
 auricular-ventricular septum. Wherever the automatic motor centers are 
 located in the heart anyone can satisfy himself that these ganglia excite and 
 maintain the rhythm of the heart. The frog's heart can be kept in rhythmi- 
 cal motion by stimulation in warm salt water for hours after it has been 
 removed from the body. A few experiments on animals will soon convince 
 one that the peripheral ganglia of the sympathetic nerve located in the heart 
 are a very significant apparatus as regards the cardiac functions. The dis- 
 turbance of the heart's rhythm by uterine disease is what we shall attempt to 
 demonstrate in its appropriate place. The most striking peripheral appara- 
 tus of the sympathetic nerve is found in the heart. Its rhythm is so perfect, 
 its cycle is so apparent and its explosion so manifest, that men sought its 
 origin outside the cerebrum. The dominating influences of the automatic 
 motor-centers on the heart are shown by the idea that in the living fetus, 
 without brain or spinal cord, the heart keeps up its rhythmic beat. In such 
 fetuses the heart ganglia are well developed. One-half of the spinal cord 
 has been removed in pigeons without disturbing the cardiac beat. Besides, 
 the inferior cervical ganglion has very intimate connections with the great 
 ganglion of Wrisberg. 
 
 2. The peripheral apparatus of the sympathetic nerve is very prominent 
 in the digestive tract. The digestive tract consists of a muscular and a 
 glandular apparatus. The muscular apparatus of the digestive tract consists of 
 a longitudinal and a circular layer, and between these two muscular layers lies 
 a system of nervous ganglia known as Auerbach's plexus. Auerbach's plexus 
 is the peripheral apparatus that induces muscular movements in the gastro- 
 intestinal passage. These little brains lying between the muscular layers are 
 the cause of intestinal peristalsis or vermicular movements of the bowels. 
 Undue stimulation of Auerbach's plexus causes colic, and insufficient. stimula- 
 tion is followed by constipation — a muscular paresis. An insufficient activity 
 in Auerbach's plexus induces a kind of ileus paralyticus. 
 
 Just under the mucous membrane of the digestive tract there lies a still 
 more delicate system of nerve" ganglia called Meissner's plexus. Dr. D. D. 
 
NERAL CONSIDERATIONS 169 
 
 Bishop, late histologist to Rush Medical College, has prepared for me very 
 beautiful specimens of Auerbach's and Meissner's plexus from dogs, by the 
 gold-staining method. These plexuses preside over the production of the 
 secretions of the gastro-intestinal passage. The office of these little brains 
 is really to control glandular secretion. The} 7 induce the secretion of 
 digestive fluids. They assume the office of regulating the proper amount 
 of fluids to digest the various foods, which office requires a nice balance. 
 Hence, Auerbach's and Meissner's plexuses are the distinct and marked 
 peripheral apparatuses of the digestive tract. Now these little brains, 
 situated in the intestinal wall, have an action quite independent of the cerc- 
 bro-spinal axis. I have often chloroformed a dog and then watched the 
 intestines perform their peristalsis after being tapped with a scalpel. If the 
 dog is kept in a warm room, the intestine will go through its peristaltic 
 motion for an hour and a half after death. The peristalsis will be strong 
 and very marked. Half an hour after death, it will be so strong that the 
 circular muscles of the intestine will contract so as to look like pale white 
 cords, or bands, around the intestine. Auerbach s and Meissner's plexuses 
 are what induce rhythm in the bowel. The presence of food, of course, 
 gives the occasion for rhythm. Hence, we must look to the peripheral 
 nervous apparatus of the digestive tract when colic, indigestion, diarrhea 
 and constipation arise, for these little brains induce motion and secretion in 
 the bowel. Of course they are under the physiological and anatomical 
 orders of the abdominal brain — a higher central organism. The pathology 
 of Meissner's plexus is shown in (a) deficient secretion, (b) excessive secre- 
 tion and (c) disproportionate secretion; that of Auerbach's, in paralysis or 
 contraction (colic). 
 
 3. The peripheral nervous apparatus of the generative organs is located 
 along the oviducts and uterus. I named these fifteen years ago, "automatic 
 menstrual ganglia." These ganglia can easily be demonstrated by taking a 
 fresh oviduct from the abdomen and putting it in warm salt water. If the 
 oviduct is teased and stimulated it will go through a peristaltic motion for 
 half an hour. It is easy to observe the longitudinal muscles of the oviduct 
 elongate and contract, still easier to watch the circular muscles of the 
 oviduct contract and dilate. I have made this experiment often enough in 
 men and animals to be thoroughly satisfied of the existence of the peripheral 
 ganglia in the oviducts and uterus. 
 
 The automatic menstrual ganglia have a monthly rhythm. They rise to 
 the maximum and sink to the minimum every four weeks. The ganglia exist 
 in the uterus, and I have found the proof of this to be most easily demon- 
 strated in the pregnant uterus of slaughtered cows, where my attention was 
 first directed to the matter. Anyone can witness it in a slaughter-house. 
 When a well-advanced pregnant uterus of a cow is cut off between the body 
 and the internal os, a most wonderful rhythmic phenomenon is observed. 
 The cow may have been dead half an hour, yet the two muscular layers of 
 the uterus can be seen to act separately and vigorously. At one time the 
 circular muscles will contract vigorously, and then the longitudinal muscular 
 
iro 
 
 I ABDOMIXAL AXD PELVIC BRAIX 
 
 fibers will contract with equal vigor. Then, again, both the layers will work 
 harmoniously together. The irregular action of the muscular layer is due 
 to the irregular traumatic stimulus applied to the uterus. The rhythmical 
 motion applies only to the oviducts and uterus. The neck of the uterus 
 
 \M^M' '■ W% W 1M ' W 
 
 PELVIC BRAIN 
 genifalH. 47 " ""^ "" repreSent5 the vaso-motor nerve (sympathetic) supply to the tractus 
 
 does not go through rhythmical motion, because it is highly supplied by 
 sacral spinal nerves. The spinal nerves prohibit rhythm. 
 
 The sympathetic nerves which supply the neck do try to make rhythm 
 but the spinal nerves to the neck predominate and sober down all rhythm. 
 Hence, the predominating spinal nerve-supply holds the neck in sober," quiet 
 
GENERAL COXSIDERATIOXS 171 
 
 subjection and allows no such wavy rhythm as goes on continually in the 
 pregnant uterus. In this idea lies a great principle in gynecology. The 
 neck of the uterus acts as its guard when pregnant. The waves of its 
 rhythm may dash and sport as they choose, yet the neck stands on sober 
 guard and permits no expulsion of the contents. The neck is never prepared 
 for an abortion, but stands like an unmoved sentinel, so that no storm-waves 
 of the uterus can drive out its contents or allow foreign invasion. The 
 offices of neck and uterus are quite different. The neck has a different blood 
 supply, a different nerve supply, a different muscular supply, and a dis- 
 tinct mucous membrane. It keeps out foreigners and prevents desertion. 
 The nerve supply of the ovary is mainly from the ovarian sympathetic, but 
 as I have so far been unable to determine the rhythm of ovulation, I will 
 investigate that later. Suffice it to say that menstruation and ovulation, so 
 far as I have studied, are different processes, and hence have a different 
 rhythm. The menstrual rhythm is a matter belonging entirely to the 
 monthly movements of the oviducts and uterus. Menstruation might be 
 called oviductal motion or the rhythmic effect of the action of the automatic 
 menstrual ganglia. The menstrual rhythm is an occasional process of the 
 uterus and oviducts, but ovulation is a constant process of the ovaries, whose 
 distinct rhythm is yet to be determined. So far I have been utterly unable 
 to determine the age and duration of the life of a Graafian follicle, for I have 
 seen ovulation in unborn babes and in women of seventy. I have examined 
 pigs, cows and sheep and found that all ovulated before birth. Ovulation 
 continues from before birth until the ovarian tissue is worn out. 
 
 I assume, then, that the peripheral nerve apparatus in the organs of 
 generation is a distinct affair, which I designated fifteen years ago as the 
 "automatic menstrual ganglia." Its mechanism is such as to subserve the 
 function of reproduction through a peculiar rhythm. The monthly rhythm 
 in pregnane}' is held in abeyance on account of the direction of energy to 
 fetal nutrition. The derangement of the function of the automatic menstrual 
 ganglia will engage our attention later. Any disturbance in these ganglia 
 gives us a clue to the diagnosis of the disease. 
 
 We will term the small nerve bulbs situated in the walls of the bladder 
 the automatic vesicular ganglia. The peripheral nervous apparatus located 
 in the bladder is markedly sympathetic, and hence will, like other viscera, 
 have its rhythm. The rhythm of the bladder is its contraction and dilata- 
 tion. It has a diastole and systole. Its rhrythm is, to some extent, lost sight 
 of, because the diastole is so much longer than the systole. It requires hours 
 for the diastole to complete itself, while the systole may be completed in a 
 few minutes or less. But the rhythm of other viscera, as the heart, is not 
 dissimilar. The heart has a diastole and a systole, and the diastole of the 
 ventricle is two-tenths of a second longer than the systole. The diastolic 
 wave of the heart is the time when the heart gets its rest — physiologically 
 and anatomically. The bladder has just as much rhythm as the heart, only 
 it is not so strikingly manifested. The bladder gets an effectual rest during 
 its long diastole. By careful dissection of a goodly number of bodies it 
 
172 THE ABDOMIXAL AND PELVIC BRAIN 
 
 can be clearly seen that the third sacral nerve of each side sends quite large 
 branches to the bladder. The fourth sacral nerve also sends branches 
 to the bladder. Under such circumstances the bladder is highly sup- 
 plied with spinal sacral nerves, which would sober down the rhythm and 
 prevent it as much as possible. The sacral spinal nerves distributed to the 
 bladder go mainly to the neck, while the sympathetic mainly supply the 
 fundus — the rhythmical portion. 
 
 This rhythm is easily demonstrated by taking the bladder from an ox 
 and filling it with fluid. The contraction of its muscular wall will soon 
 change the shape and gradually expel its contents. The neck of the bladder 
 is more supplied with sacral spinal nerves than the body. In short, the 
 great nerve center of the bladder is in the trigone. Hence, in pregnancy 
 the disturbance in the bladder is due to the uterus dragging on the neck of 
 the bladder where its sensitive (spinal) nerves exist. The female bladder is 
 capable of retaining urine longer than the male bladder, as the neck of the 
 former is not so fixed and hence is not dragged on as much when filling. 
 The neck of the male bladder is fixed with the prostatic capsule, and when 
 filled drags more or less on a fixed neck and so irritates the attending nerves. 
 The peripheral ganglia of the bladder are mainly distributed to the fundus 
 and bod} r . The diastole of the bladder during sleep is prolonged on account 
 of the quietude of the sympathetic. The peripheral ganglia in the bladder, 
 the automatic vesical ganglia, have not received much study so far. 
 
 4. The peripheral nervous apparatus of the lung I have not especially 
 investigated. That the lungs have an established rhythm is plain, which no 
 doubt is maintained by the ganglia situated in their substance. The 
 peripheral ganglia should be called the automatic pulmonary ganglia. No 
 doubt there also exists a conjoined cerebro-spinal center. 
 
 5. The peripheral nervous apparatus of the liver may not at first sight 
 seem manifest. But the liver is enormously supplied by the sympathetic, 
 the nerve of rhythm. The liver is a gland, and one who has made a study of 
 the peripheral ends of the sympathetic will have noticed that where it ends in 
 muscular organs the ganglia are large and manifest. But when it ends in 
 glands it forms a fine and delicate plexus of nerves. In the liver, the 
 ganglia are less apparent than the plexus which follows the fine vessels all 
 through the liver. The caliber of these small vessels is subject to dilatation 
 and contraction — rhythm. Every visceral organ during activity is in a state 
 of vascular congestion — a condition of turgescence or enlargement. The 
 surrounding of each viscus in the abdomen is such that it can be rapidly 
 enlarged during its functional activity, and it returns to normal without loss 
 of integrity. Now, the rhythm of the liver consists of its enlargement 
 during functional activity and its return to normal during rest. The rhythm 
 of the liver is made possible by (a) the elasticity of the peritoneum which 
 surrounds it; (b) by its surrounding elastic capsule; (c) by the elastic tissue 
 in Glisson's capsule which surrounds the vessels throughout the liver, and 
 (d) by the dilatability of the blood vessels. 
 
 Hence, the liver gland is capable of enlargement and contraction — 
 
GENERAL CONSIDERATIONS 173 
 
 rhythm — from the possession of elastic tissue, and by engorgement. When 
 the liver is functionally active it becomes turgescent, or engorged, and its 
 envelopes or capsules expand from elastic properties. When the liver goes 
 through its active rhythm its vascular excitement attracts large quantities of 
 iluid, from which it makes bile, glycogen and urea; it then returns to its 
 normal condition because the elastic capsule forces the newly-formed 
 products through the tubules to be employed in digestion. The liver in its 
 quiet, reduced form gets self-repair. Thus the liver goes through its rhythm 
 of enlargement (functional activity) and of contraction (self-repair, rest). 
 The occasion of a rhythm of a liver is food in the digestive tract. It is the 
 derangement of the rhythm of the liver by uterine disease which we will call 
 attention to later. The derangement of the liver rhythm will change the 
 three great functions of the gland, which are to make bile, glycogen and 
 urea. The derangement is brought about by disturbing the equilibrium of 
 the abdominal brain. We will term the peripheral nerve apparatus in the 
 liver the automatic hepatic ganglia. The derangement of these is manifested 
 by (a) a deficient secretion (bile, glycogen and urea) ; (b) excessive secretion, 
 and (c) by disproportionate secretion, especially the last. 
 
 6. The spleen has a peripheral nervous apparatus which enables it to do 
 its duty ic a rhythmic wave. In the case of the spleen the elastic capsule, 
 to which is added involuntary muscular fibers, enables the organ to enlarge 
 during functional activity and then to be reduced by elastic pressure to its 
 normal size. Engorgement and elasticity are the two elements which aid to 
 complete the rhythm of the spleen. 
 
 Vascular excitement, with dilatations and turgescence, characterizes the 
 functional activity and enlargement of the spleen. Its capsule expands. 
 Contraction of the elastic capsule and muscle fiber in it characterizes the 
 reduction of the spleen. Its rhythm is made up of its active enlargement 
 and its passive reduction. In the maximum stage of the rhythm, the spleen 
 performs its functions, and in the minimum stage it gets its rest and self- 
 repair. A curious feature is added to the spleen in the form of a tortuous 
 artery. The object of this spiral artery must be to withstand sudden motion or 
 enlargement, for when the spleen is large the artery is just as spiral as it is 
 in the enlarged uterus. But it may be that the tortuous artery allows a 
 greater flow of blood. Hence, the spleen performs its rhythm from the 
 peripheral nervous apparatus situated in its substance. The occasion of its 
 rhythm must be the same as that of the stomach and liver — fresh food. We 
 will term this nervous apparatus the automatic splenic ganglia. 
 
 7. The same reasoning applies to the rhythmic functions of the pancreas 
 and kidney, and also, probably, to the ovary. They come under the law of 
 vascular engorgement and elastic capsule, which enable the automatic periph- 
 eral ganglia to produce and sustain a rhythm. We thus have the auto- 
 matic renal, and also the automatic pancreatic, ganglia. 
 
 (1) We have tried to establish the view that the abdominal brain is the 
 great nerve center of the abdominal viscera and perhaps of the thoracic 
 viscera ; (2) that it is the cause of visceral rhythm ; (3) that each viscus has 
 
174 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 its own automatic peripheral ganglia or plexuses in the organ; (4) that the 
 duration of the rhythm of each viscus is determined by the mechanism of 
 the automatic ganglia situated in the organ. 
 
 The rock and base view maintained in this book is, that the abdominal 
 
 DUCTUS BILIS AND DUCTUS PANCREATICUS 
 
 Fig. 48. This cut represents an X-ray of the ducts of the liver and pancreas. Each 
 duct is ensheathed by an anastomosed, nodular, 'fenestrated meshwork of nerves which 
 demonstrates the enormous nerve supply. This is in addition to the nerve supply en- 
 sheathing the arteria hepatica. 
 
 brain is a reorganizing nerve center— a brain, a cerebrum. The abdominal 
 brain is capable of reception, reorganization and emission of nerve forces 
 involving the life of viscera (which consists of rhythm, absorption and 
 secretion). The emission of nerve forces will travel as a maximum to organs 
 possessing the greatest number of nerve strands, e.g., the genitals, kidney. 
 
GENERAL CONSIDERATIONS 175 
 
 heart and stomach, and as a minimum to organs possessing the least number 
 of nerve strands. 
 
 Having planted our orchard we will examine its fruits. We now come 
 to the application of these views to the subject of disease. Disease of any 
 of the viscera will very often be preceded by some derangement of their 
 rhythm, absorption or secretion. The common functions of viscera are 
 peristalsis (rhythm), absorption and secretion — all dominated by the 
 sympathetic nerve, i.e., the abdominal brain. To the common functions of 
 viscera (peristalsis, absorption and secretion) must be added, in the genital 
 tract, ovulation, gestation and menstruation. 
 
 The two great factors in visceral diseases, so far as regards the sympa- 
 thetic nerve, are (1) impaired nutrition, and (2) reflex action, referred pain 
 or disturbance. An important central point around which much of the 
 abdominal sympathetic turns is the female generative organs. They are 
 the one cog in the wheel which makes the watch keep defective time. 
 
 The pathology of the sympathic nerve is not so distinctly settled as that 
 of the cerebro-spinal. (1) The most significant pathology' of the sympa- 
 thetic is reflex irritation, referred disturbance. (2) Pigmentation and 
 sclerosis. The origin of the pigmentation is primarily in the spleen and 
 liver. Pregnancies, menstruation (periodic congestion), fever (malarial), 
 etc., etc., are accompanied by pigmentation. This may be due to a diseased 
 state of the blood. It is more frequently due to reflex irritation from the 
 distant organs. Some consider violent emotion as a cause of pigmentation, 
 but it is likely that it refers to some unrecognized lesion. (3) The third 
 kind of pathology of the sympathetic would be lesions secondary to those of 
 the cerebro-spinal system. (4) The fourth would be recognized and non- 
 recognized lesions of the sympathetic. I have not space here to discuss 
 these interesting and wide pathological fields, but simply mention them. 
 
 Disturbances in the Digestive Tract from Uterine Changes. — In this 
 case we have immediate and remote troubles as regards time. The chronic 
 uterine disease will produce remote malnutrition and remote reflex changes. 
 In these cases I mean diseases of the entire, or part of the generative appara- 
 tus — Pudenda, vagina, especially the uterus, oviducts and ovaries. Take, 
 for example, a case where the digestive tract is deranged on account of 
 pregnancy. In the first place the vomiting arises from trauma, stretching 
 on the uterine nerves by an expanding foreign body (contents) and the 
 dragging of the neck of the uterus on the neck of the bladder. This dragging 
 or pressure on the neck of the bladder disturbs the spinal and sympathetic 
 nerves massed there. The irritation is carried up the hypogastric plexus to 
 the abdominal brain. When the irritation arrives at the abdominal brain 
 the forces are reorganized and sent out on the various nerve plexuses which 
 radiate from this nerve center. If the force is emitted along the gastric 
 plexus, which is liable to happen on account of its large size, the stomach 
 receiving sympathetic nerves from the three branches of the celiac axis, the 
 stomach will suffer and vomiting is likely to occur. Now, in the troubles of 
 the stomach resulting from reflex disturbances from the uterus by way of the 
 
176 THE ABDOMINAL AND PELVIC BRAIN 
 
 hypogastric plexus, it may be considered that the stomach is affected in two 
 distinct parts; (a) its muscular wall (Auerbach's plexus), (b) its glandular or 
 secretory apparatus (Meissner's plexus). When the irritation from the 
 generative organs travels up the hypogastric and ovarian plexuses 'to the 
 abdominal brain it is then reorganized and emitted along the gastric plexus to 
 the automatic gastric ganglia, known as Auerbach's plexus. It affects 
 Auerbach's plexus first because it first meets it in the muscles. The result of 
 irritation of Auerbach's plexus is irregular action of the muscles of the 
 stomach — nausea or vomiting. When the irritation goes farther along the 
 gastric plexus it meets Meissner's plexus, which lies just beneath the mucous 
 membrane, and controls gastric secretion. If Meissner's plexus is consider- 
 ably irritated it may cause excessive or deficient secretion of the fluids, or the 
 fluids may be secreted in disproportionate quantities. The result will be indi- 
 gestion and fermentation, causing the development of gases. 
 
 The reflex irritation from the uterus may be of such a nature that 
 Auerbach's plexus may be insufficiently stimulated, causing paresis of stomach 
 wall, or that Meissner's plexus is so little stimulated that it will not secrete 
 sufficient gastric fluids. But the track of the nervous irritation is definite from 
 the generative organs, through the hypogastric plexus, to the abdominal brain, 
 where it is reorganized and emitted to the various viscera. This is the inter- 
 pretation of the old story that uterine disease creates stomach trouble, and 
 vice versa. By reference to a cut showing the pelvic brain, or cervico-uterine 
 ganglion, one can see at once the extensive nerve supply which attends the 
 uterus. It may be observed in cases of violent vomiting that digestion and 
 nourishment are quite good. The reason must be that Auerbach's plexus is 
 the main one affected (muscular), while Meissner's (glandular), the one which 
 really digests the food, is not much affected. In the case of chronic uterine 
 disease the whole subject is plain and practical. Such patients have malnu- 
 trition for several years. In short, it is noticeable that a woman will apply 
 for treatment of uterine disease some four years after the cervix has been 
 lacerated. The illness was increasing all the time, the last part being more 
 apparent. In stomach troubles from chronic disease of the generative 
 organs, it appears that Meissner's plexus is affected the most, as such patients 
 seldom vomit ; but they do not digest their food, which is performed by the 
 gastric fluid secreted by the influence of Meissner's plexus on the cardiac 
 and pyloric glands. 
 
 But I wish rather to note the effect of chronic disease of the generative 
 organs on the enteron intestines, which is the location of real digestion. The 
 business part of the digestive tract is the enteron, the small intestines — the 
 jejunum and ileum. The enteron is supplied by the superior mesenteric 
 artery, and along this artery goes the great superior mesenteric plexus of 
 nerves. What we will observe is the mechanism at the end of this superior 
 mesenteric nerve, viz., Auerbach's plexus. This produces bowel peristalsis, 
 rhythm. 
 
 Take, for instance, a case of chronic endometritis, salpingitis or ovaritis 
 of several years' duration. Disease of the female organs is a slow, continuous, 
 
GENERAL COXSIDERATIOXS 177 
 
 progressive process. It is a kind of evolutionary process and generally should 
 be read endometritis, plus myometritis, plus endosalpingitis, plus ovaritis, 
 plus as much peritonitis as the infection produces at the ends of the 
 oviducts. Because of this slow, evolutionary progress of female disease the 
 effect through this sympathetic nerve is of slow progress and gradual. The 
 irritation from the generative organs will travel to the abdominal brain by 
 way of the ovarian and hypogastric plexuses. It is a common observation 
 that gases may" develop in a few minutes so that fermentation is not the 
 explanation of their origin. Some attempt to explain the origin of this 
 intestinal gas by noting that it collects because the bowel muscle has lost its 
 power to contract; but the gas develops too suddenly for this theory to fit. 
 If the irritation from the uterine disease causes Meissner's plexus to secrete 
 deficient fluids, indigestion and constipation arise. So reflex irritation from 
 the generative organs, by way of the abdominal brain to the small intestine or 
 enteron can act in two ways: (1) It may so stimulate Auerbach's plexus in the 
 intestinal wall as to produce colic, and (2) so stimulate Meissner's plexus as to 
 induce excessive secretion, deficient secretion or disproportionate secretion. 
 The result here will be development of gases and diarrhea. 
 
 The abnormal stimulation of Auerbach's and Meissner's plexuses may 
 result in deficient bowel peristalsis and secretion which ends in constipation. 
 The final result of these is indigestion or malnutrition. Hence, chronic 
 uterine disease creates its disasters on the system really by malnutrition. It 
 disturbs the normal visceral rhythm. Malnutrition is manifest in pregnancy, 
 in perceptible disease of the generative organs, and at the menopause. The 
 explanation lies in the abnormal irritation of the nerves in the generative 
 organs, which is reflected through the abdominal brain to the digestive 
 tract. I have never heard or read of the method herein used to explain the 
 action of the abdominal brain on the digestive tract, but I think it is a 
 practical explanation. These views explain why animals or man lose control 
 of the bowels under fright. The violent forces emitted from the abdominal 
 brain induce excessive activity of Auerbach's plexus (colic) and Meissner's 
 plexus (secretion) and a sudden diarrhea results in the animal. In other 
 words, under high emotional influences the animal's rectal sphincters are 
 unable to resist the violent bowel peristalsis. Peristalsis is stronger than the 
 orificial sphincters. Involuntary defecation is common among children and 
 animals from fright. In older animals the cranial brain assumes more influ- 
 ence over the abdominal brain, i. e., it sobers down its violent and irregular 
 rhythm. Chronic disease of the generative organs creates malnutrition in 
 the digestive tract by disturbing its normal functional rhythm and by reflect- 
 ing irregular rhythms into the digestive tract during its times of rest and 
 repose. It does not matter what the disease of the generative organs is, so 
 that irritation arises and is reflected to the abdominal brain. Inflammation, 
 tumors or the local manifestations of the menopause, will act similarly, 
 according to the degree of irritation. The subject may be considered in the 
 following short summary: 
 
 The reflex irritation of the abdominal brain will cause Meissner's plexus 
 
178 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 to secrete (a) too much secretion (diarrhea), (b) too litte secretion (constipa- 
 tion) or (c) disproportionate secretion (fermentation). The same thing will 
 occur in any secondary organ, i. e., too much, too little or disproportionate 
 secretion. Now, I will point out a matter which long puzzled me, viz., a 
 woman who has a lacerated cervix will go through various pathological stages 
 for some five years and end as a confirmed neurotic. I have observed it for 
 years, and the order of occurrences is as follows: 
 
 1. The first stage is irritation. The irritation does not arise so much 
 from the lacerated cervix as from the endometrium (infection atrium). The 
 irritation keeps up for years, endometritis, myometritis, endosalpingitis. 
 
 2. The second stage is indigestion. The long-continued irritation 
 arising from the genitals and passing up to the abdominal brain, and being 
 
 CORROSION ANATOMY OF THE KIDNEY 
 
 Fig. 49. This cut represents the rich renal arterial supply. Each arterial branch is 
 ensheathed by an anastomosed, nodular meshwork of nerves which indicates the quantity of 
 vaso-motor nerves attending the renal organ and its duct (ureter). 
 
 there recognized and sent out on the plexuses of Meissner and Auerbach of 
 the digestive tract, soon causes too much secretion, too little secretion or 
 disproportionate secretion, which results in indigestion. 
 
 3. The third stage is malnutrition. Long-continued indigestion simply 
 results in malnutrition. The reflex irritation goes on continually. 
 
 4. The fourth stage is anemia, resulting from the indigestion and 
 malnutrition. 
 
 5. The fifth and last stage is neurosis, which is due to the nervous 
 system having been bathed in waste-laden blood for years, neurosis, psychosis. 
 
 Hence, a patient with laceration of the cervix passes through five stages: 
 
GENERAL CONSIDERATIONS 17<j 
 
 (1) irritation (infection); (2) indigestion; (3) malnutrition; (4) anemia; (5) 
 neurosis, psychosis. 
 
 We will now consider the liver as disturbed by disease of the generative 
 organs, whether it be acute or chronic. We noted that the liver was highly 
 supplied with sympathetic nerves; that it had a peripheral plexus in its sub- 
 stance. This we will style the automatic hepatic plexus. We noticed that 
 the liver was induced to perform a rhythm by its automatic plexus, and that 
 its rhythm was made possible by the elasticity of its capsules, the tissue 
 which governs its expansion and contraction (rhythm) being elastic and 
 contractile. Rhythm of the liver is made up of two distinct stages, a time 
 of activity (parenchymal secretion) and a time of repose. Its stage of func- 
 tional activity is when its capsules are expanding under the vascular excite- 
 ment of turgescence, the products of cell-work, bile, glycogen and urea being 
 secreted. Its stage of repose and self-repair is when its capsules are 
 contracting, and the blood-vessels are being depleted, the contracting capsule 
 having partly forced the cell products (bile, glycogen and urea) into other 
 regions and organs to accomplish their final object. By means of this rhythm 
 the liver secures a stage of activity and a stage of rest. 
 
 It is plain why the liver suffers so badly among liquor drfnkers. The 
 drinker has no regard for the time of rest of his liver, so he takes his 
 stimulant especially at times when the liver is at rest. The irritating fluids 
 pass by way of the gastric portal veins into the quiet, resting liver and of 
 course excite it to go through a rhythm at any time. Thus the drinker 
 deprives his liver of the needed rest. The rhythm of the liver is irregularly 
 disturbed and that calls up disease. It is precisely the same in diseases of 
 the generative organs. Irritation starts from a diseased pelvis and travels 
 up the ovarian and hypogastric plexuses to the abdominal brain. Hence, 
 the irritation is reorganized in the abdominal brain and emitted along the 
 hepatic plexus. The automatic hepatic plexus is unduly and irregularly stim- 
 ulated at times of activity and rest. The result is that the rhythmical func- 
 tion of the liver is deranged. The nice balance of its formation of bile, 
 glycogen and urea is destroyed. 
 
 The diseased pelvic organs have no respect for liver rest and they send 
 their uncertain reflexes to the liver at unseemly times. Chronic disease of 
 the pelvic organs will excite impulses which travel to the abdominal brain, 
 which resends them to the liver at such uncertain times that the liver never 
 performs its activity or rest, without more or less attempt to induce irregular 
 rhythms. The final result is that the rhythm of the liver is disturbed and that 
 the cell-products of the liver are formed irregularly. Bile, glycogen and urea 
 are formed excessively, deficiently or disproportionately, and it ends in 
 malnutrition. The skin is yellow and^ sallow, the urinary products are 
 abnormal. Diseases of the liver are manifest during pregnancy in demonstra- 
 ble pelvic diseases, and especially is this true at the menopause. The 
 anatomical nerve track followed by irritation from the generative organs to 
 the abdominal brain, and thence to the liver, is plain, and the physiological 
 results show the theory to be reasonable. Right here we may say that liver 
 
180 THE ABDOMINAL AND PELVIC BRAIN 
 
 disease and disease of the digestive tract are quite common at the menopause. 
 The explanation of this is not difficult. During the thirty years of seedtime 
 and harvest of woman the abdominal brain emits its physiological orders to 
 the automatic menstrual ganglia, situated in the uterus and oviducts, to per- 
 form their rhythm of menstruation. Thirty years of rhythm in any organ will 
 surely form a habit which it will require force to break. When the menopause 
 arrives, which occurs suddenly, the old beaten paths of the hypogastric 
 plexus, along which the menstrual orders for thirty years had been sent, 
 are suddenly cut off. This sudden cutting off of old channels, by which 
 forces were formerly emitted, is bound to make the latter accumulate in the 
 central organ or abdominal brain. Now, these accumulated, unused energies 
 must have some outlet and they will go in the direction of least resistance. 
 The great channels of easy outlet of pent-up forces in the abdominal brain 
 appear to be the gastric and superior mesenteiic plexuses, which supply the 
 digestive tract, and the hepatic plexus. Hence, in the menopause the 
 accumulated force in the abdominal brain is mainly spent on the digestive 
 tract and liver. The accumulated energies go to these in an irregular manner 
 and thus aid in disturbing their rhythm. The result is abnormal products in 
 the liver (bile, glycogen and urea), and for the digestive tract, indigestion 
 (constipation or diarrhea). 
 
 The Jieart of woman docs not escape the influence of the chief wheel of her 
 existence. It has very manifest peripheral sympathetic ganglia and is largely 
 under the control of the sympathetic nerve, as may be seen from its nice 
 rhythm. Now, from each of the three cervical sympathetic ganglia on each 
 side of the neck there goes a nerve to the heart (the heart also receives three 
 nerves on each side from the pneumogastrics). When the pelvis contains 
 diseased generative organs, the irritation arising there travels up the ovarian 
 and hypogastric nerves to the abdominal brain. 
 
 From the abdominal brain two roads lead to the heart. One road is 
 through the great splanchnics to the cervical ganglia, and as these ganglia 
 act as little brains, the force is here reorganized and sent directly to the 
 heart. Of course all irritation comes irregularly and so aids in disturbing 
 the heart's rhythm. But spinal or cranial nerves prohibit rhythm, so I think 
 the main forces from the abdominal brain travel up the pneumogastrics to 
 the fourth ventricle) and the irritation is then reflected directly to the heart. 
 Irritation, especially that coming along a cranial nerve, quickly affects the 
 rhythm in any viscus. In like manner irritation from diseased generative 
 organs may reach the heart by first going to the abdominal brain and then 
 through the splanchnics to the pneumogastrics and to the heart. 
 
 The result is that the heart is disturbed in its rhythm. It palpitates, it 
 beats irregularly. Who has not seen this in female diseases? I think 
 palpitation is most manifest at the menopause. In pregnancy the heart 
 prepares for the emergency by thickening its walls and is generally no worse 
 for undergoing the extra work incident to gestation. But let the heart meet a 
 myoma, which is continually emitting irregular reflections to it, and disturb- 
 ing its rhythm, and sooner or later it is weakened and degenerated. The heart 
 
GENERAL CONSIDERATIONS 1,1 
 
 rests and repairs itself duing part of the rhythm, but irregular reflections 
 from pelvic diseases do not allow it sufficient rest. Fatty degeneration or 
 malnutrition results'. 
 
 The heart palpitates at the menopause because the accumulated ener- 
 gies of the abdominal brain find an easy outlet through the splanchnics and 
 pneumogastrics. The menopause often requires several years for its com- 
 pletion, so the abdominal brain can get accustomed to controlling and distrib- 
 uting the accumulated energies which were once expended in the menstrual 
 rhythm. The trouble is that its accumulated but irregular energies are apt 
 to dash pell mell over some single plexus to some single viscus and then dis- 
 aster is sure to follow from inability to resist. If the accumulated energies 
 were evenly distributed, but little visceral rhythm would be disturbed. 
 
 I know of no organ so manifestly affected in the menopause as the heart; 
 perhaps for the very reason that the sympathetic nerves chiefly accompany 
 the blood-vessels. Hence, when some portion of the sympathetic system is 
 disturbed, it is apt to affect the nearest structures, which are those of the vas- 
 cular apparatus, the chief portion of which is the heart. 
 
 The same kind of reasoning is applicable to the spleen. Diseased gener- 
 ative organs reflect their irritation to the abdominal brain and then to the 
 spleen. Irritation always proceeds irregularly, and so it would disturb the 
 rhythm of the spleen, and thus create malnutrition. The spleen goes 
 through a rhythm just as do other viscera. The spleen is no doubt the chief 
 organ concerned in pigmentation. Jastrowitz, of Russia, first taught that 
 the spleen was concerned in deposit of pigment ; for he found that by severing 
 the nerves which pass to the spleen on its vessels, in dogs, irregular pigmen- 
 tation followed. Every gynecologist knows that pigmentation of the skin 
 is common at the menopause, in pregnancy and at puberty, i. e., when the 
 sympathetic nerves are more or less disturbed. Of course little doubt 
 exists that the liver has something to do with the deposit of pigment, as may 
 be noted in malaria, which exercises its brunt on the liver. Hence, the dis- 
 turbed rhythm of the spleen in uterine disturbances manifests itself by pig- 
 mentary deposit. 
 
 In disease of the uterus it is quite easy to note that the rhythm of the 
 bladder is disturbed. It is not because the fundus of the uterus rests on the 
 fundus of the bladder, but because the automatic vesical plexus is irritated. 
 The neck is dragged or pressed and the nervous mechanism suffers. 
 
 Similar explanations might be made relative to the lungs, kidneys, 
 pancreas and ovaries ; but I think sufficient has been said to show that each 
 viscus has its automatic peripheral ganglia, that each viscus executes a 
 rhythm, and that the diseased generative organs may disturb the rhythm of 
 any viscus by reflex irritation through the abdominal brain. 
 
 The peripheral nerve supply to the genitals is vast, and no organ can 
 raise such nerve storms as the generative. They are intimately and intensely 
 connected with all nerve centers, but especially those of the sympathetic. 
 How often does one see strong men faint from the simple introduction of 
 the sound into the urethra? The vast peripheral nervous apparatus ending 
 
Fig. 50. This cut represents an X-ray of the ductus 
 pancreaticus with part of the ductus bilis. Four 
 hepatic calculi are at B, one at C, one at D. Each 
 branch of the ducts are ensheathed by an anas- 
 tomosed, fenestrated meshwork of vaso-motor 
 nerves which allows an estimate of the amount of 
 vaso-motor nerves supplying the pancreas. 
 
 Fig. 50. DUCTUS PANCREATICUS WITH PART OF THE DUCTUS BILIS 
 
GENERAL CONSIDERATIONS 183 
 
 in the urethra is disturbed, and this nerve storm which sweeps up the hypo- 
 gastric plexus spends sufficient power on the heart alone to cause faintness. 
 Of course it spends a relatively large amount on every other viscus. Note 
 how pale the man becomes. The storm dwells with equal force on the whole 
 skin surface. Of all viscera the genitals are most intimately and closely 
 connected with the nerve centers, both anatomic and physiologic, for the 
 sexual instinct predominates in all races of mammals. From the very 
 physiologic and anatomic nature of the reproductive organs they demand a 
 close and intimate nervous connection with the great centers, and hence no 
 storms affect adjacent and distant viceras like those arising in the extensive 
 genital nerve periphery. 
 
 Cold Hands and Feet in Women. — Every gynecologist has witnessed cold 
 extremities in women with diseased generative organs. In this case we must 
 look to the great dominating vaso-motor center, situated in the medulla 
 oblongata. Secondary vaso-motor centers also appear to exist along the 
 main length of the spinal cord. The vaso-motor centers are reached (a) 
 through the pneumogastrics, especially by irritation coming from the abdomi- 
 nal brain; (b) by the lateral chain of the sympathetic which is prone to emit 
 its irritations along the brachial plexus, or the sacral plexus, or the lumbar 
 plexus. No doubt the irritations are emitted along each intercostal nerve, 
 but vaso-motor contractions are more manifest in the extremities. In vaso- 
 motor contractions the skin is always most blanched at the extremities, as 
 the hands or feet. When the generative organs are diseased, the irritation 
 goes to the vaso-motor centers in the medulla and cord by two routes: 
 
 1. It travels over the ovarian and hypogastric plexuses of nerves to the 
 abdominal brain. Then it is reorganized and sent along the pneumogastrics 
 to the dominating vaso-motor center in the medulla, whence it is reflected 
 over the whole body, especially to the small vessels at the extremities, on 
 which it is the most effective in blanching white the skin and cooling the 
 hands and feet. 
 
 2. It can also travel on the lateral chain from the coccyx, especially by 
 way of the hypogastric plexus. I found in dissection of cadavers (especially 
 female) that the lumbar lateral chain of ganglia were strongly and liberally 
 connected with the hypogastric plexus by large, thick nerves. Hence, the 
 irritation from the generative organs will go up the hypogastric plexus and 
 be deflected to the lumbar lateral chain and pass both to the spinal cord and 
 medulla. Then the vaso-motor centers in the medulla and cord reflect their 
 irritations to the whole body, but especially to the extremities. So that 
 irritations from the generative organs reach the vaso-motor centers in the 
 medulla and spinal cord by two routes: (a) by the pneumogastrics from 
 the abdominal brain, and (b) by the lateral chain of ganglia. The result 
 after following both routes is similar, viz., paling and cooling of the skin, 
 especially of the extremities. Physiologists have proved that the most power- 
 ful vaso-motor constrictions exist in the hands and feet. The conclusions are 
 the same as those discussed in the viscera. The end of the whole matter 
 in malnutrition, for the arterioles and capillaries have been disturbed in 
 
184 THE ABDOMINAL AXD PELVIC BRAIN 
 
 their rhythm. The vascular rhythm exists, but it has not been determined 
 as to time. But when a large area of skin (tissue) is depleted of nourishing 
 blood for a considerable time, malnutrition is sure to result. The cause and 
 effect in the woman are definite. The irritation starts in the generative 
 organs and travels by definite routes to end in influencing the sympathetic 
 nerves to contract the vessels which the}- surround. I have such women in 
 my practice continually. Yaso-motor effects on the extremities are generally 
 a remote disturbance of chronic pelvic disease. The irritation of almost any 
 viscus which will effectually disturb the abdominal brain is liable to cause 
 vaso-motor constrictions. It is mainly from the generative organs in the 
 female. By carefully studying patients one can see the immediate and 
 remote effects of pelvic disease. The immediate effect may be observed 
 to be from the localized, tangible, gross pathology. It may be pressure 
 troubles, septic troubles or otherwise. But the remote effect is through the 
 sympathetic nerve, or rather through malnutrition. A slight, unnoticed 
 irritable focus begins in the pelvis (it may be endometritis). Months 
 and years go on. Irritations accumulate in the abdominal brain and may 
 radiate on all its various plexuses. Nutrition is insidiously impaired through 
 the months and years, unbalanced reflexes gather in the abdominal brain, 
 which, in turn, disturb the normal functional rhythm of viscera. Ac- 
 cumulated energies, begotten of long continued pelvic disease, are not 
 controlled by the abdominal brain, but irregular, stormy forces are 
 emitted over the plexuses to the viscera, which unbalances their rhythm 
 and ruins their nutrition. The woman with genital disease becomes an 
 object of wretched despair and a miserable invalid. The days of her life 
 are passed between pain and sadness. Our amateur operative gynecologist 
 has forgotten that all her troubles started from a lacerated cervix or endome- 
 tritis five years ago. He is sure to extirpate her ovaries, if he can, and lo! 
 how disappointed he is if she does not get well in a month! Such a woman 
 will not get well for long periods. The only benefit of extirpating the 
 appendages was that she was compelled to lie still for a month — a dear 
 method of purchasing a few weeks' rest. The proper method to follow in 
 this numerous class of women is to hunt for the old cause and remove it, and 
 then gradually nourish the woman back to normal health. Such women are 
 called hysterical, but there is generally some pelvic pathology that precedes 
 hysteria before the abdominal brain suffers derangement. 
 
 Space forbids any discussion as to the dependence or independence of 
 the sympathetic nerve in regard to the cerebrospinal system. Yet we may 
 assert that the sympathetic is independent to a certain degree. Babies have 
 been born at full term with no cerebrospinal axis. The heart will beat 
 some time after death. I have often noted the intestines performing peri- 
 stalsis more than an hour after death. I have watched the uterus going 
 through its rhythm in slaughtered cows an hour and a half after death. The 
 independence of the sympathetic is seen in vaso-motor neuroses of the 
 extremities. The tone of vessels is maintained by the sympathetic. The 
 sympathetic controls secretion. If the brain and spinal cord of a frog are 
 
GENERAL COXSIDERATIOXS 
 
 LS5 
 
 removed, his skin will show pigmentation. The viscera have involuntary 
 movements and are out of will control, — are excluded from the mental 
 sphere. But, like the watch, which requires every cog and wheel to keep 
 time, so the sympathetic needs the cerebrospinal to maintain the balance 
 of life. 
 
 A few general ideas of the sympathetic nerve may be of interest. The 
 rhythm of the viscera, due to the abdominal brain, will, no doubt, adequately 
 explain the axial rotation of abdominal tumors. The emptying and filling 
 of hollow viscera in their continual rhythm is apt to rotate adjacent tumors 
 
 CORROSION ANATOMY 
 
 Fig. 51. This specimen of corrosion anatomy of the uterus, oviducts and ovary of a 
 newborn infant represents the blood supply of the genitals in a quiescent state. Each 
 arterial branch is ensheathed by an anastomosed, nodular, fenestrated meshwork of 
 vaso-motor nerves. This method enables one to estimate the quantity of nerve supply to the 
 uterus. 
 
 with narrow styles. Narrow pedicles are, of course, more likely to rotate 
 than thick ones. It is a curious fact that when a woman possesses more than 
 one tumor in the abdomen, there is more danger of axial rotation. A preg- 
 nant uterus or tumor doubles the danger of the twisting of the tumor on its 
 axis. The axial rotation of a tumor is, no doubt, enhanced by the sudden 
 emptying of the uterus, and its change of location at delivery. But the main 
 point in the matter is visceral rhythm, e. g., of the intestines and bladder. 
 It is estimated that 10 per cent of abdominal tumors rotate on their axes. 
 The reflexes of the abdominal brain and sympathetic ganglia are very 
 numerous. 
 
186 THE ABDOMINAL AND PELVIC BRAIN 
 
 A blow on the solar plexus causes syncope by reflex action on the heart. 
 The vagus (right) compels the heart to beat soberly, and two-thirds of the 
 right vagus goes also into the abdominal brain. But the cervical sympathetic 
 rules the heart in its rapidity and regularity. The vomiting on the passage 
 of gall-stones, or renal calculi, or that of pregnancy, shows the abdominal 
 brain to be a great reflex center and place of reorganization of forces. Notice 
 the changed pulse in peritonitis, and the tremendous collapse in intestinal 
 perforation, due to disturbed circulation. Watch the shock after colotomy, 
 due to trauma on the peritoneum. The peritoneum is mainly supplied by 
 sympathetic nerves, so it acts through the solar plexus. It is easy to see how 
 nerve storms shock the heart from peritoneal manipulation. I have noted 
 depression of the heart. The peripheral arteries contract and the heart 
 cannot drive the blood home. It is easily seen that in the abdominal brain 
 and cervical sympathetic, the great regions of reflex action play a great role 
 in neuroses and all emotional phenomena. When we feel fear or fright, the 
 effect is noticeable in the solar plexus, which lies behind the stomach. 
 Sorrow and sadness are, frequently, first felt in the abdominal brain. The 
 good-hearted David said that he "yearned for the young man in his bowels." 
 His is only a common experience that the abdominal brain plays a role in 
 emotional and neurotic phenomena because of its capacity for reflex action. 
 
CHAPTER XV. 
 
 THE INDEPENDENCE OF THE SYMPATHETIC NERVE. 
 
 The function of thetractus intestinalis is sensation, rhythm (pcrsistalsis), secre- 
 tion and absorption. It has an impart and export service. 
 ".I zcant of individuality is the }nost dangerous sign in modern civiliza- 
 tion.".— John Stuart Mill. 
 
 It may aid in comprehending the structure and function of the sympa- 
 thetic nerve, and in concluding the discussion in regard to its independence, 
 to arrange in short, concise propositions a number of observations which will 
 show that the sympathetic nerve has a large degree of independence. 
 
 1. The independence of the sympathetic system is impressively shown 
 in the distinct rhythmical action of the heart for some time after being re- 
 moved from the body. This can be best demonstrated in the frog and turtle. 
 
 2. The peristaltic and vermicular motions of the intestines after death 
 significantly point to the independence of the sympathetic nervous system. 
 The intestines of a dog will continue in peristalsis for two hours after death 
 if the room temperature be 100 degrees Fahrenheit. 
 
 3. The fetus has been born at or about term without a trace of brain or 
 cord. This shows that nutrition, growth, secretion, absorption and circula- 
 tion were conducted alone by the sympathetic — one of the strongest demon- 
 strations of its independence. 
 
 4. Experiment has shown that nutrition (which means life's function) 
 may be carried on after complete destruction of the cerebrospinal centers. 
 
 5. Nourishment without the cerebrospinal center would indicate that 
 the arteries (blood-vessels) are under the control of the sympathetic system. 
 Goltz goes so far as to say that the tone of the arteries is maintained by local 
 centers situated in their own immediate vicinity. 
 
 6. The manifestations of blushing, local congestions and eruptions 
 would tend to show that the blood acts reflexly on the vessels, affecting the 
 vaso-dilators or the vaso-constrictors. The white line (followed rapidly by a 
 red one) on stroking the skin with the finger, as in scarlet fever, indicates that 
 the vessels possess local nerve centers of control. The trauma produced on 
 the vascular centers by stroking the skin first irritates the vaso-constrictors, 
 and paleness results from constriction of the vessels. The secondary result 
 of the trauma on the vaso-constrictor is that they are paralyzed, and then the 
 vaso-dilators dominate with a resulting red line. 
 
 Bernard, in 1851, was the first to show conclusively that the sympathetics 
 controlled the caliber of the blood-vessels. Any one who has long practiced 
 medicine, observing the heart and the aorta, will be able to note that the 
 heart itself, and the aorta, have seasons of dilatation and contraction. For 
 example, in many spare, neurotic women it is common to note that the aorta 
 has periodic times of powerful rhythms or beatings. With the hand on the 
 
 187 
 
188 THE ABDOMINAL AXD PELVIC BRAIX 
 
 abdomen the inexperienced announces a growing aneurism of the abdominal 
 aorta. The aorta beats with such tremendous force that the patient will call 
 the physician's attention to the phenomenon. A few hours subsequently its 
 rhythm will be quieted and in a normal state. This phenomenon of the 
 excessive abdominal aortic rhythm, or beat, is perhaps due to the excitation 
 of the local nerve centers which control its caliber; for I could scarcely 
 detect the excessive arterial beat in another portion of the body, as the wrist. 
 At such times the heart acts slightly differently from normal. It is a little 
 more noisy and appears as if it were dilated more than usual. Another 
 phenomenon in regard to nerve centers which control vascular tone (contrac- 
 tion and dilatation) may be observed in the heart. By careful watching 
 of the heart of an individual, one may note that the heart changes at times in 
 both its method of beat and its size. Occasionally the heart will dilate, beat 
 with more noise, continue so for some hours, and then subside to its natural 
 state. This phenomenon, as well as that of aortic dilatation and contraction, 
 is doubtless due to the controlling sympathetic nerve centers localized in the 
 substance or immediate vicinity of the heart and aorta. The heart, like a 
 blood-vessel under the controlling vascular nerve centers of the sympathetic, 
 dilates and contracts and varies its rhythm still more within wide ranges. I 
 have never seen this periodic dilatation noted in an}' book. Practically 
 nothing is to be found in books concerning this peculiar periodic dilatation 
 and vigorous beating of the abdominal aorta. 
 
 7. The abdominal brain (the solar plexus, the semilunar ganglion) may 
 be viewed as a gigantic vaso-motor center for the abdominal viscera. The 
 dilatation and contraction of the heart and aorta, with the periodic varying 
 of the vigor of their rhythm (without recognizable disease), may be referred 
 to this king of vaso-motor centers — the abdominal brain. In the progress of 
 life's vascular phenomena the abdominal brain, as a vaso-motor center, 
 exercises very dominant and quite independent prerogatives. 
 
 8. The dependence and independence of the cerebrospinal and sympa- 
 thetic system of nerves may be compared to the state and federal government, 
 or the municipal and state government. The former run in harmony, when 
 friction does not arise. Yet the state lives quite a distinct individual life, 
 quite independent from the federal government. The life of each is depend- 
 ent, however, on the other. The internal life of each (as of the sympathetic 
 nerve) maintains itself. 
 
 9. The sympathetic system alone would maintain life (sensation, per- 
 istalsis, absorption, secretion), especially in each viscus, but the cerebrospinal 
 system coordinates the various viscera as a whole into a definite purpose or 
 plan. The cerebrospinal system is an executive to suggest or organize the 
 efforts of each system, ruled by the sympathetic, to combine for a common 
 object — the continuation of an organized subject. The efforts of the circu- 
 latory system would be useless were they not combined with all the efforts 
 of the digestive system, as well as those of the genito-urinary system. The 
 cerebrospinal system simply coordinates the various independent systems 
 (circulatory, digestive and genito-urinary) into a unit of life. 
 
INDEPENDENCE OF THE VASO-MOTOR NERVE 1*9 
 
 10. The phenomena of vasoneurosis of the extremities would indicate 
 a great degree of independence of the sympathetic nerve. 
 
 11. The ordered richness of the sympathetic nerves in ganglion cells, 
 similar to the cerebrospinal ganglia, would tend to demonstrate its 
 dependence. 
 
 1:2. The accumulation or aggregation of ganglion cells in the sympa- 
 thetic should be sufficient argument for considering them as small brains- 
 nerve centers of life's action. 
 
 13. The independence of the sympathetic nerve may be observed in the 
 fact that as it departs more widely from the cerebrospinal it increases in 
 elements. Increased distribution shows increased aggregation of ganglion 
 cells, e. g., the Meissner-Billroth and Auerbach's plexuses in the small 
 intestines. 
 
 14. There is a partial necessity that the sympathetic be relatively 
 independent, at least be out of the control of the cerebral center. The 
 viscera being necessitated to be in constant activity, constant rhythm, should 
 be beyond the control of the will, so that man cannot speculate on his 
 viscera. The intellect cannot disturb the function of the viscera. The 
 actions of the sympathetic ganglion are beyond the power of the will. 
 
 15. A stubborn opponent of the independence of the sympathetic nerve 
 (Hermann) freely acknowledged that automatic and reflex coordinate move- 
 ments and secretions can be the indication of the sympathetic ganglion cells 
 quite independent of the cerebrospinal symptoms. 
 
 16. A significant partial independence of the sympathetic may be 
 observed in peritonitis. The reflex irritation induced by the peritonitis causes 
 extreme vaso-motor contraction in the skin. The skin becomes waxy pale, 
 the blood is forced out of the skin by contraction of the vessels and the patient 
 dies gradually from circumference to center. The heart at first attempts to 
 work more vigorously to send the blood to the skin vessels, but the harder 
 the heart works in sending the waste-laden irritating blood to the vessels, the 
 more they contract, and gradually death approaches the heart. The inde- 
 pendence of the grip of the sympathetic nerve is seen in the gradual death 
 of the patient, beginning in the skin capillaries and ending at the heart. It 
 is a good illustration of the fact that irritation of the sympathetic nerves may 
 be sufficient to force all blood out of a part even to its death. 
 
 17. Vulpian severed the sciatic and brachial plexuses and waited until 
 the pulp of the animal's corresponding paws became pale. Now, by irritating 
 the pulp of the paws a local congestion could be produced. Hence reflex 
 irritation of vaso-motor nerves can be limited to the particular organ or tissue 
 supplied, showing a considerable degree of independence. 
 
 18. It has been suggested by Fox that myxedema is associated with the 
 independence of the sympathetic. 
 
 19. Compression or macroscopial injuries of the cervical portion of the 
 sympathetic produces such a marked physiologic phenomenon that it demon- 
 strates in itself a considerable degree of independence of the sympathetic. 
 The manifestation of compression or injury of the cervical sympathetic is 
 
190 THE ABDOMINAL AND PELVIC BRAIN 
 
 that of the irritation or paralysis. Trauma of the cervical sympathetic shows 
 marked independent functional disturbances. Exophthalmic goiter is con- 
 sidered, even by the skeptical Eulenberg and Guttmann, as a paralysis of 
 the cervical sympathetic. If the latter can produce such vast changes, and 
 such a dreadful disease, how great must be the influence of the abdominal 
 brain in its independence. In exophthalmic goiter the independence of the 
 sympathetic seems dominant, for of the great triumvirate in that disease — 
 cardiac palpitation, protrusion of the eyeball and enlargement of the thyroid 
 gland — the cardiac palpitation seldom fails. Few experimenters or 
 observers fail to connect the cardiac disturbance with the cervical sympa- 
 thetic, showing how dominating it is in this case. 
 
 20. The gastro-intestinal secretions appear to be carried on automatic- 
 ally by the Meissner-Billroth (aided by the Auerbach) plexuses of nerves, 
 which are sympathetic ganglia — automatic visceral ganglia. The automatic 
 visceral, hepatic, renal, gastro-intestinal and menstrual ganglia, all show a 
 marked degree of independence. They produce rhythm in the viscera — 
 activity and repose. Undisturbed, they rule secretion harmoniously, but 
 disturbed anatomic visceral ganglia induce 'a) excessive secretion, (b) 
 deficient secretion and (c) disproportionate secretion. The last isthe most 
 detrimental, for it creates fermentation and unbalances nutrition. 
 
 21. The independence of the automatic visceral ganglia of the sympa- 
 thetic may be noted in the idea that if one viscus becomes diseased it may 
 disturb all the others by reflex action. 
 
 22. If one viscus becomes diseased the next to become diseased is the 
 one connected with the diseased viscus by the greatest number of nerve 
 strands. If the uterus becomes diseased the next viscus in order is generally 
 the stomach. However, this is probably due to the fact that the disturbed 
 stomach functions are easily observed. 
 
 23. The abdominal brain is a center of organization for impressions 
 received from distal viscera. It is a gigantic vaso-motor center for the 
 abdominal vascular system. The abdominal brain demonstrates its inde- 
 pendence by its definite method of reorganizing reflex actions. When an 
 abdominal viscus is mildly ill, the abdominal brain reorganizes the reflex 
 impressions and transmits them mildly to adjacent viscera. But if a viscus 
 is severely and especially chronically ill, the abdominal brain reorganizes the 
 reflexes and transmits them violenth* to the adjacent viscera, according to 
 the degree of illness. Also the reflexes reorganized in the abdominal brain 
 are transmitted outward to the viscera with greatest force on the lines of 
 least resistance, which means that the nerve forces travel on the plexuses the 
 best where there are the greatest number of nerve strands. 
 
 24. The independence of the sympathetic nerve may be observed in the 
 phenomenon of sleep. It never ceases action nor sleeps, while the cerebro- 
 spinal is in abeyance for about one-third of our life. 
 
 25. E. L. Fox reports two cases of compression myelitis in the cervical 
 portion of the cord unattended by any oculopupillary or vaso-motor paralysis. 
 This would tend to show the independence of the sympathetic, especially the 
 cervical sympathetic. 
 
IX DEPENDENCE OF THE A E Rl ' I \V / '. [SUM OTO Rl US m 
 
 26. Experimenters report that irritation of some portion of the cervical 
 sympathetic will produce secretions from the parotid and submaxillary glands. 
 
 27. Fox asserts that irritation of the peripheral end of the cervical 
 sympathetic will cause protrusion of the eyeball; sedation will cause sinking 
 of the eyeball, and a slight flattening of the cornea. We know that in the 
 lids are sets of smooth, muscular fibers innervated by the sympathetic, and 
 by contraction of these the lids are opened and so the eyeball is uncovered. 
 
 28. In general it may be said that the sympathetic presides over 
 involuntary movements, nutrition and secretion, holds an important influence 
 over temperature and vaso-motor action, and is endowed with a dull 
 sensibility. 
 
 29. Experiments show that after destruction of the medulla oblongata 
 and brain of the frog irritation will cause congestion of the limbs. 
 
 30. The occurrence of pigmentation in the skin of the frog, after 
 destruction of the cerebrospinal axis, shows the independence of the sym- 
 pathetic. 
 
 31. Each histologic unit has its own nervous system, which is sufficient 
 for it within certain limits. 
 
 It may be said that the object of the lateral chain of the sympathetic is 
 to make known the great ganglionic system to the cerebrospinal system. 
 
 32. The ganglia of the uterus (sympathetic) are independent centers for 
 reflex action. That it can act independently may be shown by the repulsion 
 of a child after the death of the mother. It has a powerful reflex action on 
 the heart. It is a great independent sympathetic ganglion. Associated 
 anatomically with the abdominal brain are the following plexuses: (a) the 
 diaphragmatic; (b) the suprarenal; (c) the renal; (d) the spermatic; (e) the 
 superior mesenteric, which intimately connect it with all the abdominal 
 viscera. 
 
 33. The expulsion of feces per rectum after death of the patinet shows 
 that the sympathetic ganglia of the bowels are independent centers for reflex 
 action. 
 
 34. Pigmentation of the skin in the frog, after destruction of the cere- 
 brospinal, demonstrates the independence of the sympathetic. 
 
 35. The abdominal brain is a great reflex center. Vaso-motor centers 
 are organizing centers, and preside over the coordination of the visceral 
 rhythm. The abdominal brain is a ganglion of far reaching significance. It 
 has many connections with viscera and possesses vast influence over the 
 circulation. It presides closely over the secretion of the abdominal organs. 
 
 36. That the sympathetic is the only nervous system belonging to some 
 of the lower animals is open to doubt ; for if that were the case, no argument 
 would be required to demonstrate the independence of the sympathetic. 
 The distinction of the cerebrospinal and sympathetic as to sleep or repose, 
 since it cannot be proven, must be dropped. In any argument we must 
 admit the very intimate and mutual dependence of the sympathetic and cere- 
 brospinal nerves on each other. 
 
 37. The essential feature of the pathology of the sympathetic, and also 
 
192 THE ABDOMINAL AXD PELVIC BRA IX 
 
 one which tends to show its independence, is that the irritation in one organ 
 may be reflected through a sympathetic ganglion and thus disturb the balance 
 of the viscera. The best, most common and convincing example is irritation 
 of the cervico-uterine ganglia, which is directly reflected to the abdominal 
 brain, where the irritation is reorganized and sent to all the nerve plexuses. 
 38. The degree of independence of the sympathetic nerve must be 
 worked out on the lines of experiment and observation of the effect of disease 
 on its different parts. To what degree is the abdominal brain a center for 
 the reorganization of forces; how does it modify and transmit receptions? How 
 supreme is it over the visceral ganglia or does it coordinate their action to a 
 definite plan? Does it enhance or prohibit their action? Is the abdominal 
 brain a reflex arc for nerve forces, passing from one organ to another? In 
 other words, will one diseased organ unbalance all other organs by transmit- 
 ting its irritation by way of the reorganizing abdominal brain? 
 
CHAPTER XVI. 
 
 ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS. 
 
 The sympathetic rules tin- rhythm (peristalsis) of vascular canals and glandular 
 
 ducts of the body. 
 "The first questions to put to a zvitness are as to his name and place of residence, 
 
 and his means of knowledge of the facts concerning which he is expected 
 
 to testify." — Judge Charles B. IVaite. 
 
 After considerable microscopical investigation I am convinced that we do 
 not know the whole sympathetic nerve, nor do we fully know its distribution 
 because of its tenuity. This remark is made as evidence gained in long 
 microscopical labors on the peritoneum, in which I have been interested for 
 years. In the peritoneum we cannot tell the function of a nerve from its 
 microscopical appearance. We may assert that the width of the nerve 
 indicates its length, that a wide nerve is a long nerve. 
 
 Now a sympathetic nerve is a non-medullated nerve, i. e., the white sub- 
 stance of Schwann is lacking, at least it is not visible by our present optical 
 instruments, or the present known reagents. However, it appears to me to 
 be present in Remak's bands (sympathetic fibers), though in an exceedingly 
 thin layer. Again, many nerves in the peritoneum begin with a medullary 
 sheath and end without one. The nerve is sheathed for part of its course 
 and non-sheathed for another part. But whether we are to call a nerve 
 which is sheathed in its whole course or in a part of its course, a sympathetic 
 or a non-sympathetic, depends upon whether it shows a different function. 
 In ordinary parlance a sympathetic nerve should have no visible sheath of 
 Schwann, i. e., no medullary sheath. A sympathetic nerve is perhaps better 
 known by its function than by its microscopical appearance. In fact no 
 microscopist can decide merely by the appearance whether a nerve be sym- 
 pathetic or non-sympathetic, unless he claim that all non-sheathed nerves are 
 sympathetic. For one can trace the medulla on a nerve in the peritoneum 
 for a long distance when suddenly it disappears. Should one meet this nerve 
 unsheathed in any portion of the peritoneum, he could not decide upon its 
 function. At present we must discuss the function and not the microscopical 
 structural differences. 
 
 One of the best places to study the sympathetic nerves is in the peri- 
 toneum of the kitten (when about six weeks old). The reagent best suited 
 for practical microscopical work is as follows: Acetic acid 5 parts, gold 
 chloride 1 part, and water 994 parts. The rabbit's peritoneum is quite good, 
 but not so good as the cisterna lymphatica magna of the frog's peritoneum. 
 Now it is not difficult to trace the gangliated cords lying on each side of the 
 vertebral column. In spare subjects the branches running from the cords 
 and ganglia are plainly visible. By a little care we can trace the branches of 
 
 13 193 
 
194 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 the ganglia and cords directly to the brain and spinal cord. The sympathetic 
 system lies in front of the cerebrospinal, as a secondary system enclosed in 
 a cavity, the thoraco-abdominal, just as the cerebrospinal is enclosed in the 
 cerebrospinal canal. The sympathetic system is characterized by having 
 non-medullated nerve fibers. It frequently has large round ganglion cells 
 enclosed in thick dense capsules. 
 
 '"''ooait** 
 
 ABDOMINAL BRAIN AND PLEXUS AORTICUS 
 
 Fig. 52. This illustration presents a limited amount of sympathetic nerves in outline. 
 (George Dancer Thane). 
 
 The ganglion cells lie scattered over considerable areas, and are sepa- 
 rated by dense, thick portions of connective tissue. The ganglion cells of 
 the sympathetic do not atrophy in early old age, as claimed by some, for 
 before me lies a beautiful microscopical section of the abdominal brain of a 
 woman who died at about the age of 72, in which the characteristic feature is the 
 numerous large ganglion cells ensheathed in thick connective tissue capsules. 
 It may be that in some cases the superior cervical ganglion does develop an 
 
ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS 195 
 
 excess of connective tissue which crushes out the delicate ganglion cells, but 
 such cases I have not observed in the abdominal brain, which must serve 
 some great economic plan in the system. The significance of the abdominal 
 brain and sympathetic system must not be forgotten, as children are born 
 without a brain, and some reports note the absence of the medulla also. In 
 such children the heart and viscera have been kept going by the sympathetic 
 system. Dr. W. F. Ball, of Mantua Station, Ohio, reported such a case 
 to me. 
 
 The sympathetic nerve is characterized by accumulations of cells at cer- 
 tain points, these being known as ganglia. In the abdomen and chest the 
 ganglia have a regularity of location corresponding to definite segments of 
 the body. There is a long chain of such ganglia situated on each side of the 
 vertebral column, known as the lateral chain of sympathetic ganglia, and 
 extending from the first cervical to the last sacral vertebra. Two fine, small 
 cords connect the spinal cord with each of the ganglia of the lateral chain, 
 making a close and intimate relation of the spinal cord and lateral chain. 
 The spinal cord is doubly connected with the lateral chain. The medullated 
 branch passes from the anterior root to the ganglia. The non-medullated 
 root passes to the blood-vessels of the cord. The lateral chain is well pro- 
 tected by adjacent bony structures from any injury or pressure by viscera. 
 
 Ventral to the lateral chain there are located three nerve plexuses: one 
 in the chest, the cardiac; one in the abdomen, the abdominal brain; and one 
 in the pelvis, the utero-cervical, or as I prefer to call it, the pelvic brain. 
 The thoarcic and abdominal plexuses are single, located in the ventral line 
 of the body and possessed of a large amount of nervous ganglia and cells, 
 especially the abdominal brain. The pelvic plexus is double, situated on each 
 side of the cervico-uterine junction, and is quite a massive collection of 
 ganglia and nerve cells. All three central plexuses, the thoracic, abdominal 
 and pelvic, are bound by intimate and very close relations with the lateral 
 chain of sympathetic ganglia. Every viscus is profusely supplied with the 
 sympathetic strands, and the vast number of cords and ganglia, like the 
 equalizers on a horse power, hold in intimate relation all the viscera in a 
 delicate balance. Specialists are beginning to recognize the wonderful 
 sympathetic balance of all the viscera, for when one gets out of order it 
 untunes the chorus of the whole. In fact, if a viscus in an adult is dis- 
 turbed, it is generally the genitals, and it soon unbalances the remainder. It 
 is easy to note the large cords, the ganglia and the invertebral plexuses of 
 the sympathetic system, to note their distribution and the relations of the 
 ganglia to the viscera in spare subjects hardened by alcohol. It is not 
 difficult to see, even in rough, incomplete experiments, that there is a certain 
 independence of the ganglia distributed to the viscera. Though the latter 
 are seen to be in close relationship with the great structure of the sympa- 
 thetic, yet they show definite, independent action. An hour after death one 
 can induce the viscera in a dog to act by slight irritation or stimulation. 
 Perhaps little remains to be discovered concerning the arrangement of the 
 automatic ganglia in the viscera, or the structural arrangement of the cere- 
 
196 THE ABDOMINAL AND PELVIC BRAIN 
 
 brospinal and sympathetic systems. But much remains to be discovered in 
 regard to the functional relations of the cerebrospinal and sympathetic 
 systems. Each system may contain structures of the other, or not. As a 
 birdseye view of the sympathetic nervous system we may produce the 
 following: 
 
 1. A series of distinct ganglia connected by nerve cords, extending from 
 the base of the skull to the coccyx. 
 
 DUCTUS BILIS ET DUCTUS PANCREATIS ET AORTERIA HEPATICA 
 
 Fig. 53. This illustration represents the biliary and pancreatic ducts with the hepatic 
 artery, which are each ensheathed with a fenestrated network of sympathetic nerves. 
 
 AH, hepatic artery; I, vateis diverticulum ; II, junction of ductus cysticus and ductus 
 hepaticus ; III, ductus hepaticus ; IV, cholecyst with its duct. 
 
 2. Automatic visceral ganglia. 
 
 3. A series of three centrally located prevertebral plexuses, situated in 
 the thorax, abdomen and pelvis. 
 
 4. A series of communicating and distributing nerve fibers. 
 
 The above propositions may be reduced to three elements, viz., nerve 
 fibers and nerve cells, or ganglia and periphery. 
 
 The caudal end of the sympathetic ends in a nerve mass known as the 
 ganglion impar, and the head (frontal) end ceases in the ganglk-n of Prof. 
 
ANATOMIC AND PHYSIOLOGIC COX SI DURATIONS 197 
 
 Francois Ribes of Montpelier, France (1800-1864). I must confess that my 
 searches for Ribes' ganglion have not been fully successful. 
 
 We find the sympathetic nervous system very widely distributed and it 
 must not be considered improbable to find sympathetic centers in the cere- 
 brospinal axis. The seat of a ganglion may be anywhere and yet not partake 
 of the adjacent surroundings, i. e., sympathetic ganglia may be situated in 
 the cerebrospinal axis, yet not be an integral part of it, particularly as 
 regards function. Thus we may consider the vaso-motor center, the cardiac, 
 and other centers, located in the medulla and cord, not to be a part of them. 
 
 This view must hold as a fact, for blood-vessels which necessarily supply 
 all parts of the body, brain or spinal cord, must be supplied with sympathetic 
 nerves to regulate their caliber, but neither the nerves nor the blood-vessels 
 are of the cord or medulla. The sweat, heat (flashes) and vaso-motor 
 (flushes) centers are located in the medulla and segments of the cord. 
 Pathologic states, as at the menopause, make all these centers painfully 
 manifest. Doubtless the genital center lies in the lumbar portion of the cord, 
 though automatic visceral ganglia exist in the genital organs, such as I have 
 formerly designated "automatic menstrual ganglia." Such ganglia require 
 a month to accomplish a rhythmical cycle; they explode monthly. In the 
 spinal cord there exists a linear row of cells known as the columns of the 
 late English investigator, Dr. Clark. Some think that Clark's columns 
 exercise the function of vaso-motor action, i. e., control the caliber of blood- 
 vessels. But as Dr. Fox states, this column of Clark's does not exist 
 throughout the whole length of the cord. Should further investigations 
 demonstrate that Clark's columns have a vaso-motor function it would go a 
 long way in proving considerable independence of the sympathetic nervous 
 system. 
 
 This independence, however, does not entirely depend on the supposed 
 vaso-motor column of Clark. Definite, though limited independence can be 
 observed in portions of the sympathetic nerve by any one who will carefully 
 perform experiments on the lower animals. We of course do not overlook 
 the idea that the sympathetic system and cerebrospinal system are so 
 intimately co-related that one so blends with the other that all action seems 
 lost in the cerebrospinal mass. 
 
 When the spinal cord and brain have lost control of the intestines they 
 assume a wild and disordered action, as may be seen in a person dying of 
 brain disease. In casesjn which at the autopsy we could discover no brain 
 disease I have found from one to four invaginations after death. In such 
 cases, doubtless, after the cessation of the function of the cerebrospinal 
 masses, the sympathetic fell into a wild, confused and disordered action. 
 The muscular wall of the intestine assumed an irregular action producing 
 invagination. This latter is due to irregular action of the muscles in the 
 intestinal wall. 
 
 In a certain sense we may look at the nervous system as composed of 
 two parts, viz. : a cerebrospinal part and a sympathetic part, connected by 
 a number of single, fine, short, non-medullated strands. These strands really 
 
198 
 
 NERVES OF THE HEART 
 
 hearths U%HlF JI^TV* 16 . 3 ^^ s -™ pathetic nerves on the left side to the 
 cerv icai In in \ti h 1 N "^S s ganglion; 18 is the phrenic joined to the inferior 
 cervical ganglion at 8 by a branch, 19. This connection explains the brayine sound or 
 expiratory moan on sudden rectal dilatation. ura.Mn^ souna or 
 
ANATOMIC AND niYSIOLOGIC CONSIDERATIONS 199 
 
 connect the ganglia of the sympathetic with the brain and cord. With such 
 a constructed apparatus before us it might be stated that the sympathetic 
 system simply consists of branches of the cerebrospinal system. It may be 
 represented as a branched roadway which distributes forces from the spinal 
 cord to the viscera. It may be considered as overflow paths to carry nervous 
 energy to the periphery. The ganglia of the sympathetic system are entirely 
 outside of man's will-power. He cannot control them to hasten visceral 
 action or retard it. It is plainly of utility to man to place beyond his will- 
 power the action of viscera, as he would doubtless abuse it from selfish and 
 other purposes. 
 
 But we must claim that the sympathetic nervous system is more than 
 a mere branched roadway for the mere distribution of nervous energy from 
 the cerebrospinal axis. If nervous energy was merely to flow to the viscera 
 from the cerebrospinal axis, why all this complicated, brain-like apparatus 
 in the various sympathetic ganglia? No, the ganglia of the sympathetic are 
 centers of nervous energy, accumulations of brain cells, of reflex centers, 
 organized receivers of sensation and transmitters of motion. Is the cerebro- 
 spinal system closely related to the sympathetic system by mere relations of 
 structure, because the sympathetic ganglia and cells are imbedded in the 
 great centers, or is it because the cerebrospinal system has intrinsic and 
 final control of the sympathetic? 
 
 In the dorsal region we find the typical spinal nerve of the morphologist 
 with its three chief divisions, viz.; (a) dorsal; (b) ventral and (c) visceral 
 branch. The visceral and vaso-motor branch is contained in the ramus 
 communicans, which passes from the spinal cord to the lateral chain of the 
 sympathetic or lateral ganglia, the demedullating centers. From this lateral 
 chain of ganglia nerves pass onward to a second chain of ganglia, known as 
 the prevertebral or collateral ganglia, i. e., the cardiac, abdominal brain, 
 inferior mesenteric and pelvic brain. Milne Edwards called the nerves which 
 pass from the lateral sympathetic chain to the collateral (prevertebral) 
 chain, rami efferentes. Again, from the prevertebral (collateral) ganglia or 
 plexus, nerve fibers pass into smaller terminal ganglia in the abdominal 
 organs, or to what we designate the automatic visceral ganglia. We also 
 have, besides the three distinct sets of sympathetic ganglia, connected with 
 the ramus communicans, the posterior ganglia at the roots of the nerves as 
 they issue from the spinal canal. The ramus communicans is then connect- 
 ed with four distinct ganglia: 
 
 1. The root ganglia (proximal ganglia), i. e., the ganglia situated on the 
 posterior spinal nerves immediately after issuing from the cord. 
 
 2. The lateral chain of sympathetic (proximal sympathetic ganglia). 
 
 3. The prevertebral ganglia (distal sympathetic ganglia). 
 
 4. The automatic visceral ganglia, or terminal ganglia (distal sympa- 
 thetic ganglia). 
 
 Leaving out the first of the ganglia, we note that the ramus communi- 
 cans connects the spinal cords with three great systems of sympathetic gang- 
 lia, viz. : (a) the lateral chain (b) the prevertebral chain and (c) the automatic 
 
200 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 visceral ganglia, making a complicated and vast system distributed over a 
 wide area. In regard to the relation of this vast sympathetic system to the 
 cerebrospinal axis in general, three views have been held: 
 
 1. The first and perhaps the oldest view is that the sympathetic nervous 
 system possesses a very great independence of action. The supporters of this 
 
 RENAL VASCULAR SUPPLY 
 
 Fig. 55. This illustration presents corrosion anatomy of 3 kidneys. The renal vascular 
 blades are opened like a book. 
 
 The abundance of sympathetic nerves may be estimated by the fact that each branch of 
 the renal artery is ensheathed by an anastomatic meshwork a fenestrated network of nerves. 
 The renal calyces and pelvis lie within the open book. For nerves of the digestive tract 
 see Fig. 13. 
 
 view make the sympathetic system the exclusive center of motion and sensa- 
 tion of the thoracic and abdominal viscera. The chief establishers of this view 
 are Volkmann (1842) and Bidder (1844). Their able defense of the independ- 
 ence of the sympathetic nervous system is still entertained and published in 
 the best anatomies. Bichat (1800) advocates the independence of the 
 sympathetic ganglia, as one of the first and ablest supporters. In fact 
 
ANATOMIC AXD PHYSIOLOGIC CONSIDERATIONS 201 
 
 Bichat was one of the first to definitely conceive this notion. Before me lies 
 a rare old book which I secured from an old English collection. It is written 
 by James Davey, 1858, on "The Ganglionic Nervous System." Davey gives 
 Bichat credit for knowledge of the sympathetic ganglion. Davey began to 
 advocate the primary and essential independent function of the sympathetic 
 in 1835, as is recorded in the "Lancet." Fletcher wrote (1837) on the 
 independent action of the sympathetic. 
 
 2. The second view held was chiefly established by Valentine (1839). 
 This view makes the sympathetic system an offshoot or dependent of the 
 cerebrospinal system. It would contain no fibers except those in the brain 
 and spinal cord. 
 
 3. A third view considers the sympathetic to be composed of fibers from 
 the brain and cord, and also of other fibers which arise in the various ganglia. 
 According to this view every sympathetic nerve trunk contains both cerebro- 
 spinal and sympathetic fibers. This view should consider all nerves sympa- 
 thetic which arise in the ganglia and preside over the functions of the organs. 
 
 The question might be asked, what are the functions of the sympathetic 
 ganglia? It should be remembered that many different opinions mean 
 unsettled views. 
 
 1. We may state that the ganglia demedullate nerves. 
 
 "_'. More nerves pass out of a sympathetic ganglia than enter it ; 
 hence the ganglion is likely the originator of nervous fibers. 
 
 3. The ganglia possess nutritive powers over the nerves passing from 
 them to the periphery. 
 
 4. They are centers of reflex action, i. e., receivers of sensation and 
 transmitters of motion. 
 
 We are therefore to consider as the subject of our theme: 
 
 1. The rami communicantes. 
 
 2. The lateral chain of sympathetic ganglia. 
 
 3. The prevertebral plexuses and 
 
 4. The automatic visceral ganglia. 
 
 There are some differences between the sympathetic system and cerebro- 
 spinal axis which may be noted and discussed later. 
 
 1. We may claim that the sympathetic nerves are the visceral branches 
 of the spinal nerves and hence have a distinct function, if not structure. 
 
 2. The individual fibers of the sympathetic nerves are of smaller caliber 
 than those of the cerebrospinal or somatic nerves. 
 
 3. The sympathetic branches preponderate in non-medullated nerves. 
 
 4. The fibers of the sympathetic nerves are interrupted by nerve cells or 
 ganglia through which they pass. 
 
 5. Nerve cells are liable to accumulate into ganglia along a non-medul- 
 lated nerve. 
 
 6. The sympathetic nerves tend to form closely meshed networks or 
 plexuses, as Auerbach's and Billroth-Meissner's plexuses. 
 
 7. The somatic (cerebrospinal) nerves supply the body wall. The 
 sympathetic nerves supply the viscera. In the visceral nerves must be 
 included vascular nerves. 
 
202 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 We might call the various systems of ganglia of the sympathetic by 
 numbers. For example, the lateral chain of sympathetic ganglia may be 
 called primary ganglia. In the primary ganglia the chief nerves of the rami 
 communicantes pass. 
 
 Again, we might call the prevertebral plexuses, the secondary ganglia. 
 Many nerves from the rami communicantes enter the secondary ganglia with- 
 out entering the primary ganglia. 
 
 NERVES OF TRACTUS GENITALIS 
 
 Fig, 56. This illustration presents the nerves of the genitals according to Franken- 
 hauser. 
 
 Finally the automatic visceral ganglia might be called tertiary ganglia. 
 In short we could conveniently speak of the primary, secondary and tertiary 
 system of sympathetic ganglia. 
 
 Much interest is attached to the ramus communicans, i. e., the narrow 
 isthmus which joins the cerebro-spinal axis to the sympathetic system It is 
 important to have a clear view of these rami communicantes, for through 
 them pass the rami visceraes and rami vasculares, i. e., the rami communi- 
 cantes contain and transmit the vascular and visceral nerves, both subjects 
 of profound practical interest in medicine and surgery. 
 
ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS 203 
 
 In an anatomical sense writers understand by the term rami communi- 
 cantes, two short nerves, a double connection between the cerebrospinal axis 
 and the sympathetic system, i. e., with the lateral chain or primary ganglia. 
 One ramus communicans is white, medullated and passes directly out of the 
 anterior root of the spinal cord chiefly to the lateral chain, but some fibers 
 pass directly to the prevertebral plexus. This branch of the communicans 
 contains the visceral and vascular nerves; hence the importance to all 
 practitioners. The other ramus communicans is gray, non-medullated and 
 passes from the lateral chain of ganglia to the spinal cord. It is a vaso- 
 motor nerve, the purpose of which is to regulate the vessels of the cord and 
 its meninges. It is well to remember that the term ramus communicans 
 is a general term including all the kinds of nerves which supply the viscera 
 and blood-vessels. 
 
 I propose here to consider at some length the ramus communicans which 
 supplies the abdominal viscera and blood-vessels. In the first place, there 
 are certain fine, white, medullated nerves, as Gaskell has pointed out, which 
 pass from the spinal cord, in the white ramus communicans between the 
 second dorsal and second lumbar nerves inclusive, to supply the viscera and 
 blood-vessels. These nerves should be named as Gaskell suggests, splan- 
 chnics. Hence we will have: (1) the thoracic splanchnics; (2) the abdominal 
 splanchnics and (3) the pelvic splanchnics: A peculiar feature of these white 
 rami communicantes is that they are only found in a limited region of the 
 spinal column. They begin, as Gaskell notes, at the second dorsal and end 
 in the second lumbar. They have a very fine caliber and pass into the 
 lateral chain, where they become demedullated, and second into the prever- 
 tebral plexuses where the remainder become non-medullated. Hence, all 
 the white rami communicantes which pass through sympathetic ganglia 
 leave the ganglia as non-medullated or as sympathetic nerves to attend to 
 viscera and blood-vessels. Above the second dorsal vertebra the rami com- 
 municantes consist of the gray variety, i. e., they are peripheral nerves of the 
 lateral ganglia. Below the second lumbar vertebra they are also of the gray 
 peripheral variety. 
 
CHAPTER XVII 
 
 THE PHYSIOLOGY OF THE ABDOMINAL AND PELVIC BRAIN 
 WITH AUTOMATIC VISCERAL GANGLIA. 
 
 The sympathetic nerve which rules visceral rhythm never sleeps. Visceral 
 rhythm {peristalsis) and life are beyond the control of the will. 
 
 'Precedent is the terror of second rate men." — Dr. Joseph Parker. 
 
 The physiology of the abdominal and pelvic brain with automatic 
 visceral ganglia comprehends the real physiology of the sympathetic, as the 
 chief portion of the former is included or counted in the latter. It may be 
 asked, "What is understood by the physiology of the sympathetic nerve?" 
 We understand by the physiology of any organ the use it yields to the econ- 
 omy, or the purpose it subserves to the animal. It may be stated in the 
 beginning that it is difficult to definitely and exactly define the physiology of 
 the sympathetic nerves, as they are often largely mingled with those of the 
 cerebrospinal system. The cerebrospinal and sympathetic systems of nerves 
 have a certain initial dependence on each other, like the individuals of well- 
 ordered society. Yet certain limited liberties are assumed by both systems. 
 The Federal government presides as a central power over the various states, 
 but the latter assume many independent liberties of action. The states act 
 and execute independently of the central government. So it is in the human 
 body, an exquisitely perfect product of millions of ages; the sympathetic 
 nerve, though dependent for much of its power on the cerebrospinal axis, 
 has in its influence over circulation and the abdominal viscera a certain inde- 
 pendence of function. 
 
 The sympathetic is not merely an agent of the brain and cord. It 
 generates action itself. It is, in general, a nerve center characterized by the 
 power to receive sensation and send out motion. It has all the elements of 
 any nervous system, viz. : a ganglion cell, a conducting cord and and a 
 periphery. It is not attempted here to argue that either the cereborspinal 
 axis or the sympathetic nerve is absolutely independent of the other. The 
 fact is that each nerve system has its own special duties. Both systems must 
 be associated in order to carry on life's functions and purposes. It may be 
 said that man and woman are independent of each other; but their associa- 
 tion is required for the perfection of reproduction. In another place I have 
 arranged quite a number of propositions to show that the sympathetic nerve 
 enjoys a large degree of independence. In the discussion of its physiology 
 certain topics must be discussed, in order to better comprehend the limits and 
 factors of the field. 
 
 1. The abdominal pelvic brain, i. e., reorganizing centers. 
 
 2. A very important factor will be the vaso-motor nerves (i. e., vaso- 
 constrictors and vaso-dilators). 
 
 204 
 
ANATOMY AND PHYSIOLOGY 205 
 
 3. The automatic visceral ganglia. 
 
 4. Glandular secretions (bile, urine, gastro-intestinal juices, milk, ova 
 and semen). 
 
 5. Temperature. 
 
 6. Trophic nerves. 
 
 7. Pigmentation. 
 
 8. Reflex fibers. 
 
 9. Sleep. 
 
 The above nine divisions mark out a field for consideration. It may be 
 broadly stated that all healthy movements initiated and sustained by the 
 sympathetic nerves are involuntary movements. 
 
 The vaso-motor nerves. They are divided into vaso-constrictors and 
 vaso-dilators, and to Claude Bernard belongs the credit of first conclusively 
 showing (in 1851) that they exerted an influence over the caliber of the ves- 
 sels. Authors agree, in general, that here are vaso-motor centers located in 
 the spinal cord which control the caliber of vessels. Some place the vaso-mo- 
 tor centers in the vascular columns of Clark. Still another set of authors of 
 great respectability claim that vaso-motor centers are located along the 
 peripheral nerve branches. Doubtless there are in the walls of vessels nerve 
 cells which are in connection with the vaso-motor nerves. These vascular 
 ganglia, or nerve cells, send fibers to the muscularis of the vessel, dilating or 
 contracting it according to the nature of the despatched stimulus. 
 
 It is not yet definitely settled whether the vaso-motor nerves are con- 
 strictors or dilators, or whether there are distinct constrictors and dilators. 
 Some assert that there is a constrictor nerve only and that dilation of the 
 vessel is paresis of the constrictor. Later authority seems to point to a 
 vaso-dilator and vaso-constrictor, and the fact that there are vaso-motor 
 centers located on the vessel or adjacent to it. It is evident to observers and 
 clinicians that local variation of circulation occurs in the genital or digestive 
 tracts from reflex irritation. By slight irritation one can produce a white 
 line (vaso-constriction) and by more severe irritation one can produce a red 
 line (vaso-dilation). Cold first constricts the vessels, but it is rapidly 
 followed by vaso-dilation, a redness. Now, this local variation of circulation 
 occurs doubtless with more distinctness in the visceral organs which are so 
 highly supplied with vaso-motor nerves, and so closely situated to the 
 gigantic vaso-motor center, the abdominal brain. The significance of vaso- 
 constricting nerves becomes very evident when it is recognized that they are 
 so powerful that they can drive or squeeze all the blood out of a part. 
 
 In death from peritonitis the vaso-constrictors drive first all the blood 
 out of the skin or periphery. The blood is forced into the large arteries and 
 veins by the effect of the vaso-constrictors on the peripheral and smaller 
 vessels. The vaso-dilators may be so effectively exercised that the blood 
 escapes through the wall of the blood-vessels as in hemorrhagic peritonitis. 
 
 The vaso-motor nerves are of the sympathetic and exercise control over 
 the caliber of vessels. The controlling of the lumen of vessels constitutes a 
 vast field of physiology, in the domain of the sympathetic. It constitutes 
 
206 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 vascular tone. Section of the sympathetic dilates the vessels beyond the 
 normal. One of the chief offices of the sympathetic nerve is to preserve the 
 tone of vessels. The nerves that insure tone in vessels issue from the sym- 
 pathetic. They are always active and never in repose, — a characteristic of 
 the sympathetic nerve. They pass to the muscular coat of the vessels and 
 act as their permanent guardian, in preserving permanent vascular tone. 
 Variation in this tone constitutes incipient disease. Doubtless the 
 vascular tone is the result of a reflex matter, and the factor in the reflection 
 is the blood-wave, i. e., the trauma or irritation of the blood-wave on the 
 endothelial membrane of the vessel induces the vaso-constrictors to act per- 
 manently in preserving vascular tone. Congestion is only the abolition of 
 vascular tone. Goltz's percussion experiment demonstrates the reflex nature 
 of the action of vaso-motor nerves, as by tapping on the exposed viscera he 
 could produce dilatation of their vessels. Hence in this case the centers for 
 reflex action must lie in the walls of the vessels themselves. 
 
 For a reflex act in the vaso-motor field, there must exist several factors, 
 as (a) muscular walls or contractile tissue; (b) centripetal fibers; (c) a center 
 of reflection; (d) centrifugal fibers. 
 
 All these factors exist on and adjacent to vessels. 
 
 For the reflex centers of vaso-motor movements we may look to the 
 cardiac ganglia, the abdominal brain or, especially, to the ganglia around the 
 vessels or in their walls. Finally, we may claim that the vaso-motor nerves 
 control the caliber of vessels, that they belong to the sympathetic and that 
 those of the abdominal viscera are chiefly under the control of the gigantic 
 vaso-motor center — the abdmoinal brain. 
 
 First, we must consider the abdominal brain, the semilunar ganglia or 
 solar plexus, in the physiology of the smypathetic. This large ganglion 
 receives sensation and sends out motion. It is situated at the root of the 
 great visceral artery i. e., at the foot of the celiac axis. It lies behind the 
 stomach and entwines itself about the aorta and root of the celiac axis and 
 superior mesenteric artery. In short, it is located at the roots of the celiac, 
 renal and superior mesenteric arteries. It supplies all the abdominal viscera. 
 It is a gigantic vaso-motor center for the viscera, as is shown by its location 
 at the roots of the celiac, renal and superior mesenteric arteries — the great 
 abdominal visceral blood way. It is connected with almost every organ in 
 the body, with a supremacy over visceral circulation, with a control over 
 visceral secretion and nutrition, with a reflex influence over the heart that 
 often leads to fainting and may even lead to fatality. It rules visceral 
 rhythm. No wonder that we may consider the abdominal brain the center 
 of life itself, as the cranial brain is the center of mental and psychical forces! 
 
 The abdominal brain, or solar plexus, is composed of the aggregation of 
 coalescence of a large number of ganglia. On the two sides of the abdomi- 
 nal brain are situated the semilunar ganglia — compact masses of nerve cells, 
 nerve cords and connective tissue. During many dissections I have noted 
 that the right semilunar ganglion is the smaller, doubtless because it lies 
 behind the inferior vena cava, and hence has suffered from pressure atrophy. 
 
ANATOMY AND rilYSIOLOGY 207 
 
 Each of the semilunar ganglia receives the great splanchnic nerve of the 
 corresponding side. The other splanchnics may enter it, but it is more to 
 enter the abdominal brain. It may be here stated that although the semi- 
 lunar ganglia are located on the sides, they are practically so intimately 
 associated with the solar plexus that we insist in combining all the names 
 into one, viz. : that of Abdominal Brain. 
 
 All plexuses or strands of nerves are secondary. The significance of the 
 abdominal brain in the visceral physiology, i. e., in life, may be compared to 
 that of the sun over the planets. The influence of the sun rules the planets, 
 though they are influenced by other suns and planets (e. g., the cerebro- 
 spinal). The abdominal brain has ganglion cells (brain centers), nerve 
 strands (nerve conductors) and a peripheral nerve apparatus, just as the 
 cranial brain possesses a central, conducting and peripheral apparatus. The 
 abdominal brain can live without the cranial (shown by living fetuses with 
 no trace of cerebrospinal axis), while the cranial brain and the cord cannot 
 live without the abdominal brain. 
 
 The great sympathetic ganglia, of which the abdominal brain is the 
 ruling potentate, is the center of life itself. So long as the forces of life, 
 assimilation, circulation, respiration and secretion proceed undisturbed, as in 
 health, the abdominal brain remains a silent, steady, but ceaseless worker; 
 but being unbalanced by peripheral or central irritation, it quickly manifests 
 or resents the insult. From the abdominal brain large plexuses with numer- 
 ous nerve strands pass to every abdominal viscus, connecting the viscera into 
 a delicately balanced, nicely ordered, exquisitely, arranged apparatus for the 
 object of maintaining life. The nerve plexuses or strands are arranged along 
 the highways of nourishment — blood and lymph vessels, and vary in size 
 according to the importance of the viscus supplied. 
 
 Laignel and Lasvastine, in their experiments upon dogs, have found that 
 ablation of the solar plexus is a serious operation ; though traumatism of the 
 plexus even may cause death. They have called the solar syndrome of 
 paralysis the sum of symptoms produced by ablation of the plexus; it may 
 be superacute, acute, subacute, or chronic. The first form they have found 
 to be present in peritonitis, clinically, the second in lead colic; the others in 
 mucomembranous colitis. Certain affections, therefore, may be attributed 
 solely to disturbance of the solar plexus, and not to general systemic 
 derangement. 
 
CHAPTER XVIII. 
 
 CONSIDERATIONS FOR THE REMOVAL OF PELVIC AND 
 ABDOMINAL TUMORS. 
 
 The sympathetic is the silent companion of the cerebrospinal. The sympathetic 
 nerve is the nerve of subconscious life. 
 
 "But he did not lose sight of the present in these glowing visions of a future." — 
 Mrs. Catharine V. Waitc, "The Mormon Prophet and His Harem." 
 
 Having devoted some twenty years to the study of pelvic and abdominal 
 visceral disease, I have frequently desired to record some observations on 
 the effect of tumors in the pelvis and abdomen upon the sympathetic system. 
 Many dissections have convinced me that the vast ganglionic system, dis- 
 tributed to the viscera bordering upon the peritoneal cavity, together with 
 other glandular organs of the body, plays a significant role. Besides, when 
 it is noted that the heart and the unstriped muscles of the body, are supplied 
 by the sympathetic system, there becomes at once apparent its extensive as 
 well as intimate connection with the whole body. 
 
 Special study in the physiology and pathology of the viscera develops 
 reasons for the removal of abdominal and pelvic tumors not apparent from 
 superficial observations. It is well known that shortly after the appearance 
 of a tumor in the abdomen the health of the patient becomes more or less 
 impaired. The functions of the organs become deranged; the heart suffers 
 from abnormal action and structural change; the digestion becomes more or 
 less deranged. As the tumor increases in size, kidney diseases generally 
 develop. The liver, forming bile, glycogen and urea, sooner or later becomes 
 impaired in its rhythm. The lungs lose their rhythm and become spasmodic, 
 while the spleen shows its disturbance by pigmentary deposits in various 
 portions of the body. An attempt will here be made to explain the patho- 
 logical result of abdominal tumors on physiological and anatomical grounds. 
 
 The basis of the explanation will be by reflex action on the sympathetic 
 nerve. It may be curtly observed that pathological results due to the sym- 
 pathetic nerve are based upon reflex action. We shall assume that the 
 ganglia which are found in it, especially the abdominal brain and the three 
 cervical ganglia, are points where forces are reorganized and distributed to the 
 viscera. The first essential feature to observe in the diseased viscera is the 
 disturbance in rhythm. Though any abdominal tumor may produce the same 
 results, we shall choose a uterine myoma to illustrate our views. It is a 
 principle in physiology that when a peripheral irritation is sent to the 
 abdominal brain the reorganized forces will be emitted along the lines of 
 least resistance, so that the organ which is supplied with the greatest number 
 ot nerve strands will suffer the most. Practically this principle holds true in 
 every viscus. 
 
 208 
 
REFLEX ACTION 
 
 209 
 
 The great ganglia and cords, filled with nerve cells and nerve strands, 
 labor in the subconscious region, the vast laboratory of life and assimilation. 
 The cerebrospinal axis receives sensations and emits impulses which express 
 themselves in motion, performing labors which minister to the mind and 
 protect the body in avoiding destruction, or contribute to its nutrition. 
 
 SCHEMATIC DRAWING OF THE SYMPATHETIC NERVE 
 
 Fig. 57. X, ganglion of Ribes ; y, coccygeal ganglion ; h, heart ; k, kidney ; s, spleen ; 
 a b, abdominal brain ; s p, sptrmatic (ovarian plexus) ; i, intestine ; h p, hypogastric plexus ; 
 c g, the three cervical nerves. 
 
 The sides of the ellipse represent the lateral chain of the sympathetic. All the nerve 
 strands report to the abdominal brain. 
 
 The effects of the tumor on the heart may first be considered. An 
 abdominal tumor induces fatty degeneration of the heart. When the uterine 
 tumor irritates the peripheral ends of the hypogastric plexus, the irritation 
 is transmitted to the abdominal brain and there reorganized and emitted 
 along the splanchnic to the cervical ganglia, where, again, a reorganization 
 occurs and the force then passes down to the heart by way of the three car- 
 
 14 
 
210 THE ABDOMINAL AND PELVIC BRAIN 
 
 diac nerves. The irritation could pass directly from the uterine myoma up 
 to the lateral chain of sympathetics to the three cervical ganglia where it 
 becomes reorganized. 
 
 It no doubt transmits part of the irritation by way of the abdominal brain 
 and part by way of the lateral chain. So far as the heart is concerned, the 
 result is nearly the same, for the irritation is reorganized in each case in the 
 three cervical ganglia and transmitted to the heart. It is of course necessary 
 to consider that the irritation may be sent to the spinal cord by way of the 
 vagus and there reorganized. In such case it is sent directly to the heart by 
 the vagus. 
 
 It should be remembered that the sympathetic ganglia in the walls of the 
 heart (Ludwig's, Bidder's, Schmidt's and Remak's) are numerous and large. 
 Also that the network of cords with their ganglia, situated close to its surface, 
 constitute an extensive nerve system. It consists of the great or deep cardiac 
 plexus, otherwise known as the plexus magnus profundus of Scarpa, besides 
 the superficial cardiac plexus, with the cardiac ganglia of Wrisberg, which is 
 occasionally large from the coalescence of several ganglia, and may be 
 represented by a meshwork. In tumors of the pelvis we are dealing with the 
 effect on the vast cardiac sympathetic nervous system. The first manifest 
 objective heart symptom is irregularity. 
 
 The irritation from the uterine myoma reaches the heart in two ways: 
 
 1. The irritation passes up the hypogastric plexus to the abdominal 
 brain, where it is reorganized and emitted to all the viscera over their 
 respective sympathetic plexuses. In the case of the heart it passes up the 
 abdominal splanchnics to the three cervical ganglia of the sympathetic, 
 where it is reorganized and sent directly to the heart. 
 
 2. Some of the irritation is transmitted by way of the vagi to the 
 medulla, where it is reorganized and sent directly to the heart by the cardiac 
 nerves which supply the heart from the vagus. This is more especially the 
 case in the right vagus, as that is the cranial nerve which largely rules and 
 supplies the heart and abdominal brain. Now, this irritation from the 
 myoma goes on day and night. It gives the heart no rest. It flows to the 
 heart in the midst of a diastole, or a systole. The first great characteristic 
 of the heart (rhythm) is lost. Having lost its rhythm, the heart proceeds 
 irregularly. Irregular action means a changed nourishment; continued 
 irritation with disturbed rhythm induces the heart to overfeed itself, the 
 result being hypertrophy. 
 
 It may be noted that this hypertrophy is not brought about in precisely 
 the same way as is hypertrophy from valvulitis or aortic insufficiency ; but 
 vaso-motor dilation must play a role in over-nourishing the cardiac muscles. 
 It resembles more nearly the cardiac hypertrophy existing in goiter. That 
 from the reflex irritation in myoma is also a moderate hypertrophy, so far as 
 the writer has observed, and it is a very slow process. In the first stage the 
 heart becomes irregular, in the second hypertrophied, in the third it takes 
 on fatty degeneration. This is no doubt a preservative process, so that a 
 large, vigorously beating heart will not rupture an artery in a degenerated 
 
ORGANS EFFECTED BY REFLEXES 211 
 
 state (atheromatous or fatty). It appears certain that many old cases of 
 large uterine myoma are lost after skillful operations simply from fatty 
 degeneration of the heart. It is common to observe palpitation in patients 
 having uterine myoma, and palpitation is the characteristic symptom of a 
 weak heart. 
 
 The automatic cardiac ganglia are disturbed by reflex irritation and 
 take on an excessive nourishment. The irritation, sent to the heart over the 
 hypogastric plexus, is in one sense an increased demand for action. The 
 irritation, passing to the heart day and night, winter and summer, according 
 to a physiological law, provokes hypertrophy, if the nutritive powers are 
 good. If they are not good, the complement of hypertrophy — dilation — 
 results. 
 
 A fatty degenerated or weak heart induces low blood-pressure, which is 
 the bottom factor in waste-laden blood and deficient elimination. It allows 
 local congestions and consequent impaired nourishment. The local force of 
 such circumstances teaches to remove uterine and other abdominal tumors 
 as early as possible, so that the patient will not be left with partially or com- 
 pletely damaged viscera. 
 
 Reflexes arising from the irritation of the sympathetic in the peritoneal 
 membrane are profound in results. Irregularity, hypertrophy, and degenera- 
 tion of the heart are the effects of a reflex act, accomplished mainly through 
 the sympathetic system and due to irritation at the periphery of the hypo- 
 gastric plexus. It is transmitted to the abdominal brain, to the three 
 cervical ganglia, and some to the spinal cord, whence the reorganization of 
 the forces occurs. 
 
 The organized nervous impressions then pass to the heart over the six 
 cardiac (vagi) nerves. This abnormal force deranges the fine balance of the 
 heart's rhythm. The automatic cardiac ganglia become discolored, and in 
 time vaso-motor action and consequently nourishment are disturbed. 
 
 It may be remembered that the untoward influence on the heart, disturb- 
 ing its rhythm and consequently its nourishment, is also aided and abetted by 
 disturbing the caliber of distal blood-vessels which are controlled by the 
 sympathetic system. 
 
 The liver does not escape the evil influence of the tumor. Abdominal 
 tumors induce fatty degeneration of the liver. It may be asserted that an 
 influence on the hepatic plexus of nerves alone could stop all scretion in the 
 liver. If such a proposition be true, it need not be wondered that lesser irri- 
 tations of the hepatic nerve plexus could so alter the secretion of the liver 
 that it would degenerate the organ. The characteristic disturbance which 
 arises from the uterine myoma is a derangement of rhythm. The liver has a 
 rhythm due to (a) an elastic peritoneum inclosing it, (b) an elastic capsule 
 (Glisson's) surrounding it, and (c) to the capacity of its cells to enlarge. 
 
 The occasion of the liver rhythm is food carried to it by way of the 
 portal vein. When the peritoneal and Glisson's capsules and the cells are 
 expanded to a maximum, the liver rhythm is at its climax. Now, the prod- 
 ucts of the liver (bile, glycogen and urea) are sent to their respective homes 
 
212 THE ABDOMINAL AND PELVIC BRAIN 
 
 by contraction of the elastic peritoneum and capsule of Glisson. The liver 
 then gets its rest and repair. 
 
 The irritation from the periphery of the hypogastric plexus passes up 
 to the abdominal brain, where it is reorganized and emitted to the liver. It 
 goes to the liver from the tumor at all hours and deranges its rhythm. The 
 irritation may attempt to induce a rhythm without food, or it may flash on to 
 the liver at any stage in its rhythm. The liver rhythm is induced by the 
 automatic hepatic plexus. So it may be asserted that the irritation of the 
 uterine myoma deranges the rhythm of the liver. 
 
 The second point to consider is the altered secretion in the liver, due to 
 the reflex irritation from the uterine myoma by way of the abdominal brain. 
 The continued irritation increases the derangement and soon changes and 
 impairs the liver nourishment. The complete process from food to end pro- 
 ducts becomes imperfect and a lower grade of tissue is formed, known as fat. 
 The constantly irritated liver soon becomes able to form but little products 
 beyond fat, and degeneration follows. 
 
 It is well known that women at the menopause frequently acquire liver 
 disease. This is owing to the reflex irritation through the abdominal brain. 
 The degeneration of the hypogastric plexus will not allow it to transmit 
 sufficient physiological orders to induce a monthly rhythm, so the accumu- 
 lated energies flash to the other organs, and the derangement of the liver is 
 especially manifest, because its derangement is often followed by pigmenta- 
 tion ( yellow or brown or black) of the skin. The uterine myoma, then, by 
 reflex action, disturbs rhythm and secretion in the liver, and so its nutrition. 
 This ends in fatty degeneration. 
 
 For years I have observed that women with pelvic disorders have dis- 
 turbed kidney action. In general this kidney disturbance is renal insuffic- 
 iency, and it may after long irritation become organic disease. It may be 
 well to give a general hint here as to why the kidneys suffer so much when 
 either irritating tumors or inflammatory processes exist in the pelvic organs. 
 
 The kidneys, uterus, ovaries and oviducts develop from two very small 
 points in the embryo called the Wolffian bodies. These develop from the 
 mesoblast, as do the muscles, blood and lymph vessels, and from the genito- 
 urinary organs. Arising from the same source and supplied by the same 
 nerves and blood-vessels, the Wolffian bodies, the kidneys and genitals have 
 an intimate and close connection. The abdominal brain sends out a vast 
 chain of nerves to the kidney on each side, and the same brain sends out a 
 vast chain on each side of the genitals. These and the kidneys are only 
 different spokes in the same wheel, the hub of which is the abdominal brain. 
 Diseases in the genitals, whether tumors or inflammatory processes, produce 
 in the urine not only diminished solids but also diminished fluids. 
 
 Again on the other hand diminished kidney excretion (renal insufficiency) 
 produces diseased or, at least, disturbed genitals. Any gynecologist of some 
 years' experience has doubtless frequently observed that in women with 
 diseased genitals and deficient renal secretion, by giving diuretics— fluids in 
 small and off-repeated doses, the diseased genitals will often improve in 
 
RENAL SECRETION AFFECTED BY REFLEXES 213 
 
 direct proportion to the increase of renal secretion. Deficiency of renal 
 secretion irritates the genitals by non-removal of urinary solids. Diseased 
 genitals irritate the kidneys by reflex action. This is all accomplished 
 through the abdominal brain as a center. The genitals, kidneys and abdomi- 
 nal brain constitute a very vital triangle. In the middle of its base lies the 
 significant abdominal brain and at the apex the important genitals, while the 
 other two angles are occupied by the kidneys. The uterus and kidneys have 
 the highest nerve and blood supply of all viscera, hence they experience 
 more profoundly than other viscera the forces which are organized and 
 reorganized in the abdominal brain. In the sympathetic nervous system the 
 kidneys play a vast and immeasurable role. If by some irritation in the 
 pelvis or abdomen the kidney begins to secrete insufficiently, the whole 
 organism, together with the ganglionic nervous system, or the cyclo-gang- 
 lionic system, as Solly termed it half a century ago, will become poisoned 
 from non-elimination. From this peculiar reflex action, of which the abdomi- 
 nal brain is capable, we may yet learn that disease of the pelvic organs of 
 woman may be cured by diuretics, cathartics or diaphoretics. In other words 
 drain the skin, drain the kidneys and drain the bowels. The intimate and 
 close relations of the genitals and kidneys is plain anatomically and physio- 
 logically, as large bundles of nerves from the abdominal brain supply both. 
 Clinically, then, these closer relations have been demonstrated of late years, 
 as gynecology has progressed. The cyclo-ganglionic system is recognized as 
 a finely balanced mechanism capable of prompt response when once its 
 manifestations are understood. 
 
 For example, no one understands so well as the gynecologist the vital 
 relation which exists between deficient kidney secretion and diseased pelvic 
 organs. Effective diuretics relieve many pelvic pains. Baths and 
 diaphoretics subdue innumerable neuralgias, and cathartics disperse dragging 
 pains. A woman may have a sound kidney (so far as chemical examination 
 of the urine may indicate) and yet reflex action from the genitals may 
 induce it to secrete deficient or excessive fluids or solids, which not only 
 further disturbs the genitals with waste-laden blood but disarranges the fine 
 balance in other viscera with the same. Wherever this waste-laden blood 
 advances it produces new points for reflex irritation, unbalancing the whole 
 system. It seems to me there is no better point to work from in this con- 
 sideration than the relation of the genito-urinary system to the abdominal 
 brain. Clinical features are more manifest here than elsewhere. Gynecol- 
 ogists may even cure women of innumerable ailments by simply inducing 
 them to drink water. I have accomplished much for women during the past 
 fifteen years by inducing them to drink a full glass of water, six times daily, 
 containing a pinch of Epsom salt in solution. The late Dr. J. H. Etheridge 
 wrote instructively on renal secretion in gynecologic patients. 
 
 During menstruation girls show distinct clinical symptoms of pain in the 
 region of the kidneys, and of variation in urinary secretion, showing the 
 close relation between this and pelvic disturbances. It is clear that this pain 
 in the kidney region is due to reflexes from the menstrual organs, i. e., the 
 uterus and oviducts. 
 
214 THE ABDOMINAL AND PELVIC BRAIN 
 
 The kidney, in proportion to its size, has the highest nerve and blood 
 supply of any viscus, except the uterus. According to the recent investiga- 
 tions at Johns Hopkins University, the kidney is supplied only by sympathetic 
 nerves. It is a common observation that abdominal tumors are followed by 
 kidney disturbances. Even the gravid uterus does not allow the kidney to 
 escape irritation. This kidney disease brought about by abdominal tumors 
 is reflex. It is a physiological principle that an influence acting through the 
 nerves alone can arrest all secretion. Minor degrees of irritation will suffice 
 to increase, diminish or change the kidney secretions. Irritation of an organ 
 continued indefinitely, and modifying its action, may be sufficient to induce 
 disease. Kidney disease resulting from abdominal tumors is chiefly chronic 
 from the very nature of the case. 
 
 The first point to consider, as the initial step in chronic renal disease 
 from abdominal tumors, is partial or complete obstruction to the flow of 
 urine. 
 
 The second point to consider in chronic renal disease due to abdominal 
 tumors is reflex irritation from distant viscera. 
 
 The third point of consideration is infection. 
 
 As regards the first point, obstruction, the location and size of the tumor 
 may be noted. A partially occluded ureter, through long-continued pressure, 
 will cause renal disease. Under this head would be classed mechanical 
 impediments to the flow of urine. If the obstruction is sufficient it will 
 create hydroureter. If the hydroureter is long enough maintained the kidney 
 will secrete until blood pressure is impaired, and then in a few months 
 atrophy will follow. The writer has proved by experiments on the dog that 
 when the ureter is completely ligated, the kidney will shrink to about one- 
 fifth its original size, in five months. 
 
 The pressure of the tumor on the ureter is a silent process not often 
 recognized by the attendant. The obstruction of the ureter is like the 
 quietly growing intestinal stricture, which is rarely recognized until some 
 terrible disaster reveals a long series of old pathological conditions. The 
 main idea in the obstruction, however, is that it is partial, and by raising 
 the difficulty of urine flow, renal elminiation becomes deficient. The blood 
 then becomes waste-laden. If the obstruction is sufficient, the result will be 
 hydroureter, which being long continued (without infection) results in renal 
 atrophy, as the writer proved by tying the dog's ureter. 
 
 The second point, reflex irritation, is more significant, because it means 
 that irritation from any viscus can be reflected to the kidney, over the renal 
 plexus. The abdominal tumor irritates some contiguous viscus; this irrita- 
 tion quickly passes to the abdominal brain, by way of the sympathetic 
 plexus of said viscus, where the forces are reorganized and transmitted to 
 the kidney. There is little doubt that the rise of temperature from passing 
 a sound into a man's bladder is due to reflex irritation transmitted from an 
 oversensitive urethra. It is probable that the so-called urinary fever is reflex. 
 It modifies circulation by inducing local anemia and local hyperemia. In 
 this way nutrition quickly changes. Examples may be seen in strictures of 
 
REFLEXES AFFECT SFCRETIOXS 215 
 
 the intestine or ureter where the walls above the stricture are greatly 
 thickened. 
 
 The chief point in regard to secretions in patients with abdominal 
 tumors is a decreased or disproportionate secretion. It is common to observe 
 a patient with a tumor secreting a small quantity of urine heavily laden with 
 salts. The amount of urine voided at times appears as an alarmingly small 
 quantity. Natural reasoning from clinical and physiological bases attributes 
 the decreased quantity of urine to the irritation from the tumor transmitted 
 over the renal plexus. Autopsies on women who die of tumors prove it 
 beyond the shadow of a doubt. 
 
 Disproportionate renal secretion from the irritation of abdominal tumors 
 is also common. Albumen is the chief element found. But phosphates, 
 urates or sugar make up the varying scales of salts. Even the amount of 
 water will vary within wide limits. 
 
 The tumor of pregnancy is a common example of disturbed renal 
 secretion due to reflex action. Thus deranged renal secretion is frequently 
 due to reflex irritation, depending on the presence of an abdominal tumor. 
 The change in the secretion consists in increase, decrease or disproportionate 
 quantities. As each organ has its own distinct nerve plexus, so it should be 
 understood that reflex action is carried along distinct anatomical lines. 
 
 As regards the third point, infection, in chronic renal diease from the 
 presence of abdominal tumors a serious condition appears. 
 
 The genito-urinary tract can be infected at any point from the kidney 
 cortex to the urethral end. If the tumor presses severely enough on the 
 urinary tract, a perforation will occur, and from this perforation infection 
 will travel in either direction — toward the urethra or toward the kidney. 
 
 The result of perforation of the urinal tract will be nephritis and cystitis. 
 The perforation is most likely to occur in the bladder, from which the infec- 
 tion ascends the ureters to the kidney. It is not necessary to have a large 
 tumor to perforate the urinal tract ; simply a suppurating focus is sufficient. 
 It is not necessary to have a complete perforation of the urinary tract to allow 
 infection to gain an entrance, for the germs, or their products (ptomaines), 
 may penetrate a thin pathological wall. The final result of an infected 
 urinary tract is ureteritis, with parenchymatous or interstitial nephritis. The 
 writer has observed some disastrous results from pyosalpinx perforating the 
 bladder and intestines. It may here be noted that Doran, a most excellent 
 observer, made post-mortem examinations of forty women who had died of 
 ovarian tumors, and thirty-two had severe kidney disease. This means that 
 80 per cent, of those who died from ovarian tumors had kidney disease. No 
 doubt the kidneys were diseased from the presence of tumors. Obstruction, 
 reflex action or infection was the causative factor of renal disease, resulting 
 from pressure of tumors. 
 
 A good sample of obstruction, reflex irritation and infection of the 
 urinal tract is seen in cases of gonorrhea in men which end in stricture and 
 "catheter life." The stricture generally arises in the urethra and marks the 
 onset of obstruction to the urinary flow. This increasing obstruction induces 
 
216 THE ABDOMINAL AND PELVIC BRAIN 
 
 constant reflex irritation, and yet the man is not subjectively or objectively 
 sick. But now he begins "catheter life," which means infection. It means 
 self-destruction by his own hands. Thus to obstruction and reflex irritation 
 of the urethra he has added the fatal infection carried on his catheter, which 
 too frequently makes the fatal march swiftly onward and swiftly downward. 
 
 The kidney suffers similarly from any abdominal tumor, and chiefly by 
 reflex irritation, which passes from the abdominal brain by way of the con- 
 tiguous plexus, where it is reorganized and emitted on the large renal plexus 
 to the kidney. The writer notes that those women who come to him for the 
 purpose of having tumors removed have a very variable quantity of urea in 
 the urine. At the Woman's Hosipal the writer has the urea tested in every 
 case of laparotomy, and the amount varies from five to eleven grains to the 
 ounce. The tumors appear to play a significant role in the production of 
 varying quantities of urea. 
 
 What has been said in regard to kidney disease by reflex irritation is 
 equally prominent in floating or excessively movable kidney. The dragging 
 of the kidney on the abdominal brain, through the renal plexus, unbalances 
 the viscera very distinctly. The patient suffers from nausea, from constipa- 
 tion, from disturbed secretion and circulation and from dull dragging pains. 
 The patient may sometimes suffer similarly from an artificially fixed kidney, 
 as I have observed often after a nephropexy of my own, when viscera, which 
 are normally excessively mobile or fixed, are dislocated, they lose a part of 
 their physiology, which is motion. 
 
 Calculus in the ureter is a typical sample of disturbance in the sympa- 
 thetic nerves. One of my patients was idle ten months before I removed a 
 ureteral calculus, and she suffered from an unblanced sympathetic nervous 
 system just as a woman would from diseased genitals. 
 
 Abdominal and pelvic tumors produce disease in the digestive tract. 
 Object lessons are not only impressive to children, but to adults. The 
 wonder is how the visceral organs can adapt themselves to growing and 
 movable tumors. To-day we removed an ovarian tumor the size of a child's 
 head with a narrow pedicle of seven inches. The tumor could be pushed 
 into almost any position of the abdomen. Yet this tumor, which the patient 
 has had for about ten months, appears to have told on her health. To be 
 sure it glided where it would without any apparent trouble, but doubtless 
 the continued, repeated and accumulated traumas on the other viscera main- 
 tained a constant story of visceral insult. Every step she took induced the 
 tumor to jog and roll around in the abdomen. Occasionally it would become 
 partially wedged in the pelvis, producing congestion and disturbed circulation 
 and insults to the delicate nerves of the peritoneum. This solid tumor was 
 not like the yielding, soft viscera; but wherever it would lie it pressed and 
 disturbed circulation. It is probably true that smaller tumors of the pelvis 
 and abdomen produce much more traumatic visceral insult than larger ones 
 which move but little. The real wonder was that such a tumor as the above 
 could glide about among the mobile viscera so long and not become rotated 
 on its axis. 
 
REFLEXES ALTER GLAND SECRETIONS 217 
 
 It is probable that secreting or glandular organs suffer the most from 
 abdominal tumors, because the main damage is through reflex action, and the 
 glands are the most highly supplied with sympathetic nerves. The digestive 
 tract should be studied by means of (a) sensation, (b) motion, (c) secretion, 
 (d) absorption. The slow, continuous pressure of abdominal tumors pro- 
 duces but little recognizable sensation in the digestive tract. Another point 
 is that from inexperience the patient cannot localize the pain in the digestive 
 tract, but refers it mostly to the abdominal brain; so that the subjective 
 sensation in the digestive tract, due to tumors, is of small value. As regards 
 motion in the digestive tract, in cases of abdominal tumors, one can say that 
 in the great majority of fair or large-sized tumors motion is diminished and 
 constipation is the rule. But the main study of damage of abdominal tumors 
 in the digestive tract will be through the secretions. Secretions are altered 
 in three ways: (a) they may be excessive, (b) decreased, or (c) dispropor- 
 tionate. 
 
 The final result is indigestion. The irritation from the tumor is carried 
 on the plexus of any contiguous viscus to the abdominal brain, where it is 
 reorganized and emitted to the digestive tract over the gastric plexus, the 
 superior mesenteric plexus and the inferior mesenteric plexus. In any case 
 the brunt of the forces ends in the ganglia which lie just below the mucous 
 membrane; the ganglia constitute what is known as Meissner's plexus, which 
 rules secretion. 
 
 If the irritation be of such a nature as to produce excessive secretion, 
 diarrhea may result. The excessive secretions will decompose, ferment, and 
 induce malnutrition. It is common to observe in women with tumors, spells 
 of indigestion, and especially in times of excessive irritability. No doubt at 
 such times the irritation assumes a prominence not experienced on other 
 occasions. If the irritation is of such a nature as to diminish secretion, con- 
 stipation will likely result. An inactive digestive tract is the forerunner of 
 non-elimination and a waste-laden blood. It is common to observe anorexia 
 for weeks at a time, accompanied by constipation, in women who have 
 tumors. No doubt the main chapter in altered secretion consists in what 
 may be termed disproportionate secretion. The elements which make up 
 the digestive fluid are not secreted in normal quantities; one element is 
 deficient and the other is excessive. The normal relations of acidity and 
 alkalinity are changed so that constant fermentation arises. Again, from the 
 irritation of an abdominal tumor, individual organs do not secrete their nor- 
 mal quantity or quality. 
 
 The liver may secrete excessively or deficiently. The pancreas may do 
 too much or too little. The irritation may cause segments of the alimentary 
 canal to secrete excessively or deficiently and thus destroy the finely balanced 
 secretion of the canal as a whole. The stomach enteron, small intestines, 
 may, by the irregular irritation, do too much or too little, or act irregularly. 
 This produces decomposition in the fluid and fermentation results. Such 
 women are continually troubled with "wind on the stomach." Diarrhea and 
 constipation quickly alternate and the result is frequent attacks of acute 
 indigestion. 
 
218 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Disproportionate secretion is the most frequent and disastrous, because 
 the irritation from the tumor is irregular. It storms one day and sleeps the 
 next. But the nature of irritation is to be inconstant and to rush pell mell 
 over the nerve [plexuses, or to assume a profound quietude. Irritation 
 scampering over the plexuses month after month is sure to be followed by 
 indigestion, malnutrition, anemia; and the final ending of the poor patient 
 is neurosis. 
 
 The subject of pressure cf abdominal tumors on the digestive tract may 
 here be considered. The effect of pressure acts in two directions: (a) on the 
 alimentary canal and (b) on the tumor itself. The effect on the canal may 
 be (a) to derange the secretion and motion of the segment pressed on; (b) to 
 perforate the canal; (c) to obstruct the canal. The more serious effect of 
 the tumor pressure on the digestive tract arises from the changes which result 
 in the tumor itself. The changes arising in the tumor from the alimentary 
 canal are: (a) inflammation, (b) adhesion, (c) suppuration and (d) rupture. 
 The main idea is that infection or its product (ptomaines) enters the tumor 
 through the gut wall. 
 
 It frequently happens in laparotomy that some part of the digestive tract 
 is firmly adherent to the tumor. The cause of this adhesion is the formation 
 of exudates into organized tissue which binds the intestinal wall and tumor 
 together. The irritation from the contact of the intestinal wall and tumor 
 induces the passage of germs or their products (ptomaines) through the wall 
 of the intestine, which gives rise to an exudate. The writer has fully 
 satisfied himself that considerable inflammation, adhesion and suppuration, 
 which are found to exist in tumors, are due to the passage of the morbid 
 matter through the intestinal canal. It is not uncommon for one to find 
 from an inch to a foot of intestine firmly attached to a tumor, when the great 
 gateway of infection, the oviducts, show no traces either ancient or recent. 
 The vermiform appendix is a certain source of infection, not only in abdomi- 
 nal tumors, but also of the genital organs. 
 
 Considerable inflammation and adhesion of intestines (and occasionally 
 of other organs) when abdominal tumors exist is accounted for by infection 
 passing through the intestinal wall into the tumor. As regards suppuration 
 in abdominal tumors, due to infection arisirg from the alimentary'' canal, it 
 may be said that it is only a stage in advance of inflammation, and that 
 inflammation is only a degree short of suppuration. So that in one sense 
 they are the same process. In the case of inflammation, the white blood- 
 corpuscles have conquered the invaders and resisted further progress; while 
 in suppuration the invading infection destroys whole fields of vital tissue, 
 leaving focuses of local death — necrosis. The pus formed by these infections 
 through the intestinal wall may be safety evacuated by way of the alimentary 
 canal. But frequently fatal issues follow either rapidly or through long 
 exhausting processes. 
 
 The sympathetic pathological course which abdominal tumors induce 
 in women are: (1) irritation, (2) indigestion, (3) malnutrition, (4) anemia, 
 and (5) neurosis. The irritation passes by reflex action to the digestive tract 
 
AXIAL ROT ATI OX OF TUMORS 219 
 
 (including the liver and pancreas). The irritation destroys in the digestive 
 tract (a) the rhythm of the liver, pancreas and alimentary canal by emitting 
 irregular forces over the plexuses at irregular periods (the reflex action has 
 no regard for rhythm); (b) the irritation produced by the tumor on the canal 
 destroys its motion; (c) it destroys its sensation; (d) it destroys its normal 
 secretion ; (e) it destroys absorption. 
 
 Indigestion is a natural result of imperfect rhythm, motion, sensation, 
 absorption and secretion of the alimentary canal. Long continued indiges- 
 tion results in malnutrition; which finally ends in anemia. In anemia the 
 fluid tissue known as blood is proportionately deficient in its constituents, 
 and the innumerable nerve ganglia being bathed in waste-laden and impover- 
 ished blood, the woman is finally reduced to an irritable condition, or 
 neurosis. 
 
 One of the strange features of abdominal tumors with long pedicles is 
 that so few rotate on their axes. In autopsies I have noted the spleen resting 
 on the pelvic floor with a long, narrow pedicle, but no symptoms of rotation. 
 Dr. Lucy Waite and I have removed tumors with astonishingly long and thin 
 pedicles with no symptoms of present or past axial rotation. Dr. Orville 
 MacKellar and I removed an ovarian tumor about the size of a year-old child's 
 head with a thin pedicle about eight inches long, with no symptoms of past 
 or present rotation. We could push the tumor all over the abdomen from 
 the pelvic floor to the diaphragm. We observed the long-pedicled tumor roll 
 about among the loose intestines after opening the abdomen, and wondered 
 why its pedicle did not twist. 
 
 However, I have removed tumors which had no pedicle. They had been 
 twisted off their pedicles by axial rotation and had assumed new beds, which 
 were nourished by the newly formed vessels from adjacent viscera and tissue, 
 especially the omentum. It is a significant fact, noted by all practical gyne- 
 cologists, that when a woman acquires a tumor, it may only be recognized, she 
 will frequently fret and chafe under it until she becomes nervous and irritable 
 and her coolness and quiet serenity leave her. She also tires easily and does 
 not sleep well. 
 
 Such a case came to me a few days ago, from whom Dr. Lucy Waite and 
 I removed an orange-sized ovarian tumor per vaginam. This lady I treated 
 seventeen years ago, when she was a blooming, vivacious girl. Some ten months 
 ago she began to complain of ill-defined symptoms. A general practitioner 
 treated her a year ago and examined the pelvic organs, but failed to find the 
 tumor. Finally, she and her husband decided to consult a gynecologist, and 
 came to me. In eight to ten months, from the rotation of the tumor, her 
 nervous system had lost its fine, even balance of former years. She slept 
 poorly, was irritable, appetite was poor, and she was easily tired out and had 
 lost all her old vivacity. It was all due to reflex action from a large orange- 
 sized pelvic tumor. The disturbance will disappear with the tumor. 
 
 Abdominal tumors should be removed on account of danger of axial 
 rotation. The literature which takes note of a tumor rotating on its axis 
 covers only about thirty years. Rokitansky, of Vienna, was among the first to 
 
220 THE ABDOMINAL AND PELVIC BRAIN 
 
 call attention to the subject. The writer estimates from literature and observa" 
 tion that about 8 per cent, of ovarian and parovarian tumors rotate on their 
 axes. In 1891 Mr. Tait told the writer that he had, up to date, sixty-two 
 cases of rotated tumors. While a pupil of Mr. Tait, for six months, the 
 writer saw four tumors rotated on their axes. Almost any abdominal or 
 pelvic tumor may rotate on its axis. The writer has observed in an autopsy, 
 rotation of the cecum and ileum on each other three-quarters of a turn, but 
 insufficient to obstruct the cecal current. Volvulus is only axial rotation of 
 the sigmoid on the mesosigmoid. In the intestinal tract volvulus occurs in 
 the sigmoid flexure in 60 percent, of cases; in 30 per cent, at the cecum, and 
 in 10 per cent, in the small intestine. Axial rotation of the digestive tract 
 constitutes about 1 per cent, of all intestinal obstructions. It is no doubt 
 due to a fatless, elongated mesentery (enteroptosis) and previous constipa- 
 tion. As regards the causes of axial rotation of abdominal tumors, the writer 
 is convinced that it is due to visceral rhythm. 
 
 The first rotated ovarian tumor I observed was in Prof. Czerny's clinic 
 in 1884. The tumor was removed with fatal issue. 
 
 Any viscus which possesses an elongated attachment may rotate more or 
 less on its axis. The uterus has been found rotated so as to demand opera- 
 tion. My assistant, Dr. A. Zetlitz, operated on a patient in whom the uterus 
 was found with almost a full rotation, due to a contracting cicatrix from an 
 old inflammatory attack. The kidney can, and does, rotate on its axis, 
 resulting in partial or complete obstruction — the obstruction of its ureter 
 causing hydroureter and the obstruction of the renal vein due to twisting, inter- 
 fering with circulation and nourishment. It is possible for the spleen, in cer- 
 tain abnormal conditions, to rotate on its axis. In one autopsy I found the 
 spleen on the pelvic floor with a thin, partially rotated pedicle. 
 
 Axial rotation of abdominal tumors may be partial or complete, acute or 
 chronic. An acute case generally acts in the following manner: A woman 
 has an abdominal tumor. She has a sudden onset of pain; she will perhaps 
 vomit. In twenty-four to forty-eight hours the abdomen will gradually 
 enlarge. If it enlarges very extensively, the patient becomes pale and faint. 
 The enlargement is the result of (a) the obstruction of the return'venous flow 
 from the tightness of the twist in the pedicle; (b) the dilatation of the veins 
 in the tumor, and (c) the rupture of a vein in the tumor. 
 
 The rigid-walled artery is difficult to occlude, and so keeps pumping its 
 stream of blood into the tumor. The soft-walled, easily compressible vein 
 is quickly occluded by the twist in the pedicle, and so all or nearly all the 
 blood pumped in by the artery is retained in the tumor. The consequence 
 is a sudden abdominal enlargement. Of course a woman may bleed to death 
 into her own tumor, and such cases are on record, confirmed by autopsy. 
 The tumor may twist so much on its pedicle that it may occlude both vein 
 and artery. I had such a case in a girl twenty years old. When the abdo- 
 men was opened the tumor was gangrenous. It may rotate so vigorously that 
 it will be entirely twisted off or severed from its connections. In such cases 
 the tumoi acquires nourishment from the surrounding viscera. The trauma 
 
AXIAL ROTATION TUMORS 221 
 
 resulting from the axial rotation induces sufficient irritation to produce an 
 exudate on the surface of the tumor. This exudate undergoes organization, 
 acquiring blood-vessels, nerves and lymphatics sufficient to nourish the tumor 
 without its old pedicle. The writer saw, with Mr. Tait, one tumor sufficiently 
 rotated on its pedicle to occlude the vein and artery, which was nourished 
 by innumerable delicate, newly organized processes of visceral tissue. 
 
 In my own practice, while performing laparotomy, I have been surprised 
 to find a dermoid ovarian tumor the size of a cocoanut entirely without a 
 pedicle. It was wholly nourished by omental adhesions. The patient gave 
 me a history of a severe attack four years previous, from which time pain 
 and tenderness continuously clung to her. My attention was first called to 
 axial rotation of tumors in 1884, at Heidelberg, in the clinic of Professor 
 Czerny. One day a middle-aged lady suddenly appeared in the clinic who 
 had come from her home in the country very sick. The professor put her on 
 the table and examined her carefully. She had a high pulse and temperature 
 and a dusky countenance. She appeared very ill. Professor Czerny said: 
 "Gentlemen, I cannot make the diagnosis. I will examine her again and 
 perhaps operate tomorrow." The writer anxiously waited until the next 
 day, when, sure enough, the woman was put to sleep on the operating table. 
 On opening the abdomen, a tumor the size of a melon appeared in the 
 wound. It was dark red in color, and Professor Czerny pronounced it gan- 
 grenous. It was easily removed and its pedicle ligated. That was a cyst 
 rotated on its axis ; and, besides, it was not gangrenous, as such tumors rarely 
 become gangrenous in the abdomen, and, if washed well, will show the color 
 of normal tissue. Gangrene generally comes from tapping such cysts, or the 
 digestive tract may infect them. Cases have been frequently recorded where 
 death followed tapping. Intestinal contents entered the cyst and infection 
 resulted. 
 
 Axial rotation of abdominal and pelvic tumors may pursue a chronic or 
 slow course. In such a tumor diagnosis is very difficult. The pain in such 
 cases will be almost wholly carried by the sympathetic nerve, and pain due 
 to irritation of the sympathetic is generally a dull, heavy ache. It is a drag- 
 ging pain. Cerebro-spinal nerves induce sharp, lancinating pain. So that 
 slow axial rotation of the abdominal tumors will be accompanied by dull, 
 heavy, dragging pain. It may be noted that whenever there is more than 
 one tumor in the abdomen the chances are very much increased for axial 
 rotation. Pregnancy enhances axial rotation much more than the presence 
 of a double tumor, because the uterus empties itself suddenly, and just after 
 labor the tumor is apt to rotate. The writer has seen Mr. Tait operate on a 
 woman six weeks after delivery for an abdominal tumor which rotated about 
 three times and a half on its pedicle. She was quite ill from delivery until 
 after the operation, when she rapidly recovered. 
 
 In my practice I have observed axial rotation of ovarian tumors, ileo- 
 cecal apparatus, sigmoid flexure, ovario — oviductal apparatus in a young girl, 
 with rotation of uterus. 
 
 The strikingly easy manner in which operators speak of gangrenous 
 
222 THE ABDOMINAL AND PELVIC BRAIN 
 
 tumors in the abdomen, with recovery, calls for objections. Recovery after 
 gangrene or local death in the abdomen is extremely rare. What is usually 
 called gangrene is simply tissue filled with venous blood. 
 
 Now, if this dark tissue is removed and well washed, the gangrenous idea 
 will be dispelled by the frequent appearance of normal white tissue. Air 
 must in some way get to a tumor to admit of gangrene, and air enters by (a) 
 tapping, (b) digestive tract, (c) genito-urinary tract. If a cyst has rotated 
 sufficiently to twist off its pedicle and become nourished by adhesions to 
 adjacent viscera it is more dangerous than the original tumor on account of 
 its fixation and adhesions. It is generally more liable to infection from the 
 natural channels, from its more extensive vascular connection. A tumor 
 should be removed from its liability to axial rotation. A tumor rotated on 
 its axis is dangerous to a patient from (a) hemorrhage into the cyst, (b) gan- 
 grene, (c) because it may unduly enlarge from filling the veins of the tumor, 
 (d) it may become fixed by adhesions and thus endanger the viscera, a fixed 
 tumor being more dangerous than a movable one, (e) it may become infected 
 and suppurate, (f) chronic axial rotation may exhaust a patient by pain, (g) 
 it may result in trauma to viscera or perforation of viscera by pressure. 
 
 Abdominal tumors should be removed on account of the danger of 
 rupture. It is a fact, which the writer has definitely observed, that tumors 
 (ovarian and parovarian) will repeatedly rupture and fill in the living woman. 
 In one case under my care the parovarian cyst repeatedly ruptured and filled 
 during a year's personal observation. At the time of rupture the young 
 woman of twenty-four would experience a sense of relief. The abdomen 
 would become flattened and during a few succeeding days she would urinate 
 frequently and profusely. Years previously the writer had demonstrated 
 that if a dog's peritoneal cavity was filled with water he would urinate 
 profusely for two or three days. In removing ovarian tumors the writer has 
 found old scars where such cysts had ruptured and refilled. The rupture 
 may be due to violence or the continued pressure on some point of the 
 tumor, thinning its walls so that leakage occurs. 
 
 A rupture of non-infected cyst does no harm to a woman, but when a 
 cyst containing infected material ruptures in the abdominal cavity death is 
 almost inevitable. Hence, such tumors which menace life should be removed 
 on discovery. Cystic abdominal tumors are apt to rupture from increase of 
 abdominal pressure, which, being sustained for a long time on single points 
 of the cyst, either thin its walls so that they will leak, or rupture them by any 
 violence. In one case the writer removed an ovarian tumor which gave a 
 distinct history of rupture one year previous. A distinct scar about the size 
 of a fifty-cent piece was found on the cyst to tell the story of rupture. 
 Abdominal tumors may endanger life by rupturing into hollow viscera as 
 intestine, bladder, or vagina. From such rupture infection is almost sure to 
 follow. The worst infection follows rupture into the digestive tract, and sec- 
 ond into the bladder. The writer has removed ovarian tumors with success 
 which had ruptured into the digestive tract and almost destroyed the patient 
 by chronic suppuration and exhaustion. About the worst of such tumors are 
 
REFLEXES FROM TUMOR PRESSURE 223 
 
 ovarian dermoids, which rupture into the sigmoid or rectum, for they make 
 such dangerous adhesions. The two cysts may press so hard and long against 
 each other that the walls in contact will fuse and the rupture will occur in 
 the fused septum, which complicates by more adhesions and size of tumor. 
 
 The pressure occasioned by abdominal tumors demands their removal. 
 A tumor pressing for a long time against a gut wall may thin it so that germs 
 or their products may pass into the tumor and infect it. Inflammation fol- 
 lows and may be accompanied by suppuration. But pressure must be 
 observed to take place in two directions, viz., toward the tumor and toward 
 the viscus. The damage from pressure in the abdominal tumors is threefold : 
 (a) the effect of pressure on viscera: (b) the effect of pressure on the tumor, 
 and (c) the effect of the pressure on the function of viscera, both remote and 
 distant. This last idea was discussed under reflex action. It was shown 
 how abdominal tumors induced hydroureter by partial or complete occlusion 
 of the ureters. Tumor pressure will even induce interstitial and parenchy- 
 matous nephritis. Three-fourths of women long possessing abdominal 
 tumors have kidney disease. The tumor may press on some segment of the 
 digestive tract and induce obstruction of the fecal current, either mechanic- 
 ally or by reflex paralysis. The main point of pressure is on some fixed por- 
 tion of the intestine, the rectum, sigmoid or colon. 
 
 The canals, ureter or intestine, curiously maintain their patency for a 
 long time on account of their continual dilatation and contraction. The 
 writer has seen these canals entirely surrounded by dense tissues of tumors, 
 but a distinct tunnel still existed through the tumor, considerably larger than 
 the empty collapsed canal. The abdominal tumors, in a word, by pressure, 
 induce obstruction, mechanically or by reflex irritation (spasm or paralysis), 
 and should be removed. The continued pressure gives rise to (a) inflamma- 
 tion, by allowing infection to travel; (b) the inflammation may go on to 
 suppuration and end in perforation, internally or externally. 
 
 The effect of pressure on the circulation (vascularity) is very apparent 
 It acts mainly, or the effect is more evident, on the great venous plexuses. 
 The hemorrhoidal from the inferior mesenteric suffers the most, as many of 
 such patients have hemorrhoids. The effect of the pressure on the plexus 
 pampiniformis is also plain, as also on the vaginal plexus and the venous 
 bulb of the pudendum. Areas of tissue become cedematous. The limbs 
 swell. The pelvic organs suffer the main brunt from mechanical pressure, 
 while distant organs evidently suffer most from reflex action. The effect of 
 mechanical pressure on circulation is (a) congestion, (b) oedema, (c) dilation 
 of veins (hemorrhoids). It must not be forgotten that since the sympathetic 
 is mainly distributed to blood-vessels the reflexes from pressure|on the vessels 
 are effective and profound, local and general. 
 
 The writer has noted the effect of tumors on the color of the skin for a 
 long time. It has been recognized that pigmentation arises mainly from the 
 spleen. Jastrowitz started the view that the spleen was the source of 
 pigmentation, by dividing the sympathetic plexus going to the spleen on the 
 spiral splenic artery. This experiment enhanced pigmentation. No doubt 
 
224 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 the liver is a second source of pigment, from the fact that it buries red 
 corpuscles, and pigmentation is very noticeable in malaria which profoundly 
 affects the liver (and spleen also). But still the spleen may be credited with 
 the main origin of pigmentation. The writer has noted nearly all colors of 
 pigmentation (brown, black and yellow) in such women, especially in a 
 woman who has had a tumor a long time. The author saw a woman last 
 month who had had a tumor for sixteen years. Her color was a deep brown 
 and yellow, with patches of atrophied, glistening skin interspersed. The 
 tumor disturbs the rhythm of the spleen. The spleen is capable of a rhythm 
 by (a) its elastic covering of peritoneum, (b) its elastic capsule, (c) by the 
 power of its cells to enlarge on receiving excessive blood. When the tumor 
 irritates the splenic plexus it destroys its rhythm, and hence its nourishment. 
 The nourishment being disturbed, the distribution of its products— pigment — 
 will be disturbed. Irritation induces the spleen to produce excess of pigment. 
 The parts of the body most intensely pigmented are those -exposed to air. 
 Yet the pigmentation is general. The simplest example of pigmentation is 
 observed in pregnancy, which is generally localized in the genitals, breasts 
 and linea alba. 
 
 But abdominal tumors create more definite and general pigmentation. 
 The pigmentation is effected by the irritation passing to the abdominal brain, 
 where it is reorganized and emitted to the spleen. 
 
 The irregular forces coming at irregular intervals to the spleen derange its 
 rhythm, and consequently its nourishment. Pigmentation is the result of a 
 silent process accomplished by reflex irritation, and shows general derange- 
 ment of the visceral economy. It is merely the outward manifestation of 
 profound processes, indicating removal of the offending invader. It is diffi- 
 cult to convince physicians that a laparotomy is really demanded to remove 
 adhesions. Adhesive bands have blood-vessels, lymphatics and nerves. 
 
 A tumor should be removed because of its danger to create adhesions, 
 but after they have formed they often require removal. They should be 
 removed when they give rise to pain, when they distort and unbalance the 
 viscera. They may occasion obstruction to any hollow viscus. They may 
 strangulate some viscus. 
 
 Even the lungs do not escape the evil influence of the presence of the 
 abdominal tumor. The disturbance in the lung is mainly due to reflex irri- 
 tation which disturbs the rhythm of the lungs. 
 
 Abdominal tumors should be removed, from their liability to become 
 infected. 
 
 The question may be asked, How does an abdominal tumor become 
 infected or inflamed? Tumors frequently become infected, as is easily 
 attested at the operation, by observing adhesions — the result of infection. 
 
 The great highway by which abdominal tumors become infected is 
 through the oviducts. Any laparotomist can easily see that inflammatory 
 exudates arise at the fimbriated ends of the oviducts, and from there spread. 
 The infection travels by natural routes, especially along mucous channels. 
 It travels particularly through the left oviduct, because, as the writer has 
 demonstrated, the lumen of the left tube is larger than that of the right. 
 
TUMORS LIABLE TO INFECTION 225 
 
 The second great highway of infection of abdominal tumors is through 
 the digestive tract. Germs or their products pass through the intestinal wall 
 at pressure points and infect the tumor. 
 
 The third channel of infection is through the genito-urinary tract. A 
 fourth is by tapping, allowing air to enter. The table presented with this 
 article will show at a glance the reasons for removing abdominal tumors: 
 
 EFFECTS AND CONSIDERATIONS FOR THE REMOVAL OF ABDOMINAL PELVIC TUMORS. 
 
 Heart— 
 
 1. Irregularity. 
 
 2. Hypertrophy. 
 
 3. Fatty degeneration. 
 Lungs — 
 
 1. Disturbed rhythm — asthma. 
 
 2. Catarrh — anemic, hyperemic. 
 Liver — 
 
 1. Disturbed rhythm. 
 
 2. Disturbed secretion. 
 
 3. Pigmentation. 
 
 4. Nerve influence can check all secretion. 
 
 (a) Excessive secretion. 
 
 (b) Deficient secretion. 
 
 (c) Disproportionate secretion. 
 Kidney — 
 
 1. Nerve impression can check all secretion. 
 
 (a) Excessive secretion. 
 
 (b) Deficient secretion. 
 
 (c) Disproportionate secretion. 
 
 2. Reflex irritation. 
 
 3. Obstruction (hydronephrosis). 
 
 4. Infection. (a) Parenchymatous inflammation. 
 
 (b) Interstitial inflammation. 
 Digestive Tract — 
 
 1. Sensation. 
 
 2. Motion. 
 
 3. Secretion. 
 
 4. Pressure. 
 
 5. Absorption. 
 
 (a) Excessive secretion. 
 
 (b) Deficient secretion. 
 
 (c) Disproportionate secretion. 
 
 (a) Inflammation. 
 
 (b) Suppuration. 
 
 (c) Perforation. 
 
 (d) Adhesions. 
 
 15 
 
226 THE ABDOMINAL AND PELVIC BRAIN. 
 
 Spleen — 
 
 1. Disturbed rhythm. 
 
 2. Pigmentation. 
 Bladder— 
 
 1. Pressure. 
 
 2. Perforation. 
 3» Cystitis. 
 
 Inflammation — 
 
 1. Through oviducts. 
 
 2. Digestive tract. 
 
 3. Genito-urinary tract. 
 
 4. By tapping. 
 Circulation— 
 
 1. Congestion. 
 
 2. CEdema. 
 
 3. Hemorrhoids 
 Suppuration — 
 
 1. Infection. 
 
 2. Fistula. 
 
 3. Adhesions peritoneal. 
 
 SYMPTOMS. 
 
 Axial Rotation — 
 
 1. Due to visceral rhythm. 
 
 2. Ten per cent, of ovarian and parovarian tumors rotate. 
 
 3. Pregnancy and other tumors enhance axial rotation. 
 
 4. Diagnosticated by sudden pain and increase in size of abdomen. 
 Rupture — 
 
 1. Sudden changes in form of abdomen. 
 
 2. Diuresis. 
 
 3. Diarrhea. 
 
 4. Cystitis. 
 Pressure — 
 
 1. Inflammation. 
 
 2. Infection. 
 
 3. Perforation. 
 
 4. Hydroureter. 
 
 5. Obstruction. 
 
 6. (Edema. 
 Adhesions — 
 
 1. Induce pain. 
 
 2. Check peristalsis. 
 
 3. Cause reflex rhythm. 
 
 4. Disturb secretion. 
 
CHAPTER XIX. 
 
 THE ABDOMINAL AND PELVIC BRAIN WITH AUTOMATIC VIS- 
 CERAL GANGLIA WITH REFERENCE TO SEXUAL ORGANS. 
 
 "Instinct is a propensity prior to experience and independent of instruction." — 
 Paley. 
 
 "Probability is the rule of life." — Butler. 
 
 At this point I desire to call attention to the following points: 
 
 1. The intimate and profound connection of the genito-urinary organs 
 with the sympathetic (and cerebro-spinal) nervous system. 
 
 2. Its connection with the rectum and relation to coition. 
 
 3. The relation of the pelvic organs to *he larynx (voice) ; the fifth (gan- 
 glionic) cranial nerve, stomach and eyes. 
 
 4. Automatic menstrual ganglia. 
 
 5. The menopause. 
 
 Every observing physician sees a close connection between the genital 
 organs and the nervous system. This is not strange when one considers 
 existing conditions and the long-continued effect of evolutionary forces. Of 
 all the instincts in the animal race, the sexual instinct is dominant. This 
 instinct has an all-pervading influence in every species of animal. It governs 
 their actions. It forms habits in their lives. It induces new phases of 
 existence. All through the stages of animal evolution, every other instinct 
 must bend to the sexual. Physical and mental forces wonderfully combine to 
 make this instinct the most effectual in its consummation. The sexual 
 instinct dominates most powerfully the males, and hence the physical and 
 mental vigor of the best animals in the race survive. The cow in rut is 
 served, from sheer physical and mental vigor, by the most powerful bull. In 
 herds of animals the sexual instinct dominates most vigorously in the finest 
 males, and the weak males are cast aside that the strong ones may become 
 the parents. 
 
 The main study of zoology is reproduction. The weapons of offense and 
 defense possessed by males are primarily to cultivate and defend the sexual 
 instinct. The horns of bulls, the powerful heels of stallions, the eagle's talons, 
 and the claws of powerful feet are the weapons to defend and to carefully 
 cultivate this dominant instinct of animal life. When we pass to man, 
 the sexual instinct is rather heightened than diminished. But in man it is 
 more subtle; secretly in the depths of man's mental forces lies his sexual 
 instinct. As he has gained the ascendency in animal life by his mental 
 activities, in this light alone can be studied his sexual instincts. Thus in the 
 lowest form of physical existence sexual instincts dominate, yet in the higher 
 forms of mental existence these instincts are still more powerful. 
 
 227 
 
228 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 From such premises, patent to all observers, it is quite obvious that 
 evolutionary forces have through long ages established a very close connec- 
 tion between the nervous system and the genitals — the organs which gratify 
 the sexual instinct. Forces (mental or physical) acting through eons of ages 
 establish definite results. The increase of man's intelligence is not in pro- 
 portion to the increase of ganglion cells, but by the increase of conducting 
 cords. Chicago and New York may each represent a ganglion cell, and a 
 single railroad may represent the conducting cord. Now, when there was but 
 one railroad between New York and Chicago, little business could be done 
 on account of the limited amount of commerce which the single road would 
 accommodate. Chicago and New York, as the ganglia cells, could dispose of 
 far more business than the single road would transmit. But when the rail- 
 roads multiplied between the two centers, the business increased just in pro- 
 portion to the number of roads or conducting lines. Now, ages of natural 
 forces have established numerous lines, and vigorous lines, of connection 
 between the genitals and the nervous system. The facts which dissection 
 show are positive in demonstrating the widespread and intimate connection 
 of the genitals with the cerebro-spinal and sympathetic system. 
 
 The ganglion cells can receive and dispose of far more mental work than 
 a few conducting cords can transmit; so that the progress and advance 
 toward a higher nervous system and a higher intelligence is an increase in the 
 conducting cords or lines to transmit intelligence or ideas. Also a well 
 developed periphery is an absolute necessity for the purpose of collecting 
 ideas for transmission. An increasing sensitive periphery is required to 
 perceive the forces and comprehend ideas so that they can be sent to the 
 central ganglion. Now, the number of conducting cords which attach the 
 genitals to the nervous centers is simply enormous. Besides, the nerve 
 periphery, situated in the external genitals, is highly sensitive and highly 
 developed, so that it quickly perceives and quickly transmits the slightest 
 sensation, and evolutionary forces through the ages seem to increase the 
 sexual instinct with the progress of intelligence and mental growth. 
 
 I base these remarks on years of careful dissection of cadavers and of 
 animals. If one carefully dissects a male body he will note the extensive 
 cerebro-spinal nerves supplying the genitals, especially the penis. Of the 
 spinal nerves supplying the genitals, the main one is the pudic. But the 
 pudic nerve is composed of nearly all the third sacral, and branches from the 
 second and fourth sacral. As one examines this nerve he is forced to the 
 conclusion that it is an enormous supply for a small organ. 
 
 The periphery of the pudic nerve spreads itself like a fan over the geni- 
 tals. The branches of this fan-like nerve-apparatus supply also the bladder 
 and rectum — organs which must act and work in harmony. Hence the great 
 disturbance which arises in the pelvis (bladder, rectum or genitals) when any 
 one organ is damaged — e. g., a rectal fissure, a urethritis, or penile irritation 
 quickly disturbs the whole system. The connection of the pudic nerve with 
 the external genitals (where sensation is experienced) is vast. Not less 
 remarkable is the wonderfully harmonious action of the bladder, rectum and 
 genitals through large branches of the same pudic. 
 
GENITALS RICH WITH NERVES 229 
 
 Another peculiar spinal-nerve connection of the external genitals is the 
 supply of the pudendal nerve to the lateral walls of the penis. I have time 
 and again called the attention of medical men to the peculiar connection 
 between the gluteus maximus muscle and the external genitals by means of 
 the pudendal nerve or branch of the lesser sciatic. The gluteus maximus is 
 the real muscle that holds man upright (physically), but it is also the main 
 muscle of coition. The lesser sciatic nerve supplies only one muscle, and 
 that is the gluteus maximus, and then sends off the large pudendal branch to 
 the sides of the penis, and hence the friction of coition induces active con- 
 tractions of the gluteus maximus. The spinal-nerve supply to the external 
 genitals is mainly the large pudic and pudendal nerves. In woman the pudic 
 nerve is equally large; but the pudendal nerve is much smaller in woman 
 than in man, according to my dissections. The lesser size of the pudendal 
 nerve in woman is in direct accord with the methods of cohabitation. The 
 vigorous and aggressive activity of man in coition, and the quiet passive 
 receptivity of woman, explains the larger pudendal nerve in man. But the 
 reverse nerve supply arises in regard to the glans elitoridis and the glans 
 penis. I have dissected many a clitoris, and its nerve supply is three or 
 four times as large as that of the penis in proportion to its size. The 
 clitoris is a veritable electrical bell, which, when irritated, rings up the whole 
 nervous system. There is no doubt that adhesions of the prepuce to the 
 clitoris have led to masturbation in girls. Every gynecologist should 
 examine the clitoris, and, if preputial adhesions exist, simply break them up, 
 for the vast nerve supply of the clitoris gives great chances for profound 
 irritation. The poor girl, neglected by the mother and possibly by the 
 doctor, is soon induced to become a masturbator. 
 
 But the extensive spinal-nerve supply to the external genitals, though 
 vast and intimate, is but a small matter relative to the supply to the internal 
 genitals. The spinal-nerve supply to the external genitals is mainly sensitive, 
 so that the sexual instinct may be gratified by the organs. What I wish 
 mainly is to call attention to the profound connection of the internal genitals 
 with the nervous system by means of the sympathetic system. It is in 
 this field that the gynecologist and the genito-urinary surgeon find full play 
 for lucrative operations — for so-called aggressive surgery. In manipulations 
 and instrumental examinations of the genitals one sees the nerve storms flash 
 over the system. These nerve storms radiate over distant nerve plexuses 
 like electricity over a system of wires. Take, for example, the uterus. Its 
 sympathetic nerve supply is enormous. The cervix only, so far as I can see, 
 has spinal nerves, while the body and fundus are supplied by the sympathetic. 
 One can count some twenty or thirty strands of nerves in the hypogastric 
 plexus which originate in the abdominal brain and terminate in the uterus, 
 and the nerves are very large. The ovarian plexus — a very large plexus — 
 goes from the abdominal brain, and many of the nerves of this plexus termi- 
 nate on the oviducts and fundus of the uterus so that the sympathetic nerve 
 supply of the uterus is enormous. A large nerve supply to any organ sub- 
 jects it to the danger of sad complications and stubborn pathology. I have 
 
230 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 seen a patient in the gynecological chair make active efforts to vomit in less 
 than fifteen seconds after careful introduction of the sound. In those few 
 seconds a complicated nervous phenomenon had occurred. The irritation 
 of the endometrium had been flashed up the hypogastric plexus to the 
 abdominal brain, and there it was reorganized and dashed over the various 
 plexuses to other viscera. 
 
 The irritation, no doubt, went to every viscus similarly, but the stomach 
 manifested itself in motion (vomiting). The heart, lungs, liver, spleen and 
 digestive organs no doubt suffered similarly, but the) 7 were better able to 
 resist the irritation. A study of the hypogastric plexus and its action on the 
 uterus convinces me that pressure on the aorta for post-partum hemorrhage 
 is generally explained wrongly. It is said the pressure obstructs the blood, 
 but in reality the pressure on the hypogastric plexus irritates the peripheral 
 ends in the uterus, and induces it to contract. 
 
 This is more reasonable. The dominating influence of uterine disease is 
 due to the vast and intimate connection of the uterus (oviducts and ovary) 
 with the sympathetic nervous system. Besides, a great and complicated net- 
 work of nerves is easily deranged. The importance of the uterus demands a 
 vast and complicated nerve supply. It may be laid down as a general prop- 
 osition that the viscera have their normal function in rhythm, and the 
 disturbance of the rhythm induces disease. The main pathology of the 
 sympathetic is reflex action from some distant viscus. 
 
 The ganglia controlling the viscera are entirely out of the control of the 
 will. If the visceral movement was not involuntary or out of the mental 
 sphere men would speculate and experiment on their viscera. This fact no 
 doubt explains the curious action of neurotic women. The nerve storms 
 which emanate from a pathological uterus flash over the whole system by dis- 
 tinct nerve plexuses, and, as the will does not control any of such reflexes, 
 the patient acts on the induced feelings. The close nervous connection of 
 the uterus with the nervous system is at once seen in the great changes which 
 uterine disease induces in both the mental and physical life of a woman. 
 But anatomical facts, physiological experiment, and clinical study all show 
 that the genitals and nervous system are more highly and intimately con- 
 nected than any other system. No organ influences a woman mentally or 
 physically to such a degree as the uterus — the autocrat of menstrual life — 
 even in its normal physiological and anatomical condition, while its patho- 
 logical condition is still more manifest. It is owing to the very distinct 
 connection of the genitals with the cerebro-spinal and sympathetic system. 
 Let a woman's genitals become pathological and she acquires liver disease 
 and indigestion and becomes anemic and neurotic. Uterine disease also 
 induces eye disease and heart trouble, and the joints and muscles do not 
 escape. Pelvic diseases are often accompanied with hip, knee or ankle 
 trouble. This is no doubt due to the intimate connection of the uterus with 
 these joints through the sacral plexus; e. g., the sacro-iliac joint, the hip 
 joint, and the knee joint are all supplied by three distinct nerves — the 
 great sciatic, the anterior crural, and the obturator. Now, these three nerves 
 
GENITAL NERVES ABUNDANT 231 
 
 are really the sacral plexus. A cold contracted at the monthly period from 
 wet feet is explained no doubt by close connection of the uterus with the 
 sacral plexus, for the lower end of the sacral (the sciatic nerve) supplies the 
 feet. The disturbed circulation in women afflicted with uterine disease 
 is owing to the powerful reflexes sent over the great hypogastric plexus, 
 and the normal rhythmical contractions of the heart and its blood-vessels 
 are broken by reflex due to uterine disease. 
 
 But it is not the woman only who is afflicted with reflexes from the 
 genitals. The genito-urinary surgeon who deals with men afflicted with 
 urethral disease knows the effect often of the mere introduction of a sound 
 into the bladder. A healthy man will frequently faint from the introduction 
 of a sound, and if the urethra or genitals are long diseased he will be pro- 
 foundly shocked. This means that the urethra is extraordinarily supplied with 
 nerves. I do not see, so far, any better explanation of so-called urinary 
 fever after the introduction of a catheter than that it is "reflex." The 
 urethral irritation may travel in two ways and act in two ways: (1) It may 
 travel up the spinal cord, to the heat center either by the sacral plexus 
 through the cord or by the splanchnics through the cord and thus disturb 
 the heat center. (2) But more probably the urethral irritation is trans- 
 mitted up the hypogastric plexus to the abdominal brain and is reor- 
 ganized and emitted on the various plexuses. 
 
 It travels on the renal plexus more vigorously, owing to the more inti- 
 mate connection existing between the kidney and the genitals — e. g., the 
 ureter has a plexus, the testicle has a plexus, and, also, a part of the hypo- 
 gastric plexus forms part of the renal plexus; furthermore the kidney and 
 genitals originally arose from the same body — the Wolffian. 
 
 Now, the reflex irritation induced by the catheter on the urethra then 
 flashes up the hypogastric plexus, and the reorganized forces are sent to the 
 kidney and the irritation acts on the kidney to change its circulation ; it is 
 congested and urinary fever follows. The fainting of patients on the intro- 
 duction of a catheter is explained on the same principle. The high nerve 
 supply to the urethra being disturbed, the irritation is transmitted to the 
 abdominal brain, where it is reorganized. The reorganized forces are then 
 radiated on the various sympathetic splanchnics to the three cervical ganglia 
 and are then transmitted by their three nerves to the heart, which is induced 
 to move in a riotous manner. The heart is weakened and the patient faints. 
 The irritation of the genitals being sent to the abdominal brain, it induces 
 dilatation of the abdominal visceral circulation, and this probably explains 
 the rise of temperature. Occasionally the introduction of a sound kills a 
 patient, but that may be due to the weakness of the patient after a long-con- 
 tinued exhausting disease. Thus the nerve storms arising from the genitals 
 are entirely due to the abundant and exhausting nerve supply. The irregular 
 nerve storms arising in genitals highly supplied by nerves are profound in 
 their invasion of the whole system. They pervade all active organs and 
 disturb rhythm and induce further reflexes. Reflex action from the sympa- 
 thetic explains much — e. g., when a man begins the "catheter life" he rings 
 
232 THE ABDOMINAL AND PELVIC BRAIN 
 
 his own death knell; by the use of the catheter he induces reflexes which 
 will remorselessly follow him until death. Besides, he introduces infection 
 into the urethra and kidneys by the dirty catheter. 
 
 Thus the man goes through three stages on his road to the grave: (1) He 
 has acquired some form of obstruction to the outflow of urine from kidney 
 to penis; (2) he introduces the catheter, which calls up the wide domain of 
 reflexes; (3) he introduces infection, and death follows. If the genitals were 
 not so highly supplied by nerves, the terrible reflexes would not arise. As an 
 application of the extensive supply of sympathetic nerves to the genitals and 
 its wonderful reflexes, examine for a moment the result of coition. 
 
 The role played by the vaso-motor centers should not be lost sight of. 
 I have found, time after time, that the ganglia of the lateral chain of the 
 sympathetic, situated at the root of the pudic (third sacral), were very large, 
 and this will aid in transmission of irritation. 
 
 Conclusions. 1. The sexual instinct is the most dominant instinct of 
 animals. 
 
 2. Evolutionary forces have linked the abdominal sympathetic nervous 
 system and the genitals by numerous and intimate bands which increase with 
 the progress of higher development — i. e., sexual instincts dominate and 
 influence man, as well as the monkey and the ape, far more than the lower 
 grades of animals. 
 
 3. By reason of the growing and increasing intimate relations between 
 the genitals and the nervous system, mental forces play a greater role in the 
 production of disease. 
 
 4. I have observed that the monkey is an inveterate masturbator in 
 confinement, and his persistent attention to the genitals shows^that the 
 sexual instincts keep pace with mental progress. 
 
 5. The severe shock arising from hysterocotomy shows that the uterus 
 has an extensive nervous connection with the abdominal brain. In this 
 operation one severs the great hypogastric plexus, and I have seen an alarm- 
 ing rise of temperature (103° F.), disturbed respiration and circulation, all 
 from cutting the hypogastric plexus. The disturbance was not due to infec- 
 ttion, as almost all of it arose a few hours after the operations. Occasionally 
 removing the appendages shocks, but, as the ovarian plexus is small, the 
 shock is limited. 
 
 6. The genital and the urinary organs both arise from the Wolffian body, 
 so they are anatomically and physiologically connected, and both have an 
 enormous nerve supply, so that damage to one often injures the other by 
 reflex — e. g., hysterectomy has caused death by inducing nephritis a few days 
 succeeding the operation, the test-tube revealing three-quarters albumin 
 under the heat test. 
 
 7. The close connection between the genitals and nerve system is 
 clearly seen from the terrible nerve storms which flash over the system from 
 irritation (manual, instrumental or pathological) of the genitals — e. g., 
 irritation of the clitoris quickly disturbs the whole nerve balance. 
 
