The Abdominal and Pelvic Brain
Byron Robinson, M. D.
CONSIDERATIONS FOR THE REMOVAL OF PELVIC AND
The sympathetic is the silent companion of the cerebralspinal.
nerve is the nerve of subconscious life.
"But he did not lose sight of the present in these glowing visions
of a future."
- Mrs. Catharine V. Waite, "The Mormon Prophet and His Harem."
Having devoted some twenty years to the study of
pelvic and abdominal visceral disease, I have frequently desired to record
some observations on the effect of tumors in the pelvis and abdomen upon
the sympathetic system. Many dissections have convinced me that the
vast ganglionic system, distributed to the viscera bordering upon the peritoneal
cavity, together with other glandular organs of the body, plays a significant
role. Besides, when it is noted that the heart and the unstriped
muscles of the body, are supplied by the sympathetic system, there becomes
at once apparent its extensive as well as intimate connection with the
Special study in the physiology and pathology of
the viscera develops reasons for the removal of abdominal and pelvic tumors
not apparent from superficial observations. It is well known that
shortly after the appearance of a tumor in the abdomen the health of the
patient becomes more or less impaired. The functions of the organs
become deranged; the heart suffers from abnormal action and structural
change; the digestion becomes more or less deranged. As the tumor
increases in size, kidney diseases generally develop. The liver,
forming bile, glycogen and urea, sooner or later becomes impaired in its
rhythm. The lungs lose their rhythm and become spasmodic, while the
spleen shows its disturbance by pigmentary deposits in various portions
of the body. An attempt will here be made to explain the pathological
result of abdominal tumors on physiological and anatomical grounds.
The basis of the explanation will be by reflex action
on the sympathetic nerve. It may be curtly observed that pathological
results due to the sympathetic nerve are based upon reflex action.
We shall assume that the ganglia which are found in it, especially the
abdominal brain and the three cervical ganglia, are points where forces
are reorganized and distributed to the viscera. The first essential
feature to observe in the diseased viscera is the disturbance in rhythm.
Though any abdominal tumor may produce the same results, we shall choose
a uterine myoma to illustrate our views. It is a principle in physiology
that when a peripheral irritation is sent to the abdominal brain the reorganized
forces will be emitted along the lines of least resistance, so that the
organ which is supplied with the greatest number of nerve strands will
suffer the most. Practically this principle holds true in every viscus.
The great ganglia and cords, filled with nerve cells
and nerve strands, labor in the subconscious region, the vast laboratory
of life and assimilation. The cerebrospinal axis receives sensations
and emits impulses which express themselves in motion, performing labors
which minister to the mind and protect the body in avoiding destruction,
or contribute to its nutrition.
SCHEMATIC DRAWING OF THE SYMPATHETIC NERVE
X, ganglion of Ribes; y, coccygeal ganglion; h, heart; k, kidney; s, spleen;
a b, abdominal brain; s p, spermatic (ovarian plexus) ; i, intestine;
h p, hypogastric plexus; c g, the three cervical nerves.
The sides of the ellipse represent the lateral
chain of the sympathetic. All the nerve strands report to the abdominal
The effects of the tumor on the heart may first be
considered. An abdominal tumor induces fatty degeneration of the
heart. When the uterine tumor irritates the peripheral ends of the
hypogastric plexus, the irritation is transmitted to the abdominal brain
and there reorganized and emitted along the splanchnic to the cervical
ganglia, where, again, a reorganization occurs and the force then passes
down to the heart by way of the three cardiac nerves. The irritation
could pass directly from the uterine myoma up to the lateral chain of sympathetics
to the three cervical ganglia where it becomes reorganized.
It no doubt transmits part of the irritation by
way of the abdominal brain and part by way of the lateral chain.
So far as the heart is concerned, the result is nearly the same, for the
irritation is reorganized in each case in the three cervical ganglia and
transmitted to the heart. It is of course necessary to consider that
the irritation may be sent to the spinal cord by way of the vagus and there
reorganized. In such case it is sent directly to the heart by the
It should be remembered that the sympathetic ganglia
in the walls of the heart (Ludwig's, Bidder's, Schmidt's and Remak's) are
numerous and large. Also that the network of cords with their ganglia,
situated close to its surface, constitute an extensive nerve system.
It consists of the great or deep cardiac plexus, otherwise known as the
plexus magnus profundus of Scarpa, besides the superficial cardiac plexus,
with the cardiac ganglia of Wrisberg, which is occasionally large from
the coalescence of several ganglia, and may be represented by a meshwork.
In tumors of the pelvis we are dealing with the effect on the vast cardiac
sympathetic nervous system. The first manifest objective heart symptom
The irritation from the uterine myoma reaches the
heart in two ways:
1. The irritation passes up the hypogastric
plexus to the abdominal brain, where it is reorganized and emitted to all
the viscera over their respective sympathetic plexuses. In the case
of the heart it passes up the abdominal splanchnics to the three cervical
ganglia of the sympathetic, where it is reorganized and sent directly to
2. Some of the irritation is transmitted by
way of the vagi to the medulla, where it is reorganized and sent directly
to the heart by the cardiac nerves which supply the heart from the vagus.
This is more especially the case in the right vagus, as that is the cranial
nerve which largely rules and supplies the heart and abdominal brain.
Now, this irritation from the myoma goes on day and night. It gives
the heart no rest. It flows to the heart in the midst of a diastole,
or a systole. The first great characteristic of the heart (rhythm)
is lost. Having lost its rhythm, the heart proceeds irregularly.
Irregular action means a changed nourishment; continued irritation with
disturbed rhythm induces the heart to overfeed itself, the result being
It may be noted that this hypertrophy is not brought
about in precisely the same way as is hypertrophy from valvulitis or aortic
insufficiency; but vaso-motor dilation must play a role in over-nourishing
the cardiac muscles. It resembles more nearly the cardiac hypertrophy
existing in goiter. That from the reflex irritation in myoma is also
a moderate hypertrophy, so far as the writer has observed, and it is a
very slow process. In the first stage the heart becomes irregular,
in the second hypertrophied, in the third it takes on fatty degeneration.
