The sympathetic is the silent companion of the cerebralspinal.  The sympathetic
nerve is the nerve of subconscious life.

"But he did not lose sight of the present in these glowing visions of a future."
- Mrs. Catharine V. Waite, "The Mormon Prophet and His Harem."
 

    Having devoted some twenty years to the study of pelvic and abdominal visceral disease, I have frequently desired to record some observations on the effect of tumors in the pelvis and abdomen upon the sympathetic system.  Many dissections have convinced me that the vast ganglionic system, distributed to the viscera bordering upon the peritoneal cavity, together with other glandular organs of the body, plays a significant role.  Besides, when it is noted that the heart and the unstriped muscles of the body, are supplied by the sympathetic system, there becomes at once apparent its extensive as well as intimate connection with the whole body.
    Special study in the physiology and pathology of the viscera develops reasons for the removal of abdominal and pelvic tumors not apparent from superficial observations.  It is well known that shortly after the appearance of a tumor in the abdomen the health of the patient becomes more or less impaired.  The functions of the organs become deranged; the heart suffers from abnormal action and structural change; the digestion becomes more or less deranged.  As the tumor increases in size, kidney diseases generally develop.  The liver, forming bile, glycogen and urea, sooner or later becomes impaired in its rhythm.  The lungs lose their rhythm and become spasmodic, while the spleen shows its disturbance by pigmentary deposits in various portions of the body.  An attempt will here be made to explain the pathological result of abdominal tumors on physiological and anatomical grounds.
    The basis of the explanation will be by reflex action on the sympathetic nerve.  It may be curtly observed that pathological results due to the sympathetic nerve are based upon reflex action.  We shall assume that the ganglia which are found in it, especially the abdominal brain and the three cervical ganglia, are points where forces are reorganized and distributed to the viscera.  The first essential feature to observe in the diseased viscera is the disturbance in rhythm.  Though any abdominal tumor may produce the same results, we shall choose a uterine myoma to illustrate our views.  It is a principle in physiology that when a peripheral irritation is sent to the abdominal brain the reorganized forces will be emitted along the lines of least resistance, so that the organ which is supplied with the greatest number of nerve strands will suffer the most.  Practically this principle holds true in every viscus.
    The great ganglia and cords, filled with nerve cells and nerve strands, labor in the subconscious region, the vast laboratory of life and assimilation.  The cerebrospinal axis receives sensations and emits impulses which express themselves in motion, performing labors which minister to the mind and protect the body in avoiding destruction, or contribute to its nutrition.
 

SCHEMATIC DRAWING OF THE SYMPATHETIC NERVE       Fig. 57.  X, ganglion of Ribes; y, coccygeal ganglion; h, heart; k, kidney; s, spleen; a b, abdominal brain; s p, spermatic (ovarian plexus) ; i, intestine; h p, hypogastric plexus; c g, the three cervical nerves.       The sides of the ellipse represent the lateral chain of the sympathetic.  All the nerve strands report to the abdominal brain.

