The man who builds a home erects a temple - the flame upon the hearth is the sacred fire. - Robert Ingersoll, American (1844-1904).

The peritoneum sheaths and lines. - Dr. P. T. Burns.
 

    The ideal nervous system consists of a ganglion cell, a conducting cord and a periphery, i. e., a receiver, a transmitter and a reorganizer.  This simple view of the structure of the nervous system at once suggests its function, viz., that of reception (periphery apparatus - skin, mucosa), transmission (conducting apparatus - nerve cords), reorganization (ganglion cell-brain).  The nervous apparatus is the highest and most perfect of known organism.  Mental action or nerve force, the most subtle of all forces, depends on it.  The nervous system includes the most profound secrets of life - it is the climax of organism.  First and foremost, the zone of the physiology of the tractus nervosus is not exactly defined - it is liberally elastic.  Secondly, the pathologic physiology of the tractus nervosus possesses an expansive, undefinable zone before established pathologic anatomy can be recognized.  The pathologic physiology of the tractus nervosus comprehends the fields of neuralgia, hyperesthesia, anesthesia, sensation, motion, melancholia. hysteria, neurasthenia, with innumerable irritable weaknesses of the nervous system. Absorption, secretion and peristalsis of viscera are the elements or means by which we recognize the pathologic physiology.  In the numerous manifestations of symptoms of pathologic physiology of the tractus nervosus of the abdomen a few considerations may be suggestive and helpful in practice.  First and foremost, many subjects are not perfect physically or mentally.  Such subjects are prone to pathologic physiology.  They possess inferior anatomy and physiology.  Structure and function are of minimum perfection.  Their nervous system is not stable.  We should consider these defections or unstable conditions under long-employed or established terms, associated with which has grown a stately literature, as stigma, habitus, asthenia congenita, heredity, predisposition , degeneracy.
    Nervous persons are afflicted with pathologic physiology.  Nervous persons manifest a defective resistance.  They are incapacitated for sustained effort.  Nervous persons present premature exhaustion on persistent mental or physical effort.  The reason of the nervousness is the anatomy and physiology of the tractus nervosus is inferior, its structure and function is deteriorated.  Their nervous system is irritable, weak, defective, unstable, functionating muck of the time with disorder and friction, like some watches which maintain incorrect time.  Nervous subjects are chiefly congenital unfortunates.  They are born with defects, with stigma, a habitus, neuropathic predispositions - a condition which tends to degeneracy with facility.  Nervousness, though frequently an announcement of an enfeebled nervous system, yet it may be evoked, aggravated, by some irritation external to the nerve apparatus.  Neurotic spells appear with as much mysticism as they disappear.  The only trace is the memory of the disordered pathologic physiology.  There is doubtless more or less foundation, for these inscrutable neurotic conditions, to be established in the state of the tractus vascularis, congestion, anemia.  The tone and tension of the abdominal muscles control the abdominal circulation.  Diseases of the tractus intestinalis compromise the tractus nervosus by damaging its integrity - in structure and function.  One of the best terms to apply to subjects who are persistently afflicted with pathologic physiology is the word habitus, e. g., we have the habitus phthisicus, habitus splanchnopticus, habitus nervosus, habitus dyspepticus.  The ensemble of symptoms associated with splanchnoptosia may well be termed habitus splanchnopticus.  It is heredity in so far that the subject possesses a predisposition and the main defect is inferior anatomy and physiology.  In the habitus splanchnopticus there is the gracile skeleton, the elongated flat thorax, extensive intercostal space, acute epigastric angle, the sacculated, pendulous abdomen, limited muscularis and panniculus adiposus, the labored respiration.  The costa fluctuans decima of B. Stiller, the peculiar habitus in form presenting evident pathologic physiology.  A marked factor in pathologic physiology of splanchnoptosia is the changed defective circulation, venous congestion.  Generally, any subject with a "habitus" possesses an unstable nervous system.  The dyspepsia accompanying the habitus splanchnopticus is perhaps more due to the neuropathic disposition than to the splanchnoptosia, hence the terms dyspepsia nervosa, or stigma dyspepticum.  The habitus neurasthenicus presents pathologic physiology of the tractus nervosus - a condition of exhaustion or weakness of the nervous system, accompanied by physical and mental efficiency.  Habitus neurasthenicus is a fatigue disease of the nervous system.  It is characterized by the presence of motor, sensory, psychic and visceral symptoms - all fatigued, tired, exhausted.  This habitus is especially characterized by weakness, or inefficiency and irritability of the tractus nervosus.  The physician can detect spots of hyperesthesia, spinal irritation, fatigue of the special sense, auditory and retinal hyperesthesia - all pathologic physiology, no pathologic anatomy.  However, if pathologic anatomy exists in the body, it is liable to intensify the pathologic physiology, the subject of habitus neurasthenicus, precipitating storms of neurotic spells.  The physician can detect the pathologic physiology, but not pathologic anatomy.  The subject is afflicted more or less throughout life with pathologic physiology.  When such subjects maintain additional strains, as gestation and the care of growing children, pathologic physiology in the tractus nervosus becomes pronounced and frequent, e. g., the habitus neurasthenicus may be in abeyance, quiescent, for a long period of time when the entrance of a pelvic disease, a myometritis, salpingitis, pelvic peritenitis, - may initiate, aggravate, an intense neurotic state.  It is not due merely to the so-called reflexes, but because the habitus neurasthenicus, the weak, irritable nervous system, has been aggravated, traumatized, become unbalanced, exhausted, fatigued.  Its inherent vital power is deficient and readily passes into a state of pathologic physiology.
