The Abdominal and Pelvic Brain
Byron Robinson, M. D.
1907

  CHAPTER XXIII.

RELATION BETWEEN VISCERAL (SYMPATHETIC)
AND CEREBRO-SPINAL NERVES.

"I have observed matters contained in this book, a large part of which is myself."

"I exist, therefore, I am." - Kant.
 

THE NERVE MECHANISM OF PELVIC AND ASSOCIATED REGIONS.

    The plan of the nerve supply of the pelvis and associated regions is to bring into harmonious action the skin and mucosa and the muscles and viscera.  The object of the generative organs is not only gestation and expulsion but also for the varied necessity of copulation, of defecation, and of urination, including muscular and visceral relations.
    The nerve mechanism of the external genitals is significant and suggestive of an evolutionary plan.   The sympathetic nerves extensively supply the erectile tissues - the corpora cavernosa, glans clitoridis, and bulbi vaginae.  The erectile tissues possess rhythmical action besides being supplied with nerves from the lumbar plexus (genito-crural) and the sacral plexus (pudendal and internal pudic).  The internal pudic nerve (sacral plexus), which chiefly supplies the clitoris with large branches, terminates in the glans clitoridis or adjacent tissue in peculiar tactile or genital corpuscles.   The clitoris and considerable of the adjacent region of the distal third of the vagina is exceedingly sensitive to irritation.
     The plan of the nervous mechanism of the external genitals is to associate the genitals with certain muscles and overlying skin.  The nerves which supply the pelvis and associated viscera are: 1. The sympathetic, the hypogastric plexus and ovarian plexus, both arising from the abdominal brain; also branches of the lateral chain of the sympathetic.  The pelvic viscera thus involve nerve relations with all the other abdominal viscera.  2. The cerebro-spinal nerve supply, the lumbar plexus furnishes the genito-crural, the ilio-hypogastric, and the ilio-inguinal and inferior pudendal; also the sacral plexus supplying the internal pudic and vesical.  The cerebro-spinal nerves supplying the skin and muscle associate them with the genitals.  The skin on the pudendum, perineum, and anal region is definitely associated with the skin in the inguinal region, the inner part of the thigh and genital region, because branches from the lumbar and sacral nerve trunks supply the same regions.  For example, the genito-crural nerve supplies the skin on the pudendum and the ilio-inguinal supplies the skin over the gluteal muscles.  The genito-crural and ilio-inguinal are both branches of the lumbar plexus and what affects the pudendal skin will affect the gluteal skin.  Besides the same nerve trunk that sends branches to the skin also sends branches to the underlying muscle.  Also the internal pudic, a branch of the sacral plexus, supplies the skin on the pudendum, perineal, and anal region, while the small sciatic, a branch from the same plexus, supplies the skin on the gluteal region.  What affects the periphery of one affects that of the other.  Both must be physiologic or reflexes will arise.  By means of the pudic nerve and the small sciatic (gluteal) the skin and muscles of the pudendum, perineum and anus are brought in harmonious relation with the gluteal muscles (of coition) and skin over them.  The genitals, bladder and rectum are supplied by the hypogastric and ovarian plexuses of the sympathetic, and the sympathetic plexuses are joined by the second, third and fourth sacral spinal nerves.
    Thus viscera, skin and muscles of the pelvic region are held in close nerve association.  The numerous reflexes in the pelvic region of patients will bear close observation in affections of the pudendum, bladder and rectum.  Pain may be experienced in the perineum, in the gluteal region or down the thigh.  The explanation of this arises from the fact that all these parts, skin of pudendum, anal region, part of the thigh and gluteal region are supplied by the pudic and small sciatic nerves, which come from the same plexus that gives off branches to supply the viscera, pudendum, bladder and rectum.  Thus the pelvic viscera and the skin of the gluteal region and thigh, or perineum and external genital region, are held in association by the branches of the same spinal nerves.  The pain felt in the urethra by a woman with calculus in the bladder is due to the fact that the trigonal nerve plexus which supplies both trigone and urethra, is prolonged to terminate in the distal end of the urethra.  Pain generally is felt at the periphery of nerves, and hence the irritation of calculus in the trigone is experienced in the urethra, that is, at the termination of the trigonal plexus.  The sigmoid, two inches above the anus, is provided with very little sensation, while the last two inches in the anus is very sensitive.  This is observed by the slight pain in high malignant growth or other swellings of the rectum, by the little pain of large collections of hardened feces.  Also by the little pain induced by perforation of the sigmoid during the administration of an enema.  Its sensation is limited, like all viscera supplied by the sympathetic.  The relation of nerve mechanism between anus and the neck of the bladder is strikingly intimate.  Hemorrhoidal operations are accompanied by urine retention and bladder operations by rectal tenesmus.
    This intimate nerve relation between rectum and the neck of the bladder is chiefly due to the fourth sacral nerve, which supplies the neck of the bladder and then passes on to supply the anal skin, levator ani, and anal sphincter.  The third sacral nerve sends a large branch to terminate in the body of the bladder, but is not related to the levator ani and sphincter ani muscles.  The urethral mucosa, the muscles of the pudendum, and the chief part of the skin of the pudendum perineum and anus are supplied by the internal pudic nerve from the sacral plexus.  The sacral plexus emits the gluteal nerves which supply the gluteal muscles.  It also gives off the interior pudendal (branch of the small sciatic), which supplies directly the perineum.  Hence the external genitals and the gluteal muscles are in intimate nerve association.
    Hilton struck by the peculiar ending of the inferior pudendal nerve called it the nerve of coition.  The genito-crural and ilio-inguinal are from the lumbar plexus and supply the inguinal and vulvar regions.  The ilio-hypogastric supplies the hypogastric and groin region.
    With diseased condition of the region supplied by the genito-crural and ilio-inguinal nerves, it is explainable how women suffer by reflex action in the region supplied by the ilio-hypogastric and ilio-inguinal nerves-the inguinal region.  Many women mistake the inguinal and hypogastric pain for ovarian disease.  Irritation in the perineum or rectum may be followed by priapism.  Adhesions about the glans clitoridis or accumulated secretions under the prepuce may provoke not only local disturbances in the bladder and rectum but induce genital disturbances.  The pain felt through perineal abscess in the gluteal region and in the thigh may be explained by the pressure of the inferior pudendal nerve in the perineum.  In neuritis brought on by trauma of the inferior pudendal nerve due to much sitting on hard seats, the pain may be felt in the perineum and the region supplied by that nerve.
    Dissection discloses the inferior pudendal nerve crossing the gluteal region toward the perineum, close to the ischial tuberosity, where it is liable to occasional injury with enlarged pudendo vaginal glands.  Some patients do not sit down comfortably on account of the irritation of the periphery of the inferior pudendal nerve.
    However, the pain may be aroused at the ischial tuberosity, by an inflamed bursa or local traumatic neuritis.  Pain in the knee-joint from hipjoint disease is an ever living example of a reflex, pain starting at the periphery of the one branch of a nerve trunk, and experiencing the pain at the periphery of another branch of the same trunk.  The branches of nerve trunks (or plexuses) supply groups of muscles and skin in widely distributed regions for the purpose of associating them in function.  For example, the lumbar plexus associates the skin of the external genitals with the skin of the gluteal region by means of its branches supplying both regions, as the genito-crural, ilio-inguinal and ilio-hypogastric.
    The sacral plexus associates the action of the muscles (and skin) of the external genitals, perineum, and anus with the gluteus maximus, through branches of the same plexus supplying both regions.  The pudic, a branch of the second, third and fourth sacral spinal nerve, supplies the external genitals, perineum and anus, while the gluteal (smaller sciatic), a branch of the second, third and fourth sacral, supplies the gluteus maximus muscle (of coition).  Finally to perfect a balanced nerve association between muscles and skin of the external genitals and gluteal region, the inferior pudendal nerve actually joins the periphery of the two regions.
    A reflex is a disturbance in a distant part from some local peripheral irritation.  The pelvic viscera are liable to trauma and infection during the childbearing period from exposed mucosa and serosa, and this traumatic or infection atrium becomes a fruitful source for reflex distribution, through disturbed pelvic mechanism, due to cicatricial contraction and subsequent dislocation.  The irritation is transmitted to the abdominal brain, where it is reorganized and emitted to the organs of the abdomen and chest, disturbing their rhythm, secretion, absorption, sensation and nutrition.  The visceral rhythm becomes irregular, secretion and absorption become excessive, deficient, or disproportionate and the blood becomes waste laden.  The patient is forced slowly or rapidly through definite, though irregular, stages of disease (traumatic or infection atrium), irritation, indigestion, malassimilation, malnutrition, anemia, neurosis and psychosis.  The nerve mechanism between ovary, genitals and kidney is very intimate.  The ovarian plexus originates from the renal and hypogastric, which connection directly associates the kidney with the internal genitals, and accounts for the disturbed functional relation of kidney and internal genitals during menstruation and pregnancy (pain, albumen, and vomiting).  The intimate association of nerve relation between kidney and internal genitals is manifest in diseases of either organ.  In menstruation there is a pain in the renal regions.  Congestion of one organ produces congestion or anemia in the other (reflex action).  Renal calculus or nephritis causes pain and retraction of the testicle, and of course similar disturbances arise in the ovary, though not so easily demonstrated.  Ovarian disease may cause pain in the rectum (supplied by the hypogastric).  The ovarian and hypogastric plexus have direct communication with the abdominal brain, and hence the severe shock from injury to the ovary, uterus, or rectum, and especially the tendency to vomit.  The internal genitals (ovary, oviduct, and uterus) are in just as intimate and profound connection with the great abdominal brain as the enteron, and in trauma or infection of the genitals or enteron, will have like severe manifestations of general disturbances.

