J.Jpn. Surg. Soc.. 53(1): 48-53, 1952
宿題報告
Surgery of the Autonomic Nervous System (Principally Concerning the Problem of Abdominal Pain).
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Second Surgical Clinic (Prof. Y. Aoyagi), Kyoto University Ch. Kimura |
We have discovered that 0.5 to 1.0 cc of 2.5 to 5.0％ acetylcholine solution, injected into viscera, causes visceral sensations. Therefore, we will call this method "Acetylcholine (A.C.) Method."
We succeeded in arousing visceral sensations in 55％ of our 365 laparotomy clinical cases. Our method was successful not only in such muscular organs as alimentary canals,urinary bladders and uteruses but also in such parenchymatous ones as kidneys, pancreases and ovaries.
1. Visceral Sensations of the Alimentary Canal
As Dr. Mackenzie has described, the sites of pain originating in various parts of the alimentary canal were always felt close to the median line of the trunk, front or back. However, on the two following points our results were not identical with his: (1) In our cases local signs of visceral pain from one portion of the viscus and those from neighboring portions gave broad overlapping areas on the abdominal surface; (2) In our cases the pain was a little to the left of the median line below the navel.
The locating of these overlapping areas proves without a doubt that every part of the alimentary canal is innervated by the sensory fibers of two or more segments of the spinal cord. On the other hand, the results of our investigations on both humans and animals suggest that every part of the alimentary canal accepts the sensory fibers from the posterior roots on both sides of the spinal cord. Ray, Bronson and Neil found an interesting phenomenon that after unilateral interruption of the sympathetic trunks, there appears contralateralisation of the sites of visceral pain from the alimentary canal. However, they gave no explanation for this. We confirmed the existence of this phenomenon not only in visceral sensations but also in sensations of the somatic regions. We found that when the abdominal wall together with the sensory nerves was dissected on one side for the purpose of laparotomy, local signs of pressure on the median line of the abdominal surface were also contralateralised. From this point of view, rhe consciousness of the local sign generally depends not only on the discriminative ability of a sensory nerve but also on the integrations of sensations transmitted by two or more afferents. The Ray and Neil contralateralisation is attributed to the dysfvnction of this integration. The intergration of the sensory impulses seems to serve as the judgement of the site of the starting point rather than the relative situation of two or more points. Therefore, we call it the "initial local sign." Thus, our experiments have made clear the significance of the Ray Neil phenomenon.
Adequate stimulus, given to the various parts of the alimentary canal, resulted in referred pain at the proper regions of the abdomen while violent sudden pain made local signs of sensation rather obscure. In these patients always reported that the pain covered the whole abdomen, It was worth note that the pain represented many visceral sensations including pressure and that the pressure sensation always preceeded the pain. Visceromotor reflex (defense musculaire), resulting from stimulation of the alimentary canal, appeared in the same region of the local sign of the pain, that is an area spreading from the median line to both sides of the abdomen. The extent of the reflex contraction of the rectus abdominis muscle depends on the intensity and the position of the stimulus given to the alimentary canal. For instance, a violent stimulus, occuring suddenly, results in the contraction of the entire muscle, while, a smaller stimulus is followed by partial contraction of the muscle with the relaxation of the remaining portions. Y. Watanabe, avaliling himself of this fact, physiologically determined what segments of the spinal cord supplied the sensory nerves to which parts of the alimentary canal. His results coincided with the patterns of the visceral pain. The local sign of the viscero-sensory or viscero-motor reflex liberated from the alimentary canal always appeared along the median line of the abdominal surface from upper parts of the viscus on the upper abdomen, while from lower parts of the viscus on the lower abdomen. Therefore, it did not suggest what region of the abdomen was actually stimulated but it roughly indicated what part of the whole length of the alimentary canal had been stimulated.
a. Gastric ulcers which, during laparotomy, did not respond to mechanical stimuli caused intense pain by the acetylcholine solution injected into the ulcers themselves. Five to ten minutes after the injection, when the pain had already gone, the ulcers, themselves,but not the surrounding areas, were sensitive to finger pressure or rubbing with gauze. In relation to Dr. Katsuta's findings, it is an interesting fact that in cases of gastric ulcers,the blood which was cholinergic before operation, during and after laparotomy, changed noticeably to adrenergic. The adrenalinemia during laparotomy seemed, therefore, to blunt the gensitivity of the gastric ulcer while local increase of acetylcholine made it sensitive agam.