 8. The great nerve connection of genitals and centers indicates that all 
 
GENITAL IRRITATION CREATES REFLEXES 233 
 
 irritation should be at once removed. All preputial adhesions on the clitoris 
 should be broken up, and the same with those of the prepuce. In short, all 
 pathological conditions of the genitals should be at once righted, so that the 
 nerve balance may be maintained. 
 
 The reports of fainting and vomiting and even death during coition have 
 a scientific interest in view of the present subject. The celebrated Russian 
 general, Skobeleff, died while cohabiting with a woman of ill-fame. Attila, 
 king of the Huns, died while holding sexual relations with his young wife. 
 In a small town in Ohio, a man nearly 70 years of age was reported to have 
 died during coition. Stock men have made interesting reports in regard to 
 animals. A mare put to a stallion fell dead at the end of coition. Young 
 male animals have often fainted when first allowed to serve the female. 
 The dog coition is prolonged, which limits shock. A dog has no semen sacs. 
 The boar has an intensely violent coition, with consequent effect on his 
 viscera, as in respiration and circulation. Young stallions are the most lia- 
 ble to faint of any of the domestic animals. Young bulls become weak, 
 exhausted and tremble at first coition. A medical acquaintance related to 
 me a death in a middle-aged man about an hour after coition. 
 
 Dr. Miller related two instances which interested him very much because 
 he did not understand the explanation. A man about 60 years of age, 
 while walking to the door a few minutes after cohabiting with a strange 
 woman, fell and died immediately. In another case, at the first coition the 
 young husband fainted, and the sphincters relaxed, defecation and urination 
 resulting. One can easily observe in domestic animals that, especially in the 
 male, the respiratory rhythm is disturbed — slowed for a while and then 
 quickened. The heart will also be disturbed in its rhythm — slowed for a 
 time and then quickened. The explanation of these phenomena lies in the 
 sympathetic ganglionic system. The vesiculae seminales are very highly 
 supplied by the hypogastric plexus of nerves. As soon as the irritation is 
 produced on the nerves of the semen sacs, it is carried to the abdominal brain. 
 Then the irregular, stormy irritation accumulated in the abdominal brain is 
 radiated on the various plexuses of nerves, especially in the direction of least 
 resistance. The disturbance of rhythm will be most manifest in that organ 
 which is weakened or most sensitive. 
 
 We will consider first the sudden deaths which are due to rupture of 
 blood-vessels in the brain. Such sudden deaths are apt to occur in elderly 
 men who have weak arteries, and also death is more liable to occur when the 
 man is cohabiting with a strange woman for the first time, when he will be 
 the most excited. Such deaths seldom occur with men who repeatedly 
 cohabit with the same woman, when excitement is but ordinary. The 
 explanation is, that the irritation goes from the semen sacs, during the spasm 
 of expulsion, to the abdominal brain. Here the irritation is reorganized and 
 radiated to the vaso-motor center. The irritation may also go up the spinal 
 cord to this center. The disturbance in the vaso-motor center produces nar- 
 rowing of the caliber of the peripheral blood-vessels and thus the blood- 
 pressure is suddenly raised. At the same time the heart is slowed and hence 
 
234 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 the force is increased. It pumps the blood vigorously into the arteries and 
 the weak wall gives way under the sudden pressure. The weak cerebral 
 artery yields to the excessive blood-pressure, and death follows immediately 
 from blood extravasation. It will be noted that all such deaths have occurred 
 with elderly men who generally have weak, atheromatous arteries, with 
 degenerated walls. 
 
 In cases of vomiting and fainting, the law is just the same. The irrita- 
 tion due to the emptying of the semen sacs is conveyed to the abdominal 
 brain or up to the spinal cord. The disturbed energies are reflected to the 
 heart and stomach, and fainting and vomiting are apt to arise. It comes 
 under the same law as vomiting in pregnancy. In domestic animals, faint- 
 ing, vomiting or death is liable to occur in those animals which have a short, 
 intense orgasm, as the horse or pig. The orgasm is much more intense in 
 males, and hence they are nearly always the subjects of disturbances during 
 cohabitation. Females suffer very rarely. All this profound impression in 
 the coition of animals is due to the irritation being sent to the abdominal 
 brain, where it is reorganized and radiated out on the plexuses of the various 
 viscera. The sudden, short irritation deranges the normal rhythm, and hence 
 the pathology of fainting and vomiting. The disturbance of rhythm will be 
 the most manifest in that organ most sensitive or most essential to normal 
 life. The same rules apply precisely to man. 
 
 Men during coition occasionally faint, vomit, defecate, urinate, or die. 
 I know of a noted judge who died shoitly after connection with a girl in a 
 brothel. In Chicago, a short time ago, at one of the principal hotels, a man 
 of probably forty-eight was found dying after cohabiting with a strange 
 woman. All such deaths that I know or have read of have occurred in 
 elderly men. The smaller manifestations, such as fainting, vomiting, uri- 
 nation, and defecation, have all occurred in quite young men — mainly at the 
 first coition. The elderly men scarcely ever die while cohabiting with their 
 wives, as they are familiar with them, and the excitement of the orgasm is 
 not so violent or intense. It generally occurs with old men (in age, if not in 
 years) in first coition with a strange woman. Death may occur with an old 
 man who has not had connection with his wife for a long period, especially if 
 the orgasm is intense. I do not include in such a subject rupture of some 
 pelvic tumor, due to coition. The explanation of the matter lies in the 
 sympathetic nerve and its reflexes. The irritation of the penis is due to 
 friction, and of the semen sacs to spasm and evacuation, which is transmitted 
 to the abdominal brain and there reorganized. 
 
 The accumulated irritation in the abdominal brain is radiated rapidly and 
 on the various directions of least resistance. It rapidly ascends the splanch- 
 nics and is reorganized in the cervical ganglia and sent to the heart. The 
 irritation sent so suddenly to the heart at first violently stimulates it to a 
 vigorous action, so that the blood-pressure is raised to a high tension in 
 the brain, especially in the left cerebral artery. Old men often have friable, 
 degenerated arteries, and this sudden rise of blood-pressure induces the 
 middle left cerebral artery to rupture, and thus arises the death from coition. 
 
ANAL NERVES ABUNDANT 235 
 
 The primary cause is the reflexes arising from the semen sacs and genitals. 
 During the dissection of quite a number of cadavers, I have noticed that 
 the connections of the lateral chain of sympathetic ganglia are very large at 
 the root of the third sacral nerve. It must be remembered that the third 
 sacral makes up nearly all of the pudic nerve ; also that all the external geni- 
 tals are supplied by the pudic nerve. 
 
 Hence, we find that the pudic nerve connects itself with one of the 
 largest ganglia in the lateral chain of the pelvic sympathetic. Irritation of the 
 external genitals is quickly carried to the vaso-motor center by the close and 
 extensive connection of the cerebrospinal sympathetic. 
 
 The rectum and anus have a close connection with the sympathetic nerve. 
 
 The anus is guarded by two kinds of sphincters: (a) One, the internal 
 sphincter, ruled by the sympathetic, and this accounts for the fact that rectal 
 disease (fissure, ulcer) creates such intense disorder and neuroses among the 
 viscera through violent reflexes, (b) The other anal sphincter, the external, 
 is dominated by the spinal nerves and does not create such wild disorder 
 among the viscera by reflexes. 
 
 I have often noticed that in dilating the rectum under an anesthetic, the 
 patient would utter a kind of hoarse bray or expiratory moan, similar to the 
 braying of an ass or mule. 
 
 The reason for this violent braying or expiratory moan in rectal dilata- 
 tion is, that there is a distinct nerve strand arising from the inferior cervical 
 ganglion and passing directly to the phrenic, which controls the diaphragm, 
 e. g., rectal dilatation induces the irritation to pass to the abdominal brain 
 over the hypogastric plexus, whence it is reorganized and emitted to the 
 inferior cervical ganglion to the phrenic, which transmits it to the diaphragm, 
 which rapidly forces the air over the vocal cords. 
 
 The mare in heat will often utter a similar sound. If the mare is 
 watched, she will be seen to be disturbed occasionally, every five to eight 
 minutes. When a "spell" or disturbance arrives, she will first raise the tail, 
 and then begin to straddle and utter a kind of bray, then the pudenda is 
 spasmodically everted, followed by the emission of fluids from the pudendo- 
 vaginal gland. The explanation of this phenomenon must be made through 
 the pudic and sympathetic nerves of the rectum and genitals on the one 
 hand, and the recurrent laryngeal and sympathetic on the other. In short, 
 there is a distinct relation between the voice and the rectum. This connec- 
 tion must lie in the sympathetic nerve. If one dilates the rectum suddenly 
 the patient's skin capillaries become flushed with blood and sweating is 
 induced. 
 
 One of the most prominent features of patients suffering from rectal dis- 
 ease is their manifest nervousness. Rectal patients become irritable and 
 neurotic. The profoundly rich supply of the hypogastric to the rectum 
 explains why disease of the rectum makes neurotic subjects. 
 
 There is also an evident connection between pelvic disease and the voice. 
 Menstruating women are likely to have tonsillitis congestion, more than 
 non-menstruating women. Chronic irritation in the pelvic organs will 
 
236 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 induce chronic disease in the tonsils and throat. In some women the 
 voice changes at menstruation or during aggravation of pelvic disease. 
 Not uncommonly young women have difficulty in swallowing at menstrual 
 times, and their hearing may be a little disturbed, because of the congestion, 
 and the chronic inflammation travels up the Eustachian tube. The distant 
 relation and connection between the ovary and parotid gland is well known, 
 as in mumps and operations on the ovary. Few writers have called atten- 
 tion to the relation of pelvic disease to pharyngeal disturbances, which exist 
 by means of the connection with the sympathetic. The relation of the 
 tripod in exophthalmic goiter — heart, thyroid gland and eyeball — will be more 
 readily understood through the study of the sympathetic nerve. The enlarge- 
 ment of the thyroid in the menstrual life of women rests on the sympathetic 
 nerve. The sexual life of woman is her chief life, from a physical stand- 
 point, and as she has a larger ganglionic system than man, she demands 
 special study ; for from this chief function of her life will arise new structures 
 and diseases. 
 
 The anus is the last to become insensible under chloroform. One can 
 arouse a patient who is supposed to be dying from chloroform anesthesia, by 
 suddenly dilating the rectum; the peripheral capillaries will also dilate 
 and the cardiac and respiratory action will again resume. It is possible 
 that the same safety arises in dilating the cervix and vagina in labor, 
 as then we may give chloroform with impunity. The heart center lies 
 in the medulla, and one often observes how dilating the rectal sphincter 
 makes the capillaries flush and the skin sweat. Now, the very opposite often 
 happens, for very often when a sphincter is dilated, as in labor, urinating or 
 rectal dilation, the subject has a distinct chill. This is due to the disturbance 
 carried to the heat center in the medulla. The kind of irritation which pro- 
 duces chill and the kind which produces heat are not yet determined, but 
 both arise by means of the sympathetic nerve. 
 
 Reflexes from the rectum, e. g., fissure, produce just the same distur- 
 bance upon the system as do reflexes from the vagina or uterus. Both arise 
 by means of the sympathetic, and both result, if persistent, in malnutrition. 
 The reflexes seem to alter (stimulate, depress or produce irregularity) the 
 circulation in adjacent or remote organs. 
 
 It is well known that young girls who have a uterus badly developed and 
 anteflexed, suffer from constipation and rectal troubles. It is likely that the 
 constipation and rectal trouble is mainly due to reflex action by means of the 
 abdominal brain. It is known that long continued irritation of a voluntary 
 muscle causes fibrous degeneration and finally cicatricial contraction. Now it 
 is also well known that women possessed of rectal trouble soon acquire 
 uterine trouble. It is due to reflex action, the rectal irritation is sent up the 
 abdominal brain and reorganized and then transmitted to the uterus, inducing 
 circulatory and nutritive disturbance. 
 
 The sympathetic nerve, as its name implies, is liable to be brought in 
 unison with surroundings. For example, when the young pregnant wife 
 begins to vomit, the young husband may vomit also, a purely mental impres- 
 
INFLUENCE OF GENITAL NERVES 237 
 
 sion through the sympathetic nerve. The effect of the sympathetic on the 
 glands of woman is important. The main glands are (a) mammary; (b) the 
 sebaceous on the face and (c) those of the pudendum. As soon as menstrua- 
 tion begins (or a little later) the girl begins to have facial acne. The sebace- 
 ous glands of the face inflame, enlarge and have a severe exacerbation at 
 each monthly. Some women look almost as if they were chronic drinkers at 
 the time of menstruation. A monthly rhythm excites and exacerbates the 
 facial sebaceous glands into a chronic inflamed condition. (These glands may 
 be trying to imitate the glands in the boy in enlarging a growing beard.) The 
 trouble is due to the sympathetic and is especially active in the face by 
 reason of the presence of the ophthalmic ganglia, Meckel's ganglia, otic 
 ganglia and sub-maxillary ganglia — all sympathetic ganglia situated on the 
 fifth cranial nerve. This facial acne, highest at the maximum of the rhythm 
 of the automatic menstrual ganglia, is very annoying to many women. At 
 the climax of the menstrual rhythm, there may be noticed on some women, 
 dark discolorations, or pigmentation, just below the eyes. This pigmentation 
 of the eyelids is what is so frequently mentioned as the dark rings about the 
 eyes. It is due to deposit of pigment induced by venous congestion. The 
 congestion is brought about by the rhythmic irritation of the ophthalmic 
 ganglia (sympathetic) on the supraorbital branch of the trigeminus. The 
 congestion and pigmentation of the eyelids in menstruation must also be 
 connected with the presence of large glands known as the Meibomian glands. 
 The sympathetic nerve has a predilection and a dominating influence over 
 glands; so that the eyelid congestion and consequent pigment deposit during 
 menstruation must be associated with the ciliary ganglia of the Meibomian 
 glands. 
 
 In the pelvic diseases of young girls, I have found quite frequently an 
 association of weak eyes. This is especially the case with endometritis, 
 deficiently developed uterus and dysmenorrhea. They can use their eyes to 
 read but a few minutes at a time, without pain or the letters blurring. I 
 could find no reference to the subject in gynecological text-books. Since 
 writing the above I have learned from Dr. B. Bettman that Dr. Fritsch and 
 others have investigated the connection between pelvic and eye diseases. It 
 must be that there is some prominent connection between certain cases of 
 female generative disease and eye trouble. I have noted so many cases that 
 I cannot consider it an accident and believe there must be some physiological 
 connection. The eyes are worse at the maximum of the menstrual rhythm. 
 The explanation of this association must lie in the sympathetic nerve. 
 
 I suggested the subject to Dr. Frances Dickinson, Professor of Ophthal- 
 mology in the Chicago Post-Graduate School, who has carefully followed 
 some of the cases. So far, the doctor has reported that the eye trouble 
 seems to be in the general circulation of the eye, the visual apparatus (the 
 cornea, lens and retina) being normal. The endurance of the eye for work 
 is lessened, and it appears to me that the chronic defect in the blood canals 
 is accounted for by the disturbance in the rhythm of the diliary ganglia, and 
 the sympathetic nerve supply of the Meibomian glands accounts for the 
 
238 THE ABDOMINAL AND PELVIC BRAIN 
 
 pigmentation of the lids. What role the lachrymal glands play in the 
 matter of eye trouble through the sympathetic, I am unprepared to state. 
 
 The associated disturbances of the mammary glands in menstruation and 
 gestation, have attracted the attention of many thinkers. The problem must 
 be solved through the sympathetic nerve. The spinal nerves supplying the 
 mammary glands come from the cervical plexus and the six upper dorsal 
 nerves. The arteries which supply the gland are the long thoracic, internal 
 mammary, the intercostal arteries under the gland, and a few branches from 
 the axillary arteries. Now, on these arteries, the sympathetic nerve goes to 
 the gland. The first stage of milk secretion is a silent process reflected 
 through the cord. The second stage is a gross reflection through the splanch- 
 nic from fetal irritation in the uterus; the cerebrospinal nerves elaborate 
 milk, but the sympathetic hastens its secretion. 
 
 The original irritation nearly always arises in the pelvic organs. It 
 travels to the mammary gland in three ways: First, by the way of the 
 spinal cord; second, by way of the lateral chain of the sympathetic; third, 
 the main way is,through the hypogastric plexus to the abdominal brain and 
 then through the great sensory nerves of the viscera, viz. : the three splanch- 
 nics. But we must again consider that the mammary gland has a peripheral 
 nerve apparatus which not only shares in the genital rhythm, but also has 
 the capacity to form milk. The mammary gland must be looked on as 
 simply a modified sebaceous gland and we have noticed above how the seba- 
 ceous glands of the face are affected by menstruation and gestation. The 
 spinal nerves do not induce any rhythm in the glands as is shown in girls up 
 to puberty. But the impetus to rhythm must suddenly arise at the peculiar 
 condition known as puberty, or the period of tubal motion. 
 
 The sebaceous glands on the pudendum are large and the odor at men- 
 struation is chiefly due to their increased secretion. The pudendal glands 
 are remnants of ancient life when the female, in heat, attracted the male by 
 the increased odor emitted from the active glands. The odor during men- 
 struation is often due to the activity cf the Pudendale sebaceous glands and 
 decomposition of their products, not merely to decomposition of menstrual 
 blood. Here, as in other glandular apparatus, the sympathetic nerves play 
 an important part. 
 
 The sympathetic nerve seems to play a significant role on the heat 
 centers of the medulla. I have noticed this especially in laparotomy and 
 vaginal hysterectomy. In short, when certain bundles of sympathetic nerves 
 are cut, especially the hypogastric plexus, the temperature will rapidly rise 
 above or fall below normal. 
 
 Surgeons are alarmed at these manifestations until experience teaches 
 their real meaning. 
 
 The practical application of the sympathetic nerve in gynecological work 
 lies in its control over nutrition. Reflex irritation from a pelvic viscus will 
 remotely, or through several years, impair the whole visceral economy. 
 Remote effects of pelvic disease must be traced through the nervous system 
 (sympathetic) due to circulatory modifications. 
 
AUTOMATIC VISCERAL GANGLIA 239 
 
 The connection of the cerebral cortex (the seat of epilepsy), with ovarian 
 diseases, resulting in so-called hystero-epilepsy, is far from being proven. 
 
 The different sizes of the peripheral ganglia in the various viscera is an 
 important element in studying the sympathetic. Some viscus may have 
 abnormally small ganglia and hence its rhythm and nutrition will be defec- 
 tive. Small automatic cardiac or menstrual or gastro-intestinal peripheral 
 ganglia will be unable to do normal, vigorous, nutritive and rhythmic work, 
 thus making the visceral system defective. 
 
 Menstruation and the menopause I shall place in the realm of the sym- 
 pathetic nerve. The peculiar cycles and rhythms throughout the life ofi 
 woman demands attention. We may call attention to the wide domain of the ' 
 sympathetic nerve not only in health, but also in disease. Having made 
 considerable investigation in this subject, some of the resulting views may be 
 of interest and may stimulate the study of the sympathetic nerve. 
 
CHAPTER XX. 
 
 THE AUTOMATIC MENSTRUAL GANGLIA. 
 
 The function of the tractus genitalis is: Sensation, ovulation, secretion, absorp- 
 tion, peristalsis, menstruation, gestation. 
 
 'We are shaped and fashioned by what we love." — Goethe. 
 
 Menstruation is a regular periodic monthly rhythm of the uterus and ovi- 
 ducts. In general it begins at the age of 15 and ceases at 45, continues foui 
 days, the bloody flow amounting to two ounces and should be painless. 
 
 Menstruation belongs distinctly to the oviducts and uterus. It is a sing- 
 ular rhythmic action. It is controlled by the automatic menstrual ganglia 
 situated in the walls of the oviducts and uterus. These rhythmic little brains 
 manifest themselves to the observer by circulatory change and increased 
 motion. Menstruation might be named oviductal motion. By direct obser- 
 vation in the human, and also in animals, I have noted the following con- 
 dition midway between the monthly periods, or at times far remote from oes- 
 trus or rutting: The oviducts and uterus are of quite a pale pink color. In 
 short, they are not congested, and are in repose. But at the menstrual peri- 
 od or season of oestrus the oviducts and uterus are congested and in active 
 peristaltic motion. The oviducts are of a dark blue color from their dilated 
 vessels being filled with blood. The congestion of the uterus is intense but 
 not so manifest as the oviducts. The oviducts are swollen, thickened and 
 oedematous. They are soft and pliable. 
 
 At this time a slight irritation while removing them soon excites them 
 into active peristaltic motion. After removing such oviducts and placing 
 them in warm (salt) water they will maintain vermicular movements for 
 half an hour by gentle irritation. I have been able to make these observa- 
 tions in women because I operate at any time in laparotomy, after careful 
 preparation, even if it be in the midst of a menstrual period. As regards 
 animals I have examined several hundred genitals of recently butchered 
 sows, and the oviductal congestion at the oestrus is more apparent in them 
 than in the woman. The sow's uterus is also probably more congested. 
 Observations and experiments indicate that menstruation is a regular, 
 periodical rhythm of a blood-wave in the oviducts and uterus induced by the 
 automatic menstrual ganglia. The continually moving wave rises to a maxi- 
 mum and sinks to a minimum. The menstrual wave continues from puberty 
 to the menopause. It is a nervous phenomenon. 
 
 Ovulation is a progressive, non-periodical process. It begins before birth 
 and continues until the ovarian tissue is atrophied or worn out. It is liable 
 to occur at menstruation or cestus because of the vast blood-supply at that 
 time which hastens the follicle to ripen and burst. In the lower animals, so 
 far as I can decide, menstruation and ovulation seem to be coincident, i. e., 
 
 240 
 
AUTOMATIC VISCERAL GANGLIA 241 
 
 they occur at the same time. I have examined the cow, dog and sheep, but 
 my observation is especially based on the ovular and menstrual process as 
 seen in the sow. By the examination of some two hundred and fifty speci- 
 mens of sow's genitals in all conditions it seems to me that the oestrus of the 
 animal embraces both menstruation and ovulation in one physiologic process 
 at the same time. But as the scale of animal life ascends, the processes of 
 menstruation and ovulation seem to become more and more divorced. To 
 my mind, the best animal to begin with is the o f ow. In the cow one can see 
 more and more distinct processes with the ovaries and oviducts. Their 
 separate workings become more apparent. In the calf, before and after 
 birth, ovulation is very manifest. But the oviducts and uterus before 
 birth and for a considerable time after, are manifestly quiet and pale and 
 rudimentary, non-functional. In woman it is my observation that menstrua- 
 tion and ovulation are found distinctly separate from each other. It is true 
 that ovulation and menstruation may occur together, may be coincident, but 
 that is an accident. The processes are physiologically separate. In the 
 woman ovulation has been observed before birth, and I have seen ovulation 
 in a woman of 70, the specimens of which were presented to me by Dr. Bur- 
 gess of Milwaukee. Now, of these two great physiologic functions, ovulation 
 is a life-long process. It begins before birth and ends with ovarian atrophy. 
 But menstruation is a periodical process beginning with puberty and ending 
 with the menopause. Puberty must be observed as initiating the new exer- 
 cise of genital ganglia. A viscus assumes a new rhythm which disturbs the 
 entire system. 
 
 The views here contained are that menstruation is governed by nervous 
 ganglia situated in the walls of the oviducts and uterus. I have designated 
 these nervous structures as automatic menstrual ganglia. As a deduction 
 of this theory, oviductal motion and oviductal changes will be considered the 
 most marked phenomena of menstruation. The question may be asked : 
 What is a nervous ganglion? A nervous ganglion is a collection of nerve 
 cells. Its constituents are nerve cells and nerve fibers. It is an ideal nervous 
 center having a central, conducting and peripheral apparatus. A ganglion 
 is a little brain, a physiological center. It has the power of receiving sensa- 
 tion and transmitting motion. It is automatic in itself. It possesses the 
 power of nourishment and controls secretion. Reflex action can be demon- 
 strated in it. What are called motor, sensory, and sympathetic nerve fibers 
 are found in its composition. The peculiar feature of a nervous ganglion is 
 rhythm. It performs cyclical movements. It has a periodic function which 
 continually waxes to a maximum or wanes to a minimum. It lives a 
 rhythmic life. Its periods of action vary from a few seconds to a month. It 
 is beyond the control of the will. 
 
 1. The proof of the existence of the ganglia in the oviducts and uterus 
 is from analogy. All hollow viscera have ganglia in their walls. Histologists 
 have long known that many viscera possess ganglia which have automatic 
 power. The names of Bidder, Schmidt, Ludwig, Remak Meissner and Auer- 
 bach are associated with the discovery and description of these viscera 
 ganglia. 
 
 16 
 
242 THE ABDOMINAL AXD PELVIC BRAIN 
 
 (a) I have satisfied myself many a time, in vivisection on dogs and other 
 animals, that the heart has nervous centers or ganglia, which will continue 
 to act independently of their cerebrospinal connection. It is not only clear 
 that the heart has automatic ganglia, but that nearly all these ganglia are 
 centered in the walls of the auricles. I have often watched the heart's 
 action gradually die out from apex to base. We know by experiment that 
 the heart will perform its cycle of contraction independently of its external 
 connection. These automatic nervous ganglia situated in the wall of the 
 heart keep up its rhythm, its cyclical action, its periodic movements. They 
 explode oftener than once a second. I have severed the heart from its 
 attachments in some animals and watched its beating cease, when, if left 
 alone, it would be still forever; but by applying stimulus to the ganglia the 
 heart would again perform its rhythm. It would beat and explode just the 
 same as when it was connected to the cerebrospinal system. Hence few 
 observers doubt that the ganglia of Remak, Bidder, Ludwig and Schmidt sus- 
 tain and control the rhythm of the heart. One can prove by experiment that 
 there are several ganglia situated in the auricle by cutting pieces out of its 
 wall. If these pieces are stimulated they will go through a distinct rhythm. 
 
 (b) A large number of experiments on the intestines of animals (especi- 
 ally the dog) convinced me distinctly that the intestines are endowed with 
 automatic ganglia in a similar manner to the heart. These ganglia are called 
 the plexus of Auerbach and the plexus of Meissner-Billroth. If a dog is 
 killed and the abdomen is opened in a room of 75° F., the intestines can be 
 induced to perform peristalsis for an hour after death by tapping them occa- 
 sionally with a scalpel. As soon as the intestines are exposed to the air or 
 tapped with the scalpel, they begin to go through wonderful vermicular 
 movements resembling a moving bundle of angle-worms. I have often 
 demonstrated the peristaltic movement of the intestines more than an hour 
 after death, so that it can be stated that the automatic ganglia of the bowels 
 will perform their rhythm independently of the cerebrospinal center. In 
 autopsies I have found the intestines invaginated, and from the non-congested 
 and non-inflammatory condition of the intestinal wall I had no doubt the 
 invagination occurred entirely after the patient's death. The non-inflamma- 
 tory telescoping of the intestines in dying subjects is called the "invagination 
 of death." It can be perfectly demonstrated in a dog's intestines fifteen to 
 thirty minutes after he is dead. Hence the nervous bulbs studded over the 
 plexus of Auerbach and the plexus of Meissner-Billroth are the automatic 
 ganglia which induce, sustain, and control the rhythm of the intestines. 
 The vigorous rhythmic exercise or explosion of the intestinal ganglia is 
 what causes colic, and in bowel constriction occurring in patients having 
 thin belly walls I have observed this with perfection. The intestinal 
 rhythm caused by the ganglia can be beautifully seen in the defecating 
 intestine of a patient on whom colotomy has been performed. 
 
 I have never seen the causation of the very severe pain in angina pectoris 
 very satisfactorily explained. I would suggest that it is colic of the heart, 
 caused by abnormally vigorous action of the heart's automatic ganglia; that 
 
AUTOMATIC INTESTINAL GANGLIA 
 
 243 
 
 the desperate pain in angina pectoris is due to the excessive exercise or 
 abnormally vigorous, irregular rhythm of the automatic ganglia situated at 
 the base of the heart. Hence, clinically, no doubt, we see the abnormally 
 vigorous rhythm or irregular rhythm of the heart in what is called neuralgia 
 or spasm of the heart, or angina pectoris. The ganglia offer the best expla- 
 
 FIG.58— PELVIC BRAIN OF ADULT. 
 
 PELVIC BRAIN 
 
 Fig. 58. This illustration presents a fragment of the luxuriant nerve supply of the 
 uterus, oviducts and ovaries. 
 
 nation. Clinically, we see in the intestines the exercise of Auerbach's and 
 Meissner's ganglia in various diseases. 
 
 In colic and also bowel obstruction we see an excessively vigorous, 
 irregular action of the ganglia. We note an excessively irregular action of 
 the ganglia in the desperate, painful colic of children, which I believe 
 amounts in many cases to an invagination with subsequent spontaneous dis- 
 invagination. It may be noted that irregular action of the bowel ganglia 
 occurs in children where the cerebrum is insufficiently developed to force the 
 
244 THE ABD0M1XAL AXD PELVIC BRAIX 
 
 ganglia of Meissner and Auerbach into subjection and thus secure a regular 
 rhythm of the intestine. We also see irregular ganglionic action in the 
 bowel where the cerebrum is diseased and hence has lost a controlling 
 influence. In chronic constipation, and in the paralysis of the intestine dur- 
 ing peritonitis, we see disease of the ganglia producing such loss of power 
 that the ganglia cannot initiate or sustain sufficient peristalsis to expel the 
 bowel contents. 
 
 (c) The same statement can be made relative to the bladder. It is sup- 
 plied with two kinds of nerves. One kind is the cerebrospinal. The other 
 kind is the sympathetic nerves, which especially go to the body and summit 
 of the bladder. These nerves are studded over with ganglia which may be 
 styled automatic vesicular ganglia. These ganglia are closely associated 
 with the blood-vessels and walls of the bladder, and have an influence in con- 
 trolling the rhythm of this cyst. As an example to demonstrate the action 
 of the automatic ganglia in the bladder, I took from a stag weighing fourteen 
 hundred pounds, the bladder, penis and rectum. Twelve hours after it was 
 contracted quite small. I then dilated it, and thirty-six hours after it had 
 again contracted smaller than ever and would not contain half a pint of fluid. 
 This bladder continued its rhythmic action for mere than forty hours. It is 
 not mere elasticity, as one can watch the rhythm of segments. It can be 
 well demonstrated by injecting its blood-vessels with red fluid and then 
 watching it for a day, when the slow, cyclical rhythm can be plainly seen. 
 The sacral spinal nerves preponderate at the neck of the bladder and endow 
 it with sensation. They likely hinder it from rhythm, while the body and 
 summit of the bladder are mainly supplied with sympathetic nerves. They 
 give it blunt sensation and rhythm. But the summit and body of the bladder 
 are the parts endowed with ganglia, and they are also the parts endowed 
 with cyclical rhythm. 
 
 If a rubber bag is inserted into the bladder and then filled with fluid, 
 having its external end connected with a mercury gauge, it can be plainly 
 seen that the bladder undergoes intermittent contraction. It will demon- 
 strate its rhythm. Clinically, this rhythm can often be observed in retention 
 of urine. The filling bladder will periodically make vigorous efforts to expel 
 i:s contents, and the pain felt at those times can be easily mistaken for colic. 
 Hence the bladder is endowed with automatic vesical ganglia, which are 
 mainly situated in the walls of the body and summit, especially localized along 
 its highways of nutrition (blood and lymph tracts). These ganglia preside 
 over the rhythm of the bladder. 
 
 (d) The analogies of the heart, intestines and bladder are quite appar- 
 ent, and can reasonably be carried to the uterus and oviducts. They are all 
 hollow organs. The oviducts and uterus are no exception to the other 
 abdominal viscera. What is said in this paragraph is the result of examina- 
 tion of over seven hundred uteri, oviducts and ovaries, of woman, cow, pig, 
 sheep and dog. Some of the examination was carried on during the life of 
 the animal, and in quite a number of cases I noticed the action of the 
 oviducts in the living woman during operation. Much of the work was done 
 
AUTOMATIC VESICAL AND CARDIAC GANGLIA 245 
 
 on freshly butchered animals, where the organs were removed before the 
 general muscular twitching had ceased. My first distinct attention was drawn 
 to the idea that the heart, intestines, uterus and oviducts acted similarly, by 
 observation in the slaughter house. Dr. C. S. Miller and myself were watch- 
 ing the slaughter and evisceration of a cow weighing fifteen hundred pounds. 
 The cow was in the eighth month of pregnancy. The butcher amputated the 
 large uterus, containing the calf, a little above the internal os. I noticed 
 that the amputated portion of the uterus containing the calf went through a 
 peculiar series of rhythmic motions. But the interesting scene was the 
 amputated stump left on the body of the cow. The stump was about six 
 inches long and three inches thick. This stump performed its peculiar 
 rhythm long after the cow was dead. It slowly described circles and arcs 
 with diameters varying from an inch to four inches. Each muscular layer 
 of that thick uterus worked in perfect harmony. No uterine layer of muscles 
 interfered with any other. Every part of the uterine stump seemed to work 
 with intelligence or a kind of quasi-judgment during the rhythm. At one 
 time the circular muscular layer would go through a slow but distinct 
 rhythmic circle before any other muscular layer would begin. Then, grad- 
 ually, the longitudinal muscular layer would begin to act, and the end of the 
 stump would describe a rhythmic cycle, and thus it continued to repeat the 
 rhythmic action until we left, an hour after. During the activity of the stump 
 the most striking example of the action of the two muscular layers of the 
 uterus could be seen, for while one layer worked vigorously the other 
 remained still. Another striking example to show that the hollow uterus has 
 its own automatic ganglia may be observed by removing the uterus from a 
 cow immediately after death. The uterus should be that of a multiparous 
 cow, because such have long, thick, tortuous, helicoid arteries. Now care- 
 fully inject the utero-ovarian arteries with red fluid. Observation will easily 
 detect rhythm in the segments of this uterus for some forty hours after 
 death, in a 75° room. The rhythmic waves that pass over the uterus will 
 shift the fluid from one segment to another, so that the quantity of fluid is 
 not uniform in each segment. The rhythm sometimes takes place very 
 slowly. This phenomenon is not elasticity. But, clinically, the rhythm of 
 the pregnant uterus has been known since the art of obstetrics began. My 
 purpose here is simply to draw attention to the independent action of the 
 uterus from a cerebrospinal connection, and to show that the uterus has 
 automatic ganglia like other hollow viscera. 
 
 Labor will take place under profound anesthesia. Children have been 
 expelled from the uteri of dead women. All this is due to the nerve appara- 
 tus of the uterus. Some Frenchman severed the spinal cord of a pregnant 
 sow below the brain, thus paralyzing all the voluntary muscles which aid in 
 parturition, yet the sow had her pigs. The uterus drove one fetus into the 
 vagina, but as the abdominal muscles were paralyzed this fetus had to be 
 driven out by the second fetus, which was pushed against the first by the 
 contracting uterus. 
 
 (c) The oviduct is simply a continuation of the muscular walls of the 
 
216 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 uterus, but not of the endometrium. The endometrium seems to be a tem- 
 porary gland, whose duration of active life is the menstrual period. The an- 
 alogy of the hollow oviduct of the intestine or heart is very close. Nearly all 
 the original work done on this subject was in relation to the oviducts, for I 
 consider them the most important organ in menstruation. The object of 
 menstruation is to transport an egg from the ovary to the interior of the 
 uterus. This can be done by a properly prepared oviduct. It seems to me 
 that menstruation begins and ends in the oviducts, and that the importance 
 of the oviducts overshadows all other organs in menstruation, however, the 
 endometrium is the important prepared nest. When the oviducts begin their 
 rhythm the girl has arrived at puberty. Oviductal motion is a sign of woman- 
 hood. When the oviducts begin their cycles it is a heraldic sign that the gland 
 called the endometrium is prepared to nourish an ovum. The endometric 
 gland is no doubt often prepared to nourish an ovum before the oviductal 
 motion or menstruation, and from the examination of nearly eight hundred 
 ovaries I am fully satisfied that ovulation goes on from before birth until the 
 end of life, or till the germinal epithelium is worn out. Actual observation 
 of animals convinced me of this. One can see no changes in the ovary at 
 puberty, except that of increased vascular supply. I never could find any 
 periodicity, nor signs of it, in the ovulation in the human, cow or sheep. 
 The ovules simply ripen progressively and burst when they are mature, 
 whether that be at menstruation or at some other time. I am sure they often 
 burst by mere mechanical accident. Hence, it does seem that menstruation 
 and ovulation are two different processes. Two statements may then be 
 made relative to an egg being carried into the uterus: First, when the 
 oviduct goes through its menstrual rhythm it may secure an agg, if it hap- 
 pens to be ready and bursts. Second, the oviduct may secure an egg, if its 
 fimbriated funnel becomes glued on to the ovary at a point where there is a 
 maturing ovum. 
 
 2. The Proof of the Existence of the Ganglia in the Oviducts from 
 Direct Obsa-vation and Experiment. — If an adult female dog is taken and 
 well anesthetized, and the abdomen opened, the short white oviducts can be 
 found just posterior to the kidney, at the abdominal end of the double uterus. 
 Two important matters will be observed — first, the condition of the oviduct; 
 second, the position of the oviduct. If the animal is not in rut, which is very 
 analogous to menstruation, the oviducts will be very white, small and still. 
 They are very much contracted, and the fimbriated end generally lies as far 
 from the ovary as the fimbria ovanca will permit. In short, in the inter- 
 cestrual time non-congestion and quiescence mark the oviductal condition. 
 The condition and position of the oviduct at the period of rut are wonder- 
 fully changed. The oviduct is very much swollen and elongated; it is dark 
 blue from, especially, venous congestion. The surrounding blood-vessels 
 are enlarged, tortuous and distended. The oviduct shows convolutions and 
 tortuosities plainer now than at other times. The oviduct having become 
 longer and thicker, its entire position is changed. The strip of (muscular) 
 tissue which connects the fimbriated end of the oviduct to the ovary has 
 
AUTOMATIC MENSTRUAL GANGLIA 247 
 
 shortened, and the funnel mouth of the oviduct is closing on to some portion 
 of the ovary. At the climax of the menstrual rhythm the fimbriated mouth 
 of the oviduct is often glued or cemented on to the ovary by a kind of glairy 
 mucous exudate. The careful examination of nearly eight hundred oviducts 
 satisfactorily demonstrated to me that the oviducts go through a distinct 
 rhythm at menstruation. Menstruation is a periodic cycle of the oviducts. 
 The oviducts go through a peristaltic or vermicular motion exactly analogous 
 to the intestine. Now, there is only one kind of apparatus which produces 
 a rhythm, and that is a ganglion. Hence, as the oviducts go through a 
 rhythm, they must be influenced by a ganglion. 
 
 The changes in the oviduct at puberty are as follows: (a) It assumes 
 rhythmic movements; (b) its muscular action increases; (c) its vascularity 
 is much increased; (d) it becomes extended and loses its corkscrew or spiral 
 shape of fetal life; (e) its epithelium becomes ciliated; (f) its gross activity 
 appears mainly at the abdominal end; (g) its lumen becomes filled with fluid. 
 This fluid is to float the egg or ovum into the uterus. The cilia whip 
 the fluid in the oviduct into a current, and this wonderful anatomic and 
 physiological canal floats the ovum to the nourishing gland — the endometrium. 
 The automatic menstrual ganglia during their rhythm produce such changes 
 in the oviduct as will best prepare it to float an egg from the ovary to the 
 uterus. As the rhythmic peristalsis of the oviduct reaches its climax the 
 oviduct becomes thicker, longer and its caliber wider. The fimbria ovarica 
 shorten and draw an oviductal funnel over a part of the ovary. A dry, 
 contracted oviduct with a narrow lumen offers difficulties for the passage of 
 an ovum. If the epithelium of the oviduct is so altered by disease that it 
 does not secrete fluid, the egg may not be able to float through the oviductal 
 canal, but may become arrested in its passage, causing ectopic pregnancy. 
 The reason why an egg does not get into a child's uterus is because its 
 oviduct is deficient in motion; the fluid in its interior and the ciliated 
 epithelium are deficient. The ciliated epithelium whips an egg into the 
 uterus by means of a fluid medium. The rhythm of the oviducts, caused by 
 the ganglia, prepares them for their function. This is done by first drawing 
 the mouth of the oviduct over a part of the ovary; and, second, by flooding 
 the lumen of the oviduct with serous fluid. Of course it will be only acci- 
 dental that the mouth of the oviduct will cover a matured ovum. The vast 
 majority ovulate into the peritoneal cavity. Ovulation is a life-long process, 
 while menstruation, or rather oviductal rhythm, lasts about thirty years. 
 
 The almost entire separation of the oviduct from the ovary is peculiar 
 to the higher animals, and no doubt lessens the chances of excessive repro- 
 duction. In the hen the ovary and oviduct are continuous. The active 
 explosion of the automatic menstrual ganglia are the most marked at the 
 abdominal end of the oviduct. By direct experiment it is easy to make the 
 oviducts perform their rhythmic, vermicular movements for half an hour 
 after their removal from the living. The oviducts of a cow, sheep, dog or 
 pig can be kept moving in a warm medium by stimulating or pinching them, 
 just in the same manner as pinching the heart or tapping the intestines will 
 
248 THE ABDOMINAL AND PELVIC BRAIN 
 
 keep up the movements of those organs in vivisection. I have made this 
 experiment many times on the normal oviducts of women where they were 
 removed for various causes. While the operation is progressing one can see 
 the oviducts going through a rhythm from mere manipulation. As soon as an 
 oviduct is removed, if it be normal, a rhythmic action may be produced by 
 pinching it. The two muscular layers of the oviduct will work separately 
 before the eye. The external longitudinal muscular layer shortens the ovi- 
 duct, while the internal circular muscular layer narrows the oviductal lumen. 
 An oviduct will maintain this rhythmic motion for about half an hour, if 
 pinched or stimulated in a medium (salt water is a very good medium). 
 
 The large range of movement of a human oviduct under stimulation is 
 very marked, and the vigorous manner in which the two muscular layers of 
 the oviduct work is very noticeable. If the circular layer is well stimulated, 
 it will contract with such vigor as to resemble a pale, contracted band around 
 the point of irritation. The endometrium may be looked on as a temporary 
 gland, whose duration of life is the child-bearing period. So the automatic 
 menstrual ganglia which govern the rhythm of the oviducts and uterus, and 
 make fecundation possible are only temporary ganglia, at least so far as 
 function goes. The automatic menstrual ganglia begin their functional life 
 in the incipient oviductal motion. 
 
 This is not the only organ that acts merely at a definite period of life, 
 though the organs exist anatomically during the whole of life. The thymus 
 gland is largest at birth. The thyroid gland becomes most active in girls at 
 about fifteen. The sebaceous glands of males spring into functional activity 
 at about eighteen. When the menstrual ganglia of woman begin to cease 
 their functions forever, the sebaceous glands of the face assume an active 
 function, and a beard results. The salivary glands do not act for three 
 months after birth. No doubt the facial sebaceous glands existed always, 
 anatomically but not functionally. It has appeared to me for some time 
 that there exists some relation between the testicles and sebaceous glands in 
 the male, as there does between the automatic menstrual ganglia and seba- 
 ceous glands in the female. 
 
 Whether the rut (oestrus) of animals and the menstruation of woman are 
 the same or different processes we will not discuss now. But the function 
 of the ganglia and their actual rhythmic process would be precisely the same 
 in either case. In mammals an oviductal rhythm with its associated changes 
 is almost a necessity to transport an ovum from ovary to uterus. I could 
 not observe any difference between the state of the oviduct and the relation 
 of its mouth to the ovary in animals in rut and the menstrual process of 
 woman. The gross anatomy of both processes appeared identical. 
 
 Premenstrual Pain. — The pain immediately preceding menstruation is 
 generally not well understood. I have observed that many gynecologists of 
 the present day attribute the premenstrual pain to the uterus. They say the 
 pain is due to the mechanical obstruction to the menstrual fluid. These 
 views may apply to certain cases. But I maintain that the premenstrual 
 pain is due to an excessive action of the oviducts or a too vigorous rhythm. 
 
AUTOMATIC MENSTRUAL GANGLIA 249 
 
 The automatic menstrual ganglia are overexcited and act irregularly. The 
 excessive stimulation arises mainly from the fluid which finds its way into 
 the lumen of the oviduct. The fluid in the lumen of the oviduct, arising out 
 of its congested state, acts like a foreign body and excites oviductal action. 
 The ganglia become immoderately excited in oviducts whose lumen is 
 partially or wholly closed. The vigorous attempts of the oviducts to expel 
 the fluid confined in their lumen produce well-known agonizing pain. I have 
 examined women with distended oviducts who would repeatedly tell me that 
 the pain excited by the examination would last for hours. The oviducts 
 were simply excited into peristalsis by irritation of their ganglia. 
 
 Dyspareunia, so frequent in oviductal disease, is not merely a story of 
 pain at the time of connection, but of pain that endures for hours. Part of 
 the pain is due to trauma of irritable nerves, but the worst pain is caused by 
 setting in motion the vermicular action of the diseased oviduct. The con- 
 fined fluid in the oviducts excites them into peristalsis, just as irritating 
 substances excite the intestine into painful peristalsis. If an intestine, 
 through obstruction, cannot expel its irritating contents, the picture of pain 
 is almost identical with premenstrual pain. In fact, I have often wondered 
 whether I was dealing with intestinal or oviductal colic. It must be remem- 
 bered that muscle, governed by sympathetic ganglia, acts quite differently 
 from muscle governed by spinal nerves. One is slow and rhythmic, while 
 the other is rapid and more spasmodic. 
 
 The pelvic brain (cervico-uterine ganglion) is a large mass of aggregated 
 sympathetic ganglia situated on each side of the pelvis at the junction of the 
 uterus and cervix. It doubtless shares with the abdominal brain in originat- 
 ing, sustaining and inhibiting the menstrual rhythm. The pelvic brain, like 
 the cervical ganglia, or that of Wrisberg, occupies a subordinate position in 
 rgard to the abdominal brain. It is, however, a prevertebral ganglion. It 
 is not easy to dissect and isolate on account of its white color and resemblance 
 to adjacent tissue. It is three-quarters of an inch long and one-half an inch 
 wide in some subjects, and is more like a meshwork than the abdominal brain. 
 Its irregular meshes are pierced by numerous blood and lymph vessels and 
 connective tissue bundles. No doubt the irritable uterus, which Gooch 
 described seventy-five years ago, is caused in a great measure by an irritable 
 pelvic brain. A rhythm produced by a ganglion alone is a very delicate 
 mechanism, and it is no wonder that during the many vicissitudes of menstrual 
 life the rhythm becomes disturbed, irregular and refuses to act. Pressure of 
 the increasing size of the child's head on the cervico-uterine ganglion 
 initiati s labor. 
 
 . natomical. — The distribution of the sympathetic nerve supply and the 
 spinal n rve supply to the uterus and oviducts strengthens the theory 7 of 
 automatic menstrual ganglia. Anatomists agree that the uterine sympathetic 
 plexus branches off to supply the uterus and oviducts above the point where 
 the sacral spinal nerves join the sympathetic chain. The sympathetic plexus 
 of nerves with its ganglia supplies the upper portion (body and fundus) of 
 the uterus and the whole of the oviducts, while the sacral spinal nerves 
 
250 THE ABDOMINAL AND PELVIC BRAIN 
 
 mainly go to the cervix. Now, it is very likely that the (sacral) spinal nerves 
 have little to do with any rhythm or cyclical action. It is quite probable 
 that they hinder rhythm. 
 
 They would thus influence the cervix to live a steady life. The ganglia 
 on the sympathetic uterine and oviductal plexus, on the other hand, are 
 possessed of a peculiar property called rhythm, so their ganglia would 
 endow the uterus and oviducts with rhythm. This agrees with the observa- 
 tion that the body and fundus of the uterus and the oviducts are the main 
 part of the genital tract involved in menstruation, while the cervix and 
 vagina, mainly supplied with spinal nerves, remain fairly still. The cervix 
 is a mere guard to the uterus, and does not s*hare in menstruation. These 
 ganglia mainly follow the blood-vessels, and the tortuous helicoid arteries 
 supplying the uterus and oviducts, which, being long, give much space for 
 ganglia to exist. The ganglia no doubt control blood-supply by regulating 
 the caliber of the artery and the stay of the blood in the veins. 
 
 3. The microscope, or sometimes a strong lens, will demonstrate the 
 existence of the ganglia on the plexus of nerves going to the uterus and the 
 oviducts. The nerves show uneveness. At places they coalesce into masses, 
 and the microscope demonstrates their ganglionic character. I have fre- 
 quently been able to trace the nerves showing distinct bulbs on the posterior 
 part of the uterus. Histologists have some time ago shown that little gang- 
 lia exist in the walls of the uteri of animals. But space forbids further 
 discussion here. Every visceral organ has its own supply of sympathetic 
 ganglia brought to it on the walls of the blood-vessels. Each visceral organ 
 requring it has its own established cycle initiated in primordial life. The 
 rhythm becomes strengthened by differentiation into special organs, and by 
 repetition. 
 
 It seems to me that knowledge of the various visceral ganglia will render 
 the function of those organs and their diseases more intelligible. To intelli- 
 gibly minister to an organ diseased one must know its pathology. The 
 treatment of any disease comprehends part if not all of its pathology. To 
 me the action of the heart under varying states and pressure of the blood is 
 more intelligible with some knowledge of the automatic ganglia which 
 control its rhythm and motion. A knowledge of the functions of the cardiac 
 ganglia clears many an obscure problem and explains the heart's action 
 under varying conditions. The same may be said of the'ganglia of Meissner 
 and Auerbach in rendering intestinal peristalsis intelligible. So a study of 
 what may be termed the automatic menstrual ganglia will perhaps throw 
 more light on the action of the oviducts and uterus — organs around which 
 woman is built both mentally and physically. We suggest that the rhythmic 
 function of the endometric gland, its nidation and denidation, should not be 
 neglected as a part of menstruation. 
 
 The ganglia in the uterus and oviducts of woman generally induce a cycle 
 once a month during their functional activity. The ganglia explode monthly. 
 In the lower animals the automatic uterine and oviductal ganglia explode 
 in periods which correspond to the cycle of the rut. It is here concluded 
 
AUTOMATIC MRNSTRU.IL GANGLIA 251 
 
 that whether rut and menstruation be the same or different processes, they 
 are governed in their rhythm by the automatic uterine and oviductal ganglia. 
 
 Will these automatic ganglia aid in explaining the function of the 
 uterus, oviducts or ovary after surgical or other destructive procedures on 
 any one of the three? I think they will. That menstruation is closely con- 
 nected with the nervous system, and that, too, with the sympathetic (as it 
 has rhythm) is a common observation. Nerve disturbances disturb menstrua- 
 tion and its rhythm. A sprain in the wrist has checked menstruation. I knew 
 a patient who, while menstruating, became frightened by a whistle from a 
 train and did not menstruate for a year. Sudden changes in temperature 
 will alter its rhythm. The mere expectation of marriage will occasionally 
 make its rhythm regular. Marriage,- by mental and physical stimulation 
 to the genital apparatus, will often induce regular menstruation. When 
 the nervous system is impaired in strength by wasting disease, there may 
 not be enough vital energy to induce and sustain menstrual rhythms. 
 Tubercular girls cease to menstruate. It is a common observation that fleshy 
 persons have weak resisting powers, and fleshy women often menstruate 
 irregularly. In a precocious, abnormally developed girl we may see early 
 menstruation. In pregnancy and nursing, menstruation is arrested because 
 the nervous vitality is expended in nourishment. The miserable and painful 
 failure of an infantile uterus in menstration is rather from a deficient endome- 
 trium. If vital energies are directed into different channels, or vitality gets 
 to a low ebb, the remaining powers may be insufficient to initiate and 
 sustain the regular menstrual rhythm. Non-development occurred from 
 insufficient blood. 
 
 From the views entertained in this paper, that menstruation and ovula- 
 tion are separate processes, and that the automatic ganglia are situated along 
 the oviducts and uterus and probably closely related with the ovary, it 
 would not be expected that removal of the ovaries would always cause men- 
 struation to cease suddenly. The automatic ganglia of the oviducts and the 
 uterus are still intact and will execute their rhythm. Many gynecologists 
 testify that this theory agrees with the facts. Ovaries are extirpated and 
 oviductal motion continues. However, the destruction of a part of a con- 
 nected complex organ soon destroys the nice balance, and nourishment of 
 the ganglia would in time deteriorate, and then insufficient nerve vitality 
 with lack of ganglionic harmony would fail in starting and maintaining a 
 menstrual rhythm. Also, it may be considered that the chief, central, sexual 
 organ of woman is the ovary and the uterus and oviducts are appendages of 
 the ovary. Extirpation of the oviducts would quite effectually aid in arresting 
 menstruation, though not entirely, as many ganglia would remain in the 
 uterine wall. Yet in the very plan of the machinery the oviduct is no doubt 
 designed to execute more motion than the uterus, which could perform its 
 function while remaining quite still. By the German gynecologists, during 
 several years' residence abroad, I was informed that a removal of the ovi- 
 ducts in a vast majority of cases caused a rapid checking of menstruation. 
 Mr. Lawson Tait writes that the total removal of the oviducts arrests men- 
 
252 THE ABDOMINAL AND PELVIC BRAIN 
 
 struation in 90 per cent of cases. Is it not strange that an oviduct cut off 
 two inches from the uterus will maintain the rhythm? Actual cases prove 
 that when only the diseased ovaries are removed from women, with inflam- 
 mation existing in the oviducts, they are but little helped in their misery. 
 The active organ in menstruation is the oviduct, and it will execute its 
 rhythm unless removed. Ligating the oviducts is not a rational method, as 
 it will not check the rhythm. Nine years ago I began ligating the uterine 
 artery at the neck of the uterus after removing its appendages. This effect- 
 ually and immediately checked menstruation and rapidly atrophied the organ. 
 
 Finally, the oviducts and most of the uterus being removed, menstruation 
 will nearly always stop. The ovary, left without an oviduct, would not 
 sustain menstruation. Cases are reported where the oviducts and ovaries 
 and most of the uterus were removed, but menstruation continued. In such 
 cases, no doubt, a sufficient number of automatic ganglia were left to start 
 and sustain a menstrual rhythm. In such cases I suggest that investigation 
 of total removal of the organs and also of the reality of continued menstrua- 
 tion should be carefully done. Patients often call any bleeding menstruation. 
 
 The ovary is the central, essential, sexual organ of woman (requisite not 
 only for ovulation but internal secretion) and should be removed for malig- 
 nancy and grave disease only. 
 
 Other theories have been advanced as to the cause of menstruation. 
 Dr. Christopher Martin claims that the nerve centers are located in the 
 lumbar cord. This is doubtless based on the labors of Budge, who located 
 the center of the bladder in the lumbar cord. 
 
 I wish to thank Dr. C. S. Miller, of Toledo, Ohio, who worked long with 
 me on this subject. 
 
CHAPTER XXI. 
 
 MENOPAUSE. 
 
 "Nature has caprices which art cannot imitate." — Macaulay. 
 
 Mcnstruatio precox is followed by climacterium retardum. u 
 
 The vagina has tzvo sphincters, viz.: (a) o?ie, the internal, ruled by the 
 sympathetic ; (b) the other, the external, dominated by the spinal nerves. 
 
 The menopause ends slowly, as puberty begins. It is frequently difficult 
 to decide which produces the most profound impression on the general 
 system. The popular belief is that the period of menopause is a time of 
 danger to woman. It is claimed that she is more liable to malignant growths 
 of the genital organs or the breasts, and the average woman expects disturb- 
 ances to arise, either bodily or mentally. Popular belief that woman is more 
 liable to disease at the menopause is probably correct. 
 
 The symptoms of the menopause are: (a) cessation of the monthly flow, 
 (b) flashes of heat, (c) flashes of circulation, (d) irregular perspiration. The 
 cessation of the flow is a very irregular and indefinite matter, but generally 
 occurs at about 45 years of age. It requires an average of eighteen months 
 for menstruation to become regularly established; besides, the genitals were 
 being prepared for several years. It requires two and one-half years for the 
 monthly flow to cease, on an average. The flow ceases very irregularly, 
 even in normally physiologic cases. The flow may be scant one month, not 
 appear at all the next, and the third or fourth a flooding may occur. Should 
 the flow cease without pathologic manifestations? I would answer "No. " 
 Many no doubt will oppose this view and say that it is a purely physiologic 
 process, but it is frequently accompanied by ailments. So is labor a physi- 
 ologic process, but it is frequently accompanied by pain and other disturb- 
 ances. The cessation of menstruation means the death of a great function, 
 the atrophy of a dominating organ which has the greatest nerve supply of all 
 the viscera. 
 
 The beginning of puberty shows vast changes in the entire vascular 
 system and also much change in the whole sympathetic, besides the field of 
 nutrition. The most manifest change at puberty is shown by a perturbed 
 nervous system. 
 
 The nervous apparatus of the visceral organs may well be compared to 
 the equalizers on the horse-power of a threshing machine. When the ten 
 horses pull evenly the gearing works uniformly, but the neglect of one team 
 puts the gearing awry, and though the machine may run, its working is not 
 of such fine balance. The destruction of one function in a well-balanced 
 nervous system is sure to destroy the well-established balance in the others, 
 
 253 
 
254 
 
 THE ABDOMINAL AXD PELVIC BRAIX 
 
 so that in my opinion pathologic disturbances may be looked for at the 
 menopause. In order to make my views clear and reasonable, let us con- 
 struct a diagram of the sympathetic system. The accompanying cut (fig. 
 59) represents the sympathetic nerves. It is drawn in the form of an 
 elongated ellipse. At the upper end of the ellipse begins the cerebral com- 
 municating artery at the so-called ganglion of Ribes. The lower end of the 
 ellipse ends at the coccyx or ganglion impar. '"re" shows the connection 
 of this ellipse with the cerebro-spinal axis. The interior of this ellipse is of 
 
 A SCHEMATIC DRAWING OF THE SYMPATHETIC NERVE 
 
 Fig. 59. X, ganglion of Ribes. Y, coccygeal ganglion (impar). L., liver. K, kidney. 
 S., spleen. Sp. P., (spermatic) ovarian plexus. I., intestine. A. B., abdominal brain (center 
 of reorganization). Sp. N., splanchnic nerves. C. N., cardiac nerves. H. P., hypogastric 
 (aortic) plexus (coming from three sources). U., uterus, oviducts and ovaries. H., heart. 
 C. G., the three cervical ganglion (secondary center of reorganization). 
 
 The sides of the ellipse represent the lateral chain of the sympathetic. One nerve strand 
 goes from the abdominal brain (a. b.) to each viscus to represent its plexus. Observe that 
 the spermatic plexus (sp. p.) arises from the abdominal brain, renal plexus and aortic plexus. 
 Any irritation starting in any viscus will pass to the abdominal brain, where reorganization 
 occurs, and the forces are redistributed over the plexuses to every viscus. 
 
MENOPAUSE 255 
 
 special interest, for here lies the vast and complicated network of this 
 nervous ring, "ab" indicates the abdominal brain, solar plexus or semilunar 
 ganglia — the center or reorganizing locality of the sympathetic system. From 
 this abdominal brain, renal ganglia and the lateral sympathetic chain, 
 passes off a large plexus of nerves, down the aorta to the uterus, oviducts and 
 ovaries. This is known as the hypogastric plexus. The observation which I 
 note in the dissection of quite a number of old women is, that after the 
 menopause the genitals not only atrophy, but the hypogastric plexus also 
 shrinks. 
 
 However, the abdominal brain does not atrophy. It retains its function 
 and structure to the end of life. Dr. Adolph Meyer, formerly of Chicago 
 University, now in Worcester, Mass., writes me the following letter, which 
 explains itself: 
 
 The Worcester Lunatic Asylum. 
 Worcester, Mass., Feb. 20, 1896. 
 My Dear Dr. Robinson: — 
 
 Nearly two years ago you asked me to give you some specimens of a 
 sympathetic ganglion, to ascertain that it is not a degenerate organ, but a 
 living organ with numerous ganglion cells. Those of your opponents who 
 would not believe this may see this specimen from a woman of 74, who had 
 been insane thirty years, and died of heart rupture. The ganglion cells of 
 the semilunar ganglion are large, numerous, moderately pigmented (not more 
 than the spinal ganglia and other nerve cells). 
 
 Adolph Meyer. 
 
 The hypogastric plexus becomes smaller, finer and no doubt some strands 
 disappear at the beginning of the menopause. On this fact must be based the 
 pathologic symptoms accompanying the cessation of the menstrual function. 
 In dissecting infants which have lain in alcohol for some six weeks, the very 
 opposite condition of the hypogastric plexus may be observed, for in the 
 young child the hypogastric (sympathetic) plexus is disproportionately large 
 and can be very plainly dissected out. The explanations of the disturbances 
 of the menopause may be shown as follows: For thirty years monthly 
 rhythmic impulses have passed over the hypogastric plexus to the uterus and 
 oviducts. A fixed habit has been established and the genital organs lie in 
 the sensory and motor grasp of the hypogastric plexus. The importance 
 of the genital organs is shown by the vast nerve supply sent to them and also 
 because the hypogastric originates in great central sources. It arises plainly 
 from the abdominal brain, the renal plexus and sympathetic lateral chain. 
 It is intimately and closely associated with the whole sympathetic ellipse. 
 Now when this great nerve tract, known as the hypogastric plexus, will not 
 transmit the higher physiologic orders, it will unbalance all other parts of 
 the ellipse. If the nervous forces cannot go over an old-established line 
 they will go over the next line of least resistance. The hypogastric plexus 
 cannot carry the orders as it is atrophied and destroyed for the old work. 
 Monthly rhythm of thirty years established in the abdominal brain is not to 
 die without a struggle. This explanation will enable us to understand the 
 
256 THE ABD0M1XAL AXD PELVIC BRAIN 
 
 many pathologic manifestations of every viscus at the menopause. The 
 irritation which arose by trying to pass more nervous impulses over plexuses 
 than normal, gives origin to what is unfortunately known as "functional 
 disease. - ' It is just as organic as any disease, only we are not able to detect 
 it. Acute atrophy is a pathologic condition and no doubt this is the condi- 
 tion of the hypogastric plexus at the menopause. The sudden assumption 
 of function of the hypogastric plexus at puberty produces similar disturb- 
 ances, only the>" do not assume such definite symptoms as at the menopause. 
 The young woman has more depression than the woman in menopause, 
 unless her ovaries be diseased. The advent of menstruation is an important 
 feature in the life of woman. 
 
 After the cessation of the flow the most prominent symptom is what is 
 called flushes. Over eight}' per cent, of women will experience this peculiar 
 phenomenon at the menopause. Two distinct propositions will explain this 
 subject: Flushes result from a disturbance of the vaso-motor centers, and 
 flashes from irritation of the heat centers. Heat and circulative disturbances 
 are so intimate and go together so frequently that I shall not attempt to 
 describe them separately. The heart and vaso-motor centers are unbalanced 
 by irritation at the menopause. The hot flashes may come on rapidly and 
 irregularly for a short period, and then remain away for days. The patient 
 indicates that the disturbances are first manifest near the stomach, and then 
 rapidly spread over the head and chest. It would seem from carefully 
 watching these manifestations at the menopause that wave after wave 
 succeeds each other. I have watched them under attacks and they seem to 
 be under a desperate struggle to control themselves. The blood-vessels of 
 the head and neck appear most affected, yet the skin of the whole body 
 shares in the disturbance. The nerve impulse, which should be emitted 
 along the hypogastric plexus, is abnormally forced over other plexuses and 
 the vaso-motor becomes irritated, resulting in dilatation and contraction of 
 the peripheral vessels. All molecular action generates heat, and it may be 
 that much of the heat experienced is due to the rapid dilatation of the vast 
 number of vessels and the rapid flow of fresh blood in them. As the cheeks 
 glow the patient experiences sudden heat, the skin grows red with flushing 
 blood. Besides the disturbance of the vaso-motor and the heat center, 
 the sweat center is also irritated, the flushes and flashes followed by 
 various degrees of sweating. This is just as irregular and uncertain. The 
 quantities of sweat vary from a fine moisture to great drops. It is apparent 
 to any ordinary observer that profound disturbances arise at both puberty 
 and menopause and it is not strange that tradition attributes some diseases 
 to the advent of puberty and many grave conditions to the menopause. 
 
 The theory of disease at the menopause must rest on the unbalancing of 
 the nervous system by changing the old established nerve channel through 
 which they have carried impulses for a generation. It must rest on actually 
 diseased genitals, or atrophy of the organs on the plexuses which transmit 
 controlling forces to them. Disease at the menopause must rest on some 
 irritating center, which is chiefly the genitals and their nerves. Like many 
 
CLIMACTERIUM 257 
 
 old gynecologists, we need not look for the sole cause in the ovaries, but the 
 trouble is due to reflex irritation. Eighty per cent of such women suffer in 
 general from nervous irritability. Fifty per cent, have disturbance in the 
 heat and circulatory centers. Probably iifty per cent, suffer deranged sensa- 
 tions, hyperesthesia and anesthesia. Perhaps forty per cent, of women at 
 the menopause suffer from the headache, abdominal pain and perspiration. 
 About twenty-live per cent, of women at the menopause suffer from leucor- 
 rhea, sudden flooding and sweats. This means that all the secretory apparatus 
 of the skin, mucous membrane and centers are deranged. The first thing to 
 suspect in such patients is deceased genitals. Endometritis is an arch fiend 
 at this period in a woman's menstrual life. 
 
 Inflammation of some kind may be found in the uterus, oviducts and 
 ovaries. Acute atrophy — a form of degeneration or malnutrition — must be 
 recorded among the diseases. If no pelvic trouble be found, the whole 
 abdomen and chest must be examined for some disorder. I have found that 
 the glycerin tampon twice weekly, and the hot douche gradually increased 
 to ten quarts twice daily, often cures such patients, at least symptomatically. 
 Curetting may be required in a limited few, however it is not so dangerous 
 in the menopautic as in the young woman on account of atrophy and conse- 
 quent inability to receive infection. Radical disturbances in the menopause 
 mean disease, and generally it is located in the pelvis. Women are expected 
 to suffer from neuralgia at this time, nerve irritation, but their intellect is 
 also often disturbed, especially in the will power. General treatment 
 especially visceral drainage is right and reasonable, with baths and attention 
 to food and evacuations. The patients fret and worry and do not rest or 
 sleep well. The bromides act well, especially given at night. I make over 
 half the dose sodium bromide, as that does not irritate the skin so much as 
 potassium bromide. The bowels are best regulated by a glass of water each 
 night at bed-time, in which there is from one-half to one dram of epsom 
 salt; with the additional advice to go to stool every morning immediately 
 after breakfast, i. e., after the hot coffee has stimulated peristalsis of the 
 bowel. 
 
 It is traditional that women become like men after the menopause and 
 it is common for women to argue against removal of the ovaries, fearing 
 that hair will grow on the face and that they will become mannish. Flesh 
 may increase because of disappearing disturbances. It is common for 
 women to take on fat at the menopause. This is a form of low-grade 
 nutrition. I have examined at least half a dozen patients of this nature who 
 were considered subjects of tumors or pregnancy. But a little experience 
 and patience will prove to the physician that the tumor consists simply in 
 abnormally thick and fleshy belly walls. 
 
 No one can number the many and varied pains that attack women in the 
 menopause. Most of the pains arise around the stomach, i. e., in the 
 abdominal brain — the solar plexus. The pains which originate in the 
 epigastric region are innumerable, indefinable and baffle all systematic 
 description. We must, however, have charity sufficient to allow that these 
 
 17 
 
258 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 numberless disturbances are real to the sufferer. The "something moving 
 in the stomach" ma)' be abnormal peristalsis, induced by a diseased focus, 
 as in the globus hystericus. Whatever opinion is held by the physician, a 
 reasonable treatment should be introduced. Such patients have so little 
 confidences in themselves, their physician and their friends, that they have 
 not the will power to persist a systematic course of treatment. Hence they 
 go around from one physician to another. The duty of the physician is to 
 locate the disease and attempt to restore order in a disordered sympathetic 
 nervous system, which becomes unbalanced by reason of some irritation 
 arising from atrophy, senility and inflammation. A thorough automatic and 
 physiologic knowledge of the sympathetic nervous system is required for 
 intelligent practice in gynecology. The pathologic condition must be found 
 in order to show skill in removing it. It must be remembered that a stormy 
 puberty generally means a stormy menopause. If a girl begins menstruation 
 with pain and disturbance it generally means diseased genitals — oviducts or 
 uterus probably — and the sympathetic system will suffer. 
 
 The intimate and wide connection of the nervous system and genitals is 
 phenomenal. The nervous connection of the genitals is profound and any 
 genital trouble deeply impresses the whole system. It would not be strange, 
 also, if one uterus were found with vastly more nervous connections than 
 another, or that is, at least, much more sensitive than others. My experi- 
 ence in the dead-house, as well as observation in the living, is that viscera 
 vary much in size. In some the uterus is small, in others large, without 
 regard to the individual stature. 
 
 Menstruation must be looked upon as arising and subsiding in the 
 nervous system, especially in the sympathetic system. I would like to make 
 a plea for more study of the nervous system, and particularly the visceral 
 nervous system. From the lack of this knowledge physicians are constantly 
 mistaking nervous diseases for uterine disease. A great evil is going on toda3' 
 in regard to the misunderstanding, that a little nervousness does not always 
 belong to the ovaries or uterus. The nervous system is a vast, finely- 
 ordered, nicely-balanced machine, which can be easily disordered without 
 the least need of removing the ovary, uterus or oviduct. Some general or 
 local treatment may be amply sufficient. Too many laparotomies are being 
 done today by unskilled men without proper facilities. Sweeping removal 
 of organs is a backward step in surgery, and the general disapprobation of 
 the leading gynecologic surgeons must cry it down. It must be insisted that 
 he who would work in the peritoneal cavity must be trained. Training and 
 skill, coupled with a decent sense of right, will alone stand the test of time 
 in any branch of surgery. The colleges must begin with chairs of anatomy 
 and abdominal experiments for small classes. A large plea should be entered 
 for an attempt to understand the pathology of the sympathetic nervous 
 system, i. e., visceral nervous system. 
 
 A pathologic state is one manifesting abnormal conditions, whether 
 they are recognizable changes in structure, or simple deranged functions 
 without perceptible disordered structure. There are reflex neuroses, by 
 
MENOPAUSE 259 
 
 which I mean disturbances in distant parts produced by irritation of some 
 sensor}' or motor-peripheral area. It is easy to note that a woman is irri- 
 table or nervous, without in the least being able to locate the pathology from 
 which the disturbance originated. One of the most marked features of the 
 menopause is this kind of nervous irritability. It may be easily observed 
 that women in the menopause do not suffer from tumors and malignant 
 diseases so much as they do from disturbance in the sympathetic system 
 and cerebrospinal axis. Nervous irritability characterizes four women out 
 of five during the menopause. How does this come about? Two ideas 
 explain the complicated but slow course of the disease, viz., Reflex irrita- 
 tion and malnutrition. It can be easily seen that the nervous system is out 
 of balance in the menopause. The beginning and end of menstruation is in 
 the sympathetic nerves. Puberty is heralded by ganglionic rhythm and the 
 menopause comes in at the cessation of the rhythm. The entrance and 
 disappearance of menstruation are nervous phenomena. The genitals then 
 become a point of new irritation as puberty begins, and the genitals are 
 again the focus of irritation as the rhythm departs forever. Menstrual 
 starting chafes the system profoundly, but its cessation irritates the system 
 notably with its dying struggles. By the figure it is plain that any genital 
 irritation can be easily carried to the abdominal brain where the reorganiza- 
 tion occurs. The newly organized force will go to every viscus in the 
 sympathetic ellipse and damage the rhythm. Now the visceral rhythm is 
 fof the purpose of nutrition, and pursues its even tenor in a kind of orderly 
 manner. But irritation from a focus never comes or goes by rule. It goes 
 at all times and any time, while the viscera are performing their nutritive 
 rhythm. The irritation from the diseased focus forces itself up the hypogas- 
 tric plexus to the organizing center and is emitted to all viscera, in addition 
 to the abdominal nutrition and rhythm and disorders natural to visceral 
 rhythm. Few but the special clinical gynecologist fully recognize that 
 uterine disease is often such a slow process and that it can start a train of 
 evils. 
 
 A few weeks or months of pelvic irritation gradually produce deranged 
 visceral rhythm and consequent indigestion. The addition of indigestion 
 to a diseased visceral focus makes a double burden on the whole system. 
 The nerves become more irritable. Indigestion persists and soon brings on 
 distinct malnutrition — another burden to the ganglionic system of nerves. 
 All this continues until anemia arises, the result of waste-laden blood. 
 Now it is apparent to all, when waste-laden blood bathes all the thousands 
 of ganglia and nerve strands in the body, that the patient becomes nervous 
 or irritable. The sympathetic ellipse is unbalanced and its centers are dis- 
 ordered. It is a slow process for a woman to pass from a single focus of 
 visceral disease to a neurotic condition. The whole disturbance becomes 
 intelligible by comprehension of the nervous system and a knowledge of 
 the condition of the diseased genitals. The intelligent practitioner always 
 examines the genitals in a disordered menopause. A stormy menopause 
 means diseased genitals. It means a focus of pathology which is nearly 
 
 ■ 
 
260 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 always situated in the pelvis. The effects on the individual may be described 
 by noting how the irritation can pass up the hypo-gastric plexus to the 
 abdominal brain and being reorganized be emitted to the digestive tract. 
 The irritation goes on day and night ; when it reaches the digestive canal by 
 way of the gastric, superior and inferior mesenteric plexus, it first affects 
 Auerbach's ganglionic plexus of nerves which lie between the muscular 
 layers of the intestinal wall. This simply disturbs peristalsis and induces 
 
 LUMBAR AND SACRAL PORTIONS OF THE SYMPATHETIC (SAPPEY) 
 
 Fig. 60. 1, cut edge of diaphragm ; 2, lower end of oesophagus ; 3, left half of stomach ; 
 4, small intestine; 5, sigmoid flexure of the colon; 6, rectum ; 7, bladder; 8, prostate; 9, 
 lower end of left vagus ; 10, lower end of right vagus ; 11, solar plexus ; 12, lower end of great 
 splanchnic nerve ; 13, lower end of lesser splanchnic nerve ; 14, 14, two last thoracic ganglia ; 
 15, 15, the four lumbar ganglia ; 16, 16, 17, 17, branches from the lumbar ganglia ; 18, superior 
 mesenteric plexus ; 19, 21, 22, 23, aortic lumbar plexus ; 20, inferior mesenteric plexus ; 24, 
 24, sacral portion of the sympathetic; 25, 25, 26, 26, 27, 27, hypogastric plexus; 28,29,30, 
 tenth, eleventh and twelfth dorsal nerves : 31, 32, 33, 34, 35, 36, 37, 38, 39, lumbar and sacral 
 nerves. 
 
CLIMACTERIUM 261 
 
 perhaps some colic. But as the irritation passes to Meisner's plexus it 
 disorders secretion. 
 
 Thus the great assimilating laboratory of life is deranged. Digestive 
 disorders are common in the menopause. Liver disturbances are common. 
 The irritation passes through the abdominal brain to the liver, inducing 
 excessive, deficient or disproportionate bile, glycogen and urea. The rhythm 
 of the liver is deranged. Its rhythmical activity and quiet repose are con- 
 tinually disturbed by reflex irritation. It is easy to observe disease of the 
 liver from the condition of the patient in menopause — skin and bowel abnor- 
 malities. The route from the genitals to the heart is made plain by the 
 diagram. The irritation from the diseased genitals passes to the abdominal 
 brain, thence up the splanchnics to the three cervical ganglia, whence the 
 reorganized irritation passes to the heart over the three cardiac nerves. The 
 result is that the heart goes rapidly, irregularly — it palpitates. 
 
 After nervous irritability the woman in menopause probably suffers most 
 frequently from flushes and flashes, i. e., irritation of the vaso-motor and heat 
 centers. Her skin glows with fresh red blood or burns with prickling heat. 
 This seems to me to be merely an unbalanced condition of the nervous sys- 
 tem due to a disordered focus. The transmission goes in a tumultuous man- 
 ner, over roads which are not accustomed to so much vigorous commerce and 
 the centers are not able to orderly reorganize it. The circulation floods or 
 depletes the vaso-motor centers. 
 
 One may observe that some women enter puberty with many indescrib- 
 able pains and they continue to complain of peculiar abdominal pains during 
 the reproductive period, and at menopause they simply becomechronic grum- 
 blers and complain more and more bitterly. What must be said of such 
 women? We must not consider them as fabricating untruths for a whole 
 generation we must attempt to study the ganglionic system of the sympa- 
 thetic in order to unravel the apparent mystery. We may say that women 
 with these abdominal pains are in a poor state of nourishment. Debility 
 characterizes the ganglionic disease while irritability is the feature of cere- 
 brospinal axis pathology. Women with ganglionic diseases are weak, ill- 
 nourished creatures, often unable to do a little housework. Can we not 
 consider that such patients have hyperesthesia or anesthesia of the visceral 
 ganglia? The ganglia are little brains, for they all have the elements of the 
 cranial cerebrum, — nerve cells and processes. In short every nerve cell is a 
 unit in itself. It is an isolated anatomic unit, a neuron, a brain and a 
 reorganizing center. The essential of the cell is the nucleus because it has 
 the power of nutrition, hence reproduction. Hence each ganglion is a 
 little brain, a reorganizing center. 
 
 Now, a brain or ganglion cell receives sensation, emits motion and 
 controls nutrition. It reproduces itself, it controls secretion and lives in 
 balanced relations with its environment. Can we not think that such patients 
 have over-sensitive or irritable abdominal brains? Their visceral nerve 
 apparatus is abnormal, it is out of order. But this center holds in abeyance 
 nerve energy and nerve force. It holds all the assimilating and circulatory 
 
262 THE ABDOMIX.IL AND PELVIC BRAIX 
 
 laboratory in living tension. Such patients have not a perfect machine 
 with which to work. They are generally congenitally defective, or are 
 made so by the acquisition of some profound function, such as men- 
 struation. The female visceral nerves seem to be peculiarly liable to 
 rapid derangement. Women faint easily and slight occurrences disorder 
 their viscera. The flying of a bird will make the heart palpitate. A sudden 
 noise deranges respiration or circulation. A change of locality either corrects 
 or disorders the nervous system. The female nervous system is much more 
 unstable than the male, and no doubt that is the reason that so many 
 physicians mistake nervous disease for uterine disease. Such physicians 
 are either ignorant of the delicate nerve mechanism or are over-zealous 
 operators. 
 
 The pathologic condition of the genital organs in the natural menopause 
 is generally atrophy, absorption of fat and consequent shrinkage, lessened 
 vascular supply and consequent smaller organs. It is a pure senile atrophy. 
 The organs assumed action, served their purpose and subsided forever. Even 
 in a natural menopause the distinct dying struggle may be expected in the 
 hypogastric plexus. Puberty increases the volume of the organs, while 
 menopause lessens it. Puberty is the real birth while menopause is the real 
 death of the female genitals. The appearance of the individual organs at 
 the menopause is peculiar. The pudendum wrinkles and shrivels through 
 the absorption of fat and other tissues. In dissecting senile genitals the 
 pudendal sac of Bichat and Savage become more apparent than ever. One 
 can push the index finger into it and the greater labia will appear and feel 
 very thin, while the sac seems disproportionately large. The fat, rounded 
 form of youth obscures this peculiar pudendal sac, even in dissecting. In old 
 women the sac flattens out and exposes the clitoris and nymphse. The 
 clitoris becomes smaller and blends with the surrounding parts so much that 
 it is occasionally difficult to find. The vagina becomes smoother in its folds. 
 It contracts in every direction and frequently it may seem to thicken, but 
 that is probably a delusion from blending with other tissue. The cervix gets 
 smaller and may appear entirely absent, from the excessive shrinkage and 
 contracting of the vagina. The uterus becomes smaller and harder. It has 
 a peculiar tough, elastic feeling from the atrophy of muscular tissue. It 
 assumes to some extent the form it had before puberty, except that the neck 
 is more prominent before puberty. It straightens out. Its nerves and ves- 
 sels shrink. The oviducts are notably thinner and shorter. The circular 
 muscular layers seem to suffer most. 
 
 The ovaries atrophy very much and resemble a peach-stone on the sur- 
 face. In quite a number of old female cadavers I found them the size of 
 beans and in some it required considerable searching to find and recognize 
 them. Then we found in the contracted and atrophic broad ligament the 
 sheaths and nerves themselves atrophied. 
 
 In Women with a stormy menopause it is not unusual to find subinvolu- 
 tion. While a pupil of Lawson Tait, fifteen years ago, I gained some 
 knowledge in regard to a disease of the pudendum which may not infre- 
 
CLIMACTERIUM 263 
 
 quently be seen in women from forty to fifty, or about the menopause. It is 
 a trouble that one would easily pronounce on a glance, eczema of the puden- 
 dum. Mr. Tait remarked that it was due to a kind of climacteric diabetes; 
 that is a kind of eczema at the menopause. Dr. Martin, Mr. Tait's assist- 
 ant, was very kind in displaying to me these unfortunate cases. The labia 
 were swollen and edematous and the red flaming eczema extended far and 
 wide beyond the pudendum. The disease made the patient's life almost 
 intolerable. Mr. Tait's treatment for such cases was a solution of hypo- 
 phosphite of soda (an ounce to a pint of water). The solution should be 
 applied every two to five hours as required, to destroy the germ which 
 induced the itching. He then gave heavy doses of opium. Mr. Tait claims 
 that there is a kind of diabetes mellitis during the menopause; a limited 
 diabetes, as they all finally recover. The distress of the patient with this 
 climacteric diabetes is due to the sugary urine causing irritation of the 
 pudendum. Peculiar crusts form, due to the multiplication of the vegetable 
 germ known as Torula cerevisioe. The eczema due to this cause will spread 
 over the buttocks, over the abdomen and even to the thighs. In one case I 
 saw the eczema extend so far that the patient could walk only with difficult}'. 
 The hyposulphite of sodium arrests the formation of this germ. Mr. Tait 
 would sometimes give as high as one grain of opium three times daily and 
 then two grains at night. After a few months of such treatment the opium 
 was lessened, and in from five to ten months such patients fairly recovered. 
 They are liable to mild relapses. 
 
 M. Lecorche, of Paris, has also made researches independently of Mr. 
 Tait and curiously enough they agree in many ways. Mr. Tait carries his 
 views into more definite plans of treatment. This climacteric form of diabetes 
 is then a disease which begins at the menstrual cessation and lasts a few 
 years. Menstruation seems to give immunity from it. Nature appears to 
 finally overcome it. If the hyposulphite of sodium is inefficient to arrest the 
 trouble, on account of the fluid quickly running off the parts, an ointment 
 of sulphur will remain on the pudendum for hours. Any substance which 
 will arrest the fermentation changes in sugar is an effective remedy. I have 
 noted no special form of climacteric vaginitis, but one form is liable to arise 
 which is due to laying bare some peripheral nerves in the vaginal wall. The 
 spots are red and most exquisitely tender; they occur mainly at the pudendal 
 orifice and are very persistent. The treatment consists in applying cocaine 
 and sufficient caustic or Paquelin to entirely destroy the exposed nerves. 
 These neuromatic patches are apt to arise in women at other times also. In 
 severe cases it is best to anesthetize the patient and destroy the exposed 
 nerves widely with the Paquelin. 
 
 The special diseases of the uterus which I have observed in menopause 
 are endometritis and myometritis accompanied with leucorrhea. Chronic 
 endometritis with an excoriating discharge is frequently found. The uterus 
 is generally slightly large. The mouth is red, bleeds easily and out of it 
 runs a muco-purulent substance of varied color. The hot douche (15 quarts) 
 twice daily and the additional use of glycerin tampons cure most cases. 
 
264 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Occasionally a curetting is required, followed by the thorough application of 
 95 per cent, carbolic acid. I apply the 95 per cent, carbolic acid to the 
 endometrium three times, so that it will destroy the old inflamed endome- 
 trium, and drain with a little rubber tube or pack in gauze, and remove it in 
 twenty-four to thirty-six hours. Fortunately the senile endometritis is gen- 
 erally cured with one curetting, unlike the stubborn endometritis of youth. 
 Mild forms of endometritis in the menopause I have frequently noted. 
 The subinvolution or suspended involution is a much graver matter. It 
 has had a more evil and wide effect on health and especially on the nervous 
 system. It consists essentially of a myometritis, and so far as I can observe 
 rests on an old endometritis. It is not clear whether Klob or Rokitansky 
 is correct, in regard to the theories of the conditions producing a hyper- 
 trophic uterus. 
 
 Whether the hypertrophic uterus is due to excess of connective tissue 
 or muscle, or whether it is due to a natural proportionate increase of both is 
 
 undecided. In such cases a lax pelvic floor is often observed. So far as 
 my experience goes, the tampons and douche are insufficient and are too slow 
 for satisfactory results. Thorough curetting is the best means at command, 
 with the application of 95 per cent, carbolic acid to the whole endometrium. 
 The cure is slow at best but finally quite satisfactory. The pathology of the 
 climacteric or senile endometritis must not be lost sight of. At first the 
 leucorrhea is more abundant. It may be mucous, muco-purulent and Anally 
 purulent. The explanation of the changes of the fluid secreted from the 
 endometrium rests on the endometric glands. At first the glands are able to 
 be increased in their function ; with time they atrophy, but the inflammation 
 proceeds and finally only sero-purulent substance or chiefly pus results from 
 the glandular destruction; only now and then a glandular endometritis. The 
 remnants only of the endometrium remain and these are involved in a state 
 of low vitality. Low and mild forms of granulation are visible at the neck 
 and can be scraped out of the uterus. Slow necrosis, local death, gradually 
 proceeds until raw ulcerative surfaces are exposed and only pus will be 
 secreted. The glands have disappeared practically. 
 
 We must observe that cervical laceration frequently exists with this 
 trouble. The reason such conditions do not heal well is because the blood 
 supply and nerve supply to the uterus are now being cut off, are imperfect, so 
 that nutrition is very deficient in the uterus. For thirty years the uterus has 
 had high feeding from fresh blood and the fine control of a complicated nerve 
 apparatus, but suddenly the high feeding is curtailed and the delicately 
 balanced nerve apparatus is impaired by the atrophy of the menopause. 
 Hence low granulations, imperfect reproductions of cells, ulcerative surfaces, 
 may be expected. It must be remembered that there are other troubles 
 than cancer in the uterus at the menopause. The essential feature of the 
 climacteric uterine trouble is imperfect nutrition. This will not astonish 
 one so much after he has carefully examined and dissected or post-mortemed 
 a dozen female cadavers above 50 years of age. In them he will note 
 atrophy, shrinkage, contraction and pale white tissue. 
 
CLIMACTERIUM t? 65 
 
 The differential diagnosis between cancer and benign uterine disease 
 (endometritis) may be looked for in the case of cancer by infiltration, thicken- 
 ing and peculiar watery, sanious discharges. As regards ovarian tumors at 
 the menopause they grow more rapidly. The vital power of the patient is at 
 a lower ebb, and besides the nutrition of the ovary is degraded by dimin- 
 shed blood supply and atrophy of its nerve supply. 
 
 It would appear that the branches of the hypogastric plexus, which are 
 sent to the bladder and rectum, are not atrophied to the same degree as the 
 branches sent to the genitals (uterus, oviducts and ovaries). Yet in my 
 postmortems and dissections it appears to me that the vesical and rectal 
 branches do atrophy. The present idea of medicine is that there is an auto- 
 matic structure disordered somewhere to account for disease. A portion 
 only of a man is diseased and pathologic anatomy would always indicate the 
 origin, had we sufficient acumen. 
 
 Now in the menopause the cerebrospinal axis is disturbed through the 
 means of the vaso-motor nerves, and the circulation by some form of reflex 
 neurosis. A woman's mind is often disturbed. She has lost her old will- 
 power; her memory is impaired; she cannot concentrate effort. She is liable 
 to do damage from inability to control her own action. The law recognizes 
 any deviation from rectitude during the menopause with leniency. The 
 treatment of women during the menopause must be local, general and moral. 
 The cog in the wheel which disturbs . even physical existence must be 
 remedied. General debility and irritability must be allayed by anodynes with 
 both tonics and good nourishment, while the unhinged moral views must be 
 removed by changing the life from the old ruts which caused them. One 
 feature must not be lost sight of. When pelvic disease has started a train 
 of evils and continued for years, we cannot expect very much from mere 
 treatment, but radical removal of diseased organs often alone gives relief. 
 
 CONCLUSIONS. 
 
 1. The average menopause lasts two and one-half years. 
 
 2. It comes on slowly as does puberty. 
 
 3. A stormy puberty means a stormy menopause generally. 
 
 4. The general rule is that an early puberty means a late menopause. 
 In my opinion it simply means that early puberty and late menopause rest on 
 largely developed abdominal and pelvic brains and hypogastric plexus. 
 Precocious puberty means well developed genitals and ganglionic nerves. 
 
 5. The disturbance at the beginning of puberty is profound, but since 
 it is an active (depletive) physiologic process it quickly fits the growing and 
 adaptive nervous system. But the menopause is a destructive process. It 
 breaks up the harmony of the previous processes and unbalances the even 
 distribution of nervous energy and circulation. 
 
 6. It is probable that every viscus receives an equal or greater shock 
 at menopause than at puberty. 
 
 7. The changes at menopause consist in menstrual cessation, atrophy 
 of the genitals, the hypogastric plexus and pelvic brain. 
 
266 THE ABDOMINAL AXD PELVIC BRAIN 
 
 8. Women do not suffer at the menopause so much from malignant 
 diseases as they do from nervous troubles, neuralgias, mental deviations, 
 disturbed visceral rhythm, disordered circulation, indigestion and above all 
 neuroses. 
 
 9. The heat center (flashes), the vaso-motor center (flushes) and the 
 sweat center (perspiration), are the especial centers disturbed. Excessive, 
 deficient or disproportionate blood-supply characterizes the disturbed 
 phenomena of these centers. 
 
 10. The etiology and pathology of the menopause lies in the sympathetic 
 or ganglionic nervous system. 
 
 11. The sympathetic pathologic stages in menopause are: (a) a focus of 
 disease, or irritation (the genitals), (b) indigestion, (c) malnutrition, (d) 
 anaemia, (e) neurosis. It is a slowly progressive process. 
 
 12. Atrophy is a disease just as much as hypertrophy or inflammation. 
 Atrophy traumatises nerves by cicatritial compression. 
 
 13. Chief among the actual disease in the menopause is endometritis. 
 This is due to infection from desquation of epithelia. The peculiar flood- 
 ings doubtless depend on this inflammation. 
 
 14. The menopause is characterized by various discharges (mucous 
 membrane), leucorrhea, bronchitis, hemorrhages from the bowels, epistaxis 
 (skin) perspiration. 
 
 15. Circulatory, perspiratory and caloric changes are the common 
 heritages of the menopause. 
 
 16. A characteristic phenomenon of the menopause is an unbalanced, 
 unstable nervous system ; cerebrospinal (irritation), or sympathetic (debility). 
 
 17. Debility characterizes the trouble in the ganglionic system, while 
 irritability characterizes the cerebrospinal axis. 
 
 18. The explanation of the various phenomena lies in the nervous and 
 circulatory systems. 
 
 19. Excessive sexual desire at the menopause is indicative of disease. 
 
 20. In the menopause the nutrition is impaired, as is shown by the 
 occurrence of malignant disease in the sexual organs which are in a state of 
 retrogression. 
 
 21. A chief characteristic of uterine disease is malnutrition from 
 atrophy, which suddenly limits blood supply. This arises from the sudden 
 degeneration of the genital nerve apparatus, pelvic brain and hypogastric 
 plexus, and consequent impaired control of tissue by defective nourishment. 
 Ulcerative processes, local death and purulent secretions arise from low 
 granular cell-formations. 
 
 22. In the menopause a disturbed point has arisen in the harmony of 
 visceral rhythm. This pathologic focus must be looked on as the cause of 
 the innumerable reflex neuroses at this time of life. 
 
 23. A reflex neurosis is a disturbance in distant organs caused by the 
 irritation of a peripheral sensory or motor area. 
 
 24. The chief manifestations of disturbances during menopause are 
 those of pathologic physiology rather than pathologic anatomy. 
 
CHAPTER XXII. 
 
 GENERAL VISCERAL NEUROSES. 
 
 The Peritoneum holds in intimate connection the tractus intestinalis , tractus 
 genitalis and tractus urinarius by means of the (a) sympathetic nerve, 
 (b) blood-vessels, (c) lymphatic vessels, and {d) connective tissue. 
 
 A pathological focus, a reflex, in any one of the three great abdominal 
 visceral tracts, produces disordered rhythm or wild peristalsis in both of 
 the other tracts. 
 
 " The telegraph is the nervous sy stern of the world." — N. Y. Herald. 
 
 The subject of visceral neuroses must be considered under three heads, 
 viz. : 
 
 1. Sensory Neuroses. — The state of the sensory nerves must be con- 
 sidered. There will be two morbid states of the sensory nerves to consider: 
 (a) pathological lesions of a more or less demonstrable sort, either in actual 
 changes in structure or evident in reflex action, (b) a neuralgic condition, 
 a state in which no pathologic lesion is demonstrable, a kind of morbid or 
 exalted sensibility or over susceptibility are those of the sensory sympathetic 
 nerves. The neuralgias and exalted sensibility will be discussed under the 
 hyperesthesias of the abdominal brain and its radiating plexuses of nerves. 
 
 2. Motor neuroses, the second subject, including visceral neurosis, are 
 those of motion, such as visceral rhythm, motus peristaltus. 
 
 3. Secretion neuroses, the third subject included in visceral neuroses, 
 will include the phenomena of secretion, such as excessive, deficient or 
 disproportionate secretion. 
 
 VISCERAL NEUROSES. 
 
 Under this head we will include a series of phenomena of the viscera, 
 partly pathologic and partly reflex, partaking of a disturbance of sensation, 
 motion or secretion. By visceral neurosis we mean an undue irritability 
 or perverted function of one or more of the viscera. The pathologic con- 
 dition may be demonstrable or not. Frequently it is pathologic physiology. 
 
 In the phenomena of visceral neuroses must be included the clinical 
 fact that if one organ is disturbed it will tend to unbalance the remainder, 
 i. e., irritation is reflected by a nerve arc from one viscus to another. A 
 diseased uterus is frequently followed by a disturbed stomach. A checking 
 of normal function not only makes neurosis but indigestion, non-assimilation 
 and anemia. Such a case occurred in the person of a young woman on whom 
 I performed laparotomy. A few months after the operation she began to 
 suffer tenesmus, spasmodic dragging pain in the sacrum at defecation, and 
 colica membranacea arose. She became slowly ill, neurotic and unable to 
 work. Dr. Lucy Waite and I operated on her and all that we found was an 
 
 267 
 
268 THE ABDOMIXAL AND PELVIC BRAIN 
 
 organized peritoneal band several inches long stretching from the amputated 
 oviductal stump to the middle of the sigmoid. The peritoneal band checked 
 the normal peristaltic action of the sigmoid, producing pain, non-assimilation, 
 anemia and indigestion. She became well after the operation, gaining some 
 twenty pounds. In over a dozen cases during the past three years Dr. Lucy 
 Waite and I have reoperated for old post-operative peritoneal adhesions. 
 We generally found that some loop of bowel was attached to the amputated 
 end of the oviduct and checked more or less the bowel peristalsis. Hence, 
 partial checking or hindering of bowel peristalsis produces a peculiar kind of 
 neurosis. All one may notice at first in such cases is irritability. Pain may 
 not be spoken of as the chief annoyance. These subjects with peritoneal 
 bands, which more or less interfere with visceral rhythm and peristalsis 
 suffer in distant organs from reflex irritation radiating to them. It should 
 be remembered that reflex action goes on in health and disease. Nerves 
 like railway cars carry any kind of freight. 
 
 The essentials of a nervous system consist of (a) a central nerve cell, (b) 
 a conducting cord, and (c) a peripheral apparatus. However vast the 
 nervous system, the elements are the same. For example, the skin is the 
 peripheral apparatus, the spinal nerves are conducting cords and the spinal 
 cord the central nerve cells. The same form of illustration may be made in 
 regard to the abdominal and pelvic brain as in the central nerve cell. The 
 superior and inferior mesenteric plexuses of nerves are the conducting cords 
 (for the intestines) and the peripheral apparatus is in the mucosa. In 
 visceral neuroses pain is not always the chief symptom. Subconscious 
 irritation plays the chief role; irritation which does not come within the 
 field of recognized pain. 
 
 Among visceral neuroses we should include enteroptosia. The maladie 
 dc Glenard is doubtless a neurotic disease belonging to the domain of the 
 nervous vasomotorius. Recently Dr. Schwerdt has written some interesting 
 and well studied articles on enteroptosia. Visceral neurosis means that the 
 nervous system in the abdomen and the organs are not living in harmony. 
 The gamut of the sympathetic nerve has lost its tone. 
 
 Enteroptosia begins in respiration and from a weakness of the abdominal 
 sympathetic, which became tired and slacken in its tone. The sympathetic 
 nerves to the viscera have lost their normal power over circulation, assimila- 
 tion, secretion and rhythm; but the sympathetic nerves have lost their 
 influence over the viscera very slowly, for the enteroptosia is a very slow 
 disease at first and has a long chronic course from the beginning. It may 
 require years to develop. In a later stage of enteroptosia the disturbance 
 of feeling and motion arises, and the nervous symptoms of disturbed diges- 
 tion, aortic palpitation and dragging sensation. Later the disturbance of 
 motion occurs. The abdominal walls slacken, lose their tone and atrophy 
 even the extremities losing some of their delicate balance. But with the 
 lowering of the intra-abdominal pressure the real ptosia of the viscera begins 
 and the neurosis rapidly increases. The anatomical visceral pedicles elongate, 
 the organs begin to leave their bed. 
 
GENERAL VISCERAL NEUROSES. 
 
 869 
 
 SYMPATHETIC NERVE IN LUMBAR REGION 
 
 119 f 1 f g,6 V 1I4 ' ga , n §! ia at ?rigin of inferior mesenteric artery; 115, interiliac nerve disc: 
 114 lateral sympathetic chain ; 156, rectum ; 181, common iliacs. 
 
270 THE ABDOMINAL AND PELVIC BRAIN 
 
 The digestive tract being disturbed, the nervous system suffers from 
 auto-intoxication. Assimilation becoming deranged by a continuously dis- 
 turbed digestive tract, a vicious circle begins its progress. The motor, 
 sensory and secretory nerve apparatus, each and all, become involved. 
 Anatomically, we observe the order of visceral ptosia (I base this on some 
 seven hundred personal autopsies) to be the following: 1, the right kidney; 
 2, the stomach; 3, the small intestines; 4, the transverse colon; 5, the 
 spleen ; 6, the liver, and 7, the genitals. Visceral ptosia belongs in the vast 
 majority of living diagnoses to women, but autopsies show the disease quite 
 common in women and not rare in men. 
 
 The slackening and atrophy of the female abdominal wall makes the 
 diagnosis easy, while the retention of tone in the abdominal wall of men not 
 only makes visceral ptosia rare in men but more difficult to diagnose. The 
 typical enteroptosia occurs in old age when the sympathetic has lost its tone 
 and vigor. In a normal condition of the abdominal viscera the several organs 
 hold a, harmonious relation to each other, no nerve plexus is stretched or 
 slackened, and function, secretion, assimilation, circulation and rhythm move 
 without friction. Now, with dislocated organs dragging irregularly on the 
 nerve plexuses, deranging secretion and assimilation, the suffering becomes 
 manifest in what we know as visceral neurosis. Some designate it hysteria. 
 The lost tone and vigor of the anterior abdominal wall is unfortunate because 
 its vigorous aid to peristalsis is wanting. The loss of the muscular action 
 of the anterior abdominal wall allows congestion of blood and secretions to 
 arise; and constipation intervenes. 
 
 In visceral ptosis the skin presents anesthesia and hyperesthesia, also 
 vicarious actions to elemental products. In enteroptosia we have various 
 functional paralyses. The physical and mental vigor is paretic in entero- 
 ptosia. It produces languor. The intestinal tract is sluggish, paretic. The 
 bowel suffers in two ways, first, from auto-intoxication; second, from the 
 irritation of the decomposing material on its mucosa, which reacts on the 
 nervous system. The disturbed skin trouble in enteroptosia points to hydro- 
 therapy as the best way out. Baths open the drains of the skin. Entero- 
 ptosia is a functional disease. 
 
 In enteroptosia as a visceral neurosis we deal with several stages, each of 
 which presents distinct landmarks. 
 
 In the first stage we deal with increasing muscular weakness. The 
 pati.ent complains of manifold sensations on account of disturbances in the 
 sympathetic, anemia, defective assimilation and loss of weight. Physical 
 and mental energy become lowered and intra-abdominal pressure becomes 
 lessened. The disease may not extend further. 
 
 In the second stage of enteroptosia the name of the disease is quite apt, 
 for the individual viscera begin to leave their old, natural beds. They 
 become dislocated, and permanently fixed in wrong positions. (However, 
 by force or the patient assuming an unnatural position the dislocated viscera 
 may resume their proper position.) With the dislocated organs begin the 
 visceral neuroses, the indigestion and the auto-intoxication. In this stage 
 
GENERAL VISCERAL NEUROSES 271 
 
 the abdominal brain and its radiating plexuses, as well as the vessels sur- 
 rounded, must become adjusted to the new environments of drawing and 
 pressure; compensations of atrophy and hypertrophy will arise. For 
 example, the power of the muscular wall of the abdomen being lessened, the 
 digestive tract must compensate by increasing its muscular wall in order to 
 drive onward the fecal mass. 
 
 The third, and final, stage of enteroptosia may be observed in some old 
 people. It is the stage in which compensatory hypertrophy fails; and the vis- 
 cera becoming overfilled, depletion is very imperfect. The digestive tract is 
 unable to empty itself from the remnants of its feasts, and excessive venous 
 congestions arise, the bladder is able to expel but a little urine at a time 
 and the digestive tract suffers from the absorption of toxins and the irrita- 
 tion from decomposing material. 
 
 In one case of enteroptosia, postmortemed by Dr. Lucy Waite and 
 myself, the greater curve of the stomach rested on the pelvic floor. The 
 subject was an old man. In another case in which I performed the autopsy 
 the spleen was resting on the pelvic floor. It is common in autopsies to find 
 the right kidney movable for two inches proximalward and two inches 
 distalward — a range of four inches. The transverse colon is frequently 
 found in the pelvic cavity. 
 
 The treatment of enteroptosia may be summed up in the words, hydro- 
 therapy and abdominal support. The young surgeon who performs nephror- 
 rhaphy for movable kidney will have his hands full, if he has a large practice, 
 for I know from personal experience in autopsy and practice in gynecology 
 and abdominal surgery, that movable kidney is a very frequent occurrence. 
 I should judge that five women out of ten, who come to my office, have a 
 movable right kidney. Movable kidney is a part of enteroptosia — nephro- 
 ptosia. Now, since patients afflicted with enteroptosia surfer from auto- 
 intoxication, non-elimination, non-drainage and congestion, we must aid 
 Nature by establishing general drainage. Frequent salt baths, persistent 
 massage and abdominal supporters are required in the treatment. Above 
 all, the digestive tract must be frequently evacuated once daily by adminis- 
 tering a full glass of water with half a dram of epsom salts and ten drops of 
 tr. nux vomica every night on retiring, and insist on the patient emptying the 
 bowels regularly every morning at the same hour. The abdominal bandage 
 should be of elastic flannel and fit snugly. It may be removed at night. 
 The abdominal binder affords much comfort. In fact, one of the methods of 
 diagnosing enteroptosia is to elevate the viscera and then to note whether 
 the pain ceases. 
 
 It may not be forgotten that enteroptosia offers opportunities not only 
 for visceral neuroses, but also for obstinate constipation, which favors the 
 development of visceral neuroses by over-retention of feces, including decom- 
 position of matter, calling up irritation and auto-intoxication. Each factor 
 in enteroptosia induces a vicious circle. The factors in enteroptosia which 
 solicit constipation are: 
 
 1. Flexing of the colon by the ligamentum hepato-colicura. 
 
272 THE ABDOMINAL AXD PELVIC BRAIN 
 
 2. Flexing of the colon by the ligamentum phrenico-colicum sinistrum. 
 
 3. Flexing of the right colon by the ligamentum phrenico-colicum 
 dextrum. I have seen the right colon in the pelvis hanging by this band. 
 
 4. Flexing of the pylorus by the ligamentum hepato-duodenum. 
 
 5. Atony of the gastro-intestinal muscularis. 
 
 6. A lowering of the intra-abdominal pressure by atony of the anterior 
 abdominal muscles. 
 
 7. The excessively mobile viscera with elongated pedicles locally com- 
 promise the bowel lumen as well as that of vessels. 
 
 In sensory visceral neurosis (or neuralgia) we are doubtless dealing with 
 a peculiar form of malnutrition of the nerves of sensation. Hence in these 
 days of scalpel or no scalpel, of sweeping removal or surgical repair, it 
 behooves us to diagnose with caution the symptoms of disease. In disease we 
 are seldom dealing only with signs, which are distinct clews to disease, but 
 chiefly with symptoms which are only indications of pathology. In visceral 
 (abdominal) neuroses we are dealing with organs which possess (a) motion, 
 (b) sensation and (c) secretion; i. e., such organs have muscles which are 
 set in motion by motor nerves, sensation made manifest by some irritation 
 on the sensory nerve ends, and secretion which proceeds normally in certain 
 quantities, but in disturbed conditions, (a) excessive, (b) deficient, or (c) 
 disproportionate. 
 
 In visceral (abdominal and thoracic) neuroses we are chiefly dealing with 
 the vasomotor (sympathetic) — a nerve of rhythmical motion and dull sensa- 
 tion. The term visceral (abdominal and thoracic) neurosis is a mere name 
 of a symptom in the minds of many physicians, as we say the kettle boils 
 when we really mean that the water boils or is raised to such a degree of 
 temperature that the ebullition occurs in the water. 
 
 Visceral neurosis indicates that some deep condition, assimilation or 
 vicious process is proceeding somewhere. The observing physician of 
 experience commonly associates in his mind visceral neuroses with (a) some 
 debilitating process in age or sex. We cast about for predisposing causes 
 and examine them as a neurotic temperament, hereditary or acquired. One 
 can acquire a neurotic disposition by dissipation, sexual or with narcotics, 
 by excessive and prolonged labor, the absorption of poisonous substances, as 
 lead, arsenic or phosphorus. Rapid changes of temperature bring on visceral 
 disturbances, (b) We also take into account sex. It is difficult to say which 
 sex suffers the most from visceral (abdominal) neuroses. I should judge 
 women do. But different varieties of visceral neuroses prevail in each sex, 
 and at different periods of life. 
 
 (c) The chief age of visceral neuroses is from twenty to sixty. Few 
 cases occur before twenty and rarely after sixty. (d) The sexual life of 
 woman is rich in visceral (abdominal) neuroses at different periods as-(l) at 
 puberty, (2) at the menopause, (3) at the menstrual period, (4) daring preg- 
 nancy, (5) in the puerperium, (6) there are neuroses from excess of abstin- 
 ence from venery. In the above six factors the circulation plays an 
 important role. In short, the neurosis is secondary to some other process. 
 
GENERAL VISCERAL NEURO 
 
 373 
 
 (e) Visceral (abdominal) neuroses are commonly associated with genital 
 malnutrition, as in anemia, cachexia from malignant disease, chlorosis, 
 debility, mental or physical, from irritation, reflex action, over-strain. 
 Diabetic, gouty and rheumatic persons suffer from visceral neuroses. In the 
 above factors reflex irritation plays the chief role. 
 
 (f) In the etiology of visceral neuroses we must include all kinds of 
 trauma to nerves, contraction of cicatricial tissue, pressure of adjacent 
 organs, tumors and pressure on nerves, adjacent inflammatory tissue, dis- 
 
 SACRAL SYMPATHETIC AND SACROSPINAL NERVES 
 
 Fig. 62. This illustration is drawn from a woman about 40 years of age. 
 It represents the sacral sympathetic and sacro-spinal nerves Is, 2s, 3s, 4s and 
 os, sacral ganglia. Sc. N. sciatic nerve. The sacral sympathetic ganglia are 
 connected, anastomosed by transverse strands. 
 
 located organs dragging as in visceral ptosia; in short, trauma, pressure and 
 dragging. 
 
 (g) Many visceral neuroses rest on infection or intoxication, as malaria, 
 typhoid fever, or poisoning with lead, copper, mercury and other agents. 
 
 (h) Catching cold, rapid changes of temperature, cold and wet weather, 
 play a role in the etiology of visceral neuroses. 
 
 (i) Visceral neuroses may depend on (1) a small abdominal brain, (2) 
 deficient blood supply, (3) continued disease, (-i) premature senility, (5) 
 temporary invagination of the bowels. 
 
274 THE ABDOMIXAL AX D PELVIC BRAIX 
 
 (j) A peculiar affection of the rectum of a neuralgic character sometimes 
 arises. It occurs in robust as well as neurotic persons. The patient will go 
 to bed well and wake up at any hour of the night, with a severe pain in the 
 rectum, about the large prostatic plexuses of man and about the cervico- 
 uterine ganglia of woman. I know one patient who has had such an affection 
 for over ten years. The pain rises to a maximum and remains intense, 
 gnawing and grinding for from ten minutes to nearly an hour, when it will 
 suddenly pass away. No cause can be assigned in this case, for the patient 
 lives in apparently perfect health. 
 
 The symptom, par excellence, of visceral neuroses, is pain. The 
 patients describe the pain in manifold ways as boring, dragging, burning, 
 stabbing, pressing, lancinating, grinding and tearing. Usually the pain is 
 paroxysmal, ceasing in the intervals. The pain on lessening may be very 
 irregular, slight or intense. 
 
 Upon one point concerning neuralgia (visceral or otherwise) I am doubt- 
 ful, and that is that the nerves have distinct local points of tenderness: — Dr. 
 Yalleix's announcement, for example, of the three tender points on the inter- 
 costal nerves. But by careful examination and an opportunity to compress 
 the nerves, we would likely elicit pain in any or all points of a neuralgic 
 nerve. The patient can scarcely give distinct localities of tenderness, for 
 mechanical pressure elicits distinct pain. The irregularity of the various 
 localities of pain in visceral neuralgia shows that it is not a mere local dis- 
 order but some germinal malnutrition of the sensory apparatus. Visceral 
 neuralgia not only occurs in the trunks but along the branches of nerves, as 
 some patients will complain of pain in various regions of the hypogastric 
 trunks, but of irregular pain in the spermatic branches or in the testicle. 
 During the attacks of visceral neuralgia various accompanying secondary 
 affections arise, as vasomotor disturbances, muscular disturbances. The 
 vessels contract, lessening the amount of blood passing through them, and 
 muscular action brings contractions (colic) in local and remote regions of the 
 abdomen ; shifting, colicky cramping pains characterize the visceral neural- 
 gias. In one patient on whom we operated the second time, complaining of 
 varying pains in the right side, we found the liver and stomach prolapsed 
 considerably. Since the operations she complains of irregular pains still in 
 the right side where we made no interference. We do not operate for pain 
 in the right side, but for other reasons, yet we noted much visceral ptosia of 
 the stomach and liver in the region of these neuralgic pains. In many cases 
 I have noted the evil effects of peritoneal adhesions previous and subsequent 
 to abdominal section, and Dr. Lucy Waite and I have operated on many 
 patients a second time for the pain caused by peritoneal adhesions, fixing 
 movable viscera and interfering with their function, rhythm and peristalsis. 
 Peritoneal adhesions produce as symptoms a kind of visceral neurosis, how- 
 ever; the pain of peritoneal adhesions is certainly more constant, in the 
 language of the patient, as dragging sensation repeating itself on prolonged 
 efforts. 
 
 Peritoneal adhesions, will, no doubt, explain man}' cases of visceral 
 
GENER. I L I 'ISC E A'. I L NE L r ROSES r, 5 
 
 neuralgia. In numerous abdominal autopsies T found practically the follow- 
 ing percentage of peritoneal adhesions in the following locations, viz.— (1) 
 At the proximal ends of the oviducts, 80 percent in adults; (2) in the mes- 
 osigmoid over the left psoas, 80 per cent in adults; (3) in the ileo-coeco — 
 appendicular apparatus on the right psoas, To per cent ; (4) in the gall-bladder 
 region 45 per cent; (5) 00 per cent occurs adjacent to the spleen. Also 
 numerous peritoneal adhesions occur at the flexures of the tractus intesti- 
 nalis, viz. — (a) Flexura coli lienalis; (b) flexura coli hepatica; (c) flexura 
 duodeno-jejunalis. Peritoneal adhesions compromise the circulation (blood 
 
 91 -l-^i : t /■■ 7 
 
 CERVICAL GANGLIA 
 
 Fig. 63. 6, superior; 7, middle cervical sympathetic ganglia; 9, 1", 11, 12, 13, 
 cervical nerves (spinal) ; 24, 25, 26, 27, cervical rami communicantes ; 3, vagus; 
 20, superior cardiac from superior cervical; 2, hypoglossel. 
 
 and lymph) peristalsis, absorption and secretion of viscera, as well as trau- 
 matises (neuralgia) the visceral nerves. 
 
 Another patient complained of a varying pain along the left ovarian 
 plexus, and again for months in. the region of the left kidney. Physically, 
 nothing could be discovered except that she was very anemic. I am thor- 
 oughly convinced that considerable visceral pain arises from pressure of fecal 
 masses as they pass over the nerve plexuses, also that the hard, irritating 
 fecal masses stir up local bowel contractions (colic) as they move toward the 
 rectum. This accounts for the clinical fact that the visceral neuralgic pains 
 
276 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 fast disappear when cathartics are so used as to regulate a daily stool. In 
 my practice of gynecology nothing has produced better results in constipation 
 than the drinking of a full glass of water, with one-quarter teaspoonful of 
 epsom salts on retiring, and going to stool promptly after breakfast every 
 morning. The more I practice gynecology and abdominal surgery the more 
 I become acquainted with visceral ptosis and its evil results, and the more 
 I am convinced that visceral neuralgia has a physical basis whose pathology 
 will become more manifest with study. 
 
 It is difficult to point out, precisely, the symptoms of visceral neuralgia, 
 for the very simple fact that we do not yet know the definite functions of 
 the visceral nerves. We must compare the visceral neuralgia with the better 
 known neuralgia of the trigeminus. It has been stated that neuralgia is a 
 prayer of the nerve for nourishment or for fresh blood. We often notice 
 that a nerve subject to neuralgia is sensitive to pressure. So in our diagnosis 
 we must follow the track of sensitive nerves in the abdomen. To do this we 
 must know that there are great bundles or trunks of nerves called plexuses 
 which quite generally follow large blood-vessels. Great ganglia exist in 
 different localities of the abdomen, which space forbids even naming. In 
 short, we have to deal with the abdominal brain, the inferior mesenteric gan- 
 glion, the cervico-uterine ganglia and the lateral chain of ganglia and hosts 
 of smaller ones, all connected by nerve cords. The sympathetic nervous 
 system which supplies the abdominal viscera is partly independent of the 
 remainder of the nervous system and partly intimately connected with its 
 ganglia by fibers from the brain and cord. The ganglion fibers are the greater 
 part motor and innervate the involuntary muscles of the viscera. We deal 
 with the nervous system of the abdomen as composed of the (a) lateral chain 
 of ganglia, (b) the abdominal and pelvic splanchnics, (c) the rami commun- 
 icantes, (d) the vagi nerves, and (e) the abdominal brain with all the nerve 
 ganglia. We have but space to mention the special forms of neuralgia which 
 have been attached to different abdominal organs under the general term of 
 visceral neuralgia. Some of the following forms of visceral neuralgia have 
 gained a place in medical literature: 
 
 1. Hepatic neuralgia, or colica hepatica non-calculosa. 
 
 2. Neuralgia of the stomach, or gastralgia. 
 
 3. Enteralgia (colica mucosa Nothnagel; or better, secretion neurosis 
 of the colon). 
 
 4. Ovarian neuralgia. 
 
 5. Neuralgia rectalis. 
 
 6. Neuralgia renalis. 
 
 7. Oviductal colic. 
 
 8. Uterine neuralgia. 
 
 Hepatic neuralgia rests on the view that pain of a neuralgic character 
 arises in the liver region when gall-stones do not appear in the stool nor are 
 found in the autopsy. Andral, Budd, Frerichs, Furbinger, Durand, Bardel and 
 Schiippel are names representing belief of hepatic neuralgia with no calculus 
 as a cause. Gastralgia has been so long in medical literature that it need 
 
GENERAL VISCERAL NEUROSES 277 
 
 not be supported by any names. Enteralgia in its various indefinite forms 
 is seen by gynecologic practitioners frequently. 
 
 With more accurate study the biliary neuralgias will disappear and be 
 replaced by more accurate terms as cholecystitis, choledochitis, etc., in short 
 violent spasm or colic of some segment of the biliary ducts is due to inflamma- 
 tion or calculus. During 700 personal autopsic inspections of the abdominal 
 viscera I demonstrated that some 45 per cent of peritoneal exudates, adhe- 
 sions existed adjacent to the gall-bladder and other biliary passages. Dr. 
 Robert Morris, of New York, christened these subjects spider gall-bladder 
 adhesions. The peritoneal adhesions adjacent to the gall-bladder, will, no 
 doubt, explain much hepatic neuralgia of the older doctors as well as gastric 
 neuralgia or gastralgia. 
 
 Ovarian neuralgia is a disease glibly talked about, but very difficult to 
 diagnose. I have listened perhaps hundreds of times to descriptions of 
 patients' suffering which some would designate ovarian neuralgia. Yet 
 women do have irregular pain, slight and intense, in the ovary. The ovary 
 will be found sensitive and painful on pressure. It is the opinion of the 
 writer that so-called ovarian neuralgia is a secondary process, and yet it 
 doubtless exists, as certain as neuralgia of the upper division of the trig- 
 eminus. Neuralgia of the rectum has a definite existence. It comes and 
 goes with great irregularity, arising chiefly at night and appears in persons of 
 apparently robust health. 
 
 Neuralgia of the kidney rests on the fact that pain occurs in the region 
 of the kidney; the kidney is sensitive to pressure, and no stone has been 
 found in the kidney at the autopsy. The pain has been so severe that neph- 
 rectomy was performed, but the kidney contained no stone. In one patient 
 who had pain and tenderness in the region of the kidney for three years I 
 performed the operation of incising the kidney. No stone was found, but an 
 old scar existed in the kidney pelvis, and also opposite to the scar in the 
 kidney there existed a mass of old cicatricial tissue as large as a plum. The 
 conclusion was that a stone had once ulcerated through the pelvis of the kid- 
 ney and that she was suffering from the cicatrix in and about the kidney. 
 
 Oviductal and uterine colic, or so-called neuralgia, rests on the peculiar 
 structure of the oviducts and uterus. Their involuntary muscular walls, being 
 supplied by sympathetic nerves, are liable to be set in motion by various 
 forms of irritation, and hence from tonic and clonic spasms of their walls are 
 liable to give rise to irregular flying pains or visceral neuralgia. 
 
CHAPTER XXIII. 
 
 RELATION BETWEEN VISCERAL (SYMPATHETIC) AND 
 CEREBRO-SPINAL NERVES. 
 
 "I have observed matters contained in this book, a large part -of which is myself." 
 "I exist, therefore, I am." — Kant. 
 
 THE NERVE MECHANISM OF PELVIC AND ASSOCIATED REGIONS. 
 
 The plan of the nerve supply of the pelvis and associated regions is to 
 bring into harmonious action the skin and mucosa and the muscles and 
 viscera. The object of the generative organs is not only gestation and 
 expulsion but also for the varied necessity of copulation, of defecation, and 
 of urination, including muscular and visceral relations. 
 
 The nerve mechanism of the external genitals is significant and suggest- 
 ive of an evolutionary plan. The sympathetic nerves extensively supply the 
 erectile tissues — the corpora cavernosa, glans clitoridis, and bulbi vaginae. 
 The erectile tissues possess rhythmical action, besides being supplied with 
 nerves from the lumbar plexus (genito-crural) and the sacral plexus (pudendal 
 and internal pudic). The internal pudic nerve (sacral plexus), which chiefly 
 supplies the clitoris with large branches, terminates in the glans clitoridis or 
 adjacent tissue in peculiar tactile or genital corpuscles. The clitoris and 
 considerable of the adjacent region of the distal third of the vagina is exceed- 
 ingly sensitive to irritation. 
 
 The plan of the nervous mechanism of the external genitals is to associ- 
 ate the genitals with certain muscles and overlying skin. The nerves which 
 supply the pelvis and associated viscera are: 1. The sympathetic, the hypo- 
 gastric plexus and ovarian plexus, both arising from the abdominal brain : 
 also branches of the lateral chain of the sympathetic. The pelvic viscera 
 thus involve nerve relations with all the other abdominal viscera. 2. The 
 cerebro-spinal nerve supply, the lumbar plexus furnishes the genito-crural, 
 the ilio-hypogastric, and the ilio-inguinal and inferior pudendal ; also the 
 sacral plexus supplying the internal pudic and vesical. The cerebro-spinal 
 nerves supplying the skin and muscle associate them with the genitals. The 
 skin on the pudendum, perineum, and anal region is definitely associated 
 with the skin in the inguinal region, the inner part of the thigh and genital 
 region, because branches from the lumbar and sacral nerve trunks supply 
 the same regions. For example, the genito-crural nerve supplies the skin 
 on the pudendum and the ilio-inguinal supplies the skin over the gluteal 
 muscles. The genito-crural and ilio-inguinal are both branches of the 
 lumbar plexus and what affects the pudendal skin will affect the gluteal skin. 
 Besides the same nerve trunk that sends branches to the skin also sends 
 
 278 
 
RELATION OF CEREBROSPINAL TO SYMPATHETIC ■_<::> 
 
 branches to the underlying muscle. Also the internal pudic, a branch of the 
 sacral plexus, supplies the skin on the pudendum, perineal, and anal region, 
 while the small sciatic, a branch from the same plexus, supplies the skin on 
 the gluteal region. What affects the periphery of one affects that of the 
 other. Both must be physiologic or reflexes will arise. By means of the 
 pudic nerve and the small sciatic (gluteal) the skin and muscles of the 
 pudendum, perineum and anus are brought in harmonious relation with the 
 gluteal muscles (of coition) and skin over them. The genitals, bladder and 
 rectum are supplied by the hypogastric and ovarian plexuses of the sympa- 
 thetic, and the sympathetic plexuses are joined by the second, third and 
 fourth sacral spinal nerves. 
 
 Thus viscera, skin and muscles of the pelvic region are held in close 
 nerve association. The numerous reflexes in the pelvic region of patients 
 will bear close observation in affections of the pudendum, bladder and 
 rectum. Pain may be experienced in the perineum, in the gluteal region or 
 down the thigh. The explanation of this arises from the fact that all these 
 parts, skin of pudendum, anal region, part of the thigh and gluteal region 
 are supplied by the pudic and small sciatic nerves, which come from the 
 same plexus that gives off branches to supply the viscera, pudendum, bladder 
 and rectum. Thus the pelvic viscera and the skin of the gluteal region and 
 thigh, or perineum and external genital region, are held in association by the 
 branches of the same spinal nerves. The pain felt in the urethra by a woman 
 with calculus in the bladder is due to the fact that the trigonal nerve plexus 
 which supplies both trigone and urethra, is prolonged to terminate in the 
 distal end of the urethra. Pain generally is felt at the periphery of nerves, 
 and hence the irritation of calculus in the trigone is experienced in the 
 urethra, that is, at the termination of the trigonal plexus. The sigmoid, 
 two inches above the anus, is provided with very little sensation, while the 
 last two inches in the anus is very sensitive. This is observed by the slight 
 pain in high malignant growth or other swellings of the rectum, by the little 
 pain of large collections of hardened feces. Also by the little pain induced 
 by perforation of the sigmoid during the administration of an enema. Its 
 sensation is limited, like all viscera supplied by the sympathetic. The 
 relation of nerve mechanism between anus and the neck of the bladder is 
 strikingly intimate. Hemorrhoidal operations are accompanied by urine 
 retention and bladder operations by rectal tenesmus. 
 
 This intimate nerve relation between rectum and the neck of the bladder 
 is chiefly due to the fourth sacral nerve, which supplies the neck of the 
 bladder and then passes on to supply the anal skin, levator ani, and anal 
 sphincter. The third sacral nerve sends a large branch to terminate in the 
 body of the bladder, but is not related to the levator ani and sphincter ani 
 muscles. The urethral mucosa, the muscles of the pudendum, and the chief 
 part of the skin of the pudendum perineum and anus are supplied by the 
 internal pudic nerve from the sacral plexus. The sacral plexus emits the 
 gluteal nerves which supply the gluteal muscles. It also gives off the inter- 
 ior pudendal (branch of the small sciatic), which supplies directly the 
 
280 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 perineum. Hence the external genitals and the gluteal muscles are in 
 intimate nerve association. 
 
 Hilton struck by the peculiar ending of the inferior pudendal nerve called 
 it the nerve of coition. The genito-crural and ilio-inguinal are from the lum- 
 bar plexus and supply the inguinal and vulvar regions. The ilio-hypo- 
 gastric supplies the hypogastric and groin region. 
 
 With diseased condition of the region supplied by the genito-crural and 
 ilio-inguinal nerves, it is explainable how women suffer by reflex action in 
 the region supplied by the ilio-hypogastric and ilio-inguinal nerves — the 
 inguinal region. Many women mistake the inguinal and hypogastric pain 
 for ovarian disease. Irritation in the perineum or rectum may be followed 
 by priapism. Adhesions about the glans clitoridis or accumulated secretions 
 under the prepuce may provoke not only local disturbances in the bladder and 
 rectum but induce genital disturbances. The pain felt through perineal 
 abscess in the gluteal region and in the thigh may be explained by the press- 
 ure of the inferior pudendal nerve in the perineum. In neuritis brought on 
 by trauma of the inferior pudendal nerve due to much sitting on hard seats, 
 the pain may be felt in the perineum and the region supplied by that nerve. 
 
 Dissection discloses the inferior pudendal nerve crossing the gluteal 
 region toward the perineum, close to the ischial tuberosity, where it is liable 
 to occasional injury with enlarged pudendo vaginal glands. Some patients 
 do not sit down comfortably on account of the irritation of the periphery of 
 the inferior pudendal nerve. 
 
 However, the pain may be aroused at the ischial tuberosity, by an 
 inflamed bursa or local traumatic neuritis. Pain in the knee-joint from hip- 
 joint disease is an ever living example of a reflex, pain starting at the peri- 
 phery of the one branch of a nerve trunk, and experiencing the pain at the 
 periphery of another branch of the same trunk. The branches of nerve trunks 
 (or plexuses) supply groups of muscles and skin in widely distributed regions 
 for the purpose of associating them in function. For example, the lumbar 
 plexus associates the skin of the external genitals with the skin of the gluteal 
 region by means of its branches supplying both regions, as the genito-crural, 
 ilio-inguinal and ilio-hypogastric. 
 
 The sacral plexus associates the action of the muscles (and skin) of the 
 external genitals, perineum, and anus with the gluteus maximus, through 
 branches of the same plexus supplying both regions. The pudic, a branch 
 of the second, third and fourth sacral spinal nerve, supplies the external 
 genitals, perineum and anus, while the gluteal (smaller sciatic), a branch of 
 the second, third and fourth sacral, supplies the gluteus maximus muscle (of 
 coition). Finally to perfect a balanced nerve association between muscles 
 and skin of the external genitals and gluteal region, the inferior pudendal 
 nerve actually joins the periphery of the two regions. 
 
 A reflex is a disturbance in a distant part from some local peripheral 
 irritation. The pelvic viscera are liable to trauma and infection during the 
 childbearing period from exposed mucosa and serosa, and this traumatic or 
 infection atrium becomes a fruitful source for reflex distribution, through 
 
RELATION OF SPINAL TO SYMPATHETIC 
 
 281 
 
 disturbed pelvic mechanism, due to cicatricial contraction and subsequent 
 dislocation. The irritation is transmitted to the abdominal brain, where it 
 is reorganized and emitted to the organs of the abdomen and chest, disturb- 
 ing their rhythm, secretion, absorption, sensation and nutrition. The 
 visceral rhythm becomes irregular, secretion and absorption become exces- 
 sive, deficient, or disproportionate and the blood becomes waste laden. The 
 patient is forced slowly or rapidly through definite, though irregular, stages 
 of disease (traumatic or infection atrium), irri- 
 tation, indigestion, malassimilation, malnutrition, 
 anemia, neurosis and psychosis. The nerve 
 mechanism between ovary, genitals and kidney 
 is very intimate. The ovarian plexus originates 
 from the renal and hypogastric, which connec- 
 tion directly associates the kidney with the inter- 
 nal genitals, and accounts for the disturbed 
 functional relation of kidney and internal gen- 
 itals during menstruation and pregnancy (pain, 
 albumen, and vomiting). The intimate associa- 
 tion of nerve relation between kidney and inter- 
 nal genitals is manifest in diseases of either organ. 
 In menstruation there is a pain in the renal re- 
 gions. Congestion of one organ produces con- 
 gestion or anemia in the other (reflex action). 
 Renal calculus or nephritis causes pain and re- 
 traction of the testicle, and of course similar 
 disturbances arise in the ovary, though not so 
 easily demonstrated. Ovarian disease may cause 
 pain in the rectum (supplied by the hypogastric). 
 The ovarian and hypogastric plexus have direct 
 communication with the abdominal brain, and 
 hence the severe shock from injury to the ovary, 
 uterus, or rectum, and especially the tendency to 
 vomit. The internal genitals (ovary, oviduct, 
 and uterus) are in just as intimate and profound 
 connection with the great abdominal brain as the 
 enteron, and in trauma or infection of the gen- 
 itals or enteron, will have like severe manifesta- 
 tions of general disturbances. 
 
 CUTANEOUS NERVES OF 
 THORAX AND AB- 
 DOMEN 
 
 Fig. 64. The cutaneous 
 nerves of the thorax and abdo- 
 men, viewed from the side. (1) 
 Ilio-hypogastric. (2) Ilio-ingui- 
 nal. (4) Anterior cutaneous of 
 last thoracic. (10) Lateral cu- 
 taneous of last thoracic. (9) 
 External oblique muscle. 
 (Henle). 
 
 I. PELVIC NERVES (CEREBROSPINAL). 
 
 The sacral plexus really terminates in two great branches, the sciatic for 
 the lower limb and the pudic, which is a genital nerve, supplying the 
 internal and external genitals. 
 
 Patients suffer especially in two regions, viz. : (a) the hypogastric region, 
 (b) the lumbo-sacral region. The explanation is that the uterus by dragging 
 or pressing on the sacral spinal nerves, induces pain in the lumbo-sacral re- 
 
282 THE ABDOMINAL AND PELVIC BRAIN 
 
 gions and the pain is reflected from the lumbar cord along the ilio-hypogastric, 
 ilio-inguinal, and genito-crural nerves, branches of the lumbar plexus to the 
 hypogastric and inguinal region. 
 
 The lumbar nerves supplying the hypogastric and inguinal regions are 
 all branches of the same trunks — the lumbar plexuses. 
 
 The irritation of the periphery of any branch liable to be reflected on any 
 other branch of the same trunk. Irritation of the sacral nerves is liable to 
 be reflected from the common lumbar trunk to the branches of the hypogas- 
 tric and inguinal region. However the complaint of pain in the hypogastric 
 or inguinal region may be only in the skin and purely hyperesthetic (hysteric) 
 in character. 
 
 Gynecologic patients complain of a triumvirate of pain, viz. : in the 
 lumbo-sacral region, in the hypogastrium, and in the head. The lumbo-sacral 
 region is the great central depot of gynecologic pain. It is the central tele- 
 graphic station where irritated genitals first tell their story. In this case, a 
 sympathetic nerve which supplies the genitals relates the story to the cerebro- 
 spinal axis — a nerve of another tongue. It matters little what disease, 
 endometritis, myometritis, endosalpingitis, or peritonitis attacks the pelvis, 
 the lumbo-sacral pain is the characteristic pain. The lumbo-sacral region is 
 the sensorium for pelvic disturbances. The nerves in relation are the lumbar 
 plexus, anterior and posterior, the hypogastric plexus connected to the lum- 
 bar plexus by the rami communicantes, and the sacral plexus. In the hypo- 
 gastric region the ilio-inguinal, ilio-hypogastric and genito-crural play the 
 role. The last three have cutaneous branches, and often the skin sensation 
 . is mistaken for ovarian or other genital pain. Branches of the intercostal, 
 lumbar, and sacral nerves supply the peritoneum, but conduct chiefly to the 
 sacro-lumbar region. 
 
 Extreme precautions are required to discriminate between pain located 
 in the skin over an organ and pain in the organ itself. This may relate to 
 viscera or tumors, but is especially true of the kidney. I have performed 
 nephro-lithotomy for pain in the kidney, with the supposition that a calculus 
 existed. No calculus was found, and the intense hyperesthesia of the skin 
 over the kidney remained long afterward. Grave diagnostic or operative 
 errors may be committed by mistaking intense and persistent cutaneous 
 hyperesthesia for disease underlying viscera and structures. The anesthetic 
 and hyperesthetic zones should be mapped. It is well known among experi- 
 enced gynecologists that some peritoneal cysts are very painful. The chief 
 painful cysts are located along the oviducts and the two sides of the ligamen- 
 tum latum. This is in accord with an observation that the chief suffering of 
 gynecologic patients is from pelvic peritonitis, i. e., from dislocated or dis- 
 turbed pelvic mechanism. The peritoneal cysts, with their contents, are 
 doubtless of an inflammatory character. The pudic nerve is the source of 
 motion to the muscles of the perineum, anus, bladder, urethra and vagina. 
 It is a source of sensation to the integument of the perineum, pudendum labia, 
 mucosa of the clitoris and urethral mucosa. Irritation of the external genitals 
 creates a reflex in the spinal cord which results in turgidity of the genitals 
 
RELATIOX OF SPIX.-1L TO SYMPATHETIC 
 
 883 
 
 and finally a sense of musclar contraction in these parts of the genitals sup- 
 plied by the musclar branches of the pudic nerve. The integument and 
 immediately underlying muscles are always supplied by branches of the same 
 nerve trunk. 
 
 The irritation of the nerves of the genital integument (cutaneous branches 
 of the pudic) induces contractions of the perineal, levator-anal, anal, and 
 vaginal muscles (musclar branches of the 
 pudic) which assist in expulsion of the secre- 
 tion of the vulval glands, especially the 
 vulvovaginal. Occasionally masturbation 
 in the female may be prevented by blister- 
 ing the mucosa of the clitoris, making it so 
 tender that the subject will cease manipu- 
 lation. 
 
 In certain reported cases of fracture of 
 the vertebral column, irritation of portions 
 of the spinal cord left intact distal to the 
 seat of fracture will induce turgidity of the 
 genitals resembling erections. The expul- 
 sion of the last drop of urine is a reflex act 
 due to the irritation of the urine on the 
 sensory pudic nerves in the urethral mucosa, 
 reflecting it to the spinal cord, whence 
 the force returns on the (motor) musclar 
 branches of the pudic, expelling all the 
 urine from the urethra. 
 
 The rectum produces sympathetic dis- 
 ease in adjacent viscera, as incontinence of 
 urine, involuntary emission and neuralgic 
 pain. The explanation arises from the dis- 
 tribution of the pudic nerve to the integu- 
 ment about the anus, which permits reflex 
 motor impulses, from rectal irritation trans- 
 mitted to the spinal cord, to be reflected to 
 the adjacent genito-urinary organs and as- 
 sociated muscles. 
 
 The small sciatic nerve supplies the 
 gluteus maximus and sends a branch (the 
 inferior pudendal) to the perineum, puden- 
 dal and vagina. This explains the relation in coition, of the genitals and the 
 gluteus maximus muscle. Also it may explain perineal irritation from disease 
 along the trunk of the inferior pudendal, as hardened tissue, which may arise 
 in subjects of sedentary habits: 
 
 The periphery of the ilio-inguinal and ilio-hypogastric which in general 
 is the integument of the lower abdomen, may be the seat of neuralgia; or it 
 may be the seat of hyperesthesia or anesthesia. The pain may be paroxys- 
 
 VENTRAL DIVISIONS OF DOR- 
 SAL NERVES 
 
 Fig. 65. A view of the anterior 
 division of the dorsal nerves. The 
 cut shows the nerves distributed to 
 the muscles and skin of the abdomen. 
 It may be easily noted how an irrita- 
 tion on the skin passes to the spinal 
 cord, and thence to the abdominal 
 muscles, putting them on tension to 
 protect underlying viscera. Hirsch- 
 field and Leville.) 
 
284 THE ABDOMINAL AND PELVIC BRAIN 
 
 mal, radiating along the course of the nerves. Painful points may be detected 
 near the spinous processes of the lumbar vertebra (lumbar point), near the 
 middle of the iliac crest (iliac point), near the external inguinal ring (hypo- 
 gastric point), in the inguinal canal (inguinal point), and finally in the labial 
 points. These are Valleix's puncta dolorosa, or points of tenderness along 
 the course of nerves. 
 
 The chief feature for the gynecologist, is the periphery of the ilio- 
 hypogastric and ilio-inguinal nerves in anesthesia and hyperesthesia of the 
 skin of the hypogastric and inguinal regions. The skin of the abdomen prox- 
 imal to the umbilicus is supplied in general by the distal intercostal nerves, 
 which may be termed the respiratory region. The skin distal to the umbilicus 
 is supplied by the ilio-hypogastric and ilio-inguinal, which may be called the 
 abdominal region. 
 
 The genito-crural and dorsal branches of the lumbar nerves aid in fur- 
 nishing motor power to the region distal to the umbilicus. The skin, mus- 
 cles, and peritoneum of the abdomen are supplied by branches of the same 
 trunks, so as to preserve harmony of motion and association of sensation, 
 insuring visceral protection. 
 
 For example, if cold water be dashed against the belly, the skin sensa- 
 tion is transmitted to the spinal cord, and reflected to the abdominal muscles, 
 causing an immediate rigidity, for the protection of adjacent and underlying 
 viscera. 
 
 The harmony of the skin, muscles and peritoneum (viscera) explains how 
 massage assists in curing constipation For example, skin irritation on the 
 abdomen is transmitted to the cord, whence (a) it is reflected to the abdomi- 
 nal muscles, producing action which aids in fecal expulsion ; (i>) the reflected 
 force induces visceral peristalsis. This is motor. It appears also that the 
 sensory condition of the skin is in harmony with the sensory condition of the 
 underlying viscera. Diseased underlying abdominal viscera are apparently 
 accompanied with correspondingly disturbed sensory cutaneous areas. 
 
 The genito-crural nerve supplies only one muscle, the round ligament, 
 and finally supplies the labia. The periphery of any of the ventral divisions 
 of the lumbar plexus (the ilio-hypogastric, ilio-inguinal, genito-crural and 
 external cutaneous) may show disturbances of motion or sensation by inflam- 
 matory products, compressing any part of their trunks. In psoas abscess the 
 genito-crural and the external cutaneous might show a disturbed periphery, 
 as well as other branches of the lumbar plexus. The practical matters for 
 the gynecologist to determine in the complicated nerve mechanism of the 
 pelvis and associated relations, are: 1. Map on the abdomen the areas of 
 anesthesia and hyperesthesia. 2. Hyperesthesia of skin should not be mis- 
 taken for a diseased underlying viscus, as the ovary or kidney. 3. Areas of 
 anesthesia and hyperesthesia may change from day to day. 4. Hysteria has 
 certain stigmata, viz.: (a) anesthesia of the conjunctiva bulbi; {b) anesthesia 
 of the mucosa of pharynx; (c) anesthesia or hyperesthesia of skin (especially 
 of abdomen); {d) sudden paresis or exacerbation of muscle (knee, globus, 
 tongue, knotting of belly muscles); (e) occasional mental phenomena, and (/) 
 
RELATION OF SPINAL TO SYMPATHETIC 
 
 285 
 
 disturbance of special sense, as 
 sudden blindness or excessive 
 bearing. Some of these six 
 stigmata must be present to 
 diagnose hysteria. 5. Much 
 of the hypogastric pain com- 
 plained of by subjects is 
 located in the skin of the 
 inguinal and hypogastric re- 
 gion. This pain may be 
 caused by sensory disturb- 
 ances in the skin only, or by 
 reflex disturbances from dis- 
 eased genitals, through the 
 anterior branches of the lum- 
 bar plexus. 6. Gynecologic 
 patients complain of pain : {a) 
 in the sacro-lumbar region 
 from diseased genitals irri- 
 tating the periphery of the 
 sacro-lumbar nerves; (I?) pain 
 in the hypogastric and ingui- 
 nal region from irritation of 
 the genitals passing to the 
 lumbar cord, whence it is re- 
 organized and reflected on the 
 anterior branch of the lumbar 
 plexus; and (c) pain in the 
 head through reflexes in dis- 
 eased genitals. Perhaps the 
 occipitalis major and minor 
 constitute part of this nerve 
 route. 7. The stomach is one 
 of the chief organs to suffer 
 reflexly from diseased genitals 
 through the direct route of 
 the hypogastric plexus, ex- 
 tending from the genitals to 
 the abdominal brain, whence 
 it is reorganized and sent to 
 the stomach, over the gastric 
 plexus. The nerves which 
 supply the internal pelvic vis- 
 cera are located in general 
 between the pelvic fascia and 
 the peritoneum. 
 
 Fig. 66. (From Byron Robinson's life-size chart of 
 the Sympathetic.) Represents the abdominal brain 
 and adjacent ganglia. (55) A ganglion of the dorsal 
 lateral chain. (61) Splanchnic. {96 and 97) Rami com- 
 municantes. (67) Branches of right vagus to stomach. 
 
 (69) Trunk of right vagus entering abdominal brain. . 
 
 (70) Phrenic nerve on phrenic artery. (71) Right ab-' 
 dominal brain. (72) Left abdominal brain. (73) Gastric 
 artery. (74) Splenic artery. (75) Hepatic artery. (76) 
 Right great splanchnic. (77) Ad-renal. (79) Supra- 
 renal nerves (6). (82) Inferior renal ganglion. (83) 
 Superior renal ganglion. (84, 85, 86 and 87) Ganglia 
 on renal artery. (88) Renal artery. (89, 90 and 91) 
 Lumbar nerves. (96, 97 and 98) Rami communicantes. 
 (101, 102 and 103) Lumbar lateral chain of ganglia. (106) 
 Superior mesenteric artery surrounded by the abdom- 
 inal brain. (107, 108 and 109) Genital ganglia. (110 
 and 111) Genital ganglia (ovarian) as well as (112, 113 
 and 114) Genito-rectal ganglia. (167). Nerves around 
 the ovarian artery. (171) First lumbar nerve. (172) 
 Second. (173) Third. (176) First. (177) Second, and 
 (178) Third lumbar ganglia. (182) Genital ganglion. 
 (183) Inferior mesenteric artery. (185) Aortic branch 
 of abdominal brain. (186) Ending of left great 
 splanchnic in abdominal brain. (187) Superior, and 
 (188) inferior (left) renal ganglia. (189, 190 and 191) 
 (left) Renal ganglia. 
 
286 THE ABDOMIXAL AXD PELVIC BRALX 
 
 The cervix and vagina are mainly supplied by branches from the third 
 and fourth sacral nerves. The pudendum is supplied by the pudic, which is 
 chiefly composed of the third sacral nerve. The pudic nerve passes from the 
 pelvis from the third sacral by the way of the large sacro-sciatic foramen, 
 winds around the spine of the ischium, and re-enters the pelvis through the 
 lesser sacro-sciatic foramen; it is thus removed from the dangers of the 
 trauma due to labor. The nerve directly traumatized by labor is the obtur- 
 ator. When the child's head engages, the obturator muscles of the thighs 
 act by closing and flexing them. The pudic nerve sends branches to the 
 clitoris, to the pudendum, to the perineum, and to the rectum. Practically 
 the sacral plexus terminates in the two branches, the pudic (genital) and 
 sciatic (limb). 
 
 In teaching I have frequent!}* represented the pudic nerve by the hand. 
 For example, the arm represents the nerve itself, the thumb represents the 
 great vesical nerve just before the pudic passes from the pelvis; after the 
 pudic has re-entered the pelvis and passed along the ramus of the pubes, the 
 index finger represents the branch to the clitoris, the middle finger the branch 
 to the pudendum, the ring finger the branch to the perineum, and the little 
 finger the branch to the rectum. Thus the digits of the hand can vividly 
 represent the branches of the pudic nerve. 
 
 It can also be remembered that the pudendal nerve, a branch of the 
 small sciatic nerve, sends branches to the anus, perineum, pudendum and 
 clitoris, which unite with similar branches from the pudic to supply the same 
 organs. There is a wonderful design in the union of the periphery of the 
 pudendal and the pudic nerves. 
 
 The lesser sciatic nerve supplies but one muscle (gluteus maximus), and 
 then gives off a branch, the pudendal, which directly supplies the external 
 genitals and rectum. This arrangement of the nerve supply brings the gluteus 
 maximus muscle and the skin of the genitals in direct relation. Irritation of 
 the genitals will induce contraction of this muscle. Thus the gluteus maxi- 
 mus muscle must be considered (anatomically and physiologically) the muscle 
 of coition. Observation of copulating animals will confirm this view. 
 
 The external genitals are supplied by the plexus pudendus. A small seg- 
 ment is supplied by the fifth sacral nerve through the plexus sacro-coccygeus. 
 The chief nerves concerned in the supply of the external genitals are: 1. 
 The medial hemorrhoidal nerve; (2) the inferior vesical nerve, which sends 
 fibers to the base of the bladder and the urethra, to the vagina and middle 
 portion of the rectum: 3. The internal pudic nerve, which follows the inter- 
 nal pudic artery and divides into {a) inferior hemorrhoidal, which supplies 
 the internal and external anal sphincters and the skin of the anus; (b) the 
 perineal nerve, which supplies the skin on the perineum, the musculus trans- 
 versa perinei, sphincter ani externus, sphincter vaginae and also the labia 
 and the vestibulum vaginae; (c) the dorsal nerve of the clitoris, which passes 
 between the sphincter vaginae and ischio-cavernosus under the symphysis 
 pubis to the proximal border of the clitoris, whence it sends numerous fine 
 fibers to the skin as well as to the cavernous tissue. 
 
ANATOMY OF THE SYMPATHETIC 
 
 287 
 
 II. THE SYMPATHETIC NERVES. 
 
 The sympathetic nerve consists of, viz.: (a) ganglia (lateral chain); (/;) 
 conducting cords; (<) three ganglionic plexuses located in the chest (thoracic 
 plexus), abdomen (abdominal brain), and pelvis (pelvic brain); and («•/) auto- 
 matic visceral ganglia. The conducting cords are not sheathed; they are 
 non-medullated. The ganglia, composed of nerve cells, are little brains. 
 They are reorganizing centers, receiving sensations and sending out motion. 
 The abdominal and pelvic brains and the ganglionic plexuses are simply large 
 brains or aggregations of nerve cells. 
 
 Fig. G7. (Eyron Robinson.) From author's life-size chart of the Sympathetic. Repre- 
 sents the cervico-uterine ganglion. ( — ) The pelvic brain. (127) Second. (128) Third, 
 and (129) Fourth, sacral nerves (left). (131) Second. (132) Third. (133) Fourth, sacral 
 nerves (right). Note the connection of the second, third, and fourth sacral nerves to the 
 pelvic brain. (137 and 138) Second and third sacral ganglia. (139) Branches from the 
 second sacral. (140) Branches from the third and fourth sacral nerves to the pelvic brain 
 (141 and 142). The pelvic brain or cervico-uterine ganglion is marked (141, 142, 143, 144) and 
 (145) branches of it. Third sacral to the levator ani muscle (146). (147) Vesical ganglion. 
 (148) Ureter. (149) Bladder. (150) Vagina. (151) Uterus. (152) Nerves of bladder. (153) 
 Pudic nerve. (158) Right, and (159) left, sacral plexus. (160) Branches of hypogastric 
 plexus which do not enter pelvic brain before distribution. (161) Fallopian tube. (162) 
 Ovary. (163) Round ligament. (164) Acetabulum. (165) Spine of ischium. 
 
 A summary of the abdominal brain is: (a) It presides over nutrition; 
 id) it controls circulation; (<r) it controls gland secretion; (d) it presides over 
 the organs of generation, and (<?) it influences in a dominant way the auto- 
 matic visceral ganglia. With nerve fibers radiating on blood and lymph ves- 
 sels and to every abdominal viscus, it is no wonder that the abdominal brain 
 has been considered the center of life. 
 
 An ideal nervous system should be a neuron and consist of first, a gang- 
 
288 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 lion cell: second, a conducting cord, and, third a periphery. The sympathetic 
 nervous system possesses the neuron or three-nerve elements in an eminent 
 degree. The abdominal brain represents the central ganglion cell. Its 
 thousands of cords, distributing fibers, represent the conducting cord, while 
 the various automatic visceral ganglia represent the periphery. 
 
 The sympathetic nerve supplies the uterus, oviducts, and ovaries, as they 
 possess rhythm. Only viscera whose main nerve supply is sympathetic 
 possess rhythm. The cervix is supplied by the spinal nerves, and does not 
 possess rhythm to any marked degree. 
 
 The peritoneum is supplied chiefly by the sympathetic nerves. The 
 main spinal nerves which supply the peritoneum are the peritoneal branches 
 of the ilio-inguinal and ilio-hypogastric and distal intercostals. The sense 
 of localization in detail is yet unrecognized in the sympathetic, which prepond- 
 erates in the peritoneum and tractus intestinalis, while the cerebro-spinal 
 nerves are so much in the minority that they are uncertain in indicating 
 localized areas. 
 
 The domain of the sympathetic nerve is beyond the control of the will, 
 as the beating of the heart, uterine and intestinal contraction, erection of 
 cavernous tissue and the systole and diastole of the bladder. Man cannot 
 speculate on his sympathetic system. 
 
 The most interesting and delicate structure connected with the genitals 
 is the nervous apparatus. This consists of cerebro-spinal and sympathetic 
 or non-medullated nerves. The uterus (body), oviducts and ovaries are chiefly 
 supplied by the sympathetic nerves, while the pudendum, vagina and cervix 
 are mainly supplied by the cerebro-spinal nerves. 
 
 The hypogastric plexus originates in the abdominal brain (solar plexus), 
 and passes along the aorta. It is increased by branches from the lumbar 
 ganglia of the lateral chain of the sympathetic. The combined strands of 
 nerves now pass over the bifurcations of the aorta and sacral promontory, 
 and divide into two large bundles, each of which passes dorsal to the perito- 
 neum to the base of the ligamentum latum where it reaches the side of the 
 uterus and oviducts. Some strands pass to the rectum, but this organ is 
 chiefly supplied by the nerves passing along the inferior mesenteric artery. 
 The ovarian plexus consists of nerve strands derived from the hypogastric 
 plexus and the ganglia in the lumbar lateral sympathetic chain, and the nerves 
 passing along the ovarian artery. The ovarian plexus supplies the ovaries 
 and the ampulla of the oviducts. 
 
 At the periphery of the hypogastric and ovarian plexuses are situated 
 small ganglia along the walls of the oviducts and uterus, which I have desig- 
 nated "automatic menstrual ganglia." I have attempted to show that these 
 ganglia rule the rhythm of menstruation. The composite ganglia located at 
 the lateral borders of the cervix and vagina I have denominated the Pelvic 
 Brain. 
 
 The best method to demonstrate the nerves of the uterus I have found 
 to be the placing of an infant cadaver in pure alcohol for several weeks, when 
 the hypogastric plexus can be traced to its home on the body of the uterus 
 
ANATOMY OF THE SYMPATHETIC 
 
 289 
 
 as plainly as though it were composed of white cotton threads. The nerves 
 in the infant are much larger in proportion to its size than in the adult. 
 
 Here will be presented a few remarks on the anatomy, physiology, and 
 pathology of the sympathetic nerve, showing the principal points in gynecol- 
 ogy relative to the abdominal and pelvic brain. They are the result of my 
 
 Fig. 68. (Laville and Hirschfield.) Is a cut to illustrate the nerves of the non-pregnant 
 uterus. (1) Hypogastric plexus lying on the bifurcation of the aorta. It divides to pass each 
 side of the rectum. (2) Rectal branches on rectum (R). (3) Lumbar ganglia of the 
 sympathetic. (4) Ovarian plexus. (5) Branch of the third and fourth sacral nerves passing 
 to the pelvic brain (6 and 7) before going to the uterus. (6 and 7) Nerve plexuses on the 
 vagina and rectum. (8) Uterine nerves. (i>) Vesical plexus. (10) Trunk of it — great sciatic. 
 (11) Levator ani branch. (12) Trunk of the pudic nerve. (U) Uterus. (B) Bladder. (S) 
 Sacrum. (D) Tranversus perinei muscle cut. This cut is partly diagramatic, as the nerves 
 are not distributed in the form represented in the illustration, but represent more aggrega- 
 tions, as drawn by the author. The nerves in Savage's cut are represented too richly. 
 
 investigations of the sympathetic nerve, which I have dissected during the 
 last ten years. The claim is that the ganglia of the sympathetic nerve are 
 little brains; i. e., they receive sensation, emit motion, and control secretion. 
 They are trophic centers, and possess vaso-motor power. They are centers 
 for reflex action, and are endowed with a peculiar quality called rhythm. 
 
 19 
 
290 THE ABDOM1XAL AXD PELVIC BRAIX 
 
 The great reorganizing centers in the sympathetic nerves are the abdomi- 
 nal and pelvic brain and the three cervical ganglia. Reorganizing power of a 
 less degree exists in the lateral chain of ganglia situated at the circumference 
 of the elliptical-shaped sympathetic, and in the collateral ganglia in the chest, 
 abdomen and pelvis, and also in the ganglia situated in every viscus which I 
 have designated automatic visceral ganglia. 
 
 The sympathetic nerve consists of two lateral chains of ganglia, extending 
 from the base of the skull to the coccyx. Situated anterior to these chains 
 are collateral plexuses known as the cardiac, abdominal and pelvic. Besides 
 these there exist in all the viscera small ganglia, automatic visceral ganglia 
 — for example, the automatic hepatic, cardiac, menstrual ganglia. 
 
 The distribution of the sympathetic nerve is G?) to vessels, {b) to glands, 
 and {c) to viscera. It is connected with the cerebro-spinal nerves by the rami 
 communicantes. Its independence of the cerebro-spinal axis is not yet fully 
 settled; but children have been born at term with no cerebro-spinal axis. 
 The part of the sympathetic that appears to be most independent of the 
 cerebro-spinal axis is the cardiac, abdominal and pelvic plexuses (brains). I 
 have kept the intestines of dogs in active peristaltic waves for nearly two 
 hours after death, in a warm room, by tapping them with the scalpel. 
 
 The automatic parts of the sympathetic to which I wish to direct atten- 
 tion are, the cervical sympathetic ganglia (superior, middle, and inferior), 
 the abdominal brain (the solar plexus), and the pelvic brain (or cervico-uterine 
 plexus). Due consideration must be given to the three splanchnic groups: 
 (1) the cervical splanchnics, conducted to the stomach, heart, and lungs 
 through the spinal accessory and the vagus; ("2) the abdominal splanchnics, 
 originating from the fourth dorsal, running to the second lumbar, and thence 
 to the abdominal brain ; (3) the pelvic splanchnics, conducted to the hypogas- 
 tric plexus by means of the second, third and fourth sacral nerves, to supply 
 the rectum and the genito-urinary organs. 
 
 I have observed for some time that the connection of genital and urinary 
 systems with all the great nerve centers is intimate and profound. For exam- 
 ple, the organ which has the most intimate connection with the cerebro- 
 spinal axis and the abdominal and pelvic brain is the uterus. The eye, too, is 
 closely connected with both nervous systems, and also with the uterus. This 
 intimate nervous connection of the uterus with the nervous system increases 
 with the ascending scale of animal life. 
 
 The physiological function of the sympathetic nerve is rhythm. The 
 sympathetic nerve alone possesses this function. The power to produce 
 rhythm belongs only to a ganglion. The viscera functionate rhythmically. 
 The destruction of this periodical function causes disease. The organs which 
 have the most pronounced rhythm are those intimately connected with the 
 abdominal brain. Chief among these is the uterus and oviducts. So far as 
 I can observe, the uterus is connected with the abdominal brain by twenty or 
 thirty strong nerve strands. 
 
 The uterus and oviducts have a monthly rhythm, due to the automatic 
 menstrual ganglia situated in their walls. No doubt the higher physiological 
 
PHYSIOLOGY OF THE SYMPATHETIC 
 
 291 
 
 orders originate in the great abdominal brain. The breaking of the rhythm 
 of one viscus disturbs the rhythm of all the rest. This is in no organ so 
 significant as in the uterus, 
 because the uterus is more 
 exposed to infection and 
 trauma — disease — than any 
 other viscus. The glandular 
 endometrium, the best germ 
 culture medium, is exposed 
 to the external body service. 
 The liver has a visceral 
 rhythm, through its auto- 
 matic hepatic ganglia, simi- 
 lar to that of the uterus. 
 When new food arrives in 
 the liver from the portal 
 vein, the cells of the liver 
 begin to swell, in the per- 
 formance of their functions 
 of making bile, glycogen and 
 urea. The hepatic capsule 
 (Glisson's) and the peri- 
 toneal covering being ex- 
 tremely elastic, the liver can 
 go through its rhythm when- 
 ever occasion arises. When 
 the liver arrives at the maxi- 
 mum point of the rhythm, 
 the cells having exhausted 
 themselves in making bile, 
 glycogen and urea, these 
 three products are sent 
 home, (in the lumen of the 
 tractus intestinalis) and the 
 cells begin to contract, Glis- 
 son's capsule begins to 
 shrink, and the peritoneum 
 returns to its original state. 
 Then the liver secures rest 
 and repair, in order to be 
 able to accomplish the next 
 rhythm. It is the breaking 
 of the hepatic rhythm by 
 
 unfavorable food or distant reflexes of diseased viscera that causes disease 
 of the liver. The most prominent organ that induces irregular hepatic 
 rhythm is a diseased uterus. Alcohol, which rushes from stomach to liver 
 
 Fig. 69. (From Bryon Robinson's life-size chart of 
 the Sympathetic.) Represents the upper or neck and 
 chest portion. (7) Middle cervical ganglion. (8, 8) 
 Inferior cervical ganglion. (13, 14, 15, 16) Cervical 
 nerves. (17) First dorsal nerves. (18) Phrenic. (19) 
 Branch from inferior cervical to phrenic. (20, 21) 
 Cardiac nerves from middle and superior cervical 
 ganglia. (22, 22, and 22) Cardiac nerves from inferior 
 cervical ganglion. (23) Wrisberg's ganglion (of the 
 heart). (24 to 33) Cervical rami communicantes. (34 
 and 35) Ganglia on superior, middle and inferior car- 
 diac nerves of the cervical ganglia. (36) Verteral 
 artery. (37) Left subclavian artery. (38) Innominate 
 artery. (39) Right subclavian artery. (40) Carotid ar- 
 tery. (41) Aorta. (43) Intercostal arteries. (45, 46 and 
 47) Dorsal lateral chain of ganglia. (63) Communi- 
 cantes. 
 
292 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 through the gastric veins, taken without food, destroys the nice balance of 
 the hepatic rhythm by enticing the liver to go through its rhythm without 
 due stimulus or by unnatural stimulus. 
 
 It is plain that the heart goes through a rhythm by means of the auto- 
 matic cardiac ganglia situated in its wall. These ganglia are known as Bid- 
 der's, Schmidt's, Remak's, and Ludwig's. The vagi (especially the right) 
 give the heart the slow, steady beat, its sober, regular movements like a 
 pendulum; but the three cervical sympathetic ganglia rule the heart in regard 
 to rapidity and irregularity. It is the breaking of the cardiac rhythm that 
 causes reflex heart trouble. A diseased uterus, from the intimate and pro- 
 found nerve connection, is preeminently the organ that disturbs the heart 
 and its rhythm (by disturbed circulation in the coronary arteries). 
 
 The digestive tract has its own special rhythm through Auerbach's and 
 Billroth-Meissner's plexuses — the one presiding over the peristalsis, and the 
 other over absorption, secretions. The occasion of a digestive rhythm is food. 
 The main rhythm occurs in the enteron and the stomach. 
 
 The bladder performs a rhythm by means of automatic visceral gang- 
 lia; it has a diastole and a systole. The rhythm of the bladder is broken 
 when its nerves are dragged, as in pregnancy. 
 
 The spleen performs its rhythm by its automatic splenic ganglia. The 
 occasion of a splenic rhythm is fresh food. The spleen accomplishes its 
 rhythm by (a) the swelling of its tufts and substance, (b) by the expansion of 
 its elastic capsule, and (c) by the stretching of its peritoneal covering. It 
 rises to a maximum and sinks to a minimum. It is now in action and now in 
 repose. 
 
 Thus each viscus performs its peculiar rhythm by means of the automatic 
 ganglia situated in its substance. The higher physiological orders of the 
 abdominal brain must, of course, be obeyed. 
 
 III. PATHOLOGY. 
 
 We now come to the consideration of diseased viscera. Pathogenesis 
 through the sympathetic, in health and disease, is by reflex action. Of course 
 we have ganglionic sclerosis, recognizable and non-recognizable lesions of the 
 sympathetic, pigmentation and secondary disease, etc., but the great pathol- 
 ogy of the sympathetic nerve in gynecology is the transmission of reflexes 
 from diseased viscera. 
 
 We will take for illustration a case of uterine cervical laceration occur- 
 ring five years previous. The patient is now a pale, anemic, neurotic woman, 
 unfitted for the labor of life. A lacerated cervix (an infection atrium) is soon 
 followed by endometritis. Irritation from this is transmitted over the hypo- 
 gastric plexus to the abdominal brain, where it is reorganized. It should be 
 remembered that any irritation (force, vibration) will travel on the lines of 
 least resistance, and in the direction of least resistance from the abdominal 
 brain toward that organ having the greatest number of nerve strands. The 
 irritation reorganized will flash on all the plexuses. Reaching the liver, it 
 will disturb the hepatic rhythm, causing an over-production, an under-produc- 
 
PHYSIOLOGY OF THE SYMPATHETIC 293 
 
 tion, or an irregular production, of bile, gylcogen and urea ; and finally the 
 functions of the liver suffer impairment. Suppose we follow this same uter- 
 ine irritation to the digestive tract. At Auerbach's plexus it will cause colic, 
 lethargy, or fitful peristalsis, and at the plexus of Billroth-Meissner it will 
 induce diarrhea, constipation, or development of gases — fermentation. These 
 disturbances, after a painful progress of from six months to two years, culmi- 
 nate in indigestion. Then comes malnutrition, which results from long-con- 
 tinued indigestion. The third stage is anemia from malnutrition. The fourth 
 stage is neurosis: the ganglia have been long bathed in waste-laden blood. 
 Finally psychosis may arise. 
 
 Hence endometritis may induce: {a) indigestion, (/>) malnutrition, (c) 
 anemia, (<-/) neurosis, and (r) psychosis. 
 