    The effects of the tumor on the heart may first be considered.  An abdominal tumor induces fatty degeneration of the heart.  When the uterine tumor irritates the peripheral ends of the hypogastric plexus, the irritation is transmitted to the abdominal brain and there reorganized and emitted along the splanchnic to the cervical ganglia, where, again, a reorganization occurs and the force then passes down to the heart by way of the three cardiac nerves.  The irritation could pass directly from the uterine myoma up to the lateral chain of sympathetics to the three cervical ganglia where it becomes reorganized.
    It no doubt transmits part of the irritation by way of the abdominal brain and part by way of the lateral chain.  So far as the heart is concerned, the result is nearly the same, for the irritation is reorganized in each case in the three cervical ganglia and transmitted to the heart.  It is of course necessary to consider that the irritation may be sent to the spinal cord by way of the vagus and there reorganized.  In such case it is sent directly to the heart by the vagus.
    It should be remembered that the sympathetic ganglia in the walls of the heart (Ludwig's, Bidder's, Schmidt's and Remak's) are numerous and large.  Also that the network of cords with their ganglia, situated close to its surface, constitute an extensive nerve system.  It consists of the great or deep cardiac plexus, otherwise known as the plexus magnus profundus of Scarpa, besides the superficial cardiac plexus, with the cardiac ganglia of Wrisberg, which is occasionally large from the coalescence of several ganglia, and may be represented by a meshwork.  In tumors of the pelvis we are dealing with the effect on the vast cardiac sympathetic nervous system.  The first manifest objective heart symptom is irregularity.
    The irritation from the uterine myoma reaches the heart in two ways:
    1.  The irritation passes up the hypogastric plexus to the abdominal brain, where it is reorganized and emitted to all the viscera over their respective sympathetic plexuses.  In the case of the heart it passes up the abdominal splanchnics to the three cervical ganglia of the sympathetic, where it is reorganized and sent directly to the heart.
    2.  Some of the irritation is transmitted by way of the vagi to the medulla, where it is reorganized and sent directly to the heart by the cardiac nerves which supply the heart from the vagus.  This is more especially the case in the right vagus, as that is the cranial nerve which largely rules and supplies the heart and abdominal brain.  Now, this irritation from the myoma goes on day and night.  It gives the heart no rest.  It flows to the heart in the midst of a diastole, or a systole.  The first great characteristic of the heart (rhythm) is lost.  Having lost its rhythm, the heart proceeds irregularly.      Irregular action means a changed nourishment; continued irritation with disturbed rhythm induces the heart to overfeed itself, the result being hypertrophy.
    It may be noted that this hypertrophy is not brought about in precisely the same way as is hypertrophy from valvulitis or aortic insufficiency; but vaso-motor dilation must play a role in over-nourishing the cardiac muscles.  It resembles more nearly the cardiac hypertrophy existing in goiter.  That from the reflex irritation in myoma is also a moderate hypertrophy, so far as the writer has observed, and it is a very slow process.  In the first stage the heart becomes irregular, in the second hypertrophied, in the third it takes on fatty degeneration.  This is no doubt a preservative process, so that a large, vigorously beating heart will not rupture an artery in a degenerated state (atheromatous or fatty).  It appears certain that many old cases of large uterine myoma are lost after skillful operations simply from fatty degeneration of the heart.  It is common to observe palpitation in patients having uterine myoma, and palpitation is the characteristic symptom of a weak heart.
The automatic cardiac ganglia are disturbed by reflex irritation and take on an excessive nourishment.  The irritation, sent to the heart over the hypogastric plexus, is in one sense an increased demand for action.  The irritation, passing to the heart day and night, winter and summer, according to a physiological law, provokes hypertrophy, if the nutritive powers are good.  If they are not good, the complement of hypertrophy - dilation - results.
    A fatty degenerated or weak heart induces low blood-pressure, which is the bottom factor in waste-laden blood and deficient elimination.  It allows local congestions and consequent impaired nourishment.  The local force of such circumstances teaches to remove uterine and other abdominal tumors as early as possible, so that the patient will not be left with partially or completely damaged viscera.
    Reflexes arising from the irritation of the sympathetic in the peritoneal membrane are profound in results.  Irregularity, hypertrophy, and degeneration of the heart are the effects of a reflex act, accomplished mainly through the sympathetic system and due to irritation at the periphery of the hypogastric plexus.  It is transmitted to the abdominal brain, to the three cervical ganglia, and some to the spinal cord, whence the reorganization of the forces occurs.
    The organized nervous impressions then pass to the heart over the six cardiac (vagi) nerves.  This abnormal force deranges the fine balance of the heart's rhythm.  The automatic cardiac ganglia become discolored, and in time vaso-motor action and consequently nourishment are disturbed.
    It may be remembered that the untoward influence on the heart, disturbing its rhythm and consequently its nourishment, is also aided and abetted by disturbing the caliber of distal blood-vessels which are controlled by the sympathetic system.
    The liver does not escape the evil influence of the tumor.  Abdominal tumors induce fatty degeneration of the liver.  It may be asserted that an influence on the hepatic plexus of nerves alone could stop all secretion in the liver.  If such a proposition be true, it need not be wondered that lesser irritations of the hepatic nerve plexus could so alter the secretion of the liver that it would degenerate the organ.  The characteristic disturbance which arises from the uterine myoma is a derangement of rhythm.  The liver has a rhythm due to (a) an elastic peritoneum enclosing it, (b) an elastic capsule (Glisson's) surrounding it, and (c) to the capacity of its cells to enlarge.
    The occasion of the liver rhythm is food carried to it by way of the portal vein.  When the peritoneal and Glisson's capsules and the cells are expanded to a maximum, the liver rhythm is at its climax.  Now,. the products of the liver (bile, glycogen and urea) are sent to their respective homes by contraction of the elastic peritoneum and capsule of Glisson.  The liver then gets its rest and repair.
    The irritation from the periphery of the hypogastric plexus passes up to the abdominal brain, where it is reorganized and emitted to the liver.  It goes to the liver from the tumor at all hours and deranges its rhythm.  The irritation may attempt to induce a rhythm without food, or it may flash on to the liver at any stage in its rhythm.  The liver rhythm is induced by the automatic hepatic plexus.  So it may be asserted that the irritation of the uterine myoma deranges the rhythm of the liver.
    The second point to consider is the altered secretion in the liver, due to the reflex irritation from the uterine myoma by way of the abdominal brain.  The continued irritation increases the derangement and soon changes and impairs the liver nourishment.  The complete process from food to end products becomes imperfect and a lower grade of tissue is formed, known as fat.  The constantly irritated liver soon becomes able to form but little products beyond fat, and degeneration follows.
    It is well known that women at the menopause frequently acquire liver disease. This is owing to the reflex irritation through the abdominal brain.  The degeneration of the hypogastric plexus will not allow it to transmit sufficient physiological orders to induce a monthly rhythm, so the accumulated energies flash to the other organs, and the derangement of the liver is especially manifest, because its derangement is often followed by pigmentation (yellow or brown or black) of the skin.  The uterine myoma, then, by reflex action. disturbs rhythm and secretion in the liver, and so its nutrition. This ends in fatty degeneration.
