"Surmises are not facts.  Suspicions which may be unjust need not be stated."
- Abraham Lincoln.

"Men are merriest when they are from home." - Shakespeare.
 

    1.  Hyperesthesia of the abdominal brain (Neuralgia Celiaca) consists of a sudden violent pain in the region of the stomach.  The pain is accompanied by a sense of fainting and impending anxious dread.  It manifests itself, objectively, chiefly in the character of the circulation and in the facial appearance.  The skin is pale, the extremities cold, the muscles assume vigorous contractions, especially over the abdomen, and the heart beats under tension and may intermit.  The abdominal muscles are put on a stretch.  Some patients are occasionally relieved by pressure on the stomach.  From the intimate and close anatomical connection of the abdominal brain with all the abdominal viscera, and also the thoracic viscera, various other symptoms of a similar character to neuralgia celiaca may and do arise, as disturbance in the action of the heart and of the gastrointestinal tract.  The attacks are irregular, periodical, uncertain in time and intensity.  The attack may last a few minutes to half an hour.  The attack may disappear slowly or under a crisis of perspiration, emission of gas, vomiting or copious urination, leaving the patient apparently very exhausted.  The peculiar characteristics of the attacks in the abdominal brain determine neuralgia celiaca from inflammatory processes of the stomach.
    The most typical neuralgia celiaca coming under my notice was (1890) that of a man about 40, a real estate dealer, in whom it had persisted for perhaps ten years.  I could discover no gall-bladder, heart or ureteral trouble, and no stomach lesion.  He was attacked, irregularly, however, depending on over-exertion, several times a year.  When attacked he felt that impending death was at hand.  He screamed between paroxysms and would fall on the floor, rolling in agony for a half or three-quarters of an hour.  He anticipated the terrific attacks by preparing for them with great care of his health.  He would be very quiet f or one or two days subsequent to the attacks; otherwise he was quite healthy.  I soon lost sight of him.
    The second most typical case of neuralgia celiaca in my practice was that of a woman (1883) about 28.  She had very severe and frequent attacks which lasted some fifteen minutes; seemed to have terrible dread and anxiety, a wiry, small pulse, rigid abdominal muscles and varying pupils during the attack.  She appeared greatly relieved by pressure directly on the stomach during the attack.  She recovered with much exhaustion and relaxation; otherwise she appeared well.  She died of rectal carcinoma some twelve years later.  Neuralgia celiaca may exist in very various degrees of intensity and  duration.  In  some  very  severe  attacks  it  would  seem  from appearances and the patient's report that the suffering was more profound than an ordinary death.  The chief valuable treatment consists in securing active secretion of the skin and kidneys with free bowel evacuation.  General tone is secured by tonics and wholesome food; even temperature and quiet life tells the rest of the story.  The treatment during the attacks is purely expectant-sedative and stimulant.  Vigorous baths and wholesome suggestions are valuable.  There is often more in the advice given with the medicine than in the medicine itself.
 

CORROSION ANATOMY       Fig. 73.  Corrosion anatomy of the ductus pancreaticus and part of the ductus bilis in two subjects.  The illustration suggests the quantity of nerves to control the caliber of the numerous ducts.

 
    Neuralgia celiaca resembles angina pectoris more than any other neuralgia of the sympathetic ganglia.  It requires judgment and skill to diagnose it from some forms of angina pectoris, and its treatment is equally as doubtful.  Of course, it is physical lesions which we suspect in neuralgia of the abdominal brain, as the physician cannot consent to the view that a machine (the sympathetic ganglia) may go wrong without its becoming structurally defective somewhere.  Electricity, massage and cold packing are quite effective.  Some writers consider this subject under the terms gastralgia or gastrodynia.  But under whatever term it may be discussed, the peculiar sense of fainting, the anxiety, dread and feeling of impending destruction of the very center of life itself during the attack, and especially its action on the vascular system, sufficiently characterize it as neuralgia of the abdominal brain - neuralgia celiaca.  The diseases of the vagus manifest themselves otherwise.