This is no doubt a preservative process, so that a large, vigorously beating
heart will not rupture an artery in a degenerated state (atheromatous or
fatty). It appears certain that many old cases of large uterine myoma
are lost after skillful operations simply from fatty degeneration of the
heart. It is common to observe palpitation in patients having uterine
myoma, and palpitation is the characteristic symptom of a weak heart.
The automatic cardiac ganglia are disturbed by reflex irritation and
take on an excessive nourishment. The irritation, sent to the heart
over the hypogastric plexus, is in one sense an increased demand for action.
The irritation, passing to the heart day and night, winter and summer,
according to a physiological law, provokes hypertrophy, if the nutritive
powers are good. If they are not good, the complement of hypertrophy
- dilation - results.
A fatty degenerated or weak heart induces low blood-pressure,
which is the bottom factor in waste-laden blood and deficient elimination.
It allows local congestions and consequent impaired nourishment.
The local force of such circumstances teaches to remove uterine and other
abdominal tumors as early as possible, so that the patient will not be
left with partially or completely damaged viscera.
Reflexes arising from the irritation of the sympathetic
in the peritoneal membrane are profound in results. Irregularity,
hypertrophy, and degeneration of the heart are the effects of a reflex
act, accomplished mainly through the sympathetic system and due to irritation
at the periphery of the hypogastric plexus. It is transmitted to
the abdominal brain, to the three cervical ganglia, and some to the spinal
cord, whence the reorganization of the forces occurs.
The organized nervous impressions then pass to the
heart over the six cardiac (vagi) nerves. This abnormal force deranges
the fine balance of the heart's rhythm. The automatic cardiac ganglia
become discolored, and in time vaso-motor action and consequently nourishment
It may be remembered that the untoward influence
on the heart, disturbing its rhythm and consequently its nourishment, is
also aided and abetted by disturbing the caliber of distal blood-vessels
which are controlled by the sympathetic system.
The liver does not escape the evil influence of
the tumor. Abdominal tumors induce fatty degeneration of the liver.
It may be asserted that an influence on the hepatic plexus of nerves alone
could stop all secretion in the liver. If such a proposition be true,
it need not be wondered that lesser irritations of the hepatic nerve plexus
could so alter the secretion of the liver that it would degenerate the
organ. The characteristic disturbance which arises from the uterine
myoma is a derangement of rhythm. The liver has a rhythm due to (a)
an elastic peritoneum enclosing it, (b) an elastic capsule (Glisson's)
surrounding it, and (c) to the capacity of its cells to enlarge.
The occasion of the liver rhythm is food carried
to it by way of the portal vein. When the peritoneal and Glisson's
capsules and the cells are expanded to a maximum, the liver rhythm is at
its climax. Now,. the products of the liver (bile, glycogen and urea)
are sent to their respective homes by contraction of the elastic peritoneum
and capsule of Glisson. The liver then gets its rest and repair.
The irritation from the periphery of the hypogastric
plexus passes up to the abdominal brain, where it is reorganized and emitted
to the liver. It goes to the liver from the tumor at all hours and
deranges its rhythm. The irritation may attempt to induce a rhythm
without food, or it may flash on to the liver at any stage in its rhythm.
The liver rhythm is induced by the automatic hepatic plexus. So it
may be asserted that the irritation of the uterine myoma deranges the rhythm
of the liver.
The second point to consider is the altered secretion
in the liver, due to the reflex irritation from the uterine myoma by way
of the abdominal brain. The continued irritation increases the derangement
and soon changes and impairs the liver nourishment. The complete
process from food to end products becomes imperfect and a lower grade of
tissue is formed, known as fat. The constantly irritated liver soon
becomes able to form but little products beyond fat, and degeneration follows.
It is well known that women at the menopause frequently
acquire liver disease. This is owing to the reflex irritation through the
abdominal brain. The degeneration of the hypogastric plexus will
not allow it to transmit sufficient physiological orders to induce a monthly
rhythm, so the accumulated energies flash to the other organs, and the
derangement of the liver is especially manifest, because its derangement
is often followed by pigmentation (yellow or brown or black) of the skin.
The uterine myoma, then, by reflex action. disturbs rhythm and secretion
in the liver, and so its nutrition. This ends in fatty degeneration.
For years I have observed that women with pelvic
disorders have disturbed kidney action. In general this kidney disturbance
is renal insufficiency, and it may after long irritation become organic
disease. It may be well to give a general hint here as to why the
kidneys suffer so much when either irritating tumors or inflammatory processes
exist in the pelvic organs.
The kidneys, uterus, ovaries and oviducts develop
from two very small points in the embryo called the Wolfflan bodies.
These develop from the mesoblast, as do the muscles, blood and lymph vessels,
and from the genitourinary organs. Arising from the same source and
supplied by the same nerves and blood-vessels, the Wolffian bodies, the
kidneys and genitals have an intimate and close connection. The abdominal
brain sends out a vast chain of nerves to the kidney on each side, and
the same brain sends out a vast chain on each side of the genitals.
These and the kidneys are only different spokes in the same wheel, the
hub of which is - the abdominal brain. Diseases in the genitals,
whether tumors or inflammatory processes, produce in the urine not only
diminished solids but also diminished fluids.
Again on the other hand diminished kidney excretion
(renal insufficiency) produces diseased or, at least, disturbed genitals.
