PATHOLOGIC PHYSIOLOGY OF THE TRACTUS
GENITALIS.

BY BYRON ROBINSON, B. S., M. D., CHICAGO, ILLINOIS.

PROFESSOR OF GYNECOLOGY AND ABDOMINAL SURGERY OF WOMEN IN THE ILLINOIS MEDICAL COLLEGE.

FOR over a decade I have been attempting to make prominent in gynecologic teaching, pathologic physiology, disordered function, rather than pathologic anatomy, changed structure. It seems to me. that disorder-functions or pathologic physiology of the tractus genitalis impresses itself more indelibly on the student's and practitioner's mind than pathologic anatomy. Besides, in gynecologic practice pathologic physiology occurs tenfold more frequently in the genital tract than pathologic anatomy. For the gynecologist pathologic physiology presents innumerable views of practical interest. Pathologic physiology teaches that the circulation of an organ is a fundamental factor in comprehending its disease and administering rational treatment. It takes an inventory of the volume of blood which streams through the organ as a fundamental factor in comprehending its diseases and administering rational treatment. It takes an inventory of the volume of the blood which streams through the organs at different stages and conditions. We wrote years ago that the arteries of different viscera were supplied with automatic visceral ganglia, and we christened the peculiar nerve nodes found in the walls and adjacent to the uterus, oviducts and ovaries, as "Automatic Menstrual Ganglia." The automatic menstrual ganglia complicates the blood supply of the tractus genitalis by changing its volume during the different sexual phases. In pueritas the blood stream of the tractus genitalis is quiescent as well as its parenchymatous cells; in pubertas it is developing as well as proliferating parenchymatous cells. In menstruation the blood stream is active with active parenchymatous cells. In the puerperium there is retrogression

of blood stream and an involution of parenchymatous cells. The climacterium is the opposite of pubertas-subsidence, the decrease of blood volume and parenchymatous cells. Senescence is a repetition of pueritas-the quiescence of the genitals, their long night of rest. The circulation of an organ quotes its value in the animal economy. It rates its function. Observe the enormous volume of blood passing through the kidney or pregnant uterus in a minute.

To study pathologic physiology of any visceral tract we possess clear views as to its physiology. The physiology of the tractus genitalis is: (1) Ovulation; (2) peristalsis; (3) secretion; (4) absorption; (5) menstruation; (6) gestation; (7) sensation.

(1) On account of the numerous theoretic views connected with OVULATION and lack of space we will omit the general discussion on the pathologic physiology of ovulation. It is well known that ovulation has a wide physiologic range. We do not know the life of an ovum or corpus luteum. It was once supposed that a corpus luteum was a sign of pregnancy and the supposition gained legal or judicial position. We know that this is an error. I have found two corpora lutea on one ovary of a lamb which had not been pregnant. The internal secretion of the ovary is important and chiefly manifest by marked symptoms. on removal of both ovaries-neurosis, accumulation of panniculus adiposus, extra growth of hair, diminished energy and ambition. These symptoms may occur in women possessing both ovaries, hence, we would conclude that pathologic physiology of ovarian secretion existed. The sensation of the ovary occupies a wide zone of pathologic physiology in the mental and physical being. Forty per cent of women visiting my office remark, "I have pain in my ovaries." On physical examination we find the following conditions: First and foremost in the vast majority of women who complain of pain in the ovaries palpation of the ovaries elicits no tenderness on pressure. However, the pain of such women is located bilaterally in the area of the cutaneous distribution of the ileohypogastric and ileoinguinal nerves. It is a skin hyperesthesia-a cutaneous neurosis. The bilateral iliac region of cutaneous hyperesthesia corresponds to the segmentation or somatic visceral (ovarian) area, and presents a frequent varying zone of sensory pathologic physiology. In the vast majority of women complaining of ovarian pain no disease of the ovary can be detected-it is cutaneous hyperesthesia of the ileoinguinal and ileohypogastric nerves.

(2) PERISTALSIS (excessive, deficient, disproportionate).