    2.  Hyperesthesia of the mesenteric plexus (Neuralgia Mesenterica, enteralgia, enterodynia or colic) signifies pain in the region of the bowel supplied by the nerves accompanying the superior mesenteric artery, i. e., the region of the small intestine and the large bowel from the appendix to the splenic flexure.  The pain is irregular, dragging, sickening, pinching, boring, accompanied by a sense of tenderness over the abdomen.  The pain shifts from one segment of the bowel to another; is generally located below the umbilicus; alternates with intervals of cessation and does not generally begin suddenly, but gradually ascends to a maximum.  It may be so severe as to induce a sense of faintness.  Some patients assume positions to ease the pain, as pressing the hands on the abdomen, bending the thighs on the abdomen; some are very restless under the attacks.  The abdomen may be distended with gas or retracted.  The attack may pass off with crisis of the passage of gas, vomiting, sweating, profuse urination.  The attacks last from a few minutes to several hours.  Some patients are subject to these attacks for some months in succession.  The patient may have intervals of entire freedom from the attacks.  Yet the general observation is that constipation characterizes patients with mesenteric neuralgia.  It is understood here that the pain does not arise from a recognizable, demonstrable organic lesion, as ulceration of the mucosa, lesion of the bowel wall or serosa, but from a nervous base.  The pain may be merely short, sharp twinges, which some neurotic women describe year in and year out.  The clinical picture of the discase offers manifold variations.  Some patients have meteorism, pain about the navel, rumbling (borborygmus) in the bowels.  Some have gurgling in the intestines, which appears to be due to a sudden irregular contraction of the bowel which rapidly forces the contents onward.  In fact, patients with neuralgia mesenterica often possess a catalogue of other neurotic manifestations.  Nausea, dysuria and tenesmus may be present.  The chief accompaniment of this disease is perhaps constipation.  However, the pains of mesenteric neuralgia should not be confounded with those of intestinal colic.
    The first author of celebrity who wrote with clear views on the distinction between neuralgia mesenterica and intestinal colic was Thomas Willis (16221675), an English physician well remembered by anatomists in the "Circle of Willis, " in numbering the cranial nerves and in the nerve of Willis (the spinal accessory).  Willis observed over 280 years ago that mesenteric neuralgia was not a disease, but merely a symptom.  He said it should be distinguished, from the vulgar term, "the gripes" (intestinal colic).  Willis also noted what others see today, that the more violent attacks of mesenteric neuralgia generally have regular periods and follow the changes of the weather and the season; when once excited they yield with difficulty to remedies, do not pass off quickly, and may persist for weeks with great violence.  In regard to the seat of pain, it may be noted that in the same individual it generally repeats itself in the same region.  The nerve tract sufficiently defective to harbor a neuralgia tends to retain the defect throughout life.  It may be remembered that the superior mesenteric nerve supplies over twenty feet of small and nearly three feet of large intestines - a vast area - and besides, the small intestine shifts very much daily; hence, the pains of mesenteric neuralgia may be in the lumbar, umbilical and hypogastric regions.  If the pain occurs at the pit of the stomach, it is likely located in the transverse colon.
    The clinical picture of mesenteric neuralgia is somanifold in its aspect that it requires the best heads and the finest skill to unravel the complicated symptoms.  The differential diagnosis is difficult.  In certain cases where the symptoms lessen after the evacuation of peculiarly formed rolls of mucus there is a mixed neorosis.
    Again, the mesenteric neuralgia, while it exists, may be complicated by attacks of asthma, nausea, dysuria, hysteria or other nervous affections, to which subjects afflicted with mesenteric neuralgia are prone.  In cases of mesenteric neuralgia, certain regions of the abdominal skin may show hyperesthesia from the connection shown to exist between the viscera and the abdominal skin.  Mr. Head, of London, in "Brain," 1894, demonstrated the close relation existing between the nerves of the abdominal viscera and the nerves of certain skin areas.  Hence, in cases of mesenteric neuralgia hyperesthetic skin areas on the abdomen may be expected.  In the incipiency it may be difficult to differentiate a beginning peritonitis from mesenteric neuralgia.  But of worth in such a diagnosis as peritonitis are temperature, pain on pressure on the abdomen, general pain and increase of pain by deep pressure on the abdomen.  With time the meteorism, singultus and exudate become more evident in peritonitis.  In gallstone colic tenderness on pressure arises and is localized.  Icterus may follow to aid.  Renal colic is differentiated from mesenteric neuralgia by its being localized in the region of the kidney, by its continual radiation along the ureters toward the bladder and testicles, by the severe, dragging character of the pain, and by the occasional expulsion of a calculus; yet renal colic in some cases may so simulate mesenteric neuralgia that differential diagnosis is very difficult, if not impossible.  This might occur when the renal irritation flashes to the abdominal brain, becomes reorganized and radiates along the vast area of the superior mesenteric nerve.  An ulcer in the bowel shows constant localized pain on pressure.  The patient's history, the omission of the characteristic periodic attacks, the formation of the stools, aid in diagnosing ulcer of the intestines.  It may be impossible to make a differential diagnosis in the incipient stage of the disease.
