The Collected Papers of Irvin M. Korr
Presented by the American Ame rican Academy of Osteopaty in honor of Dr. Korr's seventiet birthday Editor fr the Academy: Barbara Peterson
American Academy Academy of Osteopahy 2630 Airport Road Colorado Springs, Coorado 80910
Copyright 1979, American Acdemy of Osteopathy Published Published for the members of the American Academy of Osteopathy
Table of Contents
I. Introducoy papes
5 6 7 9 11 13
Eitors orewor Brbr Peterson Anowlegments Pree: Irin M. orr PhD. SD. Biogrphil notes n ppreition Ju Alter Ph.D. Sientii Sientii ontributions ontributions o I M. orr orr Mihel M. M. Ptterson Ph D. Cli nil ontributions ontributions o I.M orr: orr: Ewr G. Stiles D.. AA
II Primay reseach repots: Stuies o electromyogphy, sympathetic ervous system, eflexes an elate topics
18 Quntittie stuies o hroni ilittion in humn motoneuron pools (97) (with J .S enslow n A rems) 22 Dermtom utonomi tii in reltion to segmentl motor reex treshol (198) (with Mrtin J Golstein) 23 Sin resistne ptterns ssoite with iserl isese (199) 23 The utomti reoring o eletril eletril sin resistne ptterns on the humn trun (1951) (with Prie E. Thoms) 29 eltionship between swet gn tiit n eletril resistne o the sin (1957) (with Prie E Thoms) 33 Ptterns Ptterns o eletr eletril il sin resistne in mn ( 1958 ) (with Prie Prie E Thoms n Hrr M Wright) 1 A mobie instrument or reoring eletril eletril sin resistne ptterns ptterns o the humn trun (1958) (with Prie E Thoms n Hrr M Wright) 5 Lol n regionl ritions in utneous somotor tone o the humn trun (1960) (with HM Wright n P.E. Thoms) 5 Eets o experiment mosil insults on utneous ptterns o sm ptheti tiit in mn (1962) (with HM Wright n P.E Thoms) 66 Cutneous ptterns o smptheti tiit in linil bnormlities o the the musuoseletl sstem (196) (with Hrr M Wright n John A Che) 73 Neurl n spin omponents o isese: Progress in the pplition o "thermogrph (1965) (with H.M Wright) 75 Wht is mnipultie therp? (1978) 77 Sustine smpthiotoni s tor in isese (1978) III Aoal transport tropic uncions uncions o nerves nerves
92 Stuie Stuiess in neurotrophi mehnism mehnismss (1 966) (with (with P.N Wilinson n W. W. Chorno) 93 Axonl elier o neuroplsmi omponents to muse els (1967) (with PN Wilinson n FW Chorno) 96 The nture n bsis o the trophi untion o neres: utline o re serh progrm (1967) 99 Stuies in trophi mehnisms: Does Does hnging its nere hnge hnge musle? (1967) (with F.W Chorno W.V. Cole n PN Wilinson) 100 Continue stuies on the xonl trnsport o nere proteins to musle (1970) (with GSL Appetuer) 1 02 The timeourse o xonl trnsport o neuronl proteins to musle (1 97) (with Gusto SL Appeltuer) 17 Axonl elier o soule insoluble n eletrophoreti rtions o neuronl neuronl proteins proteins to musle ( 1975) (with Gusto S. L Appeltue Appeltuer) r) 1 1 2 Eletrophoreti Eletrophoreti hrteriztion hrteriztion o neuronl bsi proteins in seetl musle (1976) (with G Appeltuer) 1 1 3 Further eletrophoret eletrophoreti i stuies on proteins o neuronl neuronl origins in selet selet musle (1977) (with Gusto SL Appeltuer) 1 1 8 Axonl migrtion o some prtieboun proteins in the hpoglossl nere n their ilure to enter the stoglossus musle (978) (with Gusto Appletuer)
trptao of rsarh fdgs
120 The eural basis of the osteopathic lesio (1947) 128 The emergig cocept of the osteopathic lesio (1948) The three fudametal problems i osteopathic research (1951) 14 The cocept of facilitatio ad its origis origis ( 1955) 1 Cliical Cliical sigificace sigificace of theacilitate theacilitatedd state 1955 158 15 8 Osteopathic research: h what whither (1957) 169 What "osteopathy ad "the osteopathic cocept mea to me (1962) 170 The sympathetic ervous system as mediator betwee the somatic ad supportive process (1970) 75 Vulerability of the segmetal ervous system to somatic isults (1970) (1 970) 178 The segmetal ervous ystem as a mediator ad rgaizer of disease processes (1970) � The trophic fuctios of erves ad their mechaisms (1972) 188 The facilitated facilitated segmet: A factor i ijury to the body framework (1973) 1 Adrew Taylor Taylor Still Memorial Memorial Lecture: Research ad practie practie a cetury later (1974) 16 Neurochemical ad eurotrophic cosequeces of erve deformatio: Cliical implicatios implicatios i relatio relatio to spial maipulatio maipulatio ( 1975) 2 Propriocep Proprioceptors tors ad somatic dysfuctio dysfuctio ( 1975) The spial cord as orgaizer of disease processes Some prelimiary perspecties (1976) 2 14 The spial cord as orgaizer f disease processes: The peripheral autoomic erous system (1979 sopath prpls pra ad profsso
224 The somatic somatic approach approach to the disease process process (195 ( 1951) 1) 228 The fuctio of the osteopathic professio: professio: A matter for decisio ( 1959) A allegory: A forgotte episode i America trasportatio history (1961) 244 Osteopathy ad medical evolutio (1962) 254 Some thoughts o a osteopathic curriculum ( 1975)
Editr's frewd This is 1979 n this er Dr. rvin M. orr elebrtes his seventieth birth. t woul hve been es to in people to ontribute their wors to Fh or Dr. orr; his inluene n rienships re wie both insie n outsie the osteo pthi proession. However the pub litions oittee o the Aerin Ae o steopth hs one wiser thing t hs propose olleting Dr. orrs wiel sttere writings into single volue or use n stu b everone liiting the birth tributes to three short introu tor esss. Even the hoie o who shul write the birth esss oul hve been proble but gin the Ae ws ortunte. At Texs ollege o steopthi Meiine where Dr. orr is proessor o eil eu tion proet ws uner w to pro ue in o "tribute n inter prettion boolet in his honor. When the TM eitors her bout the Ae proet the griousl gree to erge their writings with ours. So the hr hoies were l re e As it ppers this is thi boo but it oul hve been thier. Dr. orr spes selepretingl bout how he hs "luttere up the liter ture n he lls the ts o reing soe o his erlier wors " n exerise in osteopthi rheolog. Never theless when the publitions o ittee isusse wht ight be let out the oun theselves prising the oler ppers s oen s the newer ones. In the en it ws Dr. orr hi sel who propose lopping o the irst 2 ites o his bibliogrph representing the wor one beore he oine the ult o irsville ollege o steopthi Meiine in 1 95 Severl other ites oul be elete beuse the uplite in soe nner teril lre in lue uner nother heing. Setions re inlue ro three publishe boos ll o whih re in print s o this te the reer ight be helpe in these instnes b loo ing t the ontext in whih the esss originll were set. Everthing else oes either ro perioil liter ture or unpublishe soures. The irst two ppers in new series uner the generl title o "The Spinl or s
rgnier o Disese Proesses pper in this volue the seon lost t the se tie s it is publishe in JAA It woul hve ben iel to hve the oplete series but the two o stn lone n he others re not et written Dr orrs literr wor is ver uh live n well. ne whole spet o Dr orrs personlit h to be oitte or sheer l o spe This is repre sente b writings he lls whise n the inlue suh sober topis nephrotrihosis el suiie n the iret onversion o plnt protein into nil protein. The ltter topi whih we re ssure is it onl or the Jal pl Rl evientl hs neurotrophi spets there is subtitle relting to the i plnttion n innervtion o n er o orn. ne suspets nowing Dr. orr tht one shoul not pursue he ehnis o this sienti proess too losel t lest in ixe o pn et us inste el with ore seri ous sientii tters. Ater e introutor pprs the teril ivies netl into prir reserh reports the interprettion o reserh inings n ppers on osteopthi prtie n the osteopthi pres sion. Ppers in eh tion r rrnge hronologill with the reserh reports ivie into two rts. The irst ontins stuies on eletroogrph the sptheti nervous sste relexes n relte topis. The seon inlues stuies on xonl trnsport n the trophi untions o nerve. Dr. orr ro his rliest ssoi tion with te proession h ten pins to interpret his stuies in linil ontext whih oubtless is one o the resons or his bro n lsting inluene in ptientoriente proession. In this onnetion Dr. orr hs provie or this boo n introution to his own writings pling the in ontext with his rr. It woul be superuous to s ore bout the here. Wht shoul be si however is tht the Ae oun it privilege to honor Dr. orr on the osion o his seventieth birth. The eitor is both proessionll n personll grteul to hi or the eort n ooperion tht e this volue possible. PTRN
Acknowledgments Particular thanks are due Dr Korr. for provii materials and com ments that proved invaluable in te coice and arrgement of materi as for this volume Appreciation also is expressed to Martha I Drew PhD, director of the American Academy of Osteop athy, and to Barbara J Wood, assstant to te director, who par ticipat heavily in the production of this book Members of te publications com mittee of the American Academy of Osteopathy who participated directy in the planing of this book included: Sara E Sutton, DO FAAO, chairman; Viola M rymann, DO FU John P Goodridge DO, FAAO; William L. Johnston, DO, FAAO David A Patriquin DO FAAO; and Donad Siehl, DO FAAO Special thanks go to those who contributed introductory essays and wose names appear in connection with them and to the co-authors and ublishers of materials included in this book Individual references at the end of each paper identify exact sources Following is a list of jour nals institutions and organizations whose materials have been included erein Acta Neurovegetativa American Association for the Ad vancement of Science (Science) American Osteopatic Association (JAOA, THE D.O The Forum oj Osteopathy Health Osteopathic Magazne) American Pysiological Society (The Amerin Joual oj Physolo Joual j Applied Phy il) Electroencephalography and Cnical Neurophysiolo ElsevierNorth Holland Biomedical Press pemental Neurology Federation of American Societies for Exrimental Biology (Federation ocdngs) Kirksville College of Osteopathic Medicine (Journal oj Osteopathy) Osteothc Anna Insight Pub lishing Company Plenum Publishing Corporation The Postgraduate Institute of Osteopathic Medicine and Surgery (The Physiological Bai j Osteo pthic Medicine) .•
6
ntrouctoy essays
Preface
further eaborated by our subsequet ivestigatios. However, o ivitatio from oe of the sessio chairme, I hesitaty preseted my summary ad specuatios at the aua covetio of the America Osteopathic Associatio i uy 147 The cordia respose of those preset moved me to coside makig my thoughts avaiable to a DOs who might fid somethig of iterest i them The paper was prepared for pubicatio ad submitted to
My "osteopathic career bega with my appoitmet to the Kirksvile facuty i ecember 145 At a a· tioa covetio of the America Osteopathic Associatio seve or eight years ater, I was itroduced to a delegate who, o recogizig my ame, said (I k with a smie), "Oh yes, youre the feow who keeps cutterig up our iterature The itter to which he referred has co tiued to accumuate i the quarter- Ju j Am O cetury that foowed, to the poit A, where it appeared i that it ow seems part of the osteo- ecember 147 pathic ladscape Though bow ad The respose was amazig, ad it kicked aroud, it does ot seem to get cotiued for years Practicig Os ost, oy more scattered I am deepy apparety foud i it a ratioizagratefu, therefore, to the America tio of their ciica observatios Academy of Osteopathy for uder- ad a plausibe expaatio of the takig to tidy up the mess ad to tie it ways i which the "osteopathic up i oe eat, disposable bude lesio was hazardous to oes ad especiay for thikig the job heath It seemed to reiforce their worth doig Specia appreciatio is covictios about the vaue of osteodue Barbara Peterso for wieldig pathic maipuatio As a matter of the editorial broom ad dustpa so fact, I am tod that the artice is sti skilfuy required or recommeded readig i How did a oO, a Ph i at least some coeges of osteopathic physioogy, come to fil the pages of medicie, a practice I am icied to the osteopathic jourals with so may view as a exercise i osteopathic words quite aside from those he archeoogy (much as it peases me) set to research jourals? (Ad ith this ecouragemet (I didt perhaps eve more perpexig, why seem to eed much) it became my were so may of them read?) I retro- practice, from time to time, to report spect, it seems that a patter became i pubicatios to the osteopathic set with my very first osteopathic professio o our research, sum publicatio The artice was marizig our objectives, our fidigs, pretetiousy ad aivey etited, our views o possibe ciica sig"T Neural Basis of the Osteopathic ificace, together with additioal Lesio, as though it were a fia questios for further exporatio ad statemet testig i the aboratory or i ciica That paper bega as a persoal ex practice These papers are grouped i ercise i verbaizig to my the Sectio IV, Iterpretatio of reexcitig ew iights that came out of search fidigs They have bee my readig of Sted esows earlier based o research reports previousy research reports i the Ju j or subsequety pubished i research Nuyy ad esewhere o jouras ad preseted at scietific segmetal motor refex thresholds, meetigs These, the "Primary reout of our frst joit research effort search reports are assembed i (reported i the Am Ju Sectios II ad III y i 147, actualy my first ith my growig grasp of the veture ito the field of europhysi- meaig of he osteopathic pricioogy) ad out of my begiig pes, thaks to my coeagues at the studies of segmeta variatios i coege ad the may frieds I was sympathetic activity i humas fdig i the professio, it bega to It was, origiay, oy my itet to become evidet to me that physio summarize for mysef my uder- ogical processes ad their disturstadig of the meaig ad possibe baces i the idividua huma coud impicatios of the cocept of chroic be fuy uderstood oy i the cosegmeta faciitatio This cocept text, ot oy of huma ife, but i had aready emerged from Steds earthe specific cotext of that persos ier studies ad was reiforced ad tota life ad his or her tota physica
ad sociocutural eviromet, pas ad preset The abstract geeraizatios usualy taught i the classroom, expressed i such terms as heat rea circuatio, digestive system etc were ideed abstractios, ad they o loger sufced As I came to uderstad more ad more that a physioogica processes were coditioed by the circumstaces of the idividua ife of which they were compoets, the sciece of physioogy bega, for me, to burst out of its traditioa boudaries i a directios My studies, outside of the aboratory took me ito the cotiguous areas of the behaviora scieces socia scieces, athropology epidemioogy comparative heath care systems ecoomics ad eve the arts I bega to discer ufortuate treds ad emergig critica eeds ad probems i America health which America medicie (icudig osteopathic medicie) was ot, geeray speakig, recogizig, cofrotig or preparig for This ed me to try to "teach the osteopathic professio its busiess by presumig to poit out what I regarded as historic opportuities for which its f phiosophy ad methods uiquey prepared it The 151 paper, "The somatic approach to the disease process, was perhaps the first of this gee ith succeedig papers, the toe became more urget, exhortative ad stridet, cumiatig i the period 1562 (the period of the Caiforia crisis), i poemic ("The fuctio of the osteopathic professio [151] ad "Osteopathy ad medica evolutio, [ 162) ad eve acerbic satire ("A Aegory, [161]) Foowig the Caiforia debace, I withdrew, defeated from this area, ad abadoed (for a whie) my selfappoited roe as poiter of directios ad shouter of "Excelsior Returig to the ivory tower, I tured to the competio of reports o earlier research with my ate coeagues, Price E Thomas ad Harry M right, ad the to ew areas of research o the trophic fuctios of erves with Pau N ikiso ad Gustavo Appetauer, both of whom are aso deceased I 173 came the ivitatio to retur to the "area through the aua AT Sti Memoria Lecture at the aua covetio of the AOA 7
in New Orleans. By this time, how ever, some maturing had taken pace and I had bome convinced that a quiet dispay of the evidence on a bed of swt reasoning was in order rather than racous efforts at persa sion I think the change of tone is evident in the lecture (though it disappointed many ho preferred my fevent evagelism) I had become convinaso, that any effots to influence dirtions of osteopathic deveopment woud best be exerted through the education of our doctors to-be This conviction is reflected in a short aticle on curriculm pub lish in 975 (and in my contined effors as professor of medica educa tion at the Tex Colege of Osteo pathic Medicine) This heterogeneos group of articles through which I soght, to put it briey to divert osteopathic practice, poicy and edu cation from the pursuit of disease to the pusuit of health, comprises Sec tion V Osteopathic principles practice and profession" This sec tion is reated to a personal statement of what the osteopathic concept means to me, written n 96 and pre viously unpublished, which appears on page 69. (Incidentaly, I continue to think that the osteopahic profes sion is sti passing p an historic opportunity to ful its roe as an urgently needed reform movement in American Micine) Impossibe to incude in this col ecion, except for excerpts in Section IIis the book The eurobioogic Mechanisms in Maniplative Thera py which I edited with the expert assistance of Mrs. Ethe Huntwork pbished in 97 by Plenm Pub ishing Corporation (and avaiabe through the American Academy of Osteopathy) That volume was the product of an international work shop, sponsored by Michigan State University Colege of Osteopathic Medicine during my tenre there as professor in the Department of Biomechanics, and funded by the ational Institte of eurologica and Commnicative Disorders and Sroke It was my priviege to chair the planning committee and the con ference itself From the viewpoint of the osteopathic profession perhaps its main achievement has been to estabish manipative therapy as a vaid and fertile area for fndamenta scientiic investigation
8
The period since 95 hasfor me, achievements both in teaching and in been a great adventure which stil research wod not have been pos contines. I shall always be grateul sible There seemed to be nothing to my friends, J. S Densowthen Blacky could not fixand no de professor of osteopathic techniqe vice he cold not design and construct to sove a technical problem and director of the Still Memoria Re search Trst, and Morris Thompson Gertrde Krueger my secretary then executive vic-president (and and coleague for more than years soon-tbe president) of the Kirksvie and administrative assistant, ibrari college, for having attracted me to an accontant grant-manager and that adventure, as I stood, ncertain friend to a of s in the congomerate at a post-war fork in the roadand nown as the Division of Physiologi ca Sciences and especiay the for the many yers of their spport and encouragement as my friends and Department of Physiologywhere she coeagues still continues her sied and oya service. There are nmerous others to A the techniciansstdent assis whom I am indebted for having made the ong adventure so rewarding: tants and Felows who joined s with Prince E. Thomas, DO and sch dedication and skis in or Harry M. Wright DO who e teaching and research programs their practices in 99 and 950 re Al the stdents who responded so magnificenty to the earning oppor spectiveyto join me in research and tunities I offered them, and to the in teaching, and whothrough their academic achievements, eventuy many others who had good reason to established themseves as profession resent my exacting standards, but ay quaified physioogists Trag who eventay fond it in their icaytheir careers were cut short by herts to forgive me It is their pro fessiona achievements that have death due to cancer Eiott Lee Hix Ph.D who in made my life as a teacher sch a joined the Department of rewarding one 953 Pharmacology (then under my ad Especiay noteworthy are two former stdents Raph Wilard ministration), who also soon found excitement in the new kinds of re DO.and ames R StookeyDO. who among others) achieved the ex search questions that came ot of alted state of Deanship, and nder osteopathic theory and practicend whom I was peased to serve, rst at who made fndamenta contribtions to the pathophysioogy of viscera KCOM and currenty at TOM. A the members of the osteopathic organs He remains a close friend profession who have read my articles The ate Pa Wikinson BA • with interest and who frtherhave whose skis in radioisotope tech noogy enabled us in 966-67 to taen the time to convey their com ments and criticisms and t share demonstrate for the first time the their insights and experience. Their deivery of nervece proteins to responses to my efforts and their con musce ces via the axons, as a possible mechanism in the trophic tributions to my osteopathic ed functions of nerves. cation are deepy appreciated The osteopathic physicians who Gstavo S. Appetaer MS through the yearsand at three col who came from Urugay in 967 to eges have given so generosy of join me in that researchand whose their skis and time to hep maintain sis made possibe antitative my heath and vigor through reguar anlysis of the dynamics of axonal mnipuative care S. Densowthe deivery of protein to msce and the demonstration of four wes of ate John A Chace George A delivery each carrying different aghinWiiam ohnston and proteins His promising career aso Marion E Coy I am convinced that was interrupted by prematre death their care has been a critica factor in my contined good heath Emil D Bacorbywho came to the Coege in 95 whose sperb Finaya the osteopathic editors skils and inventiveness in eectronics and their associates whothrough the meta-woring and virtuay al pages they provided so generosly met my need for sefexpression aspects of research-and-teaching IRVN M KORR, PH D SD instrumentation were of inestimabe vaue Without them many of or .
ntodctory essays
Biographcal notes and apreciation Irin M Korr Ph.D. began his associatio with osteopathic medicine in scientific research and through a long and distinguished career he has become known as a major cotributor to te modern scientific understanding of te professions distic tie cotribution to te field of medicine The impact of his work as bee felt in basic research areas and in cliical medicine But the impor tace of Dr Korrs career and his writigs goes beyod scientific reserch to embrace both teachin and philosophy. Both in the classroom ad in areas such as curriculum planning he as become reowed for his knowedge ad insigt into the special problems of osteopathic education. Furter he has established himself in writing ad at the lectern as one of te most articulate exponets of te profes sion the philosoper wo brings to the osteopathic cocept a blend of uderstadig wisdom and enthusiasm for his subject Dr Korr was graduated from the Uniersity of Pennsylania with a Baceor of rts degree i te biolog ical sciences i 30 ad he was awarded the Master of rts degree from that uiersity i 3 The winner of a fellowship i the biological scieces at Princeto Uiersity he spent three years in graduate study there and was granted te P. D. de gree in 35 additiona year at Princeto was deoted to a postdoc toral fellowsip wit special research in cellular physiology. I te fall of 36 Dr Korr joined the aculty of the Department of Physiology at the New York Unier sity Colege of Medicine In addition to teaching he continued is iestigations in the areas of cellular metabolism ad real physiology ad with members of te Department of Psychiatry conducted researc in the fied of isui coma Tese studies were supported by te merica Philosophic Society the Plt Foudatio the merican cademy of rts and Sceces ad Warer Istitute for Terapeutic Researc From to 5 Dr. Korr was egaed researc uder e as pices of te War Departmet ad te
Ofice of Scientific Research ad Deelopment His inestigatios in aiation medicine wound ballistics and climatic physiology during this period were conducted at Columbia Uiersity Colege of Pysicians and Surgeons and at Priceton Uniersity lso during this time he was appointed senior pysiologist at the Fort Monmouth Signal Corps where e directed the Metabolic and Bio chemical Laboratory of te Climatic Research Unit. Dr. Korr joied memers of the osteopathic profession in December 5 when he accepted an appoint ment to the faculty of te Kirksille College of Osteopathic Medicine The appointment was for oe year and i his ow words Dr. Korr fully expected to return to uiersity teacing after the year. One year lengtened into thirty "One thing led to aother e as said "and I just could't leae. Im glad I stayed I wouldt hae missed it for the world. Durig tose tirty years Dr Korr sered as teacer departmental and diisional admiistrator research iestigator adisor and counselor to students interns residents faculty and staff. I 5 e was named pro fessor and chairman of the Department of Physiology. From to 6 he also sered as chairman of the Diisio of Physiological Scieces and in 6 he wa amed Distiguised Professor of Physiology. From 6 to 5 he sered as di rector of the program i eurobiology. In 5 Dr. Korr ended his tirtyyear association with the Kirksille college to accept a longstanding iitation to join the faculty of Michiga State Uniersity College of Osteopatic Medicine as professor of bio mecanics. For the next two years is energies were mainly directed toward the planning of an inteational research workshop on Neuro biologic Mecanisms i Manipulatie Therapy which was held in October The proceedings of this work shop edited and wit a preface by Dr. Korr were publised by Pleum Pubishing Corporatio in I te fall of lured by the opportunity to participate i the deelopment of a new colege Dr. Korr eft Michigan to join the faculty of North Texas State Uniersity Health
Sciencs Center/Txas College of Os teopathic Mdicin. In addition to a chance to work with a collg which he dscribes as still experimental and still willing to mak mistakes a learn from them, the appointment as professor of mdical education at NTSU/TCOM offred Dr Korr an opportunity to be surrounded by former students Some foty of his former students and associates serv on th faculty and administration of the Txas collge Dr Korr is a membr of the Amei can Physiological Society, the Society for Experimental Biology and Medi cin, th American Association of University Profssors, Sigma Xi, th Amrican Institute of iological Sci ncs, th Society of Nurosciences, and th Amrican Society for Neuro chemistry He is a Fellow in the American Association for the Ad vancemnt of Science, a Lif Member in th Harvey Society, an Honorary Life Membr of the American Acad my of Osteopathy and an Honor ar Membr of Psi Sigma Alpha and Sigma Sigma Phi, honoray scholas tic fratrnitis H is listd in American Men 0/ Science and World Who's Who in Scien and is th recipint of an honorary Doctor of Science dgree and a Living Endowment award from the Kirksville Colleg of Ostopathic Medicin Th fact that his most rcent ap pointmnt is in th ld of medical ucation rather than basic science rsearch is signicant of his rputa tion as a tacher Dr Korr is noted for his perception of th interaction betwen student and teacher and for a recognition of the burden of responsi bility on faculty. Former studnts cite his commitment to students and his ability to dne and dscrib clearly th holistc ostopathic concept in tems of modrn scientific knowl dg In published writings on duca tion, Dr. Korr mphasizes his com mitnt to maintaining the osteo pathic principle and ida by strssing th importance of integrating the holistic concept into all aras of teaching. The same nthusiasm for th osteo pathic concpt that chaacterizes his approach to teaching is evident in Dr Korr's extensive career as a lecturr H has spoken before such scintific socitis as th American Physio logical Society and the Socity for 10
Neuroscience, before a majority of the ostopathic divisional societies, and at seminars at various universities across the county Lectur invita ions have taken him twic to En gland, whre he conducted postgrad uate courses at the British School of Osteopath, he spoke at the Lincoln Institute of Halth Sciencs in Melbourne, In 1948 and again in 1959, he was th kynot speaker at the Annual Con vention and Scientific Seminar of the Amrican Osteopathic Association In 1967 he was askd to give the Scott Memorial Lecture at the Kirksvill Colleg of Osteopathic Medicine, and in 1973 he was honored by being ask- d to deliver the Andrew Taylor Still Memorial Lecture at th Annual Con vention of the American Osteopathic Association In 975, he presented the Louisa Burns Memorial Lcture at th 19th Annual Research Con ference of the American Osteopathic Association Dr. Korr's publishd writings in clude nealy 10 articles in scintic journals and abroad and they range from reports of rsearc to ssays on the philosophy of medicin Unknown to some, his writing as ranched out to include such philo sophical piecs as an allegory which compares osteopathic medicine to a railroad transportation system is short piece, "What Osteopathy and The Osteopathic Concept Man o Me has ecome a classic With the publication of this collec tion of r Korrs works, not only will his scientific research be readily availabl to the osteopathic profs sion and th scientific community, but equally th wit and wisdom of his ducational and philosophical writ ings on mdicine will b easy accessi ble to the many who are his friends colleagues and formr students JUY TER, PD
Introuctory essays
Scentfc cntrbutns f I.M. Krr Th voltion of any disciplin d pnds pon oth th acclation of knowld and th intrprtation of that knowld within th frawork of th disciplin. Withot ths two lnts providin ipts for oth rowth and rdnition of its strctr, an ara of ndavor soon cos osolt. Mdical history is rplt with apls of schools of thoht which hav passd fro istnc d to stanation of thoht, ladin to noncoptitivnss with or dynaic and rowin aras Th works of IM orr rprintd in this ook rprsnt fforts ovr th span of alost yars oth to acclat knowld and to intrprt it in th contt of ostopathic thoht In so doin, orr has also invitaly altrd th vry frawork of that thoht Th aont and ffct of ths altrations can nvr asrd accratly, althoh thir rslts will flt for th forsal ftr In this rif ovrviw and introdction I wold lik to pt orr's asic writins into historical contt, thn provid so valation of th data and intrprtations in liht of crrnt rsarch and thory This task is at onc hlin and ncssarily ipos sil to coplt hlin cas orr is first a prsonal ntor and scond a colla and ipossil to coplt cas h is still activ in oth athrin data and providin in trprtations Howvr, it is hopd that th prspctivs will hlpfl i orr rst joind th faclty at th irksvill Coll of Ostopathy and rry in 94, havin alrady stalishd hislf as a wllknown scholar in varios aras of physioloy t that ti, J Dnslows work on lctroyoraphic corrlats of palpatory findins and th ostopathic lsion was wll ndr way. Fascinatd y oth th os topathic thory of strctrfnc tion rlationships and intration of fnction, and y th pionrin work in Dnslows laoratory, orr an an intrst which has asord ch of his ssnt carr th rlation ships twn viscral and skltal coponnts of th ody
Collaoratin closly with Dnslow, orr offrd intrprtations of th data in acclatd. Th r sarch rop was soon pandd with th addition of ric Thoas, D.O, in 949, Harry M Wriht, D.O., in 90, and lliott . Hi, h .D, in 9 This rop coprisd th ncls of rsarch prsonnl which raind activ for any yars, as th paprs rprintd hr show. Othrs wr also ssntial to th rsarch, incldin il lack ory or lacki as h is still affc tionatly known to hndrds of stdnts and faclty, whos skill in ipnt dsin and constrction nald th rsarch to contin, as wll as th Chornocks, l, Chac and any othrs Iportant in this prspctiv is th fact that orr was havily involvd in nticin ost of this innovativ and ddicatd rop to irksvill drin th forativ stas of odrn ostopathic rsarch and thory ildin With th passin of yars, this rop ad any contritions to crrnt ostopathic hoht, and as th paprs prsntd hr tstify, orrs ladrship was vidnt and prvasiv Th rsarch thrst of th ro p lo st o nt in th id960s, and orr trnd to what was to his ajor rsarch contri tion to odrn nrophysioloy invstiations of th chaniss ndrlyin trophic fnctions of nrvs. Gstavo ppltar joind orr in 967 for this ajor rsarch ndavor In 974, orr l irks vill for th Michian tat Coll of Ostopathic Mdi cin and at th sa ti lft activ laoratory rsarch H has sinc n involvd in rdfin in so of his arlir intrprtations and in prsin th iplications of on of his ajor intrsts, th rol of th atonoic nrvos syst in total physioloical fnction This activity has contind with his rcnt ov to th Tas Coll of Ostopathic Mdicin Th dirction and wiht of orrs contritions to ostopathic thory and rsarch wr anifst soon aftr his arrival at irksvill Two paprs in 947, on with Dnsow and rs, wr oth rinal contritions sttin th sta for th nt yars o f work Th first papr contind Dnslows classic rsarch on lc
troyoraphic corrlats of palpa tory findins and tndd th rsts to provid clar dfinitions of th charactristics of anoral sktal scl activity which was otn fond in aras of ostopathic lsion Thr wr also spclations aot possil cass and aintainin in flncs for th ojctivly osrvd anoral activity. Th scond papr, Th nral asis of th ostopathic lsion, is on of th ost iportant of orrs works in th profssion Hr, h pt forth th idas of t nroloica lns and th facilitatd snt. This ajor thory of rional citatin of th spinal cord srvin as an anoral ara of ovractivity in drivn y oth trnal and intal sorcs of stilation and focsin this activity into anoral pattrns of skltal and viscral activity, was a concptal rakthroh. Rsarch in any aras of cntral nrvos syst activity today is rportin chaniss which cold srv as activatin and aintainin forcs for h ffcts osrvd and spclatd on in ths arly paprs It is now vi dnt that localid hypractivity in th spinal cord ay a priitiv for of pattrn larnin in th spinal rfl arcs It is perhaps nfortnat that th tr facilitatd snt was sd, as it iplid a circ scrid ara of anoral activity associatd with vrtral strctr, an intrprtation not strictly intndd in th oriinal forlations. Fro ths first paprs fowd r sarch and thoris ovr th nt 7 yars, fro 948 throh 96 Th ajor ipact o f this work was th plicit donstration, throh varios ans of th istnc of anora activity pattrns within th ato noic nrvos syst in apparntly noral as wll as disasd hans, and th corrlation of so anoral atonoic pattrns with sclo skltal anoralitis Throhot this priod orr wrot on th intractions which to hi wr vidnt twn th atonoic and skltal portions of th nrvos syst, th iplications of anoral atonoic activity for halth and disas, and th lon tr ffcts of ovractiva tion of any portion of th nrvos syst on innrvatd strctrs. Un fortnatly th concpt of clos in traction twn skltal and ato
noic nerous systes was not gener ally accepted in neurophysiology and certainly not in edicine and is only now beginning to be recognized. Thus while the concept of spinal facilitation was eident in the studies he did and superised the basic neurophysiological data show ing the actual existence of reflex pathways subsering Korr's argu ents was lacking. More recently work in arious laboratories (see e.g. Sato) is deonstrating the neural paths through which the interactions seen by Korr clinically and experi entally between skeletal and isceral structures are ediated. It should be noted that soe of Hixs work (e.g.) deonstrated in anials ery tight skeletalautonoic interactions uch earlier Howeer while eidence for the interactions long stressed by Korr and his colleagues is ounting it is stll too soon to see a general accep tance by either the edical or scien tific counity of the widespread iportance of such interactions for health and disease. arly in the 60s the research ac tiity of the original group Korr had reruited began to diinish and Korr gan to actiely follow his long standing interest in the question of secial effects of neres on innerated organs. Long standing in the feld of neurophsiolog was the belief that the onl effect of neres on their tar get organs was the release of trans itter substanc to excite the organ to actiity Howeer uch eidence such as the coplete degeneration of uscle following deneration as op posed to the atrophy of disuse if only nere ipulse trac was interrupted argues for soe other trophic ef ft or sustaining inuence of neres upon their target organs Using specially deeloped techniques nd procedures Korr found strong eidence for the deliery of protein substances transsnaptically fro the hyoglossal nere to tongue uscle bers This work published in Scien in 67 was the first eidence that neres continuously proide substances other than transitters to the organs they innerate. While practialy heretical the notion of transsynaptic protein transfer opened new istas of thought about neural regulation of physiologic process and of disease echaniss In seeral papers since Korr and ppeltauer 12
proided other data on the that work hae arkedly inuenced phenoenon and began characteriza osteopathic thought and are rich in tion of the proteins inoled p aterial for further work as well as peltauers recent untiely death left ripe for reealuation in the light of the research incoplete Howeer new fndings and interpretations of tere now exists a growing body of physiologic process. The work on eidence not onl for the passage of trophic function is only beginning to proteins fro nere to innerated be recognized and will stand as classic organ but also in the reerse direc in both concept and iportance. tion (e.g.). Inestigators in other Whether the bulk of his earlier work laboratories are close to characteriz reains acceptable as theory or ex ing soe of the actual proteins which planation after reexaination is howeer not the iportant point. Of are passed to uscle by its nere sup paraount iportance is that Korr pl (e.g.4) . While the studies and theoretical has proided the profession and the scientifc counity with a basis for arguents which led to Korrs fnd discussion and a foru for continued ing of transsynaptic protein transport are only now beginning to be ac interpretation of the tenets of os cepted this finding is certainly the teopathic philosophy. To continue to ost draatic and iportant of his reexaine and build upon what he has proided is the only fitting and career. The iplications of such slow twway counication between the proper ethod of utilizing this rich nerous syste and innerated or legacy. gans are both ast and see hard to oerestiate literally opening the frs 1 Sato A., The somatosympathetic reexe: Their way for a reolution in thought about physiolocal and clinical significance In Th neural control and feedback systes Rsrch Stat oj Spinl Manipulativ Mic. of physiological process. It is still not Goldstein, M (Ed) National Institutes of Communi known whether the transsynaptic pro cative Disorders and Stroke Monograph IS, 163-12 1975 tein deliery is a general phenoenon 2 Hix EL Reex communition between skin in the body or what all the effects and kidney a inuenced by an active vierrenal are but certainly the pioneering work reex. Fdtion Peings, 8 69 1959 done b Korr in the area will be rec 3 Thnen H Schwab M. and Barde Y-A ognized as leading the wa to one of Transfer of informaion from efftor orns to inne vating nurons by retrogade onal transport of the great adances in our knowl acromoleculs In Th Nubiologc Mnms edge of physiological control. in Manulativ Thp) Korr .M. (Ed.) Plenum; Oer the past seeral years since he New York 311332 197 has left actie laboratory research 4 Makelonis GJ and Oh TH A protein fac ion rom riphea nerve haing neurotrophic ef Korr has been forulating concepts fect on skeeta musl cells in culture Eximntal of the function and control of the Nbiolo 8 2529 197 autonoic nerous syste. His re S. Korr M. Sustained sympatheticotonia as a fac· cent paper "Sustained Sypathico tor in di. In T Nurobiologic Mn in tonia as a Factor in isease l which Manipulativ Tpy Korr 10M. (Ed.) Plenum apeared in 78 is an attept to in ew York 2292 197 M M. P P.. tegrate a ast aount of data about the effects of the autonoic nerous syste on total physiological func tion. This work together with the proprioceptie theories he has re cently propounded in an attept to explain soe of the effects of anip ulatie therapy characterizes Korrs ongoing interpretation of data within the fraework of osteopathy The perspecties and ealuations gien here indicate the breadth of Korrs efforts Viewed fro the an tage point of todays science it is a parent that uch of his data up to the idl60s has yet to be critically ealuated and replicated but stan as a guide for future research The inter pretations and theories flowing fro Introductory essays
Clnical contrbuions of IM Korr
Whn on conplas h ipac M. Korr has had on osopahic hinkin in h clinical ral on s aazd and raliz how any skills and alns wr rird. To apprcia his clinical conriion w s hav so apprciaion of h an. rin h arly 1940s r. Korr was ncorad o oin h rsarch rop a Kirksvill Coll of Osopahy and rry as i d vlop ndr h idanc of J . nslow .O. n la 944 afr a roisin carr in h aca eic arna and in iliary rsarch drin World War r. Korr was aain approachd y r. nslow and y Morris Thopson hn prsidn of h Kirksvill coll. On h n coran of officials of h Rockfllr Fondaion r. Korr considrd h challn and dcidd o oin h Kirksvill rop. n a annr consisn wih his rpaion as a aliy scinis wih an ninhii ind r. Korr ddi cad hislf o a prsi of nro physioloy and an allo ffor o assis h vlopin rsarch pro ra a Kirksvill. n 947 r. Korr was askd o adrss h achin rop of os opahic principls dianosis and hrapics a h O convnion in Chicao. His opic was h nral asis of h osopahic lsion and his prpos was o "ap a characrizaion of h osopahic lsion in rs of asic nral ha niss. Ths h sard a procss h conind hroho his carr ha of ryin o ak clinical applicaions for h profssion in rlaion o wha h was larnin in his rsarch ndavors s a rsl of ha prsnaion h profssion sard o conpla h concps of affrn oardn of h cnral nrvos sys faciliaion and h rol ha h crral cor posral iliri cnrs lar cnrs canos rcpors and ohrs can hav on h dvlopn and ainnanc of a hyprir rial sa of h cnral nrvos sys. r. Korr spclad a ha i ao h rol h faciliad sa cold hav no only on s
nally rlad orans also on h aonoic nrvos sys Ths h concp of h nroloical lns an o discssd and apprciad y h profssion. Th rol which h propriocpors ih play in h dvlopn of h faciliad rion was also poslad a ha arly sa of his carr. n ha 947 lcr Korr also warnd ha "h ariclar ran n or h osopahic lsion canno concivd as h a of disas; rahr i is on of any facors silanosly oprain. H wn on o dscri h phnonon as "a snsiizin facor a prdisposin facor a localizin facor a channlizin facor. . . . To ra only h srcral sorc of oardn is only o halfra and o nlc a os iporan par of h lsion chanis an o ak h lsion o of con. This dos no an of cors ha vry os opahic physician shold co a psychiaris h crainly s ak ino considraion h ho facors nvironnal facors fai ly rlaions oional adsns nsions c. Ths a ha arly da oh h prvniv and holisic po nials wr nvisiond. yar lar Korr prss o anohr rop his convicion ha "Th aainns of h osopahic profssion hav n possil only cas h profssion is fondd pon h solid rock of asic rh. n ha sa spch h also said "Whhr and how h pro fssion s [is] challn will drin h fr of h os opahic profssion h srvival of h osopahic concp; ha ss drind. Good ias nvr di; sociy vnally aks placs of honor for h. rin h yars 948 o 90 h Kirksvill rop invsia h ipac which faciliaion has on h aonoic nrvos sys and on orans innrvad and affcd y h aras of faciliaion. n 9 Korr wro "W hav co o rconiz ha h osopahic lsion as a phnonon of cnral faciliaion is a os iporan prdisposin local izin and proailiyincrasin facor in disas. Th n yar h dscrid os opahy as "no rly a for of hrapy rahr a road philoso 3
phy, a guide fo thinking and ating in elation to questions of health and disease. He ontinued, Fom the diagnosti viewpoint the somati omponent has geat stategi signifiane beause it makes possible the detetion and evauation of H disease poess fa in advane of the emegene of symptoms Thus in a few shot yeas, the pofession had gained a dynami spokesman who had a deep undestanding and appeiation of osteopathi onepts and a vision of the pofession's potentia t this time in his aee, Ko undestood that we have the potential to eognize, by skied osteopathi evaluation, the oss of health whih ous fa ealie than ealy disease detetion One must emembe that as the politial omponent of the pofession was tying to pove to soiety that we wee like M.D.s, Ko's was a voie ying in the wildeness and enouaging the pofession to ealize its potential and not stop at the level of allopathi aeptane and ae. t the 56 O onvention, Ko alled fo a seious eseah effot by the pofession, and said though the ollaboation of osteopathi physiians and sientists, the piniples whih guide osteopathi patie must be tansfomed into a body of woking hypotheses to guide osteopathi eseah Thus again we see a desie to develop a inialy signifiant osteopathi eseah pogam In one of the yeas immediaely peeding the MDD.O. mege in Califonia, Ko was the keynote speake at the O onvention, and he took the pofession to task He haged the pofession with the attitude that appoval has beome an end in itself, that being is moe impotant than beoming The pofession's funtion was envisioned by Ko a the ontinual examination and eexamination of all the issues and eements that detemine you obigations to soiety and the paths to thei fulfillment. He went on to say in that 5 addess, Osteopathi manipulation] is not ust anothe fom of theapy; it is a whole stategy, a whole appoah in itsef It is not meely a teatment of esions' in effet, it is the putting of infuenes into the whole man though the aessible tissues of the body, inluenes 14
whih deflet his life poesses to moe favoable paths, and whih hep put the man in bette ommand of his situation, whateve it is, whateve it may beome, whateve his illness, and whateve its etiology This noniniian gasped the ole osteopathi ae ould play in enabling patients to ealize thei health potentia His depth of undestanding of osteopathi onepts and the pofession's politia ations set the stage fo Ko to wite his mastepiee entitled n legoy It is a piee of liteatue whih should be seiously studied and ontemplated by the pofession. Its message is as elevant today as when witten in 6 in the midst of the Califonia mege. It was at this time when I fist met Ko as one of my teahes He taght by stessing piniples and onepts into whih one oud oganize the vaious assoiated fats s a student, I devoted muh of my fee time to leaning funtiona tehnique appoahes unde the guidane of Geoge ndew aughlin, DO On numeous oasions I obseved D aughlin teating D. Ko Those sessions gave me an appeiation of why Ko had suh an undestanding of osteopathi thinking Duing his teatments, Ko would be asking questions suh as, What ae you doing? What ae you papating? What do you think you ae aompishing? How do you think it woks? Ko was tying to get inside the DO.s mind to undestand his linial thought poesses and what was being peeived by the skilled palpatoy hand I have obseved the same poess on numeous oasions duing the ast eighteen yeas and that same inquiing mind systematialy evaluating the yeas of osteopathi expeiene of Bowes, Johnston, Buzze, Wison, Mithell, and othes. He funtioned in the same inquiing manne with his othe olleagues Ko ontinued to halenge the pofession with its unique potentia and pedited that mediine would ontinue to evolve towad hoisti thinking and away fom isis ae whih has been so ineffetive in impoving the health potential of the patients with honi degeneative diseases In his addess to a 6 onvention goup entited Osteopathy and Media Evolution, Ko
•
stated the osteopathi pofession is stil, in my opinion, the logia instument fo atayzing the tansition to the next highe stage, and fo offiiating at the passing of the obsoesent system He went on to say: I am onvined fom my many yeas of lose obsevation and some familiaity with the biologi mehanisms though whih the favoable influenes of manipative theapy ae mediated, that this system of theapy is a monumental ontibution to human health and welfae whih is, nevetheess, stil in its infany One must emembe that duing this same peiod, osteopathi shools wee putting less and less emphasis on osteopathi taining, and moe and moe emphasis on allopathi type taining, and osteopathi management was beoming ony an exta modality This ealization pompted Ko to say The pofession wil have to take a seahing look at the pemises whih have pemitted the entifugal migation of manipulative theapy fom the key position in a total stategy of mediine towad the paliative, aduntive, optional peiphey of linia patie He ontinued soiety now awaits has long awaited the vision and eadeship that wil guide it to a bette system of mediine, one whose stategy wil make bette use of the poduts of siene in sevie to heath He said of the osteopathi pofession, beause of its founding pupose, its histoy expeiene, insights, and skils, it] is qualified to undetake to povide that vision and leadeship Six yeas of speaking in osteopathi hospitals thoughout ou pofession has aowed me many oppotunities to addess laymen sitting on hospita boads and membes of the insuane industy I an assue you that yeas ate, the publi is stil looking fo that vision and the leadeship Ko had envisioned The same people ae now also ealizing ou potential as hospitas deeop funtioning sevies of osteopathi mediine Out of total fustation ove the pofessions appaent desie to foow the alopathi tend, Ko etuned to his laboatoy fo appoximatey ten yeas Duing that peiod, Ko and his assoiates made mao ontibutions to neuophysiologial unde Intodutoy essays
adg e aea eup axal w T dey a emedu mpae, paulaly e epa pe A dg ped m 96 973, K aed d a epuaza w ae ud e ee gae epa pae K bega empaze w ma uque eaue ea eu yem, b wud e uale wak, ak, play g e pem gey, e, wu a muukelea y em ay u e demad ad we e ea eu yem Teee, e eu omuukelea yem epee e pay ma ey e ad eae u expe u uma aae ad uqe peale ex, e ea ea epee e eday maey e w mu eae deeae e u adg e demad e dy pyal, emal mea, ad pual ae, ad w e ae ae expeed ad aed y e pmay maey le Tu e ' ea mu ay age ad adap e ua ae de maa e ea me by uzg e a mea meam Oe a e appeae w ma dy aue deeaed eey e muulkeeal yem ad be quey eae e eegy ad mea demad ad eque adapa ake pae al ga yem e bdy Caly epuaza um mpae A a exam pe, umm pae w C O expeee maked ympma mpeme, e w ak ad we exemy dy ae eaed epaay ad e eegy demad eday ga dyu ae weed uequey lwe e a demad e mpmed ep ay yem Al e 960, K aed empazg e uquee e ympae eu yem a e e aum mpe ea g e mukeea yem e y mpe m e mul eea yem e aum eu yem eee ae a e ympae eu yem Tu e ympae yem pde a ae
ue e apppae eedbak ma m e pmay maey u ad aw e ea apppaey adap m mebymme ad ely ue ea u e ea meu maaed e aa e ympae yem a eu edaly ma dyu, K gae e pe a udeadg w mapulae eapy ud ae e aum eu yem ad e eaed ea ug ped aee, K wa empazg e quee e ympae eu yem am ay ad w ma dyu mg play a e aeg ma ad pma aea upply e elaed ea wa dug e ae 1960 a k e e pae e T Wl, O, w wa a gea ad me K ad wk W, ke K, empazed e mpae deepg a epa ap· pa e pae w a ea pbem He away empaed e e a ma dyu mg be payg a, p lw, aea upply e eded ga, ad e ad ym pa eu Fed Mel , O, a eld K ad wk g egad ke K, e a empazed e e epa maageme d pay ag e pae ea ze eal pea Cay, Mel deed e ply aa, p w, aea, eu ad ympa deageme eday ma dyu, ad w ea played a e e pa e' al pem Weea W eed a epa appa e au deae ad expeed d a pe le pae ea pe deae, Me appa wa aaezed by eqe ae me " d' ea pa ule, g bd pee e, bu pepe w a ppe He beeed a e e ma mpe wa aeaed, e pae ud a eaze ea pea Tu, eea pae mg ae e ame al dag, ay pep ue deae, e u Me expeed d a uque pae ma dyu ea pae T bak up bee e equey
qued K aeme e ee a may ae mla deae pblem bu we ea ae a e ame a dea by dee ue; u ea a a uque pe ma dyu B W ad Mel aed y maagg e pae epaaly ad e ulzed mede ad ugey a daed maage e g ad ympm e deae pe B W ad Mel ad b wee la ga e epa pe, eled ealy e wk K e lal epualza a ey paed ad ebazed wa ey wee dg b pae ad ude wa ude Mell' gdae a ega appeae K' u aegg e pe k pmaly a e ad mea apable ae a keep e ae ued up deae pe Te maea le w we ee day ae eay e eea e ad e deae pee Tu pae w a e dag aue apped a ea ea uqey ad deey laly Oe e eaze epa ae ealy deed a e mpe, we e meda ad uga appae ae deed a e deae pe Vewed way epa maageme a be appeaed a a udaa m ae all pae we apppaely ped e pealy daged ma dyu Meda ad uga ae a e be uzed e e daa ae a bee pded e epa mede ug e uy ae daly demag e eeee mba, bu y epee a begg alwg u pe ealze e pea K dued eale wg K eemeged le a a e yg e wdee ad exe e pe we 1 973 e gae e Adew Tay S Mema ee He ad " e g ga eg e mpeee e epa pya pae mede adae w eabed adad que ae g ga eg e ude epa p 5
e d the vue to tot heth cre of distictive osteothic methods Tha victor hs et to be wo Korr wet o to exose the mth some hod tht osteothic ricies hve o soid bsis i biomedic reserch d mechisms 97 Korr offered ciicis hothesis cocerig the deveo met of somtic dsfuctio rob ems d cocetu mode for wh the vrious osteothic miutive techiques re effective i mgig somtic dsfuctio ddress to the New York Acdem of Osteo th etited Proriotors d omtic sfuctio Korr dis cussed the ossibe mechism co cerig somtic dsfuctio the roe the roriocetive sstem might i the mitece of these res of somtic dsfuctio d how the vrious miutive rocedures might secific evite these dsfuctios is hothesis coi cides beutifu with wht oe tes i the re of somtic ds fuctio s effective miutive rocedures re utiized summr Korr hs mde mjor cotributios to ciic osteothic medicie. e hs give usefu co cetu mode for evutig the roe tht the hosts somtic dsfuc tio m hve i owerig resistce d risig suscetibiit to tho ogic sttes This occurs b i cresig eerg d fuctio de mds o the secodr mchier of ife or viscer b terig vsomotor sttus d secodri rteri su to the vrious reted viscer b roducig fciitted sttes d terig trohic xo trsort d thus terig imuses d trohis to the reted viscer b terig rib cge thorcic d dihrgmtic fuctio d secodri imirig the hosts biit to vetite dequte d tti orm veous d mhtic retur omtic ds fuctio c so ter fferet imuses ito the cetr ervous sstem s we s the fow of retro grde trohis to te cord. Thus we c recite wht Korr sid i 9 i the ddress etited • The omtic Aroch to the isese Process We begi to rcogize therefore tht gret m disese which o the surfce re so diverse i chrcter s to require high comex sstem of 16
differeti digosis differenti ther d differeti omec ture re esseti oe disese the mifettios of n idetic rocess exressed i differet rts of the bod The roe of somtic dsfuc tio c be better recited s ri sk fctor whe oe cosiders ude errd s commet stems do ot exist i ture but o i the mids of me thus whe one com oet of the bod is fuctioig imroer the rest of the bod must dt d comeste or become comromised d become disesed ie . offeded org emerges Korr hs heged us to ook t the cotiuum rgig from otim heth to diese d deth d cosider the roe of disese of the muscuoskeet sstem s redis osig sesitizig d ocizig fctor Korr recogized tht we s Os c ddress both the host d disese comoets of the ciic robem d he recogizd we re the o rofessio tht c ow itegrte the mgemet of both the host d disesed comoets ito comrehesive heth sstem Others re miutig chirorctors hsic therists d M s but the re utiizig miutive ther s modit d frostig o othic cke ot s eve ermetig throughout ciic roch imed t ebig the tiet to reize his/her heth o teti t is oe of m deeest desires for the rofessio d iterested i comrehesive heth ce tht ech might stud d cotemte the visio Korr hs reseted the osteo thic hsici tht we might deveo uique heth cre sstem d deveo uique osteothic cur ricuum d eductio sstem which wi educte me d wome to be osteothic orieted G P s d seciists Osteothic thikig c be the mechism to ebe us to become the eders i deveoig comrehesive heth cre sstem for which the ubic is eger serchig Korr hs rovided the ciici with m toos to ebe us to obti eve of distictio which hs ever bee revious reched b the heth rofessios Wht te of m ws required to mke the cotributios Korr hs mde? t took m of scietific d
rofessio quit oe ot tred b covetio beiefs iquirig mid utiized to serch d uder std wht goes o i the mids d hds of the osteothic ciici m who coud verbize his bor tor dt i w to ecourge the ciici i its ciic ictio effective eductor d writer m who ws wiig to give u his re vious iterests d tot dedicte himsef to the eeds of the osteo thic rofessio his ew roe s rofessor of medic eductio t Texs oege of Osteothic Medicie oe must hoe tht he reizes the ecessr rofes sio suort so tht he wi see ew begiig for the cotributio he c mke to the rctice of ciic osteothic medicie Korr is ow dedictig himsef to the triig of oug hsicis who wi rovide the edershi d mower to t ti the rofessio oteti he evisioed d reseted to the ro fessio durig the st 35 ers EDWAD G. O AAO
troductor esss
Primary research reports: Studes on electroyogapy, sympatic nervous systm, efxs, and related topics
Qniive suies f chronic fciiin in humn mneuron pls* (1947) DSLOW M O and AD MS Peious studies (2, 3 4) hae i diated the existee i ma of poos f spia exteso motoeuos whih ae i a state of eduig exitatio as efeted i ow eex theshods hese wee epoduibe oe peiods of moths Pesistet diffeees i theshod wee foud fom subet to subet amog segmets of the same subet ad betwee sides of the same segmet his pape epots the foowig a the oeatio of efex theshod with othe segmeta featues ad the itesegmeta spead of exi tatio Peious obseatios of theshod diffeees wee ofimed with impoed tehis Meth
A the subets wee youg me appaety i good heath Eah ee tode a bae ih 25 gauge hypodemi eede was iseted pepediuay to the ski though a poaie whea 3 m. to the eft of the tips of the spious poesses ad ito the udeyig ee to spiae mass Eah muse ee tode was ouped with aothe 25 gauge eede whih was iseted i tademay though the whea his type of eetode paiig pemitted a highe degee of oaiatio ad se sitiity tha the eious patie 2 of paiig 2 eetodes i muse segmet apat. Atio potetias wee eoded peiousy desibed (2) he eex theshod of a gi e seg met was obtaied by detemiig the owest pessue appied oe the spious poess of that segmet whih eiited spike potetias fom the spia exteso at the same ee
Ths suds r urd by g fm h Rs und f Amra Osh Assn
s d my h sy brs h su res d mnuns f h mus h e b mrg fm h sam gm f d sn suh n m nh hs n b dm bb h gv nus ress br u nsh nghbng mus gmn n rm n d m gm sg n h rd
Measued pessue stimui wee ap pied oe the spious poess by meas of the pessue mete peious y desibed (2) o simpify tabua tio esposes to pessue stimui wee gouped ad desigated as foows: 2 kgm Low (L); 35 kgm. Medium (M); 6-7 kgm High (H) ad o atiity at the top imit 7 kgm.) of the stimuato Noe figue I howee the atua theshods a e gie additio to estabishig the oa theshod fo eah of the fou seg mets the pessue equied at eah of the fou spious poesses to eiit efex atiity fom eah of the othe thee eodig sites was detemied eey expeimet theefoe th theshods of 16 eated efex path ways wee estabished. hese fuish ed the data aso fo detemiig the extet ad faiity o f spead of exita tio amog the segmets studied
N
elt Part Treod dference; egment to egment and uect to uect
Figue 1 (aows ae to be dise gaded uti a ate setio) shows the diffeees i (oa) theshod that may exist am<g the 4 seeted seg mets of a gie subet ad amog oespodig segmets i diffeet subets heshods of 5 kgm aed L ad M i othe hats ou most fequety at ad a theshods of 6 kgm ad moe (H ad N at ad Costay of efex theshods heshods emaied essetia o stat oe peiods of moths he agest diffeee betwee dupiate detemiatios was equiaet to oe theshod goup ad ee this diffe ee was ot ommo. heshod diffeees betwee ight ad eft sides. a peious study o 30 subets (2) it was show that the mea theshod segmet ues of the ight ad eft sides did ot oiide osideabe
diegee ouig at some ees wo expeimets with the impoed eetode tehi itodued i this study ofimed the existee of theshod diffeees betwee the ight ad eft side of the same seg met oe expeimet the theshod of was N (oe 7 kgm) fo the ight musuatue ad at the same time 2 kgm fo the eft. the othe the ight side of espoded to kgm of pessue oe the spious poess whie the eft side faied to espod whe the top imit of the stimuato 7 kgm) was appied oe the same spious poess
Loatio of the sesoy eemet. Whe the peiosteum ad othe tis sues osey iestig the tips of spious poesses of ow theshod segmets wee poaiied the theshods wee osideaby ee ated ofte beyod the imit of the pessue mete otast poaii atio imited to the ski oeyig the spious poess did t i ay ase affet the theshod t appeas theefoe that impotat eeptos o ee edigs fo this efex ae ose y eated to the tip of the spious poess. Coeatio of othe haateistis with efex theshod 1 Pain Pai at the spious poess was ot ommoy podued i seg mets haig high ( o N) eex theshods ee with seee pessues beyod the age of the stimuato Whe it did ou it was feetig ad did ot outast the stimuus. o tast at L segmets (ad to a esse degee at M segmets) pai usuay oued we withi the 7 kgm. age ad ofte otasted the stimu us Futhe this ow theshod pai was iaiaby epoted as "diffeet ad said t o esembe that esutig fom a boe buise 2 Pot-traumatic orene Afte epeated stimuatio the spious poess of a L segmet ofte e maied tede fo moe tha hous; this did ot ou at H o N segmets 3 ference in pyica carac teritic of uprapinou tiue he diffeees i the papabe haate istis of the tissue oeyig L ad N spious poesses ae maked ad detetabe ee by eatiey iexpei
MG SNS efexes et
enced oservers he dfferences exst anly n the skn and n the ts sues whch closely nvest the verteral spnes n the asence of reale o jectve ethods for the study of tssue texture palpaton was reled upon and descrpton gven n sujectve ters We e eve the words "doughy and "oggy are the ost descrptve of the texture and reslen cy of the tssues overlyng the spnous procsses of ow threshod segents n hgh threshold areas the tssues are not doughy and the one outlnes are sharp and hard Dfferences n physcal papatory features of the ad jacent usces ay also e detected n low threshod areas the spna ex tensors appear to possess ess resen cy to pressure deforaton than cor respondng uscles n hgh threshold segents and "ropy and hyperesthetc undles ay ofen e den tfed he dfferences n physca charactersts aong the tssues overyng the spnous processes of segents of dfferent threshod were suffcently characterstc and aked that palpaton of these tssues y an experenced oserver pertted farly reale predcton of pressure threshold groups L M, H, or N When such predctons ade on the seected segents on each of 10 su jects y one of us J S. D were copared wth the ndependently eterned electroyographc fnd ngs the predctons were found ac curate wth respect to threshold group n 35 out of the 0 verterae palpated the reanng 5 were off y only 1 threshod group "Rest actvty Nora usce copletely at rest s characterzed y an asence of acton potentas 1 25 8 10 1517 For otanng electroyogras of the spnal extensors wth the nec essary neede contacts the prone poston provdes optal reaxaton Despte apparent relaxaton of su jects "rest actvty was freuent ly encountered at low or du threshod segents t was often necessary to poston and reposton the shoulder grde upper extre tThis erm, used by Buchhal and Cemmeson (I) o desgnae aciviy in he absence of volunary effor is o be preferred over "sponaneous aciviy. used in prevous repor from his laborory ince he ler may ncorrecy imply h he civiy originaes a he mooneuron elf
T4 T8 T10 No SEGMENTS NVLV NO SPREAD 1,18 N N N N 929 341
SEGMENTS INVOLVED 28 1 �7N N N N ' N N N N 4O. N N N N
EGMENTS NOLVED
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ig. A 30 experiments are diagrammed and aanged aording to patte. The od type numera under eah segment represents the se-threshod (dued in part / in iogram for that segment, eg , the pressure on the spinous proe of T required to eit eetriay detetae ativity in the eretor spinae mass at T The arrows indiate the inidene and diretion ofspread etween a possie pairs ofsegments. The numer on eah arrow indiates the preure appied to the spinous proess of the segment from whih the arrow originates in order to initiate ativity in the segment to whih the aow points. The asene of an arrow in one diretion or the other e tween a given pair of segments indiates that evidene of spread was not otained within the 7 gm range ofthe pressure meter Thus, etween a given pa ofsegments, dependent upon fators whih are amined in susequent setions, there may e no spread, one-way spread, or two-way spread.
es, head, and a mes he owe exemes, o o am he esess o appehensve sbje, n ode o emnae es avy n o sees fo expemens had o be emnaed bease of pessen es avy a one o moe segmens. ah of he fo sbjes a anohe me seved n a sessf expemen n whh es avy was emnaed n a ases he pessen es avy was fond a L o M segmens. ne of he sbjes, dung he nsessf expemen, was pebed by ness of hs hd; one was muh moe appehensve han he aveage sbje, and wo waked wh a mp, de o poomyes n one and an od njy n he ohe asonay, one o moe uns n an L segmen fed dung nspaon o expaon. say hs nemen avy was no ong asng and od be emnaed by he same measues whh wee effeve on odnay es avy. Appaen es avy was ony vey aey enoneed a o N segmens, and was aways easy aboshed by oeon of some posona sess. Ths, ow heshod segmens ae appaeny hypeexabe, no ony o pesse sm apped o he oespondng spnos poess, b aso, o mpuses eahng hem fom hghe enes and fom popoepos.
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n , obsevaons have been pesened onenng he esponse of segmens of he eeo spna e mse o pesse smu apped o oespondng spnos poesses. n hs seon obsevaons ae epoed on he esponses n mse segmens o smuaon of emoe spnos poeses e. on obsevaon of adaon o nesegmena spead of exaon. pead Paens. ndene and dsbuon of spead among he fo segmens fe no fve dsn paens o gops ). 1. Order oj pread Thee s a defne ode o he fequeny wh whh he dffeen aows appeaed n he sees of 30 expemens. We onsde ha hese feqenes ae an ndex of 1 , he pobaby of spead n a gven deon beween a gven
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Fg 2 rogrson ofspread For expanaon see ex The number on eah arrow ndaes he number of mes ha spread oued n ha dreon bewn ha par ofsegmens he expermens dagmme n fgure 1
pa, and 2, he ode n whh spead ends o appea n he pogesson owad ompee epoy among he 4 segmens. Ths pogesson and he feqenes ae shown n fgue 2. 2 Segmena ee The ppe 2 segmens papae n spead wh sgnfany geae feqeny han he owe wo. The nmbe of aows figs. 2) o and fom eah segmen wee as foows T88; T 92; T69; T 47§ w be noed fig. 1) ha when ony 2 segmens ae nvoved n spead hey ae nvaaby he uppe wo T and T); when ony 3 ae nvoved, hey ae he ppe 3 3. Segmea reod Feqeny of spead o and fom a gven segmen s nvesey eaed o heshod. Nospead pas onss pedomnany of and N segmens; woway spead pas onss pedomnaey of and M segmens; and he oneway spead pas exhb nemedae heshos. 4 Segmena inera Dsane beween he membes of a pa) The ndene of spead denes wh neasng dsane beween segmens.
§S ad " are he erma egme he ar brary eeed ere of egme hey are a a reae dadage a regard pred oweer were he ere eeded o nude ad egmen and a we a and wou d o how reaed parpao n pred woud probaby how he arge reae of a erany arger han ha of . he eae uperory of he upper e e of he ere woud reman
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The eaon of heshods and of segmena nevas o ndene of spead s shown n fge 3. 5 Direcion oj pread Fge 2 shows ha ndene of epha spead fa exeeds ha of ada spead exep fo a sgh ada pedomnane beween T and T ). f 32 ases of oneway spead fg. ) 29 ae epha. Fuhe, whee hee s woway spead, he heshods fo epha spead ae pedomnany owe han hose fo ada spead. anayss of he daa ndaes ha pefeena epha spead s an nns feaue of hese efexes and ha he geae fay fo epha spead exss egadess of whehe he heshod of he supeo segmen of a gven pa) s owe han, hghe han, o he same as ha of he nfeo segmen n vew of he fa ha L s and Ms ae pedomnany n he ppe seg mens, hs may be eaed o he nns deona fao. Nevehe ess, he fa emans ha, n o expemens, he efex msa esponses of L and M segmens wee eavey eas evoked by smaon of he spnos poesses of emoe o N segmens; spead n he evese deon was unommon. maon of he N spnos poess no ony faed o e esponses fom muses of he same segmen, bu aso hose of N o ) segmens whh nevene beween and he espondng L segmen. xps. 35, 22, 28, 36, fg. 1.) eeve spead of exaon o L segmes was fhe demonsaed by he appaon of sgh ae smaon o emoe aeas of skn e.g., shode o sapua) wheepon avy feqeny appeaed n L segmens, bu neve n ohes. 6. Procainizaion and pread s of nees n hs onneon, ahogh ou obsevaons ae as ye few, ha whe poanzaon of he spnos poess of an L segmen ased he sefheshod beyond 7 kgm, he efex esponsveness of ha segmen o smuaon of ohe spnos poesses emaned unhanged. Dicio
These expemens onm, n oa on and degee, ha sgnfan sbjeosubje and segmenosegmen dffeenes n spna efex MG NS, efexes, e.
hreshods our n he "norma human The daa ndae ha dfferenes n pressure hreshods refe dffer enes n enra faaon, and ha he faaon s due o a bombard men of he moneurons by mpuses orgnang, n par a eas, from pons oher han he spnous proess whh was e se of smuaon. The evdene may be summarzed as foows: 1 The L and M segmen shows hyperexaby o oa and dsan smuaon nudng ha from segmens Impuses from an N spnous proess may bypass moo neurons n nervenng hgh hreshod segmens o avae mooneurons n he venra horn of a more dsan L or M segmen 2 The effeveness of pressure a he spnous proess of segmens n eng avy from remoe L or M segmens s no asrbabe o mere faaon of onnuous mpuses from he spnous proesses or supra spnous ssues of he L and M seg mens, sne a eas from our med observaons, he responsveness of an L segmen (o dsan smuaon) s unhanged by proanzaon of he ssues osey nvesng s spnous proess 3 Spread L segmens s muh more freuen han spread fm L segmens 4 L segmes are hyperexabe o mpuses oher han hose orgnang from eerna smua on; "res avy s ommon n hese segmens. 5 Rgh and ef sdes, a he same eve, may show srkngy dfferen hreshods o pressure a he same spnous proess Loyd's sudes (1 1 2) wh faang voeys, of he uana ve reaonshp beween submna frnge and he dsharge zone n he a have ed o hs onuson ha (1 1 ) "I s unkey herefore ha any sgnfan number of mooneurons are ose o or a hreshod n he resng poo, for, f here were, he frs afferen mpuses o ener he poo shoud seure a possynap dshage H s work demonsraed ha a mooneuron poo, n he absene of a faang or es voey or boh (o he dorsa roo),s resng Ths resng sae represens a hek on he farfung nerneuron sysem
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ig Iuene ofdtane an d thrhold on spad of itation. ndividual segments apar in the graph man times as the an e pair e..g. T and T a ired ith leve 4 and 6 segments art; and T and T ti ith leve 2 segments apart and on ith levels 4 gmen apart The rohathing ode dsignat the numer ofgments in M H or to Th for example of the segments shoing no spd at a egment interval 4 H and 6 M 7 re.
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and n effe,nsuaes he fna om mon pah agans frng every me an afferen mpuse reahes he poo Whe suh a mehansm erany exss n man and whe Loyd has demonsraed n expermena preparons where ompee onro of faang, nhbory and es voeys an be mananed, our obser vaons ndae ha n " norma,na man s possbe o have ue a dfferen suaon. o ony may df feren poos, n ose anaom pro my, show dfferen (and onsan) degrees of oseness o hreshod bu, ndeed, eran poos may be a, or above,hreshod (res avy) n he absene of eerna smuaon. Sne Loyd has demonsraed ha a on sderabe poron of he es n a mooneuron poo mus be n a sae of submna eaon before dsharge from ha poo ours, seems apparen ha refe hreshods (measured by he pressure meer) are a measure of he sze of he submna frnge or of he degree of faaon mananed a a gven spna segmen Thus a kgm seg
wr
men has suh a arge subna frnge ha reavey few addona mpuses reahng (from any soure) w exend no he dsharge zone In addon o he demonsraon of enra faaon, orreaon was found among aJ he refex hreshod b, he papabe haraerss of supraspnous ssues; c, he susep by of hose ssues o asng soreness foowng mnor rauma, and d he pan hreshod (and pan haraerss) he bass for hs or reaon has no ye been earned An arave possby whh mgh aoun for hs reaonshp s ha n a gven segmen here are poos of neurons oher han aneror horn es ha are aso faaed and ha her hyperavy hrough roph vasomoor or oher n fuenes, produes he observed hanges n he ssue The ower ressane o mnor rauma and o panfu smu may be seondary o he ssue aeraons. Ceran smares o he nofensor enderness desrbed by Lews 9) are
ndaed The possby emans howeve h he oweng f he pan heshod may aso be de n pa a eas o ena faaon The faaon ndaed n he ow heshod poo may epan wha Makenze ( 13, 14) efeed o as e aggeaed esponses n an aea of abe fos and by de ev dene esabshes he ae a ehe he neneons he mooneons o boh nsey and Phps 6) n onneon wh efeed pan have aso ansaed he abe fos no ems of faaon The fna qeson o be asked n onneon wh he pesen obseva ons s onened wh he ogn o ogns of he mpses whh fa ae he ow heshod poos evea soes sgges hemseves: he hghe enes vsea popoepos e jons endons, gamens o mses) n hese epemens, how eve he hgh degee of onsany and espeay he hgh degee of oazaon o one o wo seg mens, he feqen dffeenes n heshod of gh and ef sde o f he same segmen and he absene of psyhoneo and vsea symp oms n o sbjes wod seem o e o he fs wo as majo soes We ae nned o beeve ha e faang mpses ase fom segmenay eaed sues Summa 1 The ee esponses of he eeo
spnae mses o meased pesse apped o he spnos poesses a seeed spna segmens wee sded The esene of onsan dffeenes n efe heshods of segmens n dffeen sbjes and fom segmen o segmen and fom sde o sde n he same sbje has been onmed 2 Low heshod segmens showed efe hypeeaby o pesse pon he oespondng spnos poesses o pesse pon he spnos poesses of dsan hgh heshod segmen and o mpses fom popoepos assoaed w ··Ths not to deny tat psychogenic or viserogenic impuls may ignificantly aect gmetal tresh old. Our ow expement demontate that appre hensiees, axiety, trasient illnes etc may cause wdespd lowerig of trehold n our ubject these influences appar to have be superimpoed o the pmar ad more cnstant, factos infuenig threold.
posonng, fom emoe aeas of skn and fom he hghe enes 3 s onded ha ow hesh od segmens ae hose n whh a e avey age poon of he moo neons ae mananed n a sae of faaon de o a hon bom badmen by mpses fom some nknown soe Pesmpve evdene ndaes ha he faang mpses ase fom segmenay e aed ses 4 Coeaon of moo ee heshod wh a pan heshods; , ssepby of spaspnos sses o mno ama and c wh sse ee has been demonsaed Ths sggess ha neons ohe han he mooneuons n he ow hesho segmens may be smaneosy faaed eference I. Buctal F ad S Cemmeson Ata med scad :48 1940 2 nlow, J.S J Neurophysiol 72071944 De low S ad GH C ou g J NeuopyioL 440 1941 4. Densow JS ad CC. Hasett euopyiol 59 12 Gison, AS. J. ad WB Mills Thi Jounal 336581941 6. iny JC ad RA Phillips J Neuophyio 3175, 1940. 7 fe PFA ad TJ Putnam Ac Neuo Pychiat 201, 199 8 Jacobson E. Pogressie reaxation Uiv of Chicago Pe 49 pp, 198 9 ewi T Pa ew Yok acMilla192 pp 1942 10 indley DB This Journal: 195 II. loydDPC J euophyiol 1111 12 loyd DPC Yae J Bio Med :117 1945 1 Mackenzie, J Bai :12189 14 Makenzie' Symptoms ad teir iterpreta tio odo Saw and Son pp, 1912 SeyffatH Skr orske Videnk Akad : I 1940 16 SmitC. Ti Joua 629194 17 Wedell G B Feinstei and RE. Patte Brain 179 1944
Reprint by pemission fom Ameica Jorna of Pyioogy 150229-28, 17
Abstrac: Dermatomal autonomic acviy in relation to segmental motor reflex treshod (194) M O and MA J GOLDS (invitatin)
ndng dffeenes n segmena efe heshods nvovng he spna eenso mooneons have been demonsaed n man (Densow J Neophyso 207 1944) The ow heshod segmens appea o be hose n whh a eavey age poon of he mooneons ae mananed n a sae of faaon de o hon bombadmen by mpses fom seg menay eaed ses Densow, Ko and Kems Ame Physo 5:229 1947) n he pesen nves gaon evdene has been obaned ha he faaon eends o he es of he nemedoaea omn n he oespondng segmens sne measemens of eea skn ess ane ndae segmena dffeenes n swea gand avy whh ae eaed o he moo efe heshods ea ondvy of he skn of he bak was meased n o sb jes by a onvenen modfaon of he demohmmee nde he ond ons of o epemens mos of he skn of he bak has a essane of 5 ohms o moe oweve, poons of demaomes and oasonay ene demaomes, eaed o segmens wh eded heshods have makedy eded eea essane ofen as ow as 20, ohms The ages mos onsan and mos epodbe dffeenes n skn ondvy eaed o segmena moo efe heshods ae fond n he mdne ove o nea he veebae Aeas wh eded essane ae ofen hypeeshe and some may have he haaess of gge aeas s onuded ha n segmens wh honay edued moo ee heshods a eas some of he pe gangon sympahe neons of he same segmens ae aso man aned n a sae of faaon
7
Reprinted by pemiio from edeatio Procedigs 67 1948
MG N efees e
Abstract: Ski resistace ptters asociated with visceral disease (1949
Te automatic recordin of electrical skin esisance aterns on te human run* (1951)
This abstract rports th rsults of a prliminary invstigation of th part that visral disas and irritations may play in dtrmining th lctrical skin rsistanc pattrns prviously dscribd Federation Proc : 67, 948 and this issu). wo class of patints having viscral disas hav bn xplord with th drmohm mtr (Jaspr) and found o hav lowrsistanc aras (LRA) which not only showd sgmntal rlation to th viscus involvd, but wr fairly con sistnt for a givn disas ntity and wr rlatd to th rfrrd pain pat trn. Patints who had had myocar dial infarcts had LRA ovr 2 or mor of th uppr 4 thoracic vrtbra, nar th strnum at corrsponding rib lvls and ovr th mdial dgs of on or both scapula in th cor rsponding drmatoms. In on sub jct, rpatdly xamind ovr a priod of months, such aras wr first obsrvd 3 wks prior to a cor onary occlusion. Patints with duodnal cap ulcr had aras of markdly lowrd rsistanc ovr th spinal muscls, on th right sid, opposit vrtbra T5 to T8, ovr corrsponding ribs on th antrior chst wall and to th right of th um bilicus In both disass, LRA ap pard to coincid with or ovrli th most painful or tndr parts of th rfrnc zon.
PRICE E THMA d IRVIN M KRR
epned by permi m Feden Pceedg
8: 8 99
In rcnt yars th study of rgional and sgmntal diffrncs of swat gland activity has found wid applica tion in th dtrmination of priphr al nrv filds or drmatoms affctd by trauma (, 9 0,,2,5, 9), surgical procdurs (8, 3, 20 22, 23, 26), painful syndroms and viscral disas (6, ,28), spinal cord disas (3), and xprimntal pro cdurs (2, 2). In most of thos in vstigations in which lctrical skin rsistanc masurmnt was usd, th oprator, applying th mthods of Richtr (25) or Jaspr (4), or modifi cations throf, dmarcats, with handhld xploring lctrod th aras of high rsistanc in a gnral background of low rsistanc inducd by th application of drugs or hat. h highrsistanc aras signify low swat gland activity du to impaird or intrruptd sympathtic supply to th corrsponding aras Convrsly, studis conductd in our laboratoris hav dmonstratd th xistnc of aras of low rsis tanc which prsist in a background of high rsistanc, undr conditions of rst and in th absnc of thrmo rgulatory swating Ths lowrsis tanc ras hav bn found in all of th svral hundrd subjcts x amind most of whom ar studnts in good halth h pattrns vary from subjct to subjct, but in a givn subjct, th pattrns of sgmntal distribution may rmain constant for many months (6). That is, th low rsistanc aras rmain concntratd in th sm drmatoms orrla tions hav bn stablishd in many cass with sgmntal disturbancs of viscral, myofascial nurognic and primntal origin (, 8). t has bn proposd that th prsistnt low rsistanc aras rprsnt chronic sgmntal facilitation of th sym pathtic nrvous systm similar to 'T nveigan wa sppred in par by a reeac gran m e Nina nses He Pbc He Service d b a grn rm e American Oeopic Aocn
that prviously dmonstratd for motonurons of th paravrtbral muscls (4,5). It appars thrfor, that topo graphical skin rsistanc studis may hav widr fundamntal and clinical significanc and applicability than has hrtofor bn rcognizd Un fortunatly,th convntional xplor atory tchniqus hav many disad vantags. Th mthod is vry slow, an ploration of th ntir trunk rquir ing to 2 hr., according to th com plxity of th pattrn and th skill of th oprator. To this must b addd th tim rquird for charting Sinc, in addition, th mthod ruirs traind prsonl, th numbr of studis that can b conductd in a givn priod of tim is sriously limitd Th slownss of th mthod also rndrs it unadaptabl to th x primntal study of rapid, transint altrations in th ESR pattrns Furthrmor, th mtho h� a numbr of inhrnt sourcs of rror a Th tim rquird introducs variabls du to changs in th stat of th subjct (fatigu, bordom, tc) b h pattrns found on sub jcts of diffrnt body typs must b transfrrd to standardizd body charts Th stablishmnt of a boundary may rquir th rpatd passag of th lctrod ovr a givn ara; this procdur may itslf altr th rsistanc of th ara. hs dicultis hav bn ovr com by th mthod of xploration dvlopd in this laboratory, which rapidly and photographically rcords th lctrical sin rsistanc pattrns in propr rlation to th subjct's trun h procdur rquirs a minimum of training. A singl ara is travrsd only onc in th cours of th ploration A sris of plora tions may b comptd in th tim r quird for a singl ploration by hand thus maing possibl con trolld primnta studis Anothr fatur of th mthod is its vrsatility its principl is adaptabl to modalitis othr than sin rsistanc.
B
,� ' Fg
.
.
A an B
Phoograph rors of ra skn rssan pas oan wh h auoma rmohmr Eah onguna srp rprsns h pah of a gh sour (moun ovr h porng ro) whos rghns vars wh h rssan ofh suan skn. h ark aras rprsn aras of ow ran; h arkr h ara h owr h rsan. B mans ofappropra ou posur h har appars suprmpos on h u's o h wh os n h mn rprsn h ps of h spnous prosmark a spo of gh. h numr srp a f of ah ror s h araon, showng for ha xporaon h varaons n gh rghnss wh varaons n urrn fow hrough h skn a onsan voag h rsan of a gvn ara of skn an hrfor ma from h urrn an h poraon voag (6 V n ah of h aov ass). S for furhr xpana on
as ppl o auoa do s ovso o d s s ssa a s ds u oug s a osa voag o vaa os gss o a lg sou lg sou s pad dly ov pog lod ad od s popld ov s a osa spd a aa popy posod sp o plod d su op l poogap sps o lg vay gss aodg o al ssa ds aog a ospodg sp o s o plo a ag aa a ss o o suv paal sps s odd Fgu I lusas ods o ad y s od o o su js aas o avly lo ssa appa as dad aas aog sps lo ssa da ospod g aa o od aa o sp a o a od as poss o sa ssa o ay aa o s o poogap od s pao o poogap ods Fgu sos a v o su us odadg assly s popld og as o ody a o voag o opo gu s appd ap ad plog od g oud ov pog od s ausd o vay gss u pssg s ods y as o ap aso ousd gu aa J) oud ov o d ods g sp ad vaaos sy Sussv sps a odd y aa posog o as (D) o a H T
Th div gd a g 2 ag odadlg assly a o d s suppod a o d o a aag g 3 s po pd o a ags aog a pa o paa als g 3C y a sal sy oous oo g 3D oo s s oud o aag pops oug a o
Fg 2 h auoma rmohmr h ro angh am (A) s f on h arm B whh s hng a on n o h arrag (). h arrag s prop aong h ras D a snhronous moor (E) moun on h ar rag Th moor s gar for moon n hr ron aong h ras h uh-arm (F) whh ngags h gars n hr ron aso auas an onoff swh n h gh an skn rus Ths arm as as a m swh whh auomaa nrrups hs rus a prs rms (G on h ra a h sam m as sngag h moor h ras an mov ara an prs poson on h fram for h rorng ofsussv srps Ohr ms (sr n (I) h sour of vara voag app aross h arp an porng ro aso houss araor r u an h arrr ampr whh vars gh rghnss n aoran wh varaons n ur rn hrough h skn; J) h amra. o h pvo (P) whh prms ng of h nr fram for xporaons n h vra poson.
dv appd o as dv s gad o ov aag a ap poay 333 s s do u a 3E gags ad vss gas aso auas a s suaous y us o g sou ad voag oug s gagagg poso ad us s us o ua pos o u a s auoaay o o ua poso y upg aov us ss as gs 3F o a s a s d g o lgsp a ps o dvduas o d gs a s a a d o d o poa o SS s
he rals aong whch the carrage travels are mounte n a Plexglas sleeve at each en hese sleeves are n turn supporte from the short lmbs of a rectanguar frame (fg. 2 H) whch, lke the ras, s made of one nch poshe ppe hese seeves are sld along the frame for atera pos tonng of the ras (and therefore of the electrode) Precse postonng s mae possble by a slotanpn arrangement, n whch the slots are space on the frame at ntervals of 1 5 mm Snce the electroe s 12 mm wde there s a space of 3 mm. be tween strps, an nterval arge enough to prevent overlap of strps and stl smal enough to permt contnuty of the ESR patterns. he frame s rgy supporte on one sde by a heavy boar (fg 2) affxe to the wall he frame s mounte on the boar by strong hnges whch rgdly support the frame n the horontal poston, but whch permt t tng the frame aganst the wa for easy access of the subject.
fat, t presents an llumnate surface of constant area to the camera hroughout ts fel
Fg Cloeup of dre mechnm Arm berg electrodend-lght embly (not hown) hnged to lower end of ertcl djuter (A) on crrge () whch propeed long rl (C) by ynchronou motor (D) Clutchrm (E) reere ger nd ere lmt wtch for lght nd kn crcut (F) djutble lmt
h todadIight assmby (fg. )
he roller electroe (fg A) s a stanless stee cylner 23 mm n ameter an 2 mm we he undercarrage s supporte by a pn from the arm, permttng free tltng of the axle as the roller moves over the skn Snce, also, the arm s hnge to the carrage an s free on the electrodebearng en, the eectroe rests freely on the skn, and ful contact at constant pressure s as sured throughout the lne of travel he lght source (fg. ) s an evenly etche lucte rod, 5 mm. n ameter, mounte over the roler, parallel to the axe an llumnated from one en by an enclose a lamp he exposed part of the ucte rod s 2 mm ong, correspondng to the wth o f the electroe Snce the lght source s cylnrcal, ra ther than Alhogh gUre 2 how he nren n poion or exporaon o he ruben ubje i n alo be ed or exporaion in he veria (or oher poi· ion The rae ay be roaed o ha he rail are veril (g 2) By ean o a pulley and onerwegh he rae o ravel o he arriage in he pward and downward dirion i add o ha o horizon ravel The ara i paed o ore in he horonl poiion aed a he approxia ener o he exploraion id The enire inren ay be oned on a rgd porable and raher han on a wall
C. h vaiab votag sou Dfferent voltages are apple be tween the conventonal earclp elec troe an the explorng electroe (postve) from a seres of flashlght ry cells (se C whch are connected nto the crcut n 3 V. steps by means of a gangswtch (fg. 5 S2). he range 03 V may be further sub dve by means of a potental dver for exploratons urng actve sweatng (he 050 mcroammeter s not essental but s nclued for con venence n selecton of exploraton voltage see beow). he potenta rop across the varabe resstor R shown n the crcut agram s ap ple to the grd of the amplfer (fg 5, V) whch vares the brghtness of the ght source n accordance wth the current passng through the skn D h aibato or calbraton (fg 5, S3) a seres of fxe resstances are swtched nto the crcut n turn (n place of the skn an sknelectrodes) to permt the flow of known currents, whle the brghtness of the lght s photograph cally recore E
Cosio of vaiatios of ut though th ski to vaiatios of ight itsity
Fg 4 Eletrode-ndlght embly (A) Roer elec trode etched lucte rod llumnted from one end by dl lmp n (C) houng
Snce the current dealt wth n der mohmetry s of the order of mcro amperes, amplcaton s rure for the operaton of even a small lght bulb. gure 5 ncl udes a schematc of the carrer ampler currently beng usd n our laboratores, shown n correct relaton to the varab le voltage source an calbrator crcuts he amplfer s set to gve mxmum ntensty of the lght source (whte on photo graphc record) at ero skn current an mnm um ntensty (black) at any preselecte number of mcro amperes, accorng to the desre range an senstvt he electronc crcut (see block dagram, fg 5) conssts of a local ollator, two stages of resstance couple amplfcaton an a control stage he oscllator V (a mult vbrator) produces a c/sec sgnal whch s fed through the two amplfer stages V2 an V3 and pro
Fg. 5 Cr dagram varab voag or, braor ad ampr) C1 0.02 md par 4 vo 10 mg 1 wa R9 0 d papr, 4 vo C2 RI 5OK, 1 wa R C3 0.1 d papr, 4 vo 58K, 1 wa R12 20K, 1 wa 025 d pr, 4 vo C9 C5 10 d d ro vo R13 30K, 1 wa C6 005 d papr, 4 vo 50K, 1 wa R14 C7 C8 120 d vo RI5 OK, I wa RI, R7 150K, I wa 3OK, 1 wa RI6 R2 470 oh wa RI8 3O0 ohm, I wa S R4, R5 2.2 mg SPST ogg wh OK, 1 R6 R8 S2, r 1 po, g o, ohorg roa wh DPST ogg wh TI Powr ormr, 7 vo 5 ad 6.3 vo am rma p ormr Thoao T-22S90) F Fr ho 10 5 h L GE C-40 Compo bok dagram; VI 6S7 SCLL. muvbraor V2 AMPL1 5 1 ampr modaor) V3 AMPL.2 Powr ampr 6 V 6 V4 15 LAMP GE C-40 da amp 5Y3 V5 CNTRL oro ag CALB or N varb voag or appd aro h or h abrao ror
16
ides soure of lerning urren suffiien o ligh he lmp he brilline of he lmp is deermined by he gin of V2 whih in urn is ried by he onrol ube V4 he oupu of V 4 is deermined by he urren flow hrough he skin irui nd onsequenly, hrough grid resisor (RIO) hus, he rrier signl is mpliudemoduled by riions in he resisne of he skin he osillor nd mplier sges re of onenionl design nd need no furher desripion he onrol ube V4 is employed s poen iomeer o ry he grid bis of V2 An independen powe r supply for he ple nd filmen of V4 kes i possible o ground he ple he olge drop beween he hode nd ple of V4 is hen pplied o he grid of V2 he direion f urren flow hrough he skin nd grid resisor uses he grid of V4 o beome more posiie when he urren hrough he skin (or from he libror) is deresed More urren hen flows in he ple irui oweer his inreses he poenil drop ross he ple resisor (R9) he expense of he olge drop ross he ube Under hese ondiions he olge pplied o he grid of V2 beomes less negie his inreses he mpliude of he rrier signl wih resuling inrese in b ighness of he ligh (fig 5 L) he reerse proess ours wheneer he skin resisne drops nd inreses he urren hrough he grid resisor of V4 For librion, rible soure of known urren is pplied in ple of he sk in irui by mens of rory swih S 3 Figure 6 shows noneleroni mpliier used in n erlier model of he uomi dermohmeer nd preiously desribed in preliminry repor (27) Alhough less onenien o opere hn he rrier mplifier i is of muh simpler onsruion he priniple of he deie ppers, lso o he wide rnge of possible p pliions. he indior needle of 050 mirommeer (fig 6A) ues he rible rm of n elerolyi rheos in he lmp irui his rible rm is Ushped plinum wire (g 6C) whih hs been hed o he indior needle (fig 6B) he ener of roion. he meer is suppored fe down on MG SNS, reflexes, e.
Pexiglas blo i wi two sem iula aals ig 6E ave bee ut. Ea limb o te U moves i a aal otaiig dilute HS• Move met o te mioammete eedle altes te esistae te amp iuit (ad teeoe te igt itesity toug vaato o te legt o te aid oum betwee te limbs o te ad te ixed eetodes (ig. 6. I ou devie N/6 HS povided a satisatoy age o esistaes. Pd
To odut a exploatio te aea to be expoed is exposed ad te subjet eies o a uposted tae; oe wit a ae slot omoably pe mits maitaiig te ead i te midie positio duig expoatio o te dosal suae Ay desied topogapia eatues ae idetiied ad maed Te ame is bougt ito te oizotal positio ove te sujet te ais paale to te og axis o te aea to be expoed Te eletode is paed upo te subets si ad te eigt o te ixed ed o te am is adjusted (ig. 3 o te aiage aodig to te subjet's ateoposteio dimesios. Te imits ae set o te ail aodig to te egt o te ied to be exploed A. on of poaon voag
Beoe begiig te exploatio te appopiate voltage is seeted. Beause o dieees i basi esistae amog subjets some may equie 3 V o less otes moe ta 18 V o demostatio o te gadatios i esistae We ave oud tat te voltage wi just pe mits a detetable flow o uet (about A toug most o te sk wil pemit a ie dieetiatio ad gadatio o te aeas o elative ly low esistae by defletios o te mioammete eedle ad dimmig o te ligt soue.
B aao p Followig te seletio o te ex ploatio voltage te oom is daeed exept o potogapi sae igt te amea sutte is opeed ad a alibatio stip is eoded as ollows Te ail is moved to oe side o te expoatio ield but stil witi te view o te amea ad te aiage to oe ed o te ail Te aibato is swited ito te i
put o te ampliie Te moto is stated ad te lut egaged si multaeously statig te aiage ad tuig o te ligt As te eletodeadligt assembly tavels alog te ail (eetode ot i otat wit subjet te opeato swites ea o te esistaes (g 5, S3 ito te iuit i tu tus eodig i 6 steps te vaiatios i igt itesity tougout te peseleted age o uet flow. U po ompletio o te stip te igt is tued o y te automati limit swit
C oaon Te ail is te moved to oe edge o te expoatio ield ad te aiage bougt to oe ed o te ai Te eetode is plaed o te subjets s i te peviously seleted votage is· applied to te iput o te ampliie i plae o te alibato ad te lut is egaged s peviously me tioed te swit iopoated i te lut am simultaeously tus o te igt soue ad te votage to te si eletodes At te ed o te stip tis am is automatially tust ito eutal posito as te lut am sties te limt o te ail simutaeously teuptig te iuits Te ail s te moved lateally to te ext ot te lut is egaged i te opposite dietio ad te ext stip is tus eoded About 20 se. ae equied o te exploatio o a stip equal to te legt o te aveage uma tu
Eamn of opogapa aonp
Te positios o te vaious ladmas (e.g. spious poesses sapula edge iia ests ae te eod ed by meas o a small spot o ligt. Figue sows te spious poess tus maed as wite spots. Te amea sutte is te osed te ame beaig te ail et. is tilted ba agaist te wall ad te slate beaig te data egadig te exploatio is plaed witi te amea ield but outside te exploed ield. A bigt bulb saded om te amea but iumiatig te subjet is tued o. Te exploed iel is oveed wit a bla lot ad witout advaig te im a bie expo sue is te tae By tis meas as sow i igue te eod appeas i oet motage o a potogap o te subjet's body. Te bla
Fg 6 Non-eleconc mplfe (A) mcom mee () mcommee needle beng (C) mong elecode (D) elecode fed n (E) cd ogh (F) skn elecode G o lgh cc.
lot o ouse pevets eexposue o tat potio o te ilm o wi te expoatio as bee eoded Ipa h phgaph d
s te ae sows i igue I bot sujets wee exploed wit 60 V Sie te wite aeas sigiy uet o A o less tese epeset aeas o s wose esistae exeede 6 milio oms. Fo te exploatio o igue a te ampliie ws set to ause dimout at 30 ; igue b at 2 e bla aeas i igue a teeoe idiate uets o 30A o moe tat is aeas o s i avig esistaes o less ta 2000 oms e vaious sades o gay idiate itemediate esistaes wose values a be estimated om te alibatio stp to te let o te at i wi te 30 A age as bee divded i 5 A stips (Te daest potio is idistiguisale om te bagoud tNarrowing he range, i e. lowerng he dim-ou poin increases he dffeeiaion among he high resisance area whie acrificing gadaion below he reiae orrponding o he dimou crren
tber appcaos
h prinipl of h auoai drohr an, w bli, b applid o h udy of h opographial ariaion of faur ohr han lrial kin rian. n our laboraori w ha adapd h di o h daraion of ara o f uanou hyprhia by rplaing h lrod on h ar wih an lrial or hanial iulaor h ligh or h iulaor, whih i proplld in h a annr a h kin lrod, i onrolld by h ub who urn h ligh off and on wih a hubwih o ark h hyprhi zon in ah rip. By inorporaing a rhoa in a rubbr bulb grapd by h ub, ariaion in h inniy of h pain indud by h iulaor ay alo b rordd Anohr adapaion, in whih h rollr lrod i rplad by a hrooupl, hrior or radior, for h udy of paial ariaion of kin praur on h huan runk, i in pro of onruion. orces of Error
h auoai drohr, a on rud by u, ha wo hif our of rror, boh of whih ar rlaily uniporan in our appliaion of h inrun, and boh of whih an b grly rdud or liinad by rain rfinn. 1 Sin h ara of ona b wn lrod and kin (and or rponding ara of illuinad urfa) ar onidrabl (12 x 1 2 ), ha ara oniu h lii of rror in h daraion of a boundary or in h loalizaion of a all po. hu a all po of ry low rian wihin h ara of ona of h lrod will b rordd a a rangl qual in ara o h illuinad urfa n our inigaion w appar o b daling wih gnal phnona, and hrfor hi rror i no iporan in i ill pri h idifiaion of drao Grar priion of loalizaion i, of our, aainabl hrough rduion in iz of h x ploring lrod and ligh our, a h o of pd of xploraion 2 Sin h illuinad lui rod i ound or h rollr lrod i i a o dian abo h uban ara of kin A all poiion of h lrod ohr han ho in h axi
of h ln, hrfor, rror du o parallax i prn, and h ligh will b rordd by h fil a hough iuing fro a rangl of kin u byond h lrod H owr, in h dian bwn h kin and ligh or (35 ) i all a opard wih h dian o h ara (1 ) hi rror i all. A aurd on a ub, wih h lrod ably a h xr of h rail, h axiu rror du o parallax in h inrun dribd wa 18 hi rror an b liinad by ainaining irual (opial) alignn of ln, illuinad rod and unrurfa of h lrod a all poiion in h ara fild mmary
1 A nw produr ha bn d ribd for h phoographi rord ing of lrial kin rian parn on h huan runk, or ohr ara of h body. h xploraion ar aura, alo auoai and rapid a opard wih xploraion by handhld lrod. 2 h bai prinipl of h hod i h onrion of ariaion in kin rian ino ariaion in h brighn of a ligh our. By plaing h ligh our dirly or h xploring lrod, and proplling h lrod (by ynhronou oor) or h kin a onan pd, a ara, proprly poiiond wih rp o h xplord ld, phoograph rip of ligh whih ary in brighn aording o h rian diffrn along a orrponding rip of kin. o xplor a larg ara, a ri of onui, paralll rip i rordd. 3 h adapaion of h produr o aur h opographial ariaion of faur ohr han kin rian (g kin praur, hyprhia) ar dribd or ug gd 4 h aor our of rror ar drib and hown o b uniporan in our urrn appliaion of h inrun. Rfinn whih liina or graly rdu h rror ar uggd pere cknwedge e be tnce f Mr Dwg W Legn n e degn f e dermmeer nd e cnr· n f e mecnc pr.
efeces
..
Bad B nd Dugan Wr wounds of he chs obsrvd a e Thoracic Surgery Cener Wler Reed Geeral Hopia J Thoci Su 19
:
2943 2 Buesc, S R nd Ricer C.P Ctanou ds ribuion of periprl nrs in resus monkys s drmnd by e elcrica skin resisance mod Ja Hapk Hp. Bull 1946 78:235-2 3 Crig, CB and Hre CC Swaing reacion in paiens wih diass of e spina cord A Neural yct Chicgo, 1935 478-491 4 Denslow J.S . A n nlysis o f he varbly of spinal reex rods J Neuphysol, 1
:
2215
Densow, JS, Korr IM. nd Krem, AD Quaniaive sudies of chronic fciliaion in hmn moonuron pools. Amer J Physjal 1947
229-238 6 Gumnn L Mooriche und vegeaive enzonenrefxe bi laonen riper und enrer bchnie d nervensysems Z g Neura Psych, 1933 13 7. Gumnn, L Uebr reflkorische bziun zwischn vscer und Scwissdrisn und i Bedeuung bei Erkrnkugn nere orgne (der viserosudorle reex). Ca Nl 1938
4:
:
296310 8 Guman, L. The disrbuion of disurbances of swea screion afer exirpaion of crn sym· pheic crvica ganglia in man J An 1
4
537549 9 Gumann L Topograpic sudi of disur bn of swea screon fer compee esions of ripheral nerves J Neul h 190
197-210 10 Her E nd Gasr GH Hodoer
.
and Hon, T1 Ecical skin resisance es in evuion of pripera nere injuries A Neural yh Cicgo, 196 365-380 Highe, W.B Proane nere blk in e in vesgion of pripher nerve inurie J Neul y 1942 116 12 Hymn, nd Beswick, WF Msuremen of skin ressn in riphera nere inurs. Wr
$: $:
M
1945 2582 13 Hyndman, OR and Wolkin, J The pilocarpine sweaing es: A vald indicor in differeniion of pregnglionic and poanlionic sympcomy Arh Neul Psyhi hicago 1941 21 14 Jpr, H An improvd clincl dermomeer J Neuu 15 257·2 15 Jasp H nd Robb P Sdis of eecrica skin resisnce in peripera nerve leion J Neursu 1945 26 268 16 Korr, .M and Goldsein, M.J Drmoml uonomc ciiy in laon o segenal moor reflex hreshold 1948 67 17 Korr, Skin rsisance paerns ssi wi vscerl disase P 1949 87 18 K M Exprimenal alerions in segmen a sympheic swea gland aciviy rough myofsci nd poural disurbns Pr
4$:
F
1949 88 19 Mino, L. Ube r rhn elecriscen uwide sand be umaicen affeionen des asm phcus Z Neal 1923 $
482507
Paumbo, L.T, Samr, HH., Hohf, JC and Burke E T Posorive swing perns in oracoumbar sympaecomy nd splancnicc omy Ah Neural Psh/, Chicao, 1950
56-578 21 Richr, CP nd Shw, M.B Complee ons of he spinl cord differen evs Ar Neul Psh/t Cicago 1930
17·1116
MG, SNS, rflx,
Richter CP and Wooduff BO Chang produced by sympathectomy in the electrical ristan of the skin. Sue 11, 9S7-970 23. Rcht CP and Woruff BO Lumbar sympathetic dematom in man determin by elca skin rssance mthod. J Nurop IS 8: 32333 Richt C.P. and tenasek FJ Thoracolum bar sympathtomies examined with the eltrical ski resistance meh. J Nuru, 19 12034. 2S. Richt CP. nstructions for us the cutaneous ristance rorder or dermohte" on periphera nerve injuries, sympathectomies and parartebral blks. J Neuru 1946 111 91 Richter CP. Ctanous areas dervated by upr thoacc and stellate ontomies deter mined by the eltrical skin resistance mthod. J Nuru 17 221-232 27 homas P.E and Korr .M. emiautomatic recordi of electrcal skin esistan patterns P 1950 126 2 Van Mee TE, r ow electral skin resstance in the regon of pain in painful acute sinusitis. JoHopk Hp ul 1949 8' -1S
:
Relinhip beween we gn civiy n elecric reisnce f he kin· (1957) C HOMAS and M O
F
Reprnted by rmission from EEO Clin Neuro physiol 36136 19SI.
Measureents of the electrcal resstance of the skn ESR) to the passage of drect currents ar e generally utlzed as an ndcator of sypathetc actvty In ths applcaton the technques used and the nforaton sought fall nto two rather broad classes: those desgned to easure changes n resstance n a gven area of skn eg psychogalvanc reflex or galvanc skn response studes) nd those used for easurng dfferences n resstance aong varous areas of skn For both technques the basc electrcal ethod s slar e easurng the current flow at a known voltage and convertng to resstance or conductance accordng to Oh's law). The ajor dfference n ethods s n the type of electrode used In the first class PGR or GSR) wet nonpolarzable electrodes are generally used whle n the latter class dry polshedetal explorng electrodes have been found ost satsfactory and convenent Wth ether technque t appears that actvty of the sweat glands sgnfcantly alters the resstance level In a study wth wet electrodes Darrow 1) found a lnear relatonshp etween the conductance recprocal ohs) and the aount of perspra ton produced Wth dry etal electrodes Rchter and others 3) have observed that low skn resstances were found n norally nnervated areas of heated vsbly sweatng sypathectozed patents whle denervated areas showed hgh resstance values These observatons and any others establsh vsble sweat gland actvty as an portant SRowerng factor whether easured by wet or dry electrodes In cases of heredtary ectoderal dysplasa Wagner 4) usng dry elec trodes observed consstently hgh SR values at all envronental teperatures nvestgated n kn areas contanng no sweat glands 'These invesigains were uppred in pa r b y gans rm he Nainal Inie Health (829 ad H·163) and rm e American Oepahic Asciai ad by a cnrac (N 43(00» wih he Oice Naa Research
These skn areas also showed no resstance changes related to vasootor adjustents to heat or posture The sweat glands would see therefore to be the one skn structure whose physologcal actvty produces sgnfcant varatons n skn resstance Ratclffe and epson 5) usng ry electrodes showed that sgnfcant dfferences n SR between sypathectozed and norally nnervated areas of the skn were stll deonstrable even at cool teperatures l8QC) n whch there was no vsble sweatng These varous observatons strongly ndcate that wth dry electrode technques any actvty of the sweat glands even at such low rates as occur under cool restng condtons lowers ESR below that found n the coplete absence of sweat gland ctvty The queston s now rased as to whether varatons n ESR n a gven area or ESR dfferences between areas n whch there s no vsble sweatng such as the patterned dfferences descrbed by us 6), are related to gradatons n sypathetc sudootor actvty ffratve support s suggested by the observatons of Rchter and Woodruff (7) that the sze of low resstance areas around the outh and nose was ncreased durng perods of general sypathetc actvty and decreased wth lessened sypathetc actvty though there was no vsble sweatng n ether case Low resstance areas have also been observed that were regonally or segentally related to pathologcal states of deep tssues and whch ay dnsh or dsappear when the pathologcal process s allevated 8) The partcpaton of sweat glands n these observatons was not apparent but cannot be excluded on the bass that no sweatng was vsble ow rates of sweat gland actvty that are not vsble t o the naked eye have been deonstrated by croscopc observaton 9 10) To clarfy the stuaton requres further nvestgatons nto
19
Fig Digrm of prim-phoo reordig mehod d ppere of reord he hree ompoe prim A eleroi flh ligh oure d mer re rigidly moued i rog lumium frme he mer i poiioed o h ligh from dfuio ree i refleed io he le by he be of he prim (gle equl gle ) Whe hee gle re lighly greer h urfe del of he ki d preee ofwe drop le re lerly obered Preiely pled referee mrk o prim d ki mke i poible o deermie u mber of gld per ui re of ki regrdle of he ppre gulr diorio of he ki field hi fgure he rele ize ofhe prim h bee e ggered for lriy
Fg 2. A ppere of oweg k me re of ki how i A horly fer weig beg A ie we gld pro due pool of moiure h reord drk po i he phoogrph
the ange of sn essane aues than an be elated to sweat gand atvty Ths pape pesents an expemen tal examnaton of he elatonshp between sweat gand atvy and ES R vaues measued y dy eletodes as a step towad evaluatng the elal ty of suh measuements as nd atos of sympathet sudomoto avty. Mhd
The measuements of eleta essane wee essenally ased on the method of Jaspe and Ro ( n whh a sees o f dy ells s apped to povde a wde ange of votages n 5vot seps. The voltage and d eton of uent flow wee ep onstan thoughout eah expement. Ths neessty was suggested by Rosendals (12 dentfaton of these vaables as sgnfantly nfluenng the measue values of esstane. The hosen voltage was
appled o an ndffeent eetode (athode fastened to he ea loe and mang onat wth the tssues hough ondutve pase and a dy slve ds explong eetode (anode. The onduve paste used was ganula and ung su ffed to aade he sn As demonsaed y Rhe 2 y Lews and Zoeman (14 and y Rosendal (1 ths edues he essane a the aaded pont to an nsgnfant evel. A moammee o gavanomete was nluded n the ut. The esstane vaues n the data ae ony asoutely efeale to the eeode sze sated sne Blan and nesnge (5 obseved nonnea vaatons n u en densty wh dffeen eetode szes Eah measuemen was done y mang ef (14 se fm ontat of he eletode o the sn and osevng the sale vaue of uent flow. Resstanes o ondutanes (epoa ohms wee then aulated aodng o Ohm' s law. Atve swea gands have been eoded y wo methods. In pelmnay expemens he odnestahpape mehod desed y Randal (16 was used. The sn was panted wh odne and alowed o dy. A 5m pee of stah pape was hed lghtly aganst the panted sn aea fo a sho peod (12 mn. At te end of ths tme he pape was e moved and a fesh pape pessed agans the aea The num e of spots appeang on eah pape epesented the aumulated total of all swea glands pesentng mosue to the sufae dung the tes peod. ESR measuemens wee made on sn m medately adjaen to the gland ountng aeas. Ths mehod pemed goss osevaons on ESRswea gland elatons ut had he dsadvanage tha he two measuements wee not made on pesely he same sn aeas Ths dsavantage was oveome y usng the psm ehnque desed y etsy (1 By utlzng the alteaton n eleon podued y ontat of mostue aganst one fae of he psm ave swea glands may e oseved and photoaphed as da spos though anohe fae of he psm when evenly dffused lght s shn ng though the thd fae (fgs. 1 and 2). Al phoogaph eods wee taen wthn 2 seonds of on
tat of the psm wth the sn The psm was wped lean afe eah phoogaph B y sutay adjustng the ght and amea ange the exue of the sn an also e oseved and photogaphed. n a sees of photogaphs of the same sn aea ndvdual ave glands an e dentfed y the elaonshp to the ease patten and the atvy foowed though the ente expemental peod Sne no hema pepaaton of the sn s neessay he ESR of he same aea eng phoogaphed an e otaned m medaely efoe and afte eah phoogaph. Ths pems a pese examnaon of the eatonshp eween ESR and he swea gland atvy oung n the eletode aea and the foowng o apd hanges n oth n al expemes he suje was fst alowed to es n a pone pos on at omfoale oom empeaues untl no sweatng was deteed y the psm method The suet was hen heaed y an ee hot pad on he adomen unl sweang was ndued at whh me heang was dsontnued. Reodng o ESR and swea gland avty was ntaed wh heang and onnued though he sweang peod un sweatng was no onge deeae Expma
An example of the esults oaned usng the Randal odnestahpape method and an eeode of 2.54 m s llusated n fgue . As seen n ths fgue sng gland oun was a ompaned by neasng uent fow (deeased esstane Howve when the gland oun was falng he uen fow often emaned elevated Ths mmedate postatvty lag sug gess some esdual effet of sweat gland atvty. The obsevatons of the ag and of the vaatons n on dutane a zeo gland ount sugges a nonsudof' nfuene on onduon The neessty of usng dffeent sn aeas fo ESR and gand ouns n he Randall ehnque howeve peluded any etan denfaton of nonsudof onduane fatos o assgnment of any quantatve ondutane popetes to he sweat glands. The psm tehnque made poss le to measue the uent flow and nume of atve sweat glands fom EMG SS efexes et.
the sae skin aea Results obtained in a epesentative expeient ae il lustated in figues 4 and n this ex peient heating was discontinued soon enough that only one ajo bust of sweat gland activity occued In gue 4 a vey close elationship between cuent flow and nubes of active glands can be obseved Unlike the obsevations with the Randall technique this elationship diffes only slightly fo the ising and falling stages of sweat gland activity his diffeence in ex peiental esults pobably efects the fact that in the Randall ethod oistue poduced by past glandula activity would be absobed by the pape in the gland count aea and thus not appea in subsequent papes, while in the electode aea oistue poduced by sweat glands would e ain afte secetion has ceased and continue to exet a esistance loweing effect he influence of su face oistue has been epoted by Blank and Finesinge and will be discussed late he coelation gaph of data fo the expeient shown in fgue 4 ap peas in figue he solid line was calculated by the ethod of least squaes on the assuption of a linea elationship between conductance and the nube of active glands he coelation coeffcient fo this ela tionship is 899 ± .83 a value which suggests that fo these data the assuption of lineaity can be ade with consideable assuance he equation of this line is o the fo y = a bx n the pesent application y is the total conductance ) and x is the nube of active sweat glands he coefficients a and b ae con ductance values he value of b epesents the aveage conductance inceent of each active gland he coefficient a is t he aveage value fo an additional conductig path ( whose contibution to the total conductance is not diectly elated to te nube of active glands in the test aea n tes of conductance this equation ay be witten
S
G
G
Go
G G G he ecipocals of the conduc tances G" Go and G yield the espec tive esistances R R and R• When these values ae sbstituted in equa ton the second te on the ight the R side becoes
suggesting that
sweat glands seve as paallel esistances in the electical icuit siplied ohic esistance cicuit satisfying equaton is shown in fgue 6 ctual easueents on individual glands wee ade using a fine wie electode touched to the sweat bead poduced duing activity he esistance values obseved fo in dividual glands vaied fo 3 to 20 egohs and ae siila in agnitude to the calculated values of (table ) Siila easueents ade independently by Suchi (18) yielded siila esistance values fo individual glands hese obsevations tend to conf the concet that sweat glands povide paallel high esistance paths fo conducting cu ent though the skin Siila statistical ethods wee used to exaine sepaately the ising and falling gland count potions of ech expeient he lines calculated fo ubect EB o ae shown in fgue he dashed line illustates the ising and the dotted line the fall ing gland count elations he dif feences between ising and falling gland count cuves obseved in the slopes and the nonsudoifc' coeffcient a wee elatively sall in this and in ost othe subjects s was als tue of ost subjects slopes wee steepe and nonsudoic coef ficients wee salle in ising than in falling gland count potions of the ex peient he diffeences ae not statistically signicant in these sall saples but do suggest that the con ductance of each gland is highe at the tie of active sweat expulsion than when sweat is just pesent in and aound the tubule he signicance of the changes in nonsudoific' con ductance will be discussed late able I copaes the esults fo six expeients on fou subjects hese expeients epesent the widest individual vaiations obseved in sepaate expeients he values ae tabulated in the oe fe quently used tes of esistance Ra and being espectively, the ecipocals of and he values fo ae those deteined b cu ent ow easueent at ties when no sweat gland activity was ecoded n each colun of table dif feences in the esistance values ae obseved fo subject to subject and in the sae subject in diffeent ex
f u
S
G G
R R
G
G
60
Z <«
R
7
Cn V n Cn
K
4 5 6 MNUTES
1
8
9
g. Reton / current /ow to numbers ctve gnds (Rnd method) Acte gnds were counted by Rnd odnesthpper method descrbed n tt (Imn perods nd current ows were mesu t end / ch perod Contnung hgh current ow durng /ng gnd count phse s referd to s 'g n the text.
F < «
Cl Go o _ MINUTES
g Reton /cuent ow to numbers / ctve gnds (prsm method) Current ow msurements nd photogrphc records / number / ctve gn were nty mde every sec At onset / swetng recordngs were mde t sec nters Cuent ws recorded mmedtey ter ch photogrph
R
peints he sallest diffeences ae obseved in fo the sae sub ject Diffeences aong subjects ae sallest fo the values of and lagest fo values of he pooest coelation obseved to date was in ubect HW exp lthough no explanation can be of feed at this tie, envionental tepeatue ay have been a facto in that it was lowe fo that epei ent than fo any othe Futhe studies at low tepeatues (20°24°C) ay eveal a basis fo such diffeences in the conductance sweat gland elationship as obseved in HW
R
R
3
N 5 55
F
'
V x � u
dnrn; n rnq 0 0 N 0 C
g 5. Corlaon graph for renal daa hon n g 3 old ne A how he la ohp of curn ow o glan for boh ng and dnngph ofwea gland acvy Dhed lne R how relaonhp durng only ng ph and doed ne F for fang pha Th ne alo obaned by ehod of l quar
g 6 pled cheac ofkn reance crcu Toal reance of he kn prened a pled elecrl nework A varable nur ofw glan a pcurd a a varable nuber of paralel rance " R . R R n he nework A non udorc rance RJ ao appea n parael wh gland anc and repen a varable coponen n accord wh urfa ou n dcud n he
The equaton from whch was obtaned mpes that for N = O / should equal Q • H owever the actual ly measured value when no actve sweat gands were present ( = 0 was n every case much arger than . The relaton of these observa tons to the nfluence of surface mosture provded by sweat secreton or other sources s dscussed n the next secton Dio
The physologcal sgncance of ESR gradatons s ndcated by the fndng n dfferent subjects of consstently near relatonshps between the number of sweat glands propellng osture to the surface and the con ductance through the sn The data suggest that eac secretng sweat gland lowers resstance n two ways:
a by servng as an added parale hgh resstance n the eectrca crcut and b through the nfluence of the mosture produced on the resstances of nonglandular tssues. Magntude of the average resstance vaues ( caculated for sngle glands from the expermenta data presented s smlar to actua resstances of ndvdual actve glands observed n our laboratory and n dependently by others (1 8. The con cept that sweat glands form parale resstances s also consstent wth Darrow's observatons ) that the conductvty n mhos or mcromhos (recproca ohms was neary related to the amount of perspraton. That the amount of perspraton was generally reated to the number of ac tve glands was ndcated by nvestga tons of Hertzman e al (19. The nuence of surface mosture on ESR has been demonstrated by Ban and Fnesnger (15,y Farmer and Chambers (20 and was shown by Rosendal (12, 13 to be a drect physca nfuence of mosture on nonglandular components of the sn Ban and Fnesnger showed that durng prolonged wettng of the elc trode area the resstance decreased to reach stabe vaues n 3 mnutes of mostenng. A smar tme course has been observed for hydraton of the stratum corneum (21, suggestng ths as one factor tendng to decrease the resstance. The resstance lower ng nfluence of surface mosture s aso due n part t o a change n effec tve electrode radus whch occurs when the tangenta resstance of the sn s decreased (1 5. Snce surface mosture s produced n our experments and snce the ex perments have a duraton of 1 01 5 mnute t appears qute evdent that surface mosture s present as a factor n our data. A measure of ts n fluence s suggested by the dfference between the values of and snce s obtaned before and s the average vaue obtaned durng the ad dton of surface mosture by sweat secreton. The same nfuence would account for the dfferences between the vaues of caculated for the rs ng sweat gand count porton of the experment and those caculated for the falng gland count porton If the vaues of and are affected by hydraton of the stratum corneum
TABE Coparon of perenal rul
bjEpan ! I
I
R.
Z
I i (c) I�R�m.! , i ,
u
R, mT
f
.
1
: 1
302580 43 , 4 3 1 ' 00 555 0 " 7 970 3 5 5 6 5 7 iI0 5 5 , , 3 , 9 : 5 6 5 S3
·I3t 908087 960 09 . 3 0
Al reance value are n egoh and R a recprocal of calculaed value O and O rpevely d n he R w he ance eured a a e when no ac ve glan were record Colun r gv he Peaon produc-oen coefcen of cor relaon ween he daa and a nr cur ob aned by ehod of lea quare. "Nur ofeaureen ofcorrepondng gland coun and curren ow durng each experen.
tS andard error
=
r 2
Whee n i the
umbe of msums
they should exhbt some dependence on nta hydraton as nfluenced by envronmental humdty. Athough we have not systematcally studed ths varable n repeated exprments on the same subject (B both and were lower when the humdty was ncreased. It appears therefore that under condtons of moderate envronmen ta humdty wth the drecton and magntude of appled voltage and eectrode sze constant varatons n resstance of an area of sn n a gven ndvdual are related to varatons n the number of actve sweat glands and t the surface mosture produced by ther actvty The reaton of con ductance (recprocal ohms to the number of actve sweat glands s very neary near. A gven ncrement n conducton thus reflects essentally the same ncrement n sudomotor ac tvty rgardess of the ntal eve of actvty. The bass for ths observa ton appears to be that each actve sweat gland contrbutes a conducton path that s eectrcaly analogous to addng a resstance n paralle to the other sweat gand resstances On ths bass t appears that ESR s a relable ndex to sympathetc sudomotor ac tvty. The tentatve dentfcaton of sudorfc and nonsudorfc conduc tve paths provdes a bass for future nvestgatons nto the factors n EMG SNS reflexes etc
fluencng each path Ths wll futhe clafy the combnaton of factos detemnng the electcal esstance of the skn and pemt a moe pecse ntepetaton of ESR gadatons among dffeent ndvduals and among vaous skn aeas of the same ndvdual
eferece
\
Darrow CW J Gen ychl : 41 194 2 Richer, CP J. Neursurg 181 1946 helan FG and CP Rcher Arch. Neurl. Psycha 49 44 194 4 agner H Jr Arch Der yph 6 4 192 Raclffe A Hall and RP Jepson J. Neuu 7 190 6. Thomas PE ad M Korr Elecr echalg . Neurphyl 61191 7 Rcher C and Bye G Woodruf ull Jhns pkns sp. 70 1942 8 Van Mere TE Jr . Jhns pkn sp. 8 1949 9 Jurgensen E usche Zhr kl M 144 19 10 Jurgensen E Deuhe shr kln M. 144 19 1924 Jasper H and P Robb J. Neursurg. 2 261 1 12 Rosendal T. Aca physl scandnav. 8 18 1944 1 Rosndal T Aca physl scndnav. 10 194 14 Lews T and Y. oerman J Physl 62 280 192627 1 Bank H and J E Fnenger Ah Neurl ych 6 44 1946 16 Randa C J n. Invs 2 761 1946 Psych. : 17 etsky MG A rch Neurl 279 1948. 18 Such T Jap. J Physl 7 19. 19 Herzman AB WC Randall C Pe H
&
&
E. Ederrom and R Seckendorf A . J. Phys Med
1 170 192
. Farmer, E and EG Chambers. r. J Psychl 1 27 192 21 es C Randall and AB Hertzman 12 10819 F
Reprned by prmson from Journal o Appled Physology 10 010197
Ptterns of electric skin resisnce in mn* (1958 IRVN M KORR, PRCE E THOMAS and ARRY M. WRGHT
bout 10 yeas ago we undetook electcal skn esstance exploatons upon lage numbes of subjects as pat of an appoach to the study of egonal and segmenttosegment vaatons n sympathetc actvty Dung ths same peod thee has been a geat gowth of nteest n ths field n localzed o segmental autonomc dystonas and n the functonal and clncal mplcatons and many of the nvestgatons have been epoted n ths jounal Whle the ogns sgnfcance and mechansms of these segmental deva tons n autonomc functon ae as yet pooly undestood, thee can be lttle doubt of the hgh ncdence and of the mpotance Ths epot, based on skn esstance exploatons upon seveal hunded subjects and pa tents s ntended to be a contbuton to ths feld The valdty of the electcal skn esstance method as an ndex, at least unde cetan ccumstances to sympathetc actvty seemed well establshed by evdence such as the followng Electcal skn esstance (ESR s elated to actvty of the sweat glands Ths elatonshp has been quanttatvely examned by us 2 Inteupton o etadaton of the flow of mpulses ove sympathetc pathways to a gven aea of skn causes maked elevaton of esstance n that aea, whethe a by seveance of pe o postganglonc pathways 38 9. 41 ; b lesons of the spnal cod ; c by pepheal neve lesons
2 3 12. 13 IS 36.
37 ; d) or by pharmacologic
blockade 3 Stmulaton of sympathetc pathways ethe locally o systemcal ly lowes the esstance .2123242.3
3 43.
4 lthough demacaton of (anhdotc, hghesstance aeas to whch the sympathetc supply s nte upted s shapest when done n a "he nvegaon were uoed n par by gran rom he aonal nse o Healh ublc Healh Sevce (B29 and H·32) and from he mercan Oeopahc ocaon ad b a ona (onr 24) wh he Ofce o al Reeac
backgound of sweatng (low ess tance nduced by heat o daphoetc agents, the above elatons among ESR sweat glands and sympathetc actvty hold whethe o not thee s the fank appeaance of pespaton Snce ou concen was wth topogaphcal gadaons n sympathetc actvty especally wth the possble ncdence and dstbuton of aeas manfestng exaggeated sym pathetc actvty and the possble elaton to segments of low moto eflex theshold, we tuned to the study of skn esstance pattens unde cool estng condtons n whch vble sweatng dd not occu and n whch esstance was pedomnantly hgh It s shown n ths pape that lowesstance aeas (R ae found n appaently nomal ndvduals, that the dstbuton of these aeas vaes fom ndvdual to ndvdal and that the segments of the tunk n whch the R pedomnate may eman con tant n a gven ndvdual fo long peods of tme It s of nteest to note the paallelsm (though no dect elatonshp s yet establshed to the obsevatons of Dens/ow and hs cowokes on ntesegmental vaatons n motor eex thesholds In electomyogaphc studes on eex esponses o the spnal extenso muscles, they found, n most subjects one o moe segments whch wee dstngushed fom the othes by makedly educed moto eflex theshold and n whch motoneuons (supplyng the paavetebal musculatue wee appaently mantaned n a chonc state of facltaton Pattens of dstbuton of the lowtheshold segments vaed among subjects but wee hghly constant fo each lthough most of the data on whch ths epot s based have been avalable fo seveal yeas, we have wthheld publcaton untl we could assue ouselves that the egonal skn esstance dffeences wee elated not to some andom vaaton n skn qualty o n sweat gland dstbuton
3
but to signiicant functional dif ferences Through an extended series of investigations to be cited later) regarding the nature origin and basis of LR we have become convinced that they represent nurophysio logical phenomena of considerable interest and are worthy of further in vestigation Lowresistance areas seem not to have been systematically investigated except as reflex manifestations of painful conditions or visceral disturbances see Discus sion) This and another recent paper are the rst full reports of this series of investigations; they are intended to introduce the phenomena for further study Method
Since the explortions represented in this paper were done over a period of several years a variety of methods are also represented which were developed and applied during that time. These are described in this sec tion The conventional principles of resistance measurement are however common to all three methods de scribed Essentially each method consists of measuring or recording in correct spatial relationship to the explored area the momentary current flow through skin in contact with the con stany moving exploring electrode at known voltages The voltages are tapped stepwise from a series of dry cells and applied to a n electrode fixed to an earlobe and an exploring elec trode Resistance of the skin of the earlobe is minimied and stabilied by means of a needle puncture or by ap plication of electrode paste reato area differences in current low at a given voltage therefore are due to differences in the "resistance of the skin under the exploring electrode In view of the multiplicity of unknown physical factors and "cir cuitry such as polaried interfaces and membranes capacitances and critical potentials which determine current flow through the skin at various applied voltages there seems to be little advantage in converting the primary measurements of current and voltage to an inferred quality identified as resistance and measured in ohms The term "elec n hs y seconry excory or olrao es of he rre e mnmed or emne Rer
trical skin resistance ESR) has achieved such wide usage however that it would seem unwise to in troduce new terminology provided it is borne in mind that the patterns presented here are graphic representa tions of current ows through dif ferent areas at constant specified voltage The Dermometers 1 Explora tions with HandHeld Electrode In our earlier studies we employed an in strument basically imilar to that described y Jasperl4. Current flow is read from a microammeter as the electrode is moved over the subjects skin 2 utomatic Explorations In order to minimie the sources of error the slowness the inconvenience and other objections to the above method of ESR explorations a nearly automatic dermometer was developed which photographically records ESR patterns on large areas such as the trunk The automatic dermometer con verted differences in current flow through the skin at constant voltage into variations in the brightness of a light source By placing the light source directly over the exploring electrode and by propelling the elec trode over the skin at constant speed a properly positioned camera with shutter open recorded strips of light which varied in brightness according to the ESR ie current ow) dif· ferences along corresponding strips of skin. To explore a large area a series of consecutive parallel strips is recorded. More recently we have developed a simplified more convenient and mobile adaptation of the automatic dermometer which eliminates the need for photographic procedures constant speed and optical alignment The skin resistance patterns are recorded directly on paper by a re cording galvanometer whose amplitude of oscillations is related through an amplifier to the skin cur rent. The position of the galvanometer writingpoint on the chart is related to t e position of he exploring electrode on the subject by means of a pantograph. Results obtained with all three methods are presented in this report B. Exporation Procedure 1. Ex
ploration Conditions Explorations are conducted in a quiet room main tained between 23 and 25C The subject undresses the area to be ex plored The studies shown here have been mainly on the back Before beginning the exploration it may be necessary to permit the general resistance see later) to become stabilied since it may continue to rise for a while with cooling or with rest Explorations are conducted with the subject either lying prone on a padded table with a face slot or seated comfortably on a stool with his forearms resting on a table 2. Selection of Exploration Voltage fter marking the tips of the spinous processes as landmarks on the skin the exploration voltage is selected according to the subjects general level of resistance This is done by applying increasing voltages from 15 to 18 volts) while sampling the different areas of his back with a touch of the electrode and determin ing that voltage which keeps max imum momentary) current flows well within the 50microammeter range of the meter 20 30 a) nder these conditions most of the skin of the trunk permits barey detectable cur rent ow or none 1 a or less) In this way the lowresistance areas are sharply distinguished and graded according to the method employed by large excursions of the microam meter needle hand method) dim ming of the light source on the photo graphic dermometer or widened excursions of the oscillating galvanometer of the pantographic dermometer By properly selecting the exploration voltage in such a way that the maximum range of current variations is the same in all explora· tions regardless of the general resistance leel it is possible to com pare and grade areas in the same sub ject or in different subjects according to current ow or as fractions of the general resistance Regardless of the mehod employed therefore the method con sists of the mapping and grading) of islands of low resistance (high current ow) in a general background of high resistance minimal current flow) under conditions of rest. 3. Exploring and Recording x plorations by hand were conducted in a manner similar to that described by Rchter0 for the mapping of EMG SNS reflexes etc
t! 2 .'
399 5\
�v
,
/
Fig
Fig 13
adrot areas te sweatg patet Te areas of low resstae reveaed are reorded o stadardzed body arts su as tat sow Fg 2a ad a Te reatve ress tae values are grapaly represeted o te arts by sadg of te orrespodg areas Areas w permt te flow of o more ta a at explorato votage as te eetrode passes over tem are left u saded; tose w permt a mometary flow of 20 a or more at te explorato voltage are reorded bak Te termedate values are
dvded amog four sades of gray I exploratos by te potograp metod te ESR patters are reorded o fm ad appear motage o a potograp of te subjet take mmedately upo om petg te explorato Te bla ad wte areas represet te same urret flows as desrbed above for te arts but te termedate values may e estmated by om parso wt te albrato strp w appears ea potograp ad w sows a steps sadg from 0 to 22 Te urret flows a
be estmated dretly from te pa tograp arts also I tese owever te amplfer as bee adusted so tat te wdest oslatos produg te darkest area o te art represet 0 a Te explored area s sow ea art or ret spatal relato to a patograp trag of te body outle If desred resstae or odu tae Daow' values for ay areas ay of te arts may be estmated from te explorato votage stated o ea art ad te urret flow daed by te reordg metod
Uy
-0
Figures Illustrating individualit ofESR paes and the onstan ofsegmental dstribution oflow-resistane areas in 8 subjets Note the periods intervening between sueeding explorations for eah subjet A desribed in text explorations have been done with 3 different methods: I Hand-held eectrode: Figs 2a 3a 5a, 7a 7b 8a; 2 Poogrpic recorder a, Ib 2b 3b, 4a 4b b 7, 8b 3 Pnogrpic recode 6a, 6b 8 n all figures dark areas represent low-resistane areas of skn on bak. Darkne of shading in hnd-dwn c and in oogrhic record is in proportion to urrent ow at exploration voltage; the darker the area the lower the resistane White re I} or less (resitane, in ohms at least I million tim the number of volts) bck re 20a or more; i e less than 1 /20 of basi resistane gy re intermediate values (Reprodution of these figurs has darkened the gra areas and the darker shades have beome indistinguishable from the blak areas) n the pnogrphc reord (Figs. 6a 6 b 8) amplitude ofosillations ofthe reording galvanometer are related to urrent flow through the skin The thin vertial ines (no osillation) represent areas permiing 0 to Ia a exploration voltage widest osillations represent urrent flows of30a or more n these harts therefore, the darkest area repreent /30 the basi resistane or less p of spinous proesses and the saral base are marked in photographi and pantographi harts. lso note alibration "strips, showing relation between urrent and amplitude of osiations (pantographi meth od) and between urrent and shading (photographi method) in step of 5a.