 Again, consider heart palpitation at the menopause. It can be explained 
 by reflex action. The child-bearing period of a woman is thirty years. During 
 that time regular monthly forces have been transmitted over the hypogastric 
 plexus to induce uterine and oviductal rhythm. Now, at the menopause, the 
 hypogastric plexus degenerates and will not carry the forces, which conse- 
 quently accumulate. The accumulated forces in the abdominal brain go up 
 the splanchnic to the three cervical ganglia, where they are reorganized and 
 flashed to the heart, causing it to work either too rapidly, or fitfully. This 
 explains palpitation at menopause. 
 
 Exactly the same explanation suffices for liver disease during this period. 
 
 At the menopause the heat, circulatory, and sweet centers are irritated, 
 and the woman has flashes of heat, flushes of blood and "spells" of sweating. 
 
 Pigmentation is also from reflex action: the irritation spending its main 
 force on the liver and the spleen, causes pigmentation. 
 
 The genitals are profoundly supplied by the sympathetic. Observe the 
 double lateral supply and also the central hypogastric supply. There are two 
 ovarian ganglia at the origin of the ovarian arteries. There are two giant 
 pelvic brains or cervico-uterine ganglia, and these pelvic brains are connected 
 by some thirty strands to the great abdominal brain. The uterus, the popu- 
 lar center of the genitals, though anatomically the ovary is the real central 
 genital organ, is supplied from the abdominal brain by means of the lateral 
 hypogastric plexus chain, and the second, third, and fourth sacral nerves. 
 The pelvic brain demedullates the nerves, so that, though the three sacral 
 nerves supply the uterus, it is accomplished by first sending the three sacral 
 nerves through the pelvis, where they are demedullated before reaching the 
 uterus. In an anatomic and physiologic sense the pelvic brain is of extreme 
 importance on account of its vascular influence over the uterus and oviducts, 
 on account of its control to some extent of uterine and oviductal rhythm, and 
 on account of its influence on the nourishment of the uterus and oviducts. 
 Also, perhaps, parturition is instigated by pressure or trauma of the cervico- 
 uterine ganglion by the expanding cervix ; in other words, trauma to the pel- 
 vic brain. There are adjacent ganglia to the pelvic brain which influence 
 the uterus, bladder and vagina, holding these three organs in intimate connec- 
 tion. There is the plexus vesicalis (vesical ganglion), the hypogastric plexus, 
 
294 THE ABDOMINAL AND PELVIC BRAIN 
 
 and the plexus uterovaginal (pelvic brain), all three closely connected ana- 
 tomically and also connecting anatomically and physiologically the bladder, 
 cervix and uterus. 
 
 It is daily gynecologic observation that the uterus and bladder functionate 
 together through nerve connection — especially the sympathetic. However, 
 the chief function of the pelvic brain is to rule the uterus, as will be observed, 
 by noting that the major branches of this ganglion pass to the body of the 
 uterus. A small part of the uterine nerves originates from the hypogastric 
 plexus, which supplies the side and dorsal surface of the uterus. From the 
 pelvic brain and vesical ganglion, nerves accompany the uterine artery along 
 the lateral borders of the uterus, sending branches to the uterus on the hori- 
 zontal arteries, and to the oviducts which, by union with the ovarian nerves, 
 form the ovarian ganglion. From the ovarial ganglion, nerves pass to the 
 anterior side of the uterus, to the inner and middle parts of the oviduct and 
 to the broad ligaments. 
 
 The ligamentum teres uteri is composed of nonstriped muscle and is sup- 
 plied by both the uterine and ovarian nerves. The uterus is supplied in its 
 muscularis by an extraordinary, rich network of nerves, which is continued 
 into the muscularis vaginae. The uterine mucosa has numerous ganglia dis- 
 tributed in its substance. The nerve endings pass to the epithelia of the sin- 
 gle organs. The small capillaries are enclosed in a network of nerves. 
 
 IV. GENERAL VIEWS OF PAIN IN GYNECOLOGY. 
 
 Pain in gynecology is generally described as typical in character. This 
 is observed from the terms which writers employ. Some designate the pain 
 as nongenuine, others as hysteric, and again as illegitimate, ideal or physical. 
 Perhaps with more accuracy one might designate the pain as from the cortex 
 of the cerebro-spinal axis. It should be recognized that a more rational 
 classification of pain in gynecology is demanded. 
 
 Hysteria, if the term be employed, must be recognized by definite stig- 
 mata. It is true in gynecology we are dealing chiefly with the subjective 
 sensations of the patient. The pain appears to the patient as immeasurably 
 severe and terrible. Frequently the only standard is the patient's tears, fears 
 or moans, and her comparison of dragging, tearing or boring. We can to some 
 extent estimate colic pains of hollow organs as uterine and intestinal condi- 
 tions. But it is remarkable how gynecologic patients bear the genuine pain 
 of labor and other colicky pains with little complaint and slight fear of its 
 repetition; while the immeasurable and often apparently nongenuine pain 
 of hyperesthesia causes exaggerated and bitter complaints. The intensity of 
 pain can be supposed but never sharply measured. An exudate can be pal- 
 pated, the amount of blood loss judged, the growth of a tumor estimated, 
 but the determination of pain rests alone on the dogmatic assertion of the 
 patient. It is a physical phenomenon. As Dr. Lomer states in his excellent 
 investigations, pain is an increase of touch sensation, and has a psychical 
 character. Doubtless the sensory periphery apparatus ends first in the skin 
 (hyperesthesia and anesthesia), and second in the mucosa (hyperesthesia and 
 anesthesia). 
 
RELATION OF SPINAL TO SYMPATHETIC 
 
 295 
 
 The chief center of pain for the periphery apparatus of skin or mucosa 
 lies in the dorsal sensory ganglia of the spinal cord. 
 
 Disease in either the spinal sensory ganglia or the sensory periphery, 
 unbalances the nervous system. Analysis and clinical observation would 
 indicate that the hyperesthesia and anesthesia are of central (cerebro-spinal) 
 origin. Head, of England, reported some ingenious experiments, in which 
 every visceral disease is announced through the sympathetic nerve by a speci- 
 fic zone of skin tenderness. The center of the sympathetic fiber lies directly 
 in the sensory nerve. If a sympathetic irritation arises it is reflected on the 
 tract of the sensory nerve to its specific skin periphery. The result is a spe- 
 cific tender skin zone. In fact, Head allots a typical sensory skin zone for 
 each individual viscus. For example, there is a specific zone of skin tender- 
 ness for a stone in the kidneys, a stone in the gall bladder, or a diseased uterus 
 or ovary. However, this is only another way of saying that visceral irritation 
 passes to the spinal cord, and after reor- 
 ganization, radiates on the muscular nerves 
 of the abdomen and also on the skin nerves 
 of the abdomen. Irritation of the periph- 
 ery of visceral, muscular, or skin nerves, 
 affects the other two by reflection. In any 
 case, the process of transmission of pain 
 from periphery to center is a complicated 
 one. The variation of intensity of pain is 
 equally shared by variation of its quality as 
 boring, sticking, burning, cutting, tearing, 
 dull and jumping pain. One can suppose 
 an organ pain, as a toothache, an earache, 
 ovarian pain, uterine and intestinal colic, 
 tenesmus of urethra or rectum. Organ 
 pains require an agent or irritation to start 
 them, and are not a quality of the nerves of 
 the viscus itself. 
 
 From practical gynecology, pain may be classified as follows, viz.: 
 
 1. Traumatic (wound) pain, the irritation of sensory nerves from exter- 
 nal insults. Frequent examples of traumatic pain occur in the urethral, 
 vulval, hymenial, perineal, and anal lacerations. The pain is acute, but 
 quickly subsides. However, it is easily revived by functionating of the 
 organs, or secretions flowing on the wound. Destruction of nerves, as from 
 burns or chemicals, has the most intense and persistent pain. Patients gen- 
 erally describe traumatic (wound) pain as burning or smarting. An ice bag 
 is effectual in alleviating such pain. 
 
 2. Contractile (colic) pain, the irritation of the sensory nerves through 
 muscular contraction. It is vascular spasm. The well known examples of 
 contractile pain (colic) are uterine and intestinal colic, the over-filled rectum, 
 oviducts, or urinal or gall bladder. Vaginismus, though of other origin, is a 
 typical example. This pain is rhythmic or peristaltic. It rises to a maxi- 
 mum and sinks to a minimum. It is described as an ache. 
 
 Fig. 70. (Byron Robinson.) Rep- 
 resents a plan of a dorsal nerve. 
 (Sp. c.) Spinal cord. [p. b.) Posterior 
 branch, (a. b.) Anterior branch, (g.) 
 Ganglion on posterior root. (ram. 
 com.) Ramus communicans. (sy. 
 gang.) Sympathetic ganglion, (p. c.) 
 Posterior cutaneous. (a. d. or a. c.) 
 Anterior division. (/. c.) Lateral cu- 
 taneous branch. 
 
296 THE ABDOMINAL AXD PELVIC BRAIN 
 
 3. Inflammatory pain, the irritation caused by trophic changes in sensory 
 nerves. The changes are produced by pressure (exudation) or chemical 
 effects on the sensory nerve endings. It is the degenerative disturbance in 
 the sensory nerve area. Its conditions are calor, rubor, tumor, — dolor. The 
 pain, though complicated, is described as sticky, cutting, and beating, and as 
 a rule is extraordinarily painful. 
 
 4. Neuralgic pain, the irritation produced by changes in the sensory 
 nerve itself and perhaps its ganglion. Neuralgic pain is characterized by 
 attacks and intermissions. It is typically observed in herpes zoster and 
 herpes vulvaris. The neuralgic pain is described as lancinating or lightning- 
 like in character. It is characteristic for neuralgic pain to remain limited to 
 a definite nerve territory. It is unilateral. It commonly attacks the ilio- 
 inguinal nerve or external cutaneous, also the pudendal and intercostal. 
 
 5. Hysterical pain, the irritation caused by disturbances in the cerebro- 
 spinal system. This pain is limited to no organ or nerve zone. It exists 
 perhaps equally among men, women, and children. Hysteria has nc more 
 to do with the uterus than with the liver or testicle. It is not a gynecologic 
 disease. It is true, gynecologic subjects possess it, but often from devitalized 
 power. It exists independent of nerve distribution. It is not influenced by 
 rest, or scarcely, perhaps, through drugs. The fundamental cause of hysteria 
 is heredity, the transmission of defects or a neuropathic condition. The 
 provocative agent of hysteria is some debilitating effect, mental or physical. 
 Dr. Lomer insists that the hyperesthetic and anesthetic zones of the skin are 
 geometrical figures. Hysteria depends on psychical alteration. It is gen- 
 erally described as burning pain. The two chief therapeutic agents for hyste- 
 ria are {ci) suggestions and {b) limited galvanic electricity. Hyperesthesia 
 may perhaps exist in any viscus, and the typical characteristic of hysteria 
 being hyperesthesia of the abdominal skin, that attribute could be found 
 anywhere on the skin if sought. 
 
 Hysteria distinguishes itself from all other diseases by certain stigmata. 
 One or more of these stigmata must be present to diagnose any case of hys- 
 teria. The stigmata of hysteria are: 
 
 1. Hyperesthesia of the skin, which consists in exaltation of the sensory 
 periphery. These areas, hystero-genetic zones, are especially found on the 
 skin of the abdomen. The}' are painful or over-sensitive on touch. The 
 patient is often deceived by thinking the pain in the skin of the groin refers 
 to the ovary. Hystero-genetic zones or hyperesthetic areas occur all over 
 the body, but in the sexual region they are apt to be more typical on account 
 of the patient's active attention. The skin over the ovary or the kidney may 
 be so hyperesthetic and tender that grave kidney disease may be suspected. 
 The skin over any abdominal viscus may be so tender that touching it induces 
 the patient to scream, while the viscus itself is quite healthy. Hyperesthesia 
 exists chiefly on the right side. Pinching or pricking the skin enables one 
 to discern the zones of hyperesthesia. 
 
 Hyperesthesia of the skin on the abdomen may exist with or without 
 healthy genitals. Of course the hyperesthesia of the skin is more liable to 
 
RELATION OF CEREBROSPINAL TO SYMPATHETIC 
 
 29' 
 
 exist with diseased genitals, as the genitals may be the provocative or debil- 
 itating agent inducing the hysteria. The patients who are disturbed by 
 crawling sensations on the skin, as of snakes and ants, have hyperesthesia 
 and hence have hysteria. Hyperesthetic spots anywhere on the body consti- 
 tute one of the stigmata of hysteria. I observed hyperesthetic spots year 
 after year on a woman's back. The hyperesthesia of the skin may change its 
 location. The frequency of skin hyperesthesia in the gynecologic clinic 
 induces me to believe in the wide distribu- 
 tion of hysteria, independent of gynecology. 
 
 2. Anesthesia of the skin is also another 
 stigma of hysteria. This is not so frequent in 
 the clinic. The patient complains of the skin 
 being numb and without feeling. It is found, 
 perhaps, most frequently on the skin of the 
 abdomen. Anesthesia exists chiefly on the 
 left side of the body. 
 
 3. Anesthesia of the mucosa is one of 
 the stigmata of hysteria seldom absent. The 
 test is easily made by taking a pin with a 
 small glass head and rubbing it over the eye- 
 ball. If the conjunctiva bulbi is anesthetic, 
 one can rub the pinhead over the eyeball 
 without a wink or flinch from the patient. 
 Normally the conjunctiva is very sensitive, 
 and to touch it produces reflex actions, tears 
 and pain. Nearly always in the hysteria the 
 rubbing of the pinhead on the eyeball pro- 
 duces no reflexes, no tears, no pain. Of course 
 there are many grades of anesthesia of the 
 conjunctiva bulbi. The corneal anesthesia is 
 the least frequent. The anesthesia of the 
 throat is tested by a lead pencil or sound. 
 On rubbing the mucosa of the throat, no reflex 
 nor pain arises. As Windscheid remarks, 
 however, the diagnosis of hysteria should not 
 be made from anesthesia of the throat alone, 
 as in healthy subjects the mucosa of the throat 
 may show various degrees of anesthesia. 
 
 4. Hyperesthesia of the mucosa must be remembered among the stig- 
 mata of hysteria, though infrequent. The persistent feeling of animals 
 crawling in the tractus intestinalis (abdomen) is no doubt a symptom of an 
 over-tender mucous membrane. The sudden expulsion of unchanged foods 
 from some stomachs immediately after eating is no doubt due to hyperesthesia 
 (non-toleration) of the gastric mucosa. 
 
 Hyperesthesia of the viscera is one of the known stigmata of hysteria. 
 Perhaps visceral hyperesthesia exists the most frequently in the ovary. In 
 
 DIAGRAM OF LUMBAR AND 
 
 PELVIC PLEXUSES 
 
 (QUAIN) 
 
 Fig. 71. (DXII.) Last dorsal. 
 (IS.) First sacral. (8) Pudic. 
 (Sc.) Sciatic. (V.) Lumbosacral. 
 
298 THE ABDOMINAL AXD PELVIC BRA IS 
 
 such cases the ovary is hypersensitive to touch, yet normal in size and posi- 
 tion, perfectly mobile, with no peritoneal adhesions or fever. Castration 
 does not affect the pain unless it exacerbates it. The irritable uterus of the 
 old doctors is undoubtedly of hysteric nature. To show that such cases are 
 hysteric, the uterus, oviducts and ovaries have been removed, but the pain 
 persists just as before the operation. I once operated on a hyperesthetic 
 kidney in which I suspected stone, but no stone existed and the pain persisted 
 as before the operation. Hyperesthesia of the cord and testicle frequently 
 exists. Vaginismus is perhaps as typically hysterical as any example of 
 the viscera. Vaginismus may be called up by the thought of touching the 
 vulva. It is chiefly of psychical origin and occurs in neuropathic individu- 
 als. It is common to note hyperesthesia of the orificium vaginae, and an 
 exacerbation of this leads to various grades of vaginismus. 
 
 The hymen has been extirpated in vaginismus, but without good effect. 
 There can be little doubt that hysteric bladders frequently arise in the prac- 
 tice. I once treated a patient two years for a hysteric bladder. Drugs had 
 little or no effect. Rest in bed made no change. Suggestion was the best 
 treatment. Urine was normal. It was so-called irritable bladder, hysteria. 
 The patients with irritable or hysteric uterus are the ones who prepare for 
 the child's advent by making the clothing, and sending for the midwife. 
 They suffer from labor pains, and finally call the obstetrician when labor 
 does not complete itself, only to find that the patient is not even pregnant. 
 She is misled by her irritable, hyperesthetic, hysteric uterus. The abdominal 
 cramps and colic of certain neuropathic patients are doubtless due to visceral 
 hyperesthesia or hysteria. 
 
 5. The muscular stigma of hysteria is quite common. It consists in the 
 paresis or paralysis of one or more muscles, or it consists in exacerbation of 
 contractions of one or more muscles. When the tongue suddenly ceases to 
 act, with subsequent normal action, it is quite sure to be hysterical in nature. 
 Globus hystericus is simply exacerbated activity of the esophageal and gas- 
 tric muscles. Hysteric knee is a spasmodic contraction of the muscles sup- 
 plying it. The lost voice is frequently of hysteric nature, due to disturbances 
 of laryngeal muscles. The "lumps" or tumors in the abdomen of many 
 patients are simply the contractions of certain abdominal muscles, frequently 
 accompanied by hyperesthesia of the skin over them. The patient complains 
 of a tender tumor, and the diaphragm or groups of muscles become spas- 
 modic. 
 
 6. Another stigma of hysteria is psychosis. It is perverted mental 
 action. Hysteria is chiefly manifest to the gynecologist as a psychical dis- 
 ease. It is a part of a neurosis, very changeable, and ever presenting new 
 scenes. It doubtless rests on a psycho-pathic construction. The psychosis 
 rests also no doubt on a defective system. An irritable weakness exists in 
 the nervous system. The central or peripheral nervous system is defective 
 The hysteric condition is especially susceptible to influence or suggestibility. 
 
 7. Exaltation or diminution of the special senses is also a stigma, as 
 blindness or exalted hearing. Hereditv or congenital defect is a large factor. 
 
RELATION OF CEREBROSPINAL TO SYMPATHETIC 
 
 Whatever debilitates the nervous system, local or general, invites hysteria 
 as a provocative agent. It should be remembered that genital disease 
 (infectious) is debilitating, and hence is followed frequently by hysteria. 
 Sexual diseases (in man or woman) no doubt play a vast role in hysteria. 
 They are productive agents. Of special interest are the hyperesthetic zones 
 of the abdomen; i. e., the periphery of the sensory nerves of the abdomen. 
 
 8. The sensory periphery area of the ilio-inguinal, ilio-hypogastric and 
 that of the eight lower intercostals, become exalted in sensation. Hysteria 
 is a disease of symptoms. There are two theories of hysteria extant at 
 
 ABDOMINAL BRAIN 
 
 Fig. 72. This illustration I dissected under alcohol. It represents fairly accurately the 
 cerebrum abdominale in the general subject. 
 
 present, viz.: (a) It is a psychosis, a mental disturbance. Its seat is the 
 cerebral cortex, {b) It is a neurosis or a psycho-neurosis. It is not limited 
 to the cerebral cortex, but is a disease of the whole nervous system. It is a 
 disease of rapidly changing panorama. 
 
 The treatment of hysteria must be rational, systematic, prolonged, and 
 continuously suggestive. Drain the skin by salt rubs, massage ; drain the 
 kidneys by ample drinking of fluids ; drain the bowels by proper diet, sufficient 
 laxation, and fluid and regular evacuations. Tonics to improve digestion, 
 drugs to act on the senses, especially the olfactory; electricity to act on the 
 
300 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 cerebral cortex, and continual suggestions with firm discipline. Above all 
 ideas of hysteria or neurasthenia must stand the thought that all operations 
 to cure them are to be abandoned. 
 
 In gynecologic patients there is a triumvirate of pain — back, head, and 
 stomach. It represents three groups of painful localities. 
 
 1. The lumbo-sacral region is the seat of the most prevalent and per- 
 sistent. It is the central station which interprets the pain of the pelvic 
 sensory periphery. Almost every gynecologic affection creates lumbo-sacral 
 symptoms, whether it be dislocation, inflammation, contractile pain, sacro- 
 pubic hernia, mechanical pressure or malignant growths. In short, the 
 lumbo-sacral region is the sensorium of gynecology of the pelvis. The spin- 
 al ganglion must act as local substitute for the brain. The explanation of 
 this lies in the kind of nerves: visceral, peritoneal, muscular, and cutaneous, 
 which report to the lumbo-sacral cord. 
 
 The visceral nerves are the second, third and fourth sacral and the sym- 
 pathetic—all transmit reflexes to the lumbo-sacral cord from irritation of the 
 genitals. 
 
 The peritoneal nerves are branches of the ilio-inguinal,the ilio-hypogas- 
 tric, and the seven lower intercostals, which transmit pelvic peripheral 
 irritation to the lumbo-sacral cord. 
 
 The muscular nerves of the lumbo-sacral plexus and also those of the 
 muscular seven lower intercostals transmit disturbances to the lumbo-sacral 
 cord. 
 
 The cutaneous branches of the lumbo-sacral plexuses, especially the 
 pudic, the pudendal, the ilio-inguinal, ilio-hypogastric and seven lower inter- 
 costal cutaneous branches, report irritation to the sacro-lumbar cord. 
 
 The irritation of the periphery of any of the three great branches of the 
 lumbo-sacral cord, viz., cutaneous, muscular or viscero-peritoneal, disturbs 
 the balance of the other two. Irritation of the visceral sensory periphery 
 unbalances the sensory periphery of the muscular and cutaneous nerves. 
 The spinal ganglia are reorganizers and transmit all reports to every 
 periphery. This is a cue to therapeutic agents, e. g. . cutaneous irritation is 
 carried to the spinal cord and reflected on the muscular and visceral branches, 
 stimulating both. 
 
 2. Gynecologic disease refers a group of pain to the stomach. 
 
 3. Another group is referred to the head. Laparotomy wounds seldom 
 or never give rise to pain if union is by first intention. The lower angle of 
 the wound is sometimes painful under pressure, but it is undoubtedly due to 
 suppuration from close proximity to the region of the hair. Dorsal muscles 
 are inclined to rheumatism, while those of the abdomen are not ; hence, more 
 accurate judgment arises as to painful abdominal incisions. Special atten- 
 tion should be paid to hyperesthesia of the abdominal skin by the gynecologist 
 and surgeon, as it may exist without visceral disease, and hence may be non- 
 surgical. So-called "irritable" organs with no visible or palpable anatomic 
 change, should be referred to hysteria. 
 
 When a rational treatment is systematically carried on against painful 
 
RELATION OF CEREBROSPINAL TO SYMPATHETIC 301 
 
 local disturbance, without effect, the probability is that it is a hysteric hyper- 
 esthesia. The excessive vomiting of pregnancy often has a hysteric base — 
 hyperesthesia of the gastric mucosa. In the same hysteric category must 
 often be numbered, coccygodynia, coxalgia, irritable bladder, breast, and 
 uterus, vaginismus, pruritus, dysmenorrhea, and a sense of lumbo-sacral 
 symptoms. A knowledge of the above factors is particularly valuable to the 
 operator as the sweeping removal of organs for neurosis or hyperesthesia is 
 criminal. Remember that morbid sensibility lies chiefly in the skin, and the 
 patient will complain more of a skin pinch than a deep-seated trauma. 
 What the hysteric coxalgia or hysteric knee is to the surgeon, so is the 
 hyperesthesia of the abdomen to the gynecologist. The puzzle of each 
 solves itself under the analysis for stigmata. 
 
V 
 
 
 CHAPTER XXIV. 
 
 HYPERESTHESIA OF THE SYMPATHETIC. 
 
 "Surmises are not facts. Suspicions which may be unjust need not be stated." 
 — Abraham Lincoln. 
 
 "Men are merriest when they are from home." — Shakespeare. 
 
 1. Hyperesthesia of the abdominal brain (Neuralgia Celiaca) consists of a 
 sudden violent pain in the region of the stomach. The pain is accompanied 
 by a sense of fainting and impending anxious dread. It manifests itself, 
 objectively, chiefly in the character of the circulation and in the facial 
 appearance. The skin is pale, the extremities cold, the muscles assume 
 vigorous contractions, especially over the abdomen, and the heart beats under 
 tension and may intermit. The abdominal muscles are put on a stretch. 
 Some patients are occasionally relieved by pressure on the stomach. From 
 the intimate and close anatomical connection of the abdominal brain with 
 all the abdominal viscera, and also the thoracic viscera, various other symp- 
 toms of a similar character to neuralgia celiaca may and do arise, as disturb- 
 ance in the action of the heart and of the gastro-intestinal tract. The attacks 
 are irregular, periodical, uncertain in time and intensity. The attack may 
 last a few minutes to half an hour. The attack may disappear slowly or 
 under a crisis of perspiration, emission of gas, vomiting or copious urination, 
 leaving the patient apparently very exhausted. The peculiar characteris- 
 tics of the attacks in the abdominal brain determine neuralgia celiaca from 
 inflammatory processes of the stomach. 
 
 The most typical neuralgia celiaca coming under my notice was (1890) 
 that of a man about 40, a real estate dealer, in whom it had persisted for 
 perhaps ten years. I could discover no gall-bladder, heart or ureteral trouble, 
 and no stomach lesion. He was attacked, irregularly, however, depending 
 on over-exertion, several times a year. When attacked he felt that impend- 
 ing death was at hand. He screamed between paroxysms and would fall on 
 the floor, rolling in agony for a half or three-quarters of an hour. He 
 anticipated the terrific attacks by preparing for them with great care of his 
 health. He would be very quiet for one or two days subsequent to the attacks ; 
 otherwise he was quite healthy. I soon lost sight of him. 
 
 The second most typical case of neuralgia celiaca in my practice was that 
 of a woman (1883) about 28. She had very severe and frequent attacks which 
 lasted some fifteen minutes; seemed to have terrible dread and anxiety, a wiry, 
 small pulse, rigid abdominal muscles and varying pupils during the attack. 
 She appeared greatly relieved by pressure directly on the stomach during the 
 attack. She recovered with much exhaustion and relaxation; otherwise she 
 appeared well. She died of rectal carcinoma some twelve years later. Neu- 
 
 302 
 
HYPERESTHESIA OF THE NERVUS VASOMOTOR! 
 
 303 
 
 ralgia celiaca may exist in very various degrees of intensity and duration. 
 In some very severe attacks it would seem from appearances and the patient's 
 report that the suffering was more profound than an ordinary death. The 
 chief valuable treatment consists in securing active secretion of the skin and 
 kidneys with free bowel evacuation. General tone is secured by tonics and 
 
 
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 CORROSION ANATOMY 
 
 Fig. 73. Corrosion anatomy of the ductus pancreaticus and part of the ductus bilis in 
 two subjects. The illustration suggests the quantity of nerves to control the caliber of the 
 numerous ducts. 
 
304 THE ABDOMINAL AND PELVIC BRAIN 
 
 wholesome food; even temperature and quiet life tells the rest of the story. 
 The treatment during the attacks is purely expectant — sedative and stimulant. 
 Vigorous baths and wholesome suggestions are valuable. There is often more 
 in the advice given with the medicine than in the medicine itself. 
 
 Neuralgia celiaca resembles angina pectoris more than any other neuralgia 
 of the sympathetic ganglia. It requires judgment and skill to diagnose it 
 from some forms of angina pectoris, and its treatment is equally as doubtful. 
 Of course, it is physical lesions which we suspect in neuralgia of the abdominal 
 brain, as the physician cannot consent to the view that a machine (the sym- 
 pathetic ganglia) may go wrong without its becoming structurally defective 
 somewhere. Electricity, massage and cold packing are quite effective. Some 
 writers consider this subject under the terms gastralgia or gastrodynia. But 
 under whatever term it may be discussed, the peculiar sense of fainting, the 
 anxiety, dread and feeling of impending destruction of the very center of life 
 itself during the attack, and especially its action on the vascular system, 
 sufficiently characterize it as neuralgia of the abdominal brain — neuralgia 
 celiaca. The diseases of the vagus manifest themselves otherwise. 
 
 2. Hyperesthesia of the mesenteric plexus (Neuralgia Mesenterica, 
 enteralgia, enterodynia or colic) signifies pain in the region of the bowel sup- 
 plied by the nerves accompanying the superior mesenteric artery, i. e., the 
 region of the small intestine and the large bowel from the appendix to the 
 splenic flexure. The pain is irregular, dragging, sickening, pinching, boring, 
 accompanied by a sense of tenderness over the abdomen. The pain shifts from 
 one segment of the bowel to another; is generally located below the umbilicus; 
 alternates with intervals of cessation and does not generally begin suddenly, but 
 gradually ascends to a maximum. It may be so severe as to induce a sense of 
 faintness. Some patients assume positions to ease the pain, as pressing the 
 hands on the abdomen, bending the thighs on the abdomen ; some are very rest- 
 less under the attacks. The abdomen may be distended with gas or retracted. 
 The attack may pass off with crisis of the passage of gas, vomiting, sweating, 
 profuse urination. The attacks last from a few minutes to several hours. 
 Some patients are subject to these attacks for some months in succession. 
 The patient may have intervals of entire freedom from the attacks. Yet 
 the general observation is that constipation characterizes patients with mes- 
 enteric neuralgia. It is understood here that the pain does not arise from a 
 recognizable, demonstrable organic lesion, as ulceration of the mucosa, 
 lesion of the bowel wall or serosa, but from a nervous base. The pain may 
 be merely short, sharp twinges, which some neurotic women describe year 
 in and }-ear out. The clinical picture of the disease offers manifold variations. 
 Some patients have meteorism, pain about the navel, rumbling (borborygmus) 
 in the bowels. Some have gurgling in the intestines, which appears to be due 
 to a sudden irregular contraction of the bowel which rapidly forces the con- 
 tents onward. In fact, patients with neuralgia mesenterica often possess a 
 catalogue of other neurotic manifestations. Nausea, dysuria and tenesmus 
 may be present. The chief accompaniment of this disease is perhaps 
 constipation. However, the pains of mesenteric neuralgia should not be 
 confounded with those of intestinal colic. 
 
NEURALGIA OF THE NERVUS VASOMOTORIUS 305 
 
 The first author of celebrity who wrote with clear views on the distinction 
 between neuralgia mesenterica and intestinal colic was Thomas Willis (1622- 
 1675), an English physician well remembered by anatomists in the "Circle of 
 Willis," in numbering the cranial nerves and in the nerve of Willis (the spinal 
 accessory). Willis observed over 230 years ago that mesenteric neuralgia was 
 not a disease, but merely a symptom. He said it should be distinguished from 
 the vulgar term, "the gripes" (intestinal colic). Willis also noted what others 
 see today, that the more violent attacks of mesenteric neuralgia generally have 
 regular periods and follow the changes of the weather and the season; when 
 once excited they yield with difficulty to remedies, do not pass off quickly, 
 and may persist for weeks with great violence. In regard to the seat of pain, 
 it may be noted that in the same individual it generally repeats itself in the same 
 region. The nerve tract sufficiently defective to harbor a neuralgia tends to 
 retain the defect throughout life. It may be remembered that the superior 
 mesenteric nerve supplies over twenty feet of small and nearly three feet of 
 large intestine — a vast area — and besides, the small intestine shifts very much 
 daily; hence, the pains of mesenteric neuralgia may be in the lumbar, 
 umbilical and hypogastric regions. If the pain occurs at the pit of the stomach, 
 it is likely located in the transverse colon. 
 
 The clinical picture of mesenteric neuralgia is so manifold in its aspect 
 that it requires the best heads and the finest skill to unravel the complicated 
 symptoms. The differential diagnosis is difficult. In certain cases where the 
 symptoms lessen after the evacuation of peculiarly formed rolls of mucus there 
 is a mixed neorosis. 
 
 Again, the mesenteric neuralgia, while it exists, may be complicated by 
 attacks of asthma, nausea, dysuria, hysteria or other nervous affections, to 
 which subjects afflicted with mesenteric neuralgia are prone. In cases of 
 mesenteric neuralgia, certain regions of the abdominal skin may show hyper- 
 esthesia from the connection shown to exist between the viscera and the 
 abdominal skin. Mr. Head, of London, in "Brain," 1894, demonstrated the 
 close relation existing between the nerves of the abdominal viscera and the 
 nerves of certain skin areas. Hence, in cases of mesenteric neuralgia hyper- 
 esthetic skin areas on the abdomen may be expected. In the incipiency it 
 may be difficult to differentiate a beginning peritonitis from mesenteric 
 neuralgia. But of worth in such a diagnosis as peritonitis are temperature, 
 pain on pressure on the abdomen, general pain and increase of pain by deep 
 pressure on the abdomen. With time the meteorism, singultus and exudate 
 become more evident in peritonitis. In gallstone colic tenderness on pressure 
 arises and is localized. Icterus may follow to aid. Renal colic is differen- 
 tiated from mesenteric neuralgia by its being localized in the region of the 
 kidney, by its continual radiation along the ureters toward the bladder and 
 testicles, by the severe, dragging character of the pain, and by the occasional 
 expulsion of a calculus; yet renal colic in some cases may so simulate mes- 
 enteric neuralgia that differential diagnosis is very difficult, if not impossible. 
 This might occur when the renal irritation flashes to the abdominal brain, 
 becomes reorganized and radiates along the vast area of the superior mesen- 
 20 
 
306 THE ABDOMINAL AND PELVIC BRAIN 
 
 teric nerve. An ulcer in the bowel shows constant localized pain on pressure. 
 The patient's history, the omission of the characteristic periodic attacks, the 
 formation of the stools, aid in diagnosing ulcer of the intestines. It may be 
 impossible to make a differential diagnosis in the incipient stage of the 
 disease. 
 
 The most typical species of mesenteric neuralgia known to the writer is 
 lead colic, colica saturnina. Lead colic is preceded by a stage of constipa- 
 tion accompanied by oppressive pains in the abdomen, chiefly about the 
 umbilicus. Nausea, eructations, destroy the appetite. Pinching, twisting and 
 drawing pains occur with different duration and intensity. The pains are 
 often persistently localized, do not frequently shift, occur in paroxysms. 
 The pains of lead colic, mesenteric neuralgia, are apt to arise to the highest 
 pitch at night and when they lessen are apt to leave annoying sensations, 
 allowing little rest during the intervals of paroxysms. The diagnosis is aided 
 by the patient's occupation, history association, condition and state of climate. 
 Arthritis, rheumatism and malaria induce neuralgia. 
 
 Having established the diagnosis of mesenteric neuralgia, the treatment 
 will refer to a certain extent to the etiology. Older practitioners relied too 
 much on evacuation and opium. Modern practice attempts to correct the 
 malnutrition. 
 
 The first symptom of significance in mesenteric neuralgia is pain. The 
 second symptom of importance is constipation. Both symptoms demand 
 vigorous attention. The treatment will first consist in attempting to estab- 
 lish the etiology of the mesenteric neuralgia. Is it due to dietetic defects, 
 spirituous liquors, narcotics, intestinal contents, coprostasis, colica flatulenta, 
 animal parasites, metallic poisoning, or catching cold? Or again, is the neu- 
 ralgia due to general nervous affections, as neurasthenia, to an exalted irrita- 
 bility of the bowel, nerves and ganglia? Is it caused by hysteria or locomotor 
 ataxia? Or is the mesenteric neuralgia induced by some diseased abdominal 
 viscus reflecting its irritation to the abdominal brain, whence reorganized it 
 is flashed over the vast area of the superior mesenteric nerve, rippling the 
 bowel in whole or in segments; An investigation of the above considerations 
 will influence the treatment. 
 
 First, the pain, real or pretended, will demand attention. Opium should 
 be avoided if possible. Valerian, asafetida, i. e., drugs with effect on the 
 sense of smell, influence favorably, but perhaps there is more in the sugges- 
 tion or advice which accompanies the drug than in the drug itself. I have 
 observed better results from hot, moist poultices (corn meal), making the 
 poultice a foot square and three to six inches thick and applying it over the 
 abdomen. Cold packing of the abdomen in heavy, wet towels often does 
 well. Electricity has good moral and physical effects. A hypodermic of 
 morphine, 1-16 of a grain, is effective. However, we must admit that a good 
 dose of opium, e. g., Yz to 1 grain, works wonders for a time in mesenteric 
 neuralgia. The bromides are slow but effective ■ however, they generally 
 disturb digestion. Potassium bromide should be avoided, as it irritates 
 mucosa and skin, frequently calling up rashes; 20 to 30 grains of sodium 
 
NEURALGIA OF THE NERVUS VASOMOTORIUS 
 
 307 
 
 bromide will produce a quiet nervous system, especially inducing restful 
 nights and quiet sleep. 
 
 The pain of mesenteric neuralgia being disposed of, the more important 
 subject of the curative treatment should be carefully considered. The most 
 important symptom after the pain is that of constipation. The bowels are 
 indolent and are affected but slowly, even by active purgatives. The evacua- 
 tions are scanty and difficult to perform. The feces are dry, globular in shape 
 and brittle. The patients are distressed by fruitless strainings. It is useless 
 
 CORROSION ANATOMY 
 
 Fig. 74. Corrosion anatomy of the kidney, presenting ureteral pelvis, calyces and 
 arteria renalis, suggesting the quantity of nerves required to control these canals. 
 
 to attempt to cure such patients without a strict and rigid regimen. In the 
 first place, such patients will not drink sufficiently; and, secondly, they lack 
 a regular hour for evacuation. I have treated scores of patients successfully 
 for the constipated habit by directing that a large tumblerful of water, with 
 magnesium sulphate, half of a dram to a dram dissolved in it, be drank every 
 night. Also, that the patient be directed to go to stool every morning after 
 breakfast, i. e., after the hot coffee is drank, which aids peristalsis. Direc- 
 tion should be given to eat food which leaves a large bulk of residue, as oat- 
 meal, cornmeal, and graham bread. This residual bulk stimulates the 
 
308 , THE ABDOMINAL AXD PELVIC BRAIN 
 
 intestines to active peristalsis by contact in every successive segment. Daily 
 passages of the bowel and electricity aid to rouse the indolent digestive tract 
 to normal activity. The constant use of a very small pill of aloin, belladonna 
 and strychnine is very effective. Colonic flushings two to four times weekly, 
 salt water and friction baths, aid nature in restoring lost tone. Change of 
 environment, climate, a sea voyage, but, perhaps better, long daily walks, 
 are beneficial. Horseback and bicycle riding are helpful. 
 
 The course of mesenteric neuralgia as regards life is favorable; the 
 attacks, which vary very much as regards intensity, endure from one to sev- 
 eral hours. Neuralgias arise in the sympathetic. Collins demonstrated that 
 the arteries of the abdominal viscera were possessed of great sensibility in 
 which the arteries of other parts were wanting. It is likely that the nerves 
 accompanying the mesenteric artery participate in the reflex irritation, induc- 
 ing the neuralgia. 
 
 Hyperesthesia of the hypogastric plexus consists of irregular, periodic 
 pains radiating from the abdomen to the genitals, bladder and down the 
 thighs (including the inferior mesenteric plexus), and in the rectum. The 
 hypogastric plexus passes from the abdominal brain along the aorta, common 
 iliacs, and from the bifurcation of the aorta two large strands pass on to 
 complete the pelvic brain or cervical uterine ganglia. In the female the 
 hypogastric plexus chiefly supplies the uterus and oviducts; in the male the 
 prostrate and vesiculae seminales. In both sexes it supplies the bladder, 
 along the three vesical arteries and the root of the iliac and femoral. In the 
 female the two large branches of the hypogastric plexus, composed of twenty 
 to thirty strands of nerves, pass off from the region of the inferior mesenteric 
 ganglion and end distinctly in the pelvic brain situated on each side of the 
 cervix. In the male these same branches, though less in size, pass to the 
 prostate and semen-sacs, but the pelvic brain I have found is vastly smaller 
 in males than in females. Yet a small dog possesses quite a large pelvic 
 brain on the side of the prostate and ending of the vas deferens. 
 
 The pain in hypogastric neuralgia must be sought for in the anatomical 
 tracts and periphery of the plexus, which will be (a) in the uterus and ovi- 
 ducts, (b) in the bladder, and (c) on the path of the iliaco-femoral arteries 
 (and with the inferior mesenterium), the rectum. Also, since the origin of 
 the hypogastric plexus is inseparably blended with that of the spermatic and 
 hemorrhoidal plexus, we must expect to find more or less pain occurring in 
 the ovaries, testicles, rectum and sigmoid. 
 
 So far as I am aware Romberg was the first to describe the hyperesthesia 
 of the hypogastric in 1840. It is a neuralgic affection manifested by tender- 
 ness and pain in the hypogastric region. There is a sense of pain and drag- 
 ging in the pelvis, i. e., in the uterus, oviducts, bladder and to some extent the 
 rectum. In women the pain is spoken of as dragging, i. e., as if the uterus 
 were prolapsing. The characteristic pain is paroxysmal, periodic, and is not 
 relieved by changes of position. Structural changes cannot be demonstrated. 
 Since it is not practical to separate the inferior mesenteric plexus from the 
 hypogastric on account of their intimate and close anatomic relations, we 
 
HYPERESTHESIA OE THE NERVUS VAS0M0T0R1US 309 
 
 will consider that the hyperesthesia of the inferior mesenteric or hemorrhoidal 
 plexus is intimately blended with hyperesthesia of the hypogastric plexus, 
 the periodic, and is not relieved by changes of position spoken of as hemor- 
 rhoidal neuralgia or neuralgia of the rectum, of which I knew a typical case 
 for ten years. Neuralgia of the rectum in male or female is of an intense 
 character. It is apt to arise at night in an abrupt or sudden manner and con- 
 tinue from a few minutes to an hour or two. It passes away as abruptly as 
 it arises. It creates intense suffering The best relief is opium suppositories. 
 Venereal excesses appear to aggravate it. Coition momentarily relieves, but 
 it returns quickly with more intense vigor than ever. In venereal excess the 
 neuralgia may extend with painful exacerbations along the urethra, especially 
 worse after coition. 
 
 In the range of the sympathetic, neuralgia is frequently followed by sec- 
 ondary effects, as in disturbed circulation, nutrition and secretion. 
 
 The treatment of hyperesthesia of the hypogastric and inferior mesen- 
 teric depends largely on its supposed etiology, It consists in sedatives and 
 evacuants, hydrotherapy, vaginal and rectal douches, electricity, massage 
 and strict diet. 
 
 The neuralgia of the hypogastric and inferior mesenteric plexuses exists 
 almost entirely during sexual life, and especially during its active period, and 
 though no demonstrable structural lesion may be found in the plexus of 
 nerves, yet we must be on the alert to remove all visible physical defects 
 for fear that the neuralgia is the secondary effect of the visible ones. The 
 patient should be treated as well as the disease, for it pertains to the wide 
 moral fields. Some patients, male or female, describe all sorts of pains about 
 the genitals for months, and finally they may suddenly disappear. There is 
 a strange connection, however, anatomically and physiologically, between 
 the nasal mucosa (and the olfactory nerve) and the genitals (and also the 
 rectum). Hence, it may be that valerian and asafetida will be effective 
 remedies. A stimulant such as nux vomica is often very beneficial. The 
 beneficial effects of nux vomica on the hyperesthesia of the hypogastric plexus 
 may be owing to the close relation of the lumbar portion of the spinal cord 
 and the genitals, for nux stimulates the nerves. Some old writers termed the 
 neuralgia of the hypogastric plexus menstrual colic. It must be admitted 
 that many of the neuralgic pains spoken of by patients in the hypogastric 
 regions are obscure and would perhaps fit better in the chapter on visceral 
 neurosis. 
 
 In hyperesthesia of the hypogastric plexus we must include, for conve- 
 nience, the pelvic brain. This is a massive collection of compound ganglia 
 similar to the cervical ganglia and the abdominal brain. It is located on 
 each side of the uterus. It doubtless rules the vaso-motors in the uterus, 
 innervates the uterus to a large extent, and is accountable for innumerable 
 pelvic pains and for the irritable and tender uterus which is better considered 
 in the domain of visceral neurosis. 
 
 Hyperesthesia or neuralgia of the spermatic and ovarian plexuses has 
 occupied the attention of physicans for over a century. Astley Cooper pub- 
 
310 THE ABDOMINAL AND PELVIC BRAIN 
 
 ished a notable work in 1830, and Curling wrote later. Romberg wrote on 
 the subject in 1840. 
 
 In the male the spermatic plexuses of nerves extend from the origin of 
 the spermatic artery, in the aorta, to the testicle — a long, quite rich strand 
 of nerves. The pain exists mainly in the testicle and extends to some extent 
 along the plexus, i. e., in the spermatic cord. The testicle is generally 
 slightly tender, occasionally exquisitely sensitive; some subjects feel the 
 necessity of a suspensory, and feel unable to live without it. Sometimes 
 movements cannot be tolerated and the patient lies in bed carefully protect- 
 ing the testicle from trauma or touching the bed clothing. If the testicular 
 or spermatic neuralgia becomes intense the pains radiate down the thighs into 
 the back, irritability of the stomach and even vomiting arising. Spermatic 
 neuralgia generally has a more profound effect on the mind than other similar 
 neuralgias outside of the sexual field. The subjects become melancholic, 
 iose ambition and become full of hopeless forebodings. Many of the subjects 
 have varicocele in various degrees. Spermatic neuralgia attacks man's sexual 
 domain, the most profound and dominating human instinct, and if it persist, 
 sooner or later the mind becomes deeply troubled. The patient becomes 
 really possessed with a sexual mania. 
 
 The etiology of spermatic neuralgia is not fully known, but it prevails 
 during the state of puberty and manhood. It is a disease of active sexual life 
 only. Cooper, against his will, removed three testicles for spermatic neural- 
 gia and found the gland to be perfectly healthy. Romberg had a case of 
 spermatic neuralgia where the patient insisted, against the surgeon's advice, 
 that the testicle be removed ; however, eight days later the neuralgia appeared 
 in the other testicle, and since it would be only eight days until his coming 
 marriage, he preferred to retain his last testicle. 
 
 I have observed cases of spermatic neuralgia before and after operation, 
 and am opposed to operation unless a palpable lesion exists. In males ure- 
 thral neuralgia is often closely connected with spermatic neuralgia. Such 
 forms are aggravated by coition, and especially excessive venery. Though 
 urethral neuralgia, like other neuralgias, leaves no demonstrable pathology, 
 yet such cases have frequently had a history of gonorrhea, or excessive ven- 
 ery. The passage of graduated sounds, electricity, washing out the bladder, 
 the prohibition of sexual activity, and local applications, relieve. Some old 
 authors, as Cooper, think that these neuralgias belong to a central irritation, 
 but modern investigations would tend to the view that it is a peripheral 
 irritation. 
 
 The subject of ovarian neuralgia is very indefinite. However, it is not 
 intended to deny the existence of such a disease, but the difficulty arises in 
 the diagnosis. It appears to me that the so-called ovarian neuralgia should 
 be brought within the domain of visceral neurosis. For example, every 
 gynecologist of experience has observed an irritable uterus, but it should be 
 designated under the term visceral neurosis and not uterine neuralgia. The 
 pain of so-called ovarian neuralgia passes down on each side of the lumbar 
 vertebrae into the pelvis. The pain is irregular, periodic, exacerbated at the 
 
NEURALGIA OF THE NERVUS IASOMOTORIUS 
 
 311 
 
 menstrual flow, and generally the ovaries are tender. There are certain 
 women who complain of pains in the region of the ovarian plexuses for years. 
 Physical examination discloses at times very little, if any, physical defects. 
 Yet, by close observation and treatment by heavy douches and boro-glycerin 
 tampons, one will fre- 
 quently note improve- 
 ment. The pelvic organs 
 feel more normal than at 
 the beginning, hence we 
 rather favor some form of 
 physical defect, congenital 
 or excessive venery or 
 some pathologic imperfec- 
 tion. With this view, the 
 irritable uterus of Gooch, 
 the most of the ovarian 
 and other visceral neural- 
 gias, will be more bene- 
 ficially considered under 
 visceral neurosis. 
 
 Finally, I wish to 
 state that large numbers 
 of subjects complaining 
 of ovarian neuralgia can 
 be definitely s h o w n t o 
 suffer only from pain in 
 the skin of the hypogastric 
 region — it is hyperesthesia 
 of the periphery of the 
 ilio-guinal and ilio-hypo- 
 gastric nerves. 
 
 Hyperesthesia of the 
 gastric plexus, gastric neu- 
 ralgia, is generally known 
 as gastralgia or gastrody- 
 nia. Much that was said 
 in regard to neuralgia of 
 the abdominal brain ap- 
 plies to gastralgia. Also, 
 it may be better to include 
 many of the considerations 
 of gastralgia in the chap- 
 ter on visceral neuroses. 
 Gastralgia leaves no visi- 
 ble trace of its pathology. 
 But in gastralgia we may 
 
 X-RAY OF DUCTUS PANCREATICUS AND PART 
 OF DUCTUS BILIS 
 
 Fig. 75. This illustration suggests the quantity of 
 nerves — ensheathed by a nodular, fenestrated, anastomos- 
 ing plexus — supplying these channels. 
 
312 THE ABDOMINAL AND PELVIC BRAIN 
 
 look for perverted function of the stomach, as in (a) sensation, (b) secretion 
 and (c) motion. A typical gastralgia is called up in some subjects by taking 
 ice water just following meals; in others, the gastralgia may occur at any 
 time. The chief conditions under which gastralgia is met induces the convic- 
 tion that it is secondary to some visceral disturbances, and hence the subject 
 is better placed under visceral neuroses. 
 
 The Hyperesthesia of the Cervical Ganglia. — Ganglia of such vast size 
 and possessing so much physiologic influence as the cervical must be consid- 
 ered being subject to the same diseases as other similar ganglia. Those who 
 have studied the sympathetic from clinical, experimental and autopsic 
 grounds, chiefly agree that the main pathology is found in the cervical and 
 great abdominal ganglia. The chief influence of the cervical ganglia is man- 
 ifest on the eye, vessels of the head and neck and the heart. 
 
 The Hyperesthesia or Neuralgia of the Cardiac Plexus (Angina Pectoris. 
 Stenocardia, Heberden's Disease, 1768) is a painful affection of the nerves 
 of the heart. It is so far not anatomically definable, but is undoubtedly con- 
 nected with the sympathetic nerve. 
 
 Angina pectoris is a disease based on no one factor, but depends on a 
 group of factors, which appear to have origin in the cardiac plexus. It is 
 characterized by its marked tendency to recur in paroxysms occasionally of 
 intense severity. In one case, a man fifty years of age attended by my col- 
 league, Dr. O. W. MacKellar, the patient was attacked with angina pectoris 
 and died in six hours. Hypodermic injection of morphine did not appear to 
 give relief. In conjunction with Dr. MacKellar, I performed a postmortem 
 on the patient's body fifteen hours later. I found the heart large, dilated, 
 slight fatty degeneration and the coats of the coronary arteries a little thick- 
 ened. The fatty degeneration, the sclerosis of the coronary arteries and the 
 dilatation of the cardiac walls, were distinct enough to be easily observed, 
 but not of a remarkable type. 
 
 One of my patients has suffered attacks of angina pectoris for eleven 
 years. Otherwise she has enjoyed fair health. Angina pectoris originates in 
 the circulatory system, which is ruled by the sympathetic. 
 
 The lesion of angina pectoris is so variable and uncertain that it is impos- 
 sible to designate its pathology. The cardiac plexus is so intimately and 
 closely connected with the abdominal brain, both anatomically and physio- 
 logically, that each involves the domain of the other. In angina pectoris the 
 cardiac plexus and abdominal brain are in such a state of hyperesthesia or 
 irritability that at any time a terrific attack may arise. The attack comes on 
 suddenly, frequently after some brisk exercise or mental activity. John 
 Hunter died in a paroxysm of angina pectoris, brought on by an altercation 
 with hospital authorities. 
 
 The pain begins in the re|fcm of the heart, but rapidly radiates in other 
 directions, especially down the left arm even to the fingers, perhaps by means 
 of the nervous tract made by the junction of the intercosto-humeral (second 
 dorsal) and the lesser cutaneous nerve (nerve of Wrisberg). The patient dur- 
 ing the attack is profoundly affected. The face shows anxious dread and 
 
HYPERESTHESIA OF THE NERVUS IWSOMOTORIUS 313 
 
 fear of impending death. The pulse may be small, quick and irregular. Res- 
 piration is labored, the face is pale and the patient presents a picture of 
 terrible distress. One of my patients required a couple of days to recover 
 from an attack, fearing a recurrence by any active movement. The attacks of 
 angina pectoris are uncertain in intensity, regularity or even in the organs most 
 severely attacked. Hence, the varying accounts of different observers. 
 
 The essential features which we have observed in the attacks are (1) 
 pain in the cardiac region; (2) profoundly anxious feeling of the patient, 
 and (3) disturbed heart action. The disturbed respiration may be due to the 
 terrible pain accompanying the attack. That the paroxysmal pain in angina 
 pectoris arises in the cardiac plexus we do not doubt, but why it arises there 
 and why it is paroxysmal we can only guess, as we are still doing in other 
 neuralgias. If it is due to ossification of the aorta and coronary arteries and 
 consequent pressure on the adjacent cardiac plexuses of nerves, why does it 
 occur so far apart and in such a paroxysmal character? The sympathetic cardiac 
 nerves come from wide areas, hence varied and widely distinct pain. Each 
 of the three cervical ganglia on each side sends a nerve to the cardiac plexus 
 and there repeatedly anastomoses with the vagus. 
 
 There is a form of angina pectoris which has its origin or influence in 
 the abdominal viscera. It is a reflex neurosis. The far-famed experiment of 
 Goltz served as the ground of this view. Goltz's "percussion experiment" 
 consists in tapping the intestines when the heart may be arrested (in dias- 
 tole). This idea serves perhaps to explain deaths from a blow on the pit of 
 the stomach, i. e ., on the belly brain. Hence, disturbance, pathologic con- 
 ditions in the peritoneal viscera, may produce angina pectoris by reflex irri- 
 tation, through the abdominal brain. Angina pectoris seems to be due to a 
 super-sensativeness or over susceptibility of the nervous system. However, 
 Lancereaux found in a case, which died during an attack of angina pectoris 
 from which he had long suffered, pathologic conditions in the cardiac plexus. 
 So far as I have observed cases of angina pectoris, the chief successful treat- 
 ment consists in the diligent avoidance of sudden active exercise, physical or 
 mental. 
 
 There are some different factors in angina pectoris which may be noted, 
 as (a) spasm of the heart and large blood vessels, (b) a pure neuralgia, and 
 (c) a vaso-motor disturbance produced by reflex irritation. In any or all 
 factors it appears that the sympathetic nerve predominates. The abdominal 
 brain may serve as an irritating factor. 
 
 Hyperesthesia of the splenic plexus has not received a description for 
 the reason that it does not produce definite demonstrable symptoms. The 
 plexus of nerves following the large spiral splenic artery from the abdominal 
 brain to the spleen, lying to the left side between the ninth and tenth ribs, 
 must play a significant role in life's action. The section of the large splenic 
 plexus of nerves begun by Jasckhowitz and others demonstrated that the spleen 
 had something to do with the deposit of pigment in various parts of the body. 
 It is evident that the spleen is not a very active viscus in producing pain. 
 Jasckhowitz showed that irritation of the splenic plexus and branch of the 
 
314 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 celiac axis lessened the size of the spleen, while ligation of the splenic 
 plexus distended the spleen. The vasomotor nerves of the abdominal viscera 
 are included in the sympathetic. In several hundred personal autopsies I 
 found the spleen surrounded by peritoneal adhesions in nearly 90 per cent of 
 adult subjects. Hence, it would be difficult to decide whether the pain was 
 not due to the old perisplenitis. But the spleen is innervated from the same 
 source as the stomach, and there is no reason why the spleen may not suffer 
 from neuralgia as well as the stomach. In regard to the neuralgia of the 
 splenic plexus, it will be required to work it out along the line of experiments, 
 and especially on the vasomotor nerves. 
 
 Hyperesthesia of the hepatic plexus or hepatic neuralgia (diabetes mel- 
 litus) is still an obscure subject. The hepatic artery is well surrounded by 
 strands of sympathetic nerves, and being innervated from the abdominal 
 brain or the same source as the stomach, we see no reason why the liver will 
 not suffer neuralgia pains similar to the stomach. We of course exclude 
 from hepatic neuralgia all pain produced by hepatic calculus or demonstrable 
 pathologic lesion, wherever located — in the biliary ducts, gall-bladder or 
 common duct. Again, pain in the liver might arise from some vicious con- 
 dition of the bile inducing a form of colic as it passed through the ducts to 
 the intestine, and, besides, this pain would be of a periodic or neuralgic 
 nature. Hepatic neuralgia signifies pain in the region of the liver possessed 
 of a periodic nature. It may be in hepatalgia the tangible cure is overlooked. 
 Inspissated gall may cause excruciating pain in its passage and be found in 
 the stool in dark flakes. The passage of the dry flakes of gall may be accom- 
 panied by severe pain, nausea, exhaustion and vomiting. The right vagus as 
 well as the sympathetic hepatic plexus, attends on the liver, so we must view 
 the nerve supply of the liver as mixed, but since the vagus below the diaphragm 
 is a demedullated or sympathetic nerve the final action is the same. It is 
 found that certain injuries to the solar plexus make more blood circulate 
 in the liver, and consequently an increased flow of bile. 
 
 Some writers consider that there is a casual relation between hepatic 
 neuralgia and diabetes mellitus. It is very evident among writers that there 
 exist two forms of hepatic neuralgia, viz., one accompanied with pain only 
 in the hepatic nerves, and one with pain and the excessive secretion of gly- 
 cogen (diabetes mellitus). 
 
 Dr. Powell records a case of profuse and obstinate sweating with con- 
 gested liver and diabetic urine. Doubtless the hepatic plexus has power to 
 rule the circulation of the liver to produce congestion and decongestion. Hence, 
 the influence of the sympathetic nerve is very great in diabetes mellitus. It 
 includes hyperemia of the liver, congestion in its capillaries, an influence on 
 the formation of glycogen and perhaps on the ferment necessary for its pro- 
 duction. But since the production of diabetes mellitus is a very complicated 
 process we cannot enter into its details. The influence of the sympathetic 
 in diabetes mellitus is observed in the menopause ; when the hypogastric 
 plexus is passing through a stage of atrophy women frequently have sugar 
 in the urine. 
 
NEURALGIA OF THE NERVUS I'ASOMOTORIUS 
 
 315 
 
 In this sense diabetes mellitus is identical with hepatic neuralgia. By 
 some irritation transmitted over the hepatic plexus the circulation of the 
 liver is increased, and the glycogen may be excessively formed. 
 
 The uncertainty and variability of definite lesions in diabetes mellitus 
 seem to prove that glycosuria may be induced by reflex irritation in the 
 sympathetic. Many physiologists believe that glycosuria is due to hyperemia 
 of the liver. Hyperemia of the liver is controlled by the sympathetic nerve. 
 Just as in facial neuralgia, the region of the nerve involved is surrounded by 
 
 X-RAY OF DUCTUS BILIS ET PANCREATICUS WITH ARTERIA HEPATICA 
 
 Fig. 76. This illustration presents the ducts and vessels richly supplying the liver — 
 each channel is well ensheathed with a nerve plexus. 
 
 congestion or hyperemic vessels, so in hepatic neuralgia, the vessels of the 
 region of the hepatic nerves are followed by dilation and hyperemia and 
 consequent glycosuria. It is not irritation of the hepatic plexus alone that 
 produces glycosuria; irritation of the sciatic is followed by sugar in the urine. 
 Hyperesthesia of the Pancreatic Plexus. — Pain in the pancreatic plexus 
 cannot be located or differentiated from hepatic neuralgia. The late 
 researches of Minkowski would indicate that diabetes mellitus is due to dis- 
 ease of the pancreas. Minowski and Mering have done much valuable labor 
 in the field of the pancreas which will aid in solving the problem of the rela- 
 tion of the pancreas to the diabetes mellitus. 
 
316 THE ABDOMINAL AND PELVIC BRAIN 
 
 Hyperesthesia or neuralgia of the renal plexus, nephralgia (diabetes 
 insipidus) is an affection of the nerves of the kidney unaccompanied by any 
 demonstrable anatomic lesion. The nerves of the kidney are almost entirely 
 non-medullated, i. e., sympathetic. The kidney has the richest nerve supply 
 of any organ in the body except the uterus. The renal artery is abundantly 
 studded with large ganglia, and the nerve strands form a rich network about 
 it. The kidney is closely and intimately connected to the abdominal brain 
 by a large rich plexus of nerves and ganglia. The anatomic and physiologic 
 base for vast influence of the abdominal brain over the kidney is not wanting 
 in abundance of demonstrable sympathetic nerves and ganglia. 
 
 Knoll (1671) observed polyuria after division of the splanchnics. He 
 placed canulas in the ureters and then divided one side at a time, so that he 
 could observe the variation. On the side operated, the urine was considera- 
 bly increased (hyperemia). Some writers claim that neuralgia of the renal 
 plexus is accompanied with excessive flow of urine, polyuria or diabetes 
 insipidus, while others claim that neuralgia of the renal plexus is only accom- 
 panied by pain in the nerves of the kidney and no increase of urine. In 
 neuralgia of the renal plexus all renal calculi are excluded. 
 
 Neuralgia of the renal plexus is sometimes intense and paroxysmal, while 
 at other times it is more continuous and less severe. The pain does not tend 
 to radiate along the ureter as it does in uretral calculus. It is met with in 
 persons exhausted, anemic, gouty, rheumatic and those poisoned with malaria. 
 Exposure to wet and cold are liable to give rise to renal pain. Sedatives, 
 evacuants, alteratives, electricity and massage are remedies employed against 
 the disease. It is very evident among writers that there exist two forms of 
 renal neuralgia, viz., one with pain only and one with pain and increased flow 
 of urine (diabetes insipidus). With a large sympathetic plexus rich in ganglia, 
 there is no reason, except from experiment, why the kidney should not suffer 
 neuralgia similar to the other viscera, as such a condition is recognized in 
 the nerves of the stomach, intestines, ovaries and liver. It is not presumed 
 to exclude cerebrospinal influences entirely. 
 
 However, the renal vessels are ruled by the renal plexus, an almost 
 purely sympathetic apparatus, having its origin in the abdominal brain. 
 
 In diabetes insipidus the characteristic feature does not consist in any 
 especial malnutrition of food, but in paralysis of vaso-motor constrictor 
 nerves contained in the renal plexus and consequent dilatation of renal 
 vessels. This allows excessive blood to remain in the kidney (hyperemia). 
 Much of diabetes insipidus depends on the condition of the circulating blood 
 in the kidney brought out by the force of the heart and constriction or 
 dilatation of the renal capillaries. The beneficial influence of ergot in 
 diabetes insipidus demonstrates that the disease has a vaso-motor origin and 
 maintenance. 
 
 Some writers speak of an idiopathic form of renal neuralgia, which 
 doubtless means that its origin and persistence is not understood. However, 
 as a matter of clinical knowledge, it is very rare to meet with actual renal 
 pain unless there be some pathologic lesion of the kidney or a renal calculus 
 
HYPERESTHESIA OE THE NERVUS EASOMOTORIUS 317 
 
 present. But I have met with persistent pain and tenderness in the kidney, 
 which neither urinary examinations nor renal explorations explained. 
 
 It is not probable that patients will persist for several years to complain 
 of pain and tenderness (sensativeness) in the kidney without some real base. 
 I have followed some for long periods with no discoverable pathologic facts. 
 It is like renal neuralgia. 
 
 The Hyperesthesia of the Diaphragmatic Plexus. — This form of neural- 
 gia has not been described as far as I am aware. The diaphragm is so thor- 
 oughly dominated by phrenic nerves that it is obscured and overlooked. Yet 
 the diaphragm is distinctly influenced by the sympathetic. Very careful 
 dissection will reveal in the human subject a large nerve connecting directly 
 the inferior cervical ganglion, the ganglion stellatum, with the phrenic nerve. 
 Dilatation of the rectum induces the patient to bray like an ass. It induces 
 respiration — the expiratory moan. In peritonitis the experienced abdominal 
 surgeon views with alarm the incipient sighing and irregular respiration. 
 The diaphragmatic plexus supplies and innervates the vessels of the dia- 
 phragm. The ganglion diaphragmaticum exists on the right side only, at 
 the point of junction of the sympathetic and phrenic nerves. The dia- 
 phragmatic plexus is connected with the adrenal and the hepatic plexuses. 
 Doubtless some of the sharp pains on respiration owe their origin to the 
 sympathetic in the diaphragm. 
 

 CHAPTER XXV. 
 
 MOTOR NEUROSES. 
 
 The rectum is guarded by two sphincters, vis., a larger proximal one supplied by 
 the sympathetic, and a smaller distal one supplied by the cerebrospinal 
 nerves. 
 
 "Our greatest danger now in this country is corporation wealth" — Wendell 
 
 Plumps. 
 
 INTESTINAL MOVEMENTS. 
 
 In experiments on various animals and by clinical observation on man 
 we may note various kinds of bowel movements. For the purpose of making 
 the subject more intelligible we may note that the bowel wall is composed of 
 an outer longitudinal muscular layer and of an inner circular muscular layer. 
 The bowel is lined by a mucous membrane and covered by a serous or 
 peritoneal membrane. The arterial supply is carried from the celiac axis to 
 supply the stomach (gastric artery) ; from the superior mesenteric artery to 
 supply the small intestines, the ascending colon and transverse colon; from 
 the inferior mesenteric to supply the descending colon, sigmoid and rectum — 
 in all, three segments supplied by three arteries. The nerve supply to the 
 intestines is from three sources: 
 
 1. The cranial nerve (the pneumogastric). 
 
 2. The spinal nerves, especially those entering at the distal and prox- 
 imal bowel segment. 
 
 3. The sympathetic system. 
 
 The nerve supply of the bowel is a mixed supply of cerebrospinal and 
 sympathetic. In the sympathetic nerve supply of the bowel we must name 
 some four sources, viz. : 
 
 (a) The Auerbach plexus (myentericus externus), situated between the 
 circular and longitudinal muscular layers of the bowel wall. It is a nerve 
 plexus supplying muscles. 
 
 (b) The Billroth-Meissner plexus (myentericus internus), situated 
 under the mucosa. It is a nerve plexus supplying glandular structure and 
 has to do with secretion. 
 
 (c) The abdominal brain (the solar plexus), situated around the origin 
 of the celiac axis, the superior mesenteric and renal artery. 
 
 (d) The lateral chain of sympathetic ganglia, located along each side 
 of the vertebral column. From this chain of ganglia arise the great splanch- 
 nic nerves (three or four). With a mixed nerve supply we must' designate 
 the character of the movement by the nerve which preponderates. The 
 characteristic movements of the bowel are those of a rhythm, rising biowly 
 to a maximum (spasm) and sinking slowly to a minimum (rest). 
 
 The ryhthmic, periodic movement belongs to the sympathetic nerve. 
 
 318 
 
INTESTINAL PERISTALSIS 319 
 
 So that wherever the initiation or inhibition of motion may reside for the 
 bowel wall, it is dominated by the sympathetic nerve, like all other abdom- 
 ina 1 viscera With this mixed nerve supply variously localized we may turn 
 to the physiologic movements of the intestinal tract: 
 
 1. The peculiar peristaltic movements, which consist of a contraction 
 and dilatation of the bowel lumen. — The motion is towards the anus and the 
 contents move in the same direction. The most typical animal which I have 
 examined to study the bowel peristalsis is the rabbit. In the rabbit the con- 
 traction and dilatation of the bowel wall is very rapid, traveling a foot in a 
 few seconds. Of course this rapid traveling cannot force the feces with it. 
 The analward wave is transmitted from one segment of the bowel to the 
 other, in rapid succession. But with the abdomen open and the bowel struck 
 or pinched or irritated, we must think of every successive physiologic action. 
 The peristalsis borders on pathologic conditions. In fact, one can really see 
 that the bowels move in a wild, irregular confusion. By pinching the bowel 
 wall with the finger and thumb or forceps a circular constriction will arise 
 which resembles a pale, white ring, almost closing the bowel lumen, and 
 persisting awhile. This analward alternate contraction and dilatation of the 
 bowel wall is a physiologic process of the bowel, and doubtless is not accom- 
 panied by pain unless there be a diseased segment, when pain may arise. 
 The peristalsis of the bowel is perhaps limited to a bowel with contents, i. e., 
 its contents, or, in other words, mechanical irritation that produces physio- 
 logic peristalsis. In laparotomy if one will observe, the empty bowel is 
 nearly always still unless irritated by manipulation. If one will watch the 
 bowel waves of peristalsis it will be apparent that the peristaltic waves are 
 limited from three to twenty-four inches. A peristaltic wave will start and 
 stop within a localized space. In the dog the peristaltic wave is neither so 
 rapid in its travel nor does it seem to travel over such a long distance. The 
 intensity of peristaltic waves is most marked toward the proximal end of the 
 jejunum where the muscular fibers, blood and nerve supply are large. The 
 bile and pancreatic duct pour their contents into the proximal end of the 
 bowel, and thus impel the peristaltic waves to force the contents distalward. 
 For secretion or the presence of any bowel contents is what induces peri- 
 stalsis. 
 
 2. Another form of bowel movement may be called the pendulum move- 
 ment. This is a contraction and elongation of the longitudinal muscular 
 layer which does not propel the contents analward. The lumen of the intes- 
 tine remains the same. The pendulum movement of the bowel is localized 
 and limited to short stretches of intestine. 
 
 3. A third kind of bowel action is described by Professor Nothnagel as 
 a roll motion. Though recognizing Dr. Nothnagel's keen observing powers, 
 I cannot see anything in the roll motion of the bowel except an excessive 
 physiologic, or, better, a pathologic physiology process. It is, in my opinion, 
 only a wild or stormy peristalsis; when, for example, the blood contents, gas 
 cr fluid, go onward by spells or jerks. The roll motion doubtless includes 
 those peculiar gurglings which every individual now and then experiences. 
 
320 THE ABDOMINAL AND PELVIC BRAIN 
 
 And though this form of bowel motion is not accompanied by pain, yet it 
 seems to border on the pathologic lines. Of course almost all bowel motion of 
 any distinct type belongs to the small intestines. Perhaps one can scarcely 
 ever observe the large bowel motion through the abdominal wall, if it be in a 
 physiologic state. Perhaps the roll motion of the bowel described by Noth- 
 nagel is due to an irregular action of the nerve supply, the movements of 
 which, as Auerbach's plexus, may become disordered. Formerly I thought 
 that the large bowel did not share but a very small part in the excessive 
 activity of blood motion, but recently I found a two-inch "invagination of 
 death" in the* ascending colon of an adult, so that the colon engages in a wild, 
 disordered motion of death when the cerebrospinal system has lost control 
 forever of the bowel motion (sympathetic). 
 
 Peristalsis of the small intestines does not consist of waves starting at the 
 duodenum and extending to Bauhin's valve, but the small peristalsis consists 
 of local waves which start and cease within perhaps six inches to two feet. 
 One may recognize peristaltic waves in the same animal two to three or four 
 feet apart, each going through its wave. Now it appears that bowel contents 
 cause the excitants of bowel peristalsis, and even if one observes a full bowel 
 quiet, it does not necessarily overthrow the idea that bowel contents alone 
 excite bowel peristalsis. Empty intestines are still unless excessively stimu- 
 lated. We must look for the primary anatomical point of motive force of 
 the bowel muscles in Auerbach's plexus. Among the very unsatisfactory 
 experiments are those attempting to find out the location of a nervous center 
 for bowel movement. Prlueger discovered that when the splanchnics are 
 stimulated the bowel motion is prohibited, the bowels become pale and the 
 blood-vessels become narrowed ('anemic) ; but severing the splanchnics induces 
 increased bowel peristalsis, the bowels become more filled with blood and con- 
 gestion occurs. Some assert one thing and some assert another in regard to 
 the influence of the vagus over the intestinal motion. 
 
 Ludwig, Nasse, Kupffer, Mayer and Basch found in the splanchnic prohib- 
 itory and vase-motor nerves, besides nerves which, by stimulation, irritated 
 motion in the bowel. Also Mayer and Basch could, by irritating the vagus, 
 prohibit intestinal movement. Basch and Erhmann believed from experi- 
 ments that the splanchnics were the motor nerves of the longitudinal muscular 
 layer and the prohibitory to the circular muscular layers, and that the vagus 
 stirred up the circular muscles while it prohibited the longitudinal muscles. 
 Fellner claims that he found the nervi errigentes to be the source of longitudi- 
 nal muscular action, while the hypogastric nerves were the motor nerves for 
 the circular muscles. Lately Steinach claims that the motor innervation of 
 the intestinal tract is through the posterior sensitive roots of the spinal cord. 
 The portion of the colon supplied by the inferior mesenteric artery, i. e., the 
 descending colon, sigmoid and rectum, have an analogous supply to the upper 
 portion of the digestive tract. The nerves from the spinal cord pass through 
 the rami communicantes, through the lateral chain of sympathetic ganglia 
 into the hypogastric plexus mesentericus inferior, which plexuses supply the 
 sigmoid, rectum and descending colon. The lumbar region was proven by 
 
PERISTALSIS OF TRACTUS IXTESTIXALIS 
 
 321 
 
 Goltz's experiment to have a motor center for the rectum. In this case the 
 spinal nerves course through the hypogastric and mesenteric plexuses to act 
 as motor nerves for the bowel. The sympathetic nerves and ganglia, the 
 unconscious motors of the assimilating laboratory, work steadily while the 
 
 NERVUS VASOMOTORIUS— GENERAL VIEW 
 Fig 77. The abdominal portion was accurately dissected from specimen under alcohoL 
 
 21 
 
322 THE ABDOMINAL AND PELVIC BRAIN 
 
 digestive tract has any contents. It is entirely analogous to the uterus. 
 When there exist contents in the uterus its walls pass and repass through 
 constant waves, but if it is empty, it is quiescent, it is still. So it is with the 
 bowels, an empty intestine is still a quiet one ; a full one is nearly always in 
 motion. 
 
 Anemia of the intestines lessens the peristalsis while hyperemia increases 
 the peristalsis. Chemically indifferent substances will create bowel motion 
 according to their deviation from the normal bodily temperature. It must be 
 remembered that over distention makes contraction impossible, i. e., tym- 
 panites is paralysis just exactly according to its degree of distention. Tym- 
 panites is accompanied by slight peristalsis but the pain is due to local spasm, 
 especially of the circular muscles. It appears to me that the circular muscles 
 of the bowel can so obliterate the lumen that it practically prevents all pas- 
 sage of contents. Doubtless the muscles would sooner or later tire out and 
 admit of the passages. We may say that it is extremely rare to observe the 
 physiologic bowel peristalsis through the abdominal wall. But it is not at 
 all rare to observe the bowel peristalsis through the abdominal wall in a 
 pathologic state. In the normal state the abdominal wall is so thick, and 
 the change of shape and form of the intestine is so slight that one can seldom 
 definitely mark out bowel peristalsis. In belly walls thinned by wasting dis- 
 ease and muscles thinned and separated by the stretching of the walls one 
 may map out moving bowel coils very easily. Especially is this the case in 
 bowel obstruction. 
 
 Peritalsis of a pathologic character may be (a) an increase of normal 
 movement, (b) tonic contraction, or (c) the so-called antiperistalsis. The 
 rolling motion of the bowel described by Prof. Nothnagel, I would call patho- 
 logic. If one will open dogs with peritonitis there may be observed irregular 
 bowel movements; sharp contraction of both longitudinal and circular mus- 
 cles. In fact the peristalsis has become irregular, excessive, wild. The slow, 
 normal, pendulum movements of dilatation and contraction of gut have been 
 displaced by violent movements. The bowel movement or peristalsis is 
 accordingly violent and wild as the bowel wall is inflamed. One may observe 
 increased bowel peristalsis from (a) irritating foods, (b) from strong doses of 
 physic, (c) in sudden mental disturbances, (d) in neurotic patients, (e) from 
 hot or cold fluids, drinks or foods, (f) in enteritis or peritonitis, (g) especially 
 in intestinal stenosis, (h) the absorption of lead into the system, (i) exposure 
 to cold. It did not appear to me that traveling of dogs increased the peristal- 
 sis, yet in general, motion aids to increase peristalsis. The important tetanic 
 bowel contraction is significant, for in experiment one can observe by pinching 
 a piece of bowel it will contract into a pale white cord, perhaps entirely clos- 
 ing the lumen for all practical purposes. The tetanic contraction slowly 
 yields its spasm, but doubtless is accompanied with terrific pain. For almost 
 every drop of blood is driven out of the intestinal wall and the nerves are 
 pressed in a traumatic state. If neuralgia is a demand for fresh blood, surely 
 this is a typical example. 
 
 Doubtless in the violent pain of lead-colic (colica saturina) the intestine- 
 
PERISTALSIS OF TRACTUS LXTESTINALIS 323 
 
 is contracted to a white rod and the condition of persistent pain depends on 
 various segments being successively attacked. Tonic contraction of the 
 intestine is a frequent condition of bowel stenosis. If one will sit down by 
 a patient with sufficient bowel stenosis to produce obstruction of the bowel 
 contents, by placing the hand on the abdomen he can easily perceive the 
 bowel movements, because in such patients the belly wall is usually thin. The 
 bowel movements are almost constantly felt, they gradually increase until 
 the small intestine may feel as hard as a rolling-pin under a sheet, and such a 
 hard bowel will gradually relax, when the same phenomenon will appear 
 elsewhere. It is quite probable that progressive peristalsis is not accom- 
 panied by pain, no matter how lively it is. But tonic or spasmodic contraction 
 of the bowel can be and is accompanied by the most sickening pain. The 
 chief pain from the bowels (colic) no doubt arises in disturbed or disordered 
 peristalsis. 
 
 Local inflammation in the intestine producing an irritability of the pe- 
 ripheral nerves, induces irregular, disordered and wild bowel contractions with 
 severe pain. Much has been said by writers in regard to antiperistalsis, i. 
 e., peristaltic wave directed toward the pylorus instead of toward the anus. 
 I have studied this subject considerably in an experimental method, but have 
 never been able to see distinctly anything but very irregular antiperistaltic 
 waves. I tried Prof. Nothnagel's claims that sodium salts made antiperistal- 
 sis, and that potassium salts induced peristalsis, but after several trials on dogs 
 to test the direction of the intestine I could not consider it of any practical 
 value, neither could I confirm his assertions. After laparotomy we frequently 
 observe considerable pain, and almost always accompanying this pain there 
 is more or less tympanites. The pain is due to irregular contraction of the 
 intestinal wall. Segments of the bowel become over-distended, which is a 
 kind of partial paralysis and it cannot again contract. This distended portion 
 does not give pain. The pain arises from the non-distended or partially dis- 
 tended segments which are in a state of spasm, irregular contraction and with 
 irritable peripheral nerves. 
 
 Excessive or irregular bowel peristalsis is observed among hysterical and 
 neurasthenic persons. It is recognized by gurgling, splashing or rumbling 
 noises in the abdomen. It arises in neurotic persons, yet the same person 
 generally suffers no unpleasant sensations, except the mental annoyance. 
 The rumbling noise has no especial connection with mealtimes or drinking. 
 If it occurs in women it is apt to be more active at the menstrual time. Men- 
 tal influences seem to play a role, for when the subject works or directs the 
 mental energies away from the phenomenon, the gurgling generally ceases. 
 If the abdominal walls be thin, one can observe the intestinal movements, 
 which are confined chiefly to the small intestines. Other subjective symp- 
 toms generally fail; however, gas may be belched. The diagnosis of excess- 
 ive bowel peristalsis is not difficult if one can observe the patient for some 
 time. The trouble may persist for weeks and normal stools continue during 
 the whole time. Excessive bowel peristalsis may be diagnosed from bowel 
 stenosis by its spontaneous appearance and cessation. 
 
324 
 
 THE ABDOMLXAE AND PELVIC BRAIN 
 
 It seems a characteristic of certain persons to have repeated attacks, and 
 I have observed such attacks for many years in certain persons at certain 
 times, when the mental faculties were either on a sudden tension or embar- 
 rassed. It is reported that an old and valuable servant felt obliged to give 
 up waiting on account of repeated attacks of loud gurgling when she was 
 serving at mealtimes. 
 
 Excessive peristalsis is generally confined to the small intestines. The 
 treatment of excessive bowel peristalsis should be both physical and mental. 
 Hydrotherapy, massage, galvanization of the abdomen and remedies pro- 
 
 DILATED DUCTUS HEPATICUS 
 
 Fig. 78. The dilated hepatic ducts impress with the idea of the quantity of nerves 
 attending the ducts in the form of a nodular, fenestrated, anastomosing plexus ensheathing 
 the channels. 
 
 foundly affecting the olfactory nerve, aid to bring about normal bowel peri- 
 stalsis. As remedies the bromides, arsenic, iron and nux vomica are valuable 
 adjuncts. The regulation of the diet is of first importance. 
 
 Enterospasm is a condition of the bowel in which the longitudinal or 
 circular muscular layers are in a state of excessive contraction. To see an 
 actual demonstration of this phenomenon, the most practical method is to 
 open a rabbit's or a dog's abdomen and by pinching the bowel wall with the 
 
PERISTALSIS OF TRACTUS INTESTINALIS 325 
 
 finger and thumb both the muscular layers will be observed in a state of 
 spasm. The circular muscular layer on being pinched or struck will contract 
 to a small white ring or band. The enterospasm is likely to occur in very 
 limited segments of bowel. If it be primary, it is a motor impulse, but it 
 may be secondary to a sensory neurosis when it is of a reflex nature. In such 
 a case both a motor-neurosis and a sensory-neurosis exists, that is, a mixed 
 neurosis. 
 
 Enterospasm is primarily a motor-neurosis, but is frequently combined 
 with reflex sensory factors inducing severe pain. As a result of the spasm 
 irregular constipation arises. The stool is either long retained or forcibly 
 expelled. Enterospasm may owe its origin to misuse of cathartics, the 
 entrance of lead into the system, mental effects, worms or improper use of 
 foods. Meningitis or disease of the cerebrospinal axis may play a role. 
 
 The treatment of enterospasm consists of opium and evacuants. It is 
 this form of constipation that the old physicians said, paradoxically, opium 
 cured. It cured the spasm and the bowels naturally become regular. The - 
 proper treatment, however, will consist more in diet regulation, colonic flush- 
 ings, in electrical treatment, in bromides, nux vomica, in massage and hydro- 
 therapeutic measures. 
 
 Paralysis of the bowel signifies that the contents are not forced onward, 
 though the lumen is patent; no mechanical obstruction exists. Henrot 
 announces three forms: 
 
 We first have direct paralysis of the bowel from affection of its walls, as 
 after reduced hernia; often trauma, as in laparotomy, after peritonitis, 
 enteritis, etc. 
 
 Second we have indirect or reflex paralysis, as from injury to the testicle; 
 inflammation of a bowel segment, as inflammation of the appendix, pro- 
 duces paralysis of large bowel segments, the irritation being reflected to the ab- 
 dominal brain, reorganized and sent out on the various nerve plexuses, laming 
 the said segments. An abscess in the abdominal wall may by reflex action 
 produce paralysis of a bowel segment sufficient to prevent the onward move- 
 ment of the feces. In many autopsies, experiments on animals or on humans, 
 I have noted where a small perforation had produced paralysis of adjacent 
 segments by spread of peritoneal inflammation. No mechanical obstruction 
 existed. This is what one continually hears of as obstruction of the bowels 
 — it is really peritonitis. The paralysis is due to edema and exudates pressing 
 on the peripheral nerye apparatus of the bowel wall. 
 
 Thirdly, by leaving out of consideration the cerebrospinal lesions we 
 have bowel paralysis from hysteria, melancholia, neurasthenia, from atony of 
 the bowel and from persistent coprostasis. It must be remembered that the 
 symptoms of ileusparalyticus are not easy to diagnose from genuine ileus. 
 In genuine ileus the peristalsis of the bowel is increased on the proximal side 
 of the affected locality. The therapeutic application for any form of ileus 
 depends entirely on the original cause. Should the paralysis depend on some 
 neuroses, the treatment will be regulation of diet, electricity and massage of 
 the abdomen, the careful use of evacuants and moral influences. Colonic 
 flushings are excellent in this form of neurosis. 
 
326 
 
 THE ABDOMINAL AX D PELVIC BRAIN 
 
 Deficient peristaltic action observed in old age and anemic persons de- 
 pends, perhaps, much on exhaustion, and deficient blood of a proper composi- 
 tion. Besides, deficient peristalsis means deficient secretion, and deficient 
 secretion means an empty bowel, and an empty bowel means a quiet one. 
 The parenchymal intestinal ganglia require proper blood to stimulate them 
 to action. The peristaltic movements of the bowels ".re anatomically excited 
 by the distal visceral ganglia, yet they receive and empty feces from the 
 abdominal brain impulses to accelerate or retard the bowel motion. 
 
 McKendrick believes the accelerating nerves of the bowel are from the 
 sympathetic ganglia, while the prohibiting nerves are from the lumbar spinal. 
 
 / v.'t V. v--5v • v V 
 
 FIC. 2. — PELVIC BRAIN. 
 
 NERVES OF THE INTERNAL GENITALS 
 Fig. 79. Illustration of nerves from my own dissections. 
 
 The descending colon and rectum, according to Xasse, receive motor fibers 
 from the plexuses of nerves surrounding the mesenteric artery. The general 
 notions (Fox, McKendrick, Nasse, Bridge, Kolliker) are that the gastrointes- 
 tinal ganglia send motor fibers to the bowel muscle and that these automatic 
 ganglia are stimulated reflexly by fibers running from them to the mucosa 
 (Henle). Hence, a diarrhea is a reflex matter. Pflueger believed that the 
 splanchnics were inhibitory nerves of bowel action, but Basch showed that 
 the splanchnics were inhibitory nerves only in a secondary manner by chang- 
 
I'liRISTALSIS OF TRACT US INTESTINALIS 327 
 
 ing the circulation in the bowel. The motus peristalticus in lead colic is of 
 much interest, as it should lead to the source of bowel motion, but the special 
 action of lead on tissue is not yet settled. However, it belong* without doubt 
 to the abdominal sympathetic. Is the disturbance due to the action of the 
 lead on the sympathetic ganglia? Does the lead act as an excitant on fibers 
 of the splanchnics? Both views may be retained until more precise data 
 exist. Begbie asserts that irritation of the abdominal brain (or, as he says, 
 plexuses surrounding the aorta) induces active movements of the small intes- 
 tines and colon. Valentin discovered that irritation of the fifth nerve pro- 
 duces invariably movements of the small intestines. We must remember 
 that the fifth nerve is par excellence the ganglionic cranial nerve, having eight 
 ganglia situated on its branches. It is really a sympathetic cranial nerve. 
 It is not yet clear what is the influence of the cerebrospinal system over the 
 movement of the abdominal viscera, but observers are agreed that fear, fright, 
 emanations, intensely influence the bowel movements, showing the influence 
 of the cerebrospinal axis on the bowel and sphincters. How much is this 
 due to relaxation of sphincters? As Romberg remarked fifty years ago, the 
 field of influence of the cerebrospinal axis over bowel movement is not fully 
 known. From personal experience we know that ordinarily the passing form of 
 colic, bowel spasm, is due to irritating contents. The irritation of the mucosa 
 passes to the automatic ganglia of the bowel wall, which resents the trauma 
 by muscular contraction ; the consequence is pain. 
 
 The motor bowel, automatic parenchymatous ganglion, is one of the best 
 samples to illustrate the highest degree of independence. The influence of 
 the sympathetic nerve upon the intestines has long been recognized. The 
 long controversy in relation to the influence of the great splanchnic nerve 
 upon the small intestines seems to be more definitely settled. Weber showed 
 some years ago, that the splanchnic exerts an inhibitory action upon the 
 intestines, arresting their movement. Legros and Onimus, however, claimed 
 to show by their experiments that the splanchnic is, on the contrary, the 
 motor nerve of the intestines, and, when stimulated, produces contraction of 
 the intestinal walls. 
 
 Recent experiments made by Coutade and Guyon present very clear 
 evidence that the two muscular layers of the intestine are controlled by 
 nerves of a different origin, the circular layer being controlled by branches 
 of the sympathetic, and the longitudinal by the spinal nerves. The conclu- 
 sions arrived at by these investigators are as follows, to which all experi- 
 menters do not agree : 
 
 1. The sympathetic causes contraction of the circular muscular layers 
 of the intestine and, at the same time, relaxation of the longitudinal muscular 
 coat. 
 
 2. The contraction of the small intestines depends entirely upon the 
 sympathetic, and is wholly independent of the pneumogastric. 
 
 Galvanization of the abdominal brain induces active movements of the 
 small intestines and, to a certain degree, of the large. Anatomic and physio- 
 logic experiments certainly show that branches of the abdominal brain take 
 part in the innervation of the stomach. 
 
328 THE ABDOMIXAL AXD PELVIC BRA1X 
 
 There is a ceratin kind of excessive bowel peristalsis which is disastrous 
 at any age, but especially in infancy. I refer to invagination. One-quarter 
 of all invaginations occur before one year of age, and one-half of invaginations 
 occur under ten years of age. Invagination, telescoping, intussusception, is 
 where one segment of bowel is driven into the adjacent one. Nearly all 
 invaginations are toward the anus distalward, but some report invagination 
 toward the stomach proximalward. Hektoen reports a case of proximalward 
 invagination. Invaginations are especially likely to arise in two classes of 
 subjects, viz.: (a) in children and (b) in persons dying of some cerebrospinal 
 trouble. The invaginations found in autopsies ma}* be called the invagina- 
 tion of death. I have repeatedly found this condition in human and animal 
 autopsies. 
 
 The characteristics of the invagination of death are that the}- are accom- 
 panied by no inflammatory process, no exudates, no congestions or peritonitis, 
 and are often multiple. In one dog, dying of peritonitis, I found four points 
 of invagination close to each other. They were invaginations of about an 
 inch distance each. Several times in human autopsies, I have found from 
 one to four points of invagination. The characteristics of ordinary invagina- 
 tion are that it is accompanied by severe and sudden pain and, if continued 
 long enough, by congestion, exudation and inflammation in the bowel tunics. 
 Finally, the apex will begin to bleed and slough, producing bloody stools and 
 finally peritonitis; and its results are found about the point of invagination. 
 
 Invagination is due to irregular action of the muscles in the intestinal 
 wall. It is due to irregular peristalsis. In children and persons with diseased 
 cerebrospinal systems it appears that the cerebrospinal axis, the higher nerve 
 center, has lost its normal control over the sympathetic, which rules the 
 bowels, and the result is that the intestines assume wild and disordered move- 
 ments. Not only the bowel segments but their longitudinal and circular mus- 
 cles begin to act without harmony, irregular, spasmodic. In infants and 
 children it appears that the cerebrospinal axis has not assumed full control 
 over the sympathetic which rules the bowel muscles. Since invagination 
 constitutes one-third of all forms of intestinal obstruction, regular action of 
 the gut wall assumes an important role. It is curious to note the common 
 localities of invagination. The ileo-colic and ileo-cecal constitute 50 per cent, 
 i. e., 50 per cent of invaginations occurs at the ileo-cecal valve. Thirty per 
 cent occur in the small intestines and 20 per cent occur in the colon. 
 Omitting the region of the ileo-cecal valve as having some mechanical 
 peculiarity tending to invagination, we note that there are more invagina- 
 tions in the small intestines than in the large, which must be due to a greater 
 possession of muscles. 
 
CHAPTER XXVI. 
 GASTROINTESTINAL SECRETION. 
 
 "Youth's Lexicon has no such word as fail." — Bulucr. 
 "It is our hearers zuho inspire us." — I'inet. 
 
 1. Gastrointestinal secretion is a significant and important matter in 
 animal life. Gastrointestinal secretions are under the control of the sympa- 
 thetic ganglia located in the walls of the digestive tract. We designate those 
 ganglia in general as the Billroth-Meissner plexuses (plexus myentericas 
 internus) situated immediately beneath the gastrointestinal mucosa. They 
 rule secretion. We cannot properly separate the submucous nerve plexus 
 from the Auerbach's plexus (plexus myentericus externus) which rules mus- 
 cular motion and is situated between the circular and longitudinal muscles of 
 the gastrointestinal tract. One nerve plexus is a complement of the other. 
 As secretion without motion is of little avail, and motion without secretion 
 is equally futile, peristaltic motion is necessary to sweep onward the food to 
 be attacked by fresh glandular secretion and to eliminate and drain the 
 system from the debris of food. The remnants of the gastrointestinal feast 
 must be removed by peristaltic movements. 
 
 Besides, secretion is doubtless enhanced by the massage muscular con- 
 tractions. The large degree of independence exercised by the sympathetic 
 ganglia, especially at a long distance from the cerebrospinal center, is quite 
 suggestive that there will be local as well as general gastrointestinal mucous 
 secretion. From the very construction and function of the digestive tract 
 we may expect local labors in it. At several localities new and different 
 secretions are added to the onward moving food, so that local and general 
 digestion and secretion must occur. I repeat that secretion and digestion are 
 both local and general in regard to the digestive tube. Yet the whole nerve 
 apparatus of the digestive tract is a delicately balanced matter both as 
 regards muscular and secretory activity. Let us call up matters that 
 daily occur, but are not always interpreted. For example, a person eats 
 some cucumbers or other indigestible and fermentable substance. At the 
 time that the indigestible substance is eaten the bowels may be as regular as 
 clockwork and the feces of semi-liquid character. Ten hours after eating 
 the indigestible substance, when the regular stool is to be evacuated, it will 
 be observed that: (1) the stool is delayed, the desire for stool is checked; 
 (2) if forced evacuation be exercised, the stool will be hard and relatively 
 dry, for want of secretion is manifest by distinctly formed and shaped feces. 
 
 Now what is the cause of this disturbance? The cause is unbalanced 
 secretion due to reflex irritation. The irritation is going on in the business 
 portion of the digestive tract, i. e., in the small intestines. The subject is 
 
 329 
 
330 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 conscious of this disturbance only by a little pain, colic and excessive peri- 
 stalsis. He, however, notices that an excess of gases is being formed and 
 passed per rectum. He may not sleep well, but recognizes an indefinable 
 restlessness. This irritation may be active enough to produce seminal 
 emissions during sleep. The irritation in the small intestines has unbalanced 
 the mechanism of secretion, so that it is called away from the large intes- 
 tine, causing excessive secretion in the small intestine, and hence the dry 
 formed feces in the large. It is very likely that the excessive, deficient or 
 
 DUCTUS BILIS ET DUCTUS PANCREATICUS 
 
 Fig. 80. Drawn from cross section of the pancreatic and biliary duct. The minute 
 glands of Theile may be observed in the walls of the ducts. These are the so-called glands 
 of the hepatic duct. The figure illustrates the vast domain of secretion. 
 
 disproportionate secretions may occur in separate localities of the digestive 
 tract, just as peristalsis of the tract may be a local matter. We know from 
 experiment that peristalsis may arise, continue and subside, limited to a 
 short piece of intestine. 
 
 The view of local disturbance in both peristalsis and secretion sending 
 out its reflex power and disturbing the whole digestive tract is in accord with 
 pathologic data. For example, a perforation of the appendix may so unbal- 
 ance the nerve apparatus as to feel it at the umbilicus. It is a reality. The 
 
SECRETIOX OF TRACTUS INTESTINALIS 331 
 
 secretion of the gastrointestinal mucosa is entirely beyond the control of the 
 will. In secretions we are especially dealing with the sympathetic nerve, for 
 secretions have a close relation to the size of the blood vessels. 
 
 1. All glands receive vessels. 
 
 2. All vessels have nerves to control their caliber. 
 
 The gastric secretion may be reviewed in regard to experimental data. 
 The stomach is supplied with nerves for its muscles and for its glands, as 
 motion and secretion are both necessary for normal digestion. The arrange- 
 ment of the Auerbach and Billroth-Meissner plexuses is similar to the small 
 intestines. The splanchnic nerve is the chief vasomotor nerve, i. e., vaso- 
 dilator and vasoconstrictor. This is important, for secretion in general 
 depends on the blood supply, as may be observed in location in the season of 
 "rut," in glandular congestion. But the gastric glands are ruled by the 
 sympathetic nerves, whose chief origin exists in the abdominal brain. 
 
 It must be claimed, however, that the stomach glands can act independ- 
 ently, from sympathetic influence alone, and also be changed or modified by 
 the cerebrospinal. It is doubtless true that there are not only vasomotor 
 nerves in the spinal cord but that the abdominal brain is a great vasomotor 
 center, in that the abdominal brain regulates the amount of blood to the 
 gastric glands and consequently the amount, and to a certain degree the kind, 
 of secretion of the stomach. Yet there must be secretory nerves in the 
 stomach which belong to the sympathetic. Candor requires the statement 
 that the full knowledge of the nerve supply of the gastric glands is not fully 
 known. 
 
 The independence of the sympathetic ganglia of the stomach is signified 
 by the fact that the chief stimulus to the gastric secretion is food in the 
 stomach. It is asserted by some that stimulating any of the nerves going 
 to the stomach does not influence the secretion, for it it found that secretion 
 will go on under the stimulus of food when all the stomachic nerves are 
 severed. It is claimed, therefore, that the sympathetic ganglia in the 
 stomachic walls are sufficient to act as centers for secretion. This delegates 
 large and significant powers to the sympathetic ganglia. 
 
 The sympathetic ganglia are especially liable to reflex irritation, and 
 nowhere is it more manifest than in the stomach. The gastric secretion is 
 modified by reflex stimuli from the brain, uterus, kidney, testicle, ovary, 
 heart and spinal cord, etc., etc. Emotions play a role in gastric secretion 
 
 The successful treatment of stomachic disease is significant in methods 
 of stimulating the stomach, as irritating its mucous wall, which not only 
 starts secretion, but motion as well. In ordinary stomach diseases there are 
 four factors, viz. : (a) excessive secretion, (b ) deficient secretion, (c) dispro- 
 portionate secretion, and (d) muscular motion. Washing the stomach, 
 irritating its wall with instruments or coarse food, will accomplish much in 
 inducing health. Doubtless this is the action of nux vomica and hot water. 
 The clinging germs should be washed from the dormant stomach wall and 
 the muscular movements must be stirred to excite natural secretions. It 
 has astonished me at the frequent beneficial results of irrigation of the 
 
332 
 
 THE ABDOMIXAL AND PELVIC BRAIN 
 
 stomach. It stirs to more normal rhythm the sympathetic ganglia, both of 
 secretion and motion. Besides, it washes from the stomach wall abnormal 
 matter. The stomach must have rest and repose or it cannot long stand 
 irregular irritation without resentment of the little circulation insults. 
 Hence the distal irritation from a diseased uterus, oviducts and ovaries 
 
 CROSS SECTION OF URETER 
 
 Fig. 81. Presents the tunica mucosa, muscularis and serosa of the ureter, with several 
 nerve ganglia located between the tunica serosa and muscularis. 
 
 sooner or later unbalances stomach function by its regular passage of the 
 traumatic insults to the abdominal brain where reorganization occurs, perhaps 
 with multiplication of effects. The excitation of the diseased genitals has 
 no season of rest, no day or night repose, but at any or all times it rushes and 
 flashes, now tumultuous or turbulent, now pell mell and explosive. There 
 
SECRETION OF TRACTUS IXTESTINALIS 333 
 
 is nothing like a chronic atrophic myometritic uterus to derange and unbal- 
 ance the gastric secretion and motion. 
 
 The stomach is very highly supplied with blood-vessels and nerves, 
 because it is a vast and complicated laboratory, requiring much energy to 
 hold its delicate but active processes in the balanced order. From experi- 
 mental data we may view the stomachic glands as under the control of the 
 sympathetic nerves, i. e., the ganglia in them. 
 
 L v 
 
 

 
 CHAPTER XXVII. 
 SECRETION-NEUROSIS OF THE COLON (MUCOUS COLITIS). 
 
 "You can fool some of the people all the time, and all of the people some of the 
 time, but you cannot fool all of the people all of the time." — Abraham Lincoln. 
 
 "Thinking is the talking of the soul with itself." — Plato 
 
 History notes that Dr. Mason Good gave one of the first communications 
 in regard to the above disease, in 1825, under the name "Diarrhea Tubularis." 
 Woodward collected the literature up to 1879, in the Medical and Surgical 
 History of the War of the Rebellion, Vol. I. Da Costa wrote in regard to 
 the disease, as did also Leyden in 1892. Nothnagel, in 1884, wrote an excel- 
 lent essay on the disease, naming it colica mucosa. In 1884 Krysinski, of 
 Jena, wrote an inaugural thesis on the disease, detailing six cases, and 
 sought to establish as its cause the presence and effects of microorganisms. 
 Leube thought it a nervous affection. Pick has recently written a short 
 essay on the subject. 
 
 Many different names have been applied to this disease on account of 
 the various views as to its causation. If the disease consists of an epithelial 
 inflammation, a catarrh, we may be satisfied with the designation, enteritis 
 membranacea, but should there exist only increased mucous secretion, 
 without inflammation, the terms colica mucosa would be more significant. 
 However, my studies on the subject have induced me to adopt the term, 
 secretion-neurosis. It is possible that there are two ill-defined affections in 
 this field, one being an enteritis and the other a simple increase of the 
 mucous secretion. Autopsies are so rare on subjects dying of secretion-neu- 
 rosis of the colon that no pathological basis is as yet definitely established. 
 An antemortem diagnosis must be confirmed by a postmortem examination 
 before any pathology can be accepted or established. 
 
 All observers agree that secretion-neurosis of the colon is indicated by 
 the peculiar formation and evacuation of the stools. The clinical symptoms 
 are colicky pains and the evacuation of masses of mucus. The mucous 
 masses may consist of flat long bands (even membranes), ribbons, shreds or 
 rolled tubes or scrolls. Some portions assume a spiral form. Some writers 
 assert that the masses are fibrinous, but I have examined quite a number and 
 have never observed fibrin. The mucous masses are white, grayish white, or 
 a color due to the mixing of mucus and feces, yellowish brown. By placing 
 the mucous masses in water they unroll and partially dissolve. However, the 
 peculiar form of the mucous masses may be retained if they are kept in bot- 
 tles of water for several days, as we have noted in one case. The quantities 
 of these masses evacuated by some patients are enormous. A female attended 
 by Dr. Lucy Waite and myself, would occasionally evacuate nearly half a 
 
 334 
 
SECRETION NEUROSIS OE THE COLON 335 
 
 pint of mucous membranes, masses, bands, tubes or unformed substances. 
 In a male the evacuation showed more string or ribbon-like processes. 
 
 All observers agree that women are the chief subjects of secretion-neu- 
 rosis of the colon. Litten estimates that 80 per cent are women, and accord- 
 ing to Kitagawa 90 per cent are female subjects. Dr. W. A. Evans says that 
 of the many samples sent to the Columbus Medical Laboratory 80 per cent 
 are from women. 
 
 I had a typical case in a man 36 years of age, who had the disease for nine 
 years. Some report cases in men and children. I never saw a typical case 
 in a child. Almost all writers agree that women who are subjects of secretion- 
 neurosis of the colon are neurotic, nervous, hysterical or hypochondriac. 
 The men possess a similar neurotic or hypochondriac tendency. I have had 
 several mild cases in men. 
 
 Patients afflicted with secretion-neurosis of the colon have suffered from 
 constipation for long periods previous to the outbreak of the former disease. 
 This#accords with my view that constipation is a neurosis of the colon, or fecal 
 reservoir. The attacks of such patients are irregular, but recur for years. 
 Pain of a colicky nature may suddenly arise in the abdomen and continue 
 until masses of mucus and occasionally feces are expelled. The attacks of 
 pain may be extremely severe, especially when large masses of mucus are 
 evacuated. So far as I can discover, the pain is chiefly located in the 
 transverse and descending colon and the sigmoid flexure; in general, over the 
 left abdominal region. However, when the colicky pain is severe and con- 
 tinuous, the patient may complain of pain in the whole abdominal region. 
 Some of my patients complained of pain running down the legs. Abnormal 
 sensation may arise in the genitourinary organs. After the evacuations of 
 the mucous, slimy masses, especially the larger ones, the patients appear and 
 report themselves to be entirely free from pain. Generally, the larger the 
 mucoid masses evacuated, the longer the patient remains free. However, 
 the colicky pains may be coming on for one or two days before the large 
 masses are expelled. If the evacuation be slight in quantity, the colicky pains 
 are slight, but often continuous. The appetite is generally good, except at 
 the time of attack. An enema will occasionally bring away very large masses 
 of slime. Also, there are patients who pass the mucous masses who do not 
 report nor appear to suffer pain. Hence two classes of patients present 
 themselves, viz.: some pass mucous masses with colicky pains; others pass 
 mucous masses without colicky pains. 
 
 Nothnagel, my honored teacher, the ablest of all writers on the subject, 
 shields himself by adopting the term colica mucosa et c?itcritis membranacea. 
 He acknowledges that a variety of pathological processes are here included. 
 Krysinski and Mathieu are both inclined to consider the affection an enteritis 
 and Krysinski endeavors to show that certain low organisms are the primary 
 cause. It does not seem probable that microorganisms would persist for 
 years ; and besides, were the disease caused by microorganisms we ought to 
 be able to cure it. Krysinski describes patients who simply gave a desire for 
 stool without colicky pains, i. e., merely "bearing down pains." 
 
336 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Much interest is manifested by writers, in the stools in secretion-neurosis 
 of the colon. 
 
 Microscopically, the evacuation consists of membranous or tubular gray 
 masses. They may resemble croupous membrane from the respiratory pas- 
 sages. The mucous masses may be transparent like slime, or opaque like 
 fibrin, of a grayish white, or a dirty color with pigment in it. Sometimes 
 the masses consist of large, wide and thick leathery-like membranes; at 
 other times, long ribbon-like bands or rope-like coils. The mucous masses 
 nearly always come away alone, unmixed with feces. Sometimes they 
 resemble the swollen jackets of baked potatoes. By careful manipulation 
 in water the masses of slime will generally unfold into membranes; hence 
 the term, membranous colitis. They ma}" resemble fascia or tendons, or one 
 may be deceived by milk coagula. 
 
 Microscopically, the mass substance represents a hyaline body, which 
 can be preserved only a short time in air, alcohol or water. Degenerating 
 cylindrical epithelia of almost any grade can be noted. The slimy mass 
 represents a glassy, unformed, transparent substance. If acetic acid be 
 added it assumes a wavy, striped or ground glass appearance. Glandular 
 epithelia are almost always found, shrunken, swollen or vacuolated. . Some- 
 times vast numbers of microbes are present, cholesterin crystals, triple 
 phosphates, fecal masses, pigment and occasionally round cells. 
 
 Chemical examination reveals mucin, or mucin-like material, as the 
 chief constituent. This may be considered as definitely established, as it is 
 confirmed by Clark, Thompson, Perrond, Da Costa, Hare, Pick, Nothnagel, 
 Furbringer, Hirsch, Walter, V. Jaksch, Krysinski, Kitagama, Rothmann, 
 Littre, Vanni, Leube and Pariser, a sufficient number of investigators to 
 settle the question. Some authors assert that mucin is the chief constituent 
 with other albuminous bodies. The only author we have found who claims 
 that fibrin exists in the evacuations of secretion-neurosis of the colon is P. 
 Guttmann, who apparently based his support on doubtful microscopical 
 examination. 
 
 Pathological records are rare, on account of the scarcity of material on 
 which to establish them. Nothnagel reports a case of secretion-neurosis; 
 Rothmann, one which was examined by C. Ruge. Ruge reported that "in 
 spite of careful examination of the whole intestinal tract, nothing abnormal 
 was discovered." The above patient of Rothmann presented a typical 
 picture of colica mucosa, but died from a duodenal perforation. 
 
 Rothmann had another case that died of carcinoma at the base of the 
 skull. The patient was in the hospital from June 14 to Nov. 2, 1892. By 
 taking an enema the patient evacuated large masses of mucus without pain. 
 He made no complaint. The autopsy showed in the transverse colon (where 
 it did not contain feces) and the strongly contracted parts of the descending 
 colon, injected and folded mucosa. Between the folded mucosa lay products, 
 partly membranous, partly strand-formed. The parts of the colon filled with 
 membranes contained no feces. In the ascending colon there were no mucous 
 masses, but feces, with reddened mucosa. In the sigmoid the membranes 
 
SECRETION NEUROSIS OE THE COLON 337 
 
 could be torn from the reddened mucosa without loss of substance. Feces 
 were found in the small intestine, which had reddened mucosa. The chief 
 mucous masses were found in the left half of the transverse colon, descending 
 colon and sigmoid. The microscope demonstrated the mucous masses in the 
 lower colon to consist of mucin, not fibrin. In this case there can be no 
 doubt of the existence of catarrh. Just on this point of catarrh or no catarrh, 
 investigators are divided. 
 
 We have, then, three opinions in regard to the nature of secretion-neu- 
 rosis of the colon, viz. : 
 
 1. That it is an enteritis (catarrh). 
 
 2. That it is simply excessive secretion of mucus (mucous colic). 
 
 3. That it is secretion-neurosis (nervous). 
 
 In general visceral neuroses we have, (1) motor neuroses (motus peristal- 
 ticus); (2) sensory neuroses (hyperesthesia and anesthesia); and (3) secretory 
 neuroses (excessive, deficient and disproportionate secretion). In secretion- 
 neurosis of the colon we have to deal with a patient who has all three secre- 
 tory disturbances, i. e. : deficient, disproportionate and excessive secretion. 
 These patients have generally been long sufferers from constipation (deficient 
 secretion). Then follows disproportion-secretion, but that is not so evident, 
 as it simply produces fermentation. Finally comes the formation of the 
 habit of excessive secretion of mucus. Now, this excessive secretion of mucus 
 arises from the unfortunate habit which the mucus cell had formed during 
 the early but prolonged state of constipation. The mucus cell had learned a 
 bad, persistent, nervous or irritable habit of excessive secretion. After a 
 long-continued bad habit of secreting excessive mucus, the cells were unable 
 to change their mode of life and assume normal action. Hence, as one of 
 the etiological factors of secretion-neurosis of the colon, we will assume the 
 depraved cell habit from reflex irritation. 
 
 A second factor that perhaps plays a chief role is genital disease. Secre- 
 tion-neurosis of the colon is nearly always manifested in neurotic persons of 
 the female sex. Such subjects nearly always have pelvic disease. Every 
 gynecologist knows from actual experience that pelvic disease produces con- 
 stipation, a fore-runner of secretion-neurosis. Constipation may be secondary 
 to genital disease, which, through reflex action, produces in the bowel defi- 
 cient, excessive or disproportionate secretion. Disproportionate secretion 
 induces fermentation, causing gases which distend the bowel, resulting in 
 atony and deranged nerve action in the epithelial cell. Irritation from the dis- 
 eased genitals induces the development of toxins. The toxins affect the tis- 
 sues locally, inducing colitis, if not epithelial catarrh. Besides, the absorp- 
 tion of toxins induces neurasthenia. The diseased genitals reflexly lead to a 
 train of conditions which induce defective nutrition and excretion. The 
 evacuation of glassy, viscid mucus, subsequently followed by grayish shreds, 
 extruded with pain, is pathognomonic of secretion-neurosis of the colon. 
 Gynecologists frequently observe these conditions except the grayish shreds 
 and mucomembranous layers. The pain on defecation may be but slight. 
 
 The first step in the cure of such patients is to relieve the afflicted geni- 
 22 
 
338 THE ABDOMLXAL AXD PELVIC BRAIX 
 
 tals. when improvement often supervenes. In one of my patients suffering 
 from chronic pelvic disease and also typical secretion-neurosis of the colon, 
 many complex neurotic symptoms of an intense character would occasionally 
 arise at the time of the evacuations. She presented paroxysms of pain, 
 intense colic, profound hysterical or neurotic symptoms, rapid pulse, disturbed 
 respiration ; all of which subsided very slowly after the evacuation of mucus. 
 Reflex neuroses of an intense character were present. In the intervals she 
 was quiet, presented none of the acute egoism of the hysteric, and apparently 
 had no desire for attention or notoriety. 
 
 The differentiation of the pathological process in secretion-neurosis of 
 the colon may be aided by (a) the anatomic pathologic findings in autop- 
 sies; (b) by analysis of clinical cases; (c) by examination of the evacuations; 
 and (d) by comparison with analogous processes in other mucosa. We have 
 spoken of the findings of the autopsy and in the evacuations; but too much 
 cannot be said in regard to the correct clinical symptoms. The numerous 
 names applied to the disease show that its clinical symptoms are not definitely 
 agreed upon. 
 
 Colica flatulenta is a close relative of secretion-neurosis, as is also the 
 motor neurosis (motus peristalticus) of the digestive tract. They consist of 
 invisible derangements of the sympathetic nerve. Secretion-neurosis occurs 
 in subjects who can in almost all cases be demonstrated to be neurotics. 
 
 Comparison with similar processes in analogous structures may not clear 
 up the pathology very much. In bronchitis crouposa chronica, a similar dis- 
 ease in a similar structure (mucosa), as in secretion-neurosis of the colon, 
 there is no anatomical change in the bronchial mucosa, as noted by B. Littre, 
 and there is no fibrin present. Klein, Keelson and Beschomer claim that the 
 bronchial membrane and coagula in bronchial croup are thickened mucus or 
 slime. That keen and able observer, Nothnagel, vigorously asserts as a com- 
 parison that the membranes of chronic croup speak against the fibrinous 
 product and inflammatory nature of colica mucosa. However, conflicting 
 opinions still exist in regard to the nature of the membranes in bronchial 
 croup. 
 
 Do we receive any light in secretion-neurosis of the colon by comparing 
 it with dysmenorrhea, which was first described by Morgagni in 1723, and col- 
 pitis membrancea by Farre in 185 s ? The number of terms applied to mem- 
 branous dysmenorrhea, as endometritis exfoliativa, endometritis dessicans 
 and decidua mesenteralis, signifies conflicting opinions. There are at least 
 two irreconcilable opinions in regard to membranous dysmenorrhea, the 
 inflammatory and the non-inflammatory conditions. It appears to the writer 
 that a third view should be introduced, viz., that it is a secretion-neurosis of 
 the endometrium. 
 
 However, it appears quite certain that there are two conditions classed as 
 membranous dysmenorrhea, viz., in one case the membrane consists of fibrin, 
 lymphoid cells and red blood corpuscles— a secretion-neurosis — and in another^ 
 the membrane consists of a cellular infiltrated endometrium— an inflamma- 
 
SECRETION NEUROSIS OE THE COLON 339 
 
 tory process. The second process throws off the endometrium with its blood- 
 vessels, cell infiltration and utricular glands. Hence, under the general term, 
 membranous dysmenorrhea, we are dealing with inilammatory processes 
 (endometritis), and a secretion-neurosis (a fibro-lymphoid membrane enclosing 
 accidentally red blood corpuscles from diapedesisat the monthly congestion). 
 The last process is a perverted nerve-action — a secretion-neurosis of the 
 endometrium. 
 
 In an intensely lymphatic organ like the uterus we would expect more 
 lymphoid elements in the membrane than in the colon. This would account 
 for the fibrin and lymph-cells. Also red blood corpuscles are found in the 
 evacuations of colica mucosa; and they are simply more numerous in the 
 membrane of membranous dysmenorrhea, because of the intense endometric 
 congestion, proceeding to rupture (diapedesis). Again, secretion-neurosis of 
 the endometrium, like secretion-neurosis of the colon, evacuates the mucous 
 membranes with or without pain, and at irregular intervals, showing a sus- 
 tained comparison. 
 
 To say that the above diseases of the colon and uterus are forms of mal- 
 nutrition or deranged innervation means but little. 
 
 In secretion-neurosis of the colon an explanation of the string and net- 
 formed stools may be made from the contracted condition of the irritable 
 muscle of the colon, which is thrown into folds, recesses and grooves, which 
 allow the moulded form of the retained secreted mucus to persist. It may 
 be mentioned that some confusion in diagnosis may arise by the so-called 
 colica mucosa and enteritis coexisting. In other words a catarrh and secre- 
 tion-neurosis of the colon may exist together. 
 
 The prognosis of secretion-neurosis of the colon, is, for life, favorable, 
 but for recovery, doubtful. I have known the disease to continue for nine 
 or ten years, with but slight changes. However, it is very variable in its 
 attacks, and very erratic in its occurrence. 
 
 The treatment of secretion-neurosis of the colon must be directed to the 
 nervous system, by habit, diet, physical and mental exercise, and general 
 moral influences. 
 
 Regular daily bowel movements should be secured by very slight use of 
 cathartics, considerable use of drinking fluids, and diet that leaves a large 
 residue. Baths (medicated) twice weekly are very helpful. I have made 
 some patients happy and helpful to themselves, by urging them to return to 
 their regular business, which have been stopped by other physicians. Cly- 
 sters, and high rectal and colonic irrigations, aid wonderfully in evacuating 
 the mucus. Intestinal antiseptics (HgCl 2 ), slight massage and long rests at 
 night are beneficial. Much moral influence and helpful courage is given a 
 patient, when he is told he will not die from the trouble; for thought concen- 
 strated on the disease makes him much worse — produces pathologic physiol- 
 ogy — particularly because he is almost always a neurotic. Electricity aids 
 physically and mentally. Sexual activity should be especially limited. 
 Clothing should be carefully regulated to avoid sudden changes. 
 
340 THE ABDOMIXAL AXD PELVIC BRA IX 
 
 CON'CLUSION'S. 
 
 I. These diseases should be termed secretion-neurosis or enteritis. The 
 first is of neurotic origin and course. 
 
 Both secretion-neurosis and enteritis may co-exist. 
 
 3. Secretion-neurosis of the colon occurs chiefly in neurotic females. 
 
 4. It is closely associated with genital disease. 
 It is frequently preceded by constipation. 
 The continuation of the disease is partly due to an irritable, vicious 
 
 habit of excessive epithelial activity. 
 
 7. The disease is characterized by colicky pains with the evacuation of 
 mucous masses. 
 
 It is non-fatal, variable, capricious and erratic in attacks, with impos- 
 sible prognosis as to time. 
 
 Microscopically, the evacuations appear as membranous, yellowish- 
 white masses of mucus. 
 
 10. Microscopically, one sees hyaline bodies, cylindrical epithelium, 
 cholesterin crystals, triple phosphates, round cells, various micro-organisms 
 and pigment. 
 
 II. Chemically, the evacuations consist of mucin and albuminous sub- 
 stance. 
 
 12. Secretion-neurosis of the colon is comparable to the secretion-neu- 
 rosis of the endomitrium (dysmenorrhea membranacea) or bronchial croup. 
 
 13. Secretion-neurosis of the colon appears to be limited chiefly to the 
 part of the colon supplied by the inferior mesenteric ganglion, i. e., to the 
 fecal reservoir. 
 
 14. It is a disease of the sympathetic secretory nerves and in analogous 
 to disease of the motor and sensory nerves of the viscera. 
 
 15. Its treatment consists of removing the neurosis, which lies in the 
 foreground, and regulating the secretion, which lies in the background. 
 
 Regulation of diet — especially limited to cereals, vegetables, milk, eggs 
 — exercise in open air. and systematic "visceral drainage" are the essentials 
 in treatment. 
 
CHAPTER XXVIII. 
 
 REFLEX NEUROSIS FROM DISTURBED PELVIC MECHANISM. 
 
 "Eternal spirit of the chainless mind." — Byron. 
 "I 'neasy lies the head that wears the crown.'" — Shakespeare. 
 
 The testimony in favor of the production of reflex neurosis from dislo- 
 cated genitals is ample for the gynecologist. To the physician foreign to 
 gynecology from lack of knowledge and experience, clinical and anatomical 
 facts, comparisons, methods of successful treatment, the domination of the 
 sexual system and instinct and controlling power of genital reflexes over other 
 viscera, in fact, all legitimate arguments of cause and effect, should be 
 presented. Distorted mechanism of the pelvic structures causes genital 
 dislocation. Dislocation of structures compromises circulation by the 
 strangulation of vessels and thus induces malnutrition. Dislocation of 
 structures traumatizes nerve-trunks and nerve periphery, causing pain and 
 reflexes which radiate over nerve-tracks to other viscera and there disturb 
 motion, secretion, absorption and sensation. Tension placed on a woman 
 through dislocated genitals, by compromising circulation and by trauma of 
 nerve periphery, devitalizes her system and exposes her a prey to intercurrent 
 disease and to the great functional neuroses (neurasthenia and hysteria). The 
 gynecologist by removal of the gynecologic dislocation, i. e., the focus of 
 reflexes, can demonstrate that the reflex neuroses will disappear. In view of 
 the prevailing difference of opinion between neurologists and gynecologists 
 as to the consecutive reflex neurosis of genital dislocation a careful weighing 
 of the data is demanded. Careful, comparative examination of gynecologic 
 cases gives a definite series of reflex neuroses. It is admittedly difficult in 
 each individual case to establish genuine genital reflex neurosis. The diagno- 
 sis must be made by exclusion. Improvement of the dislocation and lessening 
 of the reflex neurosis under rational treatment is ocular proof. Certain rare 
 cases arise in which no palpable, pathologic anatomic changes are perceptible 
 and still apparently the gynecologic reflex neurosis exists. There are no 
 exceptions to the rule. If an organ becomes diseased secondarily to genital 
 dislocation through reflex neurosis a correction of the dislocation may not 
 always cure the organ. For example, if a round ulcer appear in the stomach 
 secondary to gynecologic dislocation and consequent menorrhagia, the cure 
 of the genital disease would not cure the round ulcer of the stomach, which, 
 if it bleed profusely, could be excised from the stomach wall, i. e., requires a 
 specific treatment. If a general disease, such as a cardiac valvular lesion, 
 create genital dislocation through congestion, the dislocation may produce 
 reflex neurosis, but cure of the genital lesion does not involve the valvular 
 lesion. 
 
 The logical force of circumstances impresses the practical gynecologist 
 
 341 
 
342 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 that genital disease gradually spreads over the other abdominal and thoracic 
 viscera, disturbing visceral rhythm, circulation, absorption, secretion, and 
 sensation by means of arcs of reflex action. Step by step, through compro- 
 mised circulation, trauma of nerve periphery and infection of the genitals, 
 the woman acquires indigestion due to perverted secretion — excessive, dispro- 
 portionate, or insufficient. Malnutrition and anemia follow from continued 
 indigestion and finally neurosis, the inevitable consequence of progressive 
 disturbed pelvic mechanism. It requires careful observation to discriminate 
 the onward march of genital disease, since many complications arise to throw 
 one off guard, such as lumbo-sacral pain, tenesmus of sphincters (anus, vagina, 
 and bladder), hyperesthesia of the pudendum, tearing and dragging pain in 
 the thighs (anterior branches of lumbar plexus), pain in coccyx, intercostal 
 neuralgia, especially on the side of the diseased genitals, pains in the breasts 
 and irregular muscular contractions. All these are only incidents in the 
 onward march of a disease of dominating viscera, whose reflexes unbalance 
 life's physiologic laboratory. My observation places 70 per cent of disturbed 
 pelvic mechanism on the left side; however, the neurosis shifts from side to 
 side according to the renewed invasions of the genitals by disease. It is 
 significant that the neurosis falls chiefly on the side of the disturbed pelvic 
 mechanism. It is plain that the genitals have quite an independent nerve- 
 supply and also stand in intimate relation to definite regions; in other words, 
 diseased genitals have a predilection for certain nerves and nerve lesions. 
 This fact is patent in the functional crises, at puberty, during pregnancy, at 
 menstruation, and at the menopause. In pregnancy the irritation from the 
 genitals invades the stomach in a physiologic rather than the pathologic 
 degree. The grade of the genital irritation of pregnancy and menstruation 
 seldom reaches a pathologic condition. During puberty, menstruation, 
 pregnancy, and the menopause certain organs suffer, as the stomach, breasts, 
 larynx and thyroid glands. The cranial nerves deserving mention for a 
 special share during the above periods are the trigeminus and vagus, which 
 may manifest not only excessive physiologic activity but an actual pathologic 
 condition (physiology). The lack of mathematical demonstration of the 
 share of the viscera and nerves in the above-mentioned conditions is because 
 this sympathetic disturbance does not occur in ever}' case. The close relation 
 existing between ovarian disease and breast and iliac pain is often noted by 
 the gynecologist, as well as dragging pelvic pain and stomach disturbance 
 in retrodeviations of the uterus. The significant and dominating influence of 
 the genitals on the life of the individual is manifest by the exacerbation of 
 the nervous conditions at puberty, menstruation, pregnancy, and at the meno- 
 pause, i. e., at the sexual crises. If the genitals are healthy, distinct neuroses 
 ''functional) at the above phases of sexual exacerbation give a definite clue 
 to the source of the nervousness. No other viscera except the genitals pro- 
 duce through physiologic activity exacerbated phases of neuroses. The sexual 
 is the most denominating instinct in animal life. The physiologic exacerba- 
 tion of neuroses is the most definite proof of their source, since the pathologic 
 exacerbation of neuroses is so complicated that errors arise in tracing the 
 
DYSMENORRHEA MEMBRANACEA 343 
 
 origin. The coincidence of neurosis and menstruation induced Battey to per- 
 form castration in order to anticipate the menopause. However, it is my 
 opinion he began at the wrong end of the genitals, for nothing stops menstru- 
 ation like removal of the chief part of the organ of menstruation, viz. : the 
 uterus (the oviducts may be left). Menstruation is a vascular periodic wave 
 and belongs to the uterus and oviducts, not to the ovary. Hence, menstrual 
 neuroses are cured by removal of the menstrual organ and not by removal of 
 the ovary. Considerable worth should be placed on certain relations between 
 neuroses and special phases of sexual life. It may be suggested that these 
 sexual phases of exacerbation belong to life during the active existence of 
 the uterus and oviducts, i. e., or the menstrual organs — not during the active 
 life of the ovary, for activity of the latter persists from before birth until the 
 ovarian tissue is worn out at sixty or seventy years. It is an error to per- 
 form castration because the menstrual process coincides with the neurosis. 
 In such a case, should an operation be performed, it ought to be hysterectomy 
 and not ovariotomy ; the organ which induced the neurosis should be attacked. 
 However, it is simple justice to the patient to be morally sure before perform- 
 ing any operation that the organ to be attacked is the definite etiologic cause, 
 for other etiologic factors may arise to unbalance the visceral nerves of 
 woman; a stitch-abscess, a corn, or domestic irritation may simulate genital 
 neurosis. Extreme precaution is required in diagnosing the neuroses of the 
 sexual organs. This fact is observed from the varied time that a neurosis 
 may arise during menstruation. Menstruation is a complicated process; in 
 other words, what is superficially known as menstruation is perhaps only a 
 part of a comprehensive physiologic mechanism. During menstruation we 
 observe swelling of the mucosa of the uterus and oviducts, supposed matura- 
 tion and rupture of follicles (?), and various degrees of congestion of the pel- 
 vic vessels peculiar to the wave movements or vascular pelvic rhythm, 
 indicating blood-pressure. Almost any of the above factors may induce a 
 menstrual neurosis, as the neurosis may occur in the premenstrual, intramen- 
 strual, and postmenstrual period. Some neurotic factors may be displaced 
 by exacerbation, and neurosis arises. The secretion, blood, may occur at, 
 before, or after the highest neural menstrual wave. Menstruation is a change 
 of symptoms in which now one line and now another is put on tension. The 
 tension link manifests the character of the menstrual neurosis. Another 
 factor of menstrual chain, as accentuated by Kirro (1878), is that during men- 
 struation hypertrophy of the thyroid gland occurs, followed by passive conges- 
 tion of the cerebrum and consequent psychosis. Perhaps hemorrhage from 
 the nasal mucosa during menstruation is from congestion due to the sharing 
 of the thyroid in menstruation and its capacious power of blood storage. 
 With the above noted complication and many others it may be observed 
 how careful the physician must be to establish menstrual neuroses or psycho- 
 sis. Continual psychosis can, no doubt, be exacerbated by the menstrual 
 periodicity; also, in the periodic diseases there is frequently a neuropathic 
 constitution that results from congenital defects or existing pathology. For 
 example, who can measure the burden of a woman with non-development 
 
344 THE ABDOMINAL AND PELVIC BRAIN 
 
 and atrophy, i. e., before the uterus was fully developed it was attacked by in- 
 flammation, producing at first hypertrophy and ending in defective growth and 
 atrophy? Such are among the saddest patients in my practice. They suffer 
 not only from dysmenorrhoea and other painful neuroses, but from a psychosis 
 due to inevitable sterility. Rachel mourns and will not be comforted. 
 The nervous irritation issuing from the sexual organs may be from disease 
 or change of blood-pressure; in other words, from functional or anatomic 
 changes. In neurotic individuals the neurosis exists not only at the men- 
 strual wave but also in the intermenstrual time, when pelvic disease is liable 
 to exist. When a certain congruence exists between the neurosis and the 
 menstrual rhythm it is a strong indication that the neurosis is of sexual origin. 
 Experimentally the congruence of neuroses with phases of the sexual organs 
 is demonstrated by the disappearance of the neuroses after hysterectomy or 
 correlation of the uterus and uterine deviations or the destruction of pelvic 
 peritoneal adhesions or the removal of a pelvic tumor. Gynecologists fre- 
 quently note that a neurosis will begin with anatomic changes of the sexual 
 organs and the neurosis exacerbates the sexual disease. The extent and the 
 intensity of the pathology of the genitals may not stand in definite relation 
 to the neurosis. One may observe large ovarian tumors without a trace of 
 neurosis. From this clinical fact some have falsely argued that castration 
 does not cure neurosis because disease of the ovaries does not produce it. 
 There are factors in large ovarian tumors which explain partly, at least, why 
 they do not produce a neurosis. First, the tumor has sufficient room to glide 
 out of the way of pressure; second, the style is sufficiently long to avoid 
 trauma from dragging or torsion of the pedicle ; and doubtless the sensory 
 nerves which supply the walls of the ovarian cyst have been stretched beyond 
 their integrity and have ceased to transmit sensory disturbances. It is the 
 small genital tumors located in the pelvis which are likely to be accompanied 
 by neurosis. Such small tumors have a short style and are liable to dragging 
 and torsion. They are subject to pressure from their immobility. The filling 
 of the bladder and rectum traumatizes them and frequently a neurosis and a 
 small pelvic tumor exist in casual relations. The life and action of nerves 
 cannot be measured by the yard. Extreme neurosis may arise from the geni- 
 tals by an irritation of the clitoris, a slight uterine deviation or a small scar, 
 while no neurosis may be detected from extension, of sarcoma or carcinoma 
 of the uterus or large ovarian tumor. Abdominal or pelvic tumors that give 
 rise to a tendency to neurosis are generally from small, fixed growths (espe- 
 cially located in the pelvis) with short pedicles, situated within the range of 
 trauma by muscular activity and by the expansion and contraction of organs. 
 The excitation or the inhibition of nervous attacks by artificial irritation 
 is known to gynecologists. Mechanical irritation of other viscera seldom or 
 never creates a nervous attack. This experiment indicates that the capacity 
 of the genitals to dominate the nervous system is greater than that of other 
 viscera. I was called in consultation in a typical case — a young woman in 
 whom slight pressure in the ovarian region induced a wild hysteric attack, 
 while vigorous pressure would inhibit it. Such cases, not rare, are a close 
 
SECRETION XliUROSIS IN MUCOUS MEM BRAS E 345 
 
 demonstration of the dominating influence of the genitals over the system 
 and also of the origin of the neurosis. To show how carefully one must dis- 
 criminate the sources and kind of neurosis, a case from Professor Hegar may 
 be placed in evidence. She was a young, non-neurotic individual who had a 
 fist-sized right ovarian tumor with a long style, which allowed extraordinary 
 mobility; when the tumor glided into the pelvis she suffered from pressure 
 and dragging sensations. She complained daily of dragging on the pedicle, 
 pains in the lumbo-sacral region, shoulder, and iliac region. To be relieved 
 from these tormenting pains she besought Professor Hegar to operate on her. 
 She was without fever or pain for the first nine days — well and happy. On 
 the tenth day she was found with tears and sorrow, claiming that all her 
 former troubles had returned, and all embittered because the operation had 
 not relieved her. The neuralgia, the cramps, the pressure, dragging symp- 
 toms, etc., all had returned back. Professor Hegar noted that the patient 
 had fever and, on examining the abdominal incision, discovered a stitch 
 abscess; this was opened and the pains disappeared and returned no more. 
 This was a suggestive case, confirming the rule that when a subject is neu- 
 rotic for a long time any bodily irritation may be set going the old train of 
 neurotic symptoms. In other words, a primary, complex neurosis, long con- 
 tinued, may be initiated by some distant local irritation. The secondary 
 cause may be slight, such as a fright, an abscess, an injury, a disappointment 
 or an exacerbation of disturbances in a menstruation. Doubtless, in the 
 long continued neurosis a disturbed mechanism arises in the nerves, they lose 
 their fine balance of integrity in motion, absorption, secretion, or sensation, 
 and, being in a state of irritability, they are put to riot by any source of 
 attack. It is in such unfortunate cases that the neurologist has lost sight of 
 the primary cause, which was trauma and infection of the genital system, the 
 dominating neurovascular viscera. For example, those who have much 
 toothache know that any disturbance in health, as colds, getting wet, etc., 
 will finally end in the old disease of toothache. The dental nerves having 
 once become chronically unbalanced by trauma and infection, it is easy to 
 light the old flame again. Observe the man who is suffering the remote 
 effects of an ancient gonorrhea, the stricture fires up with a cold, an extra 
 drink of whiskey or slight excess in coition. The old flame in the disturbed 
 urethral mechanism may be initiated by remote secondary causes. The geni- 
 tals are defective and do not resist. Demonstrations, by experiment, can be 
 made to show that the neurosis depends on the genital disease. The reposi- 
 tion and retention of a dislocated or incarcerated pregnant uterus is frequently 
 accompanied by a disappearance of the neurosis, while paresis of the lower 
 limbs or uterine cough allows the pathology to recur and the neurosis is again 
 set afoot. Paint the cervix with AgN0 3 solution and vicious vomiting 
 follows. No doubt can arise as to the cause of the vomiting. But the ter- 
 rific vomiting would not occur by painting other viscera not so richly supplied 
 with nerves, such as the rectum or larynx. Professor Hegar had a case where 
 he could repeatedly check a "uterine cough" or irritable cough by introducing 
 a intra-uterine stem which straightened an anteflexed uterus. In the am- 
 
346 THE ABDOMINAL AND PELVIC BRAIX 
 
 phibia. in dissecting- animals that require a day to die, one can demonstrate 
 ocularly that irritating the rectum, cloaca, will start muscular contractions 
 about the stomach. Doubtless the irritation to the sensory, absorptive and 
 secreting nerves is just as severe but is not so easily seen. But every gynecol- 
 ogist knows that some women with disturbed pelvic mechanism suffer from 
 exacerbated stomach secretion and motion. It is important to demonstrate 
 the causal relations and establish the location at the beginning. This is diffi- 
 cult from the complex, yet somewhat independent, sexual nervous apparatus 
 that gives rise to the neurosis, from the peculiarly highly organized nervous 
 system of women and from the further fact that reflex neuroses are quite 
 indirect and slow in their progressive march. The original cause which may 
 be years old is overlooked in the exciting symptoms. It is not difficult to 
 connect a fresh anal fissure with its accompanying wild disturbance, but when 
 the disturbed pelvic mechanism (the anus and bladder have intimate nerve 
 connection with the genitals) progresses for long periods the cause is buried 
 in the grave of years gone by. Long experience in digital examination is the 
 prerequisite for accurate diagnosis of disturbed pelvic mechanism and for the 
 interpretation of its reflex effect. The disturbed pelvic mechanism, the 
 primary cause of sexual neurosis, begins from simple disturbances in the geni- 
 tals, such as pressure or dragging of nerves. These two conditions may be 
 combined and we cannot always discriminate one from the other. For 
 example, in the frequent vomiting of early pregnancy it is impossible to say 
 whether it is pressure dragging upon the vesical or uterine distension nerves 
 that induces uterine contractions and is followed by vomiting. After drag- 
 ging or pressure (trauma) of nerves has become initiated another more 
 distressing trauma of the genital nerves follows from catarrh, erosions, ulcer- 
 ations, and wounds which expose the periphery of the nerves — all inducing 
 reflexes which radiate to other viscera, unbalancing their rhythm, secretion, 
 absorption and sensation. The compression (trauma) of the nerve periphery 
 arises from dislocation of organs, edema, exudate, or tumor pressure. Such 
 traumatic (compression) neurosis is common in gynecology. 
 
 Compression of the periphery of the nerves may be due to cicatricial tis- 
 sue of both the pelvic peritoneum and subserosium. Rich sources of nerve 
 compression may be found in the inflamed posterior and lateral ligaments of 
 the uterus, as shown by Freund and others. The hyperplastic deposits and 
 subsequent contraction found in the uterus, ovaries, and connective tissue 
 needs but be mentioned to be rocognized. The contracting tissue of the 
 uterus painfully compromises its expansion at the monthly period and the 
 excessive ovarian cicatrices obstruct the expanding ovum and induce painful 
 reflexes. The type of dragging (traumatic) neurosis is observed in sacropubic 
 hernia or uterine prolapse and in retrodeviations of the uterus, the visceral 
 prolapse gradually developing a complex neurosis of the lumbosacral region 
 and thence spreading to unbalance the general abdominal viscera through 
 reflexes of the abdominal brain. Dragging on the style of pelvic tumors is 
 another cause. One may be able to measure, to some extent, the disturbance 
 of dragging on nerves, on over-filled rectum or bladder. I have seen the pel- 
 
NEUROSIS FROM DISTURBED VISCERA 347 
 
 vis, at autopsy, full to the brim with fecea The dragging of free tumors on 
 styles must be considerable, for strangulated axial rotation is not infrequent. 
 The best illustration of suffering from a free tumor on its style is the right 
 kidney. Its dragging and rotation give rise to nausea, vomiting, pain in the 
 back and thigh; excessive, insufficient or disproportionate secretion or absorp- 
 tion in the tractus intestinalis, inducing disturbances of digestion, and to 
 similar disorders in the renal secretion. 
 
 Compression neurosis is indelibly associated with dragging neurosis. 
 With inflamed peritoneal and subserous uterine ligaments reflex symptoms 
 occur on standing, walking, and coughing. The reposition of the pelvic 
 organs and their retention by a support relieves the symptoms. The cicatrices 
 of the cervix and vagina may present compression or dragging neurosis, often 
 accompanied, however, by endometritis, with exposed nerve endings, on 
 which play visceral secretions. In acute flexions connective tissue changes 
 cause pinching of the peripheral nerves, which manifest the neurosis chiefly 
 as dysmenorrhea. In endometritis with exposed nerve periphery the irritat- 
 ing secretions induce painful uterine colic, calling up reflexes which reorganize 
 in the abdominal brain and radiate to all abdominal and thoracic viscera, 
 vitiating rhythm, secretion, and sensation. From the swollen endometrium 
 the uterine contractions are futile to expel the secretions. The uterine con- 
 tractions produce pain by compression of the nerves imbedded in diseased 
 tissue. The gynecologist has a typical case to show the traumatic neurosis 
 of nerves compressed in exudates in the old operations of amputation of the 
 oviduct and ligation with silk, where the silk ligature becomes infected from 
 diseased oviductal mucosa and an exudate arises with monthly exacerbations. 
 It is not uncommon for such cases to last for three years, with terrible com- 
 plex neurosis and untold misery. Hysterectomy cures such cases by stopping 
 menstruation and relapses. If the uterus and bladder become imbedded in 
 exudates their expansion and also that of the rectum is hindered, and severe 
 reflex pains follow. Collection of secretions in the uterus induces contrac- 
 tion to expel them, and in contracting, the uterus drags on the adjacent fixed 
 exudates. All motion of the uterus, bladder, and rectum is accompanied by 
 compression or dragging pains — neurosis from trauma. In connective tissue 
 hyperplasia of the uterus the uterine contractions are often very painful for 
 compression of the nerves imbedded in the cicatrizing tissue. In myosalpin- 
 gitis may be observed the recurring monthly exacerbations, the old train of 
 neurosis from the oviductal colic, from congestion, contraction, or compres- 
 sion; lumbosacral neuralgia, however, the associated uterine congestion from 
 adjacent disease, must not be overlooked. In some cases I have noted 
 terrible neurotic symptoms from the amputated end of the oviduct being con- 
 nected to a loop of a sigmoid by a peritoneal band. In one case in which 
 Dr. Lucy Waite and I operated we found a thin peritoneal band extending 
 from the amputated oviductal extremity to the center of the sigmoid flexure; 
 this woman was bedridden for nearly two years with the most terrible neurosis. 
 The severing of the thin peritoneal band enabled her to recover and gain 
 some thirty pounds six months after the operation, with apparent perfect 
 
348 THE ABDOMINAL AND PELVIC BRAIN 
 
 health. Her neurosis disappeared like magic. Peritoneal adhesions may 
 bind the intestines and genitals together. Irritation of either the genitals or 
 intestines influence peristalsis, and dragging pain and intense neurotic symp- 
 toms often follow in the wake. Visceral secretions and sensations are per- 
 verted. In such cases disturbances are after mealtimes and evacuations, 
 and are caused by the induced peristalsis traumatizing nerves, imbedded in 
 exudates and congesting vessels. In some young women following castra- 
 tion and in some others following the menopause, the pudendum and vagina 
 atrophy. This doubtless is consequent upon vaginitis and atrophy of blood- 
 vessels. The vessels atrophy irregularly (one can observe red, injected 
 patches among the pale ones on the vaginal wall) and this irregularity causes 
 local congestions. In cases of vaginal atrophy coitus enhances the neurosis 
 on account of the narrow and sensitive vagina, and a kind of vaginismus 
 occurs. 
 
 Nervous irritation may be occasioned by exposure of the genital nerve 
 periphery from vaginal catarrh, papillary swellings at the vaginal introitus, 
 or the meatus urinarius externus, or from fissures or erosions about the 
 urethra, pudendum, or anus. Such lesions are often exacerbation by urina- 
 tion, defecation, coitus, or scratching, and may be accompanied by severe 
 neurosis if allowed to persist for a long time. Progressive nervous affections 
 rapidly radiate from the local lesion to the general visceral system. The irri- 
 tation may remain isolated in the nervous system of the genitals for a longer 
 or shorter period, but if long-continued or severe the neurosis eventually 
 spreads to the general nervous system and is followed by indigestion, consti- 
 pation, sleeplessness, and a state of more or less high nerve tension; in other 
 words, a peculiar nervous irritability. Entirely isolated neuroses from the 
 genitals are quite rare because the nervous apparatus of the genitals is so 
 intimately and profoundly connected with both the cerebrospinal and the 
 great sympathetic systems that disturbance in the rich nerves of the genitals 
 spreads over the whole nervous system. 
 
 Besides, the disturbed pelvic mechanism often sooner or later invades 
 the psychical apparatus and directs the mind to the diseased genitals with 
 additional disadvantage to the individual. The general practitioner is very 
 liable to treat the psychical or mental symptoms, forgetting that the disturbed 
 pelvic mechanism is the rock and base of the neurosis. Not infrequently the 
 psychical symptoms play the chief role in the disease. How often does the 
 gynecologist observe the general practitioner treating the psychical or super- 
 ficial symptoms — cardialgia, sacrolumbar neuralgia, or sexual disease with 
 little idea of its etiology — though palpable in the pelvis? In short, the psy- 
 chosis, which has a mental base, and the neurosis, which has a physical base, 
 should be carefully differentiated. However, the psychosis is generally sec- 
 ondary to the neurosis, which latter generally has a palpable pelvic origin. 
 It is what I shall term a vicious sexual circle, viz. : (a) disturbed pelvic 
 mechanism, (b) neurosis, and (c) psychosis. This is accentuated in other 
 ways by Hegar, Freund, Krantz and others to whose excellent labors I am a 
 debtor. More in detail, this vicious sexual circle consists of (a) disturbed 
 
NEUROSIS FROM DISTURBED VISCERA 349 
 
 pelvic mechanism (trauma and infection) ; (b) indigestion (from disturbed 
 visceral motion, secretion, absorption, and sensation); (c) malnutrition; (d) 
 anemia; (e) neurosis, and (f) psychosis. From the disturbed pelvic mechan- 
 ism to the psychosis is a long progressive march, a vicious sexual circle, 
 direct and indirect, due to repeated reflex pelvic storms flashing over the other 
 abdominal visceral plexuses. The viscera (as the stomach, kidney, and liver) 
 possessing the greatest number of connective nerve-cords and hence, the least 
 resistance, will suffer the most in their rhythm, secretion, and sensation. 
 After this vicious sexual circle becomes established there exists a neuropathic 
 condition. Primary and secondary symptoms then become difficult of differ- 
 entiation. Direct and indirect symptoms become mixed and the clinical pic- 
 ture becomes obscured by its complexity. The causal connection between 
 pelvic disease and neurosis (psychosis) becomes darkened and one cannot tell 
 what is primary and what is secondary, especially when the patient comes to 
 the physician late in the course of the malady. It is difficult to pick up any 
 segment of the vicious sexual circle. Action and reaction are equal. We 
 now have the degenerating influence of the general nervous system on the 
 original disturbed pelvic mechanism. In the vicious sexual circle one should 
 never disregard blood losses, as these often play a significant role. An or- 
 dinary monthly period makes women pale and, if slight additional losses occur, 
 the effect is geometrically exacerbated. Excessive, deficient, or disproportion- 
 ate blood supply to the abdominal brain and its automatic visceral ganglia 
 due to reflexes, deranges visceral motion, secretion, absorption, and sensation. 
 It would create in single viscera local disorderly reflexes. Aside from the 
 vicious sexual circle I know of no experimental method to demonstrate it, 
 except the disease itself, which gynecologists see daily. We must, as Hegar 
 observes, be limited to the indexes of its course in order to diagnose and 
 treat it. We must weigh each indication found in the progressive march of 
 symptoms throughout the vicious sexual circle from genital disease. We 
 must have definite stigmata to diagnose hysteria and not call every nervous 
 woman a hysteric. The exclusion method must be employed for each and 
 every diagnosis, and the treatment must include medical, electrical, surgical, 
 and hydrotherapeutic measures as required. Treatment is experimental but 
 should be rational. The rational diagnosis is to first establish some etiologic 
 pathologic factor, and attempt to improve or remove it. Sometimes a second- 
 ary factor, as constipation or gastric disease, requires attention in order to 
 trace our steps to the original pelvic disease. We must attempt to retrace 
 on the links of the causal chain to the swivel where the reflexes began and 
 broke their bounds. Deficient renal secretion may be another secondary 
 symptom which requires improvement before the waste-laden 61ood will cease 
 traumatizing the innumerable ganglia which it bathes. 
 
 In the diagnosis one must observe local diseases in the body which are 
 not of sexual origin. The sexual organs are not the only viscera capable of 
 producing neurosis. Be always on the alert for visceral ptosis, tuberculosis, 
 nephritis, cholecystitis, peritonitis, and appendicitis. Of course, the non- 
 sexual diseases may be coincident with sexual diseases, and both influence the 
 
350 THE ABDOMINAL AND PELVIC BRAIN 
 
 neurosis and general nourishment. Make careful bodily examinations for 
 diseases outside the genitals. Do not overlook heart lesions which allow con- 
 gestions, hepatic sclerosis which induces some ascites, chlorosis which induces 
 general paleness, with a large glandular system, yet coexists with a well-de- 
 veloped panniculus adiposus, headaches, and breathlessness, anemia, etc., etc. 
 In my experience nothing has been so successful as visceral drainage — draining 
 the skin by salt baths, the kidneys by drinking ample fluids, and the bowels 
 by salines, with set hour for evacuation. Drainage of the bowels, skin, and 
 kidneys is the rock and base of the therapeutics which will benefit the vicious 
 sexual circle. It is rational hydrotherapy. Thus, by treatment, we are 
 often enabled to run over one difficulty after another until the etiologic factor 
 is reached, which is disturbed pelvic mechanism, the beginning of the viscious 
 sexual circle. In other words, the microscope aids to diagnose tuberculosis, 
 or mercury to diagnose syphilis. In diagnosis and treatment the gynecologist 
 must always hold in his mental grasp every abdominal organ. 
 
 With the entrance and establishment of the neurosis and psychosis the 
 sexual pathologic circle is completed and persistent rational treatment is 
 required to break it. Now, any segment of the pathologic circle has a degen- 
 erating influence on the others. Pathologic processes can arise in other por- 
 tions of the body, either coincident, independent, or as a result of the 
 pathologic sexual circle. The gynecologist not only should have every 
 abdominal organ in mind but should be able to exclude all other pathologic 
 processes. Among the abdominal organs requiring special care in diagnosis 
 are the stomach and colon. Stomach and colon diseases may lead to reflexes, 
 hypochondria, neurosis, and even psychosis. Note what intense neurosis fol- 
 lows secretion neurosis of the colon (mucous colitis) ; also, that slackening or 
 paresis of the abdominal wall — splanchnoptosia — accompanied by visceral pto- 
 sis and dragging on the mesentery, can lead to lumbosacral symptoms. For 
 example, for years I have noted the hyperplasia of the genitals and hemor- 
 rhage therefrom in' mitral lesions of the heart. In this case the heart disease 
 is primary and the pelvic disease secondary. The genitals show varicose 
 veins and the pelvic disease and hemorrhage may become so severe that a 
 neurosis results. In this neurosis the diseased genitals were only a link in 
 the chain. 
 
 Of course, these conditions — variously known as neurasthenia, neurosis, 
 spinal iritation, or hysteria — may exist without palpable sexual disease, but 
 any gynecologist knows that sexual disease plays an important factor and 
 often enters in combination in their production. 
 
 Bibliography: Professor Hegar, Lohmer, Krantz. 
 
CHAPTER XXIX. 
 
 CONSTIPATION— ITS PATHOLOGIC PHYSIOLOGY AND TREAT- 
 MENT BY EXERCISE, HABITAT, DIET AND "VISCERAL 
 
 DRAINAGE." 
 
 "Noiv is the winter of our discontent made glorious summer by this sun of 
 York" —Shakespeare in Richard III. 
 
 "Literature is the immortality of speech." — Schlcgel. 
 
 Constipation is infrequent or incomplete evacuation of the colon result- 
 ing in fecal retention. 
 
 ETIOLOGY OF CONSTIPATION. 
 
 The etiology of constipation is obscure. One writer alone offers some 
 score of causes. Sluggishness of the bowel, whatever that means, is the 
 most frequently mentioned. The tractus intestinalis is practically under the 
 domain of the sympathetic nerve, nervus vasomotorius. Certain general 
 etiologic conditions may be considered: 
 
 /. Physiology of the tractus intestinalis. In the etiology of constipa- 
 tion four physiologic factors are involved, viz., (a) peristalsis, (b) absorp- 
 tion, (c) secretion, (d) sensation. Any one or all of these functions may be 
 impaired. 
 
 II. Local Causes. — The local causes of constipation may be: (1) splanch- 
 noptosia — inefficient muscular contraction; (2) constriction of some segment 
 of the colon ; (3) collections of scybola or intestinal concretions, as in cecum, 
 sigmoid and rectum; (4) enfeebled contraction of the intestinal muscularis; 
 (5) local disease, as appendicitis, cholecystitis, pelvic peritonitis mesosig- 
 moiditis — producing paresis. 
 
 III. General Causes. — The general causes of constipation are: (1) ineffi- 
 cient function (peristalsis, absorption, secretion, sensation) ; (2) excessive 
 mental or physical activity;- (3) special habits; (4) dietetic errors ; (5) diseases 
 of adjacent viscera; (6) factors which induce dryness of feces from inefficient 
 secretion or excessive absorption ; (7) impaired peristalsis of the colon. 
 
 IV. Anatomy. — The proper function of the tractus intestinalis depends 
 on a normal nerve, blood and lymph apparatus. For perfect physiology, a 
 maximum nerve, blood and lymph supply is required. The muscularis intes- 
 tinalis, as well as the mucosa intestinalis, must be perfect. From frequent 
 diseases (catarrh) of pueritas and consequent defective digestion, with result- 
 ing deficient nourishment, a non-developed and defective tractus intestinalis 
 remains for life. 
 
 Atrophic or infantile segments of the digestive tract (especially the 
 enteron or small intestine, which is the essential segment — receiving the secre- 
 
 351 
 
352 THE ABDOMINAL AXD PELVIC BRAIS 
 
 tions from liver and pancreas) burden the adult. For example, I found in 
 the personal measurements of the enteron in six hundred and five adults that 
 the length of the enteron was, maximum, thirty-two feet ; minimum, ten and 
 one-half feet, and average, twenty-one feet. The enteron (a single segment 
 and the most essential one), the business portion of the digestive tract, varies 
 more than three times its minimum length. These facts demonstrate that 
 the tractus intestinalis is frequently defective in length, in development, 
 nerve, blood and lymph — in anatomy. Abnormally diminutive digestive 
 apparatus may occur. The following recorded data secured by the personal 
 examination of six hundred and five adults, may be suggestive in regard to 
 the anatomy of the tractus intestinalis: 
 
 1. The average length of the enteron in four hundred and fifty-three 
 males was twenty-three feet. 
 
 2. The average length of the enteron in one hundred and fifty-two 
 females was nineteen feet. 
 
 3. Man's enteron averages four feet longer than that of woman. 
 
 4. The enteron increases in length most rapidly a few months subsequent 
 to birth, when it may grow one and one-half feet a month. 
 
 5. The enteron assumes its chief length in early childhood. 
 
 6. The chief variation in the length of the enteron depends on enteritis, 
 compromising the enteronic peristalsis, absorption, secretion, and sensation, 
 and consequently digestion, during early extrauterine life. 
 
 7. Extraordinary lengths of the enteron depend on the favorable condi- 
 tions of a maximum enteronic nerve and vascular supply, with maximum 
 assimilation continued beyond the usual period of enteronic development. 
 
 8. A subject with maximum length of enteron possesses a stronger con- 
 stitution than a subject with minimum length, as he can digest and economize 
 more food. 
 
 9. A maximum enteronic, nerve, vascular, glandular, and muscular 
 apparatus, with similar food, would practically produce a similar length of 
 enteron. 
 
 10. The foods which produce the most vigorous enteronic functions 
 (peristalsis, absorption, sensation, and secretion) are those that leave the 
 greatest indigestible fecal residue, which excites the enteronic muscularis into 
 peristalsis, thus attracting more blood and inciting the enteronic mucosa to 
 greater secretion and absorption — increasing digestion and, consequently, 
 enteronic growth. 
 
 11. General and local disease influence the length of the enteron, 
 especially during childhood, the period in life of rapid enteronic growth. 
 
 12. A child nourished with food which requires vigorous digestion, 
 leaves a fecal indigestible residue, as cereals, would attract more blood to 
 the enteron, enhancing its growth, than one nourished on milk only, which 
 passes through the enteron without inducing vigorous peristalsis, and leaves 
 little indigestible residue. 
 
 13. The human enteron presents colossal differences as to length: Males 
 ll/^ feet minimum, 32 feet maximum = 20 feet; female 105^ feet minimum 
 
DIETETIC QUALITIES OF FOOD 353 
 
 feet, 30 feet maximum = 19/4 feet. This variation of twenty feet is almost 
 equal to the length of an average enteron. The enteron varies over double, 
 or two and one-half times its length. 
 
 14. In adults the relation of the length of the enteron to the body length 
 is as 7.2 is to 1. There is a vast difference between the absolute and relative 
 length of the enteron of man. 
 
 15. The enteron measured in situ is three to six feet less in length than 
 when extirpated. 
 
 16. Different diseases of the enteron may result in elongation or contrac- 
 tion. The above defects are not heredity, but acquired by disease. They 
 will offer a clew to conditions for constipations. 
 
 V. Mechanical. — Constipation may arise from stricture, flexions, perito- 
 neal adhesions, neoplasm, splanchnoptosia, obstruction of lumen. 
 
 VI. Dietetic. — Quality of foods, quantify of fluid, chemical composition, 
 are important considerations. (a) Food must possess sufficient variety 
 (mixed) in quantity, quality, chemical composition, and be ingested at regular 
 intervals. The food should be mixed, however, and possess sufficient indi- 
 gestible matter to leave ample residue to stimulate peristalsis (and hence 
 absorption, sensation, and secretion). An excessive amount of coarse, indi- 
 gestible food will result in an excessive fecal residue, which excessively 
 stimulates peristalsis, absorption, secretion and sensation — resulting in mus- 
 cular fatigue and defective sensibility of the mucosa — consequently reflex 
 action is impaired, (b) Ample fluids at regular intervals should be ingested. 
 For a person of one hundred and fifty pounds three pints daily is required to 
 supply the bodily waste (i. e., for tractus intestinalis respiratorius, urinarius, 
 perspiratorius) ; eight ounces should be drunk every two hours for six times 
 daily. 
 
 Fecal matter is about seventy-five per cent fluid and twenty-five per cent 
 solid. The value of fluids for the tractus intestinalis is evident, because in 
 hot weather, with consequent vigorous activity of the tractus respiratorius, 
 constipation results. The chief value of mineral water is the quantity drunk. 
 Excessive fluids deteriorate digestion; (c) foods should possess chemical 
 qualities. Carbohydrates produce acidity, nitrogenous foods alkalinity, and 
 mixed foods neutrality of the digestive tract. Evacuation of the tractus 
 intestinalis depends on (a) sufficient volume of feces, (b) sufficient volume of 
 fluid contents, (c) the presence of substances which act as a chemical 
 irritant to peristalsis. Dr. Walter Baumgarten attempted to devise a sub- 
 stance which would not only be difficult to absorb, but would retain its 
 watery contents. He adminstered eight grains of the dry, shredded agar-agar 
 three times daily, whence he found the stool increased in volume and watery 
 content. 
 
 VII. Pathologic. — The pathologic impairment of peristalsis, secretion, 
 absorption, and sensation of the tractus intestinalis, must be studied to 
 account for the constipation. 
 
 Chronic peritonitis, an important factor in constipation, is frequently due 
 to chronic peritoneal inflammation. In the major regions of peritonitis tne 
 
 23 
 
354 THE ABDOMINAL AND PELVIC BRAIN 
 
 story of constipation is told. Chronic peritonitis occurs in the oviducts (80 
 per cent), in the ileo-coeco-appendicular region (70 per cent, over right 
 psoas), in the mesosigmoid (80 per cent, over left psoas), in the chole- 
 cyst and right colonic flexure region (45 per cent), between the right kidney 
 and the liver (40 per cent), i. e., muscular trauma on viscera induces ihe 
 migration of germs or their products through the visceral mucosa, muscularis 
 and finally into the adjacent peritoneum inciting plastic peritonitis. 
 
 There may be defective innervation of the muscularis of the digestive 
 tract and abdominal wall (splanchnoptosia). Brain and spinal cord disease 
 (insane and neurotic) and exhausted disease. 
 
 Inhibition of reflex action may arise to check defecation, as from fissure, 
 ulcer, hemorrhoid, operation, painful vesical affections, hypertrophy of anal 
 sphincter. Also constipation is associated with lethargy or sluggishness of 
 the bowels from local peritoneal or visceral inflammation, as appendicitis, 
 ovaritis, salpingitis, cholecystitis, pelvic peritonitis. It is in such cases that 
 opium (a sedative to the local irritation) acts as a cathartic. 
 
 The state of the contents of the bowels is significant as chronic dyspepsia, 
 irregular eating and evacuation and insufficient fluid accompanying the food. 
 
 Anatomic peculiarities may lead to constipation, as elongated cecum, 
 sigmoid, and adherent U-shaped transverse colon, all of which may lie in the 
 pelvis. Much of constipation is a perversion of the sympathetic nerves con- 
 trolling the tractus intestinalis. 
 
 VIII. Sex. — Woman is more liable to constipation than man, because 
 in her the tractus genitalis is violently changed periodically — robbing the 
 tractus intestinalis of its usual quantity of blood (puberty, menstruation, preg- 
 nancy, and pelvic disease) ; (2) woman is less active, more sedentary than 
 man; (3) woman is afflicted with more splanchnoptosia; (4) woman experi- 
 ences more changes in her visceral circulation (during sexual life) than man 
 (physiology and pathology of genitals). 
 
 IX. Age Relations. — In senescence constipation may occur from limited 
 food employed, limited exercise, and limited functions, due to the degenera- 
 tion of senescence. In senility, peristalsis, absorption, secretion and sensation 
 is limited from limited blood supply, due to arterio-sclerosis. In pueritas ana- 
 tomic peculiarities exist. The tractus intestinalis develop irregularly, the 
 nervous system is not in final established control, the mucosa, muscularis, 
 tractus nervosus and tractus vascularis may be defective in development. 
 Catarrh occurs with facility and frequently. The tractus intestinalis is sub- 
 ject to vast vicissitudes of fortune, both in regard to food and attacks of 
 catarrh. Hence its circulatory life — its basic life — is subject to vast, frequent 
 and rapid changes. 
 
 Constipation is a neurosis of the fecal reservoir. It belongs essentially 
 among the affections of the sympathetic nerves. 
 
 The system of nerves (including Auerbach's and the Billroth-Meissner 
 plexuses) which rule the gastro-intestinal tract is strictly in the domain of the 
 sympathetic. However, the physiological manifestations of the nerves ruling 
 the enteron are quite different from those ruling the colon. The nerves ruling 
 
CONSTIPATION BELONGS TO THE COLON 355 
 
 the enteron act with intense vigor and great rapidity. The nerves ruling the 
 colon and rectum act with moderate force and very slowly. The enteron 
 rapidly forces the contents of Bauhin's valve in a few hours. The nerves of 
 the colon and rectum act slowly, evacuating the fecal reservoir usually once 
 every twenty-four hours. 
 
 The changes in the physiological action from the vigorous, rapid motion 
 of the enteron, to the moderate, slow movement of the colon and rectum, 
 must be due to the intervention of the inferior mesenteric ganglion, located 
 at the root of the inferior mesenteric artery, which emits its radiating 
 branches along the inferior mesenteric artery, supplying the left end of the 
 transverse colon, the left colon, the sigmoid flexure and rectum. The right 
 colon and the right half of the transverse colon are supplied by the abdominal 
 brain, sending branches along the superior mesenteric artery. Now, it is 
 quite probable that the slow movement of the nerves belongs entirely to the 
 left colon, sigmoid and rectum, which is entirely supplied by branches of the 
 inferior mesenteric ganglia. 
 
 Hence, for the regular periodic evacuation of feces, a habit established 
 by ages, we must look to the immediate rhythmic control of the inferior 
 mesenteric ganglion. This is in accord with the idea that the stool, before 
 expulsion, lies in the sigmoid and rectal ampulla. That the portion of the 
 bowel concerned in evacuation is under control of a nervous mechanism, may 
 be inferred from the fact that a person can establish almost any definite hour 
 for regular defecation. A person can sometimes restrain the stool without 
 difficulty for several days. For the cause of constipation we must look to a 
 peculiar nervous disturbance in the peristalsis, absorption, secretion, and sen- 
 sation of the colon, or of that part of the colon supplied by the branches of 
 the inferior mesenteric ganglion. 
 
