330

THE SYMPATHETIC NERVOUS SYSTEM IN'OBSTETRIC AND GYNAECOLOGICAL PRACTICE

By ALBERT DAvIS, M.D., CH.M., F.R.C.S., l\I.R.C.O.G.Gynaecological Surgeon, Prince of IVales', French, Dulwich and St. Giles' Hospitals, London

The fact that some degree of pain is accepted bymost women as the normal, or periodic, accom-paniment of their reproductive life is refle-cted inthe complacency with which their medical advisers,both male and female, accept disabilities in womenwhich in male patients would demand immediateattention. As a result an enormous amount of pre-ventable pain is borne by these long-sufferingsubjects, not because it is incurable but because itis regarded as inevitable. In recent years, however,considerable attention has been directed to thepossibility of alleviating this type of pain, and thedemand has stimulated a considerable amount ofresearch into the influence of the autonomic nerve-supply of the genitalia on both their sensory andmotor functions. This has resulted in the clarifica-tion of many hitherto unexplained phenomena andin the elaboration of several methods of neuro-logical interference, both minor and major, in theattempt to interrupt pain-producing impulses orpain pathways. The purpose of this paper is tosummarize these anatomical and physiologicaldata, to correlate them with pathological observa-tion and to indicate where their application totreatment might be of value in clinical practice.

Anatomy and PhysiologyThe uterus receives sympathetic nerves from

the abdominal system and parasympathetics tromthe nervi erigentes. The abdominal fibres originatein the coeliac plexus, a complex mass of fibres andganglia arising from the confluence of the vagusand splanchnic nerves and surrounding thecoeliac axis. From here strong fibres run dowR-wards on either side of the aorta, becoming re-inforced from the renal plexuses to form the inter-mesenteric nerves. At the level of the bifurcationof the aorta these nerves fu,se to form the superiorhypogastric plexus, a bundle of several strongintercommunicating filaments better known as thepresacral nerve. After receiving branches fromthe lumbar ganglionated trunk the presacral nervepasses downwards over the fifth lumbar vertebralbody and the promontory of the sacrum, belowwhich it bends sharply backwards into the pelvisand almost immediately divides into the inferior

hypogastric plexuses. These are two flat bundlesof considerable length, each running at first down-wards, outwards and backwards along the lateralpelvic wall, behind the internal iliac vessels justlateral to the side of the rectum and medial to thelevator ani and sacral plexus. Each then enters thecorresponding sacro-uterine fold, and runs for-wards in it to join the nervi erigentes and form thepelvic plexus.The nervi erigentes carry the parasympathetic

supply to the uterus. They are long, fine branchesarising from the anterior divisions of.the middlethree sacral nerves, from which they run forwardsand outwards in the sacro-uterine folds, at theanterior end of which they join the hypogastricplexuses to form the great pelvic plexus or plexusof Frankenhauser. This is a quadrilateral flatmass of neuro-fibrous tissue lying by the side ofthe ampulla of the rectum. It serves as a vehiclefor the admixture of the sympathetic and para-sympathetic nerves which supply it, and which areby its means distributed in their correct proportionto the pelvic viscera. These receive bundles offibres from the front of the plexus, the individualviscera being supplied by nerves which mainlyaccompany the vessels to the particular organ intheir final distribution. In the uterus the nervesform a widely meshed plexus at the side of thebody, just beneath the peritoneal coat; from herethey enter the muscularis at right angles to end inthe myometrium and the capillaries. In the cervixan additional plexus is formed just beneath thesquamous epithelium of the tip. The discovery ofthis plexus (Davis, I933) has clarified certain pre-viously unexplained clinical results, e.g. the reliefof dysmenorrhoea by cervical dilatation, themechanism of first stage labour pain, the cause ofsome sudden deaths, etc. (see later).