b. Pain, originating in the appendix, when slight, was felta round the navel but when it became more severe the patient tended to refer it to the epigastrium. A lightly inflamed appendix was more sensitive to acetylnholine than a gangrenous, chronic or recurrent one. Therefore, in reccurences of appendicitis, the degree of the gastric syndrome which represents the sensitivity of the appendix itself, must be lessened.
c. The stimuration of pylorus, duodenum, gall duct and appendix by A.C. produced almost the same pain as cardialgia. This was sometimes followed by nausea and vomiting.
d. We observed visceral sensations in three pancreas cases and had the following results : one patient felt no pain by the A.C. injection into the head of the pancreas ; two patiens were examined at the median portion of the viscus and both felt severe pain in the back,-one at the ponit of Boas and the other in a zonal region extending from the from point of Boas to both sides.
2. Visceral Sensation of the Urogenital Organs.
The impulses of visceral pain from urogenital organs are believed to enter the spinal cord between the ninth thoracic and fourth sacral segment but because of the lack of white rami between the second lumbar and the second sacral segment, those afferents are classified into two groups, i.e. the thoraco-lumbar (sympathetic) and the sacral (parasym-pathetic) pathways. Sensations transmitted by sacral sensory nerves are characteristic in that they cause desire to excret.
In our study of sensations of the urogenital organs we used two methods-electric stimulation as well as our A.C. metod. These investigations were made during laparotomies under local or spinal anaesthesia. We had three factors to consider :
1. The existence of characteristics peculiar to sacral sensory nerves
2. The site of referred pain
3. Diminishment or disappearance of visceral sensation or its referred pain after anaesthesia of certain spinal segments.
Generally speaking we found that most parts of these organs are under dual sensory innervation between the thoraco-lumbar and the sacral nerves, and the visceral sensation on some parts of these organs are represented usually by the predominant side of the two. Pain in the ureter, for instance, on a part 10cm lower than the pelvix of the kidney was always accompanied by a slight desire for micturition suggesting tnat the ureter accepts sacral sensory nervous supply far more extensively than has been as yet described. On the other hand, the sensation of micturition completely disappeared after the sacral anaesthesia but there still existed a sensation of pain which was referred to the side of the abdomen. Most parts of the ureter are therefore, under dual sensory innervation and the lower the part the more definite is the predominance of the sacral sensation.
The same can be said in regard to the spermatic cord. The visceral sensation of the external inguinal ring produced the referred pain on the supra-inguinal region while in the portion between the external ring and prostate gland the pain of the viscus referred to the perineum. Therefore, at the former, the thoracolumbar sensory nervous supply seemed to be predominant, while at the latter, the sacral one. From birth on through life, the scrotal portion of a spermatic cord stands lower than the portion in the external rign or its neighbourhood. Nervertheless, the former accepts the sensory nerves from higher segments of spinal cord than the latter. From birth on through life the sensory nervous supply of the spermatic cord seems, therefore, to be in inverse relationship to the site of the viscus. Keeping in mind the ontogenetic process of descensus testis, this apparent contradiction is well understood.
3. The Sensation of the Testicle and the Ovary.
The human testicle is an organ easily available for study of visceral sensations. The contusions at the scrotum cause pain with a feeling of temporary collapse and also a deep sensation as if the testicle was getting into the abdomen. The first feeling disappears after spinal anaesthesia of the sacral segments while the second does after anaesthesia of the thoraco-lumbar segments. Thus we have for the first time analyzed two testicular sensations.
From the ontogenetic point of view the ovary is an organ analogous to the testicle. Consistently in our cases pain resulted from A.C. injection into the ovary. The site of the pain was in the suprainguinal region or in the loin just as the abdominal reference of the testicular pain. In ten clinical cases A.C. was injected into the parenchym of the ovary and in nine cases pain was felt. The nature of the ovarian pain was very suggestive,i.e. 2 patients complained of the pain''as if it were the pain of labour." These answers were very iuteresting to us. Then to examine the problem, Dr. Y. Yoshiike studied cats not long before parturition. However, in spite of the presence of nocireactions after the A.C. injection into ovary, contraction of uterus muscles never appeared. Probably the patientc omplained of pain like labour pain because the site of the referred painin the loin from the ovary bore some resemblance to pain at the beginning of labour.