 In constipation the feces are found in the colon and not in the enteron. 
 This abnormality of the colonic innervation may be congenital, or acquired. 
 Some individuals are constipated from childhood. A boy of fifteen came to 
 my office a short time ago who had never had a stool from babyhood onward 
 without a rectal injection, or some strong physic. By careful examination it 
 appeared that neither the cerebro-spinal nor the sympathetic system was fully 
 or completely developed. However, in a month, from physical procedures, 
 select food, ample fluid at regular intervals, massage, rectal injections, vigor- 
 ous riding and regular stool hours, we secured a habit of daily evacuation. 
 Here, doubtless, the trouble was congenital — deficient and imperfect develop- 
 ment. Depressing mental affections derange the regular bowel action. How- 
 ever, in constipation accompanying melancholia, or mental disturbances, it 
 seems to me that it is impossible, at present, to decide which is the cause and 
 which is the effect. To illustrate the influence of the nervous system over 
 bowel evacuation, observe how a railroad journey, a change of locality, 
 festival and change of labor, affect a constipated condition. Besides, autop- 
 sies of persons dead from other diseases teach that in constipation seldom 
 can structural lesions be demonstrated. The chief features of habitual consti- 
 pation tend to show that the abnormal condition must be sought in a neurosis 
 
356 THE ABDOMINAL AND PELVIC BRAIN 
 
 of the colon (especially to the left colon, the sigmoid and rectum). The 
 exact nature of the colonic affection is unknown. Another factor in constipa- 
 tion is that though the nervous system of the colon be fairly developed, yet 
 the muscularis of the colon is not normally developed. There is atony of the 
 colonic wall, well expressed by old Latin authors as atonia intestini. But in 
 this case perhaps the colon muscular atrophy refers to the nerves, as they 
 control the lumen of the blood-vessel, which is the real nourisher and instiga- 
 tor of function. 
 
 In regard to the relations of the skeletal muscles to the intestinal muscles, 
 in constipation, we maintain that they are entirely independent of each other, 
 except mechanically. 
 
 The subject with the most weakened and miserable condition of the 
 skeletal muscles may be absolutely regular in bowel evacuation, or may suffer 
 severe constipation. Of course, we must not omit the mechanical influence 
 of the abdominal muscles in defecation. The abdominal muscles increase 
 the intra-abdominal pressure, and thus aid evacuation, but it is not likely that 
 they increase peristalsis. Perhaps in general the skeletal or intestinal mus- 
 cles play but a small role in constipation. The matter lies closer to the nerv- 
 ous system. 
 
 Bouveret and Dunin have claimed that habitual constipation was a 
 frequent accompaniment of general nervousness, especially of neurasthenia; 
 that the neurosis was the constipation, not the constipation the cause of neu- 
 rosis. This idea is apt to prevail with most force among those physicians 
 who, in curing the patient of the general neurosis, neurasthenia, have seen 
 the constipation disappear. Fleiner asserts that stool retardation is due to 
 spasmodic contraction of the colon segments, grasping their contents. This 
 would make the trouble depend on the nervous system. 
 
 The mechanical conditions that induce constipation will not be here con- 
 sidered, except so far as their purely nervous mechanism and influence is 
 concerned. Hence, such factors as strangulation by peritonize bands and 
 through apertures, and the mechanical difficulties of splanchnoptosia and 
 pressure of abdominal tumors, are not here discussed. However, we must 
 not overlook the obstacles placed in the way of the intestinal nerves by 
 inflammation of any one of the bowel coats, or tunics, as peritonitis, or 
 Inflammation of the muscularis, or of the mucosa. As abdominal surgeons, 
 we well know that acute peritonitis produces immediate constipation, check- 
 ing peristalsis by edema, congestion and exudation, into one of the bowel 
 tunics, especially the peritoneum. The peripheral bowel nerve apparatus is 
 deranged by pressure, infection and malnutrition. It may rapidly recover. 
 But, doubtless, a crippled and defective condition frequently remains — non- 
 mechanical. As a result of peritonitis or inflammation of any one of the 
 bowel tunics, producing habitual constipation, we must especially examine 
 the flexura coli lienalis and the flexura sigmoidea. Not infrequently the 
 action of the distal end of the diaphragmatic muscles produces inflammation 
 of the left colon, by inducing migration of microbes through muscular trauma. 
 
 Also the conditions disturbing the rectal nerves must be considered as 
 
CONSTIPATION DUE TO DIMINUTIVE VISCERA 357 
 
 causing congestion and results. In constipation we only include the colon 
 segment supplied by the branches of the inferior mesenteric ganglion. It 
 must not be supposed for one moment that peritonitis around the evacuating 
 fecal depository is always recognized. Far from it, for in some six hundred 
 recorded adult autopsies I found evidences of peritonitis in the peritoneum of 
 the left colon in fully eighty per cent of subjects. In fact, in the mesosigmoid 
 alone there was about seventy-five per cent of peritonitis. 
 
 X-RAY OF DUCTUS BILIS ET DUCTUS PANCREATICUS 
 
 Fig. 82. This illustration suggests the quantity of nerves required to ensheath the 
 ducts and vessels of the liver and pancreas as fenestrated, nodular plexuses. 
 
 Constipation may arise in some persons from deficient or abnormally 
 small abdominal brain, or from premature senility in the abdominal 
 sympathetic, which innervates the gastro-intestinal tract; also from cerebro- 
 spinal disease, which inhibits sources of energy. Exhaustion, mental or 
 physical, is a potent factor in constipation. A deficient blood supply to the 
 
358 THE ABDOMINAL AND PELVIC BRAIN 
 
 parenchymal ganglion does not invigorate it sufficiently to induce peristalsis. 
 Exhaustion from over-exertion, excessive sexual action, or extra loss of blood, 
 is a common cause of constipation in young women. Depression from disap- 
 pointment, from death, from unrequited love, and many other causes, is quite 
 apparent in the youthful, producing constipation — a purely nervous phenom- 
 enon. 
 
 Constipation in lead colic is a nervous phenomenon, apparent in the 
 intestinal pain, and in the white ring-like contraction of the circular bowel 
 fibers. The etiological factor is the irritation of the parenchymal ganglia of 
 the bowel wall by the lead. Spasm, irregularity of inertia, characterizes the 
 bowel in lead colic, except in the etiology. 
 
 Violent and persistent constipation depends on perverted muscular action, 
 peristalsis, absorption, sensation or secretion, due in general to some defi- 
 ciency of nerve force. Colonic inertia may rest on deficient blood supply to 
 the parenchymal ganglia, but this is directly under the control of the sympa- 
 thetic, which holds sway over the vessel's caliber. 
 
 It must always be borne in mind that the size of the sympathetic differs 
 very much in different individuals. When a small-sized visceral nervous sys- 
 tem becomes impaired, as it easily will, its phenomena are not only marked, 
 but difficult to correct. A large dose of digitalis slows the heart, and whether 
 the spinal accessory or vagus, digitalis inhibits its action. Nothnagel sug- 
 gests that opium works similarly on the splanchnics, i. e., by slowing peris- 
 talsis. 
 
 The movements of the enteron are largely dependent on the amount of 
 blood in the intestinal wall i. e., the amount of fresh blood which supplies 
 the parenchymal ganglia. 
 
 In regard to antiperistalsis, in scores of experiments on dogs, rabbits, 
 guinea-pigs, etc., I saw no such a phenomenon. The vomiting in ileus para- 
 lyticus or peritonitis maybe due to simple contraction of the stomach on the 
 enclosed contents, when the fluids pass through the esophagus in the direction 
 of the least resistance. The monstrously large, wide cecum of herbivora, a 
 vestigial stomach, as in the cow and horse, is emptied by peristalsis and not 
 by antiperistalsis, as noted by Jreper. It may be that the peristalsis is 
 increased in diarrhea, yet it may be just as active in constipation, but in this the 
 colonic movements are vain and futile, from inability to force the contents 
 into successive new segments, for an empty bowel is a still one, and a full 
 bowel is an active one. Also active peristalsis will invite more blood into 
 the bowel wall, which, in turn, induces active motion in the segments. 
 Doubtless, herein lies the value of abdominal massage. Whatever checks the 
 flow of fresh blood to the bowel wall slows peristalsis, and this explains the 
 constipation of anemia. 
 
 The natural secretions, as the bile and the pancreatic fluids, are, perhaps, 
 sufficient alone to excite the parenchymal ganglia to action, with but little or 
 no aid from the splanchnics. Hence, from the inactive hepatic and pancreatic 
 secretion, constipation may result. Consequent swelling of the mucosa from 
 catarrh, in the bile ducts, may exclude the bile from other channels, which 
 would deprive the parenchymal ganglia of their accustomed stimulus. 
 
CONSTIPATION DUE TO PERVERTED FUNCTION 359 
 
 The relations of adjacent viscera and their condition may influence con- 
 stipation. If the accustomed secretions, bile, pancreatic and gastrointesti- 
 nal, diminish, the bowel will not receive the impulse which the normal amount 
 of secretions impart, and peristalsis partially fails. Diarrhea may be insti- 
 gated by congestion, then by edema and, instead of infiltrating the bowel 
 wall, the result may be rapid exudation and diarrhea. 
 
 Increased peristalsis, however, is not necessarily accompanied by 
 increased secretion and exudation. The irritation which produces the peri- 
 stalsis may so irritate the parietal intestinal ganglia as to lessen the caliber of 
 the blood vessels and thus check secretion. In administering certain purga- 
 tives it is found that they are followed by watery evacuations. But this may 
 be due to exalted peristalsis of the bowel, allowing insufficient time for 
 absorption, e. g., in times of quiet peace in the bowel secretion and absorp- 
 tion balance each other; but if segments of the bowel become irritated by 
 cathartics, the secretions may become very much increased. Yet, owing to 
 the vigorous peristalsis, the fluids are rushed distalward, not allowing sufficient 
 time for absorption. 
 
 Constipation is generally a form of neurosis, which may partake of a 
 sensory, motor of secretory nature. It may, however, have a complex course 
 and origin. Constipation is a condition in which the colon is not evacuated 
 daily, except by the aid of evacuants, rectal injections or physical procedures. 
 The great majority of the human family having a daily bowel evacuation 
 establishes the normal frequency at once a day. Exceptions to this rule may 
 t>e observed in certain individuals who have two stools daily, others one stool 
 in two or three days, while again Pick reports patients who have one stool a 
 week. A doubtful report was made by Dr. Robert Williams, where a woman 
 had four bowel movements a year, three months apart. 
 
 This irregularity or deviation from normal defecation, need not neces- 
 sarily be based on demonstrable pathological conditions. In constipation we 
 have several elements to consider, the mucosa, the muscularis, the blood-ves- 
 sels, the serosa, and the nerve supply. 
 
 Perhaps the greatest etiological factor of constipation is enteritis, catarrh 
 of the colonic mucosa. This would involve the secretory nerves. In fact, 
 catarrhal diseases of the colonic mucosa are the active factors in ever-chang- 
 ing forms of constipation and diarrhea, which, doubtless, involve the secretory 
 nerves more than the motor nerves. Of course, the regularity of stool 
 depends very much on the quality and quantity of food ingested, for if the 
 food leaves no residue it will conduce constipation, for the greatest of all 
 stimuli to colonic motion is food in contact with the intestinal mucosa. The 
 peripheral nerves of the intestinal mucosa receive impetus and sensation from 
 the analward moving fecal remnants. 
 
 The chief influence in constipation is the blood and food. The formation 
 of the stool depends mainly on the relation of the solids and fluids introduced 
 into the stomach. 
 
 A close relation exists in constipation between the quantity of food 
 ingested, and the resulting fecal residue, which actively counts in treatment. 
 
360 THE ABDOMIXAL AXD PELVIC BRA IX 
 
 Water is one of the best adjunct evacuants. An exclusively milk diet may 
 create constipation, because the small residue is insufficient to excite peri- 
 stalsis through the peripheral nerves. If milk creates diarrhea, it is likely 
 from some sudden development of germs, or fermentation. The utility of 
 graham bread in curing constipation lies in the fact that a large indigestible 
 residue remains, inducing colonic contraction; its contained salts either invite 
 fluids or excite peristalsis, both resulting in a kind of massage, or acting like 
 a foreign body to the mucosa. 
 
 The habits of life are closely associated with constipation. Society 
 women and traveling men, with irregular ingestion and habits, are liable to 
 constipation. Sedentary habits, deficient exercise and excessive mental work, 
 tend to produce constipation. The use of narcotics, deficient drinking of 
 water, active perspiration and uncomfortable closets play a role in inducing 
 constipation. Excessive eating or excessive ingestions in the gastrointesti- 
 nal canal may lead to atony of the intestinal wall, and consequent constipa- 
 tion. The causal relation of constipation must be sought in the digestive 
 tract itself, in the quality and quantity of food ingested, in the habits, in the 
 relations of other viscera. 
 
 In certain cerebro-spinal diseases, the sensory nerves of the intestinal 
 mucosa may be obtunded or blunted, so that the ordinary peristalsis is not 
 excited by the ordinary stimulus of food residue. The peripheral sensory 
 apparatus of the mucosa does not perceive the usual stimulus, and the bowels 
 become torpid. This is common in certains form of hysteria, or better, vis- 
 ceral neurosis. In melancholies and hypochondriacs the barometer of their 
 spirits seems often to tally exactly with the bowel activity. The greater the 
 activity of their bowels the more lively and natural their mentality. But it 
 must not be forgotten that constipation is often occasioned by the mental 
 condition. We know personally that vomiting may be induced by a physical 
 cause, or by a mental one. Some will vomit from seeing a fly in the soup. 
 So it is with a genital neurosis, it may create constipation, or may induce a 
 local neurosis by bathing the innumerable ganglia with waste-laden blood. 
 If secretion be deficient, absorption continues, the feces harden, form an 
 increasing plug, and becomes such an impediment that even vigorous peri- 
 stalsis will not produce the analward movement required. 
 
 Heredity and congenital ailments play a role through the defects in the 
 nerves of the intestines. We deal here chiefly with the purely nervous influ- 
 ence, as the intestinals of the cachectic may be confined, or may act very 
 irregularly. Persons with defective nervous systems, as idiots and the insane, 
 suffer from constipation. The ill-defined hysteric person, or the neurotic 
 subject, is painfully afflicted with constipation, with sluggish bowels, and 
 some of these very subjects are continually complaining of colicky pains, 
 which are to be interpreted as vain attempts of peristalsis to force the bowel 
 contents analward. 
 
 In constipation splanchnoptosia plays its role by flexing the intestine, 
 producing conditions which require more vigorous peristalsis to overcome; in 
 short by compromising the bowel caliber. In splanchnoptosia the hepatic 
 
FECAL RESERVOIR— PART OF TRANSVERSE COLON 361 
 
 and splenic flexures are both made more acute by the consequent dragging of 
 the ligamentutn hepatico-colicum et phrenico-colicum sinistrum. 
 
 Relaxed, pendulous abdominal walls are incapable of exerting normal or 
 sufficient pressure on the tractus intestinalis to control circulation (lymph or 
 blood) or to expel the feces. 
 
 The fecal reservoir, as previously stated, is the left half of the transverse 
 colon, the left colon, the sigmoid and rectum, the field ruled by the inferior 
 mesenteric ganglion. It has been asserted by my respected teacher, Noth- 
 nagel, that constipation is relatively frequent in comparison with the rarity 
 of peritoneal fixation. I wish respectfully to differ from this excellent and 
 instructive Viennese teacher. In some six hundred personal autopsies I found 
 peritonitis in the fecal reservoir in at least eighty per cent of the subjects. 
 This peritonitis, due to two causes, viz., traumatic muscular action of the 
 psoas magnus on the sigmoid, and of the distal left limb of the diaphragm on 
 the left colon, which induces migration of pathologic microbes to the serosa; 
 and the abrading of the mucosa of the fecal reservoir at the flexures (splenic 
 and sigmoid), allowing the wound to become infected, and the migration of 
 pathogenic germs to the serosa. 
 
 Nowhere in the body is infection from the mucal abrasion more definite 
 than at the ligamentutn phrenico-colicum sinistrum. In six hundred adult 
 autopsies we found that the fecal reservoir was afflicted with peritonitis 
 in more than eighty per cent of the cases. Did eighty percent of these cases 
 suffer from constipation? We think not. Therefore, according to our six 
 hundred autopsies, peritonitis of the fecal reservoir is far more common than 
 constipation, for eighty per cent of adults do not suffer from constipation. 
 Hence, we are forced to the opinion that peritonitis of the fecal reservoir has 
 undoubtedly an influence in inducing constipation, by traumatizing the nerves 
 presiding over defecation. The nerves may suffer from pressure by exudates 
 or edema, from congestion or malnutrition. The final outcome is derange- 
 ment of the nerves of the fecal reservoir — exaltation or debasement of sensa- 
 tion and motion. As probability is the rule of life, the results of peritonitis 
 cf the fecal reservoir is here referred to, and not acute peritonitis. I have 
 shown (Peritoneal Adhesions After Laparotomy, Anter, Gyn. and Obstet. 
 Jour., December, 1*95) that gross peritoneal adhesions (bands) attached to 
 organs cf maximum peristaltic action, as the middle of the sigmoid flexure 
 and the oviducts (or their amputated ends), the mobile bladder, or the active 
 peristaltic loop of enteron, frequently create very much pain, though not 
 necessarily constipation. Yet the finer pathological infiltrations, perhaps, 
 not even microscopic, or at least insufficient to create condition of the fecal 
 reservoir which may be far more effective in causing constipation, than the 
 gross peritoneal bands which simply fix, dislocate viscera, or parts of viscera, 
 are an important factor in inducing constipation in splanchnoptosia. Perhaps 
 splanchnoptosia should be viewed as a constitutional disease, a general neuro- 
 sis. The viscera supports very gradually elongate in splanchnoptosia, and 
 the nerves as gradually lose their tone. That the visceral nerves ar< involved 
 in splanchnotosia is very evident from the manifest derangement of the 
 
3G2 THE ABDOMINAL AND PELVIC BRAIN 
 
 nerves of sensation, motion, absorption, and secretion. Splanchnoptosia is 
 a weakening of the nervous system, a special slackening, or elongation of the 
 visceral supports, which we must acknowledge is not manifest in the digest- 
 ive tract muscles, but attacks the skeletal muscles (e. g., of the abdominal 
 wall). 
 
 Every practitioner has observed that with the induction of habitual con- 
 stipation a peculiar nervous phenomenon also arises. The popular opinion 
 is that the constipation is the cause of the neurosis, but such an opinion does 
 not always stand the test of analysis. Is the neurosis not the cause of the 
 constipation? The finer beginning of the neurosis was not observed, while 
 the grossness of constipation is discernible from beginning to end. After 
 constipation has once started, a train of symptoms may set in, as long reten- 
 tion of the feces allows them to become dry and hard from absorption of 
 fluids. The feces become pressed into the saccules of the colon, as hard, 
 irregular masses, known as scybala. Such masses, by continued pressure, 
 may produce mucus ulceration. The subject experiences fullness in the 
 abdomen and disagreeable sensations; the appetite disappears, gases are 
 eructed, and a disagreeable taste arises. The skin may assume a muddy 
 color, and the fecal masses may be covered with mucus in various quantities. 
 Some practitioners falsely attribute the slime, or mucus, to colonic catarrh. 
 The excessive mucus is due to irritation of the mucosa by the fecal masses, 
 which irritation may also induce a hyperemia of the mucosa, producing dis- 
 ordered secretion, with fermentation and gases. The fecal accumulation can 
 produce not only a transitory mucal hyperemia, excessive secretion and 
 diarrhea, but anatomic changes, such as colonic catarrh, trauma of the colonic 
 wall and local peritonitis. Considerable colic may arise from the attempts 
 of the colon to expel the large accumulated masses, which palpation may 
 reveal. 
 
 But, to speak of the difficulties arising from hardened masses of accum- 
 ulated feces is only to bring in mechanical difficulties, with all their train of 
 evils, on the three tunics of the colon and their functions, which is not our 
 chief theme. Our contention is that constipation is a neurosis of the fecal 
 reservoir. 
 
 To illustrate how intimately the nervous system rules the fecal reservoir 
 in its periodic evacuations, all that is necessary is to recall how many patients 
 relate that, on change of business, residence, or scenery, the evacuations being 
 neglected, cease their regularity. So far as I am aware, constipation always 
 has one of its results, the collection of feces in the colon, from the rectal 
 ampulla to Bauhin's valve, but the chief locality is the middle of the trans- 
 verse colon to the rectal ampulla. The collection of fecal masses in the right 
 colon is rare, and, perhaps, in the right half of the colon it is also rare, except 
 from mechanical causes, i. e, if half of the colon be full of hardened feces, the 
 right half will be full, from the physical fact of its inability to force them 
 analward. 
 
 The train of evils resulting from constipation is almost endless, e. g.. the 
 fecal masses produce pressure on the returning veins of the fecal reservoir, 
 
CONSTIPATION A NEUROSIS 363 
 
 causing congestion, especially in the rectal veins, resulting in hemorrhoids. 
 Perier has recently attempted to show that the so-called "fecal fever" is due 
 to absorption from the digestive tract. The proof of this he demonstrates by 
 a cathartic reducing the fever. This view of Perier has some show of truth 
 in it, for in puerperal sepsis, in fever after operation, a cathartic reduces the 
 fever like a charm. The drain by the cathartic directs the poison outward. 
 However, it must be remembered that high temperature subsequent to some 
 pelvic operations, is rather due to absorption of septic matter remaining in 
 the pelvis than absorption from the bowel. For long past and even to-day 
 certain widespread opinions, in regard to certain definite connections between 
 the central nervous system and constipation exist. Constipation and the cen- 
 tral nervous system are brought into close relations. All grades of symptoms, 
 from the slightest disturbance to hypochondrical and severe psychical, are 
 included as due to constipation. Certain writers have tried to show that 
 relations exist between dyspepsia and constipation on the one hand, and 
 hypochondria and melancholia on the other. Virchow started such views 
 nearly fifty years ago, and Virchow always wrote with a pencil of light. The 
 celebrated neurologist, Romberg, claimed in 1850, that constipation could 
 induce hypochondria. It is not strange that the opinion of such giants as 
 Virchow and Romberg, both strengthened by observations, should prevail so 
 long. But our belief is that constipation is a neurosis of the fecal reservoir. 
 Hence, constipation, melancholia, and hypochondria are the result of neuro- 
 sis, and not the cause. We must look to neurasthenia as the forerunner of 
 constipation, as the neurotic invader of the fecal reservoir bringing in its wake 
 constipation. When neurasthenia and melancholia enter, the process 
 becomes retarded. Recently, Dunin has favored the view that constipation 
 is the result of a neurosis and not the cause. True it is that nervous per- 
 sons do not always suffer from constipation nor are non-nervous persons 
 invariably free from it, but, first, be it remembered that the fecal reservoir is 
 chiefly under the influence of the inferior mesenteric ganglion, and its radiat- 
 ing nerves (sympathetic), and not the cerebro-spinal, though the last-named 
 exercises certain influences over the fecal reservoir; also, that the fecal neu- 
 rosis is a local affair, i. e., the peripheral nerves supplying the colon in area 
 of the inferior mesenteric artery may be attacked by disease, independently 
 of the remaining sympathetic and cerebro-spinal systems. 
 
 The general view here entertained in regard to constipation and neurosis 
 is: That the constipation is the cause of nervous symptoms, e. g., a person 
 suffers for several days from constipation and light cerebral symptoms arise, 
 as headache, dizziness, pressure in the head and inability to think well. 
 There may be feelings of heat in the head and considerable general languor. 
 The urine may be a little scanty and high-colored, with hot and dry skin. 
 There is often slight respiratory disturbance. Physicians generally attempt 
 to prove that all these cerebral symptoms depend on the several days of con- 
 stipation, from the fact that after a brisk cathartic the cerebral symptoms 
 disappear. This circle may be, and often is, repeated in the same individual. 
 
 At first sight this explanation, with its practical demonstration, seems 
 
364 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 very laudable. But is it satisfactory? Can not the neurosis, the subjective 
 light cerebral symptoms, be the cause of constipation? It is not easy to 
 give a categorical proof of this. The disturbance, or hindrance, in respiration 
 and circulation may find an explanation in the elevation of the diaphragm. 
 
 The cerebral circulation may be disturbed by the reflex irritation of the 
 abdominal viscera, transmitting the irritation by way of the lateral chain of 
 the sympathetic and the splanchnics. Leube has recently reported cases where 
 the person became dizzy from pressure in the rectum, either by fecal masses, 
 or by the finger. Here the dizziness arises from irritation of the hemorrhoidal 
 plexus of nerves. 
 
 Again, Senator suggests that the absorption of certain gases, as sulphu- 
 reted hydrogen, might induce poisonous symptoms. Xothnagel suggests that 
 in constipation ptomaines might be absorbed, inducing cerebral symptoms. 
 But Bouchard demonstrated that toxic fecal ptomaines may occur in fluid 
 feces, as is seen in the large amount found in the urine of patients afflicted 
 with diarrhea. Again, the cerebral symptoms depend on the constipation. 
 Is the argument the same with melancholia and hypochondria? Does it 
 depend on constipation? In other words, does constipation cause, in other- 
 wise healthy persons, hypochondria, or other psychoses? We think it does 
 not. The proposition should be made in two forms: 
 
 (a) Constipation may occur in otherwise healthy persons. These, we 
 claim, do not suffer the hypochondria and psychoses. 
 
 (b) Constipation occurs in patients w T ith a neurotic tendency. These 
 last are the subjects which suffer from melancholic psychoses during constipa- 
 tion. It is undeniable that psychical depression may develop during consti- 
 pation in certain persons, but the)- are of the neurotic type, and in these the 
 abdominal disturbance of the bowels would similarly affect (as disturbances in 
 any other functions) the weakest point, i. e., the part of the animal economy 
 which resists the least. Single-handed and alone constipation does not create 
 hypochondria and melancholia, but in a system burdened with neurotic tend- 
 encies, with unstable nerves, they may exist, but are, perhaps, the cause of 
 the constipation. 
 
 Virchow says the following: "Das bci cincr gewissen errcgungs faJiigkeit 
 widerstands losigkeit (predisposition), des nerven apparatus storhungen mit 
 dem character der exaltation an den sensitiven und don der depression und den 
 motorichen nerven kerrufen." Freely translated it is, "That by certain tend- 
 encies (non-resistance, predisposition) of the nervous apparatus, disturbances 
 of the abdominal viscera may produce the character of exaltation in the sen- 
 sitive nerves, and depression in the motor nerves." 
 
 It appears to me, however, that the popular professional jdea of the effect 
 of constipation on the brain is exaggerated, and much of the belief is 
 untenable. 
 
 The celebrated English author and physician, Dr. Barnes, held that con- 
 stipation was the cause of chlorosis. Perhaps this view arises from the supposed 
 fact that some of the chlorotic girls recovered after cathartic treatment. 
 But, since chlorosis is a disease of a certain age, i. e., from fifteen to twenty- 
 
RELATIOX OF TRACTUS INTESTINALIS 
 
 365 
 
 five years, such a fact remains to be proved, for the constipation accompany- 
 ing chlorosis constitutes but a small portion of the ailments atacked by it. 
 Constipation and neurosis are, nevertheless, close relatives in many subjects 
 with peculiar nervous symptoms. 
 
 The relation of the gastrointestinal canal to other viscera is of prime 
 importance as modifying peristalsis. The emphysematous lungs force the 
 diaphragm distalward, and this destroys the tendency to free peristalsis. 
 Heart, liver and kidney diseases, if they produce congestion in the bowel 
 coats — serosa, muscularis and mucosa — will lessen peristalsis and consequent 
 
 X-RAY OF DUCTUS PANCREATICUS ET DUCTUS BILIS 
 
 Fig. 83. The pancreatic and liver ducts, ensheathed by a network of fenestrated, nodu- 
 lar nerve plexuses. Also the portal vein. 
 
 fecal motion. Diabetes induces constipation by diverting fluids from the 
 intestinal tract, and the consequent drying of the feces. In the chlorotic and 
 anemic it is difficult to distinguish cause and effect. The}' are both consti- 
 pated. But the retardation of fecal movements may be followed by anemia 
 and chlorosis, or auto-intoxication. However, chlorosis belongs to females, 
 in general, from puberty to the age of twenty-five. It is a developmental 
 disease. In fevers deficient peristalsis induces constipation. Excessive 
 sweating, also, renders the feces dry, and the diminution in the amount of 
 food taken leaves less residue to stimulate peristalsis. 
 
 Fleischer suggest that in fevers the high temperature of the blood bath- 
 
3G6 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 ing the ganglia in the walls of the bowel tends to inhibit peristalsis, and 
 hence cause constipation. 
 
 Under sympathetic nerve influence we are not including constipation 
 trom mechanical factors, as volvulus, flexions, obstruction by peritoneal 
 bands and through apertures, pressure from tumors, strictures, or dislocated 
 organs. Experience teaches emphatically that enteritis, or catarrh of 
 the enteron, induces constipation. If catarrh of the colon and enteron exists, 
 diarrhea and constipation will generally alternate. The secretory, as well 
 as the motor nerves, are highly involved in catarrh. Ulcerative processes in 
 the mucosa inducing diarrhea are not included in nerve influence. We, of 
 course, have constipation in atony of the bowel wall, as well as in partial 
 paresis. 
 
 Bowel weakness arises in potators, tabetic and tubercular patients, and 
 in those with progressive splanchnoptosia. 
 
 It is plain to any one that a neurosis acts in various ways on the tractus 
 intestinalis, influencing constipation or diarrhea. The hysteric and neuras- 
 thenic both suffer from irregular constipation. It is a common observation 
 that patients who complain of abdominal neuralgias suffer more or less from 
 constipation. It appears as if the nerves of the bowel do not work in 
 harmony, the bowel is incapable of regularly emptying itself. Besides, neural- 
 gia is, doubtless, a malassimilation of a sensory nerve, and since the sensory 
 and motor nerves are complements of each other, they must work in harmony 
 to accomplish an object — evacuation. The bowel contents irritate the peri- 
 phery of a sensory nerve in the mucosa, this is carried by the organizing 
 ganglia of the muscular wall, which induces muscular motion. The blood 
 vessels of the bowel wall exert vast influence over peristalsis, and the vessels 
 are ruled by the sympathetic nerves. 
 
 With deranged nerves of the intestines there will necessarily be deranged 
 circulation, and either congestion or anemia induces a lowering of peristalsis 
 — constipation. The circulation on the surface of the body is only an index 
 of what is occurring inside. Now, it is common in neurotic persons to observe 
 a dozen marked changes in the superficial circulation in a single day. The 
 changes of circulation affect the bowel wall in a similar way that they do the 
 surface. The effectiveness of circulatory changes is, perhaps, best observed 
 in the serous covering the bowel, as in peritonitis, where constipation exists. 
 In peritonitis the bowel wall becomes edematous, congested, and the periph- 
 eral nerve apparatus is compromised by pressure and malnutrition, so that 
 we always expect constipation in peritonitis. The circulation is deranged. 
 
 In the territory of the secretory nerves, which belong to the sympathetic, 
 as well as the motor and sensory nerves of the intestines, a vast field lies 
 unopened. At ordinary times secretions progress in definite proportions, but, 
 pathologically, we have excessive, deficient, or disproportionate secretions, 
 e. g., there maybe excessive bile, HC1, gastric or pancreatic fluids, or all of 
 these may be deficient. Again, the bile may be secreted in proper amounts, 
 so that we would have disproportionate secretion, which induces fermentation, 
 the development of gases, tympany, and the undue development of certain 
 
local and general symptoms or constipation 
 
 microbes. If deficient HC1, or bile, be secreted, both of which arc antisep- 
 tic, microbes develop. Also, it must not be forgotten that deficiency of secre- 
 tion checks peristalsis, whether it be deficiency of bile, pancreatic, or other 
 gastrointestinal fluids, and slowing of peristalsis invites constipation. 
 
 To illustrate the influence of nerves over peristalsis, observe how the 
 irritation of a small fissure will induce constipation, first by abstention from 
 stool and, second, by breaking the regular habit of stool. By forcible dilata- 
 tion of the rectum the regular stool habit assumes its old course. In the case 
 of anal fissure the irritation is purely reflex on the remaining portion of the 
 gastre-intestinal canal. It would appear that constipation, in certain forms, 
 may be well remedied by daily dilatation cf the sphincter. This dilate^ and 
 flushes its peripheral capillaries. Dr. Bier reports successes in the Wiener 
 Med. Blaetter, 1891, No. 25. 
 
 The complex symptoms of constipation may be indecisively divided into 
 general and local symptoms. The general and most disastrous symptom is 
 that of auto-intoxication. It represents a series of manifestations in the 
 territory of the nervous system, whether it be chronic or acute, common 
 symptoms or headache, dizziness and neuralgias about the abdomen, as well 
 as sleepiness, melancholia, languor, a feeling of debility and nausea. Pick 
 says the visible expression of the constipation is the richness of excretory 
 principals in the urine, and the increased toxicity of the same. 
 
 One of the local symptoms of constipation is the feeling of fullness and 
 pressure in the abdomen, which is generally distended. The passage of gas 
 gives temporary relief. The diaphragm is forced proximalward, compromis- 
 ing the heart, so that it not infrequently palpitates, and the lung manifests 
 difficulty in respiration. In certain cases considerable colic is produced at 
 stool, from irritation of the bowel wall by hard fecal masses. The positions 
 of local colic from expelling hardened feces are the ampulla of the rectum, 
 the cecum, the hepatic and splenic flexures, the middle of the transverse 
 colon, and S-romanum. Large, hard, rough fecal masses not only cause much 
 pain, but they abrade the mucosa and finally produce ulcerations, which heal 
 slowly. 
 
 Visceral Circulation in Constipation. — The proverbial advice of the elderly 
 doctor, when he wishes to be social, entertaining and instructive, is to keep 
 the head cool, the feet warm, and the bowels open. 
 
 This philosophic advice is frequently theoretical, rather than practical, 
 from an application to the actual living habits of the subject. In the present 
 modes of living among women constipation plays an extensive and damaging 
 role. The evil effects of constipation extend to adjacent visceral tracts, as 
 circulation, respiration, and particularly on the tractus glandularis — secretions. 
 The most important visceral tract of life itself is the tractus vascularis, over 
 which the sympathetic nerve, nervus vasomotorius, maintains direct control. 
 An ample stream of fresh blood can not properly irrigate constipated visceral 
 organs. In constipation one or more of the four great common visceral func- 
 tions — peristalsis, secretion, sensation or absorption — are disordered. The 
 disturbance of circulation in constipation may be local or general. We 
 
368 THE ABDOMINAL AND PEWIC BRAIN 
 
 observe the profound anemia of girls, frequently following the phase of 
 puberty. The circulatory changes are at first local, later general. The 
 anemic, chlorotic girl (from fifteen to twenty-five years of age) is plump, fat. 
 and beautiful — in fact, it is the anemia of the good-looking girls. It appears 
 concomitant with the disordered local circulation (genital); the later, general, 
 disordered circulation, is accompanied by disordered, hypertrophied glandular 
 system (tractus lymphaticus) and constipation. The chlorotic girl might 
 profitably pose as an alabaster or marble statue. Hence, disordered circula- 
 tion (pubertas), accompanied by disordered general circulation, disordered 
 tractus lymphaticus, and constipation (disordered peristalsis, or secretion, or 
 absorption). 
 
 In the establishment of menstruation numerous local (genital congestion 
 or anemia) or general (chlorosis) circulatory disturbances arise. In pubertas 
 the luxuriant vessels (veins) of the ovary and its compensatory balanced arm, 
 the endometrium, become congested, engorged, which robs the blood from the 
 tractus intestinalis and disturbs not only local, but general circulation, which 
 condition is intensified in gestation. 
 
 Until the habit of menstruation is established the local change of circula- 
 tion may induce constipation. In fact, I have relieved numerous gynecologi- 
 cal patients by restoring normal evacuations of the bowels, and vice versa, 
 normal genitals may restore normal bowel evacuation. 
 
 In short, detailed attention to the circulation — a matter directly under 
 command of the sympathetic — is one of the most important factors in regu- 
 lating constipation. 
 
 It is the detailed study of sanitorium patients, as to life, habits, diet and 
 fluids, that makes the sanitorium financially profitable and suggestive, at least 
 to the so-called surgeon who is so busy with major operations that he walks 
 over gold and silver daily. The neglect of accurate diagnosis and consequent 
 neglect of detailed treatment and defects of common functions, constipation, 
 by the physician, is the reason of the multiplication of sanitoria, and the con- 
 sequent loss of feces and confidence in the home physician. 
 
 It is the duty of the physician in defects of the common visceral functions 
 — peristalsis, absorption, and secretion — to introduce visceral drainage to 
 relieve the patient of waste-laden blood, and restore normal circulation. 
 The physician should decide in detail the quality and quantity of the food 
 and fluids ingested, and determine the methods of sewerage. He should rec- 
 ognize the secretory and motor activity of the tractus intestinalis, and the 
 fascio-elastic muscular apparatus of the abdominal wall, which aids in evacu- 
 ating the bowels. 
 
 Women, especially the young, must be taught the absolute necessity of 
 regular daily evacuations, regardless of environments, time, place, views, or 
 agreeability. The woman should know that exercise, muscular activity, is 
 necessary for the abdominal muscles to force continually the bowel move- 
 ments, contents, analward. Active bodily movements, fresh air, bicycling, 
 walking, aid very much to maintain visceral circulation. 
 
 Artificial checks to respiration, as the corset or tight bands, check circu- 
 
DIAGNOSIS OF CONSTIPATION 369 
 
 lation, especially visceral, and hence peristalsis, absorption and secretions of 
 the tractus intestinalis is checked. The corset is an enemy to circulation, 
 and a friend to constipation and is unhesitatingly condemned. 
 
 Only ocular demonstration will convince a woman against corsets, so firm 
 has become the senseless iron rule of fashion. 
 
 To illustrate the important influence of circulation in constipation, the 
 first week of marriage may be noted. The extra irritation of the genitals 
 induces a genital hyperemia, a congestion which robs the blood from the 
 tractus intestinalis, leaving in its wake intestinal paresis — constipation. 
 
 Menstrual disturbances, chronic genital inflammation, entice blood from 
 the tractus intestinalis, leaving defective intestinal peristalsis from lack of 
 blood. Removal of chronic congested genitals may restore normal action of 
 the genital tract by returning to them their normal blood stream. Not only 
 does pregnancy induce constipation by enticing a continual blood stream 
 toward the genitals from the intestinal tract, but in the puerperium the 
 abdominal muscular apparatus has lost its original elastic tone, its power of 
 compression. The enforced corporeal rest and non-irritating food adminis- 
 tered engenders a constipation by disordered, unbalanced circulation. 
 
 In the puerperium, instead of an abdominal binder, the abdominal mus- 
 cles should be massaged. The patient should practice on the abdominal 
 muscles gymnastic exercises, in order to quickly restore them to normal 
 action, and thus avoid one of the prime factors of splanchnoptosia. 
 
 The abdominal binder, the enforced rest, and concentrated food in the 
 puerperium, all tend to lessen the visceral circulation, especially in the intes- 
 tinal tract, and hence to entice constipation. 
 
 The Diagnosis of Constipation. — First and foremost an examination, 
 extending from mouth to anus, is a prerequisite to diagnose constipation. 
 
 The mouth, and especially the teeth, unfold an important story. 
 
 The state of the abdominal and thoracic walls are significant. Does 
 splanchnoptosia exist with its general consequences? 
 
 What is the state of the rectum (fissure, hemorrhoid, ulcer?) is of extreme 
 importance. 
 
 The tractus vascularis tells its own story in arterio-sclerosis, which would 
 indicate defective circulation in the splanchnic area. 
 
 Careful palpation of the plexuses and connection cords of the abdominal 
 sympathetic should be practiced, as they regulate the caliber of the splanch- 
 nic vessels. Tenderness of the abdominal sympathetic plexus indicates an 
 irritable condition of the viscera. If marked sclerosis exists, the abdominal 
 aorta is palpable and tender. It is enlarged, movable, and pulsates vigor- 
 ously, The tendernesss is to be localized especially along the plexus aorticus 
 distal to the umbilicus, and in the plexus celiacus (abdominal brain) proximal 
 to the umbilicus. This tenderness indicates a neuritis of the sympathetic, or 
 vasomotor plexuses. Colic, due to spasm of vessels (arterio-sclerosis), must 
 be differentiated from colic due to enteritis. In neuritis of the sympathetic 
 plexuses, the pain and tenderness is localized in the celiac and aortic plexuses, 
 and along the route of the ensheathed, which is characterized by spasmodic 
 
 24 
 
370 THE ABDOMINAL AXD PELVIC BRAIX 
 
 and periodic exacerbation. Peritonitis announces a more diffuse tenderness, 
 and it is less spasmodic and periodic. Enteritis presents tenderness, localized 
 in the course of the enteron, and is accompanied by other symptoms, as mucus 
 in stools. The diagnosis of constipation is a small factor in practice, but the 
 finest head, with the best skill, is required to diagnose the etiology, for on 
 the cause of this malady rests the successful treatment. It is needless to say 
 that a thorough and complete physical examination is absolutely necessary. 
 For constipation may depend on the kind of food taken, on habits of life, on 
 drugs employed, or on defects in the system. Some affirm that heredity plays 
 a role in constipation; however, this is only a cloak to cover what we do no't 
 know. Many persons who have only one stool in two days, and remain 
 healthy, are not constipated, and require no treatment. 
 
 Treatment of Constipation — General Remarks. — First and foremost in the 
 treatment of constipation, should be considered the diet. Some physicians 
 have a diet list. In certain cases it is convenient, but generally of little value. 
 Oatmeal and graham bread, with milk as a beverage, leaves ample residue to 
 induce peristalsis, which soon overcomes constipation. In such cases, also, 
 a few daily colonic flushings aid wonderfully, with the establishment of a 
 regular hour for evacuation. Especial stress should be laid on the matter of 
 avoiding cathartics; they are among the chief causes of constipation. The 
 best methods of curing constipation are those which imitate nature the 
 closest, and most perfectly. They are, in order: 
 
 1. The regulation of diet (ingesta). 
 
 2. Physical procedures. 
 
 3. The judicious use of laxatives. 
 
 In the regulation of the diet several factors are requisite, viz., food which 
 leaves a large residue, which will impart the necessary constant stimulus to 
 successive bowel segments. Peristalsis requires a physical stimulus, a bolus 
 that will feel its way from stomach to anus. The diet should be a mixed one 
 of cereals, meats and fruits, as well as concentrated foods. It should be 
 eaten at regular, fixed hours. The bowel is an organ wonderfully inclined, in 
 certain persons, to assume sluggish, stubborn habits. Subjects who eat irreg- 
 ularly are apt to become just as irregular in evacuation. To show the effect 
 of the habit, observe how much more women are constipated than men — a 
 result of insufficient physical exercise, or sedentary life. Also, ample fluid 
 should be taken with the foods. 
 
 The good effect of graham bread is chiefly due to the large residue, and 
 the contained salts — both acting physically on the bowel, causing peristalsis. 
 The habits of the use of narcotics, drinking, smoking, chewing, and taking of 
 morphine, sexual abuses, over-mental activity, etc., should be modified. 
 
 The second method of treatment in constipation is the use of some physi- 
 cal procedure. Of these several are important. Among the first is the estab- 
 lishment of regular habits of evacuation and overcoming irregular ones. 
 The bowels should be evacuated every morning after breakfast, i. e., after 
 drinking hot fluid and eating hot food. 
 
 Heat starts peristalsis. The mental state has much influence over the 
 
TREATMENT OF CONSTIPATION 371 
 
 bowels, so that if the mind is set on a distinct hour for an evacuation, it is 
 prett)' sure to be secured. Another valuable factor is regular and vigorous 
 daily exercise. The most natural are walking, horseback or bicycle riding. 
 The habit of exercise is nearly always sufficient to overcome constipation. 
 Gymnastics serve a similar object. 
 
 When the above exercises are not performed, one of the sovereign cures 
 of constipation is voluntary cultivation of the abdominal muscles, or massage; 
 at first, weak or light rubbing should be employed once or twice daily; subse- 
 quently, vigorous massage should be carried on. Stroking, rubbing, tapping, 
 kneading and gripping the abdominal wall should be judiciously performed. 
 The large intestine should be massaged from cecum to rectum, following the 
 line of the colon, and the direction of the fecal current. Rolling a bag of 
 shot or dry sand over the abdomen is effective, if continued many days. Much 
 patience on the part of both physician and patient will be required to continue 
 the massage, for it may need a month to accomplish permanent results by 
 this process. Rolling on the abdomen for ten or fifteen minutes every morn- 
 ing accomplishes goods results in constipation. Another excellent remedy 
 for both its mental and physical effects, is electricity. Either the galvanic or 
 the faradic current is effective. The muscle walls of the abdomen can not 
 only be treated by electricity, but one of the electrodes may be inserted into 
 the rectum. Another physical procedure of great value for a limited employ- 
 ment in constipation is irrigation, or colonic flushings, or rectal injections. 
 However, rectal injections blunt the sensibility of the rectal mucosa. For 
 mild cases a rectal injection of one-half pint of plain or salt water is sufficient 
 to irritate the bowel, and excite an evacuation. In more stubborn cases a 
 quart of water, containing irritants, may be injected, by a fountain syringe, 
 held two feet above the patient, and allowing the fluid to flow into the bowel. 
 Another method is turn a chair upside down, place a quilt over it, and then 
 place the patient over this inclined plane, with the # hips well elevated, and 
 shoulders well down. Then allow a quart of water (containing desired ingre- 
 dients) to gradually pass into the colon. 
 
 Besides the water injections, one may employ stimulants, such as epsom 
 salts, olive oil, glycerine and water, at different temperatures. An excellent 
 rectal injection is a half pint each of molasses and milk. It is hygroscopic. 
 The irrigation is accomplished with more safety and efficiency with the foun- 
 tain syringe at a low level, e. g., about two feet above the patient's hips. 
 Cold fluid injections excite the bowels; however, warm fluids dissolve feces 
 more rapidly. 
 
 Olive oil treatment. — Constipation is benefitted by persistent course of 
 administration of olive oil for a period of months. I ordered a tablespoonful 
 after each meal. The chemical action of the olive oil is a result of the sepa- 
 ration of the oil by bile and pancreatic ferments. Through the bile and pan- 
 creatic fluids the fatty acids and soaps are produced which exert a mild chem- 
 ical action, inducing evacuation. To soften and dissolve fecal masses olive 
 oil is excellent. The value of the olive oil employed per rectum is dependent 
 not only on its physical properties as softening and dissolving feces, coating 
 
372 THE ABDOMINAL AND PELVIC BRAIN 
 
 and protecting the mucosa, and diminishing the absorption of water, but also 
 on its chemical action. 
 
 To produce an immediate stool, a cold-water rectal injection of one-half 
 a pint will be the most effective, as it at once induces active peristalsis. This 
 may be added by rolling a bag of sand or shot over the abdomen. Daily 
 dilatation of the rectum, especially when it is inclined to spasm, or is subject 
 to fissure, ulceration or hemorrhoids, is a usual procedure. However, fissures, 
 ulcers and hemorrhoids are proper cases for operations. 
 
 Finally, in the treatment of constipation, we come to use of drugs — at 
 once the most disastrous and inefficient of all methods. Cathartics are to be 
 avoided as much as possible in constipation. Constipation is generally the 
 result of catarrh. Cathartics influence catarrh injuriously by further compli- 
 cating the circulation, and inducing congestions and depletions. In the treat- 
 ment of diseases peculiar to women, which I have diligently followed for 
 twenty years, and where constipation is a common matter, I seldom advise a 
 cathartic, pure and simple. The method I have followed successfully for 
 years is what I term visceral drainage, presently to be described. Drastic 
 cathartics are the friends of constipation. The number of cathartics is very 
 great. The choice of one will depend on whether the drug is intended for 
 long or short use. If a cathartic be employed for a short use, to secure an 
 immediate evacuation, one of vigorous nature should be selected. For this 
 purpose none are superior to mild chloride, followed by magnesium sulphate. 
 The mild chloride stimulates the whole gastro-intestinal glandular apparatus, 
 while the magnesium sulphate induces a large flow of fluids into the bowel. 
 I have used these cathartics thousands of times, and have not yet observed 
 superior ones. The violent, drastic cathartics, such as croton oil, podophylin, 
 colocynth and elaterium, are seldom required. 
 
 Should a cathartic be required for prolonged use, one of a mild nature 
 should be selected, such as rhubarb, magnesium sulphate, senna, aloes and 
 cascara sagrada. Drugs administered for chronic constipation should be 
 employed at night, so that the quietude of the patient will allow the drug to 
 pass slowly over the whole mucosa. I am of the opinion that the addition of 
 belladonna to cathartic pills is superfluous, and therapeutically only adds 
 injury to insult. Tha cathartic insults the mucosa, while the belladonna 
 injures it, by attempting to deceive it by anesthesia — both enemies to the 
 normal, peaceful, mucosa life. 
 
 The beneficial effects of mineral waters, which generally depend upon 
 the contained glauber and epsom salts, are only secured by long-continued 
 use. Of the two forms of drugs, pills or liquids, given for constipation, the 
 pill form is the superior one, because it works slowly, and thus imitates 
 nature more closely. Nature always resents violent insults, with evil conse- 
 quences. Nature itself is a bundle of habits, and if we are to be successful, 
 we must imitate her methods. Hence, we must employ for constipation, diet, 
 fluid, exercise, physical procedure, and, lastly, adjuvant cathartics — we must 
 study the sympathetic nervous system. 
 
 The treatment of constipation does not consist in searching after and 
 
NEUROSIS BASIS OF CONSTIPATIOh 
 
 373 
 
 administering drugs, but rather in the avoidance of their use. We may first 
 say that constipation is not curable by any planless method, nor by any 
 planned method imperfectly executed, while there may really be non-remov- 
 able anatomical conditions causing the difficulty. Planless prescribing of 
 cathartics is worse than useless. The head and front of all therap* u1 n 
 constipation is due to an original, abnormal, nervous suspension of the . • ri- 
 stalsis of the fecal reservoir. This concerns us and our therapeutics; though 
 we may find difficulty in excluding congenital defects, such as atony of the 
 bowel wall, or constipation due to dislocated viscera. Is the constipation, as 
 
 X-RAY OF DUCTUS BILIS ET DUCTUS PANCREATICUS OF HORSE 
 Fig. 84. Bile and pancreatic ducts of horse which possess no cholecyst or gall bladder. 
 
 Dunin suggests, a mere symptom of neurasthenia? If our original proposition 
 be true, viz., that constipation is a neurosis of the fecal reservoir, cathartics 
 are not only useless, but harmful. 
 
 In constipation we should attempt to cure the neurosis, the neurasthenia, 
 when the constipation will disappear. The moral part of the patient should 
 receive attention, for often there is far more in the suggestions added to 
 medicine, than the remedies themselves can supply. If constipation depends 
 on suspension of peristalsis, either from muscular atony or deficient innerva- 
 tion, it is plain how malpractice resides in the use of cathartics. Fhysical 
 
374 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 procedures must above all be employed in muscular atony, or defective inner- 
 vation, of the fecal reservoir. In the treatment of constipation it may aid to 
 determine the etiologic cause, as atonic constipation, associated muscular 
 atrophy; neurotic constipation, associated with disorders of the cerebro-spinal 
 axis, or the sympathetic (tabes, lead poisoning) ; metabolic constipation, asso- 
 ciated with disordered metabolism, as excessive obesity, sweating, diabetes, 
 anemia; trophic constipation, associated with subjects ingesting excessive 
 meats, or other dietetic errors. 
 
 Suggestion. — I wish here to emphasize the subject of suggestion in the 
 control or cure of constipation. The control of mind over matter has no 
 uncertain sound in the aid to cure constipation. The psychic effect of a 
 well-directed suggestion is often effective in stimulating peristalsis for regular 
 stated times for evacuation. For example, tell a patient, definitely, to go to 
 stool after breakfast, as the hot coffee stimulates the bowel to action. He 
 will not only concentrate his mind on the function, but will cultivate his 
 mind for a definite period for evacuation, which I consider of vast value. 
 Occasionally, particularly in neurotics, this will effect a cure. With the 
 suggestion for a daily evacuation at a stated period should be combined 
 simple convenient remedies, as gymnastic exercise, special diet, in order that 
 the patient may observe cause and effect. 
 
 Dietetic Stivunary — Quality of foods, quantity of fluid, chemical compo- 
 sition, are important considerations, (a) Food must possess sufficient variety 
 (mixed)[in quantity, quality, chemical composition, and be ingested at regular 
 intervals. The food should be mixed, however, possess sufficient indigestible 
 matter to leave ample residue to stimulate peristalsis (and hence absorption, 
 sensation and secretion). An excessive amount of coarse, indigestible food 
 will result in an excessive fecal residue, which excessively stimulates peristal- 
 sis, absorption, secretion and sensation — resulting in muscular fatigue 
 and defective sensibility of the mucosa — consequently, reflex action is 
 impaired. 
 
 (b) Ample fluids, at regular intervals, should be ingested. For a person 
 of one hundred and fifty pounds five pints is required to supply the bodily 
 waste (i. e., tractus intestinalis, respiratorius, urinarius, perspiratorius), eight 
 ounces should be drunk every two hours for six times daily. Fecal matter is 
 about seventy-five per cent fluid and twenty-five per cent solid. The value 
 of fluids for the tractus intestinalis is evident, because in hot weather, with 
 consequent vigorous action of the tractus perspiratorius, constipation results. 
 The chief value of mineral water is the quantity drank. Excessive fluids 
 deteriorate digestion. 
 
 (c) Foods should possess chemical qualities. Carbohydrates produce 
 acidity, nitrogenous foods alkalinity, and mixed foods neutrality of the digest- 
 ive tract. Evacuation of the tractus intestinalis depends on: (a) Sufficient 
 volume of feces, (b) sufficient volume of fluid contents, (c) the presence of 
 substances which act as a chemical irritant to peristalsis. Dr. Walter 
 Baumgarter attempted to devise a substance which would not only be difficult 
 to absorb, but would retain its watery contents (be hygroscopic). He admin- 
 
FOR CONSTIPATION— VISCERAL DRAINAGE 375 
 
 istered eight grains of the dry, shredded agar-agar three times daily, whence 
 he found the stool increased in volume and watery contents. 
 
 Visceral Drainage. — I wish here to introduce a method of treatment for 
 constipation which I have employed successfully for a score of years. I have 
 termed it "Visceral Drainage." 
 
 One of the most important principles in surgery is ample drainage of 
 (septic) wounds. One of the most important principles in internal medication 
 is ample drainage of the viscera. Fifteen years of the application of what I 
 term "Visceral Drainage," in dispensary and private practice, has afforded me 
 ample time to observe its extensive application and utility. Viscera are 
 drained by several means; however, the two most rational and practical 
 methods of visceral drainage are: (A) by fluids; (B) by appropriate foods. 
 The viscera are the sewers of the body, and their proper drainage and flushing 
 is the key to health and its maintenance. Draining the viscera drains and 
 flushes the internal tissue and tissue spaces. 
 
 The muscles are powerful regulators of circulation (as exercise), hence 
 there is stimulation, which increases the tone of vessels, blood currents, and 
 prevents consequent congestion (the arch enemy) in chronic disease. The 
 myometrium, like living ligatures, control the blood supply of the uterus. 
 Visceral drainage initiates and maintains peristalsis, which controls visceral 
 blood supply. A stimulus — whether it be an icicle, red-hot iron, electricity, 
 massage, exercise — is what the flaccid muscles require to maintain peristalsis, 
 which controls secretion and absorption. The endometrium flooded with 
 excessive secretion (leucorrhea) rapidly assumes its normal secretion by stim- 
 ulating the myometrium (by douche, massage, etc.). 
 
 A — Visceral Drainage by Fluids. — The best diuretic is water. It is the 
 greatest eliminant. A man of one hundred and fifty pounds should produce 
 daily some forty-five ounces of urine. If we calculate the loss of fluid by the 
 tractus perspiratorius, tractus intestinalis, and tractus respiratorius, it will 
 require about five pints of the ingested fluid to produce daily forty-five ounces 
 of urine. Many subjects do not drink over three pints of fluid daily, and that 
 is performed chiefly at meal time, not only burdening the tractus intestinalis 
 with the meal, but fluid also. Large numbers of "people drink insufficiently 
 and suffer consequent oliguria. Such subjects are burdened with waste-laden 
 blood, inflicting irritation and trauma on the nerve periphery. They are in 
 conflict with their own secretions. Many women oppose free drinking, from 
 the idea that it creates fat. Ample quantities of fluid, at regular intervals, is 
 the safety valve of health and capacity for mental or physical labor. Ample 
 fluids not only flush the sewers of the body, but wash the internal tissues 
 and tissue spaces, relieving waste-laden blood. The soluble matter and salts 
 are not only dissolved (preventing trauma and infection) and eliminated, but 
 the insoluble matter and salts are flooded from the system, relieving waste- 
 laden blood by such powerful streams of fluid that calculus is not liable to be 
 formed. 
 
 For many years I have diluted the urine, increased its volume (conse- 
 quently, increased ureteral peristalsis), and clarified it by administering eight 
 
376 THE ABDOMIXAL AND PELVIC BRAIN 
 
 ounces of one-half or one-quarter normal salt solution, six times daily. I 
 have made sodium chloride tablets (twelve-grain, each with flavor). The 
 patient places on the tongue a half tablet (NaCl), and drinks a glass of water 
 (better hot) before each meal. This is repeated in the middle of the forenoon 
 (ten a. M.X middle of the afternoon (three p. m.), and at bedtime (nine p. m.). 
 The patient thus drinks three pints of (one-quarter to one-half) normal salt 
 solution daily. This practically renders the urine normal, and acts as ample 
 prophylaxis against the formation of urinary, hepatic, pancreatic, fecal calcu- 
 lus, and sewers the bod} 7 of waste material. The formation of a calculus can 
 not occur when ample fluid bathes the glandular exit canals. In deficient 
 fluid, crystals form calculus with facility. The maximum concentrated solu- 
 tion of urine, bile, or pancreatic juice, tends to crystalize with vastly more 
 facility than dilute urine, bile, and pancreatic juice. In "'Visceral Drainage" 
 single crystals, on first formation, are rapidly floated with facility when ample 
 fluids are present; while in small quantities of fluid, with weak stream, the 
 crystals tend to lodge, accumulate, and form calculus. Oliguria is a splendid 
 base for calculus formation. 
 
 If parenchymatous nephritis exists, the NaCl should not be administered, 
 as it excessively stimulates the renal parenchymatous cells. In such cases 
 administer the water only. 
 
 For over ten years I have been using sodium chloride tablets, more or 
 less, in my practice. During that time some practical clinical views have 
 been gained, and repeated so frequently that they have become established, 
 I think, beyond the shadow of a doubt. The following propositions have 
 been repeatedly demonstrated so many hundreds of times during the last ten 
 years in our clinics and surgical operations, that I shall consider them estab- 
 lished until otherwise disproven: 
 
 1. Sodium chloride (in one-half to one-quarter normal physiological salt 
 solution) is a powerful stimulant to the renal epithelium (tractus urinarius). 
 
 2. Sodium chloride should not be administered in parenchymatous neph- 
 ritis (not even in food), as it exacerbates and irritates the diseased, inflamed 
 parenchymatous cells. 
 
 3. Sodium chloride (in one-half to one-quarter normal physiologic salt 
 solution) is a vigorous stimulant to the epithelium of the tractus intestinalis, 
 inducing fluid to flow into the lumen, stimulating peristalsis and softening 
 the feces. 
 
 4. Sodium chloride increases absorption, secretion and peristalsis of the 
 tractus intestinalis. It is an excellent remedy to quench thirst after peritonot- 
 omy, by copious gradual rectal irrigations fallowing a pint in forty-five min- 
 utes to flow over the sigmoid and rectal mucosa). 
 
 5. The administration of eight ounces of one-half to one-quarter normal 
 physiologic salt solution (better hot), every two hours, for six times daily, 
 will increase the quantity and clarify the urine, eliminate its color, making it 
 appear almost like spring water in three to five days. The feces will be 
 softened, increase, in volume, inciting peristalsis. 
 
 6. Sodium chloride is a vigorously active stimulant to glandular epithe- 
 
VISCERAL DRAINAGE BY FOODS 377 
 
 Hum (as that of the tractus urinarius, tractus intestinalis, tractus cutis, sali- 
 vary, hepatic and pancreatic glands). 
 
 7. The effect of the one-half to one-quarter normal physiological salt 
 solution (six times daily) on the tractus urinarius is to increase the quantity 
 and clarify the urine. 
 
 B — Visceral Drainage by Foods. — To drain the viscera by proper foods 
 may sound paradoxical, but the four grand functions of the tractus intestinalis 
 — peristalsis, absorption, sensation and secretion — are maintained, practically, 
 by food alone. The appropriate food produces the appropriate degree of 
 peristalsis, and the quantity of intestinal secretions, which is absolutely 
 essential for visceral drainage — and to prevent constipation. The food that 
 will induce proper peristalsis, stimulate sensation, absorption and secretion, 
 is that which leaves a large residue to stimulate the distal bowel, enteron and 
 colon, such as cereals, oils, and vegetables. Peristalsis is necessary for secre- 
 tion, for peristalsis massages the secretory glands in the tractus intestinalis, 
 enhancing secretion, e. g. , the rational treatment of excessive uric acid in the 
 urine consists of administering food that contains elements to produce basic 
 combinations with uric acid, forming urates (usually sodium), which are freely 
 soluble. This will diminish the free uric acid in the urine. Excessive uric 
 acid in the urine is an error in metabolism. The question of diet to deter- 
 mine is: (a) What kind of food causes the calculus-producing material in the 
 urine? (b) What kind of food influences the solubility of the calculus-produc- 
 ing material in the urine? 
 
 1. The meat-eater is the individual with the maximum quantity of free 
 uric acid in the urine. Flesh is rich in uric acid. Hence, in excess of uric 
 acid in the urine, flesh (meat, fish and fowl, are all about equal in power to 
 produce uric acid) should be practically excluded, because it increases free 
 uric acid in the urine. Flesh eaters have uric acid stone, vegetarians have 
 phosphate, oxalate stone. 
 
 Generally, the subject who suffers from uric acid is a generous liver, 
 liberally consuming meat and highly-seasoned foods, indolent and sedentary 
 persons, and alcoholic indulgers. Thirty-three per cent of uric acid is nitro- 
 gen. Uric acid is derived from the nuclei that form a constituent of all cell 
 nuclei, and which are taken in the body as a food. Beef bouillon may be cell 
 administered, because the extract matters in it will scarcely increase the uric 
 acid. A general meat diet largely increases the free uric acid in the urine. 
 
 2. The food should contain matters rich in sodium, potassium and 
 ammonium, which will combine as bases with uric acid, producing alkaline 
 urates, which are perfectly soluble in the urine. These typic foods are the 
 vegetables, which not only render the necessary alkalies to reduce and trans- 
 form the free uric acid into resulting soluble urates, but leave an ample resi- 
 due to cause active intestinal peristalsis, aiding in the evacuation through the 
 digestive tract. Hence, the patient should consume large, ample quantities 
 of cabbage, cauliflower, beans, peas, radishes, turnips, and spinach in order 
 that the sodium, potassium, and ammonium existing in the vegetables may 
 combine, as bases, with free uric acid in the urine, producing soluble urates, 
 
378 THE ABDOMINAL AND PELVIC BRAIN 
 
 thus diminishing free uric acid. A vegetable diet diminishes the free uric 
 acid in the urine thirty-five per cent less than a meat diet. Again, the admin- 
 istration of eggs and milk (lactoalbumin) limits the production of uric acid. 
 The most rational advice is to order the subject to live on a mixed diet, con- 
 suming the most of that kind of food which lessens the uric acid in the urine 
 — vegetables. 
 
 If the appropriate food is so valuable in "visceral drainage treatment" of 
 the typical uric acid subject, the appropriate food selected for subjects of biliary 
 and pancreatic calculus will be relatively as useful. The foods that make 
 soluble basic salts with secretions should be selected. Besides, the selection 
 of appropriate food is frequently amply sufficient to drain the intestinal tract 
 to prevent constipation. It is true, foods alone are not a complete substitute 
 for fluids, but vast aid in visceral drainage may be accomplished by adminis- 
 tering food containing considerable indigestible matter, so that a large fecal 
 residue, saturated with fluid, will stimulate the intestines, especially the colon, 
 to continuous vigorous activity, maintaining the maximum action of the four 
 grand functions — peristalsis, absorption, sensation and secretion. For many 
 years I have treated subjects with excess of uric acid in the urine by adminis- 
 tering an alkaline laxative tablet in fluid. The tablet is composed of: 
 Cascara sagrada, one-fortieth of a grain; NaHC0 2 one grain; socotrine aloes, 
 one-third grain; KHCO3, one-third grain; MgS0 4 , two grains. The tablet 
 is used as follows: One-sixth to one tablet (or more, as required, to move the 
 bowels once daily) is placed on the tongue before meals, and followed by 
 eight ounces of water (better hot). At ten A. m., three p. m., and bedtime, 
 one-sixth to one tablet is placed on the tongue, and followed by a glassful 
 of fluid. In the combined treatment the sodium chloride tablet and alkaline 
 tablet are both placed on the tongue together. This method of treatment 
 furnishes alkaline bases (sodium and potassium and ammonium) to combine 
 with the free uric acid in the urine, producing perfectly soluble alkaline 
 urates, and materially diminishing the free uric acid. Besides, the alkaline 
 laxative tablet increases the peristalsis, absorption, sensation and secretion of 
 the intestinal tract, aiding evacuation. I have termed the sodium chloride 
 and the alkaline laxative method the "visceral drainage treatment." The 
 alkaline and sodium chloride tablets take the place of the so-called mineral 
 waters. Our internes have discovered that on entering' the hospital the 
 patient's urine presents numerous crystals under the microscope. However, 
 after following the "visceral drainage treatment" for a few days crystals can 
 not again be found. The hope of removing a formed localized ureteral, or 
 other, calculus, lies in securing vigorous ureteral or other duct peristalsis with 
 a powerful ureteral or other duct stream, aided by systematic massage over 
 the psoas muscle and per vaginam. Subjects afflicted with excess of uric acid 
 in the urine, or other form of calculus, need not make extended sojourns to 
 watering places, nor waste their time at mineral springs, nor tarry to drink 
 the hissing Sprudel, for they can be treated successfully in a cottage, or in a 
 palace. The treatment of a uric acid or other calculus consists, therefore, in 
 the regulation of food and water. It is dietetic. The control, relief and pro- 
 
TRLl. ITMENT OF CONSTIPATION 379 
 
 phylaxis of uric acid diathesis or tendency to other calculus formation, is a 
 lifelong process. When the uric acid or other calculus has passed spontane- 
 ously the patient does not end his treatment, but should pursue a constant 
 systematic method of drinking ample fluids at regular intervals, and eat food 
 which contains bases to combine with the free uric acid or other compounds 
 producing soluble urates or other soluble compounds. 
 
 I continue this treatment for weeks, months, and the results are remark- 
 ably successful. The urine becomes clarified, like spring water, and increased 
 in quantity. The tractus intestinalis becomes freely evacuated regularly 
 daily. The blood is relieved of waste-laden and irritating material. The 
 tractus cutis eliminates freely, and the skin becomes normal. The appetite 
 increases, the sleep becomes improved, the feelings become hopeful. The 
 sewers of the body are well drained and flushed. 
 
 Chronic constipation is compensatory, for during this condition a greater 
 portion of the food ingested undergoes digestion and absorption than in the 
 normal individual, and consequently the fecal residue is more limited. By 
 reason of the fecal residue there is less material, and a less favorable medium 
 for the development of bacteria, in consequence of which less irritating prod- 
 ucts occur, on which the stimulus to the required peristalsis, more or less, 
 depends. The varying pressure of the abdominal walls on the viscera modi- 
 fies the viscera circulation in quantity and rapidity. The visceral vessels, 
 especially the abdominal, constitute a kind of hemogenous reservoir for sur- 
 plus of blood, by which general blood pressure may be regulated among vis- 
 cera. The dilatation of abdominal visceral vessels may be so great that cer- 
 ebral anemia may advance to a state of syncope, collapse, or shock. We 
 may yet learn to apply Bier's congestion, or blood controlling methods, to 
 cure constipation by practicing on the sphincters. Abdominal visceral circu- 
 lation must not only be controlled for maximum digestion (which is normal 
 absorption, secretion, sensation and peristalsis of the enteron), but also for 
 maximum colon peristalsis, which is required for normal evacuation. We 
 know that mental or physical excitement at meals modifies digestion (which 
 means modification of circulation). Dilatation of the blood vessels in the 
 splanchnic area lowers the blood pressure, increases rate, rhythm and force 
 of pulse. Maximum circulation in abdominal organs is conducive to maximum 
 absorption, secretion, sensation and peristalsis. Pathologic increase of 
 circulation in the abdominal viscera leads to corresponding activity of 
 unction. This lends a clue to treat constipation. Increased secretion of 
 the glands of the tractus intestinalis, in consequence of nervous influence, is 
 well known (which refers to circulation). 
 
 Visceral congestion (chronic) leads to relaxation of visceral supports. 
 Interruption of circulation (anemia) leads to visceral spasm, colic. Spasm 
 of the muscle of the digestive apparatus produces colic. There can be slight 
 doubt, clinically, that spasmodic (anemic) constipation occurs — e. g., lead or 
 (anemic) colic. In the practice of medicine the vascular area governed by 
 the splanchnics will be more utilized in therapeutics. For example, the head- 
 aches, dizziness, faintness, syncope, vertigo, which appear and disappear 
 
380 THE ABDOMINAL AND PELVIC BRAIN 
 
 suddenly without sufficient time for autointoxication, infections, are likely to 
 produce circulatory changes in the splanchnic and producing cerebral anemia. 
 So, also, cold hands and feet, aching pains in limbs, neuralgic pains in various 
 bodily regions, may be due to excessive tendency of blood to the splanchnic 
 area. Irritation of the nerves of the splanchnic vessels are transmitted to 
 distant regions, leading to spasms (anemia, ischemia) of vessels, and pain, 
 cramps in muscles. This may explain the frequent colic, cramps, of neurotic 
 subjects. 
 
 Circulatory disturbances in the tractus intestinalis should not be mistaken 
 for: (a) Mechanical irritation from coarse food, (b) chemical irritation 
 from ingested irritants (as acids, spices, meats), (c) pathologic physiology, 
 as excessive, deficient or disproportionate secretion and consequent fermen- 
 tation (microbic). The dilatation of the splanchnic vessels are physiologically 
 opposed to the dilatation of the peripheral vessels, and since the splanchnic 
 vesstls are controlled by a nervous mechanism, it may be hoped that a definite 
 therapeutic remedy will appear that will contract, or dilate, these visceral 
 vessels. Since physiologic antagonism exists between the splanchnics and 
 peripheral vessels, agents which dilate the splanchnics contract the peripheral 
 vessels, and vice versa. The dilatation of the anal sphincter dilates and 
 flushes the peripheral capillaries with it, contracts the splanchnic vessels. 
 The peripheral vessels may be dilated by mechanical means, as massage, 
 hypertrophy, a hot and cold water chemical irritation, as mustard, turpentine. 
 
 Normal evacuations of the tractus intestinalis require an ample stream 
 of fresh blood irrigating the intestinal tract, which is accomplished by admin- 
 istering food with indigestible remnants. 
 
 The tendency of the blood stream to an}' other visceral tract than the 
 intestinal, lessens the peristalsis, absorption, sensation and secretion, favor- 
 ing constipation. 
 
 In pubertas, menstruation, gestation or chronic genital inflammation, 
 the circulation tends toward the genitals, robbing the tractus intestinalis of 
 blood, inducing constipation. 
 
 In the puerperium the patient should exercise, employ gymnastics, mas- 
 sage the abdominal muscles, ingest foods which have a residue, and limit the 
 enforced rest to a week, in order to restore muscular action and visceral cir- 
 culation, especially the intestinal. 
 
 Chronic inflammation, tumor, irritation on any one visceral tract, tends 
 to unbalance the normal circulation in all other visceral tracts — inducing con- 
 stipation — hence to improve constipation, remove the disease or disturbance 
 in other visceral tracts. 
 
 Any defective segment of the tractus intestinalis (gastrium, enteron, 
 colon) should be repaired, and any defective function (peristalsis, secretion, 
 sensation and absorption) should be restored. 
 
 A subject of one hundred and fifty pounds requires five pints of fluid daily 
 to produce ample visceral circulation (to supply the physiologic demands of 
 the tractus urinarius, tractus cutis, tractus respiratorius, tractus intestinalis). 
 
 Vegetables and graham bread (which should contain the flour, shorts and 
 
TREATMENT OF CONSTIPATION 381 
 
 bran) leave ample residue to stimulate the tractus intestinalis, inviting a vigor- 
 ous circulation. 
 
 Rectal injections and colonic irrigation should not be employed fre- 
 quently, as the rectum may lose its sensitiveness, becoming so blunted in 
 sensibility that it will forget to act when fecal matter is present. Clysters of 
 oil are excellent remedies to soften fecal masses. 
 
 Persistent use of galvanic and faradic electricity produces favorable 
 effects on constipation, the electricity energizes the abdominal walls and 
 intestinal muscles. However, I can not report such favorable results as 
 those of C. V. Wild, in his excellent essay, "Die Verheutung und Bekandlung 
 der Chronischen Verstopfung bei Frauen und Madchen." 
 
 Constipation, if pursued by both patient and physician, with favorable 
 will and energy, is practically a curable disease. 
 
CHAPTER XXX. 
 
 SHOCK. 
 
 By Lucy Wane, A. B., M. D., Head Surgeon of Mary Thompson Hospital for Women and Children. 
 
 Shock in its widest significance covers the whole of medicine. From 
 the slightest physical traumatism or the lightest mental depression to the 
 most profound impressions on the vasomotor centers causing instantaneous 
 death, the difference is only one of degree, the phenomena being the same. 
 It would therefore be impossible in one short chapter to follow out the sub- 
 jects in all its various ramifications in the field of medicine and surgery and it 
 must suffice to treat it in a comprehensive manner as an affection primarily 
 of the nervous system with the secondary involvement of the vascular system 
 as a whole. 
 
 HISTORY. 
 
 While it is only during the last fifty years that any scientific experiments 
 have been made with a view toward discovering the pathology of shock, as 
 early as 1826, Travers, in his work on Constitutional Irritation, gave an 
 exact description of the phenomena of shock. The first treatise on the sub- 
 ject I have been able to find was published in 1868, by Edwin Morris, F. R. 
 C. S. In this he states that the first mention of shock in medical literature 
 was in 1819, in the works of F. Hennen and Guthrie, writing on military 
 surgery. Morris considered death from shock due to functional disturbance 
 of the brain, the heart being affected only secondarily. He places no 
 emphasis on the part played by the sympathetic system and mentions this 
 only once incidentally as the par vagum and says it connects the spinal cord, 
 brain and heart. He treats of shock under two headings, surgical and shock 
 from mental causes. He gives the classical symptoms and concludes that 
 shock is due to paralysis of the nervous system destroying the normal 
 function of the brain and withdrawing the nervous stimulus from the heart. 
 He confuses shock and concussion of the brain, but warns against confus- 
 ing this condition with extravasation in injuries to the brain. 
 
 I have given a brief synopsis of his brochure because, being written in a 
 comprehensive manner and as late as 1868, we may assume that it contains 
 all that was known on the subject up to that date. Previous to this mention 
 was made of the subject in Cooper's "Medical Dictionary" in 1838 and in 
 Copeland's "Dictionary" in 1858. In Cooper's "Surgical Dictionary," pub- 
 lished in 1859, however, there is no mention of shock. 
 
 One of the most interesting landmarks in the history of the literature on 
 shock is Davey's work published in 1858. Under the heading of "Syncope" 
 he gives a long dissertation on the phenomena of shock, although this word 
 is used only once, and he foreshadows both the present theory of the pathol- 
 ogy and the latest treatment as demonstrated by the experiments of Dr. Geo. 
 
 382 
 
SHOCK 3S3 
 
 C. Crile and others in his observations on collapse after labor and the too 
 rapid escape of the ascitic fluid in paracentesis abdominis. "I am, however, 
 confident," he says, "that the bona fide explanation of the fact is to be 
 sought for in loss of the long-accustomed adaptation or relationship between 
 the containing and contained parts of the abdomen, whereby the ganglionic 
 nervous system is at its very center more or less paralyzed." 
 
 He says he has no doubt that the many cases of sudden death attributed 
 to cerebral hemorrhage, disease of the heart, air embolism, etc., are in 
 reality caused by "syncope," as he terms it, and that the cause is to be 
 found in the fact that "the ganglionic nervous system has been drawn on so 
 largely by the cerebro-spinal and muscular systems that there is nothing 
 remaining for the thoracic and abdominal viscera — no stimulus left for the 
 vital organs." Mr. Paget, writing in 1862, gives the phenomena and treat- 
 ment. Later Brown-Sequard and Savory (1870) made the valuable discovery 
 of the pathology of shock. Brown-Sequard announced as the result of his 
 work the theory of anaemia of the cerebral centers due to a more or less per- 
 sistent contraction of the capillaries through the vasomotor center. The 
 experiments of Goltz on frogs was the most important work done in this 
 direction until the last few years. With Brown-Sequard and Savory, he held 
 to the theory of cardiac paralysis. He showed that through the inhibitory 
 influence exerted upon the splanchnics, the abdominal vessels were suddenly 
 dilated. In Quain's "Medical Dictionary" (1884) is a statement of the 
 status of the subject of shock at that date and concludes: "For the pres- 
 ent we may thus accept as the most plausible interpretation of the symptoms 
 of shock a sudden dilatation of the abdominal vessels, attributable to an 
 inhibitory influence exerted upon the splanchnics, through the medium of a 
 special reflex center." Not much has been added to this explanation of the 
 real pathology of shock, but valuable experiments have been made in recent 
 years in the line of pathology, and some working toward a more rational 
 treatment by Geo. C. Crile, Robert Dawbarn, Harvey Cushing, Eugene 
 Boise, Guy C. Kennaman, John H. Packard and others of our own pro- 
 fession. In the extensive surgical encyclopedia edited by Dupley and Reclus 
 in 1890, "Traite de Chirurgie, " is the statement that it is only during the last 
 twenty years that shock has been studied in France and that the French, in 
 acknowledging the origin of the researches in this subject, often use the 
 English orthography, although having a legitimate word in their own lan- 
 guage, "choc." A differential diagnosis is made between shock and syncope 
 and the article concludes by saying that in fact we know nothing of the 
 pathological anatomy of shock or of its pathogenesis. The entire bibliography 
 on shock is so meager that it may be interesting from an historical stand point. 
 In addition to those already maintained, the field is practically covered by 
 the following: 
 
 Gross, "System of Survey" (1864). 
 
 Erichsen, "The Railway and Other Injuries to the Nervous System" 
 (1866). 
 
 Verneuil, "de la mort prompte apres certaines blessures ou operations" 
 (1869). 
 
384 THE ABDOMINAL AND PELVIC BRAIN 
 
 Savory, "Collapse," "Holmes System of Surgery" (1870). 
 
 Fisher, "In Volkman Samml, klin. Vortr. " (1870). 
 
 Demarquay, "In comptes rendus de l'Academie des sciences" (1871). 
 
 Renard, "Arch; Gen. demed." (1872). 
 
 Blum, "Du choc traumatique Arch, gen de med. " (1876). 
 
 Le Dentu, "Bull de la Soc. de chir. " (1877). 
 
 Vincent, "Des causes de la mort prompte apres les grands trauma tismes 
 accidentels et chirurgicaux Thesis" (1878). 
 
 Piechaud, "Que doit on entendre par l'expression de choc traumatique" 
 (1880). 
 
 Jondan Furneaux, on "Shock after Surgical Operations and Injuries," 
 "British Medical Journal" (1880). 
 
 Raffer, "La Spermantate" (1882). 
 
 Torrier, "choc traumatique Elements de path. chir. generale" (1885). 
 
 George Friedlander, "arch, fur klin. chirurg." (1903-4). 
 
 Dennis, "System of Surgery" (1895). 
 
 Mummery, Second Hunterian lecture, "New York Medical Journal" of 
 April 15, 1905. 
 
 ^ETIOLOGY. 
 
 From clinical observation of the phenomena of shock, a rather arbitrary 
 division of the aetiology has been made, viz.: Predisposing and exciting 
 causes. To establish this as a scientific classification much more must be 
 known regarding susceptibility to shock. Infants are said to be almost 
 immune, while youth is considered the period of the highest susceptibility. 
 Immunity is therefore before the age when the cerebrospinal and sympa- 
 thetic systems assume their reciprocal positions in the nervous system, sus- 
 ceptibility from the time when the untrained cerebrospinal system assumes 
 more established control over the sympathetic until the element of mental 
 influence comes in as a factor. To counterbalance this extreme suscepti- 
 bility of youth comes in the fact that at this time the resisting powers are 
 greater and many cases are recorded by different authors of recovering from 
 the most profound shock in the young which must certainly have proved 
 fatal in the old. It would almost seem that the proposition could be laid 
 down that the power to withstand and overcome shock is in inverse ratio to 
 the susceptibility. Dr. Kicrnan says that the insane are not susceptible to 
 the influences which produce shock in the sane, and in fact the effects may 
 be directly contrary — a wide field for study and speculation. Certain peoples 
 are said to be practically immune and others to be little affected. Dr. John 
 H. Packard writes interestingly on this subject. He says that Hindoos bear 
 injuries and operations impassively; that Negroes are not easily affected and 
 that Americans are especially susceptible to the influences of shock. It has 
 been observed that injuries inflicted while the subject is under the influence 
 of intoxicating liquors rarely produce severe shock. If all these clinical 
 observations can be substantiated it would point very strongly to a large 
 mental element in every case of shock, either directly or indirectly. When 
 
SHOCK 385 
 
 all is said, however, the real factor in each constitution which speaks for or 
 against susceptibility, the vital force, will after all no doubt remain the 
 unknown quantity. As regards the varying degrees of susceptibility in the 
 different organs of the body, the most vascular tissues and those most highly 
 supplied by the sympathetic nerve have been found to be most easily 
 affected. 
 
 In the present light of our knowledge we may consider as predisposing 
 causes all conditions which impair the nutrition of the nervous system and 
 consequently the circulation; exhausting diseases, prolonged physical pain 
 or mental strain, insomnia, melancholia, in fact, everything which reduces 
 vital force. Mummery says in his second Hunterian lecture that in elderly 
 patients a very high blood pressure is generally observed, largely accounted 
 for by arteriosclerosis, and that in such patients a relatively slight fall in 
 blood pressure may produce shock. It is as a predisposing cause that hemor- 
 rhage plays its proper role through the secondary physiological phenomnea 
 of anaemia which leaves the ganglia to be bathed with impoverished blood and 
 as a surgical condition to be handled surgically should be sharply differen- 
 tiated from shock proper. The exciting causes of shock may be more satis- 
 factorily considered under the classification of traumatic and mental. Direct 
 traumatism of the tissues may result from accidental injuries or from trauma 
 during the course of surgical procedures. Many writers treat this last con- 
 dition under a separate classification as surgical shock. It seems true that 
 this subject can be treated scientifically only as a subdivision of the general 
 classification of traumatism, which is either accidental or surgical. The 
 confusion has arisen by considering hemorrhage as an exciting cause of 
 shock instead of giving it its proper classification as a surgical complication 
 and secondly by the involvement of the anaesthesia in the aetiology. All sur- 
 gical writers agree that the frequency of shock has greatly lessened since the 
 general use of anaesthesia and this fact speaks loudly against operating under 
 partial or local anaesthesia, as a routine practice. I have seen patients pro- 
 foundly influenced by an excessive quantity of the anaesthetic, either on 
 account of the manner in which it was administered or the length of time 
 the patient has been held under its influence, with no symptoms of shock 
 whatever, and I cannot think the effects of long anaesthesia, serious as they 
 are, can legitimately be considered as factors in the production of shock. 
 The whole story of a depressed nervous system following a prolonged anaes- 
 thesia is told in the added traumatism caused by the repeated and unnecessary 
 handling of the tissues and the exposure to atmospheric influences tissues 
 normally protected by the coverings of fascia and skin. During extensive 
 experimentations in intestinal operations on dogs, Dr. Byron Robinson 
 demonstrated that the shock following these procedures was in direct propor- 
 tion to the amount of manipulation or traction in the abdominal viscera and 
 duration of exposure; that is, the amount of trauma inflicted upon the 
 sympathetic nerve. Sudden blows, especially in the region of the solar 
 plexus, burns and scalds involving large areas, all manner of traumatic 
 injuries, especially those producing extensive crushing of tissues, are the 
 
386 THE ABDOMINAL AND PELVIC BRAIN 
 
 principal exciting causes in shock from accidental traumatism. It has been 
 observed that burns involving a large area, causing extensive nerve periphery- 
 trauma, cause more profound symptoms than deeper burns covering a 
 small area. Irritation in one organ may produce nerve storms in a distant 
 one. The introduction of the sound in the uterus or the catheter in the male 
 urethra may produce faintness, nausea or even vomiting. Dr. Nicholas 
 Senn demonstrated a rare case in his clinic which well illustrates the prin- 
 ciple of reflex nervous irritation. The patient came into the hospital with a 
 history of anurea for sixty hours. The right kidney was enormously 
 distended, the left apparently normal. A diagnosis was made of right 
 ureteral calculus, which was removed. During the period of convalescence 
 both kidneys secreted an equal amount of urine, proving conclusively that 
 the suppression of urine from the left kidney was caused by the reflex irrita- 
 tion produced by the disturbance in the right. The size and extent of the 
 renal ganglia and their nearness to the solar plexus give to the kidneys an 
 especially strong sympathetic connection. From the first observations made 
 in the subject to the present day, all writers have recognized the mental 
 element in aetiology of the phenomena of shock. Davey, 1858, cites in detail 
 many cases and says the part played by the mind in the production of 
 "syncope" is not sufficiently appreciated. Clinical observation has estab- 
 lished the fact that a profound mental impression may cause all the nervous 
 phenomena following a blow over the solar plexus. Sad news, fright, violent 
 emotions may be followed by the same vasomotor paralysis with all its 
 accompanying nervous manifestations; and when this is said, all has been 
 said regarding our knowledge of the influence of the mind in the production 
 of the phenomena of the shock. 
 
 PATHOLOGY. 
 
 As the result of some experimentation and much speculation two theories 
 regarding the pathology of shock have been evolved, viz. : Vasomotor 
 paresis and cardiac paralysis. Almost all of the modern investigators hold 
 to the theory of vasomotor paresis. The nervous impression is conveyed to 
 the medulla by the afferent nerves, causing vasomotor paralysis and dilata- 
 tion. There is a more or less rapid fall in blood pressure. The vessels lose 
 their normal tonicity which is necessary to the rapid transition of the blood, 
 the first effect is contraction in the caliber of the capillaries, followed quickly 
 by dilatation, with at first increase in rapidity of the blood current, but in 
 proportion as the dilatation increases the rapidity decreases and may proceed 
 to a complete stasis. The right side of the heart becomes engorged and 
 does not empty at each contraction, accumulating largely in the relaxed veins, 
 leaving the arteries partially emptied; the patient bleeds into his own veins. 
 The blood is normal into the abdominal vessels. Cerebral anaemia results as 
 a natural consequence and a slowing of the activity of all the different 
 viscera dependent for the fulfillment of their physiological functions upon a 
 perfect blood supply. The influence on the heart together with all other 
 viscera is therefore secondary to the paralysis of the vasomotor system 
 
SHOCK 387 
 
 through the great reorganizing center, the solar plexus, the abdominal brain. 
 The phenomena of shock are therefore the result of a reflex inhibition affect- 
 ing all the functions of the nervous system, causing a lowering of the general 
 blood pressure, checking normal metabolism, arresting the exchanges 
 between blood and tissues; the venous blood becomes red, temperature 
 lowers in consequence of the lowered blood pressure, respiration slows and 
 we have a picture of systematic asphyxia. The entire mechanism of life is 
 deranged, the balance of power is destroyed and each organ is in an indepen- 
 dent control of its own functions for the time being and consequently only as 
 long and as thoroughly as its limited reserve force will allow. Brown- 
 Sequard, Goltz and Savory advanced the theory of cardiac paralysis. They 
 gave as the conclusion of all their experiments that shock was caused by a 
 violent impression on some portion of the nervous system acting at once 
 through a nerve center upon the heart and destroying its action. No reliable 
 findings have been found at autopsy. Parascandola claims to have found 
 certain changes in the spinal cord after profound shock affecting the cell 
 body, prolongations nucleus and nucleolus, constituting chromatolysis, frag- 
 mentation, nuclear and perinuclear. 
 
 It must be admitted that the pathology of shock after all remains very 
 indefinite and unsatisfactory, the x, as Dr. Senn has called it in the surgical 
 formula. It is therefore very difficult to give a comprehensive definition of 
 this ignis fatuus in the domain of pathology. Based in reality more on the 
 phenomena than upon the pathology, according to our present light we must 
 consider it as primarily a disturbance of the great sympathetic nervous 
 system afflicting secondarily the entire vascular system, a more or less 
 profound impression on the sympathetic nerve producing a vasomotor paresis 
 with a consequent dilatation of the right side of the heart and the large 
 vessels, especially the abdominal, and in consequence lowering the general 
 blood pressure and deranging through the solar plexus all the automatic 
 visceral ganglia, and consequently destroying their functional activity, 
 rhythm, absorption and secretion. 
 
 SYMPTOMS. 
 
 The phenomena of shock manifest themselves through the tripod of vital 
 forces, the nervous, circulatory and respiratory systems, and principally in 
 those organs most highly supplied by the sympathetic system. The rhythm 
 of the viscera is disturbed, secretions are diminished, causing an intense 
 thirst, the cry of the tissues for fluids; there is a general trophic disturbance; 
 the heart action and the respirations are increased, the temperature is sub- 
 normal, the face is pale, the lips are blue, the pupils dilated; there is nausea, 
 vomiting and restlessness, more or less pronounced according to the degree 
 of shock, until the stage of collapse, when the reflexes are lost. A cold, 
 clammy sweat appears on the entire surface of the body, and the extremities 
 are cold. Shallow respirations, with frequent sighing, yawning, hiccoughs 
 are often added to the clinical picture. 
 
 In the most profound shock, where the cerebrospinal system is involved, 
 
388 THE ABDOMINAL AND PELVIC BRAIN 
 
 this picture may be changed by the substitution for the phenomena caused 
 by a hyperirritation of the sympathetic system as nausea, vomiting and rest- 
 lessness, those manifestations resulting from a secondary depression of the 
 cerebrospinal system causing a loss of reflexes, as involuntary urination and 
 bowel movements; delirium and even stupor may appear. The cold sweat, 
 rapid, irregular pulse, subnormal temperature here persist in a more pro- 
 found degree, some observers having noted a fall in temperature of 6° F. 
 During the War of the Commune observations were taken in regard to the 
 temperature after injuries. The average temperature varied from 96.5° to 
 97.5°, the lowest registering at 93.5°. The fall was greater after shell 
 wounds and the curious fact was noted that there was a uniform lower tem- 
 perature among the insurgents than among the regular troops. 
 
 Authenticated cases have been reported where jaundice, deafness and 
 arrest of lacteal and menstrual secretions have followed profound shock. 
 Many efforts have been made to classify the nervous symptoms of shock, 
 but all are unsatisfactory for the reason that one state runs so insensibly into 
 another that it is impossible to measure the degree, except by the rate of 
 recovery, and here again come in the unsolved problems of susceptibility 
 and resistance and we simply travel in a circle and soon find ourselves at the 
 starting place again. The only classification which is any aid in diagnosis 
 and prognosis is a differentiation between the state implicating only the 
 functional activity of the sympathetic system and that in which the cerebro- 
 spinal is also involved and even here the symptoms run so imperceptibly into 
 each other that classification is elusive; even in collapse consciousness may 
 be retained until death. 
 
 The intensity of physical shock is influenced by four principal considera- 
 tions: the extent of the injury, that is, the number of nerve peripheries 
 involved; the nearness of the traumatism to the solar plexus; the character 
 of the injury, the more crushing or bruising of the nerves the greater being 
 the nervous impression ; and the severity of the pain produced. It is there- 
 fore from the standpoint of intensity rather than by means of a scientific 
 classification that we must study the phenomena of shock. 
 
 DIAGNOSIS. 
 
 The diagnosis of shock is simply the recognition of the clinical phenom- 
 ena as here we have no pathological findings to aid us. The clinical man- 
 ifestations of this nerve storm are however so pronounced that prac- 
 tically the only difficulty lies in differentiating this condition from syncope 
 caused by severe hemorrhage, with which there is danger of confounding 
 it. When syncope co-exists with shock it is often extremely difficult to 
 establish the presence of internal hemorrhage as a complication. In one 
 condition the blood leaves the peripheries and congests the abdominal vessels, 
 in the other the large and small vessels are equally deprived of the usual 
 volume of blood. In nervous shock certain tissues only lose their blood 
 supply, while there is no diminution in the quantity of blood. In the one 
 the primary violence is to the nervous system, in the other the circulatory 
 
SHOCK 389 
 
 system is attacked directly. Syncope causing always a cerebral anaemia is 
 practically identical with the last manifestations of overwhelming shock, or 
 collapse. As a recognition of the presence of hemorrhage is often of the 
 utmost importance, sometimes meaning even the saving of a life, we should 
 never rest content with a diagnosis of shock until we have excluded the 
 possibility of hemorrhage by every means in our power. If the patient is 
 seen immediately after the injury, or in surgical cases where internal hemor- 
 rhage may arise, the most reliable source for establishing a differential 
 diagnosis is by observation of the pulse and temperature. Both conditions, 
 to be sure, produce a rapid pulse with normal or subnormal temperature, but 
 there is a decided difference in the course of the pulse and temperature 
 which with careful observation one can not fail to recognize. In internal 
 hemorrhage there is a gradually rising pulse, more or less rapid according to 
 the rapidity of the bleeding, with a gradual lowering of temperature, the 
 golden rule in abdominal surgery establishing the presence of internal 
 hemorrhage laid down by Mr. Lawson Tait over twenty years ago. In 
 shock proper, however, we have the maximum rapidity of pulse and depres- 
 sion of temperature at the time of infliction of the trauma and co-existent 
 with all other clinical manifestations, as the rapid shallow breathing, cold 
 sweat, and dilated pupils. 
 
 To illustrate : A patient is taken from the operating table with a tem- 
 perature of 99°-100°, rectal, pulse 90-100. In a half hour the pulse is 110-120, 
 the temperature is found to be 98°; in another fifteen minutes to half an 
 hour the pulse has risen to 130-140 and the temperature is falling towards 97° 
 and the diagnosis of internal hemorrhage is practically established. This 
 rising of the pulse with a corresponding depression of temperature may be 
 extremely gradual and extend over hours and even days in cases of slow 
 bleeding, sometimes a mere oozing, as where an hematoma or an hema- 
 tocele is forming and before the period of infection or localized peritonitis, 
 and here of course the diagnosis is more obscure, but fortunately less urgent. 
 If, however, the patient is taken from the table with a pulse of 120-140 or 
 upwards, rectal temperatures 98°-97°, respirations 30-40, and even if these 
 conditions persist for several hours, we have no reason to fear internal 
 hemorrhage, and if after the first half hour of the patient's rest in bed the 
 pulse and respiration slow ever so little and the temperature rise even a 
 fraction of a degree we may know that we have to deal with a case of 
 recovering shock. The surgical nurse should be taught to make this differ- 
 ential diagnosis through a clinical study of pulse and temperature and 
 respiration, as it is to her that we must look for the accurate observation and 
 a prompt report of a condition in which minutes count in the saving of a life. 
 
 PROGNOSIS. 
 
 We have little to guide us in forming a prognosis, as here again the 
 unknown quantity, the vital force of the individual, the power of resistance 
 of the tissues to the nervous impression comes in as the most important 
 factor in the equation. In general the temperature is the best guide here 
 
390 THE ABDOMINAL AND PELVIC BRAIN 
 
 also. A persistence of 96° or below for several hours warrants an unfavor- 
 able prognosis while even a slight rise from time to time may be taken as a 
 happy omen. 
 
 TREATMENT. 
 
 The many and diverse theories regarding the treatment of shock shows 
 conclusively the chaotic state of the professional mind regarding this con- 
 dition. One writer is so confused in his interpretation of the phenomena 
 ? that he advised at the same time morphine, strychnia, digitalis, nitrogly- 
 cerine, whisky and citrate of caffeine. No one has done more to bring order 
 out of this chaos than Dr. Geo. C. Crile, of Cleveland, by his experiments on 
 dogs. He has practically demonstrated not only the uselessness but the harm- 
 fulness of strychnia in shock and that the rational treatment lies in raising the 
 blood pressure. He lays down the principle that the treatment must be 
 sedative to the sympathetic system and relaxing to the arterioles. To this 
 end he advises compression of the abdomen and extremities to prevent the 
 accumulation of blood in the large veins, with the administration of 
 adrenalin given with salt solution. Dr. Halsted advises morphine also 
 normal salt. It is interesting to note that Morris, as early as 1868, advised 
 opium 1-2 gr. every two hours. 
 
 Rest and heat, preferably moist, added to these remedial agents, and we 
 have certainly fulfilled the requirements for treatment in accordance with 
 all that is known of the pathology of shock, to quiet the nervous system and 
 relax the arterioles. The addition of strychnine, digitalis, nitroglycerine and 
 whisky is certainly irrational. The heart is already overworked by nature's 
 effort to repair the damage and strychnine may prove to be what the whip 
 is to the spirited horse at the end of the race, and under its influence the 
 heart may exhaust itself in a last effort. When there has been hemorrhage as 
 a complication the first indication is most assuredly to restore the volume of 
 blood, but it is certainly irrational to increase the quantity of blood suddenly 
 when the normal amount is present in the vascular system and the difficulty 
 lies in reality in properly caring for the usual quantity. It would seem 
 theoretically that increasing the volume of blood rapidly under these 
 conditions would only increase the local congestion in the large blood vessels 
 and make the ultimate restoration of the normal blood pressure more 
 difficult. Small quantities of hot water per mouth or rectum sufficient to 
 allay the thirst, or the slow, continuous rectal irrigation, which introduces 
 the fluid gradually and as the tissues are prepared to appropriate it seems to 
 me to be more rational than intravenous infusion of a large quantity of fluid. 
 Briefly stated, the treatment in hemorrhage is to restore immediately the 
 normal volume of blood, in shock to restore the normal blood pressure. 
 Dr. Robert Dawbarn calls attention to the danger of using plain water in intra- 
 venous infusion in hemorrhage and says that experiments on dogs have 
 proven that it will kill almost as quickly as prussic acid. He advises normal 
 salt solution at a temperature of 118°-120° F., one to two quarts, ten minutes 
 to be taken in introducing it. If the kidneys are not functionating normally, 
 the quantity must be lessened. 
 
SHOCK 391 
 
 Some writers make a point on the value of force of gravity and advise 
 lowering of the head. Mummery says that the ideal treatment of shock 
 would be the raising of the external air pressure, and thus substituting an 
 artificial peripheral resistance for the lost peripheral resistance caused by 
 the exhaustion of the vasomotor centers, but that as yet this method is not 
 practical. 
 
 The administration of foods and drugs by the stomach is distinctly 
 counterindicated. The same principle holds good here as in the case of the 
 heart. The stomach is exhausted and oversensitive and should not be 
 irritated or stimulated to work until the period of exhaustion has passed. 
 Perhaps the principal factor in the therapeutics of shock is rest, anatomic 
 and physiologic rest. This of course forbids all stimulants, alcoholic as well 
 as stimulating drugs. Light and sound should be excluded that the tired 
 brain may share in the general calm with which we seek to surround our 
 patient. 
 
 PREVENTION. 
 
 The preventive treatment of shock lies almost entirely in the domain of 
 surgery. Here is indeed the ounce of prevention worth a pound of cure. 
 Paget in 1868 advised hypodermics of morphine after operations before the 
 patient is restored to consciousness to lessen the shock caused by pain. 
 Davey in 1858 recommended waiting in cases of shock injuries not compli- 
 cated with hemorrhage until some of the "Promethian fire" had returned to 
 the shocked tissues. Dr. Harvey Cushing and Dr. Crile advise the cocainiza- 
 tion of main nerve trunks thus "blocking" the nerves proximal to the site of 
 operation, in severe cases where shock may be anticipated. Dr. Crile has 
 invented a pneumatic rubber suit with which he envelops the patient, which 
 he claims assists greatly in preserving the normal blood pressure. There is 
 no doubt that much can be done by the proper preparation of the patient 
 before coming to the operating table to prevent subsequent shock and the 
 practice of some surgeons of rushing nonemergency cases under the knife 
 without any preparatory treatment cannot be too strongly condemned. It is 
 self-evident that the more normal the condition of the system the greater 
 will be the resistance of shock. The indication, then, is to bring all organs as 
 far as possible to their highest function. This is especially important in the 
 case of the kidneys, bowels and skin, the great eliminatory organs; these must 
 actually secrete normally at the time of operation if we are to expect normal 
 conditions to follow. Free drainage by means of nature's own remedy, water 
 used liberally, internally and externally, for several days previous to operation, 
 will in ordinary cases be sufficient to put the kidneys and skin in good condition. 
 A free cathaisis, making sure that the entire intestinal tract is cleared, is of 
 the utmost importance. The liberal use of a normal salt solution as long 
 before the operation as possible not only aids in the systemic drainage but 
 increases the volume of the blood and promotes the rapid metabolism which 
 is so important in preserving the quality of the flood. The stomach should 
 be absolutely empty when the patient is brought to the operating table, as it 
 
392 THE ABDOMINAL AND PELVIC BRAIN 
 
 is one of the first viscera to manifest reflex irritation, and a persistent nausea 
 and vomiting keeps the patient in constant distress and the muscular system 
 in action, preventing the rest and relaxation so necessary to recovery. 
 
 Rapid operating, as rapid as is consistent with a proper attention to detail, 
 is unquestionably one of the greatest factors in the prevention of surgical shock. 
 The entire regime of the operating room should be conducive to this end. 
 Every detail, should be attended to as far as possible before the patient is 
 placed under the anaesthetic. Minutes wasted for any reason while the 
 patient is under abnormal conditions is an injustice to all concerned. In 
 abdominal surgery involving the peritoneal cavity there is little doubt that 
 shock is in almost direct proportion to the amount of handling and exposure 
 of the intestines. Mummery says that turning the intestines out of the 
 abdomen is always followed by a sudden and dangerous fall of blood pressure. 
 Methods of operating, therefore, in which these viscera are little or not at all 
 exposed can certainly claim to be a factor in the preventive treatment of shock. 
 I have frequently seen patients put to bed after the removal of large myomata 
 (hysterectomy) per vaginam with no more symptoms of shock than after a 
 normal labor. The choice of anaesthetic in cases where shock is apprehended 
 is considered by some of great importance. Mummery says that ether anaes- 
 thesia almost always causes a rise in blood pressure, while chloroform is 
 usually accompanied by a fall in blood pressure, and believes the chloro- 
 form-ether mixture to be the best anaesthetic from the point of view of 
 subsequent shock. It would seem, however, that there are more important 
 points to be considered in the choice of an anaesthetic, as the organic 
 condition of the heart, kidneys and lungs, as we have more definite know- 
 ledge of the action of ether and chloroform on these organs. The tempera- 
 ture of the operating room is of great importance, and should be kept between 
 80° and 85°F. Wetting and chilling of the body should be avoided, and heat 
 applied directly by means of a water cushion placed over the operating table 
 assists greatly in preserving the normal body temperature. The mental 
 state in which the patient comes to the operating table is no doubt an 
 important factor. Every effort should be made, therefore, to inspire the 
 patient with confidence in the success of the operation, that the demon of 
 fear may be exorcised from the sick room, that the spirit of hope may hover 
 around the last few conscious breaths and be the first to greet the awakening 
 mind struggling back to consciousness. 
 
CHAPTER XXXI. 
 
 SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE. 
 
 "Give me liberty or give me death." — Patrick Henry, American. (1136-1199.) 
 Truth should he constantly advocated because the majority constantly advocate error. 
 
 Abdominal surgery is no longer a pioneer work. It is the result of the 
 accumulated experience of the past fifty years. Its success is based on well 
 tried practices. It is a jealous field, filled with battles lost and won, marked 
 here and there with sad regrets, chagrin from unavoidable mistakes, however 
 often brightened by the light of success. A master-hand in abdominal 
 surgery is a hard-earned reputation. However, accumulative experience of 
 fifty years has still left obscure points in abdominal surgery which the genius 
 of Lawson Tait has attempted to set at rest by the exploratory and confirma- 
 tory incision — a misused and abused field. 
 
 During the past fifteen years I have been specially interested in 
 gynecology and abdominal surgery, and during these years has risen the 
 question of abdominal pain and its signification. To interpret abdominal 
 pain requires the best skill of the finest head. 
 
 Sudden, severe abdominal pain is the one significant early symptom 
 sounding the hope for relief or the knell of doom. In the interpretation of 
 sudden appearance of abdominal pain lies the physician's chance of success 
 or failure — usefulness or disaster. This cry of sudden pain may come from 
 multiple lesions or sources — it may be the appeal of a strangulated loop of 
 intestine on the verge of gangrene; the demand of an agonizing ureter 
 afflicted with a bristling calculus; the disaster of a perforated appendix in 
 the dangerous peritonitic enteronic area; the horrible, grinding, hopeless pain 
 of a biliary calculus; the calamity of a ruptured gestating oviduct; or from 
 the beginning painful perforative peritonitis of impossible diagnostic origin — 
 accompanied by excruciating pain. 
 
 Abdominal pain belongs to the domain of the nervus vasomotorius, the 
 sympathetic nerve, and should be interpreted according to its life and habits, 
 in relation to its anatomy, distribution to viscera and physiology (rhythm) 
 peristalsis. Rhythm is a physical accompaniment of life. 
 
 Severe abdominal pain is the appeal for prompt, efficient assistance. In 
 the first place, in my experience, the natural manifestation of sudden abdom- 
 inal pain is too frequently obtunded, dulled, lulled into a treacherous quietude 
 by the general practitioner's employment of large hypodermic injections of 
 morphia, which obscures diagnosis. Frequently it is the mode of onset, the 
 sudden appearance and localization of the pain that affords the sharpest aid 
 to diagnosis, and if the sharpest, delicate symptoms are obscured by morphia 
 it may jeopardize the patient's life. 
 
 393 
 
394 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Sudden pain in the abdomen is frequently the guiding, suggestive means 
 to a diagnosis. Pain in any location is the conscious expression of nerve 
 trauma, whether it be macroscopic or microscopic. 
 
 Pain is an objective as well as a subjective symptom. Its subjective 
 character forces us to depend on the patient's statement for its location, 
 severity, duration. Pain is the most constant beginning feature and frequently 
 the most constant, persistent characteristic. For this reason the practitioner 
 should secure a complete clinical history, mode of onset, location of pain, 
 
 rhythmic or constant, be- 
 fore he obscures its most 
 delicate and valuable aid 
 to diagnosis by narcotics. 
 Abdominal pain is 
 Nature's warning that 
 mischief is afoot in the 
 abdominal viscera, and its 
 manifestations should not 
 be obscured by opium until 
 sufficient evidence is 
 secured to diagnose the 
 cause. The successful di- 
 agnosis depends on the 
 most careful analysis of 
 every available symptom 
 in severe abdominal pain, 
 which is defective in a 
 narcotized patient. 
 
 A characteristic of 
 
 sudden abdominal pain is 
 
 that at first it is diffuse or 
 
 mainly in the umbilical 
 
 region (the abdominal 
 
 brain, the sensorium of 
 
 the abdominal viscera). 
 
 Gradually, with the 
 
 lapse of time — hours — it becomes more and more localized in the region of 
 
 the affected organ (beginning local peritonitis). 
 
 A suggestive symptom is that almost all patients with sudden abdominal 
 pain especially beginning peritonitis, vomit. The failure of the general 
 practitioner in appreciating the significance of sudden severe abdominal pain 
 results in late, and too frequently disastrous, surgery, also in disastrous 
 treatment by administrating cathartics, the enemy of visceral quietude. 
 
 In sudden abdominal pain the pulse in general is of more practical value 
 than temperature. In some advanced, grave abdominal diseases the pain is 
 limited or absent. Overwhelming profound sepsis has obtunded sensibility. 
 In sudden abdominal pain the first and foremost matter is its diagnosis — the 
 
 STRANGULATION OF THE SIGMOID BY BAND 
 
 ORIGINATING FROM BILATERAL 
 
 PYOSALPINX 
 
 Fig. 85. This is an illustration of a peritoneal band 
 obstructing the sigmoid from a woman physician oper- 
 ated by Dr. Lucy Waite. I assisted Dr. Waite and saw 
 the elongated band attenuated in the middle. Its rupture 
 allowed the gas to rush through the sigmoid with recovery. 
 The termination of the band (1) is at 2 and 4 on the right 
 side and at 3 on the left side. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 395 
 
 rock and base of rational treatment. The diagnosis is absolutely required 
 in order to attempt rationally to remove the cause. 
 
 Probability is the rule of life and it is just as applicable in diagnosing 
 sudden abdominal pain as in other matters. For example, when a man is at- 
 tacked by sudden abdominal pain and vomiting with rise of temperature, 
 pulse and respiration, the probability is that it is appendicitis — not perfora- 
 tion of the gastrium, enteron or colon, for that occurs perhaps one hundred 
 itimes less than perforation of the 
 appendix. 
 
 Observation. — I was called to 
 attend a physician who was at- 
 tacked with sudden abdominal 
 pain while riding in his buggy. 
 The abdominal pain from the 
 beginning was located several 
 inches to the left of the medium 
 line of the abdomen. The diag- 
 nosis was ruptured appendicitis 
 from a potential appendix, i. e., 
 one with an elongated meso-cceco- 
 appendicular apparatus capable 
 of extending or moving to loca- 
 tions distant from the usual ap- 
 pendicular site. The improbable 
 diagnosis was intestinal perfora- 
 tion, because the appendix per 
 forates perhaps a hundredfold 
 more than the intestine. In op- 
 erating on the physician forty 
 hours subsequent to the attack I 
 found the peritonitis localized to 
 the left of the medium line of the 
 abdomen in the enteronic coils 
 located in the left iliac fossa. 
 The potential appendix was 
 during operation practically in its usual location, however, surrounded 
 by peritonitis. The explanation was evident. He had a potential appendix, 
 which while wandering amongst the intestinal loops in the left half of the 
 abdomen had become perforated and immediately, before adhesions formed, 
 returned to its usual location in the right iliac fossa. The extensive, varying 
 mobility of the cecum and appendix should be included in the anatomic 
 diagnosis. 
 
 Anatomy is the solid ground of nature on which to build a rational 
 diagnosis of sudden abdominal pain. 
 
 HERNIA OF 8 FEET OF ENTERON IN 
 FOSSA DUODENO-JEJUNALIS 
 
 Fig. 86. This occurred in a woman about 35 
 years of age. The 8 feet of enteronic loops lying 
 in the fossa duodeno-jejunalis were reduced with 
 facility. 
 
396 THE ABDOMINAL AND PELVIC BRAIN 
 
 patient's history. 
 
 We should study the history of the abdominal pain in each patient for 
 aid in diagnosis. 
 
 A clinical study of abdominal pain is of the utmost importance to both 
 general physician and abdominal surgeon. Has the patient experienced 
 similar sudden abdominal pain previously? What was the length of time 
 elapsed between the previous attacks of pain? If the pain is recurrent it is 
 probably from the same original cause, e. g.„ repeated perforated appendi- 
 citis or repeated attacks from calculus Has the pain any regular persistent 
 relation to the ingestion of food or fluid? If so we examine the proximal 
 end of the tractus intestinalis, as for gastritis, ulceration, biliary passages, 
 pancreatic disease and perhaps appendicitis. If the pain persistently 
 precedes or follows defecation, search for rectal disease — hemorrhoids, fissure, 
 ulceration, carcinoma. If the pain recurs with menstruation, one examines 
 the genitals. If the pain be sudden and occurring for the first time, we should 
 scrutinize its history and every visceral function. Pain following extra 
 exertion may be due to hernial strangulation, ruptured pregnant oviduct, 
 breaking of peritoneal adhesions, formation of volvulus, rupture of a cystic 
 tumor, an ovarian cyst, or other tumor or viscus, rotated on its pedicle. 
 Pain following extra trauma may be ruptured bladder, stomach, intestines or 
 other viscera. In gestation an impending miscarriage may cause sudden 
 abdominal pain. Clinical history is the most valuable in acute abdominal 
 pain — not in chronic. Repeated rough rides with repeated abdominal pain is 
 suggestive of calculus. The repeated abdominal pains due to painful per- 
 istalsis in inflamed ducts — biliary, ureteral, intestinal, genital — is still difficult 
 to diagnose. 
 
 It should be distinctly remembered that sudden recurrent abdominal 
 pain following peritonotomy or peritonitis is mainly due to peritoneal bands 
 checking peristalsis, or painful peristalsis from inflamed viscera. Sudden 
 abdominal pain in a patient who had had hernia is liable to be from con- 
 strictions of peritoneal bands. The clinical history is frequently a pencil of 
 light in the diagnosis of sudden abdominal pain. 
 
 AGE AND SEX. 
 
 Age and sex are of extreme value in diagnosing sudden abdominal pain. 
 In woman, in the maximum sexual phase, the lesions of the tractus genitalis 
 surpass those of the tractus intestinalis. Still a differential diagnosis between 
 appendicitis and right-sided inflamed oviduct, peritoneum and ovary, is 
 frequently difficult. 
 
 Sudden pain in anemic young women may be perforating round ulcer of 
 stomach. 
 
 In children lesions of the tractus intestinalis preponderate, gastero- 
 enteritis, invagination, enterocolitis, appendicitis. 
 
 In senescence malignancy may attack the gastrum, colon, rectum, gall 
 bladder and pancreas, as well as ulceration of the intestinal tract usher in 
 pain. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 397 
 
 CHARACTER OF ABDOMINAL PAIN. 
 
 Abdominal pain may be acute or chronic, it may be tolerant or excruciat- 
 ing (peritoneal extravasation). It may be due to intra-abdominal or extra- 
 abdominal disease. It may arise from violent peristalsis (colic) in tubular 
 viscera or from inflammation. Abdominal pain may be due to disease or 
 trauma. 
 
 If one will closely watch the sudden acute abdominal pain, it will be 
 quite apparent that the character of the pain in most of the acute affections 
 is very similar. We only observe a reality in difference of degree of pain 
 from the bearable to the agonizing. In perforation the character of the 
 pain is the same in all viscera. In invagination it is paroxysmal and periodic, 
 at least at first, due to irregular and violent peristalsis. In internal strang- 
 
 HERNIA IN FOSSA DUODENO-JEJUNALIS 
 
 Fig. 87. I secured this specimen from an autopsy. The subject had numerous recur- 
 rences as was demonstrated by the marked cicatricial strictures at various points of the 
 enteron. Also saccular dilatations (9) of the enteron demonstrated repeated recurrences. 
 
 ulation it is generally intense and periodic, due to violent peristalsis; later 
 continuous and of an aching, dragging character, due to paralysis of the 
 intestinal segments. In appendicitis the pain is nearly always sudden and 
 intense, i. e., the perforative variety. The variety of appendicitis with 
 slowly increasing pain is likely lymphatic in invasion and not dangerous, 
 simply medical, though of course the appendicular mucosa may be perforated. 
 Sudden, acute abdominal pain of a lancinating character, and quite continu- 
 ous, is very likely to be due to perforation of the appendix or digestive tube, 
 and the continuous, agonizing character of the pain is a heraldic symptom 
 of diffuse peritonitis— the knell of life. It may be remembered that the 
 character of sudden acute abdominal pain will depend on the capacity of 
 any viscus for peristalsis, i. e., its capacity to cause colic by violent, wild, 
 
398 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 irregular muscular action. In peristalsis periodicity must not be forgotten, 
 and the etiology which gives rise to the initation, inducing the peristalsis. It 
 may be transitory in character, as food irritation, rapidly forming and inducing 
 invagination, or a calculus attempting to enter a duct. Or the pain may be 
 continuously periodic, as a calculus lodged in some canal, appendix, ureter, 
 enteron, colon, or biliary. Head and Sherren claim that the body is 
 endowed with three forms of sensibility conducted by three series of fibers 
 in the efferent nerves, viz. : 
 
 1. The nerves which subserve deep sensibility. The fibers of deep sen- 
 sibility or "deep touch" course chiefly with the motor nerves to the muscles, 
 
 aiding muscular protection 
 of viscera, and also supply 
 the fibrous structures con- 
 nected to the muscles — mus- 
 cular sense. 
 
 2. The nerves which 
 respond to painful impres- 
 sions and to extreme heat 
 and cold responding to light 
 touch — skin sense. This 
 second system of nerves 
 Head and Sherren term 
 "proto phatic. " 
 
 3. The nerves which en- 
 able light touch and the 
 minor degrees of tempera- 
 ture to be appreciated and 
 two points to be discrimi- 
 nated. 
 
 To the third system of 
 sensibility the name "epi- 
 critic" is applied — tempera- 
 ture and location sense. 
 The sensibility of the abdo- 
 men is a significant matter in sudden abdominal pain. 
 
 The abdominal cutaneous sensibility must be distinguished from the sen- 
 sibility of the abdominal musculature and also the condition as to whether the 
 hyperesthenia be unilateral or bilateral, symmetrical or non-symmetrical, e. 
 g., McBurney's point is frequently simply a nervous point. At this point the 
 nerves of the coecum correspond with the nerves of the abdominal wall 
 immediately ventral to it, i. e., the appendicular nerves being irritated trans- 
 mit sensations to the spinal cord where reorganization occurs and the impulses 
 are emitted over the intercostal nerves to the abdominal wall at McBurney's 
 point. The same condition will occur relative to other viscera, e. g., the 
 kidney. 
 
 Pain may be reflex or sensitive, hyperesthesia, neurosthenia, hysteria. 
 
 INVAGINATION OF ILEUM 
 
 Fig. 88. This was drawn from a child about 10 
 months old. At the operation, which was on the 4th 
 day, I could not disinvaginate the ileum without in- 
 flicting irreparable damage. The child died 12 hours 
 later. 
 
SUDDEN ABDOMINAL FALX—ITS SIGNIFICANCE 
 
 399 
 
 Gastric ulcer is especially liable to manifest pain from cold drink, solid 
 food. 
 
 In the diagnosis the pain is the most important element to both patient 
 and physician. 
 
 The anatomic and physiologic side must be studied, analytically. 
 
 It may be remembered that the dorsal and ventral (parietal) peritoneum 
 is sensitive to trauma according to individuals. The healthy visceral peri- 
 toneum is not sensitive to trauma. The healthy viscera may be handled 
 without pain. 
 
 Pain on abdominal palpita- 
 tion may arise from radiation. 
 
 Subjects vary as to their sus- 
 ceptibility of pain. 
 
 Pain manifests certain char- 
 acteristics as facial expression, 
 position of body, muscular ten- 
 sion. 
 
 Sudden abdominal pain de- 
 pends on definite cause and it 
 behooves the physician to dis- 
 cover it. 
 
 On account of the multiple 
 viscera, complex nerve supply, 
 and numerous functions the ab- 
 domen presents the most abun- 
 dant and varied pain of any body 
 region. 
 
 The sudden beginning of se- 
 vere abdominal pain is frequently 
 significant of serious trouble. 
 
 Gastric Crisis. So-called 
 abdominal crises should be stud- 
 ied with care that life may not be 
 placed in jeopardy or disastrous 
 treatment instituted. First and 
 foremost is the gastric crisis of 
 locomotor ataxia in which the 
 patient is attacked with paroxys- 
 mal vomiting and severe gastric 
 pain enduring from some hours to several days and may recur after days 
 or weeks. In such cases the symptoms of tabes dorsalis will aid the diagnos- 
 tician. 
 
 Nephritic Crisis, or the so-called "Dietl's crisis," perhaps should be 
 considered as a trauma on the nerves, vessels and ureter of a dislocated 
 kidney. Torsion of the nephro-neuro-vascular pedicle with flexion of the 
 ureter doubtless accounts for this rare phenomenon. Dietl's crisis is fol- 
 
 ILEO-CCECAL INVAGINATION 
 
 Fig. 89. Drawn from a woman about 38 
 years old. At the first operation I could easily 
 disinvaginate. The ileo-ccecal invagination re- 
 curred some two months later and at the second 
 operation I resected the coecum and reunited the 
 ileum and colon. The patient died some 10 days 
 later. Autopsy demonstrated that invagination 
 was due to an enormous coecal ulceration and the 
 colon was beset with perhaps a dozen ulcers 
 from the dimension of a dime to that of a silver 
 dollar. 1, Coecum and appendix. II, ileum. 
 
400 THE ABDOMINAL AND PELVIC BRAIN 
 
 lowed by local tenderness in the renal region, hence, infection occurred in the 
 peritoneum. 
 
 Gas in the tractus intestinalis is a frequent accompaniment of abdominal 
 pain. However, the presence of the gas does not produce the pain, as that is 
 mainly due to trauma, stretching of the inflamed nerves in the peritoneal 
 sheet. 
 
 LOCATION OF ABDOMINAL PAIN. 
 
 How far can we diagnose abdominal pain by its locality? Only to a 
 limited degree. Associated circumstances must aid in the diagnosis. There 
 are three common localities of acute abdominal pain or peritonitis, viz., 
 pelvic, appendicular and that of the gall-bladder region; and as probability 
 is the rule of life, it is well to diagnose acute abdominal pain as a disturbance 
 in one of these three localities of the peritoneum until proved otherwise. 
 
 Acute abdominal pain in general is referred to the umbilicus — in other 
 words, the region immediately over the solar plexus or abdominal brain, the 
 receiver of the impressions of abdominal viscera. Acute abdominal pain is 
 generally due to a disturbance of the peritoneum, owing to a lesion of an 
 adjacent viscus; but since the peritoneal lesion can arise from many organs 
 and from several points of the same organ, it demands the most experienced 
 diagnostic acumen and the most mature judgment to interpret the significance 
 of the lesion through the abdominal wall. No one can decide what kind 
 of wood lies under a table cloth. I have repeatedly observed in appendicitis 
 that patients say the acute pain, especially in the beginning, is over the 
 whole middle of the abdomen (solar plexus). This may be due to excessive 
 and violent peristalsis of the enteron. As regards locating the pain at any 
 point of the enteron, it cannot be done, first, because the loops of intestines 
 have no distinct order as to locality; second, the patient cannot discriminate 
 a point of pain at any given locality, perhaps from lack of practical 
 experience. 
 
 Pain in a particular area does not invariably signify that the cause of the 
 pain is located in that region. The absence of pain in regions is significant. 
 
 Though pain in the umbilical region be indeterminate of location, it is 
 frequently the knell of distress in peripheral visceral lesion as appendix, 
 oviduct, invagination, axial relation. 
 
 However, a kind of sudden severe abdominal pain may arise from violent 
 irregular peristalsis (rhythm) in non-inflamed (or slightly inflamed) tubular 
 viscera, as foreign bodies (hepatic, pancreatic, ureteral, intestinal calculus) 
 as strictures (intestinal, ureteral, biliary, pancreatic ducts, appendix, 
 oviducts). 
 
 In sudden abdominal pain (especially peritonitic extravasation) four 
 factors may be observed, viz. : (a) (Sympathetic), First, diffuse pain in the 
 central abdomen, umbilical region, solar plexus, the three abdominal sensory 
 areas, cutaneous, peritoneal and muscular are affected, shocked. The bed 
 clothing cannot be tolerated (sensory, skin) and the abdominal muscles 
 are rigid — muscular visceral protection. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 401 
 
 (b) Later localization of the pain occurs over the affected viscera 
 (peritonitis). 
 
 (c) (Spinal nerves) Rigidity of abdominal muscles arise over affected 
 viscus (somatic muscular, protection of viscera). 
 
 (d) Hyperesthesia of the skin over the affected viscus (somatic cutaneous, 
 protection of viscera). 
 
 It must be noted that cutaneous or sensory manifestations of somatic 
 spinal and visceral nerves may extend over their entire periphery, e. g., in 
 appendicitis, hyperesthesia or supersensitiveness of the skin may be found 
 in the right iliac fossa, over the pubis, pudendum, Poupart's ligament, and 
 the testicle. 
 
 In regard to the location of sudden acute abdominal pain we have to 
 
 Fig. 90. An illustration to expose the progressive steps of uterine invagination 
 (intussusception or inversion) from the depression at 1, to the completed process at 2. 1, 
 is where the invagination begins. 2, presents the progressive steps of the fundal progress 
 through the os uteri. 3, the vaginal fornices subsequent to the uterine invagination ; the 
 cervix presents a vigorous rigid ring, resembling a giant anal sphincter, with steady, 
 continuous, vigorous pressure on the invaginated portion of the uterus ; the rigid cervical 
 ring gradually yields, dilates and the uterus disinvaginates like a spring. The uterus 
 becomes reduced like a dislocated joint. Hence, like intestinal invaginations and volvulus, 
 the uterus may tend to reinvaginate. 
 
 consider (a) the seat of pain as felt by the patient; (b) the pain elicited by 
 pressure (tenderness); (c) local rigidity of the abdominal muscles; (d) anes- 
 thetic or hyperesthetic condition of the skin of the abdomen. 
 
 As to local tenderness of pain elicited by pressure, it indicates a patho- 
 logic condition of viscus or of the peritoneum (inflammatory). The pain is 
 induced by motion or disturbance communicated to a sensitive inflamed area, 
 peritoneum. 
 
 Local rigidity of abdominal muscles indicates adjacent disease of organs 
 supplied by the same nerves as the muscles which exercise a protective 
 agency, to preserve rest for damaged tissue, to assume repair, and to pre- 
 vent further damage from motion, e. g., distribution of sepsis by peristalsis. 
 Hyperesthesia or sensitiveness of the skin due to transmitted irritation, is 
 often present, but is not very reliable as to locality, for it is dependent on 
 
 26 
 
402 THE ABDOMINAL AND PELVIC BRAIN 
 
 peculiar symptoms and accompanies, more or less, though irregularly, most 
 acute abdominal affections. Of course it would be expected that the severe 
 sudden onset of pain in the renal and biliary ducts, being very near the 
 abdominal brain, would be difficult to separate from the solar plexus. Lead 
 colic may deceive the most elect as to its etiology or seat. 
 
 With few exceptions, to locate the seat of lesion in acute abdominal 
 pain, we call to aid the pain elicited by pressure. Pressing the abdominal 
 walls produces a distinct localized tenderness or pain which suggests local- 
 ized pathology. Again, rigidity or tension of the abdominal wall is suggest- 
 ive of pathologic locality. The symptom is simply purely reflex, due to 
 irritation passing from the involved viscera to the spinal cord, whence its 
 irritation is transmitted to the periphery of the distal intercostal nerves which 
 control the abdominal muscles over the seat of pain. Dashing cold water 
 on the belly will produce similar protective muscular rigidity. Hence, in 
 general, the location of the disease in the abdomen from the patient's 
 feeling of sudden acute pain, is quite indefinite. But local tenderness and 
 local pain on pressure aid much. Localized rigidity of the abdominal wall 
 is suggestive that such tension is protecting the seat of disease from motion, 
 further bacterial or fecal invasion. In short the rigid muscles are placing 
 the pathologic parts to anatomic and physiologic rest. 
 
 Vomiting is a general characteristic of sudden acute abdominal pain. In 
 sudden acute abdominal pain, from visceral lesion, Nature makes profound 
 effort to manifest its distress, however to diagnose the seat of pathology and 
 its nature from localization of the pain requires much reading between the 
 lines from experience and judgment. 
 
 Again, a vast difference exists between sudden acute abdominal pain 
 and that which progresses gradually. Much depends on the stage of the 
 disease in which the physician first visits the patient. 
 
 The signification of sudden acute abdominal pain may be more actually 
 realized by a short consideration of some of the principal conditions which 
 occasion it. 
 
 In some cases the physician is unable to localize the pain in any visceral 
 tract under such conditions, the apt remark is that probability is the rule of 
 life; hence an exploratory operation in the region of the appendix and gall- 
 bladder is justifiable in subjects jeopardized by imminent danger. The most 
 frequent point of pain or pressure is the epigastrium, the abdominal brain or 
 plexus coeliacus. 
 
 REFLEX OR REFERRED PAIN. 
 
 In general, sudden acute abdominal pain is referred by the patient to the 
 umbilical region, to the solar plexus, directly over the abdominal brain. This, 
 in my opinion, is a nervous center, possessing the power of reorganization, 
 of receiving and transmitting forces, controlling visceral circulation and 
 inducing reflex or referred pain. The irritation of peripheral visceral nerves 
 is transmitted to the abdominal pain, when reorganization may localize 
 the pain over the abdominal brain, at the seat of disease, or at a remote 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 4.03 
 
 abdominal point, due to a supersensitive nervous system. Anal fissure, or 
 ulcer, is one of the most typical examples to produce reflexes in the abdom- 
 inal viscera, especially in the tractus intestinalis. Short trauma of viscera, as 
 hernia, acute flexion of tubular viscera, induces abdominal pain and especially 
 by reflexes. 
 
 OBSCURE SYMPTOMS OF ABDOMINAL PAIX. 
 
 Reflex pain from distant areas may simulate severe abdominal pain, 
 multiplying the difficulties in differential diagnosis. 
 
 Obscure symptoms of abdominal pain arise from the invasion of the 
 
 Fig. 91. An illustration presenting complete uterine invagination. The oviducts 
 and ovaries may be entirely included within the invaginated uterus. 1, ovary ; 2, oviduct ; 
 3, round ligament; 4, uterine fundus with diamond-shaped aperture resected from its wall ; 
 5, vaginal lumen. Drawn from subject dying from trauma, shock, due to uterine invaginatic 
 2J/2 hours subsequent to labor. I performed the autopsy 4 hours after death. 
 
 peritoneum from pneumonia. In fact I have seen a half dozen physicians i 
 consultation advise and perform peritonotomy in a case of pneumonia, s 
 deceptive were the abdominal symptoms — pain, tenderness, tympaniti 
 temperature, muscular rigidity and respiration. 
 
 Pleurisy or intercostal neuralgia extending over a large area of inte - 
 costal nerves which supply the abdominal wall may simulate sudden abdom- 
 inal pain — for the trunk of a nerve being irritated manifests its sensation, 
 pain, at its periphery which, in the case of the intercostal, end in the abdominal 
 wall. 
 
404 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Abscess in the abdominal wall may simulate abdominal, peritoneal or 
 visceral pain, from irritation of the intercostal (abdominal wall) nerves. Dr. 
 Lucy Waite had in her charge in the hospital a child with an abscess in the 
 abdominal wall which simulated extremely abdominal visceral (peritoneal) 
 disease. 
 
 Amygdalitis mastitis and hysteria may simulate abdominal pain. 
 
 In post-operative peritoneal hemorrhage (peritoneal extravasation) the 
 pain is obscure, as the previously traumatized, and consequently obtunded, 
 
 sensibility of the peritoneum does 
 
 not manifest recognition of the 
 bleeding, while peritoneal hem- 
 orrhage (peritoneal extravasation) 
 from ruptured pregnant oviduct 
 produces excruciating pain. 
 
 Spinal cord lesions may sim- 
 ulate abdominal pain by a diffuse 
 sensitiveness over the affected 
 intercostal nerves, e. g., the gir- 
 dle, constricting pain in tabes 
 dorsalis or locomotor ataxia. 
 
 Uremia may be accompanied 
 by persistent vomiting. Pain in 
 right shoulder may refer to he- 
 patic disease. 
 
 Spinal caries may produce 
 pain in portions of the abdomen 
 from pressure on dorsal or lumbar 
 nerves, as sensory areas or rigid 
 muscular areas. 
 
 Testicular pain may refer to 
 a ureteral calculus. Crushed tes- 
 ticle may induce severe abdom- 
 inal pain, vomiting and shock, as 
 its route to the abdominal brain is 
 direct and rich in nerves. 
 
 Hyperesthesia of the iliac re- 
 gions are deceptive, because these 
 regions are supplied by the cuta- 
 neous branches of the ileo-hypogastric nerve (first lumbar). McBurney's 
 point is practically a skin hyperesthesia, a super-sensitiveness of skin area 
 included in the peripheral region of cutaneous twigs of the last dorsal 
 (twelfth intercostal) nerve and the ileo-hypogastric (first lumbar) nerve. 
 
 In short, if any sensory intercostal or lumbar nerve be affected (by somatic 
 diseased viscera) it will manifest sensory skin areas at its corresponding 
 periphery. 
 
 Muscular rigidity of the abdominal wall will be manifest in the somatic 
 
 VOLVULUS OF SIGMOID 
 
 Fig. 92. Drawn from a subject with physio- 
 logic or incomplete sigmoid volvulus. Z, Sig- 
 moid. The volvulus is rotated about 360 degrees. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 405 
 
 area of the spinal nerves corresponding to the diseased viscera (simulating 
 the cutaneous area). In short, if any motor intercostal or lumbar nerve be 
 affected (by somatic diseased viscera) it will manifest motor (muscular rigidity) 
 area at its corresponding periphery. 
 
 A feature of obscurity in the diagnosis in abdominal muscular rigidity is 
 that when a part of an abdominal muscle becomes irritated, the whole (and 
 not part) of the muscle becomes rigid. Hence the muscular rigidity is the same 
 for perforated appendix or gall-bladder. For general peritonitis the whole 
 abdominal muscular apparatus is 
 rigid. 
 
 In the tractus nervosus the 
 neuroma of intercostal or lumbar 
 nerves must not be overlooked. 
 I have observed three subjects of 
 neuroma on the ileo-hypogastric 
 or ileo-inguinal nerve. One in 
 Prof. Senn's clinic where a neu- 
 roma on a nerve in the abdominal 
 wall in the region of the appendix 
 was exquisitely tender inducing a 
 diagnosis of appendicitis. The 
 analytic, searching diagnostic 
 methods of Prof. Senn soon 
 discovered the tender neuroma, 
 which he removed instead of the 
 appendix. One subject, a female, 
 24 years of age, was sent to me 
 with a diagnosis of appendicitis. 
 I found a typical neuroma on the 
 lumbar nerve in the region of 
 the appendix. A third case of 
 neuroma of a lumbar nerve in 
 the appendicular region I saw in 
 consultation with Dr. I. Wash- 
 burn, of Rensselaer, Indiana. 
 Abdominal pain is the surface 
 indication of various pathologic 
 states of the abdominal organs (or 
 abdominal wall). In abdominal pain the chief skill is in the diagnosis, for the 
 correct treatment depends on the diagnosis. The more correct the diagnosis 
 the less "neurosis" will occur in abdominal pain. The abdominal wall, 
 including the cutaneous and muscular layers, receives its (chief) nerve supply 
 from the spinal cord, which contains sensor} r and motor nerves. The viscera 
 receive their (chief) nerve supply from the sympathetic, which contain sensory 
 and motor (rhythmic). (The parietal peritoneum has a mixed nerve supply.) 
 The spinal cord emits nerves through the rami communicantes to the viscera 
 
 VOLVULUS OF SIGJvlOID 
 
 Fig. 93. Drawn from a subject with physio- 
 logic or incomplete sigmoid volvulus which is 
 360 degrees rotated. 
 
406 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 and receives nerves from the viscera. The spinal cord emits nerves to the 
 abdominal wall (muscle and skin). Hence the viscera and abdominal wall are 
 in direct, harmonious, balanced relations and consequently of vast value in 
 diagnosis. Any visceral disorder is reported to the spinal cord which is at 
 once emitted to the abdominal wall for protective purposes (muscular rigid- 
 ity). The visceral walls are the thoracic and abdominal and cannot be divided 
 — they are supplied by the spinal nerves which overlap, extending from clavicle 
 
 to pelvic floor. 
 
 Man's breathing apparatus con- 
 sists of the thoracic and abdominal 
 wall. The thoracic visceral rhythm 
 (sympathetic) dominates in the tho- 
 racic wall. 
 
 All the visceral tracts except the 
 nervous may manifest painful peri- 
 stalsis from inflamed ducts or canals. 
 
 STRANGULATION BY BANDS AND 
 THROUGH APERTURES. 
 
 Strangulation by bands and 
 through apertures constitutes one- 
 third of all intestinal obstructions. 
 If the bowel loops glide through an 
 inguinal or femoral aperture, digital 
 examination will detect the cause of 
 sudden, acute abdominal pain. Ob- 
 turator and sacro sciatic hernia are 
 seldom diagnosed, so that they would 
 practically be included in internal 
 strangulation by peritoneal bands. 
 Sex does not aid in diagnosis, for 
 males and females about balance in 
 peritonitis during life, hence will 
 possess about the same amount of 
 peritonitic bands. 
 
 A history of previous peritonitis 
 tells a significant story of strangula- 
 tion by bands. Vomiting is violent, 
 pain from peristalsis is periodic and general over the abdomen. The pain is 
 not due to checking of the fecal current, but to reflex irritation of the bowel 
 at the seat of obstruction. Temperature is not conspicuous and the pulse 
 is not much changed. Tympanitis arises in exact proportion to the peristal- 
 sis of the bowel wall proximal to the seat of obstruction. At first the pain is 
 violent, but it subsides with the progress of the case, becoming more contin- 
 uous and generally diffused. If the patient be quiet, the pain is so slight 
 that it deceives the most elect. No stool, no gas per rectum, no detectible 
 
 VOLVULUS OF ILEO-CCECAL 
 APPARATUS 
 
 Fig. 94. Drawn from subject with phys- 
 iologic or incomplete volvulus of the ileo- 
 coecal apparatus. I, presents the state of the 
 volvulus — about 200 degrees. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 407 
 
 swelling at any hernial aperture with continuous abdominal pain and vom- 
 iting, demand surgical notice. The temperature and pulse are not reliable. 
 Strangulation by bands will generally give no tender location on pressure and 
 no detectible swelling; and, in fact, I have watched cases with the abdomen 
 quite soft and pliable, with no possible physical point of diagnostic value, 
 not even tympanitis, yet with obstruction which proved gangrenous on peri- 
 tonotomy. In one case the pain was at first severe, general, and almost 
 subsided the day before the operation, yet fifteen feet of intestine was as red 
 
 ENTERONIC VOLVULUS 
 
 Fig. 95. Drawn from a child 14 months old, referred to me by Dr. Walter Fitch. I 
 operated on the third day and found the pedicle, foot or style, of the volvulus to be located 
 at the coecum, the constriction being due to the rotation of. the distal end of the ileum and 
 proximal end of the jejunum around each other as an axis. On opening the abdomen the 
 colon was collapsed while the enteron was enormously distended. After releasing the vol- 
 vulitic pedicle the gas rapidly distended the entire colon and large volumes with ample stool 
 passed per rectum. The child died of peritonitis 3 days later. 4, Volvulitic pedicle of 
 enteron. 
 
 as sunset. The sudden, acute abdominal pain is not due to the constricting 
 band, but to reflex irritation transmitted to the abdominal brain, where 
 reorganization occurs, whence it is emitted to the whole digestive tract, 
 inducing violent, disordered and wild peristalsis (colic). 
 
 Acute, sudden abdominal pain, due to a constricting peritoneal band is 
 one of the most obscure to interpret. To explore the abdomen in the proper 
 time for such a case requires a wise diagnostician and a bold surgeon. The 
 matters to bear in mind by strangulation by bands are, the acute, sudden 
 abdominal pain with a violent onset, vomiting, and the distinct colicky, 
 
408 
 
 THE ABDOMINAL AND PELVIC BRAIX 
 
 peristaltic, periodic character of the suffering, not forgetting a previous his- 
 tory of peritonitis. However, the sudden, acute abdominal pain, arising from 
 a strangulation of a loop of bowel by peritonitic bands, is difficult to interpret 
 and seldom diagnosed. It may be asserted, that when a patient is suffering 
 from some grave disease, manifest by sudden acute abdominal pain, the 
 nature of which cannot be interpreted, an early exploratory laparotomy is 
 justifiable and demanded. Such obscure cases require an experienced surgeon, 
 
 skilled in abdominal work, to 
 meet any emergency, to enter the 
 peritoneum and retire rapidly. I 
 remember very distinctly the case 
 of a man, about 40, who gave 
 consent to my colleague, a gen- 
 eral practitioner, who was entirely 
 untrained by experience or obser- 
 vation in abdominal surgery. The 
 doctor told me he opened the 
 abdomen and found a band 
 stretching tightly across the right 
 colon. But he said "the colon 
 was black, and I did not know 
 what to do with it, so I closed 
 the abdomen." It is needless to 
 say that the man made a prompt, 
 fatal exit. But most cases die 
 undiagnosed. The danger of 
 strangulation by bands is gan- 
 grene and perforation. 
 
 The starting point of peri- 
 toneal bands are — (a) local peri- 
 tonitis, (b) hernial apertures 
 (inguinal, femoral, abturator, 
 fossa duodeno-jejunelis, inter- 
 sigmoid fossa, Winslow's fora- 
 men), (c) peritonitis from 
 muscular trauma (psoas, lateral 
 abdominal), (d) infective mesen- 
 teric glands, (e) operative sites, 
 (f) fimbriated ends of oviducts, 
 A history of typhoid fever, hernia, peritonitis is 
 
 VOLVULUS OF ILEO-CCECAL APPARATUS 
 
 Fig. 96. Drawn from subject with physio- 
 logic or incomplete volvulus of ileo-ccecal ap- 
 paratus. X, shows the state of the volvulus— 
 almost 360 degrees. Z, presents a large pouch in 
 the mesosigmoid. 
 
 (g) Meckel's diverticulum, 
 suggestive. 
 
 The intensity of the abdominal pain in intestinal obstruction depends on 
 the completeness of the obstruction. The pain not being inflammatory is 
 paroxysmal, rythmical, due to trauma on the nerve periphery in the intestinal 
 wall. 
 
 It should be noted that reduction by taxis of a strangulated intestine 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 409 
 
 in the hernial rings ought to be practiced with care. The danger is reduc- 
 tion in mass (without relief) and the return into the peritoneal cavity of 
 pathological intestinal segments. In strangulation, internal, it is well to 
 inquire whether a patient has suffered from peritonitis or experienced peri- 
 tonotomy. 
 
 In strangulation of an intestinal loop the symptoms will practically 
 simulate perforation or extravasating peritonitis only after the sepsis has 
 begun. 
 
 Hernia which may involve several visceral tracts (digestive, genital, 
 urinary) not infrequently presents unsuspected irritation from the natural 
 
 POSITIONS OF THE APPENDIX 
 
 Fig. 97. Pelvic position (woman 47 per cent — man 37 per cent). 2, Retro-coecal position 
 (20 per cent). 3, Potential position (23 per cent). 4, Right of psoas (18 per cent). 4, Resting 
 on the psoas (46 per cent). 
 
 hernial rings from the inimical supraumbilical hernia in the linea alba. 
 I have observed much distress and suffering in patients afflicted with hernia 
 which had been overlooked for years. 
 
 I assisted Dr. Lucy Waite to operate on a woman some 35 years of age, 
 on whom a previous peritoneal section had been performed. She had suffered 
 from obstruction of the bowels for several days with continuous vomiting. 
 Dr. Waite found an organized peritoneal band of some fifteen inches in length 
 extending tensely across a loop of intestine producing almost complete 
 obstruction. Rupture of the band afforded complete relief with recovery. 
 
 Sudden obstruction may arise from intestinal loops gliding to and fro 
 through apertures in the mesentery, omentum. 
 
410 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 INVAGINATION. 
 
 Invagination constitutes about one-third of all intestinal obstruction, and 
 the sudden, acute abdominal pain arising from this cause is more easily inter- 
 preted. Age signifies much in this case, for one-fourth of all invagination 
 occurs before the end of the first year of extrauterine life, and one-half before 
 the end of ten years. Invagination is a disease of childhood. Its mode of 
 onset is sudden and frequently violent. From some twenty-five experiments 
 in invaginating the bowel of the dog, I am sure the pain is periodic at first. 
 The griping, colicky peristalsis is rhythmic, depending on irritation. At stated 
 times the dog suddenly spreads wide his four feet and arches his back, appear- 
 ing in severe distress, then gradually recovers his natural attitude. In invagi- 
 nation blood occurs in the stool in 80 per cent of cases (especially children), 
 and the vomiting is not violent, nor even always conspicuous, for the bowel 
 is only partially occluded. Seventy per cent occur at the ileocecal appar- 
 atus, that land-mark in man's clinical history, 15 per cent in the enteron and 
 15 in the colon. Invagination manifests abdominal pain similar to an elongated 
 enterolith in the bowel, which in rotating leaves small spaces at its side for 
 the passage of gas and some liquid stool. I have, unfortunately, watched 
 a case of enterolith day after day, with some half dozen physicians, not 
 becoming able to interpret the abdominal pain or to diagnose the case, until 
 gangrene of the bowel occurred at the seat of the enterolith, when nature 
 asserted manifestation to induce us to explore the abdomen, but with a fatal 
 result. The most skilled of abdominal surgeons repeatedly examined this 
 case, but could not interpret the acute abdominal pain, which came on sud- 
 denly, though as the days glided it quietly subsided. The patient was a 
 physician, but could not localize any abdominal pain; it was diffuse. Tem- 
 perature was about 99J S deg. and 100 deg. F., and the pulse was 65 to 95, 
 almost the whole week of illness. The abdomen was generally soft and not 
 tympanitic. Very seldom can abdominal tumor be palpated in bowel invagi- 
 nation. Shock in young children is quite conspicuous, yet I personally know 
 of two autopsies in infants, who were attended in life by three of the most 
 skilled abdominal surgeons, yet the post-mortems revealed invagination as 
 the cause of death. A skilled and experienced physician, such as the late Dr. 
 Jaggard was called to an eight months infant and he stripped the clothing to 
 be more thorough in examination, and yet after all his diagnostic skill, failed 
 to locate disease in the digestive tract from lack of symptoms. The child 
 was very* pale, cried a little, and died thirty hours after the attack. The 
 autopsy revealed ileocecal invagination. 
 
 Sudden acute abdominal pain in a child may with high probability be 
 interpreted as invagination, especially if one can detect the periodic, peristal- 
 tic character, its colicky nature. Blood following in the stool is almost 
 pathognomonic. A tumor will rarely be found, and pressure on it will not 
 generally elicit tenderness, it is not at all likely the patient can locate the 
 seat of the disease from pain. Tympanites and vomiting are not conspicuous, 
 and the temperature and pulse are not reliable. The danger of invagination 
 is sloughing of the apex or neck and consequent perforation and peritonitis. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 411 
 
 Invagination presenting at the anus interprets easily the cause of pain. 
 
 Tenesmus is a prominent feature. In quite a number of cases of invag- 
 ination during the last fifteen years I could palpate a tumor but twice, and 
 that was once in an adult, spare woman where the ileocecal invagination had 
 progressed to the flexura coli lienalis. The cause of her invagination was a 
 large ulcer of the cecum, which extensively hypertrophied the cecal wall. 
 I disinvaginated the cecum; however, reinvagination occurred some weeks 
 later when resection of the cecum was practiced with fatal result. Once I 
 could palpate an invaginated tumor in a child. 
 
 r^^^ti— 
 
 POTENTIAL POSITION OF APPENDIX 
 
 Fig. 98. The appendix rests among the enteronic coils; however, on rupture it would 
 be protected by the omentum. 
 
 In actual practice we found at the Mary Thompson Hospital for women 
 and children that shock was the chief fatal factor — the children entering the 
 hospital with advanced invagination, when peritonitis had begun and the 
 pulse was uncountable. 
 
 From fifteen years of observation on infant invagination, as they enter 
 the hospital in an advanced or late stage of the disease, I am convinced that 
 on the average, more infants will recover from intestinal invagination with- 
 
412 THE ABDOMINAL AND PELVIC BRAIN 
 
 out an operation than with one. I think actual cases by number will prove 
 this claim — sound unsurgical as it may. 
 
 Slowly progressing stricture may suddenly become closed. 
 
 VOLVULUS. 
 
 Volvulus is so rare that it constitutes about one-fortieth of all intestinal 
 obstructions, and occurs mainly in men, as women and children are practi- 
 cally free from sigmoid volvulus. As in invagination so in volvulus, I was 
 always compelled to suture them in position in a dog. But I never succeeded 
 in establishing a permanent volvulus in the dog. Volvulus is characterized by 
 tympanites, and it is said by periodic pain. Volvulus occurs at the sigmoid in 
 60 per cent of subjects, at the ileocecal valve in 30 per cent, and in the small 
 intestines in 10 per cent. It is so rare that though I have seen several cases 
 of partial (physiologic) volvulus, however only one case of complete (patho- 
 logic) volvulus in man. The subject of enteronic volvulus was in a male 
 child brought to me by Dr. Walter Fitch. He was in the third day of illness. 
 I operated and relieved the volvulus of the enteron but the child died of 
 shock and infection three days later. Nicholas Senn operated successfully 
 on a man, on the eighth day, for sigmoid volvulus. He introduced a tuck 
 plication in the mesosigmoid for prophylaxis. Seven years later another 
 physician operated on the same man for volvulus, recurrence, with fatal 
 result. The man had enormous tympanites; his pain is not described as 
 severe, but no doubt the suffering is severe. 
 
 At first the pain is periodic but as time advances it becomes more con- 
 stant, with now and then exacerbations. Vomiting, though not conspicuous, 
 must arise more or less from trauma to the peritoneum. Perhaps the sudden 
 pain, chronic constipation, and rapid rise of tympanites would aid in 
 interpreting volvulus, but seldom can one diagnose such a disease from its 
 rarity. Pain no doubt would be referred to the abdominal brain. Most 
 clinicians note tympanites as a conspicuous feature of volvulus. 
 
 Weller Van Hook treated successfully a case of sigmoid volvulus of 
 eight days' standing. 
 
 From observation of the sigmoid and mesosigmoid in hundreds of autop- 
 sies I am convinced that the chief etiology of volvulus of the sigmoid is 
 elongated sigmoid located in the proximal abdomen and possessing a narrow 
 foot accompanied by mesosigmoiditis due to vigorous action of the left psoas 
 muscle which traumatizes the sigmoid, inducing migration of germs or their 
 products through mucosa, muscularis into the serosa, inciting plastic peri- 
 tonitis in 80 per cent of adults. 
 
 The plastic peritonitis in general ends in two conditions, viz. : 1. The 
 most frequent, the plastic sigmoiditis binds the left surface of the mesosig- 
 moid to the ventral surface of the psoas muscle. Such subjects cannot 
 have sigmoid volvulus from mechanical condition. 2. The second state of 
 the mesosigmoid arising from the mesosigmoiditis is a progressive shorten- 
 ing, a contraction of the base of the mesosigmoid, that is, the base or pedicle 
 of the mesosigmoid becomes a very narrow pedicle from the progressing, 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 413 
 
 contracting mesosigmoiditis, so that peristalsis of the sigmoid induces a 
 rotation or torsion of its base. In autopsies I have found partial (physio- 
 logic) rotation of the mesosigmoid, especially during the existence of mesosig- 
 moiditis — as far as 180 to 360 degrees. 
 
 Sigmoid volvulus is due to the torsion, rotation, of the narrow pedicle of 
 a mesosigmoid contracted at its foot by mesosigmoiditis. When one 
 untwists, detorsionizes, the volvulus and releases it, the sigmoid recedes, 
 rotates, like a spring into its original volvulitic condition. To prevent the 
 volvulus from returning to its original torsion in dogs I sutured it in situ. 
 Resection may be required to overcome the acute torsion. Puncture may 
 
 ABSENCE OF APPENDIX (AND CCECUM) 
 Fig. 99. Drawn from female, aged 50 years. The diagnosis in this case would be 
 
 uncertain. 
 
 be required to reduce its dimension. Most subjects have ample 'time to 
 acquire sigmoid volvulus, as they are generally over 40 years of age. There 
 is frequently physiologic sigmoid volvulus in autopsy which is partial tor- 
 sion of the mesosigmoid; however, obstruction is incomplete. The marked 
 tympanitis or meteorism of sigmoid volvulus is at first localized in the 
 left iliac fossa — a slight diagnostic point. The sigmoid is the most varied of 
 any segment of the colon in location and capacity of its lumen. The tymp- 
 anitis may be located in the right abdomen while the nontympantic enteronic 
 loops may be forced around the constricted foot of the volvulitic sigmoid. 
 Childhood is not predisposed to sigmoid volvulus, notwithstanding the 
 relatively elongated sigmoid and mesosigmoid, because the angle of mesosig- 
 
414 
 
 THE ABDOMIXAL AND PELVIC BRA IX 
 
 moid insertion (what I term von Samson's angle) is located well proximalward 
 on the lumbar vertebra. Why woman is practically free from sigmoid 
 volvulus I am, so far, unable to explain. Sigmoid volvulus occurs practically 
 in men possessing what I term the "giant verticle sigmoid" which is located 
 
 in the proximal abdomen and oc- 
 curred in perhaps 15 per cent of the 
 autopsies. The foot of this giant 
 verticle sigmoid is narrow and ^by 
 the contracting mesosigmoiditis re- 
 sults in a narrow style around which 
 may rotate the sigmoid loop. This 
 was the condition I found in physio- 
 logic volvulus which occurred in per- 
 haps 2 per cent. 
 
 APPENDICITIS. 
 
 Appendicitis is the most dan- 
 gerous and treacherous of abdom- 
 inal diseases — dangerous because it 
 kills, and treacherous because its 
 capricious course cannot be prog- 
 nosed. The peritonitis it produces 
 is either enteronic (dangerous — ab- 
 sorptive, non-exudative) or colonic 
 (mild — exudative, non-absorptive). 
 
 A concise clinical history should 
 be obtained when sudden pain arises 
 in the right side of the abdomen for 
 it might be due to perforated appen- 
 dix, gall-bladder or gestating ovi- 
 duct. The right-sided pain may 
 arise from biliary, pancreatic or ure- 
 teral calculus or ureteral flexion. 
 
 Pleurisy or intercostal neuralgia 
 (right) may confuse. In the right 
 side, so closely adjacent are eight 
 important viscera, momentous in 
 surgery, that a silver dollar will 
 touch the pylorus, gall-bladder, head 
 of the pancreas, kidney, adrenal, 
 
 APPENDIX LYING ADJACENT TO 
 MECKEL'S DIVERTICULUM 
 
 Fig. 100. This drawing was taken from a 
 subject on whom I operated for a large ab- 
 scess in the right iliac fossa and at the same 
 time I removed a perforated tube 3 inches in 
 length and of the usual appendicular dimen- 
 sion — supposing it to be the appendix. Three 
 months later the man died from appendicitis, 
 as the postmortem performed by Dr. Arthur 
 MacNeil demonstrated. The first attack and 
 abscess was from the perforation of Meckel's 
 diverticulum, located in the right iliac fossa. 
 The second attack and abscess was from per- 
 foration of the appendix, located (retro-ccecal) 
 in the right iliac fossa. 
 
 duodenum, ureter and possibly the 
 appendix. Hence differential diagnosis of sudden abdominal pain in the 
 closely adjacent multiple organs of the right side is difficult — frequently im- 
 possible. 
 
 The conditions that cause the excruciating, agonizing, shocking pain in 
 appendicitis are perforation and extravasation into the peritoneal cavity. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 415 
 
 Right-sided muscular rigidity means that the motor (intercostal) nerves 
 supplying the abdominal muscles are irritated. It may be any kind of peri- 
 toneal infection (extravasation from any viscus, hepatic, intestinal, ureteral or 
 genital). Right-sided cutaneous hyperesthesia means that the sensory 
 (intercostal) nerves supplying the abdominal skin are affected. It may 
 depend on any kind of peritoneal infection. Sudden cessation of severe 
 symptoms, as rapid diminishing of high temperature and pulse and abdo- 
 minal rigidity, is an evil omen — gangrene of the appendix has probably occur- 
 red. Immediate operation should occur. 
 
 For years I have made it a rule to recommend appendectomy to patients 
 having experienced two attacks. Fifty per cent of subjects who have had 
 one attack experienced no recurrence. 
 
 RELATION OF APPENDIX TO THE GENITAL TRACT 
 
 Fig. 101. Appendicitis and salpingitis are separate diseases, each arising from its own 
 mucosa. However, infection emanating from either may compromise the anatomy and 
 physiology of the other by peritoneal adhesions. 
 
 In perforation it is very difficult to interpret the sudden abdominal pain. 
 Associated circumstances would aid. In typhoid fever one would naturally 
 suspect perforation if sudden acute abdominal pain arose, and my colleague, 
 Dr. Weller Van Hook, successfully operated on a typhoid perforation diag- 
 nosed by his medical friend. One might think if he was called to a young 
 woman with sudden acute abdominal pain that it was a round, perforating 
 ulcer of the stomach, after excluding pelvic and appendicular disease, but the 
 sudden acute abdominal pain of perforation is so vague and indefinite that 
 only an exploratory incision would interpret it. 
 
 The sudden acute abdominal pain from appendicitis (perforation) is more 
 apt to be diagnosed from probability. Now probability is the rule of life, 
 and when one is called to a boy or man with sudden acute abdominal pain, 
 
416 THE ABDOMINAL AND PELVIC BRAIN 
 
 it is likely appendicitis. The pain of appendicitis is at first sudden and 
 generally diffuse, and in appendicitis this is, in my experience, a character- 
 istic and conspicuous feature. The sudden acute pain in appendicitis is 
 doubtless due to violent appendicular peristalsis (colic) of an inflamed 
 appendix, or to the rupture allowing the bowel contents to come in contact 
 with the peritoneum, and also inducing violent irregular peristalsis of the 
 adjacent bowel loops. It is the agonizing, excruciating pain of peritoneal 
 extravasation. Rigidity of the abdominal muscles over the seat of pathology 
 in appendicitis is a great aid to interpreting the pain. The muscular rigidity 
 is protective and due to the transmission of the visceral irritation to the 
 spinal cord, which is reflected to the abdominal skin (sensory) and to 
 abdominal muscles (motor). There is a nice balance between the peripheral 
 visceral and the peripheral cutaneous nerves in the abdominal muscles 
 through the spinal cord. Local tenderness and local rigidity of the abdominal 
 muscles is a great aid in signification of the sudden acute pain in append- 
 icitis. It might be well to suggest that the position of the appendix is located 
 at any point from the liver to the floor of the pelvis, and also many times 
 where there is more or less of a mesenterium commune, the cecum may 
 approach the vertebral column, and the appendix is then liable to lie among 
 the enteronic coils — the dangerous ground of peritonitis. It is likely the 
 pain in appendicitis depends on the seat of the disease, i. e., the mucous 
 membrane has become ulcerated, inducing painful appendicular colic (peri- 
 stalsis), while the sudden exacerbation of violent diffuse abdominal pain is 
 due to the involving of the peritoneum itself from the fecal extravasation 
 and from violent peristalsis. I see nothing especially worthy of attention in 
 the so-called McBurney point. It is skin sensitiveness. Pain over the seat 
 of disease is certainly a natural feature, and generally so over the appendix, 
 which lies under a point midway between the umbilicus and anterior superior 
 spine of the ileum. But it is not always so by any means, for I examined 
 with great and anxious care, a short time ago, a young physician with severe 
 pain over the so-called McBurney point, when on operation the long appendix 
 was in the pelvis and perforated. McBurney's point is practically a cutane- 
 ous hyperesthesia. Then again pain on pressure may be reflex, appearing in 
 remote regions of the abdomen. The sudden, acute, diffuse abdominal pain 
 arising in appendicitis, generally subsides in the right iliac fossa after thirty- 
 six hours, and one can nearly always elicit pain on pressure there. This 
 pain on pressure is doubtless the motion radiation, transmitted to a sensitive, 
 inflamed peritoneum, and not the dragging of an adhesion, as some assert, 
 for adhesion so newly formed can have no nerves formed in them. But man 
 is subject to appendicitis four times as frequently as woman, due, perhaps 
 to Gerlach's valve being small in man, and thus not allowing the foreign body 
 to escape after entrance, and due also to the greater activity of the psoas 
 muscle in man, inducing more peritoneal adhesions to compromise the 
 anatomy and physiology of the appendix. Contracting adhesions compro- 
 mises appendicular drainage. The appendix lies on the psoas muscle in 
 man more frequently than in woman, and on its longest range of activity. 
 
SUDDEN ABDOM/XAL PAIX—1TS SIGNIFICANCE 
 
 417 
 
 hence when the appendix contains virulent and pathogenic germs, the long 
 range of action of the psoas so traumatizes the appendix that it induces 
 the escape or migration of the accidental virulent pathogenic microbes 
 through the appendicular walls into the peritoneal cavity. Common sense 
 and experience would dictate that the pain on pressure would occur in any 
 point of the abdomen possessing inflamed structures. Since probability is 
 the rule of life it is well to search for pain in the three great regions of 
 dangerous peritonitis, viz., the pelvic, appendicular and gall-bladder regions. 
 In appendicitis the pain on pressure is in the ileo-coecal plexus, i. e., in the 
 
 NONDESCENDED APPENDIX 
 
 Fig. 102. The appendix is associated with the liver. The appendix (coecum) is nonde- 
 scended in males 9 per cent and in females 5 per cent. In this case there is an ileo-coecal 
 volvulus. 
 
 ileo-coecal angle, not at the so-called McBurney's point, which is a nerve 
 skin neurosis — a skin hyperesthesia. 
 
 The ileo-colic plexus may be found tender on bi-manual vaginal examin- 
 ation, especially on the right side. However, these hyperesthetic (tender) 
 points are insufficient to establish a diagnosis of appendicitis. Palpable 
 anatomic findings are the only reliable data for the diagnosis of appendicitis. 
 
 27 
 
418 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 BILIARY CHANNELS. 
 
 The digestive tract has still another common seat for sudden acute 
 abdominal pain, and that is the gall-bladder region. The sudden acute 
 abdominal pain in hepatic colic is not generally so violent as many others 
 accompanying acute diseases of the digestive tract. Patients relate that the 
 pain is aching, dragging, and in the active stage of cutting or tearing. Some 
 relate a feeling of tightness or fullness. But it depends on whether the cal- 
 culus is attempting to enter constricted portions of the duct, or whether it 
 has already entered. I have had typical cases where operation proved that 
 the calculi only attempted to enter the constricted portion of the duct. Xo 
 doubt these are the cases which say so often that they have severe pains at 
 any time, but especially after taking hot meals or hot stimulating drinks, or 
 vigorous exercise; whence arises excessive peristalsis, inducing short, tem- 
 porary hepatic colic. Now, when the gall-bladder has many calculi in it, 
 and when one more or less often attempts to engage in the neck of the gall- 
 bladder, the pain is rhythmical. It begins slowly and rises to a maximum. 
 At the maximum the pain is intense. We have observed such cases and after- 
 wards operated on them, removing many small calculi. Gall-stone exists 
 perhaps four times as frequently in women as in men; why, we do not know. 
 In my experience patients can generally locate the pain in hepatic calculi more 
 accurately and definitely than almost any other sudden acute abdominal pain. 
 They refer the pain to its proper locality; however, I must admit that this 
 reference is before rupture. After rupture of the cholecyst or duct the pain 
 is indefinite, like other perforation in the peritoneum. The sudden acute 
 abdominal pain in biliary duct disease is characterized by more slowness, 
 less acuteness, intensity and distinct periodicity, than in invagination, 
 appendicitis or perforation of the digestive tract. Jaundice is not necessary. 
 Jaundice or icterus is determined by the color of the eye-ball, and not of the 
 skin. A feature in gall-bladder pain is that it extends well towards the 
 dorsum. Age aids in diagnosing calculus in the biliary passages to some 
 extent. 
 