Central connections. In the spinal column thesympathetic efferent fibres lie in the intermedio-lateral tract and the parasympathetics in the medio-ventral. The efferents run just behind and medialto the former. The central sympathetic nuclei liein the posterior part of the hypothalamus, and theparasympathetic in its anterior portion (Beattie,1932). The cortical centres probably lie in the

by copyright. on F

ebruary 2, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.285.330 on 1 July 1949. D

ownloaded from

YUly 1949 DAVIS: Sympathetic Nervous System in Obstetric and Gynaecological Practice

pre-motor area close to those described for theintestine by Sheehan (I934).The ovary is supplied by the ovarianx plexus,

which arises from the renal and mesenteric ganglia.It consists of two or three long communicatingnerves which course downwards along the ovarianartery to the hilum, from which short branchessupply all the structures of the organ. TheGraafian follicles are each surrounded by a cup-likemeshwork, the clinical significance of which willbe discussed lIter.

Physiology. The nerves of the uterus are notessential for normal parturition, which can occurafter complete sympathetic denervation and alsoafter transection of the spinal cord. In normalcircumstances, however, there is no doubt thatthey play a considerable part in the control ofuterine activity. The precise action of each con-stituent has not yet been elucidated, but it is fairlydefinite that the sympathetic contracts the circularand inhibits the longitudinal muscle, while theparasympathetic exerts the opposite effect, theactions being mutually synergistic. The formeralso controls vascular tone and in addition carriesmost of the pain-sensory fibres from the' organ.The ovarian nerves have similar functions.With regard to sensation, the endometrium is

insensitive to the usual stimuli. It is true thatcurettage of the unanaesthetized uterus is occasion-ally painful, and that such sensitivity is abolishedby the previous intra-uterine application ofcocaine, but then the operation itself is a muchexaggerated stimulus. One is inclined to suggestthat the pain in these cases is due to the tearingof nerve-fibres as the endometrium is stripped up,rather than to a specific and wholly unphysiologicalsensibility.The peritoneal surface shares the general in-

sensibility of the visceral peritoneum elsewhere.The myometrium is of course sensitive to

certain stimuli, namely exaggerated dilatation orcontraction. A bag placed in its cavity andforcibly distended causes acute pain of both types(due to tension and spasm). The contractions oflabour and the pain of artificial dilatation of thecervix are clinical examples. The ovar3, thoughinsensitive to most stimuli, is like the testis,markedly sensitive to moderate pressure, and thepain produced in this manner is strikingly similarin the two organs.

Clinical ApplicationTo illustrate the clinical application of these

data it is convenient to consider how certainspecific painful pelvic conditions are affected byinterference, either pathological or operative, withthese autonomic pathways.

DysmenorrhoeaThe pain of spasmodic dysmenorrhoea is due to

excessive contraction of the myometrium, amount-ing literally to a spasm, with a resultant intra-uterine pressure of anything up to i8o mm. ofmercury (Moir, I934) and subsequent vascularocclusion. The pain may be muscular or vascularin origin, but in either case is of sympatheticorigin.The great majority of primary dysmenorrhoeas

are adequately relieved by carefully supervisedmedical treatment, including phvsiotherapy,specific exercises, mild analgesics, etc., but someremain intractable to these measures. These re-act well to various forms of sympathetic denerva-tion, particularly when the spasmodic elementpredominates.The oldest and simplest procedure is dilatation

oJ the cervix. This is a type of sympathectomy, forit owes its effect to rupture of the sympatheticplexus which surrounds the external os. Unlessthis is rapidly and adequately stretched, however,the plexus remains undamaged, accounting formany of the failures following the procedure. Therelief commonly observed after parturition is dueto the accompanying stretching and lacerationwhich occurs in the majority of primigravidae. Tobe effective, therefore, the procedure must becarried out radically and the cervix torn sufficientlyto accommodate a large bougie (it is euphemistic totalk of ' dilatation' beyond No. io Hegar). Inaddition, a hollow pessary must be left in thecervical canal. to prevent nerve regeneration.This somewhat barbarous procedure adds thepossibility of chronic cervicitis for infection of'th4laceration is inevitable, and with the advent of lesstraumatic methods it should fall into desuetude.