    The most typical species of mesenteric neuralgia known to the writer is lead colic, colica saturnine.  Lead colic is preceded by a stage of constipation accompanied by oppressive pains in the abdomen, chiefly about the umbilicus. Nausea, eructations, destroy the appetite.  Pinching, twisting and drawing pains occur with different duration and intensity.  The pains are often persistently localized, do not frequently shift, occur in paroxysms.  The pains of lead colic, mesenteric neuralgia, are apt to arise to the highest pitch at night and when they lessen are apt to leave annoying sensations, allowing little rest during the intervals of paroxysms.  The diagnosis is aided by the patient's occupation, history association, condition and state of climate.  Arthritis, rheumatism and malaria induce neuralgia.
    Having established the diagnosis of mesenteric neuralgia, the treatment will refer to a certain extent to the etiology.  Older practitioners relied too much on evacuation and opium.  Modern practice attempts to correct the malnutrition.
    The first symptom of significance in mesenteric neuralgia is pain.  The second symptom of importance is constipation.  Both symptoms demand vigorous attention. The treatment will first consist in attempting to establish the etiology of the mesenteric neuralgia.  Is it due to dietetic defects, spirituous liquors, narcotics, intestinal contents, coprostasis, colica flatulenta, animal parasites, metallic poisoning, or catching cold?  Or again, is the neuralgia due to general nervous affections, as neurasthenia, to an exalted irritability of the bowel, nerves and ganglia?  Is it caused by hysteria or locomotor ataxia?  Or is the mesenteric neuralgia induced by some diseased abdominal viscus reflecting its irritation to the abdominal brain, whence reorganized it is flashed over the vast area of the superior mesenteric nerve, rippling the bowel in whole or in segments.  An investigation of the above considerations will influence the treatment.
    First, the pain, real or pretended, will demand attention.  Opium should be avoided if possible.      Valerian, asafetida, i. e., drugs with effect on the sense of smell, influence favorably, but perhaps there is more in the suggestion or advice which accompanies the drug than in the drug itself.  I have observed better results from hot, moist poultices (corn meal), making the poultice a foot square and three to six inches thick and applying it over the abdomen.  Cold packing of the abdomen in heavy, wet towels often does well.  Electricity has good moral and physical effects.  A hypodermic of morphine, 1-16 of a grain, is effective.  However, we must admit that a good dose of opium, e. g., 1/2 to 1 grain, works wonders for a time in mesenteric neuralgia.  The bromides are slow but effective - however, they generally disturb digestion.  Potassium bromide should be avoided, as it irritates mucosa and skin, frequently calling up rashes; 20 to 30 grains of sodium bromide will produce a quiet nervous system, especially inducing restful nights and quiet sleep.
 

CORROSION ANATOMY       Fig. 74.  Corrosion anatomy of the kidney, presenting ureteral pelvis, calyces and arteria renalis, suggesting the quantity of nerves required to control these canals.

    The pain of mesenteric neuralgia being disposed of, the more important subject of the curative treatment should be carefully considered.  The most important symptom after the pain is that of constipation.  The bowels are indolent and are affected but slowly, even by active purgatives.  The evacuations are scanty and difficult to perform. The feces are dry, globular in shape and brittle.  The patients are distressed by fruitless strainings.  It is useless to attempt to cure such patients without a strict and rigid regimen.  In the first place, such patients will not drink sufficiently; and, secondly, they lack a regular hour for evacuation.  I have treated scores of patients successfully for the constipated habit by directing that a large tumblerful of water, with magnesium sulphate, half of a dram to a dram dissolved in it, be drank every night.  Also, that the patient be directed to go to stool every morning after breakfast, i. e., after the hot coffee is drank, which aids peristalsis.  Direction should be given to eat food which leaves a large bulk of residue, as oatmeal, cornmeal, and graham bread.  This residual bulk stimulates the intestines to active peristalsis by contact in every successive segment.  Daily passages of the bowel and electricity aid to rouse the indolent digestive tract to normal activity.  The constant use of a very small pill of aloin, belladonna and strychnine is very effective.  Colonic flushings two to four times weekly, salt water and friction baths, aid nature in restoring lost tone.  Change of environment, climate, a sea voyage, but, perhaps better, long daily walks, are beneficial.  Horseback and bicycle riding are helpful.
    The course of mesenteric neuralgia as regards life is favorable; the attacks, which vary very much as regards intensity, endure from one to several hours.  Neuralgias arise in the sympathetic.  Collins demonstrated that the arteries of the abdominal viscera were possessed of great sensibility in which the arteries of other parts were wanting.  It is likely that the nerves accompanying the mesenteric artery participate in the reflex irritation, inducing the neuralgia.