 The patient, frequently middle aged women, is suddenly seized with 
 agonizing pain in the epigastrium, vomiting and occasional collapse. The 
 pulse rapid and small, the epigastrium tender (cutaneous hyperesthesia) and 
 the right abdominal muscles rigid (intercostal motor nerves irritated, cor- 
 responding to its sensory roots of the spinal cord). With progress of the 
 case the pain localizes in the right hypochondrium and peritonitis begins. 
 I have had cases of rupture of the gall-bladder with no known premonitory 
 symptoms. 
 
 It must be borne in mind that gall-bladder perforation presents a differ- 
 ent picture than merely violent peristalsis (colic) due to gall-stone in the 
 biliary passages. 
 
 The pain of non-perforated biliary colic arises suddenly, is agonizing, and 
 especially intense in the gall-bladder region. It is generally limited in dur- 
 ation, and frequently associated with jaundice. Biliary calculus may exist 
 without pain (autopsies are rich in this testimony). 
 
SUDDEN ABDOMINAL PAIN^ITS SIGNIFICANCE 
 
 419 
 
 ACUTE HEMORRHAGIC PANCREATITIS. 
 
 The pain in acute hemorrhagic peritonitis is characterized by being sudden, 
 terrible, agonizing and remains persistent in the region of the pancreas. The 
 patient is attacked so violently that he faints, collapses. The vomitus is a 
 greenish fluid contained in bile and blood. The patient suffers intensely 
 in the epigastric region. It presents the symptoms of peritoneal extravasa- 
 tion (hence excruciating pain), small, rapid pulse, rigid abdomen with 
 sensitive, tender skin, skin cool and bedecked with a clammy perspiration. 
 Temperature ranges high. Pro- 
 found sepsis gradually deepens 
 and death supervenes in a few 
 days. Acute hemorrhagic pan- 
 creatitis is a rare disease; I saw 
 no case in some 700 autopsies. 
 It is seldom diagnosed, as we 
 still possess no standard differen- 
 tiating symptoms. Diabetes is 
 suggestive of hemorrhagic pan- 
 creatitis or fat necrosis. 
 
 EMBOLUS WITH MESENTERIC 
 VESSELS. 
 
 Embolus of the mesenteric 
 vessels, a rare disease, produces 
 sudden severe abdominal pain. It 
 is difficult to diagnose and is likely 
 to be equally difficult to treat by 
 any means at our command. The 
 difficulty will be in estimating the 
 amount of intestinal resection 
 required on account of the indefi- 
 nite demarcation of the line of 
 gangrene due to the embolus. 
 
 URINARY TRACT. 
 
 BILIARY CALCULUS DISLODGED FROM 
 MECKEL'S DIVERTICULUM 
 
 Fig. 103. This illustration is from a woman 
 physician, death from peritonitis following ente- 
 ronic obstruction by a biliary calculus, which 
 had become dislodged from Meckel's divertic- 
 ulum. 
 
 In ureteral colic it must be 
 said that the pain resembles that 
 of hepatic colic in many ways, 
 the rhythm being paroxysmal. It intermits and is often agonizingly spas- 
 modic. It requires much careful study to differentiate the sudden acute 
 abdominal pain in hepatic and ureteral colic. This is important, for the 
 plan of action is very different. The pain in appendicitis, ureteral and 
 hepatic colic are in close relation and resemble each other. 
 
 Sudden pain in the lumbar region, with progressive radiation toward the 
 inguinal region, and especially testicular retractions, is suggestive of 
 ureteral calculus. The kidney is frequently tender on pressure. Ureteral 
 
420 THE ABDOMINAL AND PELVIC BRAIN 
 
 calculus permits time to complete the diagnosis, as it is non-inflammatory, 
 hence we examine the urine for albumen, blood and pus and with the X-ray 
 for shadows. 
 
 The perforation of the ureter will result in extra-peritoneal extravasation 
 which does not induce such excruciating pain as intra-peritoneal extra- 
 vasation. 
 
 1. Pain is a cardinal symptom of ureteral calculus. 
 
 2. Pain is not a sign of ureteral calculus. 
 
 3. Pain as a single standard is liable to lead to erroneous conclusions 
 and to an incorrect diagnosis. 
 
 4. In eighty operations with pain as the guiding symptom for ureteral 
 calculus 70 per cent failed to demonstrate calculus. 
 
 5. The vast dimensions of the plexus nervosus ureteris in number of 
 ganglia and number of strands permit irritation from the ureter to pass 
 with facility and rapidity to the abdominal brain, whence it becomes 
 reorganized and emitted: (1) over the sympathetic nerves of the abdominal 
 visceral plexuses, inducing pain, aching, reflexes in the adjacent viscera; 
 (2) the reorganized irritation in the abdominal brain is emitted over the 
 spinal nerves; (a) the intercostals (pain in abdominal walls); (b) over the 
 lumbar plexus (pain in inguinal, hypogastric and external genital regions); 
 (c) over the sacral plexus (pain in the nates, genitals, rectum, thigh, leg and 
 foot). (3) The irritation of the plexus of nerves passes to the abdominal 
 brain where it is reorganized and emitted over the cranial nerves (vagus which 
 aids in inducing nausea and vomiting). These reflex pains in ureteral cal- 
 culus confuse by involving the sympathetic, spinal and cranial nerves of 
 distant regions, and also because other conditions of the ureters than ureteral 
 calculus may duplicate or simulate the reflex pain. 
 
 6. Pain simulating that of ureteral calculus is a common symptom of 
 many diseases of the abdominal viscera. 
 
 7. Ureteral calculus may exist without pain (post-mortems are rich in 
 this testimony). 
 
 8. Calculus may exist with the manifestation of pain in some adjacent 
 visceral tract only, for example, pain in testicle, or ovary (genitals). 
 
 9. Other diseases of the urinary tract than ureteral calculus may 
 simulate or duplicate a pain (ureteritis, malignancy, hematuria tuberculo- 
 sis, vesical calculus, growth, cystitis). 
 
 10. Reno-ovarian reflex, reno-testicular reflex, or reno-uterine reflex 
 pains are not signs of ureteral calculus, but are simply intensified local- 
 izations of pain along the ureter, which may exist from numerous conditions. 
 
 11. Unilateral pain, stabbing pain, muscular trauma pain (Jordan Lloyd), 
 stamping muscular pain (Clement Lucas), pain from corporeal trauma 
 (muscular), pain from the sensitive ureteral proximal isthmus or pelvis, may 
 arise from various conditions other than ureteral calculus. 
 
 12. The characteristic of pain in ureteral calculus is inconstancy, 
 variation or radiation and reflexion. It has a tendency to produce sympa- 
 thetic aching in other abdominal viscera. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 421 
 
 13. The pain in ureteral calculus depends chiefly on its position (ureteral 
 pelvis and proximal isthmus, sensitiveness) and also on the mobility of the 
 calculus. 
 
 14. Tain (colic) can arise in the 
 ureter from increased ureteral pressure 
 (calculus, stricture, flexion — obstruct- 
 ing the urinal stream), or from in- 
 flamed ureteral wall — ureteritis. 
 
 15. Ureteral-lithiasis, cholelithi- 
 asis, appendicitis, ureteritis, cystitis, 
 nephritis, may produce practically 
 identical symptoms. 
 
 Intoxications. — Uremia may be 
 accompanied by abdominal pain, lead 
 colic, blue gum line and occupation. 
 Food of concentrated nature as meats 
 may produce such concentrated urine 
 that urination is accompanied by pain. 
 
 Fig. 104. Roentgen ray of the ductus pancreaticus and part of ductus bilis (it contains 
 six hepatic calculi). From post-mortem specimens. I to II, ductus communis choledochus, 
 dilated to U inch in diameter and containing four hepatic calculi (A, B) in its distal end ; II 
 to IV, ductus cysticus, dilated to Yi inch in diameter, yet preserving in form six valvulae 
 Heisterii; II to III, ductus hepaticus, dilated to l /z inch, containing a hepatic calculus ; C, 
 cholecyst, normal dimension, containing no calculus; P, ductus pancreaticus (ductus 
 Hofmanii-Wirsungii), ductus pancreaticus accessorius (ductus Santorini). Hepatic calculi, 
 C, D and B. 
 
422 THE ABDOMINAL AND PELVIC BRAIN 
 
 TRACTUS GENITALIS. 
 
 The sudden acute abdominal pain arising from the genitals is more easily 
 interpreted and managed. The pain can be more definitely located by the 
 patient; and sudden disorganization of viscera, being accessible in the pelvis, 
 is much more within control of the gynecologist. The sudden acute abdom- 
 inal pain from the genitals is generally due to a ruptured ectopic pregnancy, 
 or the very rare matter of the rupture of a pyosalpinx into the peritoneal 
 cavity. Most of the pains are of slower origin and almost diagnosable. Sex 
 and the reproductive age aid in the interpretation of the case. 
 
 With a ruptured pregnant oviduct the patient complains of sudden 
 excruciating, terrible pain which at first is generally diffuse, but rapidly local- 
 izes in the pelvic region. The sudden pain is persistent, muscular rigidity is 
 intense, the abdomen is tender and the patient's face is anxious; with the 
 impending crisis, vomiting is not conspicuous. If the hemorrhagic peritoneal 
 extravasation is ample the pain is excruciating, and faintness, syncope, shock 
 with extreme anemia occurs. Death frequently occurs from hemorrhage. 
 
 Lawson Tait used to advocate that the oviduct would rupture not later 
 than the fourteenth week. However, it may rupture or abort at any time 
 previous to that. To the experienced gynecologist a bimanual vaginal and 
 rectal examination reveals in most cases ample evidence for an operation. 
 In sudden abdominal pain, rapid rise of pulse with lowering of temperature 
 indicates (hemorrhage) gravity and demands surgical intervention. It may 
 be stated that during a decade of attendance in the Mary Thompson Hospital 
 for women and children Dr. Lucy Waite and myself have operated on 
 considerable numbers of ruptured gestating oviducts in which the patient 
 could not furnish a clinical history of very much pain or exact date of rupture. 
 
 PYOSALPINX. 
 
 In pyosalpinx the pain may be sudden and excruciating (involving the 
 peritoneum). 
 
 The patient enforces upon herself extreme physical quietness, breathing 
 with the proximal end of the abdomen only. The thighs are flexed, the face 
 flushed, the abdomen tender, sensitive and rigid, the expression that of an 
 impending crisis. Bimanual vaginal examination reveals a large uneven 
 mass, which is excruciatingly painful. 
 
 The mass should be palpated gently for fear of rupture. One of my 
 patients with a very large pyosalpinx strained at stool, causing rupture and 
 death from peritonitis. At the autopsy I found perhaps a quart of pus, free 
 in the peritoneal cavity. She died from excruciating pain and shock in some 
 ten hours. 
 
 In regard to the character of sudden abdominal pain arising from the 
 genitalis is more easily interpreted and managed. The pain can be more 
 definitely located by the patient; and similar to other sudden acute abdom- 
 inal pain, it varies as to its mode of attack, and as to viscera affected. 
 
 The pain of pyosalpinx is generally that of a local peritonitis; however., 
 it is limited in its reflexion to other peritoneal areas. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 423 
 
 AXIAL TORSION OF PEDICLES OR VISCERA. 
 
 Torsion of style or rotation of pedicle of a viscus is characterized by 
 sudden severe abdominal pain. The intensity of the pain depends on the 
 completeness of the constriction in the pedicle. 
 
 The tumor rotated on its axis gradually enlarges because the venous 
 blood cannot return, while the arterial blood continues to pass into the 
 tumor. Ovarian tumors rotate on their axes or pedicles perhaps the most 
 frequently subsequent to parturition. The initial pain is generally severe 
 but not excruciating like extravasation in the peritoneal cavity. As usual 
 
 Fig. 105. Specimen containing pancreatic calculus. From a post-mortem ; man about 
 40 years. I to II, ductus choledochus ; II to III, ductus hepaticus ; III to IV, ductus cysticus ; 
 Sa, ductus pancreaticus accessorius ; P, separate exit of ductus pancreaticus in duodenum. 
 A calculus }i inch in length and l /d inch in diameter is incarcerated in the duct of the caput 
 pancreaticum. The calculus of the pancreatic duct projects into the lumen of the duodenum. 
 Also six calculi existed in the ductus pancreaticus, as noted in sketch. The pancreas was 
 in an advanced stage of suppuration and fatty degeneration. This specimen was kindly pre- 
 sented to me by Dr. A. M. Stober. B. J. Beuker sketched it from the pathologic, laboratory 
 of Cook County Hospital. 
 
 the pain is first diffuse, and later becomes localized in the region of the 
 increasing tumor from accumulating venous blood and nerve trauma. 
 
 Hyper-rigidity of abdominal muscles and hyperesthesia of abdominal 
 skin accompanies, exists (on account of reflex irritation in the spinal cord). 
 
 One of the most important aids to diagnosis is that the women possess 
 a tumor, and that with accompanying abdominal pain the tumor gradually 
 enlarges because the rotating pedicle easily constricts the thin walled veins, 
 while the rigid walled artery persists in injecting its continuous stream into 
 the tumor. 
 
 I have witnessed torsion of pedicles in ovarian tumors, oviduct sigmoid, 
 
[24 THE ABDOMINAL AXD PELVIC BRAIX 
 
 ileocecal apparatus, myoma, enteron, omentum and kidney. Torsion of 
 pedicles may apply to tubular viscera (ureter, intestine, oviduct J as well 
 as to vessels. 
 
 I have operated on subjects with myomata rotated to such an extent that 
 the entire original blood supply was completely obliterated, the tumor being 
 nourished by newly formed blood vessels from adjacent viscera, especially 
 from the omentum majus. Rokitansky of Vienna, first called attention to 
 the axial rotation of tumors some forty years ago. 
 
 The facility of pedicular torsion depends on the elongation and limited 
 dimension of the pedicles. Volvulus is but axial torsion facilitated in the 
 sigmoid by a narrow foot or base (due mainly to mesosigmoiditisj. 
 
 Axial torsion of the digestive tract constitutes about one-fortieth of 
 intestinal obstruction. Perhaps 6 per cent of ovarian and parovarian tumors 
 experience axial torsion. Mr. Lawson Tait saw some 70 cases, and as his 
 pupil I witnessed with admiration his amazing acumen in diagnosing and 
 successfully operating on axial rotated tumors. My assistant, Dr. A. Zetlitz, 
 operated on a patient with almost complete torsion of the uterus, and 
 examining the specimen evidence demonstrated itself that it was a slow 
 chronic process and closely associated with peristalsis. 
 
 Axial torsion of viscera may be acute or chronic, complete (pathologic) 
 or incomplete (physiologic), hence the manifestations of pain will vary. 
 
 Axial torsion of abdominal viscera (tumorsj are no doubt rotated by the 
 peristalsis of the viscus itself or that of adjacent viscera, especially the colon 
 (sigmoid), which by its rhythmic movements rotates the ovarian tumor, the 
 omentum and the ilium about the cecum. Tumors with axial torsions should 
 be at once removed, while vital viscera with axial torsion should be reduced, 
 untwisted, detorsioned, and sutured in situ, for axial torsion tends to recur. 
 It may be due to the constriction, to the blood vessels, to the peristalsis or 
 adjacent peritonitis. 
 
 CHIEF FACTORS INVOLVED IN SUDDEN ABDOMINAL PAIN. 
 
 The accompanying table presents a bird's-eye view of some of the 
 practical factors involved in sudden abdominal pain. Indelible opinions must 
 be entertained in the diagnosis as to the signification of the abdominal pain, 
 whether it be from peritonitis (septic lesion from adjacent viscera), or pain 
 from violent peristalsis (colic), or tubular viscera (due to mechanical irrita- 
 tion, calculus, stricture, flexion or from inflamed parietes). For practical 
 purposes I will present a skeletal table of sudden pain of the six visceral 
 tracts, intestinal, urinary, vascular, lymphatic, nervous, and genital. It is 
 evident that abdominal pain rests on common factors, as (a) flexion ; (b) 
 stricture; (c) calculus (violent peristalsis, colic) of tubular viscera, in which 
 the danger and pain are limited. Perforation (extravasation into the perito- 
 neum) of tubular viscera in which danger and pain are unbounded. A decade 
 ago it was thought sufficient to remember the three dangerous peritonitis 
 regions, viz., pelvic, appendicular, and gall-bladder. With the present 
 accumulated knowledge of the abdominal viscera the field presents problems 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 425 
 
 of increasing complexity as presented in the following bird's-eye view of 
 numerous causes of abdominal pain in the several visceral tracts: 
 
 Gastrium, enteron, append- 
 ix, colon 
 Biliary ducts 
 Pancreatic duct 
 
 I. Tractus Intestinaus \ 
 
 4. Volvulus 
 
 . r ). Strangulation 
 
 6. Invagination 
 
 flexion 
 
 stricture 
 
 calculus 
 
 inflammation 
 
 perforation 
 
 neoplasm 
 
 colic 
 
 sigmoid 60 per cent 
 
 ileocecal apparatus 30 per cent 
 
 enteron 10 per cent 
 j bands 
 / apertures 
 
 ileocecal apparatus 70 per cent 
 
 enteron 15 per cent 
 
 colon 15 per cent 
 
 Ulceration (gastrium, enteron, colon) 
 Splanchnoptosia 
 
 (Appendages) 
 
 (a) Liver 
 
 (b) Pancreas 
 
 (a) ducts — calculus, inflamma- 
 tion, neoplasm 
 
 (b) parenchyma, hepatitis, ne- 
 oplasm 
 
 (c) ducts — calculus, inflamma- 
 tion, neoplasm, pancreatitis 
 
 (d) parenchyma — necrosis, ne- 
 oplasm 
 
 II. Tractus Urinarius 
 
 III. Tractus Genitalis 
 
 f 1 - 
 
 u 
 
 Spleen — splenitis, neoplasm 
 Ureter 
 
 Bladder 
 Prostatitis- 
 
 f 1. Oviduct 
 
 \ 
 
 2. Ovarv 
 
 3. Uterus 
 
 IV. 
 
 r Veins — phlebitis, thrombosis 
 Tractus Vascularis < Artery — embolus 
 ' k Artery — aneurism 
 
 {peritoneum — peritonitis 
 glands — adenitis 
 ducts — lymphangitis 
 ' pain — constant, periodic 
 pain — on pressure 
 neuritis 
 neuroma 
 neuralgia 
 , hyperesthesia 
 
 flexure, stricture, calculus, in- 
 ] flammation, perforation, colic 
 
 ( calculus, inflammation, perfor- 
 
 ( ation, colic 
 vesiculitis seminales. 
 
 perforation, abortion, colic, in- 
 flammation, torsion, neo- 
 plasm 
 
 \ perforation, inflammation, tor- 
 
 ( sion, neoplasm 
 
 {perforation, abortion inflam- 
 mation, colic, torsion, neo- 
 plasm 
 
 VI. Tractus Nervosus 
 
 CONCLUSIONS AS REGARDS SUDDEN ABDOMINAL PAIN. 
 
 I. There are three kinds of sudden abdominal pain, viz. : (a) that of 
 peritonitis, perforation, inflammatory, septic lesions from adjacent visceral 
 peritoneal extravasation, continuous excruciating pain (pain continuous, 
 unlimited and life in jeopardy), as 1, perforation of the tractus intestinalis 
 
426 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 (gastrium, enteron, 
 channels). 
 
 2. Perforation 
 hydrosalpinx, uterus 
 
 3. Perforation 
 
 4. Perforation 
 chyle channels). 
 
 5. Perforation 
 embolus, oviductal 
 urinarius, genitalis, 
 or extraperitoneal. 
 
 colon, appendix — its appendages, biliary or pancreatic 
 
 of the tractus genitalis (oviductal gestation, pyosalpinx, 
 
 , ovary). 
 
 of the tractus urinarius (kidney, ureter, bladder). 
 
 of the tractus lymphaticus (chyle duct, chyle cysts, 
 
 of the tractus vascularis (aneurism, hemorrhage, 
 gestation, is hemorrhage). (The tractus intestinalis, 
 vascularis, lymphaticus may perforate, intraperitoneal 
 In extraperitoneal perforation, the pain is similar to 
 
 HEPATIC CALCULUS IN HARTMAN'S POUCH (S) AND VATER'S PAPILLA 
 
 Fig. 106. Presents hepatic calculus in the usual locations, Hartman's pouch and Vater's 
 diverticulum. A calculus in Vater's pouch aids to obstruct and infect the ductus pancreati- 
 cus. 
 
 intraperitoneal perforation except in degree, however, the danger of the 
 extraperitoneal visceral perforation is limited) ; (b) that of violent peristalsis 
 (colic, non-inflammatory) of tubular viscera, as in mechanical irritation, 
 calculus, stricture, obstruction, volvulus, flexion, oviductal gestation, par- 
 turition, constipation, aneurism, invagination, hernia, strangulation by band 
 (inflammatory), (pain limited, periodic, life not in jeopardy); (c) that from 
 painful peristalsis (colic inflammatory) from inflamed parietes of tubular 
 viscera, as ureteritis, choledochitis, salpingitis, cholecystitis, cystitis, 
 myometritis, myocorditis, enteritis, colitis, appendicitis (pain, periodic, 
 inflammatory, life not in jeopardy). First and foremost for practical pur- 
 poses it will be instructive to consider sudden abdominal pain from perfora- 
 tion of the three excretory mucous visceral tracts, viz. : intestinal, genital and 
 
SUDDEN ABDOMLXAL PAIN— ITS SIGNIFICANCE 427 
 
 urinary (as they not only perforate but develop immediate sepsis and 
 jeopardize life). Second, sudden abdominal pain should be considered 
 from perforation of the two non-excretory, non-mucous visceral tracts, viz., 
 vascular and lymphatic (as they perforate, but do not develop immediate 
 sepsis nor place life in immediate danger). 
 
 Fig. 107. Carcinoma completely obstructing the biliary and pancreatic ducts. Illustrates 
 an x-ray of enormously dilated biliary passages. The biliary ducts (excepting the gall- 
 bladder, which was three to four times its normal dimension) had a capacity of 32 ounces, 
 about six or seven times the natural capacity. The ductus communis choledochus was over 
 1% inches in diameter. The pancreatic duct admitted the index finger. The man, 69 years 
 old, a giant in stature, weighing some 250 pounds with ordinary limited fat, lost 115 pounds 
 in weight during three months' illness. The ductus cysticus, extending from II to IV, had 
 seven Heister's valves, and its lumen would admit a lead-pencil only. At B the biliary ducts 
 were deficient within the liver substance, but were really dilated on the surface. T, the 
 carcinoma (divided with the scalpel), completely severing the lumen of the biliary and pan- 
 creatic ducts. There was enormous gastroduodenal dilatation from the compression of the 
 transverse duodenum by the superior mesenteric artery (A) and vein (V). D, foldless, gran- 
 ular, proximal 2 l / 2 inches of the duodenal mucosa ; I, entrance of ductus communis chole- 
 dochus in the duodenum; Sa, ductus Santorini; P, ductus pancreaticus. The ductus 
 communis choledochus and ductus pancreaticus, located between the carcinoma and Vater's 
 diverticulum, were normal. Da, is the normal sized duodenum located distal to the com- 
 pressing superior mesenteric vein (V) and artery (A). Observe the vast dilatation of the 
 duodenum proximal to the superior mesenteric artery (A) and vein (V). I secured this rare 
 specimen at an autopsy through the courtesy of Dr. Charles O'Byrne. 
 
428 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 II. In making a diagnosis of sudden abdominal (constant) pain 
 probability is the rule of life, e. g., (a) sudden abdominal (constant) 
 pain accompanied with vomiting, abdominal rigidity, rise of pulse and 
 temperature, tympanitis, is peritonitis (perforative), as appendicular, geni- 
 tal, biliary, gastro-intestinal, hemorrhagic pancreatitis, (b) sudden (incon- 
 stant) abdominal pain with practi- 
 cally negative pulse temperature, 
 abdominal rigidity, tympanitis and 
 perhaps vomiting, is violent peri- 
 stalsis (colic), as flexion, stricture, 
 calculus, inflammation, strangula- 
 tion, invagination, volvulus, axial 
 torsion. 
 
 III. Extravasation in the peri- 
 toneal cavity is accompanied by ago- 
 nizing, excruciating pain. 
 
 IV. The leading symptoms 
 should not be obscured by opiates 
 until its complete clinical history as 
 nearly as possible is obtained. 
 
 V. The clinical history is fre- 
 quently a pencil of light in the 
 diagnosis of sudden abdominal pain. 
 
 VI. Examine the patient com- 
 pletely from head to foot (especially 
 per rectum and per vaginum). 
 
 VII. Exploratory peritonoto- 
 my is chiefly justified only in 
 ascertaining the extent of visceral 
 diseases and rarely justified to deter- 
 
 v y^' mine a diagnosis. 
 
 VIII. Delay in deciding the 
 diagnosis of sudden severe abdom- 
 inal pain should be avoided. 
 Prompt diagnosis is the sheet an- 
 chor for immediate successful med- 
 ical or surgical treatment. 
 
 IX. It must be remembered 
 that sudden severe abdominal pain 
 is a matter of gravity, and prompt 
 investigation with prompt decisions 
 
 should occur so that the patient's life may not be placed in jeopardy by 
 delay, or disastrous treatment be instituted. 
 
 X. (a) Determine, if possible, the location of the initial pain; (b) 
 inquire if the pain was at first diffuse in the central abdomen for awhile; 
 (c) later and final observe whether the pain localizes itself in the region of 
 the affected organ (peritonitis). 
 
 URETERAL CALCULI 
 
 Fig. 108. This illustrates uretera. calculus 
 in its usual location, viz., (a) in the ureteral 
 pelvis at the proximal isthmus (w), (b) in the 
 pelvic ureter at P. 
 
SUDDEN ABDOMINAL PAIN— ITS SIGNIFICANCE 
 
 429 
 
 XI. The location of the pain may be superficial (hyperesthesia of the 
 skin) or deep in the muscularis (rigidity). McBurney's point is a skin 
 hyperesthesia (from the cutaneous branches of the twelfth dorsal and first 
 lumbar nerve — ileo-hypogastric). 
 
 XII. The location of sudden abdominal pain is indicated by the segment 
 (somatic) of the spinal nerves in adjacent abdominal muscles (rigidity), skin 
 (hyperesthesia). The diseased abdominal viscus is protected, fixed by 
 muscular and nerve mechanism similar to the muscular protection fixation of 
 an inflamed joint. 
 
 XIII. The topographic anatomy of the abdominal viscera should be 
 mastered, for, it is the solid ground 
 
 of nature on which rests rational diag- 
 nosis. This can be accomplished by 
 study in the cadaver and at autopsy. 
 
 XIV. Remember the major 
 regions of peritonitis — appendicular, 
 pelvic and that of the gall-bladder. 
 
 XV. Remember the major re- 
 gions of violent peristalsis, colic (cal- 
 culus), biliary, ureteral, oviductal and 
 pancreatic. 
 
 XVI. Call the most available and 
 competent abdominal surgeon early in 
 consultation. 
 
 XVII. Remember that operations 
 do not kill — it is disease that tolls 
 the funeral bell. 
 
 XVIII. Operations on the dying 
 are unsatisfactory. 
 
 XIX. As a general idea it may 
 be stated that it is difficult to deter- 
 mine with precision the cause of 
 sudden abdominal pain. One must 
 frequently ask Jupiter to guide them 
 in the greatest field of probability (ap- 
 pendicitis, salpingitis, chole cystitis). 
 
 The operator who performs peritonotomy for abdominal pain should be 
 prepared for any emergency for the toxion of pain within the abdomen 
 sounds an alarm, the course of which can not with certainty be determined 
 externally. One can not determine the kind of wood that lies under a table 
 cloth. 
 
 XX. Abdominal pain as a single symptom is frequently delusive. 
 
 XXI. The more accurate the diagnosis in sudden abdominal pain the 
 less "neuroses," "neuralgia" or "indigestion" will occur. 
 
 XXII. A last resort to diagnose sudden abdominal pain is the "explo- 
 ratory and confirmatory incision" of Lawson Tait. 
 
 CALCULUS IN URETER 
 
 Fig. 109. Calculus at 3 which I re- 
 moved in 1898 and in 1906 I removed a cal- 
 culus from the same (left) kidney which 
 was atrophied to one-third of its normal 
 dimensions. Patient is, six months after 
 the second operation, well. 
 
430 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 GENERAL TREATMENT OF SUDDEN ABDOMINAL PAIN. 
 
 First and foremost, should be introduced: (a) anatomic rest, which is 
 maximum quietude of skeletal or voluntary muscles. Retire to bed not to 
 rise for defecation or urination; (b) physiologic rest, which is minimum 
 function of viscera. Food and fluid are prohibited per mouth. 
 
 Fig. 110. The arteria uterina ovarica 3 hours subsequent to parturition at term. Every 
 branch of the artery is ensheathed by a fenestrated plexus of nerves. 
 
 No anodynes or in minimum repeated doses until clinical history and 
 the diagnosis is completed (maximum doses of anodynes obscure the 
 diagnosis). 
 
 [Note — The method of treatment for abdominal pain by anatomic and 
 physiologic rest was especially advocated by the distinguished English 
 physician, Wilkes, in 1865 (living at present), continued by the celebrated 
 
SUDDEN ABDOMINAL 1'. UN— ITS SIGNIFICANCE -131 
 
 American, Alonzo Clark (1R07-1^7), by the "opium splint," and established 
 forever in 1888 by one of the greatest surgical geniuses of his age — Lawson 
 Tait (1845-1900]. 
 
 Heat (hot, moist cornmeal poultice, hot water bag, hot bath) aids to 
 relieve pain. 
 
 No cathartics — cathartics stimulate peristalsis, increases pain and dis- 
 tribution of sepsis. They induce vomiting. A rectal enema (or two) may be 
 employed — the composition may be equal parts of molasses and milk, soap 
 suds, glycerine, magnesium sulphate. Rectal injections of air. 
 
 BIBLIOGRAPHY. 
 
 John B. Deaver E. S. Ricketts E. Babler 
 
 J. H. Musser E. O. Smith E. Harlan 
 
CHAPTER XXXII. 
 GENERAL PATHOLOGIC PHYSIOLOGY. 
 
 Hopeful men worship the rising, pessimists the setting, sun. 
 Bumping one's head against the universe makes brains. 
 
 The subject of this paper is pathologic physiology. The theme is the 
 abnormal function of organs, or organs acting under pathologic conditions. 
 The field included lies between normal physiology and pathologic anatomy. 
 It is the zone of pathologic physiology or clinical pathology. In general it 
 is determined with facility whether the visceral functions are pursuing a 
 normal or abnormal course. In certain subjects, however, it is difficult to 
 determine whether the functions are normal or abnormal. Some subjects 
 present unmistakable pathologic symptoms for years, e. g., constipation, 
 dirrahea, renal secretion, sweating; however, such subjects, though not 
 theoretically, they are practically well. Pathologic physiology enables the 
 physician to estimate between theoretical and practical functions. Not 
 infrequently the functions of a subject vary to such a degree that it is difficult 
 to decide whether he is well or ill. I know one subject who, between forty- 
 five and sixty years of age, would periodically (several times annually) urinate 
 some five quarts daily, otherwise he was practically well. He died of an 
 acute attack of diarrhea at seventy. 
 
 To understand pathologic physiology one must possess a clear view of 
 physiology. It may be well to remember that the common function of the 
 thoracic and abdominal visceral tracts are sensation, peristalsis, absorption, 
 secretion. Disease is a deviation from one or all these common functions. 
 Disease begins as abnormal function and progresses with its repetition. The 
 study of pathologic physiology constitutes the subject of abnormal function. 
 To the four common functions mentioned of the thoracic and abdominal 
 visceral tracts we must add the three special functions of the tractus genitalis 
 — viz., ovulation, menstruation, and gestation — which offer vast fields of 
 pathologic physiology in daily practice. 
 
 Pathologic physiology arises from defects in the living protoplasm 
 (inferior anatomy and physiology) or from environments (bacteria). The 
 subject born with pathologic physiology (heredity, stigma) is unable to with- 
 stand the friction of normal life. The subject may occupy such environ- 
 ments that injurious influences affect his protoplasm, such as excessive 
 physical or mental exercise, heat, cold, bacteria. The study of pathologic 
 physiology dignifies the basic study of physiology; it impresses the student 
 with the functions and the structure of viscera. First and foremost, the 
 physiology of an organ must be studied in order that its deviations may be 
 comprehended. The study of physiology of organs will assist in compre- 
 
 4i^ 
 
GENERAL PATHOLOGIC PHYSIOLOGY 433 
 
 hending the factors which influence the functional deviations. The subject 
 of visceral peristalsis, rhythmical movements, the object of which is to propel 
 visceral contents — urine, blood, ingesta, lymph, gestation products, secret- 
 ions, carbonic acid gas — is of vast practical interest in the daily practice of 
 medicine. Viscera are continually being subject to peristaltic waves. Peri- 
 stalsis is dependent largely on visceral contents and blood supply. Hence 
 the sluggish bowels (deficient peristalsis) are improved by supplying constant 
 fresh blood. Fresh blood constantly streaming through the tractus intesti- 
 nalis, urinarius, and genitalis initiates repeated peristaltic waves. The gravid 
 uterus is in constant myometrial waves from extra blood supply. The 
 tractus intestinalis, as the fresh blood streams into its territory, is subject to 
 constantly repeating peristaltic waves. In visceral peristalsis the quantity 
 of blood bathing the automatic visceral ganglia plays a role. 
 
 Since pathologic physiology is the zone between physiology and 
 pathologic anatomy it is doubtless the incipient stage of future disease, 
 pathologic anatomy. For example, chlorosis appears to be a precursory 
 stage, a stage of pathologic physiology, to splanchnoptosia; gravidity 
 precedes splanchnoptosia. The study of pathologic physiology cultivates 
 accurate diagnosis in incipient stages of disease, enhancing opportunities 
 for prophylactic measures. Modern investigation has forced us to accentuate 
 functional (incipient) aspect of disease. It stimulates us to discover and 
 recognize abnormality of function. It is returning to physiology as basic 
 study. The discovery of an abnormal function may lead to the diagnosis of 
 a contingent disease. The disordered function in the irritable weakness of 
 the nervous system presents inferior anatomy and physiology. 
 
 Pathologic physiology attempts to instruct through disordered func- 
 tions of the living subject. Pathologic anatomy attempts to instruct 
 through changed structure in the living and dead subject. In practice, 
 recognized disordered functions, or pathologic physiology, are manifest 
 a hundred fold more than recognized pathologic anatomy. The old 
 physicians recognized pathologic physiology under another name, as 
 clinical pathology, functional or sympathetic disease. Among the first to 
 discuss pathologic physiology from a scientific or systematic standpoint 
 was Cohnheim, as found in his celebrated general pathology. However, 
 before me lies the third edition (1904) of Dr. Rudolph Krehl's book, the first 
 edition of which (1898) presented a systematic treatise on pathologic 
 physiology. Practically Dr. Krehl's book is a pioneer work on pathologic 
 physiology, systematizing the labors of Cohnheim and others, as well as 
 making vast additions to the field himself. Pathologic physiology is not 
 a new subject, for physicians recognized its existence in the past. Modern 
 laboratory methods have demonstrated that the normal functions of indi- 
 vidual organs vary within an extensive range. The border line between 
 physiology and pathologic physiology is manifest by symptoms of various 
 characteristics. Frequently organs will vary double their usual range, as the 
 quantity of urine may be two or four pints daily, defecation may be once 
 or twice daily, or every second day. Perspiration may be doubled for a 
 
 28 
 
434 THE ABDOMLXAL AXD PELVIC BRAIN 
 
 period. We may observe the heart beat 120 per minute for weeks with no 
 recognizable pathologic anatomy. 
 
 Pathologic physiology is characterized by an abnormal course of the 
 life of an organ or a series of organs. In what does normal course of organs 
 consist? We may designate as normal living processes what is found in the 
 vast majority of individuals, in man and animals, when the individuals are 
 considered healthy. It is granted that the function of an organ has normally 
 an extensive range of healthy action. For example, the quantity of uric 
 acid in the urine of the genera of aves, carnivora, herbivora, and bimana is 
 extreme!}' variable. 
 
 Perhaps man would not long survive producing a quantity of uric acid 
 which birds habitually secrete. Each genera and, perhaps, species, have a 
 law for themselves as regards the function of organs, possessing extensive 
 variation of organ functions, without being pathologic. Pathologic 
 physiology should be taught with more exactness in the colleges, so that the 
 graduates may not be compelled to learn it at the expense of their patients. 
 Pathologic physiology should be comprehensively explained to students, as 
 it enables them to secure a general view of organized viscera, as well as the 
 vicarious action of individual viscera. Besides it aids the practitioner to 
 diagnosticate disease when no pathologic anatomy demonstrably exists. 
 Pathologic physiology is the zone between physiology and pathologic 
 anatomy, an indeterminate, extensive, and frequently rapidly varying zone. 
 It is well to bear in mind that I am discussing pathologic physiology as 
 dominated by the sympathetic nerve (nervus vasomotorius). I will present 
 in this essay some views on pathologic physiology of the viscera which I 
 have taught for years in gynecological and abdominal courses. 
 
 No richer f eld exists in medicine, in inductive research, or for pro- 
 ductive scholarship than the establishing of evident cause and effect in 
 patholog'c physiology. Pathologic physiology projects physiology into the 
 field and function of philosophy. Physiology is the most noble of medical 
 studies. Science collects facts while philosophy arranges and predicates laws 
 from them. The field and function of philosophy is to deal with all classes 
 and departments of incomplete knowledge for the purpose of utilizing it for 
 man — to prolong life, lessen suffering, and increase happiness. Pathologic 
 physiology will aid in the partial reduction of medical practice to laboratory 
 investigation, e. g., senitlty, local and general, is heralded by observable 
 cellular change — development, differentiation and degeneration of its vital, 
 physiologic, process. The ceil is accompanied by a cyclic series of changes 
 from embryoism through differentiation to senescence termed by Prof. 
 Minot, cytomorphosis. (1) The first stage or embryonic cell is peculiar to 
 itself in its physiology and if prolonged by circumscribed inclusions may 
 become malignantly degenerated in the adult. (2) The second stage of. life's 
 cells, that of differentiation, consists of two states: (a) cytostatic differen- 
 tiation, or the production of a material of definite and stable composition, as 
 connective tissue, intercellular osseous substance— connective tissue frame- 
 work; (b) cytodynamic differentiation is the production of substance having 
 
GENERAL PATHOLOGIC PHYSIOLOGY 435 
 
 a metabolic function— parenchyma. (3) The third stage of life's cell is that 
 of degeneration — senescence. Hence the laboratory investigator may yet 
 discern the cause that determines cellular changes — embryonic, differentiation 
 and degeneration (senescence), i. e., the pathologic physiology of life's 
 cyclic cell and also that of disease. The philosophy of physiology at once 
 suggests that the vital processes of cells — embryologic, differentiative, 
 degenerative — cannot be abolished, however, they can be advantageously 
 modified. The destiny of the cell is an aggregative mould into organs — for 
 physiologic function. The composite organs functionating as a unit make 
 man — the animal. 
 
 Physiology or function precedes and dominates structure. Man— the 
 animal — is the drama, the play. It calls into being, function, the stage 
 accoutrements, and dramatis personam which exist and have signification to 
 subserve the drama. The play selects and arranges the scenery, creates and 
 determines the settings, lends coherence and sense to the sentence, furnishes 
 inspiration and purpose to the actors. Now, it may be true in the material 
 presentation of the play that stage furniture is the first structure element 
 manifest, it is however subordinate to the motive of the performance or 
 play. The stage material, furniture, is forgotten, lost in the functions of the 
 play. Man's body is the stage accoutrements and persons. The drama, 
 the play, is the physiology, the function. Interpreted, this means that func- 
 tion determines structure, not structure function. Progressive motion in 
 animals has traumatized, frictiomzed, the proximal end (brain), enticing 
 increasing blood supply (friction) and consequent increase of substance 
 arises, i. e. s bumping one's head against the universe develops the brain. 
 Lincoln's body, that is, his anatomy, his stage accoutrements are dead, how- 
 ever, Lincoln, master of men, his play, his physiology, his function progresses 
 unabated. John Brown's body, his physical stage accoutrements, is dead 
 but his function of liberty moves on forever, even to the latest Russian cry 
 for freedom. The staging, the physical accoutrements, of Uncle Tom's 
 Cabin have long disappeared. However, the motive of the play, the func- 
 tion of the drama, which was the freeing of the black men, has also ceased as 
 the object of the play had been accomplished. The parallel between the 
 field of music and bilology or physiology is striking. Pipes and strings are 
 the anatomy of music, but music itself, the ultimate object, is not pipes and 
 strings. It consists of a pleasing succession of agreeable sounds — music is 
 the physiology of the pipes and strings. The pipes and strings — the anatomy 
 — are made to functionate as a unit through physiology, which rules anatomy. 
 The several instruments must work in harmony — as a unit — to produce the 
 object, which is the orchestra. Sound is itself an element, unrelated, unclassi- 
 fied, having neither predicate nor attribute and cannot therefore be confused 
 with music — which is the pleasing succession of agreeable sounds to the 
 human sense and purposely designated for that object. The only functional 
 value of sound is to be a pleasant succession. 
 
 Physiology harmonizes different structures as music does pipes and strings 
 into a functionating unit. As the instruments in the orchestra must subserve 
 
436 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 the purpose of the musician 
 cells — organs — in the body 
 
 HYRTL'S EXSANGUINATED 
 RENAL ZONE (H, H, H.) 
 Fig. 111. Corrosion anatomy. 
 Left kidney. H, H, H, is what I 
 term Hyrtl's exsanguinated zone. 
 A, B, equatorial line of lateral 
 longitudinal renal border. D, dor- 
 sal vascular renal blade. V, ven- 
 tral vascular renal blade. H, H, 
 H, indicates the course of Hyrtl's 
 exsanguinated renal zone or the 
 elective line of renal cortical in- 
 cision with minimum hemorrhage 
 — located l / 2 inch dorsal to the 
 lateral longitudinal renal border. 
 The quantity of sympathetic 
 nerves required for the kidney 
 may be estimated by the number 
 of arteries in its two vascular 
 blades. 
 
 — which is music — so the aggregative molds of 
 must subserve the dignified purpose of physi- 
 ology, i. e., a functionating unit which dom- 
 inates, determines and precedes structure. 
 We concede to our materialistic friend the 
 physical basis of life and that function is not 
 purely phychic in character. In the final 
 analysis of structure or function we are deal- 
 ing with the arrangement of matter, and that 
 is structure. To illustrate that function, phys- 
 iology, dominates structure, anatomy, one need 
 only study large, noninfected, pelvic peri- 
 toneal exudates. Not long after pelvic peri- 
 toneal exudate arises blood vessels begin to 
 appear in the mass, projecting their course 
 through it, followed by lymph vessels and 
 nerves as well as an endothelial covering, 
 until the jelly-like unorganized mass is a living 
 structural unit, a functionating organism. In 
 this case did not physiology dominate, deter- 
 mine, precede anatomy? — yes, physiology is 
 the central motive power of life. Darwin 
 recognized this principle throughout his inves- 
 tigation of the origin of species. Through 
 physiology he claimed he could modify species 
 by environments that in a few years they 
 could be scarcely recognized. By environ- 
 mental influences he could modify through 
 physiologic forces the traits or characteristics. 
 Observe how the patent foramen ovale, mod- 
 ifies circulation — i. e., physiology — produces 
 the clubbed fingers. Dr. Thomas G. Atkinson 
 in the editorials of the Medical Standard for 
 July and Oct., 1906, writes instructively and 
 strikingly on .pathologic physiology. He claims 
 that the influences which determine structure 
 operate from the complex to the simple, e. g., 
 the larger functions of the body peristalsis, 
 circulation, cerebration — are the simplified 
 specific expressions of the multiple, complex, 
 impressions produced on the body in general 
 by circumstances and environment and these 
 consequently are the determining causes of 
 cellular structure. Physiology is the father of 
 anatomy, of form, of characteristics, of hyper- 
 
GENERAL PATHOLOGIC PHYSIOLOGY 437 
 
 trophy. A myoma in the uterine wall or an ovum on the endometrium 
 are the causes of uterine hypertrophy — increased blood supply has multiplied 
 the cellular elements of the uterus. Physiology or direction of excessive 
 blood to the uterus has determined the multiplication of cellular struct- 
 ure And thus the amphioxis and similar animals that superseded and 
 repeated his structure bumped their heads against the world's physical forces, 
 developing the four skull vertebra and multiplying their cerebral cells by 
 enticing blood, due to the cerebral trauma. The Japanese have long bodies 
 and short legs because they do not use the legs sufficiently to secure blood. 
 Sitting on chairs would entice more blood for larger legs. The lessons to be 
 drawn from these views are that structure has no power to modify itself. It 
 is perverted function that alters structure — pathologic physiology is the 
 father of it. Again Dr. Atkinson claims that perverted function, pathologic 
 physiology, operates from the complex to the simple. Pathologic physiology 
 finally terminates by registering itself as altered adjustment of cellular struct- 
 ure in accordance with the perverted function at issue. Structural changes 
 as a rule are the final responsive reaction of cell arrangement to pathologic 
 physiology, having their origin in the complex relations between organism 
 and environments and operating through the less and less complex physiologic 
 systems of the body. The skillful and scientific physician can discern the 
 origin and course of pathologic physiology and apply the appropriate advice, 
 drug or scalpel, first to correct the function and second to correct the struct- 
 ure. 
 
 The Chief Duty of a Physician is to Correct Function. 
 
 As nine-tenths of illness is so-called medical and one-tenth so-called surgi- 
 cal, practically the sphere of a physician's influence is limited to the field of 
 pathologic physiology, which lies between normal physiology and pathologic 
 anatomy — the zone of pathologic physiology. 
 
 The common functions of viscera (sensation, peristalsis, absorption, 
 secretion) do not perform uniformity throughout the same visceral tract and 
 hence demand special attention in physiology, e. g., secretion is more promi- 
 nent in the proximal end (cerebrum) of the tractus intestinalis while absorp- 
 tion is more pronounced in the distal end (sympathetic). These views should 
 be borne in mind when observing pathologic physiology. In excessive secre- 
 tion there is not only an expenditure of energy but also a loss of material from 
 the body. Physiology deals with the sources of energy and the transforma- 
 tion of energy. The practically wise physician seeks to trace through the 
 deviating functions the source of erroneous energy. 
 
 In the consideration of physiology or pathologic physiology the nervous 
 system must be considered a presiding genius. E. g., food within the duode- 
 num incites both the liver and pancreas to secrete through a nervous mechan- 
 ism for it appears that if bile and pancreatic juice become mixed in Vater's 
 diverticulum or immediately on arrival within the duodenum, the power of 
 the succus pancreaticus is doubled. It is well to know for practical therapeu- 
 tics (pathologic physiology) that adrenalin — a product of the adrenal medulla 
 
438 THE ABDOMINAL AND PELVIC BRAIN 
 
 — circulating in the blood appears necessary for the excitation of any nervus 
 vasomotorius. The thyroid gland manufactures some substance — thyro-iodin 
 — which aids in the proper growth of body tissues and also for the normal dis- 
 charge of the cerebral functions. The fetus during gestation secretes some 
 substance which aids in enlarging the mammary gland. The ovary secretes 
 a substance which preserves sex and nervous characteristics. Hence with 
 increasing knowledge of physiology we may be able to isolate these sub- 
 stances — adrenalin, thyro-iodin, ovarian secretion, secretions of pregnancy 
 which induce mammary hypertrophy, etc., etc. — and in their isolation place a 
 list of therapeutic messengers at our command which will correct the patho- 
 logic physiology of bodily organs. With broader knowledge of physiology 
 present, therapeutic nihilism will be replaced by rational therapeutics which 
 rest on physiology, the solid ground of nature. 
 
 The results from the study of the four grand common functions of viscera 
 (sensation, peristalsis, absorption, secretion) must be the rock and base of 
 our authority in pathologic physiology. 
 
 Irritable weakness of the nervous system presents inferior anatomy and 
 physiology. The subject of pathologic physiology will force us to study 
 the stigmata of function. It is noteworthy that before the days of legitimate 
 specialism few practical stigmata were recognized. At present every spe- 
 cialty has a chapter of abnormalities, of stigmata. In fact, the study of 
 abnormalities has proceeded to such a degree that a majority of individuals 
 are docketed with telltale stigmata of some sort or kind. The pathologic 
 physiology or stigmata of individuals may with impressive instruction be 
 termed "habitus," by which prefix we may distinctly designate certain classes 
 of subjects. We have the habitus phthisicus, habitus nervosus, and the 
 ensemble of certain symptoms may well be termed habitus splanchnoptoicus. 
 The habitus is an expression of inherited weakness, defect. It presents the 
 idea that inferior anatomy and inferior physiology has been transmitted to 
 or acquired by the individual. The tendency of modern study is to accentuate 
 the functional aspect of disease; hence it is this method of study that has 
 taught that there is an abnormality of function. The mind is a good source 
 of pathologic physiology, as by concentrated thinking one can congest 
 excessively an organ, e. g., genitals, brain. There is frequently more in the 
 physician's suggestions than in his medicine. 
 
 Rational Medicine alone will stand the test of science and time. Rational 
 medicine must be the medical amazon of truth, from which will be 
 eliminated the false lateral issues, tangenital fads, distorted views of the 
 unbalanced and the knave. Rational medicine must be founded on the solid 
 ground of Nature to stand forever. Will the teachings and knowledge of 
 pathologic physiology aid the physician to exactuate more rational practice? 
 The comprehension of pathologic physiology will extend the physician's 
 views of physiology, which should resume its original basic position in medicine. 
 The future of clinical medicine lies in the direction of pathologic physiology. 
 Rational medicine consists in the application of scientific laboratory methods 
 to the ambulatory and bedside patient. However, the laboratory seems to 
 
GENERAL PATHOLOGIC PHYSIOLOGY 439 
 
 advance periodically, beyond clinical application. In the field of science and 
 investigation there is continually clashing of opinions, with statements and 
 counter statements, with evidence and counter evidence, from which estab- 
 lished rules of practice evolve. The principles of science require during the 
 progress of discoveries, revision, reconsideration, and recasting. 
 
 The perfection of physiological, chemical, and pathologic knowledge, 
 with consequently improved technique, will enable the clinician to advance 
 on the citadel of disease rationally during the premature stage of pathologic 
 physiology with more practical hope of success. Cardiac irregularity, palpa- 
 tation (which chiefly rests on vigorous muscle or myocardium) is generally 
 pathological physiology, or abnormal disordered function (excessive, deficient 
 or irregular peristalsis) and often a nervous manifestation only. The function 
 or the physiology of the cardiac ganglia (Remak's, Bidder's, Ludwig's, and 
 Schmidt's) have become temporarily disordered, pathological, wild, irregular, 
 yet no pathological anatomy can be detected. It is well enough to attempt 
 to be scientific in explanation to the student, that cause and effect are logical 
 sequence, yet, also, to admit that we cannot detect the cause of cardiac palpi- 
 tation in any existing pathological anatomy — it is pathological physiology, 
 disordered functions, through nonrecognized channels. Pathological physiol- 
 ogy alone will explain the irritable bladder; the cystoscope does not reveal 
 the pathological anatomy. The vesical apparatus is acting unusually, it is 
 assuming an abnormal course. I have noted such bladders for years; they 
 afflict the possessor by frequent evacuations, by loss of sleep, and broken 
 rest. Who will attempt to explain the surface anesthesias by pathological 
 anatomy? They are here to-day and there to-morrow. Many a time and oft 
 have I noted the pharyngeal anesthesia in hysteria ; in fact one can apply a 
 uterine sound vigorously to the surface of the pharynx without inducing 
 nausea or reflex muscular action. 
 
 We have no more appropriate terms to apply to these phenomena than 
 pathological physiology, disordered function. In practice of medicine the 
 student should be instructed in physiological principles and not that he is 
 always to attempt to remove changed structures by his remedies or scalpel. 
 The practice of medicine is the practice of common sense. We are to use 
 means to an end. For example, if a frog's heart recently removed is placed 
 in a warm physiological salt solution, it will perform its peristalsis for a time 
 and cease; now, I can renew its peristalsis by stimulation; the stimulant 
 may be an icicle, electric current, a hot steel needle, or a current of water or 
 air. The chief duty of the profession is to aid in the resumption of normal 
 functions, not merely attempt to discover some pathological anatomy or 
 changed structure, for it would waste valuable time. We should cultivate 
 pathological physiology rather than surgery, as it will be the vast future 
 therapeutical field for nine-tenths of illness, whereas surgery is of value in 
 about one-tenth of illness. 
 
 The mind is frequently the organ that needs the stimulant of which 
 quacks, patent medicines, knaves and pretenders take advantage. Patholog- 
 ical physiology recognizes the influence of mind over matter. The sensible 
 
440 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 physician realizes that suggestions are a powerful aid to peristalsis, absorp- 
 tion, secretion and sensation, to the restoration of visceral function, and 
 though the honorable physician may not make the bold, false assertions of 
 the quack, he can suggest honest, legitimate aid and comfort to the patient. 
 The honest physician is se- 
 cret and reticent. The 
 quack is blatantly false. 
 Secrecy and reticence is bet- 
 ter than falsehood. The 
 physician can and should be 
 an honest man. The physi- 
 cian comprehending patho- 
 logic physiology becomes 
 master of suggestions for the 
 patient's benefit. The med- 
 ical profession cannot afford 
 to leave the influence of 
 mind over matter, the field 
 of suggestive therapeutics, 
 to the quack and knave. 
 The world of knowledge is 
 our parish. To alleviate 
 suffering and prolong life 
 from rational demonstra- 
 tions of science is our duty. 
 To treat the sick by any 
 legitimate means is our priv- 
 ilege. 
 
 Diagnosis. — T h e diag- 
 nosis of functional deviation 
 or abnormal visceral action 
 is the rock and base in path- 
 ological physiology. This 
 view indicates that the phy- 
 sician understands the physiology. First and foremost is the diagnosis, 
 i. e., what abnormal course are the functions assuming? Disease is abnor- 
 mal physiology, and the sooner physiological deviation is diagnosticated, 
 the sooner may effective remedial agents be instituted. To be useful 
 to a patient, the incipient stage of diseases, i. e., premature pathologic physi- 
 ology, must be detected in order to check the progress of the abnormal func- 
 tion before pathologic anatomy establishes itself. We must accomplish the 
 diagnosis by all known aid, medical technique, and laboratory methods. 
 
 Pathologic physiology will rest on laboratory methods for rational 
 knowledge and practical application. Laboratory methods are valuable 
 assets to a physician because they will increase his business of rational appli- 
 cation and success. The physician's self-confidence, which arises from 
 
 CORROSION ANATOMY 
 
 Fig. 112. Left kidney, dorsal surface (D) dorsal 
 vascular blade. — H, H, H, indicates Hyrtl's exsanguin- 
 ated renal zone, or the elective line of incision, one-half 
 inch dorsal to the lateral longitudinal renal border. 
 Observe that the elective line passes to or invades the 
 ventral renal vascular blade at the proximal and distal 
 poles. Hyrtl's zone is irregular at the renal poles. 
 The dorsal vascular renal blade is the smaller. Observe 
 the quantity of nervus vasomotorius required to en- 
 sheath the renal arteries with close fenestrated, network 
 of plexuses. 
 
GENERAL PATHOLOGIC PHYSIOLOGY 
 
 441 
 
 accurate knowledge, begets confidence in the patient, and this increases his 
 power and clientele. Laboratory methods increase the physician's efficiency, 
 and this contributes to his professional attainments. Laboratory methods 
 are invaluable to the physician himselt for his own rational view of any dis- 
 ease. Practically, patients 
 are willing to recompense a 
 physician according to his 
 ability and attainments. 
 The day is not distant when 
 the physician's power to 
 diagnosticate disease will be 
 measured by his laboratory 
 methods, especially in the 
 incipiency or in the stage 
 of pathologic physiology. 
 The judgment of the physi- 
 cian will be heavily taxed as 
 to prognosis. Unfortunately 
 some cases of splanchnopto- 
 sia appear with neurasthe- 
 nia, as an integral part, or 
 splanchnoptosia is imposed 
 on the subject of hysteria. 
 Neurasthenia and hysteria, 
 though not primary in 
 splanchnoptotics, easily 
 thrives among them. It is 
 an indication of defective 
 knowledge and judgment to 
 attribute symptoms of ne- 
 phroptosia or gastroptosia 
 that belong to general 
 splanchnoptosia. 
 
 Blood Volume. — Patho- 
 logical physiology combines 
 rational views of living or- 
 gans, more than that merely 
 based on pathological an- 
 atomy. For example, when 
 pathological physiology of 
 the kidney is studied, the 
 instructor must take rational 
 and comprehensive views of the renal viscus. Pathological physiology 
 of the kidney takes into account the condition of the kidney, the constituents 
 of the blood and volume of blood that streams through the organ. The 
 discussion of these three subjects in regard to the kidney lends a com- 
 
 HYRTL'S EXSANGUINATED RENAL ZONE 
 
 Fig. 113. Corrosion anatomy, left kidney, ventral 
 view (V) ventral renal vascular blade. — From man about 
 forty-five years of age. The ureter was injected with 
 yellow wax. The ramus dorsalis renalis was injected 
 with celloidin colored with red sulphide of mercury. 
 The trunk of the arteria renalis, including the ramus 
 ventralis renalis was injected with uncolored celloidin. 
 The tissues were corroded in HNO3 for two weeks. 
 A. R., Arteria renalis sinistra. 2, ureteral pelvis. 3, 
 proximal ureteral isthmus. H, H, H, indicates Hyrtl's 
 exsanguinated renal zone. It may be noted on the 
 ventral renal surface that the renal dorsal vascular blade 
 overlaps or invades the ventral vascular blade at the 
 proximal and distal renal poles. Hyrtl's exsanguinated 
 renal zone is not equatorial at the proximal or distal 
 renal poles nor in the central portion of the kidney. 
 The elective line of renal incision to invade the ureteral 
 pelvis with minimum hemorrhage is located l / 2 inch 
 dorsal to the lateral longitudinal renal border in the 
 central segment of the kidney and is about two inches 
 in length. The quantity of nervus vasomotorius may 
 be estimated by the number of arteries and ducts pres- 
 ent. 
 
442 THE ABDOMINAL AND PELVIC BRAIN 
 
 prehensive view to the student in making a diagnosis on the living subject, 
 e. g., the functional capacity of a kidney is the rational test, not albumen 
 and casts. It is common to observe much variation in the quantity of 
 urine, inexplainable, except by pathological physiology, for urinalysis offers 
 none. Pathological physiology teaches that the circulation of an organ is a 
 fundamental factor in comprehending diseased conditions. The teacher who 
 does not comprehend varying phases of circulation of the female genitals in 
 the different stages of pueritas (quiescent), pubertas (development), menstrual 
 (functionating), gestation (functionating), puerperal (involution), climacterium 
 (subsidence), and senescence (quiescent), makes a defective gynecological 
 teacher. No organs except the kidney, offer such an extensively varied base 
 to illustrate pathological physiology of the tractus vascularis as the female 
 genitals. 
 
 The circulation of an organ quotes its value in the animal economy; it 
 rates its function. Each organ is supplied by arteries which have automatic 
 visceral ganglia, which regulate, govern, the volume of blood which flows 
 through them. The automatic visceral ganglia tell the story why the volume 
 of blood changes so much in different conditions of the organs when the 
 parenchymatous cells of an organ functionate, as the liver during digestion, 
 the uterus during gestation, the cerebrum during thinking (cerebration), the 
 blood volume is increasingly directed to the organ through the automatic vis- 
 ceral ganglia, dilating the arteries. Hyperaemia indicates the functionating 
 brain, kidney, and genitals, and these organs occupy vast considerations in 
 practice. Pathological physiology indicates that great benefit is secured by 
 controlling circulation, blood volume, by checking peristalsis through with- 
 holding food; controlling diet controls the blood constituents to a certain 
 degree. Bier's method of artificial congestion is employing pathological 
 physiology (in the tractus vascularis) for the purpose of curing chronic 
 inflammation. 
 
 Treatment of Pathological Physiology. — The treatment of pathological 
 physiology consists: 1. In the detection and removal of causes; 2, the 
 rational regulation of visceral function, a, by fluids; b, by foods; 3, habitat; 
 4, avocation; 5, prophylaxis. 
 
 1. The Detection and Removal of Their Causes. — The detection of the 
 cause in pathological physiology requires the best head and the finest analy- 
 sis. The detection of a rectal ulcer or fissure as the cause of innumerable 
 reflexes is a credit to the diagnostician. The recognition of damaging effects 
 of preputial adhesions is important. The glans penis or clitoris is like an 
 electric bell button, the pressing or irritation of which rings the whole organism 
 into pathological physiology. A cinder in the eye is a grand master of patho- 
 logical physiology. I have known the detection and removal of a bleeding, 
 proximally located, rectal polypus to save a child's life and make a physician's 
 reputation. This little rectal polypus had bled and escaped being examined 
 for a whole year by numerous consultants. I know a gynecologist who did 
 five operations on a woman's genitals for pain in the distal abdomen. She 
 became no better, but worse. The cause of all her pain was discovered by a 
 
GENERAL PATHOLOGIC PHYSIOLOGY 443 
 
 consultant, who found a marked spinal gibbus or kyphosis of tuberculous 
 nature at the junction of the dorsal and lumbar vertebrae. The reflected pain 
 from kyphosis had dislocated the gynecologist's mind, to make a scapegoat 
 of the genitals. Frequently infected groin glands are associated with an 
 infected corn on a toe. A decayed tooth may cause earache. I knew a 
 woman of twenty-four years, experienced some eight months of crucial 
 suffering from pathological physiology. She was examined by one physician 
 who said her ovaries should be removed, two others said that she must have 
 her appendix extirpated, one physician diagnosticated neurosis, another indi- 
 gestion, finally a physician was employed who found she had a ureteral calcu- 
 lus and removed it after which she gained thirty pounds in eight weeks. 
 This an excellent example to demonstrate that, though pathological physiol- 
 ogy allows ample time for diagnosis and prophylaxis, yet it requires the finest 
 head with the finest skill of analysis to interpret the signification of abnormal 
 visceral function. Hepatic calculus may introduce pathological physiology 
 into the tractus intestinalis and associated visceral tracts, but it requires 
 experience, accumen, and skill to detect the cause of pathological physiology. 
 
 2. Rational Regulation of Visceral Function by Visceral Drainage. — 
 Pathological physiology teaches the supreme importance of visceral drainage, 
 of maintaining in normal attenuated solution bodily secretions. It teaches 
 the benefit of removing the debris of waste laden blood by means of fluids. 
 When the patient's blood and organs are saturated with waste laden material, 
 he is unprepared to resist the attacks of disease ; he is prepared for irritation, 
 for reflexes or neurotic explosions. With scientific views of pathological 
 physiology, the correction of functional deviation with rational ideas of vis- 
 ceral drainage, the physician holds the key of prophylaxis against the formation 
 of pancreatic, hepatic, and renal calculus. With ample visceral drainage, 
 with sufficient fluids taken at regular intervals for visceral functions, the pan- 
 creatic, biliary, and renal secretions would seldom precipitate their salts, and 
 colloid material or cohesive ground substance of calculus would be so atten- 
 uated that calculus would not form. 
 
 Viscera should functionate at a normal maximum for bodily safety and 
 protection. Pathological physiology takes into account of the composition of 
 glandular secretion, as the pancreatic, hepatic, and renal, with the view that 
 pancreatic, hepatic, and urinary salts, especially urates, should be maintained 
 in attenuated solution by ample fluids, that no calculi may form. A study 
 of the remedies recommended as uric acid solvents or eliminators of uric acid 
 reveals the data that are composed of two ingredients, viz. : (a) alkali, (b) 
 water. The plan is to alkalinize the blood current, and thus render the uric 
 acid more soluble and promote its elimination. The administration of an 
 alkali to dissolve uric acid concretions is of limited value. Alkalies and uric 
 acid are solvent in vitro, but cannot accomplish the same in vivo. The 
 alkalies are ingested with the foods, making soluble urates. After all, the 
 ingestion of alkalies in food and fluid cannot alter materially the uric acid. 
 However, the chief virtue lies in the quantity of water ingested at regular 
 intervals during the day. The water is the chief efficacious ingredient in uric 
 
444 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 acid remedies. The water increases the blood volume which in turn produces 
 a powerful stream irrigating the tractus urinarius and maintaining the uric 
 acid in attenuated mechanical suspension. 
 
 *u F uP' "L 14 ' This illustration represents the lymph glands or nodes located in the course of 
 the blood vessels. The lymph nodes are highly supplied by the nervus vasomotorius. ' 
 
 Pathological physiology indicates that the composition of the blood is 
 essential to health, and that its salts should not be concentrated or abnormal 
 in relation. Pathological physiology accounts for the various reflexes and 
 
GENERAL PATHOLOGIC PHYSIOLOGY 445 
 
 disordered functions from the irritation of waste laden blood and the damaged 
 functions resulting from nephrolithiasis and cholelithiasis. Pathological 
 physiology dictates that the ample fluids at regular intervals, visceral 
 drainage, is the great safeguard against waste laden blood; it is the 
 prophylaxis against cholelithiasis, pancreatolithiasis, and nephrolithiasis. By 
 the time that pathological anatomy is demonstrable, damaging structural mis- 
 chief is established, and not infrequently with a lifelong cicatrix. The vast 
 majority of palpitations of the heart cannot be explained on pathological 
 anatomy, which has been the tendency of medical progress for the past 
 decade. The nervous system so intimately and profoundly connects the vis- 
 ceral system, so solidly and compactly anastomosis the viscera, that approp- 
 riate stimulation administered to one visceral tract tends to induce adjacent 
 visceral tracts to normal functions and consequent ample visceral drainage, 
 e. g., ample volume of fluid in the tractus vascularis enhances the volume and 
 flow of the tractus lymphaticus, and the general glandular system increases 
 its flow, notably the perspiration, from the tractus cutis. Stimulation of the 
 cutaneous surface by massage or salt rubs not only stimulates the cutaneous 
 nerve periphery, but also the circulation and tractus perspiratorius. Stimu- 
 lation of the tractus muscularis by exercise stimulates and enhances the func- 
 tion of all visceral tracts. 
 
 A. Visceral Drainage by Fluids. — About eighty per cent of the body is 
 fluids while about twenty per cent is solids. All viscera functionate by 
 means of a fluid medium. Fluid forms the chief distributing or circulatory 
 agency of the organism. Liquid is essential for assimilation and metabolism. 
 Water forms the bulk of the softer tissue and is an important factor in the 
 composition of the harder. Fluid permeates or flows through all the bodily 
 structures by osmosis or distinct vessels. Water is a more important agency 
 in relating the individual to environments than food or air. It flows univer- 
 sally through the organism. It enters mainly through the tractus intestinalis, 
 and escapes through the mucous membranes, skin and the chief excretory 
 ducts. Water, as related to the skin and lungs in the form of liquid vapor, 
 affords the most important factor in controlling the temperature necessary 
 for organic existence. Diet consists on the average of six parts liquid to one 
 part dry material. These data explain why Dr. Tanner and others could fast 
 such a length of time on drinking water only. I was a watcher of Dr. Tan- 
 ner's fasting twenty-five years ago, and wondered at the ease and apparent 
 comfort of his abstaining from food so many weeks. Water is more essential 
 for the growth and sustenance of the vital system than food. The most effective 
 diuretic is water. One of the best laxatives is water. One of the best and 
 most natural stimulants to renal epithelium is sodium chloride (one half to 
 one fourth normal salt solution). The blood contains three-fifths of one per 
 cent of sodium chloride. Water is to the organism what oil is to machinery — 
 it prevents friction. For the purpose of stimulating normal visceral action 
 (the great common visceral functions are peristalsis, absorption, sensation, 
 secretion), I administer eight ounces of one-half to one-fourth normal salt 
 solution six times daily, two hours apart. (Note — Sodium chloride is contra- 
 
446 THE ABDOMINAL AND PELVIC BRAIN 
 
 indicated in parenchymatous nephritis.) Three pints (of one-half to one- 
 fourth normal salt solution efficiently influences the renal secretion for ample 
 visceral drainage. Renal drainage should be sufficient to maintain in mechan- 
 ical suspension the free insoluble uric acid to prevent calculus formations. 
 Also it should be sufficient to form soluble urate combinations with sodium, 
 potassium, and ammonium salts. 
 
 B. Visceral Drainage by Foods. — To drain the viscera by appropriate 
 foods and fluids may sound paradoxical ; however, the common functions of 
 viscera — peristalsis, absorption, sensation, secretion — are initiated and main- 
 tained by fluid and food. Rhythm is one of the grand physical manifesta- 
 tions. The tubes of the body under spiral motion assume a spiral direction. 
 Food stimulates the tractus intestinalis through its sensitive mucosa to con- 
 tinual, rhythmical, spiral motion, and consequent absorption and secretion. 
 The sodium chloride is an especial stimulant to the epithelium of the tractus 
 intestinalis. To drain the tractus intestinalis, foods which result in an ample 
 indigestible fecal residue are requisite to maintain the fundamental peristalsis 
 or rhythm necessary for its life of absorption and secretion. If the tractus 
 intestinalis be stimulated to a maximum by sufficient appropriate food and 
 fluid, adjacent visceral tracts from their intimate nervous connection (through 
 the abdominal brain), will share and assume normal function (peristalsis, 
 absorption, secretion, sensation). Rational foods must contain appropriate 
 salts whose basis may form combinations which are soluble, as sodium, potas- 
 sium, and ammonium, combined with uric acid and urates to form soluble 
 urates. 
 
 The proper foods are: Cereals (oatmeal, wheat, rice, graham bread); 
 vegetables (practically all vegetables, cooked) ; albuminoids (milk, eggs, but- 
 termilk) ; meats (limited, as they produce excessive uric acid formations. A 
 mixed diet is therefore most rational. 
 
 In order to stimulate the epithelium (sensation) of the tractus intestinalis, 
 urinarius, and genitalis and the endothelium (sensation) of the tractus vascu- 
 laris and lymphaticus with consequent increase of peristalsis, sensation, 
 absorption, secretion, in the five visceral tracts I employ a part or multiple 
 of an alkaline tablet of the following composition: 1, Cascara sagrada, one- 
 fortieth grain ; aloes, one-third grain ; sodium bicarbonate, 1 grain ; potassium 
 bicarbonate, one-third grain ; and magnesium sulphate, 2 grains. This com- 
 bination is used as follows: One-sixth to one tablet (or more as required to 
 move the bowels freely once daily) is placed on the tongue and followed by 
 eight ounces of water (better hot). Also at 10 a. m., 3 p. m., and at bedtime 
 one-sixth to one tablet is placed on the tongue and followed by a glassful of 
 any fluid. In the combined treatment one third of the sodium chloride tablet 
 (containing eleven grains) and (one-sixth to three) alkaline tablets are placed 
 on the tongue together before each meal and at 10 a m., 3pm., and bedtime, 
 followed by a glass of fluid. The six glasses of fluid may be water, coffee, 
 tea, milk, buttermilk, cream, eggnog — in short, a nourishment. This method 
 of treatment furnishes alkaline bases (sodium, potassium, and ammonium) to 
 combine with the free uric acid in the urine, producing perfectly soluble 
 
GENERAL PATHOLOGIC PHYSIOLOGY 447 
 
 alkaline urates, and materially diminishing the insoluble free uric acid in the 
 urine. Also the alkaline laxative and sodium chloride tablet increase the 
 peristalsis, absorption, secretion, sensation of the tractus intestinalis, urina- 
 rius, vascularis, lymphaticus, genitalis, which aids secretions and evacuation. 
 I have termed the sodium chloride and alkaline laxative tablets the vis- 
 ceral drainage treatment. The alkaline and sodium chloride tablet inducing 
 maximum visceral function take the place of the so-called mineral waters. 
 I continue this dietetic treatment of fluids and foods for weeks, months, and 
 the results are remarkably successful, especially in pathologic physiology of 
 visceral tracts. The urine becomes clarified like spring water and increased 
 in quantity. The tractus intestinalis becomes freely evacuated, regularly, 
 daily. The tractus vascularis maintains an active peristalsis and full volume. 
 The blood is relieved of waste laden and irritating material. The tractus 
 cutis eliminates freely, and the skin becomes normal. The appetite increases. 
 The sleep improves. The patient becomes hopeful; natural energy returns. 
 The sewers of the body are well drained and flushed to a maximum. 
 
 3. Habitat. — Habitat has chiefly relations to the environments of air, 
 exercise, heat, cold, moisture. In habitat one of the principle factors is air. 
 The functions of the lungs are sensation, peristalsis, absorption and secretion. 
 It is through the great function of respiration that the internal tissue becomes 
 related to the external world. The medium of exchange between the internal 
 tissue and the external world is the blood. The blood, an universal tissue, a 
 common transporter of oxygen and carbonic acid gas, plays a vast role in the 
 economy of organism. The red blood corpuscles during their passage through 
 the lung (external respiration), automatically appropriate the oxygen, and 
 after their return (from internal respiration) through the tractus vascularis 
 unburden acquired carbon dioxide into the expiring air. The pathological 
 physiology of respiration is a wide zone and especially in an incipient zone 
 to that of pathological anatomy. Its pathological physiology is frequently 
 amenable to treatment. The respiratory apparatus has methods of its own 
 to correct its pathological physiology, as cilia, coughing and sneezing to 
 evacuate harmful material, as mucus and foreign bodies. The grand 
 remedial agent for pathological physiology of the living is continuous, 
 ample, fresh cold air. 
 
 4. Avocation. — The avocation should suit the individual conditions. In 
 numerous cases the labor is unsuitable for the subject. The hours are too 
 long, the work is excessive or severe for the strength. The condition 
 enhances pathological physiology, rather than cures. 
 
 5. Prophylaxis. —Prophylaxis of disease is the tendency of modern 
 medicine. Pathological physiology teaches the control of disease by means 
 of diet, fluid, habitat, avocation. 
 
CHAPTER XXXIII. 
 PATHOLOGIC PHYSIOLOGY OF THE TRACTUS INTESTINALIS. 
 
 O, then beware; tlwse wounds heal ill that men do give themselves.— Shake- 
 speare. 
 
 The tractus intestinalis possesses three original segments — gastrium, enteron, 
 colon — which differ in form and dimension, anatomy and physiology; how- 
 ever, every segment possesses the four common visceral functions — sensa- 
 tion, peristalsis, absorption, secretion. 
 
 The physiology of the tractus intestinalis is peristalsis, absorption, secre- 
 tion and sensation; its object is to afford general corporeal nourishment. 
 One or all of the functions, the physiology of the tractus intestinalis may 
 present pathologic physiology without demonstrable pathologic anatomy. 
 
 A typical example of pathologic physiology in the tractus intestinalis is 
 emesis, e. g., by some, from the observation of a fly in the soup. This is 
 disordered function introduced so rapidly that pathologic anatomy had insuf- 
 ficient time to become established. The so-called reflexes are pathologic 
 physiology not pathologic anatomy. One may observe pathologic physiology 
 where a herd of cattle is placed on a boat and when the boat starts the cattle 
 become excited, nervous, a number having immediate and frequent liquid 
 stools. The peristalsis and secretion of the tractus instestinalis liquifying 
 the feces and expelling them — pathologic physiology but not pathologic ana- 
 tomy was detectable. A typical example of the utility of pathologic physiol- 
 ogy in the tractus intestinalis is the diarrhea of puerperal sepsis — which 
 frequently saves the patient. Certain kinds of food produce pathologic 
 physiology. It is an excessive fermentation — gas. This may be observed 
 the most certainly in the digestion of leguminous substances, e. g., beans. 
 Pathologic physiology may be manifest by excessive, deficient or dispropor- 
 tionate peristalsis, absorption, secretion and sensation. The practitioner 
 observes and treats the following conditions. 
 
 (1). PERISTALSIS (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 The tractus intestinalis possesses peculiar physiologic movements known 
 as peristalsis, vermicular motion passing through periodic activity and repose. 
 Though each segment (gastrium, enteron, colon) possesses peristalsis in com- 
 mon, however, the structure, function and object of each segment is so 
 different that peristalsis in each segment — gastrium, enteron and colon — is 
 best studied separately. The factors which initiate motion in the tractus 
 intestinalis are: (a) blood supply; (b) ingesta; (c) secretion; (e) temper- 
 ature; (f) sensation. 
 
 (a) Excessive peristalsis (stomach). Increased gastric movements (path- 
 ologic physiology) may arise from excessive secretion of HC1, hence exces- 
 
 448 
 
PHYSIOLOGY OF TRACTUS INTESTIXALIS 449 
 
 sively rapid gastric evacuation. Increased gastric movements or contractions 
 may arise from pyloric obstruction. Gastric, enteronic and colonic peristal- 
 tic unrest may be prominent without known cause, with perhaps an irritable 
 defective nervous system — a kind of motor neurosis. The splanchnic nerves 
 are perhaps the chief motor nerves of the digestive tract. The peristaltic 
 unrest (pathologic physiology) is eminently manifest in certain individuals as 
 evidenced by the frequent gurgling, splashing sounds heard when standing in 
 close proximity. During fright excessive intestinal peristalsis may occur 
 with sudden evacuation of the colon. Excessive peristalsis may occur during 
 pregnancy or on observation of disgusting matters (as a fly in the soup), 
 intense decomposing odors, certain forms of food create peristaltic unrest. 
 The frequent wild and disordered peristalsis in the digestive tract of the child 
 is based on pathologic physiology — not pathologic anatomy. It rests on dis- 
 ordered peristalsis due to the fact that Auerbach's plexus is not fully devel- 
 oped or established in office. The cramps, and colic and emesis, diarrhea, 
 arise and disappear so quickly that insufficient time exists for pathologic ana- 
 tomy. Vomiting is pathologic physiology as it forcibly, artificially dilates 
 the cardiac sphincter of the stomach. 
 
 (b) Deficient peristalsis. The most typical example in the tractus intes- 
 tinalis of deficient peristalsis is constipation — the so-called sluggish bowels. 
 Evacuation of the digestive tract (especially the stomach and colon) is defec- 
 tive, incomplete. Dilatation of the stomach (generally due to compression 
 of the transverse duodenum by the superior artery vein and nerve) results in 
 series of consequences as decomposion, fermentation, taxemia, inability to 
 force food through the pylorus. The acute gastric dilatation is simply an 
 exacerbation of a previous dilatation. I have shown in numerous cadavers 
 that no pyloric obstruction exists, that it is gastro-duodenal dilatation due to 
 compression of the mesenteric vessels. Gastro-duodenal dilatation is a stage 
 of enteroptosia. 
 
 (c) Disproportionate peristalsis consists of non-uniform, irregular, dis- 
 ordered muscular movements. It is peristalsis uncontrolled like the irregular 
 invaginations of death and the test of diagnosis is that the invagination is not 
 pathologic anatomy — simply pathologic physiology. 
 
 (2). SECRETION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (e) Excessive secretion, pathologic physiology is observed in diarrhea. 
 Many kinds of irritating foods induce it. Doubtless excessive secretion is 
 due to the variations in HC1. Chronic supersecretion, is perhaps connected 
 with superacidity. Excessive secretion of the tractus intestinalis is frequently 
 found in neurotic patients, in neurasthenics, in hysteria. Hunger plays a 
 role, e. g., when a hungry subject views food. Abdominal secretion occurs 
 in chronic dyspepsia. Hypersecretion doubtless depends on the blood volume 
 in the stomach, enteron or colon. Hypersecretion frequently accompanies 
 gastroptosia (which is generally gastro-duodenal dilatation) because the gas- 
 troptosia is accompanied by stagnation of food material and irritates the 
 gastric wall. The fasting stomach may present supersecretion on reception 
 
 29 
 
450 THE ABDOMINAL AND PELVIC BRAIN 
 
 of food known as alimentary supersecretion. Hyper chloridia from an 
 unknown cause. Infectious processes induce supersecretion as well as ulcer- 
 ation and epithelial desquamation. 
 
 In the duodenum, the most important segment of the tractus intestinalis, 
 arrives the extra glandular secretion succus pancreaticus, and succus bilis. 
 These naturally abundant extraglandular secretions, when possessing the 
 pathologic physiology of excess, will present a wide varying zone of effect on 
 nutrition. The excess of biliary secretion, pathologic physiology, is difficult 
 to estimate as the bile is re-absorbed and its excessive flooding stream prevents 
 the formation of biliary concrements. However, we know that in driving 
 cattle several miles previous to slaughter an excess of bile collects in the 
 cholecyst— demonstrating a wide range of variation in the time and quantity 
 of biliary secretion. Excessive biliary secretion may be the cause of glycosu- 
 ria allowing insufficient time for completion of processes. 
 
 The pathologic physiology of excess of pancreatic secretions are equally 
 difficult to estimate with that of biliary. Excessive succus pancreaticus prac- 
 tically prohibits pancreatic calculus. (Enteron and colon) excess of enteronic 
 and colonic secretion is apparent in diarrhea, in fluid evacuations. Abnormal, 
 excessive intestinal secretions are not well understood. The pathologic 
 physiology of excessive intestinal secretion rests chiefly on the kinds of 
 chemistry of food and bacteria within the digestive canal. The multiplica- 
 tion of bacteria incites the intestine to extra secretion. The abnormal bac- 
 teria process may continue within the intestinal lumen. The number of 
 bacterial residence usually constitute about one-third of the weight of the dry 
 fecal masses. It is evident from this view that bacteria are a necessary part 
 of the tractus intestinalis of higher organisms. The child's tractus intestinalis 
 possesses a bacterial flora by the fourth day of extrauterine life. Excessive 
 colonic secretion, pathologic physiology, is well known in mucous colitis, or 
 what I considered better termed, secretion neurosis of the colon. 
 
 (f) (Stomach) deficient secretion of the tractus intestinalis constitutes a 
 frequent condition of pathological physiology. The most evidently marked 
 state of deficient intestinal secretion is constipation. Deficient secretion of 
 HC1, the most significant secretory gastric function in the stomach, may exist, 
 indicating malignancy, chronic gastritis, infectious disease, acute functional 
 disease, presenting a wide zone of pathologic physiology. Deficient HC1 is 
 especially noted in gastric carcinoma. (Stomach) deficient secretion HC1 
 changes the bacterial process, as normal gastric secretion is doubtless antisep- 
 tic. The most important means to check microbic process in the stomach is 
 continuous movements of food and frequent evacuations. With deficient 
 HC1 the bacteria multiply in stagnating stomach contents increasing lactic 
 acid, which favors bacterial growth. Deficient HC1 enhances the decomposi- 
 tion of albumen in the enteron and colon. Abundant bacterial decomposition 
 from deficient HC1 produces products which irritate the gastric mucosa, induc- 
 ing pain, colic vomiting, defective appetite, gas. 
 
 (Duodenum). The business segment of the digestive tract is the enteron 
 into which flows the succus bilis et succus pancreaticus. Deficient biliary 
 
PHYSIOLOGY OF TRACTUS INTESTINALIS 
 
 451 
 
 ABDOMINAL BRAIN AND CCELIAC PLEXUS 
 
 Fig. 115. This figure presents the nerves of the proximal part of the tractus intestinalis, 
 that is, the nerve plexuses accompanying the branches of arteria coeliaca. 1 and 2 abdominal 
 brain surrounding the coeliac axis drawn from dissected specimen. H. Hepatic plexus on 
 hepatic artery. S. Splenic plexus on splenic artery. Gt. Gastric plexus on gastric artery. 
 Rn. Renal artery (left). R. Right renal artery in the dissection was rich in ganglia. Dg. 
 diaphragmatic artery with its ganglion. G. S. Great splanchnic nerve. Ad. Adrenal. K. 
 Kidney. Pn. Pneumogastric (Lt left). Ep. Right and Eps. left epiploica artery. St. Stomach 
 Py. Pyloric artery. C. Cholecyst. Co. Chole-dochus. N. Adrenal nerves (right, 10, left, 10). 
 The arterial branches and loops of the coeliac tripod (as well as that of the renals) with their 
 corresponding nerve plexuses demonstrate how solidly and compactly the viscera of the 
 proximal abdomen are anastomosed, connected into single delicately poised system with the 
 abdominal brain as a center. Hence local reflexes, as hepatic or renal calculus, disturb the 
 accurate physiologic balance in stomach, kidney, spleen, liver and pancreas. Food in the 
 duodenum (or HC1) will induce: (1) the bile to flow; (2) the succus entericus to flow; (3) 
 the duodenal glands (intestinal — especially Brunner's) to flow; (4) secretion to flow — all 
 from the same duodenal stimulant (food or HC1), presenting a delicately poised nervous 
 apparatus. 
 
452 THE ABDOMIXAL AND PELVIC BRAIN 
 
 secretion may manifest itself by clay colored stools, by icterus, by calculus 
 obstructing biliary flow. Pathologic physiology in deficient biliary secretion 
 presents a frequent and an extensive range of action. Deficient biliary secre- 
 tion occurs with deficient amounts of appropriate food, hence the necessity 
 of rational dietetics. Deficient biliary secretion lays the foundation for the 
 most distressing of hepatic diseases— hepatic calculus. The deficient hepatic 
 secretion induces a limited quantity of bile with a slow stream allowing ample 
 opportunity for crystallization and the formation of biliary concrements. 
 The hepatic calculus consists chiefly of cholesterine and calcium salts of 
 bilirubin. Naunyn has demonstrated that the quantity of cholesterine and 
 calcium salts of bilirubin are independent of the kinds of ingesta, hence to 
 prevent biliary concrements we must employ visceral drainage to maintain 
 such salts in mechanical suspension and irrigate, flood, them onward by powerful, 
 large biliary streams. For dissolving cholesterine the bile possesses power- 
 ful agents in cholate, sapo, adeps. Since cholesterine appears in the bile as 
 crystal, or in combination with desquamated epithelial cells, the powerful, large 
 biliary stream from ample visceral drainage will flood, irrigate, the precipi- 
 tated collected crystals and concrements into the duodenum. Deficient biliary 
 flow is liable to become stagnant, favoring bacterial growth and bile channel 
 infection because the volume of bile stream, being diminished, does not excite 
 the biliary channels to vigorous peristalsis and consequent defective flushing 
 of the bile passages occurs. Deficient biliary secretion is accompanied by the 
 pathologic physiology of diminished bile stream; stagnation of bile from 
 diminished biliary peristalsis; defective irrigation of the biliary passages; the 
 precipitation, formation of cholesterine and calcium and bilirubin crystals or 
 concrements; infection of the biliary passages; insufficient quantity of bile 
 for digestion (clay colored decomposed stools); icterus from obstruction of 
 bile passages and changed direction of bile stream calculus in the biliary 
 channels may produce disease only when infection arises or the calculus 
 becomes clamped (pain, colic). Inflammation (cholecystitis) creates violent 
 peristalsis of the biliary channels and hence projects the calculus in various 
 directions until it is finally impressed, engaged, whence pain and colic. 
 
 In icterus the bile with its coloring material becomes transfused through 
 the body, in the blood and lymph— presenting typical pathologic physiology. 
 Icterus depends on complete closure of the ductus choledochus communis but 
 it may depend on hepatitis. For the origin of icterus the kind of disease is 
 less significant than its seat. 
 
 Deficient pancreatic secretion is diagnosed by the undigested fat in the 
 stools. In 700 personal autopsic inspections I observed but one complete 
 failure of pancreatic secretions. This subject possessed a carcinomatous 
 invasion of the ductus choledochus and ductus pancreaticus, producing com- 
 plete obstruction of both ducts. In ten weeks the patient lost 113 pounds. 
 The biliary passages (exclusive of the cholecyst) were dilated seven times their 
 original caliber and the ductus pancreaticus was dilated some 20 times its 
 original caliber. The pancreas possesses two exit ducts, patent perhaps in 60 
 per cent of subjects. If one becomes obstructed the other acts vicariously 
 for both. 
 
PHYSIOLOGY OF TRACTUS INTESTINALIS 453 
 
 In the above cited case Santorini's duct no doubt conducted succus pan- 
 creaticus into the duodenum. Deficient secretion from the pancreas arises 
 from partial and complete obstruction of its ducts by calculus, neoplasm, or 
 by degeneration of the organ. 
 
 Deficient secretion in the enteron is not understood. Deficient secretion 
 in the colon results in the well known disease, constipation. The central 
 nervous system, as well as the abdominal sympathetic, is influential in dimin- 
 ishing secretion. In fact, the pure results of constipation are preponder- 
 ating, psychic and subjective. The assimilation of the individual constipation 
 does not suffer materially; however, defecation is laborious and the care for 
 the evacuation and anxiety as to food selection increases the neurosis; with 
 the evacuation the head becomes free, the voice becomes cheerful, the 
 effect is mainly suggestive. 
 
 (g) Disproportionate secretion is where the secretions of the segments of 
 the tractus intestinalis are irregular, non-uniform, disordered. When such 
 disordered secretions mingle, fermentation occurs with consequent tympanitis 
 meteorismus. The gastric secretions may be disproportionate, resulting in dis- 
 ordered digestion. Biliary secretion may be excessive, pancreatic secretions 
 deficient, thus making secretions disproportionate, and the same conditions 
 may occur in the enteron and colon. 
 
 (3.) ABSORPTION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (h) Excessive absorption of the digestive tract is difficult to demonstrate. 
 However, it is conceivable that the absorptive apparatus of the tractus intes- 
 tinalis might work excessively, absorbing substances which injure the system. 
 Decomposing ingesta, bacterial products, toxines, may be too rapidly 
 absorbed. Excessive absorption induces constipation. 
 
 (i) Deficient absorption in the tractus intestinalis is not infrequent. We 
 notice this factor when the food passes per rectum undigested. Excessive 
 peristaltic movements may be so rapid that insufficient time is allowed absorp- 
 tion. Deficient pancreatic secretion does not prepare the fats sufficiently 
 for absorption — hence deficient absorption, pathologic physiology, may rest 
 on many factors, neurosis, excessive or deficient peristalsis, unsuitable ingesta, 
 infection. 
 
 (j) Disproportionate absorption occurs but is difficult to demonstrate the 
 non-uniform, unequal, disordered absorption of the three segments — gastrium, 
 enteron, colon. 
 
 4. SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (k) Excessive gastric sensation (hyperesthesia of mucosa) not infre- 
 quently arises. The healthy subject notices the digesive organs only when 
 hunger arises or the gastrium becomes excessively occupied with ingesta or 
 gas ; one might state that it is a distinct function of the tractus intestinalis to 
 manifest hunger. The physical condition is also of direct influence. Hunger 
 and distension of the stomach are related because subjects afflicted with 
 super activity manifest hunger shortly after ingesting meat, which is rapidly 
 
454 THE ABDOMINAL AND PELVIC BRAIN 
 
 evacuated through the pylorus, leaving an empty stomach with recurring secre- 
 tions. Hunger and appetites do not always correspond. One may feel hun- 
 gry but does not eat, as the appetite fails. The Scotch poetry tells much of 
 a story. 
 
 Some have meat but cannot eat, 
 
 Some can eat but have no meat. 
 
 X-RAY OF DUCTUS BILIS AND DUCTUS PAXCREATICUS 
 
 Fig. 116. Presents the relations of the biliary and pancreatic ducts. These ducts are 
 ensheathed by a nodular network, or anastomosing, fenestrated meshwork of nerves ruling 
 finely poised balanced physiology dominated by the abdominal brain. 
 
 It is possible that activity of both motion and secretion induces appetite 
 which has a wide zone of pathologic physiology. In excessive sensation or gas- 
 tric hyperesthesia the sensation of gastric pressure or fullness in eating arises 
 sooner than it does in the healthy, in fact sooner than the stomach becomes 
 full. Occasionally one meets a patient who on taking ingesta experiences 
 
PHYSIOLOGY OF TRACTUS INTESTINALIS 455 
 
 gastric pain — this may be neuralgia, superacidity, ulceration, carcinoma, 
 pergastric peritoneal adhesions. The superacidity, irritable gastric muscu- 
 laris may experience pain from direct effects on the sensitive nerves, i. e., 
 superacidity induces muscular colic. The fearful "gastric crises" in tabes 
 and the other spinal affections is founded on degeneration and irritation of 
 the vagus. It is well known that certain individuals are supersensitive not 
 only in general but as special organs, e. g., some will vomit on seeing a fly 
 in the soup. From sensitive stomachs appear to arise dizziness, sensory 
 waves, neuralgia, anomalies of cardiac innervation. Also unclear functional 
 disturbances — however I would suggest that such attributes of numerous 
 disturbances rather belong to the abdominal brain. The innumerable "gas- 
 tric reflexes" are receptions, reorganizations and emissions of the abdominal 
 brain. Vomiting, sooner or later after ingesta, may occur from hyperesthesia 
 of the gastric mucosa. I have had several patients with excessive sensation, 
 or hyperesthesia, of the gastric mucosa. One patient vomited shortly after 
 taking food for fourteen years. Her stomach absorbed sufficient to maintain 
 a fair condition of flesh. Another vomited for two years almost immediately 
 after eating. Excessive sensation in the gastric mucosa presents a wide zone 
 of pathologic physiology in the various degrees of vomiting during gestation. 
 Many subjects possess an extraordinary delicacy and sensitiveness in regard 
 to the stomach. If such subjects exercise care in selection of food and pru- 
 dence in eating they remain relatively healthy. This pretended and acquired 
 idiosyncrasy is annoyingly manifest in practice when we are continually 
 meeting people who cannot take certain kinds of food, as eggs, milk, graham 
 bread, fruits, etc., etc., such patients cannot live in an ordinary boarding house. 
 Either by heredity or chiefly by habit the employment of certain kinds of 
 food have a wide range of pathologic physiology. The psychical state per- 
 haps plays the preponderating role of idiosyncrasy of foods. The so-called 
 nervous dyspeptic experiences all kinds of sensations in the stomach. There 
 is no structural change in the stomach to correspond to all the functional 
 manifestations — it is pathologic physiology. The crawling of animals within 
 the stomach and tractus intestinalis may be interpreted as ingesta or gas pass- 
 ing over the hyperesthetic or supersensitive mucosa. 
 
 (1) Deficient sensation in the tractus intestinalis doubtless explains the 
 so-called sluggish bowel, the constipation. The absorption of the food is 
 insufficient. It is not uncommon for patients to tell me that the bowels are 
 dead, no feeling in them. 
 
 (m) Disproportionate sensation is non-uniform, irregularly located hyper- 
 esthesia and anesthesia of the mucosa in the different segments of the diges- 
 tive tract — gastrium, enteron, colon. In sensation of the tractus intestinalis, 
 excessive, deficient or disproportionate, there is no relation between anomalies 
 of function and anatomic structure. Anomalies of function may present no 
 recognizable anatomic changes — it is simply pathologic physiology. The 
 gastric mucosa rapidly changes at death, hence cautious examinations are 
 required in autopsies. As regards the relations between the kind of anatomic 
 changes and functional disturbances, we are but little informed by any inves- 
 tigations. 
 
456 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 PATHOLOGIC PHYSIOLOGY OF THE TRACTUS NERVOSUS IN REGARD TO THE TRACTUS 
 
 INTESTINALIS. 
 
 The tractus nervosus influences two spheres, viz. : corporeal and mental. 
 The nervous system extends to the deepest and most profound secrets of life 
 — mental and physical, hence, it possesses the highest differentiation of all 
 visceral tracts. The functions of the tractus intestinalis vary within a wide 
 zone of pathologic physiology, e. g., many subjects pass a week without 
 defecation or subjects may practice defecations daily. The tractus intesti- 
 nalis is preponderatiyigly controlled by the abdominal sympathetic or nervus 
 vasomotorius. It requires a decade for the nervus vasomotorius to establish 
 
 DUODENUM WITH ITS TWO DUCTS— BILIARY AND PANCREATIC 
 
 Fig. 117. Illustrates the duodenum, the most important segment of the tractus intesti- 
 nalis, receiving the ductus bilis and ductus pancreaticus. The nervous system controlling 
 the secretion of the tractus intestinalis must be delicately poised, balanced, as the secretions 
 of one gland (as the liver) is a complement of the secretion of another gland (as the pan- 
 creas). The succus pancreaticus multiplies the power and utility of the bile in digestion if 
 the two glandular secretions become mixed immediately on entrance into the duodenum. 
 
 its control, its more independent rule. The wild and disordered peristalsis 
 of a child is due to the cerebrum and Auerbach's ganglionic plexus not being 
 completely balanced, in control. A child is frequently subject to peristaltic 
 unrest, intestinal invagination (pathologic physiology). Frequently not long 
 before death in adults the cerebrum and Auerbach's ganglionic plexus lose 
 their complete balance (especially the cerebrum being less influential) and 
 the invagination of death arises. I have observed 4 to 6-inch invaginations in 
 
PHYSIOLOGY OF TRACTUS INTESTINALIS 457 
 
 subjects — absolute pathologic physiology — no pathologic anatomy. Though 
 the function of the nervus vasomotorius is beyond the control of the will, 
 digestion proceeds in spite of us or while we sleep. The five abdominal vis- 
 ceral tracts (tractus genitalis, urinarius, intestinalis, lymphaticus, vascularis) 
 exist in an exquisitively balanced or poised state, hence, the so-called reflexes, 
 from one visceral tract to another, accomplished through the nervus vasomo- 
 torius, exert extensive influence in producing pathologic physiology — yes 
 many conditions of pathologic physiology arise in different visceral tracts. 
 The essential conditions of a reflex are: (a) an intact sensory periphery 
 (receiver); (b) an intact ganglion cell — pelvic or abdominal brain — (reorga- 
 nized; (c) an intact conducting apparatus (transmitter). A pure reflex con- 
 sists of a sensation transmitted to a reorganizing center which emits it over 
 a motor apparatus. 
 
 A reflex is independent of will. The abdominal viscera are not only 
 intimately connected, associated by means of the tractus vascularis, tractus 
 lymphaticus, tractus nervosus but especially by the peritoneum. Any exces- 
 sive irritation in any one of the exquisitively poised visceral tracts immedi- 
 ately unbalances the others — at first producing pathologic physiology and 
 perhaps later pathologic anatomy. Hence the sensory apparatus in each 
 visceral tract is significant. The reflex from one visceral tract to the other 
 disorders: (a) the blood circulation; (b) lymph circulation; (c) absorp- 
 tion; (d) secretion; (e) peristalsis; (f) sensation. E. g., when the gesta- 
 tion contents distends the uterus, uneven expansion stimulates, irritates the 
 sensory apparatus of the uterus. The sensation is transmitted over the plexus 
 interiliacus and plexus ovaricus to the abdominal brain where reorganization 
 occurs whence the stimulus is emitted over the plexus gastricus to the gas- 
 trium with end results of excessive gastric peristalsis and vomiting. Other 
 abdominal visceral tracts are likewise effected by this uterine reflex, but do 
 not manifest such prominent symptoms as vomiting. Vomiting is pathologic 
 physiology. Ordinary function as gestation will induce pathologic physiology 
 in the tractus intestinalis by: (a) reflexes; (b) robbing it of considerable 
 blood — the extra amount required for the tractus genitalis to gestate the child ; 
 (c) instituting indigestion and constipation, from limited blood supply. 
 A calculus in the tractus urinarius (ureter) will produce numerous reflexes 
 with consequent pathologic physiology in the several abdominal visceral 
 tracts — viz. : disordered peristalsis, absorption, secretion, sensation — not 
 pathologic anatomy. 
 
 TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS INTESTINALIS. 
 
 Since pathologic physiology is the zone between physiology and patho- 
 logic anatomy it should be practically amenable to treatment. First and 
 foremost, the diagnosis should be made and the cause removed, as a ureteral 
 calculus, anal fissure, hepatic calculus or any point of visceral or dietetic 
 irritation. The most essential feature of subjects suffering from pathologic 
 physiology of the tractus intestinalis is deficient visceral drainage. The 
 blood is excessively waste-laden from insufficient elimination. The secretions 
 
458 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 are scanty. The urine is concentrated, its crystallized salts are evident to 
 the eye. The skin is dry from insufficient perspiration. Sleep is defective 
 from the bathing of the innumerable ganglia with waste laden blood. Con- 
 stipation, deficient urine, limited perspiration, capricious appetite and 
 insomnia characterize subjects with pathologic physiology of the tractus 
 intestinalis. For many years I have applied a treatment to such subjects 
 which I term 
 
 VISCERAL DRAINAGE. 
 
 Visceral drainage signifies that visceral tracti are placed at maximum 
 elimination by dietetics, fluids, appropriate hygiene and habitat, exercise. 
 
 X-RAY OF DUCTUS BILIS, DUCTUS PANCREATICUS AND ARTERIA HEPATICA 
 
 Fig. 118. Illustrates the vast nerve supply it requires to ensheath the channels of the liver 
 and pancreas with a nodular network, a fenestrated meshwork, of nerve plexuses. The trac- 
 tus nervosus of the tractus intestinalis is solidly and compactly anastomosed. 
 
 The waste products of food and tissue are vigorously sewered before new 
 ones are imposed. The most important principle in internal medication is 
 ample visceral drainage. The residual products of food and tissue should 
 have a maximum drainage in health. I suggest that ample visceral drainage 
 may be executed by means of : (A) fluids ; (B) food. 
 
 (A.) Visceral drainage by fluids. 
 
 The most effective diuretic is water. One of the best laxatives is water. 
 One of the best stimulants of renal epithelium is sodium chloride (}£ to Y\ 
 
PHYSIOLOGY OF TRACTUS INTESTINALIS 459 
 
 physiologic salt solution). Hence I administer 8 ounces of half normal salt 
 solution to a patient six times daily, 2 hours apart. Note — NaCl is contra- 
 indicated in parenchymatous nephritis. 48 ounces of yi normal salt solution 
 efficiently increases the drain of the kidney, it sustains in mechanical suspen- 
 sion the insoluble uric acid, it stimulates other matters, it aids the sodium, 
 potassium or ammonium salts to form combination with uric acid, producing 
 soluble urates. The J4 normal salt solution effectively stimulates the peri- 
 stalsis and epithelium of the tractus intestinalis inducing secretions which 
 liquify stool, preventing constipation. 
 
 (B.) Visceral drainage by foods. 
 
 The great functions of the tractus intestinalis — peristalsis, absorption, 
 secretion — are produced and maintained by food. To drain the tractus intes- 
 tinalis foods which leave an indigestible residue only are appropriate. 
 Rational foods must contain appropriate salts whose bases may form combi- 
 nations which are soluble as sodium and potassium combined with uric acid 
 and urates to form soluble urates. The proper foods are: cereals, vegeta- 
 bles, albuminates (milk, eggs), mixed foods. 
 
 Meats should be limited, as they enhance excessive uric acid formation. 
 In order to stimulate the epithelium of the digestive tract (sensation) with 
 consequent increase of peristalsis, absorption and secretion, I use a part or 
 multiple of an alkaline tablet of the following composition : Cascara sagrada 
 GVgr.), aloes Q gr.), NaHC0 3 (gr. 1), KHC0 3 (I gr.), MgS0 4 (2 gr.). 
 The tablet is used as follows: One-sixth to one tablet (or more, as required 
 to move the bowels once daily) is placed on the tongue before meals and 
 followed by 8 ounces of water (better hot). At 10 a. m., 3 p. m., and bedtime 
 \ to 1 tablet is placed on the tongue and followed by a glassful of any fluid. 
 In combined treatment \ of (NaCl) the sodium chloride tablet containing 
 11 grains and (g- to 3) alkaline* tablets are placed on the tongue together 
 every 2 hours followed by a glassful of fluid. This method of treatment 
 furnishes alkaline bases (sodium and potassium and ammonium) to combine 
 with the free uric acid in the urine, producing perfectly soluble alkaline 
 urates and materially diminishing the free uric acid in the urine. Besides 
 the alkaline laxative tablet increases the peristalsis, absorption and secretion 
 of the intestinal tract, stimulating the sensation of the mucosa aiding evacua- 
 tion. I have termed the sodium chloride and alkaline laxative method the 
 visceral drainage treatment. The alkaline and sodium chloride tablets take 
 place of the so-called mineral waters. I continue this dietetic treatment of 
 fluid and food for weeks, months, and the results are remarkably successful 
 in pathologic physiology. The urine becomes clarified like spring water, 
 and increased in quantity. The tractus intestinalis becomes freely evacuated, 
 regularly daily. The blood is relieved of waste laden and irritating material. 
 The tractus cutis eliminates freely, and the skin becomes normal. The 
 appetite increases. The sleep becomes improved. The patient becomes 
 hopeful, natural energy returns. The sewers of the body are well drained 
 and flushed. 
 
 *The tablets are manufactured by Searle and Hereth Company, Chicago. 
 
CHAPTER XXXIV. 
 
 PATHOLOGIC PHYSIOLOGY OF THE TRACTUS GENITALIS. 
 
 "The Soul knows only Soul, the web of events is the flowering robe in which she 
 is clothed." — Emerson. 
 
 "Furnish the government with neither a kopek nor a soldier." — Final appeal of the 
 Russian Douma, dissolved by the czar, July, 1906. 
 
 For over a decade I have been attempting to make prominent in gyneco- 
 logic teaching, pathologic physiology, disordered function, rather than patho- 
 logic anatomy, changed structure. It seems to me that disorder-functions or 
 pathologic physiology of the tractus genitalis impresses itself more indelibly 
 on the student's and practitioner's mind than pathologic anatomy. Besides, 
 in gynecologic practice pathologic physiology occurs tenfold more frequently 
 in the genital tract than pathologic anatomy. For the gynecologist patho- 
 logic physiology presents innumerable views of practical interest. Pathologic 
 physiology teaches that the circulation of an organ is a fundamental factor 
 in comprehending its disease and administering rational treatment. It takes 
 an inventory of the volume of blood which streams through the organ as a 
 fundamental factor in comprehending its diseases and administering rational 
 treatment. It takes an inventory of the volume of the blood which streams 
 through the organs at different stages and conditions. We wrote years ago 
 that the arteries of different viscera were supplied with automatic visceral 
 ganglia, and we christened the peculiar nerve nodes found in the walls and 
 adjacent to the uterus, oviducts and ovaries, as "Automatic Menstrual 
 Ganglia." The automatic menstrual ganglia complicate the blood supply 
 of the tractus genitalis by changing its volume during the different sexual 
 phases. In pueritas the blood stream of the tractus genitalis is quiescent as 
 well as its parenchymatous cells ; in pubertas it is developing as well as pro- 
 liferating parenchymatous cells. In menstruation the blood stream is active 
 with active parenchymatous cells. In the puerperium there is retrogression 
 of blood stream and an involution of parenchymatous cells. The climac- 
 terium is the opposite of pubertas — subsidence, the decrease of blood volume 
 and parenchymatous cells. Senescence is a repetition of pueritas — the quies- 
 cence of the genitals, their long night of rest. The circulation of an organ 
 quotes its value in the animal economy. It rates its function. Observe the 
 enormous volume of blood passing through the kidney or pregnant uterus in 
 a minute. 
 
 To study pathologic physiology of any visceral tract we must possess 
 clear views as to its physiology. The physiology of the tractus genitalis is: 
 (1) ovulation; (2) peristalsis; (3) secretion; (4) absorption; (5) menstrua- 
 tion; (6) gestation; (7) sensation. 
 
 460 
 
PHYSIOLOGY OF TRACT US GENITALIS 461 
 
 (1) On account of the numerous theoretic views connected with ovulation 
 and lack of space we will omit the general discussion on the pathologic 
 physiology of ovulation. It is well known that ovulation has a wide physio- 
 logic range. We do not know the life of an ovum or corpus luteum. It was 
 once supposed that a corpus luteum was a sign of pregnancy and the suppo- 
 sition gained legal or judicial position. We know that this is an error. I 
 have found two corpora lutea on one ovary of a lamb which had not been 
 pregnant. The internal secretion of the ovary is important and chiefly mani- 
 fest by marked symptoms on removal of both ovaries — neurosis, accumulation 
 of panniculus adiposus, extra growth of hair, diminished energy and ambition. 
 These symptoms may occur in women possessing both ovaries, hence, we 
 would conclude that pathologic physiology of ovarian secretion existed. The 
 sensation of the ovary occupies a wide zone of pathologic physiology in the 
 mental and physical being. Forty per cent of women visiting my office 
 remark, "I have pain in my ovaries." On physical examination we find the 
 following conditions: First and foremost in the vast majority of women who 
 complain of pain in the ovaries, palpation of the ovaries elicits no tenderness 
 on pressure. However, the pain of such women is located bilaterally in the 
 area of the cutaneous distribution of the ileohypogastric and ileoinguinal 
 nerves. It is a skin hyperesthesia — a cutaneous neurosis. The bilateral iliac 
 region of cutaneous hyperesthesia corresponds to the segmentation or somatic 
 visceral (ovarian) area, and presents a frequent varying zone of sensory 
 pathologic physiology. In the vast majority of women complaining of ovarian 
 pain no disease of the ovary can be detected — it is cutaneous hyperesthesia 
 of the ileoinguinal and ileohypogastric nerves. 
 
 (2) PERISTALSIS (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (a) Excessive peristalsis of the tractus genitalis (uterus and oviducts) 
 may occur at menstruation, during gestation, parturition by the presence of 
 myomata, during the expulsion of blood coagula, placenta during congestion. 
 The phenomenon of peristalsis in the uterus and oviduct differs from the form 
 and distribution of the muscularis. The myometrium during gestation is in 
 continual peristalsis — uterine unrest. By placing the hand on the abdomen 
 of a four-month gestating woman one can feel the uterine muscular waves. 
 The gestating uterus is always prepared for an abortion, but the cervix, the 
 sentinel on guard, checks the proceeding. Fright will produce such violent, 
 disordered myometrical peristalsis as to break through the guarding cervix. 
 Many women during gestation experience considerable pain (supersensitive 
 uterus) from excessive uterine peristalsis — it is pathologic physiology. 
 Uterine peristalsis may be sufficiently excessive to rupture the myometrical 
 wall. The "after-pains," puerperal pains, is excessive peristalsis in an 
 infected myometrium. Frequently the severe pelvic pain during menstrua- 
 tion is excessive uterine and oviductal peristalsis due to its extramenstrual 
 blood supply. It is chiefly the excessive peristalsis at menstruation that 
 forces many women to assume rest in bed, for, with anatomic rest (maximum 
 quietude of bones and voluntary muscles) and physiologic rest (maximum 
 
462 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 quietude of visceral muscles) the uterine peristalsis will exist at a minimum. 
 Excessive oviductal peristalsis may produce pain of varying degrees. In 
 excessive peristalsis the automatic menstrual ganglia are stimulated by extra 
 quantities of blood or by other irritation. 
 
 PELVIC BRAIN (ADULT) 
 
 Fig ^9. Drawn from my own dissection. A, pelvic brain. In this case it is a gan- 
 glionated plexus possessing a wide meshwork. Also the pelvic brain is located well on the 
 £ a !\ n ^ j l £ e vlsceral sacral nerves (pelvic splanchnics) are markedly elongated ; V, vagina ; 
 B, b adder; O, oviduct; Ut, uterus; Ur, ureter; R, rectum ; P L, plexus interiliacus (left); P 
 K, plexus interiliacus (right); N, sacral ganglia; Ur, ureter; 5 L, last lumbar nerve- i ii, iii 
 iv sacral nerves ; 5, coccygeal nerve. Observe that the great vesical nerve (P) arises from 
 a loop between the ii and iii sacral nerves. G S, great sciatic nerve. 
 
PHYSIOLOGY OF TRACTUS GENITALIS 463 
 
 (b) Deficient peristalsis of the tractus genitalis (uterus and oviducts) is 
 not uncommon. Uterine inertia is an example known to every obstetrician. 
 Deficient uterine peristalsis allows hemorrhage in the fourth and fifth decades 
 of woman's life. Deficient peristalsis allows extraglandular secretion 
 (leucorrhea). 
 
 (c) Disproportionate peristalsis is disordered, wild muscular movements 
 in different segments of the uterus or oviduct. 
 
 (3) SECRETION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (d) Excessive secretion from the genital tract, pregnant or non-pregnant, 
 has an extensive range and varying quantity. The excessive secretion zone 
 in the tractus genitalis has an important bearing in practice. Typical patho- 
 logic physiology may be observed in the pregnant woman from whose uterus 
 may flow several ounces of white mucus daily — no pathologic anatomy is 
 detectable. Excessive uterine secretion is a common gynecologic matter. 
 The glands may not be embraced sufficiently firm by the myometrium. The 
 automatic menstrual ganglia are diseased, insufficiently supplied by blood or 
 the myometrium is degenerated. Flaccid uteri secrete excessively. Exces- 
 sive secretion and its fluid currents allow insufficient time for localization of 
 the ovum. Excessive uterine secretion is, from apt bacterial media, liable to 
 become infected. During excessive secretion physical examination frequently 
 detects no palpable pathologic anatomy — merely physiology has exceeded its 
 usual bounds. 
 
 (e) Deficient secretion of the tractus genitalis is not so manifest as its 
 opposite. The mucosa of vagina and uterus present excessive dryness, des- 
 iccation, practically as visceral functions are executed by means of fluids, 
 pathologic physiology is in evidence ; dryness and abrasion of the mucosa, 
 local irritation, chafing, local bacterial development, dysparunia, dysuria, 
 defective import of spermatozoa and export of ova ending in sterility. Defi- 
 cient secretion means that waste-laden fluids are bathing and irritating the 
 thousands of lymph channels in the body. Deficient secretion or excessive 
 dryness of the genital mucosa — pathologic physiology with no perceptible 
 pathologic anatomy — is not uncommon in gynecologic practice. Oily appli- 
 cations to subjects with deficient genital secretion may be required for pro- 
 tection of exposed nerve periphery, as abrasion, fissure, ulcers, and also for 
 relief. 
 
 (f) Disproportionate secretion may occur in the different segments of 
 the genital tract, unequal, excessive, deficient, irregular. 
 
 (4) ABSORPTION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (g) Excessive absorption presents two views, namely, a dryness of the 
 genital mucosa from excessive absorption of the mucal fluids. This resembles 
 the conditions arising in deficient secretion of the genital tract (see e). Again 
 the mucosa of the genital tract excessively absorbs deleterious substances 
 lying on its mucosa — septic or toxic. Excessive absorption in the genital 
 tract, pathologic physiology, resembles excessive absorption and conditions 
 
464 
 
 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 in other localities, as the absorption of poison ivy, lead, arsenic, among art 
 workers. The pathologic physiology possesses a wide range, for some experi- 
 ence no ill-effects while others are severely or even fatally ill from absorption 
 of same substance under similar conditions. 
 
 (h) Deficient absorption in the tractus genitalis produces an excessive 
 
 Spiral segment (utero-ovarian artery), i, 2, 3, 4, 5. 6, 7-7, 8-8, 9, 10, 11, 12, 13, 14, 15. 
 Straight segment abdominal aorta, 16. Common iliac, 17, and internal iliac, 18 
 
 OIVISIOKS OF TNE SPIRAL SEGMENT 
 
 Peliic floor segment, 1, 2, 3. 4. 
 UleriCB segment. 4, 5, 6. 
 MM segment, 
 
 6, 7-9, 6-8, 9, 
 
 4. Orarian segment, 
 9, 10, II, 12. 
 
 5. Round ligament 
 sepent, 13, 14, 15. 
 
 IMPORTANT LOCATIONS II THE SPIRAL SEGHEIT 
 Arterio-ureteral loop, 2. Cervical 
 loop, 2, 3, 4. Distal arte- 
 rio-ureteral crossing, 2. 
 Rami cervicis, 22. 
 Rami corporis, 23. 
 Rami fundi, 24. Rami 
 oviductus, 31, 32, 33. 
 
 ElS31g.'H!«i itariM 
 zones j ctalral iMgl- 
 I'jJiDji am, <bi lateral 
 csmca! ttriir, tci In* 
 lis, vi 1 unit*-' 
 tapajat 
 
 Chicago, 1902. 
 
 At ta« aast atrtta IH uteris an 
 iipctti ii sili, alst tie ureters »tt» 
 red lead aid stare*. Tie S ud an 
 
 ■as X-raeed 11 Or. Harrj Pratt's I 
 flat aid Eitctra-Tatraattiti: Laaao 
 lorj, iMbl) aagiifiti if Or. Wa. t 
 hiUik. aid tinned as a atari aj 
 Hi- Zae 0. Klaaacr. tn artist 
 
 Arterial Circulation of the Puerperal Uterus. 
 
 Four Hours Post Partum. Life Size. 
 
 Illustrating the Utero-Ovarian Vascular Circle (the Circle of Byron Robinson). 
 
 Fig. 120. This illustration demonstrates the vast amount of nervus vasomotorius it 
 requires to ensheath the arteries of the uterus. 
 
PHYSIOLOGY OF TRACTUS GENITALIS 465 
 
 discharge, the decomposition of which lays the foundation of bacterial multi- 
 plication and excoriation of mucosa and skin. 
 
 (i) Disproportionate absorption occurs in the different segments of the 
 tractus genitalis and presents pathologic physiology. However, lack of space 
 makes it impractical to discuss it. 
 
 (5) SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (j) Excessive sensation in the tractus genitalis presents a wide zone of 
 pathologic physiology. Vaginismus is the extreme type of genital hyperes- 
 thesia. The introitus vaginae of perhaps fifty per cent of women is supersen- 
 sitive. When I was a pupil of Mr. Lawson Tait he had a patient, a recently 
 married woman, from whom the husband was suing for divorce as her genital 
 hyperesthesia was so excessive that coition or examination was intolerable. 
 She had to be anesthetized to be examined, which was also suggested for 
 impregnation with the hope that gestation would relieve the condition. 
 Supersensitiveness of the pudendum is not an uncommon matter in gyneco- 
 logic practice and without demonstrative pathologic anatomy. The patho- 
 logic physiology of excessive sensation in the tractus genitalis has a wide 
 range of variation and degree of intensity. Some subjects may be afflicted 
 with excessive sensation in the pudendum for many years. The excessive 
 sensitive genitals may be manifest in the uterus or ovaries. A small number 
 complain of tenderness and soreness in the internal genitals which cannot 
 be detected as pathologic anatomy — simply excessive sensation. The gesta- 
 ting uterus may be so sensitive that it disorders adjacent viscera by reflexes. 
 The treatment of subjects with excessive genital sensation requires unlimited 
 time with continuous patience. 
 
 (k) Deficient sensation of the tractus genitalis is encountered. With 
 such subjects practically no organism occurs during coition to which they 
 are indifferent. Practically little or no treatment is required. 
 
 (1) Disproportionate sensation in the genital tract is irregular, indefinite, 
 disordered sensation arising and disappearing in its different segments prac- 
 tically without reason or rhyme. 
 
 (6) MENSTRUATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 I will present this subject through a clinical patient. Brief remarks on 
 common examples of pathologic physiology in the tractus genitalis will suf- 
 fice to illustrate and suggest. As the most apt subject to illustrate pathologic 
 physiology in the tractus genitalis I will choose that of menstruation. 
 
 To illustrate the value of pathologic physiology and the methods of teach- 
 ing it we will place a gynecologic patient before a student to elicit clinical 
 data in reference to menstruation as landmarks for diagnosis. A landmark 
 is a point for consideration physiologic, anatomic, pathologic. To teach 
 gynecology we should instruct by means of disordered function as a base. 
 Menstruation is the first practical function of the genital tract. Hence the 
 student asks in menstruation four questions, namely: (a) How old were you 
 when the monthly flow began? The patient may answer: eleven (premature), 
 
 30 
 
466 THE ABDOMINAL AXD PELVIC BRA1X 
 
 fifteen (normal), or nineteen (delayed) years of age. This answer presents 
 a wide range of beginning of the menstrual function. Now, the girl who 
 begins to menstruate at eleven generally represents pathologic physiology, 
 but not pathologic anatomy. For example, the girl who begins at eleven 
 (menstratio precox) will in the majority of cases menstruate profusely and 
 prolonged. She will experience a late climacterium. An early menstruation 
 indicates a late climacterium. Though one can palpate practically no 
 pathologic anatomy, the tractus genitalis is prematurely developed at eleven 
 years of age, premature in dimension (nerves, blood, lymph, parenchyma): 
 and function (menstruation, gestation). The blood stream to the genitals is 
 prematurely excessive, the automatic menstrual ganglia are large and pre- 
 maturely active. Her menstrual life is accompanied by excessive blood 
 supply and hemorrhage, disordered function, active parenchymatous cells, 
 prolonged reproductiveness. It is pathologic physiology, exaggerated func- 
 tion, but practically not pathologic anatomy. The girl who begins at fifteen 
 is practically normal during her menstrual life. No pathologic anatomy nor 
 pathologic physiology is manifest. The girl who begins to menstruate at 
 nineteen (menstratio retarda) is delayed with her menstrual function; late 
 menstrual appearance means early climacterium; it frequently indicates 
 amenorrhea and dysmenorrhea. It generally means defective genital blood 
 supply and limited parenchymatous cellular activity. It is pathologic 
 physiology, disordered function, limited productiveness, but frequently no 
 palpable pathologic anatomy exists. It is a fact, however, that in some 
 cases atrophy or myometritis is palpable pathologic anatomy and should not 
 be confused with subjects possessing pathologic physiology. 
 
 (b) The student asks the patient: Is the monthly flow regular? The 
 answer may be, regular or irregular. The patient with irregular menstrua- 
 tion is afflicted with pathologic physiology but no pathologic anatomy may 
 be detected. It may be stated, however, that the automatic menstrual gan- 
 glia require about eighteen months of vigorous blood supply to become suffi- 
 ciently strong and established to act regularly monthly. The same condition 
 exists in the automatic visceral ganglia (Auerbach's and Billroth-Meissner's) 
 of the tractus intestinalis of a child. 
 
 (c) The student, thirdly, asks the patient: Is the monthly flow painful? 
 The answer may be, yes or no. A normal .menstruation should be painless. 
 Dysmenorrhea or painful menstruation is pathologic physiology, disordered 
 function, but frequently no pathologic anatomy can be detected. At men- 
 struation the blood volume in the tractus intestinalis rapidly increases, blood 
 pressure is raised, compressing or traumatizing the nerves to a degree; 
 limited hematoma may occur in the endometrium, congestion is intense, 
 
 TRANSVERSE LONGITUDINAL SECTION OF UTERUS 
 
 Fig. 121. This illustration presents the endometrium (secretory and absorptive — glandu- 
 lar — apparatus) ; the myometrium (peristaltic or rhymic — muscular — apparatus) ; the peri- 
 metrium (secretory, absorptive — lymphatic — gliding apparatus). The uterus is richly sup- 
 plied by sensory and motor nerves. 
 
Fig. 121. Transverse Longitudinal Section of Uterus 
 
468 THE ABDOMINAL AND PELVIC BRAIN 
 
 inciting vigorous and disordered peristalsis of the uterus and oviducts. In 
 short the trauma or shock of menstruation of the genital tract irritates it into 
 a state of pain. It is a state of pathologic physiology, disordered function, 
 but no pathologic anatomy may be palpable. The affliction is functional. 
 
 (d) The student finally asks the patient: How many days does the 
 monthly flow continue? The answer may be, two to eight days. Two days 
 is deficient (amenorrhea or oligemia); four days is normal, eight days is 
 excessive (menorrhagia). I have examined scores of gynecologic patients 
 with over a week's flow, menorrhagia, but in many of them no pathologic 
 anatomy or change of structure could be detected. It is typical pathologic 
 physiology, disordered, unusual function. The subject is like a watch with 
 an excessively powerful mainspring. The watch has no detectable pathologic 
 anatomy, no change of structure. The mainspring, the automatic ganglia, 
 is excessively active. The organ is working excessively, the watch is gaining 
 time. The automatic ganglia are prematurely powerful, the watch spring is 
 too strong. Menorrhagia in many subjects is typical pathologic physiology. 
 The pathologic anatomy, if it exists, is too subtle for us to detect. The adult 
 life of the tractus genitalis presents an excellent field for study and teaching 
 in pathologic physiology. Its several periodic functions, its changing volume 
 of circulation, the limited life of its parenchymatous cells and its automatic 
 menstrual ganglia afford a useful field for study and development of patho- 
 logic physiology. 
 
 (7) GESTATION*. 
 
 Gestation presents many phases of pathologic physiology. There is 
 the typical pathologic physiology, namely, emesis, albuminuria, hypertrophy 
 of left ventricle, pigmentation, capricious appetite, constipation, increase of 
 panicular adiposus, the peculiar gait, venous engorgement (edema), excessive 
 glandular secretion, osteomalacia. The vomiting of pregnancy may present 
 a vast zone from slight regurgitation of food to profound anemia due to 
 limited nourishment — where pathologic physiology alone tells the tale. The 
 normal physiologic nerve relations between the tractus genitalis (uterus) and 
 tractus intestinalis (stomach) have become disordered. No pathologic anat- 
 omy is demonstrable. Constipation (pathologic physiology) is liable to arise 
 during gestation because the normal physiologic blood supply of the tractus 
 intestinalis is robbed to supply the increasing demand of the gestating genital 
 tract. The albuminuria of pregnancy is doubtless partially due to pressure 
 of the expanding uterus on the ureters and veins, obstructing venous and 
 urinal flow. The normal physiologic relations between the tractus urinaria 
 and the gestating tractus genitalis have become projected into the field of 
 pathologic physiology. Pathologic anatomy is not in evidence except as 
 ureteral dilatation — a secondary matter. A comprehensive view of pathologic 
 physiology aids in diagnosis and treatment. It will impress the practitioners 
 with the utility of visceral drainage, the administration of ample fluids at 
 regular intervals to relieve the system of waste-laden blood — irritating sub- 
 stances. Pathologic physiology teaches us to restore function and frequently 
 pathologic anatomy will take care of itself. 
 
PHYSIOLOGY OF TRACTUS GENITALIS 
 
 469 
 
 
 w^M 
 
 
 
 k -;; 
 
 
 
 rfipa» 
 
 PELVIC BRAIN IN RELATION TO THE NERVUS VASOMOTORIUS 
 
 Fig. 122. General view of the nervus vasomotoria (sympathetic). B. Pelvic brain. H. 
 Interilia nerve disc. 1 and 2. Abdominal brain. 
 
470 THE ABDOMINAL AND PELVIC BRAIN 
 
 TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS GENITALIS. 
 
 Since pathologic physiology is the zone between physiology and patho- 
 logic anatomy, it should be amenable to treatment. A diagnosis by exclusion 
 should be made. It must be remembered that in the physiology the entire 
 six abdominal visceral tracts are balanced harmonious, functionating without 
 friction — no reflexes dashing hither and yon disturbing the exquisitively poised 
 visceral physiology. In the treatment of pathologic physiology ol the tractus 
 genitalis it should be remembered that the genitals are not vital for life, but 
 that the richly nerve-supplied genitals dominate the mental and physical exist- 
 ence of woman. In the treatment of pathologic physiology there are the 
 subjects of periodic hyperemia, congestion, hemorrhages, excessive glandular 
 secretions, disturbed sensation (hyperesthesia). First and foremost in the 
 treatment of pathologic physiology of the tractus genitalis, the adjacent 
 visceral tracts must be regulated to normal states as to drainage, but espe- 
 cially as to the physiologic condition of blood. Frequently by producing daily 
 evacuation of the digestive tract and increasing the renal secretion by ample 
 fluids the pathologic physiology of the genital tract improves. The genitals 
 should be examined for adherent prepuce, pudendal fissure, pruritus pudendae, 
 or other point of irritation. The other five abdominal visceral tracts (urina- 
 rius, intestinalis, vascularis, lymphaticus, nervosus) should be examined for 
 points of visceral irritation. The frequent splanchnoptotic condition must 
 be studied and remedied. 
 
 /. VISCERAL DRAIXAGE. 
 
 For many years I have applied a treatment to such subjects which I term 
 visceral drainage. Visceral drainage signifies that visceral tracts are placed 
 at maximum elimination. The waste product of food and tissue are vigor- 
 ously sewered before new ones are imposed. The most important principle 
 in internal medication is ample drainage for every visceral tract. The residual 
 products of food and tissue should have a maximum drainage in health. I 
 suggest that ample visceral drainage may be executed by means of: (A) 
 Fluids; (B) Food. 
 
 (A) Visceral Drainage by Fluids. 
 
 The most effective diuretic is water. One of the best laxatives is H 2 0. 
 One of the best stimulants of renal epithelium is sodium chloride (one-half to 
 one-quarter physiologic salt solution). Hence I administer eight ounces of 
 half normal salt solution to a patient six times a day, two hours apart. 
 (Note. — Sodium chloride is contraindicated in parenchymatous nephritis.) 
 Forty-eight ounces of half normal salt solution daily efficiently increases the 
 drain of the kidney. It maintains in mechanical suspension the insoluble uric 
 acid; it stimulates other matters; it aids the sodium, potassium, or ammonium 
 salts to form combination with the uric acid, producing soluble urates. The 
 half normal salt solution effectively stimulates the peristalsis and epithelium 
 of the tractus intestinalis, inducing secretions which liquefy feces, preventing 
 constipation. 
 
PHYSIOLOGY OF TRACTUS GENITALIS 
 (B) Visceral Drainage by Foods. 
 
 471 
 
 The great functions of the visceral tract— peristalsis, absorption, secre- 
 tion sensation— are produced and maintained by fluids and foods. To drain 
 the tractus genitalis and adjacent visceral tracts which should be excited to 
 
 ARTERIES OF PUERPERAL UTERUS 
 
 Fig 123. Illustrates the arteries of a puerperal uterus 5 days post postum. It is a half- 
 tone-! so-called bromine photograph. It well illustrates the enormous amount of nerves it 
 would require to ensheath the numerous arteries of the uterus. The uterus was injected with 
 red lead and starch and X-rayed. It represents excellently the author s circle. 
 
 peristalsis, foods which leave an indigestible residue only are appropriate 
 All visceral tracts must be stimulated to maximum peristalsis, secretion and 
 absorption in order to aid that of the tractus genitalis. Rational foods must 
 
472 THE ABDOMINAL AND PELVIC BRAIN 
 
 contain appropriate salts whose bases may form combinations which are sol- 
 uble, as sodium, potassium and ammonium combined with uric acid and 
 urates to form soluble urates. The proper foods are cereals, vegetables, 
 albuminates (milk, eggs), mixed foods. Meats should be limited as they 
 enhance excessive uric acid formation. In order to stimulate the epithelium 
 (sensation) of the digestive and urinary tracts with consequent increase of 
 peristalsis, absorption and secretion in both I used a part or multiple of an 
 alkaline tablet of the following composition: Cascara sagrada (o grain), 
 aloes (3 grain), sodium carbonate (1 grain), potassium carbonate (3 grain), 
 magnesium sulphate (2 grains). The tablet is used as follows: One-sixth to 
 one tablet (or more, as required to move the bowels freely, once daily) is 
 placed on the tongue before meals and followed by eight ounces of water 
 (better hot). Also 10 a. m. to 3 p. m., and at bedtime one-sixth to one tablet 
 is placed on the tongue and followed by a glassful of any fluid. In the com- 
 bined treatment one-third of the sodium chloride tablet (containing eleven 
 grains) and one-sixth to three alkaline tablets are placed on the tongue 
 together every two hours, followed by a glass of fluid. The eight ounces of 
 fluid may be milk, buttermilk, eggnog — nourishing fluid. This method of 
 treatment furnishes alkaline bases (sodium, potassium and ammonium) to 
 combine with the free uric acid in the urine, producing perfectly soluble alka- 
 line urates and materially diminishing the insoluble free uric acid in the 
 urine. Besides, the alkaline laxative tablet increases the peristalsis, absorp- 
 tion and secretion of the intestinal tract, stimulating the sensation of the 
 mucosa — aiding evacuation. I have termed the sodium chloride and alkaline 
 laxative method the visceral drainage treatment. The alkaline and sodium 
 chloride tablets take the place of the so-called mineral waters. I continue this 
 dietetic treatment for weeks, months, and the results are remarkably success- 
 ful, especially in the pathologic physiology of the visceral tracts. The urine 
 becomes clarified like spring water and increases in quantity. The tractus 
 intestinalis becomes freely evacuated, regularly, daily. The caliber of the 
 tractus vascularis becomes a powerful fluid volume to carry oxygen and food 
 to tissue, while the effete matter and waste products are rapidly swept into 
 the sewer channels. The blood is relieved of waste-laden and irritating 
 material. The tractus cutis eliminates freely and the skin becomes normal. 
 The appetite increases. The sleep improves. The patient becomes hopeful, 
 natural energy returns. The sewers of the body are drained and flushed to a 
 maximum. 
 
 II. VAGINAL DOUCHE. 
 
 (1) The kind of instrument to employ is a fountain syringe of fourteen- 
 quart capacity. The simplest and most economic vaginal syringe is a four- 
 teen-quart wooden pail, the kind generally used in transporting candy or 
 tobacco. 
 
 (2) The location of the syringe should be four feet above the patient. 
 
 (3) The quantity of fluid administered in the beginning should be two 
 quarts for patients unaccustomed to its use and four quarts to those accus- 
 
PHYSIOLOGY OF TRACTUS GENITALIS 
 
 473 
 
 tomed to its use. The quantity should be increased a pint at each administra- 
 tion to fourteen quarts. 
 
 (4) The temperature of the douche should be 105° in the beginning and 
 increased one degree at each administration until it is as hot as it can be 
 borne (115° to 120 c ). 
 
 (5) The duration of the douche should be ten minutes for each gallon. 
 
 HISTOLOGY OF PELVIC BRAIN 
 
 Fig. 124. A, drawn from the pelvic brain of a girl seventeen years of age. The ganglion 
 cells are completely developed. B, drawn from the pelvic brain of a three months' normal 
 gestation. The ganglion cells are completely developed. Observe the enormous mass of 
 connective tissue present. C, child V/ 2 years old. A nerve process courses within the gan- 
 glion. Few and small ganglion cells incompletely developed. D, girl V/2 years old. A nerve 
 process branches and reunites itself with the intercellular substance. E, girl 6 years old. 
 The ganglion cells are presenting development. (Redrawn after Doctor Sabura Hashimoto.) 
 
 (6) The time to administer the douche is in the evening immediately 
 before retiring and in the morning (after which the patient should lie hori- 
 zontally for forty-five minutes). 
 
 (7) The position of the patient should be lying on the back. 
 
 (8) As to method of administering the douche the patient should lie on a 
 sufficiently inclined plane to allow the returning fluid to drain into a vessel 
 
474 THE ABDOMINAL AND PELVIC BRAIN 
 
 (pail, pan). The ironing board, wash-tub or board resting on the bath-tub 
 serve convenient purposes. The douche should not be administered in the 
 bed (unless ordered), standing or sitting postures or on the water-closet. 
 
 (9) As to ingredients a handful of sodium chloride and a teapoonful of 
 alum should be added to each gallon, the sodium chloride to dissolve the 
 mucus and pus, to act as an antiseptic and to prevent reaction, while the 
 alum is to astringe, check waste secretions and harden tissue. 
 
 (10) The vaginal tube employed in administering the douche should be 
 sterilized, boiled, and every patient should possess her own vaginal tube. 
 The most useful vaginal tube is the largest that can be conveniently intro- 
 duced or the one that distends the vaginal forces so that the hot fluids will 
 bathe the greatest surface area of the proximal or upper end of the vagina. 
 
 (11) The utility of a vaginal douche is: (a) It contracts tissue (muscle, 
 elastic and connective); (b) it contracts vessels (lymphatics, veins and 
 arteries); (c) it absorbs exudates; (d) it checks secretion; (e) it stimulates; 
 (f) it relieves pain; (g) it cleanses; (h) it checks hemorrhage; (i) it curtails 
 inflammation; (j) it drains the tractus genitalis. The utility of the vaginal 
 douche depends on the quantity of fluid, the degree of temperature, its com- 
 position, the position of the patient during administration, and on systematic 
 methods of use. 
 
 (12) Disinfectants in a vaginal douche are secondary in value to solvents 
 of mucus, pus, leucocytes. 
 
 (13) The objects to accomplish by a douche are: (a) The dissolving of 
 the elements in the discharge, as mucus, pus and leucocytes; (b) the 
 mechanical removal of morbid secretions, accumulations and foreign bodies; 
 (c) antisepsis; (d) diagnosis (and it includes number 11). 
 
 (14) The requirements of a douche; (a) It should be nonirritating; (b) it 
 should be a clear solution; (c) it should possess solvent powers of pus, and 
 especially mucus; (d) it should be continued for months; (e) omit the douche 
 for four days during menstruation. 
 
 (15) A vaginal douche, administered according to the above directions, 
 will prove to be of therapeutic value in the treatment of pelvic disease, a 
 prophylactic agent and a comfort to the patient. 
 
 (16) The vaginal douche is contraindicated in subjects with oviductal 
 gestation or acute pyosalpinx, as it is liable to induce rupture of the oviductal 
 wall, abortion or leakage of pus through the abdominal oviductal sphincter. 
 
 III. VAGINAL T AM POX. 
 
 (1) The composition of the vaginal tampon consists of a roll of medi- 
 cated cotton (hen-egg size), tied to a twelve-inch string, placed in a solution 
 of sixteen ounces of glycerine and two ounces of boracic acid. 
 
 TRACTUS VASCULARIS AND TRACTUS NERVOSUS OF THE TRACTUS 
 
 GENITALIS 
 
 Fig. 125. Illustrates the tractus nervosus of the genital tract, pregnant 5 months. The 
 utero-ovarian vascular circle (circle of author) is ensheathed by a rich nodular, fenestrated, 
 anastomosing nerve plexus. 
 
Fig. 125. Tractus Vascularis and Tractus Nervosus of the Tractus Genitalis 
 
476 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 (2) The duration of preparation of vaginal tampon should be to lie in the 
 boroglyceride solution forty-eight hours before using. 
 
 (3) The utility of the vaginal tampon is: (a) It is hygroscopic; (b) it 
 serves as a mechanical support; (c) it contracts tissue (muscle, elastic, con- 
 nective); (d) it contracts vessels, (lymphatics, veins and arteries); (e) it has- 
 tens absorption of exudates; (f) it checks secretions; (g) it stimulates; (h) it 
 curtails inflammation; (i) it drains the pelvic organs; (j) it cleanses; (k) it 
 dissolves mucus, pus and leucocytes. The utility of a vaginal tampon depends 
 on its composition, the quantity employed, the duration of its application 
 and on systematic method of use. 
 
 (4) The methods of introduction consist in placing three to five vaginal 
 tampons (with or, better, without a speculum) in the vaginal fornices in the 
 direction of least resistance. 
 
 PELVIC BRAIN (1, 2.) 
 Fig. 126. Dissected from a subject about 37 years old. 
 
 (5) Disinfectants in a vaginal tampon are secondary to its other qualities, 
 especially that of hygroscopy. 
 
 (6) The object to accomplish by a vaginal tampon is: Maximum 
 hygroscopy, dissolving the elements in the discharge, as mucus, pus, leuco- 
 cytes, the mechanical removal of morbid secretions, accumulation and foreign 
 bodies, diagnosis, and mechanical support. 
 
 (7) The diagnosis is aided by the use of a tampon by collecting and pre- 
 serving the uterine discharge (as pus, blood, debris). 
 
 (8) The requirements of a vaginal tampon are : (a) It should be nonirri- 
 tating; (b) it should possess hygroscopic power; ,(c) it should be a solvent of 
 discharges (mucus, pus, leucocytes, blood) ; (d) it should aid in the dissolv- 
 ing of the mechanical removal of morbid secretions, accumulations, and 
 
PHYSIOLOGY OF TRACTUS GENITALIS 
 
 477 
 
 foreign bodies; (e) it should be aseptic (not necessarily antiseptic); (f) it 
 should not indelibly stain the clothing (this is objection to its use as, for 
 example, ichthyol); (g) it should be reasonably economic. 
 
 (9) The frequency of application of the boroglyceride vaginal tampons 
 should be in general, twice weekly; more frequent employment may cause 
 irritation. 
 
 SACRO-PUBIC HERNIA 
 
 Fig. 127. This illustration demonstrates how the ureters, bladder and vagina are dis- 
 torted and consequently how the accompanying sympathetic nerves are traumatized. 
 
 (10) The time to apply the tampon is at night during maximum anatomic 
 and physiologic rest. 
 
 (11) The duration the tampon may remain usefully in position is ten to 
 twenty-four hours. 
 
 (12) There are no special contraindications to the application of .the 
 ^aginal tampon (in pelvic disease). 
 
478 THE ABDOMINAL AND PELVIC BRAIN 
 
 (13) The boroglyceride vaginal tampon may be beneficially applied in: 
 (a) inflammatory pelvic disease (vaginitis, endometritis, myometritis, endosal- 
 pingitis, myosalpingitis, pelvic peritonitis, proctitis, cystitis); (b) sacropubic 
 hernia (support for the uterus, cystocele and rectocele) ; (c) in genital ptosis 
 it depletes the lymphatics and veins. 
 
 (14) A vaginal tampon applied according to the above directions will 
 prove to be of therapeutic value in the treatment of pelvic disease, a pro- 
 phylactic agent and a comfort to the patient. 
 
 IV. HABITAT. 
 
 The value of fresh air was never realized so much as at present. Fresh 
 cold air cures pulmonary and other tuberculoses. The success of the sanitarium 
 is the continued use of fresh (cold) air. The subject should sleep with fresh 
 cold air passing through an open window space of three by three feet. It 
 appears to be demonstrated that cold fresh air is more beneficial than warm 
 fresh air. It is common talk among people that one winter in the mountain 
 is worth two summers for the consumptive. The curative and beneficial 
 effect of cold fresh air continually, day and night, for the family must be 
 preached in season and out of season by physicians. The windows should be 
 open all night. Fresh cold air is one of the best therapeutic agents in patho- 
 logic physiology of the tractus genitalis. 
 
 Exercise is an essential for health. Muscles exercise a dominating con- 
 trol over circulation (blood and lymph). The abdominal muscles influence 
 the caliber of the splanchnic vessels. They exercise an essential influence 
 over the peristalsis, secretion, absorption of the tractus intestinalis, unnarius, 
 vascularis and genitalis. The muscles massage the viscera, enhancing their 
 function and the rate of circulation. In the uterus, the most typical 
 example, it is prominently marked how the myometrium controls the blood 
 currents like living ligatures. The habitat that furnishes opportunity for 
 abundant fresh air and ample exercise is the one that affords the essential 
 chances for recovery of pathologic physiology in the tractus genitalis. 
 
CHAPTER XXXV. 
 
 PATHOLOGIC PHYSIOLOGY OF THE TRACTUS URINARIUS. 
 
 / belong to the great church that holds the world within its starlit aisles; that 
 claims the great and gvod of every race and clime; that finds with joy the 
 grain of gold in every creed, and Hoods with light and love the germs of 
 good in every soul. — R. Ingcrsoll. 
 
 The rising of a great hope is like the rising of the sun. — Charles Kingslcy. 
 
 The physiology or function of the tractus urinarius is: (1) peristalsis; 
 (2) secretion; (3) absorption; (4) sensation. Pathologic physiology is a 
 deviation from the usual physiology without, however, invading the field of 
 pathologic anatomy. The tractus urinarius is a fertile field to study patho- 
 logic physiology, as it presents a wide zone of varying degrees, especially 
 since recent investigations have enriched our knowledge of renal function. 
 What older physicians considered pathologic anatomy in renal function is 
 now believed to be largely pathologic physiology. The zone of kidney 
 function is a continually increasing one. In the study of pathologic physi- 
 ology of the tractus urinarius rational and comprehensive views of the renal 
 viscus will be entertained. The study comprises: (a) the condition or state 
 of the kidney; (b) the constituents of the blood; (c) the volume of blood 
 that streams through the organ. The discussion of (a), (b), and (c) in regard 
 to the kidney lends a comprehensive view to the student in making a diag- 
 nosis of the living. 
 
 We will here consider the pathologic physiology of the urinary tract or 
 Some of the common deviations from the usual physiology. 
 
 (1) PERISTALSIS (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (a) Excessive peristalsis may occur in the tractus urinarius from numerous 
 causes. The segment of the urinary tract subject to peristalsis is the ureter 
 and bladder. The ureter is an independent organ resembling the heart, 
 uterus, stomach. It possesses automatic ureteral ganglia as it performs 
 peristalsis and functionates regardless of attitude or force of gravity. 
 Excessive peristalsis is most liable to arise from excessive drinking of fluids, 
 f from diabetes or polyuria where excessive volumes of fluid passed through 
 the urinary tract in limited time. The most marked example of pathologic 
 physiology or excessive peristalsis in the urinary tract arises from the presence 
 of an ureteral calculus. The ureter experiences brusk, vigorous, violent, 
 wild and disordered movements accompanied by excruciating pain. A marked 
 example of excessive ureteral peristalsis, based, however, on pathologic 
 anatomy, is ureteritis which may be accompanied by excruciating pain. 
 From experimentation on dogs one observes that the peristalsis of the ureter 
 is brisk, vigorous, resembling that of the heart, uterus. 
 
 479 
 
480 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Fig. 128. INTIMATE RELATION OF THE TRACTUS GENITALIS AND TRACTUS 
 
 URINARIUS 
 
PHYSIOLOGY OF TRACTUS URINARIUS 481 
 
 (b) Deficient peristalsis of the urinary tract arises in connection with 
 limited drinking of fluids, limited quantity of urine (the pressure of urine 
 stimulates the ureteral peristalsis) ; a limited quantity of urine accompanied 
 by a limited peristalsis is liable to be followed by precipitation of crystals and 
 urinary calculus. However, a compensatory action arises from the fact that 
 limited urine is generally concentrated and hence is apt to irritate the ureter, 
 inducing peristalsis. It is probable that the automatic ureteral ganglia, 
 similar to the automatic intestinal ganglia (in constipation) may become 
 sluggish, inducing deficient ureteral peristalsis. 
 
 (c) Disproportionate peristalsis is irregular, unequal peristalsis in different 
 segments of the tractus urinarius, as bladder or ureter. 
 
 (2) SECRETION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (d) Excessive secretion from the urinary tract is observed most typically 
 in diabetes mellitus, insipidis or polyuria, frequently fields of simple patho- 
 logic physiology where no pathologic anatomy can be detected. 
 
 Excessive renal secretion may be marked in change of temperature from 
 warm to cold weather — a difference of a quart of urine may be noted enduring 
 for six or ten days — simple variation of renal function. The function of the 
 perspiratory apparatus has experienced a deficient secretion relatively equal 
 to the pathologic physiology of the excessive renal action. Cold, contract- 
 ing the cutaneous vessels, forcing the blood into the central large vessels, 
 and increasing heart action, will markedly increase renal secretion. Patho- 
 logic physiology, compensatory, no pathologic anatomy; it is a form of 
 vicarious physiology. Sugar may appear in the urine for some time (patho- 
 logic physiology) without demonstrable pathologic anatomy — later, however, 
 indigested fats may be found in the stools, which would call attention to the 
 pancreas. However, the pancreas may be suffering from pathologic physi- 
 ology of secretion only (excessive, deficient, or disproportionate). Pan- 
 creatic secretion may be insufficient to dissolve the fats. So that even at the 
 stage of diabetes, pathologic anatomy may not yet be afoot. Paresis 
 (sluggishness) of the renal plexus (ganglia) may allow polyuria. Constipation 
 may impose increased vicarious duties on the kidneys, compelling them to 
 eliminate products usually eliminated by the tractus intestinalis. We know 
 kidney action may be excessive, that is, comprise pathologic physiology 
 only, for we not infrequently observe one kidney successfully accomplishing 
 
 Fig. 128. This illustration demonstrates how solidly and compactly the tractus urinarius 
 and tractus genitalis are anastomosed, connected. At the proximal arterio-ureteral crossing 
 (11, 11) the ureter and ovarian artery are solidly and firmly anastomosed by the nervus 
 vasomotorius (sympathetic). Again at the distal arterio-ureteral crossing (2, 2) a similar 
 but more extensive anastomosis occurs — hence the balanced relationship between the 
 tractus urinarius and tractus genitalis. Every practitioner realizes the intimate relation of 
 the bladder and the uterus, e. g., in gestation, through the nervus vasomotorius. This 
 intimately solid anastomosis between the two visceral tracts by means of abundant nerve 
 strands aids to explain the vast and interdependent pathologic physiology observed in 
 practice. 
 
 31 
 
482 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 duplicate work. We can produce excessive secretion of urine artificially by 
 administering NaCl in ample fluids. Certain foods, as water-melon, produce 
 temporary excessive renal function, with certain subjects, apparently exces- 
 
 ILLUSTRATION OF THE FEMALE URINARY TRACT 
 
 H^Jn'JL 129 ^ Thi; \ s P? cimen was drawn from nature from my own dissection by the aid of 
 distending the ureter's veins and arteries with hardening material. The ureter (calyces 
 It wnrl n of Ureter ?w ?er) 1S ensheathe d with a nodular fenestrated web, an anastomosing 
 ? Jr Z ?lu s / m P athet £ "erves especially at the 3 ureteral isthmuses (of Byron Robinson) 3, 
 5 and the entrance in the bladder. Z, Y, 3, uretero-venous triangle (of author). The nervus 
 vasomotoria richly supplies the tractus urinarius and manifests itself violently during the 
 presence of a moving calculus or periodic hydro-ureter, or ureteritis 
 
PHYSIOLOGY OF TRACTUS URINARIUS 483 
 
 sive renal secretion (pathologic physiology) exists for years. In excessive 
 renal secretion the urinary salts may be excessive or deficient or vice versa. 
 
 (e) Deficient renal secretion may be noted in limited drinking of fluids, 
 in restricted diet in diarrhoea (vicarious), in cold weather, in debilitated 
 heart, in fevers, in concentrated foods (flesh-eaters), in sedentary habits and 
 in numerous nameless conditions. Deficient renal secretion is, from my 
 experience, a rather common condition. Deficient renal secretion may 
 present excessive or deficient urinary salts or vice versa. 
 
 In certain subjects apparently deficient renal secretions exist for years. 
 In general, deficient renal secretions are saturated with concentrated urinal 
 salts which may irritate the mucosa of the tractus urinarius sufficiently to 
 produce pathologic physiology. Deficient renal secretion may lead to 
 uremia. 
 
 (f) Disproportionate renal secretion is irregular in different segments of 
 the kidney. The urine may be excessive and the salt deficient or vice versa. 
 The renal glomeruli may secrete deficient or excessive fluids. The 
 uriniferous tubules may secrete deficient or excessive salts. 
 
 \Yhat influence has the disturbed renal secretion — the pathologic physi- 
 ology — on the general organism? Manifold injuries may occur. The con- 
 tinual loss in albuminuria is exhausting. The insufficient secretion of urinal 
 constituents from the blood leads finally to bodily disturbance. In other 
 words, pathologic physiology in renal secretion may be the incipient stage of 
 disease — pathologic anatomy. Disturbed renal secretion may be accom- 
 panied by disease in different organs — uremia, which represents the accumu- 
 lated disturbances on various organs. 
 
 (3) ABSORPTION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (g) Excessive absorption of the tractus renalis would constitute extracting 
 unusual material from the blood. In a certain sense, excessive renal absorp- 
 tion might induce excessive secretion: e. g., on urinalysis albumen may be 
 found which would suggest an inquiry as to the quantity of egg albumen the 
 subject is consuming. Considerable ingesta of albumen may lead to rich 
 albuminuria. Hence, the state or composition of the blood should be inves- 
 tigated to decide the amount of albuminuria. If there be excessive sugar 
 in the blood and sugar being absorbed by the renal apparatus will present 
 excessive secretion of sugar. This suggests inquiry into the quantity of 
 sugar ingested. 
 
 (h) Deficient absorption would indicate that the renal apparatus does not 
 extract from the blood the proper amount nor the proper material. The 
 pathologic physiology has a wide range in deficient absorption, for some 
 times we may observe an adult person eliminating 8 or 10 ounces of urine 
 daily. 
 
 (i) Disproportionate absorption constitutes irregular disordered absorption 
 of the different segments of the renal apparatus, as the glomeruli and the 
 uriniferous tubuies. 
 
484 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Fig 130. AN ILLUSTRATION OF THE ABDOMINAL SYMPATHETIC NERVE OF 
 
 THE MALE, ESPECIALLY PRESENTING THE NERVES OF 
 
 THE TRACTUS URINARIUS 
 
PHYSIOLOGY OF TRACT US UR1NARIUS 485 
 
 (4) SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 It is evident on watching an exposed ureter of a sleeping dog that the 
 sensation of the mucosa in the urinary apparatus is of vital importance, for 
 each and every time that a certain quantity of urine collects in the dog's 
 ureteral pelvis, the ureter proper executes its brusque, vigorous peristalsis 
 with remarkable rapidity. The automatic ureteral ganglia rule the ureteral 
 peristalsis. We do not realize the exquisitively poised sensory apparatus 
 of the tractus urinarius until some catastrophy occurs, as ureteral calculus, 
 to apprise us of the wild, disordered peristalsis and excruciating pain. 
 Pathologic physiology of sensation in the tractus urinarius may well comprise 
 excessive, deficient or disproportionate states for sensation much depends 
 on the composition of the urine and the state of the urinary visera. Inordi- 
 nate meat eaters produce concentrated, irritating urine, exciting excessive 
 ureteral peristalsis with consequent pain — diluting the urine relieves the 
 patient. 
 
 In excessive sensation of the tractus urinarius we will include the so- 
 called "irritated bladder," because, though cystoscopy has lessened the actual 
 number of irritable bladders by eliminating pathologic anatomy, it can not 
 exclude the subject — pathologic physiology. Irritable bladder exists without 
 demonstrable pathologic anatomy. The subjective symptoms of an irritable 
 or excessively sensitive bladder are frequent evacuations (peristalsis). The 
 bladder may require evacuations several times an hour. There is an increase 
 in frequency and intensity in the desire to urinate — excessive visceral peri- 
 stalsis. Irritable bladder may persist day and night. The desire to urinate 
 may be so intense that insufficient time is allowed to prepare the dress and 
 hence "wetting of the clothing" occurs. Excessive vesical peristalsis, 
 irritable bladder may be sufficient to cause vesical colic, which may radiate, 
 reflexly to the tractus intestinalis or genitalis, disordering the function of 
 peristalsis, absorption or secretion. E. g., the patient may evacuate feces 
 and urine simultaneously — so-called nervous diarrhea. 
 
 The irritable bladder may produce cold perspiration, emesis, chills, and 
 produce mental depression, hypochondria. The main objective symptom 
 of irritable bladder — pathologic physiology of vesical sensation and peristal- 
 sis — is hyperesthesia which manifests itself chiefly in the trigone where 
 nerves congregate. The neck and fundus may present irritability. The 
 hyperesthesia may occur as an increase in normal sensibility to tensions or 
 
 Fig. L30. An illustration of the nervus vasomotorius (sympathetic) drawn from a speci- 
 men which I secured at an autopsy through the courtesy of Professor W. A. Evans. The 
 relation of the nervus vasomotorius to the tractus urinarius is evidently intimate and abun- 
 dant. The network of nerves on the arteria renalis and ureter are apparent. The enormous 
 supply of nerves to the adrenal is remarkable — 7 in number. The solid anastomosis of the 
 plexus ovaricus with the plexus ureteris is noticeable, where the vasa ovarica (spermatica) 
 pass ventral to the ureter. The arteria renalis is ensheathed in a rich, plexiform, gangliated 
 nerve plexus. I dissected this specimen under alcohol, and the nerve relations are prac- 
 tically correct. The artist, Mr. Zan D. Klopper, followed the fresh dissection as a model. 
 The ureter (calyces, pelvis and ureter proper) is dilated bilaterally. Even the 3 ureteral 
 isthmuses (of author) are dilated. 
 
486 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 as abnormal sensibility to pressure. The abnormal sensibility may be mani- 
 fest on the presence of solid feces in the rectum, digital examination or on 
 cystoscopy. The urine may present nothing abnormal in quantity in re-act- 
 icn, chemical or physical characteristics; no hyperacidity, no excess of salts 
 concentration of urine, or glycosuria. What causes the hyperesthesia of 
 
 Ar. Vag- 
 A.l.V. 
 
 -A.&.V 
 
 recJ'-sfte a Sri a ?hlnnH PPly , t0t , he t y aCtUS urinari «s » best remembered, perhaps, by 
 TSHS^toSSSiL^JS?*? 7 ' f ° r ?! nervUS vasomotoria accompanies the arteries 
 ovarfca (soermat^ fa) artena adrenalis ; (b) arteria renalis ; (c) arteria 
 
 art-",V^ (y) arteria uteris, distal (from liac) ; (z) 
 
 clexus Th ,'ni r , / e ,t VeS1Cal artenes > e ach of which is accompanied by its own nerve 
 plexus, rtr upper part of illustration is from corrosion anatomy ' 
 
PHYSIOLOGY OF TRACTUS URINARIUS 
 
 487 
 
 the vesical wall — pathologic physiology, no demonstrable pathologic anatomy 
 — is unknown. Cystoscopic examinations and autopsies and examinations 
 demonstrate that in irritable bladder no pathologic anatomy may exist or that 
 a condition of hyperemia may exist in the bladder wall. The subjects of 
 irritable bladder in which no demonstrable pathologic anatomy exists are 
 simply nervous in character, typical pathologic physiology. The subjects 
 
 NERVES OF THE TRACTUS URINARIUS— CORROSION ANATOMY 
 
 Fig. 132. This specimen presents quite faithfully the circulation, the kidney, calyces and 
 pelvis. The two renal vascular blades I present opened like a book. The corrosion was on 
 the left kidney and the larger vascular blade is the ventral one. The vasomotor nerves 
 accompanying the urinary tract may be estimated by the fact that a rich plexiform network 
 of nerves ensheath the arteries, the calyces, pelvis and ureter proper. When the renal vas- 
 cular blades are shut like a book their thin edges come in contact, but do not anastomose. 
 The edges of the vascular blades are what I term the exsanguinated renal zone of Hyrtl, who 
 discovered it in 1868, and we, at present, employ it for incising the kidney to gain entrance 
 to the enterior of the calyces and pelvis with minimum hemorrhage. This specimen presents 
 excellently the capsular artery — Cap. A. Think of the vast amount of pathologic physiology 
 which could be created by disturbing the rich sympathetic nerve supply to the kidney. 
 
 possessing merely hyperemia of the vesical wall are of non-inflammatory type 
 or non-detectable inflammation. The irritable bladder is influenced especially 
 by two factors, viz. : (a) psychic or mental disturbances ; (b) tendency of blood 
 to the pelvic organs (bladder). The prognosis of irritable bladder, especially 
 of the severe type, is unfavorable — almost every case I have observed was 
 or has been practically life long. The treatment is hygienic, dietetic — 
 
488 
 
 THE ABDOMIXAL AND PELVIC BRAIN 
 
 visceral drainage, preserving maximum state and contents of visceral tracts. 
 For more extensive views of the subject of irritable bladder see the excellent 
 article by Hirsch, Centralbllatt f. die Grenzgebete Medizin u. Chirurgie» 
 Vol. VIII, Nos. 13 and 14. 
 
 NERVUS VASOMOTORIUS OF THE TRACTUS URINARIUS 
 Fig. 133. I dissected this specimen under alcohol. It presents excellently the solid and 
 compact anastomosis of urinary nerves to all other abdominal vasomotor nerves. Observe 
 the solid anastomosis at M and N. The reflexes observed in practice may well be inter- 
 preted by this illustration. Note the multiple, giant, ganglia accompanying the arteria 
 renalis. The nerves of the tractus urinarius presents a rich field in pathologic physiology. 
 
 There are still apparently unsolved problems in the physiology of the 
 tractus urinarius and hence multiple unsolved problems in the pathologic 
 physiology of this important visceral tract. For example, the urine (an acid 
 fluid) is derived from the blood (an alkaline fluid) by a filtration process. 
 What changes the urine into an acid fluid from the blood, an alkaline fluid? 
 The explanation must be that the blood is practically and chemically an 
 acid due to the presence of bicarbonates which are acid salts. 
 
PHYSIOLOGY OF TRACTUS URINARIUS 
 
 489 
 
 The degree of the acidity of the urine is a measure of the degree of the 
 acidity of the blood. The acidity of both urine and blood is due to acid 
 phosphates or salts of phosphoric acid (H3PO4), i. e., salts resembling acid 
 sodium phosphate (NaH 2 P0 4 ), acid calcium phosphate (CaHP0 4 ), and acid 
 magnesium phosphate (MgHPO,), which may assume more atoms in the 
 bone. 
 
 CORROSION ANATOMY (HYRTL'S EXSANGUINATED RENAL ZONE) 
 
 Fig. 134. In this specimen of corrosion anatomy the renal vascular blades (ventral and 
 dorsal) are closed like a book. It presents (left kidney) on the margin of the dorsal lateral 
 surface the exsanguinated zone of Hyrtl — the line of minimal hemorrhage for corticle renal 
 incision. A rational method to estimate the quantity of nerves of the tractus urinarius is to 
 expose the number and dimension of the arteries and other tubular ducts which are 
 ensheathed in a plexiform network — a fenestrated, nodular, neural vagina of nerves. The 
 nervus vasomotorius rules the physiology of the renal apparatus. Modern investigation 
 demonstrates an extensive zone of pathologic physiology in the domain of the kidney. 
 
 "It is, therefore, obvious that the real urinary acidity is phosphoric acid- 
 
 VToJirnl T„i,i'i,r,l Mgv 9R 1QDR 1 
 
 ity. 
 
 t is, therefore, obvious that the real urinary acidity is 
 (Editorial, New York Medical Journal, May 26, 1906.) 
 
 TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS URINARIUS. 
 
 Since pathologic physiology is the zone between physiology and patho- 
 logic anatomy it should be practically amenable to treatment. First and 
 
490 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 foremost the diagnosis should be made, and the cause removed, as ureteral 
 calculus, anal fissure, hepatic calculus or any point of general visceral irrita- 
 tion. The most general essential feature of a subject suffering from patho- 
 
 Fig. 135. This specimen I dissected with extreme care under alcohol, and the artist, Mr. 
 Zan D. Klopper, followed the dissection as a model. It well illustrates the nervus vasomo- 
 torius in relation with the tractus urinarius. 
 
 logic physiology of the tractus urinarius is deficient visceral drainage. The 
 blood is excessively waste laden from inefficient elimination. The secretions 
 are scanty. The urine is concentrated, its crystallized salts are evident to 
 
PHYSIOLOGY OF TRACTUS URINARIUS 491 
 
 the eye. The skin is dry from insufficient perspiration, sleep is defective 
 from bathing of the innumerable ganglia with waste laden blood. Consti- 
 pation, deficient urine, limited perspiration, capricious appetite, insomnia 
 and headache characterize subjects with pathologic physiology of the 
 tractus urinarius. 
 
 For many years I have applied a treatment to such subjects which I term 
 visceral drainage. Visceral drainage signifies that visceral tracts are placed 
 i at maximum elimination. The waste product of food and tissue are vigor- 
 ously sewered before new ones are imposed. The most important principle 
 in internal medication is ample visceral drainage for every visceral tract. 
 The residual products of food and tissue should have a maximum drainage 
 in health. I suggest that ample visceral drainage may be executed by means 
 of: (A) fluids; (B) food. 
 
 (a), visceral drainage by fluids. 
 
 The most effective diuretic is water. One of the best laxatives is 
 water. One of the best stimulants of renal epithelium is sodium chloride 
 (1-2 to 1-4 physiologic salt solution). Hence I administer eight ounces of 
 half normal salt solution to a patient six times a day, two hours apart. 
 (Note — NaCl is contraindicated in parenchymatous nephritis.) 48 ounces of 
 1-2 normal salt solution daily efficiently increases the drain of the kidney. 
 It maintains in mechanical suspension the insoluble uric acid, it also stimu- 
 lates other matters. It aids the sodium, potassium or ammonium salts to 
 form combination with the uric acid producing soluble urates. 
 
