Pelvic pain in women

PELVIC PAIN IN WOMEN TREATMENT

BY RESECTION OF THE SUPERIOR HYPOGASTRIC REPORT ON THIRTY,NINE CASES* ELMORE A.

KINDEL, M.D.

CINCINNATI,

NE of the important probIems that so frequentIy confronts the surgeon and the gynecoIogist is the satisfactory management of patients suffering from severe peIvic pain which may or may not be associated with anatomic abnormaIities or pathoIogic changes of the internal genita1 organs. It has been repeatedIy shown that the correction of the anatomic abnormaIity or the remova of the pathoIogic Iesion frequently gives onIy temporary reIief from dysmenorrhea or other forms of peIvic pain. As a resuIt of the striking benefits obtained by resection of the superior hypogastric pIexus in .simiIar cases by Dr. Louis G. Herrmann’ of the Department of Surgery of the University of Cincinnati, we have used this procedure upon 39 patients suffering from severe peIvic pain. UntiI quite recentIy the conception was that sensory imp&es were carried onIy by the crania1 and spina nerves. LangIey2 and his associates were IargeIy responsibIe for this concept. However, during the past one hundred years the autonomic nervous system has received more attention and cIinicians have begun to reaIize its importance in disturbances of a viscera1 sensory nature. Sufficient studies, both experimenta1 and cIinica1, have been reported to show that the sympathetic nerves are pathways not onIy for vasomotor but aIso for sensory visceraJ impuIses. In 1898 .JabouIay3 attempted to reIieve severe peIvic pain by interrupting the afferent pathways in the sacra1 sympathetic chains. HIS procedure consisted of

0

* From the GynecoIogic

Division

PLEXUS

0.

the removal of the coccyx, freeing the rectum from the hoIIow of the sacrum, and dividing the sacra1 sympathetic chain on each side. ApproximateIy a year Iater Ruggi4 advised the resection of the ovarian pIexus by the transperitoneal route. The peIvic pain was found to be relieved after this procedure. Neither the work of Jaboulay nor that of Ruggi was accepted to any extent and both procedures were soon forgotten. A compIete study of the peIvic sympathetic nerves and their reIation to peIvic pain was made by Leriche5 and his associates in 192 I. The procedure he empIoyed to reIieve this pain consisted in a periarteria1 sympathectomy of the interna iIiac (hypogastric) artery. This method met with widespread approva1 in continenta1 Europe and numerous exceIIent resuIts were obtained. About the year 1925 the much simpIer procedure of resection of the superior hypogastric pIexus was introduced by Cotte.6 Cotte used the name of presacral nerve, instead of superior hypogastric pIexus, and therefore in France this operation became known as the resection of the presacra1 nerve. NevertheIess, the results obtained by this procedure were most favorabIe and apparentIy Iasting. In 1929 Cotte gave the name of pIexaIgia to the type of pain which is primariIy IocaIized to the uterus but which radiates to the anus, coccyx and urinary bladder. ArticIes have appeared from time to time from the Mayo Clinic where Learmonth7 and his associates have been

of the Department of Surgery of the CoIIege of Medicine Cincinnati and the Cincinnati Genera1 Hospital.

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of the University

of

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investigating the functions of the sympathetic and the para-sympathetic nerves of the urinary bIadder. ApparentIy most of

FIG.

I. Diagrammatic ovary.

ilIustration of innervation (After DahI.)

of

their work has been done on maIe patients. Their experiments proved that the pIexus contains motor fibers to the musculature of the semina1 vesicIes, the ejacuIatory ducts and the septa of the prostate gIand since stimulation of the superior hypogastric pIexus caused a cIoud of seminal fluid and prostatic secretion to be forced out into the prostatic urethra. In certain cases of vesica1 dysfunction they report uniformIy good