I.  PELVIC NERVES (CEREBRO-SPINAL)

    The sacral plexus really terminates in two great branches, the sciatic for the lower limb and the pudic, which is a genital nerve, supplying the internal and external genitals.
 
CUTANEOUS NERVES OF THORAX AND ABDOMEN 

     Fig. 64.  The cutaneous nerves of the thorax and abdomen, viewed from the side. (1) Ilio-hypogastric. (2) Ilio-inguinal. (4) Anterior cutaneous of last thoracic. (10) Lateral cutaneous of last thoracic. (9) External oblique muscle.  (Henle).

    Patients suffer especially in two regions, viz. : (a) the hypogastric region, (b) the lumbo-sacral region.  The explanation is that the uterus by dragging or pressing on the sacral spinal nerves, induces pain in the lumbo-sacral regions and the pain is reflected from the lumbar cord along the ilio-hypogastric, ilio-inguinal, and genito-crural nerves, branches of the lumbar plexus to the hypogastric and inguinal region.
    The lumbar nerves supplying the hypogastric and inguinal regions are all branches of the same trunks - the lumbar plexuses.
    The irritation of the periphery of any branch liable to be reflected on any other branch of the same trunk.  Irritation of the sacral nerves is liable to be reflected from the common lumbar trunk to the branches of the hypoastric and inguinal region.  However the complaint of pain in the hypogastric or inguinal region may be only in the skin and purely hyperesthetic (hysteric) in character.
Gynecologic patients complain of a triumvirate of pain, viz.: in the lumbo-sacral region, in the hypogastrium, and in the head.  The lumbo-sacral region is the great central depot of gynecologic pain.  It is the central telegraphic station where irritated genitals first tell their story.  In this case, a sympathetic nerve which supplies the genitals relates the story to the cerebrospinal axis - a nerve of another tongue.  It matters little what disease, endometritis, myometritis, endosalpingitis, or peritonitis attacks the pelvis, the lumbo-sacral pain is the characteristic pain.  The lumbo-sacral region is the sensorium for pelvic disturbances.  The nerves in relation are the lumbar plexus, anterior and posterior, the hypogastric plexus connected to the lumbar plexus by the rami communicantes, and the sacral plexus.  In the hypogastric region the ilio-inguinal, ilio-hypogastric and genito-crural play the role.  The last three have cutaneous branches, and often the skin sensation is mistaken for ovarian or other genital pain.  Branches of the intercostal, lumbar, and sacral nerves supply the peritoneum, but conduct chiefly to the sacro-lumbar region.
    Extreme precautions are required to discriminate between pain located in the skin over an organ and pain in the organ itself.  This may relate to viscera or tumors, but is especially true of the kidney.  I have performed nephro-lithotomy for pain in the kidney, with the supposition that a calculus existed.  No calculus was found, and the intense hyperesthesia of the skin over the kidney remained long afterward.  Grave diagnostic or operative errors may be committed by mistaking intense and persistent cutaneous hyperesthesia for disease underlying viscera and structures.  The anesthetic and hyperesthetic zones should be mapped.  It is well known among experienced gynecologists that some peritoneal cysts are very painful.  The chief painful cysts are located along the oviducts and the two sides of the ligamenturn latum.  This is in accord with an observation that the chief suffering of gynecologic patients is from pelvic peritonitis, i. e., from dislocated or disturbed pelvic mechanism.  The peritoneal cysts, with their contents, are doubtless of an inflammatory character.  The pudic nerve is the source of motion to the muscles of the perineum, anus, bladder, urethra and vagina.  It is a source of sensation to the integument of the perineum, pudendum labia, mucosa of the clitoris and urethral mucosa.  Irritation of the external genitals creates a reflex in the spinal cord which results in turgidity of the genitals and finally a sense of musclar contraction in these parts of the genitals supplied by the musclar branches of the pudic nerve.  The integument and immediately underlying muscles are always supplied by branches of the same nerve trunk.
    The irritation of the nerves of the genital integument (cutaneous branches of the pudic) induces contractions of the perineal, levator-anal, anal, and vaginal muscles (musclar branches of the pudic) which assist in expulsion of the secretion of the vulval glands, especially the vulvo-vaginal.  Occasionally masturbation in the female maybe prevented by blistering the mucosa of the clitoris, making it so tender that the subject will cease manipulation.
    In certain reported cases of fracture of the vertebral column, irritation of portions of the spinal cord left intact distal to the seat of fracture will induce turgidity of the genitals resembling erections.  The expulsion of the last drop of urine is a reflex act due to the irritation of the urine on the sensory pudic nerves in the urethral mucosa, reflecting it to the spinal cord, whence the force returns on the (motor) musclar branches of the pudic, expelling all the urine from the urethra.
 
VENTRAL DIVISIONS OF DORSAL NERVES 

     Fig. 65.  A view of the anterior division of the dorsal nerves.  The cut shows the nerves distributed to the muscles and skin of the abdomen.  It may be easily noted how an irritation on the skin passes to the spinal cord, and thence to the abdominal muscles, putting them on tension to protect underlying viscera.  Hirschfield and Leville.)

