The Collected

Papers of
Irvin M. Korr
Presented by the American Academy of Osteopathy
in honor of Dr. Korr's seventieth birthday
Editor for the Academy: Barbara Peterson
American Academy of Osteopathy
2630 Airport Road
Colorado Springs, Colorado 8091 0

Copyright 1979, American Acldemy of Osteopathy
Published for the members of the American Academy
of Osteopathy



Table of Contents
I. Introductory papers
5 Editor' s foreword: Barbara Peterson
6 Acknowledgments
7 Preface: Irvin M. Korr, Ph. D. , Sc.D.
9 Biographical notes and appreciation: Judy Alter, Ph.D.
1 1 Scientific contributions of I. M. Korr: Michael M. Patterson, Ph. D.
1 3 Clinical contributions of I.M. Korr: Edward G. Stiles, D.O. , FAAO
II. Primary research reports: Studies on electromyography, sympathetic ner
vous system, reflexes, and related topics
1 8 Quantitative studies of chronic facilitation in human motoneuron pools
(1 947) (with J .S. Denslow and A. D. Krems)
22 Dermatomal autonomic activity in relation to segmental motor refex
threshold ( 1 948) (with Martin J. Goldstein)
23 Skin resistance patterns associated with visceral disease (1 949)
23 The automatic recording of electrical skin resistance patterns on the human
trunk (1 951 ) (with Price E. Thomas)
29 Relationship between sweat gland activity and electrical resistance of the
skin (1957) (with Price E. Thomas)
33 Patterns of electrical skin resistance in man (1958) (with Price E. Thomas
and Harry M. Wright)
41 A mobile instrument for recording electrical skin resistance patterns of the
human trunk (1958) (with Price E. Thomas and Harry M. Wright)
45 Local and regional variations in cutaneous vasomotor tone of the human
trunk (1 960) (with H. M. Wright and P. E. Thomas)
54 Effects of experimental myofascial insults on cutaneous patterns of sym
pathetic activity in man (1 962) (with H. M. Wright and P.E. Thomas)
66 Cutaneous patterns of sympathetic activity in clinical abnormalities of the
musculoskeletal system (1964) (with Harry M. Wright and John A. Chace)
73 Neural and spinal components of disease: Progress in the application of
"thermography" (1 965) (with H. M. Wright)
75 What is manipulative therapy? (1 978)
77 Sustained sympathicotonia as a factor in disease ( 1 978)
III. Axonal transport, trophic functions of nerves
92 Studies in neurotrophic mechanisms (1 966) (with P. N. Wilkinson and F.W.
Chornock)
93 Axonal delivery of neuroplasmic components to muscle cells (1 967) (with
P. N. Wilkinson and F.W. Chornock)
96 The nature and basis of the trophic function of nerves: Outline of a re
search program (1 967)
99 Studies in trophic mechanisms: Does changing its nerve change a muscle?
(1 967) (with F.W. Chornock, W.V. Cole, and P. N. Wilkinson)
1 00 Continued studies on the axonal transport of nerve proteins to muscle
(1 970) (with G. S. L. Appeltauer)
1 02 The time-course of axonal transport of neuronal proteins to muscle (1 974)
(with Gustavo S. L. Appeltauer)
1 07 Axonal delivery of soluble, insoluble and electrophoretic fractions of
neuronal proteins to muscle (1 975) (with Gustavo S. L. Appeltauer)
1 1 2 Electrophoretic characterization of neuronal basic proteins in skeletal
muscle (1 976) (with G. Appeltauer)
1 1 3 Further electrophoretic studies on proteins of neuronal origins in skeletal
muscle (1 977) (with Gustavo S. L. Appeltauer)
1 1 8 Axonal migration of some particle-bound proteins in the hypoglossal nerve
and their failure to enter the styloglossus muscle (1 978) (with Gustavo
Appletauer)
IV. Interprtation of research findings
120 The neural basis of the osteopathic lesion ( 1947)
128 The emerging concept of the osteopathic lesion ( 1948)
The three fundamental problems in osteopathic research (195 1)
14 The concept of facilitation and its origins ( 1955)
1 Clinical significance of thelacilitated state (1955)
158 Osteopathic research: Why, what. whither? (1957)
169 What "osteopathy" and "the osteopathic concept" mean to me (1962)
170 The sympathetic nervous system as mediator between the somatic and
supportive process (1970)
75 Vulnerability of the segmental nervous system to somatic insults ( 1970)
178 The segmental nervous system as a mediator and organizer of disease
processes ( 1970)
The trophic functions of nerves and their mechanisms ( 1972)
188 The facilitated segment: A factor in injury to the body framework ( 1973)
19 Andrew Taylor Still Memorial Lecture: Research and practice -a century
later (1974)
196 Neurochemical and neurotrophic consequences of nerve deformation:
Clinical implications in relation to spinal manipulation ( 1975)
20 Proprioceptors and somatic dysfunction ( 1975)
0 The spinal cord as organizer of disease processes; Some preliminary
perspectives ( 1976)
214 The spinal cord as organizer of disease processes: The peripheral autonomic
nervous system ( 1979)
V. Osteopathic principles, practice and profession
224 The somatic approach to the disease process ( 1951)
228 The function of the osteopathic profession: A matter for decision ( 1959)
2 An allegory: A forgotten episode in American transportation history
( 1961)
244 Osteopathy and medical evolution ( 1962)
254 Some thoughts on an osteopathic curriculum ( 1975)

Editor's foreword
This is 1 979, and this year Dr. Irvin
M. Korr celebrates his seventieth
birthday. It would have been easy to
find people to contribute their works
to a Festschrit (or Dr. Korr; his
influence and friendships are wide,
both inside and outside the osteo
pathic profession. However, the pub
lications committee of the American
Academy of Osteopathy has done a
wiser thing: It has proposed collecting
Dr. Korr's widely scattered writings
into a single volume, for use and
study by everyone, limiting the birth
day tributes to three short introduc
tory essays.
Even the choice of who shQuld
write the birthday essays could have
been a problem; but again the Acade
my was fortunate. At Texas College
of Osteopathic Medicine, where Dr.
Korr is professor of medical educa
tion, a project was under way to pro
duce a kind of "tribute and inter
pretation" booklet in his honor.
When the TCOM editors heard about
the Academy project, they graciously
agreed to merge their writings with
ours. So, the hard choices were al
ready made.
As it appears, this is a thick book,
but it could have been thicker. Dr.
Korr speaks self-deprecatingly about
how he has "cluttered up the litera
ture," and he calls the task of reading
some of his earlier works "an exercise
in osteopathic archaeology. " Never
theless, when the publications com
mittee discussed what might be left
out, they found themselves praising
the older papers as ofen as the newer
ones. In the end it was Dr. Korr him
self who proposed lopping off the
first 21 items of his bibliography,
representing the work done before he
joined the faculty of Kirksville
College of Osteopathic Medicine in
1 945. Several other items could be
deleted because they duplicated in
some manner material already in
cluded under another heading.
Sections are included from three
published books, all of which are i n
print as of this date; the reader might
be helped in these instances by look
ing at the context in which the essays
originally were set. Everything else
comes either from periodical litera
ture or unpublished sources. The first
two papers in a new series, under the
general title of "The Spinal Cord as
Organizer of Disease Processes,"
appear in this volume, the second
almost at the same time as it is
published in JAOA. It would have
been ideal to have the complete series,
but the two do stand alone -and the
others are not yet written, Dr. Korr's
literary work is very much alive and
well.
One whole aspect of Dr. Korr's
personality had to be omitted for
sheer lack of space. This is repre
sented by writings he calls whimsey,
and they include such sober topics as
nephrotrichosis, fetal suicide, and the
direct conversion of plant protein
into animal protein. The latter topic,
which we are assured is fit only for
the Joural of Irreproducible Results.
evidently has neurotrophic aspects;
there is a subtitle relating to the im
plantation and innervation of an ear
of corn. One suspects, knowing Dr.
Korr, that one should not pursue the
mechanism of this scientifc process
too closely, at least in mixed com
pany.
Let us instead deal with more seri
ous scientific matters. After the
introductory papers, the material
divides neatly into primary research
reports, the interpretation of research
findings, and papers on osteopathic
practice and the osteopathic prQfes
sion. Papers in each section are
arranged chronologically, with the
research reports divided into two
parts. The first contains studies on
electromyography, the sympathetic
nervous system, reflexes, and related
topics. The second includes studies on
axonal transport and the trophic
functions of nerves.
Dr. Korr, from his earliest associa
tion with the profession, ha taken
pains to interpret his studies in a
clinical context, which doubtless is
one of the reasons for his broad and
lasting influence in a patient-oriented
profession. In this connection, Dr.
Korr has provided for this book an
introduction to his own writings,
placing them in context with his
carer. It would be superfuous to say
more about them here.
What should be said. however, i s
that the Academy counts it a privilege
to honor Dr. Korr on the occasion of
his seventieth birthday. The editor is
both professionally and personally
grateful to him for the effort and
cooperation that made this volume
possible.
BA PETERN
5
Acknowledgments
Particular thanks are due Dr. Korr.
for providin materials and com
ments that proved invaluable in the
choice and arragement of materias
for this volume.
Appreciation also is expressed to
Martha I. Drew, Ph.D., director of
the American Academy of Osteop
athy, and to Barbara J. Wood,
assistant to the director, who par
ticipate heavily in the production of
this book.
Members of the publications com
mittee of the American Academy
of Osteopathy who participated
directly in the planning of this
book included: Sara E. Sutton,
D.O., FAAO, chairman; Viola M.
Frymann, D.O., FAAU; John P.
Goodridge, D.O., FAAO; William
L. Johnston, D.O., FAAO; David A.
Patriquin, D.O., FAAO; and Donald
Siehl, D.O., FAAO.
Special thanks go to those who
contributed introductory essays and
whose names appear in connection
with them, and to the co-authors and
publishers 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
herein.
Acta Neurovegetativa
American Association for the Ad
vancement of Science (Science)
American Osteopathic Association
(JAOA, THE D.O . The Forum oj
Osteopathy. Health. Osteopathic
Magazine)
American Physiological Society
(The Americn Joural oj Physi
olog, Joural oj Applied Phys
iolog)
Electroencephalography and Cln
ical Neurophysiolog. Elsevier-North
Holland Biomedical Press
Epermental Neurology
Federation of American Societies
for Exprimental Biology (Federation
Pocedings)
Kirksville College of Osteopathic
Medicine (Journal oj Osteopathy)
Osteopthic Annal, Insight Pub
lishing Company
Plenum Publishing Corporation
The Postgraduate Institute of
Osteopathic Medicine and Surgery
(The Physiological Bai oj Osteo
pathic Medicine)
6 Introductory essays
Preface
My "osteopathic" career began with
my appointment to the Kirksville
faculty in December 1945. At a na
tional convention of the American
Osteopathic Association seven or
eight years later, I was introduced to
a delegate who, on recognizing my
name, said (I think with a smile),
"Oh yes, you're the fellow who keeps
cluttering up our literature." The
litter to which he referred has con
tinued to accumulate in the quarter
century that followed, to the point
that it now seems part of the osteo
pathic landscape. Though blown and
kicked around, it does not seem to get
lost, only more scattered. I am deeply
grateful, therefore, to the American
Academy of Osteopathy for under
taking to tidy up the mess and to tie it
up in one neat, disposable bundle -
and especially for thinking the job
worth doing. Special appreciation is
due Barbara Peterson for wielding
the editorial broom and dustpan so
skillfully.
How did a non-D.O. , a Ph.D. in
physiology, come to fill the pages of
the osteopathic journals with so many
words - quite aside from those he
sent to research journals? (And
perhaps even more perplexing, why
were so many of them read?) In retro
spect, it seems that a pattern became
set with my very first osteopathic
publication. The article was -
pretentiously and naively - entitled,
"The Neural Basis of the Osteopathic
Lesion," as though it were a final
statement I
That paper began as a personal ex
ercise in verbalizing to mysel the
exciting new insights that came out of
my reading of Sted Denslow's earlier
research reports in the Joural oj
Neurophysiology and elsewhere on
segmental motor reflex thresholds,
out of our first joint research effort
(reported in the American Joural oJ
Physiolog in 1947, actually my first
venture into the field of neurophysi
ology) and out of my beginning
studies of segmental variations in
sympathetic activity in humans.
It was, originally, only my intent to
summarize for myself my under
standing of the meaning and possible
implications of the concept of chronic
segmental facilitation. This concept
had already emerged from Sted's ear
lier studies and was reinforced and
further elaborated by our subsequent
investigations. However, on invita
tion from one of the session chair
men, I hesitantly presented my
summary and speculations at the
annual convention of the American
Osteopathic Association in July 1947.
The cordial response of those present
moved me to consider making my
thoughts available to all D.O.'s who
might find something of interest in
them. The paper was prepared for
publication and submitted to Te
Joural oj the American Osteopathic
Association, where it appeared in
December 1947.
The response was amazing, and it
continued for years. Practicing D.O.s
apparently found in it a ratiomiza
tion of their clinical observations
and a plausible explanation of the
ways in which the "osteopathic
lesion" was hazardous to one's
health. It seemed to reinforce their
convictions about the value of osteo
pathic manipulation. As a matter of
fact, I am told that the article is still
required or recommended reading in
at least some colleges of osteopathic
medicine, a practice I am inclined to
view as an exercise in osteopathic
archeology (much as it pleases me).
With this encouragement (I didn't
seem to need much) it became my
practice, from time to time, to report
in publications to the osteopathic
profession on our research, sum
marizing our objectives, our findings,
our views on possible clinical sig
nificance, together with additional
questions for further exploration and
testing in the laboratory or in clinical
practice. These papers are grouped in
Section IV, " Interpretation of re
search findings." They have been
based on research reports previously
or subsequently published in research
journals and presented at scientific
meetings. These, the "Primary re
search reports," are assembled in
Sections II and III.
With my growing grasp of the
meaning of Lhe osteopathic princi
ples, thanks to my colleagues at the
college and the many friends I was
finding in the profession, it began to
become evident to me that physio
logical processes and their distur
bances in the individual human could
be fully understood only in the con
text, not only of human life, but in
the specific context of that person's
total life and his or her total physical
and sociocultural environment, past
and present. The abstract generaliza
tions usually taught in the classroom,
expressed in such terms as the heart.
the renal circulation, the digestive
system. etc.. were indeed abstrac
tions, and they no longer suffced.
As I came to understand more and
more that all physiological processes
were conditioned by the circumstances
of the individual life of which they
were components, the science of
physiology began, for me, to burst
out of its traditional boundaries in all
directions. My studies, outside of the
laboratory. took me into the contigu
ous areas of the behavioral sciences,
social sciences, anthropology. epi
demiology. comparative health care
systems, economics and even the
arts. I began to discern unfortunate
trends and emerging critical needs
and problems in American health
which American medicine (including
osteopathic medicine) was not, gen
erally speaking, recognizing, con
fronting or preparing for. This led me
to try to "teach" the osteopathic
profession its business by presuming
to point out what I regarded as his
toric opportunities for which its f
philosophy and methods uniquely
prepared it. The 1951 paper, "The
somatic approach to the disease
process," was perhaps the first of this
genre. With succeeding papers, the
tone became more urgent, exhortative
and strident, culminating in the
period 1959-62 (the period of the
"California crisis"), in polemic
("The function of the osteopathic
profession" [ 195 1] and "Osteopathy
and medical evolution," [ 1962J) and
even acerbic satire ("An Allegory,"
[ 1961] ).
Following the California debacle, I
withdrew, defeated. from this arena,
and abandoned (for a while) my self
appointed role as pointer of direc
tions and shouter of "Excelsior."
Returning to the ivory tower, I
turned to the completion of reports
on earlier research with my late
colleagues, Price E. Thomas and
Harry M. Wright, and then to new
areas of research on the trophic
functions of nerves with Paul N.
Wilkinson and Gustavo Appeltauer,
both of whom are also deceased.
In 1973 came the invitation to
return to the "arena" through the
annual A.T. Still Memorial Lecture
at the annual convention of the AOA
7
in New Orleans. By this time, how
ever, some maturing had taken place,
and I had beome convinced that a
quiet display of the evidence on a
bed of swet reasoning was in order,
rather than raucous efforts at persua
sion. I think the change of tone is
evident in the lecture (though it
disappointed many who preferred my
fervent evangelism). I had become
convinc, also, that any efforts to
influence diretions of osteopathic
development would best be exerted
through the education of our doctors
to-be. This conviction is reflected in
a short article on curriculum pub
lishe in 1975 (and in my continued
efforts as professor of medical educa
tion at the Texa College of Osteo
pathic Medicine). This heterogeneous
group of articles through which I
sought, to put it briefy, to divert
osteopathic practice, policy and edu
cation from the pursuit of disease to
the putsuit of health, comprises Sec
tion V, "Osteopathic principles,
practice and profession." This sec
tion is related to a personal statement
of what the osteopathic concept
means to me, written in 1962 and pre
viously unpublished, which appears
on page 169. (Incidentally, I continue
to think that the osteopathic profes
sion is still passing up an historic
opportunity to fulfll its role as an
urgently needed reform movement in
American Meicine).
Impossible to include in this col
lection, except for excerpts in Section
II, is the book "The Neurobioiogic
Mechanisms in Manipulative Thera
py" which I edited with the expert
assistance of Mrs. Ethel Huntwork,
published in 1978 by Plenum Pub
lishing Corporation (and available
through the American Academy of
Osteopathy). That volume was the
product of an international work
shop, sponsored by Michigan State
University College of Osteopathic
Medicine, during my tenure there
as professor in the Department of
Biomechanics, and funded by the
National Institute of Neurological
and Communicative Disorders and
Stroke. It was my privilege to chair
the planning committee and the con
ference itself. From the viewpoint of
the osteopathic profession, perhaps
its main achievement has been to
establish manipulative therapy as a
valid and fertile area for fundamental
scientific investigation.
8
The period since 1945 has, for me,
been a great adventure which still
continues. I shall always be grateful
to my friends, J. S. Denslow, then
professor of osteopathic technique
and director of the Still Memorial Re
search Trust, and Morris Thompson,
then executive vice-president (and
soon-ta-be president) of the Kirksville
college, for having attracted me to
that adventure, as I stood, uncertain,
at a post-war fork in the road, and
for the many years of their support
and encouragement as my friends and
colleagues.
There are numerous others to
whom I am indebted for having made
the long adventure so rewarding:
Prince E. Thomas, D.O., and.
Harry M. Wright, D.O., who lef
their practices in 1949 and 1950, re
spectively, to join me in research and
in teaching, and who, through their
academic achievements, eventually
established themselves as profession
ally qualified physiologists. Trag
ically, their careers were cut short by
death due to cancer.
Elliott Lee Hix, Ph.D., who, in
1953, joined the Department of
Pharmacology (then under my ad
ministration), who also soon found
excitement in the new kinds of re
search questions that came out of
osteopathic theory and practice, and
who made fundamental contributions
to the pathophysiology of visceral
organs. He remains a close friend.
The late Paul N. Wilkinson. B.A .
whose skills in radioisotope tech
nology enabled us in 1966-67 to
demonstrate for the first time the
delivery of nerve-cell proteins to
muscle cells via the axons, as a
possible mechanism in the trophic
functions of nerves.
Gustavo S. L. Appeltauer. M.S.,
who came from Uruguay in 1967 to
join me in that research, and whose
skills made possible quantitative
analysis of the dynamics of axonal
delivery of protein to muscle and the
demonstration of four "wlwes" of
delivery, each carrying different
proteins. His promising career also
was interrupted by premature death.
Emil D. Blackorby,who came to
the College in 1951, whose superb
skills and inventiveness in electronics,
metal-working and virtually all
aspects of research-and-teaching
instrumentation were of inestimable
value. Without them, many of our
achievements both in teaching and in
research would not have been pos
sible. There seemed to be nothing
"Blacky" could not fix, and no de
vice he could not design and construct
to solve a technical problem.
Gertrude Krueger, my secretary
and colleague for more than 21 years.
and administrative assistant, librari
an, accountant, grant-manager and
friend to all of us in the conglomerate
known as the Division of Physiologi
cal Sciences, and especially the
Department of Physiology, where she
still continues her skilled and loyal
service.
All the technicians, student assis
tants and Fellows who joined us with
such dedication and skills in our
teaching and research programs.
All the students who responded so
magnificently to the learning oppor
tunities I offered them, and to the
many others who had good reason to
resent my exacting standards, but
who, eventually, found it in their
hearts to forgive me. It is their pro
fessional achievements that have
made my life as a teacher such a
rewarding one.
Especially noteworthy are two
former students, Ralph L. Willard,
D.O., and James R. Stookey, D.O.,
who (among others) achieved the ex
alted state of Deanship, and under
whom I was pleased to serve, frst at
KCOM and currently at TeOM.
All the members of the osteopathic
profession who have read my articles
with interest and who. further, have
taken the time to convey their com
ments and criticisms and to share
their insights and experience. Their
responses to my efforts and their con
tributions to my "osteopathic" edu
cation are deeply appreciated.
The osteopathic physicians who,
through the years, and at three col
leges, have given so generously of
their skills and time to help maintain
my health and vigor through regular
manipulative care: J. S. Denslow, the
late John A. Chace, George A.
Laughlin, William L. Johnston and
Marion E. Coy. I am convinced that
their care has been a critical factor in
my continued good health.
Finally, all the osteopathic editors
and their associates who, through the
pages they provided, so generously
met my need for self-expression.
IRVIN M. KORR, PH. D. , Sc.D.
Introductory essays
Biographical notes and
appreciation
Irvin M. Korr, Ph.D., began his
association with osteopathic medicine
in scientific research, and, through a
long and distinguished career, he has
become known as a major contribu
tor to the modern scientific under
standing of the profession's distinc
tive contribution to the field of
medicine. The impact of his work has
been felt in basic research areas and
in clinical medicine. But the impor
tance of Dr. Korr's career and his
writings goes beyond scientific re
search to embrace both teaching and
philosophy.
Both in the classroom and in areas
such as curriculum planning, he has
become renowned for his knowledge
and insight into the special problems
of osteopathic education. Further, he
has established himself, in writing
and at the lectern, as one of the most
articulate exponents 'of the profes
sion, the philosopher who brings to
the osteopathic concept a blend of
understanding, wisdom and enthusi
asm for his subject.
Dr. Korr was graduated from the
University of Pennsylvania with a
Bachelor of Arts degree in the biolog
ical sciences in 1930. and he was
awarded the Master of Arts degree
from that university in 1931. The win
ner of a fellowship in the biological
sciences at Princeton University. he
spent three years in graduate study
there and was granted the Ph. D. de
gree in 1935. An additional year at
Princeton was devoted to a postdoc
toral fellowship with special re
search in cellular physiology.
In the fall of 1936, Dr. Korr joined
the faculty of the Department of
Physiology at the New York Univer
sity College of Medicine. In addition
to teaching, he continued his investi
gations in the areas of cellular metab
olism and renal physiology and, with
members of the Department of Psy
chiatry, conducted research in the
field of insulin coma. These studies
were supported by the American
Philosophic Society, the Pletz
Foundation, the American Academy
of Arts and Sciences, and Warner
Institute for Therapeutic Research.
From 1942 to 1945, Dr. Korr was
engaged in research under the aus
pices of the War Department and the
Office of Scientific Research and
Development. His investigations in
aviation medicine, wound ballistics
and climatic physiology during this
period were conducted at Columbia
University College of Physicians and
Surgeons and at Princeton Universi
ty. Also during this time, he was ap
pointed senior physiologist at the
Fort Monmouth Signal Corps, where
he directed the Metabolic and Bio
chemical Laboratory of the Climatic
Research Unit.
Dr. Korr joined members of the os
teopathic profession in December
1945 when he accepted an appoint
ment to the faculty of the Kirksville
College of Osteopathic Medicine. The
appointment was for one year, and,
in his own words, Dr. Korr fully ex
pected to return to university teaching
after the year. One year lengthened
into thirty. "One thing led to
another," he has said, "and I just
couldn't leave. I'm glad I stayed. I
wouldn't have missed it for the
world."
During those thirty years, Dr. Korr
served as teacher, departmental and
divisional administrator, research in
vestigator, advisor and counselor to
students, interns, residents, faculty
and staff. In 1945, he was named pro
fessor and chairman of the Depart
ment of Physiology. From 19S2 to
1968, he also served as chairman of
the Division of Physiological Sci
ences, and in 1968 he was named Dis
tinguished Professor of Physiology.
From 1968 to 1975, he served as di
rector of the program in neurobi
ology.
In 1975, Dr. Korr ended his thirty
year association with the Kirksville
college to accept a long-standing invi
tation to join the faculty of Michigan
State University College of Osteo
pathic Medicine as professor of bio
mechanics. For the next two years,
his energies were mainly directed
toward the planning of an intera
tional research workshop on HNeuro
biologic Mechanisms in Manipulative
Therapy," which was held in October
1977. The proceedings of this work
shop, edited and with a preface by
Dr. Korr, were published by Plenum
Publishing Corporation in 1978.
In the fall of 1978, lured by the op
portunity to participate in the devel
opment of a new college, Dr. Korr
left Michigan to join the faculty of
North Texas State University Health
Sciences Center/Texas College of Os
teopathic Medicine. In addition to a
chance to work with a college which
he describes as still experimental and
still willing to make mistakes am
learn from them, the appointment as
professor of medical education at
NTSU/TCOM offered Dr. Korr an
opportunity to be surrounded by
former students. Some forty of his
former students and associates serve
on the faculty and administration of
the Texas college.
Dr. Korr is a member of the Ameri
can Physiological Society, the Society
for Experimental Biology and Medi
cine, the American Association of
University Professors, Sigma Xi, the
American Institute of Biological Sci
ences, the Society of Neurosciences,
and the American Society for Neuro
chemistry. He is a Fellow in the
American Association for the Ad
vancement of Science, a Life Member
in the Harvey Society, an Honorary
Life Member of the American Acad
emy of Osteopathy and an Honor
ary Member of Psi Sigma Alpha and
Sigma Sigma Phi, honorary scholas
tic fraternities. He is listed in Ameri
can Men 0/ Science and World Who's
Who in Scienc, and is the recipient
of an honorary Doctor of Science
degree and a Living Endowment
award from the Kirksville College of
Osteopathic Medicine.
The fact that his most recent ap
pointment is in the feld of medical
eucation rather than basic science
research is signifcant of his reputa
tion as a teacher. Dr. Korr is noted
for his perception of the interaction
between student and teacher and for a
recognition of the burden of responsi
bility on faculty. Former students cite
his commitment to students and his
ability to defne and describe clearly
the holistic osteopathic concept in
terms of modern scientific knowl
edge. In published writings on educa
tion, Dr. Korr emphasizes his com
mitment to maintaining the osteo
pathic principle and idea by stressing
the importance of integrating the
holistic concept into all areas of
teaching.
The same enthusiasm for the osteo
pathic concept that characterizes his
approach to teaching is evident in Dr.
Korr's extensive career as a lecturer.
He has spoken before such scientific
societies as the American Physio
logical Society and the Society for
10
Neuroscience, before a majority of
the osteopathic divisional societies,
and at seminars at various universities
across the country. Lecture invita
tions have taken him twice to En
gland, where he conducted postgrad
uate courses at the British School of
Osteopathy. , and to Australia, where
he spoke at the Lincoln Institute of
Health Sciences in Melbourne, In
1948 and again in 1959, he was the
keynote speaker at the Annual Con
vention and Scientific Seminar of the
American Osteopathic Association.
In 1967 he was asked to give the Scott
Memorial Lecture at the Kirksville
College of Osteopathic Medicine, and
in 1973 he was honored by being ask-.
ed to deliver the Andrew Taylor Still
Memorial Lecture at the Annual Con
vention of the American Osteopathic
Association. In 1975, he presented
the Louisa Burns Memorial Lecture
at the 19th Annual Research Con
ference of the American Osteopathic
Association.
Dr. Korr's published writings in
clude nearly 10 articles in scientifc
journals and abroad. and. they range
from reports of research to essays
on the philosophy of medicine.
Unknown to some, his writing has
branched out to include such philo
sophical pieces as an allegory which
compares osteopathic medicine to a
railroad transportation system. His
short piece, "What 'Osteopathy' and
'The Osteopathic Concept' Mean To
Me" has become a classic.
With the publication of this collec
tion of Dr. Korr's works, not only
will his scientific research be readily
available to the osteopathic profes
sion and the scientific community,
but equally the wit and wisdom of his
educational and philosophical writ
ings on medicine will be easiy accessi
ble to the many who are his friends.
colleagues and former students.
JUY ATER, PH.D.
Introductory essays
Scientific contributions
of I.M. Korr
The evolution of any discipline de
pends upon both the accumulation of
knowledge and the interpretation of
that knowledge within the framework
of the discipline. Without these two
elements providing impetus for both
growth and redefnition of its struc
ture, an area of endeavor soon be
comes obsolete. Medical history is
replete with examples of schools of
thought which have passed from exis
tence due to stagnation of thought,
leading to noncompetitiveness with
more dynamic and growing areas.
The works of I.M. Korr reprinted
in this book represent efforts over the
span of almost 35 years both to accu
mulate knowledge and to interpret it
in the context of osteopathic thought.
In so doing, Korr has also inevitably
altered the very framework of that
thought. The amount and effect of
these alterations can never be
measured accurately, although their
results will be felt for the foreseeable
future.
In this brief overview and introduc
tion, I would like to put Korr's basic
writings into historical context, then
provide some evaluation of the data
and interpretations in light of current
research and theory. This task is at
once humbling and necessarily impos
sible to complete: humbling because
Korr is first a personal mentor and
second a colleague; and impossible to
complete because he is still active in
both gathering data and providing in
terpretations. However, it is hoped
that the perspectives will be helpful.
"Kim" Korr frst joined the faculty
at the Kirksville College of Osteop
athy and Surgery in 1 945, having
already established himself as a well
known scholar in various areas of
physiology. At that time, J.S. Den
slow's work on electromyographic
correlates of palpatory findings and
the "osteopathic lesion" was well
under way. Fascinated by both the os
teopathic theory of structure-func
tion relationships and integration of
function, and by the pioneering work
in Denslow's laboratory, Korr began
an interest which has absorbed much
of his subsequent career: the relation
ships between visceral and skeletal
components of the body.
Collaborating closely with Den
slow, Korr offered interpretations of
the data being accumulated. The re
search group was soon expanded with
the addition of Price E. Thomas,
D.O., in 1 949, Harry M. Wright,
D.O. , in 1 950, and Elliott L. Hix,
Ph.D., in 1 953. This group comprised
the nucleus of research personnel
which remained active for many
years, as the papers reprinted here
show. Others were also essential to
the research, including Emil Black
orby. or "Blackie" as he is still affec
tionately known to hundreds of stu
dents and faculty, whose skill in
equipment design and construction
enabled the research to continpe, as
well as the Chornocks, Eble, Chace
and many others. Important in this
perspective is the fact that Korr was
heavily involved in enticing most of
this innovative and dedicated group
to Kirksville during the formative
stages of modern osteopathic re
search and theory building.
With the passing of years, this
group made many contributions to
current osteopathic thought, and, as
the papers presented here testify,
Korr's leadership was evident and
pervasive. The research thrust of the
group lost momentum in t he
mid-1 960s, and Korr turned t o what
was to be his major research contri
bution to modern neurophysiology:
investigations of the mechanisms
underlying trophic functions of
nerves. Gustavo Appeltauer joined
Korr in 1 967 for this major research
endeavor. In 1 974, Korr lef Kirks
ville for the Michigan State College of
Osteopathic Medicine and at the same
time left active laboratory research.
He has since been involved in redefin
ing some of his earlier interpretations
and in pursuing the implications of
one of his major interests, the role of
the autonomic nervous system in total
physiological function. This activity
has continued with his recent move to
the Texas College of Osteopathic
Medicine.
The direction and weight of Korr's
contributions to osteopathic theory
and research were manifest soon after
his arrival at Kirksville. Two papers
in 1 947, one with Denslow and
Krems, were both germinal contribu
tions setting the stage for the next 1 5
years of work.
The fi r s t paper cont i nued
Denslow's classic research on elec-
tromyographic correlates of palpa
tory findings and extended the results
to provide clear definitions of the
characteristics of abnormal skeletal
muscle activity which was often
found in areas of osteopathic lesion.
There were also speculations about
possible causes and maintaining in
fluences for the objectively observed
abnormal activity.
The second paper, "The neural
basis of the osteopathic lesion," is
one of the most important of Korr's
works in the profession. Here, he put
forth the ideas of the "neurological
lens" and the "facilitated segment."
This major theory of regional excita
tion of the spinal cord serving as an
abnormal area of overactivity. being
driven by both external and interal
sources of stimulation and focusing
this activity into abnormal patterns of
skeletal and visceral activity, was a
conceptual breakthrough. Research
in many areas of central nervous
system activity today is reporting
mechanisms which could serve as
activating and maintaining forces for
t
he effects observed and speculated
on in these early papers. It is now evi
dent that localized hyperactivity in
the spinal cord may be a primitive
form of pattern learning in the spinal
reflex arcs. It is perhaps unfortunate
that the term "facilitated segment"
was used, as it implied a circum
scribed area of abnormal activity
associated with vertebral structure,
an interpretation not strictly intended
in the original formulations.
From these first papers flowed re
search and theories over the next 1 7
years, from 1 948 through 1 96'. The
major impact of this work was the ex
plicit demonstration, through various
means of the existence of abnormal
activity patterns within the auto
nomic nervous system in apparently
normal as well as diseased humans,
and the correlation of some abnormal
autonomic patterns with musculo
skeletal abnormalities. Throughout
this period, Korr wrote on the inter
actions which to him were evident
between the autonomic and skeletal
portions of the nervous system, the
implications of abnormal autonomic
activity for health and disease, and
the long term effects of overactiva
tion of any portion of the nervous
system on innervated structures. Un
fortunately, the concept of close in
teraction between skeletal and auto-
11
nomic nervous systems was not gener
ally accepted in neurophysiology and
certainly not in medicine, and is only
now beginning to be recognized.
Thus, while the concept. of spinal
"facilitation" was evident in the
studies he did and supervised, the
basic neurophysiological data show
ing the actual existence of reflex
pathways subserving Korr's argu
ments was lacking. More recently.
work in various laboratories (see, e.g.
Satol) is demonstrating the neural
paths through which the interactions
seen by Korr clinically and experi
mentally between skeletal and visceral
structures are mediated. It should be
noted that some of Hix's work (e.g.l)
demonstrated in animals very tight
skeletal-autonomic interactions much
earlier. However, while evidence for
the interactions long stressed by Korr
and his colleagues is mounting, it is
still too soon to see a general accep
tance by either the medical or scien
tific community of the widespread
importance of such interactions for
health and disease.
Early in the 1960s, the research ac
tivity of the original group Korr had
recruited began to diminish and Korr
bgan to actively follow his long
standing interest in the question of
special effects of nerves on innervated
organs. Long standing in the field of
neurophysiology was the belief that
the only effect of nerves on their tar
get organs was the release of trans
mitter substance to excite the organ
to activity. However, much evidence,
such as the complete degeneration of
muscle following denervation as op
posed to the atrophy of disuse if only
nerve impulse tramc was interrupted,
argues for some other "trophic" ef
fet, or sustaining infuence, of
nerves upon their target organs.
Using specially developed techniques
ind procedures, Korr found strong
evidence for the delivery of protein
substances trans synaptically from the
hypoglossal nerve to tongue muscle
fbers. This work, published in
Scienc in 1967, was the first evidence
that nerves continuously provide
substances other than transmitters to
the organs they innervate. While
practically heretical, the notion of
transsynaptic protein transfer opened
new vistas of thought about neural
regulation of physiologic process and
of disease mechanisms. In several
papers since, Korr and Appeltauer
12
provi ded other data on the
phenomenon and began characteriza
tion of the proteins involved. Ap
peltauer's recent untimely death left
the research incomplete. However,
there now exists a growing body of
evidence not only for the passage of
proteins from nerve to innervated
organ, but also in the reverse direc
tion (e.g.3). Investigators in other
laboratories are close to characteriz
ing some of the actual proteins which
are passed to muscle by its nerve sup
ply (e.g. 4).
While the studies and theoretical
arguments which led to Korr's find
ing of transsynaptic protein transport
are only now beginning to be ac-. .
cepted, this finding is certainly the
most dramatic and important of his
career. The implications of such slow,
two-way communication between the
nervous system and innervated or
gans are both vast and seem hard to
overestimate, literally opening the
way for a revolution in thought about
neural control and feedback systems
of physiological process. It is still not
known whether the transsynaptic pro
tein delivery is a general phenomenon
in the body, or what all the effects
are, but certainly the pioneering work
done by Korr in the area will be rec
ognized as leading the way to one of
the great advances in our knowl
edge of physiological control. .
Over the past several years since he
has left active laboratory research,
Korr has been formulating concepts
of the function and control of the
autonomic nervous system. His re
cent paper, "Sustained Sympathico
tonia as a Factor in Disease" l which
appeared in 1978, is an attempt to in
tegrate a vast amount of data about
the effects of the autonomic nervous
system on total physiological func
tion. This work, together with the
proprioceptive theories he has re
cently propounded in an attempt to
explain some of the effects of manip
ulative therapy, characterizes Korr's
ongoing interpretation of data within
the framework of osteopathy.
The perspectives and evaluations
given here indicate the breadth of
Korr's efforts. Viewed from the van
tage point of today's science, it is ap
parent that much of his data up to the
mid-l960s has yet to be critically
evaluated and replicated, but stanq as
a guide for future research. The inter
pretations and theories flowing
p
from
that work have markedly infuenced
osteopathic thought and are rich in
material for further work. as well as
ripe for reevaluation in the light of
new findings and interpretations of
physiologic process. The work on
trophic function is only beginning to
be recognized and will stand as classic
in both concept and importance.
Whether the bulk of his earlier work
remains acceptable as theory or ex
planation after reexamination is,
however, not the important point. Of
paramount importance is that Korr
has provided the profession and the
scientific community with a basis for
discussion and a forum for continued
interpretation of the tenets of os
teopathic philosophy. To continue to
reexamine and build upon what he
has provided is the only fitting and
proper method of utilizing this rich
legacy.
References
1. Sato, A., The somatosympathetic refexes: Their
physiologcal and clinical significance. In The
Reserch Statu oj Spinal Manipulative Meicie.
Goldstein, M. (Ed.) National Institutes of Communi
cative Disorders and Stroke Monograph IS, 163-172,
1975.
2. Hix, E.L. Refex communiction between skin
and kidney a infuenced by an active viscera-renal
refex. Federtion Pe ings, 18, 69, 1959.
3. Thonen, H., Schwab, M. and Barde. Y-A.,
Transfer of information from effetor orgns to inner
vating neurons by retrograde aonal transport of
.nacromolecules. In The Neurbiologic Melnims
in Maniulative Thertp). Korr, l.M. (Ed.), Plenum;
New York, 311-332, 1978.
4. Markelonis, G.J. and Oh, T.H. A protein frac
lion from pripheral nerve having neurotrophic ef
fects on skeletal muscle cells in culture. Exrimental
Nerbiolog, 58. 285-289, 1978.
S. Korr, l.M. Sustained sympatheticotonia as a fac
tor in disese. In Tie Neurobiologic Melnim in
Manipulative Tlerpy. Korr, 10M. (Ed.), Plenum;
New York, 229-26, 1978.
MICHAEL M. PATERSN, PH.D.
Introductory essays
Clinical contributions of
I.M. Korr
When one contemplates the impact
I. M. Korr has had on osteopathic
thinking in the clinical realm, one
must be amazed and realize how
many skills and talents were required.
To appreciate his clinical contribu
tion, we must have some appreciation
of the man.
During the early 1 940s, Dr. Korr
was encouraged to join the research
group at Kirksville College of
Osteopathy and Surgery as it de
veloped under the guidance of J. S.
Denslow, D.O. In late 1944, after a
promising career in the aca
d
emic
arena and in military research during
World War I I , Dr. Korr was again
approached by Dr. Denslow and by
Morris Thompson, then president of
the Kirksville college. On the en
couragement of officials of the
Rockefeller Foundation, Dr. Korr
considered the challenge and decided
to join the Kirksville group.
In a manner consistent with his
reputation as a quality scientist with
an uninhibited mind, Dr. Korr dedi
cated himself to a pursuit of neuro
physiology and an all-out effort to
assist the developing research pro
gram at Kirksville.
In 1947, Dr. Korr was asked to
address the teaching group of os
teopathic principles, diagnosis, and
therapeutics at the AOA convention
in Chicago. His topic was the neural
basis of the osteopathic lesion, and
his purpose was to "attempt a char
acterization of the ostopathic lesion
in terms of basic neural mecha
nisms. " Thus he started a process he
continued throughout his career, that
of trying to make clinical applications
for the profession in relation to what
he was learning in his research en
deavors.
As a result of that presentation, the
profession started to contemplate the
concepts of afferent bombardment of
the central nervous system, facili
tation, and the role that the cerebral
cortex, postural equilibrium centers,
bulbar centers, cutaneous receptors,
and others can have on the develop
ment and maintenance of a hyperir
ritable state of the central nervous
system. Dr. Korr speculated, at that
time, about the role the facilitated
state could have not only on seg-
mentally related organs, but also on
the autonomic nervous system. Thus
the concept of the neurological lens
began to be discussed and appreciated
by the profession. The role which the
proprioceptors might play in the
development of the facilitated region
was also postulated at that early stage
of his career.
In that 1 947 lecture Korr also
warned that "the articular derange
ment or the osteopathic lesion cannot
be conceived as the cause of disease;
rather it is one of many factors
simultaneously operating. " He went
on to describe the phenomenon as "a
sensitizing factor, a predisposing
factor, a localizi ng factor, a
channelizing factor. . . . To treat
only the structural source of
bombardment is only to half-treat
and to neglect a most important part
of the lesion mechanism, and to take
the lesion out of context. This does
not mean, of course, that every os
teopathic physician should become a
psychiatrist, but he certainly must
take into consideration the home
factors, environmental factors, fami
ly relations, emotional adjustments,
tensions, etc." Thus at that early date
both the preventive and holistic po
tentials were envisioned.
A year later, Korr expressed to
another group his conviction that
"The attainments of the osteopathic
profession have been possible only
because the profession is founded
upon the solid rock of basic truth."
In that same speech he also said,
"Whether - and how - the pro
fession meets [its] challenge will
determine the future of the os
teopathic profession, but not the
survival of the osteopathic concept;
that seems determined. Good ideas
never die; society eventually makes
places of honor for them."
During the years 1948 to 1 950, the
Kirksville group . investigated the
impact which facilitation has on the
autonomic nervous system and on
organs innervated and affected by the
areas of facilitation. In 195 1 Korr
wrote, "We have come to recognize
that the osteopathic lesion as a
phenomenon of central facilitation is
a most important predisposing, local
izing, and probability-increasing
factor in disease. "
The next year he described oste
opathy as "not merely a form of
therapy but rather a broad philoso-
13
phy, a guide for thinking and acting
in relation to questions of health and
disease." He continued, "From the
diagnostic viewpoint the somatic
component has great strategic sig
nificance because it makes possible
the detection and evaluation of H
disease process far in advance of the
emergence of symptoms."
Thus in a few short years, the pro
fession had gained a dynamic spokes
man who had a deep understanding
and appreciation of osteopathic con
cepts and a vision of the profession's
potential. At this time in his career,
Korr understood that we have the
potential to recognize, by skilled
osteopathic evaluation, the loss of
health which occurs far earlier than
early disease detection.
One must remember that as the po
litical component of the profession
was trying to prove to society that we
were like M.D.s, Korr's was a voice
crying in the wilderness and encour
aging the profession to realize its
potential and not stop at the level of
allopathic acceptance and care.
At the 1956 AOA convention, Korr
called for a serious research effort by
the profession, and said "through the
collaboration of osteopathic physi
cians and scientists, the principles
which guide osteopathic practice
must be transformed into a body of
working hypotheses to guide osteo
pathic research." Thus again we see
a desire to develop a clinically sig
nificant osteopathic research pro
gram.
In one of the years immediately
preceding the M.D.-D.O. merger in
California, Korr was the keynote
speaker at the AOA convention, and
he took the profession to task. He
charged the profession with the
attitude that approval has become an
end in itself, that being is more
important than becoming. The pro
fession's function was envisioned by
Korr a the "continual examination
and reexamination of all the issues
and elements that determine your
obligations to society and the paths to
their fulfillment." He went on to say
in that 1959 address, "[Osteopathic
manipulation] is not just another
form of therapy; it is a whole strate
gy, a whole approach in itself. It is
not merely a treatment of 'lesions'; in
effect, it is the putting of influences
into the whole man through the acces
sible tissues of the body, influences
14
which deflect his life processes to
more favorable paths, and which help
put the man in better command of his
situation, whatever it is, whatever it
may become, whatever his illness,
and whatever its etiology." This non
clinician grasped the role osteopathic
care could play in enabling patients to
realize their health potential.
His depth of understanding of os
teopathic concepts and the profes
sion's political actions set the stage
for Korr to write his masterpiece en
titled "An Allegory." It is a piece of
literature which should be seriously
studied and contemplated by the pro
fession. Its message is as relevant
today as when written in 1961 , in the
midst of the California merger.

It was at this time when I first met

Korr as one of my teachers. He
taught by stressing principles and
concepts into which one could orga
nize the various associated facts.
As a student, I devoted much of my
free time to learning functional tech
nique approaches under the guidance
of George Andrew Laughlin, D.O.
On numerous occasions I observed
Dr. Laughlin treating Dr. Korr.
Those sessions gave me an apprecia
tion of why Korr had such an under
standing of osteopathic thinking.
During his treatments, Korr would be
asking questions such as, What are
you doing? What are you palpating?
What do you think you are accom
plishing? How do you think it works?
Korr was trying to get inside the
D.O.'s mind to understand his clini
cal thought processes and what was
being perceived by the skilled
palpatory hand. I have observed the
same process on numerous occasions
during the last eighteen years and that
same inquiring mind systematically
evaluating the years of osteopathic
experience of Bowles, Johnston,
Buzzell, Wilson, Mitchell, and
others. He functioned in the same
inquiring manner with his other
colleagues.
Korr continued to challenge the
profession with its unique potential
and predicted that medicine would
continue to evolve toward holistic
thinking and away from crisis care
which has been so ineffective in
improving the health potential of the
patients with chronic degenerative
diseases. In his address to a 1961
convention group entitled "Osteop
athy and Medical Evolution," Korr
stated "the osteopathic profession is
still, in my opinion, the logical instru
ment for catalyzing the transition to
the next higher stage, and for officiat
ing at the passing of the obsolescent
system."
He went on to say: " I am con
vinced from my many years of close
observation and some familiarity
with the biologic mechanisms
through which the favorable influ
ences of manipUlative therapy are
mediated, that this system of therapy
is a monumental contribution to
human health and welfare which is,
nevertheless, still in its infancy." One
must remember that during this same
period, osteopathic schools were put
ting less and less emphasis on os
teopathic training, and more and
more emphasis on allopathic type
training, and osteopathic manage
ment was becoming only an extra
modality. This realization prompted
Korr to say "The profession . . . will
have to take a searching look at the
premises which have permitted the
centrifugal migration of manipulative
therapy from the key position in a
total strategy of medicine toward
the palliative, adjunctive, optional
periphery of clinical practice." He
continued "society now awaits -has
long awaited -the vision and leader
ship that will guide it to a better
system of medicine, one whose strate
gy will make better use of the prod
ucts of science in service to health. "
He said of the osteopathic profession,
"because of its founding purpose, its
history. experience, insights, and
skills, [it] is qualified to undertake to
provide that vision and leadership. "
Six years of speaking in osteopathic
hospitals throughout our profession
has allowed me many opportunities
to address laymen sitting on hospital
boards and members of the insurance
industry. I can assure you that 1 8
years later, the public is still look
ing for that vision and the leader
ship Korr had envisioned. The same
people are now also realizing our
potential as hospitals develop func
tioning services of osteopathic
medicine.
Out of total frustration over the
profession's apparent desire to follow
the allopathic trend, Korr returned to
his laboratory for approximately ten
years. During that period, Korr and
his associates made major contribu
tions to neurophysiological under-
Introductory essays
standing in the areas of neurotrophic
axonal flow. This discovery has tre
mendous importance, particularly for
the osteopathic profession.
Also during this period from 1 962
to 1 973, Korr started to discuss a
conceptualization which I have found
to be of cornerstone significance to
osteopathic practice. Korr began to
emphasize how man is unique be
cause of his central nervous system,
but would be unable to walk, talk,
play golf or tennis, perform surgery,
etc. , without a musculoskeletal sys
tem to carry out the demands and
wishes of the centrat nervous system.
Therefore, the neuromusculoskeletal
system represents the primary ma
chinery of life and enables us to
express our human characteristics
and unique personalities. In this con
text, the internal viscera represent the
secondary machinery of life which
must increase or decrease their func
tions according to the demands of the
body's physical, emotional, mental,
and spiritual states, and how those
states are expressed and acted out by
the primary machinery of life. Thus
the host's viscera must constantly
change and adapt in their functional
activities in order to maintain the
internal milieu by utilizing the various
homeostatic mechanisms. One can
then appreciate how somatic dysfunc
tion causes decreased efficiency of the
musculoskeletal system and subse
quently increases the energy and
metabolic demands and requires ad
aptations to take place in all organ
systems of the body.
Clinically this conceptualization is
of utmost importance. As an exam
ple, it is not uncommon for patients
with C. O. P. D. to experience marked
symptomatic improvement, once low
back and lower extremity dysfunc
tions are treated osteopathically and
the energy demands secondary to gait
dysfuncti ons are l owered; this
subsequently lowers the functional
demands on the compromised respi
ratory system.
Also in the 1 960s, Korr started
emphasizing the uniqueness of the
sympathetic nervous system as the
sole autonomic component innervat
ing the musculoskeletal system. Sen
sory impulses from the musculo
skeletal system into t he autonomic
nervous system therefore are via the
sympathetic nervous system. Thus the
sympat hetic system provides an ave-
nue for the appropriate feedback of
information from the primary ma
chinery to occur and allow for the
viscera to appropriately adapt mo
ment-by-moment and finely tune vis
ceral function so the internal milieu is
maintained. Since facilitation of the
sympathetic system can result second
arily to somatic dysfunction, Korr
gave the profession an understanding
of how manipulative therapy could
affect the autonomic nervous system
and the related viscera.
During this period of his career,
Korr was emphasizing the uniqueness
of the sympathetic nervous system in
vasomotor activity and how somatic
dysfunction might play a role in
altering normal and optimal arerial
supply to the related viscera.
It was during the latter 1 960s that I
took over the practice of Perrin T.
Wilson, D. O. , who was a great ad
mirer of Korr and his work. Wilson,
like Korr, emphasized the importance
of developing an osteopathic ap
proach to the patient with a health
problem. He always contemplated the
role that somatic dysfunction might
be playing in facilitation, in trophic
flow, in arterial supply to the of
fended organ, and in venous and lym
phatic return.
Fred Mitchell, Sr. , D.O. , also held
Korr and his work in high regard.
Like Korr, he also emphasized the
role osteopathic management could
play in assisting the patient to real
ize his health potential. Clinically,
Mitchell considered the possibility of
facilitation, trophic flow, arterial,
venous and lymphatic derangements
secondary to somatic dysfunction,
and how each played a role i n the pa
tient's clinical problem.
Whereas Dr. Wilson envisioned an
osteopathic approach to the various
diseases and expected to find a spe
cific lesion pattern for each specific
disease, Mitchell's approach was
characterized by his frequent state
ment: "I don't treat pain, ulcers, high
blood pressure, etc. , but people with
structural opponents. " He believed
that once the somatic component was
alleviated, the patient could start to
realize his health potential .
Thus, several patients might have
the same clinical diagnosis, say
peptic ulcer disease, etc. , but Mitchell
expected to find a unique pattern of
somatic dysfunction for each patient.
To back up this belief he frequently
quoted Korr's statement to the effect
that many of us have similar disease
problems but we each arrive at the
same final destination by different
routes; thus each has a unique pat
tern of somatic dysfunction.
Both Wilson and Mitchell started
by managing their patients osteo
pathically and then utilized medicine
and surgery as indicated to manage
the signs and symptoms of the disease
process.
Both Wilson and Mitchell, and
both were clinical giants in the
osteopathic profession, relied heavily
on the work of Korr in their clinical
conceptualization as they practiced
and verbalized what they were doing
for both patients and students.
It was under Mitchell's guidance
that I began to appreciate Korr's
contribution of challenging the pro
fession to look primarily at the host
and its homeostatic capabilities rather
than to keep one's attention focused
upon disease process. The manifesta
tions of illness which we see daily are
in reality the inter-reaction of the host
and the disease processes. Thus, 10
patients with a tissue diagnosis of
acute appendicitis can each react
uniquely and di fferently clinically.
One then realizes osteopathic care
in reality is directed at the host
component, while the medical and
surgical approaches are directed at
the disease process. Viewed in this
way, osteopathic management can be
appreciated as a foundational form
of care for all patients when appro
priately provided for their specifical
ly diagnosed somatic dysfunction.
Medical and surgical care can then be
utilized once the foundational care
has been provided. Directors of os
teopathic medicine throughout the
country are daily demonstrating the
effectiveness of this combination, but
it only represents a beginning for
allowing our profession to realize the
potential Korr discussed in his earliest
writings.
Korr reemerged i n his role as a
voice crying in the wilderness and
exhorter of the profession when in
1 973 he gave the Andrew Taylor Still
Memorial Lecture. He said: "It i s one
thing to gain recognition of the com
petence of the osteopathic physician
to practice medicine in accordance
with established standards. It is quite
another thing to gain recognition of
the soundness of osteopathic princi-
15
pies and the value, to total health
care, of distinctively osteopathic
methods. That victory has yet to be
won. " Korr went on to expose the
myth some hold that osteopathic
principles have no solid basis in
biomedical research and mechanisms.
In 1 974, Korr offered clinicians a
hypothesis concerning the develop
ment of somatic dysfunction prob
lems and a conceptual model for why
the various osteopathic manipulative
techniques are effective in managing
somatic dysfunction. In an address to
the New York Academy of Osteop
athy entitled "ProprioC
e
ptors and
Somatic Dysfunction, " Korr dis
cussed the possible mechanism con
cerning somatic dysfunction, the role
the proprioceptive system might play
in the maintenance of these areas of
somatic dysfunction, and how the
various manipulative procedures
might specifically alleviate these
dysfunctions. His hypothesis coin
cides beautifully with what one
palpates in the area of somatic dys
function as effective manipulative
procedures are utilized.
In summary, Korr has made major
contributions to clinical osteopathic
medicine. He has given a useful con
ceptual model for evaluating the
role that the host's somatic dysfunc
tion may have in lowering resistance
and raising susceptibility to patho
logical states. This occurs by in
creasing energy and functional de
mands on the secondary machinery of
life or viscera, by altering vasomotor
status and secondarily arteria supply
to the various related viscera, by
producing facilitated states and
altering trophic axonal transport and
thus altering impulses and trophins to
the related viscera, by altering rib
cage, thoracic and diaphragmatic
function and secondarily impairing
the host ' s ability to ventilate
adequately and attain normal venous
and lymphatic return. Somatic dys
function can also alter afferent
impulses into the central nervous
system, as well as the flow of retro
grade trophins to the cord.
Thus we can appreciate what Korr
said in 1951 in the address entitled
'The Somatic Approach to the
Disease Process": "We begin to
recognize, therefore, that a great
many diseases which on the surface
are so diverse in character as to
require a highly complex system of
16
differential diagnosis, differential
therapy, and differential nomencla
ture, are essentially one disease, the
manifestations of an identical process
expressed in different parts of the
body. " The role of somatic dysfunc
tion can be better appreciated as "a
risk factor" when one considers
Claude Bernard's comment " Systems
do not exist in nature, but only in the
minds of men"; thus when one com
ponent of the body is functioning
improperly. the rest of the body must
adapt and compensate or become
compromised and become diseased,
i.e . an offended organ emerges.
Korr has challenged us to look at
the continuum ranging from optimal.
health to disease and death, and
consider the role of disease of the
musculoskeletal system as a predis
posing, sensitizing and localizing
factor. Korr recognized that we as
D. O. s can address both the host and
disease components of the clinical
problem. and he recognized we are
the only profession that can now
integrate the management of both the
host and diseased components into a
comprehensive health system. Others
are manipulating - chiropractors,
physical therapists and M. D. s - but
they are utilizing manipulative
therapy as a modality and frosting
on an allopathic cake, not as leaven
permeating throughout a clinical
approach aimed at enabling the pa
tient to realize his/her health po
tential.
It is one of my deepest desires for
the profession and all interested in
comprehensive health cafe that each
might study and contemplate the
vision Korr has presented the osteo
pathic physician, that we might
develop a unique health care system
and develop a unique osteopathic cur
riculum and educational system
which will educate men and women to
be osteopathically oriented G. P. s and
specialists. Osteopathic thinking can
be the mechanism to enable us to
become the leaders in developing a
comprehensive health care system for
which the public is eagerly searching.
Korr has provided the clinician with
many tools to enable us to obtain a
level of distinction which has never
been previously reached by the health
professions.
What type of a man was required
to make the contributions Korr has
made? It took a man of scientific and
professional quality. one not trapped
by conventional beliefs. an inquiring
mind utilized to search and under
stand what goes on in the. minds and
hands of the osteopathic clinician, a
man who could verbalize his labora
tory data in a way to encourage the
clinician in its clinical application, an
effective educator and writer, a man
who was willing to give up his pre
vious interests and totally dedicate
himself to the needs of the osteo
pathic profession.
In his new role as professor of
medical education at Texas College of
Osteopathic Medicine. one must hope
that he realizes the necessary profes
sional support so that he will see a
new beginning for the contribution he
can make to the practice of clinical
osteopathic medicine. Korr is now
dedicating himself to the training of
young physicians who will provide
the leadership and manpower to at
tain the professional potential he
envisioned and presented to the pro
fession during the last 35 years.
EDWAD G. STILES, D.O . FAAO
Introductory essays
Primary research reports:
Studies on electromyography,
sympathetic nervous system,
reflexes, and related topics
IT
Quantitative studies of chronic facilitation
in human motoneuron pools* (1947)
J.8. DENSLOW, IRVIN M. KORR and A.D. KREMS
Previous studies (2, 3, 4) have in
dicated the existence, in man, of
pools of spinal extensor motoneurons
which are in a state of enduring
excitation, as reflected in low refex
thresholds. These were reproducible
over periods of months. Persistent
differences in threshold were found
from subject to subject, among
segments of the same subject, and
between sides of the same segment.
This paper reports the following: a,
the correlation of reflex threshold
with other segmental features, and b,
the intersegmental spread of exci
tation. Previous observations of
threshold differences were confirmed
with improved technics.
Methos
All the subjects were young men
apparently in good health. Each elec
trode, a bare 1 inch 25 gauge
hypodermic needle, was inserted
perpendicularly to the skin, through a
procaine wheal 3 cm. to the left of the
tips of the spinous processes T4 T6 ,
T" and Tlo, into the underlying erec
tor spinae mass. Each muscle elec
trode was coupled with another 25
gauge needle which was inserted in
tradermally through the wheal. This
type of electrode pairing permitted a
higher degree of localization and sen
sitivity than the previous practice (2)
of pairing 2 electrodes in muscle, 1
segment apart. Action potentials were
recorded a previously described (2).
The refex threshold of a given seg
ment was obtained by determining
the lowest pressure, applied over the
spinous process of that segment,
which elicited spike potentials from
the spinal extensor at the same level. t
"These studies were supported by grants from the
Reseacb Fund of tbe American Osteopathic Associa
tion.
t It is not intended to imply tbat the sensory fibers at
the spinous process and motoneurons of the muscle at
that level botb emerge from the same segment of tbe
cord, sinc such an anatomic relationship has not been
demonstrate. It i probable, bowever, that a given
spinous proess bears a closer neural relationship to
neighboring muscle segments tban remote ones and
tbat tbere is more or less parallel segmental "spacing"
in the cord.
18
Measured pressure stimuli were ap
plied over the spinous process by
means of the pressure meter previous
ly described (2). To simplify tabula
tion, responses to pressure stimuli
were grouped and designated as
follows: 1-2 kgm. Low (L); 3-5 kgm.
Medium (M); 6-7 kgm. High (H); and
no activity at the top limit (7 kgm.) of
the stimulator, None (N. In figure I,
however, the actual thresholds a
r
e
given.
In addition to establishing the local
threshold for each of the four seg
ments, the pressure required at each
of the four spinous processes to elicit
reflex activity from each of the other
three recording sites was determined.
In every experiment, therefore, the
thresholds of 1 6 related reflex path
ways were established. These furnish
ed the data also for determining the
extent and facility of spread of excita
tion among the segments studied.
Results
Part I. Threshold differences;
segment to segment and subject to
subject.
Figure 1 (arrows are to be disre
garded until a later section) shows the
differences in (local) threshold that
may exist am<ng the 4 selected seg
ments of a given subject, and among
corresponding segments in different
subjects. Thresholds of 1-5 kgm.,
called L and M in other charts, occur
most frequently at T _ and T _ a
thresholds of 6 kgm. and more (H
and N) at T. and Tlo
Constancy of reflex thresholds.
Thresholds remained essentially con
stant over periods of months. The
largest difference between duplicate
determinations was equivalent to one
threshold group and even this differ
ence was not common.
Threshold differences between right
and left sides.
In a previous study on 30 subjects (2)
it was shown that the mean threshold
segment curves of the right and left
sides did not coincide, considerable
divergence occurring at some levels.
Two experiments, with the improved
electrode technic introduced in this
study, confirmed the existence of
threshold differences between the
right and left side of the same seg
ment.
In one experiment, the threshold of
T8 was N (over 7 kgm.) for the right
musculature and, at the same time, 2
kgm. for the left. In the other, the
right side of T6 responded to 1 kgm.
of pressure over the spinous process,
while the left side failed to respond
when the top limit of the stimulator (7
kgm.) was applied over the same
spinous process.
Location of the sensory element.
When the periosteum and other tis
sues closely investing the tips of
spinous processes of low threshold
segments were procainized, the
thresholds were considerably ele
vated, often beyond the limit of the
pressure meter. In contrast, procaini
zation limited to the skin overlying
the spinous process did nlt, in any
case, affect the threshold. It appears,
therefore, that important receptors or
nerve endings for this reflex are close
ly related to the tip of the spinous
process.
Correlation of other characteristics
with reflex threshold.
1 . Pain. Pain at the spinous process
was not commonly produced in seg
ments having high (H or N) refex
thresholds even with severe pressures
beyond the range of the stimulator.
When it did occur, it was fleeting and
did not outlast the stimulus. In con
trast, at L segments (and to a lesser
degree at M segments) pain usually
occurred well within the 7 kgm.
range, and often oUtlasted the stimu
lus. Further, this low threshold pain
was i nvar i abl y r epor t ed as
"different" and said t o resemble that
resulting from a "bone bruise".
2. Post-traumatic soreness. After
repeated stimulation, the spinous
process of an L segment often re
mained tender for more than 2
hours; this did not occur at H or N
segments.
3. Diferences in physical charac
teristics ofsupraspinous tissues. The
differences in the palpable character
istics of the tissue overlying L and N
spinous processes are marked, and
detectable even by relatively inexperi-
EMG, SNS, reflexes, etc.

enced observers. The differences exist

mainly in the skin and in the tis
sues which closely i nvest the vertebral
spines. In the absence of reliable ob
jective methods for the study of tissue
texture, palpation was relied upon
and description given in subjective
terms. We bel i eve the words
"doughy" and "boggy" are the most
descriptive of the texture and resilien
cy of the tissues overlying the spinous
processes of low threshold segments.
In high threshold areas, the tissues
are not doughy and the bone outlines
are sharp and hard. Differences i n
physical palpatory features of the ad
jacent muscles may also be detected.
In low threshold areas the spinal ex
tensors appear to possess less resilien
cy to pressure deformation than cor
responding muscles in high threshold
segments, and "ropy" and hyper
esthetic bundles may often be i den
tified.
The di fferences i n physi cal
characteristics among the tissues
overlying the spinous processes of
segments of different threshold were
sufficiently characteristic and marked
that palpation of these tissues by an
experienced observer permitted fairly
reliable prediction of pressure
threshold groups (L, M, H, or N).
When such predictions, made on the
4 selected segments on each of 1 0 sub
jects, by one of us (J. S. D. ) were
compared with the independently
determined electromyographic find
ings the predictions were found ac
curate, with respect to threshold
group, in 35 out of the 40 vertebrae
palpated; the remaining 5 were off by
only 1 threshold group.
4. "Rest activity". Normal muscle,
completely at rest, is characterized by
an absence of action potentials ( 1 ,
2-5 `, 8, 1 0, 1 5-1 7) .
For obtaining electromyograms of
the spinal extensors, with the nec
essary needle contacts, the prone
position provides optimal relaxation.
Despite apparent relaxation of sub
jects "rest activity": was frequent
ly encountered at low or medium
threshold segments. It was often
necessary to position and reposition
the shoulder girdle, upper extremi-
tThis term, used by Buchthal and Clemmeson (I) to
designate activity in the absence of voluntary effort is
to be preferred over "spontaneous activity". used in
previous reports from this laboratory, since the latter
may incorrectly imply that the activity originates at the
motoneuron itself.
T
8
T
10
NO SPREAD
11,18 N
19,29
31,41
N N N
Z SEGMENTS INVOLVED
16. 7-N
3U. B
6
,7
B
5
7 34. ~

4 B
~

B . .
6..
Z3 Z

N N
7 N
N N
N N
N N
N N
3 SEGMENTS INVOLVED
4Z. 6".N
y
3B. 3 z.1-5-N
ZU.
IZ.
17.
Z.
v
4

:
"
4
-
N
~"
I'
34-N
N
N
N
N
N
7
mp. T
4
No.
4 SEGMENTS INVOLVED
3.
ZZ.
28.
3B.
Zb-
3Z.
38.
Fig. 1. All 30 experiments are diagrammed and aranged according to patter. The bold type
numeral under each segment represents the "sel-threshold" (dicused in part I) in kilogram for
that segment, e.g. , the pressure on the spinous proces ofT. required to elicit electricaly detectable
activity in the erector spinae mass at T + The arrows indicate the incidence and direction ofspread
between all possible pairs of segments. The number on each arrow indicates the presure applied to
the spinous process of the segment from which the arrow originates, in order to initiate activity in
the segment to which the arow points. The absence of an arrow in one direction or the other be
tween a given pair of segments indicates that evidence of spread was not obtained within the 7 kgm.
range ofthe pressure meter. Thus, between a given pai ofsegments, dependent upon factors which
are eamined in subsequent sections, there may be no spread, one-way spread, or two-way spread.
I
ties, head, and at times the lower
extremities, or to calm the restless
or apprehensive subject, in order to
eliminate rest activity.
In our series four experiments had
to be terminated because of persistent
rest activity at one or more segments.
Each of the four subjects at another
time served in a successful experiment
in which rest activity was eliminated.
In all cases the persistent rest activity
was found at L or M segments. One
of the subjects, during the unsuc
cessful experiment, was perturbed by
illness of his child; one was much
more apprehensive than the average
subject, and two walked with a limp,
due to poliomyelitis in one and an old
injury in the other.
Occasionally, one or more units in
an L segment fired during inspiration
or expiration. Usually this intermit
tent activity was not long lasting and
could be eliminated by the same
measures which were effective on
ordinary rest activity.
Apparent "rest activity" was only
very rarely encountered at H or N
segments, and was always easily
abolished by correction of some posi
tional stress.
Thus, low threshold segments are
apparently hyper-excitable, not only
to pressure stimuli applied to the cor
responding spinous process, but also,
to impulses reaching them from
higher centers and from propriocep
tors.
Part II.
In part I, observations have been
presented concerning the response of
segments of the erector spinae muscle
to pressure stimuli applied to corre
sponding spinous processes. In this
section observations are reported on
the responses in muscle segments to
stimulation of remote spinous pro
cesses, Le., on observations of ir
radiation or intersegmental spread of
excitation.
Spread Patterns.
Incidence and distribution of spread
among the four segments fell into five
distinct patterns or groups (fg. I).
1. Order oj spread. There is a
definite order to the frequency with
which the different arrows appeared
in the series of 30 experiments. We
consider that these frequencies are an
index of 1 , the probability of spread
in a given direction between a given
T4 T6 T8 TIO
II 0 ( 0 0 NO SPREAD
2) oo 0 0 2 SEGMENTS INVOLVED
3) 0 3 SEGMENTS INVOLVED
4) OO 0

SEGMNTS INVOVED
5)

6) OO

COPETE RECIPROCITY
+
Fig. 2. Progresion ofspread. For explanation
see text. The number on each arrow indicates
the number of times that spread occured in
that direction betwen that pair ofsegments in
the 30 experiments diagrmmed in figure 1.
pair, and 2, the order in which spread
tends to appear in the progression
toward "complete reciprocity"
among the 4 segments. This progres
sion and the frequencies are shown in
figure 2.
2. Segmental level. The upper 2
segments participate in spread with
significantly greater frequency than
the lower two. The number of arrows
(figs. I, 2) to and from each segment
were as follows:
T4-88; T6 92; T,-69; Tlo 47
It will be noted (fig. 1) that when
only 2 segments are involved in
spread they are invariably the upper
two (T4 and T6); when only 3 are in
volved, they are the upper 3.
3. Segmemal threshold. Frequency
of spread to and from a given seg
ment is inversely related to threshold.
No-spread pairs consist predominant
ly of H and N segments; two-way
spread pairs consist predominately of
Land M segments; and the one-way
spread pairs exhibit intermediate
thresholds.
4. Segmental intervals. (Distance
between the members of a pair.) The
incidence of spread dec'ines with in
creasing distance between segments.
Sinc T. and T" are the terminal segments in the ar
bitrarily selected series of segments they are at a
relative disadvantage as regards spread. However,
were the series extended to include T, and T",
segments T. and T .. as well as T. and T". would aso
show increased participation in spread. T. would
probably show the largest increase of all, certainly
larger than .. that of T". The relative superiority of the
upper sewents of the series would remain.
The relation of thresholds and of
segmental intervals to incidence of
spread is shown in figure 3.
5. Direction oj spread. Figure 2
shows that incidence of cephalic
spread far exceeds that of caudal
spread (except for a slight caudal
predominance between Ta and Tlo).
Of 32 cases of one-way spread (fig. 1)
29 are cephalic. Further, where there
is two-way spread, the thresholds for
cephalic spread are predominantly
lower than those for caudal spread.
Our analysis of the data indicates
that preferential cephalic spread is an
intrinsic feature of these reflexes and
that the greater facility for cephalic
spread exists regardless of whether
the threshold of the superior segment
(of a given pair) is lower than, higher
than, or the same as that of the in
ferior segment.
In view of the fact that L' s and M's
are predominantly in the upper seg
ments, this may be related to the in
trinsic directional factor. Neverthe
less, the fact remains that, in our ex
periments, the reflex muscular re
sponses of L and M segments were
relatively easiy evoked by stimula
tion of the spinous processes of re
mote H or N segments; spread in
the reverse direction was uncommon.
Stimulation of the N spinous process
not only failed to elicit responses
from muscles of the same segment,
but also those of (N or H) segments
which intervene between it and the
responding L segment. (Expts. 35, 22,
28, 36, fig. 1 .)
Selective spread of excitation to L
segments was further demonstrated
by the application of slight tactile
stimulation to remote areas of skin
(e. g. , shoulder or scapula) whereupon
activity frequently appeared in L seg
ments, but never in others.
6. Procainization and spread. It is
of interest in this connection, al
though our observations are as yet
few, that while procainization of the
spinous process of an L segment
raised the self-threshold beyond 7
kgm., the reflex responsiveness of
that segment to stimulation of other
spinous processes remained unchang
ed.
Discussion
These experiments confrm, in loca
tion and degree, that significant
subj ect-to-subject and segment-to
segment differences in spinal reflex
EMG, SNS, reflexes, etc.
thresholds occur i n the "normal"
human.
The data indicate that differences
in pressure thresholds reflect differ
ences in central facilitation, and t hat
the facilitation is due to a bombard
ment of the motoneurons by impulses
originating, in part at least, from
points other than the spinous process
which was the site of stimulation. The
evidence may be summarized as
follows:
1 . The L and M segment shows
hyper-excitability to local and distant
stimulation including that from N
segments. Impulses from an N
spinous process may bypass moto
neurons in intervening high threshold
segments to activate motoneurons i n
the ventral horn of a more distant L
or M segment.
2. The effectiveness of pressure at
the spinous process of N segments i n
eliciting activity from remote L or M
segments is not ascribable to mere
facilitation of continuous impulses
from t he spinous processes or supra
spinous tissues of the L and M seg
ments, since at least from our limited
observations, the responsiveness of
an L segment (to distant stimulation)
is unchanged by procainization of the
tissues closely investing its spinous
process.
3. Spread to L segments is much
more frequent than spread frm L
segments.
4. L segments are hyper-excitable
t o i mpul ses ot her t han t hose
originating from external stimula
tion; "rest activity" is common i n
these segments.
5. Right and left sides, at the same
level, may show strikingly different
thresholds to pressure at the same
spinous process.
Lloyd's studies (1 1 , 12), with
facilitating volleys, of the quantita
tive relationship between subliminal
fringe and the discharge zone in the
cat have led to his conclusion that
(1 1 ) "It is unlikely therefore, that any
significant number of motoneurons
are close to or at threshold in the
resting pool, for, if there were, the
first afferent i mpulses t o enter the
pool should secure a post-synaptic
discharge". His work demonstrated
that a motoneuron pool, in the
absence of a facilitating or test volley
or both (to the dorsal root), is resting.
This resting state represents a check
on the far-flung interneuron system
dO
O

V
H

W
u
V
u
9O
C
0
u
0 O

C
7
O

L H!{W
0 Meum
L ...
H0 I woy =. y No 1woy ZM4 No two, 0,
$prH spr.od spnod spt.ad spread sprlad 'O'tod spread sprea
2 SEGMENTS APART R SEGMENTS APART SEGMENTS APART
Fig. 3. Influence ofditance and threhold on sprad ofecitation. Individual segments appar in
the graph a many times as they can be paire, e.c.g., T. and T.o ar pired with level 2, 4, and 6
segments aprt; and T. and T. twic with level 2 segments apart and onc with levels 4 sgment
apart. The croshatching code designate the number ofsgments in L, M, H or N cteore. Thu,
for example. ofthe segments showing no sprd at a 2 segment interval. 4 WMM, 7 WMH, and 69
wreN.
and. in effect, i nsulates the final com
mon path against firing every time an
afferent impulse reaches the pool.
While such a mechanism certainly
exists in man and while Lloyd has
demonstrated it in experimental
preparations where complete control
of facilitating, inhibitory and test
volleys can be maintained, our obser
vations indicate that in "normal", in
tact man it is possible to have quite a
different situation. Not only may dif
ferent pools, in close anatomic prox
imity, show different (and constant)
degrees of closeness to threshold but,
indeed, certain pools may be at, or
above, threshold (rest activity) in the
absence of external stimulation. Since
Lloyd has demonstrated that a con
siderable portion of the cells in a
motoneuron pool must be in a state
of subliminal excitation before
discharge from that pool occurs, it
seems apparent that reflex thresholds
(measured by the pressure meter) are
a measure of the size of the
subliminal fringe or of the degree of
facilitation maintained at a given
spinal segment. Thus a l kgm. seg-
ment has such a large subliminal
fringe that relatively few additional
i mpulses reaching it (from any
source) will extend it into t he
discharge zone.
In addition to the demonstration of
central facilitation, correlation was
found among aJ the reflex threshold;
b, the palpable characteristics of
supraspinous tissues; c, the suscep
tibility of those tissues to lasting
soreness following minor trauma,
and d, the pain threshold (and pain
characteristics); the basis for this cor
relation has not yet been learned.
An attractive possibility which
might account for this relationship i s
that i n a given segment there are
pools of neurons other than anterior
horn cells that are also facilitated and
that their hyper-activity, through
trophic. vasomotor or other in
fluences, produces the observed
changes in the tissue.
The lower resistance to minor
trauma and to painful stimuli may be
secondary to the tissue alterations.
Certain similarities to the nocifensor
tenderness described by Lewis (9) are
II
indicated. The possibility remains,
however, that the lowering of the
pain threshold may also be due, in
part at least, to central facilitation.
The facilitation indicated in the low
threshold pool may explain what
Mackenzie ( 13, 14) referred to as ex
aggerated responses in an area of "ir
ritable focus" and, by direct evi
dence, establishes the latter at either
the interneurons, the motoneurons,
or both. Hinsey and Phillips (6), in
connection with referred pain, have
also translated the "irritable focus"
into terms of facilitation.
The final question to be asked in
connection with the present observa
tions is concerned with the origin or
origins of the impulses which facili
tate the low threshold pools. Several
sources suggest themselves: the higher
centers, viscera, proprioceptors (i. e. ,
j oi nts, tendons, ligaments or
muscles). In these experiments, how
ever, the high degree of constancy
and especially the high degree of
localization - to one or two seg
ments, the frequent differences in
threshold of right and left side of the
same segment, and the absence of
psychoneurotic and visceral symp
toms in our subjects would seem to
rule out the first two as major
sources. We are inclined to believe
that the facilitating impulses arise
from segmentally related structures.
Summar
1. The refex responses of the erector
spinae muscles to measured pressure
applied to the spinous processes at
selected spinal segments were studied.
The existence of constant differences
in reflex thresholds of segments in
different subjects, and from segment
to segment and from side to side in the
same subject, has been confrmed.
2. Low threshol d segments
showed reflex hyper-excitability to
pressure upon the corresponding
spinous processes, to pressure upon
the spinous processes of distant, high
threshold segments, and to impulses
from proprioceptors associated with
This i not to deny that psychogenic or viscerogenic
impulses may significantly afect segmental thresh
olds. Our own experiments demonstrate that appre
hensiveness, anxiety, transient illness, etc., may cause
widespred lowering of thresholds. In our subjects
these influences appear to have been superimposed on
the primarY, and more constant, factors influencing
thresholds.
positioning, from remote areas of
skin and from the higher centers.
3. I t is concluded that low thresh
old segments are those in which a rel
atively large portion of the moto
neurons are maintained in a state of
facilitation due to a chronic bom
bardment by impulses from some
unknown source. Presumptive evi
dence indicates that the facilitating
impulses arise from segmentally re
lated structures.
4. Correlation of motor refex
threshold with a, pain thresholds; b,
susceptibility of supraspinous tissues
to minor trauma, and c, with tissue
texture, has been demonstrated. This
suggests that neurons other than the
motoneurons in the low threshol
d
segments may be simultaneously
facilitated.
References
I. Buchthal, F. and S. Clemmeson. Acta med.
scand. 48:48, 1940.
2. Oenslow, J.S. J. Neurophysiol. 7:207,1944.
3. Denslow, J.S. and G.H. Cl ough. J.
NeurophysioL 4:430, 1941.
4. Denslow, J.S. and C.C. Hassett. 1.
Neurophysiol. 5:393. 192.
S. Gilson, A.S., Jr. and W.B. Mills. This Journal
133:658,1941.
6. Hinsey, J.C. and R.A. Phillips. J. Neurophysiol.
3:175, 1940.
7. Hofer, P.F.A. and T.J. Putnam. Arch. Neurol.
Psychiat. 42:201, 1939.
8. Jacobson, E. Progressive relaxation. Univ. of
Chicago Press, 493 pp., 1938.
9. Lewis, T. Pain. New York, MacMillan, 192 pp.,
1942.
10. Lindsley, D.B. This JournalU4:9, 1935.
II. Lloyd, D.P.C. J. Neurophysiol. 6:111,193.
12. Lloyd, D.P.C. Yale J. BioI. Med. 18:117, 1945.
13. Mackenzie, J. Brain 16:312, 1893.
14. Mackenzie,' J. Symptoms and their interpreta
tion. London, Shaw and Sons. 30 pp., 1912.
IS. Seyffarth, H. Skr. Norske Vidensk Akad. 4: I,
1940.
16. Smith, O.C. This Journal 10:629, 1934.
17. Weddell, G., B. Feinstein and R.E. Pattie.
Brain 67: 1 79, 1944.
Reprinted by permission from American Journal of
Physiology 150:229-238, 197.
Abstract: Dermatomal
autonomic activity in relation
to segmental motor reflex
tttreshold (194)
IRVIN M. KORR and
MARTIN J. GOLDSTEIN (invitation)
Enduring differences in segmental
reflex thresholds involving the spinal
extensor motoneurons have been
demonstrated in man (Denslow, J.
Neurophysiol. 7: 207, 1944). The low
threshold segments appear to be those
in which a relatively large portion of
the motoneurons are maintained in a
state of facilitation due to chronic
bombardment by impulses from seg
mentally related structures (Denslow,
Korr and Krems, Amer. J. Physiol.
105:229, 1947). In the present investi
gation evidence has been obtained
that the facilitation extends to the
cells of the intermediolateral column
in the corresponding segments since
measurements of electrical skin resis
tance indicate segmental differences
in sweat gland activity which are
related to the motor reflex thresholds.
Electrical conductivity of the skin of
the back was measured in our sub
jects by a convenient modification of
the dermohmmeter. Under the condi-.
tions of our experiments most of the
skin of the back has a resistance of
5,(,( ohms or more. However,
portions of dermatomes, and occa
sionally entire dermatomes, related to
segments with reduced thresholds
have markedly reduced electrical
resistance, often as low as 20,(
ohms. The largest, most constant and
most reproducible differences in skin
conductivity, related to segmental
motor reflex thresholds, are found in
the midline, over or near the verte
brae. Areas with reduced resistance
are often hyperesthetic and some may
have the characteristics of trigger
areas. It is concluded that in segments
with chronically reduced motor refex
thresholds, at least some of the pre
ganglionic sympathetic neurons of
the same segments are also main
tained in a state of facilitation.
Reprinted by permission from Federation Proceedings
7:67, 1948.
EMG, SNS, reflexes, etc.
Abstract: Skin resistance
patterns associated with
visceral disease (1949)
This abstract reports the results of a
preliminary investigation of the part
that visceral disease and irritations
may play in determining the electrical
skin resistance patterns previously
described (Federation Proc. 7: 67,
1948, and this issue). Two classes of
patients having visceral disease have
been explored with the dermohm
meter (Jasper) and found to have
low-resistance areas (LRA) which not
only showed segmental relation to the
viscus involved, but were fairly con
sistent for a given disease entity and
were related to the referred pain pat
tern. Patients who had had myocar
dial infarcts had LRA over 2 or more
of the upper 4 thoracic vertebrae,
near the sternum at corresponding rib
levels, and over the medial edges of
one or both scapulae in the cor
responding dermatomes. In one sub
ject, repeatedly examined over a
period of months, such areas were
first observed 3 weeks prior to a cor
onary occlusion. Patients with
duodenal cap ulcer had areas of
markedly lowered resistance over the
spinal muscles, on the right side,
opposite vertebrae T-5 to T-8, over
corresponding ribs on the anterior
chest wall and to the right of the um
bilicus. In both diseases, LRA ap
peared to coincide with or overlie the
most painful or tender parts of the
reference zone.
Reprinted by permission from Federation Proceedings
8: 87. 1949.
Tie automatic recording of electrical skin
resistance patterns on tie human
trunk* (1951)
PRICE E. THOMAS and IRVIN M. KORR
In recent years the study of regional
and segmental differences of sweat
gland activity has found wide applica
tion in the determination of peripher
al nerve fields or dermatomes af
fected by trauma (1, 9, 10, 11, 12, 15,
19), surgical procedures (8, 13, 20,
22, 23, 26), painful syndromes and
visceral disease (6, 7,28), spinal cord
disease (3), and experimental
"
pro
cedures (2, 21). In most of those in
vestigations in which electrical skin
resistance measurement was used, the
operator, applying the methods of
Richter (25) or Jasper (14), or modifi
cations thereof, demarcates, with
hand-held exploring electrode, the
areas of high resistance in a general
background of low resistance induced
by the application of drugs or heat.
The high-resistance areas signify low
sweat gland activity due to impaired
or interrupted sympathetic supply to
the corresponding areas.
Conversely, studies conducted in
our laboratories have demonstrated
the existence of areas of low resis
tance which persist in a background
of high resistance, under conditions
of rest and in the absence of thermo
regulatory sweating. These low-resis
tance areas have been found in all
of the several hundred subjects ex
amined, most of whom are students
in good health. The patterns vary
from subject to subject, but in a given
subject, the patterns of segmental
distribution may remain constant for
many months (16). That is, the low
resistance areas remain concentrated
in the same dermatomes. Correla
tions have been established in many
cases with segmental disturbances of
visceral, myofascial, neurogenic and
experimental origin (17, 18). It has
been proposed that the persistent low
resistance areas represent chronic
segmental facilitation of the sym
pathetic nervous system, similar to
'This Investigation was supported in part by a research
grant from the National Institutes of Health, Public
Health Service and by a grant from the American
Osteopathic Association.
that previously demonstrated for
motoneurons of the paravertebral
muscles (4, 5).
It appears, therefore, that topo
graphical skin resistance studies may
have wider fundamental and clinical
significance and applicability than
has heretofore been recognized. Un
fortunately, the conventional explor
atory techniques have many disad
vantages. The method is very slow, an
exploration of the entire trunk requir
ing to 2 hr., according to the com
plexity of the pattern and the skill of
the operator. To this must be added
the time required for charting. Since,
in addition, the method requires
trained personnel, the number of
studies that can be conducted in a
given period of time is seriously
limited. The slowness of the method
also renders it unadaptable to the ex
perimental study of rapid, transient
alterations in the ESR patterns.
Furthermore, the method h a
number of inherent sources of error:
(a) The time required introduces
variables due to changes in the state
of the subject (fatigue, boredom,
etc.). (b) The patterns found on sub
jects of different body types must be
transferred to standardized body
charts. (c) The establishment of a
boundary may require the repeated
passage of the electrode over a given
area; this procedure may itself alter
the resistance of the area.
These diffculties have been over
come by the method of exploration
developed in this laboratory, which
rapidly and photographically records
the electrical skin resistance patterns
in proper relation to the subject's
trunk. The procedure requires a
minimum of training. A single area is
traversed only once in the course of
the exploration. A series of explora
tions may be completed in the time re
quired for a single exploration "by
hand", thus making possible con
trolled experimental studies. Another
feature of the method is its versatility;
its principle is adaptable to modalities
other than skin resistance.
23
Dl
M

.