Alcohol injection. The aim of this procedure(Davis, 1936) is to block all the uterine nerve-supply as it lies concentrated in the'pelvic plexus.If the correct anatomical relations are borne inmind, the method is a relatively simple one andmay be carried out under minimal intravenousanaesthesia. With the patient in the lithotomyposition, the lateral fornix is exposed by oppositetraction on the cervix, and the point of a longnon-flexible needle inserted i cm. lateral to thecervix. It is then passed laterally and posteriorlyat an angle of 450 to both the horizontal andvertical planes for I.5 cm., being guided to the sideof the ampulla of the rectum by an internal finger.This is the situation of the pelvic plexus, and herei ml. of absolute alcohol is slowly injected, theneedle point being kept constantly moving andaspirated intermittently to avoid intravascular in-jection. The same procedure is then carried outon the other side. As a reinforcement a furtheri ml. of alcohol is then injected into the lateral

331

by copyright. on F

ebruary 2, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.285.330 on 1 July 1949. D

ownloaded from

POST GRADUATE MEDICAL JOURNAL

parametrium just lateral to the supravaginal cervix,to catch any fibres which may have escaped theplexus block (Blos, 1929).The results of this procedure are good. A

follow-up of 6i personal cases showed a per-manent cure-rate of 70 per cent., as against anestimated average of 20 per cent. from simpledilatation of the cervix. It is therefore the methodof choice in those cases of primary spasmodicdysmenorrhoea which are resistant to ordinarymedical measures.

Resection of the presacral nerve. In patientswho remain unaffected by single or repeatedalcohol injection the more radical operation ofpresacral sympathectomy, first described by Cottein I923, is indicated. Complete denervation ofthe uterus is unnecessary, for it is the abdominalsympathetic constituent alone which carries thecontractile impulses, exaggeration of which isresponsible for the spasm characteristic of dys-menorrhoea. These sympathetic fibres are con-centrated in front of the fifth lumbar vertebra asthe presacral nerve, and it is in this situation thatthey are most readily accessible to section.Exposure of the nerve is readily attained through

a short midline subumbilical incision. Goodanaesthesia and the highest Trendelenberg positionare essential. The intestines are packed upwards,and the sacral promontory identified. The nervelies on the body of the fifth lumbar vertebra, in thespace between the common iliac vessels. Theperitoneum over this area is picked up, incisedvertically for 4 cm. and held away laterally to ex-pose the pre-lumbar space. The plexus is nowusually easily seen coursing downwards in themiddle line as a single or as several communicatingnerves, but as it is often adherent to the posteriorparietal peritoneum this should be denuded ifthere is any difficulty in identifying the nerves. Itis also well to pick up any lateral fibres, accom-modating the whole leash in an aneurysm needle.A piece of nervous tissue 2 cm. in length is nowexcised, ligature being unnecessary as bleeding isminimal, and the peritoneum is repaired with arunning suture.The operation is a relatively simple one, and

careful identification of the neighbouring vesselsand ureter will eliminate any danger of seriousinjury. Naturally any coincident pelvic pathologywill be dealt with at the same time.The results of this operation are on the whole

good, and in carefully selected cases one canpractically guarantee at least adequate relief. Re-ports by Cannon (I937), Cannaday (1938), Green-hill (I942), Cotte (I947), and many others give ahigh percentage of cures. Of my own series of86 cases, 67 are free from pain over periods varyingfrom one to i6 years. The operation should not,,

however, be' undertaken lightly, for it carries withit the risks associated with laparotomy, and thoughthese may be minimal, they should not be hazardeduntil after the failure of minor procedures. Thatthese are reasonably successful is shown by thefact that my cases represent only 4.8 per cent. ofall patients attending with the single complaint ofdysmenorrhoea.

OvulalgiaA good many women complain of brief attacks of

pain in one or other side of the lower abdomenabout a week after menstruation (' mittel-schmerz '). The attacks are synchronous withovulation, as shown by checking with temperaturecharts and ovarian palpation. When colicky intype, the pain is probably due to tubal contractionswhich occur at this time. The tearing pain some-times complained of is almost certainly due toirritation of the parietal peritoneum by thefollicular fluid and blood liberated on rupture.Generally, however, the pain is described -as oftension type, and in these cases it almost certainlyresults from pressure on the peri-follicular plexusby a distended follicle. It has been shown else-where (Davis, 1939) how these nerves clasp thefollicle like a bowl, so that when the ovary be-comes cystic through failure to rupture (sclero-cystic disease), chronic pain of a similar naturemay result. This latter type may be exaggeratedby the congestion of the period (' ovarian dys-menorrhoea,' Browne, I939).