    For years I have observed that women with pelvic disorders have disturbed kidney action.  In general this kidney disturbance is renal insufficiency, and it may after long irritation become organic disease.  It may be well to give a general hint here as to why the kidneys suffer so much when either irritating tumors or inflammatory processes exist in the pelvic organs.
    The kidneys, uterus, ovaries and oviducts develop from two very small points in the embryo called the Wolfflan bodies.  These develop from the mesoblast, as do the muscles, blood and lymph vessels, and from the genitourinary organs.  Arising from the same source and supplied by the same nerves and blood-vessels, the Wolffian bodies, the kidneys and genitals have an intimate and close connection.  The abdominal brain sends out a vast chain of nerves to the kidney on each side, and the same brain sends out a vast chain on each side of the genitals.  These and the kidneys are only different spokes in the same wheel, the hub of which is - the abdominal brain.  Diseases in the genitals, whether tumors or inflammatory processes, produce in the urine not only diminished solids but also diminished fluids.
    Again on the other hand diminished kidney excretion (renal insufficiency) produces diseased or, at least, disturbed genitals.  Any gynecologist of some years' experience has doubtless frequently observed that in women with diseased genitals and deficient renal secretion, by giving diuretics - fluids in small and off-repeated doses, the diseased genitals will often improve in direct proportion to the increase of renal secretion.  Deficiency of renal secretion irritates the genitals by non-removal of urinary solids.  Diseased genitals irritate the kidneys by reflex action.  This is all accomplished through the abdominal brain as a center.  The genitals, kidneys and abdominal brain constitute a very vital triangle.  In the middle of its base lies the significant abdominal brain and at the apex the important genitals, while the other two angles are occupied by the kidneys.  The uterus and kidneys have the highest nerve and blood supply of all viscera, hence they experience more profoundly than other viscera the forces which are organized and reorganized in the abdominal brain.  In the sympathetic nervous system the kidneys play a vast and immeasurable role.  If by some irritation in the pelvis or abdomen the kidney begins to secrete insufficiently, the whole organism, together with the ganglionic nervous system, or the cyclo-ganglionic system, as Solly termed it half a century ago, will become poisoned from non-elimination.  From this peculiar reflex action, of which the abdominal brain is capable, we may yet learn that disease of the pelvic organs of woman may be cured by diuretics, cathartics or diaphoretics.  In other words drain the skin, drain the kidneys and drain the bowels.  The intimate and close relations of the genitals and kidneys is plain anatomically and physiologically, as large bundles of nerves from the abdominal brain supply both.  Clinically, then, these closer relations have been demonstrated of late years, as gynecology has progressed.  The cyclo-ganglionic system is recognized as a finely balanced mechanism capable of prompt response when once its manifestations are understood.
    For example, no one understands so well as the gynecologist the vital relation which exists between deficient kidney secretion and diseased pelvic organs.  Effective diuretics relieve many pelvic pains.  Baths and diaphoretics subdue innumerable neuralgias, and cathartics disperse dragging pains.  A woman may have a sound kidney (so far as chemical examination of the urine may indicate) and yet reflex action from the genitals may induce it to secrete deficient or excessive fluids or solids, which not only further disturbs the genitals with waste-laden blood but disarranges the fine balance in other viscera with the same.  Wherever this waste-laden blood advances it produces new points for reflex irritation, unbalancing the whole system.  It seems to me there is no better point to work from in this consideration than the relation of the genito-urinary system to the abdominal brain.  Clinical features are more manifest here than elsewhere.  Gynecologists may even cure women of innumerable ailments by simply inducing them to drink water.  I have accomplished much for women during the past fifteen years by inducing them to drink a full glass of water, six times daily, containing a pinch of Epsom salt in solution.  The late Dr. J. H. Etheridge wrote instructively on renal secretion in gynecologic patients.
    During menstruation girls show distinct clinical symptoms of pain in the region of the kidneys, and of variation in urinary secretion, showing the close relation between this and pelvic disturbances.  It is clear that this pain in the kidney region is due to reflexes from the menstrual organs, i. e., the uterus and oviducts.
    The kidney, in proportion to its size, has the highest nerve and blood supply of any viscus, except the uterus.  According to the recent investigations at Johns Hopkins University. the kidney is supplied only by sympathetic nerves.  It is a common observation that abdominal tumors are followed by kidney disturbances.  Even the gravid uterus does not allow the kidney to escape irritation.  This kidney disease brought about by abdominal tumors is reflex.  It is a physiological principle that an influence acting through the nerves alone can arrest all secretion.  Minor degrees of irritation will suffice to increase, diminish or change the kidney secretions.  Irritation of an organ continued indefinitely, and modifying its action, may be sufficient to induce disease.  Kidney disease resulting from abdominal tumors is chiefly chronic in the very nature of the case.
    The first point to consider, as the initial step in chronic renal disease from abdominal tumors, is partial or complete obstruction to the flow of urine.
    The second point to consider in chronic renal disease due to abdominal tumors is reflex irritation from distant viscera.
    The third point of consideration is infection.
    As regards the first point, obstruction, the location and size of the tumor may be noted.  A partially occluded ureter, through long-continued pressure, will cause renal disease.  Under this head would be classed mechanical impediments to the flow of urine.  If the obstruction is sufficient it will create hydroureter.  If the hydroureter is long enough maintained the kidney will secrete until blood pressure is impaired, and then in a few months atrophy will follow.  The writer has proved by experiments on the dog that when the ureter is completely ligated, the kidney will shrink to about one fifth its original size, in five months.
    The pressure of the tumor on the ureter is a silent process not often recognized by the attendant.    The obstruction of the ureter is like the quietly growing intestinal stricture, which is rarely recognized until some terrible disaster reveals a long series of old pathological conditions.  The main idea in the obstruction, however, is that it is partial, and by raising the difficulty of urine flow, renal elimination becomes deficient.  The blood then becomes waste-laden.  If the obstruction is sufficient, the result will be hydroureter, which being long continued (without infection) results in renal atrophy, as the writer proved by tying the dog's ureter.
    The second point, reflex irritation, is more significant, because it means that irritation from any viscus can be reflected to the kidney, over the renal plexus.  The abdominal tumor irritates some contiguous viscus; this irritation quickly passes to the abdominal brain, by way of the sympathetic plexus of said viscus, where the forces are reorganized and transmitted to the kidney.  There is little doubt that the rise of temperature from passing a sound into a man's bladder is due to reflex irritation transmitted from an oversensitive urethra.  It is probable that the so-called urinary fever is reflex.  It modifies circulation by inducing local anemia and local hyperemia.  In this way nutrition quickly changes.  Examples may be seen in strictures of the intestine or ureter where the walls above the stricture are greatly thickened.
