The Abdominal and Pelvic Brain
Byron Robinson, M. D.
GENERAL VISCERAL NEUROSES.
The Peritoneum holds in intimate connection the tractus intestinalis,
tractus genitalis and tractus upinarius by means of the (a) sympathetic
nerve, (b) blood-vessels, (c) lymphatic vessels, and (d) connective tissue.
A pathological focus, a reflex, in any one of the three great abdominal
visceral tracts, produces disordered rhythm or wild peristalsis in both
of the other tracts.
"The telegraph is the nervous system of the world." - N.Y. Herald.
The subject of visceral neuroses must be considered
under three heads, viz. :
1. Sensory Neuroses. - The state of the sensory
nerves must be considered. There will be two morbid states of the
sensory nerves to consider: (a) pathological lesions of a more or less
demonstrable sort, either in actual changes in structure or evident in
reflex action, (b) a neuralgic condition, a state in which no pathologic
lesion is demonstrable, a kind of morbid or exalted sensibility or over
susceptibility are those of the sensory sympathetic nerves. The neuralgias
and exalted sensibility will be discussed under the hyperesthesias of the
abdominal brain and its radiating plexuses of nerves.
2. Motor neuroses, the second subject, including
visceral neurosis, are those of motion, such as visceral rhythm, motus
3. Secretion neuroses, the third subject included
in visceral neuroses, will include the phenomena of secretion, such as
excessive, deficient or disproportionate secretion.
Under this head we will include a series of phenomena
of the viscera, partly pathologic and partly reflex, partaking of a disturbance
of sensation, motion or secretion. By visceral neurosis we mean an
undue irritability or perverted function of one or more of the viscera.
The pathologic condition may be demonstrable or not. Frequently it
is pathologic physiology.
In the phenomena of visceral neuroses must be included
the clinical fact that if one organ is disturbed it will tend to unbalance
the remainder, i. e., irritation is reflected by a nerve arc from one viscus
to another. A diseased uterus is frequently followed by a disturbed
stomach. A checking of normal function not only makes neurosis but
indigestion, non-assimilation and anemia. Such a case occurred in
the person of a young woman on whom I performed laparotomy. A few
months after the operation she began to suffer tenesmus, spasmodic dragging
pain in the sacrum at defecation, and colica membranacea arose. She
became slowly ill, neurotic and unable to work. Dr. Lucy Waite and
I operated on her and all that we found was an organized peritoneal band
several inches long stretching from the amputated oviductal stump to the
middle of the sigmoid. The peritoneal band checked the normal peristaltic
action of the sigmoid, producing pain, non-assimilation, anemia and indigestion.
She became well after the operation, gaining some twenty pounds.
In over a dozen cases during the past three years Dr. Lucy Waite and I
have reoperated for old post-operative peritoneal adhesions. We generally
found that some loop of bowel was attached to the amputated end of the
oviduct and checked more or less the bowel peristalsis. Hence, partial
checking or hindering of bowel peristalsis produces a peculiar kind of
neurosis. All one may notice at first in such cases is irritability.
Pain may not be spoken of as the chief annoyance. These subjects
with peritoneal bands, which more or less interfere with visceral rhythm
and peristalsis suffer in distant organs from reflex irritation radiating
to them. It should be remembered that reflex action goes on in health and
disease. Nerves like railway cars carry any kind of freight.
The essentials of a nervous system consist of (a)
a central nerve cell, (b) a conducting cord, and (c) a peripheral apparatus.
However vast the nervous system, the elements are the same. For example,
the skin is the peripheral apparatus, the spinal nerves are conducting
cords and the spinal cord the central nerve cells. The same form
of illustration may be made in regard to the abdominal and pelvic brain
as in the central nerve cell. The superior and inferior mesenteric
plexuses of nerves are the conducting cords (for the intestines) and the
peripheral apparatus is in the mucosa. In visceral neuroses pain
is not always the chief symptom. Subconscious irritation plays the
chief role; irritation which does not come within the field of recognized
Among visceral neuroses we should include enteroptosia.
