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 peristaltus.
    3.  Secretion neuroses, the third subject included in visceral neuroses, will include the phenomena of secretion, such as excessive, deficient or disproportionate secretion.

VISCERAL NEUROSES.

    Under this head we will include a series of phenomena of the viscera, partly pathologic and partly reflex, partaking of a disturbance of sensation, motion or secretion.  By visceral neurosis we mean an undue irritability or perverted function of one or more of the viscera.  The pathologic 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 pain.
    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 its tone.
    Enteroptosia begins in respiration and from a weakness of the abdominal sympathetic, which became tired and slacken in its tone.  The sympathetic nerves to the viscera have lost their normal power over circulation, 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 bed.
 

SYMPATHETIC NERVE IN LUMBAR REGION       Fig. 6l. 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 ceases.
    It may not be forgotten that enteroptosia offers opportunities not only for visceral neuroses, but also for obstinate constipation, which favors the development of visceral neuroses by over-retention of feces, including 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 phrenico-colicum sinistrum.
    3.  Flexing of the right colon by the ligamentum phrenico-colicum dextrum.  I have seen the right colon in the pelvis hanging by this band.
    4.  Flexing of the pylorus by the ligamentum hepato-duodenum.
    5.  Atony of the 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 water.
    Visceral neurosis indicates that some deep condition, assimilation or vicious process is proceeding somewhere.  The observing physician of experience commonly associates in his mind visceral neuroses with (a) some debilitating process in age or sex. We cast about for predisposing causes and examine them as a neurotic temperament, hereditary or acquired. One can acquire a neurotic disposition by dissipation, sexual or with narcotics, by excessive and prolonged labor, the absorption of poisonous substances, as lead, arsenic or phosphorus.  Rapid changes of temperature bring on visceral disturbances. (b) We also take into account sex.  It is difficult to say which sex suffers the most from visceral (abdominal) neuroses.  I should judge women do.  But different varieties of visceral neuroses prevail in each sex, and at different periods of life.
    (c) The chief age of visceral neuroses is from twenty to sixty.  Few cases occur before twenty and rarely after sixty.  (d) The sexual life of woman is rich in visceral (abdominal) neuroses at different periods as (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 role.
    (f) In the etiology of visceral neuroses we must include all kinds of trauma to nerves, contraction
 

SACRAL SYMPATHETIC AND SACRO-SPINAL NERVES        Fig. 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 strands.

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 perfect health.
    The symptom, par excellence, of visceral neuroses, is pain.  The patients describe the pain in manifold ways as boring, dragging, burning, stabbing, pressing,. lancinating, grinding and tearing.  Usually the pain is paroxysmal, ceasing in the intervals.  The pain on lessening may be very irregular, slight or intense.
    Upon one point concerning neuralgia (visceral or otherwise) I am 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
 

CERVICAL GANGLIA       Fig. 63. 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 literature:

    1.  Hepatic neuralgia, or colica hepatica non-calculosa.
    2.  Neuralgia of the stomach, or gastralgia.
    3.  Enteralgia (colica mucosa Nothnagel; or better, secretion neurosis of the colon).
    4.  Ovarian neuralgia.
    5.  Neuralgia rectalis.
    6.  Neuralgia renalis.
    7.  Oviductal colic.
    8.  Uterine neuralgia.

    Hepatic neuralgia rests on the view that pain of a neuralgic character arises in the liver region when gall-stones do not appear in the stool nor are found in the autopsy.  Andral, Budd, Frerichs, Furbinger, Durand, Bardel and 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 frequently.
    With more accurate study the biliary neuralgias will disappear and be replaced by more accurate terms as cholecystitis, choledochitis, etc., in short violent spasm or colic of some segment of the biliary ducts is due to 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 neuralgia.