Any gynecologist of some years' experience has doubtless frequently observed
that in women with diseased genitals and deficient renal secretion, by
giving diuretics - fluids in small and off-repeated doses, the diseased
genitals will often improve in direct proportion to the increase of renal
secretion. Deficiency of renal secretion irritates the genitals by
non-removal of urinary solids. Diseased genitals irritate the kidneys
by reflex action. This is all accomplished through the abdominal
brain as a center. The genitals, kidneys and abdominal brain constitute
a very vital triangle. In the middle of its base lies the significant
abdominal brain and at the apex the important genitals, while the other
two angles are occupied by the kidneys. The uterus and kidneys have
the highest nerve and blood supply of all viscera, hence they experience
more profoundly than other viscera the forces which are organized and reorganized
in the abdominal brain. In the sympathetic nervous system the kidneys
play a vast and immeasurable role. If by some irritation in the pelvis
or abdomen the kidney begins to secrete insufficiently, the whole organism,
together with the ganglionic nervous system, or the cyclo-ganglionic system,
as Solly termed it half a century ago, will become poisoned from non-elimination.
From this peculiar reflex action, of which the abdominal brain is capable,
we may yet learn that disease of the pelvic organs of woman may be cured
by diuretics, cathartics or diaphoretics. In other words drain the
skin, drain the kidneys and drain the bowels. The intimate and close
relations of the genitals and kidneys is plain anatomically and physiologically,
as large bundles of nerves from the abdominal brain supply both.
Clinically, then, these closer relations have been demonstrated of late
years, as gynecology has progressed. The cyclo-ganglionic system
is recognized as a finely balanced mechanism capable of prompt response
when once its manifestations are understood.
For example, no one understands so well as the gynecologist
the vital relation which exists between deficient kidney secretion and
diseased pelvic organs. Effective diuretics relieve many pelvic pains.
Baths and diaphoretics subdue innumerable neuralgias, and cathartics disperse
dragging pains. A woman may have a sound kidney (so far as chemical
examination of the urine may indicate) and yet reflex action from the genitals
may induce it to secrete deficient or excessive fluids or solids, which
not only further disturbs the genitals with waste-laden blood but disarranges
the fine balance in other viscera with the same. Wherever this waste-laden
blood advances it produces new points for reflex irritation, unbalancing
the whole system. It seems to me there is no better point to work
from in this consideration than the relation of the genito-urinary system
to the abdominal brain. Clinical features are more manifest here
than elsewhere. Gynecologists may even cure women of innumerable
ailments by simply inducing them to drink water. I have accomplished
much for women during the past fifteen years by inducing them to drink
a full glass of water, six times daily, containing a pinch of Epsom salt
in solution. The late Dr. J. H. Etheridge wrote instructively on
renal secretion in gynecologic patients.
During menstruation girls show distinct clinical
symptoms of pain in the region of the kidneys, and of variation in urinary
secretion, showing the close relation between this and pelvic disturbances.
It is clear that this pain in the kidney region is due to reflexes from
the menstrual organs, i. e., the uterus and oviducts.
The kidney, in proportion to its size, has the highest
nerve and blood supply of any viscus, except the uterus. According
to the recent investigations at Johns Hopkins University. the kidney is
supplied only by sympathetic nerves. It is a common observation that
abdominal tumors are followed by kidney disturbances. Even the gravid
uterus does not allow the kidney to escape irritation. This kidney
disease brought about by abdominal tumors is reflex. It is a physiological
principle that an influence acting through the nerves alone can arrest
all secretion. Minor degrees of irritation will suffice to increase,
diminish or change the kidney secretions. Irritation of an organ
continued indefinitely, and modifying its action, may be sufficient to
induce disease. Kidney disease resulting from abdominal tumors is
chiefly chronic in the very nature of the case.
The first point to consider, as the initial step
in chronic renal disease from abdominal tumors, is partial or complete
obstruction to the flow of urine.
The second point to consider in chronic renal disease
due to abdominal tumors is reflex irritation from distant viscera.
The third point of consideration is infection.
As regards the first point, obstruction, the location
and size of the tumor may be noted. A partially occluded ureter,
through long-continued pressure, will cause renal disease. Under
this head would be classed mechanical impediments to the flow of urine.
If the obstruction is sufficient it will create hydroureter. If the
hydroureter is long enough maintained the kidney will secrete until blood
pressure is impaired, and then in a few months atrophy will follow.
The writer has proved by experiments on the dog that when the ureter is
completely ligated, the kidney will shrink to about one fifth its original
size, in five months.
The pressure of the tumor on the ureter is a silent
process not often recognized by the attendant. The obstruction
of the ureter is like the quietly growing intestinal stricture, which is
rarely recognized until some terrible disaster reveals a long series of
old pathological conditions. The main idea in the obstruction, however,
is that it is partial, and by raising the difficulty of urine flow, renal
elimination becomes deficient. The blood then becomes waste-laden.
If the obstruction is sufficient, the result will be hydroureter, which
being long continued (without infection) results in renal atrophy, as the
writer proved by tying the dog's ureter.
The second point, reflex irritation, is more significant,
because it means that irritation from any viscus can be reflected to the
kidney, over the renal plexus. The abdominal tumor irritates some
contiguous viscus; this irritation quickly passes to the abdominal brain,
by way of the sympathetic plexus of said viscus, where the forces are reorganized
and transmitted to the kidney. There is little doubt that the rise
of temperature from passing a sound into a man's bladder is due to reflex
irritation transmitted from an oversensitive urethra. It is probable
that the so-called urinary fever is reflex. It modifies circulation
by inducing local anemia and local hyperemia. In this way nutrition
quickly changes. Examples may be seen in strictures of the intestine
or ureter where the walls above the stricture are greatly thickened.
The chief point in regard to secretions in patients
with abdominal tumors is a decreased or disproportionate secretion.
It is common to observe a patient with a tumor secreting a small quantity
of urine heavily laden with salts. The amount of urine voided at
times appears as an alarmingly small quantity. Natural reasoning
from clinical and physiological bases attributes the decreased quantity
of urine to the irritation from the tumor transmitted over the renal plexus.