In the majority of cases the pain of ovulalgiamay be ignored, but occasionally it is severeenough to warrant ovarian sympathectomy. Thisconsists in simple excision and ligature of a portionof the infundibulo-pelvic ligament; separate dis-section is tedious and unnecessary. The resultsare good in carefully selected cases, but thepossibility that the denervation may interfere withmaturation of the ovum in a subsequent preg-nancy should always be borne in mind.

Malignant NeuralgiaThe intractable pain of inoperable carcinoma of

the uterus may be of either visceral or somaticorigin. It is important to differentiate between thetwo clinically for the latter will obviously be un-affected by sympathetic block. Somatic pain isprobably due to a posterior radiculitis (Todd, 1934)and may be referred to the area of peripheral dis-tribution of any of the lumbar or sacral roots. It isa severe localized neuralgia, often associated withparesis and paraesthesia. The visceral pain is dueto malignant infiltration or compression of thepelvic sympathetic plexus or its branches (Bruck-ner and Mezinescu, 1903). This causes a severe

'U-IY I1949332

by copyright. on F

ebruary 2, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.285.330 on 1 July 1949. D

ownloaded from

Jfuly I949 DAVIS: Sympathetic Nervous System in Obstetric and Gynaecological Practice

generalized bearing-down pain in the pelvis, withradiation into the vulva and anal canal.

Vaginal alcohol injection is usuallv impracticablein these cases on account of local malignant in-filtration, but presacral neurectomy will relievepurely visceral pain, and should be carried outwhen the general condition of the patient issufficiently good. In debilitated subjects, andwhere abdominal masses are present, the methodof choice is intrathecal alcohol injection. This pro-cedure, introduced by Dogliotti (i93i) andpopularized by Green (I936), is designed todestroy the sympathetic pain-afferents enteringwith the posterior roots. The technique issimple, and consists in the injection of 0.5 ml. ofabsolute alcohol without admixture into the .tourthlumbar interspace, the patient lving on the sideand slightly prone, and the head end of the tabledepressed to an angle of 15 degrees. This positionis retained for an hour, and the same procedure re-peated after ten days for the opposite side. Themethod has the advantages of simplicity and safety,and can, if necessary, be carried out in the patient'sown bed. Greenhill (I947), who has an unrivalledexperience of the operation, produced completerelief in more than half of his cases. Although thewriter's personal experience is not so satisfactory,paralytic complications having occasionally fol-lowed, there is no doubt of the general efficacy ofthis type of subarachnoid injection in many casesof malignant neuralgia.Magnesium sulphate is an efficient neuro-

caustic which is less generally destructive, andBates and Judovitch (1942), have advocated itssubstitution for alcohol in subarachnoid injections.General experience (Bourne and Williams, 1945)has so far been disappointing, but the field is apromising one.Todd (I937) and Kenny (1947), have used

.idural procaine analgesia for the relief ofmalignant neuralgia with moderate success. Thetechnique is similar to that used in obstetrics, andconsists in the injection of 50 ml. of a 1.5 per cent.solution of procaine in arachis oil into the sacralcanal. The method is often difficult and the palnrelief usually temporary, but repeated injection ispracticable in experienced hands, and undoubtedlyhas its application to some cases. The same re-marks apply to #aravertebral procaine block,originally introduced by Delliapiane and Badiano(I927), and practised more recently by Jarvis(i944) and others.