A dividuaity oj ER patts g 1 to 8 repreent exporton onte on 8 erent bet n
6
ltrte the vety o pttern whh re obtne. In or explor ton o hnre o bjet we hve not on two ent pttern,
thogh ertn etre my or n ommon n ertn pn verl trbne n lthogh owretne re or wh EMG, SNS, relexe et
gnfcnty hgher freency n ome regon (eg. mbr) thn n other B Rpoduiiity of gmta Pats xporton concte pon the me bject t fferent te re o how n n g. I to 8 I n thee bject, n mot of thoe who were repetey expore over ong per of tme, the trbton of the re of low retnce howe hgh egree of reprocbty tht , the octon n rrngement of the preomnnt re, wth repect to egment evel n eft n rght e, remne remrkby contnt (more thn Yz yer n the ce of LC g n mot 4 yer for J. G g. 8) . C aiatios of diidua Pat ts "eprocbty of pttern n no ene however mpe fxty or contncy of the ze n hpe of the owretnce re or ther retnce ve, nor oe t mpy n vrbe preence of thee re n the bence of other. A we known, S n extremey be fetre, bject to nm ero n b te nfence Neverthee, epte th bty repete "mpng of the pttern of ech of mny bject rng gven y or over pero of week n month reve tht n ech bject there re certn zone or egment eve n e n whch the poaiity of fnng owretnce ve (tht hgh crrent fow) retve to the gener eve fr greter thn tht n other r Of thee, ome how hgher probbty thn other o tht prt of gven bject " pttern my be bent from tme to tme wh e other re fon n vrty every expor ton rthermore, the recrrent re of ow retnce, tht , the "hgh probbty re form pttern of trbton whch chrctertc for the bject Athogh other re of ow retnce occr, even ner the conton of or exporton, not ony re they retvey nfreent n evnecent, bt they re o p
J
(g a wee eea two ha o be eleed o lae aaon n hape ze loa on and eane ae o LRA whle he egenal ee ad e on w ey o ean eenall ged a ba area he an d eene bewee e degee o pead o he dlne
uha
ote the the ist two has is i th
g.
ppant matomal stps of low sstan.
prenty rom oow o cerbe or repocbe ptter owr better nertng of the ntre of the ptter n of o r crter for the etermton of "pttern, t of nteret t revew the rnge of vrton n S n n retore fference tht my be een n the core of nge eon of er exporton D.
asitioa ags i Pat
In coo wether n whch kn retnce (of the cothe bject) moertey hgh the re of ow S re y mmetey t
tnghbe pon brngng b ject nto the bortory for expor ton n mny remn o for pero of hor In wrm wether or foow ng phycl exerton, exctement etc the retnce o f the kn of the trnk genery ow even thogh there my be no vbe perprton, n gry cmb for ome tme fter t q bject recne n the cooe room Drng the pero of o retnce the ppcton of even the owet exporton votge of the ermometer (15 or vot) proce rge crrent fow throghot the ex porton re, renerng mpobe 7
the dfferentaton of relatvely low and hghresstance areas Wth the use of fractons of a volt however t s possble to demonstrate even under sweatng condtons lare areatoarea dfferences n current flow) s the subject rests wth the ex plored area exposed there s a general progressve elevaton n skn resstance n whch certan areas lag far behnd others and a pattern of relatvely persstent lowresstance areas emerges hat s most of the areas of the trunk cease to pass more than 1 a at the low exploraton voltages whle certan zones, whose pattern of dstrbuton s character stc for the subject stll conduct large currents at the same voltage Wth contnued rest and coolng there may be further general ncrease n resstance so that at low explora ton voltages there may be no ap parent current through most of the skn and only a few mcroamperes of current through the lowresstance areas n ncrease n voltage re establshes the wde dfferental and the pattern of lowresstance areas re emerges It s of nterest to note that n general progressve ncrease n resstance durng rest and coolng proceeds from the perphery cen tralward so that areas of low resstance appear to contract toward the mdlne§ Eventually there s stablzaton of the basc resstance and no further n creases n voltage beyond 6 to 9 volts for most subjects) are requred for the demonstraton of resstance df ferences In ths manner despte the large changes n absolute values areas of relatvely low resstance may reman dfferentable over perods of 2 or more hours although there s usually a reducton n ther sze dur ng ths perod and some LR may vansh entre y he frst areas to dsappear are those whch n precedng exploratons had shown only small or moderate current flows (eg 3 to 5 that s those whch would have appeared n gray on precng charts
§We ha e repeaedy bered h e nracn and ex pann ward he mdn nder many r msances ncdng epermena pedres res and age cng and warmng he bje ec These appear smar berans b Rch and o n changes n aa paen w esan
38
Wth prolonged rest especally at lower temperatures there develops an almost unformly hgh resstance n most subjects and only small rem nants of the orgnal pattern may be dstngushable wthn the voltage range of the dermometers he most persstent areas are those whch showed large current flows under the usual rcumstances of our explora tons hey also show early and large decreases n resstance upon re warmng the subject Of greatest nterest n ths connec ton s the fact that those low resstance areas whch are dfferen table n each subject for the longest tme durng a perod of rest and col ng as shown by seral exploratons durng such a perod are also the ones whch occur wth hghest fre quency n occasonal "samplngs over perods of weeks and whc h con sttute the domnant features of the subjects "pattern It should be ponted out that although most subjects show a basc stablty or reproducblty of pat terns conspcuous changes have been observed to occur spontaneously n a number of subjects whose patterns had been followed over perods of months or years and others have been expermentally nduced he orgns and character of these changes wll be examned n a later paper E Possibe Segmena Basis jor he Paes A segmental bass for at least some lowresstance areas s sug gested by the frequent presence of "strps of low resstance whch ap pear to have dermatomal dstrbu ton Such strps are apparent n both exploratons of Fg 2 and n Fg 7 b Fg 9 llustrats other strps that have been observed the strps may extend from spne to sternum and occa sonally encrcle the trunk In ex permental studes 9 to be reported more fully elsewhere we have also been able to nduce new low resstance areas whch show dstnctly dematomal arrangement Dicion
It appears from these studes that the reproducble patterns of low resstance areas demonstrable on human subjects consst o f those areas of skn n whch the probablty of fndng relatvely low resstance values at any tme s much greater
than for skn at other segmental levels or sdes hs hgh probablty s based on the fact that n these areas the low resstance s most persstent under condtons whch tend to elevate skn resstance and because ther resstance decreases earler and to lower levels under condtons whch tend to lower t In effect each occasonal explora ton of a subject over perods of weeks or months s the " catchng of a pattern at one stage or another of a transton from generally low levels of resstance towards genally hgh levels or vce versa he hgh reproducblty of each subject s pat terns of lowresstance areas s related to the hgh probablty wth whch the resstance of those areas wll have dropped n advance of others and stayed low after the others have rsen In short the "lowresstance areas are those whch are present for the longest perod durng each transton and therefore the most lkely to be found n occasonal samplngs On the bass of the fndngs descrbed by Thomas and Korr and others cted n the ntroducton t would appear that lowresstance areas are those n whch at the tme of measurement a) secretng sweat glands servng as parallel hgh resstance pathways through the skn are present whle none are actve n other areas b) are present n larger numbers or c) n whch larger amounts of resdual mosture from past secretory actvty) are present It would appear that one of the chef reasons that these regonal varatons n the ESR of the trunk have been prevously mssed or dsregarded despte the very large numbers of subjects that have been explored n many laboratores and clncs s that the 2 to 20 or 30fold dfferences n resstance upon whch our patterns are based are small n comparson wth the approxmately thousandfold resstancevaraton of whch human skn s capable Thus for example the resstance of cool dry skn s ordnarly treated as unformly hgh (tens of mllons of ohms) and that of sweatng skn as unformly low (tens of thousands of ohms) wth "neglgble varatons at each level In contrast our procedures and therefore our ndngs are based on the followng prncples EMG SNS reexes etc
W xamn th aratoara var aton around th gnra l rtan vl found n th ar tular ubjt at th tm of xlora ton In th way th dffrn n vl from ubjt to ubjt and from tm to tm and aon to aon n th am ubjt, ar " buffrd out. Th omarabl to t tudy of momnttomomnt vara ton around a gnral rtan lvl n ltd ara, a n yhogavan tud. 2 W ondut t xloraton undr ondton (th ubjt rtng n a oo nvronmnt n whh th gnra rtan lv modraty hgh or gradually r n thu harnng th dffrntaton of th rdual rlatvly owrtan ara That by avodng th lvl ng xtrm of vry low rtan (watng and vry hgh rtan (hld ubjt gradaton n r tan ar mot larly dmontratd W wr,nvrthl abl t o dmontrat attrn of ESR varaton ovr a wd rang of rtan lvl, nudng th ow va u ao atd wth atv watng 3 Exoraton votag adjutd to th gnral rtan lv n uh a way that th rang of urrnt vara ton farly ontant and ndn dnt of th gnral rtan vl Whn th don ry thn ara howng dnta urrnt fow bom quvalnt rgard of thr absout rtan valu That a gvn urrnt rrnt th am fraton of gnral rtan (or th am mutl of gnral ondu tan whatvr that vl ma b rgardl of th ubjt th aon or th rumtan W hav found howvr, that,for uro of dmaraton of attrn of lowrtan ara, th ror ton of xloraton votag, though mortant, not rtal Thu ang of 3 or mor vot ony afft t rang of urrnt varaton (and t darkn of hadng of th hart wthout gnfantly afftng th attrn ** Ioatd n th mannr from th ·In m n xpmn" pd m uy ss av n dma ESR pns n a a ang f un van f 2 hruh he use f pa lae and pppa ampan (Cmpa
D v W
gro vtovl hang th malr varaton n ESR at any gvn lvl aum a largr quanttatv gnfan Though n ordnary rtan maurmnt thy um agbraaly wth th ba or gnra rtan, th malr ESR varaton how ondrabl ndndn of th ba rtan v. Th ug gt t obty that th fator whh dtrmn th aratoara df frn hr rortd (and rha alo tho dtrmnng yo galvan flutuaton ar dffrnt from tho dtrmnng th gnra v at whh tho varaton tak a n th am n that th oar and fn adjutmnt f an n trumnt may b arat and qut dffrnt mhanm who aton ar agbraally addtv Mor drt vdn for a duaty of ba fator rvwd by Thomas and KoO• It ntrtng to not that Rgsbg27 alo arb h ltrodrmatogram to a ombna ton of fator At any rat thr an b lttl doubt of th raty of th ESR at trn and of thr raton to hyo log varabl Thr vry xtn and rrodublty, a wll a thr hang wth xrmntal and nal varabl ra fundamntal quton rgardng thr hyolog ba and gnfan that dmand anwrng Stud by many nvtgator td n th ntroduton to th ar aar to hav abhd qut frmly that ESR ratd to ymatht atvty xrd through th wat gland ntrru ton or rtardaton of th low of m u ovr ymatht athway vat ESR wh ymatht tmulaton rdu t Sn th rrodub ongtrm aratoara dffrn n ESR rortd hr wr n no way rlatd to any aarnt tmuaton or ntrruton of td ymatht atway n trtng quton wr rad r gardng thr orgn ba and fun tonal maton Ath ou gh t ESR attrn thmlv rmt no frm onluon on t ont th obrvaton by othr nvtgator frrd to abov on th rlaton btwn udomotor (ymatht atvty and ESR a wll a our own obrvaton on th raton btwn ESR and wat
gland atvty, uggtd that th attrnd dffrn n ESR, a maurd by u, wr ao ratd to attrnd dffrn n ymatht atvty A obl rfx orgn of RA (a wl a of othr utanou manfta ton of loal ymatht hyra tvty 6 ha bn ndatd by vral nvtgator who dmon tratd th gmntal or toograh al aoaton of ara of hyr hdro 6 of ow kn rtan or of altraton of othr ltral rort of th n wth anfu odton and vra d turban (Alo ommnt by Richt on low rtn ara aoatd wth lung nfton and ury In vw thrfor of th obl hyolog and lnal mlaton of t rtnt ara of low r tan, u a tho drbd hr w hav undrtakn xtnv nvt gaton nto tr natur ba and gnfan durng t at fw yar, om of whh hav bn drbd n rmnary rort to th Amran hyologal Soy In th n vtgaton w hav xamnd th rlaton of ESR to maurd wat gland atvty s omard th funtona ron of ow and hghrtan ara to a varty of tmul and undr a varty of r umtan, xrmntally mod fd ESR attrn and ndud nw RA xamnd gmntal and r gonal orrlaton of lowrtan ara wth othr (vaomoor nuro muular and nory fatur and wth lnal and xrmntally ndud dturban h tud whh wl b rortd mor fully n udng ar hav onvnd u that th rtnt ara of ow kn rtan do hav mortant funtona and nal mlaton rlatd to rgonal varaton n xtablty of autonom athway whh mrt fur thr nvtgaton. Th ag n xtablty aar to b arall to tho ndatd for motonuron by th tud on motor rfx thrhod td n t ntroduton to th ar Howvr bau of th unrtanty of rlatonh btwn ymatht drmatom and aravrtbral myotom, t ha not yt bn obl to dtrmn th ratonh of RA to lowthrhod 9
segmes ahogh some ommo ogs ae daed Summa
1 As a appoah o he sdy of egoa o segmea vaao sympahe avy sk essae expoaos wee oded o he baks of sevea hded sbes de esg osweag odos 2 The mehods sed ded he oveoa expoao wh hadhed eeode ad wo semaoma eodg mehods 3 The foowg ppes haaeze o mehods: a) Momeay e ow s ead o eoded oe spaa eao o he expoed aea as he expog eeode moves ove he sk whe a osa voage s apped b) Aeaoaea vaaos essae po he geea essae eve fod he sbe a he me of he expoao ae deemed ) The expoaos ae oded de odos whh essae s geeay hgh o sg d) xpoao voage s ads aodg o geea essae eve sh a way ha he age of e vaiations s fay fom egadess of he geea essae eve 4 Aeas shapy dffeeaed by ow essae hgh e) vaes wee fod a sbs The paes of dsbo vaed fom sbe o sbe 5 Repea sampg of paes eveaed ha he paes of segmea dsbo of he eavey owessae aeas wee hghy epodbe ad haaes fo eah sbe oe ove peods of may mohs ad despe age hages he geea essae eve 6 s show ha he paes oss o of sk aeas fxed ow esse b of aeas segmea eves ad sdes) whh he po ay of fdg ow essae vaes hgh e ow) as ompaed wh he geea essae a ay me s hgh As ompaed wh ohe aeas of sk hese aeas show mh age ad eae deses essae asos
a
fom geeay hgh o geeay ow eves of essae; he ow essae vaes ae mh moe pesse hese aeas asos fom geeay ow o geeay hgh eves of essae 7 s sggesed ha he faos whh deeme he aeaoaea dffeees essae may be dffee fom hose whh deeme he mh ag vaaos genea essae eve 8 A segmea og of a eas some of he owessae aeas was daed he feqe pesee of appaey demaoma sps The eao of R paes as meased hee o egoa vaaos exaby of aoom pahways s bey dsssed
2
Nrsrg Sprngd (1 945) 261-268. 16 Kodus . Dsrdrs ecrn wh ppc (194 933-934. cr Vra d har 1 7 Korr IM. and MJ Goldstein. Drmama anmc acy n ran sgmna mr r hrshd Fd rc (198) 67 18 Korr, IM Sn ssanc pans asscad wh scra dsas Fed r 1949 87 19 Korr, IM Epmna aran n sgmn a sympahc (swa gand acy hrgh myasca and psra dsrbancs Fd Prc
26
(1949) 88 20 Korr IM and P ho Sgmna pa (1951 75 rns n man Fd rc 21 Lawoh O R an d CP Rchter Th n
10
nc rn crbra pahways pn h sym· ( 1930) pahc nrs sysm Bran Lndn
18-193 22 Lie M Masrmn crca sn (1933) rssanc Arch Nr sychar 828-842 23 ne, M, and P Richter rdc aacs
29
gasrc pan accmpand wh mard changs n crca rssanc h skn Arch Nr sychar (1935 1078-1080.
33
24 Minor br rn lkrn
Hauwdrand b ramshn Akon d ( Hasympahs Zschr Nurol Brln
85
eferece
I AdaRa J Sds n a cans par r n h h crca sgmn n cardac pan (l 953) 457-472 Aca Md Sand 2. Blades B and DJ Duan, War wnds h chs bsrd a h hracc srgry cnr War ed Gn Hspa J Thrac Srg S Ls
16
13
(19) 2-3 3. Besch, SR, and P Richter, Cans dsrbuon o rphral nrs n rus mnks drmnd by h crca sn rssanc mhd (1946), 2352. Jhns Hpkns Hsp B 4. Darrow C , Snsy srry and ra changs n h sn wng bdy can J E· (1927) 197-226. pr Phsych w . Th sgncanc sn rssanc n h gh s ran h amn prspran A prmnary n J Gn Psych Wrcsr, I (1934 451-452 6 Delore . and M Leder, Inr d a hr (1952 mmr can Prss Md
8
10
60
48257 25 Palubo, L . H H Saber, J C Ho! and
Burke Pspra swang parns n hracmbar sympahmy and spanchncc ( 1950 59578 my Arch Nr sychar atcle A Ha and RP Jepo Sn rssanc changs n h wr mb ar mbar gangncmy J Nrsrg Sprngd ( 1950)
63
26
97105 27 Relseer H., Dr bdng und d
ga hyhmk ds Mnsn da gs am Errmagrmm Aca nreg Wn, Spp I (1952) Rchter CP A sdy h crca sn rssanc and h psychgaanc r n a cas (1927) nara swang Brn Lndn
50
21-235 29 Richter C.P, Th crca sn rssanc
Drna and day arans n psychphc and n (1928) nrma prsns Arch Nr Psychar
19
1059-1 7 lw JS, An anayss h araby
488508 30 Richter CP hysgca a nd n
spn r hrshds J Nrphys Sprngd,
(I929) 5-615
(1944) 7-215
h crca rssanc h sn Amr J Phys
8 Denslow JS IM Korr an d D Ks Qana sds chrnc acan n hman mnrn ps Amr J Phys {I 947)
3 1 Richer C.P ahgc sp and sm ar cn dns sdd by h crca sn rssanc (1929) mhd Arch Nr Psychar
mprar can dans Inarcs d mycard (1 951 80-96. Iangn d pn ardga 10 Goeha A A skn rssanc rcrdr r sdmmr Fd Prc (1949 55. 1 1 Gutan, L, Ubr rkrsch Bzhngn wchn Vsra nd SchwrUsn nd hr Bdng b Erkrankngn nnrr On (dr (198) srsdra ) n Nr:!
ranecns h spna crd a drn s (1930) 1 107- 1 11 6 Arch Nr sychar 33 Rchter P and BG oodr hangs prdcd by sympahcmy n h crca (1941) rssanc h sn Srgry S Ls
/05
229-238. 9 Dot J.P and C Ferr Inga d a
19
8
1
2311 12 He E GH Glar J Moldor and I
Hoen Ecca sn rssanc s n aan
prphra nr nres Arch Nr Psychar (1946) 365-380 hcag 13 Han I and Beswick Masrmn sn rssanc n prphra nr nrs War md
56
8 ( 15) 258-2 14 Jper An mpred cnca dmmr J Nurosurg, Sprngd 2 (1 95) 25-2
IS Jper and P Robb Sd crca sn rssan n prphra n sns J
21
363-375 32 Richter P and MB Shaw, mpe
10
957-970 34 Richter P and Bett G Faca
parns ecrca sn rssanc r ran sep, rna mperar, har dsrbn sensry drmams and sn dss Jhns Hkn Hsp B (1 942) 442-459 35 Rchter CP and F G helan Swa gand rspnss sympahc sman sded by h gaanc sn r mh J N rphys , Sprng d (1943) 191-194 36 Richter CP and D Kat rphra nr nrs drmnd by h crca sn rssanc (1 943) 8-651 mhd J Amr Md As 37. Richter, CP and PD Mloe Prphra nr sn chars J Nrsrg Sprngd
6
122
MG SNS eexes e
(1945) 550-552 38 Rihr P and G Wooru Lumba sympahetic dermaomes in man deermined by he electrical skin resisance method J. Neurophysiol, Springfield 1945) 323-338 39. Rhr P andF On Thoracolmbar sympathectomies examined wih the elecrical skin resisance mthod J. Nerosurg Springfield (1946) 120-134 40 Rihr P Insrcions for sing the cutaneos resistance recorder or . 'dermomeer on peripheral nerve injuries sympahectomies and paraverebral blocks J Nerosrg Springfield (1946) 181 o 1 9 1 4 1 Rihr P Ctaneos aeas deneraed by uppr thoracic and stelae ganglionectomies deer mined by he electrical skin resisance mehod J Neurosrg Springfield " (1 947) 221-232. 42 a J and JG rw Differential spinal blck. II The reacion of sdomoor and vasomoor fbrs J Clin Inves 1947) 203-216. 43. hr HG Reex aciviy wihin the sym pahetic nervous sysem Amer J Physio (1934) 593-. humr H jr The vale of skin resisance sudies in deermining he accuracy of pro caine inctions o f [he sympaheic nerves Srgery S Louis (1 2) 949-961 45 pig E. an d G Woh The viscerogalvanic reaction Arch In Med Chicago (1935) 327-340 46. G Viseral pain; plethysmographic pain-reacions dilataion of he osophags Ny Nordisk orlag A Hsk Copnhagen 190 47 Thma PE and I o The aomatic recording of elecrical sk in rsisane paerns on the human runk EEG Clin Neurophysiol (1951) 361-368 Thoma PE and rr Significance f areas of lo w ESR ed Pro (1952) 162. 49 Thom PE H. Wrigh and W Harr Relaion of swea gland recruitmen to ESR ed Pro (1953) 143 50 Thma PE and rr The relaionship btwn swea gand acivity and the etrial resistance of the skin. J Appl Physiol Wah (1957) 505510 51 Thm PE I r and H. Wrgh A mobile insrument for recording electrical skin resistance paterns of he human rnk Aca neurovege. Wien Accompanying papr) 52 Towr and P Rihr Inry and repair within the sympathetic nervos sysem II The posganglionic nerons Arch Nerol Psychiatr. (1932) 1 139-1148. 53 Va r Va J and J Gron Electrical resistance of the skin during induced emotional tress A study of normal individals and of paients wih in· ernal disase Psychosoma. Med (1950) 303-314 54 Va r E jr Low electrical skin resisance in he region of pain in painfl acute sinsitis ohns opkins osp Ull (1949) -415 5 5 Whan G An insrment for se in measr ing elecical resistance of the skin Sience (1950) 496-497 56 Wigh H I. r and P.E hma Regional or segmenta varia ions i vaomotor activi y d Pro (1953) 161
3 3
26
/
56
3
II
I
/0
2
5
III
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Reprined by permission from Jornal o Neral Transmission 17: 7796 1958
A mbe instrument fr recrding elecrical ski esistnce pttrns f the human rnk* (158 PRE E HOMAS RV M KORR and HARR M WRGH
Measurements of regonal or segmental aratons n the electrcal ress tance of the skn are frequently used to study regonal or segmental aratons n sweat gland actty and therefore n actty of sudomotor fbers of the sympathetc nerous system See Rchter7 and Korr Thomas and Wrght4 for eferences reas of relately low resstance found n these nestgatons appear to be those n whch at the tme of measurement a) secretng sweat glands serng as parallel hghresstance pathways through the skn are present whle none are present n other areas b) are present n larger numbers or c) n whch larger amounts of resdual mosture (from past secretory actty) are present (Thomas and Korr9• 1; Thomas, Wrght and Hart ) nformaton obtaned by electrcal skn resstance (ESR) measurements therefore has been found applcable to nestgatons on the perpheral sympathetc alteratons accompany ng trauma surgcal procedures panful syndroes sceral dseases spnal cord dseases and expermental procedures (Korr Thomas and Wrght' Katsuk and Wake Kor Ratcfe and Jepson! Van Metre 2 commonly employe method for obtanng ESR alues s by applyng a oltage and measurng the current ow between a fxed ndfferent electrode mostened wth conductng paste and a handheld explorng electrode The "resstance may then be calculated accordng to Ohms law The current s usually kept small 130 a) and the contact of the electrode wth a local area of skn bref to aod stmulatng or polaraton effects (Rchter) The topographc dstrbuton (pattern) of ESR
These invsigaions were suppored i part by gras from he Naional Institutes of ealth Public ealh Sevice (·29 ad 1632 and from he American Oseopahic Associaion and by a contrac (Nonr 243[]) with the Office of Naval Research
aratons s recorded on standarded body charts by dfferences n shadng Exploraton "by hand s slow does not pert followng rapd changes n pattern and requres consderable practce We hae preously reported the deelopment of a faster more coneent and objecte method for mappng ESR pat terns nolng semautomatc exploraton and photographc recordng of ESR aratons on the human trunk (photorecordng dermometer Thom and Korr) The patterns of resstance aratons were supermposed by double exposure techncs on photograph of the subjecs explored area Ths apparatus greatly facltated nestgatons of ESR patterns and ther sgnfcance The need remaned howeer for an nstrument whch fulflled the followng requrements s usable n a welllghted room 2 Records skn current aratons (ESR) drectly on the chart and makes the pattern mmedately aalable for study wthout the need for photographc processng 3 Requres less tme for the entre procedure (exploraton and recordng landmarks) 4 s easly moed from room to room eg for studes on hosptaled patents 5. Operatonal procedures should be smple enough that ery lttle tranng of operators s requred Ths paper descrbes a new nstrument whch meets these requrements The type of record obtaned s seen n Fg 1 The skn current aratons appear as a pattern on an outlne of the subject's explored area Principles of opration
The basc prncple s the conerson of aratons n skn current nto aratons n oscllaton ampltude of a recordng galanometer By couplng the galanometer to the explorng electrode through a pantograph arm the records nscrbed on statonary
V
/,1
I .
Fg ESR ecod This ecod shows he disibio ae o ESR vaiaios o he bac o sbjec S. S. Each oscillaig lie elecs he si ce vaiaios alog a si o si . wide The wide he alide o oscillaios i each si h lage he c e (a he idicaed volage lowig hogh he si a he coesodig oi o he sb jec The body olie ad sios ocesses ae aed o eeece ad coaio o he si ce (ESR ae wih ohe ecods o ocedes The calibaio si showig ce low o 02 Ja i 5 a ses aeaig i he le-had oio o he cha a be sed o evalaig he ce low i vaios aeas o si.
Fig. 2. The ecodig deoee i se. The cooes ay be ideied as ollows ( galvaoee ad caiage ) elecode assebly C aogah a; (D) bace coecig he galvaoee o he a ogah (E aogah ylo F i-ad soce oc; G higes ) aliie cool ael
pper re cotul relted topo grphclly to the po sto of the electrode the exporto re. he pths folowed by the exporg electrode re predetermed by rovdg seres of prel, properly spced, logtud ths for gvometer movemet. The spcg bewee eectrode pths, though row, vods the possby of recordg re more th oce the course of explorto As the explorg eectrode s moved log ech pth, represetg strp of s eu wdth to tht of the eectrode the movg glvometer roduces eveloe of oscltos (60 cyclessec vryg wdth proporto to the s cr ret vrtos. The vsul effect, see Fg. s tht res of reltve y low resstce per to be dr eed.
Al the essetl compo es re ccommodted moble cbet (bred wheels, the top of whch s show Fg 2. Cai
he pto grph rms (Fg. 2 C re co structed of lumum tubg for ghtess d rgdty. Oe ed s ttched to pylo (Fg. 2, E d the other provdes moutg for the exporg eectrode. Dmesos of the ptogrh hve bee chose so tht movg the exporg eectrode dstce of 2,5 cm. wll move the gvometer 1,0 cm. Al movg jots re supported by bll bergs for free d esy moto. A rgd brcet (Fg. 2, D coectg the glvometer to the ptogrph rm rovdes costt sptl reltoshp be twee the exporg eectrode d the gvometer. Paoa assmy
aaom ad mo as smy he gvometer osc-
tos re recorded drecty o Teledeltos or Electrex per. The glvometer (Fg. 2, A s mouted o crrge tht trvels smoothy o b berg wheels log two roud steel rods (the logtudl rls he whees, of Pexgs, hve cocve rug surfces shped to ft the rods. (Pexgls s very sutble or ths purose sce t s soft eough to wer to erfect ft, yet hrd eough to gve og servce. wo of the three
wheels o ech sde o f the glvom eter crrge re o the upper sur fce of ech r he other wheel o ech sde rols o the lower surfce of the r hs rrgemet eeps the crrge securey ttched to the rs whle permtg the glvometer to be moved freely the og xs of the recordg pper. Ech ed of the ogtudl pr of rs s rgdly fsteed, s show Fg 2, to metl plte. Wheels mouted o ths metl plte permt the ogtud rs berg the glvometer to trvel og two ed support rods (trsverse rls he whees o ech metl plte re pos toed s two opposg prs d clmp the rsverse rls frmly eough to prevet sew movemets of the logtudl rls . The ed support rods re t rght gles to the ogtudl rs d provde lterl movemet of the glvometer d r ssembly cross the trsverse xs of the pper. Through the summto of these lter d logtud movemets, the gvometer my, therefore, be moved over the etre recordg surfce. Ths free moto s used whe the body outle or topogrphc dmrs re beg recorded. Durg explorto the glvometer (d electrode movemet s restrcted to seres of fxed ogtudl pths by p ttched to the logtud r ssemby tht fts to seres of otches oe of the trsverse rs (Fg. 2 , F. Whe the p egges oe of the otches, ocg the ogtud rs posto, the gvometer c be moved freely the log xs of the chrt pper, but s fxed lterly oe of 25 trcs 10 cm. prt. ecuse of the 2,5 pto grph rto the explorg electrode moves 25 correspodg pths 2,5 cm rt. Sce the explorg elec trode s 13 mm. wde, ths scg provdes seprto of 2 mm. be twee strps of explored s. hs spcg effectvely prevets overl whe st permttg cotuty of ptters he xporg electrode s fltsurfced chromelted wheel, 23 mm. dmeter d 13 mm. wde he xe of ths roer electrode s ttched to sml met hous g. The whee hous g s ped to the eectrode rm
Eo od aam
MG, SS, refexes, etc.
(Fig , nd 3, A) in suh fshion tht the ontt surfe of the wheel n tilt to follow the trnsverse sopes of the explored surfe The eletrode rm is fstened to the hndle of the eletrode ssembly by hinge whih permits verti movements of the eletrode. The flt sur fe of the ele trode wil, therefore mintin full ontt with the irregulr surfes of the expored re The pressure of ontt is tht provided by the weight of the eletrode ssembly nd rm Higher pressures, if not injurious, do not signifintly lter urrent flow through the skin No further provi sion for onstny of pressure is therefore neessry The mplifier, shemtily shown in Fig. 4 is onvention hopper type nd enbles the smll urrents flow ing through the skin to vry the osil ltion mplitude of the reording gvnometer The mplifier hs low impedne, hopper input (60 yles/se., mke before brek) The low impedne minimizes the pikup of stry signls from unshielded sub jets High gin nd good stbility re provided by 4 btteryoperted stges of mplifition In ddition to its use in skin urrent reording this mplifier hs lso been used for re ording skin tempertures from thermoouples A mirommeter used for monitoring (not visible in Fig ) nd other iruit ontrols re positioned on the ontrol pnel (Fig. H) within esy reh of the opertor
Amplier and control panel
p
The sub jet is positioned s seen in Fig for exportions in the prone position Spinous proesses nd other lnd mrks re identified nd mrked on the skin An ndifferent eletrode is fstened to the er lobe, using ee trode pste to redue nd stbilize the resistne The usu routine explor tion in our lbortory is performed under onditions fully desribed elsewhere (Korr, Thomas nd Wright"; Thomas nd Korr8) i.e with the sub jet resting nd stbilized t n mbient temperture of 3 5° C Preparation of the subjet
The binet is postion ed with respet to the subjet so tht
the eletrode wil trvel over the re to be exmined During n explortion this reltionship is mintined by stops tht prevent movement o the binet. The generl resistne rnge (Korr Thomas nd Wright" is estblished by relesing the pinnd soket lok nd smping vrious res of skin to be expored with uik touh of the eletrode A voltge is hosen (3 to 8 v) whih wi produe mximum of pproximtey 530 of urrent flow for lowresistne res, nd the mplifier gin is djusted to produe pproximtely 1 m osiltions t 5 urrent flow W hen the subjets resis tne is so high tht 18 volt produe less thn 30 in lowresistne re, mplifier gin is inresed so tht ny differentil between the high nd lowresistne res n be mde pprent The longitudinl rils supporting the gvnometer re then oked in position tht wi ow the roer eetrodes to be pulled long strip of skin in the midline xplortion of eh strip is strted t shouder evel or t the hirline on the nek When the eletrode ontts the skin, the opertor oses the swith (Sw 3, Fig 4) whih simutneousy pplies the seleted voltge to the exploring eletrode nd provides the voltge for the penwriting urrent The opertor drws the eletrode long the seleted pth (kept in stright line by the rils bering the glvnometer). We hve found speed o f pproximtely 80 m/se. stisftory from the points of view of onveniene time for explortion nd rity of hrts n prtie one uiky erns to mintin uniform rte by dusting explortion speed so tht simir sping ppers between individul osiltions on the hrt H owever, s shown in Fig. 5 even lrge vritions in explortion speed hve little in fluene on the reorded SR ptterns. Suessive strips of skin re ex plored in the sme fshion The explortion pln most freuenty followed is to lternte from side to side so tht symmetril strips re explored s nerly t the sme time s possible The entire dorsl trunk n be explored in pproximty 3 minutes
Exploration
Calibration
The gvnometer is
Fig Epoig eecode. coeup of he eecode how i Fig B wie pi fae he whee houig o he epoig am ad pemi he oe eecode o i ad foow he coou of he epoed aea B The epoig aemb ued fo epoaio of iig o adig ubjec. The oud od ca ig he eecode move feey hough he aumiium m ouig bock The diecio of moio i cofied o he og ai of he od b fou ba beaig a each ed of he mou ig bock.
-
positioned to reord in ler re on one side of the hrt To reord the librtion strip, the glvnometer is moved sowy while fixed voltge (3 v) is pplied to grded series of resistnes onneted ross the input The resistnes re hosen (Sw 4 Fig 4 to produe gvnometer ex ursions tht orrespond to inresing urrent flow from 030 in 5 steps For mrking the spinous proesses, the ibrtor iruit is used t setting whih pro dues pen defetions pproximtely m wide. The lok for the longi tudinl ris is reesed the eletrode is then positioned over the previously mrked spinous proess, nd the pen writin g urrent swithed on to mrk the hrt pper This is repeted for eh spinous proess To outline the torso, spu, or other lndmrks the eletrode is drwn ong the on tours with the penwiting urrent on Topographi marking
but wth no galvanoeter oscllatons The nscrpton on the chart of all pertnent data regardng the sub ect experental condtons etc copletes the exploraton Special adaptations
,� n st
t•
'<
\)
Hnges on the cabnet top pert the entre pantograph and galvanoeter assebly to be postoned vertcally Wth the addton of counterweghts and a specal explorng electrode at tachent (Fg 3 B) the nstruent s useful for recordng patterns of standng or sttng subjects Ths nstruent has wde applca blty n recordng the topographc dstrbuton of any phenoena lted only by the ngenuty requred n devsng explorng "pckups or transducers In our laboratores an explorng therocouple has been used to obtan skn teperature patterns on the trunk
1I 4C
'h
R THO AMP
Shmt of onrtr mpr nd ssotd ruts Th hopr nput on rts th Fg dt urnt owng through th skn nto y ttng urrnt Ths rut so nud th brton nd ontrosfor rordngfrom thrmooups Rsstns r gn n kohms nd tn n mrofr
&o "
42� e sp d n m:
Fg 5 un of rtons n xporng spd on rordd urrnt ow Ths omprs rords obtnd from th ame strp ofskn t th rous trod spds ndtd Th wr obtnd byfng th porton pth of th trod nd mong th hrt ppr try tr h pss of th trod Th rords wr obtnd pproxmty 3 sonds prt Not tht n thrfod rton n trod spdprodus ry tt dfrn n th mgntud ofrordd urnt fow En wth 5fod hng n porton rt th rs ofty hgh urnt ow mn dstngushb though thr rod u r muh smr
Sorces of error
Two possble sources of error are ev dent both of whch are nor and do not serously nterfere wth appng ESR patterns One error results fro the vertcal travel of the electrode beng an arc rather than a lnear oton at rght angles to the plane of the pan tograph oveent The recorded topographc relatons are therefore slghtly dstorted Correct copara tve relatonshps can stll be an taned f the explorng electrode s used as a gude and touches the skn surface when topographc landarks are beng recorded The weght constantpressure and handlng char acterstcs of the electrode assebly (Fg 2 B) are satsfactory enough to ake the sall error acceptable The electrode assebly (Fg 3 B) devsed for exploratons of standng or sttng subjects does elnate ths error and wth soe odcatons n weght would also be satsfactory for exploratons of prone subjects The other source of error to b e consdered s due to excessve varatons n exploraton speed Ths has been dscussed n a prevous secton oraton) Ths error s readly ned by a lttle practce n the exploraton procedure Smary 1. oble nstruent for explorng
and recordng the topographc dstrbuton of ESR on the huan trunk EMG SNS reflexes etc
s bee esribe xlorios re ri e reor is ieiely vilble 2 Toori relios bewee e exlori eleroe ovble ire reori lvoeer re esblise by or like 3 Vriios i urre flow fixe vole ("resise) o sri of ski re reore o s iory r er by vriios i e osilio liue of e ov i, reori lvoeer Te SR ers of lre res re reore by exlori series of rle sris of ski Te rus is ble for reori e oori isribuio of ueous feures oer SR 5 Soures of error re ieife eir iiiio or orreios re esribe References
I Katsui S and K Wae Clinica sdies on he viscerocaneos relex. Kmamoo Med J (195 ) 9 - 10. 2. Ko IM Skin resisance aerns associaed wih visceral disease. Fed. Proc. 8 (199) 8 3. Korr IM Eerimena aeraions in segmena symaheic (swea gland) aciviy hrogh myoascial and osra disrbances. Fed. Proc. (199) 88. . Korr IM PE homas and HM Wright Pa erns o elecrical skin resisance in man. (Sbmied herewih o Aca neovege Wien.) 5 Ratcfe A Ha and RP Jepso Skin resisance changes in he lower limb aer mbar gangionecomy J Nerosrg Sringed (1950) - 105. 6. Rchter P and Bettye G Woodr Changes rodced by smahecomy in he elecrical resisance o he skin. Srgery (191) 9590 . Rchter P Insrcions or sing he caneos resisance rcorder or Dermomeer on eriheral nerve inrie symahecomies and araverebra blocks J. Nerosrg. Singed (196) 181191. 8. hom PE and IM Korr he aomaic recording o elecric skin resisance aerns on he hman rnk EEG Clin. Nerohysio. (1951) 361368. 9. hom PE and IM Korr Signiicance o areas o low ESR. Fed. Proc (1952) 162. 10. hom PE and IM Korr he relaionshi beween swea gland aciviy and he elecrica resisance o he skin. (In ress: J A. Physio. Wash (1951) 305-310. I hom PE M Wrght and C W Hart r Relaon o swea gand recrimen o ESR. Fed Proc (1953) 13. 12. Va Met. E r ow eecrical skin resisance in he region o ain in ain ace sinsis. B. Johns Hokins Hos. 8 (199) -15 .
Rerined by ermission rom Jornal o Nera Transmission 1 981 1958.
Local and regional variations in cutanous vasomotor tone of the human trunk* (1960) HM WRIGHT M KORR d P.E THOMAS
Tese suies ve bee oere wi reiol seel vriios i syei vsooor oe i or u subjes Bro re io ifferees i ueous vso oor oe i vsulr resoses, s sow by ifferees i e bloo ow,e bloo oe,e ski o or ski eerure, e, be wee fe, ruk exreiies, ve bee reoie for y yers T reio or seel ifferees i ueous vsulr oe i orly exis over e oo ry of e ruk, rele o e seel iervio of e ski, ers, owever, ever o ve bee syseilly ivesie ers o be eerlly ssue vsulr iy vsooio re uifor rouou is ski re Severl observios sues, owever, ere y be osise ooril ifferees i ueous vsooio oer fuios orolle by e syei ervous syse a Cadiovascua adustmts to th ct postu
Te es i eoyis wi resu fro e of boy osiio fro e oriol o e ere osi io evoke ive resoses of e erierl vessels wi vry or i o eir evel i e loiuil xis of e boy O ssuio of e ere osure,ere is eviee of reer vsoosriio i e lower r of e ruk e ower exreiies sruures ierve by e ore ul sees of e sil or i e uer exreiies sruures ierve by e ore suerior sees of e sil or ) gmta dfcs i th sposs of th cutaous vsss to stimui i Pama s observe ue
ous boo vessels of vrious reios of e ski y reso ifferely o vrious yes of siuli ori o eir see iervio He s
sow e exisee of osiive r ie i reive yerei followi o isei,fro e ir ervil o e fif srl eroe: e ore ul e see,e ier were e resols for reive yerei Tesols were esure by e urio of isei jus re uire o elii srie yer ei resose c mta dfcs i th si tmpatus
A seel rie i e ski eerures fro e ervil o e f srl see ws lso ob serve by i Pama: e ore ul e see,e lower e ski e erure rouou e ori lubr sees d fcs i vasomoto to b t upp ad o tmiti
Te vsooor oe f e lower u exreiy (lubr srl iervio) s bee fou o be u ier of e uer (ervil ori iervio) Gotz 8 G9 ve sow,for exle, e vsooor oe of e oe vessels is erese eir bloo fow use for e eliiio oly we e vsoilor iy of e s s bee fully exuse Rioa ad sgmta vaiatios i sudomoto activity Te ivesiios of Ko, Thomas Wight (195) 1 0 reviously
reore i is jourl,revele e exisee of reiol seel vriios i suooor iviy i suy of severl ure subjes Tese suies ere o ve i or fuiol iliios re le o reiol vriios i e ex ibiliy of uooi wys • view of e eviee ie bove, i ws eie o ivesie, i fur These invesigaions were sored in ar by grans rom he Naional Insies o Healh Pblic Healh Service (H1632) and rom he American Oseoahic Associaion.
45
have, therefore, used three indirect methods which have commonly been use in clinical studies: 1 measuement of the sin emperature, 2. measureen of the vascular compo nent of the sin coo, an 3. observation of the esponses of the sin vessels (vasoconstriction and vasodiatation) to echanical stimui. These methos enabe us to com pare the segmenttosegmnt iffe ences an regional differences in vasomotor activity in a given inividual as well as in different individuals Fig. k k With this istumet tw idetical stimulats wee daw dw the bac by a cstat speed electic mt The stimulats wee idepedetly muted feely pivtig alumium ds The itesity f the stimulus culd be vaied by chagig the psiti f the 500 gam weight the lee f each stimulat. F each idividual that i tesity fstimulus was selected which was ade quate t elicit sme degee f ethema ed espse) at al segmetal eels fm T t S
ther detail, the noma topographical gadient in cutaneous vas cular tone along the spinal cor as a bacground for studying an inter preting the local deviations and asymmetries of vascua response which we have observed in large numbes of subjects. The general significance of these deviations an their neurogenic origin are suggeste by their similarity to deviations in sympathetic sudomoto activity by Korr et al. 7 The possible clinical implications of these vasomotor deviations are suggeste by the fact that sudomotor variaions were often relaed o isceal and uscuoseletal isturbances { . Mhd
The observations presented in this paper were made over a period of several yeas, an during that time several methods were used. Athough a variety of direct and indirect methos may be used for the investi gation of the peripheal circulation (venous drainage recorders, meanflow recorders, pulsatie flow meters, perfusion systems, mechanical plethysography etc.) most of these methos either cannot be used on the intact human subject, o at best can be used only on the extremities. We 6
Skn Temperature Sin temperatures were measured with conventional welded ionconstantan thermocouples mae from 30gauge thermocouple wire and read fro a sensitive galvanometer. single "exploratoy hermocouple mouned on a pastic hanle, pemited the investigator to rapidy ascertain the sin temperature on both sies, at each segmenta leve, at points equiistant from the spinal midline. The Red Response The erythema resulting from mechanical stimulation of the sin has been calle the "re response by Lews'8 an is a part of the tripe response described by him . Although Lews has shown that vascular dilatation esuting from mechanical stro ing of the sin is not dependent on a nervous mechanism, the responses to stroing are inluenced by nervous factos, an, other investigaos have used the threshol, nensity, the time requied for the appearance ("latency) or fading ("uation) of the erythema as a measure of the superimpose sympathetic vasomotor tone of the vascuature9 . For our studies, it was necessay to develop a stimulus which could be standardized and accurately duplicate. To do this, an instument was constructed (Fig. ) which was a modification of the "sin stroer used by D Palma 9 in his study of the reactivity of bloo vessels In conducting a test, the two iden tical roundedwire stimuators were drawn in straight lines own the bac by a constantspee electric motor at the rate of 5 cm. per secon from the leve of the fist thoacic vertebra to that of he sacum The stimuators
wee made of 2 gauge copper wire and were 5/16 inch (8 mm.) in cicumference, an independently mounted on freely pivoting aluminum rods 26 cm. long. The intensity of the stiulus cou be varied in 25gram steps fom 150 to 500 grams by chaning the position of a 500gram weight on the aluminum leve of each stimulato. For any given stimuus, however, the pressure on the stimulator re mained constant for the ful excur sion of the instrument , theeby giving a uniform stimulus to all segmental evels on the bac. The stimulus was appied 1 2 inches (3 .8 cm .) on either side of the spinal midline. Fo each indiviual, that inesiy of stimuus (the weigh applie to the stimulao) was seected which was adequate to elicit some degree of erythema at al l segmental levels fom T to S. Obsevations were mae under daylight fuorescent illumina tion by two or more pesons in most cases In preliminary efforts to establish methods for quantifying the red esponse, measurement of the thresh ol, atency, intensity an uration wee trie. Measurement of thresholds was eliminate when it became evident that repeate testing of the sin alteed its esponse. The measuement of latency was also eliminated because o the rapidity with which the response evelope throughout the entire tes area. oth intensity and duration, however, showe wide ranges of graation. t was futher reveale that these two factors were proportionately related that is, the more intense the erythema, t longer its persistence. We found it convenient, therefore, to evauate the red response by determining the time interval between stimulus an isappearance of the response. The duration o "pesistence of the re response was, therefore, "grade as folows Grade Persstence of Erythema
1 2 3 4
30 secons or less 30 to 60 secons 60 to 0 seconds Moe than 0 seconds (sometimes sevea minutes) As he sequence of the disappearance of various fagments of the ine of eythema was obseved on the subject each area was appropriatey EM SNS eflexes, etc.
dlinatd as it fadd and th rad of prsistc (1 2 3 or 4) was arkd on th skin Th "rads at th various lvls on th back wr r cordd on a chart for ach individual At last 24 hours intrvnd btwn xprints on any ivn individual C Photoelectric measurement of the vascular coloration of the skin. Wetzel and Zotterman20 showd that
th vascular coloration of th skin is rlatd to th aount of holobin containd within th inut vssls and thrfor h vascular coloration of th skin is dirctly proportional to th amount of blood xposd within th vssls of a ivn ara Th blood contnt of th subpapillary vnous plxus is larly rsponsibl for th vascular coponnt of th skin col or Th photolctric thod for th asurnt of th blood contnt of th cutanous vssls is basd on th absorption of liht by th holobin of th blood Grn liht with a prdoi na nt wa v lnth of 50 is stronly absorbd by both rducd and oxynatd holobin It follows thrfor that th ratr th blood contnt of an ara of skin th ratr is th absorption of inci dnt liht of this wav lnth and vic vrsa Our thod was a odification of th ph ot ot ri c th od wh ic h AdamsRay 3 -4 usd in st udi s rlatin to rflx hyprtonus in th subpapillary vnous capillaris Th phototr (Fi 2) consistd ssn tially of a lihtsourc a filtr and two cadiu sulphid photoclls (Clairx Typ CL2) Th currnt nratd by th photoclls was asurd with a alvanotr Liht fro a 225 volt bulb (Mazda No 222) passd throuh th filtr (Schott Jna VG9) and illuind a circular ara of skin 1 8 in diatr Th hihly rflctiv surfac of whit porclain plat was usd for standardizin th quipnt and as a basi of coparion of tst aras of skin With th phototr st on th porclain plat th balanc of th brid circuit was adjustd until th alvanotr dflction was 1 00 (Th rctanc fro skin was always lss than th rflctanc fro th plat ) Th diffrnc (l R) b twn th rflctanc fro th porc lain plat () and that of a tst ara
ig 2 Phoom e omone s ma be idened olows: a salooe (Claiex e CL-2) b ie (SoUJena VG-9)' lig. is insumen was used o measue e ig absoion o e skin. Lig om e 2. 25 ol bub (Mazda No. 222) oug e le (SoJena G9) and ilumined a iula aea o e skin 18 mm. in diamee
of skin (R) is a asur of th aount of liht absorbd by th skin It is rconizd that othr factors such as pintation hair tc in addition to th blood contnt of th skin ay infunc th absorption and rctanc of liht by th skin In ths studis howvr only subjcts with no visibl local variations in skin pintation hair distribution tc wr tstd Experimental Conditions
Ths studis wr conductd in a quit roo aintaind btwn 23 and 25 C Th body was unclothd abov th lvl of th sacru and th subjct lay pron on a paddd tabl with a fac slot A priod of 30 inuts lapsd bfor xprints wr startd to allow for stabiliza tion Th tips of th spinous procsss wr arkd and nubrd In ths studis sntal lvl rfrs to th toporaphical lvl on th trunk as idntifid by th corrspondin spinous procss rathr than th dr atos Thr is howvr clos corrspondnc btwn toporaph ica l and sn tal lv l s fo r paravrtbral skin xcpt for th up prost thoracic snts All obsrvations wr ad of th paravrtbral skin inchs 3 8 c ) to th riht and lft of th spinal idlin fro th first thoracic to th fifth lubar vrtbra unlss othr wis statd
Reults Segmental patterns
a) Skin tpraturs W found undr our xprintal conditions that th diffrncs in tpratur btwn th warst and coolst aras of th skin on th trunk in any individual wr usualy lss than 2° C Wid and rlativly rapid fluctuations in tpratur such as thos sn on th xtritis do not occur Th stability and narrow ran of tpraturs on th trunk hav also bn obsrvd by othrs Nvr thlss a lonitudinal pattrn within this ran of tpraturs is rald whn th skin tpraturs at ach sntal lvl of a nubr of in dividuals ar avrad tothr As shown in Fi 3 a rprsntin th data on 4 subjcts th skin was warst in th idthoracic ara (T4 to T8) and coolst in th lubar ara (L to L) of th back This raph rvals that ths xtrs ar th apics of two ovrlappin curvs with thir convxitis in opposit dirctions (T to T I and T to L) b) Rd rsponss In ost individuals a contrast was vidnt btwn th rd rsponss in th idthoracic and lubar s nts Thus in ost individuals th rd rsponss prsistd for or than sconds (Grad 4) sotis
pcS ! f J "
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Fig 3 a. A vrag skin mra a ac sgmnal lvl. Tis gra w riv b av1ging ogr mra of aravrbral skin a ac sgmnal lvl in 14 inivials (Tr orvaions wr ma on ac inivial Fig 3 b A vg rsons g a ac mnal lvl is gra was riv b avging ogr r rons of aravrbral skin a ac sgmnal lvl in 13 inivials. (Tr obsrvaions wr ma on ac inivial T rsisnc of r rsons was gra as foows Gra 1 30 scon or ls; Gra 2 o scons; Gra 3 6 o 9 scon; Gra 4, mo an 9 scon. Fig 3 c. A vrag lg absorion a ac sgmnal lvl. T g was riv b avraging ogr lig absorion of aravrbrl skin a ac sgmnal lvl in 15 inivials. (Tr orvaio ma on c inivial. T frnc 1 R) wn rc anc from a wi olain la (1) an a of a ara of skin (R) a mr of amon of g absorb b skin
/
,
-
Fig 4 Average electrical conductance of the skn at eac segmenta eve. T gra w riv b avraging ogr lcrical oncanc (mas as crn 70w a con �an volag of ravrbral skin a ac gmnal lvl in 25 inivia
for eeral mnue n he m horacc egmen whle he eryhema fae away n le han 3 econ rae 1 ) n he lumbar eg men When he re repone grae a each egmenal leel were aerage ogeher n 13 nual (3 e on each ubjec) he uraon or per ence) of he eryhema wa longe n he mhoracc egmen o ) an hore n he lumbar egmen L o L3 ) g 3 b) hee alo are he apce of cure mlar o hoe for n emperaure hown n g 3 a. c) Bloo conen of he n In all nual examne more lgh wa aborbe n he upper hor acc egmen han elewhere an he aerage lgh aborpon alue how e a progree ecreae from he fr horacc o he fr lumbar eg men ncae of a graen n cuaneou bloo conen g 3 c) bu fferng omewha from hoe for emperaure an eryhema. 2 A "normal toracolmar patte
he graph of he aerage n emperaure an re repone g 3 a 3 b) how a cloe correlaon
uggeng a common facor. Boh ecrbe wo mooh cure whch oerlap n he horacoumbar area. he lgh aborpon cure how e enally he ame confguraon below he leel of o bu he reeral of he cure no een n he upper horacc egmen 1 o ) he reaon for he mofcaon of he upper horacc) cure no mmeaely een bu may be acrbable o fference n he n pgmenaon hcne aculary or ome oher facor. o aceran wheher he paern of n emperaure re repone an bloo conen are relae o mlar paern of ympahec acy we conuce a mulaneou negaon of he elecrcal n reance of he paraerebral n A hown by Tomas e al he elecrcal n reance paern meaure n our laboraore reec mlar paern of egmenal araon n acy of he ympahec nerou yem U ng he ES exploraon proceure whch we hae ecrbe elewhere he elecrcal conucance of he paraerebral n wa recore a each horacc an lumbar egmen n 25 nual A hown n g he elecrcal conucance of he n ncreae progreely from he r horacc o he econ lumbar eg men h graph mlar n con fguraon o ha of bloo conen a meaure by lgh aborpon g 3 c). 3. Variations in individal patterns
he paern hown aboe repreen he aerage of a number of ubjec Mo ubjec howeer howe characerc an reproucble ara on from hee bac paern. hee ara on are manfe a local or egmenal eparure from he aerage paern an a aym mere beween he rgh an lef e wh repec o he n empera ure he re repone an lgh aborpon of he n a) Local or egmenal araon n he n emperaure Syemac mappng of he egmen oegmen n emperaure reeal e local area of n whch were con enly ou of lne wh repec o he graen ha hey were hypo hermc or hyperhermc relae o ajacen area or relae o her con EMG SNS reflexe ec.
tralateral counterparts Fg 5 shows the pattens of the paravertebral skn temperatures n three ndvduals In subject J.B the temperatures of the paravertebral skn on the rght and left sdes are relatvely symmetrcal except at T and L to L Subject BM shows consderable dfferences n the skn temperatures between the rght and left sdes n the upper thoracc area (T I to T and throughout the area from T to L I n subject W . asym metres are most apparent from T 8 to T
)
b Local or segmental varatons n the red response In most ndvduals we found local areas of the paravertebral skn n whch the red response consstently faded more quckly than adjacent or contralateral symmetrcal areas Fg 6 shows the red response patterns of three ndvduals In subject SS the rght sde shows an essentally "nor mal (e. average pattern whle the left shows conspcuous aberratons especally at the lower thoracc levels The rght and left sdes of subject JE have remarkably smlar patterns from T to T dvergng t o varous degrees below ths lvel. Subject I.. shows marked devatons from the average pattern at T to T on the rght sde and n general the per sstence of the paraveebral ery thema was consstently less on the rght sde than the left from T to T 12 n ths ndvdual c ocal or segmental varatons n the lght absorpton (blood content of the skn. Smlar to the local varatons n the skn temperature and red responses we also found local areas o f the para vertebral skn n whch there was con sderable dfference n the lght ab sorpton between the rght and lef sdes at some segmental levels or be tween contguous areas Fg 7 shows the segmental lgt absorpton pat terns of three ndvduals There was very lttl dfference n the lght ab sorpton between the rght and left sdes n subject IM In subject WB the lght absorpton s also relatvely symmetrcal though wth a conspcu ous asymmetrcal area at T I I to T and others n the lower lumbar regon. Subject W W shows marked
Tem (
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Fig. 5. Individual patens of skin temperae J.B he emperare ofhe paravereral ki o he righ ad lef ide are relaively ymmerical excep a T ad o Sec B.M. how coiderale dferece i he ki emprare ewee he righ ad lef ide a T ad T ad hrogho he ara from T o ec W E. aymmeri i he paravereral ki emrare are mo appare from T o T . (Each graph a average of hree oervaio o each idividal)
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Fig 6 Indidal patens of he ed esponse ec SS he periece of he d repoe wa geerally ymmerical ewee he righ ad lefide excep a ad T S JE how marked aymmeri ewee he righ a d lef id elow he level of T • Sec . how marked deviaio from he "average pae a T o T o he righ ide ad i geeral he pr ece of he red rpo wa coiely le o he righ ide ha he lfrom T o T Each graph a averge of oervaio o each dividal
symmetres n lght absorpton be tween the rght and left sdes of the paravertebral skn at T to T the skn at the level of L to L on both sdes shows more than average lght absorpton.
Reproduby of segmena paes
The "pattern or dstrbuton of local "aberrant or "asymmetrcal areas vared from subject to subject but the pattern was characterstc for that ndvdual Tests conducted on
the same ndvdual on dfferent dates are shown n Fg 8 Indvdual pat terns of local or segmental devatons from the average patterns n the skn temperature (Fg 8 a red responses (Fg 8 b and lght absorpton (Fg 8 c of the skn showed a hgh degree of reproducblty The locaton and ar rangement of such devatons from the average patterns wth respect to segmental levels and rght and left sdes remaned remarkably constant for days or weeks.
49
LQ('N) L AbQ (l) ! - J/ I Q f U 50 0
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Fig. dividal a of ligh abopio h ligh absorpion ofh paravrbralskin on h righ and lf sid is rlaivl smmril in su bjc M. n subjc WB. conspicuous asm mris appar a o and in h lumbar ara. Subjc W W shows markd asmmris b wn h righ and lf sids a o Each graph an avrag of obsrvaions on ach in dividual.
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Fig. 8 a o c odcibiliy a hs ofskin mpraur rd rspons and lgh absorpion of h skin for ach individual sho wd a high dg of rproducibii h locaion and arangmn of local or sgmnal dviaions mmris from h avrag opographical pas r maind consan for das or wks. Fig. 8 a. h paravrbral skin mpraus of subjc E on dfn das. Fig. 8 b. h rd rpons par of subjc J.E on dfrn das. Fig 8 c. h ligh absorpion of h paravrbral skin subjc J on dfrn da
k} eepe #e ¥ D ir GD f t l g t+ s G T " · , � , E --
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Fig. 9 orlaio of par i o idividal. For comparon h parns ofskin mpraur rd spons and lgh absorpion of h paravrbral skin of subjc W.E ar shown hr. Markd asmmri bwn h righ and l sids ar apparn from o in all pas
EMG SNS, eexes et
.temperture Corretons between the skn red rpons nd ght bsorpton oj the skn
Fo ompaison, the pattens of the skin tempeatue, ed esponses and light absoption of the skin of subjet WE ae shown in Fig 9. Maked diffeenes between the ight and left sides ae appaent fom T to in all thee pattens n this aea, the skin tempeatue was onsistently oole and the pesistene of the ed esponse less on the ight side than the left side n the same subjet, howee, the light absoption of the skin was onsistently geate on the ight side than the left between 6 to T Simila oelations, among the thee pattens, and dietional disepanies between light absoption and the othe two measuements wee seen in othe subjets Discssion
Sgnne oj nddu nd ombned mesurements
The methods employed in these studies indiate that the utaneous iulation oe the entie tunk i s not unifom, as appeas to be ommonly assumed, but diffes with the segmental o topogaphial leel of the tunk skin n the nomal indiidu, inheent topogaphial pattens in the skin tempeatue, asula esponses, and blood ontent of the subpapillay plexus extend thoughout the longitudinal axis of the thoaoumba aea Although the thee measuements used in these studies eet diffeent manifestations and haateistis of the utaneous iulation , etain elationships, similaities, and dissimilaities may be onsideed he s�in tempeatue indiates the position of themal equilibium between the body and the enionment, and is used only as an indiet iteion of utaneous blood fow Howee, in a esting subjet in a onstant tempeatue, aiations in the skin tempeatue may eflet aiations in the utaneous blood fow he segmenttosegment diffeenes in tempeatue oe the topogaphy of the tunk whih we hae e oded, may, theefoe, efet, o be elated to, diffeene in utaneous blood ow The ed esponse is due to an atie dilatation of the minute utaneous
essels aused eithe dietly by mehanial stimulation o by the ation of a histaminelike substane whih is eleased following mehanial stimulation Although the asodilatation obseed in this esponse is not dependent on a neual mehanism, its intensity and duation ae inuened by neual fatos t has been shown by othe inestigatos that ental and eflex ontol of the utaneous essels is, appaently, puely ia sympatheti fibes Hene, the intensity and duation of the esponse to mehanial stimulation will etainly be infuened by existing sympatheti onstito tone The topogaphial patte of the "pesistene of the ed esponse whih we hae obseed at diffeent segmental leels on the tunk, may, theefoe, be elated to, o eflet, diffeenes in sympatheti asoonstito tone of the minute utaeous essels he asula omponent of the skin olo is elated to the state o f filling of the subpapillay enous plexus Howee, the quantity of blood i n the skin an be quite dispopotionate to the ate of blood flow though the skin • Nee theless, it has been shown that an ineased tone of the subpapillay enous plexus mediated by sympathe ti pathways diminishes the blood ontent not neessaily the blood fow) of the skin and ontibutes to pallo he topogaphial diffeenes in the asula oloation of the skin whih we hae obseed may theefoe, efet diffeenes in the sympatheti onstito tone of the enules of the skin t is obious, theefoe that beause ou thee types of obseations ae elated to diffeent knds of manifestations of the utaneous iulation, peise oelations among the thee types of data annot be expeted Neetheless, ompaison of the "aeage gaphs of the skin tempeatue and ed e sponses Fig 3) shows that, in geneal, hypothemi aeas of the skin also show diminished pesistene of the ed esponse and ie esa Thus, the wamest aea of tunk skin, T to 8 oesponds to the same aea in whih the ed esponses pesisted fo the longest peiod of time Similaly the oolest aea of the tunk skin, to , showed minima
pesistene of the ed esponse empeatue and ed esponse pattens of indiidual subjets wee also simila Vaiations in ed esponse and in skin tempeatue appea, theefoe, to be elated to aiations in a ommon fato We beliee the losely oelated egional aiations, and loal abeations of ed esponse and skin tempeatue ae both manifestations of paallel aiations in sympatheti asomoto tone, high sympatheti tone poduing hypothemia and bief ed esponses, and low tone poduing hypethemia and polonged ed esponses That the blood ontent of the skin is in some way elated to empeatue and ed esponses is lealy indiated by the fat that abeations in al thee hae the same distibution in a gien subjet Sine, howee, the dietion of the abeations in blood ontent is not onsistently elated to dietion of the abeations of tempeatue and ed esponse, the natue of the elationship is not lea Fo example, as shown in Fig 9, the appaent blood ontent of the ight side is geate than the left, wheeas the skin tempeatue and ed esonses indiate asoonstition on te ight side elatie to the left t is possible that skin olo, on the one hand, and tempeatue and the ed esponse on the othe, eet aiations in diffeent pats of the utaneous asulatue, thus aounting fo this inonsisteny As Hertzmn has pointed out, the quantity of blood in the skin and the hanges in the blood ontent of the skin an be quite dispopotionate to the leel of blood flow ad to hanges in blood fow Fo example in etain pathologial states an inease in utaneous blood ow and pallo may deelop simultaneously he pallo must epesent an inease in enous tone, while the inease in utaneous blood flow is assoiated with ateiola dilatation oeoe, the onfiguation of the "aeage patten of the light absoption also diffes fom those fo tepeatue and ed esponse he eason fo the diffeene, limited appaently to uppe thoai segments, is not lea, but may hae pat of its basis in pigmentation, skin thikness o asulaity of this pat of the tunk as ompaed to lowe segments•
Noma eona feen All three methods clearly reveal the existence in the normal individual of regional differences in vasomotor function of the skin of the trunk The basis and functional implications of the atterns are not clear but may represent adaptations to postural and thermoregutory demands he investigations of others, as well as our own, suggest that these variations have a fnona rather than an anatomic basis Heman in his studies of regional differences in cutaneou blood ows, concluded that the vascular natomy of most of the body's skin (trunk, legs and arms) is uniform with respect to the number and size of the vessels Wee and Zoeman also found that the num ber of capillries in the cheek, ear lobe, forearms and hand does not dif fer signictly D Pama3 also con cluded that it seemed reasonable to assume that segmental threshold dif ferences in the responses of the small cutaneous vessels were the reslt of functional alterations, rather than anatomic ones he existence of simi lar patterns in sudomotor activity (Fig strongly suggests that the vasomotor, Uke the sudomotor varia tions, reect normal variations in sympathetic tone A segmental pattern in the motor reflex thresholds of the paravertebral muscles, reflecting activity of the ven tral ho cells of the cord, has been shown by Densow • t is of interest, tat while these measurements re concerned with a different kind of nerous activity and while there is variable topographical displacement etween corresponding dermatoes and myotomes an essentially similar pattern was evident his suggests that the normal segmental and re gional variations of vasomotor (and sudomotor) activity reported here are functionally related to similar varia tions in activity of the ventral horn cells hat is, together they refect pattern variations in spinal integra tion of somatic and autonomic motor activity Loa aaons The local alterations in the temerature red resonse, and blood content of the sin which we found "suerimposed on the average pat tes of these measurements, may also have a fnctional basis; that is,
52
they may represent local reex altera tions in sympathetic vasomotor tone These individual patterns of local deviations in vasomotor functions ap pear to similar to the distinctive ER patterns which Ko et al 1 found in many individuals with visceral and musculoskeletal distur bances Other investigators hae also ob served local vasomotor disturbances associated with viscera distur bancesS7-6 1 • Almost 0 years ago Weoe6 observed pae areas of skin segmentally related to diseased viscera in numerous patients Aams Ray has described pallor of the skin in te fourth cervical segment in patients with cardiac pain, and in pa tients with gall bladder disease in seg mentally related dermatomes Doe7 found the skin temperature lower in the area of pain in the majority of pa tients with myocardial infarction That reflex cutaneous vasoconstric tion can be experimentally induced on the trunk has been shown by Aams Ray who was able to demonstrate pallor of the skin in the eleventh and twelfth thoracic segments when the bladder was distended, and by p who was able to induce ischemia of the skin over the sternum by distending the esophagus In view of the parallelism in vaso motor responses, under many circum stances, between skin and viscera, regions of pallor, hypothermia or other signs of cutaneous vasocon striction may be related to ischemia of reflexly related visceral tissues The reflex origin of local vso motor aberrations is indicated not on ly by their relation to visceral distur bances, but, as we have repeatedly observed, by their relation to muscu loskeletal stresses of both pathologi cal and experimental origins These relations will be subsequently reported
b
Smma 1 hese studies have been con ceed with regional or segmental variations in vasomotor activity in normal individuals 2 The methods used included the segmenttosegment measurement of the temperatre, red responses, and light absorption of the paravertebral skin 3 he observations show that the cutaneous vasomotor activity on the
truk is not uniform as apears to be commonly assumed opographical patterns of temperature, red re sponses and light absorption of the skin were found Local or segmental deviations from these average or normal to pographical patterns were found in most individuals Local deviations in all three types of observations were usually found at the same segmental levels in a given individual 6 The topographical patterns of vascular activity appear to be func tional rather than anatomic and are analogous to similar patterns in su domotor activity 7 he topographical patterns of cutaneous vasomotor manifestations appear, therefore to reflect normal regional variations in sympathetic ac tivity 8 The local deviations of vaso motor activity from the normal patterns appear to be related to local deviations in sympathetic activity
eerences
w
Herzmf, A B and Rfdfll, Regna deenc the baa and maxm at bd l n the skn J App! Phys Wah 18) 4 t 41 Red W E Skmf and J.M Sle Skn tempeatue sns nma human subjects t aus cndtns Ccuatn 1) 8-87 Di Plmf J. R and F Fer he egmnta and ageng aatns ctve hypeema n human skn Ame Heat J 14) -44 4. e M P Heg and EA Wlw he eect pstue n the pepheal c ) 780 cuatn Ame Phys! Mf HS, and A T he nfunce pstue n skn nd subcutaneus tempeatue Ame J Phys 1) 474-480 Mfe H.S M Sweee and .A. T The nuence pstue n ccuatn tme Ame J. Phys 1 ) 48 148 7 Ge RH Et changs n pstue n pephea ccuatn th speca eence t skn tempeatu eadngs and the pethysmgam C cuatn 1) 7 8 Ge R.H Rate and cnt bd l thugh skn e extemtes Ame He J
. 1
6
:
14) 14-18 Gree HD
Physgc actn nc and adnegc bckng agents n pphea ccua tn Mnnesta Md 18) 411 10 K M PE Tmas and HM W Pattens eectca skn sstance n man Acta neuveget Wen 18) 77- 1 1 . Kr and PE Tm Segmenta pat 11) 7 tens n Fd Pc 1 K M Expementa ateatns n segmen ta sympathtc seat gand actty hugh myasc and pstua dstubanc F Pc
1
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14) 88 1 Krr M Skn estance pattens acat th scea dseae Fed Pc 14) 87
8
EMG, N, rexes etc
14. Korr. IM and MJ Goltein. Dermatomal autonomic activity in relation to segmental motor reex threshold. Fed. Pr. (1948), 67 15. Thom. PE and IM Korr. Significance of areas of low ESR Fed Proc. (1952), 162 16. Thom. PE HM Wright and C W Hart, jr Reation of sweat gland recruitment to ESR. Fed. Pr (1953). 143. 17. Thom. PE, and IM Ko, The relationship between sweat gand activity and the electrical resistance of the skin 1 App!. Physio., Wash / (1957), 505-510 17 a Thom, PE IM Ko HM Wright. A mobie instrument for recording electrical skin resistance patterns of the human trunk Acta neuroveget., Wien, (1958), 97-1 18 Lew. The bood vessels of the human skin and their responses Shaw & Sons Ltd, London, 1927 19. Di Palma. JR SRM Reynolds and FI Foster, Measurement of the sensitivity of the smalest bood vessels in human skin: Responses to graded mechanical stimulatio in norma men 1 Clin Invest (1941) 333 to 343. 20 Wetzel. N. and Y Zotterman. On dif ferences in the vascular colouration of various regions of the normal skin. Heart, London, (1926) 357-369 21 . Burton. AC, Blood flow, temperature and co or of skin Blood, heart and circulation. Edited by .R. Mounton P. 308-313 American Association for the Advancement of Science Washington 1940. 22. Wiliams. GD, The measurement of skin coor Science (1933) , 192-19 3. 23. Edrds. EA. and SQ untey, The pigments and coor of iving human skin Amer. Ana. (1939), 1-33. Sheard. and LA Bnsting. The color of the skin as anayzed by spectrophotometric methods. III The roe of the superfcial blood 1 Clin. Invest. (1929), 593-613. 25 . Dent, R V, The photographic aspect of ight reflection from human skin 1 Laborat. Clin Med., S. Louis (1941) 1852-1862 26. Edwards. EA Analysis of sin coor in iving human subjects by spectrophotometric means. In Proceedings of the third conference on the bioogy of norma and atypica pigment cell growth. P. 149153, Academic Pss Inc., New York, 1953. 27. Horecker. B L , Absorption spectra of hemoglobin and its derivatives in visible and near infrared regions Bio! Che Baltimore, 4 (1943), 173-183 28. Bachem, A, and Reed. The penetration of light through the huan sin. Amer. Physio (1931), 86-91 29. Jacquez, JA. HF Kuppenheim, JA Dimitrof W McKeehan and J Huss, Specia refectance of human skin in the region 2357 m. J. App Physio., Wash. (1955) 212-214 30. Jacquez. JA and HF Kuppenheim. Spectra reectance of human skin in the region of 235-1 m. J App!. Physio!., Wash, (1955) 523 to 528. 31. Adams-Ray, J, Photometrica studies on viscerutaneous reflexes with vasoconstriction in venous capillaries Wernoe's symptom in gallbladder disease. Angiology Baltimore (1951), 51-59 32. AdamsRay. J. and G Norlen. Badder distension relex with vasoconstriction in cutaneous venous capillaries. Acta physio. Scnd (1951), 95-1 33. AdamsRay, J, Studies on a cutaneous paor reflex in the fourth cervical segment in cardiac pain Acta med Scand 4 (1953), 457-472 34. AdamsRay. J. S Hagberg and A Reuterskiold, High tone in the cutaneous venules of the lower extremities; a factor in the postura
reactions Minerva Cardioangiologica Euroa (1953), 383385 35 Hertzman, AB.• The physiology and eas urement of the periphera circulation. Physiotherap Rev. (1950) I-II 36. Hertman. AB The peripheral circuation Annua Rev. Physio., Stanford Univ, 4 (1942), 187-214 37. Hertzman. AB Soe reations between skin temperature and blood flow. Amer. J. Physio!. Med. 32 (1953), 233-2. 38. Felder, D. E Ru. H Montgomery and O Horowitz. Relationship in the toe of sin surface tmperature to mean blood ow measured with a pethysmograph Cin Sc, London (1954), 251257. 39 Green, H D, RN Lewis, ND Nickerson and AL Heller, Blood flow, periphera resistance and vascuar tone with observations on the relationship between bood flow and cutaneous temperature Amer J. Physio!. (1944), 518-536 Ga. SM, The measurent of sin temperature Amer. J. Physic Anthrop (1954), 127-130. 41 Foged, J, Normal skin temperature. Sand. Arch. Physio!. (1932), 251-278 42. Freeman, FE Linder and RF Nickeon. The biatera symmetry of sin temperature J. Nutrit (1937), 39-49 43. Fetcher. ES, JB Hall. jr, and HG Shaub. The skin teperature of an extreity as a easure of its bood ow Science (1949), 422-423. 44 Gahlen, W, and N Kluken. ber Variation Norm und Labiiatt der Hauttemperatur Kin Wschr. (1953), 754-758. 45. Van der Ghinst, M. Analyse thermomtrique des raction vasomotrices cutanes chez e chien norma et dans diffrentes conditions exprimentales. Arch intern physio (1953), 338-354. Folkow. B Nervous contro of the blood vessels Physio Rev (1955), 629-663 47. Green, H D and JH Kepchar. Contro of peripheral resistance in ajor systemic vascuar beds, Physiol Rev., Baltimore, (1959), 617-686. 48 Celander, and Folkow. B, A comparison of the sympathetic vasomotor fibre control of the vesses within the sin and usces. Acta physio! Scand (1953), 241-250. 49. Celander, The rage and control exercised by the "sympathicoadrenal system Acta physio! Scand Supp 116 (1954). 50. Baroft. H and HJ Swan. Sympathetic contro of human bood vesses Edward Arnold & Co, London 1953 51 Beecher. H K, The active contro of a parts of the capilary wall by the sypathetic nervous system Arch Physio. (1936), 123-132 . 52 Hertzman, AB Reations between cutaneous blood ow d blood content in te finger, foearm and forehead Ame 1 Physio! 4. 122132. 53. AdaRay J, "Erblasn o) - ein ktar Symt im Enyd spzll hn Ef O bach Zb!. Neuhi (1 950) 31 54 AdamsRay. J and S L'hyonie des capilaires veineux? Nouvel element du syndrome inammatoire n chir. > (194), 693 55 AamRay J. nd B Pow. m w observatin concenng th symptom "pllor in the inammation syndrome. Acta chir. Scand (1949) 221229 56 Denslow, J S.• An anaysis of the variability of spina reflex threshods Neurophysio!, Springfied, ( 1944), 207-216. 57 Nedzel. AJ Pathogenesis of nephritis due to exposure to cod. J. Uro, Baltimore (1934) 685691
58. Delo, P, and Mme Leder, Itr d l momtrie cutane Presse md (1952), 10561 59. Hansen. K, and H von Staa, Reektorisch und algetische Krankheitszeichen der inneren Orge Thieme Leipzig 1938. Konovalov. N V. Vaomotor disordes n hepatoenticular degeneration and in other livr diseases; probems of pathogenesis of vascular hypotonia Z nevropat. psichiatr., Moskva, (1955), 268-281 61 . Longo. OF, CAS Gallardo and A Ferr Las alteracines vcuonervio en la patogn as pancretitis. Rev. Asoc. md. rgent (1952), 816. 62. Wernoe. Th B Viscerokutane anemiske oner og deres tydning. Uskr Laeger, Khvn, (1923) 143147 63. Wernoe, Af Th B Smertezonediagnostik. Uskr Laeger Khvn, (1923), 615617. Weoe, Af Th B, Aestesiokopia abdominalis. Uskr Laeger, Khvn, (1920), 141 51 421 65 . We. Af Th B.• Et dianostisk system Kobenhavn, 1931. Weoe. Af Th B Smertens diagostik. Kobenhavn, 1935. 67. Dot, JB and C Ferro. Ingalit de la temprature cutane dans 'infactus du myocde t langine de poitrine Cardiologia (1 951), 886 68. Strup, GK Viscera pain: plethysmographic "pain reactions, diation of oesophagus. Ny Nor disk orlag. A. Busck, Copenhagen, 19. We gratefuly acknowledge the vauable assistance of Mr. E Blackorby in the design and construction of instruments and of Mrs Tova Brooks in the prepara tion of the ilustrations. Reprinted by permission from urnal of Neural Trsmission 22 3,3452, 1.
S
This report deals with the effects of eperimentally induced irritations and stresses in musculoskeletal tissues on the patterns of cutaneous sudomotor activity
trunk were recorded directly on paper by recording galvanometer whose amplitude of oscillations is related, through an amplifier, to the skin current The position of the galvanometer writingpoint on the chart was related to the position of the eploring electrode on the subect by means of a pantograph Records obtained with this instrument appear in Figures Records obtained with an earlier automatic dermometer Thomas and Korr2 are not included in this report
Methods
Exporaion Condiions
Effects of xperimental myofascal suls o cutaeous pates of sympathetic ctiviy i man* (1962) M KO M WGT d P TOMA
In recent years our laboratories have been engaged in the study of regional and segmental variations in sympathetic activity, as revealed by cutaneous sudomotor and vasomotor manifestations Studies of electrical skin resistance (ESR) , reported in this Journal in revealed persistent areas of low electrical skin resistance in most individuals The topographica distribution or "pattern of tese low resistance areas varied from individual to individual; but in a given individual the distribution with respect to right and left sides and segmental levels, remained constant for weeks, months and sometimes for as long three or four years Studies of regional and segmental variations in cutaneous vasomotor activity also revealed topographical "patterns that remained similarly characteristic and constant for each subect That these measurements and patterns of ESR as recorded by our methods refet variations in sympathetic activity was shown by the studies of Thomas and Korr 3 4 5 and Kawahaa and Th mas 6 Although these stuies did not reveal the physiologic ogs or functional significance of the sympathetic hyperactivity manifested in the low resistance areas, their distribution, that is, the patterned differences in sympathetic activity, were in some individuals apparently related to visceral or myofascial disturbances Reports of areas of hyperhidrosis7• 8 or low skin resistance91, lowered skin temperature4• IS and cutaneous pallor619 refley related to painful myofascial and visceral conditions also suggest such a possibility In view of the possible physiologic and clinical implications of the topographical variations, asymmetries and local aberrations in sympathetic activity, we have attempted to eplore factors that might contribute to them *_ investigaions were suppored in par by gans from he Naonal Instiutes of Healh, Public Hlh Serve (H· 1632). and fom he Am rica Oseopahc Aoiaon
54
Since the methods we have used for the study of sudomotor activityhave been previously described 2 2 , they are only briefly characterized here
ESR Exporaions
The eperiments reported in this paper were done over a period of several years During this time three methods for recording ESR were used, each yielding a different type of record However, all three methods are based on conventional principles of skin resistance measurement Essentially, each method consists of measuring or recording, in correct spatial relationship to the eplored area, the momenary current ow through the skin in contact with a constantly mving eploring electrode, at nown voltages The voltages were tapped stepwise from a series of dry cells and applied to an electrode fied to an earlobe and an eploring electrode Resistance of the skin of the earlobe was minimized by means of electrode paste Areatoarea differences in current flow at a given voltage, therefore, were due to differences in the "resistance of the skin under the eploring electrode Eplorations with handheld electrode In our earlier studies we used an instrument similar to that described by Jasper Current low was read from a microammeter as the electrode was moved over the subect's skin Figures to and to how charts obtained with this method Automatic Eplorations
In later studies a mobile automatic dermometer was developed 2 With this instrument skin resistance patterns on large areas of the dorsal
The eplorations were conducted in a quiet room maintained between and C The body was unclothed above the level of the sacrum The tips of the spinous processes were located by palpation and marked on the skin In these studies, "segmental level refers to the topographical level on the trunk as identiied by the corresponding spinous process, rather than the dermatomes There is, however, close correspondence between topographical and segmental leves for paravertebral skin, ecept at the uppermost thoracic segments The eperimental irritations used in these studies were produced by the in ection of hypertonic NaC solution into paravertebral structures The postural stresses included the artificial lengthening or shortening of one lower etrmity by the insertion or removal of heel lifts, and the inclination ot the pelvis by seating subects in tiltchairs In some of the tiltchair eperiments the changes in skeletal configuration were monitored with roentgenograms Resuls
Myojascia Iriaions
For the purpose of studying sudomotor responses to local myofascial irritation we adopted the method described by Keren in con nection with investigations of referred pain of somatic origin2 6 As Lew and Keren6 reported, when small volumes (0 to 0. ml) of hypertonic saline o NaCl) were in ected into superficial tissues (eg, skin, periosteum of the tibia, sheath of the achilles tendon) only a sharp, localized pain was produced When, however, the irritant was inected into deeper tissues, especially those on the trunk and most particularly around EMG, SNS, reees, etc
the spinal column (eg. interspinous ligaments paravertebral muscles) the local transient pain was soon followed by a crescendo of deep pain felt in areas often quite remote from the site of injection but apparently innervated from the same segment and side of the spinal cord The pain was usually accompanied by deep and cutaneous tenderness and muscular rigidity in the corresponding der matomes and myotomes. The mani festations subsided within a few min utes after a pea often of great inten sity t was our purpose to determine what changes in ESR were associated with these phenomena. n our experience with a total of 1 subjects some o f whom received two or more injections a significant change in the ESR pattern was ob tained only when we were succesful in producing referred pain. njection of superficial sructures such a s the inter spinous ligaments or periosteum of spinous processes or injection of a deeper structure which for some reason produced only local pain if any was followed either by local decreases in ESR in the immediate vicinity of the injection site or by no evident change Some subjects how ever showed a transient generalied drop in resistance with quic return to preexisting patterns. Such responses might i n apprehensive sub jects even prcede the insertion of the hypodermic needle. The injection of the periosteum of spinous pro cesses was in some cases immediate ly followed by considerable distress to the subject with diffuse and poorly localied pain nausea and faintness and pallor coldness and clamminess of the sin Two subjects (injected in midthoracic spinous processes) suf fered with vomiting and diarrhea several hours after the experiment. The appearance of ESR changes in the reference areas was especially clear following injection o f the hyper tonic saline into the erector spinae and intercostal muscles. Figures 1 2 and illustrate the results of four such injections igure 1 represents the results of two injections minutes apart in two sites in the same subject The areas of low resis tance which appeared following the injections are represented by the two rows of encircled blac spots The other areas mainly in the midline were present before the injection and
In al gures drawn charts (Fig to 6, the area the lower the restance White areas: a or le (sistance in ohms at least milion times the number oj volts)' black areas: 20 p or more ie less than 120 oj basic resistance , areas intermediate values (Reproduction oj the handdrawn charts h darkened the gray areas and the darker shad have become indtinguishable Jrom the black aas)
Fig Subect DH 2 20 4 8 Are of low skin ristance (circled black dots) elicited by the iec tion oj 03 m of 6 NaC into the erector spinae ma to the left of the spinous procs oj T and into the eighth intercostal space in the right axlary midine (both ses marked by x)
S Fig 2 Subect LL 2 2 4 8 Areas of low skin resistance crcled black dots) ecited by the iec tion oj 03 m oj 6% NaC into the erector spinae ma to the leJt oj the spino proce of T Fig 3 Subect LL 2 649: Area oj low sin resistance s_ right) resent 24 hours ter th e in ection of 03 m oJ 6% NaCl into the erector spin ae mass to the right o f the spinous procs oj
55
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Fig. 4
Fig. 6
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J
Fig ESR pattern of Subject LL I2 22 49: a) seated horizontay,' b) minut 4ter pev wa tted to the left Fig 5 ESR pattern of Subjt R 12 2349 a) seated horiz ontay; b) minutes after pevis was tited to the t c) 0 minut folowing retu to the horizonta position. Fig 6. ESR ttern of Subject D 1 3 50 a) sea ted horizontay, b) 120 minut after pev w tilted to the eft T subject showed ery itte change in h ESR patte in contst to the subjects hown in Fig 4 and 5
were representative of the ESR "pat tern (Korr, Thomas and Wright!) repeatedly observed in previous ex lorations of this subject. Immediately following the comple tion of the control exploration, 3 ml of 61 0 NaC was injected .5 cm deep into the erector spinae mass to the left of the spinous process of the 8th thoracic vertebra The subject almost immediately reported pain in the anterior chest wall in the region below the left nipple In approximate ly 3 seconds severe pain had also developed in the back over the transverse processes and rib-heads of the region T to T on the left side The new areas of low resistance began to appear during the second minute after injection and, ater 5 minutes, appeared as shown in Figure 1, by the encircled spots on the left side, at which time the pain had vanished Thirty-five minutes ater the rst injection a second injection o hyper tonic saline was made, this time into the 8th intercostal space in the right midaxillary line he pain which developed was realtively mild and was felt mainly in the anterior chest wall, in the mammary region Neverthe less, new areas of low resistance ap peared as shown on the right side in Figure 1 more conspicuously on the dorsal than ventral surface When the subject was reexplored six hours after the second injection the low-resistance areas were still evi dent in the same distribution, but they had become less punctate and nearly continuous The exploration of the chest was conducted at a volt age which permitted no more than J of current through most of the skin Nevertheless the current flow through the areas shown was suf cient to cause the two stris of low resistance skin to become sharply delineated as two erythematous bands in the course of the exploration Re sistance had returned to control levels before the next exploration 18 hours ater he encircled black spots shown in Figure 2 represent the new areas of low resistance which appeared, and re mained, over a period of 5 minutes following the injection of 3 ml of 60 NaCl into the erector spinae at the level of the fifth thoracic spinous process in another subject Numerous spots, not shown also appeared on the ventral aspect of the correspondEMG SNS, reexes, etc
,
. t;
F ig. 8 ESR patts of Sub ct S.P 1 55 a) satd horiz ontall b) 4 inuts aftr plvis was tiltd to th t c) 14 inu ts following rtu to h horiz ontal position
F ig. Ron gnogra racings of th spin of Subjct S. .: ) satd horiz onall L) sad wih plvis tild o th lf; R) satd wih plvis iltd to h righ n h pantographi rcords F igs 8 9 1 1, 1 }4 5) a plitud of oscil aions of th rcord ing galvano tr is rlatd to currnt flow through h skin T hin vrtical lins no oscillaion) rprsnt aras pr iing 0- a at xploraion voltag widst oscillaions rprsn currn ows of 30 a or or. n ths chars, hrfor, th darks aras rpr sn / 30 h basic ranc or lss Not h calibration "sr s showing rlaion bt wn currn and a p tud of osci ations in sps of 5 a
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F ig. 9 ESR pattrns of Sub ct SP. 55: a) satd horiz ontall b) 9 inuts afr plvi was ild o h rh c) 8 inuts following rturn to th horiz ontal posiion
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; H
F ig /0. Rongnogra tracings of h spin of Sub ct K ) satd horiz ontall L) sad with plvis ild o th lf; R) satd with plvis ild to th right
F ig. II ESR pattrns of Sub ct K. 19 55: a) sad hori onally b) /8 inu ts aftr plvis was tild to th left c) / / inuts fo lowing rturn to h horiz onal position
! .
, .
F ig 12 ESR p e ofSu j ect HK 7 25 55: a seated horiz ontally b 18 m inu tes after pelvis was tilted to the ight; c II m inutes following retu to the hori ontal position.
f'
F ig /3 Roentgenogram tracing of the spine of Subj ect CB: H) seated hori ontally L) seated with pelvis tilted to the left; R seated with pelvis tilted to the right.
F ig 14 ES R p e s of ubj ect CB. 62 455 a seated hori ontall b 15 m inutes after elvis was ,t
F ig 15 ESR pattes ofSubj ect CB 62 855 a seated hori ontally b 17m inutes after pelvis was tilted to the r c 14 m inutes following retu to the hori ontal position
58
EMG, SNS refexes etc.
ing dermatomes The arge encirced area shown between the vertebral column and the et scapua repre sents an area o muscular rigidity irst evident as a conspicuous bulge and easily delineable by palpation At reexploration three hours ater injec tion the muscuar rigidity had sub sided the ow resistance areas had become less punctate in distribution and the total area had become much narrower no reduction in resistance being evident beow the 7th inter space n another experiment on the same subject the right erector spinae at the eve o the 8th thoracic spinous process was injected with 03 ml 6 aCl. Only a ew small areas o moderately lowered resistance appeared durng the succeeding thirty minutes over the 8th and th verte brae and ribs. At the reexploration 24 hours ater however a large triangular area o low resistance (Fig 3 was present
Fig 6 ESR pattes of subject MO 2 278 28 wearing/8 inch heellt in right shoe c) 2 hours after r emoval of heellt
Ace Psa Ss
n the experiments to be described under this heading we studied changes in ESR patterns that olowed acutely imposed postura stress. The stresses appied were o two general inds a ateral titing o the pelvis relative to the spinal column and b artiicial alteration o relative engths o the right and let legs by means o hee lits inserted in one shoe Pevic Tis
n these experiments subjects were seated on a special stoo the seat o which coud be tilted to right or et by means o a wormgear arrangement. The subjects pevis was irmly secured with a bet i such a manner as to minimie rotation o the pevis around the vertical axis and to render the ilt (and the resuting scoliosis as purely lateral as possible The subjects arms rested on a horionta surace thereby reducing the inclination o the shoulders and orcing the compensation mainy on the thoracic and umbar segments o the spina coumn Exporations were begun ater the subject had been seated with trun exposed or a suicient period to permit stabiiation o the ESR patterns Ater competion o the contro exploration the seat was tilted in
Fig ESR patterns of Subect M inch heellt in right shoe for hours c) patte immediately upon arising the fol/owing moing d) " hours la ter, heellt stil in place
S9
,
Fig. E/ects 0/ removal 0/ heel-lts on ES patterns 0/ subect R H who had wo ! nch lt under h right heel/or more than a yr to compensate/or shortness 0/ that extmt j 44: Control ES patter (subect wearng hllt) n the mong (a 00 AM) and afteoon a 4 PM) Mong and teoon exploratons were also done on three other das wth smlar rults b) 4 Followng the ES ploraton at 30 AM, (bl) the lt was removed The gure at 40 PM (b ) shows the altered ES patte whch developed durng ths nterval
the choen diection whle the ubect eained eated. He wa then eexploed at vaiou inteval ate tltng. n oe expeient exploaton wee alo conducted afte e toation of the eat to the hozontal potion n all expeent to be hown the angle of tilt wth epect to the hoizontal wa 15° n exploa tion done with handheld electode ig to 6) the chat epeentng the expeental exploation ndicate the patten that had developed by the te the exploation wa coplete Copaion of igue a and b ndicate the change n patten which
developed in ubect LL in the coue of one hou of ittng with the left hp tilted dowwad. New aea of low eitance wee epecially aked in the lowe cevcal lowe thoacic and luba aea. Pain developed at the bae of the neck on the left ide withn 15 to 20 inute afe tilting g 5 how an expeient on anothe ubect (JR) A copaon of chat a and b eveal the new aea of low eitance which ap peaed while the ubect wa eated fo one hou wth the pelvi tilted 15° left hip down The new aea in the thoacc and luba egion, e
pecially o the left cnvex ide of the pnal cuve ad the exaggeation of the low etance aea at the cevicodoal uncto ae paticulaly to be noted Thee change wee alot entiely eveed within 0 nute afte etoation to the hoizontal poition ig. 5 c n contat to the above ubect, ubect JD ig 6) howed vey little change n ESR patten afte 10 nute of itting n the tilted po tion. Th ubect wa a tall, lende ndividual who felt eakably lttle dicofot He epoted only a light enaton of "tain n aea ove the uppe bode of both capulae. The topogaphically elated aea of lightly loweed etace whch appeaed afte about one hou ae to be noted, although they wee pobably extenion of the all aea evident above the capulae in the contol exploation. n oe ecent expeient, t ha bee poble, with the autoatic de oete Thomas Korr and Wrih to ecd the pogeve developent of new patte afte the auption of the tilted potue and thei egeio followng etun to the noal eated potue Anteo poteo oentgenoga of each ubect wee taken n the level and tilted potue n ode to viualize the confguation of the vetebal colun Tacng howng the pnal conguation in each ubect n noal and tlted itting wee ade fo thee fl and accopany the ESR patten in the following fgue Subect SP. had abnoalite of the vetebal colun evident g. H eated level a conpicuou lateal cuve in the thoacic pine with hap eveal of diection at uppe and idthoacc level gue L and R eveal the poo adaptation of the ubect to the tilted potue ad the aked lack of yety of the pinal conguation in the ight and left tilt. The ipoition of thee potue on the ubect povoked in tene and diffue udooto epone a evealed by copaion of chat b wth a petlt, ad c pottilt contol both ig. eft tlt and ig. ght tilt Diffeence n epone to left and ight tilt ae alo evealed. The hap uppe boundaie of loweitance aea at the idthoacic level n g b and the elevation of the bounday EMG SNS eflexe etc.
o uer horacic levels in he reverse il (Fig b) are esecially o be noe Subec HK ha no gross osural or sina abnormaliy evien in he roengenograms aen in he levelseae osiion (Fig. 10 H) Neverheless hose aen in he ile osiions (Fig. 10 R) reveale various resricions an asymmeries in sinal moion. Accoringly mare changes in ESR aerns occurre uring ilseaing in boh irecions he aerns of he lef an righ ils being quie ifferen. owresisance areas a lumbar levels on he righ sie were he firs o apear in iling boh o he lef an o he righ. Following he aearance of hese areas of low resisance however he aerns uring righ an lef ils eveloe quie ifferenly (comare Fig 1 1 b an 1 2 b) he aiional areas being in each case on he convex sie of he inuce sinal curve. Thus while he low resisance areas eveloe uing he il o he lef (Fig 1 1 b) were quie exensive here were only scaere small sos of low resisce in he uer righ quaran is h area however in which resisance was iffusely lowere when he il was in he reverse irecion (Fig 12), he lef e being relaively free of low resisance areas n conas wih he above subecs C.B showe on Xray examinain boh excellen verebral alignmen in he levelsea osure an smoohly roune symmerical sinal aaaion o he il of he elvis in boh irecions (Fig 1 3) The new areas of low resisance ha eveloe were small an limie mainly o he uer horacic levels (Figs. 14 , 1 5) H Ls
The exerimens reore uner his heaing illusrae he regional symaheic resonses o aricial change in lengh of one leg eiher by insering a heel lif (harrubber wege insere in one of he shoes) uner one heel or removing one o which some aaaion has been mae n his series of exerimens he osura sress was no so gross as ha imose by iling he sea 1 5, bu on he oher han he sress was ermie o ac for much longer erios of ime an uner coniions of locomoion. Consequenly he iscomfor an he changes in ESR
aerns have ofen been more severe All he subecs use in his series ha shown sable ESR aerns over erios of a leas several wees The sress was alie afer a conrol exloraion an he subec was reexlore a various inervals hereafer. The series of chars comrising Fig 1 6 shows on subec M he effec on ESR aern of wearing a lif one ay an he subsequen effec of removing i. Fi g. 1 6 a reresens he aern reeaely foun on his subec wih only minor moificaions from ay o ay. This exloraion was begun 30 minues aer he subec ha comlee a 1 Y mile wal from his home o he laboraory. His only comlain was a coninuous ache in he lumbosacral area on he righ sie i n which general region was also foun an area of moeraely lowere resisance. Xray lms aen in he saning osiion inicae ha he righ leg of his subec was aroximaely Yz inch shorer han he lef. Uon compleion of he exloraion a 3/8 inch li was lace in his righ shoe an he was insruce o wear i hroughou he ay an he following morning o reurn for an exloraion he nex morning also afer waling (wih heellif in lace) from his home. Fig 16 b shows he aern obaine he nex ay. Boh ache an lowresisance areas in he lower righ quaran ha vanishe bu he subec now comlaine of iscomfor in he mihoracic region in which here was esecially mare exension of lowresisance areas. The lif was remove a 2:30 .M. afer a "sochec reveale ha here ha been furher lowering of resisance an some exension of he areas shown in Fig 16 b Fig 1 6 c shows he aern foun he nex morning again afer he wal from he subec's home. The ache (an he lowresisance area) in h e lower righ quaran ha reurne an he mihracic ache ha been exacerbae. Areas of marely lowere resisance ha srea hroughou he miline of he bac. A oally new sri of low resisance aeare on he righ sie in he mihoracic region exening eriherally from he level of verebra T8 on he righ sie (Fig 16 c ossibly a laeral exension of he araverebral area
evien in Fig. 1 6 b). ha no reviously been observe on his subec bu i coninue o be observe on every subsequen exloraion unil he final exloraion on his subec almos 16 monhs afer he exerimen Anoher subecs resonse o arificial increase in lengh of one leg is shown in Fig 17 his subecs ESR aern reeaely recore over a erio of hree wees was remarably unisinguishe by any consicuous an ersisen areas of low resisance an he conrol aern (Fig 1 7 a) was yical. A 1 1 A.M following his exloraion a onehalf inch heel lif was insere in he subecs righ shoe He was insruce o go abou his usual aciviies an o reurn laer he same afernoon for exloraion. Fig. 1 7 b shows he aern obaine in an exploraion begun a 4 . M. a which ime he subec comlaine of iscomfor in he region of he lumbosacral unc ion The exensive evelomen of lowresisance areas below he horacolumbar uncion an in he viciniy of he cervicoorsal uncion is esecially o be noe Fig 17 c reresens he aern obaine on his subec he following morning shorly afer rising n general a recession of he lowresisance areas of he revious afernoon is evien. However by early afernoon he subec's iscomfor generalie in he low bac was sufficienly severe ha he came o he laboraory o reques isconinuaion of he exerimen an he heel lif was remove Exloraion one a ha ime isclose he aern shown in Fig 17 n general his seems an exaggeraion of he aern of he revious afernoon (Fig 17 b) Unforunaely he subec was no able o reurn unil wo ays laer (12/30) a which ime lowresisance areas were sill resen a he cervicoorsal uncion he enire miline below T s an o he righ of he orsolumbar uncion The exerimen shown in Fig. 18 was also conuce o examine he resonse o aleraion of relaive leg lengh n his case however he sress was ha of removing a lif worn for heraeuic uroses. Subec RH ha been wearing a onefourh inch lif in his righ shoe for aroximaely one year o comensae for relaive shorness of he righ
6
leg nd s prt of the tretment for lowbck pin previously suffered by this subject At the time of the eperiment he hd been symptomfree for t lest 0 months Control eplortions in this eperiment consisted of series of morning nd fternoon eplortions on four successive dys Of these one pir is shown (Figs 1 8 b) representing the etremes of vrition The subject ws engged in physicl lbor nd the two chrts on ech dy indicted the chnges in pttern which took plce in n intervl of 6 to hours Following the morning eplortion on the fth dy of the eperiment (Fig 1 8 c) the lift ws removed nd the subject continued with his work s usul returning for eplortion t : M Fig 18 d shows th e gret epnson of lowresistnce res in the lower prt of the bck which hd tken plce in the intervl The sub ject lso volunteered the informtion the the "old pin especilly in the vicinity of the lumboscrl junction hd returned in his recollection for the first time in mny months Discussion
hese studies revel some of the utonomic chnges s reected in swet glnd ctivity provoked by myofscil irrittions nd posturl stresses in humn subjects elted chnges in vsomotor ctivity to be reported seprtely lso occur In generl these chnges recorded in the skin were regionlly lterlly nd often segmentlly relted to the site of trum posturl stress or discomfort Although the responses of the swet glnds (nd cutneous blood vessels) my be viewed s incidentl refle responses of sympthetic pthwys to noious myofscil stimultion we believe they re better interpreted s modifictions of normlly eisting ptterns Viscerl circultory nd thermoregultory functions controlled by the utonomic nervous system re continully coupled in highly orgnized ptterns to musculoskeletl ctivity nd chnges in posture Tht is efferent ctivity in neuromusculr nd utonomic pthwys is s is well known functionlly coordinted by the centrl nervous system For emple ugmenttion of the blood flow to muscles tht re ctive or bout to become ctive is chieved
by differentil djustments of vsculr resistnce in ctive nd inctive tissues nd by incresed crdic output nd het loss is djusted ccording to chnged thermoregultory demnd ccompnying the musculr ctivity by chnges in cutneous blood flow nd swet secretion While in considerble prt locl djustments re effected by direct ction of c h e m i c l g e n t s ( e g C metbolites) nd physicl fctors (eg temperture) the locl d justments re integrted in comple highly orgnized refle ptterns by the centrl nervous system Indeed the ltertion of vegettive function during nd preprtory to muulr ctivity nd ccording to environmentl demnds ppers to be the specil province of the sympthetic nervous system which for these resons hs been designted "ergotropic by He21 As dptive ptterns they re continully subject to modifiction nd to "turning on nd off ccording to chnging circumstnces They so hve considerble degree of "locl sign subject s they re to modifiction ccording to locl or regionl circumstnces nd ctivities Tht is lthough the effernt components of these ptterns (motoneurons nd pregnglionic utonomic neurons lrgely spinl in origin) re multisegmentl nd under the control of bulbr diencephlic nd corticl centers their ctivity is continully influenced by fferent impulses tht rise in therml receptors pressure receptors proprioceptors pin endings etc nd tht re condcted to the spinl cord by sensory fibers entering vi the dorsl roots We believe tht the locl more or less segmentl responses of the sympthetic nervous system reported in this pper (nd the chronic segmentl fcilittion of motor pthwys previously reported8 re eggerted versions of these locl components In these stressful nd in some cses pinful eperimentl situtions ffecting smll prts of the musculoskeletl system the fferent voleys of impulses entering through individul dorsl roots pper to hve become so prepotent s to dominte tht prt (ie corresponding nd neighboring segments) of the sympthetic nervous system nd to tke precedence over verticlly orgnized
ptterns they ordinrily serve nd even to disrupt them They do not therefore meet ny prticulr functionl demnd they re not dptive nd in mny cses they persist ter the provoking insult hs ended The utonomic concomitnts of locl myofscil irrittion injury stress or pthology hve not received widespred recognition in clinicl prctice They hve received even less eperimentl investigtion other thn in such studies s on crdiovsculr or respirtory responses to pinful stimultion of vrious tissues Only two eperimentl studies on humn subjects cn be cited In study on the ptterns of referred pin produced by injections of hypertonic sline into prvertebrl muscles of the neck nd bck t vrious levels Feinstein, Langton Jameson nd Schier29 mde some incidentl observtions on "utonomic concomitnts Usully produced by in jections in the thorcic region (seldom by injections in cervicl nd scrl regions) the mnifesttions were pllor sweting brdycrdi fll in blood pressure nd subjective fintness nd nuse weting ws usully generlized seldom even being conned to the side of the pin As previously stted we hve mde similr observtions especilly following injections into periosteum following injections in pprehensive subjects or when for unknown resons prvertebrl injections were unusully pinful or distressing owever the methods used in our study lso reveled the regionl nd segmentl responses sometimes superimposed on generlized chnges in electricl skin resistnce Steinbrocker et l3 lso studied pin ptterns ssocited with locl in jections of hypertonic NC solution into myofscil structures but mde only occsionl observtions of color chnges (pllor or erythem) temperture chnge nd sweting in res of skin in the vicinity of the referred pin The ptterns of both pin nd utonomic chnges were not referble however to ny known nerve pthwys nor ws there ny evidence of segmentl reltionships Unlike the bove eperiment studies clinicl studies such s those by Trave nd by Dittrich. yield distinct nd reproducible ptterns sometimes showing segmentl rel
EMG N reflees etc
ionships and someimes no Tre! 1 desibed he pioeetion, he fan pespiation and ooing f the sin hat ma, individua and in ombination, be indued in efeene ones (in whih deep pain is aso fe) on iiaion of sensiive mofasia igge aeas, and he eddening and waming of he sin ha ma be obseved foowing infitation of he tigge aea wih poaine Tre Berry and Bigeow aso eoded hanges in pusations of he tempoa aeies assoiaed wih iitation and anestheiaion of igges in the apeius muse Dirich33 , in a pape on he auonomi onomitans of somai pain, desibed in sevea patiens he efeed pain, sinoo hange (in ense edness o anosis) and edema assoiated with inense tende spos o igges in paaspina issues of he owe ba and he {esponses o in fiation of he tigges wih po aine The autonomi hanges wee ofen quie emote fom the igges, as was aso ue in Taves sudies Thus, fo eampe, auonomi hanges in he uppe tun, shoude and uppe etemi wee demon sab assoiated with iitaion of he atissimus dosi muse a umba and saa eves of he ba The oaion of these ppaen segmen a emoe efe phenomena is asibabe, of ouse, o the fat hat he aissimus dosi eeives its inne vation fom segments C- of the spina od Anestheiaion of the igges in he endinous atah ments of this muse in he ow ba podued eief of he efeed pain and of efe auonomi hanges Tre/ on the othe hand, points out tha segmena eations o oganied neve pahwas between ous of the igge and he efeene one ae sedom ea, though the efe natue of the eationship is undeniabe The inevenion of ohe ee phenomena suh as spasm of vasa nevoum and esuing neua shemia (Robers4) has been im piaed Aso o be inuded among the ob sevaions on autonomi epeus sions of somati iiaion ae he in easing numbe of epos on vai ous foms of efe smpahei dsoph assoiaed wih musuo seea disodes o auma o mofasia issues whih ae effe
ive teated b siening of he mo ond o a few minutes and itte is fasia soue of impuses o b nown of he hanges ha ae pae boade of the appopiae smpa duing geat poated simuaion The avaiabe evidene, main of hei gangia (eg, Bonic 35 is impoan o poin out hat inia oigin, indiates ha i is efe vegetative hanges in the sin unie ha iumsanes (suh as and ohe supefiia suues ae b sevee ension on a muse) whih no means peuia assoiaed with woud pofound modif he pa affeent simuaion of mofasia tens of affeent impuses fom a oigin Simia paens of autonomi given issue o ogan oud if on hanges (as we as pain, endeness inued susain suh affeen bom and muse spasm) often aompan badment fo ong peiods withou visea disubanes n hese ases, aso iniiaing some adaptive o the impuses dominating he segmen seonda pathoogia hange in the a pathwas oiginate in inued, affeted issue that aboishes, sienes ishemi, distended o iitated inte o ohewise aes he oigina soue na ogans, but the senso fibes, of iiaion Fibosis of honia usua aompaning mpaheti stethed, iiaed o ishemi muse pathwas aso ente he spina od, is a famiia eampe of suh a via the dosa oos, aong wih those hange t seems equa unie hat innevaing he somai issues The mehanisms ivoved and the pa neuona suue, hemis and i tes of manifesaions of visea iabiit of the affeted pa of he and of somai stimuaion ma enta nevous sstem woud emain theefoe be quie simia, as song unhanged in the fae of poonged suggested b he epeiments of inense affeen bombadment is possibe, theefoe hat pa Lewis and Kegren6• The paens assoiated wih visea distubanes ens of ve ong sanding, even if wi be disussed moe fu in efe iniiaed, ma be maintained anothe pape on ha subet A b mehanisms othe han the mee peimina epot b KorO sum poongaion of hat same efe a maies ou ea findings on paiens tivit The epeiments of Kwh wih visea disease We have men and Thoms6 indiate, howeve, hat ioned hem hee on to show ha he ineased swea seeion of ow ou onep of eaggeated oa o esistane aeas is mainained b segmenta infuenes on noma oni hpeativi of effeent nonsegmenta paens appies o vis neuons supping suh aeas But he ea as we as o somati stutues. possibiit must be ef open ha he We beieve hat he sudies epoed susained hpeaivi of he effeent in his pape on the hanging patens (smpaheti) neuons, and theefoe of eetia esistane of he sin, in of he swea gands, ma, in he onunion with suh obsevaions honi phase, be due not so muh to as disussed above, sugges a east honia modiied affeen bom one possibe oigin o aego of badment as to honia aug oigins of the paens found in ap mened iitabii of ena neuons paent noma, esting subes We mus aso eave open the Ou obsevaions song indiate possibii tha some of his effeent hat the abeant aeas o ow esis hpeaivi ma no even be en tane (Kor Thoms and Wrigh) a odeed This is suggested b and of vasoonsition o diataion soe of the aeas of ow esistane (Wrigh Ko and Thoms) ma hat we have eoded We have in begin as pas of efe esponses to mind patiua hose aeas of ow enipea seams of impuses esistane whih seem o oup pats oiginaing in somati (o visea) of a singe ematome (eg, Fig in sutues o, possib, in neve ibes Kor Thoms and Wrigh' and Fig iiated b hem 1 and 16 in his pape) is difut Whehe suh a efe mehanism to aep a efe basis fo an auo oud oninue to be the susaining nomi esponse whih is imited to a mehanism fo peiods of wees, singe segmen when one eeps in months o eas is not nown Unfo mind he divegene of affeen tunae, mos epeimena sudies neuons as the ene he od and on efees ae based on bief peiods snapse on seonda neuons, he of stimuaion fations of a se fuhe divegene of he inte 3
neurons wih whih ey synape and finay he diergene of he pregangioni sympahei neurons Axons in a gien whie ramu om munians are nown o end branhes aboe and beow heir ee of enry ino he ympahei hain and o ynapse in seera gangia. Whie he highy eeie han neizaion of a refex repone or of pregangioni diharge o posgan gioni neuron of an indiidua gangion anno be enirey rued ou i woudeem ha in hee ase he pahway are more direy eeed We beiee i more iey ha irria ion may hae been drey affeing paiuar gangia gray rami om munianes enra roos spina nere primary diiion or iner osa nere. Cerainy dermaoma band of wea gland aiiy or asoonriion woud be produed by dire imuaion of any of hee ruure (Randa and o . I is poibe ha a ea in some of he experimen dire mehania (om presion friion sreh) or hemia (hypoxia aumuaed meaboies pH hif) irriaion of one or more of hese neura ruures may hae aen pae in addiion o reex phenomena. (Some of he aoiaed auar hange in he in may een be due o he iniiaion of anidromi impue in dora roo fibers Fokow7) Wheher reflexY or direy pro oed he hyperaiiy of ioaed porion of he ympahei ouflow ere no obious adapie funion. e one may expe funiona im piaion of uh hyperaiiy of isoaed porion of he sympahei ouow and if uained inia im piaions. Cerainy he affeed egmen whih our preious udies indiaed are in a sae of faiiaion anno pariipae in a we oor dinaed manner in he organized pa es of moor and auonomi aii y assoiaed wih hanges in en ironmena emperaure posure or musuar wor . Sine he par of he sympahei ouow reaed o he perien ow reisane area hae ow reflex hrehod and in genera mae exaggeraed repones ome degree of disrupion of hese paerns and some impoiion of ompenaory burdens on he oher pariipaing eemen in eah paern are o be expeed.
Ahough he auonomi on omian of myofaia simuaion repored in hi paper hae been meaured ony in he in here i no reason o asume ha hey are imied o he in Numerou inia sudie a few of whih hae been ied aboe rongy ugge ha he ympahei neuron reguaing sere ory onraie and aomoor a iiy in iera may ao be in oed. xperimena sudie by Kunz 3 Kunz and Hewood and Rcns an d Brzzee on he imuaneou auar reponses in in and iera o he ooing and warming of he sin eary reea he rih aess of omai affre o ieromoor pahway and he para eim beween he auar repone of in and isera Sudies on rena iruaion by Nedz and by in our aoraorie onfirm and exend hee obseraion An in genious udy on human ubje by Rason and Kerr· reeas he pro found refex auar hange in he muou membrane of he upper re piraory ra in repone o herma simuaion of he in in he upper par of he body. Conerey numerous udie on reflex omai onomian of iera simuaion or pahoogy show he reiproiy of reflex reaionhip beween iera and omai issue We beiee ha hee udies reeaing some ympahei manifes aion of myofaia irriaion on ribue o a earer underanding of he mehanim inoed in he wide ariey of syndrome enompaed in he aegory refex ympahei dysrophie. n he onex of he foregoing diuion hey ao hep o expain he exaerbaion of many pain yndrome (eg refex ym pahei dyrophie referred pain assoiaed wih myofasia riggers oin pains of many origin referred pain of iera origin e.) by ex poure of he paien or een a a par of he body o od by prooa ion of emoiona repone or by an enironmena hange whih in rease sympahei aiiy Some of hee impiaion nd he auonomi hange ourring in asoiaion wih muuoeea diurbane of inia origin and in aoiaion wih iera dieae wi be expored furher in ueeding repor now in preparaion
Summa
1 The purpoe of hee udie was o
examine he hanges in udomoor paerns in he in of he human run produed by experimenay in dued irriaion and ree in he musuoeea iue a a ep oward underanding he origins of he paern found in appareny nor ma indiidua Irriaion of he muuoseea isue wa produed by he injeion of hyperoni aine ino praere bra isues. Poura sree were produed by he inserion and remoa of hee if and by he aera ininaion of he pei by he use of ihair Sudomoor paern were re eaed by reording eeria in reiane on he dora sin of he horai and umbar regions in rea ion o egmena ee. . New area of ow eeria reiane appeared when he aine ineion produed referred pain he areas were disribued in he referene one in dermaome reaed o he in eion ie S Posura hange produed hange in paern whih inuded a) exaggeraion of exiing paerns and b) he appearane of new area of ow resisane (inreaed wea gand sereion) aording o he appied re he indiidua erebra adapion o he re and he area of diomfor. 6 We beiee he finding uppor he foowing hypohee: a) Tha he manifesaion of aered ympahei aiiy obered in hese sudie repreen disorion of normay exiing paern of ef feren aiiy. b) Tha he diorion begin as repone o exaggeraions of eg mena or oa afferen influenes whih ordinariy hae ony oa ad juie inuenes on he paern and ha hee impue may be iera or somai in origin. ) Tha ahough he aberran area of ow resisane desribed in norma ubes may refe hroniay aered or inenified paerns of af feren bombardmen from foi in is era or omai iue oher faors uh a adapie or pahoogia hange in hoe issues and aered enra exiabiiy may eenuay beome inoed. 7 Sine howeer he affeed
EMG SNS reexe e.
areas ay be liite in extent to single eratoes it appears that in iviual ganglia gray rai couni cantes ventral roots spinal nerves or their branches ay in soe cases be dictly, rather than reflexly ir ritate 8 Soe of the functional iplica tions of chronically altere activity in localie portions of the sypathetic outflow are ientifie. The relation of these finings to echaniss involve in such clinical phenoena as reflex �ypathetic ys trophy yofascial triggers referre pain etc is briey exaine The valuable asistance of Mr. Em D Bl ako rb with intrumentation and illustration i gratefully acknowledged We are grateful to Dr Joh n Ca US Public Health Service Spcial Research Fellow, in the Biomchanic Laboratoy of thi College for taing these roentgenogram and for hi va luable guidance i n anale of the vertebral mhanic involv in each expriment
Rfn
K IM PE and HM Wright. Pat
terns of eltcal skn restance n man Acta Neuoveget, Wen 17 (1958) 77-96 2 Wright. HM, IM Krr and PE Thm Lal and regona araton n cutaneous vasomotor tone of the human trunk Acta Neuroeget Wen 22 (19), 33-52 3 Thm PE
and IM Krr Sgnfcance of ara of low ESR Fed Pr (1952) 162 4 Thm PE. and I Krr Te relatonship betwn swat gland actty and electrcal resstance of the skn. J Appl Pysol. Wah 10 (1957) 505-510 5. PE HM Wht and C W Ht, jr
Relaton of sweat gland recrutmnt to ESR Fed Proc 12 (1953) 143 6 Kahta A and PE Thma Furer stude on the neura bas for regonal deences n ER Fed Proc 18 (1959) 7 Outtman L Ub reektorche Bezehugen zwscn Vsra und hwerUen und hre Bedutung be Erkrankungen nnerer Organe der szerosudorale Ref Conna nrol I (1938) 2311 8 Ku$ A
v Dsorders ofsecreton wth peptc ulcer Vr� deo Carko, 26 (1946) 933-934 9 K" I Exprmental alteratons n gmenal sympatetc (sweat gland) actty throug myofascal and postural dsturbances Fd Prc 8 (1949) 88 10 Krr IM Skn resstance patterns asated wth sceral dsease Fed Proc 8 (1949) 87 Levine M and C P Richer Perodc attacks of gastrc pan accompaned wt marked canges n elecrcal resstance of te skn Arc Neurl Psychatr Chcago 33 (1935) 1078-1080 12 Van Metre E jr Low electrcal skn rstance n te regon of pan n panful acute snusts Jon Hopkns Hos Bull 85 (19 4415 1 3 Spiegel
E A and MO Whl, The cogalvanc reacton Arc Int Md Ccago
56 ( 1935) 33
14 Del P and Mme Leder ntret de la t momtre cutane Presse Md 60 (1952)
and AB Hertzmann Drct examnaton of te sym patetc outfows n man J Appl Physol Wa
1056-1 15 Dret JP
(1 955) 6888 37 Flkw B
and C Ferr ngat de la tempature cutan dans I'nfacus du myade t anne de potrne Cardologa / (1951) 16 Srup OK Veral pan; plehysmographc "pan reacons dlaton of osopagus Ny Nor dsk Forlag A Buck Copnagen 1940 17 We A Th B Vcero-kutane aneske oner of deres tydnng gfLaeger 85 (1923) 143-147. 18 AdaRay
and Nr/en Bladder dsten son reex wt aoconstrcton n cutanous enous capllares Acta Pysol Scand 23 (1951) 951 19 Adams-Ra Photometrcal studes on sceocutaneous reflexes wt vaoconstrcton n enous capllares Wernoes symptom) n gallbladder dsease. Angology Baltmore 2 (1951) 51-59 . Thm, PE. and IM Krr Te automatc recordng of elecrcal skn resstance patterns on te uman trunk. EEG Cln Neurophyo 3 (1951) 36t-368 2 1 Thmas, PE I Krr and H Wrht
A moble nstrument for recordng electrca skn resstance patterns of te human trunk Act Neuroeget Wen, (1958) 97-1 22 r, H An mproed clncal dermomet J Neurosurg Sprngfeld 2 (1945) 257-2 Kegn, , Observatons on referred pan arsng from mucle Cln Sc London 3 (1938) 175-1
Kegn H On th e dstrbuton of pan ar ng from deep somatc stuctures wt chts of egmental pan aeas Cln Sc London 4 (1939) 35-
Kegn H Somatc smulatng sceral pan Cln Sc London, 4 (1940) 303-3 26 Lew and H Kegren, Obseratons relatng to refed pan vsceromotor reflexe and oter asocated phenomena Cln Sc London
Nevous control of te blood els Physol Re, Baltmore 35 (1 955) 629- 38 K IM P.E Thm and HM Wgh ymsum on the functonal mplcaton o f segmen tal fltaton J Amer Osteopath Ass 5 (1955) 265-282 39 Kunt A
Anatomc and pysologc prot of cutaneovsceral vasomotor reflex arcs. J Neurophysol Sprngfeld, 8 (1 945) 421430. Kunt A and LA He/ Crculatory reactons n te gastrontetnal tract elctd by lal cutaneous stmulaton Amer. Heat J 20 (1) 743749 4 1 Rih A
and K Br Effct of local ed cutaneous stmulaton on crculaton n duodenal arteroles and capllary beds J Neuropysol Sprngfeld 12 (1949) 131-136 42 Nede/ A, Effects of body chllng upon the blood esels of denervated and ntactkdneys n dog and rabbts J Avat Md 23 (19'2) 49-53 43 Nedzel, A and Bwn. Effts of by cllng upon te blood esels of denevated and n tac kdne n dogs and rabbts J Aat M (195 236-238
H E L Rex communcaton betwen skn and kdney a nuenc by ace rrena refe Fed Proc 18 (1959) . 45 Ratn H and W Kerr Vacula repones of te naal mucoa to temal stmul wt some obato on skn temature Amr J Pyso! 1# (195) 305310
eprnted by prmon from Journal of Neura Transmson 23: 22 33355 12
(1939) 47-71 27 He, WR
Dencepalon Autonomc and ex trapyramdal funon Grune Stratton New York 1954
Dn/w S, IM Krr and A.D Km, Quanttate studes of cronc facltaton n uman motoneuron pool Amer J Physol 105 (1947) 229-238. 29 Feintein B K Langtn RM amn
and Schie Experments on pan refered from dp omatc tue J Bone and Jont Surg 36A (1954) 981-7. 30 Steinbrcker
SA Inberg M Silr D Neustt P Kuhn and Mariln Shittne Obva
tons on pan produced by njton of ypeonc alne nto mucls and oter suppoe tsu J Cln nvest 32 (1953) 151051 3 1 Traell Pan mansms n conntve tssues n C Ragan Ed Scond Confeence on Con ncte Tssues Josa Macy Jr Foundaton (1952) 86125 32 Trae C Berr and N Bigelw
Effects of referred somatc pan structures n te reference zone Fed Proc 3 (1 944) 49 33 Dttrih, R Somatc pan and autonomc concomtants Reflex sympatetc dystrophy Amer J urg 87 (1954) 66-73 Rberts, T, Effec of occluse artera dseaes o extremte on blood supply o nerves ex permental and clncal studes on role of a ne rum Amer Hea J 35 (1948) 369-392. 35 Bnia Te management of pan Wt specal emphas on the ue of analgesc block n dagnoss pognoss and therapy Lea Fbger Pladelpa 1953. 36 Randal WC F Alander KB Cldter
65
Cuaneou paten of ympathec activity in clncal abonalitie of he muculokeleal ytem (1964) VN M KO AY M WGT n ON A CAC
In prvious invstiations hav mntally inducd irritation and rportd on rional and smntal strsss in th musculoskltal tissus variations in sympathtic activity as has alrady appard in this ournal rvald by cutanous sudomotor and N aras of lo lctrical skin rsisvasomotor manifstations• In tanc appard in aras of r studis of toporaphical variations in frrd pain and in smntally rlatd lctrical skin rsistanc (ESR) drmatoms hn th paravrral hav obsrvd prsistnt aras of lo tissus r inctd ith smalluanlctrical skin rsistanc in most titis of hyprtonic salin Postural normal" rstin individuals. Th strsss producd xaration of xtoporaphical distribution or pat istin L pattrns or licitd n trn" of ths o rsistanc aras aras of LRA accordin to th strss (L) as found to charactristic th individuals vrtbral adaptation for a ivn individual and rmaind to th strss d his discomfot rlativly constant for ks or In this papr rport our obsrmonths. Studis by Thomas and vations of sudomotor pattrns in othrs in our laboratoris hav clinical sucts ith knon musculoshon that ths masurmnts and skltal disturbancs myofascial pattrns of ESR as rcordd by our strsss and pain syndroms mthods rct variations in activity in th sympathtic fibrs. Studis of Methods rional and smntal variations in cutanous vasomotor activity also Method s o eauatio 0 shod toporaphical pattrns" in muscuoskeetaabomaities th skin tmpratur <rd rspons" Mthods of xamination utilizd in and apparnt blood contnt of th this study includd radioraphic skin and lik th ESR pattrns th studis of postur and skltal abnor vasomotor pattrns shod a hih malitis lctromyoraphic assss dr of constancy and rproduci- mnt of th activity of postural bility in any ivn individual muscls and palpatory tstin for Ths studis on apparntly ll aras of cutanous and dp tndrand rstin sucts hovr did not nss Postural radioraphic studis of rval th physioloic oriins and th spin and plvis takn ith th functional sinificanc of ths patint in th standin position ac cutanous manifstations of sym cordin to mthods hich hav pathtic activity Prliminary vi prviously bn dscribd r dnc obtaind in our laboratoris• 7 mad on som of th patints. Our and rports of aras of sudomotor lctromyoraphic procdurs ar and vasomotor dysfunction rflxly dscrid in th lnd of Fi. 8 c. rlatd to painful myofascial and Th palpatory mthods r thos viscral conditions (citd in dtail in convntionally utilizd in clinical our prvious papr) sustd that practic ths pattrnd diffrncs in sudo motor and vasomotor activity r 2 ESR Expoatios rlatd in som individuals to viscral Sinc th mthods usd for th study and myofascial disturbancs. W of cutanous sudomotor activity undrtook invstiation thrfor hich hav bn usd in ths studis of factors hich miht contribut to hav bn prviously dscribd ths local asymmtris and vari thy ill b only briy charactrizd ations in sympathtic activity . hr A dtaild rport on th chans in Th xprimnts rportd in this sudomotor pattrns in th skin of th papr r don ovr a priod of human trunk producd y xpri svral yars Durin this tim thr
mthods for rcordin ESR r usd ach yildin a diffrnt typ of rcord. Hovr all thr mthods ar asd on convntional principls of skin rsistanc masurmnt. Essntialy ach mthod consists of masurin or rcordin in corrct spatial rlationship to th xplord ara th momntary currnt flo throuh th skin in contact ith a constantly movin xplorin lc trod at knon voltas Th voltas r tappd stpis from a sris of dry clls and applid to an lctrod fixd to an arlob and an xplorin lctrod. Rsistanc of th skin of th arlob as minimizd by mans of lctrod past. Aratoara diffrncs in currnt flo at a ivn volta thrfor r du to diffrncs in th rsistanc" of th skin undr th xplorin lctrod. a) Explorations ith handhld lctrod. In our arlir studis usd an in strumnt similar to that dscribd by Jpe Currnt flo as rad from a microammtr as th lctrod as movd ovr th subcts skin. b) Automatic xplorations. In latr studis to typs of auto matic drmomtrs r dvlopd With th rst 9 diffrncs in cur rnt fo throuh th skin r convrtd into variations in th briht nss of a liht ovr th xplorin lc trod hich as proplld ovr th skin at a constant spd. A camra r cordd strips of liht hich varid in brihtnss accordin to th ESR (in vrsly as currnt flo) alon strips of skin. To liminat th disadvantas of photoraphic rcordin hovr dvlopd a drmomtr ith hich skin rsistanc pattrns on lar aras of th trunk r rcordd dirctly on papr by a rcordin alvanomtr hos amplitud of oscillations is rlatd throuh an amplir to th skin currnt '0 Th position of th alvanomtr ritinpoint on th chart as rlatd to th position of th xplorin lctrod on th subct by mans of a pantoraph Th xplorations r conductd in a quit room maintaind btn 2 and 25° C Th body as unclothd abov th lvl of th sacrum. Th tips of th spinous procsss r idntifid by palpation and numbrd In ths studis smntal" EMG SNS rflxs tc.
level refers to the topographical level on the trunk as identified by the cor responding spinous process, rather than the dermatomes. There is, how $ver cose correspondence between topographical and segmental levels for paravertebral skin, except at the uppermost thoracic segments. c) Interpretation of ESR charts n the figures showing ESR patterns the dark areas represent areas of low electrical skin resistance The dark ness of shading in the hand-drawn charts (Fig 4, 5, 8 b) and in photo graphic records (Figs. 1 3, S b ) is in proportion to current flow at explora tion votage; the darker the area the lower the resistance. White areas: I or less (resistance, in ohms, at east I milion times the number of volts); back areas 20 a or more; i. e less than I 20 of basic resistance; gray areas intermediate values (Repro duction of these figures has darkened the gray areas and the darker shades have become indistinguishable from the black areas) In the pantographic records (Figs. 6 b 7 b, 8 b ) amplitude of oscilla tions of the recording galvanometer is related to current flow through the skin The thin vertical lines (no oscil lation) represent areas permitting 0 to I a at exploration votage; widest oscilations represent current fows of 30 a or more, in these cha rs therefore the darkest areas represent I 30 the basic resistance or less Tips of spinous processes and the sacra base are marked in photo graphic (ight points and lines) and pantographic charts (short horizonta lines) In the figures both the photo graphic and pantographic charts are spatialy reated by superimposition to the subject's body
ig I Rdigp fpi D C R d ig , C I) T w i vic i ppig i i d ccdig digp i pwd pci f bc ' mid i digp w fig i i pp b iwd g p i w big fm bck i f id i d f d id ig I b ESR p f pi D CR w w ic i gi f mbc ci Rcdd wi p gpic m d f ESR xpi
Results ESR explorations were conducted on more than 30 persons presenting complaints referable to posturl and musculoskeetal disturbances such as pain, tenderness severe and per sistent backache and limitations in motion, or in whom anomalies or other potentially stressfu muscuo skeetal probems were discovered Such problems and complaints as gross inequality in legength verte bral anomaies, injuries to the spine pelvis or shouder, abnormal spinal curvatures, herniations of interverte-
bral discs spondylolistheses etc were incuded. Eight are presented to illustrate the type of information revealed in our studies Case Patient D CR, Male, 49 years (Fig. ) Complaint: Severe ache in ow back, of long standing beginning in chidhood; often incapacitating Pa tient complains of difficulty in
"straightenng up after being seated for prolonged periods and after stooping over Radiographic and physical amination. Anteroposterior Xray films of the pelvis and lower lumbar spine taken with the patie standing (Fig 1 a) revealed a) an inequality of leg length (heights of femur heads), the right being 5/8 inch (approxi mately 6 mm) shorter than the eft; b) a considerabe displacement of the pelvis to the right of the mid-heel ine; c) titing of the sacral baseplane toward the right; d) scoliosis of the lumbar spine convex to the right with considerable rotation of the vertebra bodies toward the con vexity; and e) congenital, uniateral anomalies of the first sacral segment Electrical skin resistance (Fig 1 b) The ESR pattern obtained with the photographic method, reveals the predominance of low-resistance areas in the region of the lumbosacral junc tion Case Patient H M, Male, 34 years (Fig ), Complaint This man also com plained of backache and "stiffness beginning in childhood and reported several incidents of painful back in jury and strain due to lifting and pusing in the course of his work as a farmer. Athough palpatory examina tion reveaed generaized tenderness over the back pain, tenderness and muscuar rigidity were most severe in the vicinity of the lower lumbar spine and lumbosacral j unction particular ly on the eft side Radiographic examination (Fig 2 a) of the spine revealed failure of fu sion of the neural arch of the fifth lumbar vertebra and anomalous ru dimentary or asymmetrical articula tions in the lower lumbar spine and umbosacra unction The discrepan cy in leg length t he right eg being 3 8 inch (approximately I cm) shorter than the left seems not to have pro duced significant tit of the sacral base or lumbar scoliosis. Electrical skin restance (Fig. 2 b) Lowresistance areas were mainly in the umbosacra region predominat ing on the lft side, where symptoms were most marked. Case 3 Patient W P, Male, 46 years (Fig. 3) Complaint This subject had his
F ig a Radiogaph ofpain HM sanding s x, Cas F g. b Th ESR pan of pain HM. shows os conspcuous lowrssanc aras in h lu bosacral rgion parcularly on h lf sd whr sy po s wr os arkd Rcodd wih phoographic hod.
left leg amputated more than 30 years prior to this study because of osteo myelitis. He had no complaint (other than occasional mild gastrointestinal distress) but was selected for study because of our interest in his muscu loseletal adaptations to the amputa tion Radiogapic and pysial examinaion According to elaive heights of his feur heads measured radographically in the standing posi tion his atificial leg (attached to the mid-thigh stump) was almost one inc (approximately 2.5 cm) oo
shor He had a long mid scoliotic curve convex to the left extending from the tilted sacrum to a sharp "breaover point between the sixth and seventh thoracc vertebrae Para spinal musculature was thicened and tense on the left side throughout the lengh of he scoliosis and one or wo segments above a compared with the righ side Deep tenderness was especialy mared on the lef side in the lumbar region and in the mid thoracic region Elcical skin sisanc (Fig 3) he exploration revealed a virtualy continuous area of low resistance on the left side extending from the level corresponding to the top the sacrum to the mid thoracic region Cas Pain A W., Female, 30 yeas (Fig ) Complain About two wees prior to this study the patient had slipped on an icy sidewal and falen heavily the impact being mainly on the left buttoc In addition to painful bruise of the coccyx she complained of per sistent pain and muscular spasm along the umbar spine on the left side She had also observed areas of exquisite hyperesthesia of the ow bac groin and thigh Radiogapic xaminaion revealed nothing significantly related to the complaint Elcical skin esisance Fig 4 shows areas of low resistance found on this patient They corresponded very cosey with the areas of hyper esthesia even light movement of the exploring electrode over them causing considerable discomfort. Compari son of this chart with maps of the sympathetic dermatomes based on the boundaries between high and low resistance areas found on patients following ganglionectomies at var ous segmental levels Ric and Wooduff indicate an irritative i jury of spinal roots and -2 on the left side as a consequence of the fall Case Pain M. S, Mal, yeas (Fig Complain his man a farmer was brought to the hospital unable to bear hs weight on the right leg be cause of severe lumbosacral pain on the right side with sciatic radiaton Onset followed a series of severe "bumps while driving a ractor on
F g 3 Th ESR pa ofpain P. shows a lag aa of low sisanc on h lf sid fo h dhoacc rgion o h bas of h sacru hoogaphic hod Cas 3 F g 4 Th ESR pan of A. shows low sanc aas which cospond closl o h aas of hypshsia n hs pan Exploa on wh hand·hld lrod s x Cas 4)
his farm Simar attacs though less severe had ccurred in prevous months especially following vgorous phys cal wor and operation of mo toied farm equipment on which he was seated On the basis of symptoms and physical fndings a dagnosis of
EMG SNS refees etc
ig. 5 h ESR a o an M.S. h aas o ow sisan a sh own as bak h aas o ndn a indiad by X maks. Eoaion wih handhd od s . Cas 5.
rupture of the intervertebral dsc be tween L-5 and the sacrum wh her naton on the rght sde was made. Ths dagnoss was confrmed t surgery. Electical skin esistance The lower part of the trunk o f ths patent was explored wth handheld eec trode about one hour folowng admsson to the hosptal. The areas of markedly owered resstance are shown as back spots of varous szes n Fg 5 Accordng to the system descrbed n a prevous paper' the ressance n the areas marked n back s ' 2 or less that of the back ground resstance ths case 150,000 ohms or less as compared wth a general resstance of at least 3 000000 ohms ( 1 /a of current fow or less at 3 vots) The area shown over the left lum was ntermedate (about 750000 ohms) and was shown n gray on the orgna chart: the df
ig 6 a. Radiograh oain .M anding ( a 6) ig 6 b. Th SR a o ain . M Th ara o ow ran in h umboara rgion dvod ar aying ha o h vnra ura o h ain Rordd wih anograhi m hod ( Ca 6).
ference n densty from the other areas was however lost n photo gaphc reproducton of the chart. A eas oj tendeness At our re quest the attendng physcan n dependently conducted a palpatory examnaton of the patent n whch he ected areas of most severe deep tenderness by dgta pressure and recorded thm on a chart smlar to that used for the ESR patterns Hs chart was then supermposed on ours and n the composte chart shown n Fg. 5 the areas of tenderness are n dcated by X marks. Vgorous dgtal pressure to the aeas caused not ony local pan but n most of the areas also radaon and even rmote refer ence of pan smlar to that descrbed by Tavell1 and others Case 6 Patient IM Male yeas (Fig 6) Complaint Severe pan over the
lumbosacra area. Radiogaphic examination (Fg 6 a) revealed bone change n the ar tculaton of L4 and L5 ncudng eroson of the amna of L-5 on rght sde probaby due to pressure of n feror artcuar process of L-4 The nferor facets of L4 and L5 are frontal rather than sagttal n oren taton. Electical skin esistance The pa tents ESR pattern obtaned wth the panographc method s shown n Fg. 6 b The apparenty facltated area shown n the lumbosacral area was elcted n ths subject by apply ng heat to the body Though ex plored n mdsprng (Aprl 30) at room temperature 25.6 °C , the sk n of hs back had a unformly hgh ress tance. Electrc heatng pads were ap pled to the ventral surface and the ·area shown n the fgure had ap peared after 30 mnutes. An addton al 20mnute perod of heatng pro duced ony sght upward spread of ths area. Case Patient G c Male yeas (Fig Complaint Lumbosacral pan;
ig. 7a. Radiogah o ain G , sanding s a )
dscomfort and restrcted moton at the cervcodorsal juncton and occa sona tortolls.
ig 7b h ESR a oain shows aa oow rian in h umboara and r iodosa gion whih w ad o h aas o muuoska sr. Panograhi mhod.
Radiogaphic and physical ami nation Stress at the lumbrosacra
uncton s evdent n he apparent loss of cartlage and the thckenng o f the artcuar pates between L-5 and
appeared oer a period of seeral years (oember 1 4 oember 153) to be consistently associated with the regions of sharpest angula tion of the ertebral column: the icinity of the lumbosacral junction the dorsolumbar junction the midthoracic region and at the cericodor sal junction Electromyographic observations.
An electromyographic sampling of the actiity of the posterior ertebral muscles during quiet standing (Fig 8 c) indicated that considerable actiity of the spinal extensors much stronger on one side than the other was required in these same regins for the maintenance of the erect posture in this patient hus there was con spicuous actiity of the lumbar musculature extending somewhat to the lower thoracic leels on the conex (left) side of the scoliosis and of the upper thoracic segments especially on the right side possibly because of the lateral displacement of the head and nec (Actiity of the cerical musculature was not sampled) his electromyographic study was part of a series done on a large
number of subjects many of them obsered repeatedly oer long periods of time (Ko and Thomas I S. Wright - unpublished oservationsI6). As has been shown by Floyd and Silver 1 Portnoy and Morin 18, Joseph and McCol 9. and others we too found
that some subjects were able to achiee a standing posture in which there was very little activity of the posterior vertebral muscles. How-
eer in our experience some degree of localied often asymmetrical activity was found in every subject.
he atterns of such actiity location extent relatie amount etc aried from subject to subject according to body build posture weight distribution, spin�l and pelvic
coniguration and other unidentified factors As we hae found to be true for sudomotor and asomotor activity I. 2 the patterns are remark-
ably constant and characteristic for eah subject.
Diion In the preceding report from this series of inestigations! we showed that we were able to modify the E R patterns of human subjects by experi mentally induced irritations and stresses in t he musculoseletal tissues
Intramuscular injection of small quantities of hypertonic saline for example caused the appearance of new areas of low ER in those indii duals in whom referred pain was in duced the new areas of low resistance appearing in the reference one os tural stresses caused exaggeration of existing patterns of lowresistance areas (further lowering of resistance and spreading of areas) and the ap earance of new areas of low resis tance according to the nature and lo cation of the applied stress the in diiduals ertebral adaptation to the stress and the areas of discomfort On the basis of studies by Tomas and others in our laboratories preiously cited the induced changes in E R (and accompanying asomotor changes) would seem to represent sympathetic responses to the ex perimental musculoseletal insults In discussing our findings in the foregoing paper we proposed that the sympathetic changes were not anomalous reflexes inoed de novo by the noxious myofascial stimulation but that they were modifications of normally operating patterns of somatoautonomic coordination Ex amples of these patterns are those of centrally ordered adjustment of isceral cardioascular and thermoreg ulatory functions which continually tae place according to changing muscular actiity heat production of muscular wor and posture Al though the efferent components of these reflex patterns (motoneurons and preganglionic neurons largely spinal in origin) are multisegmental and under control of higher centers their actiity is also under the contin ual influence of afferent impulses arising in peripheral receptors and nere endings coneyed oer dorsal root fbers Indeed the local and segmental sensory inputs are essential to the proper execution of the pat terns with appropriate adjustment to local circumstances and demand It was our conclusion that the sym pathetic responses (indicated by altered ER patterns) to the experi mental myofascial insults reported in the preceding paper were exaggerated ersions of the local components he studies reported in this paper on subjects with musculoseletal stresses and irritations of traumatic congenital postural or pathological origin reealed similar regional exag
gerations of sympathetic actiity Although the changes produced in the affected musculoseletal tissues in a few minutes or een a few hours by saline injection or by experimental postural stresses may be expected to bear only superficial resemblances to those associated with clinical condi tions of much longer duration such as are reported in this paper it is liely that the neural and reex mechanisms are fundaentally the same As we stated in the preious paper we beliee that the altered patterns of sympathetic actiity (as well as associ ated alterations in muscular actiity) are either reex manifestations of changes in sensory inu arising in nere endings and receptors in the musculoseletal tissues or the effects of direct insults to nere fibers (or ganglion cells) or a combination of both eertheless the question arises as to how t he processes that are inoled are modified with time Our experi mental studies certainly indicate that the altered sudomotor and asomotor actiities in the aberrant areas at least begin as parts of reflex responses to centripetal streams of impulses orig inating in somatic structures or possibly as the effects of direct mechanical or chemical irritation of nere fibers But one wonders whether the same mechanisms would continue to operate in essentially the same way for periods of wees to years Clinical and pathological ei dence indicates that in the face of chronic stress or irriation and of sus tained reflex actiity adaptie changes would tae place either in the stressed or irritated tissue (eg fibrosis of muscle) in the participat ing neurons (eg altered excitability) in the responding organs or tissues (eg altered contractility of blood essels altered secretory actiity of sweat glands) or in combinations thereof In studies to be reported more fully in a subsequent publication we inestigated the functional alterations in the aparently aberrant segments by comparing the simultaneous responses of these areas with those of apparently normal adjacent or corre sponding contralateral areas to such generalied stimuli as teration in en ironmental temperature change in osture from recumbent to standing pain threat of pain startling etc We
fond ha h sgmns rprsnd y abrran drmaoms (wh rspc o sdomoor and asomoor ac y) re profondly alrd fnconal ly Th rsponss of hs sgmns o hrmorglaory posral or mo onal dmand wr rla o h adjacn or conralaral conrol sgmns so alrd qanaly n rms of hrshold lancy magn d and draon of rspons as o b nappropra o h dmand Th drcon of h alraon n h sgmns rprsnd by lowrss anc aras ha bn conssnly n sch a drcon as o ndca facla on of h sympahc pahways o h skn hhr hs rflcs an alraon n hos nrons hmsls or ssand affrn (or pr-ganglonc) bombardmn has no bn drmnd Th rcn sds of Tho and Kwht' clarly n dca ha n or sbjcs h alrd sdomoor rsponss n h low rssanc aras wr d o changs n mpls rafc n h sdomoor pahways rahr han n h swa glands hmsls hhr changs n h swa glands wold nally occr n sch saons has no y n drmnd alhogh h oca sonal fndng of xrmly hgh rssanc narly anhdroc aras smlar n sz shap and dsrbon o low-rssanc aras rpord n hs sds sggss ha sch chags may occr Th radr s rfrrd o or pr cdng papr on xprmnal nsls and srsss for a mor dald ds csson of h horcal and clncal mplcaons of h sgmnally and rgonally pad aonomc con comans of myofascal srsss and abnormals and of h rlan work of ohr nsgaors Th prs n sdy conrms ha local changs n sympahc fncon may b no only acly and mporarly ndcd by rlaly brf xprmnal r sls b ha ndrng changs n parns of sympahc acy may bcom assocad wh mscloskl al dsrbancs of clncal orgn Ths sdy also srnghns or sg gson ha h parns of abrran aras of sdomoor and asomoor acy prosly dscrbd n ap parnly halhy sbjcs• 2 may rc sbclncal and asympomac dsrbancs of affrn bombard mn or slcd dorsal roos or of 72
drc rraon of nr fbrs or ganglon clls Th parns assoc ad wh scral dsrbancs as sch sorcs of affrn bombard mn and nral rraon wll b prsnd n h sccdng papr.