Autopsies on women who die of tumors prove it beyond the shadow of a doubt.
Disproportionate renal secretion from the irritation
of abdominal tumors is also common. Albumen is the chief element
found. But phosphates, urates or sugar make up the varying scales
of salts. Even the amount of water will vary within wide limits.
The tumor of pregnancy is a common example of disturbed
renal secretion due to reflex action. Thus
deranged renal secretion is frequently due to reflex irritation, depending
on the presence of an abdominal tumor. The change in the secretion
consists in increase, decrease or disproportionate quantities. As
each organ has its own distinct nerve plexus, so it should be understood
that reflex action is carried along distinct anatomical lines.
As regards the third point, infection, in chronic
renal disease from the presence of abdominal tumors a serious condition
The genito-urinary tract can be infected at any
point from the kidney cortex to the urethral end. If the tumor presses
severely enough on the urinary tract, a perforation will occur, and from
this perforation infection will travel in either direction-toward the urethra
or toward the kidney.
The result of perforation of the urinal tract will
be nephritis and cystitis. The perforation is most likely to occur
in the bladder, from which the infection ascends the ureters to the kidney.
It is not necessary to have a large tumor to perforate the urinal tract;
simply a suppurating focus is sufficient. It is not necessary to
have a complete perforation of the urinary tract to allow infection to
gain an entrance, for the germs, or their products (ptomaines), may penetrate
a thin pathological wall. The final result of an infected urinary
tract is ureteritis, with parenchymatous or interstitial nephritis.
The writer has observed some disastrous results from pyosalpinx perforating
the bladder and intestines. It may here be noted that Doran, a most
excellent observer, made postmortem examinations of forty women who had
died of ovarian tumors, and thirty-two had severe kidney disease.
This means that 80 percent of those who died from ovarian tumors had kidney
disease. No doubt the kidneys were diseased from the presence of
tumors. Obstruction, reflex action or infection was the causative
factor of renal disease, resulting from pressure of tumors.
A good sample of obstruction, reflex irritation
and infection of the urinal tract is seen in cases of gonorrhea in men
which end in stricture and "catheter life." The stricture generally arises
in the urethra and marks the onset of obstruction to the urinary flow.
This increasing obstruction induces constant reflex irritation, and yet
the man is not subjectively or objectively sick. But now he begins
"catheter life," which means infection. It means self-destruction
by his own hands. Thus to obstruction and reflex irritation of the
urethra he has added the fatal infection carried on his catheter, which
too frequently makes the fatal march swiftly onward and swiftly downward.
The kidney suffers similarly from any abdominal
tumor, and chiefly by reflex irritation, which passes from the abdominal
brain by way of the contiguous plexus, where it is reorganized and emitted
on the large renal plexus to the kidney. The writer notes that those
women who come to him for the purpose of having tumors removed have a very
variable quantity of urea in the urine. At the Woman's Hospital the
writer has the urea tested in every case of laparotomy, and the amount
varies from five to eleven grains to the ounce. The tumors appear
to play a significant role in the production of varying quantities of urea.
What has been said in regard to kidney disease by
reflex irritation is equally prominent in floating or excessively movable
kidney. The dragging of the kidney on the abdominal brain, through
the renal plexus, unbalances the viscera very distinctly. The patient
suffers from nausea, from constipation, from disturbed secretion and circulation
and from dull dragging pains. The patient may sometimes suffer similarly
from an artificially fixed kidney, as I have observed often after a nephropexy
of my own, when viscera, which are normally excessively mobile or fixed,
are dislocated, they lose a part of their physiology, which is motion.
Calculus in the ureter is a typical sample of disturbance
in the sympathetic nerves. One of my patients was idle ten months
before I removed a ureteral calculus, and she suffered from an unbalanced
sympathetic nervous system just as a woman would from diseased genitals.
Abdominal and pelvic tumors produce disease in the
digestive tract. Object lessons are not only impressive to children,
but to adults. The wonder is how the visceral organs can adapt themselves
to growing and movable tumors. Today we removed an ovarian tumor
the size of a child's head with a narrow pedicle of seven inches.
The tumor could be pushed into almost any position of the abdomen.
Yet this tumor, which the patient has had for about ten months, appears
to have told on her health. To be sure it glided where it would without
any apparent trouble, but doubtless the continued, repeated and accumulated
traumas on the other viscera maintained a constant story of visceral insult.
Every step she took induced the tumor to jog and roll around in the abdomen.
Occasionally it would become partially wedged in the pelvis, producing
congestion and disturbed circulation and insults to the delicate nerves
of the peritoneum. This solid tumor was not like the yielding, soft
viscera; but wherever it would lie it pressed and disturbed circulation.
It is probably true that smaller tumors of the pelvis and abdomen produce
much more traumatic visceral insult than larger ones which move but little.
The real wonder was that such a tumor as the above could glide about among
the mobile viscera so long and not become rotated on its axis.
It is probable that secreting or glandular organs
suffer the most from abdominal tumors, because the main damage is through
reflex action, and the glands are the most highly supplied with sympathetic
nerves. The digestive tract should be studied by means of (a) sensation,
(b) motion, (c) secretion, (d) absorption. The slow, continuous pressure
of abdominal tumors produces but little recognizable sensation in the digestive
tract. Another point is that from inexperience the patient cannot
localize the pain in the digestive tract, but refers it mostly to the abdominal
brain; so that the subjective sensation in the digestive tract, due to
tumors, is of small value. As regards motion in the digestive tract,
in cases of abdominal tumors, one can say that in the great majority of
fair or large-sized tumors motion is diminished and constipation is the
rule. But the main study of damage of abdominal tumors in the digestive
tract will be through the secretions. Secretions are altered in three
ways: (a) they may be excessive, (b) decreased, or (c) disproportionate.