The maladie de Glenard is doubtless a neurotic disease belonging to the
domain of the nervous vasomotorius. Recently Dr. Schwerdt has written
some interesting and well studied articles on enteroptosia. Visceral
neurosis means that the nervous system in the abdomen and the organs are
not living in harmony. The gamut of the sympathetic nerve has lost
Enteroptosia begins in respiration and from a weakness
of the abdominal sympathetic, which became tired and slacken in its tone.
The sympathetic nerves to the viscera have lost their normal power over
circulation, assimilation, secretion and rhythm; but the sympathetic nerves
have lost their influence over the viscera very slowly, for the enteroptosia
is a very slow disease at first and has a long chronic course from the
beginning. It may require years to develop. In a later stage
of enteroptosia the disturbance of feeling and motion arises, and the nervous
symptoms of disturbed digestion, aortic palpitation and dragging sensation.
Later the disturbance of motion occurs. The abdominal walls slacken,
lose their tone and atrophy even the extremities losing some of their delicate
balance. But with the lowering of the intra-abdominal pressure the
real ptosia of the viscera begins and the neurosis rapidly increases.
The anatomical visceral pedicles elongate, the organs begin to leave their
SYMPATHETIC NERVE IN LUMBAR REGION
114, ganglia at origin of inferior mesenteric artery; 115, interiliac
nerve disc; 112, lateral sympathetic chain; 156, rectum; 181, common iliacs.
The digestive tract being disturbed, the nervous
system suffers from auto-intoxication. Assimilation
becoming deranged by a continuously disturbed digestive tract, a vicious
circle begins its progress. The motor, sensory and secretary nerve
apparatus, each and all, become involved. Anatomically, we observe
the order of visceral ptosia (I base this on some seven hundred personal
autopsies) to be the following: 1, the right kidney; 2, the stomach; 3,
the small intestines; 4, the transverse colon; 5, the spleen; 6, the liver,
and 7, the genitals. Visceral ptosia belongs in the vast majority
of living diagnoses to women, but autopsies show the disease quite common
in women and not rare in men.
The slackening and atrophy of the female abdominal
wall makes the diagnosis easy, while the retention of tone in the abdominal
wall of men not only makes visceral ptosia rare in men but more difficult
to diagnose. The typical enteroptosia occurs in old age when the
sympathetic has lost its tone and vigor. In a normal condition of
the abdominal viscera the several organs hold a harmonious relation to
each other, no nerve plexus is stretched or slackened, and function, secretion,
assimilation, circulation and rhythm move without friction. Now,
with dislocated organs dragging irregularly on the nerve plexuses, deranging
secretion and assimilation, the suffering becomes manifest in what we know
as visceral neurosis. Some designate it hysteria. The lost
tone and vigor of the anterior abdominal wall is unfortunate because its
vigorous aid to peristalsis is wanting. The loss of the muscular
action of the anterior abdominal wall allows congestion of blood and secretions
to arise; and constipation intervenes.
In visceral ptosis the skin presents anesthesia
and hyperesthesia, also vicarious actions to elemental products.
In enteroptosia we have various functional paralyses. The physical
and mental vigor is paretic in enteroptosia. It produces languor.
The intestinal tract is sluggish, paretic. The bowel suffers in two
ways, first, from auto-intoxication; second, from the irritation of the
decomposing material on its mucosa, which reacts on the nervous system.
The disturbed skin trouble in enteroptosia points to hydrotherapy as the
best way out. Baths open the drains of the skin. Enteroptosia
is a functional disease.
In enteroptosia as a visceral neurosis we deal with
several stages, each of which presents distinct landmarks.
In the first stage we deal with increasing muscular
weakness. The patient complains of manifold sensations on account
of disturbances in the sympathetic, anemia, defective assimilation and
loss of weight. Physical and mental energy become lowered and intra-abdominal
pressure becomes lessened. The disease may not extend further.
