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British: Medical Journal
British: Medical Journal
British: Medical Journal
In January, 1932, while engaged in the study of the of these anatomical and physiological researches are
innervation of the pelvic viscera, it occurred to me that described in the following account, in which an attempt
some types of pelvic pain-particularly certain dysmenor- has been made, by correlating my researches with those
rhoeas, cystalgias, and pelvic neuralgias-were possibly already published, to provide a reasonably standard
the result of a neuro-vascular imbalance, or, at any rate, description of the presacral nerve in all its aspects.
under the control of the autonomic nervous system. I
had previously been particularly impressed by the brilliant ANATOMY
results of lumbar sympathectomy obtained by Telford and The presacral nerve is that portion of the abdominal
Stopford in painful neuro-vascular diseases of the extremi- sympathetic nervous system which lies anterior to the
ties, and suggested the possibility of similar relief for bodies of the fourth and fifth lumbar vertebrae, in the
pelvic pain by an equivalent operation. interval between the common iliac arteries. The term
The anatomical configuration of the nerve supply to the " presacral nerve " is a peculiarly unfortunate one, as
pelvic viscera appeared to render such a prccedure technic- the structure is usually a plexus, and is pre-lumbar in
ally easy, as the abdominal sympathetic fibres to these position throughout its course ; but the invention of this
organs are collected into a median accessible bundle. name by the anatomical authority Latarjet, and its subse-
immediately before entering the pelvis, as the presacral quent adoption elsewhere as a less cumbrous title than
nerve (superior hypogastric plexus). Cadaveric experi- the more legitimate one of " superior hypogastric plexus,"
ment prov'ed the truth of these facts, but a good deal make it necessary to follow precedent in its description.
of diffidence was naturally felt before recommending anl The nerve extends from a point a little above the level
operation whiclh involved entrance into the abdomen, and of the aortic bifurcation to the promontory of the sacrum,
which was based upon such purely th3oretical grounds. a distance of approximately 5 cm. It is formed above
Perusal of the recent literature, however, revealed that by the confluence of the intermesenteric nerves, long fine
a similar procedure had been carried out in France for para-aortic sympathetic trunks arising from the solar
some few years, under the title of " resection of the plexus and the adjacent lumbar ganglia. After passing
presacral nerve," an operation introduced by Cotte, pro- vertically downwards, a little to the left of the midline,
fessor of surgeriy at Lyons, in 1925. The results obtained the nerve terminates below by spreading out into the
by that author and by his colleagues were impressive, so structure which I have ventured to name the " middle
impressive that no hesitation was now felt in advising hypogastric plexus." This is an isosceles-shaped mass of
the operation for early performance. considerable size, from the lower angles of which emerge
Our first presacral sympathectomies were carried out in the bilateral inferior hypogastric plexuses, long narrow
March, 1932. The immediate results were excellent, and nerve bundles which run forwards and downwards along
it was felt that a definite field existed for the procedure, the pelvic wall to gain the pelvic ganglion, of which they
although many of the French statements appeared some- form the sympathetic root proper. The parasympathetic
what hyperenthusiastic. But these operative experiences supply to this ganglion is furnished by the nervi erigentes,
exhibited many obscure points of importance concerning and some additional (insignificant) sympathetic fibres also
the surgical anatomy of the field of operation, and before reach it from the sacral chain. As the pelvic viscera
proceeding further it was resolved to investigate more are supplied almost exclusively from the pelvic ganglion,
complet'ely the anatomy of the nerve itself and of its it will be seen that the presacral nerve contains practically
relations. the entire nerve supply to those organs, a fact which,
This completed, a series of seventeen patients, suffering allied to its surgical accessibility, makes the nerve th-
from a variety of conditions, were subjected to the opera- ideal site for interruptive procedures on the pelvic
tion during the subsequent twelve months. They were sympathetic.
mostly cases of Dr. W. R. Addis's, and fourteen were The immediate relations of the presacral nerve are of
operated upon by that surgeon, in ten of which I assisted. considerable importance. In front, the nerve lies in
The remaining three, by kind permission of Dr. Addis, contact with, though not attached to, the posterior parietal
were operated upon by me, in addition to three further peritoneum, through which it is occasionally visible.