&
l
i

t


, 1 '
.
'I
| t+
h
Fig. I A and B

Photographic records of electrical skin
resistance pal/ems obtained with the automatic
dermohmeter. Each l ongitudinal strip
represents the path ofa light source (mounted
over the eploring electrode) whose brightness
varies with the resistance ofthe subjacent skin.
The dark areas represent areas of low
reitance; the darker the area, the lower the
resitance. By means ofappropriate double e
posure the chart appears superimposed on the
subject's body. The white dots in the midline
represent. t he l ips of t he spi nous
processes,marked by a spot of light. The
numbered strip at left of each record is the
calibration, showing, for that exploration, the
variations in light brightness with variations in
current flow through the skin at constant
voltage. The resistance ofa given area ofskin
can therefore be etimated from the current
and the eploration, voltage (6 V. in each of
the above cases). See text for further explana
tion.
I4
Basic principles of lhe mlomalic
dermohmeler
The basic principle of the automatic
dermohmeter is the conversion of dif
ferences in skin resistance, that is,
differences in the current through the
skin at constant voltage, into varia
tions in the brightness of a light
source. If the light source is placed
directly over the exploring electrode,
and the electrode is propelled over the
skin at constant speed, a camera,
properly positioned with respect to
the explored field, with shutter open,
will photograph strips of light which
vary in brightness according to the
electrical resistance differences along
a corresponding strip of skin. To el
plore a large area, a series of con
secutive, parallel strips is recorded.
Figure I illustrates the records ob
tained by this method, on two sub
jects. The areas of relatively low
resistance appear as darkened areas
along the strips; the lower the
resistance, the darker the correspond
ing area on the record. The calibra
tion strip (at left of each record)
makes it possible to estimate the
resistance of any area of skin from
the photographic record (see inter
pretation of photographic records) .
Figure 2 shows a view of the instru
ment in use. The electrode-and-light
assembly (A) is propelled in the long
axis of the body while a known
voltage (from component I in figure
2) is applied between earclip and ex
ploring electrode. The light mounted
over the exploring electrode is caused
to vary in brightness with the current
passing between the skin electrodes
by means of the amplifier (also
housed in figure 2I). The camera (J)
mounted over the center of the field
records the light strip and variations
in intensity. Successive strips are
recorded by lateral positioning of the
rails (D) on the frame (H).
1he conslruclion oflhe aulomalic
dermohmeler
A. The drive.
The rigid arm (fig. 28) bearing the
electrode-and-light assembly at one
end, is supported at the other end
from a carriage (fig. 38) which is pro
pelled on ball bearings along a pair of
parallel rails (fig. 3C) by a small syn
chronous motor (fig. 3D). The motor
is itself mounted on the carriage
which it propels through a friction
Fig. 2
The automatic dermohmeter. The electrode
and-light asembly (A) is fied on the arm (B)
which is hinged at one end to the carriage (C).
The carriage is propelled along the rails (D) by
a synchronous motor (E) mounted on the car
riage. The motor is geared for motion in either
direction along the rails. The clutch-arm (F)
which engages the gears in either direction also
actuates an on-offswitch in the light and skin
circuits. This arm acts as a limit switch which
automatically interrupts these circuits at pre-set
etremes (G) on the rail at the same time as it
disengages the motor. The rails can be moved
laterally and precisely positioned on the frame
(H) for the recording ofsuccessive strips. Other
items (described in text): (I) the source of
variable voltage applied across the earclip and
exploring electrode; also houses calibrator cir
cuit and the carrier amplifier which varies light
brightness in accordance with variations in cur
rent through the skin; (J) the camera. Note the
pivot (P) which permits tilting of the entire
frame for explorations in the vertical position.
drive applied to the rails. The drive is
geared to move the carriage at ap
proximately 3.33 cms. /sec. , in either
direction. The clutch arm (3E) which
engages and reverses the gears also
actuates a switch which simultaneous
ly turns on the light source and
voltage through the skin when in
gear-engaging position, and turns
these circuits off in the neutral posi
tion. The clutch arm is automatically
thrown into the neutral position,
thereby interrupting the above cir
cuits, when it strikes the barriers
(figs. 2G, 3F) on the rail . These bar
riers, which determine the length of
the light-strip, are pre-set for in
dividuals of different heights, that is,
at each end of the field of explora
tion.
EMO, SNS, reflexes, etc.
The rails along which the carriage
travels are mounted in a Plexiglas
sleeve at each end. These sleeves are
in turn supported from the short
limbs of a rectangular frame (fi g. 2H)
which, like the rails, is made of one
inch polished pipe. These sleeves are
slid along the frame for lateral posi
tioning of the rails (and therefore of
the electrode) . Precise positioning is
made possible by a slot-and-pin
arrangement, i n which the slots are
spaced on the frame at intervals of 1 5
mm. Since the electrode is 1 2 mm.
wi de there is a space of 3 mm. be
tween strips, an interval large enough
to prevent overlap of strips and still
small enough to permit continuity of
the ESR patterns.
The frame is rigidly supported on
one side by a heavy board ( fi g. 2) af
fixed to the wall. The frame is
mounted on the board by strong
hi nges which rigidly support the
frame in the horizontal position, but
which permit tilting the frame against
the walJ for easy access of the
subject.
B. The electrode-and-Iight
assembly ( fi g. 4) .
The roller electrode (fig. 4A) is a
stainless steel cylinder 23 mm. i n
diameter and 12 mm. wide. The
under-carriage i s supported by a pin
from the arm, permitting free tilting
of the axle as the roller moves over
the ski n. Since, also, the arm is
hinged to the carriage and i s free on
the electrode-bearing end, the elec
trode rests freely on the ski n, and full
contact at constant pressure is as
sured throughout the line of travel.
The light source ( fi g. 4B) is an
evenly etched lucite rod, 5 mm. in
diameter, mounted over the roller,
parallel to the axle, and illuminated
from one end by an enclosed dial
lamp. The exposed part of the lucite
rod is 12 mm. long, corresponding to
the width of the electrode. Since the
light source is cylindrical , rather than
tAlthough fIgUre 2 shows the instrument in posItion
for exploration of the recumbent subject, it can also
be used for exploration in the vertical (or other) posi
tion. The frame may be rotated so that the rails are
vertical (fig. 2P). By means of a pulley and
counterweight, the rate of travel of the carriage in the
upward and downward direction is adjusted to that of
horizontal travel. The camera is placed, of course, in
the horizontal position, aimed at the approximate
center of the exploration field. The entire instrument
may be mounted on a rigid, portable stand rather than
on a wall.
Fig. 3
Close-up of drive mechanism. Arm, bearing
electrode-and-light assembly (not shown) is
hinged to lower end of vertical adjuster (A) on
carriage (8) which is propefed along rails (C)
by synchronous motor (D). Clutch-arm (E)
reverses gears and serves as limit switch for
light and skin circuits; (F) adjustable limit.
Fig. 4
Electrode-and-light assembly. (A) Rofer elec
trode; (8) etched lucite rod illuminated from
one end by dial lamp in (C) housing.
flat, it presents an illuminated surface
of constant area to the camera
throughout its field.
C. The variable voltage source.
Di fferent voltages are applied be
tween the conventional earclip elec
trode and the exploring electrode
(positive) from a series of flashlight
dry cells (size C) which are connected
into the circuit i n 3 V. steps by means
of a gang-switch (fig. 5, S2) . The
range 0-3 V. may be further sub
divided by means of a potential
divider for explorations during active
sweating. (The 0-50 microammeter is
not essential but is included for con
venience in selection of exploration
voltage; see below) . The potential
drop across the variable resistor RIO
shown in the circuit diagram is ap
plied to the grid of the amplifier (fig.
5, V4) which varies the brightness of
the light source i n accordance with
the current passing through the ski n.
D. The calibrator.
For calibration ( fig. 5 , S3) a series of
fixed resistances are switched into the
circuit i n turn (i n place of the ski n
and skin-electrodes) to permit the
flow of known currents, whi l e the
brightness of the light is photographi
cally recorded.
E. Convdsion of variations of
current through the skin to
variations oflight intensity.
Since the current dealt with i n der
mohmetry is of the order of micro
amperes, amplification is required for
the operation of even a small light
bulb.
Figure 5 includes a schematic of the
carrier amplifier currently being used
i n our laboratories, shown i n correct
relation to the variable voltage source
and calibrator circuits. The amplifier
is set to give maximum intensity of
the light source (white on photo
graphic record) at zero ski n current
and minimum intensity (black) at any
pre-sel ected number of mi cro
amperes, according to the desired
range and sensitivity.
The electronic circuit (see block
diagram, fig. 5) consists of a local
osillator, two stages of resistance
coupled amplification, and a control
stage. The oscillator VI (a multi
vibrator) produces a H c/sec.
signal which i s fed through the two
ampl i fier stages V2 and V3, and pro-
I5
1
Fig. 5
Circuit diagram (variable voltage source, clibrator and ampliier)
C1 0. 02 mid papr. 4o volts R9
C2 0.0 md paper, 4o volt RIO
C3 0. 1 md paper, 4o volts Rll
C, C9 0.25 mjd pper, 4o volt R12
C5 1.0 mjd dr electrolytic, 6 volts R13
C6 0.05 mjd paper, 4o volts R14
C7, C8 12.0 mjd. eletrlytic, 6 volts RI5
RI, R, R7 150K, I watt RI6
R2 470 ohm, J watt RI8
R4, R5 2.2 meg, J wtt Sl
R6. R8 lOK, 1 wtt
1.0 meg, 1 watt
5OK, 1 watt
58K, 1 watt
20K, 1 watt
30K, 1 watt
50K, 1 watt
lOK, I watt
3OK, 1 watt
3O0 ohms, I watt
SPST toggle switch
S2, 5 J circuit, 1 J poition, single section, non-shorting rotar switch.
5 DPST toggle switch
TI Power trnsormer, 7o volts ct, 5 and 6.3 voft flament terminal.
T Output trnsormer (Thoraron T-22S90)
F Filter choke, 10. 5 henr
L GE, C-40
VI 6SN7
V2 65
V3
6V6
V4 155
V5 5Y3
Component in block diagram;
OSCILL. multivibrator
AMPL.1 1st ampliier (modulator)
AMPL.2 Power ampliier
LAMP GE, C-40 dial lamp
CONTROL control stage
CALIB. or SIN varible voltage source applied across the skin or the calibration reitors.
16
vides a source of alternating current
sufficient to light the lamp. The
brilliance of the lamp is determined
by the gain of V2, which in turn is
varied by the control tube V 4. The
output of V 4 is determined by the
current flow through the skin circuit
and, consequently, through grid
resistor (RIO). Thus, the carrier signal
is amplitude-modulated by variations
in the resistance of the skin.
The oscillator and amplifer stages
are of conventional design and need
no further description. The control
tube V4 is employed as a poten
tiometer to vary the grid bias of V2.
An independent power supply for the
plate and filament of V 4 makes it
possible to ground the plate. The
voltage drop between the cathode and
plate of V4 is then applied to the grid
of V2.
The direction of current flow
through the skin and grid resistor
causes the grid of V 4 to become more
positive when the current through the
skin (or from the calibrator) is
decreased. More current then flows in
the plate circuit. However, this in
creases the potential drop across the
plate resistor (R9) at the expense of
the voltage drop across the tube.
Under these conditions, the voltage
applied to the grid of V2 becomes less
negative. This increases the amplitude
of the carrier signal with a resulting
increase in b
i
ightness of the light (fig.
5, L). The reverse process occurs
whenever the skin resistance drops
and increases the current through the
grid resistor of V4. For calibration, a
variable source of known current i s
applied in place of the skin circuit by
means of a rotary switch (S 3).
Figure 6 shows a non-electronic
"amplifier" used in an earlier model
of the automatic dermohmeter and
previously described in a preliminary
report (27). Although less convenient
to operate than the carrier amplifier it
is of much simpler construction. The
principle of the device appears, also,
to have a wide range of possible ap
plications.
The indicator needle of a 0-50
microammeter (fig. 6A) actuates the
variable arm of an electrolytic
rheostat in the lamp circuit. This
variable arm is a U-shaped platinum
wire (fg. 6C) which has been at
tached to the indicator needle (fig.
6B) at the center of rotation. The
meter is supported face down on a
EMG, SNS, reflexes, etc.
Plexiglas block in which two semi
circular canals (fig. 6E) have been
cut. Each limb of the U moves in a
canal containing di lute H2S04 Move
ment of the microammeter needle
alters the resistance in the lamp cir
cuit (and therefore the light intensity)
through variation of the length of the
acid column between the limbs of the
U and the fixed electrodes ( fig. 60) .
I n our device, N/6 H2S04 provided a
satisfactory range of resistances.
Froccdurc
To conduct an exploration, the area
to be explored is exposed and the sub
ject reclines on an upholstered tabl e;
one with a face slot comfonably per
mits maintaining the head in the
midline position during exploration
of the dorsal surface. Any desired
topographical features are identified
and marked. The frame is brought
into the horizontal position over the
subject, the rai ls parallel to the long
axis of the area to be explored. The
electrode is placed upon the subject' s
ski n, and the height of the fixed end
of the arm is adjusted ( fi g. 3A) on the
carriage according to the subject ' s
anteroposteri or di mensions . The
l i mits are set on the rai l according to
the length of the field to be explored.
A. Selection ofexploration
voltage.
Before beginning the exploration the
appropri ate vol tage i s sel ected.
Because of di fferences in "basic"
resistance among subjects, some may
require 3 V. or less, others more than
1 8 V. , for demonstration of the
gradations in resistance. We have
found that the voltage which just per
mits a detectable flow of current
(about IpA.) through most of the
ski n, will permit a nice differentiation
and gradation of the areas of relative
ly low resistance by deflections of the
microammeter needle and di mmi ng
of the light source.
B. The calibration strip.
Following the selection of the ex
ploration voltage, the room is dark
ened except for photographic safe
l ight, the camera shutter is opened,
and a calibration strip is recorded,
as follows. The rail is moved to one
side of the exploration field, but still
within the view of the camera, and
the carriage to one end of the rail.
The calibrator is switched i nto the in-
put of the amplifier. The motor is
started, and the clutch engaged, si
multaneously starting the carriage
and turning on the light. As the
electrode-and-light assembly travels
along the rail (electrode not i n contact
with subject) the operator switches
each of the resistances ( fig. 5, S3) into
the circuit i n turn, thus recording i n 6
steps the variations in l ight intensity
throughout the pre-selected range of
current flow. Upon completion of the
strip, the light is turned off by the
automatic limit switch.
C. The exploration .
The rail is then moved to one edge of
the exploration field, and the carriage
brought to one end of the raii. The
electrode is placed on the subject' s
s ki n, the previously selected voltage is
applied to the input of the amplifier
i n place of the calibrator, and the
clutch is engaged. As previously men
tioned, the switch incorporated in the
clutch arm simultaneously turns on
the light source and the voltage to the
ski n electrodes. At the end of the
strip, this arm is automatically thrust
into neutral position as the clutch arm
strikes the limit on the rail, simul
taneously interrupting the circuits.
The rail i s then moved laterally to the
next notch, the clutch is engaged in
the opposite di rection and the next
strip is thus recorded. About 20 sec.
are required for the exploration of a
strip equal to the length of the
average human trunk.
O. Establishment of topographical
relationships.
The positions of the various land
marks (e. g. spi nous processes, scapu
lar edges, il iac crests) are then record
ed by means of a small spot of light.
Figure I shows the spinous process
thus marked as white spots.
The camera shutter is then closed,
the frame bearing the rail, etc. , i s
ti lted back against the wall, and the
slate bearing the data regarding the
exploration is placed within the
camera field but outside the explored
field. A bright bulb, shaded from the
camera but i l l uminating the subject,
is turned on. The explored field is
covered with a black cloth, and, with
out advancing the fi l m, a brief expo
sure is then taken. By this means, as
shown i n figure I , the record appears
in correct montage on a photograph
of the subject's body. The black
Fig. 6
Non-electronic "amplifier". (A) microam
meter; (8) microammeter needle bearing (C)
moving electrode; (D) electrodes fied in (E)
acid trough; (F) U skin electrodes; (G) to light
circuit.
cloth, of course, prevents re-exposure
of that portion of the film on which
the exploration has been recorded.
latcrrctatioa of thc
hotograhic rccords
As the label shows in figure I , both
subjects were explored with 6.0 V.
Since the white areas signify current
of I /A. or less, these represent areas
of ski n whose resistance exceeded 6
million ohms. For the exploration of
figure l a, the ampli fier was set to
cause dim-out at 30 , figure I b, at
25
p
.
t
The black areas, in figure l a,
therefore, indicate currents of 30 /A
or more, that i s, areas of ski n having
resistances of less than 200,00 ohms.
The various shades of gray indicate
i ntermedi ate resi st ances , whose
values can be estimated from the
calibration stri p to the left of the
chart , in which the 30 /A. range has
been divided in 5 /A strips . (The
darkest portion is i'ndistinguishable
from the background. )
tNarrowing t he range, i . e. lowering t he dim-out point.
increases the di fferentiation among the high resistance
areas while sacrificing gradations below the resistance
corresponding to the dim-out current.
2T
Otber applicatons
The principle of the automatic der
mohmeter can, we believe, be applied
to the study of the topographical
variations of features other than elec
trical ski n resistance. I n our
laboratories we have adapted the
device to the demarcation of areas of
cutaneous hyperesthesia by replacing
the eletrode on the arm with an elec
trical or mechanical stimulator. The
light over the stimulator, which is
propelled in the same manner as the
skin electrode, is controlled by the
subject who turns the light off and on
with a thumb-switch to mark the
hyperesthetic zones in each strip. By
incorporating a rheostat in a rubber
bulb grasped by the subject, varia
tions in the intensity of the pain in
duced by the stimulator may also be
recorded.
Another adaptation, in which the
roller electrode is replaced by a ther
mocouple, thermistor or radiometer,
for the study of spatial variations of
skin temperatures on the human
trunk, is in process of construction.
Sources of Error
The automatic dermohmeter, as con
structed by us, has two chief sources
of error, both of which are relatively
unimportant in our application of the
instrument, and both of which can be
gretly reduced or eliminated by cer
tain refinements.
1 . Since the area of contact be
tween electrode and skin (and cor
responding area of illuminated sur
face) are considerable ( 1 2 x 1 2 mm. ),
that area constitutes the limit of error
in the demarcation of a boundary or
in the localization of a small spot.
Thus a small spot of very low
resistance within the area of contact
of the electrode will be recorded as a
rectangle equal in area to the il
luminated surface. In our investiga
tions we appear to be dealing with
segmental phenomena, and therefore
this error is not important since it still
permits the identification of der
matomes. Greater precision of
localization is, of course, attainable
through reduction in size of the ex
ploring electrode and light source, at
the cost of speed of exploration.
2. Since the illuminated lucite rod is
mounted over the roller electrode it is
at some distance above the subjacent
area of skin. At all positions of the
electrode other than those in the axis
2
of the lens, therefore, error due to
parallax is present, and the light will
be recorded by .the film as though
issuing from a rectangle of skin just
beyond the electrode. However, since
the distance between the skin and
light source (3.5 ems.) is small as
compared with the distance to the
camera ( 1 4 ems.) this error is small.
As measured on a subject, with the
electrode assembly at the extremes of
the rail, the maximum error due to
parallax in the instrument described
was 1 8 mm. This error can be
eliminated by maintaining virtual
(optical) alignment of lens, il
luminated rod and un
d
er-surface of
the electrode at all positions in th
camera field.
Summary
1 . A new procedure has been de
scribed for the photographic record
ing of electrical skin resistance pat
terns on the human trunk, or other
areas of the body. The explorations
are accurate, almost automatic and
rapid as compared with exploration
by hand-held electrode.
2. The basic principle of the
method is the conversion of varia
tions in skin resistance into variations
in the brightness of a light source. By
placing the light source directly over
the exploring electrode, and propel
ling the electrode (by synchronous
motor) over the skin at constant
speed, a camera, properly positioned
with respect to the explored feld,
photographs strips of light which
vary in brightness according to the
resistance differences along a cor
responding strip of skin. To explore a
large area, a series of consecutive,
parallel strips is recorded.
3. The adaptation of the procedure
to measure the topographical varia
tions of features other than skin
resistance (e.g. skin temperature,
hyperesthesia) are described or sug-
gested.
.
4. The major sources of error are
describe and shown to be unimpor
tant in our current application of the
instrument . Refi nements which
eliminate or greatly reduce these
errors are suggested.
It is a pleasure to acknowledge the valuable
assistance of Mr. Dwight W. Leighton in the
design of the dermohmeter and the construc
tion of the mechanical parts.
Refernces
l . Blade. B. and Dugan. 0.1. War wounds of the
chest observed at the Thoracic Surgery Center. Walter
Reed General Hospital. J. Thorcic Sur 194, 13:
294-30.
2. Bruesch, S.R. and Richter. C.P. Cutaneous dis
tribution of peripheral nerves in rhesus monkeys as
determined by the electrical skin resistance method.
JahnHapk. Hasp. Bull., 1946, 78:235-26.
3. Craig, C.B. and Hare, C.C. Sweating reaction in
patients with diseases of the spinal cord. Arh.
Neural. Pychit., Chicago, 1935, 33: 478-491 .
4. Denslow. J.S. An analysis of the variability of
spinal refex threholds. J. Neuraphysiol., 194, 7:
20215.
S. Denslow, J. S. , Korr, I. M. and Krems, A.D.
Quantitative studies of chronic facilitation in human
motoneuron pools. Amer. J. Physjal., 1947, lO:
229-238.
6. Guttmann. L. Motorische und vegetative genz
zonenreflexe bei lasionen pripherr und zentraler
abschnitte de nervensystems. Z. gt Neural
Psychit., 1933, 147: 2130.
7. Guttmann, L. Ueber reflektorische beziehunen
zwischen viscera und Schweissdriisen und ihr
Bedeutung bei Erkrankugen inere organe (der
viszerosudorale reflex). Can. Nerl., 1 938. 1:
296-310.
8. Guttman, L. The distribution of disturbances of
sweat secretion after extirpation of certain sym
pathetic cervical ganglia in man. J. Anal .. 19, 74:
537-549.
9. Guttmann. L. Topographic studies of distur
banc of sweat secretion after complete lesions of
pripheral nerves. J. Neurl. Pyhit., 1940. 3:
197-210.
10. Herz. E. and Glaser. G.H . Holdover. 1. and
Hoen, T.1. Electrical skin resistance test in evaluation
of peripheral nerve injuries. Arh. Neural. Pychil
Chicago, 1946, $6: 365-380.
I I . Highet, W.B. Procaine nerve blok in the in
vestigation of peripheral nerve injuries. J. Neurl.
Pychit . 1942, $: 1 10 1 16.
12. Hyman, I. and Beswick, W.F. Mesurement of
skin resistanc in pripheral nerve injuries. WarMe.,
1945, 8: 25826.
13. Hyndman, O.R. and Wolkin, J. The pilocarpine
sweating test: A valid indicator in differentiation of
preganglionic and postganglionic sympathectomy.
Arch. Neurl. Psychiat., Chicago. 1941, 4$: 9210.
14. Japer, H. An improved clinical dermohmeter J.
Neurur .. 195, 2: 25726.
15. Jasper, H. and Robb. P. Studies of electrical
skin resistance in peripheral nerve lesions. J.
Neurosur., 1945. 2: 261 . 268.
16. Korr, I.M. and Goldstein, M.J. Dermatomal
autonomic activity in rlation to segmental motor
reflex threshold. Fe. P., 1948. 7: 67.
1 7. Korr, I.M. Skin resistance patterns assoiate
with visceral disease. Fe. Prc., 1949. 8: 87.
18. KOT. I.M. Experimental alterations in segmen .
tal sympathetic (sweat gland) activity through
myofascial and postural disturbancs. Fe. Pro.,
1949, 8: 88.
19. Minor, L. Uber erhoten electrischen hautwider
stand bei traumatischen affektionen des halssym .
pathicus. Z. G. Neual. Phjal., 1923, 8$:
482 . 507.
2. Palumbo, L.T., Sambrg, H.H., Hohf, J.C.
and Burke. E. T. Postoprative sweating patterns in
thoracolumbar sympathectomy and splanchnicec
tomy. Arh. Neural. Psyh/at., Chicago, 1950, 6:
569-578.
21 . Richter, C.P. and Shaw, M.B. Complete
trtions of the spinal cord at different levels.
Arch. Neurl. Psyh/at.. Chicago. 1930, 2:
107 1 1 16.
EMG, SNS, reflexes, etc.
2. Richter. C.P. and Woodruff. B.O. Change
produced by sympathectomy in the electrical
reistanc of the skin. Surer, 191, 10: 9S7-970.
23. Richte. C.P. and Wooruff, B.O. Lumbar
sympathetic dermatome in man determine by t
electrical skin resistance method. J. Neuropllo.,
I9S, 8: 323-338.
2. Richte. C.P. and Otenasek. F.J. Thoracolum
bar sympathetomies examined with the eletrical skin
resistance metho. J. Neurour., 194. 3: 120-J34.
2S. Richter, C.P. Instructions for usilll the
cutaneous reistance reorder or .. dermohmter", on
peripheral nerve injuries, sympathectomies and
paravertebral bloks. J. Neurour., 1946, 3: 181-191.
2. Richter, C. P. Cutaneous areas deervated by
uppr thoracic and stellate gonetomies deter
mined by the eletrical skin resistance method. J.
Neurour. 197. 4: 221-232.
27. Thomas. P.E. and Korr. I. M. Semi-automatic
recordilll of electrical skin resistanc patterns. Fe.
Pr., 1950, 9: 126.
28. Van Metre. T.E., Jr. Low electrical skin
resistance in the region of pain in painful acute
sinusitis. JohnHopk. Hap. Bull., 1949. 8': 4-41S.
Reprinted by prmission from EEO Clin. Neuro
physiol J: 361-368. 19S I .
Relationship between sweat gland activity
and electrical resistance of the skin (1957)
PRICE E. THOMAS and IRVIN M. KORR
Measurements of the electrical
resistance of the skin (ESR) to the
passage of direct currents are general
ly utilized as an indicator of sym
pathetic activity. In this application,
the techniques used and the informa
tion sought fall into two rather broad
classes: 0) those designed to measure
changes in resistance in a given area
of skin (e.g. psychogalvanic reflex or
galvanic skin response studies) and b)
those used for measuring differences
in resistance among various areas of
skin. For both techniques the basic
electrical method is similar (i.e.
measuring the current flow at a
known voltage and converting to
resistance or conductance according
to Ohm's law). The major difference
in methods is in the type of electrode
used. In the first class (PGR or GSR)
wet, nonpolarizable electrodes are
generally used, while in the latter
class dry, polished-metal exploring
electrodes have been found most
satisfactory and convenient.
With either technique it appears
that activity of the sweat glands
significantly alters the resistance
level. In a study with wet electrodes
Darrow (1 ) found a linear relationship
between the conductance (reciprocal
ohms) and the amount of perspira
tion produced. With dry metal elec
trodes Richter and others (2, 3) have
observed that low skin resistances
were found in normally innervated
areas of heated, visibly sweating,
sympathectomized patients, while
denervated areas showed high
resistance values. These observations
and many others establish visible
sweat gland activity as an important
ESR- I ower i ng fact or whet her
measured by wet or dry electrodes.
In cases of hereditary ectodermal
dysplasia, Wagner (4), using dry elec
trodes, observed consistently high
ESR values at all environmental
temperatures investigated, in skin
areas containing no sweat glands.
'These investigations were supported in part by grants
from the National Institutes of Health (829 and
H1 632) and from the American Osteopathic Associa
tiOIl and by a contract (Nom 243(00 with the Office
of Naval Research.
These skin areas also showed no
resi st ance changes rel ated t o
vasomotor adjustments to heat or
posture. The sweat glands would
seem, therefore, to be the one skin
structure whose physiological activity
produces significant variations in skin
resistance.
Ratcliffe and Jepson (5), using dry
electrodes, showed that significant
differences in ESR between sym
pathectomized and normally inner
vated areas of the skin were still
demons t r abl e even a t cool
temperatures ( l 8QC), in which there
was no visible sweating.
These various observations strong
ly indicate that with dry electrode
techniques any activity of the sweat
glands, even at such low rates as
occur under cool, resting conditions,
lowers ESR below that found in the
complete absence of sweat gland ac
tivity.
The question is now raised as to
whether variations in ESR in a given
area or ESR differences between
areas, in which there is no visible
sweating, such as the patterned dif
ferences described by us (6), are
related to gradations in sympathetic
sudomotor activity.
Affirmative support is suggested by
the observations of Richter and
Woodruff (7) that the size of low
resistance areas around the mouth
and nose was increased during
periods of general sympathetic activi
ty and decreased with lessened sym
pathetic activity though there was no
visible sweating in either case. Low
resistance areas have also been
observed that were regionally or
segmentally related to pathological
states of deep tissues, and which may
diminish or disappear when the
pathological process is alleviated (8).
The participation of sweat glands in
these observations was not apparent,
but cannot be excluded on the basis
that no sweating was visible. Low
rates of sweat gland activity that are
not visible to the naked eye have been
demonstrated by microscopic obser
vation (9, 1 0). To clarify the situation
requires further investigations into
19
Fig. I. Diagram of prism-photo recording
method and appearance of record. The three
components, prism, A. electronic flash light
source, B. and camera, C, are rigidly mounted
in a strong aluminum frame. The camera is
positioned so that light from diffusion screen,
S. is reflected into the lens by the base of the
prism (angle b equals angle c). When these
angles are slightly greater than 45 0 surface
deiails of the skin and presence of sweat drop
lets are clearly observed. Precisely placed
reference marks on prism and skin make it
possible to determine numbers of glands per
unit area of skin regardless of the apparent
angular distortion of the skin field. In this
figure the relati ve size ofthe prism has been ex
aggerated for clarity.
Fig. 2. A. appearance of nonsweating skin; B.
same area of skin shown i n A shortly after
sweating began. An active sweat gland pro
duces a pool ofmoisture that records as a dark
spot in the photograph.
the range of ski n resistance values
than can be related to sweat gl and
activity.
This paper presents an experimen
tal examination of the relationship
between sweat gland activity and ESR
values measured by dry electrodes as
a step toward evaluating the reliabili
ty of such measurements as indicators
of sympathetic sudomotor activity.
Mcthods
The measurements of el ectri cal
resistance were essentially based on
the method of Jasper and Robb ( I I )
i n which a series of dry cells i s tapped
to provide a wide range of voltages in
1 . 5-volt steps. The voltage and di rec
tion of current flow were kept con
stant throughout each experiment.
This necessity was suggested by
Rosendal's ( 1 2, 1 3) identification of
these variables as signi ficantly in
fluencing the measured values of
resistance. The chosen voltage was
J0
applied to an indi fferent electrode
(cathode) fastened to the ear lobe and
making contact with the tissues
through conductive paste, and a dry,
si lver di s k, expl ori ng el ectrode
(anode) . The conductive paste used
was granular, and rubbing sufficed to
abrade the ski n. As demonstrated by
Richter (2) , by Lewis and Zotterman
( 1 4) and by Rosendal ( 1 3) , this
reduces the resistance at the abraded
point to an insignificant level. A
microammeter or galvanometer was
included in the circuit. The resistance
val ues in the data are onl y absol utely
referable to the electrode size stated
since Blank and Finesinger ( 1 5)
observed nonlinear variations in curr
rent density with di fferent el ectrode
sizes.
Each measurement was done by
making brief ( 1 -4 sec. ), firm contact
of the electrode to the ski n and
observing the stable value of current
flow. Resistances or conductances
(reciprocal ohms) were then cal
culated according to Ohm' s law.
Active sweat glands have been re
corded by two methods. In prelimi
nary experiments the iodine-starch
paper method described by Randall
( 1 6) was used. The ski n was painted
with iodine and allowed to dry. A
5-cm2 piece of starch paper was held
lightly against the painted skin area
for a short period ( 1 -2 mi n. ) At the
end of this time the paper was re
moved and a fresh paper pressed
against the area. The number of spots
appearing on each paper represented
the accumulated total of all sweat
glands presenting moisture to the
surface during the test period. ESR
measurements were made on skin im
medi ately adj acent to the gl and
counting areas. Thi s method per
mitted gross observations on ESR
sweat gland relations but had the
disadvantage that the two measure
ments were not made on precisely the
same skin areas.
This disadvantage was overcome
by using the prism technique de
scribed by Netsky ( 1 7) . By uti lizing
the alteration in reflection produced
by contact of moisture against one
face of the prism, active sweat glands
may be observed and photographed
as dark spots through another face of
the prism when evenly di ffused light
is shining through the third face ( figs.
1 and 2) . All photographic records
were taken within 2 seconds of con-
tact of the prism with the ski n. The
prism was wiped clean after each
photograph. By suitabl y adjusting the
light and camera angle the texture of
the skin can also be observed and
phot ographed . I n a seri es of
photographs of the same ski n area,
individual active glands can be iden
tified by their relationship to the
crease pattern and their activity
foll owed through the entire ex
perimental period. Since no chemical
preparation of the skin is necessary,
the ESR of the same area being
photographed can be obtai ned im
mediately before and after each
photograph. This permits a precise
examination of the rel ationship be
tween ESR and the sweat gland activi
ty occuring in the electrode area and
the following of rapid changes in
both.
I n all experiments the subject was
first allowed to rest in a prone posi
t i on at c omfor t a b l e r oom
temperatures until no sweating was
detected by the prism method. The
subject was then heated by an electric
hot pad on the abdomen until
sweating was induced, at which time
heating was discontinued. Recording
of ESR and sweat gland activity was
initiated with heating and continued
through the sweating period until
sweating was no l onger detectable.
LxcrimcataI rcsuIts
An example of the results obtained
using the Randal l iodine-starch-paper
method and an electrode of 2. 54 cm2
is illustrated in figure 3. As seen in
this figure, rising gland count was ac
companied by increasing current flow
(decreased resistance) . However,
when the gland count was falling the
current flow often remained elevated.
This immediate postactivity ' lag' sug
gests some residual effect of sweat
gland activity. The observations of
the ' lag' and of the variations in con
ductance at zero gland count suggest
a ' nonsudorific' i nfluence on conduc
tion. The necessity of using di fferent
ski n areas for ESR and gl and counts
in the Randall technique, however,
precluded any certain identification
of nonsudori fic conductance factors
or assignment of any quantitative
conductance properties to the sweat
glands.
The prism technique made i t possi
ble to measure the current flow and
number of active sweat glands from
EMG, SNS, reflexes, etc.

the same skin area. Results obtained

in a representative experiment are il
lustrated in figures 4 and S. In this ex
periment heating was discontinued
soon enough that only one major
burst of sweat gland activity occurred.
In fgure 4 a very close relationship
between current flow and numbers
of active glands can be observed.
Unlike the observations with the
Randall technique, this relationship
differs only slightly for the rising
and falling stages of sweat gland
activity. This difference in ex
perimental results probably reflects
the fact that in the Randall method
moisture produced by past glandular
activity would be absorbed by the
paper in the gland count area and
thus not appear in subsequent papers,
while in the electrode area moisture
produced by sweat glands would re
main after secretion has ceased and
continue to exert a resistance
lowering effect. The influence of sur
face moisture has been reported by
Blank and Finesinger ( 1 5) and will be
discussed later.
The correlation graph of data from
the experiment shown in figure 4 ap
pears in figure 5. The solid line was
calculated by the method of least
squares on the assumption of a linear
relationship between conductance
and the number of active glands. The
correlation coefficient for this rela
tionship is .899 .083, a value which
suggests that for these data the
assumption of linearity can be made
with considerable assurance. The
equation of this line is of the form y
= a + bx. In the present application
y is the total conductance ( G I) and x
is the number of active sweat glands
(N). The coefficients a and b are con
ductance values. The value of b
represents the average conductance
increment of each active gland ( G
g
).
The coefficient a i s the average value
for an additional conducting path
( Go) whose contribution to the total
conductance is not directly related to
the number of active glands in the test
area. In terms of conductance this
equation may be written:
G, Go + GgN (/)
The reciprocals of the conduc
tances G" Go and Gg yield the respec
tive resistances R" Ra and Rg When
these values are substituted in equa
tion / the second term on the right
side becomes NIRg suggesting that the
sweat gl ands serve as parallel
resistances in the electrical circuit. A
simplifed ohmic resistance circuit
satisfying equation / is shown in
figure 6.
Actual measurements on individual
glands were made using a fine wire
electrode touched to the sweat bead
produced duri ng acti vi ty. The
resistance values observed for in
dividual glands varied from 3 to 20
megohms and are si mi l ar i n
magnitude t o the calculated values of
Rg (table I). Similar measurements
made independently by Suchi (1 8)
yielded similar resistance values for
individual glands. These observations
tend to confirm the concept that
sweat glands provide parallel high
resistance paths for conducting cur
rent through the skin.
Similar statistical methods were
used to examine separately the rising
and falling gland count portions of
each experiment. The lines calculated
for subject EB No. 17 are shown in
figure S. The dashed line illustrates
the rising and the dotted line the fall
ing gland count relations. The dif
ferences between rising and falling
gland count curves observed in the
slopes ( G g) and the 'nonsudorific'
coefficient ( G _) were relatively small
in this and in most other subjects. As
was also true of most subjects, slopes
were steeper and 'nonsudorifc' coef
ficients were smaller, in rising than in
falling gland count portions of the ex
periment. The differences are not
statistically significant in these small
samples but do suggest that the con
ductance of each gland is higher at
the time of active sweat expulsion
than when sweat is just present in and
around the tubule. The signifcance
of the changes in ' nonsudorific' con
ductance will be discussed later.
Table I compares the results from
six experiments on four subjects .
These experiments represent the
widest individual variations observed
in 1 5 separate experiment s. The
values are tabulated in the more fre
quently used terms of resistance, R_
and Rg bei ng, respecti vel y, the
reciprocals of Ga and Gg The values
for Ra are those determined by cur
rent fow measurement at times when
no sweat gland activity was recorded.
In each column of table I dif
ferences in the resistance values are
observed from subject to subject and
in the same subject in different ex-
I K 1 - 22- 53
1. 5 Vol ts
f
Current
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MINUTES
Fig. 3. Relation 0/current /Iow to numbers 0/
active glands (Randall method). Active glands
were counted by Randall iodine-storh-paper
method described in text (I-min. periods) and
current flows were measur at end 0/ ech
period. Continuing high current fow during
/alling gland count phase is referrd to as 'lag'
in the text.
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4 5 6
MINUTES
8 9 10
Fig. 4. Relation 0/curent flow to numbers 0/
active glands (prism method). Current fow
mesurements and photographic records 0/
number 0/ active gland were initially made
every 30 sec. A t onset 0/ sweating recordings
were made at JS-sec. intervals. Curent was
recorded immediately ater ech photograph.
periments. The smallest differences
are observed in Rg for the same sub
ject. Differences among subjects are
smallest for the values of Ra and
largest for values of Ro
The poorest correlation observed
to date was in subject HW, expo 19.
Although no explanation can be of
fered at this time, environmental
temperature may have been a factor
in that it was lower for that experi
ment than for any other. Further
s t udi es at l ow t emperat ures
(20-24C) may reveal a basis for
such differences in the conductance
sweat gland relationship as observed
in HW, 19.
31
0
.
o
w
C
2
3

I
0
L
2
EB No 17
5-24 - 55
r+
F
Glond Co.n
fncreosin;
Oecreasinq
10 20 30
ACTi Ve SWEAT GLANDS PER 0.44 Cm
Fig. 5. Corrlation graph for exrimental data
shown in fg. 3. Solid line, A. shows the rla
tionhip of currnt fow to swt gland for
both ring and delning pha ofsweat gland
activity. Dhed line, R. shows relationship
during only ring pha and dotted line, F, for
faling phas. The lines wr also obtained by
method of let square.
i
Fig. 6. Simplied schematic ofskin resistance
circuit. Total resitance of the skin i
rpreented as simplied electricl network. A
variable numbr ofswet gland ar pictured as
a variable number of parallel resistances 0.
R .. . . . Rn ... Rn) in the network. A non
sudoric reitance (RJ also appear in paralel
with swt gland ritance and i reprente
a a variable component in accord with surfac
moitur infunc dicusd in the tet.
The equation from which Re was
obtained implies that for A O, R/
should equal R
Q
However, the actual
ly measured value(R
o
) when no active
sweat glands were present (^ 0)
was in every case much larger than
Re. The relation of these observa
tions to the influence of surface
moisture provided by sweat secretion
or other sources is discussed in the
next section.
Ulwuioa
The physiological signifcance of ESR
gradations is i ndicated by the finding
in different subjects of consistently
l inear relationshi ps between the
number of sweat glands propelling
moisture to the surface and the con
ductance through the skin. The data
suggest that each secreting sweat
gland lowers resistance in two ways:
JI
a) by serving as an added parallel high
resistance in the electrical circuit and
b) through the i nfluence of the
moisture produced on the resistances
of nonglandular tissues.
Magni tude of the average
resistance values (R,) calculated for
single glands from the experimental
data presented is similar to actual
resistances of i ndividual active glands
observed in our laboratory, and in
dependently by others (1 8). The con
cept that sweat glands form parallel
resistances is also consistent with
Darrow's observations (1) that the
conductivity in mhos or micromhos
(reciprocal ohms) was linearly related
to the amount of perspiration. That.
the amount of perspi ration was
generally related to the number of ac
tive glands was indicated by investiga
tions of Hertzman et al. (1 9).
The infuence of surface moisture
on ESR has been demonstrated by
Blank and Finesinger (1 5), by Farmer
and Chambers (20) and was shown by
Rosendal (1 2, 1 3) to be a direct
physical i nfluence of moisture on
nonglandular components of the
skin.
Blank and Finesinger showed that
during prolonged wetting of the elec
trode area the resistance decreased to
reach stable values in 304 minutes
of moistening. A similar time course
has been observed for hydration of
the stratum corneum (21), suggesting
this as one factor tending to decrease
the resistance. The resistance lower
ing i nfluence of surface moisture i s
also due i n part t o a change i n effec
tive electrode radius which occurs
when the tangential resistance of the
skin is decreased (1 5).
Since surface moisture i s produced
in our experiments and since the ex
periments have a duration of 1 0-1 5
minuteSt it appears quite evident that
surface moisture is present as a factor
in our data. A measure of its in
fluence i s suggested by the difference
between the values of Ro and Ra, since
Ro is obtained before, and Ra is the
average value obtained during the ad
dition of surface moisture by sweat
secretion. The same influence would
account for the differences between
the values of Ra calculated for the ris
ing sweat gland count portion of the
experiment, and those calculated for
the falling gland count portion. If the
values of Ro and Ra are affected by
hydration of the stratum corneum
TABLE I. Comparison ofeperimental reults.
Subj. 8m

!I / _ I / "'' R. I
Lxp.

`' Hu.

l " ' ' '

8, 06
'
I
25 , 5,
I
. 90: 1 I3t
EB, 13 25

6. 2 1 1 ,60 30,25 , 8043 908:, 087

EB, 14 24
,
3 , 1 1 '0.40 1 2' 25 55 0 , 960:,00
JC, 16 10
,
", 7 9. 701 30 25 . 0 52 . 840:, 19'
HW, 19 26, 5 , 7
1
41 . 6 i I 20
,
23. 85 58 . 440:. 183
JE, 2o

3 , 9
:
25 . 6 : 9
1
'4. 1 5 S3 , 90:. 04
All resistance values are in megohms, Ra and
R
g
ar reciprocals of calculated values Oa and
Ow repectively, dics e in the tet, R wa
the rsistance meaured at a time when no ac
tive gland were recorde. Column r give the
Pearon product-moment coeffcient of cor
relation btween the data and a lner curv ob
tained by method of least squares.
"Numbr of measurements of corresponding
swt gland counts and current fows during
each experiment.
tStandard error |=
r
2
2
Where n is the
number of measurements.
they should exhibit some dependence
on i nitial hydration as influenced by
environmental humidity. Although
we have not systematically studied
this variable, in repeated expriments
on the same subject (EB) both Ro and
R" were lower when the humidity was
i ncreased.
It appears, therefore, that under
conditions of moderate environmen
tal humidity, with the direction and
magnitude of applied voltage and
electrode size constant, variations in
resistance of an area of skin in a given
individual are related to variations in
the number of active sweat glands
and to the surface moisture produced
by their activity. The relation of con
ductance (reciprocal ohms) to the
number of active sweat glands is very
nearly linear. A given i ncrement in
conduction thus reflects essentially
the same i ncrement in sudomotor ac
tivity r.gardless of the initial level of
activity. The basis for this observa
tion appears to be that each active
sweat gland contributes a conduction
path that is electrically analogous to
adding a resistance in parallel to the
other sweat gland resistances. On this
basis it appears that ESR is a reliable
i ndex to sympathetic sudomotor ac
tivity.
The tentative i dentification of
sudorific and nonsudorific conduc
tive paths provides a basis for future
investigations into the factors in-
EMG, SNS, reflexes, etc.
fluencing each path. This will further
clarify the combination of factors
determining the electrical resistance
of the skin and permit a more precise
interpretation of ESR gradations
among di fferent individuals and
among various skin areas of the same
individual.
References
\. Darrow. C.W. J. Gen. Pychol, II: 451, 1934.
2. Richter, C.P. J. Neurosurg, 3: 181. 1946.
3. Whelan, F. G. and C.P. Richter. Arch. Neurol. &
Psychiat. 49: 454. 1943.
4. Wagner. H. N .. Jr. Arch. Dermot. & Syph. 65:
543, 1952.
5. Ratcliffe. A. Hall and R.P. Jepson. J.
Neurour. 7: 9, 1950.
6. Thomas. P. E. and I . M. Korr. Electro
encehalog. & Cln. Neurophysiol. 3:361, 1951.
7. Richter. C. P. and Bettye G. Woodruff. Bull.
Johns Hopkins Hosp. 70: 4, 1942.
8. Van Metre. T.E . Jr. BUl. Johns Hopkins Hosp.
85: 4. 1949.
9. Jurgensen, E. Dutsche Ztshr. fklin. Me. 144:
2, 192.
10. Jurgensen, E. Deutshe Ztschr. f.klin. Me.
144: 193. 1924.
1 1 . Jasper. H. and P. Robb. J. Neurosurg. 2: 261.
195.
12. Rosendal. T. Acta physiol. scandinav. 8: 183.
1944.
13. Rosendal. T. Acta physiol. scandinav. 5: 130,
1943.
14. Lewis. T. and Y. Zouerman. J. Physiol. 62:
280. 1926-27.
15. Blank. I. H. and J .E. Finesinger. Arch. Neurol.
& Pychit. 56: 544. 1946.
16. Randall. W.C. J. Clin. Invest. 25: 761. 1946.
17. Netsky, M. G. Arch. Neurol. & Psychit. 6:
279. 1948.
18. Suchi. T. Jap. J. Physiol. 5: 75. 1955.
19. Hertzman. A.B . W.C. Randall. C. N. Peiss, H.
E. Ederstrom and R. Seckendorf. Am. J. Phys. Med.
31: 170. 1952.
2. Farmer, E. and E.G. Chambers. Brit. J.
Psychol. 15: 237. 1925.
21. Peiss. C. N . W.e. Randall and A.B. Hertzman.
Fe. P. 12: 108, 1953.
Reprinted by permission from Journal of Applied
Physiology 10: 505510, 1957.
Patterns of electrical skin resistance
in man* (1958)
IRVIN M. KORR, PRICE E. THOMAS and HARRY M. WRIGHT
About 10 years ago we undertook
electrical skin resistance explorations
upon large numbers of subjects as
part of an approach to the study of
regional and segment-to-segment
variations in sympathetic activity.
During this same period there has
been a great growth of interest in this
field, in localized or segmental
autonomic dystonias and in their
functional and clinical implications,
and many of the investigations have
been reported in this journal. While
the ori gi ns , si gni fi cance and
mechanisms of these segmental devia
tions in autonomic function are as yet
poorly understood, there can be little
doubt of their high incidence and of
their importance. This report, based
on skin resistance explorations upon
several hundred subjects and pa
tients, is intended to be a contribution
to this field.
The validity of the electrical skin
resistance method as an index, at least
under certain circumstances. to sym
pathetic activity seemed well estab
lished by evidence such as the follow
ing:
1 . Electrical skin resistance (ESR)
is related to activity of the sweat
glands 5
,
2
8.
3
0.
32-35 . This relationship has
been quantitatively examined by us 5
0
.
2. Interruption or retardation of
the flow of impulses over sympathetic
pathways to a given area of skin
causes marked elevation of resistance
in that area, whether a) by severance
of pre- or post-ganglionic pathways
24
-2,
33. 38.
39. 41 ; b) lesions of the spinal
cord
32
; c) by peripheral nerve lesions
Z, J, Z, J. 7-
36. 37 ; d) or by pharmacologic
blockade', 4.
3. Stimulation of sympathetic
pathways either locally or systemical
ly lowers the resistance
, Z, ZJ, Z, ZY, J, J,
J"- J, J&-34
*
4. Although demarcation of
(anhidrotic, high-resistance) areas to
which the sympathetic supply is inter
rupted is sharpest when done in a
"These investigations were supported in part by
grants from the National Institutes of Health. Public
Health Service (B29 and H1632), and from the
American Osteopathic Association. and by a contract
(Nonr 243(0)) with the Office of Naval Research.
background of sweating (low resis
tance) induced by heat or diaphoretic
agents, the above relations among
ESR. sweat glands and sympathetic
activity hold whether or not there is
the frank appearance of perspira
tion
10.
26.
3
0.
5
0
.
Since our concern was with
topographical gradations in sym
pathetic activity, especially with the
possible incidence and distribution of
areas manifesting exaggerated sym
pathetic activity and their possible
relation to segments of low motor
reflex threshold, we turned to the
study of skin resistance patterns
under cool, resting conditions in
which visible sweating did not occur
and in whi ch resi stance was
predominantly high.
It is shown in this paper that low
resistance areas (LRA) are found in
apparently normal individuals, that
the distribution of these areas varies
from individual to individual and that
the segments of the trunk in which the
LRA predominate may remain con
stant in a given individual for long
periods of time. It is of interest to
note the parallelism (though no direct
relationship is yet established) to the
observations of Dens/ow and his co
workers 7. 8 on intersegmental varia
tions in motor refex thresholds. In
electromyographic studies on refex
responses of the spinal extensor
muscles, they found, in most sub
jects, one or more segments which
were distinguished from the others by
markedly reduced motor reflex
threshold and in which motoneurons
( supplyi ng the paravertebral
musculature) were apparently main
tained in a chronic state of facilita
tion. Patterns of distribution of the
low-threshold segments varied among
subjects but were highly constant for
each.
Although most of the data on
which this report is based have been
available for several years, we have
withheld publication until we could
assure ourselves that the regional skin
resistance differences were related,
not to some random variation in skin
quality or in sweat gland distribution,
33
but to significant functional dif
ferences. Through an extended series
of investigations (to be cited later)
regarding the nature, origin and basis
of LRA, we have become convinced
that they represent neurophysio
logical phenomena of considerable
interest and are worthy of further in
vestigation. Low-resistance 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 paperso
are the frst full reports of this series
of investigations; they are intended to
introduce the phenomena for further
study.
Methods
Since the explorltions 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-
standy moving exploring electrode, at
known voltagest. The voltages are
tapped stepwise from a series of dry
cells and applied to an electrode fixed
to an earlobe and an exploring elec
trode. Resistance of the skin of the
earlobe is minimized and stabilized by
means of a needle puncture or by ap
plication of electrode paste. Area-to
area differences in current flow 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 polarized 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 i n ohms. The term "elec-
tIn this way secondary excitatory or polarization
effets of the current are minimized or eliminated
(Rihter").
3
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 fows through dif
ferent areas at constant, specified
voltage.
A. The Dermometers. 1 . Explora
tions with Hand-Held Electrode. In
our earlier studies we employed an in
strument basically 'imilar to that
described by Jasperl 4. Current flow is
read from a microammeter as the
electrode is moved over the subject' s
skin.
2. Automatic Explorations. In
order to minimize 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 (i. e. current fow) dif
ferences along corresponding strips
of skin. To explore a large area, a
series of consecutive parallel strips is
recorded.
More recentlySl 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
cor di ng gal vanomet er whos e
amplitude of oscillations is related,
through an amplifier, to the skin cur
r ent . The pos i t i on of t he
galvanometer writing-point on the
chart is related to t
h
e position of the
exploring electrode on the subject by
means of a pantograph.
Results obtained with all three
methods are presented in this report.
B. Exploration 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
stabilized, 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. Sel ecti on of Expl orati on
Voltage. After marking the tips of the
spinous processes as landmarks on
the skin, the exploration voltage is
selected according to the subject's
general level of resistance. This is
done by applying increasing voltages
(from 1 , 5 to 1 8 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 50-microammeter range of
the meter (20 - 30 "a.) Under these
conditions most of the skin of the
trunk permits barely detectable cur
rent fow or none (1 "a or less).
In this way the low-resistance 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
excursi ons of t he osci l l at i ng
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 level, it is possible to com
pare and grade areas in the same sub
ject or in different subjects according
to current fow - or as fractions of
the general resistance.
Regar dl es s of t he met hod
employed therefore, the method con
sists of the mapping (and grading) of
islands of low resistance (high current
fow) in a general background of high
resistance (minimal current flow),
under conditions of rest.
3. Exploring and Recording. Ex
plorations by hand were conducted in
a manner similar to that described by
Richter40 for the mapping of
EMG, SNS, reflexes, etc.
v0 2 1048
:o45uV
20
30
." --
, /
\ * . +
.
7

Figs. 1-3
anhidrotic areas in the sweating
patient. The areas of low resistance
revealed are recorded on standardized
body charts such as that shown i n
Fig. 2a and 3a. The relative resis
tance values are graphically repre
sented on the charts by shading of
the correspondi ng areas . Areas
which permit the flow of no more
than I pa at exploration voltage as the
electrode passes over them are left un
shaded; those which permit a momen
tary flow of 20 pa or more at the ex
ploration voltage are recorded i n
black. The intermediate values are
-lS-4S
*PY
divided among four shades of gray.
I n e x pl or a t i on s by t h e
photographic method, the ESR pat
terns are recorded on fil m and appear
in montage on a photograph of the
subject taken immediately upon com
pleting the exploration. The black
and white areas represent the same
current flows as described above for
the charts, but the intermediate
values may be estimated by com
parison with the calibration strip
which appears i n each photograph,
and which shows 5 pa steps i n shading
from 0 to 22. The current flows can

'

Figs. 4-6
be estimated di rectly from the pan
tographic charts also. In these,
however, the amplifier has been ad
j usted so that the widest oscillations
(producing the darkest area on the
chart) represent 30 p. a. The explored
area is shown, in each chart, in cor
rect spatial relation to a pantographic
tracing of the body outline.
If desired, resistance or conduc
tance (Darrow') values for any areas
in any of the charts may be estimated
from the exploration voltage stated
on each chart and the current flow in
dicated by the recording method.
J5
......
Uy
.o G.

.

|
\
J. G.
"-22-41
| |~ | 0~
1 2 V
Figures 1 -8. Illustrating individuality ofESR pallems and the constancy ofsegmental distribution oflow-resistance areas in 8 subjects. Note the periods
intervening between succeeding explorations for each subject.
As described in text, explorations have been done with 3 different methods:
I. Hand-held electrode: Figs. 2a, 3a, 5a, 7a, 7b, 8a;
2. Photographic recorder: la, Ib, 2b, 3b, 4a, 4b, 5b, 7c, 8b;
3. Pantographic recorder: 6a, 6b, 8c.
In all figures dark areas represent low-resistance areas of skin on back. Darkness of shading in hand-drawn charts and in photographic records is in
proportion to current flow at exploration voltage; the darker the area the lower the resistance. White areas: I} or less; (resistance, in ohms, at least I
million time the number ofvolts); black areas: 20pa or more; i. e., less than 1/20 ofbasic resistance; gray areas: intermediate values. (Reproduction of
these figures has darkened the gray areas and the darker shades have become indistinguishable from the blatk areas.)
In the pantographic records (Figs. 6a, 6b, 8c) amplitude ofoscillations ofthe recording galvanometer are related to current flow through the skin. The
thin vertical fines (no oscillation) represent areas permilling 0 to Ipa a/ exploration voltage; widest oscillations represent current flows of 30pa or more.
In these charts, therefore, the darkest areas represent 1/30 the basic resistance or less.
Tps of spinous processes and the sacral base are marked in photographic and pantographic charts. Also note calibration "strips", showing relation
between current and amplitude of oscif(ations (pantographic method) and between current and shading (photographic method), in step of5Ja.
Resulls
A. Individuality oj ESR patters.
Figs. 1 to 8 represent explorations
conducted on 8 di fferent subjects and
J0
illustrate the diversity of patterns
which are obtained. In our explora
tions of hundreds of subjects we have
not found two identical patterns,
although certain features may occur
i n common, as in certain painful
visceral disturbances and although
low-resistance areas occur wi th
EMG, SNS, reflexes, etc.

significantly higher frequency in
some regions (e. g. , lumbar) than i n
others.
B. Reproducibility of Segmental
Patterns. Explorations conducted
upon the same subject at different
dates are also shown in Figs. I to 8. I n
these subjects, as i n most of those
who were repeatedly explored over
long periods of time, the distribution
of the areas of low resistance showed
a high degree of reproducibility; that
is, the location and arrangement of
the predominant areas, with respect
to segmental levels and left and right
sides, remained remarkably constant
(more than 2Z: years in the case of
L.C. , Fig. 5 and almost 4 years for
J. G. , Fig. 8) .
C. Variations of Individual Pat
terns. "Reproducibility" of patterns
in no sense, however, implies fixity or
constancy of the sizes and shapes of
the low-resistance areas or their
resistance values, nor does it imply in
variable presence of these areas and
the absence of all othersi. As is well
known, ESR is an extremely labile
feature, subject to numerous and sub
tile influences. Nevertheless, despite
this lability, repeated "sampling" of
the patterns of each of many subjects,
during a given day or over periods of
weeks and months, reveals that in
each subject there are certain zones or
segmental levels and sides in which
the probability of finding low
resistance values (that is high current
flows), relative to the general levels, is
far greater than that in all other
areas. Of these, some show a higher
probability than others so that parts
of a given subject's "pattern" may be
absent from time to time while others
are found in virtually every explora
tion.
Furthermore, the recurrent areas of
l ow resistance, that i s, the "high
probability" areas, form a pattern of
distribution which is characteristic
for the subject. Although other areas
of low resistance occur, even under
the conditions of our explorations,
not only are they relatively infrequent
and evanescent, but they are also ap-
tTwo charts of subject J. H. (Fig. 7 a, b) were especial
ly selected to illustrate variations in shape, size, loca
tion and resistance values of LRA while the segmental
levels and sides on which they occur remain essentially
unchanged. Note that in the lumbar area the main di f
ference between the first two charts is in the degree of
spread from the midline .
0
Fig. 9. Apparent dermatomal strips oflow resistance.
parently random, fol l owi ng no
discernible or reproducible pattern.
Toward a better understanding of
the nature of t he patterns and of our
criteria for the determination of
"pattern", it is of interest to review
the range of variations in ESR and in
area-to-area di fferences that may be
seen in the course of a single session
of serial explorations.
D. Transitional Changes in Pat
ter. I n cool weather, in which skin
resistance (of the clothed subject) is
moderately high, the areas of low
ESR are us ual l y i mmedi at el y
distinguishable upon bringing a sub
ject into the laboratory for explora
tion, and many remain so for periods
of hours. In warm weather or follow
ing physical exertion, excitement etc. ,
the resistance of the skin of the trunk
is generally low, even though there
may be no visible perspiration, and
gradually climbs for some time after
tqe subject reclines in the cooled
room. During the period of low
resistance the application of even the
lowest exploration voltages of the
dermometers ( 1 , 5 or 3 volts) produces
large current flows throughout the ex
ploration area, rendering impossible
JT
the differentiation of relatively low
and high-resistance areas. (With the
use of fractions of a volt, however, it
is possible to demonstrate, even
under sweating conditions, large
area-to-area differences in current
flow30.)
As the subject rests, with the ex
plored area exposed, there is a general
progressi ve el evati on i n s ki n
resistance, i n which certain areas lag
far behind others, and a pattern of
relatively persistent low-resistance
areas emerges. That is, most of the
areas of the trunk cease to pass more
than 1 pa at the low exploration
voltages, while certain zones, whose
pattern of distribution is character
istic for the subject, still conduct
large currents at the same voltage.
With continued rest and cooling
there may be further general increase
in resistance so that at low explora
tion voltages there may be no ap
parent current through most of the
skin and only a few microamperes of
current through the low-resistance
areas. An increase in voltage re
establishes the wide differential and
the pattern of low-resistance areas re
emerges. It is of interest to note that,
in general, progressive increase in
resistance during rest and cooling
proceeds from the periphery cen
tralward, so that areas of low
resistance appear to contract toward
the midline.
Eventually there is stabilization of
the basic resistance and no further in
creases in voltage (beyond 6 to 9 volts
for most subjects) are required for the
demonstration of resistance dif
ferences. In this manner, despite the
large changes in absolute values,
areas of relatively low resistance may
remain differentiable over periods of
2 or more hours, although there is
usually a reduction in their size dur
ing this period and some LRA may
vanish entirely. The first areas to
disappear are those which, in
preceding explorations, had shown
only small or moderate current flows
(e.g., 3 to 5 p), that is, those which
would have appeared in gray on
preceing charts.
We have repeatedly observed the contraction and ex
pansion towards the midline under many cir
cumstances. including experimental procedures. rest
and fatigue. cooling and warming of the subject. etc.
These appear similar to observations by Richter and
Wo on changes in facial patterns of low
resistance.
38
With prolonged rest, especially at
lower temperatures, there develops an
almost uniformly high resistance in
most subjects and only small rem
nants of the original pattern may be
distinguishable within the voltage
range of the dermometers. The most
persistent areas are those which
showed large current flows under the
usual ircumstances of our explora
tions. They also show early and large
decreases in resistance upon re
warming the subject.
Of greatest interest in this connec
tion is the fact that those low
resistance areas which are differen
tiable in each subject for the longest
time during a period of rest and cbol
ing, as shown by serial explorations
during such a period, are also the
ones which occur with highest fre
quency in occasional "samplings"
over periods of weeks and which con
stitute the dominant features of the
subject's "pattern".
It should be pointed out that
although most subjects show a basic
stability or reproducibility of pat
terns, conspicuous changes have been
observed to occur spontaneously in a
number of subjects whose patterns
had been followed over periods of
months or years, and others have
been experimentally induced. The
origins and character of these changes
will be examined in a later paper.
E. Possible Segmental Basis jor the
Patters. A segmental basis for at
least some low-resistance areas is sug
gested by the frequent presence of
"strips" of low resistance which ap
pear to have dermatomal distribu
tion. Such strips are apparent in both
explorations of Fig. 2 and in Fig. 7 b.
Fig. 9 illustrates other strips that have
been observed; the strips may extend
from spine to sternum and occa
sionally encircle the trunk. In ex
perimental studies y to be reported
more fully elsewhere, we have also
been able to induce new low
resistance areas which show distinctly
dematomal arrangement .
Discussion
It appears from these studies that the
reproduci bl e patterns of low
resistance areas demonstrable on
human subjects consist of those areas
of skin in which the probability of
finding relatively low resistance
values at any time is much greater
than for skin at other segmental levels
or sides. This high probability is
based on the fact that in these areas
the low resistance is most persistent
under conditions which tend to
elevate skin resistance, and because
their resistance decreases earlier and
to lower levels under conditions
which tend to lower it.
In effect, each occasional explora
tion of a subject over periods of
weeks or months is the "catching" of
a pattern at one stage or another of a
transition from generally low levels of
resistance towards geneally high
levels or vice versa. The high
reproducibility of each subject' s pat
terns of low-resistance areas is related
to the high probability with which the
resistance of those areas will have
dropped in advance of others and
stayed low after the others have risen.
In short, the "low-resistance areas"
are those which are present for the
longest period during each transition
and therefore the most likely to be
found in occasional samplings.
On the basis of the findings
described by Thomas and Korrso and
others cited in the introduction, it
would appear that low-resistance
areas are those in which, at the time
of measurement, a) secreting sweat
glands, serving as parallel high
resistance pathways through the skin,
are present while none are active in
other areas, b) are present in larger
numbers or c) in which larger
amounts of residual moisture (from
past secretory activity) are present.
It would appear that one of the
chief reasons that these regional
variations in the ESR of the trunk
have been previously missed or
disregarded, despite the very large
numbers of subjects that have been
explored in many laboratories and
clinics, is that the 2- to 20- or 30-fold
differences in resistance upon which
our patterns are based, are small in
comparison with the approximately
thousand-fold resistance-variation of
which human skin is capable. Thus,
for example, the resistance of cool,
dry skin is ordinarily treated as
uniformly high (tens of millions of
ohms) and that of sweating skin as
uniformly low (tens of thousands of
ohms), with "negligible" variations
at each level.
In contrast, our procedures and,
therefore, our fndings are based on
the following principles:
EMG, SNS, refexes, etc.
1. We examine the area-to-area
vari ations around the general
resistance l evel found in the par
ticular subject at the time of explora
tion. In this way the differences in
level from subject to subject, and
from time to time and season to
season in the same subject, are "buf
fered" out. This is comparable to the
study of moment-to-moment varia
tions around a general resistance level
in selected areas, as in psychogalvanic
studies.
2. We conduct the explorations
under conditions (the subject resting
in a cool environment) in which the
general resistance level is moderately
high or gradually risi ng, thus
sharpening the differentiation of the
"residual" relatively low-resistance
areas. That is, by avoiding the "level
ing" extremes of very low resistance
(sweating) and very high resistances
(chilled s ubjects) gradations i n
res i s t anc e are most cl ear l y
demonstrated. We were, nevertheless,
able to demonstrate patterns of ESR
variations over a wide range of
resistance levels, i ncluding the low
val ues associ ated wi th acti ve
sweating.
3 . Exploration voltage is adjusted
to the general resistance level in such
a way that the range of current varia
tions is fairly constant and indepen
dent of the general resistance l evel.
When this is done precisely, then
areas showing identical current flows
become equivalent regardless of their
absolute resistance values. That is, a
given current represents the same
fraction of general resistance (or the
same multiple of general conduc
tance) whatever that level may be,
regardless of the subject, the season
or the circumstances.
We have found, however, that, for
purpose of demarcation of patterns
of low-resistance areas, the proper
selection of exploration voltage,
though important, is not critical.
Thus, changes of 3 or more volts only
affect the range of current variations
(and the darkness of shading of the
charts) without signi ficantly affecting
the patterns.
Isolated in this manner from the
I n more recent experiments" to be reponed more
fully elseswhere. we have been able to demarcate the
ESR patterns within a total range of current variation
of 2/1. through the use of low exploration voltageS
and appropriate D.C amplification. (Compare
Levine", Whelan").
gross l evel-to-Ievel changes, these
smaller variations in ESR at any given
level assume a larger quantitative
significance. Though in ordinary
resistance measurements they sum
algebraically with the basic or general
resistance, the smaller ESR variations
show considerable independence of
the basic resistance level. This sug
gests the possibility that the factors
which determine the area-to-area dif
ferences here reported (and perhaps
also those determining psycho
galvanic fluctuations) are different
from those determining the general
level at which those variations take
place - in the same sense that the
coarse and fine adjustments of an in
strument may be separate - and
quite different - mechanisms whose
actions are algebraically additive.
More direct evidence for a duality of
basic factors is reviewed by Thomas
and Korr' O It is interesting to note
that Regelsberger27 also ascribes his
electrodermatograms to a combina
tion of factors.
At any rate, there can be little
doubt of the reality of the ESR pat
terns and of their relation to physio
logic variables. Their very existence
and reproducibility, as well as their
changes with experimental and
clinical variables, raise fundamental
questions regarding their physiologic
basis and significance that demand
answering.
Studies by many investigators,
cited in the i ntroduction to this
paper, appear to have established
quite firmly that ESR is related to
s ympathetic acti vi ty expres s ed
through the sweat glands; i nterrup
tion or retardation of the flow of im
pulses over sympathetic pathways
elevates ESR, while sympathetic
stimulation reduces it. Since the
reproducible, long-term area-to-area
differences in ESR reported here were
in no way related to any apparent
s ti mulation or i nterruption of
selected sympathetic pathways, i n
teresting questions were raised re
garding their origin, basis and func
tional implications.
Although the ESR patterns
themselves permit no firm conclusion
on this point, the observations by
other investigators referred to above
on the relation between sudomotor
(sympathetic) activity and ESR, as
well as our own observations on the
relation between ESR and sweat
gland activity'O, suggested that the
patterned differences in ESR, as
measured by us, were also related to
patterned differences in sympathetic
activity.
A possible reflex origin of LRA (as
well as of other cutaneous manifesta
tions of local sympathetic hyperac
tivityl . ' 9, 46) has been indicated by
several investi gators who demon
strated the segmental or topographi
cal association of areas of hyper
hidrosisl l . of low skin resistance
S
4
or of alterations of other electrical
properties of the skin24 27, 45 with
painful conditions and visceral dis
turbances. (Also see comments by
Richter 41 on low-resistance areas
associated with lung infections and
pleurisy.)
In view, therefore, of the possible
physiologic and clinical implications
of the persistent areas of low resis
tance, such as those described here,
we have undertaken extensive investi
gations i nto their nature, basis and
significance during the past few years,
some of which have been described in
preliminary reports to the American
Physiological Society. In these in
vestigations we have examined the
relation of ESR to measured sweat
gland activity4
8,
7
compared the
functional responses of l ow- and
high-resistance areas to a variety of
stimuli and under a variety of cir
cumstances49, experimentally modi
fied ESR patterns and induced new
LRA
1
9, examined segmental and re
gional correlation of low-resistance
areas with other (vasomotor neuro
muscular and sensory) features
1 7
. 2, S6
and with clinical and experimentally
induced disturbances
1 8, 1
9 .
These s tudi es , which wil l be
reported more fully i n succeeding
papers, have convinced us that the
persistent areas of low skin resistance
do have i mportant functional and
cl i ni cal i mpli cati ons related t o
regional variations i n excitability of
autonomic pathways which merit fur
ther investigation. These changes in
excitability appear to be parallel to
those indicated for motoneurons by
the st udies
7
8 on motor refl ex
thresholds cited i n the introduction to
this paper. However, because of the
uncertainty of relationships between
s ympathetic dermatomes and
paravertebral myotomes, it has not
yet been possible to determine the
relationship of LRA to low-threshold
J
segments, although some common
origins are indicated.
Summar
1 . As an approach to the study of
regional or segmental variation yi n
sympathetic activity, skin resistance
explorations were conducted on the
backs of several hundred subjects
under resting, non-sweating condi
tions.
2. The methods used included the
conventional exploration with hand
held electrode and two semi
automatic recording methods.
3 . The following principles
characterize our methods:
a) Momentary current fow is read
or recorded. in correct spatial
relation to the explored area, as
the exploring electrode moves
over the skin, while a constant
voltage is applied.
b) Area-to-area variations in resis
tance upon the general
resistance level found i n the sub
ject at the time of the explora
tion, are determined.
c) The explorations are conducted
under conditions i n which
resistance is generally high or
rising.
d) Exploration voltage is adjuste
according to general resistance
level in such a way that the
range of current variations is
fairly uniform, regardless of the
general resistance level.
4. Areas sharply differentiated by
low resistance (high current) values
were found in all subjets, The pat
terns of distribution varied from sub
ject to subject.
5. Repeate "sampling" of pat
terns revealed that the patterns of
segmental distribution of the relative
ly low-resistance areas were highly
reproducible and characteristic for
each subject, often over periods of
many months, and despite large
changes in the general resistance
level.
6. It is shown that the patterns con
sist. not of skin areas "fixed" in low
resistace, but of areas (segmental
levels and sides) in which the pro/.
ability of finding low resistance
values (high current fow) as com
pared with the general resistance at
any time is high. As compared with
al other areas of skin, these areas
show much larger and earlier
decreses in resistance in transitions
4
from generally high to generally low
levels of resistance; the low resistance
values are much more persistent in
these areas in transitions from
generally low to generally high levels
of resistance.
7. It is suggested that the factors
which determine the area-to-area dif
ferences in resistance may be dif
ferent from those which determine
the much larger variations in general
resistance level.
8. A segmental origin of at least
some of the low-resistance areas was
indicated in the frequent presence of
apparently dermatomal strips.
9. The relation of ESR patterns, as
measured here, to regional variations
in excitability of autonomic pathways
is briefy discussed.
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mobile instrument for recording electrical
skin resistance patterns of the human
trunk* (1958)
PRICE E. THOMAS. IRVIN M. KORR and HARRY M. WRIGHT
Measurements of regional or segmen
tal variations in the electrical resis
tance of the skin are frequently used
to study regional or segmental varia
tions in sweat gland activity and
therefore in activity of sudomotor
fibers of the sympathetic nervous
system. See Richter7 and Korr.
Thomas and. Wright4 for feferences.
Areas of relatively low resistance
found in these investigations appear
to be those in which, at the time of
measurement, a) secreting sweat
glands, serving as parallel high-resis
tance pathways through the skin, are
present while none are present in
other areas, b) are present in larger
numbers, or c) in which larger
amounts of residual moisture (from
past secretory activity) are present
(Thomas and Korr9 10; Thomas,
Wright and Hartl
I
)
_
Information obtained by electrical
skin resistance (ESR) measurements,
therefore, has been found applicable
to investigations on the peripheral
sympathetic alterations accompany
ing trauma, surgical procedures,
painful syndromes, visceral diseases,
spinal cord diseases, and experimen
tal procedures (Korr, Thomas and
Wright',' Katsuki and Wake'; Korf. 3;
Ratclife and Jepson!; Van Metre' 2).
A commonly employed method for
obtaining ESR values is by applying a
voltage and measuring the current
fow between a fixed indifferent elec
trode moistened with conducting
paste and a handheld exploring elec
trode. The "resistance" may then be
calculated according to Ohm's law.
The current is usually kept small
( 1 -30 Ita), and the contact of the
electrode with a local area of skin,
brief, to avoid stimulating or polari
zation effects (Richter6). The topo
graphic distribution (pattern) of ESR
These investigations were supported in part by grants
from the National Institutes of Health, Public Health
Service (B29 and H- 1 632l. and from the American
Osteopathic Association, and by a contract (Nonr
243[0]) with the Office of Naval Research.
variations is recorded on standard
ized body charts by differences in
shading.
Exploration "by hand" is slow,
does not permit following rapid
changes in pattern and requires
considerable practice. We have
previously reported the development
of a faster, more convenient and ob
jective method for mapping ESR pat
terns, involving semi-automatic ex
ploration and photographic recording
of ESR variations on the human
trunk (photorecording dermometer,
Thoma and Korr'). The patterns of
resistance variations were superim
posed, by double exposure technics,
on photograph of the subject's ex
plored area. This apparatus greatly
facilitated investigations of ESR pat
terns and their significance. The need
remained, however, for an instru
ment which fulfilled the following re
quirements.
Us usable in a well-lighted room.
2. Records skin current variations
(ESR) directly on the chart and makes
the pattern immediately available for
study without the need for photo
graphic processing.
3. Requires less time for the entire
procedure (exploration and recording
landmarks) .
4. Is easily moved from room to
room, e. g. , for studies on hospital
ized patients.
5. Operational procedures should
be simple enough that very little train
ing of operators is required.
This paper describes a new instru
ment which meets these requirements.
The type of record obtained is seen in
Fig. 1 . The skin current variations ap
pear as a pattern on an outline of the
subject' s explored area.
Principles of operation
The basic principle is the conversion
of variations in skin current into vari
ations in oscillation amplitude of a
recording galvanometer. By coupling
the galvanometer to the exploring
electrode, through a pantograph arm,
the records inscribed on stationary
41
J B 3-16-55
24" C 18V
I
/, 1 1 1
I
t I

Fig. 1. ESR record. This record shows the

distribution pal/ern ofESR variations on the
back of subject S. S. Each oscillating line
reflects the skin current variations along a strip
ofskin 13 mm. wide. The wider the amplitude
ofoscillations in each strip, the larger the cur
rent (at the indicated voltage) flowing through
the skin at the corresponding point on the sub
ject. The body outline and spinous processes
are marked for reference and comparison of
the skin current (ESR) pal/ern with other
records or procedures. The calibration strip
showing current flow from 0-25 Ja in 5 Ja
steps appearing in the left-hand portion of the
chart can be used for evaluating the current
flow in various areas ofskin.
Fig. 2. The recording dermometer in use. The
components may be identiied as follows: (A)
galvanometer and carriage; (8) electrode
assembly; (C) pantograph arm; (D) bracket
connecting the galvanometer to the pan
tograph; (E) pantograph pylon; (F) pin-and
socket lock; (G) hinges; (H) amplifier control
panel.
42
paper are continually related topo
graphically to the position of the elec
trode in the exploration area. The
paths fol lowed by the exploring elec
trode are predetermined by providing
a series of parallel, properly spaced,
longitudinal paths for galvanometer
movement. The spacing between elec
trode paths, though narrow, avoids
the possibil ity of recording an area
more than once i n the course of ex
ploration. As the exploring electrode
is moved along each path, represent
ing a strip of ski n equal in width to
that of the electrode, the moving gal
vanometer produces an envelope of
oscillations (60 cycles/sec. ) varying in
width i n proportion to the ski n cur
rent variations. The visual effect,
seen in Fig. I , is that areas of relative
ly low resistance appear to be dark
ened.
Loastructioa
Cabinet. All the essential compo
nents are accommodated in a mobile
cabinet (braked wheels) , the top of
which is shown in Fig. 2.
Pantograph assembly. The panto
graph arms (Fig. 2, C) are con
structed of aluminium tubing for
lightness and rigidity. One end is at
tached to a pylon (Fig. 2, E) and the
other provides a mounting for the
exploring electrode. Dimensions of
the pantograph have been chosen so
that moving the exploring electrode a
distance of 2, 5 cm. will move the gal
vanometer 1 , 0 cm. All moving joints
are supported by ball bearings for
free and easy motion. A rigid bracket
(Fig. 2, D) connecting the galvanom
eter to the pantograph arm provides
a constant spatial relationship be
tween the exploring electrode and the
galvanometer.
The galvanometer and mounting as
sembly. The galvanometer oscilla
tions are recorded directly on Tele
deltos or Electrex paper. The galva
nometer (Fig. 2, A) is mounted on a
carriage that travels smoothly on baIl
bearing wheels along two round steel
rods (the longitudinal rails) . The
wheels, of Plexigl as, have concave
running surfaces shaped to fit the
rods. (Plexiglas is very suitable for
this purpose since it is soft enough to
wear to a perfect fit, yet hard enough
to give l ong service. ) Two of the three
wheels on each side of the galvanom
eter carriage are on the upper sur
face of each rai l . The other wheel on
each side rolls on the lower surface of
the rai l . This arrangement keeps the
carriage securely attached to the rail s
while permitting the galvanometer to
be moved freely in the l ong axis of the
recording paper.
Each end of the longitudinal pair
of rails is rigidly fastened, as shown
in Fig. 2, to a metal plate. Wheels
mounted on this metal plate permit
the longitudinal rails bearing the gal
vanometer to travel along two end
support rods (transverse rails) . The
wheel s on each metal plate are posi
tioned as two opposing pairs and
clamp the iransverse rails firmly
enough to prevent skew movements
of the longitudinal rail s . The end sup
port rods are at right angles to the
longitudinal rai l s and provide lateral
movement of the galvanometer and
rail assembly across the transverse
axis of the paper.
Through the summation of these
lateral and longitudinal movements,
the galvanometer may, therefore, be
moved over the entire recording sur
face. This free motion is used when
the body outline or topographic land
marks are being recorded. During an
exploration the galvanometer (and
electrode) movement is restricted to a
series of fixed l ongitudinal paths by
a pin attached to the longitudinal
rail assembly that fits into a series of
notches in one of the transverse rai l s
(Fig. 2, F) . When the pi n engages one
of the notches, locking the longitu
dinal rails in position, the galvanom
eter can be moved freely i n the long
axis of the chart paper, but is fixed
laterally in one of 25 tracks 1 , 0 cm.
apart. Because of the I . 2, 5 panto
graph ratio the exploring electrode
moves in 25 corresponding paths 2, 5
cm. apart . Since the exploring elec
trode is 13 mm. wide, this spacing
provides a separation of 1 2 mm. be
tween strips of explored ski n. This
spacing effectively prevents overlap
whil e still permitting continuity of
patterns.
Exploring electrode attachment. The
exploring electrode is a flat-surfaced,
chrome-plated wheel, 23 mm. in
diameter and 13 mm. wide. The axle
of this roller electrode is attached to a
small metal housing. The wheel hous
ing is pinned to the electrode arm
EMG, SNS, reflexes, etc.
(Fig. 2, B and 3, A) in such a fashion
that the contact surface of the wheel
can tilt to follow the transverse slopes
of the explored surface. The electrode
arm is fastened to the handle of the
electrode assembly by a hinge which
permits vertical movements of the
electrode. The flat surface of the elec
trode wi l l, therefore, maintain full
contact with the i rregular surfaces of
the explored area. The pressure of
contact is that provided by the weight
of the electrode assembly and arm.
Higher pressures, i f not injurious, do
not signi ficantly alter current flow
through the ski n. No further provi
sion for constancy of pressure is
therefore necessary.
Amplifier and control panel. The
amplifier, schematically shown in
Fig. 4 is a conventional chopper type
and enables the small currents flow
ing through the skin to vary the oscil
lation amplitude of the recording gal
vanometer. The amplifier has a low
i mpedance, chopper i nput (60
cycles/sec. , make before break). The
low impedance minimizes the pickup
of stray signals from unshielded sub
jects. High gain and good stability are
provided by 4 battery-operated stages
of amplification. In addition to its
use in skin current recording this
ampl i fier has also been used for re
cording ski n temperatures from ther
mocouples.
A microammeter used for monitor
ing (not visible in Fig. 2) and other
circuit controls are positioned on the
control panel (Fig. 2, H) within easy
reach of the operator.
Ocratioa
Preparation of the subject. The sub
ject is positioned as seen in Fig. 2 for
explorations in the prone position.
Spinous processes and other land
marks are identified and marked on
the skin. An indi fferent electrode is
fastened to the ear lobe, using elec
trode paste to reduce and stabilize the
resistance. The usual routine explora
tion i n our laboratory is performed
under conditions fully described else
where (Korr, Thomas and Wright";
Thomas and Korr8) i . e. with the sub
ject resting and stabilized at an am
bient temperature of 23 - 25 C.
Exploration. The cabinet is position
ed with respect to the subject so that
the electrode will travel over the area
to be examined. During an explora
tion this relationship is maintained by
stops that prevent movement of the
cabinet. The general resistance range
(Korr, Thomas and Wright") is
established by releasing the pin-and
socket lock and sampling various
areas of skin to be explored with a
quick touch of the electrode. A
voltage is chosen (3 to 1 8 v) which wil l
produce a maximum of approximate
ly 25-30 of current flow for low
resistance areas, and the amplifier
gain is adjusted to produce approx
imately 1 cm. oscillations at 1 5 pa
current flow. When the subject' s resis
tance is so high that 1 8 voltS produce
less than 30 pa in a low-resistance
area, amplifier gain is increased so
that any di fferential between the
high- and low-resistance areas can be
made apparent.
The longitudinal rails supporting
the galvanometer are then locked i n a
position that wi l l allow the roller elec
trodes to be pulled along a strip of
ski n in the midline. Exploration of
each strip is started at shoulder level
or at the hairline on the neck. When
the electrode contacts the ski n, the
operator closes the switch (Sw. 3, Fig.
4) which simultaneously applies the
selected voltage to the exploring elec
trode and provides the voltage for the
pen-writing current . The operator
draws the electrode along the selected
path (kept in a straight line by the
rails bearing the galvanometer) . We
have found a speed of approximately
8-1 0 cm/sec. satisfactory from the
points of view of convenience, time
for exploration and clarity of charts.
In practice one quickly learns to
maintain a uni form rate by adjusting
exploration speed so that similar
spacing appears between individual
oscillations on the chart. However, as
shown i n Fig. 5, even large variations
i n exploration speed have little in
fluence on the recorded ESR pat
terns.
Successive strips of skin are ex
plored in the same fashion. The ex
ploration plan most frequently fol
lowed is to alternate from side to side
so that symmetrical strips are ex
plored as nearly at the same time as
possible. The entire dorsal trunk can
be explored in approximately 3 min
utes.
Calibration. The galvanometer is
Fig. 3. Exploring electrodes. A. A close-up of
the electrode shown in Fig. 2 B. A swivel pin
fastens the wheel housing to the exploring arm
and permits the roller electrodes to tilt and
follow the contours ofthe explored area. B.
The exploring assembly used for exploration of
silting or standing subjects. The round rod car
rying the electrode moves freely through the
aluminium mounting block. The direction of
motion is confined to the long axis of the rod
by four ball bearings at each end ofthe mount
ing block.
positioned to record in a clear area on
one side of the chart . To record the
calibration strip, the galvanometer is
moved slowly while a fixed voltage (3
v) is applied to a graded series of re
sistances connected across the input.
The resistances are chosen (Sw. 4,
Fig. 4) to produce galvanometer ex
cursions that correspond to increas
ing current flow from 0-30 pa i n 5 pa
steps.
Topographic marking. For marking
the spinous processes, the calibrator
circuit is used at a setting which pro
duces pen deflections approximately
I cm. wide. The lock for the longi
tudinal rails is released, the electrode
is then positioned over the previously
marked spinous process, and the pen
writing current switched on to mark
the chart paper. This is repeated for
each spinous process. To outline the
torso, scapula, or other landmarks
the electrode is drawn along the con
tours with the pen-writing current on
4J
.. ," In
s.t...
''' 1I ''4' C
t

.. '.h.
l : w
'-:<t l
t5P-THEPV0P AMHFER
Fig. 4. Schematic of converter ampliier and associated circuits. The choppr input converts the
dirct currnt /owing through the skin into 60-cycle alterating current. This circuit also include
the calibration and controls for recording from thermocouples. Resistances are given in kilohms and
capcitance in microfarads.
4
"
o
I
u
.
o
&
.
"
o
I
u
42 ! 25
LIcft008 8#aa 0 |B cm,/ #a ,
Fig. 5. Inuence of variations in exploring
speed on recorded current /ow. This compares
records obtained from the same strip ofskin at
the various eletrode speeds indicated. Thee
were obtained by fiing the eploration path of
the electrode and moving the chart paper
laterally ater each pass of the eletrode. The
records were obtained approximately 30
seconds apart. Note that even a thre-fold
variation in electrode speed produces very little
diference in the magnitude ofrecorded current
flow. Even with a 5-fold change in eploration
rate the areas ofrlatively high currnt /ow r
main distinguishable although their recored
value are much smaler.
but with no galvanometer oscilla
tions. The inscription on the chart of
all pertinent data regarding the sub
ject, experimental conditions, etc.
completes the exploration.
Special adaptations
Hinges on the cabinet top permit the
entire pantograph and galvanometer
assembly to be positioned vertically.
With the addition of counterweights
and a special exploring electrode at
tachment (Fig. 3 B) the instrument is
useful for recording patterns of
standing or sitting subjects.
This instrument has wide applica
bility in recording the topographic
distribution of many phenomena,
limited only by the ingenuity required
in devising exploring "pickups" or
transducers. In our laboratories an
exploring thermocouple has been
used to obtain skin temperature pat
terns on the trunk.
Sources of error
Two possible sources of error are evi
dent, both of which are minor and do
not seriously interfere with mapping
ESR patterns. One error results from
the vertical travel of the electrode be
ing an arc rather than a linear motion
at right angles to the plane of the pan
tograph movement. The recorded
topographic relations are, therefore,
slightly distorted. Correct compara
tive relationships can still be main
tained if the exploring electrode is
used as a guide and touches the skin
surface when topographic landmarks
are being recorded. The weight,
constant-pressure, and handling char
acteristics of the electrode assembly
(Fig. 2, B) are satisfactory enough to
make the small error acceptable. The
electrode assembly (Fig. 3, B) devised
for explorat
i
ons of standing or sitting
subjects does eliminate this error and
with some modifcations in weight
would also be satisfactory for ex
plorations of prone subjects.
The other source of error to be con
sidered is due to excessive variations
in exploration speed. This has been
discussed in a previous section (E
ploration). This error is readily
minimized by a little practice in the
exploration procedure.
Summary
1. A mobile instrument for exploring
and recording the topographic distri
bution of ESR on the human trunk
EMG. SNS, reflexes, etc.
has been described. Explorations are
rapid and the record is immediately
available.
2. Topographic relations between
the exploring electrode and a movable
direct recording galvanometer are
established by a pantograph linkage.
3. Variations in current flow at a
fixed voltage ("resistance") along a
strip of skin are recorded on sta
tionary chart paper by variations in
the oscillation amplitude of the mov
ing, recording galvanometer. The
ESR patterns of large areas are re
corded by exploring a series of paral
lel strips of skin.
4. The apparatus is adaptable for
recording the topographic distribu
tion of cutaneous features other than
ESR.
5. Sources of error are identified
and their minimization or corrections
are described.
Rcfcrcncc
I. Katsuki. S o and K. Wake. Clinical studies on the
viscero-cutaneous reflex. Kumamoto Med. J. 6 (1954).
97 - 107.
2. Kor. I. M o Skin resistance patterns associated
with visceral disease. Fed. Proc. 8 (1949). 87.
3. Korr. I. M Experimental alterations in segmental
sympathetic (sweat gland) activity through myofascial
and postural disturbances. Fed. Proc. 8 (1949). 88.
4. Korr. I. M + P.E. Thomas and H.M. Wright. Pat
terns of electrical skin resistance in man. (Submitted
herewith to Acta neuroveget Wien.)
5. Ratclife. A. Hall and R.P. Jepson. Skin
resistance changes in the lower limb after lumbar
ganglionectomy. J. Neurosurg Springfield. 7 (1950).
9 - 105.
6. Richter. c.P o and Bettye G. Woodruff Changes
produced by sumpathectomy in the electrical
resistance of the skin. Surgery 10 (1941). 957-970.
7. Richter. c.P.. Instructions for using the
cutaneous resistance recorder or .. Dermometer" on
peripheral nerve injuries. sympathectomies and
paravertebral blocks. J. Neurosurg.. Spingfield. 3
(1946). 1 81 -191 .
8. Thoma. P.E = and I.M. Korr. The automatic
recording of electrica skin resistance patterns on the
human trunk. EEG Clin. Neurophysiol. 3 (1951).
361-368.
9. Thoma. P. E o and I.M. Korr. Significance of
areas of low ESR. Fed. Proc. II (1952). 162.
10. Thomas. P.E o and I.M. Korr. The relationship
between sweat gland activity and the electrical
resistance of the skin. (In press: J. Appl. Physiol. .
Wash o JO (1951). 305-310.
I I . Thoma. P. E o M. Wright and C. W. Hart. ir o
Relatjon of sweat gland recruitment to ESR. Fed.
Proc. 12 (1953). 143.
12. Van Metr. T. E.. ir. . Low electrical skin
resistance in the region of pain in painful acute
sinusitus. Bull. Johns Hopkins Hosp. 85 ( 1949).
40-4 1 5.
Reprinted by permission from Journal of Neural
Transmission 17: 7. 98-10. 1958.
08 8R0 t6g0R8 V8t80R8 R
u8Rc0u8 V880m00t 0R6 0 h6
hum8R tuRK" (1900)
H. M. WRIGHT, l. M. KORR, and P. E. THOMAS
These studies have been concerned
with regional and segmental varia
tions in sympathetic vasomotor tone
in normal human subjects. Broad re
gional differences in cutaneous vaso
motor tone and in vascular responses,
as shown by differences in the blood
fow, the blood content, the skin col
or and skin temperature, . e. g. , be
tween face, trunk and extremities,
have been recognized for many years.
That regional or segmental differ
ences in cutaneous vascular tone
might normally exist over the topog
raphy of the trunk, related to the
segmental innervation of the skin, ap
pears, however, never to have been
systematically investigated. It appears
to be generally assumed that vascular
ity and vasomotion are uniform
throughout this skin areal
-
3 Several
observations suggest, however, that
there may be consistent topographical
differences in cutaneous vasomotion
and other functions controlled by the
sympathetic nervous system.
a) Cardiovascular adjustments to
the erect posture.
The changes in hemodynamics which
result from a change of body position
from the horizontal to the erect posi
tion evoke adaptive responses of the
peripheral vessels which vary accord
ing to their level in the longitudinal
axis of the body. On assumption of
the erect posture, there is evidence of
a greater vasoconstriction in the
lower part of the trunk and the lower
extremities - structures innervated
by the more caudal segments of the
spinal cord - than in the upper ex
tremities - structures innervated by
the more superior segments of the
spinal cord4-9
b) Segmental differences in the
responses ofthe cutaneous vessels to
stimuli.
Di Palma3 has observed that cutane
ous blood vessels of various regions
of the skin may respond differently to
various types of stimuli according to
their segmental innervation. He has
shown the existence of a positive gra
dient in reactive hyperemia following
local ischemia, from the third cervical
to the fifth sacral dermatome: the
more caudal the segment, the higher
were the thresholds for reactive
hyperemia. Thesholds were measured
by the duration of ischemia just re
quired to elicit a standardized hyper
emic response.
c) Segmental diferences in the skin
temperatures.
A segmental gradient in the skin
temperatures from the cervical to the
ffth sacral segment was also ob
served by Di Palma3: the more caudal
the segment, the lower the skin tem
perature throughout the thoracic and
lumbar segments.
d) Diferences in vasomotor tone be
tween upper and lower etremitie.
The vasomotor tone of the lower
human extremity (lumbar and sacral
innervation) has been found to be
much higher than that of the upper
(cervical and thoracic innervation).
Goetz" and Green9 have shown, for
example, that the vasomotor tone of
the toe vessels is decreased and their
blood flow used for heat elimination
only when the vasodilator capacity of
the hands has been fully exhausted.
e) Regional and segmental variations
in sudomotor activity.
The investigations of Korr, Thomas
and Wright (1 958 ) 1 0 previously
reported in this journal, revealed the
existence of regional and segmental
variations in sudomotor activity in a
study of several hundred subjects.
These studies appeared to have im
portant functional implications re
lated to regional variations in the ex
citability of autonomic pathways
lC
I'
.
In view of the evidence cited above,
it was decided to investigate, in fur-
"These investigations were supported in part by grants
from the National Institutes of Health. Public Health
Service (H-1632). and from the American Osteopathic
Association.
45
Fig. 1. Ski n stroker. With this instrument two
identical stimulators were drawn down the
back by a constant speed electric motor. The
stimulators were independently mounted on
freely pivoting aluminum rods. The intensity of
the stimulus could be varied by changing the
position ofthe 500 gram weight on the lever of
each stimulator. For each individual, that in
tensity ofstimulus was selected which was ade
quate to elicit some degree of erythema (red
response) at all segmental /evels from T, to S, .
ther detai l , the "normal " topo
graphical gradient in cutaneous vas
cular tone along the spinal cord as a
background for studying and inter
preting the local deviations and asym
metries of vascular response which we
have observed i n large numbers of
subjects. The general significance of
these deviations and their neurogenic
origin are suggested by their similari
ty to deviations i n sympathetic sudo
motor activity by Korr et al .
I
{
1
7 . The
possible clinical implications of these
vasomotor deviations are suggested
by the fact that sudomotor variations
were often related to visceral and
musculoskeletal disturbancesl{-
1
4
.
Mcthods
The observations presented i n this
paper were made over a period of
several years, and during that time
several methods were used. Although
a vari ety of di rect and i ndi rect
methods may be used for the investi
gation of the peripheral circulation
(venous drainage recorders, mean
flow recorders, pulsatile flow meters,
perfusi on syst ems , mechani cal
plethysmography etc. ) most of these
methods either cannot be used on the
intact human subject, or at best can
be used only on the extremities. We
40
have, therefore, used three indirect
methods which have commonly been
used in clinical studies: 1 . measure
ment of the ski n temperature, 2.
measurement of the vascular compo
nent of the skin color, and 3. observa
tion of the responses of the skin ves
sels (vasoconstriction and vasodilata
tion) to mechanical stimul i .
These methods enabled us to come
pare the segment-to-segment differ
ences and regional di fferences i n
vasomotor activity in a given indi
vidual as well as in di fferent in
dividuals.
A. Skin Temperature.
Skin temperatures were measured
wi th conventi onal welded i ;on
constantan thermocoupl es made
from 30-gauge thermocouple wire
and read from a sensitive galvanom
eter. A single "exploratory" thermo
couple mounted on a plastic handle,
permitted the investigator to rapidly
ascertai n the ski n temperature on
both sides, at each segmental level , at
poi nt s equi di s t ant from t he
spinal midline.
B. The "Red Response ".
The er yt hema r es ul t i ng from
mechanical stimulation of t he skin
has been called the "red response" by
Lewis' 8 , and is a part of the triple
response described by hi m. Although
Lewis has shown that vascular dilata
tion resulting from mechanical strok
ing of the skin is not dependent on a
nervous mechani sm, the responses to
stroki ng are i nfluenced by nervous
factors, and, other investigators have
used the threshold, intensity, the time
required for the appearance ("laten
cy") or fading ("duration") of the
erythema as a measure of the super
imposed sympathetic vasomotor tone
of the vasculature' 9 .
For our studies, it was necessary to
develop a stimulus which could be
standardized and accurately dupli
cated. To do this, an instrument was
constructed (Fig. 1) which was a
modification of the "ski n stroker"
used by Di Palma ' 9 in his study of the
reactivity of blood vessels.
In conducting a test, the two iden
tical rounded-wire stimulators were
drawn i n straight lines down the back
by a constant-speed electric motor at
the rate of 4. 5 cm. per second from
the level of the first thoracic vertebra
to that of the sacrum. The stimulators
were made of 1 2 gauge copper wire
and were 5/ 1 6 inch (8 mm. ) in
ci rcumference, and i ndependently
mou n t e d on f r eel y pi v ot i ng
aluminum rods 26 cm. long. The
intensity of the stimulus could be
varied i n 25-gram steps from 1 50 to
500 grams by changing the position of
a 500-gram weight on the aluminum
lever of each stimulator.
For any given stimulus, however,
the pressure on the stimulator re
mained constant for the full excur
sion of the instrument , thereby giving
a uniform stimulus to all segmental
levels on the back. The stimulus was
applied 1 Y2 inches ( 3. 8 cm. ) on either
side of the spinal midline.
For each individual, that intensity
of stimulus (the weight applied to the
stimulator) was selected which was
adequate to elicit some degree of
erythema at al l segmental levels from
T, to S, . Observations were made
under daylight fluorescent illumina
tion by two or more persons i n most
cases.
In preliminary efforts to establish
methods for quantifying the red re
sponse, measurement of the thresh
old, latency, intensity and duration
were tried. Measurement of thresh
olds was eliminated when i t became
evident that repeated testing of the
ski n altered its response. The
measurement of latency was also
eliminated because of the rapidity
with which the response developed
throughout the entire test area. Both
intensity and duration, however,
showed wide ranges of gradation. It
was further revealed that these two
factors were proportionately related;
that is, the more intense the ery
thema, the longer its persistence. We
found it convenient, therefore, to
evaluate the red response by deter
mining the time interval between
stimulus and disappearance of the
response.
The duration or "persistence" of
the red response was, therefore,
"graded" as follows:
Grade Persistence ofErythema
1 30 seconds or less
2 30 to 60 seconds
3 60 to 90 seconds
4 More than 90 seconds
(sometimes several minutes)
As the sequence of the disappear
ance of various fragments of the line
of erythema was observed on the sub
ject, each area was appropriately
EMG, SNS, reflexes, etc.

delineated as it faded, and the grade

of persistence (1 , 2, 3 or 4) was
marked on the skin. The "grades" at
the various levels on the back were re
corded on a chart for each individual.
At least 24 hours intervened between
experiments on any given individual.
C. Photoelectric measurement of the
vascular coloration of the skin.
Wetzel and Zotterman20 showed that
the vascular coloration of the skin is
related to the amount of hemoglobin
contained within the minute vessels,
and therefore, the vascular coloration
of the skin is directly proportional to
the amount of blood exposed within
the vessels of a given area. The blood
content of the subpapillary venous
plexus is largely responsible for the
vascular component of the skin col
or22.
The photoelectric method for the
measurement of the blood content of
the cutaneous vessels is based on the
absorption of light by the hemoglobin
of the blood2, 2630. Green light, with
a predominant wave length of
550m. , i s strongly absorbed by both
reduced and oxygenated hemoglobin.
It follows, therefore, that the greater
the blood content of an area of skin,
the greater is the absorption of inci
dent light of this wave length, and
vice versa.
Our method was a modification of
the photometric method which
Adams-Ray
3
l -34 used in studies
relating to reflex hypertonus in the
subpapillary venous capillaries. The
photometer (Fig. 2) consisted essen
tially of a light-source, a filter, and
two cadmium sulphide photocells
(Clairex Type CL-2). The current
generated by the photocells was
measured with a galvanometer. Light
from a 2.25 volt bulb (Mazda No.
222) passed through the filter (Schott
Jena VG-9) and illumined a circular
area of skin 1 8 mm. in diameter.
The highly reflective surface of
white porcelain plate was used for
standardizing the equipment and as a
basis of comparison of test areas of
skin. With the photometer set on the
porcelain plate, the balance of the
bridge circuit was adjusted until the
galvanometer deflection was 1 00 mm e
(The refectance from skin was
always less than the reflectance from
the plate. ) The difference (l o-R) be
tween the reflectance from the porce
lain plate (10) and that of a test area
A
Fig. 2. Photometer. The compone ts may be identified a follows: a crystal photocel (Clairex Type
CL-2); b filter (SchoU-Jena VG-9),' c light. This instrument was used to measure the light absorption
of Ihe skin. Light from the 2.25 volt bulb (Mazda No. 222) ps through the filter (Schott-Jena
VG-9) and illumined a circular area of the skin 18 mm. in diameter.
of skin (R) is a measure of the
amount of light absorbed by the skin.
It is recognized that other factors,
such as pigmentation, hair, etc. , in
addition to the blood content of the
skin, may influence the absorption
and refectance of light by the skin2
23. 2. 28-30. In these studies, however,
only subjects with no visible local
variations in skin pigmentation, hair
distribution, etc. , were tested.
Experimental Conditions.
These studies were conducted in a
quiet room maintained between 230
and 250 C. The body was unclothed
above the level of the sacrum and the
subject lay prone on a padded table
with a face slot. A period of 30
minutes elapsed before experiments
were started to allow for stabiliza
tion. The tips of the spinous processes
were marked and numbered. In these
studies, "segmental" level refers to
the topographical level on the trunk
as identified by the corresponding
spinous process, rather than the der
matomes. There is, however, close
correspondence between topograph
ical and segmental levels for
paravertebral skin, except for the up
permost thoracic segments.
All observations were made of the
paravertebral skin 11 inches (3. 8
cm. ) to the right and left of the spinal
midline from the first thoracic to the
fifth lumbar vertebra, unless other
wise stated.
Rcull
!. Segmental patterns
a) Skin temperatures.
We found, under our experimental
conditions, that the differences in
temperature between the warmest and
coolest areas of the skin on the trunk
in any individual were usually less
than 2 C. Wide and relatively rapid
fluctuations in temperature, such as
those seen on the extremities, do not
occur. The stability and narrow range
of temperatures on the trunk have
also been observed by others. Never
theless, a longitudinal pattern within
this range of temperatures is revealed
when the skin temperatures at each
segmental level of a number of in
dividuals are averaged together.
As shown in Fig. 3 a, representing
the data on 14 subjects, the skin was
warmest in the mid-thoracic area (T
to T 8) and coolest in the lumbar area
(LI to L.) of the back. This graph
reveals that these extremes are the
apices of two overlapping curves,
with their convexities in opposite
directions (T } to T and T to L,).
b) Red responses.
In most individuals a contrast was
evident between the red responses in
the mid-thoracic and lumbar seg
ments. Thus, in most individuals, the
red responses persisted for more than
seconds (Grade 4) - sometimes
47
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---- Lt Ste
c
Fig. 3. Avrage thoraeo-Iumbar ptterns.
Fig. 3 a. A verage skin tempratur at each segmental level. This graph wa derived by ave1ging
together the temperatur of the paravertebral skin at each segmental level in 14 individuals. (Three
obervations were made on each individual.)
Fig. 3 b. A verge rd response grde at each smental level. Tis graph was derived by averaging
together the red reponse of the paravertebral skin at each segmental level in 13 individuals. (Three
observations were made on each individual.) The persistence of the red response was graded as
folows: Grade 1. 30 second or les; Grade 2, 30 to 6 seconds; Grade 3. 60 to 9 second; Grade 4,
mor than 9 second.
Fig. 3 c. A verage light absorption at each segmental level. Thi grph was derived by averaging
together the light absorption of the paravertebral skin at each segmental level in 15 individuals.
(Thre obervation wr made on ech individual.) The diference (10 -R) btwen the refec
tance from a white porelain plate (10) and that ofa tet area ofskin (R) i a measure ofthe
amount oflght absorbe by the skin.
T
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Fig. 4 Average electrical conductance of the
skin at each segmental level. Thi graph wa
derived by averaging together the electrical
conductance (measurd as currnt J70w at con
tant voltage) ofthe pravertebral skin at each
sgmental level in 25 individuals.

for several minutes - in the mid

t horaci c segme nt s , whi le t he
erythema faded away in less than 30
seconds (Grade 1 ) i n the lumbar seg
ments.
When the red response "grades" at
each segmental level were averaged
together in 1 3 i ndividuals (3 tests on
each subject), the duration (or persis
tence) of the erythema was longest i n
the mid-thoracic segments (T4 to T7)
and shortest i n the lumbar segments
(LI to L
3
) (Fig. 3 b). These, also, are
the apices of curves similar to those
for skin temperature, shown in Fig.
3 a.
c) Blood content of the skin.
In all i ndividuals examined, more
light was absorbed in the upper thor
acic segments than elsewhere, and t he
average light absorption values show
ed a progressive decrease from the
first thoracic to the first lumbar seg
ment, indicative of a gradient in
cutaneous blood content (Fig. 3 c),
but differing somewhat from those
for temperature and erythema.
2. "normal" thoraco-lumbar
patter.
The graphs of the average skin
temperatures and red responses (Figs.
3 a, 3 b) show a close correlation,
suggesting a common factor. Both
describe two s mooth curves which
overlap in the thoraco-Iumbar area.
The light absorption curve shows es
sentially the same configuration
below the level of T4 to T" but the
reversal of the curve is not evident i n
the upper thoracic segments (T ) t o
T4)' The reason for the modification
of the upper (thoracic) curve is not
immediately evident, but it may be
ascribable to differences in the skin
pigmentation, thickness, vas cularity
or some other factor.
To ascertain whether the patterns
of skin temperature, red response and
blood content are related to similar
patterns of sympathetic activity, . we
conducted a simultaneous investiga
tion of the electrical skin resistance of
the paravertebral skin. As shown by
Thomas et al.
1 S-
1
7
, the electrical skin
resistance patterns measured in our
laboratories refect similar patterns
of segmental variations in activity of
the sympathetic nervous system. Us
ing the ESR exploration procedure
which we have described elsewherel7a,
t he electrical conductance of t he
paravertebral skin was recorded at
each thoracic and lumbar segment in
25 individuals. As shown i n Fig. 4,
the electrical conductance of the skin
increases progressively from the frst
thoracic to the second lumbar seg
ment. This graph is similar in con
figuration to t hat of blood content as
measured by light absorption (Fig.
3 c).
J. Variations in individual patterns.
The patterns shown above represent
the averages of a number of subjects.
Most subjects, however, showed
characteristic and reproducible varia
tions from these basic patterns. These
variations are manifest as local or
segmental departures from t he
"average" patterns and as "asym
metries" between the right and left
sides with respect t o the skin tempera
ture, the red responses, and light ab
sorption of the skin.
a) Local or segmental variations in
the skin temperature.
Systematic mapping of the segment-
to-segment skin temperatures reveal
ed local areas of skin which were con
sistently "out of line" with respect to
the gradient, that is, they were hypo
thermic or hyperthermic relative to
adjacent areas or relative to their con-
EMG, SNS, reflexes, etc.
.
tralateral counterparts.
Fig. 5 shows the patterns of the
paravertebral skin temperatures in
three individuals. In subject J. B. the
temperatures of the paravertebral
skin on the right and left sides are
relatively symmetrical, except at T 3
and L, to L1 Subject B. M. shows
considerable differences in the skin
temperatures between the right and
left sides in the upper thoracic area
(T ) to T ) and throughout the area
from T9 to L3 In subject W. E. , asym
metries are most apparent from T to
Ti l.
b) Local or segmental variations in
the red response.
In most individuals we found local
areas of the paravertebral skin in
which the red response consistently
faded more quickly than adjacent or
contralateral symmetrical areas. Fig.
6 shows the red response patterns of
three individuals. In subject S. S. the
right side shows an essentially "nor
mal" (i.e. average) pattern while the
left shows conspicuous aberrations
especially at the lower thoracic levels.
The right and left sides of subject
J . E. have remarkably similar patterns
from T to T 9 diverging to various
degrees below this level. Subject I. K.
shows marked deviations from the
average pattern at T
4
to Ts on the
right side, and, in general, the per
sistence of the paraveltebral ery
thema was consistently less on the
right side than the left from T _ to T
Z
in this individual.
c) Local or segmental variations in
the light absorption (blood content)
of the skin.
Similar to the local variations in the
skin temperature and red responses,
we also found local areas of the para
vertebral skin in which there was con
siderable difference in the light ab
sorption between the right and left
sides at some segmental levels, or be
tween contiguous areas. Fig. 7 shows
the segmental light absorption pat
terns of three individuals. There was
very little difference in the light ab
sorption between the right and left
sides in subject I. M. In subject W. B. ,
the light absorption i s also, relatively
symmetrical, though with a conspicu
ous asymmetrical area at T ) ) to T I 2
and others in the lower lumbar
region.
Subject W. W. shows marked
SNI Temp (e)
Ski n Jmprel $In Tm/.C
J/ Jr dV
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Z

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i
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5
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5
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Fig. 5. Individual patterns of skin temperature. In subjet J.B. the temperatures ofthe paravertebral
skin on the right and left sides are relatively symmetrical, except at T, and L, to L" Subject B.M.
shows considerable diferences in the skin temperature between the right and left sides at T, and T,
and throughout the area from T. to L,. In subject W. E., asymmetrie in the paravertebral skin
tempratures are most apparent from T. to T, ,. (Each graph is an average ofthree observations on
each individual.)
1tlu/n$4 dlN 1tISf"nSI dlm ,et,SP"R$#111 1
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7
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Fig. 6. Individual patterns of the red response. In subject S.S. the persistence ofthe rd response
was generally symmetrical between the right and leftsides except at T. and T" . Subjet J.E. shows
marked asymmetries between the right and left side below the level of T . Subject I.K. shows
marked deviations from the "average" patter at T. to T, on the right side, and, in general, the per
sitence of the red respons was consistently les on the right side than the leftfrom T. to T, . (Each
graph i an averge of3 observations on each Individual.)
asymmetries in light absorption be
tween the right and left sides of the
paravertebral skin at T to T.; the
skin at the level of Lz to LJ on both
sides shows more than average light
absorption.
4. Reproducbity ofsegmental
patters.
The "pattern" or distribution of
local "aberrant" or "asymmetrical"
areas varied from subject to subject,
but the pattern was characteristic for
that individual . Tests conducted on
the same individual on different dates
are shown in Fig. 8. Individual pat
terns of local or segmental deviations
from the average patterns in the skin
temperature (Fig. 8 a), red responses
(Fig. 8 b) and light absorption (Fig. 8
c) of the skin showed a high degree of
reproducibility. The location and ar
rangement of such deviations from
the average patterns with respect to
segmental levels and right and left
sides remained remarkably constant
for days or weeks.
49
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=11:
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Lilt >ISQJjlitQ ('N-I) "''Li1t AbSQljllo (lffI)
-f J/ I SQ 6 7f f Ul J I J 7
7

7
H
/4
, /

Fig. 7. Individual patterns of light absorption. The light absorption ofthe paravertebral skin on the
right and left side is relatively symmetricl in subject I. M. In subject W.B. conspicuous asym
metries appear at Til to Til and in the lumbar area. Subject W. W. shows marked asymmetries be
twen the right and left sides at T. to t,. (Each graph i an average of 3 observations on each in
dividual.)
7

'
N

J
J

J
/1

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4
n
u
I
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4
`:
Fig. 8 a to c. Reproducibility patterns. The ptters ofskin temperature, red response and light absorption of the skin for each individual showed a high
degre ofreproducibility. The location and arrangement of local or segmental deviations (aymmetries) from the average topographical patters re
mained constant for days or weeks.
Fig. 8 a. The paravertebral skin temperaturs of subject WE. on difernt dates.
Fig. 8 b. The red reponse pattern of subject J.E. on different dates.
Fig. 8 c. The light absorption of the paravertebral skin subject J. P. on different date.
J

D
Tl
g
J
f
S
G
7
8
.
Tt
11
11
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t
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i
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Fig. 9. Correlations of patterns in one individual. For comparion, the patterns ofskin temperature,
red rsponse and light absorption of the paravertebral skin of subject W.E. are shown here.
Marked asymmetrie between the right and let sides are apparent from Ts to T/1 in all 3 patters.
50 EMG, SNS, refexes, etc.
5. Correlations between the skin
temperature. red reponse and light
absorption ojthe skin.
For comparison, the patterns of the
skin temperature, red responses and
light absorption of the skin of subject
W. E. are shown in Fig. 9.
Marked differences between the
right and left sides are apparent from
T6 to T' 2 in all three patterns. In this
area, the skin temperature was consis
tently cooler and the persistence of
the red response less on the right side
than the left side. In the same subject,
however, the light absorption of the
skin was consistently greater on the
right side than the left between T to
T1 2 Similar correlations, among the
three patterns, and directional dis
crepancies between light absorption
and the other two measurements were
seen in other subjects.
Discussion
Signiicance ojindividual and
combined measurements.
The methods employed in these
studies indicate that the cutaneous
circulation over the entire trunk is not
uniform, as appears to be commonly
assumed, but differs with the segmen
tal or topographical level of the trunk
skin. In the normal individua, in
herent topographical patterns in the
skin temperature, vascular responses,
and blood content of the sub papillary
plexus extend throughout the longi
tudinal axis of the thoraco-Iumbar
area. Although the three measure
ments used in these studies refect dif
ferent manifestations and characteris
tics of the cutaneous circulation2
0