3 Thom P E. nd IM Korr, Th rltioship btwn swt glnd ctiiy nd lctril rsistan of th skin J App. Physiol Wash /0 (195 505-51 4 Kahata A nd PE Thoms Furhr studis
on th nura bis or rgional difrncs in ESR Fd Proc 8 (1959) 80 S Thom PE and A Kahata Nurl ator undrlying arations in ltril skin rsistn of pparntly non-swting skin Appl Physiol. Wah 6 Korr IM Exprimental ltertions in sgmntl sympathtic (swat gland) atiity through myoasil nd postural distu rbans Fd Pro 8 (1949) 88 7 KO I.M Skin rsist ptrns assoiatd with iral diss Fd Pro 8 199. 87 8 Korr M HM. Wrght nd PE Thom Ef cts of primental myoasia insults on utanous patrns of sympthti tiity in mn At neurogt Win 1926 329-355 9 Thom, PE, d IM KO Th utomati rording o ltril skin rsistn pttrns on th human trunk Eltronphlogr 3 l 9 5 1 , .•
Summa
1 Ths sds on 1 30 pans ha bn concrnd wh opograph cal parns of sdomoor acy assocad wh known mscloskl al dsrbancs myofascal srsss and pan syndroms 2. Th mhod mployd for masrng sdomoor acy as an ndcaor of rgonal raons n sympahc acy was a of rcordng h lcrcal rssanc of h skn (SR) Radographc lc romyographc and palpaory x amnaons as wll as ohr conn onal clncal mhods wr sd n h alaon of h msclosklal dsrbancs 3 Th obsraons frqnly showd h prsnc of rgonal and sgmnal parns of low lcrcal skn rssanc (LRA n aras of r frrd pan and drmaoms sgmn ally rlad o h msclosklal srbancs or myofascal srsss 4 Ths parns of alrd lcr ca skn rssanc appar o rfc ndrng changs n h parns of sympahc acy assocad wh msclosklal dsrbancs of clncal orgn 5 Ths sds sggs ha h parns of abrran aras of sdo moor and asomoor acy whch w ha prosly dscrbd n ap parnly normal sbjcs may rc sbclncal and asympomac sorcs of affrn bombardmn or slcd dorsal roos or of drc r raon of nr fbrs or ganglon clls Tha s h alr parns of sympahc acy appar o b hr rflx manfsaons of changs n snsory np arsng n nr ndngs and rcpors n h msclosklal sss or h fcs of drc nsls o nr fbrs (or ganglon clls) or a combnaon of boh
361368 10 Thoms PE IM Ko and HM Wright A mobil instrumnt or rcording ltrial skin rsistan ptterns o th humn trunk Ata nurovgt in 17 1958). 97-1 Jspe H An improd linil drmomr J Nurosurg Springfild 2 195 2572
12 Deslow JS JA Chace OR Gutsohn nd M G Kumm Mthods in tking nd intrprting wightaring X-ray films J Amer Ostopth Ass.
54 1955 3-670 13 Rchtr, C P , and B Woodrf Lumbr ympthti dmatome in mn dtrmind by th ltrial skin rsitnc mthod J Nurophysio! Springield 8 95 323338 1 Trav/, J Pain mchanisms in onti tissus in C Rgn Ed. Sond Conerne on Con nti Tissus Josih My Jr Foundtion 1952)
825 15 Kor, I.M nd PE Thom Sgmntl pt terns in man Fd Pro. 1951 75 16 Wrgh H M Unpublished obsrations 17 Flo, W and PHS Siler Th untions
o th rtores spina muscls i n crtin momnts and posturs in mn J Physiol 9 1 955 1 84203 18 Portoy H nd F Morn Eletromyogrphi study o postural muls in arious positions and momnts Amr J Physio! 6 1956 122-126 19 Joseh J Man's postur; eltromyographi tudi p 88 Thomas Springfild 19 Jph J. nd I. MCol Eltromyogrphy of musls o postur: postrior rtbrl musl in mls J Phio! 5 1961 3337 21 Thom PE HM. Wrh nd C. W Hat jr Rltion of swat gnd ritmnt to ESR F Pro I953 13 22 Kor IM PE Thom nd HM Wrht Symposi um on th untional implitio of gmn tal acilittion J Amer Ostopth Ass 54 (1955)
265-282 Rprint by prmiion rom 10urnl o Nurl Trnsmission 25: 589 19
Rfnc Korr, IM, PE Thomas and HM Wrigh Pat ters o lctrial skin rsistanc in man. Ata nurovget Win 1958). 7796 2 Wght HM IM Kor nd PE Thom Loal and rgionl ari tions in utnous asom tor ton of th humn trunk Act nuroegt, in
(1). 33-52
EMG, SNS rfxs c
Neural and spinal components of disease: Pogress in the aplication of " termograpy (1965) H M WRIGH and IM KORR The participation of the peripheral neves ad the spina od in various clinial syndromes has bee reog nized in cinial practie for many years. Among the most familiar ob sevations of the neural and reflex omponents of disease are those on referred pain, but many bservers have also described the other patho physiologic hanges that often occur in the tissues of the "reference zones. These changes inlude ten derness, hanges in the blood flow and/or blood ontent of the skin, sweating, muscle contration, vaious trophi hanges, and othrs Simila patterns of manifestations, often simulating those of visceral oigin, may be associated with paful mus culoseeta disturbanes or myo ascia irritations. Last Septembe, a 5-year study was initiated at KOS, of measurements of physiologic activities and e sponses in intat human subjects that efect segmental and regional vaia tions in ativity of peripheral sen�ory, motor, and sympathetic neurons of the spinal cord n this poet, both norma (precinical) subects and linica patients with various somatic and viscea distu rbanes ae being in vestigated The observations, most of which are being made on the dorsal trunk, inude the manifestations mentioned previously, that is, pain, changes in vasomotion and sweating, and muscle ativity. Structural, palpatoy, and radiographi examinations are used in the identification and evaluation of vertebal anomalies, areas o f stress or lesion, abnomal curvatures, and various musculoskeletal disturbanes In individuals with visceal disease, the usual diagnosti tests are done Finaly, the relations between the indings on the trun and the clinica signs, symptoms, and pathologi uppoted by lh A.T. l OSeopalh Fondalion and Rsarch Inslilul; Ba of Reac of lhe Amcan OSeopah Assoao a Geea Rsac Uppl a ( R o lhe Naliona Insliluls of Heah
(-); 9·
findings, in both somati and visceral syndromes, wil be examined in each individua. Some of our patients, as wel as most of our norma sub ects, are dran from the Student Health Service of the college. Dr ra Rumney, diretor of the Student Health Program, and mebers of his division, are responsibe for the clinical aspecs of this proet This preiminary report deals with only one phase of this poect: cutaneous vasomotor ativity . We are using the new tehnique of ther mogaphy as one method of study ing the skin tempeatue as it is eated to utaneous vasomoto a tivity In prinipe, this eenty developed instument (ig I alled a "themograph * geneates themal photographi images of he body by measuring the infared energy emit ted by the skin Biefy stated, the infaed energy emitted by the skin fals on a sanning mirro and is then foused on a sen sitive thermistor heat detetor After the infared radiation has been on verted by the thermistor to an eec trial signa, and the signal has been ampified and pocessed, the popo tional output is used to ontrol the in tensity of a glow moduator tube which emits visible light, and this light is foused on the film of a laoid amera. The maxmum scan time is 4 minutes and, depending on the size of the aea to be sanned, may be only 1 minute or less. Thus, a perfety registered, quant i tative ecord of the infraed emission from the obet is obtained directly from the density of the photographic fim; that is, the hotter the obect, the white its image A hand-hed infrared thermomete (not visible in igure is used o determine the temperature range o delta T (6T of the aea to be ther mographed. Kowing the 6T of the area, the sensitivity of the ther mograp can be set. o example, to 'Bans Enginin Company, amod onne· u!
ig. The themogaph nstuent and san nng mo Not sh own n ths ptue s a handhed naed themomete whh s used n detemnng the tempeatue ange o the aea to be studed by themogaphy o the photo ompaao whh s used to measue the opta densty o the themogams hange the film from white to blac at a 6T o 0° reuires a lower sensi tivity than if the 6 is 2 ° . The greate the sensitivity setting, the greater the contrast in the picture "bright ness control on the instrument sets the low temperature point in the temperature differential seleted by the sensitivity n the first phase of this program, two or more thermogams on the bak have been recorded on each of the 02 members of the firstyear lass at KOS igures 2 to 5 sho the thermograms reorded on four of these students. n each case, the in dividua is lying face down on a heat pad (whih gives a white backgound for the picture The temperature of the heat pad is appoximately 100° n the thermogams, the warm aeas appear whi e and the ool areas black, with inteediate tempera tures in vaying shades of gray The "thermal gay scale, seen to the left of the subects, i s a caibation device whereby one can ompare the optical density of any point on the ther mogram with the optical density pro duced by known tempeatues. Thus, the vaious shad es of gray of the ther mogram can be conveted to temperature if that is desired The thermograms of the four in dividuals shown in igures 2 to 5 show that the topographi distribu tion of warm and ool areas on the bak vaies with di ffeent individuals, and at different eves on the tunk in a given individual Of the 02 individ uals in the firstyear class of OS,
(far lef)
Thermgram f ubjet . Obere the large warm (whie) area that ver mt f the thrai regin and the warm "band in the lumbar area and al belw the arum The blak dt are markerplaed n the pine f T6 and 2; the tp f the arum i al marked. The ide f the bdy are l (blak). The individual i lying n a heat pad whih appear white at the ide f the bdy. The thermal gray ale i een at the left fthe ubjet Fi (left t enter) Thermgram fube R. B. The temperature patte fthi individual i quite dferent frm the indiidual in igure Nte the lng "ld treak dwn the midline f the ba tending fm t and the aymmetrial lumbar area F (right fenter). Thermgram fubjet The ditributin f warm and l area in thi individual i dferent frm that f the ubjet in igure 1 and 2 The aymmetrial lumbar area i al f interet Fi. (right) Thermgram f ubjet S B. Nte the large ld area in the nek and the large warm triangular lumbar area f thi individual
Fig. Tw thermgram n ubjet J. G The ne n the left wa taken n Nv 5 1964 and the ne 0 the right Ja 22 1965 The tw thermgram appear almt idential.
(left)
Tw thermgram fubet S. B. The ne 0 the left wa taken Sept. 2 1964 and the ne n the right an 27 1965 The warm triangular lumbar area appear maller in the later thermgram Fg. right). Tw thermgram fubjet B The ne n the left wa taken n September 30 196 and the ne n the right n Jan. 5 1965 Nte the hange in the lumbar area in the later piture
EMG SNS eexe ec
no two ndduls hd themogms extly le lthough most n dduls hd etn etues n om mon We he lso equently oseed tht n some ndduls the tempe tue pttens wee symmetl o deed etween the ght nd let sdes t etn leels on the tun To stn these tempetue pt tens nd espelly the sym metl o ent es e mn stle o y om dy to dy o month to month, we too mo themogms o seleted ndduls gn te seel wees o months Fgues 6 7, nd 8 show tw the mogms on eh o thee deent ndduls tn on deent dtes In eh se n ntel o seel wees nteened etween the two themogms It my e oseed tht most etues o the tempetue pttens emned emly ons tnt lthough etn etues n the themogm my hng wth tme thepy, o othe tos As peously mentoned we ound tht most themogms hd etn temptue etues n ommon Fo exmple n most ndduls the sdes o the ody e ool the lum e espelly oe the spnous poesses s e wm, the ne s wm nd so oth In ode tht we mght ette ntepet the themo gms, nd ptully the tempe tu pttens oe the petel es we dd qunttte nlyss o the themogms o 0 suets t eh segmentl leel om the ne to the sum Ths ws don wth photoompto espelly mde o ths pupose whh mesues the op tl densty o ny pont on the the mogm The optl densty o pentge o opty n e on eted to tempetue tht s desed y ompng the optl densty to tul tempetues on the lton o gy sle esuements we mde oe the spnous posses exept t T , T6, T , nd S) nd t dstnes o 2 nd mm ltel to the mdlne on the themogms whh oesponds oughly to nd nhes ltel to the mdlne on the We ound tht n the ege n dul, the ne s qute wm oth n th mdlne nd ltelly the tempetues thoughout the tho e show only smll deenes ut
wth slght tendeny to e wme n the mdtho e thn t the eodosl e nd thoolum unton Tempetues e ey wm n the lum e oe the mdlne, ut dlne s one psses ltelly om the mdlne Questons mmedtely se on enng the mehnsms o the wm nd old es nd the physolog sgnne Ae the wm es elted to gte utneous lood low? less epoton om the sn? th tty o undelyng musls? Ae the old es elted to soon stton? to s o swetng? o othe tos? In n ttempt to setn the nswes to some o thes questons, w e now engged n the seond phse o ths pogm: tht s, to detemne the untonl deenes etween the wm nd old es, to setn how these es e elted to deenes n utneous lood low lood ontent, sul tty swet glnd tty musle tty, nd so oth Also, we wsh to setn how these es unton und stess nd ptpte n elex esponses Othe methods peously des\ed n ou ely wo e eng used o ths pupose Fnlly we wsh to now wht eltonshp the symmetl o ent tempe tue pttens e to somt o sel lesons The stutul nd plptoy exmntons stutul xys nd othe dgnost dt on the mems o ou stye lss e now n the poess o eng nlyzed wth the ssstne o D Rumney, o ths pupose Reprinted by permisio from JAOA : 98-92
965
Introductory note: What is manipulatve therapy? (1978) One o th unusul etues o th Woshop ws tht ew o th neuo sentsts who onend to ontute the nowldge hd hd ny po ontt wth the o mdn to whh they we to m th on tutons Most o them d stll unetn o the lene o th seh, done o qute deent puposes to the suet o th Woshop Bus te Woshop settng ws tht o oum the thn ln they dpted wth ette peepton o len, yet wthout le mge o how mnp ulte thepy s pomed o o ts lnl lue It seems lely tht mny edes moe nteested n th neous system thn n mnul medn, wll nd themseles wth sml unetntes out the ltte To them we eom mend, s we dd to the ptpnts the poedngs o n ele wo shop sponsoed y the Ntonl Insttute o Neuologl nd Com munte Dsodes nd Stoe nd oe the ollowng pgphs Mnpult thepy noles t pplton o utely dtemnd nd spelly detd mnul oes to the ody Its oete s to mpoe molty n es tht e estted, whethe the esttons wthn onts, n onnete tssus o n seletl musles Th onsequnes my e the mpoement o postu nd loomoton the el o pn nd dsomot the mpoement o unton elswhe n the ody nd enhnement o th sens o well eng Dgnoss, ledng to the sleton o ody stes o mnpulton nd the mode o mnpulton s sed on nlyss o t ptents hstoy nd omplnts nd on the eluton o sgns poded y plpton (tssue textue musul nd sl tenson ont moton nd omplne sn tempetue nd mostue, y sul oseton ody ontou postue loomoton, sn olo), nd y *NINCDS Mgrah No. I The Reseah Stas ofSpinal Manpuave Therapy, dd by M Glte, Behda Maryla 7
75
adioaphic and othe instumental means Manipulative pocedues, even in the hands of the same pactitione, va accodin to the findins and thei chanes in each visit the va fom pactitione to pactitione, fom patient to patient, and, fo the same patient, fom visit to visit Manipulative theap is no moe a unifom theapeutic entit than is sue, pschiat o phamacotheapeutics Clinical effects ae thouht to be achieved thouh impovement in musculoskeleal biomechanics, in dnamics of the bod fuilds (includin blood ciculation and lmphatic dainae) and in nevous function It is on the last that this Wokshop as focused ts concen, theefoe, as ith neithe the clinical efficac of manipulation no its evaluation, but ith its neual and neuonal mediation Wht re he neurobologc mechsms?
It has been clea fo man decades that the nevous sstem is a mao mediato of the clinical effects of manipulative thea, et the pecise mechanisms ae still, fo the most pat, obscue n vie of the bueonin of the neuosciens in ecent eas, it seemed timel to convene a eseach okshop to examine to hat extent that eat mass of ne knolede miht illuminate the neuobioloic mechanisms at ok in manipulative theap, hile at the same tie to discen ne and fundamental aeas in the neuosciences fo exploation The obectives of the Wokshop on hich this volume is based ee 1. To identif ne fundamental questions in neuobiolo hich emee fo clinical obsevations in the pactice of manipulative theap 2 To seek anses in eseach alead accomplished To identif and poect needed lines of eseach The desin of the Wokshop as based on the folloin assumptions and hpotheses t seemed to the plannes of the Wokshop that the musculoskeletal poblems to hich manipulative theap is addessed initiate thei impaiment of nomal phsioloical pocesses in to pima as
1 Alteations in senso input fom the muscles, tendons, bones, oints, liamnts and othe tissues hich ae involved in the musculoskeletal abeation 2 Diect insult to neuons, neves and oots, and associated lial, connectivetissue and vascula stuctues Accodin to ou hpotheses, both the chanes in affeent input and the taumainduced chanes in excitation and conduction of neual elements poduce in tun chanes in the cental nevous sstem and in the peiphe, eected in abeant senso, moto and autonomic func tions We chose to ive emphasis to the impact on autonomic function and, theefoe, to somatoautonomic inteelations The chanes in affeent input (and the esultant chanes in effeent output) and the nevetauma both affect, also, neuonal functions hich ae not basd on excitation and conduction of impulses, much as the ma be fcd by impulses These functions ae subsumed unde such ubis as axonal tanspot, tanssnaptic influences, tophic function, neuotophic elations, neuontaetcel inteactions, etc Hence, the Wokshop as oanized aound to mao themes impulsebased and nonimpulsebased mechanisms, intoduced b the Fragsung implicit in epots b clinicians skilled in manipulative theap as tauht and pacticed in thee diffeent pofessions t became clea in the couse of discussions, not onl beteen clinicians and scientists but beteen to oups of neuoscientists, that thee is no clean sepaation beteen impulsebased and nonimpulsebase mechanisms Each is involved in and inuenced b the othe, and distubances in each potentiall contibute to dsfunction elsehee and ae subect to manipulative amelioation f baies existed, the ee in minds and methods, and not in the biolo ical sstem povin aain that conceptual baies until identied and assulted ae often much less pemeable than cellula baies Pehaps one bpoduct of the Wokshop, theefoe, as a somehat moe coheent and unied vie of nevous function and plasticit, incopoatin
both eflexes and neuotophicit, both the instantaneous and the lon tem phenomena An impotant featue in the desin of the Wokshop as the dialoue beteen clinician and scientist The clinicians ee chosen not onl fo thei clinical poficenc in the application of manipulative theap, but fo thei concen, expessed in publications, about mechanism The neuoscientists ee selected not onl fo the qualit and impotance of thei eseach, but fo the elevance of thei ok, as peceived b the pannrs to manipulative theap and to the poblems ith hich it deals While no mao anses have as et emeed, the a has been opened fo the fomulation of ne, appoachable questions and testable hpotheses. Rpitd pmiio om IM o Eito Nobioogi Mhim i Mipt Thpy m ubihig Cotio Nw o 978 p 7
EMG, SNS eflexes, etc
Sustand sympatcotoia as a facto in diseas (78) . There is a large though scattered body of cinica and experimental iterature that gives the distinct impression of a significant often critica sympathetic component as a common feature in a large variety of syndromes. Chronic hyperactivity of the innervating sympathetic pathways seems to be a prevailing theme in many clinical con ditions invoving many organs and tissues. Whatever the etiological or therapeutic implications it appears that this widey shared feature of local regiona or segmental sympathetic hyperactivity is overlooked or dismissed because of the barriers erected by speciaization. Thus the ophthamologist is not ordinariy exposed to the gastroenteroogical literature the gastroenterologist to the cardioogical the cardioogist to the gynecoogica etc. Each discoverer of a sympathetic component seems therefore to regard it as peculiar to this or that disease within his or her rea of speciaization rather than as part of a general theme My ongtim exposure to osteopathic theory and practice and my research experience in related ieds have ed me to the folowing hypotheses: ( 1) Longterm hyperactivity of particular sympathetic pathways is deleterious to the target tissues and ay indeed have a rather general cinica significance. (2) Cinical manifestations are determined by the organs or tissues which are innervated by the hyperactive sympathetic neurons each responding in its own way even to the sympathetically induced vasoconstriction that may be a common factor (3) The h impulse traffic in selected sympathetic pathways may be related to musculo skeletal dysfunction especially in the spina and paraspina area. It is the purpose of this paper to review the support for these hypotheses in availabe knowledge of
the autonomic ervous syste in experimental findings including our own and in cinical iterature The sympathetic roe in muscuoskeeta actvity
One of the most important roles of the sympathetic nervous system (SNS) not always emphasized or recognized in textbooks is part of its ergotropic" function (Hess 1954) that of adjusting circultory metaboic and visceral activity according to postura and muscuoskeetal demand. These ajustments incude changes in cardiac output in distribu tion of blood flow by regulation of peripheral resistance in heat dissipation through the skin and release of stored metaboites. These adjustments are of systemic nature yet they have a high degree of locaization according to the site and te amount of muscular activity. (It is understood of course that autoregulation is also important and often the dominant factor in these adjustments.) In order for the SNS to perform this role it must receive directly (through segmenta afferent pathways) and indirectly (through the higher centers) sensory input from the musculoskeletal system. Coote has given us an excellent review of this aspect. It seems safe to assume that the SNS would be similarly in formed about strain injury or malfunction of some part of the musculoskeletal system (e.g. of a joint) and that there would be a ma jor impact locally or segmentally if a segment of the vertebral column was involved On this assumption in the late 1940s my colleagues and I at the Kirksville College of Osteopathic Medicine undertook studies on human subjects to see if any altera tion in sympathetic activity as associated with the vertebral and paravertebral dysfunctions to which osteopathic physicians give attention in diagnosis and therapy In a series of studies in which we used sudomotor and cutaneous vasomotor activity as physioogical
indicators of topographical variations in sympathetic activity we showed the following (1) In most individuals even under cool resting conditions there are areas of hydrated skin associated with persistent lowgrade sweatgland activity (reflected in ow eectrica skin resistance hence lowresistance areas" L) and of high vasomotor tone (Wright Korr & homas 1953; Thomas & Korr 1957; Thomas Korr & Wright 1958; Thomas & Kawahata 1962) (2) The segmental patterns of distribution of these aberrant areas varied from subject to subjt but were highy constant and reproducible for each subject over periods of months. This is not to say that the actua shapes and sizes of the aberrant areas were invariable; they were areas in which at any given time the probability was very high as compared with all other areas that we woud find high sudomotor and vasomotor activity. They were areas for example in which in the course of cooling the warm lighty perspiring subject the sweatgland activity persisted ong after it had subsided in other ars and were the first to respond with increased activity as the subject was warmed (Korr Thomas & Wright 1958; Wright Korr & Thomas 1960). (3) These areas of sympathetic hyperactivity correlated we in segmental distribution with existing musculoskeletal strain trauma deep and superficia tenderness electromyographic activity of paraspina muscles etc New areas coud be induced experimentaly with postura and myofascial insult which were related regionally or segmentally to the site of insult (Korr Wright & Thomas 1962 Korr Wright & Chace 1964). (4) Simiar signs of sympathetic hyperactivity were found to be associated with viscera pathology apparenty in areas of referred pain and tenderness segmentally related to the viscera pathology In a few subects studied over long periods of time the aberrant areas appeared in advance of the rst symptoms of visceral disease (Korr 1949) (5) The sympatheticaly hyperactive areas of skin funcioned differenty from the normal areas. Thus the sudomotor responses of the lowresistance areas to a variety of factors 77
were gro eaggerated Thi wa demontrated in a group of ubject who had ammetrica pattern, that i, in whom we had found ow eec trica kin reitance on one ide at a gien egmenta ee, whie the contraatera area wa norma. A preiou hown (Thoma & Korr, 1957; Thoma & Kawahata, 1962), we fund that in a owreitance area, there wa conpicuou weatgand actiit under coo, reting condition when, a hown b mot area of the trunk (incuding the contraatera area), there wa no eidence of thermoreguator demand for weat ecretion. That ame owreitance area ao made eaggerated udomotor repone (earier and more rapid recruitment of weat gand and more copiou ecretion) to generaized timui (eg, heating other part of the bod), painfu timui, threat of pain and other emotiona timui. Thee area eemed to be continua in, or erging on, a "cod weat (Korr, Thoma & Wright, 1955) On the bai of thee nding and other conideration, we concuded that periphera pathetic pathwa at egmenta ee correponding to omatic dfunction in and around the pina coumn are n a tate of chronic faciitation imiar to that hown b Denow and hi coworker for neuromucuar actiit (Denow & Haett, 1942; enow 1944; Denow, Korr & Krem, 1947). Peritent oca, regiona or dermatoma eeation in mpathetic ac tiit and predipoition to high actiit appear to be reated to pina and parapina motor dfunction a dicoed b oteopathic papator diagnoi n genera, the concept of chronic egmenta faciitation ha been found to be conitent with oberation in oteopathic practice, and hepu in their rationaization The concept ha recent been re ewed in a broader contet (Korr, 1976) and reeamined in term of conditioning, habituation and en itization in pina ree pathwa (Patteron, 1976).
Th infn of ymphi innion What i the cinica ignificance of chronic faciitation and hperactiit o mpathetic inneration on ariou tiue and organ? Let u 78
reiew firt the phioogica infuence o mpathetic inneration Thi i a great dea more aried than can be acribed to the reguation mere o eocrine ecretion and o contraction in mooth and cardiac uce and the metaboic energizing of thee actiitie, a i wide taught The iterature, ome o it quite od and ong ignored, indicate a much arger repertoire, a iutrated b the oowing eampe
Skeletal muscle
The mpathetic inneration of keeta muce appear to hae a direct augmentor efect on the energetic of keeta muce, ib imiar to the inotropic efect on cardiac muce ("Orbei phenomenon; ee Bach, 1953; Ke & Bach, 1959) t ao appear to faciitate neuromucuar tranmiion (Hutter & Loewentein, 1955; Naedo, 1960). Smpathetic inneration i ao inoed in the deeopment o contracture foowing trauma to the pina cord (Gaitakaa, 1965)
Perpheral sensory mechansms Seera tpe of receptor and ene organ hae been hown to be inuenced b mpathetic impue n genera, the effect of repetitie mpathetic timuation i faciitator, that o f increaing the requenc of afferent dicharge and owering the threhod n ome cae, threhod ma be reduced to zero, cauing afferent dicharge without direct timuation of the receptor In hort, the effect of increaed impue traffic in the mpathetic fiber innerating receptor i that o f eaggerating their dicharge, cauing them to report a greater intenit o timuation than i actua occurring The enor mechanim in which mpathetic infuence ha been demontrated incude (a) muce pinde (Hunt, 1960; Edred, Schnitzein & Buchwad, 1960); (b) tactie rceptor (Chernetki , 1 964a); (c) tate receptor (Chernetk i, 1 964a); (d) ofactor apparatu (Tucker & Beider, 1955); (3) carotid inu chemo and baroreceptor (Koizumi & Sato, 1969; Mi & Sampon, 1969; Sampon & Mi, 1970; Mcoke, 1975); ( Pacinian corpuce (Loewentein & AtamiranoOrrego, 1956); (g) retina (Macetti, Marzi & Berucchi, 1969); and (h) cochea (Vai'e, 1962)
3 Central nervous system Foowing the demontration b Bonaet, De and Heibe (1954) of adrenergic eement in the reticuar formation and of the effect o the SNS thereon and on the reticuopina tem, a erie of tudie appeared in the Soiet iterature, indicating trong inuence o the uperior cerica gangion on cortica and ubcortica actiit Thu, Karamian (1958) and hi coworker, Soertinkaa (1957), found that uniatera remoa of the uperior cerica gangion in rabbit reuted in behaiora change, in cuding owered intenit and een tota diappearnce of etabihed poitie foodconditioned motor reee Thee effect were accompanied b proound change in pontaneou cortica eectrica actiit and in repone to periphera timuation The effect were more marked in the ipiatera hemiphere After remoa of both e and right gangia oowed b adrena demeduization, the EEG otage became er untabe and change in behaior and repone to periphera timuation ao took pace Subcutaneou inecton o adrenain produced a tranient return to norma actiit TaAn (1960) demontrated that gangionectom ao affected eectrica actiit of the hpothaamu. n a ater tud, TaAn and Geehkoa (1961) tudied the effect on the recruitment reaction in the ipiatera hemiphere of stmulatng one cerica mpathetic nere in cat (The recruitment reaction i the increae in cortica eectrica actiit produced b timuation of nonpecific thaamic nucei.) In mot cae, m pathetic timuation reduced the ampitude of the reaction in the ipiater hemiphere Occaiona, uua on repeated timuation, there wa an increae ntraenou adrenain more conitent weakened the recruitment reaction. n contrat, there eemed to be itte mpathetic infuence on the primar repone of the auditor corte to timuation of the pec nuceu, the media genicuate bod Change in eetrca actit of the iua region of the cerebra corte foowing uniatera etirpation o the uperior cerica gangion in rabbit upport Zagoru'ko' concuion (1965) that the mpathetic inneration primari infuence the EMG, S, refee, etc
echniss esponsible fo the genetion of the bckgound electicl ctivity the hyth ssiiltion ection" epoduction of vious fequencies of shing light nd the secondy coponents of the induced esponses to light Aleksnyn nd Autunin (1959 obseved diffuse electicl ctivtion on stiultion of the cevicl sy pthetic neve nd concluded tht the sypthetic effect is on the totl bin, including the eticul fo tion nd tht the coticl effect is not necessily edited by the eticul fotion Gnglionectoy lso po duced electicl chnges in bth co ticl nd subcoticl stuctues, of such ntue s to indicte diffuse in hibition Obsevtions of Vesel kin (1959 on the pigeon indicte tht the ceebellu is siilly unde diect influence of the sypthetic innev tion The wok of Skoglund (1961 nd of Chenetski (1964b indictes tht the fcilittoy influence of the SNS y lso extend to the spinl cod In the ct Skoglund showed tht theshold doses f nodenlin con veted singlespike esponses to singl ffeent volleys to epetitive dischges set up dischges in initilly silent cells nd incesed the fequency f peiling ctivity In the fog, Chenetski showed tht sypthectoy kedly educed in tesensoy fcilittion of the leg fexion eex He ttibuted the depes sion to educed centl nevous esponsiveness in the bsence of the sypthetic infuence To wht extent these SNSelted chnges e bsed on vsooto chnges is difficult to deteine especilly in view of conflicting epots egding the ole of SNS innevtion on cicultion though the CNS Whethe the obseved chnges are of indiect vsooto oigin o e the oe diect effects on neuonl excittion o etbolis such as tht descibed by Hunte nd Stefnik (1975 the influence of th sypthetc innevtion on CNS function sees n ipotnt nd neglected e of neuophysiology despite the obvious ipotnce of the ctecholines in bin function nd dysfunction Coaera circuaion
Bdin (1956 showed tht follow
ing expeientl occlusion of the lingul tey inteuption of the sypthetic innevtion of the tongue getly cceleted the developent of colltel cicultion. Siilly Dnske (1957 using the ClkChbe bbite technique found tht uniltel sypthectoy incesed the developent of teiovenous nstoses, both in nube nd diete
neve stiultion Indee the etbolic esponse is delyed by the ccopnying vsoconstictin. The independence is futhe substntited by the fct tht the dipyte esponses to sypthetic stiultion e blocked by denegic ecepto ntgonists, whees the vsooto esponses involve eceptos Fedhol 1970 Fedhol et l 1975 Rosell & Belfge 1975
Bone growh
Reicuoendoheia sysem
Sypthetic innevtion hs been found to exet n ipotnt influence on longitudinl bone gowth Kottke Gullickson & Olson 195 Othe inuences e.g on the esponse of bone to estogens Rosenfeld et , 1959 nd on the ctivity of bone cells possibly in collgen elbotion nd tix fotion Chiego & Singh 1974 hve lso been epoted
Adipose issue
It is now well estblished tht dipose tissue y lso be egded s tue effecto ogn king its own specific esponses to stiultion of its sypthetic innevtion The sypthetic innevtion is equisite fo the pid lipolysis elese of fee ftty cids nd glyceol tht tkes plce in cold exposue nd fo the slowe lipolysis in stvtion Sypthetic blockde o sypthectoy the lt te usully done uniltelly, the contltel ft pd seving s contol) pevents the dptive esponse Poletti & Vetu, 1964; Hull & Segll, 1965 Sypthectoized dipose tissue inceses in ft con tent, suggesting tonic influence on the blnce between elese nd obiliztion Electicl stiultion of the neve supply to dipose tissue cuses the elese of fee ftty cids nd glyceol Obviously, sypthetic excittion eithe expeientlly o s pt of n dptive esponse such s tht t cold involves the pid ctiv tion of sevel enzye systes The nodenlin content nd etbolis in dipose tissue is the se s in othe ogns with denegic innev tion Fedhol 1970. The lipolytic effect of sypthetic stiultion with ccopnying glyogenolysis nd incese in O con suption e not dependent on the concuent vsooto esponses to
In 1953 Kuntz suized the evidence then vilble tht sy pthetic innevtion hs ipotnt influences not only on blood ow though the bloodfoing tissues but lso on such specific functions nd fctos s the phgocytic ctivity of the eticuloendothelil cells of bone ow on eythopoiesis nd on the elese nd distibution of leucocytes nd on endothelil peebility. Linke (1953 showed tht polonged, lowfequency stiultion of the splnchnic neves lub sypthetic tunks nd sypthetic neves to the live (but not to the spleen cused lge inceses in ciculting eticulocytes nd nooblsts The inceses laste fo peiods of 0 in to 30 h depending on the neves stiulted. esponses to stiultion of the sypthetic neves wee unchnged by clpi of the denl blood vessels. In oe ecent study on the aow of the t feu DePce nd Webbe (1975 using electostiul on nd ophological ethods hve extended these olde bsevtions. They found bundnt denegic fibes teinting on teies nd fibes cusing though penchy close to ny ow cells but no evidence of teintions on these cells. Stiultion of lub sypthetic tunks tiggee the elese of lge nubes of eticulocytes nd neutphils into the ciculting blood The chnges ffeting othe cells wee soewht vible The echnis govening the elese of blood cells fo the bone ow following sypthetic stiultion sees to be selective one ppently involving the sinusoidl wll. O n the bsis of cited electon icogphic evidence n the studies of nueous othe invstigtos the uthos conclude tht the tnsitte elesed t sy 79
patheti terminals inreases the (ap parently ative) passage of selted hite blood ells through ells of the sinusoidal all in a manner similar to that desribed for erythroytes Edoce yem
One of the most interesting examples of sympatheti ontrol is that on the pineal body and through the pineal on other endorine systems par tiularly those related to sexual development and reprodution (For revies see Wurtman Axelrod Kelly 1968; Wolstenholme Knight 1971 .) The pineal ontrols the release of releasing fators for luteinizing hormone follile stimulating hor mone and prolatin inhibiting and releasing fators This pineal ontrol of releasing fators is mediated by the elaboration and seretion of melatonin and other polypeptide hor mones hih exert antigonadal a tion The synthesis of melatonin is under the ontrol of the sympatheti inner vation of the pineal from the superior ervial ganglion Synthesis is augmented in the dark and redued in the ligt te opti pathays someho being involved in the regulation of impulse traffi in the sympatheti branh to the pineal (Brooks shikaa Koizumi 1975) This aounts for the impaired groth and sexual development of rats raised in the dark and for diurnal behavioral phenomena related to photoperiodiity These behavioral phenomena also reet the influene of the pineal on funtions of the higher enters on the brain Setion of the sympatheti innervation of the pineal obliterates the diurnal flutua tion of melatonin synthesis and related diurnal hanges and bloks the antigonadal and groth inhibiting inuene of the pineal in the dark Other more diret inuenes of the sympatheti innervation on sere tion of hormones by endorine have lng been knon eg • on the thyroid (Friedgood Cannon 1940; Comsa 196; Loe vy Brok 1949; Melander et 1974) on the adrenal ortex (Jung Comsa 1958) on the seretion of insulin by the panreas (Porte 1971; Shevhuk Sandulyak Rybahuk 1970) and the testile (Khodorovski 1964) Koizumi and Brooks (197) have summarized re
ent onfirmation and extension of these older observations on the sym patheti ontrol of endorine fun tion he
There are many other examples of sympatheti influene on various funtions and proesses eg on en zyme ativity (ordenfet Ohlin Stromblad 1960) on mitosis and RA and DA synthesis (Shneyer 197) and on groth and develop ment of the salivary glands (Wells Handelman Milgram 1961 ) and of the kidney (Hix 1966) Additional examples ill be found in the revie by Koizumi and Brooks (97� Still others inluding the sympatheti onditioning of tissue responses to ohe fators eg to parasym patheti stimulation hormones et are evident in onnetion ith linial and pathologial manifestations of sympatheti hyperativity disussed in the next setion The examples disussed above hoever ill serve to illustrate the diversity of sym patheti influenes hih annot be explained merely on the basis of regulation of seretion and ontra tion (inluding that of blood vessels) The diversity of the effets of stimulating various peripheral sym patheti pathays is not in the in fluenes of the sympatheti neurons but in the epoe of the innervated tissues and organs The responses are as varied as the tissues and organs hih are innervated virtually every tissue in the body Sympateti stimulation introdues no ne qualities but modifies (inreases or dereases aelerates or retards stimulates or inhibits) the inherent funtional properties of the target tissue eah therefore responding in its on manner Clncal mpact of ympathetc hyperactvty
t should not be surprising in vie of these diverse organ and tissue responses that sympatheti hypera tivity sustained over long periods of time may tend to produe pathologial hanges in the target tissues the linial impat varying ith the tissue and its role in the body Evidene for sympatheti om ponents in a variety of linial distur banes is revieed in this setion The evidene is in four ategories (a) the
manifestations that is signs symp toms and pathophysiology; (b) the ef fets of hroni experimental stimula tion () the effets of therapeuti or experimental interruption or redu tion of sympatheti ativity; and (d) morphologial hanges in sym patheti omponents Sine sympatheti vasomotor bers are ontritor in most areas ishemia of various degrees is often a ommon onsequene of sympatheti hypera tivity The redued blood flo ould in turn alter the funtional properties of the tissues and their responses to other fators eg parasympatheti or endorine influene t may also render them vulnerable to various agents (suh as normal digestive seretions infetious agents and toxins) and less able to reover from insult In some of the folloing ex amples of the pathogeni influenes of sympatheti hyperativity the vasomotor omponent is learly evi dent; in others it is of minor impor tane or is obsured by other sympatheti effets Neuogec umoay edema
A dramati example of the pathogeni influene of intense sym patheti disharge is neurogeni pulmonary edema Severe pulmonary edema ith marked vasular onges tion ateletasis intraalveolar hemorrhage and proteinrih edema uid appears very rapidly after severe often fatal blos to the head and other severe injuries to the en tral nervous system (CS) t ours quite independently of underlying pulmonary or ardia disease t has been produed experimentally in various speies by blunt head trauma eletrolyti lesions in various parts of the brain sudden large inreases in erebrospinal fluid pressure (see Theodore Robin 1976 for referenes) hyperbari oxygen (ohnson & Bean 1957) injetion of hloramine (Rudin 196) and loal ized pulmonary infartion (abins et a 196) Of great interest is the fat that pulmonary ede ith its assoiated hanges is also produed by stimulation of the stellate ganglia Conversely treatment of animals ith various adrenergi bloking agents or extirpation of stellate or other sympatheti ganglia prior to ad ministration of any of the above forms of trauma and stimuli om EMG SS reflexes et
t vnt th aaanc of umona ma It m to b aum b mot wok in thi that th SNS inuc umona ma i u to vacua on an hmonamic chang in th uona cicuation ha incuing contiction of umona vin (aowitz 175); oth facto uch a chang in caia mabiit hav ao bn otuat (Thoo & Robin 176) In th cou of thi tniv tui on umona ma o uc b ha tauma high ogn u an tat gangion timuation Bckman an hi co aboato (Bckman & Houihan 173; ot & Bckman 174; Bckman Ban & Baock 174; Ston & Bckman 175) hav im icat anoth nonvacu fac to Th hav montat un th cicumtanc a ag abut ca in ung comianc accom ani b a ag inca of minimum ufac tnion an of choto contnt of th wah fui Th chang in comianc an u fac tnion a tntativ acib to ica (intaavoa) choto In monk an cat th chang in ung comianc oc cu inn of o in a vanc of an ign of ung inju uch a congtion o ma Whatv th mchanim vn tua ico it i w tabih that v ung amag ma b o uc b intn mathtic bom bamnt of th ung tigg in vaiou wa
2. Pept ule ad paeatt Smathtic comonnt hav bn intifi in tic uc (g DSouaPia 15) an in an catiti Gag an Gii ( 5 1) an Wak an Pmbton (155) how th thautic ffct of con uction bock in ancatiti Giof t a (165), on th oth han montat that mpathtic timuation convt mi non tha biinuc ancatiti to th hmohagic ncotizing an tha fom That thi mathtic ffct ma b acibab to vaocontiction i inicat b an ai tu b Bock Wakim an Baggnto (154). In thi imnta tu obtuction of th flow of ancatic juic vn whn mitt to mi
with bi ouc on nonncotic chang in th anchma of th panca Whn howv I bif ichmia wa uimo on obtuction of th ancatic uct anchma ncoi vo which vai in vit with th g of atia obtuction L ion comaab to acut hmo hagic ancatiti in man w occa iona ouc b ichmia aon
3 Ateopathy Guttin LaTaia an Lwi (162) ouc th hitoogica fatu o f atiocoi in th ao ta b utain timuation of th anchnic nv in unnthtiz at Smathtic timuation a ant ouc om chang in th aia wa that favo th vo mnt of atiocotic ion A tnnc towa thomboi m to hav bn a facto It i intting in thi connction that in tui on imnta thomboi in th abbit a nvation of th a mak accat thomboi (Fow 14 Cho 167) 4 Cadovaula-eal ydome. Hypeteo It ha ong bn u c t o n t h b a i o f hioogica hamacothautic an bhavioa coniation that high activit of th iha SNS i an imotant contibuting facto in at at om fom of atia htn ion Thi ha bn ifficut to tabih b ict man in a tint Rcnt tui of Wain Diu & Habgath (173) in which th co mutiunit mathtic activit in kin an muc nv hav i imina uot fo thi hothi In a mo quan titativ tu on pontanou htniv at Iiuchijima tui (173) inicat a much high ffnt imu taffic in th anchnic nv of htniv than of nomotniv at Heat Deae Among th mot thatning an oftn fata comica tion foowing mocaia infaction a vnticua fibiation an oth ahthmia Th cnt wok of va invtigato inicat that hightn ichag though th mathtic innvation of th hat ma b a mot imotan facto In an imnta tu on tanint coona occuion in cat with th
u of ict coing tchniqu Maiani Schwatz an Zanchtti (16) how an inca ichag in mot of th fib tt (in th thi thoacic amu communican) Th fl which th autho chaactiz a a mathtic caiocaiac f occu ao i n th ina anima i not n on th baocto on vaga o on ict anoic timuation of gangionic nuon. th hav foun that imn ta coona occuion ow th vnticua fibiation thho (tmin b titiv ctica timuation of th vntic) an in ca th incinc · o ctoic ichag an ahthmia Angic bocka an abation of th tat gangia otct th hat againt th maniftation an vn vnt thm cia uing th fit fw hou of occuion (Hai Bocag & to 175 ; ik Bug & Abikov 175) Conv timuation of th tat gangia vn in th abnc of coona oc cuion mak ow th fibiation thho Whn gangionic timuation wa uim o on occuion th thho wa fa bow that foowing occuion aon Th concuion that otinfaction mathicotonia i a citica facto in th tigging of c toic activit an biation i fu th uo b th montation that caiac mathctom io to occuion otct againt th com ication an ow th motait at (Fowi t a 174) A tu with uniata tctom o vib co bock of iniviua tat gangia va ignificant iffnt inunc of th ight an ft gangia on caiac citabiit ha comaab to th w tabih iffnc with pct in inotoic a n chonotoic inunc (Schwaz Snbo & Bow 176) Thu ft mathtic nvation of th hat ai th vnticua fibiation thho 72 ± 3 cnt abov conto vau wha ight i nvation loweed th thho 48 ± 14 cnt Th autho biv that th obva tion h ain th athogni of vnticua ahthmia an fibia tion (.g in th oca ong QT nom) aociat with inca mathtic activit Th com
81
mend eft telectomy a a ogica meaure in patient at hgh rik from uch arrhythmia when medica therapy ha not been effectie Schwartz 1976) ha further propoed on the bai of thee oberation and tudie on infant that the Sudden Infant Death Syndrome i due to the long QT yndrome brought on by an abrupt ympathetc dicharge taking pace through aymmetrica cardiac ympathetic nneration in which the rght ide for ome reaon (congenita?) ubnorma in actiity At any rate it eem clear that the increaed ympathetic dicharge to the heart which accompanie myocardial infarction (Maliani et a 1 969) greatly imperi the effectie function of the heart and the uria of the patient There i not ony the hazard of ectopic actiity and fbrillation but alo cardioacceeration and increaed oxygen demand Ao to be condered i the probability that the ncreaed ympathetic dicharge to the heart include that of the receptor ympathetic coronary contrictor (Szentin & JuhazNgy 1963a 163b eigl 1975) whch woud contribute to ntenification and pread of the myocardal ichemia Indeed it i poible that hyperactiity of thee neuron would contribute to coronary arteriopam implicated in acute myocardial ichema and angina pectori The apparent nhibitory infuence of the ympathetic nneration on the deelopment of coateral circulaton preiouy dicued may alo hae important impication for the patient with coronary artery dieae Other example of ympathetic component in cardioacular dieae are the foowing (a) Dietzman et a 1973) found heightened SNS actity during cardiogenic hock in dog Renal and ntetina acular bed were mot affected Reduction of SNS infuence engthened the urial period Thee tudie upport the concept that the SNS pay a letha role in cardiogenic hock n dog (b) Raab 1963) and Kaye McDonad and Randall 1961) hae hown that hyeractity of cardac ympathetic pathway may produce eere cardiac leion (c) Barger 1960) found that retention of Na and water in congetie 8
heart faiure acribabe to increae n ympathetic actiity in the kdney A a matter of fact the rena ympathicotonia i eident before the deelopment of heart failure Blocking the adrenergic nere produced diurei and natriurei In patient with uretera calcul and during experimental timuation of the ureter in human and dog (by ureteral catheterization) Hix 1970) found the renal ympathetic pathway markedy faclitated on the affected ide In thee ubject uperimpoed emo tonal timu caued unilatera abrupt reduction in gomeruar tration and renal bood fow In dog Kottke Kubcek and Viche 1945) produced arterial hypertenion by chronic rena arterynere timuation It i of interet in th connection that Anelmino 1950) found that noocaine blockade of the renal in neration reduced arterial blood preure in mot eclamptic patient improed diurei and in ome topped coma and conulon Blockade of the telate ganga in thee patient improed diure topped coma and conulion in oe and improed ubjectie manifetaton including headache ocuar diturbance and nauea
which at eat from the therapeutic iewpoint hyperactiity of the ympathetic inneration i a critica feature The manfetaton (and the inciting factor) of thee yndrome occur in uch great ariety with repect to intenity and quaity of the pain motor dyfunction ympathetic dyfunction and trophic diturbance that many different term hae been nented refecting not ony thee ariation but alo the pecial interet emphae and iewpoint of the oberer Among the term for thee entite" are the folowing minor cauagia refex ympathetic dytrophy Sudek' atrophy panfu oteoporoi acute atrophy of bone houderhand yndrome (foowing myocardia infarcton or troke) chronic traumatic edema pottraumatic pain yndrome ympathetic neuroacuar dytrophy traumatic angiopam pottraumatic preading neuralga ypathalgia peripheral trophoneuroi and other The mot faored n current iterature eem to be reex (or pottraumatic) ympathetic dytrophy and pottraumatic pain yndrome (Patman et a 1973 Thompon et a 1975 Genant et a 1975 Kozin et a 1976 Kleinert et a 1973; Omer & Thoma 1974) The Posttramati pain snd romes term mimocauagia" (propoed by Thompon et a) and minor The expected repone to trauma in an extremity after proper treatment i cauagia" howeer would eem to orderly and predictable heang of the be mot ueful epeciay for thoe wound return of function return of familiar with caualgia through circuatory dynamc and gradua clinica experience or through the ceaton of pain Occaionaly thi caical decripton of cauagia by predictabe repone react in a S Weir Mitche and aocate in bizarre fahion depte adequate report of ther experience wth guntreatment and the abence of any ob- hot wound in the American ii iou factor detrimental to prompt War ad in more recent reiew healing Pain may become eere and (Richard 1967) unrelenting with a marked diparity The pain may ary from the exbetween eerity of pain and the ap- tremey eere burning unreenting parent injury Sympathetic dyfuncperonaitydetroyng type of ful tion uualy oeractiity become caualga to the equay chronic but eident Trophic change uually en- more toerable pain of the minor" ue to arying degree and if the pro- cauagia Hyperetheia may be o ce left unattended for any length exquiite that the patient cannot of time they become rreerible" tolerate the weight of cothing on the extremity the gentet touch or the Th i the way that the urgeonauthor of a contribution to the ightet air current Paroxym of management of pottraumatic yn- een more intene pain are often trigdrome introduce their paper gered by any of the aboe and by uch (Thompon Patman & Peron mnor dturbance a noie change 1975) The paragraph i a ynopi of n ambient temperature or moement of the limb The imb i hed a iman aortment of caualgiaike yndrome affecting the extremite in mobil a poibe The patient i EM SNS relexe etc
therefore exremely resistan to herapy. The manfesations of sympaheic dysfuncion include vasospasm and hyperhidrosis cold and we skin cyanosis and chronic edema In some cases however or emporarily in an early stage he skin may be ho and dry as well as edemaous possibly due o the release of vasoactive agents and irriants from sensory endings by anidromic impulses (discussed later) The most bizarre manfesations are those in he "rophic category They include change in he thickness texure and other qualiies of he skin changes in he nails and hair growh shorening of tendons atrophy of musculaure oseoporo sis and other degenerative changes in bones joints (which become siff and even frozen) and juxta-aricular issues The arhropathies and other skeleal changes have recently re ceived horough sudy by Genan e al (1975) and Kozin et al (1976) wih fine-deail radiography radionuclide echniques and mineral analyses The degenerative changes in bone "frozen joints muscle arophy etc; have been ascribed by some o immobilizaion of he affeced limb by the paien and this is almost cer tainly a facor Wowever he distri bution of pahological changes be speaks a central neural mechanism heher he trophic manifesations are due to circulaory changes some other inuences of sympathetic im pulse activity or the non-impulse mechanisms discussed by ohers in the orkshop remains to be invesi gated Anoher feaure difficul o explain is the gross disparity between the re sponse on he one hand (he' severiy persistence and progressive naure of he pain and oher manifesations) and the injury on the oher. In some cases he injury may no only be non penetraing bu so slight ha it would ordinarily be dismissed as a superfi cial bump or a bruise in oher cases it may be a small fracure a minor sur gical procedure a laceraion a tool dropped on he foo One of he mos remarkable com mon features of hese syndromes and heir varins is heir responsiveness o interrupion of impulse traffic in the sympathetic innervation of the affted extremiy In many cases he pain and autonomic manifestations
may be immediaely relieved by blockade of he appropriate gangia (ipsilaeral sellate or lumbar) The relief may oulas by several hours or days he usu aneshetic action of he agen injeced around he ganglia The relief may even be permanent following a single block or a series of blocks hen as is more usual and if the ganglionic blockade has given temporary relief oulasing aneshetic action then permanen relief and "cure may be obained with surgical inerruption of the sympaheic path way o he exremiy Ganglionic blockade and sympa hecomy are much less likely to be effective if diagnosis and effective reamen have been oo long de layed Mos auhors urge early recog niion and reament of he syndrome no only because delayed interrupion of the loc sympahicoonia is less likely o be effecive (which in urn ofen prevens examination of he extremiy and applicaion of sup porive measures such as physical therapy) bu because he rophic and degenerative changes may become so advanced as o be irreversible. Under such circumstances even were the pain and vasomoor changes even ually relieved the paient would be left wih a disfigured and disabled exremiy and ofen wih severe emoional disturbances No hypohesis has ye been offered ha satisfacorily explains reex sym patheic dysrophy In general three mechanisms (Sernschein et a 1975) seem to have won adherents: (l) Increased excitability (facilita ion) of inernuncial neuronal pools a the involved cord levels presum ably incied by aberran sensory inpu from the injured site Sensory moor and sympatheic pahways are hough o be affeced by the en hanced central exciatory sate The increased sympatheic discharges pro duce changes in the periphery which incite secondary afferen discharges hus iniiaing and sustaining vicious auogenic cycles of impulses (2) xcitation of ecopic impulses in pain bers by impulses passing in neigh borig sympathetic post ganglioni bers (ineraxonal "cross talk laeral or ephaptic transmis sion "rifcia synapse) The ani dromic (as well as orhodromic afferen) impulses riggered in his manner are thought by some o re-
lease vasoactive agents and irrians a he endings (3) Various adaptaions of the gate control theory of pain hile hypotheses (2) and (3) may possibly conribue to undersanding of the pain componens of the syn dromes hey offer none regarding he signs of sympahicotonia (which he frst hypothesis does) or of he rophic manifesaions (which are re ferable at leas in part o he sym pahicoonia) This seems a worthy area for investigaton perhaps in an animal model which simulaes he causalgialike syndromes The preparation described by Kennard (1950) may be a promising one wih which to begin 6. Oher skelel disorders In 1957 Herfort frst reported
ex cellen results following lumbar sym pathecomy in patients bedridden by arhriic pain in weigh-bearing joins. The exirpation of he lumbar ganglionic chain affected the rheuma toid activity only in the denervaed exremities and equally good resuls were obtained in rheumaoid and oseoarhriic dsiease Neurons and neurogial supporting cells in sym paheic ganglia surgically removed from paiens wih chronic poly arthriis showed morphological signs of prolonged preganglionic simula ion (Kuntz 1958) Coujard (19) reported a variey of oseodysrophies produced in the guinea pig by irraion of the sym patheic fibers in he sciatic nerve (and by diencephalic lesions) The bony manifestations included various arhropahies mimicking hose of abes and syringomyelia alteraion of calcium fixation and heteroopic oseogenesis such as spicules on he periosteum and umor-like ou growths of bone Koke et al (l958) sudied longiu dinal bone growh in children who had paresis of one leg and nearly nor mal strength in he other after acute anerior poliomyelitis The average rae of growh of he bones of pareic legs was substanially less han ha of normal legs oal exremity length was 829 percent of normal Trea ment with a sympaholytic drug re ored growh to he rate of the nor mal leg T authors attribued the rearded bone growh o reflex hyper activity of SNS in response o cold 83
hich rt in vacntrictin in th xtrmity an inhibit piphya bn rth hy cit an arir ty in hich chrnic niatra timatin f th mbar ym pathtic chain in pppi btantia y rc grth f th hi imb n th timat i. Cjar (1957) hvr rprt vinc that th ympathtic innrvatin infnc th nitivity f bn an thr ti t mrphgntic hrmn W may a inc in thi catgry many cnica rprt n th painf jint ynrm knn a hrhan ynrm ccaina y a itring q t mycaria infarctn an trk hich i ftn ramaticay rpniv t tat bck. Sm f th ti ar cit in th rfrnc f th frging c tin n rfx ympathtic ytrphy. hock
rtratmnt f xprimnta anima t b bjct t tramatic hk (Lvy Nrth & W 1954; & rczg 1956) r hmr rhagic hck (Brgr 1965) ith arnrgic bcking agnt at crtain critica rang r ith ym pathctmy prtct thm aaint th tha ffct. pparnty a i tr in thr cinica itatin . . . th ympathtic icharg i a prtctiv mchanim bt initiat prc hich ar trimnta t rvivia" (Lvy t a. 1954).
Heatotocty
hi princip i again itrat in ivr pathy prc by a minitratin f carbn ttrachri ccring t th vinc f Cavrt an Bry (19) th charactritic hpatic chang ar th rt f maiv ichar f th priphra SNS. hi a t hpatic ichmia hypxia an ncri arn th cn tra vin f th hpatic b an cr tain chang in nzym activiti ic in an arir ctin f thi papr th ympathtic icharg a ra fatty aci frm th priph ra fat pa an th cnqnt pitin f ipi in th ivr
The Ute
On th bai f hir n xprimn ta rk ith anima an rvi f cinica an rarch itratr Shabanah th an Maghan ( 1964) cnc that many nxpain
bttrica an gyncgica cni tin invving itrbanc in trin cntractiity may b . rat t abnrma nrhmra caativ factr rfct in a na pictr f atnmic imbaanc ympathtic hypractivity" ty by Mir an Marha (1965) n rabbit n pprt t thi cncin hy fn that tima tin f th hypgatric nrv in hibit pntan trin cntrac tin in rabbit trat ith trgn + prgtrn. hi ffct a abih by arnrgic bcking agnt bt a nchang by atrpin r hxamthnim.
-
10 The eye as a mode lustatn symathetc uences on tssue onses to othe factos)
h r f th innrvatin f th y in ch irr a gacma ha ng bn nr ty bt n car pictr ha mrg pit vinc fr an imprtant ympathtic in fnc n intracar prr thrgh innc n frmatin r rainag f aq hmr r bth Sympathtic infnc n th pr mabiity f th baq bar rir t prtin an thrfr t ritanc may a b a majr factr (Langham 1958) h trimnta infnc f th ympathtic innrvatin n th rpn f th y t othe factr i mch carr. Fr xamp hn th trigmina nrv a intrrpt cr na cratin vp in a f th anima (cat). rir tctmy prvnt th in in amt a f th anima an prmitt haing if th in i appar (Bakr & t tib 1959). an McKay (1972) m ntrat th prtctiv ffct f ympathctmy in qit a iffrnt kin f itatin. Sytmic bactria ntxin in rabbit prc a mark incra in car vacar prmabiity primariy in th iriia prtin f th ciiary prc. h in· itia cnqnc i ma f by hmrrhag an thrmbi. t ganginic ympathctmy (xtirpa tin f th prir crvica gangin) rc th vrity f th car r pn t ytmic ntxin hi ffct rqir vra hr t ap par an at 4 h aftr aminitratin f th txin t th niatray ym pathctmiz rabbit thr a a
cra in th atr vacar pr mabiity a mar by 125 Irm abmin in trma hmrrhag an in mav thrmbi in th ym pathctmiz y a cmpar t th cntraatra r hamprat y h apparnt xacrbating in fnc f th ympathtic innrva tin in cnjnctin ith ytmic n txin i by n man pciar t th y. i vint fr xamp frm th rprt f thr invtigatr cit by an McKay ympa thtic nrvatin an arnrgic bcking agnt ar knn t p pr r prnt thr ractin t n txin (ca an gnraiz Schartzman ractin) fr a th y an i cnrn it cr tainy m imprtant t invtigat frm th tigica an thraptic a a pathphyigica vi pint th r f th ympathtic in nrvatin in ch cmmn an amagin irr a viti r iriti. 11 . the exam
Othr cinica itatin may b cit in hich a cntribting xacrbating an ftn critica r f th ympa thtic innrvatin ha bn im picate bt hich ar ny mn tin hr itht cmntatin in th intrt f pac. h inc citi mgacn priphra vacar ia cr f th g rmatiti ptrgica paraytic i vari ia f th kiny pytrn' cntractr an pvic cngtin" in mn. ma f cinica vinc byn th cp f thi papr mch f it mpirica inicat an imprtant r f th priphra atnmic nrv ytm an particary th SNS in trmining ractivity ritanc an rpn f inivia ti an thrfr th fn f th ntir ranim t infcti txic an tignic an irritativ agnt. h in fnc apparnty xtn t ch prc a infammatin immn ractin anaphyaxi argic maniftatin an phyica argi" hr i vn vinc fr ympathtic infnc n th rpn f ti t carcinnic agnt an n immnbigic mchanim that trmin tmr tak" in xprimnta impant. (S fr xamp StinWrb ky 1974) h intrfac btn nrcinc an immngy an M SNS rfx tc
micobioogy woud b wothy aas o invstigation, om scintiic and cinica viwoints Th noma" inluncs o sympathtc innvation on vaious ndogans, discussd in an ai sction, may aso bxpctd to b dtious whn th impus activity is intnsd and sustaind. Fo xamp, asy xaggatd pots om sympathtcay bombadd cptos, spciay bao and chmocptos, woud ctainy hav a distubing ct on x guatoy mchanisms. This woud b tu aso o SS inuncs on CNS unctions Th cts o sympathtic hypactivity on th ticuondothia systm, at mtaboism, nzym activity, ndocin systms and oths may aso b xpctd to b hamu ov ong piods o tim Finay, it is impotant to mnton agan that any cinica distubanc o augmntd tssu vunabity in which ischmia is a contibuting ac to otn may b atd to sympathtic hypactivity in viw o th stong consticto nunc o sympathtic vasomoto ibs 12 her knd s of evdence for gener SNS roe n d ese procees (a) Neurophoogc Poound
mophoogica atations a xhibitd by gangion cs in gangia movd sugicay n th tatmnt o patints with vaious disass and at autopsy Th is aso makd poiation o nuogia suppoting cs Th changs a such as to ndcat ovstimuation o th gangion cs, and indd many atations sn in sugicay movd gangia and thi cua componnts hav bn inducd xpimntay by poongd pgangionic stimuation (Kuntz, 195; Schiw, 1965) (b) Irrve Lesons Poongd itation, with vaious agnts and injuis, o pipha sympathtic stuctus (.g., coata o paavtba gangia, spanchnc nv) o o snsoy bs in spina nvs poducs many typs o sion and dysuncton o vsca and somatic stuctus, otn tha, which simuat natuay occuing pathoogy (Mosing, 1957; Riy t a, 1955)
hanss
In considing th paticipation o th SS in disas pocsss, w a conontd wth an appant paadox. On th on hand, thanks spciay to th pioning studis o WB. Cannon, w hav asn to b impssd with th impotant o o th SS in oganizng adaptv, momnttomomnt sponss o th o orgnsm to changs in nvionmnt, postu and physcia activity, and to njuy and mgncis As adaptv sponss, thy a potctiv and appopiat to th stuation (o to what is pcivd to b th situation). On th oth hand, w hav many xamps o hamu and vn indanging cts o sympathtic activity whch is ocusd too ntnsy and o too ong on ndvdu ssues nd orgns
Th os o th high cnts, incuding th cba cotx, in ntiating and oganzng somatoautonomic spons pattns a now aiy w undstood. Howv, in a pvaiing mphasis on ths who body pattns, which a basd on th capacity o th SNS to dischag as a who and to boadcast its inuncs thoughout th body, th s a tndncy to ovook th hgh dg o oca and giona conto that is ssntia to pop xcution o th sponss, as thy chang om momnt to momnt Much o th capacty o ocaization sids o cous in som o th high cnts, which can dict dscnding impuss (g., via coticospina ibs) to appopat nuon poos But th pcis moduation o th oca an d giona componnts o th tota pattn s basd on snsoy signas om pa ticipating and actd tissus and ogans and on spcicity and sctivty o connctions, though sgmnta pathways, btwn a nts and sympathtc nuons. hs two moitis o th tota pattns sm to cspond to what nuophysioogists, codng om sympathtic nts at vaious spina vs, as thy stmuat sctd somatc ants, hav dsignatd as at" (supaspina) and ay (spna) somatosympathtic xs (Kozumi & Books, 1972). A o nay a o th tota SS nuon poo can b activatd in this way via th supaspna pathways Ony a action o th poo,
howv, is activatd by th sam ant stmuation via th spn pathways; and som somatic ants (Goup I) sm to hav no accss, nomay, to sympathtic nu ons va sgmnta pathways Th acton o th nt (pgangionic) nuon poo that activatd via spina pathways by stimuation o sctd soatic ants is concntatd at th cospondng spina v, th numb o sponding nuons dcining shapy with incasing sgmnta intva (viwd by Kozum & Books, 1972, and by vaious authos in Sato, 1975) n oth wods, th ay and most dict impact o impuss nting via a givn dosa oot (and hnc coming om a givn dmatom, myotom viscotom) is mainy ocusd on th nuons whos axons mg though th cosponding vnta oots (convying moto and sym pathtc impuss to ogans and tissus n th sam body sgmnts) I suggst that th cinica dstubancs which a appanty basd on hypactivty n atd sympathtc pathways, dscbd n th pvious scton a abatons o ths oca and gona dback mchanisms. hy appa to b tiggd by unusua pattns o ant impuss oignating n pat in inud, stand, mpad o chmicay atd tssus o at sits o njuy in nvs o oots. h abation appas to b sustand (and intnsiid) by ith (I) sconday ant dschags om tissus bombadd by th sympathtc impulss, (2) actatoy changs n th spina cod, o both Wh th nita tauma nd not b panu to aunch th vcous cyc, pan may b bought on by th sympathtic dischag (g, in ischmia) and by ata (phaptc) tansmsson at sits o nv domaton, om sym pathtc postgangionc axons to nghbong unmynatd snsoy bs h abation may aso bgin as a componnt o a tota spons pattn. h pattns a adaptv and potctv whn ntatd by cicumstancs ky to occu n daiy anima , such as nvonmnta xtms, xtion ( ght o ght), nuy by xtna ocs, that o njuy and dath, hypoxia tc Whn 85
confroned with circumsances unlikel to have been encounered in he course of evolution of hese adaptive smpahetic paerns, he responses ma no onl be inappropriae, but even harmful and derimenal o survival Tus, while reex vasoconsricion (and accompaning cardiovascular and oher ssemic changes ma be appropriate for, le us sa, a painful laceraion of an exremit, smpathetic hperac tivi with resulant ischemia is otall inappropriate and deiniel con raindicated" for a joint which is painfull irriated or inamed The ischemia itself causes pain which further intensifies he smpahetic discharge The vicious ccle set up in that manner aggravaes the pahological sate (Kuntz, 198 For similar reasons, heightened smpahetic discharge o a hear alread laboring under impairment b mocardial ischemia can onl, as we have seen, further impair and burden he hear and decrease the probabilit of survival Bodil responses to anoxia, a common hazard in terresrial life, ae the adaptive product of evolution, which become destrucive and lethal when evoked b a cir cumstance as unlikel as high O tension (Rame & Goldsen 197 Similar, spinall organized reflexes seem o operate in the therapeuic application of hot packs, cold packs and counerirritans (eg, rubefacients to the skin in he egion of inflamed, congested, ischemic, edemaous or injured viscera and joints When, however, the skin over apparenl healh organs is chilled, the responses ma be such as to redispose to infection or other illness as, for example, in the upper respirator tract (Ralston & Kerr, 194 gastroinestinal tract (ichins & Brizzee, 1949 or kidne (Nedzel, 196 One of the most ineresting and clinicall signiican feaures of these aberrant, spinall organized somatosmpahetic reflexes is he making of snaptic connections ha are not ordinaril in use This is similar to the experimenal situaion in which Group I afferens, which do not have access o smpahetic neurons via the earl" , spinal pathwas, are able, hrough he opening of potenial" pahwas, o ac ivae hese neurons when he spinal 86
cord is moderatel cooled (Koizumi & Brooks, 1972 The resul in the clinical siuaion is o link, reexl, somatic and visceral strucures which are no functionall coupled in an normal bodil acivi or adapive response patern In the clinical siua ion, he become linked onl b vir ue of he segmenal proximi of heir innervaing neurons Not onl is this reflex enanglemen" nonadap tive and harmful to each of he sruc ures involved in his aberran relex coupling, bu i is disruptive of the adaptive reex paerns in which these organs and issues are called on to paricipae Dsfunctional, segmental coupling is clearl illustrated in paerns of referred pain and associaed phenomena, of boh visceral and somatic origin No onl is the disribuion of referred pain (eg, from ischemic mocardium o ches wall, upper back, left shoulder and arm unrelaed o an normal func tional patern, but he same is rue of the relex motor and smpaheic (sudomoor and vasomotor responses in he reference zones The relex responses o the iniiaing insul are no onl useless, bu secondar paholog ma be insigaed in he reference zones (as in posinfarcion shoulderhand sndrome The affected tissues ma in urn become secondar sources of abnormal af ferent bombardment hat helps sus ain, intensif and spread the smpaheic hperactivi Alhough referred pain and reex paterns of visceral origin have been more horoughl invesigaed and described i is importan o poin ou ha similar and even indistinguishable paterns ma be iniiated from deep somatic structures (Lewis & Kellgren, 1939 Kellgren, 1940; Travell & Rinzler, 1949 Reflex acivi hrough smpathetic path was seems o be elicied wih equal facili b painful somaic or visceral afferent simulaion un 198, and wih no fundamenta diffrence in he manifestaions Relation to maniulative theray
In accordance with the objecives of he Workshop, I venture o offer for exploration hpotheses which purpor to link he clinical and ex perimental maeri just reviewed and their apparent mechanisms o hose at
work in manipulaive therap In view of he rich access of somatic afferens, via spinal and supraspinal pathwas, o smpatheic neurons, i would be rul amazing if even relativel minor disturbances in moion of intervertebral or other joints which are amenable o manipulaive herap, did no have autonomic and, herefore, circulaor, meabolic and visceral repercussions of some degree It would be equall surprising if he cost did not increase wih ime and wih he superimposition of oher derimenal facors in he patients life On the basis of available data and m observaions of the skillful pracice of manual medicine over a hird of a centur as a phsiologis, I sug gest tha: 1 Local musculoskeletal dsfuncions, especiall in and around he ax ial and weightbearing pars of he skeleon, are clinicall significan no onl because of he motor impairment and the pain that are someimes presen, but also because the in sigae or contribute o he sustained smpahicoonia which is a common feature in so man sndromes Like those sndromes, he also appear o be aberrant versions of he spinal (earl" somaosmpaheic reflexes discussed above The disturbance in the cord is due o disorted patterns of afferen impulses from (a he affeced musculoskeleal tissues and/or (b irriative lesions of nerves, roos and ganglia, such ha adaptive, appropri ae responses are not possible (In view of he sharpl delineaed dermatomal bands showing smpaheic hperacivi ofen encountered in our studies i is likel ha part of the segmenal smpahicoonia ma be due to irriaion of smpahetic ganglia 3 Effecive manipulaion is ha which resuls in he reesablishment of coheren patterns of afferent input such ha ocal adjusive reflexes are once more appropriae and har moniousl integrated in he toal, supraspinall direced paterns of acivi and adapive response The mos criical effect, clinicall, is he subsidence of smpaheic hperac ivit and its pahogenic, pain producing inluences 4 Improvemen in the afferen in pu is accomplished b appropriae EMG, SNS, reflexes, ec
adjumen o acua neoeu elaonp mucle eng and mucula acal and lgamenou enon a enable ee ue once moe o epo n coeen po pocepe paen and n e ame poce by eeg mecancal deomaon o aon o neual ucue 5 Te mecanm ae e ame wen e pmay peubaon o e cod o ceal ogn and e mucuokeleal noemen o econdary ele ogn a occu n aocaon w eeed pan Te eapeuc eec (among oe) o manpuaon l o ow e cou cyce and educe e ym paec dcage o e ceal and omac ucue wc ae become eexly coupled o e uua demen 6 Te mpang eec o bomecancal nu o nee on e ane o nomaon (and mae al) epoed n a lae econ o e Wokop ae a lo pa o e po poed mecanm n manpulae eapy a elecd n ou eale pubcaon (Appelaue & Ko 1 1; Ko 12 Ko & Ap pelaue 14 Ko Wlknon & Conock 16)
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Szetivy M ad A JuhszNagy The phyioogcal role of the cona contrctor br 11 The roe of the coroa vaomotor in metabolc adaptato of the coroares Qu. J. pl. Phyl 481051 18 1963b
Tay·A V Chge the eectrica actvity of the cortex and hypothalamus followng abato of the suprior and nferior cerical ympathetic ganglia i the rabbt Schn Phyl. J USS Tnl 46957965 19
TayAn, V ad M. G Gelekhoa The iluence of the cerical ympathetic nere and th e effct of ome pharmacologica btacs o the "rcruitment reac tion Schn Phyl J USS Tanl 47 18-29 11
Thodore J and ED Robn Speuato o eurogenic pulmona edema (NPE) Am. p D 1 13405·410 1976
Thoma PE ad A Kawahata Neural factor uneryng ariatio n eectrcal k retance of appartly onweatg skin J Appl Phy 17912 12
Thoma PE and IM Ko Relationhip be twn wet glad act ity and the elctrcal retac of the kin J Appl Phyl 10505510 1957 . Thoms PE IM Korr ad HM Wright A mobie trumet for rordg eletrical kn retace patterns of the human trunk. Act Nug. 17971 1958
Thompo JE RD Patma ad AV Pero Maagemet of postt �aumatc pa ydrome cauagia) Am Sug 41 5992 1 975 Travell J ad S.H Rinzler Pa ydrome of the chet muce reembace to effort agia and myocarda farction, a relef by local block Cn. Md Ac J 59333-338 1948
Tucker D ad LM Beidler Autonomic nerous ytem ifuence o olfactory receptor J Nuphy 18362 1955
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Wotehome GEW ad J Kght dtors Th Pnl Glnd C Fundan Symp odo:
Church gto 1971 Wght HM IM Korr ad PE Thomas Regioal or egmetal arato asomotor actvi y n Pc 12161 1953 Wright HM I M Korr ad PE Thomas ocal and regoal araton cutaneou asomotor toe
89
Piy x i v
9
src: udies in neurorophic mechnisms (16) .M. KORR PN. WLKNSON and F.W. CHORNOCK
When a erihera nerve is cu he axons searaed from heir cel bodies undergo degeneraion because each deends on he coninua delivery of cyolasmic consiuens which arise in he cel body for he mainenance of is inegriy. Profound changes usualy of degeneraive naure also ake lace in endorgans endorgans suied by he inerrued nerve fibers We are esing he hyohesis ha he rohic deendence of nonnervous cels on heir innervaion is aso based on he coninual deivery of neuroasmic comonens comonens via he axon We reored a his Co nference nference las year ha isooe·abeed subsances in ce bodies of hyoglossal and vaga neurons of rabbis were carried eriheraly by axolasmic fow a he rae of aroximaey 55 mm er e r day and ha hey reached and sread hrough he erihera organs (ongue and hear) innervaed by hese nerves. Radioaciviy in he ongue rogressed from base o i When one hyogossa nerve was crushed radioaciviy was arresed a he sie of he crush and accumuaed on he roxima side In hese ex erimens radioaciviy was found o be imied o he innervaed side of he ongue Since ha reor we have aied microscoic auoradiograhic mehods o deermine he disribuion of he nervedelivered subsances wihin he ongue Folowing is a summary of our findings Axon branches and endings wihin he ongue were richy agged 2 P0 was foun foundd wihin wihin he musce cels among he sriaions (ossiby mainy in he Abands) in he nuclei and in he sarcoasm around he nuclei 3 Camino acids resumaby incororaed in roeins a eas in ar were more diffusely disribued in he muscle cels
abeling aeared firs in he base of he ongue and rogressed oward he i 5 Only background aciviy occurred in eihelial secreory con necive adiose and oher issues in he ongue ha are innervaed by nerves oher han he hyoglossa nerve 6 When one hyoglossa nerve was crushed ony background aciviy was eviden on he denervaed side even aer he inac side was srongy abeed When agged subsances were ermied o reach he issue via he boodsream labeing was no longer limied o he musce cels I ex ended aarenly o al ceular com onens on he denervaed as we as he innervaed side. Moreover abe ing of ongue musce was redom inany inersial raher han in racelular I aears herefore ha sub sances arising in he ce bodies of erihera neurons are carried via heir axons o erihera issues where hey may cross he uncions and ener ino he ceular srucure or meaboic machinery of hose issues. We sugges ha his mechanism ro ro vides a basis for neurorohic in uence. Sudies are in rogress o idenify some of he neuroasmic comonens and heir roles in he erihera nonnervous cels. We are aso exoring he ossibiiy sug gesed by he reiminary evidence of migraion from muscle o nerve ha here is normaly a muua woway exchange of cyoasmic comonens across he secialied uncions be ween neurons and he cells ha hey innervae Reprnted b pemssn from JAOA 65 99,
9.
Aided by Grant T·2139 from th Amran Osteopathic Assciation and y Grant FR·0549· from th Natna Institutes f Healh t t he Kirksvie Coege Osteopathy and Srgery.
Axona ransor and rohic sudies
x ivy rpi pt l ll (1967) M KORR PN WLKNSON and W CHORNOCK
Maiteace o te axos i e rieral erves deeds o te co tiua delivery o res cytoasm eaborated i te cell bodies Te cytolasm aaretly roelled i a eristatic maer by te axo ax o is cotiuay moved out o te cell body ad alog te etire egt o te axo axo ad all o its braces su yig tem wit comoets tat are used i axoal maiteace ad ac tivity ad tat are ot or are isu cienty) sulied by oter sources suc as blood or oter extracelular fluids ad Scwa cells or by sy tesis witi te axo Te tota volume o euroasm may be re laced several times eac day Iterru Iterrutio tio o axolasm axolasmic ic co co tiuity results i Waleria degeera tio o ibers searated rom teir cel bodies Ater a iterval tat varies wit te egt o te distal stum degeeratio or oter troic cages begi i te musce or oter cells i ervated by te iterruted fibers tese cages are cleary disti guised rom tose iduced by iter rutio o imulses We ave tested te yotesis tat te troic dee dece o a cell o its iervatio is as i te case o te axo also based o te cotiua deliery by te axo o substaces tat origiate i te erve cel We oud tat substaces labeled wit isotoes) i selected ervecel bodies are coveyed dow teir axos across te unctios ad ito te cels tat tey iervate We abeled yoglossa ad vaga euros wit iorganic osate or Camio acids by directy aly ing soutios o tese substaces to te osterior ti o te oor o te ourt vetricle i rabbits (1 to 25 kg) accordig to te metod o iai Te solutios were deosited in ortios eac cotaiig 35 to 32 c o radi radioact oactivit ivity) y) at to 2miute itervals We assured our selves tat good absortio occurred
I
I
Supp i p y a ga fm Amica Ospaic Assciai W a Gl Haa f is assisac i islgca ssng
ad tat cotamiatio o te ce rebrosia fuid CSF) ad bee avoided A total o 5 to 2 c were alied to te erve nucei i tis maer Tis reort is based o studies studies o 1 5 rabbits rabbits We demostrated te secicity o our tecique i aimals kiled ad examied at various times ater te labelig cas o te itact aimals sowed tat diuse abelig rarely occurred ad tat we it did it was sligt ad trasitory Treedime sioa scaig o various erves ex cised rom te eck sowed tat o tese oly te vagu s ad yogossa were radioactive We tere ad bee emorrage aroud te surgica site or floodig o te ventricle wit CSF durig alicatio o te isotoe radioactivity o te aimal was diuse ad secicity was ost adioactivity as a irregularly saed waverot o te tree dimensioal scas advaced along te vagal ad yoglossal truks at about 5 to 5 mm/day a value com arable to rates o 1 to 11 mm/day reorted or oter mammaia erves ad a d corresodig corresodig wel to te rate 5 2 mm/day) o regeeratio regeeratio o te vagus erve Scas o wole orgas ad autoadiogras o sec tios to 2 mm) o tissue sowed tat radioactivity reaced te togue ater about days ad te atria o te eart eart ater 9 or 1 days Te roximal musculature o te togue became radioactive earier ad more itesey ta te ti Crusig o oe yo glossa erve arrested radioactive material at te site o te crusig were te substace accumuated ad resuted i uiateraly radioac tive togues Havig sow tat radioactive material ad bee trasorted to te erieral tissues ony by te nerves we te used microautoradiograic studies to determine te distributio i te togue o radioactive sub staces coveyed by te yogossa nerve Our metods were tose described by Koriwa ad eblod i wic slides bearing ti sectios
I
o tissue ixed embedded sectioed ad staied ematoxyli ad eosi) i te usual maer were covered by a ti layer o Eastma liquid emulsio TB3. Tese slides were stored i te dark at 5°C util eriic sa lig sowed tem ready to be d veloed ad reared or microscoic study We dealt wit extremely low cocetratios o radioactiv material i te togue i cotrast to te amouts tat ca be itroduced by areteral iectio We tereore cut tissue sectios ticker ) ta is desirable desirable or good resolutio ad still oud exteded exosure times u to 5 mots) necessary However as we beatedly discovered we ad r covered oly a smal ortio o te radioactivity we ad bee able to i troduce ito te erve cels Desite te relatively tick sectios we could wit careul ocusig o te microscoe trace te tracks o silver grais to articular cellular struc tures altoug tese relatiosis are ot always distict i te oto gras take at a sigle ocal level I order order to mak m akee te sarse silver grais i te togue more cosicuous we ave otograed te rearatios troug asecotrast otics wic cause te grais to aear as somewat elarged brigt sots Figure 1 a sows so ws tat ta t te radioac tive articles were desey acked i te truk o a yoglossal erve wose cell bodies ad bee labeed 9 days earlier wit glycie2C radioactivity i te erve seat was virtually abset Tis gure il ustrates oe o our exerimetal er rors more time betwee betwee labelig ad killig te aima) sould ave bee allowed or te erve to emty itsel ito te togue Figure 1 b ad c are sectios sectios ro rom m te togue o te same aimal as in Fig 1 a abeed moecules were dis tributed trougout te roximal musce ces tose i te viciity o te etry o te erve) in te ibers ucei ad sacrolasm adioactivity o te ti at te same time was still sarse ad was aarety coce trated maiy i te uclei Tis di erece betwee base ad ti aar etly related to te legt o te eura atway ad ossibly to te desity o iervatio ad to te greater attritio o radioactive sub stances i te oger assage was a
rdiciviy f ng ngu u hn n nl l dlvry prv prvnd nd n n id id nd b g Unilrl rdiciviy Mucl f ngu L Lf f hypgll nrv cu hypgll nucli lbld ih glycin_IC Th d) Mu ll d n 8h 8 h dy. ( ()) Lf Lf id (b) righ id (c nd d) niml lld Mucl cl f ngu. Righ hpgll nuclu lbld ih -phph. L Lf f hy hypgl pgll l nuclu unlbld Th niml illd n h h 8 h dy dy (c Lf Lf (d (d) righ .
A urdigr urdigrph ph f f hy hypgl pgll l nucli nucl i lbld ih gly glycin cin- C Th rbbi illd 9 dy dy r h h lbld ubnc p pid Lngiudinl Lngiudin l cin f f h h righ hypgll nrv pgrphd in brigh ligh (unli h hr hr f f hich r n in phcnr) (b) Muclfrm Muclfrm priml pr in f f ngu righ id id Lbling ppr ppr brigh p. p. N hr h r cll in m cin (c)) Muc (c Mucl l frm frm dil prin f ngu righ id N nn mucl cll cll.. A ll mgnid mgnid 1 1 im.
94
osstet featue whethe the ael was P-phosphate of amo as aeg of els othe tha muse els (a some setos, ahes o axos) was, as Fg a eggle o aset Whe eual evey of aele sustaes was lme o oe se, thee was ulatea aeg of togue muse ells (Fg ) Seos show Fg , a a wee take fom the togue of a at whh the lef hypogossal eve ha ee ut mmeately efoe the hypoglos sa ue wee aele wth gye- • The eft se (Fg a) showe eay sgs of egeeao a o aoavty I the omal, e vate seo (Fg ) the musle els wee stogy aele (Fgue llustates a feque fg some
of ou pepaatos, the tasvese agme of aoatve susaes he muse fes Pese oaza o awats auoaogaphs of hghe esoluto es oluto ) he esults wee the same ohe expemets whh a smal segme segm e of eve was ushe a ax opasm otuy theey e upe whe the goss otuy of he uk a pesumay of e oeual u spaes was peseve o aeg of els ohe ha musle was ou o ehe sde I wo expemts we wee ae to ae he hypoglossa (a vagus) eve oy o oe se whe eavg tat the eves o oh ses heey em a a g ay questo of aee physo oga sate o the eevae se I oe ama (Fg ad ) oy the ght hypoglossal ueus ha Axoa taspot a toph sues
la (ofm y mo autoaogaphs of th hypogossal vs a, ospogy, oy th ght s of th togu a Athough th togu ossts of a ag vaty of tssus a ls (mus l, vaous ssoy mts, o tv a apos tssus, pthum, glas, oo vssls, a so foth) a s, ospogy, vat y vaous vs (hypogossa, faa, tgma, glossophayga, a sympatht), oy th muss of th togu a supp y th hypo gossa, a hav ossttly fou that oy th musl ls a lal ou ppaatos, as sho y gs a o alg s vt oth tssus of togus hh musl s stogy a (g , a-) I otast, h th CS of o a t ha om otamat th th aoatv mata, th t oy sufa of th ama as aoatv, a al th tssus of th togu smaty a (g ) Aoth sgfat fatu of ths ppaato s that, uk thos sho gs a , th as osa aoatvty tstta a appaty tavas ua spas Ou osvatos at that, h aoat sustas sltvy tou to hypo glossa uos, ths sustas, o th vatvs, ovy o th aos oy to th mus s of th togu a that thy ah th mu s s oy va ths aos o vy ay so h a mous appaty oss th uomusua juto to ta lua ompots of th mus W suggst that th pomosta ovya a tua tasf of sustas fom th v l may ul th soa toph a oth ogtm flu ot as o mpulss, of phpha uos o th mtaosm futo, v opmt, fftato, goth, a gato of th stutus that thy vat
Fg . (a) erou land (b) mu cou land a nd (c) allate papla om tonue hown in i. d Note there i no labelin o thee tiue d Labelin b way o the etracellular luid. he cerebropinal luid o the ourth entricle wa contaminated with P- phophate and the animal killed on the 9th da. iue other than mucle are labeled and the pae o radioactiity in mucle i altered rom that hown in i. 3.
i
ddndu
uth ofmg th aoa vy of sustas syths th pkayo s th hgh g of "pvay o stvty f that vy As may pt oy a poto of th hypogossa uos
9
robably ose loses o e surae) reive radioaive reursor by our meods ad oly ose euros a are labeled a so o seak make deliver Tis is illusraed i ig wi or lak o sae ould o be iluded i e origial arile i n Tis oomirogra sows a musle asile ross sio) rily agged wi pH sur rouded by oers a are uagged Refences
I. P Wess and HB Hiscoe, J Exp. Zool. 107.315 (18) A J Sams, L.L Boyarsky, RW Gerard Lbet Brust, Amer J Physol 1 1 (1951); H. Kng, Tras Amer Neurol. As 83 1 (958 H Waelsh and A Lajha Physol Rev 41 7(11) P Weis n Reona Neurochemsty S.S. ety ad J Elkes Eds (Pergamon New York 11) p S hs, D. Dalrymple, G. Rchards, Exp Nerol. 5, 49 (12) Oroz and CP. Leblond Scence 137 1 7 (12) AC Taylor and P. Wess Pro Na Acad U.S. 54 52 (5) 2 P. Wes, AC Taylor PA Plla, Scece 136
30 (12) 3 GH Parker Amer. Natur 147 (1932) E
Gutmann, Z Vodka, J. Zelen, Physol. ho 4 C (1955): J.V Luco Eyurre, J Neurophysol. 18, (1955) O Denny·Brown and C Brner Arch. Neurol. Phat 5 I (1): NC. Jefferson T gawa, H Neeles Amer J Physol. 193, 563 (1958) E Gut mann Re Can. Bo. 21 353 (12) 5 Th work wa summarzed n prelmnary form .M. Kor PN. Wlknon F.W. Chornk Fed. Pr. 25, 570 (1) 6. P Man J. Neurhem 10 859 (13) 7 Pcker Nuclr odel 6S 8 L Guth and S Jacobson Exp Neurol 14 439
(1) 9 BM Koprwa d CP Leblond J Hstochem. Cythem 10 (12) 10 E Gutman Ed Te Deneat Mucle (Czhoslovak Aademy of Sences Prague 12)
E Gutmann and P. Hn, Te Eff of Use an d D su se on Ne ur om us cu la r Fun c on Czechosloak Academy o f Scenc Pague 963) M. Snger and JP had Eds Mhansms of Neura Regeneraton Progre n Bran Rrch (Eler Amsterdam 1), ol 13
Reprnt by permsson from Scence 55342·345, 20 Jan 67 and from JAA 0571, 17
T n i phi i v Oi g 967) We i e ourse o embryoi develome e advaig axo i o a erieral euro reaes ad ois e ells i is o iervae a i erellular arersi a uioal ui is ormed wi edures or e lie o e orgaism. Te om lee diereiaio ad oiued grow ad develome o ese ells ad o e orgas ey orm are deede uo e esablisme ad maieae o e iervaio Tis as bee demosraed or skeleal musles or various glads sesory orgas ad visera Tis morogeei deedee o orga or issue uo is iervaio does o ed wi embryoi lie A similar deedee or maie ae or or resoraio o sruural iegriy ad o uioal emial ad morologi roeries ad eve or e survival o some issues is oiued rougou lie Tese diverse iluees o erieral euros usually lumed ogeer as e roi uios o erves ave bee sudied i various ways e mos ommo beig o examie ow e issue or orga ages wi regard o sruure uio resoses meabolism e eera aer i is deervaed eely owever several ivesigaors ave sudied ow e orga or issue ages we i beomes sulied by a erve oer a is ow. We e euro ad e ells i suies are searaed as by uig or rusig e erve ages begi i e deervaed ells wi may rogress over eriods o may days mos or eve years. Tese ro gressive ages may resul i ro oudly alered uioal ad mor ologi araerisis i imaired aaiy or grow ealig ad regeeraio i alered eyme a iviy mioi aiviy meabolism ad emial omosiio. esoses o various subsaes simuli ad eviromeal aors are oe quie modiied ad may eve be reversed i direio. Deervaio may eve ually resul i omlee dediere
ao ad degeeraio o some issues. Tese ilude o oly ee ors su as musles ad glads bu sesory orgas ad reeors also degeerae we disoeed rom eir sesory euros. Te ages a ollow deerva io ave bee learly disiguised as o aure ourse ad exe rom ose due o arres o imulse rai i e erve blokade o rasmis sio aross uios or disuse o e issues Quie obviously arres o imulses or o aiviy ould ardly be e basis or e deervaio aroy o sesory ells ad orgas sie i is ey a iiiae e erve imulses wi are odued o e eral ervous sysem Evidee a umulaed rom diverse exerimeal aroaes ad liial observa ios leads uequivoally o e olusio a e eural iluees wi e osdeervaio ages ree are deede o uo exi aory roesses or euroumoral rasmiers bu uo e maie ae o roolasmi oiuiy bewee e erveell body a oe ed o e axo ad e oraile sereory or reeor ells a e oer. Tese logerm roerydeer miig iuees o euros uo oeural ells ave also bee dem osraed by chngng eir iervaio as well as widrawig i For examle swiig e erves o slow ad as skeleal musles red ad wie musles reseively su as e soleus ad laaris) resuls i eir ieroversio wi orre sodig ages i emial mea boli ad isologi araerisis Wa is e aure ad e bio logia basis o ese diverse o imulse odiioig susaiig roi iluees o euros? We do o ye kow bu we are well o e way o idig ou Tis ombied quesio o aure ad meaism o roi iluee log a area o mysery ad oeure is ow be omig a very aive area o ivesi gaio. I is a ield io wi we ave
Axoal rasor ad roi sudies
venured ony receny is Con ference eard our irs reliminary and enaive reor years ago and a somewa more osiive one las year and o wic we ave made a sma bu aarenly rovocaive conribuion. We wis in is resenaion o describe wa we are rying o find ou abou bo e naure and mecanism of roic in fluence ow we are going abou i and wa in genera we ave ob served so far In our firs conribuion o e quesion of mecanism we demonsraed we beieve a e eieral neuron coninuay inecs some of is own cyoasmic comonens assembed in e cel body and con veyed down e axon ino e cels a i suies Wi e use of auo radiograic meods i was ossible o race e ransor of isooe abeed subsances in yoglossa neurons down e axons and ino e muscle ces of e ongue. On e basis of our observaions we roosed e yoesis a e nerve exers is roic suorive and roery deermining influences on e cels i suies roug e neuroasmic comonens a i ransfers o em In e nex sage of is asec of our sudies for wic we are now rearing we wis o seek wo kinds of informaion 1) Wa subsances or kinds of subsances are us ransferred from e nerve cel o e mus ce cel? ) Wa is e fae of ese subsances in e reciien cels? Ta is o wa cel ars or organees miocondria sacroasm Gogi bodies nuclei e ceera do ey go and in wa sequence? In order o seek e answers o e firs quesion e ideniy of e subsances ransferred e folowing basic rocedure is folowed Various recursors or comonens of more comlex molecues agged wi C radiocarbon) or H riium) are insiled ino e brainsem nucei of e yogossa nerves of rabbis. Afer abou weeks sufficien for muc of e agged nervecel cyolasmic maerial o be rans ored down e axons across e uncions and ino e musce ces e animal is kiled and e ongue and nerves are quickly excised Tese issues are en disinegraed and ex raced. Te exracs are fracionaed and e various fracions analyed
and esed for deerminaion of e subsances ino wic e isooe abeed recursors ave been incor oraed or convered Wa kinds of subsances may be involved in e ransfer? Te reaions beween eriera nerve cels and e cels ey innervae ave been sown o be so secific and e roeries influenced by e nerves so diverse a one is ed o susec a e secificiy and diversiy are based on roeins or nucleic acids or bo Te ikeliood a roeins may be ransferred from nerve cel o musce cel is srongy suggesed by our exerimens wi agged amino acids as recursors esecialy in e ig o f accumulaed evidence a amino acids in e ce bodies are raidly incororaed ino roein wic en asses down e axon and a very lile if any free amino acid is found in e axolasm. Te ossibiliy of ransfer of nervecel ribonucleic acid A) o musce ces is suored by recen demonsraions of is resence and of is roximodisal migraion in axons Te quesion may be raised wi good reason owever weer suc arge molecues are abe o ass across e unciona membranes Bu even is doub seems abou o be resoved by e recen evidence for inocyosis e ransfer of cyolasmic vesicles across e moor endlae. Te demonsraion of e inercelular ransfer of Aemae or of subsances synesied under A coding woud of course be of grea eoreical significance. To seek answers o our second quesion e fe of e ransferred subsances waever ey may urn ou o be) in e reciien ces orions of e same secimens wic are exraced for cemica sudies wil be rocessed for igresoluion auo radiogray We exec in is way o idenify more recisey and secificay an in our revious invesigaion e cel srucures in wic e radioacive subsances are found a various imes afer enering e musce ces from e nerve erminal Wen we know wa subsances ass from nerve cel o musce cel and were ey go in e musce cel we sal ave a fairly good idea of wa ey do ere and ow nerve ces influence e ife isory of eir non neura ife arners.
e us urn now from our sudies on e mechnsms of neuroroic funcion o our oers aimed a is nue In ese our basic sraegy is o sudy e srucural funciona and cemica canges induced in a given issue by subsiuing a foreign innervaion for is own; and is is e area on wic we ave concenraed during e as year. As described in e accomanying absrac we ave been abe o induce ongue muscle o acce vagal innervaion in lace of yoglossal and diaragm o acce fibers of e vagus or recurren aryngea nerves in ace of renic. We oe soon aso o innervae sernomasoid musces wi yoglossa nerves Afer sufficien ime as been alowed o 1 5 mons for e nerve o grow o e muscle for funcioning uncions o be esablised and for e muscle o recover rom is emorary denervaion e degree of success of e sub siued innervaion is assessed by eecro myograic rocedures wile e nerve is simulaed above and below e anasomosis and beore and afer secioning e nerve a various oins Te animals are en kiled and secimens of e ongue or diaragm aken from bo e norma and oeraed side for comarison are reared for isoogic sudy or sudy of moor endlae morlogy for deerminaion of concenra ions of various subsances and of e aciviies of various enymes Wie coninuing is roec designed o reveal wh in e muscle cels is subec o neural influence we wis o ink i o e oer roec on how Our aroac is based on e remise reviously exressed a e relaionsi beween a aricular nerve or grou of nerve cels and is endogan and e diverse influences of nerves are eac based on secific A or roein molecues We wis o deermine by anaysis of nerveandmuscle arners no ony weer e A or roein fracions vary from nerve o nerve and endorgan o endorgan bu also weer aricuar fracions of ro ein or A are common o e nerve cels and muscle cels wic are oined. ascinaing and cinicaly imoran quesions of immunocemisry and auoimmune reacions are raised by is ossibiiy.) As a
97
coroary we wsh to ind out, when foregn nnervaton s estabshed to a usce, not ony whether new and dfferent proten fractons are n dud n that usce by ts new nerve (as takes pace n the nterconverson of fast and sow usces on crossn nervaton), but whether any, and which, of the new proten fractons are dentca to those n the nerve, ether drecty transferred or syn thesed n the usce ce under nerveRNA drecton There are of course st other key uestons regardng the nature and echans of trophc functon that ust be expored A few that are aso on our agenda are for exape 1 What roe s payed n trophc functon by the transport of sub stances n the endoneura spaces ten the axons, such as has been under study for soe years by Ap petauer who recenty oned ths progra? What, f any, s the roe of substances transported fro the Schwann ces, through the yen sheaths to th axon and whch there by bypass the ce body? In vew of the evdence that the trophc reatonshp between neuron and (for exape) usce ces s ute a utua one n whch the neuron s dependent n any ways upon ts connecton to ts nonneura partners s there aso transfer of substances across the uncton n the opposte d recton, ro usce ce to axon, wth upstrea transport to the neuron? Concerned as a these uestons are wth the feong, drect nuences exerted between neurons and ther ce partners and wth the exchange of ceuar ateras drecty between ces (rather than through bood or other extraceuar uds) they have cruca sgnfcance to soe of the ost fundaenta areas of ceuar and oecuar boogy n addton however, they have soe exctng cnca pcatons In vew of the profound nfuences exerted by nerves on the structure, functon growth, etabos, and regenera tve power of nnervated tssues and organs and on ther responses and adaptatons to any factors, t ay be expectd that under certan cr custances the nfuences of a gven nerve ay bcoe adverse and detr enta to the organ t nnervates, 98
thereby conrbutng to dsease The evdence for neurogenc esons and dysfuncton, n endess varety, abounds n experenta and cnca terature and n day practce What knds of crcustances cause perphera neura nfluence to become adverse? Aost any factor whch ore or ess endurngy exag gerates or suppresses the exctabty actvty, and energyexchange of the neuron retards ts rearkaby hgh rate of proten synthess, uatatvey odfes the products of that syn thess, or pedes the axopasc fow of those substances, woud be detrenta to the nnervated ces and organs Aong those factors, therefore, woud probaby be the abnora bobardent of perpher a neurons, va descendng pathways, due to enta or eotona stress, tenson, or nhbton; or va sensory pathways, due to envronenta stress Aong the aso woud prob aby be soe of the nutrtona, toxc and vra nsuts to neurons Most certany nvoved and on a vast scae are the drect physca and checa nsuts posed on nerves (and on the vesses that noursh d dran the) by the struc tures and tssues through whch they ust pass, on ther way fro ther orgns, argey n the spna cord, to ther perphera ternas For these reasons, t s these, the yofasco skeeta tssues, that provde the environment for ost of the cyto pas of perphera nerve that n the axons (and n the Schwann ces that apparenty noursh the axons) t s aso these nerveenvronng yo fascoskeeta tssues that are subect to, and that produce the argest forces n the body and that through contracte and hgh etaboc actv ty produce profound checa changes These physcocheca fac tors n the tssues through whch, and between whch, nerves pass woud aost certany affect the uaty and fow of neuropas and of endo neura fuds ost partcuary n areas of uscuoskeeta stress and deforaton, sustaned uscuar contracton adheson, edea, fo rana or dura copresson, et cetera It s the sae tssues aso, tat through ther proproceptors profoudy affect the exctabty and actvty and therefore the etabo s of perphera neurons
Ths area the ongter n fuences of the nnervaton on the condition of ce, organs and tssues and the aberratons of these n fuences due to behavora, envron enta, nutrtona postura, and echanca factors s one of the ost pervasvey sgnfcant and, as yet, unexpored areas of cnca edcne It ay even be possbe one day to treat the afunctonng or dseased organ hrough ts nnerva ton (aost certany a echans n anpuatve therapy) or by adns traton of specfc neura substances We hop that n seekng answers to soe of the fundaenta uestons, we ay aso contrbute to a sgnf cant advance n therapeutcs References Wess P Ed Gee euoo. he Uves y of Chago Ps Chgo 50 Gum E, Ed he deeved muse Pubsg House of he Cehosov demy of ees Prgue 6 3 Gum E d H P. Eds he effe of use d dsse o euomus fuos Po eedgs of symosum held ude he sososh of he eo Uo of Physologl ees Publshg Houe of he Cehosov demy of ees Pgue 63 4 ge d hd JP Eds esms of eur egeero Poges Br Reseah vo 3 Eeve New Yo 64 5 Buler J Ees J d Eles R eos bewee mooeuoes d muses e se of he hes seeds of he esoses J. Physol (odo) 50473 Feb 6 Bue .J. d ews DM Furher obse os o mmml oss-eved selel muse. J Pysol (odo) 73435 y 65 7. Gh d Wso PK h e fuee of evo o he soube oes of sow d f muses of he . Ex Neol 7077 J 67. 8 Kor Wso PN d Coro FW. sudy roh mehsms JO 356 My 65 Ko Wso P.N d Cho FW des euooh mehsms JO 65 y 66 0 Kor, Wso PN d Choo FW xo delvey of euolsm omes o mse els ee 55345 0 J 67 Koeg E yhe mehsms he ao RN mye-fee axos of he J Neuohem 3576 y 65 N DGomo d DGolmo edmeo hess of o RN bb J Neuohem 3755 66 3 des K. d v Dg oozyose moohe Edle Nu wsete 53656 De ( . 4 Ko e l udes oh mesms Does hgg s eve hge mus e? JO 66 y 67. 5 elue G e Ue of C- -yse o egmes of oml eve Ex Neuo 5 Jul 65 6 eue G d EE ooo
oa transport and trophc studes
of C-14 lsne no snl roos snl gangl nd erherl nerves of he r x erol 1448495 r . 1 nger and leer he rnsor of 'Isdne rogh e hwnn nd meln she no e xon nldng reevlon of meln fnon J or 108115 ov 66
Tis gm is md ossibl b t cobotion o PN Wikinson BA W Chonock PhD S.L Atur nd th utor o t Kirksvi Cog nd W V. Co DO o th Knss City Colg o Ostoth nd Sug W gtu to Dr Col nd his Cog or his miontomi contributions to tis rogm Rerned ermsson from JO 664-8
Studes n trophc mchansms: Does changng ts nerve change a muscle? (196) ORR W CHORNOCK WV COE nd PN WKNSON
In addton to egatng contacte and eceto actvt o oent to oent b change n pe ow pephea neon ao eet a vaet o ongte condtonng and ppotve nence on the gowth egeneaton tcte etabo and nctona capact o the ce the nnevate Fo oe te ot notab keeta ce the neve ae eenta o te ve antenance and vva O pev o tde gget that the tophc ppot and condtonng o ce b t nnevaton a be baed on the contna deve o pecc neopac coponent to the ce ce he peent tde ae dected towad bette ndetandng o the nate and knd o tophc n ence eeted b neve he a appoach to th ed ha been to wthdaw the tophc nence b cttng the neve to the te and then to td the change that have taken pace at vao te o owng denevaton whe coect ng pobe o the change de ee to ntepton o pe O appoach ha been to hange the nnevaton athe than wthdaw t We wh to know how a gven te o ogan change when t ndced to ake a nctona non wth a neve othe than t own What pop ete o the te ae peay detened b the neve ce to whch t joned and what n the neve ce ae the detenng acto Seventthee neventeventon have been peoed on an ea nbe o abbt In 5 o thee the hpogoa nnevaton to one de o
the tonge wa epaced b the vag vagohpogoa anatoo) In 4 othe the phenc neve to one hedaphag wa epaced ethe b the vag vagophenc anatoo ) o b the ecent angea neve he eande wee conto pepaaton Steen o thee con ted o ecton and edate e anatoo o one hpogoa o phenc neve a conto o the e ect o tepoa denevaton and o vao degee o ennevaton Eght wee peanent natea de nevaton In addton each ana povded t own conto the no a ha o the tonge o the noa hedaphag o copaon wth the epeenta de The tonge and daphag o oe o the opeated ana ae now beng tded o nctona tc ta and chemca change at va o peod p to 1 5 onth ate ge Eectoogaphc tde ae done nde anethea on the tonge o daphag o each ana o evaaton o pontaneo actv t and epone to taton o the neve above and beow the non Eectoogaphc ecodng e peated ate vao ecton have been peoed to detene the oce o oce and the etent o the nnevaton te eectoo gaphc td the te ae eovd o cocopc td o ophoogc change n ce te and oto endpate change n concentaton o cetan checa coponent o eape gcogen noganc pho pho and nonpoten ntogen) and n the actvt o cetan enze
Foegn nnevaton ha been acheved at eat to oe degee n 1 5 o the epeenta ana eaned th a In oe ennevaton and egeneaton) o the ce b the oegn neve wa copete o aot copete In othe t wa pata the et o the ce eanng atophed In ana whee the oot o the ogna nnevaton had not been copete etpated we occa ona ond that the nnevaton wa ed o that n egeneatng the ogna neve had pevented oegn nnevaton o had even e paced t ate t had been etabhed Epeca nteetng theoetca eton ae aed b pobe e paceent o otoneon b pe gangonc neon whch odna nape on wth othe potgan gonc) neon whch n tn nnevate ooth o cadac ce o gand ce) t th tage o o n vetgaton t t too ea to oe anwe to thee eton o to decbe the ophoogc and bo checa tanoaton ndced b oegn nnevaton Reference 1 Korr Wlnson P nd Chono FW des n neroroh mehnsms JO 65 2 Korr I Wlnson P nd Corn FW xonl delver of nerolsm omonens o msle ells ene 15542-5 20 Jn 6 Rerned ermsson from JO 66 980, 1 96
9
Cti ti t x tt v ti t cl (1970) I.M. KORR ad SL. APPLAER
We underook e sudy o e axona deivery o acrooecuar coonens o nerve ces o usce as a ossibe ecanis in e roic uncion o nerves In our irs sudy using auoradiogray we deonsraed suc deivery by yogossa axons o uscle ces o e ongue ollowing e alicaion radioacivey labeled recursors o e nerve ce bodies in e oor o e our venrice in rabbis. In subsequen sudies reored in ar a is con erence as year we deonsraed a beween 13 and 3 days aer labeing yogossal neurons in e edua wi Ceucine radioacive roein coud be exraced ro e ongue usces in quaniies wo o ree ies arger an coud be ascribed o incororaion o C eucine carried in e bood Saler excesses were eviden severa days beore and aer e 3 o 3day eriod In e as year we ave exended ese sudies o a uc arger series o exeriens and eoyed uc ore reined eods Te new eods include 1) ore recise and reroducibe abeing o e yo gossa neurons and concenraing e abe as ar as ossibe on one side; 2) exracion o roeins wi cod 1 er cen ricoroaceic acid TCA) 3) use o eucine abeed wi riiu H o exreey ig seciic aciviy 3557) curies er iioe) aking ossibe e acieveen o uc iger eves o incororaed radioaciviy an was ossibe wi C and () use o inerna iquid sciniaion or radioassay o exraced racions o issue seciens insead o surace couning. In a series o saoeraed rab bis in wic e Heucine 8 icrocuries was ineced inraerioneay we conired a e sylo yoid and yoyoid usces inner
I
Su d b PS Ra ch Gan N NS'799 frm h aina Inu Nurlial sass d Sk d by a an rm h Amran ahi Asan
vaed by e acia and rigeina nerves resecivey) were a a inervas aer inecion reiabe indicaors o e aoun o radioacive roein wic ad been incororaed by e ongue uscles innervaed by e yogossa nerve) ro boodborne Heucine Tereore in e exeri ena anias in wic yogossa neurons ad been resened wi Hleucine 8 icrocuries) direcy alied o e loor o e our ven rice e excess o roeinincoro raed radioaciviy er iligra o res ongue usces over a o e conro usces syoyoid and yoyoid) reresens radioacive roeins conveyed o e ongue usces by e yogossa nerve Anias were sacriced a various inervas ro severa ours o 76 days aer e H eucine absorbed on a sa iece o ier aer ad been aied or 15 inues o e le side o e oor o e our venri ce Seciens o e oowing issues were obained ro eac ania 1) our consecuive segens o e e yogossa nerve o indicae any ongiudina gradiens) 2) e rig yoglossa nerve or coarison wi e le o indicae e degree o unilaeraiy o abeling; 3) e and rig syoyoid and yoyoid usces a is our seciens o conro usces) () ree orions eac in ongiudina sequence) o e e geniogossus and syogossus usces o e ongue 5) bood asa; and 6) eduary issue ro e our venrice Seciens o conro and exeriena uscles were aso reared or subsequen auoradiograic sudy Seciens were raidy oogenied a 2 C roeins and oer acrooecuar coonens recii aed by cod 1 er cen TCA were wased wice wi cod TCA and en wi a series o organic sovens Te roein reciiaes were digesed wi Souene ackard Insruen Coany) and couned in ouene based uor cockais a eiciencies o aroxiaey 36 er cen Ali
quos o ooed neuraied TCA suernaans acidsoube co onens incuding unincororaed recursor) were couned in uor cockais eusiied in a 21 VV) ixure o ouene and TrionX a eiciencies o aroxiaey 23 er cen Te organic soven wases were discarded Couns were cor reced or background and or quencing and convered o disinegraions er inue er iigra d/g) o res issue ackard Triarb Sciniaion Secroeer Mode #3375 Exce in ose anias sacriiced wiin e irs ew days aer aicaion o e Heucine o e yogossa nuceus e aoun o unin cororaed recursor a is radioaciviy o e suernaans) was very sa in reaion o a o e TCA reciiaes roein racions); ony e aer are reored in is absrac Aso or reasons o breviy we sa coen only on nervedeivery o e sylogossus usce o e ongue daa on e genioglossus sowing cerain quaiaive dierences wi be reserved or a uer reor Wi our resen eods and aerias we ave been abe o inroduce uc ore radioaciviy ino e neurons wi a roorionaey uc saer wasou ino e bood and in coarison wi our revious reor ave exanded e nervedeivered coonen o oal ongueusce radioaciviy a is couns in e roein racion) iry o iyod On e basis o yive exeriens successuly coeed us ar wi is agniicaion i as been ossibe o conir un equivocaly e deivery o roein o usce y nerve and in addiion o disce a leas ree waves o roein ransor raveing a dieren raes down e nerve o e uscle Soe uncerainy as o e recise nuber and duraion o e waves eseciay e sower ones reains because o unavoidabe aniaoania variaions or exae in nerve eng) and because o e ssibiiy o overa o e wake o one wave and e rising ase o e succeeding one We exec e waves o be ore disincy reveaed wi addiiona daa Te oowing are e aaren waves a is oin in e invesiga ion Axona ransor and roic sudies
1 The first wave of raioactive protein an the most efinitive reaches the musce within the first 24 hours after uptake of the Heucine by the neurons. This protein apparenty has a short hafife in the mus ce anor nerve enings since by the thir ay intramuscuar raioactive protein has faen almost to contro vaues an remains ow for severa ays onger even though protein raioactivity in the nerve is quite consierabe uring this same perio 2 Another wave begins reaching the musce on about ay 1 peaking at ay 14. ntramuscuar raioactive protein remains eevate unti about ay 16 after which it fals precipi tousy. 3 Another rapi rise begins aer ay 1 9 to a peak at ay 20 the protein raioactivity in the styogossus re maining in genera wel eevate unti ay 29 ater which it ecines graualy over the next ays or more to contro vaues. n contrast with that in the first wave therefore this protein appears much more stable (The 133 ay perio ini cate in our preiminary investigation using C leucine an surface counting correspons to waves 2 an 3.) The evience for two or more waves is consonant with accumuat ing eviene from a number of ab oratories that axoplasm oes not move at a uniform rate as ha been thought but instea there are severa systems of axopasmic trans port carrying proteins of ifferent properties an probaby ifferent functions at very ifferent rates (1) a fast system transporting proteins proximoistay at rates of to severa hunre mmay epening on species an kin o neuron (2) an intermeiate system operating at rates of severa (for exampe 5 1 1) mmay an (3) an apparenty basic axopasmic stream of about 1 mmay Since it may be assume that in each animal at least a portion of the raioactive protein extracte from the musce ha been containe in in tramuscuar nerve enings we must await stuy of autoraiograms sti in process to etermine in which phases of which waves the crossing into musce cels occurs an the ocation of the raioactivity in the musce cels (t is interesting that the autoraio
graphic ata previousy reporte by us were taken from animas sacrice uring the eary part of what is now ientiie as the secon wave.) nfortunatey because of the low activity ong exposures are require for the autoraiographic portion of these investigations We hope also by electrophoretic an other means to ientify proteins share by the hypogossal nerve an tongue musces an to etermine the istribution of raioactivity among the protein fractions uring the if ferent waves of eivery Referece l. Kor IM, Wlko, P a Chook F.W Axoa lvr of rolam omo o m S : a 67 . Korr lM a Aa r GS L S o h rafr of oa ro o mu Prmar ror AA 68:798 u 68 ak R.. Axom rao of lab o ra ra mooro Exl uro 968 Ew BS ad Graf Fa a ow omo axoa raor of ro C o 8908 S 68 h S Sabri MI. a oho Fa raor m of mara mammaa rv fbr S 668687 Fb 69 6 aro S E Axolam raor uro R Prog ll (o.4) 0-9 67
Apprecaton s expressed to Mrs Nancy Keth and Mrs Shaon Bery for ther excelent techncal assstance The partcpaton of Mr John Klgoe second year student, during the ummer was also most valuable We are grate· ful for the assstance o Mr Paul N Wlknson n arous aspects of sotope technology Rr b rmo from AA 69 7678 970
Te mecourse of xonal rnsor of neuronal roes o muscle* (94) RV M. KOR R nd GUSTAVO SL APPLTAUR
he longte inluence o nee on tiue and ogan hae been the ubject o an tudie eoed in an ecie and in aiou wa e iewed b Guth 6 ) hu innea tion i eential o the ebonic and otnatal deeloent o cetain tiue and ogan and o the ainte nance o thei tuctual and unc tional integit Alo lib egenea tion in lowe eebate deend on the eence o the eiheal nee and o an adeuate atio o neual a to lib a Counion between nee uling ucle o dieent te hae hown that the gene eeion in taited ucle i ubject to neual egulation 8 9) he echani o thee and othe tohic inluence ae not et clea othe than that the ae baed not on iule conduction but on integit o connection betwen the neuon and the endogan Seeal ea ago we eented adioautogahic eidence that oe acoolecule ntheized in the hogloal nee cell bodie and coneed oioditall in the ao la aaentl co the oneual junction and ente the tongue ucle 1) Neetoucle tane wa deontated in a eiod 815 da ate aling ecuo to the neuon hi peiod wa elected on the bai o the aaent elocit o aolaic ow aoiatel 5 da) eealed b 4can o the hogloal nee W e ooe that uch neetoucle tane o e ciic neuolaic coonent ight la an iotant ole in the aiou tohic inluence o nee hi eot eent ou inding in a uantitatie tud o the tan ot o neuona otein eaued a oteinincooated adioactiit At aiou tie ate aling ti
Suppr b G N NS-0919 rm h N ue H b gr rm Amr Oep A reu repr Apr 9 (3)
2
tiated leucine to hogloal neuon otein and nonotein action wee etacted o tongue ucle ad hogloal nee and adio aaed Radioautogahic eaa tion wee ade o otion o the ae ucle ecien in ode to tud the localization o the adio actie coonent hee will be the ubject o a ubeuent eot Methods
Surgcl Prepron. o the inta enticula labeling o hogloa neuon we ued 148 New Zealand abbit o both ee weighing 1 6 kg ediatel beoe the oeation a olution containing 80 Ci o 4HLleucine eciic ac tiit 05 Ci/M Aeha Seale) wa aidl educed in olue b eaoation oe Dieite at e duced eue t wa abobed on a all iece o ilte pape 1 5 x 05 ) with one uace coeed with Paa i that wa haped to it the let ide o the outh enticle nde entobabital anetheia the loo o the outh enticle wa e oed e uch in the anne de cibed b Miani 19) o kee the aea ee o ceeboinal luid a poteio chooidecto wa e oed and the aea wa daed with neuougical abobent Cod an and Shutle nc) o which the uid wa withdawn b aia tion. he ti containing the iotoe wa then laced pae ide down on the aea oe the let hogloal nucleu o 15 in t wa then e oed; the aea wa ket d o an additional in he wound wa then cloed Antibiotic Pize Co biotic) wa adiniteed ate ge and on thee otoea a B thi techniue we wee able to concentate ot o the ecuo into the let hogloal nee and let ide o the tongue Ou laceent o the pecuoaden ae wa uch that o the two tongue ucle a led uch oe oteinincoo ated adioactiit accuulated in the tloglou than in the genioglou
ucle and thi eot i liited to the tloglou o the intaeitoneal injection a iila ha) opeation wa done on 1 8 additional abbit i n which the ae alied to the loo o the en ticle contained no Heucine and in which 10 l o noal aline contain ing 1 60 CHleucine wa injected in taeitoneall
Tue Specmen Oeated abbit wee killed b eanguination unde light entobabital anetheia at ec iied tie ate adinitation o the labeled ecuo he ollowing tiue ecien wee taken a) Con tol ucle let and ight tlohoid and lohoid ucle ee late); b) ongue ucle let and ight tlo glou and let and ight genioglo u ucle each cut into egent in the oiodital ai; c) Ho gloal nee between eegence o the caniu and oint o ent into tongue ucle wee cut into ou egent; d) edulla let hal o oo o 4th enticle); e) blood laa Mucle ecien wee cae ull cleaned in a cold oitcha be o nee banche and connectie tiue unde a diecting icocoe he epineuiu wa tied o all nee ecien Exrcon All ocedue wee ca ied out at 4C te addiion o 5 g o ctalline boine eu albu in a caie the tiue ecien wee indiiduall hoogenized in gla eel with cloeitting eon etle containing 4 l tichlo acetic acid CA) and 05 g caie leucine he hoogenate wee cen tiuged o 10 in at 1 0 RPM he ellet wee twice ehoogenized and wahed with 4 l o 10 CA olution he ooled uenatant heeate identiied a CAoluble action) o each o the ecien wa neutalized with KCO and bought to a inal olue o 5 l with ditilled wate A 5 l aliuot o each CAoluble action wa taken o adioaa he ellet wa twice again ehoog enized and wahed with each o the ollowing olution atio indicated b olue) 8 l ethanolethe 1 1) 1 0 l ethanolchloooethe 1 ) ; and 10 l ethe he eain ing eciitate will be eeed to a the otein action Aonal tanpot and tohic tud
The radioativity of the TCAsolu· ble frations was determined aord ing to the method of Patterson and Greene (21. The ounting effiieny was 23. Tests showed that more than 99 of the free leuine was reovered in the TCAsolube fration. The protein frations were di gested for 1 hr at room temperature in 01 m water and 2 m Soluene (Pakard nstrument Co Digests were dissoved in 18 m of toluenebased sintillators (PPOPOPOP mixture and ounted in the Pakard #3375 TriCarb Sintiation Spe trometer The ounting efieny was 2 After quenhorretion the radioativity was expressed as disinte grations per min per miligram of fresh tissue (dpmmg Re
/ P ! Fig. Exriment howing rul day ter ham oration and in tperitoneal injection of'H-leucine Ordinaedpm/mg frh weight of the ario pecimen BlackTCAinoluble fcion; rayTCA olublefraction Crohatched(Mmedula and Pplma) total radiaciy NL, NRhypogloal nerv lt and right egment in proximodta equence; SL SRtylohyoid mucle lt and right MHL MHRmylohyoid mule lef and right L Rgenioglou mucle lef and righ SL SRtyloglou mcle l and right
Contro or norporaton o bood born prrsor by tong ms t
is inevitable that a portion of the original preursor harge applied to the surfae of the medua wil be ost to the erebrospina fluid and thene to the boodstream and that some loss to body uids ontinues through out eah experimenta period t was neessary therefore to measure in eah animal how muh of the radio ative protein in the tongue musle represented inorporation of H·leuine arried in the bood or this purpose we sought musles innervated by nerves other than the hypogossa whih inorporate the same amounts of bood·borne euine per mg of tissue as do the tongue muses n a series of shamoperated ani mas in whih the tritiated leuine was ineted intraperitonealy the stylo hyoid and myohyoid musles innervated by branhes of the faial and trigeminal nrves respetively inorporated irulating euine into pro tein in amounts very similar to those in the genioglossus and styogossus muses of the tongue. igure 1 shows the resuts of one suh shamoperated rabbit kied 18 days after surgery and intraperitoneal inetion The graph iustrates the ose orrespondene of protein (as wel as total radioativity of the ontrol muses to that of the tongue musles. Also shown on the same sale of radioativity are the extrarania portions of the hypogossa nerves desheathed and ut into four segments o approximatey equa
2
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g. Incorporaion of blodboe Hleucine into protein by ongue and control mucle Ordinatedpmmg frh ight aciaday afer ham opeion and inraperioneal ecion average of por tio of yloglsu mcle SL average of conrol mucl SL SR ML MR ee Fig
m
Fig. periment howing reult day ter inraentricular ad mintraion of Heucine Symbo ame a in Fig. Noe Zfold d ference in radioaciviy cal for nee and mucle
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Fig Summry of periment with intrventriulr dmintrtion of 'Heuine Ordintdpmmg freh weight bi-d ter d minitrtion -erge of portion of left tloglou m ule (SL -erge of4 ontrol m ule (SL SR ML MR hoing portion of proein inorporting bloodboe preuor
DY ¢ Fig Ttment ofdt from Fig 4 preenting 2 nd 4d men nd tndrd devition "orreted for pprent doge -SL mule; ontrol
ength Radioactiit (undierenti ated into protein and acidsoube ractions) o medua and bood pasma were routine determined in a o the eperimenta animas pri mari to monitor our techniques and do not enter into anasis o the data In a specimens in this eperi ment maimum protein radioactiit was beow dpm/mg igure 2 shows the resuts o 18 such eperiments the specimens o stogossus and contro musce ha ing been taken at arious interas be tween 1 and 76 das ater the intra peritonea injection Eident the contro musces that we seected gie a reiabe inde o radioactie protein incorporating boodborne Heucine in the stogossus musce o the tongue each o the eperiments described in the net section we thereore used the stohoid and mohoid musces to indicate the boodderied portion o protein radioactiit in the tongue musces the remainder being
ascribabe to deier ia the hpo gossa nere
Inanicua abing jypga nun igure 3 shows one e periment in which the Heucine had been appied direct to the et hpo gossa nuceus as described The rabbit was kied and the specimens taken 1 1 7 5 das ater surger Unike ig 1 the scaes or nere radioactiit and or musce radio actiit dier b 2od that in the neres being much higher than in the musces The protein radioactiit o the et nere was much higher than that o the right nere (Neerteess the radioactiit in the ght ere was substantia and indicates as did the other eperiments that some di usion o the precursor across the me dian sucus and perhaps to other parts o the entrice oor was unaoid abe and a ariabe in our eperi ments) orresponding the e stogossus musce had much higher protein radioactiit than the right
which was on sight higher than the contro ees As preious men tioned and tpica o the other eperiments the et geniogossus musce receied much ess radioactie protein than the et stogossus Apparent no measurabe amount o radioactie materia unincor porated in protein reached the aon (ig 1 NL NR) orresponding amost a o the radioactiit e tracted rom the et stogossus musce (SL) was in the protein (TAinsoube) phase This is to be contrasted with the much arger por tion o supernatant radioactiit (probab arge unincorporated pre cursor) when the precursor was ab sorbed b the musces rom the bood stream (contro musces in ig 3 and a o the musces in ig ) igure 4 graphica presents the data rom the et stogossus and the contro musces in 148 such e periments Three eperiments were done or each o the irst 42 das in the intera between appication o precursor to the hpogossa nuceus and the kiing o the rabbit Ater 42 das eperiments were at onger in teras Each eperiment is repre sented b two points The open cir ces each representing the aerage o our contro musces show that throughout the entire period o 76 das there was a sma and progres sie decining portion o radioactie protein ascribabe to incorporation o boodborne Heucine The soid circes each representing the aerage o three portions o et stogossus musce show that unike eperiments with intraperitonea in jections the protein radioactiit o te et stogossus musce was we aboe ntromusce ees through out most o the 76 das and that waing and waning o protein radio actiit was eident during the rst das The rst peak o actiit occurred within the irst 24 hours aboecontro actiit being eident ater 6 hours oowed b seera other waes and then a gradua de cine oer the net month or so In such a stud as this man ac tors some intrinsic to the animas others eperimenta enter into the spread o data or each postabeing inter In anazing the data we hae tried to compensate or aria tions in some o the actors One im portant animatoanima ariabe is Aona transport and trophic studies
in th lngth of th n contibut ing to popotional aiations in tanspot tim; th slow th miga tion th wid th aiations Accodingly w diidd th nti xpimntal piod into th abi tay subpiods using twoday mans fo th fist 10 days thday mans fo th following piod to day 33 and fouday mans to day 42 Anoth impotant aiabl is in th actual amount of pcuso pn tating th hypoglossal nuclus and maining aailabl fo incopoation into potin Latha and Toth 14 15 showd that maximum pntation of lucin into bain tissu aft sub aachnoid administation is achid in th fist 5 min and that 1 h lat only of th amount which had pntatd had bn incopoatd in to potin 0% was still in th TCA solubl faction and 2% had lft th bain That is th mao ason fo dcas in f amino acid was fux ath than incopoation into po tin Hnc in sking to compnsat fo aiations in ffcti dos of Hlucin w adoptd th pmis that fux fom th bain appantly by acti tanspot 14 into th plasma (fom which it was thn ab sobd and incopoatd by th muscls in ou study was dictly latd to th amount that had pn tatd into th mdullay tissu W thfo applid to th data fo th lft styloglossus muscl fom ach animal in this sis a coction fac to that tansfomd th aag alu of th contol muscls fo that animal into th man fo that 2 3 o 4day piod Th data tatd as dscibd abo ha bn plottd in Fig 5 and in dicat fou piods of aial of nbon potin incopoating labld lucin Th fi st wa bgins to appa within a fw hous paking n th st and scond days and d lining to almost contol lls by day 3 Th scond wa which co sponds to that in ou pious adio autogaphic study 12 paks b twn days 9 and 14 A thid wa paks btwn days 22 and 27 A fouth is idnt in th 3040 day intal aft which potin adioac tiity dclins gadually. Th toughs seem to psnt olap of th d clining phas of on wa and th is ing phas of th succding on That
is duing at last a pat of ach wa oth than th fist potin adioac tiity may psnt th algbaic sum of olapping was and possibly in clud sidus of pcding was Cosponding fluctuations of poximodistal tanspot along th hypoglossal ns w also idnt but sinc th adioassay of th n xtacts psntd potin in tansit though latily long potions of n a pcis dinition of was was not possibl Dicuion
Ths findings indicat that at any gin tim a mixtu of potins ca id in th hypoglossal axons is ach ing th tongu muscl Som of ths potins ha bn synthsizd by th pikayon a fw hous ali som a month ali and th maind at two intmdiat piods Ths was may b ascibd in pat to dif fnt ats of axonal tanspot of potin which ha bn shown to ay in mammalian ns fom a slow at of 125 mm/day up to sal hundd mm/day with an intmdiat at btwn ths two xtms idnt in som axons 2 4 16 In th abbit Kalsson and Sstand 1 1 found fou ats of intaaxonal tanspot in th tinal ganglion clls 150 40 612 and 2 mm/day but Sstand 23 found only two ats in th hypoglossal n 300 mm/ day and 5 mm day as wll as two somwhat high ats in th agus n W ha no x planation fo th appant discp ancy btwn thi findings and ous Ou xpimntal dsign dos not pmit accuat masumnt o ats of axonal tanspot cosponding to th fou was but ough stimats can b mad on t basis of th xta canial xtamuscula lngths of th hypoglossal ns in ou abbits (an aag of about mm and th tim of aial in t h muscl. Sinc n dlid adioacti potin was alady psnt in th shotst of ou xpimntal piods 6 h th at of tanspot would ha bn no lss than 160 mm/day Th fouth wa sms to cospond to th mam malian slow" at of 125 mmday Th was may b latd not only to tanspot ats but also to diff ncs in dpatu tim aft lucin uptak Doz has shown that som
sdntay potin may main in th cll body fo piods up t o two wks bfo bing dispatchd into th axon 3 It is conciabl that a lat stat" may otak an ali stat" but slow unn W popos that th multipl was of nuonal potin aiing at th mus cl a th poduct of ths two fac tos at of tanspot and intal btwn pcuso incopoation and ntanc into th axon hillock. W cannot asctain fom th data of this pat of th study what potion if any of ach wa of potin actual ly nts th muscl clls and how much has maind in th intamus cula n ndings and w must await compltion of ou analysis of th adioautogaphic spcimns tan fom th sam animals Ou pious adioautogaphic study 12 ctainly suppots tansunctional tanf duing what is now idntifid as th cond wa Th is no ason to bli that such tansf would b limitd to ony on of th fou was oo sinc th publication of that pot and t h compltion of th psnt study 13 pots ha ap pad which stongly suggst tans synaptic tansf of potins witin th cntal nous systm 5 10 20 Ths obsations a consonant with th ampl and gowing idnc that potins do nomally mo in and out of clls (g 22 Ou hypothsis 12 that th poxi modistal conyanc of potins fom n clls may undli thi tophic influncs is suppotd by cnt studis Lntz 17 1 dmonstatd that such influncs can b po ducd n ro and that thy a mdiatd by diffusibl thmolabil substancs lasd by n clls Al buququ t al 1 showd that blocking axonal tanspot without impaiing th ability of th n to maintain muscl actiity causd th appaanc of tophic sig ns of dn ation In th psnt study it was possibl to distinguish fou paks of dliy which pobably cospond to sal ats of axoplasmic tanspot Th adioacti matial seems to b dli d ath cntinuously to th n tminals and possibly thaft to th muscl In a puls xpimnt such as this th psnc of sal olapping was mas it difficult to dtmin whth matial tans
poted at a discete ate witin te neve can be found in te musce at a simiay discete time inteva Con sequenty, in anote study now ap poacing competion, we ave cosen to diffeentiate te abeed poteins on te basis of te specific macomoecues compising eac of te waves Tis study indicates tat soube poteins caied in tee of te fou waves ae eectopoeticay distinct and tat eectopoeticay identica poteins ae, in coespond ing intevas, subsequenty found in te musce Te consistent obsevation tat ony cetain of te adioac tive axona poteins appea in te musce extacts suggests seective axontomusce tanspot Of couse, in addit ion to adioautogapi c studies anayses wi utimatey ave to be made on potions of musce devoid of neve teminas, to acetain wete tanssynaptic tanspot of tese potein species as actuay occued Refeences I. Albuquerque, E.X JE. Wanick JR Tase and M Sanone 1972 Effts of vinblastine and colchicine on neual egulation of the fat nd sow skeletal mucl of the rat Exp Neul 37 '7-634 2 Barondes SH. (Ed 1967 oplamic tansot. Neusci. R gm Bu. 5: 31-419 3 Dz B and HL Konig 1970 Localiation of protein metabolism in neuon, pp 93-108 In Pro tein Meabolism of the Nevous System" Abel Lajtha [Ed) Plenum New York 4 Gafstein B 19. Axonal transpo Com muniction between soma and synapse, pp 1 1 25 I Advance in Bihemical Psychophamacology E . Costa and P. Greengard Eds). Raven New Yok 5 Gafstein B 197 1 Tanneuronal transfer of radioactivity in the cental nevous sytem Science 172 771 79 6. Guth L 18 Tophic" inuences of nerve on muscle Physiol Rev. 48 5-687 7 Guth L Ed 1969 Trophic" effects of veebrate neuons. Neuri Res Program Bull. 7 173 8 Guth L FJ Samaha and R.W Albes 1970. The neura gulation of some phenotypic differences between the fiber types of mammalian skeletal muce Neul. 26: 1 1 35 9. Guth L P J Dempsy and T Cooper 1 97 1 Maintenance of neurotrophically regulated poteins in denevated skell a nd cadiac mue p Nero 32 478488 10 Ingoglia NA B Gafste!n B.S McEwen, and G McQuaie. 193 Axonal transot of adioactivity in the goldsh optic system following in taocular injection of labell RNA pecursors 151615. Nechem. Kalsson, JO nd J Sjrnd 1971 Syn thesis migration and turnove of potein in retinal gangion cells J Nerchem 1 8 749767 12. Korr I.M PN Wilkinson and FW Cho nock 17 Axonal deliver of neuoplasmic com ponent to mucle cells Sciece 1 55: 342345
13 Kr IM and GSL Appeltauer 1971 A onal tansport of nervecell proteins to muscle Fed Pro. 30 5 14 Lajtha A and J Toth 1961 . The brain barrie system II Uptake and tranport of amino acids by the bain. J Neuochem 8 216225 I Lajtha A and J Tth. 1962. The bain barie I I The efflu of intacerebraly ad ytem Neurochem ministered amino acids from the bain. 9 1212. 16 Laek R 1 70 Protein trnsport in neurons Inea Rev Neubi/ 13 : 89324 17 Lent TL 1971 Neve trophic function I vt aay of effects of neve tiue on mucle choinesterase activity Sien 171187189 18 ent TL 1972. Development of the neuomuscular junction Part Ill Degeneration of moto end plate after enervation and maintenance 93103. in vitr by nerve epant J Ce. Bi 19 Miani N 1963 Anyi of the somatoxonal movement of phospholipids in the vagus and ypogoal nerves Neurochem 859874 20 Neae J.H EA Nele and BW Aganoff 1972 Radioautography of the optic ttum of the goldfish ae intraocular inection of (H Proline 407·410 iece 21 Patteron MS and Greene 15. Mesuement of low energy betaemiter in auou solution by liquid scintillation counting of emulsions Anal hem 854857 22 Ryer H J P 1 968 Uptake of protein by mam malian cells An underdeveoped area Science 3-3 23. Sjtrnd J 1970 F and low component of aoplamic transport in the hypoglossa and vagu neves of the rabbit Bai Res 461467.
J
J
7
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Repinted by pemson from Eperimental Neurology 43: 452463 1 974.