    The rectum produces sympathetic disease in adjacent viscera, as incontinence of urine, involuntary emission and neuralgic pain.  The explanation arises from the distribution of the pudic nerve to the integument about the anus, which permits reflex motor impulses, from rectal irritation transmitted to the spinal cord, to be reflected to the adjacent genito-urinary organs and associated muscles.
    The small sciatic nerve supplies the gluteus maximum and sends a branch (the inferior pudendal) to the perineum, pudendal and vagina.  This explains the relation in coition, of the genitals and the gluteus maximum muscle.  Also it may explain perineal irritation from disease along the trunk of the inferior pudendal, as hardened tissue, which may arise in subjects of sedentary habits.
    The periphery of the ilio-inguinal and ilio-hypogastric which in general is the integument of the lower abdomen, may be the seat of neuralgia; or it may be the seat of hyperesthesia or anesthesia.  The pain may be paroxysmal, radiating along the course of the nerves.  Painful points may be detected near the spinous processes of the lumbar vertebra (lumbar point), near the middle of the iliac crest (iliac point), near the external inguinal ring (hypogastric point), in the inguinal canal (inguinal point), and finally in the labial points.  These are Valleix's puncta dolorosa, or points of tenderness along the course of nerves.
    The chief feature for the gynecologist, is the periphery of the iliohypogastric and ilio-inguinal nerves in anesthesia and hyperesthesia of the skin of the hypogastric and inguinal regions.  The skin of the abdomen proximal to the umbilicus is supplied in general by the distal intercostal nerves, which may be termed the respiratory region.  The skin distal to the umbilicus is supplied by the ilio-hypogastric and ilio-inguinal, which may be called the abdominal region.
    The genito-crural and dorsal branches of the lumbar nerves aid in furnishing motor power to the region distal to the umbilicus.  The skin, muscles, and peritoneum of the abdomen are supplied by branches of the same trunks, so as to preserve harmony of motion and association of sensation, insuring visceral protection.
    For example, if cold water be dashed against the belly, the skin sensation is transmitted to the spinal cord, and reflected to the abdominal muscles, causing an immediate rigidity, for the protection of adjacent and underlying viscera.
    The harmony of the skin, muscles and peritoneum (viscera) explains how massage assists in curing constipation.  For example, skin irritation on the abdomen is transmitted to the cord, whence (a) it is reflected to the abdominal muscles, producing action which aids in fecal expulsion; (b) the reflected force induces visceral peristalsis.  This is motor.  It appears also that the sensory condition of the skin is in harmony with the sensory condition of the underlying viscera.  Diseased underlying abdominal viscera are apparently accompanied with correspondingly disturbed sensory cutaneous areas.
 
     Fig.66. (From Byron Robinson's life-size chart of the Sympathetic.) Represents the abdominal brain and adjacent ganglia. (55) A ganglion of the dorsal lateral chain. (61) Splanchnic. (96 and 97) Rami communicates.  (67) Branches of right vagus to stomach.  (69) Trunk of right vagus entering abdominal brain.  (70) Phrenic nerve on phrenic artery.  (71) Right abdominal brain.  (72) Left abdominal brain.  (73) Gastric Hepatic artery. (76) Adrenal. (79) Suprarenal (6).  (82) Inferior renal ganglion.  (83) Superior renal ganglion.  (84, 85, 86 and 87) Ganglia on renal artery.  (88) Renal artery.  (89, 90 and 91) Lumbar nerves.  (96, 97 and 98) Rami communicates.  (101, 102 and 103) Lumbar lateral chain of ganglia.  (106) Superior mesenteric artery surrounded by the abdominal brain.  (107, 108 and 109) Genital ganglia.  (110 and 111) Genital ganglia (ovarian) as well as (112, 113 and 114) Genito-rectal ganglia.  (167) Nerves around the ovarian artery.  (171) First lumbar nerve. (172) Second. (173) Third. (176) First. (177) Second and (178) Third lumbar ganglia. (182) Genital ganglion.  (183) Inferior mesenteric artery. (185) Aortic branch of abdominal brain. (186) Ending of left great splanchnic in abdominal brain. (187) Superior, and (188) inferior (left) renal ganglia. (189, 190 and 191) (left) Renal ganglia.

    The genito-crural nerve supplies only one muscle, the round ligament, and finally supplies the labia.  The periphery of any of the ventral divisions of the lumbar plexus (the ilio-hypogastric, ilio-inguinal, genito-crural and external cutaneous) may show disturbances of motion or sensation by inflammatory products, compressing any part of their trunks.  In psoas abscess the genito-crural and the external cutaneous might show a disturbed periphery, as well as other branches of the lumbar plexus.  The practical matters for the gynecologist to determine in the complicated nerve mechanism of the pelvis and associated relations, are: l.. Map on the abdomen the areas of anesthesia and hyperesthesia. 2. Hyperesthesia of skin should not be mistaken for a diseased underlying viscus, as the ovary or kidney. 3. Areas of anesthesia and hyperesthesia may change from day to day. 4. Hysteria has certain stigmata, viz.: (a) anesthesia of the conjunctiva bulbi; (b) anesthesia of the mucosa of pharynx; (c) anesthesia or hyperesthesia of skin (especially of abdomen); (d) sudden paresis or exacerbation of' muscle (knee, globus, tongue, knotting of belly muscles); (e) occasional mental phenomena, and (f) disturbance of special sense, as sudden blindness or excessive hearing.  Some of these six stigmata must be present to diagnose hysteria. 5. Much of the hypogastric pain complained of by subjects is located in the skin of the inguinal and hypogastric region.  This pain may be caused by sensory disturbances in the skin only, or by reflex disturbances from diseased genitals, through the anterior branches of the lumbar plexus. 6. Gynecologic patients complain of pain: (a) in the sacro-lumbar region from diseased genitals irritating the periphery of the sacro-lumbar nerves; (b) pain in the hypogastric and inguinal region from irritation of the genitals passing to the lumbar cord, whence it is reorganized and reflected on the anterior branch of the lumbar plexus; and (c) pain in the head through reflexes in diseased genitals.  Perhaps the occipitalis major and minor constitute part of this nerve route. 7. The stomach is one of the chief organs to suffer reflexly from diseased genitals through the direct route of the hypogastric plexus, extending from the genitals to the abdominal brain, whence it is reorganized and sent to the stomach, over the gastric plexus.  The nerves which supply the internal pelvic viscera are located in general between the pelvic fascia and the peritoneum.
    The cervix and vagina are mainly supplied by branches from the third and fourth sacral nerves.  The pudendum is supplied by the pudic, which is chiefly composed of the third sacral nerve.  The pudic nerve passes from the pelvis from the third sacral by the way of the large sacro-sciatic foramen, winds around the spine of the ischium, and re-enters the pelvis through the lesser sacro-sciatic foramen; it is thus removed from the dangers of the trauma due to labor.  The nerve directly traumatized by labor is the obturator.  When the child's head engages, the obturator muscles of the thighs act by closing and flexing them.  The pudic nerve sends branches to the clitoris, to the pudendum, to the perineum, and to the rectum.  Practically the sacral plexus terminates in the two branches, the pudic (genital) and sciatic (limb).
    In teaching I have frequently represented the pudic nerve by the hand.  For example, the arm represents the nerve itself, the thumb represents the great vesical nerve just before the pudic passes from the pelvis; after the pudic has re-entered the pelvis and passed along the ramus of the pubes, the index finger represents the branch to the clitoris, the middle finger the branch to the pudendum, the ring finger the branch to the perineum, and the little finger the branch to the rectum.  Thus the digits of the hand can vividly represent the branches of the pudic nerve.
    It can also be remembered that the pudendal nerve, a branch of the small sciatic nerve, sends branches to the anus, perineum, pudendum and clitoris, which unite with similar branches from the pudic to supply the same organs.  There is a wonderful design in the union of the periphery of the pudendal and the pudic nerves.
    The lesser sciatic nerve supplies but one muscle (gluteus maximus), and then gives off a branch, the pudendal, which directlv supplies the external genitals and rectum. This arrangement of the nerve supply brings the gluteus maximus muscle and the skin of the genitals in direct relation.  Irritation of the genitals will induce contraction of this muscle.  Thus the gluteus maximus muscle must be considered (anatomically and physiologically) the muscle of coition.  Observation of copulating animals will confirm this view.
    The external genitals are supplied by the plexus pudendus.  A small segment is supplied by the fifth sacral nerve through the plexus sacro-coccygeus.  The chief nerves concerned in the supply of the external genitals are: 1. The medial hemorrhoidal nerve; (2) the inferior vesical nerve, which sends fibers to the base of the bladder and the urethra, to the vagina and middle portion of the rectum; 3. The internal pudic nerve, which follows the internal pudic artery and divides into (a) inferior hemorrhoidal, which supplies the internal and external anal sphincters and the skin of the anus; (b) the perineal nerve, which supplies the skin on the perineum, the musculus transversus perinei, sphincter ani externus, sphincter vaginae and also the labia and the vestibulum vaginae; (c) the dorsal nerve of the clitoris, which passes between the sphincter vaginae and ischio-cavernosus under the symphysis pubis to the proximal border of the clitoris, whence it sends numerous fine fibers to the skin as well as to the cavernous tissue.