21
,
24, 3 5-3 7 , certai n rel ati onshi ps,
similarities, and dissimilarities may
be considered.
The sin temperature indicates the
position of thermal equilibrium be
tween the body and the environment,
and is used only as an indirect
criterion of cutaneous blood flow
2
1 ,
3
5-
45. However, i n a resting subject in
a constant temperature, variations in
the skin temperature may reflect
variations in the cutaneous blood
flow. The segment-to-segment differ
ences in temperature over the topog
raphy of the trunk which we have re
corded, may, therefore, reflect, or be
related to, difference in cutaneous
blood fow.
The red response is due to an active
dilatation of the minute cutaneous
vessels caused either directly by me
chanical stimulation or by the action
of a histamine-like substance which is
released fol l owi ng mechani cal
sti mul ati on
1 8
, Al though the
vasodi latati on observed i n thi s
response is not dependent on a neural
mechanism, its intensity and duration
are infuenced by neural factors. It
has been shown by other investigators
that central and reflex control of the
cutaneous vessels is, apparently,
purely via sympathetic fibers 4
6
-5
1 .
Hence, the intensity and duration of
the response to mechanical stimula
tion will certainly be influenced by ex
isting sympathetic constrictor tone.
The topographical pattern of the
"persistence" of the red response
which we have observed at different
segmental levels on the trunk, may,
therefore, be related to, or reflect,
differences in sympathetic vasocon
strictor tone of the minute cutaneous
vessels.
The vascular component of the
skin color is related to the state of fill
i ng of t he subpapi ll ary venous
plexus20 However, the quantity of
blood i n the skin can be quite dispro
portionate to the rate of blood flow
through the skin
1 21
,
3
5-37. 52. Never-
theless, it has been shown that an in
creased tone of the subpapillary
venous plexus mediated by sympathe
tic pathways diminishes the blood
content (not necessarily the blood
flow) of the skin and contributes to
pallor3
1-3
4
, 53-55. The topographical
differences in the vascular coloration
of the skin which we have observed.
may. therefore, reflect differences in
the sympathetic constrictor tone of
the venules of the skin.
It is obvious, therefore. that be
cause our three types of observations
are related to different kfnds of
manifestations of the cutaneous
ci rcul ati on, preci se correl ati ons
among the three types of data cannot
be expected. Nevertheless, com
parison of the "average" graphs of
the skin temperature and red re
sponses (Fig. 3) shows that, i n
general, hypothermic areas of the
skin also show diminished persistence
of the red response and vice versa.
Thus, the warmest area of trunk skin,
T 4 to T y corresponds to the same
area in which the red responses per
sisted for the longest period of time.
Similarly the coolest area of the
trunk skin, LI to L
4
, showed minimal
persistence of the red response.
Temperature and red response
patterns of individual subjects were
also similar. Variations in red re
sponse and in skin temperature ap
pear, therefore, to be related to varia
tions in a common factor. We believe
the closely correlated regional varia
tions, and local aberrations of red
response and skin temperature are
both manifestations of parallel varia
tions in sympathetic vasomotor tone,
high sympathetic tone producing
hypothermia and brief red responses,
and low tone producing hyperthermia
and prolonged red responses.
That the blood content of the skin
is in some way related to temperature
and red responses is clearly indicated
by the fact that aberrations in all
three have the same distribution in a
given subject. Since, however, the
direction of the aberrations in blood
content is not consistently related to
direction of the aberrations of tem
perature and red response, the nature
of the relationship is not clear. For
example, as shown in Fig. 9, the ap
parent blood content of the right side
is greater than the left, whereas the
skin temperature and red responses
indicate vasoconstriction on the right
side relative to the left. It is possible
that skin color, on the one hand, and
temperature and the red response. on
the other, refect variations in dif
ferent parts of the cutaneous vascula
ture, thus accounting for this incon
sistency. As HertzmanS2 has pointed
out, the quantity of blood in the skin
and the changes in the blood content
of the skin can be quite dispropor
tionate to the level of blood flow and
to changes in blood flow. For exam
ple. in certain pathological states an
increase in cutaneous blood fow and
pallor may develop simultaneously,
The pallor must represent an increase
in venous tone, while the increase in
cutaneous blood flow is associated
with arteriolar dilatation.
Moreover, the configuration of the
"average" pattern of the light ab
sorption also differs from those for
temperature and red response. The
reason for the difference, limited ap
parently to upper thoracic segments,
is not clear, but may have part of its
basis in pigmentation, skin thickness
or vascularity of this part of the trunk
as compared to lower segments23 26
, 28
.
51
Normal regional diference.
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 patterns are not clear. but may
represent adaptations to postural and
thermoregulatory demands.
The investigations of others, as
well as our own, suggest that these
variations have a functional rather
than an anatomic basis. Hertzmanl in
his studies of regional differences in
cutaneous blood fows, concluded
that the vascular anatomy of most of
the body's skin (trunk, legs and arms)
is uniform with respect to the number
and size of the vessels. Wetzel and
ZottermanZo also found that the num
ber of capillaries in the cheek, ear
lobe, forearms and hand does not dif
fer signifcatly. Di Palma3 also con
cluded that it seemed reasonable to
assume that segmental threshold dif
ferences in the responses of the small
cutaneous vessels were the result of
functional alterations, rather than
anatomic ones. The existence of simi
lar patterns in sudomotor activity
(Fig. 4) strongly suggests that the
vasomotor, Uke the sudomotor varia
tions, refect normal variations in
sympathetic tone.
A segmental pattern in the motor
reflex thresholds of the paravertebral
muscles, reflecting activity of the ven
tral hor cells of the cord, has been
shown by Denslow' 6 It is of interest,
that while these measurements are
concerned with a different kind of
nervous activity, and while there is
variable topographical displacement
between corresponding dermatomes
and myotomes, an essentially similar
pattern was evident. This 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. That is, together they reflect
patterne variations in spinal integra
tion of somatic and autonomic motor
activity.
Local abrrations.
The local al terati ons i n the
temperature, red response, and blood
content of the skin which we found
"superimposed" on the average pat
ters of these measurements, may
also have a functional basis; that is,
52
they may represent local refex altera
tions in sympathetic vasomotor tone.
These individual patterns of local
deviations in vasomotor functions ap
pear to b similar to the distinctive
ESR patterns which Korr et al.
10-
1
3
found in many individuals with
visceral and musculoskeletal distur
bances.
Other investigators have also ob
served local vasomotor disturbances
associated with visceral distur
bancesS7-6
1
Almost 40 years ago
Weroe62-6 observed pale areas of
skin segmentally related to diseased
viscera in numerous patients. Adams
Ray31 , 33 has described pallor of the
skin in the fourth cervical segment in
patients with cardiac pain, and in pa
tients with gall bladder disease in seg
mentally related dermatomes. Doret67
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 Adams
Ray31 who was able to demonstrate
pallor of the skin in the eleventh and
twelfth thoracic segments when the
bladder was di stended, and by
Stirup61 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 vaso
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.
Summar
1 . These studies have been con
cered with regional or segmental
variations in vasomotor activity in
"normal" individuals.
2. The methods used included the
segment-to-segment measurement of
the temperature, red responses, and
light absorption of the paravertebral
skin.
3. The observations show that the
cutaneous vasomotor activity on the
trunk is not uniform, as appears to be
commonly assumed. Topographical
patterns of temperature, red re
sponses and light absorption of the
skin were found.
4. Local or segmental deviations
from these average or "normal" to
pographical patterns were found in
most individuals.
5, 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. The 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.
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Horowitz. Relationship in the toe of skin surface
temperature to mean blood flow measured with a
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between blood flow and cutaneous temperature.
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des reaction vasomotrices cutanees chez Ie chien
normal et dans differentes conditions experimentales.
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control of human bl ood vessels. Edward Arnold &
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blood fow ad blood content in the finger, forearm
and forehead. Amer. 1. Physio!. 150(1947). 122-132.
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kutancr Sympthicus-Rcrex im EntzUnunpyndro
- spezicll nah clrugschen Einsffcn i Obr
bauch. Zb!. Neurohir. 10 (1950), 3-1 1 .
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infammation syndrome. Acta chir. Scand. 9 (1949),
221-229.
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mometrie cutanee. Presse mCd. 6 ( 1952), 1056-10.
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und algetische Krankheitszeichen der inneren Organe.
Thieme, Leipzig, 1938.
6. Konovalov. N. V. . Vasomotor disorders in
hepatolenticular degeneration and in other liver
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(1955), 268-281 .
61 . Longo. O.F., C.A.S. Gallardo and A. Ferrri.
Las alteraci6nes vasculo-nervioss en la patogenia de
las pancreatitis. Rev. Asoc. mCd. argent. 6 (1952),
8-16.
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zoner og deres tydning. Uskr. Laeger, K'hvn, 85
(1923), 143-147.
63. Wernoe, Af Th. B Smertezone-diagnostik.
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Kobenhavn, 1931 .
6. Weroe. Af Th. B.. Smertens diagnostik.
Kobenhavn, 1935.
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temperature cutanee dans I'infarctus du myocarde et
l'angine de poitrine. Cardiologia 19 ( 1951), 80-86.
68. Stilrup, G.K o Visceral pain: plethysmographic
"pain reactions", dilation of oesophagus. Ny!. Nor
disk Forlag. A. Busck, Copenhagen, 194.
We gratefully acknowledge the valuable assistance
of Mr. E. Blackorby in the design and construction of
instruments and of Mrs. Tova Brooks in the prepara
tion of the illustrations.
Reprinted by permission from 10urnal of Neural
Trasmission 22: 3,34-52, 19.
5J
Effects of experimental myofascial
insults on cutaneous patterns of sympathetic
activity in man* (1962)
I.M. KORR, H.M. WRIGHT, ad P.E. THOMAS
In recent years our laboratories have
been engaged in the study of regional
and segmental variations in sym
pathetic activity, as revealed by
cutaneous sudomotor and vasomotor
manifestations. Studies of electrical
skin resistance (ESR) , reported in this
Journal in 19581, revealed persistent
areas of low electrical skin resistance
in most individuals. The topographi
cal distribution or "pattern" of these
low resistance areas varied from in
dividual 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 a three or four years. Studies
of regional and segmental variations
in cutaneous vasomotor activity also
revealed topographical "patterns"
2
that remained similarly characteristic
and constant for each subject.
That these measurements and pat
terns of ESR as recorded by our
methods reflect variations in sym
pathetic activity was shown by the
studies of Thomas and Korr 3, 4. 5 and
Kawahata and Th
o
mas 6. Although
these studies did not reveal the physi
ologic ongms 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 vis
ceral or myofascial disturbances.
Reports of areas of hyperhidrosis7 8
or low skin resistance9-13, lowered
skin temperaturel4
IS
and cutaneous
pallorl6--19 reflexly related to painful
myofascial and visceral conditions
also suggest such a possibility.
In view of the possible physiologic
and clinical implications of the topo
graphical variations, asymmetries
and local aberrations in sympathetic
activity, we have attempted to explore
factors that might contribute to them.
*T_ investigations were supported in part by grants
from the National Institutes of Health, Public Helth
Service (H 1632). and from the American Osteopathic
Association.
54
This report deals with the effects of
experimentally induced irritations
and stresses in musculoskeletal tissues
on the patterns of cutaneous
sudomotor activity.
Methods
Since the methods we have used for
the study of sudomotor activity-have
been previously describedl,
2,
2
1
, they
are only briefly characterized here.
ESR Explorations.
The experiments 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 explored
area, the momentary current fow
through the skin in contact with a
constantly moving exploring elec
trode, at known voltages. The volt
ages were tapped stepwise from a
series of dry cells and applied to an
electrode fixed to an earlobe and an
exploring electrode. Resistance of the
skin of the earlobe was minimized by
means of electrode paste. Area-to
area differences in current flow at a
given voltage, therefore, were due to
differences in the "resistance" of the
skin under the exploring electrode.
1. Explorations with hand-held
electrode.
In our earlier studies we used an in
strument similar to that described by
Jasperll. Current flow was read from
a microammeter as the electrode was
moved over the subject's skin.
Figures 1 to 6 and 16 to 18 show
charts obtained with this method.
2. Automatic Explorations.
In later studies a mobile automatic
dermometer was developed 21. With
this instrument skin resistance pat
terns on large areas of the dorsal
trunk were recorded directly on paper
by recording galvanometer whose
amplitude of oscillations is related,
through an amplifier, to the skin cur
rent. The position of the galvano
meter writing-point on the chart was
related to the position of the explor
ing electrode on the subject by means
of a pantograph. Records obtained
with this instrument appear in Figures
8,9, 11, 12, 14, 15. Records obtained
with an earlier automatic dermometer
(Thomas and Korr20) are not included
in this report.
Exploration Conditions.
The explorations were conducted in a
quiet room maintained between 230
and 250 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, "segmen
tal" level refers to the topographical
level on the trunk as identified by the
corresponding spinous process,
rather than the dermatomes. There is,
however, close correspondence be
tween topographical and segmental
levels for paravertebral skin, except
at the uppermost thoracic segments.
The experimental irritations used in
these studies were produced by the in
jection of hypertonic NaCl solution
into paravertebral structures. The
postural stresses included the artifi
cial lengthening or shortening of one
lower extrcmity by the insertion or re
moval of heel lifts, and the inclina
tion ot the pelvis by seating subjects
in tilt-chairs. In some of the tilt-chair
experiments the changes in skeletal
configuration were monitored with
roentgenograms.
Results
Myojascial Irritations.
For the purpose of studying
sudomotor responses to local myo
fascial irritation we adopted the
method described by Kellgren in con
nection with investigations of refer
red pain of somatic origin
2
3-26 As
Lewi and Kellgren26 reported, when
small volumes (0.1 to 0. 3 ml) of
hypertonic saline (61o NaCl) were in
jected into superficial tissues (e.g.,
skin, periosteum of the tibia, sheath
of the achilles tendon) only a sharp,
localized pain was produced. When,
however, the irritant was injected into
deeper tissues, especially those on the
trunk and most particularly around
EMG, SNS, refexes, etc.
the spinal column (e. g. , 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 peak often of great inten
sity. It was our purpose to determine
what changes in ESR were associated
with these phenomena.
In our experience with a total of 1 5
subjects, some of 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. Injection of
superficial structures, such as 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, generalized
drop in resistance, with quick return
to pre-existing patterns. Such
responses might, i n apprehensive sub
jects, even precede 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
localized pain, nausea and faintness,
and pallor, coldness and clamminess
of the skin. Two subjects (injected in
mid-thoracic 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 of the hyper
tonic saline into the erector spinae
and intercostal muscles. Figures 1, 2
and 3 illustrate the results of four
such injections.
F
igure 1 represents
the results of two injections, 35
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 black spots. The
other areas, mainly in the midline,
were present before the injection and
In all figures dark areas rprsent low-resistance areas (LRA) of skin. Darknes of shading In hand
drawn charts (Fig. 1 to 6, 16 to 18) is in proportion to currentfow at exploration voltage; the darker
the area the lower the resistance. White areas: / pa or less; (rsistance. in ohms, at least 1 million
times the number oj volts),' black areas: 20 p or more; i. e., less than 1120 oj basic resistance , ' gray
areas: intermediate values. (Reproduction oj the hand-drawn charts ha darkened the gray areas and
the darker shade have become inditinguishable Jrom the black aras.)
Fig. 1. Subject D.H. 12 20 48: Area of low skin reistance (circled black dots) elicited by the inec
tion oj 0.3 mi. of 600 NaCI into the erector spinae mass to the left of the spinous proces oj T. and
into the eighth intercostal space in the right axillary, midline (both sites marked by x).
FilS.
Fig. 2. Subject L.L. 12 21 48: Areas of low skin resistance (circled black dots) elcited by the injec
tion oj 0.3 mi. oj 6% NaC1 into the erector spinae mas to the leJt oj the spinou process of T,.
Fig. 3. Subject L.L. 12 649: Area oj low skin resistance
(Ts_I
I
'
right) present 24 hours ater the in
jection of 0.3 mi. oJ 6% NaCl into the erector spinae mass to the right of the spinous proces oj T,.
55
Fig. 4
I
Fig. 6
.
f
I
1
. \,
I

' J
Fig. 4. ESR patterns of Subject L.L. I2 22 49: a) seated horizontally,' b) 6 minute 4ter pelvi was
tited to the left.
Fig. 5. ESR patterns of Subjet J.R. 12 2349: a) seated horizontally; b) 6 minutes after pelvis was
tilted to the let; c) 30 minute following retur to the horizontal position.
Fig. 6. ESR ptterns of Subject J.D. 1 3 50: a) seated horizontaly,' b) 120 minutes after pelvi wa
tilted to the left. Ti subject showed very little change in hi ESR patter in contrst to the subjects
shown in Figs. 4 and 5.
5
were representative of the ESR "pat
tern" (Korr, Thomas and Wright!)
repeatedly observed in previous ex
olorations of this subject.
Immediately following the comple
tion of the control exploration, 0.3
ml of 611 0 NaCl was injected 2.5 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 30 seconds severe pain had also
developed in the back. over the
transverse processes and rib-heads of
the region T, to Tlo on the left side.
The new areas of low resistance began
to appear during the second minute
after injection and, after 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 after the frst
injection a second injection of hyper
tonic saline was made, this time into
the 8th intercostal space in the right
mid-axillary line. The 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 re-explored
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
lJ of current through most of the
skin. Nevertheless. the current flow
through the areas shown was suff
cient to cause the two strips 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
later.
The 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 0.3 ml of
600 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 correspond-
EMG, SNS, refexes, etc.

"
F ig. 7. Roentgenogram tracings ofthe spine of
Subject S.P .: H) seated hori z ontally; L) seated
with pelvis tilted to the left; R) seated with
pelvis tilted to the right.
In the pantographi c records (F igs. 8, 9, 1 1, 12 ,
}4, 1 5), amplitude ofoscil l ations ofthe record
ing galvanom eter is related to current flow
through the skin. Th e thin vertical lines (no
oscillation) represent areas perm itting 0-1 p a
at exploration voltage; widest oscillations
represent current f ows of 30
p
a or m ore. In
these charts, therefore, the darkest areas repre
sent / /30 the basic resistance or less. Note the
calibration "stris" showing relation between
current and ampli tude of osci ll ations in steps
of5
p
a.
L
."

'''_J
r,
'
"'
m
>

/

J

, ,

. .
=
=

j
-.
/

"

:
'-.
;1r
$L
-'_l
.. " !

H
F ig. /0. Roentgenogram tracings of the spine
of Subj ect H.K. H) seated hori z ontally; L)
seated with pelvis tilted to the left; R) seated
with pelvis tilted to the right.
I
'
" .
|l.
\ '

'I
"
F ig. 8 ESR patters ofSubj ect S. P. 6 17 55: a) seated hori z ontally; b) 4 m inutes after pelvis was
tilted to the left; c) 14 m inutes following retur to the hori z ontal position.
I
F ig. 9. ESR patterns ofSubj ect S.P. 616 55: a) seated hori z ontall y; b) 9 m inutes after pelvi S was
tilted to the right; c) 8 m inutes following return to the hori z ontal position.
F ig. II. ESR patterns ofSubj ect H.K. 7 19 55: a) seated horiz onlally; b) /8 m inutes after pelvis was
tilled to the left; c) / / m inutes fol lowing return to I he horiz ontal position.
57
c
m
i

.
F ig. 12. ESR po l/ ems of Subj ect H.K. 7 25 55: a) seated hori z ontall y; b) 18 m inutes after pelvis was
tilted to the right; c) I I m inutes following retur to the hori z ontal position.
f'
58
F ig. /3. Roentgenogram tracings of the spine
of Subj ect C.B.: H) seated hori z ontall y; L)
seated with pelvis tilted to the left; R) seated
with pelvis tilted to the right.
F ig. 14. ESR po l/ ems of S ubj ect C.B. 62 455: a) seated hori z ontall y; b) 15 m inutes after p elvis was
,t illed to the left; c) 14 m inutes following return to the hori z ontal position.
F ig. 15 . ESR patters of Subj ect C. B. 62 855: a) seated hori z ontall y; b) 1 7 m inutes after pelvis was
tilted to the right; c) 14 m inutes following retur to the hori z ontal position.
EMG, SNS, refexes, etc.

ing dermatomes. The large encircled

area shown between the vertebral
column and the left scapula repre
sents an area of muscular rigidity first
evident as a conspicuous bulge and
easily delineable by palpation. At re
exploration three hours after injec
tion, the muscular rigidity had sub
sided, the low resistance areas had
become less punctate in distribution
and the total area had become much
narrower, no reduction in resistance
being evident below the 7th inter
space.
In another experiment on the same
subject, the right erector spinae at the
level of the 8th thoracic spinous pro
cess was injected with 0. 3 ml 600
NaCl. Only a few small areas of
moderately lowered resistance ap
peared during the succeeding thirty
minutes, over the 8th and 9th verte
brae and ribs. At the re-exploration
24 hours later, however, a large
triangular area of low resistance (Fig.
3) was present.
Acute Postural Stres.
In the experiments to be described
under this heading we studied
changes in ESR patterns that follow
ed acutely imposed postural stress.
The stresses applied were of two
general kinds: a) lateral tilting of the
pelvis, relative to the spinal column
and b) artificial alteration of relative
lengths of the right and left legs 'by
means of heel lifts inserted in one
shoe.
Pelvic Tilts.
In these experiments subjects were
seated on a special stool the seat of
which could be tilted to right or left
by means of a wormgear arrange
ment. The subject's pelvis was firmly
secured with a belt il such a manner
as to minimize rotation of the pelvis
around the vertical axis and to render
the tilt (and the resulting scoliosis) as
purely lateral as possible. The sub
ject's arms rested on a horizontal sur
face, thereby reducing the inclination
of the shoulders and forcing the com
pensation mainly on the thoracic and
lumbar segments of the spinal col
umn.
Explorations were begun after the
subject had been seated, with trunk
exposed, for a sufficient period to
permit stabilization of the ESR pat
terns I. After completion of the con
trol exploration, the seat was tilted in
Fig. 16. ESR patters of subject M.O. 12 2748 - 123048: a) without heel-lift; b) 24 hours after
wearing 3/8 inch heel-lit in right shoe; c) 24 hours after removal of heel-lit.

t,
d
Fig. 1 ESR patterns of Subject A.M. 12 27 48 - 122848: a) without heel-lift; b) afer wearing !
inch heel-lit in right shoe for 5 hours; c) patter immediately upon arising the fol/owing moring;
d) "! hours later, heel-lit still in place.
5
.,
Fig. 18. E/ects 0/ removal 0/ heel-lits on ESR patterns 0/ subject R. H. who had wor ! inch lit
under his right heel/or more than a yer to compensate/or shortness 0/ that extrmity. oj 12124149:
Control ESR pattern (subject wearing hel-lift) in the moring (a 1, 9:00 A.M.) and afteroon (a 2,
4:15 P.M.). Moring and ateroon explorations were also done on three other days with similar
reults. b) 12128149: Following the ESR eploration at 9:30 A.M., (bl) the lit was removed. The
fgure at 4:05 P.M. (b 2) shows the altered ESR patter which developed during this interval.
the chosen direction while the subject
remained seated. He was then re
explored at various intervals after
tilting. In some experiments explora
tions were also conducted after res
toration of the seat to the horizontal
position.. In all experiments to be
shown the angle of tilt with respect to
the horizontal was 1 5. In explora
tions done with hand-held electrodes
(Fig. 4 to 6) the charts representing
the experimental exploration indicate
the patterns that had developed by
the time the exploration was com
plete.
Comparison of Figures 4 a and 4 b
indicates the change in pattern which
6
developed in subject L.L. in the
course of one hour of sitting with the
left hip tilted downward. New areas
of low resistance were especially
marked in the lower cervical, lower
thoracic and lumbar areas. Pain
developed at the base of the neck on
the left side within 1 5 to 20 minutes
after tilting.
Fig. 5 shows an experiment on
another subject (J.R.). A comparison
of charts a and b reveals the new
areas of low resistance which ap
peared while the subject was seated
for one hour with the pelvis tilted
1 5, left hip down. The new areas in
the thoracic and lumbar regions, es-
pecially on the left (convex side of the
spinal curve) and the exaggeration of
the low resistance areas at the cer
vicodorsal junction are particularly to
be noted. These changes were almost
entirely reversed within 30 minutes
after restoration to the horizontal
position (Fig. 5 c).
In contrast to the above subjects,
subject J.D. (Fig. 6) showed very
little change in ESR pattern after 1 20
minutes of sitting in the tilted posi
tion. This subject was a tall, slender
individual who felt remarkably little
discomfort. He reported only a slight
sensation of "strain" in areas over
the upper borders of both scapulae.
The topographically related areas of
slightly lowered resistance which ap
peared after about one hour are to be
noted, although they were probably
extensions of the small areas evident
above the scapulae in the control ex
ploration.
In more recent experiments, it has
been possible, with the automatic der
mometer ( Thomas. Korr and
Wright21), to record the progressive
development of new patterns after the
assumption of the tilted posture and
their regression following return to
the normal seated posture. Antero
posterior roentgenograms of each
subject were taken in the level and
tilted postures in order to visualize
the configuration of the vertebral col
umns. Tracings showing the spinal
confguration in each subject in nor
mal and tilted sitting, were made
from these films and accompany the
ESR patterns in the following figures.
Subject S.P. had abnormalities of
the vertebral column evident in Fig. 7
H (seated level) as conspicuous lateral
curves in the thoracic spine, with
sharp reversals of direction at upper
and mid-thoracic levels. Figures 7 L
and R reveal the poor adaptation of
the subject to the tilted posture and
the marked lack of symmetry of the
spinal confguration in the right and
left tilt. The imposition of these
postures on the subject provoked in
tense and diffuse sudomotor re
sponses as revealed by comparison of
chart b with a, pre-tilt, and c, post-tilt
control in both Fig. 8 (left tilt) and
Fig. 9 (right tilt).
Differences in response to left and
right tilt are also revealed. The sharp
upper boundaries of low-resistance
areas at the mid-thoracic level in Fig.
8 b and the elevation of the boundary
EMG. SNS, reflexes, etc.
to upper thoracic levels in the reverse
tilt (Fig. 9 b) are especially to be
noted.
Subject H.K. had no gross postural
or spinal abnormality evident in the
roentgenograms taken in the level
seated position (Fig. 10 H). Never
theless, those taken in the tilted posi
tions (Fig. 10 L, R) revealed various
restrictions and asymmetries in spinal
moti on. Accordi ngl y, marked
changes in ESR patterns occurred
during tilt-seating in both directions,
the patterns of the left and right tilts
being quite different. Low-resistance
areas at lumbar levels on the right
side were the first to appear in tilting
both to the left and to the right.
Following the appearance of these
areas of low resistance, however, the
patterns during right and left tilts
developed quite differently (compare
Fig. 1 1 b and 1 2 b), the additional
areas being in each case on the convex
side of the induced spinal curve.
Thus, while the low resistance areas
developed during the tilt to the left
(Fig. 1 1 b) were quite extensive, there
were only scattered small spots of low
resistace in the upper right quad
rant. It is thi area, however, in which
resistance was diffusely lowered when
the tilt was in the reverse direction
(Fig. 1 2) , the left side being relatively
free of low resistance areas.
In contrast with the above subjects,
C. B. showed, on X-ray examinati
o
n,
both excellent vertebral alignment in
the level-seat posture and smoothly
rounded, symmetrical spinal adapta
tion to the tilt of the pelvis in both
directions (Fig. 1 3). The new areas of
low resistance that developed were
small and limited mainly to the upper
thoracic levels (Figs. 14, 1 5).
Hel Lits.
The experiments reported under this
heading illustrate the regional sym
pathetic responses to artifcial change
in length of one leg, either by insert
ing a heel lift (hard-rubber wedge in
serted in one of the shoes) under one
heel, or removing one to which some
adaptation has been made.
In this series of experiments the
postural stress was not so gross as
that imposed by tilting the seat 1 50,
but, on the other hand, the stress was
permitted to act for much longer
periods of time, and under conditions
of locomotion. Consequently, the
discomfort and the changes in ESR
patterns have often been more severe.
All the subjects used in this series had
shown stable ESR patterns over
periods of at least several weeks. The
stress was applied after a control ex
ploration, and the subject was re
explored at various intervals there
after.
The series of charts comprising Fig.
1 6 shows, on subject M.O., the effect
on ESR pattern of wearing a lift one
day and the subsequent effect of
removing it. Fig. 1 6 a represents the
pattern repeatedly found on this sub
ject with only minor modifications
from day to day. This exploration
was begun 30 minutes afer the sub
ject had completed a 1 Y' mile walk
from his home to the laboratory. His
only complaint was a continuous ache
in the lumbosacral area on the right
side, in which general region was also
found an area of moderately lowered
resistance. X-ray flms taken in the
standing position indicated that the
right leg of this subject was approx
imately 7t inch shorter than the left.
Upon completion of the exploration a
3/8 inch lift was placed in his right
shoe and he was instructed to wear it
throughout the day and the following
morning to return for an exploration
the next morning, also after walking
(with heel-lift in place) from his
home.
Fig. 16 b shows the pattern ob
tained the next day. Both ache and
low-resistance areas in the lower right
quadrant had vanished, but the sub
ject now complained of discomfort in
the midthoracic region in which there
was especially marked extension of
low-resistance areas. The lift was
removed at 2:30 P. M. , after a "spot
check" revealed that there had been
further lowering of resistance and
some extension of the areas shown in
Fig. 16 b.
Fig. 1 6 c shows the pattern found
the next morning, again after the
walk from the subject's home. The
ache (and the low-resistance area) in
the lower right quadrant had returned
and the midthoracic ache had been
exacerbated. Areas of markedly
lowered resi stance had spread
throughout the midline of the back.
A totally new strip of low resistance
appeared on the right side in the mid
thoracic region, extending peripheral
ly from the level of vertebra T 8 on the
right side (Fig. 16 c; possibly a lateral
extension of the paravertebral area
evident in Fig. 1 6 b). It had not pre
viously been observed on this subject
but it continued to be observed on
every subsequent exploration until
the final exploration on this subject
almost 16 months after the experi
ment.
Another subject's response to ar
tificial increase in length of one leg is
shown in Fig. 1 7. This subject's ESR
pattern, repeatedly recorded over a
period of three weeks, was remark
ably undistinguished by any conspic
uous and persistent areas of low
resistance, and the control pattern
(Fig. 1 7 a) was typical. At 1 1 :0
A. M., following this exploration, a
one-half inch heel lift was inserted in
the subject's right shoe. He was in
structed to go about his usual activi
ties and to return later the same after
noon for exploration. Fig. 1 7 b shows
the pattern obtained in an exploration
begun at 4:0 P. M. , at which time the
subject complained of discomfort in
the region of the lumbosacral junc
tion. The extensive development of
low-resistance areas below the
thoracolumbar junction and in the
vicinity of the cervicodorsal j unction
is especially to be noted. Fig. 1 7 c
represents the pattern obtained on
this subject the following morning
shortly after rising. In general, a
recession of the low-resistance areas
of the previous afternoon is evident.
However, by early afternoon the sub
ject's discomfort, generalized in the
low back, was sufficiently severe that
he came to the laboratory to request
discontinuation of the experiment,
and the heel lift was removed. Ex
ploration done at that time disclosed
the pattern shown in Fig. 1 7 d. In
general, this seems an exaggeration
of the pattern of the previous after
noon (Fig. 1 7 b). Unfortunately, the
subject was not able to return until
two days later ( 1 2/30), at which time
low-resistance areas were still present
at the cervicodorsal junction, the en
tire midline below T s and to the right
of the dorsolumbar j unction.
The experiment shown in Fig. 1 8
was also conducted t o examine the
response to alteration of relative leg
length. In this case, however, the
stress was that of removing a lift
worn for therapeutic purposes. Sub
ject R.H. had been wearing a one
fourth inch lift in his right shoe, for
approximately one year, to compen
sate for relative shortness of the right
0I
leg and as part of the treatment for
low-back pain previously suffered by
this subject. At the time of the experi
ment he had been symptom-free for
at least 10 months.
Control explorations in this experi
ment consisted of a series of morning
and afternoon explorations on four
successive days. Of these, one pair is
shown (Figs. 1 8 a, b), representing
the extremes of variation. The subject
was engaged in physical labor and the
two charts on each day indicated the
changes in pattern which took place
in an interval of 6 to 7 hours. Follow
ing the morning exploration on the
ffth day of the experiment (Fig. 1 8 c)
the lift was removed and the subject
continued with his work as usual,
returning for exploration at 4:0
P.M. Fig. 18 d shows the great expan
sion of low-resistance areas in the
lower part of the back which had
taken place in the interval. The sub
ject also volunteered the information
the the "old pain", especially in the
vicinity of the lumbosacral junction,
had returned, in his recollection, for
the first time in many months.
Discussion
These studies reveal some of the
autonomic changes as refected in
sweat gland activity, provoked by
myofascial irritations and postural
stresses in human subjects. Related
changes in vasomotor activity, to be
reported separately, also occur. In
general these changes recorded in the
skin, were regionally, laterally and
often segmentally related to the site
of trauma, postural stress or discom
fort. Although the responses of the
sweat glands (and cutaneous blood
vessels) may be viewed as incidental
reflex responses of sympathetic path
ways to noxious myofascial stimula
tion, we believe they are better inter
preted as modifications of normally
existing patterns. Visceral, circula
tory and thermoregulatory functions,
controlled by the autonomic nervous
system, are continually coupled, in
highly organized patterns, to muscu
loskeletal activity and changes in
posture. That is, efferent activity in
neuromuscular and autonomic path
ways is, as is well known, functional
ly coordinated by the central nervous
system.
For example, augmentation of the
blood flow to muscles that are active
or about to become active is achieved
62
by differential adjustments of vascu
lar resistance in active and inactive
tissues and by increased cardiac out
put; and heat loss is adjusted, accor
ding to changed thermoregulatory de
mand accompanying the muscular ac
tivity, by changes in cutaneous blood
flow and sweat secretion. While, in
considerable part, local adjustments
are effected by direct action of
chemi cal agent s (e. g. , C02t
metabolites) and physical factors
(e.g., temperature), the local ad
justments are integrated in complex,
highly organized reflex patterns by
the central nervous system. Indeed,
the alteration of vegetative function
during and preparatory to muSular
activity and according to environ
mental demands appears to be the
special province of the sympathetic
nervous system, which for these
reasons, has been designated
"ergotropic" by Hes21,
As adaptive patterns they are con
tinually subject to modification and
to "turning on and off" according to
changing circumstances. They also
have a considerable degree of "local
sign", subject as they are to modifi
cation according to local or regional
circumstances and activities. That is,
although the efferent components of
these patterns (motoneurons and pre
ganglionic autonomic neurons largely
spinal in origin) are multisegmental
'and under the control of bulbar,
diencephalic and cortical centers,
their activity is continually influenced
by afferent impulses that arise in ther
mal receptors, pressure receptors,
proprioceptors, pain endings, etc.,
and that are conducted to the spinal
cord by sensory fibers entering via the
dorsal roots.
We believe that the local, more or
less segmental responses of the sym
pathetic nervous system reported in
this paper (and the chronic segmental
facilitation of motor pathways pre
viously reported28 are exaggerated
versions of these local components.
In these stressful and, in some cases,
painful experimental situations af
fecting small parts of the musculo
skeletal system, the afferent volleys
of impulses entering through in
dividual dorsal roots appear to have
become so prepotent as to dominate
that part (i.e., corresponding and
neighboring segments) of the sym
pathetic nervous system, and to take
precedence over vertically organized
patterns they ordinarily serve, and
even to disrupt them. They do not,
therefore, meet any particular func
tional demand, they are not adaptive
and, in many cases, they persist after
the provoking insult has ended.
The autonomic concomitants of
local myofascial irritation, injury,
stress or pathology have not received
widespread recognition in clinical
practice. They have received even less
experimental investigation, other
than in such studies as on cardiovas
cular or respiratory responses to pain
ful stimulation of various tissues. On
ly two experimental studies on human
subjects can be cited. In a study on
the patterns of referred pain produc
ed by injections of hypertonic saline
into paravertebral muscles of the
neck and back at various levels,
Feinstein, Langton, Jameson and
Schitler29 made some incidental
observations on "autonomic con
comitants". Usually produced by in
jections in the thoracic region
(seldom by injections in cervical and
sacral regions), the manifestations
were pallor, sweating, bradycardia,
fall in blood pressure and subjective
faintness and nausea. Sweating was
usually generalized, seldom even be
ing confned to the side of the pain.
As previously stated, we have made
similar observations, especially
following injections into periosteum,
following injections in apprehensive
subjects or when, for unknown
reasons, paravertebral injections were
unusually painful or distressing.
However, the methods used in our
study also revealed the regional and
segmental responses sometimes
superimposed on generalized changes
in electrical skin resistance.
Steinbrocker et al30 also studied
pain patterns associated with local in
jections of hypertonic NaCI solution
into myofascial structures, but made
only occasional observations of color
changes (pallor or erythema), temper
ature change and sweating in areas of
skin in the vicinity of the referred
pain. The patterns of both pain and
autonomic changes, were not
referable, however, to any known
nerve pathways, nor was there any
evidence of segmental relationships.
Unlike the above experimental
studies, clinical studies, such as those
by Travel and by Dittrich. yield
distinct and reproducible patterns,
sometimes showing segmental rela-
EMG, SNS, reflexes, etc.
tionships and sometimes not.
Travel!' 1 described the piloerection,
the frank perspiration and cooling of
the skin that may, individually and in
combination, be induced in reference
zones (in which deep pain is also felt)
on irritation of sensitive myofascial
trigger areas, and the reddening and
warming of the skin that may be
observed following infiltration of the
trigger area with procaine. Travel,
Berry and BigelowJ2 also recorded
changes in pulsations of the temporal
arteries associated with irritation and
anesthetization of triggers in the
trapezius muscle.
Dittrich 33 , in a paper on the
autonomic concomitants of somatic
pain, described in several patients the
referred pain, skin-color change (in
tense redness or cyanosis) and edema
associated with intensely tender spots
or triggers in paras pinal tissues of the
lower back and the {esponses to in
filtration of the triggers with pro
caine. The autonomic changes were
often quite remote from the triggers,
as was also true in Travell's studies.
Thus, for example, autonomic
changes in the upper trunk, shoulder
and upper extremity were demon
strably associated with irritation of
the latissimus dorsi muscle at lumbar
and sacral levels of the back. The
location of these
a
pparently segmen
tally remote reflex phenomena is
ascribable, of course, to the fact that
the latissimus dorsi receives its inner
vation from segments C6-8 of the
spinal cord. Anesthetization of the
triggers in the tendinous attach
ments of this muscle in the low back
produced relief of the referred pain
and of reflex autonomic changes.
Travel/H, on the other hand,
points out that segmental relations or
organized nerve pathways between
locus of the trigger and the reference
zone are seldom clear, though the
reflex nature of the relationship is
undeniable. The intervention of other
refex phenomena such as spasm of
vasa nervorum and resulting neural
Ischemia (Robertsl4) has been im
plicated.
Also to be included among the ob
servations on autonomic repercus
sions of somatic irritation are the in
creasing number of reports on vari
ous forms of "reflex sympathetic
dystrophy" associated with musculo
skeletal disorders or trauma to
myofascial tissues which are effec-
tively treated by silencing of the myo
fascial source of impulses or by
blockade of the appropriate sympa
thetic ganglia (e.g., Bonica 35 ).
It is important to point out that
reflex vegetative changes in the skin
and other superficial structures are by
no means peculiarly associated with
afferent stimulation of myofascial
origin. Similar patterns of autonomic
changes (as well as pain, tenderness
and muscle spasm) often accompany
visceral distrubances. In these cases,
the impulses dominating the segmen
tal pathways originate in injured,
ischemic, distended or irritated inter
nal organs, but the sensory fibers,
usually accompanying smpathetic
pathways also enter the spinal cord,
via the dorsal roots, along with those
innervating the somatic tissues. The
mechanisms involved and the pat
ters of manifestations of visceral
and of somatic stimulation may
therefore be quite similar, as strongly
suggested by the experiments of
Lewis and Kellgrenl6 The patterns
associated with visceral disturbances
will be discussed more fully in
another paper on that subject. A
preliminary report by KorrlO sum
marizes our early findings on patients
with visceral disease. We have men
tioned them here only to show that
our concept of exaggerated local or
segmental influences on normally
nonsegmental patterns applies to vis
ceral as well as to somatic structures.
We believe that the studies reported
in this paper on the changing patterns
of electrical resistance of the skin, in
conjunction with such observations
as discussed above, suggest at least
one possible origin - or category of
origins -of the patterns found in ap
parently normal, resting subjects.
Our observations strongly indicate
that the aberrant areas ot low resis
tance (Korr, Thomas and Wrightl)
and of vasoconstriction or -dilatation
(Wright, Kor and Thomas2) may
begin as parts of reflex responses to
centripetal streams of impulses
originating in somatic (or visceral)
structures or, possibly, in nerve fibers
irritated by them.
Whether such a reflex mechanism
could continue to be the sustaining
mechanism for periods of weeks,
months or years is not known. Unfor
tunately, most experimental studies
on reflexes are based on brief periods
of stimulation - fractions of a sec-
ond to a few minutes - and little is
known of the changes that take place
during greatly protracted stimulation.
The available evidence, mainly of
clinical origin, indicates that it is
unlikely that circumstances (such as
severe tension on a muscle) which
would profoundly modify the pat
terns of afferent impulses from a
given tissue or organ could, if con
tinued, sustain such afferent bom
bardment for long periods without
also initiating some adaptive or
secondary pathological change in the
affected tissue that abolishes, silences
or otherwise alters the original source
of irritation. Fibrosis of chronically
stretched, irritated or ischemic muscle
is a familiar example of such a
change.
It seems equally unlikely that
neuronal structure, chemistry and ir
ritability of the affected part of the
central nervous system would remain
unchanged in the face of prolonged,
intense afferent bombardment.
It is possible, therefore, that pat
terns of very long standing, even if
reflexly initiated, may be maintained
by mechanisms other than the mere
prolongation of that same reflex ac
tivity. The experiments of Kawahata
and Thomas6 indicate, however, that
the increased sweat secretion of low
resistance areas is maintained by
tonic hyperactivity of efferent
neurons supplying such areas. But the
possibility must be left open that the
sustained hyperactivity of the efferent
(sympathetic) neurons, and therefore
of the sweat glands, may, in the
chronic phase, be due not so much to
chronically modified afferent bom
bardment as to chronically aug
mented irritability of central neurons.
We must also leave open the
possibility that some of this efferent
hyperactivity may not even be cen
trally ordered. This is suggested by
some of the areas of low resistance
that we have recorded. We have in
mind particularly those areas of low
resistance which seem to occupy parts
of a single dermatome (e.g., Fig. 9 in
Korr, Thomas and Wright'. and Fig.
1 and 1 6 c in this paper). It is diffcult
to accept a reflex basis for an auto
nomic response which is limited to a
single segment when one keeps in
mind the divergence of afferent
neurons as they enter the cord and
synapse on secondary neurons, the
further divergence of the inter-
63
neurons with which they synapse and,
finally the divergence of the
preganglionic sympathetic neurons.
Axons in a given white ramus com
municans are known to send branches
above and below their level of entry
into the sympathetic chain and to
synapse in several ganglia.
While the highly selective chan
nelization of a reflex response or of
preganglionic discharge to postgan
glionic neurons of an individual
ganglion cannot be entirely ruled out,
it would'seem that, in these cases, the
pathways are more directly selected.
We believe it more likely that irrita
tion may have been directly affecting
paricular ganglia, gray rami com
municantes, ventral roots, spinal
nerves, primary divisions or inter
costal nerves. Certainly, dermatomal
bands of sweat gland activity or
vasoconstriction would be produced
by direct stimulation of any of these
structures (Randall and coil. 36). It is
possible that at least in some of the
experiments direct mechanical (com
pression, friction, stretch) or
chemical (hypoxia, accumulated
metabolites, pH shift) irritation of
one or more of these neural structures
may have taken place, in addition to
refex phenomena. (Some of the
associated vascular changes in the
skin may even be due to the initiation
of antidromic impulses in dorsal root
fibers (Folkow37).
Whether reflexlY or directly pro
voked, the hyperactivity of isolated
portions of the sympathetic outflow
serves no obvious adaptive function.
Yet one may expect functional im
plications of such hyperactivity of
isolated portions of the sympathetic
outfow and, if sustained, clinical im
plications. Certainly, the affected
segments, which our previous studies
indicated are in a state of facilitation,
cannot participate in a well coor
dinated manner in the organized pat
ters of motor and autonomic activi
ty associated with changes in en
vironmental temperature, posture or
muscular work2
-s.
38. Since the parts
of the sympathetic outtow related to
the persistent low resistance areas
have low reflex thresholds and, in
general, make exaggerated responses,
some degree of disruption of these
patterns and some imposition of
compensatory burdens on the other
participating elements in each pattern
are to be expected.
Although the autonomic con
comitants of myofascial stimulation
reported in this paper have been
measured only in the skin, there is no
reason to assume that they are limited
t o the skin. Numerous clinical
studies, a few of which have been
cited above, strongly suggest that the
sympathetic neurons regulating secre
tory, contractile and vasomotor ac
tivity in viscera may also be in-.
volved. Experimental studies by
Kuntz 39, Kuntz and Haelwood4 and
Richins and Brizzee41, on the
simultaneous vascular responses in
skin and viscera to the cooling and
warming of the skin, clearly reveal
the rich access of somatic afferefts to
visceromotor pathways and the paral
lelism between the vascular responses
of skin and viscera. Studies on renal
circulation by Nedz
(
l42. 43, and by
H' in our laboratories, confirm
and extend these observations. An in
genious study on human subjects by
Ralston and Kerr' reveals the pro
found reflex vascular changes in the
mucous membranes of the upper re
spiratory tract in response to thermal
stimulation of the skin in the upper
part of the body. Conversely
numerous studies on reflex somatic
concomitants of visceral stimulation
or pathology, show the reciprocity of
reflex relationships between visceral
and somatic tissues.
. We believe that these studies,
revealing some sympathetic manifes
tations of myofascial irritation, con
tribute to a clearer understanding of
the mechanisms involved in the wide
variety of syndromes encompassed in
the category, "reflex sympathetic
dystrophies". In the context of the
foregoing discussion, they also help
to explain the exacerbation of many
pain syndromes (e.g., reflex sym
pathetic dystrophies, referred pains
associated with myofascial triggers,
joint pains of many origins, referred
pain of visceral origin, etc.) by ex
posure of the patient, or even a small
part of the body, to cold, by provoca
tion of emotional responses, or by an
environmental change which in
creases sympathetic activity.
Some of these implications and the
autonomic changes occurring in
association with musculoskeletal
disturbances of clinical origin and in
association with visceral disease will
be explored further in succeeding
reports now in preparation.
Summar
1. The purpose of these studies was to
examine the changes in sudomotor
patterns in the skin of the human
trunk produced by experimentally in
duced irritation and stresses in the
musculoskeletal tissues, as a step
toward understanding the origins of
the patterns found in apparently nor
mal individuals.
2. Irritation of the musculoskeletal
tissues was produced by the injection
of hypertonic saline into paraverte
bral tissues. Postural stresses were
produced by the insertion and
removal of heel lifts and by the lateral
inclination of the pelvis by the use of
tilt-chairs.
3. Sudomotor patterns were re
vealed by recording electrical skin
resistance on the dorsal skin of the
thoracic and lumbar regions in rela
tion to segmental level.
4. New areas of low electrical
resistance appeared when the saline
injection produced referred pain; the
areas were distributed in the reference
zone, in dermatomes related to the in
jection site.
S. Postural changes produced
changes in patterns which included a)
exaggeration of existing patterns and
b) the appearance of new areas of low
resistance (increased sweat gland
secretion), according to the applied
stress, the individual's vertebral
adaption to the stress and the areas of
discomfort.
6. We believe the findings support
the following hypotheses:
a) That the manifestations of
altered sympathetic activity observed
in these studies represent distortions
of normally existing patterns of ef
ferent activity.
b) That the distortions begin as
responses to exaggerations of seg
mental or local afferent influences
which ordinarily have only local ad
justive infuences on the patterns, and
that these impulses may be visceral or
somatic in origin.
c) That although the aberrant areas
of low resistance described in normal
subjects, may reflect chronically
altered or intensified patterns of af
ferent bombardment from foci in vis
ceral or somatic tissues, other factors,
such as adaptive or pathological
changes in those tissues and altered
central excitability, may eventually
become involved.
7. Since, however, the affected
EMG, SNS, refexes, etc.
areas may be limited in extent to
single dermatomes, it appears that in
dividual ganglia, gray rami communi
cantes, ventral roots, spinal nerves or
their branches may in some cases be
dirctly, rather than reflexly, ir
ritated.
8. Some of the functional implica
tions of chronically altered activity in
localized portions of the sympathetic
outflow are identified.
9. The relation of these findings to
mechanisms involved in such clinical
phenomena as reflex ympathetic dys
trophy, myofascial triggers, referred
pain, etc. , is briefy examined.
The valuable assistance of Mr. Emi D.
Bl ackorby wi t h i nstrumentati on and
illustrations is gratefully acknowledged.
We are grateful to Dr. Joh n A. Chace, U. S.
Public Health Service Special Research Fellow,
in the Biomechanics Laboratory of this
College. for taking these roentgenograms and
for his valuable guidance in analyses of the ver
tebral mehanics involve in each experiment.
Rcfcrcncc8
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reactions in the gastro-intestinal tract elicited by loal
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Reprinted by permiSSion from Journal of Neural
Transmission 23: 22, 330355, 192.
05
Cutaneous patterns of sympathetic activity
in clinical abllornlalities of the
musculoskeletal system (1964)
IRVIN M. KORR, HARRY M. WRIGHT and JOHN A. CHACE
In previous investigations we have
reported on regional and segmental
variations in sympathetic activity as
revealed by cutaneous sudomotor and
vasomotor manifestationsl 2. I n
studies of topographical variations i n
electrical skin resistance (ESR) , we
have observed persistent areas of low
electrical skin resistance in most
"normal" resting individuals ' . The
topographical distribution, or "pat
tern", of these low resistance areas
(LR) was found to be characteristic
for a given individual and remained
relatively constant for weeks or
months. Studies by Thomas and
others in our laboratories3-s have
shown that these measurements and
patterns of ESR, as recorded by our
methods, refect variations in activity
in the sympathetic fibers. Studies of
regional and segmental variations in
cutaneous vasomotor activity also
showed topographical "patterns" in
the skin temperature, < fred response"
and apparent blood content of the
skin; and, like the ESR patterns, the
vasomotor patterns showed a high
degree of constancy and reproduci
bility in any given individual2
These studies, on apparently well
and resting subjects, however, did not
reveal the physiologic origins and
functional si gni ficance of these
cutaneous manifestations of sym
pathetic activity. Preliminary evi
dence obtained in our laboratories6 7
and reports of areas of sudomotor
and vasomotor dysfunction reflexly
related to painful myofascial and
visceral conditions (cited in detail in
our previous paper S), suggested that
these patterned differences in sudo
motor and vasomotor activity were
related in some individuals to visceral
and myofascial disturbances . We
undertook investigation, therefore,
of factors which might contribute to
these local asymmetries and vari
ations in sympathetic activity .
A detailed report on the changes in
sudomotor patterns in the skin of the
human trunk produced by experi-
mentally induced irritation and
stresses in the musculoskeletal tissues
has already appeared in this journals.
New areas of low electrical skin resis
tance appeared in areas of re
ferred pain and in segmentally related
dermatomes when the paravertebral
tissues were injected with small-uan
tities of hypertonic saline. Postural
stresses produced exaggeration of ex
isting LR patterns or elicited new
areas of LRA according to the stress,
the individual's vertebral adaptation
to the stress ad his discomfort.
In this paper we report our obser
vations of sudomotor patterns in
clinical subjects with known musculo
skeletal disturbances, myofascial
stresses and pain syndromes.
Methods
1. Methods /or evaluation 0/
musculoskeletal abnormalities.
Methods of examination utilized in
this study included radiographic
. studies of posture and skeletal abnor
malities, electromyographic assess
ment of the activity of postural
muscles, and palpatory testing for
areas of cutaneous and deep tender
ness. Postural radiographic studies of
the spine and pelvis, taken with the
patient in the standing position ac
cording to methods which have
previously been described
1
2, were
made on some of the patients. Our
electromyographic procedures are
described in the legend of Fig. 8 c.
The palpatory methods were those
conventionally utilized in clinical
practice.
2. ESR Explorations.
Since the methods used for the study
of cutaneous sudomotor activity
which have been used in these studies
have been previously described
1
9, 10
,
they will be only briefy characterized
here.
The experiments 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 explored
area, the momentary current flow
through the skin in contact with a
constantly moving exploring elec
trode, at known voltages. The volt
ages were tapped stepwise from a
series of dry cells and applied to an
electrode fixed to an earlobe and an
exploring electrode. Resistance of the
skin of the earlobe was minimized by
means of electrode paste. Area-to
area differences in current flow at a
given voltage. therefore. were due to
differences in the "resistance" of the
skin under the exploring electrode.
a) Explorations with hand-held
electrode.
In our earlier studies we used an in
strument similar to that described by
Japer
1 1
. Current flow was read from
a microammeter as the electrode was
moved over the subject's skin.
b) Automatic explorations.
In later studies two types of auto
matic dermometers were developed9,
10,
With the frst 9, differences in cur
rent flow through the skin were con
verted into variations in the bright
ness of a light over the exploring elec
trode which was propelled over the
skin at a constant speed. A camera re
corded strips of light which varied in
brightness according to the ESR (in
versely as current flow) along strips
of skin.
To eliminate the disadvantages of
photographic recording, however, we
developed a dermometer with which
skin resistance patterns on large areas
of the trunk were recorded directly on
paper by a recording galvanometer
whose amplitude of oscillations is re
lated. through an amplifer, to the
skin current '0. The position of the
galvanometer writing-point on the
chart was related to the position of
the exploring electrode on the subject
by means of a pantograph.
The explorations were conducted in
a quiet room maintained between 23
and 25 C. The body was unclothed
above the level of the sacrum. The
tips of the spinous processes were
identified by palpation and num
bered. In these studies, "segmental"
EMG, SNS, reflexes, etc.
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, close correspondence between
topographical and segmental levels
for paravertebral skin, except at the
uppermost thoracic segments.
c) Interpretation of ESR charts.
In 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 bi) and in photo
graphic records (Figs. 1 -3, S bii) is in
proportion to current flow at explora
tion voltage; the darker the area the
lower the resistance. White areas: I
or less (resistance, in ohms, at least
I million times the number of volts);
black areas: 20 pa 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 biii) 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 pa at exploration voltage; widest
oscillations represent current flows of
30 pa or more, i n these charts ,
therefore, the darkest areas represent
I 30 the basic resistance or less.
Tips of spinous processes and the
sacral base are marked in photo
graphic (light points and lines) and
pantographic charts (short horizontal
lines). In the figures both the photo
graphic and pantographic charts are
spatially related, by superimposition,
to the subject's body.
Rcu|l
ESR explorations were conducted on
more than 1 30 persons presenting
complaints referable to postural and
musculoskeletal disturbances, such as
pain, tenderness, severe and per
sistent backache and limitations in
motion, or in whom anomalies or
other potentially stressful musculo
skeletal problems were discovered.
Such problems and complaints as
gross inequality in leg-length, verte
bral anomalies, injuries to the spine,
pelvis or shoulder, abnormal spinal
curvatures, herniations of interverte-
Fig. I a. Radiograph ofpatient D. C. R., stand
ing (see text, Case I). The white vertical line
appearing in this and succeeding radiographs is
the upward projection ofthe subject 's mid-heel
line". All radiographs, as well as other figures
in this paper, are to be viewed as though the pa
tient were being seen from the back; i.e., left
side is on the reader's left hand side.
Fig. I b. The ESR pattern of patient D. C.R.
shows low resistance areas in the region of the
lumbosacral junction. Recorded with the
photographic method ofESR exploration.
bral discs, spondylolistheses, etc. ,
were included.
Eight are presented to illustrate the
type of information revealed in our
studies.
Case I. Patient D. C. R. , Male, 49
years (Fig. IJ.
Complaint: Severe ache i n low
back, of long standing, beginning in
childhood; often incapacitating. Pa
ti ent compl ai ns of di ffi cul ty i n
"straightening up" after being seated
for prolonged periods and after
stooping over.
Radiographic and physical ex
amination. Antero-posterior X-ray
films of the pelvis and lower lumbar
spine, taken with the patiert. standing
(Fig. 1 a) revealed a) an inequality of
leg length (heights of femur heads),
the right being 5/8 inch (approxi
mately 1 6 mm. ) shorter than the left;
b) a considerable displacement of the
pelvis to the right of the mid-heel line;
c) ti lting of the sacral base-plane
toward the right; d) scoliosis of the
lumbar spine, convex to the right,
with considerable rotation of the
vertebral bodies toward the con
vexity; and e) congenital, unilateral
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 j unc
tion.
Case 2. Patient H. M. , Male, 34 years
(Fig. 2J
Complaint: This man also com
plained of backache and "stiffness"
beginning in childhood and reported
several incidents of painful back in
j ury and strain, due to lifting and
pushing in the course of his work as a
farmer. Although palpatory examina
tion revealed generalized tenderness
over the back, pai n, tenderness and
muscular rigidity were most severe in
the vicinity of the lower lumbar spine
and lumbosacral j unction, particular
ly on the left 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
lumbosacral junction. The discrepan
cy in leg length, the right leg being 3 8
inch (approximately I cm. ) shorter
than the left, seems not to have pro
duced significant tilt of the sacral
base or lumbar scoliosis.
Electrical skin resistance (Fig. 2 b) .
Low-resistance areas were mainly in
the lumbosacral region, predominat
ing on the left side, where symptoms
were most marked.
Case 3 Patient W. P. , Male, 46 years
(Fig. 3).
Complaint: This subject had his
07
F ig. 2 a. Radiograph ofpatient H.M., standing
(see text, Case 2).
F ig. 2 b. The ESR pattern of patient H.M.
shows m ost conspicuous low-resistance areas in
the lum bosacral region, particularly on the left
s
i
de, where symptoms were m ost m arked.
Recorded with photographic m ethod.
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
loskeletal adaptations to the amputa
tion.
Radiographic and physical ex
amination. Accordi ng to relative
heights of his femur heads measured
radiographically in the standing posi
tion, his aFtificial leg (attached to the
mid-thigh stump) was almost one
i nch (approximately 2. 5 cm. ) too
08
short. He had a long mild scoliotic
curve, convex to the left, extending
from the tilted sacrum to a sharp
"breakover" point between the sixth
and seventh thoracic vertebrae. Para
spinal musculature was thickened and
tense on the left side throughout the
length of the scoliosis and one or two
segments above, as compared with
the right side. Deep tenderness was
especially marked on the left side in
the lumbar region and in the mid
thoracic region.
Electrical skin resistance (Fig. 3).
The exploration revealed a virtually
continuous area of low resistance on
the left side, extending from the level
corresponding to the top o the
sacrum to the mid thoracic region.
Case 1. Patient A. W. , Female,
30 years (Fig. 1J.
Complaint: About two weeks prior
to this study the patient had sli pped
on an icy sidewalk and fallen heavily,
the impact being mainly on the left
buttock. In addition to painful bruise
of the coccyx, she complained of per
sistent pain and muscular spasm
along the l umbar spine on the left
side. She had also observed areas of .
exquisite hyperesthesia of the low
back, groin and thigh.
Radiographic examination revealed
nothing significantly related to the
complaint.
Electrical skin resistance. Fig. 4
shows areas of low resistance found
on this patient. They corresponded
very closely 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 vari
ous segmental levels (Richter and
Woodruffl 3 ) , indicate an irritative in
j ury of spinal roots L- l and L-2 on
the left side, as a consequence of the
fall.
Case J. Patient M. S. , Male, 12years
(Fig. J/.
Complaint: This man, a farmer,
was brought to the hospital unable to
bear his weight on the right leg be
cause of severe lumbosacral pain on
the right side, with sciatic radiation.
Onset followed a series of severe
"bumps" while driving a tractor on
F ig. 3. The ESR patter ofpatient W P. shows
a large area of low resistance on the left side,
from the m idthoracic region to the base of the
sacrum . Photographic m ethod (see text, Case
3).
F ig. 4. The ESR pattern of A. W. shows low
resistance areas which correspond closely to the
areas ofhyperesthesia in this patient. Explora
tion with handheld electrode (see text, Case 4).
his farm. Similar attacks, though less
severe, had occurred in previous
months, especially following vigorous
physi
'
cal work and operation of mo
torized farm equipment on which he
was seated. On the basis of symptoms
and physical findings a diagnosis of
EMG, SNS, reflexes, etc.
Fig. 5. The ESR paller ojpalienl M.S. The
areas oj low resislance are shown as black
SpOIS: Ihe areas oj lendernes are indicaled by
X marks. Exploralion wilh hand-held eleclrode
(see lexl. Case 5).
rupture of the intervertebral disc be
tween L-5 and the sacrum, with her
niation on the right side was made.
This diagnosis was confirmed at
surgery.
Electrical skin resistance. The
lower part of the trunk of this patient
was explored with hand-held elec
trode about one hour following
admission to the hospital. The areas
of markedly lowered resistance are
shown as black spots of various sizes
in Fig. 5 . According to the system
described in a previous paper' the
resistance in the areas marked in
black is ' 20 or less that of the back
ground resistance, 10 this case
1 50, 000 ohms or less as
'
compared
with a general resistance of at least
3, 000,000 ohms ( 1 /a of current flow
or less at 3 volts) . The area shown
over the left ilium was intermediate
(about 750,000 ohms) and was shown
in gray on the original chart: the dif-
Fig. 6 a. Radiographs ojpatient I.M., standing (see tet, Case 6).
Fig. 6 b. The ESR palter ojpatient I. M. The areas oj low resitance in the lumbosacral region
developed aJter applying heat to the ventral surJace oj the patient. Recorded with pantographic
method (see text, Case 6).
Fig. 7 a. Radiograph ojpatient G. c, standing (see tet, Case 7).
Fig. 7 b. The ESR palter ojpatient G. c. shows areas ojlow resistance in the lumbosacral and cer
vicodorsal regions which were related to the areas ojmusculoskeletal stres. Pantographic method.
ference in density from the other
areas was, however, lost in photo
graphic reproduction of the chart.
A reas oj tenderness. At our re
quest, the attending physician in
dependently conducted a palpatory
examination of the patient in which
he elicited areas of most severe deep
tenderness by digital pressure and
recorded them on a chart similar to
that used for the ESR patterns. His
chart was then superimposed on ours
and, in the composite chart shown in
Fig. 5, the areas of tenderness are in
dicated by X marks. Vigorous digital
pressure to the areas caused not only
local pain but, in most of the areas,
also radiation and even remote refer
ence of pain similar to that described
by Travell1 4 and others.
Case 6. Patient I. M. , Male, 2years
(Fig. 6).
Complaint: Severe pain over the
lumbosacral area.
Radiographic examination (Fig.
6 a) revealed bone change in the ar
ticulation of L-4 and L-5, including
erosion of the lamina of L-5 on right
side, probably due to pressure of in
ferior articular process of L-4. The
inferior facets of L-4 and L-5 are
frontal, rather than sagittal, in orien
tation.
Electrical skin resistance. The pa
tient' s ESR pattern, obtained with the
pantographic method, is shown in
Fig. 6 b. The apparently facilitated
area shown in the lumbosacral area
was elicited in this subject by apply
ing heat to the body. Though ex
plored in mid-spring (April 30) at
room temperature 25. 6C, the skin of
his back had a uniformly high resis
tance. Electric heating pads were ap
plied to the ventral surface and the
area shown in the figure had ap
peared after 30 minutes. An addition
al 20-minute period of heating pro
duced only slight upward spread of
this area .
Case /. Patient G.C., Male, 2Iyears
(Fig. /).
Complaint: Lumbosacral pai n;
discomfort and restricted motion at
the cervicodorsal junction and occa
sional torticollis.
Radiographic and physical eami
nation. Stress at the lumbrosacral
j unction is evident in the apparent
loss of cartilage and the thickening of
the articular plates between L-5 and
0
J. G.
Fig. 8 a. Radiographs of patient J. G. , standing (see text, Case 8).

L
j'

__ I
..... I

'
Fig. 8 b. The ESR patters of patient J. G. taken over a period of 4 years consistently shqwed areas of low resistance at the lumbosacral, the dorso
lumbar and the cervico-dorsal junctions and in the midthoracic region. The relation of the patterns to clinical findings is discussed in the text. - 8 bi.
November 1949; patter recorded with hand-held electrode. - 8 bii. March 1951; photographic method. - 8 biii. November 1953; pantographic
method.
Fig. 8 c. Electromyographic record of the posterior vertebral muscles during quiet standing, in patient J.G. - The cardiac artifact is evident on each
record, but is easily distinguished from electromyographic activity which was consistently most marked. in this subject. at the upper thoracic levels
(especially on the right side) and at lumbar levels on the left side. Slight or moderate activify, as shown here, was also usually evident at lower thoracic
levels.
Activity of the paravertebral muscles at various segmental levels during standing was sampled in the following manner. Silver surface electrodes were
tightly affixed to the skin at selected sites (resistance lowered with electrode paste) over the spinal extensors. Electrodes were placed at levels
corresponding to the tips of spinous processes of alterate vertebrae T I, T 3, T 5 . . . L 5, on left and right sides. Electrodes were led through a switchbox
to four differential amplifiers (Offner) for recording with pen writers (and for monitoring with cathode ray oscilloscope and loudspeaker).
Two consecutive electrodes on each side T - T3, T3 - T5 . . . L3 - L5) served as electrode pairs, thus sampling activity in the intervening
musculature. Four such areas (electrode pairs) were sampled simultaneously, the switchbox making possible a survey of the entire length of thoracic and
lumbar spine (16 electrode pairs) within 30 seconds. Subjects were asked to stand at rest and relaxed, serial records being taken until activity had subsided
to a minimum.
S- 1 on the left side (Fig. 7 a). Asym
metry with respect to planes of the
articular surfaces (sagittal on the left,
more nearly frontal on the right) be
tween L-4 and L-S and between L-S
and S- 1 may have contributed to the
stress. A lateral ti l t of the cervical
spine to the right is also evident i n the
fil m.
Examination of the patient dis-
closed considerable muscular splint-
ing in the l umbar area, particularly
on the left side, and fixity of the
thoracic spine with some loss of the
normal posterior convexity. The pa
tient' s head was carried in a forward
position. This was associated with
considerable thickening of tissue over .
the cervicodorsal junction and much
muscular tension i n this area.
Electrical skin resistance (Fig. 7 b) .
Pantographic exploration showed
that the areas of low resistance
predominated i n areas of ski n which
are regionally related to areas of
musculoskeletal stress.
t i on; occi pi tal and subocci pi tal
headaches.
Radiographic examination. Mul ti
pl e lateral curves of the spinal column
are evident in Fig. 8 a, possibly
' related to the discrepancy in leg
length, the l eft femur head being ap
proximately one inch ( 2. S em. ) lower
than the right. One scoliotic curve,
convex to the left, involves the entire
lumbar spine. The planes of the ar
ti cular surfaces between L-3 and L-4,
L-4 and L-S , L-S and S- I appear to be
factors in the l umbosacral stresses
contributing to the symptoms in this
area. Another lateral curve, also con-
vex to the left, involves the lower half
of the thoracic spine, wi th relatively
sharp angulations at the extremes of
the curve, T- 1 2-L- l and T-S-T-6.
The cervical spine (not shown) leaned
considerably to the l eft, there also be
ing a lateral curvature, convex to the
right, and a sharp i nflection at the
cervicodorsal j unction. This patient
carried his head well over the l eft
Case d. Patient J.G. , Male, 2J years
(Fig. dJ.
shoulder, with considerable tension in
the posterior cervical musculature on
the right side.
Complaint: Pain in low back; pain
and sti ffness at cervicodorsal j unc-
70
Electrical skin resistance. The ma
jor areas of l ow resistance (Fig. 8 b)
L H
Fig. 8 c
.....
1 00".
J G 3 IS SI
!' ."d, ,
EMG, SNS, reflexes, etc.
appeared over a period of several
years (November, 1 949 -November,
1 953) to be consistently associated
with the regions of sharpest angula
tion of the vertebral column: the
vicinity of the lumbosacral j unction,
the dorsolumbar junction, the mid
thoracic region and at the cervicodor
sal junction.
Electromyographic observations .
An electromyographic sampling of
the activity of the posterior vertebral
muscles during quiet standing (Fig.
8 c) indicated that considerable ac
tivity of the spinal extensors, much
stronger on one side than the other,
was required in these same regions for
the maintenance of the erect posture
in this patient. Thus, there was con
spicuous activity of the lumbar mus
culature, extending somewhat to the
lower thoracic levels, on the convex
(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 neck. (Activity of the cervical
musculature was not sampled.)
This electromyographic study was
part of a series done on a large
number of subjects, many of them
observed repeatedly over long periods
of time (Kor and Thomas
I
S. Wright
- unpublished observationsI 6). As
has been shown by Floyd and Silveri
1
,
Portnoy and Morin 1 8, Joseph and Mc
Coli, 19. 2 and others, we too found
that some subjects were able to
achieve a standing posture in which
there was very little activity of the
posterior vertebral muscles. How
ever, in our experience, some degree
of localized, often asymmetrical ,
activity was found in every subject.
The patterns of such activity -
location, extent, relative amount,
etc. , varied from subject to subject,
according to body build, posture,
weight distribution, spinl and pelvic
configuration and other, unidentified
factors. As we have found to be
true for sudomotor and vasomotor
activity I. 2 the patterns are remark
ably constant and characteristic for
each subject.
Ucuon
In the preceding report from this
series of investigations!, we showed
that we were able to modify the ESR
patterns of human subjects by experi
mentally induced i rritations and
stresses in the musculoskeletal tissues.
I ntramuscular inj ection of small
quantities of hypertonic saline, for
example, caused the appearance of
new areas of low ESR in those indivi
duals in whom referred pain was in
duced, the new areas of low resistance
appearing in the reference zone. Pos
tural stresses caused exaggeration of
existing patterns of low-resistance
areas (further lowering of resistance
and spreading of areas) and the ap
pearance of new areas of low resis
tance according to the nature and lo
cation of the applied stress, the in
dividual ' s vertebral adaptation to the
stress and the areas of discomfort. On
the basis of studies by Tlomas and
others in our laboratories previously
cited3-, the induced changes in ESR
(and accompanying vasomotor
changes) would seem to represent
sympathetic responses to the ex
perimental musculoskeletal insults.
In discussing our findings in the
foregoing paper, we proposed that
the sympathetic changes were not
anomalous reflexes, invoked de novo
by the noxious myofascial stimula
tion, but that they were modifications
of normally operating patterns of
somato-autonomic coordination. Ex
amples of these patterns are those of
centrally ordered adjustment of vis
ceral, cardiovascular and thermoreg
ulatory functions which continually
take place according to changing
muscular activity, heat production of
muscular work 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 activity is also under the contin
ual influence of afferent impulses
arising in peripheral receptors and
nerve endings, conveyed over dorsal
root fibers. 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 ESR patterns) to the experi
mental myofascial insults reported in
the preceding paper were exaggerated
versions of the local components.
The studies reported in this paper
on subjects with musculoskeletal
stresses and irritations of traumatic,
congenital, postural or pathological
origin revealed similar regional exag-
gerations of sympathetic activity. Al
though the changes produced in the
affected musculoskeletal tissues in a
few minutes or even 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 likely
that the neural and refex mechanisms
are fundamentally the same. As we
stated in the previous paper' , we
believe that the altered patterns of
sympathetic activity (as well as associ
ated alterations in muscular activity)
are either refex manifestations of
changes in sensory input arising in
nerve endings and receptors in the
musculoskeletal tissues or the effects
of direct insults to nerve fibers (or
ganglion cells) or a combination of
both.
Nevertheless, the question arises as
to how the processes that are involved
are modified with time. Our experi
mental studies certainly indicate that
the altered sudomotor and vasomotor
activities 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
nerve fibers. But one wonders
whether the same mechanisms would
continue to operate in essentially the
same way for periods of weeks to
years. Clinical and pathological evi
dence indicates that in the face of
chronic stress or irriation and of sus
tained reflex activity, adaptive
changes would take place either in the
stressed or irritated tissue (e.g. ,
fibrosis of muscle), in the participat
ing neurons (e.g. , altered excitability),
in the responding organs or tissues
(e.g., altered contractility of blood
vessels, altered secretory activity of
sweat glands) or in combinations
thereof.
In studies to be reported more fully
in a subsequent publication3,2I.22 we
investigated the functional alterations
in the apparently aberrant segments
by comparing the simultaneous re
sponses of these areas with those of
apparently normal adjacent or corre
sponding contralateral areas to such
generalized stimuli as ateration in en
vironmental temperature, change in
posture from recumbent to standing,
pain, threat of pain, startling, etc. We
7I
found that the segments represented
by aberrant dermatomes (with respect
to sudomotor and vasomotor activi
ty) are profoundly altered functional
ly. The responses of these segments to
thermoregulatory, postural or emo
tional demand were, relative to the
adjacent or contralateral control
segments, so altered quantitatively, in
terms of threshold, latency, magni
tude and duration of response, as to
be inappropriate to the demand. The
direction of the alteration in the
segments represented by low-resis
tance areas have been consistently in
such a direction as to indicate facilita
tion of the sympathetic pathways to
the skin. Whether this reflects an
alteration i n those neurons
themselves or sustained afferent (or
pre-ganglionic) bombardment has not
been determined. The recent studies
of Thoma and Kawahata' clearly in
dicate that in our subjects the altered
sudomotor responses in the low
resistance areas were due to changes
in impulse traffc in the sudomotor
pathways rather than in the sweat
glands themselves. Whether changes
in the sweat glands would eventually
occur in such situations has not yet
been determined, although the occa
sional finding of extremely high
resistance, nearly anhidrotic, areas,
similar in size, shape and distribution
to low-resistance areas reported in
these studies, suggests that such
changes may occur.
The reader is referred to our pre
ceding paper' on experimental insults
and stresses for a more detailed dis
cussion of the theoretical and clinical
implications of the segmentally and
regionally pattered autonomic con
comitants of myofascial stresses and
abnormalities, and of the relevant
work of other investigators. The pres
ent study confrms that local changes
in sympathetic function may be not
only acutely and temporarily induced
by relatively brief experimental re
sults, but that enduring changes in
patterns of sympathetic activity may
become associated with musculoskel
etal disturbances of clinical origin.
This study also strengthens our sug
gestion that the patterns of aberrant
areas of sudomotor and vasomotor
activity previously described in ap
parently healthy subj ectst 2 may
refect subclinical and asymptomatic
disturbances of afferent bombard
ment, over selected dorsal roots, or of
72
direct irritation of nerve fibers or
ganglion cells. The patterns associ
ated with visceral disturbances as
such sources of afferent bombard
ment and neural irritation will be
presented in the succeeding paper.
Summar
1 . These studies on 1 30 patients
have been concerned with topograph
ical patterns of sudomotor activity
associated with known musculoskel
etal disturbances, myofascial stresses
and pain syndromes.
2. The method employed for
measuring sudomotor activity, as an
indicator of regional variations in
sympathetic activity, was tnat of
recording the electrical resistance of
the skin (ESR). Radiographic, elec
tromyographic and palpatory ex
aminations, as well as other conven
tional clinical methods, were used in
the evaluation of the musculoskeletal
disturbances.
3. The observations frequently
showed the presence of regional and
segmental patterns of low electrical
skin resistance (LRA) in areas of re
ferred pain and dermatomes segmen
tally related to the musculoskeletal
disturbances or myofascial stresses.
4. These paterns of altered electri
cal skin resistance appear to reflect
enduring changes in the patterns of
sympathetic activity associated with
. musculoskeletal disturbances of
clinical origin.
5. These studies suggest that the
patterns of aberrant areas of sudo
motor and vasomotor activity, which
we have previously described in ap
parently normal subjects, may refect
subclinical and asymptomatic sources
of afferent bombardment, over
selected dorsal roots, or of direct ir
ritation of nerve fibers or ganglion
cells. That is, the altered patterns of
sympathetic activity appear to be
either reflex manifestations of
changes in sensory input arising in
nerve endings and receptors in the
musculoskeletal tissues or the effects
of direct insults to nervt fibers (or
ganglion cells) or a combination of
both.
References
I . Korr, I. M., P.E. Thomas and H.M. Wright, Pat
terns of electrical skin resistance in man. Acta
neuroveget .. Wien. 17 ( 1 958). 77-96.
2. Wright. H.M., I.M. Korr and P.E. Thoma,
Local and regional variations in cutaneous vasomotor
tone of the human trunk. Acta neuroveget . , Wein. 22
(1 9). 33-52.
3. Thoma, P. E .. and I.M. Korr, The relationship
between sweat gland activity and electrical resistance
of the skin. J. Appl. Physiol. , Wash. , /0 ( 1 957,
505-510.
4. Kawahata. A . and P.E. Thomas. Further studies
on the neural basis for regional differences in ESR.
Fed. Proc. /8 ( 1959). 80.
S. Thomas. P.E . and A. Kawhata. Neural factors
underlying variations in electrical skin resistance of
apparently non-sweating skin. J. Appl. Physiol..
Wash. , 19. 1 7.
6. Korr. I. M . Experimental alterations in segmental
sympathetic (sweat gland) activity through myofascial
and postural disturbances. Fed. Proc. 8 (1949), 88.
7. KOI, I. M., Skin resistance patlerns associated
with visceral disease. Fed. Proc. 8 ( 1 949). 87.
8. Korr. IM., H.M. Wright and P.E. Thoma Ef
fects of experimental myofascial insults on cutaneous
patlerns of sympathetic activity i n man. Acta
neuroveget . Wien, 23 ( 1 926). 329-355.
9. Thomas, P.E., and I.M. KOI, The automatic
recording of electrical skin resistance patterns on the
human trunk. Electroencephalogr. 3 ( l 951 ) ,
361-368.
10. Thomas. P. E., I. M. Korr and H.M. Wright. A
mobile instrument for recording electrical skin
resistance patterns of the human trunk. Acta
neuroveget . Wein. 17 ( 1 958). 97-10.
I I . Jasper, H., An improved clinical dermometer.
J. Neurosurg . Springfield. 2 ( 1 945), 257-26.
12. Denslow. J.S., J.A. Chace, O.R. Gutensohn
and M. G. Kumm, Methods in taking and interpreting
weight-baring X-ray films. J. Amer. Osteopath. Ass.
54 ( 1 955), 63-670.
1 3. Richter, C. P., and B. O. Woodruff Lumbar
sympathetic dermatomes in man determined by the
electrical skin resistance method. J. Neurophysio!..
Springfield. 8 (1945), 323-338.
14. Travel/, J., Pain mechanisms in connetive
tissues in C. Ragan. Ed. Second Conference on Con
nective Tissues. Josiah Macy Jr. Foundation ( 1 952),
86-125.
15. Korr, I. M., and P.E. Thoma. Segmental pat
terns in man. Fed. Proc. 10 ( 1 951 ), 75.
16. Wright, H. M . Unpublished observations.
17. Floy, W.F, and P. H.S. Silver, The functions
of the erectores spinae muscles in certain movements
and postures in man. J. Physiol. 129 ( 1955). 1 84-203.
1 8. Portnoy. H., and F. Morin. Electromyographic
study of postural muscles in various positions and
movements. Amer. J. Physio!. 186 ( 1 956), 122-126.
19. Joseph. J., Man's posture; electromyographic
studies. p. 1-88, Thomas, Springfield. 196.
2. Joeph J., and I. McColl, Electromyography of
muscles of posture: posterior vertebral muscles in
males. J. Physio!. 157 ( 1 961 ), 33-37.
21. Thoma, P.E., H.M. Wriht and C. W. Hart,
jr.. Relation of sweat gland reruitment to ESR. Fe.
Proc. 12 ( I 953), 143.
22. Korr, I.M., P.E. Thoma and H.M. Wriht.
Symposium on the functional implication of segmen
tal facilitation. J . Amer. Osteopath. Ass. 54 ( 1 955).
265-282.
Reprinted by permission from 10urnal of Neural
Transmission 25: 589-6, 196.
EMG, SNS, reflexes, etc.

P0ul0l 0nd Sln0l Comon0nlS o dlS00S0
Vrogl0SS ln lh0 0pllC0llon o
' lh0lmogl0hy` (195)
H. M. WRI GHT and I . M. KORR
The participation of the peripheral
nerves and the spinal cord in various
clinical syndromes has been recog
nized in clinical practice for many
years. Among the most familiar ob
servations of the neural and reflex
components of disease are those on
referred pai n, but many observers
have also described the other patho
physiologic changes that often occur
i n the tissues of the "reference
zones. " These changes include ten
derness, changes in the blood flow
and/or blood content of the ski n,
sweating, muscle contraction, various
trophic changes, and others. Similar
patterns of manifestations, often
simulating those of visceral origi n,
may be associated with painful mus
culoskeletal disturbances or myo
fascial irritations.
Last September, a 5-year study was
i ni tiated at KeOS, of measurements
of physiologic activities and re
sponses in intact human subjects that
reflect segmental and regional varia
tions in activity of peripheral senory,
motor, and sympathetic neurons of
the spinal cord. I n this project, both
normal (preclinical) subjects and
clinical patients with various somatic
and visceral disturbances are being in
vestigated.
The observations, most of which
are being made on the dorsal trunk,
incl ude t he manifestations mentioned
previously, that is, pai n, changes in
vasomotion and sweating, and muscle
activity. Structural , palpatory, and
radiographic examinations are used
in the identification and evaluation of
vertebral anomalies, areas of stress or
lesion, abnormal curvatures, and
various musculoskeletal disturbances.
In individuals wi th visceral disease,
the usual diagnostic tests are done.
Finally, the relations between the
findings on the trunk and the clinical
signs, symptoms, and pathologic
Supported by lhe A. T. Slill OSleopal hic Foundalion
and Research Inslilule; Bureau of Research of lhe
American OSleopalhic Associalion (T-ZO); and
General Research SUppOrl Gram ( I SOI FR 054390)
of lhe Nal ional Inslilules of Heahh.
findings, i n both somatic and visceral
syndromes, will be examined i n each
individual . Some of our patients, as
well as most of our "normal" sub
jects, are drawn from the Student
Health Service of the college. Dr.
Ira Rumney, director of the Student
Health Program, and members of his
division, are responsible for the
cli nical aspects of this project.
This preliminary report deals wi th
only one phase of this project:
cutaneous vasomotor acti vity. We are
using the new technique of "ther
mography" as one method of study
ing the skin temperature as it is
related to cutaneous vasomotor ac
tivity. I n princi pl e, this recently
developed instrument (Fig. I) called a
"thermograph" * generates thermal
photographic images of the body by
measuring the i nfrared energy emit
ted by the ski n.
Briefly stated, the i nfrared energy
emitted by the ski n falls on a scanning
mirror and is then focused on a sen
sitive thermistor heat detector. After
the i nfrared radiation has been con
verted by the thermistor to an elec
trical signal, and the signal has been
amplified and processed, the propor
tional output is used to control the i n
tensity of a glow modul ator tube
which emits visi ble light, and this
light is focused on the film of a
Polaroid camera. The maximum scan
ti me is 4 minutes and, depending on
the size of the area to be scanned,
may be only 1 minute or less. Thus, a
perfectl y regi stered , quant i tati ve
record of the i nfrared emission from
the object is obtained directly from
the density of the photographic fi l m;
that i s, t he hotter t he object, the
whiter its image.
A hand-held i nfrared thermometer
(not visible in Figure 1) is used to
determine the temperature range or
delta T ( 6T) of the area to be ther
mographed. Knowing the 6T of the
area, the sensitivity of the ther
mograph can be set . For example, to
' Barnes Engineering Company, Slamford, Connee
lieu!.
Fig. I . The thermograph instrument and scan
ning mirror. Not shown in this picture is a
hand-held infrared thermometer which is used
in determining the temperature range of the
area to be studied by thermography. or the
photo comparator which is used to measure the
optical density of the thermograms.
change the film from white to black
at a 6T of 1 0 requires a lower sensi
tivity than if the 6T is 2 . The greater
the sensitivity setti ng, the greater the
contrast in the picture. A "bright
ness" control on the instrument sets
the low temperature point in the
temperature di fferential selected by
the sensitivity.
I n the first phase of this program,
two or more thermograms on the
back have been recorded on each of
the 1 02 members of the first-year
class at KeOS. Figures 2 to 5 show
the thermograms recorded on four of
these students. In each case, the in
dividual is lying face down on a heat
pad (which gives a white background
for the picture. The temperature of
the heat pad is approximately 1 00
F. ) . In the thermograms, the warm
areas appear whi te and the cool areas
black, with i ntermediate tempera
tures in varying shades of gray. The
"thermal gray scal e, " seen to the left
of the subjects, is a calibration device
whereby one can compare the optical
density of any point on the ther
mogram with the optical density pro
duced by known temperatures. Thus,
the various shades of gray of the ther
mogram can be converted to
temperature if that is desired.
The thermograms of the four in
dividuals shown in Figures 2 to 5
show that the topographic distribu
tion of warm and cool areas on the
back varies with di fferent individuals,
and at di fferent levels on the trunk in
a given individual. Of the 1 02 individ
uals in the first-year class of KeOS,
7J
74
Fig. 2 (far left). Thermogram of subject B. B. Observe the large warm (while) area that covers most of the thoracic region and the
warm "band" in the lumbar area and also below the sacrum. The black dots are markers placed on the spines ofT. T6. and T2; the
top of the sacrum is also marked. The sides of the body are cool (black). The individual is lying on a heat pad which appears white at
the sides ofthe body. The thermal gray scale is seen at the left ofthe subject. Fig. 3 (left to center). Thermogram ofsubject R. B. The
temperature patter ofthis individual is quite different from the individual in Figure I. Note the long "cold" streak down the midline
ofthe back. etending from T to 7. and the asymmetrical lumbar area. Fig. 4 (right ofcenter). Thermogram ofsubject K H The
distribution of warm and cool areas in this individual is diferent from that of the subjects in Figures 1 and 2. The asymmetrical
lumbar area is also ofinterest. Fig. 5. (right). Thermogram ofsubject S.B. Note the large cold area in the neck and the large warm
triangular lumbar area of this individual.
Fig. 6. Two thermograms on subject J. G. The one on the left was
taken on Nov. 5. 1964. and the one 01 the right 01 Jail. 22. 1965.
The two thermograms appear almost identical.
Fig. 7 (left). Two thermograms ofsubject S. B. The one 01 the left was taken Sept. 23. 1964. and the one on the right. Jan. 27. 1965.
The warm triangular lumbar area appears smaller in the later thermogram. Fig. 8 (right). Two thermograms ofsubject B. B. The one
on the left was taken on September 30. 1964. and the one on the right. on Jan. 5. 1965. Note the change in the lumbar area in the later
picture.
EMG, SNS, refexes, etc.
no two individuals had thermograms
exactly alike, although most in
dividuals had certain features in com
mon.
We have also frequently observed
that in some individuals the temper
ature patterns were "asymmetrical"
or differed between the right and left
sides at certain levels on the trunk. To
ascertain if these temperature pat
terns - and especially the asym
metrical or "aberrant" areas - re
main stable or vary from day to day
or month to month, we took more
thermograms of selected individuals
again after several weeks or months.
Figures 6, 7, and 8 show twe ther
mograms on each of three different
individuals taken on different dates.
In each case an interval of several
weeks intervened between the two
thermograms. It may be observed
that most features of the temperature
patterns remained remarkably cons
tant, although certain "features" in
the thermogram may change with
time, therapy, or other factors.
As previously mentioned, we found
that most thermograms had certain
temperature "features" in common.
For example, in most individuals the
sides of the body are cool, the lumbar
area - especially over the spinous
processes - is very warm, the neck is
warm, and so forth. In order that we
might better interpret the thermo
grams, and particularly the temper
ature patterns over the paravertebral
areas, we did a quantitative analysis
of the thermograms of 30 subjects at
each segmental level from the neck to
the sacrum. This was done with a
photocomparator especially made for
this purpose which measures the op
tical density of any point on the ther
mogram. The optical density - or
percentage of opacity - can be con
verted to temperature, i f that is
desired, by comparing the optical
density to actual temperatures on the
cal i brati on or "gray scal e . "
Measurements were made over the
spinous processes (except at Tl , T6,
Tl 2, and Sl ) and at distances of 2 and
4 mm. lateral to the midline on the
thermograms - which corresponds
roughly to 2 and 4 inches lateral to
the midline on the back.
We found that in the "average" in
dividual, the neck is quite warm both
in the midline and laterally; the
temperatures throughout the thoracic
area show only small differences but
with a slight tendency to be warmer in
the midthoracic area than at the
cervico-dorsal area and thoracolum
bar junction. Temperatures are very
warm in the lumbar area over the
midline, but decline as one passes
laterally from the midline.
Questions immediately arise con
cerning the mechanisms of the warm
and cold areas and their physiologic
significance. Are the warm areas
related to greater cutaneous blood
flow? less evaporation from the skin?
the activity of underlying muscles?
Are the cold areas related to vasocon
striction? to areas of sweating? or
other factors?
In an attempt to ascertain the
answers to some of these questions,
we are now engaged in the second
phase of this program: that is, to
determine the functional differences
between the warm and cold areas, to
ascertain how these areas are related
to differences in cutaneous blood
flow, blood content, vascular reac
tivity, sweat gland activity, muscle ac
tivity, and so forth. Also, we wish to
ascertain how these areas function
under stress and participate in reflex
responses. Other methods previously
descri\ed in our early work are being
used for this purpose. Finally, we
wish to know what relationship the
asymmetrical or aberrant temper
ature patterns bear to somatic or
visceral lesions. The structural and
palpatory examinations, structural
x-rays, and other diagnostic data on
the members of our first-year class
are now in the process of being
analyzed, with the assistance of Dr.
Rumney, for this purpose.
Reprinted by permission from JAOA 6: 918-921 .
1965.
Introductory note:
What is manipulative
therapy? (1978)
One of the unusual features of the
Workshop was that few of the neuro
scientists who convened to contribute
their knowledge had had any prior
contact with the area of medicine to
which they were to make their con
tributions. Most of them arrived still
uncertain of the relevance of their
research, done for quite different
purposes, to the subject of the
Workshop. Because the Workshop
setting was that of a forum rather
than a clinic, they departed with a
better perception of relevance, yet
without a clear image of how manip
ulative therapy is performed or of its
clinical value.
It seems likely that many readers,
more interested in the nervous system
than in manual medicine, will find
themselves with similar uncertainties
about the latter. To them, we recom
mend, as we did to the participants,
the proceedings of an earlier work
shop sponsored by the National In
stitute of Neurological and Com
municative Disorders and Stroke,
and offer the following paragraphs.
Manipulative therapy involves the
application of accurately determined
and specifically directed manual
forces to the body. Its objective is to
improve mobility in areas that are
restricted, whether the restrictions are
within joints, in connective tissues or
in skeletal muscles. The consequences
may be the improvement of posture
and locomotion, the relief of pain
and discomfort, the improvement of
function elsewhere in the body and
enhancement of the sense of well
being.
Diagnosis, leading to the selection
of body sites for manipulation and
the mode of manipulation, is based
on analysis of the patient's history
and complaints and on the evaluation
of signs provided by palpation (tissue
texture, muscular and fascial tension,
joint motion and compliance, skin
temperature and moisture), by visual
observation (body contour, posture,
locomotion, skin color), and by
*NINCDS Monograph No. IS. The Researh Status
of Spinal Manipulative Therapy, edited by M. Gold
stein, Bethesda, Maryland, 1 976.
75
radiographic and other instrumental
means.
Manipulative procedures, even in
the hands of the same practitioner,
vary according to the findings and
their changes in each visit; they vary
from practitioner to practitioner,
from patient to patient, and, for the
same patient, from visit to visit.
Manipulative therapy is no more a
uniform therapeutic entity than is
surgery, psychiatry or pharmaco
therapeutics. Clinical effects are
thought to be achieved through im
provement in musculoskeletal bio
mechanics, in dynamics of the body
fuilds (including blood circulation
and lymphatic drainage) and in ner
vous function. It is on the last that
this Workshop was focused. Its con
cern, therefore, was with neither the
clinical efficacy of manipulation nor
its evaluation, but with its neural and
neuronal mediation.
What are the neurobiologic
mechanisms?
It has been clear for many decades
that the nervous system is a major
mediator of the clinical effects of
manipulative therapy, yet the precise
mechanisms are still, for the most
part, obscure. In view of the burgeon
ing of the neurosciencs in recent
years, it seemed timely to convene a
research workshop to examine to
what extent that great mass of new
knowledge might illuminate the
neurobiologic mechanisms at work in
manipulative therapy, while at the
same time to discern new and funda
mental areas in the neurosciences for
exploration.
The objectives of the Workshop on
which this volume is based were:
1 . To identify new fundamental
questions in neurobiology which
emerge from clinical observa
tions in the practice of manip
ulative therapy. .
2. To seek answers in research al
ready accomplished.
3. To identify and project needed
lines of research.
The design of the Workshop was
based on the following assumptions
and hypotheses. It seemed to the
planners of the Workshop that the
musculoskeletal problems to which
manipulative therapy is addressed
initiate their impairment of normal
physiological processes in two
primary ways:
7
1 . Alterations in sensory input
from the muscles, tendons,
bones, joints, ligaments and
other tissues which are involved
in the musculoskeletal aberra
tion.
2. Direct insult to neurons, nerves
and roots, and associated glial,
connective-tissue and vascular
structures.
According to our hypotheses, both
the changes in afferent input and the
trauma-induced changes in excitation
and conduction of neural elements
produce. in turn, changes in the cen
tral nervous system and in the
periphery, refected in aberrant sen
sory, motor and autonomic' func
tions. We chose to give emphasis to
the impact on autonomic function
and, therefore, to somato-autonomic
interrelations.
The changes in afferent input (and
the resultant changes in efferent out
put) and the nerve-trauma both af
fect, also, neuronal functions which
are not based on excitation and con
duction of impulses, much as they
may be affected by impulses. These
functions are subsumed under such
rubriCs as axonal transport, trans
synaptic influences, trophic function,
neurotrophic relations, neuron
target-cell interactions, etc. Hence,
the Workshop was organized around
two maj or themes, impulse-based and
nonimpulse-based mechanisms, in
troduced by the Fragestellung implicit
in reports by clinicians skilled in
manipulative therapy as taught and
practiced in three different profes
sions.
It became clear in the course of
discussions, not only between clini
cians and scientists but between two
groups of neuroscientists, that there
is no clean separation between
impulse-based and nonimpulse-based
mechanisms. Each is involved in and
infuenced by the other, and distur
bances in each potentially contribute
to dysfunction elsewhere and are sub
ject to manipulative amelioration. If
barriers existed, they were i n minds
and methods, and not in the biolog
ical system; proving again that con
ceptual barriers, until identifed and
assulted, are often much less perme
able than cellular barriers. Perhaps
one byproduct of the Workshop,
therefore, was a somewhat more
coherent and unifed view of nervous
function and plasticity, incorporating
both reflexes and neurotrophicity,
both the instantaneous and the long
term phenomena.
An important feature in the design
of the Workshop was the dialogue
between clinician and scientist. The
clinicians were chosen not only for
their clinical proficiency in the ap
plication of manipulative therapy,
but for their concern, expressed in
publications, about mechanism. The
neuroscientists were selected not only
for the quality and importance of
their research, but for the relevance
of their work, as perceived by the
planners, to manipulative therapy
and to the problems with which it
deals. While no maj or answers have
as yet emerged, the way has been
opened for the formulation of new,
approachable questions and testable
hypotheses.
Reprinted by permission from I. M. Korr, Editor,
Neurobiologic Mechanisms in Manipulative Therapy.
Plenum Publishing Corpration, New York. 1 978. Pp.
IS-17.
EMG, SNS, reflexes, etc.
Sustained sympathicotonia as a factor
in disease (1978) .
There is a large though scattered body
of clinical and experimental literature
that gives the distinct impression of a
significant, often critical sympathetic
component as a common feature in a
large variety of syndromes. Chronic
hyperactivity of the innervating sym
pathetic pathways seems to be a
prevailing theme in many clinical con
ditions, involving many organs and
tissues. Whatever the etiological or
therapeutic implications, it appears
that this widely shared feature of
local, regional or segmental sym
pathetic hyperactivity is overlooked
or dismissed because of the barriers
erected by specialization. Thus, the
ophthalmologist is not ordinarily ex
posed to the gastroenterological
literature, the gastroenterologist to
the cardiological, the cardiologist to
t he gynecol ogi cal , et c. Each
discoverer of a sympathetic compo
nent seems, therefore, to regard it as
peculiar to this or that disease within
his or her area of specialization,
rather than as part of a general
theme.
My l ong- t i me expos ur e t o
osteopathic theory and practice and
my research experience in related
fields have led me to the following
hypotheses:
( 1 ) Long-term hyperactivity of
par t i cul ar s ympat het i c
pathways i s deleterious t o the
target tissues and may indeed
have a rather general clinical
significance.
.
(2) Clinical 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 sympa
thetically induced vasocon
striction that may be a com
mon factor.
(3) The ',bih impulse traffic in
selected sympathetic pathways
may be related to musculo
skeletal dysfunction, especially
in the spinal and paraspinai
area.
It is the purpose of this paper to
review the support for these
hypotheses in available knowledge of
the autonomic nervous system, in ex
perimental findings, including our
own, and in clinical literature.
The sympathetic role in musculo
skeletal activity
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, 1 954),
that of adjusting circulatory, meta
bolic and visceral activity accord
ing to postural and musculoskeletal
demand. These adjustments include
changes in cardiac output, in distribu
tion of blood flow by regulation of
peripheral resistance, in heat dissipa
tion through the skin, and release of
stored metabolit es. These ad
j ustments are of systemic nature, yet
they have a high degree of localiza
tion according to the site and the
amount of muscular activity. (It i s
understood of course that autoregula
tion is also important and often the
dominant factor in these ad
justments.)
In order for the SNS to perform
this role, it must receive, directly
( t hr ough s egment al affer ent
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
1 940's, 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 was
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 physiological
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, low-grade sweat-gland ac
tivity (reflected in low electrical skin
resistance, hence "low-resistance
areas, " LR) and of high vasomotor
tone (Wright, Korr & Thomas, 1 953;
Thomas & Korr, 1 957; Thomas, Korr
& Wr i ght , 1 95 8 ; Thomas &
Kawahata, 1962).
(2) The segmental patterns of
distribution of these aberrant areas
varied from subject to subjet, but
were highly constant and reproduc
ible for each subject over periods of
months. This is not to say that the ac
tual shapes and sizes of the aberrant
areas were invariable; they were areas
in which, at any given time, the prob
ability was very high, as compared
with all other areas, that we would
find high sudomotor and vasomotor
activity. They were areas, for exam
ple, in which in the course of cooling
the warm, lightly perspiring subject,
the sweat-gland activity persisted long
after it had subsided in other ares,
and were the first to respond with in
creased activity as the subject was
warmed (Korr, Thomas & Wright,
1958; Wright, Korr & Thomas, 1 960).
(3) These areas of sympathetic
hyperactivity correlated well, in
segmental distribution, with existing
musculoskeletal strain. trauma, deep
and superficial tenderness, elec
tromyographic activity of paraspinal
muscles, etc. New areas could be in
duced experimentally with postural
and myofascial insult which were
related regionally or segmentally to
the site of insult (Korr, Wright &
Thomas, 1 962; Korr, Wright &
Chace, 1 964).
(4) Similar signs of sympathetic
hyperactivity were found to be
associated with visceral pathology,
apparently in areas of referred pain
and tenderness, segmentally related
to the visceral pathology. In a few
subjects studied over long periods of
time, the aberrant areas appeared in
advance of the frst symptoms of
visceral disease (Korr, 1 949).
(5) The sympathetically hyperactive
areas of skin functioned differently
from the normal areas. Thus, the
sudomotor responses of the low
resistance areas to a variety of factors
77
were grossly exaggerated. This was
demonstrated in a group of subjects
who had asymmetrical patterns, that
is, in whom we had found low elec
trical skin resistance on one side at a
given segmental level, while the con
tralateral area was normal.
As previously shown (Thomas &
Korr, 1 957; Thomas & Kawahata,
1 962), we found that in a low
resistance area, there was con
spicuous sweat-gland activity under
cool, resting conditions when, as
shown by most areas of the trunk (in
cluding the contralateral area), there
was no evidence of thermoregulatory
demand for sweat secretion. That
same low-resistance area also made
exaggerated sudomotor responses
(earlier and more rapid recruitment
of sweat glands and more copious
secretion) to generalized stimuli (e.g. ,
heating other parts of the body),
painful stimuli, threat of pain and
other emotional stimuli. These areas
seemed to be continually in, or verg
ing on, a "cold sweat" (Korr,
Thomas & Wright, 1 955).
On the basis of these fndings and
other considerations, we concluded
that peripheral sympathetic pathways
at segmental levels corresponding to
somatic dysfunction in and around
the spinal column are jn a state of
chronic facilitation similar to that
shown by Denslow and his co
workers for neuromuscular activity
(Denslow & Hassett, 1 942; Denslow.
1 944; Denslow, Korr & Krems, 1 947).
Persistent local, regional or der
matomal elevation in sympathetic ac
tivity and predisposition to high ac
tivity appear to be related to spinal
and paras pinal motor dysfunction as
disclosed by osteopathic palpatory
diagnosis. In general, the concept of
chronic segmental facilitation has
been found to be consistent with
observations in osteopathic practice,
and helpful in their rationalization.
The concept has recently been re
viewed in a broader context (Korr,
1 976) and re-examined in terms of
conditioning, habituation and sen
sitization in spinal reflex pathways
(Patterson, 1 976).
1hc nflucncc8 of8)mpalhclc
nncralon
What is the clinical significance of
chronic facilitation and hyperactivity
of sympathetic innervation on
various tissues and organs? Let us
T8
review first the physiological in
fluence of sympathetic innervation.
This is a great deal more varied than
can be ascribed to the regulation
merely of exocrine secretion and of
contraction in smooth and cardiac
muscle and the metabolic energizing
of these activities, as is widely taught.
The literature, some of it quite old
and long ignored, indicates a much
larger repertoire, as illustrated by the
following examples.
1. Skeletal muscle.
The sympathetic innervation of
skeletal muscle appears to have a
direct augmentor effect on the
energetics of skeletal muscle, pssibly
similar to the inotropic effect on car
diac muscle ("Orbeli phenomenon";
see Bach, 1 953; Kelly & Bach, 1 959).
It al so appears to faci l itate
neuromuscular transmission (Hutter
& Loewenstein, 1 955; Naseldov,
1 960) . Sympathetic innervation is
also involved in the development of
contractures following trauma to the
spinal cord (Galitaskaya, 1 965).
2. Peripheral sensory mechanisms.
Several types of receptors and sense
organs have been shown to be in
fluenced by sympathetic impulses. In
general, the effect of repetitive sym
pathetic stimulation is facilitatory,
that of increasing the frequency of af
ferent discharge and lowering the
threshold. In some cases, threshold
may be reduced to zero, causing af
ferent discharge without direct
stimulation of the receptor. In short,
the effect of increased impulse traffic
in the sympathetic fibers innervating
receptors is that of exaggerating their
discharge, causing them to report a
greater intensity of stimulation than
is actually occurring. The sensory
mechanisms in which sympathetic in
fluence has been demonstrated in
clude: (a) muscle spindle (Hunt, 1960;
Eldred, Schnitzlein & Buchwald,
1 960); (b) tactile receptors (Chernet
ski , 1 964a); (c) taste receptors
(Chernetski, 1 964a); (d) olfactory ap
paratus (Tucker & Beidler, 1 955); (3)
carotid sinus chemo- and barorecep
tors (Koizumi & Sato, 1 969; Mills &
Sampson, 1 969; Sampson & Mills,
1 970; McCloskey, 1 975); (f Pacinian
cor pus cl es ( Loewens t ei n &
Altamirano-Orrego, 1 956); (g) retina
(Mascetti, Marzi & Berlucchi, 1 969);
and (h) cochlea (Vasil'ev, 1 962).
J. Central nervous system.
Following the demonstration by Bon
vallet, Dell and Heibel (1 954) of
adrenergic elements in the reticular
formation and of the effect of the
SNS thereon and on the reticulospinal
system, a series of studies appeared in
the Soviet literature, indicating strong
influence of the superior cervical
ganglion on cortical and subcortical
activity. Thus, Karamian (1 958) and
his co-worker, Sollertinskaya (1957),
found that unilateral removal of the
superior cervical ganglion in rabbits
resulted in behavioral changes, in
cluding lowered intensity and even
total disappearnce of established
positive . food-conditioned motor
refexes. These effects were accom
panied by profound changes in spon
taneous cortical electrical activity and
in responses to peripheral stimula
tion. The effects were more marked
in the ipsilateral hemisphere. After
removal of both lef and right ganglia
followed by adrenal demedullization,
the EEG voltage became very unsta
ble and changes in behavior and
response to peripheral stimulation
also took place. Subcutaneous injec
tion of adrenalin produced a transient
return to normal activity.
Tay-An ( 1960) demonstrated that
ganglionectomy also affected elec
trical activity of the hypothalamus. In
a later study, Tay-An and Gelehkova
(1961) studied the effects on the
recruitment reaction in the ipsilateral
hemisphere of stimulating one cer
vical sympathetic nerve in cats. (The
recruitment reaction is the increase in
cortical electrical activity produced
by stimulation of non-specifi c
thalamic nuclei. ) In most cases, sym
pathetic stimulation reduced the
amplitude of the reaction in the ip
silateral hemisphere. Occasionally,
usually on repeated stimulation, there
was an i ncrease. Intravenous
adrenalin more consistently weak
ened the recruitment reaction. In con
trast, there seemed to be little sym
pathetic influence on the primary
responses of the auditory cortex to
stimulation of the specic nucleus,
the medial geniculate body.
Changes in electrical activity of the
visual regions of the cerebral cortex
following unilateral extirpation of the
superior cervical ganglion in rabbits
support Zagorul ' ko' s conclusion
( 1965) that the sympathetic innerva
t i on pri mari l y i nfluences the
EMG, SNS, reflexes, etc.
mechanisms responsible for the
generation of the background elec
trical activity, the "rhythm assimila
tion reaction" (reproduction of
various frequencies of fashing light)
and the secondary components of the
induced responses to light.
Aleksanyan and Arutunian (1 959)
observed diffuse electrical activation
on stimulation of the cervical sym
pathetic nerve, and concluded that
the sympathetic effect is on the total
brain, including the reticular forma
tion, and that the cortical effect is not
necessarily mediated by the reticular
formation. Ganglionectomy also pro
duced electrical changes in both cor
tical and subcortical structures, of
such a nature as to indicate diffuse in
hibition. Observations of Vesel kin
(1 959) on the pigeon indicate that the
cerebellum is similarly under direct
influence of the sympathetic innerva
tion.
The work of Skoglund ( 1 961) and
of Chernetski ( 1964b) indicates that
the facilitatory influence of the SNS
may also extend to the spinal cord. In
the cat, Skoglund showed that
threshold doses of noradrenalin con
verted single-spike responses (to
single afferent volleys) to repetitive
discharges, set up discharges in ini
tially silent cells and increased the
frequency of prevailing activity. In
the frog, Chernetski showed that
sympathectomy markedly reduced in
tersensory facilitation of the leg flex
ion refex. He attributed the depres
sion to reduced central nervous
responsiveness in the absence of the
sympathetic influence.
To what extent these SNS-related
changes are based on vasomotor
changes is difficult to determine,
especially in view of conflicting
reports regarding the role of SNS in
nervation on circulation through the
CNS. Whether the observed changes
are of indirect vasomotor origin or
are the more direct effects on
neuronal excitation or metabolism,
such as that described by Hunter and
Stefanik (1975), the influence of the
sympathetic innervation on CNS
function seems an important and
neglected area of neurophysiology,
despite the obvious importance of the
catecholamines in brain function and
dysfunction.
4. Colateral circulation.
Bardina (1 956) showed that, follow-
ing experimental occlusion of the
lingual artery, interruption of the
sympathetic innervation of the
tongue greatly accelerated the
development of collateral circulation.
Similarly, Dansker (1957), using the
Clark-Chamber rabbit-ear technique,
found that unilateral sympathectomy
i ncreased the devel opment of
arteriovenous anastamoses, both in
number and diameter.
5. Bone growth.
Sympathetic innervation has been
found to exert an important influence
on longitudinal bone growth (Kottke,
Gullickson & Olson, 1958). Other in
fuences, e. g. , on the . response of
bone to estrogens (Rosenfeld et aI . ,
1959), and on the activity of bone
cells, possibly in collagen elaboration
and matrix formation (Chiego &
Singh, 1 974) , have also been
reported.
6. Adipose tissue.
It is now well established that adipose
tissue may also be regarded as a true
effector organ making its own
specific responses to stimulation of its
sympathetic innervation. The sympa
thetic innervation is requisite for the
rapid lipolysis (release of free fatty
acids and glycerol) that takes place in
cold exposure and for the slower
lipolysis in starvation. Sympathetic
blockade or sympathectomy (the lat
ter usually done unilaterally, the con
tralateral fat pad serving as control)
prevents the adaptive response
(Paoletti & Vertua, 1 964; Hull &
Segall, 1 965). Sympathectomized
adipose tissue increases in fat con
tent, suggesting a tonic influence on
the balance between release and
mobilization.
Electrical stimulation of the nerve
supply to adipose tissue causes the
release of free fatty acids and
glycerol. Obviously, sympathetic ex
citation, either experimentally or as
part of an adaptive response such as
that to cold. involves the rapid activa
tion of several enzyme systems. The
noradrenalin content and metabolism
in adipose tissue is the same as in
other organs with adrenergic innerva
tion (Fredholm, 1970).
The lipolytic effect of sympathetic
stimulation with accompanying
glycogenolysis and increase in O
2
con
sumption are not dependent on the
concurrent vasomotor responses to
nerve stimulation. I ndeed. the
metabolic response is delayed by the
accompanying vasoconstriction. The
independence is further substantiated
by the fact that the adipocyte
responses to sympathetic stimulation
are blocked by adrenergic p-receptor
antagonists, whereas the vasomotor
responses i nvol ve a- recept ors
(Fredholm, 1 970; Fredholm et al .
1 975; Rosell & Belfrage, 1 975).
7. Reticuloendothelial system.
I n 1 953 Kuntz summarized the
evidence then available that sym
pathetic innervation has important
i nfluences not only on blood fow
through the blood-forming tissues,
but also on such specific functions
and factors as the phagocytic activity
of the reticuloendothelial cells of
bone marrow, on erythropoiesis and
on the release and distribution of
leucocytes and on endothelial
permeability. Linke ( 1 953) showed
t hat prol onged, l ow- frequency
stimulation of the splanchnic nerves,
lumbar sympathetic trunks and sym
pathetic nerves to the liver (but not to
the spleen) caused large increases in
circulating reticulocytes and nor
moblasts. The increases lasted for
periods of 80 min to 30 h. depending
on the nerves stimulated. Responses
to stimulation of the sympathetic
nerves were unchanged by clampin
of the adrenal blood vessels .
I n a more recent study on the mar
row of the rat femur, DePace and
Webber ( 1 975), using electrostimula
don and morphological methods,
have extended these older observa
t i ons . They found abundant
adrenergic fibers terminating on
arteries and fibers coursing through
parenchyma close to many marrow
cells. but no evidence of terminations
on these cells. Stimulation of lumbar
sympathetic trunks triggered the
rel ease of l arge numbers of
reticulocytes and neutrophils into the
circulating blood. The changes affect
ing other cells were somewhat
variable. The mechanism governing
the release of blood cells from the
bone marrow following sympathetic
stimulation seems to be a selective
one apparentl y i nvol vi ng the
sinusoidal wall. On the basis of cited
electron micrographic evidence and
the studies of numerous other in
vestigators, the authors conclude that
the transmitter released at sym-
79
pathetic terminals increases the (ap
parently active) passage of seleted
white blood cells through cells of the
sinusoidal wall, in a manner similar
to that described for erythrocytes .
8. Endocrine systems.
One of the most interesting examples
of sympathetic control is that on the
pineal body and, through the pineal,
on other endocrine systems, par
ticularly those related to sexual
development and reproduction. (For
reviews, see Wurtman, Axelrod &
Kelly, 1 968; Wolstenholme & Knight,
1971 . ) The pineal controls the release
of releasing factors for luteinizing
hormone, follicle stimulating hor
mone and prolactin inhibiting and
releasing factors. This pineal control
of releasing factors is mediated by the
el aborati on and secreti on of
melatonin and other polypeptide hor
mones which exert antigonadal ac
tion.
The synthesis of melatonin is under
the control of the sympathetic inner
vation of the pineal, from the
superior cervical ganglion. Synthesis
is augmented in the dark and reduced
in the light, the optic pathways
somehow being involved in the
regulation of impulse traffic in the
sympathetic branch to, the pineal
(Brooks, Ishikawa & Koizumi, 1 975).
This accounts for the impaired
growth and sexual development of
rats raised in the dark and for diurnal
behavioral phenomena related to
photoperiodicity. These behavioral
phenomena also refect the influence
of the pineal on functions of the
higher centers on the brain. Section
of the sympathetic innervation of the
pineal obliterates the diurnal fluctua
tion of melatonin synthesis and
related diurnal changes, and blocks
the anti gonadal and growth
inhibiting infuence of the pineal in
the dark.
Other. more direct, infuences of
the sympathetic innervation on secre
tion of hormones by endocrine have
long been known, e.g . on the thyroid
(Friedgood & Cannon, 1 940; Comsa,
1963; Lowe, Ivy & Brock, 1 949;
Melander et aI. , 1974), on the adrenal
cortex (Jung & Comsa, 1 958), on the
secretion of insulin by the pancreas
(Porte, 1971 ; Shevchuk, Sandulyak &
Rybachuk, 1 970) and the testicle
(Khodorovski, 1 964). Koizumi and
Brooks (1 972) have summarized re-
8
cent confirmation and extension of
these older observations on the sym
pathetic control of endocrine func
tion.
9. Others.
There are many other examples of
sympathetic influence on various
functions and processes, e.g. , on en
zyme activity (Nordenfelt, Ohlin &
Stromblad, 1960), on mitosis and
RNA and DNA synthesis (Schneyer,
1 973) and on growth and develop
ment of the salivary glands (Wells,
Handelman & Milgram, 1961 ) and of
the kidney (Hix, 1 966). Additional
examples will be found in the review
by Koizumi and Brooks ( l 97. Still
others, including the sympathetic
conditioning of tissue responses to
other factors, e.g. , to parasym
pathetic stimulation, hormones, etc. ,
are evident in connection with clinical
and pathological manifestations of
sympathetic hyperactivity discussed
in the next section. The examples
discussed above, however, will serve
to illustrate the diversity of sym
pathetic influences which cannot be
explained merely on the basis of
regulation of secretion and contrac
tion (including that of blood vessels).
The diversity of the effects of
stimulating various peripheral sym
pathetic pathways is not in the in
fluences of the sympathetic neurons,
but in the reponses of the innervated
tissues and organs. The responses are
as varied as the tissues and organs
which are innervated - virtually
every tissue in the body. Sympathetic
stimulation i ntroduces no new
qualities, but modifies (increases or
decreases, accelerates or retards,
stimulates or inhibits) the inherent
functional properties of the target
tissue, each, therefore, responding in
its own manner.
Clinical impact of sympathetic
hyperactivity
It should not be surprising, in view of
these diverse organ and tissue
responses, that sympathetic hyperac
tivity, sustained over long periods of
t i me, may t end t o produce
pathological changes i n the target
tissues, the clinical impact varying
with the tissue and its role in the
body. Evidence for sympathetic com
ponents in a variety of clinical distur
bances is reviewed in this section. The
evidence is in four categories: (a) the
manifestations, that is, signs, symp
toms and pathophysiology; (b) the ef
fects of chronic experimental stimula
tion; (c) the effects of therapeutic or
experimental interruption or reduc
tion of sympathetic activity; and (d)
morphological changes in sym
pathetic components.
Since sympathetic vasomotor fbers
are contrictor in most areas, ischemia
of various degrees is often a common
consequence of sympathetic hyperac
tivity. The reduced blood flow would,
in turn, alter the functional properties
of the tissues and their responses to
other factors, e.g. , parasympathetic
or endocrine influence. It may also
render them vulnerable to various
agents (such as normal digestive
secretions, infectious agents and
toxins) and less able to recover from
insult. In some of the following ex
amples of the pathogenic influences
of sympathetic hyperactivity, the
vasomotor component is clearly evi
dent; in others it is of minor impor
tance or is obscured by other
sympathetic effects.
1. Neurogenic pulmonary edema.
A dramati c exampl e of t he
pathogenic influence of intense sym
pathetic discharge is neurogenic
pulmonary edema. Severe pulmonary
edema, with marked vascular conges
ti on, atelectasi s, i ntra-alveolar
hemorrhage and protein-rich edema
fuid, appears very rapidly after
severe, often fatal blows to the head
and other severe injuries to the cen
tral nervous system (CNS). It occurs
quite independently of underlying
pulmonary or cardiac disease. It has
been produced experimentally in
various species by blunt head trauma,
electrolytic lesions in various parts of
the brain, sudden large increases in
cerebrospinal fluid pressure (see
Theodore & Robin, 1 976, for
references), hyperbari c oxygen
(Johnson & Bean, 1957), injection of
chloramine (Rudin, 1 963) and local
ized pulmonary infarction (Kabins et
aI. , 1 962). Of great interest is the fact
that pulmonary eder with its
associated changes, i s also produced
by stimulation of the stellate ganglia.
Conversely, treatment of animals
with various adrenergic blocking
agents or extirpation of stellate or
other sympathetic ganglia prior to ad
ministration of any of the above
forms of trauma and stimuli com-
EMG, SNS, reflexes, etc.