The final result is indigestion. The irritation
from the tumor is carried on the plexus of any contiguous viscus to the
abdominal brain, where it is reorganized and emitted to the digestive tract
over the gastric plexus, the superior mesenteric plexus and the inferior
mesenteric plexus. In any case the brunt of the forces ends in the
ganglia which lie just below the mucous membrane; the ganglia constitute
what is known as Meissner's plexus, which rules secretion.
If the irritation be of such a nature as to produce
excessive secretion, diarrhea may result. The excessive secretions
will decompose, ferment, and induce malnutrition. It is common to
observe in women with tumors, spells of indigestion, and especially in
times of excessive irritability. No doubt at such times the irritation
assumes a prominence not experienced on other occasions. If the irritation
is of such a nature as to diminish secretion, constipation will likely
result. An inactive digestive tract is the forerunner of non-elimination
and a waste-laden blood. It is common to observe anorexia for weeks
at a time, accompanied by constipation, in women who have tumors.
No doubt the main chapter in altered secretion consists in what may be
termed disproportionate secretion. The elements which make up the
digestive fluid are not secreted in normal quantities; one element is deficient
and the other is excessive. The normal relations of acidity and alkalinity
are changed so that constant fermentation arises. Again, from the
irritation of an abdominal tumor, individual organs do not secrete their
normal quantity or quality.
The liver may secrete excessively or deficiently.
The pancreas may do too much or too little. The irritation may cause
segments of the alimentary canal to secrete excessively or deficiently
and thus destroy the finely balanced secretion of the canal as a whole.
The stomach enteron, small intestines, may, by the irregular irritation,
do too much or too little, or act irregularly. This produces decomposition
in the fluid and fermentation results. Such women are continually
troubled with "wind on the stomach." Diarrhea and constipation quickly
alternate and the result is frequent attacks of acute indigestion.
Disproportionate secretion is the most frequent
and disastrous, because the irritation from the tumor is irregular.
It storms one day and sleeps the next. But the nature of irritation
is to be inconstant and to rush pell mell over the nerve plexuses, or to
assume a profound quietude. Irritation scampering over the plexuses
month after month is sure to be followed by indigestion, malnutrition,
anemia; and the final ending of the poor patient is neurosis.
The subject of pressure of abdominal tumors on the
digestive tract may here be considered. The effect of pressure acts
in two directions: (a) on the alimentary canal and (b) on the tumor itself.
The effect on the canal may be (a) to derange the secretion and motion
of the segment pressed on; (b) to perforate the canal; (c) to obstruct
the canal. The more serious effect of the tumor pressure on the digestive
tract arises from the changes which result in the tumor itself. The
changes arising in the tumor from the alimentary canal are: (a) inflammation,
(b) adhesion. (c) suppuration and (d) rupture. The main idea is that
infection or its product (ptomaines) enters the tumor through the gut wall.
It frequently happens in laparotomy that some part of the digestive
tract is firmly adherent to the tumor. The cause of this adhesion
is the formation of exudates into organized tissue which binds the intestinal
wall and tumor together. The irritation from the contact of the intestinal
wall and tumor induces the passage of germs or their products (ptomaines)
through the wall of the intestine, which gives rise to an exudate.
The writer has fully satisfied himself that considerable inflammation,
adhesion and suppuration, which are found to exist in tumors, are due to
the passage of the morbid matter through the intestinal canal. It
is not uncommon for one to find from an inch to a foot of intestine firmly
attached to a tumor, when the great gateway of infection, the oviducts,
show no traces either ancient or recent. The vermiform appendix is
a certain source of infection, not only in abdominal tumors, but also of
the genital organs.
Considerable inflammation and adhesion of intestines
(and occasionally of other organs) when abdominal tumors exist is accounted
for by infection passing through the intestinal wall into the tumor.
As regards suppuration in abdominal tumors, due to infection arising from
the alimentary canal, it may be said that it is only a stage in advance
of inflammation, and that inflammation is only a degree short of suppuration.
So that in one sense they are the same process. In the case of inflammation,
the white blood corpuscles have conquered the invaders and resisted further
progress; while in suppuration the invading infection destroys whole fields
of vital tissue, leaving focuses of local death - necrosis. The pus
formed by these infections through the intestinal wall may be safely evacuated
by way of the alimentary canal. But frequently fatal issues follow
either rapidly or through long exhausting processes.
The sympathetic pathological course which abdominal
tumors induce in women are: (1) irritation, (2) indigestion, (3) malnutrition,
(4) anemia, and (5) neurosis. The irritation passes by reflex action
to the digestive tract (including the liver and pancreas). The irritation
destroys in the digestive tract (a) the rhythm of the liver, pancreas and
alimentary canal by emitting irregular forces over the plexuses at irregular
periods (the reflex action has no regard for rhythm); (b) the irritation
produced by the tumor on the canal destroys its motion; (c) it destroys
its sensation; (d) it destroys its normal secretion; (e) it destroys absorption.
Indigestion is a natural result of imperfect rhythm,
motion, sensation, absorption and secretion of the alimentary canal.
Long continued indigestion results in malnutrition; which finally ends
in anemia. In anemia the fluid tissue known as blood is proportionately
deficient in its constituents, and the innumerable nerve ganglia being
bathed in waste-laden and impoverished blood, the woman is finally reduced
to an irritable condition, or neurosis.
One of the strange features of abdominal tumors
with long pedicles is that so few rotate on their axes. In autopsies
I have noted the spleen resting on the pelvic floor with a long, narrow
pedicle, but no symptoms of rotation. Dr. Lucy Waite and I have removed
tumors with astonishingly long and thin pedicles with no symptoms of present
or past axial rotation. Dr. Orville MacKellar and I removed an ovarian
tumor about the size of a year-old child's head with a thin pedicle about
eight inches long, with no symptoms of past or present rotation.