Pain results following the resection of the superior hypogastric pIexus. The first work pubIished in the English Ianguage along these Iines pertaining to the femaIe is an articIe by Fontaine and Herrmann* in 1932. They report the resection of the superior hypogastric pIexus in 22 cases with exceIIent resu1t.s. Their work was done in Leriche’s cIinic in Strassbourg. The patients operated upon in their series were divided into three groups. The first group was made up of patients with neither peIvic pathoIogy nor organic Iesion to account for the peIvic pain. For this group the name of functiona dysmenorrhea was empIoyed. The second group incIuded those cases with sIight pathoIogicaI processes in the peIvis, which do not react favorabIy to ordinary gynecoIogic therapy. Patients presenting a definite pathoIogic Iesion such as an inoperabIe carcinoma giving rise to severe pain were inchrded in the third group of cases. However, in this Iatter group of cases a more extensive remova of the peIvic sympathetic nerves was advocated. At the time of the resection of the superior hypogastric pIexus any anatomic abnormaIity that was present was corrected and any diseased structure was removed. The innervation of the ovary is mainIy from the ovarian pIexus which arises from the intermesenteric and renaI pIexuses and follows the course of the ovarian artery. On reaching the suspensory Iigament of the ovary the fibers of this pIexus are distributed in somewhat the folIowing manner. One branch which is called the externa1 tubuIar branch supphes the farIopian tube. The other branches of the plexus suppIy the ovary itseIf. A number of smaI1 termina1 Maments of the tubuIar branch course through the broad Iigament to reach the IateraI side of the uterus (Fig. I). The nerve suppIy to the uterus is derived from the great plexuses of Frankenhaeuser which are situated in the broad ligaments on each side of the uterus and are made up of fibers from the hypogastric and sacra1 pIexuses (Fig. 2).

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The formation of t.he superior hypogastric pIesus is as foIIows: Situated at the origin of the superior mesenteric

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midhne and wiI1 be found to have two or three main divisions with intercommunieating fibers. The Iargest part of the pIexus

n&n ;n utero-vd$nal plexus FIG. z. Diagrammatic

ilIustration

of extrinsic

artery is the superior mesenteric pIexus. In its downward course this pIexus becomes known as the intermesenteric pIexus which then divides on approaching the inferior mesenteric artery into a right and a Ieft inferior mesenteric plexus. These two divisions of the inferior mesenteric pIexus again reunite about one inch beIow the artery and proceed downward to make up the media1 part of the superior hypogastric pIexus (Fig. 3). AIong either side of the vertebra1 coIumn in this Iocation is situated the Iumbar sympathetic chain with its four ganglia. Fibers from these four ganglia, especiaIIy from the first two, join with the thin branches of the inferior mesenteric pIexus to form the superior hypogastric pIexus. This pIexus is to be found in a triangIe formed by the bifurcation of the aorta and the promotory of the sacrum. It Iies directIy behind the posterior peritoneum and frequentIy in thin individuaIs may be seen through it. The pIexus Iies in Ioose areoIar tissue directIy over the spine to the Jeft of the

nerves of uterus and vagina.

(After DahI.)

passes over the Ieft common iIiac artery and approaches the midIine as it descends. Many different names have been given to this pIexus. One of the most commonIy referred to is the presacra1 nerve. We have made a study of the anatomy of this structure. Our aim has been to determine whether it is reaIIy a pIexus of nerves or a singIe nerve trunk. ? hrough the cooperation of *the Anatomica Department and the Department of PathoIogy of the Cincinnati Genera1 HospitaI we were afforded the opportunity of examining 23 cadavers and 5 bodies at autopsy. In addition we have carefulIy observed the structure in everyone of the 39 patients who have been subjected to this operation. Thus we have studied in a11 67 human bodies and in a11 of them we observed a true pIexus formation. These observations were aIways made by two or more individuaIs. Figure 4 shows the fundamenta1 structure of the superior hypogastric pIexus. At the promotory of the sacrum

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the pIexus divides into the right and Ieft inferior hypogastric nerves. These nerves proceed deep into the cuI-de-sac and are

Pain

the parasympathetics inhibit contraction. Resection of the superior hypogastric pIexus causes no aIteration of the sexual

FIG. 4. Fundamental

FIG. 3. Formation

of superior hypogastric Herrmann.)

pIexus.

(After

finaIIy Iost in the mass of nervous tissue of that region which is caIIed the hypogastric ganglia. One of the functions of the hypogastric pIexus is to exert a vasoconstrictor action on the vesseIs of the internal genitaI organs. It also inhibits the secretion of the genital gIands. The para-sympathetic fibers bring about VasodiIatation in the vessels and at the same time stimuIate the genita1 gIands to secretion. It is not known which of the two systems initiates uterine contractions. Reports by DahIg state that the sympathetic fibers act as stimmators while

DECEMBER, rg35

structure plexus.

of superior

hypogastric

function in women. FoIIowing the resection of the superior hypogastric pIexus the patient may compIain of sIight frequency of urination. This usuaIIy does not Iast for more than two or three days and is due to the division of the inhibitor fibers. Other than this there is no other aIteration in vesical function. It is dehniteIy known that the parasympathetic system can take care of the storage and discharge of urine. The fibers of this system are indispensabIe in this respect. Some pain fibers from the bIadder are carried by the sympathetic nerves. However, a large part of them are carried by the parasympathetics.