    The chief point in regard to secretions in patients with abdominal tumors is a decreased or disproportionate secretion.  It is common to observe a patient with a tumor secreting a small quantity of urine heavily laden with salts.  The amount of urine voided at times appears as an alarmingly small quantity.  Natural reasoning from clinical and physiological bases attributes the decreased quantity of urine to the irritation from the tumor transmitted over the renal plexus.  Autopsies on women who die of tumors prove it beyond the shadow of a doubt.
    Disproportionate renal secretion from the irritation of abdominal tumors is also common.  Albumen is the chief element found.  But phosphates, urates or sugar make up the varying scales of salts.  Even the amount of water will vary within wide limits.
    The tumor of pregnancy is a common example of disturbed renal secretion due to reflex action.      Thus deranged renal secretion is frequently due to reflex irritation, depending on the presence of an abdominal tumor.  The change in the secretion consists in increase, decrease or disproportionate quantities.  As each organ has its own distinct nerve plexus, so it should be understood that reflex action is carried along distinct anatomical lines.
    As regards the third point, infection, in chronic renal disease from the presence of abdominal tumors a serious condition appears.
    The genito-urinary tract can be infected at any point from the kidney cortex to the urethral end.  If the tumor presses severely enough on the urinary tract, a perforation will occur, and from this perforation infection will travel in either direction-toward the urethra or toward the kidney.
    The result of perforation of the urinal tract will be nephritis and cystitis.  The perforation is most likely to occur in the bladder, from which the infection ascends the ureters to the kidney.  It is not necessary to have a large tumor to perforate the urinal tract; simply a suppurating focus is sufficient.  It is not necessary to have a complete perforation of the urinary tract to allow infection to gain an entrance, for the germs, or their products (ptomaines), may penetrate a thin pathological wall.  The final result of an infected urinary tract is ureteritis, with parenchymatous or interstitial nephritis.  The writer has observed some disastrous results from pyosalpinx perforating the bladder and intestines.  It may here be noted that Doran, a most excellent observer, made postmortem examinations of forty women who had died of ovarian tumors, and thirty-two had severe kidney disease.  This means that 80 percent of those who died from ovarian tumors had kidney disease.  No doubt the kidneys were diseased from the presence of tumors.  Obstruction, reflex action or infection was the causative factor of renal disease, resulting from pressure of tumors.
    A good sample of obstruction, reflex irritation and infection of the urinal tract is seen in cases of gonorrhea in men which end in stricture and "catheter life." The stricture generally arises in the urethra and marks the onset of obstruction to the urinary flow.  This increasing obstruction induces constant reflex irritation, and yet the man is not subjectively or objectively sick.  But now he begins "catheter life," which means infection.  It means self-destruction by his own hands.  Thus to obstruction and reflex irritation of the urethra he has added the fatal infection carried on his catheter, which too frequently makes the fatal march swiftly onward and swiftly downward.
    The kidney suffers similarly from any abdominal tumor, and chiefly by reflex irritation, which passes from the abdominal brain by way of the contiguous plexus, where it is reorganized and emitted on the large renal plexus to the kidney.  The writer notes that those women who come to him for the purpose of having tumors removed have a very variable quantity of urea in the urine.  At the Woman's Hospital the writer has the urea tested in every case of laparotomy, and the amount varies from five to eleven grains to the ounce.  The tumors appear to play a significant role in the production of varying quantities of urea.
    What has been said in regard to kidney disease by reflex irritation is equally prominent in floating or excessively movable kidney.  The dragging of the kidney on the abdominal brain, through the renal plexus, unbalances the viscera very distinctly.  The patient suffers from nausea, from constipation, from disturbed secretion and circulation and from dull dragging pains.  The patient may sometimes suffer similarly from an artificially fixed kidney, as I have observed often after a nephropexy of my own, when viscera, which are normally excessively mobile or fixed, are dislocated, they lose a part of their physiology, which is motion.
    Calculus in the ureter is a typical sample of disturbance in the sympathetic nerves.  One of my patients was idle ten months before I removed a ureteral calculus, and she suffered from an unbalanced sympathetic nervous system just as a woman would from diseased genitals.
    Abdominal and pelvic tumors produce disease in the digestive tract.  Object lessons are not only impressive to children, but to adults.  The wonder is how the visceral organs can adapt themselves to growing and movable tumors.  Today we removed an ovarian tumor the size of a child's head with a narrow pedicle of seven inches.  The tumor could be pushed into almost any position of the abdomen.  Yet this tumor, which the patient has had for about ten months, appears to have told on her health.  To be sure it glided where it would without any apparent trouble, but doubtless the continued, repeated and accumulated traumas on the other viscera maintained a constant story of visceral insult.  Every step she took induced the tumor to jog and roll around in the abdomen.  Occasionally it would become partially wedged in the pelvis, producing congestion and disturbed circulation and insults to the delicate nerves of the peritoneum.  This solid tumor was not like the yielding, soft viscera; but wherever it would lie it pressed and disturbed circulation.  It is probably true that smaller tumors of the pelvis and abdomen produce much more traumatic visceral insult than larger ones which move but little.  The real wonder was that such a tumor as the above could glide about among the mobile viscera so long and not become rotated on its axis.
    It is probable that secreting or glandular organs suffer the most from abdominal tumors, because the main damage is through reflex action, and the glands are the most highly supplied with sympathetic nerves. The digestive tract should be studied by means of (a) sensation, (b) motion, (c) secretion, (d) absorption.  The slow, continuous pressure of abdominal tumors produces but little recognizable sensation in the digestive tract.  Another point is that from inexperience the patient cannot localize the pain in the digestive tract, but refers it mostly to the abdominal brain; so that the subjective sensation in the digestive tract, due to tumors, is of small value.  As regards motion in the digestive tract, in cases of abdominal tumors, one can say that in the great majority of fair or large-sized tumors motion is diminished and constipation is the rule.  But the main study of damage of abdominal tumors in the digestive tract will be through the secretions.  Secretions are altered in three ways: (a) they may be excessive, (b) decreased, or (c) disproportionate.
    The final result is indigestion.  The irritation from the tumor is carried on the plexus of any contiguous viscus to the abdominal brain, where it is reorganized and emitted to the digestive tract over the gastric plexus, the superior mesenteric plexus and the inferior mesenteric plexus.  In any case the brunt of the forces ends in the ganglia which lie just below the mucous membrane; the ganglia constitute what is known as Meissner's plexus, which rules secretion.