J
relinar reor in r Fed r., March 19
Axona tanspot and topic studies
Axonal deivery of solube, insoluble and electrophoretic fractions of neurona proteins to muscle* (1975) GUAVO AELAUER and IRIN M KOR
or more than a century the role of peripheral nerves in the ifferentia tion an maintenance of skeletal mus cles has een a maor area of research an eate (4 7 8). Many tentative explanations for the trophic relationship etween nerve an muscle have een ase on those nervecontrolle functions which are well known to in fluence the muscle properties such as the release of acetylocholine the transmission of impulses an the initiation of muscular contraction. hese activities however cannot alone account for all the changes that may occur in the muscle after its in nervation is isture. he nerve may also influence the muscle y the release of sustances which participate in muscle ifferen tiation an which are essential for the maintenance of structural an functional integrity. Research one at this laoratory has shown that after the aministration of Pphosphate an Caele aminoacis to hypo glossal neurons of raits some raioactive macromolecules that are transporte along the axons cross the neuromuscular unction an are incorporate into the muscle cells (13). A later stuy showe that lael e nerve proteins reach the muscle at four ifferent time perios with peaks at approximately 1 12 22 an 34 ays after incorporation of Heucine y the neurons (12). he experiments reporte here were esigne to etermine whether ifferent proteins are axonally conveye in each time perio an whether there is selectivity in the nervetomuscle transfer. he raioactive proteins transporte in the four perios were compare with respect to relative specific activities of solule an insol ule proteins an relative specific ac 'upported by NIH Gran No N-0919 from the National Insittes of Neroogical Diseases ad roke and by a grant from the American Oseopathic ssiaion We are graefu to Mr Rober N May for prepaaion of the figres
tivities of solule fractions separate y acrylamie gel electrophoresis Methods
wentythree New Zealan white raits of either sex weighing 1.82.4 kg were use. or the intraventricular laeling of hypoglossal neurons 250 Ci of 45Heucine (AmershamSearle specific activity 3858 Cim) were eposite on two mall pieces of filter paper. he fourth ventricle was then expose an each paper place on the area over the left hypoglossa nucleus for 20 min. he surgical tech niques were those previously e scrie (12) except that posterior choroiectomy was omitte. rga prodrs.
Tss spmns he aits were
kille at each of the four peak perios following the aministration of tritiate leucine 1 12 22 an 34 ays (5 raits each) an also at 43 ays (3 raits). he following specimens were taken (a) mda (left half of he floor of ventricle IV) () ft hypogossa nrv (extracranial por tion ivie into a proximal an a istal segment) (c) ft styogosss ms (which is innervate y the hypoglossal nerve) an () ontro mss (poole stylohyoi an mylohyoi muscles which are innervate y the facial an trigeminal nerves respectively an which were use to etermine the incorporation of looorne tritiate leucine y the styloglossus muscle (12). Because of their small size nerve an meulla specimens were supplemente with sciatic nerve an meulla from unop erate animals (see later). Etraton prodrs. All tissues
an solutions were kept at 02 C Each specimen was first homogenize in saline solution (.25 1 per mg fresh tissue) an centrifuge at 1 3 800 g for 1 hr. Each precipitate was then twice rehomogenize an washe with 5 ml saline containing 2.5 mg
serum alumin an 2.5 mg leucine as carriers. After an extraction with organic solvents one as previously escrie (12) it was prepare for liqui scintillation counting. he precipitate material will e referre to as the nsob protn fraton he supernatant from the irst centrifugation was separate into two measure portions. One part was poole with aliquots representing the same fractional volumes of the secon an thir supernatants. After the aition of 2.5 mg serum alumin it was extracte with 10 trichloroacetic aci an organic solvents (1 2). he precipitate ientifie as the sob protn fraton, was also prepare for raioassay. Etrophort sparaton of so b protns rom the remaining part
of the first supernatant two to four 0.125 ml aliquots were fractionated y acrylamie gel isc electrophoresis at pH 8.3 an 7.5 concentration in 15 cm long tues (Canalco nc.). Each gel was staine with Coomassie lue washe with istille water an cut into 3440 segments as shown in ig. 2 with loops of human hair. he equivalent segments from the two to four gels otaine for each tissue specimen were poole weighe an prepare for liqui scintillation counting as escrie in the net section. Experience showe that cutting the gels accoring to the an patterns rather than in slices o f uniform thickness gave a much more accurate an reproucile approach to the stuy of raioactivity istriution among the various fractions. In ifferent atches of gels the position of the ans relative to the trackingye an an to the cathoe en of the gel varie slightly whereas all wellefine raioactivity peaks appeare at precisely the same staine ans in all animals. It is possile that a given staine segment may inclue several proteins iffering in concentration staining properties an incorporation of raioactivity. Nevertheless the sites of concentration of proteinincorporate raioactivity were more than sufficiently iscrete reproucile an referale to staine ans to make possile reliale comparisons of raioactivity istriution from animal to animal an perio to perio
00 0000 00 00 U 00 Z 00
D
.
00
(A (DA)
d d d d
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i I. A erae pecic actii in tera tion per minute per millram reh tiue o the inoluble (ark bar an oluble protein (clear bar. Data were aerae rom ie (a -34) or three animal (a 43). The or inate cale are much lower or mucle than or meulla an ne re becaue the actiit ha been ilute in the relatiel lare mucle ma
M
MU B
H
K
+
i Electrophoretic pae o meulla ME nere (N an mucle (MU. The bracket an number inicate the wa the el were lice The lenth o the ement were obtaine rom the weiht o the el lice an aerae or all 23 animal The ement were nu mbere rom the buer ront to war the cathoe. Equialen t num ber o not repreent equialent protein ban in the ierent tiu The letter eination, A -K are ex plaine in the leen or i 3
1
For all specmens radioactvty was determined in a Packard 3375 Liquid Scintllaton Spectrometer for 50 mn at 70 gan and 50-1000 wndow settngs The soluble and insoluble proten frac tons were dgested n 0. 1 5 ml water and 1 .5 ml NCS AmershamSearle frst for 6 hr at room temperature then for 90 n at 50 C. Before the fnal 30 mn of dgeston 0 1 ml 30% hydrogen peroxde was added to each val to prevent color quench ng A fter 3 hr at room temperature the dgests were dssolved n 15 ml touenebased scin t ator Spectra fluor Amersham Seare contanng 0. ml Triton X 1 00 After 3 addtonal hr the vals were placed n the scntiaton spec rometer and counted after tempera ture equlbration. The equvaent gel slces from each tsue were placed in scintl ation vas and dred t 90 C for hr. After the addtion of 0. 1 mg serum albumin to each val the samples were digested n 0.4 m l 30% hydrogen peroxide frst at 60 C for 16 hr and after the add tion of 1 5 ml NCS at 50 C for 90 mi n Snce the hydrogen peroxide and NCS treatments yeld volatle rado actve materials al ncubations were carried out n hermeticay sealed vals Dgests were also cooled to 5 C before openng the vals for ad dton of the scintllator. The dgests were then lef at room temperature for 3 hr and a fter cooling to 1 5 C dissolved n 0 ml scntllaton cocktal and 04 ml TrtonX100 Before countng the vals contanng the dgests were brefly opened three tmes under a fume hood at ntervals of 3 hr n order to elmnate some volatle uenchng agent probably oxygen The recovery of radoactivty was determned by processng nonradio actve specmens to whch a known amount of Hleucine had been added Recovery was 99% for the soluble and nsouble protens and 96% for the gels. The countng eff cency as determned by internal standardzaton was 43% for aU specmens The specifc actvtes of total proten extracted from stylo glossus muscles in ths study as n the prevous one 1 were relatvely ow as compared wh those of nerve and medulla. Nevertheless the threefold larger dose of Hleucne used n ths study rased the levels substantally
d
and good relablity was obtaned n those anmals kiled between 1 and 34 days after Hleucne admnstra tion The lowest counts obtaned n an anmal for an dentfable rado actvty peak peak G at day 34 Fg 3D see results were 69.7 countsmn above a background of 90 .40
=
lul f f gl g In each anmal the
specfc actvty dsntegratons per mn per mg fres tssue of each gel segment was calculated by the formula:
x (m a upnaan) cun/n) (m s s x b s
dpm
where .4 s a correcton factor for the countng effciency and for the activty ost whle processng the sam pe; 05 ml s the volume of tssue extract used for each gel and the total volume of supernatant was ob taned by addng the ml of salne n whch the sample was homogenzed and the calculated water content of the specmen ( I ) For plottng each gel was divded nto 40 arbtrary length unts. See Fgs. and 3. The average ength of the correspondngly numbered ge segments of each tssue obaned from te fve anmals three at 43 days klled at a gven postsurgcal nterval was calculated as follows
ege g ge = L W L
s the weght of the pooed
equvalent gel segments n each scntllaton val from each anmal dvded by the number of gels pooled s the number of anmas klled at the selected postsurgcal tme and n s the total number of segments nto ch the gel was dvded muscle 38 nerve 34 medulla 40 See Fg Although the electrophoretc pro cedure used concentrated certan pro tens nto wel defned bands t dd not provide for a comple te separaton of all the radoactve protens Some tmes a dsnctly hgh level of rado actvty located at a given band was accompaned by lower but sgnf cant levels of actvty in the negh boring gel segments or radoactvty was spread over extended lghtly Axona transport and trophc studes
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Fig Sc actiit dstribtion along the electrophoretic gels of medla and nere specimens. The ales indicated tyogou-onto present the amont of neredeliered radioactiit in the stloglosss mscle The abscissae represent the segments into which the gels were ct. The height the bars represents the specic actiit (disintegrations per minte per milgramsfresh te per length ofthe gel segment (see text) Data were aeraged from e (das or the animals (da Letters AK represent eqialent fractions with high spc actiities in the dferent tes
'] J 'i
stained ge potions The adioac tivity not concentated into bands appeaed as a sot of backgound" ove which the discete eaks po ected that made the adioactivity of each gel segment dependent on its ength Thus fo a bette visualiza tion of the adioactivity distibution in the ges the esults wee potted as histogams (see Figs. 3 and 4 The abscissae epesent the gel segments (intevas between numbeed ines the height of each ba epesents the aveage adioactivity concentation in each gel segment and the aea in dicates the aveage adioactivity con tained in the segment pe milligam of tissue The height of each ba was calcuated with the fomua
DA '
Fig Specic actiit dtribtion along the electrophoretic gels of the control mscl. Acissae and ordinates are the same as in Fig. .
dpmmg averg dpm/mg E E W W W avrae egh f sgm m W dpmmg -
C In ode to detemine whethe the sciatic neve is a suitabe caie" to be mixed with the hypoglossal neve specimens the band distibutions in eectophoetic gels of these neves wee compaed The same bands wee pesent in both neves and the pattens did not vay signficantly with the distance fom the cental nevous system Also to examine whethe in this study as in the pevious one (12 the stylohyoid and myohyoid musces wee eiabe contols fo the incopoation of
0/
bloodbone Hleucine into the styoglossus musce five additional shamopeated abbits wee inected intapeitoneally with 250 i HL leucine In each anima the styogossus and conto musces behaved similaly with espect to adioactive uptake by soluble and inslube po teins and exhibited the same band pattens and adioactivity distibution in the eectophoetic gels. Reult
Sube and nube ten Figue 1 shows the specic activities (expessed as disintegations pe min pe mg of fesh tissue dpmmg of the insolube and soube poteins of the medula and the two segments of the hypoglossal neve. The data fo the styogossus musce howeve ae shown as dfeene in specific ac tivity between the styloglossus and contol musce Since all the musces used in this expeiment incopoate the same amount of boodbone adioactivity into thei potein fac tions these diffeences epesent poteinincopoated adioactivity that has eached the styogossus muscle though the hypogossal neve A simila teatment of data was not found necessay fo the neve se ments since neve adioactivity afte intapeitonea inections of Heucine was negigible when com paed to intaventicula vaues (12 We can thus assume that the activity found in the neve was tanspoted axonay fom the neve cel body
The adioativity of both fations fom the medua was highest at day afte whih it deined with time In the neve both soube and insoube poteins had a pea of ativity at day 12 The ativity of the soube poteins was the same in t he poima and dista segments at day 1 , afte whih it was sighty highe in the dista potion Insoube potein adioativity was fist highe in the poima segment a evesa of this poimodista gadient had oued by day 34 when the ativities had beome vey ow Amost a of the nevetanspoted adioativity that eahed the styogossus muse in the fist day was in the insoube potein fation The highest speifi ativities wee found at day 12 fo the insoube poteins and at day 22 fo the soube poteins
Elerophore fraon Eetophoeti fationation pemitted the identifiation of 3440 ptein bands in eah speimen (Fig 2. As epained in ethods" the eetophoeti pattens wee the same fo the styogossus and onto muses and fo the poima and dista segments of the hypogossa neve of eah anima Howeve vaiations between the same tissues of diffeent animas did ou Bands that wee soid in some animas appeaed spit in othes and bands that wee day stained in some wee faint in othes Nevetheess it was aways possibe to math the euivaent poteins in the diffeent animas on the basis of band onguation and position in the ges Using the same iteia it was aso possibe to estabish euivaene among the potein bands in the diffeent tissues The distibution of adioativity in the eetophoeti ges of the medu a poima and dista segments of the hypogossa neve and of the nevetanspoted soube poteins in the styogossus muse (epesented by the diffeenes in vaues between the styogossus and onto muses ae shown in Fig 3. Between 1 and 43 days the eetophoetogams ehibited distint peas of ativity whih ae identied in the tet by the ettes AK The heights of a of the peas identied by ettes diffeed signifianty fom those of the neigh boing segments (p < 0.05). The dis tibution of adioativity in the ges
vaied with time and was diffet fom the medua neve and muse, athough peas of ativity oud be oated ove euivaent potein bands At eah time peiod, the eetophoeti distibutions of ativity in the poima and dista potions of the hypogossa neve wee neay aie At day most of the medua and neve adioativity appeaed in a singe dispesed hi" fomed by potein whih is not onentated into a band pobaby some basi potein The medua had sevea additiona peas o ativity of whih one oated at the buffe font (A and one situated at the athode end (K appeaed at equivaent positions in the neve ges As shown in Fig 1 , no signifiant amount of neuonay synthesized soube potein had yet eahed the styogossus muse When howeve, the speimens wee homogenized in saine ontaining 05 TitonX the hi" did appea in the muse ges (unpubished esuts At day 12 the hypogossa neve had in addition to the high ativities at the buffe font (A and athode end (K thee age peas (C H and J and five sma peaks (B E F G and 1. Some of them (E G and H wee paaeed by high ativities ove the oesponding medua segments; othes (B and J had been peeded by euivaent medua peas at day 1 Of the highativity neve segments ony C was neithe peeded no aom panied by high ativity in the medua Neve peaks F and I saey etended beyond the hi," and the equivaent peas of the medua may have been ompetey hidden by the ativity of the adaent segments At da 1 2, s ome nevetanspoted soube adioativity was found in the styogossus muse It was mainy onentated at peas A, G H and K and ove a hi" whih etended fom segments 3 1 35 Euivaent peas oud be oated in the medua and neve Aso a simia hi" was pesent at euivaent positions in the neve and medua patiay obsued by pea J Between days 1 2 and 22 the adioaity of the neve ges deeased by moe than 80% (note odinate saes but with the eeption of B, a peaks pesisted In the same inteva the nevetanspoted adio
ativity to the styogossus muse doubed and peaks C and J appeaed At day 4 the neve ativity was ow and most of the peas wee no onge disenibe The styogossus muse showed the same peaks of a onay tanspoted adioativity as at day 22. By day 4 ony taes of adioativity emained in the ges Not a of the medua peaks ap peaed in the neve Pea D fo eampe was aways onfined to the medua Simiay neve peas E and F did not appe in the styogossus muse Convesey neve pea C did not have an euivaent in the medua whie a muse peas had euivaents in the neve Figue 4 shows the speifi ativity distibution in the onto muse ges Ativity peas, most of them ess than 1 dpm/mg, appeaed mainy at those segments that ontained thik and daky stained potein bands Thee ativity peaks wee oated at appaenty the same positions as intaventiua peks A and K No signifiant ativity onentations wee found in the segments ontaining peas C H and J indiating that these adioative poteins in the styogossus muse ae pobaby not synthesized in the muse but ae suppied by the neve oeove by modifying eetophoeti poedues in sevea ways (pH 9 and 8.6 ge onentations of 45 to 15% it was possibe to show that segments A G and K onsist of potein mitues indiating that the adioative omponents at these sites may aso be entiey nevedeiveed Dcuon
These epeiments taing the tanspot of vaious adioative potein fations fom hypogossa neuons though aons to the styogossus muse show that diffeent mitues of poteins eah the muse in the fou peiods peviousy deineated (1 2 and offe an epanation fo thei diffeent aiva times Perod 1 peak a day 1 The pedominane of adioativity in the insoube fation of the muse at this time an be attibuted to the fast aona fow whih aies mainy patiuate eements ( 0, 1 1 14 16 17. Perod peak a day This aiva time appeas to be onuent with the peiod of highest ativity Aona tanspot and tohi studies
found fo the neve potein Inouble potein adioactivity caied by a owe aonal ow pedominate but ome of the oube neuona potein ao each the muce duing thi peiod Prod 3 pk t dy Thi peak conit mainy of oube potein which have been deayed in thei paage fom nve to muce Prod pk t dy 3 Thi peiod pobaby epeent the aival at the mucle of inoube potein caied in a eativey ow aona team and may be eated to the evea of the poimodita gadient of inoublepotein adioactivity aong the neve in the 2234 day in teva Thi wave of inoubepotein adioactivity i upeimpoed on the continued high activity of the ouble faction which had eached the muce in the peceding peiod The data indicate ao that tanfe of adioactive potein between adacent neve egmen i quaitatively diffeent fom that between the dit egment of the neve and the tyogou muce In the poima and dit neve egment the eectophoeticay epaated adioactivity peak appeaed and diappeaed imutaneouy indicating that tanfe of thee potein between the adacent neve egment i noneective and that it poceed at ate ufficient to achieve neay equa peciic activitie within the 112 day inteval tudied In contat clea dicontinuitie appeaed between neve and tyogou muce a efected in eative activitie of oube and inoube potein and in eectophoetic ditibution of adioactivity among the ouble faction Some adioactive potein enteed the muce in the ame inteva in which they appeaed in the neve (A G H and K; alo the 31 3 egment hi" peent at day 12) othe wee deayed in tanfe to muce (C and J and ti othe wee not found in the muce at al (E and F It i poible that thoe aona potein which coud not be ocated in the mucle gel had in fact eached the mucle but had then undegone eithe poteoyi o tuctual alteation Hweve in ode to account fo the ecluion of highy adioactive potein uch a E and F which have a ong hafife in the peikayon and aon poteoyi at the muce would
have to be ditinctivey apid and highy elective Ateatn in the tuctue of at eat one neuona potein doe appaenty occu in the aon Pote in C which appeaed in neve but not in medula may have been the eut of pitting ecombination o tuctual ateation of ome medula potein Since a the adioactive peak found in the tyogou muce ge wee ao peent in the neve it eem that moecua ateation wee not common and ae not eponibe fo the abence of peak E and F in the muce Thee eut do not eiminate the poibiity that the adioactive po tein both oluble and inolube found in the tylogou mucle wee confined to the neve temina. Peviou autoadiogaphic evidence of tanfe of aona potein to muce aound day 12 (13) ugget that inolube potein may be incuded in that tanfe Howeve thi emain to be etabihed Nevethele on the bai of unimpeded nonelective movement of oube potein aong the neve we houd epect a imia tanfe fom aon to temina foowed by accumuation of ome potein and degadation of othe It i howeve difficult to epain on the bai of thi mode why the entance into the neve temina of ome ouble potein like C and J houd be blocked at day 12 and o f E and F at day 22 It i impobabe that thi dicontinuity epeent the font of poimoditally advancing wave" of adioactive olube potein ince uch wave font" neve appeaed between the two neve egment It woud alo be difficult to epan the ecuion of potein E and F fom the neve temina f active ocalized poteolyi wee combined with unimpeded tanpot along the aon it woud eult in the diappeaance of thee highactivity faction fom the neve within a 1 1 2 day peiod intead of thei peitence fom day 1 2 unti at leat day 34 The equence of event decibed i moe conitent with the hypothei that ome aona potein have been eectively tanfeed to mucle Thi i uppoted by the autoadiogaphic tudie caied out peviouy (13) which howed neuomucua tanfe of potein in the peiod which in
lude day 12 It i impobable that uch tanfe woud be imited to potein caied only in the 12day wave Thi hypothei i alo in ageement with moe ecent evidence indicating tanynaptic tanfe of potein ( 6, 9, 1) It mut be noted howeve that othe autoadiogaphic tudie on the aona tanpot did not evea movement of potein beyond the neve temina (2 3 1) and that the ocalization of the neuonaly yntheized abeed potein inide the tylogou muce wi have to be caified by fute tudie A an epanation of the peence of abeled potein in the potynaptic eement it ha been popoed that aona potein may be degaded to amino acid which ae then tanfeed to othe tiue and ued fo oca potein ynthei (13 1) The data peented in thi tudy do not uppot thi hypothei Wee thi the cae the aonay tanpoted adioactivity in the tyogou mucle houd yied the ame eectophoetic peak a found fo the conto muce On the contay mot of the potein which ehibited eativey high adioactivity in the conto muce emained conpicuouy unabeed by the aona ow Conveely a dicued in connection with Fig 4 the mot highy adioactive potein in the tyogou muce ae appaenty neveuppied and not autochthonouy yntheized We beieve that the nding e poted hee eveaed a tanpot of changing mitue of neuonay yntheized potein at vaiou potabeing peiod They alo uppot the hypothei peviouy peented and dicued (12 13) that ome of thee potein ae eectivey tanfeed to mucle whee they mediate neuotophic infuence Thee finding alo emphaize the need fo futhe eeach in thi impotant but pooly undetood aea eerence Am PL , DS Dme 1972 Am e d og wer oe, pp 392-98 I oog D ook," Vo eero of Ame Soee for Experme oog ehe Mr 2 ro W W M ow P Ke 197 Obeo o he rpor of roe bee roe he em of he hk ran Res. 5: 77·105 o M oeh, P Mrko, M Per, Sr J. Shobh 1972 orbo o f ·
opasmc raspor o syapc srucure and uc os. In J Neu 7787 4 Ecces J 1963 Ierraonshp bewn he erve ad musce ce pp 1928. In The Eec o ad Dsuse on Neuromuscuar Funcon E Guma ad P H [Eds Pubshg House o he zechosova Academy o Scece Prague 5 Gobus A HD Lux P Schuber ad P Kaups 971 abeg o neaby neurons oowng he raceuar oophoress o H gyce Aa R 325 6 Grase B 1 971 Traseurona raser o radacvy he cera ervous sysem. Se 177-179 7 Guh L 1968 Trophc uecs o nere o musce Phys Re 5687 8 Gum E ad P Hn 1962 Deervaon sudes research o neurorophc reaohps pp 356 In The Deevaed Musce" E Gumann [Ed Pubshng House o he zehosovak Academy o Sceces Prue. 9 Hendrso A 1972 Eecron mcrocopc dsbuo o opasmc raspor J mp Neul 381397 10 Karso J-O ad J. Ssrad 1 972 Sy hess mgraon ad urnover o proes n rena gangon ces J Neuhem 749767 I I Kdwa AM ad S Ohs. 99. ompoens o as and sow phases o opasmc ow J Neuhem 1 10511 12 12 Korr I M ad G Appeauer 1974 The me coue o axona raspo o eurona proes o muc Ep Nel 452-463 13 Ko IM PN Wkso ad FW hor nock 1967 Axona devery o neupamc com poes o muce ces Scene 342345 14 McEwen BS and B Grasen 1968 Fas and sow compoes xona raspor o poe J e. B 494508 I Neae J H EA Neae ad BW Agrao 1 92 adoauograpy o he opc ecum o he godsh aer racuar neco o H proe Sen 7410 16 Sjsrad J 1970 Fas ad sow compoes o axopasmc raspor he hypogosa ad vagus erves o he rabb. Ban Re 461467 17 Sjsrad J. , ad JO Karssn 1969 Axo· pamc ranspr he opc erve and rac o he rabb: a bchemca ad radoauographc sudy J Nechem 833844
U
s
eprned by permsson rom Expermena Nuroogy 46 132146 1975.
Abstract: Eectrophoetc charactezaton of neuona basc potens n skeeta musce* 1976 APPTAR nd KORR In 96 Ko, Wilkinson and Cho nock (Scinc 55 342 found that potins synthsizd in th pikaya of moto nuons a axonally tans potd and incopoatd into th muscl clls thy innat Futh studis ha ld to th lctophotic chaactization of som nto muscl dlid acid potins that a axonally tanspotd to skltal muscls 3Hysin was administd to th 4th nticl of abbits Th animals w sacificd 0 days folowing th administation of th pcuso Solubl xtacts fom th hypoglossal n and styloglossus muscl w factionatd by disclctophosis at pH42 and 5 gl concntation In th hypoglossal n gls total adioactivity was highst at day 12 aft th 3Hlysin administation It was concntatd mainly at th anod ic nd and in on staind band. Fiv oth abld potins also appad in th gls Th ndlid adio actiity in th styloglossus muscl gls was highst at day 34 It was highly concntatd at th anodic nd of th gls and in on potin band, and lss concntatd in 4 oth potins Th lctophotic mobilitis of th adioacti potins in th n gls and of quialnt adioacti potins in th muscl gls w th sam N basic potins sm to tal without obstacl along th axons to th n tminas, and fom th thy slowly pntat th muscl Th is no chang in th lcto photic mobility of th potins du ing this pocss Suppred b h Ame Oteopahi Aaon nd by NI H Gra #NS·0791 eprned by pmisin rom Neurcience Abrc 96
2 Par 1
Axonal tanspot and tophic studis
Ft t g k * (1977) GUSTAVO APPETAUER and RVN M. KORR
Skeletal musles annot survive without motor innervation This neural inuene has not yet been satisfatorily explaine in terms of neurotransmitter release or ontrol of musle ativity by the nerve (11) The possibility has been raise that the nerve releases into the musle some substanes that o not at as neurotransmittrs, but whih influ ene the anaboli proesses in the musle ells (, 10) This theory reeive support from the autoraio graphi stuy by Korr l (1 5), who showe that after labeling the fourth ventrile of rabbits with P phosphate an Cabele amino ais labele maromoleules migrate along the hypoglossal axons an appeare in the tongue musles Subsequent stuies reveale that axonally transporte proteins arrive at the styloglossus musle at four time intervals, with peaks at approximate ly 1, 12, 22, an 34 ays after their synthesis in the hypoglossal nuleus (14) An analysis of the soluble pro teins by is eletrophoresis H 83 migration towar the anoe) le to the harateriation of a group of proteins responsible for the peak foun at Day 22 (2) n the present stuy, by using a ifferent eletro phoreti tehnique p H 4 2 migration towar the athoe) we were able to resolve other axonal proteins that reah the musle, inluing some that are responsible for the peak foun at Day 34, an to analye their pattern of axonal migration an arrival at the musle ds
Thirty New Zealan white rabbits weighing 1 to 21 kg were use The surgial an sampling proeures 'Suppored by Gran NS-079 fom h Naional In tue of Neuroogca Dases ad Sroke Naona Iniue of Heah and by h Amerian Oeoph socaon We apprea he sku ehna asiae of Mr Davd Parin M Deboah Sp ad Mis Deborah Bower We are ao afu o Mr Rober Ken or he ompur proeg o h daa
were those use before (2, 14) ner Nembutal anesthesia, the hypoglossal nuleus of eah animal was labele with 250 Ci H lysine HC (Amersham/Searle, 818 Cimmol) The speimens, taken 1 to 70 ays later, onsiste of the lf hpoglol (ivie into three segments), the lf loglou ucl whih it innervates, an cool ucl (the poole stylohyoi an mylohyoi) use to measure the inorporation of blooborne raioativity into the styloglossus musle Beause in this type of stuy of nervetomusle transfer it is essential to reue the amount of nerve tissue in the musle speimens to a minimum all musle regions reeiving nerve branhes were ut away uner a isseting mirosope Cholinesterase staining showe that few en plates remaine in the speimens The speimens were first homogenie at 0 to 2°C in aetate buffer H 57 an 008 M, ontaining 007 TMD N N tetramethylethylene iamine) 375 ml bufferg tissue) an entrifuge 20 min at 13800 The supernatant whih will be referre to as "soluble extrat was then analye eletrophoretially The preipitate was twie rehomogenie an washe with 1 5 ml buffer rehomogenie in buffer ontaining 0 5% Triton X (375 mlg tissue), an left 1 h at room temperature The soluble material, whih will be referre to as "Triton X extrat was separate by entrifugation an also analye eletrophoretially The eletrophoreti analyses were arrie out in two to six 015ml portions of eah soluble an Triton X extrat by the metho of Reisfel l p H 42 an 15% gels, runs towar the athoe (18)], with the sepating an staking loaing gels ontaining 01 an 025% Triton X respetively After the run, the gels were e an staine with Coomassie brilliant blue 250
(Serva) ut into segments and assaye for raioativity as esribe previously (2) or aa proessing the forulas use previously (2) were aapte to the new extration an eletropho reti proeures as follows Scic ivity (dpm/mg) 2,35 ml ota surnatant) (cunmin) 0.15 m frsh tie numbr o ) er ent o gment axi in F 4) - .55 I wI I er ctivit onentrtion ( in Fi 4) W 755 (icw
X M X _
where 2.35 is the ounting effiieny orretion fator 015 is the extrat volume in eah eletrophoreti gel n is a referene gel segment ontaining a protein ban with equal mobility in all tissues an extrats (protein in ig see below); is the number of animals kille at eah interval; an W is the weight of eah gel segment obtaine from eah animal The number 2755 makes the average istane between the anoi en of the gels an the fastestoving protein equal to 4000 so that the graphs are omparable to those publishe previously (2) suls
lcophoc po of po The staine proein patterns of
the eletrophoreti gels are shown in ig 1 ah tissue an extrat ha its peuliar pattern so that in orer to math their equivalent proteins it was neessary to run eletrophoresis with samples mixe in grae amounts The letters A through H iniate some proteins with equivalent eletrophoreti mobilities thus etermine (see below) doc olubl po The raioativity istributions in the eletrophoreti gels of the nerve soluble proteins an of the nervetransporte soluble proteins in the styloglossus musle whih is represente by the ifferene in values between the stylo glossus an ontrol musles (2 1 are shown in ig 2 Several proteins ha prominently high ativities that appeare as peaks in the histograms Peaks appearing in the musle gels an their equivalents in the nerve gels are labele A through H etters are shown in igs 2, 4 only if the ativity onentrations iffere signifiantly S 005) between the peaks an the
3
C
HD
E
F G
Mn
NERVE SOLULE
l l l ll l l
C HD E
F G
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MUSCLE SOLULE
NERVE TRTOX C H D
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Fi I Eectrpretic ptterns f te slble nd ritn etrcts frm nerve n d mscle. e brcets nd nmbers indicte te wy te els were sliced e lents f te sements re te veres frm te tree nerve specimens nd frm te stylsss nd cnt rl mscle specimens f te 3 nimls e sements re nmberedfrm te nde t wrd te ct de; eqivlent n mbers d nt represent eqivlent prtein bnds in te different electrpretic ptterns. e letters tr H sw t e psitin f nere-deivered prteins t t e stylsss mscle
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negbong egment. n te ypogoa neve ge evea aoactvty peak appeae at Day I , an ome emane vbe at Day 70 two of tem A and D qute pomnenty. By Day 1 ao actvty wa gty ge n te ta tan n te poma neve eg ment. dffeence nceaed at onge ntva but became conpc uou ony by Day 34 wen te actv te a eceae to about onet of te Day1 vaue Mot peak foun n te neve ge wee ao entfabe by Day n te tyogou muce ge. A n te neve peak A and D wee te mot pomnent n te muce Te coue of appeaance of adoactvty vaed fo ffeent muce poten Peak H wa vbe ony at Day an te e manng peak wee entfabe be tween Day an 70. n contat to te tyogou muce te pecfc actvte of te conto muce not own wee vey ow and ony two gnfcant peak at te poton of A an H wee foun. To eamne te aona fow an n copoaton o ndvdua poten n t t e tyogou muce te pecf c actte of te ge egment con tanng te mot pomnent peak A an D toug G wee aveaged an potte agant tme makng te aveage ay1 vaue of te tee neve egment equa to 100 to enae compaon etween facton wt ffeent actvte g. 3. n a tee neve egment te aoactv ty o mot of te oue poten n ceaed apy fom Day I to 1 eceae to 5 by Day an ten eceaed vey owy teeafte ecepton wee H an poten at egment 36. n te muce poten A an D tog E ae te Fi. . Br rps depictin specific ctivity distribtin n te eectrpretic es f sbe prteins extrcted frm nerve ndfrm msce t vris intervls fter inectin f H lysine e ves indicted s stysss cntr (dference between stylsss nd cnt represent te mnt f nerve-deivered rdictivity in te stylsss mscle; teir pe vles nd te eqivlen t pes in te nerve re indicted s tr H e bscisse represent te sement s int wic te es were ct e eit f te brs represents te specific ctivi ty (dpmminm fres tisse per ent f te el (see tt) Dt were vered frm five (Dys I nd 34), fr (Dys 1 45 nd 56) r tree nimls (Dy 7
Aona tanpot and topc tue
highest ativity at Day 34 ration behave simiarly although its Day22 an Day34 vaues i not iffer at the 005 evel of signifiane The ativity of fration G, however was areay near maximum by ay 12 When plotting the ratios between the spei ativity of G an the other proteins as obtaine from eah anima (ig 3 there was a sharp an signifiant erease in values between Days 12 an 34 iniating an earier appearane an possiby a shorter ifetim of raioativity in musle for G than for A through
B
Radoatty n Trton X Etrats
The results obtaine for the Triton X extrats are ilustrate in ig 4 The speifi ativities were ower than those in the soluble extrats Two if ferent groups of raioative proteins were foun in the hypoglossa nerve One of them was present at the ista part of the nerve at Day 12 an on siste of ve ativity peaks four of them equivaent to D through G Th other group ontaine seven peaks (one with the eetrophoreti mobiity of D whih appeare in the proximal nerve segment at Day 12 an move sowy in the ista iretion reahing the en f the nerve by Day 45 The amount of nervetransporte raioa tivity in the Triton Xsoluble fration of the stylogossus musle was at all times ow an no ear peaks ou be iserne in the gels Discussion
ona ow of protns Somatoax-
onal transfer an axona flow an o ur at various rates Both proesses an take pae rapily giving the assi piture of the "fast ax oplasmi ow (1 whih is prob aby responsible for the raioativity peaks A an H in the styoglossus muse at Day 1 Other soluble pro teins (peaks A through G) foowe a pattern esribe previousy (2 slow penetration into the nerve as re veae by their highest ativity at Day 12 followe by a fast proximoistal ow as reveale by their pattern of inrease an then erease raioa tivity whih took pae simutaneously in the three nerve segments Most proteins in the Triton X extrat move proximoistaly at 1 to 15 mm per ay aoring to what has been alle slow axoplasmi flow (1) t is not possible to tell whether
the other raioative proteins in the Triton X extrat foun in the ista nerve segment at Day 12 migrate as insouble omplexes or were boun to partiles oaly Nrvoms dvr The prox
imoista flow of proteins was either interrupte or interfere with to various egrees between the istal nerve segment an the styloglossus muse The anoemigrating "ai proteins stuie previously (2 either i not enter the muse or reahe their highest ativity in muse at Day 22 whereas most of the athoemi grating basi proteins examine in this stuy i penetrate the muse but foowe heterogeneous patterns
with at east three frations reahing a peak at Day 34 These resuts onfirm previous finings that two ifferent groups of neurona proteins penetrate the stylogossus muse by Days 22 an 34 after their synthesis (2 14 Beause soube proteins (other than fration H in this stuy showe ony minor ifferenes in their patterns of appearane an isappearane in the nerve these istint perios probably represent ifferent rates of nervetomusle transfer an ifferent ife times in the muse There was tte or no nerveto musle transfer of proteins in the Triton X fration Ater the arriva of most raioative proteins at the istal nerve segment between ays 34 an
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N ENEEEN 5 23-25 1 - 9 25-29 172 a F 23 31 33 313537 33
ocation of these proteins in the mus ce ces isoation of the proteins, an etermination of their function
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I Alvaez j and M Pschel 972 Transfer of material from efferent axon to enry epithelium in the goldfish vestibular sytem Brain Res 37: 26278 2 Appeltauer G and M Korr 97 Axonal delivery of sluble inluble and electrophoretic frac tins f neural proteins to mucle p. Neul
46 Caagrande VA
and JK Harting 97 Tranneuronal transfer of tritiated proline in the visual pathways f the tr hrw Tupa gi Bin 67-72 R. 4 Drger UC 974 Autoradigraphy of tritiated pline and fuco transpoed tranneuronally from eye t the visual cortex in pigmented and albino mice 284292 Brain R Dr B H Koenig and DiGiamber din 97 Axnal migration of protein and g1ycoproein t nve ending l Radiautographk anaysi of te renewal of prtin in neve endings of chicen ciliary ganglion after intracerebal inection of 'H lysine Bn Re 927 6 Globu A HD Lu P chubert and P Kaup 97 abelling of nearby neurns following the intracellular iontophoreis of H glycine Anat Re :2 7 Grafein B 97 Tranneurona transfer of radioactivity in the cntral nervous ystem Scene
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Fg Graph ofaege pe att atpk A and D through G pott agant tme Nere 2 and ! are the proma meda and dta nee egment tyogu ontro the d feren between the tyogu and ont au The aerage Day2 aue of the three nere egment were made equa to The et t the nere and mue ge egmen ontanng eah k Tuoer ofneredeered radoatty to tyog mue wa dferent forA through F andfor G. Th ndated by the to between the atty of G and the atty of the other egment n h anma ( tt hown n the ower rght
the musce activities ecrease an remaine at trace eves inicating excusion of these proteins from the musce The very ow activities foun in the musce etween Days an 3 cou e the effect of contamination or ining of soue pro teins to partices Tnssnpc nsfe of poens
Numerous stuies have reveae a transsynaptic transfer of protein oun raioactivity (, 3, , 8 2, 3, , 7, 92 However it has een recognize that proucts resut ing fom roteoysis at neve terminas ae utiize y surouning cels (, 2 an the finings may refect a transceuar transfer of sma moecues an not of protein This is not the case in at east some trans neurona (9 20 an nervetomusce transfers (2 n the present stuy if the raioactive proteins in the styo gossus musce were synthesize oca y the eectrophoretic istriution of nerveeivere raioactivity shou resut in the aeing of mainy proteins A an H as foun after the
systematic inection an in the con tro musces. Thus reutiization of nerve reakown proucts may ac count for the resuts foun at Day , ut not at Day 2 or ater The main prolem invove in these electrophoretic stuies is contamination of the musce specimens y nerve terminas which was sma, as inicate y the few en pates foun in styogossus musces is secte ike the specimens use in the experiments an y the fact that raioactive proteins that penetrate the entire ength of nerve examine were not foun in significant amounts in the stylogossus musce The possiiity that the neuronay synthesize proteins in the musce were coine to an extremey highy concentrate in the few re maining nerve terminas is improae in view of the autoraiographic stuies which ocate raioactivity insie the musce ces Because nervetomusce eivery is an important suect in view of its possie roe in trophic interactions experiments wi e continue towar fining the
2: /7779 8 Grafstein B and R aureno 97 Transport of radioactivity from eye t viual crtex in te moue Exp Neuro/ 39: 447 9 Guth 968 "Trophic influence of nerve 687 on muscle Phyil Rev 0 Gutmann E 96 Neurotrophic relation A n 7726 n, Rev Phil I Harris AJ 974 nductive function of the 20 nervou ystem A nn. Rev Phiol 2 Heacoc AM and BW Agranff 977 Reutilizatin of precuror following xonl tranpor of H proline labelled protein Brain Res
424 Hendricon, A 972 Electrn microscopic
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Cmp ditribution f aoplamic transpo Nerl : 897 4 Kor M and G Appelauer 974 The time curse of axonal transpor of neuronal prteins to mucle Exp Neurl. 446 Korr lM P Wilinsn and FW Cho 7 Axnal delivery o f neuroplmic cmpnent to muscle cell Sne : 424 6 ubnsa 97 On aoplamic flw In Rev Nebl 24296 7 Neale JH EA Neale and BW Agranff 972 Radiautgraphy f the optic tectum f the goldh after intraocular inection of (H) proline Scene 176: 40740 8 Reisfeld RA V ewis and DW Williams 962 Dic electrophoresis of bsic proteins and pp tide on polyacylamide gels Na (Lnd) :
2828 9 Schwab ME and H Thenen 976 Electrn micrcopic eidence for a tranynaptic migration of tetanus toxin in spinal crd motneuron: An autoradiographic and morphometric tdy Brain Res.
: 2227
chwab M and H Thoenen 977 eletive tran-ynaptic migration f teanus oxin after retrograde aonal transport in pripheral ympathetic nerve A comparion with nerve growth factor Brain Res 22 49474
Axona transport an trophic stuies
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Abstact: Axonal migation of some parcle-bound proteins in the hypoglossal nee and their faiure to enter the styloglosss muscle
rophoreic haaerization of nertomscl deliveed basc proein AOA 629 Dec 6
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n 967 Korr Wilkinson an Chornock foun that aer labelling the fourth ventricle of rabbits with 32P phosphate or 1C amino acis macromolecules migrate along the hypo glossal axons an appeare in the tongue muscles Stuies were then unertaken with the purpose of char acterizing nervetomuscle trans porte proteins an etermining their patterns of axonal flow an entry into the muscle first series o stuies was conucte on the axonal soluble proteins t was foun that elec trophoretically separate fractions ha their highest raoactivity in the nerve at ay 2 ater labellng o the hypoglossal neurons lso the activity appeare an ecrease si ultaneously in the proxial an istal potions o the neve inally ater variale tie intervals some o the raioactive proteins entered the styloglossus muscle in the tongue The present stuy revealed a co pletely iferent ynamics for a group o proteins that were etache ro the particulate eleents o the eulla nerve an muscle with TritonX an then nalyze by isc electrophoresis pH 2 an 15 per cent gel concentration) fter label ling the ventricle with 3H lysine raioactive proteins appeare in the most proximal portion of the nerve at ay 2 Susequently they migrate proximoistally at a rate of approximately 1 5 mm per ay an ap peare in the most istal portion of the nerve by ay p to ay 70 no significant levels of raioactivity were foun in equivalent electrophoretic ractions of the styloglossus muscle Reference Kor, M Wilkinson PN. and Chonock
W Axonal delivey of neuoplamic components
o musle cells Science 5532·5 Jn 6 2 Appelauer GSL. and Ko M Aonal deve of solble inoluble and elecrophoreic frac ions of neuona proeins o muscle Ep Neuol )326 Jan 5 3 Appelaue GS, and Ko IM Elec
xonal transport an trophic stuies
Ierpretaio of research fidigs
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or o th man prncpls n ostopathy appar to b: 1. Jonts and thr spports ar sbjct to anatomc and nctonal drangmnts. 2. Ths drangmnts hav dstant as wll as local cts 3 Thy ar rlatd, drctly or ndrctly, to othr pathologc nlncs. . Thy may b rcognzd, and thr local and dstant cts nncd avorably by manplaton Accptng th xstnc o jont drangmnts (ostopathc lsons, t s or prpos n ths papr to xamn not th mchancal and tologcal actors nvolvd, bt rathr th ndamntal bass or prncpls 2 and 3 and to a small xtnt prncpl , and to rport progrss n or ndrstandng thro. Th ostopathc lson has many aspcts whch ar partly rvald n th local and dstant cts rrrd to as prncpl 2. Incldd among ths ar: 1 Hprsthsa, spcally o th mscls and vrtbra 2. Hyprrrtablty, rlctd n altrd msclar actvty and n altrd stats o msclar contracton. 3 Changs n tss txtr o mscl, connctv tss, and skn Chags local crclaton and n th xchang btwn blood and tsss. S Altrd vscral and othr atonomc nctons. How ar ths cts prodcd? What ar th cntral actors rsponsbl or ths manstatons o strctral and postral abnormalts? What n th ntrnsc natr o th ostopathc lson s th bass or th prphral, palpabl, and clncal cts? What ndamntal changs tak plac as a rslt o ctv manplatv thrapy? ·Prnd bfr h Taching Grp n Opahi Prinipl, Dagni and Thrapi a h Fiy Fir Anna Cnvni h Aria Opahi Aciain hiag Jy 2 47 Th rarh n whih hi papr i bad wa ad pibl b gran r h Rarh Ci h Arian Opahi Aiain
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h dtald answrs to ths qstons ar, o cors, not yt avalabl, bt rlably ndcatd ar th gnral natr o th nal answr and th drcton n whch w mst procd n ordr to obtan t. Th rsarch pro gram o th Krksvll laborators s dsgnd to procr som o ths answrs throgh xploraton o th ntmat mchansms nvolvd n th ostopathc lson. W blv that th answrs ar obtanabl only throgh ndamntal, xprmntal rsarch and that th mrgng concpt o th lson and ts mplcatons wll hav consdrabl mpact on th practc o ostopathy In ths papr wll b prsntd som o or crrnt vws, som o th practcal mplcatons, and som spclatons. Th dtals o th xprmntal mthods and th raw data, avalabl n arlr pblcatons, wll not b prsntd, bt rathr th gnral xprmntal approach and th mmdat conclsons thrrom. rom ths, n trn, wll b drawn som gnralzatons.
Te eural basis of te osteopati lesio
Wthn th nrvos systm, n th phnomna o xctaton and nhbton o nrv clls, and n synaptc and myonral transmsson, l th answrs to som o th most mportant thortcal and practcal ostopathc problms Th xstnc o a nral bass or th lson has bn known, o cors, or a long tm. Th sgmntal rlaton o th ostopathc lson to ts somatc and vscral cts s xplanabl n no othr way Th actvty and condton o th tsss and organs ar drctl nncd, throgh xctto an nhbton, by th rnt nrvs hch mrg rom th cntral nrvos systm and whch condct mplss to ths tsss and organs (g. or xampl
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A. Antror horn clls (Motonrons msclar contracton B Latral horn clls (Sympathtc
C Latral horn clls vasomotor actvty D Latral horn clls swat gland scrton E. Latral horn clls plorcton Vra
. Latral horn clls smooth mscl contracton O Latral horn clls glandlar scrton H Latral horn clls vasomotor actvty Th actvty o ths organs and clls s drctly dtrmnd by th actvty o thr motor nrvs. Ths nrv actvty s masrd n trms o (a Th nmbr o mplss condctd by ach rnt nrv br and (b th nmbr o brs nvolvd. Ths, n th absnc o mplss n th corrspondng motor nrv, a mscl s compltl at rst Th amont o contracton (tnson prodcd or dgr o shortnng at any momnt s n proporton to th nmbr o motonrons whch ar condctng mplss at that momnt and th avrag nmbr o mplss pr scond whch ach s condctng to th mscl Wth crtan modcatons ths prncpl also appls to organs othr than mscl. Abnor malts n ths rgans ar prodcd by ovractvty or ndractvty o th rnt nrvs Seoary effets of eural imbalae
It s mportant to mphasz, howvr, that not all th cts o ovractvty or ndractvty o th rnt nrons ar drct and mmdat. Scondary cts otn assm prdomnat mportanc Ths, a mscls ovractvt, ovr a long prod o tm, may rslt n bross and mjor chmcal and mtabolc changs ndractvty, n atrophy. Ovractvty o sympathtc brs whch control artrols may rslt n local anoxma, nlammaton, al trd capllary prmablt, dma, tc Imbalanc n th rnt nrons controllng th smooth msclatr o th gastrontstnal tract may rslt n accdt or spasm wth sros cts on dgston and ab ntrprtaton o rsarch
sorpton and thror on th ntr body conomy. Ovractvty or undractvty o th nurons controllng glands may rsult n dsastrous shts n acdbas lud and lctrolyt balanc and n such condtons as pptc ulcrs I th gland happns to b on o th ndocrns th cts may b spcally srous and xtn sv W may or th prsnt purpos nclud th spnothalamc brs among th "rnt nurons Ths convy pan snsatons to th bran and whn ovractv produc not only physcal but also mportant psychologcal changs wth potntal ly srous and xtnsv chags n motor and vscral actvty Wth th crucal mportanc o th rnt nurons n mnd mor prcs ormulaton o th problm s possbl Thr ar thr man qustons What actors control th actvty th numbr o mpulss n th rnt nrv brs? 2 How dos structural abnormalty .. th ostopathc lson play upon ths actors to produc ovractvty or undractvty o ths brs and thror o th organs whch thy nnrvat? 3 How dos manpulatv thrapy play upon ths actors to rstor balanc and caus rgrsson o sgns and symptoms? Factos contollng effeent actvty
t us procd to th rst quston What actors has physologcal rsarch dmonstratd to b prmary n th control o actvty o th rnt nurons? Two man prncpls hav spcal prtnnc hr. A Th prncpl o rcprocty stats that through th ntwork o ntrnurons (also known as ntrnuncal nurons ntrcalatd nurons and connctor nurons) whch s stuatd wthn th cntral nrvous systm vry nuron potntally nluncs and s nluncd by almost vry othr nuron n th body. B Th prncpl o convrgnc stats that many nrv brs con vrg upon and synaps wth ach motonuron. Ths prsynaptc brs convy mpulss rom a larg varty o sourcs to th rnt nuron whch thror rprsnts a nal common path t us xamn how ths prncpls oprat wth rspct to th antror horn clls kpng n mnd
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Fig I -Diagrammatic representation o segmental re path ways among somatic and vceral Jerents and eJJerents Affs (Dorsal root neurons): AFrom spinous process, joints; B-From stretch and tension receptors proprioceptors) in muses and tendons CFrom touch preure and pain endings in skin From cera ABC-Somatic Jerents ffrs: b-motoneurons to skeletal muse csympathetic postgangionic neurons to blood essels o skin and muse to sweat glands and piomotor muscles o skin; dsympathetic postgangionic neurons to isceral smooth muse blood vessels and glands; SSpinothalamic bers nteeurons L - Lateral ho cells sympathetic preganglionic neurons) VG Vertebral ganglon C G Coateral ganglion
that thy probably oprat n a smlar ashon upon th othr rnt nurons (g . Each antror horn cll rcvs mpulss rom a larg numbr o sourcs through th prsynaptc brs whch convrg upon and synaps wth t All th dscndng tracts n th spnal cord convyng mpulss rom such sourcs as th crbral cortx rd nuclus mdulla oblongata th vstbular nucl cr bllum th pons supror collcul and othr hghr cntrs stablsh synaptc connctons wth th antror horn cll or th mdaton o voluntary moton qulbrum postural rlxs vsuospnal rlxs and othrs Th proprocptors strtch and tnson rcptors stuatd n th tndons and n th muscls thmslvs ar a stady and contnuous sourc o mpulss. Thy xrt thr nlunc drctly through th dorsal root brs nto whch thy dscharg thr mpulss or ndrcty through th hghr postural and qulbrum cntrs Arnt brs rom th vscra may also play an m portant rol n act vry arnt nrv br whthr t mdats touch pan prssur tmpratur sght or any othr sns modalty xrts nunc upon th nal common
path rprsntd b th motor nrvs. 2 Som o th convrgng brs xrt an xctatory nlunc othrs an nhbtory nlunc on th sam motonurons 3. Th actvty o th motonuron at any momnt that s th rquncy wth whch t dlvrs mpulss to th muscl brs rprsnts a dynamc balanc among all th xctatory and nhbtory nuncs bng xrtd by th many nurons whch convrg upon t. Th proprocptors and som o th hghr cntrs through thr stady tonc control act as govr nors or burs Th balanc how vr s shtd rom momnt to mo mnt n accordanc wth changs n th ntrnal and xtrnal nvronmnt and n rspons to volton As pr vously statd pathology rsults whn th balanc s shd too ar n on drcton or th othr (xctaton or nhbton) or too long. 4 Th collctv acton o th pr synaptc nrv brs upon th nal common path s urthr rlctd n th phnomna known to physolo gsts as rnorcmnt and acltaton. Bor th antror horn cll can dscharg mpulss nto th muscl brs t must tsl rcv xctatory mpulss smultanously rom a numbr o prsynaptc brs Statd
1
another way efore a given stimulus (eg , to the sin) produce a reflex muscular response, the anterior horn cell must rst e "warmed up or "ut on edge (facilitated) y implses from other (excitatory) fiers which synapse with it. The efferent neuron must already e in a state of suthreshold or suliminal excitation In other words, the various fiers converging upon a given group of motoneurons must cooperate (reinforce each other) in order to open the final common path leading to the muscle. In a whole nerve it has een demonstraed that a considerale portion of the nerve ers must e in a state of suliminal excitation efore any of them fire and cause scular contraction. This requirement serves as a margin of safety or an insulaon, preventing muscles from responding to every impulse which reaches the anterior horn cell. 6. When a signicant percentage of the anterior horn cells in a given segment of the spinal cord is maintained in a state of suliminal excitation, they rquire little additional stimulus to produce a reflex response. Tis is reflected in our frequent use of the terms on edge, jumpy, "tense, which imply motor aspects of psychic imalance In individuals thus characterized the anterior horn cells are maintained close to or at, threshold, even during rest. Th otopathic ion and th acto cotoing nt activity
The second question in our series of thr was " What is the relation of the osteopathic lesion to the aove factors? How do anatomic and functional derangements of the joints and their supports operate on these factors to produce seriously altered activity of the efferent neurons? Considerale light is eing thrown upon this prolem y the research in progress at Kirsville College of Ostpathy and Surgery under the directorship of Dr. J S. Denslow. The research has revealed close relations etween lesion mechanisms n certain wellestalished physiological principles The general exrimental approaches and the major conclusions from each are presented in the following section.
Expimnta
Rx thhol
Denslow, proceeding from the o servation made y all osteopathic physicians that pressure to the spinous processes of esioned segments produces much more contraction in the spinal extensor muscles, and with less pressure, than is true at nonlesioned segments, set out to determine in a precise, ojective manner how much pressure is re quired at each spinous process to elicit reflex contraction of the spinal extensor at the same level. In other words, his oject was to determine whether, and to what degree, esioned segments were distinguished from the normal y differences in reflex threshold. Muscular activity was determined electromyograpically, that is, y recording the electrical signs of muscular activity Measured pressure stimuli were applied to the spinous processes by means of a calirated pressure meter which simulated te action of the osteopathic thum At each segment gradualy increasing pressure stimuli were appied to the spinous process until just detectale activity in the erector spinae mass was otained; this represented the refex threshold for that segment. The reflex arc under investigation might e said to consist of these parts spinous process dorsal root fier, interneuron, anterior horn cell, and muscle fiers (See Fig. 2 disregarding segmental designations and intersegmenta connections.) This pioneer study upon a large numer of human sujects resulted in the demonstration that the reex thresholds in lesioned segments were much lower than in normal segments. The more severe the lesion, as determined y palpation, the lower the threshold he thresholds may e constant over periods of months. What is the asis for the owered reflex threshold of the lesioned segment? There were two ovious alternatives. (1) Th o pin t was reasonae to suppose that the pressure receptors and nerve endings in the tender spinous process were hypersensitive and that, per gram of pressure, they fired more impuses at th anterior horn cells than did the corresponding endngs in the normal spinous process. (2 Hypiitabl
motonuon It appeared equally reasonale to suppose that for some reason or other the anterior horn cells of the spinal extensor muscle in the lesioned segments were maintained at a higher level of excitaility. n order to decide which was the more liely alternative the following experimental approaches were undertaen. Intgmntal pa 0/ itation
A lead to the answer was given in experiments in which spread of excitation from segment to segment was examined in relation to their respective thresholds, to the distance etween them, and to other factors The experiments were conducted as follows (Fig. 2). The four thoracic segments, designated as 4, T6 8 and l, were seected for this series of experiments on 30 sujects Needle electrodes were inserted into the spinae erector mass 5 cm. to the left of the spinous process in each of the four segments, for the detection and recording of muscular activity. Pres sure stimui were applied to the spinous processes with the pressure meter. The minimum pressure stimui (threshold) required at each of the four spinous processes to eicit activity from each of the four muscle segments was then determined in turn. Thus the pressure required upon the spine at ' to elicit activity in the muscle at T4, in the muscle at T6, in the muscle at T8 and in the muscle at Tl was determined. This was then repeated at the other spinous processes, giving four thresholds at each spinous process, sixteen in all, in each experiment The results will e summarized y illustrating with one hypothetical suject, eliminating some qualications for the sae of revity t was found that there was much more spread to lesioned segments than/ lesioned segments. Thus, if T6 were a severely lesioned segment (very low threshold) while 8 and T (neglecting T4 for the moment) were normal or high threshold segments, the following otained t reuired very ittle pressure to the spinous process of T6 to elicit activity of the muscle in the same segment ut even very strong pressure stimuli to te same spinous process faled to pro Interpretation of researc
uce ay sigs of aciviy i e muscles a T8 or T Coversely aloug eve very ig ressures o e sious rocesses of e laer wo segmes rouce o aciviy i eier of ese segmes relaively slig ressures uo e sious rocesses of eac of em i simulae reflex coracio a T Tus exciaory imulses eerig e cor a T "yasse e mooeuros of e same segme a ose of a eigorig ig resol segme o emerge or rouce effec a a more remoe lesioe segme f T were moeraely lesioe (as was ofe e case if ere was a eiso a T) i ariciae i excage of exciaio wi T u usually oly rvd exciaio from T8 a T Our coclusio from is series of exerimes ca e simly sae i a aalogy Te aerior or cell of e esioe segme rereses a ell easily rug from a umer of us uos wile e sious rocess or us uo of e esioe segme oes o easily rig ells oer a is ow Te yerexciailiy of e lesioe segme (a is e rela ively low reflex reso) is emosrale wiou alyig res sure o e corresoig sious rocess Proan stds
was of ieres i is coecio o eermie weer a ow e ex ciailiy of e lesioe segme was affece y esesiizaio of e sious rocess wi rocaie Ifil raio of e erioseum arou e sious rocess raise e local resol o a of a ormal seg me a is i was o loger ossile o rouce reflex resose of e musce of a segme wi slig moerae or eve eavy ressure simuli o e sious rocess of a segme coras owever srea of ex ciaio to a segme from oer segmes remaie uimaire al oug ressure o e rocaiize sious rocess of T o loger elici e reflex coracio a T i was sil ossile o elici coracio a T y ressure uo sies T8 a T Tus e yerexciailiy of e lesioe segme was agai emo srae ieeely of e sious
F 2 - Daram of reex pat way noed n expermenta meaurement of ementa re treo and of nterementa pread of taton See text p - enory endn n pnou proe a d aendn and deendn nterementa neuron m - eretor pnae ma e reordn eetrode
rocess i exiss eve we e sious rocess is esesiize atra dfrns
O a few sujecs e reflex resses o o sies of e same segme were simulaeously oserve (ig 2 T) was fou a e sial exesors o oe sie of e segme may reso reflexly o very slig ressure uo e sious rocess wile e oer sie requires muc iger ressure o e same sious rocess I oer wors low or ig resos are o ermie y e sious rocess Te euros i e lef a rig ors of e same segme may e maiaie i iffer e egrees of exciailiy Te lef a rig "els are rug wi if fere egrees of faciliy from e same "us uo Rst atvty.
Te iffereial exciaiiy of aerior ors i esioe a olesioe segmes was furer
a clearly sow i exerimes i wic e aerior or cels were exose o o imulses from sious rocesses u o geeralize simuli comig from wii a wiou e oy We a aie is roe a com eey rlaxe ere is usually o aciviy i e sial muscles ere is o eve oe as iicae y e asece of acio oeials i ose muscles Tis is rue usually eve of segmes i lesio Occasioally owever i was fou a muscular aciviy ersise i e asece of exeral simula io Te sujecs a o e carefully osiioe a reosiioe o elimi ae as far as ossile e affere omarme from e rorioce ors I was fou a we res aciviy i occur i was almos ivarialy i e lesioe low resol segmes Tus e seg me i lesio is e mos sesiive o osiioal sress coveye y e rorioceors i e muscles a eos. Meal facors may also e re sosie for es aciviy Sujecs wo are areesive axious or emoioally use ofe sow er sise res aciviy Suc aciviy was always mos marke i e lesioe segme ofe i occurre ony i e lesioe segmes Te lesioe segme is us yerresosive o imulses esceig from e cererum Tacile simui also emosrae e yerexciaiiy of e aerior or cells i e segme of lesio f e ack was sligly scrace or ickle wi a i as over e souler or scaular area coiuig aciviy i e sial exesors a e esioe segme was ofe recii ae u very rarely i e o lesioe segme of e same sujec Tus imuses from ouc a lig ressure receors i ski also fi e mos resosive aerior or cels i e segmes of lesio Occasioally we fou a moor ui wic fire i sycroy wi isiraio or exiraio suc a ui was ivariay siuae i e lesioe segmes Aarely suc segmes are yerresosive also o imulses from ular a oie ceers Intrprtaton of prmnts
Te followig geeral coclusios
may be daw fom hese expeimes as egads o moo aciiy i esioed segmes 1 A oseopahic esio is associ aed wih a segme of he spia cod which has a ow moo efex heshod, i.e., i epeses a hypeexciabe seg me of he cod A eas i he esioed segmes sudied by us i may be said ha he baace has bee shifed oo fa fo oo og owad he exciaoy side 2. The oweed efex heshods ae demosabe idepedey of he eaed spious pocess. Ee hough chages i he pa pabe chaaceisics ad i pai sesiiy of he spies ae impoa diagosic feaues, hey ae appaey secoday o ohe, moe fudamea aeaios i he cod This aspec wi be discussed ae. 3 The esio epeses a aei o oo a eas some of whose mooeuos ae maiaied i a sae i which hey ae ea iey hypeexciabe o a impuses which each hem I a seee esio may of he moo euos ae so cose o hesh od, ee whe he subec is a es ad eciig comfoaby, ha i euies ey few addi ioa impuses fom he euos which syapse wih hem o igge hose moo euos io oe aciiy. Those addiioa impuses may come appaey fom amos ay souce he spious pocess is bu oe such souce 4 The esio, heefoe, is o be coceied, o as a adiaig cee of iiaio, speadig exciaio o ohe segmes, bu ahe as a segme upo which iiaio is focused I epeses a pace i he cod whee baies o mooeuo exciaio hae bee oweed ad which, heefoe, chaeizes impuses io musces eceiig moo ieaio fom ha segme
Bai for egmenal hyperciabiiy Wha is he basis fo his segmea hypeexciabiiy? Wha keeps he mooeuos of he esioed segme o edge," ha is, a a high ee of
subimia exciaio? These aeio ho ces ca be maiaied i his faciiaed sae by coiuous ad excessie bombadme fom some uiig souce o souces
The ource of impule Wha ae he uiig souces of impuses wih which h e aeio ho ces i he esioed segmes ae coiuousy ad excessiey bom baded? Fis, hei excessie aciiy is appaey associaed wih pos ua, mechaica, ad aicua deagemes. Secod, i mus be ecogized ha hey ae appaey a highy sabiized ad choic souce Refex heshods i segmes of esio hae bee foud o be ey cosa oe peiods of mohs ad ee yeas. Thid, i mus be ec ogized ha hey ae pobaby highy ocaized, ofe esicig hei faciiaig effec o oy oe o wo segmes The souces which, i ou opiio, mos cosey fufi hese uaifica ios ae he popiocepos, e., he sech, esio, ad pessue ecep os i he musces ad coecie issues. Fis, posua, mechaica, ad aicua deagemes uuesio aby cause iceased fibeegh o esio i he musces ad edos o a eas oe side of he aicuaio i uesio The popiocepos ae highy sesiie o chages i fibe egh o esio. Secod, hey ae he oadapig ype of ecepo They keep fiig impuses io he cod ia he dosa oo fibes as og as hey ae ude esio ad a feuecies which ae popoioa o he esio The highe he esio, he highe he affee bombadme fo as og as he esio is maiaied Thid, he affees fom po piocepos o oy hae segmea disibuio, bu hey specificay ifuece he aciiy of he musces o which hey ae mos cosey eaed o i which hey ae siuaed This specificiy exeds o oy o he musces hemsees, bu o specific musce heads I is hough ha he musce spide ces efexy ifuece oy he musce fibes i hei im mediae iciiy. I his way, highy ocaized, icious cyces of iiaio may be se up We, heefoe, beiee ha hese
ecepos pay a pomie oe i maiaiig segmea hypeexci abiiy i aeas of esio. As a esu of he coiuous baage of im puses which hey e io he cod a hei ee, he aeio ho ces of he coespodig segme ae maiaied i a sae of choic faciiaio a a high ee of subimia exciaio, ee duig es
fec of chronic faciaion I hese segmes, heefoe, i may be said ha he oma isua io" which keeps he effee euos fom fiig i espose o eey impigig impuse has become wo Sice ude oma codiios of ife, euiig cosa adusme o he exea ad iea eio mes, euiig moio ad he maieace of he eec posue, so may impuses fom so may souces ae cosay impigig o he mooeuos, i a segmes of he cod, ha hose which ae aeady faciiaed, as i he esioed segme, wi ieiaby be moe acie ha he ohe The musce fibes o which hey ae coeced wi he be excessiey high i oe If mai aied fo sufficie peiods of ime his hypeous woud ead o exua, mophoogic, chemica, ad meaboic chages which may, i u, become secoday ad choic souces of iiaio.
Oher neuron We hae hus fa discussed oy he mooeuos ad aeaios i moo eex aciiy i aeas of esio Wha of he ohe effee ee fibes ad he ogas ad issues which hey ieae? Ou expeimea sudies hae demosaed ha cosey ad ua iaiey coeaed wih oweed moo efex heshods ae hee ohe feaues of he esio: (1 Ae aio i he exue of he issue oe yig he spious pocess, (2 oweed pai heshod, ad (3) iceased suscepibiiy o auma 1 Tissue exue: As is we kow o oseopahic physicias, hee ae sikig chages i he exue of he issues oe he spies of esioed segmes I was foud ha he degee of chage i issue exue was so cosey eaed o he degee of oweig of moo efex hesh Iepeaio of eseach
old rom th normal that Dnslow through palpaton o subjcts pror to ach lctromyographc dtrmnaton o lx thrshold was abl to prdct wth rmarkabl accuracy th rlx thrshold o ach sgmnt t s probabl that ths changs n txtur ar du to local changs n vasomotor actvty lud balanc capllary prmablty trophc actors and othr aturs whch ar drctly or ndrctly undr th nlunc o th atral horn clls o th sympathtc nrvous systm. 2 Pan thrshold A drct corrlaton was ound btwn motor rlx thrshold and sgmntal snstvty to pan. As s wll known th spns n lsond sgmnts ar uch mor tndr than thos n normal sgmnts. n othr words t s asr to rach th "conscousnss o th patnt th crbral cortx through th lsond sgmnt than through th nonlsond hs w ntrprt as sgnyng a acltaton o th spnothalamc brs. 3. Suscptblty to trauma t was ound that on appls qual mchancal rrtaton (masurd mpacts) to th spnous procsss o lsond and nonlsond sgmnts th ormr may rman panul or svral days whras th subjct soon orgts whch o hs normal spns rcvd th poundng W may conclud rom ths corrlatons wth motor rlx thrshold that nurons othr than th antror horn clls may also b acltatd and mantand n a stat o hyprxctablty n th lsond sgmnt hs appars to b tru at any rat o crtan o th prganglonc brs o th sympathtc nrvous systm and o th spnothalamc brs convyng pan snsaton to th hghr cntrs. Exprmnts ar now n progrss to stablsh th dgr o nvolvmnt o nurons o th sympathtc nrvous systm. Drmatomal altratons n swat gland actvty ar bng dtrmnd by masurng th lctrcal conductvty o th skn n lsond and nonlsond sgmnts. W ar masurng altraton n th actvty o sympathtc brs controllng vasomotor actvty by lctrcal masurmnts o skn and dp muscl tmpratur. Although ths studs ar stll n a prlmnary stag t has bcom vdnt that
sympathtc actvty n th skn s altrd n lsond aras and that nstrumnts usd or th masurmnt o ths prphral changs and othrs whch ar contmplatd wll n on orm or anothr bcom valuabl dagnostc ads. hy ar much mor snstv than ngrtps and crtanly asr to standardz. hr s no rason to doubt that latral horn clls whch nlunc spcc vscral unctons ar undamntally smlar to thos controllng th swat glands. A projct n collaboraton wth Dr. D.E. Druckr o th Dpartmnt o Physology s undr way or th objctv and prcs dtrmnaton o altratons n varous vscral unctons rsultng rom acut xprmntal spnal lsons n anmals. h cts on vscral uncton n normal unansthtzd dogs o lsons n sgmnts rlatd to th vscus undr xamnaton wll b compard wth th cts o smlar lsons lswhr At prsn ths nvstgatons ar lmtd to a study o rnal blood low glomrular ltraton and tubular scrton h kdny was slctd or th rst such nvstgaton bcaus mthods or quanttatv study n normal anmals and humans ar hghly dvlopd and bcaus o th clncal sgncanc o rnal blood low and rnal mtabolsm n conncton wth such ntts as hyprtnson. Smlar studs upon othr vscral organs ar projctd or th nar utur. t s hopd that rom ths studs wll mrg a clarr undrstandng o th rlatons o th ostopathc lson to vscral dsas. Characterzato of the eso
On th bass o th xprmntal studs so ar blv w ar rady to attmpt a charactrzaton o th ostopathc lson n trms o basc nural mchansms t us rst summarz our gnral conclusons. 1 ormally rnt nurons ar kpt rom rng n rspons to vry mpuls that rachs thm by th act that a rlatvly hgh lvl o sub lmnal xctaton or acltaton must b stablshd by oth mpulss convrgng upon thm bor th rng pont s rachd. hs rqurmnt srvs as a sot o nsulaton 2 n th lsond sgmnt ths
nsulaton has bn waknd A larg porton o th rnt nurons ar kpt nar th rng pont (a cltatd) vn undr condtons o rst by chronc arnt bombardmnt rom sgmntally rlatd structurs 3 Proprocptors ar undoubtdly an mportant sourc o ths bombardmnt but any sgmntally rlatd structur may b such a sourc A pathologcal vscus or a cutanous trggr spot or any othr nlamd or rrtatd structur whch concntrats ts arnts n on or a w dorsal roots may b rsponsbl or mor or lss tonc acltaton. (h clos rlaton o th ostopathc lson to rrrd pan mchansms s clar but spac dos not prmt a dscusson o ths most mportant aspct) h rng procss n th acltatd rnt nurons may b compltd by any mpulss mpngng on thos nurons whthr th sourc o thos mpulss b th crbral cortx postural and qulbrum cntrs bulbar cntrs cutanous rcptors or othrs Should ths suprmposd bombardmnt b sucnt and ndurng th acltatd nurons (and th organs thy nnrvat) may b mantand n a contnuous stat o xcssv actvty. h stat o acltaton may xtnd to all nurons havng thr cll bods n th gmnt o th cord rlatd to th lson ncludng th antror horn clls prganglonc brs o th sympathtc nrvous systm and apparntly th spnothalamc brs 6. Bcaus a structural dct an ostopathc lson snstzs a sgmnt to mpulss rom all sourcs and or rasons prvously gvn th lsond sgmnt s to b consdrd not a radatng cntr o rrtaton but rathr a nurologcal lns whch ocuss rrtaton upon that sgmnt Bcaus o th lowrd barrrs n th lsond sgmnt xctaton s chan nlzd nto th nrvous outlow rom that sgmnt 7 t s a trusm n nurophysology that whn somthng s xctd somthng unctonally rlatd s smultanously nhbtd Although n our studs w hav not yt drctd attnton to ths aspct t cannot b doubtd that acltaton n th sgmnt o lson also xtnds to
5
neurons eetng nhbtory nuences upon other neurons or organs It ay the be concluded that: An tothic lion nt cittd gmnt o th inl cod mintind in tht tt b imul o ndogno oigin nting th coonding dol oot A tuc tu, ciing nt n b om tht gmnt tho otnti xd to csi x cittion o inhibition aipati Thrapy
e coe now to the last queston hat, bascally, does anpUlate therapy do? Here, we can oly guess, but at least our guesses are based o soud, eperentally establshed hypothess Manpulate procedures appled by osteopathc physcas nduce relato of uscle whch has been antaned n a cotnuously co tracted state and whch, as a atter of fact, ay not be able to rela spotaneously, een when ectaton s reoed (cotracture) The n crease uscleber length eases the tenso on the proproceptors n the uscles and tedons, brgg about at least a teporary dnuto n afferent bobardent of tat segent of the cord Snce the ecesse tendous ad uscular tenson produced aroud a jont, let us say, by soe boy ds placeent tends reely to produce ore tenson, the anpulate easng of tenson breaks a cous cycle Stll another type of cous cycle ay be n operato and be broken by apulate therapy (Fg 1). Through oerectato of sypa thetc bers the segent of leson, sceral pathology ay be estab lshed The anteror hor cells ay then be subjected to addtonal bobardet wth pulses con eyed by sceral afferents, thus caung eaggerato of the soatc leso wch, n turn, further rrtates the scus Mpulate relaato of the uscles ay break ths cycle, too, through dnuto of proprocepto dscharge to the cord Een a bref respte fro ths rrtaton allows better opportunty for the natural healg processes to operate By anpulate rearrageent of the skeleton ad through postural adjustents, the orgnal cause of the stran, that s the ecesse tenson on 26
uscles, tedons, ad lgaents, ay be elnated ad the benefcal results ade ore lastng Ths s uquestoably an oer splfed erso of the basc effects of anpulato, but t certaly wll sere s a workng hypothess, as a gude to further eperental est gaton Spctios
Assung the portance of the pro proceptors the leson echas, t ust be kept nd that any segetally related structure whch seds afferents to the spnal cord ay be an portat partcpant n the establshet or antenace of the leso� In fact, through the network of tereurons, practcally any afferent, segentally related or ot, ay eert soe nfluence To all these sources of pulses ust be added the suprasegental sources all the hgher ceters, fro edulla to cerebral corte whch contrbute to the descedng spl tracts Many of these are contnuous and hghly arable sources of pulses They eert ther fluece ectatory or btory upo efferet neurons at eery leel of the spnal cord It s, dd, ost portant to keep n d that the efferet neurons do represet fal coon paths shared by a host of pulse sources, n addton to those assoc ated wth jot ad supportng ts sues I ths lgt, t s apparent that the artcular derangeent or the osteopathc leson cannot be con ceed as the cu of dsease; rather t s one of ay factors sul taeously operatng The leson s a ost portant factor t s a sestzng factor, a predsposg factor, a localzng factor, a cha nelzg factor The leso senstzes a segent of the cord, lowers the barrer, facltates wtout ecessarly producng syptos, although sgns of ts presence ay be deostrated by the osteopathc physcan Suffcent addtoal
+n a doubul whh h s vr a ngl au o any whhr h s an olad ologal ao n any lnal ny Eah ao opa n h onx o many ao and odu ran only n a an ombnaon o aos
ectato as to be superposed upon that fro artcula ad per artcular orgns Ths s not to ze the portace of the osteopathc leson On the contrary t s to wde the cocept For one thg, t certanly ponts Up the treedous cotrbuton that osteopatc dagnoss and therapy can ake to preente edcne To osteopathc pyscans there s, of course, othng unfaar the practcal aspects of ths cocept Oe patent has relately seere esons, yet s syptonfree, panfree, ad not readly subject to fatgue, etc an other patet wt ery slar lesons, on the other hand, ay be subjec to serous dsturbances drectly related to those lesos Further, the lesos of the frst patent ay "act up under certan crcustaces, and then subsde nto "quescece agan hy? hat accounts for the dfferece between such patents, and between te "actgup ad "quescent perods n the sae patent? In our opnon and, I belee plct te osteopathc cocept, oe portat bass for the dfference les dffereces n the aount of nerous ectato con tuously pngg on the efferet neuros of the lesoed segents, oer and aboe that fro the uscles ad jonts The leson operates dfferet contets wth dfferet effects Gen an artcular dsturbace whch, through the echanss dscussed aboe, deternes the loction of the low threshold segents, te the seerty of the leso, the assocated pathology, and the response to treatent wll be to a great etent, ofte to a decse etet, deterned by ow uch addtoal euro pressure fro other sources s chrocally preset Such pressure ay be present upon all the segets, but because of lowered syaptc barrers, the effects wll be eaggerated at the lesoned seent The leso ot only focuses t agfes Ths superposed ectato ay coe fro ay of the sources pre ously enuerated, ad others, whch coerge upo the ateror horn cels and the other efferent neuros: the corte, the basal gagla, cerebellu, estbuar ucle bulbar ceter, the eyes (a the Iterpretaton of research
ecspinal racs), r any seady, n ic surce f ipulses Since all hese surces ay direcly affec, farably r unfarably, he lesin and is assciaed phenena, hey are all prperly wihin he prince f he sepahic phy sician All f he ay cnribue he lesin and is effecs n al bdy ecny Ipran as is he srucural facr, reaen f i alne is n rea he paien as a whle and wuld be, if I inerpre i crrecly, a crrupin f he sepahic cncep I shall ry illusrae wih ne surce f bbarden which is f ery general signicance, naely he cerebral crex As preiusly indi caed, he wrds "ense, high srung, upy, keyedup n edge are re han figures f speech They bespeak he wellrec gnized fac ha psychic sress, einal ibalance, enirnenal srains, ec, influence and are refleced n r aciiy an increased uscular ne and hyper respnsieness, in generally lwered reex hreshlds A failiar illusra in is he exaggeraed knee erk f a ense indiidual (Oher ypes f ibalance ay, f curse, hae de pressing r inhibry effecs, resuling in faigue, hyperreexia, ineria and her syps) These are biusly due ipulses passing dwn he descend ing spinal racs and ipinging direcly r hrugh inerneurns, n he anerir hrn cells and increasing heir exciabiliy and aciiy In a segen already sensiized by an sepahic lesin he effecs will be especially seere Jus as ipran is he fac ha descending ipulses ay exacerbae he lesin and pr duce increased effecs n segenally relaed rgans, ay cause r inensify pain, and ake he lesin less respn sie anipulaie herapy T rea nly he srucural surce f b barden is nly halfrea and neglec a s ipran par f he lesin echanis, and ake he lesin u f cnex This des n ean, f curse, ha eery se pahic physician shuld bece a psychiaris, bu he cerainly us ake in cnsiderain he he facrs, enirnenal facrs faily relains, einal adusens, ensins, ec
In his ligh he as ye unexplred relains f sepahy psychs aic edicine bece bius I is nw well esablished ha any rganic ills including angina pec ris, gasric and dudenal ulcer, gallbladder disease, ucus cliis, asha and hers, ay be direcly relaed psychneurses, eina ibalances, and anxieies Wha facrs deerine he rganic anifesain f he neurses? The aunic nerus syse, f curse, has reginal represenain in he cerebral crex and he hyphalaus is under crical influence I has been hugh ha he uncnscius ay selec he rgan r rgans be affeced Wihu preudging hese and her heries, i wuld see s prfiable, clinically and experienally, explre he prbabiliy ha he incidence and lcain sepahic lesins ay be an ipran facr in deerining he incidence and naure f psychs aic ills Cerain aspecs f his hyphesis are under experienal inesigain in he Kirksille labraries
5 The effec f he lesin as a predispsing and lcalizing facr is ephasized and discussed in relain cerain aspecs f sepahic pracice Rfrns I Dnlow J S. n analyi of th variability of pina rx thrhod J. Nurophyiol 707 July 9 Dnlow J S Korr . M and Krm D Quantitativ tudi of hroni failitation in human motonuron pool m. J. hyiol, 093 ug. 947 3 loyd, D. . C ntrllular tranmiion in owl' Txtboo of phyiology ditd by J F. Futon Ed w B Saundr Co hiladlphia 94 p 34 4. Shrrington C S Corrlation of rx and th prinipl of th ommon path. Brit. Rp. 747-74 ug ; abtr Brit M J. 3 ug 7 Lornt d N R. Synapti timulation of motonuron a loal pro J. Nurophyiol. 9 May 93 6 loy d, D Rflx aion in rlation to th pattrn and priphral our of affrnt timulation J Nurophyiol. 9 Marh 943
Rprintd by prmiion from JO 47 9 947
Summa
1 . Se f he neural echaniss inled in he sepahic lesin, in is lcal and disan effecs, and in anipulaie herapy are exained 2 The resuls f experienal inesigains are presened which indicae ha he lesin is assciaed wih a segen f he spinal crd which is hyperexciable all ipulses which reach i, and ha he hyperexciabiliy ay exend any neurns haing heir cel bdies in ha segen 3. I is cncluded ha sepahic lesin represens a faciliaed segen f he spinal crd ainained in ha sae by ipulses f endgenus rigin enering he crrespnding drsal r All srucures receiing efferen nere fibers fr ha seg en are, herefre, penially expsed excessie exciain r inhibiin 4 Eidence is presened ha he srech and ensin endrgns prpriceprs) in he uscles and endns are he s ipran surce f afferen ipulses which prduce he changes in he crd ha are assciaed wih he sepahic lesin 7
T ging concpt of th ostoptic sion* (1948) Th srvivl growth chivmnts nd incrsing ctivnss o ostopthy r lont tstimony to th sondnss o th principls pon which it ws ondd Th ttinmnts o th ostopthic prossion hv bn possibl only bcs th prossion is ondd pon th solid rock o bsic trth Its continud growth nd prstig indict tht thos trths contin to b corrctly pplid nd soundly dvlopd Th tim hs com howvr whn incrsing ttntion must b givn to th thorticl rsrvs upon which contind tchnicl dvnc is prdictd or mny rsons ths rsrvs hv bn consmd r mor rpidly thn thy hv bn rplnishd In ostopthy s in ll tchnologicl spcts o modrn li lrg bcklogs o ndmntl inormtion mst b mintind nd nlrgd i contind prcticl dvncs r to b ssrd Thy r indd th springs rom which th dvncs ow In ostopthy ths rsrvs consist o or ndrstnding o th bsic biologicl procsss nd mchnisms ssocitd with th phnomnon dsigntd s th ostopthic lsion Tody this ndrstnding is not or t lst ntil vry w yrs go ws not grt dl lrgr thn in Stills dy Althogh knowldg o th mchicl spcts o th lsion (th "cus) nd o its clinicl mnisttions (th ct) hs grtly dvncd thr hs bn no prlll dvnc in or knowldg o th procsss intrvning btwn ths two spcts o th probl Ths procsss r th problms bor s tody Givn lsion so wll known to ostopthic physicins throgh thir trind ingrs nd throgh xrys how dos it prodc its cts? Throgh wht mchnisms nd chnnls dos it impir th dnsiv rprtiv nd homosttic unctions o th body? How dos prdispos to diss
I
Baed o a adde of he ame ie ead befoe he Geea Seio of he FySeond ua Coe ion o he meca Oeoahic oiaion Boo Juy 9 98
8
How dos it pst physiologicl ilibri? Wht procsss dos it initit? Th vry tr o ostopthy distinct nd dvncd systm o prctic is dirctly rltd to th ccurcy nd thoroughnss with which ths stions cn b nswrd in th nxt w yrs It is my prpos in this ppr to prsnt or crrnt thoris rgrding ths cntrl spcts o th ostopthic lsion Thn I wish to drw som o th prcticl implictions o ths mrging concpts Prdoxiclly I shll prsnt or crrnt thoris by dling to lrg xtnt with othr mttrs It is possibl to do this bcus thos othr mttrs r so intimtly nd somtims insprbly rltd to th ostopthic lsion Th discovry o ths rltions is s importnt s th discovry o th nw cts bot th lsion itsl bcs with th stblishmnt o ch sch rltion whol body o knowldg rdymd nd slly still growing; is tomticlly incorportd into th ostopthic concpt With vry sch incorportion or concpts in which clinicl nd prossionl dvncs hv thir origin r dpnd nd widnd Th history o scinc physicl biologicl or mdicl rcords gin nd gin th collps o ncs sprting scintiic nd tchnicl ilds As rslt o crtin ndmntl discovris ntir ilds o scintiic prsit whol schools o thoght nd mjor concpts bgin to dvlop nd ttrct discipls Ths lds my dvlop indpndntly nd rmin sprt on rom th othr nd pprntly nrltd or mny yrs Howvr s th knowldg nd ndrstnding within ch ild ccmlts throgh xprinc nd rsrch it bcoms pprnt in mny css tht th wlls which sprt ths ilds hv vry littl substnc in ct thy xist only in th minds o mn nd not in ntr itsl Ech ild bgins to drw rom nd giv to th othr nw nd dditionl mning inlly thy mrg owhr is this bttr illstrtd
thn in th lds o immdit intrst to th ostopthic prossion I hv slctd or discussion only thr mjor ilds which rom or prspctiv ppr to hv mch bsic nd distinctiv sbstnc in common Ech hs yildd mjor body o concpts school o thoght or school o prctic Ech origintd indpndntly t dirnt priods nd in thr dirnt contris sprtd by thosnds o mils nd ndr vry dirnt circmstncs Tody thy r djoining ilds nd th ncs btwn thm r crmbling Thy hv in common th ollowing gnrl concpts: 1 Th body is nit; ll prts nction in th contxt o th ntir orgnism 2 Diss is rction o th orgnism s whol Abnorml strctr or nction in on prt xrts bnorml inlnc on othr prts nd thror on th totl body conomy 3 Th orgnism hs th inhrnt cpcity to dnd itsl to rpr itsl nd to rsist srios psts in ilibri Th nrvos systm plys dominnt orgnizing rol in th diss procsss Thr is somtic componnt to vry diss which is not only mnisttion o th diss bt an mpoan onbng fao
6 Approprit trtmnt o th somtic componnt hs importnt thrptic vl in tht it lds to improvmnt in th othr componnts Th concpts I rr to r ( th ostopthic (2 th concpt o rrrd pin nd ssocitd phnomn nd 3) th concpt o diss dvlopd by A D Sprnsky nd his collgs in Lningrd Ths concpts hv not only hd vry dirnt origins but vry dirnt corss o dvlopmnt Th ostopthic concpt soon ld to th dvlopmnt o most ctiv thrptic wpon which bcm nd or mor thn 60 yrs hs bn th bsis or nw nd xpnding school o prctic rom th bginning this wpon ostopthic mnipltiv thrpy ws so rvolutionry nd so ctiv tht th mjor concrn o its dsignrs dvloprs nd prctitionrs ws with (1) Lrning how to us it most Intrprttion o rsrch
ctvly 2) wnnng th rght to us t (3) dtrmnng ts cts on th varous lls to whch man s hr and ) rproducng th wapon wn nng rcruts puttng th wapon n thr hands and tachng thm how bst to us t. Possssd o such a wapon but wth w othr matral rsourcs and proccupd wth thos struggls n th ac o opposton t s undrstandabl that th oundrs th dscpls and th arlr practtonrs o ths school ound t mpossbl to ngag n th mor lsurly pursuts o nvstgatng xprmntally th undamntal bass or th ctv nss o thr thraputc wapon. Th oundrs o th othr two schools dd not howvr strk upon nw thraputc masurs n th arly dvlopmnt o th concpts. Thy and thr dscpls thror dvotd thmslvs to skng th mchansms whrby pathologcal procsss ar ntatd and th channls whrby pathology o on par acts othrs Ths nvstgatons hav ld to xtnsv rsarch programs whch ar now conductd throughout th world and whch hav won much support and many rcruts Ths rsarch programs hav mad avalabl a grat walth o normaton whch has ld to som sound thory Ths n turn lk all good thory s today ladng to good practc. w and promsng orms o thrapy ar mrgng rom th work o ths schools. It s to b xpctd that ths orms o thrapy xprmntal though thy may b to day but basd as thy ar on rapdly xpandng bods o undamntal knowldg wll rapdly dvlop and ncras n applcablty and ctvnss As I hop to dm onstrat both o ths lds o nvstgaton ar actually concrnd wth crtan undamntal aspcts o th ostopathc lson though thy may not b rcognzd as such In prparng ths lctur I hav ound t convnnt to rvw th work o ths two lds rrrd pan and th work o th Spransky school bor summarzng th mrgng concpt o th ostopathc lson sc that concpt s mrgng not only rom ostopathc rsarch and xprnc but rom thr n tgraton wth contrbutons o ths two schools n partcular
Referre ain an assoiate henomena
Ths ld o nvstgaton had ts most mportant bgnnngs n En gland n th work o Sturg Ross Had Macknz and othrs n th arly 80's and 90's. Mor rcntly mportant contrbutons hav bn mad by Sr Thomas ws and hs coworkrs also n Brtan and by a numbr o laborators and mdcal nsttutons n ths country. Ths workrs wr prmarly concrnd wth th somatc manstatons o vscral dsas spcally th somatc pan and wth rlatd phnomna. Evn vry suprcal study n th ld o rrrd pan rvals th clos rsmblanc o ths syndrom to th ostopathc lson. Macknz or nstanc many yars ago spok o th trad o somatc manstatons o vscral pathology () rrrd pan (2 hypralgsa and (3) motor ph nomna
. Rfrrd an In many cass th pan o vscral dsas s lt not n th organ tsl but s rrrd to th soma that s skn muscls tc ry otn ths somatc structurs do not ovrl th ara o dsas and may b rmot rom t. It was soon dmonstrad howvr that th zon o rrnc bars a sgmntal rlatonshp to th ara o orgn both ar nnrvatd rom th sam sgmnts o th spnal cord. Th pan s sad to b rrrd to th corrspondng drmatom and myo tom Many xampls ar amlar to th physcan Th pan o angna pctors orgnatng n th myocardum and rrrd to th chst wall th back shouldr and mdal surac o th arm rnal colc whch producs ntns pan n th lowr back and gron rrtaton o th daphragm whch s rrrd to th bas o th nck and shouldr tp.
2 Hpralga Tndrnss s also ound n somatc structurs sg mntally rlatd to th pathologcal vscus a. Cutanous tndrnss th ovrsnstvty to pnchng and to rcton n th drmatoms rlatd to th sck vscus b Muscular tndrnss and xag gratd snstvty o th muscls to dp prssur and
c. Tndr spnous procsss In trstngly nough to ostopathc physcans Macknz placd grat dagnostc sgncanc on th tndr spnous procsss H dmonstratd or nstanc that dsass o th hart wr commonly assocatd wth tndr spns T to T stomach wth T to T8 lvr wth T8 to T; rctum and utrus to S2. 3 Motor hnomna Mac knz dscrbd th spasm ustand contracton and rgdty n muscls sgmntally rlatd to th patholog cal organ H ncludd undr motor phnomna th autonomc changs n th zon o rrnc although thy proprly blong n a ourth catgory. What s th bass or th rrrd pan complx? Much o th nal answr s crtan to b ound n th spnal cord. g. [sam as g. 1 n prcdng artcl» Thr s obvous ntrchang o xctaton among all th typs o nurons whch mt or hav thr org n a gvn sgmnt o th spnal cord Th dorsal root a rnt) brs convyng cntrptal mpulss rom all th tssus somatc and scral th varous rnt or motor nurons ncludng thos whch hav thr cll bods n th antror horn and whch rgulat actvty o th skltal musculatur and thos orgnatng n th ntrmdolatral column whch gulat vscral ac tvty motor and scrtory) swat gland actvty vasomoton tc Th spnothalamc brs whch convy snsaton o pan to th hghr cntrs ar also obvously nvolvd n th complx Alhough th spnothalamc brs can b xctd by mpulss transmttd by th arnt brs rom th vscra nvrthlss th crbra cortx procts or rrs ths snsatons to somatc structurs whos arnt brs ntr th sam dorsal root. S th papr by Druckr or a rvw o th mchansms) On th bass o ths obsrvatons Macknz dvlopd th hypothss o h rrtabl ocus. Ths hy pothss statd n ssnc that rrtaton rom th vscra convyd by th arnt brs rndrs many o th nrv clls n th sam sgmnt hyprrrtabl As a rsult tssus and organs nnrvatd rom that sgmnt ar actd by th vscral pathol ogy Th rrtabl ocus hypothss
2
as since een oifie an restate in accorance wit ore oern concets of facilitation More recently ewis an is col league, J H. Kellgren, sowe tat te enoenon of ain reference was not eculiar to visceral irritation, since siilar an even ientical at terns ("trias) cou e evoke y irritation of eelying soatic structures. ey foun tat inection of 01 to 03 cc. of 6 er cent soiu clorie solution into certain igaents, tenons, an uscles, coul rouce intense ain in relatively large an often reote areas of te corresoning eratoe an yotoe e ain reference was accoanie y te oter conents of te classical tria, naely cutaneous an uscular yeragesia an uscular rigiity Even ore striking was te eonstration tat suc localize irritation of te intersinous ligaents or sinal extensor uscles in certain segents, rerouce wit reark ale recision te ain atterns an oter soatic enoena wic are associate wit visceral atology is was true to suc an extent tat atients wo a exerience te rea isease coul not istinguis etween te exerientaly inuce an te naturally occurring synroes. or instance, te inection of te eigt cervical intersinous igaent wit te yertonic saline soution ro uce a erfect facsiile of an angina attack, not only wit resect to ain istriution (incluing te susterna ain an te raiation own te unar surface of te ar), ut also te yeragesic areas, te uscular rigiity, an te sense of coression of te cest Inection of te first luar intersinous igaent rouce te tyica ain istriution of renal coic (ower ack, lower a oen, groin, an scrotu), rigiity of aoinal an sina usces, yeralgesia, an often a arke cre asteric reflex on te corresoning sie. (In our own aoratory, we ave not only confire tese oserva tions, ut ave eonstrate certain associate autonoic canges.) urteroe, tese workers an oters eonstrate tat exeri ental traua to certain visceral organs rouce recorale contrac tions of skeeta usces in cor resoning segents ese con
tractions cou e aost erfecty is genera aroac as een rerouce (wit resect to location, receiving esecialy significant eaitue, an tie caracteristics) veloent in te ans o f ravel an y irritation of certain soatic er coleagues at Cornell niversity strtures in te sae segent Meica Colege ey were ale to (Stuies on te converse, naely te rouce coete an ieiate influence of soatic irrtations on relief fro cariac ain ue to viscera function, are in rogress in yocarial infarct y infiltrating our aoratories.) aroriate trigger areas wit ilute It ay e conclue fro tese rocaine yroclorie. , ese oservations tat not only oes were intensey yerestetic areas irritation or atology in one tissue ocate in te yofascia structures or organ stir u anora activity of of te reference zone (usualy in te oter tissues in te corresoning ectoralis aor, etoralis inor, or segents, ut tat te cex te serratus anterior). Wen sufficienty near te surface te trigger areas a of te overa resonse to te riary atology organzd b coul also e effectively locke y sraying te overying skin wit etyl h nal cord e characr of te attern is eterine y te segent clorie. Relief fro ain was not or segents wic are involve, an ony ieiate, ut lasting Relief not y te tissue wic is first was otaine for erios of onts irritate (soatic or visceral) nor y an even years. It is of interest tat te nature of te irritation. wen siiar trigger areas, in atients It was early recognize y workers wit skeleta uscle isorers witin tis fiel tat te seconariy out organic isease, are irritate, as irritate structures tat is, tose y neeing, referre ain occurs tissues in te zone of reference, ay wic is inistinguisae in teselves, as a result of tis ato- istriution an quaity fro te logica influence, ecoe seconary susternal an raiating ain of sources of irritation eaing to te coronary insufficiency. estaisent of a vicious cycle is \ Of interest to tose faiiar wit recognition as fore te asis for te osteoatic concet an te certain iortant teraeutic ea- current teories of te osteoatic sures wic ave egun to eerge lesion are te exanations of tese fro tis work Given suc a attern, oservations roose y tese incuing viscera atology an te workers us ravel an Rinzler reference enoena, ten wy not say, "e ost reasonae exlana eliinate te irritation contriute y tion is tat te initial insult, weter te ost accessie art of te to visceral or soatic structures, sets colex te soatic coonent? in otion a cain of events eretu e otentialities of tis aroac ate y a vicious cycle of nerve were inicate 20 years ago y Weiss iulses wic ave no furter an Davis wo sowe tat at east eenence on afferent iuses te ain, ue to visceral atology, fro te eart an wic are rocou e relieve y local anesteti aly trnsitte to an fro te zation of te skin areas to wic te soa y virtue of sustaine faciitaain is referre It is of secial tion of te noxious iuses y te interest tat te reief fro ain often cose selfreexciting cains of outaste te execte uration of internuncial neurons in te central te ocal anestesia y consierae nervous syste. Aarenty, even erios of tie. rief interrution of tis sefOter work (reviewe y Wolff sustaining cycle of nerve iulses at an Har an Wolff an Wof) any oint in te cain ay e effecas eonstrate tat te sustaine tive in eranently aolising it. uscular contractions or sass L In exanation of te lasting effect wic are art of te referre ain of tis rief interrution y local atterns, ay teselves corise soatic ock teray tey offer te sources of irritation oca infitra ossiility tat te "soatic trigger tion of te rigi uscles, ientifie y ecaniss contriute to te er alation, relaxe tose usces, etuation of te riary source reieve te ain, an often rouce of ain, tat is, te coronary iroveent in te associate auto insufficiency In suort of tis noic isturances yotesis tey refer to te evience
Interretation of researc
btaed by Ldgre that lcal aesthetat f the precrdal structures prduced mprvemet the crary crculat Althugh the authrs are careful t t make therapeutc clams usupprted by ther bservats they pt ut that he relef f pa due t mycardal farct may tself have true thera peutc effect sce there s evdee that pa may duce ree spasm f cllateral crares Autmc chages the e f referece are well establshed but t has ly recetly begu t be apprecated that the bld vessels supplyg the bra ad spal crd may als be cluded the e f referece Travell ad Bgelw have recetly shw fr stace that phemea f hystera may be medated by afferet mpulses frm trgger areas skeletal muscles hether these es are actvated by psychgec stress r (epermetal) trauma the same clcal patters are prduced The patters are fte b arre ad may be t ly spatally but als segmetally remte frm the smatc trgger area Ifltrat f the apprprate ad specfc smatc structures dramatcally releved dsrders f vs resprat mtr pwer ad cutaeus sesa t (eg glveadstckg paresthesas) The ccept s advaced that "hgh testy stmul frm smatc trgger areas reely prduce pr lged vascstrct wth partal schema localized areas f the bra spal crd r perpheral erve structures The authrs pt ut that these patters rasg the threshld f ectablty at the syapse the cetral ervus sytem drectly by geeral aesthesa hypss r psychtherapy may be epected t accmplsh the same result as blckg the surce f us mpulses at the smatc trgger area N attempt has bee made ths sect t revew ths feld but rather t preset a few utstadg e amples ad t establsh several prtat ccepts (Fr mre cmprehesve revews see refereces 8, 1 4 a 15 These may be sum mared as fllws: 1 There s etesve terchage thrugh the spal crd amg the varus structures vsceral ad smatc bld vessels glads
smth muscle skeletal muscle sk etc whch draw ther ervat frm the same segmet Pathlgy r rrtat f e f these structures may lead t the estab lshmet f a patter f chages all the thers The patter s determed mre by the part f the ervus sys tem affected tha by the rrtated structure r the ature f the rrtat 3 a result f these asscated pathlgcal prcesses ew surces f rrtat may be prduced whch lead t the establshmet f a aut geetc vcus cycle f ervus mpulses 4 Iterrupt f ths cycle fr eve a bref perd may permaetly prevet r greatly delay ts reestablshmet permttg the repara tve prcesses (eg the vscera) t prceed uder mre favrable crcumstaces S Hghly lcaled areas skele tal muscle r myfascal structures frequetly becme mprtat surces f afferet mpulses these cm plees refrcg r facltatg the prmary rrtat r eve becmg depedet f t Iactvat f the smatc cmpet f the patter asscated wth vsceral pathlgy may dsrupt the patter ad break the vcus cycle 6 s has therapeutc mprt t ly because the smatc cmpet s accessble ad easly lcaled but als because t may be the mst m prtat factr sustag the (prmary) pathlgy 7. The patters are t eclusvely segmetal vew f the vlvemet f the vasculature f the cetral ervus sytem Vaspasm the bra spal tracts r erves may prduce secdary effects qute re mte segmetally frm the lcus f prmary rrtat The work of the Leningrad Laboratorie
thut gg t the elabrate detal whch the wrk f Sperasky ad hs cwrkers deserves let us summare the ma ccluss t whch ther etesve labratry ad clcal bservats have led them 1 . The ervus system t ly partcpates every dsease but plays a dmat rle rgag the pathlgcal prcesses ad the varus mafestats
Sustaed rrtat flamma t r pahlgy f muscles sk be vscera r erus structures tates prcesses the erus sytem whch may lead t certa fuc tal ad rgac chages desgated as " eurdystrphy Oce tated the prcesses the ervus system d t requre the ctued act f the rrtat ad the eurdystrphy may persst lg after the prmary pathlgy has healed 3 The eurdystrphy epresses tself thrugh pathlgcal ad trphc chages the varus rgas ad tssues rst usually the seg mets related t the prmary pathl gy ad later ther segmets The etre bdy may thus be affected 4 The ature f the prcess ad ts fal epress are depedet f the ature f the rrtat chemcal physcal r blgcal The blgcal agets the ts bac tera vruses etc act fuda metally the same way as the chemcal ad physcal rrtats they merely tate the prcess whch the becmes depedet f the prmary pathlgy S Ths rle f the ervus system appears t be based up much slw er prcesses tha ere mpulses trphc prcesses (Sperasky em phased repeatedly that hs apprach s dstgushed by ts dfferet utlat f the tme factr) These trphc fucts f the ervus sys tem may well have ther bass the mvemet f substaces alg the a (as well as mpulses) as dcated by the recet bservats f ess ad Schmtt 6 As a result f the prmary les lastg ad mcrscpcally demstrable effects the eus system may be prduced whch may rema latet fr lg perds f tme The sgs f the rgal rr tat may lg have dsappeared befre the frst sgs f the dsease appear A recet dramatc llustrat f chages the crd whch persst ed after the healg f the ral les appeared a reprt by Frak ste H The ft pads f cats were t is of nteet that man as ao Man showd tha ontaton o rdt of ltal mul asocatd wth vscal atholo ould man taind n th aant absn of nv mulss Smla dt obv n aoaton wth th otoath leson dbd n latr ton
i
ctd t turpt, produc pa ad lammato ad t typ cal lmp ad lmbtdraal pattr Atr om tm t rrta to dappard o o t lammato r dtctabl ad t amal o lor lmpd or "a vord t pa At t tm t cat a dcrbratd, ad t a oud tat t potur aumd by t amal r mlar to to producd a dcrbrat amal cv t tmulato upo t oot corrpod to tat c ad ad t lo, amly, lo o t actd l ad crodto I otr ord rl o t oral rrtato rappard, al tou tat rrtato ad appartl vad Frat cocludd tat t tal rrtato ad t up om altrd tat t t pal cord t altrd tat prtd or om tm atr t prcptat lo ad ubdd, but a makd by acto o t r ctr Rmoval o orbra prmttd t pattr aocatd t t altrd tat to r mr Frat mpld, alo tat uc tat t rvou ytm, orall tabld by rrtatv proc, prdpo to da, tou ty may b mad or om tm To mt ar o to pa t vulrabl mt o t rvou ytm c may rv a oc o da proc udr crta crcumtac T cocpt bar a dtct rmblac to tat orally dvlopd by Mac t cocpt o t lr o t ara o "rrtato byod t durato o t tal tmulato It ll b rcalld tat Mac alo blvd tat oc tabld t rrtabl ocu rmad or a varabl prod o tm atr t tal ourc o rrtato ad b rmovd, ad co tud to luc t actvty o tructur rvatd by tat mt or om tm Smlarly, a oto patc lo may t r yar tout produc ymptom T ct o a v rrtato, tat , t da pattr t vok ay, dpd larly o t cod to o t "ubtratum, t patt ad rvou ytm ratr ta upo t rrtato tl T "ub tratum var rom dvdual to dvdual, ad t t dvdual rom tm to tm accord to 3
crcumtac vromtal lu c tc T da ad t trap mut b codrd t cott o t patt a a ol 8. T cocpt ar today pro vd t ba or trapy Att to ocud, ot o t o d oram rrtat, or prmar lo but ratr o t rvou ytm, ad mor pccally o to part (, pal mt c ac ca ora t da proc I c, t obct o trap to altr t balac o rvou actor uc a mar a to provd optmal crcumtac or t oprato o t ormal rparatv ad dv proc o t body T prcpl r llutratd a lar r o ca o lobar pu moa , Spraky ad coorkr ad prvouly dmo tratd prmtal amal tat t tmulato o ory rv d mucl ad ara rvatd rom t mdulla ob loata ad uppr mt o t cord or drct mcacal ad cm cal tmulato o t part o t rvou ytm, could produc pro oud pulmoary ca vr m lar to pumoa T ca t lu may dvlop t a mut "Tratmt mut tror b drctd ot oly at t dad lu but alo at t aocatd rvou dturbac T utd tat tratmt o pu moa m b drctd at t rv mt volvd T abov prmt od tat t rv ro volvd r coctd t t crvcaltoracc mt o t pal cord ad t adact mdulla obloata T atror brac o t mt cpt to upply t ad c ad trmt, upply t ora o t ct ad mdatum pccally volvd pumoa ut t potror brac o t rv ar dtrbutd t lo mucl ad o t p ad ck u b att t potror brac c av o drct cocto t t lu all act trou
otr ao pcc rv mt o t lu I vral udrd ca o lobar pumoa oldr dur t F campa ad dur World War II rmarkabl rult r obtad by ct to 0 cc o 05 pr ct ovoca tradrmally to a damodapd ara td atall rom to T4 ad covr t mdal alv o t capula T tratmt, v arly, uually ollod by a drop o tmpratur by cr to ormal t 1 8 to 24 our om ca a drop o l occur t 48 our Roluto o t pumoc co oldato b a t tmpratur drop ad t ral codto mprov Covalcc ort ad uvtul T tratmt o pcc c bcal rult r obtad alo acut or croc catarral pumoa, ad t typ o pumococc rpobl o t da dd ot uc t ctv o t tratmt Laboratory ad clcal data up port t bl tat t traputc rult actd mor by t t o t applcato ta by t dru §
� s o eres ha Speask21 warns ha oce hag obaned a aorabe herapec eec he eece procedure shod no be repead or aoher red e aoher es aorabe baace gh reu Oepahc physcas w recogze he sary o S' Fnd ad eae aone"
§When hs work was reey reewed beore he sear o he oseopahc eson a Krkse, seera eber o he cnca sa rarked upo how sar was he coure o he dsease oowg hs herapy o ha ( her experece) oowg oseo pahc reaen o obar peoa
Th osophc concp
T bac prcpl o t practc o otopat d ot, o cour, b rvd dtal or a otopatc audc W all tat tm brfly, parapra tm omat, t t oro md, ad rv t bac proc trou c t prcpl oprat a ty av b rvald by rct rarc otopatc ad otr ttuto 1 A T Stll ully rcod ad or t rt tm corporatd to a t o practc t capacty o t uma oram to rt ad dd tl aat oou luc to rt or compat or altrato qulbra ad to rpar tl 2 ully rcod ad cor poratd to practc, t uty o t body a prd t act tat abormal tructur or ucto o part rt abormal luc o otr part
Itrprtato o rarc
3 . e uma rgaim, preum
ab beaue f it impete adaptati t te eret tae, i ig ubet t aatmi ad futia deragemet f it ad teir upprt, epeia e vertebra, pevi, ad ter eigt bearig artiuati 4 ee "errr i eigtbearig uavrab affet te truture ad futi f eigbrig ad ditat part f te bd tu iitiatig ad tributig t pat gia ifuee ad pree i mpex f te artiuar diturbae ad it aiated pemea a bee deigated a t e oteopat leion S. e pia ei i aiaed it: a) Tedere r pereteia f te paraveebra tiue ad te verig te vertebrae ki, mue, etive tiue); b) muuar age rigidit, utaied trati r trature), rpie, ad ered mtr refex tred ) autmi age, a refeted i textura age f te uprapiu tiue, vamtr age, atera ti i viera ad ter autmi futi ad d) pai, i, e it ur, i f te "deep variet it i rater diffue ad ma b e radiatig r "referred "** 6 e ei ma be deteted ad evauated trug it aiated pemea 7 e tepati ei i eived a a mt imprtat ad frequet etigia, predipig, exaerbatig, ad utaiig fatr i dieae, trug te etabimet ad maiteae f a viiu e f irritative, ifammatr, ad ter patgia pree i impair te defeive ad reparative apai tie f te uma rgaim 8 t ma be preet fr varig perid f time itut te pr duti f mptm 9 e ei ma be rreted r imprved trug te appiati f apprpriate maipuative tei A ig effetive tem f tepati maipuative terap a bee de veped ereb ei f ma kid ad ati ma be rreted 10 rreti f te ei i terrupt te viiu e ad i fed b regrei, ameirati, ·h iliy b hi oplx h lil rrr pi pr oiu
r abiti f te reated pat gia pree Eimiati f te ei prvide mre favrabe ir umtae fr te perati f te defeive, reparative ad me tati meaim f te bd 1 Reet reeare duted at te Kirkvie abratrie upprt te ui tat te patter f a ad ditat effet f te artiuar diturbae ad aiated pem ea te tepati ei mpex are mediated ad rgaized b te etra ervu tem te ei expree itef primari troug te part f te ervu tem it i it i aiated rre ti f te ei prvide a mre favrabe baae f ervu fatr Sie tee reeare ad te ept i emerge frm tem ave bee reet revieed te i be brie ummarized ad uppemeted b te advae tat ave bee made ie te pubiati f te revie a tr t preet ur ept damia rater ta i te rgia rder i i te ave deveped e reader ma fid it epfu t refer frequet t Figure 1 .) e diturbae f a artiuati exert it ifuee diret trug te ft tiue i urrud ad upprt it ere i k meaim ereb te pitia reatiip f t be r t vertebrae a be "regitered exept trug te tiue Furter, e ave te frequet iia bervati tat a tepati ei eed t ave aiated it it a gr artiu ar dipaemet At a rate, a a reut, fr itae, f a iterverte bra ei eter it be deribed a a ubuxati, a fexi, extei, r rtati ei) te paravertebra) mue, ted, ad igamet at eat e ide f tat artiuati are ubeted t, ad maitaied at, exeive tei i aue te prprieptr ed rga i mue ad ted eitive t age i egt ad tei) t fire ireaed uber f impue it te r repdig egmet f te pia rd, via te dra rt fiber it i te are eted e fre que f te impue fired b te reeptr i i prprti t te degree f tret everit f te ei) ad ie tee reeptr are reative adaptig, te barrage i
maitaied a g a te tei i maitaied e tret r mtati refexe are efreguatr ad efexitig at i, beaue te dra rt fiber afferet) bearig impue frm te prprieptr ape diret it te aterir r e i dut impue t te efame mue egmet, te treted mue are furter timuated t prdue ti mre tei i ma be a im prtat fatr i te maiteae f te artiuar deragemet e it i etabied eaue f te apti e ti f te dra rt fiber, diret ad trug iteruia eur, ti ervu timuati affet, ptetia r atua, te exit abiit f a eur i ave teir rigi e bdie) i te rre pdig egmet f te pia rd ee iude t te aterir r e, 33 3 but a te e f te itermediatera um, i are te pregagii eur f te mpateti ervu tem Te iude a te eur urig i te pia trat i i ertai true f te piaami iber i dut impue t te brai fr te regitrati f pai ad tere i evidee tat it appie t ter trat termiatig i upraegmeta truture A a reut f te utaied barrage f impue, tee eur, i te egmet f te rd aiated it te ei, are redered ad mai taied perexitabe t a impue i rea tem regarde f teir ure impue frm ter eg met f te rd, frm te iger eter, iudig te erebra rtex, frm te ki, et e iibitr apet f te ei ave t et reeived experimeta ivetigati) e egmet f te ei i aid t be a faiitated egmet f te rd, e i i "te barrier ave bee ered! e efferet mtr) eur i tee egmet ma be aid t be maitaied " edge i a tate f ubimia exitati), ad eai triggered it ativit b rea tive fe additia impue frm a ure
!
i hough by o h h pl ll rpr h ul rxly rgul h iiy h ul ibr i h i iiy h y ou or h r r ropi o rul ou i ul oi wih i
33
nc th nrons whch hav thr orgn n th sgmnt o lson as n all sgmnts o th spnal cord rprsnt nal common paths, th actvty o ths nrons (and th strctrs thy nnrvat) wll b dtrmnd by th balanc o nhbtory and xctatory mplss whch rach thm. Gvn a scnt backgrond o nros actvty sch as tat dscndng rom th crbral cortx ts nlnc wll b magnd and channlzd throgh th acltatd sgmnts that s th sgmnts o lson. As a rslt th rnt nrons (and ntraspnal nrons) havng thr cll bods n ths sgmnts wll dscharg abnormally ntns strams o mplss nto th tsss whch thy spply whch wll thror b mantand n altrd stats o actvty. Th sgmntal changs may ncld altratons n contractl stats, n blood low throgh varos strctrs and organs, n vscral motlty n rats and qalty o scrton, tc. I mantand or scnt prods o tm ths altrd stats o actvty ntably ld to pathologcal prosss n th actd strctrs whch n trn bcom scondary sorcs o arnt rrtaton Anothr vcos cycl s st n moton n whch ach strctr rxly throgh th corrspondng sgmnts o th cord, rrtats th othr componnts. Contnaton o ths procsss lads to proond strctral and nctonal drangmnts o thos tsss trophc changs whch no longr dpnd pon nrv mplss or thr mantnanc. As was shown by Dns low and Hasstt, and conrmd many tms snc th paravrtbral mscls n th sgmnts o lson rman rgd and apparntly shortnd and ndr tnson, n th complt absnc o acton potntals that s wthot stmlaton rom th antror horn clls. By dnton ths s a stat o contractr a rvrsbl loss o th ablty to rlax on th part o th contractl lmnts. (It wll b rcalld that Macknz ond smlar stats o skltal mscl assocatd wth vscral rrrd pan.) Ths mscls
s h ee ht ee the ere crco ce by the eo ros org tse po hch pce o mch emphs he "re of the rery s secory to chges he ero sysem
ar hyprsthtc and nqstonably contn to b a sorc o rrtatons to th cord. It s mportant to rcognz that trophc, clllar and nctonal changs to prolongd rrtaton and opraton o th vcos cycl may xtnd also to th cntral nrvos systm tsl. Co has obtand vdnc that mcroscopcally dmonstrabl changs n th cord ar assocatd wth th xprmntal lson; ths bar a dstnct r smblanc to th changs dscrbd by workrs n pransky's laboratory and by othrs. Ths pathologcal changs may comprs an ndrng rrtabl ocs n ts ltral sns and may b an mportant actor n th chronc lson. rthrmor as ndcatd n an arlr scton, localzd partal schma may b prodcd n th nrvos systm by prphral rrtatons. Kglbrg and Lhmann hav shown that mpard crclaton throgh nral lmnts may rndr thm not only hyprxctabl bt spontanosly actv, n whch stat thy may thslvs srv as trggr zons. Althogh th abov prsntaton o th concpt o th nral bass o th ostopathc lson has bn concrnd wth th sgmntal mchansms and manstatons althogh th prmary ocs s wthn th sgmnt o lson and althogh th pattrn o pathologcal procsss assocatd wth th lson s spcally conspcos n th tsss sgmntally rlatd to th lson, th mportanc o th xtrasgmntal and sprasgmntal cts s not b mnmzd, and s dmonstratd n daly ostopathc practc. Thy, too, may b organzd by th nrvos systm n at last two ways whch hav alrady bn mntond: (a) throgh th systm o ntrnncal nrons and spnal tracts and (b) by th prodcton o localzd vasospasm and partal schma n th nrvos systm. Th lson apparntly may rrtat ascndng nuons whch trmnat n varo pa o th bran. Throgh dscndng tracts and cranal nrvs sch as th vags, ths may n trn altr th ncton o tsss sgmntally rmot rom th prmary lson Ths concpt has bn nvokd by Col to accont or th wdsprad cts whch h clams or th xprmntal lson n th rabbt. Its smlarty to th sprad
o nrodystrophs n pranskys vw, s sggstv. mlarly, accordng to th vws o Travll and Bglow partal schma n parts o th bran stm d to lsons n th crval sgmnts cold also prodc arng cts. Th vdnc or th opraton o ths mchansms n th ostopathc lson s howvr, stl prsmptv. Accordng to th abov concpts, th bass or th ctvnss o ostopathc thrapy ls n slncng th somatc componnt o th complx by abolshng th contractr spasm or sstand contracton (and schma) o th skltal mscls n th lsond sgmnt. Lastng cts ar obtand by corrctng th mchancal or artcar dstrbanc whch mposd th strss. It s not a vtal qston actng th valdty o ths concpts as to whch part o th complx coms rst. Th mod o opraton o th soatc componnt (th ostopathc lson) s ndamntally th sam whthr th msclar and artclar dstrbanc was th prmary prcptatng actor n th complx or whthr t s scondary to rtatons whch ars lswhr n th sgmnt .g. n th vscra. Onc stablshd, t plays a major rol or vn th most mportant rol n th sbsqnt dvlopmnt o th pathologcal pattrn. Ths s amply spportd not only by clncal ostopathc xprnc (th scondary rlx lson) bt t s now a wl accptd act that th sstand msclar contractons n th classc vscral rrrd pan pattrn bcom an mportant contrbtor to th vcos cyc; t has also bn dmonstratd by Wo and hs coworkrs or hadachs o varos knds and orgns. Th mportant thng s that th somatc componnt whthr prmary or sc ondary, s accssbl and rsponsv to tratmnt and that approprat tratmnt o ths componnt by stablshng a mor avorabl balanc o nral actors, bnts all th strctrs assocatd n th pattrn and thror th ntr body. Te tren to a unitary concept of isease
Thr major lds o mdcal thoght whch hav had vry drnt orgns and drnt corss o dvopmnt, hav bn brly r Intrprtaton o rsach
iewed ad ow o ae a ea dea a i fudaea i coo. A ee coo ae, ipiciy o expiciy, acceped ceai baic picipe o eeaizaio a wic ey ae aied ou ey diffee expeiece ad pocee of eaoi. Tey appea o be coceed wi ey iia, if o ideica, peoea, aou eac ay coceie of e diffeey. A ee coo aee a e oaic copoe of e dieae pae, of wic e o copicuou feaue ae e uaied ucua coacio (iidiy, pa, coaue), e eoy cae (pai, ypeeeia) ad aooo cae, i o oy a i o ypo of dieae, bu a ao coibui faco o e dieae, ad a i ay be a piay eiooica faco A ae eefoe dieced eapeuic aeio o i copoe becaue of i acceibiiy ad epoiee o eae, ad becaue of e deoaio a ipoee i i copoe eu i ipoee i e oe, ou ieupio o eadaio of a iciou cyce of ipue (o opic ifuece) coui ou e cea eou ye. T e eae of i copoe i e ey coe of e oeopaic ye of pacice, wie o e oe i i a be expeiea o aciay o oe fo of eapy. i ipoa o poi ou a i a fou ao ed of pacice, wic i daiy becoi a ae ad oe ipoa pa of e eai a ad ciece, i iiaey boud, by ecai, o e ee eiewed aboe. diicie feaue, oo, i e epai o e eou ye, epeciay e ceebu, a e oize of, ad ee a a piay eiooic faco i, dieae Refeece i ade, of coue, o pycooaic edicie. Repeeaie of a ee of e coo peiouy eiewed ae paced epai o e ie cee, epeciay e ceeba coex, i e oe of iibii, excii, exaeai, aki, eifoci, o iiiai e dieae pae ediaed by e owe ee. Tae ad Bieow, Teobad ad oe ae doe i fo e efeed pai coo Fakei a de
oaed e ifuece of e ceebu o e peoeo de iaed a euodyopy by Speaky ad i foowe Ko a acibed o e oeopaic eio coic eea faciiaio) a ocaizi, caeizi ad pedipoi ifuece i e bodiy expeio of ea o eoioa ibaace i o upii a i i bei o widey ecoized. Afe a, e eou ye exe i ifuece o e body ucue ou e effee euo wic ae fia coo pa eceii ad fuei ipue fo a o of ouce i e body, o e ea of wic i e ceeba coex a ee coo ee appea o be a deepai of e pecificiy bewee e eiooica ae o e o e ad ad e aifeaio of e dieae o e oe. We ee a appoac o a uiay cocep i wic dieae i coceied, o a e effec of i ae o a upo i oa o a, bu ae a e rean f e rganm a a e nu nfuene i bei iceaiy ecoized, ad epeciay i e aboe fou fied, a e oai ca epod i oy a iied ube of pae o oxiou ifuece Te pae e caace of e dieae i deeied by e paie, ad o by e offedi o iadi ae e eou ye ceaiy a a key oe i e oaizaio of e pae Tee coo, e i be aid o be caaceized by ei epai o e iiaiie ao dieae ae a o ei diffeece "Tee ae o iee ee ae oy i peope. Pobe n e uue of e oeo one
Tee ae ay ipoa ipicaio i e aboe oy fo e oeopaic pofeio Te pee wie i ady e peo o daw e eo fo e pofeio, bu i i be we o poi ou oe ipoa fac ad ake oe pedicio uppoed by e foeoi ad by ece cieific ad edica adace i cea a e baic cocep upo wic oeopay i baed ad wic ae bee dea wi o uccefuy fo oe a a afceuy ae eceii iceai ieiaie aeio ad iceai eapeuic epai fo oe ao coo
of edica ou ad pacice. Woke i ee oe coo ae aied a ee baic cocep by paie, ieie, ad exeie expoaio of baic ecai Tey ae aied a ee cocep ou ey diffee expeiece ad pocee of ou a a e oeopaic pofeio, ad, ideed, i ik of e ad appy e i a e diffee coex Te oeopaic pofeio a eaed i pace i ioy ad ociey, owee, ou ai deeoped, ad effeciey ad kifuy appied, a ye of diaoi ad eapeuic baed o e oe of e oaic ucue i dieae a deoaed, aou i i o ye ecoized by e oe coo, a e oaic copoe ca be o diecy ad effeciey ifueced ad cooed by adue of e eeba ad paaeeba ucue i e , by ecoiio ad coecio of e oeopaic eio Oe iuaio wi uffice Te oaic ie aea wic Rize ad Tae ae foud i e uce of e oacic cae, i aociaio wi ceai cae of cooay iufficiecy ad ucua diode, ae appaey ideica wi, ad ceaiy iia o, oe cooy aociaed wi e ib eio faiia o e oeopaic pyicia Adue of e aicuaio of e ibead o e eeba i foowed by diappeaace of ieey ypeeeic po i e eau ad pecoa uce ad eief fo pai. I i ipoa o eca, ao, a ib eio i e uppe ee ofe poduce pai pae ad oe ubecie peoea ypica of aia pecoi ediae copee, ad ai eief i obaied upo coecio of e eio a ye of diaoi ad eapy ad e cocep of e eio diiui oeopay fo a oe coo, ad ey ae poeed by o oe coo Aduie aipuaie eapy, a e ea of i pacice, diiuie e oeopaic pyicia fo a oe We u be uick o ecoize, owee, i e i of e foeoi, a woke i oe coo of pacice ae paci iceai ipoace, wi epec o dieae upo e pocee wic ae aociaed wi o iiiaed by e oeopaic eio, ad ae akig e 5
os and eectve attempts to base theapy on the ntepton o those pocesses Athough t s mpossble to make accate pedctons one can say wth a hgh degee o cetanty that contnued nvestgatons by these wokes mst nevtably lead to the development o new and bette oms o theapy. Although t s possble that they wll "dscove the osteopathc leson tsel and the dect methods o ts teatment, t s mch moe pobable, n vew o the pesent decton o the wok, that they wll ccumvent the leson by leanng how moe eectvely to deal wth the pocesses t sets up As a esult o o own eseaches we ae pesented wth vey pomsng appoaches t the development o new oms osteopathc theapy n whch the leson s teated smply by peventng ts eect on the body The apdty wth whch these appoaches ae pused wll be dete mned to a lage extent by the esouces whch ae made avalable It can also be stated wth a hgh degee o cetanty that the stage has been set by hstoy and scentc advance, o the emegence, n the nea ute, o the osteopathc concept, o fom o aoh as the domnant system o pactce We beleve ths to be tue egadless o what uthe the osteopathc poesson does abot the development o the osteopathc concept n pepaaton o ths hstoc ole. In what way s hstoy makng a place o osteopathy as the domnant system o pactce? om ts vey bth osteopathy was aced wth oweul competton m the concept o the "oegn gent n dsease Pastes dscovees almost concded wth those o Stll. The bacteologcal concept o dsease the concept that dsease was caused by ths ogansm o that was sweepng the wold (as wee the dseases whle Stll and hs ew ollowes wee patently and heocally stugglng o ecognton o the osteopathc concept Ths was takng place at a tme (the thd and outh quates o the last centuy when medcal scence was pactcally nonexstent n ths county, and when, although geat stdes wee beng made n Euope (Pasteu, chow, Ehlch, Metchnko, Muelle, Benad, not one esult o eal scentc 3
nvestgaton had yet been successully appled to theapy, at a tme when the nectous and contagous dseases wee the mao health poblem, and when the aveage le was cut ve shot by dsease "caused by nvadng agents Today, as a eslt o the temendous advances n ou knowledge o the nectous agents and the modes o tansmsson, n mmunology, peventve medcne, chemotheapy, n the socal contol o dsease, n santaton, etc., the nectous dseases e no longe the mao health poblem o the wold In the past 0 yeas we have seen them, one by one, succumb to these advances, untl today the bggest klles among these dseases have been all but eadcated. A contnuous declne n ncdence o all nectous dseases may be elably expected. Ths declne s stkngly llustated n the leadng causes o death In 00, tubeculoss, pneumona and the acute ntestnal dseases, entets and typhod eve, wee way out ont Pneumococcus pneumona today s a vanshng dsease typhod eve s vtually eadcated tubeculoss seems destned o a smla ate Today the man klles ae the chonc degeneatve dseases, whch clam the vctms lagely om the olde segments o the populaton As a esult o these advances thee has been a geat ncease n the aveage le expectancy. Pesons n the mddle and late yeas compse a much lage segment o the populaton than at the tme o the oundng o osteopathy In the last 0 yeas the popoton o people ove 60 yeas o age has doubled It s now 0 pe cent and s expected to double n the next geneaton om 33 to 6 alone the aveage age at death nceased om 82 to 62 Howeve, although the pecentage o people ove 60 has nceased, the aveage man at 60 has the same le expectancy as had a man o 60 n 00 about yeas In othe wods, lves saved om nectous dseases ae stll beng lost at an age not a om the tadtonal ones o the past They ae beng lost to the chonc degeneatve dseases the dseases o matuty and senescence, the unctonal dsodes Lage segments o matue and olde pesons lve hghly estted, unpoductve exstences, budened wth dscomot
and dsablty, esultng om these dseases As D Leonad A. Scheele stated upon hs nducton as Sugeon Geneal, "We nd ouselves aced wth an enomous pesonal and natonal bden o dsease n the adlt populaton, the most poductve element o o socety It s possble that we shall not be able clealy to dene healthy matuty untl we lean moe about the chonc degeneatve dseases and untl we attempt to apply h oulao ou knowedge o these dseases We have barely stated to exploe the mao causes o death and llhealth among adults al uld) Although chonc and degeneatve dsodes ae spoken o as dseases o matuty o o mddle and late le, t s not adequately appecated that oten they have the begnnngs n youth and chldhood Ealy le and chldhood ae themselves too equently vctmzed by the chonc dseases and dsablng unctonal dsodes. h dseases ae today the bggest klles, the bggest cpples, and among ou most pessng socal poblems Today the osteopathc concept s the only one sucently boad and sucently untay n ts outlook, upon whch a m o pactce can be based, that s capable o encompassng all these dseases Today osteopathy s the only system o pactce whch has peventve potentaltes wth espect to these dseases Medcal pactce as yet has no key, no cleacut, and cetanly no ma appoach to the peventon o these dsodes Teatment s stll lagely pallatve, symptomatc, o substtutonal A ew llustatons wll suce In the teatment o dabetes melltus n whch such geat advances have been made snce the dscovey and solaton o nsln, the dsease tsel the panceatc decency s taken o ganted The peventon o ths decency, o even the elmnaton o the bass o the decency, has eceved no pactcal theapeutc attenton Wthot mnmzng the mpotance and the magntde o the advances made n the ecent past thogh eseach, notunately no moe than ths can be sad o the othe chonc degeneatve dseases and nctonal dsodes What can be postvely sad about the o o heat dsease, co Intepetaton o eseach
ar ri perei ad periperal vacular dieae e ki dieae e arriide kide dieae reuai pepic ulcer ad e edcrie diur ace? Ca i e e aid a edical ciece i e tratmnt ee dieae a ge re a a ep ed e palliai e ig ad p r ed e reae e erial ep i e dieae prcee? I ac e er ial prce i uuall reerred a e caue e dieae e ed crie dieae are caued uderr veracivi i glad r a; e are accrdil read u a ciai acr led e ver r uderacivi? acrie e auic ialace r e uder r veracivi aer lad i erel eg e quei e ucce epa i e reae a ee dieae ad e prie epa i eir prevei lie i e llig ree acr: 1 e ideiicai a ar predipig ad priar eilical acr i dirder aeci a par e d 2. deecaili i eve ver earl age; ad 3 I aeaili crreci bor i de irreparale daage ll ree i er rd ea e recgii ad apprpriae rea e e epaic lei grea deal ever reai e leared ere epa i adequael prepared r i rle a e preveive edicie rr 1 e eecivee epaic erap i prevei ad alleviai dirder all kid eed e preciel evaluaed a a cale i require reliale cpari ege e ppulai receivi epaic erap i e a icidece e variu dieae rali durai e ille cvalecece ec aiic e crl ege e ppulai are alread apl availale I i diicul cceive a re iraive ad re cvici urve e erapeuic ad preveive eri epa a e cpari lare rup cildre e ic i uder epaic aagee e er ad lli eir edical recrd i aduld
e epaic prei a ipl eed adequael i uicie periece i adequae crl i ecive eug ed i careul eug recrdig ad i u cie uer e value ep a i a large uer alig cdii epeciall e deal i i e variu pecialie ic ave develped ice ill da I i eie ea rer c veie paic reae 2 Oepaic ccep ad ecic ave e develped e pi ere e ca e applied eec ivel ntr populaton i e ae a a e preveive edicie da prec illi a a ie agai ieciu dieae 3 rea dea re eed e leared au e acr leadi e develpe e lei e rucural pural ceia e vireal ieriale ccupai al age acivi ad er acr Wa aai i i regard culd e re iraive a udie lare uer cildre i diere ae rup r e icidece le i variu kid i relai e variu acr? i uld ake pile educai ae peple e prnton o t l on 4 We eed reliale eail applied ed deeci e lei ic a e uilied e la ppulai a e a eei r earl crreci 5 We eed lear a rea deal re au e lei iel ad e prcee ic i iiiae ad uai Wiu quei e ie lar ad kill required r e crreci eac lei e a cerai lii up e a applicaili preeda epai erap al ug da a lar ad kill are e ai r e ver ucce epa ad i diici r er r erap O e ai ur pree kledge i i eirel cceivale a a iger re eeral le lariu r epa a e acieved prevei r ierrupi e eec ei prevei r alig e prcee a lei iiiae erever e lei a e ad eever e ccur i piili a alread ee reerred ad i i ipra recall a e prcee aciaed i e lei are receiv
ig idepread aei i e paic iiui I uld appear r e reig a cider a e epaic ccep i e ae da a i a a e ie i icepi i a eriu iake edeavr kp i e ae i eve a re iake i de ipl deparure r e udaeal illia priciple u raer eir eei eplaai ad elarai a rece advace i geeic ad clg ave de r e Dariia priciple e ccep iel a ee greal e riced ad develped ad i r applicai i rae eecive e ave ee ideed u i pra e epaic ccep i diere da r e iple rea a i a e rle pla i re pec e aial eal ad i perae i a ver diere ce cial pliical cieiic ecic r a i ill da livig rki ccep ad e e paic ccep i cerail a culd reai e ae ile e cee arud i i rared e ad re ipra place i e rld cee r e epaic c cep a ee ad ciue e prepared e ccep ad e ec ic u ciue evlve ill a place i i i e cee ad perae i e e ce u e u evlve a a acceleraed pace ecaue e cee i cagig rapidl Cncuin
I uar e r i perpec ive e lli appear e e ar ak ere e prei da pracice epa a eave quei leaie i e id e paie a a i diicive au epa a a e pracice ad erei lie i eri I vie e cliicall ad eperieall deraed rle e epaic lei a a predip i ad eilgica acr e que i i eriul raied eer a epaic picia a e ral ri ild e l erap ic da ca crrec i Oe ca cerail quei e id r ivai a epaic picia ca aide e perul ad preveive eap ic e ale pee r palliaive ad p aic erapie ipl ecaue e 13 7
ae moe oeet o eae to ap y. Oe a etay queto the tety of ay oteopath pya o at the eapo ade to oea dtto from othe phya. B e profeo mut etabh a eeah proram of uh matude ad podutee a beft te h tor mpotae of the oteopath oept I Th requred to prode the formato ad the e te h pepare oteopathy for t roe a the etra theme the ea ad peeto of tomoo o a ma ae. e eed data ad t moe data C e oteopat oee mut beome amo te bet ttuto te ord fo te ta of phy a phya ho be pe paed to meet the ro haee phya o touh ter ta etfi oteopathy po de te teady team of eeded fomato ad data phya ho eek ad ko ho to appy etf adae to the eath of makd; phya ho ko o to teah othe to do kee Our oee mut be taffed by te bet phya ad the bet ett ho mut be e the mea th h to do the bet ork he faute mut be uffety ae that o membe o budeed th pedaoa o a dute that he aot otbute thou eea to the koede h fed he thrd uquetoaby te mot mportat of te tree tak beaue the fufmet of the other to a e a toe oered th oraato eato ad pub eato fo from the fuf met of th oe e oteopat profeo ha eaed a tae of de eopmet ee t pore from o o be mted by ad det popoto to te poe ad efae of t tra ad reea poam Thee tak t oud appea ae the order of te day for the oteo path pofeo It mpotat to emembe that the etf od ad makd eera are euta the tue of te oteopath profeo aat t oppoet; they ae ee dfferet to the queto of t ua ad otued oth a a diin and epaae profeion. hey ae ot euta hoee te queto of
tuth eu utruth epeay a t affet te eat ad efare of umaty e t tat make pobe te otued ad rapd de eopmet of oteopaty to t fuet poteta are te ey t tat at te ame tme ead to t uer a aeptae a a uperor ad dpeabe fom of pate e refer aa to data od o troetbe fat permt o aterate ouo; ot opo ot quotato ot the oated da mat ae ot ee fat but te etf ubtae fat a be tr tory ad oety ae peeted the oteopath pofeo t a eat haee ad a reat oppo tuty the deeopmet of oteopa ty to t fuet mae pote ta Beaue of t utrou haf etuy of uefu appato of the oteopat oept th profe o ha bee bet equpped by h tory to meet th haee eter ad ho te pofeo meet te aee deteme the futue of te oteopath profeo but no the ura of te oteopat oept; ha eem determed Good dea eer de; oety ee tuay make pae of hoor fo tem If th pofeo doe ot take that hto opportuty ad meet that hee te ote ertay To paraphae a apom of S am Oer I ee redt oe to the ma or te pofeo) ho oe te od ot to the oe to hom te dea ft our The htoy of te oteopat profe o ho that oe a aee ha bee eoed araby that aee a bee met ad th hoor feencs Korr I M . Research program for the osteopathc professo J Am. Osteop A 47369375 March 1948 2 Sturge W A: Phenomena of angia pectors and ther bearng upon theoy o f couter-rritation Brain 5492510 1 8823 3 Ross J: On the egmetal dstributio of sn oy dorders Brain 103 33361 1 8878 4 Hed H On disturbaces of sesation with epecal reference to the pai n of visceral diase. B rai 16 133 1893; or 1:339480, 1894 5 Mackenze J Some pins bearng on the asciato of sensory disorders and viseral disee. Bran 16321 354 1893. 6 ewis n he Mcmlln Co N o 1942
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Mackezie, J Symptoms and their interpreta ton d 2 Paul B. Hoeber New York 1912 p. 3 ff (Alo later edtions) 8 Drucker D Referred pan ad the osteopathc lesion J Am Osteop A 47:623-629 Aug. 1948 9 Hinsey JC and Phillips RA Observatios pon diaphragmatic sesatio J europhysiol 315-181 Marh 190 10 Lewis, T ad Kellgre JH Obervatios relatg to referred pain, vis cero·motor reees ad other ssoated phenomena Clin Sc 447·71, June 1939 I Kellgren J H Somatic simulatg sceral pai Cl Sc 403·3 Oct 190 1 2. Downma CB B ad McSwiney BA: Reflees eliited by vsceral stmulato i acute spinal animal J Phyio! 10589, Jly 15, 196 13 Weis S ad Davis D Sigiicace of af ferent impulses from skin in mehaism of viscera pain skin infiltrato a s sefl therapeutic measure Am JM Sc. 17651536, Oct 1928 14 Wolff HG, and Hardy JD: O ature of pan Physio! Rev 2 16199 April 1 947 15. Wolff HG, and Wolf S Pai Charles C Thomas, Sprigield Ill 1948 16 Travell, J and Rinzler S H Relief of cardac pa by loal blok of somatic trigger areas Pro Soc per. BoI Med 63:8482 o 1946 1 Rinzler S.H and Travell J Therapy drected at somatic ompoent of cardiac pain Am Heart J 35 248·251 March 1948 18 Lindgren, I Ctaneous prordialanesthesia in angia poris and coroary oclusion n ex perimetal study Cardiologia 1 1 207-213, 19467 19 Traell, J and Bgelow H Role of somatc trgger areas patterns of hyteria Psychosom Md 9353·363 ovDc 194 20 Roberts J T Role of asa nervorum eseially regard to referred pan" Fd Proc 7103, 1948 21 Sperasky AD Basis for theory of medcie Interatioal Pblishers New York 14 p 452 ff 22 Wess P Site of cell growth Scien 15 1 1 Nov 28 1947 23 Schmitt, OH Measuremet of electrical eergy release, impedance and longitudial transport i nerve by differential electrode techiques Fed Pro : 1 1948 24 rankstei SI. One unconsiderd form of part played by ervous system in development of dsase Science 12 Sept 12 1947 25 Spransky, AD perimenta ad cliical lobar pnemona Am Re Soviet Med 2:22·2 Ot
9
26 Gisburg M: Pathogenesis and treatment of lobar pemonia Am Rev Soviet Md. 22836, Oct
9
27 Deming, G. Backgroud for rational therapy Oseop Med. 128 Aug 65, Ot 1943 2:20 Ja 1944 28 Korr, I M Neural basis of ostopathc lsio J Am Osteop. A 47:19 11 98 Dec 1947 29 loyd, DPC. Condctio ad syaptic tranmsson of relex response to stretch n spnal cats J Neurophysol 6317·326, July 1943 30 Denslow, JS ad Hassett CC Central ex ctatory tate associatd wth pstral abnormalites J erophysiol 5:393·02, Sept 1942 31 Denslow J S An aalyss of ariablity of spinal ree thresholds J Neurophyso\ 720215, July 1944 32. Denslow JS Korr I. M and Krems, AD: Quatitative studies of chroic facilitation human motoeuron pools. Am. J Physio 105229-238 Aug 1947 33. Korr, IM., ad Goldstein MJ Dermatom autonomic activity in relation to segmetal motor
Itepetato of reeah
rx rsol F Pro 67 1948 4 Col WV Oopai lion omplx J Am Otop A 47 99-4 99-4 April 1948 5 ugbrg E njur tivi n triggr zon" in umn nrv Brin 1 04 D 1 946 36 Lmnn J E Et Et o spi on mm mm mlin mlin A nrv nrv ibr ibr Am J. Psiol 1 19 I 110 197 7 obl GW. om gnologil spts o rfrr pin J Ob Gn Bri. Emp
5-7 Aug 1946 8 guin CA. onpt of i Poom 8:557 JuAug 1946 9 Wolf Eprimnl rr ino osomi pnomn in miin in 107:6769 Jun 18 1948 Ln A A. till founr o otop Journl Printing Co Kirvill o 1 Long ER il in n ongr i in 107 05-07 r 6, 1948
4 mn b Dr Lonr A l upon in ution urgon Gnrl Publi H ri Frl Frl uri Agn Agn April 1948 J A Oop Oop A 47 47474 47474 1 948 Lng A: A riw of rr introution Ostop 1 57-64 Ot 194
prin b rmiion rmiion rom JAOA 48: 171 8 1 948
e ree fudmenl roblems n oseoc reserc (1951) e reedin reedingg aer n t i i Sym ium ae been rgre rert n fur different but related lae f infrmatin lleted at a ertain tage in te life f a ertain gru f indiidual e beliee the urey i unique in teati itry fr a number f rean inerent in it a rah t teati fundamental and tere terefre fre t te wle wle que tin f ealt and dieae. Firt it i an enemble f tree nentinal reliable guide t teati diagn i and teray wih ae been brugt t a ig leel f tandardi zatin in mbinatin with a m letely bjetie metd fr te ealuatin f lein enmena Ti bjetie metd i but ne f many in re f deelment in the Deartment f Pyilgy fr ti ure. Send te urey i unique in tat it i a tudy n early tage f atlgial ree in a redmi nantly ealty ulatin hee are atlgial ree wi reeie n nideratin in allati ra tie In te early tage in wi tey are fund in thi gru f yung men and wmen tey are fr te mt art aymtmati aymtmati it nly nl y few e etin wuld tey ae rided te bai fr a iit t a yiian ffie. Sine thi i a ntinuing urey wi ride fr bera tin f tee atlgial ree and their rene t teray er a lng erid it ride a new and mu needed ara we beliee t truly reentie mediine The immediate alue f ti urey lie in te fat that it a made it ible t arrie at a learer and mre uniied frmulatin f te fun
damental teati rblem than a eer been attainable befre. It I t ha al illuminated te ath tat mut be taen tward teir lutin It i te ure f ti aer t diu tee rblem and teir arae. arae. It i well etablied tat the tural trutural r meanial ab nrmality nwn a te teati lein et in mtin a mle yiathlgial re we ure eed and ultimate manife tatin are influened by all te fatr in uman life wih aue ne in diidual t differ frm anter e ultimate bjetie f te re earh team u a the ne rere ented in thi Symium i ntin ually t arm te yiian with better and better methd f deteting ealuating reenting and farably influening te dieae re aiated wit te teati le in i an be amlied nly trugh elratin int it intrini nature it thi in mind ur urey hw tat the fundamental fundamental rblem befre teati reear wrer tday are eentially tree in number e all tem fundamental beaue ea i entral t lie at te te bai f tua tuand nd f ter ter wi the teathi rfein enunter in daily ratie. e lutin f the entral ne ride the bai fr the lutin f te numeru erieral ne related t it Prgre in iene i meaured by te regnitin f te entral entral rbl rblem em and te rel relu u tin f te many many int te few. Diu in f te tree fundamental rb lem fllw
. The leson process
e ae deignated te firt rblem a te lein re itelf e deelment and aried manifeta tin f te teathi lein are rganized by a mle re et in mtin by ertain tree In ti Symium we are nerned rimar ily wit te imed n te bdy by graity r influened by graity t nw aear well etablied that ti re i refle refle in nature and tat te flw f imule alng te mle atway i initiated by timulatin f me enry at r at wih are yet t be identified. One in itiated ti yle f imule mehw utain itelf and reed t rganize te ariu but related manifetatin f te lein mle mle Te re may be initiated aarently by graity wi ating trug te leer f te eletal ytem ime tree n the tiue whi urt and me tee leer In abnrmal bdy meani tee tree eeiely eite and n tinue t eite te reetr and nere ending wi are renie t tenin reure alteratin in lengt and t differential in tee• eir rene are regitered un te entral neru ytem trugh afferent fiber entering te r rending egment By definitin tee mrie te rrietie ytem f te bdy. Teir eat mde f atin under abnrmal weigt bearing tree remain t elab rated. ma in the reeding par in ti Symium a reented a rmiing ara t te funtinal analyi f rrietin in dif fere ferent nt natura naturally lly ur urring ring 39
skeletal configurations associated with faulty weight bearing Still other sources of primary irritations are yet to be identied What is the process which, when initiated by weight bearing or other stresses, organizes the mnifestations of the lesion complex? What are the bonds between the various compo nents of the lesion complex? What is the pattern into which they fit? Prog ress in this eld requires rst the cear identication of the components of the lesion compl The manifesta tions of the osteopathic lesion, regard less of its nature, location, or origin, appear to fal into three main categories. They are (1) the sensory and spra segmental; (2) the motor or neuro muscular, and (3) the autonomic or vegetative 1 Let us consider consider the suprasegm suprasegmen en tal component rst. It is easier to reach the conscious and other higher levels of the nervous system through the lesioned segment than through the nonlesioned. Commonly this is ex pressed in hyperesthesia and hyper algesia (and spontaneous pain if pres ent), but it extends aso to other more subtle i nfuences nfuences on higher-level functions not yet evaluated 2. The second category of manifestations is the motor or neuromus cular This category includes local aterations in tensions and contractile states These are manifested to the physician as palpable rigidity and limitations or resistance to motion, to the patient as pain or fatigue. 3 The third category is the auto nomic or vegetative. When we reect on the many different kinds of tissues and organs under autonomic control and their many different different activities, w e see that autonomic influence is ex tremely varied in its expression. Ac tually, however there are only two possible categories of expression of autonomic influence: alterations in smooth muscle activity and altera tions in secretory activity The first, of course, includes vasomotor activi ty as well as visceral In these three three categories categories supra supra segmental, motor, and autonomic are encompassed, we believe, al observed and possible manifestations of the osteopathic lesion. The details of these manifestations, and there is an infinite multitude of patterns, are determined primarily by the locus and 14
secondarily by other factors to be discussed For example, depending upon the segments involved, sympathetic hyperactivity exerted pon the bron chioles will have quite a different manifestation and effect on the body from that resulting from similar hyperactivity exerted, through other segments, upon the colon or the eye, the stomach or th heart, the kidney or the pancreas, the adrenal cortex or the thyroid, although the same fun damental process is common to all Further, int ense sympathetic hyperac tivity may produce ischemia in di ferent tissues, including the central nervous system itself, but the effects on the body will show many varia tions in accordance with segmental level Thus, we see the limitless range of manifestations that may result from the same fundamental process according to its site of action. It is important to recognize that these three general categories in which the osteopathic lesion expresses expresses itself itself aga again, in, the sprasegm sprasegment� ent�l l the motor motor and the autonom autonomic ic are not unique to the osteopathic lesion The same general manifestations and the same fundamental process lying at their basis are associated with a great many other pathologica pro cesses those of primary visceral origin, those of traumatic origin, those of microbial origin, and those having a large psychogenic element I In essence, this means that the same central process may be initiated in different ways the postral stress is only one of many The pattern is determined by the locus and not by the initiator. This is partially recognized in the designation, "secondary refex lesions. We begin to recognize, therefore, that a great many diseases which on the surface are so diverse in character as to reqire a highly complex system of differential diagnosis, therapy, and nomenclature are essentially one disease, the manifestations of an identical process expressed in dif ferent parts of the body When e have learned the intrinsic nature of the process we shall now how to prevent or interrupt it wherever it may be, whatever its mode of initia tion, and thereby deal in a nified system with many diverse diseases, rather than with each one in a dif ferent way. Today, the science of
osteopathy offers the only approach to a unitary concept of health and disease, bcause it alone recognizes the universaity of this process and its signs Since only osteopathy nows how to recognize and deal with the early stages of this process, it pro vides the only basis today for the preventive medicine of tomorrow The process lying at the basis of these three general categories of clinical manifestations remains to be identified, and this, perhaps, is one of the most important problems before society today since it may very well be the ey to many of the chronic degen erative erative disorde disorders rs the main main causes causes of ill-health, premature senility, and dath What clues are there? We have come to recognize in the past few years that the lesion complex, that is, the three categories of manifesta tions, is organized by the central ner vos system• The pattern of expres sion potential or actual, is deter mined by the parts of the nervous sys tem involved. Other factors can only inuence the fllness of its expression at any given time Recent research in our laboratories indicates that osteo pathic lesions are associated with segments of the spinal cord fro which impulses fow more easily along ascending neurons to the sen sory and other higher centers, along its anterior horn cells to skeletal muscles, and along the autonomic outflow to smooth muscle and glands of many different inds These three inds of neurons, corresponding to the three general manifestations, are, in the lesioned segment, always closer to activity or are continually more ac tive than corresponding neurons in other segments It taes less of a stim ulus, from any source, to send them into activity and to sustain activity. For this reason, we have come to thin of the segment in lesion as a facilitated segment. 2, S I t is a neurological lens which focses and exaggerates irritations pon those tissues which it supplies In short, le sioned segments are those which are, in the true physiological sense, in a continal state of "alarm or are continually bordering on a state of alarm Over a period of time damage, to some extent, is inevitable. 2. The tme fctor
This brings us to the second fundanterpretation of research
mental problem mental problem the ime ime ator ator Here we are onerned with the hanges hat take plae as he proess ages We n ow very wel rom lin ial experiene that the lesion omplex and is many maniestations do not spring ull blown into being; here may be many years beween beween the i nitiation o the lesion proess and he ull or even partial expression o he latent patern The strutural survey* being on duted on several hundred shool hildren by Waae M Pearson and George Rea and their oworkers at the Kirksville College o Oseopathy and Surgery indiaes hat serious weightbearing and other skeletal abnormalities aready have a high re queny in hildren between the ages o 6 and owever, the physial indings and the obvious welbeing and vigor o most o these hildren in the ae o apparently serious postural stress stresses es indiate tha tha the lesion proess has no yet produed striking physiopathologial hanges. We an reliably predi, however, on the basis o he survey whih is the subjet subj et o his Symposium , hat hese same proesses wil have aken some o by the time hese hildren have reahed rea hed he average age o he stu dent body a Kirksvile Colege, even though serious sympoms may still not have atained high inidene Even asual observaion supports the addiional prediion tha ahes and pains, as wel as hroni disease, will have beome a daily eature in the lives o many o these hildren by he time they have reahed the average age o the Kirksvie aulty. The seed or these disabilities is already planted in those postura stresses o whih these youngsers are, or the most part, so blissuly unaware today The stages through whih he lesion proess passes over a period o years has hardly been explored We know ha he primary proess indues pathologial hanges in various issues inluding visera and he nervous system isel, as disussed under the irst problem and ha these in turn beome seondary soures o irritat ion . These seondary
6
<h uey me pe y he pga f egu phy i Cuny a h he ege T pga i dre d y Ve ead he Depme P a ad Cuy eah Oe
xito of t th
O
soures not only ontribute to the maintenanee and exae maintenan exaerbation rbation o the pathology bu over a period o time they may aually shit the balane o pathologial ores to new and even opposite diretions The same may be said o he various adaptive or om pensatory reations and tissue hanges eliited by the primary lesion A n exitatory eet eet may resolve itsel into an inhibitory eet and vie versa Certainly, the aute lesion is qui te distint in many aspets rom rom the hroni one A great deal remains to be learned regarding these various seondary and teriary hanges and onsequenes. The terms we use to desig nate or desribe them, saisying though they may be to the user, are only names or desriptions tha leverly oneal a lak o knowledge. The words words rophiity" and rophi hange," or example, represent a rih and unexplored world t is important to remind ourselves in this onnetion hat in the subjes o his survey, he seondary and tertiary hanges are no yet ully deve oped and, to that exten, the patholog ia proesses whh we are sudying are, as ye, hiey prelinial or sublinial and presumably sill revers ible The imporane o this onept to he prevention o disease is lear
Other factors
Now we ome o he third undamen tal problem Other ators whih deisively inluene the lesion proess We have ome to reognize hat the osteopahi lesion as a phenomenon o entra ailitaion is a most importan predisposing loalizing, and probabiliyinreasing aor in disease. t is very oten the deisive aor. As he most aessibe ator in the disease omplex, the osteopahi proession has learly demonstrated that the treament o the lesion may make the dierene between relatively good heah and reatively reat ively poor heath . As our survey has made quite lear, he degree degree o un ess o expression o the pattern behind he lesio n omplex omplex is greaty in uen uened ed by a large variety o aors These obviously inlude al the ators that distinguish one individual rom anoher: the onsitutiona aors another generi term behind whih we vainy ry o oneal ignorane), age, environment, past
F Meemen Me emen ele n re· nce (See
hisory, nurition, emotions, per sonaiy, and many others A given sruural deet may produe no linial maniestations in one in dividual and a serious one in another A relaively quiesent lesion ma mayy sud deny, under a new se o irum sanes, or gradualy, as hrough the proess o growing older, bring into maniestaion he ull laent pattern o proesses and maniestaions in herentt i n that part o the entral nerheren stage o vous sysem. At our present stage knowedge, we an have ony a notion regarding the general d o the infuene o these ators but litle more. The inluene o erebral ators, or example, on the speed o the undamental proess and the ullness o its expression, is impliitly reognized in the pratie o psy hosomais. or wan o a more diret approah to the proess, psyhotherapy is, o ourse, eminently useul in the treatment o disease. The emergene o psyhosomatis in reent years bespeaks the triumphant reognition, in allopahi pratie, tha here, a last, is an etiologial approah to hroni dis ease. The oseopahi esion, how ever has or hree quarters o a enury been known to provide a more speii somati handle or the manipulaion, lierally, o he proess proess itsel. These, then, are the undamenal problems beore oseopathi sientisss today: ( I ) The primary proes entis proesss initiated by postural stress whih organizes the pattern o the lesion ompex, the hanges and aruals wih ime, and (3) the oher ators whih inuene he rate and ulness o expression o the pattern There are, o ourse, ourse, many other problems problems Careul refetion, however, shows
11
Fg 2b Fg 20 Fg 3 Fg 2 lu Fg lut tto to of cotc of of egme egmet tll dt dtbut buto o of o o etce etce e hded hded). ). E Eplot ploto o 2 mo mo th pt o o me ubect b d df ffeet method d dfeet exme e ecoded 20 d 2b Th ce ce eected eected to ho eteme to ze hpe d tet of of lo etce e tce e e hle h le egmet vol voled ed emed eetl eetl uchged. uc hged. Ot Othe he epl eplt to o tet) Fg 3 Blte demtoml tp tp of of lo k etce e tce fou oud d c cee of cut e gtt Fg. 40
Fg. 4b
Fg 50
Fg. 5b
Fg 40 d 4b Effect of tmucul ecto of of h hpeto petocc le ecto ecto of 3 cc of 6 pe ce t odum chlode to te mked b left eecto pe m t t egh th thocc egmet d d ght tecotl tecotl t th h thocc) cue pp ppece ece of of e o o etce etce e e coe coepodg podg demm. N Nee e e ec eccled cled dtguh dtguhfom fom pe-etg pe-etg e) Fg. 50 d d 5b. Dtbuto of the e e eel hou f fte e epemet of Fg Fg 40 40 d 4b
that most of ose that ome to min ae pephea an wil fall into ine as nfomation aumulates on the ental ones Methods of the Depament of Physiology
n the spae that emains wish to eview a few of the metos tat ae beng aapte an evelope in te Depatment of Physiology fo the investigation of te poblems is usse above an f inopoation into this ontinuing suvey t must be emphase that these
1
poeues ave been eveope fo investigative puposes ony an ae by no means to be onsiee eay fo inlusion in te iagnosti amamentaium. Athough it is pobabe that at east some of tese poeues poeues wil eventualy be of inia vaue sine tey o evaluate segmental featues assoiate with inia istubanes a geat ea moe inomation emains to be aumulate an analye befoe it an be nown wat inia signifiane o assign to these measuemens Denslow an his owoes5•• have
sown tat te spina esion as assoiate wit it a low moto efle theso that is it taes ess of a stimuus to inue elex musula ativity in te lesione tan in te nonlesione segment. is means that in the lesione segments, the anteio on es at east of te paavetebal muses, ae in a state of ypeiitabiity e segment is sai to be failitate wit espet to moo ativity. e ae now oelat ing measuements to ote segmenta eatues e atues wit moto efle theshol t was of inteest to etemine ntepetation of esea
1·7' 4
&· i
Fg.
