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-Bannerman, 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 1846, with Robert Lee.  Walter's book appeared in 1783.  Lee's in 1841 and Frankenhauser'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 ganglionated mass located at the cervico-vaginal function has experienced a variety of terms during the past two centuries.
    Synonymus. - The pelvic sympathetic plexus (plexus sympathicus); Cervio-cuterine ganglion (ganglion cervicis uterinum - Waltber, 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 vesicorectal 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 fundamentalis 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 the 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 grouplof connected ganglia-Tiedemann (1822), Moreau (1789-1862).  Jastreboff (1881), Rein (1902), Sabura Hashimoto (1892), Pessimski (1892), 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 bonypelvis, 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 (hypogastricus).  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, hypogastricus, 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 fomix.  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 cervico-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 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 vascular 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 connective 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, ganglionated 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 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 perhaps 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 membranous.  The largest ganglia are located in the central portion and diminishes 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 circumference.  Ganglia of various dimensions and form, macroscopic and microscopic, 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, however, 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, neurilemma or muscle.  In the gestating uterus the pelvic brain measures 1 1/2 inches in length, in width 1 inch, thickness 1/5.
    Form. - The pelvic brain is in general triangular, trowel-shaped, frequently quadrangular in outline.  It is a more or less solid, compact, composite 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 coalescence 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 pelvic brain are not well defined 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, however, 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 receiving 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 uterinus, 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 centripetal 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 plexiform, cords, while the efferent nerves radiate mainly from the distal and median border of the pelvic brain as luxuriant leashes or richly ganglionated 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 plexiform 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 demonstrated 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.

Afferent Nerves.

1.  Plexus interiliacus (hypogastricus).
2.  Rami ganglionum sacralium.
3.  Rami nervorum sacralium.
4.  Plexus arteriae ovaricoe.
5.  Plexus arteriae uterinae.
6.  Plexus arteriae ligarnenti 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.
    The color is whitish-gray, brown; a liberal admixture of white conectiven tissue.
    The consistence is moderately dense from association of  abundant connective tissue.
    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 interiliacus (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, composite 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 - 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 (hypogastricus) bladder.  The pelvic brain is located at the distal end of the plexus interiliacus.  It lies ensconced in the dense parametrial 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 plexuses.  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 (hypogastricus); (2) ganglia lumbalis; (3) plexus hemorrhoidalis; (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 (hypogastricus) 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 vaginalls with ganglionated masses at the points of nerve strand coalescence; (5) plexus clitoridis, a rich and luxuriant ganglionated plexus supplying the 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 composite ganglia of the cranial brain.  No parts of the pelvic cellular tissue remains free from traversing nerves and ganglia.  It is not only the subserosium 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 network 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 pronounced 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 preparation because of its resemblance to adjacent connective tissue in structure and color.  It is whiter than the abdominal brain.  To observe correct relations the pelvic brain must be dissected in situ.  The most complete observations 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 wbence 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 relations of the pelvic brain to the abdominal brain is subordinate in function and location, similar to the relations of the cerebellum to the cranial cerebrum; 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 localized peripheral nerve apparatus - automatic visceral ganglia - located in the parenchyma of the organs possessing a partially independent and more persistent 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 subordinate to the sympathetic peripheral center.  The lumbar center is not absolutely necessary for conception, gestation and parturition, as these processes 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 ganglionic nerve apparatus of the uterus (including the pelvic brain), macroscopic 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 ganglionated network of nerve plexuses.
    The pelvic brain is the localized, subconscious, vegetative, sympathetic, automatic nerve apparatus for the 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, orginally 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 parenchyma 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 extirpated. (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.  However, 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 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.

(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 diagnosis which is the basis of rational treatment.  It will aid to extend so-called medical gynoecology which is constructive, and limit so-called surgical gynecology 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 plenipotentiary to reconcile the spinal and sympathetic forces for appropriate use in the genital tract and associated viscera.