    Hyperesthesia of the hypogastric plexus consists of irregular, periodic pains radiating from the abdomen to the genitals, bladder and down the thighs (including the inferior mesenteric plexus), and in the rectum.  The hypogastric plexus passes from the abdominal brain along the aorta, common iliacs, and from the bifurcation of the aorta two large strands pass on to complete the pelvic brain or cervical uterine ganglia.  In the female the hypogastric plexus chiefly supplies the uterus and oviducts; in the male the prostrate and vesiculoo seminales.  In both sexes it supplies the bladder, along the three vesical arteries and the root of the iliac and femoral.  In the female the two large branches of the hypogastric plexus, composed of twenty to thirty strands of nerves, pass off from the region of the inferior mesenteric ganglion and end distinctly in the pelvic brain situated on each side of the cervix.  In the male these same branches, though less in size, pass to the prostate and semen-sacs, but the pelvic brain I have found is vastly smaller in males than in females.  Yet a small dog possesses quite a large pelvic brain on the side of the prostate and ending of the vas deferens.
    The pain in hypogastric neuralgia must be sought for in the anatomical tracts and periphery of the plexus, which will be (a) in the uterus and oviducts, (b) in the bladder, and (c) on the path of the iliaco-femoral arteries (and with the inferior mesenterium), the rectum.  Also, since the origin of the hypogastric plexus is inseparably blended with that of the spermatic and hemorrhoidal plexus, we must expect to find more or less pain occurring in the ovaries, testicles, rectum and sigmoid.
    So far as I am aware Romberg was the first to describe the hyperesthesia of the hypogastric in 1840.  It is a neuralgic affection manifested by tenderness and pain in the hypogastric region.  There is a sense of pain and dragging in the pelvis, i. e., in the uterus, oviducts, bladder and to some extent the rectum.  In women the pain is spoken of as dragging, i. c., as if the uterus were prolapsing.  The characteristic pain is paroxysmal, periodic, and is not relieved by changes of position.  Structural changes cannot be demonstrated.  Since it is not practical to separate the inferior mesenteric plexus from the hypogastric on account of their intimate and close anatomic relations, we will consider that the hyperesthesia of the inferior mesenteric or hemorrhoidal plexus is intimately blended with hyperesthesia of the hypogastric plexus, the periodic, and is not relieved by changes of position spoken of as hemorrhoidal neuralgia or neuralgia of the rectum, of which I knew a typical case for ten years.  Neuralgia of the rectum in male or female is of an intense character.  It is apt to arise at night in an abrupt or sudden manner and continue from a few minutes to an hour or two.  It passes away as abruptly as it arises.  It creates intense suffering.  The best relief is opium suppositories.      Venereal excesses appear to aggravate it.  Coition momentarily relieves, but it returns quickly with more intense vigor than ever.  In venereal excess the neuralgia may extend with painful exacerbations along the urethra, especially worse after coition.
    In the range of the sympathetic, neuralgia is frequently followed by secondary effects, as in disturbed circulation, nutrition and secretion.
    The treatment of hyperesthesia of the hypogastric and inferior mesenteric depends largely on its supposed etiology, It consists in sedatives and evacuants, hydrotherapy, vaginal and rectal douches, electricity, massage and strict diet.
    The neuralgia of the hypogastric and inferior mesenteric plexuses exists almost entirely during sexual life, and especially during its active period, and though no demonstrable structural lesion may be found in the plexus of nerves, yet we must be on the alert to remove all visible physical defects for fear that the neuralgia is the secondary effect of the visible ones.  The patient should be treated as well as the disease, for it pertains to the wide moral fields.  Some patients, male or female, describe all sorts of pains about the genitals for months, and finally they may suddenly disappear.  There is a strange connection, however, anatomically and physiologically, between the nasal mucosa (and the olfactory nerve) and the genitals (and also the rectum).  Hence, it may be that valerian and asafetida will be effective remedies.  A stimulant such as nux vomica is often very beneficial.  The beneficial effects of nux vomica on the hyperesthesia of the hypogastric plexus may be owing to the close relation of the lumbar portion of the spinal cord and the genitals, for nux stimulates the nerves.  Some old writers termed the neuralgia of the hypogastric plexus menstrual colic.  It must be admitted that many of the neuralgic pains spoken of by patients in the hypogastric regions are obscure and would perhaps fit better in the chapter on visceral neurosis.
    In hyperesthesia of the hypogastric plexus we must include, for convenience, the pelvic brain.  This is a massive collection of compound ganglia similar to the cervical ganglia and the abdominal brain.  It is located on each side of the uterus.  It doubtless rules the vaso-motors in the uterus, innervates the uterus to a large extent, and is accountable for innumerable pelvic pains and for the irritable and tender uterus which is better considered in the domain of visceral neurosis.