We could push the tumor all over the abdomen from the pelvic floor to the
diaphragm. We observed the long-pedicled tumor roll about among the
loose intestines after opening the abdomen, and wondered why its pedicle
did not twist.
However, I have removed tumors which had no pedicle. They had
been twisted off their pedicles by axial rotation and had assumed new beds,
which were nourished by the newly formed vessels from adjacent viscera
and tissue, especially the omentum. It is a significant fact, noted
by all practical gynecologists, that when a woman acquires a tumor, it
may only be recognized, she will frequently fret and chafe under it until
she becomes nervous and irritable and her coolness and quiet serenity leave
her. She also tires easily and does not sleep well.
Such a case came to me a few days ago, from whom
Dr. Lucy Waite and I removed an orange-sized ovarian tumor per vaginam.
This lady I treated seventeen years ago, when she was a blooming, vivacious
girl. Some ten months ago she began to complain of ill-defined symptoms.
A general practitioner treated her a year ago and examined the pelvic organs,
but failed to find the tumor. Finally, she and her husband decided
to consult a gynecologist, and came to me. In eight to ten months,
from the rotation of the tumor, her nervous system had lost its fine, even
balance of former years. She slept poorly, was irritable, appetite
was poor, and she was easily tired out and had lost all her old vivacity.
It was all due to reflex action from a large orange-sized pelvic tumor.
The disturbance will disappear with the tumor.
Abdominal tumors should be removed on account of
danger of axial rotation. The literature which takes note of a tumor
rotating on its axis covers only about thirty years. Rokitansky,
of Vienna, was among the first to call attention to the subject.
The writer estimates from literature and observation that about 8 per cent.
of ovarian and parovarian tumors rotate on their axes. In 1891 Mr.
Tait told the writer that he had, up to date, sixty-two cases of rotated
tumors. While a pupil of Mr. Tait, for six months, the writer saw
four tumors rotated on their axes. Almost any - abdominal or pelvic
tumor may rotate on its axis. The writer has observed - in an autopsy,
rotation of the cecum and ileum on each other three-quarters of a turn,
but insufficient to obstruct the cecal current. Volvulus is only
axial rotation of the sigmoid on the mesosigmoid. In the intestinal
tract volvulus occurs in the sigmoid flexure in 60 per cent. of cases;
in 30 per cent. at the cecum, and in 10 per cent. in the small intestine.
Axial rotation of the digestive tract constitutes about 4 per cent. of
all intestinal obstructions. It is no doubt due to a fatless, elongated
mesentery (enteroptosis) and previous constipation. As regards the
causes of axial rotation of abdominal tumors, the writer is convinced that
it is due to visceral rhythm.
The first rotated ovarian tumor I observed was in
Prof. Czerny's clinic in 1884. The tumor was removed with fatal
Any viscus which possesses an elongated attachment
may rotate more or less on its axis. The uterus has been found rotated
so as to demand operation. My assistant, Dr. A. Zetlitz, operated
on a patient in whom the uterus was found with almost a full rotation,
due to a contracting cicatrix from an old inflammatory attack. The
kidney can, and does, rotate on its axis, resulting in partial or complete
obstruction - the obstruction of its ureter causing hydroureter and the
obstruction of the renal vein due to twisting, interfering with circulation
and nourishment. It is possible for the spleen, in certain abnormal
conditions, to rotate on its axis. In one autopsy I found the spleen
on the pelvic floor with a thin, partially rotated pedicle.
Axial rotation of abdominal tumors may be partial
or complete, acute or chronic. An acute case generally acts in the
following manner: A woman has an abdominal tumor. She has a sudden
onset of pain; she will perhaps vomit. In twenty-four to forty-eight
hours the abdomen will gradually enlarge. If it enlarges very extensively,
the patient becomes pale and faint. The enlargement is the result
of (a) the obstruction of the return venous flow from the tightness of
the twist in the pedicle; (b) the dilatation of the veins in the tumor,
and (c) the rupture of a vein in the tumor.
The rigid-walled artery is difficult to occlude,
and so keeps pumping its stream of blood into the tumor. The soft-walled,
easily compressible vein is quickly occluded by the twist in the pedicle,
and so all or nearly all the blood pumped in by the artery is retained
in the tumor. The consequence is a sudden abdominal enlargement.
Of course a woman may bleed to death into her own tumor, and such cases
are on record, confirmed by autopsy. The tumor may twist so much
on its pedicle that it may occlude both vein and artery. I had such
a case in a girl twenty years old. When the abdomen was opened the
tumor was gangrenous. It may rotate so vigorously that it will be
entirely twisted off or severed from its connections. In such cases
the tumor acquires nourishment from the surrounding viscera. The
trauma resulting from the axial rotation induces sufficient irritation
to produce an exudate on the surface of the tumor. This exudate undergoes
organization, acquiring blood-vessels, nerves and lymphatics sufficient
to nourish the tumor without its old pedicle. The writer saw, with
Mr. Tait, one tumor sufficiently rotated on its pedicle to occlude the
vein and artery, which was nourished by innumerable delicate, newly organized
processes of visceral tissue.
In my own practice, while performing laparotomy,
I have been surprised to find a dermoid ovarian tumor the size of a cocoanut
entirely without a pedicle. It was wholly nourished by omental adhesions.
The patient gave me a history of a severe attack four years previous, from
which time pain and tenderness continuously clung to her. My attention
was first called to axial rotation of tumors in 1884, at Heidelberg, in
the clinic of Professor Czerny. One day a middle-aged lady suddenly
appeared in the clinic who had come from her home in the country very sick.
The professor put her on the table and examined her carefully. She
had a high pulse and temperature and a dusky countenance. She appeared
very ill. Professor Czerny said: "Gentlemen, I cannot make the diagnosis.