cases similarly treated for other surgeons. Behind, it is separated from the last lumbar vertebrae
Each specimen of presacral nerve was examined both by the left common iliac vein above and the middle
macroscopically and microscopically, and the physiological sacral artery below. It is, however, effectively separated
effects of the operation upon each of the patients studied from these structures by being almost completely enclosed
both immediately and remotely afterwards. The results in a fairly tough bilaminar sheath formed by a condensa-
* A Hunterian Lecture delivered before the Royal College of tion of the subperitoneal areolar tissue. Although the
Surgeons of Fng!and on February 5th, 1934. nerve is somewhat adherent to this sheath the latter is
[3835]
2 JULY 7, 1934] THE PRESACRAL NERVE [THE BRITISH
MEDICAL JOURNAL
very easily dissectible fromi the structures in front and a variable (disputed) number of segments. The para-
behind, a fact which explains the ease with which the sympathetic extends from the fourth lumbar segment
whole nerve plexus may be separated at operation. The through the remaining portion of the cord.
mesosigmoid lies to the left of the nerve, but occasionally The evidence for a centre more cranially placed tends
it crosses the midline, in which case the nerve can only to become more dubious- with advancing research, so
be reached by dissection through its layers. -much so that some modern writers, including Dahl, deny
The exact tormn exhibited by the presacral nerve-a their existence completely, a view shared by the writer.
m-atter of paramount surgical importance-has been the The problem has been admirably reviewed by Cotte, who
subject of much controversy. Latarjet, Bergier, Morrison- points out that while Ferrier, Franck, Bechterew, and
Lacombe, and Roussel all consider that in the majority Meyer produced contraction of the bladder by cortical
of cases a clean-cut single true " presacral nerve " is stimulation, Dennig denies the existence of a specific
present, but Hovelacque, Kalberg, Chianello, Delmas, cortical vesical centre, while the presence of similar sub-
Cordier, Ferey, Jianu, Bernard, Laux, Learmonth, Segond, cortical centres in the thalamus (Mislavsky, Mosso, and
1-lartmann-Weinberg, and Elant all equally hold the Pellicani), or in the corpus striatum (Czylharz and
opposite view that the usual disposition is one of several Marburg), is still more problematical. Similarly, though
parallel nerves intercommunicating to form a plexus of Gall places the genital centre in the cerebellum, Goltz,
varying width. The solution of these divergent views Moebius, Kraft-Ebing, and Bechterew consider it present
would appear to lie in the varying standards of dissection in the cortex, while Muller and Dahl deny its cranial
adopted, allied to a lack of appreciation of the condensa- existence altogether. The problem, it will be seen,
tion which, in formalin-prepared cadavers, often coalesces remains more than obscure, but the recent views would
nerve fibres and fibrous tissue into an- apparently single appear to be more reasonable.
structure. Taking thesle fallacies into consideration it
seems certain that the so-called presacral " nerve " is far Course of the Nerve Fibres
more often a true plexus than a single nerve, a fact borne The sympathetic efferent fibres pass out in the anterior
out in my own observations. Thus in 45 (75 per cent.) root and then, via the white rami communicantes, to the
of my sixty dissections a plexus of some type was present, corresponding ganglion of the lateral sympathetic chain.
a single true nerve being found in only fifteen. Similarly, From here they pass either to the solar plexus or mesen-
only two of ten operative specimens showed the structure teric ganglia, from which they are relayed to the preo
of a single nerve. sacral nerve, or directly from the sympathetic chain to
HISTOLOGY reach the nerve or its parent trunks in their ganglionic
Specimens of the presacral nerve removed in fifteen roots. They then pass downwards through the middle
operations, and from ten cadavers, were examined histo- and inferior hypogastric plexuses, the pelvic plexus, and
logically, a variety of staining methods being employedI its nerves of distribution, to reach the particular pelvic
in each case. These included supravital and intravital viscus for which they are destined.
methylene-blues, modifications of the Golgi, Cajal, and The peripheral cell stations in these fibres lie, according
Bielschowsky techniques, and the usual cold contrast to generally accepted theory, in any of the large ganglia
methods, and all equally showed the ne-rve as consisting of the pathway, or in the -small ganglia lying alongside
esentially of several nerve bundles lying in a fibro-fatty the supplied viscera, and a considerable amount of dis-
cellular network. The number of nerve bundles present cussion has centred round the exact site adopted for these
varies widely in different specimens, according to the relays. But as we have shown above, the whole
size of the individual plexus, and each contains many abdominal sympathetic system contains thousands of
bundles of ganglion cells disposed amongst the nerve microganglia in its constituent fibres, and it seems un-
fibres. The sympat-hetic nerve fibres are myelinated and necessary even to attempt to postulate a few definite
non-myelinated in about equal proportion as a rule (Cotte positions of relay, when the cell stations may be situated
and Noel), but occasionally, as in some of my specimens, at any one of so many places.