    Hyperesthesia or neuralgia of the spermatic and ovarian plexuses has occupied the attention of physicians for over a century.  Astley Cooper pubished a notable work in 1830, and Curling wrote later.  Romberg wrote on the subject in 1840.
    In the male the spermatic plexuses of nerves extend from the origin of the spermatic artery, in the aorta, to the testicles long, quite rich strand of nerves.  The pain exists mainly in the testicle and extends to some extent along the plexus, i. e., in the spermatic cord.  The testicle is generally slightly tender, occasionally exquisitely sensitive; some subjects feel the necessity of a suspensory, and feel unable to live without it.  Sometimes movements cannot be tolerated and the patient lies in bed carefully protecting the testicle from trauma or touching the bed clothing.  If the testicular or spermatic neuralgia becomes intense the pains radiate down the thighs into the back, irritability of the stomach and even vomiting arising.  Spermatic neuralgia generally has a more profound effect on the mind than other similar neuralgias outside of the sexual field.  The subjects become melancholic, lose ambition and become full of hopeless forebodings.  Many of the subjects have varicocele in various degrees.  Spermatic neuralgia attacks man's sexual domain, the most profound and dominating human instinct, and if it persists sooner or later the mind becomes deeply troubled.  The patient becomes really possessed with a sexual mania.
    The etiology of spermatic neuralgia is not fully known, but it prevails during the state of puberty and manhood.  It is a disease of active sexual life only.  Cooper, against his will, removed three testicles for spermatic neuralgia and found the gland to be perfectly healthy.  Romberg had a case of spermatic neuralgia where the patient insisted, against the surgeon's advice, that the testicle be removed; however, eight days later the neuralgia appeared in the other testicle, and since it would be only eight days until his coming marriage, he preferred to retain his last testicle.
    I have observed cases of spermatic neuralgia before and after operation, and am opposed to operation unless a palpable lesion exists.  In males urethral neuralgia is often closely connected with spermatic neuralgia.  Such forms are aggravated by coition, and especially excessive venery.      Though urethral neuralgia, like other neuralgias, leaves no demonstrable pathology, yet such cases have frequently had a history of gonorrhea, or excessive venery.  The passage of graduated sounds, electricity, washing out the bladder, the.prohibition of sexual activity, and local applications, relieve.  Some old authors, as Cooper, think that these neuralgias belong to a central irritation, but modern investigations would tend to the view that it is a peripheral irritation.
    The subject of ovarian neuralgia is very indefinite.  However, it is not intended to deny the existence of such a disease, but the difficulty arises in the diagnosis.  It appears to me that the so-called ovarian neuralgia should be brought within the domain of visceral neurosis.  For example, every gynecologist of experience has observed an irritable uterus, but it should be designated under the term visceral neurosis and not uterine neuralgia.  The pain of so-called ovarian neuralgia passes down on each side of the lumbar vertebrae into the pelvis.  The pain is irregular, periodic, exacerbated at the menstrual flow, and generally the ovaries are tender.  There are certain women who complain of pains in the region of the ovarian plexuses for years.  Physical examination discloses at times very little, if any, physical defects.  Yet, by close observation and treatment by heavy douches and boro-glycerin tampons, one will frequently n o t e improvement.  The pelvic organs feel more normal than at the beginning, hence we rather favor some form of physical defect, congenital or excessive venery or some pathologic imperfection.  With this view, the irritable uterus of Gooch, the most of the ovarian and other visceral neuralgias, will be more beneficially considered under visceral neurosis.
    Finally, I wish to state that large numbers of subjects complaining of ovarian neuralgia can be definitely shown to suffer only from pain in the skin of the hypogastric region - it is hyperesthesia of the periphery of the ilio-guinal and ilio-hypogastric nerves.
 

X-RAY OF DUCTUS PANCREATICUS AND PART OF DUCTUS BILIS       Fig. 75.  This illustration suggests the quantity of nerves - ensheathed by a nodular, fenestrated, anastomosing plexus - supplying these channels.

    Hyperesthesia of the gastric plexus, gastric neuralgia, is generally known as gastralgia or gastrodynia.  Much that was said in regard to neuralgia of the abdominal brain applies to gastralgia.  Also, it may be better to include many of the considerations of gastralgia in the chapter on visceral neuroses.  Gastralgia leaves no visible trace of its pathology but in gastralgia we may look for perverted function of the stomach, as in (a) sensation, (b) secretion and (c) motion.  A typical gastralgia is called up in some subjects by taking ice water just following meals; in others, the gastralgia may occur at any time.  The chief conditions under which gastralgia is met induces the conviction that it is secondary to some visceral disturbances, and hence the subject is better placed under visceral neuroses.