(B) 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 genitals, 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 vasomotor center (cerebrum vasculare) for the tractus genitalis ruling the vast and varying phases of circulation (congestion and anoemia 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 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 frequency 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 hemorrhage the cervical ganglion must be consulted.  In certain cases of postpartum hemorrhage the older obstetricians claimed that by compressing the aorta the haemorrhage war, 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 manipulation 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 myorhetrium - the elastic and muscular bundles of which under its control act like living ligatures - checking the bleeding.  Again, certain cases of postpartum 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 postpartum hemorrhage four procedures 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, intrauterine digital irritation stimulates the pelvic brain through the peripheral ganglionated nerve plexuses which limits the vascular lumen.
    The pelvic brain initiates, sustains and concludes parturition (peristalsis, labor). Alexander Keilinann'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 distalward movement of the child the labor is intensified in a geometrical ratio.
    The more distalward 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 1890, 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 beginning 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 influencing 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 sympathetic 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 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 myometrium.  In slow labors accompanied by uterine inertia the pelvic brain could be stimulated digitally per rectum or by rectal clysters or electricity, inducing 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 cathartics 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 accompanying the arteria epigastrica superior and inferior to the common iliac artery, whence the route continues on the plexuses accompanying the arteria
rotundi ligamenti to the plexus uterinus (and to the pelvic brain).  Therefore, 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 mammae are still more evident and frequent.  If the tractus genitalis be stimulated by pregnancy, 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 gynaecology, 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 pregnant 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 wondrous 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 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 manifest from the stomach by disordered rhythm (vomiting or nausea), absorption and secretion.
    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, maximum 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 hypereemia, congestion, may aid inincreasing the connective tissue cells.
    IV. Gestation. - During pregnancy the profound and continuous hyperaemia, the permanent exalted engorgement, produces an increase, a multiplication 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 of 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 nongravid subjects.
    V.  Puerperiun. - In the devascularization of the puerperal stage cellular 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.  Senescence. - In senescence the arteria uterina loses its spirality, becomingextended, its lumen becomes diminished, its walls become hypertrophied and the volume of blood supplying the pelvic brain (and genitals) gradually decreases with consequent atrophy.  The interganglionic connective and nerve tissue increases, multiplies. while the parenchyma (ganglion cells) becomes atrophied, compressed to death by cicatrization and lack of blood.  By progressive interganglionic nerve and connective tissue multiplication 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 (i.e., for the segment supplied by the arteria uterina).

(C) 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 percent 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 inflammatory process penetrates to various degrees in the pelvic subserosum with resulting round-cell infiltration and subsequent contraction of cellular tissue.  In ce1lulitis 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 deviation from inflammatory consequences than the tractus gerlitalis.  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 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) myometritis.  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 gynecologist 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 ligamenturn 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 bilaterally 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 interwoven with dense subperitoneal pelvic connective tissue, presenting difficulties 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 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, one and one-half inches; width, one inch, and thickness, one-fifth of an inch.  Theform is triangular, quadrangular.  The borders, or contour, are irregular 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, separation.
    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 splanchnics) 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 urinarius (ureter, bladder); (c) part of the tractus intestilialis (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.
    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 foetal 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 ganglionic 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 ganglion 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., ovulation, 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 gestation.  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 hyperoemia, congestion, increases the connective tissue.
    (d)  In gestation the profound and constant hyperaemia, exalted engorgement, produces a multiplication of ganglion cells and an increase of connective 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.

    (C) Pathology. - The pelvic brain is subject to disease similar to other abdominal viscera.  As the tractus genitalis is frequently subject to infection and, consequently, inflammatory processes during its maximum activity, the pelvic brain, no doubt, becomes diseased and manifests symptoms.  Peritonitis, 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 postpartum hemorrhage massage of the pelvic brain may be accomplished per rectum, per vaginam, manipulation of the uterus or light stroking of the plexus interillacus inducing the elastic and muscular bundles of the myometrium to contract like living ligatures, controlling vessel lumen.