In the second stage of enteroptosia the name of
the disease is quite apt, for the individual viscera begin to leave their
old, natural beds. They become dislocated, and permanently fixed
in wrong positions. (However, by force or the patient assuming an unnatural
position the dislocated viscera may resume their proper position.) With
the dislocated organs begin the visceral neuroses, the indigestion and
the auto-intoxication. In this stage the abdominal brain and its
radiating plexuses, as well as the vessels surrounded, must become adjusted
to the new environments of dragging and pressure; compensations of atrophy
and hypertrophy will arise. For example, the power of the muscular
wall of the abdomen being lessened, the digestive tract must compensate
by increasing its muscular wall in order to, drive onward the fecal mass.
The third, and final, stage of enteroptosia may
be observed in some old people. It is the stage in which compensatory
hypertrophy fails; and the viscera becoming overfilled, depletion is very
imperfect. The digestive tract is unable to empty itself from the
remnants of its feasts, and excessive venous congestions arise, the bladder
is able to expel but a little urine at a time and the digestive tract suffers
from the absorption of toxins and the irritation from decomposing material.
In one case of enteroptosia, postmortemed by Dr.
Lucy Waite and myself, the greater curve of the stomach rested on the pelvic
floor. The subject was an old man. In another case in which
I performed the autopsy the spleen was resting on the pelvic floor.
It is common in autopsies to find the right kidney movable for two inches
proximalward and two inches distalward - a range of four inches.
The transverse colon is frequently found in the pelvic cavity.
The treatment of enteroptosia may be summed up in
the words, hydrotherapy and abdominal support. The young surgeon
who performs nephrorrhaphy for movable kidney will have his hands full,
if he has a large practice, for I know from personal experience in autopsy
and practice in gynecology and abdominal surgery, that movable kidney is
a very frequent occurrence. I should judge that five women out of
ten, who come to my office, have a movable right kidney. Movable
kidney is a part of enteroptosia - nephroptosia. Now, since patients
afflicted with enteroptosia suffer from autointoxication, non-elimination,
non-drainage and congestion, we must aid Nature by establishing general
drainage. Frequent salt baths, persistent massage and abdominal supporters
are required in the treatment. Above all, the digestive tract must,
be frequently evacuated once daily by administering a full glass of water
with half a dram of epsom salts and ten drops of tr. nux vomica every night
on retiring, and insist on the patient emptying the bowels regularly every
morning at the same hour. The abdominal bandage should be of elastic
flannel and fit snugly. It may be removed at night. The abdominal
binder affords much comfort. In fact, one of the methods of diagnosing
enteroptosia is to elevate the viscera and then to note whether the pain
It may not be forgotten that enteroptosia offers
opportunities not only for visceral neuroses, but also for obstinate constipation,
which favors the development of visceral neuroses by over-retention of
feces, including decomposition of matter, calling up irritation and auto-intoxication.
Each factor in enteroptosia induces a vicious circle. The factors
in enteroptosia which solicit constipation are:
1. Flexing of the colon by the ligamentum hepato-colicum.
2. Flexing of the colon by the ligamentum
3. Flexing of the right colon by the ligamentum
phrenico-colicum dextrum. I have seen the right colon in the pelvis
hanging by this band.
4. Flexing of the pylorus by the ligamentum
5. Atony of the gastrointestinal muscularis.
6. A lowering of the intra-abdorninal pressure
by atony of the anterior abdominal muscles.
7. The excessively mobile viscera with elongated
pedicles locally compromise the bowel lumen as well as that of vessels.
In sensory visceral neurosis (or neuralgia) we are
doubtless dealing with a peculiar form of malnutrition of the nerves of
sensation. Hence in these days of scalpel or no scalpel, of sweeping
removal or surgical repair, it behooves us to diagnose with caution the
symptoms of disease. In disease we are seldom dealing only with signs,
which are distinct clews to disease, but chiefly with symptoms which are
only indications of pathology. In visceral (abdominal) neuroses we
are dealing with organs which possess (a) motion, (b) sensation and (c)
secretion; i. e., such organs have muscles which are set in motion by motor
nerves, sensation made manifest by some irritation on the sensory nerve
ends, and secretion which proceeds normally in certain quantities, but
in disturbed conditions, (a) excessive, (b) deficient, or (c) disproportionate.