there is considerable predominance of one or other type. The parasympathetic-sacral autonomic-fibres to the
They are enclosed in a- thick fibro-elastic sheath, and are pelvic viscera pass from the medio-ventral column of the
accompanied by tiny vasa nervorum. sacral cord through the anterior roots of the second, third,
The ganglion cells are collected at intervals in each and fourth sacral nerves. They leave these trunks to
pass, without the intervention of a lateral spinal ganglion,
ner'p bundle into microganglia, and correspond to the to the pelvic plexus, in the nervi erigentes (which for this
types described by Stohr and Cajal as characteristic of
the sympathetic nervous system-namely, astrocytes, reason have been taken as homologous with white rami
crown- cells, and glomerular cells. Each contains a well- communicantes). Their subsequent course corresponds to
marked nucleus and nucleolus, and is surrounded with a that described for the sympathetic fibres proper.
varying number of tiny " satellite " cells. The course of the afferent autonomic fibres from the
This arrangement is identical with the histological -pelvic viscera, and even their existence, are equally the
structure of the intermesenteric nerves, as described by subject of a good deal of highly theoretical dispute.
Leriche and Fontaine, a fact which, considering the con- Gaskell asserted that a centripetal sensory pathway was
tinuity of the presacral nerve with them, is not surprising. non-existent in the autonomic nervous system, visceral
Indeed, the whole abdominal sympathetic nervous system sensation being conveyed via the cerebro-spinal nerves,
may be regarded as a vast arrangement of microscopic but our post-operative studies have convinced us of the
ganglia joining very short relays of sympathetic fibres, truth of the teaching of thie modern French school to the
myelinated or non-myelinated in varying proportion cont-rary. These fibres probably pursue a si-milar course
according to level. to the efferent nerves, with the exception of a detour via
the posterior roots t-o gain the centre in the posterior root
Central Connexions of Presacral Nerve ganglion.
PHYSIOLOGY
The spinal centres for the efferent fibres of the
abdomino-pelvic sympathetic and parasympathetic systems As with the functions of the sympathetic system else-
lie- respectively in the intermedio-lateral and medio-ventral where, the functions of the presacral nerve may be -divided
columns at the base of the anterior horn. The former up as follows:
evxtends from the first dorsal to the second lumbar seg- (a) Motor. (c) Sensory. (e) Nutritional
ment inclusive, to be continued in the sacral region over (b) Vasomotor. (d) Glandular.
JULY 7, 1934] THE PRESACRAL NERVE I ME~DICAL
r THE BRITISH
JOURNAL
3
L MEDICAL JOURNAL d
It is, of course, impossible to divorce any one of these strictor. Leriche and Stricker showed that excitation of
functions from the others, but for the sake of clarity they the presacral nerves produced vaso-dilatation in the pelvic
will be consid?red separately, correlated with current viscera verified microscopically, but, on the other hand,
literature and the results of personal observation. Sweet and Thorpe found that lower abdominal sympathec-
tomy exercised no apparent influence upon the oestrous
The Motor Function cycle of rats. In short, some authors believe that the
Perusal of the literature written upon this subject sympathetic is vaso-constrictor to the pelvic viscera, and
reveals a bewildering variety of findings and opinions. the parasympathetic vaso-dilator, while the reverse opinion
Valentin, Heddaus, Scanzoni, Rohrig, Bartling, Korner, is held by others.