    The Hyperesthesia of the Cervical Ganglia. - Ganglia of such vast size and possessing so much physiologic influence as the cervical must be considered being subject to the same diseases as other similar ganglia.  Those who have studied the sympathetic from clinical, experimental and autopsic grounds, chiefly agree that the main pathology is found in the cervical and great abdominal ganglia.  The chief influence of the cervical ganglia is manifest on the eye, vessels of the head and neck and the heart.
    The Hyperesthesia or Neuralgia of the Cardiac Plexus (Angina Pectoris.  Stenocardia, Heberden's Disease, 1768) is a painful affection of the nerves of the heart.  It is so far not anatomically definable, but is undoubtedly connected with the sympathetic nerve.
    Angina pectoris is a disease based on no one factor, but depends on a group of factors, which appear to have origin in the cardiac plexus.  It is characterized by its marked tendency to recur in paroxysms occasionally of intense severity.  In one case, a man fifty years of age attended by my colleague, Dr. 0. W. MacKellar, the patient was attacked with angina pector is and died in six hours.  Hypodermic injection of morphine did not appear to give relief.  In conjunction with Dr. MacKellar, I performed a postmortem on the patient's body fifteen hours later.  I found the heart large, dilated, slight fatty degeneration and the coats of the coronary arteries a little thickened.  The fatty degeneration, the sclerosis of the coronary arteries and the dilatation of the cardiac walls, were distinct enough to be easily observed, but not of a remarkable type.
    One of my patients has suffered attacks of angina pectoris for eleven years.  Otherwise she has enjoyed fair health.  Angina pectoris originates in the circulatory system, which is ruled by the sympathetic.
    The lesion of angina pectoris is so variable and uncertain that it is impossible to designate its pathology.  The cardiac plexus is so intimately and closely connected with the abdominal brain, both anatomically and physiologically, that each involves the domain of the other.  In angina pectoris the cardiac plexus and abdominal brain are in such a state of hyperesthesia or irritability that at any time a terrific attack may arise.  The attack comes on suddenly, frequently after some brisk exercise or mental activity.  John Hunter died in a paroxysm of angina pectoris, brought on by an altercation with hospital authorities.
    The pain begins in the region of the heart, but rapidly radiates in other directions, especially down the left arm even to the fingers, perhaps by means of the nervous tract made by the junction of the intercosto-hunieral (second dorsal) and the lesser cutaneous nerve (nerve of Wrisberg).  The patient during the attack is profoundly affected.  The face shows anxious dread and fear of impending death.  The pulse may be small, quick and irregular.  Respiration is labored, the face is pale and the patient presents a picture of terrible distress.  One of my patients required a couple of days to recover from an attack, fearing a recurrence by any active movement.  The attacks of angina pectoris are uncertain in intensity, regularity or even in the organs most severely attacked.  Hence, the varying accounts of different observers.
    The essential features which we have observed in the attacks are (1) pain in the cardiac region; (2) profoundly anxious feeling of the patient, and (3) disturbed heart action.  The disturbed respiration may be due to the terrible pain accompanying the attack.  That the paroxysmal pain in angina pectoris arises in the cardiac plexus we do not doubt, but why it arises there and why it is paroxysmal we can only guess, as we are still doing in other neuralgias.  If it is due to ossification of the aorta and coronary arteries and consequent pressure on the adjacent cardiac plexuses of nerves, why does it occur so far apart and in such a paroxysmal character?  The sympathetic cardiac nerves come from wide areas, hence varied and widely distinct paid.  Each of the three cervical ganglia on each side sends a nerve to the cardiac plexus and there repeatedly anastomoses with the vagus.
    There is a form of angina pectoris which has its origin or influence in the abdominal viscera.  It is a reflex neurosis.  The far-famed experiment of Goltz served as the ground of this view.  Goltz's "percussion experiment" consists in tapping the intestines when the heart may be arrested (in diastole).  This idea serves perhaps to explain deaths from a blow on the pit of the stomach, i. e ., on the belly brain.  Hence, disturbance, pathologic conditions in the peritoneal viscera, may produce angina pectoris by reflex irritation, through the abdominal brain.  Angina pectoris seems to be due to a super-sensativeness or over susceptibility of the nervous system.  However, Lancereaux found in a case, which died during an attack of angina pectoris from which he had long suffered, pathologic conditions in the cardiac plexus.  So far as I have observed cases of angina pectoris, the chief successful treatment consists in the diligent avoidance of sudden active exercise, physical or mental.