II. THE SYMPATHETIC NERVES.

    The sympathetic nerve consists of, viz.: (,z) ganglia (lateral chain); (b) conducting cords; (c) three ganglionic plexuses located in the chest (thoracic plexus), abdomen (abdominal brain), and pelvis (pelvic brain); and (d) automatic visceral ganglia.  The conducting cords are not sheathed; they are non-medullated.  The ganglia, composed of nerve cells, are little brains.  They are reorganizing centers, receiving sensations and sending out motion.  The abdominal and pelvic brains and the ganglionic plexuses are simply large brains or aggregations of nerve cells.
 
     Fig. 67. (Byron Robinson.) From author's life-size chart of the Sympathetic.  Represents the cervico-uterine ganglion. (-) The pelvic brain. (127) Second. (128) Third, and (129) Fourth, sacral nerves (left). (131) Second. (132) Third. (133) Fourth, sacral nerves (right).  Note the connection of the second, third, and fourth sacral nerves to the pelvic brain. (137 and 138) Second and third sacral ganglia. (139) Branches from the second sacral. (140) Branches from the third and fourth sacral nerves to the pelvic brain (141 and 142). The pelvic brain or cervico-uterine ganglion is marked (141, 142, 143, 144) and (145) branches of it.  Third sacral to the levator ani muscle (146). (147) Vesical ganglion. (148) Ureter. (149) Bladder. (150) Vagina. (151) Uterus. (152) Nerves of bladder. (153) Pudic nerve. (158) Right, and (159) left, sacral plexus. (160) Brancbes of hypogastric plexus which do not enter pelvic brain before distribution. (161) Fallopian tube. (162) Ovary. (163) Round ligarnent. (164) Acetabulum. (165) Spine of ischium.

    A summary of the abdominal brain is: (a) It presides over nutrition; (b) it controls circulation; (c) it controls gland secretion; (d) it presides over the organs of generation, and (e) it influences in a dominant way the automatic visceral ganglia.  With nerve fibers radiating on blood and lymph vessels and to every abdominal viscus, it is no wonder that the abdominal brain has been considered the center of life.
    An ideal nervous system should be a neuron and consist of first, a ganglion cell: second. a conducting cord, and, third a periphery.  The sympathetic nervous system possesses the neuron or three-nerve elements in an eminent degree.  The abdominal brain represents the central ganglion cell.  Its thousands of cords, distributing fibers, represent the conducting cord, while the various automatic visceral ganglia represent the periphery.
    The sympathetic nerve supplies the uterus, oviducts, and ovaries, as they possess rhythm.  Only viscera whose main nerve supply is sympathetic possess rhythm.  The cervix is supplied by the spinal nerves, and does not possess rhythm to any marked degree.
    The peritoneum is supplied chiefly by the sympathetic nerves.  The main spinal nerves which supply the peritoneum are the peritoneal branches of the ilio-inguinal and ilio-hypogastric and distal intercostals.  The sense of localization in detail is yet unrecognized in the sympathetic, which preponderates in the peritoneum and tractus intestinalis, while the cerebro-spinal nerves are so much in the minority that they are uncertain in indicating localized areas.
    The domain of the sympathetic nerve is beyond the control of the will, as the beating of the heart, uterine and intestinal contraction, erection of cavernous tissue and the systole and diastole of the bladder.  Man cannot speculate on his sympathetic system.
    The most interesting and delicate structure connected with the genitals is the nervous apparatus.  This consists of cerebro-spinal and sympathetic or non-medullated nerves.  The uterus (body), oviducts and ovaries are chiefly supplied by the sympathetic nerves, while the pudendum, vagina and cervix are mainly supplied by the cerebro-spinal nerves.
    The hypogastric plexus originates in the abdominal brain (solar plexus), and passes along the aorta.  It is increased by branches from the lumbar ganglia of the lateral chain of the sympathetic.      The combined strands of nerves now pass over the bifurcations of the aorta and sacral promontory, and divide into two large bundles, each of which passes dorsal to the peritoneum to the base of the ligamentum latum where it reaches the side of the uterus and oviducts.  Some strands pass to the rectum, but this organ is chiefly supplied by the nerves passing along the inferior mesenteric artery.  The ovarian plexus consists of nerve strands derived from the hypogastric plexus and the ganglia in the lumbar lateral sympathetic chain, and the nerves passing along the ovarian artery.  The ovarian plexus supplies the ovaries and the ampulla of the oviducts.
    At the periphery of the hypogastric and ovarian plexuses are situated small ganglia along the walls of the oviducts and uterus, which I have designated "automatic menstrual ganglia." I have attempted to show that these ganglia rule the rhythm of menstruation.  The composite ganglia located at the lateral borders of the cervix and vagina I have denominated the Pelvic Brain.
    The best method to demonstrate the nerves of the uterus I have found to be the placing of an infant cadaver in pure alcohol for several weeks, when the hypogastric plexus can be traced to its home on the body of the uterus as plainly as though it were composed of white cotton threads.  The nerves in the infant are much larger in proportion to its size than in the adult.
 
     Fig. 68. (Laville and Hirschfield.) Is a cut to illustrate the nerves of the non-pregnant uterus. (1) Hypogastric plexus lying on the bifurcation of the aorta.  It divides to pass each side of the rectum. (2) Rectal branches on rectum (R). (3) Lumbar ganglia of the sympathetic. (4) Ovarian plexus. (5) Branch of the third and fourth sacral nerves passing to the pelvic brain (6 and 7) before going to the uterus. (6 and 7) Nerve plexuses on the vagina and rectum. (8) Uterine nerves. (9) Vesical plexus. (10) Trunk of it - great sciatic. (11) Levator ani branch. (12) Trunk of the ptidic nerve. (U) Uterus. (B) Bladder. (S) Sacrum. (D) Tranversus perinei muscle cut.  This cut is partly diagramatic, as the nerves are not distributed in the form represented in the illustration, but represent more aggregations, as drawn by the author.  The nerves in Savage's cut are represented too richly.