\
� � Afternoon seated (b) mornng standing � resstance pa/ern wt h postre postre and atvty See text text)) a (c) late ateoon standng Changes n skin resstance a
fM C" t 4 J I.
Fg F g.
,
HH 4 .
-.
� � �k ting g sacral sacral base plane acte scoloss " (See te a a)) e ve veeat Eects of tltltin eat b) rght sde eleated hou r (c (c)) retu of leel seat seat
wheter te aciitatio exteed to oter euros i the lesoed seg mets We tured o the sympathetc outlow a, as Tomas state i te precedig paper o tis Symposium, have use t e electrical electrical ski resistace metho or this purpose.9 this metho, the sweat glads are te physiological idicators o the relative actvty o the lateral hor cells i the various segmets. Figure sows a ski resistace exploratio progress. Kow votag vo tages es are applie applie throug t he sk i such a way that he curret whic ows measure mllioths o a mpere, i dicates te resistace resistace o te
sk ueryig te exporg elec troe at a give time By austig the voltage so that little or o curret lows through through most o the sk , are areas as o low resistace are sarply di eretiate by excursios o the microammeter eedle. These idigs are te recored o body carts Te low resistace areas represet sympathetic hyperactivty. Repeated exporatios over log perios perio s o may subects ave show tha low resistace areas are peset all subects that the istrbutio o low resstace areas, that is, o sympat symp at etic hyperactvi ty vares rom diviual to idiviual, but
tat i a give ivual, the segmetal istributio may remai costat or may mots these segmets, thereore, the sympathetic outlow appears to remai i a state o activity while elsewhere it is at rest . hyperactivity, activity, or stat statee o alarm , This hyper presumby exteds o oly to te sweat glads, but to structures i ervated by te sympathetcs boo vessels ad viscera Figure compares two explora ' tios doe iepedetly by two examiers moths apat o the same subect a ilustrates the stability o te patters. ote tat altough te sie, sape a itesity
4
i 8a i. 8b i. 8c 8 Hee-t eXpeiment (ee tet.) (a) Conto, (b) 24 hos ajte t inseted in ih t shoe (c) 24 hos ajte emoa oj t. i 9 Device jo semiatomatic photoaphic ecodin oj skin esistance pattens. The ecodin camea is monted above the sbect. i 1 Recod made b device shown in i. 9 Dak aeas as in hand epoations " epesent aeas oj oweed esistance. Recod is photoaphicay speimposed on sbect 's bod Nmbeed white dos indicate tips oj spinos pocesses Note caibation stip on ejt jom which acta esistance oj an aea can be accatey detemined
of te areas are variable sne ey may ange wit posture previous aivity temperatue et etea te low resstane areas remain onentate in te same segmens e segmental nature of tese pattens is furte eflete in e frequently obseve ermaomal strips of ow resistane ofen extending from spne o senum. Figure 3 l ustates an exreme ase of dermaomal invovement in a young man urng an ata of aute gastritis Over several preeing monts e a onsstently sowe sympateti yperatvty in te sixt to nint torai segments Fairly speifi an onsan patterns ave been sown to be assoiate wit ertain viseal synromes e low ressane aeas ourring in tose segmens from wi te invove vsus erives its nnervaion n several ases we ave observed e appearane of ese paterns long in avane of te firs symptoms Sine ou primary onern in ts symposum is wit myofasial an postural stress te
60
6 v" 0 P i. 1
44
patens assoated wi visera sease wil not be eviewed in ts pape. me oes no permit review of te vaious patterns we ave foun assoiate wit aue lesion patology severe ba isores tauma an te effets of treatmen. e next five figures ilustrate te effets on sn resistane patterns of experi mentally indue myofasial irrita tions an postura stressses Figure 4 sows te effet of injet ing 03 . of 6 per ent soium oide soluon ino seea muse e ringe areas on e le ft appeae witn a few minutes folowing te inetion of te ypertoni salt souton one in deep into te spinae ereor mass a te eigt tora segment (sie mare by X e areas (inged) on te ig folowe ineion into e interosa a e nint interspae X. Note te in vovement of entre ermatomes. Several ours aer e newy inue area appeare as sown n Figue 5 n te ourse of exploaton tese ermatomes beame vivi yperemi srips due to te repeae passage of urren aoug all oe areas expore a te same volage remane unange in appearane Figue 6 sows a series of expora ions of a subjet wo is e vtim of fequent baaes n e lumba region. e fis art (6a) sows is paten n te aftenoon wile seated e mile art (6b) sows is pattern in e morning wile in e nerpretaion of resear
sning posiion Te i c (c n exploion one in e sning posiion le in e fe noon of e sme y fe ful ys wok sows e gely ex ggee effec of coninue civiy n figue on e sympeic nevous sysem in e fcilite segmens. gue 7 illuses some of e effecs of posul sess n e fis exploion, e conol (7 e subjec ws see on eing soo wi is elbows esing on e esk befoe im ollowing e compleion of is exploion, e ig en of e sool ws ise 1 /2 inces, wile e oewise minine s posiion. e mie exploion (7b ws me e en of n ou. Te new es us inuce e quie con spicuous especily e one in e lowe ocic egion, on e lef sie, loce on e convex sie of e inuce spinl cuve Te i c (7c sows e effec of eun o level se igue 8 llustes one of e expeimens in wic posul sesses e inuce o moifie by mens of eel lifs. Te fis c (8 sows e pen w ic ben cce isic of is subjec ove peio of sevel mons. His ig femu e ws ppoximely Y inc lowe n is lef He ws occsonlly ouble wi pin in e owe lumb e, on te ig sie, coesponing o e low esisnce e in egion , especilly fe exeion Tis exploion ws one in e moning following 1 mile wlk A / inc eel lif ws insee in e ig soe immeiely fe is exploion . Te subjec woe e lif ougou e y n e followg moning wile engge in is usul civiies n uing e 1 Y mile wlk o e booy. Te secon c (8b sows e exploion of moning. T e exensive low esisnce in e lowe ig sie s been elimine, bu ee is fleup n expnsion of e es in e ocic segmens inicing we beeve, sevee insuls o tese segmens Te lft ws emove fe is explo ion Te i c (8c sows e skin esisnce pen on is subjec e following m oning gin fe 1 mile wlk. Te e ove e ileum eune n ee ws fue incese in sympeic ypeciviy
g.
II
Comparon of hand a nd auoma c" exploraon. (See ex.)
13
g Par of equpmen for meauremen of cuaneou and deep mucle emperaure wh galanomeer and hermocouple ncorporaed n fne hypodermc needle Skn hermocouple and conan emperaure bah for reference hermocouple are no hown
g 12 Colormerc ualzaon of regonal dference n wea gland ac y he me hod ze he color change of cobal chlorde from blue red when moened n our preparao he coba a mxed wh hygrocopc calcum al o ncreae he conra. Phoographed hrough an appropr· ae red fler blue area (dry) appear dark red (mo) appear faded he phoograph aken a hor neral (noe me on each pcure) how he regonal dfference n he rae of hermoregulaory weang repone n h ubec. he expermen may be repeaed by permng he ubec o cool, whereupon he blue color reurn Mld hermoregulaory repone nduced by applyng hea o exreme or enral urface
4
Fg 14 Th masumnt of musc hadnss and snc, b contact tm and bound of doppd wgh
Fg 1 Masumn of sgmna pan thshods cutano us dapton of Had Wof·Good thma stmuus mthod
Fg 6a Fg 16b Fg 6 Rn a aanc pmnt S tt) Tand dog unansthtzd h as cd ag oums of wat though stomach tub to stabsh duss ntanous nfuson was admnstd though n n paw a) Un spcmn bng takn though catht (b) Bood spcmn bng takn fom xtna ugua n Th dog s Ma " happ tan of as of pmnta wok and spctd maton of th knn s
3
4
n he hoacc segmens pesumably nuce by a secon acue posual ausmen he s kn essance exploaons by means o he hanhel elecoe ae slow an eous equng om 30 o 90 mnues o each exploaon. hey heeoe make mpossbe he suy o ap changes. hey eque a consable amon o anng on he pa o e obsee an paence on he pa o he subjec. Fgue 9 shows an nsumen esgne n ou laboaoy an consuce n he laoaoy machne hop2 whch phoogaphcaly ecos he elec cal skn essance paens almos auomacally, n abou 10 mnues. can be opeae n he eca poson o he suy o acue posual sess as well as n he hozonal. Space oes no pem a escpon o he nsumen excep o say ha he unk s exploe auomacaly n longunal sps an ha a lgh moune oe he explong eecoe s cause by a smple ampl e o ay n bghness n accoance wh he essance o he skn oe whch passes A camea moune aboe ecos hese sps o lgh o ayng nensy as hough hey wee comng om he coesponng sp o skn sel By means o a conolle oubleexposue he eco s accuaely supempose on a phoogaph o he subecs boy wh he boy pomnences make (Fg. 10). Fgue I I shows a compason o one o ou eaes auomac exploaons wh a han exploaon one mmeaely aewa. oe he hgh egee o coeponence beween he wo; he m hoacc emaomal sp on he gh se s especally clea n he phoogaphc eco. s o nees o pon ou ha he subec use o hese ex ploaons was he one use n makng Fgue 8 Howee he exploaons ecoe n Fgue I I wee one 1 6 monhs lae by anohe expemene he chas n Fgue 8 especaly he h (8c) ae almos supemposable on he lae ones agan sessng he sably an choncy o he segmenal paens o sympahec hypeacy. he phoogaphc emomee has aleay mae posble a conseable expanson o ou pogam wll make possbe a ap eauaon o nepeaon o eseach
he diagnoi or prognoi vae of kin reiane hrogh he orrea ion of paern wih many kind of inia eniie in arge nmber of paien Figre 12 how one proedre nder deveopmen in or abora orie for he viaiaion of regiona or egmena differene in wea gand aiviy by oorimeri mean. Oher via and phoographi eh ni invoving foreene or regiona oor differene nder ravioe and infrared igh reaed o differene in bood ppy and ie fid are ao nder inveiga ion. Figre 1 3 how ome of e eqipmen iied in he mearemen of aneo and deep me empera re a a gide o vaomoor aiviy or infammaion a vario deph in reaion o eion pahoogy Thermoope have been onred in No. 26 gage hypoderm neede whih an be inered ino me endon or igamen a vario deph and a differen egmen Anoher ype of hermo pe no hown i ed for he reording of kin emperare A high degree of abiiy of he paern of egmena diribion of reaivey warm and reaivey oo kin ha been demonraed in eah of a arge nmber of bje whie he pa ern vary from bje o bje Large differene in inramar emperare have ao been fond beween neighboring egmen The ignifiane of hee differene i expeed o emerge from orreaion wih oher egmena feare In Figre 14 i hown anoher devie beig deveoped in or aboraie for he preie and objeive mearemen of me hardne and reiieny wih whih we hope o be abe o qaniae abnormaiie in ie exre aoiaed wih pora and oher dirbane In addiion hirey A. ohnon PhD ao of he Depar men of Phyioogy i onding a dy on he hemia and meaboi hange in onrared me o freqeny aoiaed wih eion pahoogy Figre IS how one approah we are aking o he enory or praegmena omponen of he eion ompex Thi mehod permi he preie mearemen of aneo
pain hrehod a vario egmen for orreaion wih oher egmena mearemen Anoher proedre i being deigned for he mearemen of hyperageia in deeper ie The mod whih have been briefy reviewed here and oher in proe of devepmen are hara eried by a high degree of preiion and objeiviy in ha hey are reaivey independen of he bjeive ene and j dgmen o f he oberver; hey are herefoe more eaiy bje o onfirmaion. They are haraeried ao by he fa ha hey are appiabe o he dy of he oeopahi eion ompex in i nara habia o o peak a i or in he hman body Throgh anaye of he paern in whih hee vario egmna feare and oher o be added appear we ha aqire a deeper inigh ino he proee whih organie hoe pa ern. I an be aid ha hrogh hee proedre a re phyioogia moai of he oeopahi eion ha begn o be aid More dire approahe reqire of ore he e of experimena anima In one inveigaion onded by Dr ohnon and he wrier we are aemping o evaae he effe of myofaia irriaion appied o vari o egmen of he bak on rena fnion epeiay rena hemo dynami. e eeed he kidney beae mehod are now avaiabe for he preie mearemen of he amon of bood fowing hrogh he kidney per mine he rae of go merar raion and bar aiviy in he ina naneheied anima or hman and he ae and hroni ef fe hereon of vario experimena eion. I poenia imporane o ardiovaarrena dieae i ear. Figre 1 6 how an experimen in progre on one of or ix dog whih have been rained o ie i and a eae for evera hor whie hey reeive waer hrogh omah be (o inde direi) and inraveno inf ion and whie nmero bood and rine peimen are aken a preie inerva Oher viera die iiing roengenoogi and oher ehni are in prope In anoher erie of experimen o be begn in he near fre we ha nderake a dire anayi by eerophyio ogia mehod of he exhange of
exiaion beween he omai and aonomi nervo yem Cnclsin
In onion we wih o affirm or beief ha from h die and from he oninaion and expanion of h rvey a repored in hi ympoim here wi emerge new and nforeeen approahe o rgen and nivera heah probem whoe oion are inheren in he oeo pahi onep
eferences Krr I M. Emerging cncep spahic lesin J. Am. Osep A 81138 Nv 18 2 Krr I M Neural basis f he spahic lesin J Am Osp A 4191·198 Dec 194 3 Swif R J Smallnerve mr sysem in relain seahic lesin J Am Oep A 93838 M ch 195 4. Drucer DE Reerd ain and he se pahic lesin. J Am Osep A 669 Aug 18 5 Denslw J.S Krr I M. and Krems A D Quaniaive sudie f chrni aciliain in human mneurn pls Am J Physi 159·38 Aug 19 6 urns Pahgenesis visceral disease wing erebral lesins American Osepahi Assciain Chicag 1948 Denlw J S and Hasse C. C Cenral eciary sae assciaed wih psural ab nrmaliies. J Neuphysil 59342 Sep. 194 8 Denslw J S. Analysis variabiliy spinal reex hrehlds J Neurphysil ·15 July 194 9 Krr I M. and Gldsein M J Der· mamal aunmic aciiy in reain segmenal mr ree hreshld Federain Prc 6 March 1948 1 Krr M Sin resisance paerns assciad wih iceral disease. Ferain Pr 8888 March 1949 Krr M Exprimenal alerains in segmenal sympaheic (swea gland) aciviy hrugh myascial and psural disurbances Federain Prc 888 March 1949 M Semiau 1 Thma . E and Krr maic recding elecrical sin risane paerns Federain Prc. 916 March 195
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Reprind by prmissin rm JAOA 54·416 1951
7
The conce of fclon nd s orgns* (1955) s sysu s a rer a a r asec f e f e researc r gras beg cduced seac sus I as eyed e geer us sur f e seac r fess rug e Aerca Oseac Assca a f e Naa Isues f Hea ad f e Ofce f Nava Researc I seecg a rbe fr ves ga e researcer us defy e brad geera area wc e wses wrk e areas wc ad e secfc r wc e wses exre e area e rea f a r e ers ad e kds f fra e wses seek e audece w e rerts sud ave e beef f a reary ersectve e frs art f s aer s erefre deved rea Because e recg f e seac es ad f s r ace e eal f a s a dsc ve feaure f seac ery ad racce as ur bece e ufruae cus caracerze researces uder se ac ausces as researcers "e seac es "e ef fecs f e seac les s r a fuc r srucure r se er vara f e sae ee e beeve a far re a s s requred defy e area ad becve f eac vesga I ac ceg suc a desga fr a researc rec e acces eer e reduc f e sce eag ad cexy f e es e ls se by e rec r e acces a s ureasc esae f wa ca be accsed by a ua beg r gru f ua begs a sge edeavr r eve a ere fee Eve wrse uess e vesgar us s ques aure excy ad uequvcaby e ay receve aswers quess er a se e ks e s askg Sce a ysca us rs cae Ba a n a a at h Gna Sin y-Eghth Aua Cn h Aan Opah Aiain Canaa 954.
8
ad dagse a seac es befre e ca rea e er "seac es as rug usage ce desgae e ds f ay a raer se ds cree ey a g r srucure wc e ca ad wc e ca ace s ad As s fe aes e desga bece e g sef I sees a e se ac es s becg cy equaed w e aabe oomt at f e csea f cex bgc rcesses wc e es ruly rereses I ur s s scefcay as wrg seadg ad urducve as equag gy csura w dabees eus I s as dagerus as assug a e vsbe ar f e ceberg s the ceberg e seac rfess s ear g s ace e wrd f e eag arts rug desrag a e abvesurface afesa s a sg f ad a arca a arge assve dagerus rcess g g bew ad a frces r ery aed a accessbe ar ay ve e etre ceberg war waers uc researc ur as bee deved "rvg e exsece f e ceberg a s requred rder a seay ay w ear s lace e et wrd s e dscsure f e aure f e rcesses gg bew e surface er rgs e facrs a fuece e ad er rea e abvesurface afesas urer cca advace s area awas suc dscsure by fuda ea researc e seac es eve f rug usage as ce rere se y e aabe agy f e sac r uscuskeea ssues us erefre be vewed a re reseg e ca sac facrs ccas ad afesas f a gy rgazed resse f e ma a hole e deads sresses ad sus wc are ar f s fe ad wc e s que adequae ese clude s esecay e sresses f gravaa rg wc as uscuskee
a syse s esecay subec s resse vves e erac f ay rcesses gg ay ssues edaed rug e ervus ad crcuary syses ad beg cualy caged w e cr cusaces acvy ad al e facrs erag e dvduals fe s s e ar f e ceberg yg belw e surface. ere s dub f s ese cexy Here uke e vg ceberg ere s e rgd fxy f reas bewee e cscuus ad cscuus ces w resec quay race rgs sry r eve ca aced w suc a vas ad dee rbe e vesgar us care fuy seec ad equay carefuy defe a asec f e a ad e kds f fra e seeks w a asec He us avd e dager f defyg e asec wc c cues him as the seac es e sudy fr exae f verebra sra r er sac ces s syyus w e sudy f e seac es assue s s desry s very eag ad re deere a bdaey vesga r e very e a e vere bra sra begs e ere bdy s aready rgazg s resses ad fr a e e su ad e resse ave searae exsece The re f nesgn
e abrary vesgas a Krksve ave bee dreced a a udersadg f e re f e ervus sye rgazg a resse a e segea eve e rgra f e Deare f Py sgy as bee ccered esecay w e ecass aers ad aways f ercage bewee e sac ad auc dvss f e ervus syse e secfcay "e seac es ese are sudes f facrs ad ecass rsc urerre as wl be sw yslgc ess ave ee desraed ese sudes wc are csey reaed by aure ad ca e eea ccay defed as seac ess by e seac ysca ese vesgas are s very yu ad ey ave bu scrace e surface Peras er a c Ierrea f researc
tributin has been nt s much the new infrmatin which has been yielded but that thrugh that infrmatin and thrugh relating it t ther previusly eplred areas it has becme pssible t restate sme ld basic stepathic prblems in such a way that fr the irst time they becme apprachable by eperimental methds In the time that is available fr this research reprt we cannt pssibly summarize 8 years f research but we can sh w ur general strategy the directin in which we are prbing a few f the kinds f infrmatin we have fund a few tentative generalizatins and finally ur interpretatin f the clinical significance f these indings as we see them nw The strategy f ur apprach t this aspect f the general prblem tk its rigin in the clinical bservatins f thusands f stepathic physicians ver a perid f several decades. Tw main generalizatins established te pint f departure and directin f ur investigatin. 1 The signs and symptms assciated with the stepathic lesin include (a) the presence f tenderness spntaneus pain r bth (b) altered functins and activities f the assciated muscles (c) vasmtr sudmtr and frequently visceral changes In shrt they include disturbances in a basic triad f nervus functins sensry mtr and autnmic. Our studies are cncerned with alteratins f these functins their interrelatins and their assciatin with ther features at the segmental level. 2 Every stepathic lesin had its rigin and develpment in the cntet f the life and acivities f the individual in whm it is fund. The lesin therefre with its assciated sensry mtr and autnmic disturbances has meaning and is interpretable nly in that cntet We A virually unexplored field eists in a furh categoy f nervous funtion - the soalled op hic funion. Eploration in his feld awais he deelpment and appliain f atifay mehods fo he study f he lw longtem nenes of peripheal neve Fibers pn he iue whih hey innervate in a to he fae reodable impulseanmied inuences The ophi funions of neve unquetionably have a ery impran baing n he phenomena wih which oeopahic physiians dal They ae a rih field fo eplain by phyiologiss bihemi pahlgis and hes
have studied these disturbances (and their eperimental mdificatin) in their natural habitat" in the vluntary subects and patients in whm they are fund. (Althugh certain aspects and features f the stepathic lesin and related phenmena may be eperimentally simulated in animals cnclusins drawn frm such studies are applicable t the naturally ccurring lesin in man nly t the etent that their basic similarity t the naturally ccurring phenmena can be demnstrated) In rder t study the triad f nervus functins in man it has been necessary t develp adapt and apply methds which wuld yield reliable infrmatin regarding activities in reginal r segmental sensry mtr and autnmic pathways which wuld d s withut altering thse activities and withut disturbance f the human subject himself and which wuld make pssible a cmparisn f the activities in disturbed areas with thse in the nrmal With these methds and with thers in cntinual prcess f develpment it became pssible t begin the uncvering f what w e have called a physilgic msaic the related patterns f variatins in sensry mtr and autnmic activity in the varius segments. Frm the patterns in each f these three frm their relatins t each ther and frm their respnses t eperimentally induced r spntaneusly ccurring variables it is becming pssible t deduce the nature f the prcesses which rganize thse patterns The details f thse prcesses and the precise mechanisms the patterns and pathways f interchange between the smatic and autnmic divisins f the nervus system can be studied f curse nly in eperimental animals in which the invlved parts f the nervus system can be epsed and directly eplred by electrphysilgic recrding f impulses and by ther methds Such eperiments are nw in prgress Pvus sus hs aa Investigatins cnducted at the Kirksville Cllege have indicated that the musculskeletal stress initiates r is assciated with unbalanced streams mpulses entering the central nervus system and that these have
the effect f upsetting the delicate balance f that part f the nervus system with which the lesined part is mst directly cnnected. This was first demnstrated fr the muscular r mtr cmpnent by Denslw and his clleagues in the early 19s He demnstrated that the segments which are in lesin as determined by subjective clinical criteria cmmnly utilized by him and many ther stepathic physicians (tissueteture abnrmality and deep hyperalgesia) were bjectively distinguishable by physilgic criteria f mtr activity Segmental mtr ree threshlds were determined by measuring in kilgrams the amunt f pressure applied t the spinus prcess f each segment which just evkes cntractin f the paravertebral muscles at that segmental level. Muscular cntractins were detected and evaluated by electrmygraphic recrding esined segments invariably re quired weaker stimuli than did nnlesined segments The lesined segment was therefre said t be characterized by lwer mtr refle threshlds the mre severe the lesin the lwer the threshld In a later study Denslw Krr and Krems demnstrated that diffuse and remte stimuli including thse frm the higher centers and stimuli that ccur in nrmal life preferentially ecited the pathways t paravertebral muscles f the lesined segments. Respnses ccurred in these segments t impulses frm many surces while at the same time nnlesined segments remained quiescent nder cnditins in which there was generalized muscular cntractin the activity in the lesined segments was relatively eaggerated The easier pening f the mtr pathways in lesined segments suggested that this was a sustained fm f the phenmenn f facilitatin under study in numerus neurphysilgic labratries and that like the eperimentally induced frm it t had its rigin in a sustained afferent bmbardment by impulses frm sme segmentally lcated surce In the net few years the Department f Physilgy adduced a large bdy f eperimental evidence that segmental pathways mediating the ther tw members f the triad f nervus functins namely the
Fg. 1
Fg. 4
Fg 3
Fg 2
Fgs. 4. Coparson o Sgntal Pas n th Sa Subct
Fg. . Lesion Pathology Dagraatc rprsntat on o th dstrbut on and rlat srt o ostopath c lson patholog as dtrnd b palpator xanaton. Fg 2. Electrical Skin Resistance (ER) Sn rsstanc oband wth photographc rcordng droh tr Dar aras �orrspon d to aras o low sn rsstanc on th subc s bac h rsstanc o ths aras s lss than pr cnt o th hghrsstanc (wht) aras. h gh spots n th dln ar th tps o th spnous procsss Fg 3 Cutaeos Vasca Resposes. Dagra showng th rlat ntnst an prsstnc o th rd rsons to standardzd chancal stu laton n drnt rgons on lt and rght sds o th bac h thn lns rprsnt bl and short-duraton rsponss n corrspondng strps osn. Ednc dscud latr ndcats hgh ascular ton n ths aras. Fg 4 Acv Sul anous lctroographc actt o th spnal tnsor uscls a th sgnal lvs rcordd whl th of the Spial Extesor Muscles. subct s standng qutl.
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eoy ad he auoomc mgh alo be maaed a ae of hypeably ad hypeacvy ·11 The eoy compoe wee evaluaed hough meaueme of cuaeou pa hehold vaou demaome ad hough mappg aea of cuaeou ad deep hype ehea The auoomc comoe lmed hee ude o he ympahec dvo becaue of egmea dbuo ha bee ealuaed hough meauee of he acve o f e wea glad ad bood vee of he k Tha hee cuaeou ucue eved a phyologc dcao of he acvy of he ympahec ouflow o he coepodg aea o egme EVdece fo hypeably of eoy pahway wa foud he peece mo ubjec of pee aea of loweed pa hehold a d o f edee o he eg of wea glad acvy we ued a f o he meaueme of he eleccal eace of he k Sk eace had bee how by ohe o be loweed by wea ece o ad elevaed abece (See Refeece fo efeece) The obly of loca o egmea hypeable ympahec pahway wa f uggeed by he fdg of aea wh coely low eleccal k eace mo ubjec eve
I
0
ude cool eg codo whe wea glad acvy wa geealy abe wa alo uggeed by he elaed ad pee aea of ea vely cool k ad ohe g of hgh vacula oe
An ilusraiv cas
The kd of pae wh whch we ae coceed ad he eea ohp w be lluaed o a le ubjec Th pae whoe clcal au o eeva o h pupoe wa expoed wh he vaou mehod ove a peod of may moh dug whch me he pae emaed emakably co a A ample of each of he kd of pae how gue -4 gue a dagammac epe eao of he dbuo ad eave evey of oeopahc eo pahology a deemed a palpa oy examao by D Delow Epecay copcuou ae he evee eo he lumboacal blaeal ly; he lumba aea epecally o he gh de; a he mdhoacc eve o he gh de The cevca leo wll be degaded fo h pupoe becaue he phyologc e wee med o he hoacc umba ad uppe acal egme The peece of a eoy com poe elao o h eo pahoogy wa mafe he deep
hypeehea pee he ame aea Meaueme by he hemal adao mehod ou laboaoe howed oweed cuaeou pa hehold eeally he ame aea gue how he eecca k eace (ESR) pae of h ubjec a phoogaphcally ecoded wh a eay mode of he auomac demohmee developed ou lab oaoe 1 4 The dakeed aea o he phoogaph epee he ocao o he u bjec of oweace aea of k whoe eace le ha 10 ha of he omal hgh eace aea whch ae uhaded h phoogaph A a dcao of e evy of he mehod he whe aea h cha dcae eace of 0,000000 ohm o me he black aea 00,000 o le The mlay egoal dbuo bewee he owe ace aea ad he clcally deemed ae of leo pahology o be oed Evdece fo egmeay eaed dffeece vaomoo oe how gue 3. Th a dagam mac epeeao of he ed epoe of he paapa k o boh de o adadzed mechacal okg o be dcued lae The h e epee p of k whch he ed vaodlaao
epeao of eeach
rspons was wak sggstng ss- masrmnts thmsvs Th tand vasospasm n ths aras assmpton that th masrmnts Crtanly th asymmtrs n skn rlct drncs n nrognc tmpratr whch w hav rpatd- swat gland and bloodvssl actvty ly obsrvd and n vasclar rspons wold rst nd to b provd vald btwn rght and lt sd o th Th xstnc o hyprrrtabl or sam sgmnts sggstd dstrbd acltatd sympathtc pathways vasomotor actvty n ths aras wold o cors hav vry rch gr rprsnts n lct romyo- ndamntal and clncal mplcagraphc stdy o th smltanos tons actvty o th paravrtbral msIntrgng ndcatons that sch clatr n ths sbjct at th varos mplcatons cold otn b attachd sgmntal lvls drng qt stand- to th aras o low lctrcal rssng. Th asymmtrcal and xag- tanc bgan to mrg rom or gratd msclar contracton to b xploratons o larg nmbrs o notd n th lmbar and ppr and sbjcts both patnts and apparmdthoracc lvls ndcats hypr- ntly halthy ndvdals In a larg actvty o sgmntal motor pathways prcntag of patnts sgmntal at ths lvls rlatons wr stablshd btwn th Ths stdy was slctd ot o hn- pathologc organ or strctr and th drds not bcas t s typcal bt aras o low ESR Sgmntal rla bcas o th nsally hgh dgr tons btwn th pathologc tss o topographc rlatonshps among and th skn rsstanc pattrn wr th snsory atonomc and motor by no mans always clar bt th pattrns and thr rlaton to th rlatons wr spcally sharp n lson pattrn whch gratly smply thos ntts n whch thr was a th prsntaton o th prncpls pan componnt nvolvd Th topographc rlatonEvn mor xctng mplcatons shps btwn ctanos atonomc bgan to mrg atr svral yars o and snsory) atrs and th myo- xplorng larg nmbrs o apparascal may not always b xpctd to ntly halthy prsons ncldng many b so clos bcas o th drncs o or stdnts In a growng nmbr n prphral dstrbton o nrv o sch ndvdals sgns and spply vn rom th sam sgmnt symptoms o vscral dsas or to skn to mscl asca t ctra xampl coronary artry dsas and Th cas dos rv to llstrat pptc lcr) appard months and som o th knd o masrmts yas atr th dmonstraton or rst and pattrns wth whch w dal It apparanc) o promnnt aras o also srvs to llstrat a gnralza- low lctrcal rsstanc n drmaton whch bgan to mrg rom or toms rlatd to th nvolvd vscra xploratons o larg nmbs o Som o ths symptomr sbjcts sbjcts In th most con- who latr dvlopd vscral sas spcosly abrrant sgmnts as had had prxstng skn rsstac ndcatd by or mthods th dva- pattrns rsmblng thos ond on tons hav consstntly bn n sch a patnts wth smlar dsass) In drcton as to ndcat ncrasd othr sbjcts symptoms and dsas rrtablty o at last som rpr- n somatc or vscral strctrs sntatvs o ach o th knds o sgmntally rlatd to th lownrv clls snsory motor and rsstanc drmatoms appard or sympathtc arsng n that part o th rst tm or ntrmttntly) th nrvos systm ollowng prods o svr strss sch as nal xamnatons systmc The nex prbe: h e meaning f nctons and motonal concts he paerns In stll othr sbjcts w wr abl Thr can b lttl dobt that thr s to dmonstrat that nw and promncrasd rrtablty o th snsory nnt aras o low lctrca skn and motor pathways n abrrant sg- rsstanc cold b ndcd xmnts Th ndngs o low lctrcal prmntally by act strsss and skn rsstanc low skn tmpratr myoascal rrtatons and accand bl rd rsponss sggst that dntally as a rslt o trama th sam may b tr or th symThs obsrvatons wr strong aspathtc pathways Ths howvr sranc that th prsstnt ra o low s by no mans stablshd by th lctrcal rsstanc whatvr ts
bass s a nctonally and clncally sgncant sgn and that t markd at last n som cass physologcally abnormal and rlatvly vlnrabl sgmnts o th body Ths obsrvatons thror jstd a dpr and mor thorogh nvstgaton o th bass and manng o th ctanos lctrcal rsstanc and vasclar pattrns In ordr to stablsh whthr th low skn rsstanc low skn tmpratr t ctra trly rprsnt local or sgmntal acltaton o sympathtc pathways wth all ts nctonal and clncal mplcatons w ndd th answrs to th ollowng qstons. Do th sn rsstanc and vasclar pattrns rlct nrognc varatons n sbmotor and vasomotor actvty? 2 Ar h sympathtc pathways to th lsond or lowrsstanc aras mo asly opnd and sstand n actvty by stml and actors opratng n daly l? 3 I ths ar answrd armatvly dos th local sympathtcotona xtnd also to strctrs othr than th swat glands and ctanos vssls? Th ollowng two paprs basd on rcnt stds llstrat or vstgatons o ths qstons and som o th answrs obtand As so otn happns n basc rsarch n th cors o rthr tstng th hypothss o acltaton w also larnd a grat dal mor abot t and ts manng to th lvng man Th stds on th swat glands ar dscssd n th nxt papr epd b permon om "Smpom o h o mpio of Sgmn Fio 6·68 1 fom
JAOA
11
lncl snfcnce of e fcled se (1955) I appears ro sudies suc as ose a ae been presened in wic cerain sensory oor and auo noic caracerisics are easured on or near e surace o e body a: 1 Aberran segens o e spina cord occur in os indiiduas in cuding appareny eay persons. 2 ese segens are abnora in eir onic aciiy and in eir responses o arious siui. 3. In ese segens a eas soe o e neurons ediaing sensory oor and auonoic uncion are ainained in a sae o ypere ciabiiy wic ey anies in eir easier augened and proonged responses o ipuses reacing e ro any sources. 4 ey are ereore suscepibe o susained and eaggeaed aciiy under condiions o daiy ie. 5 e inuence noray eered by ese neurons on e issues wic ey innerae ay ereby be eag geraed. 6 ese segena disurbances appear o be pysioogic esions reaed by naure and ocaion o e cinica penoena designaed as oseopaic esions. Since our eperiens sowed a e paways roug ese segens incuding ose o e sypaeic ouow were ore easiy "opened and susained in aciiy ese obser aions urer srengen and enric e ypoesis o cronic segena aciiaion oug o be associaed wi e oseopaic esion. 8 776 Wa does aciiaion ean uncionay and cinicay? In genera i eans a e issues inneraed ro e esioned segen and ereore e indiidua as a woe are sensiied o a e inuences operaing wiin and wiou e indiidua. Faciiaion o e enory paways in e disurbed or esioned segens eans a ere is easier access o e nerous syse in cuding e iger ceners roug ese segens e esioned segen is one roug wic enironena canges especiay noious or painu siui ae eaggeraed ipac upon e an 52
Faciiaion o moor paways eads o susained uscuar ensions eaggeraed responses posura asyeries and iied and painu oion. Since e usces ae ric sensory as we as oor inneraion under ese condiions ey and re aed endons igaens oin cap sues e ceera ay becoe sources o reaiey inense and unbaanced aeren sreas o ipuses. e pysiopaoogic eecs o aciiaion o oca ympei paways depend o course on e srucures wic are inneraed by ose paways; a is wi iscera wi bood esses wi gands. Our sudies sowed e e isence o aciiaed sypaeic paways o e swea gands and bood esses in e sin inneraed ro e disurbed segens and ius raed e eecs o suc aciiaion on eir uncions and on eir re sponses o ipuses arising in arious recepors and in e iger inegraie and cerebra ceners. I is iporan o deerine weer ese cuaneous signs are indicaie aso o aciiaion oe sypaeic paways o oer organs issues and bood esses in neraed ro e sae or reaed segens. Significance of cuaneous signs of oca sypaheicoonia
Eperiena sudies designed o cariy is quesion are now in prog ress in reaion o e idney. As ye e eidence ainy cinica and pre supie is srong 1) a oca sy paeic yperaciiy reeced in e sin ay be associaed wi sy paeic yperaciiy in e iscera (2 a e cuaneous aniesaions are associaed wi disurbances esewere in e segen and (3 a oca sypaeic yperaciiy is an iporan acor in disease. is ei dence wi be briey suarized. 1 As saed in e inroducory paper o is syposiu proinen areas o ow ESR are oen ound in deraoes segenay reaed o paoogic iscera. Hyperidrosis in deraoes reaed o paoogic iscera as aso been deonsraed by oers.778
2. In a signiican percenage o ap pareny eay subjecs proinen areas o ow ESR ared segens in wic oer disease aer appeared or wic were especiay suscepibe o disurbances under sressu condi ions. 3 Ciica repors are rapidy ac cuuaing in e ieraure a any serious cinica eniies are associaed wi oca auonoic ibaance in e direcion o sypaeicoonia een wen e aniesaions o e disease are ose wic woud be siuaed in eperiena anias by parasypaeic siuaion). Syp oaic reie asing iproeen and een cures ae been acieed roug surgica paracoogic or oer bocades o e sypaeic paways o e inoed organs.7988 4 A nuber o · iscera and oer cronic diseases appear o begin as isceic saes o e inoed issues due o oca neurogenic asospas. is asospas sees o be o sy paeic origin and is aso associaed wi asospas paor ypoer ia) in reaed segens o sin. 333687899 5 I appears we esabised roug cinica and eperiena in esigaions a e asooor responses in sin and in iscera are quie parae. Siui wic eici asoconsricion in one coony do so in e oer aso. 8996 is is e paern o course associaed wi diuse sypaeic aciaion or eape in uscuar eors and in cerain responses o inense enir onena or eoiona siuaion wen bood is suned ro iscera and sin o e s eea usces) I appears cerain ereore a e aciiaion o oca sypaeic paways o e sin suc as a deonsraed in our swea gand and ascuar sudies is coony par o a generaized sypaeic yperir riabiiy aecing oer issues inner aed ro reaed pars o e ner ous syse. I appears equay cer ain a e resu susained oc sypaeic yperaciiy as considerabe cinica signiicance any diseases especiay o e cronic degeneraie ype being associaed wi and peraps ascribabe o yperaciiy o e sypaeic inneraion o e aeced organs and o soaic srucures reey reaed o e.
Inerpreaion o researc
Why s th xaggraton o sympathtc nnc so dangros and so rqnty an tologc and contrbtory actor n dsas? ormaly th sympathtc nrvos systm plays a most mportant rol n organzng th adaptv and protctv adjstmnt o th bodys rsorcs to n vronmntal varatons and xtrms to msclar work to motonal strss to alarm t ctra It spprsss th actvty o ntrnal organs not mmdatly nvolvd n th mrgncy acton and shnts th blood sppy rom ths organs and rom th skn to th skltal mscs Bt hgh lvls o sympthtc actvty normally occr only ntrmttntly or or rlatvly br prods Whn howvr sch sympathtcotona whthr local or gnral bcoms sstand thn th assocatd rdcton n vscral blood ow nhbton o srtory and smoothmscl actv ty spasm or sphnctrs t ctra vntally rslt n som damag and dysncton o th actd organs and n dstrbanc o th ntr body conomy Naure, origins, and significance of segmena sympaheicoonia
Or laboratory obsrvatons and th many yars o clncal obsrvatons n ostopathc practc appar not only to hav stablshd that th ostopathc lson rprsnts sch a stat o local sympathtcotona bt thy also xtnd or ndrstandng o ts natr rgs and cncal sgncanc I th backgrond o th avalab knowldg or stds ndcat that ndr condtons o daly l thr may b stady strams o mplss lowng ot o th acltatd sgmnts throgh th sympathtc pathways to th strctrs whch thy nnrvat byond or n conct wth dmands mad by th homostatc mchansms ndr crcmstancs n whch sympathtc actvaton ordnarly occrs th drv throgh th actatd sgmnts s ntatd arlr rachs hghr ntnsts soonr and s sstand longr than n othrs ndr condtons o chronc nvronmnta or motonal strss or xampl th dtros nncs wll b prrntaly ocsd pon and channzd throgh th acltatd sgmnts Th lsond sgmnt thror s
on whch s contnally n or bor- hyprhdross may gv way to drng on a stat o alarm hypohdross th vasospasm may accordng to or sdomotor and gv way to vasomotor atona wth vasomotor stds t sms trally stass ngorgnt nlammaton to b n a " cold swat In sch a sg- dma t ctra That s n th mnt snc th "mrgncy sympa- chronc stat whn dgnratv thtc mchansms ar rqntly changs thratn th ntal symopratng vn ndr "rstng pathtcotona may b maskd condtons snc thy rapdy apTh mattr o changs assocatd proach maxmm actvty ndr mld wth chroncty mrts at last br stmlaton and snc thy may b xamnaton snc som o th manmantand nar maxmm actvty by statons o longsstand sympataxng l statons th margn b- thtc hypractvty ar sch as to gv twn rstng and maxmm lvls s th nwary physcan tologc and narrowd n short th physologc dagnostc cls and thror als rsrv s rdcd As or stds on gds to thrapy n th chronc stat th skn show th brdn o compn- th sstand sympathtcotona wth saton s thrown on th othr sg- ts assocatd schma and trophc mnts and organs Th total rsorcs changs may hav so altrd th o th ndvdal hmsl ar ths m- charactr o th tss and ts pard rsponss to normal nrvos and horWhthr or not ovrt dsas dvl- mona actors as to mak t an ops dpnds o cors pon th nrlabl ndcator o ths actors total rsorcs o th ndvdal and Excssv sympathtc actvty by nth dmands mad pon thm Th crasng th snstvty or rsponss gratr th dmands mad by th o th organ to norma parasympatotal nvronmnt or by th n- thtc stmlaton may as n pptc dvdal hmsl n rlaton to hs lcr and othr ntts actaly rsorcs th gratr th nvason o smlat parasympathtc hypractvphysologc rsrv and th hghr th ty (that s th rsponss to xprprobabty tht th lsond acl- mntal stmlaton o parasympathttatd sgmnt wl bcom th d- c nrvs n anmals Morovr th vdnc s now csv actor lmtng th adqacy o thos rsorcs th gratr th cr- qt convncng that ocal sympatanty that th tsss o th acl- thtcotona may actally prod tatd sgmnt wll b mpard and parasympathtc dstrbancs Two damagd by th xaggraton o sn- basc mchansms ar ndcatd (1) sory motor and sympathtc n- Throgh (sympathtc vasomotor lncs th gratr th probablty brs controllng blood ow throgh that dsas wl start n or throgh th parasympathtc cranal and th actat sgmnt or n th mh- sacral nc and parasympathtc ansms whch carry th brdn com- nrv trnks and (2) altraton o th tsss so that th arnt dschargs pnsaton Th prcs syndroms whch may rom ths tsss to parasympathtc dvlop rom th dltros n- cntrs wll also b altrd Sch als lnc o sstand sympatht- and nbaancd "sgnals rom ths cotona wll o cors b dtrmnd tsss wll dstrb th rglatory by th prmary targt organs whch parasympathtc rxs and mask n trn wl b dtrmnd by th oca- th orgnal sympathtc manstaton o th sgmnts whch hav tons Th cts throgh both bcom acltatd Th sam dstr- mchansms may b so rmot sgbanc thror throgh acton mntaly rom th st o th sympa pon drnt tsss may hav a thtcotona as to obscr th rlatonshp larg varty o manstatons It s mportant to rcognz also Smlar rlatonshps apply wth rthat th manstatons may chang spct to th ndocrns ot only dos wth tm or xamps crtan sstand sympathtcotona altr th prmnary obsrvatons mad by s rsponss o tsss to th crclatng whch ar rchy conrmd by obsr- hormons bt schma o any ndovatons mad by many othr nvst- crn gland d to ocal sympathtgators sggst that n th chronc cotona may prodc wdsprad stat th prphral mchansms may and rmot cts whch do not show as t wr "atg ot th thr prary sympatht orgn
15
Ther is little dout therefore of the serous and protean manifestations of sustaned loca regonal or segmental sympathetcotonia What are its orins? The are fairly acceptale tres ofer n the lterature to explain generalized sympatheticotonia as n anxiety states certain types of hypertenson and hyper thyroidsm and most are ased on dsturances of the hgher centers of general metaolsm or of one or more of the endocrine glands Few satisfactory hypotheses ae offered however in explanaton of the localized sympatheticotonia of a few selted segments of the nervous system What can our growing nowledge aout the osteopathc leson contriute to our understanding of the origins of segmental sympatheticotona? On the asis of availale nowledge regarding the related reflex mhanisms it aprs that the segmta sympathetic hyactivity originat as t of a highly organiz reex response organzed t the spinal cord level that the response is set in moton y certan forms of sustained irrtation arsing in one or mor tissues nnervated from the corresponding segment that this afferent rritation faclitates the mante nance and exaggeraton of impulse tafc in the sensory motor and autonomic pathways which orgnate in this segment that such exaggerated trafc may e produced and sus tained in these facilitated segmental pathways y impulses reaching the segment from any source Perhaps ecause of this neurologic focusing that taes place through the facltated segment and ecause of the assocated tsue changes and activtes the reex process once intiated sustains itself even long after the oiginal facilitating factors may have passed The faciitating factors may arse in individual tissues or organs ( 1) whch have een drectly suected to inury stress or irritation or (2 to whch irritations or excessive and prolonged demands have een drected y the otal eone of the ndivdual to life situations and environmental factos Many possle nitiators of such local disturance have een postu lated and some of them certainly are valid However one of osteopathys maor contriutons to the ological
and medica sciences is the demonstration that factors whch evoe the segmental responses arse with very hgh frequency in the weghtearng or axial portions of the musculoseletal system Th soatic coponnt
Man's musculoseletal system s an incomplete and imperfect certanly an unstale adaptation of a as cally quadruped system to ped stance and locomoton he components of a perfect cantlever rdge have een somewhat rearranged an modfied y evolutionary process to form a less adequate syscraper 97 There is no dout that gravity s far more demanding of mans resources than o other mammalan speces. As a result local postural stresses asymmetres myofasca tensons and rritatons and artcular and periarticular disturances have a peculiarly hgh ncdence n man her proality always hgh ncreases wth time In man therefore gravity has ecome an envronmental factor of great importance to hs heath Mans responses to gravtatonal factors the postural and rightng refexes though adaptatons of those nherted from lowerform ancestors are characteristc of man the species They are however ndividually modfied y many of the factors which dstinish one ndivd ual from another and y circumstance Although foc of musculoseletal stress or rritaton may rise as the drect result of nury to specfic areas they develop mainly as part of the odys total adaptaton to the erect posture The parts of the musculoseletal system whch n each ndivdual are especially taxed in the maintenance of the erect leveleyed posture wll e largely determined y factors of physcal configuration attitudes hats occupation activites and environment and y the nherent and developing defects asymmetres and anomales. In the musculoseleta stress then we have dentifed a ver frequent ntatng factor to whch man s peculiarly suject to help account for the local sympatheticotona found to e assocated wth and contriutory to so many apparently dfferent chronc functonal disorders to whch man appears also to e pecularly susceptle As will e shown however the
signicance of the musculoseletal component in dsease is not solely n the initiation of the local autonomic imalance It appears nadequately understood that the pan tenderness muscular rgdty and autonomc disturances individually recognzed as manfestations of pathologc processes are the nterrelated components of a complex response organzed y the central nervous system As was previously stated the evocatve factors whch set in moton the segmental response may arse n any tssue or organ as a result of insult to it or excessive demand upon t The response organzed via the trad of nervous nfluences (or possly a tetrad if the trophc functions are ncluded) is ascally the same for all and extends to some degree to all the tssues somatic and visceral drectly related to the correspondng part of the nervous system 6,8 Through the reciprocity of nuences etween visceral and somatc tssues va the central nervous system vsceral pathology produces dsturances n musculoseletal structures. his s recognzed in the concept of the secondary reex osteopathic lesion and n the splintng associated wth panful vsceral syndromes. From clncal practice and from numerous studies on such phenomena as referred pan vscerosomatc re exes trgger zones et cetera the evdence s convncing that visceral irrtaton commonly nitiates through relex pathways the trad of sensory autonomc and motor changes n the somatic tissues of whch a conspcuous feature s muscular rgdty and tension It needs to e emphaszed however that the tender hypertonc muscles n the reference zone are not merely the reflex anetation of visceral rritation They and the assocated articular and periartcular structures ecome active partcpants n the dsease process itself as they give rse to dstured patterns of afferent (proprioceptve) omardment of the central nervous system which sustan and exacerate the sturance in a vicous selfpropelled crcle of mpulses In the vertical stance the relex somatic dsturance s even further intensified under the mpact of gravtatonal stress tendng further to promote the disease pro nterpretaton of research
cess e total postural response of te patient to gravitationa factors is altere new compensations are exacte an new stresses set up. e muscuoskeleta component terefore terefore is not ony an important initiating factor for te facilitate sympateticotonic state ut also a sustaining an exacerating factor even wen seconarily inuce roug te inevitale participation of te somatic component especially ta portion in te axial weigtearing portion of te trunk te patways troug te isture segmens of te cor are maintaine in te faciitate state suect to te exaggerate impact of factors witin an witout te iniviua incuing tat of gravity. Conusions
n tis section we eneavor to summarize riefy te etiologic iagnostic an terapeutic implications of tese inings an concusions estimony to te asic sounness of te etiologic etiologic concept is tat guies to iagnosis an terapy flow irecty from it. Etoog mpatons
1 e "osteopatic esion as ientifie y palpatory an oter clinical criteria is te local or regionally iscrete somatic component of a reflexly organize an sustaine response to stresses irritations an excessive emans pace upon specific tissues or organs y te environment an y te total activities responses an aaptations of te iniviual 2 Because of te sustaine facilitafacilita tion of sensory motor mo tor an autonomic patways te esione segment acts as a neurologic lens focusing an exaggerating te effects of impuses from many sources upon te tissues innervate from tat segment troug tat segment te iniviual is suect to te exaggerate impact of life situations an environmenta factors o te facilitate segment an te structures wic it suppies an terefor tereforee to te organism as a woe even orinariy innocuous life situations ecome reativey stressfu an taxing an many continualy eman an evoke te costly reservereucing protective response 3 As a special corollary corollary of numer 2 Among te source of impuses wic exact exaggerate exaggerate toll of tissues tissue s
troug facilitate segments are te lesions asg n aaptation to te iger cereral centers e osteo- erect posture is sigificatly iu conguration tis a patic lesion is unquestionaly an ence y oily conguration important etermining factor in te pears to e an important factor in te oily expression of emotional ills reationsip etween oy type an te incience of various iseases confics an tension. . e local initiating stresses in man arise most frequently in te agnost mpatons musculoskeleta musculoskeleta system ecause o f is On te asis of te etiologic signifiincompete aaptation to te vertical cance of te lesion ust outline te stance an as part of eac fining of an osteopatic lesion iniviuals postural aaptation to marks a segment in wic or troug gravitational factors. wic te proaiity of isease is Regarless of te moe of initi relatively ig At est te lesione ation owever a somatic component segment is a vulnerale segment exis reflexly estalise wic reflexy acting compensations from te entire exacerates an sustains te faci- organism at worst it signifies tat itatory process an sensitizes every ecompensation ecompensation as areay ensue. isease process process to te influence influence of Wereas most iagnostic proceures availale toay ett tat presgravity 6 e local or segmental sympa- ence of isease procses only after teticotonia an neurovascular is- some egree of ecompensation as turances increasingy recognize as occurre recognition of te osteocontriuting to enogenous cronic patic esion reveals early invasion of iseases appear to e a prominent pysioogic reserve an preispopart of tis general process sition to isease Osteopatic lesions 7 Accoring to conclusions num- appear to e or to reflect te "silent er 2 an 3 weter or not an te nsiious fift column isorers rate an egree to wic isease wic leaing meical tinkers ave evelops troug te facilitate seg- concue nee to e sougt "in apment will e etermine y te total parenty wel people an wic are emans upon te iniviual an y te earliest vanguars of cronic e oter oter factors psycologic nu- isease. tritional social ereitary age et cetera cetera wic influe influence nce is tota Thrat mpto aequacy We ave terefore an 1 Asie from palliation terapeuimportant reciproca relationsip in tic attention must oviousy e given wic te osteopatic lesion in- to all te controlale factors in an evitay impairs uman aequacy to aroun eac patient wic inuence some extent extent wie te importance of is tota fitness an resources Because te facilitation associte esion to te iniviua is etermine y is tota aequacy to is ate wit te osteopatic esion intotal environment an to te ife creases te vuneraility of te insituations e encounters an creates. iviua to all factors ecisive e lesion increases te importance critica importance soul e a of every stress stress an every efect every tace to te treatment of osteopatic stress an every efect reners te t e im- lesions. portance of te lesion more critical 3 Since al existing lesions impair 8 Since te response to local stress te resources of te il patient for furirritation or excessive eman is ter resistance an recovery rgard asic asical alyy te same same troug troug te te ss ss of of thr apparnt apparnt toog ra tria or tetra) of nervous inf in fluences luences ton to th nss, no terapy can e te pote potenti ntial al clinica clinica manifest manifestaa- compete witout te maximum liertions wil e etermine y te seg- ation of tose resources ment invo involve lve an its associ associate ate Wereas in nonosteopatic tissues rater tan y te te nature of practice te treatment of oca or te insult "etioogic agent) itself segmenta autonomic imaance ore same process process acting troug if- inariy requires te iffuse alteration ferent segments an tissues prouces of autonomic activity trougout te a variety of synromes e location oy treatment of te lesion offers a of te lesion etermnes te target specific approac to te local autonomorgans an terefore te potentia ic isturance associate wit many "iseases Since te location of te cronic iseases
55
The direct participaton of the somatic component in basic responses to disturbing inuence it accessi bility and its rnsive to ap propriate therapy render it a direct and strategic instrumentality through wich to modify te response (the diseae process) and to augment the individuals capacity for response, resistance, recovery, and adaptation 6 In conclusion, since the osteo pathic lesion both reflects and in us the aduacy of the individ u's rerve and rour becaue it reflects and influences the adequacy of his responses to te demands of life, and because it reflects and in fluences his vulnerability and predisposition, early diagnosis and treatment of te osteopathic lesion offer a direct and systematc ap proach to the prevention of cronic disease for which, as far as we can tell, there is as yet no substitute The origins of the lesion, the pro cesses with which it is associated and their implications to mans health have hardly egun to be explored This is the major challenge before the osteopathic profession today References l Korr IM: How fa on the scientifc road? J Ostop 561316 D 19 2 Korr, IM Rearch progm for osteopthic profesion Am Osteop A 73-375 Mach 198 3 Kor,
IM: Thr fundamenta poblem in osteopathic rach. J. A Osteop A 5007416 Apil 1951 Denslow, J S and Cogh, G H : Reflex Reflex ativity in spina exten extenrs rs J Nerophysiol :3037 Sept. 191. Deslow, J S. , Htt, CC.: Centa ex5 Deslow, citatoy state sociated with postura abnormaities. Nerophyio. 5393-02 Sept 192 6 Denlow, JS Anlysis of variability of spinal refe thrholds J. Neophysio 7207215 Jly 1 9 9 7 Desow,
JS. Korr IM., and Krems AD Quantittive studies of chronic filitation in human motoneuon ools Am Physiol. 105229238 Aug. Aug. I97 I97 8 Korr, IM. and Godstein MJ: Dermatomal autonomic activity in reltion to egmenta motor thrhod. Federation Federation Pro 767 March 198 9 Korr IM Skin resistance ptterns assoiated with viscera disease Fdertion Proc. 88788 March 19 10
Korr I. M. Experimental Experimental alterations alterations in segmen segmen tl sympatheti (sweat gnd) activity through myofscl and otura distrbances Federation Proc 888 March 19 1 1 Korr, IM, nd Thoma, PE.: Sgmenta pt terns in man Fedeation Pro 1075 March 1 9 5 1 cuaeos s 12 Richter, C P Instuctions for sing cuaeo ristance rcorder or "dermometer on pripheral neve injries sympathectomies, and paravertebral blks J Neurosurg 3 1 8 1 1 9 1 May 196
13 Hrdy J.D, Woff, H.G and Goodell, H: Stdies on in New method for measuring pin threshold: observations observations on spatial summation of pain. 969657 Jly 1940 . Clin Invstigation 1 969657 1 Thoas, PE. and Korr, IM.: Autoatic recording of elctrical skin resistance atterns on human trnk Cin Neurophysiol 3 361368 Aug 1951 15
Thomas Thomas P E and Korr, I M : Signifia Signifiance nce of areas areas of low ESR Federation Federation Pro 1 1 1 6 2 March 1952 Thoma 16 Thoma
PE Wrigh t H.M , and Hart CW. Jr: Relation f sweat gand reritment to ESR. Fderation Fderation Proc 12 13, March 1953 Wight, H M, Korr, M and Thom Thomas as PE: 17 Wight, Regional or sgmental variations in vasomotor activi ty Federation Pro 1 2 1 6 1 March 1953 1 8 Blades B. and Dugan 0 War wounds of chest obseed at Thoracic Srgey Center Water 293 Rd Genea Hospital J Thoracic Srg 1 3 293 9. Aug 1 9. 19 Grimson, KS: Tota thoraic and partial to total lmbar sympthectomy and eliac gangion tomy in treatment of hyprtension Ann Surg 1 1753775 Oct 191 20 Gutmann L: Distibtion of distrbances of sweat scretion after etirpation of ceain sympathetic cervica ganglia in man J Anat 753759 July 1. L T, el a. a. : Postoperative sweating 2 1 Palumbo, LT, tt n olm symhtomy sp tomy Neu & Psycat 635578 Apl Apl . . 2 H E et a: Etl skin r t in evaluation of priphera nerve injues Arch Nerol Psychiat 56365380 Oct 196 23 Hyman I and Beswick WF. Measurement of skin resistance in peripheral nerve inries War Med 82582 Oct 195 Jspr, H, and Robb, P: Studies of electrical skin resistan in periphera nere esions J. Neurosurg 21268 July 195 25 Richter, CP, and Levine M: Sympathectomy in man its effect on eectrical eectrical resistance resistance of skin Arch Neuro Psychiat 387567 Oct 1937 Rt CP , Otenek, F.: Thoalmbar 26 Rt symthom ed wth eltrl skn r meh J Nurrg 311 Mach 1 1 27 27 Richter C P Cutaneos areas denervated by pr thoracic and and stellate gngionectomies deter mined by eletric skin resistance method J Neurosurg 221232 May 197 28 Thompson Thompson J E Brose N A and Smithwick RH: Patterns of eletril skin resistanc folowing sympathtomy. sympathtomy. Ach Srg 6031455 Mac 1950 29 Whelan FG, and Richter P: Eectrical skin resistane technic usd 10 map areas areas o f ski n affte afftedd by sympthtomy and by other surgical or funciona factors Arch Neurol & Psychiat 9556 March
35 Corvie CB Anoemia and brain disse Caf Med 79 21217 Sept 1953 36 Longo OF, Galardo C.AS and erraris A Contribution la pathognie des pancratites aiges Arch mal App 013021317 Dec 1951 37
Longo, O.F O.F Sosa Gallardo, CA and Ferraris A Las a1teraci6ns vsuloneviosas en la paognia de as pancretitis agudas Rev Aso md. ant 816 J 1 50 50 12 Shagas, G : Studies of bood bood 38 Malmo R .B , and Shagas, pressure in psychiatric patients nder stress Psychosom Md 18293 MarchApril 1952 39 39 Barcro H and Swan HJC: Sympathetic control of human blood vesses Edward Arnod Co ondon 1 953 Harris, KE and Marv in H M.: In nervation nervation of mammalian capillari by vasoonstrictor sympathetic nerves Heart 1135138 D 1927 1 Kntz, A: Afferent innervation of peripheral -ood vessels throgh sympathetic tunks; its clinia impications Soth MJ 673678 Ag 1951 2· Burton, AC Blood low, temrature and co or of skin in Bood Heart and Circuation, dited by FR Moton Pbication of American Association for Advancement of Science No. 13 Sience Prs Washington 19 pp 308313 3 Burton AC. Laws of physic and ow in blood vesses, in Viscera circulation Ciba Foundation Symposim Summit NJ 1953 pp 708 Hertman, AB: Physiology of heart and cir clation and its clinical appication in physical medicine: symposium; Physioogy and measrement of peiphera circuation. Phys Ther apy Rev. 30471481 Nov 1950 5 Hertzman AB: Some relations btween skin tempratre and bood fow Am J Phys Med 32233251 May 1953 Shard, C Temerat Temerature, ure, skin , th erma regla regla 6 Shard, tion in Mdical phsycis dited by O Gasser. Year Book Publishers Chicago 1950 Vol II, pp 1 1201 1201 123 7 Wise,
Minor V: Ein Nees Verfahren u der klinischen Untersuchung der Schweisabsondeung 302308 8 Jan 1928 Deuthe Ztschr f Nervenh 10 1 30230 3 Randal, WC Qantitation and regiona distribtion of sweat gands in man J Clin Investigation 25761767 Sept 196 32 Wada M and Takagaki, T Simple and ac curate method for detecting secretion of sweat Tohoku J Epr Med 9;28 Oct I I 198 198 33 AdmsRy J, and Hagrg S.: L'hyonie des capiaires vineu nouvel ment d syndrome inammatoir Lyon chi 6937 NovD
s Flid dispacement and pressure pethysomography in Methods in mdical resarch edited by VR. Poter Year Book Publishers 98 Vo I pp 18191 Chicago 1 98 Goet R.H Clinical pethysmography South African M.J 2222435 Jy 10 198 Herzman,, AB : Blood supply of vario varioss skin 9 Herzman area as estimated by photolectric plethysmograph Am. J Physiol 123280 Nov 1938 50 Hertzman AB and Dilon J.B. Applications of photoeectric pethysmography in peripheral vasclar disse Am Heart J 2075761 19 5 1 Hertzman AB. Randal WC and Johim K E Estimation of ctaneous ctaneous blood ow with photoeetric plethysmograph Am J Physio 15716726 March 196 52 Hertman AB, and Randall W.C: Estima tion of ctaneos blood ow with photoelectric pethysmograph in presnce of arteria pathology Federation Pro 6 130 March 197 53 Herman, AB Photetc plehysmog rahy of skin in Meths in mil ch, it by V.R Poter Year Book Pbishers hicago 19 Vo I pp 177182 Crawford JH: Studies on human capilaries observations on capiary circuation in norma sbects J Clin Instigation 235136 Apri 926 Dury A W an d Wrigh S : Stdis of 55 Dury human capiaries; present day technique for study of human capillaries Am J M S 185673 May
199 3
933 56
193 30
AdamsRay J and Pernow B. Some new observations concerning symptom palor in infam mation syndrome Acta chir Scandinav 98221229 1 99 99
Brown GE Skin capillaries in Raynads disease Arch nt Med. 355673 Jan. 1925 57 Chiavaci L V and Pnam TJ Capi pic obons i c of multipl eros
nterpretation of researc
7782 May 1949 Arch. euro Psyhiat 61 7782 8 Griffit JQ, Jr: Frquent occurrence of ab normal cutaneous apillaries in constitutional neurastheni states Am J M Sc 183:180187 Feb. 1932 9 Naide, M., Sayen, A and Comroe, B.I: Caracteristic vascular pattern in patients with rheumatoid arthritis Arch. Int. Md 76 139142 94. Sept 1 94. . DiPalma J.R Reynolds SR.M and Foster, F: Measurement of sensitivity of smallest blood vsels in in uman skin res ponses to graded mcanical stimulation in normal men J Clin Investigtion 20333343 July 1941 6 1 DiPalma J.R, and Foster Fl. Sensitivity of smaest cutaneous blood vessels; uantitative rsponses to graded mhanical stimulation and to local ischemia in arerial hypertension, arteriosclerosis, and certain allied disorders J Clin Invtigation 2167683 Nov. 12. 62 Lewis, T Blood vessels of human skin a d their responses. Shaw Sons, London, 19. and 63 DiPalma JR and Foster F1. Segmental and ageing variations of reactive hyperemia in human skin Am Heart J 24332344 Sept 1942. Mayeron HS, and Toth LA Influence of posture on ski n and subcutaneous tempratures tempratures Am J. Physiol 12:474480 March 1939. 6 Nielsen, M. Herrington, LP, and Winslow, CEA Effect of posture upon peripheral circula ton Am J Physiol 127:7380 Oct 1939 Indirect Henschel, A, Brozek J and eys, A Indirect vasodilatation in normal man and in schiophrenic pa tients J Appl Physiol. 434034 Nov 191 67 Gibbon, JH. Jr, and Landis, EM Vasodilatation Vasodilatation in lower extremities in respons to im· mersing forearms in warm water J Cin [nvestiga tion II 1019-036 Spt 1932 68 AdamsRay AdamsRay J. "Erblass "Erblassen en (Pallor (Pallor ein kutaner Sympathicusreex im Entzndungssyndrom speziell nach hirurgen Eingrffen im Ober [03-11 190 190.. bauch ntralbl. Neurochir [03-11 69 AdamsRay J Photometrical studies on visceroutaneous relexes with vasocontriction in venous capillaries (Wernoes symptom in gallbladder dieases Angiology 21·9 Feb 19 Ingalit de la 70 Doret, JP and Ferrero temprature temprature utane dans Iinfarctus du myocarde et Ingne Ingne de poitrine Cardiologia 1980·% 191. somatic 7 \ . Travell J, and Bigelow NH Role o f somatic trigger areas in patterns of hysteria Psycosom Med 933363 ovDec 1947 72 Travel, J Pain mechanisms in onnective tisues, in Transactions of the Sond Conference on Connective Tissues, edited by Ra gan Josia h Macy, Jr Foundation, New York 191 pp 86-12 73 Strup, G Visceral pain plethysmographic "pain reactions dilatation of oesophagus Nyt nor· disk forlag forlag Arnold Busck Copenhagen, 1940 74 Delore P, and Leder Mme): Intrt de la termotrie cutan Prs m< :1091 July 19 192. 7 orr lM eural basis of ostopathic lesion J Am Osteop A 47191·198 Dec 17 76 orr IM Emerging concept of osteopathic Ie sion J Am Osteop A. 48127138 Nov 1948. 7 7 Gu tt ma nn L Ue be r re fl ek to ri sc he Beiehungen wischen Visera and Schweissdrsn und ihre Bdeutung bei Erkrankungen innerer Orgae (der Viserosudorale Refle) Confinia neurol. 12%311 1938 78. Van Metre, TE Jr Low electrical skin resistance in region of pain in painful acute sinusitis Bull Johns Hopkins Hosp 4·41 Dec 1949 79. Ansemino J eue Wege der Eklampsie und Praeklampsiebehandlung: Die Bkade des ierenbereichs und d Ganglion stellatum. J. Suisse
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de Med. 801373 801373 ·1377 190 190 Danel PM, d Prhad MML Effts of stimulation of hepatic nerves and of adrenaline uon circulation of portal venous blood within liver. J Po 1 14:38·48 14:38·48 Aug. 27 191. 8 1 van Gelderen Zur Physiologie der menschlichen iereninnervation Helvet chir acta 16423431 16423431 D 1949. 82 Reilly J, el 1 1 e role du systeme nerveux en pathologie renale Masson et Cie Pars 1942. Treatment of acute nephritis Am. 83 Shpirt, Y Treatment 107·1 10 10 April 18 Rev Soviet Med. 107·1 Spitzer N and Friedman Friedman 84 Steinbrocker H H Shoulderhand syndrome syndrome in reex dystrophy of uppr extremity Ann Int Med 29:22·2 July 1948 ostoperative problems problems of 8. Upham R . Pr and ostoperative gall ract Am J Gastroenterol 21 366·38 April 94 86 Ussher, .T.: Viscerospinal Viscerospinal syndrome syndrome new concept of visromotor and sensory changes i rela ion to deranged spinal structures Ann n t Med Med 132072 May 1940. 87 White J., Smith wick, RH an d Simeone, FA. Autonomic nervous system anatomy physiology and and surgical application E d 3. Macmillan Co New York, 192 88 Winbury, MM and Green DM: Studies on nevous nevous an d humoral control control of coronary circulation Am J Ph\ 170:63 Sept 192. 89 Nedzel A.J: Pathogenesis of nephritis due to 68691 May 1934. eposure to cold J. Urol 31 68691 Palumbo LT Sympathectomy in treatment of Buergers disease Postgrad Med 9:2219 March 191. 9 1 Ratshow M Die Bedeutung von Gefssreex en fr die Prognose innerer Erkrankungen Acta Neuroveg 8202210 193. physiologic properties properties 92 unt, A Anatomic and physiologic o utaneovisceral vasomotor reflex arcs. J ·429 ov 194 europhysio 842 ·429 93 edzel AJ. Temprature changes in trachea and kidey in relation to heat and cold on skin Proc So Ep BioI Med 30 691·692 March 1933 94 edzel, AJ: Temperature changes in liver in relation to heat and cold on skin Proc Soc Exp. BioI Md 30:6896 March 1933 9. Raston, H. and err WJ.: Vascular responses of nasal mucosa to termal stimui with some observations on skin temprature Am J Phyl. 1430·310 July 194 % Ricins CA, and Brie .: Effect of localid cutaneous stimulation on cirulation in duodenal arterioles and capillary beds J Neurophysiol 1 2 1 3 1 · 1 7 Marh 19 97 Wright HM Heath and biped stance J Am. Osteop A 13[·32 July 192 Referred pain and osteopat hic 98 Druker DE Referred leion J. Am. Osteop A 47623629 Aug 1948 Stieglit, Stieglit, E J Medicine Medicine in aging population M Clin oth Ameria 3329308 March 19
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Reprinted by permision fom Symposim on the utional Impliatio o Segmeal Failitation, rom JAOA 4 277282 19.
57
nc ar uually o uch a natur that thy ar, a a mattr o cour, dbatd and ttd wn th xAn examination of its content, direction and reation to the tng chool or chool o mdcn. function of osteopathic medicine* (1955) Howvr, a chool o thought, convncd o t ntal valdty may nd t ncary to organz tl nto Durng much o th l o th oto- on dclar or tl n rvc to a nw proon proon a parat parat chool chool pathc proon th bulk o t r octy and by th drcton o th o pract practc c whn t pot poton on on ourc and t nrg a an orga progr whch t apr to mak th u dmd wthout con nzd proon ha bn dvotd to draton by th xtng chool o mdcn, whn th xtng chool wnnng th rght to practc and to Resar an funin f tach accordng to t own prncpl spai miine wll not dbat th u o, a mot uually th ca, whn thy do not and to dvlopng th aclt and vn rcognz th xtnc o an pronnl or carryng out tho two Te urpoe o Reearc uncton In th ac o th pro Why ould th otopathc pro- u Th th only raon or th on lmtd rourc, only rlatv on now turn all pobl rourc to xtnc o th otopathc pro ly lght attnton ha bn gvn n rarch? Lt u mmdatly lm on It hypoth, only uprcalth cour o th truggl to urthr nat anwr too rquntly gvn or ly xamnd, wr dmd a xploraton and dvlopmnt o ot mpld Rarch no don to m- dogma and t practc a cultt. opathy pcal contrbuton contrbuton o t pr, to wn rcognton, prtg, or d and utcaton or a paat prncpl, o th bologc phnomna nancal upport or vn to prov chool o mdcn contnu a long wth whch t dal, and o th prac- on contnton Wlcom a th a th u rman and a long a tcal mplmntaton o tho prn- may b a byproduct o good that chool approach not adcpl. rarch, whn thy bcom th quatly condrd, ttd, or appld Th truggl or rcognton and prmary obctv o rarch thy by othr chool rght to xtnd and dlvr t r- dat t vry purpo arch ha Th proon ulll that nd vc rapdly approachng vctory. only on purpo th curng o and thror ut t contnud long a t aum aum Mor and mor matral and human rlabl normaton and undrtand- xtnc only o long rourc can thror b lbratd, ng about tho apct o natur n ull rponblty or th applcaton and mor and mor bcom aval- whch on ntrtd or n whch t approach and mthod n prac abl or purut o th rlatvly on k gratr powr o prdcton tc, or tranng uccdng gnracontrol n th ca, human human ton o phycan or uch practc, nglctd pha o proonal l and control rarch and dvlopmnt at th c halth and da. and or connuo ploraon and ntc and clncal lvl It thr It wa o wll xprd by ranc ranc developmen roug reearc It or tmly ndd urgnt, that th Bacon thr and a hal cntur ago: mut contnu tho rponblt otopathc proon thoroughly x Human knowldg and human untl uch tm a th prvalng amn t oblgaton and t oppor- powr ar coxtnv; or gnoranc chool o mdcn prpard to actunt n th ara. Th papr n- o cau prvnt u rom producng cpt at lat th potntal valdty o tndd to b a mall contrbuton to ct atur can b ruld only by th otopathc approach and to ath xploraton. In th avalabl bng obyd; or th cau whch um or har th rponblt pac w can only dnty om o thory dcovr gv th rul whch Th, howvr, wll nvolv a bac r r th ky quton and ndcat om practc appl or natur to b orntaton o mdcn to a drnt o th dron n whch to k th oby obyd d and thu ruld ruld t mut mut vwpont vwpont or at la latt to th ncorporaton o a drnt vwpont anwr rt b undrtood Today, t Th why o my thrart thrart qu almot unvrally agrd that th rom that whch t appar to rlct ton rlatd to th mportanc road to control ovr human halth today That day not yt hr, but t whch attachd by th pro on to l only through wdnng and on th way. Th otopathc movth accumulaton o nw knowldg dpnng o our bac knowldg o mnt uccul uccul to th dgr that t and undrtandng or th ulllmnt human natur and human bology n hatn that rorntaton o t uncton Th what o all thr apct Th only dbat, n otopathc rarch dtrmnd by vw o th ncrangly prng Te precou drop n e ocean what th proon condr to b t problm problm o o human da, around Rarch Rarch o th th largt largt pobl ncapabl rponblrponbluncton and th natur o th oto- th u O wa do control cop an ncapabl pathc contrbuton Th whthr cont, n what drecon do t l, ty o th proon bcau a vat th dr drct cto onn o ot oto opa path thc c and through wc o th unxplord amount o knowldg and undr rarch rarch nparab nparabl l rom th ld o bac knowldg th rout tandng rman to b dclod and "what and wll b dtrmnd by th mot crtan and drct? dvlopd whch abolutly nlongtrm obctv whch th pro dpnabl to th dong o th ob Te debae o e ue whch th proon ha t tl It around th u and around th and or whch t cam nto xtnc · on t peened t Gene Seon n u alon that dvrgnt chool o W mut rankly ac th act that adnu onention o the men Oteopthi mdcal thought ar Th dr vanc n undrtandng and control oiton New Yo ty Ju 7 96
O Why w whh?
Intrprtaton o rarch
f factrs and penmena t wic stepatic medicine ascribes critical imprtance ave been minte as cm pared wit biic and medica ad vance in enera, and, indeed, as cmpared wit te advances f te stepatic prfessin itsef As was stated at te cnventin f tis Assciatin 8 years a Th Th tm h h om whn whn nr nr ng ng t t tnton mut b gn to th thort rr uon whh ontnud thn dn rdtd For mny ron th rrv h bn onumd fr mor rdy th thy h bn rnhd n otothy n thnoog pt of modrn f rg bkog of fundmnt nformton mut mntnd nd nrgd f ontnud rt rt dn r to b urd Thy r ndd th rng from whh th dn ow
Te fllwin prtest may be made, as it as been, by sme w cnine t view researc as a ry ilaffrded by te stepatic pr fessin, rater tan as an inescapabe biatin and pprtnity Tey pint t tat a tremends vme f medical researc is already in pr cess trt te wrd invlvin investments investments f biins f dars and tens f tsands f individas wrking in tsands f instittins Tey remind s tat mc f te prdct f tis researc is availabe t, and incrprated in, stepatic edcatin and practice Te cntrib tin made nder stepatic aspices, even even nder te best f circmstances, can be bt a drp in tat vast cean Of wat imprtance can tat drp r any any drp be in sc an cean cean In te first pac, ttal researc prress is made p f cntless cn tribtins ranin frm minte in scale t rand in manitde Secnd, wile sme kinds f investiatins can be cndcted nly n te rand scale and wie, iven ter essential factrs, te mre te researc te faster te prress, manitde is nt wat cnts cnts It is ne r mre f sc elements as te fllwin tat ive imprtance t any researc and its prdcts te sinificance f te cn tribtin its tta impact n knw ede, te meanin it imparts t a previsy accmated mass f facts, te carity it brins t an area f cnfsin r inrance, its cata ytic effect n te rwt f nder standin, te breadt f eneral izatin it makes pssible, te nmber
and imprtance f periperal prb ems wse reatins it reveals and t wse nified cmpreensive sl tin it ffers an apprac, te new prblems it raises and te new in qiries it stimates, te new r re fned cntr and predictin it makes pssible I n srt, imprtant as is te scae f peratins, peratins, wat cnts is te manitde f te secrets tat te re searc nlcks te nrav nraveli elin n it makes pssibe We may draw a simie frm re searc and tecngy temseves It reqires bt n crystal, f special natre, at te rit time, nder te prper circmstances, t release frm stin, fr arvestin, precis crystas crystas f enzyme enzyme,, rmne, rmne, r virs idden witin an accmlatin f cmple amrps etracts It re qires bt a reativey minte qanti ty f cemicas, f prper natre, t carify a lare bdy f trbid water and tereby revea new wrds f f pe nmena and previsy nseen rela tinsips And s it is wit researc Drps f researc ave aain and aain in te past carified vast reser virs f accmlated knwede, brt new areas areas t it, iven new meanin t ld areas, and reveaed tat many apparenty nrelated is ands f knwede were bt te perficia prjectins f a cmmn, deeperyin base Te researc mst ask ttaly new qestins f natre r d qestins in a new way Ostepatic researc i cncerned wit areas nt nw recnized r ade qately eplred by ters, and wit nrecnized cnnectins amn areas tat re bein eplred It des ask a new kind f qestin and tere fre seeks different different kinds kin ds f answers Tese answers ave a specia and rent pertinence t man ealt at tis particar stae f civilizatin Qetion nd nwer: nked nnwered rantin te imprtance f tse answers, it may sti be prtested tat teir qest is an nfair and an interabe brden pn te prfes sins imited resrces Wy nt eave it t tse w are aready ricy eqipped, staffed, fnanced, and eperienced t accmmdate tis drp in teir cean Te reply is simpe Te answers will nt cme nless tey are st,
and tey wil nt be st ness te eeker imsef asks te rit qes tins and asks tem in te rit way Te answers wic stepaty seeks cannt emere in te crse f r as byprdcts f investiatins int ter qestins Answers t nasked qestins are nt answers at al answers t qestins incrrectly asked are wrng answers regardess f te vaidity vaidity f te bservatins r te precisin f te measrements pn wic tey are based Tey are nly data wse meanin mst await te askin f te crrect qestins Tis is wat Paster meant by te "pre pared mind Te qestins wic stepatic investiatrs ask and sld ask emere frm ypteses wse essen tia vaidity is demnstrated at least t te satisfactin f stepatic pysi cians and teir patients Were tese qestins bein asked wit sfficient freqency and clarity in nnste patic instittins, it cld be ny becase te centra ypteses cn stittin te stepatic cncept were bein iven sfcient cnsideratin and credibility t merit frter testin testin and epratin Were tat tre, all need fr a separate prfessin wld ave been eiminated Qtion prodt of of preving pe petiv tiv Wy are te qestins wic are cen tra t stepatic tery and prac tice nt bein asked wit adeqate freqency and trness in al f te medical researc tat is gin n Certainy, it is nt fr te want f traditinal academic freedm, te freedm freedm f te individal investigatr t flw is wn interests r crisi ty Te pint is tat qestins asked by individa investiatrs are fra ments f te arer qestins asked by bilic and medical science as a we Tese, in trn, t a larer de gree tan is cmmnly recnized, are stimated and frmated in ac crdance wit a prevaiing, t ndefined, rientatin wit respect t qestins f eat and disease, and in accrdance wit te prbems wic are a re identified (and te way tey are defned) in te crse f clinica practice Eac individa investia tin is, s t speak, an eddy crrent derived frm and cntribtin t te prevaiin wind, speeding it sme 59
what occasonally deflectng t a lttle he ssue s not whether the prevalng wnd s an ll wnd whch t most certanly s not havng brought especally durng the past halfcen tury rch treasures of medcal advance and new understandng for whch all humanty s grateful he ssue rather s whether enoug of the answers to human health problems le along ts projected path whether the prevalng orentaton central hypotheses and objectves pont the best possble path he os teopathc approach represents as yet a zephyr n qute another drecton a basc deflecton from the orgnal path. ts propulsve force cannot acheve full development or be adequately utlzed untl there s some reorentaton of the prevalng wnd n ts dreton. hs can be acheved n no other way than by objectve r refutable demonstraton of the prom se that les along the osteopathc path n other words osteopathc ques tons are not beng suffcently asked of nature outsde of the osteopathc professon because they do not sprng from the prevalng conceptual framework n whch medcal practce and research are orented the "need for the answers s not suffcently rec ognzed and even the answers whch are dsclosed lose meanng n the prevalng contexts. hs s not to say that medcal research s barren of the answers whch osteopathc nvestgators seek and would seek othng as we have repeatedly shown could be further from the truth. Whle vrtually all as pects of bology have some pertnence to osteopathc thought practce and research medcal and bologc lterature s replete also wth mportant parts of specal answers whch we would seek. But because they arse n response to other questons ther sgnfcance s mssed or altered and because the comprehensve conceptual framework whch encompasses these fragments s not recognzed the lnks among the fragments are not per ceved and they reman mscellaneous fragments n wdely scattered felds of nvestgaton. When however the lnks are revealed wth the ad of a cohesve comprehensve framework these fragments are seen to represent a major new trend n medcne one
envsoned n the osteopathc approach Prevalng medcal perpecve
t s not possble at ths tme nor am peronally qualfed to undertake an analyss of the basc perspectves the conceptual framework the central hypotheses and the objectves whch appear to gude the domnant school of medcne and whch serve as ponts of departure for medcal nvestgaton hs has been admrably done by a number of wrters wthn and wthout the medcal professon and ther vews may be summarzed as follows. Whle many nformed medcal leaders and educators pont out that t s not enough t s dffcult to escape the generalzaton that the functon of medcne s vewed as the combatng of dsease he basc strategy appears to ncorporate the followng ele ments: (1) the careful characterza ton of each dsease and ts manfestatons so that n dagnoss one may be dstngushed from another and the progress and severty of each case may be evaluated ( the search for the cause or causes of the ndvdual dseases (3 the dentfcaton and descrpton of the processes nvolved () the search for and devsng of ex pedents to attack the causes and/or to modfy the processes nvolved the more specfc to the dsease the better () the allevaton of the manfestatons and sequelae of the dsease 6 preventon of dsease by specfc measures and through detecton and treatment of early sgns of dseass he road to human health from ths vewpont s n the elmnaton of mans dseases one by one group by group through understandng each more mnutely Modern medcne therefore s commonly descrbed sometmes n prde and sometmes n crtcsm as etologcal and curatve (remedal) wth occasonal specula tve glances n what are termed eco logcal drectons Prevalng perpecve n medcal reearc
n accord wth ths strategy medcal research certanly that massve por ton wth delberate or recognzable clncal mplcatons s predomnant ly drected at understandng of the dentfable dseases ther causes mechansms processes and dstnc
tons and at developng techncs for recognzng evaluatng and modfy ng them and ther manfestatons Snce dseases for the most part are referable to pecfc cells tssues organs and processes the mcro scope of bologc and medcal research has been turned wth evern creasng concentraton and wth more and more mnuteness and precson upon these and ther expermental and pathologc alteratons untl t has become one of the most proudly avowed objectves of modern medcal scence to explan man and hs dseases n molecular terms n terms of hs most elemental component parts and processes n terms of physcs and chemstry t would serve no useful or just purpose to crtcze these vast and obvously successful efforts nor to mnmze ther mportance to our understandng of lfe and to the con trol of health he only ssue agan s whether ths approach s the only or the best approach to human bology and to the buldng of human health ndeed to the conquest of dsease. Medcal achevements of re cent years have been so numerous and so dramatc that the possblty of another let alone a better ap proach hardly seems thnkable or necessary he mplct assumpton prevals that we need only to pros ecute ths approach long enough and ntensvely enough and nevtably all of the techncal answers to human health needs wll come t s approprate to ask however as many are now askng whether the mcroscope fguratvely speakg s the best nstrument wth whch to acqure perspectve whether mnute study o dsease can ever yeld a com prehensve understandng of health whether the examnaton of solated factors and phenomena n controlled experments ndspensable as they are to bologc study can ever reveal that world of phenomena whch s the product of the uncontrolled nterplay of many factors and n whch the bologc mpact of each factor s contnuously modfed by the changng constellatons n whch t operates t s approprate to ask whether human health and ts control can ever be acheved through study of the parts and processes large and small whch man shares wth other anmals wthout searchng attenton to the nterpretaton of research
peciar demands that hman ife and individa ives pace pon these mechanisms Can satisfactory nderstanding of these mechanisms in man ever e achieved otside of their operationa context, the circmstances nder which they are reqired to operate, the adaptations to which they are reqired to contrite, the ases to which they are expose, and a other factors associated with hman organisms and arising in hman ife? What of the peciary hman factors which modify and impair the operation of these parts, processes, integrative mechanisms, and moecar reactions, casing heath t fai an iseases to emerge? It is important to qestion whether the road to heath ies throgh treatment of these diseases rather than throgh contro of the factors of which diseases are the proct, to which, indeed, they are adaptations It is ap propriate to ask whether the most minte stdy of peptic cer, for exampe, can ever do more than te aot peptic cer, withot reveaing what ais the man who has one, now why is it ioogic adaptation to the ife that he ives whether, inee, minte stdy of the ravage and debr 0/ de/ea of the hman organ ism, of the adapaon o de/ea an of / e knd 0/de/ea can ever ead to the origins and natre of hman de/eaably an therefore toward its contro. The reevance and vaiity of these qestions have ecome increasingy sharp, and the etioogica and crative approach has een mor e and more shaken in recent years with the emergence of the chronic degenera tive diseases The chronic degenerative diseases have increased with aarming rapidity as the infectios diseases have sside an are, as former Srgeon Genera Scheee state, the major front today These diseases, chronic in origin as we as in dration, are the prodct of whoe ives in a their aspects, the podcts of inadeqacy an maadaptation of the hman eing to the tota ife that he ives an has ive To view them as the effects of specific cases which need ony to e ientified, isoate, and destroye an for which cres ony await discovey is to eny their very natre. As Dos an others have pointed ot, hman difference are no ess impor
tant in the infectios diseases, despite the participation of specic, identifiae casative agents In the face o f the tremendos accmation of estaished disease of defeated organs and tisses which confronts the physician today, it is certainy his oigation to se the est paiative, crative, and preventive methods at his isposa; and ner the exigencies of daiy practice this may e the ony oigation he can ffi Of this there can e no jst criticism. We can, however, qestion with consieray more vaidity whether research which aso remains, directy or inirecty, diseaseoriented can ever yied the comprehensive answers which todays heath needs emand. These qestions gather new meaning as we watch the growth and mtipication of vast research programs, pic campaigns, fona tions, instittes, and departments for the stdy of individa diseases or grops of diseases, an so few for the stdy of factors, featres, origins, and mechanisms which they have in common. Te oeopac queon
The osteopathic orientation is impicit in these qestions This orientation is not, nor was it ever, the excsive creation of the osteopathic profession Parts of it have een recognize for centries and it is more often and more comprehensivey expressed today than ever efore However, commony as it is pro caimed, and freqenty as it i the theme of prefaces and forewords, it has yet had itte impact on medica practice and virtay none on asic medica research Its hoistic, organismic, and ecoogica impications are isaine y meica scientists, argey preoccpied with the moecar an microscopic approaches, as eing more within the ream of meica art than of science It is ony within this organismic concepta framework that the conspicosy istinctive contrition of osteopathy, namey the recognition of mscoskeeta factors in heath an disease and their manipative management, has its meaning Ony within this framework can it e inteigie, interesting, and chaenging as an area for investigation Sqeeze into the framework of etioogica and crative medicine it is (jsty, in my
opinion) rejected a preposteros incongrity. For these reasons and for others erived from them, the ioogic qestions which osteopathic medicine raises an for which the profession came into existence are sti not eing sfficienty prsed in nonosteopathic instittions, nor are they ikey to e in the immediate ftre Becase of the earing of these qestions on the nderstaning of hman ioogy an on hman heath and its contro, it is the inescapae oigation of the osteopathic profession to prse them with maxima and ever increasing intensity This is the why of osteopathic research The conen and direcion o oseopahic research
Oeopac concep v workng ypoee
et s now trn to the what and whither of my threepart qestion What is osteopathys concepta framework? Osteopathic concepts of heath an disease as ases for thoght, teaching, and iscssion and as gies for practice have een stated many times in ifferent ways Each physician eveops his own whether or not he veraizes them For these prposes and according to varios standards, varios versions have served more or ess adeqatey The greatest vae, however, of any hypothesis or ody of hypotheses, sch as osteopathic concepts are, ies in the degree to which it stimates and gides frther inqiry, the degree to which it ientifies areas for, and directions of, investigation in short, in the degree to which it gides its own nfoing I think we cannot escape the concsion that, a i comonly preed, the osteopathic concept has not serve we in this regard As it is commony expressed primariy for physicians and physicianstoe ioogic scientists find itte in it to stimate, chaenge, or excite their ordinariy restess cri osities, certainy not enogh to divert them from areas of investigation which they aready fnd engaging an to which they eagery dedicate their ives To the ioogic scientist, statements of he concept appear to consist party of generaizations, so roay stated an so sefevident
6
that they offer itte to examine, to doubt, to test, or to question, and party of references to vaguey de fined phenomena which, for him, either do not exist or ppear of isoated and trivial bioogic interest. Aready presented with more possible and worthwhie research problems than he can attack in a ifetime, he is understandably unattracted to phe nomena of whose existence he has no certainty and, in any case, whose con nections with identifiabe phenomena and probems he does not perceive. It is as though he were asked to scru tinize a shadow by turning a bright ight upon it. In short, a commony expreed, the osteopathic concet asks no clear questions, presents and identifies no probems, is neither stimulus nor guide to research and to its own un folding. The present generalizations or basic bologic aws, such as those regarding the unity of the body, the intrinsic capacities of the human body, and the oneness of structure and function, appear to be trite, sef evident axioms and therefore not areas for investigation, only because their bioogic implications have never been adequatey expored. Indeed, it is my beief that herein is one of osteopathy's largest potential con tributions to the biologic sciences It is not that osteopathy recognizes and obys" different bioogic aws, but rather at east at the clinica eve that it has more deepy explored and applied the impication of those universay recognized laws.22 Principes which have become guides to osteopathic practice remain but pious banaities for others. The unexplored areas and directions of inquiry which they encompass need, therefore, to be identified. Labes regarding factors and phe nomena, such as structure," struc tura integrity, osteopathic lesion," et cetera, which have widey diverse, though somewhat overap ping, meanings for those reativey few persons who have cinical experi ence with the henomena, have no meaning for the preponderant seg ment of the biomedica word which does not have direct experience with them A bioogic entity which is variousy viewed as (1) a vertebra strain, (2) a subte subuxation, () an error in ocomotion, (4 a complex re sponse of the entire person focalized
through a portion of the spina cord, a facilitated segment 6) a palpable alteration in the para vertebral tissues, (7 ) anatomic displacement of one or more verte brae, 8) disturbances in spinal kinesioogy, 9) a postura stress, (1 0) the body's repone to a postural stress, ( ) any structura abnor mality which disturbs function and possiby hundreds of others is, as such, hardly an identifiable subect for investigation. It is as though of a group of bi ologists setting out to investigate and determine the nature of the elephant, one scrutinizes the tail, another the trunk, the third the ear, the fourth a leg or tusk, and stil another the trumpeting of the elephant or the vibrations of the earth as it runs by or the screams of other frightened ani mals each in the beief that hat is the elephant! The deveopment oj working ypote.
In my opinion, then, this is a task of highest priority: The restating of osteopathic principes in terms of basic biologic issues and probems and in the context of todays and tomorrow's health needs. Noncom mittal idioms and labels, deveoped when knowedge of bioogic mecha nisms was meager, and conveying many private meanings or none at al, need to be translated into, or related to, phenomena which have been and can be identified and recognized in the biologic and medical sciences. It wi avai nothing from this viewpoint, however, merely to set out to restate "the osteopathic concept" in other words and to defne and re define "the osteopathic esion." We need to spel out the derivations and extensions of these generalizations and their impications to various fieds and aspects of the biologic sciences We need to identify the categories of biologic phenomena, factors, mechanisms, processes, components, relationships, and inter reationships which are or appear to be related to the osteopathic lesion," which have or appear to have a bearing upon it, and upon which the lesion has or appears to have a bear ing. (See, for example, recent papers by Wright3 and Thomas. ) Only in this way can the interest and partici pation of biologic scientists be won
and only in this way can they begin the formuation of their own special ized conceptua frameworks to guide their contributions to osteopathic theory, practice, and education. This can be accompished ony through close colaboration between quaifed bioogic investigators and osteopathic physicians who have rich backgrounds in osteopathic theory and practice and, as far as possible, in research. Their obective should be, not the deveopment of a satisfy ing statement, " but a body of work ing hypotheses which invite, through investigation, their own revision, eaboration and even replacement. Even with our present limited know edge, I beieve it is now possible to do a suficiently satisfactory ob that quaified biologic and medical sci entists woud, upon studying those hypotheses, not only fnd them chal lenging, but also find the places where they could make their best contributions. In the absence of such a body of hypotheses, a qualified investigator who, et us say, through having oined the faculty of one of the osteopathic colleges, is presented with the opportunity (or obigation) to do osteopathic research" does not readiy find his way in," and does not readiy identify osteopathic" probems within his specialty to which he can gratifyingy apply his taents and knowledge. He must, therefore, with such guidance as he obtains at the colege, construct for himsef a hypothesis, a persona in terpretation of some aspect of the osteopathic concept, adequate at east to enable him to formuate a probem in his feld. In essence, he identies some unknown" pointed to by hi interpretation of osteopathic theory and endeavors to reate it to some known" in his field. The soundness and comprehensiveness of his con cep, therefore, significantly infu ence his eection of the area of the investigation and of the approach, and the value of the investigation. In similar manner, we, the futime professiona staff of the Department of Physiology and harmacology at the Kirksvile Colege of Osteopathy and Surgery, consisting at present of four professiona physioogists and two D.O.s who have become profes sional physioogists, have had to con struct our own osteoathic concets Interpretation of research
to serve as guies an conceptua contexts for our work We were fortunate in the fact that research ha ong een an important activity at the Kirksvie Coege of Osteopathy an Surgery an that we cou have a soun introuction to osteopathic theory from an investigators viewpoint Over the years these epartmenta concepts have unergone many revisions an eaorations as our unerstaning has grown an as new knowege from researches a over the wor incuing our own has accumuate. At each stage our eneavor has een not ony to construct imite frameworks for our own immeiate investigations ut aso as perspectives for our teaching of the physioogic sciences oreover we have trie to interpret an reinterpret the osteopathic concept in such a way that it wou e meaningfu an even chaenging to ioogic an meica scientists who have ha no prior contact with osteopathy an in such a way that scientists in any asic meica fie cou e stimuate to an enae to esign soun projects utiiing their particuar ackgrouns of training taent knowege an experience How we our hypotheses have serve ony time wi te We can certainy say that newcomers to our epartment have een ae to fin their paces so to speak reativey quicky. Osteopathic journas have een most generous with the space they have mae avaiae to us to conuct, in puic these persona exercises in sefexpression Since our concepts at various stages of eveopment have appeare in these journas over a perio of years (see eferences to 4 22 an other references therein), there is no nee to restate them in etai I wish ony to restate those essentia points that ea to the identiication (a) of promising ut reativey unexpore areas of physioogy an reate sciences an () of previousy uniscose reations etween areas areay uner exporation One workng ypoe
There are many factors in human ife the human environment an human ioogy which inuence the capacities of the human organism to meet the emans of ife to meet
stress an to aapt to, resist comat, an compensate for unfavorae eements in the environment in short to maintain an recover heath. These vary from iniviua to iniviua The infuence or impact of a given factor in a given iniviua is etermine not ony y the quaity an quantity of that factor ut aso y the tota consteation of factors at the time an in the past. An iniviuas heath his responses an capacity for aaptation to various environmenta factors ife situations an emans his vuneraiity efeataiity susceptiiities to iness capacity for recovery et cetera, are therefore the proucts of his entire ife Hence the importance and infuence of any given factor may vary from iniviua to iniviua an from time to time i n a particuar iniviua Whatever his other functions it is the essentia function of the physician to promote eveop ierate an restore insofar as possie these capacities in those iniviuas for whose heath he is reponsie He oes this y anaying an atering the factors in a favorae irection, minimiing those which impair these capacities. Of a possie factors ony a reativey few at east with our present knowege, are reaiy suject to human contro Of these ony a few have a major or ecisive infuence on heath The osteopathic profession attaches specia importance to the unfavorae factors arising in the muscuoskeeta system for the foowing reasons oca isturances particuary in the axia portion of the muscuoskeeta system have a pecuiary high incience in man ecause of the specia emans mae y gravitationa forces on the erect muscuoskeeta system. 2 Through the circuatory an nervous systems there is in heath an isease rich intechange of infuences etween the muscuoskeeta system an other tissues an organs 3 A isture portion of the axia muscuoskeeta system, therere impairs to some extent, an/or refects impairment of functions of other tissues an organs; those with which it is most cosey reate neu roogicay are most irecty affecte. 4 egaress of its origin, whether
primary or seconary, the muscuoskeeta isturance impairs the capacity for resistance an recovery an tens to promote an sustain existing isease processes Such a functiona isturance represents a point of high vuneraiity even in the apparenty heathy human organism whose effect on the tota man is infuence y many other factors in his ife. 6 These ocaie isturances in the muscuoskeeta system an the responses to them are readiy etectae even in the asence of sujective symptoms or isease 7 They are reaiy accessie to irect an specific moification an treatment. 8 They are responsive to appropriate treatment. 9 The strategic importance of this physiopathoogic disturance then appears to ie in the foowing circumstances egaress of its rea or apparent reation to any symptoms or ientifiae isease in a given iniviua a To some extent it impairs an taxes the capacities efine aove It exaggerates or unfavoray moifies the impact of a other factors; c. Its treatment therefore tens to insuate the iniviua against the unfavorae factors in his ife, in his environment an in himsef, renering them ess eeterious to his ioogic capacities an resources. . It is etectae, an accessie an responsive to treatment. e Prevention eary etection and tratment of this isturance offer a vauae approach to the prevention of i heath as we as to therapy. denyng area for nvegaon and er connecon
Through our continua examination of the physioogic impications of osteopathic principes as we interpret an reinterpret them key areas in nee of investigation have ecome ientifie. They are areas which we have een ae to ientify an characterie from our speciaie an reativey imite viewpoint as physioogists in effect questions to which we have foun we nee the answers The same cou e one an nees to e one, y speciaists in the other asic meica sciences. It is important to emphasie that
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ou concen is no alone wih aeas which ae now uneploed. is jus as ipoan o econize hose aspecs of he bioloic and edical sciences which ae o have been unde acive invesiaion bu whose beain on oseopahic heoy and pacice has no peviously been econized and o which new eanin ay be bouh by oseopahic heoy An ipoan pa of ha new eanin is in he nerrean aon appaenly isolaed aeas which ae heeby disclosed n disclosin he beain of a iven ield o aspec of oseopahic heoy and pacice a whole body of knowlede usually sill owin is, as i wee, incopoaed ino oseopahic heoy pacice, and eseach and coninues o enich he and o be eniched by he. Siilaly, he disclosue of ineelaions and connecions aon pesenly isolaed fields opens up channels of inechane in which each eld daws fo and ives o he ohes new and boade eanin while hei cobined ipac on knowlede and huan powe is enlaed ndeed, have fel fo a lon ie ha one of he eaes poenial conibuions of oseopahic heoy o he bioloic sciences lies in he cohesiveness which i ipas o akes possible aon any disciplines and fields of knowlede and echnic in he dissoluion of walls sepaain scienific and echnical fields, which eis only in he inds of en and no in naue iself in evealin he coon deepelyin bases which ie oehe appaen islands of fac and knowlede in he openin of new edia of echane aon any ields Sme lurave area ollowin ae bu a few of he aeas idenied by one oup of physioloiss in one of he oseopahic collees hese ae inended o descibe no individual eseach pojecs bu vas aeas in need of eploaion 1 he physioloy of huan diffeences: While we need o coninue o accuulae eve oe knowlede fo eaple abou he adenal coe he hea, he duodenu, e ceea i is vey necessay o econize ha hese ae absacions and eneal
izaions based ainl, on sudies on hihly sandadized epeienal anials As fa as an is concened, hee is no eely he huan adenal bu Hays Janes Robes, and Mays adenal and Hays e 1) adenal when an infan, a child a youn adul a iddleaed adul, a sepuaenaian. is in he diffeences hei naue, hei quaniy hei oiins, hei consequences ha we should bein o look fo diffeences in healh in esisance in suscepibiliy adapabiliy loneviy fo he facos ha ake he diffeence beween success and failue as a huan oanis n sho, we need o bein o sudy he funcion of any iven pa and he ineaion of he pas no only as isolaes bu in paicula huan cones 2 he echaniss paens and pahways of inechane beween hose poions of he nevous syse which ae concened wih life in he eenal envionen sensoy and oo) and ha poion concened wih he inenal envionen auonoic): While he soaic and he auonoic funcions of he nevous syse have been subjecs of sudy fo any yeas and while viually evey ac and aciviy of he inac oanis involves he siulaneous coodinaed and ineaed paicipaion of boh hee has been and sill is eakably lile invesiaion of he inechane beween he As a esul, uch of he eanin of each is los and all of hei unified eanin. is ineesin howeve ha his aea is unde consideable invesiaion a he clinical level ouside of oseopahic cicles and he evidence is accuulain apidly ha uch of huan disease is elaed o o he poduc of failue in soaicauonoic ineaion eveheless i eains a viin field fo fundaenal sudy of echaniss and pocesses 3 he slow and lone inuences of neve aciviy: he iediae esponses of vaious issues and oans o volleys of ipulses have been and coninue o be inensively sudied. Howeve despie he abundan clinical evidence ha he esponses and popeies of issues o susained neve aciviy o susained cessaion of neve aciviy)
ae pofoundly aleed wih ie ha paholoic adapaions occu, and despie he fac ha hese lone esponses ae no usually pedicable fo, and ae ofen conadicoy o, he shoe effecs, hey ae viually uneploed We idenify a few of he subcaeoies unde his headin. a he ophic funcion of peipheal neves While he eisence of ophic influence is widely econized, is naue eceives lile sudy b he influence of he auonoic innevaion, a vaious levels of aciviy and ove poaced peiods, on he funcions of vaious oans and issues, includin he endocine lands c he lone adapaions of he blood vessels, blood flow dainae e ceea, o susained oveaciviy o undeaciviy of he auonoic innevaion. d. he adapaion of skeleal uscles o susained ension acive and passive, and he lone influences of aleed aciviy of hei auonoic innevaion e Influence of peipheal neve aciviy a vaious inensiies and duaions on cellula funcion foaion of enzyes, eabolis eeabiliy, inechane wih blood and inesiial uid, owh, cell division e ceea f Cellula adapaions o lone odeae o ineien isceia . Sudy no only of he esponses of oans and issues o susained siulaion o inhibiion) of hei sypaheic o paasypaheic innevaion bu he seconday aleaion of he esponses of hese issues o ohe influences fo eaple nevous hoona and cheical. 4 uiion fluid echanes and ciculaion in neves and neve issues fcos influencin he; effecs of hei disubances on neve funcion and on he issues which hey innevae S All aspecs of efeed pain he lone esponses of, and chanes in issues of he efence zone soaicovisceal and visceosoaic eflees. 6 ies and ie phenoena 7 Physioloic, paholoic opholoic and cheical bases fo aleaion in he eue of vaious nepeaion of eseach
tissues, such as are used i osteopathic diagosis. he physioogy, pathoogy, ad chemistry of the fascias ad other coective tissues; the effects of ateratios i their tesios ad other physica ad chemica properties o the fuctios, activities, circuatio, draiage, et cetera of other tisues 9 Spia kiesioogy; the study ot oy of vertera motio ut the patters ad mechaisms of itegratio of tota spia activity; the roes of idividua musces, their reguatio ad itegratio with others he origis of ad adaptatios to postura ad ocomotor stress associated with the erect stace 10 Proprioceptive activity; the reportig to the ervous system of the activity, tesios, positios, motios, ad other circumstaces i the muscuoskeeta system ad the somatic ad autoomic resposes to such reportig 11 Atered fuctoa ad ceuar states of musce; cotracture, firosis, et cetera, ad their experimeta ateratio 12 . Neuroedocrie factors ifuecig resistace to ad resposes to ifectio. 13 Gross ad microscopic examiatio, i autopsies, of the spia coum, the spia cord ad its memraes ad ood vesses, paravertera tissues, et cetera, i reatio to ciica history his represets a treasure of iformatio which has hardy ee tapped A system of autopsy i which osteopathic questios ca e asked ad aswered awaits deveopmet idetifyig a few of the fieds of ivestigatio to which osteopathic pricipes have ed us as physioogists, have deieratey avoided expicit referece to the osteopathic esio. t is ot our purpose to disregard it, for it is itimatey reated to a of the categories of pheomea eumerated aove, ad may more Accumuatio of kowedge i those areas is essetia to our uderstadig of the osteopathic esio Our oective is more precise defiitio of proems for ivestigatio he too commoy accepted premise that osteopathic research is research o "e osteopathic esio o o the effects of the osteopathic esio, et cetera has, eieve, ee a serious deterret to scietific progress i osteopathy
he first ad oe of the most difficut ad importat steps i ay research is a cear statemet of the proem, a uamiguous formuatio of the questio to e put to ature o propose research o a etity represeted y a ae or a phrase which has, as previousy emphasized, may varied, private meaigs to persos withi the professio ad oe to scietists outside the professio is a faiure to state the proem Eve worse, the research is too ofte a effort to make the osteopathic esio cofirm or coform to a precoceived etioogic framewor which distorts its very ature. The eements o an adequate eseach pogam
t is ovious that the opportuities for osteopathic research are vast ad potetiay of tremedus sigificace to sciece, heath, ad society, as we as to the osteopathic professio t is equay ovious that research activity ad achievemet uder osteopathic auspices have ee miute i cotrast with these opportuities As was stated i the itroductio, through its achievemets i ciica practice, egisatio, puic recogitio, ad educatio, the professio is ow etter prepared tha ever to tur its attetio ad resources to this reativey egected phase of its fuctio have tried over a protracted period to eumerate i some ogica system the essetia eemets for raisig osteopathic research activity to a eve ad a scae more eary commesurate with the magitude of the opportuities variay, my ists have reduced themseves to oe cetra ad, ideed, the oy truy idispesae eemet to which a others are cotriutory persoe his cocusio is i compete agreemet ith poicies deveoped through may years y research foudatios, gratig agecies, the Natioa stitutes of eath, ad others that ivestmet shoud e made, ot i projects, ut i ivestigators i providig them with the circumstaces ad the meas to work i areas of their seectio, i their way, ad further to deveop their skis ad those of others Te key eleen
my opiio, the osteopathic pro
fessio sti eeds to appreciate the fu sigificace of the key eemet quaified ivestigators here is o questio that a cosiderae amout of medica ad some osteopathic research, much of it of great vaue, has ee doe ad is doe y persos primariy occupied i other fuctios, such as ciica practice, teachig, ad admiistratio; ad this shoud aways e ecouraged Nevertheess, the fact remais that the research areas opeed y osteopathic theory ad practice are of such ature ad scope as to demad futime (or eary futime ivestigatio y scietists, to whom research is ot merey a avocatio or sideie to e daed i i oes spare time, ut to whom research is a way of le the only way of ife for which they studied ad prepared for may years, ad for which, throughout their professioa ives, they are cotiuay preparig esearch is o ess a speciaty tha the practice of medicie or surgery or ay other professio ad, i may ways, is much mor rigorous i its demads t is fooish to assume that a oe eeds, esides equipmet ad suppies, i order to do creditae research is the decisio to do it or to stimuate others to do it he proper activatio of osteopathic research demads the recruit met of a adequate corps of such workers who, give adequate meas ad circumstaces, woud ot oy themseves udertake such research, ut aso woud attract others, trai others from withi ad without our studet odies, erich ad mutipy the efforts of the parttime ad cii ca ivestigators, ad who woud vitaize our educatioa programs here are o satisfactory sustitutes i research for quaified researchers whatever the degrees they may have, whatever their forma traiig. vestigators such as my Kirksvie co eagues, JS Desow, P.E homas, ad Wright, ad others i the osteopathic professio are testimoy to the fact that osteopathic physicias to whom research has ecome a way of ife ad who have the iate aiity ad motivatio ca, with the assistace, guidace, ad coaoratio of professioa scietists, themseves ecome wequaified professioa scietists ow, the, attract ad recruit such
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a cor of ce? h hod a aeed ce aread eahed or e o e eahed a a eacher ad eaor a er edca choo, or reearch e wh h ere ad arao we deed ee e coderao o eoe a a oeoahc o? h hod he eoe hef o he hazard of dcrao whch are rodc of r rejdce ad orace reard oeoah ad he oeoahc ro feo? ha d of adaae ca e offere whch w oweh hee dea ero deerre? here o oe awer he ro feo e ae o defe ad of fer h ch oore o ze h ae for ha owede ad fr ha wefare a are aaae owhere ee Fro ow eroa eerece ca a wh coee coco ha oeoahc edcao ad reearch an ada offer ch qe chae, ec ad raf oore he eed o e deed, ade ow, ad eeed Ienaon of e oppoun 1 hee oore oeoahc reearch ad edcao are dered fro, ad eara reaed o he eca fco of oeoahc ed ce The oeoahc rofeo herefore eqoca er, decare ef wh reec o wha coder o e, ad deo rae o e eca dce coro o ha heah ad wefare o he ee of oda' ad oorrow' heah roe ad wha ed o do oward coed deeoe of h oe a So occed ha he rofeo ee eah ef ha a ear o hae foroe a ea a e, he eca roe ha o ere, he qe coro o ae ad of whch he r e a a recoza qe coro he o reao for he rofeo ef, o wod e e o reao for a ce o affae hef wh he oeoahc oe e ha qe coro e caref defed a he oece of he rofeo ad a ecear e ae oward reazao Oe of he a oece of he cr e rearao he Kre Coee of Oeoah ad Srer
for roeced Decade of Proe (151% he cear ad rece forao of ha coro (a a de o he reorder of edca oa reearch ad cca ro ra h re eed o e doe he oeoahc rofeo a a whoe 2. A a coroar he rofeo ead hca, choar, each er, ad ce , wh he he of ce ad oher ode he rofeo, ef he area of he oedca cece whch oeoah c heor, racce, ad reearch hae how o e of crca orace o he derad of fe ad o he coro of heah ad o e eed of eorao Or ow effor h dreco, reewed a earer eco eed o e rea eeded ad o a he ac edca cece Impemenaon of e oppoun e b e pofeon a cear deed eca fco ad he coro whe o ae, he rofeo he whoeheared acce ad co ef o he dea ha ca ae ha coro ad herefore re ad coe deeoe o dco he ece ar owede ad derad hroh rea eaded reearch rora eed he o decare ad deorae eo o or a ecear wa he eora o of area reaed o eca co ro h reqre 1 Forao of arorae oc whch reearch eahed a a aor fro for he rofeo 2 Recoo, ad rea creaed or, of he dece roe of he oeoahc coee for he ha he of he reearch w e codced, o he ha c e wod coe ad he ha fre eaor w e recred ad raed he coee ha he ecear crc ace eed o e creaed A w e how hee crcace do o e e 3 he deeoe ad oor of rora for he recre ad ra of reearch worer 4 he deeoe ad rocre e of reorce for carr o he aoe h coe fro hree orce a he rofeo ef hroh
he aee ad aocao of arer fd ecfca for reearch ad deeoe Dero of fd, reorce, ad aeo fro erhera fc o ad ace whch oeo ah' oca coro cao e ade o hoe whch ca e ade c Soce he c, oere fodao, e ceera Soce hroh oerea aece ad roh rae ad c hahroc aece ad fodao, doe o core o he or of oeoac ed ce oeoahc edcao ad oeoahc reearch rooro o he eef whch dere ad ca dere fro he Nor here reao o eec ha w, ha a far eer coreheo ha ow ha of he oca ae of he cae whch aed o or he c ad aece are aread reeed wh a ehora of oore o or edeaor edcao, reearch, ad cca ad reee edce whch are de ora worh ora o heah ad wefare ad hoef or ccef Oeoahc edce, edcao ad reearch ca w her hare of oce' or o whe he rofeo ca deorae ha ora oca ad heah eed ad oore e whch are o e e ad whch he oeoahc rofeo, hroh o ad hroh edcaoa reearch, ad deeoea rora qe qaed o ee e he ecear or h h edeaor oo he qe for oce or de ed o he car ad he fr e wh whch he rofeo de fe ad decre he dce coro are o ae ad o he o ad reorce r o deeoe Impemenaon of e oppoune b e oege he reearch wor carred o dda he fac rea ha o da, reearch a ac of o he wor of he dda roer o he deree ha ro ded for, ore, ad ecoraed he o whch he wor or oo reao o or edcaoa o or
erreao of reearch
coleges that we nee to give or main attention Ony if research is an activity of or coleges can we hope to attract scientists to or faclties Or coeges have yet throgh firm policy an program to establish re search as one of their prmary fnctions an then with the conse of qaifie scientists to make al possi ble provision for it. Whie it may be proteste that the first an highest obligation of each night the estab lishment an maintenance of the highest ecationa stanars the fact remains that the highest ecational stanars are not achievable nless research is a basic activity of the coege. Te statement often mae by aministrators an epartment heas of osteopathic coleges We havent time for research mst by eliber ate poicy be mae as patently absr as We havent time to conct classes. t is in the spirit the atmosphere an the ab of inqiry which give ife to programs of higher ecation. Withot them a professiona colege concts not so mch an ecational program as a training program. The profession it trains is ess a earne profession than a profession of tech nicians We mst franky face the fact that whatever avances the osteo pathic coleges have with the spport of the profession mae in recent years an they have been tremenos sch a spirit of inqiry of schoary traition oes not yet pervae or colege atmospheres Pro as we are an have goo reason to be of the physicians or coleges proce that physician is a better one who has ive an stie in an atmosphere of inqiry who has at east observe the seeking an weighing of evience who has be come aware of the nknowns an the qestions in meical theory as wel as the accepte the assme an the estalishe in meial practice an who is aware of the steps that are taken an can be taken towars their sotion an towars frther eveopment. A close book is never an exciting or eifying one however ecorative it may be on the shef. We nee frankly to examine how the ninqiring often octrinaire presentation of os teopathic theory giving it the appearance of a cose book is affecting osteopathic ecation practice an
progress The osteopathic concept mst be seen as a tool rater than as a cree. What we nee as Bertran Rssel sai is not the will to believe bt the wish to fin ot which is the irect opposite steopathy an osteopathic ecation mst lve on the frontiers or not at al The osteopathic concept st be seen throgh or ecational programs as the yong living growing an exciting thing it is instea of the tire o banaity it so often appears t mst be presente as the eness fiel of exploration which it is an not merely as the proct of past ig gings which ike a mmmy nees to be preserve Osteopathic ecation nees to be vitalize by faclty mem bers who can ea the explorations by scientists whose lives are ive on the frontiers. Throgh or coleges opportnities in research an for training for research careers mst be create an mae known to or stent boies Whie it may be lamente that accoring to a recent estimate only abot two ot of every 100 meical stents eventally become in vestigators how fortnate the osteopathic profession col fee if one investigator were recrite from each cass of approximatey 5 osteopathic physicians who graate each year! Ony the rare stent has become aware of the rich oppor tnities in osteopathic research an of th gratification excitement an oys in research as a career. Unqestionably the most effective acor in attracting physicianstobe to research an in preparing them for research an for acaemic careers is throgh contact with active research ers on their own campses as an intrinsic part of their professiona ecation t was my goo fortne to have oine an osteopathic coege which not ony ha by carefly formate poicy mae research one of its primary fnctions not only ha to the imit of its resorces provie for it an not ony ha been abe to emon strate its firm intent with past achievement bt which also was able to chalenge an excite the interest of scientists with son escriptions of the nimite opportnities in osteopathic research an ecation. The colege has throgh the years sbecte its policies with respect to
research to continal close scrtiny an revision t has continally soght the resorces for enlargement of its research potential an has felt as obligate to make its fns available for research as for teaching an cinica service t has continally soght the means to attract more scientists an to create the circmstances most concive to their proctivity The college has ong recognize that the reqirements of the teacherinvestigator in comparison with those of the teacher are for the col ege a great ea more exacting. This inces not ony premim salaries an more eaborate facilities an eqipment bt also spportive technical personne Even frther it has recognize that one of the scientists greatest nees is for other scientists with whom to exchange ieas an skils an with whom to share teach ing an other responsibiities. t has therefore encorage each estab lishe investigator to srron himsef with other investigators to the imit of avaiable resorces Since there is nothing in an instittion more attractive to a scientist than other scientists an recore scientific achievement (thogh it is still very smal) the recritment of scientists has become progressively facil itate in recent years an grant fns have become more ample. Recognizing its responsibiity to prepare for society an for the profession ftre investigators as wel as practitioners the colege has also from its own fns establishe a system of nergraate fellowships Uner this system seecte stents are invite to take their sties towars the DO egree over an extene perio an aitional 1 2, or more years ring which they receive specia training throgh participation in the teaching an research programs of epartments of their choice an ring which tie they receive financia assistance from the colege Whie in recent years this colege has enoye the benefits of sbstantial research grants from the American Osteopathic Association governmental agencies an private fonations an inivials it is not sfciently recognize that the gondwork ha been ai years in avance an contines ever to be lai throgh
6
) th stalshmnt of rsarch as a prmary functon of th colg 2) th formulaton wth th counsl of scintsts and scintfc agncs of sound naling and guiding polcy which is in continua voution (3) larg pror nvstmnt, from its own funds, n faclitis matrl, and pr sonn 4 wilngnss and radinss to invst n ach proct amounts qual to and usually largr than, th grants awardd to it (5 wlingnss and radnss to support dpartmn ta staffs much largr and far mor pnsv than thos rqurd for tachng alon and (6 th aiity to crat an acadmc cimat in which rsarch dvopmnt and scholar shp can prospr hl achivmnts n rsarch as wll as in othr aras) hav n far too small and progrss far too slow to satisfy thr th administrators of th colg or th invstigators, whi too fw dpartmnts ar ngagd in rsarch, and whi many circum stancs urgntly rqurd for gratr achivmnts and progrss hav yt to cratd, t has only n my pupos to mphasz that such prog rss as has n mad and w mad s th product not of fortuitous crcumstancs ut of polcy and pan ning and of much sacric y th Colg as a whol Summ nd concusions
1 Rapdly growng accptanc and support of th ostopathic profssion y pulic govrnmntal ducation a, and grantng agncis and othrs now mak t possil for th profs sion to dvot a grat da mor of its attnton and rsourcs to a nglctd phas of its functon as a profssion poration and dvlopmnt of its spca contriution to human hath and to th iologic and mdcal scncs 2 h fulflmnt of th dsnctv function of th ostopathc schoo of mdicn, th making of its spcia contriuton th ony rason for ts stnc dpnds on th acclr atd accumuation of ssntial knowl dg undrstandng and mthod ology n crtan aras of th iologc and mdcal scincs 3 Th prvailing orntaton of mdcin today, and thrfor of mdcal rsarch s such that thr s rativly littl ntrst in, or rcognizd nd for knowldg in
ths aras and littl rcognton of vtal ntrrlations among thos of th aras that are ng invstgatd. As a rsult ploration n ths aras is ngctd or fragmntary 4 o th dgr that th profsson attachs importanc and social vau to its dstinctv contrution to human halth and thrfor to th dgr that it can ustify its istnc as a profsson to that dgr is t olgatd to assum rsponsity for poration and dvopmnt n ths aras, n ordr that it may mak that contrution 5 h profssion's gratst and most critical nd in th mtng of that rsponsity, s for adquat numrs of tantd qualfd ful tim nvstgatortachrs n al of th mdcal scncs to conduct r sarch to hlp dfn th aras of n vstgaton to attract and chalng othr scintsts through thir achv mnts n ths aras to train othr in vstgators and to vtalz our duca tional programs 6 In ordr to win th intrst and partcpaton of quafid scintists th profsson must al to offr such challngng opportuntis to contriut to human halth and to human knowldg as ar avaia nowhr ls Ostopathic rsarch can aundanty offr such uniquy challngng, citing and gratifyng opportunts. hy nd to idn tifd mad known, and imp mntd. In ordr to idntify and din ths opportunits: a Th profssion must unQuv ocaly dcar itsf as to what t con sidrs to , and dmonstrats to ts spcia dstinctiv contriuton to human halth and wlfar and as to what it ntnds to do towards ts con tinud dvlopmnt Just as a rcognizay unqu contrution is th only rason for th profsson itslf, so would it th only rason for a scntist to affat himsf with th ostopathic movmnt Aras of th iomdcal scincs which ostopathc thory practic and rsarch hav shown to of crtica importanc to th undr standng of lif and to th contro of hath ut which ar in nd of ploration, nd to dntfd hs can don through amination and dvlopmnt in trms of growing oogcal mdcal knowldg of th
mpications of asc ostopathic prncpls hat is, through th co aoration of ostopathc physcians and scintists th princips whch gud ostopathc practc must transformd nto a ody of workng hypothss to guid ostopathc rsarch 8 In ordr to implmnt th oppor tuntis thus dnd, th folowng stps must takn y th profssion as a who a It must wholhartdly accpt and commt itslf to th ida that it can mak its spcia contriution to socty and thrfor survv and contnu its dvopmnt ony y disclosing th ncssary knowdg through graty pandd rsarch programs h profsson must thn for mulat and osrv th ncssary pocis to stash rsarch as a ma or front for th profssion For this purpos, as for othrs it shoud utiz th st scntfc and duca tional counsl which s availal. c. It must giv a possl sup port to th ostopathic colgs n thr dcisv rol n this ndavor d. h profsson must gn to dvrt funds, rsourcs, prsonn, and ffort from th asorng prphra aras in whch ostopathy's spca contruton cannot mad to thos cntral ons in which t can t must vry soon dcd whch ar priphral functons and whch th cntra ons for which it was stalishd Crtainly t can said of any profsson with a nw ida and imitd rsourcs that for vry dolar and vry manhour spnt on foowng, that much ss rmains for ladng for rngng th da to fru iton h ostopathic profsson nds to dtrmn th optimal ratio for tslf and mak th ncssary ad ustmnts. Ostopathic mdicin, osto pathic ducaton, and ostopathc rsarch must wn thir shar of socitys support hs can accom pshd whn th profssion can dmonstrat that important socal and halth nds and opportuntis ist whch ar n ing mt and which th ostopathc profssion is unquy qualfd to mt givn th ncssary support Succss dpnds upon th carty and firmnss wth which th profssion dntfs and dscris th distnctiv contru Intrprtaton of rsarch
ton t asps to mak and upon th vson and soucs t tuns to ts dvlopmnt. 9 It s though th ostopathc col lgs and afflatd nsttutons that all of th abov must fnd th x psson, fo t s n th collgs that th bulk of th sach wll b con ductd t s to thm that scntsts would com and t s n thm that futu nvstgatos wll b cutd and tand Th ostopathc collgs a not yt ady fo ths ol, and thy must bgn to ppa Ths qus, fist, that sach b fmly stablshd a priary functon of ach collg, as t s fo oth nsttu tons of hgh and pofssonal ducaton Scond, th ncssay nablng and gudng polcs must b fomulatd Hgh ducatonal stan dads," fo whch all th ostopathc collgs contnually stv, a no long achvabl unlss sach s a basc functon of th collg Ostopathc ducaton ugntly nds to b vtalzd by a pvasv spt and habt of nquy 10 In concluson, at ths stag of hstoy, scntfc pogss n
ostopathc mdcn s th shotst and sust oad to soctys und standng, accptanc, and suppot of th ostopathc contbuton to human halth and wlfa, and th ony oad to th makng of that con tbuton Rfrncs I Korr I M Emerging concep of oeopahic leion J Am Oeop A 1271, Nov 1 . 2 Kor IM Thom PE and Wrigh HM Symposium on uncional implicaion of segmenal aciliaion reearch repor J Am Oeop A 5652 Jan 55 Wrigh HM Origin and maniesaions of local vasomoor diurbances and heir clinical ignificance J Am Osop A 5621722 156 . Thom P E Neuroacular acors in diseae To be publihed 5. Siegli E J A uure or preenive medicine The Commonwealh Fund New or 5 6 Galdon I Meaning o ocial medicine Harvard Uniersiy Pre Cambridge Mas 15 7. Jenen J Modern concep in medicine Moby Co S Loui 15 pp 1725 8 Poenger FM Sympom o viceral disae Ed 7. C V Moby Co S Loui 5. . Wolff HG Sress and dieae Charles C Thomas Springield III 15 0 Brain R Need or philoophy of medicine Lance 156 May 16 15 I I Ediorial Failure o modern medicine J Am Oeop A 55 12125 Oc 155. Halliday J L Pychosocial medicine udy of
cv
ic ociey WW Noron Co New Yo 1 1 Seguin CA Conp o dieae Pychoom Med 252257 July-Aug 16 1 Selye H Sre and dieae Science 1 2262561 Oc 7 155 Reecion o n u dy of phyiology 15 . Lewi Ann Rev Phyiol 6110 5 6. Lap EE d Medical reearch midcenury urvey Lile Brown and Co Boon 155 pp xxii ii 5 vol 1 pp 67 ol 2 17 Carlon AJ and Johnon V Machinery of body Ed . Univeriy of Chicago Pre Chicago 15. I Tainer ML Medicine' golden age riumph of experimenal mehod Tran NY Acad Sc 2227, Jan 156 Dubo J Biochemical deerminan of microbial diseae Harard Univeriy Pre Cam bridge Ma 5 0. Galdon I ed Beyond he germ heory Healh Educaion Council New or 15 2 1 . Hinle L E Jr and Plummer N. Ho or in human illnes; occurrene o diference in general ucepibili y o ill ne among goup of adul men Clin R Pr 210 April 15 22 Korr I M Biological bais for osopahic con cep J Oeop 611 April 15 2 Allen E M and Endico K M Public Healh Service research grans in biology Bull Am In BioI Sc 121 April 5 2. Endico KM and Allen EM Growh of medical research 15 and roe o Publi c Healh Service research gran Science 1 17 Sep 25 15. 25 Lp EE ed Op cit., ref 16 p 2 ol
0
Reprined by prmision from JAOA 56 2755 57.