"










pletely prevents the appearance of
pulmonary edema.
It seems to be assumed by most
workers in this feld that the SNS
induced pulmonary edema is due to
vascular responses and hemodynamic
changes in the pulmonary circulation,
perhaps including constriction of
pulmonary veins (Kadowitz, 1 975);
other factors such as changes in
capillary permeability have also been
postulated (Theodore & Robin,
1 976). In the course of their extensive
studies on pulmonary edema pro
duced by head trauma, high oxygen
pressure and stellate ganglion
stimulation, Beckman and his col
laborators (Beckman & Houlihan,
1 973; Droste & Beckman, 1 974;
Beckman, Bean & Blaslock, 1 974;
Sexton & Beckman, 1 975) have im
plicated another, non-vascula, fac
tor. They have demonstrated, under
these circumstances, a large, abrupt
decrease in lung compliance, accom
panied by a large increase of
minimum surface tension and of
cholesterol content of the wash fluid.
The changes in compliance and sur
face tension are tentatively ascribed
t o inc reas ed ( i nt r a- al veol ar)
cholesterol. I n monkeys and cats
these changes in lung compliance oc
curred independerly of, or in ad
vance of, any signs of lung injury
such as congestion or edema.
Whatever the mechanisms even
tually disclosed, it is well established
that severe lung damage may be pro
duced by intense sympathetic bom
bardment of the lungs, triggered in
various ways.
2. Peptic ulcer and pancreatiti.
Sympathetic components have been
identified in peptic ulcer (e.g. ,
DeSousa-Pereira, 1 959) and i n pan
creatitis. Gage and Gillespie (l95 1)
and Walker and Pembleton ( 1 955)
showed the therapeutic effects of con
duction block i n pancreati ti s.
Gilsdorf et al. (1 965), on the other
hand, demonstrated that sympathetic
stimulation converted mild, non
lethal, bile-induced pancreatitis to the
hemorrhagic, necrotizing and lethal
form. That this sympathetic effect
may be ascribable to vasoconstriction
is indicated by an earlier study by
Block, Wakim and Baggenstoss
(1 954). In their experimental study,
obstruction of the flow of pancreatic
j uice, even when permitted to mix
with bile, produced only non-necrotic
changes in the parenchyma of the
pancreas. When, however I brief
i schemia was superimposed on
obstruction of the pancreatic duct,
parenchymal necrosis developed
which varied in severity with the
degree of arterial obstruction. Le
sions comparable to acute hemor
rhagic pancreatitis in man were occa
sionally produced by ischemia alone.
J. Arteriopathy.
Gutstein, LaTaillade and Lewis
( 1962) produced the histological
features of arteriosclerosis in the aor
ta by sustained stimulation of the
splanchnic nerve in unanesthetized
rats. Sympathetic stimulation ap
parently produced some change in the
arterial wall that favored the develop
ment of arteriosclerotic lesions. A
tendency toward thrombosis seems to
have been a factor. It is interesting in
this connection that in studies on ex
perimental thrombosis in the rabbit
ear, denervation of the ear markedly
accelerated thrombolysis (Fowler.
1 949; Cho, 1 967).
4. Cardiovascular-renal syndromes.
Hypertension. It has long been
s us pect ed , o n t he bas i s o f
physiological, pharmacotherapeutic
and behavioral considerations, that
high activity of the peripheral SNS is
an important contributing factor in at
least some forms of arterial hyperten
sion. This has been difficult to
establish, by direct means, in pa
tients. Recent studies of Wallin,
Delius & Habgarth ( 1 973), in which
they recorded multiunit sympathetic
activity in skin and muscle nerves,
have yielded preliminary support for
this hypothesis. In a more quan
titative study on spontaneously
hypertensi ve rats, Iri uchij i ma' s
studies (1973) indicated a much
higher efferent impulse traffic in the
splanchnic nerves of hypertensive
than of normotensive rats.
Heart Disease. Among the most
threatening and often fatal complica
tions following myocardial infarction
are ventricular fibrillation and other
arrhythmias. The recent work of
several investigators indicates that
heightened discharge through the
sympathetic innervation of the heart
may be a most important factor. In
an experimental study on transient
coronary occlusion in cats, with the
use of direct recording techniques,
Malliani, Schwartz and Zanchetti
( 1969) showed an increase discharge
in most of the fibers tested (in the
third thoracic ramus communicans).
The reflex, which the authors
characterized as a sympathetic
cardio-cardiac reflex, occurred also in
the spinal animal, did not depend on
the baroreceptors, on vagal refexes
or on direct anoxic stimulation of
preganglionic neurons.
Others have found that experimen
tal coronary occlusion lowers the
ventricular fibrillation threshold
(determined by repetitive electrical
stimulation of the ventricle) and in
creases the incidence of ectopic
di s c harges and ar r hyt hmi as .
Adrenergic blockade and ablation of
the stellate ganglia protected the heart
against these manifestations and even
prevented them, especially during the
first few hours of occlusion (Harris,
Bocage &Otero. 1975; Kliks, Burgess
& Abildskov, 1 975). Conversely,
stimulation of the stellate ganglia,
even in the absence of coronary oc
clusion, markedly lowered the
fi br i l l at i on t hr es hol d. When
ganglionic stimulation was superim
posed on occlusion, the threshold was
depressed far below that following
occlusion alone. The conclusion that
postinfarction sympathicotonia is a
critical factor in the triggering of ec
topic activity and fbrillation is fur
ther supported by the demonstration
that cardiac sympathectomy prior to
occlusion protects against these com
plications and lowers the mortality
rate (Fowlis et al. , 1 974).
A study with unilateral stellectomy
or reversible cold block of individual
stellate ganglia revealed significantly
different infuences of the right and
left ganglia on cardiac excitability,
perhaps comparable to the well
established differences with respect in
inotropic and chronotropic infuences
(Schwartz, Snebold & Brown, 1 976).
Thus, left sympathetic denervation of
the heart raised the ventricular
fibrillation threshold 72 3S percent
above control values, whereas right
sided denervation lowered the
threshold 48 1 4 percent. The
authors believe that these observa
tions help explain the pathogenesis of
ventricular arrhythmias and fibrilla
tion (e. g. , in the so-called long Q-T
syndrome) associated with increased
sympathetic activity. They recom-
8I
mend left stellectomy as a logical
measure in patients at high risk from
such arrhythmias, when medical
therapy has not been effective.
Schwartz (1 976) has further pro
posed, on the basis of these observa
tions and studies on infants, that the
Sudden Infant Death Syndrome is
due to the long Q-T syndrome
brought on by an abrupt sympathetic
discharge taking place through asym
metrical cardiac sympathetic innerva
tion in which the right side is, for
some reason (congenital?), subnor
mal in activity.
At any rate, it seems clear that the
increased sympathetic discharge to
the heart which accompanies myocar
dial infarction (Malliani et ai. , 1 969)
greatly imperils the effective function
of the heart and the survival of the
patient. There is not only the hazard
of ectopic activity and fibrillation,
but also cardio-acceleration and in
creased oxygen demand. Also to be
considered is the probability that the
increased sympathetic discharge to
the heart includes that of the
a-receptor sympathetic coronary con
strictors (Szentivany & Juhasz-Nagy,
1 963a, 1963b; Feigl, 1975) which
would contribute to intensification
and spread of the myocardial
ischemia. Indeed, it is. possible that
hyperactivity of these neurons would
contribute to coronary arteriospasm
implicated in acute myocardial
ischemia and angina pectoris. The ap
parent inhibitory influence of the
sympathetic innervation on the
development of collateral circulation,
previously discussed, may also have
important implications for the patient
with coronary artery disease.
Other examples of sympathetic
components in cardiovascular disease
are the following:
(a) Dietzman et aI. (1 973) found
heightened SNS activity during car
diogenic shock in dogs. Renal and in
testinal vascular beds were most af
fected. Reduction of SNS influences
lengthened the survival period. These
studies support the concept that the
SNS plays a lethal role in cardiogenic
shock in dogs.
(b) Raab ( 1 963) and Kaye,
McDonald and Randall ( 1 961 ) have
shown that hyperactivity of cardiac
sympathetic pathways may produce
severe cardiac lesions.
(c) Barger ( 1 960) found that reten
tion of Na and water in congestive
82
heart failure is ascribable to increase
in sympathetic activity in the kidney.
As a matter of fact, the renal sym
pathicotonia is evident before the
development of heart failure. Block
ing the adrenergic nerves produced
diuresis and natriuresis. In patients
with ureteral calculi and during ex
perimental stimulation of the ureter
in humans and dogs (by ureteral
catheterization), Hix (1 970) found the
renal sympathetic pathways markedly
facilitated on the affected side. In
these subjects superimposed emo
tional stimuli caused unilateral,
abrupt reduction i n glomerular fltra
tion and renal blood flow. In dogs,
Kottke, Kubicek and Visscher ( 1 945)
produced arterial hypertension by
chronic renal artery-nerve stimula
tion.
It is of interest in this connection
that Anselmino (1 950) found that
novocaine blockade of the renal in
nervation reduced arterial blood pres
sure in most eclamptic patients, im
proved diuresis and, in some, stopped
coma and convulsions. Blockade of
the stellate ganglia in these patients
improved diuresis, stopped coma and
convulsions in some and improved
subjective manifestations including
headache, ocular disturbances and
nausea.
5. Posttraumatic pain syndromes.
"The expected response to trauma in
an extremity after proper treatment is
orderly and predictable healing of the
wound, return of function, return of
'
circulatory dynamics, and gradual
cessation of pain. Occasionally this
predictable response reacts in a
bizarre fashion despite adequate
treatment and the absence of any ob
vious factors detrimental to prompt
healing. Pain may become severe and
unrelenting, with a marked disparity
between severity of pain and the ap
parent injury. Sympathetic dysfunc
tion, usually over-activity, becomes
evident. Trophic changes usually en
sue to varying degrees, and if the pro
cess is left unattended for any length
of time they become irreversible."
This is the way that the surgeon
authors of a contribution to the
management of posttraumatic syn
dromes i ntroduce thei r paper
(Thompson, Patman & Persson,
1975). The paragraph is a synopsis of
an assortment of causalgia-like syn
dromes affecting the extremities, in
which, at least from the therapeutic
viewpoint, hyperactivity of the sym
pathetic innervation is a critical
feature.
The manifestations (and the in
citing factors) of these syndromes
occur in such great variety, with
respect to intensity and quality of the
pain, motor dysfunction, sympathetic
dysfunction and trophic distur
bances, that many different terms
have been invented reflecting not only
these variations but also the special
interests, emphases and viewpoints of
the observers. Among the terms for
these "entities" are the following:
minor causalgia, reflex sympathetic
dystrophy, Sudek's atrophy, painful
osteoporosis, acute atrophy of bone,
shoulder-hand syndrome (following
myocardial infarction or stroke),
chronic traumatic edema, post
traumatic pain syndromes, sym
pathetic neurovascular dystrophy,
t r aumat i c angi os pas m, pos t
traumatic spreading neuralgia, sym
pathalgia, peripheral trophoneurosis,
and others. The most favored in
current literature seem to be refex
(or posttraumatic) sympathetic dys
trophy and posttraumatic pain syn
dromes (Patman et al. , 1 973; Thomp
son et aI. , 1 975; Genant et ai. , 1 975;
Kozin et aI. , 1 976; Kleinert et aI. ,
1 973; Omer & Thomas, 1 974). The
terms "mimocausalgia" (proposed
by Thompson et al.) and "minor
causalgia", however, would seem to
be most useful, especially for those
familiar with causalgia through
clinical experience or through the
classical descriptions of causalgia by
S. Weir Mitchell and associates, in
reports of their experience with gun
shot wounds in the American Civil
War, and in more recent reviews
(Richards, 1 967).
The pain may vary from the ex
tremely severe, burning, unrelenting,
personality-destroying type of full
causalgia to the equally chronic but
more tolerable pain of the "minor"
causalgias. Hyperesthesia may be so
exquisite that the patient cannot
tolerate the weight of clothing on the
extremity, the gentlest touch or the
slightest air current. Paroxysms of
even more intense pain are often trig
gered by any of the above and by such
minor disturbances as noise, change
in ambient temperature or movement
of the limb. The limb is held as im
mobile as possible. The patient is,
EMG, SNS, reflexes, etc.
therefore, extremely resistant to
therapy.
The manifestations of sympathetic
dysfunction include vasospasm and
hyperhidrosis, cold and wet skin,
cyanosis and chronic edema. In some
cases, however, or temporarily in an
early stage, the skin may be hot and
dry as well as edematous, possibly
due to the release of vasoactive agents
and irritants from sensory endings by
antidromic impulses (discussed later).
The most bizarre manifestations
are those in the "trophic" category.
They include change in the thickness,
texture and other qualities of the
skin, changes in the nails and hair
growth, shortening of tendons,
atrophy of musculature, osteoporo
sis and other degenerative changes in
bones, joints (which become stiff and
even frozen) and juxta-articular
tissues. The arthropathies and other
skeletal changes have recently re
ceived thorough study by Genant et
al. ( 1 975) and Kozin et al. ( 1 976) with
fine-detail radiography, radionuclide
techniques and mineral analyses.
The degenerative changes in bone,
"frozen" joints, muscle atrophy,
etc.; have been ascribed by some to
immobilization of the affected limb
by the patient, and this is almost cer
tainly a factor. Wowever, the distri
bution of pathological changes be
speaks a central neural mechanism.
Whether the trophic manifestations
are due to circulatory changes, some
other infuences of sympathetic im
pulse activity or the non-impulse
mechanisms discussed by others in
the Workshop remains to be investi
gated.
Another feature difficult to explain
is the gross disparity between the re
sponse, on the one hand (the' severity,
persistence and progressive nature of
the pain and other manifestations),
and the injury, on the other. In some
cases the injury may not only be non
penetrating but so slight that it would
ordinarily be dismissed as a superfi
cial bump or a bruise; in other cases it
may be a small fracture, a minor sur
gical procedure, a laceration, a tool
dropped on the foot.
One of the most remarkable com
mon features of these syndromes and
their variants is their responsiveness
to interruption of impulse traffic in
the sympathetic innervation of the
affeted extremity. In many cases, the
pain and autonomic manifestations
may be immediately relieved by
blockade of the appropriate ganglia
(ipsilateral stellate or lumbar). The
relief may outlast by several hours or
days the usua anesthetic action of
the agent injected around the ganglia.
The relief may even be permanent
following a single block or a series of
blocks. When, as is more usual, and
if the ganglionic blockade has given
temporary relief outlasting anesthetic
action, then permanent relief and
"cure" may be obtained with surgical
interruption of the sympathetic path
way to the extremity.
Ganglionic blockade and sympa
thectomy are much less likely to be
effective if diagnosis
'
and effective
treatment have been too long de
layed. Most authors urge early recog
nition and treatment of the syndrome
not only because delayed interruption
of the local sympathicotonia is less
likely to be effective (which, in turn,
often prevents examination of the
extremity and application of sup
portive measures such as physical
therapy), but because the trophic and
degenerative changes may become so
advanced as to be irreversible. Under
such circumstances, even were the
pain and vasomotor changes even
tually relieved, the patient would be
left with a disfigured and disabled
extremity and often with severe
emotional disturbances.
No hypothesis has yet been offered
that satisfactorily explains refex sym
pathetic dystrophy. In general, three
mechanisms (Sternschein et aI. , 1 975)
seem to have won adherents:
(l ) Increased excitability (facilita
tion) of internuncial neuronal pools
at the involved cord levels, presum
ably incited by aberrant sensory input
from the injured site. Sensory, motor
and sympathetic pathways are
thought to be affected by the en
hanced central excitatory state. The
increased sympathetic discharges pro
duce changes in the periphery which
incite secondary afferent discharges,
thus initiating and sustaining vicious,
autogenic cycles of impulses.
(2) Excitation of ectopic impulses
in pain fbers by impulses passing in
neigh boring sympathetic post
ganglionic fibers (interaxonal "cross
talk", lateral or ephaptic transmis
sion, "artificial synapse"). The anti
dromic (as well as orthodromic,
afferent) impulses triggered in this
manner are thought by some to re-
lease vasoactive agents and irritants
at the endings.
(3) Various adaptations of the gate
control theory of pain.
While hypotheses (2) and (3) may
possibly contribute to understanding
of the pain components of the syn
dromes, they offer none regarding the
signs of sympathicotonia (which the
first hypothesis does) or of the
trophic manifestations (which are re
ferable, at least in part, to the sym
pathicotonia). This seems a worthy
area for investigation, perhaps in an
animal model which simulates the
causalgia- l i ke syndromes . The
preparation described by Kennard
( 1 950) may be a promising one with
which to begin.
6. Other skeletal disorders.
In 1 957 Herfort first reported ex
cellent results following lumbar sym
pathectomy in patients bedridden by
arthritic pain in weight-bearing
joints. The extirpation of the lumbar
ganglionic chain affected the rheuma
toid activity only in the denervated
extremities, and equally good results
were obtained in rheumatoid and
osteoarthritic dsiease. Neurons and
neuroglial supporting cells in sym
pathetic ganglia surgically removed
from patients with chronic poly
arthritis showed morphological signs
of prolonged preganglionic stimula
tion (Kuntz, 1 958).
Coujard ( 1 96) reported a variety
of osteodystrophies produced in the
guinea pig by irritation of the sym
pathetic fibers in the sciatic nerve
(and by diencephalic lesions). The
bony manifestations included various
arthropathies mimicking those of
tabes and syringomyelia, alteration of
calcium fixation, and heterotopic
osteogenesis, such as spicules on the
periosteum and tumor-like out
growths of bone.
Kottke et al. (l 958) studied longitu
dinal bone growth in children who
had paresis of one leg and nearly nor
mal strength in the other after acute
anterior poliomyelitis. The average
rate of growth of the bones of paretic
legs was substantially less than that of
normal legs; total extremity length
was 82.9 percent of normal. Treat
ment with a sympatholytic drug re
stored growth to the rate of the nor
mal leg. Th authors attributed the
retarded bone growth to reflex hyper
activity of SNS in response to cold,
83
which results in vasoconstriction in
the extremity and inhibits epiphyseal
bone growth. They cite an earlier
study in which chronic unilateral
stimulation of the lumbar sym
pathetic chain in puppies substantial
ly reduced growth of the hipd limb on
the stimulated side. Coujard ( 1 957),
however, reported evidence that the
sympathetic innervation influenced
the sensitivity of bone and other
tissues to morphogenetic hormones.
We may also include in this
category many clinical reports on the
painful joint syndrome known as
shoulder-hand syndrome, occasional
ly a distressing sequel to myocardial
infarction and stroke, which is often
dramatically responsive to stellate
block. Some of these studies are cited
in the references of the foregoing sec
tion on reflex sympathetic dystrophy.
7. Shock.
Pre-treatment of experi mental
animals to be subjected to traumatic
shock (Levy, North & Wells, 1 954;
Ross & Herczeg, 1 956) or hemor
rhagic shock (Berger, 1 965) with
adrenergic blocking agents at certain
critical dose ranges or with sym
pathectomy protects them against the
lethal effects. Apparently, as is true
in other clinical situations, " . . . . the
sympathetic discharge is a protective
mechanism, but initiates processes
which are detrimental to survivial"
(Levy et ai. , 1 954).
8. Hepatotoxcity.
This principle i s again illustrated in
liver pathology produced by ad
ministration of carbon tetrachloride.
According to the evidence of Calvert
and Brody (196), the characteristic
hepatic changes are the result of
massive discharge of the peripheral
SNS. This leads to hepatic ischemia,
hypoxia and necrosis around the cen
tral vein of the hepatic lobule and cer
tain changes in enzyme activities. As
discussed in an earlier section of this
paper, the sympathetic discharge also
releases fatty acids from the periph
eral fat pads and the consequent
deposition of lipids in the liver.
9. The Uteru.
On the basis of their own experimen
tal work with animals and review of
clinical and research literature,
Shabanah, Toth and Maughan ( 1 964)
concluded that many unexplained
8
obstetrical and gynecological condi
tions involving disturbances i n
uterine contractility may be ". . . .
related to abnormal neurohumoral
causative factors reflected in a fnal
picture of autonomic imbalance -
sympathetic hyperactivity."
A study by Miller and Marshall
( 1 965) on rabbits lends support to this
conclusion. They found that stimula
tion of the hypogastric nerve in
hibited spontaneous uterine contrac
tions in rabbits treated with estrogen
+ progesterone. This effect was
abolished by adrenergic blocking
agents, but was unchanged by
atropine or hexamethonium.
10. The eye (as a model il ustrating
sympathetic inuences on tissue
reponses to other factors).
The role of the innervation of the eye
in such disorders as glaucoma has
long been under study, but no clear
picture has emerged despite evidence
for an important sympathetic in
fluence on intraocular pressure,
through infuences on formation or
drainage of aqueous humor or both.
Sympathetic influence on the per
meability of the blood-aqueous bar
rier to protein, and therefore outfow
resistance, may also be a major factor
(Langham, 1 958).
The detrimental influence of the
sympathetic innervation on the
responses of the eye to other factors is
much clearer. For example, when the
trigeminal nerve was interrupted, cor
neal ulcerations developed in all of
the animals (cats). Prior stellectomy
prevented the lesion in almost all of
the animals, and permitted healing if
the lesion did appear (Baker & Oot
tlieb, 1 959).
Howes and McKay ( 1 972) dem
onstrated the protective effect of
sympathectomy in quite a different
kind of situation. Systemic bacterial
endotoxin in rabbits produces a
marked increase in ocular vascular
permeability, primarily in the iridial
portion of the ciliary process. The in
itial consequence is edema. followed
by hemorrhages and thrombi. Post
ganglionic sympathectomy (extirpa
tion of the superior cervical ganglion)
reduced the severity of the ocular re
sponse to systemic endotoxin. This
effect required several hours to ap
pear, and at 4 h after administration
of the toxin to the unilaterally sym
pathectomized rabbit there was a
decrease in the altered vascular per
meability as measured by
1 25
I-serum
albumin, in stromal hemorrhages and
in small-vessel thrombi in the sym
pathectomized eye as compared to the
contralateral or sham-operated eye.
The apparent exacerbating in
fluence of the sympathetic innerva
tion in conjunction with systemic en
dotoxin i s by no means peculiar to the
eye. As is evident, for example, from
the reports of other investigators
cited by Howes and McKay, sympa
thetic denervation and a-adrenergic
blocking agents are known to sup
press or prevent other reactions to en
dotoxins (local and generalized
Schwartzman reaction). As far as the
eye alone i s concerned, it would cer
tainly seem important to investigate,
from the etiological and therapeutic,
as well as pathophysiological, view
points, the role of the sympathetic in
nervation in such common and
damaging disorders as uveitis or iritis.
11. Other example.
Other clinical situations may be cited
in which a contributing, exacerbating
and often critical role of the sympa
thetic innervation has been im
plicated, but which are only men
tioned here without documentation in
the interest of space. These include
col i t i s, megacolon, peri pheral
vascular disease, ulcers of the legs,
dermatitis, postsurgical paralytic il
eus, various diseases of the kidney,
Dupuytren's contracture and "pelvic
congestion" in women.
A mass of clinical evidence, beyond
the scope of this paper. much of it
empirical, indicates an important role
of the peripheral autonomic nervous
system, and particularly the SNS, in
determining reactivity, resistance and
responses of individual tissues - and
therefore the defenses of the entire
organism - to infectious, toxic, an
tigenic and irritative agents. These in
fluences apparently extend to such
processes as inflammation, immune
reacti ons, anaphylaxi s, allergic
mani fest at i ons and "phys i cal
allergies". There i s even evidence for
sympathetic i nfluences on the
response of tissues to carcinogenic
agents and on immunobiologic
mechanisms that determine tumor
"take" in experimental implants.
(See, for example, Stein-Werblow
sky, 1 974.) These interfaces between
neuroscience and immunology and
EMO, SNS, reflexes, etc.

microbiology would be worthy areas
of investigation, from scientific and
clinical viewpoints.
The "normal" influences of sym
pathetic innervation on various end
organs, discussed in an earlier
section, may also be-expected to be
deleterious when the impulse activity
is intensifed and sustained. For ex
ample, falsely exaggerated reports
from sympathetically bombarded re
ceptors, especially baro- and che
moreceptors, would certainly have
a disturbing effect on reflex
regulatory mechanisms. This would
be true also of SNS influences on
CNS functions. The effects of sym
patheti c hyperacti vi ty on the
reti culoendotheli al system, fat
metabolism, enzyme activity, en
docrine systems and others may also
be expected to be harmful over long
periods of time.
Finally, it is important to mention
again that any clinical disturbance or
augmented tissue vulnerability in
which ischemia is a contributing fac
tor often may be related to sym
pathetic hyperactivity in view of the
strong constrictor influence of sym
pathetic vasomotor fibers.
12. Other kinds of evidence for a
general SNS role in d iease proceses.
(a) Neuropathological. Profound
morphological alterations are ex
hibited by ganglion cells in ganglia
removed surgically in the treatment
of patients with various diseases and
at autopsy. There is also marked pro
liferation of neuroglial supporting
cells. The changes are such as to in
dicate overstimulation of the gan
glion cells, and indeed many alter
ations sen in surgically removed
ganglia and their cellular components
have been induced experimentally by
prolonged preganglionic stimulation
(Kuntz, 1 958; Schilew, 1 965).
(b) Irritative Lesions. Prolonged ir
ritation, with various agents and in
juries, of peripheral sympathetic
structures ( e . g. , col l ateral or
paravertebral ganglia, splanchnic
nerve) or of sensory fbers in spinal
nerves produces many types of lesion
and dysfunction of visceral and
somatic structures, often lethal,
which simulate naturally occurring
pathology (Mosinger, 1957; Reilly et
at, 1955).
Mehanisms
In considering the participation of the
SNS in disease processes, we are con
fronted with an apparent paradox.
On the one hand, thanks especially to
the pioneering studies of W. B. Can
non, we have reason to be impressed
with the important role of the SNS in
organizing adaptive, moment-to
moment responses of the total
organism to changes in environment,
posture and physcial activity, and to
injury and emergencies. As adaptive
responses, they are protective and ap
propriate to the situation (or to what
is perceived to be the situation). On
the other hand, we have many ex
amples of harmful and even life
endangering effects of sympathetic
activity which is focused too intensely
and for too long on individual tissues
and organs.
The roles of the higher centers,
including the cerebral cortex, in
initiating and organizing somato
autonomic response patterns are now
fairly well understood. However, in a
prevailing emphasis on these whole
body patterns, which are based on the
capacity of the SNS to discharge as a
whole and to broadcast its infuences
throughout the body, there is a ten
dency to overlook the high degree of
local and regional control that is
essential to proper execution of the
responses, as they change from mo
ment to moment. Much of the capaci
ty for localization resides of course in
some of the higher centers, which can
direct descending impulses (e. g. , via
corticospinal fibers) to appropriate
neuron pool s. But the precise
modulation of the local and regional
components of the total pattern is
based on sensory signals from par
ticipating and affected tissues and
organs and on specificity and selec
tivity of connections, through
segmental pathways, between af
ferents and sympathetic neurons.
These two moieties of the total pat
terns seem to correspond to what
neurophysiologists, recording from
sympathetic efferents at various
spinal levels, as they stimulate
selected somatic afferents, have
designated as "late" (supraspinal)
and "early" (spinal) somatosympa
thetic refexes (Koizumi & Brooks,
1972). All or nearly all of the total
SNS neuron pool can be activated
in this way via the supraspinal path
ways. Only a fraction of the pool,
however, is activated by the same
afferent stimulation via the spinal
pathways; and some somatic affer
ents (Group I) seem to have no ac
cess, normally, to sympathetic neu
rons via segmental pathways. The
fraction of the efferent (pregangli
onic) neuron pool that i activated via
spinal pathways by stimulation of
selected somatic afferents is concen
trated at the corresponding spinal
level, the number of responding
neurons declining sharply with in
creasing segmental interval (reviewed
by Koizumi & Brooks, 1 972, and by
various authors in Sato, 1975). In
other words, the "early" and most
direct impact of impulses entering via
a given dorsal root (and hence coming
from a given dermatome, myotome
or viscerotome) is mainly focused on
the neurons whose axons emerge
through the corresponding ventral
roots (conveying motor and sym
pathetic impulses to organs and
tissues in the same body "seg
ments").
I suggest that the clinical distur
bances which are apparently based on
hyperactivity in related sympathetic
pathways, described in the previous
section, are aberrations of these local
and regional feedback mechanisms.
They appear to be triggered by
unusual patterns of afferent impulses
originating in part in i nj ured,
strained, impaired or chemically
altered tissues or at sites of injury in
nerves or roots. The aberration ap
pears to be sustained (and intensified)
by either (I) secondary afferent
discharges from tissues bombarded
by the sympathetic impulses, (2)
facilitatory changes in the spinal
cord, or both. While the initial
trauma need not be painful to launch
the vicious cycle, pain may be
brought on by the sympathetic dis
charge (e. g. , in ischemia) and by
lateral (ephaptic) transmission at sites
of nerve deformation, from sym
pathetic postganglionic axons to
neighboring unmyelinated sensory
fibers.
The aberration may also begin as a
component of a total response pat
tern. The patterns are adaptive and
protective when initiated by cir
cumstances likely to occur in daily
animal life, such as environmental ex
tremes, exertion (" fight or fight"),
injury by external forces, threat of in
jury and death, hypoxia, etc. When
85
confronted wi th ci rcumstances
unlikely to have been encountered i n
the course of evolution of these adap
tive sympatheti c patterns, the
responses may not only be inap
propriate, but even harmful and
detrimental to survival. Thus, while
refex vasoconstriction (and accom
panying cardiovascular and other
systemic changes) may be appropriate
for, let us say, a painful laceration of
an extremity, sympathetic hyperac
tivity with resultant ischemia is totally
inappropriate and definitely "con
traindicated" for a joint which is
painfully irritated or infamed. The
ischemia itself causes pain which fur
ther intensifies the sympathetic
discharge. The vicious cycle set up in
t hat manner aggravat es t he
pathological state (Kuntz, 1958). For
similar reasons , heightened sym
pathetic discharge to a heart already
laboring under i mpairment by
myocardial ischemia can only, as we
have seen, further impair and burden
the heart and decrease the. probability
of survival. Bodily responses to anox
ia, a common hazard in terrestrial
life, are the adaptive product of
evolution, which become destructive
and lethal when evoked by a cir
cumstance as unlikely as high O2 ten
sion (Ramey & Goldstein, 1 957).
Similar, spinally organized reflexes
seem to operate in the therapeutic ap
plication of hot packs, cold packs and
counterirritants (e.g. , rubefacients) to
the skin in the region of inflamed,
congested, ischemic, edematous or in
jured viscera and joints. When,
however, the skin over apparently
healthy organs is chilled, the
responses may be such as to
predispose to infection or other ill
ness, as, for example, in the upper
respiratory tract (Ralston & Kerr,
1 945), gastrointestinal tract (Richins
& Brizzee, 1 949) or kidney (Nedzel,
1956).
One of the most interesting and
clinically significant features of these
aberrant, spinally organized so
matosympathetic reflexes is the
making of synaptic connections that
are not ordinarily in use. This is
similar to the experimental situation
in which Group I afferents, which do
not have access to sympathetic
neurons via the "early" , spinal
pathways, are able, through the open
ing of "potential" pathways, to ac
tivate these neurons when the spinal
86
cord is moderately cooled (Koizumi &
Brooks, 1 972). The result in the
clinical situation is to link, refexly,
somatic and visceral structures which
are not functionally coupled in any
normal bodily activity or adaptive
response pattern. In the clinical situa
tion, they become linked only by vir
tue of the segmental proximity of
their innervating neurons. Not only is
this reflex "entanglement" nonadap
tive and harmful to each of the struc
tures involved in this aberrant reflex
coupling, but it is disruptive of the
adaptive refex patterns in which
these organs and tissues are called on
to participate.
Dysfunctional, segmental coupling
is clearly illustrated in patterns of
referred pai n and associated
phenomena, of both visceral and
somatic origin. Not only is the
distribution of referred pain (e.g. ,
from ischemic myocardium to chest
wall, upper back, left shoulder and
arm) unrelated to any normal func
tional pattern, but the same is true of
the reflex motor and sympathetic
( s udomot or and vas omot or )
responses i n the reference zones. The
reflex responses to the initiating insult
are not only useless, but secondary
pathology may be instigated in the
reference zones (as in postinfarction
shoulder-hand syndrome). The af
fected tissues may in turn become
secondary sources of abnormal af
ferent bombardment that helps sus
tain, intensify and spread the sym
pathetic hyperactivity. Although
referred pain and refex patterns of
visceral origin have been more
thoroughly investigated and de
scribed, it is important to point out
that similar and even indistinguish
able patterns may be initiated from
deep somatic structures (Lewis &
Kellgren, 1 939; Kellgren, 1 940;
Travell & Rinzler, 1 949). Reflex
activity through sympathetic path
ways seems to be elicited with equal
facility by painful somatic or visceral
afferent stimulation (Tunt', 1958),
and with no fundamental difference
in the manifestations.
Relation to manipulative therapy
In accordance with the objectives of
the Workshop, I venture to offer for
exploration hypotheses which pur
port to link the clinical and ex
perimental materia j ust reviewed and
their apparent mechanisms to those at
work in manipulative therapy. In
view of the rich access of somatic af
ferents, via spinal and supraspinal
pathways, to sympathetic neurons, it
would be truly amazing if even rela
tively minor disturbances in motion
of intervertebral or other joints,
which are amenable to manipulative
therapy, did not have autonomic and,
therefore, circulatory, metabolic and
visceral repercussions of some degree.
It would be equally surprising if the
cost did not increase with time and
with the superimposition of other
detrimental factors in the patient's
life.
On the basis of available data and
my observations of the skillful prac
tice of manual medicine over a third
of a century as a physiologist, I sug
gest that:
1 . Local musculoskeletal dysfunc
tions, especially in and around the ax
ial and weight-bearing parts of the
skeleton, are clinically significant not
only because of the motor impair
ment and the pain that are sometimes
present, but also because they in
stigate or contribute to the sustained
sympathicotonia which is a common
feature in so many syndromes. Like
those syndromes, they also appear to
be aberrant versions of the spinal
("early") somatosympathetic reflexes
discussed above.
2. The disturbance in the cord is
due to distorted patterns of afferent
impulses from (a) the affected
musculoskeletal tissues and/or (b)
irritative lesions of nerves, roots and
ganglia, such that adaptive, appropri
ate responses are not possible. (In
view of the sharply delineated der
matomal bands showing sympathetic
hyperactivity. often encountered in
our studies. i t is likely that part of the
segmental sympathicotonia may be
due to irritation of sympathetic
ganglia.)
3. Effective manipulation is that
which results in the reestablishment
of coherent patterns of afferent input
such that local adjustive reflexes are
once more appropriate and har
moniously integrated in the total,
supraspinally directed patterns of ac
tivity and adaptive response. The
most critical effect, clinically, is the
subsidence of sympathetic hyperac
tivity and its pathogenic, pain
producing influences.
4. Improvement in the afferent in
put is accomplished by appropriate
EMG, SNS, reflexes, etc.
adjustment of articular, interosseus
relationships, muscle lengths and
muscular, fascial and ligamentous
tensions that enable these tissues once
more to report in coherent pro
prioceptive patterns; and, in the same
process, by relieving mechanical
deformation or irritation of neural
structures.
5 . The mechanisms are the same
when the primary perturbation of the
cord is of visceral origin, and the
musculokeletal involvement is of
secondary, reflex origin, as occurs in
association with referred pain. The
therapeutic effect (among others) of
manipulation is still to slow the
vicious cycle and reduce the sym
pathetic discharge to the visceral and
somatic structures whi ch have
become reflexly coupled to their
mutual detriment.
6. The impaIrIng effects of
biomechanical insult to nerve on the
transfer of information (and materi
al), explored in a later section of the
Workshop, are also part of the pro
posed mechanisms in manipulative
therapy, as reflected in our earlier
publications (Appeltauer & Korr,
1 975, 1 977; Korr, 1972; Korr & Ap
peltauer, 1 974; Korr, Wilkinson &
Chornock, 1 967).
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8

Primary research reports:

Axonal transport,
trophic functions of nerves
I
9I
Ablracl: bludic in
ncurolrophic mcchanim
(196)
I.M. KORR, P.N. WILKINSON, and
F.W. CHORNOCK
When a peripheral nerve is cut, the
axons separated from their cell bodies
undergo degeneration because each
depends on the continual delivery of
cytoplasmic constituents which arise
in the cell body for the maintenance
of its integrity. Profound changes,
usually of degenerative nature, also
take place in end organs supplied by
the interrupted nerve fibers. We are
testing the hypothesis that the trophic
dependence of nonnervous cells on
their innervation is also based on the
continual delivery of neuroplasmic
components via the axon.
We reported at this Conference last
year that isotopelabeled substances
in cell bodies of hypoglossal and
vagal neurons of rabbits were carried
peripherally by axoplasmic flow at
the rate of approximately 5. 5 mm.
per day and that they reached and
spread through the peripheral organs
(tongue and heart) innervated by
these nerves. Radioactivity in the
tongue progressed from base to tip.
When one hypoglossal nerve was
crushed, radioactivity was arrested at
the site of the crush and accumulated
on the proximal side. In these ex
periments radioactivity was found to
be limited to the innervated side of
the tongue.
Since that report we have applied
microscopic autoradiographic meth
ods to determine the distribution of
the nerve-delivered substances within
the tongue. Following is a summary
of our findings:
1 . Axon branches and endings
within the tongue were richly tagged.
2. P120. - was found within the
muscle cells: among the striations
(possibly mainly in the A-bands), in
the nuclei, and in the sarcoplasm
around the nuclei.
3. Cl4amino acids, presumably in
corporated in proteins, at least in
part, were more diffusely distributed
in the muscle cells.
Aided by Grant T2139 from the American
Osteopathic Association and by Grant FR054390
from the National Institutes of Health to the Kirksville
College of Osteopathy and Surgery.
4. Labeling appeared first in the
base of the tongue and progressed
toward the tip.
5 . Only background activity
occurred in epithelial, secretory, con
nective, adipose, and other tissues in
the tongue that are innervated by
nerves other than the hypoglossal
nerve.
6. When one hypoglossal nerve was
crushed, only background activity
was evident on the denervated side,
even after the intact side was strongly
labeled.
T. When tagged substances were
permitted to reach the tissue via the
bloodstream, labeling was no longer
limited to the muscle cells. It ex
tended apparently to all cellular com
ponents, on the denervated as well as
the innervated side. Moreover, label
ing of tongue muscle was predom
inantly interstitial, rather than in
tracellular.
It appears, therefore, that sub
stances arising in the cell bodies of
peripheral neurons are carried via
their axons to peripheral tissues
where they may cross the junctions
and enter into the cellular structure or
metabolic machinery of those tissues.
We suggest that this mechanism pro
vides a basis for neurotrophic in
fuence. Studies are in progress to
identify some of the neuroplasmic
components and their roles in the
peripheral non-nervous cells. We are
also exploring the possibility, sug
gested by the preliminary evidence of
migration from muscle to nerve, that
there is normally a mutual two-way
exchange of cytoplasmic components
across the specialized junctions be
tween neurons and the cells that they
innervate.
Reprinted by permission from JAOA 65: 9991,
196.
Axonal transport and trophic studies

Axonal delivery of neuroplasmic

components to muscle cells (1967)
I.M. KORR, P.N. WILKINSON, and F.W. CHORNOCK
Maintenance of the axons in pe
ripheral nerves depends on the con
tinual delivery of fresh cytoplasm
elaborated in the cell bodies. The
cytoplasm, apparently propelled in a
peristaltic manner by the axon, 2 is
continually moved out of the cell
body and along the entire length of
the axon and all of its branches, sup
plying them with components that are
used in axonal maintenance and ac
tivity and that are not (or are insuff
ciently) supplied by other sources,
such as blood or other extracellular
fluids and Schwann cells, or by syn
thesis within the axon. The total
volume of neuroplasm may be re
placed several times each day.
Interruption of axoplasmic con
tinuity results in Wallerian degenera
tion of fibers separated from their cell
bodies. After an interval that varies
with the length of the distal stump,)
degeneration or other trophic changes
begin in the muscle or other cells in
nervated by the interrupted fibers;
these changes are clearly distin
guished from those induced by inter
ruption of impulses.3,4 We have tested
the hypothesis that the trophic depen
dence of a cell on its innervation is, as
in the case of the axon, also based on
the continual delivery, by the axon,
of substances that originate in the
nerve cell. We found that substances
(labeled with isotopes) in selected
nerve-cell bodies are conveyed down
their axons, across the j unctions, and
into the cells that they innervate.
We labeled hypoglossal and vagal
neurons with pH-inorganic phosphate
or C!4-amino acids by directly apply
ing solutions of these substances to
the posterior tip of the floor of the
fourth ventricle in rabbits ( 1 . 4 to 2. 5
kg) according to the method of
Miani. The solutions were deposited
in l-pl portions (each containing 3. 5
to 32 pc of radioactivity) at 10- to
20-minute intervals. We assured our
selves that good absorption occurred
Supported in part by a grant from the American
Osteopathic Association. We thank Dr. Gilbert Hart
man for his assistance in histological processing.
and that contamination of the ce
rebrospinal fluid (CSF) had been
avoided. A total of 50 to 20 pc were
applied to the nerve nuclei in this
manner. This report is based on
studies on 1 5 rabbits.
We demonstrated the specifcity of
our technique in animals killed and
examined at various times after the
labeling. Scans of the intact animals
showed that diffuse labeling rarely
occurred and that, when it did, it was
slight and transitory. Three-dimen
sional scanning' of various nerves ex
cised from the neck showed that, of
these, only the vagus and hypoglossal
were radioactive. When there had
been hemorrhage around the surgical
site or flooding of the ventricle with
CSF during application of the
isotope, radioactivity of the animal
was diffuse and specifcity was lost.
Radioactivity, as an irregularly
shaped wave-front on the three
dimensional scans, advanced along
the vagal and hypoglossal trunks at
about 5 to 5. 5 mm/day, a value com
parable to rates of 1 to 1 1 mm/day
reported for other mammalian
nerves and corresponding well to the
rate (5. 2 mm/day) of regeneration of
the vagus nerve. Scans of whole
organs and autoradiographs of sec
tions (1 to 2 mm) of tissue showed
that radioactivity reached the tongue
after about 5 days and the atria of the
heart after 9 or 1 0 days. The proximal
musculature of the tongue became
radioactive earlier and more intensely
than the tip. Crushing of one hypo
glossal nerve arrested radioactive
material at the site of the crushing,
where the substance accumulated,
and resulted in unilaterally radioac
tive tongues.
Having shown that radioactive
material had been transported to the
peripheral tissues only by the nerves,
we then used microautoradiographic
studies to determine the distribution
in the tongue of radioactive sub
stances conveyed by the hypoglossal
nerve. Our methods were those
described by Kopriwa and Leblond,9
in which slides bearing thin sections
of tissue fixed, embedded, sectioned,
and stained (hematoxylin and eosin)
in the usual manner were covered by a
thin layer of Eastman liquid emulsion
NTB-3. These slides were stored in
the dark at 5C until perioic sam
pling showed them ready to be de
veloped and prepared for microscopic
study.
We dealt with extremely low
concent rat i ons of r adioact ive
material in the tongue, i n contrast to
the amounts that can be introduced
by parenteral injection. We therefore
cut tissue sections thicker (6p) than is
desirable for good resolution and still
found extended exposure times (up to
5Yz months) necessary. However, as
we belatedly discovered, we had re
covered only a small portion of the
radioactivity we had been able to in
troduce into the nerve cells. Despite
the relatively thick sections we could,
wi th careful focusi ng of t he
microscope, trace the tracks of silver
grains to particular cellular struc
tures, although these relationships are
not always distinct in the photo
graphs taken at a single focal level. In
order to make the sparse silver grains
in the tongue more conspicuous, we
have photographed the preparations
through phase-contrast optics, which
cause the grains to appear as
somewhat enlarged bright spots.
Figure 1 a shows that the radioac
tive particles were densely packed in
the trunk of a hypoglossal nerve
whose cell bodies had been labeled 9
days earlier with glycine-2- C1 4;
radioactivity in the nerve sheath was
virtually absent. This fgure il
lustrates one of our experimental er
rors; more time (between labeling and
killing the animal) should have been
allowed for the nerve to "empty"
itself into the tongue.
Figure 1 , b and c, are sections from
the tongue of the same animal as in
Fig. 1 a. Labeled molecules were dis
tributed throughout the proximal
muscle cells (those in the vicinity of
the entry of the nerve), in the fibers,
nuclei, and sacroplasm. Radioactivity
on the tip at the same time was still
sparse and was apparently concen
trated mainly in the nuclei. This dif
ference between base and tip, appar
ently related to the length of the
neural pathway and, possibly, to the
density of innervation and to the
greater attrition of radioactive sub
stances in the longer passage, was a
9J
li. I. Autoradiographs of hypoglossal nuclei
labeled with glycine-2-C". The rabbit was
killed 9 days ater the labeled substance was ap
plied. (a) Longitudinal section of the right
hypoglossal nerve photographed in bright light
(unlike the others. al of which were taken in
phase-contrast). (b) Musclefrom proximal por
tion of tongue. right side. Labeling appears as
bright spots. Note other cells in same section.
(c) Muscle from distal portion of tongue. right
side. Note nonmuscle cells. All magnified 512
times.
4
Fig. Z. Unilateral radioactivity of tongue when axonal delivery was prevented on one side. (a and b)
Muscle of tongue. Left hypoglossal nerve cut; hypoglossal nuclei labeled with glycine_I_C
t
4. The
animal was killed on 8th day. (a) Left side; (b) right side. (c and d) Muscle of tongue. Right

hypoglossal nucleus labeled with P-phosphate. Left hypoglossal nucleus unlabeled. The animal
was killed on the 8th day. (c) Left; (d) right.
consistent feature, whether the label
was PH- phosphate of C4-amino
aci ds. Labeling of cells other than
muscle cells (and, in some sections,
branches or axons) was, as in Fig. 1, b
and c, negligible or absent.
When neural delivery of labeled
substances was l imited to one side,
there was unilateral labeling of
tongue muscle cells (Fig. 2). Sections
shown in Fig. 2, a and b, were taken
from the tongue of a rabbit in which
the left hypoglossal nerve had been
cut i mmediately before the hypoglos
sal nuclei were labeled with glycine-I
e14 The left side (Fig. 2a) showed
early signs of degeneration and no
radioactivity. In the normal, inner
vated section (Fig. 2b) the muscle
cells were strongly labeled. (Figure 2b
i l lustrates a frequent finding in some
of our preparations, the transverse
al i gnment of radioactive substances
in the muscle fibers. Precise localiza
tion awaits autoradiographs of higher
resol ution. ) The results were the same
in other experiments in which a small
segment of nerve was crushed and ax
oplasmic continuity thereby inter
rupted while the gross continuity of
the trunk and, presumably, of en
doneural fluid spaces was preserved.
No labeling of cells other than muscle
was found on either side. In two
experi ments we were able to label the
hypoglossal (and vagus) nerve only
on one side, while leaving intact the
nerves to both sides, thereby eliminat
ing any question of altered physio
logical state on the denervated side.
In one animal (Fig. 2, c and d) only
the right hypoglossal nucleus had
Axonal transport and trophic studies

been labeled (confirmed by micro

autoradiographs of the hypoglossal
nerves) and, correspondingly, only the
right side of the tongue waS labeled.
Although the tongue consists of a
large variety of tissues and cells (mus
cle, various sensory elements, connec
tive and adipose tissues, epithel i um,
glands, blood vessels, and so forth)
and is, correspondingly, innervated
by various nerves (hypoglossal ,
facial , trigeminal, glossopharyngeal,
and sympathetic), only the muscles of
the tongue are supplied by the hypo
glossal, and we have consistently
found that only the muscle cells are
labeled in our preparations, as shown
by Figs. 1 and 2.
No labeling is evident in other
tissues of tongues in which muscle
cells were strongly labeled (Fig. 3,
a-c). In contrast, when the CSF of
one rabbit had become contaminated
with the radioactive material, the en
tire body surface of the animal was
radioactive, and all the tissues of the
tongue were indiscriminately labeled
(Fig. 3d). Another signi ficant feature
of this preparation is that, unli ke
those shown in Figs. 1 and 2, there
was considerable radioactivity in
interstitial and apparently intravas
cular spaces.
Our observations indicate that,
when radioactive substances were
selectively introduced into hypo
glossal neurons, these substances, or
their derivatives, were conveyed
down the axons only to the muscle
cells of the tongue and that they
reached the muscle cells only via these
axons - or very nearly so. The label
ed molecules apparently crossed the
neuromuscular junction into intra
cellular components of the muscle.
We suggest that the proximo-distal
conveyance and intercellular transfer
of substances from the nerve cell may
underlie the so-called trophic and
other long-term influence not based
on impulses, of pheripheral neurons
on the metabolism, function, devel
opment, di fferentiation, growth, and
regeneration of the structures that
they innervate.
lD
Addendum
Further confi rmi ng t he axonal
delivery of substances synthesized in
the perikaryon is the high degree of
"privacy" or selectivity of that
delivery. As may be expected only a
portion of the hypoglossal neurons
Fig. J (a-c). (a) Serous gland, (b) mucous gland, and (c) vallate papilla from tongue shown in Fig.
2d. Note there is no labeling of these tissues. (d) Labeling by way of the extracellular fluid. The
cerebrospinal fluid of the fourth ventricle was contaminated with P"-phosphate and the animal
killed on the 9th day. Tissues other than muscle are labeled and the pal/er of radioactivity in
muscle is altered from that shown in Fig. /-3.
Fig. 4
5
(probably those closest to the surface)
receive radioactive precursor by our
methods, and only those neurons that
are labeled can, so to speak, make
delivery. This is illustrated in Fig. 4,
which for lack of space could not be
included in the original article in
Science. This photomicrograph
shows a muscle fascicle (cross
setion) richly tagged with l' sur
rounded by others that are untagged.
BcfcNacc
I. P. Weiss and H.B. Hiscoe, J. Exp. Zool. 107.315
(198); A. J. Samuls, L.L. Boyarsky, R.W. Gerard.
B. Libet. B. Brust, Amer. J. Physiol. 16. 1 (1951); H.
Konig, Trans. Amer. Neurol. Ass. 83. 16 (1958); H.
Waelsch and A. Lajlha. Physiol. Rev. 41. 70(191);
P. Weiss. in Regonal Neurochemistry, S.S. Kety and
J. Elkes. Eds. (Pergamon. New York. 191). p. 7;
S. Ohs, D. Dalrymple, G. Richards, Exp. Neurol. 5,
349 (192); B. Oroz and C.P. Leblond, Science 137.
107 (192); A.C. Taylor and P. Weiss. Proc. Nat.
Acad. 5. U.S. 54, 1521 (195).
2. P. Weiss, A.C. Taylor. P.A. Pillai, Science 136.
330 (192).
3. G.H. Parker. Amer. Natur. 6. 147 (1932); E.
Gutmann, Z. Vodicka, J. Zelena, Physiol.
Bheoslv. 4, Z (1955): J.V. Luco C.
Eyzuirre, J. Neurophysiol. 18, M(1955).
4. O. DennyBrown and C. Brener. Arch. Neurol.
Psyhiat. 51. I (194 ): N.C. Jefferson, T. Ogawa, H.
Neceles. Amer. J. Physiol. 193, 563 (1958); E. Gut
mann. Rev. Can. BioI. 21, 353 (192).
5. This work was summarized in preliminary form
ii I.M. Korr. P.N. Wilkinson. F.W. Chornok, Fed.
Pro. 25, 570 (196).
6. P. Miani, J. Neurohem, 10, 859 (193).
7. Picker Nucler Model 61(2S.
8. L. Guth and S. Jacobson. Exp. Neurol. 14, 439
(196).
9. B.M. Kopriwa ad C.P. Leblond. J. Histochem.
Cytohem. 10. (192).
10. E. Gutmann, Ed The Denervate Muscle
(Czehoslovak Academy of Sciences, Prague, 192);
E. Gutmann and P. Hnl, E., The Effet of Use
and Di suse on Neuromuscul ar Functi ons
(Czechoslovak Academy of Science, Prague, 1963):
M. Singer and J.P. Shade. Eds + Mehanisms of
Neural Regeneration, Progress in Brain Reerch
(Elsvier, Amsterdam, 19), vol. 13.
Reprinte by permission from Science 155:342345, 20
Jan 67; and from JAOA 6: 1057101, 197.
The nature and basis of the trophic
function of nerves: Outline of a research
program (1967)
When, in the course of embryonic
development, the advancing axon tip
of a peripheral neuron reaches and
joins the cells it is to innervate, an in
tercellular partnership - a functional
unit - is formed which endures for
the life of the organism. The com
plete differentiation and continued
growth and development of these
cells and of the organs they form are
dependent upon the establishment
and maintenance of the innervation.
This has been demonstrated for
skeletal muscles, for various glands,
sensory organs, and viscera.
This morphogenetic dependence of
organ or tissue upon its innervation
does not end with embryonic life. A
similar dependence - for mainte
nance or for restoration of structural
integrity, and of functional, chemical
and morphologic properties, and
even for the survival of some tissues
- is continued throughout life. 2-4
These diverse influences of peripheral
neurons, usually lumped together as
the "trophic" functions of nerves,
have been studied in various ways,
the most common being to examine
how the tissue or organ changes with
regard to structure, functi on,
responses, metabolism, et cetera,
after it i s denervated. Recently,
however, several investigators have
studied how the organ or tissue
changes when it becomes supplied by
a nerve other than its own.
When the neuron and the cells it
supplies are separated, as by cutting
or crushing the nerve, changes begin
in the denervated cells which may
progress over periods of many days,
months or even years. These pro
gressive changes may result in pro
foundly altered functional and mor
phologic characteristics; in impaired
capacity for growth, healing, and
regeneration; in altered enzyme ac
tivity, mitotic activity, metabolism,
and chemical composition. Responses
to various substances, stimuli, and
environmental factors are often quite
modified, and may even be reversed
in direction. Denervation may even
tually result in complete dedifferen-
tlatlon and degeneration of some
tissues. These include not only effec
tors, such as muscles and glands, but
sensory organs and receptors also
degenerate when disconnected from
their sensory neurons.
The changes that follow denerva
tion have been clearly distinguished,
as to nature, course, and extent, from
those due to arrest of impulse traffic
in the nerve, blockade of transmis
sion across junctions, or "disuse" of
the tissues. Quite obviously, arrest of
impulses or of activity could hardly
be the basis for the denervation
atrophy of sensory cells and organs
since it is they that initiate the nerve
impulses, which are conducted to the
central nervous system. Evidence ac
cumulated from diverse experimental
approaches and clinical observa
tions2-4 leads unequivocally to the
conclusion that the neural influences
which the post-denervation changes
refect are dependent, not upon excit
atory processes or neurohumoral
transmitters, but upon the mainte
nance of protoplasmic continuity
between the nerve-cell body at one
end of the axon and the contractile,
secretory, or receptor cells at the
other.
These long-term, property-deter
mining infuences of neurons upon
non-neural cells have also been dem
onstrated by changing their inner
vation as well as withdrawing it. For
example, switching the nerves to slow
and fast skeletal muscles (red and
white muscles, respectively, such as
the soleus and plantaris) results in
their interconversion, with corre
sponding changes in chemical, meta
bolic, and histologic characteristics. `
What is the nature, and the bio
logical basis, of these diverse non
impulse, conditioning, sustaining,
trophic influences of neurons? We do
not yet know, but we are well on the
way to finding out. This combined
question of nature and mechanism of
trophic influence, long an area of
mystery and conjecture, is now be
coming a very active area of investi
gation. It is a field into which we have
Axonal transport and trophic studies

ventured only recently - this Con

ference heard our first preliminary
and tentative reportS 2 years ago and
a somewhat more positive one last
year9 -and to which we have made a
small, but apparently provocative
contribution. 1 0 We wi sh in thi s
presentation to describe what we are
trying to find out about both the
nature and mechanism of trophic in
fluence, how we are going about it,
and what, in general, we have ob
served so far.
In our first contribution to the
question of mechanism, 1 0 we demon
strated, we believe, that the peripher
al neuron continually injects some of
its own cytoplasmic components,
assembled in the cell body and con
veyed down the axon, into the cells
that it supplies. With the use of auto
radiographic methods, it was possible
to trace the transport of isotope
labeled substances in hypoglossal
neurons down the axons and into the
muscle cells of the tongue. On the basis
of our observations, we proposed the
hypothesis that the nerve exerts its
trophic, supportive, and property
determining influences on the cells it
supplies through the neuroplasmic
components that it transfers to them.
In the next stage of this aspect of
our studies, for which we are now
preparing, we wish to seek two kinds
of information: (1) What substances
or kinds of substances are thus trans
ferred from the nerve cell to the mus
cle cell? (2) What is the fate of these
substances in the recipient cells? That
is, to what cell parts or organelles -
mitochondria, sacroplasm, Golgi
bodies, nuclei, et cetera - do they
go, and in what sequence?
In order to seek the answers to the
first question - the identity of the
substances transferred - the follow
ing basic procedure is followed.
Various precursors or components of
more complex molecules, tagged with
CI4 (radiocarbon) or H3 (tritium) , are
instilled into the brainstem nuclei of
the hypoglossal nerves of rabbits.
After about 3 weeks, sufficient for
much of the tagged nerve-cell
cytoplasmic material to be trans
ported down the axons, across the
j unctions, and into the muscle cells,
the animal is killed, and the tongue
and nerves are quickly excised. These
tissues are then disintegrated and ex
tracted. The extracts are fractionated
and the various fractions analyzed
and tested for determination of the
substances into which the isotope
labeled precursors have been incor
porated or converted.
What kinds of substances may be
involved in the transfer? The rela
tions between peripheral nerve cells
and the cells they innervate have been
shown to be so specific, and the prop
erties influenced by the nerves so
diverse, that one is led to suspect that
the specificity and diversity are based
on proteins or nucleic acids or both.
The likelihood that proteins may be
transferred from nerve cell to muscle
cell is strongly suggested by our ex
periments with tagged amino acids as
precursors, 1 0 especially in the light of
accumulated evidence that amino
acids in the cell bodies are rapidly in
corporated into protein, which then
passes down the axon, and that very
little if any free amino acid is found
in the axoplasm. 4 The possibility of
transfer of nerve-cell ribonucleic acid
(RNA) to muscle cells is supported by
recent demonstrations of its presence,
and of its proximodistal migration, in
axons.ll,12
The question may be raised with
good reason, however, whether such
large molecules are able to pass across
the junctional membranes. But even
this doubt seems about to be resolved
by the recent evidence for pinocytosis
- the transfer of cytoplasmic vesicles
- across the motor end-plate. 1 3 The
demonstration of the intercellular
transfer of RNA-template or of sub
stances synthesi zed under RNA
coding would, of course, be of great
theoretical significance.
To seek answers to our second
question, the fate of the transferred
substances (whatever they may turn
out to be) in the recipient cells, por
tions of the same specimens which are
extracted for chemical studies will be
processed for high-resolution auto
radiography. We expect in this way to
identify, more precisely and specifi
cally than in our previous investi
gation,lo the cell structures in which
the radioactive substances are found
at various times after entering the
muscle cells from the nerve terminal:.
When we know what substances pass
from nerve cell to muscle cell and
where they go in the muscle cell, we
shall have a fairly good idea of what
they do there and how nerve cells in
fluence the life history of their non
neural life partners.
Let us turn now from our studies
on the mechanisms of neurotrophic
function to our others, aimed at its
nature. In these our basic strategy is
to study the structural, functional,
and chemical changes induced in a
given tissue by substituting a foreign
innervation for its own; and this is the
area on which we have concentrated
during the past year. As described in
the accompanying abstract, 14 we have
been able to induce tongue muscle to
accept vagal innervation in place of
hypoglossal, and diaphragm to accept
fibers of the vagus or recurrent
laryngeal nerves in place of phrenic.
We hope soon also to innervate
sternomastoid muscles with hypo
glossal nerves. After sufficient time
has been allowed -6 to 1 5 months -
for the nerve to grow to the muscle,
for functioning junctions to be
established, and for the muscle to
recover from its temporary denerva
tion, the degree of success of the sub
stituted innervation is assessed by
electro myographic procedures while
the nerve is stimulated above and
below the anastomosis, and before
and after sectioning the nerve at
various points.
The animals are then killed and
specimens of the tongue or dia
phragm, taken from both the normal
and operated side for comparison,
are prepared for histologic study, for
study of motor end-plate morphol
ogy, for determination of concentra
tions of various substances and of the
activities of various enzymes.
While continuing this project, de
signed to reveal what in the muscle
cells is subject to neural influence, we
wish to link it to the other project, on
how. Our approach is based on the
premise, previously expressed, that
the relationship between a particular
nerve or group of nerve cells and its
end-organ, and the diverse influences
of nerves are each based on specific
RNA or protein molecules. We wish
to determine, by analysis of nerve
and-muscle partners , not only
whether the RNA or protein fractions
vary from nerve to nerve and end
organ to end-organ, but, also,
whether particular fractions of pro
tein or RNA are common to the nerve
cells and muscle cells which are
joined. (Fascinating, and clinically
important, questions of immuno
chemistry and autoimmune reactions
are raised by this possibility.) As a
T
corollary, we wish to find out, when
foreign innervation is established to a
muscle, not only whether new and
different protein fractions are in
ducd in that muscle by its new nerve
(as takes place in the interconversion
of fast and slow muscles on cross-in
nervation'), but whether any, and
which, of the new protein fractions
are identical to those in the nerve,
either directly transferred or syn
thesized in the muscle cell under
nerve-RNA direction.
There are, of course, still other key
questions regarding the nature and
mechanism of trophic function that
must be explored. A few that are also
on our agenda are, for example:
1 . What role is played in trophic
function by the transport of sub
stances in the endoneurial spaces be
twen the axons, such as has been
under study for some years by Ap
peltauer,
U.16
who recently joined this
program?
2. What, if any, is the role of
substances transported from the
Schwann cells, through the myelin
sheaths, to the axon, and which there
by bypass the cell body?
J. In view of the evidence that the
trophic relationship between neuron
and (for example) muscle cells is quite
a mutual one, in which the neuron is
dependent in many ways upon its
connection to its non-neural partners,
is there also transfer of substances
across the junction in the opposite di
rection, trom muscle cell to axon,
with "upstream" transport to the
neuron?
Concerned as all these questions
are with the lifelong, direct infuences
exerted between neurons and their
cell partners and with the exchange of
cellular materials directly between
cells (rather than through blood or
other extracellular fuids), they have
crucial significance to some of the
most fundamental areas of cellular
and molecular biology. In addition,
however, they have some exciting
clinical implications. In view of the
profound influences exerted by
nerves on the structure, function,
growth, metabolism, and regenera
tive power of innervated tissues and
organs and on their responses and
adaptations to many factors, it may
be expected that, under certain cir
cumstances, the influences of a given
nerve may become adverse and detri
mental to the organ it innervates,
98
thereby contributing to disease. The
evidence for neurogenic lesions and
dysfunction, in endless variety,
abounds in experimental and clinical
literature and in daily practice.
What kinds of circumstances ma
cause peripheral neural influence to
become adverse? Almost any factor
which more or less enduringly exag
gerates or suppresses the excitability.
activity, and energy-exchange of the
neuron, retards its remarkably high
rate of protein synthesis, qualitatively
modifies the products of that syn
thesis, or impedes the axoplasmic
flow of those substances, would be
detrimental to the innervated cells
and organs. Among those factors,
therefore, would probably be the
abnormal bombardment of peripher
al neurons, via descending pathways,
due to mental or emotional stress,
tension, or inhibition; or. via sensory
pathways, due to environmental
stress. Among them also would prob
ably be some of the nutritional, toxic,
and viral insults to neurons.
Most certainly involved -and on a
vast scale - are the direct physical
and chemical insults imposed on
nerves (and on the vessels that
nourish ad drain them) by the struc
tures and tissues through which they
must pass, on their way from their
origins, largely in the spinal cord, to
their peripheral terminals. For these
reasons, it is these, the myofascio
skeletal tissues, that provide the
environment for most of the cyto
plasm of peripheral nerve - that in
the axons (and in the Schwann cells
that apparently nourish the axons). It
is also these nerve-environing myo
fascio-skeletal tissues that are subject
to, and that produce, the largest
forces in the body, and that through
contractile and high metabolic activi
ty produce profound chemical
changes. These physicochemical fac
tors in the tissues through which, and
between which, nerves pass, would
almost certainly affect the quality and
flow of neuroplasm and of endo
neurial fluids, most particularly in
areas of musculoskeletal stress and
deformation, sustained muscular
contraction, adhesion, edema, fo
raminal or dural compression, et
cetera. It is the same tissues, also,
that through their proprioceptors
profoundly affect the excitability and
activity, and therefore the metabo
lism, of peripheral neurons.
This area - the long-term in
fluences of the innervation on the
condition of cells, organs and tissues,
and the aberrations of these in
fluences due to behavioral, environ
mental, nutritional, postural, and
mechanical factors is one of the
most pervasively significant and, as
yet, unexplored areas of clinical
medicine. It may even be possible one
day to treat the malfunctioning or
diseased organ through its innerva
tion (almost certainly a mechanism in
manipulative therapy) or by adminis
tration of specific neural substances.
We hope that in seeking answers to
some of the fundamental questions,
we may also contribute to a signifi
cant advance in therapeutics.
References
1. Weiss. P., Ed.: Genetic neurolog. The Universi
ty of Chicago Pres. Chicago. 1950.
2. Gutmann. E., Ed.: The denervated muscle.
Publishing House of the Czechoslovak Academy of
Sciences. Prague. 1962.
3. Gutmann, E + and Hnlk. P., Eds.: The effect of
use and disuse on neuromuscular functions. Pro
ceedings of a symposium held under the sponsorship
of the International Union of Physiological Sdences.
Publishing House of the Czechoslovak Academy of
Sciences. Prague. 1963.
4. Singer. M o and Schade. J.P Eds.: Mechanisms
of neural regeneration. Progress in Brain Research.
vol. 13. Elsevier. New York, 1964.
5. Buller, A.J Eccles. J.e.. and Eccles. R.M.: In
teractions between motoneurones and muscles in re
spect of the characteristic speeds of their responses. J.
Physiol (London) 150:417-39. Feb 6.
6. Buller, A.J., and Lewis. D.M.: Further observa
tions on mammalian cross-innervated skeletal muscle.
J Physiol (London) 178:343-58. May 65.
7. Guth, L.. and Watson. P.K.: The influence of in
nervation on the soluble proteins of slow and fast
muscles of the rat. Exp Neurol 17:107-17. Jan 67.
8. Korr. I.M., Wilkinson, P.N., and Chornock.
F.W.: A study in trophic mechanisms. JAOA
6:935-6. May 65.
9. Korr. I.M + Wilkinson. P.N and Chornock.
F.W.: Studies in neurotrophic mechanisms. JAOA
65: 99-1. May 66.
10. Korr, I.M., Wilkinson. P.N + and Chornock.
F.W.: Axonal delivery of neuroplasmic components
to muscle cells. Science 155: 342-5. 20 Jan 67.
11. Koenig. E.: Synthetic mechanisms in the axon.
II. RNA in myelin-free axons of the cat. J Neurochem
12:357-61. May 65.
12. Miani, N = DiGirolamo. A and DiGirolamo.
M.: Sedimentation characteristics of axonal RNA in
rabbit. J Neurochem 13:755-9. 1966.
13. Andres. K.H and v. Doring. M.:
Mikropinozytose in motorischen Endplatten. Natur
wissenschaften 53:615-6, Dec ( I ) 6.
14. Korr, I.M.. et al.: Studies in trophic
mechanisms: Does changing its nerve change a mus
cle? JAOA 66:989.9, May 67.
15. Appeltauer, G.S - et al.: Uptake of C"- L-Iysine
into segments of normal rat sciatic nerve. Exp Neurol
12:215-9. Jul 65.
16. Appeltauer. G.S., and Sa, E.E.: Incorporation
Axonal transport and trophic studies
of C-14 lysine into spinal roots, spinal ganglia and
peripheral nerves of the rat. Exp Neurol 14:484-95,
Apr 6.
1 7. Singer, M., and Salpeter, M.M.: The transport
of 'H-I-bistidine tbrough tbe Schwann and myelin
sheatb into tbe axon, including a reevaluation of
myelin function. J Morpb 1 20:281 -31 5, Nov 66.
This program is made possible by the
collaboration of P.N. Wilkinson, B.A., F. W.
Chornock, Ph.D., a.S.L. Appeltauer and the
author
.
all of the Kirksville College, and W. V.
Cole, D.O., of the Kansas City College of
Osteopathy and Surgery. We are grateful to
Dr. Cole and his College for his microanatomic
contributions to this program.
Reprinted by permission from JAOA 66:74-78, 197.
Studies in trophic mechanisms: Does
changing its nerve change a muscle? (1967)
l.M. KORR, F.W. CHORNOCK, W. V. COLE and P.N. WILKINSON
In addition to regulating contractile
and secretory activity from moment
to moment by changes in impulse
fow, peripheral neurons also exert a
variety of long-term conditioning and
supportive influences on the growth,
regeneration, structure, metabolism,
and functional capacity of the cells
they innervate, For some tissues,
most notably skeletal muscle, the
nerves are essential for tWeir very
maintenance and survival . Our prev
ious studies suggest that the trophic
support and conditioning of muscle
by its innervation may be based on
the continual delivery of specific
neuroplasmic components to the
mucle cells. ``

The present studies are

directed toward better understanding
of the nature and kinds of trophic in
fluence exerted by nerves.
The usual approach to this field has
been to withdraw the trophic influence
by cutting the nerves to the tissues,
and then to study the changes that
have taken place at various times fol
lowing denervation, while "correct
ing" if possible for the changes due
merely to interruption of impulses.
Our approach has been to change the
innervation, rather than withdraw it.
We wish to know how a given tissue
or organ changes when it is induced
to make a functional union with a
nerve other than its own. What prop
erties of the tissue are speciicaly
determined by the nerve cells to which
it is joined, and what, in the nerve
cells, are the determining factors?
Seventy-three nerve-interventions
have been performed on an equal
number of rabbits. In 25 of these, the
hypoglossal innervation to one side of
the tongue was replaced by the vagus
(vago-hypoglossal anastomosis). In
24 others, the phrenic nerve to one
hemidiaphragm was replaced either
by the vagus (vagophrenic anastomo
sis) or by the recurrent laryngeal
nerve. The remainder were control
preparations. Sixteen of these con
sisted of section and immediate re
anastomosis of one hypoglossal or
phrenic nerve as controls for the ef
fects of temporary denervation and
for various degrees of re-innervation.
Eight were permanent unilateral de
nervations. In addition, each animal
provided its own control - the nor
mal half of the tongue or the normal
hemidiaphragm - for comparison
with the experimental side.
The tongues and diaphragms from
some of the operated animals are now
being studied for functional, struc
tural, and chemical changes at var
ious periods up to 1 5 months after
surgery. Electromyographic studies
are done, under anesthesia, on the
tongue or diaphragm of each animal
for evaluation of spontaneous activi
ty and response to stimulation of the
nerve above and below the union.
Electromyographic recording is re
peated after various sections have
been performed to determine the
source or sources and the extent of
the innervation. After electromyo
graphic study the tissues are removed
for microscopic study of morphologic
changes in cells, tissues, and motor
end-plates, changes in concentration
of certain chemical components (for
example, glycogen, inorganic phos
phorus, and non-protein nitrogen)
and in the activity of certain enzymes.
"Foreign" innervation has been
achieved, at least to some degree in 1 5
of the experimental animals examined
thus far. In some, re-innervation (and
regeneration) of the muscle by the
foreign nerve was complete or almost
complete. In others, it was partial,
the rest of the muscle remaining
atrophied. In animals where the roots
of the original innervation had not
been completely extirpated, we occa
sionally found that the innervation
was mixed or that, in regenerating,
the original nerve had prevented
foreign innervation or had even re
placed it after it had been established.
Especially interesting theoretical
questions are raised by possible re
placement of motorneurons by pre
ganglionic neurons which ordinarily
synapse only with other (postgan
glionic) neurons (which, in turn,
innervate smooth or cardiac muscle
or gland cells) . At this stage of our in
vestigations it is still too early to offer
answers to these questions or to
describe the morphologic and bio
chemical transformations induced by
foreign innervation.
References
1. Korr, LM., Wilkinson, P.N., and Chornock,
F.W.: Studies in neurotrophic mechanisms. JAOA
65:91, May 6.
2. Korr, I.M., Wilkinson, P.N., and Cbornok,
F.W.: Axonal delivery of neuroplasmic components
to muscle cells. Science 155:342-5, 20 Jan 67.
Reprinted by permission from JAOA 66: 7980, 1 967.
99
Continued studies on the axonal transport
of nerve proteins to muscle (1970)
I.M. KORR and G.S.L. APPELTAUER
We undertook the study of the axonal
delivery of macromolecular compo
nents of nerve cells to muscle as a
possible mechanism in the trophic
function of nerves. In our first study,
using autoradiography, we demon
strated such delivery by hypoglossal
axons to muscle cells of the tongue,
following the application of radioac
tively labeled precursors to the nerve
cell bodies in the floor of the fourth
ventricle in rabbits. In subsequent
studies reported in part at this con
ference last year, we demonstrated
that between 1 3 and 30 days after
labeling hypoglossal neurons in the
medulla with C1'-leucine, radioactive
protein could be extracted from the
tongue muscles in quantities two
to three times larger than could
be ascribed to incorporation of
C "'-leucine carried in the blood.
Smaller "excesses" were evident
several days before and after the 1 3 to
30-day period.
In the pas year. we have extended
these studies to a much larger series
of experiments. and employed much
more refined methods. The new
methods include: (1 ) more precise and
reproducible labeling of the hypo
glossal neurons, and concentrating
the label, as far as possible. on one
side; (2) extraction of proteins with
cold 1 0 per cent trichloroacetic acid
(TCA); (3) use of leucine labeled with
tritium (H )of extremely high specific
activity (35-57) curies per millimole).
making possible the achievement of
much higher levels of incorporated
radioactivity than was possible with
CU; and (4) use of internal liquid
scintillation for radioassay of ex
tracted fractions of tissue specimens,
instead of surface counting.
In a series of sham-operated rab
bits in which the HI-leucine, 80
microcuries. was injected intraperito
neally. we confirmed that the stylo
hyoid and mylohyoid muscles (inner-
Supported by PHS Research Grant No. NS'7919
from the National Institute of Neurological Diseases
ad Stroke, ad by a grant from the American
Osteopathic Association.
IW
vated by the facial and trigeminal
nerves, respectively) were, at all inter
vals after injection, reliable indicators
of the amount of radioactive protein
which had been incorporated by the
tongue muscles (innervated by the
hypoglossal nerve) from blood-borne
HI-leucine. Therefore, in the experi
mental animals in which hypoglossal
neurons had been presented with
HI-leucine (80 microcuries) directly
applied to the floor of the fourth ven
tricle, the excess of protein-incorpo
rated radioactivity per milligram of
fresh tongue muscles over that of the
control muscles (stylohyoid and
mylohyoid) represents radioactive
proteins conveyed to the tongue
muscles by the hypoglossal nerve.
Animals were sacrifced at various
intervals from several hours to 76
days after the HI- leucine, absorbed
on a small piece of filter paper. had
been applied for 1 5 minutes to the left
side of the foor of the fourth ventri
cle. Specimens of the following tis
sues were obtained from each animal:
(1 ) four consecutive segments of the
left hypoglossal nerve (to indicate any
longitudinal gradients) ; (2) the right
hypoglossal nerve, for comparison
with the left, to indicate the degree of
unilaterality of labeling; (3) left and
right stylohyoid and mylohyoid
muscles (that is, four specimens of
control muscles) ; (4) three portions
each (in longitudinal sequence) of the
left genioglossus and styloglossus
muscles of the tongue; (5) blood
plasma; and (6) medullary tissue from
the fourth ventricle. Specimens of
control and experimental muscles
were also prepared for subsequent
autoradiographic study.
Specimens were rapidly homoge
nized at 0-2 C. Proteins and other
macromolecular components precipi
tated by cold 1 0 per cent TCA were
washed twice with cold TCA, and
then with a series of organic solvents.
The protein precipitates were digested
with Soluene (Packard Instrument
Company) and counted in toluene
based fuor cocktails, at efficiencies
of approximately 36 per cent. Ali-
quots of pooled, neutralized TCA
supernatants ("acid-soluble" com
ponents including unincorporated
precursor) were counted in fuor
cocktails emulsified in a 2: 1 (V: V)
mixture of toluene and Triton-X- l O,
at efficiencies of approximately 23
per cent. The organic solvent washes
were discarded. Counts were cor
rected for background and for
quenching, and converted to disinte
grations per minute per milligram
(dpm/mg.) of fresh tissue (Packard
Tri-Carb Scintillation Spectrometer
Model #3375).
Except in those animals sacrificed
within the first few days after applica
tion of the HI-leucine to the hypo
glossal nucleus, the amount of unin
corporated precursor (that is, radio
activity of the supernatants) was very
small in relation to that of the TCA
precipitates (protein fractions); only
the latter are reported in this abstract.
Also, for reasons of brevity, we shall
comment only on nerve-delivery to
the styloglossus muscle of the tongue;
data on the genioglossus, showing
certain qualitative differences, will be
reserved for a fuller report.
With our present methods and ma
terials we have been able to introduce
much more radioactivity into the
neurons with a proportionately much
smaller "washout" into the blood,
and, in comparison with our previous
report,2 have expanded the nerve
delivered component of total tongue
muscle radioactivity (that is, counts
in the protein fraction) thirty- to
fifty-fold. On the basis of ffty-five
experiments successfully completed
thus far, with this magnification, it
has been possible to confirm un
equivocally the delivery of protein to
muscle by nerve and, in addition, to
discer at least three "waves" of pro
tein transport traveling at different
rates down the nerve to the muscle.
Some uncertainty as to the precise
number and duration of the waves,
especially the slower ones, remains,
because of unavoidable animal-to
animal variations (for example, in
nerve length) and because of the
possibility of overlap of the wake of
one wave and the rising phase of the
succeeding one. We expect the waves
to be more distinctly revealed with
additional data.
The following are the apparent
waves at this point in the investiga
tion:
Axonal transport and trophic studies
1 . The first wave of radioactive
protein, and the most definitive,
reaches the muscle within the first 24
hours after uptake of the H3-leucine
by the neurons. This protein appar
ently has a short half-life in the mus
cle and/or nerve endings, since by the
third day intramuscular radioactive
protein has fallen almost to control
values, and remains low for several
days longer even though protein
radioactivity in the nerve is quite con
siderable during this same period.
2. Another wave begins reaching
the muscle on about day 1 0, peaking
at day 14. Intramuscular radioactive
protein remains elevated until about
day 1 6, after which it falls precipi
tously.
3. Another rapid rise begins afer
day 1 9 to a peak at day 20, the protein
radioactivity in the styloglossus re
maining, in general, well elevated un
til day 29, after which it declines
gradually over the next 4 days or
more, to control values. In contrast
with that in the first wave, therefore,
this protein appears much more
stable. (The 1 3-30 day period indi
cated in our preliminary investiga
tion,2 using C '4-leucine and surface
counting, corresponds to waves 2
and 3.)
The evidence for two or more
waves is consonant with accumulat
ing evidence from a number of lab
oratories that axoplasm does not
move at a uniform rate, as had been
thought, but, instead, there are
several systems of axoplasmic trans
port carrying proteins of different
properties, and probably different
functions, at very different rates; ( 1 )
a fast system transporting proteins
proximodistally at rates of 4 to
several hundred mm.l day, depending
on species and kind of neuron; (2) an
intermediate system operating at rates
of several ( for example, 5- 1 1 )
mm.lday; and (3) an apparently basic
axoplasmic stream of about 1
mm.lday.3-6
Since it may be assumed that, in
each animal, at least a portion of the
radioactive protein extracted from
the muscle had been contained in in
tramuscular nerve endings, we must
await study of autoradiograms still in
process to determine in which phases
of which waves the crossing into mus
cle cells occurs, and the location of
the radioactivity in the muscle cells.
(It is interesting that the auto radio-
graphic data previously reported by
usl were taken from animals sacrifc
ed during the early part of what i s
now identified as the second wave.)
Unfortunately, because of the low ac
tivity, long exposures are required for
the autoradiographic portion of these
investigations.
We hope also, by electrophoretic
and other means, to identify proteins
shared by the hypoglossal nerve and
tongue muscles and to determine the
distribution of radioactivity among
the protein fractions during the dif
ferent waves of delivery.
References
l. Korr, I.M., Wilkinson, P. N. , and Chorock,
F.W.: Axonal delivery of neuroplasmic components
to muscle clls. Science 155:34245, Jan 67.
2. Korr, l.M., and Appeltauer, G.S. L.: Studies on
the transfer of neuronal protein to muscle cells:
Preliminary report. JAOA 68:79-81, Jun 68.
3. Lasek, R.J.: Axoplasmic transport of labeled
proteins in rat ventral motoneurons. Exptl Neurol
21: 41-51, 1968.
4. McEwen, B.S., and Grafstein, B.: Fast and slow
components in axonal transport of protein. J. Cell
Bioi 38: 494508, Sep 68.
5. Ochs, S., Sabri, M.I., and Johnson, J.: Fast
transport system of materials in mammalian nerve
fibers. Science 163: 686-87, 14 Feb 69.
6. Barondes, S., Ed.: Axoplasmic transport.
Neurosci Res Prog BullS, (No.4) 305-419, 15 De 67.
Appreciation is expressed to Mrs. Nancy Keith
and Mrs. Sharon Biery for their excellent
technical assistance. The participation of Mr.
John Kilgore. second year student, during the
summer was also most valuable. We are grate
ful for the assistance of Mr. Paul N. Wilkinson
in various aspects of isotope technology,
Reprinted by permission from JAOA 69: 76-78, 1970.
I0I
The time-course of axonal transport of
neuronal proteins to muscle* (1974)
IRVIN M. KORR and GUSTAVO S.L. APPELTAUFR
The long-term influences of nerves
on tissues and organs have been the
subject of many studies, performed in
many species and i n various ways (re
viewed by Guth 6, 7), Thus, innerva
tion is essential for the embyronic
and postnatal development of certain
tissues and organs and for the mainte
nance of their structural and func
tional integrity, Also, limb regenera
tion in lower vertebrates depends on
the presence of the peripheral nerves
and of an adequate ratio of neural
mass to limb mass. Cross-unions
between nerves supplying muscles of
different types have shown that the
gene expression in straited muscle is
subject to neural regulation (8, 9).
The mechanisms of these and other
"trophic" influences are not yet
clear, other than that they are based
not on impulse conduction but on
integrity of connection between the
neurons and the end-organs.
Several years ago, we presented
radioautographic evidence that some
macromolecules synthesized in the
hypoglossal nerve cell bodies and
conveyed proximodistally in the axo
plasm apparently cross the myoneural
junction and enter the tongue muscles
( 1 2) . Nerve-to-muscle transfer was
demonstrated in a period 8-1 5 days
after applying precursor to the
neurons. This period was selected on
the basis of the apparent velocity of
axoplasmic fow (approximately 5
mml day) revealed by 41-scans of the
hypoglossal nerves. We proposed that
such nerve-to-muscle transfer of spe
cific neuroplasmic components might
play an important role in the various
trophic influences of nerves.
This report presents our findings |
in a quantitative study of the trans
port of neuronal protein, measured as
protein-incorporated radioactivity.
At various times after applying tri-
'Supported by Grant No. NS-07919 from the National
Institutes of Health and by a grant from the American
Osteopathk Association.
tpreviously reported in April. 1971 (1 3).
102
tiated leucine to hypoglossal neurons
protein and nonprotein fractions
were extracted from tongue muscle
and hypoglossal nerves and radio
assayed. Radioautographic prepara
tions were made from portions of the
same muscle specimens in order to
study the localization of the radio
active components. These will be the
subject of a subsequent report.
Methods
Surgical Preparation. For the intra
ventricular labeling of hypoglossal
neurons, we used 1 48 New Zealand
rabbits of both sexes, weighing
1 .6-2.3 kg. Immediately before the
operation, a solution containing 80
pCi of 4-S-lH-L-leucine (specific ac
tivity 30-57 Ci/mM; Amersham
Searle) was rapidly reduced in volume
by evaporation over Drierite at re
duced pressure. It was absorbed on a
small piece of filter paper ( 1 . 5 x 0. 75
mm) with one surface covered with
Para film that was shaped to fit the
left side of the fourth ventricle.
Under pentobarbital anesthesia, the
floor of the fourth ventricle was ex
posed, very much in the manner de
scribed by Miani ( 1 9). To keep the
area free of cerebrospinal fluid, a
posterior choroidectomy was per
formed and the area was dammed
with neurosurgical absorbent (Cod
man and Shurtleff, Inc.), from which
the fuid was withdrawn by aspira
tion. The strip containing the isotope
was then placed paper side down on
the area over the left hypoglossal
nucleus for 1 5 min. It was then re
moved; the area was kept dry for an
additional 2 min. The wound was
then closed. Antibiotic (Pfizer Com
biotic) was administered after surgery
and on three postoperative days.
By this technique we were able to
concentrate most of the precursor
into the left hypoglossal nerve and
left side of the tongue. Our placement
of the percursor-Iaden paper was such
that of the two tongue muscles sam
pled, much more protein-incorpo
rated radioactivity accumulated in the
styloglossus than in the genioglossus
muscle, and this report is limited to
the styloglossus.
For the intraperitoneal injection, a
similar (sham) operation was done on
1 8 additional rabbits in which the
paper applied to the floor of the ven
tricle contained no 3H-Ieucine and in
which 10 ml of normal saline contain
ing 1 60 pCPH-leucine was injected in
traperitoneally.
Tis ue Specimens. Operated rabbits
were killed by exsanguination under
light pentobarbital anesthesia at spec
ified times after administration of
the labeled precursor. The following
tissue specimens were taken: a) Con
trol muscles: left and right stylohyoid
and mylohyoid muscles (see later); b)
Tongue muscles: left and right stylo
glossus and left and right genioglos
sus muscles, each cut into 3 segments
in the proximodistal axis; c) Hypo
glossal nerves, between emergence
from the cranium and points of entry
into tongue muscle, were cut into
four segments; d) medulla (left half
of foor of 4th ventricle); e) blood
plasma. Muscle specimens were care
fully cleaned, in a cold moistcham
ber. of nerve branches and connective
tissue under a dissecting microscope.
The epineurium was stripped from all
nerve specimens.
Extractions. All procedures were car
ried out at 2-4C. After addition of 5
mg of crystalline bovine serum albu
min as carrier, the tissue specimens
were individually homogenized in
glass vessels, with close-fitting Tefon
pestles, containing 4 ml lOOo trichlor
acetic acid (TCA) and 0. 5 mg carrier
leucine. The homogenates were cen
trifuged for 10 min at 1 0,00 RPM.
The pellets were twice rehomogenized
and washed with 4 ml of 1 00 TCA
solution. The pooled supernatant
(hereafter identified as TCA-soluble
fraction) from each of the specimens
was neutralized with K2COl and
brought to a final volume of 25 ml
with distilled water. A 5 ml aliquot of
each TCA-soluble fraction was taken
for radioassay.
The pellet was twice again rehomog
enized and washed with each of the
following solutions (ratios indicated
by volume) :8 ml ethanol-ether ( 1 : 1) ;
1 0 ml methanol-chloroform-ether ( 1 :
2 : 3) ; and 10 ml ether. The remain
ing precipitate will be referred to as
the protein fraction.
Axonal transport and trophic studks
The radioactivity of the TCAsolu
ble fractions was determined accord
ing to the method of Patterson and
Greene (21 ). The counting efficiency
was 230. Tests showed that more
than 9900 of the free leucine was
recovered in the TCA-soluble frac
tion. The protein fractions were di
gested for 1 6 hr at room temperature
in 0. 1 ml water and 2 ml Soluene
(Packard Instrument Co. ). Digests
were dissolved in 1 8 mi of toluene
based scintillators (PPO-POPOP
mixture) and counted in the Packard
#3375 Tri-Carb Scintillation Spec
trometer. The counting effciency was
4200 . After quench-correction, the
radioactivity was expressed as disinte
grations per min per milligram of
fresh tissue (dpmlmg).
Results
Control jor incorporation oj blood
borne precursor by tongue muscle. It
is inevitable that a portion of the
original precursor charge applied to
the surface of the medulla will be lost
to the cerebrospinal fluid and thence
to the bloodstream, and that some
loss to body fuids continues through
out each experimental period. It was
necessary therefore to measure, in
each animal, how much of the radio
active protein in the tongue muscle
represented incorporation of lHleucine
carried in the blood. For this purpose
we sought muscles innervated by
nerves other than the hypoglossal
which incorporate the same amounts
of blood borne leucine per mg of
tissue as do the tongue muscles.
In a series of shamoperated ani
mals in which the tritiated leucine was
injected intraperitoneally, the stylo.
hyoid and mylohyoid muscles, inner
vated by branches of the facial and
trigeminal nerves, respectively, incor
porated circulating leucine into pro.
tein in amounts very similar to those
in the genioglossus and styloglossus
musces of the tongue.
Figure 1 shows the results of one
such sham-operated rabbit killed 1 8
days after surgery and intraperitoneal
injection. The graph illustrates the
close correspondence of protein (as
well as total) radioactivity of the con
trol muscles to that of the tongue
muscles. Also shown, on the same
scale of radioactivity, are the extra
cranial portions of the hypoglossal
nerves, desheathed and cut into four
segments of approximately equal
0FM7M

M
d
K
M 9 Z d , M MMM l Z l Z
NL N LH W W
l l
L
Fig. I.Expriment showing reults I8days ater sham opration and in
trperitoneal injection of'H-leucine. Ordinate-dpm/mg freh weight of
the various specimens. Black-TCA-insoluble frction; Oray-TCA
soluble-fraction; Cros-hatched-(M-medulla and P-plama) total
radioactivity. NL, NR-hypoglossal nerve, let and right; segments 1-
in proximodistaf sequence; SL, SR-stylohyoid muscle, let and right,'
MHL, MHR-mylohyoid muscle, left and right; OL, OR-genioglosus
muscle, left and right; SOL, SOR-styloglossus muscle. let and right.
w r M
--
`

" 0 f " 0
0 0
0
c 0 8 4

Fig. 2. Incorporation ofblood-bore 'H-leucine into protein by tongue
and control muscles. Ordinate-dpm/mg freh wight; abscisa-days
after sham opertion and intraperitoneal inection. -average ofJpor
tion of styloglos us mucle (SOL) O-average of4 control muscle (SL,
SR, ML, MR; see Fig. I).
9UUU
ZUUU
M | Z 9 | Z 0 4
DPM/mg

` ` `
NL NH H
Fig. J. Eperiment showing results II. /5days after intraventricular ad
minitration of 'H-Ieucine. Symbol same as in Fig. 1. Note ZOfold di
ference in radioactivity scales for nerve and muscle.
I0J
30
I .
I
,
,
,
,

UU
W~. .
c
, ,
g ,
.
. g
,
Z
. ,
9

, ,
DPN
K
_

.
" ,
. . . ' .