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It has been repeatedIy shown that section of the superior hypogastric plexus does not alter the normal menstrua1 cycIe. An atypica1 or suppIementarv period may occur shortIy after the patrent has had this procedure performed. This is frequentIy the case and this shouId not be considered the norma menstrua1 period as it is to be expIained on the basis of an intense hyperemia produced by section of the sympathetic nerves. The normaI menstrua1 cycIe is not disturbed. The Iutein hormone appears to act independently of any nervous control. However, its action seems to be increased by the hyperemia brought about by the neurectomy. The physioIogy of parturition is not impaired. It has been shown that section of the entire sacra1 cord, as we11 as the sympathetic pIexus requires onIy the application of low forceps in childbirth, because of the paraIysis of the perinea1 and vulvar muscIes. In addition there are many cases on record in which norma parturition took pIace in patients who had previously been subjected to a resection of the superior hypogastric pIexus for the reIief of some painfu1 condition in the peIvis. In every one of the 39 patients subjected to a resection of the superior hypogastric pIexus, there was a definite history of hypogastric pIexaIgia. The kind of pain which is typica of irritation of the superior hypogastric plexus is of a duI1, dragging nature, feIt deep in the peIvis, referred to the rectum, coccyx and to the inner aspects of the thighs, present not only at the onset of periods, but aIso between menses. These regions correspond to the distribution of the fibers from the superior hypogastric pIexus. Pain which is referred to the back, Iumbar regions and occasionaIIy to the obturator regions should not be confused with true pIexaIgia since it is the resuIt of disturbance in the ovarian sympathetic pIexus. We do not aIways find the history of pain, with its varied radiation so compIete as already outhned. The history may reveal that the individual has been having only

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severe dysmenorrhea whiIe at other times the severe dysmenorrhea may aIso be accompanied and is frequently accom-

FIG. 3. Surgicd

approach to superior hypogastric

pIems.

panied by radiation to one of the various regions mentioned. There were 3 cases in this entire group in which a history of dysmenorrhea was not present. However, these cases presented other features of a hypogastric pIexaIgia, nameIy deep-seated, duI1 dragging pain accompanied by radiation to the various regions mentioned. In 34 cases dysmenorrhea was a very prominent symptom and in a11 of them, the usua1 medica methods were employed in an attempt to bring about reIief. Twenty-one patients compIained of so severe a dysmenorrhea that in spite of the usual methods for reIief they were compeIIed to go to bed. In several of our cases this one symptom alone was enough to cause the patient to present herseIf for surgica1 treatment. In practicahy every case there was a history of deep-seated, duI1, dragging pain. At no time was a resection of the superior hypogastric pIexus considered on this history alone, but before employing this procedure we were carefu1 to have in

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addition the presence of dysmenorrhea, or the radiation of this pain either to the rectum, to the coccyx, or to the inner aspects of the thighs. Radiation of the peIvic pain was present in a11 but 9 cases. The most frequent region to which it was referred was the rectum. Rectal radiation was present in 21 cases. Fourteen patients compIained of pain radiating to the coccyx, while in 19 cases there was a history of radiation of the pain to the inner aspects of the thighs. Radiation of the pain to a11 three regions at the same time was rather infrequent. This situation was present in onIy 8 of the cases. Therefore, whenever a history was given of peIvic pain of a duI1, dragging nature feIt deep in the peIvis, with or without dysmenorrhea and with radiation of this pain to either the rectum, the coccyx or the inner aspect of the thighs, or to a11 three regions, we recommended the resection of the superior hypogastric pIexus. OccasionaIIy the onIy history was that of a severe intoIerabIe dysmenorrhea, from which the patient obtained no relief by the various other forms of surgica1 or medica therapy, and after having granted them a fair tria1 we recommended this new type of surgica1 therapy. The shortest duration of symptoms presented in this series was of two months; whiIe at the other extreme we obtained one history of hypogastric pIexaIgia of fifteen years’ duration and another patient had symptoms of ten years’ duration. Eleven of our patients had symptoms for onIy one year, and the majority of them for onIy two to four months. The number of patients having symptoms for two and three years was smaII: onIy 4 cases in each instance. Six of the patients were admitted having complaints of four years’ duration. The history of the remaining 7 patients showed that they had been having pain from five to fifteen years. The youngest patient in our series was one of sixteen years. In this case her symptoms had been severe for three years,