Wt' 'steopthy" nd ' the osteptc concept" men t me (192) Fo m, ostopathy s on of th gat volutonzng das that lght th cous of hstoy and mak ts tunng ponts Oth such gat das hav bn th concpts of voluton and natual slcton quantum thoy and th thoy of latvty Ths hav had mmns mpact on th bo logcal and physcal scncs, on ou undstandng of natu and of mans plac n t, on tchnology and on ou way of lf Th mpact of ostopathy th body of concpts ncopoatd n, and adatng fom, ostopathy, howv you call t, whatv ts futu dsgnaton ts mpact on mdcn and human halth, and thfo on vy aspct of human lf, wll vntually b qually tansfomng Whn th mplcatons of th os topathc concpt a adquatly xplod ndd, n th cous of xplong thm th pactc of mdcn and th basc appoachs to halth and dsas wll b tans fomd and lvatd to a hgh path Th ostopathc pofsson s th
nstumnt of that da, and t wll suvv and posp accodng to how wll t svs that da Th xploa ton and dvlopmnt of th osto pathc da and ts mplcatons, and th mplmntaton of th da n pactc, must thfo b n th hands of thos who at last appcat th badth of th da, who cog nz th magntud of ts potntal n human pogss, and who undstand th sponsblty to t It s much too bg and mpotant an da to b ntustd to thos whos only concn wth th da s wth how wll o how pooly that da o on of ts sutably dlutd, dstotd, couptd and convntonalsoundng vsons svs th nstumnt, that s, th docto and th pofsson. Fo thm ostopathy s not an da much ls a bg d to b advancd on bhf of manknd Fo thm t s bu t a commodity to b sold n whatv gus t wi quckly and n lag volum, and wth gatfyng ag gandizmnt of th agnt I thnk w nd, n som way, to
nfus nto th pofsson an ap pcaton of th mmnsty of th da, of th pofssons sponsbl ty to t, and of th vast oppotunts to sv t Doubtlss, ths wll qu hoc stps I do not s th pofs son takng thos stps, ppang to tak t hm o contmplatng thm Fnally, I blv that th osto pathc collgs cannot bgn to fulfll th ol untl thy cognz that th functon s not mly to tach ostopathy as a way of makng a lv ng, but pmaly as a way of lf, as on of th gat volutonzng das of human hstoy It s th functon of th collg to ppa fo socty phy scans who can appcat th scop of th da and ts potntal fo human wlfa and who can und stand and fulfll th sponsblty to t As long as ths s mbd, all ls, fom th slcton of studnts to dsgn of th cuculum, fom th stuctu and composton of th facul ty to th contnt of ach ddactc hou and th natu of ach cinica i n, wll fall nto pop s v 69
T yi vu y i w i uiv 970) Throughout the history o medicine physicians have een very much concerned with our insides with our interna organs with the interna environment with our viscera. In modern times as our knowedge and skis in viscera diagnosis and therapy have increased our preoccupation with our viscera has increased This is a to the good except that if carried too far it eads us to overook the crucia point that human ife the kind you and I ive and see in eah other does not consist of viscera activity. ife is not a composite of the functions of the viscera. an does not perform gomeruar fitration and tuuar reasorption; he does not vasodiate he does not constrict and he does not oxygenate; he does not peristase and he does not secrete ife is not the sum of the activity of our interna organs, despite the preoccupation of medicine with those interna organs What do human ife consist of? What does man do? an does a the things that we see each other do He moves runs works pays tennis uids uidings paints pictures makes music makes ove to paraphrase the fower chidren he makes ove and war. He is creative. He teaches earns writes educates practices medicine does surgery gives osteopathic manipuations. If you ook at these activities oectivey you wi see that in a of them the ody as a whoe is moved or some part of the ody is moved; and the common feature the indispensae sustratum is the contraction of skeeta muscuature. Human ife is expressed through the contractie processes of striated musce Every aspect of human ife is acted out y the odys musces and oints Everything man does to express his aspirations and convictions can e perceived y others ony through his earing and demeanor and utterances and these are composites of myriads of ney controed motions. So we egin to see that even the
highest inteectua activity is acking in vaue except insofar as it can e acted out in and upon the environment and y eing communicated to others. Education itsef is sometimes deined as a change in ehavior and ehavior is produced y musces acting on oints. Here then is an important concusion which I think is impicit in the tota osteopathic perspective that the muscuoskeeta system is the primary machinery of ife These are the ody parts that act together to transmit and modify force and motion through which man acts out his ife. But since machinery must e suppied with motive power in order to function our concept of the primary ioogic machinery shoud incude its direction y the nervous system acting in response to the continua sensory input that reports what is going on in the outside environment and what is going on in the ody itsef hence the neuromuscuoskeeta system h ro of th scra
If the muscuoskeeta system and the nervous system that directs it comprise the primary machinery of ife then what is the function of a the rest of the odiy machinery with which medicine is so much concern? As the tite suggests their function is entirey supportive. Their concern is with the care and maintenance of the primary machinery of ife which means suppying fues and uiding materias disposing of wastes and end products taking care of the defense and repair and regener ation of components and in genera maintaining reguation of the interna environment in which the ces of the primary machinery carry out their function The muscuoskeeta system is the argest mass of the ody and the main consumer usces consume more energy more rapidy and in wider ranges than any other tissues in the ody_ In a matter of seconds the musces demand for oxygen can vary over a very wide range The enormous turnover in ody energy in
voves immense consumption of raw materias immense production of metaoic wastes and the dissipation of the arge amount of heat which is the chief yproduct of this machinery as it is of any machinery. The proems in ogistics and heat exchange ca into ay the speciaized functions of a the viscera organs and the hemodynamic apparatus responsie for interna transport But these matters of ogistics are not the maor responsiiity of the odys supportive machinery The crucia fact is that the consumed sustances must e restored as rapidy as they are consumed and waste products removed as fast as they are deposited into the interna environment to the end that the ood chemistry wi remain reativey unchanged. In other words interna aance must e maintained and this is the essence of homeostasis And so we see from the roadest viewpoint that the two types of ody machinery are in a sense the direct opposites of each other The primary machinery of ife is concerned with what we might term heterokinesis the great diversity of activities performed y the human eing with his musces and oints in a great diversity of environments The supportive machinery is concerned with the checks and aances that constitute homeostasis the physioogic equiirium that prevents those extremes of activity from draining the odyresources disaing the neuromuscuoskeeta system and destroying the individua Therefore heath requires that from moment to moment the viscera functions of the ody must e continuay attuned or adusted to what the ody as a whoe is doing how the person is acting at that moment with his neuromuscuoskeeta system. Tuning in this sense seems to me a itte more precise than mere adustment that is tuning impies a ringing into harmony of many different functions and gradations of function to meet the muscuoskeeta demands. To maintain the ood chemistry in optimum aance there must e instantaneous adustments in the oxygencarrying capacity of the ood as we as adustments in its uffering capacity since musce activity produces arge amounts of acid Interpretation of research
Fgu Coton of th inl od a hora or upper lumbar levels, showng: noy o fnt (dorsal roo) neurons and her fbe (bla), onveyng mpulses from reepors and endngs n soma and vseral ues; motonon (venral ho ells, lgher), supplyng moor nnervaon o seleal musulaure; sympahe neurons (lghes), he preganglon neurons n he nermedolaeral ell olumn, whose fbers (sod lnes) synapse n gangla wh neurons (posganglon fbers, nerruped nes) whh nnervae vsera and eran elemens (eg blood vessels, sw glands and ploereor musles n soma sruures seondary seory neuron (spnohalam) s also ndaed, onveyng mpulses o hgher eners and medang sensaons of pan and emperaure
metabolites Lage amounts of ox ygen ae consumed age amounts of cabon dioxide ae elaboated and put into the blood steam and it is the function of the iscea to peent esultant shifts in blood chemisty Anothe pat of the tuning pocess is the continual adustment of heat loss fom the skin by changes in blood fow and in eapoation so that body tempeatue aiations ae minimum The pocess may also incude in an emegency the suppession of such iscea actiities as can wait until nomal outine is estoed Digestie functions especily may be sup pessed tempoaily by inhibition of peistasis and secetion and a tightening of sphinctes in the eent of some ioent actiity o theatened ham. Bood fow distibution also must be shifted fom moment to mo ment in accodance with which pats of the musculoskeletal system ae do ing what All of these tuning functions these continual adustments of the suppo tie machiney to the demands of the pimay machiney must of couse be diected integated and contoled
Fgure 2 Atonom no tm: sympahe and parasympahe dvsons Sold lnes orgnang n enral nervous sysem (bransem and spnal ord) represen preganglon bers Inerruped lnes (arng n gangla) represen pganglon fbers oman numerals ndae ranal parasympahe nule rab numerals ndae erval, hora, lumbar and saral segmens of he spnal ord, and he segmenal orgns (nermedolaeral ell olumns) of he sympahe nervous dvson (T] o -) and saral poron of he parympahe dvson seral sures are represened whn he human gure on he rgh hand sde n four man groupngs: hose of he head and ne hora abdomnal; pelv and genal (Te adrenal medula s nnervaed by sympahe pregangon neurons, rossng he abdomnal poron of he dagram) Soma sruures nludng he neuromusuloseleal sysem, are reprened on he lefhand sde of he dagram I wll be noed ha, unle he vsera, whh are dually nnervaed he auonomally nner vaed elemens n he soma sruures reeve her auonom supply elusvelyfrom he sympahe dvson
and this is pecisely the function of the sympathetic neous system as the mediato between the somatic and suppotie machiney of life e eleen f pec funcn
The sympathetic neous system is continually acting in esponse to com mands fom the highe centes which as they cal fo specic physical ac tiity call at the same time fo the ap popiate isceal adustment that will make such actiity possible The sympathetic system like the neuo muscula system also esponds con tinually to a feedback of sensoy in fomation coming in fom aious pats of the body chiefly by way of the dosal oots in the spinal cod The sympathetic neous system is aso highly esponsie to infinitesimal changes in blood chemisty In sum may its function depends on the speeding in of infomation fom he highe centes fom the sensoy input oe affeent pathways to the spina cod and fom chemica changes in the blood steam These ae ey elementay things y pupose in eiewing them hee is
not to emind you of things you may hae fogotten but athe to inite you to look at them fom a somewhat diffeent iewpoint Sometimes it is difficut to see od famiia things in a new light but when you do accom plish this ey often something new appeas And some new things hae begun to appea to us in elation to the function of the autonomic ne ous system and especialy the sympathetic potion of that system. One of the new concepts that hae emeged is the one stated a moment ago: that it is pecisely thefunction of the sympathetic neous system to tune isceal function fom moment to moment to adust ciculation and metabolism and othe functions acoding to what the mind and body ae demanding and what the enion ment is enfocing at a gien moment This is not as you might assume simply a estatement of an od idea It is a stilldeeoping iew encompass ing olde obseations whose implica tions wee not completely undestood and new findings made in aious sepaate lins of eseach The com pehensie intepetation that is
emergig refects fidigs i two mai areas the srprsig iqity ad cotinity of sympathetic fnc tio ad its modatio of cear physioogy Relan beween e w aunmc brances
I order to derstad the sym pathetic roe i tnig ad mod atig ody fctios it is essetia that we derstad the differeces etwee the sympathetic ervos system ad the parasympathetic ner vos system Oe of the sti prevaent myths that we eed to demoish for a time is the geera impressio that ife is essetialy a tgofwar etwee these two systems that it is merey a matter of adstig aaces etwee the two; that they are merey eqa and op posite two sides of the same coin Nothig cod e frther from the trth They are totay differet systems with differet origis ad fctioa orgaizatio ad distri tio They work i differet areas ad do differet thigs for the tota ody ecoomy The parasympathetic system whose mai otow is the vagal otfow to most of the viscera is co cered maiy with protecting the iteal evironmet For this reaso a distigished physioogist has characterized it as sservig e dophylactic fnctions He has aso appied to it the term trophotropic ecase it is cocered with tritio with repeishing ody stores which are depeted der sympathetc irec tion I cotrast the sympathetic system is descried as ergotropic It is co cerned with the performance of work y the ody as a whoe with the rapid mscar se of energy ad the ex chage of energy etwee ody ad eviromet It is cocered aso i or meta ad emotioa attitdes toward that work ad or resposes to evironmetal forces The fctioal orgaizatio of the atoomic nervos system has ee graphicaly ilstrated i may dif feret ways Whe yo ook at a crosssectio of the spia cord (Fig 1 1 .) for exampe yo may see the af feret dorsa root ers i a singe segmet coveyig the ipt of iformatio from the ski the oits ad msces the proprioceptors ad
I
1
other parts ad from the viscera themseves; and of corse the vetra hor ces hich sppy the ierva tio to the skeeta msces Bt or immediate cocer is with the iter medioatera cel com a diagram of which wi show the tota sym pathetic otfow from the first thoracic vertera to the second m ar segmet ad the strctral rea tios etwee this organizatio ad that of the parasympathetics The schematic renderig of the sites o cetra origi of the periphera atoomic system ooks rather ike a ciica thermometer (Fig 12) with the representig the rainstem ad the te the spia cord marked off i segmets I sch a scheme yo see two og diffse coms represetig the spia and etire origi of the sympathetic er vos system and for the parasympa thetics a grop of discrete cei in the raistem ad in the sacra sec tios of the spia cord If the diagram is elarged y ies eading to orgas inervated (those repre seted o the righthand side of Fig 1) the first impressio may we e that the viscera prodomiate Becase of or preoccpatio with the traditioay emphasized da in ervatio of these orgas many text istratios sti fai to give the com pete pictre or emphasize oy vis cera inervatio Bt if the somatic strctres of the ody are icded i the schematic renderig (represeted o the eftside of the schema) it ecomes very cear that ony the sym pathetic system seds atoomic i ervatio to those strctres There is o parasympathetic distrition to what I have caed the primary machiery of ife I that machinery the sympathetic ervos system is i compete atoomic cotro Even i cosiderig the viscera meetig paces of the two systems we caot speak of their cofctio as some sort of contest for domiatio Goig frther ito detai we ca see that from the cetra origis where ce odies that is the pregangioic nerons receive im pses from a over the ody the parasympathetic aims its pregagioic neros amost directy at individa viscera or parts of viscera At each orga there is a syapse i or o or cose to the orga itsef where the short ostgagioic eros take
off I cotrast we see that the sym pathetic ervos system has the prepoderance of its postgagionic origis i a chai of gagia close to the spina com extendig from the soccipita regio dow to the cada ed of the spina com Ths the pregagioic portio of the sympathetic system with its og co mar origin in the spia cord ex hiits sti greater divergece in the distritio of its fiers to gagia along the spia com; this meas that the postgagionic erons sp pyig the periphera strctres are very ong I additio there are of corse sppementary gagia or pexses i the adomina cavity which i tr give off shorter postgagionic eros to the varios tisses inervated Aother stage of divergence is evidet therefore in the distrition of sympathetic post gagioic fiers throghot the ody With respect to the crrety e argig view of sympathetic fctio three significat poits emerge from this rief smmary of atoomic or gaization 1) There is ot a singe tisse of the ody which does ot receive some kid of sympathetic iervatio with its primary origi i the spia cord ad a secodary origi i the gagia most of them aiged i the paravertera pair of chais 2) Parasympathetic iece is imited etirey to the viscera orgas i ac cordace with the edophyactic ad trophotropic fctio of the para sypathetic nervos system 3 The sympathetic ervos system is the vasomotor system of the ody The third poit idicates perhaps the most importat distinctio e twee sympathetic ad parasym pathetic fctio The sympathetic system iervates the ood vesses of the ody the resistance vesses as we as the capacitace vesses so it has profod infece o resistace to fow ad circatig ood vome Withi the heart it profody ifences oth rate ad force of cotractio The parasympathetic system y way of the vags exerts cosiderae cotro over heart rate t itte regatio of the vascar compoets of the cardiovascar system the maor exceptio of corse eig i the pevic area So the sympathetic system y seectivey idcig vasomotor ac Interpretatio of research
tivity in varios parts of the ody and inflencing rate and force of the heart can ater not only the amont of lood flow t also the distrition of lood from one part of the ody to another according to where the action is and what kind of rega tion is reqired at any given moment In other words the sympathetic system controls the odys ifeine its capacity for fnction and srvival In view of this crcia activity and the associated energy exchanges it can e seen as indicated in Fig 1., that the sympathetic nervos system actally occpies a most strategic position etween the viscera and the somatic tisses tning ody fnction in accordance with what is going on in the environment as evidenced y what the main energy consmers the skeeta msces are doing from moment to moment This is the heart of the concept of the sympathetic system as mediator and in my opinion the crcia area o inflence of osteopathic practice If the sympathetic nervos system is going to e sensitive to the environment to the demands eing paced on the ody as a whole and to the way in which the individa himself interprets those demands then of corse it is going to e sensitive to impses coming down from the higher centers which organize the motor patterns that we are concerned aot And if this is essentia nder norma conditions then it is even more essen tial nder conditions of pathoogic change This is not to disparage the roe of the parasympatetic nervos system in the health and vigor of the mscloskeeta system; it is most important Bt this point conven tionaly receives emphasis enogh and what we need more is to pt the sympathetic system in proper perspective as the chief mediator the chief tner of viscera activity and its responses to peripheral and externa infence Mode of action of the sympathetic system
When we come to the qestion of how the sympathetic system performs the fnctions toched on aove we again enconter some cherished notions that are preserved and perpetated in textooks and cass rooms We teach them ecase of the weight of traditio and expediency
t at the same time we try to convey the clear impression that these con ventional ideas are in some instances dios or ntre and in any case inadeqate In simplest terms traditional teaching centers on the concept that atonomic fnction comprises two eqa and opposite ranches that are concerned with regating smooth mscle activity and secretory activity one exciting and the other inhiiting so that all we need to do is aance these actions and we have perfect heath In relatively recent years the concept has een modified in some qarters y the term integrated instead of antagonistic with reference to the two types of atonomic fnction On the other hand some of the newest texts ael the atonoic nervos system as the viscera nervos system which again tends to perpetate miseading connotations In this traditiona view the mode of action of the atonomic innerva tion is to indce more or ess contraction of mscle elements in the viscera organs and lood vesses or more or ess secretion in the viscera ths innervated; adjstments of celar metaoism that depend on the amont of contraction or of secre tion Over the years a tremendos literatre has accmated which indicates the incompete natre of sch a description of sympathetic fnction t the oservations have een reported separately and individay The tota pictre has never een assemed perhaps ecase there is no place to fit the pieces into the comfortale concept of te d ality of atonomic fnction and its ncompicated preoccpation with smoothmsce or secretory activity Some of these new oservations are now sixty or seventy years od t are sti looking for a conceptal home Te Orbel penoenon
Among the first of the nonconformist oservations was that reported y a distingished Rssian physiologist A Orei arond the trn of the centry He had done the cassic frog experiments famiiar to al of yo invoving stimlation of the sciatic nerve and had recorded the amplitde of the gastrocnemis response to varios intensities and freqencies of stimation Then he wondered
what wold happen if he stimated the sympathetic gangia innervatin the gastrocnemis mscle at the same time the sciatic nerve was stimlated. He tried this and fond that the amplitde of contraction was greatly increased In other words the sym pathetic stimation apparently ag mented the amont of energy released y the mscle To offset the chance that the effect was de somehow to vasomotor activity and increased ood flow he repeated the experi ment with this factor controlled and the reslt was the same; the power of contraction was increased perhaps throgh an improvement in the trans fer mechanism etween metaolis and the contractile process He extended the oservation frther and showed that after sciatic stimlation to the point of mscle fatige and imminent contractre the introdc tion of sympathetic stimlation restored the msce to its origina condition This work has een disconted or ignored for many years; in fact very few investigations aong the same line have een reported The most recent are those carried ot y M. Bach who conirmed many of Oreis findings and extended them and elaorated on the mechanism involved Faclaon of ranssson
Some investigators inclding Htter and owenstein have shown that stimlating the appropriate ganglia will also facilitate neromsclar transmission namely the ease with whch the excitatory process crosses the myoneral jnction the motor endplate Ordinarily when motor fiers are stimated not all the msce fiers innervated y a given nerve are roght into activity t when the sympathetics are excited simtaneosy there is some change at the jnction which makes it easier for impses to cross Del and Bonvalet among many others have shown that the sympathetics and adrenergic agents also have a profond effect on the centra excitatory state of the nervos system itself; there is a faciitation of synaptic transmission The reslt is an aerting effect on the sympathetic system as mediator etween viscera and the somatic tisses making it mch more responsive to what is going on
Cerebral mecanms
We know of corse that the sympathetic innervation extends to the ood vesses sppying the rain and the centra nervos sytem and can exert a profond infence on ood fow to these tisses Ordinariy this is a negigie roe ecase rain circation is regated argey throgh arteria ood pressre, t it is we estaished that nder certain conditions, when the sympathetics are stimated in a given area, for exampe the sperior cervica gangion, there is strong contractie activity in the vesses to the rain to the degree that cerera ischemia may e prodced his is proay the asis for the sccess of nerve ock, steate and other ocks, in overcoming ischemic nervos disorders Beyond this nerovascar contro is the fact that sympathetic innervation has a profond infence on cerera fnction itsef, even the highest inteective fnctions The rests in experimenta animas have demonstrated, for exampe, that varios interventions in the sperior cervica sympathetic gangia can either impede or acceerate the rate of earning or forgetting of conditioned refexes and profondy modify rnwave patterns So we see that the sympathetics have infences which are not ascriae merey to regation of smoothmsce or secretory activity Inbon of ealng
There is a fairy arge iteratre showing the profond inence of sympathetic innervation on revery from varios forms of tisse injry Ths, experimenta cornea cerations de to esions of the trigemina nerve are heaed or prevented y steatectomy Other stdies have demonstrated a strong inhiition of the rate of regeneration of injred tisses, the rate of heaing of experimenta scars eing acceerated y sympathetic denervation The rate of deveopment of coatera circation foowing experimenta iation of vesses in aoratory animas is acceerated on the corresponding side y niatera ganionectomy he coatera circation to varios tisses may e greaty impeded when the sympathetics are maintained in an excited state. So we have an infence on the rate of
regeneration or heaing and on the rate of recovery from varios insts mmunoendocrne reponse
We know that the sympathetic system infences immne reactions, aergic responses, infammatory processes in varios tisses There are profond infences on cear metaoism, on the enyme profies of varios tisses, on the rate and qaity of protein synthesis, on active transport across ce memranes A whoe series of investigations have een carried ot on the effects of sympathetic fnction on endocrine activites the thyroid especiay seems to e sensitive to changes in sympathetic tone, t the same is tre of the pititary which comes nder the inence of the sperior cervica gangion he pinea ody has recenty een the sject of mch investigation and is now reveaed as paying a roe in sexa fnction in ower animas and in providing mch of the asis for dirna rhythm I t has een demonstrated that there is a sma twig of fiers going to the pinea gand from the pper cervica gangia and when these fiers are ct the pinea ody oses its dirna rhythm nfluenc on oer ssue responses
There is a arge series of investigations demonstrating the crcia infence exerted y sympatheti innervation on responses that tisses make to other infences, whether parasympathetic, endocrine, environmenta or other One instance of sch research is that which has shown in yong animas a striking ateration in gonad response to gonadotropic hormone as the rest of sympathetic stimation Workers at the University of innesota some years ago showed that when the sympathetics to one side, the ower sympathetic gangia, were removed in pppies the ones on that side grew arger than on the opposite side; conversey, chronic stimation of the sympathetic otow prodced a stnting of growth Athogh this was given a vasomotor interpretation, it may aso e regarded as an atered response to the somatotropic hormone At the New York niversity Schoo of edicine, Gtstein appied an ingenios method for maintaining continos stimation of the
spanchnic otfow in rats and with this he was ae to prodce varios kinds of atheroscerotic and arterioscerotic esions incding those often fond in man Athogh many iochemica and other factors entered into the arterioscerosis, the sympathetic neroexcitation appeared to e a critica conditioning infence casing the arteria tisses to ater their responses to the other factors Here again we see the importance of the concepta framework ecase there are others who have aso stimated the spanchnic nerve chronicay Bt Gtstein was interested in atheroscerosis and imited his remarkae techniqes to the examination of the aorta; others were concerned with hy pertension and directed their stdies to the kidney, sti others were interested in the dodenm and ooked ony at the pper gastrointestina tract. Each of these stdies on one organ or fnction or another is of corse a vaae contrition. Bt as ong as the research, and the reporting of the research, is speciaied and compartmentaied according to the organ or fnction invoved, not ony is there dpication of research effort t mch more important, common denominators are overooked Ths the gastroenteroogist who reads mainy the gastroenteroogic iteratre cannot e aware of oservations, et s say, of the effects of sstained, intense sympathetice stimation on the eye, the heart or the ngs reported in the correspondingy speciaied jornas and that they represent essentiay the same kinds of infences that he has oserved on the dodenm, except that they are eing expressed throgh other tisses and organs each in its own way In the same way, varios cinica disorders referred to different organs may share a common neropathoogica process expressing itsef throgh different physioogica indicators common dnomntor
One cod go on and on with a detaied inventory of a these diverse inences that are ceary ascriae to the postgangionic nerons of the sympathetic nervos system Oviosy the nerons themseves can hardy e that diverse they are very mch the same, they ook aike nder the microscope, the impses they Interpretation of research
conduct ae nealy identical, the mediatos at the unctions ae limited to the catecholamines o acetylcholine So wheein lies the diesity? It seems clea that the answe is in the tissues themseles, the cells to which the sympathetic influence is diected We emege with an impotant basic concept, that sympathetic inneation inuences citically and pofoundly the cellula physiology of whatee ogan is inoled and the influence is in accodance with the natue of the cell, with what it happens to be doing at the moment, with the challenge that confonts it and with the othe influences it is subect to at th e moment Hee is a athe common facto which applies to all tissues The myocadial cell esponds only as a heat cell would A sweat gland esponds as a sweat gland would A gonad esponds as a gonad, likewise the duodenum o the panceas The sympathetic inuence in eey case is pecisely the same, the physiologic esponse of the taget tissue depends on the natue of its constituent cells ost of the wok that has been e poted in this field has demonstated that when sympathetic tone to a gien aea is pesistently inceased, the influences ae almost inaiably adese In many disease states the sympathetic component is found to
be augmented and exaggeated, many isceal diseases ae accompanied by demonstable neuopathologic changes in the sympathetic neous system, and ey often, good esults ae achieed by suppession of the sympathetic impulses to the paticu la ogan inoled This is not meely a genealized sympathetic inhibition, but athe an aimed influence to a paticula ogan by way of a paticula banch of the sympathetic outfow frn I Hs W R The Diencephaon - Auonomic and Exrapymida Funclios Nw rk Gr & Sra 954 2 Bach L N Bras acla h k rk ad h Orl c" m J Phio :05 953 3 Hr O F and W Lwnn Nar rar aclan ahc la h rg" J Physio 305595 95 5 4 Dll P Ball ad A Hgl "ous symphique deie e conoe eicuie de a moii spie Eececeph d CU Neuo phyio V 5996 8 954 5 Vlkn N P Th c nlaral cral
lc h crcal ahc nv and h cs s harac lgcal sanc n h rcr racn Secheno Phyioogica
o
Joua of he SSR 4 829 96 0 Zagrlk T. On h lc h
crcal sahc r ad adral h dcd rss h al s h ra Schno Phyioogica Jua f he SS 5 54 5 Bakr Grg S d Crnl G
Th r crnal lcra n h drad crcal sahc An xrnal d cas" Pc Sf Meeing Mayo inic 344448 959 2 Crckhak A H ad Harr Acclrad
wd halg ra ar ar cal ah J Ph Bc 3:8 95 3 arda A Ec r h CNS n cllaral rcla" h A n Giso Emoi 335558 956 4 Wra chard J l Axld and J
E Fchr la nhs h al glad Ec lgh dad h sahc n s" Sience 43 328 329 964 5 Gllcksn Gl r W. G Kck ad F J Kk Ecs lan lar s ahc r lgd nal grwh n dg." ed Poc 0:5 95. Gsn Wlla H Ja N Laallad and
ahc n crllar lrcal ac n h g Dkady 24 29 3 , 959 6 Sllrkaa T N Th c h lcrcal ac h crral crx ral h srr ahc crcal gagla Dokdy
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2 454 95 Kaan A I Ic h sahc
d r r h Pgrada I Oahc dc ad Srgr r he Phyioogic ai o Oephic Medicine
adral s rlx a a hghr ll h cral rs ss Sechenov Phyioogica
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V unerbly of he segmel
nervous sysem o somc nsus (90) The influence of the peipheal sympathetic neous system is usuall iewed as being limited to the egulation of the contaction of smooth and cadiac muscle and of secetion by cetain glands Howee, thee ae many welldemonstated inuences that do not it this peailing concept Among them ae influences on contaction and fatigability of skeletal muscle, neuomuscula tansmission, gowth, healing, deelopment of col lateal ciculation, inflammatoy pocesses, synthesis of homones and enzymes and on the esponses to othe factos and stimuli The ey di esity of the influences that hae been demonstated suggests that the diesity is not in the sympathetic fibes but in the kinds of cells
r h lcrcal ac h ra" Proceedig f he cdemy f Scienes SS 2523 959 9 Taa Va ad G Blkha Th
that they inneate, and that the postganglionic sympathetic fibes condition and modify the inheent physiology" of the inneated cell, whatee that might be Among the diese influences which ae of special inteest in connection with the theme of this semina ae those, usually excitatoy, exeted by sympathetic ibes on the sensoy mechanisms of the body As I ecall, it was fist demonstated in the olfactoy appaatus and late the taste buds that stimulating the sympathetic inneation to the nose and the tongue actually inceases the sensitiity of the eceptos so that they espond to much smalle quantities of neuochemicals The findings hae since been extended to the
muscle spindle, cutaneous eceptos and the othe somatic eceptos that D Buzzell discussed and it is now clea that when sympathetic hypeactiity is maintained, the dischages fom the eceptos ae pofoundly alteed in fequency and patten and they may actually begin dischaging een when they ae not being stimu lated So we get a false input whic upsets the neous system and initiates icious cycles Such consideations highlight the two basic pinciples that hae been emphasized in these discussions that health equies continual tuning of the isceal functions to somatic and enionmental demand and that it futhe equies the smooth sequential opeation of the somatic machin ey esponsible fo sensoy input to the spinal cod Fom these we deie the coollay that illhealth and disease can be ascibed to a beak down in communication between the 75
wo major componens of he ody he viscera and he somaic The resing disorders in heah may e indced in severa ways firs when he mscoskeea sysem (or he en vironmen i acs on and responds o) he primary machinery makes excessive or inappropriae demands on he viscera second when meaning ess informaion is fed ino he ner vos sysem o he poin ha an ap propriae or adapive response is im possie and hird when he viscera make oay inappropriae inade qae or confsed responses o somaic demands. The role of the spina or
Oseopahic conceps have ong placed emphasis on he sraegic roe of he spina cord in somaoviscera daion and in he organizaion of disease processes. Essenialy his roe speaking graivey is ha of a keyoard hrogh which he rain finds expression. The spina cord is he srcre where mos of he odys innervaion egins i is where mos of he neves emerge; i is where mos connecions are mad e eween he isses and organs of he ody on he one hand and he cenral nervos sysem on he oher Ao percen of he sensory informaion from he ody isef is fed ino he spina cord where i receives is firs preiminary coding Ogoing com mnicaions from he cenra nervos sysem aso are processed in he cord commands from he higher ceners re ceive heir final coding here efore hey are sen o over efferen pah ways. For he oseopahic cinician per haps he chief significance of he spina cord ies in is roe as he pace of oigin of he sympaheic nervos sysem as he place where visceroso maic coordinaion is achieved and where commnicaions do reak down when sch coordinaion fais. The sympaheic ofow is an impor an par of he oa efferen o ow going o a pars of he ody and nng viscera circaory and meaoic aciviy according o he arge and rapidy changing re qiremens of he skelea msc lare Wih respec o or keyoard image of he spina cord i is impor an o noe ha nike he piano and simiar insrmens he cord re 6
sponses are no organized in erms of singe noes. When a key is pshed y he higher ceners i eicis whole composiions of paerned aciviy which he rain comines modlaes and orchesraes in si higher com pex forms. The asic paerns of organized aciviy however are i ino he spina cord as he ody deveops An insance of his is he ar chaic paern of foregged ocomo ion ha man has inheried in he corse of his evoion (he swinging of he arms in waking and rnning) Now wha do we mean y pa erned aciviy? We know ha he paerns of feedack o he spina cord are highy organized; he ner vos sysem does no read individa signas he changing paerns of signas from many sorces How are he norma paerns mediaed y he spina cord and how do hey reae o he segmena divisions? Firs e me remind yo o f he kinds of nerve ces we are concerned wih in he spina cord. We have he sen sory fiers whose ce odies are in he dorsa roo gangia he anerior horn cels which sppy moor inner vaion of he skeea msces and he aera horn ces he origin of he sympaheic ofow o he viscera ood vesses and so on. (These in fences from he cord are ased on he condcion of implses in one way or anoher in addiion here are rophic inflences which seem o depend no on nerve impses raher on an exchange of ssances eween nerons and he isses which hey innervae And al hree kinds of nerons exer sch a rophic infence) The simpes fexion of a join sch as merely ending he eow invoves a high degree of coordinaion of a grea many nerons he moor horn cels and he sympaheic nerons he exension of my eow join in voves mch more han a simpe mo ion of he arm i prodces a shif in he cener of graviy of my enire ody caing for an adjsmen in he posra mechanisms nerons in he ow ack and he egs so ha I do no fa a on my face and so he cener of graviy is kep over he ase provided y my fee. In shor he sim pe ac of exending my arm rings in nerons p and down he whoe sp na comn. Simiary he simpe pro cess of drawing in a reah acivaes
nerons sppying he head and neck he diaphragm he inercosa and adominal mscare nerons scaered hrogho he cord are in voved and rogh in a he appro priae momen and freqency in order o prodce a singe reah In oher words whoe sympho nies of moor aciviy and accom panying spporive aonomic acivi y are organized y he spina cord and whie hese paerns are eing payed on he spina keyoard y he higher ceners conina adjsmens are eing made according o he informaion fed in over a he dorsal roo fiers. This inp is coninaly modaing and adjsing he pa erns of aciviy according o he siaion ha exiss in he ims and joins from momen o momen. The imporan poin is ha hese paerns of aciviy invove nerons p and down he spina cord each e ing caed ino pay according o he paern reqired a he momen no according o where he neron is ocaed in he cord according o wha srcre i innervaes Where i ives segmenay is of no impor ance or concern is wha i conros wha mechanism needs o e caed in a any given momen. This presens s wih an ineresing paradox he norma paerns of aciv iy mediaed y he spina cord are comee nonsemena in nare he paerns are ongidinay orga nized ye he spna cord is ovios y segmened and he physician is very mch concerned wih segmena rea ionships echanisms of referred pain for exampe may e exremey imporan in diagnosic proems and here he segmena reaionships are very conspicos. Neverheess in norma ife segmena reaionships do no appear The reasons for his paradox may e es conveyed y anoher isra ive simie Consider a eaify ex eced parade of skied marching men where he many ranks and co mns are seen as paerned aciviy of he whoe parade. We do no see in divida ranks and cerainy no in divida marchers we see paerned moion. B e somehing go wrong e one of he marchers lose sep and his rank immediaey ecomes conspicos The oher marchers canno compensae in a coordinaed manner and soon he ranks on eiher side are Inerpreaion of research
als thrwn int cnfsin an then we see the segental relatinshi It is sething lie this that cases segental relatinshis in the sine t eerge int view ner cnitins f clinical isrers A segent "in view is a segent in trble Hw shall we recncile the arax? First by realizing that the thing that is segente is the arr that hses an rtects the cr The cr itself is nsegente an flexible bt its bny sit f arr at tains exibility nly thrgh the seg entatin rvie by the vertebrae The nly way t bring lines f c nicatin fr the central nervs syste t the erihery f the by i s thrgh hles in the arr lace at re r less reglar intervals be ween the vertebrae I n nral life the segentatin is nt f the sinal cr itself the segentatin is in the assebling f the nerve fibers int "cables rts an nerves that can ass t t the tisses innervate What is segente is ingress an egress nt the fnctin f the cr itself In aitin t the neral rela tin t sinal segents we nte a segental relatinshi in the sheaths srrning the ral an arachni extensins f the cr an als in the bl vessels that sly the cr an the nerve rts What we are cncerne with here is the cr letely encase in bne an having t ae cnnectins with the erihery thrgh hles in its ar r the intervertebral fraina Nw lest y anticiate that I a g ing t tal abt the fashine "inche nerves an sch I a nt I a ging t tal abt ch re sbtle inflences that exert rfn effects n cr fnctin an its c nicatins These fraina cntain nt nly the nerves an rts an their sheaths bt als qantities f fat cnnective tisse eriste bl vessels an s frth We nw nw that it taes very slight lcal ize ressre r echanical efra tin t istrb the excitability an cnctivity f the nerns that ha en t be assing thrgh a fraen at the fcs f the ressre r efr atin Mchanical hazard
T areciate the vlnerability f the segental nervs syste t satic inslts it st be nerst that
ch f the athway taen by the nerves as they eerge fr the cr i s actally thrgh seletal scle The great cntractile frces f seletal scles with the accanying cheical changes exert rfn in ences n the etablis an ex citability f the nerns n this envi rnent the nerns are sbect t qite cnsierable echanical an cheical infences f varis ins cressin an trsin an any thers I rein y als that the nerve sheaths which are extensins f the eninges srrning the sinal cr exten fr a cnsierable istance alng the rts an these rt sleeves ae it ssible fr s t ve r sinal clns ver a wie range witht frictin he nerves slie sthly in an t as we ve in varis irectins Slight echani cal stresses ay ver a eri f tie rce ahesins cnstric tins an anglatins ise by this rtective layer Since arteries are art f the strc tres that ass thrgh the fraen the arterial bl sly t bth the bny cln an the sinal cr is art f the sae anastsis s that a istrbance in ne inevitably has se effect n the ther Althgh very slight ressre n the artery ay nt ince cclsin it es rce trblence f flw r ther seris heynaic cnseqences The rsal rt ganglia are articlarly vlnerable in this regar thrgh shar anglatin f the recrrent branches f the raiclar arteries that sly the ganglia Resltant ische ia f the rsal rt cells can lea t rgressive lss f sensry feebac invlving the rsal rt ganglia This sggests that ch f the tr istrbance in l age ay reresent sensry lss esecially rrice tive feebac at least as ch as irect tr lss With resect t vens sly an rainage we have a rather strategic int becase the vens ressre is extreely lw an slight cngestin f the vessels as they ass thrgh the fraen will case se aing bac int the area f vens rain age hese eeats ressres are engh t rce effects n nerve cnctin that I will entin in a ent echanical hazars t the sya thetic ganglia are esecially signifi
cant becase f the lcatin f these strctres firly resse against the vertebral cln ner the arietal eritne an lera an in clse arxiatin t the cstvertebral nctins Obvisly these ganglia are sbect t treens stresses i se by tins that tae lace alst cntinally Als sbect t great echanical stress is the ganglinic chain i n the nec which is highly vable an therefre vlner able t istrtins f ther ins All f these stresses can have rfn inence n the hysilgy f the nerve cells Assing that sch echanical istrbances f nern fnctin tae lace what are the effects in relatin t the segental nervs syste? Obvisly great ressre will interrt nerve cnctin bt this is nt what we are st cncerne abt Rather we are cncerne with intervertebral frces in an n either sie f the fraina an thse case by the cntractin f scles acting n the nerve trns that haen t be assing thrgh the An again we are cncerne nt with the aage reslting fr vertebral traa r herniate iscs bt rather sbtle ressres efratins an cir clatry changes eea cngestin cressin anglatin ischeia etc hese sbclinical states rce three ins f istrbance in nerve fnctin 1 Increase in neral excitability at the int f istrbance abratry sties an clinical tests thrght the wrl have enstrate that alst insignificant efratin f the nerve trn ay case that st t bece sntanesly active ese cially if there are siltanes cheical changes e t lcal scl activity An reeber that ilses arising at sch sites rcee in bth irectins twar the cr an twar the erihery whereas nr ally ilses arise either at the cen tral r eriheral "en an rcee in ne irectin Ilses ths reach the cr that i nt riginate in se eriheral rerting statin an signals reach effectrs that were nt isatche fr the cr. 2 Triggering f sernerary i lses: As a nral ilse asses the istrbe site fr se sensry recetr r a tr nern it es nt sily ass thrgh bt instea 77
riggers a whoe rain of impuses so i is foowed and accompanied by a whoe barrage The frequency of dis charge from and ino he spina cord is increased he acua frequency of discharge from and ino he spina cord is increased he acua frequen cy of discharge o he periphery is in creased and he paerns garbed so ha according o he ype of neurons we ge disurbed musce conracion vasomoion and so for. 3. Crossak" Nerve fibers in a given roo or nerve are higy privae pahwas. Wha passes down a fiber is no he business of is neighbors in he same nerve he insuaion is quie effecive. Nevereess every passing impuse norma generaes sma eecrica fieds in is viciniy as i moves aong he fiber Bu where dis urbances of he nerve have in creased exciabiiy of is axons crossak" ma ae pace beween axons I is ike a conversaion on our eephone when oher ines saring our cabe feed ino our ine. Tus an impuse on is way o a musce may se off impuses in a sm paheic neuron or in he pain fibers apparen by aera ransmission from one nerve iber o anoher a he sie of very sigh compression and usua from arge sensory or moor fbers owards smaer fibers such as he pain fibers and sympaheic fbers. Moreover he sympaheic fibers especiay e pregangionics in
he roo are arger an he pain fibers so hey in urn may rigger pain impuses This means aso a any emoiona response or empera ure change whic ses off sympae ic aciviy may cause pain ha does no originae in he peripher bu raher somewhere aong he conduc ion pahway These conducion phenomena have a profound effec on e funcioning of he spina cord Tey generae noise" which he spina cord canno conver ino usefu informaion In addiion he pain wic a firs is no ocaed in he peripery soon be comes so roug a hese reex mechanisms and hrough he sus ained conracion and disurbed sym paheic acivi. The issues suppied by e disurbed neurons become secondary sources of feedback o he spina cord and soon we have a sef susaining progressive cycing phe nomenon. And remember a hese mechanica disurbances are due o very sigh forces exered b reaive sig issue changes in he in erverebra foramina and in para spina srucures changes o which man is especiay suscepibe because of his verica posiion and he associaed verebra compression dded o a hese consideraions is a basic concep which peraps shoud have been discussed firs namey he fac ha when a issue is disurbed wheher bone or join or igamen or musce he oca sresses are con
inuay repored o he spina cord hus jamming" he norma rans mission of paerned feedback from periphera areas The feedbac from he invoved issue over is afferen paway becomes a asing and insis en garbing of informaion reaching e cord over seecive dorsa roos I is his kind of hing couped wi e mechanica disurbances menioned above a evenua knocks individ ua segmens ou of sep" and wih hem he issues and organs and func ions deriving heir innervaion from ose segmens Thus he vericay organied funcion in e cord be comes oriona conspicuous a he disured eve and e cinica disorder mus en be considered in erms of segmena reaionsips In summary ese are he somaic insus e sources of incoeren and meaningess feedback a cause he spina cord o ha norma operaions and freee" he saus quo in he of fending and offended issues I is hese phenomena ha are deecabe a he body surface and are refeced in disorders of musce ension issue exure viscera and circuaory func ion and even secreory funcion he eemens ha are so much a par of oseopahic diagnosis
Te segmenl nvous sysem s medor nd orgnzer of dsese processes (90)
he oseopaic humb wih a pres sure meer of his own design whic coud appy measured prese amouns of pressure. Then simuaing he moions made by e examining digi e used eecromyograph o measure he firs momen ha he paraverebra musces began o re spond o he simuus. He was abe o show ha where his fingers said somehing was wrong somehing in deed was wrong and he demonsraed ha in hose areas of oseopahic e sion he moor reex hreshods were ow I ook a smaer simuus o eici musce response a he cor responding eve of he paraspina muscuaure han a he socaed nor ma segmens And he demonsraed his resus o me ver dramaicay when I began o work wih he pressure meer and he
If one coud poin o a specifc ime and say his was where he modern era of oseopaic researc began I hink i woud be wih ha of J .S Densow beginning in e ae 930s and cuminaing i n wo papes in he Journa of Neurophys}oogy on moor refex hreshods a various spina segmens in human subjecs• In his work Dr. Densow pu his nger on wha has urned ou o be e cener of he whoe roube He began wih a very simpe observaion ha is famiiar o a oseopahic phsicians who use eir hands a grea dea: ha as you examine he paien e hands end o sop in cer 78
ain areas and your experience es you a somehing is wrong here You find for exampe, ha as you press upon he issues of he spinous process here are cerain areas where he musces respond ver quick and ohers where you can press quie vigorousy and i is as ough he body does no noice Suc effecs are very difficu o quaniae and wa Dr Densow did in effec was o begin he ask of measuring objecive ese sube changes in musce response ih he hep of counseors in e basic sciences and biomedica fieds e underook sudies in wich he repaced
Rpd pem m he Pgada I e Ospah di ad uge rm he Phigic B Oehi icie p
Inerpreaion of research
eectromyograph. As I studied each spina segmnt in a given human suject I found that I was ae to arrive at the significant prssure threshod ony through a procss of tria and er ror, whras Dr Dnsow having ex amined the patient, woud go to ach segment and preset the pressure meter at an anticipated eve and com cose or ven at threshod aout 90 percent of th time. And this was th rst inkage twen the sujectiv osteopathic approach and the com petey impersona instrumenta ap proach to the diagnosis and treatment of muscuoskeeta disorders Anayic metods
Having estaished the fundamenta point that motor reex threshods ar ow in areas of segmenta distur anc, the next step was to determine the asis for the owring and to devise procedures for anayzing it With th hp of a grant from th American Osteopathic Association a study was dsignd which woud measure the ectromyographic response of four segments simutaneous ly as the spinous processes wer stimuated y th prssure meter Th segments chosen were T4, 6, 8 and 0, and ach measurmnt incuded not ony the refex activty at th cor responding sgmnt ut aso how much pressur was required at each of the four spinous procsss to trig ger musce activity at the other thr eves Thus each singe rcording ses sion provided data on 16 reflx arcs. The principa finding that emerged might est iustratd y a vry simp and hypotheticaxamp rememer that in an actua human suject the picture woud e much more compex showing the seg ment at T6 to e so distured that very sight mechanica pressure on th spinous process would elicit hyperac tivity of the spinal extnsor muscs at that eve At the same tim, the sg ment at T0 might e norma y cinica and neuroogic critria so that even the top eve of pressure appied here wou not produce activity But somehow or othr the stimuus woud ascend through the spina cor and e expressed through T6 without pro ducing activity in intervning or highr norma sgmnts The effect that w osrved was rathr ike the eevator signasystem in a ta uiding a el can e rung at its own
eve quite easiy without ringing the es at other eves, ut on the other hand it is easiy rung from evls aov and eow When we anesthetied the tissues in the spinous process at the disturd segment we coud no onger icit activity y appying pressure at that point ut when we moved to a norma sgmnt and appid pressur, the e at the distured sgment was rung as easiy as fore Oviousy somthing was going on inside which was keep ing that segment distured and for the first time w egan to use a term that made it possie for us to egin communicating with feow physioo gists this segment was in a state of
Then the question ecam What
fcon
aout norma stimui? Aftr a we do not go around prodding each othr at spinous procsses To examine this point we made use of severa natura ractions incuding th sujcts initia apprehnsion and tnsness, his startd rsponse to a sudden loud noise or to a painfu stimuus and th tension evoked y emarrassing ques tions or y a fak piece of ad news In vry instance the tnsions first found xpression in segments where thrshods had en demonstrated to e ow and with reaxation these were the ast musces to quit firing We aso tested the rsponse to caron dioxide accumulation y means of a rrathing apparatus and found that as rspiration cam deeper and ac cessory respiratory muscs wr cad in the rst eves o e rcruitd wre those at the ow thrshod sgments For m a ginnr in th fid, this was a very xciting perio Our findings charactrid th kind of phenomnon we were deaing with, which w ventualy descried as a state of chronic segmenta facii tation, at east with respect to the motor antrior horn ces innervating th spina muscuature In my first artic for the AOA oul in 97, I referred to this as a neuroogica ens which focused irritation upon th siond segment and magnifid its responss These were the segments that took the eating, day in and day ut, undr impuses coming from anywher, incuding the higher centers of the nervous system. The nxt stage was an area of grat intrest to me caus of war research
where I had gun to see the tre mendous damage that could e done y the sympathtic nervous system adly usd. Was sympathetic refex activity aso faciitatd in the aerrant segments? And if it was, what woud it mean to viscera function, to circuation, to th person as a whoe? We wr going to have to work with human eings cause we wanted to study the sympathetic phenomena as they occur undr natura conditions and in the tota context of the in dividua And since it was necessary to keep our experimenta sujects intact we turned to the skin as a readiy accssi, nicly segmntd structure for which dermatoma maps had en estaished so that we coud identify segmnta reationships And we decided first on th swat gands as our physioogica indicators of sympathtic activity The human kin, eing usualy quite dry on the surfac, has a very high resistance to the passage of eectric current ut in th presence of moisture from the sweat gans th resistance is ower Threfore, we turnd to the measurement of eetrica resistance of the skin as a measure of th numr of sweat gands which were secreting at any given moment in a given area. Our first instrument was assemd from a fw dry ces and a microammeter, with siver eectrods (two dies for which I have nevr en reimursed!) fashioned so that one coud appie to the ear for exampe, whie th othr was usd for xploration Our oject was to find th situations parae with what we had oserved on skeeta musces in other words, sweatgand activity in areas undr coo, rsting conditions in which swat gands in most areas remained inactive With such dvices for measuring ectrica skin resistance, aong with thermocoupe instruments for ma suring variations in skin temperatur, w aoriousy expored and mapped out surfac aras of varying resistanc and tempratur, then drew hes on ody charts to see what pattrns of segmenta disturance wr present Now we have a sophis ticatd instrumnt uit in our own shops in which an electrode mounted on a pantograph "rides ack and forth on the sujct picking up vari ations in currnt fow through the
1
ski which are recorded y a osciaig gavaomeer. Eveay hese scaig ies compose a opographic map of he sjecs ody srface wih areas of igh or dark shadig ha show where resisace is high or ow respecivey ad he correspodig segmea disriio of sympaheic aciviy I shor we have a wrie record of he sae of sympaheic aciviy as reeced i swea gad aciviy ad caeos ood ow i a give area a a give ime I he dark areas of ow resisace he ski is mois ecase of coia sweagad aciviy i respose o sympaheic simaio which remais high despie he fac ha here may e o aca eed for ay hermoregaory swea secreio. As ime we o ad we examied hdreds of sjecs we fod ha each had a raher characerisic paer ha remaied fairy cosa; he sie of he areas migh vary he segmea disriios reaied he idividas characerisic paer. We cod ideify he sjec from his ES eecrica ski resisace char amos as readiy as oe ca from figerpris. 6 Or mos rece acqisiio is he hermograph which isead of measrig ski emperare y meas of hermocopes operaes y readig he ifrared radiaio from he ody srface ad recordig i o Poaroid fim amos isaaeosy givig s a accrae herma map of he ody ememer ha here he ack areas are cod he whie areas sow warmh ad oe ca e he sesiiviies ad differeias qie sharpy These isrmes ca deec circaory disraces resig from mscoskeea disorders as we as vascar esios sch as hromosis ad varios ifammaory saes They aso pick p mors ad cacers. I or sdies however we are cocered more wih he eromscoskeea aspecs A more moder approach o he eecromyographic sdy of segmea moio ad refex hresods is he mehod sig a 8chae Grass eecroecephaograph eaig s o sdy eigh segmes simaeosy ad wih isaaeos swichig we ca sampe aciviy i ay mipe of eigh segmes i a maer of secods.
The grea mer of phoographic records we have accmaed hrogh he years form a ieresig refecio of he grada progress i echiqes ad isrmeaio i his area of oseopahic research. Ad sice i may isaces we have fairy compee seria sdies of sige idividas we ca race ad evaae respose paers ad oe he cosisecy of correaios ewee experimea ad ciica oservaios. We have fod ha eecromyographic paers of posre are as characerisic of a idivida as are he skiresisace ad hermograph paers Pai hreshod paers ad areas of caeos ad deep ederess are qie characerisic ad cosa ad i a geera way cosey reaed o each oher epeaedy i has ee demosraed ha he disriio of areas of ow eecrica ski resisace ha is areas of sympaheic erve aciviy correspod qie we o he aca erve disriio from he esioed segme i he spie B yo ms o ook for perfec correspodece ewee ski resisace ad he disriio of he deeper pahoogic disrac ecase a area of ski which is segmey reaed o a paricar msce does o ecessariy overie ha msce. Wih he aissims dorsi for exampe he myofascia disrace migh e over he hip he refex maifesaios wod e i mc higher derma omes ecase his msce has is iervaio from he cervica par of he spia cord Aoher mehod we made se of i his asic research was a simpe procedre which is par of a physica exaiaio as doe y some oseopahic physicias The wo examiig figers sraddig he spia com are repeaedy draw dowward o he paraspia ski i a red sripe appears o each side which sigas eryhema Areas where he redess fades ad disappears very qicky idicae vasocosricio de o sympaheic hyperaciviy We deveoped a isrume for qaifyig he pressre ad appyig i a cosa speed he measrig he draio of redess afer he fricioa simaor has ee passed over he ski Ths we cod deec for exampe areas of iese vasocosricio o oe side or he oher
i he viciiy of he mar segmes ad agai we fod a high degree of correspodece wih he maa ciica examiaio. Si oher mehods for sdy of caeos vascare ad moor aciviy were deveoped ad have ee descried i picaios Clinical appliaions
Havig esaished he are of he hyperrefexia ad raced is paer i reaio o ivoved spia segmes or ex sep was o see wheher we cod modify hese paers Firs i was ecessary o devise ways of idcig mscoskeea disraces ad a variey of echiqes were esed. For exampe oe of or favorie echiqes has ee o sea he sjec o a soo which ca e ied, wih a sea e o immoiie he pevis ad he sjecs eows resig o a ae so ha his orso remais eve The y droppig oe hip we ca idce a ace scoiosis eiher o he ef or righ ad oe he skeea adapaio radiographicay ad he accompayig chages i eecrica ski resisace paers. I sch experimes he aorma paers of idced rama ad irriaio rer o he origia sae prompy afer he sjecs pevis ecomes eve agai We were qie rave wih oher peopes odies i hose eary days may isaces we isered hee is i oe of he sjecs shoes creaig a arificia ieqaiy i egegh as mch as a haf o hree qarers of a ich ad had hem wak wih his for a day or wo efore reexamiaio I oe memorae case a sdepaie wih cosiderae discomfor i he ower righ qadra of he ack cofirmed y ski resisace maps was asked o wear a hee if for a day ad rer he foowig morig. A ha ime we fod ha he paer o he ower righ had ee washed o areas of sympaheic hyperaciviy i oher segmes of he ody had ee iesified The hee if was removed ad whe he paie rered he ex day we fod ha he had ee wreched he oher way Ths i he corse of some 48 hors wiho adeqae preparaio he had ee sjeced o qie a wrechig adjsme so ha here was a gross exaggeraio of he origia Ierpreaio of researc
isturace a the iitiatio of aitioa isturaces esewhere i the oy We ater iscovere that the iuce isturace i the mithoracic area persiste for may moths aer his experimet Aother techique we ofte use was to iject a tiy it of hypertoic soium chorie ito the iterspious igamets or paravertera musces iucig irritatio which wou ea i aout 30 secos to sue referre pai a musce cotractio a withi a few miutes there were ew areas of ow resistace o the sujects oy i correspoig ermatomes I other wor, y reativey ocalie segmetal isuts to the musculoskeleta system we have prouce rather sustatia isturaces i sympathetic fuctio at east as refecte i sweatga activity a i vascuar a circulatory chages Over the years we examie a great may patiets a ega to see certai cosistet correatios etwee certai visceral isturaces a isturaces i sympathetic ervous fuctio The relatioships or patters were speciay marke i isorers with marked pai compoets such as peptic ulcer, pacreatitis, choecystitis, ysmeorrhea itese coic isturaces a rea stoes But we o ot take this to impy causa reatioships I am merey poitig out that there were these segmeta relatioships that ega to emerge a we ega to cal these patters y the ame of the pathoogic isturace thus, c ary patter uoea ucer patter, gastric ucer patter a so o it was iterestig to ote that the uoeal patter was quite ifferet from the gastric patter There was variatio from oe patiet to aother; evertheess certai cosistet a commo features appeare i those charts Occasioaly we wou see these patters i apparety heathy stuets or facuty memers a the uer stress or after the passage of time we wou ofte see a correspoig viscera isease emerge i these iiviuals But the questio of whether a how the eary muscuoskeetal sigs may e specificaly like to the causatio of the utimate viscera isorer sti requires a great ea of ivestigatio I other stuies we reate suomotor a vasomotor
[
patters to regioa isturaces i the oy framework eawhie, we have strog suggestive eviece of the maer i which the spia areas of ow threshos for motor a pai refexes with the associate sympathetic hyperactivity might operate cotiuousy i aily life a thus cause impairmet of fuctio This is est iustrate y seria stuies i cases such as oe we ivestigate i 93 ivovig a youg ioogist who showe asymmetry etwee the eft a right sies i the lumar segmets of the spie He ha a gastroitestia proem a certai serious ski esios ut our cocer was ot for the ciica situatio ut rather for the marke isturace o the eft sie as compare with the right with respect to its meaig i terms of segmeta facilitatio We use sweat secre tio, photographicaly recore or electricay iicate as our physioogica iicator of sympathetic activity Eve after the suject ha ee recliig for a og perio i a cool room, we fou sweat secretio goig o quite activey o the eft sie ut oe o the right Whe heat was appie to the aome we recore a immeiate icrease i sweatgla activity o the eft, whereas miutes passe efore the right sie showe ay reactio Not oy was recruitmet of gas more rapi o the eft ut the voumes of secre tio were greater By actua cout however the umer of sweat gas per square ich of oy surface was the same o oth sies Whe pai stimui of grauate severity were appie to a foot or the ack of a eg, agai there was a urst of sweatga activity o the eft or faciitate sie of the umar spie The same ki of ifferece cou e emostrate with startig or other kis of psychoogica stimuatio I other wors, what we saw was what we ha ote much earier with respect to the motorrefex thresho eviece of spiacor segmets remaiig i a faciiate, hyperexcitale state respoig prematurely a i a exaggerate maer to stimui which shou ot e of ay fuameta sigificace, ut proucig a the isturaces of sympathetic hyperactivity that appear to e relate to isturaces i visceral fuctios f you regar the sweat ga as
you wou a viscera orga or a oo vesse costricte i a visceral orga or i the rai or other oy part, you ca sese the possiiities with respect to ciica impact The poit is that here we have a commo feature of sympathetic hyperactivity a the specific ciica impact epes o the target of this aormal activity Each orga, each cel respos i characteristic maer to that isturace, alog with other iflueces it is eig sujecte to at the same momet a aso the coitios estaishe y its past history This says i effect that here is a segmet of spia cor which is i a state of cotiua aarm iteraly i a co sweat with a the cosequeces ote i the correspoig state of acute stressful emergecy We caot say that this 4hoursaay state of aarm resuts i iless o a efiite oetooe asis We ca oy say that these isture segmets are reativey vuerae, that the proaiity is higher Whether or ot it ecomes ciicay sigificat epes o the perso we are ealig with a a the circumstaces of his ife past, preset a future Here is where other ufavorae circum staces i the patiets aiy ife may tip the aace here is where a aorma stress respose wi te to fi the earliest a most severe expressio Trpic funcin f nerves
A very excitig area of ivestigatio i which we are egage at preset is that of the trophic fuctio of erves You may reca that i my first lecture i this symposium I emphasize that i aitio to the impulsemeiate iueces of erve fiers goig to tissues, there was aothe ifluece that was characterie as trophic, y which erves are show to e essetia to the growth, evelopmet sefmaiteace a surviva of tissues Nerves have ee show actuay to istruct tissue what ki of tissue to e That is, the erve exerts a propertyetermiig ifluece o the structure it supplies structuray, fuctioaly a chem icay. This has ee emostrate i experimets ivovig crossiervatio surgical crossuio i aoratory aimas a we are stuyig the trasformatios that take pace i tissue whose reguar
innration has n rplacd y nrs of anothr typ h ustion has n How dos a nr transmit iogntic information and iochmi ca matrials to th tisu? As you know whn a nr is cut th part of th fir distal to th cut withrs and dis. his is caus th nr fir is mrly a long n thrad of protoplasm which ha s n spun out of th nr cll in th cntral nrous systm and which is ing continually nourishd y th nr cll. Flowing down ry singl nr fir is a stram of nrcll cytoplasm in a olum grat that th nr cll is said to turn or its matrial compltly thr or four tims a day and this flow is ssntial to th continual nourishmnt of th firs thmsls aong thir ntir lngth And s o w askd oursls Is it possil that th innratd muscl or organs shar this trophic dpn dnc on th nr cll and that at last crtain componnts of th axo plasm ar transfrrd from nr clls to ody tissus? o tst th hypothss w did what I hop will turn out to th first of a long sris of ry xciting instigations h mthod which has n dscrid in dtai S inols th application of radio acti sustancs dirctly to nr clls undr controlld conditions prmitting us to trac th sustancs to spcific muscl clls and dm
onstrat that th sustanc ntrs ia th nr clls and not th lood stram or crrospinal fuid. Now w ar ngagd in trying to idntify th sustancs that ar transfrrd and thir fat and rol in th muscl clls I wish thr wr tim to draw som of th infrncs from this ry rif sampl of our rsarch ut prhaps you can draw thm for your sls W can gin to s som of th implications of ths sgmntal disturancs which com so con spicuous in rspons to actually uit sutl disturancs and insults to th nuromusculoskltal systm Whn you add th possiility of a dirct trophic influnc to what w know of sympathtic mdiation y way of r flx actiity and th farraching ffcts of sgmntal facilitation, you gin to s how far w ha yt to go in dfining th rol of th sgmntal nrous systm as a mdiator and organizr of disas procsss and th xciting promis in this fild of rsarch Referene I Denslow J S and C C Hase, "The central exciatory state associated with postural ab normaliies J Neurophysio, 5 :393402, 1 942 2 Denslow J S An analysis of the variability of spinal refle hrholds J Neuropho 7207-216, 944 3 Dslow, J S , I M Korr and A D Krems Quantitaive studies of chronic faciiation in human mooeuron pools Am. J. Physio 105229238 1947
Te roic funcions of nerves an er mecanisms (1972) Rsarch contriutions that my associats and I ha mad to th undrstanding of mchanisms undr lying th trophic functions of nrs ha n rportd At prsnt thrfor I should primarily lik to dlinat and charactriz th gnral ara in which our work is intndd to a contriution and to cony som prspctis as to what is mant y trophic functions and, scondarily to summariz our indings What i mean by rophi funcion?6'
Until rlatily rcntly physi ologists nurophysiologist nuro
chmists and n clinicians wr rathr slfconscious aout th us of th word trophic as it applis to nrs hy usually nclosd it twn quotation marks or prcdd it with th words socalld as though to disclaim any rsponsiility for it or any conictions aout its xistnc t smd to surroundd y an aura of mysticism Prhaps this was caus trophicity was so difi cult to rconcil with th wll sta lishd and much ttr undrstood function of nrs that of con ducting signals in th form of impulss from on part o f th ody to anothr n that ara on dals with
4 Kor r Irvi n M The neural bsis of the ost pahic lesion JAOA 47 191 98 1947 5 Thomas, Price E Irvin M Korr ad Hay M Wrigh "A mobile instumen for rcordin g elcrical skin resistan paterns of he human unk Act Neuroveg XVII (2):97 958 6 Korr Irvin M Price E Thomas and Harry M Wright Patterns of electrical skin resisance in man Act Neuroveg XVII (127796, 1958 7 Wrigh H M and J M Ko "Neural and spinal components of diseas Progres in the application of hemography JAOA 919 21 965 8 Wright H M, M Korr and P E Thoms Local and regional variaions in cuaneous vasomoor tone of the human trunk Act Neuoveg XXII 335 19 9 Wright Hary M "Masuremen of he cutaneous circulaion J Apped Phyio 20696702 965 10 Ko, I M • H M Wrigh and P E Thomas ffcts of eperimenal myofascial insuls on cuaneous patterns of sympahetic aciviy in man At Neureg 23329355 1962 I Korr I M H M Wrigh and John A Chace Cutaneous paterns of sympahetic acivity in clinical abnormaliies of the musculoskeletal sysem Act Neuoeg XXV 589, 1 964 12 Korr Irvin M P E Thomas and H M Wrigh "Symposium on the functional implicaions of segmenal faciliaion JAOA 54265282 1955 13 Ko M P N Wilkinson and F W Chornock Aonal delivery of neuroplasmic components to muscle cells Science 155342345 967 14 Korr I M The naure and basi& of the rophic funion of nerv Ouline of a resarch program JAOA 667478 967 5 Korr M pp 343346 in "Aoplamic Trans port Neuciences Reserch Pog Buetn Vol 15 No 4 1967 Reprinted by permission from The Postgraduate Insitue of Osteopathic Medicine and Surgey from The Physioogi Bs of Oseopthic Medicine p 7384, 970
phnomna that ar masurd in millisconds or sconds or at most in minuts whras in trophic func tions th tim lmnt is gratly protractd h procsss and ph nomna discussd in this papr go on for months, yars and n whol liftims Dr Pattrson's work rportd in this symposium, straddls th lin twn th two typs of function sinc h is studying long trm changs in th rapid ph nomna Cnica manifains
Long trm clinica manifstations of nurotrophic influncs ha n known for hundrds and n thousands of yars h atrophy of muscls rsulting from what now is known as antrior poliomylitis was crtainly known and picturd y th ancint Egyptians allusions to Intrprtation of rsarch
smla stbaces have bee ascbe to Hppocates a ce tal atophes follow eve wos battle have bee ow fo cetes Some of the fest escptos clcal lteate ae those of S We Mtchell who escbe eostophes eslt fom wos the Cvl Wa He ave the ame "casala (b pa) to the eslts of these es whch tamate eves the extemtes bt le the tepte Soe of these es wee followe b emaabl otesqe efoma tos a mopholoc abomaltes the extemtes a the co poet tsses Osteopathc phscas of cose thohot the hsto of the po fesso have place eat emphass o the tophc chaes evet to the ee a the palpat ha the qalt of the tsses aeas of leso a D. Deslow has scsse soe of those ths smposm Atoph of eevato he most cospcos a most thoohl ste of the tophc chaes ae those whch occ seletal mscle afte eevato whethe t be b tepto of eves o eath of the eve cells (as polo) Mscle s massve a elatvel spefcal a chas ts se a fcto ae eal evet. Moeove becase t has bee thoohl ste moe ma be ow abot mscle stc tall fctoall a chemcall tha abot a othe tsse Fo a lo tme t was assme that the atoph whch followe eevato was eall atoph of sse the cessato of actvt follow the tepto of moto eve mplses It ow s ow a I wsh thee wee tme to o to the evece that the atoph of eevato a the atoph of sse these stc tal fctoal a bochecal aspects ae qte ffeet ate a cose thoh the fome oes atall cle aspects a compoets of the latte What seems to be volve s ot so mch te pto of mplses (a theefoe of cotactle actvt) bt scoec to betwee eve cells a mscle cells A athe amatc a obvos
cofato of the fact that atoph s e to scoecto betwee eo a e oa athe tha aest of mplse tafc s pove b the tophc chaes whch tae place tsses that ot ol o ot epe o eve mplses fo the actvt bt whch ee tat the mplses the eve fibes that sppl them I am spea of cose of seso oas a ecep tos Whe fo example the losso phaeal eve o oe se s ct the taste bs o the same se o f the toe soo be to effeetate bac to epthel evetall vash completel O eevato effeetato s tee a copletel oal stato appaa ts s estoe Mateace of oal stcte s ot the sole tophc flece Iee t wll be see that the wo "tophc o loe s appopate to the vaet of lotem fleces epeet of eve mplses of pepheal eves o the e oas Let me etf soe of the othe cateoes of tophc fcto Coto fleces of eves Neves also see to exet a coto ece o the fctoal pop etes of some tsses a o the esposes to othe eces I ex pemetal aals eevato of s fo example appeas to a et ts ssceptblt to the acto of cacoec aets Othe vest atos have ste the effects of eevato o the espose of va os oas to ceta specf homoes. Mophoeetc fleces Aothe cateo of the tophc flece of eves s that of mo phoeess. he stes at ths collee b D Hx a hs colleaes o the postatal evelopet of the mam ala e pove otable exaples Whe the eve sppl to oe e s tepte the ppp befoe the teth o eleveth a of lfe the evelopet of the e s tepte at that pot If howeve eevato s oe afte the ctcal peo has passe appaetl the eve has left ts mpt o the e so t s esposve to c clat owthpomot factos hece thee s some ovelapp of mophoeetc a coto fleces
he mophoeetc fleces of eves have bee most extesvel ste emboc evelopmet a lae vaet of speces It s ow fo example that the complete evel opmet of mscle eqes that the eve sppl each the scle a that a cto be establshe If that s pevete o f t s tepte the the mscle oes ot complete ts ffeetato a evelopmet o hav ffeetate t eoes effeetato a vashes Role of eve eeeato Aothe cateo of tophc fctos of eves s elate to eeea to Ceta amphba (ewts) ae capable of eeeat ete lmbs a tals afe amptato If the foelmb s aptate at the hme s fo example the stmp eoes effeetato a blastea s fome a effeetato a eeeato tae place tl the lmb s completel estoe I the extesve stes of Se t was emo state that f the eve s emove fom the stmp eeeato oes ot tae place He showe also b patal esecto of the eve that t s ot ecessa fo the ete eve stmp to be peset bt that a ceta theshol amot of eve tsse s ecessa althoh t ma cosst etel of seso fibes A copaso of speces capble of sch eeeato wth closel elate speces that ae ot eveale that the fome have a hh ato of eve mass to total lb ass (ease tems of cosssectoal aea at the ct sface) Ses pepae m ase the qesto that locall follows What wll happe the oeeeat speces f the exst ato s cease b hpeevato that s b toc to the stmp a toal evato fom elsewhee the amal He fo that he was able to ce a hh eee of eeeato the fo a a speces of la whch omall caot eeeate ts tal o lmbs. Moe ecetl a eve moe a matcall aothe vestato ell b a sla metho was able to ce eeeato of ch of a lb a mammal It was a p tve mammal to be se a opossm bt a mamal oetheless hese achevemets obvosl ase
83
a kind of exciting theoretica and cinica quetion nd impication A for cinica impication it houd be mentioned under the heading of regeneration that variou tudie have hown the importance of intact nerve uppy to the heaing of wound and to repair of defect in ki n bone and other tiue in mammaian pecie incuding man Reguation of gene expreion A trophic function that i perhap of the greatet theoretica importance ha been characterized by Guth a the neura contro of genic expreion Thi apect of trophic function ha been ceary demontrated on keeta muce Skeeta muce fa into two main categorie namey red and white with variou intermediate categorie between thee two extreme The two type differ not ony in coor but morphoogicay functionay and chemicay Red muce i owy contracting and reaxing muce; twitche are of ong duration and red muce i ent into utained tetanic contraction with owfrequency timuation; it i poken of a tonic potura muce White muce i phaic rapidy contracting muce with brief twitche a nd require hi ghfrequency timuation to produce tetanu The muce differ in microcopic tructure in many conpicuou way in the fiber themeve their nucei their motor end pate and their ubceuar component Their metaboim i totay different That of red muce i argey aerobic energy bein derived mainy from oxidative metabo im White muce on the other hand i capabe of a high degree of anaerobic gycoytic metaboim Moreover, they have different enzyme and enzyme activitie they differ markedy in their protein component yieding different eectrophoretic pattern There are many other difference incuding ome no doubt that remain to be dicovered ow what happen when the nerve to red and white (ow and fat) muce are witched by cro reinnervation of the proxima tump of one to the dita tump of the other and time i aowed for neura regeneration? Thi experiment ha bn done many time by many invetigator on variou pecie and muce combination and on anima
of variou age An important generaization emerge that a remarkabe degree of cro tranformation take pace athough the degree of competene of the tranformation varie omewhat with pecie with the muce that are eected and with the criteria whether tranformation i ju dged by tructure a dicoed by ight and eectron microcopy or by hitochemica pattern chemica compoition metaboic pathway or activity of variou enzyme A high degree of crotranformation take pace by a the e criteria Thi mean in effect that the nerve intruct the muce a to what kind of muce to be or at eat ha much to ay about it Apparenty muce i puripotenti that i it compement of gene prepare it to be red or white muce or any intermediate variety But it i apparenty the nerve which grow into it in the coure of embryonic deveopment and which ordinariy join with it for ife that determine which of the gene of the muce ce wi be repreed and which wi be expreed Such a mechanim woud enure the genetic compatibiity of the two kind of ce (motor neuron and muce ce which are joined in a ifetime partnerhip a a function unit and each of which i uee without the other and may even wither away on eparation of the two In the foregoing categorie I have offered but a partia inventory of the ocaed trophic function and it may be een readiy why I have reervation about the appropriatene of encompaing uch a diverity of neura infuence in a word that ha ony nutritiona connotation How do nerves exert their trophic inences?
Not by u
To eturn to the mot famiiar and conpicuou expreion of neurotrophic infuence why doe a muce (or other end organ) atrophy when it nerve i evered? f what ha it been deprived by denervation which i eentia for it maintenance? I wih there were time to go into a the evidence but one important generaization ha emerged from many different kind of experiment and many different cinica obervation and that i that nerve impue
are not the eentia eement Though thi i not efevident in the cae of triated muce (which depend on nervedeivered impue for initiation and contro of it activity) thi concuion i unavoidabe in the atrophy for exampe whic h take pace in enory organ derived of their afferent innervation What doe eem to be eentia (and et u return to muce a the exampe) i integrity of connection between the nerve ce and the muce ce it innervate Eentia to the maintenance of muce are viabe neuron axon and myoneura junction regarde of whether there i impue traffic A ong a protopamic continuity i maintained in the axon even if it i nonconducting the eentia neurona trophic infuence continue to be exerted Such atrophy that doe take pace a a reut of interruption of impue (and diue o f the muce) ha been found to be much e evere much more readiy revered and different in many way from the atrophy that occur foowing axona interruption What about the axon ite
Mechanim other than impue mut be ought to expain a thee divere neurotrophic inuence It eemed to me a good many year ago that an important cue might ie in the waerian degeneration of the axon itef which begin after pro� topamic continuity between it and it mother ce i interrupted by cutting compreion freezing or appication of chemica agent How doe the axon dita to the interruption know" that it ha been eparated from the ce body? Another important cue eemed to be offered by the obervation that the onger the tump eft attached to the muce the onger the time before trophic change tructura functiona and chemica began to take pace Athough it may be quetioned whether there i trict proportionaity between ength of tump and deay time what eemed to matter wa how much nerve ubtance wa e attached to the denervated tiue A i true of a ce there i continua turnover of cytopamic component incuding not ony variou moecuar pecie ike metaboite protein nuceic acid and enzyme but tructura eement uch a mito Interpretation of reearch
cha he ae call bea w be eae a ctall be eplace e the flece f the ees (DNA) the cles accace wh the specfc ate f the cel I mst cells these pcesses a clectplasmc eacts ae cae ve staces mease mcs he patte st escbe apples eve cells wth the mptat ffeece tha b fa the laest pat f the ctplasm (especally f a pepheal e) has bee sp t t a l slee thea Hece the teacts bewee the cell by a the cyplasm the ax (axplasm) a the eplacemets f csme wt cmpets tae place ve staces mease t mcs b cemees a the scac eve metes Hw? Wess a Hsce shwe he late 190's hat thee s a cal flw f axplasm fm he cel b a a the ete leth f the ax a all ts baches ctally eplesh cmpets se p he ax cmpets that ae pesmaby specc t that e that f e a t spple by the bl steam b the Schwa cells. he ate f fw was estmate at ab 1 mm. pe ay hs mptat scve has sce bee cfme ma tmes may speces a ma eves a chl elabate . It w s w that whle a 1 mm pe a ate s cmm t ma mammala eves sme cmpets (f whch ptes have bee the mst extesvel ste) ma be taspte at mch hhe ates p t seveal he mllmetes pe ay It s w als that the mt pwe f ths taspt s pve by the ax tsef Axplasmc lw ctes f a whle eve thse axs that ae sepaate fm the cell bes as f example stal stmps eft attache t mscle
f a mscle) cell s as the case f the ax als base the ctal elve b the ax f sbstaces that ate the eve cell? he mst ect appach t ths qest t seeme s wl be (1 ) t sppl the selecte eve cells stpelabele pecss whch wl be absbe by the cells a cpate t lae mlecles sch as ptes (2) t tace he ma f the macmleclecpate aactvty w the ax a (3) t see hw mch csses the ct a etes the msce cels whle () excl ( meas a cect f) elve b a the meas (f example the bl steam) I st sty we se aaaphc meths whch maes f the stbt f aactvt tsses ae ece ss specmes speca phtaphc flm mcscpc slemte tsse sects clea emls cve the sects Mcscpc examat f the sles eables e t eteme the pecse stbt a lca f aac ve patcles cells a tsses help ese etect f the expectely me amts f aacve cmpets we emplye cmps labele wth elavel st beta emttes cab1 a phsphs32 he hyplssal eve a te mscate seeme t ffe the ea system f meet the f eqemets st emeate Iee I have te vce m cecte that the te a ts evat wee especall ese s that we cl cay t ths st. We chse the abbt becase t s lae eh t pemt elatvely easy scal access t the l f the fth vetce f the ba whch the hyplssal cles s cate a becase t s small eh s that ae eh mbes f amals cl be ept afte peat f eh pes amal cae facltes
KO rsrc n mcnisms
A uoradographc fndngs'
Axopimc transport.
Basc queston and epermenal strategy
O he bass f the wlee f axplasmc taspt m asscates a I ase selves the fllw qest a may eas a Is t pssble that the tphc epeece
elma ss ataaphs a theemesa scas f eves tae fm abbts lle at ffeet pes ate appcat f mte vlmes f stpetae pecs slt t the hyplssal cle (a avabl t the ehb sal cle f the vas) shwe ( I)
hat selectve label was sccessfl (2) hat the aacve mateal was taspe al the hplssal (a vas) eves a a ate f fm 5 t 5 5 mm pe ay (3) tha aactvy bea each he base f the te fm 5 t 6 as afte sey (a the hea va the vas afte 9 10 as) a () tha f e f the hplssal eves ha bee ct cshe the lms shwe aactvty ly he evate se f the te O mcscpc ataaphs all f them pepae fm amals le fm 8 t 15 as afe he hypssal es wee labele a the left eve ct shwe that: (1) Ol the ht se was scatl abele (he left se shw ly bac actvt) a he aactve patcles wee wth the mscle cells (2) he aactvt appeae fs at the base f the te a avace ve seveal ays he p accace wh he eate leth f the eve pathwa t the tp a (3) Despte the vaety f tsses a cells the te (mscle epthelm bl vessels las a sesy appaats) evate b caal eves V VII IX X a XI a sympathetc bes l the mscles f the te (evate by caal eve XII) ctae sfcat amts f aactv Sce the aactve pacles the mscle cells wee f wth vas pats f the mscle cells (cle css stats a sacpasm) as well as temal eve bes a mt e plates these eslts cvce s that at least betwee the ehth a the ffeeh a afte eal label evecell ptes eache a wee ee ecte by the axs the msle cells I pblshe ept f these fs we ppse that ths tecella tasfe "ma ele the scale tphc a the ltem ece t base mpses f pepheal es the metab lsm fc evelpme ffeeat wth a eeeat f he stctes that the evate
Wha knds of subsances are ransfered, when and h ow much?
Wth ths peceete emstat f the etmscle cellt cell tasfe f appaetl macm
lcular substances (at least they remained fixed in te muscle cells and resisted ashing out in the course of histologic processing) our attention ten turned to identification of at least the kinds of substances and the quantitative time course of their delivery shall speak only of our most recently completed series of studies in this area and omit th e intermediate stages. n these studies Mr. .L. Appeltauer formerly of the University of ruguay has played a most important role n the studies under discussion we undertook to examine the delivery of proteins for the following reasons ) Having used C4 labeled amino acids in some of the earlier autoradiographic experiments we could safely assume that at least some of the radioactive particles in the muscle cells were protein; 2) A large amount of information is already available in the literature regarding te axoplasmic transport of protein; (3) The infinite variety of proteins me possible the high degree of specificity that seems to be involved. Leucine labeled with tritium (H J) at high specific activities was applied to the left hypoglossal nucleus of each of the rabbits used in the study. The dose in each experiment (80 microcuries) was absorbed on a small piece of fiter paper cut to cover the nucleus and then applied to the floor of the fourth ventricle for 5 minutes after which it was removed and the wound closed Te rabbits then were killed at various periods aer surgey and the tissues to be studied for radioactive protein content were removed. (Surgical details and methods for separation of cell proteins from other components have bn described elsewere) Although we examined the hypoglossal nerves medulla and other tissues also for the sae of brevity shall speak mainly of our findings in the styloglossus muscle o f the tongue on the labeled (left) side. Since some leakage of the tritiated leucine into the blood stream is unavoidable it was necessary for us to determine in eac animal what portion of the radioactive protein extracted from te tongue muscle represented radioactive leucine incorporated from the blood stream We had previously shown on shamoperated rabbits in
Fig. Waves of axonal transport of tritium labeled nerve-cell proteins to muscle (hypogloal nerve o st/og/osal muscle) D ferences between open and closed circles n dicate nerve-delivered radioactive protein
which tritiated leucine had been intraperitoneally injected that the stylohyoid muscles (innervated by cranial nerve V) and the mylohyoid muscles (innervated by cranial nerve V) incorporated the same amount (per milligram of tissue) of bloodborne tritiated leucine as the tongue muscles and were therefore an ideal control. Tese muscles were therefore removed from each experimental animal and analyed for radioactive protein; they revealed for each animal what portion of the total proteinincorporated radioactivity in the tongue muscles was due to tritiated leucine taken up from the blood stream the balance being radioactive protein delivered by the hypoglossal nerve. After we ad satisfied ourselves regarding the reliability of our methods for introducing tritiated leucine into the hypoglossal neurons for separa tion of proteins and other components and for assay of radioactivity by internal liquid scintillation we undertook the actual experimentation We performed three experiments fo each of the days between surgery and removal of issue specimens (called the postlabeling interval) and confirmed the finding of our autoradiogaphic studies that there was a wave of delivery of radioactive protein between days 8 and 5 after application of the radioactive amino acid to the hypoglossal neurons. Mutpe waves t would have been pleasat if we had been able to accept tha hertwarming conirmation and go on to the next phase of the investigation However tentative forays into earlier and later periods revealed that nervetransported protein was reaching the muscle as early as 6 ours (the short
est period measured) after application of the radioactive leucine to the hypoglossal neurons and that apparent ly much larger waves of delivery occurred long after the fteenth day. t appeared that delivery times would have to be measured both by clock and by calendar. n order to reveal the dynamics of axonal delivery of neuroplasmic proteins to muscle as well as possible yet without makig lifetime careers of just this one study we eventually performed approximately 50 experiments three experiments each providing three specimens of styloglossal muscle and four specimens of control muscles (and other tissues) for each postabeling interval from day (or fraction thereof) to 42 days and thereafter individual experiments at longer intervals until the seventysixth day at whic time proteinincorporated radioactivity in the tongue muscle was still significantly higer than the levels of the control muscles During the years when many investigators of axonal transport were finding and confirming that there was not one rate as had been thought but multiple rates of movement of different proteins (or other components) varying from a fraction of a millimeter per day to several hundred millimeters per day we were disclosing multiple waves of arrival of neuronal proteins at the muscle By appropriate averaging and statistical treatment of our data (to be described in detail elsewhere and performed to compensate for variations in nerve length among different animals which of course influence arrival time and for unavoidable variations in actual dose of radioactive leucine) we have shown four distinct waves of delivery of proteinincorporated radioactivity to the tongue muscle by the hypoglossal nerve (Fig 1) The irst begins within a few hours after application of the precursor to the neurons and reaches a peak between te irst and second days the protein in this wave seems to be metabolied and eliminated rapily from te mus cle. The second wave which corresponds o that in our previous autoradiographic studies aks between days 9 and 4 A third peaks between days 22 and 2 A fourth wave is evident in the interval between days 30 and 35 after which protein radioactivity declines gradually nterpretation of research
Intepetton 0/ ults
How oes oe taslate these plse labeli epeimets ito what is o i o omall What has bee fo fo the toe a hpolossal eve of the abbit ma be assme to be te with vaios moificatios of othe eves a e oas i othe species Bt with ea to the omal abbit o ata seeme to i icate that at a ive time a mi te of poteis caie i the hpo lossal aos is cotiall eachi the toe mscle Some of it ha bee sthesie b the peiao a few hos befoe some abot a moth befoe a the est t two i temeiate peios hese waves ma be ascibe i pat to iffeet ates of aoal taspot of potei a i pat to iffeeces i epate time (It is ow that some poteis ma emai i the cell bo fo lo as 2 wees befoe bei ispatche ito the ao It is ot cetai fo these ata aloe what potio of each wave of potei actall etes the mscle cells a how mch has emaie i the itamscla eve eis his owlee mst await completio of o st of the atoaioaphs pe pae fom these epeimets. O pevios atoaioaphic st ce tail ave covici eviece of cossi i the seco wave Althoh the oma still pesists amo ma athos of tetboos a mooaphs that cell membaes ae impemeable to poteis the peetatio of cell membaes b poteis a eve lae paticles seems o loe to be the poblem it se to be Cosieable eviece has accmlate that lae potei molecles o tavese cell membaes a itecellla ctios b active taspot pioctosis ischae of vesicla cotets o mometto momet chaes i pemeabilit At a ate thee is easo to believe that cellla baies ae ot so im peetable as coceptal baies ofte ae Cuent nd pojected studes
I oe to test the hpothesis that iffeet eoal poteis (o mi tes of poteis ae taspote a elivee to the mscle i the fo iffeet waves of aioactive potei M Appletae a I ae labeli the hpoossal eos i
ma abbits i the mae pevi osl escibe a sacifici them fo the tise specimes at the pea peios ietifie b the pevios e peimets We ae sepaati solble fom isolble poteis b cetif atio a measi the shifts i istibtio of aioactivit betwee the two factios I aitio we ae factioati the solble poteis i each wave b isc el electophoesis to etemie the chai pattes of istibtio of aioactivit amo the ma factios a to etemie which poteis ae fo i both the mscle a its eve Althoh we ae fii ma eciti this (i cli appaet selectivit as to which of the eve poteis each the mscle it is mch too eal to e pot o these o to aw a cocl sios We hope evetall to be able to factioate the isolble (stctal poteis also b aiet ltace tifatio a b the se of electo micoscop to ietif the sbcellla compoets i each of the factios a the to mease the aioactivit of each Clncl mpctons
his wo stol sppots the co cept that peipheal eves sppli vios tisses a oas ot ol coct implses to o fom those stctes bt sppl them with po teis (a othe sbstaces that ae essetial fo thei maiteace a selfepai that iflece thei vaios chaacteistics a thei fc tioal capacit a that coitio thei esposes to othe factos i cli eve implses ciclati sbstaces homoes micobes a toic sbstaces his cocept has ma eciti cliical implicatios Some of these have bee biefl e ploe a ee ot be epeate hee Sffice it to sa that a facto which fo a potacte peio altes the activit (a theefoe the ee echae metabolism o potei sthesis of the eo o which im pees aoal taspot col case the eal ieces o the ie vate stctes to become avese a etimetal theeb cotibti to isease Sch factos col icle istbaces (fo eample emotioal stess i escei implse taffic fom hihe cetes implse tafic i seso pathwas fom vaios
�
pats of the bo titioal factos s a toicoloic aets vial islts chaes i the chemical e viomet of the eos a thei aos a of cose the mechaical stesses a lae foces eete o a eeate b the mofasciosel etal tises thoh which the eves pass a the accompai chemical chaes i these tisses It seems lie l that the effcac of maiplative theap ma occ i pat thoh alleviatio of some of these etime tal factos Referenes Korr Wlknon P N
nd Chornok
rw Axonl delvery of neuroplm omponen
o mle ell Sene 1 2 20 Jn 67 (Reprned JAOA 6607-61 y 67) Korr I nd Appler G SL Sude on he rnfer of neronl proen o mule el Prelmnry repor JAOA 68 1- Jun 69 Korr I nd Appeluer GS L Connued de on he xonl rnpor of nerve proen o mule JAOA 69 028-0 Jn 70 Korr I nd Appluer GSL onl rnpor of nerve-ell proen o mule. Abr d Pro 0 rApr 71 Korr he nure nd b of he roph fnon of nerve Olne of rerh progrm JAOA 66988 y 67 6 Gumnn E ed. The denred muse Pblhng Hoe of he Czeholovk Ademy of Sene Prgue 96 7 Gumnn E nd Hnk P d. The efe of e nd de on neromuulr fnon Pro edng of ympoum held Lble ner Prge Sepember 18 1962 Elever Publhng Co Amerdm 196 8 Guh L "Troph nuene of nerve on mule Phyiol Rev 887 O 9 Gh L "Troph effe o verebre neuron A repor bed on n NRP wrk on Neuro R Prog Bll 7 1·70 Apr 69 0 Gmnn E ebol rebly of he denervd mule I n Gumn ' I I H EL he roph fnon of verl nerv In Sympom The phyologl b of oeoph mdne Pogrdue Inue of Oeoph edne nd Surgery New ork 970. Snger Nervou onrol of he regrowh of body pr n verebre In Gumnn nd Hn k pp 8-9 ell mb regeneron Induon n e newborn opum Sene 61 86 9 Jul 68 Bronde SH nd Smon E Jr. Ax oplm rnpor A repor of n NRP work eon held Aprl 2 967 Nero Re Prog Bull 07-1 I 67. 1 Grfen B Axonl rnpor Commun on bewn om nd ynpe Adv Bohem Pyhophrml 11 6 ek RJ Proen rnpor n neuron In Rev Nerobol. 892 70 7 We P nd Hoe H Expermen on he mehnm of nerve growh J Exp Zool 079 Apr 8 h dy w ppored by PHS Reerh Grn No NS0791 9 from he Nonl In e of Nerolog Dee nd Sroke nd by grn from he Amern Oeoph Aoon
,
Reprnd by prmn from JAOA 7 6171 197
Te fcled segmen: A fcor n jury o e ody frmework (193) Oseopahic physicians have aways eied fo hei diagnosic evaaion of sesses and sains of he mco skeea sysem pon he sbjecive sensaions and pecepions ha emege fom hei papaoy and kinesheic examinaions They ae concened wih sch hings a s vey sbe changes in isse exe isse defomabiiy easiciy esiience join moion and ohe sch chaaceisics. These ae pey sbjecive jdgmens ha ae made fom momen o momen and gide he physicians diagnosis and heapy. These pocedes inodce emendos difficies in commnicaion becase a sensaion is eniey pivae somehing ha simpy canno be shaed. This is e of a sensaion b hee is a specia ifficy wih espec o papaion becase whie any wo o moe pesons can simaneosy ook a he same view o isen o he same sonds o ase he same concocions no wo peope can p hei nges pon he same spo pecisey a he same momen They can do i ony in seqence and his inodces ea pobems of commnicaion beween pofessions beween peope fom eache o sden is somehing we ae si sdying In he ae 930's and he eay 940's S. Densow DO a disingished facy membe a Kiksvie Coege of Oseopahic Medicine began a seies of sdies o see if he cod objecify he pocedes ha a oseopahic physicians do each i n his own way each one paying paica aenion o skin o msce o deepe sces Densow paid mch aenion o he exe of he isses ove he spinos pocesses and he was in eesed in he esponsiveness of he paaveeba mscae o he digia pesse ha he appied o he spinos pocesses. B he ecognied ha his ype of obsevaion was he same as ha made by ohe oseopahic physicians who noed eaed isse changes in he aea ha fo many yeas we have caed he oseopahi� esion So Densow saed o mease he pesse ha is appied a each spinos
pocess each segmen and eecomyogaphicay o deemine wha pesse is eqied o eici he fis signs of eex esponse of he msces a he coesponding segmens In ohe wods he did wha he physioogis knows as he measemen of moo efex heshods excep ha insead of eecica sims o his o ha neve Densow appied mechanica pesse meased fom o 7 kg of pesse o he ip of he spinos pocess and ecoded ha pesse which bogh abo a efex esponse as indicaed on he eecomyogam Densow was he fis oseopahic physician o be eeced o membeship in he Ameican Physioogica Sociey on he basis of hese invesigaions and hose ha foowed. O of hese eay obsevaions emeged he concsion ha he socaed aea of oseopahic esion was eaed o a segmen of a spina cod in which he eex moo heshods had been oweed I ook ess pesse o eici he fis efex esponse of he paaveeba and paaspina msces Densow sdied age nmbes of sbjecs and emeged wih he ahe impoan geneaiaion ha his segmena esion was one wih a ow moo efex heshod As he sdied sbjec afte sbjec he fond ha he paens of disibion of he ow heshods wee ahe ending A given individa cod be picked p week afe week monh ae monh and esseniay he same paen of disiion of ow heshods wod be fond and he paens wee somewha chaaceisic of he individa Neveheess hee wee ceain aeas ha wee fond o be moe vneabe han ohes in he neck especiay a he aanooccipia aea a he jncion of he canim and cevica spine a he jncion of he cevica spine and he eaivey igid hoacic spine and in he mbosaca aea These wee he aeas of highes feqency of ow heshods o oseopahic esion Having js joined he Kiksvie facy I deveoped a gea peocc
paion wih he oseopahic esion I woked wih Densow in he aboaoy whee vonee sdens wee he sbjecs ecoding eadings fom he appicaion of he pesse mee he had devised I deemined ha ow efex moo heshods wee fond in he aea of he oseopahic esion and ha high eex moo heshod aeas of he spina isses indicaed noma segmens This ed s ino he invesigaions of he physioogica mechanisms ndeying he oweing of eex moo heshods in segmena spina aeas Fom his wok emeged he concep of h oni c segmena faciia ion efecing he hypesensiiviy and hypeesponsiveness of he affeced segmens of he spina cod o impses fom viay any soce in e body Deais of his wok and ohe eaed sdies have been bogh ogehe in a pbicaion fom he Posgadae Insie of Oseopahic Medicine and Sgey Some vey pacica ideas and pocedes have meged fom o sdies. The ieae on he sympaheic i sysem which has become a speciay fo me indicaes ha in amos any kind of ama o he mscoskeea sysem o fo ha mae o any viscea sysem he sympaheic nevos sysem is amos invaiaby bogh ino pay And vey ofen i jiicipaes in a mos inappopiae I manne which no ony does no con 1 ibe o ecovey fom he injy b acay podces obe ha _ oongs i I exaggeaes and exacebtes he disbance and ends owad posiive feedback owad he pepeaion of vicios cyces The syndome he injy becomes moe and moe disabing he moe oveacive he sympaheic nevos sysem becomes onvesey heapy dieced o nomaiing o qieing he invoved segmens of he sympaheic nevos sysem is vey ofen qie beneficia and someimes amos miacos as shown in he cassic sdies of S ei Miche on casagia and casagiaike syndomes ding he ivi a e know ha he sympaheics ae he main vasomoo conoing sysem of he body hey cono he caibe of mos of he vesses of he body Theefoe when he sympaheics ae hypeiiabe in a given
\' I
!
Inepeaion of eseach
aea a ve semet a ve pephea stbto thee s that aea a teec fo ethe exaeate vasocostcto o exaeate vasolato o a mxte of the two whch cotbtes to chaos a the pepetato of pathoo Whe cotol the bloo sppl to a ve aea o cotol ts fe o coto ts capact fo ecove ts capact to esst fecto ts capact to s vve a mata ts tet as a tsse he mpotace of the smpathetcs s efecte a temeos vaet of posttamatc vasomoto stbaces. he effects of expeme tal atea occlso a we l state b Baas stes whch he occle the lal ate a the showe that b smpathec tom emoval of the speo cevcal ala the eveopmet of colateal cclato was teme os acceeate o the occle se 199, Fowle showe that smpathetc stmato poce a sl of bloo the abbt's ea the caplaes Smpathectom aoectom the abt wth the expemeta thomboss mae acceeate thombolss thee he fo he a eve fve he pe cet. aothe sees of stes sha a Has showe that smpathectom acceeate wo hea abbts' eas. Bea a Bocca a epot befoe the Seco Wol Coess of Aesthesoosts showe that heal tme ha bs was shotee a sca a othe loca complcatos wee emate b sm pathetc eve bloc. No s afts wee ecessa most cases a thee wee o hpetophc scas. Uces o f vaos s the es a esewhee wee mpove b aloectom. Amo the most teest stes ae those o boes ots a teeth. Hefot a Nceso a o sees of stes showe that latea smpathectom fo exampe patets wth ethe osteo o hemato athts thee was eat eef of pa a cease mobt of the ots whethe hps ees o aes o the smpathectome se a fascat st at the U
�
's
vest of Mesota Kotte lcso a Oso fo that che who ha cotacte poo of oe le the smpathetcs ae hpeac tve the s o the affecte se s co a sal s wet cat smpathetc hpeactvt Boe owth these chle o the af fecte se s ece f howeve smpathectom s pefome the the boe owth s estoe a the eqalt of the e leth s matae. aothe st lcso et a showe b choc stmato of the smpathetc lmba cha o oe se b ao tasmsso wth m pate electoes to the amas that smpathectom poce o les o the coespo se Amo the most exct fa meta stes ae those show the fece of the smpathetcs o se so mechasms themseves. Stmlat w cease the sestv t of ctaeos ecepto a msce spes a eve case them to fe spotaeosl falsel epo stetch o cotact a case exae ate esposes. othe wos the smpathetc stmlato poces chaotc feebac e abe fomato whch s fe to the evos sstem fom the tsses a whch of cose ca o oth bt ceate moe a moe chaos a case the stbace to pesst oe a loe hee ae ma stes show that the smpathetc evos sstem s a mpotat patcpat the mateace of spt paf vscea patholo fo exampe sm pathectom o a ve se wl elax the aboma mscate o that se• At Coell Uvest Lo Chapma Stewat Woff Haol Woff a Hee ooe have oe ma beatf stes o the fece of the smpathetcs both ps a ms o vaos alec a flammato fectos pocesses he show the ctca mpotace of the smpathetc stbto to sch mafestatos as eema tcaa ethema tch etc Pehaps the most amatc exampes ae those whch epeset a temeos vaet of posttaatc somes that bea wth Mtchels escpto of casaa oa a s of compex omecate have
bee eveope to escbe those pheomea acco to the specal teests of the vestato sch as casalae somes the mo casaas the smpathaas the smpathetc stophes the efex stophes the sholeha some pseoaa the tophoeoses etc Stes b Lvsto Shmace Mafel Steboce Rsse Caste a ma othes all testf to the temeos mpotace of facltato of the smpathetc pathwas hs teate has bee evewe pat b Appezele. O the bass of o stes theefoe we see that the aea of semeta factato whee the "a effect the smpathetc evos sstem has bee te p the aeas o semets ae vleable he tsses evate theefom ae especal vleabe especal ssceptbe to fo a vaet of easos a ae esstet to ecove hat s wh theap ecte to the qet of the smpathetcs especall whe ame at specfc semet s mpotat Althoh we accept te effcac of smpathetc bocae b o sle aesthesoosts m opo thee s stl oth moe ef fectve tha slle osteopath mapatve theap apple to the semet whch facltato exsts
�
Referees I Denow and e CC e enra ex iaory ae aoiaed wi poura abnormaiie
5
(942 92 2. Denow An anayi o e variabiiy o (9 pina reex reod J europhysio 20726. Denow Korr IM and Krem AD
J europhysio
7
Qaniaive die o roni aiiaion in uman mooneuron poo Am J Physio
22928 4 Korr IM T neura bai o e oeopai e ion JAOA (94 9·98. . Te ogradae Iniue o Oeopi
4
Mediine and rgery ympoium on e yioogia Bai o Oeopai ediine New Yor 970 6 Korr I Toma E and Wrig M aern o eeria in reiane in man Aca
XV:
(98 7796 7 Wrig M and Korr IM Neura and pina
euroeg
omponen o dieae rogre in e appiaion o ( 96 9892. ermograpy JAOA 8 Wrig M Korr IM and Toma E oa and regiona variaion in aneo vaomoor one o e man rn Aa euroeg
XX
(9 2 9 Wrig M Meauremen o e uaneo ir aion J Appe Physio ( 96 69602 0 Korr IM Wrig M and Tom E Ee o experimena myoaia inu on uaneo paern o ympaei aiviy in man Aca euroeg
(962 29
89
. K�r, I.M. Wrght HM. and Cha J A Cutaneous pattern of pathetc actvty n clnca abnormalt on the muculokeetal ytem Acta
y
XXV (9) 598
Neroeg Korr
IM Thoma PE and Wrgt, HM Sympoum on the functonal mplcaton of egmental facltation. JAOA 54 (955 ) 65-8 3. Bardna RA Effect of njury of the CNS on colateral crculaton. Ark h A nt Gto Embr
33 I (956) 5558.
Fower P., Jr. Caplay crculaton wth change n ympathetc actvty. I Blood dge from ympahetc tmulaton Proc Soc fr Expr Boi
M (99) 5959 5 . Cruckhank AH
and Harr, R Accelerated wound healng n rabbt' ear after evcal ympathtomy Jur Pth d Bt 3: I (957) 778 6 Brena, S and Boca, M Clnca ealuaton of the ympathetc nerve block n the management of evere burn of the hand Abstrct Snd Wod Cogre f Anthesgts Abstrct 58 (Sept 0 ) Toronto Canada 7. Palou, J. Lumbar ympathtomy n the treatment of hypertenve chemc ulr of the eg (Mar toreU' Syndrome rcato X (955)39 8 Quano Mendez H Vaocutaneouyndrome of the leg (non·pefc ucer) Ango 84 (957) 34-3. 9 Baker GS. and Gotleb, CM The preeton
of corneal uceraton n the denerated eye by cerca ympathectomy: An expemental tudy n cat Pr
3:
Slf Mt Myo c ( 959) 787. 0 . Herfort RA xtended ympathectomy n the treatment of cronc tht J Amer Gert So ( 957) -95 . Kotte F J , Gulckon G. Jr. a nd Oon ME
5
Stude on the dturbance of longtudna bone gowth II Effec of the ympathetc nerou ytem on longtudnal bone gowh after acute anteror polomyet. Arch fPhys Med d Rehab 39 ( 958) 770-779 Gulckon, G Jr Kubcek WG. and Kottke,
F ffect of tmulaton of lumbar ympathetc nere on longtudnal bone gowth n dg Fed Pr 3.
1 I ( 95) 56.
Chernek KE Sympathetc enhancement of prpheral enory nput n the frog J Nurophysi
XXV 3 (964) 9355 Galtkaya, NA How the excluon of arou
omponent of nneraton act on te funona properte of the keletal muce Fzo Zhur SSSR
6 (953) 7078
Gatkaya N.A Role o the ympathetc ne vou ytem the deeopment of contraure arng n the prence of pna ord trauma. Fj; h 5
51 4
SSSR M MSheo : (965) 5-5 6 Capman LR. The partcpaton of te ner ou ytem n the nlammatory reacon Annas N Aadey of Scen (96) 74708 7. AppenzeUer O Te Automc Nervos System New York Eleer 970
Y
116
Reprnted by permon from Oteopathc Annal 0 78 973
Andrew Taylor Stil memorial lecure: Research and practic - a century laer (1974) On une 22 874 ndrew ar Si fung he reee he anner f Oepah * One hundred ear aer we an a a he did in hi au igraph ha i ha wihd he r ne and iard f p piin"* he epahi prfe in ha ndued a ng reene uphi rugge fr regniin reg niin f ief a a heaingar pr fein and f i eer a quai fied phiian and urgen hi rugge ha uinaed in a rapid uein f riuph f regni in aepane righ repn iiiie and ppruniie whih hae added up a pee ir reen arked he graning f fu praie righ in he a hdu ae hi has een a grea ir wn a grea and grea dd and he prfein and he i ere hae eer rean e prud We u hweer ephaie a fundaena diinin: I i ne hing gain regniin f he peene f he epahi phiian praie ediine in ardane wih ea ihed andard I i quie anher hing gain regniin f he undne f epahi prinipe and he aue a heah are f diinie epahi ehd Tha ir ha e e wn he fir ir i u preude he end whih exend in ipr ane end he prfein and he i dire ere a f ankind Unfrunae he e pahi prfein ee n hae appreiaed hw eenia hi diin in i I ee hae aued eiher ha he fir ir wa he fina ne r ha in and ief i inuded he end I de n and if awed a een precude he end In he ure f i ng rugge fr regniin he e pahi prfin appear hae frgen wh i ugh regniin enae i deier and den rae a wide and fu a pie Stl AT Atobograpy of Andrew T Stl The author, Krkvlle Mo 8
he enefi f epah prinipe and ehd In frgeing he pr fein ha peried epahi anipuain ip fr i pae a a ke eeen n epahi praie I prpe hw: () ha n rar a h ha ha een awed ipede heir wider appiain epahi prinipe and ehd hae a id ai in iedia reearh and igi ehani (2) ha epahi papar diagni and anipuain irue f he ehani hrugh whih he p erae a we a heir denraed effia repreen penia a ru grea and urgen needed n riuin a heah are () ha epahi prinipe and ehd n n are inauae in he are f he indiidua u ha he ffer reiae guideine he refrua in f he jeie pririie and preie f inia praie genera and he needed reruuring f heah are deier in he nain a a whe and (4) ha he epahi prfein u nw deide wheher eek he fue deepen f he diinie nriuin fr whih i hardwn righ and regniin hae prepared i r wheher aep he righ and regniin a he uiae fufien f i purpe he pe f cenific dechen
ad he prfein ainained he diinin eween ief a an inru en and he unique f ha inruen i igh hae een he need e a diigen in earning and dipaing he eidene fr he aidi f epahi prinipe and e pahi anipuain a i ha een in denraing genera inia · peene Inead i ha een ea fr he wh wih diun and reri he enefi f epahi anipuaie ediine n he preie ha here ha een n ienifi de nrain f a ehani hrugh whih epahi anipuain ud ignifian ipre he inia au f a pern r infuene he ure f an ine I i ie epe he fai f Inerpreain f reearh
this pmis Oiaily, this post of scitific tachmt of waiti fo th vic to com i bfo mai sch a impotat mt is amiab It bcoms atisci tific, howv, wh s as a cs ot to oo at th vic that s i, a it bos o isposibiity wh its ffct is to imit th avaiabi ity of a mostaby vaab fom of iaosis a thapy It is v o ttabl, I biv, wh th ostopathic physicia himsf is his patits th bfits of that iaosis a thapy, stifyi his lct with a ostsiby scitific pos ls this scitific tachmt, which is clicial bfits to miios of psos, th sam scitific tachmt which, ya aft ya, swps ito wispa s thaptic ats that a soo, thoh oft ot soo oh, swpt iht ot aai h absity of th pos of sci tific catio was also mostat cty i coctio with acpct hoh ow a pactic fo ctis i Chia a Japa, acpct has b a as a oital ciosity otsi th alm of scitific mici h physicia who a ivstiat acpct a apply it i pactic fac sco a v ostacism by his colas Almost oviht th sitatio has cha Acpct is n It is b i pactic, taht, a ivsti at o a icasi sca a th most spct of mical, acamic, a ovmtal as pics hysicias who w pviosy a with sspicio a sy i ma as tachs of acpct, as a, v, thi ct ppils Was th a s bathoh i o ow of th mchaisms lyi th pactic of acpc t Di last ya s th pbicatio of a asca obbli sty mostati th fficacy of ac pct o thosas of patits a i os of isass a ciica sitatios No A pactic o ct as pov, scitific a othoo sy bcam accpt ab bcas a fw istiish fis i Amica mici visit th opls Rpbic of Chia, ma som stha obsvatios of acpct i pactic, a t to
pot, W hav s acpct a it wos I shot, th wholsal cha i attit is bas, ot o cofic at by sach, bt o oo flis which ha b at by som ita tioa io matchs O has aso to wo, th, why a systm of iaosis a tha ptics iios to this coty, a asiy obsv, with a o istiish co of ciical sccss a v wii pbic accptac, has ot cit th sam a cptivity o wii iqiy Som of th asos a, of cos, th poct, ot of scitific mt, bt of oaiatioal, political, a co omic attits hy a th poct, ot of th aboatoy, bt of th mat plac hi fasity is pos by facts that com fom th laboatoy I ct cas, sach which has b wll coct i ostopathic istittios a sposibly pot i scitific oas has mostat a so biooic basis, spcialy i a a fl mchaisms, fo th appicatio of ostopathic maipatio I wlcom this lct as a oppotity to smmai, at last i pat what this sach has stabish O limit tim mas th tmost bvity cs say, bt fll ocmtatio wil b fo i th pbicatios fom which ths coclsios m I hop that th pofssio wil s this ifomatio to shatt th myth that fo so o has b alow to sta i th way Folowi this bif cosia tio of som obiooic mchaisms ivov i ostopathic ma ipativ mici, I wo i to viw with yo a fw of thi ciical impicatis, a th a fw of th obliatios a oppotitis that thos impicatios pst to yo as a pofssio Sry f rbigic ci
Fclon (lowd hsholds) J S Dn DO nd 1940, nchd th dn n b t ch nd tpthc pc ttn cntnn tdtn t h K C Otpthc Mdcn nvsttn nt th nphs chn ndn tpthc pctc Th ch h bn ns pptd b th Acn Ot pthc Asctn b th Ntn nttt f th nd b h K C nd t n
of moo phwys n lsond smns
I thos smts of th spia co which spply ivatio to " sio compots of th msco st systm, th atio ho cls (a pobably itos which syaps po thm a maitai i a stat of faciitatio I this stat, ths v cs hav low fl thshos hat is, thy a hyp sposiv to impss achi thm fom ay pat of th boy o fom ay pat of th bai It qis ativy fw impss, fom ay soc, to iitiat a sstai activity i ths os, a thi sposs a aat As a slt, th mscls which a ivat fom ths faciitat motoo pools a i cotactio wh thi cotpats i oth s mts a at st thy a i sto cotactio wh oy posta to is ca fo, a thy coti to cotact o aft th physioloic ma has pass hi mtabolic a ciclatoy qimts a cospoiy icas a sstai I aiy lif, thfo, ths mscls "ta a bati which is fct ov a pio of tim, i pysiopatholoic chas that, i t, icit scoay f sposs swh
Dbd snsoy nps o lsond smns
Choic smta facilitati is appaty maitai by istb patts of afft ipt to th co fom cptos a ssoy is ith i msclosta stcts o visca stcts, o both, tas mitt thoh cospoi osa oots
Fclon of symphc phwys
h smta facilitatio ot oly affcts atio ho cls, bt ts to th oth catoy of fft os of th spia co, th atal ho cls, which pst th otflow of th sympathtic vos systm Faciitatio of ths os sts i icas imps taffic to visca a to boo vsss of vit ally all tisss
jWh nt s n dsntn n a bsc h th t "stpth n s n cnctn n tpthc phcn t h psnts n hd nc xpnc, hv dnt th pc
1
Susained exaggeraed smpaheic simuaion ma over a period of ime ead o chronic circuaor changes in arge issues and viscera organs which can of course pro found impair heir funcion and even hreaen heir surviva High smpaheic one can aso ead o oher changes in srucure funcion and funciona capaciies High sm paheic one ma aer organ and issue responses o hormones infec ious agens and ood componens I aers ceuar meaoism and ma evenua ead o serious pahoogic changes
Experimenta inuction oj
jacitate segments Simiar and reaive enduring changes in moor and auonomic paerns can perimentay induced in seeced segmens appropriae mofascia irriaions and muscuo seea sresses.
5 Leaing an memory in the
spina cor Spina reexes and response paerns mediaed and organized he spina cord are no as sereoped and im muae as has een hough The spina cord can earn and remem er new ehavior paerns Experi mena he spina cord can e augh new paerns appropri ae manipuaing he afferen inpu o he porions of he cord eing esed. Indeed chronic segmena faciiaion ma e viewed as he reenion of a new hai of oca hperreacivi As he resu of disured afferen inpu segmens of he spina cord reaed o oseopahic esions ma e said o have acquired aerran e havior paerns which adverse af fec he organs and issuesha carr ou he aerran ehavior The affec he person as a whoe disrup ing he arger paerns in which he affeced segmens paricipae.
6
rophic iuences oj nerves an their bis The rophic infuence of nerves on he organs and issues ha he supp has ong een a recognized u ms erious phenomenon in oseopahic heor and pracice We are now rapid approaching an undersand ing of how nerves exer hese ong erm infuences which canno e
ascried o impuse conducion Our research cear impicaes cerain proeins and possi oher high specic susances of arge compex moecuar srucure which are sn hesized in he periphera nerve ces These neurona componens are ranspored down he engh of he axon and as we have shown hen cross he unciona arriers ino he issue ces This asic mechanism seems o e invoved in a varie of neurorophic infuences he es nown o f which is he mainenance of srucura func iona and iochemica inegri of musces cerain sensor organs and oher issues Inerrupion of his mechanism eads o aroph and de generaion I seems o e invoved aso in he reguaion of growh prenaa and posnaa deveopmen regeneraion and heaing and in he reguaion of he aii o respond o hormones and oher circuaing susances Of specia scienific and cin ica impor is he fac ha he same ind of mechanism seems o e re sponsie for he neura reguaion of he acivi and expression of he gees i n seea musce and possi oher issues Hence an facor which for a proraced ime aers he meaoism and proein snhesis o f he neuron or which impedes axona ranspor coud oc he neura infuece on he innervaed srucures or cause i o ecome adverse and derimena here conriuing o disease Among he mos proae facors are he compressive forces and mechani ca sresses occurrig in he mofas cia issues and channes hrough which he nerves pass he accompa ning chemica chages in hese issues and heir aerran sensor inpu
Changes in somatc tissues as basis jor pa/patory iagnosis The mechanisms discussed in secions o 6 resu herefore in wo mai inds of aerran neura infuences on issues ad orgas innervaed from he affeced segmens of he spina cord (a exaggeraed efferen impuse rafc (moor and sm paheic; and ( aeraion of neurorophic suppor and codiioning These aered neura and reex in uences produce changes in exure
resiienc moii and oher phsi ca quaiies of superficia issues which are suec o deecion and evauaion sied discerning papaion and someimes visua ispecion The provide much of he asis for oseopahic diagnosis I is hese ocaized papae changes in he accessie somaic issues ha signa o he oseopahic phsician ha somehing is amiss The oseopahic phsician nows ha he dis urance ma no e imied o hose somaic issues u ha i ma ex end a he ime of examinaion or a someime in he fuure o oher neuroogica reaed issues or organs The sied papaor can e remar a accurae even in his quantitative evauaion of he severi of he dis urance as shown correaion e ween he degree of faciiaion (ow ering of refex hreshods and he degree of papae anormai and of hperagesia Through he pa pae changes in he somaic issues he phsician can monior he effi cac of his reamen and he response and progress of he paien I is imporan o emphasize ha he pahoogic changes in he somaic issues are frequen asmpomaic; he paien ma have een unaware of an impairmen or discomfor uni areas of enderness are demonsraed o him during he course of papaor examinaion In hese seven iems I have sum marized our undersanding ased on research of he neuroogic mech anisms (a hrough which somaic dsfuncion ma impair heah and impede recover from iness; ( hrough which he cinica saus and progress of a paien ma e refeced in his somaic issues; and (c hrough which oseopahic manipuaion ma favora infuence he oa heah and cinica progress of a paien These are no means a he neuroogic mechanisms aou which here is firm nowedge from re search Nor are he neuroogic mech anisms he on ones invoved Bood fow mphaic drainage and oher hdrodnamic facors aong wih heir funciona and meaoic coroaries are aso suec o im pairmen forces and impedimens imposed muscuoseea issues and o ameioraion manua ap pied correcive forces I have deier Inerpreaion of research
atel chose howeve to limit m smma to those mechaisms with which o ma eas I have ha istha expeiece; a the will sice o the ppose o this lecte Icomplete a smma as this is o the available eseachbase owlee it still epesets a sbstatial basis i bioloic mechaism o the pactice o osteopathic maiplative meicie hee has eve bee a vali scietiic excse o ot examii a assessi the eicac o cliical methos that have ove ma ecaes bee eael accepte a soht b a sbstatial semet o the poplatio A o that the mechaisms thoh which those methos opeate ae bette estoo thee ca be o aonal ba ies to exploi a appli thei implicatios a potetial as boal as possible inica impications
What ae the cliical implicatios o those mechaisms a how o the elate to the total health cae o the iivial Becase o the special emas mae b avitatioal oces o the hma bo mscloseletal stesses paticlal i the axial weihtbeai potios o the mscloseletal sstem have a peclial hih iciece i ma he esltat mscloseletal stais te to become selsstaii becase o the ate o the tisses ivolve a thei aaptatios to these postal a locomoto stesses becase o popioceptive a elex mechaisms a becase o the abses o ail lie he ma become poessivel moe sevee a moe extesive with time he ma pesist a poess lo ate the iitial acilitati actos have passe Becase o the iqeess o the iivial a o his lie a hece iqeess o the emas which he places o his mscloseletal sstem the seveit a pattes o istibtio o these aeas o mscloseletal sctio (palpable osteopathic lesios) ma va om peso to peso as o thei ieces o health hoh the commicatio chaels povie b the ciclato a evos sstems a istbe potio o the mscoseletal sstem impais to some extet the ctio o othe tisses a oas especiall those
with which it is eoloicall most closel elate Covesel mscloseletal istbaces ma o the same easo elect istbaces elsewhee o example i visceal oas Bt sch secoa (elex) mscloseletal istbaces ae ot meel maneaon o the visceal isoe; thoh aeet eebac the somatic tisses become paticipats i a cotibtos to the patholoic pocess Hece whethe o pima o secoa oii the mscloseletal sctio theates homeostasis to some extet i the health peso a tes to pomote a sstai ooi patholoic pocesses i the patiet he semetal acilitatio associate with osteopathic lesios cases the aecte semets o the co to behave lie eoloic leses which ocs implse tac a chael it thoh the eeet pathwas both moto a smpathetic to the tisses ievate om those semets hose tisses ae ths expose to the haas o exaeate moto activit a hpesmpatheticotoia both o which ae commol implicate i ma isease states o these eex actos ca ow be ae the abeat tophic actos elate to alteatios i axoal taspot Hece i a peso alea ill these mechaisms impai the atal capacities a esoces o esistace epai a ecove a te to polo a to exacebate the illess. I a ealy peso the lesioe semet epesets a site a chael o icease vleabilit Whethe o ot isease evelops epes po the othe actos i that peso a i his lie iheite evelopmetal eviometal motioal social titioal taatic micobial a othes. he moe emai ey ae the moe citical is the acilitati peisposi iece o the osteopathic esio a the moe the balace is tippe towa illess he mechaisms ivolve i the lesio pocess icease the pobabilit o isease (a the seveit o existi isease) b ocsi maii a avoabl moii the impact o othe actos What etemies which oas a tisses tae the eatest ail abse a which iseases evelop o ae moe liel to evelop his epes o which semets ae ivolve a
theeoe which oas a tisses ae i the lie o ie o ece the acilitatio a the tophic impaimet is to ece the i a the vleabilit o the taets a o the peso himsel. he state o osteopathic iaosis a maiplative theap lies theeoe i the ecoitio o the somatic compoet o isease a i the appeciatio o its peisposi exacebati a sstaii ilece i the total ma. he state lies i the ea accessibilit o the somatic compoet to etectio a evalatio a its esposiveess to appopiate teatmet Realess o the eal o appaet elatioship o the somatic compoet to smptoms o ietiable isease i a ive patiet amelioatio (o whe possible "sileci) o this compoet itepts a vicios cicle o etimetal ieces a libeates the atal mechaisms o esistace epai a ecove Recoitio a teatmet o somatic sctio i the health peso iceases his islatio aist the avoable actos i his lie i his eviomet a i himsel eei them less eleteios to his bioloic capacities a esoces a him less vleable I the health peso osteopathic lesios epeset eal sliht a evesible epates om health be/oe the ca be assie labels as soes o iseases a eve beoe the ca be etecte b sal methos Hece osteopathic meicie icopoati maiplative theap a othe appoaches sch as titioal behavioal a eviometal which also sppot a isecmbe iheet bioloic capacities a esoces epesets a comphesive stateic a sstematic appoach ot meel to theap bt to the maiteace o health which is ae all the most compehesive omo pevetive meicie Osteopatic manipuation in perspective
It has bee show I hope that osteopathic methos have a soli basis i bioloic mechaism a that the implicatios o avaces i o estai o those mechaisms ae immesel ich i cliical pomise Cleal the osteopathic "cotibtio col be a tl eat cotib
1
tin t th hath f th natin N aid ratina x rain if it r xitd fr agni and in diida hargd with th rpni biity f garding and prting hath fr nt xpring th pib a f inding that ntribtin in dia datin and dia prati gnray. A I ha arady indiatd hw r th tpathi prfin ha yt t dnt it wn nitin abt th a f tpathi prin ip and thd in tta hath ar and t dntrat it it nt t tah dp and appy th prinip and thd a brady and fftiy a pib. Whn it has dn thrgh it phy iian it rganiatin and it in tittin th tpathi prfin wi ha wn a new right: th right indd th bigatin t init that th prinip and thd ar t iprtant no t b arfy n idrd fr inrpratin in what prprt t b intif prhn i diin A ry fndanta pint t b ad in thi nntin n that ha bn rkd fr a ng ti The vaue of the oseopathic contribuion to oa heah care can be correcy assessed ony within he concepua con in which it arose and in which it operaes Dirgard f thi pint
ha haprd th dpnt f th ntribtin and it tiiatin in prati Cntind ffrt t q t pathi anipati diin int an inpatib (atay iniia n pta frawrk an ny ntin t ditrt and br th ignifian and a f th tpathi ntri btin t hath ar and t nify it ipat n th dirtin f di a dpnt a a wh Wd it nt b abrd t appy th r fr paying nd ring ba ba t baktba n th pri that aftr a baktba diffr fr baba ny in th additina tw ttr k and It i n abrd t fr trity apathi prinip n tpathi diin n th pri that th attr i ditinti by ir t ny f tw additina thniq papatry diagni and anipati thrapy t itrat Otpathi anipatin ind ing it diagnti pnnt i nt ry anthr thrapti daity 9
r thiq in a ng and r grwing atag f daiti and thniq It annt b appid and aatd a thgh it wr a di atin r phyia agnt dignd fr th arag a and indiatd r ntraindiatd in wha annr fr thi r that dia r nditin fr aiating thi r that ypt r fr batting thi r that tigi agnt Nr an it b iwd and aatd a thgh it wr a ing dirt nifr ntity indpndnt f th partiar ndrtanding and ki f th in diida phyiian f th indiid aity f th patint and f th niq irtan f thir intr atin Otpathi anipatin i a wh yt f diagni appraia thrapy and prphyaxi En whn bin appid priariy fr th rif f ypt h a bakah and hadah r fr th tratnt f di a anipati thrapy pa th indiida a a wh n a r nary ptia phyigi path hat path niq fr ah indiida ad th w prn tward gratr wbing and a wrd ptibi ity t in in gnra and th i pr n tward rry and tward th r hih if it t fr within I ha fnd it ranab t i ai an tpathi tratnt a an initaby px tranatin b twn tw han bing In th r f ah tratnt tw prn ar phyiay phyigiay and n pyhgiay inkd in a ybrnti p in whih ah r pnd ntinay t th thr rpn t hi wn hanging ipt A in phyia fr f thrapy th phyiian k t gid th pa tint t bhair pattrn that ar ty and r farab t hi hath. nik prribd thrapti th niq r agnt anipati thrapy a a yt a a wh apprah dpnd fr it fay n an infinit arity f adaptatin t th niq and ntinay hanging rqirnt f th indiida It dpnd n th phyiian abiity t a and t t th rqir nt It an ny b a ffti a th phyiian art and in ak it Obiy th arat ant f th potenia a f tpathi
anipUati thrapy in tta hath ar rqir th axi dp nt f th phyiian knwdg aity dgnt and ki. hi i nt t ay hwr that anything than prb i witht inia a. It i a rftin f th rit f th tpathi apprah that anipatin adinitrd by tpathi phyiian f drat ki ha thrght th yar prdd rarkab rt fr whih iin f prn ha bn gratf Indd what t trngy t tiat tdnt t dp thir anipati i ar th frqnty atnihing inia rt n thy btain with thir wn a yt inxprt ffrt. I hp I a aking it ar that I iw tpathi diagni and anipati thrapy a an ara f diin at dp pr ai in it pathphyigi ra tinhip that it i a xating and danding f pritnt tdy ng and ti prati and ard ndar a any thr ara f di in. hyiian wh ar a pihd in thi ara rit thir prfin hight t. I bi thi ara f diin t b f h grat a t han hath that t iit r t withhd it bnfit fr whatr ran i thiay r ay and hany indfnib In th r f th prfin itri trgg fr rgnitin it ptn t prati diin tpathi anipatin ha fan fr th prhni anri ntd tratgy in whih it ar and f whih it i an ntia part int a fragntd diarintd frawrk in whih it and dpnt ar riy ipdd and in whih it annt piby b prpry aatd. In h an in patib npta rawrk th f tpathi anipati thrapy ha tndd r and r tward th paiati adnti ptina priphry f inia prati a anthr in th ng it f phyia thniq wrd l re f edcne
h tpathi prfn i nw ad n it t t rtr n t at tpathi anip atin t it ky pitin in a tta tratgy f diin and t k it aratd dpnt and rfin Intrprtatin f rarh
met towar the fuest impemetatio of that strate Not to o so whether b efaut or b ecisio wou be to reouce a commitmet a a opportuit of immese a historic maitue Whie such a tota strate appicabe at a stae of techooic eveopmet has o existe as a cocept a as the basis for esi of heath care it oes ot et exist i practice except possib i sma oca experimeta moes he structura a fuctioa reesi of heath care eiver sstems accori to such a strate has a specia eve uret reevace toa It is becomi more a more wie appreciate§ that the prevaii heath care eiver sstem is a mostrous aachroism echooica avace as meicie is its practice with its socia poitica a ecoomic aspects is eare to a era that has o passe he acute ifectious iseases a the quic iers especia of the ou that prevaie a hafcetur a oer ao have are bee repace b oterm iesses of the aut the ai a the ae that crippe a that i raua A sstem which cotiues to be base o episoic treatmet is absur a traica iappropriate at a time whe the ee is for a shift from perioic iiviua visits to extee cotiuous care from sic care to we care from emerec fieritheie care to prevetive "floo cotro from the paiatio of isease to the maiteace of heath It is o coiciece that the coceptua framewor which for so ma ears has offere such vauabe uieies to the care of the iiviua patiet also provies vauabe uieies to the esi of heath care eiver sstems so uret eee toa It is o coiciece that out of that framewor have emere methos that wou impemet the proostic prevetive heathmaitaii heathrecovei whoema approaches that are essetia compoets of those eee sstems hese vaues have awas bee impicit i osteopathic pricipes a practice he ew eemet is i easi emostrabe timeiess §S, o example: Glazie WH: Tak o medicine Scien Am 22837, Ap 73.