(a) Excessive peristalsis of the tractus gentalis (uterus and oviducts) may occur at menstruation, during gestation, parturition by the presence of myomata, during the expulsion of blood coagula, placenta during congestion. The phenomena of peristalsis in the uterus and oviduct differs from the form and distribution of the muscularis. The myometrium during gestation is in continual peristalsis— uterine unrest. By placing the hand on the abdomen of a four-month

SHOWING THE ORIGIN OF THE GENITAL NERVES.

S, abdominal brain; E, showing origin of spermatic (ovarian); F, shows origin of right genital nerve on the spermatic (ovarian artery); J, presents the plexus interiliacus which originates in the plexus aorticus. This illustration was drawn with extreme care from a It presents what I call the swan-shaped sperimen which I dissected under alcohol. ureters which are dilated and prevents ureteral valves (V). IV, presents the anastomosis of the plexus ureteritis with the plexus spermaticus (ovaricus)."

gestating woman one can feel the uterine muscular waves. The gestating uterus is always prepared for an abortion but the cervix, the sentinel on guard, checks the proceeding. Fright will produce such violent, disordered myometrial peristalsis as to break through the guarding cervix. Many women during gestation experience considerable pain (supersensitive uterus) from excessive uterine peristalsis—it is pathologic physiology. Uterine peristalsis may be sufficiently excessive to rupture the myometrial wall. The "after-pains," puerperal pains, is excessive peristalsis in an infected myometrium. Frequently the severe pelvic pain during menstruation is excessive uterine and oviductal peristalsis due to its extramenstrual blood supply. It is chiefly the excessive peristalsis at menstruation that forces many women to assume rest in bed, for, with anatomic rest (maximum quietude of bones and voluntary muscles) and physiologic rest (maximum quietude of visceral muscles) the uterine peristalsis will exist at a minimum. Excessive oviductal peristalsis may produce pain of varying degrees. In excessive peristalsis the automatic menstrual ganglia are stimulated by extra quantities of blood or by other irritation.

(b) Deficient peristalsis of the tractus genitalis (uterus and oviducts) is not uncommon. Uterine inertia is an example known to every obstetrician. Deficient uterine peristalsis allows hemorrhage in the fourth and fifth decades of woman's life. Deficient peristalsis allows extraglandular secretion (leucorrhea).

(c) Disproportionate peristalsis is disordered, wild muscular movements in different segments of the uterus or oviduct.

(3) SECRETION (excessive, deficient, disproportionate).

(d) Excessive secretion from the genital tract, pregnant or nonpregnant, has an extensive range and varying quantity. The excessive secretion zone in the tractus genitalis has an important bearing in practice. Typical pathologic physiology may be observed in the pregnant woman from whose uterus may flow several ounces of white mucus daily no pathologic anatomy is detectable. Excessive uterine secretion is a common gynecologic matter. The glands may not be embraced sufficiently firm by the myometrium. The automatic menstrual ganglia are diseased, insufficiently supplied by blood or the myometrium is degenerated. Flaccid uteri secrete excessively. Excessive secretion and its fluid currents allows insufficient time for localization of the ovum. Excessive uterine secretion is, from apt bacterial media, liable to become infected. During excessive secretion physical examination frequently detects no palpable pathologic anatomy-merely physiology has exceeded its usual bounds.

(e) Deficient secretion of the tractus genitalis is not so manifest as its opposite. The mucosa of vagina and uterus present excessive dryness, dessication, practically as visceral functions are executed by means of fluids, pathologic physiology is in evidence; dryness and abrasion of the mucosa, local irritation, chafing, local bacterial development, dysparunia, dysuria, defective import of spermatozoa and export of ova

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Drawn from my own dissection. A, pelvic brain. In this case it is a ganglionated plexus possessing a wide meshwork. Also the pelvic brain is located well on the vagina, and the visceral sacral nerves (pelvic splanchnics) are markedly elongated; V, vagina; B, bladder; O, oviduct; Ut, uterus; Ur, ureter; R, rectum; P L, plexus interiliacus (left); P R, plexus interiliacus (right); N, sacral ganglia; Ur, ureter; 5 L, last lumbar nerve; i, ii, iii, iv, sacral nerves; 5, coccygeal nerve. Observe that the great vesical nerve (P) arises from a loop between the ii and iii sacral nerves. G S, great sciatic nerve.