The Abdominal and Pelvic Brain
Byron Robinson, M. D.
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-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
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.
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.
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
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
(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
(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.
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
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
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
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
V. Puerperiun. - In the devascularization
of the puerperal stage cellular elements will perhaps degenerate, atrophy,
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
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
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
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
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
(b) In pubertas the ganglion cells are completely
(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
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).
Eustachius, B. (died 1574). Tabul.T Anatomicae, Amsterdam, 1722.
de Graaf, Regner (1641-1673). Opera omnia, Amsterdam, 1705.
Willis, Thomas (1622-1675). Cerebri nervorumque description Geneva,
Haller, Albertus (1708-1777). Elementa physiologic. Laus,
Vieussens, R. (1641-1716).
Walter, J. G. (1734-1818). Tabulao nerv. thoracis et abdominis.
Hunter, William (1718-1783). Anatomic description of the pregnant
Osiander, F. B. (father) (1757-1822). Handbuch der Entbindungskunst,
Osiander, J. F. (son) (1787-1855). Literario a mediocrum ordine
proemio Commentatio-physiologica quae disserata uterum nervos habere in
certamine. Literario a mediocrum ordine preemiornat. Goettingen,
Bourgery, J. M. (1797-1845), 1840, and Claude Bernard (1813-1778),
Tiedemann, Friedricus (1781-1861). Tabulae nervorum uteri.
Lobstein, J. G. C. F. (1777-1815). De nervi sympathici humani
fabrica, etc. Paribsii, 1823.
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.
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,
Hirschfeld and Laville. Neurologie descript. et iconographic
du systeme nerveux. Paris, 1853.
Frankenhauser, Ferdinand (died 1894). Die Nerven de Gebaermutter.
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
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
Ph. Jung. Untersuchung ueber die Innervation der welblichen Genital-Organe.
Monatsschrift fur Geburtshiilfe und Gyndkologie, Bd. 21. Heft 1,
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,
PELVIC BRAIN OF AN INFANT
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,
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,
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
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.
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.
(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
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.