Hece i uri the resposibe aecies i our societ to uertae thorouh evauatio of the potetia cotributio of osteopathic maipuative therap to tota heath care a i isisti that this be oe i the correct practice framewor the professio wou at the same time be ivi uique eaersip i the reovatio of our archaic sstem of practice Now strethee b its compete acceptace as a professio of phsicias b broaer a eeper scietific fouatios a b amost a cetur of emostrate efcac the osteopathic professio as it prepares for its seco cetur is i a most auspicious positio for ivi that crucia eaership to the reformatio movemet i meicie his cou be the professio's reatest triumph a the utimate ivi memoria to its fouer
**
Refeences Listed hee ae mainly hose pulicaions which are eadily aailale to physicians and in which the oigina sarch, pulished elsewhere had een eiewed and clinical implicaions dawn Only hose prmay reseach pulicaions are included which may e o special histoic ineres Reeeces o he original woks and o elaed eseach y ohers can, howeer ound in he eiew pulicaions hat ae cited heein Pulicatios e in chonological ode o show hisocal proession
Denslow J S a nd Clough GH : Relex aciiy in spinal extensos J Neuophysiol 4:4307 Sep 4 Denslow, JS Anayis o ariailiy o spina eex hesholds J Neuophysiol 72071 5, Jul Deslow JS An analysis o he iriailiy o spinal relex arcs JAOA 44:35762 Ap 45 Denslow J S.: The place o he oseopahi ncep in he healing as JAOA 46·7 Aug 47 Denslow JS, Ko, IM, and Kems, AD: Quantiaie sudie o chronic aciliaion in human moorneuonpools Am J Physiol 15 022938 Aug 47 Kor, IM The neual asis o he oseopathic lesion. JAOA 47 9 8 Dec 47 Korr IM.: The emerging concep o he osteo pahic lesion JAOA 48: 12738, No 48 Symposium Denslow J.S. An appoach to skele al componens in healh and disease, JAOA 50399·403 Ap 5 Thomas, Pice E. An appoach o he analysis o spinal sress hough is physiological maniestations JAOA 504037, Ap 5 Ko, lM. The hee undamental polems in osteopahic eseach JAOA 50:40716 Ap 51 Denslow, JS: The somaic component JAOA 52:258·6 Jan Symposium Kor IM Thomas PE and Wight H.M. Sympoium on the uncional im· plications o egmenal acilitation JA OA 54:265·82 Jan 55 Ko I M The concept o aciliaon and its oigins JAOA 54265·68, Jan
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Thomas, P .E Sympahetic aiiy in acilita s mens: Sudomotor sudies JAOA 54269·72 Jan 55 Wright H.M: Sympaheic aciity in aciliat segments: Vasomoo studies. JAOA 5427376 Jan 55 Ko, IM. Clinical signicace o the aciliae sate. JAOA 54:277·82 Jan 55 Wright HM: The origins and maniesaions o local asomoo disurances and thei clinica signcance JAOA 562724 Dec 56 Kor IM. Osteopahic reeach: Why, what hithe? JAOA 5627585, Jan 57 Thoma, P E : Neuoascular aco disease JAOA 56339·44 Fe 57 Denslow J S et a Ceain chaaceisics o he nomal single moto uni JAOA 57257·6, De 57 Hix, EL. Ueeoenal eex aciliaing renal asoconsico esponses o emoional sess Am J Physiol 92: 19·7, 958 Tilley, R.M, Young GS., ad Ele, JN Practical aspecs o iscerosomaic elex inechange wih special eeence o sugey. Yeaook. Academy o Applied Osteopahy Camel, Cali., 959 Ele J.N: Paerns o espose o he paraeeral musculaue isceral stimuli. Am J Physiol 19842933 Fe Ele JN Relex elaionships o paaeteal muscles. Am J Physiol 2:93943, May 6 Wigh HM Pogess in osteopathic eseach: A eiew o inesigaions in the Diisio o Physiological Sciences Kiksille College o Oseopahy ad Sugey JAOA 6 34752, Ja n 62 Denslow JS, and Chace JA.: Mehanica sresses i he human luma spine and pelis JAOA 6 7052, May 62 Wrigh HM New pespeie in medicine The ole o the nerous sysem in disease JAOA 62 057·63 Aug 63 Denslow, JS Palpaion o he musuloskelea sysem. JAOA 63 075 , Aug. Ko, IM, Wilkinso, PN. and Chonock FW: Axonal deliey o neuoplasmic componens to muscle cells Science 55:342·5, 20 Jan 67 Ko, IM The aure and as o he trophic uncion o neres Ouline o a eseach pogam JAOA 66748 May 67 Macalane, MD: A eno·enal asoconsicor elex. Am J Physiol 218:856 Ma 70 Symposium Ko, lM, Buzell K.A. and Hix E L.: The physiological asi s o oseopathic edicine moderaed y GW Norhup. Posgaduae Isiute o Osteopahic Medicine and Surgey New Yok, 1970 Symposium Denslow, J.S., Paeson, MM. and Ko, l.M: Louisa Bus Memoal Symposium JAOA 72: 497 Oc 72 Denslow, J S Neual ass o he somaic component in healh and disease and is clinical management �AOA 72: 49-56 Oct Pateson, MM Spina esponses Saic or dyamc JAOA 72:5663 O 72 Kor, l M : Th e ophic uctions o neres an d hei mechaisms JASOA 72:637 Oc 72
epinted
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y pmission rom JAOA 73 362370
1 974.
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Northup GW Oseopathic medicine An Amecan reormaion AOA Chicago 1966
15
Neurochemca and neurorophc consequences of nerve deformaon: Clncal mpcaons n relaon o spnal manpuaon* (1975) The purpose of this paper is to relate findings on the sbjects of axonal transport, trophic functions, and neural chemistry and metabolism to the sbject of spina manipulation The ways in which these functions, processes, and mechanisms might be affected by neretrunk deformations o musculoskeleta origins, which in turn are amenable to manipulatie therapy, will be identified and, where possible, characteried iscussion will be limited to those circmstances in which axons surie, disabled though they may be Therefore, emphasis will not be on degeneration and regeneration, but on first degree injry, as described by Sunderland. While this may be a useful efort, other than a ew clues, the only prodcts are more unanswered questions Questions that arise are How many compression, stretching, angulation, or other deormations of neres and nere roots by srrounding structures influence neural chemistry and metabolism and the synthesis and axnal transport o macromolecules and subcellular structres? How do these neural effects in turn infuence the tissues, organs, and processes under neural control and regulation? A nere or nere root is far more complex than a mere aggregate of axons and their myelin sheaths. A nere may een be iewed as an integrated organ consisting of many diferent kinds o cells, tissues, and their products eertheless, and or obios reasons, the preailing emphasis of studies on neral mechanisms and their impairment has been on the axons. The study of axons, howeer, does not answer the central questions
·B on he ho don o peenon by Sdney Oh nd Dvd E Pee he Wokhop "The eh S o Spnl Mnp· ve Thepy Feb 975 he Non n e o Helh See NINDS Monogph No 5 S men o Heh Edon nd Wele
regarding the nerochemical and neurotrophic conseqences of neural deformation We need to know how the nonaxonal components of nere trunks, especially those that sere ntritie functions and that proide or control the enironment of the axons, are affected by deormation, and how these in trn aect neuronal chemistry, metabolism, synthesis, axonal transport, and trophic relations. These nonaxonal components include the Schwann cells and myelin, the aslar elements, the arious mesenchymal components, and the endoneurial flids and their low channels Unfortunately, little is known abot how some o these arious components contribute to neural economy nder normal circmstances, much less under circumstances arising from mechanical insult The ollowing may suggest how these arious components o the nere may be afected by deformation Axn Axopasc ranspor
Proximodista cellligal) transport Attenuation of the axon by compression or deformation impedes axoplasmic transport beyond the compression The axon becomes swollen with dammedp axoplasm immediately proximal to the compressed segment, while distaly the axon may become reduced in diameter A smaller swelling on the distal side of the compression reflects dammedup axoplasmic components moing owar the cell As long as sfficient axoplasmic passage through the stenotic segment is permitted, axoplasmic continuity is presered and the trophic relations between the perikaryon and its long cytoplasmic process continue, though probably with some impairment The axon distal to the lesion suries and wallerian degeneration is forestalled.
Moreoer, trophic maintenance o the axon ensures continued trophic support o innerated structures As long as connection is maintained between nere cell and, for example, muscle cells, whether or not impulses are being or een can be transmitted, the muscle cells remain intact and unctional Acetylcholine sensitiity remains, as in the completely normal motor nit, limited to the jnctional area and no fasciclation is seen We do not yet know, howeer, the effects either on the axon other than attenation) or on the innerated tisses o the slowing of the axoplasmic supplies, or indeed whether the change in axoplasmic transport is purely qantitatie The motoneuron, for example, is essential not only for the anenance of muscle, but it also exerts a ariety of trophic influences on its strcture, excitability, contractile properties, enyme actiity, metabolism, et cetera, indeed on its genic expression These infuences, as Ochs has indicated, seem to be based o axoplasmic transport and on the actal transsynaptic deliery of neuronal proteins and other sbstances to the muscle cells. How does the slowing, and possible qualitatie alteration, o this deliery afect the functions and properties o the muscle or other innerated structre)? Such questions are o immense clinical as well as theoretical interest We do know that nder such condtions o axonal continuity, the axon distal to the lesion, thogh thinner, remains capable of excitation and condction. Whether or not the neuron as a whole is unctional, that is, whether it can condct implses from one end to the other, depends on the state of the injured segment At that site the axon may transmit impulses normally, or cnduction may be blocked, or it may be hyperexcitable and, in the liing, breathing, moing animal or human, it may oscillate back and forth rom one state to the other. Conduction block may, howeer, be persistent, and recoery may be delayed for hors, days, or months, een after a momentary deormation, as in concussion The afected fbers suddenly reawaken to actiity, as Sunderland ! describes. The chemical and strctral basis or the unctional states normal, conduction block, hyerexcitability is nknown We can only Interpretation o research
assume ha he ae somehow elae o he eee of polaao of he es membae alhouh leasue has also aw ou aeo o he sae of paaoal mel Hece ecao fuco a ophc fuco ae compleel ssocae hs sublehal eee of aoal efomao Smla ssocao ma be pouce epe meall (o heapeucall) b chemcal o phscal aes apple o he eve whch bloc couco eve fo lo peos of me (fo eample local aeshecs col pessue, e ceea) whou eup he ao I s of hsoc ees ha ol ecel was possble o pouce epemeall, he evese ssocao whch a ophc fluece was bloce b phama coloc efeece wh fas aoplasmc aspo whle he eve emae fucoa as a asme of mpulses Of couse, whe aoplasmc aspo s euce o he po ha s o loe aequae fo aoal maeace couco soo fals a wallea eeeao esues Up o hs po emoval of he compess foce pems esbuo of ammeup aoplasm a he ecove of he euo
Reoae (cellulpeal) aspo As evewe b Ochs aoal aspo owad he cell bo has also bee emosae a sue has bee show ha poes muscle ma ee he eve a be covee o he cell bo hs aspo oo, ma be epece o be eae b aoal compesso Isofa as hs seves a feebac fuco ha chemcall "foms he euo abou ccumsaces he pephe a heeb eulaes peaal mopholo meabolsm poe shess sapoeess a possbl eve ee epesso hs eaao ma be epece o have eleeous effecs hs s aohe mpoa aea fo vesa o o ol fo obvous heocal easos bu because elaes o he clcal mpac of aoal mpeme a he value of spal map ulao Schwnn ces n mein shehs
Ase fom he ole of he Schwa cells he fomao of mel sheahs, whch ae mpoa m
pulse couco, hee s evece of he ole aoal uo a ee echae also houh o e well uesoo, appeas ha hese cells ma suppl esseal subsaces possbl houh he Schmaema clefs ha ae o supple b he euo o va bloo a ssue flus Defomao of a eve almos vaabl volves efomao a eve supo of Schwa cell a mel laes As he wo of DeBow a Bee amo ohes has show hese sucues especall he vc of he oes of Rave ma ueo cose able supo ue semes of eve he aos houh he ema ac ueo cospcuous chemcal chaes eflece alee sa popees a he affece oes Howeve lle s ow abou he effecs of such chaes o aoal chems meabolsm aspo, o ophc fuco coas wh he moe subsaal uesa of he ole of mel ecao a couco Howeve vew of he emosao b Ochs a cowoes ha fas aoplasc aspo s eee b meabolc pocesses wh he ao euce access of Schwasupple meaboles ma be epece o mpee o eve bloc such aspo Sce he subsaces such as lcopoes whch ae apl aspoe seem o be especall mpoa o he aoal es a sapc a moeual asmsso eve local soaao of he Schwa cell a mel laes ma have seou cosequeces
B vesses
Defomao of a eve o spal oo almos evabl pouces efoma a eve occluso of he vessels suppl he eve Because of he ch aasomoss a ffuso of o e fom suou ssues a aace eve semes occluso of he bloo vessels suppl a peph eal eve ove eve a coseable sech of eve oes o ecessal esul schema much less aoa he effecs of epemeal schema, wh he use of bloopessue cuffs o ouques o eual fuco humas a amals as eece sesao a moo a auoom c fuco have bee sue b ma vesaos wh va a
eve coflc esuls Iepea os of he esuls ae eve moe ambuous because wh hese mehos s o possble o sush bewee he effecs of schema a hose of eual compesso Howeve sues of he effecs of local efomao o of aoa o epose o solae eves clel cae ha he especve mechasms lea o couco bloc ae que ffee as eflece fo eample ffee oes of suscepbl amo fbe pes a ve ffee amcs of uco a ecove fom bloc Of couse schema of suffice es a uao oes cause eeeao of he schemc a sal poos ess sevee o befe schema pouces couco bloc whou eeeao Hpeecabl occus u he uco a posschemc peos Whe he pefuso ae chocall s euce bu o o he po of complee schema, ffee bes he same eve ma a he same me be vaous fucoal saes a fom omal couco o hpeecabl (ecopc supeumea mpulses) o couco bloc o eeeao he eee of schema a eual sfuco ma flucuae wh moo bloo pessue a ohe vaables he fucoal sae whehe omal ocouc o hpeecb le of he hps (schemc) eve fbes s elae o he es membae poeal, whch also s eee b oos he ao Mechacal suls o elavel moeae pessue ha selecvel occlues he ves a he eve ouce subaces ohe ha, o ao o schema As ohe ssues veous obsuco pouces hpeema cease asuao a eema Accumulao of efblla lus almos ceal eas he echae of subsaces bewee he aos a ohe elemes he eve wh eme o aoal meabolsm a o he pocesses ha epe o aoal meabolsm fo ee a fo specfc subsaces Aleaos spaal elaoshps wh he eeaous eve a osmoc elaos also ma have ef fecs o ecao a couco Aohe faco o be cosee as a complcao of he cease asu
97
daion is e accuulaion of roein in e eraaonal uids, and e resulan endency oard fibrosis Tis occurs aso in cronically isceic nerves. \ Te conseuences of rculaory ebarrassen in sinal roos ay be eeced o be e sae as for eriera nerves Tere are several facors, oever, a render e roos uc ore vulnerabe in is regard Locaion of e sina roos iin e inerverebra foraen is i n isef a grea azard Sinal roos lack e roecion of eineuriu and erineuriu. 3 Since eac roo is deenden on a single radicuar arery enering via e foraen, e argin of safey rovid ed b y collaeral aays is inial 4 Venous congesion ay be ore coon in e roos because e radicular veins robaby ould be coressed iediaey by any re ducion of forainal diaeer Tere is also e ossibiiy of reu fro e segenal veins roug ressure daaged vaves and venous conges ion ould ave addiional con seuences because e seling, being iin e foraen, ould conribue o coression of e oer in raforaina srucures 5 Circulaion o e dorsal roo gangion esecialy is vunerable for anaoic reasons son by Berg ann and Aleander i s ineresing o seculae o a degree isceia (or venous conges ion) of e dorsa roo gangion af fecs is roein eabois or e rouing ecanis discussed by Ocs, hic aarenly conros e reaive raes of eoraion of neurona roeins oard e sina cord as coared oa oard e eriery n is connecion i is i oran o reeber a sensory neurons are no ess oen roicaly an oor neurons. Also, i should be noed a because e radicular areries conribue subsanialy o e lood fo of e sinal cord, re duced radicular flo over several seg ens aso could affec cenral neurons and inrasinal aons.
(and ossiby erineuriu) and o e evidence for circulaion of e endoneuria fluids in bo irec ions. Lie or noing is knon of e origins or fae of e endoneurial fuid, e cannes of o, or e rousive ecaniss ndeed, if e observaions of Weiss and co orkers are correc, a roio isa fo coninues in e iving nerve afer arres of circuaion and even in coeey ecised nerves, en e are resened i si anoer ysery regarding e source and sie of e oor oer Tere aears o be good evidence for connecions of endoneuria saces i oer uid coarens direc or indirec or across selecivey er eabe ebranes, ih subarac noid sace, and subdura sace cenray, and i yaics disay and in e eineuriu Briery, for eae, rooses ha e eriradicuar cudesac of e subaracnoid sace is a subsidiary sie for e ecrein of cerebrosina fuid (in ic e roos are baed) ic ay ass ino e sina nerve as el as ino segena y can nes Wa is e roe of e endoneuria fluid in e nuriion, ionic and osoic baance and eabois of e neuron, and in e rocesses a deend uon e, incuding ecia ion, conducion, aonal ransor, and roic funcions? Unforunae y, e kno as lie abou e func ion of e endoneuria fo as e do abou is ecaniss We can as sue a a e very eas i serves e sae funcion as inersiial fuids in oer issues, for eae, as ediu of ecange beeen e issue cels and e bood. We aso can assue, oever, a e ongiudina arrangeen, e aareny can nelized o, and e inercange i fuid coarens of e cen ra nervous syse underie soe ad diiona funcions secific o nerve. Waever ey are, ey aso ay be eeced o be igy vunerabe o ecanica insul o e nerve
Inersiil flis in he nere
Te srucure and reaivey obvious funcions of e eineuriu, eri neuriu, and endoneuriu are rea sonably e undersoo, and ave been suarized concisely by Sun
he connecie isses
Te foregoing discussion of edea dras aenion o e eisence of uid saces iin e erve, rovid ed by, or encosed by, endoneuriu 98
erland. Te failiar funcions, esecialy of e eineuriu, inclue iaring coacness and coesive ness o e nerve suor coar enalizaion, i e erineuriu binding ogeer and encoassing e funicui and e endoneuriu en seaing e individua fibers i eir Scann and yn layers guiding regeneraing aons back o eir aroriae erinas ro viding and suoring cannes for fo of inersiia uids, bood, and y acing as diffusion barriers and efending agains ecanical, ceical, and icrobia insu n connecion i neural ceis ry, eabois, and aoasc ransor, i is ikely a in e nerve e esencya coonens ay ay an unusua, ers uniue, roe in e reguaion of fluid voue and coosiion and of osoic euilibri u n e nora nerve e dynaic baance beeen ydrosaic and oncoic ressures sees o be beeen e radia ressure eered by e eineuriu an aer absorion by endoneuria and inersiia col agen, so abundan in nerve, as easure as easize Lorene de N as son a en e eineuriu is ecanicaly breaced or eakened, e nerve sels enor ousy, i rogressive ickening of e endoneuriu and enargeen of e inerfibrillar saces. Under ese condiions, one ay eec disurbances in ecange beeen bood and aons, in neural ceisry, eabois, ransor, and elecrical roeries. Tis is anoer area for suy i odern eods, for is neuroysiologic ineres and relaion o sinal aniuaion he neron
Having eained e roe of aona and non aona coonens of nerves and roos i a vie o eir invove en in e effecs of eforaion, i is no ie o reurn o e neuron is ioran o reeber a neura ceisry eabois, and aona ransor are subec o aleraion no ony by neura and radicular defor aion bu by e aciviy of e cor resonding nervece bodies Aos any facor a ore or less enduring y eaggeraes e rae of iulse discarge by neurons aso affecs e energy reuireens, eabolis, and, alos ineviably, roein syn nerreaion of researc
thesis and turnover As Densow has shown intervertebra and other musuoskeeta strains designated as osteopathi lesions and responsive to manipuative therap are assoiated with faiitated segments of the spinal ord In those segments motoneurons and neurons of the smpatheti nervous sstem are maintained in a hperirritabe state presumab b disturbed patterns of afferent input from proprioeptors and other endings in the stressed tissues. 28 In this state and under onditions of dail ife the affeted neurons tend to be in onstant or reative high ativit when orresponding neurons in neighboring and ontraatera segments are quiesent or on mid ative The effets of suh hroni ativit provoked and sustained b musuoskeeta disturbanes on neura hemistr metaboism axona transport and trophi inuene and on the retrograde infuenes from the target tissues hard have been expored et the are of great importane to the subjet of spina manipuation Fina it is important to reemphasie the evidene that periphera nerves not onl ondut impuses to or from the es tissues and organs that the supp but that the aso deiver to them substanes snthesied in the e bod most notab proteins that are essentia for their deveopment maintenane and repair that infuene their various harateristis and funtiona apaities and that ondition their responses to various fators both phsioogi and noxious. An fator that for a protrated period aters the quait or quantit of the axona transported substanes not on might affet impuse transmission but oud ause the trophi influenes to beome adverse and detrimenta thereb ontributing to disease In onsidering the neurologi impat on human heath of postura and biomehania defets in the bod framework that are amenabe to manipuative therap we n o onger an imit ourselves to disturbanes in impuse traffi Conspiuous and distressing as are the resutant pain and the motor sensor and autonomi dsfuntion the more subte and insidious trophi onsequenes of disturbanes in axopasmi om
position and transport are no ess important It seems ike that muh of the effia of manipuative therap is reated to the ameioration of these trophi fators 0
References Sunderland S Nerve and nerve injuie. William and Wilkin Co, Balimore 968 2 Guth, L Tophic inuence of neve on mu cle Phyiol Rev 48587 Oct 3 Drachman D B ed. Symposium Trophic function of the neuron Ann NY Acad Sci 228 423 22 Mar 74 4 Och, S acor inuening aoplamic flow and neurl rophic effect. Preened at Wo kshop on Reearch Statu of Spinal Manipulaive Therapy Behesda, Maryland eb 75 5 Korr, IM. Wilkinon P.N. and Chornock W. Aonal delivey of neuroplamic componen to muscle cell. Science 55 3425 20 Jan 67 6 Korr I.M., and Appeltauer S Th time coure of aona tranpor of neuronal protein o mucle Ep Neurol 4345263 May 74 7 Appeltaue .S., and Kor, IM Aonal delivey of oluble, inoluble and elerophoreic frac ion of neuronal proein o mucle. Ep Neurol 46 3246 Jan 75 8 Pleasue D.E Neve roo compresion; effec on neural chemiry and meabolim Peented a Wokhop on Research Statu of Spinal Manipulative Therapy Betheda, Mayland eb 75 9 Rober D and Oeter, Y.T. Elecrodiagosi f nerveimpul deped keletal mucle J Appl Phyiol 2843943 Apr 70 0 Albuquerque E X. et al. : Effect ofvinblatine and colchicine on neural regulaion of he fa and low skeletal mucle of the a. Exp Nerol
ganglia and piphea nee of the ra Ep eurl 448495 Apr 2 Brierly JB. and ield J ae of intraneur injtion a demontraed by us of radioacive pho phoru J Neurol Neurourg Pychiat 28699 May 49 22 Bodian D Some physiologic apect of polio virus infeion. Havey Le 5223-56 958 23 Bakin Y I, Dolgachev I P and Kielev, P. N
Poibiliy of movement of ubtance along a neve Herald Roengenol Radiol (Tran!) 36 953 24 Dorang LA and Mazke HA: The fate of a adioopaque medium ineed into the ciatic nerve J Neuopath p Neuol 92532 Jan 25 Kurdiumov N A. On the rucue of perineu ral pae and efferen lymphaic pathway from he cerebopinal neve Arkh Ana 4426 Mar 63 26 Lorente de N R.: Obervation on he propr ie of he epineuium of fog nerve Symp Quan Bio 729935 952 27 Denlow JS Pathophyiologic evidence fo
the oseopahic leion: The known unknown, and contoveri JAOA 7 c 75 28 Kor I.M Popiocepor ad omatic dyfuncion. JAOA 7463850 M 75 29 Korr I M. The nature and bai of the ophic function of nerve outline of a reearch rogam JAOA 9848 May 67 30 Ko I.M. The rophic funcion of nere and their mechanim JAOA 72637 Oct 72
S
Repinted by permiion from JAOA 75 444 975
37734 972 Singer M and Salpeter MM The tansport
of 3HI-hiidine hough he Schwan and myelin sheah ino the on inclding a eevaluaion of myelin function. J Morph 202835 Nov 66 2 Denny-Bown D.E. and Benner C. Paralyi of nerve induced by direc preue and by tournique. Arch Neuol Psychia 526 Jan 4 I eion in 3 Denny-Brown, D.E, and Brenner periphera nerve reuling from compreson by pring clip Arch Neurol Pychia 52 9 Jul4 4 Och S Energy metabolim and pply of P o he fat aoplmic ansport mehanim in nee ed Proc 33 04958 Apr 74 5 Gerad RW Meabolim and funcion in the nerou ytem In Neuochemiry: the chemical dynamic of brain and nerve dited by KAC lliott IH. Page and J.H. Quatel harle C. Thomas Springfeld 955 6 Brink . Nerve metabolim. In Metabolim of he nevou ytem. Edied by D. Richter. Pergamon Pre New York 957 and Aleander L Vacular 7 Bergmann upply of pinal ganglia Ach Neurol Pychiat 467682 Nov 4 8 Wei P e al Proximodital fuid convec ion in endonerial pace of peripheral nerves demontrated by colored and radioactive iotope racer. Am J Phyiol 435240 Apr 45 9 Bierly JB: Senory ganglia recent anatomical physiological and pahological ontribu tion Aca Pychiat e Neurol Scandinav 3055376
955
Appelauer G.SL. and Sa Inco poaion of 4 lyine into pinal oo pinal
Proprocptors and somac dysunction* (195) The musuoskeet system is the most mssive system o the body yet in the peomne o its ininite epetoie o motions nd postues it is the most deitey ontoed nd oodinted Aodingy the musuoskeet system is the eipient o ost o the eeent outow om the ent nevous system (CNS with the gest potion by going vi the vent oots o the spin od to the muses whih y out the moto ommnds o the C NS t i s ess we ppeited howeve tht o eted esons the musuoskeet system is so the o th e pepondent sensoy input t o the CNS n input tht is so the most widesped the most ontinuous nd the most vibe This sensoy eedbk om ountess thousnds o epoting sttions in myosi nd tiu omponents enteing the od vi the dos oots is essen ti to the momenttomoment on to nd ine djustment o postue nd oomotion n ddition to thi s inuene on the moto pthwys the sensoy epot ing is seetivey outed to vious othe entes thoughout the nevous system inuding o ouse he eeb otex whee it entes into onsiousness nd the odeing o voition moto tivity Reevnt potions o the epots so eh nd e utiized by the utonomi nevous sytem in the tuning o vise i utoy nd metboi tivity to musuoskeet demnd ndeed the sensoy input om the musuo skeet system is so extensive intensive nd unesing s to be domi nnt inuene on the CNS nd thee oe the peson s whoe t my be expeted theeoe tht distubnes in the sensoy input om the musuoskeet system whethe geney o oy woud signiinty impi not ony moto untion but so othe untions nd tht o the peson himse Fo
· on a ltur in at th 71t Clinal Con
r o th Nw or adm o Otoath in onuntion with th otraduat nttut o Otothi Mdiin and Sur anuar 2 1 7. A' n n lir ron aard n uut 7
Osh
2
those engged in the study o the neu nd eex mehnisms tht pemise is t the het o the ini signiine o the osteopthi esion now modishy nd euphemisti y designted s somti dysuntion" One o the ist pod uts o expeiment eseh into those mehnisms pioneeed by Densow ws the onept o honi segment iittion n 97 the hypothesis ws stted s oows: (An) otoath lon nt a faltatd gmnt of th nal od mantand n that tat by mul of ndognou ogn ntng th oondng doa oot Al tutu ng ffnt n fb fom that g mnt a thfo otntally xod to x xtaton o nhbton
n speuting uthe bout the site o the endogenous oigin" the utho suggested tht the popioep tos ptiuy the muse spindes wee the most ikey ndidtes be use: they woud be sensitive to musuoskeet stesses 2 they e nondpting eeptos sustining stems o impuses o s ong s they e mehniy stimuted nd 3) thei inuene is highy speii to the muses ting on the eted joints nd the oesponding spin segments n the intevening 28 yes eseh in mny neuophysioogi b otoies hs immensey inesed ou undestnding o the popioeptos Conuenty eseh unde osteopthi uspies (eviewed by vious uthos hs substntiy inesed ou undestnding o the mehnisms invoved in somti dys untion This ppe is n eot to detemine wht impotne my sti be sibed to the popioeptos in the oigin o segment iittion (the ini signiine o whih hs so been expoed t is shown tht thee is ow even stonge eson to view the popioeptos nd most ptiuy muse spindes s key eements in the neu bsis o the osteopthi esion" A new theoy is oeed bout the neu mehnisms opeting in the osteopthi esio nd bout thei etion to osteo pthi mniptive thepy The pptoy itei o identiy
ing nd evuting the musuoskeet disodes th t e designted osteopthi esions hve been desibed nd tught in mny dieent wys Physiins die in the wys tht they use these itei in dignosis nd s guides to thepy Howeve thee seems to be gene geement on the impotne o t est one etue deesed mobiity edued nge o ese o joint mo tion in one o moe pnes nd on the impotne o estoing mobiity t so seems to be geney ssumed tht the esistne to motion is within the joint itse sibbe to tiu ition o to the visoesti pope ties o igmentous stutues This ssumption needs to be eexmined t hs howeve been so deepy impiit in osteopthi th nking tht it is seom vebized muh ess ques tioned o seve esons Fist the view o the pthi esion s bony" stutu" inteveteb o tiu dengement hs suh veneted oigins s to bode on dogm This tdition view is einoed diy by ntomiywoded desiptions tht impy dispements nd teed inteosseous etionships even when suh desiptions e ompnied by potesttions tht the osteopthi e sion i s o ouse distu bne nd not bone out o pe " Seond the esistne to mo tion nd edued nge o moti whteve thei oigin mniest in edued joint mobiity Thid in mnipution the vetebe o othe bones e ommony the eves to whih the mnu oes e ppied nd eetiveness o tetment is eeted in thei impoved mobiity Th brin powr of usc
To physioogist it seems muh moe esonbe tht te imittion nd esistne to motion o joint tht hteize n osteopthi e sion do not odiniy ise within the joint but e imposed by one o moe o the muses tht tvese nd move the joint O the somti tissues (o exmpe veteb nd pve teb muse is the ony tive one the one pbe o seenegized independent motion nd o deveoping get widey vibe nd pidy hnging oes The othe tissues e pssivey moved immobiized pushed pued ompessed nd teed in ntepettion o eseh
shape b forces exteral to themselves those of msclar orii a those exteral to the bo sch as ravit While sall thii of mscles as the motors of the bo proci motio b their cotractio it is importat to remember that the same cotracile forces are also tilie to oppos motio B the applicatio of cotrolle coteracti forces co tracti mscle absorbs mometm (for example of a swii limb a relates resists retars a arrests motio ee the eer fctio of seletal mscle is o less importat to the cotrol of motio tha its -mparg fctio. Both are base o the same celllar mechaisms those ivolve i cotractio Valable a qatitative isihts ito this aspect of msclar fctio as it relates to the behavior of lesioe semets have come from ob servatios reporte b osteopathic phsicias who are sille i socalle "fctioal techiqe While as i other maiplative approaches mo bilit is to thm a importat criterio the emphasis i this approach is ot o rag of exterall impose ("passive motio bt o as of iitiatio of active patietee ere motio this form of maiplatio the fiers of the palpati ha are place o tisses of the se met er examiatio while the other ha sials a ies the pa tiet throh varios motios i which that vertebral semet par ticipates. Usi fiertip criteria of "ease a "bi the phsicias escribe what seems lie expoetiall chai resistace (bi to motio aro oe axis or aother i the le sioe semet. hat is o iitiatio of motio there is a rapi rise i resistace i oe irectio a accelerati collapse alo the opposite cotrast the olesioe semet moves relativel freel i all irec tios aatomicall appropriate to the oit or oits offeri ol liearl chai resistace. Hoover Bowles a hsto have evelope cberetic approaches to osteopathic palpator iaosis a maiplative therap that have opee ew lies of iqir i cli the preset oe am ratefl to them for their ma provocative "persoal commicatios.
Althoh these athors have catiosl avoie ascribi the chai resistace i the lesioe semets to a particlar tisse am covice that their reports are cosistet with the hpothesis that "bi is the active oppositio or phsioloic "protest of mscle to the motio i a particlar irectio a "ease is icrease cooperatio a compliace i the other ee the evelopmet of resistace is ac compaie b a sesatio of "bch ip er the palpati fiers similar to that whe mscles i the ex tremities are voltaril cotracte t is therefore propose as a premise for this paper that it is i its capcit as a brae that a mscle ma become the maor a hihl vari able, impeimet to mobilit of the lesioe "oit whether the motio is proce b exteral forces or b other mscles Msclar resistace is ot base o iextesibilit as miht be expecte of toh coective tisses bt o chaes i the eree of activatio a eactivatio of the cotractile mechaism What wol case a mscle to be have i that maer icreasi or ecreasi its cotractio (a brai power accori to irectio of motio of the oit First the amot of cotractio from momet to momet is cotrolle b variatios i implse traffic alo the motor axos sppli the mscle. Seco the implse traffic varies with chai levels of excitatio of the aterior hor cells which thir ar accorace with chai afferet ipt ri the oit motio. What are the sorces of the chai afferet bom barmet ri the oit motio Proproceptors
he proprioceptors are the sesor e oras to loo to for a aswer to this qestio sice it is the that sial phsical chaes i the mscloseletal tisses he three mai cateories of proprioceptors are those relate to oit positio a motio to teo tesio a to mscle leth Jo rcpors
Eis locate i a aro oits (for example i capsles a lia mets report oit motio positio a possibl force. he Rffii eis especiall strateicall
istribte i the capsles report irectio a velocit of motio a positio ver accratel here is little or o eviece however that these oit receptors have a irect iflece o motor activit throh semetal pathwas he certail o ot exert a omiat selective ilece o iivial mscles heir collective ilece is o postral a locomotor patters throh the hiher ceters icli the cerebellm a the cerebral cortex Attetio is irecte therefore to receptors more irectl relate to msclar cotractio: those i the teos reporti chaes i tesio a those i mscle itself reporti chaes i leth Or crret owlee of the strctre a fctio of these receptors has bee amirabl eviewe b Ho a Heema
8
Golg o rcpors
he oli eis are locate i teos close to the mscloteios ctio (Fi 1, teo a afferet pathwa Plli o the teo istorts these eis casi ischare of implses ito the spial cor via afferet ibers he tesio to which these eis are sesitive is er phsioloic coitios sall exerte b active cotractio of the mscle itself Li i toh teo which is i series with mscle a relativel ieli the teo eis are resposive ot to hes i leth bt to chaes i force Chae i leth occrs mail i the mch more compliat a activel shortei mscle. he teo eis remai silet or earl silet whe a mscle shortes withot e velopi mch tesio bt whe the mscle cotracts aaist a loa or ixe obect or aaist the cotractio of ataoistic mscles the ischare of the teo eis is i proportio to the tesio that is evelope. hat is the afferet ipt varies with the tesio exerte b the mscle o the teo rearless of the mscle leth he ischares of the teo eis are covee to the spial cor b orsal root ibers (Fi. 1, where the excite hbory itereros that sapse with motoeros cotrolli the same mscle he effect of their ischare therefore is ihibitor tei to oppose the frther evelopmet of tesio b the
1
.
Fig Irvatio of kltal mul Motor: a alpha motouro to mai trafua m ul fibr; g gamma motouro to itrual mul br Sory T uro ovyig impu from Golgi ig i to A uro oyig impul from aulopiral (prima ig i pil F uro o yig impu from !orpray (o ary ig i pil (td fom Bz
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Fig. 2 Sory futio of th pil. A t lf, i mul at rtig lgth; tr i trth mul a t right i o tratig mul Rlati impul frquy ho i th upr rightha or of ah iagram From B
muce ha o poduce eaxaon Th que oppoe o he behavo a he eoned egmen decbed above Muse spin Muce pnde ae much moe com pex han he endon ecepo Each pnde ha wo nd of enoy end ng each wh dffeen cena cn necon and eex nfuence and a mucua componen wh own moo nnevaon Spnde ae caeed houghou each uce n numbe ha vay wh he funcon of he muce and he decacy of cono The geae he pnde den y he ne he cono Ony hoe dea of ucue and funcon ha ae eena o he pu poe of h eay w be evewed The eade efeed o ohe ouce fo fuhe dea uch a Hou and Henneman o ecen edon of ohe exboo n medca phy oogy Strctre-nction o the ce pine
ne he endon endng pnde ae whn he muce ef and u ounded by muce fbe aanged n paae wh hem and aached o hem a boh end The eena feaue ae dagammed n Fg Ceay echng he muce ao 2
eche he pnde and hoenng of he muce acen he pnde Each pnde encoed n a connec ve ue heah and abou 3 mm ong ha evea hn muce fbe They ae dened a nafua fbe o dnguh hem fom he much age and moe powefu (ex afua) fbe ha compe he bu of he muce The nafua fbe ae aached o he heah a each end. They pa hough an expanded ymph pace n he mdde of he pn de Th poon of each fbe ahe deney nuceaed and ony feeby conace f a a The nafua muce fbe ae n nevaed by gama oo fbe ognang n he vena hon and pang hough he vena oo (Fg 1 g) n cona o he apha moo neuon uppyng he exafua muce fbe (Fg a) he gamma ao nown a fumoo neuon ae ma n e and he axon que hn The mpoance of he fumoo nnevaon ndcaed by he fac ha he gamma fbe compe one hd of he vena oo oufow The enoy endng of he pnde ae n coe eaon o he equaoa (nuceaed nonconace) poon of he nafua fbe The ocaed pmay endng wound aound he be and decbed a he an nuopa endng (Fg IA) Sec
onday fowepay endng occu on ehe de of he pmay endng and ae conneced o hnne myen aed axon (Fg F) Boh ae en ve o ech of he cena poon of he pnde Sensory enings Fg 2 AC uae dagammaca y how he pmay endng epond o change n muce engh When h muce eched (Fg 2B) beyond eng engh (2A) he pnde ao eched caung he pmay and econday endng o fe a n ceaed fequence n popoon o he degee of ech Shoenng of he muce (Fg 2C whehe by own conacon o by pave ap poxmaon of aachmen ow he dchage popoonaey and may even ence Fo he pupoe of h pape dcuon w be med o he pmay endng abou whch much moe nown han abou he econday endng
t
tOne dsncon may be wrh menonng Alhough dscharg of bh yps f endngs are more or proprona o engh. he primary (annuspra) endng h he addna feare Iha 1s frequenc frng drng a srech s n prporn o he f change Tha s he econdary dng apparenly repr lengh a any mmen, bu he prmary endng repr boh velcy of srech and hence of jon mon and engh hence jon poson The prmary endng hereby provdes a predce or ancpary npu o he neu syem Th refinemen wll n howver ncuded n he dcuson
nepeaon of eeach
The spindle is an essential feedback mechanism by which the system that is controlled, in this case skeletal muscle, continually reports back to the controller the central nervous system (CNS). The feedback from the primary endings o each spindle is conveyed by orsal root iber di rectly, that is, monosynaptically, to the motoneurons of the same muscle There is consierable evience that the eedback may be even more precisely localized than that to the motoneurons controlling the muscle fibers in the immediate vicinity o the spinle This would provide or a high egree o precision ad specifc ity of reflex regulation The infuence of the aferent ischarge o the spindle on the moto neurons o the same muscle is excitatory That is, when a muscle is stretched it is reflexly stimulated by its spindles to contract, and thereby to resist stretching. Conversely, shortening of the muscle decreases the aerent ischarge, reuces the excitation o the motoneurons, thus favoring relaxation (that is, length ening) o the muscle. The inuence of the muscle spindle, thereore, is to cause the muscle to resist change in length in either irection The spindle is thus the sensory component o the familiar stretch, or myotatic, reex. It is an extremely important mechanism in the mainte nance o posture, since it causes the extensor and elevator muscles, which tend to be stretched uner gravita tional inuence, to contract against the force o gravity in a smoothly regulated manner The same mechanism operates in the misname tendon reflexes o clinical practice. The tap on the tendon momentarily stretches the muscle, exciting the spindles, which in turn excite a contractile response. Through collaterals and inter neurons spinles also inluence the activity o muscles other than those in which they are located, such as antagonists and synergists, but these infuences and the polyneuronal path ways that are involved are not essential to this discussion. Intrausa use bers
How do the intrafusal muscle fibers infuence spindle discharge? Since their ends are firmly anchored, con traction o these ibers stretches the
middle portion in which the sensory endings are situated, increasing their discharge The efect of intrafusal contraction on the endings and their response is inistinguishable from that prouced by stretch o the extrafusal fibers, and the two efects are aitive. That is, at any muscle length, intrausal contraction would increase the spindle discharge, as would an increase in muscle length stretch of the muscle while the intra fusal fibers are contracte prouces a more intense spindle discharge than when the intrafusal fibers are at rest or less contracte Gaa otoneurons
The function o the gamma neurons, in turn, is to control contraction of the intrafusal fibers, and, through them, the requency o the spindle discharge at a given muscle length, and the change in that frequency per millimeter change in length (sensitivity) The higher the gamma activity, the larger the spindle response Fig 3 shows the relation ship o afferent impulse frequency to muscle length at different levels of gamma neuron activity. Thus, the higher the gamma neuron activity, the higher the spindle ischarge at a given muscle length (vertical dashed line) and the shorter the length of muscle at which a given impulse frequency is generated (horizontal ashed line). Reaton 0 aphatogaa and etrausatontrausa
The importance o the foregoing in formation, at least or the purposes of this paper, is in relation to the regulation of the activity of skeletal muscles The key fact is that the high er the spindle discharge, the greater the reflex contraction of the muscle. What that contraction accomplishes epens on the other orces acting on the joints crossed by that muscle. ut, as a generalization, the greater the contraction, the more the muscle tens to shorten an move the joint, and the more it resists being stretched by movement of the joint in the op posite direction Under normal resting conitions, the gamma activity is apparently such as to sustain a tonic afferent ischarge from the spindle This maintains the alpha motoneurons in a moderately facilitate state a state
g Iuene f mule leng n pindle impue fequeny a dfeen leel f gamma mneun aiiy See e
o readiness and the muscles in lowgrae tonic contraction at their resting lengths Gamma activity may be turned up or down from this basal level The higher the gamma activity, because of its iuence on the excitatory spindle ischarge, the more forceul the muscles contraction and the greater its resistance to being lengthene. During high gamma activity, the spindle may, in eect, be calling for contraction when the muscle is already shorter than its resting length It may be helpful to view spindle function in relation to muscular activity in still another way Since the sensry enigs o the spindle are stimulate by mechanical distortion, whether caused by contraction of the intrausal fibers or by stretch o the main muscle (or both), the spinle in efect reports not absolute length o extrafusal fibers, but length reative to that of the intrafusal fibers The greater the disparity, however it is produced, the greater the discharge an the greater the contraction of the muscle In other words, the very small intrausal fibers, i nside the scattered spinles, seem to serve as variable standards of comparison against which the main muscle is continually measured an adusted; variations o the stanar ar under gamma control An increase in intrafusalextrausal isparity increases the aferent ischarge, which elicits a contractile response o the extrafusal fibers, which in turn tends to nullify the disparity and to silence the spindle The greater the gamma activity the more the muscle must shorten before the spinle is turned back down to tonic, resting ischarge. Thus, the CNS can elicit, and precisely control, 2
M
o
I
i
I
,
3
5 Fig. 4 Chang in spindle dichae and tendon ending dcharge (T during a brief contraction of the mcle M
RL
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L+X
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Fig Individual and combined iuences of muscle length rting length [RL and two deg of stretch), gamma neuron activity and muscle contraction on spindle dcharge
the contraction an relaation of (alphainnerate uscle through its gaaeiate control of the seeral uscle ibers in each spinle That is the gaa neurons in controling the illigra forces an icron contractions of a fe inute fibers inirectl regulate the ilogra forces an centieter contractions of assie seletal uscle. ro this iepoint it becoes clear h the gaa loop" is often iee a highgain seroechanis an the gaa neurons as the gaincontrol coponents of the sste The gamma system i ormal life
t is coenient to begin iscussion of the role o f the gaa sste in locootion an posture b escribing hat happens hen a uscle supporting a oerate loa is stiulate to contract briefl. As escribe earlier the spinle is slacene uring the shortening of the uscle an the spinle ischarge is reuce een silence. This is iagraaticall represente in ig 4 (M an S. For contrast the siultaneous change in the (inhibitor feebac fro the tenon (T reporting the tension eelope b the uscle ur ing its shortening is also shon The cobine reports fro these to sources eep the CNS continuall ap 0
prise of tensionlength that is loaotion changes When the spinle is silent the CNS is of course eprie of iportant inforation. This a not be a serious loss for a brief titch such as that inicate in ig 4 When hoeer the uscle is cale on to carr out elcontrolle otion hile it reains in a shortene state (as for exaple the biceps brachialis ith the elbo sharpl bent the n the oss of that inforation coul be a serious one an coul een be isabling. As a atter of fact there oul be a serious ipairent i te coure of shortening since spinle sensitiit to lengthchange oul progressiel ecrease as the spine slacens What eice oes the CNS hae for ensuring that the spine reains reliabl operatie throughout all length changes of the uscle? A clue is offere b ig. hich shos in a hpothetical experient spinle ischarge in seeral sets of circustances at resting length an at to egrees of stretch (X an 2X) at rest an uring a titch of the uscle an each of these ith an ithout gaa ischarge The ischarge is increase b stretch an b gaa actiit it is reuce b shortening of the uscle for hich copensation can be ae b appropriate intrafusal contraction uner gaa contro This is precisel the echanis that the CNS uses t cals for ajustie tightening an slacening of the spinle b changing the gaa ischarges to the intrafusal fibers. Eientl as a uscle shortens in response to ipulses in the alpha otoneurons paralle olles of ipulses a be ispatche through the gaa neurons to stiulate the intrafusal fibers to contract an tae up the slac as it eelops Conersel the intrafusal fibers are per itte to lengthen as the extrafusal uscle fibers relax an lengthen uner lpha irection n this a b appropriatel aring the intrafusal lengthstanar the response of the spinle to each illieter change in length an therefore the gain"of the entire echanis can be ept relatiel constant as a uscle lengthens an shortens Through the sae echanis the CNS retains the option hoeer to ary spinle sensitiit an gain in
accorance ith the ins of otion that are being calle for an in accorance ith other circustances Gaa actiit an hence gain a een be preset accoring to the ength changes that are calle for or antici pate in a gien otion Through its control of gaa actiit the CNS can set the liits the axiu lengthening that ill be acceptable an the egree of shortening at hich the spinle ou so to spea be unloae an its ischarge turne bac to basal tone This continua setting resetting an presetting of intrafusal fiberlength through the gaa neurons a be iee as autoatic gain control" of the lengthreguating echanis for each uscle Gain is continuall being ajuste in accorance ith the otions an the positions that are being olitionall an reexl calle for. For exaple hen a tennis plaer prepares to return a ball ith a fast forehan stroe the gaa actiit is turne on (lo gain thus peritting large changes in uscle length uring the preparator bacsing an the forar sing On the othr han hen the plaer is at the net an ishes iniu otion o f his racet for a short olle shot the gaa actiit oul be turne up (high gain to narro the range of ength changes that oul be refexl peritte. Siilarl ith the iolinist ho uses the full length of the bo in a legato passage an then uses but a halfinch of so for a staccato passage. Or the golfer tring for a long rie an then a short chipshot Of course gainsettings are subject to continual changes i te coure of each otion Also gain control is iniiual exercise for each participating uscle accoring to its role fro oent to oent The cerebral infuences illustrate aboe in arious oluntar actiities a hoeer also be alaaptie setting the spinle sensitiit an gain inappropriatel for regulation of uscular actiit n tension an aniet states or in situations that are (or are perceie to be threatening gaa actiit a be set too high for efficient soothl coorinate otion. n these states the uscles are tense stiff resistant to change in length The iniiual is sai to be jup" an spastic" an he nterpretation of research
e o move i a accao mae Hi eo" eee ae popo ioaey eaggeae Gaige ha igeioy how how icoec a icipaio o he mcua eo equied o eampe o i a objec may cae he gai o be e oo high wih eio a pai coeqece. Hi iuae aice oe may vaabe iigh io he oigi o back pobem a o he mechaim o hei maipuaive ameioaio The spinde and soatic dsfunction
How may hi iomaio eae o mcuokeea dibace eig ae a oeopahic eio? po poe a a hypohei ha i he eioe aea he gai" ha bee ed p i he pie o oe o moe o he mce ohe wo accoig o hi cocep he i chage o he gamma mooeuo o he eaed pia egme ae aie a high eqecie keepig he iaua ibe i a choicay hoee ae i which he ichage eqecie o he pie a i which hei equecy chage pe miimee ae eaggeae How cou hi have bee ogh abo? he cocuece o he o owig wo cicumace cou beieve iigae he higheqecy gamma iig: ) og ceay oeed coacio ig a mome 2 whe he muca aachme (o eampe o wo veebae have bee coey a abpy appoi mae by oce o aco ha have no bee ceay oee he abup appoimaio o he aach me wih eqay abp a aicipaed ackeig o he mce cou be bogh abou eihe by a eea oce o impac o by aicipae yiedig o a oa o oce oppoig a og iomeic coac io he ey ackee ae he pie wo be iece equay ey caig (o coiuig o ca o he ackee ie mce o og coacio via he apha mooeo he N eceivig o eeback wo ao geay iceae he gamma ichage o he ia a ibe i he pie eme hei epoig O ecoi (o ee ecovey o he boy om he oce moio e o he aachme (o eampe he veebae o hei eig eaiohip
wou be oppoe bu o ece aiy pevee by he ow (e ey eia muce e he iece o gaviaioa oce aagoi a poua eee which wou be edig o ech he muce back owa eig egh he pide wou be coiuay ichagig a hogh he N oeig he muce o ei he moe he ech he uch moe he eiace ho be emembee ha he moe he eiace ha i coacie eio he moe he j oi ace wou be pee ogehe a hei icioa eiace i ceae hee wou be ie vaue a hi age o eveopme o he hypoh ei i caaogig he may ki o ccumace mio accie " ad micoama o aiy ie i which hee wo aco og coacio ad ackpoce pieiece cou copie o up he pide gai he hough eae ca obe e viage o ecouc om peoa ad ciica epeiece may ch cicmace. he hypohei ha i popoe abou he oeopahic eio i pimaiy cocee wih he high pie gai Fuhe pecaio a o how i may come abou i heeoe eee ui he pimay hypohei ha pove viabe heeoe o a ew i aio o he mae i which high gai pie ucio may hep e pai a ome cioa chaac eiic o oeopahic eio ad b he eicacy o ceai maipuaive pocede hee iaio ae oee a gieie o eig he heoy i pacice
a) How he spinde ay be reaed o cerain esion characerisics
he highgai hypohei i coie wih a oe a e paaio o he eepy iig eiace o moio ( bi" i oe diecio a he equay pecipio coape o eiace (iceaig eae" i he oppoie iecio ice o eao give above he aeced mce wo eve i e ig poe be ue ome egee o ech hey wou be o he ee ie o eay ea" ha i i coia acive coacio ad papaby had a yieig hey wo ao be povoked io oge a oge coacio by he e
aggeae pie ichage a moio ha e o eghe he aece muce occ. 2 To he egee ha pie e ey eguae he coacio o muce ibe i hei immeiae viciiy he hypohei wo ao epai he opie" oe o i muce i ee aea High ei iviy o eece pie i a mce wou pouce pam i coepo igy eece acice which wou ee ike igh co i he muce. 3. ice he joi ha ae coe by he aece mce ae com pee wih hei uace ighy ap poe hey oo wo apea i" a icu o gap wod be epece ha ch joi wou be mch moe ikey o pop" whe oceuy gappe ha hoe o compee by muca oce he highgai pie may ao coibe o he cach" ha i omeime ecouee whe muce have bee cae (o pemie o hoe a beow hei aua eig egh Howeve i he makey hoeed ae he eoy a ee mechaim may be compi caed by a chage i he coacie ae oe i which he mce may have o he abiiy o ea a i coacue. 5 aiey ha ggee i e poe o hi hypohei ha aiue by he N o p he gamma i chage whe he pide ha bee ieced by make hoeig o he mce may e i oepoig pie hi he gge may ac cou o ead" egme i which mce have become makey un epoive o chage i egh b) Is spindegain rese by eecive anipuaive procedur?
ice accoig o he hypohei ha ha bee popoed ceai cioa abeaio o eJoe egme oaby impaime o mo biiy may be acibabe o gamma iuce iaua coacio i i popoe a a cooay ha ec io o gamma ichage may be a key eeme i he eoaio o mobiiy a heeoe i he eicacy o maipaive heapy Foowig ae a ew e" o hi ggeio Accoig o he hypohei moio ha i cioay oiee maipaive echic e o avo eae"ae hoe ha appoimae he aachme o he aece mce 25
redig heir ei d permiig hem hre A he mi ie i he direi ee irlerl dipri rrw. Th i he relive legh he mle e gi begi rrepd mre lel h he irl iber The hreed pidle everhele ie ire depie he leig he mi mle d he NS i grdlly ebled r dw he gmm dihrge d i r eble he mle rer e erl i reig legh ee he phii h led he pie hrgh repeii he leiig pre wih hwever w eeil dieree ir i i de i lw mi wih gele mlr re d ed here hve bee rprie" r he S he pidle h ied repr hrgh Prembl he mprei he ed i wld l be relieved b h predre 2 A vrie miplive predre ivlve r eem hve e heir implii beive he rehig he hperi mle i he leied egme. i prped h w mehim perig eiher idividll r ily i hee predre my ribe he rer he pidle mre rml gieig wih rel reli he le: i Sreh he irl iber. rel reh he mle gi i pidlemiied reie i re mehill rmied he pidle Thi wld prde brrge ere imple h high reqe eivbl igl he NS r dw he g m dihrge ii red re he mle wld re l be rmied i ed ig iee dihrge b he Glgi edig. i hgh h he ihiir ilee hi ere ip eed he gmm a well he lph mer ribig reli bh he irl d erl iber. Thee mehim wld eem pere i h mlerehig predre ig i hrgh heir ll rge mi i prigig " d i lwly pplig lwl releig ml prere rverel he lg i mle r emple he pil 2
eer The m l be impli ed i he miplive predre ivlvig highveli hrmplide re hee predre he eed mle re rehed gi heir reie b pprprie piiig he pie bere he hr i pplied (e mpied b pppig d he el he mpreed i i bre The gppig he i h prbbl dded rher ireme legh he lredy rehed mle (d ied pidle d ei he ed. Relee" m l be bied wih brpl pplied re by miiig ei he hperi mle while hey le g " prembl i repe bidig pi dle bmbrdme. 3 The me mehim (reh he irl iber d Glgi dihrge eem be perig i he miplive ehi i whi h der he phii gide he patient pplie he rreive re b ive mle ri. r emple he pie my be ired ph r pll gi ppig re pplied b he phii hi predre he pie i i ee rig he ee mle imerill he predre beig repeed prgreivel ireig legh ih eh imeri ri high ei i develped i he ed d eh ew mle legh he pidle i l rehed bh r ribig reeig pidlegi rml level. Apprely imilr rel m be bied b eliiig imeri ri he hperi mle b heir gi hi predre he phii i re iliig he piiple reiprl iervi. The ihibir ilee hi mehim lie h he ed reepr m l be epeed e he gmm well he lph mer oncding coen
prpig hi rher lrge ple r he mle pidle i he erl bi he ephi lei" 5 here i iei eldig r deremphiig he rle her er ip r rele mehim Reiprl iervi d he Glgi ed edig hve lred bee implied i i wih he pidle. Alm erily ivlved der
vri irme re imple rm vrie reepr d pi edig i d rd i rre ligme ed i i d vier; mle reepr her h he pidle m l b e ivlved hld be pied h whever heir her ilee hee my direly r idirel eie r ihibi gmm mer ivi Nr i i ieded impl h he pidle i the re ilii egme he pil rd ied wih ephi lei. O he rry i i bemig ireigl evide h he pil rd de idividll red" d repd diree repr rm hi r e reepr. The rd eem rher del wih l pattes lleively preeed i b ip rm m reprig i The pil rd eem beme gied (ilied? whe he repr rm w r mre i re liig d he per herere ielligible ( l hppe he higher eer wih direig ee i mi ie. Spidle whih gmm dihrge hve bee ireed m igil ribe mmig d grblig" he ip per The highgi pidle wld r emple lel repr he pil rd h heir mle lly i hreed red e w rehe erl i mimm legh Thi wld igi he rd h he mle verebrl hme were widel epred whe ll correcty repred b he i reepr he re lel pprimed There bvil be pprprie rele repe irreilble repr igiig h he i i imlel leed d eeded Segmel ilii" i begiig pper mre lie e egmel eri." A egme i h e i me degree dirpive ever l ivi per i whih i priipe. eive mipli i h whih rere i rd i rig" wih i eighbr Mei hld be mde r h wld ribe sustain ing he eggered pidle dihrge i mle he leied egme. Oe ere mi di erprei reerh
that ha eceve empha ecet ea a a eult o eeach the Kvlle laboatoe local m pathetc hpeactvt (ummae b Ko a Ko Buell a H) Oe o the eect o mpathetc hpeactvt ceae a eet chae om the ple Ioa ple put luece mpathetc pealoc euo the pal co a eluta vcou ccle ma be evae he hpothe a ol that the "leoe emet behaves a thouh amma motoeuo actvt ("a) that emet ha bee tue up I peet th hpothe I hope whethe o ot t tu out to be val that t tmulate tet a qu clcal pactce a the laboato lea to ew ht oue theo a moe ecacou pactce.
Rrncs I Korr, IM. Propriocpto and the behavior of lesioned segments. Oteopathic Annal 2 1 2-32 Aug 74
2 Denslow J S An analysi of the vaiability of spinal reex threholds J NeurophyioI 720 7-1 5 u l 44 3 Denslow J S An aalysis of the irritabili ty of spinal reex arcs JAOA44 35 7·62, Apr 45 4 Denslow J.S Korr, IM, and Krems AD: Quantitatie studies o f chronic facilitation i n human motoneuron pools Amer J Physiol 1 5 0:22938 Aug 47. 5. Korr IM The eural basi of the osteopathi lesio JAOA4 7 1 91 8 Dec 47 6 Korr IM Thomas, PE ad Wright HM Sympoium on the functional implications of egmen ta l facilitation JAOA 54 26582 J an 55 7 Korr, IM. Buzell KA and Hi E Sym· posium on the physiological bais of osteopathic medicine W Norhup Mo deator Postgrad uate Institute of Ostopathic Medicine and Surgery New York 1 970 8 Denslow, J S: Neural basi of t he somatic com ponent in heal th and disease and its cli nical manage· ment AOA 72 1495 6 Oc 2 9. Pattrson M M : Spin al resposes Stati c or dynamic? JAOA 72 15 6·63 , ct 2 1 0 Korr, IM The trophic functions of neres and their mechanisms JAOA 72:1 6371 , Oct 72 Korr, I.M Andrew aylor Still memorial lec t ure Research and practive a century later. JAOA 73 362·70 Jan 74 1 2 Hoover, HV. : A hopeful road ahead for oathy. Prt I and I JAOA 6248598 Fb 63 Part III JAOA 628 1 6 Mar 63. 13. Bowle CH. A funcional orientation for
T z S iy v (176) he pupoe o th atcle to e t a to chaactee bel the wa whch the pal co ma cotbute to lle thouh the luece t eet o the tue a oa o the bo Subequet a tcle wll eame each o thee wa a the uel mecham wth appopate ocumetato om the eeach lteatue he cocept o the pal co a a oae o eae pocee bae o two welletablhe peme (1) he pal co a hhl comple oae o omal aaptve actvt a ( all eae whateve t atue a whateve the ole o the co the hhl oa e epoe o aaptato o the total oam to tub acto a aou t I the peece o tub acto the pal co a t pepheal eteo cotue to behave acco to the atue otuatel the epoe that ae theeb oae ue thee c
cumtace ae equetl malaap tve a eleteou t appopate theeoe to be wth a umma o the wa whch the pal co ucto a oae o omal aaptve actvt Beoe the pocee to cuo o pathoec co ucto t ecea to eame the mea o pal co "emet (ot to be coue wth vetebal emet) omal a clcal tuato Spn cr Inmn n cmmn cn
he pal co the o o mot o the evato o the bo It that poto o the cetal evou tem whee b a mot o the eve oate ee eve tue a oa o the bo eceve ome o evato om the pal co he pal co the te o e t va the oal oot o mot o the "omato about the bo tel t the co that mpule
technic Academy of Applid Ostopathy Year Bok Part I 1 7791 1 955; Part II 1 0714, 1 96; Par III 538, 1 957. 14 Jo hnston, WL Manipulative pecfics JAOA 615359, Mar 62 15 Johnton, WL: Manipulative skill JAOA 66:389407 Dec 1 6 Johnston, WL Segmental behavior durig motion: I A palpatory tudy of somatice relation JAOA 7235261 , Dec 72 II Somatic dysfunction the clinical distortion JAOA 7236173 D 72 1 Extending ehaiora l boundaries JAOA 72462·75, Jan 73 1 7 Houk and Hennema E eedback control of muscle Intr odu ctory concepts In Med ical phyiology Edited by Mountcastle Ed 13 CV Mosby St Louis, 1 974 1 8 Henneman E Peripheral mechanisms involvd in the ontrol of mucle In Md ical physiology Edited by V Mountcatle Ed 1 3 CV_ Mosby, St Louis 1 974. 1 9 rainger H.: Basic meh anism of t he com� mon " crick THE DO. 928, Ju 69 Bailey, H.W: Peronal commuicatio 2 1 Bowle, C.H Peonal ommunication 22 Koizumi K and Brooks, C The autonomc nerous ystem and it role in ontrolling visceal ac· tivitie. In Medical physiology. Edited y V Mount astle. Ed 13 CV Mosy St Louis 1 974, p
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Reprinted by pe rmission from AOA 74: 638-650 1 975
om mot o the tue o the bo eceve the t cee at aa a out o tam o elewhee clu the ba the te o o o the "al commo path the pal co alo the al comma cete Oe that ae ue cocul o ucocoul the hhe cete o mot o the moto actvt o the bo ae ue to the pal co whch ecoe them o to pea a the compoe a patche the ac tual oe to the mucle evate b motoeuo a to othe tue a oa evate b the autoomc evou tem he latte clue bloo veel vcea weat la et cetea evate b the mpathetc evou tem whch ha t ete o the pal co a well a thoe vceal tuctue that eceve the evato om the acal poto o the paam pathetc vo o the autoomc evou tem o the momet ou coce wll be wth the actvt o the eletal muculatue a ee theeoe the pal co the eboa o whch the ba pla whe t call o actvt o o chae actvt But each e the coole ou ot a 07
indiidual one uch a he con racion o a paricular group o mu cle iber bu a whole melody" o aciiy een a ymphony" o mo ion n oher word buil ino he cord i a large reeroire o pattes o aciiy each inoling he com plex harmoniou delicaely balanced orcheraion o he conracion and relaxaion o many mucle The brain hi nk" in erm o whole mo ion no indiidual mucle call eleciely or he preprogrammed paern in he cord and brainem modiying hem in counle way and combining hem in an ininie ariey o ill more complex pa ern ach aciiy i alo ubjec o urher modulaion reinemen and adjumen by he aeren eedback coninually reaming in rom he paricipaing mucle endon and join Spinl cord s rophic cener
eore urher examining he mean ing o paern" (which o coure are baed on conrolled impule ra ic) i i imporan o emphaize ha impule (and he neuroranmier releaed a neuroeecor juncion) are no he ole mean by which pinal neuron inuence inneraed iue mpule are he mean by which momenomomen aciiy i regulaed hrough exciaion and in hibiion n addiion here are he longerm inluence on he ruc ural uncional chemical and meabolic properie which are ub umed under rophic uncion o nere" or ome iue mo noably riaed mucle neurorophic uppor i een eenial or urial The rophic uncion appear o be relaed o he deliery o neuronally ynheized macromolecule raher han o he conducion o impule may be aumed howeer ha he rophic condiioning o ariou mucle and oher iue i relaed o he uncional role o hoe iue ha i he par hey play in he ariou cordorganized aciiy pa ern Since he oerwhelming ma joriy o peripheral neuron and nere are cordderied and cord conneced he pinal cord may be aid o be reponible hrough i organizaion or paerning rophic influence al o
208
Spinl perns
The paern o aciiy o which hae reerred are eenially euialen o he amiliar named moor reexe uch a he (ip ilaeral) lexor relex croed exenor reflex rech reex e ceera The relexe howeer are commonly iewed a he relaiely ereoyped repone each baed on an anaomically deinable arc o peciic imuli Thee imuli which are uually ariicial in conradiinc ion o hoe encounered in daily lie are experimenally or diagnoically applied o eleced area or ruc ure or example elecrical imula ion o an aeren nere or area o kin a endon ap a pinprick preer o iew hee reee no a ereoyped mechanim eer ready o be prung ino acion rom ap propriae puhbuon bu a he phyiologi way o demonraing he builin highly pastic paern o moion ha are aailable o be com bined and ynheized ino oal ac iiie uch a walking dancing wimming Thee modiiable aem blable highly organized relex module" colleciely compoe he maie auomaic reflex ubrae on which he conciouly deigned oliional acion are baed The oliional par o eery aciiy i he mall conpicuou ip o a maie largely ubconciou and iniible iceberg Tha relex ma which rom momen o momen auomaically adju he mucular orce around each join he par o he body o each oher and o he body a a whole and o he body o he orce o graiy e ceera reliee he corex o reponibiliy or aenion o hee counle deail and enable i o concenrae on he objecie deign and execuion o he learned killed oliional com ponen o each moion The reexe buil ino he pinal cord and brainem are he large porion o he iceberg A ha already been menioned he pinal relexe decribed a plaic" are ubjec o coninual modulaion and adjumen in orce elociy ampliude rajecory inal coniguraion and o orh ar o he modiying inluence o coure are coneyed oer decending pah way rom he higher cener uch a he moor corex and eibular
nuclei Much o he adjumen and reinemen are due howeer o he ceaele eedback coneyed o he cord hrough he doral roo rom he paricipaing and aeced par o he muculokeleal yem Unlike he experimenal iuaion in which a nere or i ending are imulaed hee egmenal enory pahway are no ordinarily reponible or ini tiating moor aciiy ha i or eliciing relexe bu or regulaing hem according o oliional demand he oal moion in proce and he circumance in he inoled mucle join ligamen and en don Our concern unil now ha been wih mucle and moor aciiy bu i i imporan o recall ha he pinal cord i he ie o origin alo o he ympaheic nerou yem (SNS) Thi anaomic inimacy beween he ympaheic diiion o he auo nomic nerou yem and he omaic nerou yem i mo ap propriae ince i i one o he main uncion o he SNS coninually o une iceral meabolic and cir culaory aciiy o he rapidly chang ing requiremen o he keleal muculaure ery moor aciiy organized ia he omaic inneraion originaing in he pinal cord alo in ole he imulaneou coordinaed aciiy o he SNS and he iue and procee regulaed by i Spinal paern" hereore mu be iewe no merely a moor reflex paern bu a omaoympaheic paern n order or he SNS o mee i upporie reponibiliie" o he muculokeleal yem i mu be coninually appried o he aciiie and reuiremen o ha yem Hence omaoauonomic inegraion i poible only wih imulaneou a eren inpu boh o he mooneuron and o he ympaheic preganglionic neuron in he cord rom he higher cener ia decending pahway and rom counle muculokeleal reporing aion ia he doral roo he quesion of seens
i eiden ha he execuion o een a ery imple moion uch a he lex ion o he elbow inole immenely complex delicaely conrolled and rapidly changing impule raffic in houand o mooneuron (and ym paheic neuron) inneraing no on nerpreaion o reearch
ly the mucle travering the elbow oint, but thoe arranging and fixing the houlder and writ Imule freuency in each axon i continually aduted, by reynatic neuron ac cording to the contribution that the mucle fiber that it innervate are to make at a given moment he com lexity related to the elbow oint alone i immene that related to the ret of the extremity i even much more o If one add to thi that maive ortion of the iceberg con cerned with adutment of the oture of the ret of the body in accordance with the motion of the arm and with autonomic uort for exam e for aroriate ditribution of blood ow the comlexity i almot beyond imagining In the execution of a given motion and it autonomic uort, what are the criteria according to which efferent neuron are called into lay from moment to moment? he neuron are brought into action according to what effector (for exam le which mucle or grou of arteriole) lie at the eriheral end and not according to egmental level Indeed, the articiating neuron may be ditributed throughout the inal cord he correonding enory in ut are alo widely and nonegmentally dioed In other word the neuronal bai for even a imle refex attern, uch a a exor reflex, ha a vertical (multiegmental) ditribution rather than the horizontal (uniegmental) arrangement imlied by the uual rere entation of a reex arc" Indeed, it can be afely aid that no total motion i carried out through a ingle inal egment fferent neuron that are collectively involved in a given motion are collaborator not becaue they are neighbor in fact, they may be widely cattered but becaue cofunction of their effectors i reuired Hence, egmental relation (functional coordination of organ and tiue innervated from the ame egment) are not the bai for normal function and behavior, imortant a they may be in clinical ituation he articiation of individual egment i not aarent in total attern of activity In cordorganized attern the anonymity of individual egment i imilar to that of in dividual row in a column of well
\
drilled marching men: All that one ee i the flow of motion in the total arade ut let one of the row be diarrayed by mite of one or two of the marcher and that row i im mediately conicuou What i more, a row in front and behind eek to comenate, the entire arade i oon in diarray So it i with the inal attern Segment are in evidence only in dyfunction they are out of te" with the ret of the arade " A egment in view i a eg ment in trouble, a are all the attern in which it articiate Where, then, i the egmentation? What are the egment imlied by egmental relationhi" egmen tal nervou ytem" egental athway?" Segmentation i certainly not inherent in the inal cord itelf, in which egmented tructure i no more evident than egmented function he egmentation aear to be en tirely in the tringing of line" of communication between the cord and the erihery Segmentation i the bunching of nerve fiber into the comact cable" that we identify a the inal root and inal nerve ex tending bilaterally from C to S It i they that are egmentally arrayed and not the inal cord to which and from which they tranmit imule o what i the egmental arrange ment of the root and nerve related? he egmental grouing of nerve fiber wa not, aarently in evolutionary adatation to ome func tional demand Segmentation eem to have been imoed in the coure of evolution by the egmented truc ture of the bony armor that sur roun the inal cord, but it i not in the cord hat i it i the egmented inal column, rather than the cord, that dictate the egmental arrange ment of eriheral nerve fiber: he axon are bunched and comacted for aage through more or le regularly aced hole in the armor the intervertebral foramina he comacting of a articular grou of axon (emerging in rootlet from the cord) into a articular cable" i urely a matter of location without regard to the attern in which thoe axon normally cofunction In hort, neuron are, a reviouly tated, recruited according to what they innervate and what activity i be ing called for, and no according to
which intervertebral foramen they a through It i for thee reaon that egmental relationhi having no bai in normal neurohyiology, are irrelevant to normal behavior rominent though they may be in clinical ractice Segent in iew
efore we examine how egment, normally anonymou and inviible are made to coe into view in clinical ituation let u review the manner in which they are in view clinicaly Segmental relationhi erha are mot familiarly evident in the henomenon of referred ain Pain ariing in a viceral organ due, for examle to chemical irritation am or ditention often i felt in tead (or alo) in omatic tructure that receive their innervation from the ame egment a the vicu he ain i aid to be referred to correonding dermatome myotome and clerotome which make u the reference zone " he reference zone may be uite remote from the ite of intigation, a when an organ or tiue ha migrated in the coure of embryonic develoment taking it innervation with it (for examle, the diahragm) oo often overlooked i the fact that the henomenon of referred ain i not olely if at all a matter of faulty ercetion or enory lo calization by the atient Obecive athohyiologic change can be found in the reference zone for ex amle, vaomotor and udomotor ac tivity, mucle am Over a eriod of time thee may lead to chronic organic" change in the affected tiue At variou tage the tiue in the reference zone may become econdary ource of afferent bom bardment with the etablihment of elfutaining viciou circle of im ule and reflexe A hown many year ago reference i not olely from vicu to oma Pain in a mucle bone or oint may be referred to other egmentally related omatic truc ture, alo with accomanying obec tive change in the reference one Much of the ractice of oteoathic medicine, of coure i baed on egmental relationhi imilar, and oibly identical to thoe ex emlified by referred ain and aociated henomena By alatory
ad ohe mea he oeopahi phyiia dee ad evalae he pahophyiologi hage i he omai ie egmeally elaed o diodeed i The palpaoy fidig may eve oibe baially o he diagoi of ieal pahologi dibae The oeopahi phyiia eogie howee ha egmeal elaiohip ae woway uu elaiohip; ha he omai hage i he efeee oe (whehe o o pai i pee) o oly re pahologi poee i he vieal e b alo in uene hem ally favoably eopahi maiplaive heapy i deiged o exe favoable iee o hi exhage poibly by ileig o ohewie aleig he affee imple affi omig fom he omai ompoe o ha he iio ile" a ome o a hal ad pemi healig poee o opeae de moe favoable imae. The oeopahi phyiia eogie alo ha e pead of pahophyiologi iflee alog egmeal pahway may begin wih omai dyfio ad ivolve aoomi a well a omai pahway wih oeee o ieal ad omai ie ad fio Maiplaive heapy i dieed owad amelioaio of omai dyfio egadle of whehe i i pimay o eoday wih he expeaio ha hi will beefi e o he ame egmeal ii The widely aeped oep of egmeal failiaio a i elae o omai dyf io peme oly ha hogh ome iee ha eleively affe a gie egme o gop of egme ad ha i pobably oveyed ove hei doal oo eo loaed i ha poio of he pial od ae maiaied i a hypeexiable ae podig eoy moo ad aoomi maifeaio. The ppoe i hi eio ha o bee o examie egmeal elaiohip i deail b oly o haaeie hem by illaio o oa liial ad omal imae ffiiely. Th a le i he dodem may hogh pai affee yapig i he od povoke ilaoy dibae exeive weaig paapial ad ab
domial mla oaio pai ad edee i joi mle ad aea of ki ha li ke he dodem ae ieaed fom midhoai egme. Coeely omai dyfio i hee egme may hogh egmeal pahway iolvig he plahi oflow pode fioal hage i he dodem ha pedipoe i o aodigeio I omal life howeve hee i o meaigfl dialoge" bewee he dodem ad egmeally elaed ie o oga a lea oe ha i eeial o hei fioal eglaio o iegaio hei fio beig ie idepede of eah ohe. The midhoai paaeebal mlae fo example make o oibio o dodeal fio j a he dodem i o iolved i loomoio o maieae of poe. Thee i o eao i omal fe heefoe fo hem o ommiae wih eah ohe · eve hogh boh dodem ad mlae ae o o peak hooked p o he ame poio of he pial od hogh a haed able" paig hogh a paila hole i he boy amo Howeve hold eihe he dodem (o oie he illaio) o he egmeally elaed poio of he veebal olm beome fiely ad appopiaely ijed he aiviie ad poblem of oe oo beome he bie of he ohe hogh a ewly eablihed pay lie" ha povoke boh io oial iappopiae oadapive deleeio epoe. The dipive eagleme ha ae h eaed by egmeal failiaio ae deleeio o oly o he ieded pae b alo o he oal pae i whih hey paiipae hee o he oal peo I effe a egme ha goe o of ep meig p he eie paade The eio befoe ow i how do egme ge o of ep How gnt co into iw
How do ie ad oga ha odiaily hae lile die fioal ieaio o iedepedee h a he dodem ad midhoai demaome ad myoome beome eagled wih ad dibed by eah ohe hogh he eve ad od level ha hey hae I eekig o ideify he mehaim I hall o
oide h fao a die ama o he pial od ielf The mo ommo dibig fao eem o fall io wo mai aegoie ( ) dibae i affee ip; ad (2) phyiohemial dibae i eoal exiaio ad odio. ah of hee will be deibed biefly. A will be ee he eod aegoy oibe o he fi. I may alo o de imae ha ide he fi. I ohe wod hogh diffee i mehaim hey may be pee ogehe ad idiigihable i hei impa Dibed affee ip a Fom he mlokeleal yem A peioly meioed eam of imple oially ee he od via he doal oo fom peialied eepo (popioepo) i mle joi edo ad ligame. They ae i effe ade whih oe hage i hape (maily legh) of he e i whih hey ae iaed o i he foe (eio pee) aig po hem io aiaio i imple feey i he eoy be ha ed i hem. Thee affee fibe have eal oeio ha ae appopiae o hei peipheal edig Colleively hee edig ae he oe of ifomaio abo imae i he peiphey oially fed bak io he eal eo yem Alhogh a ha bee aid he eepo ae eah epoive maily o hage i foe o hape of he ie i whih hey ae embedded he vaiey of hei eiiviie epoe ad loaio (fo example a Rfi edig i a peifi poio of a paila joi aple a pidle i a paila faile of mle fibe a Golgi edig i a paila poio of a edo) ad he vaiey of hei eal oeio ae h ha olleiely hey epo o he dieio eloiy ad amplide of moio of eah pa ad o poiio load eiae e eea Thi oio feedbak bje o apid hage i aodae wih aiviy ad poe i oially ed by he CS o adj effee dihage (moo ad aoomi) i aodae wih he aiviy alled fo ad wih he imae i he paiipaig ad affeed pa of he body Alhogh he pial od i apable of makig diee epoe Iepeaio of eeah
to experimental stimulation o this or that proprioceptor, it ordinarily does not read" individual reports rom the innumerable reporting stations Rather, it seems to watch the chang ing patterns o their collective reports. These patterns present to the cord a continual motion picture o what is going on out there," which it utilizes in ormulating its com mands to all the tissues out there." As has already been emphasized, this patterned eedback reaches the cor via the dorsal roots along the en tire length o the spinal cord. The central inluence o a given volley o impulses in a given sensory iber is determine by its central connections (which postsynaptic neurons?) an the reuency o the impulses, and not by the oramen and root through which it reaches the cord. When, whatever the reason, there is a isturbance in the movement o a particular intervertebral, costo vertebral, or other joint, involving such unctional disturbances as muscle spasm (an hence persistent changes in length and tension), tor sion or other deormation o the cap sule, or persistent asymmetric ligamentous tension, then the a ected proprioceptors will re eually persistent and iscordant barrages o impulses These enter the cord via the one or two dorsal roots in which the corresponding sensory ibers lie. In other words, instead o con tributing to the luctuating hum" o eedback on which the cord relies or reinement and ajustment o its motor autonomic patterns, they transmit a steady roar" into the cord over those selected roots. That portion o the cord becomes dominated by thi s noisy input, and i n that portion o the cord the picture" o the periphery which the NS steadily watches is garble an distorted by the high noisetosignal ratio Reports rom the various pro prioceptors may be so conlicting that the cor is presented with pictures" o impossible situations Its responses to such unintelligible reporting can not possibly be adaptive, any more th nausea and vomiting can be said to be adaptive to the conused sen sory reporting in motion sickness and vertigo The central excitatory state at the corresponding level (and side) o the cord is exaggerated, leading to the
establishment o an irritable ocus," describe in recent years in terms o acilitated segments In the portions o the cor that are receiving the noisy, garbled input, all kinds o neurons become susceptible to acilitation," making exaggerated responses to incoming impulses rom any source. Unintended partners, such as the duodenum and spinal muscles, in themselves on the same party line, and responding together and to each other in ways that make no unctional sense. These portions o the cord thereore, can not participate appropriately in the vertical patterns in which they are or dinarily involved, resulting in aulty, disarrayed patterns. I the ring o pain endings is added to this segmented inpu, then the roaring" input and the domina tion o the aecte portion o the cor is even more severe and the noisetosignal ratio even higher How much the disruptive inluence o activity o pain ibers on spinal pat terns is ascribable to imbalance be tween smalliber and largeiber activity and how much to other ac tors, such as subjective responses, has yet to be etermined. b From the viscera Similarly roaring," segmentally dominating inputs may develop as a reult o visceral disturbances that activate pain endings. Visceral pain bers are mainly associated with sympathetic nerves (or example the splanchnic), traversing the ganglia without synapse and entering the cord through the orsal roots alng with somatic sensory ibers The acilita tion thus produced extens to the neurons supplying the somatic struc tures, producing muscular spasm, vasomotor and sudomotor changes, reerred" pain an tenerness There is apparently no undamental dierence in mechanism or response whether the disturbing input arises in viscera or in somatic structures oth are disruptive to spinal patterns, and each soon invokes into the istur bance other structures, the inner vation o which courses n the same spinal roots an enters through the same oramina 2 hysicochemical isturbances o excitation and conduction a. The kinds and origins o in sults to nerves and neurons The con cern in this section is with the eects
o various types o direct bio mechanical insult to nerves, axons, an nerve cells, and o the secondary metabolic disturbances. These insults have a high incidence in man because o the compressive orces associated with the upright stance, and because o some o the motor an postural demands o various occupations, athletic activities, habitual postural aults, muscular tensions et cetera. ut nerves, in general, are vulnerable to deormation, with structural and unctional conseuences, along their entire length, especially where they pass over bone, through bony canals, across tissue interaces, and so orth. As a result, nerves may be subject to stretch, constriction, compression, torsion, angulation, and ischemia. I man, the spinal roots, spinal nerves, and the primary divisions are especially vulnerable not only because o the hazards associate with the in tervertebral oramina, but because o the hazars associated with structures on which segmentation has also been imposed by the spinal column, name ly, the meninges (dural pouches, root sleeves) and blood essels (spinal and radicular arteries and veins). Detailed examination o the speciic kinds o mechanical hazards common to each structure is not ap propriate to this preliminary article. One need only mention such actors as the ollowing compression by nar wing o the oramen; ahesions between roots and sleeves, causing angulation, shearing and constric tion shearing orces acting upon nerves passing through ascia com pression (or example, o posterior rami o spinal nerves) by sustained contraction o the paravertebral muscles through which the nerves pass constriction at duro arachnoi junctions o root pouches compres sion within oramina secondary to venous congestion (compression o spinal an radicular veins) Hypoxia, pH shits, and other chemical changes in the nvironments o the nerves due to ischemia (compression o spinal arteries, sustained contrac tion o muscles through which nerves pass, et cetera) are also important actors in the alteration o axonal ex citation a nd conduction Separate consideration must be given to the paravertebral sym pathetic ganglia The cervical ganglia are subject to reuent micro trauma 2
beause of hei oaion in a highy obie pa of he body and hei poiiy o powefu uses. he hoai and uba gangia ae vuneabe beause of ei ose eaion o bony suues (veebae ibs) and opession by and possiby adhesion o paiea peua o peioneu. Copession as has been deonsaed ay bok yphai dainage of pas of he gangioni hain wih sevee edea and sweing of he affeed gangia. he gangia of ouse onain he e bodies of posgangioni neuons ha inevae vaious vasua gandua and visea suues. b. he hanges in neuona funion esuing fo die insu. In onsideing he effes of defoa ion of usuoskeea oigin on neves and neve e bodies i is ipoan o ephasize ha ou onen is no wih aasophi siua ions in whih whoe neves o oos ae ushed o even in whih ondu ion has been boked in a o os of he aons. In he eee ase of ouse invoving whoesae ineupion of axopasi oninuiy hee woud be a oa oss of neua fun ion wih waeian degeneaion disa o he insu. In he oe odeae siuaion of onduion bok in soe of he bes in a neve hee woud be oesponding oss of sensoy and oo funion whih igh be ansien o fuuaing In suh ases he sensoy o oo defiis woud no even be peepibe. Howeve sine soe ypes of fibes ae oe susepibe o defoaion bok han ohes gabed sensoy inpu and inopee and unoodinaed effeen oupu ay be he iniay oe signifian onse quenes. he pedoinan onsequene of he oe oon and oe sube defoing foes whih wee he sube of he foegoing seion is quie diffeen. hey ause no he oss of eiabiiy bu on he onay hypeeiabiiy and he hypeiiabiiy syndoes ha i engendes. The hypeeiabiiy o aized a he sies of defoaion is anifesed in sevea ways whih have been sudied in neves and oos duing sugia eposue and whih an be siuaed epeienay. In eviewing hese anifesaions i is ipoan o eebe ha odi
naiy neve ipuses ae aunhed a he en of neve bes a he ena o eua ends in effeen fibes and a he peiphea ends in sensoy fibes and ha ipuses pass in ony one dieion eihe owad he CNS o owad he peiphey. he foowing ae he anifesaions of hypeiiabiiy a sies of defoaion 1 Ipuses ae geneaed a he de foaion sie fo eape a a onsiion o anguaion o a he edge of a onge opessed aea and hey ae popagaed in boh dieions hese of ouse ae supe nueay ipuses supeiposed on hose being geneaed in he usua way enay o a he peiphea ending. 2 ains of ipuses ae iggeed by noa ipuses as hey pass hough he defoed ous. Eah noay geneaed ipuse heefoe has a gossy apified and poonged effe enay o peipheay Cossak beween bes ay ake pae. Unde noa i usanes eah fbe is in effe a pivae ine effeivey insuaed fo is neighbos in he neve o oo and ony endoend (synapi) ansission ous A he hypei iabe foi howeve he sa eeia fieds ha aopany eah ipuse as i oves aong a fibe ay be suffiien o igge ipuses in neighboing fibes. This aea sideoside (ephapi) ansission is usuay fo age bes o sa bes. 4 ain and possiby ohe endings in he epineuiu ay be addiiona soues of ipuses povoked by soe ypes of defoaion espeiay sehing o sweing of neves. They ay be esponsibe fo he pain and endeness aong he ouse of a neve in soe peiphea neuopahies. Ces in he paaveeba sy pahei gangia whih ae odinaiy eied ony by pesynapi ipuses deiveed by pegangioni fbes fe sponaneousy unde ondiions of gangioni defoaion edea o ohe seonday hanges in hei envionen 6 A signifian degee o f naow ing of aons by onsiion o opession is known o ipede he aona anspo of neve e yo pas. Consideabe sweing due o
he daing of aopas ous poia o he obsuion whie disay he aon beoes quie aenuaed. Sine vaious poeins and ohe ope subsanes in a given aon ae anspoed a wo o oe aes vaying fo appoiaey 1 . pe day o appoiaey pe day and by diffeen ehaniss hanges in oposiion of he aon disa o he obsuion and in he iue of subsanes eahing he einas ae aos eain. If aenuaion supasses a iia degee aopasi oninuiy is ineuped and he disa aon undegoes wae ian degeneaion. Te beair "egmen in iew
How do he disubanes in affeen inpu and in neuona eiaion and onduion ae he funion of he affeed segens? Sine disubed eiaion and onduion ineviaby disub affeen inpu i is no possibe o eaine hei espeive ipas on od funion eniey sepaaey. Ony he fis fou ies in he foowing sape of ipas ae siy eaed o abean nuona eiaion and onduion he ohes epesen insepaaby o bined ipas. 1 Eopi ipuses in affeen fbes aising as hey do soewhee aong he aons ahe han a he endings pesen fase sensoy info aion o he od siuaions ha have no basis in he peiphea issues in whih he affeed bes end. The oa affeen inpu paen hee foe is deepivey inensified ibaaned gabed. If he neve defoaion has siuaneousy podued onduion bok in age fas yeinaed fibes (whih onvey signas fo skin eepos and popioepos) ausing safibe doinane hen he sensoy haos in ha pa of he od woud be even wose. Ony nonsensia esponses an be ade o nonsensia infoaion and a oabody paens in whih he dysfuniona segens paiipae woud be in disaay o soe een 2 Siiay eopi ipuses in effeen fibes ae eaningess o ands whih ja he ea enay issued oands onve he o gibbeish and esu in unoo dinaed oo and auonoi esponses. Inepeaion of eseah
3 Sie der oditios i whih ross�tak ors the diretio o atera trasmissio is rom are ibers to sma ibers exessie atii ty is prooked i the pai ibers ad i sympatheti ibers Uder these irmstaes the passi o im� pses i are A bers sh as those mediati toh or proprioeptio or those ierati skeeta mse may be expeted to prode pai that has o basis i the periphery aom paied or ot by paresthesia o arios kids t may aso prode ia the sympatheti ieratio sh maiestatios as asoostritio sweati isera atiity or isera ihibitio that was ot etray ordered t is possibe thoh ot estab ished that amo the sma ibers itimized by rosstak are the am ma ibers otroi the sesitiity o the mse spide The eet wod bexaerated tesio i the aeted mses ad resistae to haes i eth 4 Sie impses that arise e topiay somewhere ao the eth o the axo are propaated i both diretios ortho ad atidromi ay we eed aso to osider the e es o the aidromi or wroway impses Those i motor ibers o reahi the e bodies i the etra hor are kow to ater the exitabi ity o those eros i the ihibito! dirtio The eet o orse wod be to ose the motor atiity i whih those eros partiipate A simiar iee thoh ot ye demostrated may aso be expeted i sympathei eros Atidromi impses i sesory ibers hae bee show to prode prood asodiatio ad hyperemia at east i ski somewhat i the maer o a axo reex" 5 The haos i aeret ipt ad eeret otpt ases the aeted semets ad the oras tisses pro esses ad atiities that they otro to be ot o step with disrptio o the ertiay oraized atiity patters i whih they partiipate 6 Somatosympatheti iteratio so essetia to msoskeeta tio wod aso be disrpted 7 As has bee show or semeta somati dystio the assoiated aiitatio or reasos preseted aboe exteds to the sympatheti otow The eets o the sym
patheti hyperatiity deped o whih o the ibers are ioed that is o what es tisses ad oras are itimized by the exaerated sympatheti bombardmet ah ora or tisse respods aordi to its ow iheret atre. The iia impat the sydromes that may be proded ie siiet time ad other otribtory ators i the per so's ie deped thereore o the semeta ee sie that determies whih oras ad tisses may be i the ie o ire Frther examiatio o this most importat aspet o semeta dys tio is ar beyod the sope o this artie bt it is importat to poit ot that there is a siiiat sympatheti ompoet i may possiby most sydromes ad diseases Therapy direted at sie i or redi impse trai i the aeted sympatheti pathways is ote ameioratie Frthermore may o the most serios maiesta tios o sstaied sympatheti hyper atiity aside rom the asospasti ishemia so ote preset are so dierse as ot to be expaiabe by oetioa iews o the sympathet i eros system that is soey i terms o atered otratie (smooth ad ardia mse ad seretory a tiity The sympatheti otow exerts iees o may other kids o es ad ear proesses whih i sstaied sympatheti hyperatiity beome pathooi ad aberrat The atre o the haes aris with the tisse ad ora i qestio The sympatheti impses merey modiy the inheren ear tios ad proesses other words the diersi ty o iia maiestatios o oa or semeta sympatheti hyperatii ty is i the diersity o the es tisses ad oras ierated by the sympatheti eros system This aspet o semeta dys tio wi be the sbjet o aother ar tie 8 Sie at east seera oras ad tisses somati ad isera ier ated rom a ie semet or rop o semets may be aeted by semeta dystio eah be omes i tr a sore o aeret bombardmet ah thereore o tribtes to the estabishmet ad maiteae o a iios ire o im pses ad eah is itimized by the others ipts
9 Fiay the eets o somati i st o eres ad ere es are ot oy o exitatio ad odtio. To the extet that deormatio o ax os impedes axoa trasport the trophi iee o those eros may be proody impaired. Aso to the extet that drii a ero to sstaied hyperatiity aters its metaboism it may be expeted that the sythesis o proteis ad other maromoees that are axoay trasported may aso be atered with trophi oseqees to the ier ated es ad tisses Reence epc npue ep
O the basis o the oreoi ior matio ad perspeties osteopathi maipatie therapy appears em piriay to be desied ( 1) to orret or ameiorate the biomehaia i sts to eres ad ere es that ead to distrbaes i exitatio odtio ad trophi tio; 2 to ater the proprioeptie ad other dishares rom somati tisses i sh a maer as to restore baaed iteiibe reiabe patters o se sory eedbak to the spia ord; ad 3) to sote or siee the somati i pt to the iios ires iitiate esewhere ths otribti to arrest or retardatio o impse trai i the irar party ies. To a are extet it may be said that mh o the basis or the osteo pathi emphasis o the spia om ies i the semetatio that i dystio the spia om im poses o the tio o the spia ord o the patters that the spia ord oraizes ad o the era strtres throh whih it expresses that oraizatio No other system o therapy appears to address itse ade qatey to the roe o the spia ord as oraizer o disease proesses Rpre ero ro JO 76 4, 1976
3
The spina cord as oganizer of disease processes: The periphera autonomic nerous sysem (979) The first article in this series presened some preliminary perspec tives about the spinal cords role in organizing disease processes. Refer ence was made o hyperacivity of he sympahetic innervaion of various issues and organs as a common feature in many syndromes Evidence for the origin of sympathetic hyperactivity in somatic dysfunction was also briefly summarized Since the sympathetic nervous system (SNS) has its enire origin within the spinal cord review of this aspect of pathophysiology seemed ap propriae for the second aricle in the series However i has been my ex perience tha undersanding in this area is often impaired by he archaic and obfuscating myhs and miscon ceptions tha prevail about the auto nomic nervous system (ANS). A pref atory review of fundamentals there fore seemed desirable and that is the purpose of this article In his review I shall not be con cerned with anatomic physiologic and pharmacologic details hose be ing abundanly available in many texbooks and monographs Rather my concern is wih basic design functional organization and general role in he oal boy economy perspecives tha are ofen obscured by he very plethora of deails as well as by hallowed and hoary concepts ha are belied by the facs Mh and miconcepion
Among he mos persisent myths is hat he two ivisions of the ANS he sympathetic and parasympathetic are equal and opposie moieties one being inhibiory where he other is ex citatory one positive he other neg aive one yin he other yang The implication usually conveyed is that normal life is a nicely balanced tug ofwar between these two divisions and hat it is the physician' function o redress "auonomic imbalance usually with appropriately lyic or mimetic meicaions Alhough this view is widely held by physicians (and ohers) it will be
shown tha the two divisions are vast ly different systems Indeed only one of them he sympahetic can truly be called a sysem They differ in their basic design central origins periph eral distribuion (overlapping though it is) and the sensory stimuli to which they respond. Accordingly they dif fer fundamentally in mode of opera tion and in their roles in the total body economy Another prevalent myth is that postganglionic neurons exert only wo kinds of infuence on their target organs: Motor (regulation of con tractile activity of smooth and cardiac muscl and cretomotor (control of secretion by various exocrine glands) As will be shown however the reper toire of he ANS is a great deal larger and more diverse than tha eaion of he AN o he mucuoskeea em
I must confess tha my own compre hension of he ANS remained quite turbid through years of teaching auonomic physiology despie a reasonably broad acquaintance with the growing knowledge about the ANS A coherent perspective did not begin to emerge until I had acquired some understanding of the theoretical basis (as distinguishe from the em piric) for osteopathic emphasis on the musculoskeletal system in maintain ing and restoring health and in the care of the ill Throughout its hisory medicine has emphasize the internal organs and their disturbances and diagnos ic and therapeuic methods have largely been directed a the origins and manifesations of those distur bances In the absence of frank problems of the musculoskeleal system that system has implicitly been regarded only as he vehicle for carrying the viscera about Rewarding as the visceral emphasis has been through he centuries it is important o keep in mind however that human activiy behavior of the person is not a composite of visceral functions such as perisalsis
secretion digestion vasomotion and glomerular filtration Human activity is the coninually changing composite of he activities of striated muscles most of them pulling on bony levers their conracions and relaxations or chestraed by he central nervous system in response to external and internal stimuli and to volition Even those distinguishing features of the human species related o inel lect and affect hat are associated with unique cerebral development abiliy o accumulate and ransmit knowledge reason imagination cre aivity compassion conceptualiza ion inquisitiveness about self life and the universe e cetera are im portant because they result in equally unique actions all musculo skeleally mediated that have led to the producs (and problems) of human life culture and civilization as we know them It is hrough he neuromusculoskeletal system tha we act ou our humanity and our in dividual personalities in he infinite variey of ways of being human We are even recognizable by the idiosyn craic ways in which we stand and move that is by the ways in which we use our musculoskeletal sstems Since even he highes moral ethical philosophical and religious principles have value only insofar as hey lead to appropriae behavior they too must be aced ou or com municated through the contractile ac tivities of muscles. Similarly i is through our musculoskeleal systems tha we act out and communicate our attiudes feas hopes aspiraions beliefs and childhood conditioning If as has been said education is the changing of behavior then education has is ultimae expression in changed patterns of muscular activiy It is for hese and related reasons tha I came to view he neuromuscu loskeletal system as he primary machinery of life the instrumentality hrough which we behave as human beings each in his or her own way2 What then are the functions of he viscera with which the pracice of medicine is so much concerned Their role from this perspecive is to maintain and service the primary machinery and o create the opimal circumsances for its operation Such service includes 1) providing and delivering as rapidly (more or less) as they are consumed he raw products Interpreation of research
incuding oxygen which serve as energyaden fues and as materias for ceuar sefrenewa; (2) removing the products of metaboism more or ess a rapidy as they are prduced; (3 dissipating the heat that is pro duced; (4) otherwise controing the composition and physica properties of the interna environment in which the component ces ive; and (S) pro tecting against foreign substances and invading organisms. (In performing these services "for the muscuo skeeta system the viscera are of course aso doing the same for each other in the course of maintaining homeostasis By virtue of their mass and their high and rapidy changing metaboic rate the musces are in effect the consumers of the body and the tota body economy is continuay adjusted to meet their varying demands from moment to moment and in the ong run he "responsibiity for "tun ing viscera circuatory and meta boic activity to muscuar (and envi ronmenta especiay thermoregua tory demand rests with the ANS in conjunction of course with the en docrine system From the viewpoint presented here the rapid moment tomoment adjustments in accor dance with eves of exertion and posture (or anticipation conscious or unconscious of exertion are or chestrated argey by the SNS The parasympathetic division makes the ongterm adjustments according to customary muscuar activity (and en vironmenta demand therefore ac cording to personaity temperament occupation habits sports recreation age cimate season et cetera t maintains and repenishes the stores of fues nutrients and precursors from which the argest withdrawas are made under direction of the S NS It is for reasons such as these that Nobe aureate WR Hess used the term "ergotropic signifying energy expenditure and exchange to de scribe activity patterns in which the SNS pays a dominant roe and the terms "trophotropic and "endo phyactic signifying nourishment conservation and guarding of the in terna environment to characterize those patterns in which the parasym pathetic division participates From this viewpoint aso it be comes evident that iness resuts from or even s disparity between the
demands of what have caed the " primary machinery and the ogistic meeting of those demands by the maintenance machinery Indeed that is the basis of therapeutic rest: n such disparity the muscuoskeeta system is ess abe to function and when the disparity is sufficienty great one takes to ones bed thereby reducing the demand and the dispari ty unti the basis for the disparity is corrected Traditiona medicine has ooked to the viscera part of the euation as the basis for disparity Doubtess this is freuenty the case However be ieve a more compete and baanced euation incudes the foowing fac tors in the viscerosomatic disparity Muscuoskeea Excessive in sufficient or inappropriate muscuo skeeta demand; somatic dysfunc tion; errors and probems of ocomo tion and posture 2 Behavora Inappropriate ("neurotic behavior; hence misuse of the muscuoskeeta system "psy chosomatic disorders 3 Communcave Impaired com munication between viscera and so matic components through nervous and vascuar channes; "noisy "garbed incompete interrupted 4 Vcera Defect dysfunction or other viscera impairment S Mupe Any one of the pre vious may be the origina or domi nant factor in the somatoviscera "disparity and therefore in a given iness he disparity however soon invoves one o r more of the other fac tors freuenty cuminating in a sef sustaining vicious cyce Fncon orgnizon o he AS
n this section we sha examine schematicay the design and struc ture of the two divisions of the ANS as reated to their respective roes in the body economy Figures through 6 show the basic design of the periph era ANS and the differences in func tiona organization between the sym pathetic and parasympathetic divi sions Cenra orgn
he pregangionic neurons of the ANS coectivey represented in Figure are situated within the cen tra nervous system where they re ceive the converging inuences of a arge number of presynaptic neurons
F. Daammat w oj bntm an pna o pntn on oj th N that th oaton oj th oj on (panon nuon) n th nta nou ytm. Th nuon a ubt to a at aty ojpynapt un In th an a th aam th ympatht on n th nt oj th oumn an th paympatht at th top an bottom oman numa pnt paaympatht ana nu ab numa nat a thoa umba an aa mnt ojth pna o an th mnta on (ntmoata oumn) oj th ympatht on (TJ to L2) an th aa poton oj th paym patht on (2 to
he presynaptic axons convey im puses from many neurona and sen sory sources he pregangionic ce bodies are grouped into neuron poos known as nucei and ce coumns he pregangionic neurons of the parasympathetic or craniosacra divi sion occur in two main and widey separated popuations the crania and the sacra he crania portion consists of four pairs of discrete nucei I II VI I IX and X; the sacra portion occupies three (usuay sacra segments of the intermedioatera ce coumn of the spina cord he sym 25
Fi Paaveteba cains 0/ sympatetic ania an te peanionic be eavin te spina co via te venta oots an wite ami betn T an 2) Encice pais o oups 0/ ana inicate fusions tat ae commony foun
paheic pregaglioic euro are grouped io a pair of log coiu ou uclei he iermediolateral cell colum of he cord exedig from T1 to L2 Pregangioni ouow an the gangia
The axo of he ympaheic pregaglioic euro iue from he cord via the veral roo (ogeher with o of mooeuro i he veral hor) ad hrough the horacic ad upper lumbar iterverebral foramia o yape with pogaglioic euro he cell bodie of which are grouped i h e gaglia (Fig. 2) I he N mo of he yape are wih euro i he paraverebral gagia liked i lef ad righ chai extedig over he etire legh of the pia colum. Upo eerig he chai a each evel he pregaglioic 6
Fi Va stuctues ae pesente witin te man/ie in/ou main oupin tose 0/ ea an nk toacic abom ina pevic an enita. Ony te paasympatetic innevation sown n t an te mainin i soi ines epent peanionic ons an inteupte ines epesent ptanionic ons
axo ad heir collateral may ur upward o r dowward or boh t o y ape o oly i ipiegmetal ga glia bu ao i gaglia at higher ad lower level. Neuro i the cervical gaglia receive all of heir pregagli oic iervatio from the upper thoracic egme ad hoe of he lower lumbar ad acral egmet from cord level L2 ad above. Oher pregaglioic axo (T5 ad lower) compriig he plachic erve proceed hrough he chai withou yape o ermiae i ouyig or collaera gaglia (for example celiac ad meeteric) o lef ad righ ide. ome of he pregaglioic axo however ermiae i he adreal medulla (Vicera are grouped io he four major regio a how i Figure 36 he orga of each regio havig certai iervaioal feature i commo.) The ierva
io of he adrea medulla i how i Figure 4 The pregaglioic axo iuig from craial uclei III VII ad IX yape i craial gaglia (ciliary pheopalatie oic ad ubmadib ular) wherea hoe of the vagu erve X) yape i mall caered gaglia lyig i cloe relatio to the iervated vicera. (Paraympahetic gaglia ad vicera are o idividu aly idetified i he diagram.) Ga glia receivig he acral ouow are of both the collaeral ad itriic type a how i Figure 4 Dtribution ofpostgangoni fibers
The potgaglioic axo are of coure thoe that deliver the auto omic ifluece o he edorga tha hey iervae. The repecive i ervaio field of he ympatheic Ierpreaio of reearch
and parasympaheic divisions are hereore relaed o heir respecive roles in he body economy. The para sympaheic ganglia provide innervaion o all he viscera (ig 3. Those conneced o he upper hree cranial nuclei have a raher limied disribuion o srucures in he head he impulses rom each nucleus being raher speciically direced o one or wo organs (or example eye and lacrimal and salivary glands) The vagus however diverges o a wide innervaion ield including organs in he neck horax and abdomen. The sacra oulow has is inuence on he pelvic organs and geniala. Blood vessels relaed o sexual (erecile) uncion also receive sacral parasym paheic innervaion. The sympaheic ganglia provide innervaion o all o he organs sup plied by he parasympaheic (ig 4) (ympaheic and parasympaheic disribuion o par o a given organ may dier however as in he case o he eye and he urinary bladder) I is in hese dually innervaed organs all visceral wih he excepion o he eye ha sympaheicparasympaheic "anagonism may be expeced. Bu even in hese i is a leas as much a maer o · delicae coordinaion o dieren onic inluences as i is o anagonism Oen he sympaheic and parasympaheic inluences are no so much oppoie in direcion as feren in qualiy (or example in salivary secreion). Dual innervaion does no how ever exend o he vasculaure This is almos enirely he domain o he N (he major excepion being he dual innervaion o vessels in pelvic organs and genialia). Through he conrol o he conracile aciviy o he smoohmuscle elemens in are rioles areries and veins (and even larger lymphaic vessels) he N can regulae he peripheral resisance disensibiliy vascular capaciy and arerial pressure and hrough hese he disribuion o blood in he vascu lar ree eecive ilraion pressure in he capillaries and he apporion men o he cardiac oupu among he pars o he body in accordance wih heir meabolic requiremens or roles in he body economy The N hereore is ruly he vasomoor componen o he nervous sysem Te sympaheic innervaion o he hear hrough is chronoropic
Fig . Smpatetic innevation oj vcea stuctus as been ae sowing ua innevation oj most vcea Note tat smptetic postgangionic innevation in an nk an te to oiginate in paveteba gangia Tose ojte aomen an some vic ogans aise in outing gangia o ampe ceiac an mesenteic) Note aso tat te aena mua sown un t sie oj iapagm) is inneate b smpatetic pegangonic neuons an tat boo v eceive tei innevation peominate Jom te smpatetic ivion
(rhyhm) and inoropic (orce o conracion) inluence has a major in uence on he venricular pressure head and on cardiac oupu. The vagus prooundly aecs he rhyhm o he hear hrough is cardioinhibi ory inluence bu he degree and sig niicance o any inoropic inluences are sill under debae. The N hereore may be said o mediae he cenral regulaion o he enire cardiovascular sysem in accordance wih wha is going on in he body as a whole. Wha is he innervaion o he mos massive pars o he body namely he musculoskeleal sysem and oher somaic issues As is indicaed in igure 5 he auonomic innervaion is exclusively sympaheic via he chain ganglia and spinal nerves he axons o which erminae in muscles bones aricular srucures ligamens endons oher connecive issues and skin. I is o be noed ha he
nervous sysem isel also receives auonomic innervaion and as ar one can ell his is also exclusively sympaheic As an example o prevailing per specives o he AN his major ou low o inegumen and neuromuscu loskeleal sysem which I have called he "primary machinery is usualy represened in he ypical schema o he AN by an inconspicuous lile drawing o a blood vessel a swea gland and a hair ollicle a he ouer edge o he diagram as can be seen in one o he mos requenly consuled schemaa. In keeping wih he main sphere o medical pracice visceral innervaion is he main subjec o he ypical diagram while he larges par o he body he musculoskeleal sys em is scarcely ideniied igure 6 summaries he posgan glionic disribuion discussed hereo ore as well a he basic design o he AN and is divisions Cerain 27
a (nnexsen paasypahec hne cespndng he adeneduay hnes, wud esu n ue physgc chas
Reaion ofperiphera ANS o somaic innervaion
------------
In accdance wh funcna eans f he SNS he uscusee a syse and s espnsveness envnena changes (f exape n heeguan, he SNS s as naey eaed anacay uscuseea nnevan, bh sensy and As Fgue 7 shws SNS ufw and he suppy he seea usces begn cse gehe n he cd, whee hey ae subjec ay f he sae pesynapc nfuences The axns f he pegangnc ces and f he neuns hen eave he cd gehe va he vena s he axns pceedng enan n seea usces he pegangnc axns pceedng synapses n he ganga Hweve, he axns ae agan ejned by sypahec fbes naey he psgangnc axns eneng he spna neves (va he a c uncanes n he way ssues f he nec un, and exees Because neuns and sypahec pegangnc neuns ae sub jec sa pesynapc sensy, naspna and supaspna (ha s hghecene npus hey ae as bh vuneabe dsubances va hese npus Say, snce he ax ns cuse gehe n he spna s and n he spna neves whch as ncude sasensy fbes, sac and sypahec fbes ae gehe vuneabe defan and he aua f bechanca gn. The cnca pcans f hese sasypahec dsubances wee dscussed n he pevus pape, and he echanss and anfesans w be he pay subjec f he nex I s nevehe ess pan ephasze ha evey huan acn nvves he s uaneus cdnaed acvy f he sac and aunc nevus syses and ha dysfuncn f ne nevaby eads dysfuncn f he he Le he SNS he saca uw f he paasypahec dvsn as has cse funcna eans wh he uscuseea syse as n ena n sexua necuse and pau
+
f-------------4------------- ------------4-· · · �
4----------------------------------------------------4------------- f------------- ------------- f-------------4------------ t f------------------
Fig Somaic sucu, incuding he muscuoskeea sysem (and he neous sysem ise ae epened on he ef side of he diagam Noe ha somaic scus eceie hei auonomic suppy exusiey fom he sympaheic diion (ia he spina ne)
feaues ae edaey evden 1 . Une he paasypahec dv sn, whse sphee s as eney vscea, he sypahec dvsn p vdes aunc nnevan every pa f he bdy, ncudng he ne vus syse sef 2 Une he paasypahec, whch s eay a cecn f hghy pvae" nes ndvdua gans and ssues, dvegence s a cnspcu us feaue f he SNS Ne, fs f a, he ahe exensve g n he spna cd, hen he fannngu" f he pegangnc axns ganga ang he ene engh f he vee ba cun and he caea gan ga and, f hese, he spead f he psgangnc axns hughu he bdy T be ephaszed agan s he genea vas e f he SNS whch s pa f s capacy f bzng esuces hughu he bdy 4 Fnay s sybzed n Fgue 6 he SNS s, n effec, saegcay suaed beween he vscea and sac ssues, wheeby
can adjus funcn f he vscea (gh sde f he daga he deands and equeens f he neguenay and neuuscuse ea syses (ef sde Obvusy, une he paasypa hec dvsn, he ganzan f he SNS pvdes f cdnaed, bdywde badcasng f sypahec nfuences, enfced and susaned by ccuang epnephne and nepnephne f he adena edua. Ye, e he paasypahe c, he SNS s as capabe f seecve, cazed acvy. Cena acva n f he ene sypahec dv sn, as n exen, eegency (ea peceved, envnena ex ees, esus n wechesaed, adapve changes n vscea ccua y, and eabc acvy hugh u he bdy The SNS, heefe, can be apppaey descbed as a syse I n cnas, he uney even (funaey f cena acvan f he ene paasypahec ufw, ha s, suaneus, nense acv f a fu pas f cana nuce and he saca nuce he ccuan f
nepean f eseach
4· • • • • • •
' •. . . . . . .
4·····
" • • • • • •••
-
4············
........ .............. ......... .............. ............... . . . .::::. . . . . _...
Fig 6. Schema of he peipheal auonomic neou em, compeed (Repined ih permion
tion, in wic coodintion of i· ce nd oto ctiity i eenti Accodingy, ti pt of te p· yptetic outow it oigin nd coue in coe etion to te otoneuon In contt, te entie cni outfow itte if ny e tion to oto function, in cco dnce wit it eotene fo in· netion of keet uce Afferentpatways in reation to ANS
Te enoy input to wic tey e pond o efect te epectie oe of te two diiion of te ANS Te epone of te SNS to enoy input fo ecepto in kin, uce, oint, et cete, i egent nd upegent ptwy in wt e coe to e ced otoyp tetic efee e igy ognized n dptie Feedck fo po piocepto i ipotnt in oc nd egion djutent ccoding to ite nd kind of ctiity. Tee efee e een te uect of intenie tudy nd eceent eiew in ecent ye.8 Ditunce i n tee efee nd tei cinic nifettion e een peiouy eiewed, nd wi e eined in Pt III of ti eie I need ony epie now
tt ince ti continu enoy feed ck fo te o to te SNS i e· enti fo no function, otic dyfunction wi o e couni cted to te SNS wit dee effect on ote ypteticy inneted tuctue Atoug ot diiion e e ge of effeent ptwy, nue ou enoy fie un in yptet i nee uc te oity of te pncnic nd in pyptetic nee uc te gi nd peic pncnic Toe in te yptetic tunk e ecited y noiou, pinfu tte in te ice, uc eee ditention, ceic iittion p nd icei. It i of inteet tt tee pin fie, toug inteneuon, not ony tiute yptetic pegngionic neuon in te cod, t poducing cnge in tget ogn (fo epe, ice, ood ee, wet gnd), ut tey o ecite neigoing otoneuon, poducing te utined ucu contction o often ocited wit efeed pin of ice oigin In contt te enoy fie un ning witin pyptetic nee ing feedck fo iou epot ing ttion in te ice In g f
feent ptwy, fo epe, tee ign ee iny egutoy oe in epition, cicution, digetion nd ote ice function In te c cicuit, tey ign uc icutnce fune, tt i, edine fo ecution, of i y dde nd ectu In tee c epe, ucu ctiity i in oked to it nd ep to eecute piiy ice ctiity Te con· ee i tue of te SNS wic d ut ice fnction to uppot ucu ctiity Repertoire of SNS
In iew of te diegence of te y ptetic outfow to ituy eey ti ue in te ody, it i ipotnt to k wt effect ipue ctiity in tee effeent ptwy on tee di ee tiue nd ogn Ti i key quetion to epoe in peption fo uey of te cinic effect of y ptetic ctiity, wic i te uect of te tid tice in ti eie 5 A edy een entioned, tee ee to e peent icon ception in ti egd, too. Te tdi tion iew i tt wtee te ef fect of yptetic ctiity (nd, 9
iflueces o ipi metabolism have bee show to be quite iepeet of sympathetic iflueces o bloo ow 7
Fi Co Cosection section of te spina co at toacic o uppe uppe umba umba eves eves Sensoy Sensoy (osa oot oo t anon anon neu an tei fibes fibes (back (back convey con vey impus impus fom ece eceptos an an enins in i n somatic soma tic an viscea u u Motoneuo Motoneu o (venta (ven ta o ces ces ite i te an tei t ei os suppy suppy moto innevation to skeeta skeeta muscuatu muscuat u Sympatetic Sympatetic neuons (tt (tt te pean peanionic ionic neuons in te intemeioatea coumn coumn wose bes (so ines ines synae synae in ania wit postanionic neuns te ons of wic (intepte (intepte nes nes innevate i nnevate vcea an cetain components compon ents ofsomatic ofsomatic tsu onay onaysensoy neuon neuo n (spinot pin otaamic aamic convs impuses impuses to e centes ce ntes an meiat sensations ofpain ofpain an tempeatue (epinte wit pemion ion 2
presumaby hyperactivity) they are meiate by regulatio of cotractio of smooth or cariac musce (the smooth musce icuig that of bloo vesses) a of secretio by exocrie glas such as sweat glas a gas of the igestive tracts. The truth is however that the sympathetic repertoire is a great eal more iverse tha that as the followig few examples wil iicate (The experimeta a ciical eviece for the foowig statemets a the correspoig bibliographic refereces ca be fou i a earlier paper.)9 1 Me Stimuatio of the sympathetic iervatio of skeetal muscle icreases the force of cotractio imiishes the fatigue of repetitively stimulate musce or elays its oset a facilitates euromuscuar trasmissio. 2 Perpera sensory meanms
Sympathetic activity ifueces the fucto fucto of various sesory sesory orgas i most cases i the irectio of i crease excitabiity that is owere threshols a a exaggerate frequecy of ischarge Receptors a sesory orgas i which this effect has bee emostrate icue musce spies tactie receptors taste receptors ofact ofactory ory appara apparatus tus chemo chemo a baroreceptors of the caroti sius pacii pacii a corpusces retia a cochea.
O
Centra nervous system CNS
Sympathetic ifueces emostrate by stimuatio abatio iterruptio gagioic bockae et cetera have bee show o various parts of the NS icluig the cerebra cortex a subcortica structures reticuospia system hypothalamus cerebelum a spial cor Effects have bee show o behavior (for example ateratio of estabishe coitioe motor reflexes) eectro ecephalographic patters resposes to various kis of stimui motor refexes a may others sigifyig a irect ifluece o euroa excitability a activity. 4 Deveopme Deveopment nt of oatera ru aton folowig arterial occusio is
impee by sympathetic activity a is accelerate by sympathectomy S . Sympathetic activity exerts a importat ifluece o atvty of
bone es an on ongtuna bone growt
6 Stimuatio of the sympathetic iervatio of apose tssue favors lipoysis (release of free fatty acis a glycerol) glycerol) whereas iterruptio of impulse traffic icreases fat cotet a resut that suggests a toic ifluece o fat metaboism Iee the rapi ipoysis that takes pace urig col exposure exposure a the slow lipolysis urig starvatio starvatio o ot occur i sympathectomize fat pas These sympathetic
Retcuoenotea system
Sice boe marrow has a rich sympathetic iervatio it is ot surprisig to fi effects of sympathetic activity ot oy o boo fow but o erythropoiesis phagocytic activity of reticuoeotheia cels reease a istributio of eukocytes a eothelia permeabiity. 8 Sympathetic iflueces have bee emostrate o various en ocrne organs icuig thyroi areal cortex pacreas testicle a piea boy The pieal boy is of specia iterest i this coectio. Its eaboratio of melatoi which iflueces growth goaa evelopmet a sexual activity is cotrole by sympathetic iervatio from the superior cervical gaglio The secretio of melatoi folows a iural cyce i that sythesis is icrease crease i the ark (ihibitig growth a sexual evelopmet) a ecrease i the light Whe the sympathetic fibers to the piea boy are sectioe the iural fuctuatio of melatoi sythesis a the associate iura chages i behavior cease Uer these coitios the aima kept i the ark is o loger subject to the atigoaa a growthihibitig ifuece of the pieal boy 9 May other exampes cou be give of sympathetic iflueces o ezyme activity mitosis sythesis of ucleoproteis growth a evelopmet a o resposes of various tissues to other factors (for example hormoes parasympathetic stimuatio toxis) The variety of the effects of stimulatig peripheral sympathetic pathways oes ot lie i the sympathetic euros or their iflueces but i the resposes of the orgas that are iervate. These resposes are as iverse as the target tissues a orga orgas s virtualy every every tissue i i the boy. Sympathetic stimuatio rather tha itroucig ew quaities moifies the iheret physioogy a moecular processes of the compoet cells so that each tissue respos i its ow way his provies the basis for uerstaig the iversity of cliica co sequeces (iscusse i a succeeig Iterpretatio Iterpretatio of research research
paper) o hronia eaggerated smpatheti inenes assoiated with somati dsntion dsntion Appreciation is expressed to r Robert N ay, Director Audiovisual Department, Kirksville College College of Oseopathic Oseopathic edicine for the illustrations in this paper and for teaching the author the principle of "progressie disclosure
eferences
Korr IM: The sinal cor as organizer of iease roce Some reliminar ersectives AOA 6:355, Se 6 Korr IM: The smathetic nevous sstem as meiator beteen the somatic an suotive o cese In The hsioogica hsioogica basis of osteoathic micine b The Postgauate Intitute of Os teopathic teopathic Micine Micine an Surger Surger The Isti tute, Ne Yok, 90 3 Hess, Hess, W R The ience iencehalon halon autonomic autonomic an etaramial functions Gune & Stratton, Ne ork 95 Netter, F: The iba collection of meical i lustations The nervous sstem iba, Ne York, . Vol late 5, . 8 5. Kor M. The sinal cor as oganizer of is rcesses Hperactivit of smathetic innervain as a common facto i isease. AOA, c 9, in rs rs 6 Kozum!, K an Brooks, M: The integration of autonomic sstem reactions A iscussion of auto nomic eflexes, eflexes, thei r control an their association i th somatic somatic reactions reactions Ergeb Phsio 6: 68, 9 Sat o, A E: ental oganiation oganiation of the auto nomic nervous sstem Smosium Brain Res Scial isue No 3) 8 3 8, 8, Ar 5 8 oote, oote, H Somatic Somatic sources sources of affere afferent nt inut as factor in aberrant autonomic, sensor a moto fuctio In The neuobiologic mchaisms in manip ulative thera, eite b IM Korr Plenum Press Ne ork 98 9 Kor, M Sustaine smathicotonia as a factor in isease In o cit, ref 8 0 Kor, IM, Thomas, PE, an Wright, HM: Patterns of eectrica ski esistance in man. Acta Neuroveg :96, 958. I I Wright, HM, Korr, I.M, a Thomas, PE: Loal a regional variations in cutaneous asomotor tone of the human trunk Acta Neuroeg 335, 9 Kor, IM, Wright, HM, an Thomas, PE: Effects of eerimental mofascial insults on cutane ous atterns of smathetic activit in man. Acta Neuroveg 33 955, 96 3 W ight, ight, H M Pogress Pogress in osteoathi osteoathicc rearch rearch A reie of investigatios in the ivision of Phsio logical logical Sciences, Kir ksille ollege of of Osteoath an Suge Suge AOA 6 35, an 6 Kor, I.M, Wright HM an hace, A: utaeous atterns of smathetic activit in clinical abnormalities of the musculoskeletal sstem. Acta Neuroeg 5 589, 5 Wright, H.M. Pesectie in osteoathic meicine. Kirksille ollege of Osteothic Meiine, Kirksville, Mo, 96.