    If the irritation be of such a nature as to produce excessive secretion, diarrhea may result.  The excessive secretions will decompose, ferment, and induce malnutrition.  It is common to observe in women with tumors, spells of indigestion, and especially in times of excessive irritability.  No doubt at such times the irritation assumes a prominence not experienced on other occasions.  If the irritation is of such a nature as to diminish secretion, constipation will likely result.  An inactive digestive tract is the forerunner of non-elimination and a waste-laden blood.  It is common to observe anorexia for weeks at a time, accompanied by constipation, in women who have tumors.  No doubt the main chapter in altered secretion consists in what may be termed disproportionate secretion.  The elements which make up the digestive fluid are not secreted in normal quantities; one element is deficient and the other is excessive.  The normal relations of acidity and alkalinity are changed so that constant fermentation arises.  Again, from the irritation of an abdominal tumor, individual organs do not secrete their normal quantity or quality.
    The liver may secrete excessively or deficiently.  The pancreas may do too much or too little.  The irritation may cause segments of the alimentary canal to secrete excessively or deficiently and thus destroy the finely balanced secretion of the canal as a whole.  The stomach enteron, small intestines, may, by the irregular irritation, do too much or too little, or act irregularly.  This produces decomposition in the fluid and fermentation results.  Such women are continually troubled with "wind on the stomach."  Diarrhea and constipation quickly alternate and the result is frequent attacks of acute indigestion.
    Disproportionate secretion is the most frequent and disastrous, because the irritation from the tumor is irregular.  It storms one day and sleeps the next.  But the nature of irritation is to be inconstant and to rush pell mell over the nerve plexuses, or to assume a profound quietude.  Irritation scampering over the plexuses month after month is sure to be followed by indigestion, malnutrition, anemia; and the final ending of the poor patient is neurosis.
    The subject of pressure of abdominal tumors on the digestive tract may here be considered.  The effect of pressure acts in two directions: (a) on the alimentary canal and (b) on the tumor itself.  The effect on the canal may be (a) to derange the secretion and motion of the segment pressed on; (b) to perforate the canal; (c) to obstruct the canal.  The more serious effect of the tumor pressure on the digestive tract arises from the changes which result in the tumor itself.  The changes arising in the tumor from the alimentary canal are: (a) inflammation, (b) adhesion. (c) suppuration and (d) rupture.  The main idea is that infection or its product (ptomaines) enters the tumor through the gut wall.
It frequently happens in laparotomy that some part of the digestive tract is firmly adherent to the tumor.  The cause of this adhesion is the formation of exudates into organized tissue which binds the intestinal wall and tumor together.  The irritation from the contact of the intestinal wall and tumor induces the passage of germs or their products (ptomaines) through the wall of the intestine, which gives rise to an exudate.  The writer has fully satisfied himself that considerable inflammation, adhesion and suppuration, which are found to exist in tumors, are due to the passage of the morbid matter through the intestinal canal.  It is not uncommon for one to find from an inch to a foot of intestine firmly attached to a tumor, when the great gateway of infection, the oviducts, show no traces either ancient or recent.  The vermiform appendix is a certain source of infection, not only in abdominal tumors, but also of the genital organs.
    Considerable inflammation and adhesion of intestines (and occasionally of other organs) when abdominal tumors exist is accounted for by infection passing through the intestinal wall into the tumor.  As regards suppuration in abdominal tumors, due to infection arising from the alimentary canal, it may be said that it is only a stage in advance of inflammation, and that inflammation is only a degree short of suppuration.  So that in one sense they are the same process.  In the case of inflammation, the white blood corpuscles have conquered the invaders and resisted further progress; while in suppuration the invading infection destroys whole fields of vital tissue, leaving focuses of local death - necrosis.  The pus formed by these infections through the intestinal wall may be safely evacuated by way of the alimentary canal.  But frequently fatal issues follow either rapidly or through long exhausting processes.
    The sympathetic pathological course which abdominal tumors induce in women are: (1) irritation, (2) indigestion, (3) malnutrition, (4) anemia, and (5) neurosis.  The irritation passes by reflex action to the digestive tract (including the liver and pancreas).  The irritation destroys in the digestive tract (a) the rhythm of the liver, pancreas and alimentary canal by emitting irregular forces over the plexuses at irregular periods (the reflex action has no regard for rhythm); (b) the irritation produced by the tumor on the canal destroys its motion; (c) it destroys its sensation; (d) it destroys its normal secretion; (e) it destroys absorption.
    Indigestion is a natural result of imperfect rhythm, motion, sensation, absorption and secretion of the alimentary canal.  Long continued indigestion results in malnutrition; which finally ends in anemia.  In anemia the fluid tissue known as blood is proportionately deficient in its constituents, and the innumerable nerve ganglia being bathed in waste-laden and impoverished blood, the woman is finally reduced to an irritable condition, or neurosis.
    One of the strange features of abdominal tumors with long pedicles is that so few rotate on their axes.  In autopsies I have noted the spleen resting on the pelvic floor with a long, narrow pedicle, but no symptoms of rotation.  Dr. Lucy Waite and I have removed tumors with astonishingly long and thin pedicles with no symptoms of present or past axial rotation.  Dr. Orville MacKellar and I removed an ovarian tumor about the size of a year-old child's head with a thin pedicle about eight inches long, with no symptoms of past or present rotation.  We could push the tumor all over the abdomen from the pelvic floor to the diaphragm.  We observed the long-pedicled tumor roll about among the loose intestines after opening the abdomen, and wondered why its pedicle did not twist.
However, I have removed tumors which had no pedicle.  They had been twisted off their pedicles by axial rotation and had assumed new beds, which were nourished by the newly formed vessels from adjacent viscera and tissue, especially the omentum.  It is a significant fact, noted by all practical gynecologists, that when a woman acquires a tumor, it may only be recognized, she will frequently fret and chafe under it until she becomes nervous and irritable and her coolness and quiet serenity leave her.  She also tires easily and does not sleep well.
    Such a case came to me a few days ago, from whom Dr. Lucy Waite and I removed an orange-sized ovarian tumor per vaginam.  This lady I treated seventeen years ago, when she was a blooming, vivacious girl.  Some ten months ago she began to complain of ill-defined symptoms.  A general practitioner treated her a year ago and examined the pelvic organs, but failed to find the tumor.  Finally, she and her husband decided to consult a gynecologist, and came to me.  In eight to ten months, from the rotation of the tumor, her nervous system had lost its fine, even balance of former years.  She slept poorly, was irritable, appetite was poor, and she was easily tired out and had lost all her old vivacity.  It was all due to reflex action from a large orange-sized pelvic tumor.      The disturbance will disappear with the tumor.