General DisplacementsThe lateral horizontal axis of rotation of the

uterus passes through the supravaginal cervix,approximately at the level of the pelvic plexus.The organ may therefore be anteverted or retro-

verted without exerting any undue nervous trac-tion. This accords with the well-known clinicalfact that ' physiological ' displacement in either ofthese directions is normally painless. The pain ofpathological retroversion is, in the majority ofcases, the result not so much of the abnormalposition as of its original inflammatory cause ex-cept in exaggerated cases where the cervix ispushed so far forward as to exert undue tension onthe uterosacral ligaments. In prolapse, however,the uterine descent necessarily exerts considerabletension on the plexus with the resultant referredbackache characteristic of the condition. In thiscondition a distinction must be made betweensimple cystocele and rectocele and true uterineprolapse. The former displacements involvemerely a longitudinal traction on the long nervespassing downwards in the loose tissue between thevagina and the bladder or rectum; as a con-sequence both conditions may be relativelypainless.

Recto-vaginal EndometriomaThe often intensely painful nature of this con-

dition is well known, although at first sight thelooseness of the cellular tissue between the vaginaand the rectum appears to negative any consider-able nerve traction. This is indeed true of iion-infiltrating tumours and one has seen a hugerecto-vaginal dermoid which remained symptom-less until it produced obstruction during labour.The rapidly invasive tendency of an endometrioma,however, soon involves the nerves contained in theseptum and instead of being pushed aside they areinfiltrated by and enclosed within the tumour.The nerves in question are long fine filamentsdescending from the inferior border of the pelvicplexus. They are extremely numerous beingdestined for the supply of more than two-thirds ofthe vagina and rectum and microscopic section ofthe retrovaginal septum reveals their astonishingrichness and complexity. Endometriomatous in-volvement of this rich meshwork is in itself notnecessarily painful but the increased pressureaccompanying the periodic menstrual enlargementof the tumour is responsible for the characteristicsevere vaginal and rectal neuralgia.Of similar aetiology is the so-called 'pelvic cry.'

This is a reflex call of peculiar character which maybe elicited by pressure in the pouch of Douglas inthe lightly anaesthetized patient during anabdominal operation, or by similar pressure in theposterior fomix when making a pre-operativevaginal examination. It has variously been called' Albertin's reflex ' (after the surgeon who firstdescribed it), the 'Esplanade reflex' (for theextraordinary reason that the Japanese actorshoused in the Esplanade during the Paris ex-

333

by copyright. on F

ebruary 2, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.285.330 on 1 July 1949. D

ownloaded from

POST GRADUATE MEDICAL JOURNAL

hibition made a similar noise) and by other names,but the name ' pelvic cry' appears most appro-priate. It is due, of course, to almost directstimulation of the pelvic plexus which occupieseach side of the base of the pouch and is onlyseparated from the peritoneum by a small amountof cellular tissue.A similar reflex is often produced by the separa-

tion of the upper part of the posterior vaginalmucosa during the. performance of posterior col-porrhaphy. It has been considered by somewriters as identical with the ' rectal call ' of analdilatation but is really of quite different aetiology.As has been shown above, the nerves from thepelvic plexus destined for the vagina and rectumenter the former from behind and the latter fromin front. They are concentrated, therefore, in therectovaginal septum, particularly in its upper part,and it is the operative stimulation of this extremelyrich nervous meshwork which causes the reflexlaryngeal spasm.

PericervicitisThe cervix, like the uterus, is normally in-

sensitive to movement. Violent displacement ofeither organ during examination or coitus is, ofcourse, uncomforable but actual pain is caused onlyif the movement is predominantly vertical, for theposition of the pelvic plexus at the fixed junctionprotects its branches from traction except in thisaxis. In inflammatory diseases of the pericervicaltissues, however, painful movement of the cervixmay be a striking clinical phenomenon; it is alsothe cause of the severe dyspareunia often ex-perienced by these patients. The underlyingcondition is an inflammatory infiltration in thelateral cervical parametrium and the uterosacralligaments, resulting as a rule from endocervicitis,and the symptoms are rapidly relieved by para-cervical alcohol injection when the acute phase hassubsided.