,

. . ' - " .

. . . :
.
. .
.
:
.
.
.

_
.
.
, .
. .
' . "
`
g
.
"
1
'
,

.
.

.
| f-

, .

g
P

O
I
9 "

., : . :. r
.
,_( ).: u" tgfg
. .
8
".
.
lU Z N %
Fig. 4. Summary ofeperiments with intraventricular adminitration of
'H-Ieucine. Ordinatedpm/mg fresh weight; abscisa-days ater ad
ministration . -average of3 portions of left styloglossus muscle (SOL).
O-average of4 control muscles (SL, SR, ML. MR) showing portions of
protein incorporating blood-bore precuror.
o o
o
K
o o
&
o
0Y AP ADI5TAT|0N
Fig. 5. Tratment ofdata from Fig. 4 presenting 2, 3 and 4-day means and
standard deviations. "Corrected" for apparent dosage . -SOL muscle;
O-control.
length. Radioactivity (undifferenti
ated into protein and acid-soluble
fractions) of medulla and blood
plasma were routinely determined in
all of the experimental animals, pri
marily to monitor our techniques,
and do not enter into analysis of the
data. In all specimens in this experi
ment, maximum protein radioactivity
was below 4 dpm/mg.
Figure 2 shows the results of 1 8
such experiments, the specimens of
styloglossus and control muscle hav
ing been taken at various intervals be
tween 1 and 76 days after the intra
peritoneal injection. Evidently, the
control muscles that we selected give
a reliable index of radioactive protein
incorporating blood-borne lH-leucine
in the styloglossus muscle of the
tongue.
meach of the experiments described
in the next section, we therefore
used the stylohyoid and mylohyoid
muscles to indicate the blood-derived
portion of protein radioactivity in the
tongue muscles, the remainder being
10
ascribable to delivery via the hypo
glossal nerve.
Intraventricular labeling ojhypoglos
sal neurons. Figure 3 shows one ex
periment in which the 3H-Ieucine had
been applied directly to the left hypo
glossal nucleus, as described. The
rabbit was killed and the specimens
taken 1 1 . 7 5 days after surgery.
Unlike Fig. 1 , the scales for nerve
radioactivity and for muscle radio
activity differ by 20-fold, that in the
nerves being much higher than in the
muscles. The protein radioactivity of
the left nerve was much higher than
that of the right nerve. (Nevertheless,
the radioactivity in the right nerve
was substantial, and indicates, as did
the other experiments, that some dif
fusion of the precursor across the me
dian sulcus and perhaps to other parts
of the ventricle floor was unavoid
able, and a variable in our experi
ments.) Correspondingly, the left
styloglossus muscle had much higher
protein radioactivity than the right,
which was only slightly higher than
the control levels. As previously men
tioned, and typically of the other
experiments, the left genioglossus
muscle received much less radioactive
protein than the left styloglossus.
Apparently no measurable amount
of radioactive material unincor
porated in protein reached the axon
(Fig. 1 , NL, NR). Correspondingly,
almost all of the radioactivity ex
tracted from the left styloglossus
muscle (SOL) was in the protein
(TCA-insoluble) phase. This is to be
contrasted with the much larger por
tion of supernatant radioactivity
(probably largely unincorporated pre
cursor) when the precursor was ab
sorbed by the muscles from the blood
stream (control muscles in Fig. 3, and
all of the muscles in Fig. I ) .
Figure 4 graphically presents the
data from the left styloglossus and
the control muscles in 1 48 such ex
periments. Three experiments were
done for each of the first 42 days in
the interval between application of
precursor to the hypoglossal nucleus
and the killing of the rabbit. After 42
days, experiments were at longer in
tervals . Each experiment is repre
sented by two points. The open cir
cles, each representing the average of
four control muscles, show that
throughout the entire period of 76
days there was a small and progres
sively declining portion of radioactive
protein ascribable to incorporation of
blood-borne 3H-Ieucine.
The solid circles, each representing
the average of three portions of left
styloglossus muscle, show that unlike
experiments with intraperitoneal in
jections, the protein radioactivity of
the left styloglossus muscle was well
above control-muscle levels through
out most of the 76 days, and that
waxing and waning of protein radio
activity was evident during the frst
4 days. The frst peak of activity
occurred within the first 24 hours,
above-control activity being evident
after 6 hours, followed by several
other waves, and then a gradual de
cline over the next month or so.
In such a study as this, many fac
tors, some intrinsic to the animals,
others experimental, enter into the
spread of data for each post-labeling
interval. In analyzing the data we
have tried to compensate for varia
tions in some of the factors. One im
portant animal-to-animal variable is
Axonal transport and trophic studies
in the length of the nerve, contribut
ing to proportional variations in
transport time; the slower the migra
tion, the wider the variations.
Accordingly, we divided the entire
experimental period into three arbi
trary subperiods, using two-day
means for the first 10 days, three-day
means for the following period to day
33, and four-day means to day 42.
Another important variable is in
the actual amount of precursor pene
trating the hypoglossal nucleus and
remaining available for incorporation
into protein. Lajtha and Toth ( 14, 1 5)
showed that maximum penetration of
leucine into brain tissue after sub
arachnoid administration is achieved
in the first 5 min, and that 1 hr later
only 800 of the amount which had
penetrated had been incorporated in
to protein, 1 0% was still in the TCA
soluble fraction and 82% had left the
brain. That is, the major reason for
decrease in free amino acid was effux
rather than incorporation into pro
tein.
Hence, in seeking to compensate
for variations in effective dose of
3H-leucine, we adopted the premise
that effux from the brain, apparently
by active transport ( 1 4), into the
plasma, (from which it was then ab
sorbed and incorporated by the
muscles in our study), was directly re
lated to the amount that had pene
trated into the medullary tissue. We
therefore applied to the data for the
left styloglossus muscle from each
animal in this series a correction fac
tor that transformed the average
value of the control muscles for that
animal into the mean for that 2, 3 or
4-day period.
The data treated as described above
have been plotted in Fig. 5, and in
dicate four periods of arrival of
nerve-borne protein incorporating
labeled leucine. The first wave begins
to appear within a few hours, peaking
n the frst and second days, and de
clining to almost control levels by
day 3 . The second wave, which corre
sponds to that in our previous radio
autographic study ( 1 2) , peaks be
tween days 9 and 14. A third wave
peaks between days 22 and 27. A
fourth is evident in the 30-40 day
interval, after which protein radioac
tivity declines gradually. The troughs
seem to represent overlap of the de
clining phase of one wave and the ris
ing phase of the succeeding one. That
is, during at least a part of each wave
other than the first, protein radioac
tivity may represent the algebraic sum
of overlapping waves and possibly in
clude residues of preceding waves.
Correspondi ng fluctuations of
proximodistal transport along the
hypoglossal nerves were also evident,
but since the radioassay of the nerve
extracts represented protein in transit
through relatively long portions of
nerve, a precise definition of waves
was not possible.
Discussion
These findings indicate that at any
given time a mixture of proteins car
ried in the hypoglossal axons is reach
ing the tongue muscle. Some of these
proteins have been synthesized by the
perikaryon a few hours earlier, some
a month earlier, and the remainder at
two intermediate periods. These
waves may be ascribed in part to dif
ferent rates of axonal transport of
protein, which have been shown to
vary in mammalian nerves from a
slow rate of 1-2. 5 mm/day up to
several hundred mm/day, with an
intermediate rate between these two
extremes evident in some axons (2, 4,
1 6). In the rabbit, Karlsson and
Sjostrand ( 1 1 ) found four rates of
intra-axonal transport in the retinal
ganglion cells ( 150, 40, 6- 1 2 and 2
mm/day), but Sjostrand (23) found
only two rates in the hypoglossal
nerve (300 mm/ day and 5 mm/ day,
as well as two somewhat higher rates
in the vagus nerve). We have no ex
planation for the apparent discrep
ancy between their findings and
ours.
Our experimental design does not
permit accurate measurement of rates
of axonal transport corresponding to
the four waves, but rough estimates
can be made on the basis of the extra
cranial, extramuscular lengths of the
hypoglossal nerves in our rabbits (an
average of about 4mm) and the time
of arrival in the muscle. Since nerve
delivered radioactive protein was
already present in the shortest of our
experimental periods, 6 hr, the rate of
transport would have been no less
than 1 60 mm/day. The fourth wave
seems to correspond to the mam
malian "slow" rate of 1-2. 5 mm/day.
The waves may be related not only
to transport rates but also to differ
ences in departure time after leucine
uptake. Droz has shown that some
sedentary protein may remain in the
cell body for periods up to two weeks
before being dispatched into the axon
(3). It is conceivable that a "late
starter" may overtake an earlier
"starter" but slower "runner. " We
propose that the multiple waves of
neuronal protein arriving at the mus
cle are the product of these two fac
tors: rate of transport and interval
between precursor incorporation and
entrance into the axon hillock.
We cannot ascertain from the data
of this part of the study what portion,
if any, of each wave of protein actual
ly enters the muscle cells, and how
much has remained in the intramus
cular nerve endings, and we must
await completion of our analysis of
the radioautographic specimens taken
from the same animals. Our previous
radioautographic study ( 1 2) certainly
supports transjunctional transfer
during what is now identified as the
second wave. There is no reason to
believe that such transfer would be
limited to only one of the four waves.
Moreover, since the publication of
that report and the completion of the
present study ( 1 3) , reports have ap
peared which strongly suggest trans
synaptic transfer of proteins within
the central nervous system (5, 10, 20).
These observations are consonant
with the ample and growing evidence
that proteins do normally move in
and out of cells (e. g. , 22).
Our hypothesis ( 1 2) that the proxi
modistal conveyance of proteins from
nerve cells may underlie their trophic
influences is supported by recent
studies. Lentz (1 7, 1 8) demonstrated
that such influences can be repro
duced in vitro, and that they are
mediated by diffusible, thermolabile
substances released by nerve cells. Al
buquerque et al. ( 1 ) showed that
blocking axonal transport, without
impairing the ability of the nerve to
maintain muscle activity, caused the
appearance of trophic signs of dener
vation.
In the present study it was possible
to distinguish four peaks of delivery,
which probably correspond to several
rates of axoplasmic transport. The
radioactive material seems to be deliv
ered rather continuously to the nerve
terminals and possibly thereafter to
the muscle. In a pulse experiment
such as this, the presence of several
overlapping waves makes it difficult
to determine whether material trans-
16
ported at a discrete rate within the
nerve can be found in the muscle at a
similarly discrete time interval. Con
sequently, in another study now ap
proaching completion, : we have
chosen to differentiate the labeled
proteins on the basis of the specific
macromolecules comprising each of
the waves. This study indicates that
soluble proteins carried in three of the
four waves are electrophoretically
distinct and that electrophoreticaUy
identical proteins are, in correspond
ing intervals, subsequently found i n
the muscle. The consistent observa
tion that only certain of the radioac
tive axonal proteins appear in the
muscle extracts suggests selective
axon-to-muscle transport. Of course,
, in addition to radioautographic
studies. analyses will ultimately have
to be made on portions of muscle de
void of nerve terminals, to ascertain
whether transsynaptic transport of
these protein species has actually oc
curred.
References
I. Albuquerque, E.X., J. E. Warnick, J. R. Tasse,
and F.M. Sansone 1 972. Effets of vinblastine and
colchicine on neural regulation of the fast and slow
skeletal muscle of the rat. Exp. Neurl. 37: '67-634.
2. Barondes. S.H. (Ed.) 1 967. Axoplasmic
transport. Neurosci. Re. PagIm Bull. 5: 3 1 1-419.
3. Draz, B. and H.L. Koenig. 1 970. Localization of
protein metabolism in neuron, pp. 93-108. In "Pro
tein Metabolism of the Nervous System." Abel Lajtha
[Ed.). Plenum. New York.
4. Grafstein, B. 199. Axonal transport: Com
munication between soma and synapse, pp. 1 1 25. In
Advances in Biohemical Psychopharmacology." E.
Costa and P. Greengard (Eds.). Raven. New York.
5. Grafstein, B. 1 97 1 . Transneuronal transfer of
radioactivity in the central nervous system. Science
172: 1 771 79.
6. Guth, L. 198. "Trophic" infuences of nerve on
muscle. Physiol. Rev. 48: 65-687.
7. Guth. L. (Ed.). 1 969. "Trophic" effects of
vertebrate neurons. Neuroi. Res. Program Bull. 7:
1-73.
8. Guth. L., F. J. Samaha, and R.W. Albers. 1 970.
The neural regulation of some phenotypic differences
between the fiber types of mammalian skeletal muscle.
E. Neurol. 26: 1 261 35.
9. Guth. L. . P. J. Dempsey. and T. Cooper. 1 97 1 .
Maintenance of neurotrophically regulated proteins in
denervated skeletal and cardiac muscle. Exp. Neurol.
32: 478-488.
10. Ingoglia. N.A = B. Grafste!n. B.S. McEwen,
and I.G. McQuarrie. 1973. Axonal transport of
radioactivity in the goldfsh optic system following in
traocular injection of labelle RNA precursors. J.
Neurchem. 2: 165-1 61 5.
I I . Karlsson, J.O. and J. SjOstrand. 1971 . Syn
thesis. migration and turnover of protein in retinal
ganglion cells. J. Neurochem. 1 8: 749-767.
1 2. Korr. I. M P. N. Wilkinson. and F.W. Chor
nock. 197. Axonal delivery of neuroplasmic com
ponents to muscle cells. Science 1 55: 342-345.
tPreliminary report in pres (Fed. Pro., March 1974).
10
1 3. Karr. I . M = and G.S.L. Appeltauer. 1 971 . Ax
onal transport of nerve-cell proteins to muscle. Fed.
Proc. 30: 65.
14. Lajtha. A oand J. Toth. 1961 . The brain barrier
system - II Uptake and transport of amino acids by
the brain. J. Neurochem. 8: 21 6-225.
IS. Lajtha. A + and J. Tath. 1962. The brain barrier
system III The efflux of intracerebrally ad
ministered amino acids from the brain. J. Neurochem.
9: 1 9-212.
1 6. Lasek. R.J. 1 970. Protein transport in neurons.
Interal. Rev. Neurobio/. 1 3: 289-324.
17. Lentz. T.L. 1971 . Nerve trophic function: In
vitro assay of effects of nerve tissue on muscle
cholinesterase activity. Scienc 1 71 : 1 87189.
1 8. Lentz. T. L. 1972. Development of the
neuromuscular junction. Part I l l . Degeneration of
motor end plates after denervation and maintenance
in vitro by nerve explants. J. Cell. Bioi. 55: 93-103.
19. Miani. N. 1 963. Anaysis of the somato-axonal
movement of phospholipids in the vagus and
bypoglossal nerves. J. Neurochem. 10: 859874.
20. Neale. J. H E.A. Neale and B.W. Agranoff.
1 972. Radio-autography of the optic tectum of the
goldfish afer intraocular injection of ('H) Proline.
Sience 176: 40741 0.
21 . Patterson. M. S. and R.C. Greene. 195.
Measurement of low energy betaemitlers in aqueous
solution by liquid scintillation counting of emulsions.
Anal. Chem. 37: 854-857.
22. Ryser, H.J.P. 1 968. Uptake of protein by mam
malian cells: An underdeveloped area. Science 159:
39-39.
23. SjOstrand. J. 1 970. Fat and slow components
of axoplasmic transport in the hypoglossal and vagus
nerves of the rabbit. Brain Res. 18: 461 -467.
Reprinted by permission from Experimental
Neurology 43: 452-463. 1 974.


Axonal transport and trophic studies
Axonal delivery of soluble, insoluble and
electrophoretic fractions of neuronal
proteins to muscle* (1975)
GUSTAVO S. L. APPELTAUER and IRVIN M. KORR
For more than a century, the role of
peripheral nerves in the differentia
tion and maintenance of skeletal mus
cles has been a major area of research
and debate (4, 7, 8). Many tentative
explanations for the trophic relation
ship between nerve and muscle have
been based on those nerve-controlled
functions which are well known to in
fluence the muscle properties, such as
the release of acetylocholine, the
transmission of impulses, and the
initiation of muscular contraction.
These activities, however, cannot
alone account for all the changes that
may occur in the muscle after its in
nervation is disturbed.
The nerve may also influence the
muscle by the release of substances
which participate in muscle differen
tiation and which are essential for the
maintenance of structural and func
tional integrity. Research done at this
laboratory has shown that, after the
administration of 32P-phosphate and
14C-Iabeled amino-acids to hypo
glossal neurons of rabbits, some
radioactive macromolecules that are
transported along the axons cross the
neuromuscular j unction and are
incorporated into the muscle cells
( 1 3) . A later study showed that label
ed nerve proteins reach the muscle at
four different time periods, with
peaks at approximately 1 , 12, 22 and
34 days after incorporation of
3H-Ieucine by the neurons (1 2) . The
experiments reported here were de
signed to determine whether different
proteins are axonally conveyed in
each time period and whether there is
selectivity in the nerve-to-muscle
transfer. The radioactive proteins
transported in the four periods were
compared with respect to relative spe
cific activities of soluble and insol
uble proteins and relative specific ac-
'Supported by NIH Grant No. NS-07919 from the
National Institutes of Neurological Diseases and,
Stroke and by a grant from the American Osteopathic
Assoiation. We are grateful to Mr. Robert N. May
for preparation of the figures.
tivities of soluble fractions separated
by acrylamide gel electrophoresis.
Methods
Surgical procedures. Twenty-three
New Zealand white rabbits of either
sex, weighing 1 . 8-2. 4 kg were used.
For the intraventricular labeling of
hypoglossal neurons, 250 JCi of
4-5- 3H-L-Ieucine (Amersham-Searle,
specific activity 38-58 CilmM) were
deposited on two small pieces of filter
paper. The fourth ventricle was then
exposed, and each paper placed on
the area over the left hypoglossal
nucleus for 20 min. The surgical tech
niques were those previously de
scribed ( 1 2) , except that posterior
choroidectomy was omitted.
Tissue specimens. The rabbits were
killed at each of the four peak periods
following the administration of tri
tiated leucine: 1 , 12, 22 and 34 days (5
rabbits each) , and also at 43 days (3
rabbits). The following specimens
were taken: (a) medulla (left half of
the floor of ventricle IV); (b) left
hypoglossal nerve (extracranial por
tion, divided into a proximal and a
distal segment); (c) left styloglossus
muscle (which is innervated by the
hypoglossal nerve) ; and (d) control
muscles (pooled stylohyoid and mylo
hyoid muscles, which are innervated
by the facial and trigeminal nerves,
respectively, and which were used to
determine the incorporation of
blood-borne tritiated leucine by the
styloglossus muscle ( 1 2) . Because of
their small size, nerve and medulla
specimens were supplemented with
sciatic nerve and medulla from unop
erated animals (see later) .
Extraction procedures. All tissues
and solutions were kept at 0-2 C.
Each specimen was first homogenized
in saline solution (6.25 11 per mg
fresh tissue) and centrifuged at 1 3, 800
g for 1 hr. Each precipitate was then
twice rehomogenized and washed
with 5 ml saline containing 2. 5 mg
serum albumin and 2. 5 mg leucine as
carriers. After an extraction with
organic solvents, done as previously
described ( 1 2) , it was prepared for
liquid scintillation counting. The pre
cipitated material will be referred to
as the insoluble protein fraction.
The supernatant from the first
centrifugation was separated into two
measured portions. One part was
pooled with aliquots representing the
same fractional volumes of the sec
ond and third supernatants. After
the addition of 2. 5 mg serum albu
min, it was extracted with 1000 tri
chloroacetic acid and organic solvents
( 1 2) . The precipitate, identified as the
soluble protein fraction, was also
prepared for radioassay.
Electrophoretic separation ofsolu
ble proteins. From the remaining part
of the first supernatant, two to four
0. 1 25 ml aliquots were fractionated
by acrylamide gel disc electrophoresis
at pH 8. 3 and 7. 51o concentration in
1 5 cm long tubes (Canalco, Inc. ).
Each gel was stained with Coomassie
blue, washed with distilled water and
cut into 34-40 segments, as shown in
Fig. 2, with loops of human hair. The
equivalent segments from the two to
four gels obtained for each tissue
specimen were pooled, weighed and
prepared for liquid scintillation
counting as described in the next
section.
Experience showed that cutting the
gels according to the band patterns,
rather than in slices of uniform thick
ness, gave a much more accurate and
reproducible approach to the study of
radioactivity distribution among the
various fractions. In different batches
of gels, the position of the bands
relative to the tracking-dye band and
to the cathode end of the gel varied
slightly, whereas all well-defined
radioactivity peaks appeared at pre
cisely the same stained bands in all
animals. It is possible that a given
stained segment may include several
proteins differing in concentration,
staining properties and incorporation
of radioactivity. Nevertheless, the
sites of concentration of protein
incorporated radioactivity were more
than sufficiently discrete, reproduc
ible and referable to stained bands to
make possible reliable comparisons
of radioactivity distribution from
animal to animal and period to
period.
I0T
<00,UUU
l
200,000
VLDULLA
.
40,00
|
NER
2UD00
(PXIMAL)

U
m
o

40,00
`
.
NERVE
[ 30,00
(DISTAL)

l
200_
|00
t
^
|d 2d Zd d 4$
Fig. I. Average specific activity (disintegra
tions per minute per milligram fresh tissue) of
the insoluble (dark bars) and soluble proteins
(clear bars). Data were averaged from five
(days 1-34) or three animals (day 43). The or
dinate scales are much lower for muscle than
for medulla and nerve because the activity has
been diluted in the relatively large muscle mas.
NE
N
NU
6 6 H J 8
'

Fig. 2. Electrophoretic pallers of medulla
(ME), nerve (N) and muscles (MU). The
brackets and numbers indicate the way the gels
were sliced. The lengths of the segments were
obtained from the weights of the gel slices and
averaged for all 23 animals. The segments were
numbered from the buffer front toward the
cathode. Equivalent numbers do not represent
equivalent protein bands in the different
tissues. The letter designations, A-K, are ex
plained in the legend for Fig. 3.
108
Radioassay. For al l speci mens,
radioactivity was determined in a
Packard 3375 Liquid Scintillation
Spectrometer for 50 mi n at 7000 gai n
and 50- 1 000 wi ndow settings. The
soluble and insoluble protein frac
tions were digested in 0. 1 5 ml water
and 1 . 5 ml NCS (Amersham-Searle)
first for 1 6 hr at room temperature,
then for 90 mi n at 50 C. Before the
final 30 min of digestion, 0. 1 ml 30%
hydrogen peroxide was added to each
vial to prevent color quenching. After
3 hr at room temperature, the digests
were dissolved in 1 5 ml toluene-based
scintil lator (Spectra fluor , Amersham
Searle) contai ni ng 0.2 ml Triton
X- 1 00. After 3 additional hr the vials
were placed in the scintillation spec
trometer and counted after tempera
ture equilibration.
The equivalent gel slices from each
tissue were placed in scintil lation vials
and dried at 90 C for 2 hr. After the
addition of 0. 1 mg serum albumin to
each vial, the samples were digested
in 0. 4 ml 30% hydrogen peroxide first
at 60 C for 1 6 hr and, after the addi
tion of 1 . 5 ml NCS, at 50 C for 90
mi n. Since the hydrogen peroxide and
NCS treatments yield volatile radio
active materials, all incubations were
carried out in hermetically sealed
vials. Digests were also cooled to
-1 5 C before opening the vials for ad
di tion of the scintillator. The digests
were then left at room temperature
for 3 hr and, after cooling to -1 5 C,
dissolved i n 10 ml scintillation
cocktail and 0. 4 ml Triton-X- 1 00.
Before counting, the vials containing
the digests were briefly opened three
times under a fume hood, at i ntervals
of 3 hr, in order to eliminate some
volatile quenching agent (probably
oxygen).
The recovery of radioactivity was
determined by processing nonradio
active specimens to which a known
amount of l H-leucine had been
added. Recovery was 99% for the
soluble and insoluble protei ns, and
96% for the gel s. The counting effi
ciency, as determined by i nternal
standardization, was 43% for aU
specimens. The specific activities of
total protein extracted from stylo
glossus muscles, in this study as i n the
previous one ( 1 2) , were relatively low
as compared with those of nerve and
medul l a. Nevertheless, the threefold
larger dose of l H-leucine used in this
study raised the levels substantially,
and good reliability was obtained in
those animals ki lled between 1 2 and
34 days after l H-leucine admi nistra
tion. The lowest counts obtained in
an animal for an identifiable radio
activity peak (peak G at day 34,
Fig. 3D see results) were 69. 7
counts/min above a background of
29. 0 ( 1 . 40) .
Calculation of specific activities of
gel segments. I n each animal, the
specific activity (disintegrations per
min per mg fresh tissue) of each gel
segment was cal culated by the
formula:
dpo
Z.4 7 (o| ioia|supe:aa|aa:, (couats/m|a,
. l ml (o,|resa t .ssae) (aamoetote|spoo|eo)
where 2. 42 is a correction factor for
the counting efficiency and for the
activity lost while processing the sam
ple; 0. 1 25 ml is the volume of tissue
extract used for each gel ; and the
total volume of supernatant was ob
tained by adding the ml of saline i n
which the sample was homogenized
and the calculated water content of
the specimen ( I ) .
For plotting, each gel was divided
i nto 40 arbitrary length units. (See
Figs. 2 and 3. ) The average length of
the correspondingly numbered gel
segments of each tissue obtained
from the five animals (three at 43
days) ki l led at a given postsurgical
i nterval was calculated as follows:
+l h
average | cngth o| scgneut "
L
K is the weight of the pooled
equivalent gel segments in each
scintillation vial, from each animal,
divided by the number of gels pooled;
m is the number of animals killed at
the selected postsurgical time, and n
is the total number of segments into
which the gel was divided (muscle 38,
nerve 34, medulla 40) . (See Fig. 2. )
Although the electrophoretic pro
cedure used concentrated certain pro
teins i nto well defined bands, it did
not provide for a complete separation
of all the radioactive proteins. Some
times a distinctly high level of radio
activity located at a given band was
accompanied by lower, but si gni fi
cant, levels of activity in the neigh
boring gel segments; or, radioactivity
was spread over extended lightly
Axonal transport and trophic studies

k

j
, "
K

vw

` @
! p (p


Wm

*
m

34dg

0'

-
1 ? < >
K
M

41

1 Y ZD O M
M
MX
'
9!|M
tmvQ
T ^
. 11 u
1 B

omo;
. ,. . . .
1 T d W
43dg
k,
I
K
v1

'21
_ v rw
WW
1 < H
urw
% N
fiirjpM
1 ' d'
Nw
- ~
t=A
! 1 <
4 *
L
w|m
1 1 #
Fig. 3. Spifc activity distribution along the electrophoretic gels ofmedulla and nerve specimens. The values indicated a styloglossus-control rpresent
the amount ofnerve-delivered radioactivity in the styloglossus muscle. The abscissae represent the segments into which the gels were cut. The height o/
the bars represents the speciic activity (disintegrations per minute per milfigramsfresh tis ue) per length ofthe gel segment (see text). Data were averaged
from fve (days 1-34) or thre animals (day 43). Letters A-K represent equivalent fractions with high speic activities in the diferent tis ues.

o
.

' i
0-

43 DAYS
`7 f I |X
' !
B 5
Fig. 4. Speciic activity ditribution along the
electrophoretic gels of the control muscles.
Abscissae and ordinates are the same as in
Fig. 3.
stained gel portions. The radioac
tivity not concentrated into bands
appeared as a sort of "background, "
over which the discrete peaks pro
jected, that made the radioactivity of
each gel segment dependent on its
length. Thus, for a better visualiza
tion of the radioactivity distribution
in the gels, the results were plotted as
histograms (see Figs. 3 and 4). The
abscissae represent the gel segments
(intervals between numbered lines);
the height of each bar represents the
average radioactivity concentration in
each gel segment; and the area in
dicates the average radioactivity con
tained in the segment per milligram of
tissue. The height of each bar was
calculated with the formula:
v-:.,-c,/,
8Vct8gf lfnglh ul--,--:
c,J,
E E W W
W
m
jW # c,],
,

Controls. In order to determine

whether the sciatic nerve is a suitable
"carrier" to be mixed with the hypo
glossal nerve specimens, the band dis
tributions in electrophoretic gels of
these nerves were compared. The
same bands were present in both
nerves, and the patterns did not vary
significantly with the distance from
the central nervous system. Also, to
examine whether, in this study as in
the previous one ( 1 2) , the stylohyoid
and mylohyoid muscles were reliable
controls for the incorporation of'
blood-borne 3H-leucine into the
styloglossus muscle, five additional
sham-operated rabbits were injected
intraperitoneally with 250 /ei 3H-L
leucine. In each animal, the stylo
glossus and control muscles behaved
similarly with respect to radioactive
uptake by soluble and insoluble pro
teins, and exhibited the same band
patterns and radioactivity distribu
tion in the electrophoretic gels.
Results
Soluble and insoluble proteins.
Figure 1 shows the specifc activities
(expressed as disintegrations per min
per mg of fresh tissue -dpm/mg) of
the insoluble and soluble proteins of
the medulla and the two segments of
the hypoglossal nerve. The data for
the styloglossus muscle, however, are
shown as diferences in specific ac
tivity between the styloglossus and
control muscle. Since all the muscles
used in this experiment incorporate
the same amount of blood-borne
radioactivity into their protein frac
tions, these differences represent pro
tein-incorporated radioactivity that
has reached the styloglossus muscle
through the hypoglossal nerve. A
similar treatment of data was not
found necessary for the nerve seg
ments, since nerve radioactivity after
i nt r aper i t oneal i nj ec t i ons of
3H-leucine was negligible when com
pared to intraventricular values ( 1 2) .
We can thus assume that the activity
found in the nerve was transported
axonally from the nerve cell body.
10
The radioactivity of both fractions
from the medulla was highest at day
I , after which it declined with time.
In the nerve, both soluble and insolu
ble proteins had a peak of activity at
day 1 2. The activity of the soluble
proteins was the same in the proximal
and distal segments at day 1 , after
which it was slightly higher in the
distal portion. Insoluble protein
radioactivity was first higher in the
proximal segment; a reversal of this
proximodistal gradient had occurred
by day 34 when the activities had
become very low.
Almost all of the nerve-transported
radioactivity that reached the stylo
glossus muscle in the first day was in
the insoluble protein fraction. The
highest specific activities were found
at day 1 2 for the insoluble proteins,
and at day 22 for the soluble proteins.
Electrophoretic fractions. Electro
phoretic fractionation permitted the
identification of 34-40 pr
o
tein bands
in each specimen (Fig. 2). As ex
plained in "Methods, " the electro
phoretic patterns were the same for
the styloglossus and control muscles
and for the proximal and distal
segments of the hypoglossal nerve of
each animal. However, variations
between the same tissues of different
animals did occur. Bands that were
solid in some animals appeared split
in others, and bands that were darkly
stained in some were faint in others.
Nevertheless it was always possible to
match the equivalent proteins in the
different animals on the basis of band
confguration and position in the
gels. Using the same criteria, it was
also possible to establish equivalence
among the protein bands in the dif
ferent tissues.
The distribution of radioactivity in
the electrophoretic gels of the medul
la, proximal and distal segments of
the hypoglossal nerve, and of the
nerve-transported soluble proteins in
the styloglossus muscle (represented
by the differences in values between
the styloglossus and control muscles)
are shown in Fig. 3. Between 1 and
43 days, the electrophoretograms
exhibited distinct peaks of activity
which are identifed in the text by the
letters A-K. The heights of all of the
peaks identifed by letters differed
significantly from those of the neigh
boring segments (p < 0.05). The dis
tribution of radioactivity in the gels
110
varied with time and was differet
from the medulla, nerve and muscle,
although peaks of activity could be
located over equivalent protein
bands. At each time period, the elec
trophoretic distributions of activity in
the proximal and distal portions of
the hypoglossal nerve were nearly
alike.
At day I , most of the medulla and
nerve radioactivity appeared in a
single, dispersed "hill , " formed by
protein which is not concentrated into
a band, probably some basic protein.
The medulla had several additional
peaks of activity of which one, lo
cated at the buffer front (A), and one
situated at the cathode end (K), ap
peared at equivalent positions in the
nerve gels. As shown in Fig. 1 , no
significant amount of neuronally
synthesized soluble protein had yet
reached the styloglossus muscle.
When, however, the specimens were
homogenized in saline containing
0. 500 Triton-X- l O, the "hill" did
appear in the muscle gels (unpub
lished results).
At day 1 2, the hypoglossal nerve
had, in addition to the high activities
at the buffer front (A) and cathode
end (K), three large peaks (C, H and
J) and five small peaks (B, E, F, G,
and 1). Some of them (E, G and H)
were paralleled by high activities over
the corresponding medulla segments;
others (B and J) had been preceded by
equivalent medulla peaks at day 1 . Of
the high-activity nerve segments, only
C was neither preceded nor accom
panied by high activity in the medul
la. Nerve peaks F and I scarcely ex
tended beyond the "hill , " and the
equivalent peaks of the medulla may
have been completely hidden by the
activity of the adjacent segments.
At day 1 2, some nerve-transported
soluble radioactivity was found in the
styloglossus muscle. It was mainly
concentrated at peaks A, G, H and K
and over a "hill" which extended
from segments 3 1-35. Equivalent
peaks could be located in the medulla
and nerve. Also, a similar "hill" was
present at equivalent positions in the
nerve and medulla, partially obscured
by peak J.
Between days 1 2 and 22, the radio
activity of the nerve gels decreased by
more than 80% (note ordinate
scales), but with the exception of
B, all peaks persisted. In the same
interval, the nerve-transported radio-
activity to the styloglossus muscle
doubled, and peaks C and J appeared.
At day 34, the nerve activity was
low, and most of the peaks were no
longer discernible. The styloglossus
muscle showed the same peaks of ax
onally transported radioactivity as at
day 22. By day 43, only traces of
radioactivity remained in the gels.
Not all of the medulla peaks ap
peared i n the nerve. Peak D, for ex
ample, was always confined to the
medulla. Similarly, nerve peaks E and
F did not appe
a
r in the styloglossus
muscle. Conversely, nerve peak C
did not have an equivalent in the
medulla, while all muscle peaks had
equivalents in the nerve.
Figure 4 shows the specific activity
distribution in the control muscle
gels. Activity peaks, most of them
less than 1 dpm/mg, appeared mainly
at those segments that contained
thick and darkly stained protein
bands. Three activity peaks were
located at apparently the same posi
tions as intraventricular peaks, A, G
and K. No significant activity concen
trations were found in the segments
containing peaks C, H and J, indi
cating that these radioactive proteins
in the styloglossus muscle are prob
ably not synthesized in the muscle,
but are supplied by the nerve. More
over, by modifying electrophoretic
procedures in several ways (pH 9.7
and 8. 6; gel concentrations of 4. 5
to 1 5%) it was possible to show that
segments A, G and K consist of pro
tein mixtures, indicating that the
radioactive components at these sites
may also be entirely nerve-delivered.
Discussion
These experiments, tracing the trans
port of various radioactive protein
fractions from hypoglossal neurons
through axons to the styloglossus
muscle, show that different mixtures
of proteins reach the muscle in the
four periods previously delineated
( 1 2), and offer an explanation for
their different arrival times:
Period , peak at day . The pre
dominance of radioactivity in the
insoluble fraction of the muscle at
this time can be attributed to the fast
axonal flow, which carries mainly
particulate elements ( l 0, 1 1 , 14,
1 6, 1 7) .
Period 2, peak at day J 2. This ar
rival time appears to be concurrent
with the period of highest activity
Axonal transport and trophic studies
found for the nerve proteins. Insolu
ble protein radioactivity, carried by a
slower axonal fow, predominates but
some of the soluble neuronal proteins
also reach the muscle during this
period.
Period J, peak at day 22. This peak
consists mainly of soluble proteins
which have been delayed in their pas
sage from nerve to muscle.
Period 4, peak at day J4. This
period probably represents the arrival
at the muscle of insoluble protein car
ried in a relatively slow axonal
stream, and may be related to the
reversal of the proximodistal gradient
of insoluble-protein radioactivity
along the nerve in the 22-34 day inter
val. This wave of insoluble-protein
radioactivity is superimposed on the
continued high activity of the soluble
fractions which had reached the mus
cle in the preceding period.
The data indicate also that transfer
of radioactive proteins between adja
cent nerve segmen
t
s is qualitatively
different from that between the dista
segment of the nerve and the stylo
glossus muscle. In the proximal and
distal nerve segments, the electro
phoretically separated radioactivity
peaks appeared and disappeared
simultaneously indicating that trans
fer of these proteins between the ad
j acent nerve segments is nonselective
and that it proceeds at rates sufficient
to achieve nearly equal specific ac
tivities within the 10- 1 2 day intervals
studied. In contrast, clear discon
tinuities appeared between nerve and
styloglossus muscle, as reflected in
relative activities of soluble and in
soluble proteins and in electrophore
tic distribution of radioactivity
among the soluble fractions. Some
radioactive proteins entered the mus
cle in the same intervals in which they
appeared in the nerve (A, G, H and
K,also the 31 -35 segment "hill" pres
ent at day 1 2); others were delayed in
transfer to muscle (C and J) and still
others were not found in the muscle
at all (E and [.
It i s possible that those axonal pro
teins which could not be located in
the muscle gels had in fact reached
the muscle, but had then undergone
either proteolysis or structural altera
tions. H
o
wever, in order to account
for the exclusion of highly radioactive
proteins, such as E and F, which have
a long half-life in the perikaryon and
axon, proteolysis at the muscle would
have to be distinctively rapid and
highly selective.
Alterations in the structure of at
least one neuronal protein does ap
parently occur in the axon. Protein C,
which appeared in nerve but not i n
medulla, may have been the result of
splitting, recombination or structural
alteration of some medulla protein.
Since all the radioactive peaks found
in the styloglossus muscle gels were
also present in the nerve, it seems that
molecular alterations were not com
mon, and are not responsible for the
absence of peaks E and F in the mus
cle.
These results do not eliminate the
possibility that the radioactive pro
teins, both soluble and insoluble,
found in the styloglossus muscle were
confined to the nerve terminals.
Previous autoradiographic evidence
of transfer of axonal protein to mus
cle around day 12 ( 1 3) suggests that
insoluble proteins may be included in
that transfer. However, this remains
to be established. Nevertheless, on
the basis of unimpeded, nonselective
movement of soluble proteins along
the nerve, we should expect a similar
transfer from axon to terminal,
followed by accumulation of some
proteins and degradation of others.
It is, however, difficult to explain,
on the basis of this model, why the
entrance into the nerve terminals of
some soluble proteins, like C and J,
should be blocked at day 1 2, and of E
and F at day 22. It is improbable that
this discontinuity represents the
fronts of proximodistally advancing
"waves" of radioactive soluble pro
teins, since such "wave fronts" never
appeared between the two nerve seg
ments. I t would also be difficult to
explain the exclusion of proteins E
and F from the nerve terminals. If ac
tive localized proteolysis were com
bined with unimpeded transport
along the axon, it would result in the
disappearance of these high-activity
fractions from the nerve, within a
10- 1 2 day period instead of their per
sistence from day 1 2 until at least day
34.
The sequence of events described is
more consistent with the hypothesis
that some axonal proteins have been
selectively transferred to muscle. This
is supported by the auto radiographic
studies carried out previously ( 1 3)
which showed neuromuscular trans
fer of proteins in the period which in-
eludes day 1 2. It is improbable that
such transfer would be limited to pro
teins carried only in the 1 2-day wave.
This hypothesis is also in agreement
with more recent evidence indicating
transsynaptic transfer of proteins (5,
6, 9, 1 5). It must be noted, however,
that other auto radiographic studies
on the axonal transport did not reveal
movement of proteins beyond the
nerve terminals (2, 3, 1 7) and that the
localization of the neuronally syn
thesized labeled proteins inside the
styloglossus muscle will have to be
clarified by further studies.
As an explanation of the presence
of labeled protein in the postsynap
tic elements, it has been proposed
that axonal proteins may be degraded
to amino acids, which are then trans
ferred to other tissues and used for
local protein synthesis ( 1 3, 1 5). The
data presented in this study do not
support this hypothesis. Were this the
case, the axonally transported radio
activity in the styloglossus muscle
should yield the same electrophoretic
peaks as found for the control mus
cles. On the contrary, most of the
proteins which exhibited relatively
high radioactivity in the control
muscles remained conspicuously
unlabeled by the axonal fow. Con
versely, as discussed in connection
with Fig. 4, the most highly radio
active proteins in the styloglossus
muscle are apparently nerve-supplied
and not autochthonously synthesized.
We believe that the fndings re
ported here revealed a transport of
changing mixtures of neuronally syn
thesized proteins at various post
labeling periods. They also support
the hypothesis, previously presented
and discussed ( 1 2, 1 3), that some of
these proteins are selectively trans
ferred to muscle, where they mediate
neurotrophic influences. These find
ings also emphasize the need for
further research in this important but
poorly understood area.
References
I. Allmann. P.L., and D.S. Dittmer. 1972. Animal
tissues and organs; water content, pp. 392-398. In
"Biology Data Book," Vol. I . Federation of
American Societies for Experimental Biology.
Bethesda. Maryland.
2. Crossland. W.J., W. M. Cowan, and J. P. Kelly.
1973. Observations on the transport of radioactively
labelled proteins in the visual system of the chick.
Brain Res. 5: 77105.
3. Cuenod, M., J. Boesch, P. Marko, M. Perisic, C.
Sandri, and J. Schonbach. 1972. Contribution of a
111
oplasmic transport to synaptic structure and func
tions. Int. J. Neurosci. 4: 77-87.
4. Eccles, J.C. 1963. Interrelationship betwen the
nerve and muscle cell, pp. 19-28. In "The Effect of
Us and Disuse on Neuromuscular Functions." E.
Gutmann and P. Hnlk [Eds.J. Publishing House of
the Czechoslovak Academy of Sc:ences, Prague.
5. Globus, A. , H. D. Lux, P. Schubert. and P.
Kaups. 1971 . Labelling of nearby neurons following
the intracellular iontophoresis of H' glycine. Anal.
Re. 169: 325.
6. Grafstein. B. 1 971 . Transneuronal transfer of
radioactivity in the central nervous system. Scince
17: 177-179.
7. Guth, L. 1 968. "Trophic" infuences of nerve on
muscle. Physiol. Rev. 48: 65-687.
8. Gutmann, E v and P. Hnik. 1962. Denervation
studies in research of neurotrophic relationships, pp.
1 3-56. In "The Denervated Muscle." E. Gutmann
[Ed.). Publishing House of the Czechoslovak
Academy of Sciences, Praue.
9. Hendrikson, A. 1 972. Electron microscopic
distribution of aoplasmic transport. J. Compo
Neurol. 14: 381-397.
10. Karlsson, J.-O., and J. Sj(strand. 1 972. Syn
thesis. migration and turnover of proteins in retinal
ganglion cells. J. Neurochem. 18: 749-767.
I I . Kidwai, A. M. , and S. Oehs. 1969. Components
of fast and slow phases of aoplasmic fow. J.
Neurochem. 16: 1 105 1 1 12.
12. Korr, I . M. , and G. Appeltauer. 1974. The time
course of axonal transport of neuronal proteins to
muscle. Exp. Neurl. 4: 452-463.
1 3. Korr, I . M o P. N. Wil kinson, and F.W. Chor
nock, 1967. Axonal delivery of neuroplasmic com
ponents to muscle cells. Science 155: 342345.
14. McEwen. B. S s and B. Grafstein, 1 968. Fast and
slow components in axonal transport of protein. J.
Cel. Bioi. 3: 494-508.
I S. Neale, J. H E.A. Neale, and B.W. Agranoff.
1 972. Radioautography of the optic tectum of the
goldfsh after intraocular injection of ('H) proline.
Scienc176: 47410.
16. SjOstrand. J. 1970. Fast and slow components
of axoplasmic transport in the hypoglossal and vagus
nerves of the rabbit. Brain Res. 18: 461 -467.
1 7. Sj(strand, J. , and J.-O. Karlsson. 1 969. Axo
plasmic transport in the optic nerve and tract of the
rabbit: a biochemical and radioautographic study. J.
Neurochem. 16: 833844.
Reprinted by permission from Experimental
Neurology 46: 1 32146. 1975.
111
Abstract: Electrophoretic
characterization of neuronal
basic proteins in skeletal
muscle* (1976)
O. APPELT AVER and I . M. KORR
In 1 967 Korr, Wilkinson and Chor
nock (Science 1 55: 342) found that
proteins synthesized in the perikarya
of motor neurons are axonally trans
ported and incorporated into the
muscle cells they i nnervate. Further
studies have led to the electrophoretic
characterization of some nerve-to
muscle delivered acid proteins that
are axonally transported to skeletal
muscles.
3H-Iysine was administered to the
4th ventricle of rabbits. The animals
were sacrificed 1 -70 days following
the administration of the precursor.
Soluble extracts from the hypoglossal
nerve and styloglossus muscle were
fractionated by disc-electrophoresis
at pH4.2 and 1 500 gel concentration.
In the hypoglossal nerve gels, total
radioactivity was highest at day 1 2
after the 3H-lysine administration. It
was concentrated mainly at the anod
ic end and in one stained band. Five
other labelled proteins also appeared
in the gels. The nerve-delivered radio
activity in the styloglossus muscle gels
was highest at day 34. It was highly
concentrated at the anodic end of the
gels and in one protein band, and less
concentrated in 4 other proteins. The
electrophoretic mobilities of the
radioactive proteins in the nerve gels
and of equivalent radioactive proteins
in the muscle gels were the same,
Nerve basic proteins seem to travel
without obstacle along the axons to
the nerve terminals, and from there
they slowly penetrate the muscle.
There is no change in the electro
phoretic mobility of the proteins dur
ing this process.
'Supported by the American Osteopathic Association
and by NI H Grant #NS07919.
Reprinted by permission from Neuroscience Abstracts
2: Parts 1 & II. 1976.
Axonal transport and trophic studies
Further electrophoretic studies on proteins
of neuronal origins in skeletal muscle*
(1977)
GUSTAVO S.L. APPEL TAUER and IRVIN M. KORR
Skeletal muscles cannot survive
without motor innervation. This
neural infuence has not yet been
satisfactorily explained in terms of
neurotransmitter release or control of
muscle activity by the nerve (9- 1 1 ) .
The possibility has been raised that
the nerve releases into the muscle
some substances that do not act as
neurotransmitters, but which influ
ence the anabolic processes in the
muscle cells (9, 1 0) . This theory
received support from the autoradio
graphic study by Korr et al. ( 1 5) , who
showed that after labeling the fourth
ventricle of rabbits with [HP]
phosphate and 1 4C-Iabeled amino
aci ds , l abel ed macromol ecul es
migrated along the hypoglossal axons
and appeared in the tongue muscles.
Subsequent studies revealed that
axonally transported proteins arrived
at the styloglossus muscle at four time
intervals, with peaks at approximate
ly 1 , 12, 22, and 34 days after their
synthesis in the hypoglossal nucleus
( 1 4) . An analysis of the soluble pro
teins by disc electrophoresis (pH 8. 3,
migration toward the anode) led to
the characterization of a group of
proteins responsible for the peak
found at Day 22 (2). In the present
study, by using a different electro
phoretic technique (p H 4. 2 migration
toward the cathode) we were able to
resolve other axonal proteins that
reach the muscle, including some that
are responsible for the peak found at
Day 34, and to analyze their pattern
of axonal migration and arrival at the
muscle.
Methods
Thirty New Zealand white rabbits
weighing 1 . 9 to 2. 1 kg were used. The
surgical and sampling procedures
'Supported by Grant NS-07919 from the National In
stitute of Neurological Diseases and Stroke. National
Institutes of Health. and by the American Osteopathic
Association. We appreciate the skillful technical
assistance of Mr. David Parlin. Miss Deborah Speer.
and Miss Deborah Bower. We are also grateful to Mr.
Robert Kern for the computer proce,sing of the data.
were those used before (2, 1 4) . Under
Nembutal anesthesia, the hypoglossal
nucleus of each animal was labeled
with 250 ,Ci L- PH] lysine HCl
(Amersham/Searle, 8- 1 8 Cilmmol) .
The specimens, taken 1 to 70 days
later, consisted of the left hypoglossal
nerve (divided into three segments),
the left styloglossus muscle which it
innervates, and control muscles (the
pooled stylohyoid and mylohyoid)
used to measure the incorporation of
blood-borne radioactivity into the
styloglossus muscle.
Because in this type of study of
nerve-to-muscle transfer it is essential
to reduce the amount of nerve tissue
in the muscle specimens to a mini
mum, all muscle regions receiving
nerve branches were cut away under a
dissecting microscope. Cholinesterase
staining showed that few end plates
remained in the specimens.
The specimens were first homoge
nized at 0 to 2C in acetate buffer
(pH 5. 7 and 0.08 M, containing
0. 076"0 TEMED (/ / N', N'-tet
ramethylethylene diamine); 3 .75 ml
buffer/g tissue) and centrifuged 20
min at 1 3, 800g. The supernatant,
which will be referred to as "soluble
extract, " was then analyzed electro
phoretically.
The precipitate was twice rehomog
enized and washed with 1 5 ml buffer,
rehomogenized in buffer containing
0. 5% Triton X (3. 75 ml/g tissue), and
left 1 h at room temperature. The sol
uble material, which will be referred
to as "Triton X extract, " was sep
arated by centrifugation and also
analyzed electrophoretically.
The electrophoretic analyses were
carried out in two to six 0. 1 5-ml
portions of each soluble and Triton X
extract by the method of Reisfeld et
al. [pH 4. 2 and 1 5% gels, runs
toward the cathode ( 1 8)] , with the
sepaating and stacking - loading
gels containing 0. 1 and 0. 625%
Triton X, respectively. After the run,
the gels were fIed and stained with
Coomassie brilliant blue 0-250
(Serva), cut into segments, and
assayed for radioactivity as described
previously (2).
For data processing, the formulas
used previously (2) were adapted to
the new extraction and electropho
retic procedures, as follows:
Spcifc activity (dpm/mg)
2,35 7 (ml total suprnatant) } (count/min)
0.15 X (mg fresh ti . ue) 7 (numbr of gls po le)'
average length of sgment (xaxis in Figs. 2. 4)
=
- 21.55 I w/I I W,
average activity concentration (y &N in Figs. 2. 4)
L=r/7.55
@ r
(spci
f
c activity)
.
w
where 2. 35 is the counting efficiency
correction factor; 0. 1 5 is the extract
volume in each electrophoretic gel; n
is a reference gel segment containing
a protein band with equal mobility in
all tissues and extracts (protein 0 in
Fig, ! , see below); m is the number of
animals killed at each interval; and W
is the weight of each gel segment ob
tained from each animal. The number
27. 55 makes the average distance
between the anodic end of the gels
and the fastest-moving protein equal
to 40. 00, so that the graphs are
comparable to those published previ
ously (2).
Results
Electrophoretic separation of pro
teins. The stained protein patterns of
the electrophoretic gels are shown in
Fig. 1 . Each tissue and extract had its
peculiar pattern so that, in order to
match their equivalent proteins, it
was necessary to run electrophoresis
with samples mixed in graded
amounts. The letters A through H
indicate some proteins with equiva
lent electrophoretic mobilities thus
determined (see below) .
Radioactivity in soluble proteins. The
radioactivity distributions in the elec
trophoretic gels of the nerve soluble
proteins and of the nerve-transported
soluble proteins in the styloglossus
muscle [which is represented by the
difference in values between the stylo
glossus and control muscles (2, 1 4)J
are shown in Fig. 2. Several proteins
had prominently high activities that
appeared as peaks in the histograms.
Peaks appearing in the muscle gels
and their equivalents in the nerve gels
are labeled A through H. Letters are
shown in Figs. 2, 4 only if the activity
concentrations differed significantly
(PS 0.05) between the peaks and the
IIJ
A B C H0 E
| f
' | | | | | | | | | | | | | | | | |
A B
c
C H0 E
t f
| l l l l l l | | l l l l l l | |

A B C H 0 E
| | |
9

| | J
| | | | | | | ' ' | ' | | ' ' ' | ' | | ' | | |
| c
|

||
H
| |
!
NERVE
|5OLUBLE)
MU5CLE
|5OLUBLE)
NERVE
| TR| TONX)
MU5CLE
| TR| TONX)
Fig. I. Electrophoretic patterns of the soluble and Triton Aextracts from nerve and muscle. The
brackets and numbers indicate the way the gels were sliced. The lengths of the segments are the
averages from the three nerve specimens and from the styloglossus and control muscle specimens of
the 30 animals. The segments are numbered from the anode toward the cathode; equivalent numbers
do not represent' equivalent protein bands in the different electrophoretic patterns. The letters A
through H show the position ofnerve-delivered proteins to the styloglossus muscle.
A

.
J
'
N]HM] : wLvc z _ ; = .

. _ .
. .. t
i x !9
0xS
^ !
uavt
'

o
i
i
|
|
O!
114
. 3
. _ , _ _ .
1 K
1
nLSvL Z
&
n(uv( z
3s l r 2

i iO 2O
u(nvL 3
i o

|0

K
xLO(ossus-
cOJoL
(

'' . ' ' |

+
sJxtLossus-
couJoL

=
sxio6Lossus-
coJoL
neighboring segments.
I n the hypoglossal nerve gels,
several radioactivity peaks appeared
at Day I , and some remained visible
at Day 70, two of them, A and D,
quite prominently. By Day 12 radio
activity was slightly higher in the dis
tal than in the proxi mal nerve seg
ment. This di fference increased at
longer i ntervals, but became conspic
uous only by Day 34, when the activ
ities had decreased to about one-sixth
of their Day- 1 2 values.
Most peaks found in the nerve gels
were also identifiable by Day 1 2 in the
styloglossus muscle gels. As in the
nerve, peaks A and D were the most
prominent i n the muscle. The course
of appearance of radioactivity varied
for di fferent muscle proteins. Peak H
was visible only at Day I , and the re
maining peaks were identifiable be
tween Days 1 2 and 70. In contrast to
the styloglossus muscle, the specific
activities of the control muscles (not
shown) were very low and only two
significant peaks, at the positions of
A and H, were found.
To examine the axonal flow and in
corporation of individual proteins in
to the styloglossus muscle, the specif
ic activities of the gel segments con
taining the most prominent peaks (A
and D through G) were averaged and
plotted against time, making the
average Day- 1 2 values of the three
nerve segments equal to 1 00 to enable
comparisons between fractions with
di fferent activities (Fig. 3). In al l
three nerve segments, the radioactivi
ty of most of the soluble proteins in
creased sharpl y from Days I to 1 2,
decreased t o 2500 by Day 22, and
then decreased very slowly thereafter
(exceptions were H and protein at
segment 36) . In the muscle, proteins
A and D through L reached their
Fig. 2. Bar graphs depicting specific activity
distribution along the electrophoretic gels of
soluble proteins extracted from nerve and from
muscle at various intervals after injection of
L f' Hl lysine. The values indicated as
styloglossus - control (difference between
styloglossus and control represent the amount
of nerve-delivered radioactivity in the
styloglossus muscle; their peak values and the
equivalent peaks in the nerve are indicated as A
through H. The abscissae represent the
segments into which the gels were cut. The
height of the bars represents the specific activi
ty (dpmlminlmg fresh tissue) per length ofthe
gel (see text). Data were averaged from five
(Days I, 22, and 34), four (Days 12, 45, and
56), or three animals (Day 70).
Axonal transport and trophic studies
highest activity at Day 34. Fraction F
behaved similarly, although i ts
Day-22 and Day-34 values did not
differ at the 0.05 level of significance.
The activity of fraction G, however,
was already near maximum by Day
12. When plotting the ratios between
the specifc activity of G and the
other proteins as obtained from each
animal (Fig. 3), there was a sharp and
significant decrease in values between
Days 1 2 and 34, indicating an earlier
appearance and possibly a shorter
lifetime of radioactivity in muscle for
G than for A through F.
Radioactivity in Triton A Extracts.
The results obtained for the Triton X
extracts are illustrated in Fig. 4. The
specific activities were lower than
those in the soluble extracts. Two dif
ferent groups of radioactive proteins
were found in the hypoglossal nerve .
One of them was present at the distal
part of the nerve at Day 12 and con
sisted of fve activity peaks, four of
them equivalent to D through G. The
other group contained seven peaks
(one with the electrophoretic mobility
of D) which appeared in the proximal
nerve segment at Day 12 and moved
slowly in the distal direction reaching
the end of the nerve by Day 45. The
amount of nerve-transported radioac
tivity in the Triton X-soluble fraction
of the styloglossus muscle was at all
times low, and no clear peaks could
be discerned in the gels.
Discussion
Axonal fow ofproteins. Somatoax
onal transfer and axonal flow can oc
cur at various rates. Both processes
can take place rapidly, giving the
classic picture of the "fast ax
oplasmic fow" ( 1 6), which is prob
ably responsible for the radioactivity
peaks A and H in the styloglossus
muscle at Day 1 . Other soluble pro
teins (peaks A through G) followed a
pattern described previously (2): slow
penetration into the nerve, as re
vealed by their highest activity at Day
12, followed by a fast proximodistal
fow, as revealed by their pattern of
increased and then decreased radioac
tivity which took place simultaneous
ly in the three nerve segments. Most
proteins in the Triton X extract
moved proximodistally at 1 to 1 . 5
mm per day, according to what has
been called "slow axoplasmic flow"
( 1 6) . It is not possible to tell whether

1
the other radioactive proteins in the
Triton X extract, found in the distal
nerve segment at Day 12, migrated as
insoluble complexes or were bound to
particles locally.
Nerve-Io-muscle delivery. The prox
imodistal flow of proteins was either
interrupted or interfered with to
various degrees between the distal
nerve segment and the styloglossus
muscle. The anode-migrating "acid"
proteins studied previously (2) either
did not enter the muscle or reached
their highest activity in muscle at Day
22, whereas most of the cathode-mi
grating "basic" proteins examined in
this study did penetrate the muscle,
but followed heterogeneous patterns,
with at least three fractions reaching a
peak at Day 34. These results confirm
previous findings that two different
groups of neuronal proteins penetrate
the styloglossus muscle by Days 22
and 34 after their synthesis (2, 1 4) .
Because soluble proteins (other than
fraction H in this study) showed only
minor differences in their patterns of
appearance and disappearance in the
nerve, these distinct periods probably
represent different rates of nerve-to
muscle transfer and different life
times in the muscle.
There was little or no nerve-to
muscle transfer of proteins in the
Triton X fraction. After the arrival of
most radioactive proteins at the distal
nerve segment between Days 34 and
1 15
|0
_
100
EL SECNENTS
FRACON NERVE
P I - 4
| - |
L -
-
| ~
Nerve l
Nerve 3
M>0If 5YWL
| O
| ~ ^
-
| ~ O
~ *~
10 20 30 40 50 60 70
Doys
Styloglossus - Control
(Fraction and )

_ i 1 l
0 10 20 30 40 50 60 7
Styloglossus- Control
( Fraction 0l
Doys
Fig. J. Graphs ofaverge specic activitie at peks A and D through G plotte against time. Nerves
I, 2, and ! are the proximal, medial, and dital nere segments; styloglos us - control is the di
ferenc between the styloglos us and contrl value. The average Day-I2 values ofthe three nerve
segments were made equal to I0. The inet lits the nerve and muscle gel segments containing each
pk. Turover of nerve-delivered radioactivity to styloglosu muscle was diferent for A through
F and for G. Thi i indicated by the rtios between the activity ofG and the activity of the other
segments in ech animal (setet) shown in the lower right.
45, the muscle activities decreased
and remained at trace levels, indicat
ing exclusion of these proteins from
the muscle. The very low activities
found in the muscle between Days 1
and 34 could be the effect of con
tamination or binding of soluble pro
teins to particles.
Trans-synaptic transfer of proteins.
Numerous studies have revealed a
trans-synaptic transfer of protein
bound radioactivity ( 1 , 3, 4, 6-8, 1 2,
1 3, 1 5, 1 7, 1 9-24). However, it has
been recognized that products result
ing from proteolysis at nerve termi
nals are utilized by surrounding cells
(5, 1 2) and the findings may reflect a
transcellular transfer of small mole
cules and not of protein. This is not
the case in at least some trans
neuronal ( 1 9, 20) and nerve-to-muscle
transfers (2) . In the present study, if
the radioactive proteins in the stylo
glossus muscle were synthesized local
ly, the electrophoretic distribution of
nerve-delivered radioactivity should
result in the labeling of mainly pro
teins A and H, as found after the
II
systematic injection and in the con
trol muscles. Thus, reutilization of
nerve breakdown products may ac
count for the results found at Day 1 ,
but not at Day 1 2 or later.
The main problem involved in
these electrophoretic studies is con
tamination of the muscle specimens
by nerve terminals, which was small,
as indicated by the few end plates
found in styloglossus muscles dis
sected like the specimens used in the
experiments and by the fact that
radioactive proteins that penetrated
the entire length of nerve examined
were not found in significant
amounts in the styloglossus muscle.
The possibility that the neuronally
synthesized proteins in the muscle
were confined to and extremely
highly concentrated in the few re
maining nerve terminals is improb
able in view of the autoradiographic
studies ( 1 5) which located radioactivi
ty inside the muscle cells. Because
nerve-to-muscle delivery is an impor
tant subject in view of its possible role
in trophic interactions, experiments
will be continued toward finding the
location of these proteins in the mus
cle cells, isolation of the proteins, and
determination of their function.
References
I. Alvarez, j., and M. PlIschel, 1972. Transfer of
material from efferent axons to sensory epithelium in
the goldfish vestibular system. Brain Res. 37: 265278.
2. Appeltauer, G., and I.M. Korr, 1975. Axonal
delivery of soluble. insoluble and electrophoretic frac
tions of neural proteins to muscle. Ep. Neural. :
1 321 46.
3. Casagrande, V.A and J.K. Harting. 1975.
Transneuronal transfer of tritiated proline in the
visual pathways of the tre shrew. Tupaiglis. Brin
Re. %: 367-372.
4. DrAger, U.C. 1974. Autoradiography of tritiated
proline and fucose transported transneuronally from
eye to the visual cortex in pigmented and albino mice.
Brain Re. M: 284-292.
S. Droz, B., H.L. Koenig, and L. DiGiambera
dino, 1973. Axonal migration of protein and
g1ycoprolein to neve endings. l. Radioautographk
analysis of tile renewal of protein in nerve endings of
chicken ciliary ganglion after intracerebral injection of
'H lysine. Brin Res. W. 93-127.
6. Globus, A., H.D. Lux. P. Schubert, and P.
Kaups. 1 971 . Labelling of nearby neurons following
the intracellular iontophoresis of 'H glycine. Anat.
Ree. 16:325.
7. Grafslein, B. 1971 . Transneuronal transfer of
radioactivity in the central nervous system. Science
172: /77-179.
8. Grafstein, B., and R. Laureno. 1 973. Transport
of radioactivity from eye to visual cortex in tile mouse.
Exp. Neuro/. 39: 44-57.
9. Guth. L., 1 968. "Trophic" influences of nerve
on muscle. Physial. Rev. M. 65-687.
10. Gutmann. E. 1 976. Neurotrophic relations. An
nu, Rev. Physial. M: 1 77-216.
I I . Harris. A.J. 1 974. Inductive functions of the
nervous system. Annu. Rev. Physiol. :251 -305.
12. Heacock. A.M and B.W. Agranoff. 1977.
Reutilization of precursor following axonal transport
of 'H proline labelled protein. Brain Res. 22:
243254.
1 3. Hendrickson, A. 1972. Electron microscopic
distribution of axoplasmic transport. J. Camp.
Neural. 14: 381397.
14. Korr, I.M., and G.S.L. Appeltauer. 1 974. The
time course of axonal transport of neuronal proteins
to muscle. Exp. Neural. 4t 452-463.
1 5. Korr, l.M., P. Wilkinson, and F.W. Chorok.
197. Axonal delivery of neuroplasmic components to
muscle cells. Scince 155: 342-345.
16. Lubinska, L. 1975. On axoplasmic flow. In/.
Rev. Neurbial. 17: 241-296.
17. Neale. J.H E.A. Neale, and B.W. Agranoff.
1 972. Radioautography of the optic tectum of the
goldfISh after intraocular injection of ('H) proline.
Science 176: 407-410.
18. Reisfeld, R.A., V.J. Lewis. and D.W. Williams.
1962. Disc electrophoresis of basic proteins and pep
tides on polyacrylamide gels. Natur (Lond.) 195:
281-283.
19. Schwab, M.E + and H. Thoenen. 1976. Electron
microscopic evidence for a transsynaptic migration of
tetanus toxin in spinal cord motoneurons: An
autoradiographic and morphometric study. BrainRes.
10: 213-227.
2. Schwab. M and H. Thoenen. 1977. Selective
trans-synaptic migration of tetanus loxin after
retrograde axonal transport in peripheral sympathetic
nerves: A comparison with nerve growth factor. Brain
Res. 122: 459-474.
Axonal transport and trophic studies

21. Speht, S.C., and B. Grafstein. 1973. Ac

cumulation of radioactive protein in mouse cerebral
cortex after injection of H'-fucose into the eye. E.
Neurol. 4: 705-722.
22. Specht, S.C., and B. Grafstein. 1977. Axonal
transport and transneuronal transfer in mouse visual
system following injection of ['HI fucose into the eye.
Ep. Neurol. %: 352-368.
23. Thies, M., and H. Rahmann. 1 976. Unter
suchungen zum Verlauf der Projektionsbahnen im
olfaktorischen System der Teleosteer sovie zum
transneuronalen Transport von 'H-Histidin
markierten Verbindungcn. Zool, Jahrb. Abt. Allg.
Zool. Physiol. M: 1 1 3- 1 30.
2. Wiesel, T.N., D.M. Hubel, and D.M.K. Lam.
1974. Autoradiographic demonstration of ocular
dominance columns in the monkey striate corte by
means of transneuronal transport. Brain Res. W:
273-279.
Reprinted by permiSSIOn from Experimental
Neurology 57: 713-724, 1977.
P
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Fig. 4. Bar graphs ofspecific activity distribution along the electrophortic gel ofthe Trton 7
tracts. Abscissae and ordinates same U in Fig. 2.
IIT
Abstract: Axonal migration of
some partcle-bound proteins
in the hypoglossal nene and
their failure to enter the
styloglossus muscle
GUSTAVO APPELTAUER and
IRVIN M. KORR
In 1 967 Korr, Wilkinson. and Chor
nock' found that. afer labelling the
fourth ventricle of rabbits with 32-P
phosphate or 14-C amino acids. mac
romolecules migrated along the hypo
glossal axons and appeared in the
tongue muscles. Studies were then
undertaken with the purpose of char
acterizing nerve-to-muscle t rans
ported proteins and determining their
patterns of axonal flow and entry into
the muscle. A first series of studies
was conducted on the axonal soluble
proteins.23 It was found that elec
trophoretically separated fractions
had their highest radioactivity in
the nerve at day 1 2 after labelling
of the hypoglossal neurons. Also. the
activity appeared and decreased si-
multaneously in the proximal and
distal portions of the nerve. Finally,
after variable time intervals, some of
the radioactive proteins entered the
styloglossus muscle in the tongue.
The present study revealed a com
pletely different dynamics for a group
of proteins that were detached from
the particulate elements of the medul
la, nerve, and muscle with Triton
X- tO, and then analyzed by disc
electrophoresis (pH 4.2 and 1 5 per
cent gel concentration) . After label
ling the ventricle with 3-H lysine,
radioactive proteins appeared in the
most proximal portion of the nerve at
day 1 2. Subsequently they migrated
proximodistally at a rate of approxi
mately 1 .5 mm. per day, and ap
peared in the most distal portion of
the nerve by day 45. Up to day 70, no
significant levels of radioactivity were
found in equivalent electrophoretic
fractions of the styloglossus muscle.
Bcfcrcacc
1 . Korr, I. M. , Wilkinson, P.N., and Chornock.
F.W.: Axonal delivery of neuroplasmic components
to muscle cells. Science 155: 34245, Jan 67.
2. Appeltauer, G.S.L .. and Korr. l . M. : Axonal
deliver of soluble, insoluble and electrophoretic frac
tions of neuronal proteins to muscle. Exp Neurol
461 ): 132-46, Jan 75.
3. Appeltauer. G.S.L., and Korr. I. M. : Elec-
II8
trophoretic Characterization of nerve-to-muscle
delivered basic protein. JAOA 76:294. Dec 76.
Supported by AOA Research Grant #75-122. "The
Isolation of Some Neuronal Proteins Delivered to
Muscles and the Determination of Their Function."
through the AOA Bureu of Research, and through
NIH Grant #NS-07919.
Reprinted by permission from JAOA 77: 479. 1978.
Axonal transport and trophic studies
Interpretation of research findings
II9
The neural basis of the osteopathic
lesion*t (1947)
Four of the main principles in
osteopathy appear to be:
1 . Joints and their supports are
subject to anatomic and functional
derangements.
2. These derangements have distant
as well as local effects.
3. They are related, directly or in
directly, to other pathologic in
fluences.
4. They may be recognized, and
their local and distant effects in
fuenced favorably by manipulation.
Accepting the existence of joint de
rangements (osteopathic lesions), it is
our purpose in this paper to examine
not the mechanical and etiological
factors involved, but rather the fun
damental basis for principles 2 and 3
and to a small extent principle 4, and
to report progress in our understand
ing thereof.
The osteopathic lesion has many
aspects which are partly revealed in
the local and distant effects referred
to as principle 2. Included among
these are:
1 . Hyperesthesia, especially of the
muscles and vertebrae.
2. Hyperirritability, reflected in
altered muscular activity and in
altered states of muscular contrac
tion.
3. Changes in tissue texture of mus
cle, connective tissue, and skin.
4. Charges in local circulation and
in the exchange between blood and
tissues.
. Altered visceral and other auto
nomic functions.
How are these effects produced?
What are the central factors responsi
ble for these manifestations of struc
tural and postural abnormalities?
What in the intrinsic nature of the
osteopathic lesion is the basis for the
peripheral, palpable, and clinical ef
fects? What fundamental changes
take place as a result of effective
manipulative therapy?
Presented before the Teaching Group on Osteopathic
Principles, Diagnosis and Therapeutics at the Fifty
First Annual Convention of the American Osteopathic
Association, Chicago, July 21 , 1947.
tThe research on which this paper is based was made
possible by grants from the Research Committee of
the American Osteopathic Association.
II0
The detailed answers to these ques
tions are, of course, not yet available,
but reliably indicated are the general
nature of the final answer and the
direction in which we must proceed in
order to obtain it. The research pro
gram of the Kirksville laboratories is
designed to procure some of these
answers through exploration of the
intimate mechanisms involved in the
osteopathic lesion. We believe that
the answers are obtainable only
through fundamental, experimental
research and that the emerging con
cept of the lesion and its implications
will have considerable impact on the
practice of osteopathy.
In this paper will be presented some
of our current views, some of the
practical implications, and some
speculations. The details of the ex
perimental methods and the raw data,
available in earlier publications,
l,J
will not be presented, but rather the
general experimental approach and
the immediate conclusions therefrom.
From these, in turn, will be drawn
some generalizations.
The neural basis of the osteopathic
lesion
Within the nervous system, in the
phenomena of excitation and inhibi
tion of nerve cells, and in synaptic
and myoneural transmission, lie the
answers to some of the most impor
tant theoretical and practical osteo
pathic problems. The existence of a
neural basis for the lesion has been
known, of course, for a long time.
The segmental relation of the osteo
pathic lesion to its somatic and vis
ceral effects is explainable in no other
way.
The activity and condition of the
tissues and organs are directly in
fuenced, through excitation and in
hibition, by the efferent nerves whIch
emerge from the central nervous sys
tem and which conduct impulses to
these tissues and organs (Fig. !). For
example:
Mucle.
A. Anteri or horn cel l s ( Moto
neurons) - muscular contraction
B. Lateral horn cells (Sympathetic
preganglionic neurons through
postganglionic neurons) - vaso
motor activity
Skin.
C. Lateral horn cells - vasomotor
activity
D. Lateral horn cells - sweat gland
secretion
E. Lateral horn cells - piloerection
Viscera.
F. Lateral horn cells - smooth mus
cle contraction
L. Lateral horn cells - glandular
secretion
H. Lateral horn cells - vasomotor
activity
The activity of these organs and
cells is directly determined by the ac
tivity of their motor nerves. This
nerve activity is measured in terms of:
(a) The number of impulses con
ducted by each efferent nerve fiber
and (b) the number of fibers in
volved. Thus, in the absence of im
pulses in the corresponding motor
nerve, a muscle is completely at rest.
The amount of contraction (tension
produced or degree of shortening) at
any moment is in proportion to the
number of motoneurons which are
conducting impulses at that moment
and the average number of impulses
per second which each is conducting
to the muscle. With certain modifica
tions this principle also applies to
organs other than muscle. Abnor
malities in these 'rgans are produced
by overactivity or underactivity of the
efferent nerves.
Secondary effects of neural
imbalance
It is important to emphasize, how
ever, that not all the effects of over
activity or underactivity of the effer
ent neurons are direct and immediate.
Secondary effects often assume pre
dominate importance. Thus, a mus
cle's overactivity, over a long period
of time, may result in fibrosis and
major chemical and metabolic
changes; underactivity, in atrophy.
Overactivity of sympathetic fbers
which control arterioles may result in
local anoxemia, inflammation, al
tered capillary permeability, edema,
etc. Imbalance in the efferent neurons
controlling the smooth musculature
of the gastrointestinal tract may
result in faccidity or spasm with
serious effects on digestion and ab-
Interpretation of research
sorption and, therefore, on the entire
body economy. Overactivity or
underactivity of the neurons control
ling glands may result in disastrous
shifts in acid-base, fluid, and electro
lyte balance and in such conditions as
peptic ulcers. If the gland happens to
be one of the endocrines, the effects
may be especially serious and exten
sive. We may for the present purpose
include the spinothalamic fibers
among the "efferent" neurons. These
convey pain sensations to the brain
and, when overactive, produce not
only physical but also important
psychological changes with potential
ly serious and extensive changes in
motor and visceral activity. With the
crucial importance of the efferent
neurons in mind, more precise for
mulation of the problem is possible.
There are three main questions:
1 . What factors control the activi
ty, i . e. , the number of impulses, in
the efferent nerve fbers?
2. How does structural abnor
mality, i . e. , the osteopathic lesion,
play upon these factors to produce
overactivity or underactivity of these
fibers and, therefore, of the organs
which they innervate?
3. How does manipulative therapy
play upon these factors to restore
balance and cause regression of signs
and symptoms?
Factors controlling efferent activity
Let us proceed to the first question.
What factors has physiological re
search demonstrated to be primary in
the control of activity of the efferent
neurons? Two main principles have
special pertinence here.
A. The principle of reciprocity
states that through the network of in
terneurons (also known as internun
cial neurons, intercalated neurons,
and connector neurons), which is
situated within the central nervous
system, every neuron potentially in
fluences, and is influenced by, almost
every other neuron in the body.
B. The principle of convergence
states that many nerve fibers con
verge upon, and synapse with, each
motoneuron. These presynaptic
fibers convey impulses from a large
variety of sources to the efferent
neuron which, therefore, represents a
final common path. 4
Let us examine how these prin
ciples operate with respect to the
anterior horn cells, keeping in mind
e

-

.
*
.
A
`
t
I

' :

*
:
"*ee
W

"T
l V
Fig. I. -Diagrammatic representation oj segmental refepathways among somatic and viceral
ajJerents and eJJerents.
Afferents (Dorsal root neurons):
A-From spinous process, joints; B-From stretch and tension receptors (proprioceptors) in
musdes and tendons; C-From touch, presure and pain endings in skin; DFrom vicera;
ABC-Somatic ajJerents.
Efferents: b-motoneurons to skeletal musde; c-sympathetic postganglionic neurons to blood
vessels oj skin and musde; to sweat glands and pilomotor muscles oj skin; d-sympathetic
postganglionic neurons to visceral smooth musde, blood vessels and glands; S-Spinothalamic
fbers; I ~ Intereurons; L - Lateral hor cells (sympathetic preganglionic neurons); V. G. -
Vertebral ganglion; C. G. - Colateral ganglion.
that they probably operate in a
similar fashion upon the other ef
ferent neurons (Fig. 1 ) .
1 . Each anterior horn cell receives
impulses from a large number of
sources through the presynaptic
fibers which converge upon and
synapse with it. All the descending
tracts in the spinal cord, conveying
impulses from such sources as the
cerebral cortex, red nucleus, medulla
oblongata, the vestibular nuclei, cere
bellum, the pons, superior colliculi ,
and other hi,her centers, establish
synaptic connections wi th the
anterior horn cell for the mediation
of voluntary motion, equilibrium,
post ural r efl exes, vis uospi nal
reflexes, and others. The propriocep
tors, stretch and tension receptors sit
uated in the tendons and in the
muscles themselves, are a steady and
continuous source of impulses. They
exert their influence directly through
the dorsal root fibers into which they
discharge their impulses or, indirect
Iy, through the higher postural and
equilibrium centers. Afferent fibers
from the viscera may also play an im
portant role. In fact, every afferent
nerve fiber, whether it mediates
touch, pain, pressure, temperature,
sight, or any other sense modality, ex
erts infuence upon the final common
path represented by the motor nerves.
2. Some of the converging fibers
exert an excitatory influence, others
an inhibitory influence on the same
motoneurons.
3 . The activity of the motoneuron
at any moment, that is, the frequency
with which it delivers impulses to the
muscle fibers, represents a dynamic
balance among all the excitatory and
inhibitory infuences being exerted by
the many neurons which converge
upon it. The proprioceptors and some
of the higher centers, through their
steady, tonic control, act as gover
nors or buffers. The balance, how
ever, is shifted from moment to mo
ment in accordance with changes in
the internal and external environment
and in response to volition. As pre
viously stated, pathology results
when the balance is shifted too far in
one direction or the other (excitation
or inhibition) for too long.
4. The collective action of the pre
synaptic nerve fibers upon the fnal
common path is further reflected in
the phenomena known to physiolo
gists as reinforcement and facilita
tion. Before the anterior horn cell can
discharge impulses into the muscle
fibers, it must itself receive excitatory
impulses simultaneously from a
number of presynaptic fibers. Stated
1Z1
another way: Before a given stimulus
(e.g. , to the skin) c produce a reflex
muscular response, the anterior horn
cell must frst be "warmed up" or
"put on edge" (facilitated) by im
pulses from other (excitatory) fibers
which synapse with it. The efferent
neuron must already be in a state of
subthreshold or subliminal excita
tion. In other words, the various
fibers 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
been demonstrated that a con
siderable portion of the nerve fbers
must be in a state of subliminal ex
citation before any of them fire and
cause muscular contraction.
. This requirement serves as a
margin of safety or an insulaton,
preventing muscles from responding
to every impulse which reaches the
anterior horn cell.
6. When a signifcant percentage of
the anterior horn cells in a given seg
ment of the spinal cord is maintained
in a state of subliminal excitation,
they require little additional stimulus
to produce a reflex response. This is
reflected in our frequent use of the
terms . "on edge, " "jumpy, "
"tense," which imply motor aspects
of psychic imbalance. In individuals
thus characterized the anterior horn
cells are maintained close to, or at,
threshold, even during rest.
The osteopathic leion and the
factors controlling effernt
activity
The second question in our series of
thre was "What is the relation of the
osteopathic lesion to the above
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? Con
siderable light is being thrown upon
this problem by the research in
progress at Kirksville College of
Ostepathy and Surgery under the
directorship of Dr. J. S. Denslow.
The research has revealed close
relations between lesion mechanisms
and certain well-established physio
logical principles. The general ex
primental approaches and the major
conclusions from each are presented
in the following section.
12
Experimental
Refex threhold.
Denslow, ' proceeding from the ob
servation made by all osteopathic
physicians that pressure to the spi
nous processes of lesioned segments
produces much more contraction in
the spinal extensor muscles, and with
less pressure, than is true at non
lesioned segments, set out to
determine i n a precise, objective
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 object was to determine
whether, and to what degree, lesioned
segments were distinguished from the
normal by differences in reflex
threshold.
Muscular activity was determined
electromyographically, that is, by
recording the electrical signs of
muscular activity. Measured pressure
stimuli were applied to the spinous
processes by means of a calibrated
pressure meter which simulated the
action of the osteopathic thumb. At
each segment gradually increasing
pressure stimuli were applied to the
spinous process until just detectable
activity in the erector spinae mass was
obtained; this represented the reflex
threshold for that segment. The reflex
arc under investigation might be said
to consist of these parts: spinous
process. dorsal root fiber, inter
neuron, anterior horn cell, and
muscle fibers. (See Fig. 2, dis
regarding segmental designations and
intersegmental connections.)
This pioneer study upon a large
number of human subjects resulted in
the demonstration that the refex
thresholds in lesioned segments were
much lower than in normal segments.
The more severe the lesion, as
determined by palpation, the lower
the threshold. The thresholds may be
constant over periods of months.
What is the basis for the lowered
reflex threshold of the lesioned
segment? There were two obvious
alternatives. (1 ) The sore spine. It
was reasonable 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 impulses at
the anterior horn cells than did the
corresponding endings in the normal
spinous process. (2) Hyperirritable
motoneurons. It appeared equally
reasonable to suppose that for some
reason or other the anterior horn
cells of the spinal extensor muscle
in the lesioned segments were main
tained at a higher level of excitability.
In order to decide which was the more
likely alternative. the following
experimental approaches were under
taken. l
Intersegmental spread 0/
ecitation.
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
between them, and to other factors.
The experiments were conducted as
follows (Fig. 2). The four thoracic
segments, designated as T4, T6, T8.
and Tl O, were selected for this series
of experiments on 30 subjects. 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 stimuli were applied to the
spinous processes with the pressure
meter.
The minimum pressure stimuli
(threshold) required at each of the
four spinous processes to elicit
activity from each of the four muscle
segments was then determined in
turn. Thus, the pressure required
upon the spine at 1to elicit activity
in the muscle at T4, in the muscle at
T6, in the muscle at T8 and in the
muscle at Tl O 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 be summarized by
illustrating with one hypothetical
subject, eliminating some qualifica
tions for the sake of brevity.
It was found that there was much
more spread to lesioned segments
than/rom lesioned segments. Thus, if
T6 were a severely lesioned segment
(very low threshold) while T8 and TIO
(neglecting T4 for the moment) were
normal or high threshold segments,
the following obtained. It required
very little pressure to the spinous
process of T6 to elicit activity of the
muscle in the same segment; but even
very strong pressure stimuli to the
same spinous process failed to pro-
Interpretation of research
duce any signs of activity in the
muscles at T8 or TID. Conversely,
although even very high pressures to
the spinous processes of the latter two
segments produced no activity in
either of these segments, relatively
slight pressures upon the spinous
processes of each of them did
stimulate reflex contraction at T6.
Thus, excitatory impulses entering
the cord at TID "by-passed" the
motoneurons of the same segment
and those of a neighboring high
threshold segment, to emerge or
produce effect at a more remote
lesioned segment.
If T4 were moderately lesioned (as
was often the case if there was a
leison at T6), it participated in
exchange of excitation with T6, but
usually only received excitation from
T8 and TID.
Our conclusion from this series of
experiments can be simply stated in
an analogy. The anterior horn cell of
the lesioned segment represents a bell
easily rung from a number of push
buttons, while the spinous process or
push button of the lesioned segment
does not easily ring bells other than
its own. The hyperexcitability of the
lesioned segment (that is, the rela
tively low reflex threshold) i s
demonstrable without applying pres
sure to the corresponding spinous
process.
Procaine studies.
It was of interest in this connection to
determine whether and how the ex
citability of the lesioned segment was
affected by desensitization of the
spinous process with procaine. Infil
tration of the periosteum around the
spinous process raised the local
threshold to that of a normal seg
ment, that is, it was no longer
possible to produce reflex response of
the muscle of that segment with
slight, moderate, or even heavy
pressure stimuli to the spinous
process of that segment.
In contrast, however, spread of ex
citation to that segment from other
segments remained unimpaired; al
though pressure to the procainized
spinous process of T6 no longer elicit
ed reflex contraction at T6, it was still
possible to elicit contraction at T6 by
pressure upon spines T8 and TID.
Thus, the hyperexcitability of the
lesioned segment was again demon
strated independently of the spinous
d 9
Fig. 2 -Diagram ofrefexpathways involved
in experimental measurement of segmental
refethreshold and of intersegmental spread
of ecitation. (See text.)
sp-sensory endings in spinous process; a, d -
ascending and descending intersegmental
neurons; m - erector spinae mass; e -
recording electrodes.
process; it exists even when the
spinous process is desensitized.
Bilateral diferences.
On a few subjects the reflex responses
on both sides of the same segment
were simultaneously observed (Fig. 2,
T6) . It was found that the spinal
extensors on one side of the segment
may respond reflexly to very slight
pressure upon the spinous process
while the other side requires much
higher pressure to the same spinous
process. In other words, low or high
thresholds are not determined by the
spinous process. The neurons in the
left and right horns of the same
segment may be maintained in differ
ent degrees of excitability. The left
and right "bells" are rung with dif
ferent degrees of facility from the
same "push button. "
Rest activity.
The differential excitability of
anterior horns in lesioned and
nonlesioned segments was further
and clearly shown in experiments in
which the anterior horn cells were
exposed, not to impulses from
spinous processes but to generalized
stimuli coming from within and
without the body.
When a patient is prone and com
pletely relaxed there is usually no
activity in the spinal muscles; there is
not even tone, as indicated by the
absence of action potentials in those
muscles. This is true, usually, even of
segments in lesion.
Occasionally, however, it was
found that muscular activity persisted
in the absence of external stimula
tion. The subjects had to be carefully
positioned and repositioned to elimi
nate as far as possible the afferent
bombardment from the propriocep
tors. It was found that when rest
activity did occur, it was almost
invariably in the lesioned, low
threshold segments. Thus, the seg
ment in lesion is the most sensitive to
positional stress, conveyed by the
proprioceptors in the muscles and
tendons.
Mental factors may also be re
sponsible for test activity. Subjects
who are apprehensive, anxious, or
emotionally upset often show per
sistent rest activity. Such activity was
always most marked in the lesioned
segment; often it occurred only in the
lesioned segments. The lesioned
segment is thus hyper-responsive to
impulses descending from the
cerebrum.
Tactile stimuli also demonstrated
the hyperexcitability of the anterior
horn cells in the segment of lesion. If
the back was slightly scratched or
tickled with a pin, as over the
shoulder or scapular area, continuing
activity in the spinal extensors at the
lesioned segment was often precipi
tated, but very rarely in the non
lesioned segment of the same subject.
Thus impulses from touch and light
pressure receptors in skin also find
the most responsive anterior horn
cells in the segments of lesion.
Occasionally we found a motor
unit which fired in synchrony with
inspiration or expiration; such a unit
was invariably situated in the lesioned
segments. Apparently such segments
are hyper-responsive also to impulses
from bulbar and pontine centers.
Interpretation ofexperiments.
The following general conclusions
1ZJ
may be drawn from these experiments
as regards to motor activity in
lesioned segments.
1 . An osteopathic lesion is associ
ated with a segment of the
spinal cord which has a low
motor reflex threshold, i. e. , it
represents a hyper-excitable seg
ment of the cord. At least in the
lesioned segments studied by us
it may be said that the balance
has been shifted too far for too
long toward the excitatory
side.
2. The lowered reflex thresholds
are demonstrable independently
of the related spinous process.
Even though changes in the pal
pable characteristics and in pain
sensitivity of the spines are
important diagnostic features,
they are apparently secondary
to other, more fundamental
alterations in the cord. This
aspect will be discussed later.
3 . The lesion represents an anteri
or root at least some of whose
motoneurons are maintained in
a state in which they are rela
tively hyperexcitable to all
impulses which reach them. I n a
severe lesion many of the moto
neurons are so close to thresh
old, even when the subject is at
rest and reclining comfortably,
that it requires very few addi
ti onal i mpul ses from the
neurons which synapse with
them to trigger those moto
neurons into overt activity.
Those additional impulses may
come apparently from almost
any source; the spinous process
is but one such source.
4. The lesion, therefore, is to be
conceived, not as a radiating
center of irritation, spreading
excitation to other segments,
but rather as a segment upon
which irritation is focused. It
represents a place in the cord
where barriers to motoneuron
excitation have been lowered
and which, therefore, chan
nelizes impulses into muscles
receiving motor i nnervation
from that segment.
Basis for segmental hyperecitability.
What is the basis for this segmental
hyperexcitability? What keeps the
motoneurons of the lesioned segment
"on edge, " that is, at a high level of
12
subliminal excitation? These anterior
horn cells can be maintained in this
facilitated state by continuous and
excessive bombardment from some
untiring source or sources.
The source ofimpulses.
What are the untiring sources of
impulses with which the anterior horn
cells in the lesioned segments are
continuously and excessively bom
barded? First, their excessive activity
is apparently associated with pos
tural, mechanical, and articular
derangements. Second, it must be
recognized that they are apparently a
highly stabilized and chronic source.
Reflex thresholds in segments of
lesion have been found to be very
constant over periods of months and
even years. Third, it must be rec
ognized that they are probably highly
localized, often restricting their
facilitating effect to only one or two
segments.
The sources which, in our opinion,
most closely fulfill these qualifica
tions are the proprioceptors, Le. , the
stretch, tension, and pressure recep
tors in the muscles and connective
tissues.
First, postural, mechanical, and
articular derangements unquestion
ably cause increased fiber-length or
tension in the muscles and tendons on
at least one side of the articulation in
question. The proprioceptors are
highly sensitive to changes in fiber
length or tension.
Second, they are the nonadapting
type of receptor. They keep firing
impulses into the cord via the dorsal
root fibers as long as they are under
tension and at frequencies which are
proportional to the tension. The
higher the tension, the higher the
afferent bombardment for as long as
the tension is maintained.
Third, the afferents from pro
prioceptors not only have segmental
distribution, but they specifically
influence the activity of the muscles
to which they are most closely related
or in which they are situated. This
specificity extends not only to the
muscles themselves, but to specific
muscle heads. It is thought that the
muscle spindle cells reflexly influence
only the muscle fibers in their im
mediate vicinity. In this way, highly
localized, vicious cycles of irritation
may be set up.
We, therefore, believe that these
receptors play a prominent role in
maintaining segmental hyperexcit
ability in areas of lesion. As a result
of the continuous barrage of im
pulses which they fre into the cord
at their level, the anterior horn cells
of the corresponding segment are
maintained in a state of chronic
facilitation - at a high level of
subliminal excitation, even during
rest.
Efects ofchronic faciltation.
In these segments, therefore, it
may be said that the normal "insula
tion" which keeps the efferent
neurons from firing in response to
every impinging impulse has become
worn. Since under normal conditions
of life, requiring constant adjustment
to the external and internal environ
ments, requiring motion and the
maintenance of the erect posture, so
many impulses from so many sources
are constantly impinging on the
motoneurons, in all segments of the
cord, that those which are already
facilitated, as in the lesioned segment,
will inevitably be more active than the
other. The muscle fibers to which
they are connected will then be
excessively high in tone. If main
tained for sufficient periods of time
this hypertonus would lead to
textural, morphologicll, chemical,
and metabolic changes which may, in
turn, become secondary and chronic
sources of irritation.
Other neurons.
We have thus far discussed only the
motoneurons and alterations in
motor refex activity in areas of
lesion. What of the other efferent
nerve fibers and the organs and
tissues which they innervate?
Our experimental studies have
demonstrated that closely and quan
titatively correlated with lowered
motor reflex thresholds are three
other features of the lesion: (1) Alter
ation in the texture of the tissue over
lying the spinous process, (2) lowered
pain threshold, and (3) increased
susceptibility to trauma.
1 . Tissue texture: As is well known
to osteopathic physicians, there are
striking changes in the texture of the
tissues over the spines of lesioned
segments. It was found that the
degree of change in tissue texture
was so closely related to the degree
of lowering of motor reflex thresh-
I nterpretation of research
old from th
e
normal that Denslow,
through palpation of subjects prior to
each electromyographic determina
tion of reflex threshold, was able to
predict with remarkable accuracy the
reflex threshold of each segment.
It is probable that these changes in
texture are due to local changes in
vasomotor activity, fluid balance,
capi llary permeabi l i ty, trophi c
factors, and other features which are
directly or indirectly under the in
fluence of the lateral horn cells of the
sympathetic nervous system.
2. Pain threshold: A direct correla
tion was found between motor reflex
threshold and segmental sensitivity to
pain. As is well known, the spines in
lesioned segments are much more
tender than those in normal seg
ments. In other words, it is easier to
reach the "consciousness" of the
patient, i . e. , the cerebral cortex,
through the lesioned segment than
through the nonlesioned. This, we
interpret as signifying a facilitation of
the spinothalamic fibers.
3. Susceptibility to trauma: It was
found that if one applies equal
mechanical irritation (measured
impacts) to the spinous processes of
lesioned and nonlesioned segments,
the former may remain painful for
several days, whereas the subject
soon forgets which of his normal
spines received the pounding.
We may conclude from these cor
relations with motor reflex threshold
that neurons other than the anterior
horn cells may also be facilitated and
maintained in a state of hyper
excitability in the lesioned segment.
This appears to be true, at any rate,
of certain of the preganglionic fibers
of the sympathetic nervous system
and of the spinothalamic fibers
conveying pain sensation to the
higher centers.
Experiments are now in progress to
establish the degree of involvement 'of
neurons of the sympathetic nervous
system. Dermatomal alterations in
sweat gland activity are being
determined by measuring the elec
trical conductivity of the skin in
lesioned and nonlesioned segments.
We are measuring alteration in the
activity of sympathetic fibers con
trolling vasomotor activity by
electrical measurements of skin and
deep muscle temperature. Although
these studies are still in a preliminary
stage, it has become evident that
sympathetic activity in the skin is
altered in lesioned areas and that
instruments used for the measure
ment of these peripheral changes, and
others which are contemplated, will
in one form or another become
valuable diagnostic aids. They are
much more sensitive than fingertips
and certainly easier to standardize.
There is no reason to doubt that
lateral horn cells which influence
specifi c vi sceral functi ons are
fundamentally similar to those
controlling the sweat glands. A
project, in collaboration with Dr.
D. E. Drucker of the Department of
Physiology, is under way for the
objective and precise determination
of alterations in various visceral
functions resulting from acute experi
mental spinal lesions in animals. The
effects on visceral function, in
normal unanesthetized dogs, of
lesions in segments related to the
viscus under examination will be
compared with the effects of similar
lesions elsewhere. At present, these
investigations are limited to a study
of renal blood flow, glomerular fil
tration, and tubular secretion. The
kidney was selected for the first such
investigation because methods for
quantitative study in normal animals
and humans are highly developed and
because of the clinical significance of
renal blood flow and renal metab
olism in connection with such entities
as hypertension. Similar studies upon
other visceral organs are projected
for the near future. It is hoped that
from these studies will emerge a
clearer understanding of the relations
of the osteopathic lesion to visceral
disease.
Characterization of the lesion
On the basis of the experimental
studies so far, I believe we are ready
to attempt a characterization of the
osteopathic lesion in terms of basic
neural mechanisms. Let us first
summarize our general conclusions.
1 . Normally, efferent neurons are
kept from firing in response to every
impulse that reaches them by the fact
that a relatively high level of sub
liminal excitation - or facilitation -
must be established, by other im
pulses converging upon them, before
the firing point is reached. This
requirement serves as a sort of
insulation.
2. In the lesioned segment this
insulation has been weakened. A
large portion of the efferent neurons
are kept near the firing point (fa-
cilitated), even under conditions of
rest, by chronic afferent bombard
ment from segmentally related
structures.
3. Proprioceptors are undoubtedly
an important source of this bom
bardment, but any segmentally
related structure may be such a
source. A pathological viscus, or a
cutaneous trigger spot, or any other
inflamed or irritated structure which
concentrates its afferents in one or a
few dorsal roots may be responsible
for more or less tonic facilitation.
(The close relation of the osteopathic
lesion to referred pain mechanisms is
clear, but space does not permit a
discussion of this most important
aspect.)
4. The firing process in the fa
cilitated efferent neurons may be
completed by any impulses impinging
on those neurons, whether the source
of those impulses be the cerebral
cortex, postural and equilibrium
centers, bulbar centers, cutaneous
receptors, or others. Should this
superimposed bombardment be suf
ficient and enduring, the facilitated
neurons (and the organs they inner
vate) may be maintained in a continu
ous state of excessive activity.
5. The state of facilitation may ex
tend to all neurons having their cell
bodies in the segment of the cord
related to the lesion, including the
anterior horn cells, preganglionic
fibers of the sympathetic nervous
system, and apparently the spino
thalamic fibers.
6. Because a structural defect, an
osteopathic lesion, sensitizes a seg
ment to impulses from all sources,
and for reasons previously given, the
lesioned segment is to be considered
not a radiating center of irritation,
but rather a neurological lens which
focuses irritation upon that segment.
Because of the lowered barriers in the
lesioned segment, excitation is chan
nelized into the nervous outflow from
that segment.
7. It is a truism in neurophysiology
that when something is excited, some
thing functionally related is simul
taneously inhibited. Although in our
studies we have not yet directed atten
tion to this aspect, it cannot be
doubted that facilitation in the
segment of lesion also extends to
1Z5
neurons exerting inhibitory infuences
upon other neurons or organs.
It may then be concluded that:
An oteopathic leion represents a
faciltated segment ofthe spinal cord
maintained in that state by impulse
of endogenou origin entering the
coresponding dorsal root. Al struc
tur, receiving eferent nerve fiber
from that segment are, therefore,
potentialy expoed to eces ive ex
citation or inhibition.
Manipulative Therapy
We come now to the last question:
What, basically, does manipUlative
therapy do? Here, we can only guess,
but at least our guesses are based on
sound, experimentally established
hypothesis.
Manipulative procedures applied
by osteopathic physicians induce
relaxation of muscle which has been
maintained in a continuously con
tracted state and which, as a matter
of fact, may not be able to relax
spontaneously, even when excitation
is removed (contracture). The in
crease in muscle-fiber length eases the
tension on the proprioceptors in the
muscles and tendons, bringing about
at least a temporary diminution in
afferent bombardment of that
segment of the cord.
Since the excessive tendinous and
muscular tension produced around a
joint, let us say, by some bony dis
placement tends refexly to produce
more tension, the manipulative easing
of tension breaks a vicious cycle.
Still another type of vicious cycle
may be in operation and be broken
by manipulative therapy (Fig. 1 ).
Through overexcitation of sympa
thetic fbers in the segment of lesion,
visceral pathology may be estab
lished. The anterior horn cells may
then be subjected to additional
bombardment with impulses con
veyed by visceral afferents, thus
causing exaggeration of the somatic
lesion which, in turn, further irritates
the viscus. Maipulative relaxation of
the muscles may break this cycle, too,
through diminution of proprioceptor
discharge into the cord. Even a brief
respite from this irritation allows
better opportunity for the natural
healing processes to operate.
By manipulative rearrangement of
the skeleton and through postural
adjustments, the original cause of the
strain, that is the excessive tension on
126
muscles, tendons, and ligaments, may
be eliminated and the beneficial
results made more lasting.
This is unquestionably an over
simplified version of the basic effects
of manipulation, but it certainly will
serve as a working hypothesis, as a
guide to further experimental investi
gation.
Speculations
Assuming the importance of the pro
prioceptors in the lesion mechanism,
it must be kept in mind that any
segmentally related structure which
sends afferents to the spinal cord may
be an important participant in the
establishment or maintenance of the
lesion In fact, through the network
of interneurons, practically any
afferent, segmentally related or not,
may exert some influence.
To all these sources of impulses
must be added the suprasegmental
sources - all the higher centers, from
medulla to cerebral cortex - which
contribute to the descending spinal
tracts. Many of these are continuous
and highly variable sources of im
pulses. They exert their influence -
excitatory or infibitory - upon
efferent neurons at every level of the
spinal cord.
It is, inded, most important to
keep in mind that the efferent
neurons do represent final common
paths shared by a host of impulse
sources, in addition to those associ
ated with joint and supporting tis
sues. I n this light, it is apparent that
the articular derangement or the
osteopathic lesion cannot be con
ceived as the cause of disease; rather
it is one of many factors simul
taneously operating.; The lesion is a
most important factor - it is a
sensitizing factor, a predisposing
factor, a localizing factor, a chan
nelizing factor. The lesion sensitizes a
segment of the cord, lowers the
barri er, faci litates - without
necessarily producing symptoms,
although signs of its presence may be
demonstrated by the osteopathic
physician. Sufficient additional
+In fact. it is doubtful whether there is ever a single
cause of any effect. whether there is ever an isolated
etiological factor in any clinical entity, Each factor
operate in the context of many factors and produces
certain effects only in a certain combination of
factors.
excitation has to be superimposed
upon that from articular and peri
articular origins. This is not to
minimize the importance of the
osteopathic lesion. On the contrary it
is to widen the concept. For one
thing, it certainly points Up " the
t remendous cont ri but i on that
osteopathic diagnosis and therapy
can make to preventive medicine.
To osteopathic physicians there is,
of course, nothing unfamiliar in the
practical aspects of this concept. One
patient has relatively severe lesions,
yet is sympton-free, pain-free, and not
readily subject to fatigue, etc; an
other patient with very similar lesions,
on the other hand, may be subject to
serious disturbances directly related
to those lesions. Further, the lesions
of the first patient may "act up"
under certain circumstances, and
then subside into "quiescence"
again. Why? What accounts for the
difference between such patients,
and between the "acting-up" and
"quiescent" periods in the same
patient? In our opinion and, I
believe, implicit in the osteopathic
concept, one important basis for the
difference lies in differences in the
amount of nervous excitation con
tinuously impinging on the efferent
neurons of the lesioned segments,
over and above that from the muscles
and joints. The lesion operates in
different contexts with different
effects.
Given an articular disturbance
which, through the mechanisms
discussed above, determines the
location of the low threshold
segments, then the severity of the
lesion, the associated pathology, and
the response to treatment will be to a
great extent, often to a decisive
extent, determined by how much
additional neuron pressure from
other sources is chronically present.
Such pressure may be present upon
all the segments, but because of
lowered synaptic barriers, the effects
will be exaggerated at the lesioned
segent. The lesion not only focuses;
it magnifies.
This superimposed excitation may
come from any of the sources pre
viously enumerated, and others,
which converge upon the anterior
horn cells and the other efferent
neurons: the cortex, the basal
gangl i a, cerebel l um, vestibular
nuclei, bulbar center, the eyes (via the
Interpretation of research