BIBLIOGRAPHY OF THE PELVIC BRAIN (GANGLION CERVICALE).

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Bourgery, J. M. (1797-1845), 1840, and Claude Bernard (1813-1778), 1840.
Tiedemann, Friedricus (1781-1861).  Tabulae nervorum uteri.  Heidelberg, 1822.
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Kilian, F. (1800 ' -1864).  Die Nerven des Uterus.  Zeltschrift 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.
Jobert de Lamballe (1779-1867).  Comptes des science de L'Acad6mie, T. XII., No. 20, Mai 17.  Recherches sur la disposition des nerfs de l'uterus, etc.
Langenbeck's Atlas.  Tafel 11 and 12.  Fasc. iii.  Neurologie.
Louget.  Anatomie und Physiologie des Nerven-System.  Bonn, 1819.
Hirschfeld and Laville.  Neurologie descript. et iconographic 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. 1865.
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. 1879.
Jostreboff.  These St. Petersburg, 1881.  Anatomio normal et pathologique du ganglion cervicale de l'uterus.
Freund, W. H. Verh. der Nat.  Vers.  Strassburg, lS85.
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 1899.
Mayer, R. Virch.  Arch.  Bd. 85.
Franz.  Centralblatt f.Gynecol., No. 24. 1904.
Freund, W. A. Festschrift fur Chrobak. 1903.
von Herff, Miinchen.  Medicin.  Wochensch., No. 4. 1892.
Gawronsky.  Arch. f. Gyn.  Bd. 47. 1894.  Nerve endings in the uterus.
Knupffer.  Wegen der Ursache des Geburtseintritts.  Inaugural dessertation.  Dorpat, 1892.
Waldeyer, Wm.  Das Becken.  Bonn, 1899.
Pissemski, S. Monatsschrift f. Gehurtshiilfe und Gyndkologic, Bd. 17. 1903.  Zur Anatomie des Plexus fundarrientalis uteri belm Weibe und gewissen Thieren.
Ph. Jung.  Untersuchung ueber die Innervation der welblichen Genital-Organe.  Monatsschrift fur Geburtshiilfe und Gyndkologie, Bd. 21.  Heft 1, Jan., 1905.
Hashimoto, Sabura.  Beitrdge zur Geburt und Gynakol.  Bd. 8. Heft I, 1894. (Anatomy and histology of the cervical ganglion).
Freund, W. A. Verhand. d. 76.  Nat.  Vers.  Breslau, 1904.
 

PELVIC BRAIN OF AN INFANT       Fig. 31. A, pelvic brain; B, plexus vesicalis; V, plexu 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; 0, 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 magnifying lens the efferent nerves of this pelvic brain (plexus rectalis, vaginalis, vesicalis, uterinus) resemble luxuriant leashes (cat o' nine tails) or richly ganglionate 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 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 network, 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 that 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.

PELVIC BRAIN       Fig. 40.  An illustration of the pelvic brain, drawn from my own dissection.  The plexus interiliacus (bypogastricus) 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. 0. 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.

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.  Ut., uterus.  Ur., ureter.  R., rectum.  P. L., plexus interiliacus (left).  P. R., plexus interiliacus (right).  N., sacral ganglia.  Ur., ureter severed to expose the pelvic brain. 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.

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.

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 gestate on.  The ganglion cells are completely developed.  Observe the enormous mass of connective tissue present. (C) Child - 1 1/2 years old.  A nerve process courses within the ganglion.  Few and small ganglion cells incompletely developed. (D) Girl 1 1/2 years old.  A nerve process branches and reunites itself with the infercellular substance. (E ) Girl 6 years old.  The ganglion cells are presenting development. (Redrawn after Dr. Sabura Hashimoto.)

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 (hypogastricus) 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 theuterus. 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 Frankenhauser were employed.