Reint b permissio from AOA 98, Oct 99 The thir ae in this series, "The sinal cor as oganier of isease ocesses Heactivit of smthetic innervation as a commo factor in iea ros, aeare in AOA in ecember 99. This ar is a s technical vesion of a loger aer in this collection, Sstain Smathicotonia as a Facto in isease, hich begins on age
2
Osteopathic principles, practice and profession
223
The somatic approach to the disease process* (1951) The osteoathc oesson as ounded n ode to develo and ut nto actce a concet o health and dsease hch as not nooated n the medcal actce o the day and hch emaned unncooated ate the omulgaton o that concet by Stll. It s motant esecally ae moe than theequates o a cen tuy, o o the mnoty mnoty school school the evolutona evolutonayy one one eodcally eodcally to eexamne ts oston and to evalu ate the justcaton o ts contnu ance as a seaate school o actce o the healng ats The only j ustca ustca ton ould be that the concet has oved sound and stll has not been adoted by the majoty school Wth ths n mnd t s my uose n ths lectue to comae on a un damental bass the to majo schools o healng that exst today I beleve that at the esent tme ths can best be done by assayng the aoaches and the otentals o each th e sect to the most ugent health b lems acng mannd Ths must be done, o couse n the lght o the most ecent advances bought by e seach on oblems o both schools and n the lght o the exeence and thnng eoted by many hys cans I sh esecally to exess my aecaton o the excellent sum mazaton o the to schools by Geoge W Nothu you esdent I have booed not only hs deas but some o hs omulatons The comason o the to schools can by no means be a smle one o the eason that only one o the schools s denable Alloathc medcne s not subject to denton o the eason that t s not guded by any unyng and evasve set o ncles. Osteoathy on the othe hand s guded by cetan boad and geneal natual ncles t alone, theeoe, may be tuly desgnated and dened as a system Thee ae vey clea easons o the lac o unyng ncle n allo athy uon hch a system coul be based The man eason s the lace o ·Bad on an add psd a h i of h ady ady of ppli Osoah Osoah wau y 0 1951
4
etology n ts thnkng As Edad J Stegltz, dstngushed geatst, stated The concet o secc etology, so s o fnely hased hased by och n h s ostulates ostulates and blndly olloed olloed by geneatons o bacteologs and clncans has etaded ogess n etologc analyss analyss o many yeas yeas " In the alloathc ve dsease s equated th the athogenc agent dsease s oduced by the acton o a gven athogenc agent and s chaactestc o that agent In shot, thee ae as many dseases o knds o dseases as thee ae etologes." Fom ths veont t s natual that the theaeutc attenton o the hyscan should be ocused on the etologcal agent o ts eects eects He has essentally only to theaeutc alte natves Fst ossble, emove the athogenc agent o bloc ts acton ang tust that th the a d o suo tve measues the eects o that agent ll someho be evesed se cond alng the dentfablty o emovablty o the athogenc agent, they aly othe agents o measues hch tend to oduce ooste e ects. Indeed, the tue meanng o the od alloathy" s othe o o oste eect o aecton As ll be shon ths veont aeas to be a elc o the bygone days hen the dseases o exogenous" ogn hose etologes" could be den ted th mcobes o othe n vades edomnated. The uncton o the hyscan th esect to these dseases s ethe to event access o the nvade to the human o to e move t and ts eects as soon ate nvason as ossble Ths aoach has to majo and nevtable actcal consequences. The st s eoccuaton th the deences among dseases athe than th the eatues that they have n common One exesson o ths consequence s that one o the most hghly esteemed o the medcal ats s that o deental dagnoss We must ecognze that n essence d eental dagnoss esolves tsel n many cases nto a quest o labes to be attached to the vaous constella tons o sgns sgns and symtoms symtoms that s eects eects om om hch the hyscan hyscan
endeavos to eason bac to the etology t has been my vlege to atcate n a lage numbe o clncal coneences n hch ndngs and hstoes ae eveed n geat detal th the sole objectve o nam ng the dsease." The coneees n many cases nd themselves at a com lete loss theaeutcally untl a sats yng lael s ound at hch ont a geat sgh o achevement may be head notunately, as ll be shon too small a ecentage o the comlants hch ae bought to a doctos oce oce today can be ackaged and labeled as dscete enttes notunately also the geneal ublc has been alsely educated to beleve that the hyscan s a alue unless he can assgn an messve ttle to hat s ong th me" The second majo consequence o the alloathc aoach s the eoc cuaton th end esults Ths s m lct n the statement that the stategy o alloathc actce s to oduce eects ooste to those o the etologcal agent notunately, n the case o most o the dseases to hch I shall ee n ths lectue hen the eects eects have aleady alea dy become aaent though symtoms and sgns the dsease ocess s aleady qute advanced and oten beyond e vesal Ths lmts the uncton o the alloathc hyscan to the thee Rs eleve ea o emove" That s eleve the atent's symtoms ossble atch u the debs o the dsease ocess beyond atchng, then emove he debs Ths s elected n the alloathc atttude toad sugey The atchng o emoval o the debs o the dsease ocess s veed as ea o emoval o the oendng" ogan athe than the oended ogan as though that ogan ee the cause" o the dsease athe than a vctm o a con tnung ocess Let us no comae the stategy o osteoathy Fom the osteoathc veont dsease s by no means syn onymous th, chaactestc o, o even detemned by the ectatng o athogenc agent. Also, m the osteoathc veont, dseases have a geat deal moe n common than not. Indeed all human dseases have n common a most motant eatue man man hmsel hmsel Fom ths veont theeoe dsease s not the acton o a gven Osteoathc ncles
pathogenc agent athe eae the epone of the nual to the tmuu of the pathogenc agent A a matte of fact the tncton be teen the pathogenc an nonpatho genc agent not a fe one but may be etemne n many cae by the epone of the nual human oganm A pefectly nomal tmu u to one nua may elct a eaeepone n anothe ompe a man the fact e man that he can epon n ony a lmte numbe of ay etemne by hs natue athe than that of the "pathogen In the oteopathc e theefoe t become the futon of th phycan to unetan the pat ten of epone of human n gen eal h patent n patcua an though that unetanng to ate the epone n a faoable ecton an to peent the unfaoable e pone If t tue a Pope tate that "he pope tuy of mankn man then t euay tue that "the tuy of dsease man I It to be note that n chaactez ng oteopathy nohee hae I men tone manpulate theapy Manp ulaton happen to be one of the bet theapeutc moalte aaabe o day fo ateng man' patten of epone to noou an othe tmul n faoabe ecton an fo eneng hm e uneable It mut be conee a but one component hoee of oteopathc theapy nce a apect of man' lfe conton an etemne h epone teopathy theefoe not meely a fom of theapy but athe a boa pho ophy a gue fo thnkng an actng n eaton to ueton of heath an eae Let u no pocee to compae the potenta of thee to appoache th epect to the mot ugent health pobem of the tme In the pat 4 ecae thee ha been a majo tan fomaton n the eae pctue pa alee by a change n the age t buton of ou populaton A a eult lagey of the conuet of the mot mpotant nfectou o commun cabe eae though aance n pubc heath peente mecne mmunoogy antbotc et cetea thee ha been a amatc nceae n aeage ongety It may be a that e hae a ap y agng popuaton Fo eample ung the pat yea the numbe
of peon oe the age of 65 ha n ceae tce a apy a the popu laton telf Peon oe the age of 65 hae uauple nce the begn nng of the centuy hle the ente populaton ha ony oube I pecte by the nte State Bueau of the enu that by 980 apo mately 40 pe cent of ou popuaton l ecee 45 yea of age moe than 20 mlon peon l be oe the age of 65 h aance hoee " tante by the mmene tol of polonge ablty o f ayng egee concen tate manly n th mot apy gong egment of ou popuaton he heang at ae toay peente th a ne batch of cppe an klle the eae of beakng on an eang out epecally but not ecluey aocate th matuty hee ae the eae hch one "get athe than "catche hee ae the "enogenou eae ognatng thn the patent athe than "eogenou one bought by nae hee ae the eae hch the ay pubc commonly egnate a the "toube heat toube kney touble tomach toube ga bae touble r efe of coue to the chonc e geneate eae ncung the aou kn o f caoacuaena eae the athte nepht peptc ulce abete metaboc an enocne oe et cetea he n cence o f thee eae o at an o appallng n total abty that they hae been egnate a the "majo font by the Sugeon Geneal of the nte State Pubc ealth Sece It etmate that thee ae 25 mlon ctm n th county one peon n eey a ctm of uch eae that nealy eey famy n th county touche n ome egee by chonc oe Although they ae epecaly aoc ate th matuty thee eae hae many ctm among the youth of ou county Man thu beng pae ealy eath by the nfectou eae only that he may uccumb at a ate age to the mey an ablement of chonc eae A Stegltz tate "he buen of chonc eae both nualy an collectey fa geate than the oca coneuence of hgh motaty fom acute nee A man uckly ea a ee tagey
to hmelf h famly an the com munty than one able fo many yea A a meaue of the nae uacy of the heang at th epect to thee eae the fact that athough n the pat 4 ecae the pecentage of peon oe 60 year of age ha oube the aeage man at toay ha the ame fe epec tancy a ha a man of n 9 It mght be a n ummay that the conuet of the mao nfectou eae ue to the aance n the clnca cence ha peente humanty th at leat eualy eou pobem to hch thee ae a yet no cetan ane What the appoach of allopathc mecne to th "enomou peonal an natonal buen of eae n the aut populaton the mot pouc te eement of ou ocety In bef t pecely the ame a that peouly outlne Mecne an the eeach to hch t ge ecton contnue the uet fo nonetent n ua caue upon hch to bae the nual cue fo the nua eae In the abence of knolege egang pecc etooge hch can be oate o eoce fom the boy o hoe acton can be bocke the mecal pofeon mut con tnue to content tef th ameloatng eneffect th ymptomatc o paate teatment Stegltz tate n h ntoucton to a ecent ympoum on honc eae the tay gnfcant objecte of prevenon of ongtem lne omtte fom thee collcte pape becaue thee a lttle to of fe but "eegong concen e goe on to ay he teatment of chonc eae afte abement ha occue euaent to lockng the table oo afte the hoe toen Aopathc mecne theefoe n telf n the poton of eang th eneffect of unknon eto oge Inee n t uet fo t n ual caue t ha often confue effect th caue hu fo eampe e ee abete meltu "caue by panceatc nuffcency hen actua y that efect tef a neay te mnal lnk mmeately peceng the ymptom n a ong chan of po cee o take a moe ecent ee opment heumato atht now acbe to a metaboc efect aocate th aenocotca nf fcency heea that nuffcency 115
slf on of h suls of a copl dsas pocss ha lk an oh chonc dsass a hav had s ogn an as bfo h gnc of spos A pacc basd on h apd vsal of ndffcs whou accss o ologcal facos s ndd a pacc basd on pozaons f h blood pssu s hgh gv so hng ha wll low ; f h app s poo sula ; f h wgh s cssv duc ; f on of h pans ndocn glands s ovacv hn poson ov all o pa of o gv an anagons; f h pan s dfcn n so ndocn o oh coponn hn suppl o sula s souc Falng an of hs hn sc h pans lf so ha h a lv whn hs ld phsologcal ans; add as o hs lf bu no lf o hs as Th funcon of h (allopahc) phscan wh spc o chonc dgnav dsas s wll sud up b anoh conbuo o h afonond sposu n an acl nld "Mas of ongT llnss Jugn Rusch sas "Mas of chonc dsas hus bcos an ogansc ask of phsologcal and pschologcal adapaon Th phscan can habla h pan b hlpng h o fnd a nw adjusn o a changd nnal and nal nvonn and to accept his tota or partia invaiism as part oj a new reaity (alcs suppld)
Though hs appoach h can ob vousl b ll hop fo cu of chonc dsas and uch lss fo pvnon Wh s allopahc an of chonc dsass "quvaln o lock ng h doo af h hos s soln Th unknown ndognous ologs a canl a faco bu Sglz offs anoh poan faco All hs dsods bgn aspoacall and a b wll advancd bfo subcv coplans of sufcn nns as o caus h pan o sk dca asssanc Th lsson o b bd s ha w us sach fo hs sln nsdous ffh colun dsods n appanl wll po pl and no wa unl h bco obvous b ov lson Bu sas Rusch n dcal schools achng s sll gad o acu cond ons whl chonc coplans such 226
as hadach backach fagu nson o pan a al psnd n dcal ounds alhough h cops h bulk of h cass n pva pacc On wonds wha ann of psuason would b qud o convnc hs psnavs of h o advancd sgn of h dcal pofsson ha wha h a skng unwngl and canl blndl s h osopahc lson n hus chaaczng h allo pahc appoach o chonc dgnav dsas h s no nnon of nzng h valu of h n dous conbuons of dcal sach and dcal pacc o h lf of huan suffng assocad wh hs dsass Mllons of suf fs hav gvn and wll fo so connu o gv hanks fo nsuln coson and ATH pan lvng agns and hundds of oh advancs M onl pupos s o sula connud awanss ha hs odals val as h a a no dcd a h dsas pocss slf canl no n s asp oac sags bu a h anfsaons o sags of h pocss af "h hos has bn soln whn so dg of nvalds us b accpd as "pa of a nw al Th nd fo an appoach o h fundanal dsas pocss n ach cas ans As Fsch sad n an cn acl dcd a h pop ncopoaon of can cn advcs no osopahc pacc " Su g ovs paholog; dos no cu So s wh so dugs; h lv h spos whou cung h dsas H gos on o sa "Th a no ousd agncs whch wll cu dsas u cos fo whn; cos fo aangng hos pats whch a ou of od Wha s h ponal plc n h osopahc concp wh spc o h "ajo fon Rsach n ou laboaos and of laboaos n lad flds houghou h wold and ou own clncal pnc hav ld us o h followng conclusons 1 Th osopahc lson as dnd b palpao and oh cun clncal ca psns h soac coponns of a basc gnal dsas pocss oganzd pal (ha s n s al sags a las) b h cnal nvous ss 2 Th ponal o acua pan of anfsaons of hs pocss ha
s h "dsas s dnd s locus h lvl of h nvous ss nvolvd Obvousl h vaous ogans and ssus nnvad fo dffn pas of h nvous ss wll spond n dffn was o h sa pocss o sulus 3 As n all naual pocsss h spd of hs pocss and h fullnss of psson of s pan of anfsaons (ha s h sv) a nfluncd b an facos consu onal facos ag nvonn pas hso nuon oons and psonal 4 Th sa pocss a b nad n dffn was alhough n h osopahc vw s os coonl nad n h soac (o fascosklal) sucus hough posual sss; ha s h spons (pan of anfsaons) s d nd no b h "ologcal agn o pahogn bu b h s of s acon and h phsologcal sa of h pan A posual sss hfo p sns a dcsv faclang o pobablncasng faco n dsas pdsposng h nvolvd sgns and hfo h ndvdual as a whol o h acon of noous sul and aggang h sponss of hos sgns o all sul noal and noous B s psnc o absnc h lson a dcsvl dn h pans vulnabl o noous nfluncs hs sponss o dal ssss and sul and vn dn whh a � gvn agn sulus o nvonn al chang s o b classfd as pahognc o no As a localzng and channlzng faco dns wh h pocss s nad wha ogans and ssus a pal affcd and hfo wha h anfsaons h "dsas wll b f oh facos conbu suffcnl o h a and fullnss of psson of h pocss As a localzng faco a fo apl dn h s and hfo h nau of h bodl psson of oonal (pschosoac) dsubancs Snc h dsbuon of posual and chancal ofascosklal ssss s unqusonabl nuncd b bod p o habus h a b h an faco n h wllcognzd laonshp bwn bod p and h ncdnc of vaous chonc dsass Osopahc pncpls
From the diagnotic viewpoint the omatic component ha great trategc ignificance becae it make poibe the detection and evaation of the dieae proce far in advance of the emergence of ymptom Oteopathic eion appear to repreent the ient, inidio, fifth comn diorder in apparenty we peope, oght by Stiegitz hether the omatic component of the baic proce i primary (a in potra tre or of econdary refex origin (a in vicera dieae, once it i etabihed it i no onger a mere manifetation of the proce bt ha become a contribting, excerbating, and perpetating infence, which mt be given f conideration in therapy regarde of the primary etioogy A the mot acceibe, the mot eaiy recognizabe, and (in the hand of the oteopathic phyician the mot reponive component, it i the trategic one throgh which to in fence the proce itef and inter rpt the vicio cyce of atogenic impe • e begin to recognize, therefore, that a great may dieae which on the rface are o divere in character a to reqire a highy compex ytem of differentia diagnoi, differentia therapy, and differentia nomenca tre, are eentiay one dieae, the manifetation of an identica proce expreed in different part of the body hen we have earned the intrinic natre of the proce, we ha know how to prevent or interrpt it wherever it may be, whatever it mode of initiation, and thereby dea in a nified ytem with many divere dieae rather than with each one in a di fferent way he i ntrin ic natre of the proce i the bject nder invetigation in the Kirkvie reearch program oday, therefore, the oteopathic concept offer the ony approach certainy the ony nitary, baic, and ytematic approach to the treatment and prevention of chronic dieae becae: 1 It aone recognize the common denominator of the fndamenta dieae proce . It i aware of a very common etioogica factor in the initiation of that proce gravity in the face of man' incompete adaptation to the erect tance
3. hrogh it omatic component the oteopathic eion the fndamenta dieae proce can be detected and evaated ong before ir reveribe damage ha been done before the tabe door ha even been opened 4 hrogh it omatic component, an acceibe, pecific, reponive and effective ever i provided for the manipation and interrption of the dieae proce itef In thee for point, I beieve, ie the ftre of the oteopathic concept becae in that concept are impicit ome of the anwer to ome of mankind' mot imperative probem Advanced a that concept i, however, it can offer ony the ap proach in it preent tage of deve opment it i not yet ready for that ftre, for the foowing reaon 1 he natre of the fndamenta dieae proce the eion proce i inadeqatey ndertood . Athogh the ipornce of the reationhip between gravity and bodiy trctre i thoroghy recognized in oteopathic practice, or knowedge of the interpay of thoe reationhip i too frag mentary to provide a bai for the prevention of the initiation of the proce, o important to the prevention of fnctiona and organic dieae 3 he method of detection and evaation of the proce by the preent bjective papatory procedre are too crde, too bject to error, too difct of tandardization 4 Athogh manipative therapy i today the ony modaity which i ef fectivey directed at the fndamenta dieae proce, it i too ow, too aborio, too diffict of tandardization Frthermore, the crrent diag notic and manipative procedre, reativey exceent a they are, are not keyed to the magnitde of the prob em here are aready 5 miion victim of chronic dieae in thi contry aone and many miion more in whom it need to be pre vented Method mt be deveoped for the detection, evaation, prevention, and treatment of the dieae proce which have ma appicabiity A tated by Srgeon enera Scheee, It i poibe that we ha not be abe ceary to deine heathy matrity nti we attempt to
appy in the entire popation or knowedge of thee dieae . J hee anwer to the probem of the chronic dieae mt be deveoped, and wi be deveoped, becae ociety i demanding the anwer hey can fow ony from a arge reervoir of baic information which in trn i achievabe ony throgh enarged program of fndamenta reearch In view of the nhappine of the medica profeion with it own temporization and expedient and it qet for a more baic approach, it mt inevitaby arrive at a imiar concion he oteopathic concep therefore, in one form or another, ha a certain and briiant ftre a the ogica, nitary, ytematic bai for the treatment and prevention of chronic dieae a the preventive medicine of tomorrow he ftre of the oteopathic profession however, wi be to a deciive degree deter mine by the contribtion it make throgh fndamenta and cinica reearch, to the frther deveopment of thi concept hrogh it 75 year of exerience it i the mot richy preed profeion to ndertake thi great reponibiity to ociety oday fnmenta reearch on a arge cae offer the mot direct (perhap the ony road to the oteopathic profeion' rightf pace in ociety and to it preparation for that pace Refeene
I orhup . W Osopah onp o dsas a ra auaon J A Oop A 502-11 1950 . Sgl EJ dn n an agn£ popuaon . n orh Ara 339530 arh 1949. Sh LA San upon nduon Surgon nral Pu Hah Sr dra Sur Agn Apr 5 194 J A Osop A 4747474 a 194 4. Rush ar o ongr ns n orh Ara 45446 arh 1949 5 shr R L. Osopah ars ar J A Osop A 505-514 Jun 95 6 Rnr SH and Tra! J Thrap drd a soa opo nn o ada pan A Har J. 5426 194 7. Korr ura as o h osopah son J A Osop A 47199 94 Korr Ergng onp o h oopah on J A Oop. A 41-1 o. 194 9 Korr Th undaa pro n osopah rarh J A Oop A 50407-416 Apr 95 10 Korr . Rarh progra or h oopah poson J A Oop A 476975 arh 1 1 Korr Ho ar on h sn road? J Oop 5616 949
Rprnd prson ro JAOA 510105 195
227
to o th ostopath posso: A att o dso (199 he theme of ths Coveto "U fog Hoos Osteopathc Mece s a chaegg oe M assge tas as eote was to e scbe fom m vewpot as a phs oogst osteopathc college some of the hoos that ma easoabl be epecte to fol fo the osteopathc pofesso. Bt I soo scovee that m tas was a mpossbe oe he hoos we see at a gve momet ae eteme b the paces whee we sta a the ectos whch we face a the mbe of possble hoos s te. Bt the o hoo that fols s the oe towa whch we move a the ol as log as we move towa t Yo pofesso ow stas o ma platfoms a faces ma ectos fstate a ceta abot the fte becase ts avalabe esoces caot sppot movemet all of ts peset ec tos Fom whch of the ma plat foms a whch of the ma ectos s o pofesso to see ts fog hoos? Oe thg s ceta Uless ths ecso s mae ve soo the osteopathc pofesso ma loo towa ma hoos bt oe that fols. he ol possbl cose oe that has a hope of sccess s oe to whch the pofesso ca wth t a covcto commt tself a whch eve segmet ca f ts oe he ecso theefoe mst be a ogae ecso Fo obvos easos the ecso mst be oe whch socet ca fee a stae a to whch t ca whole heatel a geeos commt tself Yo caot eastcal as socet as o have te to o to commt tsef befoe o o a wthot socets commtmet o cose ca be og pse a o hoos foe Socets g met theefoe mst awat o ecso Yo have befoe o the a mometos a get ecso What o o wsh o pofessos
*
on he eyno dd o 63rd Annu Connion o he Amein Oeophi Aoiion jy 1 199 Chigo inoi
22
cotbto to socet to be? I em phase "pofessos cotbto becase the pofesso s fa moe tha a aggegato of phscas a stttos st as a hma beg s fa moe tha the sm of hs bo pats Its esposbtes ae fa geate tha the sm of o val esposbtes st as hma lfe s moe tha the fcto of ogas I epeat ess the pofes sos fcto s soo estabshe a the pofesso commtte to t a of ts peset oas ae shot oes a the theme of ths Coveto s bt a le phase epessg a va hope. Ufotatel o ae ot ea to mae the ecso a some pepaato s ecessa hee steps ae eqe 1 Yo mst become awae of the nee o econ hee s lttle the peset cose of o affas that eects a eep pevasve awaeess that a ebeate ecso o the ght cose ees to be mae hee s stea the mple covcto that of all the peset coflictg coses the ght oe wll somehow eveta peva 2 Yo mst eame a e sta the ne n scope o e econ Whle o mae ma ec sos (a ma moe w be mae at ths Coveto oe sce the oe that mae o fog has bee as epocha chaacte as the oe that ow awats o elbeato 3 Yo mst ognze o ecson Whe o ogaatos mae ma ecsos o pofesso s ot ow ogae to mae oe of ths chaacte I popose theefoe to eame wth o (1) some of the easos wh ths ecso ees to be mae a how the ee came abot (2) the chaacte of the ecso a (3) how t s to be mae Fal I shal po pose a hoo fo yo fog N fr cisin
Each of the estg pofessos has evolve to meet some socal ee whch s tself the poct of socal clta a techoogc evolto a whose essetal chaacte s
geea estoo b socet I the cose of ts evolto each po fesso has bee chage b socet wth the meetg of that ee whch becomes ts chaacteg fcto Socet mposes eglato whle at the same tme gvg potecto a sppot I geea theefoe po fessos o ot ee to ece what the espectve fctos sha be bt ol how the ae to be cae ot Uqel the osteopathc pofes so ot evove o was the ee oe geeal estoo b socet Istea t aose e novo a sef appote so to spea to a tas whch the pofesso tsef eclae a efe a whch t aoe estoo a to meet a ema whch t aloe ecoge he pofessos fog a self appotmet wee mae b the chateg of the st osteopathc co ege 1892 Its sefee tas was to teach a to pt to pactce p cpes a methos whch t beleve wo "mpove o peset sstem of mece Havg fo the e stg meca pofessos eceptve to these pcpes a methos the foes ece to estabsh a po fesso whch wol test evelop a appl them It has bee fom the begg a ph stge whch o have ha mma sppot fom socet a eetg oppos to fom powef ogaatos a pofessos Nevetheess the teveg 67 eas o have estab she oself as a stog epe et pofesso oe of the two svvg mecal pofessos ths cot a potetall a most powef foce fo goo socet At temeos cost to o ow hma a matea esoces o have tae a ecate oselves a each othe bt o ow eca toal a cca stttos a establshe a pofesso of 13 phscas sevg mllos of pesos Yo have bee awae the ghts to pactce as fl alfe phscas a to ceate ma othes as o ca moe o ess o ow mage Yo pofesso ow has a powefl voce whch s hea wth fa geate effect tha oe wol epect fom o mbes he pblc ceasgl sees a gatefll eceves the se vces of osteopathc phscas Few ecogtos a pveges ema to be wo ee the wthhog of Osteopathc pcpes
reognon, approval, an prvlege now rases ore uesons n he pub n abou he obev an he oves of he whholer han abou he opene of oseopah phsans n all, hs has been an � ense aheveen unahe n he hsor of professons Wha, hen, s our proble? An why s neessary agan o ee an elare he reasons for our pro fessons esene? Your aor frusraon, as ou enf , s he lak of resoures o o all he hngs ou now fee ourself able o o, n he ual an on he sale o whh ou aspre n oher wors, he rgh, reognons, an prvleges ou have been aware are largel perssve he reova of srnaor obsales Soey sll gves lle of he posve suppor gves o he funons an nsuons of oher professons, hrough aes, aor phlanhrop, subsana en owens, an oher spefaly esgne provsons Whle soe graefull aeps he serves offere b oseopah phsans, an wll ngl pas for eah serve, sll feels lle or no oblgaon o he oseopah professon or o he n suons whh are s founanhea Afer 67 ears, a vas aoun of our effor onnues o be epene n he ues for her suppor These are forable obsales, ore obsruve o our progress, an even our esene, han ever before Bu he are now far ore of our own reaon an perpeuaon, an herefore far ore sube o our reoval, han ou see o be aware s beyon ebae ha ou have esablshe yourself as a professon Bu s e long pas e o ask agan, "For wha? For wha have ou fough hs long, har, uphl sruggle o esablsh ourself? For wha have ou esablshe a new professon? You fn ourself able o answer only n ers of he serves elvere b nvual phsans an her ns an hospals Bu where s he answer ha speaks for he professon? Wha o ou wsh o o ogeher? Beause here s no rea answer o hs ueson, he oseopah professon self ebaes wheher has a funon of s own an a reason for separae esene, ye woners why soey feels no opellng sense of responsbl for s
anenane Unless you soon ee wha he funon of he oseopah professon s a eson no oher professon s alle on o ake n vual phsans a, for a whe, onnue o prosper suh s he e an for eal serve, bu he professon wll aroph an vansh for wan of a funon Why s here no longer a rea, lear, uneuvoal answer o he ueson, "Wha s he funon for whh ou have esablshe an an ane hs professon? s here no longer a nee for he funon one "professe? On he onrar, sees o e ha ou have been so long an so eepl absorbe n esablshng ourself ha ou have forgoen for wha, you no longer ask for wha, an, ore han ou are aware, rghs, reognons, an approval have beoe ens n he selves Beng has beoe ore poran han beong Unforu nael, esene of he professon s no n self reason for esene, an selfpreservaon s n self no a fun on So eepl have ou been engage n wha began as a sruggle for he rghs o prae an eah aorng o our own prnples, an o suh an een have ou won hose rghs b evelopng an eonsra ng profeny n he pleenaon of oher prnples, ha our own have beoe a lle vague, rrelevan an even obsruve o our presen ens Though now possesse of a grea voe, our professon asks, "Wha wll wn approval fro who? ore ofen han "Wha s rgh for us?; an sas hose hngs whh beleves are epee of So preoupe wh eeng he sanars of ohers, has vruall reln ushe all responsb for seng sanars for self So uh have ou been preoupe wh bulng our professonal engne, an a agnfen engne s, ha ou have neglee o la rak, an now an no ue reall where was o go Conseuenl, our aor sruggles oa are no so uh for soes approval of he engne, whh has been approve an uly are, as for he prvlege of runnng on he raks of oher professons, owar esnaons of her hoosng The grave probles ha now bese ou an onl grow an ulply unl our professon s oe o s
own ourse, or unl s abolshed nee, soe ebers of our pro fesson forunaely, onl a few, bu unforunael a few n hgh plaes fn heselves so overwhele by hese probles ha he serousl propoun hs onluson: Tha he oseopah professon, a ense os an sarfe, esablshe self, won an anane s eny for 67 ears, so ha oul, wh a floursh, esablsh self, surrener s en, an reurn o oblvon! s o be epee, of ourse, ha lke oher oveens n hsor, hs one, oo, has s "suer solers an sunshne paros Bu s sa ha a learne professon pers self, be ause of s neson, o oune nane an even serousl ebae suh rag nonsense Le us now eane how our graves probles an soe of our greaes obsaes arse fro your own uneran regarng he fun on of our professon 1 Havng no lear age of he funon of he oseopah profes son, as has of ohers, soe has ha o efne ha funon n ers whh oes unersan an regulae s perforane aorng o rera an sanars wh whh s falar o beng able, herefore, o efne s sake n ha funon soe anno efne s respobl n sharng he os of he pofes son's separae anenane a he os of euang oseopah phs ans You are reue, herefore, o seeng suppor, n proporon o our nubers, for hs or ha serve, hs or ha proe or eneavor, or hs or ha nsuon or eparen Bu soe reans unoe o he professon as a whole 2 Unl he professon s o e o he onrbuon proposes o ake o soe, an have no on ssen, relable gue o he forula on of longer pol n effe, your professon enless ebaes how o arry ou s funon whou a lear vew of wha ha funon s Whou suh a gue, he onl poss ble "pol s epeen: Tha whh wll wn approval for hs or ha av, fro hs or ha one of our an publs, a hs or ha e Over a pero of ears, was nevable ha everhng, espeall esgn, shoul have been sarfe for versfaon As a resu, he 229
poession and its atiities toda eet not so muh ou design as its man epedient adaptations to etenal onliting pessues as the shape o a tee ma eet the peailing winds and a ok the oes that eode it . The poession neutaizes its geat stength and dissipates its esoues in diese and oniting eots beause without a lea iew o its enta untions and its pima objeties it an hae no dependabe sale o alues o assignment o pioities and o appotionment o its esoues ah aea o poessional endeao ompetes with ee othe aea o endeao o inestment and suppot one siphoning o esoues needed b the othe One aea momentai thies while anothe on whih it utimatel depends is pemitted to stare nestment in eah aea is made on its own meits at a gien time without egad o ongtem balaned deelopment o al o them The esuting imbalanes an ind on epedient oetion in a zigzag ouse Let me ite one suh imbalane apidl ineasing in seeit and hazad The aea o ou poessions lagest inestment toda a eeeding all othes is in hospitas While in themsees o ouse high desiable the mushooming o hospitas has siphoned o so muh o ou poessions esoues that ou oleges ou e soue go begging Conese the need o ou hospitas o sta membes and intens is apid outunning the apait o ou oleges to podue them een the aiding o the olege aulties has beome an aepted patie One has an image o jet planes so ast and poweu that the ontinual outae the tankes whih ae to eue them in light Pehaps een moe impotant than the uantitatie aspets o this imbalane ae the uaitatie aspets t is pooundl and adesel aeting the entie eduational sstem o ou poession the poessional oientation o its euits and gaduates the ualit o inten taining the geogaphi distibution o osteopathi phsiians the ethis o patie the media speialties and most pooundl o all the e untion o the osteopathi poession t is ommitting ou poession to a ouse
upon whih it has not onsiousl deided This eampe o imbalane has man ountepats The uestion in eah ase is not on what is the eatie impotane o the aious aeas and endeaos but what at a gien stage along ou ouse is the oet baane among them? This annot be detemined until ou hae as a poession deided upon ou ouse 4 Beause o its indeision ou poession has inited upon its oleges a Babe o onliting ideoogies pinipes paties and objeties whie demanding eellene in eah Puusit o "ompeteness has podued uiula whih gow b aetion athe than b design t has ed moe and moe to diuseness to supeiialit to auisition o unoganized masses o knowedge and tehni to saiie o pespetie and uniing themes and to neglet o essentials Design o the ental oe o osteopathi eduation awaits the poession ommitment to its own hoizons 5 Unti a ommitment to ou poessions mission is made ou an hae no ealisti basis o attating euits to ou poession no o desibing thei uaiiations 6. Just as ou now gie soiet itte basis o deining its obigations to ou so hae ou insuiient basis o detemining the ull sope o ou obigations to soiet 7 Beause ou hae not deided upon the patiula ontibution o ou poession and made lea to ousees and to soiet thei speia ualities ou ae edued to measuing ou stength in uantitatie tems the numbes o ou phsiians the numbes o ou annua gaduates the numbes o hospitas and hospital beds the numbes o speialties and speiaists the numbes o dolas the atio o DOs to Ds and o DOs to the population and so oth he gowing assumption that to peai ou must do so b shee weight o numbes an onl ontibute to a gowing sense o utilit and the uthe ependitue o ou meage esoues in unewading entues You stugge to ompensate o ou minoit position when ou shoud be apitaizing on it 8. Fo the same easons thee ae
misappehensions about the source o ou stength You poession appeas to beiee that its stength is to be ound moe in stamps o appoal b seappointed magistates o mediine who in thei own minds ae mediine than in the pubi ou poession sees whih is the utimate judge and the soue o ou suppot As a esut ou oten at as though ou belieed ou stength is to be nutued b mimi b oaks o potetie ooation b ompomise o pinipes b oganized ompliane b appeasement and b adaptation to what is pesibed o ou b oganizations o anothe poession athe than what is designed o ou b ouse Reent eents oud poaim the utilit o this appoah Histo eeas that obiion is the ate o those who ask onl "What is aeptabe? and not "What is ight? These then ae the eal obstales that beset ou toda as ou ontemplate ou past ahieements with justiiable pide and ou utue ouse without etaint The ae engendeed and pepetuated b ou poession nonommitment to a untion o its own design The ommitment beomes moe ugent with eah passing moment; o the onge it is postponed the moe diut does it beome and the moe do ou suende the esponsibilit o making it t ma appea that a that is euied is a satising and esounding deinition o the noun "osteopath and the adjetie "osteopathi On the onta it is ou ations that gie meaning to ou tems and not ie esa Osteopathi mediine is not a eestial bod that happened to ome into being subjet to obseation and desiption but not to inteention t is a podut o human design and human eation t is theeoe ontinual subjet to human design Hene osteopathi mediine is an item not o deinition but o deision The uestion is not "What is it? but athe "What do ou popose that it beome and that it do? This is the deision beoe ou Let us now eamine the natue o that deision the iteia on whih it is to be based Nur o con
Foowing ae some o the onsidea Osteopathi piniples
tios b which or professio mst philosophical techical a meical be ie i its selectio of the hori- ecisio of sch comprehesive scope os it proposes to fol for societ that it wol heceforth over the the professios loterm cotrib- mai of all other ecisios. It is ot tio I part the are seste b oe to be assie to some committhe foreoi smptoms of ie- tee some epartmet or some cisio brea it is oe to be mae b the e1 he cotribtio mst fill a tire professio a its istittios It social ee oe i the limitless sphere is ot a aeora isse to be reof hma health. solve b parliametar procere i 2 he ee mst be oe which is perioic sessios of chambers a ot met or liel to be met b a cocils or i smoefille cacs other professio however lare the rooms a to be leislate ito eareas of overlap a collaboratio istece b maorit vote. Rather it is with other professios oe to be cotiall evelope ac 3 he cotribtio mst be of cori to searchi eamiatio a sch scope character a eri reeamiatio of hma ees a vale as to stif iee ema of this professios share i the the eistece rowth a meeti of those ees his is a ecievelopmet of the professio sio o loterm irectios of It mst be of sch vale as to evelopmet to ie all or efmerit societs cotii a forts at ever level; oe which will eeros spport particlarl of the ive esig to or life as a profes istittios i which the cotribtio sio is evelope taht a elivere. he ecisio I am proposi is ot 5 It mst be oe which ca ite What will serve the professio the professio to which the profes- best bt What a how will the sio ca reservel commit itself professio serve best Oraia a i which ever semet ca fi tioal ecisios mae withot rear its most ratifi role. for the cetral fctio of the profes6 It mst be withi or provice sio ca i the lo r settle a withi or realiable power. It othig a at best bri ol ilmst emere therefore from or lsor a passi avataes to the histor eperiece character a i professio I effect or profes sihts as a professio from or ow sioal oraiatios are preoccpie iterpretatios of societs ees a with secoar proceral isses from or ow etermiatio of the while the primar isses a obec path to their flfillmet. tives have et to be ietiie with 7 It mst provie comprehesive meas to the e before the e has esi for the professios total ef- bee ecie. A et it is these fort for its evelopmet for the ac- secoar ecisios which toa qisitio a tiliatio of its etermie the professios core a resorces for the ecatio of its its ftre histor Beatifll phsicias a for their practice. It oraie for ecisios o tactics mst provie iace i the for or professio has et to oraie mlatio of polic a i the efii- for ecisios o basic strate tio a flfillmet of the I cosieri how to oraie for professio obliatios to societ this ecisio two this are clear First hos bs nd sns of Oraniin fr in
Alrea so well oraie for ma is of ecisios o ma woer wh it shol be ecessar to oraie i particlar for this oe For this reaso his is a ecisio that o are ot ow oraie to mae his is ot st aother political or oraiatioal ecisio to be recor e proclaime or file as merel aother resoltio a ew blaw a ew coe of ethics or eve a ew set of obectives for the Associatio It is a social scietific itellectal
h pofsson who dpl con cd bou s cous nd s hozons nd h v n us fnd h w o x h n fluenc on h ffs of h pofs son nd on h plon ofs cous Seco ou wll nd ncul ldeshp no lss hn polcl ldshp Leaers are reqire who
are qalifie to ietif a weih the cliical scietific social a professioal as well as the political a ecoomic elemets that are ivolve It is a matter for or serios
attetio that for wat of appropriate forms ma of or reatest a wisest phsicias ca have little i ece o or professios corse For sch a ecisio o also ee the active a perhaps eve the omiat participatio of or ecators for it is the i the lo r who ive meai to or ecisios throh the qalificatios attites a perspectives the iclcate i the phsicias the pt ito societs ser vice each ear. Bt eve their fctio is ow more etermie b political cosieratios tha it shol be a more tha we lie to amit. Ecatioal process mst be free of political iflece. A stro acaemic wi of or professio cetere aro bt ot limite to or collees still ees to be evelope. Its chief fctio wol be the cotial amiatio a reeamiatio of all the isses a elemets that etermie or obliatios to societ a the paths to their flfillmet It is these cosieratios that shol ie the affairs of the professio a etermie th e tac tics a the weapos of oraia tioal warfare with which to strethe orself i societs behalf The hrin fr yur unfin
Dsn
I the foreoi iscssio the or esi has appeare promietl several times. I cosieri the fctio of the professio or cocer is ot with the chai istrme talities proceres a methos of health care a of professioal fctio Rather it is with the total a eri esi accori to which the are selecte evelope applie a replace Or cocer is with the total ratioale that ies the se of the phsicias sills a of the pro fessios resorces While i itself relievi o pai a cri o isease esi ratioale or meical philosoph is cosciosl or ot a biqitos a essetial compoet i the theor a practice of meicie a part of ever iaosis a ever treatmet While meical sstem a epressio which coves m meai better tha a other trasces the iivial aspects aets aecies a eve the professios of health care it is the total framewor that i
2
corporae a ue hem all I eeme he egree a he ualy of her egao o a fucoal hoe he eg beh ha ega o he pupoe of opeao effecvee a he eco of proge Syem ca of coue eve be oge ha he echcal compoe avalable o a a gven me a ye coual u fog ehape hoe compone a eveal he place a he pec cao fo e oe hough he compone kowlege a meho may chage he yem hey eve may ema he ame yem he ee ha a ver ema he ame ve a a ma he ame ma whle he ubance coualy chage I cooe whehe o o hey ae explcly ae he cenral aege of mecal pracce he obecve he crera fo ucce he pepec ve he bac peme he value he fame of efeece he way of hkg abou healh a eae a he econ ake he ue fo new kowege a echc he vey hozo whoe ufolng ough Meca yem o only gue he phyca aly pacce bu mol h profeoa way of lfe; eeme he fucon of phyca an of he pofeo; ee he obgao o v ua an o a of ocey Thu yem boh he cocepual max aou whch he oa ap parau of healh cae ogaze a he eoogc evome n whch ha apparau fuco Syem ubec o egn bu o o covery I fou o aue bu he mn of men a emoae he wok Mecal yem herefoe ubec o reeg mpoveme o eplace me he nee fo a chage of yem may ema whaeve he echcal avace whaeve he ew covee a he new cue I ee he nee fo bee yem may even be enfe by cec echncal a ocal avace The aeuacy of a pacula y em of mece meaue o o much by he exng heah au a by he effecvee wh whch ue avalable kowlege a echc o behaf of huma heah a by he ay efe ow uccee faure uncomplee ak an u olve pobem a meca cen 3
who eepy cocee wh he pee healh ee of ocey ha can be me bu ae o a who ac uae wh he oeopahc pofe o a hoy I am convnce ha he ceal fuco of h po feo o bg o beg a yem of mece whch wl make he mo effecve ue of he fu of cence a whch wll gve momeum o vegao a evelopme ee e eco Le u exame he poble houghou log ecoe hoy mecne lke elgon a polc ha bee ubec o cleavage o chool of hough a pacce I eopec howeve he choo appear o have falle o wo ma camp The "goe hea of boh ae aceable o auy Iee a Dubo• p ay "he myh of Hygea a clepu ymbolze he evereg ocllao bewee wo ffere po of vew mece I oe fom o anoher hey have a way exe mulaeouly al cv lzao Boh ae cenble oay hough a he pa he cul of Hygea e o be egece a he kll of celpu loom lage a bgh he m of man p A sepius
he cea heme of he yem ym bolze by cepu a oma oay ha bee he coce fo he afflco o whch ma he a ucepble ccog o h yem eae whaeve may be a abou hem ae vewe a eae a auoomou ee whch heaen ma aack hm aoy hm empoaly o pemaey able hm pa hm euce h capace fo pleaue a fo wok a hoen h lfe Whe accog o h cocep vual ffe he ucepb y eance a epone o he vaou eae each of he eae evehee a ey wh a cve aual hoy ubec o oly mo mofcao by he "ho Deae ae ubec o e fcaon ecpo an clafca o oology noogaphy a f feeal ago accog o he epecve caue eoogy (2 he ogan fuco an pocee ha are affece pahology; (3 he naue of he ubace phyo pahology (4) he effec o ma
feao ympomaoogy clcal pcue a () he heapeuc meaue o whch hey epo he cenal aegy of h yem of mece o enfy he eae a guh from ohe o evauae evey; o lea moe an more accuaely an mnuely he uc ue a pocee nvolve a he evao fom he oma o map he coue of he eae; o efy caue a o f a appy heapy whch wll emove block o avo he caue whch wl hal ear o evee he poce o whch wll emove epa o eleve he "effec of he eae a pefeably all of hem I ho accog o h heme he fuco of he phyca o evee beween he paen a h eae He efee poeco a kgh hng amo alway eek g upeo weapo fo combag eae a eagely exchangg h lg fo arow h aow fo magc bulle a h bue fo aomc weapo ccog o h yem he key ueo he phy can ue are: Wha ha he pa e go I wha pa of he boy Wha caue faly Wha goo fo Fo evey eae hee a caue o combao of caue ofe ukow bu alway o be ough a fo every eae a cure aleay a ha o awang covey ccog o h yem ue cue pecae o eame of caue Unfouaely "of he wo houa affco kow huma paho ogy we kow he eology of le han haf hee beg pecely hoe ha ma ha commo wh hghe mammal Of he eveal hune new phamaceucal a bologcal a he coule new ume a meho whch ae mae avaable each yea few have anyhng o o wh he caue of he eae owa whch hey ae ece The popone ema cofen nevehele ha gve me an aeuae eeach pogam ceee aoun each eae o eae caegoy he caue a cue wll be covee a man eae wll be "pcke off oe by one unl healh ha bee wo he empha of coue no o excluve a I have awn no oe chaaceze any pacula pofe o hough eem moe nc Oeopahc pcple
to medicine in the United States than elsewhere. We al rejoice, for exam pe, in the growing recognition that to approach man's diseases rationally or, to use the language of this system, in order to solve their etioogic secret" - we must turn to man himself: the whole man, the in dividual man Nevertheess, this recognition is sti a rhetorical one, evident mainy n exhortations exressions of hoe, and avowals of faith, more cleary expressed in prefaces of textbooks than in prac tice Progress is sti sought, measured, and acclaimed according to how precisey and mnutey man can be dissected into his component arts, processes, and molecuar secies, how specificaly his diseases can be identified and reated to those components, and how specifically they can be treated by pysicians especiay quaified to dea wit them This system, unfortunatey, encom passes no reconciement between the whole man and his components; it must, therefore, conti nuay aspire to or pretend to travel two divergent paths whie, in fact, it strides along the one it knows best It holds aloft the banner of te Whole Man, while it proceeds, nosoogicaly, diagnos ticay, and therapeuticaly to take im apart I have refrained from naming this system because I have been more con cerned with presentin an attitude, a way of thinking, than with arriving at denitions Te system I have charac terized (some will say caricatured) as appeared under a number of abes, euphemisms, and epithets Among the more recent ones are alo pathic, etiologic, specifistic, curative, remedial, reconstructive, scientific, and modern medicine
l
Hygeia
The primary concern of the other system of medicine is not the natural history of diseases, but of men From this viewpoint, disease and diseases are not merely the superimposed ef fects of adventitious causes They are not epiphenomena o f patho oic moecular and biologic pro cesses which intrude upon ife They ae ife, life under unfavorabe cir cumstances those of disparity be tween the capacities, resources and resonses of the individual, on the one and, and te demands and te
circumstances of his life, on the other Disease and diseases, there fore, are understandabe, not as en tities in themseves, but as aspects or phases of the individuals natural istory, in terms of h nature in rea tion to his total environment Since the individuas total history and tota constelation of capacities and resources, demands and circum stances - and therefore his responses and adaptations - are unique for him, disease is bioray Our ill nesses, our leves of heath, our pre dispositions, our resistance, re sonses, and adaptations to all the eements in our environments are, therefore, as much a record and a cumination of our individual biog rahies as are our ersonalities We are wat we are today argey because of what happened to us yes terday and everyone has had a differ ent series of yesterdays The ap parent sameness of diseases in dif ferent individuas and the cassifiabil ity of diseases are testimony to the fact that man can resond in ony a limited number of ways to an infinite variety of provoking factors His il nesses, ike is other responses, reflect his nature, rather than the quaities of all the factors that act upon him The ilnesses of man can find expression ony through a limited number of instruments; his organs and tissues can behave only according t o their respective natures The diseases - the aberrations of the individual organs and processes of the human body - are, therefore, much more subject to treatment by formua than are the inesses of the human being For these reasons, the same diseases" in different in dividuas may have very different causes," and different diseases in different individuals may have very simiar causes From this view point, therefore, the concept of specific etioogy i s untenable The patients true ilness, then, is not te disease, the particuar aberra tion of organ, cel, or process His il ness is in his tota being; it involves and refects al the factors that make him a unique individual The patient with duodenal ulcer is not i because of his ulcer; he has the ulcer because e is i It is a phase, an expression, a comlication of his ilness as a human being; it is the natura extension of biologic process under the circum
stances of is ife The question of the diseased orans and rocesses is sec ondary to the nature and origins of the patients ilness While minute study of his ucer, and of peptic ucer as a penomenon in itself, with its own natura history, has revealed a great deal about peptic ulcer and what to do about t suc study can reveal nothing about the ill ness of the man or what to do about hm It is upon him that this system of medicine ams its available arsenal of methods From this viewpoint it is as ridicuous to say that peptic ucer is a gastroenterologic disease caused by hyperacidity and hypermotility of the stomac as to say that a womans tears are an ophthalmooic afliction caused by hypersecretion of the lacri mal gands Normality and health, and ab normaity and disease, therefore, are not searate phenomena Normal processes and disease processes are not different kinds of processes; they are the same processes, structures, and phenomena oerating under dif ferent circumstances There is but one continuous spectrum, of infinite numbers of hues, one blending wit the oter, extending from health at one end to disease at the other, and not two separate and distinct spec trums Any part of the spectrum is completey understandable ony in the context of the whole To be con cerned exclusivey with either end of the spectrum is to be scientifically or medicay color bind and to restrict ones understanding even of that end It is the concern of this system of medicine to understand the factors that deect ife processes toward the wrong end of the spectrum It main tains that studying ony the arrival at that end cannot yield that under standing From this persective, therefore, it is not merey the function of the hy sician to intervene between the pa tient and his disease, but, in Gregs6 words, to keep or to put the patient in command of the situation This requires the development and libera tion of his resources and te achieve ment of his best possible way of life This means, first, the identification of tose factors in the human oran ism, in human ife, and in the human environment which inuence his resources and capacities, and then the adjustment of those whic are criticl
2
an which are subect to contro The system therefore is preicate on the recognition that it is the patient who must get we an stay we that cure comes from within it is base upon the fuest iberation an eveopment of the heaing forces of ature' This systm by no means scorns paiative treatment as is commony suppose It recognizes that paiation the treatment of iseases their manifestations symptoms an processes is an essentia part of tota therapy But i t insists that paiation is not enough an that the treatment of iseases is ony paiation. It insists aso that the paiation not be such regaress of its immeiate effects as to jeoparize the patients' own resources an capacities or to impair an retar their recovery an their future maintenance an eve opment Accoring to this system then progress ies in the irection of continuay increasing knowege an unerstaning of man an his nature an of men an their ifferences of the impacts an emans of human ife in genera an of human ves in particuar on bioogic structure an function an of how they in turn meet those emans an influence the capacity for human ife This from the perspective of this system is the roa to human heath. Whie the promotion of heath raising the eves of weness' wi inevitaby bring increase freeom from is ease the conquest of iseases is not in itsef heath Like the system symboize by Ascepius this one too has ha many abes among them: ecoogic hoistic physioogic constructive socia an in its broaest sense psychosomatic meicine 8 The roe of the osteopathic profession
Uner the etioogicremeia system of meicine research has since the epochmaking investigations of Pasteur an Koch prouce theoretic an cinica achievements so immense that they constitute the buk of moern meicine The ski of Ascepius ooms" 2 arger an brighter in the min of man than ever before It seems natura to assume that proecte into the future this is the roya roa to heath an that the vast isease buren that con fronts man to 34
ay wi inevitaby yie to crash programs" empoying the same approach It wou seem to be ony a matter of overcoming technica if ficuties an iscovering the necessary causes an cures However as I sha show conviction is mounting throughout the meica wor that the prevaiing system oes not meet nor by its very nature can it meet the heath nees an the isease probems that preominate toay A tren sti sow an unorganize is increasingy evient in the irection of ecoogic physioogic meicine The tren to this system of meicine from the prevaiing one or the achievement of a proper integration between them is the great improvement in meicine which is now in the process of socia cinica an scientiic evoution What has this t o o with your profession You areay know the answer This is but the moern ver sion of the very transition the very improvement in our present system" for which your profession was estabishe The osteopathic profession came into existence in 892 as a sma but vanguar force in this transition an as the ony organize voice for the ecoogicphysioogic system of meicine It was not the first voice nor is it now the ony voice there are many in meicine sci ence government an eucation but it was an sti is the ony organized voice Furthermore unike its scattere preecessors it came in to existence not ony with principes phiosophy an expectant" confience in natura heaing forces but it brought with it a new awareness new strategy a n new skis It reformuate in the knowege an the anguage of the time the whoeman approach an its centra strategy of support an iberation of the inherent processes of homeostasis aaptation resistance an recovery But it aso ientifie if not for the first time certainy more rmy than ever before certain criticay important factors an some of the most common impeiments to these processes that arise in human ife Even more important it eveope remarkaby effective cinica methos for etect ing evauating an inuencing them These factors an impeiments have their origins in the aaptations
an maaaptations to the unique an unceasing emans that gravity makes upon the human being They are reate to the anatomic rearrangements associate with verticaity an to man's incompete structura an functiona aaptations to the erect stance The emans of gravity present man with pecuiary ifficut bioogic probems" which are ony now beginning to receive systematic investigation Primariy biomechanica in origin they are probems in circuation in istribution of fluis in rainage of organs tissues an cavities in the mechanica aspects of viscera function in gestation an parturition in the seconary effects on ceuar function an metaboism an most particuary in the massive motor system of the boy through which we act on our environment an express our very ives Impropery or inaequatey sove these probems become important an even ecisive impei ments to these various functions Whie they appear to have ony oca an minor significance to one who searches ony for isease they impair an impee not ony the functions of the immeiatey affecte organs but through the communication systems of the boy the functions of others They exaggerate an unfavoraby moify the impact of other variabes in human ife: environmenta emotiona socia nutritiona traumatic hereitary congenita an microbia Their presence thus inevitaby impairs to some extent the iniviua's capacity for aapting to the circumstances of his ife for resisting threats to his heath an for recovery from isease The impairment becomes more critica the more unfavorabe the other circumstances in the iniviua's ife an in himsef The mitigation of these impeiments therefore iberates the forces of resistance recovery an aaptation an to a significant egree insuates the iniviua against unfavorabe factors renering them ess impor tant These factors are unique in their high incience in man in the scope an nature of their infuences an in their amenabiity to contro by Wn h rn hmn n w York Cy o h n o dy ron rn undr h drcon o Mn Junmnn MD
Osteopathic principes
meos evise a evelope by e oseopaic professio Te sperficia tisses a e moor system of e boy or meas of ex cae wit a of actio o te ex era eviromet ca revea mch abot e aeqacy of or iivia aaptatios to raviatioa ema a to te isceri observer are also mirrors of the itera eviro met Systematicaly evaate by meos evise a aapte by te osteopaic professio tey revea iformatio abot te perso as a wole wic as yet is ot obtaiabe ro ay oter meas Te frame work a itemet of he boy therefore bo refect a ifece te eath of te iivia Tere ca be o obt for tose wo ave eveope te ecessary skils for ose wo ave beefite from ose skils a for tose wo ave some erstai of e biooic facors a mecaisms wic are i volve a osteopatic maipla ive herapy a its associate ia ostic mehos provie vales i ealh service for wic tere are as yet o sbstittes Importat as tis cotribio was owever a mch as yor profes sio i its eary istory cocerate o he eveopmet a appicatio of te ew iaostic a terapetic skils ceere aro boy mecaics i was ever a excsive emphasis for he professio tho i was for may iivia members Te professio eary recoize tat e care of te woe ma reqire he appropriate iteratio of al meos a measres wic wo cotribte o is wellbei a ex plicily state so i the carter of its frs coee Te professio sot from the beii o iroce a more com preesive more raioal a more effecive dsn ito te woe of meicie oe wic wo ie te selecio se a evelopmet of e pysicias etire armame arim It recoize at e system col be o beter ha he oal metooloy at serve it However te professio isiste a wit oo reaso a o system of meicie col be compreesive wic i o ive aeqate cosieratio a herapeic ateio to biomeca cal factors Bt it ever isise a ese be te sole cosieratios I
wecome cosieratio of all other facors a wecome a se w e privilee to o so) a oter meos ta co hep ive expressio o te tota esi Tis icle ay a al metos i srery obsetrics a te treatmet of iseases eeray" wic wol coribte to webei wic wol promote te paies ow resorces a ep im take comma of is sitatio a wic wol o treat oe illess wile opei oors to oters Tis toal esi this improveme i or preset sysem of meicie" toeter with a most importat co tribtio to its impemetatio is wha te osteopatic professio 67 years ao soht to itroce io meicie a for which it establise itsef It is eiable tat smal i maie hoh i was i was a maificet beii I brot ew ope a ew scope a ew prac tical meai to the oistic ma cetere system of meice eqale i its eire 2300year isory Ths i my opiio is te reat missio o wich is pro fessio mst oce aai aress itsef Ths is e vas horizo wic awais yor foi Does t satsy the tea?
oes it meet the criteria for te cor rect ecisio? Time oes ot permi e testi of al the criteria pose i binnin w i mnifnt in iw f t irumtn fundr f t tti mmnt ud nt td mr diffu tim tim wn t mdi trm w runnin mt trn in t it dirtin i w t rid f mt riitu nd f t tiiurtiifiti du t mkin diri f Pur K n Brin nd r ri nd mn tr Witin r r rid f itr t diri brut nfidnt xttin tt mdiin w rd t idntif n b n t if u f mn di idntif nd drib t ifi ur ti itd wit tm nd t find n t r rk ifi mi r bii ur wi wud kmt t u nd und tir fft In rid t fwd rid tt inidd wit t ntir if f t ti rfin rtr rr w md n mdiin tn in f it riu itr ru bn mnifn drmti t im t undrnd r ud rd bn ritiu tim in wi t k t nin t wrd f t nd fr ntr r I i timn t t r rnt f t r tti mmnt t t ur t dtrmintin nd ki f t rfin tt nt n w t n w w in ti rt win trm but t it w b t d n nd n miruu t rw
a earier sectio I shal terefore test oly te most ecisive criteria those wich if me wil araee e meeti of te ohers os fll a socal nd on of such mporanc as o dmand h connud xsnc of h oso pahc profsson and o jus socs mos nrous suppor? Is there a real ee or a cae i te sysm? Tis i seems o me is te most ecisive criterio of all a i terefore merits te mos rioros testi ortately mc of tis testi as alreay bee oe a wi coclsive rests As metioe earier more a more meica eaers a scoars ave coce hat briliat a meros as ave bee e sccesses of specifisic meicie i has faile abysmaly to mee existi ealh ees Nor wil e failre be tre to trimph by e overcomi of tecica ifficties a by te iscovery of missi cases a cres It wil cotie o fail becase of its basic iaeqacies watever e tecical avaces Becase of e atre a scope of te me eal ees tis faire ca oly coie o ave icreasily wastef a raic coseqeces o or society I seeki aswers a e basic eve to ese overwelmi probems tese meical eaers have eoqey emosrae that sais facory proress i te sotio of ese problems awais e applicatio of priciples cocere more wit te factors tat etermie mas vlerabiity a wit the cres for al te iseases to wic he is or becomes verabe Te basic soess of sc a pysioloic sys tem ow ows more seaiy a ever tro the azzle of specifsic meicie a reveals more sharply ta ever e itrisic iaeqacies of practice base larely o ocries of specific etiooy a cre Te wriis of Sieris9 Gre bos Stieitz Gasto1 SeyeJ Wolff4 ese a 7 to ame a few are especially eservi of yor carefl sty As a mater of fac if tis professio is to ive serios atteio o its orizos he sty of ese works ms i eviably be a part of ta attetio A smmary of ese cotribtios is far beyo the scope of tis paper a ime permits seecte ocmeatio
5
fro only one or wo of hese wrngs I onvne ha were hs professon o gve areful suy o only one, he os reen one, of hese volues The Mirge ofeh, by Ren Dubos, woul n s own sense of reon renewe an s onfene n he rghness of s founng purpose reawakene I s a wse exng, an beaufully wren book, by one of he worls os sngushe robologss A soberng onluson eerges fro he suy of hese works ha s well subsanae by he reen Na onal Healh Survey an oher auhorave repors on he sae of he naon's healh No only s he sae of Aeran healh no supe ror, as we boas, bu, properly easure, s poor an geng worse If one exanes no he fgures for reue eah raes an for nrease lfe expeany a brh (whh are usually snerree as proveens n healh an n lon gevy ) bu he aoun an kns of llness, s saggerng n agnue an sealy nreasng A he pres en e 10 per en of he average Aeran's noe goes for eal are, an hospals anno be bul fas enough o aooae he sk Foryone per en of he populaon have one or ore hron sease on ons an 17 llon persons, abou oneenh of he populaon, are par ally or opleely sable by s ease alone One ou o every four zens wl have o spen soe onhs or years n an nsuon for en al sease One woners, wh Dubos, wheher he preense of superor healh s no self raply beong a enal aberraon Is no a eluson o prola he presen sae of healh as he bes n he hsory of he worl, a a e when nreasng nubers of persons n our soey epen on rugs an on o ors for eeng he ornary prob les of everyay lfe 2 1 We see o have forgoen he hulang shok hs ounry fel no long ago when he Seleve Serve progra reveale he ense aoun of sease an sably n he rea of our ounry An no sass an reveal he low level of vgor whh os of us have oe o regar as nora 7 I s grly ausng ha even he wor euphor whh use o ean a sae of wellbeng,
has graually oe o esgnae an abnoral sae! Bu surely he onques of he ounable seases, prolae as an aheveen of senf ene esfes o he effeveness of s ehos I s no proble o eonsrae ha, onrary o he prevalng presson, no only have he nfeous seases no been on quere, bu hey onnue o be a reenous buren As Dubos shows, he sleang presson s reae by he use of an naequae yarsk oraly for evalu ang he porane of a eal proble an he progress n he solu on Now ha he wesprea epes an plagues of he pas, wh her wholesale oraly, have been brough uner onrol, he on nue use of hs nex s eepve an angerously oforng If, n sea of erely ounng he nuber of lves ene by sease, one easures he oal aoun of lfe spole by sease, or he eono os n rugs hospals, an oor's blls an n reue prouvy, he buren of nfeous sease s re veale as sll reenous Mrobal seases have no been onquere Raher, physans an senss have resgne heselves o he belef ha a relave proeon agans he an be bough a he os of a huge ran so 2 S By no eans s he grea reuon n oraly o be ssse as un poran Bu auray an perspeve ean reognon ha he grea erease n epe oraly of he pas few eaes s uh less a pro u of senf ene han of huanaran oveens an soal progress eang o proveens n soal paerns, n physal envron en, n sanaon, n lvng san ars, an n nuron I s a prou also of naural proesses of aapa on beween an an robe an even of suh faors as he nrou on of nexpensve, easyoauner oon unergarens, shorer workng hours, an oher nenal an aena rusanes 10 1 These faors have onrbue ore o he onrol of nfeon han all rugs an eal praes 224 The oll of huan lves exae by nfeon ha begun o erease several eaes before onrol easures nspre by he ger heory
were pu no effe an alos a en ury before he nrouon of an robal rugs The onser of nfeon ha beoe a ere shaow of self before ene oul prove raonal an senf ehos for s onrol The effe of he anbaeral rugs has been bu a rpple on he longesablshe elne n oraly, a elne largely arbuable o wesprea prove en n huan faors Ths s no o eny, of ourse, he grea effeveness of rugs an al praes n nerrupng an prevenng any nfeous proesses, even any whh woul be faal, bu s o pu he n proper an urgenly neee perspeve Moreover, hs s no erely a aer of hsoral perspeve, for has ral bearng on our presen prob le Eologurave ene, so preoupe wh sease an eah an wh her robal auses, fns lle of neres n he huan faors whh per he o becoe auses Overlooke s he sple bu val everyay observaon ha whle, eranly by enon, robes are essenal eleens n he prouon of nfeous seases, he fa re ans ha nfeon usually ours, an even exss for whole lfees, whou prouon of sease Dsease s he exepon I s he on sequene, no of nfeon, bu of a breakown of he ehanss of a apaon an ressane In an he provoave ause of robal s ease ay be a surbane n any of he faors of hs exernal or nernal envronen 2 79 As Paseur hself sa, unresre ulpla on of gers s no less a onsequene of llness han s ause For hs reason, rugs anno be effeve n he long run unl seps have been aken o orre he physologal an soal onons orgnally respons ble for he sease " p l Thus, onsruve a fore as he orne of spef eology has been n eal researh, anno prove a sasfaory aoun of he ausa on of even he robal seases, n whh spef eolog faors are known A syse of ene whh bases self on suh a orne, whh res s sklls so uh agans nfe ous agens an so lle fo he an whh reles so uh on bulles an Oseopah prnples
shtgns aie at the ininite vaiety inectis agents whie neglecting t ientiy an inlence the acts which eteine as vneability an esistance t al the; a syste which isegas an psets the natal pcesses tal aapta tin between an an icbe sch a syste can ny cntine t ail t eet even the pbes in ectis isease whi ch it p cais as its aea geatest sccess Even wse it ceates new pbles se ties wse in the lng n than thse that ae slve he cent staph pbe which is paging Aeican hspitals is bt ne exa pe Geat as has been this genea ai e with espect t the inectis iseases hw ch geate is the aile - etilgicay theapetica ly an peventively - with espect t thse iseases which cannt even etey be ascibe t invaing agents an which tay ae even a a geate ben than the inectis iseases hey the chnic kiles an cipples - the heat an caivas ca iseases the etablic iseases the cllagen iseases cance peptic ce an any the ngte iseases - ae even e than the inectis iseases the pcts whle cnstelatins han ac ts hese nw pesent a ben incaclably iense pptins aleay vewheling even the palliative esces eicine an gwing at an inceasingly api ate• A syste which cntines in a hpeess qest he cases each an he ces each while negect ing the han acts which they aise can ny be egae basicaly as a aie hweve biliant eective an wece the expeient eases with which it te pies Unlike the inectis iseaes which an shaes with the anials the egeneative iseases ae ast peclia t an It is a chalenge t the expeiente t pce even thei st palli acsiies in anials he natal biltin eenses w ich an shaes with the anials aginst the icbia pathgens - eve inaatin ine eactins phagcytsis an s th - ae the aaptive pcts evltin he egeneative iseases ae qite anthe pble
As the expessin peciay han ailties natal an sel inlicte they an nt the eenses ae the pcts han evtin Inee thee can be ew i any aap tive bigic eenses against the apily changing stesses peclia t han ie any the an ceate an cetainly nt against ans wn inaeqate isiecte espnses t thse stesses In st cicstances the bigic espnses an aaptatins ae wse than the pvking acts an ae in theseves isease t n ly ae they nt selliiting bt they bece sstaining an exacebating acts initiating an ppeing vicis ci ca pcesses which cntinaly ex act lage an age tls the in ivia as he ages an as the is paity wiens between his bilgic esces an the eans pn the In eect the patient wites age an lage checks n a shink ing accnt F the st pat the chnic egeneative iseases ae nt the e ects specic cases which can be ientie excise cbate an abishe with agic bets hey ae the pcts whe ives hei igins an thei basic anage ent (in cntaistinctin t thei paliatin) ae t be n in the uniqe nate an his ie an his envinent in the ieences ang en that case the t e bak n sepaate an ivegent physi gic paths in the act that an is eqie t live a han ie with bilgic appaats which h inheite we anias Hpes ies in the ceatin thse cicstances which wi peit each inivia t stay n his st avabe physigic paths an eect hi navabe paths speak cases cues an evesal is t eveal ignance the basic chaacte chnic egenea tive isease A sty ecenty cplete at C nel Univesity Meica Clege by Hinke an W8 agniicenty epities the piacy han ac ts in al isease he ilness pat tens ing 20yea peis in yng ath appxiately 35 peple awn the abla ty ppatin eveae that epises ilness wee st neven ly istibte On furh the in ivias expeience a mar
all the epises ilness that ha c ce ang al the pepe whi le anthe th ha nly 5 t 1 0 p cent the ilnesses Even e statin than the wie ieences in ssceptibility was the cpehensiveness the nnselectiv ity the ssceptibility he aths state h ff uptbty to w ot py th ut of ff uptbty to o o oth pf y ro I y goup th b py ff th susptblty to l i grl rgrdlss 0/ ts typ or 0/ th usl gts iold hu h ub of po of l p by u th ub of fft typ of yo tht h hbt o Athough gt y of th y o ght o o o two og y t po of w ot t to fw yt; t th ub of o of l p by u th ub of h og yt o o k th ub o f po h p h hbt of g ty of toog. H w ky to h o 'jo b f-gg w o o b tt . [It upp]
In the pinin the aths these inings ae st easnably ex plaine by assing that they ae epenent pn acts peating within the inivia inlencing his espnses t the geat vaiety the acts knwn t be capabe casing isease Cnsistently high iness ates in ssceptibe inivials eect cntining inabiity · th in ivia t ake aeqate aapta tins t his ttal ilie One the st signiicant eslts the sty was the eakable cn stancy iniviua illness pattens it inicates "ha he ns pa erns f hese pepe were reave e nuened b he herapeu ef frs f he phsans wh reaed hem (Itaics spplie) It ay be asse that these theapetic e ts wee easnably epesentative speciisticetilgic eicine an incle a epesentative sapling the seveal hne new phaace tical pcts an iace gs p ce each yea selecte thei eectiveness in each ilness Pehaps nthing e cealy aaties the basic inaeqacy a syste eicine which in the nae scence cncentates s ha n in ivia iseases thei cases an thei ces while in its cntept what it egas as achai
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37
philoophy it o tragically diregard the man and the factor in him which determine hi ulnerability to illne in general Hinkle and W olff conclude Ultmately medce wl have to take accout o th teatmet o lle It vey pob· able that a ceag popoto o the theapeutc eot wll have to be dected at the patet' elato to h evomet w w o mk y si improm i The poblem tad beoe u a a te challege to medce, ad ot a a eay oppotuty [talc uppled]
Obiouly it i becoming more widely recognized that dieae and mot particularly the rapidly riing tide of degeneratie dieae can be temmed only through identification and control epecially prophylactic identification and control of the ariable in the human organim and in hi life ituation which determine the phyiologic path he trael Thi recognition howeer ha had little impact on medical practice The baic trategy remain eentially un changed though a tranformation in medical knowledge and technic ha taken place Society urgent need for the holiticecologicphyiologic ap proach i now far greater than eer That approach now offer the only hope But unfortunately thi moe ment till await organized dedicated leaderhip and implementation Thi i the moement the great improe ment in the deign of health care that thi profeion a it only organized oice et out to lead 6 year ago6 Seldom in hitory ha an organized group of men and women perceied graped and then eemingly relin quihed a greater opportunity Preented by it hitory and now by ociety with an immene opportuni ty your profeion till debate whether it ha a function of it own and a reaon for exitence and wonder where the reource would come from if it had Fortunately there i till time a little time for a econd chance Were thi profeion to proclaim to the world again and again factually clearly courageouly that thi i the moement it eek to propel and why and were it to demontrate that gien the mean it i qualified to do o it wou be gien the mean There i no doubt that the rt criterion " there need for a change of ytem i amply atified I th function appropriate to, and 238
within the power o the oteopathic profeion?
Not only wa thi moement toward holitic medicine your found ing purpoe it i a rich part of your total experience a a profeion It i ore deeply a part of your inight than of any other profeion more than you apparently recognize and certainly more than now find expre ion in your function a a profeion Your profeion i till the greatet reeroir of phyician oriented in it principle and killed in their applica tion You are now tronger better organized better armed more ac cepted than eer before Though you are now preoccupied with number ome of your greatet aet are thoe proided by your mall ize mobility maneuerability flexibility You hae the independence that impart power to eery minority moement You lack only the commitment the coniction the objectie to put that power into motion and to gie it direction
Doe it offer comprehenive deign for your tota effort and for the mobiization and utiization of your reource?
The anwer to thi quetion alo i a reounding affirmatie a you would dicoer Long aborbed in catching up and keeping up with all the adance in modern medicine and with meeting tandard in all the in trumentalitie and technic of medicine you would now be able to gie leaderhip and to et new tan dard in the integration of thoe in trumentalitie and of the aailable knowledge on behalf of human health It would become poible for eery egment of the profeion eery pecialty eery phyician and eery organization to define their own bet role and for the profeion a a whole to achiee balance among all of it many often conflicting area of endeaor t would offer deign for new and needed form of profeional organization and of clinical practice Similarly the profeion ha long operated on the apparent premie that oteopathic education conit of a more or le conentional medical curriculum to which imply another element ha been added like the cherry on an ice cream undae The profeion would recognize that an improed ytem of medicine de
mand an improed ytem for the education of phyician truly oteopathic curriculum till await deelopment The profeion and it educator would dicoer that the horizon that i propoed for your un folding proide the bai for total deign of the curriculum of it com ponent and of it facultie De manding a the ytem doe new form of medical practice it would alo precribe the new form and in trumentalitie of medical education Doe it define your tak and your obigation?
Let me identify but two which are of uch at ignificance that they alone would demand the exitence of your profeion The irt i the continued deelop ment of one of your mot important and certainly your mot conpicuou ly ditinctie contribution to medi cine Were you fully to commit your elf to the function which ha been propoed you would dicoer that oteopathic manipulatie therapy with it ancillary diagnotic method i not merely another form of therapy in your total arenal t i not one which may be aritrarily withheld from the patient jut becaue it mechanim are not undertood be caue the phyician ha not taken the trouble to deelop the neceary kill becaue he nd it incon enient or becaue it i politically inexpedient You would dicoer that you hae no greater moral right to withhold manipulatie therapy than any other therapy But it i not jut another form of therapy it i a whole trategy a whole approach in itelf It i not merely a treatment of "leion in effect it i the putting of influence into the whole man through the acce ible tiue of the body influence which deflect hi life procee to more faorable path and which help put the man in better command of hi ituation whateer it i whateer it may become whateer hi illne whateer it etiology To peak and to think of maniplatie therapy a though it were a dicrete uniform entity independent of the unique undertanding and kill of the in diidual phyician one which can be deigned for a mythical "aerage man a omething which can in wholeale manner be declared "indi cated or "contraindicated for thi Oteopathic principle
or that condition or to regard it as an aspect of physical medicine is to miss the strategic significance f osteopathic manipulative therapy and to imit its great potential As a physiologist who has studied deeply in this area I am firmly con vinced that this is an area of mdicin of such vastness of such depth of such endess ramifications and interconnections and of such import to human heath that it i s as demanding as exacting as honorabl a life work as any other. Its potentia has hardly een expored Commitment to the proposed horion will help you rcog nie your obigation to give manipulative therapy and its cognate arts and sciences thir appropriate status and full expression in your educational system and through that in practice Abov al it wil guide you in th recognition and th fulfilment of your obigations in the deveopment of this contribution. I convinced that commitment to the tota design of which I have spoken wil in itself give grat impetus to that development not only within your profession and its institutions but throughout the world. For ex ampe there can be no doubt that th unfavorabe infuences of musculoskletal stress and the favorale influences of ostopathic manipula tive therapy are mediated to a large extent by the periphra and seg mnta nervous systm In the past quartercentury ther has ben an immens increase in aboratory and cinica investigation in very civiied country demonstrating () the dci siv infuence of th innervation of tissues not ony on thir momenttomoment activities but on their tota condition and on thir rsponses to al other factors; (2) the subversiv "organier roe of the spinal cord brain stem and peripheral nrvs in virtualy every disease process and (3) the common origins of the unfavorale influences in the muscuo skeletal and other somatic tissues of the ody The literature is now so vast xtending into every function every organ very disase every area of health and disease as to constitute a massive new movemnt in mdicine. This is a movmnt to which the ostopathic profession shoud long ago have given leadership. ot ony has it not given that leadership but it seems not even aware that the move
ment is under way nfortunaty becaus ther has en no conceptual framwork to unite them these countess contributions remain scatterd fragments which nd no place in prvaiing frameworks The erecting of the needed framework by this profession woud hav tremen dous impact on this and many other aras of investigation and would give needed direction to its own investiga tions. The second obigation with which I woud iustrate may be designated as medical statesmanship The function of physicians and particuarly of their professions is fa more than the practice and advancement of their art They must be dpy concerned with al factors in society which have a significant bearing on human heath They must seek with the cooperation of all social agencies the best possibe environments for human ife Among the factors that dply affect th pulic health and the effctiveness of mdical service are the forms and structure of medical srvic itsef and the socia conomic and politica framework in which mdicin is practiced Thr is much that is good of cours in th present framwork of medica practice. But thre is aso much that is inimical to the health needs of society much that prevents the best use of cinical taent much that needlessly and severely imits its availabiity and exaggrates its cost much that prevents the most effective utiliation of available knowledge and tchnic much that degres th physician and the profession of mdicin much that is evi And much therfor that the public finds in creasingy intolrab It is not a coincidence that these same features ar comptely inimica to th grat contributions the osteopathic profession set out to ma Indeed they ar incompatib with and indefi nitely postpone the practice of any system of comprehensiv constructive prophylactic ecoogic medicine Such a system of medicine not ony demands a change in the structur of medica service but provides the design The strong voice of this profession has yet to be heard on ths issues. It has een remarkably wiling to acquiesce to the prsent framework and to demonstrate its ability to
adapt to it Its silence on these issues contrasts sharply with the vigor with which this sam profssion battles for rights and privileges for itself To giv support even by silenc to thos parts of the framwork and those forms and aspects of mdical practice which for socity's sae ned changing is to end your strength to the prevention of the unfolding of your own brightest horions ow is the tim for mdical citicism and medica statesmanship of the highest order. ow is the tim to utiie your organied strength fearessy creatively imaginativey and unselfishly in the pomotion of the needed hangs This is not ony you oligation as a profession. It is the only way along with development and dissmination of your own clinica scientific and humanistic con tributions to win the strength and the support from society that you so dsperately need. nclun
You hav bfore you then a momntous decision: the functio you propose to perform for society I do not know whether you wil mak a decision or what dcision you would make. I do now that to make th wrong decision or to dlay much longer (which is the same thing) is to miss you second and ast chanc to abdicate the right to existenc as a profssion and to make of yur illustrious history a shameful fiasco Far far worse it woud delay for many decades a great forward step in human halth and therefore contribute to untold waste of human lif in needless suffering In effect the decision is between becoming as you set out to b the head of a new movement in medicine or the withering appendag of a dclining one Accoding to its decision the ostopathic profession eithr will aways loom bright in the mind of man or be recorded as a passing footnot in the history of medicine. What horion then do you propose to unfold? What contribution to society do you wish to mak? That is the decision efore the osteopathic profession It wil eithr merit societys nurturing or it will not Society wil b the udge of that Socitys udgment awaits your dcision
3
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An allegory A forgotten episode in Americn transportation history From Brdr' Digt April
21
Tis story came to igt a few years ago wile foundations were eing dug for a new fission power plant in Kan souri. Te cornerstone of wat ad apparenty een a scool or a irary was uncovered and found to contain several ooks, in wic were recorded te facts from wic tis summary as een drawn. More tan years ago, in te ate 1850s, wen mecanied transportation in tis country was stil very young and uite primitive, tere was a young railroader named Taylor Andrews, wo worked on te only existing ine of te time Young Taylo was te sort of person wo was incined to dout tat te way tings were eing done was necessariy te est way, and wo was always ooking or etter ways of doing tings He egan to ecome convinced, as e rode up and down te railroad line, oading and unoading freigt at one depot after anoter, and continualy firing te engine as it went ack and fort etween stations, tat someting was wrong wit te asic principles How foois it is, e tougt, to make te same stops at te same communities to deiver te many litte ting tey needed and used up day after day. Wy not, e mused deliver, instead, te raw materias, tools, and macinery wt wic tey could manufacture and raise te tings tey needed? By deivering meansofproduction instead of con sumer goods, te railroad could ep eac community develop its own economy, allowing it to ecome more sefsufficient and ess dependent on frequent deliveries. He recognied, of course, tat suc a system would re quire different kinds of equipmen tan were ten in existence or even on te drawing oards. Equipment woud e needed, e reasoned, wic could make occa sional mass deiveries rater tan many smal ones to eac community of macinery, toos and raw pro ducts. Te cars would ave to e lower and wider to carry te massive freigt and te engines woud ave to e a great dea more powerful How
wastefu, e toug, tat engines must use so muc of teir power just to move teir own weigt and to carry suc immense stocks of teir own fuel over undreds and tousands of miles Tere must e some way of reducing engine and fuel mass, or peraps even of designing an engine wic someow draws its fuel as it runs. Tayor studied tese prolems over a period of years and y te early 1870s, e ad ecome convinced tat suc an engine was possile and, terefore, tat te kind of economyuilding rairoad system e envisioned was feasile. By 187 e ad drawn is preiminary plans and specifications for te engines, te strong, capacious cars, and te widegauge tracks and a sketc of te system as a wole, and proudly egan sowing tem to oter rairoad men. He tried to sow tem to felow workers on te line engineers, firemen, rakemen, section ands, foremen, district managers, station masters, te vice president in carge opromotion, development, advertising, design, etc., and even to te president and te cairman of te oard Ms Opposon Everywere te
response was essentially te same. "onsense. Humug. We don't need a new system Tis is te way railroading as aways een done. Our present system is te ony possie system. If a etter way were possie, we's ave found it ourselves ong ago. Te leaders in te railroad said, "We don't know wat cray ting you've drawn up tere, ut it's wrong and it's unRailroad and suversive, and we wouldn't touc it wit a foot camsaft. And wo are you, anyway, to tel te experts ow to run teir usiness? Hardly anyody in te railroading word would even ook at is sketces But Taylor Andrews was not one to e easily discouraged So sure was e tat is genera plans were sound, tat for 18 more years e continued to refine and develop tem and to take tem from rairoader to Osteopatic principes
railroader rom shop to shop and station to station asing only that his plans at least e tested that at least a little pilot model e set up; at least hnk aout it But more and more doors were shut in his ace until it ecame evident even to him that there was no hope in ucing the existing system and that there were ony two alternatives: either orget the whole thing or get started on it himse Transecon s o By 1892 his mind was made up "The only thing to do he said "is to set up my own mode rairoad system and sho that it wors and etter than the one we now have With a ew nonrailroaders and one or two reugee rairoaders rom other countries he organized and incorporated a small company with the express purpose o estalishing "an improved system o railroading They named t h ei r c om p an y T r an s ec o n representing portation or stronger omies They managed to interest some investors set up a little shop secured some right o way and egan accumulating parts and scrap meta with which to start construction The irst thing they did was to lay a mile or two o road trac in the direction they wanted their system eventually to go and egan assemling their locomotive right on the tracs As their wor progressed others oined them; still others rought scrap or old tools and even money; some came ust to hep or to run errands n the course o a ew years Andrews and his little and had ecome quite a large and determined group They completed their irst engine and one or two latcars and ran them ac and orth on their short length o tracs endlessly testing improving reining revising replacing and "ironing out the ugs (We presume this quaint phrase reers to some sort o metal grill or excluding the many insects which would ave een drawn in rom the atmosphere together with the uel How this was accomplished and precisely how the engine perated we shall never now since the technical language used to descrie the woring o the engine and other equipment is now utterly uninteligile) ome time ater the tun o the
twentieth century they and many others who had ridden ac and orth on the short tracs were convinced that the time had come to complete their pilot system All that remained was to complete the laying o their irst line o tracs and open up or usiness to demonstrate to the entire rairoad industry and the world in genera that with the right ind o equipment there cou e a etter system o railroading which ou lierate communites rom their growing dependence on daily deliveries o consumer goods Presens Pan Ad so a ew o the
more presentale and articulate memers o the group doed their overalls put on their unday suits and set out or the state capito to see permission to extend thei tracs to a ew communities in the chosen direction and to license Transecon or carrying meansoproduction (Taylor Andrews now aging stayed home to eep the engine wiped and in unctioning order) "Very well said the Railroad ommission and other oicial Guardians o the Puic Welare "we can't see any need or all this tomoolery ut there's no law against it o we'll approve you or a license to operate your twoit spur providing you can prove to our satisaction that you now how to operate a locomotive and a reight line and can give the ind o service people have come to expect o railroas "But the delegates oected "our proposed system is not ust another railroad; it's Transecon t should e udged y its on standards and not y those we're trying to improve "Poppycoc the Oicial Guardians responded "it may e a ancycon or whateveryoucalit to you ut sure sounds lie a railroad line to us We'll hve to inspect you Ges OnceOver everal hundred application orms and a thousand letters later the ommission made a visitation to Kansouri to inspect the engine and other equipment They were accompanied o course y expert advisers rom Big Rairoad One loo was enough "This will never do they exclaimed "o train has ever run on such ridiculously wide tracs on
trary to all estalished standas And what's the matter with you locomotive? That s a locomotive isn't it? oos lie nothing we've ever seen and we've seen hem all O viousy too smal to e powerul enough And where's the tender? What? onsense! Every engine must carry a certain minimum o uel at al times Also we don't see any ender sirts or hucaps Asoluely essential And only one cowcatcher! ou kno the law requires one in ront an in ac in case you have to reverse And no smoestac! Hogwash; smoe or no no engine is complete without a smoestac And you're going to have to put on some chrome trim all around lots o it Ater the inspection the crestallen Transeconners sat around deating and shaing their heads or many days Quite a ew were in avor o chucing the whoe thing and returning to their rms and shops And soe o them did But the stalwarts said "o we must go on This is igger than all o us ure te narrower gauge deeats some o our purpose ure the unnecessary uel car and all the chrome the hucaps ender sirts extra cowcatcher and dummy smoestac will waste hal o our power ut at least we can mae a start And when we've proved how good our system can e even under all those handicaps then e can gradually widen the tracs again and tae o the superuous load As a matter o act some o them even thought the engine would loo pretty with the trim and extra attachments Conforms Then ccee. t was decided to mae the required changes The men wored hard and long narrowing the trac and wheelases on the engine and cars putting on outriggers to eep them rom toppling over and putting on tons o trim and other paraphernalia And the ommission was invited or another inspection trangest looing equipment we've ever seen they said "ut it seems to meet minimum railroad standards n act we rather lie those outriggers Equipment approved ow what are you going to carry? hen they were told they said "o that won't do Oh all rght go
ahead and carry that eansofproduction stuff if you insist but youre also going to have to carry the things that people need and want and have coe to expect railroads to bring the bread ilk eggs etchup cravats stereopticons ithers and andolin picks gudrops curtains hair oil antia cassars footstools rocking chairs and the like And Sears Roebuck cataogs so they can order ore Ater uch eate the Transeconners reluctantly agreed to carry an assortent of consuer goods in addition to such eansofprduction as they could also carry And they proceeded to finish laying the tracks to a few of the any counities they hoped eventually to serve Eveoe Poe Transecon began to prosper in its sall way and the counities it served also prospred especialy those they could persuade to accept deliveries of eansofproduction for the devel opent of their own industry and agriculture radually Transecon was abe to add a few ore engines all welltried with chroe and euipped with tenders fenders soestacks and cowcatchers Many ore people cae to work for the line and new counities grew up along the right of way deanding its services As the years went on Transecon grew in euipent staff and resources and won approval after approval and recognition after recognition However it found itself ore and ore asorbed in doing the things which had to be done to win and keep approval and recognition and less and less in the building of an iproved syste of railroading Life for Transecon had becoe a continual race to keep up with the changing standards prescribed by Big Railroad It becae so involved in continualy changing the width of the tracks to eet "advancing standards and adding new iproveents such as tailfins power string and even calliopes to replace outoded whistles and bells that there was little opportunity to lay ew trac Eq Right To be sure these
probles were difcult enough ut in its uest for "eual rights which 141
gradually becae its slogan Transecon's greatest proble was the freight it was reuired to carry To prove the full diversity of its qualiications Transecon had continually to deonstrate its wilingness and its ability to carry the countless new consuer goods which endlessly rolled off the asseby ines and floded the arket in response to advancing standards and to eet the deands of the populace for "the very latest Aong the ites for which Transecon sought and proudly won approval were autoobiles ashing achines hair curlers pens for writing under water refrigerators electric guitars devices for shaving peaches ixasters caeras lipsticks phonographs radios ovie fis coic books hula hoops and any others totaly unfailiar to us now It even won the right to carry products that were known to dull the senses cripple the intellect and destroy the wil to work: television (apparently a priitive for of teesense) tobacco (a noxious weed which was soehow burned in the outh and its fues inhaled) and liuor (as far as we can tell a kind of beverage containing high concentrations of an alkyl hydroxide known as ethy alcohol) Inevitably it becae ore and ore of a proble to find space for the eansofproduction freight More and ore it was left until last on the loading platfor until it becae the practice there was enough power and the space was not required for consuer goods to load it in the caoose Transeconners becae very proud of their ability to eet the advancing ig Railroad standards and to carry the things that were in deand in fashion and expected of the
of the Board who stil reebered Taylor Andrews now deceased and said when they were given perission to speak "entleen aren't we forgetting that our basic concept was to help our counities to develop independent econoies? Haven't things gotten kind of turned around? Isn't it the consuer goods that should be in the caboose? The young progrssive leaders tried to be very patient with the aging veterans and said "Now grandpop were not forgetting Just putting first things first Railroading has coe a long way since Transecon Railroad egan and we have to eet advancing standards As a omete railroad were going to have to prove our copetence in every possible area of railroading You do agree dont you that we have to be coplete? Now you go back to your checkers Don't worry when were fully recognized that will be tie enough to give soe thought to eansofproduction and like you say to developing econoies' We ight even put on soe ore cabooses As ore and ore cars had to be added to carry the growing vaiety and volue of consuer goods and since there wasnt tie or oney to develop ore powerful engines the caboose was with increasing freuency left standing on a siding "Pick it up the next trip the engineers sad "or aybe the oe after During visitations of distinguished Railroaders and Coissioners the idle · cabooses were occasionally pointed to as the Transeconic Contribution to Coprehensive FulScope Railroading When however they eventually failed even to elicit polite curiosity the cabooses were painted to look like private cars for the president and board of directors
A Loded Cbooe "See they boasted "we ay be sal and we ay be poor but we can carry the sae kinds of things ig Railroad carries but i dditio please note we also have a loaded caboose Gradually the previous deiveries of eansofproduction deteriorated faster than it was replaced and the counities served by Transecon becae ore and ore dependent on daily deliveries of consuer goods This troubed the few old ebers
F Aoved Finay one day (no precise date was given but it sees to have been in the late 9 or early 19s) the great news burst upon the land "Transecon is fuly and unreservedly approved as a fully ualified and coplete railroad eual in rights and privileges to Big ailroad (The Big Railroaders of course still crossed their ars and sad "They're still nothing but unRairoad cultists; it is unethical for us to work with the )
Osteopathic principles
After due celebration of their vic tory, the Traneconner turned to ex panding thei line aying «ow well how them what a railroad ytem a be like But the old men who remembered had died off Nobody could recall in what direction the had et out to lay the track, how to build elf-fueling engine, and the purpoe of all the heavy freight ruting in the camouflaged cabooe on the iding For a year or o, therefore, Tranecon laid track beide the track of Big Railroad and made deliverie at the ame tation It oon became obviou to everyone that it wa foolih to lay duplicate track and give duplicate ervice Beide Tranecon wa rapidly running out of money for expanion and for replacement of deteriorating equipment Beide, the Commiioner kept aying "We dont need two of you One of you mut go e' Jon You Finally, the Great
Deciion wa made Again, a many year earlier, the more preentable and articulate f the Traneconner (none of whom, of coure, now owned overall and all of whom wore Sunday uit eery day) went to call upon the Big Railroader aying "Weve alway been very nice to you and lately youve been real nice to u and beide, a everybody know we both want what bet or Humanity So, why dont we become one big happy company? Wed be willing to run our equipment on your track and we wont charge you for the equipment if you wont charge u for the ue of the track After a brief caucu, the Big Railroader aid, "Well all right; we ou ue a few more engine and car But your are in pretty poor hape o if you want to come in with u youll have to x them up our way and well run them together according to our policie After uitable objection, the Traneconner agreed holding rm ly however, to one tipulation: that their joining with the Big Railroad be publicized not a an aborption which ome ignoramue called it, but a the amalgamation of two equal complete ytem and that a name be agreed on which would appropri ately memorialize for poterity the Traneconic part of the amalgama
tion Accordingly they propoed the name Traneconic Railroad Thi of coure, wa rejected and after a hort debate and a erie of com promie, a name wa agreed on which properly recognized the Traneconic Contribution to More Comprehenive FullerScope Rail roading: Big Railroad wa changed to Bigger Railroad And that i how Tranecon came to pa The yellow page from which thi tory wa obtaind record that after the amalgamation there wa great celebration in the home and hop of the former Traneconner who were now Big Railroader, and the lat page conclude with the word, "Miion accomplihed *
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Porpt One century after the cloe of the Traneconic epiode it i difcult even for profeional hitorian to undertand what it wa they were celebrating and what miion they conidered accom plihed From preent perpective it would eem that if their objective had been to wk for Big Railroad they could have done o at the very outet and avoided an exhauting 7year truggle If, on the other hand, their objective had been to launch, a they aid, an "improved ytem of railroading, one wonder how they could have celebrated, a the crowning triumph of their 7year truggle, the placing of their equip ment at he ervice of the old ytem Certainly, the opportunity to develop the improved ytem remained before them until that time One wonder how acceptance by Big Railroad became for them the higher goal and how abject urrender wa interpreted a victory Thee quetion are all the more perplexing in the middle of the twentyfirt century, when we remember that that old ytem ha long been replaced and that our entire tranportation ytem and the economie it upport, though now technically more advanced, are baed on the ame principle a thoe of the original Tranecon movement A far a we can now tell however Tranecon only urviving contribu tion to civilization are the yellow page from which thi tory ha been taken Reprinted by rmiion fom THE I (8): 1. Apil lL
Osteoathy ad medica evolutio (1962) Organid diin as onsistntly opposd t xistn of t ostopai profssion and vigorously rsistd its growt Tat t profs sion as survivd su powrful opposition, and prosprd and grown in spit of it, is tstiony to its vitality Howvr, wil t ostopati pro fssion was prospring and growing, t opposition of politial diin was also growing in intnsity and vigor, and t ontst is now at t disiv stag For t rst ti organid diin as sudd in gaining substantial organid suppor for ts fforts fro witin t ostopati profssion itslf Enouragd by its triup in California, organid politial diin as dlard its intntion* of arrying tis stratgy to its logial "onlusion t pial liination of t ost�opati profssion T survival of t ostopati profssion is now or gravly tratnd tan vr bfor, for wil its dfnss against xtrnal attak ar strong, ty provid o iunity aginst ie ollaps Organid ostopaty rspondd to ts nw trats to survival by strongly raffiring its intntion to ainain its sparat and indpndnt xistn, and donstratd its dtrination by rating a siabl war st troug dus inrass and assssnts, "to proot t publi alt by prsrving and xtnding t availability of ostopati alt ar in all stats t Essntial as is t will to surviv and to rsist absorption and dstru tion, survival of t profssion dands tat its funtion pofe io av survival valu It dands, also, tat its brs undrstand Ba on an addr by the am titl gien at th annual meing o th Mihin oiation o Otopathi hyiian and Surgon Gan d Rapid Otobr 3 1 Dr Korr i hairman o th Diiion o hyiologa Sin Kirkvill Colege o Otpathy and Surgery n a tatmen unanimouly adoptd by th Houe o Dlgat mrian Mdial ociation Jun 28 11 t th nnual Conention o the mran Oto phi oiation July
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tat funtion and its valu to soity in ordr tat, individually and in organid aggrgat, ty ay ddiat tslvs to its prforan and iprovnt Tat funtion, otivatd by lar undrstanding o its valu, and wll prford, is t sour of t profssions strngt and it would s to b t priary rsponsibility of t profssions organiations to nsur and proot t xris and dvlopnt of tat strngt owr is tis or luidly illus tratd tan in t vry atastrop to wi t profssions organia tions ar now aking tir rspons Can w rally rgard it only as a oinidn tat California was t ostopati profssions largst, "ost powrful, and "strongst sgnt? Can w rally avoid t onlusion tat, aving bn t first to suub to t blandisnts of organid diin, it was, in fat, t weke? Do w not av o plling rason to qustion t validity of t ritria by wi t profssion as asurd strngt and powr? Is it not a possibility tat t pursuit of wat pe for strngt and powr ay b t vry sour of waknss, and tat it as bn bougt, and ay again b bougt, at suiidal pris? Can w avoid t onlusion tat pr srving and xtnding t availability of "ostopati alt ar, ostnsiby ost apy avalab in California, dos not nssarily "pr srv t profssion and ay vn astn its dis? Can w not b on d tat in its proupation wit quantity as a asur of strngt, t profssion ay av forgottn tat its tru strngt is in t quality praps t spial quality of its funtion? Can w, in sort, disrgard t paradox tat truly ostopati alt ar was, in fat, fblst wr t profssion was "stron gst? If it asks qustions wi ar sufiintly inisiv and saring, t ostopati profssion an larn so xtrly valuabl lssons fro its xprin in California, and its ours nfort will b disivly dtrind by t lssons it dos
larn ltoug t California pro ssion was t largst blosso on t ostopati vin, it was, in fat, and ad long bn, a dying part of t vin, baus it os to "anipat itslf fro its roots t tis point, in y opinion, t raindr of t profssion would do wll to look to i roots, and to turn all possibl rsours to nourising t ls its otr inistrations, watvr ty ay b and owvr wll don, will, as in California, b to a ollow, dying strutur T pro fssion now or tan vr nds to rturn to and dvlop t sours of its vitality T Cafora profssion ad obviously didd tr was not suffiint rason, if any, for t ontinudxistn of t ostopati profssion T raindr of t pro fssion as in rspons, raffird its onvition tat tr re good rasons for its ontinud indpndnt xistn It is now allngd, tr for, to ak lar wat tos rasons ar Wat, otr tan survival, ar its purposs and objtivs? Wat i its funtion in soity? Wat is, sould b, or ould b its valu to soity? Wat is t profssion for? Ts sa qustions av bn askd b for! but now ty mu riv answrs, lst t answr fro Caifornia stand, wit inality, as t rigt on The myh o onohc medcne, or Wy nt wo schoos o medcne?
It igt b wll, in t qust for lari ty on ts issus, to bgin wit a si pl qustion: Wy sould tr b or tan on profssion of diin? s so oftn appns, a qustion bgins to answr itslf wn it is in vrtd: "Wy houd' tr? Wy sould tr o b two tr, or vn or profssions of diin? In asking t qustion tat way w bgin, idiatly, to dstroy a yt wit wi ost popl of tis oun try av livd so long tat ty av forgottn its origins in uan onit and uan dsign, and av aptd it as toug it wr as inrnt a part of our nvironnt as t atospr and as natural as t wtnss of t watr Evn tos ostopati pysiians, for xapl wo igt b xptd to rog ni it as artifat ar oftn its if vitis In fat, t ostopati pro Ostopati prinipls
sso os pp pp h myh by s cquscc s wll s by c wo h poso hlps ppu h myh ps s ow pm hs s h myh h h can b bu o u posso o mc h o o cous h oms hs log om h sc; h oly ts mmbs hols o c g om c "p po suos h bo ghul xclus h os cusos popos pc os jugs o mc; h oly hy oly hy can b physcs; h hy hy alne h h gh o cool ll spcs o mcl pcc; h hs s so xobly c o l h hy h ogzos suos are mc hs myh hs so much coo ou hkg h y oh pos so woulb posso o goup o m wom h psums o spk pcc h m o mc s by s y spss uomclly suspc mus o h poco o scc socy subm o jugm h jugm o cous o the mcl posso h oly "l posso h oy ccpbl s by sl ppom h oly arbter o s Bcus how y oh po sso oulb posso o goup o pcos s ous h oly "l posso ps om h oly ccpbl s s ps act uccpbl; s cul o mposos chls o upss whos pcc pcpls whou b o scuy hly wog gous Is hs mus b h l o physc h gh o pcc "mc W h ccp hs myh so log h y w posso glss o h souss o s pcpls h ccy o s pcc hs bs oly h mos h mos po boy gh o xsc whch mus coully by jusy g xplg why wh wy psums o b om mc Osophc phys cs h spoksm g subsc cc o hs myh ry m hy ccp s sobl s ou o sw h quso
"How os osophy om mc? o o o s my s h quso s s bsu s "How o obs om bs? o "How os sculpu om ? wos boh h quso h sw h by mplc o ccp h pms h h om posso s h s gs whch ll ohs mus b msu W h l wh hs myh so log h w o log s h lucous pox o sysm by whch w posso o mc c w h gh o xsc oly by qulyg o ccpc by h om school o mc hby endng s xsc W shugggly ccp sysm whch h oly possbl sl o ppol s h kss o h hs s h g myh wh whch h Amc publc hs l by whch hs b cmz o my cs hs s h g myh o whch h osophc posso hs o p (Clo hg hus b h mos succssul) o uhlssly schg ou xposg s bsc lsss o ll o s o wom h des mc blog o o h mcl pos so? Who are s jugs cusos gus popos s bs? Mc s cly nt h xlus poc o p popy o y pcul posso og zo o ssoco o suos y mo h uco blogs o h chs o lgo o h clgy musc o pomg ss h h o sghs cos Mc s s boy o kowlg sklls usgs xpc cls scs g cs suos l o hlh blogg o al o socy Mc hs ol hough h cumul xpc o h hsoy o h hum c I mo socy s h pouc o h cs o ozs o possos ocos uss s sccs hyscs glss o cmc g o pcul pos so hos chg wh h sposbly o lg mcl servce wh wlg som o h sums pplyg som o h methds o clcl mc hy pcc hy "pom hy
pply sums mhos hlh c hy o o wn m c; hy o s psoco hy o o sg c o wh lly w xcpos uu o plo h cous o s pogss h pcc o mc s g ough cllg sl whou h ogo o ohs Th oution of miin
Mc ho s ps p pouc o hum culu k ll oh mjo os sococulul phom lk hum culu sl mc lwys hs b o s log s h hum c sus lwys wl b coul pocss o olu o hs oluo s o mly h ccumulo uo o bo logc clcl cs h mulplco m o mhos sums I s lso h oluo o wys o loog h cs wys o rgg hm pg h coguos o usg hm cs ccumul much mo ply h usg I s h oluo o scales vale and emphass, h oluo o strateges and systems o ulzg h cs pplyg h mhos sums I s lso h uolg o perspectves bou hum hlh ss I s h oluo o h bjectves o mc cl pcc o h cocps g g h blgatns and qalcatns physcans I clus h olu o o cocps gg h scal cntexts o mcl pcc sho h oluo o mc s s much h oluo o deas behnd medcne s pcc s s o h kowlg chqu h u u uu by hos s I s pmly hs s compsg h phlosophy o mc h m h c os o h qus o w mcl kowlg chqu I s hs s h m h scos o whch h m s pp o whch gos skg h gs scbs o hm P c o o h pl phlos ophy o mc s h ll l [h] lh h whol lump o mcl pcc sch Bcus chqu s sy o s xpc sy o scb
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douent and beaue it hange i daatiall aid we oelook the eaie eene o the eec tie tategie otiation and ide that undelie the o the tehniu and thei deign and that guide the uet o new one We alo oelook theeoe thei lowe le daati hange Neethele thoughout the eoded hito o ediine the nueou hool ult oeion and te o ediine tha t hae had a lae in that hito hae been oed not onl aound ethod and intuent but aound the uh ubtle et owe ull otiating onet and tategie Soe o the hool ult te and oeion o ediine hae been oundl baed othe not Soe hae had e b ie lie eithe beaue the did not hae igniiant anwe to huan health need and bette wa o inteeting and utiliz ing aailable knowledge o beaue the ould not onine enough eo le that the had Othe uied o long eiod eithe beaue the did oe bette wa o utilizing aailable knowlge in the tuggle againt die o beaue o the euaie n o thei oonent and the will to bliee o the huan eie Eah ha had iat o n huan health and oe iat on the oue o dial hito oe aoable oe un aoable Soe hae eeded oge and o e hae etaded i t he oeitene o two o oe hool te o oeion in the ae ea ha been th e ule hei lietie wee uuall oelaing athe than oetenie A doinant enduing hool wa oten lanked o uounded b othe oing in o going out tiing o aendan o eiting deline All leaned o the at oe bette o oe willingl than othe eah leaned o the othe and eah eleted ejeted and adated the aailable ethod and knowledge to it own ee tie oe with good ue othe with le ue But o eah howee bie o olonged it lie and howee ile o elaboate it biogah ie and deline wa the ineitable thee he ie and deline o aiou hool o te o iine eiall o thoe whih held wa o long eiod and had n ollowe a be egaded a
landak o tage in the eolution o ediine he hito o ediine in thi ount though elatiel bie alo elet eha een with unuual lait the eolution o ediine and the tuggle o uial and doinane aong hool o edi ine A athe lage eie o hool and ult i to be ound in ou hito thooniani natuo ath hioati hoeoath alloath eletii oteoath Mot oweul ot enduing and ot ueul o all o oue ha been alloathi ediine The lopc er of medca evoluon
Sine the aing o hoeoath the te alloath and alloathi ediine hae allen into diue Alloath ha won an guie deignated b an euhei Mot edial leade and eduato diown thi identit and all o othe aoahe Neethele the oe wheling bulk o edial atie i till guided b alloathi onet he ae now o deel ingained o uh a at o ou enionent and atten o thinking that we ae no longe awae o thei eitene A a atte o at a a deontation o eedo o doga and ied in ile it ha beoe ahionable to den adheene to an edial hilooh he oigin o the allathi a oah ae lot in antiuit t i eha the ot diet the ot ob iou and the ilet aoah ndo o eee the alition and it anietation ounteat the ation o the agent o ato eued to aue it; the o eii the attak on the dieae and it aue the bet te Aloath eceied it geatet ietu o the eohaking ienti adane that ae in the latte at o the nineteenth and the eal at o the twentieth entu when the dioeie o Pateu Koh Vihow Ehlih and othe gae good eaon to hoe that edi ine wa now well on the wa to haateizing and dieentiating an dieae identiing thei aue and deeloing the ean to obat the and that in tie an' dieae would be onueed one b one until health had been won o huanit
Although the eeiene and i ene o ueeding ea hae di elled the bai o that hoe it ha neethele eited a a kind o in idiou aith whih guide uh o ou eeah and whih oide the aewok o the oganization and inaning o eeah o edial eduation and atie and o the forms o atie hat aith oten ioul eeed b uh adoni tion a teat the dieae b eliinating the aue i enewed o tie to tie b a dioe o deeloent that eit oe ti uh oe one o anothe o ou di eae one that an be aibed to a eii aue uual one o an ontibuting o eential a to The decne nd fl of llophc medcne
While the geat a o linal a tie in the eiting hool o atie inluding the oteoathi i lagel alloathi in oientation and while the doinant edial oeion oe uel alloathi than an i agniientl oganized and eak with uh a loud oie that it i egaded not a a atiula hool o ediine but a ediine itel the at eain that it s no ediine Alloath i but anothe tage in the eolution o ediine and like the othe it too will a Wh will it a? t will a o the ae eaon that othe tadition in titution intitutional o agen ie and goenent a t will a becaue it doe not adeuatel eet the need o oiet beaue the deet in it bai tateg eclude the ull ue o aailable eoue and knowledge in the wa againt dieae and o health What i oe the ailue beoe deee and deee a tie goe on hi i tue in ite o the geat adane that th e alloathi aoah ha oteed and the at eeah that it ha inied A baiall unound o ahai tateg annot oibl ake ound ue een o the bet o the ioeent in tati and tehniue that it a itel inie and it leae idle o undeeloed othe that ae no le and oten oe eaiou he bai at o srgc ailue ha o a long tie howee been onealed b dazzling dila o tatial baua and tehnial ituoit b Oteoathi inile
nlss srs of sarlng scovrs ha f h van hop ha wha ar fcs n asc prss an sragy wll sohow raca y s covrs as y una or ha hs fcs wll accp as n hrn n cn slf lco an onous as hs chncal an clnca avancs ar, hy can no longr concal h fac ha a asc falur rans an ha wll connu o pn hatvr h rfnns n chnqu an h nsons n nowlg Alhough h asc prs of causancur has always n ologcally un soun howvr "scnfc an prcs ay a o appar ha unsounnss s oay rval uch or sharply an a uch grar cos o huany han vr for Th gap wn huan n an h capacy of h allopahc sragy o ha n wns aly Tha s why allopahc cn s a passng sag n h voluon of cn Slo awar vn of h xstnc of hs asc prss of pracc, an vn lss awar of s naquacy, physcans an hr profssons an nsuons connu o so proc cup wh sass n hr gra vary an wh sasorn chnqu, ha hy ovrloo h ssnc of huan sas an s huan orgns Nowhr, n y opnon, has hs n or sharply an or succnc ly ocun han n a suy con uc a on of h lang unvrs y cal schools an pulsh aou 3 yars ago In hs suy h parns of halh an llnss ovr pros of a las 20 yars n aul lf wr su n approaly 35 nvuals h followng pons ry suar rg fro hs onunal suy 1 In all groups (accorng o na onal orgn, occupaon s cra) h llnss parns rval ha hr wr w ffrncs n suscply o llnss hus, on fourh of h nvuas ha a a jory of all h psos of llnss, whl, a h ohr r anohr fourh ha only 5 o 1 0 pr cn of h llnsss 2 ffrncs n suscply was o lnss n nral rahr han o spcc synros In as h ur of psos of llnss rnc y an nvual ncras
hr was a paralll ncras n h vary of synros an n h nur of organ syss nvolv. H was lly o hav or aor, vn lfnangrng, llnsss as wll as or nor llnsss 3 Ths prssn ffrncs n suscply o llnss n gnral ar os rasonaly plan y "assung ha hy ar pnn upon facors oprang whn h n vual, nfluncng h as, h fr quncy an h gr o whch h rspons o h gra vary of ohr factors nown o capal of caus ng sas Th rlav consancy of n vual llnss parns no only sup pors hs hypohss, u "ncn ally ncas ha h llnss pa rs of hs popl wr rlavly ll nunc y h hrapuc f fors of h physcans who ra h Pon 4 rgng so "ncn ally fro hs spln nvsga on, s an ncsv ncn of h allopahc approach an a clar nfcaon of s nhrn fc Allopahc cn s so proccup wh "h naural hsory of s ass, wh "h nfcaon of spcc sass an of corrlaon wh rla sorrs, wh "h ologcal ass of hr anfsa ons an h aloraon of sas or sypos y cal agns, wh unrwarng aps "o luc a h ula causs ha ovr loos h roos (an ponal for conrol) of huan sas n h facors n h huan organs, n huan lf, an n h huan n vronn ha conru o parurs fro halh whavr fors hy ay a I so prouly splays n nvua "psos of llnss, s array of slls n s ngushng wn sass n hr vas vary an n alorang hr or or lss characrsc parns of anfsaon ha ovrloos h ovous fac ha uch possly vn h csv par of h con rol of llnss n s aloscopc vary ls n h conrol of "sus cply o llnss n gnral Ths nhrn fc has long n a srous on Bu s consquncs
Quoao a o a ac o ca ah by A Shao eco of h Naoa Iu of Hah Pubc Hah Sv
ar now far or grav an vr cos ncrasngly ragc an n crasngly cosly wh Th urn of llnss s so as (accorng o a rcn Naonal Halh Survy, 1 pr cn of h populaon hav on or or chronc sas con ons an llon prsons ar o so gr sal y sas alon) ha has ourun h capacy of avalal cal rsourcs o al wh vn pallavly Evn wors, h gap cos wr an wr wh for whl hr ar alray ns of llons n n of car ns of llons or fro ryonc lf onwar, ar contnual sarng on h physologc pahs ha la o h sa ns of noun an ar, wh ncrasng rapy, swllng h rans of h chroncally ll Graful as w hav vry rason o for rfnn an ulplcaon of chnqus slls, nsruns an agns for h nfcaon of ll nsss, for agnoss, aloraon, copnsaon, pallaon, rpar prolongaon of lf ha orn cal scnc has prov, h fac s now or ovous han vr ha howvr far hs ulplcaon an rnn ar carr, an howvr uch w ncras h uantt of cal rsourcs an prsonnl (s snal as ha s), hy canno cop wh h ounng of llnss, uch lss slow In spang prv ously of h gra proccupan wh sass, I conclu ha "a sys whch connus n a hoplss qus for h causs of ach an h curs for ach whl nglcng h huan facors fro whch hy o ars, can only rgar ascally, as a falur howvr rllan, ffcv an wlco h pn asurs wh whch porzs Th onan cal profsson s of cours, cong aculy awar of h naquacy of h prsn sys of pracc n h fac of h growng urn of llnss Mos of s nllcual scnfc, uconal an pulc halh lars ar of cours ca o h provn of cal srvc so vn o h n of sng ways of vlopng an nng h avalaly of h osopahc conruon Th nr profssonal snars sponsor y h Founaon for Rsarch of h Nw Yor Acay of sopahy, an a possl y grans fro h
J
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ockelle Bothes und ae a splendid example o such eots The pc am o the medical poession howeve the most pow eul and most lavishly suppoted lobby goup in the nation seeks with inceasing despeation to pe seve the status quo to einoce its domination o the medical scene and to extend its lie It seeks to do so by concealing the inadequacy o the pesent system om an inceasingly impatient public by cying diveting alams about cultism socialized med icine and thid paties and by epeating the hackneyed shibboleths o the sacedness o the patientdoc to elationship eedom choice the sanctity o pivate entepise and eeosevice Fom such cynical selcenteed viewpoints it is impos sible o oganized medicine to egad osteopathic sevice whateve its eal value as anything othe than a theat to its pepondeant authoity The most damatic and selconta dictoy act o despeation by political medicine is now being consummated in the state o Calionia Thee the medical poession is pepaing to absob into its own anks ate appopiate quaantine the vey "cult which it has publicly despised o so long destoying it as a menace to its continued hegemony Having encouaged and witnessed the completion o this pilot model o destuctionbyabsoption in one state the House o Delegates o the Ameican Medical Association can didly and conidently in its con vention last June delcaed its inten tion to complete the demolition state by state It is diicult to chaacteize it as anything othe than an act o as tounding and gigantic stupidity that the victims could seek and welcome thei own destuction as thei cown ing achievement as the ultimate in pestige and ecognition! Even moe astounding is the act that thee continue to be othes in the osteo pathic poession also willing victims who would like the entie poession to enoy the same "ec ognition I they have thei way the osteopathic poession will soon be accepted ecognized and appoved to death hateve the machinations o the dealmakes in both poessions hateve despeate and iy mea
sues o selpotection they may esot to and whateve nical acts may be engendeed by "association attitudes § they eveal a the moe clealy that the old medical ode is passing that it is passing because it is ailing and mus pass and that a new ode a supeio system o medicine is on the way he next higher stage of medicine
The next stage o medicine will be one that bette meets the health needs o the day and that bette anticipates the apidly changing needs o moden so ciety It will not be concened only with ecognizing peventing and teating individual episodes and types o illness It will diect its pimay eots at the ullest exploitation libeation and development o mans natual biologic esouces o po ductive lie It will be engaged much less in nervenng in the in conceivably complex biologic po cesses o the human oganism than in ceating cicumstances in and aound the individual that will perm thei optimal opeation and in emnng mpedmens to thei opeation This emeging highe stage o medicine will be concened with the identiication and contol o those actos and vaiables in the indi vidual in the human oganism as a species in human lie in society and in the envionment that signiicantly and decisively inluence the ability to stay on optimal physiologic paths to esist delection om those paths and to etun to them Its eots will be diected not so much at the so called speciic "causes o disease as at the actos that pemit them to becme causes Its concen will be moe with elimination and contol o actos contibuting to susceptibility to illness in geneal than with the cataloging o diseases and thei teatment in thei endless vaiety It will combat disease not so much by agmented and expedient attacks on dseses as by conceted pogams o maintenance and impovement o health o "aising levels o wellness 6 The pactitiones o the emeging school o medicine will tun thei mao attention theeoe to the §A euphemsm ha James A Shannon MD Dror of Naona nsues of Heah offeed a susue fo "professona aoues'
contol o those actos which have been ecognized o many yeas even centuies the inheitable the de velopmental the nutitional the psy chologic the social occupational eceational envionmental and so oth because they ae cental to this stategy Howeve in addition these pactitiones will paticulaly ecognize the need to help man and the individual patient to make his best possible adaptation thoughout lie to an envionmental acto that has neve eceived adequate attention one that makes moe exacting de mands on the human than on any othe mammalian species gavity The emeging school o medicine will almost cetainly theeoe ind it necessay to place special emphasis on the musculoskeletal system Fo this is the system which beas the main bunt o gavitational stess It is the main instument o active lie in the extenal envionment and as the most massive system o the body and the lagest consume o mateial and enegy in the total body economy it places popotionate demands on all othe tissues o the body being in tegally linked to them though the ciculatoy and nevous systems and intimately inluencing them and being inluenced by them The newe pac titiones theeoe will lean to evaluate in individuals the adequacy o esouces magins o eseve bio logic deects incipient and advance pathologic pocesses and unctional inadequacies though thei inevitable eection in the somatic issues o the body They will lean to intoduce avoable inluences pophylactic and theapeutic hrugh those tissues Though such an appoach physi cias will n he curse fmnserng he and duing "episodes o illness educe "susceptibility to illness in geneal I am convinced om many yeas o obsevation that this is pecisely what happens in the couse o discening and skillul os teopathic pactice whateve the "pesenting complaint The patient is placed on a bette physiologic path In shr I m deepy cnvnced h he nex hgher sge f medcne ng n he wy nd nw desper ey needed - w be guded by hse prncp whch n her cn nuy evvng frm cnsue
Osteopathic pinciples
"he oseophc cncep. Indeed I
have long e ha he oseopahic poession should be egaded should egad isel no ony s a poession bu as a oveen o he coninua eoienaion o edicine in he needed diecion, and o leading he ansiion o he nex highe sage o edical evoluion. The poession ise like is conceps, has o he ie o is ounding been in coninual evoluion I has been auing and pepaing o his evenual ole even while sociey neihe undesood ha ole no saw he need o i. The oseopahic poession is a las being inved o assue ha ole. The osteopthic profession nd the trnsition to the next stge
This ansiion has been coing a ong ie; i has been possbe o a long ie. I has been "delayed no so uch o wan o adequae knowl edge and echnique (never enough hough adequae o a good sa) bu o wan o appopiae saegy. Moe accuaely he delay has been o wan o undesanding he need o a new saegy. One has long been in eadiness u ecogniion o is soundness and appopiaeness has bn delayed by edical adiion ohodoxy and "auhoiy. Mos egeaby i has been and is being, delayed because he oseopahic po ession has been diveed o is pah by subissive deeence o ha ohodoxy. Whehe he nex highe sage wi be ecognized as "oseopahic whehe he oseopahic poession povides he siuus ha bings i ino exisence and whehe i be coes he nucleus o he new poes sion depend aos eniely on he oseopahic poession isel is decisions and couse o acion in he iediae uue. hough sall in nubes and liied in esouces, hough vacilaing and unceain as o is diecion and hough bese wih inenal pobles, he oseopahic poession is si in y opinion, he ogical insuen o caayzing he ansiion o he nex highe sage and o oiciaing a he passing o he obsoescen syse. I believe his o be ue because his poession is sill he wods ages esevoi o physi cians and insiuions wih he neces say inighs an sils who do o coud appy he needed saegies
in hei daiy pacice and eaching. I is sil he only orgnzed voice aong nueous individua voices, espousing he new saegy. Eihe he oseopahic poession wil vey soon ededicae isel o he unolding o new hoizon in edi cine, and oeve "loo big in he ind o an, o i wi vanish o he scene and be ecoded, i a all "as a passing oonoe in he hisoy o edicine. " ! Eihe he oseopahic poession wil eancipae isel esoluely and ievesibly o he gea edical yh discussed ealie, o i will becoe inceasingly eneshed in i and hopelessy seduced by i whaeve poesaions o he conay is associaions ay po clai. The longe he delay, he oe dicu and he ess likely he eancipaion. Which couse he oseopahic po ession chooses depends o a vey lage degee on he lessons i chooses o lean o he Calionia expei ence In eec, i us choose be ween wo aenaives ( ) A quk end by ashionable suicide, by being acceped and appoved ino obivion. This is he alenaive chosen by he Calionia Oseopahic Associaion. (2) A long, had lie on he edica onies. This is he oppouniy opened o he poession by he couse o hisoy. Thee see o be no "sae ineediae posiions, and ceainly no sable ones Th is alenaive is easy; he oad has al eady been poined and aveled pa o he way. The ohe is a gea deal oe diicul and he couse o whee he poession is now has ye o be ploed. In ode o be able o po he couse he poession us ee a nube o peequisies: I us ecognize ha a couse needs o be ploed. 2 . A desinaion o goal o objecive us be esabished. The poession us deeine whee i is now and in wha diecion(s) i is acing, wih espec o he goals i ses. 4 I us hen plo he couse in es o he poicy, poga ogani zaion, educaion, and so oh, ha will ove he poession as apidly as possible o is pesen siuaion owad is uiae objecives. 5 In ode o ake acion on he oegoing peequisies, i us is
esablish he necessay echaniss. Meeting the prerequisites
Ae 6 yeas o seving and obsev ing he oseoahic poession I us conclude ha none o hese peeq uisies is pesenly saisied. I us conclude, oeoe ha hey cno begin o be saised beoe he po ession is appopiaely oganized o coninua and poessionwide ex ploaion o such basic issues as ae ipied by he is ou ies above. I is signiican an ionic ha a hough he poession is we oga nized o alos evey pocedua and poicy decision i has no eecive ous and councils o he exploa ion o such undaenal quesions as hese. I is o hese easons ha I have peviousy pesued and now do again o bing o he poessions aenion he ugen need o he ac celeaed developen o inellecual as well as poliica eadeship and o he esablishen o ous and councils an " acadeic wing e gional in disibuion ye cenaly coodinaed ha would lead he enie poession a he gas oos in he coninua sudy o he issues and eleens ha deeine he po essions obligaions o sociey and he pahs o hei ulilen. A I have indicaed hee and ese whee I ind i dicul o believe ha he poession can cai is igh o exisence as an independen schoo o edicine wih any obecive less han ha o inoducing a new and needed design o saegy ino he pacice o edicine ha o piloing by exaple he ansiion o a supeio syse o edica pacice. This is pecisely wha accoding o he chae o he s school ** i se ou o do wha hisoy now invies i o do and wha i c now, having won he igh a iense cos pe pae isel o do The quesion is no longe "Wha is oseopahy o "Wha ae he disincive eaues o oseopahic edicine Th e quesion now is, "In wha diecion does he oseopahic poession, on he basis o is philosophy pincipes and expeience, believe ha o edicine should ove, and is eady o lead he way by seing an exa ple The poession canno seek o
"
•• dsgn f wh s mpv u psn sysm
9
xpc ociy ongr inn in i wih any or confidnc han ha wih which i can anwr hi qion hi i h qion which h profion prpar if o anwr. o h oopahic profion ha a progra for h ipron of h naiona hah? Can h oopahic profion offr a br ragy or h car of h crrny an piodicay i for rdcing h aring backog of in ha ha aray accad and for rdc in h ra of i accaion? a i offr nw acic or h ip naion of hi ragy? an i offr dign for h pracic of dicin which wi b or ffica cio or conoica or broady aaiab and or pr nai? Wi dicin pracicd according o h dign ak f r propr of h fri of ci nc? Are h pcia far of oopahic hah car ch or if i bco h od wi hy b ch a o rai h of indiid a and pbic hah and rdc h incinc riy and draion of in? o ha i i h anwr qion ch a h ha a r h profion a in h ong rn o ociy ha wigh h raon r i xinc and ha wi dcid ociy inn in h prof ion hy ar ch or riab criria for appraia of an apiring choo of dicin han whhr i aifi h andard of anoter choo of dicin whi i di paying nogh diincin o jify i indpndnc I i i ch a h ha hod gid h ric of h profion h prac ic of i br h progra and poici o i organizaion and h caiona and cinica and ciniic aciii of i iniion. I i hrfor for h dy and roion o i ch a h ha h prof ion ho b organizing isf hi i h inipnab fir p y o b akn Prhap h o diffic pr rqii of a o ffi i h hird: rining whr h profion i now an in wha dircion i fac hi an a rci fxaina ion a pnraing criny of rcn and crrn poici and objci in rpraion of rcn n. Of a
h n ho in aiornia ha bn h o diring and hod hrfor b h o an ingf. h aning ha h prof ion xrac in h cor of i f criny wi drin whhr ho n rrn h nd of on ra and h bginning of anohr in o opahic hiory or ry h nd o f ha hiory; ha i whhr oo pahic hiory conin a h riing pha of a highr ag of dicin or whhr i bco h dcining pha of an phra c h ragdy of aifornia I b i i no o ch in h o o h profion of i arg gn i arg hopia on of i cog financia ppor and o forh gra a h o ar h ragdy i ha h a dfcion i an objci and nqioca ar of h prof ion own dob a o whhr i fncion ha nogh a o jify i conind xinc h ipac of aifornia can b conracd ony by an qay objci and nqio ca donraion ha h proion does ha a fncion ha ha fncion i of ch criica iporanc a o dand ociy ppor an ha in h an h oopahic proion i prpard o prfor ha fncion. In hi proc o f fxainaion h profion wi ha o drin o wha xn i poici ha con rib o h aifornia iaion and o wha xn hy ini oter aifornia bi i can b hown ha h coap of h proion in aifornia did no happn n spte of h profion poici; ha i wa no a dparr ro i cor b an xnion of i cor; ha i wa an niry ogica and n high y probab cinaion of h pro fion accraing dri dring h pa wo or hr dcad for accpanc: accpanc no of i princip b of h rofion if a a choo o dicin cop and aqa according o orhodox criria. ndd h aifornia Oo pahic Aociaion achid h i a in accpanc. Accpanc and approa by te pub ar of cor nia for ria nfor nay in acqicing and king o adap o h yh ha i b jdg according o h andard of h ony fy accpd choo of dicin h oopahic prof
ion ha condcd i rgg for accpanc and approa ndr r iniica o indpndn ria aifornia ha ry ad h o ccf adapaion in oo pahic hiory. Accoodaion o hi yh ha coid h oopahic profion o a cor of ch prcario brink anhip a ha nr bn known n in inrnaiona affair Hr i y iag of whr i i now. h profion nacioy rdg highr and highr aong a narrow dg aron h dica onain. h dg i bondd on h brink id by an which faor accp anc and approa and on h rock id by diincin h widh bwn h gi h profion i dg of indpndn paran o and on nfornay for ario raon h g ha bn ging narrowr and narrowr ni i anihing poin i ao in igh aifornia prhap ighy in h angard on hi rai ookd ahad and aw h anihing poin and apd or h brink whi on raind o ap or. Saddnd and aard h r aindr of h profion igna i ro drinaion o conin i arch iny aong h a anihing pah h rior now or firy nid by hir bra n i h oghr ik onain cibr in h hop ha hr wi b no frhr fa aing opn h poibiiy ha any fa (or ap i or iky o an diar for h nir afari I wod howr ony b diar owha earler han h incapab on a h nd of h rai On obio on i hi: If i ry wan conind and ind pndn xinc h oopahic profion g off h yh ngndrd dg of diincin bfor i i forcd off and ono i own indpndn cor� on ha i a broad and niid and a oid a oopahic phioophy dand on ha go whr oopahic objci indica on ha ha h dign ha oopaic ragy dica and on ha a of dicin hod ra Anohr on i obio: Poici pracic organizaiona for d caiona progra and horr objci ha ar or h raining i appropria for kping h Oopahic princip
rofession trdging along the vanishing trail are absrdl inaroriate for getting the rofession ff that tail and onto the one that has no end Te selsciny
t sees therefore that if the rofession reall wishes to srvive as an indeendent rofession it st lot a new corse and reare to travel it t cannot lot the corse as we have shown withot ndertaking a searching and rthless exaination of each of its own featres that the rofession itself has designed or eritted to develo Which of the rofessions olicies rogras and fors of organization which edcational rogras activities and objectives kee the rofession coitted to the vanishing trail Which of the have been t on like rotective garents as art of the adatation to the th that kees the rofession on the recarios narrowing lane between saeness and distinctiveness and revents it fro roceeding in selfdeterined directions Which of the heav accotreents it now carries and bs at great cost are sefl if at all onl for travel on the resent ath Which of the navigational gides that it has adoted kee it "hoing on this sicidal corse Let s onl identif a few for exale.
1
The cmpete etie
As has been reviosl said the things that hsicians d are ch ore evident to the senses than what the think - that is the rinciles objectives and strategies that gide the doing The osteoathic rofession born of idea and of aroaches to the flfillent of the idea has conceded to this too in its adatation to the th of standard edi cine. t has eritted itself to be coared to the "standard it has coared itself to the standard and it has even easred its own rogress b coaring catalogs of the ethods and rocedres in which accetable coetence is to be fond aong its ebers and b coaring the inventories of instrents and agents that are tilized in their ractice. Having adoted this raidl shifting criterion of its qalifications a a rofession aarentl withot de
liberate decision arrived a b organized rofessionwide std it cold do no less than deicate itself throgh its ndergradate and ostgradate teaching rogras throgh sorting olicies and throgh its ractice to the develoent and aintenance of axi versatilit in the clinical arts " Corehensive and "fllscoe becae slogans in osteoathic edcation The collective O according to this reise had to be a jack of a edical trades Having adoted this standard the rofession dared not be ess colete than the doinant school since a reertoire less than colete ight il ractice below standard According to this reise throfessions vale to societ and therefore its viabilit is assed to be rortional to the size and variet of its reertoire Under this reise the rofession has ade hge and vastl disroortionate investents fro its liited han and aterial resorces in seeking to atch coetence with the edical rofession in alost ever field and techniqe of ractice at the cost of develoing he idea behind its ractice and frthering its own contribtions to ractice t has cltivated diffseness of service and diversit of techniqe at the cost of clarit of rose and incisiveness of strateg tt Since new and additional ethods and instrents are continall being develoed the alread hge reertoires of the edical and osteoathic rofessions are steadil growing. The easre of "distinctivenss according to the criteria therefore becoes narrower b the da The differential in the catalog of things that doctors do and in the inventor of instrents and agents with which the do the is a vanishing one. For
tThis s anoher image ha come o mind. The pro fession's siuaion in hi regard i remiicen of a device inended o dramaize he Swis isrumen makers ar and ofe o found i culery diplay I purpors o an aemby of insume ha is a compac a a pocke kife, ye a veraile a a whole che of ol or eve a machine shop Unfouaely i bsle wih many blade i chise cisors bole-openers canopeners crewdives plies and oher insrumens and has so many ue, ha i unwieldy for aY purpoe is a rfec symbol of he exchage of uiliyo-purpoe for dis· play of diveriy of growh b y accreion raher han by deg
b
i
b
poe
this reason the "edge of distinctivness along which the rofession roceeds is also a vanishing one. The rofession therefore needs to exaine ver carefll the i lied reise that in order to clai its right to indeendent existence as a school of edicine it st be "co lete or nothing t needs to seek throgh clarifcation of objectives and sharening of strateg a ore discriinating gide to the selec tion and develoent of its clinical ethodolog to the design of its edcational rogras and to the develoent and deloent of its resorces
2.
Ostepathic manipuatie theapy
Osteoathic anilative thera began as a central and indisensable art of a total strateg n its contless fors it is designed to eliinate critical iedients to the otial oeration of adative hoeostatic defensive restorative and rearative rocesses thereb heling and eritting the individal to ove to a hsiological ath ore favorable to the best se and develoent of his biologic resorces. t is nt a theraetic techniqe or agenc for intervening in the biologic rocess for the treatent of this or that disease or the alleviation of this or that sto or the eliination of this or that etiologic agent On he contrar it is C whole syste of diagnosis araisal thera and rohlaxis sbject to infinite variet of adatations to individal reqi ents whereb favorable in flences are introdced to the han organis throgh the anall accessible tisses of the bod Those inences case the biologic and therefore han otential to be ore fll released ore aroriatel tilized and ore fll exressed in health or in recover fro ill health in the cre that st coe if it coes at all fro within Osteoathic anilative thera is a sste which rorts not to ake the atient well bt to hel the atient get ell. t is indeed designed to hel "t the atient in oand of the sitation convinced fro an ears of close observation and soe failiari wit the biologic echaniss throgh which the favorable inflences of
anipuative therapy are ediated that this syste of therapy is a onuental contribution to huan heath and wefare which is neverthe ess still in its infancy It can row to heathy aturity ony in the sort of edica environment that wil be provided by the next hiher stae of edicine as part of a tota stratey that will put it into axial service nfortunatey in the prevailin purview it has becoe or certainy is in daner of becomin only one of the on and owin inventory of therapeutic odalities or tech niques Not bein comony used in edica practice it has become the differentia the sybol of distinc tiveness the pus in the naive Dplus concept It has been torn fro the comprehensive man oriented stratey in which it arose and of which it is an essentia part and has been set in apathic diseaseoriented fraework in which its use and deveopent are seriously ipeded and in which it can not possiby be propery evauated As an entire syste of clinica ap praisa and therapeutics which ac cordin to the skis and judent of the physician has to be precisey custoade to the patient and to his continualy chanin circu stances it cannot be rearded and revauated as thouh it were a sinle discrete entity a particu dru or physica aent any ore than one could for exape eneralize about the effectiveness of psychiatry or physica edicine or pharaco therapy in the treatent of a par ticular disease entity To no small deree its effectiveness however it is easured is deterined by who does the administerin. As a whoe syste which ust fro oent to oet be adapted to the unique needs of the individual its effectiveness can be ony as reat a the judent knowlede and skils of the physician perit it to be. The syste is of such vastness and depth and is such a totay unique cobination of art and science that the necessary skills are inevitably predicated on innate abiity under standin of the systes purpose and potential knowlede of its bioloic basis and principes continual and persistent study and on and etic uous practice. Too often therefore the effectiveness of osteopathic 252
anipative practice is juded by the indifferent results obtained by those who do not have the requisite skils To measure the value of the syste by such criteria is very uch ike con demnin Beethoven for every bad perforance of his usic However the more we are wilin to accept bad performance the ore Beethoven's usic ay as we be banished! The profession therefore will have to take a searchin look at the preises which have peritted the centrifual miration of manipulative therapy fro the key position in a tota stratey of edicine towad the paiative adjunctive optiona periphery of clinical practice The profession wil if it s committed to independent existence have to take the steps to ensure the continued de velopent of the necessary perspec tives and skis aon its mebers by appropriatey desined proras of education and to ensure continua improveent of understandin and method by appropriately desined proras of research
3
Osteopathc educaton
urricular desins and educational edia and ethods whatever their individualy ood features which are desined to prepare succeedin en erations of physicians to folow aon the narrow prescribed lane between saeness and distinctiveness wil obviously not prepare physicians for pioneerin on the medical frontiers Whie our collees unquestionaby train abe and acceptaby versatile physicians accordin to the ac cepted standards an unknown per centae of who also dispay soe distinctive features of osteopathic edicine curricula ust be especialy desined to produce in arer num bers physicians who understand the ission o f the osteopathic profession and the reorientation in the practice of edicine it has the opportunity to lead It is in the collees that the re orientation of the profession as a whoe is to be achieved over a period of time One cannot expect that such orientation can be led by physicians who theseves are inextricably com itted to the present course Obvi ously if our youn physicians are to be prepared for the pioneerin that continued independent existence de ands our faculties ust be ed by
those who understand the need for pottin new courses and who are pre pared by precept and by skilfu example to do so. It is fooish to expect that succeedin enerations of DO's can be prepared to eet the historic opportunity of leadin the reorientation in edicine by es sentialy orthodox curricula in which the osteopathic contribution is unadherent frostin on the cake in stead of the eaven throuhout the loaf But curricuar redesin can become possibe only as the profes sion undertakes the searchin ex amination of its basic preises ob jectives and strateies Otherwise like al other aspects of professiona function it can only be another i provisation on a dyin thee For siilar reasons the profession wil have to exaine to what extent its prorams of postgraduate education are desined to orient physicians in the required direction and to sharpen the skis necessary for ovin in those directions as copared with the deree to which they are desined to continue oveent aon the es tabished path
The profson s nestments
The larer the investent one akes in a iven venture or endeavor the ore one becoes coitted to it. If the profession is truy deterined as it procais to continue its indepen dent existence and to extend the avail ability of osteopathic health care then it cannot avoid a relentess exaination of the deree to which its past current and conteplated in vesents keep it coitted to paths and circumstances that ilitate aganst its continued existence We miht take but one exaple the ost obvious one Overwhelinly the rofession's larest sinle investent in ters of money materiel and manpower is in the construction and operation of hospitas While he in creased availability of osteopathic health care made possible by these hospitals is of unquestionabe value to comunity health the profession if it is serious about continued independent existence wil have to deterine the deree to which this hue investent in hospitals and in education for practice in hospitas deters the profession fro ivin leadership in the developent of a syste whose main objective is as far Osteopathic principes
as possibe to keep peope ou of hospitas
5
Puc educaon concuson
This y fifth exape of areas needing reexaination sees an ap propriate way to recapituate soe points and at ast to concude this paper t sees unarguabe that the osteopathic profession wi survive as it wishes to and as a profession prosper ony as ong and as we as society understands the professions contribution to its wefare appreci ates its stake in the professions surviva and success and is wiing to invest in it accordingy This in turn depends on what the profession seeks by word and by practice to convey to society about its roe and how successfuy it con veys it Finay this in turn is deterined by the professions own view of its purpose and function a an independent profession and by the courage carity conviction and quaity with which it adheres to its purpose and seeks to perfor that function Obviousy the confidence with which the profession seeks pub ic understanding and support can be no greater than the confidence it has in its own function and in its abiity given the opportunity and the eans to carry it out t present as a resut of the widey pubicized action recenty taken by the osteopathic professions argest divisiona society the pubic has unfortunatey rather convincing evi dence that the profession itsef is not very sure that its function whatever it is is suficienty iportant to war rant its continued independent exis tence The eected representatives of the reainder of the profession responded with a ringing decaration to the contrary That avowa can have eaning owever ony insofar as the profession can rather quicky and unequivocay deonstrate that it has a function that this profession is the best quaified to perfor it that it is of such iportance a to deand its continued existence and as to justify a necessary support and encourageent by society What function have tried to show that society now awaits has ong awaited the vision and eader ship that wi guide it to a better syste of edicine one whose strate gy wi ake better use of the prod
ucts of science in service to heath. have tried to show that the osteopath ic profession because of its founding purpose its history experience in sights and skis is quaified to undertake to provide that vision and eadership The profession has the opportunity therefore to ake cear that such a superior syste of edi cine is entirey feasibe to expain to deonstrate in its own practice what its features and advantages are and coud be to prove that the profes sion given the eans is quaifie to ead the way and to prescribe and recoend what kinds of pubic and governenta actions poicies and progras are required in order to hasten the transition Fro this viewpoint therefore it wi no onger suffice for the profes sion in pubic education progras to te what osteopathy s and how it dffers t is now required to te in what direction it proposes that a of edicine ove and what it wi take to ove it in that direction t wi no onger suffice for the profession to seek equitabe nondiscriinatory incusion aong with other heath prfessions in pubic and govern entsponsored progras in egisation and in the awarding of privi eges opportunities grants and subsidies Deanded now is specia dscmnaoy consideration in recognition of the specia and unique function of the osteopathic profession and of its unique requireents n order to do this as we ave said the profession ust first set up the echaniss the forus the edia the acadeic wing which wi ake possibe the definition of that function the setting of objectives the ruthess sefscrutiny and assessent of its present situa tion the searching review revision and repaceent of the inappropriate poicies and progras by which it is encubered and the potting of its own independent course unfettered by the yth of a standard edi cine This is an iense task but if the profession is to survive it is one that ust be undertaken very soon There is no doubt that it wi require great courage great vision new kinds of eadership and prodigious effort The stakes are huge The rewards are as great as an has ever known
References
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1 Ko : Funcion of oopahic pofion; mae fo deciion Am Oeop A. 5977 . 1959 2 Hinkle L E . and Wolff H G Ecoloic inveiaion of relaionhip bewen illn lif xpeienc and ocial nvionmn. Ann n M 49 7188 Dec 1958 Shannon A Smpium on wold micin; nelcd avenu o knowle ublic Halh Rp 76:80805 Sep 1961 rocdin of Fouh Semina of h Founda ion fo Reeach of New York Acadm of Oeopah New Yok NY Februa 17-18 11 noaphic ancip unpublihe. Shannon A Teimon befo nrov mnal Relaion Subcommi of Commie on Governmn Opeaion of Hou of Rpnaiv on Healh Rearch and rainin Auu 1·2 1961 US Govemen inin Offic Whino DC 1961 6 Dunn H L oin of aack for aiin lvel of wllne Na A 9225-25 ul 1957 7 G A Challen o onmpoa medicine. Columbia Univei Nw Yor 1956
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Repined b pemiion fom AOA 61 : 5 15·526 12
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me hughs n an seathc crrculum 1975 here seems o be a idely shared hough unvoied onviion among eduaors ha urriular design onsiss o arranging and rearranging hundreds o hours eah o hem ap propriaely labeled ih he name o a ourse (an ology an organ sysem or diseaseaegory) and ih he naure o he eahersuden en ouner (leure laboraory lini e eera) his aademi game o hekers is oninued in h e hope ha ou o i ill emerge ha magial arrangemen hih embodies ei ieny inegraion and edua ional exellene Hundreds o ur riulum ommiees all over he ounry are engaged in his kind o exerise e everybody knos ha no maer ho leverly arranged a bunh o eeds remains a bunh o eeds and ha hey never ge o look or smell like roses Wha I m saying is ha i maers muh less ho he hours are arranged han ha gs n in hose hours individually and olleively I ish o ideniy bu o aors ha deermine ho orh hile hose hours are irs i is imporan o remember ha proessional eduaion is a pro ess a ransaion ha goes on beeen o groups o people eahers and sudens he qualiy o he proess an be no beer han he qualiy o he persons ho oin i n he proess Sine you anno hoose he sudens unil you have assembled a leas a minimal auly and sine i is he auly ho in ee ill be hoosing he sudens he hoie o he auly is he mos riial aor n deermining he urriulum and is qualiy hereore hoose he auly ih he umos are In hoosing your auly members look areully a heir qualiiaions Bu look ih speial are o he per son ho hs he qualiiaions or like he person qualiiaions eiher gro or hey sagnae I is he prsn ho deermines in ha ay ho ell and o ha ends he qualiia ions are used heher hey are dy nami or sai reaive or imiaive searhing or saisied impelling or mpeding o insiuiona progress
Choose men and omen ho ill serve ell as models o he kinds o persons and physiians you ish your sudens o beome he seond essenial aor is ha he auly share obeives and priniples o hih hey an hole hearedly ommi hemselves o guide hem in heir onered eors hoever diverse he approahes o he obeives and he inerpreaions o he priniples Given hese o essen ials he ellhosen auly and he shared obeives and guidelines a urriulum suied o boh wlvv, n cnin vv I sh n prscrib.
b
In my opinion he oseopahi philosophy ses orh obeives and priniples or oseopahi eduaion so learly ha i never eases o amaze me ho lile hey have been used by our olleges in he design o aulies urriula and eduaional programs Insead he philosophy ih is derivaive obeives prin iples and mehods has usually been relegaed o an individual deparmen hih aording o is omposiion is eiher an island or a ra aash in a urbulen sea Le me illusrae in o or hree ays ho he oseopahi philosophy cn serve in urriular design I shall begin ih he priniple ha he body is a uni or hoever one hooses o express ha onep o me his means ha he oseo pahi urriulum mus hroughou ous on he oal person By all means minuely sudy he ompo nen ells issues organs sysems and proesss and he kinds o hings ha an go rong in hem and ih hem Bu alays do so in he onex o he oal and pariular lie in hih hey pariipae In his om ponen pars and proesses man diers hardly a all rom oher mammals and as a maer o a mos o our knoledge abou he pars has ome rom sudy o oher animals Neverheless man is a oally dieren kind o organism and he pars operae in a oally di eren kind o lie I is upon hose unique human eaures ha he oseo
pahi urriulum should onen rae I is in ha onex ha he pars should be sudied or i is ou o hose unique eaures ha mans healh problems arise Man uses his biologial mahinery so similar o ha o oher animals o live a oally dieren kind o lie in man made and manransorme environ mens (We all hem ulure and ivilizaion) He uses hose pars in dieren ays and makes dieren kinds o demands upon hem oo requenly deleerious Mans ill nesses are he produs o hmn lie and are derivaives o his naure as a oal person he sudy o human healh and disease is ally unreal isi apar rom his priniple or man is more han a olleion o organs and issues here is anoher orollary o he body is a uni ha is o equal signiane ye hih only ai denally i a all inds is ay ino he medial urriulum And ha is ha here is an ininie variey o ays o being human his is an enor mous elaboraion on he heme dis ussed in he oregoing paragraph Alhough all o us have essenially he same kins o ells issues and organs hey dier no only aording o our herediary endomens bu aording o he oal personal and uerly unique onexs in hih hey operae and hv operaed hrough ou our lives hey have been urhe diereniaed aording o our indi vidual biographies ondiioning behavior aiudes posures per sonaliies belies uses and abuses o he biologial appaaus and all he dieren kinds o lives e live Ou o hese human dierenes have ome he ide range o dier enes among humans even ihin a given ommuniy ih respe o levels o vigor susepibiliy o illness in general and o diseases in pariu lar requeny and kinds o illness he lengh and qualiy o he lie and he auses and manner o dying Vieed in his ay diseases ould be seen no as he ees o adveni ious auses bu as he resuls o iving, under less han avorable irumsanes o eah abou h hear h somah h hyroid gland e eera as hough hey ere uni orm in all o us and uninluened by personal onex and individual biography is absurdly naive and sim Oseopahi priniples
pii For hee reaon and oher he bioo of human difference in reaion o heah and dieae mu ao be a cenra heme in oeopahic educaion Emphai on heah raher han dieae ha on been an imporan feaure of oeopahic houh. The carefu ud of human difference a par of he phician rainin woud ie new power and ubance o hi emphai In our cenurieod preoc cupaion wih dieae and dieae and heir repecie caue" and more recen wih he one ou of four who conrac dieae X he 342 ou of 10 who uccumb o dieae Y and 27382 per who die of di eae Z, we compee oerook he eon o be earned from hoe who don and epecia from hoe who don conrac any of hee dieae and who ie heah ie In hor we need o earn he caue" of ea a a phenome non" in ief and i a phe nomenon A an od phioogi I hae a fair ood rap of he dei cac of he coune homeoaic baance of he compexiie ha ener ino he reuaion of rowh and ce diiion or of areria bood preure or of rena funcion or di eion or hemaopoiei or wha eer And i i herefore unceain aonihin o me ha hin don o wron a o more oen een uni era ha eerybody doen e cancer hperenion bood dcra ia and he oher dieae We need o ook fr he caue of cancer" and hperenion" e ceera he anwer are o be found in he ud of heah and heah peope and he man way of bein and re mainin heah a bproduc of he ud of human difference Le me offer a hird coroar of he principe of bod uni I dea wih he mo conpicuou di incie" feaure of oeopahic medi cine and i i uua ubumed under he principe of rucurefuncion reaionhip u for me i ha mo meanin wihin he uni conex. I refer o he primac of he mucuo keea em in he oa bod uni hi i no on he mo maie and he mo enercon umin porion of he bod bu i i he em under he direcion of he nerou em wih which we carr ou human acii ac in and on our
enironmen and on each oher ac ou our indiiduaiie hope fear beief and our educaion A ee he icera circuaion meaboim i upporie For heah he oa bod econom mu be coninua and accurae uned from momen o momen and in he on run o he rapid chan in and onerm requiremen he mucuokeea em Thi mu be accompihed in each of u accordin o he kind of mucokeea em we hae and he wa ha we ue i; ha i accordin o he kind of ife we ac ou wih i. he mucuo keea em i he recipien of mo of he oupu o he cenra nerou em and he ource of mo of he inpu o he cenra nerou em hrouh i nerou and acuar connecion he mucu okeea em boh refec and infuence wha oe on eewhere in he bod. hi i eem o me i a he er bai for papaor dianoi and manipuaie herap Therefore hi coroar he pecia pace of he mucuokeea em in he oranimic uman cheme of hin mu ao ener prominen ino he dein of an oeopahic cur ricuum A anoher exape of how oeo pahic phiooph can ener ino curricuar dein e me ake anoher of he aowed (bu neeced) princi pe I i he ancien principe of v medicar naurae reworded b i in erm of he bod manufacurin i own medicine More recen (and ore erboey i ha been ampiied o ae ha he body ha inheren capaciie for uch hin a rei ance o and recoer from inur noxiou infuence re inaion and infecion for mainenance of and reurn o homeoaic equiibri um; for heain and repair; for com penaion for irreparabe damae in hor he capaciie o a we and e we I eem inecapabe o me ha an oeopahic curricuum mu o a er are exen be concerned wih he minue ud of hee capaciie and heir mechanim wih he man facor in and around he peron which uain renhen and de eop hem; and wih he man oher facor ha impede and impair hem n in hi wa can he phicia be prepared o uppor reinforce i b
erae and diencumber he deeop men and operaion of hee inrinic mechanim n in hi way i he enabed o perform he hihe func ion of he phicia he main enance and reoraion of heah which acua i he mo compre henie form of preenie medicin (o which we a pa uch piou bu ain iperice) I i of coure in he conex of faorab infuenc in hee efpreerin and ef reoraie mechanim ha oeo pahic manipuaie herap ha (or houd hae) i core roe in cinica pracice I coud o on o iurae wih oher of he oeopahic principe and wih oher coroarie bu m purpoe wa on o iurae from m perona iewpoin Your facu wi of coure hae o do hi for ief from i coecie iewpoin And he wldo i if he are choen we and if he can be heped o ee i imporance Le me concude wih a few houh ha ma hae ome ree ance o he rea ak before ou and our coeaue 1 I houd be obiou h a curricuum baed on oeopahic principe in he manner ha I ue croe a he famiiar deparmena boundarie and ha o be oranized on a framework which i indifferen o hoe manmade barrierI ha awa (we ince 1936, whe I fir bean eachin phicianobe) eemed aburd o me ha inead of pannin he eachin of he phician in accordance wih or er need and wih he wa he or he wi work we pan i for he conenience of he facuy and in accordance wih he wa ha cieni (and oher pecia i) are caified and caaoued a mean hae deparmen e ceera for adminiraie or oher purpoe bu he eacing mu be deined in accordance wih he de cared obecie and uidin prin cipe and no accordin o he con eniona pieon hoe" o pu i anoher wa he curricuum houd be deined accordin o man naure raher han accordin o he conried naure of an iniuion. 2 Aboe a in hi connecion don hae a eparae deparmen (wih correpondin coure) of oeopahic heor and pracice (prin cipe and echnique or whaeer he 255