 The half normal salt solution effectively stimulates the epithelium of 
 the tractus intestinalis, inducing secretions which liquefy feces, preventing 
 constipation. 
 
 (b). visceral drainage by foods. 
 
 The great functions of the tractus urinarius — peristalsis, absorption, 
 secretion, sensation — are produced and maintained by fluids and food. To 
 drain the tractus urinarius the adjacent visceral tracts should be excited to 
 peristalsis, hence foods which leave an indigestible residue only are appro- 
 priate, all other visceral tracts must be stimulated to maximum peristalsis, 
 secretion, absorption in order to aid that of the tractus urinarius. Rational 
 foods must contain appropriate salts whose bases may form combinations 
 which are soluble, as sodium, potassium, and ammonium combined with uric 
 acid and urates to form soluble urates. The proper foods are cereals, veg- 
 etables, albuminates (milk, eggs), mixed foods. Meats should be limited as 
 they enhance excessive uric acid formation. 
 
 In order to stimulate the epithelium (sensation) of the digestive and 
 urinary tract with consequent increase of peristalsis, absorption and secretion 
 in both, I use a part or multiple of an alkaline tablet of the following com- 
 position: Cascara Sagrada (1-40 grain), Aloes (1-3 grain), NaHC0 3 (1 grain), 
 KHC0 3 (1-3 grain), MgS0 4 (2 grains). Tablet* is used as follows: 1-6 to 1 
 
 *The sodium chloride and alkaline tablets are manufactured by Searle and Hereth 
 Co., Chicago. 
 
NERVUS VASOMOTORIUS OF THE TRACTUS URIXARIUS 
 (COXGEXITALLY DISLOCATED) 
 
 Fig. 136. This illustration is drawn from a specimen I secured at an autopsy. The right 
 kidney was dislocated, resting on the right common iliac artery, with its pelvis (P) and hilum 
 facing vemtralward. The adrenal (Ad.) remained in situ. It was a congenital renal disloca- 
 tion, and was accompanied with congenital malformations in the sympathetic nerve, or 
 nervus vasomotorius. 1 and 2 is the abdominal brain. It sends five branches to the 
 adrenal from the right half (2). Though the sympathetic system is malformed, yet the prin- 
 cipal rules as regards the sympathetic ganglia still prevail, viz., ganglia exist at the origin of 
 abdominal visceral vessels, e. g., 3, at the origin of the inferior mesenteric artery ; at the 
 root of the renal vessels, HP is no doubt the ganglion originally at the root of the common 
 iliacs (coalesced). In this specimen the right ureter was 5 inches'in length, while the left was 
 ll l / 2 . This specimen demonstrates that the abdominal brain is located at the origin of the 
 renal, celiac, and superior mesenteric vessels — i. e., it is a vascular brain (cerebrum vasomo- 
 torius). The solid and compact anastomosis of the nervus vasomotorius of the tractus 
 urinarius with nerve plexuses of all other abdominal visceral tracts is evident 
 
PHYSIOLOGY OF TRACTUS URINARUJS 493 
 
 tablet (or more, as required to move the bowels freely, once daily) is placed on 
 the tongue before meals and followed by 8 ounces of water (better hot). 
 Also at 10 a. m., 3 p. m., and at bedtime 1-6 to 1 tablet is placed on the 
 tongue and followed by a glassful of any fluid. In the combined treatment, 
 1-3 of the (NaCl) sodium chloride tablet (containing 11 grains) and (1-6 
 to 3) alkaline tablets are placed on the tongue together every two hours and 
 followed by a glass of fluid. The six glasses of fluid may be milk, butter- 
 
 Fig. 137. Illustrates the relation of the spinal nerves to the tractus urinarius, especially 
 to the plexus lumbalis. The ureter is intimately connected with the genito-crural nerve (A) ; 
 hence the pain reflected in the thigh and scrotum in ureteral colic and other ureteral diseases. 
 (2) Ileo-inguinal nerve. 
 
 milk, cream, eggnog — nourishment. This method of treatment furnishes 
 alkaline bases (sodium, potassium, and ammonium) to combine with the free 
 uric acid in the urine, producing perfectly soluble alkaline urates and 
 materially diminishing the insoluble free uric acid in the urine. Besides, the 
 alkaline laxative tablet increases the peristalsis, absorption and secretion of 
 the intestinal tract, stimulating the sensation of the mucosa — aiding evacu- 
 ation. 
 
 I have termed the sodium chloride and alkaline laxative method the vis- 
 
494 THE ABDOMINAL AXD PELVIC BRAIX 
 
 ceral drainage treatment. The alkaline and sodium chloride tablets take the 
 place of so-called mineral waters. I continue this dietetic treatment of fluids 
 and food for weeks, months, and the results are remarkably successful, 
 especially in pathologic physiology of visceral tracts. The urine becomes 
 clarified like spring water and increased in quantity. The tractus intestinalis 
 becomes freely evacuated, regularly, daily. The blood is relieved of waste 
 laden and irritating material. The tractus cutis eliminates freely and the 
 skin becomes normal. The appetite increases. The sleep improves. The 
 patient becomes hopeful, natural energy returns. The sewers of the body 
 are drained and flushed to a maximum. 
 
 Had space permitted it might have enhanced the clearness of the 
 above subject to first discuss the pathologic physiology of the tractus 
 urinarius, and, second, to discuss the pathologic physiology of the con- 
 tents of the tractus urinarius. 
 
CHAPTER XXXVI. 
 
 PATHOLOGIC PHYSIOLOGY OF THE TRACTUS NERVOSUS 
 
 (ABDOMINALIS). 
 
 The man who builds a home erects a temple — the flame upon the hearth is the 
 sacred fire.— Robert Ingersoll, American (1844-1904). 
 
 The peritoneum sheaths and lines. — Dr. P. T. Burns. 
 
 The ideal nervous system consists of a ganglion cell, a conducting cord 
 and a periphery, i. e., a receiver, a transmitter and a reorganizer. This 
 simple view of the structure of the nervous system at once suggests its func- 
 tion, viz., that of reception (periphery apparatus — skin, mucosa), transmission 
 (conducting apparatus — nerve cords), reorganization (ganglion cell — brain). 
 The nervous apparatus is the highest and most perfect of known organism. 
 Mental action or nerve force, the most subtle of all forces, depends on it. 
 The nervous system includes the most profound secrets of life — it is the climax 
 of organism. First and foremost, the zone of the physiology of the tractus 
 nervosus is not exactly denned — it is liberally elastic. Secondly, the patho- 
 logic physiology of the tractus nervosus possesses an expansive, undefinable 
 zone before established pathologic anatomy can be recognized. The patho- 
 logic physiology of the tractus nervosus comprehends the fields of neuralgia, 
 hyperesthesia, anesthesia, sensation, motion, melancholia, hysteria, neuras- 
 thenia, with innumerable irritable weaknesses of the nervous system. 
 Absorption, secretion and peristalsis of viscera are the elements or means by 
 which we recognize the pathologic physiology. In the numerous manifesta- 
 tions of symptoms of pathologic physiology of the tractus nervosus of the 
 abdomen a few considerations may be suggestive and helpful in practice. 
 First and foremost, many subjects are not perfect physically or mentally. 
 Such subjects are prone to pathologic physiology. They possess inferior 
 anatomy and physiology. Structure and function are of minimum perfection. 
 Their nervous system is not stable. We should consider these defections or 
 unstable conditions under long-employed or established terms, associated 
 with which has grown a stately literature, as stigma, habitus, asthenia con- 
 genita, heredity, predisposition, degeneracy. 
 
 Nervous persons are afflicted with pathologic physiology. Nervous per- 
 sons manifest a defective resistence. They are incapacitated for sustained 
 effort. Nervous persons present premature exhaustion on persistent mental 
 or physical effort. The reason of the nervousness is the anatomy and 
 physiology of the tractus nervosus is inferior, its structure and function is 
 deteriorated. Their nervous system is irritable, weak, defective, unstable, 
 functionating much of the time with disorder and friction, like some watches, 
 which maintain incorrect time. Nervous subjects are chiefly congenital 
 
 495 
 
496 THE ABDOMINAL AND PELVIC BRAIN 
 
 unfortunates. They are born with defects, with stigma, a habitus, neuro- 
 pathic predispositions — a condition which tends to degeneracy with facility. 
 Nervousness, though frequently an announcement of an enfeebled nervous 
 system, yet it may be evoked, aggravated, by some irritation external to the 
 nerve apparatus. Neurotic spells appear with as much mysticism as they 
 disappear. The only trace is the memory of the disordered pathologic physi- 
 ology. There is doubtless more or less foundation, for these inscrutable 
 neurotic conditions, to be established in the state of the tractus vascularis, 
 congestion, anemia. The tone and tension of the abdominal muscles control 
 the abdominal circulation. Diseases of the tractus intestinalis compromise 
 the tractus nervosus by damaging its integrity — in structure and function. 
 One of the best terms to apply to subjects who are persistently afflicted with 
 pathologic physiology is the word habitus, e. g., we have the habitus phthisi- 
 cus, habitus splanchnopticus. habitus nervosus, habitus dyspepticus. The 
 ensemble of symptoms associated with splanchnoptosia may well be termed 
 habitus splanchnopticus. It is heredity in so far that the subject possesses 
 a predisposition and the main defect is inferior anatomy and physiology. In 
 the habitus splanchnopticus there is the gracile skeleton, the elongated flat 
 thorax, extensive intercostal space, acute epigastric angle, the sacculated, 
 pendulous abdomen, limited muscularis and panniculus adiposus, the labored 
 respiration. The costa fluctuans decima of B. Stiller, the peculiar habitus 
 in form — presenting evident pathologic physiology. A marked factor in 
 pathologic physiology of splanchnoptosia is the changed defective circulation, 
 venous congestion. Generally, any subject with a "habitus" possesses an 
 unstable nervous system. The dyspepsia accompanying the habitus splanch- 
 nopticus is perhaps more due to the neuropathic disposition than to the 
 splanchnoptosia, hence the terms dyspepsia nervosa, or stigma dyspepticum. 
 The habitus neurasthenicus presents pathologic physiology of the tractus ner- 
 vosus — a condition of exhaustion or weakness of the nervous system, accom- 
 panied by physical and mental efficiency. Habitus neurasthenicus is a fatigue 
 disease of the nervous system. It is characterized by the presence of motor, 
 sensor}', psychic and visceral symptoms — all fatigued, tired, exhausted. This 
 habitus is especially characterized by weakness, or inefficiency and irritability 
 of the tractus nervosus. The physician can detect spots of hyperesthesia, 
 spinal irritation, fatigue of the special sense, auditory and retinal hyper- 
 esthesia — all pathologic physiology, no pathologic anatomy. However, if 
 pathologic anatomy exists in the body, it is liable to intensify the pathologic 
 physiology, the subject of habitus neurasthenicus, precipitating storms of 
 neurotic spells. The physician can detect the pathologic physiology, but not 
 pathologic anatomy. The subject is afflicted more or less throughout life 
 with pathologic physiology. When such subjects maintain additional strains, 
 as gestation and the care of growing children, pathologic physiology in the 
 tractus nervosus becomes pronounced and frequent, e. g., the habitus neuras- 
 thenicus may be in abeyance, quiescent, for a long period of time when 
 the entrance of a pelvic disease, a myometritis, salpingitis, pelvic peritenitis, 
 may initiate, aggravate, an intense neurotic state. It is not due merely to the 
 
PHYSIOLOGY OF TRACTUS NERVOSUS 497 
 
 so-called reflexes, but because the habitus neurasthenicus, the weak, irritable 
 nervous system, has been aggravated, traumatized, become unbalanced, 
 exhausted, fatigued. Its inherent vital power is deficient and readily passes 
 into a state of pathologic physiology. 
 
 A lesson right here may be pointed that surgeons should operate for sur- 
 gical indications only, not for function indications. First and foremost, the 
 gynecologist must learn to decide by an analytic exclusion diagnosis whether 
 the subject has a habitus neurasthenicus, a pelvic disease, or the two com- 
 bined. The test of a gynecologist is his ability to diagnose the disease — not to 
 do an operation. 
 
 The exquisitely, finely balanced nervous system of woman makes it liable 
 to imperfections of development — stigmata. Such a perfect organism as the 
 tractus nervosus is prone to disease. The intimate and profound relation of 
 the tractus nervosus to the tractus genitalis in woman demands that a gynecol- 
 ogist be a physician of comprehension, or knowledge, understanding the vast 
 fields of the tractus nervosus and tractus genitalis, as well as their profound 
 relation. 
 
 The indiscreet and general surgeon announces that gynecology is "pass- 
 ing," and has become a segment of general surgery. This assertion presents 
 limited comprehension. Is the oculist and aurist passing? Is the dermatol- 
 ogist, neurologist and laryngologist passing? Among the Germans, the most 
 profoundly learned in medicine, specialists are progressively increasing. The 
 fact is that legitimate gynecology, like all other specialities, is just beginning. 
 Gynecology to-day is practically as broad as the entire medical field of thirty 
 years ago. The gynecologist must comprehend not only the organs in his 
 own special field (tractus genitalis), but also the adjacent organs involved in 
 practice or stimulating gynecological disease, as the tractus intestinalis, trac- 
 tus nervosus, and tractus urinarius. In the interest of the patient, no special- 
 ist can be limited exactly to the organs of his own specialty, for he should 
 study the organs secondarily afflicted or dependent on the affections of the 
 viscera on which he practices. The specialist must understand the anatomic 
 and pathologic relations of specialized organs to adjacent territories, as vom- 
 iting (tractus intestinalis) to pregnancy (tractus genitalis), as albumin (tractus 
 urinarius) to pregnancy (tractus genitalis). 
 
 The more intimate changing relations of associated organs in structure 
 and function, the more valuable will be the study of the differential diagnosis 
 in disease. The gynecologist should execute all necessary technique which 
 will enable him to diagnose and treat diseases, dependent on or associated with 
 the tractus genitalis — as cystitis, ureteritis, splanchnoptosia, mammary dis- 
 ease, constipation, nephritis, proctitis, thyroid disease. The borders of a 
 specialty cannot be marked by the rim of a circle, but by the diseases de- 
 pendent on and resulting from the specialized system of viscera. Every 
 special science gradually unfolds its own dependent and associated relations. 
 
 Gynecology has been a typical example. It forced a divorce from general 
 surgery, to which it never will return, from sheer magnitude. One mind 
 cannot master more than one visceral tract with its relations. The unfolding 
 
 32 
 
498 THE ABDOMINAL AND PELVIC BRAIN 
 
 of gynecology has increased the interest and usefulness of its domain. It 
 has shown the delicate balance and relations of all abdominal viscera on the 
 abdominal sympathetic brain. Practically all progress, new ideas, must 
 come from specialists. The specialist is a permanent factor in medical pro- 
 gress, from whom will practically emanate discoveries and rational treatment. 
 However, the present and future specialist will not be limited to a single 
 visceral tractus for the diagnosis and therapy of his independent field, but 
 will study adjacent or remote visceral tracts which may lend aid in the dif- 
 ferential diagnosis and rational treatment. The gynecologist should diagnose 
 and treat all diseases primarily or secondarily, dependent on the life, function 
 and pathologic conditions of the tractus genitalis, as sacropubic hernia, 
 rectocele, vesicocele, splanchnoptosia; dependent on rapid and frequent gesta- 
 tions (nephroptosia, gastroptosia, coloptosia, hepaptosia — relaxed abdominal 
 walls). The rock and base of medical practice (special or general) is the 
 diagnosis which enables the physician to employ rational treatment, to act 
 for the best interest of the patient. Large numbers of women with marked 
 splanchnoptosia dependent on the work performed by the tractus genitalis, 
 as gestations, come to the gynecologist. The tractus genitalis, though prim- 
 arily the basic cause of splanchnoptosia, itself is no more ill than the tractus 
 urinarius, tractus intestinalis, or the relaxed abdominal walls. It is the duty 
 of the gynecologist to treat such cases. The general surgeon is no more an 
 expert in special departments than is the general practitioner. The reason 
 for the operation, i. e., the diagnosis, is a thousand fold more expert than the 
 mere technique of surgical procedure. Predisposing factors to pathologic 
 physiology in the tractus nervosus are defective nurtrition, variations of 
 metabolism, chlorosis, anemia, hemorrhages, deficient or excessive secretion, 
 premature senescence, strained physical and mental efforts. Heredity trans- 
 mits defects which are the foundation for aggravated pathologic physiology. 
 When the subject has an established habitus, as habitus splanchnopticus, 
 habitus neurasthenicus, habitus phthisicus, and predisposing factors become 
 imposed to, the subject is burdened with extreme pathologic physiology. An 
 excellent example of artificial habitus is the numerous stigmata arising from 
 the total removal of ovaries in young women, which condition might be 
 termed habitus ovaricae neurasthenicus. The young woman with castrated 
 ovaries experiences an intense, aggravated, premature climacterium — she is 
 suffering from pathologic physiology of the tractus nervosus. The patient 
 is afflicted with flushing (disturbed circulatory centre), flashes (disturbance of 
 caloric centre), perspiration (disturbance of the perspiratory centre). She has 
 depression, melancholia, excessive panniculus adiposus, growths of hair. In 
 some subjects the sensation of the tractus nervosus of the abdomen is awry. 
 Subjects complain of animals crawling within the abdomen. This matter 
 may be explained by supersensitiveness or hyperesthesia of the mucosa of 
 the tractus intestinalis from gas or contents. More than one operation has 
 been performed for such condition. It may be incidentally remarked that 
 it requires much study and discreet judgment to decide neurosis of the tractus 
 nervosus abdominalis and the nervous disturbances produced by the dominat- 
 
PHYSIOLOGY OF TRACTUS NERVOSUS 
 
 4S9 
 
 ing nerve-supplied genital tract — both conditions induce, aggravate, patho- 
 logic physiology in the abdominal nerves, e. g., one of the most characteristic 
 lesions accompanying the habitus neurasthenicus — producing pathologic 
 physiology — is defective development of the tractus genitalis. I think among 
 the scores of women I have examined with defective development of the gen- 
 itals that at least 95 per cent were neurotics manifesting pathologic physiol- 
 ogy of the tractus nervosus. Does the neurosis precede (congenital), accom- 
 pany the defective development of the genitals or is it accidental to it? The 
 most probable view is that it is congenital, and marks an ill development of 
 
 Fig. 138. Nerves of the internal genitals. 
 
 the organism. The habitus neurasthenicus or habitus hystericus are not dis- 
 eases of the genitals but of the nervous system with an hereditary burden and 
 perhaps an acquired burden. These conditions required vast study to differ- 
 entiate in gynecologic practice. The habitus chlorosis is another example of 
 a disease closely associated with the tractus genitalis. It is doubtless hered- 
 ity ; occurs in girls from fourteen to twenty-four years of age, i. e., at puberty 
 or the developmental stage; is accompanied by increased panniculus adiposus 
 
500 THE ABDOMINAL AND PELVIC BRAIN 
 
 and neurotic symptoms. Chlorosis is associated with defective development 
 of the genitals in 75 per cent of subjects. Genital functions are defective. 
 The nerves governing secretion (ovarian) are perhaps defective. In diagnos- 
 ing pathologic physiology of the abdominal nervous system it is well to 
 determine the etiology, as acquired factors enhance conditions, e. g., the 
 tractus nervosus of a pregnant woman is more irritable, more liable to patho- 
 logic physiology, than the non-pregnant. The nursing woman is frequently 
 in a state of pathologic physiology. 
 
 TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS NERVOSUS. 
 
 The treatment of subjects with disturbances — pathologic physiology — in 
 the abdominal nerves is difficult in ordinary practice because the acquired 
 factors are inseparably associated with continuous environments, with hab- 
 itat. The etiology and consequent habitus or stigma must be diagnosed by 
 careful examination in individual subjects. The reason the sanatorium is so 
 successful in the treatment of the nervous patients is the patient is removed 
 from the environments, from the habitat, in which the disease developed. 
 The provocative or aggravating factors must be generally eliminated. It 
 may be constipation, deficient drinking of fluids, the ingesting of improper con- 
 centrated foods, which leave insufficient indigestible residue to provoke intes- 
 tinal peristalsis. It may be sedentary habits, insufficient exercise or deficient 
 fresh air. It may be excessive work and worry, insomnia. In the subject 
 with the habitus neurasthenicus I am in general opposed to the so-called 
 Mitchell rest cure. The neurasthenic may possess fatigued nerves but not 
 fatigued muscles. I attempt to treat the neurasthenic by maintaining her in 
 the fresh air and muscular activity all day. In the subjects I administer 
 active visceral drainage and coarse foods which leave a large undigestible 
 residue. She is improved by the bicycle, by games requiring muscular 
 activity, rides which massage the viscera, fresh air, appropriate diet, and 
 ample fluid at regular intervals. Some neurasthenics are practically unman- 
 ageable. I am now treating a woman twenty-seven years of age who has lain 
 in bed for three years. She says her nerves could not stand walking in the 
 sunshine. Physically I can detect no pathologic anatomy — simply pathologic 
 physiology. By forced feeding she retains ample flesh. During the last six 
 months, by all kinds of persuasion, we succeeded in inducing her to walk one 
 block daily. Maximum visceral drainage and appropriate dietetics maintains 
 apparently a healthy physique. We agree with Dr. John G. Clark that 
 several kinds of neurasthenics exist. The gynecologist meets with three kinds 
 of neurasthenics, viz., (a) a neurasthenic of congenital origin — habitus neuras- 
 thenicus congenita — who practice almost continually genital introspection 
 where the physicians can not detect genital pathologic anatomy. She is 
 constantly occupied by views regarding genital and sexual life. The treat- 
 ment of such neuropathic subjects is lifelong, firm discipline, hygiene, 
 dietetic, fresh air for twenty-four hours a day, ample fluids, physical exercise, 
 (b) A neurasthenic with coincident visceral lesion but each entirely independ- 
 ent of the other, as may occur in the tractus genitalis, tractus intestinalis, 
 
PHYSIOLOGY OF TRACTUS NERFOSUS 501 
 
 tractus urinarius. In the second condition the additional treatment is to 
 remove the lesions of the sole visceral tract; (c) a third kind of neurasthenic 
 is where the neurasthenia is dependent on an organic, visceral lesion. The 
 tractus nervosus of the originally predisposed, neuropathic subject was pro- 
 voked, aggravated, into a state of pathologic physiology by the organic lesion. 
 The treatment of this third class is repair of the organic lesion and systematic 
 visceral drainage by means of fluids and foods. 
 
 1. Dietetic. The diet of neurotic patients should be regulated under 
 strict discipline. It should consist of cereals, vegetables, albuminates (egg, 
 milk), and limited meals — mixed diet. The high spices, cakes, puddings, 
 pies, stimulants should be eliminated. 
 
 2. Fluids. Ample at regular intervals — 8 ounces every two hours for 
 at least six times daily. This forty-eight ounces of fluids daily may be 
 nourishing fluid — as, milk, buttermilk, eggnog, cereal gruels. 
 
 3. Salt rubs, which the patient administers to herself once or twice 
 daily, at stated times for stated duration. 
 
 4. Massage, which should be administered as much as possible by the 
 patient herself. The patient can be taught massage of the abdominal mus- 
 cles, which especially benefits the abdominal visceral tracts. 
 
 5. Exercise is absolutely necessary for health. The neurotic patient 
 continually complains of tiredness and fatigue. The fatigue belongs to the 
 nerves. It is not muscle fatigue, hence the muscular activity should be vig- 
 orously maintained in walking, riding, games — all distracting the patient's 
 attention from herself. Muscular exercise influences circulation and hence 
 nourishment. 
 
 6. Fresh air should be continuous day and night. The sleeping-window 
 should be open all night. The window of the day-room should be continu- 
 ously open. Cold, fresh air is an invaluable therapeutic agent in neurasthenic 
 disturbances and tuberculoses. 
 
 In order to assist the foods and fluids to secure maximum visceral drain- 
 age I place on the tongue every two hours a tablet containing 3 grains of 
 sodium chloride (NaCl) and a part or multiple of an alkaline tablet [composed 
 of aloes (\ gr.), cascara sagrada (jj gr.), NaHC0 3 (1 gr.), KHC0 3 (\ gr.), 
 and MgS0 4 (2 gr.),] followed by 8 ounces of fluid. This visceral drainage 
 method I followed systematically for weeks and months, resulting in success- 
 ful maximum visceral drainage, with increased nourishment, improved sleep. 
 The elimination of waste-laden products benefits the nervous system — the 
 pathologic physiology is reduced to a minimum and the patient recovers. 
 
CHAPTER XXXVII. 
 
 PATHOLOGIC PHYSIOLOGY OF THE TRACTUS VASCULARIS. 
 
 New ideas are first resented, second tolerated and finally adopted. 
 Men may come and men may go, but I go on forever. — Tennyson's Brook. 
 
 The functions of the tractus vascularis are peristalsis (rhythm), secretion, 
 absorption, sensation. Its object is to transport universal nourishing fluid, 
 the blood, to the general body. In pathologic physiology of the tractus vas- 
 cularis there are two concomitant factors with which to deal, viz., (A) the 
 vascular tract, (B) its contents. The pathologic physiology of the tractus 
 vascularis and its contents each possess a wide range. 
 
 (A) THE VASCULAR TRACT. 
 
 The tractus vascularis is a cylindrical tube possessing the form of a 
 complete circle, with localized constrictions (capillaries) and dilatations 
 (heart-arteries, and veins). This vascular canal circulates universal fluid tissue 
 through the body. It has a dual object for tissue, viz., that of import and 
 export service. The tractus vascularis will become of vast therapeutic utility. 
 Dr. Bier, a man of forty-five years of age, Professor of Surgery in Bonn, 
 Germany, has preached for years the value of artificial congestion in the 
 cure of disease. Bier's introduction of artificial congestion is one of the great- 
 est contributions to medicine of the present century. Lister's contribution was 
 but a temporary matter, for now we do not need it, as we have learned asep- 
 sis. Bier's method will always be useful while the tractus vascularis remains. 
 Men may come and men may go, but the tractus vascularis goes on forever. 
 Bier suggests to the profession to control the segments of the tractus vascu- 
 laris and its contents for therapeutic purposes. 
 
 In the study of the pathologic physiology of the hemogenous tract the 
 exact functions must be held in view, viz., peristalsis, secretion, absorption 
 and sensation. The condition of the arterial wall and the diameter of the 
 lumen influence the flow of blood. The lumen of the artery is controlled 
 by a plexiform, nodular, fenestrated network of nerves and ganglia which 
 ensheaths the artery. The lumen of the artery is regulated chiefly by reflexes 
 that arise in different regions of the body. Stimulation of peripheral nerve 
 will induce generally reflex arterial constriction and this elevates blood pres- 
 sure. All nervous impulses from the heart are capable of governing the cali- 
 bre of arteries; therefore, the degree of arterial contraction depends chiefly 
 on the nervous impulses which they receive. For the theme of our subject — 
 the abdominal vessels — the condition of the numerous abdominal arteries 
 innervated by the splanchnic nerves is of significant importance in regard to 
 maintaining peripheral resistance, as opposed to the splanchnic innervation. 
 
 502 
 
PHYSIOLOGY OF TRACTUS VASCULARIS 503 
 
 A brief discussion of the four physiologic functions of the tractus vascularis 
 in a condition of pathologic physiology will suffice to present our views. 
 
 (1) PERISTALSIS (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (a) Excessive peristalsis of the vascular tract is a common occurrence in 
 life. The marble paleness of fright and fear present excessive contraction 
 of vessels. The cold hands and feet of certain persons show spasm of vessels. 
 Excessive cardiac activity is frequently noted. The cardiac hypertrophies 
 remain long in the stage of pathologic physiology as compensatory hypertro- 
 phies. In certain renal diseases the arterial pressure (arterial peristalsis) 
 increases gradually until the myocardium has attained maximum dimensions 
 for the coronary arteries to nourish. Excessive arterial peristalsis may be 
 an indefinite time in the stage of pathologic physiology, as cardiac hypertro- 
 phy, arterial sclerosis, nephritis. It is during the stage of pathologic physi- 
 ology of the previous immediately noted disease that medical treatment is of 
 practical value by the therapeutic application of appropriate dietetics, fluids 
 and methods of living. Vigorous exercise will produce excessive peristalsis 
 of the tractus vascularis. Not infrequently we observe the abdominal aorta 
 maintaining an extraordinarily vigorous peristalsis for hours — in fact, it 
 performs with such vigor that the inexperienced may diagnose abdominal 
 aneurism. It is the detection of excessive vascular peristalsis (pathologic 
 physiology) in its incipient stage that allows ample time to remove the causes 
 of disease before the destructive pathologic anatomy has appeared in the line 
 that renders utility to medical skill. 
 
 Excessive peristalsis does not always result in forcing excessive blood to 
 tissue, because the arterial pulse caused mainly by the variation of pressure 
 within the artery and the results of intermittent expulsion of blood jets from 
 the heart may become so deranged and disordered that blood pressure is low. 
 Arterial blood pressure depends on the amount of blood forced into the 
 arteries by the heart and the peripheral arterial resistance. In other words, 
 blood pressure depends on the blood volume, rigidity of arterial walls and 
 opportunity of escape. Age influences blood pressure. We note pathologic 
 physiology of the tractus vascularis in asphyxia. Lead colic is usually associ- 
 ated with high arterial pressure as well as the early stages of peritonitis. 
 Renal disease may induce high arterial pressure, i. e., an excessive vascular 
 peristalsis. 
 
 (b) Deficient peristalsis of the vascular system is frequently encountered. 
 The myocardium and arterial muscularis may be diminutive. The vascular 
 lumen may be limited. The nervus vasomotorius may be inactive, sluggish, 
 of minimum power. We frequently meet the small, weak cardiac and pulse 
 action. Deficient arterial peristalsis results in deficient tissue nourishment 
 and cerebral action. We frequently meet persons with deficient vascular 
 peristalsis from dietetic and habitat errors. The subjects consume concen- 
 trated foods and insufficient fluids, with a resulting pulse of limited volume 
 and power. This deficient arterial peristalsis and power is pathologic. Physi- 
 ology, however, sooner or later passes from the incipient stage to that of 
 
504 THE ABDOMINAL AND PELVIC BRAIN 
 
 established pathologic anatomy by continued repetition. The employment of 
 ingesta, which leaves a large indigestible residue, and ample fluids at regular 
 intervals, quickly restores a pulse of full volume, i. e., vigorous arterial peri- 
 stalsis presenting volume and power. Errors of habitat, inactivity, sedentary, 
 may be accompanied by deficient arterial peristalsis, which are promptly 
 improved by appropriate exercise. Deficient peristalsis of the heart or 
 inability to drive the congested blood through the lungs will, however, act as 
 a prophylaxis against pulmonary tuberculosis (it is a cure by congestion). 
 
 Extensive areas of blood vessel dilatation may initiate a marked fall in 
 arterial pressure and slowing of circulation, for the quantity of blood is 
 insufficient to occupy the entire vascular calibre if dilated. General vascular 
 dilatation may result from general loss of vascular elasticity and consequent 
 expansion of the vessel lumen. A general loss of vascular tonus may occur. 
 If the splanchnic vessels lose their tonus they become distended with blood, 
 while the arteries, especially to the periphery, skin, become but partially 
 depleted. In certain autopsies the splanchnic vessels appear so extensively 
 distended with blood that the subject seemed as if he had bled to death in his 
 own abdominal vessel. Deficient peristalsis may be due to paresis of the 
 vaso-motor centre. 
 
 (c) Disproportionate peristalsis of the tractus vascularis consists in irreg- 
 ularity of action in different segments of the vascular tract, e. g., the blushing 
 of embarrassment, the flushing of the climacterium, is local dilatation of the 
 vascular tracts. The clubbed fingers of the subject with patent foramen ovale 
 is pathologic physiology of the blood channel. The most patent example of 
 disproportionate peristalsis of the vascular tract is the defective cardiac valves 
 — the cardiac insufficiency. The disproportionate arterial peristalsis is due 
 to abnormal volumes of blood in local segments of the tractus vascularis, e. g., 
 in insufficiency of the aortic valves the coronary arteries receive excessive 
 blood and produce cardiac hypertrophy. The volume of blood remains excess- 
 ive in the heart and dependent portions of the body, while in portions of the 
 body where force is required to propel the blood, it is deficient. 
 
 Disproportionate arterial peristalsis may be observed during gestation 
 when the arteria uterina ovarica sports an excessive volume of blood. During 
 constipation the arteria mesenterica inferior is transporting insufficient blood, 
 and hence inducing insufficient colonic peristalsis for regular fecal evacuations. 
 The giant hypertrophic member of the body presents an excellent example 
 of disproportionate vascular peristalsis. The mottled surface is dispropor- 
 tionate circulation. Disproportionate arterial peristalsis may be observed 
 in the maximum functions of the several visceral organs, e. g., food in the 
 gastrium or enteron entices extra blood. Extra fluids increase especially the 
 activity of the arteria renalis. Excessive, deficient, disproportionate vascu- 
 lar peristalsis may long remain in the field of pathologic physiology^-func- 
 tional disease — allowing ample time for diagnosis and therapeutic correction 
 before the field of pathologic anatomy — compromised structure — is reached. 
 
506 THE ABDOMINAL AND PELVIC BRAIN 
 
 (2) SECRETION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (d) Excessive secretion of the vascular tract may be observed in edema, 
 ascites. 
 
 (e) Deficient secretion presents few practical examples. 
 
 (f) Disproportionate secretion is irregular secretion in different segments 
 of the vascular tract. 
 
 (3) ABSORPTION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 (4) SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 (g) Excessive sensation in the tractus vascularis indicates an irritable 
 weakness in the nervus vasomotorius (sympathetic), which rules the visceral 
 tract. It appears that it is the blood in the vascular lumen which incites 
 peristalsis, as may be demonstrated in the urine and the ureter. 
 
 The excessive sensation in the vascular tract is synonymous with the state 
 of the nervus vasomotorius. Some vascular tracts with inferior anatomy and 
 physiology execute peristalsis in a wild, irregular, violent, disordered manner 
 on slight provocation ; they possess excessive sensation, pathologic physiol- 
 ogy, or are afflicted with a habitus nervosus, stigma nervosus. I have 
 observed the heart executing its action irregularly and 120 per minute for 
 weeks with no demonstrable pathologic anatomy. Such a person possesses 
 an excessive sensation in the tractus vascularis. It is an abnormal function. 
 The excessive beating of the abdominal aorta, and beating in various parts of 
 the body, refers to excessive sensation — hyperesthesia — in the tractus vascu- 
 laris. Blood contents in the tractus vascularis may be waste laden, irritat- 
 ing, and should be sewered by fluids. 
 
 (h) Deficient sensation in the vascular tract may be observed in the slow, 
 sluggish pulse. In icterus the pulse may be 50; sensation isobtunded, dulled, 
 by morbific elements bathing the innumerable sympathetic ganglia, checking 
 their excitability. 
 
 (i) Disproportionate sensation is irregular sensation in different segments 
 of the tractus vascularis. Also one may observe in certain persons local con- 
 gestions or anemia. Cold feet or hands produce disproportionate circulation 
 in the body. 
 
 TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS VASCULARIS. 
 
 The treatment of pathologic physiology of the tractus vascularis consists 
 in correcting the deviation of its functions (which are peristalsis, absorption, 
 secretion and sensation). 
 
 Since pathologic physiology of the tractus vascularis lies between physi- 
 ology and pathologic anatomy, it should be amenable to treatment. First 
 and foremost, a diagnosis should be made and cause removed. The treatment 
 is accomplished through: (a) Ample fluids administered at regular intervals; 
 (b) appropriate diet; (c) rational habitat; (d) suitable avocation. Maximum 
 elimination or visceral drainage is the rational treatment. 
 
PHYSIOLOGY OF TRACTUS VASCULARIS 507 
 
 (a) Visceral Drainage by Fluids. — The most general feature of a patient 
 suffering from pathologic physiology of the tractus vascularis is deficient vis- 
 ceral drainage. The sovereign remedy is water. One of the best laxatives 
 is water. The most rational stimulant to the renal (and intestinal) epithe- 
 ilium is sodium chloride — common salt (one-fourth to one-half normal physi- 
 ologic salt solution). I administer eight ounces of one-fourth to one-half 
 normal salt solution every two hours for six times daily, i. e., three pints 
 daily. (Note. — NaCl is contraindicated in parenchymatous nephritis.) The 
 three pints of normal salt solution fill the lumen of the artery and induce 
 normal reflexes. The pulse becomes a full volume. The powerful arterial 
 stream sewers the body of waste laden blood and irritating material. The 
 arteries functionate best with a maximum volume of blood. Also the fluids 
 induce maximum functions of adjacent visceral tracts — urinary, intestinal, 
 perspiratory. Perfect elimination — maximum visceral drainage — may pre- 
 vent arterial sclerosis. Maximum visceral drainage maintains in mechanical 
 suspension the insoluble uric acid (preventing the formation of ureteral cal- 
 culus) and the cholesterine (preventing the formation of hepatic calculus). 
 
 It aids the sodium, potassium and ammonium salts to form combinations 
 with uric acid, producing soluble urates. The eight ounces of one-half or 
 one-quarter normal salt solution six times daily stimulates the epithelium of 
 the tractus perspiratorius (inducing sweating) and the epithelium of the trac- 
 tus intestinalis, inducing secretions which liquefy feces, preventing constipa- 
 tion. It also stimulates the epithelium of the tractus urinarius, inducing 
 increased quantities of urine. The druggist manufactures for me sodium 
 chloride, tablets of twelve grains each, from which I can employ fragments 
 or multiples in the treatment.* 
 
 (b) Visceral Drainage by Foods. — The great functions of the tractus 
 vascularis — peristalsis, absorption, secretion, sensation — are produced and 
 maintained by fluids and foods. To drain the tractus vascularis, the adjacent 
 visceral tracts (intestinal, urinary, perspiratory) should be excited to peri- 
 stalsis. Hence, for the intestinal tract foods which leave an indigestible 
 residue only are appropriate; all adjacent visceral tracts must be stimulated 
 to maximum peristalsis, secretion, absorption, in order to aid that of the 
 tractus vascularis. Rational foods must contain appropriate salts whose 
 bases may form combinations which are soluble, as sodium, potassium and 
 ammonium combined with uric acid and urates. The proper foods are 
 cereals, vegetables, albuminates (milk, eggs), mixed foods. Meats should be 
 limited, as they enhance uric acid formation and waste-laden blood. 
 
 In order to stimulate the epithelium (sensation) of the digestive, urinary 
 and perspiratory tracts, with consequent increase of peristalsis, absorption 
 and secretion, I use a part or'a multiple of an alkaline tablet of the following 
 composition: Cascara sagrada, one-fortieth of a grain; aloes, one-third of a 
 grain; NaHC0 3 , one grain; KHCO3, one-half grain; MgS0 4 two grains. 
 The tablet* is used as follows: 
 
 *The sodium chloride and alkaline tablets are manufactured by Searle & Hereth Co., 
 Chicago. 
 
508 THE ABDOMINAL AND PELVIC BRAIN 
 
 One-sixth to one tablet (or more as required to move the bowels freely 
 once daily) is placed on the tongue before meals and followed by eight 
 ounces of water (better hot). Also at 10 a. m., 3 p. m. and at bedtime one- 
 sixth to one tablet is placed on the tongue and followed by a glassful of any 
 fluid (buttermilk is excellent). 
 
 The Combined Treatment {Sodium Chloride mid Alkaline Tablets). — In 
 the combined treatment one-third of the NaCl, the sodium chloride tablet 
 (containing twelve grains), and one-sixth to two alkaline tablets are placed 
 on the tongue together before each meal, followed by eight ounces of fluid 
 (better hot), and also at 10 a. m. , 3 p. m. and at bedtime, followed by eight 
 ounces of fluid (buttermilk is excellent), i. e. , every two hours, and followed 
 by a glass of fluid. The six eight-ounce glasses may be fluid food — as milk, 
 buttermilk, cream, beef tea, egg-nog — fluid nourishment. This visceral 
 drainage treatment furnishes alkaline bases (sodium, potassium and ammon- 
 ium) to combine with the free uric acid in the urine, producing soluble urates. 
 Besides, the alkaline laxative tablet increases the peristalsis, sensation, 
 absorption and secretion of the intestinal tract, stimulating the sensation of 
 the mucosa, aiding evacuation. It ends in correcting the pathologic physiol- 
 ogy of the tractus vascularis. The object of the visceral drainage treatment 
 is to improve elimination and digestion. 
 
 I have termed the sodium chloride and alkaline laxative method the 
 visceral drainage treatment. The alkaline and sodium tablets take the place of 
 the so-called mineral waters. I continue this dietetic treatment of fluids and 
 food for weeks, months, and the results are remarkably successful, especially in 
 pathologic physiology of the tractus vascularis and adjacent visceral tracts. 
 The pulse volume becomes full. The urine becomes clarified like spring- 
 water and increased in quantity. The tractus intestinalis becomes freely 
 evacuated regularly daily. The blood is relieved of waste laden and irritat- 
 ing material. The tractus cutis eliminates freely, and the skin becomes normal. 
 The appetite increases. The sleep improves. The patient becomes hope- 
 ful, natural energy returns. The sewers of the body are drained and flushed 
 to a maximum. 
 
 The maximum function of viscera by means of fluid diet, activity, induces 
 maximum drainage of viscera, eliminating irritating matters from the body 
 and insures normal peristalsis and normal reflexes for the vascular tract. 
 
 (c) The habitat should be suitable. It should allow fresh air day and 
 night. Environments constitute much of the essence of living. 
 
 (d) The avocation should suit the physique. In maximum elimination — 
 complete visceral drainage — every visceral tract (urinary, intestinal, perspira- 
 tory) must normally functionate. Hence all rational therapeutics (fluid, diet, 
 habitat, avocation) must be applied to secure maximum, universal visceral 
 drainage. No single visceral tract can functionate defectively without damage 
 to adjacent tracts. 
 
PHYSIOLOGY OF TRACTUS VASCULARIS 50«J 
 
 ( A) PATHOLOGIC PHYSIOLOGY OF THE CONTENTS OF THE TRACTUS VASCULARIS. — 
 
 THE BLOOD. 
 
 The pathologic physiology of the blood cannot be separated from the 
 pathologic physiology of the several visceral organs. The blood represents 
 universal fluid tissue and every organ receives and emits material to it. The 
 blood has an import and export service (transporting oxygen to tissue and 
 carbonic acid gas and waste products from tissue). The significant blood — a 
 medium of exchange between the external world and the tissues— enters every 
 organ through the tractus vascularis, distributing nutritive material to every 
 tissue. It is the source of all secretion. When one concludes the enormous 
 amount of interchange (assimilation and waste) between the blood and tissue, 
 it becomes evident that the pathologic physiology of the blood is a wide zone. 
 It also becomes evident that the zone of pathologic physiology is an incipient 
 zone to that of pathologic anatomy. First, in the foreground of pathologic 
 physiology of the contents of the tractus vascularis should be included those 
 diseases which indicate dominant, recognized changes in the blood, as anemia, 
 chlorosis. Second, single symptoms may represent the changes of an 
 unknown disease, as cachexia ub carcinoma, diseases of the adrenals. 
 
 Here projects in the foreground (primary) hemogenous disease or (secon- 
 dary) visceral disease. The composition of the blood — plasma, red and white 
 corpuscles — depends to a certain extent on the condition of the tissue in the 
 different districts of the body. Though the blood contains an extensive 
 variety of substances, its composition is relatively constant on account of the 
 rapid flow of its current, and the rapid secretion of substances occurring in it 
 in excess. The composition of the blood will change when pathologic physi- 
 ology arises in any organ. The essential constituents of the blood with which 
 the physician deals are: (a) red corpuscles (130, to 1000 parts); (b) white 
 corpuscles (253, to 1000 reds) ; (c) plasma (800, to 1000 parts of blood). The 
 great typical fields of pathologic physiology of the contents of the tractus 
 vascularis are 1, anemia— e. g., chlorosis; 2, leukemia— e. g., splenic and 
 glandular diseases; 3, cachexia — e. g., carcinoma and adrenal diseases. 
 
 Changes in the blood cells and hemaglobin are recognized with relative 
 facility and hence they are more certainly known than the changes in the 
 plasma. The contents of the tractus vascularis — the blood — presents a rich 
 field for study in pathologic physiology and fortunately for prophylaxis. The 
 blood has an extensive range of pathologic physiology through the variation 
 of hemaglobin, through change in number of white and red corpuscles, through, 
 changing composition of plasma. The study of the varying stages of anemia 
 (e.- g., chlorosis) and hyperemia (congestion) present far-reaching possibilities 
 in therapeutics. We will first consider the red corpuscles. 
 
 /. Red Blood Corpuscles and Hemaglobin (1000 Reds to 3 Whites). 
 
 The red blood corpuscles constitute about \ of the blood (130, to 1000 
 parts of blood). The most striking feature of pathologic physiology of the 
 blood is anemia. In anemia the marked phenomenon is a reduction of the 
 hemaglobin or the red corpuscles or both. Other related changes doubtless 
 
510 THE ABDOMINAL AND PELVIC BRAIN 
 
 occur in the white corpuscles and plasma. Anemia presents many forms, 
 acute and chronic, and grades (from delicate paleness to pernicious anemia) 
 as well as numerous conditions of etiology (acute, or chronic loss of blood). 
 The simplest form of acute anemia results from sudden loss of blood, through 
 vascular wounds, hemorrhages, e. g., during parturition excessive quantities 
 of blood may be lost simply producing anemia. The grades of anemia 
 depend on the relative quantity of blood loss. Should the hemorrhage 
 exceed a certain bound the patient dies from suffocation; there are insuffi- 
 cient red corpuscles to transport oxygen to the tissue for internal respiration. 
 Should the patient lose suddenly 15 per cent to 30 per cent of corporeal 
 blood, it may require weeks and months to recuperate, during which time 
 certain phases of pathologic physiology of the tractus vascularis may be 
 observed. The patient presents a pale appearance. 
 
 The simplest form of chronic anemia results from periodic, repeated or 
 continuous loss of blood, as menorrhagia from uterine myoma, repeated loss 
 of blood from hemorrhoids, from renal papillae. The blood shows a dimin- 
 ishing quantity of hemaglobin. Chronic and acute anemia are not independ- 
 ent diseases, they are clinical symptoms of pathologic physiology. In 
 anemia there is to consider: 1, the quantity of oxygen in the lung; 2, the 
 quantity of hemaglobin in the blood ; 3, the rate of transportation by the 
 blood current; 4, the degree of interchange of the oxygen and carbonic acid 
 gas with the tissue. Anemia may arise not only from hemorrhage but from 
 insufficient formation of red blood corpuscles. The red blood corpuscles 
 forming organs are acting abnormally. Starvation as a rule does not cause 
 anemia. If the hemaglobin escape from the red blood corpuscles into the 
 plasma the condition is called hemaglobinemia. The liver forms its bile pig- 
 ments from hemaglobin, hence in hemaglobinemia the bile, urine and feces 
 will become richer in coloring matter. The pathologic physiology of hema- 
 globin (albuminous coloring matter of blood) includes a wide zone. It is 
 impossible to assert the minimum quantity of hemaglobin compatible with 
 life. Anemia may progress to the stage of air hunger. I have observed several 
 patients recover with less than 12 per cent of hemaglobin. Operations are 
 dangerous with hemaglobin less than 30 per cent. The above data demon- 
 strate that the normal blood stream transports more oxygen than is absolutely 
 required for tissue repair and waste. Nature employs excessive, abundant, 
 supplies. 
 
 The blood relates itself differently in the various form of chronic and 
 acute anemia. In the field of chronic anemia, chlorosis is, clinically, a 
 typically well-characterized anemic disease which prevails almost exclusively 
 in females between the ages of 11 and 25 years — the developmental 
 period. The etiology of chlorosis is incompletely known ; it is a kind of adoles- 
 cent pathologic physiology of the blood — perhaps a sexual phase, like a vari- 
 cocele, as it practically recovers spontaneously. The patient presents various 
 transition grades of color from normal rosy red to pale green. The patient 
 presents a plump paniculus adiposus — chlorosis is the anemia of good looking 
 girls. The formation of the blood volume may be normal, the plasma, white 
 
PHYSIOLOGY OF TRACTUS VASCULARIS 511 
 
 and red corpuscles, however, altered in relations. The composition of the 
 blood may be changed. There may be diminished red corpuscles and 
 hemaglobin. Acute and chronic anemia occupy extensive zone of pathologic 
 physiology allowing time for prophylaxis. 
 
 A third class of anemia may be designated pernicious anemia, a disease 
 in which the red blood discs may finally assume the highest grade of changes 
 in dimension, form and composition — ultimately evident pathologic anatomy. 
 However, pernicious anemia has a considerable range of pathologic physiol- 
 ogy. Anemia renders in general to the diminution of the red blood disc and 
 hemaglobin — with less reference to the white blood corpuscles of plasma. 
 
 II. White Blood Corpuscles {Leucocytes). 
 
 The normal relation of white to red is 3 in 1000. The pathologic anatomy 
 relation is 50 to 1000. The zone of pathologic physiology of the blood 
 extends through a range of 4 to 40 whites to 1000 reds. In other words, leu- 
 cocytosis is 1000 reds to 4 whites. From these data the leucocytes of the 
 blood are labile elements markedly influenced by conditions. Leucocytosis 
 is pathologic anatomy where there are 50 whites per 1000 reds. In leucocy- 
 tosis there exists an abnormal number of white blood corpuscles. There are 
 mononuclear and polynuclear white corpuscles. The origin of the white 
 corpuscle is not definitely settled (spleen, bone marrow, lymphoid tissue). 
 Leucocytes is supposed by some to be the rupture of hypoplastic gland tissue 
 into the circulation. This accounts for the various kinds of cells found in the 
 blood. On account of the variation of the number of leucocytes from diff- 
 erent normal conditions of life — digestion, gestation, age, sex — there will be 
 physiologic leucocytosis. The leucocytosis of pathologic physiology is 
 of special interest to us, though its signification is not always understood. 
 For example, is the leucocytosis of infectious disease of utility to the patient? 
 The leucocytes may rise to 30 whites to 1000 reds. Does it furnish a clue for 
 diagnostic and therapeutic purposes? Pathologic physiology as regards leu- 
 cocytosis is prevalent in middle life. Unfortunately the pathologic physiol- 
 ogy of leucocytosis frequently merges into pathologic anatomy before 
 diagnosis has been established and when treatment becomes of little avail in 
 an advanced terminal disease. With established pathologic anatomy in leu- 
 cocytosis (especially and splenic hypertrophy) the termination of the disease 
 is generally fatal in a couple of years. The hope of treatment benefiting a 
 leucocytotic is while the disease is in the plane of pathologic physiology. 
 
 Leucocytosis was first observed by Xavier Bichat (1771-1802) in 1800. 
 Velpeau observed the hypertrophy of the spleen in relation to leucocytosis. 
 Donne ( ) in 1844 thought that leucocytosis was due to imperfect transfor- 
 mation of white into red corpuscles. In 1845 Dr. Hughes Bennett and Dr. 
 Craigie each published a case. To Dr. Hughes Bennett is due the credit of 
 recognizing the salient features of leucocytosis and he proposed the term leu- 
 cocythemia. In 1845 Rudolph Virchow published, originally and independ- 
 ently, excellent details and comprehensive views of a case. To this date the 
 changes in the blood had been recognized only after death. The changes of 
 
512 THE ABDOMINAL AND PELVIC BRAIN 
 
 the blood during life in leucocytosis was first observed by Dr. H.W. Fuller. 
 The first case of leucocytosis diagnosed during life in Germany was by Dr. 
 Vogel in 1848. At present writing no known remedy is capable of checking 
 the fatal course of leucocytosis. 
 
 Cachexia presenting a peculiar white, waxy color of the skin, depends 
 on the deteriorating effect of the disease on individual organs as from malig- 
 nancy, tuberculosis, arsenic, malaria, alcohol, goiter, etc. Cachexia is associ- 
 ated with a condition of chronic ill health depending on depraved state of 
 blood, from loss of blood elements, malnutrition or the presence of morbific 
 elements (uremia, defective elimination). Pathologic physiology plays a 
 considerable role in the pre-cachectic stage, previous to the establishment of 
 recognizable pathologic anatomy. The term cachexia and constitutional dis- 
 ease are with some synonymous. 
 
 III. Plasma {Liquor Sanguinis). 
 
 Blood plasma is composed of blood serum and fibrin. Fibrin constitutes 
 about | of 1 per cent of blood. If blood contains 1 per cent of fibrin it has 
 merged into pathologic anatomy, which is especially observed in inflammatory 
 states. The range of pathologic physiology as regards fibrin is from \ of 1 
 per cent to | of 1 per cent in the ascending scale. In the descending scale 
 it may be less than tV of 1 per cent, as in the anemias and septicaemias. 
 The knowledge of pathologic physiology of blood coagulation is defective, 
 hence our knowledge of the pathologic physiology of blood coagulation is 
 likewise defective. The plasma of the blood is of significance on account of 
 the contained fibrin which is the base of thrombosis and ultimate embolism. 
 The blood serum is able to destroy varieties of foreign cells and bacteria. 
 The blood plasma contains numerous ferments, which act as an enzyme, 
 alexin or complement. Some suppose that the leucocytes produce the 
 alexins. The signification of the blood plasma may be noted in the ideal 
 administration of certain so-called anti-toxins to cure disease, as, diphtheria, 
 tetanus. If foreign cells, as bacteria, be injected into an animal the blood 
 serum of the animal acquires the property of causing the cells to agglutinate. 
 The blood serum contains a variety of substances with a variety of function. 
 It is well for the practitioner to remember for practical purposes, that the 
 chief salts of the serum are sodium chloride (NaCl), sodium carbonate 
 (NaHC0 3 ) with phosphates and alkalies. If the blood plasma becomes 
 diluted, attenuated, it is said to be in a state of hydraemia, as in kidney and 
 heart disease. The blood may become thick, excessively condensed, as in 
 Asiatic Cholera or in extensive watery diarrhea. 
 
 Treatment of Pathologic Physiology of the Blood. 
 
 The treatment of pathologic physiology of the blood demands a knowl- 
 edge of etiology. When the red corpuscle, white corpuscle or plasma 
 manifests abnormal function (pathologic physiology), first and foremost must 
 we begin the search for the diagnosis with vigor, as the diagnostic data are 
 still few and somewhat uncertain. If it be anemia from loss of blood (uterine 
 
PHYSIOLOGY OF TRACTUS VASCULARIS 513 
 
 sarcoma, myoma, hemorrhoids, the condition may be palliated or cured. If 
 it be anemia from chlorosis, a sexual phase, the health can be improved by 
 treatment, and also it is a self limited disease (15 to 24 years). The associated 
 conditions of glandular hypertrophy may aid as a general hyperplasia, splenic 
 or hepatic hypertrophy. The pathologic physiology of the blood should allot 
 the physician ample time to diagnose and institute appropriate treatment 
 before the destructive fatal pathologic anatomy dominates the field. When 
 the fatalistic cachexia presents its specter, pathologic physiology of the blood 
 has generally merged into hopeless pathologic anatomy. 
 
 PATHOLOGIC ANATOMY. 
 
 The detection of the terminal disease (pathologic anatomy) from the 
 pathologic physiology of the blood requires the best heads and the finest of 
 skill. If the terminal carcinoma could be detected in the stage of pathologic 
 physiology, i. e., in the precarcinomatous stage, it could be practically cured, 
 as it is in the incipient stage— a local disease. The diagnosis of the pathologic 
 physiology of the blood cannot be separated from the pathologic physiology 
 of individual viscera. For example, carcinoma of any viscus produces patho- 
 logic physiology of the blood (cachexia). Again, pathologic physiology of 
 the blood may arise with no palpable course until hypertrophy of the glands, 
 spleen, or liver appears. 
 
 Leukemia, a disease of middle life, though in the incipient stage is that 
 of pathologic physiology, yet leads later to pathologic anatomy and generally 
 to a fatal issue, however, through a chronic course. Leukemic changes arise 
 through rupture of the hyperplastic tissue in the vascular tract. This 
 explains the variety of cells found in the blood. The etiology of leukemia is 
 unknown. Some consider it an infectious disease. Leukemia was, originally, 
 chiefly referred to the spleen but other sources, as the bone marrow, account 
 for a share. The various forms of leucocytosis may exist as long as patho- 
 logic physiology endures — ultimately pathologic anatomy appears. Whether 
 the origin of the leucocytes be the spleen or glands one cannot decide until 
 physical symptoms arise. The study of pathologic physiology of the blood 
 will progress when physicians practically examine all patients, and the subject 
 of hematology is constantly taught as a required curriculum in the colleges. 
 It is by cultivation of the study of pathologic physiology of the blood that 
 we may hope for early diagnosis of impending disease, the application of 
 effective remedies as well as rational prophylaxis. When pathologic physi- 
 ology of the blood can only be discovered, the aim of the clinician must be 
 to correct the abnormal deviation, the abnormal function, of plasma, red or 
 white corpuscle. These consist in the application of therapeutics, as diet 
 (food and fluid), induction of maximum visceral function (visceral drainage), 
 recognized remedies, (habitat, avocation), prophylaxis. 
 
 33 
 
CHAPTER XXXVIII. 
 
 THE PATHOLOGIC PHYSIOLOGY OF (I.) TRACTUS LYMPHATI- 
 
 CUS, (II.) LYMPH. 
 
 An original and enterprising man is opposed — opposition develops strength, and 
 criticism accuracy. 
 
 A fever in your blood! Why, then, incision would let her out in saucers. — 
 Shakespeare, in Love's Labor Lost. 
 
 I. TRACTUS LYMPHATICUS. 
 
 The tractus lymphaticus begins and ends in the veins. It is a venous 
 appendage. It was a late developmental addition, differentiation of the 
 blood vascular system — an additional circulatory apparatus. 
 
 The tractus lymphaticus resembles the tractus venosus, (a) in possessing 
 afferent or converging vessels which course from periphery to center; (b) in 
 being divided into two sets — superficial and deep', (c) in contour, the 
 possession of valves — constrictions and dilatations. 
 
 The tractus lymphaticus differs from the tractus venosus, (d) in 
 traversing glands; (e) in its reverse arrangement — i. e., the lymphatic vessel 
 does not increase in dimension from periphery to center like the vein; (f) the 
 progressive movements of the lymph depend exclusively on the parietes of 
 the lymphatic vessel — that of the venous blood chiefly on the cardiac action ; 
 (g) the lymphatics communicate with intercellular spaces and serous sacs. 
 
 The tractus lymphaticus consists of: (A), {VASA LYMPHATIC A), 
 Peripheral Anastomosing Plexuses of Lymph Vessels, which originate in the 
 meshes of the connective tissue. These lymph channels, converging and 
 uniting, pass to the lymph glands, or nodes. In the pathologic physiology 
 of the lymph vessels redness (hyperaemia) along the line of vessels and 
 oedema are conspicuous features. 
 
 Vasa lymphatic or lymph vessels arising from all parts of the body were 
 discovered almost simultaneously by George Joylife (1637-1658), an English 
 physician, in 1652; Olaf Rudbeck (1630-1702), a Swede of Upsala in 1651; 
 Thomas Bartholin (1616-1680), a Danish anatomist of Copenhagen from 1650 
 to 1667. Bartholin proposed the name vasa lymphatica. The chief location 
 of lymphatic vessels is the connective tissue especially associated with blood 
 vessels. The valves of lymphatic vessels are absent at their origin and in the 
 capillaries. The valves are paired and numerous but irregularly located in 
 the collecting vessels, however, rare in the final collecting trunks — thoracic 
 ducts. The arrangement of the vasa lymphatica consist of: (a) superficial 
 or epifascial set and (b) deep or subfascial set — communicating with each 
 other. The general organs or regions of the body are drained by converging, 
 collecting lymphatic vessels — intermediate collecting trunks. The lymph 
 capillaries consist of valveless endothelial tubes. The common collecting 
 trunks consist of three coats, viz., (a) the internal endothelial layer; (b) the 
 middle muscular layer; (c) the external connective tissue layer. 
 
 514 
 
TRACTUS LYUrHATlCUS AND LYMPH 
 
 515 
 
 Chyle Vessels (Lac fen Is). 
 
 Vasa chylifera or the lacteals were first observed in the mesentery of man 
 by Herophilus (310 B. C. ), a Greek physician living in Egypt, while he was 
 dissecting living criminals. 
 
 Erasistratus (34O-280 B. C), a Greek 
 physician, observed the chyle vessels or 
 lacteals while dissecting kids but named 
 them arteries. However, Gasparo Aselli 
 (1581-1626) professor of anatomy and 
 surgery at Pavia, Italy, a prince among 
 anatomists, discovered the lacteals while 
 performing vivisection in a dog. July 23, 
 1622, Aselli 's work (lacteals) was pub- 
 lished posthumous by his friends. 
 
 (B), (GLANDULE LYMPH AT- 
 LCAi), Lymph Glands or Nodes, which 
 are structures that receive (afferent ves- 
 sels) and emit (efferent vessels) lymph 
 vessels. The glands produce leucocytes 
 and modify traversing material. It is 
 estimated that man has some 500 lymph 
 glands or nodes and that the lymph 
 traverses one or more glands before ter- 
 minating in (subclavian) veins. Glands 
 alter lymph owing to slow circulation. 
 The glands modify the traversing inert or 
 living particles and imprison them, as the 
 carbon infiltration glands of the bronchia. 
 In pathologic physiology of the tractus 
 lymphaticus hypertrophy or tenderness 
 of the glands is a conspicuous character- 
 istic. 
 
 (C), (TRUNCL LYMPHATLCL), 
 Lymph Trunks, are large lymph vessels 
 which conduct or transport the lymph 
 from the lymph glands or nodes to the 
 (subclavian) veins. The chief ones are 
 the left and right thoracic ducts. 
 
 The lymph trunks are the thoracic 
 duct (left) and the thoracic duct (right). 
 Formerly it was thought the wounds of 
 the thoracic duct were fatal, however, 
 recent observation (H. Cushing, P. Allen, 
 and others) demonstrates that the thor- 
 acic duct wounds are frequently not fatal, recovery resulting from: (a) 
 spontaneous closure (coagulation contraction of the duct wall) ; (b) free 
 
 • and richt lymphatic ducts. 
 
 DUCTUS 
 
 THORACICUS 
 ET SINISTER 
 
 DEXTER 
 
 Fig. 140. The left thoracic duct with 
 the chief (a) isthmus constriction in its 
 central portion, the dilated (b) cisterna 
 lymphatica at its distal end and the (c) 
 cervical dilatation at its proximal end 
 (which terminates in the vena subclavia 
 sinistra), the right thoracic duct term- 
 inating in the vena subclavia dextra. Is 
 the caliber of the thoracic duct (left) 
 sufficient to transport f of the lymph of 
 the organism? (Gray). 
 
51G 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 collateral circulation; (c) ligation (suture) of the wound. If the duct 
 leaks lymph it should be ligated proximal and distal to the perforation, 
 allowing resumption by collateral circulation. (The lymphatic system 
 includes the terms canalicular system, perivascular lymph spaces, lymph cap- 
 illaries, chiliferous vessels — pleural, peritoneal, pericardial and synovial 
 (serous) cavities, stomata, lacteals.) 
 
 The number of lymph channels and glands are unequally or non-uni- 
 formly distributed in the organ- 
 ism, occurring most frequently in 
 vascular parts. The number and 
 caliber depend on the density of 
 tissue. Lymph channels (closed, 
 e. g., peritoneum, pleura), in gen- 
 eral are lined by endothelium in 
 contradistinction to (unclosed) 
 channels, (e. g., digestive and 
 genital tracts), which are lined by 
 epithelium. The valves of lymph 
 channels are folds of endothelium. 
 The tractus lymphaticus possesses 
 more variation than any other 
 visceral tract. The form of the 
 whole branching lymphatic vas- 
 cular system is that of a cone. 
 The cone base or periphery is the 
 vast connective tissue spaces of 
 the whole body. The cone apex 
 or center is the termination of the 
 lymphatic trunk (thoracic ducts) 
 in the veins (subclavian). 
 Lymphatic vessels arise from 
 intercellular spaces, however, 
 especially from immediately be- 
 neath free surfaces as skin serosa, 
 mucosa. The lymphatic vessels 
 are solidly and compactly anas- 
 tomosed. Hence the lymph 
 plasma may flow in all directions 
 (like the blood in the utero- 
 ovarian artery) direct or reverse to insure complete cell nourishment under 
 complicated conditions. The object of the tractus lymphaticus is universal 
 cell nourishment and universal cell drainage. The functions of the tractus 
 lymphaticus (sensation, peristalsis, absorption, secretion) is controlled by the 
 nervus vasomotorius (sympathetic). The tractus lymphaticus is richly sup- 
 plied by a plexiform, nodular network, a fenestrated anastomosed meshwork 
 of the nervus vasomotorius which controls its physiology. The lymphatic 
 
 Fig. 141. *-The lymphatics of the head und neck. 
 
 LYMPHATICS OF HEAD AND 
 
 (Sappey.) 
 
 NECK 
 
 Fig. 141. This figure presents the source (vasa 
 lymphatica), glands (glandular lymphatics) and 
 termination of the right thoracic duct (in the right 
 subclavian vein). The direction of the lymph chan- 
 nels demonstrated why the lymph glands in the 
 neck enlarge toward the clavicle. (Sappey.) 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 517 
 
 vessels accompany the veins. The lymphatic vessels ensheath the veins as a 
 plexiform anastomosing net or fenestrated meshwork — resembling the plexi- 
 form, nodular net or fenestrated anastomosing meshwork of the nervus 
 vasomotorius ensheathing the arteries, i. e., the nervus vasomotorius ensheath 
 the arteries as the tractus lymphaticus ensheath the veins. 
 
 Thoracic Duct (Unpaired). 
 
 Ductus thoracicus sinistra, ductus pecquetianus, was discovered by Jean 
 Pecquet (of Paris, France, 1622-1674) in 1(349, in a dog. It was discovered by 
 Olaus Rudbeck (of Upsala, 
 Sweden, 1630-1702) in man, 
 in 1650. 
 
 Also Thomas Bartholin 
 (1616-1680) is credited with 
 discovery of the thoracic 
 duct in man. John Wesling 
 in 1634 saw the thoracic 
 duct. The thoracic duct is 
 in general \ of an inch in 
 diameter and 18 inches in 
 length with non-uniform cal- 
 iber and sinuous course with 
 minimum caliber at its mid- 
 dle portion. It is especially 
 dilated at the distal end (re- 
 ceptaculum lymphatica) and 
 at the proximal end is an 
 elongated ampulla (which I 
 shall term its cervical dila- 
 tatioii). 
 
 The thoracic duct may 
 bifurcate, forming two or 
 several branches, a network, 
 and reunite in its course. 
 Its valves are the most lim- 
 ited in number and dimen- 
 sions of any portion of the 
 tractus lymphaticus. Its two 
 most remarkable valves are located at its ("cervical dilatation") termination in 
 the subclavian vein where the free borders of the valves are directed toward 
 the venous lumen in order to oppose influx of venous blood into the thoracic 
 duct. The two ductus thoracici — ductus thoracicus major (sinister) et minor 
 (dexter) — flow in the direction of least resistence, i. e., they flow into the sub- 
 clavian veins at the most distant point from the intra-thoracic and intra- 
 abdominal pressure. Has a duct of two lines or £ of an inch in diameter 
 ample lumen to allow % of the lymphatic fluid (constituting about \ of the 
 bcdy weight) to traverse it? 
 
 LYMPHATICUS ENSHEATHING A VEIN 
 
 Fig. 142. The lymphatic vessels ensheathing the por- 
 tal vein as a plexiform, anastomosing nodular (valves) 
 fenestrated meshwork. The tabular lymph apparatus 
 richly ensheathing the vein transports abundant fluid 
 for nourishment. (Teichman.) 
 
518 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Ductus TJwracicus dextra is located at the right side and base of the neck. 
 Its dimensions are: length an inch, diameter 1-8 of an inch. It terminates 
 in right subclavian vein. It is the common collecting lymph trunk for the 
 right side of the head and neck, right proximal extremity, right lung, right 
 heart. The thoracic duct is nonuniform 
 in caliber, possessing dilatations (reser- 
 voirs) and constrictions (isthmuses). 
 
 (1) Receptaculum Lymphatica {Distal 
 Dilatation). 
 
 Receptaculum chyli, cisterna chili, 
 cisterna lymphatica or chyle reser- 
 voir was discovered [by Jean Pecquet 
 (1622-1674) of Paris, France, in 1649. 
 The cisterna lymphatica was independ* 
 ently discovered by Olaf Rudbeck (1630- 
 1702), president of the University of 
 Upsala, Sweden. In general the dimen- 
 sions of the receptaculum lymphatica is 
 \ of an inch in diameter and 2 l /> inches 
 in length. It is an oblong formed sac or 
 dilatation at the distal end of the thoracic 
 duct, located opposite to the I and II 
 lumbar vertebrae. 
 
 (2) Cisterna Lymphatica Cervicis 
 {Proximal Dilatation). 
 
 The thoracic duct in the region of the 
 neck possesses a dilatation which may be 
 termed the "cervical dilatation" or cis- 
 terna lymphatica cervicis. It is a spindle 
 or oblong formed swelling of the duct 
 located at its terminal end. It, as well as 
 other dilations, has been termed an am- 
 pulla. 
 
 (3) Isthmus Medius {Middle Isthmus). 
 
 A LYMPHATIC GLAND WITH ITS 
 
 AFFERENT AND EFFERENT 
 
 VESSELS 
 
 Fig. 143. The valved afferent vessels 
 are more numerous than the valved effer- 
 ent (Testut). 
 
 The thoracic duct possesses a min- 
 imum caliber at its medial portion, hence 
 
 I shall term this the middle isthmus. It is the chief constriction or isthmus 
 of the thoracic duct. 
 
 II. THE LYMPH (LYMPH PLASMA). 
 
 The contents of the tractus lymphaticus consists of: (A) the lymph or 
 lymph plasma — a fluid tissue; (B) the leucocyte — a guest of lymph plasma. 
 
TRACTUS LYMPHATICUS AND LYMl'H 
 
 519 
 
 (A). Lymph — Lymph Plasma. 
 
 Lymph plasma originates from blood plasma. The lymph or lymph 
 plasma originates as a capillary infiltration from the blood serum. Lymph 
 is doubtless also a product of cell secretion. In composition lymph plasma 
 appears to be a mechanical and secretive product from the blood. Perhaps 
 lymph should be viewed chiefly as a secretion of the endothelial (blood cap- 
 illary) cell. Lymph is different from blood — it is more acid (is less in 
 glucose), as urine is more acid than blood. Lymph plasma is fluid that has 
 escaped from the blood plasma in the capillaries and its composition varies 
 according to source and organ activity. It is a peculiarity that though the 
 lymph should be viewed chiefly as the product of cell secretion, instead of 
 being eliminated externally, it is returned to the venous blood, to retravel 
 
 LYMPH VESSELS OF THE TRACHEAL MUCOSA 
 
 Fig. 144 Observe anastomosing superficial and deep lymphatics as well as valves. The 
 number and caliber of the lymph channels demonstrate its functional transporting capacity. 
 (Teichman.) 
 
 the arteries. However, the lymph is modified by the lymph glands and pul- 
 monary endothelium (oxygen). It is a process which resembles the elabora- 
 tion of the ductless glands (spleen, thyroid, ovary, thymus, adrenal). 
 
 Physically the lymph is in general an odorless, colorless, viscid fluid. 
 Digestion produces a milky color in lymph plasma. The quantity of lymph 
 is estimated from \ to \ the weight of the body. The quantity varies 
 extensively according to corporeal activity. Its specific gravity is 1.017. 
 Practically the lymph is a transparent alkaline fluid, perchance, of reddish 
 yellow color. It is soluble in water, becoming turpid in alcohol Lymph 
 coagulates with more facility than blood and becomes a scarlet red in contact 
 with oxygen and purple red in contact with carbonic acid. The lymph plasma 
 performs an export and an import service. It conducts nourishment (fluid) 
 to the cell and floats waste material (fluid) from the cell. It performs its 
 
520 
 
 THE ABDOM1XAE AND PELVIC BRAIX 
 
 labor through a fluid medium, saturating the cell (nourishment) and irrigating 
 the cell (drainage). Lymph plasma coagulation renders less fibrin than that 
 of blood plasma. This is significant, for fibrin is liable to obstruct vessels 
 and produce thrombosis — eventually embolism. The chief chemical constit- 
 uents of lymph consists of albuminoids (less than that of blood) fats, various 
 metalic salts (NaCl phosphates, sulphates, alkaline carbonates). 
 
 (B). Leucocyte — White Blood Corpuscle. 
 
 The origin of the leucocyte is: (a) medulla (bone marrow); (b) mesob- 
 last (blood vascular endothelium); (c) connective tissue; (d) lymph glands 
 or nodes. 
 
 The location of the . l/liVi/ <MJM§&$£Ni(&S$^ 
 leucocyte is in order of 
 frequency: (a) in the 
 lymph plasma; (b) in the 
 blood plasma; (c) in the 
 connective tissue. 
 
 The structure of a leu- 
 cocyte consists of a nu- 
 cleus and a surrounding 
 protoplasm. 
 
 The number of leu- 
 cocytes in man to the 
 cubic millimeter are about 
 8,000 (Ranvier). The 
 number of leucocytes are 
 increased after passing 
 through glands. The 
 number of leucocytes is 
 greater in the center than 
 in the periphery of the 
 body organism. 
 
 The neucleus of the 
 leucocyte varies in num- 
 ber, dimension, form, 
 location. The nucleus is 
 surrounded by proto- 
 plasm, an almost imper- 
 ceptible zone of non- 
 homogenous matter. 
 
 The polymorphism of the leucocyte nucleus has vigorously engaged numerous 
 cytologists with consequent multiple views as to its cause. 
 
 The protoplasm varies in form, dimension, structure. The contents of 
 the protoplasm varies from environments as iron granules, redblood corpus- 
 cles, debris, microbes or their products, particles of air and so forth. 
 
 Physically the leucocyte is practically a colorless, soft, extensible non- 
 
 INGUINAL GLANDS OF LYMPHATICS 
 
 Fig. 145. This figure represents the course of the lympha- 
 tics from the genitals and rectum to the abundant inguinal 
 glands — barriers of infection which imprison, sterilize or 
 digest (destroy) infectious or inert material. The inguinal 
 glands are affected by carcinoma and infectious material 
 from genitals and rectum. (Sappey.) 
 
TRACTUS LYMPHATICUS AND LYMPH 521 
 
 homogenous mass of protoplasm, noncapsulated (without covering). It is 
 viscous and adheres to the most smooth surface. Thus when circulation 
 
 slows it lodges against vessel wall. 
 
 to a a 
 
 LYMPHATICS OF THE INTERNAL GENITALS 
 
 Fig 146 This illustration of the lymphatics after Dr. Wm. Nagel and Porier demonstrates 
 that the lymphatics accompany the vessels-in this figure they follow the utero-ovarian 
 vascular circle (circle of Byron Robinson). The lymphatics of the genitals are of practical 
 importance on account of the frequent location of carcinoma in the genitals and their dis- 
 tribution of the carcinoma through the lymphatics. 
 
 The chief chemical constituents of a leucocyte are, albuminoids, nuclein, 
 insoluble matter, fat cholestrin. These substances are important in meta- 
 bolism, e. g., the nuclein will produce uric acid. 
 
522 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 Biologically the leucocyte or white corpuscle possesses the primary prop- 
 erties of living matter, viz. : sensibility, mobility (rhythm), peristalsis, 
 absorption, secretion, reproduction. One of the most significant characteris- 
 tics of the leucocyte is that of viability endowing it with the quality of a pro- 
 
 LYMPH CHANNELS AND GLANDS DRAINING THE TRACTUS GENITALIS 
 
 (SAVAGE) 
 
 Fig. 147. The tractus genitalis is abundantly supplied by lymphatics and consequently 
 possesses a rich lymphatic drainage. The tractus genitalis is peculiarly liable to be attacked 
 by bacterial infection and carcinoma — both manifest in the annexed tractus lymphaticus. 
 Infectious or carcinomatous material, on account of the luxuriant anastomoses of the genital 
 lymph channels may appear to avoid certain of the adjacent genital glands and to attack 
 glands more distant from the genitals. In other words the infectious or carcinomatous 
 material may not attack the genital lymphatic glands in the direct order of the course of 
 their arrangements. This illustration demonstrates the futility of attempting to extirpate 
 all the lymphatic glands attending a carcinomatous infected genital tract — microscopically 
 one is incapable of deciding whether a lymph gland be hypertrophied from bacterial infec- 
 tion or carcinomatous infection. 
 
 tector, a body guard — a mobile sentinel. It is a migratory cell (the wandering 
 cell of Recklinghausen). It is a mobile tissue inspector, a heraldic warner 
 for bodily protection. The leucocyte is a guardian against foreign invaders. 
 it is a tester of ingesta, it is a filtering barrier, a retention prison. 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 523 
 
 The leucocyte absorbs, imprisons, sterilizes matter. It digests some 
 material (food, bacteria), it imprisons some (indigestible, coloring matter), 
 it sterilizes some (bacteria, ferments). These properties enable the leucocyte 
 to protect or supervise against excessive invasion of bacteria, poisonous 
 matter, ferments. 
 
 The leucocyte reproduces itself by amitosis (direct division) and karyo- 
 kinesis (indirect division). The leucocyte is a primordial factor of life and 
 its perpetuation. 
 
 The leucocyte is a vital, primordial, protoplasmic element which retains 
 its primary property of free and independent life — sensation, motion, absorp- 
 tion, secretion, reproduction — adopting itself to differentiation, environ- 
 ment. It is a functionator preceding a constructor. 
 
 The vital resistance or constitutional power of a leucocyte is remarkable 
 against destructive agen- 
 cies. Yerworn demon- 
 strated that 24 hours after 
 bodily death of the organ- 
 ism the majority of the 
 leucocytes are living. 
 They may retain their 
 properties external to the 
 general organism for 3 
 weeks (Recklinhausen, 
 Ranvier). 
 
 The chief classifica- 
 tion of different leucocytes 
 are : (a) microcytes ; (b) 
 macrocyscs ; (c) cells with 
 neutrophile granules; (d) 
 cells with acidophile 
 granules; (e) cells with 
 metachromatic basophile 
 granules. This classifica- 
 tion demonstrates the extensive range of physiology (and consequent exten- 
 sive field of pathologic physiology) included within the range of the leucocytes. 
 As disease is deviating or abnormal physiology the key to its etiology, 
 therapuesis and prophylaxis accurate knowledge of organ functions. The 
 functions of the tractus lymphaticus are: I, sensation; II, peristalsis; III, 
 absorption; IV, secretion. Disease in the lymphatic tract consists in devia- 
 tion, abnormal repetition, of one or all the above four functions. The four func- 
 tions manifesting pathologic physiology in the disease of the tractus lympha- 
 ticus will be recognized by being excessive, deficient, disproportionate. 
 
 I. SENSATION (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 1. Excessive sensation in the tractus lymphaticus may be associated with 
 irritability of the peripheral nerve ending in the endothelium. Also the 
 lymph plasma may contain irritating matter. 
 
 LYMPHATIC CHANNELS DRAINING CERVIX AND 
 VAGINA (POIRIER) 
 
 Fig. 148. This excellent illustration demonstrates the 
 facility with which cervical and vaginal carcinoma (the 
 most prevalent forms) may become distributed through the 
 tractus lymphaticus annexed to the tractus genitalis. 
 

 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Fig. 149. 
 
 LYMPH CHANNEL (A. A.) OF PYLORIC END OF 
 RABBIT'S OMEXTERuX 
 
 2. Deficient sensation in 
 the lymphatic tract may be 
 due to excessive or over- 
 whelming poisonous sub- 
 stances in the lymph plasma 
 or paresis (blunted sensibil- 
 ity) of the peripheral nerve 
 ending in the endothelium 
 (traumatic paresis from 
 compression cedemaj. De- 
 ficient bodily activity may 
 cause deficient lymph flow 
 and consequent deficient 
 sensation. 
 
 3. Disproportionate sen- 
 sation in the tractus lym- 
 phaticus may arise from an- 
 esthesia, hyperesthesia in 
 its different segments and 
 also from different composi- 
 tion of lymph plasma from 
 different organs. Also dis- 
 proportional bodily muscular 
 activity may share producing 
 disproportional sensation. 
 
 II. PERISTALSIS (EXCESSIVE, 
 DEFICIENT. DISPROPOR- 
 TIONATE). 
 
 4. Excessive peristalsis 
 may arise from irritating 
 lymph plasma or irritation 
 of the walls of the lymph 
 tract from supersensitiveness 
 of the endothelium. The 
 
 Fig. 149. A. A, is a lymph 
 channel from which I penciled the 
 peritoneal endothelium and 
 stained with AgX03- One can 
 observe a dozen stomata vera on 
 this lymph channel, directly com- 
 municating with the peritoneum. 
 Xote the sinuous outline of the 
 endothelium composing the 
 lymph channel. Parallel to this 
 lymph channel is a zone of peri- 
 toneal endothelium stained with 
 AgXOs, presenting stomata vera 
 S. V.) and endothelium without 
 sinuous borders. 
 
TR. ICTUS LYMPHATICUS AND LYMPH 
 
 525 
 
 lymph vessels contract from their own parietes — no apparatus like the 
 heart propel their contents. Peristalsis in the lymph channel is obvious 
 chiefly in the ductus thoracicus. The rate and volume of lymph flow 
 depends on the rate and volume of blood flow, on tissue pressure and muscular 
 activity. In certain localities the lymph flow must depend on the difference 
 of blood pressure and that of the lymph in the tissue. Obstruction of the 
 thoracic duct would induce excessive, vain peristalsis in the lymph channels. 
 Extra distention of the left subclavian vein might induce excessive peristalsis 
 in the thoracic duct. Extraordinary muscular activity may induce excessive 
 peristalsis. 
 
 
 
 TRANSITION OF LYMPH CAPILLARIES INTO LYMPH TRUNKS WITH VALVES 
 
 —SACCULATIONS 
 
 Fig. 150. a, beginning of lymph trunk; b, b, lymph reservoirs: magnified 15 times. 
 (Teichman.) 
 
 5. Deficient Peristalsis or stasis of lymph occurs in tissue with limited 
 elastic tension. The same condition favors venous stasis. Also force of 
 gravity favors lymph stasis. Hence general lymph oedema occurs in the ankle 
 region or lumbao-sacral region. The obstruction of a single lymph channel 
 (or vein) does not necessarily produce cedema because the lymph (or venous 
 channel) may assume a collateral circulation from rich anastomosis. Transu- 
 dation of lymph may not produce cedema as the lymph may be transported 
 by the lymphatics. 
 
 If general venous stasis exists the blood pressure in the left subclavian 
 is raised and lymph cedema may be general and peristalsis of the lymphatics 
 
526 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 is vain. Lymphatic peristalsis may be deficient when the tissues adjacent to 
 the capillaries have been distended with consequent loss of elasticity and 
 power of contraction. Diminished elastic pressure of the adjacent tissue on 
 the lymph spaces diminishes the rate of flow of lymph plasma. Deficient 
 peristalsis (lymph flow) occurs subsequent to tissue inflammation, for the elas- 
 tic tissue pressure is diminished, paretic. 
 
 6. Disproportionate Peristalsis (flow) may be observed subsequent to dif- 
 ferent degrees and different localities of tissue distention following oedema 
 from varying elastic tissue pressure. Subsequent to inflammatory tissue pro- 
 cesses the adjacent elastic tissue pressure is unequal, nonuniform, inducing 
 lymphatic peristalsis or flow disproportionate. 
 
 in. 
 
 SECRETION" (EXCESSIVE, DEFICIENT, DISPROPORTIONATE). 
 
 7. Excessive secretion of lymph plasma may be manifest by oedema, tis- 
 sue fluid accumulation, nephritic cedema. Excessive secretion of lymph plasma 
 is difficult to discriminate from insuffi- 
 cient drainage or transportation of 
 lymph. Excessive secretion of lymph 
 may be found in tissue oedema and 
 especially in the serous cavities. In 
 nephritic cedema (not accompanied by 
 cardiac deficiency) the excessive lymph 
 collected in the tissue is doubtless due 
 to simple stasis, however, for our view, 
 the lymph is excessive. The nephritic 
 oedema occurs first in the subcutaneous 
 tissue and particularly in the tissue 
 possessing limited elastic pressure, e. 
 g., about the ankles and dorsal surface 
 of the lumbar and sacral regions. The 
 lymph oedema may be excessive, lymph 
 formation or accumulation being from 
 obstruction to its escape. The quan- 
 tity of lymph which escapes from the 
 blood capillaries depends on the differ- 
 ence in pressure" between the lymph 
 spaces and the blood capillaries. Whether there be excessive lymph secretion 
 or lymph stasis — lymph oedema — it is similiar in effect. The stasis of blood in 
 veins results in lymph stasis — lymph cedema. The organs or tissue become 
 most oedematous or swollen which possess the most limited elastic pressure — in 
 fact exactly where venous stasis is at a maximum. The lymph stasis may be 
 local as when a vein is accluded by a thrombosis, or general as when a lung 
 or heart is debilitated. However, mere obstruction of a vein may not pro- 
 duce lymph or venous stasis as circulation in the vein and lymph channels is 
 rich on anastomatic collateral routes. An increased lymph transudation may 
 produce no lymph oedema as the lymph channel anastomoses may transport 
 
 LYMPH CHANNELS AND GLANDS OF 
 THE MESENTERON (HORNER) 
 
 Fig. 151. Subject dead from ascites. 1, 
 thoracic duct 2, section of aorta. 3, adja- 
 cent aortic glands. 4, superficial lympha- 
 tics of intestines. 5, 6, 7, lymphatic channels 
 and glands of enteron and mesenteron. 
 
Tit ICTUS LYMPHATICUS AND LYMPH 
 
 52? 
 
 the excess of lymph sufficiently rapid to equalize the lymph circulation. If 
 there be general venous stasis general lymph oedema may arise from rise of 
 blood pressure in the left subclavian vein obstructing the flow of lymph from 
 the thoracic duct. Local lymph oedema may arise from previous extradisten- 
 tion of tissue which consequently is deficient in elastic pressure. It is evident 
 that the elasticity of tissue and muscular activity exercises a powerful influ- 
 ence over the rate of lymph flow and local accumulation of lymph plasma. 
 
 In regard to the nephritic oedema it may be noted that oedema occurs in 
 parenchymatous nephritis — not in interstitial nephritis — and is no doubt due 
 to retention within the body of the watery portion of the urine. A test of 
 this matter may be made by the ad- 
 ministration of sodium chloride (which 
 stimulates, irritates, excites renal epi- 
 thelium). In the nephritic oedema from 
 lymph stasis less than normal urine is 
 evacuated and the oedema increases as 
 the urine diminishes and vice versa. 
 Now, administer 8 ounces of normal 
 salt solution every two hours 8 times 
 daily and the urine will rapidly in- 
 crease in quantity and clarification, 
 resembling spring water, while the 
 oedema will diminish. It must be well 
 borne in mind that sodium chloride 
 irritates, damages inflamed renal epi- 
 thelium, hence should not be admin- 
 istered in parenchymatous nephritis. 
 Hammerschlag has shown that patients 
 with parenchymatous nephritis possess 
 diluted blood — an hydraemia or hydrse- 
 mic plethora. No doubt some dam- 
 age, lesion, exists in the capillary 
 wall in nephritic oedema, because 
 the heart shares in the process by 
 presenting hypertrophy. Dr. A. \V. 
 
 Howlett asserts that nephritic oedema apparently depends in some subjects 
 on excess of sodium chloride within the body, i. e., the subject secretes defi- 
 cient quantities of sodium chloride on account of kidney defects (parenchyma- 
 tous nephritis) which in turn necessitates an accumulation of fluids (lymph 
 within the tissues). Whatever the exact factors be I am distinctly convinced 
 during the past decade as regard the action of sodium chloride on renal epithe- 
 lium (irritation, excessive, or deficient secretion), that profound effects are 
 exercised on the kidneys by the amount of sodium chloride ingested. So-called 
 Indurated lymph oedema occurs subsequent to extirpation of the lymph gland 
 in a territory of considerable dimension. 
 
 8. Deficient secretion of lymph plasma is difficult to demonstrate, although 
 
 LYMPHATIC DRAINAGE OF DIA- 
 PHRAGM 
 
 Fig. 152. The centrum tendineum of the 
 diaphragm is drained by lymph trunks — two 
 anterior and two posterior (3, 3,) — which 
 terminate in the thoracic duct 5, 5, valves of 
 lymphatic trunks. D, D, thoracic duct. 6. 
 7, 8, dilated lymph spaces in the diaphragm. 
 The dark circular disc represents the point 
 of the central tendineum where the heart 
 rests, in which disc there are no lymph 
 spaces. 
 
528 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 it undoubtedly occurs especially where tissue is dense and hence where little 
 lymph will escape, however, in atrophic tissue doubtless deficient lymph is 
 secreted. 
 
 9. Disproportionate secretion of lymph is evident 
 in different regions of the body. The resistence offered 
 by the different degrees of tissue elasticity and pres- 
 sure accounts for its share. Also the lymphatics are 
 unequally distributed. The erect attitude presents 
 disproportionate lymph secretion from force of grav- 
 ity. In the erect attitude the force of gravity exposes 
 extra tissue pressure in certain localities, as the ankle 
 and foot region. 
 
 IV. ABSORPTION (EXCESSIVE, DEFICIENT, 
 DISPROPORTIONATE) . 
 
 10. Excessive; 11, deficient; 12, disproportionate, 
 absorption of lymph plasma is difficult to demonstrate 
 and time and space here forbids. 
 
 THE DIAGNOSIS OF PATHOLOGIC PHYSIOLOGY IN THE 
 TRACTUS LYMPHATICUS. 
 
 PROFILE VIEW OF 
 
 THE DUCTUS 
 
 THORACICUS 
 
 Fig. 153. 1, the cervi- 
 cal dilatation of the thor- 
 acic duct terminating in 
 the left subclavian vein. 
 2, the isthmus of the thor- 
 acic duct in the dorsal 
 region. 3, receptactdum 
 lymphatica. 
 
 For rational views and practical purposes defi- 
 nite ideas should be entertained of the functions of 
 an organ. It is evident that to the tractus lymphat- 
 
 icus the four common visceral functions (sensation, peristalsis, absorption, 
 secretion) belong. When these four functions of the tractus lymphaticus 
 pursue a normal course there is no pathologic physiology — no disease 
 
 exists — and no correction of func- 
 tion or therapeusis is demanded. 
 As water basins are the great centers 
 of civilization, so the lymph channel 
 is the great center of nourishment. 
 In both instances it is the facility 
 of a transporting fluid medium which 
 accomplishes the object. The sig- 
 nification of the tractus lymphaticus 
 is evident when it is realized that it 
 is the highway of cell nourishment 
 and cell drainage. Along the bor- 
 ders of the great lymph stream every 
 cell is a harbor for import and export 
 service. The object of the tractus 
 LYMPH CHANNELS IN THE PERI- lymphaticus is universal cell nour- 
 TONEUM ishment and universal cell drainage. 
 
 Fig. 154. The lymph vessels present elon- Pathologic physiology of the tractus 
 gated endothelium, valves, dilatation and con- , . . , . 
 
 struction. lymphaticus is the zone between nor- 
 
TRACTUS LYMPHATICUS AND LYMf'll 
 
 529 
 
 mal physiology and pathologic anatomy and should be amenable to therapeu- 
 tics. Pathologic physiology will constitute a useful field for the cultivation 
 of physiology, diagnosis, therapeutics, rational practice and prophylaxis. 
 As the tractus lymphaticus is of vast utility in the animal economy, having 
 an import service (transportation of cell nourishment) and an export service 
 (transportation of cell drainage), its pathologic physiology comprises a cor- 
 respondingly extensive zone. Pathologic physiology in the tractus lymphati- 
 cus is disordered or abnormal function, the beginning of disease. Pathologic 
 anatomy is a disordered or abnormal structure, the establishment of disease. 
 Disease begins as abnormal function and its progress consists in a repetition 
 of the abnormal or deviating physiology. Modern radical surgery in tubercu- 
 
 LYMPHATICS FROM ENTERON OF GUINEA PIG WITH PLEXUS MYENTERI- 
 
 CUS OF AUERBACH (FREY) 
 
 Fig. 155. a, b, a, b, Auerbach's Plexus (Plexus myentericus) ; c, narrow and d, larger lymph 
 channels. This excellent illustration demonstrates the intimate relation of the rich plexuses 
 of the nervus vasomotoiius and rich plexuses of the vasa lymphatica. 
 
 losis and carcinoma depends for its sucess on a knowledge of the anatomic 
 distribution of the lymph channels and glands. The pathologic physiology 
 in the lymphatic glands and channels may suggest a diagnosis by leading the 
 physician to a local lesion along their route as enlarging inguinal glands may 
 indicate a genital or rectal lesion, they may lead to the discovery of septic 
 foci or solutions of continuity in distant regions, e. g., an infected foot, a 
 corn, a bunion. A rising pathologic physiology in the axillary glands may 
 enable the physician to diagnose advancing carcinoma. The location of the 
 lymphatic glands and the route of the lymphatic channels are the essentials 
 in the diagnosis. This is strikingly manifest in the phenomena that extensive 
 removal of lymph glands may result in induration of lymph oedema. The 
 anatomy is the solid ground to determine the direction of lymph channels 
 
530 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 and location of lymph glands. Lymph glands enlarge generally from 
 bacterial disease, carcinoma or sarcoma. Enlarging lymph glands herald the 
 advance of disease. The tractus lymphaticus stands as a sentinel on guard 
 over normal bodily nourishment. It niters and checks the deleterious and 
 poisonous substance from gaining access to the parenchymatous cell. The 
 lymph glands imprison inert substance 
 and the carcinomatous cell, retarding 
 the progress of carcinoma. The de- 
 tectable route of the most implacable 
 and deadly enemy of man— carcinoma 
 — is through the tractus lymphaticus. 
 The early detection and treatment of 
 the precarcinomatous stage must be 
 accomplished by the recognition of 
 pathologic physiology of the tractus 
 lymphaticus. The lymph system pre- 
 sides as a tissue inspector and protector. 
 It digests, imprisons, sterilizes in the 
 interest of the general organism. The 
 lymph plasma possesses a body guard 
 in its guest — the army of leucocytes. 
 
 RELATIONS OF THE TRACTUS LYMPHAT- 
 ICUS TO PRACTICAL MEDICINE. 
 
 Clinicians are recognizing the nu- 
 merous relations of the lymphatic sys- 
 tem to practical medicine and surgery. 
 Metastatic manifestations, both bac- 
 teriologic and neoplastic, extend 
 through definite routes of lymph chan- 
 nels and their associated glands, and 
 the object of pathologic physiology 
 is to detect the process in ample time 
 to save the organism from destruc- 
 tion by establishing irreparable pa- 
 thologic anatomy. Armed with a 
 knowledge of the physiology of the 
 tractus lymphaticus and its topo- 
 graphic anatomy the physician is fore- 
 warned as to its course of incipient 
 pathologic physiology and considera- 
 tions of rational treatment should engage his attention. First and fore- 
 most the luxuriant anastomoses of the lymph channels appear to allow 
 bacterial or carcinomatous material to avoid attacking certain lymph glands 
 in the route of the lymph channels. In other words the bacterial or carcino- 
 matous material may not attack lymphatic glands in the direct order of their 
 
 RECTAL GLANDS AND LYMPHATICS 
 
 Fig. 15& This figure illustrates the route 
 of carcinomatous or other infectious mate- 
 rial through the numerous rectal lympha- 
 tics and glands (Gerota). 
 
TRAC TUS LYMPHATICUS AND LYMPH 
 
 531 
 
 channels and topographic course. The lymph channels are so richly anas- 
 tomosed that the course of the lymph current may be direct or reverse. Dr. 
 Emil Ries has demonstrated this view as regards carcinoma in the route of 
 the tractus lymphaticus draining the tractus genitalis. Again the physician 
 is unable to decide macroscopically whether a lymph gland is hypertrophied 
 from bacterial or carcinomatous infection. Hence from abundant anastomoses 
 of lymph channels, thrombotic or other obstruction may induce metastatic 
 manifestations in lymph tracts not primarily involved. The extensive 
 removal of lymph channels and glands, as those of the axilla for carcinoma of 
 the mamma, seldom produces lymph oedema or stasis because the luxuriant 
 anastomoses of lymph channels 
 allow the lymph to flow in multi- 
 ple directions. The tractus mus- 
 cularis through its activity, its 
 massage, exercises a wonderful 
 influence over the flow of the 
 lymph. In states of bodily re- 
 pose the respiratory muscles pur- 
 sue continuous rhythmical motion 
 maintaining continuous lymph 
 flow. A comprehensive view of 
 drainage may be secured by a 
 study of the tractus lymphaticus, 
 as cells are nourished and drained 
 by the lymph fluid. A lympha- 
 gcgue is an agent which increases 
 the flow of lymph. Lymph in- 
 creases its rate of flow under the 
 influence of pilocarpin, ergotine. 
 The rate of flow of any fluid 
 depends on its consistency. The 
 consistency of the lymph depends 
 on the quantity of fluid injected. 
 Drainage and nourishment of cells 
 depends on the rate of lymph 
 flow as well as on its quantity 
 and quality. The degree of muscular activity or massage determines relatively 
 the rate of lymph flow. Muscular activity or massage increases the cardio- 
 vascular action and consequently the blood pressure is elevated. We fre- 
 quently observe lymph oedema in the abdominal wall in subjects with large 
 abdominal tumor. Here the lymph accumulates in dependent tissue with 
 deficient elasticity, and pressure or mechanical obstruction occurs. The blood 
 pressure within the artery is tenfold greater than the blood pressure within 
 the vein and complete circulation of the blood requires less than a minute. 
 Hence the venous pressure is vastly greater than that of the lymphatics, how- 
 ever, experiments demonstrate that the lymphatic circulation is vigorous and 
 
 STOMATA VERA CONNECTING THE PER- 
 ITONEUM WITH THE SUBPERITONEAL 
 LYMPH CHANNELS 
 
 Fig. 157. From rabbit's omentum. The 
 endothelium was brushed away and the base 
 stained with l /z per cent of AgN03 and haema- 
 toxylin. The stomata vera (s. v., 9 of them) are 
 patent channels, communicating tubes, connecting 
 the peritoneum with the sub-peritoneal lymph 
 spaces and vessels. 
 
532 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 rapid, e. g. salt solution injected in the connective tissue (as beneath the 
 mammae) rapidly enters the blood circulation. 
 
 TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS LYMPHATICUS AND 
 
 THE LYMPH. 
 
 In general T \ of illness or complaints is pathologic physiology — disordered 
 function — and to is surgery — pathologic anatomy — disordered structure. 
 Modern research is re-instating 
 rational therapeutics, i. e., the cor- 
 rection of disordered function. 
 Practically the field of influence and 
 utility of a physician is limited to 
 the zone of pathologic physiology 
 (which lies between physiology and 
 pathologic anatomy). The chief 
 duty of the physician is to restore 
 function. The deviating functions 
 to restore in pathologic physiology 
 of the tractus lymphaticus are sen- 
 sation, peristalsis, absorption, secre- %LX 
 tion. Pathologic physiology of the 
 tractus lymphaticus is best corrected 
 and normal function maintained by 
 natural methods or rational thera- 
 peutics. The rational agent of 
 therapeutics for the treatment of 
 pathologic physiology of the tractus 
 lymphaticus are: I, Fluids; II, 
 Food; III, Habitat; 1Y, Avocation; 
 V, Drugs; VI, Surgery; VII, Mis- 
 cellaneous. 
 
 Since pathologic physiology of 
 the tractus lymphaticus is the zone 
 between physiology and pathologic 
 anatomy it should be amenable to 
 treatment. In the treatment of pa- 
 thologic physiology of any abdom- 
 inal visceral tract it must be remem- 
 bered that the half dozen visceral 
 tracts normally functionate in per- 
 fect harmony — no friction — and if 
 any one tract be disordered the ex- 
 quisite physiologic balance of all is 
 
 disturbed. The pathologic physiology of the tractus lymphaticus is treated 
 mainly indirectly, i. e., through the influence of other visceral tracts, e. g., 
 (1) the tractus vascularis must be restored to normal as to composition 
 
 LYMPH GLAND WITH VASA EFFEREN- 
 TIA ET AFFERENTIA (TOLDT) 
 
 Fig. 158. A schematic illustration of a 
 lymphatic gland with the entering vessels (vasa 
 efferentia, 7) and departing vessels (vasa affer- 
 entia, 11). 9 points to the stroma in trie hilum. 4, 
 substantia corticalis. 1 and 5, connective tis- 
 sue capsule. 6, surface of lymph tract. Observe 
 that in the region of 9 and 10 are afferent and 
 efferent vessels anastomoses without first 
 entering the gland. 
 
TRACTUS LYMPHATICUS AXD LYMPH 
 
 533 
 
 (blood, plasma, oxygen) and pressure (cardio-vascular function must be 
 normal; venous flow depends on arterial blood pressure); e. g., (2) the tractus 
 muscularis must functionate normally (lymph largely depends on muscular 
 activity, on respiration, condition of veins). The pathologic physiology of 
 any viscus is frequently restored by stimulating the four common functions 
 of other viscera (sensation, peristalsis, absorption, secretion). 
 
 I. VISCERAL DRAINAGE BY FLUID. 
 
 The most useful and safe diuretic is water. It is the natural functionat- 
 ing medium for the kidney. One of the best laxatives is water. Thirst 
 is nature's demand for fluid. 
 Water is the most important 1^ ^0 
 
 constituent of protoplasm, com- 
 prising some 70 per cent of it. 
 I was a watcher of Dr. Tanner 
 25 years ago when he lived 40 
 days on water alone — without 
 food. However, a few days 
 without water is imminently 
 fatal. The quantity of water 
 required by the organism varies 
 with the quantity eliminated. 
 The quantity of water elimi- 
 nated, approximately, by a sub- 
 ject of 150 lbs. at rest, is for 
 the tractus urinarius 45 ounces, 
 for the tractus respiratorius 12 
 ounces, for the tractus per- 
 spiratorius 8, for the tractus 
 intestinalis 5 ounces — a total 
 elimination of 70 ounces, al- 
 most 5 pints of fluid. It will 
 therefore require two quarts for 
 the demands of elimination or 
 to satisfy living functionation. 
 Many subjects do not drink 
 over three pints daily and that 
 is administered chiefly at meal 
 time, not only burdening the 
 tractus intestinalis with solid 
 food, but fluid also. Many subjects drink insufficiently and suffer consequent 
 oliguria, deficient drainage. Such subjects are burdened with waste laden 
 blood, inflicting irritation and trauma on the nerve periphery. They are in 
 conflict with their own secretions. Many women oppose free drinking from 
 the idea it creates fat. 
 
 Ample quantities of fluid at regular intervals is the safety valve of health 
 
 LYMPHATICS OF AXILLA AND MAMMA 
 
 Fig. 159. This illustration demonstrates the 
 course of infectious material or carcinoma from 
 mamma to axillary glands. The tractus lymphaticus 
 possesses numerous channels with ample lumen. 
 
 (Sappey.) 
 
534 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 and capacity for mental or physical labor. Ample fluids not only flush the 
 sewers of the body, but wash the internal tissues and tissue spaces, relieving 
 waste laden blood. The soluble matter and salts are not only dissolved (pre- 
 venting calculus, trauma and in- 
 fection) and eliminated, but the 
 insoluble matter and salts are 
 floated from the system, relieving 
 waste laden blood by such power- 
 ful streams of fluid that calculus 
 is not liable to be formed. One 
 of the most effective and natural 
 stimulants to the renal epithelium 
 is sodium chloride. (Note — 
 Sodium chloride should not 
 be employed in parenchymatous 
 nephritis.) For ten years I have 
 diluted the urine, increased its 
 volume (consequently increased 
 ureteral peristalsis) and clarified 
 it by administering 8 ounces of 
 ^2 or 34 normal salt solution six 
 times daily. I have manufac- 
 tured sodium chloride tablets (12 
 gr. each with flavor). The pa- 
 tient places on the tongue a half 
 tablet (NaCl) and drinks a glass- 
 ful of water (better hot) before 
 each meal. This is also repeated 
 in the middle of the forenoon (10 
 A. M.), middle of the afternoon 
 (3 P. M.), and at bedtime (9 P. 
 M.). The patient thus drinks 3 
 pints of (/{ to Y*) normal salt 
 solution daily. This practically 
 renders the urine normal, and acts 
 as ample prophylaxis against the 
 formation of urinary, hepatic, 
 pancreatic, faecal calculus, and 
 drains the body of waste material. 
 The formation of calculus cannot 
 occur when ample fluid in vig- 
 orous streams bathe, flood the 
 glandular exit canals. With a 
 deficient fluid stream, crystals 
 form a calculus with facility. 
 The maximum concentrated solu- 
 
 DUCTUS THORACICUS, SINISTER ET 
 DEXTER (TOLDT) 
 
 Fig. ICO. This illustrates well the terminating 
 lymph trunks as an anastomosing network on the 
 dorsal wall. Note : (a) the isthmus of the thoracic 
 duct (at its middle portion, 27); (b) the recep- 
 taculum lymphatica (25) at its distal end ; (c) the 
 thoracic dilatation or ampulla at its proximal end. 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 535 
 
 tion of urine, bile or pancreatic juice tends to crystallize with vastly more 
 facility than dilute urine, bile and pancreatic juice. In "visceral drainage" 
 single crystals on first formation are rapidly floated with facility by the ample 
 fluids present, while by diminutive quantities of fluid, and consequently aggre- 
 gation, the crystals tend to precipitate, lodge, accumulate and form calculus. 
 Oliguria is a splendid base for calculus formation in the ureter. For over 
 ten years I have been using sodium chloride, normal salt solution, more or 
 less in my practice. During that time some practical clinical views have 
 been demonstrated and repeated so frequently that they have become estab- 
 lished, I think, beyond the shadow of doubt. The following propositions 
 have been repeatedly demonstrated hundreds of times — during the last ten 
 years — in the clinics of Dr. Lucy Waite and mine and in our surgical opera- 
 tions that I shall consider them established 
 until otherwise disproven : 
 
 1. Sodium chloride (Y to Y normal 
 physiologic salt solution) is a powerful stim- 
 ulant to the renal epithelium (tractus urina- 
 rius). 
 
 _. The administration of 8 ounces of Y* 
 to % normal physiologic salt solution (better 
 hot) every two hours for six times daily will 
 increase the quantity and clarify the urine, 
 by diluting its color and salts making it 
 appear almost like spring water in 3 to 5 
 days. (Note — Sodium chloride should not 
 be administered in parenchymatous ne- 
 phritis — not in fluid or food — as it exacer- 
 bates, irritates, the diseased, inflamed 
 parenchymatous cell.) 
 
 8. Sodium chloride (in Y* to % normal 
 physiologic solution) is a vigorous stimulant 
 to the epithelium of the tractus intestinalis 
 and its appendages. Normal salt solution 
 is an excellent remedy to quench thirst 
 subsequent to peritonotomy by rectal lavage — a pint every hour. 
 
 4. Sodium chloride is vigorously active stimulant to (glandular) epithe- 
 lium as that of the tractus urinarius, intestinalis, genitalis, cutis respiratorius, 
 salivary, hepatic and pancreatic glands. It stimulates the four common vis- 
 ceral functions — sensation peristalsis, absorption, secretion. It is a natural 
 stimulant (to epithelium and endothelium) as it constitutes over Yi of 1 per 
 cent of the blood. The lymph plasma arises from the blood plasma. What- 
 ever dilutes the blood plasma will therefore dilute the lymph plasma. Eight 
 ounces of partial normal salt solution 6 times daily will increase the blood 
 volume and consequently increase the lymph volume which will irrigate, flush 
 the lymph spaces and wash the cells. Also increased blood volume increases 
 the pressure or rate of lymph flow, perfecting visceral drainage. Since the 
 
 PERIVASCULAR LYMPHATIC 
 (GEGENBAUER) 
 
 Fig. 161. A, perivascular lympha- 
 tic of the turtle's aorta. B. cross sec- 
 tion of an artery from the cerebrum 
 presenting perivascular lymph spaces 
 divided by partitions. It is known 
 as the perivascular lymph space of 
 His. The Virchow-Robin space is 
 the lymph space in the adventitia of 
 blood vessel wall. 
 
536 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 lymph plasma contains not only the nourishment for the cells but also the 
 waste product of the cell the drainage of the tractus lymphaticus should be 
 rather excessive than deficient as the abundant fresh nourishment vitalizes, 
 energizes the cell. Cell function is performed through a fluid medium, hence 
 water, which is a fluid transporter, a solvent, an eliminator and regulator of 
 temperature, is first and foremost essential in the pathologic physiology of 
 the tractus lymphaticus. We live in a fluid medium and elimination demands 
 a compensatory supply so that the cells may continue their submerged aqua- 
 tic life. Living cells, which is life, will persist in a fluid medium only. 
 Ample water drinking affords a bath for the cells. Absorption of fluids from 
 the tractus intestinalis is especially stimulated by NaCl and C0 2 , i. e., nor- 
 mal salt solution surcharged 
 with carbonic acid gas passes 
 into the tractus vascularis 
 and consequently in the 
 tractus lymphaticus the most 
 rapidly of any fluid. 
 
 Sodium chloride is the 
 most important inorganic 
 salt in the body, e. g., blood 
 plasma contains 0. 7 per cent ; 
 lymph plasma contains 0.6 
 per cent; saliva contains 0.8 
 percent; gastric secretions 
 0.2 per cent; pancreatic se- 
 cretions 0.3 per cent; bile 
 contains 0.7 per cent; mus- 
 cle contains 0.7 per cent; 
 cerebro-spinal fluid contains 
 0.5 per cent; milk contains 
 0.23 per cent; cedematous 
 contains 0.8 per cent. So- 
 dium chloride, being univer- 
 sally distributed in the body, 
 plays some role of maximum 
 importance in the animal economy. Sodium chloride maintains the body 
 solutions at a fixed density, therefore maintaining the body tissue at a 
 proper percentage of water. It maintains blood plasma density in order to 
 suspend red corpuscles, and lymph plasma density in order to maintain in 
 suspension the guests — white blood corpuscles. Cattle breeders know that 
 a herbivora will not thrive well without a certain quantity of NaCl. Deer 
 will travel miles to frequent the "lick." Carnivora secure sufficient NaCl 
 from their food. 
 
 NaCl is required for a stimulus to muscular contraction. NaCl is of spe- 
 cial value to digest vegetables (vegetarians). NaCl plays a maximum role in 
 the physiology of the animal economy. Its elimination from diet produces 
 
 SUPERFICIAL(SMALLER) AND DEEP (LARGER) 
 ANASTOMOSING LYMPHATICS 
 
 Fig. 162. From the skin of a child's scrotum. This 
 cut demonstrates the magnitude and importance of the 
 lymphatic apparatus. (Teichman.) 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 :,::: 
 
 pathologic conditions. In parenchymatous nephritis it should be adminis- 
 tered in a minimum quantity as it excessively stimulates the inflamed renal 
 cell. For further details regarding NaCl see Dr. Herbert Richardson, Amer- 
 ican Medicine, July, 1906. 
 
 The power of rapidly absorbing water in the tractus intestinalis is in the 
 following order, viz.: (a) absorption is rapid and vigorous in the enteron; 
 (b) absorption is moderately rapid and vigorous in the colon — (however I 
 have observed a pint an hour absorbed per rectum and sigmoid); (c) absorp- 
 tion occurs slowly and moder- 
 ately in the stomach. Ample 
 water inhibited at regular in- 
 tervals serves as a medium for 
 prompt conveyance of nourish- 
 ment to the cells. It acceler- 
 ates the current of the blood 
 and lymph plasma — at once 
 promptly nourishing and drain- 
 ing the cells. Ample fluids at 
 regular intervals increase the 
 volume and rate of blood flow, 
 hence circulation is more rapid 
 and thus the blood absorbs 
 more oxygen in a definite time 
 to be transported in life to the 
 tissue. Visceral drainage fur- 
 nishes a maximum nourishment 
 and drainage to cells and hence 
 furnishes a maximum vitality 
 to the organism. In patho- 
 logic physiology of the tractus 
 lymphaticus — as in tissue oede- 
 ma or "dropsies" — ample fluids 
 (carbonated normal salt solu- 
 tion) at regular intervals are 
 beneficial, producing rapid re- 
 lief, from extrarenal, cutaneous 
 and intestinal elimination. In- 
 sufficient fluid ingesta makes 
 the body resemble a stagnant 
 pool, while ample fluid ingesta invigorates it to a 
 is a vital stimulant for cell function. 
 
 LYMPHATICS AND GLANDS OF THE MESEN- 
 TERON 
 
 Fig. 163. This figure represents excellently the 
 relation of the mesenteronic lymphatics and glands 
 to the vasa mesenterica. The several tiers, rows of 
 mesenteronic lymphatic glands, present characteris- 
 tic hypertrophy in pathologic physiology of tractus 
 lymphaticus associated with the enteron. (Henle.) 
 
 mountain stream. Water 
 
 (b) visceral drainage by food. 
 
 To drain viscera by appropriate food may sound paradoxical, but 75% of 
 food is fluid and both solid and fluid ingesta excite the four grand common 
 visceral functions of the tractus lymphaticus, viz., sensation, peristalsis, 
 
53S 
 
 THE ABDOMIXAL AXD PELVIC BRA IX 
 
 absorption, secretion, which are initiated, maintained and subside by fluid 
 and food. The appropriate food produces the appropriate degree of sensa- 
 tion, peristalsis, absorption, secretion in the tractus intestinalis for function- 
 ation. The food that will induce proper sensation, peristalsis, absorption 
 and secretion is that which leaves a maximum indigestible residue to stimulate 
 the enteron and colon, such as cereals and vegetables Peristalsis is neces- 
 sary for secretion, for peristalsis massages the secretory glands in the tractus 
 intestinalis, enhancing secretory activity. The question of diet to determine 
 is: (a) what kind of food causes calculus-producing material in the urine, 
 pancreatic secretion or bile? (b) what kind of food influences the solubility 
 
 _i£if-.« 
 
 THE INGUINAL GLANDS RECEIVING THE RECTAL AND GENITAL LYMPH 
 
 CHANNELS (TOLDT) 
 
 Fig. 164. This figure demonstrates that rectal or genital infectious or c^r' inomatous 
 material will be transported to the inguinal glands — hence the hypertrophy ard tenderness 
 of the inguinal glands are indicators of pathologic physiology in the genitals and re:tum. 
 
 of the calculus-producing material in the urine, pancreatic secretion or 
 bile? (1) The meat eater is the individual with the maximum quantity 
 of free uric acid in the urine. Flesh is rich in uric acid. Hence, in 
 excess of uric acid in the urine, flesh (meat, fish, and fowl are all about 
 equal in power to produce uric acid) should be practically excluded, 
 because it increases free uric acid in the urine, e. g., the rational treatment 
 of excessive uric acid in the urine consists of administering food that contains 
 elements to produce basic combinations with uric acid, forming urates (usually 
 sodium) which are free soluble, this will diminish the free uric acid in the 
 urine. Excessive uric acid in the urine is an error in metabolism. Flesh 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 539 
 
 eaters have uric acid and stone. Vegetarians have phosphate, oxalate stone. 
 Generally the subject who suffers from uric acid is a generous liver, liberally 
 consuming meat and highly seasoned foods, indolent and sedentary persons, 
 and alcoholic indulgers. 33% of uric acid is nitrogen. Uric acid is derived 
 
 \ 
 
 S^^U 
 
 LYMPH GLANDS AND CHANNELS RELATING TO MAMMA AND NECK 
 
 (TOLDT) 
 Fig. 165. This illustration demonstrates the relation of the mamma to the axillar -y 'glands 
 and subclavicular glands. This is especially important in pathologic Phy slol °g> ° f ' h * r ,?£ ~ 
 of infectious and carcinomatous material. It is evident that the only hope in controlling 
 carcinoma is by observing its pathologic physiology in the precarcinomatous stage. 
 
540 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 from the nuclei that form a constituent of all cell nuclei and which are taken 
 in the body as food. Beef bouillon may be administered because the extract 
 matters in it will scarcely increase the uric acid. A general meat diet largely 
 increases the free uric acid in the urine. (2) The food should contain matters 
 rich in sodium, potassium and ammonium, which will combine as bases with 
 uric acid, producing alkaline urates that are perfectly soluble in the urine. 
 
 These typic foods are the vegetables which not only render the necessary 
 alkalies to reduce and transform the free uric acid into resulting soluble 
 urates, but leave an ample indigestible faecal residue to cause active intestinal 
 peristalsis, aiding in the evacuation 
 through the digestive tract. Hence, 
 the patient should consume large, 
 ample quantities of cabbage, cauli- 
 flower, beans, peas, radishes, tur- 
 nips, spinach in order that sodium, 
 potassium and ammonium existing 
 in the vegetable may combine as 
 bases with free uric acid in the urine- 
 producing soluble urates, thus 
 diminishing free uric acid. A veg- 
 etable diet diminishes the free uric 
 acid in the urine 35% less than a 
 meat diet. Again the administration 
 of eggs and milk (lactoalbumen) lim- 
 its the production of uric acid. The 
 most rational advice is to order the 
 subject to live on mixed diet, con- 
 suming the most of that kind of food 
 which lessens the uric acid in the 
 urine — vegetables. Physiologic ob- 
 servations demonstrate that the char- 
 acter and quantity of the ingesta 
 determine the character and quan- 
 tity of the elimination. If the ap- 
 propriate food is so valuable in 
 "visceral drainage" in the treatment 
 of the typical uric acid subject the 
 appropriate food selected for the subjects of biliary and pancreatic, faecal 
 calculus, will be relatively as useful. The foods that make soluble basic 
 salts with secretions should be selected. Besides, the selection of appro- 
 priate food is frequently amply sufficient to drain the intestinal tract to 
 prevent constipation. It is true, foods alone are not a complete substitute 
 for fluids, but vast aid in visceral drainage may be accomplished by admin- 
 istering food containing considerable coarse residual indigestible matter so 
 that a maximum faecal residue will stimulate the intestines, especially the 
 colon, to continuous vigorous activity, stimulating to a maximum action of 
 
 LYMPHATICS OF WALL OF ENTERON 
 OF CALF (INJECTED) 
 
 Fig. 166. 1, First upper lymphatics within 
 the intestinal villi. 2, next lower layer inter- 
 nal (sub mucous) lymphatic network. 3, next 
 lower layer langlobate glands (10). 4, ex- 
 ternal layer of lymphatic network (observe 
 the valves in this layer). 5, circular muscular 
 layer. 6, peritoneal layer. (Teichman.) 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 541 
 
 the four grand functions — sensation, peristalsis, absorption and secretion. 
 For twenty years I have treated subjects with excess of uric acid in the 
 urine by administering an alkaline laxative in fluid. The alkaline tablet is 
 composed of cascara sagrada (3V gr. ), aloes (\ gr.), NaHC0 3 (1 gr.), 
 KHCO3 (} gr.), MgS0 4 (2 grs.). The tablet is used as follows: i to 1 
 tablet (or more, as required to move the bowels once daily) is placed on the 
 tongue before meals and followed by 8 ounces of water (better hot). At 10 
 a. m., 3 p. m., and bedtime the administration is repeated and followed by a 
 glassful of fluid. 
 
 In the combined treatment the appropriate dose of the sodium chloride 
 and alkaline tablet are both placed on the tongue together immediately fol- 
 lowed by the 8 ounces of fluid six times daily. This method of treatment 
 furnishes alkaline bases (sodium and potassium and ammonium) to combine 
 
 INJECTED LYMPHATIC VESSELS OF THE TONGUE 
 
 Fig. 1G7. The ample transporting lymph apparatus is demonstrated by numerous chan- 
 nels with ample lumen. (Teichman.) 
 
 with the free uric acid in the urine, producing perfectly soluble alkaline 
 urates and materially diminishing free uric acid in the urine. Besides, the 
 sodium chloride and alkaline laxative tablets stimulate the sensation, peristalsis, 
 absorption and secretion of the intestinal tract (and all other visceral tracts) — 
 aiding evacuation. I have termed the sodium chloride and alkaline laxative 
 method the visceral drainage treatment. The alkaline and sodium chloride 
 tablets take the place of the so-called mineral waters. Our internes have 
 discovered that on entering the hospital the patient's urine presents numerous 
 crystals under the microscope. However, after following the "visceral drain- 
 age treatment" for a few days, crystals can scarcely be found again. The 
 hope of removing a formed, localized ureteral or other calculus lies in secur- 
 ing vigorous ureteral or other duct peristalsis with a powerful ureteral or 
 other duct stream. Transportation of ureteral calculus is aided by system- 
 atic massage over the psoas muscle and per vaginam. Subjects afflicted with 
 
542 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 excess of the uric acid (and consequent ureteral calculus) in the urine or 
 other form of calculus need not make extended sojourns to watering places, 
 nor waste their time at mineral springs nor tarry to drink the hissing Sprudel 
 or odorous sulphur, for they can be treated sucessf ully in a cottage or palace 
 by " visceral drainage." The treatment of a uric acid or other calculus 
 consists, therefore, in the regulation of food and water. It is dietetic. The 
 control, relief and prophylaxis of uric acid diathesis or tendency to other 
 calculus formation is a lifelong process. When the uric acid or other cal- 
 culus has passed spontaneously the patient does not end his treatment, but 
 should pursue a constant systematic method of drinking ample fluids at regu- 
 lar intervals and consume food which contains bases to combine with free 
 uric acid or other compounds producing soluble urates or other soluble 
 compounds. 
 
 LYMPHATICS OF THE VERMIFORM APPENDIX 
 
 Fig. 168. The lymphatics are injected and present valves. There are two conglobete 
 glands. This lymph apparatus can transport infection with facility on account of its num- 
 erous channels of large dimensions. (Teichman.) 
 
 I continue this treatment for weeks, months, and the results are remark- 
 ably successful. The urine becomes clarified like spring water, and increased, 
 in quantity. The volume and rate of blood flow is increased, transporting 
 increased oxygen to tissue. The volume and rate of lymph flow is increased, 
 transporting increased nourishment to the cell and increasing cell drainage, 
 energizing and vitalizing the organism. 
 
 The tractus intestinalis becomes freely evacuated, regularly daily. The 
 blood is relieved of waste laden and irritating material. The tractus cutis eli- 
 minates freely, and the skin becomes normal. The appetite increases. The 
 four grand common visceral functions — sensation, peristalsis, absorption and 
 secretion — are acting normally. The sewers of the body are well drained and 
 flushed. The sleep becomes improved. The feelings become hopeful. 
 
TRACTUS LYMPHATICUS AND LYMPH 
 
 543 
 
 (c) HABITAT IN VISCERAL DRAINAGE. 
 
 Habitat includes all methods of living from the sedentary to the ath- 
 letic, from the paralytic to the traveler. In general the habitat will refer 
 chiefly to the tractusmuscularis and tractus respiratorius. Muscular activity, 
 vigorous exercise, enhances two grand functions, viz., tractus vascularis and 
 tractus glandularis. 
 
 The muscles are powerful regulators of circulation (blood and lymph) 
 hence their stimulation (exercise) increases the tone of vessels, magnifies 
 blood currents to viscera which consequently multiplies common visceral 
 function (sensation, peristalsis, absorption and secretion), ending in free 
 visceral drainage. Muscular activity 
 increases blood volume, universally 
 improving nutrition. Maximum 
 blood volume is the primary base of 
 visceral peristalsis. The most typical 
 popular example of the muscles con- 
 trolling the blood circulation is that 
 of the uterus. The myometrium like 
 elastic living ligatures controls the 
 uterine blood supply (and conse- 
 quently its functions), (sensation, 
 peristalsis, absorption, secretion, 
 menstruation and gestation), hence 
 drainage with flaccid muscles drain 
 glandular secretion, as in the uterus, 
 may be excessive (leucorrhea). 
 
 Exercise is an essential for 
 health. Muscles exercise a domi- 
 nating control over circulation (blood 
 and lymph). The abdominal mus- 
 cles influence the caliber of the 
 splanchnic vessels. They exercise an 
 essential influence over peristalsis, 
 secretion, absorption, of the tractus 
 intestinalis, urinarius, vascularis and 
 genitalis. The muscles massage the 
 viscera, enhancing their function and 
 
 the rate of circulation with consequent free drainage. In the uterus, the 
 most typical example (especially marked during parturition), is prominently 
 demonstrated how the myometrium controls the blood currents like elastic 
 living ligatures. The myometrial bundles by continual contraction decreases 
 the dimension and blood volume of the uterus at a moment's notice subse- 
 quent to parturition. The muscular system is equally and continually 
 influential, at all other time as it is parturition, over circulation and visceral 
 function. Regular vigorous habits enhance visceral drainage. 
 
 The value of fresh air was never realized so effectively and practically as 
 
 
 
 
 
 LYMPH VESSELS OF DOG'S STOMACH 
 
 Fig. 169. a, a, superficial layer ; b, b, deep 
 layer, anastomosing lymphatics. It shows a 
 rich transporting tubular apparatus. (Teich- 
 man.) 
 
544 THE ABDOMINAL AND PELVIC BRAIN 
 
 at present. Fresh cold air cures pulmonary and other tuberculoses. The 
 success of the sanitorium is the continued use of fresh (cold) air. The sub- 
 ject should sleep with fresh continuous cold air passing through an open 
 window space of 3x3 feet. Every physician should advocate the continuous 
 open window, day and night for living and sleeping room. It appears to be 
 demonstrated that cold fresh air is more beneficial than warm fresh air. It 
 is common talk among people that one winter in the mountains is worth two 
 summers for the consumptive. Much of man's disease is house disease. It is 
 lack of oxygen and exercise. The curative and beneficial effect of cold fresh 
 air continually, day and night, for the family must be preached in season 
 and out of season by the physician. The windows should be open all night. 
 Fresh cold air is one of the best therapeutic agents in pathologic physiology 
 of viscera. It stimulates viscera to active function and consequent visceral 
 drainage. Observe the wonderful results of systematic deep breathing, — 
 chest expansion. It utilizes ample oxygen which is rapidly transported to 
 the tissue by the tractus vascularis. If one observes the naked body in rapid 
 deep breathing it will be observed that man's respiratory apparatus extends 
 from his nostrils to his pelvic floor, i. e., it extends to the territory of the 
 spinal (intercostal and lumbar) nerves. Hence, by stimulating to a maximum 
 the functions of the tractus respiratorius (sensation, peristalsis, absorption, 
 secretion) — e. g., by systematic deep respiration — vast benefits result to the 
 organism. The habitat that furnishes opportunity for abundant fresh air, like 
 an open tent on the plains and ample muscular exercise, is the one that affords 
 the essential chances for recovery of pathologic physiology viscera. It en- 
 hances visceral drainage. Fresh air is required to transport a continuous, 
 ample supply of oxygen to the muscular apparatus to maintain its normal 
 tone, its contractions and relaxations. 
 
 (d) avocation in visceral drainage. 
 
 The suitability of avocation to health is a daily observation. The pris- 
 oners confined in a cell, the clerk confined in a store, stand in contrast to 
 the subjects living in the field, and the traveler continually exposed 
 to sun and wind. The sedentary occupation confining the laborer affords 
 insufficient muscular exercise or fresh air to maintain ample visceral drain- 
 age. Visceral drainage is required for health as nourishment. Fresh air 
 aids visceral drainage by transporting well oxygenized blood to the viscera 
 which stimulates the four common visceral functions. The avocation should 
 suit the laborer's physique that the four common visceral functions may be 
 normally maintained. 
 
 CONCLUSIONS REGARDING VISCERAL DRAINAGE. 
 
 Normal visceral drainage is the key to health. It is maintained by ap- 
 propriate fluid, food, habitat, avocation. Visceral drainage depends on the 
 normal activity of the four common visceral functions (sensation, peristalsis, 
 absorption, secretion). The chief factor in appropriate visceral drainage is 
 ample fluid administered at regular intervals. It requires five pints of fluid 
 
TRACTUS LYMPHATICUS AND LYMPH 545 
 
 daily to compensate for the visceral elimination. The function of water in 
 the organism is: — 1, elimination; 2, solvent; 3, transporter ; 4, regulator of 
 the temperature. The cells of the body (parenchymatous and connective 
 tissue) functionate in a fluid medium. Life can persist in a fluid medium 
 only. Visceral drainage is a vast factor in correcting the pathologic physi- 
 ology of viscera and especially the tractus lymphaticus. Therapeutics must 
 be rational, for nature alone can cure. Therapeutics must imitate and aid 
 nature in restoring function by natural agents. Practically the influence 
 of a physician is limited to pathologic physiology, i. e., the zone between 
 normal physiology and pathologic anatomy. The physician's chief duty is 
 to correct function. Visceral drainage produces maximum cell nourishment 
 and maximum cell drainage, hence creates maximum energy and vitalizes the 
 organism. Practically ample fluids at regular intervals is recommended 
 in pathologic physiology of the viscera, e. g., in obesity, in diabetes, in rheum- 
 atism, in fevers, cholelithiasis, nephrolithioses, constipation. Water is a 
 vital stimulant to the life of a cell. 
 
CHAPTER XXXIX. 
 
 SPLANCHNOPTOSIA (ATONIA GASTRICA). 
 
 Factors. 1. Deranged respiration (due to thoracic splanchnoptosia). 
 2. Relaxed Abdominal wall. 3. Altered form of Abdominal cavity (Pendu- 
 lous). 4. Elongation of visceral supports (mesenteries). 5. Gastro-duodenal 
 Dilation (due to compression of the transverse duodenal segment by the 
 superior mesenteric artery, vein and nerve). Splanchnoptosia signifies 
 abnormal distalward movement (sinking prolapse) of viscera. Atonia 
 gastrica signifies abdominal relaxation which is preceded by thoracic relaxa- 
 tion. Splanchnoptosia is included in the diseases of the vasomotor nerve 
 (sympathetic) because the chief and final effect lies in its domain. It is true 
 that the thoracic (diaphragm) and abdominal wall (supplied by spinal nerves) 
 are the primary factors in maintaining and fixing the thoracic and abdominal 
 organs in their normal physiologic position, that relaxation of the thoracic 
 (diaphragm) and abdominal walls are the primary factors in splanchnoptosia, 
 and that in treatment the thoracic (diaphragm) and abdominal walls (areas 
 of respiration) are the primary factors for consideration. However, the 
 damaging effects on the life of the patient rests on the seven visceral tracts 
 (supplied mainly by the sympathetic nerve) viz: — (1) Tractus Respiratorius, 
 (2) Tractus nervosus, (3) Tractus vascularis, (4) Tractus lymphaticus, (5) 
 Tractus intestinalis, (6) Tractus urinarius, (7) Tractus Genitalis (in the order 
 enumerated). 
 
 Pathological Relations. 
 
 The object of this essay is to demonstrate the relations of splanchnopto- 
 sia (atonia gastrica) — to pathologic conditions, as deranged innervation, 
 circulation, respiration, secretion, absorption, muscularis. Relaxation of 
 tissue — muscle, elastic, connective — means elongation of the same. A 
 triumvirate of conditions in splanchnoptosia demand skilled consideration 
 viz. : Anatomy, Physiology and Pathology of the thoracic and abdominal 
 viscera. 
 
 In the first place we wish to employ scientific nomenclature only. 
 Splanchnoptosia indicates the ptosis (falling) of the thoracic and abdominal 
 viscera and is the general term we will adopt. It is constantly accompanied 
 by relaxation of the thoracic (diaphragm) and abdominal walls. Gastroptosia 
 signifies abdominal ptosis (not merely of the stomach). Atonia Gastrica 
 signifies abdominal relaxation (and should for accuracy) displace gastroptosia. 
 However, since in stomachoptosia (ptosis of the stomach only) there are 
 other associated visceral ptoses, the terms gastroptosia and atonia gastric are 
 equivalent terms for they both include visceral ptoses and relaxation of the 
 
 546 
 
SPLASCIIXOPTOSIA 
 
 547 
 
 abdominal walls. Enteroptosia is ptosis of the abdominal viscera in general 
 and may include those of the thoracic cavity. I shall reserve for the term 
 enteroptosia the signification of ptosis of the enteron (duodenum, jejunum, 
 and ileum). Coloptosia means ptosis of the colon, and its anatomic seg- 
 ments can be designated by an adjective as coloptosia transversa. 
 
 Dr. Achilles Rose of New 
 York and Dr. Kossman of 
 Berlin should be credited for 
 an attempt to introduce 
 scientific nomenclature in 
 this subject. 
 
 Splanchnoptosia though a 
 single unit is a general dis- 
 ease of the thoracic and ab- 
 dominal viscera accom- 
 panied by relaxation of the 
 thoracic and abdominal mus- 
 cular walls. In short splanch- 
 noptosia prevails wher- 
 ever the nerves of respira- 
 tion innervate. In splanch- 
 noptosia not only several 
 viscera are simultaneously 
 affected but also the thoracic 
 and abdominal walls are re- 
 laxed. From an erroneous 
 and limited view of the 
 founder of splanchnoptosia 
 (Glenard) and the accepta- 
 tion of the error by numer- 
 ous followers the idea has 
 prevailed that ptosis of 
 single viscera occur and to 
 them numerous pathologic 
 symptoms have been at- 
 tributed. Hence a stately 
 
 ~. , Wrt A , , , n- literature has arisen from 
 
 Fig. 170. A female splanchnoptotic, a multipara, . 
 
 ventral view of relaxed abdominal walls. Observe that nephroptosia, stomacnopto- 
 the relaxed abdominal walls pass sufficiently distalward g j a co lop.tosia (transversa), 
 to conceal the genitals from view. Note the marked dis- ' . „ 
 
 talward position of the umbilicus. There is a depression enteroptosia, etc., etc. Un 
 at the epigastrium. The abdomen is flattened (changed ^j s error { single visceral 
 in form), pendulous. . , , , , , ,. 
 
 ptosis has been founded the 
 
 irrational surgery of so-called visceral pexies. One viscus may be afflicted 
 
 with greater degree of ptosis than another, however, splanchnoptosia is a 
 
 general process affecting the thoracic and abdominal walls, the visceral 
 
 mesenteries and visceral shelves. 
 
548 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 The following table will explain itself: 
 
 TABLE OF NOMENCLATURE IN SPLANCHNOPTOSIA WITH RESULTS. 
 
 I. Tractus 
 
 Respiratorius 
 
 II. Tractus 
 Nervosus 
 
 III. Tractus 
 
 Lymphaticus 
 
 IV. Tractus 
 Vascularis 
 
 V. Tractus 
 Intestinalis 
 
 VI. Tractus 
 Urinarius 
 
 VII. Tractus 
 Genitalis 
 
 } 
 
 Ptosis Pulmonalis 
 
 Ueu 
 
 ro-Ptosia 
 
 Ptosis Lymphaticus 
 
 } 
 
 Ptosis Vascularis 
 
 1. Gastroptosia 
 
 2. Enteroptosia 
 
 3. Coloptosia 
 
 4. Hepato-Ptosia 
 
 5. Pancrea-Ptosia 
 ^6. Lienoptosia 
 
 1. Adrenoptosia 
 
 2. Nephroptosia 
 
 3. Uretero-Ptosia 
 
 4. Vesico-Ptosia 
 
 1. Ovario-Ptosia 
 
 2. Oviducto-Ptosia 
 
 3. Metro-Ptosia 
 ,4. Elytro-Ptosia 
 
 n 
 
 I 
 
 'excessive respiration 
 . deficient respiration 
 Result-! disordered respiration 
 
 distalward movement of the 
 diaphragm 
 
 rtrauma (elongation, pain) 
 fmotion 
 Result- 1 altered function <^ secretion 
 [^sensory 
 
 ^neurosis 
 
 fflexion 
 I stenosis 
 Result^ elongation 
 j dilatation 
 (^neurosis 
 
 'cardioptosia 
 flexion 
 stenosis 
 elongation 
 dilatation 
 neurosis 
 
 fflexion 
 stenosis 
 elongation 
 dilatation 
 Result*} neurosis 
 
 Result< 
 
 Result^ 
 
 Altered 
 
 flexion 
 stenosis 
 dilatation 
 neurosis 
 
 Result< 
 
 Altered 
 
 'flexion 
 stenosis 
 neurosis 
 
 Altered 
 
 secretion 
 absorption 
 peristalsis 
 sensation 
 
 secretion 
 absorption 
 peristalsis 
 sensation 
 
 secretion 
 absorption 
 peristalsis 
 sensation 
 
 Historical, 
 
 Though Aberle, Rollet, Rayer, and Oppoltzer presented views of 
 splanchnoptosia, it is probable that J. B. Morgangni (Italian, 1682-1771) was 
 among the first to describe splanchnoptosia anatomically. However, it is 
 my opinion that Rudolph Virchow (1821-1902), my honored teacher, deserves 
 the credit of calling the attention of physicians to splanchnoptosia. He did 
 this practically in 1853 in the fifth volume of his archives by an article 
 entitled "An Historical Critical and Exact Consideration of the Affections of 
 the Abdominal Cavity." The great genius of Virchow is displayed in this 
 
SPLANCHNOPTOSIA 
 
 549 
 
 extensive autopsic investigation, thirty-two years before Glenard stamped 
 his views on the profession. He called especial attention to dislocation of 
 viscera by peritonitis and advocated that they were the starting points of 
 various symptoms of dyspepsia and indigestion. To Kussmaul we owe the 
 
 first definite views of gastro- 
 psia. The French following 
 Glenard view splanchnoptosia 
 as a congenital affection. The 
 Germans are opposed to this 
 view and maintain that splanch- 
 noptosia is an acquired disease 
 as through pregnancy, peri- 
 tonitis, method of dress, avoca- 
 tion, living and so forth. 
 Others view splanchnoptosia 
 as a combined effect, congeni- 
 tal predisposition and post 
 natal acquisition. Among some 
 authors, chiefly German, the 
 view is entertained that 
 splanchnoptosia is a reversion 
 to embryonic condition i. e., the 
 viscera gradually reverse their 
 embryonic growth and develop- 
 mental process. 
 
 The year 1885 was an event- 
 ful one in the pathology and 
 treatment of relaxed abdominal 
 walls, and consequent splanch- 
 noptosia. This was the period 
 in which Glenard's labors be- 
 came known. But Glenard was 
 not the only one working on 
 the subject of splanchnoptosis. 
 Czerney and Keher, of Heidel- 
 berg, were presenting cases of 
 visceral ptosis in their clinics in 
 1884 and as a pupil I gained 
 some views on the subject. 
 However, during a whole year's 
 study in Berlin in 1885, with 
 distinguished surgeons, the 
 subject was not once discussed. Subsequently, in a year's course of study 
 with noted German specialists, Professor Schroder showed many subjects of 
 splanchnoptosis. Dr. Landau, who wrote "Wander Niere" (wandering kid- 
 ney) and "Wander Leber" (wandering liver), gave extensive courses and 
 
 Fig. 171. A lateral view of a female splanch- 
 noptotic, a multipara, showing relaxed abdominal 
 walls and umbilicus in a distalward location. The 
 abdomen is pendulous. An attitude of lordosis is 
 assumed for balancing support 
 
550 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 discussed relaxed abdominal walls and consequent splanchnoptosia, in an in- 
 teresting manner. In fact, among Germans the term "Hangebauch" (hang- 
 ing belly) has been common for twenty-five years. Dr. August Martin 
 presented instructive views on the subject in his excellent gynecologic 
 course to physicians. During the past twenty years I have pursued the 
 
 Fig. 172. A female splanchnoptotic with the ventral abdominal walls removed, present- 
 ing the viscera in an advanced state of splanchnoptosia. The diaphragm is exposed showing 
 the vena cava (v), the aorta (a) and the oesophagus (ce) projecting through it. A typical 
 splanchnoptotic relation appears with the liver and the stomach (st). In this subject the 
 stomachis practically vertical. The right and transverse colon are forced in the greater 
 pelvis with the main enteronic loop. The flexura coli sinistra (sp) is dragged distalward. 
 The notable phenomenon in this subject is the hypertrophy and distalward movement of the 
 right hepatic lobe — it is at its present stage a typical Riedel lobe. 
 
SPLANCHN0PT0S1A 551 
 
 study of splanchnology among hundreds of gynecologic patients, both medi- 
 cal and surgical, and in the personal abdominal inspection of six hundred 
 adult autopsies. In this paper I will present essentials of the knowledge 
 gained in that experience. 
 
 General Views of Splanchnoptosia from Embryology. 
 
 The abdominal viscera are maintained in their normal physiologic posi- 
 tion by: (a) nerves and vessels; (b) peritoneum; (c) ligaments; (d) visceral 
 pressure; (e) ligaments; (f) visceral shelves; (g) abdominal walls (muscular 
 and osseous). The first idea of importance is that no organ is absolutely or 
 immovably fixed but that each viscus is endowed with a certain degree of 
 movement, hence, the irrational surgical fixation (pexies) of organs is 
 obvious. The mobility of organs is due to various factors as: (a), attitude 
 (prone or erect); (b), respiration; (c), material within the tractus intestinalis 
 (ingesta, gas); (d), material within the tractus urinarius (urine); (e), muscu- 
 lar movement of viscera (rhythm) and abdominal wall; (f), gestation (ma- 
 terial within the tractus genitalis). Hence the abdomen should be viewed as 
 occupied with viscera capable of more or less mobility — that fixation of 
 abdominal viscera is abnormal, as e. g., peritoneal bands and visceral 
 pexies. 
 
 The embryology of the abdominal viscera is an unending source of inter- 
 est. It is not a surpiise that after noting the development and axial rotation 
 of the tractus intestinalis the view should be entertained that splanchnoptosia 
 is a reversion of development and axial rotation of the digestive tube, i. e., 
 that the tractus intestinalis (and its appendages) has retraced its lines of 
 development. In the early embryo the tractus intestinalis is a straight tube 
 extending from mouth to anus in the middle line of the body (with the liver, 
 spleen and pancreas). Gradually with the progress of months the coecum 
 passes from left to right across the ventral surface of the enteron (duodenum) 
 and ends at birth in the region of the right kidney. 
 
 The liver gradually passes from the middle line to the right proximal 
 quadrant of the abdomen ending in the adult in the right concavity of the 
 diaphragm. This process of hepatic development is not complete at birth 
 for the large (pot) belly of the child is due to a large liver. In typical 
 splanchnoptosia the position of the abdominal organs stimulate those of the 
 embryo and infant. Seeking a clue for treatment from embryologic phenom- 
 ena it would be that splanchnoptosia is a general visceral disease and that 
 rational treatment should be applied to the abdominal walls — not to single 
 viscera as visceral pexies. 
 
 Clinical Aspects. 
 
 From a clinical view certain organs may appear of more significance in 
 splanchnoptosia than others. For example the general surgeon who does 
 not investigate the subject of splanchnoptosia centers his observations in idol 
 worship on the liver, kidney, uterus or stomach and with his cranium com- 
 pletely occupied with visceral pexies (heathen gods in physiology) initiates 
 
552 THE ABDOMINAL AND PELVIC BRAIN 
 
 his campaign of pexies or visceral fixation by suturing one of those organs to 
 the abdominal wall. What has he accomplished? He has produced one 
 lesion (visceral fixation) in attempting to improve another (supposed excess- 
 ive visceral mobility). Generally the worst is visceral fixation because the 
 fixation is unphysiologic, irrational and affects but a detached part, a seg- 
 ment of the general splanchnoptosia. The therapeusis should be applied to 
 the abdominal wall. 
 
 The embryologic view demonstrates that the seven visceral tracts (respi- 
 ratorius, intestinalis, circularis, lymphaticus, nervosus, urinarius and geni- 
 talis) are practically alike affected — splanchnoptosia is a unit though a general 
 disease. However, the symptoms of splanchnoptosia of some visceral tracts 
 are not so manifest as that of others e. g., the tractus nervosus is practically 
 manifest as that of the urinarious and intestinalis. Embryology suggests 
 that viscera of late development and distant fixation from the radix mesen- 
 terica (coeliac and superior mesenteric arteries) are prominent in splanch- 
 noptosia as the liver, stomach, colon, genitals, kidney. They are distantly 
 removed from the solid anchorage of the radix mesenterica and their solid 
 fixation is hence more limited by peritoneal bands to the abdominal wail. 
 
 For example the liver is practically fixed to the diaphragm only. Its 
 fixation to the radix mesenterica is limited by the anchorage it may obtain 
 from the arteria hepatica ensheathed with its fibrous tissue from the aorta 
 and its encasement of plexiform nerve network from the abdominal brain. 
 It must be admitted, however, that the late mesenterial development or 
 expanding of the base of mesenteries, the increased areas of peritoneal 
 adhesions (non-pathologic) to the dorsal wall as occurs in the liver, colon, 
 stomach enteron serves as valuable fixation for the viscera. These acquired 
 basal mesenterial expansions produce compact solidarity of organs re-enforc- 
 ing the supporting strength of the radix mesenterica (vascular). 
 
 GENERAL PATHOGENESIS OF SPLANCHNOPTOSIA. 
 
 The method of origin (aetiology) and development of splanchnoptosia 
 is explained by different authors through different views. The divergent 
 views entertained depend on the assumed beginning base — whether splanch- 
 noptosia be due to (a) congenital predisposition; (b) acquired defects from 
 life's opposing forces; (c) reversion to embryologic conditions or (d) a com- 
 bination of the three preceding factors. 
 
 First, a congenital predisposition suggests a characteristic body form or 
 congenital weakness or fragility of tissue which predisposes the individual in 
 the conflict of life's resisting forces to splanchnoptosia. 
 
 Second, acquired defects producing splanchnoptosia, attempts to explain 
 rationally the varied factors as rapidly repeated gestations, sudden loss of 
 fatty tissues, pathologic conditions of the abdominal wall, body form, the 
 influence of visceral motion in respiration, the evil effect of living and dress- 
 ing (constricting bands), as well as various industries and traumata. 
 
 Third, reversion to embryonic conditions would practically be a con- 
 stitutional predisposition and hence belong to congenital predisposition. 
 
SPLANCHNOPTOSIA 553 
 
 Fourth, the view which includes the combined factors of each theory 
 (congenital or acquired defects) of splanchnoptosia is the more rational, 
 because the disease is generally prevalent among all nations. 
 
 Anatomy and Physiology. 
 
 In the pathogenesis of splanchnoptosia two factors must be carefully 
 investigated, viz. : Anatomy and physiology. The anatomy must not only 
 include the elements — connective tissue, muscle, elastic fiber and bone — but 
 bodily form, attitude, avocation, modes of life. The physiology must 
 include all the consideration of visceral functions — respiration, gestation, 
 circulation, absorjtfion, secretion and rhythm. 
 
 Glenard a physician at Lyons, France, who practiced at Vichy observed 
 that splanchnoptosia was closely related to neurasthenia and nervous dyspep- 
 sia. Glenard observed three groups of symptoms viz: (1) (atonia gastrica) 
 abdominal relaxation or lack of tone in the abdominal wall which presented: 
 (a) deformity of the abdominal wall; (b) flabbiness, relaxation of the abdom- 
 inal wall; (c) ease with which the hypochondrium may be compressed. (2) 
 Splanchnoptosia presented: (a) (gastroptosia) splashing sounds in the 
 stomach; (b) epigastric pulsation; (c) nephroptosia; (d) coloptosia transver- 
 sum. (3) Enteroptosia presented three signs: (a) a palpable contracted band 
 of the transverse colon ; (Glenard's corde transverse colique) (b) the coecum ; 
 (c) the sigmoid. 
 
 Glenard found at Vichy resort 148 cases of splanchnoptosia in 1,310 
 subjects — ll c /c He practiced among a neurotic class of subjects. Glenard 
 believed that the starting point of splanchnoptosia is the sinking of the 
 flexura coli hepatica due to relaxation of the ligamentum flexura hepatica. 
 He considered that ptosis of single viscera could occur in four conditions, viz. : 
 (a) neurosis; (b) hepatic disease; (c) dyspepsia; (d) general or conditional 
 illness. The three main symptoms of splanchnoptosia according to Glenard 
 are colic, stenosis, nephroptosia and hepatic deformity. Glenard studied 40 
 splanchnoptotic autopsies and concluded that when the suspensory ligaments 
 of the stomach and intestines are relaxed accompanied by the distalward 
 movements of these viscera, stenosis will occur, and the coecum alone will 
 maintain its normal form as it has no suspensory ligament. Glenard's belt 
 test of splanchnoptosia consists in the physician standing behind the patient, 
 elevating the abdomen with the handsr and if it affords relief the diagnosis is 
 confirmed. The characteristic symptoms are: sensations of weakness, 
 abdominal discomfort, constipation. 
 
 Space forbids further views from Dr. Frantz Glenard, the founder of 
 splanchnoptosia whose excellent book of 875 pages lies before me. It was 
 published in 1899 and entitled the author to the pathologic eponym 
 '"Glenard's disease." The title of the book is "Des Ptoses viscerales Diag- 
 nostic et nosographie (enteroptosie — Hepatisme)." It is a monument of 
 industry which will be admired for all time. 
 
 Through all the pathogenesis of splanchnoptosia neurosis is a constant 
 accompaniment, inseparably connected. In 1896 Stiller published an article 
 
THE ABD0M1XAL AND PELVIC BRAIX 
 
 in which he claims that there is a neurasthenic stigma (stigma neurastheni- 
 cum), the floating tenth rib (costa decima fluctuens). Stiller believes that 
 splanchnoptosia rests on embryologic defect (vitium primas formationis). 
 
 This should be known by the 
 pathologic eponym St fil- 
 er's costal stigma." This 
 view is supported by rinding 
 nephroptosia in children. 
 Splanchnoptosia subsequent 
 to parturition (puerperium) 
 should be designated by the 
 pathologic eponym "Lan- 
 dau's splanchnoptosia." 
 
 Splanchnoptosia accom- 
 panying chlorosis should be 
 designated by the pathologic 
 eponym "Meinert's splanch- 
 noptosia. " Dr. Einhorn be- 
 lieves that constricting bands 
 (corset) play a large role in 
 the pathogenesis of splanch- 
 noptosis. 
 
 Keith' s TJieory. 
 
 In the pathogenic theories 
 of splanchnoptosia the latest 
 most elaborate and compre- 
 hensive is that of Arthur 
 Keith, in the Hunterian lec- 
 tures of 1903, published in 
 the London Lancet, March 
 7, and 14, 1903. Mr. Keith 
 claims in these most excel- 
 lent and well studied lectures 
 that splanchnoptosia is the 
 result of a vitiated method 
 of respiration. Keith's in- 
 vestigations o f splanch- 
 noptosia were conducted on 
 an anatomic base rather than 
 a clinical one and include 
 vast labors based on the solid 
 ground of nature. I wish 
 here to acknowledge my in- 
 debtedness to Mr. Arthur 
 Keith. 
 
 Fig. 173. Represents the abdominal and thoracic 
 organs separated by the diaphragm. The pillars or 
 crura of the diaphragm (AC and A C) are marked, 
 demonstrating that inspiration drags (forces) the thor- 
 acic organs distalvvard. Observe that the pericardium 
 is solidly and firmly fixed to the diaphragm, hence in 
 inspiration, when the diaphragm moves distalward, the 
 heart, lungs, and great thoracic vessels must accompany 
 it 
 
SPLANCHNOPTOSIA 555 
 
 Additional lure tors in Etiology. 
 
 1. Intra abdominal pressure. 
 
 Factors which increase intra-abdominal pressure: 1, Gestation. 2, Food. 
 3, Fluid. 4, Meteorism. 5, Adispose deposits. 6, Ascites. 7, Tumors. 
 8, Pleurisy. 9, Feces. 10, Urine. 11, Gastro-duodenal dilatation. 12, 
 Coughing, 13, Contracted pelvis. 14, Blood and lymph volume. 
 
 2. Relaxed abdominal walls. 
 
 This consists in elongation and separation of fascial and muscular fibres 
 of the anterior abdominal walls, the thoracic and pelvic diaphragm. 
 
 3. Compression of the transverse segment of the duodenum by the 
 superior mesenteric artery, vein and nerve. 
 
 4: Congenital defects in the nervous, muscular and visceral systems. 
 
 5. Defective food and excessive labor. 
 
 6. Lordosis or anterior curvature of the vertebral column enhances 
 splanchnoptosia. 
 
 7. With the progress of relaxed abdominal walls there is a dispropor- 
 tionate or abnormal relation established between the nervous and muscular 
 systems, and coordination is defective and hence nourishment and function 
 are also defective. The trauma to the sympathetic nervous system produces 
 excessive, deficient or disproportionate secretions and peristalsis in the vis- 
 cera, hence nourishment is again defective. With the advance of splanch- 
 noptosia the blood and lymph vessels become stenosed, their mechanism 
 disturbed, producing irregular circulation and hence nourishment is again 
 defective. 
 
 Splanchnoptosia is a kind of neurosis. It is devitalizing of the sympa- 
 thetic system in which vitality of the neuro-vascular visceral pedicle is 
 impaired, it becoming elongated, stretched. Perhaps the elastic tissue is 
 degenerated. 
 
 Notwithstanding the manifold theories and dreams of respected authors 
 and the easily recognized original work of industrious investigators in 
 splanchnoptosia I am still convinced that one of the great factors of splanch- 
 noptosis is the waist or constricting band, not merely the corset, for a corset 
 may be worn so loose that it practically does no damage. During the past 
 15 years Dr. Lucy Waite and the author have dissected over 35 female bodies 
 for practical topographical and applied anatomy of the abdominal and pelvic 
 viscera. We opened the cadaver and then with the two hands as a corset 
 band or any form of waist band the body was compressed and the result on 
 the abdominal viscera noted. What will happen in tightening the waist 
 band? The answer is clearly evident in watching the progress of constricting 
 the band. First the right more mobile kidney moves medianward and ven- 
 tralward, compressing the junction of the descending and transverse duodenal 
 segments, ending in a position almost in the middle of the abdomen. The 
 kidney suffers the most movement dislocation of any abdominal organ. The 
 liver is compressed as is shown in autopsies in the corset liver, the gall- 
 bladder projects ventralward, allowing stagnation of bile and subsequent 
 formation of hepatic calculi. The daily effect of the waist or constricting 
 
 
THE ABDOMINAL AXD PELVIC BRA IX 
 
 band is diminutive, but continued from week to week, month to month, and 
 year to year, its end results are enormous in changing and damaging structure 
 and function. It constricts the right colon, compromising cecal evacuation, 
 the canalization of the ureter, renal and ovarian veins and inferior vena cava. 
 The nephroptosia elongates the renal vessels especially, the artery which is 
 sheathed in a network of ganglia not only traumatizing them, but, by tugging 
 and dragging on the abdominal brain, the trauma produces the stigmata of 
 hysteria and other neuroses. 
 
 Peritoneal and Omental Adhesions. 
 
 I wish here to direct the attention of the practitioner to a fertile field in 
 the etiology of splanchnoptosia which in short is peritoneal and omental 
 adhesions. I have published numerous articles during the past decade advo- 
 cating the evil influence of peritoneal adhesions on the abdominal viscera. I 
 am gratified to observe that several physicians as Robert T. Morris and sev- 
 eral others are realizing the value of these views. In hundreds of autopsies I 
 have noted the structures of the genitals, appendix, gall-bladder and sigmoid 
 apparently ruined by contracting peritoneal adhesions distorting the viscera 
 into a shapeless mass. 
 
 I have explained for years how these peritoneal adhesions induced by 
 muscular trauma, created distorted physiology, ending in appendicitis, 
 cholecystitis, sigmoiditis and salpingitis. Peritoneal adhesions fix the viscera 
 in a single mass so that the several viscera cannot glide on each other. The 
 solid visceral mass acts like a solid piston in the abdomen forcing the viscera 
 distalward. The omentum is frequently found extensively adherent to the 
 pelvic viscera which drags the viscera in the proximal abdominal distalward 
 at every respiration. Peritoneal adhesions are extensively vicious factors in 
 compromising visceral anatomy and physiology and abetting remarkably 
 splanchnoptosia and other diseases. 
 
 General Views. 
 
 If single viscera become markedly splanchnoptotic, prolapsed by acci- 
 dent, trauma, the general painful neurotic symptoms of splanchnoptosia are 
 markedly absent The existence and results of splanchnoptosia are not fully 
 explained. The difficulty has its seat: (a), in the determining of the exact 
 or normal position of viscera; (b), the exact forces which establish an organ 
 in its position; (c), the views of the cause or origins of splanchnoptosia are 
 so various as to obscure the picture; (d), the symptoms are so complex that 
 splanchnoptosia appears like a conglomerate disease. The confusion is due 
 to the multiple points from which the disease has been established. The 
 history of splanchnoptosia is that of displacement of single organs. 
 
 Glenard, though comprehending a limited field, combined them into a 
 single disease, a unit which should now be termed splanchnoptosia because 
 it involves the thoracic and abdominal viscera (as well as their respective 
 enclosing walls). Splanchnoptosia is a disproportion, a disturbed relation 
 between cavity lumen (chest, abdomen) and contents (viscera) not only 
 
SPLANCHNOPTOSIA 557 
 
 anatomically but physiologically, that is the functionating organs are working 
 in a distorted, dislocated position hence experiencing a change of form and 
 function. 
 
 The thoracic and abdominal cavities should be viewed as one general 
 lumen, simply divided by the diaphragm. The vertebral column may be 
 viewed as a mast maintaining its erectness by means of the erector spinse 
 muscles. The ribs, sail arms, receive support from the fixed mastoid process 
 through the sterno-cleido mastoid muscle. The viscera are anchored, fixed 
 to the dorsal wall — the great mast. The solid, visceral contents are confined, 
 maintained to the mast by the circular, fibro-elastic muscular band — the 
 thoracico-abdominal walls. 
 
 The physiology of viscera must be credited with the greatest role in 
 splanchnoptosia for during their maximum functions the weakest and most 
 defective anatomy begins to yield — especially in the diaphragm (in inspira- 
 tion), in the abdominal walls (in gestation, ingesta, gas, defecation) ; in the 
 circulation, variation of the volume of arterial, venous and lymphatic 
 fluids. Intra-abdominal pressure is the contraction of the circular fibro- 
 elastic muscular abdominal wall plus atmospheric pressure. 
 
 Mechanism of Splanchnoptosia. 
 
 We know that the extra-abdominal pressure is greater than the intra- 
 abdominal pressure, for, on peritoneal section the atmosphere rushes in with 
 an audible sound. This view would oblige the visceral supports (mesenteries 
 and ligaments) to assume the office of not only anchorage but that of fixation 
 (and support). Viscera are essentially supported by underlying ones (visceral 
 shelves) like bricks in a wall. Schwerdt estimates that the viscera mesen- 
 teries or ligaments support about one-eighth of the organ weight. The 
 fixation of the viscera to the (dorsal) abdominal wall and their share in the 
 visceral support might be compared to a boat at anchorage. The boat rests 
 on the water, which represents the compact supporting visceral shelves (like 
 bricks in a wall). The anchor cable (mesenteries, ligaments) merely decides 
 the limit or space range of the boat (in fact seldom becoming tensionized). 
 The banks of the water represent the abdominal wall. 
 
 The principal support of the viscera are: (a), the compact underlying 
 visceral shelves; (b), the abdominal wall; (c), the visceral supports (mesen- 
 teries, ligaments) perhaps suspending one-eighth of the weight of the viscera. 
 By placing a body erect and removing the ventral wall the viscera pass dis- 
 talward, prolapse, sink, placing the visceral mesenteries and ligaments on 
 tension. The visceral mesenteries or ligaments might be compared to a 
 string attaching a specimen in a fluid filled jar, to the cork. The string 
 support is limited, but without it the specimen would sink or rest on the 
 floor of the jar. 
 
 The abdominal viscera are located more distalward while in the erect 
 attitude (1 inch) than the prone position. The more solid organs as liver, 
 kidneys, uterus and foreign material occupied segments of the tractus intes- 
 tinalis pass distalward with more facility while organs containing gas pass 
 
558 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Fig. 174. This illustration demonstrates the dorsal fixation and location of the mesen- 
 teries of the abdominal viscera. The dotted spaces surrounded by black lines are the bases 
 or areas of mesenteric insertion. 1, Ligamentum triangulum sinistrum ; 2, ligamentum 
 suspensorium (teres) hepatis; 3 and 5, vena cava (distal); 4, arteria phrenica dextra; 16, 
 omentum gastro-hepaticum ; 15, ligamentum gastro-phreneum ; 8, arteria coeliaca; 7, arteria 
 gastrica; 12, arteria linealis; 13, arteria hepatica; 14, spleen; 17, mesocolon transversum ; 
 
SPLANCHNOPTOSIA 55'J 
 
 proximalward with more facility. Abdominal organs are limited in motion 
 through the mesenteries, ligaments and adjacent organs. The abdominal 
 wall exercises an opposition to the static pressure of viscera. With increased 
 contents (ingesta, fluids, gestation) the ventral abdominal wall yields. If 
 a body be hung by the head and the abdomen incised the viscera will prolapse. 
 In the resting upright attitude the abdominal wall offers but passive pressure 
 opposition to the viscera. 
 
 The reason for the slow progress in the knowledge of splanchnoptosia 
 among medical men is: (a), the autopsic reports, for the past years, have 
 been of limited practical value as regards splanchnoptosia. The reason of 
 this fact is that when the subject is in the prone but especially the dorsal 
 position the organs assume chiefly their normal physiologic location. The 
 pathologist does not appear to have anything to report; (b), the clinician 
 seldom witnesses an autopsy on a previously diagnosed splanchnoptotic. 
 Hence the autopsist and clinician have practically opposed each other — pos- 
 sessed no views in common — did not agree and also seldom met at an autopsy. 
 The pathologist in the morgue returned no evidence to aid the clinician on 
 the living. In the symptomatology heretofore a tendency has existed to 
 attribute excessive symptoms to single splanchnoptotic organs, especially the 
 genitals, kidneys, stomach and liver, and deficient symptoms to other organs 
 as the colon, enteron, vascular system and nervous system. Splanchnoptosia 
 is a unit — a general disease. Also excessive symptoms have been attributed 
 to single organs in order to prepare the road for the irrational pexy. 
 
 ANATOMY AND PHYSIOLOGY OF SPLANCHNOPTOSIA. ABDOMINAL WALLS. 
 
 The abdominal walls consist of oblique, perpendicular and transverse 
 muscular layers woven in a powerful fascial band. 
 
 All abdominal muscles are fixed on bony parts, as the costal, iliac and 
 pubic crests, as well as the vertebral column, while the diaphragm is inserted 
 into the ribs and vertebral column with its vault fixed by the pericardium. 
 The abdominal wall is covered externally by skin and internally by peri- 
 toneum — both powerful and elastic membranes. Certain weak, yielding 
 muscular and fascial lines exist in the abdominal walls, viz. : 
 
 1. Musculi recti abdominales arise from the pubic crest and become 
 inserted into the ribs and os sternum. The two recti muscles which lie parallel 
 to each other are the ones which preserve the delicate visceral poise. Slight 
 extra intra-abdominal pressure produces diastasis of the muscles. In splanch- 
 noptosis, the recti show (a) diastasis, (b) elongation, and (c) separation of 
 the fibres, (d) extensive thinning and flattening, and (e) atrophy. 
 