In visceral (abdominal and thoracic) neurosis we
are chiefly dealing with the vasomotor sympathetic) - a nerve of rhythmical
motion and dull sensation. The term visceral (abdominal and thoracic)
neurosis is a mere name of a symptom in the minds of many physicians, as
we say the kettle boils when we really mean that the water boils or is
raised to such a degree of temperature that the ebullition occurs in the
Visceral neurosis indicates that some deep condition,
assimilation or vicious process is proceeding somewhere. The observing
physician of experience commonly associates in his mind visceral neuroses
with (a) some debilitating process in age or sex. We cast about for predisposing
causes and examine them as a neurotic temperament, hereditary or acquired.
One can acquire a neurotic disposition by dissipation, sexual or with narcotics,
by excessive and prolonged labor, the absorption of poisonous substances,
as lead, arsenic or phosphorus. Rapid changes of temperature bring
on visceral disturbances. (b) We also take into account sex. It is
difficult to say which sex suffers the most from visceral (abdominal) neuroses.
I should judge women do. But different varieties of visceral neuroses
prevail in each sex, and at different periods of life.
(c) The chief age of visceral neuroses is from twenty
to sixty. Few cases occur before twenty and rarely after sixty.
(d) The sexual life of woman is rich in visceral (abdominal) neuroses at
different periods as (1) at puberty, (2) at the menopause, (3) at the menstrual
period, (4) during pregnancy, (5) in the puerperium, (6) there are neuroses
from excess of abstinence from venery. In the above six factors the
circulation plays an important. role. In short, the neurosis is secondary
to some other process.
(e) Visceral (abdominal) neuroses are commonly associated
with genital malnutrition, as in anemia, cachexia from malignant disease,
chlorosis, debility, mental or physical, from irritation, reflex action,
over-strain. Diabetic, gouty and rheumatic persons suffer from visceral
neuroses. In the above factors reflex irritation plays the chief
(f) In the etiology of visceral neuroses we must
include all kinds of trauma to nerves, contraction
SACRAL SYMPATHETIC AND SACRO-SPINAL NERVES
62. This illustration is drawn from a woman about 40 years of
age. It represents the sacral sympathetic and sacro-spinal nerves
1s, 2s, 3s, 4s and 5s, sacral ganglia. Sc. N. sciatic nerve.
The sacral sympathetic ganglia are connected, anastomosed by transverse
of cicatricial tissue, pressure of adjacent organs, tumors and pressure
on nerves, adjacent inflammatory tissue, dislocated organs dragging as
in visceral ptosia; in short, trauma, pressure and dragging.
(g) Many visceral neuroses rest on infection
or intoxication, as malaria, typhoid fever, or poisoning with lead, copper,
mercury and other agents.
(h) Catching cold, rapid changes of temperature,
cold and wet weather, play a role in the etiology of visceral neuroses.
(i) Visceral neuroses may depend on (1) a
small abdominal brain, (2) deficient
blood supply, (3) continued disease, (4) premature senility, (5) temporary
invagination of the bowels.
(j) A peculiar affection of the rectum of
a neuralgic character sometimes arises. It occurs in robust as well
as neurotic persons. The patient will go to bed well and wake up
at any hour of the night, with a severe pain in the rectum, about the large
prostatic plexuses of man and about the cervicouterine ganglia of woman.
I know one patient who has had such an affection for over ten years.
The pain rises to a maximum and remains intense, gnawing and grinding for
front ten minutes to nearly an hour, when it will suddenly pass away.
No cause can be assigned in this case, for the patient lives in apparently
The symptom, par excellence, of visceral neuroses,
is pain. The patients describe the pain in manifold ways as boring,
dragging, burning, stabbing, pressing,. lancinating, grinding and tearing.
Usually the pain is paroxysmal, ceasing in the intervals. The pain
on lessening may be very irregular, slight or intense.