4. Viscero-visceral Reflex.
The kidney accepts exclusively the thoracolumbar sensory fibers and a painful stimulus on the viscus referred to the side of the epigastrium or to the loin. A 40-year-old male who had been suffering from the syndrome of gastric ulcer with symptoms such as cardialgia, black stool and vomiting was relieved by removal of the lime kidney on the left side. We examined by retrograde pyelography a 22-year-old female who not stand for more than half an hour on account of cardialgia, nausea and vomiting. We found that when both renal pelves were full of moljodol, she suffered exactly the same severe pains on the left side of the epigastrium as she had suffered before. Therefore, we performed renal decapsulation of the left kidney. The patient recovered. This syndrome should be called "reno-gastric syndrome."
The site of the pain resulting from A.C. stimulation of the uterus indicated something different from descriptions in books. In addition to the pain in the suprapubic region, cardialgia with nausea often followed. The nausea caused by stimulation of the uterus may possibly explain the reflex hyperemesis in pregnancy but the sensory nervous supply illustrating thing is still unknown. A 22-year-old female who began to suffer from cardialgia,vomiting and an irritable colon at the beginning of pregnancy, was relieved by the pregnancy,was relieved by the presacral sympathectomy (Cotte and Meigs). This suggests the existence of the utero-gastric and utero-colic reflex via hypogastric plexus. A man on whom vasectomy was performed becausc of leprosy felt nausea when retropubic portion of the spermatic cordl was tracted during the operation. In our clinic Dr. Y. Watanabe found, in his experiments on cats, that vomiting was caused by stimulation at any part of the abdomiual viscera when a subcutaneous injection of acetylcholine or physostigmine had been given. Especially in the vagotonic state, the uterogastric or the renogastric syndrome must, therefore, be brought into existence as viscerovisceral reflexes. This is true in regard to Aschner's reflex which is principally carried by a sensory trigeminal nerve. Dr. N. Kimur-a clearly demonstrated in his experiments on rabbits that the reaction of Aschner's reflex could affect the sympathetic as well as the parasympathetic nervous system. He did this by giving a preliminary stimulus to the sympathetic or the parasympathetic region of the hypothalamus.
5. Spinal Anesthesia, as a Method of Treatment for the Dynamic Stenosis of the Alimentary Canal.
As is well known, the ileus often takes place as the result of long time spastic contractions at a certain part of the bowel and when the peristalsis of the bowel is generally somewhat inhibited, as if paralyzed. A painful stimulus given any place on the body inhibites the movement and the tone of the alimentary canal. Using the A.C. method, Dr. Y. Watanabe demonstrated that pain, even in the case of colic of the bowel, reflexly inhibits peristalsis and the tonus of the remaining parts of the bowel. This reflex is liberated from the autonomic centre of the medulla oblongata or its neighbourhood, because it, as Dr. Y. Yoshiike demonstrated, disappeared, after trans-section between the 2C-3C segments of the spinal cord. The mechanism of the ileus-syndrome by the spasm of the bowel is not, therefore, due only to the spasm itsself, but also to the peristaltic and tonic inhibition of the other parts which is caused by the colic. A 20-year-old female who had been suffering from meteorism, colic pain and sometimes from ileus syndrome, was relieved by posterior rhizotomy between the 9T-12T segments. A 40-year-old male who, for a year after gastric resection for a gastric ulcer, suffered from the socalled "dumping syndrome" got well when treated by alcohol anaesthesia at the posterior root of the lower thoracic segments.
These cases tell us that extraordinary impulses conveyed by the visceral afferent nerves can cause excessive sympathetic activity which in turn plays a part in the mechanism of spastic constipation, meteorism and the dynamic ileus. By a single induction of spinal anaesthesia, Stabins, Telford ＆ Simmons treated several cases of mega.colon with excelent results. Availing ourselves of this method,we succeeded in the treatment of meterism and constipation which occurred after appendectomies. It is conceivable that in these cases sensory blockages must have played a role which caused inhibition of excessive sympathetic activity.