    Here will be presented a few remarks on the anatomy, physiology, and pathology of the sympathetic nerve, showing the principal points in gynecology relative to the abdominal and pelvic brain.  They are the result of my investigations of the sympathetic nerve, which I have dissected during the last ten years. The claim is that the ganglia of the sympathetic nerve are little brains; i. e., they receive sensation, emit motion, and control secretion. They are trophic centers, and possess vaso-motor power.  They are centers for reflex action, and are endowed with a peculiar quality called rhythm.
    The great reorganizing centers in the sympathetic nerves are the abdominal and pelvic brain and the three cervical ganglia.  Reorganizing power of a less degree exists in the lateral chain of ganglia situated at the circumference of the elliptical-shaped sympathetic, and in the collateral ganglia in the chest, abdomen and pelvis, and also in the ganglia situated in every viscus which I have designated automatic visceral ganglia.
    The sympathetic nerve consists of two lateral chains of ganglia, extending from the base of the skull to the coccyx.  Situated anterior to these chains are collateral plexuses known as the cardiac, abdominal and pelvic.  Besides these there exist in all the viscera small ganglia, automatic visceral ganglia - for example, the automatic hepatic, cardiac, menstrual ganglia.
    The distribution of the sympathetic nerve is (a) to vessels, (b) to glands, and (c) to viscera.  It is connected with the cerebro-spinal nerves by the rami communicantes.  Its independence of the cerebro-spinal axis is not yet fully settled; but children have been born at term with no cerebro-spinal axis.  The part of the sympathetic that appears to be most independent of the cerebro-spinal axis is the cardiac, abdominal and pelvic plexuses (brains).  I have kept the intestines of dogs in active peristaltic waves for nearly two hours after death, in a warm room, by tapping them with the scalpel.
The automatic parts of the sympathetic to which I wish to direct attention are, the cervical sympathetic ganglia (superior, middle, and inferior), the abdominal brain (the solar plexus), and the pelvic brain (or cervico-uterine plexus).  Due consideration must be given to the three splanchnic groups: (1) the cervical splanchnics, conducted to the stomach, heart, and lungs through the spinal accessory and the vagus; (2) the abdominal splanchnics, originating from the fourth dorsal, running to the second lumbar, and thence to the abdominal brain; (3) the pelvic splanchnics, conducted to the hypogastric plexus by means of the second, third and fourth sacral nerves, to supply the rectum and the genito-urinary organs.
    I have observed for some time that the connection of genital and urinary systems with all the great nerve centers is intimate and profound.  For example, the organ which has the most intimate connection with the cerebrospinal axis and the abdominal and pelvic brain is the uterus.  The eye, too, is closely connected with both nervous systems, and also with the uterus.  This intimate nervous connection of the uterus with the nervous system increases with the ascending scale of animal life.
The physiological function of the sympathetic nerve is rhythm.  The sympathetic nerve alone possesses this function.  The power to produce rhythm belongs only to a ganglion.  The viscera functionate rhythmically.  The destruction of this periodical function causes disease.  The organs which have the most pronounced rhythm are those intimately connected with the abdominal brain.  Chief among these is the uterus and oviducts.  So far as I can observe, the uterus is connected with the abdominal brain by twenty or thirty strong nerve strands.
 
     Fig. 69. (From Bryon Robinson's life-size chart of the Sympathetic.) Represents the upper or neck and chest portion. (7) Middle cervical ganglion. (8, 8) Inferior cervical ganglion. (13, 14, 15, 16) Cervical nerves. (17) First dorsal nerves. (18) Phrenic. (19) Branch from inferior cervical to phrenic. (20, 21)  Cardiac nerves from middle and superior cervical ganglia. (22, 22, and 22) Cardiac nerves from inferior cervical ganglion. (23) Wrisberg's ganglion (of the heart). (24 to 33) Cervical rami communicantes. (34 and 35) Ganglia on superior, middle and inferior cardiac nerves of the cervical ganglia. (36) Verteral artery.  (37) Left subclavian artery.  (38) Innominate artery.  (39) Right subclavian artery. (40) Carotid artery (41) Aorta. (43) Intercostal arteries. (45, 46 and 47) Dorsal lateral chain of ganglia. (63) Communicantes.

    The uterus and oviducts have a monthly rhythm, due to the automatic menstrual ganglia situated in their walls.  No doubt the higher physiological orders originate in the great abdominal brain.  The breaking of the rhythm of one viscus disturbs the rhythm of all the rest.  This is in no organ so significant as in the uterus, because the uterus is more exposed to infection and trauma - disease - than any  other viscus.  The glandular endometrium, the best germ culture medium, is exposed to the external body service.   The liver has a visceral rhythm, through its automatic hepatic ganglia, Similar to that of the uterus.  When new food arrives in the liver from the portal vein, the cells of the liver begin to swell, in the performance of their functions of making bile, glycogen and urea.  The hepatic capsule (Glisson's) and the peritoneal covering being extremely elastic, the liver can go through its rhythm whenever occasion arises.  When the liver arrives at the maximum point in the rhythm, the cells having exhausted themselves in making bile, glycogen and urea, these three products are sent home, (in the lumen of the tractus intestinalis) and the cells begin to contract, Glissonís capsule begins to shrink, and the peritoneum returns to its original state.  Then the liver secures rest and repair, in order to accomplish the next rhythm.  It is the breaking of the hepatic rhythm by unfavorable food or distant reflexes of diseased viscera that causes disease of the liver.  The most prominent organ that induces irregular hepatic rhythm is a diseased uterus.  Alcohol, which rushes from stomach to liver through the gastric veins, taken without food, destroys the nice balance of the hepatic rhythm by enticing the liver to go through its rhythm without due stimulus or by unnatural stimulus.
    It is plain that the heart goes through a rhythm by means of the automatic cardiac ganglia situated in its wall.  These ganglia are known as Bidder's, Schmidt's, Remak's, and Ludwig's.  The vagi (especially the right) give the heart the slow, steady beat, its sober, regular movements like a pendulum; but the three cervical sympathetic ganglia rule the heart in regard to rapidity and irregularity.  It is the breaking of the cardiac rhythm that causes reflex heart trouble.  A diseased uterus, from the intimate and profound nerve connection is preeminently the organ that disturbs the heart and its rhythm (by disturbed circulation in the coronary arteries).
    The digestive tract has its own special rhythm through Auerbach's and Billroth-Meissner's plexuses - the one presiding over the peristalsis, and the other over absorption, secretions.  The occasion of a digestive rhythm is food.  The main rhythm occurs in the enteron and the stomach.
The bladder performs a rhythm by means of automatic visceral ganglia; it has a diastole and a systole.  The rhythm of the bladder is broken when its nerves are dragged, as in pregnancy.
    The spleen performs its rhythm by its automatic splenic ganglia.  The occasion of a splenic rhythm is fresh food.  The spleen accomplishes its rhythm by (a) the swelling of its tufts and substance, (b) by the expansion of its elastic capsule, and (c) by the stretching of its peritoneal covering.  It rises to a maximum and sinks to a minimum.  It is now in action and now in repose.
    Thus each viscus performs its peculiar rhythm by means of the automatic ganglia situated in its substance.  The higher physiological orders of the abdominal brain must, of course, be obeyed.