Pain and since she had obtained no reIief by other measures, we feIt resection was necessary. We do not ordinariIy recommend the procedure in patients as young as this. The oIdest one of the group was forty-four years. The average age was 26.3 years. The great majority of our patients had had no previous operations. However, 9 of the patients incIuded in this series had had previous operations. In a11 but 2 instances the patients compIained of symptoms suggestive of hypogastric pIexaIgia at the time of the first operation. There was only temporary reIief foIIowing the first Iaparotomy in a11 except these 2 cases. Both of these patients gave no history of hypogastric pIexaIgia at the time of ‘the first operation. One presented a11 the symptoms of an acute appendicitis. The appendix was removed through a McBurney incision. In this case the onset of hypogastric pIexaIgia was some years Iater. In the other case the patient had the Ieft ovary and the appendix removed. She was free from peIvic pain for six years thereafter. However, at that time she deveIoped characteristic symptoms of the disturbance and three months Iater was admitted to the hospita1. Perhaps the most interesting case in the entire series is that of a nineteen year oId coIored gir1 who had been subjected to an operation at the age of seventeen years. The onIy pathoIogica1 condition found at the time was a small ovary containing severa cysts. ConsequentIy a11 that was done was a paracentesis of this ovary. Appendectomy was done as a routine procedure. The appendix showed no definite pathoIogica1 change. This patient obtained absoIuteIy no rehef. She was readmitted to the hospita1 on three different occasions because of persistent severe peIvic pain. Th is was the first patient whom we subjected to a resection of the superior hypogastric pIexus for the relief of severe peIvic pain. This case wilI be referred to in detai1 a IittIe Iater.

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There were 2 other cases somewhat simiIar, however, showing more peIvic pathology. The first of these cases was that of a woman operated upon at the onset of her peIvic pain. It was necessary to do a GiIIiam suspension and a resection of one ovary. The appendix was removed as a routine procedure. In the second case the right tube and ovary were removed and a routine appendectomy was done. Neither one of these patients obtained relief and after having been carried along on dispensary treatment without relief for one year were again referred to the hospita1. In 3 of 9 cases onIy the appendix was removed and with no reIief of the symptoms. The Iast patient in this group was subjected to a diIatation and curettage and tracheIorrhaphy. This patient’s symptoms appeared to be progressive and she was finaI1.y readmitted with a verv typica history of hypogastric pIexaIgia. The ooeration of resection of the suoerior hypogas’tric p1exu.s has been performed in two distinct types of cases: those in which there was no associated peIvic disease, and those in which a pathoIogica1 condition was aIso present. Anatomic abnormaIities have not been considered pathoIogica1 entities, since so many women are known to have maIpositions of the peIvic viscera without symptoms. This grouping was made rather on the operative findings than on preoperative cIinica1 examinations. We fee1 that an operative diagnosis of the hndings is more exact and more accurate. There were 20 patients in the first group and 8 of these had some degree of retroversion. Nineteen had associated pathoIogicaI changes with a history of hypogastric pIexaIgia. A routine appendectomy was done in each instance where the appendix was present. AI1 pathoIogica1 Iesions were properIy treated at this operation and a11 abnormalities of position were corrected. The resection of the plexus was aIways the fina step of the operation before cIosing the abdomina1 waI1. However, when infection was encountered no attempt was made to resect the pIexus, in spite of a