    A lesson right here may be pointed that surgeons should operate for surgical indications only, not for function indications.  First and foremost, the gynecologist must learn to decide by an analytic exclusion diagnosis whether the subject has a habitus neurasthenicus, a pelvic disease, or the two combined.  The test of a gynecologist is his ability to diagnose the disease - not to do an operation.
The exquisitely, finely balanced nervous system of woman makes it liable to imperfections of development - stigmata.  Such a perfect organism as the tractus nervosus is prone to disease.  The intimate and profound relation of the tractus nervosus to the tractus genitalis in woman demands that a gynecologist be a physician of comprehension, or knowledge, understanding the vast fields of the tractus nervosus and tractus genitalis, as Well as their profound relation.
    The indiscreet and general surgeon announces that gynecology is "passing," and has become a segment of general surgery.  This assertion presents limited comprehension.  Is the oculist and aurist passing?  Is the dermatologist, neurologist and laryngologist passing?  Among the Germans, the most profoundly learned in medicine, specialists are progressively increasing.  The fact is that legitimate gynecology, like all other specialities, is just beginning.  Gynecology today is practically as broad as the entire medical field of thirty years ago.  The gynecologist must comprehend not only the organs in his own special field (tractus genitalis), but also the adjacent organs involved in practice or stimulating gynecological disease, as the tractus intestinalis, tractus nervosus, and tractus urinarius.  In the interest of the patient, no specialist can be limited exactly to the organs of his own specialty, for he should study the organs secondarily afflicted or dependent on the affections of the viscera on which he practices.  The specialist must understand the anatomic and pathologic relations of specialized organs to adjacent territories, as vomiting (tractus intestinalis) to pregnancy (tractus genitalis), as albumin (tractus urinarius) to pregnancy (tractus genitalis).
    The more intimate changing relations of associated organs in structure and function, the more valuable will be the study of the differential diagnosis in disease.  The gynecologist should execute all necessary technique which will enable him to diagnose and treat diseases, dependent on or associated with the tractus genitalls - as cystitis, ureteritis, splanchnoptosia, mammary disease, constipation, nephritis, proctitis, thyroid disease.  The borders of a specialty cannot be marked by the rim of a circle, but by the diseases dependent on and resulting from the specialized system of viscera.  Every special science gradually unfolds its own dependent and associated relations.