Young's syndrome. James Young has recentlydrawn attention to the frequent association ofiliac fossa pain with chronic cervicitis. Both are,of course, common gynaecological disorders butthe fact that they may be aetiologically connectedhas hitherto escaped observation. Clinicallv thesvndrome manifests itself in chronic lowerabdominal pain, dyspareunia and leucorrhoea, withno obvious pelvic pathology except cervicitis.The pain in the iliac fossa may be evoked by move-ment of the cervix which is itself often exquisitelytender. The pain is resistant to all the routinemethods of treatment including major operativeprocedures, but it reacts immediately to proto-caine injection of the pelvic plexus. Young ex-plains this phenomenon by suggesting that thehypogastric pain is a true visceral pain, the iliac

fossa pain being referred from the cervix to theabdominal area of its peripheral parietal segmentalrepresentation, the iliac fossa. This application ofthe Head-Mackenzie theory of visceral sensibilityto the cervix is at once ingenious and clinicallysatisfactory, and though exception may be takenon anatomical grounds to the implication that thecervical innervation is exclusively autonomic, thereis no doubt that Young's hvpothesis adequatelyexplains many hitherto difficult cases.

Posterior ParametritisIn this condition, the clinical features of which I

have called the ' posterior parametritis syndrome,'the lower part of the pelvic plexus and its adjacentnerves are involved in a diffuse lymphangitis asthey lie within the uterosacral folds. The primarycause is a severe chronic cervicitis, and as a resultof the constant inflammatory process the secondaryneuritis is similarly constant. The patient thuscomplains of continuous low backache, aggravatedby menstruation and coitus. The uterosacralligaments are readily palpated from the vagina ashard, tender, projecting cords with the uteruspulled into anteversion by their secondary con-tracture. Many French authors, notably Molin(I929), believe the condition to be due to the un-satisfied spasm of coitus interruptus, but thoughthis practice may aggravate the disorder, there canbe little doubt of its primary inflammatory origin.Novocaine injection of the utero-sacral ligaments is asatisfactory treatment for this syndrome. Themethod is a simDle one and consists in the injectionof I ml. of 2 per cent. novocaine into the mostanterior identifiable extremity of each ligament.Anaesthesia is unnecessary and though the initialrelief is often only temporary, the procedure iseasily repeated. In intractable cases, absolutealcohol may be substituted, though here the totalquantity used is halved, and the injection placedsuperficially and medially to avoid ureteric anduterine vessel dlamage.

Ectopic GestationThe pain in unruptured tubal gestation is due to

local tension on the circular submucous plexuscaused by rapid enlargement within the lumen. Itis continuous, fairly severe and neuralgic incharacter, with interspersed colic resulting fromreflex tubal contraction.When an ectopic gestation ruptures, the pain is

equally characteristic. It occurs in attacks lastingfrom a few to several minutes and is ' tearing' incharacter. The early attacks are due to the initialprojection of blood on to the sensitive peritoneumand later to involvement of fresh areas by bodilymovements or further haemorrhage. The pain isprecisely the same as that of perforated peptic

Yulyl I1949334

by copyright. on F

ebruary 2, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.285.330 on 1 July 1949. D

ownloaded from

July I949 DAVIS: Sympathetic Nervous System in Obstetric and Gynaecological Practice

ulcer. Graafian follicle haemorrhage or any othercondition causing acutera extvasation on to ahitherto normal peritoneal surface is referred to thearea of peripheral distribution of the particularspinal segments affected. These vary con-siderably and although the pain is usually situatedin the lower abdomen commencing in the iliacfossa of the affected side, it may extend consider-ably higher, and I recently saw a case in which thepain was so exclusively epigastric that a diagnosisof perforated gastric ulcer was made and actedupon by a general surgeon. The shoulder tip painso often present is probably due to diaphragmaticirritation, both the phrenic nerve and thecutaneous nerves of the shoulder being derivedfrom the third, fourth and fifth cervical segments.Of additional interest is the manner in which insmall haemorrhages, and in the early stages oflarger ones, the pain is localized to the shoulder ofthe same side as the rupture. Scheumann issceptical of the accuracy of this fact, but withRubin and others I have found it correct in themajority of cases.