 10, ligamentum casto-coelicum ; 11, kidney; a, omentum gastro-splenicum ; 18, shows 
 dot between blades of omentum majus ; 19, adfenal bodies ; 20, foramen winslowi ; 22, 
 arteria mesenterica superior; 23, arteria renalis dextra; 24, mesocolon sinistrum. (Inser- 
 tion line of its two blades.) 25, duodenum transversum (covered by peritoneum) ; 26, 
 mesocolon dextrum. (Insertion line of its right and left blade.) 27, ureter (shimmering 
 through the peritoneum) ; 28, aorta ; 29, mesenteron ; 30, arteria mesenterica inferior ; 31, 
 arteria colica dextra; 32. arteria iliaca communis; 33, arteria iliaca externa; 34, arteria 
 iliaca interna ; 35, mesosigmoid. (Double blades.) 36, uterus ; 37, urinaria vescicae ; 38, 
 ligamentum rotundum uteri ; 39, ovarium ; 40, oviductum (sinistrum). 
 
560 
 
 THE ABDOMLXAL A\D PELVIC BRAIN 
 
 2. The fascial lines which yield in splanchnoptosia are (a) the linea 
 alba, which I have noted three inches wide, the fascial fibres are elongated 
 and separated, making the abdominal wall very thin and lax in the median 
 line, (b) the lineae semilunaries which also become quite thin and lax, the 
 fascial fibres elongate and separate, (c) the fibres of the linea transversa, 
 inscriptiones tendinat or the abdominal ribs, which elongate and separate. 
 The physiologic action of the abdominal wall is a combined one, as the 
 
 varied direction of its 
 muscular fibres indicate. 
 We may indicate its 
 physiologic action in cer- 
 tain directions. 1. The 
 abdominal wall acts as a 
 circular band, to fix and 
 support the abdominal 
 viscera as the neurovas- 
 cular visceral pedicles are 
 not intended for primary 
 mechanical visceral sup- 
 port. 2. The abdominal 
 wall is a highly elastic 
 apparatus. It distends and 
 contracts fitting the ab- 
 dominal contents. The 
 skin and peritoneum are 
 exceedingly elastic. Ob- 
 serve how the skin and 
 peritoneum will return 
 without a fold to the nor- 
 mal state after distention 
 from gestation, ascites or 
 tumors, etc. 3. The physi- 
 cal function of the ab- 
 st^Z dominal wall is aided by 
 its capacity of contraction 
 and of extension in res- 
 piration, defecation, uri- 
 nation, expulsion of uter- 
 ine contents; in laughing 
 and coughing. In short it is the function of the abdominal wall to contract 
 and dilate during the volume changes of the abdominal contents, as well as 
 the volume changes in the thorax. 4. The physiological function of the 
 abdominal wall is to maintain a vigilant guard, a vigorous but delicate 
 elastic regulation of abdominal visceral contents. The elastic spanning of 
 the abdominal walls maintains a delicate visceral poise. 
 
 Fig. 175. Represents the separation and elongation of 
 the recti abdominales in splanchnoptosia. 
 
SPLAXCHXOPTOSIA 
 
 561 
 
 Etiology of Relaxation. 
 
 Relaxed abdominal walls arise in various forms in different subjects. 
 Not all thin abdominal walls are relaxed, neither are all relaxed abdominal 
 walls thin. The elements, the fascial, elastic and muscular fibres must be 
 separated and elongated to constitute relaxed abdominal walls, which are 
 best observed in the erect attitude. The causes of relaxed abdominal walls 
 
 Fig. 176. The diaphragm. (Ventro-distal view.) This illustration presents 
 the central tendon of the diaphragm with its important long right (RC) and 
 short left (LC) crus. The right diaphragmatic crus extends to the (IV) 
 lumbar vertebra. ■ The crura of the diaphragm have a fixed immobile spinal 
 insertion and forcible drag the central tendon of the diaphragm with its 
 attached percardium distalward at every inspiration. In the physiology of the 
 stronger inspiration and weaker expiration begins splanchnoptosia. The in- 
 spiratory muscles from sheer force — and to the crura must be attributed the 
 chief factor. 
 
 lie in the elements of the wall itself, viz. : fascia, muscle, peritoneum, skin 
 and elastic fibres. The fine tonus of the wall, its delicate elasticity may be 
 lost. Its fascia and muscular fibres are separated and elongated. It is 
 flaccid and hangs excessively distalward and the unsupported viscera follow it. 
 There seems to be a limited life for the abdominal walls, as there is for the 
 
562 THE ABDOMINAL AND PELVIC BRAIN 
 
 utero-ovarian vascular circle of the genitals. For the abdominal walls begin, 
 as a widely applicable rule, to relax at about 35, and continue to relax or 
 atrophy to the end of life. There can be no doubt that the elastic fibres 
 elongate and separate, perhaps also atrophy, for the abdominal wall is not 
 only relaxed but is thinned, attenuated. It may be that at a time of malnu- 
 trition the abdominal walls become relaxed, never subsequently recovering 
 their normal state. Relaxed abdominal walls frequently follow continuous 
 fevers, gestation, ascites or any factor which increases intra-abdominal 
 pressure. The most frequent supposed cause of relaxed abdominal wall is 
 rapidly repeated gestation. In every gestation physiologic dastasis of the 
 musculi recti abdominales occur. It is not infrequent to find the recti mus- 
 cles three inches apart at the end of gestation. But relaxed abdominal walls 
 are not confined to women, as the testimony of the 450 recorded autopsies 
 of men proved, there being frequent splanchnoptosia in these subjects. 
 
 The pelvic, thoracic and abdominal viscera are liable to frequent disloca- 
 tion. In visceral inspection of 600 adult autopsies I found local peritoneal 
 adhesions in over 80 per cent. In other words, more adult subjects have 
 dislocated viscera from peritoneal adhesions than normally situated ones. 
 The neuro-vascular visceral pedicle, the mesentery, becomes elongated and 
 its root glides distalward on the dorsal abdominal wall. The distalward 
 dislocation of the dorsal attachments of the mesentery allows (a) elongation 
 of the mesentery, (b) an excessive range of visceral motion, (c) the abdomi- 
 nal and the pelvic organs pass distalward and become impacted in the pelvis, 
 (d) Splanchnoptosia compromises circulation and deranges absorption secre- 
 tion, (e) disorders peristalsis, (f) traumatizes nerve periphery, (g) it impairs 
 nourishment, (h) it produces especially indigestion, (i) it invites constipation. 
 Splanchnoptosia accompanies a defective nervous system of perhaps congen- 
 ital origin. As it increases every decade, after 35 years of age it is liable to 
 cause stenosis or partial obstruction of the canals, tractus intestinalis from 
 traction of one part and elongation of other parts of the mesenteries. It 
 compromises canalization. The effects of splanchnoptosia (Glenard's disease, 
 1884), on individual abdominal organs, are varied and numerous. 
 
 Intestinal Tract. 
 
 The tractus intestinalis is affected chiefly by: (a), compromising of circu- 
 lation, blood and lymph supply, i. e., congestion and decongestion, (b) 
 trauma of nerve centers, strands and nerve periphery, (c) complication from 
 loss of peristalsis and atony of bowel muscle, (d) gastro-intestinal catarrh 
 and indigestion from excessive, deficient and disproportionate secretions, 
 absorptions. Also dragging on the abdominal brain, an independent nerve 
 center producing nausea, neurosis, headache, reflexes, and deranges secretion 
 and motion on other viscera, (e) Dilatation of the stomach and duodenum, 
 caused by the superior mesenteric artery, vein and nerve, obstructing the 
 duodenum at this point where they cross the transverse segment. The 
 stomach is especially liable to dilatation from the above causes, where the 
 prolapse of the enteron (enteroptosia) is sufficiently advanced to allow the 
 
SPLANCHNOPTOSIA 
 
 563 
 
 enteronic loops to pass distalward into the lesser pelvis and particularly 
 when the subject lies on the back, for then the superior mesenteric artery, 
 vein and nerve are put on a stretch and they constrict vigorously the trans- 
 
 f a V'u diaphragm. (Dorsal view.) This illustration presents the central 
 
 tendon and the attached pericardium with the powerful right and left crura. During 
 inspiration the diaphragmatic crura, immovably fixed by insertion in the spinal column 
 contract drawing the tendon of the diaphragm, to which the pericardium is attached, 
 distalward. bplanchnoptosia begin the respiratory organs, i. e., in the conquering of the 
 inspiratory muscles R. A. R, right acute fibres. 
 
564 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 verse portion of the duodenum, (f) The enteronic loops being dislocated 
 (enteroptosia) into the pelvis, peristalsis, absorption secretion, circulation 
 and nerve periphery are compromised, followed by catarrh, constipation and 
 indigestion, (g) The colon, especially the colon transversum, may lie in the 
 lesser pelvis, producing similar compromising circumstances as in the 
 enteron. (h) The appendages (liver, pancreas, and spleen) of the tractus 
 intestinalis, in ptosis are compromised in circulation, secretion, absorption, 
 peristalsis and nerve periphery. 
 
 Genital Tract. 
 
 In splanchnoptosia the genital tract suffers, especially in circulation and 
 nerve periphery as well as secretion and absorption. Uteroptosia may arise 
 to such an excessive degree of mobility that the uterus may be forced proxi- 
 mal to the umbilicus and 
 in any portion of the great 
 pelvis. 
 
 Urinary Tract. 
 
 The urinary tract suffers 
 in splanchnoptosia, chiefly 
 from dislocation of the 
 kidney (right) nephropto- 
 sia. From several hun- 
 dred autopsic inspections 
 and living abdominal sec- 
 tions, I can say that in 
 many subjects the kidney 
 (right) has extensive mo- 
 tion and is significant in 
 gynecology, as its symp- 
 toms mimic or simulate 
 genital disturbances. In 
 
 my practice 60 per cent of subjects possess a kidney range of 4 inches, 2 
 inches proximalward and 2 inches distalward. Large numbers of subjects 
 have a right kidney range of 3 inches, 1 1-2 inches proximalward and 1 1-2 
 inches distalward. The mobility of the right kidney is of extreme impor- 
 tance in multipara have a movable kidney nephroptosia — proved by 
 examination in the horizontal and erect positions. The mobility of the 
 right kidney is due to (a) the longer right renal artery, (b) the liver through 
 the diaphragm forces the right kidney distalward, (c) muscular trauma of 
 the diaphragm, quadratus lumborum and constricting waist bands, (d) 
 absorption of pararenal fat, (e) the abdominal cavity of woman is funnel- 
 shaped, with the large end of the funnel distalward and hence the kidney 
 receives less support distally than it does in man, (f) subinvolution attacks 
 the "Wolfian body." (g) The erect attitude. By continual relaxation of 
 the abdominal walls its physiological and anatomic functions are impaired. 
 
 Fig. 178. Proximal view of the pelvic floor. This 
 illustration is drawn from my own dissection (by Dr. 
 Sholer) to present the diaphragma pelvis. 
 
SPLANC IIXOPTOSIA 
 
 565 
 
 The physiological regulation and chief anatomic support of the viscera are 
 unbalanced, and the delicate visceral poise is lost. The abdominal viscera 
 move distalward, become prolapsed following the relaxed abdominal walls. 
 The condition of relaxed abdominal walls is followed by splanchnoptosia. 
 Of the three great systems of the abdominal viscera, the tractus genitalis, 
 tractus urinarius and the tractus intestinalis, the last suffers the most 
 severely. Relaxed abdominal walls are followed by dislocated viscera. 
 A viscus is dislocated when it is permanently out of position. In general 
 a dislocated viscus suffers from trauma of its nerve periphery and its blood, 
 and lymph vascular system is compromised. Splanchnoptotic organs 
 become hypertrophied. Also the nourishment of a dislocated viscus is defec- 
 ive, irregular. Dislocated or prolapsed viscera are the segments of vicious 
 circles. Relaxed abdominal walls are followed by partial hernia, especially in 
 the pouches of the most 
 yielding parts, as the linea 
 alba, supraumbilical and 
 the 1 i n e a e semilunares 
 or the various defective 
 rings. 
 
 In the following scheme 
 are noted not only the 
 great factors in splanch- 
 noptosia, but other de- 
 tailed factors: 
 
 The diaphragm. 
 
 The diaphragm is a 
 muscular barrier anchored 
 like a buoy between the 
 thoracic and abdominal 
 viscera. It rises and falls 
 with the ebb and flow of 
 respiration. There is a 
 weaker expiratory flow. 
 
 It is a muscular dome for the abdominal viscera and a muscular floor for 
 the thoracic viscera. The viscera move to and fro with the diaphragm. The 
 average height of the diaphragm is on a level with the fifth costal cartilage 
 and its general fluctuating range level is two inches. 
 
 The variation in the level of the diaphragm represents the phases of a 
 respiratory rhythm. The distalward displacement of the diaphragm is an 
 essential feature in splanchnoptosia. For the liver, spleen, stomach and 
 kidneys are firmly bound to its abdominal surface. The diaphragm is sup- 
 ported in its position first: by the abdominal muscles forcing the abdominal 
 viscera proximalward against its distal concavity; second, it is supported by 
 the thoracic viscera; by fusion of the pericardium to its proximal surface, 
 the heart, great thoracic blood-vessels, trachea and lungs which attach the 
 
 Fig. 179. Distal view of the pelvic floor. This cut is 
 drawn by Dr. Sholer from my own dissection. The 
 proximal and distal fascia of the levator ani is removed 
 as in previous fig. 
 
 visceral tide — a stronger inspiratory ebb and a 
 
566 THE ABDOMINAL AND PELVIC BRAIN 
 
 proximal surface of the diaphragm to the dorsal thoracic wall; third, the 
 costal support is from the 6 lower ribs and spinal support from the I, II and 
 III lumbar vertebrae Hence the abdominal, thoracic, costal and spinal 
 supports are required for a normal position of the diaphragm. A defect in 
 any support (contraction or relaxation) of the diaphragm prepares the road 
 for splanchnoptosia. 
 
 The crura of the diaphragm send strong fibers to the pericardium, 
 (through the central tendon) roots of the lung (reflected pleurae), vena cava, 
 the great thoracic vessels, connective tissues of the oesophagus and trachea 
 — all diaphragm and thoracic viscera, being solidly and compactly bound 
 together. With each inspiration the crura of the diaphragm contract on 
 their immobile spinal origin and draw the thoracic viscera (and force the 
 abdominal) distalward. The vigorous contraction of the diaphragmatic crura 
 (in inspiration) is the most important factor in producing incipient splanch- 
 noptosia. For reasons, not fully known, the (inspiratory) diaphragmatic 
 supports of certain individuals yield and splanchnoptosia begins. The yield- 
 ing of the diaphragm supports occur first in the muscles of inspiration. 
 The diaphragm (especially the crura) during contraction (inspiration) forces 
 the mediastinal contents — heart (pericardium), trachea and oesophagus — 
 distalwards, which elongates the mediastinal mesentery, composed of pleural 
 reflections. By viewing a patient laterally with the fluoroscope the heart 
 may be observed to move proximalward and distalward during respiration. 
 The range of proximalward and distalward action of the heart (and conse- 
 quently the diaphragm which is fixed to the pericardium) is considerable 
 especially in subjects with abdominal type of respiration and in such the 
 distalward movements of the heart is the greater. 
 
 Influence of DiapJiragm in Splanchnoptosia. 
 
 When the diaphragmatic supports begin to yield the inspiratory distal- 
 ward movements (displacements) of the thoracic viscera are a cause of incip- 
 ient splanchnoptosia. Since the pericardium is not only solidly attached to 
 the diaphragm but is also solidly attached to the roots of the lung, thoracic 
 vessels, oesophagus and trachea a movement of the diaphragm (induced 
 chiefly by crural contractions) must be accompanied by movements of the 
 thoracic viscera. In short, the diaphragm is connected to the mediastinum, 
 pericardium root of lung, thoracic vessels, oesophagus trachea, vagi and the 
 respiratory expansion is gained chiefly by a distalward movement of the dia- 
 phragm accompanied by the thoracic viscera — lungs and heart. It is when 
 this distalward movement of the diaphragm (inspiration) becomes excessive 
 (from relaxation of diaphragmatic supports) that splanchnoptosia begins. 
 (We will at present not dispute that atonia gastrica abdominal relaxation 
 develops concomitant as respiration includes the abdominal muscles.) The 
 diaphragm is a digastric muscle with two origins viz. : (a) spinal origin 
 (vertebral column — crura — and arcuate fibers; (b) ventral origin (from the 6 
 lower ribs) and by the contractions of its two bellies enhances thoracic space 
 for inspiration, therefore its share in incipient splanchnoptosia is evident. 
 
SPLANCHNOPTOSIA 
 
 567 
 
 From the above evidence it is obvious that the distalward movements of the 
 diaphragm (in respiration) will depend on the opposition offered by the 
 abdominal viscera through the strength of the abdominal wall, as well as the 
 mobility of the 6 lower ribs. If the muscles of the abdominal wall offer 
 normal resistance to the distalward movements of the abdominal viscera the 
 diaphragm will be supported by the abdominal viscera (liver, spleen, pan- 
 creas, stomach, kidneys) and cannot descend. However, if atonia gastrica 
 (abdominal relaxation) exist the diaphragm shares in the thoracic and abdom- 
 inal splanchnoptosia with consequent abdominal type of respiration. If, 
 however, the contraction of the diaphragm (crura) cannot force the abdomi- 
 nal viscera distalward the thoracic viscera must expand (in respiration) 
 within the thorax with consequent thoracic type of respiration. Splanch- 
 noptoses experience abdominal types of respiration. 
 
 Spinal Segment. 
 
 The spinal segment of the diaphragm has a constant function, i. e., its 
 contraction (inspiration) forces both thoracic and abdominal viscera distal- 
 ward. The ventral segment of the diaphragm is otherwise for its action on 
 the lower 6 ribs depends 
 on the position of the ribs. 
 If the lower 6 ribs become 
 misplaced the action of 
 the diaphragmatic muscles 
 become altered. The ab- 
 dominal type of respira- 
 tion signifies that the pul- 
 monary space is gained 
 chiefly by the expansion 
 of the distal end of the 
 thorax. The thoracic type 
 of respiration signifies that 
 the pulmonary space is 
 gained mainly by the ex- 
 pansion of the proximal 
 end of the thorax. 1. It 
 may be noted therefore 
 that the fixation of the 
 thoracic viscera is through: (a) the thoracic, diaphragmatic and abdominal 
 muscles; (b) thoracic vessels; (c) the oesophagus; (d) the trachea; (e) the 
 pericardium; (f) dorsal thoracic mesentery (reflected plurae); (g) the thoracic 
 fascia; (h) vagi and phrenic nerves. 2. The motion of the thoracic viscera 
 is noted through: (a) the expansion (inspiration) of the chest; (b) the 
 movements of the diaphragm ; (c) the motion of the abdominal wall. The 
 thoracic diaphragm is one of the most important respiratory muscles. 
 It is innervated by a single nerve (Phrenic) therefore it contracts, func- 
 tionates, as a single muscle. Diaphragma thoracis serves as a floor, 
 
 Fig. 180 represents a normal transverse segment of 
 the abdominal wall. About the umbilicus. 1, rectus; 2, 
 skin; 3, fascia; 4, fascia; 5, external oblique; 7, trans- 
 versalis ; 8, peritoneum ; 9, linea semilunaris ; 10, linea 
 alba; 11, spinal muscles; 12, quadratus lumbarium ; 13, 
 psoas muscle ; 15, vena cava, and 16, aorta. 
 
568 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 a support for the thoracic viscera. Its peripheral origin is from the 
 sterum, ribs (lower 6), and lumbar vertebras (I to III). Its fibers are inserted 
 in the central tendon. Its special fixum punctum is the vertebral column. 
 Its punctum mobile is the centrum tendineum with the two apertures 
 (vena cava and oesophagus. The aortic aperture is practically immobile). 
 Diaphragma thoracis resembles diaphragma pelvis in physiology and 
 anatomy. Both have (a) a similar fixum punctum, (circular bony origin) ; 
 (b) similar punctum mobile (central tendon); (c) both support super- 
 imposed viscera ; (d) both have 3 apertures for visceral transmission ; (e) both 
 diaphragms are respiratory; (f) both muscles by constriction limit the 
 apertures of visceral transmission ; (g) both contract as a single muscle ; (h) 
 both share in splanchnoptosia. They differ in that contraction of the pelvic 
 diaphragm draws the 3 visceral apertures proximalward, and ventralward, 
 
 while contraction of the 
 thoracic diaphragm draws 
 the visceral apertures dis- 
 talward and dorsalward. 
 Distalward movement of 
 the thoracic diaphragm in 
 splanchnoptosia trauma- 
 tizes, injures, stretches 
 the phrenic and vagi 
 nerves hence will derange 
 respiration (inducing neu- 
 rosis). 
 
 Derangement of respi- 
 ration is clinically evident 
 among splanchnoptostics. 
 
 Fixation and Motion of the 
 Thoracic Viscera. 
 
 Fig. 181 illustrates a transverse section of the abdo- 
 men, about the umbilicus of a splanchnoptotic. The 
 fascial and muscular fibres of the abdominal wall are 
 elongated and separated, the primary factor in the splanch- 
 noptosis, 1, rectus; 2, linea alba; 3, 5, linea semilunaris; 
 6, skin; 7, fascia; 8, external oblique; 9, internal oblique; 
 10, transversalis; 11, transversalis fascia; 12, the peri- 
 toneum; 13, vena cava; 14, aorta; 16, quadratus lum- 
 borum ; 15, psoas; 17, vertebra; 18, spinal nucleus. 
 
 Splanchnoptosia begins 
 in the deranged anatomy 
 and physiology of the 
 tractus respiratorius. At 
 every inspiration the 
 crura of the diaphragm 
 contracts on the pericar- 
 dium (which is fixed to the diaphragm) which in turn drags on the great 
 thoracic vessels which finally tugs on the mediastinal structures (oesophagus, 
 trachea and pulmonic mesentery) carrying the thoracic viscera and forcing the 
 abdominal viscera distalward. The viscera are poised between the two great 
 systems of inspiratory and expiratory muscles which are arrayed in rhythmic 
 opposition during life. 
 
 The victory of the inspiratory muscles over their opponent, the expiratory 
 muscles, is the beginning of splanchnoptosia. 
 
SPLANCHNOPTOSIA 569 
 
 Students should be taught that not only the muscles of the thoracic wall 
 belong to respiration but also the abdominal muscles are an integral part. 
 The thoracic and abdominal muscles are a breathing apparatus. Man's 
 respiratory muscles extend from face to pelvic floor. 
 
 The XII intercostals with the I and II lumbar nerves practically supply 
 the muscles of respiration which extend from manubrium to symphysis 
 pubis. 
 
 A knowledge of the movements of the viscera during respiration indicates 
 the method and location of their fixation within the thoracic and abdominal 
 cavities. 
 
 Any prominent deviation of the respiratory muscles is accompanied by 
 deranged visceral movements resulting in splanchnoptosia, disordered ana- 
 tomy and physiology. We will devote a few remarks to the diaphragm in 
 splanchnoptosia. 
 
 The Respiration in Splanchnoptosia {irregular). 
 
 The prominent symptoms of the respiration in splanchnoptosia are short- 
 ness of breath, irregular long respiration, difficult breathing and asthmatic 
 breathing with cardiac palpitation. The relaxed abdominal muscles, the 
 respiration muscles, have lost their power and perfect muscular relaxation is 
 not possible. Complete respiration is muscular relaxation and contraction. 
 In the erect attitude the dislocated liver drags on the diaphragm through its 
 coronary ligaments, and through the vena cava. Besides, the liver is in turn 
 dragged on by the tractus intestinalis through its two ligaments attached 
 to the liver, viz., ligamentum hepato-colicum and ligamentum hepato-cavo- 
 duodenale, resulting in disturbance of a respiratory organ — the diaphragm. 
 The irregular respiration — a frequent symptom of relaxed abdominal walls 
 and consequent splanchnoptosia — is another link in the viscious circle, 
 because it imperfectly and irregularly oxidizes the blood, disturbing nutrition. 
 
 CONSIDERATION OF VISCERAL FIXATION IN SPLANCHNOPTOSIA. 
 
 Fixation and Movement of A bdominal Viscera. 
 
 (a) Abdominal viscera fixed immovably in position {to radix mesentericd) 
 not sharing in respiratory movements {duodenojejunal flexure and body of 
 pancreas). I examined the viscera of numerous quadrupeds, some 20 mon- 
 keys, apes, baboons (i. e., animals which sit or stand practically erect in life) 
 and several hundred humans. The testimony from the investigations is that 
 the more the animal lives in the erect attitude the more firmly and extensively 
 are the viscera fixed to the abdominal walls. The extensive and firm fixation 
 of abdominal viscera to the abdominal walls found in man (and erect apes) 
 marks the final process developing in erect animals. However firm and 
 extensive the fixation of viscera to the abdominal wall, it plays a minor 
 role in the prevention or cure of splanchnoptosia, in comparison with dia- 
 phragm and muscular abdominal walls. I found marked relaxed abdominal 
 walls and advanced splanchnoptosia in erect apes. The method of abdom- 
 inal visceral fixation may now be considered. 
 
570 THE ABDOMINAL AND PELVIC BRAIN 
 
 Through the courtesy of Prof. W. A. Evans I was sufficiently fortunate to 
 secure an autopsy on the orang recently dying in the Lincoln Park Zoologic 
 department. This human-like orang, a native of Borneo, was a female some 
 10 years of age and weighed 80 pounds. The thoracic and abdominal vis- 
 cera resembled those of man in relation (to peritoneum), form, fixation and 
 motion. The appendix was precisely typical of man, six inches in length, 
 and was located in the pelvis (woman's appendix lies in the pelvis in 48 per 
 cent of subjects). The coecum rested on the psoas muscle, however, since 
 the orang does not walk (but sits) the psoas had not produced sufficient 
 trauma to cause pericoecal peritoneal adhesions. The colon in all its seg- 
 ments resembles that of man in relation, form, fixation and motion. The 
 transverse colon measured 12 inches while the sigmoid flexure measured 13 
 inches in length. 
 
 In one matter of degree (not of difference) the colon presented more 
 numerous appendicae epiploicae than that of man. The fixation of the 
 viscera on the dorsal abdominal wall, the location of the mesenteries, and 
 the radix mesenterica, the relation of pancreas, liver, duodenum, stomach 
 and spleen were duplicates of homo. The omentum majus resembling man's 
 (except its blades had not completely coalesced) ceased at the flexura 
 hepatica. The tractus genitalis in relation (to peritoneum), form, fixation 
 and location precisely resemble that of man. In the orang the relation (to 
 peritoneum and viscera) of the diaphragm, the most important respiratory 
 apparatus, precisely resembles that of man in location, relation, fixation and 
 motion. The psoas muscle was relatively not so large as that of man because 
 the orang does not walk (practically lives sitting). In the orang especially, 
 but also in the human-like apes, baboon, monkeys I found that their viscera 
 were similarly developed and point for point was fixed in detail similar to 
 those of man. The method of visceral fixation in man is due to respiration 
 and attitude. 
 
 Radix Mesenterica. 
 
 The radix mesenterica or root of the mesentery consists of the coeliac 
 axis and superior mesenteric artery encased by its fibro-muscular sheath (pro- 
 longed from the sheath of the aorta and diaphragmatic crura). The root of 
 the mesentery (major visceral arteries) arise from the aorta as it enters the 
 abdominal cavity between the crura diaphragmatica and at the junction of 
 the intercrural arch through which the aorta encased in its fibrous sheath 
 enters the abdominal cavity may be termed the hilum of the peritoneum. In 
 a limited area located at the root of the mesentery only is the abdominal 
 viscera immovably fixed in position. The root of the mesentery is the solid 
 immovable center around which the abdominal viscera play in the ebb and 
 flow of respiration. 
 
 From the root of the mesentery (coeliac and superior mesenteric arteries) 
 radiate strong fibrous bands from the sheath of the aorta and fibro-muscular 
 bands from the diaphragmatic crura, on the peripheral arterial trunks toward 
 the viscera (stomach, spleen, liver, pancreas and enteron) At the root of the 
 
splanchnoptosis! 
 
 571 
 
 mesentery is located the solar plexus, ganglion coeliacum (abdominal brain) 
 which emits rich plexiform network of nerves along the fibrous sheaths of the 
 arterial trunks to the viscera. Numerous lymphatic vessels pass along the 
 vascular sheath. A considerable fibro-muscular band, muscle of Treitz 
 (musculus suspensorius duodeni), (Wenzel Treitz, Bohemian, 1819-1874, Prof. 
 
 Fig. 182. This figure illustrates the viscera of a female orang from Borneo. 
 Its age was about ten years. App., appendix, six inches long, lying on the 
 pelvic floor; U., uterus; C, coecum ; F.S., signoid flexure; Am., oviductal 
 ampulla; Ov., ovary; St., stomach; G., gall bladder; L., liver; hook drawing 
 the severed omentum majus proximalward. 
 
 Pathology in Prague) is emitted from the diaphragmatic crura (right or left) 
 to terminate in the duodeno-jejunal flexure binding it solidly to the root of 
 the mesentery. 
 
 The dorsal surface of the corpus pancreaticus is solidly and firmly bound 
 by strong fibrous tissue in the fork between the coeliac and superior mesen- 
 teric arteries. Hence whatever form of splanchnoptosia may afflict other 
 
572 
 
 THE ABDOMINAL AXD PELVIC BRAIX 
 
 abdominal viscera the duodenojejunal flexure and the middle of the body of 
 the pancreas remain fixed, immovably, in position. The radix mesenterica, 
 root of the mesentery, is immovably fixed in position and hence does not 
 move in respiration. The duodenal-jejunal flexure and body of the pancreas 
 
 are firmly fixed to the root 
 of the mesentery and hence 
 do not share in respiratory 
 movements of the viscera. 
 All abdominal viscera (ex- 
 cept those fixed to the root 
 of the mesentery as the duo- 
 deno - jejunal flexure and 
 body of the pancreas) are 
 fixed to the abdominal wall 
 and therefore share in re- 
 spiratory movements. (Re- 
 mark: — From the above 
 anatomic facts reports of ex- 
 tensive hernia do not record 
 the pancreas or duodenum as 
 having passed through the 
 hernia ring into the hernial 
 sac.) 
 
 (b) A bdominal viscera 
 fixed to the abdominal wall 
 and sharing in respiration. 
 (The only exception are the 
 duodenojejunal flexure and 
 pancreas.) A brief ref- 
 erence to the fixation of in- 
 dividual viscera to the ab- 
 dominal wall and their share 
 respiratory movements 
 
 ID 
 
 Fig. 183. The areas of peritoneum shown at 25 and 
 27, as well as at 34 and 11, also at 5, 8, 12, 14, are addi- 
 tional aids to support the viscera. They are practical 
 extensions of the mesenterial bases. The granular areas 
 are the mesenterial bores, while the intervening areas 
 are where the peritoneum is fixed to the abdominal wall. 
 
 will now be made in or- 
 der to comprehend the nature and anatomy of the vast domain of splanch- 
 noptosia. 
 
 Fixation of Tractus Intestinalis. 
 
 The degree of firmness and extent of fixation of the tractus intestinalis 
 increases with the erect attitude. The erect apes and man form the culmi- 
 nation of extensive fixation of abdominal viscera. The erect attitude is 
 responsible for splanchnoptosia. From careful examination of the viscera of 
 mammals, monkey and erect apes, it is evident to me that all these animals 
 progress through precisely the same stages of visceral development and that 
 visceral fixation is exactly the same, analogous in all— the chief change in all 
 the visceral fixation is due to attitude (erect) and respiration. 
 
SPLANCHNOPTOSIA 573 
 
 In the fixation of abdominal viscera there must be held in view (a) the 
 abdominal wall; (b) respiration and erect attitude; (c) the mesenteries — their 
 basal organ and method of insertion on the abdominal wall. The mesenteries 
 are not for mechanic support but for the conduction of nerves, vessels and 
 prevention of visceral entanglement. The mesenteries separate the viscera 
 into compartments which enables them to be supported with greater facility 
 by means of visceral shelves. I. The primary visceral support except the 
 abdominal wall is vascular: (a) coeliac axis; (b) the superior mesentery 
 artery; (c) the inferior mesentery artery. II. The secondary visceral sup- 
 port to the abdominal wall is peritoneal adhesions (cellular-non-pathologic). 
 In splanchnoptosia the base or insertion of the mesentery on the dorsal 
 abdominal wall may glide distalward. The basal fixation of the foetal 
 mesentery is unlike that of the adult. The base of the foetal mesentery 
 contains the cells, which later multiply, spreading into the broad base of 
 the adult mesentery that lends to erect man his extensive width of mesenteric 
 adhesions. 
 
 A few remarks should be made as regards the acquired mesenteric adhe- 
 sions of erect man. 
 
 /. Mesogastric Adhesions. 
 
 In quadrupeds like the cat the origin or root of the mesogastrium is at 
 the coeliac artery, the radix mesenterica. With the erect attitude the root 
 of the mesogastrium becomes increasingly adherent to the dorsal abdominal 
 wall in an oblique line. From the coeliac axis, the mesogastric root, the 
 adhesions spread leftward over the adrenal and kidney to the spleen which is 
 attached to the mesogastrium. In embryos and infants one can trace the 
 development of the mesogastric adhesions from the single point, the radix 
 mesenterica to the extensive adhesions of adult man. The mesogastric 
 adhesions or insertion on the dorsal wall aids in the fixation of the stomach. 
 
 2. Mesoduodenal Adhesions. 
 
 The duodenal loop is early in the human embryo entirely free, non- 
 adherent, and is still free in adult lower mammals. Gradually in man the 
 rightward movement of the liver draws the duodenal loop with it and the 
 right side of the mesoduodenum loses its endothelium and its mesenterii 
 membrana propria becomes adherent to 'he right dorsal wall and especially 
 to the renal hilum. In dissection and operations in the biliary passages the 
 mesoduodenal adhesions are released with facility. However, the mesoduo- 
 denal adhesions afford a strong support to the duodenum itself and also make 
 of the duodenum a solid visceral shelf for the liver and stomach. The 
 mesoduodenal adhesions are especially solid dorsal to the line crossed by 
 the colon (coecum) in its journey to the right iliac fossa. 
 
 The duodenum is the most fixed segment of the tractus intestinalis due 
 to: (a) the muscles of Treitz; (b) the extensive fixation of the mesoduode- 
 num ; (c) ligamentum hepato-duodenale; (d) biliary passages; (e) pancreas (the 
 body of which is solidly fixed to the coeliac axis). Observe the absence of 
 
574 THE ABDOMINAL AND PELVIC BRAIN 
 
 the duodenum (and the pancreas) in hernial reports on account of their solid 
 fixation to the immobile radix mesenterica. 
 
 3. Mescnteronic Adhesions. 
 
 The mesenteronic adhesions (of man) extend some six inches in an 
 oblique line from the duodeno-jejunal flexure to the coecum. Originally in 
 features the mesenteron and mesocolon were in one line, and fan-shaped, 
 being attached by its apex to the coeliac axis or radix mesenteria. With 
 development of the tractus intestinalis a rotation occurred on the radix mesen- 
 terica and the coceum journeyed to the right, crossing ventrally to the 
 duodenum, forming extensive acquired fixations for the testinal tract. The 
 extent of the mesenteronic adhesions (which are on the right side) depends 
 on the degree of distalward movement acquired by the coecum. Frequently 
 (9 per cent in man and 5 per cent in woman according to my 700 autopsies) 
 the journey of the coecum to the right iliac fossa becomes interrupted (non- 
 descent of coecum) at any point distal to the liver. In such a case the 
 mesenteron (except the duodenum) and a corresponding pact of the trans- 
 versum and right colon are suspended practically (without adhesions) by the 
 radix mesenteria, i. e., the superior mesenteric artery (as it originates from 
 the aorta about one-half inch from the coeliac axis). 
 
 Not long before birth (man) the mesenteronic adhesions beginning at the 
 transverse (or right) colic margin radiate distalward toward the right ilias 
 fossa. From dissection it will be observed that with normal mesenteronic 
 adhesions, the chief enteronic support is practically the radix mesenteria, 
 i. e., the arteria mesenterica superior. This can be demonstrated with 
 facility in the dead. However, the mesenteronic adhesions lend solid support 
 to the enteron aiding to a high degree to prevent enteroptosia. 
 
 4. Mesocolic Adhesions. 
 
 Acquired mesocolic adhesions in the erect attitude assume two directions, 
 viz. : (a) those of the left colon; (b) those of the right colon. Originally the 
 mesocolon was located in the medium line. With development of the foetus 
 the left mesocolic blade becomes adherent to the lumbar wall especially the 
 splenic flexure becomes fixed to the ventral surface of the left kidney and the 
 left colon becomes fixed to the lumbar wall as far as the intersigmoid fossa. 
 This extensive peritoneal adhesion in the lumbar region added to the vas- 
 cular support (inferior mesenteric artery) reinforces to a high degree the 
 effective fixation of the left colon. It also forms a peritoneal compartment 
 for enteronic loops. 
 
 (b) Adhesions of the Right Colon. 
 
 By peritoneal adhesions of the transverse colon, the hepatic flexure and 
 right colon are fixed in position. The coecum and appendix being projections 
 from the original digestive tube possess no peritoneal adhesions to the abdom- 
 inal wall. In all erect apes examined as to the right colon I found the same 
 exact condition of peritoneal adhesions as man except that in man the axial 
 rotation of the tractus intestinalis was more advanced or complete ending 
 
 
SPLAAC11N0PT0SIA 575 
 
 with coecum in the right iliac fossa or in the lesser pelvis. In man the peri- 
 toneal adhesions of the right colon are more extensive than that of the left 
 colon (which seldom possesses a mesocolon). The adhesions fixing the 
 duodenum to the abdominal wall and the adhesions fixing the right colon to 
 the abdominal wall are practically developed at the same time. The adhe- 
 sions of the right colon spreads over the mesoduodenum, duodenum, distal 
 ventral face of the right kidney and right lumbar region. The mesocolon 
 being fixed to the immobile mesoduodenum lends strong support to the 
 fiexura colihepatica. The transverse colon and hepatic flexure of the colon 
 secure additional peritoneal fixation apparatus from the fact that as soon 
 as the rotating coecum comes in contact with the ballooned mesogastrium a 
 fusion of the mesogastrium and mesocolon from base to viscera occur. 
 Finally the mesogastrium (or rather gastro-colic omentum) envelopes the 
 entire proximal segment of the colon. 
 
 On the left colon there is an important fixation apparatus known as the 
 ligamentum costo-colicum (sinistrum) located on the ventral surface of the 
 left kidney. On the right colon there is a similar fixation apparatus liga- 
 mentum costo-colicum (dextrum) located at the distal pole of the right 
 kidney. This band prevents frequently the coecum from further distalward 
 movements and also from falling into the lesser pelvis. The ligamentum 
 costo-colicum dextrum is an important fixation apparatus for the coecum 
 (and appendix) and prevents frequently the coecum from being a resident 
 in the lesser pelvis. Not infrequently the ligamentum costo-colicum dextrum, 
 together with the right colon, offers more or less support to the right kidney 
 especially at its distal pole. At birth, so far as I am able to report on some 
 60 infant autopsies, the coecum lies in general at the junction of the duode- 
 num and kidney. 
 
 The peritoneal adhesions of the right colon are formed while the child is 
 learning to walk, i. e., by the end of 18 months. The peritoneal adhesions 
 of the tractus intestinalis (secondary visceral supports) to the dorsal wall of 
 the abdomen reinforce to remarkable degree the strength of the primary 
 visceral supports (arteria coeliaca, mesenterica superior et inferior). The 
 secondary visceral supports (acquired peritoneal adhesions form visceral 
 shelves), the contact of the viscera, like bricks in a wall, form solid barriers 
 for visceral support. The mesenterial partitions among the viscera, producing 
 peritoneal compartments aid in visceral support by distributing their force 
 separately against the abdominal wall. 
 
 Respiration Movements of the Tractus Intestinalis. 
 
 The transverse colon moves freely with respiration as it is a shelf for 
 the sub-diaphragmatic viscera (stomach, liver and spleen). The fiexura coli 
 dextra (lying ventral to the right kidney) and the fiexura coli sinistra (lying 
 ventral to the left kidney) move with the kidneys in respiration. Since the 
 transverse mesocolon acts as a visceral shelf it is markedly forced distalward 
 during splanchnoptosia, especially in enteroptosia. I have seen it lying on the 
 pelvic floor and once 9 inches in an inguinal hernia, where as its average 
 
576 THE ABDOMINAL AND PELVIC BRAIN 
 
 location is immediately proximal to the umbilicus. The two colonic flexures 
 in coloptosia produce vigorous traction in the kidneys. 
 
 In the usual autopsy the enteron is found in a compartment formed by 
 the mesocolonic square and closed ventrally by the omentum majus. The 
 transverse mesocolic shelf prevents the subdiaphragmatic viscera from 
 exercising vigorous respiratory movements on the enteron. Defective res- 
 piratory movements of the diaphragm will aid in forcing the enteron distal- 
 ward, from the right and left lumbar regions, into the lesser pelvis. In final 
 advance states of enteroptosia, the transverse segment of the duodenum 
 becomes obstructed by the traction, compression of the superior mesenteric 
 artery, vein and nerve — a distant stage in splanchnoptosia. 
 
 The tractus intestinalis is affected chiefly in splanchnoptosia by: (a) 
 compromising of circulation, blood and lymph supply, i. e. ( congestion and 
 decongestion, (b) trauma of nerve centers (ganglia), strands and nerve 
 periphery, (c) complication from loss of peristalsis and atony of bowel mus- 
 cle, (d) gastro-intestinal catarrah and indigestion from excessive, deficient 
 and disproportionate secretions. Also dragging on the abdominal brain, an 
 independent nerve center producing nausea, neurosis, headache, reflexes, and 
 deranged sensation, secretion and motion on other viscrea. (e) Dilatation of 
 the stomach and duodenum, caused by the superior mesenteric vessels at the 
 point where they cross the transverse segment. The stomach is especially 
 liable to dilatation from the above causes, where the prolapse of the enteron, 
 enteroptosia, is sufficiently advanced to allow the enteronic loops to pass 
 distalward into the lesser pelvis and particularly when the subject lies on the 
 back, for then the superior mesenteric artery, vein and nerve are put on a 
 stretch and they constrict vigorously the transverse portion of the duodenum, 
 (f) the enteronic loops being dislocated (enteroptosia) into the plevis, peri- 
 stalsis, secretion, circulation, sensation and nerve periphery are compromised, 
 followed by catarrh, constipation and indigestion, (g) the colon, especially 
 the colon transversum may lie in the lesser plevis producing similar com- 
 promising circumstances as in the enteron. (h) The appendages (liver, 
 pancreas, and spleen) of the tractus intestinalis, in ptosis are compromised 
 in circulation, secretion, absorption, sensation and nerve periphery. 
 
 CONSIDERATIONS OF GASTROPTOSIA AS PART OF SPLANCHNOPTOSIA. 
 
 The stomach is fixed to the diaphragm by the oesophagus and part of the 
 gastro-hepatic omentum (peritoneum). It is fixed to the liver by the gastro- 
 hepatic omentum (peritoneum), hepatic artery, biliary duct and ligamentum 
 hepato-duodenale and peritoneum (all important bands). The stomach is 
 fixed to the radix mesenterica by the gastric artery. The root of the mesen- 
 tery is not only an important gastric support, but a solid anchor, around 
 which occur all visceral movements. Besides the stomach rests on visceral 
 shelves composed of the transverse colon and its mesentery, pancreas, 
 duodenum and left kidney. It is maintained on the visceral shelves by the 
 abdominal muscles. The distal end of the stomach is bound to the diaphragm 
 through the liver (gastro-hepatic and meshepaticon) and in a similar manner 
 
SPLANCHNOPTOSIA 
 
 577 
 
 the proximal end of the stomach is bound to the diaphragm, through the 
 spleen (gastro-splenic, lienorenal and suspensory ligament) which i?, how- 
 ever, a band of limited strength. 
 
 The Respiratory Movements of the Stomach. 
 
 The diaphragm rests on the liver, stomach and spleen like a muscular 
 dome, hence with each respiration the above three organs (if the stomach be 
 
 Fig. 184. Gastro-duodenal dilatation — gastroptosia. This illustration is drawn from 
 the subject. This subject was 67 years old, dying of carcinoma of the ductus bilis et ductus 
 pancreaticus. It is a so-called transverse stomach, and as the stomach dilates it extends 
 more distalward until in this case it extended to the pelvis. Du and D presents the enor- 
 mously dilated duodenum, obstructed by the superior mesenteric artery A and vein V. 
 Observe the difference in dimension between the duodenum immediately to the right of the 
 mesenteric vessels and that immediately to the left of them. The jejunum, J., is normal in 
 dimension, while the duodenum is as large as a man's arm. A segment of the stomach 
 and duodenum is resected at D to show the dimension of the distal duodenum. I, a 
 resected segment of the ventral surface of the duodenum in order to expose Vater's 
 papilla. O, elongated oesophagus. In this subject the pylorus was dilated in proportion 
 to the duodenum and gastrium. This figure is from the same subject as Fig. 185. I secured 
 this specimen at an autopsy by the professional courtesy of Dr. Charles O'Byrne. 
 
578 THE ABDOMLXAL AND PELVIC BRAIX 
 
 distended) will act similarly — pass distalward according to the resistance 
 offered by the muscles of the abdominal wall. The distended stomach will 
 move ventralward at each inspiration. The stomach exists in the shape of 
 a wedge with its base to the left. The liver also exists in the shape of a 
 wedge with its base to the right. The apex of the liver wedge proximally 
 overlaps the apex of the stomach wedge distally. At every inspiration the 
 apex of these wedges glide on each other, shortening the gastro-hepatic 
 omentum, while at each expiration the gastro-hepatic omentum is placed on 
 tension. The radix mesenterica or root of the mesentery having sent one of 
 its branches to the liver — the hepatic artery — and the other branch to the 
 stomach — the gastric artery — it remains the central axis around which the 
 stomach and liver rotate. A third branch of the radix mesenterica — the 
 splenic artery — passes to the spleen, hence, the root of the mesentery is the 
 central axis of the visceral rotation (in respiration) of the liver, stomach and 
 spleen. Strong fibrous sheaths of connective tissue and nerves radiate on 
 the hepatic, gastric and splenic arteries to their respective viscera constitut- 
 ing an important band between the viscera and the immobile mesentery root. 
 The ventral elevation of the epigastrium at each inspiration is mainly due to: 
 (a) The contraction of the diaphragmatic viscera (liver, stomach and spleen) 
 distalward; (b) the apices of the liver and stomach wedges glide on each 
 other toward their bases increasing their dorso-ventral diameters. The 
 degree of elevation of the epigastrium at each inspiration depends on the 
 resistance of the abdominal wall and the splanchnoptotic state of the dia- 
 phragm and of the subdiaphragmatic viscera. 
 
 Clinicians may observe that hepatic calculus is more frequent in splanch- 
 noptosia but this is rationally explained by the facility in splanchnoptosia of 
 infectious processes invading the biliary passages from lack of visceral drain- 
 age and stasis of tissue fluids — blood and lymph. In splanchonptotics the 
 ducts are flexed, especially the biliary ducts, obstructing the normal flow of 
 visceral products. Gastroptosia is practically constantly accompanied by 
 gastric dilatation. Gastric dilatation must be viewed as a result of displace- 
 ments and not a cause. In gastroptosia the vessels and nerve plexuses are 
 traumatized, elongated, which impairs gastric innervation, circulation (lymph 
 and blood), nourishment and a muscularis ending in dilatation. 
 
 In general it may be noted that the coeliac axis (the immobile root of the 
 mesentery vessels with strong fibrous and neural sheaths) is a secure support 
 to the liver, stomach and spleen. However, the visceral shelves of the sub- 
 diaphragmatic organs must not be overlooked. The pancreas (with its 
 corpus securely bound to the immobile coelac axis with strong fibrous tissue) 
 is the strongest visceral shelf support. The next strongest visceral shelf is 
 the duodenum which in the adult is devoid of dorsal epithelial peritoneum 
 but the strong fibrous subperitoneal tissue binds the whole proximal duodenum 
 to the dorsal wall while the distal duodenum is solidly bound to the cruva of 
 the diaphragm by the muscle of Treitz, (musculus suspensorius duodeni) and 
 to the coliac axis by strong fibrous tissue. Hence the duodenum and 
 pancreas (both fixed to the root of the mesentery) are excellent visceral 
 
SPLAKCHK0PT0S1A 
 
 579 
 
 shelves for liver, stomach and spleen. (Duodenum and pancreas are the rara 
 avis in hernia.) When the splanchnoptosia has advanced sufficiently to 
 involve the proximmal duodenum and head of the pancreas the duodenum is 
 liable to present a diverticulum at the location of entrance of the ducts 
 
 choledochus communis, 
 while the pancreas being 
 fixed in its middle (corpus) 
 will locate its head near 
 sacral promotory. 
 
 Hepatoptosia and gas- 
 troptosia rest chiefly on two 
 causes, viz: (a) relaxation of 
 the abdominal walls; (b) 
 constriction of the trunk by 
 clothing. In both (a) and 
 (b) the normal respiration 
 has become deranged. 
 
 Gastroptosia. 
 
 Gastroptosia or atonia 
 gastrica signifies abdominal 
 relaxation. It includes dis- 
 talward movement of the 
 stomach and relaxation of 
 the abdominal wall. It is a 
 part and parcel of splanch- 
 noptosia. Gastroptosia 
 (or its equivalent atonia 
 gastrica) practically includes 
 the terms dilatation of 
 stomach, ectasis ventriculi, 
 insufficiency of the stomach, 
 gastric insufficiency, motor 
 insufficiency, ischochymia 
 (retention of chyme), myas- 
 thenia, extasis gastrica, 
 because it signifies abdomi- 
 nal relaxation and relaxa- 
 tion includes dilatation and 
 motor insufficiency. There- 
 fore gastroptosia is a proper, 
 comprehensive, scientific 
 term which signifies ptossi, 
 dilatation and motor insufficiency of the stomach. Gastroptosia is of para- 
 mount importance to physicians as its existence is frequent in every day 
 practice. 
 
 Fig. 185. Carcinoma completely obstructing the 
 biliary and pancreatic ducts. From same subject as 
 Fig. 184. Illustrates an X-ray of enormously dilated bil- 
 iary passages. The biliary ducts (excepting the gall- 
 bladder, which was three to four times its normal 
 dimension) had a capacity of 32 ounces, about six or 
 seven times the natural capacity. The ductus communis 
 choledochus was over \ l /\ inches in diameter. The 
 pancreatic duct admitted the index-finger. The man, 69 
 years old, a giant in stature, weighing some 250 pounds 
 with ordinary limited fat, lost 115 pounds in weight dur- 
 ing three months' illness. The ductus cysticus, extend- 
 ing from II to IV, had seven Heister's valves, and its lu- 
 men would admit a lead-pencil only. At B the biliary 
 ducts were deficient within the liver substance, but were 
 really dilated on the surface. T, the carcinoma (divided 
 with the scalpel), completely severing the lumen of the 
 biliary and pancreatic ducts. There was enormous gas- 
 troduodenal dilation from the compression of the trans- 
 verse duodenum by the superior mesenteric artery (A) 
 and vein (V). D, foldless, granular, proximal 2 l / 2 
 inches of the duodenal mucosa; 1, entrance of ductus 
 communis choledochus in the duodenum ; Sa, ductus 
 Santorini ; P, ductus pancreaticus. The ductus com- 
 munis choledochus and ductus pancreaticus, located 
 between the carcinoma and Vater's diverticulum, were 
 normal. Da is the normal sized duodenum located 
 distal to the compressing superior mesenteric vein (V) 
 and artery (A). Observe the vast dilatation of the 
 duodenum proximal to the superior mesenteric artery 
 (A) and vein (V). I secured this rare specimen at an 
 autopsy through the courtesy of Dr. Charles O'Byrne. 
 
580 
 
 THE ABDOMLXAL AXD PELVIC BRA IX 
 
 In early embryonic life the stomach is absolutely vertical and the child 
 is practically born with a vertical stomach and besides I have observed 
 scores of permanently vertical stomachs in adult autopsies (perhaps from 
 arrest of development). With the growth of the child the stomach rotates 
 following the atrophying liver. In the adult the rotated stomach is supplied 
 on its ventral surface (left) by the left vagus and on the c surface (right) 
 
 by the right vagus. Food 
 aids by its weight and dis- 
 tention to force the stomach 
 distalward. In gastroptosia 
 the lesser curvature and py- 
 lorus moves distalward. 
 
 Etiology. 
 
 Gastroptosia arises from a 
 variety of causes. Disor- 
 dered respiration with con- 
 sequent descensus of the 
 diapnragm and distorted dis- 
 tal thorax (ribs) is among the 
 first disturbances. In short 
 gastroptosia coexists with 
 splanchnoptosia. Gastro- 
 ptosia may be due to an ab- 
 normally distalward location 
 of the diaphragm. In hepa- 
 toptosia the liver forces the 
 pylorus distalward and to the 
 left. Relaxed abdominal 
 walls, rapidly repeated 
 pregnancies, infected puer- 
 perium i i. e., practically sub- 
 involution of the abdominal 
 wall). compression from 
 waist bands, liver or spleen 
 tumors, pleuritic effusions or 
 adhesions, pericarditis are 
 fruitful causes of gastro- 
 ptosia. I have observed in 
 autopsies that peritoneal and 
 especially omental adhesions play an extensive role in gastroptosia. 
 
 Gastroptosia is congenital or acquired. The acquired gastroptosia is 
 discernible in the change in normal relations of the space in the proximal 
 abdomen and distal thorax especially in the manifestation of respiration. In 
 general we observe at post mortems two forms of gastroptosia, viz. : (a) the 
 whole stomach appears 'with the lesser curvature and pylorus with a trans- 
 
 Fig. 186. This illustration presents the horizontal 
 stomach, which in gastroptosia dilates from pylorus to 
 cardiac extremity, and passes distalward as in Fig. 184— 
 a gastro-duodenal dilatation. Sig. represents the 
 sigmoid flexure in a 180 deg. condition of phvsiologic 
 vol v.:. 
 
SPLANCHNOPTOSIA 
 
 581 
 
 verse position) moving caudal, (b) the distalward moving stomach assumes 
 more or less a distinctly vertical position. 
 
 I wish to state, that, from personal autopsic observation in the abdomi- 
 nal viscera in over 700 subjects, the stomach varies extensively: (a) in 
 
 position, (b) in dimension, 
 (c) in form. 
 
 Gastroptosia may be due 
 to constitutional defects or 
 anomalies in both sexes. 
 The peculiar formed chest, 
 as funnel shaped, chicken 
 breast, may be observed in 
 subjects with gastroptosia 
 which is part and parcel of 
 splanchnoptosia. Gastro- 
 ptosia occurs in subjects with 
 tubercular habitus — consti- 
 tutional defects. 
 
 Gastroptosia (or splanch- 
 noptosia) does not as a rule 
 occur in strong robust sub- 
 jects. Obvious stigmata of 
 degeneracy accompanying 
 splanchnoptosia subjects 
 with elongated narrow tho- 
 rax are liable to gastroptosia 
 because the diaphragm oc- 
 cupies an abnormally distal- 
 ward location. Pulmonary 
 emphysemia or pleural effu- 
 sions force the diaphragm 
 distalward favoring gastro- 
 ptosia (and concomitant 
 splanchnoptosia). Mechan- 
 ical conditions may enhance 
 stomachoptosia as supraum- 
 bilical hernia, inguinal or 
 femoral hernia, peritoneal 
 adhesions. Rapidly repeated 
 gestations present a large 
 field of gastroptosia so fully 
 discussed by Landau as well as rapid loss of large quantities of fat. In multi- 
 para and subjects with loss of quantities of flesh the abdominal muscles 
 become relaxed and lose their delicate active poise in maintaining the vis- 
 cera in their normal physiologic position. 
 
 Fig. 187. This represents a vertical stomach. Dur- 
 ing gastro-duodenal gastroptosia the chief gastric dilata- 
 tion occurs at the distal end of the stomach. The 
 superior mesenteric, S, compressing the transverse 
 duodenum, causes the gastro-duodenal dilatation. This 
 figure presents a non-descended cecum, and an ileum, 
 I, adherent to the ileopsoas muscle. 1, 2, 4 represent- 
 ing the dorsal insertion line of the meso-sigmoid. 
 
>82 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 Gastric Dilatation in Splanchnoptosia. 
 
 Many times I have observed in autopsy extensively dilated stomach, the 
 existence of which in life had not been suspected, first, because the physical 
 condition of the patient was favorable and second compensatory action 
 between stomach and pylorus was still favorable. A relation exists between 
 the dimensions of the pylorus and that of the stomach — a compensatory 
 action. I performed an operation on a woman who had vomited for years 
 with a dilated stomach. In this case the pylorus had dilated slightly and its 
 flexion increasing by ptosis 
 obstructed the free evacua- 
 tions of the stomach con- 
 tents. 
 
 Again we note autopsies in 
 which a subject possesses a 
 markedly dilated stomach 
 with slight difficulty in 
 evacuation of stomach con- 
 tents through the pylorus 
 because the pyloric ring had 
 dilated proportionately with 
 the stomach dilatation allow- 
 ing free evacuation, free 
 passage of food from 
 stomach to duodenum, free 
 drainage — here is compen 
 satory dilatation- of stomach 
 and pylorus, resembling that 
 of the cardiac valves, how- 
 ever, suddenly the stomach 
 and pyloric compensatory 
 action may fail and the 
 patient passes swiftly on- 
 ward and swiftly downward 
 — exactly as ''a valvular 
 heart lesions. 
 
 The etiology of gastro- 
 ptosia may be sought chiefly 
 
 in constitutional defects. However, mechanical derangement is sufficiently 
 obvious in gastroptosia. Gastro-duodenal dilatation which plays such an ex- 
 tensive role in splanchnoptosia will be discussed and illustrated in a future 
 chapter. Combined gastro-duodenal dilatation due to the compression of 
 the transverse duodenal segment by the superior mesenteric artery vein 
 and nerve is a frequent condition and though I have published articles on it 
 for a decade it is still but limitedly recognized. 
 
 The symtomatology may be practically negative or of the most aggra- 
 
 Fig. 188. illustrates gastroptosia. The colon 
 transversum forced distalward into the pelvis by the 
 stomach. 1, liver with hepatoptosia ; 2, stomach in the 
 lesser pelvis; 3, 4, duodenum dilated; 5, the jejunum, 
 normal caliber; 6, transverse colon. This cut repre- 
 sents gastro-duodenal dilation — the second stage of 
 splanchnoptosis. 
 
 The artist neglected to present the duodenum 
 dilated. 
 
SPLANCHNOPTOSIA 583 
 
 vated kind. It may be stated, in general, that gastroptosia is without 
 symptoms so long as the stomach functionates normally which mainly 
 prevails while the subject is in favorable physical condition. Gastroptosia 
 presents symptoms when detention and composition food occurs and general 
 infection results. Indirect symptoms may arise as in splanchnoptosia, e. g., 
 fatigue, debility, constipation, insomnia. Meinert insist that gastroptosia is 
 a common cause of chlorosis. 
 
 The symptoms of gastroptosia are generally proportionate to the degree 
 of stomachic dilatation. Kussmaul originally observed that gastroptosia is 
 frequently accompanied by a disturbance of the motor nerves of the stomach. 
 This may be due to the trauma traction on the vagi from change of gastric 
 position. Gastroptosia frequently coexists with multiple nervous symptoms, 
 but the nervous symptoms may be due to splanchnoptosia. However, gas- 
 troptosia is a disease and is liable to be accompanied by disturbed motion, 
 absorption, secretion and sensibility of the stomach. Change of form and 
 position of the stomach may not lead to any more nervous symptoms than 
 change of form and position of the uterus, however dislocation of the uterus, 
 i. e., permanent fixation, is the result of some disease. 
 
 Malposition of the stomach does not produce neurasthenia any more 
 than malposition of the uterus. The position of a mobile viscus is not 
 responsible for neurosis, for mulitple positions or multiple deviations must 
 not be considered abnormalities. It is disease that produces neurosis, not 
 position of viscera. Original disease which produced the malposition of the 
 viscus should be held responsible for the nervous disturbance. Again there 
 can be no doubt that the symptoms of gastroptosia and nephroptosia are 
 constantly mistaken for each other especially by the careless examining sur- 
 geon with a tendency to nephropexy. There is no characteristic stomach 
 contents peculiar to gastroptosia. In gastroptosia pain is generally prevalent 
 in the proximal abdomen and lumbar regions. It is true that subjects with 
 gastroptosia (a part and parcel of splanchnoptosia) present multiple neurotic 
 symptoms simulating disturbed mobility, secretion, absorption and sensibility 
 of the stomach. However, this may belong in the congenital debility or 
 predisposition of the patient — due to the disturbance created by anatomically 
 dislocated viscera and consequently pathologic physiology. Gastroptosia 
 increases the weight of the stomach. 
 
 Diagnosis. 
 
 Gastroptosia is less recognized than nephroptosia which is diagnosed 
 with more facility and besides the pexyites are more vigorously in search of 
 nephroptotic victims. 
 
 Percussion and auscultation with various quantities of fluid in the 
 stomach may suggest the position and dimension of the stomach. 
 
 Palpable epigastric pulsation, absence of projecting abdominal wall in 
 the epigastrium and projecting abdominal walls in the hypogastrium aid in 
 the diagnosing gastroptosia. 
 
 The most exact method to determine the position and dimension of the 
 
584 THE ABDOMIXAL AXD PELVIC BRA IX 
 
 stomach is by inflation, viz. : (a) by generation of gas within the stomach. 
 The most frequent method of gastric inflation practiced is by directing the 
 patient to drink a glass of water containing some sodium bicarbonate and 
 immediately to drink another glass of water containing tartaric acid whence 
 carbonic acid gas is formed distending the stomach by air. (b) Another 
 method to inflate the stomach is by introducing into the stomach a tube 
 whence air is forced through it for distention, whence its form, position and 
 dimension may be observed through the abdominal wall, (c) A third method 
 of diagnosing the form, position and dimension of the stomach is by distend- 
 ing the stomach by fluid. 
 
 When the major curvature is at or below the umbilicus and the pylorus 
 and lesser curvature have moved distalward the diagnosis of gastroptosia is 
 confirmed. A healthy stomach maintains the position of its borders regard- 
 less of the subject's attitude. In gastroptosia the borders of the stomach 
 change according to the patient's position. In gastroptosia with the patient 
 in the erect posture the major stomach curvature and pylorus will be more 
 caudal, while if the patient's posture is recumbent the pylorus and major 
 curvature cephalad. Succussion (splashing sound) is a method to diagnose 
 gastroptosia by agitating air and water in the stomach through shaking the 
 body. The splashing sound may also be obtained by palpating the stomach 
 while the patient is in the recumbent position. A splashing sound elicited 
 from the stomach means practically gastroptosia — relaxation, atony. Some 
 persons by practicing pressure of the abdominal muscles of the stomach can 
 produce various sounds in the stomach. Such persons perhaps possess 
 abnormally a large stomach and powerful abdominal muscles, however, like 
 a fakir have exaggerated an anomaly. Gastroptosia may be diagnosed by 
 transillumination, i. e.. introducing an electric light in the stomach whence 
 its contour may be observed. This method was advocated in 1845 by Case- 
 nave, later in 1867 Milliot improved it by experimentation, however, Dr. 
 Max Einhorn of New York practically first made successful use of (the gastro- 
 diaphane) transillumination of the stomach in man and demonstrated the 
 utility of gastro-diaphanes copy. 
 
 Inspection may present a depression in the epigastrium and a projection 
 in the umbilical region. This method of diagnosis may be sufficient in spare 
 persons to announce gastroptosia. The X-ray may be used to note the posi- 
 tion of the stomach by administering substances which will cast a shadow, 
 as subnitrate of bismuth or metallic salts administered in capsules. Treat- 
 ment is medical, mechanical, surgical. 
 
 Treatment. 
 
 1. The medical treatment consists in regulation of diet and function. 
 The dietetic management consists in administering limited quantities of 
 prescribed food at regular three-hour intervals. The diet should be cereals, 
 vegetables, milk and eggs. All high seasoned food, pastry, pie, cake, spices, 
 meat should be excluded to avoid fermentation. 
 
 The most essential medical treatment consists in "visceral drainage" as 
 
SPLANCHNOPTOSIA 
 
 585 
 
 ample sewerage the evacuating channels should be flushed. Gastroptotics 
 may live healthy with ample visceral drainage. The tissues and tissue 
 spaces in gastroptosia (splanchnoptosia) require flooding, washing, so that 
 the subject may be free from waste laden blood and residual debris. Every 
 evacuating visceral tract (tractus intestinalis, perspiratorius, urinarius res- 
 piratorious) should perform maximum duty. The sheet anchor treatment for 
 gastroptosia is regulation of food and fluid, and maximum sewerage of 
 visceral tracts. Dietetics, hygiene, anatomic and physiologic rest, properly 
 supervised, tend extensively to the welfare in the life of a splanchnoptotic. 
 
 2. Mechanical treat- 
 ment in gastroptosia judic- 
 iously applied affords won- 
 derful relief. Stomachic 
 irrigation occasionally ren- 
 ders much comfort. The 
 treatment consists in the ap- 
 plication of abdominal wall 
 to support the viscera. This 
 is accomplished by various 
 kinds of abdominal binders 
 — elastic and non-elastic. I 
 use sometimes an abdominal 
 binder within which is placed 
 a pneumatic rubber pad 
 which is distended with air 
 to suit the patient's comfort. 
 Dr. E. A. Gallant employs 
 a suitable fitting corset. 
 The adhesive strapping 
 method of Achilles Rose is 
 practical, rational and 
 economical and affords ex- 
 cellent relief. The recum- 
 bent position aids the patient. 
 The mechanical method at- 
 tempts the forcible reposi- 
 tion of the stomach to its normal physicologic position and there to main- 
 tain it by aids applied to the abdominal wall — a rational method. Preg- 
 nancy practically relieves the gastroptosia for a season. Splanchnoptotics 
 experience more comfort from rational adhesive strapping (mechanical sup- 
 ports) than from surgical procedures. 
 
 3. Surgical treatment in gastroptosia is a very limited field. It espouses 
 two methods, viz. : (a) The surgery is applied to the stomach itself as gas- 
 troenterostomy, the Heinicke-Mickulicz operation (both tend to cure by 
 visceral drainage) the replication of the stomach parietes or the attempt to 
 shelve the stomach by omentum or mesentery (both unphysiclogic, irrational). 
 
 Fig. 189 illustrates the third stage of splanch- 
 noptosia, viz. : gastro-duodenal dilatation. It shows the 
 transverse colon (5) in the lesser pelvis. The widely 
 dilated stomach (1) is drawn leftward by hooks (10) 
 from its bed to show the duodenum (2) dilated by the 
 superior mesenteric artery, vein and nerve, (3) 4, the 
 normal calibered loops of enteron ; 6, right colon ; 7, 
 cecum ; 8, the appendix. Note the enteron loops 
 crowded into the lesser pelvis. 
 
THE ABDOMIXAL AXD PELJ'IC BRAIX 
 
 (b) The abdominal wall is employed to support the stomach as by incision 
 and over-lapping like a double breasted coat, or by enclosing, uniting the 
 two musculi recti abdominales in one sheath. Both methods attempt to 
 relieve by lessening the abdominal cavity and forcing the stomach into its 
 normal physiologic position ('both rational"). A third method is to perform 
 gastropexy. i. e., suture the stomach to the abdominal wall (limited, irrational 
 in generalj. 
 
 HEPATOPTOSIA, COLOPTOSIA AND ENTEROPTOSIA IN SPLAXCHXOPTOSIA. 
 
 Fixation of the Livt • 
 
 The liver is firmly fixed to the diaphragm only. It has the most exten- 
 sive fixation to the diaphragm of any abdominal' viscus, hence the action of 
 the diaphragm in respiration will be the most comprehensive. The structures 
 which maintain the liver in contact with the concavity of the diaphragm are: 
 a) peritoneal folds; (b) connective tissue : (c) vessels; (d) abdominal mus- 
 cles (most important;. The liver rests on a visceral shelf, composed of the 
 stomach, duodenum, right kidney, pancreas and transverse colon. The vena 
 cava and hepatic veins by their intimate fusion with both liver substance and 
 the diaphragm constitute a strong bond of union. The dorsal mesentery of 
 the liver — the mesepaticon meso-hepor — is constituted by the extensive con- 
 nective tissue which binds the right lobe of the liver to the distal concave 
 surface of the diaphragm together with the reflexion of peritoneum which 
 surrounds the connective tissue area. 
 
 The mesepaticon forms the most important passive band of the liver and 
 diaphragm. The right and left lateral ligaments are mere extensions of the 
 mesepaticon. The suspensory ligament, the remnant of the ventral hepatic 
 mesentery, is long and loose to allow respiratory movements. An excellent 
 example of what the respiratory movements of viscera may accomplish is 
 observed in the bursa of Spiegel. Spiegel's lobe moves proximalward and 
 iistaiward with each respiration and by this continual action has formed a 
 diverticulum in the lesser sac of the peritoneum — Bursa spigelii. The 
 proximalward and distalward movements of Spiegel's lobe produced by the 
 diaphragm in respiration is responsible for Spiegel's diverticulum in the peri- 
 toneum. 
 
 Respiratory Movements of the Liz-cr. 
 
 If one studies the diaphragm it will be observed that its muscular con- 
 tractions tend toward the radix mesenterica. When the diaphragm contracts 
 (inspiration) on the broad dorso-^rcximal dome-like hepatic surface it will 
 force the liver distalward, % r.:ralward and medianward. At every inspira- 
 tion the liver pounds en the abdminal viscera distal to it like a hammer, 
 especially in thorazic splanchnoptosia. The degree of distalward movements 
 the liver in inspiration depends on the resistance offered by the muscles of 
 the abdominal wall. These movements of the liver in inspiration imposed 
 on it by the diaphragm do not disturb its function, on the contrary doubtless 
 aid in massaging the liver into vigorous function. 
 
SPLANCHNOPTOSIA 
 
 The normal respiratory movements of the liver may become disturbed 
 by relaxation of the diaphragm or abdominal walls which rob it of normal 
 support. Tight lacing may force the liver from its visceral niche and shelf 
 whence the normal inspiratory muscular action becomes ungeared. Peri- 
 hepatic peritoneal or pleuritic adhesions particularly distort respiratory 
 muscular actions on the liver and consequent normal function. Hepato- 
 Ptosia is not a rare condition, especially when the liver has lost its visceral 
 shelf and the abdominal walls become relaxed. 
 
 Etiology of Hepato-Ptosia. 
 
 Hepato-Ptosia is a part and parcel of splanchnoptosia and depends on 
 the same causes — as deranged respirations, relaxed abdominal walls, yielding 
 of the diaphragm, hepatic ligaments and visceral shelves (kidney, duodenum 
 transverse colon, pancreas, stomach) peritoneal and omental adhesions, 
 plueritic effusions and exudates asthma, rapidly repeated pregnancies, heredi- 
 tary or congenital debilities, persistent vomiting and coughing, hernia, 
 tight waist band, corsets, trauma, congenital predisposition. 
 
 The elongation of the hepatic ligaments are secondary to the relaxation 
 of the abdominal wall. Further etiologic factors in hepato-ptosia are the 
 weight of the liver, cholelithiasis, weight of the gall-bladder, laxity or elon- 
 gation of the hepatic ligaments (which are probably secondary to the relaxa- 
 tion of the abdominal wall), trauma as during parturition, disappearance 
 of the visceral shelves. The chief immediate course of hepato-ptosia is 
 relaxation of the ventral abdominal wall. The liver like the uterus rests on 
 a floor or visceral shelf. 
 
 Frequency. 
 
 Hepato-Ptosia occurs the most frequently in women. During the past 
 15 years I have observed about one typical advanced clinical case a year; 
 however, numerous subjects may be observed with a moderate degree of 
 hepato-ptosia, especially those having a tendency to develop Riedel's lobe. 
 The frequency of hepato-ptosia is concomitant with splanchnoptosia, which 
 is a common ailment. Perhaps seven women suffer from hepato-ptosia to 
 one man. I have examined subjects of extreme hepato-ptosia in whom I 
 could palpate the liver per vaginum. The history of hepato-ptosia is recent, 
 as Portal was among the first to call attention to it in autopsy (1304) and the 
 first case described in the living was by Cantani in 1866. Autopsies revealed 
 its condition previous to that, but its interpretation remained unsolved. 
 
 The liver lies in an excavation in the concavity of the diaphragm resting 
 on a visceral shelf. Its primary maintainers are the power of the abdominal 
 wall. Its secondary maintainers are the suspensory, coronary, triangular, 
 ligaments and mes-hepaticon, mesohepar. The elongation of these five sup- 
 ports allows distalvvard movements of the liver. Floating liver is intimately 
 associated with splanchnoptosia— is part and parcel of it — for in autopsy it 
 is common to note the kidney, hepatic flexure, enteron passing distalward 
 before the liver. I have personally examined in the living and dead about a 
 
588 THE ABDOMLXAL AXD PELVIC BRAIX 
 
 dozen typical, advanced, so called Riedel's lobes. In every subject of 
 marked Riedel's lobe splanchnoptosia was marked. The vast majority of the 
 subjects were women. 
 
 First, when the right liver lobe becomes forced excessively distalward 
 the costal margin tends to separate the proximal form the distal part of the 
 lobe by compressing a crease in the liver. The distal part of the right lobe 
 which is extended distal to the costal margin becomes an increasing Reidel's 
 lobe. Second, the space between the distal costal margin and the proximal 
 crest of the ilium allows Riedel's lobe to develop, as here the abdominal 
 walls offer the direction of least resistance. 
 
 Symptomatology. 
 
 The symptoms of hepato-ptosia are acute or chronic, partial or complete. 
 In general the clinical symptoms are dragging pain in the abdomen, nausea, 
 vomiting, dizziness, constipation alternating with diarrhcea, ascites, a peculiar 
 rhythmic distressing "hepatic" cough with numerous neurotic disturbances 
 and malassimilation. Curiously enough one not infrequently meets a subject 
 with hepato-ptosia presenting no objective symptoms. 
 
 Diagnosis. 
 
 The diagnosis rests on bimanual palpation, percussion, a mobile mass in 
 right side, change in location of tumor by change of attitude. Liver dullness 
 changes with different positions and the liver may be felt in each different 
 position. The liver in hepato-ptosia may assume any position in the abdom- 
 inal cavity. If the kidney is not enlarged nephroptosia can be differentiated 
 from hepato-ptosia; however, with enlarged kidney it may be impossible. I 
 have examined subjects with the best of experts in urology, where it was 
 impossible to decide until peritonotomy was executed. 
 
 An excellent factor in diagnosis is to attempt to replace the liver with 
 the patient recumbent, which if successful is confirmatory of hepato-ptosia; 
 examine the liver in the erect and prone position. As the liver passes distal- 
 ward it is liable to rotate to the right on the ligamentum umbilicale as an 
 axis. A warning is offered that Riedel's lobe should be differentiated from 
 hepato-ptosia. Riedel's lobe is a direct extension distalward of the distal 
 portion of the right hepatic lobe. Its etiology, though obscure, appears to 
 be associated with diseases of the gall-bladder, cholelithiasis or tight waist 
 bands. 
 
 The development of Riedel's lobe appears to be intimately connected 
 with cholelithiasis; however, I have seen Riedel's lobe sufficiently frequent 
 in both the living and the dead with no cholelithiasis present, to know it is. 
 not the only cause. 
 
 Occasionally we can diagnose floating liver of considerable degree 
 accompanied apparently by no symptoms. I have observed subjects of 
 hepato-ptosia when a distinct bulging presented in the distal right quadrant 
 of the abdomen with no symptoms. 
 
 In hepato-ptosia the liver rotates on its pedicle (transverseaxis), the 
 
SPLANCHNOPTOSIA 
 
 589 
 
 torsion of which compromises its anatomy and physiology (biliary ducts, 
 Porta) vein, hepatic artery, lymphatics and nerves). With change of position 
 (hepato-ptosia) the liver experiences change of form. Hepato-ptosia does 
 not occur without dislocation and change of adjacent organs. In hepato- 
 ptosia the change in form and 
 position of the liver is not due 
 merely to pressure of the abdomi- 
 nal wall (muscle or bony) but to 
 the necessity of physiologic move- 
 ment as liver rhythm and applica- 
 tion of adjacent viscera against 
 the liver by respiratory move- 
 ments. The liver is dislocated 
 through disease, i. e., by patho- 
 logic physiology or pathologic 
 anatomy of adjacent viscera or 
 body walls. 
 
 Treatment. 
 
 The treatment is: 1, Medical, 
 such as diet, "visceral drainage," 
 stimulation of the functions of the 
 visceral tracts to a maximum 
 degree of elimination by injesting 
 liberal quantities of fluids at 
 regular intervals, ample horizon- 
 tal rests. Forced nutrition aids 
 in restoring the fat cushions. The 
 patient must avoid excessive or 
 traumatic exertions. 2, Mechan- 
 ical treatment consists in forcible 
 reposition and maintaining the 
 liver in its normal physiologic 
 position. Apply abdominal bin- 
 ders, adhesive strapping or an 
 applicable, suitable corset (Galla- 
 net). The mechanical methods 
 afford wonderful relief, especially 
 Achilles Rose'smethod of adhesive 
 strapping. 3, Surgical. Hepato- 
 pexy should be performed only as 
 a last resort. It has an extremely 
 performed over 50 times since its 
 Overlapping the abdominal walls 
 tional and secures more successful 
 ish the abdominal cavity and force 
 tion in the diaphragmatic concavi 
 
 Fig. 190. Coloptosia. The transverse colon 
 extends into the lesser pelvis. Coloptosia 
 increases the flexion of the flexura hepatica coli 
 and the flexura linealis coli, increasing the diffi- 
 culty and friction of fecal circulation. Z The 
 cupola of the sigmoid, presenting a physiological 
 sigmoid volvulus. CO Coecum located in the 
 lesser pelvis, with the appendix Ap. II. Ileum, 
 coursing proximalward and parallel with the right 
 colon, assuming conditions favorable to an ileo- 
 cecal volvulus. X illustrates that during volvulus 
 of the sigmoid it appropriates peritoneum, and 
 formulates it into an additional elongated meso- 
 sigmoid. 
 
 limited field of usefulness. It has been 
 introduction in 1877 with doubtful results, 
 like a double breasted coat is more ra- 
 results, as such a procedure would dimin- 
 the liver in its normal dome-like excava- 
 ty and on its normal visceral shelf. 
 
590 THE ABDOMINAL AND PELVIC BRAIN 
 
 Coloptosia. 
 
 The colon has received some attention in splanchnoptosia from its rela- 
 tion to nephroptosia and hepato-ptosia gastroptosia : (a) Coloptosia transversa. 
 
 The dislocation of the middle of the transverse colon producing more or 
 less of a curve with its concavity proximalward, is one of the most frequent 
 factors in splanchnoptosia. Dislocation of the colon is placed in relation 
 with the relaxed abdominal wall with elongation of the mesocolon with con- 
 stipation, with tight waist bands, with gastroptosia, nephroptosia, hepato- 
 ptosia; however, no one theory is satisfactory. 
 
 It is true that by circular constriction of the abdomen one can force 
 some viscera proximalward and many distalward. However, at autopsy I 
 found even in youth, in nullipara in absence of corset, that the colon trans- 
 versum may be located well distalward from the umbilicus. We can observe 
 that not only the mesocolon transversum was elongated but also the ligamen- 
 tum gastro-colicum, i. e., the visceral mesenteries were elongated. With 
 the elongated mesocolon transversum the transverse colon can assume vari- 
 ous positions. 
 
 In autopsy it is common to observe the middle of the transverse colon 
 projection into the pelvis and not frequently the colon may lie in the lesser 
 pelvis and on its floor. The middle loop of the transverse colon can be 
 moved with facility to any portion of the peritoneal cavity. The enteronic 
 loops may glide proximalward ventral to the transverse colon. The right 
 portion of the transverse colon is frequently prevented from distalward 
 movements by reason of pathologic peritoneal adhesions binding it to the 
 liver. The mesocolon transversum measures generally 4>^ inches; however, 
 in subjects of coloptosia, I have observed it nine inches in length and fre- 
 quently six inches. The membrana mesenterii propria, i. e., the submesocolic 
 tissue, vessels and nerves, are elongated, attenuated. Coloptosia trans- 
 versum plays a prominent role in autopsic observations. 
 
 Hepato-ptosia and nephroptosia may be advanced sufficiently to force 
 the colonic hepatic flexure so far distalward that it becomes reversed. In 
 such cases the colon extends from the coecum obliquely across the abdomen 
 to the spleen. The clinical hisotory of such patients was mostly unknown. 
 However, I am not convinced that these marked dislocations of the right 
 and transverse colon manifested grave symptoms. For the transverse colon 
 in general will measure about 22 inches, and since the abdominal cavity 
 between the points of the splenic and hepatic flexures is some 14 inches the 
 transverse colon must assume a sinuous or looped course of more or less 
 deviation from an extended line. 
 
 Coloptosia Dextra. 
 
 The right colon becomes of significant interest in coloptosia on account 
 of its relation to nephroptosia and hepato-ptosia, the appendix and tractus 
 genitalis as well as to the fact that the colon dextrum not infrequently pos- 
 sesses a mesocolon. The resistance to coloptosia dextra is chiefly offered by 
 the ligamentum costo-colicum dextrum, which vigorously fixes the cecum, in 
 
SPLANCHNOPTOSIA 501 
 
 many subjects, checks its distalward movements, preventing it from becoming 
 a resident in the lesser pelvis (woman 20%, man 10$ ). 
 
 The base or root of the right mesocolon is fixed to the ventral surface of 
 the distal renal pole, hence maintains intimate relations to nephroptosia 
 dextrum. The right colon is about eight inches plus two inches for the 
 cecum, assumes a sinuous or looped course in most bodies and the additional 
 loops of moderate coloptosia dextra perhaps produce few symptoms. 
 
 Coloptosia Sinistra. 
 
 The left colon is so infrequently dislocated from the fact that it is rarely 
 possessing a mesocolon that I omit its discussion in coloptosia. 
 
 Coloptosia Sigmoidea, 
 
 It is difficult to define splanchnoptosia of the sigmoid, as it has an exten- 
 sive normal range of mobility. In general it is 17 inches in length in woman 
 and 19 in man. Its mesosigmoid will average V/2 inches. The base of the 
 mesosigmoid insertion — its foot — is but a few inches in length and hence the 
 sigmoid will move about freely in the peritoneal cavity. In autopsies the 
 sigmoid may be found the most frequently in the lesser pelvis (65% to75%), 
 in the right iliac fossa (15%), in the proximal abdomen (15%). It may be 
 in contact with the spleen, stomach, liver or cecum. The most distinct 
 reason for the nonsplanchnoptotic state of the sigmoid is that the trauma of 
 the psoas produces more or less plastic peritonitis in the mesosigmoid (meso- 
 sigmoiditis) in 80% of subjects and the mesosigmoiditis contracts the meso- 
 sigmoid, fixing it to the Psoas muscle, preventing coloptosia sigmoidea. It 
 is claimed that in coloptosia of the sigmoid that it forms dangerous obstruct- 
 ing angulation which is yet to prove. 
 
 Symptomatology. 
 
 The symptoms of coloptosia include many due to general splanchnop- 
 tosia. Some of the symptoms are (a) constipation; (b) diarrhoea — (a) and 
 (b) alternating — (c) colonic catarrh, mucous colitis or which I prefer to term 
 secretion neurosis of the colon. The colonic secretion, absorption, sensa- 
 tions, and peristalsis may be excessive, deficient or disproportionate. 
 Fermentation, and borbyrigmus arise. Dragging sensations, fatigue, debility, 
 multiple nervous symptoms. In general the symptoms of coloptosia are 
 stenosis compromised and irregular caliber, dilatation, retention, obstruction, 
 constipation, disturbed circulation and ennervation, relaxed abdominal wall, 
 pendulous abdomen, practical relief of symptoms on assuming the prone 
 position. 
 
 The dislocation of the colon favors constipation because the defective 
 abdominal wall has lost its effective power to force the faeces distalward. 
 Since in dyspepsia, nervopathies of the tractus intestinalis, no local subjec- 
 tive pain is experienced hy the patient, we do not palpate the abdomen 
 sufficiently frequently. First and foremost we should palpate the abdomen 
 to determine whether the pathologic physiology of the tractus intestinalis be 
 
592 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 secondary or primary. Many diseases have an intestinal origin. Dyspepsia 
 refers to the stomach only. 
 
 Splanchnoptosia is a disease of malnutrition. Palpation of the tractus 
 intestinalis attempts to explore systematically the various segments and 
 susceptibility to pain caliber, contents, tension, and mode of fixation. 
 Simon's method of rectal exploration with the hand we discard as unsuitable. 
 In palpation of the abdomen we must devote sufficient time to understand 
 the occasional variation in the aortic rhythm. As to Glenard's colic cord 
 we must consider the small contracted stomach, the pancreas and colon 
 transversum, as any one may be mistaken for the ""colic cord." Whatever 
 this cord can be, found in perhaps 10 r /c of splanchnoptoses, we should attempt 
 to note its accessibility, position, length, form, volume, consistence, mobility, 
 sensation. In palpation the idea of gliding the intestinal segments under 
 the hand or gliding the hand over them must be practiced. The colic cord is 
 located in the relation with the umbilicus. In the diagnosis of coloptosia 
 search should be made for colonicptosia, dilation, constriction, stenosis, 
 atony, decalibration, obstruction, retention. 
 
 Diagnosis of coloptosia ma}' be confirmed by colonic inflation per rectum 
 whence one can by inspection and percussion trace the course of the colon 
 fairly accurately. By palpation one may manipulate the colon. Glenard 
 mentions a diagnostic clue to coloptosia transverse which he calls "corde 
 colique transverse" — the cord of the transverse colon. I have practiced on 
 this subject in the dead splanchnoptotic and it is my opinion that Glenard's 
 cord of the transverse colon is simply the pancreas in general. It may be 
 possible from the direction, dimension, location, consistence, mobility, 
 sensibility, inflation, of the '"colic cord" to detect the transverse colon in 
 splanchnoptosia. The cecum and right colon will be best located by 
 inflation whence inspection and percussion are further aids. We must 
 attempt to note the location, dimension, consistence, mobility of the cecum 
 and right colon. 
 
 In the diagnosis of coloptosia the means at hand are (a > inspection; (b) 
 palpation; (c) distension, inflation; (d) consistence; (e) mobility; (f) sen- 
 sibility; (g) colonic peristalsis. 
 
 Treatment. 
 
 The treatment of coloptosia is medical, mechanical, surgical. 
 
 1. Medical treatment is comprised in diet, regulation of function, ample 
 anatomic and physiologic rest and appropriate hygiene. First and foremost 
 is what we term "visceral drainage." By appropriate food which results in 
 ample faecal residue, copious fluids at regular intervals with established hours 
 for evacuation. It may be practically claimed that every case can be con- 
 trolled. If colonic secretion, absorption and peristalsis be appropriately 
 stimulated by proper food and ample fluid the colonic circulation and in- 
 nervation will practically remain normal and the coloptotic though necessarily 
 afflicted with a certain amount of pathologic physiologic physiology will 
 remain practically with a few symptoms. 
 
SPLANCHNOPTOSIA 593 
 
 2. Mechanical treatment comprises abdominal bands, corsets, adhesive 
 strapping, prone attitude. Adhesive strapping (of Achilles Rose), which is 
 economical, practical and rational, has in my practice rendered much comfort 
 to patients. 
 
 3. Surgical treatment in coloptosia is absolutely limited. It comprises 
 two methods, viz.: (a) operations on the colon itself, fixing it to the abdom- 
 inal wall or other viscus — colopexy. As coloptosia is but a part and parcel 
 of splanchnoptosia, colopexy is limited in its range and rational application, 
 (b) The surgical treatment of diminishing the space of the peritoneal cavity 
 by incising the abdominal and reuniting by superposition, overlapping its 
 fascial and muscular walls like a double breasted coat, though limited in 
 application, is the more rational. This treatment attempts forcible retro- 
 position of the colon to its normal location and maintenance in its normal 
 visceral shelf by the abdominal wall. 
 
 Enteroptosia. 
 
 In enteroptosia the enteron passes distalward and ventralward. In 
 advanced cases the enteron passes almost entirely into the lesser pelvis. In 
 this condition the transverse duodenum is compressed against the vertebral 
 column by the superior artery, vein and nerve — the axial cord of the mesen- 
 teron producing gastro-duodenal dilation. If the abdominal wall becomes 
 relaxed the mesenteron becomes elongated from the viscera following the 
 walls, the enteronic loops pass distalward into the pelvis and ventralward in 
 contact with the relaxed abdominal wall. Besides the basal mesenteronic 
 insertion on the dorsal wall passes distalward. 
 
 In advanced enteroptosia, the enteron experiences mulitple flexions, 
 stenoses, dilation, dislocation, compromising circulation (faecal, blood and 
 lymph), peristalsis, decalibration and traumatizing nerve periphery. In 
 enteroptosia the enteron not only changes its location but also its form, 
 hence pathologic physiology must be expected as altered secretion, absorp- 
 tion, peristalsis, and sensation. The blood and lymph circulation is com- 
 promised by flexion, elongation, contraction or dilation of the vascular 
 channels ending in malassimilation. 
 
 The splanchnoptotic is continually in the condition of pathologic physi- 
 ology. In splanchnoptosia absorption, secretion and sensation are disturbed, 
 the blood and lymph occupy the greater and lesser pelvis, hence the nerves 
 and vessels are placed on tension, in which the soft walled veins and 
 lymphatus suffer. In the examination of the abdomen for enteroptosia, in- 
 spection, palpation, percussion, attitude, location the gliding movement, aus- 
 cultation the belt test, gurgling, should be employed. The consistence, 
 limited dimension and multiple enteronic coils increase the difficulty in 
 diagnosis. The enteronic coils are confined in the colonic square, greater and 
 lesser pelvis. Attenuated abdominal walls aid in diagnosis. 
 
594 THE ABDOMINAL AXD PELVIC BRAIN 
 
 NEPHROPTOSIA IN SPLANCHNOPTOSIA. 
 
 Fixation of the Kidney (traetus urinarius). 
 
 The two most important factors maintaining the kidney in position are 
 the muscular action of the diaphragm and abdominal wall. The action of 
 the diaphragm is direct, that of the abdominal muscles indirect through the 
 adjacent viscera. Ventral to the right kidney are the liver, duodenum, colon 
 and enteron. Ventral to the left kidney are the stomach, spleen, colon and 
 enteron. Next to the muscles in importance is the perirenal tissue — the 
 fatty capsule in which the kidney lies imbedded. 
 
 The perirenal areolar tissue binds the kidney to the diaphragm and at 
 the proximal renal pole it fuses with the meshepaticon on the right side 
 while on the left side the perirenal tissue fuses with suspensory ligament of 
 the spleen and coronary ligament. A strong renal support is the renal 
 pedicle composed of the renal artery, vein, nerve plexus, lymphatics and 
 fibrous sheath which emanates from the radix mesenterica. The renal pedi- 
 cle limits the extent of renal motion because the renal artery arises so near 
 the radix mesenterica — the coeliac artery — that its origin is practically 
 immobile. The kidney possesses no visceral shelf, simply a shallow renal 
 fossa or niche. It lies proximalward and distalward on the dorsal abdominal 
 wall in a shallow renal groove. Hence the structures or bands which main- 
 tain the kidney in position are: (a) the diaphragm and abdominal wall; (b) 
 perineal capsule; (c) renal pedicle; (d) viscera (indirect). 
 
 Respiratory Movements of the Kidney. 
 
 The respiratory motion of the kidney is due to the contraction of the 
 diaphragm on its proximal dorsal surface. The kidney experiences respira- 
 tion movements which include all splanchnoptotic viscera. The proximal 
 dorsal surface of the kidney lies on the diaphragm (hence diaphragmatic 
 area) while the distal dorsal surface lies on the lumbar structures (Psoas, 
 quadratus and transversal muscles, hence lumbar area). Inspiration forces 
 the kidney distalward and ventralward (rotation) by means of the diaphragm 
 while expiration allows the return of the kidney to its physiologic location 
 (to its renal niche in the abdominal wall). No doubt the ratatory motion 
 of the kidney if extensive produces pain from renal pedicle torsion. (Dietl's 
 Crisis). 
 
 The kidney becomes nephroptotic by decreasing its subdiaphragmatic 
 space. On the right side the liver and kidney completely occupy the right 
 subdiaphragmatic dome and one or both must yield in splanchnoptosia when 
 the subdiaphragmatic space is diminished, hence Riedel's lobe or nephroptosia 
 or both results. From clinical observation it may be observed that the 
 right kidney is manifestly nephroptotic 10 fold more than the left and that 
 woman have 10 fold more nephroptosia than man. However, this is more 
 apparent than real and refers rather to palpable degrees than to actualities. 
 
 If one examines a series of embryos, no difference can be observed 
 between the right and left kidneys in males and females, hence the difference 
 
SPLANCHNOPTOSIA 595 
 
 in position and degree of nephroptosia is a post natal acquirement. One 
 special variable element arises and progresses after birth and that is the rela- 
 tion of the coecum to the kidney. The difference in position of the kidney 
 begins in male and female at pubertas. At pubertas in females the diameter 
 of the interiliac space begins to increase more rapid than the diameter of 
 the intercostal space producing a distalward expanding funnel in the body 
 trunk and this truncated funnel is irregularly compressed by the construction 
 of clothing aiding to force the viscera distal to the corset line of constriction. 
 In long trunked, waisted women the constriction of the corset may force the 
 kidney proximalward dorsal to the liver surface. In short waisted women 
 the corset is the more liable to force the kidney distalward extending it from 
 the costo-diaphragmatic space where it is palpated with facility. 
 
 The Relation of Nephroptosia to the Liver or Bile Ducts. 
 
 The nephroptotic kidney maintains two relations with the liver, viz.: 
 (a) The kidney may be extended distal to the liver when its peritoneal and 
 subperitoneal tissue connections may produce traction on the biliary passages, 
 flexing and obstructing them a distalward nephroptosia. I published such 
 a case with illustration in the Medical Critic, May, 1903. In this subject a 
 peritoneal band extended from the kidney to the ductus choledochus commu- 
 nis, (b) The nephroptotic kidney may pass proximalward on the dorsal sur- 
 face of the liver. This is proximalward nephroptosia — a symptomless 
 dislocation. The influence of the nephroptotic kidney on the colon (hepatic 
 flexure) or coecum is marked, however, limited in clinical influence. 
 
 Nephrotosia ends in compromising of the subdiaphragmatic space, as: 
 (1) contraction of the diaphragm on a relaxed abdominal wall (as in respira- 
 tion). (2) by collapse of chest walls (consequent to disease); (3) constric- 
 tion of the trunk (by clothing). The left kidney is limited in motion in 
 nephroptosia because it is maintained in position by the splenic flexure of 
 the colon. 
 
 The production of appendicitis by nephroptosia, as reported by Edebohls. 
 I have been unable to confirm clinically or by autopsy. 
 
 Nephroptosia has no special influence on disease of the tractus genitalis. 
 In nephroptosia the essential element to observe is the ventralward displace- 
 ment produced by axial rotation on the renal pedicle induced by the dia- 
 phragm and which constitutes the mobile kidney that rotates on its pedicle 
 occasioning a "crisis." It is not the distalward nor proximalward dislocation 
 of the kidney that produces the so-called crisis. 
 
 Nephroptosia, Ren Mobilis. 
 
 Floating or movable kidney, Nephroptosia, has received the major 
 attention in splanchnoptosia and has unfortuately been the scapegoat for the 
 numerous symptoms belonging to general splanchnoptosia. It is admitted 
 that nephroptosia may be the most striking feature in the examination of 
 the splanchnoptotic patient, however, in the vast majority of subjects it is 
 but a part and parcel of splanchnoptosia. What is nephropotsia? It is 
 
596 
 
 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 understood to be excessive renal mobility. The kidney is a mobile organ, 
 not absolutely fixed. It moves with respiration, perhaps Vi an inch of range. 
 It is difficult to draw the line between a normally mobile kidney and a path- 
 ologic one except through complex clinical symptoms. 
 
 Perhaps 10$ of subjects only possessing palpably mobile kidney suffer 
 from nephrcptosia. In my practice among women I have palpated and 
 perceived mobile right kidney in 609c of subjects. However, 60 x of 
 patients were not afflicted with nephroptosia — floating kidne\ — as no symp- 
 toms existed. In some 700 personal autopsic abdominal inspections I found 
 that the general movement of the right kidney in its f jssal bed was one inch 
 
 Fig. 19L This figure presents established hepatic dislocation. 1, 
 diaphragm ; 2, meshepaticon ; 3, lobus dexter hepatis ; 4, ligamentum suspen- 
 sorium hepatis ; 5, colon transversum ; 6, enteron. 
 
 proximalward and one inch distalward. The left kidney moved about one- 
 quarter of an inch less in its proximalward and distalward translations. 
 
 In the bodies of large men the right kidney would not infrequently move 
 over \)z inches proximalward — a range of renal movements of over 3 inches 
 iproximo-distalward). ('However, it is my opinion that the dorso-ventral 
 renal motion — the axial rotation of the kidney on its neuro-vascular visceral 
 pedicle that inflicts damage and pain.) These subjects during life had not 
 complained of mobile kidney nor had it been diagnosed. From the indura- 
 tion of the perirenal areola, fatty capsule, the kidney has a greater range of 
 motion in the living than the dead. 
 
SPLAXCHXOPTOSIA 597 
 
 Etiology of Nephroptosia. 
 
 The main causes are: (a) a predisposing body form; (b) rapid loss of 
 perineal fat; (c) rapidly repeated gestations; (d) heredity — degeneration, 
 inferior anatomy and physiology; (e) yielding of diaphragmatic supports; 
 (f) debilitating disease, form and dimension of the renal fossa. The renal 
 fossa varies in form and dimensions within certain limits in different individ- 
 uals. The narrower the distal end of the renal fossa the more immobile the 
 kidney. The renal fossa is broader and shallower in woman than man, hence 
 more ren mobilis in woman than man. The broad, shallow fossa renalis 
 connected with a funnel-shaped trunk accounts for increased renal mobility. 
 
 Frequency of Nephroptosia. 
 
 I think that 10% of female adults are afflicted with symptomatic nephrop- 
 tosia. In 60% of adult women visiting my office I can palpate mobile 
 kidney. 
 
 Age Relations of Nephroptosia. 
 
 Nephroptosia is at its maximum frequency and extent at 40 years of age. 
 
 Diagnosis of Nephroptosia. 
 
 Nephroptosia is diagnosed by bimanual palpation in the lumbar region 
 while the patient assumes the dorsal, prone, semi-prone and erect attitude. 
 Mobile kidney should not be mistaken for neurosis. 
 
 If, in nephroptosia, one can find distinct renal pain, renal tenderness, 
 renal hypertrophy, and that the ureteral pelvis of the same side will contain 
 a greater quantity of fluid than the other, periodic hydro-ureter has probably 
 begun. If in a kidney of extensive mobility irregular pain presents it is 
 probably due to rotation of the kidney on its uretero-neuro-vascular pedicle 
 (Dietl's crisis) and ureteral dilatation (periodic hydro-ureter) has probably 
 begun. 
 
 Position of the Kidney. 
 
 In about 15% of subjects the kidneys are of the same level. Doubtless 
 the combination of longer right renal artery, the erect attitude (force of 
 gravity) and the liver explains the variation in position between the right 
 and left calyces and pelvis (kidney). 
 
 In mammals the right kidney lies more proximal than the left because 
 the right renal artery is longer, the attitude or force of gravity tends proxi- 
 malward and the liver does not wedge itself between the kidney and dia- 
 phragm so vigorously as in that of man. Also the left liver half is much 
 more developed in quadrupeds than man and hence the gastrium and spleen 
 is more distalward than in man. Hence taking into account the larger size 
 of the right hepatic lobe and the larger volume of the embryonic liver which 
 checks the growth of the Wolffian body proximalward (Strube) it would 
 appear that the liver has considerable influence in the more distal position 
 of the right than the left kidney. There is an age and functional relation 
 of the position of the kidney, especially in children and women. A child's 
 
598 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 kidney is more distal than that of an adult on account of its relative small 
 volume and large volume of the liver. Also during reproduction when the 
 elements of the abdominal wall (elastic, muscular and connective tissue) 
 elongate and separate, allowing the kidney to move distalward. Besides the 
 splanchnoptosia that increase after 30 years of age lends data to an age and 
 functional relation of the renal position. 
 
 The statment is common among general surgeons who are prone to per- 
 form nephropexy, that the right kidney, which is most frequently operated, 
 extends distalward to crista iliaca. However, if one will carefully examine 
 100 male and female cadavers in regard to the position of the kidney and iliac 
 crestit it will be found that the distal pole of the male kidney will be chiefly 
 jioi an inch proximal to the iliac crest and that the distal pole of the female 
 kidney will average over }4 inch proximal to the iliac crest. Perhaps in man 
 10% of right distal kidney poles touch the iliac crest and perhaps 20% in 
 woman touch the iliac crest. 
 
 The left kidney is more proximally located. When the distal renal pole 
 projects distal to the crest of the ilium pathologic conditions (splanch- 
 noptosia) will probably exist. The kidneys are located in an excavation 
 (what I shall term renal fossa) on the dorsal wall of the abdominal cavity 
 on each side of the vertebral column fixed to the diaphragm and lumbar mus- 
 cle by the capsula adiposa renalis or perirenal tissue, anchored medially by 
 the neuro-vascular renal pedicle and maintained ventrally by the intra- 
 abdominal pressure (adjacent viscera and abdominal wall). A most excellent 
 and practical standard, notwithstanding individual variations for kidney 
 measurements and for the purpose of noting the position of the kidney is 
 the crista iliaca. I used it as the chief standard in all measurements in some 
 700 autopsies. In general the distal pole of the kidney extends to the IV 
 lumbar vertebra. In the examination of over 620 cadavers (man 465, 
 woman 155), the general average was that the right kidney was one finger 
 (^inch) proximal to the iliac crest while the left kidney was 2 fingers {1% 
 inches). 
 
 The kidneys of woman were about Vz inch more distal than those of man. 
 In about 15% of the females the right distal kidney pole was on a level 
 with the crista iliac. These data have no relation with the artificial range of 
 motion that one can impose on the kidney during life and in the cadaver. 
 The kidneys of males had not such a high per cent of distalward position nor 
 such free motion as those of females. However, individual variation is 
 prominent for in some male cadavers I found the highest form of free mobil" 
 ity, e. g., in one large male cadaver the right kidney presented a proximal- 
 ward range of 2 inches and a distalward range of 2 inches — a total vertical 
 range of 4 inches. Conclusions in regard to the factors affecting the position 
 of the kidney: 1. The chief factors in retaining the kidney in position is the 
 length of the neuro-vascular renal pedicle, in short the arteria-renalis. 2. 
 Pressure and counter-pressure of adjacent viscera. 3. Intra-abdominal 
 pressure (pelvic and thoracic diaphragm and ventral abdominal walls). 4. 
 Bodily attitude and force of gravity. In man the right kidney is located 
 
SPLANCHNOPTOSIA 
 
 51)9 
 
 distalvvard to the left. In quadrupeds, the right kidney is located proximal 
 to the left. In man and quadrupeds the right arteria renalis is the longer. 
 5. The shape of the trunk, especially of woman, is that of a funnel with the 
 larger end distalward. G. In woman age and functional relations aid in 
 inducing nephroptosia. 7. The diminished amount of panniculus adiposus 
 renalis, through absorption tends to nephroptosia. 8. Elongation and 
 separation of the elements (fascia, muscle and elastic fiber) of the abdominal 
 wall, relaxation are among the most potent factor as regards the position of 
 the kidney. 9. The peritoneum aids in maintaining the kidney in position. 
 
 10. The liver, in foetal and 
 adult life, the long right 
 renal artery, the absence of 
 the colon on the ventral right 
 renal surface, the shallow 
 right renal bed or niche and 
 the less strong perineal 
 fascia in the right kidney 
 makes the right kidney more 
 mobile than the left. 
 
 Symptoms of Nephroptosia. 
 
 Among the chief disturbing 
 symptoms of nephroptosia I 
 think is renal anteversion, 
 torsion of the renal pedicle 
 with ureteral flexion. Tor- 
 sion of the renal pedicle can 
 be observed in life only in 
 the erect attitude as the 
 recumbent position, imme- 
 diately corrects renal dislo- 
 cation. When the subject 
 of nephroptosia sits or stands 
 the proximal pole of the 
 kidney moves ventralward 
 producing torsion or rotating of the renal pedicle (artery, vein, nerves, 
 lymphatics) and flexion of the ureter. Torsion of the renal pedicle, renal 
 anteversion, compromises the renal lymph, venous and arterial vessels as well 
 as traumatizes the nerves in the renal pedicle. Doubtless the essential 
 benefit of mechanical abdominal supports in nephroptosia is the correction of 
 the renal anteversion and consequent correction of torsioned renal pedicle. 
 Doubtless Dietl's crisis is torsion of the renal pedicle. Kidneys with ex- 
 tensive range of motion (3 to 4 inches) in the living may be accompanied 
 with no symptoms. We frequently observe this phenomena. If the 
 proximal pole of the kidney becomes detached from the diaphragm, as it 
 does in nephroptosia renal anteversion begins its slow march which is con- 
 
 Fig. 192. This figure represents advanced hepatic 
 dislocation. 1, diaphragm ; 1, hepaticon ; 3, dexter et 
 sinister lobus hepatis ; 5, ligamentum rotundum hepatis. 
 The liver is advanced sufficiently distalward to conceal 
 colon, enteron, and kidneys. 
 
600 THE ABDOMINAL AND PELVIC BRAIN 
 
 tinually accelerated by the distalward movements of the liver and spleen 
 through the contracting diaphragm. Renal anteversion and consequently 
 torsion of renal pedicle may be observed in the large, s;jare splanchnoptotic 
 multipara by palpating especially the right kidney. During the last 15 years 
 in some 700 autopsies I have tested the renal range of motion in large 
 numbers. The verticle or proximo-distal translation of renal motion is but 
 a factor in nephroptosia. I have found both in the living and dead that the 
 dorso-ventral renal translation motion and the torsion or twisting of the renal 
 pedicle are potent factors in the symptom-complex of nephroptosia. 
 
 The dorsal-ventral movements of the kidney consists of ventralward 
 motion only in a zone of perhaps 2 inches. 
 
 Nephroptosia comprehends the view of clinical symptoms complex in 
 which the role of dragging sensations, pain in the anterior crural and genito- 
 crural nerves, gastric crisis, constipation, dyspepsia and various degrees of 
 neuroses, violent palpitation in the epigastrium. Pains in the sacral and 
 lumbar region. Dietl's crisis — paroxysmal attacks of severe and intense 
 pain, nausea and vomiting. Dietl's crisis may be due to torsion of the renal 
 pedicle or to periodic hydro-ureter. We may note improvement during 
 pregnancy and discomfort during menstruation. Increased symptoms during 
 walking occur and relief of symptoms on assuming the prone position. The 
 above symptoms simulate those of splanchnoptosia. Nephroptotic symptoms 
 are generally an incident only in splanchnoptosia. A warning is here offered 
 not to attribute symptoms to nephroptosia that belong to splanchnoptosia. 
 For practically nephroptosia and splanchnoptosia are coexistent. 
 
 Treatment of Nephroptosia. 
 
 I. Medical. 
 
 (a) Visceral drainage. The most important treatment in nephroptosia 
 (which practically coexists with splanchnoptosia) is what I shall term visceral 
 drainage, i. e., maximum sewerage or flushing by ample fluids of the tractus 
 intestinalis, urinarius and perspirations with liberal supply of coarse foods 
 which leave an indigestible foecal residue to stimulate peristalsis in the colon, 
 (b) Position. Nephroptoses should assume the recumbent position as much 
 as convenient for they possess inferior anatomy and physiology. It relieves 
 symptoms — acts as a prophylaxis and aids in curing by inducing the kidneys 
 to persist in their normal prevertebral fossae. (c) Nutrition. Improve 
 nutrition in order to redeposit the perirenal areolar capsule, (d) Pregnancy. 
 Gestation improves nutrition (and acts as a temporary mechanical support), 
 (e) Massage, (f) Gymnastics, (g) Electricity. 
 
 II. Mechanical. 
 
 Mechanical treatment signifies forcible reposition and retention of the 
 kidney in its normal physiologic location. This is excuted by: (1) Attitude. 
 The horizontal position relieves symptoms and aids in curing the disease. 
 (2) Abdominal binders, (a) These may be elastic or nonelastic and are 
 applied during the day (or erect attitude), (b) An elastic binder which 
 
SPL.I.XCJLXOPTOSIA 601 
 
 contains between the binder and abdomen a pneumatic rubber pad (Byron 
 Robinson). This binder is applied while recumbent and the pneumatic pad 
 distended to suit the comfort of the patient. (3) The corset. This method 
 has been successfully conducted by Dr. E. A. Gallant of New York. The 
 corset is made under individual measurements, applied while in the prone 
 position and removed for the recumbent attitude. (4) Adhesive strapping. 
 This is executed by means of adhesive straps applied to the abdomen and 
 is known as Achilles Rose's method (also independently introduced by Dr. 
 N. Rosewater of Cleveland, Ohio, and Dr. B. Schmitz of Germany): Straps 
 of adhesive plaster of various width are passed entirely around the body, 
 elevating and maintaining the abdominal viscera in the normal physiologic 
 position. Rose's method of adhesive strapping is simple, economical, 
 rational and of vast practical utility. (5) Pregnancy. Gestation temporarily 
 relieves the symptoms of nephroptosia. 
 
 The Effect of Relaxed Abdominal Wall and consequent splanchnoptosia in 
 
 Neph rop to si a. 
 
 Women with relaxed abdominal walls frequently suffer with nephrop- 
 tosia. In regard to the nephroptosia, the renal secretion is deficient, excess- 
 ive, or disproportionate. The exact relations of factors of the nephroptosia 
 and relaxed abdominal walls to the disturbed renal secretion are not easy to 
 be determined. 
 
 The disturbed renal secretion would appear to be mainly due to disturbed 
 renal mechanism. The renal artery, vein and ureter become compromised 
 in relation to the nephroptosia. The passing distalward of the kidney from 
 relaxed abdominal walls stenoses the ureter and renal vein. The blood pres- 
 sure in the renal vein is low, and hence light disturbed renal mechanism will 
 easily compromise its blood flow. 
 
 In nephroptosia the distal pole of the kidney approaches the vertebral 
 column disproportionately, and hence compromises the lumen of the ureter, 
 damming the urine. Outside of disturbed urine flow from changed renal 
 mechanism, equally disturbing factors in nephroptosia arise from trauma to 
 the renal plexus. The renal plexus is a large collection of nerve plexuses and 
 ganglia, and besides it is directly connected with the ganglia coeliacum, the 
 abdominal brain, the largest ganglia in the body, which, being a reflex center 
 outside of the spinal cord, reorganizes the reflexes and sends them to all 
 other abdominal viscera. Thus the patient with nephroptosia complains of 
 nausea and vomiting and dragging pains. She gradually becomes neurotic 
 from reflexes due to trauma on the renal plexus. The damage in nephrop- 
 tosia is, perhaps, in order: 
 
 1. Trauma of the renal plexus (and abdominal brain), producing a 
 vicious circle by continuous reflexes on the abdominal viscera. 
 
 2. Traumatic stenosis of the vena cava, ovarian and renal veins. 
 
 3. Stenosis of the ureter with dislocation of the kidney, preventing 
 drainage. 
 
 4. Trauma of renal artery. 
 
602 
 
 THE ABDOMINAL AND PELVIC BRAIN 
 
 5. A combined dislocation of the renal mechanism is changing the rela- 
 tion of the renal vein, artery and ureter, a disturbed mechanism of the 
 uretro-ureteral triangle. 
 
 6. The producing cf deficient, excessive or disproportionate renal 
 secretion. 
 
 7. The subject with right nephroptosis suffers nausea, headache, foul 
 breath, gastric disturbances and 
 constipation, accompanied by 
 the stigmata of hysteria and 
 other neuroses. As nephro- 
 ptosia is only a part and parcel 
 of general splanchnoptosis, 
 nephropexy, which should be 
 done by placing the kidney in 
 the abdominal wall without 
 sutures, must be limited in its 
 local and general utility, prac- 
 tically to periodic hydroureter. 
 
 The Uretero-Vcnoits Triangles. 
 {Byron Robinson.) 
 
 In dissecting, one finds on the 
 left side of the body a triangle 
 formed by the ureter on the left 
 side, the ovarian vein on the 
 right side, and the renal vein 
 on the proximal end or base. 
 The sides of the triangle are 
 about 2 to o inches and the base 
 (the renal vein,) is about 1 inch. 
 The apex of the triangle is at 
 the proximal arterio-ureteral 
 crossing of the utero-ovarian 
 artery, located proximal or 
 distal to the iliac crest. 
 
 This is what I term the left 
 uretero-venous triangle. Its 
 outlines are distorted in left 
 nephroptosis. 
 
 On the right side of the body 
 what I term the right uretero-venous triangle is formed by the ureter on the 
 right side, the vena cava and ovarian vein on the left side, and the renal vein 
 on the proximal end or base. The right uretero-venous triangle is about an 
 inch at its base (the renal vein) and 2 inches on its sides. Its apex is at the 
 proximal arterio-ureteral crossing of the utero-ovarian artery, and is located 
 V/-2 to 2 inches distal to the iliac crest. The significant factor in the right 
 
 Fig. 193. presents a common condition found 
 especially in the multipara. The left kidney is pre- 
 sented as normal to compare the contrast. 1, right 
 kidney with its distal pole projecting distal to the 
 iliac crest; 2, the elongated right arteria renalis. 3, 
 the ureter in a sinuous course. B, point where vasa 
 ovarica crosses ventral to the ureter (apex of utero- 
 venous triangles of author). A presents the apex of 
 the utero-venous triangle of the left side. 4, left 
 kidney. 5, left ureter. 6, left arteria renalis. O, 
 oesophagus. C, arteria coeliaca. S, arteria mesen- 
 terica superior. V, vena cava. 
 
SPLANCHNOPTOSIA 603 
 
 uretero-venous triangle is that in nephroptosia it becomes markedly dis- 
 torted, compromising the lumen of the ureter, ovarian and the renal veins. 
 The uretero-venous triangles, bilateral distinct, constant structures, are signi- 
 ficant landmarks in topographical anatomy. I have not observed them 
 named or described. They vary considerably in size from the varying 
 location of the apex at the crossing of the ureter by the ovarian vein and 
 artery. The apex of the uretero-venous triangle I have designated as the 
 proximal arterio-ureteral crossing (of the utero-ovarian artery). In nephro- 
 ptosia the uretero-venous triangle is distorted and the lumen of the vein and 
 ureter is compromised. 
 
 III. Surgical. 
 
 Nephropexy in general is irrational and unjustifiable (except in periodic 
 hydroureter), because: (a), it is unphysiologic to fix mobile viscera; (bj, the 
 kidney does not remain fixed ; (c), the nephroptosia is but an incident, a 
 fragment of splanchnoptosia; (d), the remaining or adjacent viscera are 
 deranged, splanchnoptotic; (e), the surgeon attempts to relieve one lesion 
 or disease (excessive mobility) by producing another lesion or disease (fix- 
 tion ) — which is the more irrational; (f), the multiple methods of nephropexy 
 condemn it; (g), nephropexy does not remove the splanchnoptotic symptoms 
 which coexist ; (h), surgeons do not agree as to the idications for nephropexy, 
 as the symptoms of nephroptosia are not proportionate to the degree of 
 mobility; (i), the mortality of nephropexy is at least 1 per cent; (j), nephro- 
 pexy should be systematically refused, discarded, condemned, for more 
 rational methods (unless periodic hydroureter exist). The therapeusis should 
 be executed through the abdomial wall (medical, mechanical, surgical). The 
 incised abdominal walls should be superimposed, overlapped like a double- 
 breasted coat. It is doubtfully justifiable to perform nephropexy on a 
 replaceable kidney unless periodic hydroureter can be demonstrated. 
 
 Nephropexy should be performed only after all palliative measures have 
 been tried. 
 
 By observing the final results of nephropexy extending over a decade and 
 including numerous subjects, it is not flattering. Professor John A. Robison, 
 of Chicago, relates to me personally that during the past ten years that a 
 considerable number of his patients had visited different surgeons and had 
 undergone the operation of nephropexy. Dr. J. A. Robison asserts that he not 
 only observed that the patients received no benefits from the nephropexy but 
 that the results were damaging in almost every subject. 
 
 GASTRO-DUODENAL DILATATION IN SPLANCHNOPTOSIA. 
 
 A Phase or Complication in Splanchnoptosia. 
 
 The dilatation of the stomach and duodenum (gastro-duodenal dilation) is 
 due to pressure of the superior mesenteric artery \ vein and nerve on the tran- 
 vsersc segment of the duodenum- 
 
 In 1^93, the time of the Chicago World's Fair while giving courses to 
 physicians on abdominal visceral anatomy and its applied surgery, I became 
 
604 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 interested in the manner in which the transverse segment of the duodenum 
 was compressed by the superior mesenteric artery, vein and nerve. I well 
 remember the discussions of the physicians in the classes at that time, who 
 concluded that the superior mesenteric vessels and nerves would not obstruct 
 the duodenum, because the duodenal contents were almost entirely fluid and 
 gas. However, we all observed that in a spare, though normal subject, the 
 superior mesenteric vessels and nerves very suspiciously compressed the 
 transverse duodenal segment. We selected spare, fatless, subjects for vis- 
 ceral demonstration, and the distinct mechanical apparatus of mesenteric 
 
 Fig. 194 is a cut to illustrate the position of the duodenum and the superior 
 mesenteric artery, vein and nerve. 1, the superior mesenteric vein ; 2, superior 
 mesenteric artery, the nerve not represented in the cut ; 3, distal end of 
 duodenum; 4 and 5, stomach; 6, hepatic artery; 7, splenic artery; 8, gastric 
 artery, the hepatic and gastric arteries making what I shall term the gastro- 
 hepatic circle; 9, the oesophagus; 10, the gall-bladder; 11, the pylorus; 12, the 
 duodenum; 13 and 16, gastro-epiploca sinistra et dextra; 17, spleen; 15, part of 
 liver. This cut shows that the duodenum in the acute mesenterico-aortic 
 angle is the acute mesenterico-vertebral — however, the real angle of strangula- 
 tion. 
 
 vessels and nerve clamping the transverse duodenum against the vertebral 
 column as a base made an indelible impression. 
 
 I have persued the matter during the past thirteen years in subjects 
 possessing visceral ptosis, and found that when the coils of enteron lie in the 
 pelvis the superior mesenteric artery vein and nerve compress the transverse 
 segment of the duodenum in such a manner that gastro-duodenal dialatation 
 begins in the transverse segment of the duodeum immediately on the right 
 side of the superior mesenteric vessels and nerve. I have observed this so 
 
SPLAKCHXOPTOSIA 
 
 605 
 
 frequently in hundreds of autopsies thatl know it to be an important factor 
 in gastro-duodenal dilatation in persons suffering from visceral ptosis, 
 splanchnoptosia. 
 
 Previous to 1893 I had performed a considerable number of autopsies, 
 but without detailed records of abdominal inspection. Since 1893 I have 
 detailed records of personal autopsic inspection of the abdomen in 160 adult 
 
 Fig. 195. shows the relation of the duodenum transversum, pancreas, celiac 
 axis, superior mesenteric artery, vein and nerve with the stomach drawn proxi- 
 mally. 1 and 2, superior mesenteric artery and vein ; 3, aorta ; 4 and 5, transverse 
 segment of duodenum passing posterior to vessels ; 6 and 7, pancreas ; 8, spleen ; 
 9, splenic artery; 10, hepatic, and 11, gastric arteries forming the gastro-hepatic 
 circle; 13, portal vein; 14, duodenum ; 15 and 16, stomach ; 17 and 18, epiploic 
 arteries. This cut shows how naturally the vessels could compromise the dis- 
 talward-moving fecal current in the duodenum. The fixation of the transverse 
 segment of the duodenum by the muscularis suspensorius and the fibrous band 
 from the left crus of the diaphragm is not drawn in the cut. 
 
 females, and 480 adult males and some 50 children. Besides, I have -also 
 pursued the study of visceral ptosis, and relaxed abdominal walls — splanch- 
 noptosia in the living patients and abdominal sections. In clinics and 
 autopsy it is realized with facility that splanchnoptosia is a frequent, com- 
 mon disease. I systematically examined in the 700 detailed autopsies the 
 tractus intestinalis, tractus genitalis, the tractus urinarius and also the peri- 
 toneum. 
 
 Since Glenard's celebrated labors on splanchnoptosia (1884) considerable 
 
606 THE ABDOMINAL AND PELVIC BRAIN 
 
 study has been devoted to the position of the abdominal viscera. The study 
 of the position of the abdominal viscera has progressed, however, in an 
 irregular method. When Dr. Eugene Hahn, the brilliant Berlin surgeon, 
 first introduced and performed nephropexy, superficial surgeons made a rush 
 for a so-called new operation, with little idea that nephroptosia is only a 
 part and parcel of general splanchnoptosia. Visceral ptosis may begin in 
 early years of age, and increases every subsequent decade of life. My 
 knowledge of splanchnoptosia or visceral ptosis was gained during the past 
 twenty years by the personal autopsic inspection of 700 adult abdomens, 50 
 children, quite a number of fetuses with hundreds of peritonotomies. 
 
 I have been for years attempting to prove, by post-mortem examination 
 and peritonotomies and celiotomies, that in a considerable number of cases 
 dilatation of the stomach is caused through pressure of the superior mesen- 
 teric artery, nerve and vein on the transverse segment of the duodenum. In 
 these subjects the stomach does not begin to dilate at the pylorus, but in the 
 duodenum at the right side of the superior mesenteric artery, vein and nerve. 
 The stomach alone is not dilated. The compression of the duodenum by 
 the superior mesenteric artery and vein and nerve is typically manifest in a 
 subject with splanchnoptosia or visceral ptosis, and especially while lying on 
 the back. Practically it is not gastric dilatation — it is gastro-duodenal 
 dilatation. 
 
 In 700 autopsies I have noted perhaps 50 advanced typical subjects 
 presenting some distinct and some extensive gastro-duodenal dilatation, 
 which began in the duodenum on the right side of the superior mesenteric 
 artery, vein and nerve. 
 
 The careful dissector wonders why the superior mesenteric artery, vein 
 and nerve, all bound in a strong fibrous bundle and tightly compressing the 
 transverse segment of the duodenum, do not produce obstruction in the 
 duodenal segment of the tractus intestinalis. At first thought it is because 
 the bowel contents in the duodenum is liquid or gas. This may be always, 
 or nearly always true in absolutely normal subjects, but in the numerous 
 subjects with splanchnoptosia or visceral ptosis it is not true. It must be 
 remenbered that gastro-duodenal dilatation is a phase or stage or a complica- 
 tion in progressive splanchnoptosia. The more splanchnoptosia exists the 
 more the loops of the enteron pass distalward into the lesser pelvis, dragging 
 and tugging on the superior mesenteric artery, vein and nerve, which more 
 and more tightly constricts the duodenum transversum, because the latter 
 scarcely at all moves distalward. If the subject possesses considerable 
 splanchnoptosia, and for any reason lies considerable time on back, the 
 gastro-duodenal dilatation may progress quite readily. J 
 
 The most typical case in the living I have witnessed was one to whom 
 Dr. Coons, of Chicago, called me in 1898. The patient, a man, about 45 
 years of age, had been in bed perhaps 5 months with hip-joint disease. He 
 had some lordosis. The abdomen was enormously distended, and he vomited 
 continually. I thought of some form of obstruction in the tractus intestinalis, 
 and proposed that abdominal section gave the only faint hope of relief. The 
 
SPLAAiilXOPTOS/A 
 
 r,07 
 
 patient quickly and cheerfully gave his consent. I made an incision in the 
 median abdominal line and found the abdomen absolutely filled from pelvic 
 to thoracic diaphragm with a white, shiny distended cyst, which proved to be 
 the enormously dilated stomach and duodenum. If the subject had been a 
 woman the tumor would be immediately taken for an ovarian cyst. In the 
 patient's debilitated condition I could do nothing with such an enormous 
 dilated stomach, and finding no apparent intestinal obstruction closed the 
 19, f|fi?i ^>> abdominal incision. The 
 
 m patient subsequently died 
 
 and an autopsy was 
 allowed. We found the 
 enormously dilated 
 stomach and duodenum — 
 gastroduodenal dilatation 
 — caused by constriction 
 of the superior mesenteric 
 artery vein and nerve on 
 the transverse segment of 
 the duodenum. The 
 subject possessing con- 
 siderable degree of 
 splanchnoptosia and lor- 
 dosis, with several months 
 lying on his back in bed 
 made the progress of the 
 gastro-duodenal dilatation 
 rapid in its course. 
 Gastro-duodenal dilata- 
 tion — a slow, gradual, 
 chronic process — doubt- 
 less accounts for numerous 
 so-called idiopathic gas- 
 tric dilations subsequent 
 to laparotomies. The ex- 
 planation of acute gastric 
 dilatation (it is gastric- 
 duodenal dilation) is an 
 exacerbation of chronic 
 gastro-duodenal d i 1 a t a- 
 tion. In every fifty autopsies I have noted typical cases where it was gastro- 
 duodenal dilatation, not merely gastric dilatation. In many cases one 
 observes a slight dilatation which does not present itself as typical, but by 
 careful examination and test by forcing the gaseous contents of the stomach 
 through the duodenum distinct gastro-duodenal dilatation can be seen to 
 begin at the right side of the band formed by the combination of the superior 
 mesenteric artery, vein and nerve. 
 
 Fig. 196. is a cut to illustrate the final growing gastro- 
 duodenal dilatation due to obstructing the duodenum by the 
 superior mesenteric artery, vein and nerve. The white 
 portion of the stomach and duodenum represent the nor- 
 mal size, the adjacent dark portion is the dilated part. 1 
 and 2, the superior mesenteric vein and artery; 3, aorta; 
 4, the non-dilated portions of the duodenum, distal to the 
 constricting vessels ; 5 and 6, original normal stomach; 9 
 and 10, the non-dilated duodenum; 11, 12, 13 and 14, the 
 dilated portions of the duodenum; 15, the hepatic, and 16 
 and 17, the gastric arteries forming the gastro-hepatic cir- 
 cle ; 18, aorta; 19, celiac artery ; 20, esophagus ; 21, hepatic 
 artery; 22, spleen; 23, pylorus. In this cut the acute 
 mesenterico-vertebral angle shows plainly how it strangles 
 or obstructs the transverse duodenal segment in visceral 
 ptosis. 
 
608 
 
 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 One can easily experiment on the cadaver to prove that the obstruction 
 lies at the point of the duodenum where it is crossed by the superior mesen- 
 teric artery, veins and nerve. By placing the superior mesenteric artery, 
 vein and nerve on a tension, i. e., by dragging the enteronic loops distalward 
 and compressing the gas in the stomach, the obstruction is plainly visible 
 by a distension of the duodenum at the 
 right side of the structure (vessels and 
 nerve) which constrict the duodenum 
 transversum. The dilatation is caused 
 first by gas and second by fluids. I 
 have studied the subject of gastro- 
 duodenal dilatation from 1893 and since 
 I have found no records of it in litera- 
 ture, except that of Albrecht, in 1899, 
 six years after I began, it seems to be 
 original. The subject of gastro-duo- 
 denal dilatation as caused by the con- 
 striction of the superior mesenteric 
 artery, vein and nerve is original with 
 me. I published my first formal article 
 in 1900. 
 
 Dr. John M. T. Finney, associate 
 
 professor of surgery in Johns Hopkins 
 medical school, wrote the following in 
 the Annals of Surgery: "It is a fact 
 worthy of note in passing that Dr. 
 Byron Robinson of Chicago in 1900 
 appears to have been the first one in 
 this country to bring this condition to 
 the attention of the profession in a 
 publication." 
 
 In 1896 I made an abdominal au- 
 topsy on a case for Dr. Holman. We 
 found extensive gastro-duodenal dilata- 
 tion with marked distalward disloca- 
 tion of the stomach (gastroptosia). 
 
 The woman vomited, I was in- 
 formed, for a couple of years before 
 her death, which appeared during life 
 as a kind of marasmus. Death was 
 
 Fig. 197. a profile view of the acute 
 mesenterico-aortic (mesenterico-vertebral) 
 angle presenting the method of duodenal 
 obstruction by the mesenteric vessels. 
 This obstruction is especially increased 
 when in visceral ptosis. The loops of 
 enteron drag on the superior mesenteric 
 artery (3) and pass in the direction of the 
 arrow toward the pelvis. The mesenterico- 
 aortic angle (eventually the mesenterico- 
 vertebral angle) has already advanced to a 
 partial obstruction of the duodenum. 1, 
 duodenum; 2, aorta; 3, superior mesenteric 
 artery; 4, superior mesenteric artery pass- 
 ing to coils of enteron; 5, superior mesen- 
 teric angle passing to colon; 6, transverse 
 colon ; 7, blades of omentum majus passing 
 proximalward to gastrium; 3, blades of 
 omentum majus passing distalward; 10, 
 inferior mesenteric artery; 11, abdominal 
 aorta lying between the origin of the supe- 
 rior and inferior mesenteric arteries. The 
 arrow points to the pelvis and indicates how 
 the superior mesenteric artery clamps 
 tighter and tighter the duodenum with 
 advancing visceral ptosis. 
 
 undoubtedly due to malassimilation, 
 
 due to disturbances in the system caused by extensive gastro-duodenal dilata- 
 tion. 
 
 In 1895 Drs. Fruth and Henry, of Ohio, referred to me a patient who 
 had scarcely kept fluid or food long in the stomach for twenty months or 
 more. She was emanciated, and I could detect only a distended or dilated 
 
SPLANCHNOPTOSIA 609 
 
 stomach. The gastroptosia is easily detected, for, after the stomach is irri- 
 gated, it is pumped full of air and this method easily demonstrates its outline. 
 I thought this patient had a stricture of the pylorus, and perhaps a carcinoma, 
 but she did not lose flesh nor had she paled sufficiently for malignancy. On 
 opening the abdomen all we found was an enormous gastro-duodenal dilata- 
 tion which extended distal to the pelvic brim, yes, into the lesser pelvis. 
 I performed gastrojejunostomy with my segmented rubber plates. She 
 made a favorable recovery, and wrote to me seven years after the operation 
 that she was perfectly well. Dr. Henry, of Fostoria, Ohio, her physician, 
 reported in 1905, ten years subsequent to the operation, that she is well. In 
 hundreds of personal autopsic abdominal inspections I have noted the state 
 of the duodenum and stomach since 1893, and gastro-duodenal dilatation is a 
 common disease in subjects over 30 years of age, especially in multiparae, in 
 whom I have palpated the liver partly resting in the lesser pelvis. After 
 fifteen years of observation of visceral ptosis I am convinced that gastro- 
 duodenal dilatation is the indirect cause of ill health and of many deaths in 
 persons above thirty years of age. 
 
 Gastro-duodenal dilatation is not found in normal subjects. It would 
 appear that the main disturbance in gastro-duodenal dilatation begins when 
 the enteronic loop passes distalward over the pelvic brim or promontory. It 
 might appear strange that the mechanical arrangements of animal structure 
 would tend to destroy its own existence. A little study of this region will 
 explain why the duodenal obstruction arises. The gist of the explanation 
 lies in the anatomic fact that (a) the transverse duodenal segment in the 
 splanchnoptosia does not travel distalward as rapidly as does the enteron. 
 (b) In adults the duodenum possesses a mesenterii membrana propria only 
 (no peritoneal mesentery). It does not possess a peritoneal mesentery. 
 This fact alone explains why the duodenum does not move distalward as 
 rapidly as the remaining enteron, which possesses a 6-inch mesenteron. (c) 
 Again, the musculus suspensorius duodeni of Treitz arises adjacent to the 
 coeliac axis and inserts itself into the duodenum, circumscribing limited 
 motion to it — duodenum — practically imposing localized fixation on the 
 doudenum. This second important anatomic factor serves as a second 
 explanation why the transverse segment of the duodenum does not pass as 
 rapidly distalward as the enteron, which is maintained by an elongated mes- 
 entery, (d) A third explanation why the transverse duodenal segment does 
 not pass distalward as rapidly as the enteron is that, the transverse duodenal 
 segment maintained by the mesenterii membrana propria, does not yield 
 and follow the relaxed abdominal walls as does the mobile enteron. Hence, 
 since the transverse segment of the duodenum does not travel distalward as 
 rapidly as the enteron in visceral ptosis, it becomes clamped tighter and 
 tighter in the diminishing acute angle between the vertebral column and 
 the mesenteric cord (formed by the mesenteric vein, artery and nerve). The 
 chief clamping of the duodenum begins when the enteronic coils pass distal- 
 ward into the lesser pelvis. The expanding and proximalward moving 
 uterus during pregnancy forces the enteronic coils proximalward, increas- 
 
(510 
 
 THE ABDOMINAL AXD PELVIC BRAIN 
 
 ing the angle between the vertebral column and 
 mesenteric artery, vein and nerve), and this 
 
 Fig. 198 shows diagrammatically how the superior 
 mesenteric artery, vein and nerve obstructs the trans- 
 verse segment of the duodenum as it crosses the verte- 
 bral column. Increasing enteroptosis (i. e., the passing 
 of the enteron more and more into the lesser pelvis) 
 makes more and more acute the mesenterico-vertebral 
 angle, and, as the duodenum does not pass distalward as 
 rapidly as the enteron, obstructs rapid progress. 1, 
 vertebral column ; 2 and 3, normal stomach ; 4, the dark 
 outline represents the dilated portion ; 5, superior mes- 
 enteric artery ; 6, superior mesenteric vein ; 5, 6, and 7 
 are bound by a strong sheath of connective tissue into a 
 bundle as large as the little and ring finger. Occasion- 
 ally in visceral ptosis one must lift several pounds in 
 order to elevate this superior mesenteric band from the 
 duodenum. 8, the white, is normal duodenum; 9 and 
 11, dark, is the dilated portion of the duodenum due to 
 the obstructing mesenteric vessels and nerve, hence the 
 end result is gastro-duodenal dilatation; 11, the enter- 
 onic loops in the pelvis dragging the mesenteric vessels 
 over the sacral promontory like a rope over a log. The 
 colon transversum is resected and removed P. S. In 
 the abdomen of such a case of visceral ptosis as Fig. 184 
 the stomach would extend to the sacral promontory and 
 the transverse duodenum would be relatively slightly 
 moved distahvard on account of its fixation apparatus 
 (i. e., the musculus suspensorius duodeni and the fibrous 
 band connecting the duodenum to the right crus of the 
 diaphragm). In enteroptosia the superior mesenteric 
 artery, vein and nerve must elongate and attenuate, 
 unlike the uterine artery in pregnancy, which not only 
 elongates, but thickens. 
 
 the mesenteric cord (superior 
 relieves the gastro-duodenal 
 obstruction similar to an 
 abdominal binder. 
 
 One scarcely sees the duo- 
 denum in a hernia. The 
 text-books on hernia note 
 that every organ of the ab- 
 domen has been found in 
 hernia except the duodenum, 
 pancreas and liver. Dr. 
 Lucy Waite and myself have 
 made autopsies in which the 
 stomach rested on the pelvic 
 floor. This extends tubular 
 viscera and dislocates the 
 parts so that partial obstruc- 
 tion arises from mesenterial 
 vessels. 
 
 In 1794, when Sir Astley 
 Cooper and Mr. Cline per- 
 formed an autopsy on Mr. 
 Gibbon, one of the greatest 
 of English writers and phi- 
 losophers, they found the 
 whole tractus intestinalis 
 except the duodenum (and 
 cecum) in the hernial sac. 
 The distinguished patient 
 had suffered and died from 
 a left inguinal hernia, and 
 the fact of the long con- 
 tinued hernia and visceral 
 ptosis shows that the trans- 
 verse duodenum is the last 
 segment of the tractus intes- 
 tinalis to yield to the drag- 
 ging hernial sac, the lax 
 abdominal wall and intra- 
 abdominal pressure. For 
 thirty years, in the case of 
 Mr. Gibbon, the duodenum 
 transversum had resisted 
 traction of the hernial sac 
 and intra-abdominal pressure 
 and still practically retained 
 
SPLANCHNOPTOSIA 611 
 
 its relative position. The scrotal hernial swelling extended to his knees, 
 placing all neuro-vascular visceral pedicles on high tension, as well as extend- 
 ing pathologically tubular viscera and visceral ligaments. 
 
 I have observed no record of the duodenum or pancreas in a hernia. My 
 dissections appear to demonstrate the musculus suspensorius duodeni chiefly 
 originates in the tissues about the coeliac axis, and is then inserted into the 
 duodenum transversum as a broad, ribbon-like muscular band. Besides a 
 powerful fixation apparatus is given to the duodenum by a strong fibrous (and 
 perhaps muscular) band, which, by traction, shows that it arises from the left 
 crus of the diaphragm. Hence, the coeliac axis and the crus of the dia- 
 phragm being the fixation apparatus of the transverse duodenum by means 
 of the musculus suspensorius duodeni and the fibro-muscular band from the 
 crus of the diaphragm, the duodenum transversum becomes the most fixed 
 organ of the abdomen. 
 
 Diagnosis of Gastro-Duodenal Dilatation. 
 
 To be useful to subjects afflicted with gastro-duodenal dilatation (a phase 
 of splanchnoptosia) we must first and foremost establish the diagnosis. The 
 first postulate to entertain is that in established splanchnoptosia gastro- 
 duodenal dilatation — a phase, a step in the progress of splanchnoptosia — in 
 all probability exists. The gastric dilatation can be established with facility 
 by aid of the sodium bicarbonate and tartaric acid test of the forcing of air 
 in the stomach demonstrating the contour of the stomach. If gastric dilata- 
 tion exists in splanchnoptosia the probability is that duodenal dilatation also 
 exists, i. e., gastro-duodenal dilatation is the probable diagnosis. To my 
 mind this explains the so-called acute idiopathic dilatation of the stomach 
 subsequent to laparotomies. A factor that increases gastro-duodenal dilata- 
 tion is the dorsal position of the patient which is assumed almost immediately 
 after the operation. The trauma and infection resulting from manipulation 
 of the viscera becomes suddenly manifest after the operation by paresis of 
 the stomach and consequent rapid dilatation. Splanchnoptotics do not 
 resist infection vigorously. The gastric fluids and gases accumulate and not 
 being expelled distalward or proximalward distend the stomach. There is 
 nothing idiopathic in this condition. The factors are evident, viz: (a) a pre- 
 existing gastro-duodenal dilatation (splanchnoptosia); (b) gastric (visceral) 
 paresis from traumatic manipulation; (c) gastric (viscera) paresis from 
 infection. The stomach contents of patients suffering from so-called acute 
 (idiopathic) gastric dilatation subsequent to peritonotomy seems to flow out 
 of the mouth like a river— it resembles the facile flow from the verticle 
 stomach of an infant. The treatment for such patients is immediate and 
 repeated gastric lavage furnishing immediate and wonderful relief. All fluids 
 and foods for such a patient should be by gradual slow rectal irrigation — say 
 a pint of normal salt solution should be introduced in the rectum every two 
 hours and require thirty minutes to flow from the fountain syringe into the 
 rectum. 
 
Gl: 
 
 THE ABDOMIXAL AND PELVIC BRAIX 
 
 The Treatment of Gastro-Duodenal Dilatation Due to Compression of the 
 Superior Mesenteric Artery, Vein ami Nerve. 
 
 (1) Medical; (2) mechanical; (3) surgical. 
 /. Medical. 
 
 The medical treatment has regard to maintaining normal functions of 
 the stomach (and other viscera), viz.: (a) sensation; (b) peristalsis; (c) 
 secretion ; (d) absorption. The functions of the stomach are maintained by 
 
 appropriate foods and fluids. 
 
 (A) Fluids. 
 
 The splanchnoptotic requires 
 ample drainage of the tractus 
 intestinalis (and urinanus). 
 The patient should drink eight 
 ounces of fluid (the most useful 
 is Vz to Y\ normal salt solution) 
 ever)' two hours for six times 
 daily. The fluids stimulate 
 sensation, peristalsis, absorp- 
 tion, secretion in the stomach 
 enabling the gastrium to wash 
 itself, to irrigate its surface and 
 by stimulation of its muscularis 
 to evacuate itself. The sodium 
 chloride stimulates the gastric 
 epithelium. The fluid increases 
 the blood volume (which es- 
 pecially stimulates gastric peri- 
 stalsis), eliminates waste laden 
 material especially through the 
 kidney and bowel. In order to 
 stimulate the tractus intestinalis 
 to maximum function or activ- 
 ity I add to the eight ounces of 
 one-half normal salt solution 
 every two hours a part or multi- 
 ple of an alkaline tablet (com- 
 posed of cascara sagrada (1-40 
 gr.), NaHC0 3 (gr. 1), KHC0 3 
 (1-3 gr.),MgS0 4 , (2 gr.), Aloes (gr. 1-3). The tablet is used as follows: One- 
 sixth to one tablet (or more as required to move the bowels, once daily) is 
 placed on the tongue before meals and followed by 8 ounces of water (better 
 hot). At 10 a. m., 3 p. m., and bedtime one-sixth to one tablet is placed on 
 the tongue and followed by a glassful of fluid. In the combined treatment 
 the fragment or multiples of sodium chloride tablet and alkaline tablet are 
 
 Fig. 199. (author) illustrates the superior mesen- 
 teric artery, vein and nerve bound in a large strong 
 bundle and clamping the transverse segment of the 
 duodenum, producing gastro-duodenal dilatation. 
 1, superior mesenteric vein ; 2, nerve and third 
 artery; 9, the duodenum on the right side of the 
 vessels and nerve. The artery, vein and nerve forms 
 the mesenterico-aortic angle, but the actual compres- 
 sion angle is the mesenterico-vertebral angle. The 
 loops of enteron are drawn to the left in order to 
 expose the vessels and nerve. 
 
SPLAXCHXOPTOSIA 
 
 G13 
 
 both placed on the tongue together. I employ for the sodium chloride 
 solution or NaCl tablets of 12 grains each and use fragments of it. 
 
 (B) Foods. 
 
 Appropriate foods are a necessity in gastroduodenal dilatation. Food 
 must be wholesome as cereals, vegetables, albuminoids. All fermentative 
 foods should be avoided, as pies, cakes, pastries, puddings, concentrated 
 spices and condiments. The appropriate food excites the functions of the 
 stomach which promptly evacuates itself. If food remains in the stomach 
 for over 3>2 hours indigestion, 
 fermentation will result. In 
 gastro-duodenal dilatation the 
 essential necessity is rapid and 
 complete gastric evacuation, 
 i. e., maximum stomach drain- 
 age. In gastro-duodenal dila- 
 tation two conditions exist, 
 viz. : (a) one is where the py- 
 loric ring dilates in proportion 
 to the gastro-duodenal dilata- 
 tion. This condition permits 
 favorable gastric evacuation ; 
 (b) the second condition is 
 where the pyloric ring does not 
 dilate in proportion to the 
 gastro-duodenal dilatation. 
 This condition is unfavorable 
 for proper gastric evacuation 
 and is a serious menace to the 
 splanchnoptotic. It is a con- 
 dition requiring surgical inter- 
 ference — gastrojejunostomy. 
 
 Maximum nourishment pro- 
 duces and maintains a normal 
 panniculus adiposus which aids 
 to maintain, support, viscera in 
 their normal physiologic 
 position. 
 
 Numerous subjects exist with advanced gastro-duodenal dilatation, but 
 do not suffer marked symptoms because physical conditions are favorable and 
 the pyloric ring is ample in dimensions to allow complete gastric evacuation. 
 In 1894 Dr. Lucy Waite and I performed an autopsy on a man 70 years of 
 age. We found gastro-duodenal dilatation advanced to the degree that the 
 stomach rested on the pelvic floor. No record of any symptoms existed dur- 
 ing life because the pyloric ring was proportionately dilated with the gastrium 
 and duodenum offering limited obstruction to the evacuation of the stomach 
 
 Fig. 200. An illustration of the clamping of the 
 duodenum, in splanchnoptosia, by the mesenteric 
 vessels. D, duodenum, the enteronic coils are well 
 distalward in the lesser pelvis. 
 
614 
 
 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 contents. Whereas in another autopsy in 1895 on a woman who vomited for 
 two years with gastro-duodenal dilatation the data was reversed. In this 
 female subject I found enormous gastro-duodenal dilatation and the stomach 
 projected practically to the lesser pelvic floor — however, the pyloric ring 
 was remarkably limited in dimension and gastric contents were forced 
 through with difficulty. Residual food and fermentation occurred. The 
 continued combined treatment of the 3 pints of )i sodium chloride solution 
 and alkaline tablets 1-6 to 3, as required to move the bowels once daily, are 
 the necessary visceral drainage treatment in gastro-duodenal dilatation 
 (splcnchnoptosia). - The alkaline and sodium chloride tablets take place of 
 
 the so-called mineral waters. I con- 
 tinue this dietetic treatment of 
 fluids and foods for weeks, months 
 (the splanchnoptotic requires life- 
 long treatment) and the results are 
 remarkably successful especially in 
 pathologic physiology of visceral 
 tracts. The urine becomes clarified 
 like spring water and increased in 
 quantity. The tractus intestinalis 
 becomes freely evacuated, regularly, 
 daily. The tractus vascularis in- 
 creases in volume and power. The 
 blood is relieved of waste laden and 
 irritating material. The tractus 
 cutus eliminates freely, and the skin 
 becomes normal. The appetite in- 
 creases. The sleep improves. The 
 patient becomes hopeful, natural 
 energy returns. The sewers of the 
 body are drained and flushed to a 
 maximum. Subjects with gastro- 
 duodenal dilatation should take a 
 limited quantity of food every three 
 hours for four times daily so that 
 the stomach may not be extensively 
 distended or taxed. 
 
 Fig. 201 represents gastro-duodenal dilata- 
 tion ending when the mesenteric vessels cross 
 the transverse duodenum. 
 
 //. Mechanical. 
 
 (i) Abdominal binders generally afford comfort and relief in gastro- 
 duodenal dilatation (if the pylons is proportionately dilated). The kinds 
 employed are: (a) the author's pneumatic rubber pad placed within an 
 abdominal binder and distended to suit the comfort of the patient (it should 
 be removed at night). (b) E. Gallant's corset. (c) Achilles Rose's 
 adhesive strapping. The above mechanical contrivances afford vast comfort 
 and relief in gastro-duodenal dilatation by: (1) forcing the viscera proximal- 
 
SPLANCHNOPTOSI. / 615 
 
 ward in their normal physiologic position. It aids the stomach in 
 evacuation. (2) They force the viscera (especially the enteron) proximalward 
 and increase the dimension of the mesenterico-vertebral angle relieving the 
 transverse duodenum of pressure and permitting free evacuation of stomach 
 and duodenum. Achilles Rose's rubber adhesive strapping is particularly 
 useful — rational, practical, economical. 
 
 (2) Position. I found that by experimenting with the dead body that 
 position had much to do with the pressure of the mesenteric vessels on the 
 duodenum. The pressure of the mesenteric artery, vein and nerve on the 
 transverse segment of the duodenum is the greatest when (a) the patient 
 lies on the back and the enteronic coils lie in the pelvis; (b) when lying 
 on the abdomen the pressure is mainly relieved; (c) when the patient is 
 turned on the side the pressure is relatively light. Hence the best position 
 of the patient in gastro-duodenal dilatations is lying on the abdomen; and 
 second, lying on either side. Lying on the back or standing increases 
 compressions of the duodenum by the mesenteric vessels. 
 
 III. Surgical. 
 
 Surgical intervention should be applied to gastro-duodenal dilatation 
 when all other therapeutic measures have been tested and failed. 
 
 (/) Visceral anastomosis or Gastrojejunostomy. I consider one of the 
 most useful surgical methods to overcome extreme gastro-duodenal dilatation 
 is gastrojejunostomy. It limits the food journey and time for fermentation, 
 and facilitates gastro-duodenal drainage. I proved in gastrojejunostomy 
 in dogs, ten years ago, that it will enable the stomach to completely evacu- 
 ate itself, to contract because the food does not tarry in the stomach but 
 passes immediately into the jejunum and ileum, the business portion of the 
 tractus intestinalis. Any segment of the tractus intestinalis containing no 
 contents or over which no food travels will remain contracted. Anyone can 
 prove this by excluding a segment of the bowel from faecal circulation; it 
 soon contracts and remains in that condition. 
 
 Gastroenterostomy is the most certain and useful of all operations for 
 gastro-duodenal dilatation. It affords the one necessity, gastric evacuation 
 — complete visceral drainage. I have reports of gastro-enterostomy for 
 gastro-duodenal dilatation of 12 years' duration and perfectly well. 
 
 C?) Superposition of the abdominal wall. Longitudinal overlapping of 
 the abdominal wall resembling a double breasted coat is an excellent opera- 
 tion for some subjects afflicted with gastro-duodenal dilatation. I perform it 
 with permanently burned silver wire sutures, three to the inch. In the Mary 
 Thompson Hospital during the past five years its application has been 
 remarkably successful. The Mayos have advocated the proximo-distal 
 superposition of the abdominal walls (especially in umbilical hernia). 
 
 (3) Resection of the duodenum. The duodenum could be resected at a 
 point to the right of the constricting mesenteric vessels and its divided ends 
 reunited ventral to that of the constricting mesenteric vessels. Perhaps it 
 would be practically better to perform gastrojejunostomy. 
 
616 THE ABDOMINAL AND PELVIC BRAIN 
 
 (4) Enclosing the musculi recti-abdominales in a single sheath. My atten- 
 tion was called to the subject of lax abdominal walls by Prof. Karl Schroeder, 
 whose pupil I was for a year. 
 
 In that year (1884-1885) Prof. Schroeder, the greatest gynecologic 
 teacher of his age, was at the zenith of his fame, and his clinic was vast ; 
 in fact, he tapped the whole of Europe for his material. He discussed in his 
 clear style the misfortune of lax abdominal walls, and he resected large oval 
 segments of the abdominal wall lying between the diastatic recti-abdominales. 
 He then united the sheaths of the recti in the median line. But Prof. 
 Schroeder said then to his pupils that he was not fully satisfied ; however, it 
 was the best surgery that he knew at that time. Later German surgeons 
 improved on Schroeder's idea by splitting the sheath of the recti and enclos- 
 ing both the recti-abdominales in one sheath by uniting the recti sheaths 
 ventral and dorsal to the recti muscles. 
 
 In 1894, Prof. N. Senn, in his clinic, began splitting the sheaths of the 
 recti-abdominales and uniting the sheaths anterior and posterior, enclosing 
 both musculi recti-abdominales in a single sheath. 
 
 In 1895, Dr. Orville W. MacKellar and I operated on a woman pregnant 
 for five months for an ovarian tumor where the diastasis, of the recti-abdom- 
 inales was very marked, and the uterus, on coughing or extra intra-abdominal 
 pressure, would project between the recti-abdominales. We united the split 
 sheaths of the recti ventrally and dorsally, enclosing the two musculi recti- 
 abdominales in one sheath. Dr. MacKellar reports to me that his case is 
 perfectly well and the operation was a success. Dr. MacKellar was at the 
 delivery and the recti sheaths remain perfectly intact. For a large post- 
 operative hernia for the past four years at the Mary Thompson Hospital I 
 have split the recti and enclosed them in a single sheath for every one with 
 sufficient experience knows that the post-operative hernia of any consider- 
 able size in women over 35 is in nearly every case accompanied by visceral 
 ftosis. Dr. MacKellar and I have records to show that ten years after the 
 enclosing of the two recti-abdominales in a single sheath for visceral ptosis 
 (utero-ptosis) the operation is a success. The mesenteron is not to suspend 
 the enteron but to act as a neurovascular visceral pedicle and to prevent 
 the enteron from entanglement with either viscera. It is the abdominal wall 
 that holds the viscera in position. Besides, I showed in 600 detailed records 
 of personal autopsic abdominal inspections that in 96 per cent of subjects the 
 enteron had a mesenteron sufficiently long to herniate through the inguinal 
 femoral or umbilical ring. Hence, the mesenteries must be viewed as neuro- 
 vascular visceral pedicles, and not as suspensory organs, while the abdominal 
 walls are the great supporters and retainers of the viscera. And as every 
 anatomist knows the recti-abdominales are among the chief regulators or 
 governors of visceral poise, at least they retain the viscera in their first 
 delicate normal balance. Besides, enclosing the recti abdominales in a 
 single sheath my plan of operating in very extreme cases is to sever the 
 recti-abdominales and invaginate one rectus sheath into the other and fix 
 them with sutures. This is similar to the "stove pipe" operation on the 
 
SPL.LXCIIXOPTOSIA G17 
 
 intestines that I presented to the profession in 1891 (Annals of Surgery, 1891 
 and "Practical Intestinal Surgery," L891). 
 
 TRACTUS GENITALIS IN SPLANCHNOPTOSIA. 
 
 Fixation of the Tractus Genitalis. 
 A. Pelvic diaphragm (primary support). 
 
 Diaphragm pelvis consist of muculus levator ani plus its superior and 
 inferior fascia. What maintains the genital organs in their normal positions? 
 
 (a) The form and function of the pelvic floor (levator ani with its proxi- 
 mal and distal fascia), (b) The position of the genitals and the adjacent 
 viscera. The mesenteries of the tractus genitalis (ligamenta lata) are not for 
 mechanical support. They are to conduct vessels, nerves, and to maintain 
 structures in order for function. It is true that the ligamenta saco-uterina 
 acts as vigorous supports if placed on tension but in their present normal 
 state of existence they simply direct the cervix dorsalward. The vagina 
 extends from the pubus to the cervix and the sacro-uterine and the liga- 
 ments extend from the sacrum (rectum) to the cervix. Hence the vagina and 
 sacro-uterine ligaments act as a supporting beam on which the cervix and 
 uterus is supported. The same story, that the thoracic and abdominal viscera 
 are chiefly maintained in position by their respective walls, is true as regards 
 the position of the pelvic viscera, and its walls. The so-called uterine liga- 
 ment (mesenteries of the genitals act only in pathologic relations as in sacro- 
 pubic hernia). As an anatomic demonstration that the pelvic floor supports 
 the uterus one can observe (with evacuated bladder and rectum and uterus in 
 physiologic position) that the transverse vaginal slit in the pelvic floor lies 2 
 inches ventral to the cervix (i. e., the corpus uteri lies doro-ventral across 
 the transverse vaginal slit). If pressure be exercised on the corpus uteri, 
 exactly as intra-abdominal pressure is applied the previous position of the 
 uterus will not be endangered, i.e., it will not enter the vaginal slit but 
 simply force the pelvic floor distalward. In other words the pelvic floor, 
 the distal wall of the pelvic or levator ani maintains the tractus genitalis 
 (uterus) in the normal physiologic position. If one wishes (in the cadaver) 
 to force the uterus through the vagina, vaginal slit in the pelvic floor the 
 hand seize the fundus and corpus while the cervix is pushed vigorously dis- 
 talward in the vaginal slit where the cervix may be observed in the entroitus 
 vaginae. 
 
 If the pressure is removed from the uterus it returns to its normal posi- 
 tion. One cannot force the corpus and fundus through the vaginal slit with 
 any ordinary hand power. During energetic forcing of the cervix through 
 the vaginal slit the ligamenta rotunda, ligamenta lata and ligamenta sacro- 
 uterina are scarcely put on tension (they are entirely secondary supports). 
 If all the uterine ligaments are severed and the experiment repeated the 
 cervix can be forced through the vagina to the entroitus only. The impos- 
 sibility of forcing the corpus and fundus through the vaginal slit and entroi- 
 tus vaginae is due to the increasing volume of the corpus and fundus on 
 
G18 THE ABDOMINAL AND PELVIC BRAIN 
 
 account of the addition of the oviducts, vessels, nerves, and ligamenta lata. 
 The sacro-pubic hernia of senescence is due to atrophic conditions of the 
 genitals which glide through the vaginal slit from diminutive volume. Zie- 
 genspeck claims that sacro-pubic hernia (uterine prolapse) is due to the 
 difference between intra-abdominal pressure and atmospheric pressure. 
 Hence the primary support of the pelvic viscera (genitals) is the pelvic 
 floor — levator ani with its proximal and distal fascia. By relaxation it in- 
 cludes the tractus genitalis in splanchnoptosia. 
 
 Diaphragma thoracis resembles diaphragma pelvis in physiology and 
 anatomy. Both have (a) a similar fixum punctum (circulatory bony origin), 
 (b) similar punctum mobile (central tendon), (c) both support superimposed 
 viscera, (d) both have three apertures for visceral transmission, (e) both 
 diaphragms are respiratory, (f) both muscles by contsriction limit the 
 apertures of visceral transmission, (g) both contract as a single muscle 
 (h) both share in splanchnoptosia. They differ in that contraction of the 
 pelvic diaphragm draws the 3 visceral apertures proximalward and ventral- 
 ward, while contraction of the thoracic diaphragm draws the visceral 
 apertures distalward and dorsalward. 
 
 (B) Ligmenta Uterina (secondary supports). 
 
 All uterine ligaments arise from the pelvic wall and become inserted in 
 the lateral borders of the uterus. They act as guy ropes, to maintain the 
 uterus in a physiologic position in order to functionate. The ligamenta lata, 
 the real neuro-vascular visceral pedicle is a physiologic support only not a 
 mechanical serving as a conducting bed for vessels, nerves and tubular viscera. 
 These secondary uterine supports in splanchnoptosia become primary which 
 is a pathologic condition. 
 
 Movements of the Tractus Genitalis During Respiration. 
 
 To demonstrate that the diaphragm pelvis is a muscle sharing in respira- 
 tion one need only to witness a single perineorrhaphy. Whence the proximal- 
 ward and distalward movements of the levator ani are evident. To prove that 
 the genitals share in respiration one need only to observe the regular motion of 
 6 month gestating uterus or the motion of the vagina and uterus in a cough- 
 ing anaesthetized patient, whence not only the blue vagina everts through 
 the vaginal slit, but the uterus may also be present at the pudendum. The 
 genitals and pelvic floor move with respiration. The respiratory movements 
 of the genitals are the chief factors in genital ptosis. To illustrate if in a 
 case of uterine prolapse or better sacro-pubic hernia the uterus may be 
 returned to the pelvis and the patient told to force it distalward. She 
 immediately inspires deeply whence she retains the inspired air, ifixes the 
 thoracic diaphragm, and forces the uterus rapidly distalward through the 
 vagina external to the pudendum. She accomplishes this act by respiratory 
 motion. With relaxation of the pelvic the uterine fundus passes dorsalward 
 and the cervix by this mechanism gains entrance to the vaginal slit in the 
 pelvic floor whence intra-abdominal pressure forces the uterus distalward. 
 
SPLANCHNOPTOSIA 619 
 
 If the uterus loses its volume becomes atrophic, respiratory movements may 
 force it distalward through the vaginal slit without loss of integrity of the 
 pelvic floor. 
 
 The continual respiratory trauma, when visceral supports are deranged, 
 produce progressive sacro-pubic hernia. From a study of the anatomic sup- 
 ports of the genitals it is evident how irrational are the surgical attempts to 
 fix the uterus in some preconceived position by means of hysteropexy or the 
 shortening of some secondary uterine support. It appears that the function 
 of respiration is not confined to a single location in the spinal cord, but 
 extends to wide areas on its egress nerves so that man's trunk is a respiratory 
 apparatus closed at the proximal and distal end by a diaphragm — both 
 actively involved in respiratory movement. The relaxation of the pelvic 
 floor and consequent genital ptosis is simply a demonstration of the patho- 
 logic anatomy, and physiology of respiration. The genitals present various 
 grades of splanchnoptosia. In the first place the portio vaginalis is found 
 moved distalward in the pelvic axis, the corpus may be in normal anteflexion, 
 but more frequent in a beginning of retroflexion — the whole uterus is excess- 
 ively mobile. In the second place the entire uterus lies parallel and against 
 the sacrum (rectum). The cervix is not infrequently fixed through para- 
 metritis posterior. According to the degree of genital splanchnoptosia arise 
 pain in the back and sacrum, radiating pain in the extremities, menstrual 
 disturbances, venous congestion and constipation. Later the cervix projects 
 through the pudendum. Advanced splanchnoptosia of the genitals presents 
 prominent features of relaxation of the pelvic floor and venous congestion. 
 
 Etiology of Genital Ptosia. 
 
 The chief etiology of genital ptosia is: 
 
 (I) Results of parturition, i. e., elongation, separation or laceration 
 of the pelvic floor tissue (the levator ani muscle and its proximal and distal 
 fascia). 
 
 (II) Atrophy of the genitals. 
 
 (III) Respiratory movements forcing the genitals distalward (constantly 
 forcing the deranged genitals in the direction of least resistance). 
 
 (IV) Relaxation of the thoracic and abdominal walls. 
 
 (V) Superimposed splanchnoptotic viscera. 
 
 (VI) Genital sub-involution (infection). 
 
 The Treatment of Genital Splanchnoptosia. 
 
 The treatment should be medical, mechanical, surgical. 
 
 /. Medical. 
 
 One of the essential remedies is visceral drainage. Hot vaginal douche 
 (with salt and alum as ingredients) increased to 12 quarts which contracts 
 tissue (elastic, muscle, connective), massage, electricity, ample and horizontal 
 rest are valuable means. The boroglyceride tampon serves as an excellent 
 remedy. It is hygroscopic and may be prepared so that it can be worn one 
 to several days. 
 
620 THE ABDOMINAL AND PELVIC BRAIN 
 
 II. Mechanical. 
 
 The horizontal position should be used as much and frequent as possible. 
 Abdominal binders (in which may be placed a pneumatic rubber pad) Achil- 
 les Rose's adhesive strapping, Galant's corset furnish much comfort. Various 
 kinds of pessaries may be worn. 
 
 III. Surgical. 
 
 Since the uterus is supported by the pelvic floor rational surgical pro- 
 ceedures should be applied to it in splanchnoptosia. Relaxed pelvic floor 
 means relaxed, elongated, fibrous separation of the levator ani with its 
 superior and inferior fascia. Hence perineorrhaphy should include the care- 
 ful repair of the levator ani with its superior and inferior fascia. It is fascia 
 that supports, not muscle. Ventral colporraphy aids in forcing the bladder 
 proximalward and narrowing the vaginal exit. The most effective and 
 enduring operation for splanchnoptotic genitals is: (a) amputation of the cer- 
 vix (if required), (b) ventral colporrhaphy (c) and extensive colpo-perineorra- 
 phy, i. e., an extended Tait flap splitting operation with reunion of the torn 
 muscle and fascia of the levator ani. In cases of uterine atrophy exten- 
 sive vaginal narrowing is required. For splanchnoptosia of the genitals 
 hysterectomy should not be performed (as it renders supports less efficient). 
 The uterus is the key to the support of the genital viscera. I have seen sub- 
 jects of splanchnoptotic genitals where the uterus had been removed and sub- 
 sequently the everted, distended vagina extended to the middle of the thigh 
 with almost hopeless views of repair. As to suspending or fixing the geni- 
 tals to the abdominal wall proximal to the pelvis it is an irrational operation, 
 unphysiologic and harmful. The anatomy and physiology of the genitals 
 belong to the pelvis. 
 