Gynecology has been a typical example.  It forced a divorce from general surgery, to which it never will return, from sheer magnitude.  One mind cannot master more than one visceral tract with its relations.  The unfolding of gynecology has increased the interest and usefulness of its domain.  It has shown the delicate balance and relations of all abdominal viscera on the abdominal sympathetic brain.  Practically all progress, new ideas, must come from specialists.  The specialist is a permanent factor in medical progress, from whom will practically emanate discoveries and rational treatment.  However, the present and future specialist will not be limited to a single visceral tractus for the diagnosis and therapy of his independent field, but will study adjacent or remote visceral tracts which may lend aid in the differential diagnosis and rational treatment.  The gynecologist should diagnose and treat all diseases primarily or secondarily, dependent on the life, function and pathologic conditions of the tractus genitalis, as sacropubic hernia, rectocele, vesicocele, splanchnoptosia; dependent on rapid and frequent gestations (nephroptosia, gastroptosia, coloptosia, hepaptosia - relaxed abdominal walls).  The rock and base of medical practice (special or general) is the diagnosis which enables the physician to employ rational treatment, to act for the best interest of the patient.  Large numbers of women with marked splanchnoptosia dependent on the work performed by the tractus genitalis, as gestations, come to the gynecologist.  The tractus genitalis, though primarily the basic cause of splanchnoptosia, itself is no more ill than the tractus urinarius, tractus intestinalis, or the relaxed abdominal walls.  It is the duty of the gynecologist to treat such cases.  The general surgeon is no more an expert in special departments than is the general practitioner.  The reason for the operation, i. e., the diagnosis, is a thousand fold more expert than the mere technique of surgical procedure.  Predisposing factors to pathologic physiology in the tractus nervosus are defective nurtrition, variations of metabolism, chlorosis, anemia, hemorrhages, deficient or excessive secretion, premature senescence, strained physical and mental efforts.  Heredity transmits defects which are the foundation for aggravated pathologic physiology.  When the subject has an established habitus, as habitus splanchnopticus, habitus neurasthenicus, habitus phthisicus, and predisposing factors become imposed to, the subject is burdened with extreme pathologic physiology.  An excellent example of artificial habitus is the numerous stigmata arising from the total removal of ovaries in young women, which condition might be termed habitus ovaricae neurasthenicus.  The young woman with castrated ovaries experiences an intense, aggravated, premature climacterium - she is suffering from pathologic physiology of the tractus nervosus.  The patient is afflicted with flushing (disturbed circulatory centre), flashes (disturbance of caloric centre), perspiration (disturbance of the perspiratory centre).  She has depression, melancholia, excessive panniculus adiposus, growths of hair.  In some subjects the sensation of the tractus nervosus of the abdomen is awry.  Subjects complain of animals crawling within the abdomen.  This matter may be explained by supersensitiveness or hyperesthesia of the mucosa of the tractus intestinalis from gas or contents.  More than one operation has been performed for such condition.  It may be incidentally remarked that it requires much study and discreet judgment to decide neurosis of the tractus nervosus abdominalis and the nervous disturbances produced by the dominating nerve-supplied genital tract - both conditions induce, aggravate, pathologic physiology in the abdominal nerves, e. g., one of the most characteristic lesions accompanying the habitus neurasthenicus - producing pathologic physiology - is defective development of the tractus genitalis.  I think among the scores of women I have examined with defective development of the genitals that at least 95 percent were neurotics manifesting pathologic physiology of the tractus nervosus.  Does the neurosis precede (congenital), accompany the defective development of the genitals or is it accidental to it?  The most probable view is that it is congenital, and marks an ill development of the organism.  The habitus neurasthenicus or habitus hystericus are not diseases of the genitals but of the nervous system with an hereditary burden and perhaps an acquired burden.  These conditions required vast study to differentiate in gynecologic practice.  The habitus chlorosis is another example of a disease closely
 

Fig. 138.  Nerves of the internal genitals.

associated with the tractus genitalis.  It is doubtless heredity; occurs in girls from fourteen to twenty-four years of age,  i. e., at puberty or the developmental stage; is accompanied by increased panniculus adiposus and neurotic symptoms.  Chlorosis is associated with defective development of the genitals in 75 percent of subjects.  Genital functions are defective.  The nerves governing secretion (ovarian) are perhaps defective.  In diagnosing pathologic physiology of the abdominal nervous system it is well to determine the etiology, as acquired factors enhance conditions, e. g., the tractus nervosus of a pregnant woman is more irritable, more liable to pathologic physiology, than the non-pregnant.  The nursing woman is frequently in a state of pathologic physiology.

TREATMENT OF PATHOLOGIC PHYSIOLOGY OF THE TRACTUS NERVOSUS.