Frankenhauser, Cyon, von Basch, and Howden, on experi- Now one of the most striking sequelae of resection of
mental grounds, ascribed a motor function for the pelvic the presacral nerve in our cases has been the almost
organs to the lower abdominal sympathetic nerves, a view universal increase in the time and quantity of menstrua-
flatly contradicted by Beck and Killian, who asserted that tion. A period of two or three days has often been
they were inhibitory, while Kehrer, Reimann, Langley, and lengthened to one of seven or eight, while the menor-
Gaskell suggested that both functions were served by these rhagia has occasionally been. a source of considerable in-
nerves. It would appear that the precise part played by convenience. In addition, a striking post-operative result
the sympathetic in the motor supply of the pelvic organs in all cases was the appearance of a menstrual period
must remain doubtful, but a probable cause for the diver- twenty-four to thirty-six hours after operation. This
gence of views may be a variation in its action in different period, although possessing the characteristics of normal
animals. The question of prime importance is: Is the menstruation, had usually no relation to the normal
abdominal sympathetic nerve supply to the pelvis-that rhythm, which remained unchanged, the next period
is, the presacral nerve-motor or inhibitory? appearing at the usual- time. It would thus appear that
A case of particular interest in connexion with this the presacral nerve exercises a profound effect of a vaso-
question occurred in our series. A patient was carefully constrictor or vasotonic nature upon the blood vessels
observed during parturition, following resection of the of the pelvic viscera, a fact which explains the abundance
presacral nerve. She was an elderly primipara, aged 42 of the sympathetic nerve supply to the vessels of those
years, yet the labour was precipitate, a most unusual organs.
occurreInce in this type of patient. In addition, we have The Sensory Funct!cn
noticed as a striking post-operative sequel in all our cases A variety of authors have published a very considerable
that the bladder and rectum are emptied easily and fre- number of cases in which resection of the presacral nerve
quently in the few hours following operation and sub- has produced complete and lasting relief of pelvic pain,
sequently, an unusual (and most desirable) event in a sequel which we have repeatedly observed in our own
abdominal surgery. cases. The question remains: Has the sympathetic
There is nowadays a tendency to refuse to accept the system in general, and the presacral nerve in particular,
old theory of the action of the sympathetic as an inhibitor, any sensory function in the usually accepted sense of the
and of the nervi erigentes as excitor, of contraction of term? The experiments of Learmonth and of Leriche,
the pelvic organs, but the case cited above, and the post- who managed to elicit pain by traction on the central
operative sequelae mentioned, are a striking corroboration cut end of the presacral nerve in a patient and a dog
of that imiode of action. It must be admitted that the respectively, and the fact that both Frigyesi and Finsterer
case was an isolated one, and that the phenomenon is could perform pelvic operations under local anaesthesia of
very occasionally reproduced normally; but being quite the nerve, are each corroborative evidence of the existence
divorced from any influence by the subject herself, and of such a sensory function. Cotte, Lawen, Mixter, Kuntz,
so admissible as an uncontrolled experiment, it does pro- Aburel, and Crainicianu all support this view of the sym-
vide some support for the view of the presacral nerve as pathetic as a conductor of pain fibres, though the rnajority
an inhibitor of contraction. When the presacral nerve- of modern authorities, in the absence of any anatomical
the sympathetic supply-is resected the sacral para- proof, have been so far unable to accept it. But ther-
sympathetic system is allowed unchecked activity in per- is no doubt that sympathectomy does-though not in-
forming its function as a detrusor of the uterus, just as variably-relieve pain, and that permanently; and though
it is of the bladder and rectum. (It is interesting to note the hypotheses that have been advanced to explain this
that three patients, previously constipated, were com- are all, singly, somewhat unsatisfactory, each lies within
pletely cured of this disability after resection of the pre- the region of possibility. They are:
sacral nerve for other conditions.) 1. The sympathetic system contains specific sensory
It is possible, as was partly suggested by Bard, that fibres (Aburel).
the spasmodic cystalgias, dysmenorrhoeas, and rectalgias 2. The relief of pain is the result of vaso-dilatation, the
are due to irregular contraction, with spasm, of the subsequent increase in blood supply allowing of mnore
musculature of the appropriate organ, the result of efficient removal of metabolic products (Telford and
an upset of the normal sympathetic-parasympathetic
Stopford, Lewis).