III.  PATHOLOGY.

    We now come to the consideration of diseased viscera.  Pathogenesis through the sympathetic, in health and disease, is by reflex action.  Of course we have ganglionic sclerosis, recognizable and non-recognizable lesions of the sympathetic, pigmentation and secondary disease, etc., but the great pathology of the sympathetic nerve in gynecology is the transmission of reflexes from diseased viscera.
    We will take for illustration a case of uterine cervical laceration occurring five years previous.  The patient is now apale, anemic, neurotic woman, unfitted for the labor of life.  A lacerated cervix (an infection atrium) is soon followed by endometritis. Irritation from this is transmitted over the hypogastric plexus to the abdominal brain, where it is reorganized.  It should be remembered that any irritation (force, vibration) will travel on the lines of least resistance, and in the direction of least resistance from the abdominal brain toward that organ having the greatest number of nerve strands.  The irritation reorganized will flash on all the plexuses.  Reaching the liver, it will disturb the hepatic rhythm, causing an over-production, an under-production, or an irregular production, of bile, glycogen and urea; and finally the functions of the liver suffer impairment.  Suppose we follow this same uterine irritation to the digestive tract.  At Auerbach's plexus it will cause colic, lethargy, or fitful peristalsis, and at the plexus of Billroth-Meissner it will induce diarrhea, constipation, or development of gases-fermentation.  These disturbances, after a painful progress of from six months to two years, culminate in indigestion.  Then comes malnutrition, which results from long-continued indigestion.  The third stage is anemia from malnutrition.  The fourth stage is neurosis: the ganglia have been long bathed in waste-laden blood.  Finally psychosis may arise.
    Hence endometritis may induce: (a) indigestion, (b) malnutrition, (c) anemia, (d) neurosis, and (e) psychosis.
    Again, consider heart palpitation at the menopause.  It can be explained by reflex action.  The child-bearing period of a woman is thirty years.  During that time regular monthly forces have been transmitted over the hypogastric plexus to induce uterine and oviductal rhythm.  Now, at the menopause, the hypogastric plexus degenerates and will not carry the forces, which consequently accumulate.  The accumulated forces in the abdominal brain go up the splanchnic to the three cervical ganglia, where they are reorganized and flashed to the heart, causing it to work either too rapidly, or fitfully. This explains palpitation at menopause.
    Exactly the same explanation suffices for liver disease during this period.
    At the menopause the heat, circulatory, and sweet centers are irritated, and the woman has flashes of heat, flushes of blood and "spells" of sweating.
    Pigmentation is also from reflex action: the irritation spending its main force on the liver and the spleen, causes pigmentation.
    The genitals are profoundly supplied by the sympathetic.  Observe the double lateral supply and also the central hypogastric supply.  There are two ovarian ganglia at the origin of the ovarian arteries.  There are two giant pelvic brains or cervico-uterine ganglia, and these pelvic brains are connected by some thirty strands to the great abdominal brain.  The uterus, the popular center of the genitals, though anatomically the ovary is the real central genital organ, is supplied from the abdominal brain by means of the lateral hypogastric plexus chain, and the second, third, and fourth sacral nerves.  The pelvic brain demedullates the nerves, so that, though the three sacral nerves supply the uterus, it is accomplished by first sending the three sacral nerves through the pelvis, where they are demedullated before reaching the uterus.  In an anatomic and physiologic sense the pelvic brain is of extreme importance on account of its vascular influence over the uterus and oviducts, on account of its control to some extent of uterine and oviductal rhythm, and on account of its influence on the nourishment of the uterus and oviducts.  Also, perhaps, parturition is instigated by pressure or trauma of the cervicouterine ganglion by the expanding cervix; in other words, trauma to the pelvic brain.  There are adjacent ganglia to the pelvic brain which influence the uterus, bladder and vagina, holding these three organs in intimate connection.  There is the plexus vesicalis (vesical ganglion), the hypogastric plexus, and the plexus utero-vaginal (pelvic brain), all three closely connected anatomically and also connecting anatomically and physiologically the bladder, cervix and uterus.
    It is daily gynecologic observation that the uterus and bladder functionate together through nerve connection-especially the sympathetic.  However, the chief function of the pelvic brain is to rule the uterus, as will be observed, by noting that the major branches of this ganglion pass to the body of the uterus.  A small part of the uterine nerves originates from the hypogastric plexus, which supplies the side and dorsal surface of the uterus.  From the pelvic brain and vesical ganglion, nerves accompany the uterine artery along the lateral borders of the uterus, sending branches to the uterus on the horizontal arteries, and to the oviducts which, by union with the ovarian nerves, form the ovarian ganglion.  From the ovarial ganglion, nerves pass to the anterior side of the uterus, to the inner and middle parts of the oviduct and to the broad ligaments.
    The ligamentum teres uteri is composed of nonstriped muscle and is supplied by both the uterine and ovarian nerves.  The uterus is supplied in its muscularis by an extraordinary, rich network of nerves, which is continued into the muscularis vaginae.  The uterine mucosa has numerous ganglia distributed in its substance.  The nerve endings pass to the epithelia of the single organs.  The small capillaries are enclosed in a network of nerves.

IV.  GENERAL VIEWS OF PAIN IN GYNECOLOGY.

    Pain in gynecology is generally described as typical in character.  This is observed from the terms which writers employ.  Some designate the pain as nongenuine, others as hysteric, and again as illegitimate, ideal or physical.  Perhaps with more accuracy one might designate the pain as from the cortex of the cerebro-spinal axis.  It should be recognized that a more rational classification of pain in gynecology is demanded.
    Hysteria, if the term be employed, must be recognized by definite stigmata.  It is true in gynecology we are dealing chiefly with the subjective sensations of the patient.  The pain appears to the patient as immeasurably severe and terrible.  Frequently the only standard is the patient's tears, fears or moans, and her comparison of dragging, tearing or boring.  We can to some extent estimate colic pains of hollow organs as uterine and intestinal conditions.  But it is remarkable how gynecologic patients bear the genuine pain of labor and other colicky pains with little complaint and slight fear of its repetition; while the immeasurable and often apparently nongenuine pain of hyperesthesia causes exaggerated and bitter complaints.  The intensity of pain can be supposed but never sharply measured.  An exudate can be palpated, the amount of blood loss judged, the growth of a tumor estimated, but the determination of pain rests alone on the dogmatic assertion of the patient.  It is a physical phenomenon.  As Dr. Lomer states in his excellent investigations, pain is an increase of touch sensation, and has a Psychical character.  Doubtless the sensory periphery apparatus ends first in the skin (hyperesthesia and anesthesia), and second in the mucosa (hyperesthesia and anesthesia).
    The chief center of pain for the periphery apparatus of skin or mucosa lies in the dorsal sensory ganglia of the spinal cord.

    Disease in either the spinal sensory ganglia or the sensory periphery unbalances the nervous system.  Analysis and clinical observation would indicate that the hyperesthesia and anesthesia are of central (cerebro-spinal) origin.  Head, of England, reported some ingenious experiments, in which every visceral disease is announced through the sympathetic nerve by a specific zone of skin tenderness.  The center of the sympathetic fiber lies directly in the sensory nerve.  If a sympathetic irritation arises it is reflected on the tract of the sensory nerve to its specific skin periphery.  The result is a specific tender skin zone.  In fact, Head allots a typical sensory skin zone for each individual viscus.  For example, there is a specific zone of skin tenderness for a stone in the kidneys a stone in the gall bladder, or a diseased uterus or ovary.  However. this is only another way of saying that visceral irritation passes to the spinal cord, and after reorganization, radiates on the muscular nerves of the abdomen and also on the skin nerves of the abdomen.  Irritation of the periphery of visceral, muscular, or skin nerves, affects the other two by reflection.  In any case, the process of transmission of pain from periphery to center is a complicated one.  The variation of intensity of pain is equally shared by variation of its quality as boring, sticking, burning, cutting, tearing, dull and jumping pain. , One can suppose an organ pain, as a toothache, an earache, ovarian pain, uterine and intestinal colic, tenesmus of urethra or rectum.  Organ pains require an agent or irritation to start them, and are not a quality of the nerves of the viscus itself.
 