tectospinal tracts), or any steady, ton
ic source of impulses.
Since all these sources may directly
affect, favorably or unfavorably, the
lesion and its associated phenomena,
they are all properly within the
province of the osteopathic phy
sician. All of them may contribute to
the lesion and to its effects on total
body economy. Important as is the
structural factor, treatment of it
alone is not to treat the patient as a
whole and would be, i f I interpret it
correctly, a corruption of the
osteopathic concept.
I shall try to illustrate with one
source of bombardment which is of
very general signifcance, namely, the
cerebral cortex. As previously indi
cated, the words "tense," "high
strung, " "jumpy, " "keyed-up,"
"on edge" are more than figures of
speech. They bespeak the well-rec
ognized fact that psychic stress,
emotional imbalance, environmental
strains, etc. , influence and are
reflected in motor activity - an
increased muscular tone and hyper
responsiveness, in generally lowered
refex thresholds. A familiar illustra
tion is the exaggerated knee jerk of a
tense individual. (Other types of
imbalance may, of course, have de
pressing or i nhibit ory effect s,
resulting in fatigue, hyperrefexia,
inertia and other symptoms.)
These are obviously due to
impulses passing down the descend
ing spinal tracts and impinging,
directly or through interneurons, on
the anterior horn cells and increasing
their excitability and activity.
In a segment already sensitized by
an osteopathic lesion the effects will
be especially severe. Just as important
is the fact that descending impulses
may exacerbate the lesion and pro
duce increased effects on segmentally
related organs, may cause or intensify
pain, and make the lesion less respon
sive to manipulative therapy. To treat
only the structural source of bom
bardment is only to half-treat and
to neglect a most important part of
the lesion mechanism, and to take the
lesion out of context. This does not
mean, of course, that every osteo
pathic physician should become a
psychiatrist, but he certainly must
take into consideration the home
factors, environmental factors ,
family relations, emotional adjust
ments, tensions, etc.
In this light the as yet unexplored
relations of osteopathy to psychoso
matic medicine become obvious. It
is now well established that many
organic ills, including angina pec
toris, gastric and duodenal ulcer,
gallbladder disease, mucous colitis,
asthma and others, may be directly
related to psychoneuroses, emotional
imbalances, and anxieties. What
factors determine the organic
manifestation of the neuroses? The
autonomic nervous system, of course,
has regional representation in the
cerebral cortex and the hypothalamus
is under cortical influence. It has been
thought that the unconscious may
select the organ or organs to be
affected. Without prejudging these
and other theories, it would seem
most profitable, clinically and
experimentally, to explore the
probability that the incidence and
location of osteopathic lesions may
be an important factor in determining
the incidence and nature of psychoso
matic ills. Certain aspects of this
hypothesis are under experimental
investigation in the Ki rksvi l l e
laboratories.
Summar
1 . Some of the neural mechanisms
involved in the osteopathic lesion, in
its local and distant effects, and in
manipulative therapy are examined.
2. The results of experimental
investigations are presented which
indicate that the lesion is associated
with a segment of the spinal cord
which is hyper-excitable to all
impulses which reach it, and that the
hyperexcitability may extend to any
neurons having their cell bodies in
that segment.
3. It is concluded that osteopathic
lesion represents a facilitated segment
of the spinal cord maintained in that
state by impulses of endogenous
origin entering the corresponding
dorsal root. All structures receiving
efferent nerve fibers from that seg
ment are, therefore, potentially
exposed to excessive excitation or
inhibition.
4. Evidence is presented that the
stretch and tensi9n end-organs
(proprioceptors) in the muscles and
tendons are the most important
source of afferent impulses which
produce the changes in the cord that
are associated with the osteopathic
lesion.
5. The effect of the lesion as a
predisposing and localizing factor is
emphasized and discussed in relation
to certain aspects of osteopathic
practice.
References
I . Denslow. J. S. : An analysis of the variability of
spinal refex thresholds. J. Neurophysiol. 7:207-215.
July 1 94.
2. Denslow, J. S.; Korr, I. M., and Krems, A.D.:
Quantitative studies of chronic facilitation in human
motoneuron pools. Am. J. Physiol, 105:229-238,
Aug. 1 947.
3. Lloyd, D. P. C. : Intercellular transmission, in
Howell's Textbook of physiology. edited by J. F.
Fulton. Ed. IS. w. B. Saunders Co Philadelphia,
1 946, p. 134.
4. Sherrington, C. S. : Correlation of refexes and
the principle of the common path. Brit. As. Rep.
74:728-741 , Aug. 18, 19; abstr., Brit. M. J. 2:43,
Aug. 27. 19.
5. Lorente de N6, R. : Synaptic stimulation of
motoneurons W a local proces. J. Neurophysiol.
1 : 1952, May 1938.
6. Lloyd, D. P. c.: Reflex action in relation to the
pattern and peripheral source of afferent stimulation.
J. Neurophysiol. 6: 1 1 1-1 19, March 1943.
Reprinted by permission from JAOA 47: 1911
98,
1947.
117
The emerging concept of the osteopathic
lesion* (1948)
The survival, growth, achievements,
and increasing effectiveness of
osteopathy are eloquent testimony to
the soundness of the principles upon
which it was founded. The attain
ments of the osteopathic profession
have been possible only because the
profession is founded upon the solid
rock of basic truth. Its continued
growth and prestige indicate that
those truths continue to be correctly
applied and soundly developed.
The time has come, however, when
increasing attention must be given to
the theoretical reserves upon which
continued technical advance is
predicated. For many reasons these
reserves have been consumed far
more rapidly than they have been
replenished. In osteopathy, as in all
technological aspects of modern life,
large backlogs of fundamental in
formation must be maintained and
enlarged if continued practical ad
vances are to be assured. They are,
indeed, the springs from which the
advances fow.
In osteopathy these reserves consist
of our understanding of the basic
biological processes and mechanisms
associated with the phenomenon des
ignated as the osteopathic lesion.
Today this understanding is not, or at
least until a very few years ago was
not, a great deal larger than in Still ' s
day. Although knowledge of the
mechaical aspects of the lesion (the
"cause") and of its clinical mani
festations (the "effect") has greatly
advanced, there has been no parallel
advance in our knowledge of the
processes intervening between these
two aspects of the probleP.
These processes are the problems
before us today. Given a lesion - so
well known to osteopathic physicians
through their trained fingers and
through x-rays - how does it
produce its effects? Through what
mechanisms and channels does it
impair the defensive, reparative, and
homeostatic functions of the body?
How does H predispose to disease
?
'Based on an address of the same title read before the
General Sessions of the Fifty-Second Annual Conven
tion of the American Osteopathic Association.
Boston, July 19, 1948.
II8
How does it upset physiological
equilibria? What processes does it
initiate? The very future of osteop
athy, 8 a distinct and advanced
system of practice, is directly related
to the accuracy and thoroughness
with which these questions can be
answered in the next few years.
It is my purpose in this paper to
present our current theories regarding
these central aspects of the osteopath
ic lesion. Then I wish to draw some of
the practical implications of these
emerging concepts. Paradoxically, I
shall present our current theories by
dealing to a large extent with other
matters. It is possible to do this
because those other matters are so
intimately, and sometimes insep
arably, related to the osteopathic
lesion. The discovery of these
relations is as important as the
discovery of the new facts about the
lesion itself because, with the estab
lishment of each such relation, a
whole body of knowledge, ready
made and usually still growing; is
automatically incorporated into the
osteopathic concept. With every such
incorporation our concepts, in which
clinical and professional advances
have their origin, are deepened and
widened.
The history of science - physical,
biological, or medical - records
again and again the collapse of fences
separating scientific and technical
fields. As a result of certain funda
mental discoveries entire fields of
scientific pursuit, whole schools of
thought, and major concepts begin to
develop and attract disciples. These
felds may develop independently and
remain separate one from the other,
and apparently unrelated, for many
years. However, as the knowledge
and understanding within each field
accumulates, through experience and
research, it becomes apparent in
many cases that the walls which
separate these fields have very little
substance; in fact , they exist only in
the minds of men, and not in nature
itself. Each field begins to draw from,
and give to the other, new and
additional meaning. Finally they
merge.
Nowhere is this better illustrated
than in the fields of immediate
interest to the osteopathic profession.
I have selected for discussion only
three major fields which, from our
perspective, appear to have much
basic and distinctive substance in
common. Each has yielded a major
body of concepts, a school of thought
or a school of practice. Each origi
nated independently, at different
periods and in t hree di fferent
countries, separated by thousands of
miles, and under very different
circumstances. Today they are ad
joining fields and the fences between
them are crumbling. They have in
common the following general
concepts:
1 . The body is a unit; all parts
function in the context of the entire
organism.
2. Disease is a reaction of the
organism as a whole. Abnormal struc
ture or function in one part exerts ab
normal influence on other parts and,
therefore, on the total body economy.
3. The organism has the inherent
capacity to defend itself, to repair
itself, and to resist serious upsets in
equilibria.
4. The nervous system plays a
dominant organizing role in the
disease processes.
5 . There is a somatic component to
every disease which is not only a
manifestation of the disease, but an
important contributing factor.
6. Appropriate treatment of the
somatic component has important
therapeutic value in that it leads to
i mpr ovement i n t he ot her
components.
The concepts I refer to are: ( 1 ) the
osteopathic, (2) the concept of re
ferred pain and associated phenome
na, and (3) the concept of disease
developed by A. D. Speransky and
his colleagues in Leningrad. These
concepts have not only had very
different origins, but very different
courses of development.
The osteopathic concept soon led
to the development of a most effec
tive therapeutic weapon which
became, and for more than 60 years
has been the basis for a new and
expanding school of practice. From
the beginning, this weapon - osteo
pathic manipUlative therapy - was
so revolutionary and so effective that
the major concern of its designers,
developers, and practitioners was
with: ( 1 ) Learning how to use it most
Interpretation of research
effectively, (2) winning the right to
use it, (3) determining its effects on
the various ills to which man is heir,
and (4) reproducing the weapon, win
ning recruits, putting the weapon in
their hands and teaching them how
best to use it.
Possessed of such a weapon, but
with few other material resources,
and preoccupied with those struggles
in the face of opposition, it is un
derstandable that the founders, the
disciples, and the earlier practitioners
of this school found it impossible to
engage in the more leisurely pursuits
of investigating experimentally the
fundamental basis for the effective
ness of their therapeutic weapon.
The founders of the other two
schools did not, however, strike upon
new therapeutic measures in the early
development of the concepts. They
and their disciples, therefore, devoted
themselves to seeking the mechanisms
whereby pathological processes are
initiated, and the channels whereby
pathology of one part affects others.
These investigations have led to
extensive research programs which
are now conducted throughout the
world and which have won much
support and many recruits.
These research programs have
made available a great wealth of
information, which has led to some
sound theory. This, in turn, like all
good theory, is today leading to good
practice. New and promising forms
of therapy are emerging from the
work of these schools. It is to be
expected that these forms of therapy,
experimental though they may be to
day, but based as they are on rapidly
expanding bodies of fundamental
knowledge, will rapidly develop and
i ncrease i n appl i cabi l i t y and
effectiveness . As I hope to dem
onstrate, both of these felds of
investigation are actually concerned
with certain fundamental aspects of
the osteopathic lesion, though they
may not be recognized as such.
In preparing this lecture, I have
found it convenient to review the .
work of these two fields - referred
pain and the work of the Speransky
school - before summarizing the
emerging concept of the osteopathic
lesion, si
n
ce that concept is emerging,
not only from osteopathic research
and experience, but from their in
tegration with contributions of these
two schools in particular.
Referred pain and associated
phenomena
This field of investigation had its
most important beginnings in En
gland in the work of Sturge, 2 Ross, 3
Head,4 Mackenzie, and others i n the
early 80's and 90' s. More recently
important contributions have been
made by Sir Thomas Lewis and his
co-workers, 6 also in Britain, and by a
number of laboratories and medical
institutions in this country. These
workers were primarily concerned
with the somatic manifestations of
vi sceral disease, especially the
somatic pain, and with related
phenomena.
Even very superficial study in the
field of referred pain reveals the close
resemblance of this syndrome to the
osteopathic lesion. Mackenzie,' for
instance, many years ago spoke of the
triad of somatic manifestations of
visceral pathology: ( 1 ) referred pain,
(2) hyperalgesia, and (3) motor phe
nomena.
1 . Referred Pain. * In many
cases, the pain of visceral disease is
felt not in the organ itself, but is
referred to the soma, that is, skin,
muscles, etc. Very often these somatic
structures do not overlie the area of
disease and may be remote from it.
It was soon demonstrated, however,
that the zone of reference bears a
segmental relationship to the area of
origin; both are innervated from the
same segments of the spinal cord. The
pain is said to be referred to the
corresponding dermatome and myo
tome. Many examples are familiar
to the physician: The pain of
angina pectoris, originating in the
myocardium and referred to the chest
wall, the back, shoulder, and medial
surface of the arm; renal colic, which
produces intense pain in the lower
back and groin; irritation of the
diaphragm which is referred to the
base of the neck and shoulder tip.
2. Hyperalgesia. * Tenderness is
also found in somatic structures seg
mentally related to the pathological
viscus:
a. Cutaneous tenderness - the
over-sensitivity to pinching and to
friction in the dermatomes related to
the sick viscus;
b. Muscular tenderness and exag
gerated sensitivity of the muscles to
deep pressure; and
c. Tender spinous processes. In
terestingly enough to osteopathic
physicians, Mackenzie' placed great
diagnostic significance on the tender
spinous processes. He demonstrated,
for instance, that diseases of the heart
were commonly associated with
tender spines Tl to T4; stomach, with
T4 to T8; liver, with T8 to TI l ;
rectum and uterus, L5 to S2.
3. Motor Phenomena. - Mac
kenzie described the spasm, ustained
contraction, and rigidity in muscles
segmentally related to the pathologi
cal organ. He included under motor
phenomena the autonomic changes in
the zone of reference although they
properly belong in a fourth category.
What is the basis for the "referred
pain complex"? Much of the final
answer is certain to be found in the
spinal cord. (Fig. I [same as Fig. 1 in
preceding article. There is obvious
interchange of excitation among all
the types of neurons which meet or
have their origin in a given segment of
the spinal cord: The dorsal root (af
ferent) fbers conveying centripetal
impulses from all the tissues, somatic
and
v
isceral; the various efferent or
motor neurons, including those which
have their cell bodies in the anterior
horn and which regulate activity of
the skeletal musculature, and those
originating in the intermediolateral
column which tegulate visceral ac
tivity (motor and secretory) , sweat
gland activity, vasomotion, etc. The
spinothalamic fibers which convey
sensation of pain to the higher centers
are also obviously involved in the
complex. Although the spinothalamic
fibers can be excited by impulses
transmitted by the afferent fibers
from the viscera, nevertheless the
cerebral cortex projects or "refers"
these sensations to somatic structures
whose afferent fibers enter the same
dorsal root. (See the paper by
Drucker' for a review of the
mechanisms.)
On the basis of these observations
Mackenzie developed the hypothesis
of the "irritable focus. " This hy
pothesis stated, in essence, that
irritation from the viscera, conveyed
by the afferent fibers, renders many
of the nerve cells in the same segment
hyperirritable. As a result, tissues and
organs innervated from that segment
are affected by the visceral pathol
ogy. The "irritable focus" hypothesis
IZ9
has since been modified and restated
in accordance with more modern con
cepts of facilitation. 9
More recently Lewis and his col
league, J. H. Kellgren, 1O showed that
the phenomenon of pain reference
was not peculiar to visceral irritation,
since similar and even identical pat
terns ("triads") could be evoked
by irritation of deep-lying somatic
structures. They found that injection
of 0. 1 to 0. 3 cc. of 6 per cent sodium
chloride solution into certain liga
ments, tendons, and muscles, could
produce intense pain in relatively
large and often remote areas of
the corresponding dermatome and
myotome. The pain reference was
accompanied by the other com
ponents of the classical triad, namely
cutaneous and muscular hyperalgesia
and muscular rigidity.
Even more striking was the demon
stration that such localized irritation
of the interspinous ligaments or
spinal extensor muscles in certain
segments, reproduced with remark
able precision the pain patterns and
other somatic phenomena which are
associated with visceral pathology.
l l
This was true to such an extent that
patients who had experienced the real
disease could not distinguish between
the experimentally induced and the
naturally occurring syndromes. For
instance, the injection of the eighth
cervical interspinous ligament with
the hypertonic saline solution pro
duced a perfect facsimile of an an
ginal attack, not only with respect to
pain distribution (including the
substernal pain and the radiation
down the ulnar surface of the arm),
but also the hyperalgesic areas, the
muscular rigidity, and the sense of
compression of the chest. Injection of
the first lumbar interspinous ligament
produced the typical pain distribution
of renal colic (lower back, lower ab
domen, groin, and scrotum), rigidity
of abdominal and spinal muscles,
hyperalgesia, and often a marked cre
masteric reflex on the corresponding
side. (In our own laboratory, we have
not only confirmed these observa
tions, but have demonstrated certain
associated autonomic changes. )
Furthermore, these workers l o and
others demonstrated that experi
mental trauma to certain visceral
organs produced recordable contrac
tions of skeletal muscles in cor
responding segments. These con-
I
tractions could be almost perfectly
reproduced (with respect to location,
amplitude, and time characteristics)
by irritation of certain somatic
strutures in the same segment.
(Studies on the converse, namely the
influence of somatic irritations on
visceral function, are in progress in
our laboratories. )
It may be concluded from these
observations that not only does
irritation or pathology in one tissue
or organ stir up abnormal activity of
other tissues in the corresponding
segments, but that the complex -the
patter of the overall response to the
primary pathology - is organized by
the spinal cord. The character of the
pattern is determined by the segment
or segments which are involved, and
not by the tissue which is first
irritated (somatic or visceral) nor by
the nature of the irritation.
It was early recognized by workers
in this field that the secondarily
irritated structures, that is, those
tissues in the zone of reference, may
themselves, as a result of this patho
logical influence, become secondary
sources of irritation - leading to the
establishment of a vicious cycle. This
recognition has formed the basis for
certain important therapeutic mea
sures which have begun to emerge
from this work. Given such a pattern,
including visceral pathology and the
reference phenomena, then why not
eliminate the irritation contributed by
the most accessible part of the
complex - the somatic component?
The potentialities of this approach
were indicated 20 years ago by Weiss
and Davis who showed that at least
the pain, due to visceral pathology,
could be relieved by local anestheti
zation of the skin areas to which the
pain is referred. It is of special
interest that the relief from pain often
outlasted the expected duration of
the local anesthesia by considerable
periods of time.
Other work (reviewed by Wolff
and Hardyl4 and Wolff and Wolfl S)
has demonstrated that the sustained
muscular contractions or spasms
which are part of the referred pain
patterns, may themselves comprise
sources of irritation. Local infiltra
tion of the rigid muscles, identified by
palpation, relaxed those muscles,
relieved the pain, and often produced
improvement in the associated auto
nomic disturbances.
This general approach has been
receiving especially significant de
velopment in the hands of Travell and
her colleagues at Cornell University
Medical College. They were able to
produce complete and immediate
relief from cardiac pain due .to
myocardial infarct by infiltrating
appropriate trigger areas with dilute
procaine hydrochloride.
1
6
, 1
7 These
were intensely hyperesthetic areas
located in the myofascial structures
of the reference zone (usually in the
pectoralis major, petoralis minor, or
serratus anterior) . When sufficiently
near the surface the trigger areas
could also be effectively blocked by
spraying the overlying skin with ethyl
chloride. Relief from pain was not
only immediate, but lasting. Relief
was obtained for periods of months
and even years. It is of interest that
when similar trigger areas, in patients
with skeletal muscle disorders with
out organic disease, are irritated, as
by needling, referred pain occurs
"which is indistinguishable in
distribution and quality from the
substernal and radiating pain of
coronary insufficiency. "
1
7
Of interest to those familiar with
the osteopathic concept and the
current theories of the osteopathic
lesion are the explanations of these
observations proposed by these
workers. Thus Travell and Rinzlerl
6
say, "The most reasonable explana
tion is that the initial insult, whether
to visceral or somatic structures, sets
in motion a chain of events perpetu
ated by a vicious cycle of nerve
impulses which have no further
dependence on afferent impulses
from the heart and which are prob
ably transmitted to and from the
soma by virtue of sustained facilita
tion of the noxious impulses by the
closed self-reexciting chains of
internuncial neurons in the central
nervous system. " Apparently, even
brief interruption of this self
sustaining cycle of nerve impulses at
any point in the chain may be effec
tive in permanently abolishing it.
` In explanation of the lasting effect
of this brief interruption by local
somatic block therapy they offer the
possibility that the "somatic trigger
mechanisms contribute to the per
petuation of the primary source
of pain," that is, the coronary
insufficiency. In support of this
hypothesis they refer to the evidence
Interpretation of research

obtained by Lindgren that local

anesthetization of the precordial
structures produced improvement in
the coronary circulation. Although
the authors are careful not to make
therapeutic claims unsupported by
their observations, they point out that
the relief of pain due to myocardial
infarction may itself, have true thera
peutic effect since there is evidence
that pain may induce refex spasm of
collateral coronaries.
Autonomic changes in the zone of
reference are well established, but
it has only recently begun to be
appreciated that the blood vessels
supplying the brain and spinal
cord' 9
,
20 may also be included in the
zone of reference. Travell and Bige
low" have recently shown, for
instance, that phenomena of hysteria
may be mediated by afferent impulses
from trigger areas in skeletal muscles.
Whether these zones are activated by
psychogenic stress or (experimental)
trauma, the same clinical patterns are
produced. The patterns are often bi
zarre, and may be not only spatially,
but also segmentally remote from the
somatic trigger area. I nfiltration of
the appropriate and specific somatic
structures dramatically relieved
disorders of vision, respiration,
motor power, and cutaneous sensa
tion (e.g. , glove-and-stocking pares
thesias). The concept is advanced that
"high intensity stimuli from somatic
trigger areas refexly produce pro
longed vasoconstriction with partial
ischemia in localized areas of the
brain, spinal cord, or peripheral
nerve structures." The authors point
out that, in these patterns, raising the
threshold of excitability at the
synapse in the central nervous sytem
directly, by general anesthesia,
hypnosis or psychotherapy, may be
expected to accomplish the same
result as blocking the source of
noxious impulses at the somatic
trigger area.
No attempt has been made in this
section to review this field, but rather
to present a few outstanding ex
amples and to establish several
important concepts. (For more
comprehensive reviews see references
8, 1 4, and 1 5.) These may be sum
marized as follows:
1 . There is extensive interchange,
through the spinal cord, among the
various structures, visceral and
somatic, blood vessels, glands,
smooth muscle, skeletal muscle, skin,
etc. , which draw their innervation
from the same segment.
2. Pathology or irritation of one of
these structures may lead to the estab
lishment of a pattern of changes in all
the others. The pattern is determined
more by the part of the nervous sys
tem affected than by the irritated
structure or the nature of the
irritation.
3. A a result of these associated
pathological processes new sources of
irritation may be produced, which
lead to the establishment of an auto
genetic vicious cycle of nervous
impulses.
4. I nterruption of this cycle for
even a brief period may permanently
prevent, or greatly delay its re-es
tablishment, permitting the repara
tive processes (e.g. , in the viscera) to
proceed under more favorable
circumstances.
. Highly localized areas in skele
tal muscle or myofascial structures
frequently become important sources
of afferent impulses in these com
plexes, reinforcing or facilitating the
primary irritation, or even becoming
independent of it. Inactivation of the
somatic component of the pattern
associated with visceral pathology,
may disrupt the pattern and break the
vicious cycle.
6. Tbis has therapeutic import, not
only because the somatic component
is accessible and easily localized, but
also because it may be the most im
portant factor in sustaining the
(primary) pathology.
7. The patterns are not exclusively
segmental, in view of the involvement
of the vasculature of the central
nervous sytem. Vasopasm in the
brain, spinal tracts, or nerves may
produce secondary effects quite re
mote segmentally from the locus of
primary irritation.
The work of the Leningrad
Laboratories
Without going into the elaborate
detail which the work of Speransky2'
and his coworkers deserves, let us
summarize the main conclusions to
which their extensive laboratory and
clinical observations have led them.
1 . The nervous system not only
participates in every disease but plays
a dominant role in organizing the
pathological processes and their
various manifestations.
2. Sustained irritation, inflamma
tion, or pathology of muscles, skin,
bone, viscera, or nervous structures
initiates processes in the nervous
sytem which may lead to certain func
tional and organic changes designated
as "neurodystrophy. " Once initiated,
the processes in the nervous system
do not require the continued action of
the irritant, and the neurodystrophy
may persist long after the primary
pathology has healed.
3. The neurodystrophy expresses
itself through pathological and
trophic changes in the various organs
and tissues, frst, usually, in the seg
ments related to the primary pathol
ogy, and later in other segments.
The entire body may thus be affected.
4. The nature of the process, and
its final expression, are independent
of the nature of the irritation -
chemical, physical, or biological. The
biological agents - the toxins, bac
teria, viruses, etc. - act funda
mentally in the same way as the
chemical and physical irritants; they
merely initiate the process, which
then becomes independent of the
primary pathology.
. This role of the nervous system
appears to be based upon much slow
er processes than nerve impulses -
trophic processes. (Speransky em
phasized repeatedly that his approach
is distinguished by its different
utilization of the time factor.) These
trophic functions of the nervous sys
tem may well have their basis in the
movement of substances along the
axon (as well as impulses), as
indicated by the recent observations
of Weiss22 and Schmitt. 23t
6. As a result of the primary
lesion, lasting, and microscopically
demonstrable, effects on the nervous
system may be produced which may
remain latent for long periods of
time. The signs of the original irri
tation may long have disappeared
before the first signs of the disease
appear.
A recent dramatic illustration of
changes in the cord which persist
ed after the healing of the orignal
lesion appeared in a report by Frank
stein. The foot pads of cats were
tIt

is of interest that many years ago Mackenze
showed that contractions or rigdity of skeletal musle
associated with visceral pathology could b main
tained in the apparent absence of nerve impulses.
Similar rigidity i observe in association with the
osteopathic lesion W i described in later sections.
131
injected with turpentine, producing
pain and inflammation, and the typi
cal limping and limb-withdrawal
pattern. After some time the irrita
tion disappeared, no signs of the
inflammation were detectable and
the animal no longer limped or "fa
vored" the paw. At this time the
cat was decerebrated, and it was
found that the postures assumed by
the animal were similar to those
produced when a decerebrate animal
receives intense stimulation upon the
foot corresponding to that which had
had the lesion, namely, flexion of the
affected leg and crossed-extension. In
other words, reflex signs of the
original irritation reappeared, al
though that irritation had apparently
vanished. Frankstein concluded that
the initial irritation had set up some
altered state within the spinal cord;
this altered state persisted for some
time after the precipitating lesion had
subsided, but was masked by action
of the higher centers. Removal of f1e
forebrain permitted the pattern
associated with the altered state to re
emerge. Frankstein implied, also,
that such states in the nervous system,
originally established by irritative
processes , predispose to disease,
though they may be masked for some
time. Those segments are, so to
speak, the vulnerable segments of the
nervous system which may serve as
foci of disease processes under certain
circumstances.
This concept bears a distinct
resemblance to that originally
developed by Mackenzie, the concept
of the lingering of the area of
"irritation" beyond the duration of
the initial stimulation. It will be
recalled that Mackenzie also believed
that once established, the irritable
focus remained for a variable period
of time after the initial source of
irritation had been removed, and con
tinued to influence the activity of
structures innervated by that segment
for some time. Similarly, an osteo
pathic lesion may exist for years
without producing symptoms.
7. The effect of a given irritation,
that is, the disease pattern it evokes,
if any, depends largely on the condi
tion of the "substratum, " the patient
and his nervous system, rather than
upon the irritation itself. The "sub
stratum" varies from individual to in
dividual, and within the individual
from time to time according to
131
circumstances, environmental influ
ences, etc. The disease - and the
therapy - must be considered in the
context of the patient as a whole.
8. These concepts are today pro
viding the basis for therapy. Atten
tion is focused, not on the offe
n
ding
organism, irritant, or primary lesion,
but rather on the nervous system, and
more specifically on those parts (e. g. ,
spinal segments) which in each case
organize the disease process. I n
essence, the object of therapy i s to
alter the balance of nervous factors in
such a manner as to provide optimal
circumstances for the operation of
the normal reparative and defensive
processes of the body.:
These principles were illustrated in
a large series of cases of lobar pneu
monia. 2 S
,
2 6 Speransky and hi s
coworkers had previously demon
strated in experimental animals that
intense stimulation of sensory nerve
endings in muscle and skin, in areas
innervated from the medulla ob
longata and upper segments of the
cord, or direct mechanical and chemi
cal stimulation of these parts of the
nervous system, could produce pro
found pulmonary changes, very simi
lar to pneumonia. These changes in
the lung may develop within a few
minutes. "Treatment must therefore
be directed not only at the diseased
lung but also at the associated
nervous disturbance. This
suggested that treatment of pneu
monia in men be directed at the nerve
segments involved. . . . The above
experiments showed that the nerve
regions involved were conected with
the cervical-thoracic segment of
the spinal cord and the adjacent
medulla oblongata. The anterior
branches of this segment, except
those supplying the head. neck and
extremities, supply the organs of the
chest and mediastinum specifically
involved in pneumonia. But the
posterior branches of these nerves are
distributed in the long muscles and
skin of the spine and neck. Thus by
anesthetizing these posterior branches
which have no direct connection with
the lungs we shall affect through
It is of interest that Speransky21 warns that once
having obtained a favorable therapeutic effect, the
effective procedure should not be repeated or another
tried, since another, less favorable balance might
result. Osteopathic physicians will recognize the
similarity to Still's "Find it, fix it, and leave it alone."
other axons specific nerve segments
of the lung. "H
I n several hundred cases of lobar
pneumonia in soldiers during the
Finnish campaign and during World
War II remarkable results were
obtained by injecting 6 to 70 cc. of
0. 5 per cent novocain intradermally
into a diamond-shaped area extend
ing sagitally from 3 to T4 and
covering the medial halves of the
scapulae. The treatment, when given
early, is usually followed by a drop of
temperature by crisis to normal
within 1 8 to 24 hours; in some cases a
drop of lysis occurs within 48 hours.
Resolution of the pneumonic con
solidation begins as the temperature
drops and the general condition
improves. Convalescence is short and
uneventful. The treatment is non
specific since beneficial results
were obtained also in acute or chronic
catarrhal penumonia, and the type
of pneumococci responsible for
the disease did not infuence the
effectiveness of the treatment .
Laboratory and clinical data sup
port the belief that the therapeutic
result is affected more by the site of
the application than by the drug. "
The osteopathic concept
The basic principles of the practice of
osteopathy need not, of course, be
reviewed in detail for an osteopathic
audience. We shall state them briefly,
paraphrasing them somewhat, with
the foregoing in mind, and review the
basic processes through which these
principles operate as they have been
revealed by recent researches in
osteopathic and other institutions.
1 . A. T. Still fully recognized, and
for the first time incorporated into a
system of practice, the capacity of the
human organism to resist and defend
itself against noxious influences. to
resist or compensate for alterations i n
equilibria, and to repair itself.
2. He fully recognized and incor
porated into practice, the unity of the
body as expressed in the fact that
abnormal structure or function in one
part exerts abnormal influence on
other parts.
When this work was recently reviewed before the
seminar on the osteopathic lesion at Kirksville, several
members of the clinical staff remarked upon how
similar was the course of the disease following this
therapy to that (in their experience) following osteo
pathic treatment of lobar pneumonia.
Interpretation of research
3 . The human organism, presum
ably because of its incomplete
adaptation to the erect stance, is
highly subject to anatomic and
functional derangements of joints
and their supports, especially the
vertebral, pelvic, and other weight
bearing articulations.
4. These "errors" in weight-bear
ing unfavorably affect the structure
and function of neighboring and
distant parts of the body. thus
initiating and contributing to patho
logical influences and processes.
This complex of the articular
disturbance and its associated
phenomena has been designated as
the osteopathic lesion.
S. The spinal lesion is associated
with: (a) Tenderness or hyperesthesia
of the paravenebral tissues and those
overlying the vertebrae (skin, muscle,
connective tissue); (b) muscular
changes - rigidity, sustained con
traction (or contracture), ropiness,
and lowered motor reflex thresholds;
(c) autonomic changes, as reflected in
textural changes of the supra-spinous
tissues, vasomotor changes, altera
tions in visceral and other autonomic
functions; and (d) pain, which, when
it occurs, is of the "deep" variety; it
is rather diffuse and may be radiating
or "referred. "**
6. The lesion may be detected and
evaluated through its associated
phenomena.
7. The osteopathic lesion is con
ceived as a most important - and
frequent - etiological, predisposing,
exacerbating, and sustaining factor in
disease, through the establishment
and maintenance of a vicious cycle of
irritative, inflammatory, and other
pathological processes which impair
the defensive and reparative capaci
ties of the human organism.
8. It may be present for varying
periods of time without the pro
duction of symptoms.
9. The lesion may be corrected or
improved through the application of
appropriate manipulative technic. A
highly effective system of osteopathic
manipulative therapy has been de
veloped whereby lesions of many
kinds and locations may be corrected.
10. Correction of the lesion in
terrupts the vicious cycle and i"
followed by regression, amelioration,
'The similarity between this complex and the
classical referred pain pattern i s obvious.
or abolition of the related patho
logical processes. Elimination of the
lesion provides more favorable cir
cumstances for the operation of the
defensive, reparative and homeo
static27 mechanisms of the body.
1 1 . Recent researches conducted at
the Kirksville laboratories support the
conclusion that the patterns of local
and distant effects of the articular
disturbance and associated phenom
ena -the osteopathic lesion complex
- are mediated and organized by the
central nervous system; the lesion
expresses itself primarily through
those parts of the nervous system
with which it is associated. Correc
tion of the lesion provides a more
favorabie balance of nervous factors.
Since these researches and the
concepts which emerge from them
have been recently reviewed28 they
will only be briefy summarized and
supplemented by the advances that
have been made since the publication
of the review. I shall try to present
our concepts dynamically rather than
in the chronological order in which
they have developed. (The reader may
find it helpful to refer frequently to
Figure 1 .)
The disturbance of an articulation
exerts its influence directly through
the soft tissues which surround
and support it. There is no known
mechanism whereby the positional
relationships of two bones or two
vertebrae can be "registered" except
through those tissues. Further, we
have the frequent clinical observation
. that an osteopathic lesion need not
have associated with it a gross articu
lar displacement. At any rate, as a
result, for instance, of an interverte
bral lesion (whether it be described as
a subluxation, a flexion, extension, or
rotation lesion) the (paravertebral)
muscles, tendons, and ligaments on at
least one side of that articulation are
subjected to, and maintained at,
excessive tension. This causes the
proprioceptors (end organs in muscle
and tendon sensitive to changes in
length and tension) to fire increased
nurbers of impulses into the cor
responding segment of the spinal
cord, via the dorsal root fibers with
which they are connected. The fre
quency of the impulses fired by those
receptors is in proportion to the
degree of stretch (severity of the
lesion?); and since these receptors are
relatively nonadapting, the barrage is
maintained as long as the tension is
maintained.
The stretch or myotatic reflexes are
self-regulatory and self-exciting. That
is, because the dorsal root fibers
(afferents) bearing impulses from the
proprioceptors synapse directly29 with
the anterior horn cells which conduct
impulses to the self-same muscle
segments, tt the stretched muscles are
further stimulated to produce still
more tension. This may be an im
portant factor in the maintenance of '
the articular derangement once it is
established.
Because of the synaptic connec
tions of the dorsal rot fibers, directly
and through internuncial neurons,
this nervous stimulation affects,
potentially or actually, the excit
ability of all neurons which have their
origins (cell bodies) in the corre
sponding segment of the spinal cord.
These include not only the anterior
horn cells,
!
but also the cells of
the intermediolateral column, which
are the preganglionic neurons of the
sympathetic nervous system. They
include also the neurons coursing in
the spinal tracts. This is certainly true
of the spinothalamic fibers which
conduct impulses to the brain for the
registration of pain, and there is
evidencel' that it applies to other
tracts terminating in suprasegmental
structures.
As a result of the sustained barrage
of impulses, these neurons, in the
segment of the cord associated with
the lesion, are rendered and main
tained hyperexcitable to all impulses
which reach them regardless of their
source - impulses from other seg
ments of the cord, from the higher
centers, including the cerebral cortex,
from the skin, etc. (The inhibitory
aspects of the lesion have not yet
received experimental investigation.)
The segment of the lesion is said to be
a facilitated segment of the cord, 32
one in which "the barriers have been
10wered. "2 ! The efferent (motor)
neurons in these segments may be
said to be maintained "on edge" (in a
state of subliminal excitation), and
easily triggered into activity by rela
tively few additional impulses from
any source.
ttl! is thought by some that the spindle cells (receptors
in the muscles) refexly regulate the activity of the
muscle fibers in their immediate vicinity. This may
count for the strands or "ropiness" so frequently
found in muscle associated with lesions.
133
Since the neurons which have their
origin in the segment of lesion, as in
all segments of the spinal cord, rep
resent final common paths , the
activity of these neurons (and the
structures they innervate) will be
determined by the balance of in
hibitory and excitatory impulses
which reach them. Given a sufficient
background of nervous activity, such
as that descending from the cerebral
cortex, its influence will be magnified
and channelized through the facili
tated segments, that is, the segments
of lesion. As a result, the efferent
neurons (and intraspinal neurons)
having their cell bodies in these
segments will discharge abnormally
intense streams of impulses into the
tissues which they supply, which will
therefore be maintained in altered
states of activity. The segmental
changes may include alterations in
contractile states, in blood flow
through vari ous structures and
organs, ;; in visceral motility, in rates
and quality of secretion, etc.
If maintained for suffcient periods
of time, these altered states of activity
inevitably led to pathological pro
csses in the affected structures which
in turn, become secondary sources of
afferent irritation. Another vicious
cycle is set in motion, in which each
structure refexly, through the cor
responding segments of the cord,
irritates the other components. Con
tinuation of these processes leads to
profound structural and functional
derangements of those tissues -
trophic changes - which no longer
depend upon nerve impulses for their
maintenance. As was shown by Dens
low and Hassett, and confirmed
many times since, l 2 the paravertebral
muscles in the segments of lesion
remain rigid and apparently short
ened, and under tension, in the
complete absence of action poten
tials, that is, without stimulation
from the anterior horn cells. By
defnition this is a state of contracture
- a reversible loss of the ability to
relax on the part of the contractile
elements. (It will be recalled that
Mackenzie found similar states of
skeletal muscle associated with
visceral referred pain.) These muscles
lt is thus seen that even the altered circulation
induced by the lesion in various organs and tissues,
and upon which Still placed so much emphasis (the
"rule of the artery"), is secondary to changes in the
nervous system.
I
are hyperesthetic and unquestionably
continue to be a source of irritations
to the cord.
It is important to recognize that
trophic, cellular and functional
changes, due to prolonged irritation
and operation of the vicious cycle,
may extend also to the central ner
vous system itself. CoieH has obtained
evidence that microscopically de
monstrable changes in the cord are
associated with the experimental
lesion; these bear a distinct re
semblance to the changes described
by workers in Speransky's laboratory
and by others. These pathological
changes may comprise an enduring
"irritable focus" in its literal sense
and may be an important factor in the
chronic lesion. Furthermore, as
indicated in an earlier section,
localized partial ischemia may be
produced in the nervous system by
peripheral irritations. KugelbergH
and Lehmannl6 have shown that
impaired circulation through neural
elements may render them not only
hyperexcitable but spontaneously
active, in which state they may them
selves serve as "trigger zones. "
Although the above presentation of
the concept of the neural basis of the
osteopathic lesion has been concerned
with the segmental mechanisms and
manifestations, although the primary
focus is within the segment of lesion,
and although the pattern of patho
logical processes associated with the
lesion is especially conspicuous in the
tissues segmentally related to the
lesion, the importance of the extra
segmental and suprasegmental effects
is not be minimized, and is demon
strated in daily osteopathic practice.
They, too, may be organized by the
nervous system in at least two ways
which have already been mentioned:
(a) through the system of internuncial
neurons and spinal tracts and (b) by
the production of localized vaso
spasm and partial ischemia in the
nervous system. The lesion apparent
ly may irritate ascending neurons
which terminate in variou! parts of
the brain. Through descending tracts
and cranial nerves such as the vagus,
these may in turn alter the function of
tissues segmentally remote from the
primary lesion. This concept has been
invoked by Cole3 to account for the
widespread effects which he claims
for the experimental lesion in the
rabbit. Its similarity to the spread
of neurodystrophies in Speransky's
view, is suggestive. Similarly, accord
ing to the views of Travell and Bige
low' 9 partial ischemia in parts of the
brain stem, due to lesions in the
cervical segments, could also produce
far-flung effects. The evidence for the
operation of these mechanisms in the
osteopathic lesion is, however, still
presumptive.
According to the above concepts,
the basis for the effectiveness of
osteopathic therapy lies in silencing
the somatic component of the com
plex, by abolishing the contracture,
spasm, or sustained contraction (and
ischemia) of the skeletal muscles in
the lesioned segment. Lasting effects
are obtained by correcting the me
chanical or articular disturbance
which imposed the stress.
It is not a vital question, affecting
the validity of these concepts, as to
which part of the complex comes
first. The mode of operation of the
somatic component (the osteopathic
lesion) is fundamentally the same
whether the muscular and articular
disturbance was the primary, pre
cipitating factor in the complex, or
whether it is secondary to irritations
which arise elsewhere in the segment,
e. g. , in the viscera. Once established,
it plays a major role, or even the most
important role, in the subsequent
development of the pathological
pattern. This is amply supported not
only by clinical osteopathic experi
ence (the secondary "reflex" lesion),
but it is now a well accepted fact that
the sustained muscular contractions
in the classic visceral referred pain
pattern become an important con
tributor to the vicious cycle; it has
also been demonstrated by Wolff and
his coworkers for headaches of
various kinds and origins. ' The
important thing is that the somatic
component, whether primary or sec
ondary, is accessible and responsive
to treatment, and that appropriate
treatment of this component, by
establishing a more favorable balance
of neural factors, benefits all the
structures associated in the pattern -
and therefore the entire body.
The trend to a unitary concept
of disease
Three major fields of medical
thought, which have had very differ
ent origins and d,ifferent courses of
development, have been briefly re-
Interpretation of research
viewed and shown to have a great
deal that is fundamental in common.
All three schools have, implicitly or
explicitly, accepted certain basic
principles or generalizations at which
they have arrived through very dif
ferent experiences and processes of
reasoning. They appear to be con
cerned with very similar, if not
identical, phenomena, although each
may conceive of them differently.
All three schools agree that the
somatic component of the disease
pattern, of which the most con
spicuous features are the sustained
muscular contraction (ri gi di ty,
spasm, contrature), the sensory
changes (pain, hyperesthesia) and
vasomotor changes, is not only a sign
or symptom of disease, but a major
contributing factor to the disease,
and that it may be a primary
etiological factor.
All have therefore directed thera
peutic attention to this component
because of its accessibility and
responsiveness to treatment, and
because of the demonstration that
improvement in this component
results in improvement in the others,
through interruption or retardation
of a vicious cycle of impulses (or
trophic influences) coursing through
the central nervous system. The treat
ment of this component is the very
core of the osteopathic system of
practice, while to the others it is at
best experimental or ancillary to
other forms of therapy.
It is important to point out that still
a fourth major feld of practice,
which is daily becoming a larger and
more important part of the healing
arts and sciences, is intimately bound,
by mechanism, to the three reviewed
above. Its distinctive feature, too, is
the emphasis on the nervous system,
especially the cerebrum, as the or
gaizer of, and even as a primary
etiologica factor in, disease. Ref
erence is made, of course, to psy
chosomatic medicine. Representa
tives of all three of the schools
previously reviewed have placed
emphasis on the higher centers ,
especially the cerebral cortex, i n the
role of inhibiting, exciting, exaggerat
ing, masking, reinforcing, or initiat
ing the disease patterns mediated by
t he lower levels . Travell and
Bigelow, l 9 Theobald and others
have done it for the referred pain
school ; Frankstein has dem-
onstrated the i nfluence of the
cerebrum on the phenomenon de
s
ig
nated as neurodystrophy by Speran
sky and his followers. Korr28 has
ascribed to the osteopathic lesion
(chronic segmental facilitation) a
localizing, channelizing, and pre
disposing influence in the bodily
expression of mental or emotional
imbalance. It is not surprising that
this is being so widely recognized.
After all, the nervous system exerts its
influence on the body structures
through the efferent neurons which
are final common paths receiving and
funneling impulses from a host of
sources in the body, not the least of
which is the cerebral cortex.
In all these schools there appears to
be a de-emphasis of the specificity be
tween the etiological agent on the one
hand and the manifestations of the
disease on the other. We see an ap
proach to a unitary concept in which
disease is conceived, not as the effect
of this agent or that upon this organ
or that, but rather as the reaction of
the organism as a whole to noxious
influences. 38 It is being increasingly
recognized, and especially in the
above four fields, that the organism
can respond in only a limited number
of patterns to noxious influences. 39
The pattern the character of the
disease is determined by the pa
tient, and not by the offending or in
vading agent; the nervous system cer
tainly has a key role in the organiza
tion of the patterns. These schools,
then, might be said to be character
ized by their emphasis on the similar
ities among diseases rather than on
their differences. "There are no ill
nesses; there are only ill people. "
Possibilities i n the future of the
osteopathic concept
There are many important implica
tions in the above "story" for the os
teopathic profession. The present
writer is hardly the person to draw the
lesson for the profession, but it might
be well to point out some important
facts and make some predictions sup
ported by the foregoing and by recent
scientific and medical advances.
It is clear that the basic concepts
upon which osteopathy is based and
which have been dealt with so suc
cessfully for more than a half-century
are receiving increasing investigative
attention and increasing therapeutic
emphasis from other major schools
of medical thought and practice.
Workers in these other schools have
arrived at these basic concepts by pa
tient, intensive, and extensive ex
ploration of basic mechanism. They
have arrived at these concepts
through very different experiences
and processes of thought than has the
osteopathic profession, and, indeed,
still think of them and apply them in
a very different context.
The osteopathic profession has
earned its place in history and society,
however, through having developed,
and effectively and skillfully applied,
a system of diagnosis and therapeu
tics based on the role of the somatic
structures in disease. It has demon
strated, although it is not yet recog
nized by the other schools, that the
somatic component can be most
directly and effectively influenced
and controlled by adjustment of the
vertebral and paravertebral structures
- i. e. , by recognition and correction
of the osteopathic lesion. One il
lustration will suffice. The somatic
trigger areas which Rinzler and
Travell 1 7 have found in the muscles of
the thoracic cage, in association with
certain cases of coronary insufficien
cy and muscular disorders, are appar
ently identical with, and certainly
similar to, those commonly associ
ated with the rib lesions familiar to
the osteopathic physician. Adjust
ment of the articulation of the rib
head on the vertebra is followed by
disappearance of intensely hyperes
thetic spots in the serratus and pecto
ral muscles and relief from pain. It is
important to recall, also, that rib le
sions in the upper segments often pro
duce pain patterns and other subjec
tive phenomena typical of angina pec
toris. Immediate, complete, and last
ing relief is obtained upon correction
of the lesion.
That system of diagnosis and ther
apy and the concept of the lesion dis
tinguish osteopathy from all other
schools, and they are possessed by no
other school. Adjustive manipulative
therapy, as the heart of his practice,
distinguishes the osteopathic physi
cian from all others. We must be
quick to recognize, however, in the
light of the foregoing, that workers in
other schools of practice are placing
increasing importance, with respect to
disease, upon the processes which are
associated with or initiated by the os
teopathic lesion, and are making se-
135
rious and effective attempts to base
therapy on the interruption of those
processes.
Although it is impossible to make
accurate predictions one can say with
a high degree of certainty that contin
ued investigations by these workers
must inevitably lead to the develop
ment of new and better forms of ther
apy. Although it is possible that they
will "discover" the osteopathic lesion
itself and the direct methods for its
treatment, it is much more probable,
in view of the present direction of
their work, that they will circumvent
the lesion by learning how more ef
fectively to deal with the processes it
sets up. As a result of our own re
searches we are presented with very
promising approaches to the develop
ment of new forms o
f
osteopathic
therapy in which the lesion is treated
simply by preventing its effect on the
body. The rapidity with which these
approaches are pursued will be deter
mined to a large extent by the re
sources which are made available.
It can also be stated with a high
degree of certainty that the stage has
been set by history and scientific ad
vance, for the emergence, in the near
future, of the osteopathic concept, in
one form or another, as the dominant
system of practice. We believe this to
be true regardless of what further the
osteopathic profession does about the
development of the osteopathic con
cept in preparation for this historic
role.
In what way is history making a
place for osteopathy as the dominant
system of practice? From its very
birth osteopathy was faced with
powerful competition from the con
cept of the "foreign agent" in
disease. Pasteur' s discoveries almost
coincided with those of Still. The
bacteriological concept of disease -
the concept t hat disease was
"caused" by this organism or that -
was sweeping the world (as were the
diseases) while Still and his few
followers were patiently and heroical
ly struggling for recognition of the
osteopathic concept. This was taking
place at a time (the third and fourth
quarters of the last century) when
medical science was practically non
existent in this country, and when,
although great strides were being
made in Europe (Pasteur, Virchow,
Ehrlich, Metchnikoff, Mueller, Ber
nard), not one result of real scientific
IJ0
investigation had yet been successful
ly applied to therapy, 40 at a time when
the infectious and contagious diseases
were the major health problem, and
when the average life was cut very
short by disease "caused" by in
vading agents.
Today, as a result of the tremen
dous advances in our knowledge of
the infectious agents and their modes
of transmission, in immunology, pre
ventive medicine, chemotherapy, in
the social control of disease, in sani
tation, etc. , the infectious diseases are
no longer the major health problem
of the world. In the past 40 years we
have seen them, one by one, succumb
to these advances, until today the big
gest killers among these diseases have
been all but eradicated. A continuous
decline in incidence of all infectious
diseases may be reliably expected.
This decline is strikingly illustrated in
the leading causes of death. In 1 900,
tuberculosis, pneumonia and the
acute intestinal diseases, enteritis and
typhoid fever, were way out front.
Pneumococcus pneumonia today is a
vanishing disease; typhoid fever is
virtually eradicated; tuberculosis
seems destined for a similar fate. 4 !
Today the main killers are the chronic
degenerative diseases, which claim
their victims largely from the older
segments of the population.
As a result of these advances there
has been a great increase in the
average life expectancy. Persons in
the middle and late years comprise a
much larger segment 'of the popula
tion than at the time of the founding
of osteopathy. In the last 40 years the
proportion of people over 60 years of
age has doubled. It is now 1 0 per cent
and is expected to double in the next
generation. From 1 933 to 1 946 alone
the average age at death increased
from 58. 2 to 64.2.
However, although the percentage
of people over 60 has increased, the
average man at 60 has the same life
expectancy as had a man of 60 in 1 900
- about 1 4 years. In other words,
lives saved from infectious diseases
are still being lost at an age not far
from the traditional ones of the
past. 4. They are being lost to the
chronic degenerative diseases, the
diseases of maturity and senescence,
the functional disorders. Large seg
ments of mature and older persons
live highly restricted, unproductive
existences, burdened with discomfort
and disability, resulting from these
diseases. As Dr. Leonard A. Scheele
stated upon his induction as Surgeon
General, 4
2
"We find ourselves faced
. . . with an enormous personal and
national burden of disease in the adult
population, the most productive ele
ment of our society. It is possible that
we shall not be able clearly to define
healthy maturity until we learn more
about the chronic degenerative dis
eases and until we attempt to apply in
the entire population our knowledge
of these diseases . . . . We have barely
started to explore . . the major
causes of death and ill-health among
adults. " (Italics supplied.)
Although chronic and degenerative
disorders are spoken of as diseases of
maturity or of middle and late life, it
is not adequately appreciated that
often they have their beginnings in
youth and childhood. Early life and
childhood are themselves too fre
quently victimized by the chronic
diseases and disabling functional
disorders. These diseases are today
the bi ggest ki l l ers , t he bi ggest
cripplers, and among our most press
ing social problems.
Today the osteopathic concept is
the only one sufficiently broad and
sufficiently unitary in its outlook,
upon which a system of practice can
be based, that is capable of encom
passing all these diseases. Today
osteopathy is the only system of prac
tice which has preventive potential
ities with respect to these diseases.
Medical practice as yet has no key, no
clear-cut, and certainly no systematic
approach to the prevention of these
disorders. Treatment is still largely
palliative, symptomatic, or substitu
tional. A few illustrations will suffice.
In the treatment of diabetes mellitus,
in which such great advances have
been made since the discovery and iso
lation of insulin, the disease itself -
the pancreatic deficiency - is taken
for granted. The prevention of this
deficiency, or even the elimination of
the basis for the deficency, has
received no practical therapeutic
attention. Without minimizing the
importance and the magnitude of the
advances made in the recent past
through research, unfortunately no
more than this can be said of the
other chronic degenerative diseases
and functional disorders.
What can be positively said about
the prevention of heart disease, cor-
Interpretation of research
onary thrombosis, hypertension and
peripheral vascular diseases, the skin
diseases, the arthritides , ki dney
diseases, rheumatism, peptic ulcer,
and the host of endocrine distur
bances? Can it yet be said that
medical science, in the treatment
of these diseases, has gone more than
a step beyond the palliation of the
signs and symptoms, or beyond the
treatment of the terminal step in the
disease processes? In fact, the ter
minal process is usually referred to as
the cause of the disease. The endo
crine diseases are "caused" by under
or overactivity of this gland or that;
they are accordingly treated. But
what combination of factors led to
the over- or underactivity? To ascribe
them to "autonomic imbalance" or
to the under- or overactivity of
another gland is merely to beg the
question.
The success of osteopathy in the
treatment of many of these diseases
and the promise of osteopathy in
their prevention, lie in the following
three factors:
1 . The identification of a major
predisposing and primary etiological
factor in disorders affecting al parts
of the .body;
2. Its detectability in even very
early stages; and
3. Its amenability to correction
before it does irreparable damage. All
three, in other words, mean the
recognition and appropriate treat
ment of the osteopathic lesion.
A great deal, however, remains to
be learned before osteopathy is ade
quately prepared for its role as the
preventive medicine of tomorrow.
1 . The effectiveness of osteopathic
therapy in preventing and alleviating
disorders of all kinds needs to be
precisely evaluated on a mass scale.
This requires reliable comparisons of
segments of the population receiving
osteopathic therapy with those not, as
to incidence of the various diseases,
mortality, duration of the illness,
convalescence, etc. Statistics on the
control segment of the population are
already amply available. It is difficult
to conceive of a more informative -
and more convincing - survey of the
therapeutic and preventive merits of
osteopathy than the comparison of
two large groups of children one of
which is under osteopathic manage
ment, the other not - and following
their medical records into adulthood.
The osteopathic profession has simply
not tested adequately, with sufficient
persistence, with adequate controls,
with objective enough methods, with
careful enough recording, and in suf
fcient numbers, the value of osteop
athy in a large number of baffling
conditions - especially those dealt
with in the various specialties which
have developed since Still' s day. It is
sometimes too easy to resort to con
venient symptomatic treatment.
2. Osteopathic concepts and
technics have to be developed to the
point where they can be applied effec
tively to entire populat ions, in the
same way that the preventive medi
cine of today protects millions at a
time against infectious diseases.
3. A great deal more needs to be
learned about the factors leading to
the development of the lesion - the
structural, postural, congenital, en
vironmental, inheritable, occupation
al, age, activity, and other factors.
What again, in this regard, could be
more informative than studies on
large numbers of children in different
age groups for the incidence of le
sions of various kinds, in relation to
those various factors? This would
make possible education of masses of
people on the prevention of the le
s ion.
4. We need reliable, easily applied
methods of detection of the lesion
which may be utilized by the lay
population that they may benefit
from early correction.
5. We need to learn a great deal
more about the lesion itself and the
processes which it initiates and sus
tains. Without question, the time.
labor, and skill required for the cor
rection of each lesion set a certain
limit upon the mass applicability of
present-day osteopathic therapy, al
though today that labor and skill are
the basis for the very success of
osteopathy, and of its distinction
from other forms of therapy. On the
basis of our present knowledge it is
entirely conceivable that a higher,
more general, less laborious form of
osteopathy may be achieved by pre
venting or interrupting the effects of
tesions, by preventing or abolishmg
the processes that lesions initiate -
wherever the lesions may be and
whenever they occur. This possibility
has already been referred to, and it is
important to recall that the processes
associated with the lesion are receiv-
ing widespread attention in nonosteo
pathic insitutions.
It would appear from the foregoing
that to consider that the osteopathic
concept is the same today as it was at
the time of its inception is a serious
mistake. Any endeavor to keep it the
same is even a worse mistake. This
does not imply departure from the
fundamental Stillian principles, but
rather their extension, explanation,
and elaboration. as recent advances
in genetics and cytology have done
for the Darwinian principles. The
concept itself has been greatly en
riched and developed, and its forms
of applications, its range of effective
ness have been widened. But most im
portant, the osteopathic concept is
di fferent today for the simple reason
that it has new roles to play with re
spect to the national health, and it
operates in a very different context -
social, political, scientific, economic
- from that in Still's day. A living,
working concept - and the osteo
pathic concept is certainly that -
could not remain the same while the
scene around it is transformed. A new
and more important place in the
' world scene for the osteopathic con-
cept has been, and continues to be,
prepared. The concept and the tech
nics must continue to evolve, to fill
that place, fit in with the scene, and
operate in the new context . But they
must evolve at an accelerated pace
because the scene is changing rapidly.
Conclusion
In summary, then, from this perspec
tive, the following appear to be the
major tasks before the profession to
day:
A. So to practice osteopathy as to
leave no question, leastwise in the
mind of the patient, as to what is
distinctive about osteopathy as a sys
tem of practice and wherein lie its
merits. In view of the clinically and
experimentally demonstrated role of
the osteopathic lesion as a predispos
ing and etiological factor, the ques
tion is seriously raised whether any
osteopathic physician has the moral
right to withhold the only therapy
which today can correct it. One can
certainly question the wisdom or mo
tivation of any osteopathic physician
who casts aside the powerful and
preventive weapon which he alone
possesses for palliative and symp
tomatic therapies simply because they
137
are more convenient or easier to ap
ply. One can certainly question the in
tegrity of any osteopathic physician
who casts the weapon aside to conceal
his distinction from other physicians.
B. The profession must establish a
research program of such magnitude
and productiveness as befits the his
toric importance of the osteopathic
concept. This is required to provide
the information and the new technics
which will prepare osteopathy for its
role as the central theme in the heal
ing and prevention of tomorrow on a
mass scale. We need data, and still
more data.
C. The osteopathic colleges must
become among the best institutions in
the world for the training of physi
cians - physicians who will be pre
pared to meet the growing challenge;
physicians who, through their train
ing in scientific osteopathy, will pro
vide the steady stream of needed in
formation and data; physicians who
will seek and know how to apply
scientific advances to the health of
mankind; physicians who will know
how to teach others to do likewise.
Our colleges must be staffed by the
best physicians and the best scientists
who must be given the means with
which to do their best work. The
faculties must be sufficiently large
that no member is so burdened with
pedagogical or clinical duties that he
cannot contribute, through research,
to the knowledge in his field.
The third is unquestionably the
most important of the three tasks,
because the fulfillment of the other
two, as well as those concerned with
organization, legislation and public
relations, will flow from the fulfill
ment of this one. The osteopathic
profession has reached a stage of de
velopment where its progress from
now on will be limited by, and in
direct proportion to, the progress and
welfare of its training and research
programs.
These tasks, it would appear, are
the order of the day for the osteo
pathic profession.
It is important to remember that
the scientific world and mankind in
general are neutral in the struggle of
the osteopathic profession against its
opponents; they are even indifferent
to the question of its survival and
continued growth as a distinct and
separate profession. They are not
neutral, however, in the question of
13
truth versus untruth, especially as it
affects the health and welfare of
humanity. The things that will make
possible the continued and rapid de
velopment of osteopathy to its fullest
potential are the very things, that, at
the same time, will lead to its univer
sal acceptance as a superior -and in
dispensable - form of practice. We
refer again to data, solid, incon
trovertible fact which permits no
alternative conclusion; not opinions,
not quotations, not the isolated dra
matic case, not even faith, but "the
scientific substance in which faith can
be intrinsic, "' ;
History and society have presented
the osteopathic profession with a
great challenge and a great oppor
tunity -the development of osteopa
thy to its fullest man-serving poten
tial. Because of its illustrious half
century of successful application of
the osteopathic concept, this profes
sion has been best equipped by his
tory to meet this challenge. Whether
- and how - the profession meets
the challenge will determine the
future of the osteopathic profession,
but not the survival of the osteopathic
concept; that seems determined.
Good ideas never die; society even
tually makes places of honor for
them. If this profession does not take
that historic opportunity and meet
that chalenge, then others certainly
will. To paraphrase an aphorism of
Sir William Osler' s: In science credit
goes to the man (or the profession)
who convinces the world, not to the
one to whom the idea first occurs.
The history of the osteopathic profes
sion shows that once a challenge has
been recognized - invariably that
challenge has been met - and with
honor.
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Interpretation of research
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Science 107: 305-307, March 26, 1948.
The three fundamental problems in
osteopathic research (1951)
The preceding papers on this Sympo
sium have been progress reports on
four different but related classes of
information collected at a certain
stage in the life of a certain group of
individuals. We believe the survey is
unique in osteopathic history for a
number of reasons inherent in its ap
proach to osteopathic fundamentals
- and therefore to the whole ques
tion of health and disease. First, it is
an ensemble of three conventional,
reliable guides to osteopathic diagno
sis and therapy which have been
brought to a high level of standardi
zation, in combination with a com
pletely objective method for the
evaluation of lesion phenomena. This
objective method is but one of many
in process of development in the
Department of Physiology for this
purpose.
Second, the survey is unique in that
it is a study on early stages of
pathological processes in a predomi
nantly healthy population. These are
pathological processes which receive
no consideration in allopathic prac
tice. In the early stages in which they
are found in this group of young men
and women, they are for the most
part asymptomatic. With only few ex
ceptions would they have provided
the basis for a visit to a physician's
office. Since this is a continuing
survey which provides for observa
tion of these pathological processes
and their response to therapy over a
long period, it provides a new and
much needed approach, we believe,
to truly preventive medicine.
The immediate value of this survey
lies in the fact that it has made it
possible to arrive at a clearer and
more unified formulation of the fun-
damental osteopathic problems than
has ever been attainable before. It has
also illuminated the paths that must
be taken toward their solution. It is
the purpose of this paper to discuss
these problems and their approaches.
It is well established that the pos
tural, structural, or mechanical ab
normality known as the osteopathic
lesion, sets in motion a complex
physiopathological process, whose
course, speed, and ultimate manifes
tation are influenced by all the factors
in human life which cause one in
dividual to differ from another.
The ultimate objective of the re
search team, such as the one repre
sented in this Symposium, is contin
ually to arm the physician with better
and better methods of detecting,
evaluating, preventing, and favorably
influencing the disease process
associated with the osteopathic le
sion. This can be accomplished only
through explorations into its intrinsic
nature.
With this in mind, our survey
shows that the fundamental problems
before osteopathic research workers
today are essentially three in number.
We call them "fundamental" because
each is central to -lies at the basis of
- thousands of others which the os
teopathic profession encounters in
daily practice. The solution of the
central one provides the basis for the
solution of the numerous peripheral
ones related to it. Progress in science
is measured by the recognition of the
central problems - and the resolu
tion of the many into the few. Discus
sion of the three fundamental prob
lems follows:
42. Statement by Dr. Leonard A. Scheele upon in
duction 8 Surgeon General, Public Health Service.
Federal Security Agency, April S, 1 948. J . Am.
OSleop. A. 47:472-474. May 1 948.
43. Long, F. A. : A review of research; introduction.
Osteop. Med. 1 :57-64. Oct. 1943.
Reprinted by prmission from JAOA 48: 127-1 38.
1 948 .
1. The lesion process
We have designated the first problem
as the lesion process itself. The
development and varied manifesta
tions of the osteopathic lesion are
organized by a complex process set in
motion by certain stresses. In this
Symposium we are concerned primar
ily with those imposed on the body by
gravity or influenced by gravity. It
now appears well established that this
process is reflex in nature and that the
flow of impulses along the complex
pathways is initiated by stimulation
of some sensory path or paths which
are yet to be identified. Once in
itiated, this cycle of impulses
somehow sustains itself and proceeds
to organize the various but related
mani festati ons of t he l esi on
complex. '
The process may be initiated,
apparently, by gravity which, acting
through the levers of the skeletal
system, imposes stresses on the tissues
which support and move these levers.
In abnormal body mechanics, these
stresses excessively excite and con
tinue to excite those receptors and
nerve endings which are responsive to
tension, pressure, alteration in
length, and to differentials in these.2l
Their responses are registered upon
the central nervous system through
afferent fibers entering the cor
responding segments. By definition
these comprise the proprioceptive
system of the body. Their exact mode
of action under abnormal weight
bearing stresses remain to b elabo
rated. Thomas, in the preceding papr
in this Symposium, has presented a
promising approach to the functional
analysis of proprioception in dif
ferent - naturally occurring -
139
skeletal configurations associated
with faulty weight bearing. Still other
sources of primary irritations are yet
to be identifed.
What is the process which, when
initiated by weight bearing or other
stresses, organizes the manifestations
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 feld requires frst the clear
identifcation of the components of
the lesion comple. The manifesta
tions of the osteopathic lesion, regard
less of its nature, location, or origin,
appear to fall into three main
categories.
They are (1 ) the sensory and supra
segmental; (2) the motor or neuro
muscular, and (3) the autonomic or
vegetative.
1 . Let us consider the suprasegmen
tal component frst. 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 also to other
more subtle influences on higher-level
functions not yet evaluated.
2. The second category of manifes-
tations is the motor or neuromus
cular. This category includes local
alterations 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 refect
on the many different kinds of tissues
and organs under autonomic control
and their many different activities, we
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 categories - 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 i nvolved, sympathetic
hyperactivity exerted upon 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 the heart, the kidney
or the pancreas, the adrenal cortex or
the thyroid, although the same fun
damental process is common to all.
Further, intense sympathetic hyperac
tivity may produce ischemia in dif
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
itself - again, the suprasegmentl,
the motor and the autonomic - 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 pathological 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 postural stress is
only one of many. The pattern is
determined by the locus and not by
the initiator. This is partially
recognized i n the designati on,
"secondary reflex lesions. "
We begin to recognize, therefore,
that a great many diseases which on
the surface are so diverse in character
as to require 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 we
have learned the intrinsic nature of
the process, we shall know how to
prevent or interrupt it wherever it
may be, whatever its mode of initia
tion, and thereby deal in a unified
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, because it alone recognizes
the universality of this process and its
signs. Since only osteopathy knows
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 key to many of the chronic degen
erative disorders - the main causes
of ill-health, premature senility, and
death.
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
vous system. 1 2 The pattern of expres
sion, potential or actual, is deter
mined by the parts of the nervous sys
tem involved. Other factors can only
infuence the fullness 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 from
which impulses flow 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 kinds. These three
kinds 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 takes less of a stim
ulus, from any source, to send them
into activity and to sustain activity.
For this reason, we have come to
think of the segment in lesion as a
faci l itated segment. 2, S I t is a
neurological lens which focuses and
exaggerates irritations upon those
tissues which it supplies. In short, le
sioned segments are those which are,
in the true physiological sense, in a
continual 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 time factor
This brings us to the second funda-
Interpretation of research
mental problem - the time factor.
Here we are concerned with the
changes that take place as the process
ages. We know very well from cli nical
experience that the lesion complex
and its many manifestations do not
spring full blown i nto being; there
may be many years between the i nitia
tion of the lesion process and the full
or even partial expression of the la
tent pattern.
The structural survey* being con
ducted on several hundred school
children by Wallace M. Pearson and
George Rea and their coworkers at
the Ki rksville College of Osteopathy
and Surgery indicates that serious
weight-bearing and other skeletal ab
normalities already have a high fre
quency in children between the ages
of 6 and I 2. However, the physical
findings and the obvious well-being
and vigor of most of these children -
in the face of apparently serious
postural stresses - indicate that the
lesion process has not yet produced
stri ki ng physiopathological changes.
We can reliably predict, however, on
the basis of the survey which is the
subject of this Symposi um, that these
same processes will have taken some
toll by the time these children have
reached the average age of the student
body at Ki rksville College, even
though serious symptoms may still
not have attained high incidence.
Even casual observation supports the
additional prediction that aches and
pains, as well as chronic disease, wi l l
have become a dai l y feature i n the
lives of many of these children by the
time they have reached the average
age of the Kirksvill e faculty. The seed
for these di sabi l i ties is al ready
planted i n those postural stresses of
which these youngsters are, for the
most part , so blissfully unaware to
day. The stages through which the le
sion process passes over a period of
years has hardly been explored.
We know that the primary process
i nduces pathol ogical changes i n
various tissues including viscera and
the nervous system itself, as discussed
under the first problem, and that
these in turn become secondary
sources of i rritation. These secondary
<This survey is made possible by the program of
regular physical cxaminat|ons ofAdair County rural
school children at thcCollege Clinic. This program is
directcd by Vernon H. Casner, D.O., head of the
Department of Public Health and County Health
Officer.
sources not only contribute to the
maintenance and exacerbation of the
pathology, but over a period of time
they may actually shi ft the balance of
pathological forces to new and even
opposite di rections. The same may be
said of the various adaptive or com
pensatory reacti ons and t i ssue
changes elicited by t he primary le
sion, An excitatory effect may resolve
itsel f into an inhibitory effect and
vice versa. Certainly, the acute lesion
is qui te distinct i n many aspects from
the chronic one,
A great deal remains to be learned
regarding these various secondary
and tertiary changes and their conse
quences. The terms we use to desig
nate or describe them, satisfying
though they may be to the user, are
only names or descriptions that
cleverly conceal a lack of knowledge.
The words "trophicity" and "trophic
change, " for example, represent a
rich and unexplored world.
It is important to remind ourselves
in this connection that in the subjects
of this survey, the secondary and ter
tiary changes are not yet ful l y devel
oped and, to that extent, the patholog
ical processes which we are studying
are, as yet, chiefly preclinical or sub
clinical and presumably still revers
ible. The i mportance of this concept
to the prevention of disease is clear.
J. Other factors
Now we come to the thi rd fundamen
tal problem: Other factors which
decisively i nfluence the lesion pro
cess, We have come to recognize that
the osteopathic lesion as a phenom
enon of central facilitation is a most
important predisposing, localizing,
and probability-increasing factor in
disease. I t is very often the decisive
factor. As the most accessible factor
in the disease complex, the osteo
pat hi c pr ofes s i on has cl ear l y
demonstrated that the treatment of
the lesion may make the di fference
between relatively good health and
relatively poor heal th.
As our survey has made quite clear,
the degree of fullness of expression of
the pattern behind the lesion complex
is greatly i nfluenced by a large variety
of factors, These obviously include
al l the factors that distinguish one in
dividual from another: the constitu
tional factors (another generic term
behind which we vainly try to conceal
ignorance), age, environment, past
Fig. I. Measuremenl oj eleclrical skin resis
tance. (See lel.)
history, nutrition, emotions, per
sonality, and many others, A given
structural defect may produce no
clinical manifestations in one in
dividual and a serious one i n another,
A relatively quiescent lesion may sud
denly, under a new set of circum
stances, or gradually, as through the
process of growing older, bring into
manifestation the full latent pattern
of processes and manifestations in
herent i n that part of the central ner
vous system. At our present stage of
knowledge, we can have only a notion
regarding the general direction of the
i nfluence of these factors, but little
more.
The i nfluence of cerebral factors,
for example, on the speed of the
fundamental process and the fullness
of its expressi on, i s i mpl i ci tl y
recognized in the practice of psy
chosomatics. For want of a more
direct approach to the process,
psychotherapy is, of course, emi
nently useful in the treatment of
disease. The emergence of psychoso
matics in recent years bespeaks the
triumphant recognition, in allopathic
practice, that here, at last, is an
etiological approach to chronic dis
ease. The osteopathic lesion, how
ever, has for three quarters of a
century been known to provide a
more specific somatic handle for the
manipulation, literally, of the process
itself.
These, then, are the fundamental
problems before osteopathic sci
entists today: ( I ) The primary process
initiated by postural stress which
organizes the pattern of the lesion
complex, (2)the changes and accruals
with time, and (3) the other factors
which influence the rate and fullness
of expression of the pattern. There
are, of course, many other problems ,
Careful reflection, however, shows
141

99
W
M
u+v
m
Fig. 20
J. H Z
Fig. 2b Fig. 3
Fig. 2. /llustration ofconstancy ofsegmental distribution oflow resistance areas (shaded). Explorations 2 months apart, on same subject, by different
methods and diferent examiners are recorded in 20 and 2b. This case was selected to show extreme variations in size, shape, and intensity of low
resistance areas while segments involved remained essentially unchanged. (Other explanations in text.) Fig. 3. Bilateral dermatomal strips oflow skin
resistance found in case ofacute gastritis.
Fig. 40 Fig. 4b Fig. 50 Fig. 5b
Figs. 40 and 4b. Effects ofintramuscular injection ofhypertonic saline. Injections of0.3 cc. of6 per cent sodium chloride into sites marked by (left
erector spinae mass at eighth thoracic segment and right intercostal, ninth thoracic) cause appearance of new low resistance areas in corresponding
dermalOmes. (New areas encircled U distinguish from pre-existing areas.) Figs. 50 and 5b. Distribution ofthe new areas several hours after experiment of
Figs. 40 and 4b.
that most of those that come to mi nd
are peripheral and will fall into line as
i nformation accumulates on the
central ones.
Methods of the Department of
Physiology
In the space that remains I wish to
review a few of the methods that are
being adapted and developed in the
Department of Physiology for the
investigation of the problems dis
cussed above and for incorporation
into this continui ng survey.
It must be emphasized that these
14I
procedures have been developed for
investigative purposes only and are by
no means to be considered ready for
inclusion in the diagnostic arma
mentari um. Although i t is probable
that at least some of these procedures
will eventually be of cli nical value,
since they do evaluate segmental
features associ ated wi th cl i ni cal
disturbances, a great deal more
i nformation remains to be ac
cumulated and analyzed before it can
be known what cli nical significance to
assign to these measurements.
Denslow and his coworkers578 have
shown that the spi nal lesion has
associated with i t a low motor reflex
threshold, that is, it takes less of a
stimulus to induce reflex muscular
ativity i n the lesioned than i n the
nonlesioned segment. This means
that in the lesioned segments, the
anterior horn cel ls, at least of t he
paravertebral muscles, are in a state
of hyperirritability. The segment is
said to be, faci litated with respect to
motor activity. We are now correlat
ing measurements to other segmental
features with motor reflex theshold.
I t was of i nterest to determine
I nterpretation of research

llB
tHng .9

. .
P
W
.
0 l -
.:.

Fig. . Changes in skin resistance pal/ern with postllre and activity. (See text.) (a)Afternoon, seated; (b) morning, standing; (c) late afteroon, standing.
M6m Hl J. . 66
t Z l Z
Z'90
&B

d lnf,

fP
9 M

W~
.
W"

/
Fig. 7. Efects oftilting sacral base plane. "acllte scoliosis. " (See text. (a) Level seat. (b) right side elevated I hour, (c) retur oflevel seat.
whether the facil itation extended to
other neurons in the lesioned seg
ments. We turned to the sympathetic
outflow and, as Thomas stated in the
preceding paper of this Symposium,
have used the electrical ski n resistance
method for this purpose.9. I O. 1 1 In this
method, the sweat glands are the
physi ol ogi cal i ndi cat or s of t he
relative activity of the lateral horn
cells in the various segments.
Figure shows a ski n resistance
expl orat i on in progres s . Known
voltages are applied through t he ski n
in such a way that t he current which
flows, measured in mi llionths of an
a
mpere, indicates the resistance of the
ski n underlying the exploring elec
trode at a given time. By adj usting
the voltage so that little or no current
flows through most of the ski n, areas
of low resi stance are sharply di f
ferent i ated by excursi ons of t he
microammeter needle. These findings
are then recorded on body charts.
The low resistance areas represent
sympathetic hyperactivity.
Repeated explorations over long
periods on many subjects have shown
that low resistance areas are present
in all subjects; that the distribution
of low resistance areas, that is, of
sympat hetic hyperact i vi t y, vari es
from individual to individual, but
t hat i n a gi ven i nd i vi dual , t he
segmental distribution may remain
constant for many months. In these
segments, therefore, the sympathetic
outflow appears to remain i n a state
of activity while elsewhere i t is at rest.
Thi s hyperactivity, or state of alarm,
presumably extends not only to the
sweat glands, but to structures in
nervated by the sympatheti cs -
blood vessels and viscera.
Figure 2 compares two explora
tions done i ndepe
'
ndently by two
examiners 2 months apart on the
same subject and i ll ustrates the
stability of the patterns. Note that
although the size, shape and intensity
14J
144
Fig. 8a Fig. 8b Fig. 8c
8. Heel-lift eXperiment (See text.) (a) Control, (b) 24 hours ajter lift inserted in right shoe, (c) 24 hours ajter removal oj lift.
L 6 vo|u
6 | 3 5O | | O 8M.
Fig. 10
Fig. 9. Device jor semiautomatic photographic
recording oj skin resistance patterns. The
recording camera is mounted above the
subject. Fig. 10. Record made by device shown
in Fig. 9. Dark areas, as in "hand
explorations, " represent areas oj lowered
resistance. Record is photographically
superimposed on subject 's body. Numbered
white dots indicate tips oj spinous processes.
Note calibration strip on lejt, jrom which
actual resistance oj any area can be accurately
determined.
of the areas are variable, since they
may change with posture, previous
activity, temperature, et cetera, the
low resistance areas remain concen
trated in t he same segments.
The segmental nature of these
patterns is further reflected in the
frequentl y observed dermatomal
stri ps of l ow resi stance, often
extending from spi ne to sternum.
Figure 3 illustrates an extreme case of
dermatomal i nvolvement in a young
man during an attack of acute gas
tritis. Over several preceding months
he had consistently showed sym
pathetic hyperactivity i n the sixth to
ninth thoracic segments.
Fai r l y s peci fi c and const ant
patterns have been shown t o be
associ ated wi th certai n vi sceral
syndromes, the l ow resistance areas
occurring in those segments from
which the involved viscus derives its
i nnervati on.
l 0
I n several cases we
have observed the appearance of
these patterns long in advance of the
fi rst symptoms. Since our primary
concern in this symposium is with
myofascial and postural stress, the
patterns associated with visceral
disease wil l not be reviewed i n this
paper.
Time does not permit review of the
various patterns we have found asso
ciated with acute lesion pathology,
severe back disorders, trauma, and
the effects of treatment. " The next
five figures illustrate the effects on
ski n resistance patterns of experi
mentally induced myofascial i rri ta
tions and postural stressses.
Figure 4 shows the effect of inject
ing 0.3 cc. of 6 per cent sodium
ch
i
oride solution into skel etal muscle.
The ringed areas on the left appeared
within a few minutes following the
injection of the hypertonic salt solu
tion one inch deep into the spinae
erector mass at the eighth thoracic
segment (site marked by X). The
areas (ri nged) on the right followed
injection into the i ntercostal at the
ninth interspace (X) . Note the in
volvement of entire dermatomes.
Several hours later the newly i nduced
area appeared as shown in Figure 5.
I n the course of exploration, these
dermatomes became vivid hyperemic
strips due to the repeated passage of
current although all other areas, ex
plored at the same voltage, remained
unchanged i n appearance.
Figure 6 shows a series of explora
tions of a subject who i s the victim of
frequent backaches in the lumbar
regi on. The first chart (6a) shows his
pattern in the afternoon while seated.
The middle chart (6b) shows his
pattern i n the morning while in the
I nterpretation of research
standing position. The third chart
(6c), an exploration done i n the
standing position late in the after
noon of the same day after a full
day' s work, shows the greatly ex
aggerated effect of continued activity
and fatigue on the sympathetic
nervous system i n the facilitated
segments.
Figure 7 illustrates some of the
effects of postural stress. In the first
exploration, the control (7a), the
subject was seated on a treating stool
with his elbows resting on the desk
before him. Following the completion
of this exploration, the right end of
the stool was raised 1 1/2 inches, while
he otherwise maintained his position.
The middle exploration (7b) was
made at the end of an hour. The new
areas thus induced are quite con
spicuous, especially the one in the
lower thoracic regi on, on the left side,
located on the convex side of the
induced spinal curve. The third chart
(7c) shows the effect of return to a
level seat.
Figure 8 i l lustrates one of the
experiments in which postural stresses
are induced or modi fied by means of
heel li fts. The first chart (8a) shows
the pattern which had been character
istic of this subject over a period of
several months. His right femur head
was approximately 7 i nch lower than
his left. He was occasionally troubled
with pain in the lower l umbar area,
on the right side, corresponding to
the low resistance area in that regi on,
especi al l y after exert i on. Thi s
exploration was done i n the morning
following a 1 12 mile wal k. A 1/2 inch
heel l i ft was inserted in the right shoe
immediately after - this exploration.
The subject wore the lift throughout
the day and the fol lowing morning
while engaged in his usual activities
and during the 1 Y mi le walk to the
laboratory. The second chart (8b)
shows the expl orati on of that
morning. The extensive low resistance
i n the lower right side has been
eliminated, but there is a flare-up and
expansion of the areas in the thoracic
segments, indicating, we believe,
severe insults to these segments. The
lift was removed after this explora
tion. The third chart (8c) shows the
skin resistance pattern on this subject
. the following morning, again after a
1 12 mile wal k. The area over the
ileum returned, and there was further
increase in sympathetic hyperactivity
Fig. II. Comparison of "hand" and "automatic" explorations. (See text.)
Fig. 12. Colorimetric visualization of regional
diferences in sweat gland activity. The method
Ulilizes the color change of cobalt chloride
from blue O red when moistened. In our
preparation the coball sail is mixed with
hygroscopic calcium salts to increase the
contrast. Photographed through an appropri
ate red filter, blue areas (dry) appear dark; red
(moist) appear faded. The photographs, taken
at short intervals (note time on each picture),
show the regional differences in the rate of
thermoregulatory sweating response in this
subject. The experiment may be repeated by
permitting the subject to cool, whereupon the
blue color returns. Mild thermoregulatory
response is induced by applying heat to
extremities or ventral surface.
Fig. J. Part of equipment for measurement of
cutaneous and deep muscle temperatures with
galvanometer and thermocouples incorporated
in fine hypodermic needles. Skin lhermocouple
and constant temperature bath for "reference"
thermocouples are not shown.
145
Fig. 16a
Fig. 14. The measurement ofmuscle hardness
and resiliency, by contact time and rebound of
dropped weighl.
Fig. 15. Measuremenl of segmenlal pain
thresholds (cutaneous). Adaption of Hardy
WolffGoodell thermal stimulus method.
Fig. 16b
Fig. 16. Renal clearance experiment. (See text.) Trained dog, unanesthetized, has received large
volumes of water through stomach tube to establish diuresis; intravenous infusion was administered
through vein in paw. (a) Urine specimen being taken through catheter. (b) Blood specimen being
taken from external jugular vein. The dog is "Ma, " happy veteran ofJyears ofexperimental work
and respected matron of the kennels.
140
in the thoracic segments, presumably
induced by a second acute postural
adj ustment .
The ski n resistance explorations by
means of the hand-held electrode are
slow and tedious, requiring from 30
to 90 mi nutes for each exploration.
They, therefore, make impossible the
study of rapid changes. They require
a considerable amount of training on
the part of the observer and patience
on the part of the subject. Figure 9
shows an instrument designed in our
laboratory and constructed in the
laboratory machine shop, ' 2 which
photographical l y records the elec
trical ski n resistance patterns almost
automatically, in about 10 minutes. I t
can be operated in the vertical
position, for t he study of acute
postural stress, as well as in the
horizontal . Space does not permit a
description of the instrument, except
to say that the trunk is explored
automatically i n longitudinal strips,
and that a light mounted over the
exploring electrode is caused, by a
simple amplifier, to vary in brightness
in accordance with the resistance of
the skin over which i t passes. A
camera mounted above records these
strips of light of varying intensity, as
though they were coming from the
corresponding strip of ski n itself.
By means of a controlled double
exposure, the record is accurately
superi mposed on a photograph of the
subj ect ' s body, with the body promi
nences marked. (Fig. 1 0) .
Figure I I shows a comparison of
one of our earl i est automati c
explorations with a hand exploration
done i mmediately afterward. Note
the high degree of correspondence
between the two; the mid thoracic
dermatomal strip on the right side is
especially clear i n the photographic
record. It is of i nterest to point out
that the subject used for these ex
plorations was the one used in
maki ng Figure 8. However, the
explorations recorded in Figure I I
were done 1 6 months later by another
experimenter. The charts in Figure 8,
especially the third (8c) are almost
superimposable on the later ones,
again stressing the stability and
chronicity of the segmental patterns
of sympathetic hyperactivity.
The photographic dermometer has
already made possible a considerable
expansion of our program. It will
make possible a rapid evaluation of
I nterpretation of research
the diagnostic or prognostic value of
skin resistance, through the correla
tion of patterns with many kinds of
clinical entities in large numbers of
patients.
Figure 12 shows one procedure
under development in our labora
tories for the visualization of regional
or segmental differences in sweat
gland activity, by colorimetric means.
Other visual and photographic tech
nics , involving fluorescence or
regional color differences under
ultraviolet and infra-red light, related
to differences in blood supply and
tissue fluids, are also under investiga
tion.
Figure 1 3 shows some of the equip
ment utilized in the measurement of
cutaneous and deep muscle tempera
ture as a guide to vasomotor activity
or inflammation at various depths,
in relation to lesion pathology.
Thermocouples have been con
structed in No. 26 gauge hypodermic
needles which can be inserted into
muscle, tendon, or ligament at
various depths and at different
segments. Another type of thermo
c
o
uple, not shown, is used for the
recording of skin temperatures. A
high degree of stability of the patterns
of segmental distribution of relatively
warm and relatively cool skin has
been demonstrated in each of a large
number of subjects, while the pat
terns vary from subject to subject.
Large differences in intramuscular
temperature have also been found
between neighboring segments. The
significance of these differences is
expected to emerge from correlation
with other segmental features.
In Figure 1 4 is shown another
device being developed in our
laboratm:ies, for the precise and
objective measurement of muscle
hardness and resiliency, with which
we hope to be able to quantitate
abnormalities in tissue texture
associated with postural and other
disturbances. In addition, Shirley A.
Johnson, Ph. D. , also of the Depart
ment of Physiology, is conducting a
study on the chemical and metabolic
changes in contractured muscle, so
frequently associated with lesion
pathology.
Figure IS shows one approach we
are taking to the sensory or
suprasegmental components of the
lesion complex. This method permits
the precise measurement of cutaneous
pain thresholds at various segments
for correlation with other segmental
measurements. Another procedure is
being designed for the measurement
of hyperalgesia in deeper tissues.
The methods which have been
briefly reviewed here, and others in
process of development, are charac
terized by a high degree of precision
and objectivity in that they are
relatively i ndependent , of the
subjective senses and judgment of the
observer; they are therefore more
easily subject to confirmation. They
are characterized, also, by the fact
that they are applicable to the study
of the osteopathic lesion complex in
its natural habitat, so to speak -as it
occurs in the human body. Through
analyses of the patterns in which
these various segmental features, and
others to be added, appear, we shall
acquire a deeper insight into the
processes which organize those pat
terns. It can be said that, through
these procedures, a true physiological
mosaic of the osteopathic lesion has
begun to be laid.
More direct approaches require, of
course, the use of experimental ani
mals. In one investigation, conducted
by Dr. Johnson and the writer, we are
attempting to evaluate the effect of
myofascial irritations applied to vari
ous segments of the back on renal
function, especially renal hemo
dynamics. We selected the kidney
because methods are now available
for the precise measurement of the
amount of blood flowing through the
kidney per minute, the rate of glo
merular fltration and tubular activity
in the intact unanesthetized animal or
human, and the acute and chronic ef
fects thereon of various experimental
lesions. Its potential importance to
cardiovascular-renal disease is clear.
Figure 1 6 shows an experiment in
progress on one of our six dogs which
have been trained to lie still and at ease
for several hours while they receive
water through stomach tubes (to in
duce diuresis) and intravenous infu
sions and while numerous blood and
urine specimens are taken at precise
intervals.
Other visceral studies, utilizing
roentgenologic and other technics,
are in prospect. In another series
of experiments to be begun in the
near future, we shall undertake a
direct analysis, by electrophysio
logical methods, of the exchange of
excitation between the somatic and
autonomic nervous systems.
Conclusion
In conclusion, we wish to affirm our
belief that from such studies and
from the continuation and expansion
of such surveys as reported in this
Symposium, there will emerge new
and unforeseen approaches to urgent
and universal health problems whose
solutions are inherent in the osteo
pathic concept.
References
I . Korr. I . M. : Emerging concept of osteopathic
lesion. J. Am. Osteop. A. 48:127-138. Nov. 198.
2. Korr, I. M. : Neural basis of the osteopathic
lesion. J. Am. Osteop. A. 47: 1 91 1 98, Dec. 1 947.
3. Swift. R. J. : Small-nerve motor system in
relation to osteopathic lesion. J. Am. OSleop. A.
49:378-380, Mich 1950.
4. Drucker, D. E. : Referred pain and the osteo
pathic lesion. J. Am. Osteop. A. 47:623629, Aug.
198.
5. Denslow. J. S. , Korr, I. M. , and Krems, A. D. :
Quantitative studies of chronic facilitation i n human
motoneuron pools. Am J. Physio!. 150:229238, Aug.
1 947.
6. Burns, L. : Pathogenesis of visceral disease
foHowing vertebral lesions. American Osteopathic
Association. Chicago, 1948.
7. Denslow, J. S., and Hassett, C. C. : Central
excitatory state associated with postural abo
normalities. J. NeuTophysiol. 5:393402. Sept. 1942.
8. Denslow. J. S.: Analysis of variability of spinal
reOex thresholds. J. Neurophysiol, 7: 20721 5. July
1944.
9. Korr. I. M. , and Goldstein, M. J. : Der
matomal autonomic activity in relation to segmental
motor reOex threshold. Federation Proc. 7:67, March
1 948.
10. Korr, L M. : Skin resistance patterns associated
with visceral disease. Federation Proe. 8: 8788, March
1949.
I I . Korr, L M. : Experimental alterations i n
segmental sympathetic (sweat gland) activity through
myofascial and postural disturbances. Federation
Proc. 8:88, March 1949.
12. Thomas. P. E., and Korr, L M. : Semiauto
matic recording of electrical skin resistance patterns.
Federation Proc. 9: 126. March 1950.
Reprinted by permission from JAOA 50:407416.
195 1 .
147
The concept of facilitation and its
origins* (1955)
This symposium is a report on a ma
jor aspect of one of the research pro
grams being conducted in osteopathic
institutions. It has enjoyed the gener
ous support of the osteopathic pro
fessi on t hrough t he American
Osteopathic Association, that of the
National Institutes of Health, and of
the Offce of Naval Research.
In selecting a problem for investi
gation the researcher must identify
the broad general area in which he
wishes to work, the areas which ad
j oin it, the specific portion which he
wishes to explore in the area, the rela
tion of that portion to the others, and
the kinds of information he wishes to
seek. The audience to whom he
reports should have the benefit of
that preliminary perspective. The first
part of this paper is, therefore,
devoted to orientation.
Because the recognition of the
osteopathic lesion and of its impor
tance to the health of man is a distinc
tive feature of osteopathic theory and
practice, it has, in our opinion,
become the unfortunate custom to
characterize researches under osteo
pathic auspices, as researchers on
"the osteopathic lesion, " on "the ef
fects of the osteopathic lesion on"
this or that function or structure, or
some other variation of the same
theme.
We believe that far more than this
is required to identify the area and
objective of each investigation. In ac
cepting such a designation for a
research project one accepts either the
reduction of the scope, meaning, and
complexity of the lesion to the limits
set by the project or one accepts a
most unrealistic estimate of what can
be accomplished by a human being or
group of human beings in a single
endeavor - or even in an entire
lifetime. Even worse, unless the in
vestigator puts his question to nature
explicitly and unequivocably he may
receive answers to questions other
than those he thinks he is asking.
Since a physician must first locate
"Based in part on papers read at the General Sessions,
Fifty-Eighth Annual Convention of the American
Osteopathic Association, Toronto, Canada, July 14,
1954.
148
and diagnose an osteopathic lesion
before he can treat it, the term
"osteopathic lesion" has, through
usage, come to designate, in the
minds of many, a rather simple, dis
crete entity, a thing or structure to
which one can point and on which
one can place his hand. As so often
happens, the designation becomes the
thing itself. I t seems that the osteo
pathic lesion is becoming implicitly
equated with the palpable concomit
ants of the constellation of complex
biologic processes which the lesion
truly represents. In our opinion this is
scientifically as wrong, misleading,
and unproductive as equating gly
cosuria with diabetes mellitus. It i s
as dangerous as assuming that the
visible part of the iceberg i s the
iceberg.
The osteopathic profession is earn
ing its place in the world of the
healing arts through demonstrating
that the above-surface manifestation
is a sign of, and a participant in, a
large, massive, dangerous process go
ing on below, and that forces prop
erly applied to that accessible part
may move the entire iceberg into
warm waters.
Too much research, in our opinion,
has been devoted to "proving" the
existence of the iceberg. l What is
required in order that osteopathy may
now earn its place in the scientifc
world is the disclosure of the nature
of the processes going on below the
surface, their origins, the factors that
influence them and their relation to
the above-surface manifestations.
Further clinical advance in this area
awaits such disclosure by funda
mental research.
The osteopathic lesion - even i f
through usage i t has come to repre
sent only the palpable pathology of
the somatic or musculoskeletal tissues
- must therefore be viewed a rep
resenting the local, somatic factors,
concomitants, and manifestations of
a highly organized response of the
man a a whole to the demands,
stresses, and insults which are part
of his life and to which he is not
quite adequate. These include most
especially the stresses of gravitational
origin to which man' s musculoskele-
tal system is especially subject. This
response involves the interaction of
many processes going on in many
tissues, mediated through the nervous
and circulatory systems and being
continually changed with time, cir
cumstances, activity, and all the
factors operating in the individual' s
life. This i s t he part of the iceberg
lying below the surface. There is no
doubt of its immense complexity.
Here, unlike the nonliving iceberg,
there is not the rigid fixity of
relationship between the conspicuous
and inconspicuous components -
with respect to quantity, importance,
origins, history, or even location.
Faced with such a vast and deep
problem the investigator must care
fully select and equally carefully
define an aspect of the total and the
kinds of information he seeks within
that aspect. He must avoid the danger
of identifying the aspect which oc
cupies him as the osteopathic lesion.
The study, for example, of vertebral
strain or other somatic components i s
not synonymous with the study of the
osteopathic lesion. To assume so is to
destroy its very meaning and to pre
determine a blind-alley investigation.
From the very moment that the verte
bral strain begins, the entire body
is already organizing its responses,
and from that moment on the insult
and the response have no separate
existence.
The area of investigation
The laboratory investigations at
Kirksville have been directed at an
understanding of the role of the
nervous sytem in organizing that
response at the segmental level. The
program of the Department of Phy
siology has been concerned especially
with the mechanisms, patterns and
pathways of interchange between the
somatic and autonomic divisions of
the nervous system.
While not specifically on "the
osteopathic lesion, " these are studies
of factors and mechanisms intrinsic
to it. Furthermore, as will be shown,
"physiologic lesions" have been
demonstrated in these studies which
are closely related, by nature and
location, to the phenomena clinically
identified as osteopathic lesions by
the osteopathic physician.
These investigations are still very
youn, and they have but scratched
the surface. Perhaps their main con-
Interpretation of research
tribution has been not so much the
new information which has been
yielded, but that through that in
formation and through relating it to
other previously explored areas. it
has become possible to restate some
old basic osteopathic problems in
such a way that for the first time
they become approachable by experi
mental methods. In the time that is
available for this research report we
cannot possibly summarize 8 years of
research but we can show our general
strategy. the direction in which we
are probing, a few of the kinds of
information we have found, a few
tentative generalizations, and finally
our interpretation of the clinical
significance of these findings as we
see them now.
The strategy of our approach to
this aspect of the general problem
took its origin in the clinical
observations of thousands of osteo
pathic physicians, over a period of
several decades. Two main general
izations established the point of
departure and direction of our in
vestigation.
1 . The signs and symptoms associ
ated with the osteopathic lesion
include (a) the presence of tenderness,
spontaneous pain or both; (b) altered
functions and activities of the
associated muscles; (c) vasomotor,
sudomotor, and. frequently, visceral
changes. In short, they include dis
turbances in a basic triad of nervous
functions - sensory, motor, and
autonomic. t Our studies are con
cerned with alterations of these
functions, their interrelations, and
their association with other features
at the segmental level.
2. Every osteopathic lesion had its
origin and development in the context
of the life and activities of the in
dividual in whom it is found. The
lesion. therefore. with its associated
sensory, motor, and autonomic dis
turbances, has meaning and is
interpretable only in that context. We
t A virtually unexplored field exists in a fourth
category of nervous function - the so-called trophic
functions. Exploration i n this field awaits the
development and application of satisfactory methods
for the study of the slow. long-term innuences of
peripheral nerve Fibers upon the tissues which they
innervate. in contrast to the faster. recordable.
impulse-transmitted innuences. The trophic functions
of nerve unquestionably have a very important
bearing on the phenomena with which osteopathic
physicians deal. They are a rich field for exploration
by physiologists. biochemists. pathologists and others.
have studied these disturbances (and
their experimental modification) in
their natural "habitat" - in the
voluntary subjects and patients
in whom they are found. (Although
certain aspects and features of the
osteopathic l esi on and related
phenomena may be experimentally
simulated in animals, conclusions
drawn from such studies are applica
ble to the naturally occurring lesion in
man only to the extent that their basic
similarity to the naturally occurring
phenomena can be demonstrated. )
I n order to study the triad of
nervous functions in man it has been
necessary to develop. adapt, and
apply methods which would yield
reliable information regarding activi
ties in regional or segmental sensory,
motor, and autonomic pathways,
which would do so without altering
those activities and without dis
turbance of the human subject him
self, and which would make possible
a comparison of the activities in
disturbed areas with those in the
normal.
With these methods and with
others in continual process of
development i t became possible t o
begin the uncovering of what we have
called a physiologic mosaic - the
related patterns of variations in
sensory, motor, and autonomic ac
tivity in the various segments. From
the patterns in each of these three.
from their relations to each other,
and from their responses to experi
mentally induced or spontaneously
occurring variables it is becoming
possible to deduce the nature of
the processes which organize those
patterns. The details of those
processes and the precise mech
anisms, the patterns, and pathways of
interchange between the somatic and
autonomic divisions of the nervous
system can be studied, of course. only
in experimental animals, in which the
involved parts of the nervous system
can be exposed and directly explored
by electrophysiologic recording of
impulses and by other methods. Such
experiments are now in progress.
Previous studies in this area
Investigations conducted at the Kirks
ville College have indicated that the
musculoskeletal stress initiates, or is
associated with, unbalanced streams
ot Impulses entering the central ner
vous system. and that these have
the effect of upsetting the delicate
balance of that part of the nervous
system with which the lesioned part is
most directly connected. This was
first demonstrated for the muscular
or motor component by Denslow and
his colleagues in the early 1 94's. 46
He demonstrated that the segments
which are in lesion, as determined by
subjective clinical criteria commonly
utilized by him and many other osteo
pathic physicians ( ti ssue-texture
abnormality and deep hyperalgesia),
were objectively distinguishable by
physiologic criteria of motor activity.
Segmental motor refex thresholds
were determined by measuring, in
kilograms, the amount of pressure
applied to the spinous process of each
segment which just evokes contrac
tion of the paravertebral muscles at
that segmental level. Muscular con
tractions were detected and evaluated
by electro myographic recording.
Lesioned segments invariably re
quired weaker stimuli than did non
lesioned segment s. The lesioned
segment was therefore said to be
characterized by lower motor reflex
thresholds - the more severe the
lesion the lower the threshold.
In a later study, Denslow, Korr,
and Krems demonstrated that
diffuse and remote stimuli, including
those from the higher centers, and
stimuli that occur in normal life,
preferentially excited the pathways
to paravertebral muscles of the
l esi oned segment s. Responses
occurred i n these segment s, to
impulses from many sources, while at
the same time nonlesioned segments
remained quiescent . Under condi
tions in which there was generalized
muscular contraction the activity in
the lesioned segments was relatively
exaggerated. The easier opening of
the motor pathways in lesi oned
segments suggested that this was a
sustained form of the phenomenon of
facilitation under study in numerous
neurophysiologic laboratories and
that, like the experimentally induced
form, it too had its origin in a
sustained afferent bombardment by
impulses from some segmentally
located source.
In the next few years the Depart
ment of Physiology adduced a large
body of experimental evidence that
segmental pathways mediating the
other two members of the triad of
nervous functions, namely the
149
Fig. 1 Fig. 2 Fig. 3
Figs. 1-4. A Comparison ofSegmental Pal/ems in the Same Subject.