It is important to remember that small haemor-rhages into the tubal wall mav closely simulate thepain of tubal rupture or tubal abortion, and in apatient operated upon recentlv under this diagnosisthere was no free blood whatever, a distended butunruptured isthmic gestation being present. Thepain in this case occurred in spasms, described ascutting in character, but there was no distensionpain or colic. A further point is that the firstsymfptom in manv cases of ectopic gestation is theactual rupture, though close subsequent enquirywill often reveal the presence of some previous dis-comfort often so slight as to be almost unnotice-able. Variations in individual sensibilitv, togetherwith differences in the rapidity of the tubal dis-tention would appear to account for thisdiscrepancy.

Labour PainsThe neurogenic basis of the pains of labour is

somewhat complicated. The pain is actually feltin the uterus itself in only a small number of cases.In the majority it is referred to the peripheral areaof distribution of the last two dorsal, the firstlumbar and the middle three sacral nerves. It isthus felt mainly in the deeper parietes of thelumbar, sacral, inguinal and hypogastric regions,and is accompanied by definite modificationsin cutaneous sensibility (hyperaesthesia, hyper-algesia). This reference is further proved by thefact that the subcutaneous novocaine injection ofthe appropriate areas often relieves the pain.

In spite of this, however, the peripheral cerebro-spinal nerves involved are not themselves directlyaffected by pressure from the uterus, as has often

been suggested. Such direct pressure is anatomic-ally impossible, for the projection of the lumbarvertebrae effectively prevents simultaneous bi-lateral pressure on the nerves of the lumbar plexus,while the sacral plexus, as Aburel points out, iswell protected by tautly stretched ligaments. Onemay therefore postulate a primary stimulation ofthe pelvic plexus from the myometrial nerve-endings which are themselves directly stimulatedbv the chemical accumulation of muscular hyper-contraction, centripetal transmission taking placealong the autonomic nerve-pathways describedabove and overflow in the spinal cord to theadjacent posterior root ganglia resulting in refer-ence along the posterior roots to the peripheralareas of supply of the particular cerebrospinalnerves affected.

Phlegmasia Alba DolensApart from the severe and often intractable

pain associated with this condition, the permanentoedema and disability which so often follow giveits appearance in the young parturient a particularsignificance. The pain and much of the subsequentvascular damage are due to arterial spasm, reflexfrom the acute venous thrombophlebitis. Tocounteract this Leriche (1934) carried out lumbarganglionic block (the sympathetic being pre-dominantly vaso-constrictor). The techniqueconsists in the injection of 5 cc. of a i per cent.procaine hydrochloride solution into. and aroundthe lumbar sympat4etic cord. With the patientlying horizontally and on the side, the needle isinserted at a point 3 cm. lateral to the spinous pro-cess, and passed until the transverse process isreached. It is then moved medially and passed afurther 3 cm. along the lateral border of thevertebra where it reaches the ganglionated cord.The injection is made after preliminarv aspiration.My own experience of this method is restricted andthe results equivocal, but there is no doubt of thedramatic improvement when the injection issuccessful, the intense pain immediately dis-appearing, and the oedema rapidlv diminishing.

SummaryAn endeavour has been made to show that most

types of pelvic pain in women have a relativelysimple neurological basis. The pain may be dueto direct traction on nerve trunks, to irritation ofnerve endings or to malignant or inflammatoryinfiltration of nerve plexuses. The frequencywith which microscopic abscesses are found in pre-sacral nerves removed for intractable pelvic painhas been shown elsewhere (Davis, 1938). It is, ofcourse, obvious that the prime factor in relievingpain is the removal or other treatment of anyobvious gross pathology, but there remains a

335by copyright.

on February 2, 2020 by guest. P

rotectedhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.25.285.330 on 1 July 1949. Dow

nloaded from

336 POST GRADUATE MEDICAL JOURNAL July 1949

considerable number of patients in whom clinicalchanges are not obvious. In these cases appro-priate neurosurgery, from alcohol injection tosection, is of considerable value. Such measuresare held also to be a valuable adjunct to generalpelvic surgery in the eradication of long-standingand previously intractable pain.