    Abdominal tumors should be removed on account of danger of axial rotation.  The literature which takes note of a tumor rotating on its axis covers only about thirty years.  Rokitansky, of Vienna, was among the first to call attention to the subject.  The writer estimates from literature and observation that about 8 per cent. of ovarian and parovarian tumors rotate on their axes.  In 1891 Mr. Tait told the writer that he had, up to date, sixty-two cases of rotated tumors.  While a pupil of Mr. Tait, for six months, the writer saw four tumors rotated on their axes.  Almost any - abdominal or pelvic tumor may rotate on its axis.  The writer has observed - in an autopsy, rotation of the cecum and ileum on each other three-quarters of a turn, but insufficient to obstruct the cecal current.  Volvulus is only axial rotation of the sigmoid on the mesosigmoid.  In the intestinal tract volvulus occurs in the sigmoid flexure in 60 per cent. of cases; in 30 per cent. at the cecum, and in 10 per cent. in the small intestine.  Axial rotation of the digestive tract constitutes about 4 per cent. of all intestinal obstructions.  It is no doubt due to a fatless, elongated mesentery (enteroptosis) and previous constipation.  As regards the causes of axial rotation of abdominal tumors, the writer is convinced that it is due to visceral rhythm.
    The first rotated ovarian tumor I observed was in Prof.  Czerny's clinic in 1884.  The tumor was removed with fatal issue.
    Any viscus which possesses an elongated attachment may rotate more or less on its axis.  The uterus has been found rotated so as to demand operation.  My assistant, Dr. A. Zetlitz, operated on a patient in whom the uterus was found with almost a full rotation, due to a contracting cicatrix from an old inflammatory attack.  The kidney can, and does, rotate on its axis, resulting in partial or complete obstruction - the obstruction of its ureter causing hydroureter and the obstruction of the renal vein due to twisting, interfering with circulation and nourishment.  It is possible for the spleen, in certain abnormal conditions, to rotate on its axis.  In one autopsy I found the spleen on the pelvic floor with a thin, partially rotated pedicle.
    Axial rotation of abdominal tumors may be partial or complete, acute or chronic.  An acute case generally acts in the following manner: A woman has an abdominal tumor.  She has a sudden onset of pain; she will perhaps vomit.  In twenty-four to forty-eight hours the abdomen will gradually enlarge.  If it enlarges very extensively, the patient becomes pale and faint.  The enlargement is the result of (a) the obstruction of the return venous flow from the tightness of the twist in the pedicle; (b) the dilatation of the veins in the tumor, and (c) the rupture of a vein in the tumor.
    The rigid-walled artery is difficult to occlude, and so keeps pumping its stream of blood into the tumor.  The soft-walled, easily compressible vein is quickly occluded by the twist in the pedicle, and so all or nearly all the blood pumped in by the artery is retained in the tumor.  The consequence is a sudden abdominal enlargement.  Of course a woman may bleed to death into her own tumor, and such cases are on record, confirmed by autopsy.  The tumor may twist so much on its pedicle that it may occlude both vein and artery.  I had such a case in a girl twenty years old.  When the abdomen was opened the tumor was gangrenous.  It may rotate so vigorously that it will be entirely twisted off or severed from its connections.  In such cases the tumor acquires nourishment from the surrounding viscera.  The trauma resulting from the axial rotation induces sufficient irritation to produce an exudate on the surface of the tumor.  This exudate undergoes organization, acquiring blood-vessels, nerves and lymphatics sufficient to nourish the tumor without its old pedicle.  The writer saw, with Mr. Tait, one tumor sufficiently rotated on its pedicle to occlude the vein and artery, which was nourished by innumerable delicate, newly organized processes of visceral tissue.
    In my own practice, while performing laparotomy, I have been surprised to find a dermoid ovarian tumor the size of a cocoanut entirely without a pedicle.  It was wholly nourished by omental adhesions.  The patient gave me a history of a severe attack four years previous, from which time pain and tenderness continuously clung to her.  My attention was first called to axial rotation of tumors in 1884, at Heidelberg, in the clinic of Professor Czerny.  One day a middle-aged lady suddenly appeared in the clinic who had come from her home in the country very sick.  The professor put her on the table and examined her carefully.  She had a high pulse and temperature and a dusky countenance.  She appeared very ill.  Professor Czerny said: "Gentlemen, I cannot make the diagnosis.  I will examine her again and perhaps operate tomorrow." The writer anxiously waited until the next day, when, sure enough, the woman was put to sleep on the operating table.  On opening the abdomen, a tumor the size of a melon appeared in the wound.  It was dark red in color, and Professor Czerny pronounced it gangrenous.  It was easily removed and its pedicle ligated.      That was a cyst rotated on its axis; and, besides, it was not gangrenous, as such tumors rarely become gangrenous in the abdomen, and, if washed well, will show the color of normal tissue.  Gangrene generally comes from tapping such cysts, or the digestive tract may infect them.  Cases have been frequently recorded where death followed tapping.  Intestinal contents entered the cyst and infection resulted.
    Axial rotation of abdominal and pelvic tumors may pursue a chronic or slow course.  In such a tumor diagnosis is very difficult.  The pain in such cases will be almost wholly carried by the sympathetic nerve, and pain due to irritation of the sympathetic is generally a dull, heavy ache.  It is a dragging pain.  Cerebro-spinal nerves induce sharp, lancinating pain.  So that slow axial rotation of the abdominal tumors will be accompanied by dull, heavy, dragging pain.  It may be noted that whenever there is more than one tumor in the abdomen the chances are very much increased for axial rotation.  Pregnancy enhances axial rotation much more than the presence of a double tumor, because the uterus empties itself suddenly, and just after labor the tumor is apt to rotate.  The writer has seen Mr. Tait operate on a woman six weeks after delivery for an abdominal tumor which rotated about three times and a half on its pedicle.  She was quite ill from delivery until after the operation, when she rapidly recovered.
    In my practice I have observed axial rotation of ovarian tumors, ileocecal apparatus, sigmoid flexure, ovario - oviductal apparatus in a young girl, with rotation of uterus.
    The strikingly easy manner in which operators speak of gangrenous tumors in the abdomen, with recovery, calls for objections.  Recovery after gangrene or local death in the abdomen is extremely rare.  What is usually called gangrene is simply tissue filled with venous blood.
    Now, if this dark tissue is removed and well washed, the gangrenous idea will be dispelled by the frequent appearance of normal white tissue.  Air must in some way get to a tumor to admit of gangrene, and air enters by (a) tapping, (b) digestive tract, (c) genito-urinary tract.  If a cyst has rotated sufficiently to twist off its pedicle and become nourished by adhesions to adjacent viscera it is more dangerous than the original tumor on account of its fixation and adhesions.  It is generally more liable to infection from the natural channels, from its more extensive vascular connection.  A tumor should be removed from its liability to axial rotation.  A tumor rotated on its axis is dangerous to a patient from (a) hemorrhage into the cyst. (b) gangrene, (c) because it may unduly enlarge from filling the veins of the tumor, (d) it may become fixed by adhesions and thus endanger the viscera, a fixed tumor being more dangerous than a movable one, (e) it may become infected and suppurate, (f) chronic axial rotation may exhaust a patient by pain, (g) it may result in trauma to viscera or perforation of viscera by pressure.
    Abdominal tumors should be removed on account of the danger of rupture.  It is a fact, which the writer has definitely observed, that tumors (ovarian and parovarian) will repeatedly rupture and fill in the living woman.  In one case under my care the parovarian cyst repeatedly ruptured and filled during a year's personal observation.  At the time of rupture the young woman of twenty-four would experience a sense of relief.  The abdomen would become flattened and during a few succeeding days she would urinate frequently and profusely.  Years previously the writer had demonstrated that if a dog's peritoneal cavity was filled with water he would urinate profusely for two or three days.  In removing ovarian tumors the writer has found old scars where such cysts had ruptured and refilled.  The rupture may be due to violence or the continued pressure on some point of the tumor, thinning its walls so that leakage occurs.