I will examine her again and perhaps operate tomorrow." The writer anxiously
waited until the next day, when, sure enough, the woman was put to sleep
on the operating table. On opening the abdomen, a tumor the size
of a melon appeared in the wound. It was dark red in color, and Professor
Czerny pronounced it gangrenous. It was easily removed and its pedicle
ligated. That was a cyst rotated on its axis;
and, besides, it was not gangrenous, as such tumors rarely become gangrenous
in the abdomen, and, if washed well, will show the color of normal tissue.
Gangrene generally comes from tapping such cysts, or the digestive tract
may infect them. Cases have been frequently recorded where death
followed tapping. Intestinal contents entered the cyst and infection
Axial rotation of abdominal and pelvic tumors may
pursue a chronic or slow course. In such a tumor diagnosis is very
difficult. The pain in such cases will be almost wholly carried by
the sympathetic nerve, and pain due to irritation of the sympathetic is
generally a dull, heavy ache. It is a dragging pain. Cerebro-spinal
nerves induce sharp, lancinating pain. So that slow axial rotation
of the abdominal tumors will be accompanied by dull, heavy, dragging pain.
It may be noted that whenever there is more than one tumor in the abdomen
the chances are very much increased for axial rotation. Pregnancy
enhances axial rotation much more than the presence of a double tumor,
because the uterus empties itself suddenly, and just after labor the tumor
is apt to rotate. The writer has seen Mr. Tait operate on a woman
six weeks after delivery for an abdominal tumor which rotated about three
times and a half on its pedicle. She was quite ill from delivery
until after the operation, when she rapidly recovered.
In my practice I have observed axial rotation of
ovarian tumors, ileocecal apparatus, sigmoid flexure, ovario - oviductal
apparatus in a young girl, with rotation of uterus.
The strikingly easy manner in which operators speak
of gangrenous tumors in the abdomen, with recovery, calls for objections.
Recovery after gangrene or local death in the abdomen is extremely rare.
What is usually called gangrene is simply tissue filled with venous blood.
Now, if this dark tissue is removed and well washed,
the gangrenous idea will be dispelled by the frequent appearance of normal
white tissue. Air must in some way get to a tumor to admit of gangrene,
and air enters by (a) tapping, (b) digestive tract, (c) genito-urinary
tract. If a cyst has rotated sufficiently to twist off its pedicle
and become nourished by adhesions to adjacent viscera it is more dangerous
than the original tumor on account of its fixation and adhesions.
It is generally more liable to infection from the natural channels, from
its more extensive vascular connection. A tumor should be removed
from its liability to axial rotation. A tumor rotated on its axis
is dangerous to a patient from (a) hemorrhage into the cyst. (b) gangrene,
(c) because it may unduly enlarge from filling the veins of the tumor,
(d) it may become fixed by adhesions and thus endanger the viscera, a fixed
tumor being more dangerous than a movable one, (e) it may become infected
and suppurate, (f) chronic axial rotation may exhaust a patient by pain,
(g) it may result in trauma to viscera or perforation of viscera by pressure.
Abdominal tumors should be removed on account of
the danger of rupture. It is a fact, which the writer has definitely
observed, that tumors (ovarian and parovarian) will repeatedly rupture
and fill in the living woman. In one case under my care the parovarian
cyst repeatedly ruptured and filled during a year's personal observation.
At the time of rupture the young woman of twenty-four would experience
a sense of relief. The abdomen would become flattened and during
a few succeeding days she would urinate frequently and profusely.
Years previously the writer had demonstrated that if a dog's peritoneal
cavity was filled with water he would urinate profusely for two or three
days. In removing ovarian tumors the writer has found old scars where
such cysts had ruptured and refilled. The rupture may be due to violence
or the continued pressure on some point of the tumor, thinning its walls
so that leakage occurs.
A rupture of non-infected cyst does no harm to a
woman, but when a cyst containing infected material ruptures in the abdominal
cavity death is almost inevitable. Hence, such tumors which menace life
should be removed on discovery. Cystic abdominal tumors are apt to
rupture from increase of abdominal pressure, which, being sustained for
a long time on single points of the cyst, either thin its walls so that
they will leak, or rupture them by any violence. In one case the
writer removed an ovarian tumor which gave a distinct history of rupture
one year previous. A distinct scar about the size of a fifty-cent
piece was found on the cyst to tell the story of rupture. Abdominal
tumors may endanger life by rupturing info hollow viscera as intestine,
bladder, or vagina. From such rupture infection is almost sure to
follow. The worst infection follows rupture into the digestive tract,
and second into the bladder. The writer has removed ovarian tumors
with success which had ruptured into the digestive tract and almost destroyed
the patient by chronic suppuration and exhaustion. About the worst
of such tumors are ovarian dermoids. which rupture into the sigmoid or
rectum, for they make gainst such dangerous adhesions. The two cysts
may press so hard and long against each other that the walls in contact
will fuse and the rupture will occur in the fused septum, which complicates
by more adhesions and size of tumor.
The pressure occasioned by abdominal tumors demands
their removal. A tumor pressing for a long time against a gut wall
may thin it so that germs or their products may pass into the tumor and
infect it. Inflammation follows and may be accompanied by suppuration.
But pressure must be observed to take place in two directions, viz., toward
the tumor and toward the viscus. The damage from pressure in the
abdominal tumors is threefold: (a) the effect of pressure on viscera: (b)
the effect of pressure on the tumor, and (c) the effect of the pressure
on the function of viscera, both remote and distant. This last idea
was discussed under reflex action. It was shown how abdominal tumors
induced hydroureter by partial or complete occlusion of the ureters.
Tumor pressure will even induce interstitial and parenchymatous nephritis.
Three-fourths of women long possessing abdominal tumors have kidney disease.
The tumor may press on some segment of the digestive tract and induce obstruction
of the fecal current, either mechanically or by reflex paralysis.
The main point of pressure is on some fixed portion of the intestine, the
rectum, sigmoid or colon.