L
I
Fig. 4
Fig. 1. Lesion Pathology. Diagrammatic representation of the distribution and relative severity of osteopathic lesion pathology as determined by
palpatory examination. Fig. 2. Electrical Ski n Resistance (ESR). Skin resistance oblained with Ihe photographic recording dermohmeter. Dark areas
orrespond to areas of low skin resistance on the subjeci 's back. The resistance of these areas is less than 5 per cent of the high-resistance (white) areas.
The /ighl spots in the mid-line mark the tips of the spinous processes. Fig. 3. Cutaneous Vascular Responses. -Diagram showing the relative intensity
and persistence ofthe red response to standardized mechanical stimulation in different regions on left and right sides ofthe back. The thin lines represent
feeble and short-duration responses in corresponding strips ofskin. Evidence discussed later indicates high vascular tone in these areas. Fig. 4. Activity
of the Spinal Extensor Muscles. Simullaneous electromyographic activity ofthe spinal extensor muscles al the segmental levels recorded while the
subject is standing quietly.
sensory and the autonomic, might
also be maintai ned i n a state of
hyperirritability and hyperactivity.
8 1 1
The sensory component s were
evaluated through measurement of
cutaneous pain thresholds i n various
derma tomes and through mapping
areas of cutaneous and deep hyper
esthesia. The autonomic component,
l i mi ted in t hese s t udi es to t he
sympathetic division because of i
t
s
segmental di st ri but i on, has been
e
v
aluated through measurement of
the activities of the sweat glands and
blood vessels of the ski n. That i s,
these cutaneous structures served as
physiologic i ndicators of the activity
of the sympathetic outflow to the cor
responding areas or segments.
EVidence for hyperirritability of
sensory pathways was found i n the
presence , i n most s ubj ect s , of
persistent areas of l owered pai n
threshold and of tenderness. For the
testing of sweat gland activity we
turned at first to the measurement of
the electrical resistance of the ski n. 8
Ski n resistance had been shown by
others to be lowered by sweat secre
tion and elevated in its absence. (See
Reference 1 2 for references.) The
possi bi l i ty of l ocal or segmental
hyperirritable sympathetic pathways
was first suggested by the finding of
areas with consistently l ow electrical
skin resistance i n most subjects, even
150
under cool resting conditions, when
sweat gland activity was generally
absent. It was also suggested by the
related and persistent areas of rela
tively cool skin and other signs of
high vascular tone.
l l
An ill ustrative case
The ki nds of patterns with which we
are concerned, and their interrela
tionships, wi l l be i l l ustrated on a
si ngle subject. This patient, whose
cl i ni cal status i s not relevant to
this purpose, was explored with the
various methods over a period of
many months during which time the
patterns remained remarkably con
stant . A sample of each of the kinds
of patterns is shown i n Figures 1 -4.
Figure is a diagrammatic repre
sentation of the distri bution and
relative severity of osteopathic lesion
pathology as determined i n a palpa
tory examination by Dr. Denslow.
Especialy conspicuous are the severe
lesions in the lumbrosacral bilateral
ly; the l umbar area, especially on the
right side; and the midthoracic levels
on the right side. The cervical lesions
will be disregarded for this purpose
because the physiologic tests were
l i mited to the thoracic, lumbar, and
upper sacral segments.
The presence of a sensory com
ponent i n relation to this lesion
pathology was manifest in the deep
hyperesthesia present in the same
areas. Measurements by the thermal
radiation method i n our labora
tories showed lowered cutaneous pain
thresholds i n essentially the same
areas.
Figure 2 shows the electrical skin
resistance (ESR) pattern of this
subject as photographically recorded
with an early model of the automatic
dermohmeter developed in our lab
oratories.
1
4 The darkened areas on
the photograph represent the location
on the subject of low-resistance areas
of ski n, whose resistance is less
than 1 120 that of the normal, high
resistance areas, which are unshaded
in this photograph. As an indication
of the sensitivity of the method the
white areas i n this chart indicate
resistances of 20,000,000 ohms or
more, the black areas, 1 00, 000 or
less. The si mi l ari ty i n regional
distribution between the l ow-re
sistance areas and the clinically
determined are
a
s of lesion pathology
is to be noted.
Evidence for segmental l y related
di fferences in vasomotor tone is
shown in Figure 3. This is a diagram
matic representation of the red
responses of the paraspinal skin on
both sides to standardized mechanical
stroking to be discussed later. The
thin lines represent strips of skin
i n which the red, vasodilatation
I nterpretation of research

response was weak, suggesting sus

tained vasospasm in these areas.
Certainly the asymmetries in skin
temperature which we have repeated
ly observed and in vascular response
between right and left side of the
same segments suggested disturbed
vasomotor activity in these areas.
Figure 4 represents an elect rom yo
graphic study of the simultaneous
activity of the paravertebral mus
culature in this subject at the various
segmental levels during quiet stand
ing. The asymmetrical and exag
gerated muscular contraction to be
noted in the lumbar and upper and
midthoracic levels indicates hyper
activity of segmental motor pathways
at these levels.
This study was selected out of hun
dreds not because it is typical, but
because of the unusually high degree
of topographic relationships among
the sensory, autonomic, and motor
patterns and their relation to the
lesion pattern, which greatly simplify
the presentation of the principles
involved. The topographic relation
ships between cutaneous (autonomic
and sensory) features and the myo
fascial may not always be expected to
be so close because of the differences
in peripheral distribution of nerve
supply, even from the same segment,
to skin, to muscle, fascia, et cetera.
The case does
s
erve to illustrate
some of the kinds of measurements
and patterns with which we deal. It
also serves to illustrate a generaliza
tion which began to emerge from our
explorations of large numbers of
subj ect s . ' In t he most ' con
spicuously aberrant segment s, as
indicated by our methods, the devia
tions have consistently been in such a
direction as to indicate increased
irritability of at least some repre
sentatives of each of the kinds of
nerve cells - sensory, motor, and
sympathetic - arising in that part of
the nervous system.
The next problem: the meaning of
the patterns
There can be little doubt that there is
increased irritability of the sensory
and motor pathways in aberrant seg
ments. The findings of low electrical
skin resistance, low skin temperature,
and feeble red responses suggest that
the same may be true for the sym
pathetic pathways. This, however,
is by no means established by the
measurements t hemselves . The
assumption that the measurements
reflect differences in neurogenic
sweat gland and blood-vessel activity
would first need to be proved valid.
The existence of hyperirritable or
facilitated sympatheti c' pathways
would, of course, have very rich
fundamental and clinical implica
tions.
Intriguing indications that such
implications could often be attached
to the areas of low electrical resis
tance began to emerge from our
explorations of large numbers of
subjects, both patients and appar
ently healthy individuals.9,
1
0 In a large
percentage of patients segmental
relations were established between the
pathologic organ or structure and the
areas of low ESR. Segmental rela-
. tions between the pathologic tissue
and the skin resistance pattern were
by no means always clear, but the
relations were especially sharp in
those entities in which there was a
pain component.
Even more exciting implications
. began to emerge after several years of
exploring large numbers of appar
ently healthy persons including many
of our students. In a growing number
of such individuals, signs and
symptoms of visceral disease (for
example, coronary artery disease and
peptic ulcer) appeared months and
years after the demonstration (or first
appearance) of prominent areas of
low electrical resistance in derma
tomes related to the involved viscera.
(Some of these symptom-free subjects
who later developed visceral disease
had had pre-existing skin resistance
patterns resembling those found on
patients with similar diseases. ) In
other subjects symptoms and disease
in somatic or visceral structures
segmentally related to the low
resistance dermatomes appeared for
the first time (or intermittently)
following periods of severe stress,
such as final examinations, systemic
infections, and emotional conflicts.
In still other subjects we were able
to demonstrate that new and promi
nent areas of low electrical skin
resistance could be induced ex
perimentally by acute stresses and
myofascial irritations and acci
dentally as a result of trauma.
3IO
These observations were strong as
surance that the persistent area of low
electrical resistance, whatever i ts
basis, is a functionally and clinically
significant sign and that it marked, at
least in some cases, physiologically
abnormal and relatively vulnerable
segments of the body. These observa
tions, therefore, justified a deeper
and more thorough investigation of
the basis and meaning of the cutane
ous electrical resistance and vascular
patterns.
In order to establish whether the
low skin resistance, low skin tempera
ture, et cetera truly represent local or
segmental facilitation of sympathetic
pathways, with all its functional and
clinical implications, we needed the
answers to the following questions.
l . Do the ski n resistance and
vascular patterns reflect neurogenic
variations in submotor and vaso
motor activity?
2. Are the sympathetic pathways .
to the lesioned or low-resistance areas
more easily opened and sustained in
activity by stimuli and factors operat
ing in daily life?
3. If these are answered affirma
tively, does the local sympatheti
cotonia extend also to structures
other than the sweat glands and
cutaneous vessels?
The following two papers, based
on recent studies,
1
S

1
7
illustrate our
investigations of these questions and
some of the answers obtained. As so
often happens in basic research, in
the course of further testing the
hypothesis of facilitation, we also
learned a great deal more about it
and its meaning to the living man.
The studies on the sweat glands are
discussed in the next paper.
Reprinted by permission from "Symposium on the
Functional Implications of Segmental Facilitation".
from JAOA54: 265268, 1955.
151
Clinical significance of the facilitated
state (1955)
It appears from studies such as those
that have been presented, in which
certain sensory. motor, and auto
nomic characteristics are measured
on or near the surface of the body,
that:
1 . Aberrant segments of the spinal
cord occur in most individuals, in
cluding apparently healthy persons.
2. These segments are abnormal in
their tonic activity and in their
responses to various stimuli.
3. In these segments at least some
of the neurons mediating sensory,
motor, and autonomic function are
maintained in a state of hyperex
citability, which they manifest in their
easier, augmented, and prolonged
responses to impulses reaching them
from many sources.
4. They are therefore susceptible to
sustained and exaggerated activity
under conditions of daily life.
5. The infuence normally exerted
by these neurons on the tissues which
they innervate may thereby be exag
gerated.
6. These segmental disturbances
appear to be physiologic lesions
related, by nature and location, to the
clinical phenomena designated as
osteopathic lesions.
Since our experiments showed that
the pathways through these segments,
including those of the sympathetic
outfow, were more easily "opened"
and sustained in activity, these obser
vations further strengthen and enrich
the hypothesis of chronic segmental
facilitation thought to be associated
with the osteopathic lesion.
8
,7s,76 What
does facilitation mean, functionally
and clinically? In general, it means
that the tissues innervated from the
lesioned segment, and therefore the
individual as a whole, are sensitized
to all the infuences operating within
and without the individual.
Facilitation of the sensory path
ways in the disturbed or lesioned
segments means that there is easier
access to the nervous system - in
cluding the higher centers - through
these segments. The lesioned segment
is one through which environmental
changes - especially noxious or
painful stimuli - have exaggerated
impact upon the man.
152
Facilitation of motor pathways
leads to sustained muscular tensions,
exaggerated responses, postural
asymmetries, and limited and painful
motion. Since the muscles have rich
sensory as well as motor innervation,
under these conditions they and re
lated tendons, ligaments, joint cap
sules, et cetera may become sources
of relatively intense and unbalanced
afferent streams of impulses.
The physiopathologic effects of
facilitation of local sympathetic
pathways depend, of course, on the
structures which are innervated by
those pathways; that is, which
viscera, which blood vessels. which
glands. Our studies showed the ex
istence of facilitated sympathetic
pathways to the sweat glands and
blood vessels in the skin innervated
from the disturbed segments and illus
trated the effects of such facilitation
on their functions and on their re
sponses to impulses arising in various
receptors and in the higher integrative
and cerebral centers. It is important
to determine whether these cutaneous
signs are indicative also of facilitation
ofthe sympathetic pathways to other
organs, tissues, and blood vessels in
nervated from the same or related
segments.
Significance of cutaneous signs of
local sympatheticotonia
Experimental studies designed to
clarify this question are now in prog
ress in relation to the kidney. As yet,
the evidence. mainly clinical and pre
sumptive, is strong ( 1 ) that local sym
pathetic hyperactivity refected in the
skin may be associated with sym
pathetic hyperactivity in the viscera,
(2) that the cutaneous manifestations
are associated with disturbances
elsewhere in the segment, and (3) that
local sympathetic hyperactivity is an
important factor in disease. This evi
dence will be briefy summarized.
1 . As stated in the introductory
paper of this symposium, prominent
areas of low ESR are often found in
dermatomes segmentally related to
pathologic viscera. Hyperhidrosis in
dermatomes related to pathologic
viscera has also been demonstrated by
others.77,7
8
2. In a significant percentage of ap
parently healthy subjects, prominent
areas of low ESR marked segments in
which overt disease later appeared or
which were especially susceptible to
disturbances under stressful condi
tions.
3 . Clinical reports are rapidly ac
cumulating in the literature that many
serious clinical entities are associated
with local autonomic imbalance i n
t he direction of sympatheticotonia
(even when the manifestations of the
disease are those which would be
simulated in experimental animals by
parasympathetic stimulation). Symp
tomatic relief, lasting improvement,
and even "cures" have been achieved
through surgical, pharmacologic, or
other blockades of the sympathetic
pathways to the involved organs .7
9
-88
4. A number of visceral and other
chronic diseases

appear to begin as
ischemic states of the involved tissues
due to local neurogenic vasospasm.
This vasospasm seems to be of sym
pathetic origin and is also associated
with vasospasm (pallor, hypother
mi a) in related segments of
skin.
33,34,
6
8-
7
0,8
9
-
9
1
5 . It appears well established
through clinical and experimental in
vestigations that the vasomotor
responses in skin and in viscera are
quite parallel. Stimuli which elicit
vasoconstriction in one, commonly
do so in the other also.
8
9
9
2-
9
6 (This is
the pattern, of course, associated
with diffuse sympathetic activation,
for example, in muscular efforts and
in certain responses to intense envir
onmental or emotional stimulation,
when blood is shunted from viscera
and skin to the skeletal muscles. )
I t appears certain, therefore, that
the facilitation of local sympathetic
pathways to the skin, such as that
demonstrated in our sweat gland and
vascular studies, is commonly part of
a generalized sympathetic hyperir
ritability affecting other tissues inner
vated from related parts of the ner
vous system. It appears equally cer
tain that the resultat sustained loca
sympathetic hyperactivity has con
siderable clinical significance, many
diseases, especially of the chronic
degenerative type, being associated
with, and perhaps ascribable to,
hyperactivity of the sympathetic in
nervation of the affected organs and
of somatic structures refexly related
to them.
Interpretation of research
Why is the exaggeration of sym
pathetic infuence so dangerous and
so frequently an etiologic and con
tributory factor in disease? Normally,
the sympathetic nervous system plays
a most important role in organizing
the adaptive and protective adjust
ment of the body's resources to en
vironmental variations and extremes,
to muscular work, to emotional stress,
to alarm, et cetera. It suppresses the
activity of internal organs not im
mediately involved in the emergency
action and shunts the blood supply
from these organs and from the skin
to the skeletal muscles. But high
levels of sympathetic activity normal
ly occur only intermittently or for
relatively brief periods. When,
however, such sympatheticotonia -
whether local or general - becomes
sustained, then the associated reduc
tion in visceral blood flow, inhibition
of seretory and smooth-muscle activ
ity, spasm or sphincters, et cetera,
eventually result in some damage and
dysfunction of the affected organs
and in disturbance of the entire body
economy.
Nature, origins, and significance of
segmental sympatheticotonia
Our laboratory observations and the
many years of clinical observations in
osteopathic practice appear not only
to have established that the osteo
pathic lesion represents such a state
of local sympatheticotonia, but they
also extend our understanding of its
nat ure, OrI gms , and cl i ni cal
significance.
In the background of the available
knowledge, our studies indicate that
under conditions of daily life there
may be steady streams of impulses
flowing o
u
t of the facilitated seg
ments through the sympathetic path
ways to the structures which they in
nervate, beyond - or in confict with
- demands made by the homeostatic
mechanisms. Under circumstances in
which sympathetic activation or
dinarily occurs, the "drive" through
the facilitated segments is initiated
earlier, reaches higher intensities
sooner, and is sustained longer than
in others. Under conditions of
chronic
'
environmental or emotional
stress, for example, the deleterious in
fluences will be preferentially focused
upon and channelized through the
facilitated segments.
The lesioned segment, therefore, is

one which is continually in, or bor

dering on, a state of "alarm";
according to our sudomotor and
vasomotor studies, it seems literally
to be in a "cold sweat. " In such a seg
ment, since the "emergency" sympa
thetic mechanisms are frequently
operating even under "resting"
conditions, since they rapidly ap
proach maximum activity under mild
stimulation and since they may be
maintained near maximum activity by
taxing life situations, the margin be
twen resting and maximum levels is
narrowed; in short, the physiologic
reserve is reduced. As our studies on
the skin show, the burden of compen
sation is thrown on the other seg
ments and organs. The total resources
of the individual himself are thus im
paired.
Whether or not overt disease devel
ops depends, of course, upon the
total resources of the individual and
the demands made upon them. The
greater the demands made, by the
total environment or by the in
dividual himself, in relation to his
resources, the greater the invasion of
physiologic reserve and the higher the
probability th
a
t the lesioned, facil
itated segment will become the de
cisive factor limiting the adequacy of
those resources; the greater the cer
tainty that the tissues of the facil
itated segment will be impaired and
damaged by the exaggeration of sen
sory, motor, and sympathetic in
fluences; the greater the probability
that disease will start in, or through,
the facilitate segment or in the meh
anisms which carry the burden of com
pensation.
The precise syndromes which may
develop from the deleterious in
fluence of sustained sympatheti
cotonia will, of course, be determined
by the primary target organs, which
in turn will be determined by the loca
tion of the segments which have
become facilitated. The same distur
bance, therefore, through action
upon different tissues, may have a
large variety of manifestations.
It is important to recognize also
that the manifestations may change
with time. For examples, certain
preliminary observations made by us,
which are richly confirmed by obser
vations made by many other investi
gators, suggest that in the chronic
state the peripheral mechanisms may,
as it were, "fatigue out"; the
hyperhidrosis may give way to
hypohidrosis; the vasospasm may
give way to vasomotor atonia, with
stasis, engorgement, inflammation,
edema, et cetera. 17 That is, in the
' chronic state, when degenerative
changes threaten, the initial sym
patheticotonia may be masked.
The matter of changes associated
with chronicity merits at least brief
examination, since some of the mani
festations of long-sustained sympa
thetic hyperactivity are such as to give
the unwary physician etiologic and
diagnostic clues and, therefore, false
guides to therapy. In the chronic state
the sustained sympatheticotonia, with
its associated ischemia and trophic
changes, may have so altered the
character of the tissue and its
responses to normal nervous and hor
monal factors as to make it an
unreliable indicator of these factors.
Excessive sympathetic activity, by in
creasing the sensitivity or responses
of the organ to normal parasympa
thetic stimulation, may, as in peptic
ulcer and other entities, actually
simulate parasympathetic hyperactiv
ity (that is, the responses to experi
mental stimulation of parasympathet
ic nerves in animals).
Moreover, the evidence is now
quite convincing that local sympa
theticotonia may actually produce
parasympathetic disturbances. Two
basic mechanisms are indicated: (l)
Through (sympathetic) vasomotor
fibers controlling blood flow through
the parasympathetic cranial and
sacral nuclei and parasympathetic
nerve trunks, and (2) alteration of the
tissues so that the afferent discharges
from these tissues to parasympathetic
centers will also be altered. Such false
and unbalanced "signals" from these
tissues will disturb the regulatory
parasympathetic reflexes and mask
the, original sympathetic manifesta
tions. The effects, through both
mechanisms. may be so remote, seg
mentally. from the site of the sympa
theticotonia as to obscure the rela
tionship.
Similar relationships apply with re
spect to the endocrines. Not only does
sustained sympatheticotonia alter the
responses of tissues to the circulating
hormones, but ischemia of any endo
crine gland, due to local sympatheti
cotonia, may produce widespread
and remote effects which do not show
their prhary sympatheti origin.
15J
There is little doubt, therefore, of
the serious and protean manifesta
tions of sustained local, regional, or
segmental sympatheticotonia. What
are its origns? Thee are fairly accept
able theries offere in the literature
to explain generalized sympathetico
tonia, as in anxiety states, certain
types of hypertension, and hyper
thyroidism, and most are based on
disturbances of the higher centers, of
general metabolism, or of one or
more of the endocrine glands. Few
satisfactory hypotheses are offered,
however, in explanation of the local
ized sympatheticotonia of a few
seleted segments of the nervous sys
tem. What can our growing know
ledge about the osteopathic lesion
contribute to our understanding of
the origins of segmental sympatheti
cotonia?
On the basis of available knowl
edge regarding the related reflex
mehanisms it apprs that the seg
metal sympathetic hypactivity orig
inate as prt of a highly organize
refex response, organized at the
spinal cord level; that the response is
set in motion by certain forms of sus
tained irritation arising in one or
more tissues innervated from the cor
responding segment; that this affer
ent irritation facilitates the mainte-
nance and exaggeration of impulse
traffc in the sensory, motor, and
autonomic pathways which originate
in this segment; that such exaggerated
traffc may be produced and sus
tained in these facilitated segmental
pathways by impulses reaching the
segment from any source. Perhaps
because of this neurologic focusing
that takes place through the facili
tated segment and because of the as
sociated tisue changes and activities,
the refex process, once initiated, sus
tains itself even long after the original
facilitating factors may have passed.
The facilitating factors may arise in
individual tissues or organs ( 1 ) which
have been directly subjected to in
jury, stress, or irritation or (2) to
which irritations or excessive and pro
longed demands have been directed
by the total response of the individual
to life situations and environmental
factors.
Many possible initiators of such
local disturbance have been postu
lated and some of them, certainly, are
valid. However, one of osteopathy's
major contributions to the biological
15
and medical sciences is the demon
stration that factors which evoke the
segmental responses arise with very
high frequency in the weight-bearing
or axial portions of the musculo
skeletal system.
The somatic component
Man's musculoskeletal system is an
incomplete and imperfect -certainly
an unstable - adaptation of a basi
cally quadruped system to biped
stance and locomotion. The compo
nents of a perfect cantilever bridge
have been somewhat rearranged and
modified by evolutionary process to
form a less adequate skyscraper.
There is no doubt that gravity is far
more demanding of man's resources
than of other mammalian species. As
a result, local postural stresses, asym
metries, myofascial tensions and irri
tations, and articular and peri-artic
ular disturbances have a peculiarly
high incidence in man. Their prob
ability, always high, increases with
time. In man, therefore, gravity has
become an environmental factor of
great importance to his health.
Man's responses to gravitational
factors - the postural and righting
reflexes - though adaptations of
those inherited from lower-form
ancestors, are characteristic of man
the species. They are, however, in
dividually modified by many of the
factors which distingish one individ
ual from another and by circum
stance. Although foci of musculo
skeletal stress or irritation may rise as
the direct result of injury to specific
areas, they develop mainly as part of
the body's total adaptation to the
erect posture. The parts of the
musculoskeletal system which, in
each individual, are especially taxed
in the maintenance of the erect, level
eyed posture, will be largely deter
mined by factors of physical configu
ration, attitudes, habits, occupation,
activities, and environment and by
the inherent and developing defects,
asymmetries, and anomalies.
In the musculoskeletal stress, then,
we have identified a very frequent ini
tiating factor, to which man is pecu
liarly subject, to help account for the
local sympatheticotonia found to be
associated with, and contributory to,
so many apparently different chronic,
functional disorders, to which man
appears also to be peculiarly suscep
tible. As will be shown, however, the
significance of the musculoskeletal
component in disease is not solely in
the initiation of the local autonomic
imbalance.
It appears inadequately understood
that the pain, tenderness, muscular
rigidity, and autonomic disturbances
individually recognized as manifesta
tions of pathologic processes are the
interrelated components of a complex
response organized by the central ner
vous system. As was previously
stated, the evocative factors which set
in motion the segmental response
may arise in any tissue or organ as a
result of insult to it or excessive de
mand upon it. The response - orga
nized via the triad of nervous in
fluences (or possibly a tetrad if the
trophic functions are included) - is
basically the same for all and extends,
to some degree, to all the tissues,
somatic and visceral, directly related
to the corresponding part of the ner
vous system.
1b
'

Through the reciprocity of in

fuences between visceral and somatic
tissues via the central nervous system,
visceral pathology produces distur
bances in musculoskeletal structures.
This is recognized in the concept of
the secondary, refex osteopathic le
sion and in the "splinting" associated
with painful visceral syndromes.
From clinical practice and from nu
merous studies on such phenomena as
referred pain, viscero-somatic re
fexes, trigger zones, et cetera, the
evidence is convincing that visceral ir
ritation commonly initiates, through
reflex pathways, the triad of sensory,
autonomic, and motor changes in the
somatic tissues, of which a conspicu
ous feature is muscular rigidity and
tension.
It needs to be emphasized, how
ever, that the tender, hypertonic
muscles in the reference zone are not
merely the reflex maniestations of
visceral irritation. They and the asso
ciated articular and periarticular
structures become active participants
in the disease process itself as they
give rise to disturbed patterns of
afferent (proprioceptive) bombard
ment of the central nervous system
which sustain and exacerbate the dis
turbance in a vicious, self-propelled
circle of impulses. In the vertical
stance the reflex somatic disturbance
is even further intensified under the
impact of gravitational stress, tending
further to promote the disease pro-
Interpretation of research
cess. The total postural response of
the patient to gravitational factors is
altered, new compensations are ex
acted, and new stresses set up.
The musculoskeletal component,
therefore, is not only an important ini
tiating factor for the facilitated, sym
patheticotonic state, but also a sus
taining and exacerbating factor even
when secondarily induced. Through
the inevitable participation of the
somatic component, especially that
portion in the axial, weightbearing
portion of the trunk, the pathways
through the disturbed segments of the
cord are maintained in the facilitated
state, subject to the exaggerated im
pact of factors within and without the
individual, including that of gravity.
Conclusions
In this section we endeavor to sum
marize briefly the etiologic, diag
nostic, and therapeutic implications
of these findings and conclusions.
Testimony to the basic soundness of
the etiologic concept is that guides to
diagnosis and therapy flow directly
from it.
Etiologic implications
1 . The "osteopathic lesion, " as
identified by palpatory and other
clinical criteria, is the local or
regionally discrete somatic compo
nent of a reflexly organized and sus
tained response to stresses, irrita
tions, and excessive demands placed
upon specific tissues or organs by the
environment and by the total activi
ties, responses, and adaptations of
the individual.
2. Because of the sustained facilita
. tion of sensory, motor, and autonom
ic pathways, the lesioned segment
acts as a neurologic lens, 7 1 focusing
and exaggerating the effects of im
pulses from many sources upon the
tissues innervated from that segment;
through that segment the individual is
subject to the exaggerated impact of
life situations and environmental fac
tors. To the facilitated segment and
the structures which it supplies and
therefore to the organism as a whole,
even ordinarily innocuous life situa
tions become relatively stressful and
taxing and many continually demand
and evoke the costly, reserve
reducing protective response.
3. As a special corollary of number
2: Among the source of impulses
which exact exaggerated toll of tissues
through facilitated segments are the
higher cerebral centers. The osteo
pathic lesion is unquestionably an
important determining factor in the
bodily expression of emotional ills,
conflicts, and tension.
4. The local initiating stresses, in
man, arise most frequently in the
musculoskeletal system because of his
incomplete adaptation to the vertical
st ance and as part o f each
individual' s postural adaptation to
gravitational factors.
5. Regardless of the mode of initi
ation, however, a somatic component
is reflexly established which reflexly
exacerbates and sustains the facil
itatory process and sensitizes every
disease process to the influence of
gravity.
6. The local or segmental sympa
theticotonia and neurovascular dis
turbances, increasingly recognized as
contributing to endogenous chronic
diseases, appear to be a prominent
part of this general process.
7. According to conclusions num
ber 2 and 3, whether or not and the
rate and degree to which disease
develops through the facilitated seg
ment, will be determined by the total
demands upon the individual and by
the other factors - psychologic, nu
tritional, social, hereditary, age, et
cetera - which influence his total
adequacy. We have, therefore, an
important reciprocal relationship in
which the osteopathic lesion in
evitably impairs human adequacy to
some extent, while the importance of
the lesion to the individual is deter
mined by his total adequacy to his
total environment and to the life
situations he encounters and creates.
The lesion increases the importance
of every stress and every defect; every
stress and every defect renders the im
portance of the lesion more critical.
8. Since the response to local stress,
irritation, or excessive demand is
basically the same - through the
triad (or tetrad) of nervous influences
- the potential clinical manifesta
tions will be determined by the seg
ment involved - and its associated
tissues -rather than by the nature of
the insult ("etiologic agent") itself.
The same process, acting through dif
ferent segments and tissues, produces
a variety of syndromes. The location
of the lesion determines the target
organs and therefore the potential
"diseases. " Since the location of the
lesions ansmg
i
n adaptation to the
erect posture is significantly infu
enced by bodily confguration, this ap.
pears to be an important factor in the
relationship between body type and
the incidence of various diseases.
Diagnostic implications
On the basis of the etiologic signifi
cance of the lesion just outlined, the
finding of an osteopathic lesion
marks a segment in which, or through
which, the probability of disease is
relatively high. At best the lesioned
segment is a vulnerable segment, ex
acting compensations from the entire
organism; at worst, it signifies that
decompensation has already ensued.
Whereas most diagnostic proce
dures available today detet that pres
ence of disease proceses only after
some degree of decompensation has
occurred, recognition of the osteo
pathic lesion reveals early invasion of
physiologic reserve and predispo
sition to disease. Osteopathic lesions
appear to be or to reflect the "silent,
insidious, fifth column disorders"
which leading medical thinkers have
concluded need to be sought "in ap
parently well people" 99 and which are
the earliest vanguards of chronic
disease.
Theraptic impliction
1 . Aside from palliation, therapeu
tic attention must obviously be given
to all the controllable factors in and
around each patient which infuence
his total fitness and resources.
2. Because the facilitation associ
ated with the osteopathic lesion in
creases the vulnerability of the in
dividual to all factors, decisive,
critical importance should be at
tached to the treatment of osteopathic
lesions.
3. Since all existing lesions impair
the resources of the ill patient for fur
ther resistance and recovery, regard
less of their apparent etiologic rela
tion to the illness, no therapy can be
complete without the maximum liber
ation of those resources.
4. Whereas, in nonosteopathic
practice, the treatment of local or
segmental autonomic imbalance or
dinarily requires the diffuse alteration
of autonomic activity throughout the
body, treatment of the lesion offers a
specific approach to the local autonom
ic disturbance associated with many
chronic diseases.
155
5. The direct participation of the
somatic component in basic responses
to disturbing infuences, its accessi
bility, and its repnsiveess to ap
propriate therapy render it a direct
and strategic instrumentality through
which to modify the response (the
disease process) and to augment the
individual's capacity for response,
resistance, recovery, and adaptation.
6. In conclusion, since the osteo
pathic lesion both reflects and in
fuecs the adeuacy of the individ
ua's reerves and reourcs, because
it reflects and influences the adequacy
of his responses to the demands of
life, and because it reflects and in
fluences his vul nerability and
predisposition, early diagnosis and
treatment of the osteopathic lesion
offer a direct and systematic ap
proach to the prevention of chronic
disease for which, as far as we can
tell, there i,s as yet no substitute.
The origins of the lesion, the pro
cesses with which it is associated, and
their implications to man's health
have hardly begun to be explored.
This is the major challenge before the
osteopathic profession today.
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157
Osteopathic research: Why, what, whither?
An examination of its content, direction, and relation to the
function of osteopathic medicine* (1955)
During much of the life of the osteo
pathic profession, the bulk of its re
sources and its energies as an orga
nized profession has been devoted to
winning the rights to practice and to
teach according to its own principles
and to developing the facilities and
personnel for carrying out those two
functions. In the face of the profes
sion's limited resources, only relative
ly slight attention has been given in
the course of this struggle to further
exploration and development of oste
opathy's special contribution -of its
principles, of the biologic phenomena
with which it deals, and of the prac
tical implementation of those prin
ciples.
This struggle for recognition and
rights to extend and deliver its ser
vices is rapidly approaching victory.
More and more material and human
resources can therefore be liberated,
and more and more become avail
able. for pursuit of the relatively
neglected phase of professional life -
research and development at the sci
entifc and clinical level. It is there
fore timely, indeed urgent, that the
osteopathic profession thoroughly ex
amine its obligations and its oppor
tunities in this area. This paper is in
tended to be a small contribution to
this exploration. In the available
space we can only identify some of
the key questions and indicate some
of the dire
ctl
ons in which to seek the
answers.
The "why" of my three-part ques
tion is related to the importance
which is attached by the profession to
the accumulation of new knowledge
and understanding for the fulfillment
of its function. The "what" of
osteopathic research is determined by
what the profession considers to be its
function and the nature of the osteo
pathic contribution. The "whither"
- the direction of osteopathic
research - is inseparable from the
"what" and will be determined by the
long-term objectives which the pro-
B on a talk presented at General Sessions. An
nual Convention of the American Osteopathic
Association. New York City. July 1 7. 1 956.
I58
fession declares for itself in service to
society and by the direction of the
progress which it aspires to make.
Research and the function of
osteopathic medicine
The Purpose oj Research.
Why should the osteopathic profes
sion now turn all possible resources to
research? Let us immediately elimi
nate answers too frequently given or
implied. Research is not done to im
press, to win recognition, prestige, or
financial support or even to prove
one's contentions. Welcome as these
may be as by-products of good
research, when they become the
primary objectives of research they
defeat its very purpose. Research has
only one purpose: the securing of
reliable information and understand
ing about those aspects of nature in
which one is interested or in which
one seeks greater power of prediction
and control - in this case, human
health and disease.
It was so well expressed by Francis
Bacon three and a half centuries ago:
"Human knowledge and human
power are coextensive; for ignorance
of causes prevents us from producing
effects. Nature can be ruled only by
being obeyed; for the causes which
theory discovers gives the rules which
practice applies. " For nature to be
obeyed - and thus ruled - it must
first be understood. Today, it is
almost universally agreed that the
road to control over human health
lies only through widening and
deepening of our basic knowledge of
human nature and human biology in
all their aspects. The only debate, in
view of the increasingly pressing
problem of human disease, is around
this issue: Of what does "control"
consist, in what direction does it lie,
and through which of the unexplored
fields of basic knowledge is the route
most certain and direct?
The debate ojthe issue.
It is around this issue and around this
issue alone that divergent schools of
medical thought arise. The differ-
ences are usually of such a nature that
they are, as a matter of course,
debated and tested within the ex
isiting school or schools of medicine.
However, a school of thought, con
vinced of its essential validity. may
find it necessary to organize itself into
a new profession - a separate school
of practice - when its position on
this issue is dismissed without con
sideration by the existing schools of
medicine, when the existing schools
will not debate the issue or, as is most
usually the case, when they do not
even recognize the existence of an
issue. This is the only reason for the
existence of the osteopathic profes
sion. Its hypotheses, only superficial
ly . examined, were dismissed as
dogma and its practice as cultist.
Need and justification for a separate
school of medicine continue as long
as the issue remains and as long as
that school's approach is not ade
quately considered, tested, or applied
by other schools.
The profession fulfills that need -
and therefore j ustifies its continued
existence -only so long as it assumes
full responsibility for the application
of its approach and methods in prac-
. tice, for training succeeding genera
tions of physicians for such practice,
and Jor continuous eploration and
development through research. It
must continue those responsibilities
until such time as the prevailing
school of medicine is prepared to ac
cept at least the potential validity of
the osteopathic approach and to as
sume or share these responsibilities.
This, however, will involve a basic re
orientation of medicine to a different
viewpoint - or at least to the incor
poration of a different viewpoint -
from that which it appears to reflect
today. That day is not yet here, but it
is on the way. The osteopathic move
ment is successful to the degree that it
hastens that reorientation.
The precious drop in the ocean.
Research - of the largest possible
scope -is an inescapable responsibil
ity of the profession because a vast
amount of knowledge and under
standing remains to be disclosed and
developed which is absolutely in
dispensable to the doing of the job
which the profession has set itself -
and for which it came into existence.
We must frankly face the fact that ad
vances in understanding and control
Interpretation of research
of factors and phenomena to which
osteopathic medicine ascribes critical
importance have been minute as com
pared with biologic and medical ad
vance in general, and, indeed, as
compared with the advances of the
osteopathic profession itself. As was
stated at the convention of this
Association 8 years ago:
The time has come . . . when increasing at
tention must be given to the theoretical reserves
upon which continued technical advance is
predicated. For many reasons these reserves
have been consumed far more rapidly than
they have been replenished. In osteopathy, as
in all technological aspects of modern life,
large backlogs of fundamental information
must b maintained and enlarged if continued
practical advances are to be assured. They are,
indeed, the springs from which the advances
fow. '
The following protest may be
made, as it has been, by some who
continue to view research as a luxury
ill-afforded by the osteopathic pro
fession, rather than as an inescapable
obligation and opportunity: They
point out that a tremendous volume
of medical research is already in pro
cess throughout the world involving
investments of billions of dollars and
tens of thousands of individuals
working in thousands .of institutions.
They remind us that much of the
product of this research is available
to, and incorporated in, osteopathic
education and practice. The contribu
tion made under osteopathic auspices,
even under the best of circumstances,
can be but a drop in that vast ocean.
Of what importance can that drop -
or any drop - be in such an ocean?
In the first place, total research
progress is made up of countless con
tributions ranging from minute in
scale to grand in magnitude. Second,
while some kinds of investigations
can be conducted only on the grand
scale and while, given other essential
factors, the more the research the
faster the progress, magnitude is not
what counts. It is one or more of such
elements as the following that give
importance to any research and its
products: the significance of the con
tribution, its total impact on knowl
edge, the meaning it imparts to a
previously accumulated mass of
facts, the clarity it brings to an area
of confusion or ignorance, its cata
lytic effect on the growth of under
standing, the breadth of general
ization it makes possible, the number
and importance of peripheral prob
lems whose relations it reveals and
to whose unified comprehensive solu
tion it offers an approach, the new
problems it raises and the new in
quiries it stimulates, the new or re
fined control and prediction it makes
possible. In short, important as is the
scale of operations, what counts is the
magnitude of the secrets that the re
search unlocks - the unraveling it
makes possible.
We may draw a simile from re
search and technology themselves. It
requires but one crystal, of special
nature, at the right time, under the
proper circumstances, to release from
solution, for harvesting, precious
crystals of enzyme, hormone, or virus
hidden within an accumulation of
complex amorphous extracts. It re
quires but a relatively minute quanti
ty of chemicals, of proper nature, to
clarify a large body of turbid water
and thereby reveal new worlds of phe
nomena and previously unseen rela
tionships.
And so it is with research.
"Drops" of research have again and
again in the past clarified vast reser
voirs of accumulated knowledge,
brought new areas to light, given new
meaning to old areas, and revealed
that many apparently unrelated is
lands of knowledge were but the
s
uperficial projections of a common,
deeper-lying base. The research must
ask totally new questions of nature or
old questions in a new way.
Osteopathic research is concerned
with areas not now recognized or ade
quately explored by others, and with
unrecognized connections among
areas that are being explored. It does
ask a new kind of question and there
fore seeks different kinds of answers.
These answers have a special and
urgent pertinence to human health at
this particular stage of civilization.
Questions and answers: unaked.
unanswered.
G
ranting the importance of those
answers, it may still be protested
that their quest is an unfair and an
intolerable burden upon the profes
sion's limited resources. Why not
leave it to those who are already
richly equipped, staffed, financed,
and experienced to accommodate this
drop in their ocean?
The reply is simple. The answers
will not come unless they are sought,
and they will not be sought unless the
seeker himself asks the right ques
tions and asks them in the right way.
The answers which osteopathy seeks
cannot emerge in the course of or as
by-products of investigations into
other questions. Answers to unasked
questions are not answers at all;
answers to questions incorrectly asked
are wrong answers, regardless of
the validity of the observations or the
precision of the measurements upon
which they are based. They are only
data whose meaning must await the
asking of the correct questions. This
is what Pasteur meant by the "pre
pared mind. "
The questions which osteopathic
investigators ask and should ask
emerge from hypotheses whose essen
tial validity is demonstrated at least to
the satisfaction of osteopathic physi
cians and their patients. Were these
questions being asked with sufficient
frequency and clarity in nonosteo
pathic institutions, it could be only
because the central hypotheses con
stituting the osteopathic concept were
being given sufficient consideration
and credibility to merit further testing
and exploration. Were that true, all
need for a separate profession would
have been eliminated.
Quetions as products ofprevailng
perpctive.
Why are the questions which are cen
tral to osteopathic theory and prac
tice not being asked with adequate
frequency and thoroughness in all of
the medical research that is going on
Certainly, it is not for the want of
traditional academic freedom, the
freedom of the individual investigator
to follow his own interests or curiosi
ty.
The point is that questions asked
by individual investigators are frag
ments of the larger questions asked
by biologic and medical science as a
whole. These, in turn, to a larger de
gree than is commonly recognized,
are stimulated and formulated in ac
cordance with a prevailing, though
undefined, orientation with respect to
questions of health and disease, and
in accordance with the problems
which are identified (and the way they
are defined) in the course of clinical
practice. Each individual investiga
tion is, so to speak, an eddy current
derived from and contributing to the
prevailing wind, speeding it some-
159
what, occasionally deflecting it a
little.
The issue is not whether the pre
vailing wind is an ill wind, which it
most certainly is not, having brought,
especially during the past half-cen
tury, rich treasures of medical ad
vance and new understanding for
which all humanity is grateful. The
issue, rather, is whether enough of
the answers to human health prob
lems lie along its projected path;
whether the prevailing orientation,
central hypotheses, and objectives
point the best possible path. The os
teopathic approach represents - as
yet -a zephyr in quite another direc
tion, a basic deflection from the
original path. Its propulsive force
cannot achieve full development or be
adequately utilized until there is some
reorientation of the prevailing wind
in its direction. This can be achieved
in no other way than by objective, ir
refutable demonstration of the prom
ise that lies along the osteopathic
path.
In other words, osteopathic ques
tions are not being sufficiently asked
of nature outside of the osteopathic
profession because they do not spring
from the prevailing conceptual
framework in which medical practice
and research are oriented; the "need"
for the answers is not sufficiently rec
ognized and even the answers which
are disclosed lose meaning in the
prevailing contexts.
This is not to say that medical re
search is barren of the answers which
osteopathic investigators seek and
would seek. Nothing, as we have re
peatedly shown, l-4 could be further
from the truth. While virtually all as
pects of biology have some pertinence
to osteopathic thought, practice,
and research, medical and biologic
literature is replete also with impor
tant parts of special answers which we
would seek. But because they arise in
response to other questions, their sig
nificance is missed or altered and, be
cause the comprehensive conceptual
framework which encompasses these
fragments is not recognized, the links
among the fragments are not per
ceived and they remain miscellaneous
fragments in widely scattered fields of
investigation. When, however, the
links are revealed with the aid of a
cohesive, comprehensive framework,
these fragments are seen to represent
a major new trend in medicine - one
IW
envisioned in the osteopathic ap
proach.
Prevailing medical perspectives.
It is not possible at this time, nor am I
personally qualified, to undertake an
analysis of the basic perspectives, the
conceptual framework, the central
hypotheses, and the objectives which
appear to guide the dominant school
of medicine and which serve as points
of departure for medical investiga
tion. This has been admirably done
by a number of writers within and
without the medical profession, 5
- 1 4
and their views may be summarized
as follows.
While many i nformed medical
leaders and educators point out that it
is not enough, it is difficult to escape
the generalization that the function of
medicine is viewed as the combating
of disease. The basic strategy appears
to incorporate the following ele
ments: (1 ) the careful characteriza
tion of each disease and its manifesta
tions so that, in diagnosis, one may
be distinguished from another and
the progress and severity of each case
may be evaluated; (2) the search for
the cause or causes of the individual
diseases; (3) the identification and de
scription of the processes involved;
(4) the search for and devising of ex
pedients to attack the causes and/or
to modify the processes involved -
the more specific to the disease, the
better; (5) the alleviation of the mani
festations and sequelae of the disease;
(6) prevention of disease by specific
measures and through detection and
treatment of early signs of diseass.
The road to human health, from
this viewpoint, is in the elimination of
man's diseases, one by one, group by
group, through understanding each
more minutely. Modern medicine,
therefore, is commonly described,
sometimes in pride and sometimes in
criticism, as etiological and curative
(remedial) , with occasional specula
tive glances in what are termed eco
logical directions.
Prevailing perspectives in medical
research.
In accord with this strategy, medical
research, certainly that massive por
tion with deliberate or recognizable
clinical implications, is predominant
ly directed at understanding of the
identifiable diseases, their causes,
mechanisms, processes, and distinc-
tions and at developing technics for
recognizing, evaluating, and modify
ing them and their manifestations.
Since diseases, for the most part, are
referable to specific cells, tissues,
organs, and processes, the micro
scope of biologic and medical re
search has been turned with ever-in
creasing concentration and with more
and more minuteness and precision
upon these and their experimental
and pathologic alterations, until it
has become one of the most proudly
avowed objectives of modern medical
science to explain man and his
diseases in molecular terms, in terms
of his most elemental component
parts and processes, in terms of
physics and chemistry. 1
5
- 1
7
It would serve no useful or just
purpose to criticize these vast and ob
viously successful efforts, nor to
minimize their importance to our
understanding of life and to the con
trol of health. The only issue, again,
is whether this approach is the only -
or the best - approach to human bi
ology and to the building of human
health, indeed, to the conquest of
disease. Medical achievements of re
cent years have been so numerous and
so dramatic that the possibility of
another - let alone, a better - ap
proach hardly seems thinkable or nec
essary. The i mpli ci t assumption
prevails that we need only to pros
ecute this approach long enough and
intensively enough, and inevitably all
of the technical answers to human
health needs will come.
It is appropriate to ask, however,
as many are now asking, whether the
microscope, figuratively speaking, is
the best instrument with which to ac
quire perspective, whether minute
study of disease can ever yield a com
prehensive understanding of health;
whether the examination of isolated
factors and phenomena in controlled
experiments, ' 8 indispensable as they
are to biologic study, can ever reveal
that world of phenomena which is the
product of the uncontrolled interplay
of many factors, and in which the
biologic impact of each factor is con
tinuously modified by the changing
constellations in which it operates.
It is appropriate to ask whether
human health and its control can ever
be achieved through study of the
parts and processes, large and small,
which man shares with other animals
- without searching attention to the
Interpretation of research
peculiar demands that human life and
individual lives place upon these
mechanisms. Can satisfactory under
standing of these mechanisms in man
ever be achieved outside of their
operational context, the circum
stances under which they are required
to operate, the adaptations to which
they are required to contribute, the
abuses to which they are exposed, and
all other factors associated with
human organisms and arising in
human life? What of the peculiarly
human factors which modify and im
pair the operation of these parts, pro
cesses, integrative mechanisms, and
molecular reactions, causing health to
fail and diseases to emerge? It is
important to question whether the
road to health lies through treatment
of these diseases rather than through
control of the factors of which
diseases are the product, to which, in
deed, they are adaptations. It is ap
propriate to ask whether the most
minute study of peptic ulcer, for ex
ample, can ever do more than tell
about peptic ulcer, without revealing
what ails the man who has one, now
why is it his biologic adaptation to the
life that he lives: whether, indeed,
minute study of the ravages and
debris 0/de/eat of the human organ
ism, of the adaptations to de/eat, and
of 00the kinds 0/de/eat can ever lead
to the origins and nature of human
de/eatability and therefore toward its
control.
The relevance and validity of these
questions have become increasingly
sharp, and the etiological and
curative approach has been more and
more shaken in recent years with the
emergence of the chronic degenera
tive diseases. The chronic degenera
tive diseases have increased with
alarming rapidity as the infectious
diseases have subsided and are, as
former Surgeon General Scheele
stated, the "major front" today.
These diseases, chronic in origin as
well as in duration, are the product of
whole lives in all their aspects, the
products of inadequacy and maladap
tation of the human being to the total
life that he lives and has lived. To
view them as the "effects" of specific
"causes" which need only to be iden
tified, isolated, and destroyed and for
which "cures" only await discovery is
to deny their very nature. As Dubos
and othersl 9-21 have pointed out,
human differences are no less impor-
tant in the infectious diseases, despite
the participation of specifc, iden
tifiable causative agents.
In the face of the tremendous accu
mulation of established disease - of
"defeated" organs and tissues -
which confronts the physician today,
it is certainly his obligation to use the
best palliative, curative, and preven
tive methods at his disposal; and
under the exigencies of daily practice
this may be the only obligation he can
fulfill. Of this there can be no just
criticism. We can, however, question
wi th considerably more validity
whether research which also remains,
directly or indirectly, disease-oriented
can ever yield the comprehensive
answers which today's health needs
demand. These questions gather new
meaning as we watch the growth and
multiplication of vast research pro
grams, public campaigns , founda
tions, institutes, and departments for
the study of individual diseases or
groups of diseases, and so few for the
study of factors, features, origins,
and mechanisms which they have in
common.
The osteopathic questions.
The osteopathic orientation is implic
it in these questions. This orienta
tion is not, nor was it ever, the ex
clusive creation of the osteopathic
profession. Parts of it have been
recognized for centuries and it is
more often and more comprehensive
ly expressed today than ever before.
However, commonly as it is pro
claimed, and frequently as it is the
theme of prefaces and forewords, it
has yet had little impact on medical
practice and virtually none on basic
medical research. Its holistic, organis
mic, and ecological implications are
disdained by medical scientists, large
ly preoccupied with the "molecular"
and "microscopic" approaches, as
being more within the realm of
medical art than of science.
It is only within this organismic
conceptual framework that the con
spicuously distinctive contribution of
osteopathy, namely, the recognition
of musculoskeletal factors in health
and disease and their manipulative
management, has its meaning. Only
within this framework can it be in
telligible, interesting, and challenging
as an area for investigation. Squeezed
into the framework of etiological and
curative medicine it is (justly, in my
opinion) rejected 8 a preposterous
incongruity.
For these reasons and for others
derived from them, the biologic ques
tions which osteopathic medicine
raises -and for which the profession
came into existence -are still not be
ing sufficiently pursued in nonosteo
pathic institutions, nor are they likely
to be in the immediate future.
Because of the bearing of these ques
tions on the understanding of human
biology and on human health and its
control, it is the inescapable obliga
tion of the osteopathic profession to
pursue them with maximal and ever
increasing intensity. This is the
"why" of osteopathic research.
The content and direction of
osteopathic research
Osteopathic concepts vs. working
hypotheses.
Let us now turn to the "what" and
"whither" of my three-part question.
What is osteopathy' s conceptual
framework? Osteopathic concepts of
health and disease - as bases for
thought, teaching, and discussion and
as guides for practice - have been
stated many times in different ways.
Each physician develops his own
whether or not he verbalizes them.
For these purposes and according to
various standards, various versions
have served more or less adequately.
The greatest value, however, of any
hypothesis or body of hypotheses,
such as osteopathic concepts are, lies
in the degree to which it stimulates
and guides further inquiry, the degree
to which it identifies areas for, and
directions of, investigation - in
short, in the degree to which it guides
its own unfolding. I think we cannot
escape the conclusion that, as u u
commonly epressed, the osteopathic
concept has not served well in this
regard.
As it is commonly expressed -
primarily for physicians and phy
sicians-to-be - biologic scientists
find little in it to stimulate, challenge,
or excite their ordinarily restless curi
osities, certainly not enough to divert
them from areas of investigation
which they already find engaging and
to which they eagerly dedicate their
lives. To the biologic scientist,
statements of the concept appear to
consist partly of generalizations, so
broadly stated and so self-evident
101
that they offer little to examine, to
doubt, to test, or to question, and
partly of references to vaguely de
fined phenomena which, for him,
either do not exist or appear of
isolated and trivial biologic interest.
Already presented with more possible
and worth-while research problems
than he can attack in a lifetime, he is
understandably unattracted to phe
nomena of whose existence he has no
certainty and, in any case, whose con
nections with identifiable phenomena
and problems he does not perceive. It
is as though he were asked to scru
tinize a shadow by turning a bright
light upon it.
In short, as commonly expressed,
the osteopathic concept asks no clear
questions, presents and identifies no
problems, is neither stimulus nor
guide to research and to its own un
folding. The present generalizations
or basic biologic laws, 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, self
evident axioms and therefore not
areas for investigation, only because
their biologic implications have never
been adequately explored. Indeed, it
is my belief that herein is one of
osteopathy' s largest potential con
tributions to the biologic sciences. I t
i s not that osteopathy recognizes and
"obeys" different biologic laws, but
rather - at least at the clinical level
- that it has more deeply explored
and applied the implications of those
uni versal l y recogni zed l aws . 2 2
Principles which have become guides
to osteopathic practice remain but
pious banalities for others. The
unexplored areas and directions of
inquiry which they encompass need,
therefore, to be identified.
Labels regarding factors and phe
nomena, such as "structure, " "struc
tural integri t y, " "osteopathi c
lesion, " et cetera, which have widely
diverse, though somewhat overlap
ping, meanings for those relatively
few persons who have clinical experi
ence with the phenomena, have no
meaning for the preponderant seg
ment of the biomedical world which
does not have direct experience with
them. A biologic entity which is
variously viewed as ( 1 ) a vertebral
strain, (2) a subtle subluxation, (3) an
error in locomotion, (4) a complex re
sponse of the entire person focalized
162
through a portion of the spinal cord,
(5) 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
kinesiology, (9) a postural stress, (1 0)
the body's response to a postural
stress, ( I I) any structural abnor
mality which disturbs function -and
possibly hundreds of others - is, as
such, hardly an identifiable subject
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 still 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 belief that that is
the elephant !
The development oj working
hypothese.
I n my opinion, then, this is a task of
highest priority: The restating of
osteopathic principles in terms of
basic biologic issues and problems
and in the context of today's and
tomorrow's health needs. Non-com
mittal idioms and labels, developed
when knowledge of biologic mecha
nisms was meager, and conveying
many private meanings or none at all,
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 will avail nothing from this
viewpoint, however, merely to set out
to restate "the osteopathic concept"
in other words and to define and re
define "the osteopathic lesion. " We
need to spell out the derivations and
extensions of these generalizations
and their implications to various
fields and aspects of the biologic
sciences. We need to identify the
categories of biologic phenomena,
factors, mechanisms, processes,
components, relationships, and inter
relationships 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. 4) Only in
this way can the interest and partici
pation of biologic scientists be won,
and only in this way can they begin
the formulation of their own special
ized conceptual frameworks to guide
their contributions to osteopathic
theory, practice, and education.
This can be accomplished only
through close collaboration between
qualified biologic investigators and
osteopathic physicians who have rich
backgrounds in osteopathic theory
and practice and, as far as possible,
in research. Their objective should
be, not the development of a satisfy
ing "statement, " but a body of work
ing hypotheses which invite, through
investigation, their own revision,
elaboration, and even replacement.
Even with our present limited knowl
edge, I believe it is now possible to do
a sufficiently satisfactory job that
qualified biologic and medical sci
entists would, upon studying those
hypotheses, not only find 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, let us say, through having
j oined the faculty of one of the
osteopathic colleges, is presented with
the opportunity (or obligation) to
"do osteopathic research" does not
readily find his way "in, " and does
not readily identify "osteopathic"
problems within his specialty to
which he can gratifyingly apply his
talents and knowledge. He must,
therefore, with such guidance as he
obtains at the college, construct for
himself a hypothesis, a personal in
terpretation of some aspect of the
osteopathic concept, adequate at least
to enable him to formulate a problem
in his field. In essence, he identifes
some "unknown" pointed to by his
interpretation of osteopathic theory
and endeavors to relate it to some
"known" in his field. The soundness
and comprehensiveness of his con
cept, therefore, significantly influ
ence his election of the area of the
investigation and of the approach,
and the value of the investigation.
In similar manner, we, the full-time
professional staff of the Department
of Physiology and Pharmacology at
the Kirksville College of Osteopathy
and Surgery, consisting at present
of four professional physiologists and
two D. O. 's who have become profes
sional physiologists, have had to con
struct our own osteopathic concepts
Interpretation of research
to serve as guides and conceptual
contexts for our work. We were for
tunate in the fact that research had
long been an important activity at the
Kirksville College of Osteopathy and
Surgery and that we could have a
sound introduction to osteopathic
theory from an investigator's view
point. Over the years these "depart
mental" concepts have undergone
many revisions and elaborations as
our understanding has grown and as
new knowledge - from researches all
over the world, including our own -
has accumulated.
At each stage, our endeavor has
been not only to construct limited
frameworks for our own immediate
investigations, but also as perspec
tives for our teaching of the phys
iologic sciences. Moreover, we have
tried to interpret and reinterpret the
osteopathic concept in such a way
that it would be meaningful and even
challenging to biologic and medical
scientists who have had no prior con
tact with osteopathy and in such a
way that scientists in any basic
medical field could be stimulated to,
and enabled to, design sound projects
utilizing their particular backgrounds
of training, talent, knowledge, and
experience. How well our hypotheses
have served, only time will tell. We
can certainly say that newcomers to
our department have been able to
find their places, so to speak, rela
tively quickly.
Osteopathic journals have been
most generous with the space they
have made available to us to conduct,
in public, these personal exercises in
self-expression. Since our concepts,
at various stages of development,
have appeared in these journals over
a period of years (see References 1 to
4, 22, and other references therein) ,
there is no need to restate them in
detail. I wish only to restate those
essential points that lead to the
identification (a) of promising but
relatively unexplored areas of phys
iology and related sciences and (b)
of previously undisclosed relations
between areas already under explora
tion.
One working hypothesis.
There are many factors, in human
life, the human environment, and
human biology which infuence the
capacities of the human organism to
meet the demands of life, to meet
stress, and to adapt to, resist, com
bat, and compensate for unfavorable
elements in the environment - in
short, to maintain and recover health.
These vary from individual to in
dividual. The influence or impact of a
given factor in a given individual is
determined not only by the quality
and quantity of that factor but also
by the total constellation of factors
at the time and in the past. An in
dividual's health, his responses, and
capacity for adaptation to various
environmental factors, life situations,
and demands, his vulnerability, "de
featability," susceptibilities to illness,
capacity for recovery, et cetera, are
therefore the products of his entire
life. Hence, the importance and
influence of any given factor may
vary from individual to individual
and from time to time in a particular
individual.
Whatever his other functions, it is
the essential function of the physician
to promote, develop, liberate, and re
store, insofar as possible, these
capacities in those individuals for
whose health he is reponsible. He
does this by analyzing and altering
the factors in a favorable direction,
minimizing those which impair these
capacities. Of all possible factors only
a relatively few, at least with our
present knowledge, are readily sub
ject to human control. Of these only
a few have a major or decisive in
fluence on health.
The osteopathic profession at
taches special importance to the
unfavorable factors arising in the
musculoskeletal system for the fol
lowing reasons:
1 . Local disturbances, particularly
i n the axial porti on, of the
musculoskeletal system have a
peculiarly high incidence in man
because of the special demands made
by gravitational forces on the erect
musculoskeletal system.
2. Through the circulatory and
nervous systems there is, in health
and disease, rich interchange of in
fluences between the musculoskeletal
system and other tissues and organs.
3. A disturbed portion of the axial
musculoskeletal system, therefore,
impairs to some extent, and/or
reflects impairment of, functions of
other tissues and organs; those with
which it is most closely related neu
rologically are most directly affected.
4. Regardless of its origin, whether
primary or secondary, the musculo
skeletal disturbance impairs the ca
pacity for resistance and recovery and
tends to promote and sustain existing
disease processes.
5. Such a functional disturbance
represents a point of high vul
nerability even in the apparently
healthy human organism, whose
effect on the total man is influenced
by many other factors in his life.
6. These localized disturbances in
the musculoskeletal system and the
responses to them are readily de
tectable, even in the absence of
subjective symptoms or disease.
7. They are readily accessible to
direct and specific modification and
treatment.
8. They are responsive to appro
priate treatment.
9. The strategic importance of this
physiopathologic disturbance, then,
appears to lie in the following cir
cumstances:
Regardless of its real or apparent
relation to any symptoms or identi
fiable disease in a given individual:
a. To some extent it impairs and
taxes the capacities defined above;
b. It exaggerates or unfavorably
modifies the impact of all other
factors;
c. Its treatment, therefore, tends
to insulate the individual against the
unfavorable factors in his life, in his
environment, and in himself, render
ing them less deleterious to his
biologic capacities and resources.
d. It is detectable, and accessible
and responsive to treatment.
e. Prevention, early detection, and
treatment of this disturbance offer a
valuable approach to the prevention
of ill health as well as to therapy.
Identiying areas for investigation
and their connections .
Through our continual examination
of the physiologic implications of
osteopathic principles as we interpret
and reinterpret them, key areas in
need of investigation have become
identified. They are areas which we
have been able to identify and char
acterize from our specialized and
relatively limited viewpoint as
physiologists - in effect, questions
to which we have found we need the
answers. The same could be done,
and needs to be done, by specialists in
the other basic medical sciences.
It is important to emphasize that
10J
our concern is not alone with areas
which are now unexplored. It is just
as important to recognize those as
pects of the biologic and medical
sciences which are or have been under
active investigation, but whose
bearing on osteopathic theory and
practice has not previously been
recognized and to which new mean
ing may be brought by osteopathic
theory. An important part of that
new meaning is in the interrelations
among apparently isolated areas
which are thereby disclosed. In dis
closing the bearing of a given field or
aspect of osteopathic theory and
practice, a whole body of knowledge,
usually still growing, is, as it were,
incorporated into osteopathic theory.
practice, and research and continues
to enrich them and to be enriched by
them.
Similarly, the disclosure of in
terrelations and connections among
presently isolated fields opens up
channels of interchange in which each
feld draws from and gives to the
others new and broader meaning,
while their combined impact on
knowledge and human power is en
larged. Indeed, I have felt for a
long time, that one of the greatest po
tential contributions of osteopathic
theory to the biologic sciences lies in
the cohesiveness which it imparts or
makes possible among many disci
plines and fields of knowledge and
technic; in the dissolution of walls,
separating scientific and technical
fields, which exist only in the minds
of men and not in nature itself; in
revealing the common deeper-lying
bases which tie together apparent
islands of fact and knowledge; in the
opening of new media of exchange
among many fields.
Some illustrative areas.
Following are but a few of the
areas identifed by one group of
physiologists in one of the osteopath
ic colleges. These are intended to
describe not individual research
projects but vast areas in need of
exploration.
1 . The physiology of human dif
ferences:
While we need to continue to ac
cumulate ever more knowledge, for
example, about the adrenal cortex,
the heart, the duodenum, et cetera, it
is very necessary to recognize that
these are abstractions and general-
16
izations based, mainly, on studies on
highly standardized experimental
animals. As far as man is concerned,
there is not merely the human adrenal
but Harry's, Jane' s, Robert's, and
Mary's adrenal, and Harry's (et 01.)
adrenal when an infant, a child, a
young adult, a middle-aged adult, a
septuagenarian. It is in the differ
ences - their nature, their quantity,
their origins, their consequences -
that we should begin to look for
differences in health, in resistance, in
susceptibility, adaptability, longevi
ty - for the factors that make the
di fference between success and
failure as a human organism. In
short, we need to begin to study the
function of any given part and the
integration of the parts not only as
isolates but in particular human
contexts.
2. The mechanisms, patterns, and
pathways of interchange between
those portions of the nervous system
which are concerned with life in the
external environment (sensory and
motor) and that portion concerned
with the internal environment (auto
nomic) :
While the somatic and the au
tonomic functions of the nervous
system have been subjects of study
for many years, and while virtually
every act and activity of the intact
organism involves the simultaneous,
coordinated, and integrated partici
pation of both, there has been and
still is remarkably little investigation
of the interchange between them. As
a result, much of the meaning of each
is lost, and all of their unified
meaning. It is interesting, however,
that this area is under considerable
investigation at the clinical level
outside of osteopathic circles, and
the evidence is accumulating rapidly
that much of human disease is related
to or the product of failure in so
matic-autonomic integration. Never
theless it remains a virgin field for
fundamental study of mechanisms
and processes.
3 . The slow and long-term infu
ences of nerve activity:
The immediate responses of vari
ous tissues and organs to volleys
of impulses have been and continue
to be intensively studied. However,
despite the abundant clinical evidence
that the responses and properties of
tissues to sustained nerve activity (or
sustained cessation of nerve activity)
are profoundly altered with time, that
pathologic adaptations occur, and
despite the fact that these long-term
responses are not usually predictable
from, and are often contradictory to,
the short-term effects, they are
virtually unexplored. We identify a
few of the subcategories under this
heading.
a. The trophic function of periph
eral nerves. While the existence of
trophic influence is widely recog
nized, its nature receives little study.
b. The influence of the autonomic
innervation, at various levels of
activity and over protracted periods,
on the functions of various organs
and tissues, including the endocrine
glands.
c. The long-term adaptations of
the blood vessels, blood flow, drain
age, et cetera, to sustained over
activity or underactivity of the
autonomic innervation.
d. The adaptation of skeletal mus
cles to sustained tension, active and
passive, and the long-term influences
of altered activity of their autonomic
innervation.
e. Influence of peripheral nerve
activity, at various intensities and
durations, on cellular function:
formation of enzymes, metabolism,
permeability, interchange with blood
and interstitial fuid, growth, cell
division, et cetera.
f. Cellular adaptations to long
term moderate or intermittent
ischemia.
g. Study not only of the responses
of organs and tissues to sustained
stimulation (or inhibition) of their
sympathetic or parasympathetic in
nervation, but the secondary altera
tion of the responses of these tissues
to other influences, for example,
nervous, hormonal, and chemical.
4. Nutrition, fluid exchanges, and
circulation in nerves and nerve
tissues; factors influencing them;
effects of their disturbances on nerve
function and on the tissues which
they innervate.
S. All aspects of referred pain; the
long-term responses of, and changes
in, tissues of the refernce zone;
somaticovisceral and viscerosomatic
reflexes.
6. Triggers and trigger phe
nomena.
7. Physiologic, pathologic, mor
phologic, and chemical bases for
alteration in the texture of various
Interpretation of research
tissues, such as are used i n osteo
pathic diagnosis.
8. The physiology, pathology, and
chemistry of the fascias and other
connective tissues; the effects of
alterations in their tensions and other
physical and chemical properties on
the functions, activities, circulation,
drainage, et cetera of other tissues.
9. Spinal kinesiology; the study
not only of vertebral motion but the
patterns and mechanisms of integra
tion of total spinal activity; the roles
of individual muscles, their regula
tion and integration with others. The
origins of and adaptations to postural
and locomotor stress associated with
the erect stance.
10. Proprioceptive activity; the re
porting to the nervous system of the
activity, tensions, positions, mo
tions, and other circumstances in the
musculoskeletal system and the
somatic and autonomic responses to
such reporting.
1 1 . Altered functional and cellular
states of muscle; contracture, fibro
sis, et cetera, and their experimental
alteration.
12. Neuroendocrine factors influ
encing resistance to and responses to
infection.
1 3. Gross and microscopic ex
amination, in autopsies, of the spinal
column, the spinal cord and its mem
branes and blood vessels, paraver
tebral tissues, et cetera, in relation to
clinical history. This represents a
treasure of information which has
hardly been tapped. A system of
autopsy in which osteopathic ques
tions can be asked and answered
awaits development.
In identifying a few of the fields of
investigation to which osteopathic
principles have led us as physiolo
gists, I have deliberately avoided
explicit reference to the osteopathic
lesion. It is not our purpose to
disregard it, for it is intimately related
to all of the categories of phenomena
enumerated above, and many more.
Accumulation of knowledge in those
areas is essential to our understanding
of the osteopathic lesion. Our ob
jective is more precise definition of
problems for investigation. The too
commonly accepted premise that os
teopathic research is research on "the
osteopathic lesion" or on "the effects
of the osteopathic lesion, " et cetera
has, I believe, been a serious deterrent
to scientific progress in osteopathy.
The first and one of the most difficult
and important steps in any research is
a clear statement of the problem, an
unambiguous formulation of the
question to be put to nature. To
propose research on an entity rep
resented by a label or a phrase which
has, as previously emphasized, many
varied, private meanings to persons
within the profession and none to
scientists outside the profession is
a failure to state the problem. Even
worse, the research is too often an
effort to make "the osteopathic
lesion" confirm or conform to a pre
conceived etiologic framework which
distorts its very nature.
The elements of an adequate
research program
It is obvious that the opportunities
for osteopathic research are vast and
potentially of tremendous signifi
cance to science, health, and society,
as well as to the osteopathic pro
fession. It is equally obvious that
research activity and achievement
under osteopathic auspices have been
minute in contrast with these op
portunities. As was stated in the
introduction, through its achieve
ments in clinical practice, legislation,
public recognition, and education,
the profession is now better prepared
than ever to turn its attention and
resources to this relatively neglected
phase of its function.
I have tried over a protracted
period to enumerate in some logical
system the essential elements for
raising osteopathic research activity
to a level and a scale more nearly
commensurate with the magnitude of
the opportunities. Invariably, my
lists have reduced themselves to one
central and, indeed, the only truly
indispensable element to which all
others are contributory - personnel.
This conclusion is in complete agree
ment with policies developed through
many years by research foundations,
granting agencies, the National Insti
tutes of Health, and others: that
investment should be made, not in
projects, but in investigators - in
providing them with the circum
stances and the means to work in
areas of their selection, in their way,
and further to develop their skills and
those of others. 2324
The key element.
In my opinion, the osteopathic pro-
fession still needs to appreciate the
full significance of the key element -
qualified investigators. There is no
question that a considerable amount
of medical and some osteopathic re
search, much of it of great value, has
been done and is done by persons pri
marily occupied in other functions,
such as clinical practice, teaching,
and administration; and this should
always be encouraged. Nevertheless,
the fact remains that the research
areas opened by osteopathic theory
and practice are of such nature and
scope as to demand full-time (or
nearly full-time) investigation by
scientists, to whom research is not
merely an avocation or sideline to be
dabbled in in one's spare time, but to
whom research is a way oflie " the
only way of life - for which they
studied and prepared for many years,
and for which, throughout their pro
fessional lives, they are continually
preparing. Research is no less a
specialty than the practice of medi
cine or surgery or any other profes
sion and, in many ways, is much
more rigorous in its demands. It is
foolish to assume that all one needs,
besides equipment and supplies, in
order to do creditable research is the
decision to do it or to "stimulate"
others to do it.
The proper activation of osteo
pathic research demands the recruit
ment of an adequate corps of such
workers who, given adequate means
and circumstances, would not only
themselves undertake such research,
but also would attract others, train
others from within and without our
student bodies, enrich and multiply
the efforts of the part-time and clini
cal investigators, and who would
vitalize our educational programs.
There are no satisfactory substitutes
in research for qualified researchers
whatever the degrees they may have,
whatever their formal training. Inves
tigators such as my Kirksville col
leagues, J. S. Denslow, P. E. Thomas,
and H. M. Wright, and others in the
osteopathic profession are testimony
to the fact that osteopathic physicians
to whom research has become a way
of life and who have the innate ability
and motivation can, with the assis
tance, guidance, and collaboration of
professional scientists, themselves
become well-qualified professional
scientists.
How, then, attract and recruit such
105
a corps of scientists? Why should a
talented scientist, already established
or likely to be established as a teacher
and investigator in a university,
medical school, or research institute,
with his interests and aspirations well
defned, even give consideration to
employment at an osteopathic institu
tion? Why should he expose himself
to the hazards of discrimination
which are products of still surviving
prejudices and ignorance regarding
osteopathy and the osteopathic pro
fession? What kinds of advantages
can be offered which will outweigh
these undeniably serious deterrents?
There is only one answer. The pro
fession must be able to define and of
fer him such opportunities to utilize
his talents for human knowledge and
f
o
r human welfare as are available
nowhere else. From my own personal
experience I can say with complete
conviction that osteopathic education
and research can abundantly offer
such uniquely challenging, exciting,
and gratifying opportunities. They
need to be identifed, made known,
and implemented.
Identication of the opportunities.
1 . These opportunities in osteopathic
research and education are derived
from, and inseparably related to, the
special function of osteopathic medi
cine. The osteopathic profession
must, therefore, in unequivocal
terms, declare itself with respect to
what it considers to be, and demon
strates to be. its special distinctive
contribution to human health and
welfare - to the meeting of today' s
and tomorrow' s health problems -
and what it intends to do towards
continued development of this poten
tial. So occupied has the profession
been in establishing itself that it ap
pears to have forgotten, at least a lit
tle, the special purposes that it is to
serve, the unique contribution it is to
make - and of which i t is the instru
ment. Just as a recognizably unique
contribution is the only reason for the
profession itself, so would it be the
only reason for a scientist to affiliate
himself with the osteopathic move
ment. That unique contribution must
be carefully defined as the objective
of the profession and all necessary
steps taken towards its realization.
One of the main objectives of the cur
rent preparations by the Kirksville
College of Osteopathy and Surgery
16
for its projected Decade of Purpose
( 1957-1 %7) is the clear and precise
formulation of that contribution (as a
guide to the re-ordering of its educa
tional. research, and clinical pro
gram). This urgently needs to be done
by the osteopathic profession as a
whole.
2. As a corollary. the profession' s
leading physicians, scholars, teach
ers, and scientists must, with the help
of scientists and others outside the
profession, identify the areas of the
biomedical sciences which osteopath
ic theory, practice, and research have
shown to be of critical importance to
the understanding of life and to the
control of health and to be in need of
exploration. Our own efforts in this
direction, reviewed in an earlier
section, need to be greatly extended,
and to all the basic medical sciences.
Implementation of the opportunities
by the profession.
Having clearly identified its special
function and the contribution i t
wishes to make, the profession must
then wholeheartedly accept and com
mit itself to the idea that it can make
that contribution and therefore
survive and continue its development
- only by disclosing the neces
sary knowledge and understanding
through greatly expanded research
programs. It needs then to declare
and demonstrate its intention to sup
port in all necessary ways the explora
tion of areas related to its special con
tribution. This requires:
1 . Formulation of appropriate
policy in which research is established
as a major front for the profession.
2. Recognition, and greatly in
creased support, of the decisive role
of the osteopathic colleges, for it is in
them that the bulk of the research will
be conducted, it is to them that sci
entists would come, and it is in them
that future investigators will be
recruited and trained. It is in the
colleges that the necessary circum
stances need to be created. As will be
shown these circumstances do not yet
exist.
3 . The development and sponsor
ing of programs for the recruitment
and training of research workers.
4. The development and procure
ment of resources for carrying out the
above. This must come from three
sources:
a. The profession itself, through
the assessment and allocation of
larger funds specifically for research
and development.
b. Diversion of funds, resources,
and attention from peripheral func
tions and activities in which osteop
athy' s social contribution cannot be
made to those in which it can be
made.
c. Society, the public, government,
foundations , et cetera.
Society, through its governmental
agencies and through private and
public philanthropic agencies and
foundations, still does not contribute
to the support of osteopathic medi
cine, osteopathic education, and
osteopathic research in proportion to
the benefits which it derives and can
derive from them. Nor is there reason
to expect that it will, until it has a far
better comprehension than it now has
of the social value of the cause which
it is asked to support.
The public and its agencies are
already presented with a plethora of
opportunities to support endeavors in
education, research, and clinical and
preventive medicine which are de
monstrably worthy, important to
health and welfare, and hopeful or
successful . Osteopathic medicine,
education, and research can win their
share of society'S support only when
the profession can demonstrate that
important social and health needs and
opportunities exist which are not be
ing met and which the osteopathic
profession, through its institutions
and through its educational, research,
and developmental programs, i s
uniquely qualified to meet - given
the necessary support.
Thus, this endeavor, too the
quest for society's support de-
pends upon the clarity and the firm
ness with which the profession iden
tifies and describes the distinctive
contribution it aspires to make and
upon the vision and resources it turns
to its development.
Implementation ofthe opportunities
by the colleges.
While research work is carried out by
individuals, the fact remains that, to
day, research is an activity of institu
tions. The work of the individual
prospers to the degree that it is pro
vided for, supported, and encouraged
by the institution in which he works.
For obvious reasons, it is to our
educational institutions - our
Interpretation of research
colleges - that we need to give our
main attention. Only if research is an
activity of our colleges can we hope to
attract scientists to our faculties.
Our colleges have yet, through firm
policy and program, to establish re
search as one of their primary func
tions, and then, with the counsel of
qualified scientists, to make all possi
ble provision for it. While it may be
protested that the first and highest
obligation of each night is the estab
lishment and maintenance of the
highest educational standards the fact
remains that the "highest educational
standards" are not achievable unless
research is a basic activity of the col
lege. The statement often made by
administrators and department heads
of osteopathic colleges, "We haven't
time for research," must, by deliber
ate policy, be made as patently ab
surd as "We haven' t time to conduct
classes. "
It is in the spirit, the atmosphere,
and the habit of inquiry which give
life to programs of higher education.
Without them a professional college
conducts not so much an educational
program as a training program. The
profession it trains is less a learned
profession than a profession of tech
nicians. We must frankly face the fact
that whatever advances the osteo
pathic colleges have, with the support
of the profession, made in recent
years - and they have been tremen
dous - such a spirit of inquiry, of
scholarly tradition, does not yet per
vade our college atmospheres.
Proud as we are, and have good
reason to be, of the physicians our
colleges produce, that physician is a
better one who has lived and studied
in an atmosphere of inquiry, who has
at least observed the seeking and
weighing of evidence, who has be
come aware of the unknowns and the
questions in medical theory as well as
the accepted, the assumed, and the
established in medical practice, and
who is aware of the steps that are
taken and can be taken towards their
solution and towards further develop
ment.
A closed book is never an exciting
or edifying one, however decorative it
may be on the shelf. We need frankly
to examine how the uninquiring,
often doctrinaire, presentation of os
teopathic theory, giving it the appear
ance of a closed book, is affecting
osteopathic education, practice, and
progress. The osteopathic concept
must be seen as a "tool" rather than
as a "creed. " "What we need, " as,
Bertrand Russell said, "is not the will
to believe, but the wish to find out,
which is the direct opposite. " Osteop
athy - and osteopathic education
-must live on the frontiers, or not at
all. The osteopathic concept must be
seen, through our educational pro
grams, as the young, living, growing,
and exciting thing it is, instead of the
tired old banality it so often appears.
It must be presented as the endless
field of exploration which it is and
not merely as the product of past dig
gings which, like a mummy, needs to
be preserved. Osteopathic education
needs to be vitalized by faculty mem
bers who can lead the explorations,
by scientists whose lives are lived on
the frontiers.
Through our colleges, opportuni
ties in research and for training for
research careers must be created and
made known to our student bodies.
While it may be lamented that,
according to a recent estimate, 2 S only
about two out of every 1 00 medical
students eventually become in
vestigators, how fortunate the
osteopathic profession could feel if
one investigator were recruited from
each class of approximately 50
osteopathic physicians who graduate
each year! Only the rare student has
become aware of the rich oppor
tunities in osteopathic research and of
th gratification, excitement, and
joys in research as a career. Unques
tionably the most effective factor in
at t ract i ng physi ci ans- t o- be t o
research and i n preparing them for
research and for academic careers is
through contact with active research
ers on their own campuses, as an
intrinsic part of their professional
education.
It was my good fortune to have
joined an osteopathic college which
not only had, by carefully formulated
policy, made research one of its pri
mary functions, not only had, to the
limit of its resources, provided for it,
and not only had been able to demon
strate its firm intent with past
achievement, but which also was able
to challenge and excite the interest of
scientists with sound descriptions of
the unlimited opportunities in osteo
pathic research and education. The
college has, through the years, sub
jected its policies with respect to
research to continual close scrutiny
and revision. It has continually
sought the resources for enlargement
of its research potential and has felt
as obligated to make its funds avail
able for research as for teaching and
clinical service. It has continually
sought the means to attract more
scientists and to create the circum
stances most conducive to their pro
ductivity.
The college has long recognized
that the requirements of the teacher
investigator, in comparison with
those of the teacher, are, for the col
lege, a great deal more exacting. This
includes not only premium salaries
and more elaborate facilities and
equipment, but also supportive tech
nical personnel. Even further, it has
recognized that one of the scientist's
greatest needs is for other scientists
with whom to exchange ideas and
skills and with whom to share teach
ing and other responsibilities. It has
therefore encouraged each estab
lished investigator to surround
himself with other investigators to the
limit of available resources. Since
there is nothing, in an institution,
more attractive to a scientist than
other scientists and recorded scien
tific achievement (though it is still
very small), the recruitment of scien
tists has become progressively facil
itated in recent years, and grant funds
have become more ample.
Recognizing its responsibility to
prepare, for society and for the pro
fession, future investigators as well as
practitioners, the college has, also
from its own funds, established a
system of undergraduate fellowships.
Under this system selected students
are invited to take their studies
towards the D. O. degree over an ex
tended period - an additional 1 , 2,
or more years - during which they
receive special training through par
ticipation in the teaching and research
programs of departments of their
choice and during which time they
receive financial assistance from the
college .
While, in recent years, this
college has enjoyed the benefits of
substantial research grants from the
American Osteopathic Association,
governmental agencies, and private
foundations and individuals, it is not
suffciently recognized that the ground
work had been laid years in advance
and continues ever to be laid through
10T
( 1 ) the establishment of research as a
primary function of the college; (2)
the formulation, with the counsel of
scientists and scientific agencies, of
sound enabling and guiding policy
which is in continual evolution; (3)
large prior investment, from its own
funds, in facilities, materiel, and per
sonnel; (4) willingness and readiness
to invest in each project amounts
equal to, and usually larger than, the
grants awarded to it; (5) willingness
and readiness to support departmen
tal staffs much larger and far more
expensive than those required for
teaching alone; and (6) the ability to
create an academic climate in which
research, development, and scholar
ship can prosper.
While achievements in research (as
well as in other areas) have been far
too small, and progress far too slow
to satisfy either the administrators of
the college or the investigators, while
too few departments are engaged in
research, and while many circum
stances urgently required for greater
achievements and progress have yet
to be created, it has only been my
purpose to emphasize that such prog
ress as has been made and will be
made is the product not of fortuitous
circumstances but of policy and plan
ning and of much sacrifice by the
College as a whole.
Summar and conclusions
1 . Rapidly growing acceptance and
support of the osteopathic profession
by public, governmental, education
al, and granting agencies and others
now make it possible for the profes
sion to devote a great deal more of its
attention and resources to a neglected
phase of its function as a profession:
exploration and development of its
special contribution to human health
and to the biologic and medical
sciences.
2. The fulfillment of the distinctive
function of the osteopathic school of
medicine, the making of its special
contribution -the only reason for its
existence - depends on the acceler
ated accumulation of essential knowl
edge, understanding, and method
ology in certain areas of the biologic
and medical sciences.
3. The prevailing orientation of
medicine today, and therefore of
medical research, is such that there is
relatively l i ttle interest i n, or
recognized need for, knowledge in
16
these areas and little recognition of
vital interrelations among those of
the areas that are being investigated.
As a result, exploration in these areas
is neglected or fragmentary.
4. To the degree that the profession
attaches importance and social value
to its distinctive contribution to
human health - and therefore to the
degree that it can justify its existence
as a profession - to that degree is it
obligated to assume responsibility for
exploration and development in these
areas, in order that it may make that
contribution.
5 . The profession's greatest and
most critical need, in the meeting of
that responsibility, is for adequate
numbers of talented, qualified, full
time investigator-teachers in all of the
medical sciences - to conduct re
search, to help define the areas of in
vestigation, to attract and challenge
other scientists through their achieve
ments in these areas, to train other in
vestigators, and to vitalize our educa
tional programs.
6. In order to win the interest and
participation of qualified scientists,
the profession must be able to offer
such challenging opportunities to
contribute to human health and to
human knowledge as are available
nowhere else. Osteopathic research
can abundantly offer such uniquely
challenging, exciting, and gratifying
opportunities. They need to be iden
tified, made known, and imple
mented.
7. In order to identify and define
these opportunities:
a. The profession must uneQuiv
ocally declare itself as to what it con
siders to be, and demonstrates to be,
its special distinctive contribution to
human health and welfare and as to
what it intends to do towards its con
tinued development. Just as a recog
nizably unique contribution is the
only reason for the profession itself,
so would it be the only reason for a
scientist to affiliate himself with the
osteopathic movement.
b. Areas of the biomedical
sciences which osteopathic theory,
practice, and research have shown to
be of critical importance to the under
standing of life and to the control of
health, but which are in need of ex
ploration, need to be identified. This
can be done through examination and
development, in terms of growing
biological medical knowledge, of the
implications of basic osteopathic
principles. That is, through the col
laboration of osteopathic physicians
and scientists, the principles which
guide osteopathic practice must be
transformed into a body of working
hypotheses to guide osteopathic
research.
8. In order to implement the oppor
tunities thus defned, the following
steps must be taken by the profession
as a whole:
a. It must wholeheartedly accept
and commit itself to the idea that it
can make its special contribution to
society - and therefore survive and
continue its development - only by
disclosing the necessary knowledge
through greatly expanded research
programs.
b. The profession must then for
mulate and observe the necessary
policies to establish research as a ma
jor front for the profession. For this
purpose, as for others, it should
utilize the best scientific and educa
tional counsel which is available.
c. It must give all possible sup
port to the osteopathic colleges in
their decisive role in this endeavor.
d. The profession must begin to
divert funds, resources, personnel,
and effort from the absorbing,
per i pher al areas i n whi c h
osteopathy' s special contribution
cannot be made to those central ones
in which it can. It must very soon
decide which are peripheral functions
and which the central ones for which
it was established. Certainly it can be
said of any profession with a new idea
and limited resources that for every
dollar and every man-hour spent on
following, that much less remains for
leading, for bringing the idea to fru
ition. The osteopathic profession
needs to determine the optimal ratio
for itself and make the necessary ad
justments.
e. Osteopathic medicine, osteo
pathic education, and osteopathic
research must win their share of
society's support. This can be accom
plished when the profession can
demonstrate that important social
and health needs and opportunities
exist which are not being met and
which the osteopathic profession is
uniquely qualified to meet - given
the necessary support . Success
depends upon the clarity and firmness
with which the profession identifies
and describes the distinctive contribu-
Interpretation of research
tion it aspires to make and upon the
vision and resources it turns to its
development.
9. It is through the osteopathic col
leges and affiliated institutions that
all of the above must find their ex
pression, for it is in the colleges that
the bulk of the research will be con
ducted; it is to them that scientists
would come; and it is in them that
future investigators will be recruited
and trained. The osteopathic colleges
are not yet ready for this role, and
they must begin to prepare. This re
quires, first, that research be firmly
established a a primary function of
each college, as it is for other institu
tions of higher and professional
education. Second, the necessary
enabling and guiding policies must be
formulated. "High educational stan
dards, " for which all the osteopathic
colleges continually strive, are no
longer achievable unless research is a
basic function of the college.
Osteopathic education urgently needs
to be vitalized by a pervasive spirit
and habit of inquiry.
10. In conclusion, at this stage of
hi story, sci enti fic progress i n
osteopathic medicine i s the shortest
and surest road to society' s under
standing, acceptance, and support of
the osteopathic contribution to
human health and welfare, and the
only road to the making of that con
tribution.
References
I . Korr, I . M. : Emerging concept of osteopathic
lesion. J. Am. Osteop. A. 48: 1 27- 138, Nov. 1 948.
2. Korr, I . M. , Thomas, P. E. , and Wright, H. M. :
Symposium on functional implications of segmental
facilitation; research report. J. Am. Osteop. A.
54:265-282, Jan. 1955.
3. Wright, H. M. : Origins and manifestations of
local vasomotor disturbances and their clinical
significance. J. Am. Osteop. A. 56: 21 7-224, D.
1 956.
4. Thomas, P. E.: Neurovascular factors in disease.
To be published.
5. Stieglitz, E. J. : A future for preventive medicine.
The Commonwealth Fund, New York, 1945.
6. Galdston, I . : Meaning of social medicine.
Harvard University Press, Cambridge, Mass., 1954.
7. Jensen, J. : Modern concepts in medicine. c. v.
Mosby Co. , St. Louis, 1953, pp. 17-25.
8. Pottenger. F. M. : Symptoms of visceral disease.
Ed. 7. C. V. Mosby Co. , St. Louis. 1953.
9. Wolff. H. G. : Stress and disease. Charles C.
Thomas, Springfield, III., 1953.
10. Brain. R.: Need for philosophy of medicine.
Lancet 1 :959-964. May 16, 1953.
I I . Editorial: Failure of modern medicine. J. Am.
Osteop. A. 55: 123-125, Oct. 1955.
12. Halliday, J.L.: Psychosocial medicine; study of
sick society. W. W. Norton & Co., New York, 1 98.
13. Seguin, C.A.: Concpt of disease. Psychosom.
Med. 8: 252257, July-Aug. 1 946.
14. Selye, H. : Stress and disease. Science
1 22:625-631 , Oct. 7, 1955.
15. Loewi, 0. : Refections on study of physiology.
Ann. Rev. Physiol. 1 6: 1 - 10, 1954.
16. Lape, E.E cd. : Medical research; midcentury
survey. Little, Brown and Co., Boston, 1955. pp. xxii
xxii, 3-85, vol. 1; pp. 3-67, vol. 2.
1 7. Carlson. A. J. , and Johnson, V.: Machinery of
body. Ed. 4. University of Chicago Press, Chicago,
1 953.
IS. Tainter, M. L. : Medicine'S golden age; triumph
of experimental method. Trans. N. Y. Acad. Sc.
1 8:2.-227, Jan. 1956.
19. Dubos, R. J. : Biochemical determinants of
microbial disease. Harvard University Press, Cam
bridge, Mass. , 1954.
20. Galdston, I . , ed.: Beyond the germ theory.
Health Education Council, New York. 1954.
2 1 . Hinkle, L. E + Jr., and Plummer, N. : "Host ra- .
tor" in human illness; occurrence of differences i n
general susceptibility t o illness among group of adult
men. Clin. Res. Pree. 2: 102. April 1954.
22. Korr, I . M. : Biological basis for osteopathic con
cept. J. Osteop. 61 : 1 3- 1 9, April 1 954.
23. Allen, E. M .. and Endicott. K. M. : Public Health
Service research grants in biology. Bull. Am. Inst.
BioI. Sc. 3: 1 9-21 . April 1953.
24. Endicott, K. M + and Allen, E. M. : Growth of
medical research 1 941 1 953 and rol e of Public Health
Service research grants. Science 1 1 8:337-343. Sept. 25.
1953.
25. Lape. E.E., ed.: Op cit., ref. 16, p. 288. vol. I.
Reprinted by permission from JAOA 56: 275-285,
1957.
What' 'osteopathy" and' 'the osteopathic concept" mean to me (1962)
For me, osteopathy is one of the great
revolutionizing ideas. that light the
course of history and mark its turning
points. Other such great ideas have
been the concepts of evolution and
natural selection; quantum theory
and the theory of relativity. These
have had immense impact on the bio
logical and physical sciences, on our
understanding of nature and of man's
place in it, on technology and on our
way of life. The impact of osteopathy
-the body of concepts incorporated
in, and radiating from, osteopathy,
however you call it, whatever its
future designation - its impact on
medicine and human health, and
therefore on every aspect of human
life, will eventually be equally
transforming.
When the implications of the os
teopathic concept are adequately
explored - indeed, in the course of
exploring them - the practice of
medicine and the basic approaches to
health and disease will be trans
formed and elevated to a higher path.
The osteopathic profession is the
instrument of that idea, and it will
survive and prosper according to how
well it serves that idea. The explora
tion and development of the osteo
pathic 'idea' and its implications, and
the implementation of the idea in
practice, must therefore be in the
hands of those who at least appreciate
the breadth of the idea, who recog
nize the magnitude of its potential in
human progress, and who understand
their responsibility to it.
It is much too big and important an
idea to be entrusted to those whose
only concern with the idea is with
how well or how poorly that idea -
or one of its suitably diluted, distorted,
corrupted and conventional-sounding
versions - serves the instrument, that
is, the doctor and the profession. For
them osteopathy is not an idea -much
les a big ide - to be advanced on
behaf of mankind. For them it is but a
commodity to be sold - in whatever
guise it wil h, quickly and in large
volume, and with gratifying ag
grandizement of the agent.
I think we need, in some way, to
re-infuse into the profession an ap
preciation of the immensity of the
idea, of the profession's responsibili
ty to it, and of the vast opportunities
to serve it. Doubtless, this will require
heroic steps. I do not see the profes
sion taking those steps, preparing to
take them or contemplating them.
Finally, I believe that the osteo
pathic colleges cannot begin to fulfill
their role until they recognize that
their function is not merely to teach
osteopathy as a way of making a liv
ing, but primarily as a way of life, as
one of the great revolutionizing ideas
of human history. It is the function of
the college to prepare for society phy
sicians who can appreciate the scope
of the idea and its potential for
human welfare and who can under
stand and fulfill their responsibility to
it. As long as this is remembered, all
else, from the selection of students to
design of the curriculum, from the
structure and composition of the facul
ty to the content of each didactic hour
and the nature of each clinical expri
enc, will fall into proper prspve.
169
The sympathetic nervous system as mediator
between the somatic and supportive
processes (1970)
Throughout the history of medicine.
physicians have been very much con
cerned with our insides. with our in
ternal organs, with the internal en
vironment, with our viscera. In
modern times. as our knowledge and
skills in visceral diagnosis and
therapy have increased, our preoc
cupation with our viscera has in
creased. This is all to the good, except
that if carried too far it leads us to
overlook the crucial point that human
life, the kind you and I live and see in
each other, does not consist of vis
ceral activity.
Life is not a composite of the func
tions of the viscera. Man does not
perform glomerular filtration and
tubular reabsorption; he does not
vasodilate, he does not constrict and
he does not oxygenate; he does not
peristalse and he does not secrete.
Life is not the sum of the activity of
our internal organs, despite the
preoccupation of medicine with those
internal organs.
What doe human life consist of?
What does man do?
Man does all the things that we see
each other do. He moves, runs,
works, plays tennis. builds buildings,
paints pictures, makes music, makes
love - to paraphrase the flower
children, he makes love and war. He
is creative. He teaches, learns, writes,
educates, practices medicine, does
surgery, gives osteopathic manipula
tions.
If you look at these activities objec
tively, you will see that in all of them
the body as a whole is moved or some
part of the body is moved; and the
common feature, the indispensable
substratum, is the contraction of
skeletal musculature. Human life is
expressed through the contractile pro
cesses of striated muscle. Every
aspect of human life is acted out by
the body's muscles and joints.
Everything man does to express his
aspirations and convictions can be
perceived by others only through his
bearing and demeanor and utter
ances, and these are composites of
myriads of fnely controlled motions.
So we begin to see that even the
1T0
highest intellectual activity is lacking
in value except insofar as it can be
acted out, in and upon the environ
ment and by being communicated to
others. Education itself is sometimes
defined as a change in behavior and
behavior is produced by muscles act
ing on joints.
Here then is an important conclu
sion which I think is implicit in the
total osteopathic perspective: that the
musculoskeletal system is the primary
machinery of life. These are the body
parts that act together to transmit and
modify force and motion through
which man acts out his life. But since
machinery must be supplied with
motive power in order to function,
our concept of the primary biologic
machinery should include its direc
tion by the nervous system acting in
response to the continual sensory in
put that reports what is going on in
the outside environment and what is
going on in the body itself; hence, the
"neuromusculoskeletal" system.
The role of the viscera
If the musculoskeletal system and the
nervous system that directs it com
prise the primary machinery of life,
then what is the function of all the
rest of the bodily machinery with
which medicine is so much concerne?
As the title suggests, their func
tion is entirely supportive. Their con
cern is with the care and maintenance
of the primary machinery of life,
which means supplying fuels and
building materials, disposing of
wastes and end products, taking care
. of the defense and repair and regener-
ation of components and in general
maintaining regulation of the internal
environment in which the cells of the
primary machinery carry out their
function.
The musculoskeletal system is the
largest mass of the body and the main
consumer. Muscles consume more
energy, more rapidly and in wider
ranges, than any other tissues in the
body_ In a matter of seconds, the
muscles' demand for oxygen can vary
over a very wide range. The enor
mous turnover in body energy in-
volves immense consumption of raw
materials, immense production of
metabolic wastes and the dissipation
of the large amount of heat which is
the chi ef by-product of thi s
machinery, as it is of any machinery.
The problems in logistics and heat ex
change call into play the specialized
functions of all the visceral organs
and the hemodynamic apparatus re
sponsible for internal transport.
But these matters of logistics are
not the major responsibility of the
body' s supportive machinery. The
crucial fact is that the consumed
substances must be restored as rapid
ly as they are consumed and waste
products removed as fast as they are
deposited into the internal environ
ment to the end that the blood
chemistry will remain relatively un
changed. In other words, internal
balance must be maintained and this
is the essence of homeostasis.
And so we see, from the broadest
viewpoint, that the two types of body
machinery are in a sense the direct op
posites of each other. The primary
machinery of life is concerned with
what we might term heterokinesis, the
great diversity of activities performed
by the human being with his muscles
and joints in a great diversity of
envi ronment s . The support i ve
machinery i s concerned with the
checks and balances that constitute
homeostasis, the physiologic equili
brium that prevents those extremes of
activity from draining the body
resources, disabling the neuromuscu
loskeletal system and destroying the
individual.
Therefore, health requires that
from moment to moment the visceral
functions of the body must be con
tinually attuned or adjusted to what
the body as a whole is doing, how the
person is acting at that moment with
his neuromusculoskeletal system.
Tuning, i n this sense, seems to me a
little more precise than mere adjust
ment - that is, tuning implies a
bringing into harmony of many
different functions and gradations of
function to meet the musculoskeletal
demands.
To maintain the blood chemistry in
optimum balance there must be in
stantaneous adj ustments in the
oxygen-carrying capacity of the
blood, as well as adjustments in its
buffering capacity, since muscle ac
tivity produces large amounts of acid
Interpretation of research
Figur J.l: Cross-section of the spinal cord at thoracic or upper lumbar
levels, showing: sensory or afferent (dorsal root) neurons and their
fiber (black), conveying impulses from receptors and endings in somatic
and visceral tis ues; motoneurons (ventral hor cells, lighter), supplying
motor innervation to skeletal musculature; sympathetic neurons
(lightest), the preganglionic neurons, in the intermediolateral cell column,
whose fibers (solid lines) synapse in ganglia with neurons (postganglionic
fibers, interrupted lines) which innervate viscera and certain elements
(e. g" blood vessels, swet glands and piloerector muscles) in somatic
structures. A secondary senory neuron (spinothalamic) is also indicated,
conveying impulses to higher centers and mediating sensations ofpain
and temperature.
Figure J .2: Autonomic nervous system: sympathetic and parasympathetic
divisions. Solid lines originating in central nervous system (brainstem and
spinal cord) represent preganglionic fbers. Interrupted lines (ariing in
ganglia) represent postganglionic fibers.
Roman numerals indicate cranial parasympathetic nuclei; Arabic
numerals indicate cervical, thoracic, lumbar and sacral segments of the
spinal cord, and the segmental origins (intermediolateral cell columns) of
the sympathetic nervous division (T-] to L-l) and sacral portion of the
parasympathetic divison.
Visceral strctures are represented within the human fgure on the right
hand side in four main groupings: those ofthe head and neck; thoracic;
abdominal; pelvic and genital. (The adrenal medulla is innervated by
sympathetic preganglonic neurons, crossing the abdominal portion of the
diagram.)
metabolites. Large amounts of ox
ygen are consumed, large amounts of
carbon dioxide are elaborated and
put into the blood stream and it is the
function of the viscera to prevent
resultant shifts in blood chemistry.
Another part of the tuning process is
the continual adj ustment of heat loss
from the skin, by changes in blood
flow and in evaporation, so that body
temperature variations are minimum.
The process may also include, in an
emergency, the suppression of such
visceral activities as can wait until
normal routine is restored. Digestive
functions, especially, may be sup
pressed temporarily by inhibition of
peristalsis and secretion and a
tightening of sphincters in the event
of some violent activity or threatened
harm. Blood flow distribution also
must be shifted from moment to mo
ment in accordance with which parts
of the musculoskeletal system are do
ing what.
All of these tuning functions, these
continual adjustments of the suppor
tive machinery to the demands of the
primary machinery, must of course
be directed, integrated and controlled,
Somatic structures, including the neuromusculoskeletal system, are
repreented on the left-hand side of the diagram. It will be noted that,
unlike the viscera, which are dually innervated, the autonomically inner
vated elements in the somatic structures receive their autonomic supply
exclusivelyfrom the sympathetic division.
and this is precisely the function of
the sympathetic nervous system as the
mediator between the somatic and
supportive machinery of life.
The elements of sympathetic function
The sympathetic nervous system is
continually acting in response to com
mands from the higher centers, which
as they call for specifc physical ac
tivity call at the same time for the ap
propriate visceral adj ustment that
will make such activity possible. The
sympathetic system, like the neuro
muscular system, also responds con
tinually to a feedback of sensory in
formation coming in from various
parts of the body, chiefly by way of
the dorsal roots in the spinal cord.
The sympathetic nervous system is
also highly responsive to infinitesimal
changes in blood chemistry. In sum
mary, its function depends on the
speeding in of information from the
higher centers, from the sensory input
over afferent pathways to the spinal
cord and from chemical changes in
the blood stream.
These are very elementary things.
My purpose in reviewing them here is
not to remind you of things you may
have forgotten but rather to invite
you to look at them from a somewhat
different viewpoint. Sometimes it is
difficult to see old familiar things in a
new light, but when you do accom
plish this very often something new
appears. And some new things have
begun to appear to us in relation to
the function of the autonomic ner
vous system and especially the sym
pathetic portion of that system.
One of the new concepts that have
emerged is the one I stated a moment
ago: that it is precisely the'function of
the sympathetic nervous system to
tune visceral function from moment
to moment , to adjust circulation and
metabolism and other functions, ae
cording to what the mind and body
are demanding and what the environ
ment is enforcing at a given moment.
This is not, as you might assume,
simply a restatement of an old idea. It
is a still-developing view encompass
ing older observations whose implica
tions were not completely understood
and new findings made in various,
separate lines of research. The com
prehensive interpretation that is
171
emerging reflects findings in two
main areas, the surprising ubiquity
and continuity of sympathetic func
tion and its modulation of cellular
physiology.
Relation between the two autonomic
branches
In order to understand the sym
pathetic role in tuning and modu
lating body functions it is essential
that we understand the differences
between the sympathetic nervous
system and the parasympathetic ner
vous system. One of the still
prevalent myths that we need to
demolish for all time is the general
impression that life is essentially a
tug-of-war between these two
systems: that it is merely a matter of
adjusting balances between the two;
that they are merely equal and op
posite, two sides of the same coin.
Nothing could be further from the
truth. They are totally different
systems, with different origins and
functional organization and distribu
tion. They work in different areas
and do different things for the total
body economy.
The parasympathetic system,
whose main outfow is the vagal
outflow to most of the viscera, is con
cerned mainly with protecting the
interal environment. For this reason
a distinguished physiologist has
characterized it as subserving en
dophylactic functions. He has also
applied to it the term trophotropic,
because it is concerned with nutrition,
with replenishing body stores which
are depleted under sympathetic cJirec-
tion.
"
In contrast the sympathetic system
is described as ergotropic. It is con
cerned with the performance of work
by the body as a whole, with the rapid
muscular use of energy and the ex
change of energy between body and
environment. It is concerned also in
our mental and emotional attitudes
toward that work and our responses
to environmental forces.
The functional organization of the
autonomic nervous system has been
graphically illustrated in many dif
ferent ways. When you look at a
cro.ss-section of the spinal cord (Fig.
1 . 1 .) for example, you may see the af
ferent, dorsal root fbers in a single
segment, conveying the input of in
formation from the skin, the joints
and muscles, the proprioceptors and
1T7
other parts and from the viscera
themselves; and of course, the ventral
horn cells which supply the innerva
tion to the skeletal muscles. But our
immediate concern is with the inter
mediolateral cell column, a diagram
of which will show the total sym
pathetic outflow, from the first
thoracic vertebra to the second lum
bar segment, and the structural rela
tions between this organization and
that of the parasympathetics.
The schematic rendering of the
sites of central origin of the
peripheral autonomic system looks
rather like a clinical thermometer
(Fig. 1 . 2) , with the bulb representing
the brainstem and the tube the spinal
cord marked off in segments. In such
a scheme you see two long, diffuse
columns representing the spinal, and
entire origin of the sympathetic ner
vous system and for the parasympa
thetics a group of discrete nuclei in
the brainstem and in the sacral sec
tions of the spinal cord. If the
diagram is enlarged by lines leading
to organs innervated, (those repre
sented on the right-hand side of Fig.
1 .2) , the first impression may well be
that the viscera prodomi nate.
Because of our preoccupation with
the traditionally emphasized dual in
nervation of these organs, many text
illustrations still fail to give the com
plete picture or emphasize only vis
ceral innervation. But if the somatic
structures of the body are included in
the schematic rendering (represented
on the left-side of the schema) it
becomes very clear that only the sym
pathetic system sends autonomic in
nervation to those structures. There is
no parasympathetic distribution to
what I have called the primary
machinery of life. In that machinery
the sympathetic nervous system is in
complete autonomic control. Even in
considering the visceral meeting
places of the two systems, we cannot
speak of their co-function as some
sort of contest for domination.
Going further into detail, we can
see that from the central origins
where cell bodies, that is, the
preganglionic neurons, receive im
pulses from all over the body, the
parasympathetic aims its pregangli
onic neurons almost directly at in
dividual viscera or parts of viscera.
At each organ there is a synapse in or
on or close to the organ itself where
the short postganglionic neurons take
off. In contrast, we see that the sym
pathetic nervous system has the
preponderance of its postganglionic
origins in a chain of ganglia close to
the spinal column, extending from
the suboccipital region down to the
caudal end of the spinal column.
Thus the preganglionic portion of the
sympathetic system, with its long col
umnar origin in the spinal cord, ex
hibits still greater divergence in the
distribution of its fibers to ganglia
along the spinal column; this means
that the postganglionic neurons sup
plying the peripheral structures are
very long. In addition there are, of
course, supplementary ganglia or
plexuses i n the abdominal cavity
which in turn give off shorter
postganglionic neurons to the various
tissues innervated. Another stage of
divergence is evident, therefore, in
the distribution of sympathetic post
ganglionic fibers throughout the
body.
With respect to the currently en
larging view of sympathetic function,
three significant points emerge from
this brief summary of autonomic or
ganization: 1) There is not a single
tissue of the body which does not
receive some kind of sympathetic in
nervation with its primary origin in
the spinal cord and a secondary origin
in the ganglia, most of them aligned
in the paravertebral pair of chains.
2) Parasympathetic infuence is limited
entirely to the visceral organs, in ac
cordance with the endophylactic and
trophotropic function of the para
sympathetic nervous system. 3) The
sympathetic nervous system is the
vasomotor system of the body.
The third point indicates perhaps
the most important distinction be
tween sympathetic and parasym
pathetic function. The sympathetic
system innervates the blood vessels of
the body, the resistance vessels as well
as the capacitance vessels, so it has
profound influence on resistance to
flow and circulating blood volume.
Within the heart it profoundly
influences both rate and force of
contraction. The parasympathetic
system, by way of the vagus, exerts
considerable control over heart rate,
but little regulation of the vascular
components of the cardiovascular
system, the major exception, of
course, being in the pelvic area.
So the sympathetic system, by
selectively inducing vasomotor ac-
Interpretation of research