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definite indication for it. This precaution was taken to prevent any infection of the retroperitonea1 space. The approach is faciIitated by a somewhat longer midIine incision, extending sIightIy above the umbilicus. In selected cases where it is desired not to have a midIine scar a Pfannenstiel incision may be made. This gives a very adequate approach also to the pIexus, and the scar becomes hidden in the hairline. With the patient in the Trendelenburg position and the intestines packed upward and out of the way the sigmoid is retracted to the Ieft, exposing a triangle between the bifurcation of the aorta and the promotory of the sacrum (Fig. 5). Incision is then made in the peritoneum in the midIine from the apex to the base of the triangle. The pIexus is frequentIy seen behind the peritoneum in a thin individua1. It Iies in the Ioose areoIar tissue shghtly to the Ieft of the midIine and wiI1 be found to have two or three main divisions with intercommunicating fibers. The pIexus is picked up with a hook and by means of a dissector is stripped of a11 adherent areoIar tissue. Without tying or cIamping the nerve fibers of the pIexus about one inch of it shouId be removed. BIeeding is seldom encountered and when present is sIight. The peritoneum shouId be cIosed with a fine catgut or siIk suture. The darkened area in Figure 3 represents the portion of the pIexus to be resected. SIight vagina1 bleeding foIIowed on the second or third day after the procedure had been performed. This is due to the increased vascuIarity of the uterus which foIIows such a sympathetic neurectomy. BIeeding is of short duration, and in our experience, sIight. But it stresses one point which we think important; that is, careful hemostasis during the pelvic operative procedure. Other than bIeeding there are no untoward symptoms following this operation. We have been abIe to carry out followup examinations upon 37 of the 39 patients operated upon. In 2 cases postoperative pneumonia resulted in death. We have

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been unable to follow 4 cases, al1 of which showed exceIIent resuIts on discharge from the hospita1. Ten of our patients have been foIIowed for a period of from one to six months. In 4 of these the resuIt was exceIIent; 3 were very good; 2 were good, and one was fair. Five cases have been foIIowed from six months to one year. The resuIts in this group of cases are exceIIent in 2, good in one, fair in one and poor in one. Sixteen or aImost one-half of the cases have been foIIowed for more than two years. Four of these patients have become pregnant since discharge and in each case the pregnancy was norma in a11 respects. Six patients in this series experienced the maximum benefit of the operation. In one case the resuIt was very good. It was good in 3, fair in 2 and poor in 4. SUMMARY

To summarize: of the 3’9 patients, 2 died. Four of the cases we were unabIe to foIIow but in a11 of these the immediate resuIts were exceIIent. Of the remainder exceIIent resuIts were obtained in 14 cases, very good resuIts in 4, good resuIts in 6, fair resuIts in 4 and absoIuteIy no benefit foIIowed this operation in 5 of the cases. (See TabIe I.) We beIieve that the hypogastric pIexus carries the important pathways of sensation from the interna genita1 organs to the meduIIary centers and that section of the superior hypogastric pIexus is a safe, simpIe and effkacious way of interrupting these pathways. On the basis of the foregoing resuIts we fee1 justified in recommending the resection of the superior hypogastric pIexus and beIieve that it has a definite pIace in gynecoIogic surgery, but shouId be empIoyed in carefuIIIy seIected cases and shouId notbe used as a remedy for a11 peIvic distress. It is not to be used as an immediate procedure in a11 cases of pIexaIgia; particuIarIy is this true in adoIescent girIs whose first few periods may be irregular and painful. In many instances this pain disappears in a few years and especiaIIy after a pregnancy.

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TABLE I FOLLOW-UP RESULTS Number of patients operated upon.. . Postoperative deaths.. Number of patients we Were unable to foIIow

39

z 4

No. of Cases Results ExceIIent. IO Very good. Good. Fair.. 6 months to I year.. ExceIIent. 5 Good. Fair.. Poor. 2 years and more. . . ExceIlent. 16 Very good.. Good. Fair. Poor. I

Follow-up Period to6months......

Four of this last group have had norma since discharge from the hospita1.

4 3 2

I 2

I I 1 6 I 3

2 4

pregnancies

Summary Cases operated upon.. Postoperative death.. No foIIow-up.. .. . ExceIIent resuIts.. . . Very good results.. .. Good resuIts.. . . . . . Fair results.. .. PoorresuIts...................................

.

. . . . . . . . . 39 .

.

.

.....

. .. . . .... . ... . .. .... .. . .. . . .. .. . . . . .. .. . ... ..