The canals, ureter or intestine, curiously maintain
their patency for a long time on account of their continual dilatation
and contraction. The writer has seen these canals entirely surrounded
by dense tissues of tumors, but a distinct tunnel still existed through
the tumor, considerably larger than the empty collapsed canal. The
abdominal tumors, in a word, by pressure, induce obstruction, mechanically
or by reflex irritation (spasm or paralysis), and should be removed.
The continued pressure gives rise to (a) inflammation, by allowing infection
to travel; (b) the inflammation may go on to suppuration and end in perforation,
internally or externally.
The effect of pressure on the circulation (vascularity)
is very apparent It acts mainly, or the effect is more evident, on the
great venous plexuses. The hemorrhoidal from the inferior mesenteric
suffers the most, as many of such patients have hemorrhoids. The
effect of the pressure on the plexus pampiniformis is also plain, as also
on the vaginal plexus and the venous bulb of the pudendum. Areas
of tissue become cedematous. The limbs swell. The pelvic organs
suffer the main brunt from mechanical pressure, while distant organs evidently
suffer most from reflex action. The effect of mechanical pressure
on circulation is (a) congestion, (b) oedema, (c) dilation of veins (hemorrhoids).
It must not be forgotten that since the sympathetic is mainly distributed
to blood-vessels the reflexes from pressure on the vessels are effective
and profound, local and general.
The writer has noted the effect of tumors on the
color of the skin for a long time. It has been recognized that pigmentation
arises mainly from the spleen. Jastrowitz started the view that the spleen
was the source of pigmentation, by dividing the sympathetic plexus going
to the spleen on the spiral splenic artery. This experiment enhanced
pigmentation. No doubt the liver is a second source of pigment, from
the fact that it buries red corpuscles, and pigmentation is very noticeable
in malaria which profoundly affects the liver (and spleen also).
But still the spleen may be credited with the main origin of pigmentation.
The writer has noted nearly all colors of pigmentation (brown. black and
yellow) in such women, especially in a woman who has had a tumor a long
time. The author saw a woman last month who had had a tumor for sixteen
years. Her color was a deep brown and yellow, with patches of atrophied,
glistening skin interspersed. The tumor disturbs the rhythm of the
spleen. The spleen is capable of a rhythm by (a) its elastic covering
of peritoneum, (b) its elastic capsule, (c) by the power of its cells to
enlarge on receiving excessive blood. When the tumor irritates the
splenic plexus it destroys its rhythm, and hence its nourishment.
The nourishment being disturbed, the distribution of its products - pigment
- will be disturbed. Irritation induces the spleen to produce excess
of pigment. The parts of the body most intensely pigmented are those
exposed to air. Yet the pigmentation is general. The simplest
example of pigmentation is observed in pregnancy, which is generally localized
in the genitals, breasts and linea alba.
But abdominal tumors create more definite and general
pigmentation. The pigmentation is effected by the irritation passing
to the abdominal brain, where it is reorganized and emitted to the spleen.
The irregular forces coming at irregular intervals to the spleen derange
its rhythm, and consequently its nourishment. Pigmentation is the
result of a silent process accomplished by reflex irritation, and shows
general derangement of the visceral economy. It is merely the outward
manifestation of profound processes, indicating removal of the offending
invader. It is difficult to convince physicians that a laparotomy
is really demanded to remove adhesions. Adhesive bands have blood-vessels,
lymphatics and nerves.
A tumor should be removed because of its danger
to create adhesions, but after they have formed they often require removal.
They should be removed when they give rise to pain, when they distort and
unbalance the viscera. They may occasion obstruction to any hollow
viscus. They may strangulate some viscus.
Even the lungs do not escape the evil influence
of the presence of the abdominal tumor. The disturbance in the lung
is mainly due to reflex irritation which disturbs the rhythm of the lungs.
Abdominal tumors should be removed, from their liability to become
The question may be asked, How does an abdominal
tumor become infected or inflamed? Tumors
frequently become infected, as is easily attested at the operation, by
observing adhesions - the result of infection.
The great highway by which abdominal tumors become
infected is through the oviducts. Any laparotomist can easily see
that inflammatory exudates arise at the fimbriated ends of the oviducts,
and from there spread. The infection travels by natural routes, especially
along mucous channels. It travels particularly through the left oviduct,
because, as the writer has demonstrated, the lumen of the left tube is
larger than that of the right.
The second great highway of infection of abdominal
tumors is through the digestive tract. Germs or their products pass
through the intestinal wall at pressure points and infect the tumor.
The third channel of infection is through the genito-urinary
tract. A fourth is by tapping, allowing air to enter. The table
presented with this article will show at a glance the reasons for removing
EFFECTS AND CONSIDERATIONS FOR THE REMOVAL OF ABDOMINAL PELVIC TUMORS.
3. Fatty degeneration.
1. Disturbed rhythm - asthma.
2. Catarrh - anemic, hyperemic.
1. Disturbed rhythm.
2. Disturbed secretion.
4. Nerve influence can check all secretion.
(a) Excessive secretion.
(b) Deficient secretion.
1. Nerve impression can check all secretion.
(a) Excessive secretion.
(b) Deficient secretion.
2. Reflex irritation.
3. Obstruction (hydronephrosis).
(b) Interstitial inflammation.
Digestive Tract -
(a) Excessive secretion.
(b) Deficient secretion.
1. Disturbed rhythm.
1. Through oviducts.
2. Digestive tract.
3. Genito-urinary tract.
4. By tapping.
3. Adhesions peritoneal.
Axial Rotation -
1. Due to visceral rhythm.
2. Ten percent of ovarian and parovarian tumors
3. Pregnancy and other tumors enhance axial
4. Diagnosticated by sudden pain and increase
in size of abdomen.
1. Sudden changes in form of abdomen.
1. Induce pain.
2. Check peristalsis.
3. Cause reflex rhythm.
4. Disturb secretion.