3. The pain is vasomotor in origin, being an upset of the
equilibrium. The spasm would appear to be the result normal sympathetic-parasympathetic balance. Correction of
of overaction of the sympathetic inhibitory factor, this by removal of the offending constituent-the sym-
removal of which, by -resection of the presacral nerve, pathetic presacral nerve-cures the condition by restoring
equilibrium (Bard).
cures the condition by allowing the peristaltic action of 4. The sensory fibres in the svmpathetic nerves are really
the sacral parasympathetic supply to proceed un- cerebro-spinal in derivation (Mixter).
trammelled. This reasoning is, of course, highly The first theory exhibits too many unsatisfactory points
theoretical, but it does suggest a factor which, in view for complete acceptance. It is based almost entirely on
of our cases, cannot be ignored. theory, and is not verified anatomically. The second is
more satisfactory, but is even more theoretical, as the
The Vasomotor Funct.on immediate relief of pain following sympathectomy (which
Spielberg, von Basch and Hoffman, Rein, Langley would appear to support it) was not characteristic of our
and Anderson, and Crainicianu all stated, on experimental cases, in several of whom the first menstrual period was
grounds, that the hypogastric nerves were vaso-constrictor, still more painful than the preceding. The third is an
but Barrington holds that they are vaso-dilator, while old theory revivified, and, apart from its purely hypo-
Rohrig suggested that they were both dilator and con- thetical basis, leaves the question open as to why the
4 JULY 7, 19341 THE PRESACRAL NERVE r THE BRITISE
[MEDICAL JOURNAL
sympathetic constituent alone should be the cause of In several specimens changes indicative of a subacute
upset. The last is unverified anatemically. One is there- inflammatory reaction were present in the presacral nerve.
fore inclined' to conclude that the presacral nerve has no These changes were similar to those described by Cotte
specific sensory function per so, and that the relief of pain and Dechaume, and Jianu, and consisted in congestion
following its eradication is vaso-dilator in origin, the exact of the nerve, capillary thrombi, leucocytic nodules,
mode of action being unknown. oedema of the sheaths, and often a small round-celled
infiltration. The ganglion cells' themselves, however,
The Glandular Function showed the most profound changes. In many groups
some cells were complete, others showed absence of
Barrington has shown that the hypogastric nerves con- of nucleolus, the last being
nucleus, others absence accom-
trol the mucin secretion of the glands of Cowper and
Bartholin, and Cotte and others have cured extreme panied by an increase in the number of " satellite" cells
leucorrhoea by resection of the presacral nerve, a result and by thickening of the microganglion sheaths. In one
also obtained in two of our own cases. Gaskell states specimen the single presacral nerve present was found to
in his book that the nerve cells which supply secretory be permeated by squamous epithelium from a coincident
fibres to purely epidermal glands-for example, the sweat carcinoma of the cervix, in a similar manner to the
case reported by Ferey.
glands-all belong to the sympathetic system, and are
connected with the central nervous system by the It should be noted that several sections were taken
thoracico-lumbar outflow of connector nerves. At the almost serially to prove that the appearances described
were not due to the level of section. In many cases the
extremities of the body, where the entoderm and ectoderm
come together, the ectodermal and entodermal glands may changes were striking, and included loss of cell substance
become fused to form one gland, with the result that the and fragmentation of the Nissl bodies. But these changes
gland is supplied with secretory nerves both from the have been observed elsewhere in apparently normal sym-
sympathetic and from the external nervous systems. pathetic nerves, and before a standard of what may
Now several cases of pruritus have been reported cured be considered as basically normal is adopted one
by resection of the presacral nerve, and we ourselves have must hesitate to accept the appearances described as
observed similar results. There have, on the other hand, pathological, particularlly as they did not correspond
been failures, and it is tempting to ascribe the cure, on with the clinical symptoms in any definite manner. On
the one hand, to a glandular origin for pruritus, and the the other hand, importance is lent to these findings by
failure, on the other, to an embryological anomaly. It the fact that in only one out of forty-one specimens
must, of course, be admitted that the theory of direct of the lumbar sympathetic cord removed by them foi
sympathetic sensory supply to the skin itself is untenable neuro-vascular diseases of the lower extremity did Telford
as an explanation of these cases. I examined every case
and Stopford find any pathological changes.
submitted to presacral resection carefully for anaesthesia,
and in only one could find even a suggestion of change. SURGERY
The physiological basis upon which is founded the
The Nutrlt.onal Function surgery of the sympathetic system in general has been,
and still remains, more highly controversial and doubtful
Takahashi found degenerative changes in the testis
following excision of the hypogastric nerves, but Bacq in its fundamrntal asp2cts than almost any other operative
failed to confirm these findings. Cannon and his associates rationale, and from what has been gathered from the
have shown that no nutritional changes follow complete
preceding consideration of the physiology of the pre-
sacral nerve itself it will be appreciated that indications
sympathectomy in rats, yet Leriche cured a case of for its removal must necessarily rest upon a very insecure
kraurosis by sympathectomy. We ourselves have noticed
no change of a nu'tritional nature in our cases. The relief
foundation.
of kraurosis was probably vaso-dilator in origin, and it
Indications for Resection of Presacral Nerve
would appear that all similar cases have a similar source.