 Ventral abdominal hysteropexy should not be performed in a reproduc- 
 tive subject. Also patients do not present symptoms indicative of malposi- 
 tion of the uterus. The position of the uterus has no special relation to 
 disease. As the symptoms do not emanate from the position of the uterus 
 fixing it will have no relation to the symptoms (except to exacerbate them). 
 The symptoms of patients with retroversions for example emanate from other 
 causes than the uterus. 
 
 RESULTS OF RELAXED ABDOMINAL WALLS ON THE TRACTUS INTESTINALIS. 
 
 In splanchnoptosia one of the most damaging influences rests on the trac- 
 tus intestinalis — sensation, peristalsis, absorption and secretion are deranged. 
 The normal position of the tractus intestinalis with its appendages (liver, 
 pancreas, and spleen), is changed disordered. The circular band apparatus 
 of the abdominal wall is relaxed. The elongated neuro-vascular visceral 
 pedicle allows the segments of the tractus intestinalis and its appendages 
 to follow the relaxed abdominal wall, and hence move out of their normal 
 physiologic range, compromising blood and lymph circulation and traumatiz- 
 ing nerve periphery. There is at once a disproportionate action between 
 traumatized nerve periphery and separated, elongated fascial and muscular 
 
SPLAXCIIXOPTOSIA 
 
 621 
 
 fibres of the abdominal wall. Muscular tone and nerve energy become 
 deranged. Since the abdominal wall becomes relaxed, the segments of the 
 tractus intestinalis become dislocated permanently from a normal position. 
 Since the neuro-vascular visceral pedicles are not elastic, and not for the 
 purpose of mechanical support, the viscera will pass distalward, i. e., in the 
 direction of least resistance. There is pathologic physiology and pathologic 
 anatomy. The spacious abdominal cavity allows the viscera to shift and 
 
 Fig. 202. Represents the surgical procedure which encloses the musculi recti 
 abdominales in a single sheath. 1 and 2 represent the anterior sheaths of the 
 recti partially united in the middle lines. 10 and 12 represent the posterior 
 sheaths of the recti partially united in the middle line. 5, the linea alba. 8 and 
 9 the recti sheaths lifted up to show the recti muscles. This operation I have 
 employed for 5 years. 
 
 glide from weight according to the position of the patient. The mesenteries 
 of course elongate when their essential support, the abdominal wall, yields. 
 The visceral supports or visceral fixation apparatus are (a) the abdominal 
 wall, (b) the pelvic diaphragm, (c) the thoracic diaphragm {d) what I shall 
 term "visceral shelves." Any yielding of any one of these segments a, b, c, 
 
622 THE ABDOMINAL AXD PELVIC BRAIN 
 
 or d increases the abdominal space and creates a disordered relation 
 between viscera and supports with consequent pathologic physiology. 
 It may be a neurosis malassimilation from disordered circulation (lymph 
 and blood), or it may be disordered visceral motion (peristalsis) from 
 the trauma and infection of the ganglia mysenterica (Auerbach's ganglia) or 
 disordered secretion from disordered action of the Billroth-Meissner plexuses 
 from trauma and infection. Constipation may occur. The form of the 
 abdomen pendulous shows that the tractus intestinalis is dislocated distal- 
 ward. In aged and spare persons the actual form of the bowel segments and 
 the peristaltic movements may be observed through the thin abdominal wall. 
 The tractus intestinalis in splanchnoptosia is manifoldly dislocated. On 
 account of the fact that while the subject of relaxed abdominal walls does 
 not manifest the disease while lying on the back because the abdomen is flat, 
 the autopsist does not observe the splanchnoptosia. It is the clinician who 
 is impressed with the splanchnoptosia, when the subject is in the erect atti- 
 tude manifesting the "hanging belly," but the clinician loses his usefulness 
 because he scarcely witnesses the autopsy. It is the clinical and autopsic 
 observation that demonstrates vividly the required data. The great segments 
 of the tractus intestinalis, gastrium, enteron, and colon, become disordered, 
 deranged in relation, changed in situation. The flexures of the tractus 
 intestinalis become more flexed, rigid supports become elongaced, secondary 
 supports are put on tension and the lumen of the tractus intestinalis is 
 stenosed, compromised in numerous places. Canalization is compromised. 
 The rigid ligaments as the ligamentum hepato-duodenale, ligamentum costo- 
 colicum, will not yield as much as the adjacent slacker and weaker 
 ligaments, hence the hepatic and splenic flexures become more and 
 more flexed, stenosed. Food passes them with difficulty. For example, 
 there are 5 points to consider in regard to the fixation apparatus of 
 the duodenum, viz. : 
 
 1. The duodenum is as a whole fixed. It has lost its peritoneal mesen- 
 tery on both surfaces of the mesoduodenum and its middle mesenteric layer 
 (membrana mesenterii propria) is fixed or coalesced to the dorsal wall. It 
 is also fixed by the musculus suspensorius duodeni, and the strong ligament- 
 ous band from the left crus of the diaphragm. Also the head and body of 
 the pancreas aid in fixing the duodenum. 
 
 2. The pylorus or proximal end of the duodenum is fixed to the vertebral 
 column, to the liver, kidney and stomach. 
 
 3. The flexura duodenalis jejunalis or distal end of the duodenum is, 
 especially fixed by musculus suspensorius duodeni and the strong fibrous and 
 ligamentous band from the left crus of the diaphragm. 
 
 4. The duodenum being fixed, it can not move distalward, while all the 
 other abdominal organs glide distalward during splanchnoptosis. Hence 
 since the transverse segment of the duodenum becomes fixed it becomes 
 compressed by the superior mesenteric artery, vein and nerve, inducing 
 gastro-duodenal dilatation. The compression of the duodenum is due to 
 the mesenterico-aortic (vertebral) angle becoming more and more acute as 
 
SPLAXCUXOPTOSIA 
 
 623 
 
 the splanchnoptosia progresses, and finally, when the enteron lies mainly in 
 the pelvis, the mesenterico-vertebral angle is very acute, allowing only a 
 small space for the duodenum. The passing distalward of the stomach 
 stenoses the fixed pylorus, and the passing distalward of the enteron makes 
 more and more acute the flexura duodeno-jejunalis, because the distal end 
 of the duodenum especially is quite rigidly fixed. The simple anatomic 
 fact in splanchnoptosia is that the proximal end of the duodenum is dilated 
 (with the stomach). The ileo-cecal sphincter and angle are not so much 
 stenosed, as both colon and distal ileum move distalward together, retaining 
 the normal angle or relations. The duodenum may be deranged by the 
 mobile right kidney through the ligamentum duodcno-renale. The dragging 
 
 Fig. 203. Byron Robinson's rubber air pad for splanchnoptosia half dis- 
 tended. It is to be placed inside an abdominal supporter. 1, side of rubber 
 pad ; 2, the rubber tube through which the rubber pad can be distended with 
 air. (This rubber air pad is manufactured by John Drake & Co., of Chicago.) 
 
 of the dislocated kidney aids to flex or stenose the duodenum, the retention 
 of foods in the stomach, and thus enhances gastric fermentation, catarrh 
 and dilatation. 
 
 The Flexura Colt Hepatica. 
 
 The flexura coli hepatica suffers in splanchnoptosia, because as the 
 stomach passes distalward it forces the colon transversum before it and hence 
 makes more and more acute the hepatic flexure. I have seen the transverse 
 colon in the pelvis and 9 inches of it as an inguinal hernia. It would at first 
 appear impossible for the food to pass such acute colonic angles, but it should 
 be remembered the peristalsis is continued by means of the activity of local 
 
624 
 
 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 segments. However, since the hepatic flexure is generally an obtuse or right 
 angle, its flexure is seldom drawn so acutely by the ligamentum hepatocolicum 
 as to produce very vigorous stenosis. Besides, in splanchnoptosis the liver yields 
 through its mesohepar and follows to some extent the distalward movements 
 of the hepatic flexure, relieving its angle from acute flexing. 
 
 The Flexura Coli Lienalis. 
 
 The flexura coli lienalis forms normally an acute angle. It is the remnant 
 of the ligamentum recto-lienalis of the lower mammals and quadrumana. It is 
 
 a distinct, direct apparatus fixing the colon 
 to the costal wall and kidney. In splanch- 
 noptosia the splenic flexure is forced dis- 
 talward and its angle made more acute. 
 The spleen also participates in the gen- 
 eral splanchnoptosis passing distalward, 
 gliding ventral to the colon, as shown in 
 the autopsies, as far as the pelvic floor. 
 This increases the acuteness of the 
 colonic flexure, obstructing the fecal cur- 
 rent. The stomach also forces the middle 
 of the transverse colon distalward, which 
 stenoses the hepatic and splenic colonic 
 flexures in direct degree to the extent of 
 the gastroptosia (splanchnoptosia). 
 
 Also the colon transversum in extensive 
 distalward movements is often forced into 
 a V-shaped condition, with acute adjacent 
 panetel flexions becoming adherent by 
 plastic peritoneal adhesions, due to bac- 
 teria or their products passing through the 
 colonic mucosa, myocolon to the serosa, 
 resulting in peritoneal exudates and or- 
 ganized peritoneal adhesions. All dis- 
 location of the viscera compromises them 
 in physiology and anatomy especially if 
 it be by a progressively contracting peri- 
 toneal adhesion. All dislocation of viscera 
 compromises function, peristalsis, sensation, absorption, secretion — fecal 
 blood and lymph circulation and traumatizes nerve periphery. Besides, 
 splanchnoptosia is a general term. The tractus intestinalis and its append- 
 ages, the tractus urinarius, the tractus genitalis, lymphaticus, vascularis 
 and nervosus, all share in the distalward movement due to relaxed walls, 
 so that splanchnoptosia of the tractus intestinalis is made worse by the 
 nephroptosia (especially on the right side), hepatoptosia, splenoptosia and 
 genital ptosis. The enteroptosia is especially responsible for the gastro- 
 duodenal dilatation, because the duodenum cannot pass distalward from a 
 
 Fig. 204. (Byron Robinson) profile 
 view to illustrate the pressure of the 
 rubber air pad on the abdomen. 1, dis- 
 tended pneumatic rubber pad; 2, wall 
 of abdominal supporter over pneumatic 
 rubber pad. 
 
SPLANCHNOPTOSIA 
 
 definite fixation apparatus, and the superior mesenteric artery, vein and 
 nerve — the constricting arm — compresses the transverse duodenum the 
 more acutely the more the enteronic loops pass distalward into the pelvis. 
 Again, the distalward dislocation of the colon favors fecal accumulation, 
 which favors migration of germs or their products through mucosa, muscu- 
 laris into the peritoneum, inducing plastic peritoneal exudates and organized 
 peritoneal adhesions. The peritoneal adhesions compromise anatomy and 
 physiology of the segments of the tractus intestinalis. Again, a tractus 
 intestinalis made defective by dislocation and fecal accumulation becomes an 
 easy prey to muscular trauma. Muscular trauma of the psoas, for example, 
 makes over 70 per cent, of the peritoneal adhesions on the right side (adja- 
 cent to the appendix, cecum, and distal ilium), and over 80 per cent, on the 
 left side (in the mesosigmoid). Other abdominal muscles produce equal 
 damage in proportion to their power of traumatism by trauma of their seg- 
 ments of the tractus intestinalis. In minimum and maximum defect the 
 more damage arises in the tractus intestinalis from muscular trauma than 
 other visceral tracts. 
 
 The fecal accumulations produce maximum damage when collected in 
 the most dependent colonic segments, as the cecum, middle or transverse 
 colon and sigmoid; besides it favors hernia, invagination and volvulus. 
 Doubtless it is the stenosed and superior flexed splenic flexures of the colon 
 which produce the dull pain and fecal accumulation with dulness on percus- 
 sion. The multiple stenosing of various segments of the tractus intestinalis 
 (and perhaps the ductus hepaticus) in splanchnoptosia is of a temporary 
 character, because on change of the erect to the horizontal position the 
 stenosis of the tractus intestinalis is damaging from the point of circulation, 
 nourishment and assimilation. 
 
 Splanchnoptosia induces trauma on secretory, sensory and motor nerves, 
 it produces irregular congestion and decongestion, muscularis is impaired by 
 irregular local contraction and dislocation. Dislocation of the tractus intest- 
 inalis favors absorption of deleterious products. The relaxed abdominal walls 
 having lost their power of contraction, the fecal current is defectively driven 
 distalward. From loss of tone in the diaphragm, abdominal wall and pelvic 
 floor, through excessive distention, defecation is difficult and hence fecal and 
 gas accumulations are distressing. Discomfort almost always attends the 
 patient with any considerable degree of splanchnoptosia from traumatized 
 nerves, or from distension with gas or food, from incapacity of the abdominal 
 walls to maintain the viscera in the normal physiologic position. If a subject 
 with distinct relaxed abdominal walls be examined per vaginum or per rectum, 
 stagnated fecal accumulation may be found in the sigmoid and if the cecum 
 assume the pelvic position (female 20 per cent., males 10 per cent.), it may 
 also be found occupied with feces. The abdominal wall (thoracic and pelvic 
 diaphragm) having lost its tone, defecation is not only difficult but defect- 
 ive. Besides, long retained feces in the colon induce catarrh of the colon 
 resulting in the absorption of toxic substances. Mcteorism arises in splanch- 
 noptosia from excessive, deficient or disproportionate secretion and conse- 
 
62G THE ABDOMINAL AXD PELVIC BRAIN 
 
 quent fermentation, from stenosing of the tractus intestinalis, from loss of 
 power in the abdominal walls, from catarrh due to constipation, from expan- 
 sion of gas due to rise of the temperature after toxic absorption. Such 
 subjects have a foul-smelling breath from the gases being absorbed by the 
 veins in the tractus intestinalis and becoming exhaled through the lungs. 
 Meteorism induces pain and discomfort from nerve pressure, and dislocated 
 viscera and obstruction to circulation. The results of splanchnoptosia are 
 constipation, catarrh of the different segments of the tractus intestinalis, 
 icterus through pressure, and stenosing of the ductus hepaticus. Also the 
 nephroptosia induces stenosing of the duodenum and ureter by flexing and 
 rotation. 
 
 Patients subject to splanchnoptosia suffer frequently from discolored skin 
 and irregular kidney secretion, also from nausea, vomiting, irregular and 
 obscure pains, with continual weakness, debility. From these anatomic and 
 physiologic considerations it is amply evident that in order to support the 
 viscera in splanchnoptosia the thoracic and abdominal walls (with pelvic and 
 thoracic diaphragm) must be forced into rational application. 
 
 In splanchnoptosia it must be remembered that the anatomy thoracic 
 and abdominal viscera (tractus respiratorius, intestinalis, vasculoris, genitalis, 
 lymphaticus, urinarius nervosus) is dislocated and that the physiology of these 
 seven visceral tracts is deranged. 
 
 The chief aim of therapeutics in splanchnoptosia is to restore function, 
 physiology. We may live comfortable with pathologic anatomy, however, 
 in general we live in discomfort with pathologic physiology. 
 
 CIRCULATION IN SPLANCHNOPTOSIA. 
 
 In operating on the deep glands of the neck, where the large veins are 
 isolated, it is very plain that respiration governs to a certain extent the 
 venous circulation. Now, the diaphragm, plevic and thoracic, as well as the 
 ventral abdominal walls are relaxed, it becomes evident in difficult defecation 
 and in the same manner the venous circulation of the abdomen suffers from 
 lack of pressure. With relaxed abdominal walls, the abdominal veins (and 
 the entire system) are congested and stenosis results. As a sample of the 
 evil effects of relaxed abdominal walls and consequent splanchnoptosis, in 
 rapidly repeated pregnancy there is heart weakness, because the veins of the 
 abdomen are too constantly, excessively occupied with excessive blood, 
 robbing the heart of its required amount. Since receiving instruction of 
 Prof. Schroder, some twenty years ago, I continued the study and investiga- 
 tion of splanchnoptosia. In relaxed abdominal walls one sees the distended 
 veins of the extremities, and extensive and prominent veins of the pudenum, 
 as well as the large hemorrhoidal nodes. Besides frequent and free uterine 
 hemorrhages occur. Splanchnoptosia has deleterious effect on the pelvic 
 organs by pressure and especially by obstructing the venous return flow. In 
 post mortems I have carefully noted that subjects with splanchnoptosia 
 possess a plexus pampiniformis extended with straight, irregularly dilated 
 veins. Spiral and uniform calibered veins are normal. In advanced splanch- 
 
SPLANCHNOPTOSIA 
 
 
 noptosia the pelvic veins, especially the genitals and those of the rectum, 
 are widely and irregularly dilated, containing enormous quantities of blood. 
 This causes hyperaemia, congestion and stasis of the pelvic organs, resulting 
 in hemorrhage, malnutrition, and pathologic changes in the genitals as hyper- 
 trophy. The liver suffers likewise from congestion, hyperaemia and blood 
 stasis, for it drains the tractus intestinalis (spleen and pancreas) and the 
 liver, by its dislocated position, compromises the blood current, especially 
 in the portal and hepatic veins, besides, the dislocated liver drags or com- 
 presses the inferior vena cava, stenos- 
 ing it. Stagnation, stasis, congestion, 
 hyperaemia are the characteristics of 
 the circulation in the splanchnoptotic. 
 If the liver be dislocated to any con- 
 siderable extent, which is frequent in 
 gynecologic patients, the definite rela- 
 tions of the portal vein are disturbed, 
 the liver veins and the inferior cava 
 are dislocated or compromised, as the 
 vena cava lies on the rigid dorsal wall. 
 Venous circulation is more physiologic 
 and of complex delicate nature than 
 arterial, which is more mechanical, and 
 is easily compromised as is noted by 
 the enlargement, conspicuously ob- 
 served in the inferior and superior epi- 
 gastric veins. Continuous hyperaemia, 
 congestion and stenosis in the dislo- 
 cated viscera produces pathologic 
 changes in the organs themselves, 
 impairing sensation, motion, secretion, 
 absorption, and nutrition. We have 
 thus a vicious circle which might be 
 called the visceral disease. Relaxed 
 abdominal walls and consequent 
 splanchnoptosia disturb a wide area 
 of complicated functions. They distort 
 an extensive and delicate mechanism, 
 resulting in impaired respiration, cir- 
 culation, sensation, motion, absorption, 
 and secretion and in the end result in malnutrition and neurosis. 
 
 Tension of the visceral vessels in splanchnoptosia limits their lumen and 
 consequently more vigorous heart action is required to force the blood to the 
 viscera— taxing the heart's power, ending in anaemia, congestion, throbbings, 
 headaches, dizziness. With loss of the controlling influence of the abdominal 
 wall on the visceral circulation a fullness of feeling or weight in the abdomen 
 may occur from visceral congestion and continuous congestion may lead to 
 relaxation of visceral supports occurring in splanchnoptosia. 
 
 Fig. 205. Byron Robinson's pneumatic 
 rubber air pad is fitted to the abdomen inside 
 the abdominal supporter. 2, 3 are rubber 
 tubes passing between the limbs to fix the 
 abdominal supporter. It requires several 
 days, a week for patients to become ad- 
 justed to the pad. Patience on the part of 
 the patient and encouragement on part of 
 the physician will soon adjust the use of 
 the pad. 
 
628 THE ABDOMINAL AND PELVIC BRAIN 
 
 In splanchnoptosia the visceral circulation is impeded by flexion, dilata- 
 tion, constriction, decalibration, elongation, of vessels (and the accompany- 
 ing plexiform nerve sheath is consequently traumatized). In splanch- 
 noptosia the veins from thin, flaccid walls, deficient muscularis and slow 
 pressure current suffer more than the arteries which possess rigid walls, 
 powerful muscularis and vigorous high pressure current. Atonia gastrica is 
 responsible for two important phenomena of visceral vessels, viz. : (a) flexion 
 or angulation ; (b) elongation and consequent decrease in lumen, decalibra- 
 tion. Conspicuous examples of flexion or angulation of vessels may be 
 observed in extensively distalward movements of the kidney which is fre- 
 quently located in the middle of the abdomen on the pelvic brim and the 
 spleen which is not infrequently found located at any point from the kidney 
 to the pelvic floor. The distalward dragging of the viscera at different points 
 on the visceral ligaments fixed to the abdominal wall flexes or angulates the 
 vessels in extra-extended ligaments producing hyperaemia or anaemia, 
 engorgement or ischaemia. If one explores by dissection the abdominal 
 visceral vessels in a normal subject and again in a splanchnoptotic subject by 
 comparison it will be observed that the visceral vessels of the splanchnoptotic 
 may be several inches longer than those of the normal subject, e. g., when 
 the kidney lies in the iliac fossa or lesser pelvis, when the spleen lies on 
 the pelvic floor, when the enteron lies almost completely on the pelvic floor. 
 
 The visceral vessels become elongated in splanchnoptosia and elongation 
 compromises the canals and lumen of the vessels, limiting vascular supply, 
 inviting defective viscera, resulting in innervation, constipation, deficient 
 secretion, limited and disordered peristalsis. In enteroptosia the superior 
 mesenteric artery and vein is the one set of vessels which suffers from drag- 
 ging, trauma, from marked elongation of parietes and constriction of lumen. 
 The elongated superior mesenteric artery, vein and nerve constricts, stenoses 
 the transverse segment of the duodenum by compression. Thus in splanch- 
 noptosia one distorted viscus compromises another. It may be observed that 
 the visceral vessels are compelled to elongate in splanchnoptosia as their 
 base or origin, the aorta, is immobile. In gestation the utero-ovarian artery 
 elongates, experiences parietal hypertrophy, increases its spirality and 
 diameter of its lumen. However, gestation practically cures, symptomat- 
 ically relieves splanchnoptosia for some six months. In splanchnoptosia 
 practically the opposite condition to that of the arteria uterina ovarica in 
 gestation occurs in the visceral arteries, viz. : the visceral arteries elongate, 
 decrease in diameter, diminish in spirality, experience parietal atrophy. 
 Finally during the elongation of visceral vessels vast sympathetic nerve 
 trauma is inflicted on the plexiform, nodular network of nerves which 
 ensheath the visceral vessels, damaging vascular function (especially rhythm) 
 for the tractus vascularis and tractus nervosus is an automaton. Hence, 
 from the dragging of the viscera on their elongated tensioned vessels, from 
 vessel extension, flexion and trauma on associated ganglia, excessive, deficient, 
 or disproportionate circulation arises. In splanchnoptosia palpatation, 
 vigorous beating in the abdominal aorta which may be palpated from partial 
 
SPLANCHNOPTOSIA 629 
 
 uncovering or exposure of the aorta by dislocated viscera and atrophy of the 
 abdominal wall. The arterial pulse beat is disordered — irregular, deficient, 
 excessive. Splanchnoptoses are afflicted frequently with debility, impend- 
 ing weakness, faint with facility and present rapid, variegated changes in 
 circulation in different parts of the body. The patient is flushed (conges- 
 tion), pale (anaemic), mottled (disproportionate circulation). They have 
 headaches from irregular cerebral circulation and extensive abdominal 
 venous stasis. In autopsies on some advanced splanchnoptoses the 
 numerous vastly distended blue veins presenting among the abdominal 
 viscera suggest the idea that the patient had bled to death in his own 
 abdominal veins. The veins of the viscera and ganglia are engorged, flooded 
 with stagnant venous blood surcharged with carbonic acid gas — while the 
 arterial blood invigorated with life's messenger, oxygen, is excluded. 
 
 The similar conditions as regards haemogenous circulation in splanchno- 
 ptosia may be practically applied to the lymphatic circulation in splanch- 
 noptosia. 
 
 The abdominal walls aid to regulate the circulation in the viscera 
 (especially in the veins). The abdominal vessels (veins) are a kind of 
 reservoir for surplus blood by which blood pressure and other visceral supply 
 is regulated. If the abdominal muscles become deficient the blood will 
 accumulate in the abdominal veins to the detriment of other viscera, e. g., 
 the cerbro-spinal axis — manifesting many nervous phenomena. The exten- 
 sive venous stasis in the abdomen from atonia gastrica deranges visceral 
 function (peristalsis, absorption, secretion, sensation) ending in malassimila- 
 tion (indigestion, fermentation, meteorism, constipation). The meteorism so 
 frequent an accompaniment of the splanchnoptotic is a marked factor in 
 disturbing circulation and digestion. In the splanchnoptotic the dilatation 
 of the blood vessels in the splanchnic area may lead to a decrease in general 
 blood pressure and consequent increase of cardiac action. The symptoms 
 due to the pathologic physiology of circulation in the abdominal vessels are 
 varied and numerous as rate, nature, force cf peristalsis in the heart, and 
 consequent effect on the abdominal viscera. The extent of distention of the 
 abdominal vessels would no doubt produce pathologic manifestations as 
 dragging, feeling of fulness, weight. Long continued congestion due to 
 vaso-motor paralysis (from lack of abdominal pressure) may account for 
 relaxation of visceral supports. The manipulation of the plexiform nodular 
 network ensheathing the arteries may be followed by palpation and be found 
 tender, sensitive — indicating an irritable condition of the blood vessels, 
 arteritis, arterio-sclerosis, or a neuritis of the ensheathing nerve plexus 
 (which is the more probable). 
 
 Dilatation of the splanchnic vessels appear to be physiologically opposed 
 to a similar condition of the peripheral vessels and the exquisite balance is 
 due to a nerve mechanism. Our remedies should be applied with 2 views, 
 viz. : (a), to deplete the visceral congestion. This can be especially accom- 
 plished by visceral drainage and aided by mechanical supports, the abdomi- 
 nal wall which regulates venous circulation (as by binders, Rose's strapping); 
 
630 THE ABDOMINAL AXD PELVIC BRAIN 
 
 (b), stimulate the peripheral or cutaneous vessels (by friction heat, chemicals) 
 in order to entice the blood to the surface (as massage, salt rubs, hydro- 
 therapy, wet cold pack). 
 
 TRACTUS NERVOSUS IN SPLANCHNOPTOSIA. 
 
 The ideal nervous system consists of: (a) a ganglion cell (a central 
 receiver and reorganizer), (b) a conducting cord (a transmitter), (c) a peri- 
 phery (a sensory apparatus, a collector). In splanchnoptosia the ideal 
 nervous apparatus is deranged. I am^convinced from years of observation — 
 in the living and dead — that the tractus nervosus in splanchnoptosia indicates 
 inferior anatomy and physiology with more facility than other visceral tracts. 
 Splanchnoptotics are prone to be afflicted with stigmata, degeneracy, a habi- 
 tus. They possess a weak, irritable nervous system. They are not perfect 
 physically or mentally. Their anatomy and physiology are inferior structure 
 and function of minimum perfection. The nervous system is unstable. 
 Splanchnoptotics manifest defective resistance, and are incapacitated for 
 sustained effort, presenting premature exhaustion on persistence mentally or 
 physically. Their tractus nervosus functionates under friction most of the 
 time like some watches which maintain incorrect time. Splanchnoptotics are 
 chiefly congenital, physical unfortunates. They are born with defects, stig- 
 mata, a habitus, a neuropathic predisposition — a condition or state which 
 tends to degeneracy with facility. One of the best terms to apply to subjects 
 with excessive distalward movement of viscera, relaxed muscles, defective 
 circulation, and defective nourishment is the word habitus, e. g., we meet 
 the subjects with habitus splanchnopticus, habitus nervosus, habitus 
 phthisicus, habitus dyspepticus. The ensemble of symptoms associated with 
 splanchnoptosia may well be termed habitus splanchnopticus. It is heredity 
 in so far that the subject possesses a predisposition and the main defect is 
 inferior anatomy and physiology. In the habitus splanchnopticus there is 
 the gracile skeleton, the elongated, flat thorax, extensive intercostal space, 
 acute epigastric angle, the sacculated pendulous abdomen, limited muscularis 
 and panniculus adiposus, the labored respiration. The costa fluctuans dec- 
 ima of B. Stiller, the peculiar habitus in form— presenting evident patho- 
 logic physiology. A marked factor in pathologic physiology of splanchnop- 
 tosia is the changed defective circulation, venous congestion. Generally any 
 subject with a '"habitus" possesses an unstable nervous system. The habitus 
 splanchnopticus is perhaps more due to neuropathic disposition than to 
 the splanchnoptosia, hence the term dyspepsia nervosa, or stigma dys- 
 pepticus. The habitus neurasthenicus presents pathologic physiology of the 
 tractus nervosus — a condition of exhaustion or weakness of the nervous 
 system accompanied by physical and mental inefficiency. Habitus neuras- 
 thenicus is a fatigue disease of the nervous system. It is characterized by the 
 presence of motor, sensory, psychic and visceral symptoms — all fatigued, 
 tired, exhausted. This habitus is especially characterized by weakness, or 
 inefficiency and irritability of the tractus nervosus. The physician can detect 
 spots, of hyperesthesia, spinal irritation, fatigue of the special sense, 
 
SPLANCHNOPTOSIA i;;;i 
 
 auditory and retinal hyperesthesia. When the subject predisposed to the 
 habitus splanchnopticus is afflicted with strain, as gestation, the care of 
 growing children, extra mental or physical effort, the tractus nervosus — 
 habitus neurasthenicus — manifests itself deranged with rapidity and facility. 
 Also the instability of the tractus nervosus in splanchnoptosia is aggra- 
 vated, irritated with facility in the habitus neurasthenicus by disease, as 
 salpingitis, myometritus, pelvic peritonitis. The weak, irritable tractus 
 nervosus with its inherent defective vital power — its deteriorated anatomy 
 and physiology — readily passes into a state of manifest pathologic physiology. 
 In splanchnoptosia the nervous system is involved in manifold conditions. 
 In fact, in splanchnoptosia the nervous system is the central reference of in- 
 vestigators. Hence, writers note that splanchnoptoses are afflicted with mel- 
 ancholia neurasthenia, nervous dyspepsia, neurosis, irritability, weakness and 
 debility. The splanchnoptotic experiences pain of various kinds in any por- 
 tion of the abdomen. They are afflicted with heavy feelings in the abdomen. 
 Pain radiates to the scapulae, especially in the region of the V to the VII dorsal 
 vertebrae. The pain is increased in the erect and decreased in the prone 
 attitude (indicating nerve trauma). Continuous standing, long labor or severe 
 efforts increase the pain. The multiple pain of the splanchnoptotic is 
 described as dull, sticking, dragging, boring, cramps, faintness, lumbar and 
 sacral pains. Some have pain in many parts of the body. The sensible 
 visceral nerves and ganglia become traumatized, dragged by the dislocated 
 viscera. The visceral arteries are ensheathed by a ganglionated, plexiform 
 network of nerves. In splanchnoptoses the visceral arteries become elon- 
 gated (sometimes several inches, in extra length) and their ensheathing 
 nerves stretched, damaged, traumatized, altering their functions. The pain 
 is protean. Hegar called it Lendenmarks symptome, i. e., lumbar cord symp- 
 toms. The dislocated viscera drag on the great plexuses, resulting in irri- 
 tability. Hyperesthesia and anaesthesia of the abdomen exist over the 
 site of viscera— which suggests caution in pronouncing the stigmata of 
 hysteria. The plexus aorticus is frequently so stimulated that the vigorous, 
 violent aortic pulsations may be mistaken for an aneurysm. When no 
 anatomic or histologic changes in the nerves can be demonstrated we are com- 
 pelled to resort to such terms as neurosis, molecular disturbances in the nerve 
 substance or peripheral. Is splanchnoptosia due to a relaxation of the entire 
 nervous system? Splanchnoptosia attacks the motor nerves as it is shown by 
 muscular fatigue, energy. Evident incapacity for bodily labors present. 
 The sensory nerves may suffer in splanchnoptosia as in anaesthesia and para- 
 aesthesia. The patient is sensitive to heat and cold. Exaltation and depres- 
 sion occur. The sympathetic nerve or nervus vasomotorius receives the 
 brunt of the disease as is manifest in disturbed secretion, absorption, sensa- 
 tion and rhythm (peristalsis) of viscera. Violent aortic palpation of the 
 aorta exists. Secretion, absorption and peristalsis may be excessive, deficient 
 or disproportionate. 
 
632 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 Frequency of SplancJinoptosia. 
 
 In the vast majority of splanchnoptoses in general the viscera are dis- 
 placed, prolapsed, and the visceral walls relaxed. Splanchnoptosia is perhaps 
 six times more prevalent in females than in males (some say ten). I have no 
 method to estimate the frequency of splanchnoptosia in my own practice ex- 
 cept from the frequency of mobile kidney and in the personal autopsic 
 abdominal inspection of over 650 adults and 75 children, infants, fetuses. 60% 
 of the female patients in my practice present palpably mobile kidney, not 
 splanchnoptosia, as no pathologic symptoms accompany many. The diffi- 
 culty of estimating the frequency of splanchnoptosia is due — and also the 
 conditions of splanchnoptosia which present symptoms — to the different views 
 of different authors. I should estimate that 20% of the women with mobile 
 kidney, in my private practice, have demonstrable splanchnoptosia — with 
 attributable symptoms (i. e., 20% of 60% =12%). Part of this 20%, say 12%, 
 do not suffer markedly, for in many the physical condition remains favorable. 
 Practically twenty years includes the clinical and autopsic study of splanch- 
 noptosia, hence, older statistics are almost worthless. Twenty years ago Mr. 
 Lawson Tait, one of the greatest surgical geniuses of his age, and my own 
 well-remembered teacher, denied movable kidneys. The difficulty with sta- 
 tistics in splanchnoptosia is that it presents a wide range from the minimum 
 scarcely perceptible to the maximum grade — an unsightly, sad appearance. 
 Hence we still lack a recognized standard to estimate the frequency of 
 splanchnoptosia. 
 
 Symptomatology of SplancJinoptosia. 
 
 Splanchnoptosia presents complex symptoms. It may exist without 
 recognizable symptoms or be accompanied by the most aggravated kind. 
 The general subjective symptoms of splanchnoptosia are (debility) a general 
 sense of weakness; an impending irritable nervousness (neurosis), frequent re- 
 lief in the prone position (attitude). Practically, splanchnoptosia should be 
 viewed as pathologic physiology, as a disease of symptoms and the object of 
 the physician is to restore function. Fatigue and pain are marked. The gen-, 
 eral objective symptoms are: (abdomen) flattened pendulous abdomen 
 especially in the epigastric region (Stellar's costalstigma), sensitiveness to 
 pressure in the region of the tenth rib, palpation reveals excessive, multiple, 
 visceral mobility. A cord-like transverse colon (which is probably the pan- 
 creas) may be established by gliding it on the aorta. A marked pulsation of 
 the aorta, constipation. A peculiar phenomenon may exist in splanchnop- 
 tosia which is in short that the intensity of the symptoms may not correspond 
 to the degree of splanchnoptosia. This doubtless depends on favorable or 
 unfavorable physical conditions. Marked splanchnoptosia may exist with 
 practically no symptoms while a slight degree of splanchnoptosia may exist 
 accompanied with striking symptoms. Frequently the visceral ptosis is so 
 slight that it is overlooked and consequently the treatment is misapplied. 
 An important matter in atonia gastrica, splanchnoptosia, is that symptoms are 
 pronounced while the patient is in the erect attitude. With the patient lying 
 
SPLANCHNOPTOSIA 633 
 
 prone the symptoms diminish and may disappear. This phenomenon deludes 
 many physicians who consider merely that the patient requires physical rest. 
 Frequently I have noted immediate relief by supporting the abdomen with 
 the hands from behind the patient (Glenard's belt test). Besides the ordinary 
 symptoms of fatigue, dragging, there is backache and side ache The back- 
 ache in splanchnoptosia may be due to fatigue of the sacro-spinalis muscle 
 simulating that observed in corpulent persons with fatty abdomen where 
 the muscle becomes overworked in maintaining the center of gravity which 
 is projected excessively ventralward. In respiration in splanchnoptotics the 
 expiratory power is not only lessened by loss of tone in the abdominal mus- 
 cles but the floor of the thorax, the diaphragm, is dragged distalward by the 
 distalward moving viscera. The epigastrium may show a marked depression. 
 The relation of the diaphragm and ribs is disturbed, inducing shortness of 
 breath on exertion. To observe the splanchnoptotic one must examine in 
 the prone and erect attitude with trunk clothing removed. The patients fre- 
 quently complain of weakness, dizziness, fatigue which may be enhanced by 
 the distalward moving viscera dragging, traumatizing the splanchnic (sympa- 
 thetic) nerves. Most cases of splanchnoptosia are accompanied by pendulous 
 abdomen, changed in form, however, with normal abdominal walls a single 
 viscus may glide excessively distalward while mechanical pendulous abdomen 
 ma}' be caused by fat deposit. Splanchnoptosia may exist without symp- 
 toms so long as the physical condition is favorable. Atonia gastrica springs 
 into prominence in association with neurosis and so-called nervous dyspepsia. 
 The symptoms of the splanchnoptotic are chiefly those of neurasthenia, 
 neurosis. Pain may be felt and is mainly referred to the lateral and dorsal 
 region. Splanchnoptosia is practically a unit though a general disease, 
 seldom do single viscera suffer ptosis. Exception may arise from sudden 
 trauma, for example, instrumental parturition, sudden physical strain. 
 However, the ordinary case of recognizable splanchnoptosia, atonia gastrica, 
 is general visceral ptosis with relaxed enclosing walls. Splanchnoptosia must 
 not be judged by the extent of dislocated viscera but by the degree of dis- 
 tress — the intensity of symptoms, the pathologic physiology. The distalward 
 dislocation of the diaphragm is an essential feature of splanchnoptosia. 
 Hence in marked subjects of splanchnoptosia the chest is deformed, the 
 thoracic viscera occupy abnormal positions and the abdominal viscera are 
 splanchnoptotic — the subject generally presents stigmata, physical defects, 
 tubercular habitus, deformed distal thoracic borders. A study of the sub- 
 ject of splanchnoptosia has exposed many previous puzzles. A faint feeling 
 after the morning rising, fatigue after exercise sense of weight in distal and 
 dorsal abdomen, dragging in epigastrium, flatulence, constipation, frequent 
 micturition, lends clues to widespread splanchnoptosia. Neurasthenia, flaccid 
 and pendulous abdomen, loss of flesh, diastasis of the recti muscles shed light. 
 The aorta frequently strongly pulsates, and with spare subjects one feels 
 what Glenard calls the "transverse colon cord," however, I am fully satisfied 
 at present after investigating these symptoms frequently in autopsies that 
 this transverse band or "colon cord" is the pancreas mainly. 
 
634 THE ABDOMLXAL AXD PELVIC BRAIN 
 
 General Symptoms. 
 
 Writers continually associate splanchnoptosia and nervous dyspepsia. 
 It seems to me such terms as nervous dyspepsia should be abandoned because 
 later investigations have demonstrated that the various symptoms of splanch- 
 noptosia are practically due to the malposition and consequent pathologic 
 physiology of viscera. In marked subjects of splanchnoptosia the symptoms 
 of degeneracy present as B. Stillar's floating tenth rib (decima costa fluc- 
 tuans) neurasthenia, so-called nervous dyspepsia. 
 
 Splanchnoptotics may improve with advancing senescence. This must 
 mean that the neurosis and so-called nervous dyspepsia improves — not the 
 splanchnoptosia for splanchnoptosia practically increases with senescence, 
 that is after 35. The explanation must lie in the adjustment and compen- 
 satory action of the splanchnoptotic organs. The anatomy and physiology 
 of the dislocated organs has become used to the order of things. Meinert 
 has written extensively on the relation of chlorosis and splanchnoptosia. 
 It is more probable that the relations of chlorosis and splanchnoptosia are 
 distant and rather that the defective constitutional power exposes the subject 
 to both splanchnoptosia and clorosis — congenital and acquired defects 
 which favor both diseases. 
 
 The symptoms of splanchnoptosia are distension, expansion of thoracic 
 and abdominal walls. The thoracic and abdominal viscera are dislocated, 
 succulated, flexed. The visceral function (peristalsis, absorption, secretion, 
 sensation) are disturbed. 
 
 The symptoms of splanchnoptosia are functional, physiologic disturban- 
 ces rather than definite marked anatomic or pathologic anatomy lesions. 
 The major visceral functions sensation, peristalsis, absorption, secretion are 
 deranged. The visceral tracts, viz. : — Respiratory, circulatory, digestive, 
 urinary, genital, nervous are compromised in physiology and anatomy. 
 Pathology is evident chiefly in pathologic physiology only. 
 
 GENERAL TREATMENT OF SPLANCHNOPTOSIA. 
 
 The treatment should be medical, mechanical, surgical. 
 /. Medical Treatment. 
 
 The essentials of medical treatment in splanchnoptosia are: (1), hygiene; 
 (2), visceral drainage; (3), diet; (4), habitat; (5), avocation, electricity, 
 spray, douche. Advice is frequently of more value to a splanchnoptotic than 
 medicine. 
 
 Splanchnoptosia is practically a medical disease belonging to the inter- 
 nist. The physician should treat not merely single organs but the patient. 
 Symptoms of general splanchnoptosia and neurosis should not be attributed 
 to single dislocated organs as nephroptosia, hepatoptosia gastroptosia. The 
 subjective difficulties should be treated and not merely the clinical findings, 
 because the patient may be suffering more severely than the physical findings 
 indicate. In splanchnoptosia the chief treatment consists in correcting the 
 pathologic physiology of the thoracic and abdominal viscera as well as the 
 
SPLANCHNOPTOSIA 635 
 
 restoration of the strength, firmness and elasticity of the enclosing walls. 
 Unfortunately the restoration of elasticity, of excessively extended muscle 
 and connective tissue is difficult. The aim of the physician should be restor- 
 ation of function. In splanchnoptosia there are four grand factors to con- 
 sider; viz.: (a) relaxation of the thoracic and abdominal walls, (b) distalward 
 movements of contained viscera (splanchnoptosia) (c) gastro-duodenal 
 dilatation, (d) change of form of thorax, (flared), and abdomen (pendulous). 
 On these basic factors will rest the rock and base of our plans in treatment. 
 
 (/) Hygiene. 
 Hygiene has reference to the method of living, the quantity and quality 
 of ingested fluid and food, the exercise of functions, the quantity and quality 
 of fresh air employed and the relations of environments. In hygiene the 
 advice of a physician is frequently more useful than drugs. 
 
 (2) Visceral Drainage. 
 
 The splanchnoptotic suffers almost continually from pathologic physi- 
 ology and the chief medical treatment consists in correcting diseased visceral 
 physiology or function. For the splanchnoptotic the most important 
 treatment from beginning to end is ample visceral drainage. The best 
 diuretic is H 2 0. The sovereign visceral drainage fluid is different grades of 
 physiologic salt solution. I administer 8 ounces of ^2 to % physiologic 
 salt solution before each meal (better hot) and between meals, i. e., the 
 subject drinks 8 ounces of l A to Y\ physiologic salt solution every 2 hours 
 or 3 pints daily regardless of other fluids. (Note — sodium chloride should 
 not be administered to subjects afflicted with parenchymatous nephritis.) 
 
 The sodium chloride stimulates the epithelium of the tractus urinarius 
 and tractus intestinalis. In addition to the physiologic salt solution I 
 administer on the tongue at the same time a part or multiple of an alkaline 
 tablet (composed of: Cascara sagrada, one-fortieth of a grain; aloes, one- 
 third of grain; NaHC0 3 , one grain; KHCO3, one-half grain; MgS0 4 2grain.) 
 The sodium chloride tablet contains 11 grains. The combined treatment 
 consists in placing (J to 2) alkaline tablets as required to produce one bowel 
 movement daily and {Vz to Y\) sodium chloride tablet on the tongue (every 
 two hours) followed immediately by a half a pint of H a O 6 times daily. 
 The plan of treatment I term the "visceral drainage" treatment, continuing 
 it for weeks, months and the results are remarkably successful. The urine 
 becomes clarified resembling spring water and increased in quantity. The 
 tractus intestinalis becomes amply evacuated regularly daily. The blood is 
 drained of waste material. The tractus cutis eliminates freely, and the 
 skin becomes normal. The appetite increases. The sleep becomes improved. 
 The feelings become more hopeful. The sewers of the body are vigorously 
 drained and flushed. The greatest principle in medicine and surgery — 
 drainage — is accomplished. 
 
 (j) Diet. 
 
 The diet influences visceral function equally with fluids, the main ideal 
 of diet for the splanchnoptotic is that it shall be coarse, voluminous, and 
 
THE ABDOMIXAL AXD PELVIC BRAIX 
 
 result in ample, indigestible faecal residue in order to stimulate the 
 functions of the tractus intestinalis (peristalsis, absorption, secretion, sensa- 
 tion). The kinds of foods for the splanchnoptotic should be (a) cereals 
 (oatmeal, prepared wheat, rice, graham bread — i. e., the entire wheat as 
 bran, shorts, and flour), (b) vegetables (cooked), (c) albuminoids (milk, 
 eggs), (d) meats (limited in quantity). Diet should be strictly regulated. 
 Food should be administered every three hours in limited quantities. All 
 fermentative substances should be avoided. Fruits unless strictly regulated 
 do more harm than good (from fermentative processes). Pies, puddings, 
 cakes, sugars, sauces, and condiments should be prohibited. Diet should 
 be wholesome and nutritive to produce fat for visceral padding whence the 
 visceral shelves and fossae are increased and the abdominal wall thickened 
 enabling it to diminish the abdominal cavity to aid in visceral reposition and 
 maintenance in the normal physiologic position. One of the essential 
 pathologic conditions in splanchnoptosia is malnutrition, inanition. Splanch- 
 noptosia is best cured by rebuilding the organism which signifies normal 
 blood and panniculus adiposus. The practical therapeutics in splanchno- 
 ptosia is to improve the pathologic physiology, for splanchnoptotics live 
 continually under pathologic physiology. The visceral drainage treatment 
 improves health. It places visceral function and elimination at a maximum. 
 Hence, the subject is better prepared to institute local repair which means 
 resisting and checking infection, absorbing exudates. The visceral drainage 
 treatment can be conducted at the patient's home, be it a cottage or a palace, 
 without cessation of his occupation. There is no necessity of making long 
 sojourns to distant watering places to drink hissing sprudel or odorous 
 mineral waters. 
 
 (./). Habitat. 
 
 Habitat or the environments of life are significant in the general treat- 
 ment of the splanchnoptotic. First and foremost, the splanchnoptotic should 
 have ample fresh air night and day. The window should be open all night 
 summer and winter. Clothing should be suspended from the shoulder avoid- 
 ing all tight waist bands. Physical exercise should be regular and practiced 
 daily. 
 
 (5). Avocation. 
 
 The business or association of a splanchnoptotic is a matter of importance 
 as he is unable mentally or physically to withstand persistent continued effort. 
 Mental and physical rest is necessary for the subject afflicted with inferior 
 anatomy and inferior physiology. Heavy labor he cannot endure. Constant 
 standing on the feet for hours exhausts the splanchnoptotic. He should 
 assume a horizontal position frequently in order to change the circulation 
 and rest the fatigued muscles. Assuming frequent physical rests the splanch- 
 noptoses inferior physiologic functions and inferior anatomic structures 
 may maintain fair health and accomplish a reasonable degree of labor. 
 
SPLANCHNOPTOSIA 637 
 
 (tf). Electricity. 
 
 Electricity is of considerable value in relaxed abdominal walls, especially 
 faradization of the muscles. 
 
 (r). The Cold Douche or Spray. 
 
 The cold douche or spray is of limited value. It can be applied to the 
 abdomen, per vaginam or per rectum. 
 
 II. MECHANICAL TREATMENT. 
 
 The essentials of mechanical treatment is forcible reposition and main- 
 tenance of the viscera, on the visceral shelves and in the visceral fossae — 
 i. e., viscera are restored and maintained within the normal physiologic 
 position. 
 
 The object of mechanical treatment is forcible visceral reposition and 
 retention of the organs (on their shelves in their fossae), i. e., in their normal 
 physiologic position by means of the abdominal wall. In the treatment the 
 unfavorable standing posture, the excessive physical labor, the imperfect 
 respiration in the distal zone of the chest and the absence of tone in the 
 abdominal wall should be considered. The dislocated viscera, in splanch- 
 noptosia, are easily replaced, reduced to their physiologic range of action 
 and maintained with facility through rational therapy applied to the abdom- 
 inal wall. The reposition of dislocated groups of viscera in splanchnoptosia 
 to their normal physiologic range improves related visceral functions and 
 structure. Splanchnoptoses are mainly neurotics, mechanical reposition of 
 the visceral on their visceral shelves and in their visceral fossa, ameliorates 
 the neurosis, affords ample relief and comfort. Splanchnoptotics are 
 neurotics, consequently unable to judge; therefore, should not be informed 
 as to the excessive mobility of individual organs. 
 
 (1). Abdominal Supporters. 
 Much utility, relief and comfort arises from the use of properly fitting 
 abdominal supporters. The kinds we have used are: (1), non-elastic, (2), 
 elastic, and (3) the author's pneumatic ax shafted rubber pad which can be 
 placed within an elastic or non-elastic abdominal binder and distended with 
 air to suit the comfort of the patient. The objection urged against the use 
 of an abdominal binder in splanchnoptosia that it does not teach the muscles 
 self-strength, is worthless as the objection against the use of a splint in 
 fractures. The fact to remember is that the abdominal muscles are extended, 
 stretched beyond self or independent help. Abdominal supporters do not cure, 
 but properly fitting ones help the patient to relief, comfort and usefulness. 
 It is not sufficient to recommend an abdominal binder. The physician should 
 examine it to be sure that it fits properly, both for the grade of splanchno- 
 ptosia and for the avocation of the patient. The difficulty of fitting a proper 
 support is due to the varying position of the patient — walking, sitting or 
 lying. I have invented a rubber air pad which is the shape of an axe. This 
 is placed within a binder and subsequently distended with air through an 
 attached rubber tube to the desired dimension. The rubber pneumatic pad 
 
638 THE ABDOMIXAL AND PELVIC BRAIX 
 
 insures a uniform fitting of the abdomen like a water bed, whether spare or 
 fleshy, and also the dimensions may be adjusted tc the comfort, relief of the 
 patient. The binders are useful in moderate nephroptosia, which is the 
 easiest of all portions of splanchnoptosia to aid, but when it has become 
 advanced, binders are not only of little value but frequently harmful. In 
 severe or distinctly diagnosable hepatoptosia (with liver projected into the 
 lesser pelvis, I have seen none or little utility in binders. All tight waist 
 bands should be removed, and the clothing should be suspended from the 
 shoulders or from hooks on a corset waist. If one experiments on a dead 
 body with a tight-fitting corset, the organ which will suffer the most extensive 
 displacement will be the right kidney. All commercial tight corsets should 
 be abandoned but a so-called waist corset is useful to adjust and from which 
 to suspend clothing. 
 
 Since a binder is to reposit the viscera by restoring elongated and sepa- 
 rated fascial and muscular fibres of the abdominal walls it must fit snugly, 
 especially in distal abdomen. Unfortunately binders glide and slide and 
 do not continually maintain a force on the distal surface (of the visceral 
 shelf) of the viscera. The viscera may glide distal to the binder. Two 
 rubber tubes must be employed passing between the limbs to fix the binder 
 so that it will not slip proximalward. The binder generally only forces 
 dorsalward and proximalward the abdominal wall, but the addition of the 
 author's rubber pad adds to this the forcing of the viscera proximalward by 
 acting like a pregnant uterus which elevates the viscera toward the thoracic 
 diaphragm. If the splanchnoptosia is not excessively advanced, the rubber 
 visceral air pad being adjusted and distended with air while the patient lies 
 on the back (Trendelenburg's posture) will prevent the viscera gaining the 
 lesser pelvis — the dangerous ground for stenosis of ducts, vessels and viscera, 
 and traumatizing nerve periphery. The binder should be removed or 
 loosened for the night's rest. 
 
 (2). Horizontal Position. 
 
 A dominant factor in splanchnoptosia is venous congestion during erect 
 attitude, hence the splanchnoptotic should assume especially the horizontal 
 position. When a patient with established splanchnoptosia assumes the 
 erect attitude, the viscera in general pass distalward with the extra-expanded 
 abdominal walls, the veins immediately enlarge, the abdominal wall is put on 
 a tension, and it projects or bulges distal to the symphysis pubis sufficiently 
 to conceal the genitals from the patient's view. The patient in the erect 
 attitude assumes a position of lordosis as in advanced pregnancy, in order to 
 secure a compensator}' weight balance. 
 
 In the horizontal position the patient with splanchnoptosia should lie 
 on the side and not on the back. All patients with established splanchno- 
 ptosia suffer from gastro-duodenal dilatation (a phase in the progress of 
 splanchnoptosia) due to pressure of the superior mesenteric artery, vein and 
 nerve on the transverse segment of the duodenum. I experimented with 
 dead subjects who had been afflicted with splanchnoptosia. and when such 
 
SPL.l.XClLXOPTOSIA G39 
 
 subjects were placed on the back, the viscera, especially the enteronic loops, 
 passed distinctly more and more into the lesser pelvis, dragging and tugging 
 on the superior mesenteric artery, vein and nerve, which compressed mon 
 and more the transverse segment of the duodenum. When the subject of 
 splanchnoptosia lies on the back, the enteronic loops glide into the lesser 
 pelvis, which makes the superior mesenteric artery, vein and nerve approach 
 closer and closer to the vertebral column and thus diminishing the 
 superior mesenterico-vertebral angle, vigorously compressing the transverse 
 duodenum. 
 
 I have observed personally splanchnoptosia and gastro-duodenal dilata- 
 tion progress until the stomach completely occupied the abdomen like an 
 ovarian cyst. (The more acute the mesenterico-vertebral angle becomes, the 
 more the transverse duodenum segment is compressed.) Pregnancy increases 
 the (superior) mesenterico-vertebral angle, forcing proximalward the enter- 
 onic loops and thus releasing the transverse duodenum from pressure. A 
 great benefit in the wearing of an abdominal binder or Rose's strapping 
 is to increase the (superior) mesenterico-vertebral angle, releasing the duo- 
 denum from compression and preventing increased gastro-duodenal dilata- 
 tion. Lying on the abdominal surface of the body, with a pillow under the 
 thorax and the symphysis pubis would be the ideal position to insure the 
 maximum (superior) mesenterico-vertebral angle (as it exists in quadrupeds) 
 Hence the splanchnoptotic should lie in the horizontal lateral position as 
 much as is convenient to increase the (superior) mesenterico-vertebral angle, 
 to avoid venous congestion and to prevent the viscera from passing distal- 
 ward, producing stenosis and flexion of the lumen of the vessels, ducts and 
 viscera. Lying on the back, or standing, diminishes the mesenterico- 
 vertebral angle and increases the compression of the duodenum by the 
 mesenteric vessels and nerves. 
 
 (j). Massage. 
 
 The massage of the abdominal wall as well as that of the tractus intes- 
 tinalis aids materially in the treatment. However, it is of limited value. 
 
 (4). Achilles Rose's Adhesive Strapping. 
 
 I wish to recommend strongly the strapping of the splanchnoptotic 
 abdomen by rubber adhesive plaster introduced first by Dr. Achilles Rose of 
 New York and independently later by Dr. N. Rosewater of Cleveland, Ohio, 
 Dr. Walther Nicholas Clemm of Darmstadt, Germany, and Dr. B. Schmitz 
 of Wildungen, Germany. 
 
 Dr. Achilles Rose's strapping method is rational, economical and practi- 
 cal and affords prompt comfort and effective relief. Abdominal binders slip 
 and glide but adhesive straps will remain permanently in place and not slip. 
 
 Method of Applying the Adhesive Strap. 
 
 Previous to applying the abdominal adhesive straps the abdominal skin 
 should be thoroughly cleaned with soap and water and later alcohol to dissolve 
 oily substances applied in the line of adhesive straps. The patient should 
 
640 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 be strapped either in the standing position by elevating the abdominal wall 
 (Glenard's belt test) by the hands before the straps are applied or strapped 
 in the Trendelenburg's position. 
 
 Place an adhesive strap 2 inches in width around the trunk immediately 
 proximal and parallel to the crest of the pubis, Poupart's ligament and crests 
 of the ilia, superimposing or overlapping the adhesive straps on the medial 
 dorsal line. The dorsal position of the adhesive straps is located considera- 
 ble proximal to the ventral position which endows the straps with its useful, 
 visceral supporting properties. 
 
 Secondly, apply a pyramid formed adhesive strap 3 inches wide ventrally 
 and 2 inches wide dorsally immediately proximal and parallel to the first 
 adhesive strap. These two lateral adhesive straps overlap ventrally and 
 dorsally. This method of adhesive strapping forces the abdominal wall 
 and viscera proximalward so that the relaxed portion of the abdominal 
 wall is in the region of the umbilicus and stomach. In other words the 
 adhesive strapping reverses the position of the abdominal splanchnoptosia 
 (atonia gastrica), i. e., the excessive mobile viscera and relaxed abdominal 
 wall are transferred to the proximal end of the abdomen (instead of the distal 
 end). I allow the adhesive straps to remain in position for 10 days to a 
 month. Local bathing can be practiced with the adhesive straps in position 
 (avoiding the moistening of the immediate region of the straps). Beginners 
 are apt to apply the strap too tightly. Dr. E. Gallant of New York reports 
 excellent results from his corset method of treatment. Patients experience 
 prompt and ample relief from mechanic supports, avoiding the danger of a 
 fragmentary operation, its recurrence and the inevitable unfavorable cellular 
 and peritoneal adhesions accompanying viscero-pexy. 
 
 (III). SURGICAL. 
 
 Surgery is not advised excepting for obvious pathologic lesions. 
 Splanchnoptosia cannot be cured by surgery though every abdominal viscus 
 has imposed on it a '"Pexy. " Some surgeons encourage splanchnoptosia by 
 allowing and advising the patient to leave the bed in an incredible limited 
 time subsequent to an abdominal section or peritonotomy. The treatment 
 of splanchnoptosia is, in general, not by the scalpel, needle and suture. The 
 surgical therapeutics employed to relieve in splanchnoptosia are: (a) appli- 
 cation to the abdominal wall, (b) viscero-pexy, (c) visceral anastomosis. 
 
 (A) Abdominal Walls. 
 
 (1) Resection of portions of abdominal wall. (2) Union of musculi recti 
 abdominalis in a simple sheath. (3) Superposition of abdominal wall. 
 
 (/). Resection of Portions of the Abdominal Wall. The early attempts 
 to diminish the abdominal cavity in splanchnoptosia originated from the 
 gynecologists, particularly from Prof. Karl Schroeder and Dr. Landau of 
 Berlin, Germany. I was a pupil of Dr. Theodore Landau in 1555 and his 
 books, "Wander Niere" and "Wander Leber," have been for teachers and 
 authors an unbounded source of credited and uncredited data. 
 
SPLANCHNOPTOSIA 
 
 641 
 
 ( •■. Union of the Musculi Recti Ab dominates in a Single Sheath. My 
 
 attention was first called to the subject of relaxed abdominal walls by Prof. 
 Karl Schroeder whose pupil I was for a year. In that year (1884-1885) Prof. 
 Schroeder of Berlin, Germany, the greatest gynecologic teacher of his age, 
 was at his zenith of fame, and his clinic was vast. In fact, he tapped the 
 whole of Europe for his material. He discussed in his clear style the mis- 
 fortune of lax abdominal wall lying between the diastatic recti abdominales. 
 
 ABDOMINAL WALLS 
 
 Fig. 206. Presenting the fascia and muscles of the abdominal wall with the 
 introduction of sutures. 
 
 He then united the sheaths of the recti in the median line. But Prof. 
 Schroeder said then to his pupils that he was not fully satisfied, however, it 
 was the best surgery that he knew at that time. Later German surgeons 
 improved Schroeder's ideas by splitting the sheaths of the two recti muscles 
 and enclosing both muscles in one sheath by uniting the recti muscle sheaths 
 dorsally and ventrally and dorsally to the recti muscles. 
 
 In 1895, Dr. Orville W. MacKellar and I operated on a woman pregnant 
 
642 THE ABDOMINAL AND PELVIC BRAIN 
 
 four or five months, where the diastasis, the musculi recti abdominales was 
 very marked, and the uterus, on coughing or extra intra-abdominal pres- 
 sure, would project between the recti abdominales. We united the split 
 sheaths of the recti muscles ventral and dorsal, enclosing the two musculi 
 recti abdominales in one sheath. Dr. MacKellar reports to me at present 
 (1906) that his patient is perfectly well, and the operation was a success. Dr. 
 MacKellar was at the deliver}' and the recti sheaths remained perfectly intact. 
 For the post-operative hernia, for years past at the Mary Thompson Hospital, 
 I have split the recti and enclosed them in a single sheath. Every one with suffi- 
 cient experience knows that post-operative hernia of any considerable size, 
 in women over 40, is in every case accompanied by splanchnoptosia. Dr. 
 MacKellar and I have records to show that 11 years after enclosing the two 
 recti abdominales in a single sheath, for splanchnoptosia, the operation is a 
 success. The mesenteries are not for mechanical support to suspend the 
 viscera, but to act as a neuro-vascular visceral pedicle, and to prevent the 
 entanglement with other viscera. It is the abdominal wall that maintains 
 the viscera in position. 
 
 Besides, I showed in over 600 detailed records of personal autopsic 
 abdominal inspection, that in 96% of subjects the enteron had a mesenteron 
 sufficient in length to herniate through the inguinal, femoral and umbilical 
 rings. Hence the mesenteries must be viewed as neuro-vascular visceral 
 pedicles, and not as suspensory organs, while the abdominal walls are the 
 essential supporters and retainers of the viscera. And as every anatomist 
 knows, the recti abdominales are among the chief regulators or governors of 
 visceral poise, at least they retain the viscera in their first delicate normal 
 balance. 
 
 In uniting the two recti abdominales into a single sheath the operation 
 may be performed without entering the peritoneal cavity or after laparotomy. 
 During the past 4 years I have practically abandoned the union of the muscli 
 recti abdominales in a single sheath for the operation of superposition, over- 
 lapping of the abdominal walls, taught me by Mr. Jordan Lloyd, of Birming- 
 ham, England, in 1891. 
 
 (3). Superposition of the Abdominal Walls. In 1891 in a visit to Mr. 
 Jordan Lloyd of Birmingham, England, he demonstrated to me the operation 
 of superposition (overlapping) of the abdominal walls in abdominal section 
 to strengthen the line of union. He used a matras form of suture. Since 
 that time I have employed the superposition (overlapping, like a double- 
 breasted coat) of the abdominal wall. Contrary to Mr. Jordan Lloyd, I 
 employ the buried silver wire suture — some 3 to an inch. The superposition 
 or overlapping of the abdominal walls in splanchnoptosia is the most 
 rational, effective, durable and successful of all parietal surgical procedures. 
 It diminishes, to the desired extent, the abdominal cavity, forcibly repositing 
 organs on their visceral shelves and in their visceral fossae and retaining 
 them in their normal physiologic position. I have superposed, or overlapped, 
 some abdominal walls as much as 3 inches on each side, diminishing th e 
 abdominal cavity by six inches of the ventral wall. I observed that some 
 
SPLANCHNOPTOSIA 643 
 
 patients with extensive superposition of the abdominal wall, and consequent 
 diminution of the abdominal cavity, complained for a few months of com- 
 pression feelings, as if the abdomen were too tight or constricted. 
 
 (B) Viscero-pexy {fixation of organs). 
 
 All abdominal viscera are physiologically mobile, hence, to perform 
 viscero-pexy, or visceral immobilization, fixation of any organ, is unphysio- 
 logical or in other words viscero-pexy produces a physiologic and anatomic 
 lesion. Excessive visceral mobility is exchanged for visceral fixation. That 
 is, to cure one disease (excessive visceral mobility), another lesion (visceral 
 fixation) is substituted. Therefore viscero-pexy is in general an irrational, 
 harmful, surgical procedure. However, in surgery as in other matters 
 the lesser evil should be chosen, i. e., one should choose which is the 
 greater evil, excessive visceral mobility or visceral fixation — viscero- 
 pexy. The lesion of viscero-pexy or visceral fixation is compromisa- 
 tion of physiology and anatomy, viz. : the lymph and blood circulation as 
 well as peristalsis, absorption, secretion, sensation, are compromised. Nerve 
 periphery is traumatized. The viscero-pexy in order of frequency have been 
 the following: hystero-pexy, nephro-pexy, gastro-pexy, hepato-pexy, spleno- 
 pexy and colo-pexy. In general viscero-pexy is irrational surgery and will 
 be limited in application, as: 
 
 (a) It attempts to cure one lesion (excessive visceral mobility) by pro- 
 ducing another lesion (visceral fixation). Which is the worse? It is unjusti- 
 fiable surgery that substitutes one pathologic visceral position for another 
 (for a mobile, pathologic visceral position is no doubt less damaging than 
 a fixed pathologic position). 
 
 (b) It attempts to cure a general defect or disease (splanchnoptosia — 
 excessive visceral mobility) by fixation (a physiologic and anatomic lesionj 
 of a single part (e. g., nephroptosia) fragment of the dislocated viscera. 
 Also, when, accidentally, by trauma ptosis of single viscera occur the dis- 
 tinct, marked symptoms and suffering are not indicated. Instead of irrational, 
 individual viscero-pexy, the diminution of the abdominal cavity is more 
 rationally secured by Rose's abdominal strapping (or a binder) or by the 
 superposition, overlapping of the abdominal walls (mechanical), as this does 
 not produce the unfortunate peritoneal fixation lesions of viscero-pexy yet 
 forcibly reposits the viscera on their normal anatomic shelves and 
 within physiologic range. If splanchnoptosia is to be cured by 
 viscero-pexy it will require multiple visceral and parietal operations 
 on one and the same patient as nephro-pexy, gastro-pexy, spleno- 
 pexy, hepato-pexy, entero-pexy and in females (the usual subjects) 
 utero-pexy. Observe what extreme compromisation of visceral anatomy 
 and physiology this would entail. Besides, the thoracic and abdom- 
 inal walls will require effective repair (diminution). Hence a dangerous 
 number of surgical repetitions would confront the patient. 
 
 (c) The viscero-pexy (a lesion of visceral fixation) is generally tempo- 
 rary as the viscus becomes practically eleased sooner or later from absorp- 
 
644 THE ABDOMLXAL AXD PELVIC BRALX 
 
 tion of the adjacent artificial parietovisceral exudate, from absorption or the 
 yielding of suture, from the trauma of the visceral peristalsis, from adjacent 
 muscular trauma, from the trauma of respiration (especially the diaphragm), 
 from lack of support of the abdominal wall. 
 
 d i The viscero-pexy compromises visceral function and structure, of 
 which the most striking example is that of dystocia due to hystero-pexy I 
 have performed autopsy, the death being directly due to dystocia resulting 
 from hystero-pexy. Fixation damages other viscera similarly, perhaps 
 according to the degree of solidarity of fixation. 
 
 (e) The peritonotomy or the invasion of the peritoneum alone, regard- 
 less of the viscero-pexy, may produce considerable damaging peritoneal 
 adhesions, compromising not only the structure and function of the fixed 
 viscus, but also of adjacent viscera. Peritoneal adhesions are ample reasons 
 in many subjects for primary or secondary peritonotomy. I have shown in 
 hundreds of autopsies that peritoneal adhesions damage viscera by compro- 
 mising anatomy and physiology, e. g., especially in the caeco-appendicular, 
 gall-bladder, sigmoid and pelvic regions — that a peritonotomy is required. 
 
 (f) The patient is not suffering nor are the symptoms due to dislocation 
 of single organs (in splanchnoptosia) — the suffering and symptoms are the 
 result of general dislocation of viscera (splanchnoptosia — neurosis) and 
 extra-expansion of the abdominal and thoracic walls, i. e., splanchnoptosia. 
 
 (g) Viscero-pexy is irrational because it compromises visceral function 
 (peristalsis, absorption, secretion sensation) and structure (the connective 
 tissue and the parenchyma of the organs is damaged). 
 
 (h) Viscero-pexy compromises circulation (blood and lymph). It 
 traumatizes nerve periphery. It deranges nourishment, resulting in malassi- 
 milation, neurosis. 
 
 (i) Viscero-pexy is a pathologic surgical substitute for hygienic meas- 
 ures with a high cost and risk. The anatomic rest (maximum quietude of 
 voluntary muscles) and physiologic rest (minimum function of viscera) in 
 bed, with mental hope of cure, tells the favorable story rather than the 
 viscero-pexy. 
 
 (j) The patient recovers after the viscero-pexy from symptoms which 
 did not practically belong to the organ attacked. It was a mistake in 
 diagnosis and an unnecessary operation. E. g., to fix a retroverted state of 
 the uterus is to substitute one pathologic condition for another, and also 
 the subject is not suffering from the retroversion but either from complica- 
 tions or disease, as neurosis. 
 
 (k) Three views may be held on the favorable reports in viscero-pexy 
 or visceral fixation, viz. : (1) the patient secures a period of favorite 
 anatomic and physiologic rest in bed after the viscero-pexy — with mental 
 hope of cure. In other words the viscero-pexy is a hygienic measure — 
 with high price and risk. (2) The patient recovers after the viscero-pexy 
 from symptoms which did not belong to the attacked organ. The symptoms 
 presented by the patient were due to other causes — especially neurosis 
 (neurasthenia, hysteria). It was a mistaken diagnosis. Hence for individual 
 
SPLANCHNOPTOSIA 645 
 
 viscero-pexy should be substituted rational hygienic measures and correct 
 diagnosis. Neurosis should not be mistaken for splanchnoptosia or entero- 
 ptosia. (3) A third view in the favorable reports of viscero-pexy is that 
 they are prematurely published. The operation from the anatomic and 
 physiologic rest in bed, as well as diminution of the accompanying neurosis, 
 has afforded temporary relief. Individual viscero-pexy in the majority of 
 subjects does not secure permanent relief. 
 
 INDIVIDUAL VISCERO-PEXY. 
 
 Viscero-pexy on two organs — kidney and uterus — has become unfortu 
 nately prevalent during the past decade. 
 
 NEPHROPEXY. 
 
 Nephro-pexy sJiould be performed for periodic hydro-ureter only. 
 
 If in nephroptosia one detects distinct renal pain, renal tenderness, renal 
 hypertrophy and that the ureteral pelvis of the same side contains a greater 
 quantity of urine than the pelvis of other side, periodic hydro-ureter has 
 probably begun. If in a kidney of extensive mobility, and irregular pain 
 presents it is probably due to rotation of the kidney on its uretero-neuro- 
 vascular-vascular-visceral pedicle (Dietl's crisis) and ureteral dilatation (peri 
 odic hydro-ureter) has probably begun. 
 
 As regards nephro-pexy there is practically one condition which indi- 
 cates nephro-pexy and that is periodic hydro-ureter. In this case the 
 damage of periodic hydro-ureter is greater than — unphysiologic renal fixation 
 — that of nephro-pexy. Besides, nephro-pexy is generally not permanent; the 
 kidney again appears in the field of nephroptosia. The patient has assumed 
 the risk of operation, with its consequent anatomic and physiologic damage, 
 peritoneal and connective tissue adhesions, for temporary relief. The multi- 
 ple methods of executing nephro-pexy condemn it. Practically every advo- 
 cate of the irrational nephro-pexy pretends to possess his own method. Also 
 nephroptosia is but a fragment of splanchnoptosia, and to produce a single, 
 pathologic, unphysiologic, harmful viscero-pexy to cure a general spanchnopto- 
 sia adds further damage to the patient. Nephro-pexy has perhaps a mortality 
 of 2 f /o (the dead are not reported — the living are reported). In nephroptosia 
 the most rational treatment is mechanical reposition and retention of the kid- 
 ney by means of mechanical supports (for 60% of adult women possess mo- 
 bile kidney), it avoids operation with consequent connective tissue and peri- 
 toneal adhesions. It is a doubtful justifiable surgical procedure to per- 
 form nephro-pexy on a replacable kidney, when the organ can be retained by 
 mechanical means, i. e., by utilizing the abdominal wall through a binder — 
 strapping — if no periodic hydro-ureter exists (because mechanical aids 
 will reposit and maintain the kidney in its normal position a 1000 times more 
 physiologic than fixation — nephro-pexy). If nephro-pexy be performed (for 
 periodic hydro-ureter) it should be executed according to the Senn method — 
 i. e., the distal pole of the kidney should be placed in the wound in the 
 abdominal wall and maintained there by a loop of gauze without sutures. 
 
646 THE ABDOMINAL AND PELVIC BRAIN 
 
 Later the kidney is fixed in this position by granulations and the skin is drawn 
 over its longitudinal border by means of adhesive straps. 
 
 Hystero-pexy. 
 
 As regards fixation of the genital organs we offer the following considera- 
 tion: Hystero-pexy should not be performed on a reproductive subject. (Alex- 
 ander operation is a pathologic surgical substitute for hygienic measures at a 
 high cost and risk. It demands repetition as frequent as man requires his 
 hair cut.) Since the primary support of the genitals is the pelvic floor, 
 rational surgery suggests pelvic floor repair for general support in visceral 
 ptosis. Anatomically and physiologically the genitals belong permanently 
 in the pelvis. The genital organs are permanent pelvic organs, hence it is 
 irrational to remove them from the pelvis into the abdomen in order to fix 
 them permanently to the abdominal wall — the genital nerve, lymph and 
 blood apparatus are located in the pelvis in the resting state. 
 
 To create new external supports external to the pelvis for the genitals 
 (ventral hystero-pexy) is unphysiologic, pathologic, as it dislocates the organs 
 and compromises structure and function — especially mobility and peristalsis — 
 beside disturbing adjacent organs. The utility of ventral (abdominal) hystero- 
 pexy has not been established; however, its damaging effects have been 
 recognized many hundreds of times : (a) in pain following the operation, (b) 
 from dystocia, (c) in abortions, due to it, (d) in the necessity of surgical 
 procedures in parturitions (as instrumental delivery symphysiotomy, 
 Caesarian section, Porro operation), (e) in the necessity of producing abor- 
 tions, (f) from postoperative hernia (Theilhaber repor' 3 30% of hernia 
 subsequent to ventral hystero-pexy — and these were p ^ctically originally 
 aseptic subjects), (g) in the mortality of some, 2%. 
 
 To forcibly substitute or transform secondary genital supports into 
 primary ones or to create artificial ones is rarely applicable and of doubtful 
 utility. However, secondary supports are more rational than to create 
 artificial new supports external to the pelvis. The Alexander operation, of 
 shortening the round ligaments, is imposing on a secondary uterine support 
 (the round ligaments) the duty of a primary uterine support. 
 
 (B) Visceral Anastomosis. 
 
 The anastomosis of viscera employed to relieve in splanchnoptosia are 
 the stomach and enteron. The reason for this is that gastro-duodenal dilata- 
 tion is simply a phase in splanchnoptosia due to the compression of the 
 duodenum by the superior mesenteric vessels. Gastro-enterostomy allows 
 the food to escape from the stomach into the enteron without first passing 
 through the obstructed portion of th^ duodenum from the compression of the 
 superior mesenteric artery vein and nerve. With rapid stomach evacuation 
 and no food in the duodenum the gastro-duodenal dilatation is quickly 
 changed to gastro-duodenal contraction. (See discussion of gastro-duodenal 
 dilatation.) 
 
SPLANCHNOPTOSI. 1 647 
 
 RESUME AS REGARDS SPLANCHNOPTOSIA. 
 
 1. Splanchnoptosia presents two grand divisions, viz. : I. Thoracic 
 splanclinoptosia\\\i\c\\\x\c\xi<\v$, the factors of: (a) relaxation of the thoracic 
 wall (with diaphragm), (b) thoracic splanchnoptosia (heart and lungs), (c) 
 consequent deranged function of the thoracic viscera and wall (respiration 
 and circulation). II. Abdominal splanchnoptosia which, includes the factors 
 of: (d) relaxed abdominal walls (atonia gastrica), (e) splanchnoptosia of 
 abdominal viscera (the six visceral tracks), (f) elongation of mesenteries 
 (neuro-vascular visceral pedicle), (g) gastro-duodenal dilatation (due to com- 
 pression of transverse portion of the duodenum by the superior mesenteric 
 artery vein and nerve), (h) altered form of the abdomen (erect — pendulous, 
 prone — projecting laterally). 
 
 In general, in splanchnoptosia, canalization is compromised, nerve pe- 
 riphery traumatized, common visceral function (peristalsis, secretion, absorp- 
 tion, sensation) deranged; circulation (blood, and lymph) disordered; 
 respiration disturbed — ending in malnutrition and neurosis. 
 
 Splanchnoptosia compromises the lumen of ducts, vessels and viscera — 
 tubular canals — through flexion, stenosis, decalibration, elongation, constric- 
 tion. 
 
 2. The numerous and complex groups of symptoms produced by 
 splanchnoptosia must be considered independent of inflammatory processes. 
 
 The symptoms of the splanchnoptotic are complex and numerous. 
 Each cause in splanchnoptosia produces a vicious circle of — pathologic 
 physiology — pathologic effects on the visceral tracts — digestive, genital, urin- 
 ary, lymphatic, vascular, nervous, respiratory — impairing nourishment. 
 Splanchnoptosia is often mistaken and wrongly diagnosed as neurasthenia, 
 nervous exhaustion, hysteria, spinal anaemia, menopause, nervous dyspepsia, 
 and neurosis. 
 
 Splanchnoptosia appears to be chiefly of congenital disposition as its sub- 
 jects are generally feeble, slender, atonic, neurotic, marked with a habitus, 
 ill-nourished, deficient in vital force with marked inferior physiologic func- 
 tion and inferior anatomic structure, with apparently a hard struggle to battle 
 for life and against its forces. It seems sufficiently difficult for the 
 splanchnoptotic to live merely — without attempting productive labors or to 
 rear children. Splanchnoptotics are inferior physically and incapable of 
 sustained effort mentally. They are easily fatigued and present a neurotic 
 life. Splanchnoptosia rests on evident inferior anatomy and inferior physi- 
 ology — on stigma, on habitus, on heredity. The heredity of the splanchnop- 
 totic is habitus splanchnopticus. 
 
 In splanchnoptosia the visceral tracts are deranged in function (mani- 
 festing pathologic physiology) and their anatomy is distorted (the elastic, 
 muscular and connective tissue fibres are elongated and separated). 
 Splanchnoptotic organs are liable to become hypertrophic — e.g., spleen, 
 liver, uterus — from hyperaemia (especially venous congestion). 
 
 3. In splanchnoptosia in common, the tractus intestinalis, urinarius, 
 vascularis, respiratorius, lymphaticus, genitalis, experience excessive, 
 
G48 THE ABDOMINAL AND PELVIC BRAIN 
 
 deficient disproportionate function peristalsis, absorption, secretion, sensa- 
 tion) ; excessive mobility (distalward dislocation), obstruction (from flexion), 
 pain. 
 
 In splanchnoptosia the chief manifestation of distinctive characteristic 
 features are: 
 
 (a) From the tractus intestinalis, viz. : indigestion, fermentation, meteor- 
 ism, constipation, malassimilation. 
 
 (b) From the tractus urinarius, hydro-ureter (periodic), axial rotation 
 of renal pedicle (Dietl's crisis). 
 
 (c) From the tractus genitalis, hyperaemia, hypertrophy, abortion. 
 
 (d) From the tractus vascularis, hyperaemia, anaemia, cardiac and 
 aortic palpitation. 
 
 (e) From the tractus lymphaticus, congestion, decongestion, hyper- 
 trophy. 
 
 (f) From the tractus nervosus, irritability (from trauma), instability, 
 debility, neurosis. 
 
 (g) From the tractus respiratorius, excessive, deficient, disproportionate 
 respiration. 
 
 The splanchnoptotic is the typical subject of manifest pathology 
 physiology (i. e., he lives in the zone between normal physiology and 
 pathologic anatomy). 
 
 Splanchnoptosia consists of a distalward dislocation of thoracic and 
 abdominal viscera resulting from extra extended walls. A viscus is dislocated 
 when it is permanently fixed. More adults have dislocated viscera (e. g., 
 splanchnoptosia and from peritoneal adhesions) than normal ones. 
 
 B. Stillar's costal stigma or floating tenth rib — costa decima fluctuens — 
 I have studied insufficiently to make authoritative statements. 
 
 The objective appearance of the splanchnoptotic is neurotic, slender 
 with gracile skeleton, flattened thorax, increased intercostal spaces, delicate 
 and poorly nourished, pale, non-energetic; a sad, helpless picture. Splanch- 
 noptoses form a distinct class with peculiar characteristics resembling the 
 class of tubercular subjects to which they are related. 
 
 Splanchnoptosia is a general disease of the abdominal and thoracic 
 viscera; the tractus respiratorius, intestinalis, vascularis, nervosus, urinarius, 
 lymphaticus, genitalis are equally affected, but from anatomic mechanism 
 and manifestations the tractus nervosus (neurosis) and tractus intestinalis 
 (indigestion), appear to suffer the most. 
 
 Since my clinic and private practice has consisted of 85% of women I 
 can not estimate the percentage of splanchnoptosia as regards sex; however, 
 in over 650 personal autopsic abdominal inspections (475 men, 160 women) 
 splanchnoptosia was amply evident in men. 
 
 Rapidly repeated gestations play an influential role in progressive 
 splanchnoptosia, as when the fascial, elastic and muscular fibre of some 
 abdominal walls are once well elongated and separated (expanded) they cfo 
 not return to normal. 
 
SPLANCHNOPTOSIA 
 
 The second, third, fourth, fifth decades of life are the chief ages of 
 suffering in splanchnoptosia. 
 
 The symptoms which chiefly predominate in splanchnoptosia are from 
 the side of the nervous, digestive, and circulatory systems. From the 
 nervous sphere one observes mental depression, melancholy, excitability, 
 irritability, and the nervous stigmata, as e. g., neurosis, hysteria, neuras- 
 thenia. From the side of the circulatory system one observes hyperaemia, 
 anaemia, cardiac, and aortic palpitations— excessive peristalsis. The aorta 
 may appear as a beating tumor which may be mistaken for aortic aneurysm, 
 because the aorta (while in the prone attitude) is so extensively uncovered, 
 exposed by separated viscera, presenting a protection of thin abdominal wall 
 only. 
 
 From the side of the digestive system one observes indigestion, fer- 
 mentation, meteorism, constipation. These three groups of symptoms are 
 marked in every advanced case of splanchnoptosia. 
 
 I can not agree with Meinert in attempting to establish an evident 
 etiologic relation between chlorosis and splanchnoptosia. I could observe 
 no distinct relation in series of observation. 
 
 The large number of women who have not borne children, who have not 
 laced tight, who have not suffered from ascites, nor wasting disease, how- 
 ever being afflicted with splanchnoptosia, indicates a predisposing or con- 
 genital factor. 
 
 In splanchnoptosia there are two factors to study, viz. : (a) congenital 
 and predisposing cause, (b) exciting cause. The secondary or exciting 
 causes are any forces which tend to debilitate (elongate and separate the 
 fibres of the abdominal parietes), the abdominal wall, as rapidly repeated 
 gestation, abdominal tumors, ascites, septic disease, constipation, and wast- 
 ing disease, especially the disappearance of panniculus adiposus and adjacent 
 to the viscera. A congenitally defective system may persist in maintaining 
 fair health ; however, exciting or aggravating causes may precipitate invalid- 
 ism with facility. 
 
 Splanchnoptosia may exist with no recognizable symptoms, however, 
 while the subject is in fair physical condition. The rule is that splanch- 
 noptosia may be accompanied by pathologic physiology (and pathologic 
 anatomy) in part or all of the visceral tracts (thoracic or abdominal). 
 
 Splanchnoptosia is a general disease — not a local one. It belongs to the 
 area of respiration, which is the trunk. This is well to remember when the 
 pexyite is attempting to impose fixation on some single viscus (which 
 should remain physiologically mobile). 
 
 The physician should learn to discriminate the effects in splanchnoptosia 
 from the different visceral tracts, e. g., nephroptosia and genital ptosis 
 manifest almost identical symptoms. The immediate relief by mechanical 
 treatment of forcible reposition by adhesive strapping would decide in favor 
 of nephroptosia as support from the abdominal walls is inefficient in genital 
 ptosis. 
 
 Observe how nephroptosia from trauma of the plexus renalis produces 
 
650 THE ABDOMIXAL AXD PELVIC BRAIN 
 
 reflex symptoms on the proximal end of the tractus intestinalis, ending in 
 nausea, pain, malassimilation, constipation, neurosis. Ureteral calculus 
 induces vomiting, and sooner or later renal and gastric disease coexists. 
 Genital disease occasions more gastric disturbances than the reverse because 
 the gastric functions (secretion, absorption, peristalsis, sensation) are 
 deranged more effectually than those of the genitals. Trauma or infection 
 of the nerve periphery of any abdominal visceral system deranges the 
 peristalsis, absorption, secretion, sensation of the other abdominal systems. 
 The connection between diseases of the tractus genitalsis (uterus) and tractus 
 intestinalis (stomach) is profound and intimate. Disease of the uterus and 
 stomach frequently coexist. A differential diagnosis of the symptoms arising 
 from nephroptosia, from genital ptosis or from gastroptosia is often difficult, 
 as similar symptoms may be referable to any one of these visceral tracts. This 
 may be due first to the nerve tract, the center of which is not in the brain or 
 spinal cord but in the sympathetic nervous system — (e. g., cerebrum abdom- 
 inale or cerebrum pelvicum). From reflex action symptoms arise which 
 relate to kidney, stomach or uterus. The reflex tracts being anastomosis 
 ovarica, anastomosis pudendo-haemorrhoidalis, anastomosis genito-gastrica, 
 anastomosis cutaneo-cavernosa, anastomosis collateralis and the nervi 
 splanchnic!. Also the anastomosis utero-coeliaca, anastomosis utero-cerebro- 
 spinalis, anastomosis reno-coeliaca. The immediate routes of the reflex are 
 direct connections of the vagus (excluding the ganglion abdominales) with the 
 sympathetic nervous system. The second manner in which the mistakes may 
 occur are due to dislocation of the respective organs. As splanchnoptosia is 
 a general disease, local operation — viscero-pexy — as nephro-pexy, hystero- 
 pexy, hepato-pexy, gastro-pexy, colo-pexy, will evidently be of limited value. 
 
 In diagnosis the patient's trunk should be divested of_clothing. Respir- 
 ation should be observed in both the erect and prone attitude. Every 
 abdominal organ should be palpated in the erect and prone attitude. 
 Glenard's belt test may be employed. Inspection, palpation, percussion, 
 gastric distension and colonic inflation are decisive aids to diagnosis. 
 
 Splanchnoptosia is congenital disease attacking the abdominal and 
 thoracic viscera. Observers associate with splanchnoptosia other stigmata as 
 exopthalmic goiter, myxoedema, neurosis, defective physical form, Stiller's 
 floating rib. It begins in disordered function — pathologic physiology — and 
 structure of the tractus respiratorius. Man must be considered to possess 
 respiratory muscles in whatever location the spinal nerves supply the 
 thoracic and abdominal wall. The intercostal (thoracic) and lumbar 
 (abdominal) nerves are not sharply separated in function. Man's muscular 
 trunk is a respiratory apparatus. The diaphragm is the most important 
 organ in splanchnoptosia. The splanchnoptotic is mainly a neurotic (and 
 hysteria if not present thrives well). Mechanical reposition of organs 
 through therapy applied to the abdominal wall rapidly ameliorates the 
 symptoms and that is the general rational treatment. The symptoms of the 
 splanchnoptotic are chiefly those of neurasthenia with or without local 
 distress or pain. Pain may be experienced anywhere; however, it is chiefly 
 
SPLANCHNOPTOSIA 651 
 
 referred to the smaU of the back. The first impression one receives in study- 
 ing splanchnoptosia is a picture of multiplicity, kaleidoscope, dissimilars. 
 However, with continued investigation the dislocated organs present them- 
 selves in groups and types. In splanchnoptosia the viscera of the thorax, 
 abdomen and pelvis share proportionally in the disease. 
 
 GENERAL CONCLUSION AS REGARDS SPLANCHNOPTOSIA. 
 
 Splanchnoptotic (dislocated) organs are accompanied by more or less 
 change of form and consequently function. No dislocation in the form of an 
 organ occurs without dislocation and change of form and relaxation of neigh- 
 boring organs. In splanchnoptosia the change of form of organs is not due 
 merely to the pressure of opposing adjacent organs or the abdominal wall 
 (muscle or skeleton) but the change of organ form is due to function or to 
 physiology it is due to the physiologic necessity of visceral motion rhythm. 
 Practically no organ becomes dislocated without co-existing relaxation of the 
 abdominal wall. The dislocation of single organs does not occur without 
 changing the relations of adjacent organs. 
 
 Pathologic Physiology. 
 
 In the rise and progress of splanchnoptosia two matters should be held 
 in view, viz. : (a) pathologic physiology, and (b) mechanical pathology. 
 Pathologic physiology is disordered function which is abnormal innumerable 
 times before the pathologic anatomy is perceptible. It is true organs have 
 a wide range of normal physiology but in splanchnoptosia the organs have 
 progressed beyond the normal physiologic range and have entered the 
 range of pathologic physiology. In splanchnoptosia the pathologic anatomy 
 is difficult to detect, judge and estimate. However, it is plainly evident that 
 the physiology of the organs and enclosing walls is pathologic because the 
 functions are going wrong and it is the office of rational treatment to correct 
 the erroneous physiology. A large field of the pathologic physiology in 
 splanchnoptosia is mainly mechanic — it is visceral and parietal dislocation — 
 hence mechanical pathology will demand the chief consideration in the sub- 
 ject. First, in splanchnoptosia by appropriate stimulation {visceral d)-ainagc) 
 of the organs affected with the sluggish, pathologic physiology to normal 
 maximum action, tolerant, normal physiology is restored. Second by the 
 mechanic measure applied to the abdominal and thoracic walls the 
 mechanical pathology is rationally removed. 
 
 In splanchnoptosia the linea alba may be elongated and expanded, 
 stretched to a thin blade. 
 
 In splanchnoptosia the organs should be first palpated in the horizontal 
 or prone position and the outline marked with colored chalk, later in the 
 erect position whence the difference in location of the viscera is plainly 
 evident during the horizontal and erect attitude. The percussion should be 
 executed both in the standing and lying position and in each case the organs 
 outlined with colored chalk. 
 
 Umbilicus. A test of splanchnoptosia is the change of position of the 
 umbilicus on coughing while standing and while lying. With pendulus 
 
652 THE ABDOMINAL AND PELVIC BRAIN 
 
 abdomen the umbilicus moves proximalward while standing and coughing 
 but not while reclining. The amount of proximalward movement of the 
 umbilicus is an index to the degree of splanchnoptosia. If the proximal half 
 of the rectus abdominalis be relaxed the umbilicus moves distalward. In 
 coughing while in the most erect attitude, the proximal half of the rectus is 
 contracted and hence the umbilicus moves proximalward. To make a 
 diagnosis of splanchnoptosia the patient's clothing should be removed from 
 the trunk. 
 
 The symptoms of splanchnoptosia may be grouped into three phases, 
 viz. : (a) the prodromal phase in which arises neurasthenia, hysteria hypo- 
 chondria. They are subjective symptoms. Visceral dislocation and relaxed 
 parietes may be insufficiently advanced to diagnose. However, in this first 
 stage the viscera becomes dislocated and the parietes become relaxed, the 
 intra-abdominal pressure becomes reduced. In this phase the circulation 
 (lymph and blood) begins to be compromised, as well as visceral channels; 
 secretions are diminished and toxic absorption becomes evident. 
 
 (b) The second stage of splanchnoptosia is characterized by dyspepsia, 
 constipation, colic, headache, dizziness, insomnia, weakness, loss of flesh, 
 marked visceral dislocation and relaxation of muscular parietes. Anaemia, 
 tympany and foecal stagnation exist. Lack of intra-abdominal pressure is 
 marked. The visceral ligaments are elongated. 
 
 (c) The third stage of splanchnoptotic symptoms are characterized by 
 multiple, many sided subjective symptoms. The clinical picture is pro- 
 nounced, body weight diminishes, capacity for nourishment is at a minimum, 
 muscular weakness is at a maximum with scarcely sufficient capacity of forc- 
 ing stool through the rectum. Functional anuna and psychical changes may 
 exist. Sensation is blunted. Glandular secretions, absorptions and visceral 
 peristalsis are extremely deranged. Symptoms become manifold, and the 
 patient is a pathologic picture. 
 
 The treatment of splanchnoptosia is: 
 
 I. Medical (hygienic regulation of visceral function, diet, habitat, avoca- 
 tion). 
 
 The medical treatment for splanchnoptosia is by means of ample visceral 
 drainage of the tractus intestinalis and tractus urinarius which increases the 
 volume of fluid in the lumen of the tractus vascularis and tractus lymphaticus, 
 effectually sewering, draining the body of waste laden material. It is 
 visceral drainage, appropriate food, ample rest. 
 
 II. Mechanical (forcible reposition and maintenance of viscera in their 
 normal physiologic position — i. e., on their visceral shelves and in their 
 visceral fossae). j 
 
 The mechanical treatment consists in the employment of abdominal 
 binders, especially Achilles Rose adhesive strapping (being rational, econom- 
 ical and practical). The straps do not slip. Also the author's abdominal 
 binder within which is placed a pneumatic rubber pad which can be distended 
 with air to suit the patient's comfort. The splanchnoptotic must make the 
 best of his hereditary burden and assume as much (horizontal) rest as 
 possible. 
 
SPLANCHNOPTOSIA G53 
 
 777. Surgical (superposition of the abdominal wall, viscero-pexy anas- 
 tomosis.) 
 
 The surgical treatment consists of: (a) viscero-pexy, i.e., fixation of 
 mobile viscus to the abdominal wall (extremely limited, as it attempts to cure 
 one alleged visceral lesion — excessive mobility — by producing another — 
 visceral fixation). (b) Diminishing the abdominal cavity and forcing the 
 mobile organs on their visceral shelves and visceral fossae by superposition 
 (overlapping) the elastic, fascio-muscular apparatus of the abdominal wall 
 like a double breasted coat (rational, practical), (c), Anastomosis as gastro- 
 enterostomy. 
 
 Some of the photographs in this chapter were executed by Dr. William 
 E. Holland, from my wall charts. 
 
 A PARTIAL BIBLIOGRAPHY OF SPLANCHNOPTOSIA 
 
 Rudolph Virchow — Virchow's Archiv., vol. V, 1853. An historical, critical and exact con- 
 sideration of the affections of the abdominal cavity. 
 Aberle, Rallet, Rayer, J. B. Morgazni, Kusmaul, Bayer, Hertzka, Lindner. 
 Fischer-Benyon, Becker and Lenhoff, Frickhinger, Kuttner, Strauss, Chvostek, Memert, 
 
 Kelling, Huber, Flemer, Hufschmidt, Ewald, Bruggemann, B. Stiller, Bial, Obvortzow, 
 
 Boaz, Ostertag. 
 Frantz Glenard — Articles from 1885 to 1906. Book on splanchnoptosia (875 pages) published 
 
 in 18 
 Theodore Landau — Wander Nieve, 1881. 
 Theodore Landau — Wander Leber, 1887. 
 C. Schwerdt — Beitrag (splanchnoptosia), 1807. 
 J. G. Sheldon — Is Nephroptosis Hereditary? 1903. 
 
 Byron Robinson — Gastro-duodenal Dilatation, Cincin-Lancet-Clinic, Dec. 8, 1900. 
 A. W. Lea — Enteroptosis, Medical Chronicle, 1902. 
 Saunby— British Med. Jr., Nov. 29, 1902. 
 Beyea— Pennsyl. Med. Jr., Nov., 1902. 
 
 Charles Adron — Splanchnoptosia in Pregnancv, Am. Jr. Surg, and Gvnecol., July, 1902. 
 A. P. Francine— Gastroptosis, Philadel. Med. Jr., Jan. 3, 1903. 
 J. D. Steele — Analyses of 70 cases of gastroptosis, Am. Jr. Med. Assn., Nov. 8, 1902, also 
 
 Jan. 25, 1902. 
 R. C. Coffey — A method of suspending the stomach, Philadel. Med. Jr., Oct. 11, 1902. 
 Earnest Gellant — The Rational Treatment of movable kidney and associated ptosis, Am. Jr. 
 
 Surg, and Gvnecol., Dec, 1902, N. Y. Med. Jr., April 29, 1905. 
 Robert J. Reed— Movable Kidney, Philadel. Med. Jr., Nov. 8, 1902. 
 L. Schoeler — Movable Kidney, Virg. Semi-Med. Monthly, April 14, 1899. 
 J. E. Moore — Splanchnoptosis from a surgical standpoint, Jr. Am. Med. Assn., July 29, 1905. 
 O. Kraus — Emfluss des Korsetts, 1904. 
 
 H. Quincke — Enteroptose, Therapic de Gegenwart, XLIV, page 538. 
 H. A. McCullum— British Med. Jr., Feb. 18, 1905. 
 
 Thomas R. Brown — Enteroptosis, American Medicine, July and August, 1903. Three articles. 
 C. A. Meltzurg — Enteroptose und Intra-abdominales, Druck, 1898. 
 Byron Robinson— Splanchnoptosia, Philadel. Med. Jr.. Nov. 30, Dec. 7, 1901. 
 J. M. Taylor — The Rational Treatment of visceral ptosis, N. Y. Med. Jr., Aug. 4, 1906. 
 J. N. Le Conte— Gastroptosis, N. Y. Med. Jr., July 25, 1903. 
 Arthur Keith — Hunterian Lectures, Lancet, March 7, 1903. 
 L. Krez — Frage der Enteroptose, 1892. 
 
 H. Goelet — Annals of Gynecology and Pediatry, vol. XV, 1903. 
 M. L. Harris— Movable Kidney, Jr. Am. Med. Assn., June 1, 1901, Feb. 13, 1904. 
 C. A. Meltzurg— Gastroptose, Wiener Med. Presse, Julv 28, Aug. 4, Aug. 11, Aug. 18, Aug. 25, 
 
 1895. 
 J. Chalmers Da Costa — Xephroptosia, N. Y. Med. Jr., Aug. 4, 1906. 
 Agness C. Vietor — Splanchnoptosia, Boston Med. and Surg. Jr., Aug. 9, Sept. 9, 1906. 
 Achilles Rose and R. C. Kemp — Atonia Gastrica (Book), 1906. 
 R. Weissmann — Leber Enteroptose, Monograph. 
 
CHAPTER XL. 
 
 SYMPATHETIC RELATION OF THE GENITALIA TO THE 
 OLFACTORY ORGANS. 
 
 One's rainbow of desires changes color with the passing years. 
 
 It is when you come close to a man in conversation that you discover what his 
 real abilities are. — Samuel Johnson. 
 
 It is a curious fact that even laymen have for ages noted that the organ 
 of smell is closely related to the generative organs, but it is very recently 
 that specialists (gynecologists and rhinologists) are putting together the con- 
 nected story. The relation of the olfactory organ and nasal mucous mem- 
 brane with the genitals are by way of the sympathetic. The anatomic path 
 of travel from the nasal mucous membrane to the genitals is through the fifth 
 cranial nerve, or trigeminus, which is supremely the ganglionic cranial nerve, 
 It is the type of mixed nerves. It has eight ganglia situated on its branches. 
 It also sends a large branch to the mucous membrane of the nose — the nasal 
 nerve. T'us will at once explain its wide influence in reflection or disease, 
 because of lis extensive influence over the caliber of adjacent blood and 
 lymph vessels, and the extensive periphery in the nasal mucosa, allowing 
 opportunity for numerous reflexes. 
 
 Let us examine for a moment the ganglia of the trigeminus (trifacial or 
 fifth cranial nerve — the ganglionic nerve of the brain). A significant statement 
 may precede the short description, by saying that one of the chief offices of 
 a ganglion is to demedullate nerves. 1, We may note the Gasserian ganglion 
 of the fifth cranial nerve, situated in a depression in the apex of the petrous 
 portion of the temporal bone. The ganglion is as large as the end of the 
 little finger. The ganglionic nature of this swelling was perceived by 
 Raimund Balthasar Hirsch, a Vienna anatomist, in 1765, who christened it 
 the "Ganglion Gasserii" in honor of his teacher, Gasserius, who in 1779 was 
 "Privat Docent" in anatomy under Prof. Joseph Jans, in Vienna. Since 
 Du Bois-Remond announced from personal experience that he thought facial 
 neuralgia was due to spasmodic contraction of the blood vessels controlled 
 by the sympathetic, surgeons have attempted to cure facial neuralgia by 
 destruction of Gasser's ganglion. This is at least a recognition of the 
 sympathetic nature of the Gasserian ganglion, and its consequent influence 
 over the caliber of the blood vessels. 
 
 The Gasserian ganglion has close and intimate connection with the 
 sympathetic nerves. The blood vessels alone which are necessary to supply 
 the Gasserian ganglion would produce a close and intimate relation between 
 the sympathetic and trifacial. The trigeminus shows a very intimate and 
 extensive connection with the tonsils, the sebaceous glands of the face and 
 
 654 
 
RELATION Of GENITALIA TO OLFACTORY ORGANS 655 
 
 genitals. This is seen at puberty of both boys and girls (facial acne), and 
 in the menopause. The changes in voice of boys at puberty, and the changes 
 of voice of women at the monthly, may be easily worked out anatomically, by 
 dissecting out the connection between the superior cervical ganglion and the 
 pneumogastric and glossopharyngeal. Also the spheno-palatine sends 
 branches to the tonsils in the descending palatine nerves. One may find 
 from three to five branches of nerves passing from the superior cervical gan- 
 glion to the glosso-pharyngeal and pneumogastric nerves. During menstrua- 
 tion the vocal cords are congested and hence the hoarse, husky voice; and a 
 similar but permanent physiological process of congestion and growth 
 occurs in the boy at puberty. Hence the close and intimate relations of the 
 vocal cords (voice) and nasal mucosa (smell) and reflex action with the genitals, 
 have a distinct, concrete, anatomical explanation. Besides, the larynx is 
 supplied by the sympathetic branches which accompany the superior and 
 inferior recurrent laryngeal nerves. 
 
 2. The ophthalmic, lenticular or ciliary ganglion is a pinhead sized gan- 
 glion situated in the orbit. It is closely connected by roots with the nasal 
 branch of the fifth nerve, i. e., has relations with the nasal mucosa, by a 
 sympathetic branch from the cavernous plexus. It is also connected with 
 the third cranial. This second ganglion has intimate connections with the 
 nasal mucosa. Joseph Guiscard Duverny (1648-1730), a French anatomist, 
 discovered this ganglion. 
 
 3. The spheno-palatine, or Meckel's ganglion, situated in the spheno- 
 palatine fossa and on the superior maxillary branch of the trifacial, is a large 
 mass of nerve cells. It is intimately connected with the nasal mucosa by the 
 descending palatine nerves. The spheno-palatine ganglion was discovered 
 and described by Johann Friednch Meckel (1717-1774), a celebrated German 
 anatomist. Like all the other ganglia of the fifth cranial nerve, it possesses 
 motor, sensory and sympathetic roots. It sends a considerable nerve supply 
 to the tonsils. Hence we again observe that this ganglion shares in distribut- 
 ing nerves to the nasal mucosa and the region of the tonsils. But the premise 
 of our argument is that the fifth nerve, being studded by eight sympatheic 
 ganglia, is intimately and closely connected, anatomically and functionally, 
 with the genitals. Therefore what affects the fifth nerve will affect the geni- 
 tals, and vice versa. 
 
 4. The optic or Arnold's ganglion is located just below the foramen ovale, 
 on the inferior maxillary branch of the trifacial. Its sympathetic branches 
 are derived from the sympathetic plexuses which surround the adjacent mid- 
 dle meningeal artery. It is connected with the facial and glosso-pharyngeal 
 nerves and sends branches to the tensor palati. In our library may be seen 
 Friednch Arnold's "Anatomie des Menschen," 3 vols. On page 909, Vol. II, 
 Arnold says, "Der Ohrknoten wurde von mir im Winter 1825-26 endeckt. " 
 In English, "'The optic ganglion was discovered by me in the winter of 1825- 
 26." Professor Arnold noted 75 years ago that many tried in vain to show 
 that others than himself discovered the ganglion. This ganglion shows con- 
 nection with the larynx by way of the glosso-pharyngeal and tensor palati ; 
 and, through the Vidian nerve and Meckel's ganglion, with the nasal mucosa. 
 
656 
 
 THE ABDOMIXAL AXD PELVIC BRAIX 
 
 5. The submaxillary ganglion is situated on the lingual branch of the 
 inferior branch of the trifacial nerve. Its sympathetic branch is derived 
 from the plexus which surrounds the adjacent facial artery. This ganglion 
 was discovered by Meckel in 1745. It has been named after him— Ganglion 
 Meckelii Minus. The ganglion communicates with the facial or the seventh 
 nerve. 
 
 Fig. 207. Nerves of internal genitals, pelvic brain, dissected under alcohol. 
 
 6. The sublingual or Blandin's ganglion is situated on the branch of 
 nerves going to the sublingual gland. This collection of nerves may be only 
 a plexus or a ganglion. It should have a similar connection with the submax- 
 illary ganglion. Phillippe Frederic Blandin (1793-1849). a French surgeon, 
 first described this ganglion in 1349. 
 
 7. The ganglion of Bockdalek is located at the junction of the middle 
 superior dental nerve with the anterior superior dental nerve. It is not con- 
 stant, and besides, the swelling may not always be a ganglion, i. e., may not 
 
RELATION OF GENITALIA TO OLFACTORY ORGANS 657 
 
 contain nerve-cells. It lies above the upper canine tooth. Its discovery is 
 due to Victor Alexander Bockdalek, Professor of Anatomy in Prague until 
 1869 (papers published in 1866), and Victor Bockdalek, his son, also an anato- 
 mist in Prague. However, it appears to be the father who discovered this 
 ganglion, previous to 1851. 
 
 8. The ganglion of Valentine is situated at the junction of the middle 
 superior dental nerve and posterior superior dental nerve. It is located above 
 the second bicuspid tooth. The ganglion was discovered by Gabriel Gustave 
 Valentine (1810-1883), a German anatomist. All the ganglia of the fifth 
 cranial or trifacial have systematic connections. 
 
 We should have known that the trigeminus is supremely the ganglionic 
 cranial nerve; that it is closely and intimately connected, especially with the 
 genitals by way of the sympathetic tracts; also that the trigeminus is closely 
 and intimately connected, especially with the nasal mucosa, and to a consid- 
 erable extent with the larynx and vocal cords. There are found to be num- 
 erous and intimate connections between the fifth cranial nerve (the trigeminus) 
 and the seventh cranial nerve (the facial). Observation shows the intimate 
 relation is accomplished by means of the sympathetic nerves, especially the 
 ganglia on the trifacial. This physiologic relation of the genitals to the tri- 
 facial and facial nerves may be plainly observed in the sexual relations and 
 cohabitations of animals. 
 
 Irritation of the nasal mucosa will cause congestion and erection. 
 Occasionally irritation of the genitals will cause congestion of the face or the 
 region of the trigeminus. Urethral irritation will induce "gritting" of the 
 teeth, i. e., action of the masseter muscles, supplied by the inferior branch 
 of the fifth. 
 
 Dr. A. G. Hobbs describes two cases of severe priapism, accompanying 
 acute rhinitis (Jour. Am. Med. Assn., 1897). On spraying the nasal mucosa 
 with cocaine the priapism immediately subsided. Opium affected the 
 priapism in each case, but only to slight degree. 
 
 A reflex sneeze is not infrequent previous to erection. In preparations 
 for coition the involvement of the nasal mucosa is quite apparent in animals, 
 as the horse, dog, bull, etc. In monkeys the nasal mucosa is not only 
 involved in coition, but it is evident that the larynx is highly involved, from 
 the active and vigorous chattering, emitted previous to and during coition. 
 The mare neighs at the approaching of the stallion or cow bellows at the 
 approach of the bull, the growling of dogs, noise of cats and cackling of hens, 
 are doubtless not accidental at times of coition, but due to irritation of 
 nerve tracts. 
 
 The tissue covering the turbinated bones is quite erectile. A nasal reflex 
 will induce an erectile action in the corpora cavernosa. We know that the 
 genitals are intimately and profoundly supplied by the sympathetic nerves. 
 We know that the fifth nerve is supremely the ganglionic (sympathetic) nerve 
 of the brain. The fifth nerve sends a rich supply to the nasal mucosa and to 
 the larynx through the vagus and glosso-pharyngeal. 
 
 Clinically and anatomically we note a close and intimate relation 
 
 42 
 
658 THE ABDOMINAL AND PELVIC BRAIN 
 
 between the genitals and the nasal mucosa, the larynx and the sebaceous 
 glands of the face. The whole manifestation is due to reflex action carried 
 through the sympathetic nerves. The frequent hemorrhages from the 
 nose during and subsequent to puberty in both sexes, demonstrate the inti- 
 mate relation of the nasal mucosa. Again, why is it that so many women we 
 note with chronic uterine disease also have rhinitis in different forms? A 
 typical example came to my office a few days ago. She was 24 years old and 
 single. At 20 she began to be irregular in menstrual function, and to have 
 menorrhagia. Digital examination revealed quite a large, hypertrophic, 
 metritic uterus, fixed by old adhesions, with distinct retroflexion. She said 
 she bled frequently at the nose. The tissues covering the turbinated bones 
 were thickened, inflamed and congested. Chronic rhinitis and metritis co- 
 existed. 
 
 Many diseased generative organs co-exist with diseased nasal mucosa. 
 The eight ganglia on the fifth cranial nerve — (1) Ganglion Gasser; (2) 
 Ophthalmic; (3) Spheno-palatine; (4) Optic; (5) Submaxillary; (6) Sublin- 
 gual; (7) Bockdalek; (8) Valentine — not only show the sympathetic nature 
 of the fifth cranial nerve, but also intimate relation with the nasal mucosa, 
 larynx, abdominal brain, and especially with the genitals. 
 
 NASAL DYSMENORRHEA. 
 
 The relationship between the nasal mucous membrane and the sexual 
 apparatus is often forgotten. One should always remember that there is 
 always a woman behind the uterus. In cases of persistent dysmenorrhea 
 relief may sometimes be afforded by painting the genital spots in the nose 
 with 1 per cent solution of cocaine, as demonstrated by Schift, Emil Ries, 
 Fliess and others. During menstruation there is congestion of the Schneid- 
 erian membrane not present during the rest of the month; a congestion which 
 may also be produced by violent sexual excitement — the popular expression 
 "bride's cold" being a laity recognition of the relation between the nose and 
 the sexual sphere. In most people there is a temporary swelling of the nasal 
 mucous membrane just preceding and during the sexual act, disappearing 
 with detumescence. 
 
INDEX 
 
 Suhject Page 
 
 Anesthesia 297 
 
 Angina Pectoris 313 
 
 Appendicitis 414 
 
 Brain, Abdominal 
 
 02, 112, 195, 225, 287, 300, 318 
 
 Anatomy 112, 123 
 
 Afferent 112 
 
 Efferent 114 
 
 Holotopy 54, 131 
 
 Idiotopy 54, 115, 133 
 
 Position 114 
 
 Skelotopy 54, 114, 131 
 
 Syntopy 54, 114, 131 
 
 Ganglia 118 
 
 Diaphragmatic ..." 118 
 
 Splanchnica 118 
 
 Renalia 118 
 
 Borders 116 
 
 Dimensions 115 
 
 Form 115 
 
 Surfaces 116 
 
 Relations 122 
 
 Genitalis 123 
 
 Intestinalis 123 
 
 Urinarius 123 
 
 Physiology 123, 129, 163, 287 
 
 Circulation 163 
 
 Nutrition 163 
 
 Reproduction 163 
 
 Secretion 163 
 
 Visceral Automatic Ganglia 163 
 
 Brain, Cranial 63, 159, 121 
 
 Brain, Pelvic 131-152 
 
 Anatomy and Topography 131, 152 
 
 Arrangement 135 
 
 Borders 134 
 
 Dimensions 133 
 
 Fenestra 136 
 
 Form 134 
 
 Ganglia 138 
 
 Ganglionic Cells 138 
 
 Holotopy 131 
 
 Idiotopy 133 
 
 Position 131 
 
 Skeletopy 131 
 
 Syntopy 131 
 
 Physiology 144-156 
 
 Age Relation 150 
 
 Climacterium 150, 154 
 
 Digestive Disturbances 175, 186 
 
 Gestation 150, 155 
 
 Menstruation 150, 155 
 
 Pathological Remarks 151 
 
 Pubertas 150, 155 
 
 Pueritas 150, 155 
 
 Subject p AGB 
 
 Brain, Pelvic — 
 Physiology — 
 
 Senescence 150-155 
 
 General Considerations 159, 180 
 
 Rhythm 169 
 
 Bowel Atomy 325 
 
 Calculus Hepatic 314 
 
 Cholecystitis 452 
 
 Colonic Appendicitis 414 
 
 Colic Lead 306 
 
 Constipation 351-377 
 
 Age Relation 354 
 
 Anatomy ;j,5 1 
 
 Causes 35 1 
 
 Diagnosis 869 
 
 Dietetic 353 
 
 Etiology 351 
 
 Fluids 375 
 
 Foods 377 
 
 Mechanical 353 
 
 Physiology 351 
 
 Pathology 353 
 
 Treatment 370 
 
 Sex 354 
 
 Visceral Circulation 367 
 
 Visceral Drainage 375 
 
 Fluids 375 
 
 Foods 375 
 
 Digestive Tract Disturbances 175 
 
 Diabetes Mellitus 314, 315 
 
 Diabetes Insipidus 316 
 
 Enteralgia 304 
 
 Entorodynia 304 
 
 Enteromic Appendicitis. 414 
 
 Enteroptosia 268, 270 
 
 Exopthalmic Goiter 19, 20 
 
 Gastralgia 304, 311 
 
 Gastrodinia 304, 311 
 
 Glycouria 315 
 
 Ganglia 79 
 
 Aortic Visceral 108 
 
 Automatic Visceral 239, 277 
 
 Arteriae Phrenic 120 
 
 Automatic Menstrual 240, 252 
 
 Cervical 312 
 
 Diaphragmatic 118 
 
 Lumbalis 79 
 
 Oviductal 246 
 
 Renalis 118 
 
 Sacralis 80 
 
 Semilunar, Left 118 
 
 Right 120 
 
 Sympathetic 289, 31S 
 
 Physiology 289 
 
 Visceral, Abdominal and Pelvic 
 Brain, Physiology 204 
 
 659 
 
660 
 
 INDEX 
 
 Subject Page 
 
 Ganglia — 
 
 Visceral, Automatic, Abdominal and 
 Pelvic Brain, Reference to Sexual 
 
 Organs 227 
 
 Genitalis, Tractus, Pathologic Physiol- 
 ogy 432-437 
 
 Avocation 447 
 
 Blood Volume 441 
 
 Diagnosis 440 
 
 Prophylaxis 447 
 
 Visceral Drainage. 
 
 Habitat 447 
 
 Fluids 445 
 
 Foods 446, 459 
 
 Douches 472 
 
 Fluids. 472 
 
 Gestation 468 
 
 Habitat 477 
 
 Menstruation 465 
 
 Ovulation 461 
 
 Peristalsis 461 
 
 Secretion 463 
 
 Sensation 465 
 
 Tampon 474 
 
 Treatment 47, 480 
 
 Gentalia, Female 304. 341, 346, 347 
 
 Traumatic 346 
 
 Ovarian Tumor Weight 346 
 
 Pressure Neurosis 347 
 
 Olfactory Organs 654-658 
 
 Nasal Dysmenorrhcea 658 
 
 Neurosis 341-350 
 
 Puberty . 253, 259, 342 
 
 Menstruation 343 
 
 Pregnancy 342 
 
 Menopause 200, 253 
 
 Tumors 208, 221, 356. 396, 423 
 
 Infection 208 
 
 Cicatrices 208 
 
 Sexual Crisis 227, 342 
 
 Abdominal and Pelvic Brain with 
 Automatic Visceral Ganglia. .227, 239 
 
 Genitalis, Tractus 87 
 
 Anatomy 87 
 
 Interiliacus Plexus 92 
 
 Ovaricus Plexus 90 
 
 Pelvic , 94 
 
 Rectalis 96 
 
 Sacralis Spinalis 92 
 
 Uterinus, Plexus 94 
 
 Vaginalis, Plexus • 96 
 
 Vesicalis, Plexus 96 
 
 Physiology 98 
 
 Peristalsis 100 
 
 ' Rhythm 100 
 
 Gynecological 294 
 
 Hyperesthesia 296, 317 
 
 Abdominal Brain 302 
 
 Cardiac Plexus 312 
 
 Cervical Ganglia 312 
 
 Diaphragmatic Plexus 317 
 
 Gastric Plexus 311 
 
 Hepatic Plexus 314 
 
 Hypogastric Plexus 308 
 
 Inferior Mesentric 309 
 
 Mucosa 297 
 
 Mesenteric 304 
 
 Ovarian 310 
 
 Subject Page 
 
 H yperesthesia — 
 
 Pancreatic Plexus 316 
 
 Pelvic Brain 309 
 
 Renal 316 
 
 Splenic Plexus 313 
 
 Spermatic. 310, 319 
 
 Sympathetic 302 
 
 Skin 296 
 
 Secretions 32'J, 333 
 
 Auerbach's Plexus 329 
 
 Billroth-Meissner 329 
 
 Excessive 329 
 
 Deficient 331 
 
 Disproportionate 331 
 
 Gastric 331 
 
 Glands 331 
 
 Muscular Motion 33 1 
 
 Nose 331 
 
 Treatment 331 
 
 Hysteria Stigmata 284, 296,325 
 
 Cutaneous 300 
 
 Head 300 
 
 Lumbosacral 300 
 
 Muscular 300- 
 
 Muscular Stigma 298 
 
 Neurosis 343 
 
 Pain 300 
 
 Peritoneal 300 
 
 Pyschosis 298, 343, 344 
 
 Special Senses 298 
 
 Stomach 300 
 
 Treatment 300 
 
 Stigma 284, 296 
 
 Heberden's Disease 312 
 
 Hyperesthesia 296 
 
 Hysteria 325 
 
 Icterus 452 
 
 Invagination 410 
 
 Intestinalis, Tractus, Physiological 
 
 Pathological 448 
 
 Nervosis 456 
 
 Pathologic 448 
 
 Peristalsis : 448 
 
 Intestinalis 62 
 
 Anatomy 62 
 
 Arteria Hepatical 65 
 
 Cceliacus 62 
 
 Ductus Bilus 65 
 
 Gastricus 62, 64 
 
 Hemorrhoidal Plexus. 
 
 Medius 70 
 
 Inferior 70 
 
 Hepaticus 64, 65 
 
 Mesenterica Superior Plexus 67 
 
 Physiology. 
 
 Distal End Supply 74 
 
 Middle 73 
 
 Proximal 72 
 
 Lymphatic Tract 514, 545 
 
 Absorption 516 
 
 Genital ■ 123 
 
 Intestinal 123 
 
 Peristalsis 516 
 
 Secretion 516 
 
 Sensation 516 
 
 Treatment 533 
 
 Urinarius 1 23 
 
 Melancholia 325 
 
INDEX 
 
 661 
 
 Subject 1 
 
 Menopause 253, 259, 280, 314, 
 
 Flushes 
 
 Flashes 
 
 Malnutrition 
 
 Reflex Irritation 
 
 Sweat Centers 
 
 Uterine Disturbances 
 
 Menstruation 
 
 Automatic Menstrual Ganglia 
 
 Neurosis 
 
 Psychosis 343, 
 
 Premenstrual Pain 
 
 Nerves 
 
 Anatomy 
 
 Cerebral 278 
 
 Cerebrospinal Relation 
 
 Genital External 
 
 Pelvic 
 
 Peritoneum 
 
 Spinal 278- 
 
 Splanchnic 42 
 
 Sympathetic, Independence of . . . . 
 Sympathetic. .187, 287, 292, 294, 
 
 Trigeminus 
 
 Vagus , 
 
 Vasomotor 
 
 Visceral Sympathetic 278, 
 
 Pathological 
 
 Neuralgia 307 
 
 Cardiac 
 
 Celica 
 
 Diaphragmatic 
 
 Gastric 
 
 Hypogastric 
 
 Hemorrhoidal 
 
 Mesenteric 304, 
 
 Ovarian 
 
 Renal 
 
 Splenic 
 
 Urethral 
 
 Nerves Vascularis 103- 
 
 Anatomy 103 
 
 Aortic Visceral Ganglia, 108 
 
 Physiology 106- 
 
 Nerves. 
 
 Genital 
 
 Pelvic 
 
 Peritoneum 
 
 Cerebral. 298, 
 
 Neurasthenia 
 
 (Neurosis Abdominalis) 495 
 
 Absorption 
 
 Asthenia 
 
 Congenita 
 
 Degeneracy Habitus 
 
 Heredity 
 
 Predisposition 
 
 Secretion 
 
 Sensation 
 
 Stigma ' 
 
 Treatment 
 
 Neurosis 267 
 
 Enteralgia 
 
 Gastralgia 
 
 Hepatis 
 
 Hysteria 
 
 Melancholia 
 
 Neurasthenia 
 
 'age 
 
 342 
 
 256 
 256 
 259 
 259 
 256 
 312 
 343 
 240 
 343 
 344 
 248 
 342 
 290 
 302 
 278 
 286 
 278 
 288 
 302 
 , 43 
 187 
 304 
 342 
 342 
 205 
 302 
 281 
 •317 
 312 
 302 
 317 
 311 
 302 
 309 
 309 
 310 
 316 
 314 
 310 
 ■110 
 -106 
 -110 
 -110 
 
 286 
 278 
 .288 
 302 
 .325 
 -501 
 495 
 496 
 497 
 497 
 .497 
 .498 
 .498 
 .498 
 .499 
 .500 
 -277 
 304 
 .304 
 .276 
 .284 
 325 
 325 
 
 Subject Pace 
 
 Neurosis — 
 
 Oviductal 277 
 
 Peristalsis 277 
 
 Rectalis 277 
 
 Renalis 277 
 
 Uterine 277 
 
 Visceral 267 
 
 Neuroses, Colon Secretion 334 
 
 Age 335 
 
 Catarrh 337 
 
 Chemical 336 
 
 Colicky Pains 384 
 
 Microscopical Examinations 336 
 
 Motor Neuroses 337 
 
 Mucous Colic 337 
 
 Mucous Stools 334 
 
 Menstrual 343 
 
 Nervous 337 
 
 Pathology 336 
 
 Treatment 339 
 
 Neuroses, Motor 318 
 
 Anemia 322 
 
 Abdominal Brain 318 
 
 Atomy of Bowels 325 
 
 Auerbach's Plexus 318 
 
 Bilbroth-Meissner's Plexus 318 
 
 Cranial Nerves 318 
 
 Colon 334 
 
 Enterospasm 324 
 
 Intestinal Movements 318 
 
 Invagination 328 
 
 Hysteria 284, 296, 325 
 
 Melancholia 325 
 
 Paralysis 325 
 
 Sympathetic Ganglia 318 
 
 Spinal Nerves 318 
 
 Sympathetic System 318 
 
 Nervosus, Tractus 495-501 
 
 Physiological Pathological. 
 
 Abdominalis 495 
 
 Absorption 496 
 
 Secretion 498 
 
 Sensation 499 
 
 Treatment 500 
 
 Neuroma 405 
 
 Nephralgia 316 
 
 Neurasthenia 325 
 
 Obstructions 406, 414 
 
 Apertures 406 
 
 Appendicitis 414 
 
 Bands 406 
 
 Colonic 414 
 
 Enteronic 414 
 
 Invagination 410 
 
 Pancreatic Secretions 452 
 
 Strangulation 406 
 
 Volvulus 412 
 
 Pains 393 
 
 Abdominal 393 
 
 Abdominal, Sudden 393, 441 
 
 Age 396 
 
 Appendicular 400 
 
 Character 397 
 
 Gastric 399 
 
 Nephritic 399 
 
 Pelvic 400 
 
 Sex 396 
 
 Reflex 402 
 
662 
 
 INDEX 
 
 Subject Page 
 
 Pains — 
 Reflex — 
 
 Abscess in Abdominal Wall 404 
 
 Amygdalitis Mastitis 404 
 
 Appenditis 414 
 
 Axial Torsion of Viscera 424 
 
 Complete 424 
 
 Incomplete 424 
 
 Biliary Channels 418 
 
 Embolism with Mesenteric Vessels, 419 
 
 Genitals. . . . 422 
 
 Hyperesthesia 404 
 
 Intoxication 421 
 
 Invagination 410 
 
 Mesenteric Vessels Embolus 419 
 
 Muscular Rigidity 410 
 
 Neurasthenia 325 
 
 Pancreatic Hemorrhage, Acute.. . .418 
 
 Pyosalpinx 422 
 
 Pleurisy 402 
 
 Spinal Caries 404 
 
 Spinal Cord and Hysteria 404 
 
 Strangulation by Bands through 
 
 Apertures 419 
 
 Strangulation 406 
 
 Testicular 404 
 
 Paralysis 325 
 
 Direct 325 
 
 Indirect 325 
 
 Pathologic 322 
 
 Peristalsis 322, 326 
 
 Normal 322 
 
 Deficient 324 
 
 Increased 326 
 
 Pendulum 319 
 
 Rhythmic 318 
 
 Roll Motion 319 
 
 Spinal 318 
 
 Sympathetic System 318 
 
 Sympathetic Lateral Chain 318 
 
 Tonic Contractions 322 
 
 Plexus Aorticus Abdominalis 46, 51 
 
 Anatomy 46, 49, 76, 78, 98 
 
 Ganglia 46, 48 
 
 Nerve Trunks and Cords 48, 49 
 
 Physiology 49, 51, 71, 76 
 
 Age Relation 59 
 
 Interiliac Vasomotor 52 
 
 Interiliacus Truncus Plexus 56 
 
 Interiliacus, Distal End 58, 92 
 
 Utility in Practice 60 
 
 Arteria Uterinae 80 
 
 Cceliacus 62, 64 
 
 Communis Arterie 80 
 
 Gastricus 63, 64 
 
 Genital 87 
 
 Ganglia Lumbales 79 
 
 Hemorrhoidal 70 
 
 Medium 70 
 
 Inferior 70 
 
 Hypaticus 62, 64, 65 
 
 Hypogastricus 80, 308 
 
 Iliacus Communis Arteriae 82, 92 
 
 Lienalis 62, 68 
 
 Mysentericus 69 
 
 Inferior 69, 80 
 
 Superior 67 
 
 Ovaricus 78, 90, 310 
 
 Subject Page 
 
 Plexus Aorticus Abdominalis — 
 Physiology — 
 
 Pelvic Brain 94 
 
 Rectalis 96 
 
 Renalis 76 
 
 Sacralis Spinalis 92 
 
 Sacralis 81 
 
 Supra Renalis 76 
 
 Ureteris 78 
 
 Urethralis 81 
 
 Uterinus 94 
 
 Vaginal 96 
 
 Vesicalis 96 
 
 Pathological 546-549 
 
 Pathogenesis 552 
 
 Polyuria 316 
 
 Pregnancv 342 
 
 Psvcosis.'. 342, 344 
 
 Puberty 253, 259, 342 
 
 Respiratorious 548, 569, 648 
 
 Sexual Crisis 342 
 
 Shock 382-392 
 
 Diagnosis 388 
 
 Etiology 384 
 
 Historv 382 
 
 Pathology 386 
 
 Prevention 391 
 
 Prognosis 389 
 
 Symptoms 387 
 
 Treatment 390 
 
 Spinal Segment 567 
 
 Strangulation 406 
 
 Splanchnoptosia (Atonia Gastrica) 546-653 
 
 Adhesions 556-574 
 
 Mesocolic 574 
 
 Mesoduodenal 573 
 
 Mesogastric 573 
 
 Mesenteronic 574 
 
 Omental 556 
 
 Peritoneal 556 
 
 Bibliography 653 
 
 Physiology and Anatomy. . . 553, 559 
 
 Circulation 626 
 
 Colon, Right . .574 
 
 Diaphragm 565, 566 
 
 Factors 555 
 
 Etiological 555 
 
 Fixation and Motion of Thoracic 
 
 Viscera 568, 569 
 
 Fixation of Intestinal Tract 572 
 
 Mechanism 557 
 
 Radix Mesenterica 570 
 
 Relaxation 561 
 
 Segment, Spinal 567 
 
 Theory, Keith's 554 
 
 Pathological Relations 546 
 
 Clinical 551 
 
 Embryologv 511 
 
 Genitals...' 564, 617, 648 
 
 Historical 548 
 
 Intestinalis 562, 575, 648 
 
 Lymphaticus 648 
 
 Nervosus 630, 631, 648 
 
 Pathogenesis 552 
 
 Respiratorius 548, 569, 648 
 
 Urinarius 564, 594, 648 
 
 Vascularis 648 
 
 Coloptosia 590, 591 
 
INDEX 
 
 663 
 
 Subject Page 
 
 Splanchnoptosia (Atonia Gastrica) — 
 Coloptosia — 
 
 Symptoms 591 
 
 Treatment 592 
 
 Fnteroptosia 593 
 
 Fixation 017 
 
 Flexure Coli Hepatica 623 
 
 Flexure Coli Lienalis 624 
 
 Castroptosia 576 
 
 Dilitation 582 
 
 Diagnosis 583 
 
 Etiology 580 
 
 Respiration 577 
 
 Treatment 584 
 
 Gastro-Duodenal Dilatation 004 
 
 Diagnosis 611 
 
 Treatment 612, 617 
 
 Genitals 504, 017. 619, 648 
 
 Fixation 617 
 
 Respiration 618 
 
 Hepatoptosia 268, 274, 586 
 
 Diagnosis 588 
 
 Etiology 587 
 
 Frequency 587 
 
 Fixation of Liver 586 
 
 Movements, Respiratorv 586 
 
 Treatment ' 589 
 
 Nephroptosia o'.)4, 603 
 
 Age 597 
 
 Diagnosis 597 
 
 Etiology 597 
 
 Fi xation 594 
 
 Frequenev 597 
 
 Relation 595 
 
 Respiration 594 
 
 Robinson, Byron, Triangle 602 
 
 Symptoms . . 
 
 Treatment 603 
 
 Neuroses 630, 631, 648 
 
 Frequency 632 
 
 Symptoms . 632 
 
 Treatment 634 
 
 Sympathetic Nerve 
 
 39, 187, 287, 292, 294. 304 
 
 Absorption 187, 188 
 
 Anatomy and Physiologic Anat- 
 omy 33, 38, 192, 203, 290 
 
 Automatic Menstrual Gang- 
 lia 240 : 252 
 
 Cervical 40 
 
 Circulation 187 
 
 Classification of Diseases . . . .28, 32 
 Considerations for Removal of 
 
 Tumors 206. 226 
 
 Dorsal 42 
 
 Growth 187 
 
 Gvnecology 175, 292 
 
 Historical Sketch . 11. 27 
 
 Independence of Sympathetic 
 
 187, 192 
 
 Macroscopic 21, 26 
 
 Microscopic 26, 27 
 
 Nutrition 187 
 
 Pathology in Gynecology 292 
 
 Pelvic 44 
 
 Peristalsis 188 
 
 Subject 1 j agb 
 
 Splanchnoptosia (Atonia Gastricaj — 
 Sympathetic Nerve — 
 Anatomy — 
 
 Physiology of Abdominal and 
 Pelvic Brain with Automat- 
 ic Visceral Ganglia 204, 207 
 
 Relation to Cerebrospinal 278 
 
 Sacral 44, 45 
 
 Secretion 187 
 
 Sensation 188 
 
 Thoracic 42, 43 
 
 Trunks of 39, 45 
 
 Uterine Changes 17.") 
 
 Vasomoter Nerves. 205 
 
 Pathologv, 187, 287, 292, 294, 304 
 
 Tumors 221 
 
 Axial Rotation 
 
 221, 324, 356, 396, 425 
 
 Reflex Action on Sympathetic. . 208, 226 
 
 Kidney 'A\7 
 
 Urinarius 76, 80, 98,123 
 
 Anatomy 76 
 
 Arteria Uterina 80 
 
 Arteria Communis. . 80 
 
 Ganglia Sacrales 80 
 
 Ganglia Lumbales 79 
 
 Hypogastrics 80 
 
 Mesentericus Inf 80 
 
 Mesentericus Sup 80 
 
 Ovaricus (Spermaticus) 78 
 
 Renahs 16, 78 
 
 Renalis Superior 76 
 
 Sacralis 81 
 
 Uretens 78 
 
 Urethrahs 81 
 
 Vesicales 80 
 
 Urinarius, Tractus, Phvsiological Patho- 
 logical ' 479-494 
 
 Absorption 483 
 
 Peristalsis 479 
 
 Secretion 481 
 
 Sensation 485 
 
 Treatment 489 
 
 Uremia 404 
 
 Urinary Colic. . 419 
 
 Vascularis, Tractus 502 
 
 Pathologic Physiology of . . . .502, 513 
 
 Combined Treatment 
 
 Excessive Secretion 506 
 
 Deficient 506 
 
 Disproportionate . 506 
 
 Peristalsis 503 
 
 Excessive 503 
 
 Deficient 503 
 
 Disproportionate 503 
 
 Vascular Tract 502 
 
 Visceral Drainage by Fluids 507 
 
 Visceral Drainage by Foods 507 
 
 Pathologic Physiology of the Blood, 509 
 Red Blood Corpuscles and Hem- 
 
 aglobin 509 
 
 Plasma (Liquor Sanguinis) 512 
 
 Pathologic Anatomy 513 
 
 Treatment 512 
 
 White Blood Corpuscles 511 
 
 Vascularis 648 
 
 Volvulus 412 
 
LIST OF ILLUSTRATIONS 
 
 No. ' Page 
 
 1 An Illustration of the Sympathetic Nerve 13 
 
 2 An Illustration of the Abdominal Sympathetic Nerve of the Male 29 
 
 3 A Diagram of Sympathetic from Proximal to Distal End 34 
 
 4 Abdominal Brain, Lumbar Lateral Chain 35 
 
 5 Lumbar and Sacral Portions of the Sympathetic 37 
 
 6 Trunk of the Vasomotor 41 
 
 7 Plexus Aorticus Abdominalis 47 
 
 8 Plexus Aorticus Abdominalis 50 
 
 9 Plexus Interiliacus 53 
 
 10 Plexus Interiliacus of Adult 55 
 
 1 1 The Vasomotor Interiliacus Plexus 57 
 
 12 Plexus Interiliacus of Adult 59 
 
 13 The Nerves of the Tractus Intestinalis 63 
 
 14 Anastomosing Arteries of the Tractus Intestinalis 67 
 
 15 Nerves of the Hepatic Artery and Biliary Duct 69 
 
 16 Arteries of Ccecum and Appendix 71 
 
 17 N-ray of Ductus Pancreaticus and Part of Ductus Bilis 73 
 
 18 Arterial Supply of Tractus Urinarius 77 
 
 19 Nerves of Tractus Urinarius, Corrosion Anatomy 79 
 
 20 Corrosion Anatomy (Hyrtl's Exsanguinated Renal Zone) 81 
 
 21 Nerves of Tractus Urinarius 83 
 
 22 Corrosion Anatomy 84 
 
 23 Relation of Spinal Nerves at Tractus Urinarius 85 
 
 24 Nerves of Tractus Genitalis 89 
 
 25 Nerves of Tractus Genitalis, Pregnant about Three Months. . . 91 
 
 26 Genital Nerves of Infant 93 
 
 27 Genital Nerves of Adult 95 
 
 28 The Nerves of the Tractus Genitalis 97 
 
 29 The Arterial Circulation of the Puerperal Uterus 99 
 
 30 Circles, Arcs and Arcades of the Abdominal Arterie- 105 
 
 31 Nerves Accompany the Arteries 107 
 
 32 Nerves of the Blood-vessels 109 
 
 33 Abdominal Brain 113 
 
 34 Abdominal Brain 117 
 
 35 Abdominal Brain 119 
 
 36 Abdominal Brain 121 
 
 37 Abdominal Brain 125 
 
 38 Ganglion Cells in the Abdominal Brain 127 
 
 39 Abdominal Brain of an Infant 132 
 
 40 Pelvic Brain 137 
 
 41 Pelvic Brain of an Adult 143 
 
 42 Pelvic Brain 149 
 
 43 Pelvic Brain 153 
 
 44 Pelvic Brain of an Adult . . 157 
 
 45 Cardiac Nerves 162 
 
 46 Abdominal Brain and Coeliac Axis 166 
 
 47 Pelvic Brain 170 
 
 48 Ductus Bilis and Ductus Pancreaticus 174 
 
 49 Corrosion Anatomy of the Kidney 178 
 
 50 Ductus Pancreaticus with Part of Ductus Bilis 182 
 
 51 Corrosion Anatomy, Uterus, Oviducts and Ovary of New-born Infant 185 
 
 52 Abdominal Brain and Plexus Aorticus 194 
 
 53 Ductus Bilis and Ductus Pancreaticus et Aorta Hepatica 196 
 
 54 Nerves of the Heart 198 
 
 55 Renal Vascular Supply 200 
 
 664 
 
LIST OF ILLUSTRATIONS 665 
 
 No. p ACe 
 
 . r >U Nerves of the Tractus Genitalis 202 
 
 . r )7 Schemic Drawing of the Sympathetic Nerve 209 
 
 58 Pelvic Brain , 243 
 
 59 A Schematic Drawing of the Sympathetic Nerve ' 254 
 
 60 Lumbar and Sacral Portions of the Sympathetic (Sappey) 260 
 
 6 1 Sympathetic Nerve in Lumbar Region 263 
 
 62 Sacral Sympathetic and Sacro-spinal Nerves 273 
 
 63 Cervical Ganglia 275 
 
 64 Cutaneous Nerves of Thorax and Abdomen 281 
 
 65 Ventral Division of Dorsal Nerves 283 
 
 66 Sympathetic, from Life-size Chart Sympathetic 285 
 
 67 Sympathetic, from Life-size Chart Sympathetic 287 
 
 68 Nerves of Non-pregnant Uterus 287 
 
 69 Life-size Chart of Sympathetic 291 
 
 70 Plan of Dorsal Nerve 295 
 
 71 Diagram of Lumbar and Pelvic Plexus 297 
 
 72 Abdominal Brain 299 
 
 73 Corrosion Anatomy of Ductus Bilis 303 
 
 74 Corrosion Anatomy of Kidney 307 
 
 75 X-ray of Ductus Pancreaticus and Part of Ductus Bilis 311 
 
 76 X-ray of Ductus Bilis et Pancreaticus with Arteria Hepatica 315 
 
 77 Nervus Vasomotorius 321 
 
 78 Dilated Ductus Hepaticus , 324 
 
 70 Nerves of the Internal Genitals 326 
 
 80 Ductus Bilis et Ductus Pancreaticus 330 
 
 81 Cross-section of Ureter 332 
 
 82 X-ray of Ductus Bilis et Ductus Pancreaticus 357 
 
 83 X-ray of Ductus Pancreaticus et Ductus Bilis 365 
 
 84 X-ray of Ductus Pancreaticus et Ductus Bilis of Horse 373 
 
 85 Strangulation of the Sigmoid by Band Originating from Bilateral Pyosalpinx 394 
 
 86 Hernia of Eight Feet of Enteron in Fossa Duodeno-Jejunalis 395 
 
 87 Hernia in Fossa Duodeno-Jejunalis 397 
 
 88 Invagination of Ileum 398 
 
 89 Ileo-Coecal Invagination 399 
 
 90 Progressive Steps of Uterine-invagination . . 401 
 
 91 Complete Uterine Invagination 403 
 
 92 Volvulus of Sigmoid 404 
 
 93 Volvulus of Sigmoid i 405 
 
 94 Volvulus of Ileo-Ccecal Apparatus 406 
 
 95 Enteronic Volvulus 407 
 
 96 Volvulus of Ileo-ccecal Apparatus 408 
 
 97 Position of the Appendix 409 
 
 98 Potential Position of Appendix 411 
 
 99 Absence of Appendix (and Coecum) 413 
 
 100 Appendix Lying Adjacent to Meckel's Diverticulum 414 
 
 101 Relation of Appendix to the Genital Tract 415 
 
 102 Nondescended Appendix 417 
 
 103 Biliary Calculus Dislodged from Meckel's Diverticulum 419 
 
 104 X-ray of the Ductus Pancreaticus and Part of Ductus Bilis 421 
 
 105 Specimen Containing Pancreaticus Calculus 423 
 
 106 Hepatic Calculus in Hartman's Pouch (S) and Vater's Papilla 426 
 
 107 Carcinoma Completely Obstructing the Biliary and Pancreatic Ducts 427 
 
 108 Ureteral Calculi 428 
 
 109 Calculus in Ureter 429 
 
 110 The Arteria Uterina Overica Three Hours after Parturition at Term 430 
 
 111 Hyrtl's Exsanguinated Renal Zone 436 
 
 112 Corrosion Anatomy Kidney 440 
 
 113 Hyrtl's Exsanguinated Renal Zone 441 
 
 114 Lymph Glands in Course of Blood Vessels 444 
 
 115 Abdominal Brain and Coeliac Plexus 451 
 
 116 X-ray of Ductus Bilis and Ductus Pancreaticus 454 
 
 117 Duodenum with Its Two Ducts — Biliary and Pancreatic 456 
 
 118 X-ray of Ductus Bilis, Ductus Pancreaticus and Arteria Hepatica 458 
 
 119 Pelvic Brain (adult) 462 
 
 120 Arterial Circulation of the Puerperal Uterus 464 
 
 121 Transverse Longitudinal Section of Uterus 467 
 
 122 Pelvic Brain in Relation to the Nervus Vasomotorius 469 
 
 123 Arteries of Puerperal Uterus 471 
 
 124 Histology of Pelvic Brain 473 
 
666 LIST OF ILLUSTRATIONS 
 
 No. . . Pace 
 
 125 Tractus Vascularis and Tractus Nervosus of the Tractus Genitalis 475 
 
 126 Pelvic Brain 476 
 
 127 Sacro-pubic Hernia 477 
 
 128 Intimate Relation of the Tractus Genitalis and Tractus Urinarius 480 
 
 129 Illustration of the Female Urinary Tract 482 
 
 130 An Illustration of the Abdominal Sympathetic Nerve of the Male, Especially 
 
 Representing the Nerves of the Tractus Urinarius 484 
 
 131 Nerve Supply Tractus Urinarius 486 
 
 132 Nerves of the Tractus Urinarius, Corrosion Anatomy 487 
 
 133 Nervus Vasomotorius of the Tractus Urinarius 488 
 
 134 Corrosion Anatomy (Hyrtl's Exsanguinated Renal Zone) 489 
 
 135 Nervus Vasomotorius in Relation with the Tractus Urinarius 490 
 
 136 Nervus Vasomotorius of the Tractus Urinarius (Congenitally Dislocated) 492 
 
 137 Relation of Plexus Lumbalis to Tractus Urinarius 493 
 
 138 Nerves of the Internal Genitals 499 
 
 139 Lymphatics 505 
 
 140 Ductus Thoracicus Dexter et Sinister 515 
 
 141 Lymphatics of Head and Neck 516 
 
 142 Lymphatics Ensheathing a Vein 517 
 
 143 A Lymphatic Gland with Its Afferent and Efferent Vessels 518 
 
 144 Lymph Vessels of the Tracheal Mucosa 519 
 
 145 Inguinal Glands of Lymphatics 520 
 
 146 Lymphatics of the Internal Genitals 521 
 
 147 Lymph Channels and Glands Draining the Tractus Genitalis (Savage) 522 
 
 148 Lymph Channels Draining Cervix and Vagina (Poirier) 523 
 
 149 Lymph Channel (A. A.) of Pyloric End of Rabbits 524 
 
 150 Transition of Lymph Capillaries into Lymph Trunks with Valves— Sacculations. . 525 
 
 151 Lymph Channels and Glands of the Mesenteron (Hoenir) 526 
 
 152 Lymphatic Drainage of Diaphragm 527 
 
 153 Profile View of the Ductus Thoracicus 528 
 
 154 Lymph Channels in the Peritoneum 528 
 
 155 Lymphatics from Enteron of Guinea Pig with Plexus Myentericus of Auerbach 
 
 (Frey) • 526 
 
 156 Rectal Glands and Lymphatics ^ 
 
 157 Stomata Vera Connecting the Peritoneum with the Subperitoneal Lymph Channels, ool 
 
 158 Lymph Glands with Vasa Efferentia et Afferentia (Toldt) 532 
 
 159 Lymphatics of Axilla and Mamma 533 
 
 160 Ductus Thoracicus Sinister et Dexter (Toldt) ^34 
 
 161 Perivascular Lymphatic (Gegenbauer) 535 
 
 162 Superficial (Smaller) and Deep (Larger) Anastomosing Lymphatics 536 
 
 163 Lymphatics and Glands of the Mesenteron 537 
 
 164 The Inguinal Glands Receiving the Rectal and Genital Lymph Channels (Toldt) . . o'SS 
 
 165 Lymph Glands and Channels Relating to Mamma and Neck (Toldt) 539 
 
 166 Lymphatics of Wall of Enteron of Calf (Injected) 540 
 
 167 Injected Lymphatic Vessels of the Tongue 541 
 
 168 Lymphatics of the Vermiform Appendix 542 
 
 169 Lymph Vessels of Dog's Stomach 543 
 
 170 Splanchnoptotic, a Ventral View 547 
 
 171 Splanchnoptotic, Lateral View 54J 
 
 172 Splanchnoptotic, Abdominal Walls Removed ^50 
 
 173 Abdominal and Thoracic Organs Separated by the Diaphragm 554 
 
 174 Dorsal Fixation and Location of the Mesenteries ^° 
 
 175 Separation and Elongation of the Recti Abdominalis in Splanchnoptosia 560 
 
 176 The Diaphragm (Ventro-distal View) 561 
 
 177 The Diaphragm (Dorsal View) £°3 
 
 178 Proximal View of the Pelvic Floor (Sholer) 564 
 
 179 Distal View of the Pelvic Floor <™> 
 
 180 A Normal Transverse Segment of the Abdominal Wall • • 5b7 
 
 181 A Transverse Section of the Abdomen, about the Umbilicus of a Splanchnoptotic, 568 
 
 182 Viscera of a Female Orang from Borneo 571 
 
 183 Areas of Peritoneum - • 572 
 
 184 Gastro-duodenal Dilatation. Gastroptosia d <7 
 
 185 Carcinoma Completely Obstructing the Biliary and Pancreatic Ducts 579 
 
 186 The Horizontal Stomach, Gastroptosia 580 
 
 187 The Vertical Stomach, Gastroptosia ^81 
 
 188 Gastroptosia <*£ 
 
 189 Splanchnoptosia, The Third Stage 58o 
 
 190 Coloptosia 589 
 
 191 Presents Established Hepatic Dislocation 5 yb 
 
LIST OF ILLUSTRATIONS 667 
 
 No. Page 
 
 192 Presents Advanced Hepatic Dislocation 599 
 
 193 Common Condition Found in Multipara 602 
 
 194 Position of Duodenum and the Superior Mesenteric Artery, Vein and Nerve 604 
 
 195 Relation with Stomach Drawn Proximally 605 
 
 196 Gastro-duodenal Dilatation ." tin; 
 
 197 Profile view of Obstruction 608 
 
 198 Superior Mesenteric Artery, Vein and Nerve Obstructs the Transverse Segment of 
 
 Duodenum as it Crosses the Vertebral Column 610 
 
 199 Gastro-duodenal Dilatation 612 
 
 200 Clamping of Duodenum by the Mesenteric Vessels 613 
 
 201 Gastro-duodenal Dilatation Ending when the Mesenteric Vessels Cross the Trans- 
 
 verse Duodenum til 1 
 
 202 Closure of Musculi Recti Abdominales in a Single Sheath 621 
 
 203 Byron Robinson's Rubber Air Pad for Splanchnoptosia 623 
 
 204 Byron Robinson's Rubber Pad, Profile View 624 
 
 205 Byron Robinson's Rubber Pad, Adjusted 627 
 
 206 Placing of Sutures in Fascia and Muscles of the Abdomen 641 
 
 207 Nerves of Internal Genitals dissected under Alcohol 656 
 
LIST OF NAMES 
 
 A 
 
 Page 
 
 Aberle 548 
 
 Addison 19 
 
 Akermann 17 
 
 Alexander 12 
 
 Allen 515 
 
 Andersch 16 
 
 Andral 276 
 
 Arabians 11 
 
 Aran 19 
 
 Aristotle 11, 12 
 
 Arnold 16, 655 
 
 Aselli 515 
 
 Atkinson 436, 437 
 
 Auerbach 62, 168, 169, 241, 242, 243, 
 
 244, 250, 260, 292, 293, 329, 354, 466, 526, 622 
 Axman 16 
 
 B 
 
 Babler 431 
 
 Bachat 14, 15, 16, 17, 262 
 
 Baker 17 
 
 Ball 17 
 
 Bardel 276 
 
 Barnes 3l>4 
 
 Bartholine 514, 517 
 
 Basch 320, 326 
 
 Basedows 19, 30 
 
 Basel 52 
 
 Battey 343 
 
 Bauhin 320, 355,362 
 
 Baumgarten 353, 374 
 
 Bayly 17 
 
 Beck Snow. .18, 24, 25, 52, 130, 131, 156, 158 
 
 Beclard 14 
 
 Begbie 327 
 
 Bell 19 
 
 Bennett 511 
 
 Bernard 19,38, 130, 187 
 
 Bergan 16 
 
 Beschomer 338 
 
 Beuker 423 
 
 Bichat 14, 15, 16, 17, 511 
 
 Bidder ... .18, 19, 104, 168, 241, 242, 292, 439 
 
 Bier 367, 379, 442, 502 
 
 Bilroth 68, 78, 292, 293 
 
 Billroth-Meissners 
 
 62, 68, 70, 104, 318, 329, 466, 554, 622 
 
 Bishop 169 
 
 Blane 16 
 
 Blandin 656 
 
 Blumenbach 14, 17 
 
 Bockdalek V. A 656, 657, 658 
 
 Bockdalek V 657 
 
 Boivin 156 
 
 Page 
 
 Bohemian 571 
 
 Bouchard 364 
 
 Bourgery 130, 156 
 
 Bouveret 356 
 
 Bowman 17, 112 
 
 Brachet 15, 16, 17 
 
 Bridge 326 
 
 Brown 435 
 
 Brown-Sequard 19 
 
 Broussais 15, 16, 17 
 
 Budd 276 
 
 Budge 19,252 
 
 Buffon 16 
 
 Burgess 241 
 
 Burdachi 33 
 
 Cabanis 16 
 
 Cautani 587 
 
 Casenare 584 
 
 Chapin 20, 21, 159 
 
 Chaussier 14, 33, 34 
 
 Clark 336, 431, 500 
 
 Clay 18, 25, 156 
 
 Clemm 639 
 
 Cline 610 
 
 Cohnheim 433 
 
 Cohnstein 147, 158 
 
 Collins 308 
 
 Coons 606 
 
 Cooper 18, 309, 310, 610 
 
 Coutade 327 
 
 Craigie 511 
 
 Crisis 594 
 
 Cruveilhier 19 
 
 Curling 310 
 
 Czerney 549 
 
 D 
 
 Dalrymple 25 
 
 Dambo 147 
 
 Darwin 436 
 
 Davy 14, 15, 16, 17, 18 
 
 Deaver 431 
 
 DeCosta 334, 336 
 
 Descartes Reni 12 
 
 Dietl 594, 597, 600, 645 
 
 Donne 511 
 
 Du Boise 19 
 
 Dun 356 
 
 Durand 276 
 
 Duverney 16, 655 
 
 668 
 
LIST OF NAMES 
 
 G69 
 
 E 
 
 Edebohls 
 
 Einhoen 554 
 
 Ellinger 
 
 Erasistratus 12, 
 
 Erhmann 
 
 Eulenberg 18, 19,20, 21, 159, 
 
 Eustachius 12, 22 
 
 Evans 29, 112, 117, 119,335 
 
 Pagb 
 
 .595 
 ,584 
 
 147 
 ,515 
 .320 
 
 190 
 , 156 
 
 570 
 
 Farre 338 
 
 Fellner 320 
 
 Finney 608 
 
 Fitch 407, 412 
 
 Fleiner 356 
 
 Fie i seller 365 
 
 Fletcher 16, 17 
 
 Fliess : 658 
 
 Flower 34 
 
 Fox 21, 159, 189, 190, 326 
 
 Frankenhauser 12, 
 
 17, IS, 26, 27, 88, 90, 130, 140, 141, 158, 159 
 
 Francoise 29 
 
 Frey 27, 526 
 
 Frerichs 276 
 
 Freund 130, 151, 156, 158, 346, 348 
 
 Fruth 608 
 
 Fuller 512 
 
 Furbinger 276, 336 
 
 Gail 15, 17 
 
 Gallant 585, 614 
 
 Galen Claudius 11, 27 
 
 Gallianet 589, 601, 620, 640 
 
 Gaskell 21, 159 
 
 Gasser 658 
 
 Gasserius 654 
 
 Gawvousky 158 
 
 Gegenbauer 535 
 
 Gerlachs 416 
 
 Gerald 16, 268 
 
 Gerota 530 
 
 Gianozzi 19 
 
 Gibbon 615 
 
 Glenard 610 
 
 547, 549, 553, 556, 562, 592, 605, 633, 640 
 
 Goetz 18 
 
 Goltz 146, 158, 313, 321 
 
 Gooch 249,311 
 
 Good 15, 234 
 
 Graff 22 
 
 Grant 16 
 
 Gray 515 
 
 Graves 19, 30 
 
 Griesinger 20 
 
 Gubler 21 
 
 Gunn 16 
 
 Guttman 18, 19, 20, 21, 159, 190, 336 
 
 Guyon 327 
 
 H 
 
 Hall 16, 17, 18 
 
 Hahn 606 
 
 Pace 
 
 Haller 16, 22, 67, 156 
 
 Hammerschlag 527 
 
 Hare 336 
 
 Harlan 431 
 
 Hartmans 426 
 
 Hashimoto Sabura 131, 153, 158, 175 
 
 Head 295, 305, 398 
 
 Hearst 21 
 
 Heberden 19, 30, 312 
 
 Hegar 345, 348, 349, 350, 631 
 
 Heffer 19, 158 
 
 Heister 427 
 
 Hekton 328 
 
 Heinicke — Mickulicz 585 
 
 Henry 608, 609 
 
 Henles 19, 35, 52, 71, 281, 326, 537 
 
 Henrot 325 
 
 Hermann 189 
 
 Herophilus 12, 5]:, 
 
 Hersh field 26, 158, 283, 289 
 
 Hilton 280 
 
 Hippocratis 12 
 
 Hirsch 336, 488 
 
 Hoare 14, 373 
 
 Hofman 73 
 
 Howlett 527 
 
 Huber 16 
 
 Hunter, J 17, 23, 26, 312 
 
 Hunter, Wm 18, 23, 26, 156 
 
 Hyrtl. .79, 81, 127, 14S, 436, 440, 441, 487, 489 
 
 J 
 
 Jackhowitz 313 
 
 Jacquemier 24 
 
 Jaksch 336 
 
 Jaggard 410 
 
 Jans 654 
 
 Jactreboff 131, 158 
 
 Jastowitz 19, 181 
 
 Jaylife 514 
 
 Jobert, J. A 26 
 
 Jobert, De Lamella 131 
 
 Jreper 358 
 
 Jung 131, 141, 158 
 
 K 
 
 Keher 549 
 
 Kehrer 27, 141 
 
 Keilmann 146, 158 
 
 Keith 554 
 
 Kerner 140 
 
 Killian 18, 26, 27, 156 
 
 Kirro 343 
 
 Klein 338 
 
 Kitagama 335, 336 
 
 Klopper 490 
 
 Knoll 19, 316 
 
 Koch 27, 140, 158 
 
 Kokitanskv 264 
 
 Kolliker 19, 27, 326 
 
 Kossman 547 
 
 Krantz 348, 350 
 
 Kraus 16 
 
 Kressmaul 549 
 
 Krehls 433 
 
 Knjsinski 334, 335, 336 
 
 Kunpffer 130, 158, 320 
 
: 
 
 LIST OF NAMES 
 
 Pacb 
 
 Lancicus 
 
 Lancereaux 313 
 
 Landau 548 
 
 Lambell 18,158 
 
 Larastine 152 
 
 Larage 
 
 Lecorche 263 
 
 Le Gallois 14, 17 
 
 Lee 17, 18,24,25,2 ;. 156, 159 
 
 Legros 327 
 
 Leube 334, 336, 
 
 Leville - 
 
 Leyden 
 
 Lincolns 435 
 
 Litten 335 
 
 Littre 
 
 Lloyd - r: - 42o, 642 
 
 tein 16, 18, 24. 156,159 
 
 Lohmer 350 
 
 Lomer 29, 42, 96 
 
 Longet 158 
 
 Lucas B5, 42" 
 
 Ludwig . . .19, 104, 168, 241, 242, 292, 32", 339 
 Luschka 34 
 
 M 
 
 MacKellar 312. 61l 
 
 Mayo 16, 615 
 
 Martin 2.2, 203, 550 
 
 Mayer 20, 158, 255, 320 
 
 Manee 16 
 
 Mathieu 330 
 
 McNeil 414 
 
 Meckel 14, 293, 408, 414, 419 
 
 McBurneys - 104,416,417,427 
 
 McKindrick 326 
 
 Meinert 634 
 
 Meirert 554 
 
 Mering 315 
 
 Meissner 241, 243, 244, 250, 292 
 
 Meissner, Billroth- 242 
 
 Mitchell, Weir 
 
 Miller : 245, 2-52 
 
 Minkowski 315 
 
 Milliot 
 
 Minot 35 5 
 
 Morris 2,7. 556 
 
 Morgangui 16, 33- 
 
 Monro 14 
 
 Muller 17 
 
 Musser 431 
 
 N 
 
 Nagel 521 
 
 Napier 
 
 Nasse 19, 320, 32-; 
 
 Naunyn 452 
 
 Neelson 338 
 
 Nothnagel 319, 
 
 322. 323, 334. 335. 336, 33*. 3J 
 
 iyrne 29, 112, 117, 427. 577, 57 
 
 Onimus 327 
 
 Oppoltzer ,. 548 
 
 Pace 
 
 Osiander, J. F 23, 156 
 
 Osiander 18, 156 
 
 P 
 
 Pacquet 517, 518 
 
 Patherson 159 
 
 Pariser 336 
 
 Parry 19, 30 
 
 Paw 30 
 
 Perrond 336 
 
 Pessimski 131, 150, 158 
 
 Petit 16 
 
 Philip 15 
 
 Perier 363 
 
 Pfeulers 19 
 
 Pflueger 19, 320, 326 
 
 Pick 3:!4. 336, 359, 367 
 
 Pickford 19 
 
 Pinel 14 
 
 Poetal 5-7 
 
 Polle 27 
 
 Pouparts 30 
 
 Powell 314 
 
 P '-.rier 521 
 
 Prochaska .14, 17 
 
 R 
 
 Rachel 334 
 
 Radcliff 16 
 
 Ralando 17 
 
 Ranvier 520, 523 
 
 Rauber 21, 159 
 
 Rayer 547 
 
 Recklinghausen 522, 523 
 
 Reid 16 
 
 Reil 16 
 
 Rein 130, 131. • 146, 147 
 
 Remak, 16, 19, 104, 140, 168, 241, 242, 292, 439 
 
 Remond 654 
 
 Reyner de Graff 156 
 
 Richmond and Gall 15, 17 
 
 Richardson 537 
 
 Ribes 33, 254 
 
 Rickets 131 
 
 Riedel 550, 587, 588, 594 
 
 Ries 531, 658 
 
 Robin 16 
 
 Rhorig 158 
 
 Robinson Bvron 
 
 _ ■'. 130, 147, 158, 255, 285, 2^7, 291, 
 295, 482, 521, 602, 603, 606, 623, 624, »:27 
 
 Rochefontaine 19 
 
 Rokitansky 424 
 
 Rollet 
 
 Romberg 308, 310, 327, 363 
 
 Rose 547, 585, 589, 593, 601, 614,615,620, 639 
 
 Rosewater 601, 639 
 
 Rothmann 336 
 
 Rudbeck 514, 517, 516 
 
 Rudolphi :.... 16 
 
 Ruge 336 
 
 s 
 
 Salvage . 26 
 
 Sam son von 414 
 
 Santoeine 453 
 
LIST OF NAMES 
 
 671 
 
 Pace 
 
 Sappev. 260, 516, 520, 
 
 Savage 262, 289, 522 
 
 pa 11 
 
 Schanzoni 148 
 
 Schiff IS 
 
 Schroeder 616,64] 
 
 Schlem 18 
 
 Schmitz 603 
 
 Schneiderian 
 
 Schmidt 104, 168, 241, 242, 292, 439 
 
 Schroder 549, 640 
 
 Schiippel 27ti 
 
 Schwerdt 268, 557 
 
 Senn N 405, 412, 616 
 
 Sedlein 12 
 
 Senator 36 1 
 
 Sherren 398 
 
 Sholer 564, 565 
 
 Smith 31 
 
 Solly IT 
 
 Sommering 16 
 
 Spugel 586 
 
 Stiller 496, 553, 554, 630, 634 
 
 Steinach 320 
 
 Stilling 33 
 
 Stober 421 
 
 Stube 597 
 
 Tait, Lawson.,251,263,422, 424, 429, 431, 465 
 
 Tanner 445, 533 
 
 Tarchanoff 19 
 
 Teichman, 517, 519, 525, 536, 540, 541, 542, 543 
 
 Testut 518 
 
 Theile 330 
 
 Thompson 336 
 
 Tiedemann..l8, 22, 23, 24. 26, 52, 130, 156 
 
 Todd 17. 112 
 
 Toldt 532, 534. 538. 539 
 
 Treitz 571, 573 
 
 Valentine 52, .127. 657, 658 
 
 Valleix's 274. 284 
 
 TaC.E 
 
 Van Hook 
 
 Vanni 
 
 27, 4:<7 
 
 Verworn 
 
 Velpeau 
 
 Vesalius 
 
 Vidian 
 
 Viensseni, K 12. 14. 22. 42, 
 
 Virchow 363, 511, 
 
 Virchow-Robin 
 
 Vogel 
 
 Volkmann 19 
 
 Vulpian 189 
 
 \V 
 
 Waite. Lucy 268, 271 S 
 
 347. ,i!»4, 404, 109, 422, 533, 555. 610, 613 
 
 Wagner 16 
 
 Waldeyer 52, 158 
 
 Walther 130 
 
 Walter.... 16, 19, 22. 24,25, 130, 156, 336 
 
 Washburn 405 
 
 Watzer 15, 17 
 
 Weber 16, 327 
 
 Wenzel 571 
 
 Wesling 517 
 
 Wild 381 
 
 Wilford 16 
 
 Windscheid - 3 
 
 Williams 359 
 
 Wilkes 430 
 
 Willis . . .12, 14, 15. 22, 33. 88. 112. l.v . 
 
 Wirsing 
 
 Winslow 14. 15. 408 
 
 Wrisberg, 16, 35, 106, 112. 168, 249, 291, 312 
 
 Wolffian. 597 
 
 Woodward 334 
 
 Wutzer 15, 17 
 
 z 
 
 Zetlitz 424 
 
 Ziegenspeck 618 
 
 Zinn. . . 14 
 
QP368 
 R56 
 Robinson 1907 
 
 Abdominal and pelvic brain.