2 4 14 4 6 4 5

We feel certain that a faiIure to recognize this type of peIvic pain (pIexaIgia) accounts for some of the poor resuIts in gynecoIogic surgery. This is evident in the fact that one-fourth of our patients had been operated upon previously. CASE

REPORTS

We have seIected 3 cases from the series to represent the typica symptom-complex which responds most favorabIy to a resection of the superior hypogastric pIexus. CASE I. A white woman, twenty-seven years of age, had had two previous admissions to the hospita1 for the complaint of Iower abdomina1 pain. Her first admission was on the surgical servic’e for a questionabIe appendicitis; Iater she was readmitted on the gynecoIogica1 service because of a dull, dragging pain in the Iower abdomen. The pain radiated to the inner aspects of the thighs. In addition she had a very marked dysmenorrhea. The peIvic examination showed onIy a retrocession of the uterus. This patient was subjected to a GiIIiam suspension, appendectomy and a

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resection of the superior hypogastric pIexus. On discharge from the hospita1 she was absoIuteIy free of pain, and has been foIIowed for over two years and is entireIy free of symptoms. CASE II. A white woman, thirty-five yearsof age, had been having deep-seated, duI1, dragging pain referred to the sacrum, coccyx and inner aspects of the thighs for severa years. She also compIained bitterIy of marked abdominaI cramps at the time of her menstrua1 periods. Pelvic examination reveaIed a Iaceration of the perineum, Iaceration of the cervix and a second degree retroversion of the uterus. The operation consisted of a diIatation and curettage, trachelorrhaphy, perineorrhaphy, phcation of the round Iigaments, appendectomy and a resection of the superior hypogastric pIexus. She obtained compIete reIief of pain and since operation has been reIieved of a11 her previous symptoms. CASE III. A colored gir1, nineteen years of age (referred to earIier in this paper). At the age of seventeen she began having periodicattacks of deep-seated, duI1 dragging pain referred to the inner aspects of the thighs, together with very severe dysmenorrhea. She was subjected to a Iaparotomy and the appendix was removed after a paracentesis of the Ieft ovary had been done. The patient did not obtain any relief. She was admitted to the hospita1 on three other occasions and since the examinations revealed nothing she was sent home to continue vaginal douches. No reIief was obtained by this form of therapy. At the time of her Iast admission, Doctor Herrmann examined this patient and gave the opinion that she was an ideal case for a sympathetic neurectomy. He performed the resection of the superior hypogastric pIexus and aIso a Ieft saIpingo-oophorectomy because of the extreme cystic degeneration of that

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ovary. The patient had an uneventfu1 postoperative course. She has become pregnant since the operation and at this time, over two years since operation, is entireIy free of symptoms of pelvic pain. This was the first patient of the series that was operated upon. REFERENCES I. HERRMANN. L. G.

Resection of the superior hypogastric pIexus for the reIief of peIvic pain. J. Med.,

(Aug.) 1933. 2. LANGLEY, J. N., and ANDERSON, H. E. On the innervation of the peIvic and adjoining viscera. Part XV, The internal generative organs. J. Pbysiol., 16: 410, 1894. 3. JABOULAY, M. Le traitement de la nkvralgie peIvienne par Ia paraIysie du sympathique sac& Lyon mkd., 90: IOZ, 1899. 4. RUGGI, G. DeIIa simpatectomia ae co110 ed all’adame. Policlin., 6 C: 193, 1899. L.a simpatectomia abdominale utero-avarica come mezzo di cura di alcuni Iesioni interne negei organi genitali delIa donna. Bologna, ZanicheIIK 1899. Risultanze definitive avute delle simpatectomia abdominaIe. Boll. SC. Med., 1901. 5. LERICHE, R. La chirurgie de Ia douIeur. Presse mtd., 35: 496; 561, 1927. 6. COTTE, G. Sur Ie traitement des dysmknorrhkes r&beIIes par Ia sympathectomie hypogastrique p&i-arterieIIe ou Ia section du nerf p&sac&. Lyon mkd., 56: 153, 1925. 7. LEARMONTH,J. A contribution to the neurophysioIogy of the urinary bladder in man. Brain, 54 (Pt. 2), ‘93’. Treatment of vesica1 pain. J. Ural., 26: I 3, 193 I. 8. FONTAINE, R., and HERRMANN, L. G. CIinicaI and experimental basis for surgery of the peIvic sympathetic nerves in gynecology. Surg. Gynec. Obst., 54: ‘33, 1932. 9. DAHL, W. Die Innervation der weibIichen Genitahen. Ztscbr. f. Geburtscb. u. Gynaek., 78: 539, 1916. Die Nervenversorgung der weibIichen GeschIechtsorgane, Ztscbr. f. Geburtsb. u. Gynaek., 78: 339, r924. Also: MueIIer, Springer.

L.

R.

Die

Lebensnerven.

BerIin,