     Fig. 70. (Byron Robinson.) Represents a plan of a dorsal nerve. (Sp. c.) Spinal cord. (p. b.) Posterior branch. (a.b.)Anteriorbranch. (g.) Ganglion on posterior root. (ram. com.) Ramus communicans. (sy. gang.) Sympathetic ganglion. (p. c.) Posterior cutaneous. (a. d. or a. c.) Anterior division. (I. c.) Lateral cutaneous branch.

    From practical gynecology, pain may be classified as follows, viz.:
    1.  Traumatic (wound) pain, the irritation of sensory nerves from external insults.  Frequent examples of traumatic pain occur in the urethral, vulval, hymenial, perineal, and anal lacerations.  The pain is acute, but quickly subsides.  However, it is easily revived by functionating of the organs, or secretions flowing on the wound.  Destruction of nerves, as from burns or chemicals, has the most intense and persistent pain.  Patients generally describe traumatic (wound) pain as burning - or smarting.  An ice bag is effectual in alleviating such pain.
    2.  Contractile (colic) pain, the irritation of the sensory nerves through muscular
contraction.  It is vascular spasm.  The well known examples of contractile pain (colic) are uterine and intestinal colic, the over-filled rectum, oviducts, or urinal or gall bladder. Vaginismus, though of other origin, is a typical example.  This pain is rhythmic or peristaltic.  It rises to a maximum and sinks to a minimum.  It is described as an ache.
    3.  Inflammatory pain, the irritation caused by trophic changes in sensory nerves.  The changes are produced by pressure (exudation) or chemical effects on the sensory nerve endings.  It is the degenerative disturbance in the sensory nerve area.  Its conditions are calor, rubor, tumor, - dolor.   The pain, though complicated, is described as sticky, cutting, and beating, and as a rule is extraordinarily painful.
    4.  Neuralgic pain, the irritation produced by changes in the sensory nerve itself and perhaps its ganglion.  Neuralgic pain is characterized by attacks and intermissions.  It is typically observed in herpes zoster and herpes vulvaris.  The neuralgic pain is described as lancinating or lightninglike in character.  It is characteristic for neuralgic pain to remain limited to a definite nerve territory.  It is unilateral.  It commonly attacks the ilioinguinal nerve or external cutaneous, also the pudendal and intercostal.
    5.  Hysterical pain, the irritation caused by disturbances in the cerebrospinal system.  This pain is limited to no organ or nerve zone.  It exists perhaps equally among men, women, and children.  Hysteria has no more to do with the uterus than with the liver or testicle.  It is not a gynecologic disease.  It is true, gynecologic subjects possess it, but often from devitalized power.  It exists independent of nerve distribution.  It is not influenced by rest, or scarcely, perhaps, through drugs.  The fundamental cause of hysteria is heredity, the transmission of defects or a neuropathic condition.  The provocative agent of hysteria is some debilitating effect, mental or physical.  Dr. Lomer insists that the hvperesthetic and anesthetic zones of the skin are geometrical figures.  Hysteria depends on Psychical alteration.  It is generally described as burning pain.  The two chief therapeutic agents for hysteria are (a) suggestions and (b) limited galvanic electricity.  Hyperesthesia may perhaps exist in any viscus, and the typical characteristic of hysteria being hyperesthesia of the abdominal skin, that attribute could be found anywhere on the skin if sought.
    Hysteria distinguishes itself from all other diseases by certain stigmata.  One or more of these stigmata must be present to diagnose any case of hysteria.  The stigmata of hysteria are:
    1.  Hyperesthesia of the skin, which consists in exaltation of the sensory periphery.  These areas, hystero-genetic zones, are especially found on the skin of the abdomen.  They are painful or over-sensitive on touch.  The patient is often deceived by thinking the pain in the skin of the groin refers to the ovary.  Hystero-genetic zones or hyperesthetic areas occur all over the body, but in the sexual region they are apt to be more typical on account of the patient's active attention.  The skin over the ovary or the kidney may be so hyperesthetic and tender that grave kidney disease may be suspected.  The skin over any abdominal viscus may be so tender that touching it induces the patient to scream, while the viscus itself is quite healthy.  Hyperesthesia exists chiefly on the right side.      Pinching or pricking the skin enables one to discern the zones of hyperesthesia.
    Hyperesthesia of the skin on the abdomen may exist with or without healthy genitals.  Of course the hyperesthesia of the skin is more liable to exist with diseased genitals, as the genitals may be the provocative or debilitating agent inducing the hysteria.  The patients who are disturbed by crawling sensations on the skin, as of snakes and ants, have hyperesthesia and hence have hysteria.  Hyperesthetic spots anywhere on the body constitute one of the stigmata of hysteria.  I observed hyperesthetic spots year after year on a woman's back.  The hyperesthesia of the skin may change its location.  The frequency of skin hyperesthesia in the gynecologic clinic induces me to believe in the wide distribution of hysteria, independent of gynecology.
    2.  Anesthesia of the skin is also another stigma of hysteria. This is not so frequent in the clinic. The patient complains of the skin being numb and without feeling. It is found, perhaps, most frequently on the skin of the abdomen.    Anesthesia exists chiefly on the left side of the body.
    3. Anesthesia of the mucosa is one of the stigmata of hysteria seldom absent. The test is easily made by taking a pin with a small glass head and rubbing it over the eye-ball. If the conjunctiva, a bulbi is anesthetic, one can rub the pinhead over the eyeballwithout a wink or flinch from the patient.  Normally the conjunctiva is very sensitive, and to touch it produces reflex actions, tears and pain. Nearly always in the hysteria the rubbing of the pinhead on the eyeball produces no reflexes, no tears, no pain. Of course there are many grades of anesthesia of the conjunctiva bulbi. The corneal anesthesia is the least frequent.    The anesthesia of the throat is tested by a lead pencil or sound.  On rubbing the mucosa of the throat, no reflex nor pain arises.    As Windscheid remarks, however, the diagnosis of hysteria should not be made from anesthesia of the throat alone, as in healthy subjects the mucosa of the throat may show various degrees of anesthesia.
 
DIAGRAM OF LUMBAR AND PELVIC PLEXUSES  (QUAIN) 

     Fig. 71. (DXII.) Last dorsal.  (IS.) First sacral. (8) Pudic.  (Sc.) Sciatic. (V.) Lumbo-sacral.