    A rupture of non-infected cyst does no harm to a woman, but when a cyst containing infected material ruptures in the abdominal cavity death is almost inevitable. Hence, such tumors which menace life should be removed on discovery.  Cystic abdominal tumors are apt to rupture from increase of abdominal pressure, which, being sustained for a long time on single points of the cyst, either thin its walls so that they will leak, or rupture them by any violence.  In one case the writer removed an ovarian tumor which gave a distinct history of rupture one year previous.  A distinct scar about the size of a fifty-cent piece was found on the cyst to tell the story of rupture.  Abdominal tumors may endanger life by rupturing info hollow viscera as intestine, bladder, or vagina.  From such rupture infection is almost sure to follow.  The worst infection follows rupture into the digestive tract, and second into the bladder.  The writer has removed ovarian tumors with success which had ruptured into the digestive tract and almost destroyed the patient by chronic suppuration and exhaustion.  About the worst of such tumors are ovarian dermoids. which rupture into the sigmoid or rectum, for they make gainst such dangerous adhesions.  The two cysts may press so hard and long against each other that the walls in contact will fuse and the rupture will occur in the fused septum, which complicates by more adhesions and size of tumor.
    The pressure occasioned by abdominal tumors demands their removal.  A tumor pressing for a long time against a gut wall may thin it so that germs or their products may pass into the tumor and infect it.  Inflammation follows and may be accompanied by suppuration.  But pressure must be observed to take place in two directions, viz., toward the tumor and toward the viscus.  The damage from pressure in the abdominal tumors is threefold: (a) the effect of pressure on viscera: (b) the effect of pressure on the tumor, and (c) the effect of the pressure on the function of viscera, both remote and distant.  This last idea was discussed under reflex action.  It was shown how abdominal tumors induced hydroureter by partial or complete occlusion of the ureters.  Tumor pressure will even induce interstitial and parenchymatous nephritis.  Three-fourths of women long possessing abdominal tumors have kidney disease.  The tumor may press on some segment of the digestive tract and induce obstruction of the fecal current, either mechanically or by reflex paralysis.  The main point of pressure is on some fixed portion of the intestine, the rectum, sigmoid or colon.
    The canals, ureter or intestine, curiously maintain their patency for a long time on account of their continual dilatation and contraction.  The writer has seen these canals entirely surrounded by dense tissues of tumors, but a distinct tunnel still existed through the tumor, considerably larger than the empty collapsed canal.  The abdominal tumors, in a word, by pressure, induce obstruction, mechanically or by reflex irritation (spasm or paralysis), and should be removed.  The continued pressure gives rise to (a) inflammation, by allowing infection to travel; (b) the inflammation may go on to suppuration and end in perforation, internally or externally.
    The effect of pressure on the circulation (vascularity) is very apparent It acts mainly, or the effect is more evident, on the great venous plexuses.  The hemorrhoidal from the inferior mesenteric suffers the most, as many of such patients have hemorrhoids.  The effect of the pressure on the plexus pampiniformis is also plain, as also on the vaginal plexus and the venous bulb of the pudendum.  Areas of tissue become cedematous.  The limbs swell.  The pelvic organs suffer the main brunt from mechanical pressure, while distant organs evidently suffer most from reflex action.  The effect of mechanical pressure on circulation is (a) congestion, (b) oedema, (c) dilation of veins (hemorrhoids).  It must not be forgotten that since the sympathetic is mainly distributed to blood-vessels the reflexes from pressure on the vessels are effective and profound, local and general.
    The writer has noted the effect of tumors on the color of the skin for a long time.  It has been recognized that pigmentation arises mainly from the spleen. Jastrowitz started the view that the spleen was the source of pigmentation, by dividing the sympathetic plexus going to the spleen on the spiral splenic artery.  This experiment enhanced pigmentation.  No doubt the liver is a second source of pigment, from the fact that it buries red corpuscles, and pigmentation is very noticeable in malaria which profoundly affects the liver (and spleen also).  But still the spleen may be credited with the main origin of pigmentation.  The writer has noted nearly all colors of pigmentation (brown. black and yellow) in such women, especially in a woman who has had a tumor a long time.  The author saw a woman last month who had had a tumor for sixteen years.  Her color was a deep brown and yellow, with patches of atrophied, glistening skin interspersed.  The tumor disturbs the rhythm of the spleen.  The spleen is capable of a rhythm by (a) its elastic covering of peritoneum, (b) its elastic capsule, (c) by the power of its cells to enlarge on receiving excessive blood.  When the tumor irritates the splenic plexus it destroys its rhythm, and hence its nourishment.  The nourishment being disturbed, the distribution of its products - pigment - will be disturbed.  Irritation induces the spleen to produce excess of pigment.  The parts of the body most intensely pigmented are those exposed to air.  Yet the pigmentation is general.  The simplest example of pigmentation is observed in pregnancy, which is generally localized in the genitals, breasts and linea alba.
    But abdominal tumors create more definite and general pigmentation.  The pigmentation is effected by the irritation passing to the abdominal brain, where it is reorganized and emitted to the spleen.
The irregular forces coming at irregular intervals to the spleen derange its rhythm, and consequently its nourishment.  Pigmentation is the result of a silent process accomplished by reflex irritation, and shows general derangement of the visceral economy.  It is merely the outward manifestation of profound processes, indicating removal of the offending invader.  It is difficult to convince physicians that a laparotomy is really demanded to remove adhesions.  Adhesive bands have blood-vessels, lymphatics and nerves.
    A tumor should be removed because of its danger to create adhesions, but after they have formed they often require removal.  They should be removed when they give rise to pain, when they distort and unbalance the viscera.  They may occasion obstruction to any hollow viscus.  They may strangulate some viscus.
    Even the lungs do not escape the evil influence of the presence of the abdominal tumor.  The disturbance in the lung is mainly due to reflex irritation which disturbs the rhythm of the lungs.
Abdominal tumors should be removed, from their liability to become infected.
    The question may be asked, How does an abdominal tumor become infected or inflamed?      Tumors frequently become infected, as is easily attested at the operation, by observing adhesions - the result of infection.
    The great highway by which abdominal tumors become infected is through the oviducts.  Any laparotomist can easily see that inflammatory exudates arise at the fimbriated ends of the oviducts, and from there spread.  The infection travels by natural routes, especially along mucous channels.  It travels particularly through the left oviduct, because, as the writer has demonstrated, the lumen of the left tube is larger than that of the right.
    The second great highway of infection of abdominal tumors is through the digestive tract.  Germs or their products pass through the intestinal wall at pressure points and infect the tumor.
    The third channel of infection is through the genito-urinary tract.  A fourth is by tapping, allowing air to enter.  The table presented with this article will show at a glance the reasons for removing abdominal tumors:

EFFECTS AND CONSIDERATIONS FOR THE REMOVAL OF ABDOMINAL PELVIC TUMORS.

Heart -
    1.  Irregularity.
    2.  Hypertrophy.
    3.  Fatty degeneration.

Lungs -
    1.  Disturbed rhythm - asthma.
    2.  Catarrh - anemic, hyperemic.

Liver -
    1.  Disturbed rhythm.
    2.  Disturbed secretion.
    3.  Pigmentation.
    4.  Nerve influence can check all secretion.
        (a)  Excessive secretion.
        (b)  Deficient secretion.
        (c)  Disproportionate secretion.

Kidney -
    1.  Nerve impression can check all secretion.
        (a)  Excessive secretion.
        (b)  Deficient secretion.
        (c)  Disproportionate secretion.
    2.  Reflex irritation.
    3.  Obstruction (hydronephrosis).
    4.  Infection.
        (a)  Parenchymatous inflammation.
        (b)  Interstitial inflammation.

Digestive Tract -
    1.  Sensation.
    2.  Motion.
    3.  Secretion.
    4.  Pressure.
    5.  Absorption.
        (a)  Excessive secretion.
        (b)  Deficient secretion.
        (c)  Disproportionate secretion.
        (a)  Inflammation.
        (b)  Suppuration.
        (c)  Perforation.
        (d)  Adhesions.

Spleen -
    1.  Disturbed rhythm.
    2.  Pigmentation.

Bladder -
    1.  Pressure.
    2.  Perforation.
    3.  Cystitis.

Inflammation -
    1.  Through oviducts.
    2.  Digestive tract.
    3.  Genito-urinary tract.
    4.  By tapping.

Circulation -
    1.  Congestion.
    2.  Edema.
    3.  Hemorrhoids

Suppuration -
    1.  Infection.
    2.  Fistula.
    3.  Adhesions peritoneal.

SYMPTOMS.

Axial Rotation -
    1.  Due to visceral rhythm.
    2.  Ten percent of ovarian and parovarian tumors rotate.
    3.  Pregnancy and other tumors enhance axial rotation.
    4.  Diagnosticated by sudden pain and increase in size of abdomen.

Rupture -
    1.  Sudden changes in form of abdomen.
    2.  Diuresis.
    3.  Diarrhea.
    4.  Cystitis.

Pressure -
    1.  Inflammation.
    2.  Infection.
    3.  Perforation.
    4.  Hydroureter.
    5.  Obstruction.
    6.  Edema.

Adhesions -
    1.  Induce pain.
    2.  Check peristalsis.
    3.  Cause reflex rhythm.
    4.  Disturb secretion.