There are some different factors in angina pectoris which may be noted, as (a) spasm of the heart and large blood vessels, (b) a pure neuralgia, and (c) a vaso-motor disturbance produced by reflex irritation.  In any or all factors it appears that the sympathetic nerve predominates.  The abdominal brain may serve as an irritating factor.
    Hyperesthesia of the splenic plexus has not received a description for the reason that it does not produce definite demonstrable symptoms.  The plexus of nerves following the large spiral splenic artery from the abdominal brain to the spleen, lying to the left side between the ninth and tenth ribs, must play a significant role in life's action.  The section of the large splenic plexus of nerves begun by Jasckhowitz and others demonstrated that the spleen had something to do with the deposit of pigment in various parts of the body.  It is evident that the spleen is not a very active viscus in producing pain.  Jasckhowitz showed that irritation of the splenic plexus and branch of the celiac axis lessened the size of the spleen, while ligation of the splenic plexus distended the spleen.  The vasomotor nerves of the abdominal viscera are included in the sympathetic.  In several hundred personal autopsies I found the spleen surrounded by peritoneal adhesions in nearly 90 per cent of adult subjects.  Hence, it would be difficult to decide whether the pain was not due to the old perisplenitis.  But the spleen is innervated from the same source as the stomach, and there is no reason why the spleen may not suffer from neuralgia as well as the stomach.  In regard to the neuralgia of the splenic plexus, it will be required to work it out along the line of experiments, and especially on the vasomotor nerves.
    Hyperesthesia of the hepatic plexus or hepatic neuralgia (diabetes mellitus) is still an obscure subject.  The hepatic artery is well surrounded by strands of sympathetic nerves, and being innervated from the abdominal brain or the same source as the stomach, we see no reason why the liver will not suffer neuralgia pains similar to the stomach.  We of course exclude from hepatic neuralgia all pain produced by hepatic calculus or demonstrable pathologic lesion, wherever located - in the biliary ducts, gall-bladder or common duct.  Again, pain in the liver might arise from some vicious condition of the bile inducing a form of colic as it passed through the ducts to the intestine, and besides, this pain would be of a periodic or neuralgic nature.  Hepatic neuralgia signifies pain in the region of the liver possessed of a periodic nature.  It may be in hepatalgia the tangible cure is overlooked.  Inspissated gall may cause excruciating pain in its passage and be found in the stool in dark flakes.  The passage of the dry flakes of gall may be accompanied by severe pain, nausea, exhaustion and vomiting.  The right vagus as well as the sympathetic hepatic plexus, attends on the liver, so we must view the nerve supply of the liver as mixed, but since the vagus below the diaphragm is a demedullated or sympathetic nerve the final action is the same.  It is found that certain injuries to the solar plexus make more blood circulate in the liver, and consequently an increased flow of bile.
    Some writers consider that there is a casual relation between hepatic neuralgia and diabetes mellitus.  It is very, evident among writers that there exist two forms of hepatic neuralgia, viz., one accompanied with pain only in the hepatic nerves, and one with pain and the excessive secretion of glycogen (diabetes mellitus).
    Dr. Powell records a case of profuse and obstinate sweating with congested liver and diabetic urine.  Doubtless the hepatic plexus has power to rule the circulation of the liver to produce congestion and decongestion.  Hence, the influence of the sympathetic nerve is very great in diabetes mellitus.  It includes hyperemia of the liver, congestion in its capillaries, an influence on the formation of glycogen and perhaps on the ferment necessary for its production.  But since the production of diabetes mellitus is a very complicated process we cannot enter into its details.  The influence of the sympathetic in diabetes mellitus is observed in the menopause; when the hypogastric plexus is passing through a stage of atrophy women frequently have sugar in the urine.
    In this sense diabetes mellitus is identical with hepatic neuralgia.  By some irritation transmitted over the hepatic plexus the circulation of the liver is increased, and the glycogen may be excessively formed.
    The uncertainty and variability of definite lesions in diabetes mellitus seem to prove that glycosuria may be induced by reflex irritation in the sympathetic.  Many physiologists believe that glycosuria is due to hyperemia of the liver.  Hyperemia of the liver is controlled by the sympathetic nerve. just as in facial neuralgia, the region of the nerve involved is surrounded by congestion or hyperemic vessels, so in hepatic neuralgia, the vessels of the region of the hepatic nerves are followed by dilation and hyperemia and consequent glycosuria.  It is not irritation of the hepatic plexus alone that produces glycosuria; irritation of the sciatic is followed by sugar in the urine.
 

X-RAY OF DUCTUS BILIS ET PANCREATUS WITH ARTERIA HEPATICA       Fig. 76.  This illustration presents the ducts and vessels richly supplying the liver - each channel is well ensheathed with a nerve plexus.