Upon one point concerning neuralgia (visceral or
otherwise) I am doubtful, and that is that the nerves have distinct local
points of tenderness: Dr. Valleix's announcement, for example, of the three
tender points on the intercostal nerves. But by careful examination
and an opportunity to compress the nerves, we would likely elicit pain
in any or all points of a neuralgic nerve. The patient can scarcely give
distinct localities of tenderness, for mechanical pressure elicits distinct
pain. The irregularity of the various localities of pain in visceral
neuralgia shows that it is not a mere local disorder but some germinal
malnutrition of the sensory apparatus. Visceral neuralgia not only occurs
in the trunks but along the branches of nerves, as some patients will complain
of pain in various regions of the hypogastric trunks, but of irregular
pain in the spermatic branches or in the testicle. During the attacks
of visceral neuralgia various accompanying secondary affections arise,
as vasomotor disturbances, muscular disturbances. The vessels contract,
lessening the amount of blood passing through them, and muscular action
brings contractions (colic) in local and remote regions of the abdomen;
shifting, colicky cramping pains characterize the visceral neuralgias.
In one patient on whom we operated the second time, complaining of varying
pains in the right side, we found the liver and stomach prolapsed considerably.
Since the operations she complains of irregular pains still in the right
side where we made no interference. We do not operate for pain in
the right side, but for other reasons, yet we noted much visceral ptosia
of the stomach and liver in the region of these neuralgic pains.
In many cases I have noted the evil effects of peritoneal adhesions previous
and subsequent to abdominal section, and Dr. Lucy Waite and I have operated
on many patients a second time for the pain caused by peritoneal adhesions,
fixing movable viscera and interfering with their function, rhythm and
peristalsis. Peritoneal adhesions produce as symptoms a kind of visceral
neurosis, however; the pain of peritoneal adhesions is certainly more constant,
in the language of the patient, as dragging sensation repeating itself
on prolonged efforts.
Peritoneal adhesions, will, no doubt, explain many
cases of visceral neuralgia. In numerous abdominal autopsies I found
practically the following percentage of peritoneal adhesions in the following
locations, viz. - (1) At the proximal ends of the oviducts, 80 per cent
in adults; (2) in the
6, superior; 7, middle cervical sympathetic ganglia; 9, 10, 11, 12, 13,
cervical nerves (spinal); 24, 25, 26, 27, cervical rami communicantes;
3, vagus; 20, superior cardiac from superior cervical; 2, hypoglossel.
mesosigmoid over the left psoas, 80 percent in adults; (3) in
the ileo-coeco-appendicular apparatus on the right psoas, 70 per cent;
(4) in the gall-bladder region 45 per cent; (5) 90 per cent occurs adjacent
to the spleen. Also numerous peritoneal adhesions occur at the flexures
of the tractus intestinalis, viz. - (a) Flexura coli lienalis; (b) flexura
coli hepatica; (c) flexura duodeno-jejunalis. Peritoneal adhesions compromise
the circulation (blood and lymph) peristalsis, absorption and secretion
of viscera, as well as traumatises (neuralgia) the visceral nerves.
Another patient complained of a varying pain along
the left ovarian plexus, and again for months in the region of the left
kidney. Physically, nothing could be discovered except that she was
very anemic. I am thoroughly convinced that considerable visceral
pain arises from pressure of fecal masses as they pass over the nerve plexuses,
also that the hard, irritating fecal masses stir up local bowel contractions
(colic) as they move toward the rectum. This accounts for the clinical
fact that the visceral neuralgic pains fast disappear when cathartics are
so used as to regulate a daily stool, In my practice of gynecology nothing
has produced better results in constipation than the drinking of a full
glass of water, with one-quarter teaspoonful of epsom salts on retiring,
and going to stool promptly after breakfast every morning. The more
I practice gynecology and abdominal surgery the more I become acquainted
with visceral ptosis and its evil results, and the more I am convinced
that visceral neuralgia has a physical basis whose pathology will become
more manifest with study.
It is difficult to point out, precisely, the symptoms
of visceral neuralgia, for the very simple fact that we do not yet know
the definite functions of the visceral nerves. We must compare the
visceral neuralgia with the better known neuralgia of the trigeminus.
It has been stated that neuralgia is a prayer of the nerve for nourishment
or for fresh blood. We often notice that a nerve subject to neuralgia
is sensitive to pressure. So in our diagnosis we must follow the
track of sensitive nerves in the abdomen. To do this we must know
that there are great bundles or trunks of nerves called plexuses which
quite generally follow large blood-vessels. Great ganglia exist in
different localities of the abdomen, which space forbids even naming.