But the sympathetic supply to the skin glands is signi- Indeed, most of the physiology of the nerve has beeni
ficant; and although the skin changes in some vaso- studied post- rather than pre-operatively, the indications
motor disorders are probably vascular in origin, it is pos- being arrived at on purely theoretical grounds. As a
sible that the sympathetic does exercise a separate nutri- consequence, when resection of the presacral nerve was
tional function in the integument, although its presence first mooted by Cotte, these indications were somewhat
there does not appear indispensable. limited. With advancing experience and enthusiasm,
however, more and more diseases were subjected to the
procedure, with the result that it became used as a
Summary of Functions of Presacra! Nerve sort of universal panacea for a great variety of pelvic
The presacral nerve is motor and vaso-constrictor to th- conditions, thus repeating the very similar wave which
pelvic organs. In addition, it is glandulomotor, and followed the introduction by Leriche of that authority's
possibly nutritional. The relief of pain which follows earlier sympathetic operations (on some of which, it should
resection of the nerve is probably the result of the vaso- be stated, Cotte's operation is merely a slight advance-
motor rather than of any sensory function, but the ment).
absence of any definite sensory fibres in its substance At the present time, Continental opinion (with one or
is by no means certain. two exceptions) remains at the peak of enthusiasm. Our
own experience, however, based upon operative work and
PATHOLOGY combined with caution and close consideration of the
Present knowledge of the pathology of the sympathetic physiological facts and theories, has considerably re-
system is both sparse and theoretical, principally on stricted our ability to agree to all the indications sug-
account of the fact that so many variations occur in gested by the French authorities, and has limited our
apparently normal characteristics that the basis of indications to the following diseases:
normality remains extremely doubtful. We have, how-
1. Dysmenorrhoea.
ever, encountered changes which, even if later shown 2. Idiopathic pelvic neuralgia in both sexes.
to be within the bounds accepted as normal, are of a 3. Pelvic pain the result of inoperable carcinoma.
certain interest from the possibly pathological point of 4. Cystalgia.
view. 5. Rectalgia.
JULY l, 1 984] THE PRESACRAL NERVE rM 5'
We have, moreover, severely limited ourselves in the Our own cases show a cure rate of approximately 50 per
individual cases, using the procedure as a last resort- in cent., and I would suggest that this -figure represents the
practically all the patients subjected to it. Only those result which may be expected in the majority. It would
cases in which all the usual medicinal and minor operative appear to suggest that more care- than has hitherto been
procedures had been tried out and found insufficient were the custom should be employed in the selection of cases
treated by resection of the nerve, and then only after coII- for what is, after all, a majof operation, with all the in-
sideration of the possible presence of neurosis. As an conveniences and risks implied in that term. In suitable
additional and most frequent indication we have added cases the operation is often brilliantly successful, con-
the operation to other procadures decided upon beforehand verting a life of misery into one of at least tolerance,
as a preventive of the persistence of pain in cases of and there is no doubt that when the present wave of
pelvic disease in which pain has been a long-standing somewhat misguided enthusiasm has abated, resection of
symptom. the presacral nerve will take its deservedly secure place
Technique of the Operation in the select list of the permanently beneficial operations.
I have elsewhere described the technique of the opera-
tion of resection of the presacral nerve in considerable CONCLUSIONS
detail, and it is only necessary to mention here its more 1. The presacral nerve or superior hypogastric plexus
salient features. The abdomen is entered via a generous is never presacral, and rarely a single nerve.
paramrdian incision, and the bowel packed away from the 2. Histologically it is composed of sympathetic nerve
operative site. The sacral promontory is then identified fibres and microganglia.
and the level of the aortic bifurcation noted. A longi- 3. It is vaso-constrictor and motor to the pelvic viscera.
tudinal incision is made in the posterior parietal per te- Its pseudo--,ensnrr properties are probably vasomotor in
neum in the mid- foundation. It is
line, extending from also glandulomotor
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