BIBLIOGRAPHY

BATES, W., and JUDOVITCH, B., Anaesthesiology, 3, 663.BEATTIE, J. (I932), 7. Canad. Med. Ass., 26, 400.BROWNE, O'D. (I939), Irish3'. Med. Sc., 65, 73.BLOS, D. (1929), Munch. Med. Wchnschr., 76, 1173.BRUCKNER and MEZINES, C. V. (1903).CANNADAY, J. E. (1938), Trans. Int. Coll. Surg., I, I6o.

CANNON, D. J. (I937), 7. Obst. and Gyn., Brit. Emp., 44, 13.COTTE, G. (1925), Lyon Med., Ii5, 153.DAVIS, A. (I93),.7. Obst. and Gyn., Brit. Emp., 40, 481.DAVIS, A (1936), Lancet, x, 8o..DAVIS, A. (I939),,7. Obst. and Gyn., Brit. Emp., 46, 962.DAVIS, A. (1938), ' Dysmenorrhoea,' Oxf. Univ. Press, London,

p. 12I.DELLIAPINE, G., and BADIANO, P., Clin. ostet. sinec., 29,

537DOGLIOTTI, A. M. (I931), Presse Med., 39, 1249.GREENHILL, J. P., and SCHMITZ, H. E. (1936), Am. Y. Obst.and Gyn., 31, 290.

GREENHILL, J. P. (I947), Brit. Med. Y., 2, 859.GREENHILL, J. P. (I942), Year Book of Obst. and Gyn., p. 543.JARVIS, S. M. (i944), Am. _7. Obst. and Gyn., 47, 33S.KENNY, M. (i947), Brit. Med. 3'., 2, 862.LERICHE, R. (I934), Presse Med., 42, 148I.MOIR, C. (I934), Trans. Edin. Obst. Soc., 54, 93.SHEEHAN D (I934), 7. Physiol., 83, 177.TODD, T. F. (I937), Lancet, 2, 555.

* NEW HEINEMANN BOOKS 1949 *OCCUPATIONAL EYE DISEASES

By JOSEPH MINTON, M.D., F.R.C.S.Deals with the injuries that can occur to the eye in factories and workshops. Of special interest to doctors in the indus-trial medicine service, surgeons, and medical officers of health.

Demy 8vo. x76 pages. 30 illustrations, Io coloured plates. (Ready approx. August.) I7s. 6d.

THE COMPARATIVE ANATOMY AND PHYSIOLOGYOF THE LARYNX

By V. E. NEGUS, M.S., F.R.C.S. (author of Mechanism of the Larynx)The subject is divided into sections connected with the numerous functions of the larynx. The original specimensfrom which the majority of the illustrations are derived are in the Museum of the Royal College of Surgeons of England.

Med. 8vo. 204 pages. I90 illustrations. (Ready approx. uly.) 30s.

THE CONQUEST OF MALARIABy JAIME JARAMILLO-ARANGO

A unique history tracing the treatment of malaria from quinine to the latest drug paludrine, based on South American,Spanish, Portuguese, and Italian documentary sources never before available. Written by a distinguished CentralAmerican physician with a world-widle outlook. Of special interest to tropical disease experts, botanists, historians.

Demy 8vo. 136 pages. 20 illustrations. (In preparation.) I6S.NEW EDITIONS:*POSITIONING IN RADIOGRAPHY. sth edition by K. C. CLARK. 75s.COMPLETE OUTLINE OF FRACTURES. 3rd edition by J. GRANT BONNIN. 30s.STERNAL PUNCTURE. 4th edition by ALFrm PiNE and J. L. HAmILTON-PATESN. I5S.SOCIAL BIOLOGY. 2nd edition byAN DALE. i3s.THE RHESUS FACTOR. 2nd edition by G. FULTON ROBmETS. 3s. 6d.TEXT-BOOK OF GYNAECOLOGY. 3rd edition by J. H. PEn. 'zs. 6d.

WM. HEINEMANN * MEDICAL BOOKS * LTD 99 GREAT RUSSELL ST* LONDON W.C.1

by copyright. on F

ebruary 2, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.25.285.330 on 1 July 1949. D

ownloaded from