6. The Humoral Active Substances in the Blood
As Musser ＆ Grimm have already reported, adrenergic and cholinergic nature of blood does not necessarily represent sympaticotony and parasympaticotony. This is due to the adrenal gland, i.e. the adrenailn secretion from the adrenal medulla easily reacts not only to painful sensations but also to the choline like substance increased in the blood and often changes the nature to adrenergic. This is because the adrenal medulla is innervated by the chol nergic nerve.
By sensitisation with horse serum Dr. Yamamura observed the nature of rabbits' blood in anaphylactic shock. He found a remarkable tendency of the blood to decline to adrenergic during shock, whereas terrible spasms of bronchus and intestines accompanied the shock. This was a sign of the parasympathetic excitation of viscera. This inverse phenomenon between the tissue-and blood-reaction no longer appeared if both adrenal glands had been removed
7. Observations on the Radiation of Visceral Pain to the Legs
Pain of the abdominal viscera, especially of the urogenital organs, radiates sometimes to the legs, but our clici al investigations, using the A.C. method, were not successful in the demonstration of this fact. In order to pursue the problem further, we studied the effects of electric stimulation of the sympathetic trunk which is considered the main pathway of the visceral sensory fibers. We cut off certain portion of the sympathetic trunk and the central end was stimulated by the induction current. We experimented on on three cases and during the sympathectomies we stimulated between 3T and 4T ganglion but there was no radiation of the pain to the arms. We performed the same experiments on four cases of Raynaud's disease in the foot and we stimulated the segments between the 3L and 4L ganglions. Two patients reported that they felt pain at the front and median regions of the thigh of the stimulated side. Even in these successful cases, the pain, however, violent it was, did not extend beyond the median portion of the thigh, This is probably because of the lack of the white rami between L2-S2 segments of the spinal cord. The spinal nerves of the legs, motor or sensory, belong to the same segments between L2-S2, so that if the visceral sensory impulses are transferred to the spinal nerve originating in the same segment, they must be free from viscerogenic reflexes. In these spinal segments, however, the upper and the lower limits (L2 ＆ S2) still receive some of the visceral sensory nerves which are, therefore, able to cause the referred pain at the corresponding areas of the legs. In the spinal nerves the front and median regions of the thigh belong to L1 and L2 so that only this area can be influenced by the visceral sensory impulses via the lumbar segments. On the posterior side of the legs the area which belong to S2 is along the course of the trunk of the sciatic nerve. This area is, therefore,under the influence of those visceral sensations via the sacral nerves. Almost the same things might be said in regard to the defense musculaire of the legs.
These anatamical and physiological facts, together with our results, make clear that the animal functions of the legs are, to a certain extent, independent of the visceral reflex.The same is true in regard to the arms, because the spinal nerves there start or enter the spinal cord between C5-T2 segments but the existence of the white rami is not demonstrated within the scope of the cervical segments so that the visceral afftrent fibers from the thoracic organs can fal in with the spinal nerves of the arms only between Tl-T2 segments and within these segments only the pain is able to radiate to the corresponding areas of hands, i.e. to the ulnar region. Weiss, Pollock and Davis illustrated the mechanism of the transmission of visceral sensory impulses to the referred pain, analyzing it into three processes,the first to visceral afferent, the second to a somatic or a sympathetic efferent and finaly to a somatic or a proprioceptive afferent course. But there was no sign that sympathetic efferents play roles in the mechanism of the radiation of visceral pain because, if it were so, the pain would have been likely to appear at the end of the extremities where there is the highest tonus of the autonomicn erves. The sympatheticn erves which are distributed in the extremities are always able to relay the impulses of visceral sensation because their outflow from the spinal cord begins in the thoracolumbar segments (T1-L2), This is a point of striking contrast with the spinal nerves there. In spite of this fact, why did our investigations fail to produce referred pain at the end of the extremities? Perhaps it was because our methods of stimulation were inadequate for this purpose.
It is well known that patients who are suffering from gastric ulcer, bronchial asthma, angina pectoris etc. often complain that they feel chilly, pricking, or that they perspire freely on the palms of the hands and the soles of the feet. This is possibly due to the continuous influence of the visceral sensory impulses on the autonomic nerves of the extremities. These phenomena, however, are somewhat different from the radiation of the present abdominal pain. These syndromes are the result of long time stimulation of viscerogenic impulses and thus do not always need a strong stimulus as radiation cases which always cause pain.
(author's abstract)
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