    4. Hyperesthesia of the mucosa must be remembered among the stigmata of hysteria, though infrequent.  The persistent feeling of animals crawling in the tractus intestinalis (abdomen) is no doubt a symptom of an over-tender mucous membrane.  The sudden expulsion of unchanged foods from some stomachs immediately after eating is no doubt due to hyperesthesia (non-toleration) of the gastric mucosa.
    Hyperesthesia of the viscera is one of the known stigmata of hysteria.  Perhaps visceral hyperesthesia exists the most frequently in the ovary.  In such cases the ovary is hypersensitive to touch, yet normal in size and position, perfectly mobile, with no peritoneal adhesions or fever.  Castration does not affect the pain unless it exacerbates it.  The irritable uterus of the old doctors is undoubtedly of hysteric nature.  To show that such cases are hysteric, the uterus, oviducts and ovaries have been removed, but the pain persists just as before the operation.  I once operated on a hyperesthetic kidney in which I suspected stone, but no stone existed and the pain persisted as before the operation.  Hyperesthesia of the cord and testicle frequently exists.  Vaginismus is perhaps as typically hysterical as any example of the viscera.  Vaginismus may be called up. by the thought of touching the vulva.  It is chiefly of Psychical origin and occurs in neuropathic individuals.  It is comnion to note hyperesthesia of the orificium vaginae, and an exacerbation of this leads to various grades of vaginismus.
    The hymen has been extirpated in vaginismus, but without good effect.  There can be little doubt that hysteric bladders frequently arise in the practice.  I once treated a patient two years for a hysteric bladder.  Drugs had little or no effect.  Rest in bed made no change.  Suggestion was the best treatment.  Urine was normal.  It was so-called irritable bladder, hysteria.  The patients with irritable or hysteric uterus are the ones who prepare for the child's advent by making the clothing, and sending for the midwife.  They suffer from labor pains, and finally call the obstetrician when labor does not complete itself, only to find that the patient is not even pregnant.  She is misled by her irritable, hyperesthetic, hysteric uterus.  The abdominal cramps and colic of certain neuropathic patients are doubtless due to visceral hyperesthesia or hysteria.
    5.  The muscular stigma of hysteria is quite common.  It consists in the paresis or paralysis of one or more muscles, or it consists in exacerbation of contractions of one or more muscles.  When the tongue suddenly ceases to act, with subsequent normal action, it is quite sure to be hysterical in nature.  Globus hystericus is simply exacerbated activity of the esophageal and gastric muscles.  Hysteric knee is a spasmodic contraction of the muscles supplying it.  The lost voice is frequently of hysteric nature, due to disturbances of laryngeal muscles.  The "lumps" or tumors in the abdomen of many patients are simply the contractions of certain abdominal muscles, frequently accompanied by hyperesthesia of the skin over them.  The patient complains of a tender tumor, and the diaphragm or groups of muscles become spasmodic.
    6.  Another stigma of hysteria is psychosis.  It is perverted mental action.  Hysteria is chiefly manifest to the gynecologist as a Psychical disease.  It is a part of a neurosis, very changeable, and ever presenting new scenes.  It doubtless rests on a psychopathic construction.  The psychosis rests also no doubt on a defective system.  An irritable weakness exists in the nervous system.  The central or peripheral nervous system is defective The hysteric condition is especially susceptible to influence or suggestibility.
    Exaltation or diminution of the special senses is also a stigma, as blindness or exalted
hearing.  Heredity or congenital defect is a large factor.
    Whatever debilitates the nervous system, local or general, invites hysteria as a provocative agent.  It should be remembered that genital disease (infectious) is debilitating, and hence is followed frequently by hysteria.  Sexual diseases (in man or woman) no doubt play a vast role in hysteria.  They are productive agents.  Of special interest are the hyperesthetic zones of the abdomen; i. e., the periphery of the sensory nerves of the abdomen.
 
ABDOMINAL BRAIN 

     Fig. 72.  This illustration I dissected under alcohol.  It represents fairly accurately the cerebrum abdominale in the general subject.

    8.  The sensory periphery area of the ilio-inguinal, ilio-hypogastric and that of the eight lower intercostals, become exalted in sensation.  Hysteria is a disease of symptoms.  There are two theories of hysteria extant at present, viz.: (a) It is a psychosis, a mental disturbance.  Its seat is the cerebral cortex. (b) It is a neurosis or a psycho-neurosis.  It is not limited to the cerebral cortex, but is a disease of the whole nervous system.  It is a disease of rapidly changing panorama.
    The treatment of hysteria must be rational, systematic, prolonged, and continuously suggestive.  Drain the skin by salt rubs, massage; drain the kidneys by ample drinking of fluids; drain the bowels by proper diet, sufficient laxation, and fluid and regular evacuations.  Tonics to improve digestion, drugs to act on the senses, especially the olfactory; electricity to act on the cerebral cortex, and continual suggestions with firm discipline.  Above all ideas of hysteria or neurasthenia must stand the thought that all operations to cure them are to be abandoned.
    In gynecologic patients there is a triumvirate of pain - back, head, and stomach.  It represents three groups of painful localities.
    1.  The lumbo-sacral region is the seat of the most prevalent and persistent.  It is the central station which interprets the pain of the pelvic sensory periphery.  Almost every gynecologic affection creates lumbo-sacral symptoms, whether it be dislocation, inflammation, contractile pain, sacropubic hernia, mechanical pressure or malignant growths.  In short, the lumbo-sacral region is the sensoriuin of gynecology of the pelvis.  The spinal ganglion must act as local substitute for the brain.  The explanation of this lies in the kind of nerves: visceral, peritonea], muscular, and cutaneous, which report to the lumbo-sacral cord.
    The visceral nerves are the second, third and fourth sacral and the sympathetic - all transmit reflexes to the lumbo-sacral cord from irritation of the genitals.
    The peritoneal nerves are branches of the ilio-inguinal,the ilio-hypogastric, and the seven lower intercostals, which transmit pelvic peripheral irritation to the lumbo-sacral cord.
    The muscular nerves of the lumbo-sacral plexus and also those of the muscular seven lower intercostals transmit disturbances to the lumbo-sacral cord.
    The cutaneous branches of the lumbo-sacral plexuses, especially the pudic, the pudendal, the ilio-inguinal, ilio-hypogastric and seven lower intercostal cutaneous branches, report irritation to the sacro-lumbar cord.
    The irritation of the periphery of any of the three great branches of the lumbo-sacral cord, viz., cutaneous, muscular or viscero-peritoneal, disturbs the balance of the other two.  Irritation of the visceral sensory periphery unbalances the sensory periphery of the muscular and cutaneous nerves.  The spinal ganglia are reorganizers and transmit all reports to every periphery.  This is a cue to therapeutic agents, e. g., cutaneous irritation is carried to the spinal cord and reflected on the muscular and visceral branches, stimulating both.
    2.  Gynecologic disease refers a group of pain to the stomach.
    3.  Another group is referred to the head.  Laparotomy wounds seldom or never give rise to pain if union is by first intention.  The lower angle of the wound is sometimes painful under pressure, but it is undoubtedly due to suppuration from close proximity to the region of the hair.  Dorsal muscles are inclined to rheumatism, while those of the abdomen are not; hence, more accurate judgment arises as to painful abdominal incisions.  Special attention should be paid to hyperesthesia of the abdominal skin by the gynecologist and surgeon, as it may exist without visceral disease, and hence may be nonsurgical.  So-called "irritable" organs with no visible or palpable anatomic change, should be referred to hysteria.
    When a rational treatment is systematically carried on against painful local disturbance, without effect, the probability is that it is a hysteric hyperesthesia.  The excessive vomiting of pregnancy often has a hysteric base - hyperesthesia of the gastric mucosa.  In the same hysteric category must often be numbered, coccygodynia, coxalgia, irritable bladder, breast, and uterus, vaginismus, pruritus, dysmenorrhea, and a sense of lumbo-sacral symptoms.  A knowledge of the above factors is particularly valuable to the operator as the sweeping removal of organs for neurosis or hyperesthesia is criminal.  Remember that morbid sensibility lies chiefly in the skin, and the patient will complain more of a skin pinch than a deep-seated trauma.  What the hysteric coxalgia or hysteric knee is to the surgeon, so is the hyperesthesia of the abdomen to the gynecologist.  The puzzle of each solves itself under the analysis for stigmata.