    Hyperesthesia of the Pancreatic Plexus. - Pain in the pancreatic plexus cannot be located or differentiated from hepatic neuralgia.  The late researches of Minkowski would indicate that diabetes mellitus is due to disease of the pancreas.  Minowski and Mering have done much valuable labor in the field of the pancreas which will aid in solving the problem of the relation of the pancreas to the diabetes mellitus.
    Hyperesthesia or neuralgia of the renal plexus, nephralgia (diabetes insipidus) is an affection of the nerves of the kidney unaccompanied by any demonstrable anatomic lesion.  The nerves of the kidney are almost entirely non-medullated, i. e., sympathetic.  The kidney has the richest nerve supply of any organ in the body except the uterus.  The renal artery is abundantly studded with large ganglia, and the nerve strands form a rich network about it. The kidney is closely and intimately connected to the abdominal brain by a large rich plexus of nerves and ganglia.  The anatomic and physiologic base for vast influence of the abdominal brain over the kidney is not wanting in abundance of demonstrable sympathetic nerves and ganglia.
    Knoll (1871) observed polyuria after division of the splanchnics.  He placed canulas in the ureters and then divided one side at a time, so that he could observe the variation.  On the side operated, the urine was considerably increased (hyperemia).  Some writers claim that neuralgia of the renal plexus is accompanied with excessive flow of urine, polyuria or diabetes insipidus, while others claim that neuralgia of the renal plexus is only accompanied by pain in the nerves of the kidney and no increase of urine.  In neuralgia of the renal plexus all renal calculi are excluded.
    Neuralgia of the renal plexus is sometimes intense and paroxysmal, while at other times it is more continuous and less severe.  The pain does not tend to radiate along the ureter as it does in uretral calculus.  It is met with in persons exhausted, anemic, gouty, rheumatic and those poisoned with malaria.  Exposure to wet and cold are liable to give rise to renal pain.  Sedatives, evacuants, alteratives, electricity and massage are remedies employed against the disease.  It is very evident among writers that there exist two forms of renal neuralgia, viz., one with pain only and one with pain and increased flow of urine (diabetes insipidus).  With a large sympathetic plexus rich in ganglia, there is no reason, except from experiment, why the kidney should not suffer neuralgia similar to the other viscera, as such a condition is recognized in the nerves of the stomach, intestines, ovaries and liver.  It is not presumed to exclude cerebrospinal influences entirely.
    However, the renal vessels are ruled by the renal plexus, an almost purely sympathetic apparatus, having its origin in the abdominal brain.
    In diabetes insipidus the characteristic feature does not consist in any especial malnutrition of food, but in paralysis of vaso-motor constrictor nerves contained in the renal plexus and consequent dilatation of renal vessels.  This allows excessive blood to remain in the kidney (hyperemia).  Much of diabetes insipidus depends on the condition of the circulating blood in the kidney brought out by the force of the heart and constriction or dilatation of the renal capillaries.  The beneficial influence of ergot in diabetes insipidus demonstrates that the disease has a vaso-motor origin and maintenance.
Some writers speak of an idiopathic form of renal neuralgia, which doubtless means that its origin and persistence is not understood.  However, as a matter of clinical knowledge, it is very rare to meet with actual renal pain unless there be some pathologic lesion of the kidney or a renal calculus present.  But I have met with persistent pain and tenderness in the kidney, which neither urinary examinations nor renal explorations explained.
    It is not probable that patients will persist for several years to complain of pain and tenderness (sensativeness) in the kidney without some real base.  I have followed some for long periods with no discoverable pathologic facts.  It is like renal neuralgia.
    The Hyperesthesia of the Diaphragmatic Plexus. - This form of neuralgia has not been described as far as I am aware.  The diaphragm is so thoroughly dominated by phrenic nerves that it is obscured and overlooked.  Yet the diaphragm is distinctly influenced by the sympathetic.  Very careful dissection will reveal in the human subject a large nerve connecting directly the inferior cervical ganglion, the ganglion stellatum, with the phrenic nerve.  Dilatation of the rectum induces the patient to bray like an ass.  It induces respiration - the expiratory moan.  In peritonitis the experienced abdominal surgeon views with alarm the incipient sighing and irregular respiration.  The diaphragmatic plexus supplies and innervates the vessels of the diaphragm.  The ganglion diaphragmaticum exists on the right side only, at the point of junction of the sympathetic and phrenic nerves.  The diaphragmatic plexus is connected with the adrenal and the hepatic plexuses.  Doubtless some of the sharp pains on respiration owe their origin to the sympathetic in the diaphragm.