In short, we have to deal with the abdominal brain, the inferior mesenteric
ganglion, the cervico-uterine ganglia and the lateral chain of ganglia
and hosts of smaller ones, all connected by nerve cords. The sympathetic
nervous system which supplies the abdominal viscera is partly independent
of the remainder of the nervous system and partly intimately connected
with its ganglia by fibers from the brain and cord. The ganglion
fibers are the greater part motor and innervate the involuntary muscles
of the viscera. We deal with the nervous system of the abdomen as
composed of the (a) lateral chain of ganglia, (b) the abdominal and pelvic
splanchnics, (c) the rami communicantes, (d) the vagi nerves, and (e) the
abdominal brain with all the nerve ganglia. We have but space to
mention the special forms of neuralgia which have been attached to different
abdominal organs under the general term of visceral neuralgia. Some
of the following forms of visceral neuralgia have gained a place in medical
1. Hepatic neuralgia, or colica hepatica non-calculosa.
2. Neuralgia of the stomach, or gastralgia.
3. Enteralgia (colica mucosa Nothnagel; or
better, secretion neurosis of the colon).
4. Ovarian neuralgia.
5. Neuralgia rectalis.
6. Neuralgia renalis.
7. Oviductal colic.
8. Uterine neuralgia.
Hepatic neuralgia rests on the view that pain of
a neuralgic character arises in the liver region when gall-stones do not
appear in the stool nor are found in the autopsy. Andral, Budd, Frerichs,
Furbinger, Durand, Bardel and Schuppel are names representing belief of
hepatic neuralgia with no calculus as a cause. Gastralgia has been
so long in medical literature that it need not be supported by any names.
Enteralgia in its various indefinite forms is seen by gynecologic practitioners
With more accurate study the biliary neuralgias
will disappear and be replaced by more accurate terms as cholecystitis,
choledochitis, etc., in short violent spasm or colic of some segment of
the biliary ducts is due to inflammation or calculus. During 700
personal autopsic inspections of the abdominal viscera I demonstrated that
some 45 per cent of peritoneal exudates, adhesions existed adjacent to
the gall-bladder and other biliary passages. Dr. Robert Morris, of
New York, christened these subjects spider gall-bladder adhesions.
The peritoneal adhesions adjacent to the gall-bladder, will, no doubt,
explain much hepatic neuralgia of the older doctors as well as gastric
neuralgia or gastralgia.
Ovarian neuralgia is a disease glibly talked about,
but very difficult to diagnose. I have listened perhaps hundreds
of times to descriptions of patients' suffering which some would designate
ovarian neuralgia. Yet women do have irregular pain, slight and intense,
in the ovary. The ovary will be found sensitive and painful on pressure.
It is the opinion of the writer that so-called ovarian neuralgia is a secondary
process, and yet it doubtless exists, as certain as neuralgia of the upper
division of the trigeminus. Neuralgia of the rectum has a definite
existence. It comes and goes with great irregularity, arising chiefly
at night and appears in persons of apparently robust health.
Neuralgia of the kidney rests on the fact that pain
occurs in the region of the kidney; the kidney is sensitive to pressure,
and no stone has been found in the kidney at the autopsy. The pain
has been so severe that nephrectomy was performed, but the kidney contained
no stone. In one patient who had pain and tenderness in the region
of the kidney for three years I performed the operation of incising the
kidney. No stone was found, but an old scar existed in the kidney
pelvis, and also opposite to the scar in the kidney there existed a mass
of old cicatricial tissue as large as a plum. The conclusion was
that a stone had once ulcerated through the pelvis of the kidney and that
she was suffering from the cicatrix in and about the kidney.
Oviductal and uterine colic, or so-called neuralgia, rests
on the peculiar structure of the oviducts and uterus. Their involuntary
muscular walls, being supplied by sympathetic nerves, are liable to be set in
motion by various forms of irritation, and hence from tonic and clonic spasms
of their walls are liable to give rise to irregular flying pains or visceral