    The treatment of subjects with disturbances - pathologic physiology - in the abdominal nerves is difficult in ordinary practice because the acquired factors are inseparably associated with continuous environments, with habitat.  The etiology and consequent habitus or stigma must be diagnosed by careful examination in individual subjects.  The reason the sanatorium is so successful in the treatment of the nervous patients is the patient is removed from the environments, from the habitat, in which the disease developed.  The provocative or aggravating factors must be generally eliminated.  It may be constipation, deficient drinking of fluids, the ingesting of improper concentrated foods, which leave insufficient indigestible residue to provoke intestinal peristalsis.  It may be sedentary habits, insufficient exercise or deficient fresh air.  It may be excessive work and worry, insomnia.  In the subject with the habitus neurasthenicus I am in general opposed to the so-called Mitchell rest cure.   The neurasthenic may possess fatigued nerves but not fatigued muscles.  I attempt to treat the neurasthenic by maintaining her in the fresh air and muscular activity all day.  In the subjects I administer active visceral drainage and coarse foods which leave a large undigestible residue.  She is improved by the bicycle, by games requiring muscular activity, rides which massage the viscera, fresh air, appropriate diet, and ample fluid at regular intervals.  Some neurasthenics are practically unmanageable.  I am now treating a woman twenty-seven years of age who has lain in bed for three years.  She says her nerves could not stand walking in the sunshine.  Physically I can detect no pathologic anatomy - simply pathologic physiology.  By forced feeding she retains ample flesh.  During the last six months, by all kinds of persuasion, we succeeded in inducing her to walk one block daily.  Maximum visceral drainage and appropriate dietetics maintains apparently a healthy physique.  We agree with Dr. John G. Clark that several kinds of neurasthenics exist.  The gynecologist meets with three kinds of neurasthenics, viz., (a) a neurasthenic of congenital origin - habitus neurasthenicus congenita - who practice almost continually genital introspection where the physicians can not detect genital pathologic anatomy.  She is constantly occupied by views regarding genital and sexual life.  The treatment of such neuropathic subjects is lifelong, firm discipline, hygiene, dietetic, fresh air for twenty-four hours a day, ample fluids, physical exercise. (b) A neurasthenic with coincident visceral lesion but each entirely independent of the other, as may occur in the tractus genitalis, tractus intestinalls, tractus urinarius.  In the second condition the additional treatment is to remove the lesions of the sole visceral tract; (c) a third kind of neurasthenic is where the neurasthenia is dependent on an organic, visceral lesion.  The tractus nervosus of the originally predisposed, neuropathic subject was provoked, aggravated, into a state of pathologic physiology by the organic lesion.  The treatment of this third class is repair of the organic lesion and systematic visceral drainage by means of fluids and foods.
    1.  Dietetic.  The diet of neurotic patients should be regulated under strict discipline.  It should consist of cereals, vegetables, albuminates (egg, milk), and limited meals-mixed diet.  The high spices, cakes, puddings, pies, stimulants should be eliminated.
    2.  Fluids.  Ample at regular intervals - 8 ounces every two hours for at least six times daily.  This forty-eight ounces of fluids daily may be nourishing fluid - as, milk, buttermilk, eggnog, cereal gruels.
    3.  Salt rubs, which the patient administers to herself once or twice daily. at stated times for stated duration.
    4.  Massage, which should be administered as much as possible by the patient herself.  The patient can be taught massage of the abdominal muscles, which especially benefits the abdominal visceral tracts.
    5.  Exercise is absolutely necessary for health.  The neurotic patient continually complains of tiredness and fatigue.  The fatigue belongs to the nerves.  It is not muscle fatigue, hence the muscular activity should be vigorously maintained in walking, riding, games - all distracting the patient's attention from herself.  Muscular exercise influences circulation and hence nourishment.
    6.  Fresh air should be continuous day and night.  The sleeping-window should be open all night.  The window of the day-room should be continuously open.  Cold, fresh air is an invaluable therapeutic agent in neurasthenic disturbances and tuberculoses.
    In order to assist the foods and fluids to secure maximum visceral drainage I place on the tongue every two hours a tablet containing 3 grains of sodium chloride (NACI) and a part or multiple of an alkaline tablet [composed of aloes (1/3 gr.), cascara sagrada (1/40 gr.), NaHCO3 (1 gr.), KHCO3 (1 gr.), and MgSO4 (2 gr.),] followed by 8 ounces of fluid.  This visceral drainage method I followed systematically for weeks and months, resulting in successful maximum visceral drainage, with increased nourishment, improved sleep.  The elimination of waste-laden products benefits the nervous system - the pathologic physiology is reduced to a minimum and the patient recovers.