tivity in various parts of the body and

influencing rate and force of the
heart, can alter not only the amount
of blood flow but also the distribu
tion of blood from one part of the
body to another, according to where
the action is and what kind of regula
tion is required at any given moment.
In other words, the sympathetic
system controls the body's lifeline, its
capacity for function and survival.
In view of this crucial activity and
the associated energy exchanges, it
can be seen, as indicated in Fig. 1 . 2,
that the sympathetic nervous system
actually occupies a most strategic
position between the viscera and the
somatic tissues, tuning body function
in accordance with what is going on
in the environment, as evidenced by
what the main energy consumers, the
skeletal muscles, are doing from
moment to moment. This is the heart
of the concept of the sympathetic
system as mediator and, in my opin
ion, the crucial area of influence of
osteopathic practice.
If the sympathetic nervous system
is going to be sensitive to the environ
ment, to the demands being placed on
the body as a whole and to the way in
which the individual himself inter
prets those demands, then of course it
is going to be sensitive to impulses
coming down from the higher centers
which organize the motor patterns
that we are concerned about. And
if this is essential under normal
conditions then it is even more essen
tial under conditions of pathologic
change. This is not to disparage the
role of the parasympatgetic nervous
system in the health and vigor of the
musculoskeletal system; it is most
important. But this point conven
tionally receives emphasis enough
and what we need more is to put the
sympathetic system in proper per
spective as the chief mediator, the
chief tuner of visceral activity and its
responses to peripheral and external
influence.
Mode of action of the sympathetic
system
When we come to the question of
how the sympathetic system performs
the functions touched on above, we
again encounter some cherished
notions that are preserved and
perpetuated in textbooks and class
rooms. We teach them because of the
weight of tradition and expediency,
but at the same time we try to convey
the clear impression that these con
ventional ideas are in some instances
dubious or untrue and in any case
inadequate. In simplest terms, tradi
tional teaching centers on the concept
that autonomic function comprises
two equal and opposite branches that
are concerned with regulating smooth
muscle activity and secretory activity,
one exciting and the other inhibiting,
so that all we need to do is balance
these actions and we have perfect
health. In relatively recent years the
concept has been modified in some
quarters by the term "integrated"
instead of "antagonistic" with
reference to the two types of auto
nomic function. On the other hand,
some of the newest texts label the
autonomic nervous system as the
"visceral nervous system, " which
again tends to perpetuate misleading
connotations.
In this traditional view, the mode
of action of the autonomic innerva
tion is to induce more or less con
traction of muscle elements in the
visceral organs and blood vessels or
more or less secretion in the viscera
thus innervated; adjustments of cellu
lar metabolism that depend on the
amount of contraction or of secre
tion. Over the years, a tremendous
literature has accumulated which in
dicates the incomplete nature of such
a descri pti on of sympat het i c
function, but the observations have
been reported separately and in
dividually. The total picture has never
been assembled, perhaps because
there is no place to fit the pieces into
the comfortable concept of the du
ality of autonomic function and its
uncomplicated preoccupation with
smooth-muscle or secretory activity.
Some of these "new" observations
are now sixty or seventy years old but
are still looking for a conceptual
home.
The Orbeli phenomenon
Among the first of the nonconformist
observations was that reported by a
distinguished Russian physiologist,
L. A. Orbeli, around the turn of the
century. He had done the classic frog
experiments, familiar to all of you,
involving stimulation of the sciatic
nerve, and had recorded the ampli
tude of the gastrocnemius response to
various intensities and frequencies
of stimulation. Then he wondered
what would happen if he stimulated
the sympathetic ganglia innervating
the gastrocnemius muscle at the same
time the sciatic nerve was stimulated.
He tried this and found that the
amplitude of contraction was greatly
increased. In other words, the sym
pathetic stimulation apparently aug
mented the amount of energy released
by the muscle. To offset the chance
that the effect was due somehow to
vasomotor activity and increased
blood flow, he repeated the experi
ment with this factor controlled and
the result was the same; the power of
contraction was increased, perhaps
through an improvement in the trans
fer mechanism between metabolism
and the contractile process. He
extended the observation further and
showed that after sciatic stimulation
to the point of muscle fatigue and
imminent contracture, the introduc
tion of sympathetic stimulation
restored the muscle to its original
condition.
This work has been discounted or
ignored for many years; in fact, very
few investigations along the same line
have been reported. The most recent
are those carried out by L. M. N.
Bach, 2 who confirmed many of
Orbeli's findings and extended them
and elaborated on the mechanism
involved.
Facilitation oftransmission
Some investigators, including Hutter
and Lowenstein, have shown that
stimulating the appropriate ganglia
will also facilitate neuromuscular
transmission, namely, the ease with
which the excitatory process crosses
the myoneural junction, the motor
end-plate. Ordinarily, when motor
fibers are stimulated not all the
muscle fibers innervated by a given
nerve are brought into activity, but
when the sympathetics are excited
simultaneously there is some change
at the junction which makes it easier
for impulses to cross. Dell and
Bonvallet, 4 among many others, have
shown that the sympathetics and ad
renergic agents also have a profound
effect on the central excitatory state
of the nervous system itself; there is a
facilitation of synaptic transmission.
The result is an alerting effect on the
sympathetic system as mediator
between viscera and the somatic
ti ssues making it much more
responsive to what is going on.
1TJ
Cerebral mechanims
We know of course that the sym
pathetic innervation extends to the
blood vessels supplying the brain and
the central nervous system and can
exert a profound influence on blood
flow to these tissues. Ordinarily this is
a negligible role because brain
circulation i s regulated l argely
through arterial blood pressure, but it
is well established that under certain
conditions, when the sympathetics
are stimulated in a given area, for
example the superior cervical gang
lion, there is strong contractile
activity in the vessels to the brain to
the degree that cerebral ischemia may
be produced. This is probably the
basis for the success of nerve block,
stellate and other blocks, in over
coming ischemic nervous disorders.
Beyond this neurovascular control
is the fact that sympathetic innerva
tion has a profound influence on
cerebral function itself, even the
highest intellective functions. The
results in experimental animals have
demonstrated, for example, that vari
ous interventions in the superior
cervical sympathetic ganglia can
either impede or accelerate the rate of
learning or forgetting of conditioned
reflexes and profoundly modify
bran-wave patterns.S-1 O So we see that
the sympathetics have i nfluences
which are not ascribable merely to
regulation of smooth-muscle or se
cretory activity.
Inhibition of healing
There is a fairly large literature
showing the profound infuence of
sympathetic innervation on recvery
from various forms of tissue injury.
Thus, experimental corneal ulcera
tions due to lesions of the trigeminal
nerve are healed or prevented by
stellatectomy. " Other studies have
demonstrated a strong inhibition of
the rate of regeneration of injured
tissues, the rate of healing of experi
mental scars being accelerated by
sympathetic denervation. , 2 The rate
of development of collateral cir
culation following experimental
ligation of vessels in laboratory
animals is accelerated on the cor
responding side by unilateral gangli
onectomy. The collateral circulation
to various tissues may be greatly
impeded when the sympathetics are
maintained in an excited state. So we
have an influence on the rate of
1T4
regeneration or healing and on the
rate of recovery from various insults.
Immuno-endocrine reponse
We know that the sympathetic system
influences immune reactions, allergic
responses, inflammatory processes in
various tissues. There are profound
influences on cellular metabolism, on
the enzyme profiles of various tissues,
on the rate and quality of protein
synthesis, on active transport across
cell membranes.
A whole series of investigations
have been carried out on the effects
of sympathetic function on endocrine
activites - the thyroid especially
seems to be sensitive to changes in
sympathetic tone, but the same is true
of the pituitary which comes under
the infuence of the superior cervical
ganglion. The pineal body has re
cently been the subject of much
investigation and is now revealed as
playing a role in sexual function in
lower animals and in providing much
of the basis for diurnal rhythm. It has
been demonstrated that there is a
small twig of fibers going to the
pineal gland from the upper cervical
ganglia and when these fibers are cut
the pineal body loses its diurnal
rhythm. 1 4
influence on other tissue responses
Ther e i s a l ar ge s er i es o f
investigations demonstrating the
crucial influence exerted by sym
pathetic innervation on responses
that tissues make to other influences,
whether parasympathetic, endocrine,
environmental or other. One instance
of such research is that which has
shown in young animals a striking
alteration in gonad response to
gonadotropic hormone as the result
of sympathetic stimulation. Workers
at the University of Minnesota some
years ago' l showed that when the
sympathetics to one side, the lower
sympathetic ganglia, were removed in
puppies the bones on that side grew
larger than on the opposite side;
conversely, chronic stimulation of
the sympathetic outfow produced a
stunting of growth. Although this
was given a vasomotor interpretation,
it may also be regarded as an al
tered response to the somatotropic
hormone.
At the New York University School
of Medicine, Gutstein applied an
ingenious method for maintaining
continuous sti mulation of the
splanchnic outflow in rats and with
this he was able to produce various
kinds of atherosclerotic and arterio
sclerotic lesions including those often
found in man. ' 6 Although many
biochemical and other factors entered
into the arteriosclerosis, the sym
pathetic neuroexcitation appeared to
be a critical conditioning influence
causing the arterial tissues to alter
their responses to the other factors.
Here again we see the importance
of the conceptual framework because
there are others who have also stimu
lated the splanchnic nerve chronically.
But Gutstein was interested in athero
sclerosis and limited his remarkable
techniques to the examination of the
aorta; others were concerned with hy
pertension and directed their studies
to the kidney, still others were inter
ested in the duodenum and looked
only at the upper gastrointestinal
tract. Each of these studies on one
organ or function or another is of
course a valuable contribution. But as
long as the research, and the report
ing of the research, is specialized and
compartmentalized according to the
organ or function involved, not only
is there duplication of research effort
but much more important, common
denominators are overlooked. Thus
the gastroenterologist who reads
mainly the gastroenterologic litera
ture cannot be aware of observations,
let us say, of the effects of sustained,
intense sympathetice stimulation on
the eye, the heart or the lungs
reported in the correspondingly
specialized journals and that they
represent essentially the same kinds
of influences that he has observed on
the duodenum, except that they are
being expressed through other tissues
and organs each in its own way. In
the same way, various clinical dis
orders referred to different organs
may share a common neuropath
ological process expressing itself
through different physiological "in
dicators. "
The common denominator
One could go on and on with a
detailed inventory of all these diverse
infuences that are clearly ascribable
to the postganglionic neurons of the
sympathetic nervous system. Obvi
ously the neurons themselves can
hardly be that diverse - they are very
much the same, they look alike under
the microscope, the impulses they
Interpretation of research
conduct are nearly identical, the
mediators at the junctions are limited
to the catecholamines or acetylcho
line. So wherein lies the diversity?
It seems clear that the answer is in
the tissues themselves, the cells to
which the sympathetic influence is
directed. We emerge with an impor
tant basic concept, that sympathetic
innervation infuences critically and
profoundly the cellular physiology of
whatever organ is involved and the
influence is in accordance with the
nature of the cell, with what it
happens to be doing at the moment,
with the challenge that confronts it
and with the other influences it is
subject to at the moment.
Here is a rather common factor
which applies to all tissues. The
myocardial cell responds only as a
heart cell would. A sweat gland
responds as a sweat gland would. A
gonad responds as a gonad, likewise
the duodenum or the pancreas. The
sympathetic infuence in every case is
precisely the same, the physiologic
response of the target tissue depends
on the nature of its constituent cells.
Most of the work that has been re
ported in this field has demonstrated
that when sympathetic tone to a given
area is persistently increased, the
influences are almost invariably
adverse. In many disease states the
sympathetic component is found to
be augmented and exaggerated, many
visceral diseases are accompanied
by demonstrable neuropathologic
changes in the sympathetic nervous
system, and very often, good results
are achieved by suppression of the
sympathetic impulses to the particu
lar organ involved. This is not merely
a generalized sympathetic inhibition,
but rather an aimed influence to a
particular organ by way of a par
ticular branch of the sympathetic
outflow.
References
I . Hess. W. R. The Diencephalon - Autonomic
and Extrapyramidal Funclions. New York, Grune &
Stratton, 1 954.
2. Bach, L. M. N. "Brainstem facilitation of the
knee jerk and the Orbeli effect." Am, J. Physiol.
1 71 :705, 1953.
3. Hutter, O. F. and W. R. Loewenstein, "Nature
of neuromuscular facilitation by sympathetic simtula
tion i n the frog. " J. Physiol, 130: 559-571 , 1955.
4, Dell, P. , M. Bonvallet and A. Hugelin. "Tonus
sympathique, adrenaline el controle reticulaire de la
molricite spinale. .. Eleclroenceph. and CUn. Neuro
physiol. VI: 599-61 8, 1954.
5. Veselkin, N. P. "The effect of uni lateral cervical
sympathectomy on cerebellar electrical activity in the
pigeon." Doklady 124: 129- 1 3 1 , 1959.
6 . . Sollertinskaya, T. N, "The effect on the
electrical activity of the cerebral cortex of removal of
the superior sympathetic cervical ganglia. " Doklady
1 12: 145-147, 1 957.
7. Karmian, A. I. "Infuence of the sympathico
adrenal system upon reflex activity at higher levels of
the central nervous system." Sechenov Physiological
Joural ofthe USSR 44:285-295, 1958.
8. Aleksanyan, A. N. "The effect of sympathetic
Yulnerability of the segmental
nervous system to somatic insults (1970)
The influence of the peripheral
sympathetic nervous system is usually
viewed as being limited to the regula
tion of the contraction of smooth and
cardiac muscle and of secretion by
certain glands. However, there are
many well-demonstrated infuences
that do not fit this prevailing concept.
Among them are influences on con
traction and fatigability of skeletal
muscle, neuromuscular transmission,
growth, healing, development of col
lateral circulation, inflammatory
processes, synthesis of hormones and
enzymes and on the responses to
other factors and stimuli. The very di
versity of the influences that have
been demonstrated suggests that the
diversity is not in the sympathetic
fibers but in the kinds of cells
that they innervate, and that the
postganglionic sympathetic fibers
condition and modify the inherent
"physiology" of the innervated cell,
whatever that might be,
Among the diverse i nfluences
which are of special interest in con
nection with the theme of this seminar
are those, usually excitatory, exerted
by sympathetic fibers on the sensory
mechanisms of the body.
As I recall , it was first demonstrat
ed in the olfactory apparatus and
later the taste buds that stimulating
the sympathetic innervation to the
nose and the tongue actually increases
the sensitivity of the receptors so that
they respond to much smaller quanti
ties of neurochemicals. The findings
have since been extended to the
nerves on the electrical actIVIty of the brain."
Proceedings of the Academy of Sciences USSR
1 25: 236- , 1 959.
9. Tai-an. Van and M. G. Belekhova. "The
influence of the cervical sympathetic nerve and the
effects of some pharmacclogical substances on the
'recruitment reacti on' . " Sechenov Physiological
Joural of the USSR 47: 1 8-29, 1 961 .
1 0. Zagorul'ko, T. M. "On the i nfluence of the
cervical sympathetic nerve and adrenalin on the
induced responses of the visual system of the rabbit . "
Scchcnov Physiological Joural of the USSR
5 1 :54-6, 195,
1 1 . Baker, George S. and Cornelius M. Gottlieb.
"The prevention of corneal ulceration in the
denervated eye by cervical sympathectomy: An
experimental study i n cats." Proc. Sttf Meeting
Mayo Clinic 34:474.478, 1959.
12. Cruickshank, A. H. and R. Harris . .. Accelerated
wound healing in rabbits' ears after cerival sym
pathectomy." J. Path. Bact. 73: 1 77- 1 81 , 1957.
13. Sardina, R. A, "Effect of injury of the CNS on
collateral circulation." Arkh. Anal. Gislol. Emhroil.
33:55-58, 1956.
14. Wurtman, Richard J. , Julius Axelrod and Josef
E, Fischer. "Melatonin synthesis in the pineal gland:
Effect of light mediated by the sympathetic nervous
system. " Science 1 43: 1 328-1 329, 1964.
1 5. Gullickson, Glenn Jr., W. G. Kubicek and F. J .
Konke. "Effects of stimulation of lumbar sym
pathetic nerves on longitudinal bone growth in dogs. "
Fed. Proc. 10:56, 1 95 1 .
16. Gutstein, William H. , Jean N. Lataillade and
Leon Lewis, ,. Role of vasoonstriction in eperimenta
arteriosclerosis. " Clrulalion Researh X:925-932,
1 962.
Reprinted by permISSIOn from the Postgraduate
Institute of Osteopathic Medicine and Surgery, from
The Physiologic Basis oJ Osteopathic Medicine, p.
2 1-38, 1 970.
muscle spindle, cutaneous receptors
and the other somatic receptors that
Dr. Buzzell discussed and it is now
clear that when sympathetic hyper
activity is maintained, the discharges
from the receptors are profoundly
altered in frequency and pattern and
they may actually begin discharging
even when they are not being stimu
lated. So we get a false input whic
h
upsets the nervous system and
initiates vicious cycles.
Such considerations highlight the
two basic principles that have been
emphasized in these discussions: that
health requires continual tuning of
the visceral functions to somatic and
environmental demand and that it
further requires the smooth; sequen
tial operation of the somatic machin
ery responsible for sensory input to
the spinal cord, From these we derive
the corollary that ill-health and
disease can be ascribed to a break
down in communication between the
175
two major components of the body,
the visceral and the somatic. The
resulting disorders in health may be
induced in several ways: first when
the musculoskeletal system (or the en
vironment it acts on and responds to)
- the primary machinery - makes
excessive or inappropriate demands
on the viscera; second when meaning
less information is fed into the ner
vous system to the point that an ap
propriate or adaptive response is im
possible; and third when the viscera
make totally inappropriate, inade
quate or confused responses to
somatic demands.
The role of the spinal cord
Osteopathic concepts have long
placed emphasis on the strategic role
of the spinal cord in somatovisceral
C9QJ_diation and in the organization
of disease processes. Essentially this
role, speaking fguratively, is that of
a "keyboard" through which the
brain finds expression. The spinal
cord is the structure where most of
the body's innervation begins; it is
where most of the nerves emerge; it is
where most connections are made be
tween the tissues and organs of the
body on the one hand and the central
nervous system on the other. About
Wpercent of the sensory information
from the body itself is fed into the
spinal cord where it receives its first
preliminary coding. Outgoing com
munications from the central nervous
system also are processed in the cord;
commands from the higher centers re
ceive their final coding here before
they are sent out over efferent path-
#
ways.
For the osteopathic clinician per
haps the chief significance of the
spinal cord lies in its role as the place
of origin of the sympathetic nervous
system, as the place where visceroso
matic coordination is achieved and
where communications do break
down when such coordination fails.
The sympathetic outflow is an impor
tant part of the total efferent out
fow, going to all parts of the body
and "tuning" visceral, circulatory
and metabolic activity according to
the large and rapidly changing re
quirements of the skeletal muscu
lature.
With respect to our "keyboard"
image of the spinal cord, it is impor
tant to note that unlike the piano and
similar instruments, the cord re-
IT0
sponses are not organized in terms of
single notes. When a "key" is pushed
by the higher centers it elicits whole
compositions of patterned activity,
which the brain combines, modulates
and orchestrates in still higher com
plex forms. The basic patterns of
organized activity, however, are built
into the spinal cord as the body
develops. An instance of this is the ar
chaic pattern of four-legged locomo
tion that man has inherited in the
course of his evolution (the swinging
of the arms in walking and running.)
Now what do we mean by "pat
terned activity?" We know that the
patterns of feedback to the spinal
cord are highly organized; the ner
vous system does not read individual
signals but the changing patterns of
signals from many sources. How are
the normal patterns mediated by the
spinal cord and how do they relate to
the segmental divisions?
First let me remind you of the kinds
of nerve cells we are concerned with
in the spinal cord. We have the sen
sory fibers whose cell bodies are in
the dorsal root ganglia, the anterior
horn cells which supply motor inner
vation of the skeletal muscles and the
lateral horn cells, the origin of the
sympathetic outflow to the viscera,
blood vessels and so on. (These in
fluences from the cord are based on
the conduction of impulses in one
way or another, but in addition there
are trophic influences which seem to
depend not on nerve impulses but
rather on an exchange of substances
between neurons and the tissues
which they innervate. And all three
kinds of neurons exert such a trophic
influence.)
The simplest flexion of a joint such
as merely bending the elbow involves
a high degree of coordination of a
great many neurons, the motor horn
cells and the sympathetic neurons.
The extension of my elbow joint in
volves much more than a simple mo
tion of the arm: it produces a shift in
the center of gravity of my entire
body calling for an adjustment in the
postural mechanisms - neurons in
the low back and the legs - so that I
do not fall fat on my face and so the
center of gravity is kept over the base
provided by my feet. In short the sim
ple act of extending my arm brings in
neurons up and down the whole spi
nal column. Similarly the simple pro
cess of drawing in a breath activates
neurons supplying the head and neck,
the diaphragm, the intercostal and
abdominal musculature - neurons
scattered throughout the cord are in
volved and brought in at the appro
priate moment and frequency in
order to produce a single breath.
In other words, whole "sympho
nies" of motor activity and accom
panying supportive autonomic activi
ty are organized by the spinal cord
and while these patterns are being
played on the spinal keyboard by the
higher centers, continual adjustments
are being made according to the
information fed in over all the dorsal
root fibers. This input is continually
modulating and adjusting the pat
terns of activity according to the
situation that exists in the limbs and
joints from moment to moment.
The important point is that these
patterns of activity involve neurons
up and down the spinal cord, each be
ing called into play according to the
pattern required at the moment -
not according to where the neuron is
located in the cord but according to
what structure it innervates. Where it
"lives" segmentally is of no impor
tance, our concern is what it controls,
what mechanism needs to be called in
at any given moment.
This presents us with an interesting
paradox: the normal patterns of activ
ity mediated by the spinal cord are
completely nonsegmental in nature
the patterns are longitudinally orga
nized -yet the spinal cord is obvious
ly segmented and the physician is very
much concerned with segmental rela
tionships. Mechanisms of referred
pain, for example, may be extremely
important in diagnostic problems and
here the segmental relationships are
very conspicuous. Nevertheless, in
normal life segmental relationships
do not appear.
The reasons for this paradox may
be best conveyed by another illustra
tive simile. Consider a beautifully ex
ecuted parade of skilled marching
men, where the many ranks and col
umns are seen as patterned activity of
the whole parade. We do not see in
dividual ranks and certainly not in
dividual marchers, we see patterned
motion. But let something go wrong,
let one of the marchers lose step and
his rank immediately becomes conspic
uous. The other marchers cannot
compensate in a coordinated manner
and soon the ranks on either side are
Interpretation of research
also thrown into confusion and then
we do see the segmental relationship.
It is something like this that causes
segmental relationships in the spine to
emerge into view under conditions of
clinical disorders. A segment "in
view" i s a segment in trouble .
How shall we reconcile the
paradox? First by realizing that the
thing that is segmented is the armor
that houses and protects the cord.
The cord itself i s unsegmented and
flexible but its bony suit of armor at
tains fexibility only through the seg
mentation provided by the vertebrae.
The only way to bring lines of com
munication from the central nervous
system to the periphery of the body i s
through holes in the armor placed at
more or less regular intervals , be
tween the vertebrae. In normal life the
segmentation is not of the spinal cord
itself; the segmentation is in the
assembling of the nerve fibers into
"cables" - roots and nerves - that
can pass out to the tissues innervated.
What is segmented is ingress and
egress, not the function of the cord
itself. In addition to the neural rela
tion to spinal segments we note a
segmental relationship in the sheaths
surrounding the dural and arachnoid
extensions of the cord and also in the
blood vessels that supply the cord and
the nerve roots.
What we are concerned with here i s
the cord completely encased i n bone
and having to make connections with
the periphery through holes in its ar
mor, the intervertebral foramina.
Now lest you anticipate that I am go
ing to talk about the 019-fashioned
"pinched nerves" and such, I am not.
I am going to talk about much more
subtle influences that exert profound
effects on cord function and its com
munications. These foramina contain
not only the nerves and roots and
their sheaths, but also quantities of
fat, connective tissue, periosteum,
blood vessels and so forth. We now
know that it takes very slight, local
ized pressure or mechanical deforma
tion to disturb the excitability and
conductivity of the neurons that hap
pen to be passing through a foramen
at the focus of the pressure or defor
mation.
Mechanical hazards
To appreciate the vulnerability of the
segmental nervous system to somatic
insults it must be understood that
much of the pathway taken by the
nerves as they emerge from the cord i s
actually through skeletal muscle. The
great contractile forces of skeletal
muscles with the accompanying
chemical changes exert profound in
fuences on the metabolism and ex
citability of the neurons. In this envi
ronment the neurons are subject to
quite considerable mechanical and
chemical influences of various kinds,
compression and torsion and many
others. I remind you also that the
nerve sheaths, which are extensions
of the meninges surrounding the
spinal cord, extend for a considerable
distance along the roots and these
root sleeves make it possible for us to
move our spinal columns over a wide
range without friction. The nerves
slide smoothly in and out as we move
in various directions. Slight mechani
cal stresses may, over a period of
time, produce adhesions, constric
tions and angulations imposed by this
protective layer.
Since arteries are part of the struc
tures that pass through the foramen,
the arterial blood supply to both the
bony column and the spinal cord is
part of the same anastomosis, so that
a disturbance in one inevitably has
some effect on the other . Although
very slight pressure on the artery may
not induce occlusion, it does produce
turbulence of flow or other serious
hemodynamic consequences. The
dorsal root ganglia are particularly
vulnerable in this regard through
sharp angulation of the recurrent
branches of the radicular arteries that
supply the ganglia. Resultant ische
mia of the dorsal root cells can lead to
progressive loss of sensory feedback
involving the dorsal root ganglia.
This suggests that much of the motor
disturbance in old age may represent
sensory loss, especially propriocep
tive feedback, at least as much as
direct motor loss.
With respect to venous supply and
drainage, we have a rather strategic
point because the venous pressure i s
extremely low and slight congestion
of the vessels as they pass through the
foramen will cause some damming
back into the area of venous drain
age. These edematous pressures are
enough to produce effects on nerve
conduction that I will mention in a
moment.
Mechanical hazards to the sympa
thetic ganglia are especially signifi-
cant because of the location of these
structures firmly pressed against the
vertebral column under the parietal
peritoneum and pleura and in close
approximation to the costovertebral
junctions. Obviously these ganglia
are subject to tremendous stresses im
posed by motions that take place
almost continually. Also subject to
great mechanical stress i s the
ganglionic chain in the neck which is
highly movable and therefore vulner
able to distortions of other kinds. All
of these stresses can have profound
infuence on the physiology of the
nerve cells.
Assuming that such mechanical
disturbances of neuron function do
take place, what are the effects in
relation to the segmental nervous
system? Obviously great pressure will
interrupt nerve conduction, but this is
not what we are most concerned
about. Rather we are concerned with
intervertebral forces, in and on either
side of the foramina and those caused
by the contraction of muscles acting
on the nerve trunks that happen to be
passing through them. And again, we
are concerned not with the damage
resulting from vertebral trauma or
herniated discs but rather subtle
pressures, deformations and cir
culatory changes (edema, congestion,
compression, angulation, ischemia,
etc.) These subclinical states produce
three kinds of disturbance in nerve
function:
1 . Increase in neural excitability at
the point of disturbance: Laboratory
studies and clinical tests throughout
the world have demonstrated that
almost insignificant deformation of
the nerve trunk may cause that spot
to become spontaneously active espe
cially if there are simultaneous
chemical changes due to local muscle
activity. And remember that impulses
arising at such sites proceed in both
directions, toward the cord and
toward the periphery, whereas nor
mally impulses arise either at the cen
tral or peripheral "end" and proceed
in one direction. Impulses thus reach
the cord that did not originate in
some peripheral reporting station and
signals reach effectors that were not
dispatched fr.m the cord.
2. Triggering of supernumerary im
pulses: As a normal impulse passes
the disturbed site from some sensory
receptor or a motor neuron, it does
not simply pass through but instead
177
triggers a whole train of impulses so it
is followed and accompanied by a
whole barrage. The frequency of dis
charge from and into the spinal cord
is increased, the actual frequency of
discharge from and into the spinal
cord is increased, the actual frequen
cy of discharge to the periphery is in
creased and the patterns garbled so
that, according to the type of
neurons, we get disturbed muscle
contraction, vasomotion and so
forth.
3. "Cross-talk": Nerve fibers in a
given root or nerve are highly private
pathways. What passes down a fiber
is not the business of its neighbors in
the same nerve; the insulation is quite
effective. Nevertheless every passing
impulse normally generates small
electrical fields in its vicinity as it
moves along the fiber. But where dis
turbances of the nerve have in
creased excitability of its axons,
"cross-talk" may take place between
axons. It is like a conversation on our
telephone when other lines sharing
our cable feed into our line.
Thus an impulse on its way to a
muscle may set off impulses in a sym
pathetic neuron or in the pain fibers,
apparently by lateral transmission
from one nerve fiber to another at the
site of very slight compression and
usually from large sensory or motor
fibers towards smaller fibers such as
the pain fibers and sympathetic
fibers. Moreover, the sympathetic
fibers especially the preganglionics in
the root are larger than the pain
fibers, so they in turn may trigger
pain impulses. This means also that
any emotional response or tempera
ture change which sets off sympathe
tic activity may cause pain that does
not originate in the periphery but
rather somewhere along the conduc
tion pathway.
These conduction phenomena have
a profound effect on the functioning
of the spinal cord. They generate
"noise" which the spinal cord cannot
convert into useful information. In
addition, the pain which at first is not
located in the periphery soon be
comes so through all these refex
mechanisms and through the sus
tained contraction and disturbed sym
pathetic activity. The tissues supplied
by the disturbed neurons become
secondary sources of feedback to the
spinal cord and soon we have a self
sustaining, progressive cycling phe
nomenon. And remember, all these
mechanical disturbances are due to
very slight forces exerted by relatively
slight tissue changes in the in
tervertebral foramina and in para
spinal structures, changes to which
man is especially susceptible because
of his vertical position and the
associated vertebral compression.
Added to all these considerations is
a basic concept which perhaps should
have been discussed first, namely the
fact that when a tissue is disturbed,
whether bone or joint or ligament or
muscle, the local stresses are con-
The segmental nevous system as a mediator
and organizer of disease processes (1970)
If one could point to a specific time
and say this was where the modern
era of osteopathic research began, I
think it would be with that of J . S.
Denslow beginning in the late 1 930's,
and culminating in two papers in the
Journal of Neurophys}ology on
motor reflex thresholds at various
spinal segments in human subjects. 1 2
In this work Dr. Denslow put his
fnger on what has turned out to be
the center of the whole trouble. He
began with a very simple observation
that is familiar to all osteopathic
physicians who use their hands a
great deal: that as you examine the
patient the hands tend to stop in cer-
178
tain areas and your experience tells
you that something is wrong here.
You find, for example, that as you
press upon the tissues of the spinous
process there are certain areas where
the muscles respond very quickly and
others where you can press quite
vigorously and it is as though the
body does not notice.
Such effects are very difficult to
quantitate and what Dr. Denslow did,
in effect, was to begin the task of
measuring objectively these subtle
changes in muscle response. With the'
help of counselors in the basic
sciences and biomedical fields he
undertook studies in which he replaced
tinually reported to the spinal cord,
thus "jamming" the normal trans
mission of patterned feedback from
peripheral areas. The feedback from
the involved tissue over its afferent
pathway becomes a lasting and insis
tent garbling of information reaching
the cord over selective dorsal roots. It
is this kind of thing, coupled with the
mechanical disturbances mentioned
above, that eventually knocks individ
ual segments "out of step" and with
them the tissues and organs and func
tions deriving their innervation from
those segments. Thus the vertically
organized function in the cord be
comes horizontally conspicuous at
the disturbed level, and the clinical
disorder must then be considered in
terms of segmental relationships.
In summary, these are the somatic
insults, the sources of incoherent and
meaningless feedback that cause the
spinal cord to halt normal operations
and " freeze" the status quo in the of
fending and offended tissues. It is
these phenomena that are detectable
at the body surface and are reflected
in disorders of muscle tension, tissue
texture, visceral and circulatory func
tion and even secretory function -
the elements that are so much a part
of osteopathic diagnosis.
Reprinted by permission from The Postgraduate In
stitute of Osteopathic Medicine and Surgery, from
The Physiologic Bai of Osteopthic Medicine. p.
53-61 , 1 970.
the osteopathic thumb with a pres
sure meter of his own design which
could apply measured, pre-set
amounts of pressure. Then simulating
the motions made by the examining
digit, he used electromyography to
measure the first moment that the
paravertebral muscles began to re
spond to the stimulus. He was able to
show that where his fingers said
something was wrong, something in
deed was wrong and he demonstrated
that in those areas of osteopathic le
sion the motor refex thresholds were
low. I t took a smaller stimulus to
elicit muscle response at the cor
responding level of the paras pinal
musculature than at the so-called nor
mal segments.
And he demonstrated his results to
me very dramatically when I began to
work with the pressure meter and the
Interpretation of research
electromyograph. As I studied each
spinal segment in a given human sub
ject I found that I was able to arrive
at the significant pressure threshold
only through a process of trial and er
ror, whereas Dr. Denslow having ex
amined the patient, would go to each
segment and preset the pressure meter
at an anticipated level and come close
or even at threshold about 90 percent
of the time. And this was the frst
l inkage between the subjective
osteopathic approach and the com
pletely impersonal instrumental ap
proach to the diagnosis and treatment
of musculoskeletal disorders.
Analytic methods
Having established the fundamental
point that motor refex thresholds are
low in areas of segmental distur
bance, the next step was to determine
the basis for the lowering and to
devise procedures for analyzing it.
With the help of a grant from the
American Osteopathic Association a
study was designed which would
measure the electro myographic re
sponse of four segments simultaneous
ly as the spinous processes were
stimulated by the pressure meter. The
segments chosen were T-4, 6, 8, and
10, and each measurement included
not only the reflex activity at the cor
responding segment but also how
much pressure was required at each
of the four spinous processes to trig
ger muscle activity at the other three
levels. Thus each single recording ses
sion provided data on 16 reflex arcs.
The principal finding that emerged
might best be illustrated by a very
simple and hypothetical" example -
remember that in an actual human
subject the picture would be much
more complex - showing the seg
ment at T-6 to be so disturbed that
very slight mechanical pressure on the
spinous process would elicit hyperac
tivity of the spinal extensor muscles at
that level. At the same time, the seg
ment at T - 1 0 might be normal by
clinical and neurologic criteria so that
even the top level of pressure applied
here would not produce activity. But
somehow or other the stimulus would
ascend through the spinal cord and be
expressed through T-6 without pro
ducing activity in intervening or
higher normal segments. The effect
that we observed was rather like the
elevator signal-system in a tall
building: a bell can be rung at its own
level quite easily without ringing the
bells at other levels, but on the other
hand it is easily rung from levels
above and below.
When we anesthetized the tissues in
the spinous process at the disturbed
segment we could no longer elicit ac
tivity by applying pressure at that
point but when we moved to a normal
segment and applied pressure, the bell
at the disturbed segment was rung as
easily as before. Obviously something
was going on inside which was keep
ing that segment disturbed and for
the first time we began to use a term
that made it possible for us to begin
communicating with fellow physiolo
gists: this segment was in a state of
facilitation.
Then the question became: What
about normal stimuli? After all we do
not go around prodding each other at
spinous processes. To examine this
point we made use of several natural
reactions including the subject's
initial apprehension and tenseness,
his startled response to a sudden loud
noise or to a painful stimulus and the
tension evoked by embarrassing ques
tions or by a fake piece of bad news.
In every instance the tensions first
found expression in segments where
thresholds had been demonstrated to
be low and with relaxation these were
the last muscles to quit firing. We
also tested the response to carbon
dioxide accumulation by means of a
rebreathing apparatus and found that
as respiration became deeper and ac
cessory respiratory muscles were
called in, the frst levels to be
recruited were those at the low
threshold segments.
For me, a beginner in the field,
this was a very exciting period. Our
findings characterized the kind of
phenomenon we were dealing with,
which we eventually described as a
state of chronic segmental facili
tation, at least with respect to the
motor anterior horn cells innervating
the spinal musculature. In my first
article for the AOA Joural in 1 947, 4
I referred t o this as a neurological
lens which focused irritation upon the
lesioned segment and magnified its
responses. These were the segments
that took the beating, day in and day
0ut, under impulses coming from
anywhere, including the higher
centers of the nervous system.
The next stage was an area of great
interest to me because of war research
where I had begun to see the tre
mendous damage that could be done
by the sympathetic nervous system
badly used. Was sympathetic reflex
activity also facilitated in the aberrant
segments? And if it was, what would
it mean to visceral function, to cir
culation, to the person as a whole?
We were going to have to work with
human beings because we wanted to
study the sympathetic phenomena as
they occur under natural conditions
and in the total context of the in
dividual. And since it was necessary
to keep our experimental subjects
intact we turned to the skin as a
readily accessible, nicely segmented
structure for which dermatomal maps
had been established so that we could
identify segmental relationships. And
we decided first on the sweat glands
as our physiological indicators of
sympathetic activity.
The human skin, being usually
quite dry on the surface, has a very
high resistance to the passage of elec
tric current but in the presence of
moisture from the sweat glands the
resistance is lower. Therefore, we
turned to the measurement of elec
trical resistance of the skin as a
measure of the number of sweat
glands which were secreting at any
given moment in a given area. Our
first instrument was assembled from
a few dry cells and a microammeter,
with silver electrodes (two dimes for
which I have never been reimbursed! )
fashioned so that one could be ap
plied to the ear, for example, while
the other was used for exploration.
Our object was to find the situations
parallel with what we had observed
on skeletal muscles; in other words,
sweat-gland activity in areas under
cool, resting conditions in which
sweat glands in most areas remained
inactive.
With such devices for measuring
electrical skin resistance, along with
thermocouple instruments for mea
suring variations in skin temperature,
we laboriously explored and mapped
out surface areas of varying re
sistance and temperature, then drew
these on body charts to see what
patterns of segmental disturbance
were present. Now we have a sophis
ticated instrument, built in our own
shops, in which an electrode mounted
on a pantograph "rides" back and
forth on the subject, picking up vari
ations in current flow through the
1T
skin which are recorded by an oscil
lating galvanometer. Eventually these
scanning lines compose a topographic
map of the subject's body surface,
with areas of light or dark shading
that show where resistance is high or
low respectively, and the correspond
ing segmental distribution of sym
pathetic activity.
In short we have a written record of
the state of sympathetic activity as
refected in sweat gland activity and
cutaneous blood fow in a given area
at a given time. In the dark areas of
low resistance the skin is moist
because of continual sweat-gland
activity in response to sympathetic
stimulation which remains high de
spite the fact that there may be no
actual need for any thermo-regula
tory sweat secretion. As time went on
and we examined hundreds of sub
jects, we found that each had a rather
characteristic pattern that remained
fairly constant; the size of the areas
might vary but the segmental dis
tributions retained the individual' s
characteristic pattern. We could
identify the subject from his ESR -
electrical skin resistance chart -
almost as readily as one can from
fingerprints. 6
Our most recent acquisition is the
thermograph, which, instead of
measuring skin temperature by means
of thermocouples, operates by read
ing the infra-red radiation from the
body surface and recording it on
Polaroid film almost instantaneously
giving us an accurate thermal map of
the body. ' Remember that here the
black areas are cold, the white areas
s
h
ow warmth and one can
s
et the
sensitivities and differentials quite
sharply. These instruments can detect
circulatory disturbances resulting
from musculoskeletal disorders, as
well as vascular lesions such as
thrombosis and various inflam
matory states. They also pick up
tumors and cancers. In our studies,
however, we are concerned more with
the neuromusculoskeletal aspects.
A more modern approach to the
electromyographic study of seg
mental motion and reflex thresholds
is the method using an 8-channel
Grass electroencephalograph, en
abling us to study eight segments
simultaneously, and with instanta
neous switching we can sample activity
in any multiple of eight segments in a
matter of seconds.
I80
The great numler of photographic
records we have accumulated through
the years form an interesting re
flection of the gradual progress in
techniques and instrumentation in
this area of osteopathic research. And
since in many instances we have fairly
complete serial studies of single in
dividuals, we can trace and evaluate
response patterns and note the con
sistency of correlations between
experimental and clinical observa
tions. We have found that electromyo
graphic patterns of posture are as
characteristic of an individual as are
the skin-resistance and thermograph
patterns. Pain threshold patterns and
areas of cutaneous and deep tender
ness are quite characteristic and
constant and in a general way closely
related to each other.
Repeatedly it has been demon
strated that the distribution of areas
of low electrical skin resistance -
that is, areas of sympathetic nerve
activity - correspond quite well to
the actual nerve distribution from the
lesioned segment in the spine. But
you must not look for perfect cor
respondence between skin resistance
and the distribution of the deeper
pathologic disturbance, because an
area of skin which is segmentally
related to a particular muscle does
not necessarily overlie that muscle.
With the latissimus dorsi, for ex
ample, the myofascial disturbance
might be over the hip but the reflex
manifestations would be in much
higher derma tomes because this
muscle has its innnervation from the
cervical part of the spinal cord.
Another method we made use of in
this basic research was a simple
procedure which is part of a physical
examination as done by some osteo
pathic physicians. The two examining
fingers straddling the spinal column
are repeatedly drawn downward on
the paras pinal skin until a red stripe
appears on each side which signals
erythema. Areas where the redness
fades and disappears very quickly
indicate vasoconstriction due to
sympathetic hyperactivity. We de
veloped an instrument for quanti
fying the pressure and applying it at
constant speed, then measuring the
duration of redness after the fric
tional stimulator has been passed
over the skin. Thus we could detect,
for example, areas of intense vaso
constriction on one side or the other
in the vicinity of the lumbar segments
and again we found a high degree of
correspondence with the manual
clinical examination. Still other
methods for study of cutaneous
vasculature and motor activity were
developed and have been described in
publications.8, 9
Clinical applications
Having established the nature of the
hyperreflexia and traced its pattern in
relation to involved spinal segments,
our next step was to 'see whether we
could modify these patterns. First it
was necessary to devise ways of
inducing musculoskeletal distur
bances and a variety of techniques
were tested. For example, one of our
favorite techniques has been to seat
the subject on a stool which can be
tilted, with a seat belt to immobilize
the pelvis and the subject's elbows
resting on a table so that his torso
remains level. Then by dropping one
hip we can induce an acute scoliosis
either to the left or right and note the
skeletal adaptation radiographically
and the accompanying changes in
electrical skin resistance patterns. In
such experiments the abnormal pat
terns of induced trauma and irritation
return to the original state promptly
after the subject's pelvis becomes
level again.
We were quite brave with other
people's bodies in those early days. In
many instances we inserted heel lifts
in one of the subject's shoes creating
an artificial inequality in leg-length -
as much as a half to three - quarters
of an inch -and had them walk with
this for a day or two before re
examination. In one memorable case,
a student-patient with considerable
discomfort in the lower right
quadrant of the back, confirmed by
skin resistance "maps, " was asked to
wear a heel lift for a day and return
the following morning. At that time
we found that the pattern on the
lower right had been "washed out"
but areas of sympathetic hyperac
tivity in other segments of the body
had been intensified. The heel lift was
removed and when the patient re
turned the next day we found that he
had been wrenched the other way.
Thus in the course of some 48 hours,
without adequate preparation, he
had been subjected to quite a wrench
ing adjustment so that there was a
gross exaggeration of the original
Interpretation of research
disturbance and the initiation of
additional disturbances elsewhere in
the body. We later discovered that the
induced disturbance in the mid
thoracic area persisted for many
months afer his experiment.
Another technique we often used
was to inject a tiny bit of hypertonic
sodium chloride into the interspinous
ligaments or paravertebral muscles
inducing irritation which would lead,
in about 30 seconds, to sudden re
ferred pain and muscle contraction,
and within a few minutes there were
new areas of low resistance on the
subject' s body in corresponding
dermatomes. In other words, by rela
tively localized segmental insults to
the musculoskeletal system we have
produced rather substantial dis
turbances in sympathetic function, at
least as reflected in sweat-gland
activity and in vascular and cir
culatory changes.
Over the years we examined a great
many patients and began to see cer
tain consistent correlations between
certain visceral disturbances and
disturbances in sympathetic nervous
function. The relationships or pat
terns were especially marked in dis
orders with marked pain components
such as peptic ulcer, pancreatitis,
cholecystitis, dysmenorrhea, intense
colic disturbances and renal stones.
But we do not take this to imply
causal relationships - I am merely
pointing out that there were these
segmental relationships that began to
emerge and we began to call these pat
terns by the name of the pathologic
disturbance - thus, c% nary pat
tern, duodenal ulcer pattern, gastric
ulcer pattern and so on: it was
interesting to note that the duodenal
pattern was quite different from the
gastric pattern. There was variation
from one patient to another; never
theless, certain consistent and com
mon features appeared in those
charts. Occasionally we would see
these patterns in apparently healthy
students or faculty members and then
under stress or after the passage of
time we would often see a corre
sponding visceral disease emerge in
these individuals. But the question of
whether and how the early musculo
skeletal signs may be specifically
linked to the causation of the ultimate
visceral disorder still requires a great
deal of investigation. In other studies
we related sudomotor and vasomotor
patterns to regional disturbances in
the body framework.
\ \
Meanwhile, we have strong sugges
tive evidence of the manner in which
the spinal areas of low thresholds for
motor and pain reflexes with the
associated sympathetic hyperactivity
might operate continuously in daily
life and thus cause impairment of
function. This is best illustrated by
serial studies in cases such as one we
investigated in 1953, involving a
young biologist who showed asym
metry between the left and right sides
in the lumbar segments of the spine.
He had a gastrointestinal problem
and certain serious skin lesions but
our concern was not for the clinical
situation but rather for the marked
disturbance on the left side as com
pared with the right with respect to
its meaning in terms of segmental
facilitation. We used sweat secre
tion, photographically recorded or
electrically indicated. as our physi
ological indicator of sympathetic
activity. Even after the subject had
been reclining for a long period in a
cool room, we found sweat secretion
going on quite actively on the left side
but none on the right. When heat was
applied to the abdomen we recorded
an immediate increase in sweat-gland
activity on the left, whereas 1 5
minutes passed before the right side
showed any reaction. Not only was
"recruitment" of glands more rapid
on the left but the. volumes of secre
tion were greater. By actual count,
however, the number of sweat glands
per square inch of body surface was
the same on both sides. When pain
stimuli of graduated severity were
applied to a foot or the back of a leg,
again there was a burst of sweat
gland activity on the left or facilitated
side of the lumbar spine. The same
kind of difference could be demon
strated with startling or other kinds
of psychological stimulation. In other
words, what we saw was what we had
noted much earlier with respect to the
motor-reflex threshold: evidence of
spinal-cord segments remaining in a
facilitated, hyperexcitable state
responding prematurely and in an
exaggerated manner to stimuli which
should not be of any fundamental
significance, but producing all the
disturbances of sympathetic hyper
activity that appear to be related to
disturbances in visceral functions. [ 2
If you regard the sweat gland as
you would a visceral organ or a blood
vessel constricted in a visceral organ
or in the brain or other body part,
you can sense the possibilities with
respect to clinical impact. The point is
that here we have a common feature
of sympathetic hyperactivity, and the
specific clinical impact depends on
the target of this abnormal activity.
Each organ, each cell. responds in
characteristic manner to that distur
bance, along with other influences it
is being subjected to at the same
moment and also the conditions
established by its past history. This
says in effect that here is a segment of
spinal cord which is in a state of
continual alarm, literally in a cold
sweat, with aU the consequences
noted in the corresponding state of
acute stressful emergency.
We cannot say that this 24-hours-a
day state of alarm results in illness on
a definite one-to-one basis. We can
only say that these disturbed seg
ments are relatively vulnerable, that
the probability is higher. Whether or
not it becomes clinically significant
depends on the person we are dealing
with and all the circumstances of his
life, past, present and future. Here
is where other unfavorable circum
stances in the patient's daily life may
tip the balance; here is where an ab
normal stress response will tend to
find the earliest and most severe
expression.
Trophic function of nerves
A very exciting area of investigation
in which we are engaged at present is
that of the trophic function of nerves.
You may recall that in my first lec
ture in this symposium I emphasized
that in addition to the impulse
mediated infuences of nerve fibers
going to tissues, there was another
influence that was characterized as
trophic, by which nerves are shown to
be essential to the growth, develop
ment, self-maintenance and survival
of tissues. Nerves have been shown,
actually, to instruct tissue what kind
of tissue to be. That is, the nerve
exerts a property-determining influ
ence on the structure it supplies,
structurally, functionally and chem
ically. This has been demonstrated
in experiments involving cross
innervation -surgical cross-union -
in laboratory animals and we are
studying the transformations that
take place in tissue whose regular
181
innervation has been replaced by
nerves of another type. The question
has been: How does a nerve transmit
biogenetic information and biochemi
cal materials to the tissue?
As you know, when a nerve is cut
the part of the fiber distal to the cut
withers and dies. This is because the
nerve fiber is merely a long. fne
thread of protoplasm which has been
spun out of the nerve cell in the
central nervous system and which is
being continually nourished by the
nerve cell. Flowing down every single
nerve fiber is a stream of nerve-cell
cytoplasm in a volume s great that
the nerve cell is said to "turn over"
its material completely three or four
times a day and this flow is essential
to the continual nourishment of the
fibers themselves along their entire
length. And so we asked ourselves: Is
it possible that the innervated muscle
or organs share this trophic depen
dence on the nerve cell and that at
least certain components of the axo
plasm are transferred from nerve cells
to body tissues?
To test the hypothesIs we did what
I hope will turn out to be the first
of a long series of very exciting
investigations. The method. which
has been described in detail,
13, 14, \J
involves the application of radio
active substances directly to nerve
cells under controlled conditions
permitting us to trace the substances
to specific muscle cells and dem-
onstrate that the substance enters via
the nerve cells and not the blood
stream or cerebrospinal fluid. Now
we are engaged in trying to identify
the substances that are transferred
and their fate and role in the muscle
cells.
I wish there were time to draw
some of the inferences from this very
brief sample of our research but
perhaps you can draw them for your
selves. We can begin to see some of
the implications of these segmental
disturbances which become so con
spicuous in response to actually quite
subtle disturbances and insults to the
neuromusculoskeletal system. When
you add the possibility of a direct
trophic influence to what we know of
sympathetic mediation by way of re
flex activity and the far-reaching
effects of segmental facilitation, you
begin to see how far we have yet to go
in defining the role of the segmental
nervous system as a mediator and
organizer of disease processes and the
exciting promise in this field of
research.
References
I . Denslow, J. S. and C. C. Hassett, "The central
excitatory state associated with postural ab
normalities." J. Neurophysiol, 5:393-402, 1 942.
2. Denslow, J. S. "An analysis of the variability of
spinal reflex thresholds." J. Neurophylol. 7:207-216,
1 944.
3. Denslow, J. S. , I . M. Korr and A. D. Krems.
"Quantitative studies of chronic facilitation in human
motoreuron pools." Am. J. Physiol. 105:229-238,
1 947.
The trophic functions of nerves and their
mechanisms (1972)
Research contributions that my
associates and I have made to the
understanding of mechanisms under
lying the trophic functions of nerves
have been reported. l-s At present,
therefore, I should primarily like to
delineate and characterize the general
area in which our work is intended to
be a contribution and to convey some
perspectives as to what is meant by
trophic functions, and, secondarily,
to summarize our findings.
What is meant by trophic
functions?6'
Unti l relatively recentl y, physi
ologists, neurophysiologist, neuro-
181
chemists, and even clinicians were
rather self-conscious about the use of
the word "trophic" as it applies to
nerves. They usually enclosed it be
tween quotation marks or preceded it
with the words "so-called" - as
though to disclaim any responsibility
for it or any convictions about its
existence. It seemed to be surrounded
by an aura of mysticism. Perhaps this
was because trophicity was so diffi
cult to reconcile with the well estab
lished and much better understood
function of nerves - that of con
ducti ng si gnal s in the for m of
impulses from one part of the body to
another. In that area one deals with
4. Korr, Irvin M. "The neural basis of the osteo
pathic lesion. " JAOA 47: 191 -198, 1 947.
5. Thomas, Price E., Irvin M. Korr and Harry M.
Wright. "A mobile instrument for recording electrical
skin resistanc patterns of the human trunk." Acta
Neuroveg. XVII ( 1 -2):97-10, 1958.
6. Korr, Irvin M. , Price E. Thomas and Harry M.
Wright, "Patterns of electrical skin resistance in
man." Acta Neuroveg. XVII ( 1 -2):77-96, 1958.
7. Wright, H. M. and J. M. Korr. "Neural and
spinal components of disease: Progress in the
application of themography." JAOA 6:91 8-921 ,
1965.
8. Wright, H. M., J. M. Korr and P. E. Thomas.
.. Local and regional variations in cutaneous
vasomolor tone of the human trunk." Acta
Neuroveg. XXII: 33-52, 196.
9. Wright, Harry M. "Measurement of the
cutaneous circulation." J. Applied Physiol.
20:696-702, 1965.
10. Korr, I. M . H. M. Wright and P. E. Thomas.
"Effects of experimental myofascial insults on
cutaneous patterns of sympathetic activity in man."
Acta Neuroveg. 23:329-355, 1962.
I I . Korr, I . M. , H. M. Wright and John A. Chace.
"Cutaneous patterns of sympathetic activity in clinical
abnormalities of the musculoskeletal system." Acta
Neuroveg. XXV: 589-6, 1 964.
12. Korr, Irvin M., P. E. Thomas and H. M.
Wright. "Symposium on the functional implications
of segmental facilitation." JAOA 54:265-282, 1955.
13. Korr, I. M .. P. N. Wilkinson and F. W.
Chornock. "Axonal delivery of neuroplasmic
components to muscle cells." Science 1 55:342-345,
1967.
14. Korr, I. M. "The nature and basi& of the
trophic function of nerves: Outline of a research
program. " JAOA 66:74-78, 1 967.
1 5. Korr, I. M. pp. 343-346 in "Axoplasmic Trans
port. " Neurciences Research ProgramBuletin Vol.
1 5. No. 4. 1 967.
Reprinted by permission from The Postgraduate
Institute of Osteopathic Medicine and Surgery, from
The Physiologic Basi of Osteopathic Medicine. p.
73-84, 1970.
phenomena that are measured in
milliseconds or seconds or, at most,
in minutes, whereas in trophic func
tions the time element is greatly
protracted. The processes and phe
nomena discussed in this paper go
on for months, years, and even whole
l i fetimes. Dr . Patterson' s work,
reported i n this symposium, straddles
the line between the two types of
function, since he is studying long
term changes in the rapid phe
nomena.
Clinical manifetations.
Long - term clinical manifestations
of neurotrophic i nfluences have
been known for hundreds and even
thousands of years. The atrophy of
muscles resulting from what now is
known as anterior poliomyelitis was
certainly known and pictured by the
ancient Egypti ans; al l usi ons t o
Interpretation of research
si mi l ar di sturbances have been
ascribed to Hippocrates; and cer
tainly atrophies following nerve
wounds in battle have been known
for centuries. Some of the finest
descriptions in clinical literature
are those of S. Weir Mitchell. who
described neurodystrophies resulting
from wounds in the Civil War. He
gave the name "causalgia" (burning
pain) to the results of these injuries.
which traumatized nerves in the ex
tremities but lef them uninterrupted.
Some of these injuries were followed
by remarkably grotesque deforma
tions and morphologic abnormalities
in the extremities and their com
ponent tissues.
Osteopathic physicians, of course,
throughout the history of the pro
fession, have placed great emphasis
on the trophic changes, evident to
the eye and the palpating hand, in
the quality of the tissues in areas
of lesion, and Dr. Denslow has
discussed some of those in this
symposium.
Atrophy of denervation
The most conspicuous - and most
thoroughly studied - of the trophic
changes are those which occur i n
skeletal muscle after denervation -
whether it be by interruption of
nerves or death of the nerve cells
(as in polio). Muscle is massive and
relatively superficial, and changes in
its size and function are readily
evident. Moreover, because it has
been thoroughly studied, more may
be known about muscle - struc
turally, functionally, and chemically
- than about any other tissue.
For a long time it was assumed that
the atrophy which followed denerva
tion was really atrophy of disuse -
the cessation of activity following the
interruption of motor nerve impulses.
It now is known - and I wish there
were time to go into the evidence -
that the atrophy of denervation and
the atrophy of disuse in these struc
tural, functional, and biochemical
aspects are quite different in nature
and in course, though the former
does naturally include aspects and
components of the latter. What seems
to be involved is not so much inter
ruption of impulses (and therefore of
contractile activity), but disconnec
tion between nerve cells and muscle
cells.
A rather dramatic and obvious
confirmation of the fact that atrophy
is due to disconnection between
neuron and end organ, rather than
arrest of impulse traffc, is provided
by the trophic changes which take
place in tissues that not only do not
depend on nerve impulses for their
activity but which indeed initiate the
impulses in the nerve fibers that
supply them. I am speaking, of
course, of sensory organs and recep
tors. When, for example, the glosso
pharyngeal nerve on one side is cut,
the taste buds on the same side of the
tongue soon begin to dedifferentiate
back into epithelium, eventually van
ishing completely. On reinnervation,
redifferentiation is triggered, and
completely normal gustatory appara
tus is restored.
Maintenance of normal structure is
not the sole trophic influence. In
deed, it will be seen that the word
"trophic" no longer is appropriate to
the variety of long-term influences,
independent of nerve impulses, of
peripheral nerves on their end organs.
Let me identify some of the other
categories of trophic function.
Conditioning influences of nerves.
Nerves also seem to exert a condition
ing infuence on the functional prop
erties of some tissues and on their
responses to other infuences. In ex
perimental animals, denervation of
skin. for example, appears to aug
ment its susceptibility to the action of
carcinogenic agents. Other investi
gators have studied the effects of
denervation on the response of var
ious organs to certain specific hor
mones . 1 0
Morphogenetic influences.
Another category of the trophic in
fluence of nerves is that of mor
phogenesis. The studies at this college
by Dr. Hix 1 1 and his colleagues on the
postnatal development of the mam
malian kidney provide notable ex
amples. When the nerve supply to one
kidney is interrupted in the puppy
before the tenth or eleventh day of
life, the development of the kidney is
interrupted at that point. If, however,
denervation is done after the critical
period has passed, apparently the
nerve has left its imprint on the
kidney, so it is responsive to cir
culating growth-promoting factors;
hence, there is some overlapping of
morphogenetic and conditioning in
fluences.
The morphogenetic influences of
nerves have been most extensively
studied in embryonic development, in
a large variety of species. It is known,
for example, that the complete devel
opment of muscle requires that the
nerve supply reach the muscle and
that a junction be established. If that
is prevented, or if it is interrupted,
then the muscle does not complete its
differentiation and development or,
having differentiated, it undergoes
dedifferehtiation and vanishes.
Role of nerve in regeneration.
Another category of trophic func
tions of nerves is related to regenera
tion. Certain amphibia (newts) are
capable of regenerating entire limbs
and tails after amputation. If the
forelimb is amputated at the humer
us, for example, the stump undergoes
dedifferentiation; a blastema i s
formed, and redifferentiation and re
generation take place until the limb is
completely restored. In the extensive
studies of Singer, it was demon
strated that if the nerve is removed
from the stump, regeneration does
not take place. He showed also by
partial resection of the nerve that it is
not necessary for the entire nerve
stump to be present, but that a certain
threshold amount of nerve tissue is
necessary - although it may consist
entirely of sensory fibers.
A comparison of species capable of
such regeneration with closely related
species that are not revealed that the
former have a high ratio of nerve
mass to total limb mass (measured in
terms of cross-sectional area at the
cut surface) . Singer' s prepared mind
raised the question that logically
follows:
What will happen, in the nonregener
ating species, if the existing ratio is in
creased, by hyperinnervation, that is
by introducing into the stump addi
tional innervation from elsewhere in
the animal? He found that he was
able to induce a high degree of regen
eration in the frog and in a species of
lizard which normally cannot regen
erate its tail or limbs.
More recently and even more dra
matically another investigator,
Mizell. by a similar method, was
able to induce regeneration of much
of a limb in a mammal. It was a prim:
itive mammal, to be sure, an opos
sum, but a mammal nonetheless.
These achievements obviously raise
I8J
all kinds of exciting theoretical and
clinical questions and implications.
As for clinical implications, it should
be mentioned under the heading of
regeneration that various studies have
shown the importance of intact nerve
supply to the healing of wounds and
to repair of defects in skin, bone, and
other tissues, in mammalian species
including man.
Regulation of gene expression.
A trophic function that is perhaps of
the greatest theoretical importance
has been characterized by Guth as the
neural control of genic expression.
This aspect of trophic function has
been clearly demonstrated on skeletal
muscles.
Skeletal muscle falls into two main
categories, namely, red and white,
with various intermediate categories
between these two extremes. The two
types differ not only in color, but
morphologically, functionally, and
chemically. Red muscle is slowly con
tracting and relaxing muscle; twitches
are of long duration, and red muscle
is sent into sustained tetanic contrac
tion with low-frequency stimulation;
it is spoken of as tonic, postural mus
cle. White muscle is phasic, rapidly
contracting muscle, wi th brief
twitches, and requires high
-
frequency
stimulation to produce tetanus. The
muscles differ in microscopic struc
ture in many conspicuous ways in the
fibers themselves, their nuclei, their
motor end plates, and their subcellu
lar components. Their metabolism is
. totally different. That of red muscle
is largely aerobic, energy bein
,
de
rived mainly from oxidative metabo
lism. White muscle, on the other
hand, is capable of a high degree of
anaerobic, glycolytic metabolism.
Moreover, they have different en
zymes and enzyme activities; they dif
fer markedly in their protein com
ponents, yielding different elec
trophoretic patterns. There are many
other differences, including some, no
doubt, that remain to be discovered.
Now, what happens when the
nerves to red and white (slow and
fast) muscles are switched, by cross
reinnervation of the proximal stump
of one to the distal stump of the
other, and time is allowed for neural
regeneration? This experiment has
ben done many times by many in
vestigators, on various species and
muscle combinations, and on animals
18
of various ages. An important gener
alization emerges: that a remarkable
degree of cross transformation takes
place, although the degree of com
pleteness of the transformation varies
somewhat with species, with the
muscles that are selected, and with
the criteria, whether transformation
is judged by structure, as disclosed by
light and electron microscopy, or by
histochemical patterns , chemical
composition, metabolic pathways, or
activity of various enzymes. A high
degree of cross-transformation takes
place by all these criteria.
This means, in effect, that the
nerve instructs the muscle as to what
kind of muscle to be, or at least has
much to say about it. Apparently
muscle is pluripotential; that is, its
complement of genes prepares it to be
red or white muscle or any intermedi
ate variety. But it is apparently the
nerve which grows into it in the
course of embryonic development,
and which ordinarily joins with it for
life, that determines which of the
genes of the muscle cells will be
repressed and which will be ex
pressed. Such a mechanism would en
sure the genetic compatibility of the
two kinds of cells (motor neurons and
muscle cells) , which are joined in a
lifetime partnership as a functional
unit, and each of which is useless
without the other and may even
wither away on separation of the two.
In the foregoing categories I have
offered but a partial inventory of the
so-called trophic functions, and it
may be seen readily why I have reser
vations about the appropriateness of
encompassing such a diversity of
neural influences in a word that has
only nutritional connotations.
How do nerves exert their trophic
infuences?
Not by impulses.
To return to the most familiar and
conspicuous expression of neuro
trophic influences, why does a muscle
(or other end organ) atrophy when its
nerve is severed? Of what has it been
deprived, by denervation, which is
essential for its maintenance? I wish
there were time to go into all the
evi dence, but one i mport ant
generalization has emerged from
many different kinds of experiments
and many different clinical observa
tions, and that is that nerve impulses
are not the essential elements.
Though this is not self-evident in the
case of striated muscle (which
depends on nerve-delivered impulses
for initiation and control of its activi
ty), this conclusion is unavoidable in
the atrophy, for example, which takes
place in sensory organs deprived of
their afferent innervation. What does
seem to be essential (and let us return
to muscle as the example) is integrity
of connections between the nerve cell
and the muscle cells it innervates.
Essential to the maintenance of mus
cle are viable neurons, axons, and
myoneural junctions, regardless of
whether there is impulse traffic. As
long as protoplasmic continuity is
maintained in the axon, even if it is
nonconduct i ng, t he essent i al
neuronal trophic influence continues
to be exerted. Such atrophy that does
take place as a result of interruption
of impulses (and disuse of the muscle),
has been found to be much less
severe, much more readily reversed,
and different in many ways from the
atrophy that occurs following axonal
interruption.
What about the axon itsel
Mechanisms other than impulses
must be sought to explain all these
diverse neurotrophic influences. It
seemed to me, a good many years
ago, that an important clue might lie
in the wallerian degeneration of the
axon itself which begins after pro
toplasmic continuity between it and
its mother cell is interrupted, by cut
ting, compression, freezing, or appli
cations of chemical agents. How does
the axon distal to the interruption
"know" that it has been separated
from the cell body? Another impor
tant clue seemed to be offered by the
observation that the longer the stump
left attached to the muscle, the longer
the time before trophic changes -
structural, functional, and chemical
- began to take place. Although it
may be questioned whether there is
strict proportionality between length
of stump and delay time, what seemed
to matter was how much nerve
substance was lef attached to the
denervated tissue.
As is true of all cells, there is con
tinual turnover of cytoplasmic com
ponents, including not only various
molecular species like metabolites,
proteins, nucleic acids, and enzymes,
but structural elements such as mito-
Interpretation of research

chondria. They are continually break
ing down or being degraded and con
tinually being replaced under the in
fluence of the genes (DNA) i n the
nucleus, in accordance with the spe
cific nature of the cell. In most cells
these processes and nucleocytoplas
mic interactions are carried on over
distances measured in microns.
Axopiamic transport.
141
6
The pattern just described applies to
nerve cells, with the important differ
ence that by far the largest part of the
cytoplasm (especially of a peripheral
neuron) has been spun out into a long
slender thread. Hence, the interac
tions between the cell body and the
cytoplasm in the axon (axoplasm) and
the replacements of consumed or
worn-out components take place over
distances measured not in microns
but in centimeters and, 8 in the sciat
ic nerve, in meters. How? Weiss and
Hiscoe1? showed in the late 1 940's
that there is a continual flow of ax
oplasm from the cell body and along
the entire length of the axon and all
its branches, continually replenishing
components used up in the axon -
components that are presumably
specific to that neuron or that kind of
neuron, and not supplied by the
blood stream or by the Schwann cells.
The rate of flow was estimated at
about 1 mm. per day. This important
discovery has since been confirmed
many times in many species and many
nerves, and richly elaborated on. It
now is known that, while a 1 mm. per
day rate is common to many mam
malian nerves, some components (of
which proteins have been the most ex
tensively studied) may be transported
at much higher rates, up to several
hundred millimeters per day. It is
known also that the motor power for
this transport is provided by the axon
itself. Axoplasmic flow continues for
a while even in those axons that are
separated from their cell bodies, as,
for example, in distal stumps left at
tached to muscle.
KCOM research on mechanisms
Basic question and experimental
strategy.
On the basis of the knowledge of axo
plasmic transport, my associates and
I asked ourselves the following ques
tion a good many years ago: Is it
possible that the trophic dependence
of a (muscle) cell is, as in the case of
the axon, also based on the continual
delivery, by the axon, of substances
that originate in the nerve cell? The
most direct approach to this question,
it seemed to us, would be ( 1 ) to sup
ply to the selected nerve cells isotope
labeled precursors which would be
absorbed by the cells and incorpo
rated into larger molecules such as
proteins; (2) to trace the migration
of the macromolecule-incorporated
radioactivity down the axon; and (3)
to see how much crosses the junction
and enters the muscle cells, while (4)
excluding (or measuring and correct
ing for) delivery by any other means
(for example, the blood stream).
In our frst study we used auto
radiographic methods in which im
ages of the distribution of radio
activity in tissues are recorded, in
gross specimens, on special photo
graphic film, or, in microscopic slide
mounted tissue sections, on nuclear
emulsion covering the sections. Mi
croscopic examination of the slides
enables one to determine the precise
distribution and location of radioac
tive particles in cells and tissues.
To help ensure detection of the ex
pectedly minute amounts of radio
active components, we employed
compounds labeled with relatively
strong beta emitters, carbon-1 4 and
phosphorus-32.
The hypoglossal nerve and tongue
musculature seemed to offer the ideal
system for meeting the four require
ments j ust enumerated. Indeed, I
have often voiced my conjecture that
the tongue and its innervation were
especially designed so that we could
carry out this study. We chose the
rabbit because it is large . enough to
permit relatively easy surgical access
to the floor of the fourth ventricle of
the brain, in which the hypoglossal
nucleus is located, and because it is
small enough so that large enough
numbers of animals could be kept,
after operation, for long enough
periods in our animal care facilities.
Autoradiographic findings.'
Preliminary gross autoradiographs
and three-dimensional scans of nerves
taken from rabbits killed at different
periods after application of minute
volumes of isotope-tagged precursor
solution to the hypoglossal nuclei
(and unavoidably to the neighboring
dorsal nuclei of the vagus) showed (I)
that our selective labeling was suc
cessful; (2) that the radioactive
material was transported along the
hypoglossal (and vagus) nerves at a
rate of from 5 to 5. 5 mm. per day; (3)
that radioactivity began reaching the
base of the tongue from 5 to 6 days
after surgery (and the heart, via the
vagus, after 9 or 10 days); and (4) that
if one of the hypoglossal nerves had
been cut or crushed, the flms showed
radioactivity only on the innervated
side of the tongue.
Our microscopic autoradiographs,
all of them prepared from animals
killed from 8 to 1 5 days after the
hypoglossal neurons were labeled and
the left nerve cut, showed that:
( 1 ) Only the right side was signifi
cantly labeled (the left side showing
only background activity), and the
radioactive particles were within the
muscle cells;
(2) The radioactivity appeared first
at the base of the tongue and ad
vanced over several days to the tip, in
accordance with the greater length of
the nerve pathway to the tip; and
(3) Despite the variety of tissues
and cells in the tongue (muscle, epi
thelium, blood vessels, glands, and
sensory apparatus) innervated by
cranial nerves V, VII, IX, X, and XII
and sympathetic fbers, only the mus
cles of the tongue (innervated by
cranial nerve XII) contained signifi
cant amounts of radioactivity.
Since the radioactive particles in
the muscle cells were found within
various parts of the muscle cells
(nuclei, cross striations, and sarco
plasm) as well as in terminal nerve
fibers and motor end plates, these
results convinced us that, at least be
tween the eighth and the fifteenth day
after neuronal labeling, nerve-cell
proteins reached and were indeed in
jected by the axons into the musCle
cells. In our published report of these
findings we proposed that this inter
cellular transfer "may underlie the
so-called trophic and other long-term
infuence not based on impulses, of
peripheral neurons on the metabo
lism, function, development, differ
entiation, growth, and regeneration
of the structures that they innervate."
What kinds ofsubstances are
transferred, when and how much?
With this unprecedented demonstra
tion of the neuron-to-muscle, cell-to
cell transfer of apparently macromo-
IM
lecular substances (at least they re
mained fixed in t
h
e muscle cells and
resisted washing out in the course of
histologic processing), our attention
then turned to identification of at
least the kinds of substances and the
quantitative time course of their
delivery. I shall speak only of our
most recently completed series of
studies i n this area and omit the inter
mediate stages. In these studies, Mr.
a.s.L. Appeltauer, formerly of the
University of Uruguay, has played a
most important role.
In the studies under discussion
2
- we
undertook to examine the delivery of
proteins for the following reasons: ( 1 )
Having used L' ' labeled amino acids
in some of the earlier autoradio
graphic 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 the axoplasmic transport of
protein;
(3) The infinite variety of proteins
makes possible the high degree of
specificity that seems to be involved.
Leucine labeled with tritium (HJ) 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 micro
curies) was absorbed on a small piece
of filter paper, cut to cover the
nucleus, and then applied to the floor
of the fourth ventricle for 15 minutes,
after which it was removed, and the
wound closed. The rabbits then were
killed at various periods afer surgery,
and the tissues to be studied for
radioactive protein content were re
moved. (Surgical details and methods
for separation of cell proteins from
other components have ben described
elsewhere.)
Although we examined the hypo
glossal nerves, medulla, and other
tissues also, for the sake of brevity I
shall speak mainly of our findings i n
the styloglossus muscle of 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
each animal what portion of the
radioactive protein extracted from
the tongue muscle represented radio
active leucine incorporated from the
blood stream. We had previously
shown, on sham-operated rabbits in
18
Fig. 1. Waves of axonal transport of tritium
labeled nerve-cell proteins to muscle
(hypoglossal nerve to sty/og/ossal muscle). Di
ferences between open and closed circles in
dicate nerve-delivered radioactive protein.
which tritiated leucine had been in
traperitoneally injected, that the
stylohyoid muscles (innervated by
cranial nerve VII) and the mylohyoid
muscles (innervated by cranial nerve
V) incorporated the same amount
(per milligram of tissue) of blood
borne tritiated leucine as the tongue
muscles, and were therefore an ideal
control. These muscles were therefore
removed from each experimental ani
mal and analyzed for radioactive pro
tein; they revealed, for each animal,
what portion of the total protein
incorporated 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 had satisfied ourselves re
garding the reliability of our methods
for introducing tritiated leucine into
the hypoglossal neurons, for separa- '
tion of proteins and other compo
nents, and for assay of radioactivity
by internal liquid scintillation, we
undertook the actual experimenta
tion. We performed three experiments
for- each of the days between surgery
and removal of tissue specimens
(called the postlabeling interval) and
confirmed the finding of our auto
radiographic studies that there was a
wave of delivery of radioactive pro
tein between days 8 and 1 5 after
application of the radioactive amino
acid to the hypoglossal neurons.
Multiple "waves?'
It would have been pleasant .if we had
been able to accept tha
i
' -
heart
warming confirmation and go on to
the next phase of the investigation.
However, tentative forays into earlier
and later periods revealed that nerve
transported protein was reaching the
muscle as early as 6 hours (the short-
est period measured) after application
of the radioactive leucine to the hypo
glossal neurons and that apparent
ly much larger waves of delivery
occurred long after the ffteenth day.
It appeared that delivery times would
have to be measured both by clock
and by calendar.
In order to reveal the dynamics of
axonal delivery of neuroplasmic pro
teins to muscle as well as possible, yet
without making lifetime careers of
just this one study, we eventually per
formed approximately 1 50 experi
ments: three experiments, each pro
viding three specimens of styloglossal
muscle and four specimens of control
muscles (and other tissues) for each
postiabeling interval from 1 day (or
fraction thereof) to 42 days and,
thereafter, individual experiments at
longer intervals until the seventy-sixth
day, at which time protein-incorpo
rated radioactivity in the tongue
muscle was still significantly higher
than the levels of the control muscles.
During the years when many inves
tigators of axonal transportl4
1
6 were
finding and confirming that there was
not one rate, as had been thought,
but multiple rates of movement of
different proteins (or other compo
nents) varying from a fraction of a
millimeter per day to several hundred
millimeters per day, we were disclos
ing 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 animal s,
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 protein-incorporated
radioactivity to the tongue muscle by
the hypoglossal nerve (Fig. 1 ). The
first begins within a few hours after
application of the precursor to the
neurons and reaches a peak between
the first and second days; the protein
in this wave seems to be metabolized
and eliminated rapidly from the mus
cle. The second wave, which corre
sponds to that in our previous auto
radiographic studies, paks between
days 9 and 14. A third peaks between
days 22 and 27. A fourth wave is evi
dent in the interval between days 30
and 35, after which protein radioac
tivity declines gradually.
Interpretation of research

Interpretation 0/reults.
How does one translate these pulse
labeling experiments into what is go
ing on normally? What has been
found for the tongue and hypoglossal
nerve of the rabbit may be assumed to
be true, with various modifications,
of other nerves and end organs in
other species. But with regard to the
normal rabbit, our data seemed to in
dicate that at any given time a mix
ture of proteins carried in the hypo
glossal axons is continually reaching
the tongue muscle. Some of it had
been synthesized by the perikaryon a
few hours before, some about a
month before, and the rest at two in
termediate periods. These waves may
be ascribed in part to different rates
of axonal transport of protein and in
part to differences in departure time.
(It is known that some proteins may
remain in the cell body for long as
2 weeks before being dispatched into
the axon.)
It is not certain from these data
alone what portion of each wave of
protein actually enters the muscle
cells, and how much has remained in
the intramuscular nerve endings. This
knowledge must await completion of
our study of the autoradiographs pre
pared from these experiments. Our
previous auto radiographic study cer
tainly gave convincing evidence of
crossing during the second wave.
Although the dogma still persists
among many authors of textbooks
and monographs that cell membranes
are impermeable to proteins, the
penetration of cell membranes by
proteins and even larger particles
seems no longer to be the problem it
used to be. Considerable evidence has
accumulated that large protein
molecules do traverse cell membranes
and intercellular junctions, by active
transport, pinocytosis, discharge of
vesicular contents, or moment-to
moment changes in permeability. At
any rate, there is reason to believe
that cellular barriers are not so im
penetrable as conceptual barriers
often are.
Curent and projected studies.
In order to test the hypothesis that
different neuronal proteins (or mix
tures of proteins) are transported and
delivered to the muscle during the
four different waves of radioactive
protein, Mr. Appletauer and I are
labeling the hypoglossal neurons in
many rabbits, in the manner previ
ously described, and sacrificing them
for the tissue specimens at the peak
periods identified by the previous ex
periments. We are separating soluble
from insoluble proteins by centrifu
gation and measuring the shifts in
distribution of radioactivity between
the two fractions. In addition, we are
fractionating the soluble proteins in
each wave by disc gel electrophoresis
to determine the changing patterns of
distribution of radioactivity among
the many fractions, and to determine
which proteins are found in both the
muscle and its nerve. Although we are
finding many exciting things (in
cluding apparent selectivity as to
which of the nerve proteins reach the
muscle), it is much too early to re
port on these or to draw any conclu
sions.
We hope eventually to be able to
fractionate the insoluble (structural)
proteins also, by gradient ultracen
trifugation and by the use of electron
microscopy to identify the subcellular
components in each of the fractions,
and then to measure the radioactivity
of each.
Clinical implcations.
This work strongly supports the con
cept that peripheral nerves, supplying
various tissues and organs, not only
conduct impulses to or from those
structures, but supply them with pro
teins (and other substances) that are
essential for their maintenance and
self-repair, that i nfluence their
various characteristics and their func
tional capacity, and that condition
their responses to other factors, in
cluding nerve impulses, circulating
substances. hormones, microbes, and
toxic substances. This concept has
many exciting clinical implications.
Some of
'
these have been briefly ex
plored and need not be repeated
here. Suffice it to say that any factor
which for a protracted period alters
the activity (and therefore the energy
exchange), metabolism, or protein
synthesis of the neuron or which im
pedes axonal transport could cause
the neural infuences on the inner
vated structures to become adverse
and detrimental, thereby contributing
to disease. Such factors could include
disturbances (for example, emotional
stress) in descending impulse traffic
from higher centers, impulse traffic
in sensory pathways from various
parts of the body, nutritional factors,
drugs, and toxicologic agents, viral
insults. changes in the chemical en
vironment of the neurons and their
axons, and, of course, the mechanical
stresses and large forces exerted on
and generated by the myofascioskel
etal tissues through which the nerves
pass, and the accompanying chemical
changes in these tissues. It seems like
ly that the efficacy of manipulative
therapy may occur in part through
alleviation of some of these detrimen
tal factors.
References
I. Korr. I. M .. Wilkinson, P. N = and Chornock.
F.W.: Axonal delivery of neuroplasmic components
to muscle cells. Science 1 55:3425. 20 Jan 67
(Reprinted. JAOA 66: 1057-61 . May 67).
2. Korr, I . M .. and Appeltauer. G.S. L. : Studies on
the transfer of neuronal protein to muscle celis,
Preliminary report. JAOA 68: 1 03-5. Jun 69.
3. Korr. I . M . . and Appeltauer. G. S. L. : Continued
studies on the axonal transport of nerve proteins to
muscle. JAOA 69: 1028-30, Jun 70.
4. Korr. I. M . . and Appeltauer. G. S. L. : p onal
transport of nerve-cell proteins to muscle. Abstract.
Fed. Proc. 30:65, Mar-Apr 71 .
5. Korr, I. M. : The nature and basis of the trophic
function of nerves. Outline of a research program.
JAOA 66:984-8, May 67.
6. Gutmann. E + ed.: The denervated muscle.
Publishing House of the Czechoslovak Academy of
Sciences. Prague. 1 962.
7. Gutmann. E and Hnlk, P eds. : The effect of
use and disuse on neuromuscular functions, Pro
ceedings of a symposium held at Liblice near Prague,
September 1823. 1 962. Elsevier Publishing Co
Amsterdam. 1963.
8, Guth. L.: "Trophic" infuences of nerve on
muscle. Physiol. Rev. 48:65-87. Oct M.
9. Guth, L. : "Trophic" effects of vertebrate
neurons. A report based on an NRP work session.
Neurosci Res Prog Bull 7: 1 70. Apr 69.
10. Gutmann. E.: Metabolic reactibility of the
denervated muscle. In Guttman '.
I I . Hix. E. L. : The trophic function of visceral
nerves. In Symposium: The physiological basis of
osteopathic medicine. Postgraduate I nstitute of
Osteopathic Medicine and Surgery. New York. 1 970.
12. Singer. M. : Nervous control of the regrowth of
body parts in vertebrates, In Gutmann and Hnik.' pp.
83-94.
1 3, Mizell. M. : Limb regeneration. Induction in the
newborn opossum. Science 161 :2836. 19 Jul 68.
14. Barondes. S.H and Samson. F.E . . Jr.: Ax
oplasmic transport. A report of an NRP work session
held April 2-4, 1967. Neurosci Res Prog Bull
5: 307-41 5. IS D67.
1 5. Grafslein, B.: Axonal transport. Communica
tion between soma and synapse. Adv Biochem
Psychopharmacol I: 1 1 25. m.
16. Lasek, R. J. : Protein transport in neurons. Int
Rev Neurobiol. 1 3:289324. 70.
17. Weiss, P e and Hiscoe. H, B, : Experiments on
the mechanism of nerve growth, J Exp Zool
107: 31 595, Apr 48,
This study was supported by PHS Research Grant No.
NS-0791 9 from the National Institute of Neurological
Diseases and Stroke. and by a grant from the
American Osteopathic Association.
Reprinted by permission from JAOA 72: 1 63 1 71 ,
1972.
I8T
The facilitated segment: A factor in injury
to the body framework (1973)
Osteopathic physicians have always
relied for their diagnostic evaluation
of stresses and strains of the musculo
skeletal system upon the subjective
sensations and perceptions that
emerge from their palpatory and kin
esthetic examinations. They are con
cerned with such things as very subtle
changes in tissue texture, tissue defor
mability, elasticity, resilience, joint
motion, and other such characteris
tics. These are purely subjective judg
ments that are made from moment to
moment, and guide the physician's
diagnosis and therapy.
These procedures introduce tre
mendous difficulties in communi
cation, because a sensation is entirely
private - something that simply can
not be shared. This is true of all sen
sation, but there is a special
d
ifficulty
with respect to palpation, because
while any two or more persons can si
multaneously look at the same view
or listen to the same sounds, or taste
the same concoctions, no two people
can put their fngers upon the same
spot precisely at the same moment.
They can do it only in sequence, and
this introduces real problems of com
munication between professions, be
tween people, from teacher to stu
dent. It is something we are still
studying.
In the late 1 930's and the early
1 940' s, 1. S. Denslow, D. O. , a distin
guished faculty member at Kirksville
College of Osteopathic Medicine
began a series of studies to see if he
could objectify the procedures that all
osteopathic physicians do, each in his
own way, each one paying particular
attention to skin or muscle or deeper
structures. Denslow paid much atten
tion to the textur.e of the tissues over
the spinous processes, and he was in
terested in the responsiveness of the
paravertebral musculature, to the dig
ital pressure that he applied to the
spinous processes. But he recognized
that this type of observation was the
same as that made by other osteo
pathic physicians who noted related
tissue changes in the area that for
many years we have called the osteo
pathi lesion.
So Denslow started to measure the
pressure that is applied at each spinous
18
process, each segment, and electro
myographically to determine what
pressure is required to elicit the first
signs of refex response of the muscles
at the corresponding segments. In
other words, he did what the physiol
ogist knows as the measurement of
motor reflex thresholds, except that
instead of electrical stimulus to this or
that nerve, Denslow applied mechan
ical pressure measured from 1 to 7 kg
of pressure to the tip of the spinous
process, and recorded that pressure
which brought about a reflex re
sponse as indicated on the elec
tromyogram
. 1
,
2
Denslow was the first osteopathic
physician to be elected to membership
in the American Physiological Society
on the basis of these investigations
and those that followed.
Out of these early observations
emerged the conclusion, that the so
called area of osteopathic lesion was
related to a segment of a spinal cord
in which the reflex motor thresholds
had been lowered. It took less pres
sure to elicit the first reflex response
of the paravertebral and paras pinal
muscles.
Denslow studied large numbers of
subjects and emerged with the rather
important generalization that this
segmental lesion was one with a low
motor reflex threshold.
As he studied subject after subject,
he found that the patterns of distribu
tion of the low thresholds were rather
enduring. A given individual could be
picked up week after week, month
afer month, and essentially the same
pattern of distribution of low thresh
olds would be found, and the patterns
were somewhat characteristic of the
individual.
Nevertheless, there were certain
areas that were found to be more vul
nerable than others: in the neck,
especially at the atlanto-occipital area
at the junction of the cranium and
cervical spine; at the junction of the
cervical spine and the relatively rigid
thoracic spine; and in the lumbosacral
area. These were the areas of high
est frequency of low thresholds or
"osteopathic lesion.
t t
Having j ust joined the Kirksville
faculty, I developed a great preoccu-
pation with the osteopathic lesion. I
worked with Denslow in the labora
tory where volunteer students were
the subjects, recording readings from
the application of the pressure meter
he had devised. I determined that low
reflex motor thresholds were found in
the area of the osteopathic lesion and
that high refex motor threshold areas
of the spinal tissues indicated normal
,segments. This led us into the in
vestigations of the physiological
mechanisms underlying the lowering
of refex motor thresholds in seg
mental spinal areas. ' From this
work emerged the concept of
"'hronic segmental facilitat ion, "
reflecting the hypersensitivity and
hyperresponsiveness of the affected
segments of the spinal cord to im
pulses from virtually any source in
l
the body.
Details of this work and other
related studies have been brought
together in a publication from the
Postgraduate Institute of Osteopathic
Medicine and Surgery. Some very
practical ideas and procedures have
merged from our studies.6
1
2
The literature on the sympathetic
i system, which has become a specialty
:
for me, indicates that in almost any
kind of trauma to the musculoskeletal
system or, for that matter, to any
visceral system, the sympathetic ner
vous system is almost invariably
brought into play. And very often it
rticipates in a most inappropriate
( manner, which not only does not con-
tribute to recovery from the injury,
but actually produces trouble that
_ prolongs it. It exaggerates and exacer
b
l
tes the disturbance, and tends
toward positive feedback. toward the
perpetuation of vicious cycles. The
syndrome - the injury - becomes
more and more disabling the more
overactive the sympathetic nervous
system becomes.
Conversely, therapy directed to
normalizing or quieting the involved
segments of the sympathetic nervous
system is very often quite beneficial,
and sometimes almost miraculous, as
shown in the classic studies of S. Weir
Mitchell on causalgia and causalgia
like syndromes during the Civil War.
We know that the sympathetics are
the main vasomotor controlling
system of the body; they control the
caliber of most of the vessels of the
body. Therefore, when the sympa
thetics are hyperirritable in a given
Interpretation of research

area, in a given segment, in a given
peripheral distribution, there is in that
area a tendency for either exaggerated
vasoconstriction or exaggerated vaso
dilation, or a mixture of the two,
which contributes to chaos and the
perpetuation of pathology. When you
control the blood supply to a given
area, you control its life; you control
its capacity for recovery, its capacity
to resist infection, its capacity to sur-
vive and maintain its integrity as a
tissue.

The importance of the sympathetics

is reflected in a tremendous vari
ety of post-traumatic vasomotor dis
turbances. The effects of experimen
tal arterial occlusion an: well il
lustrated by Bardina's studies in
which he occluded the lingual artery
and then showed that by sympathec
tomy - removal of the superior cer
vical ganglia - the development of
collateral circulation was tremen
dously accelerated on the occluded
side.
In 1 949, Fowler showed that sym
pathetic stimulation produced a
sludging of blood in the rabbit's ear
in the capillaries. Sympathectomy -
ganglionectomy - in the rabbit with
the experimental thrombosis marked
ly accelerated thrombolysis, three
hundred, four hundred, and even five
hundred per cent. ' 4
I n another series of studies, Oruik
shank and Harris showed that sympa
thectomy accelerated wound healing
in rabbits' ears.
Brena and Bocca, i n a report
before the Second World Congress of
Anesthesiologists, showed that heal
ing time in hand burns was shortened,
and scarring and other local com
plications were eliminated by sym
pathetic nerve block. No skin grafts
were necessary in most cases and
there were no hypertrophic scars. , .
Ulcers of various kinds i n the legs and
el sewhere were i mproved by
ganglionectomy.
l!V
Among the most interesting studies
are those on bones, joints, and teeth.
Herfort and Nickerson in a long
series of studies, showed that in uni
lateral sympathectomy, for example,
in patients with either osteo- or
rheumatoid arthritis, there was great
relief of pain and increased mobility
of the joints, whether hips, knees, or
ankles, on the sympathectomized
side. 20
In a fascinating study at the Uni-
versity of Mi nnesota, Kottke,
'Gullickson and Olson, found that in
children who had contracted polio of
one leg, the sympathetics are hyperac
tive; the skin on the affected side is
cold, and usually is wet, indicating
sympathetic hyperactivity. Bone
growth in these children on the af
fected side is reduced. If, however,
sympathectomy is performed, then
the bone growth is restored, and the
equality of the leg length is main
tained.
In another study, Gullickson, et
aI. , showed by chronic stimulation of
the sympathetic lumbar chain on one
side by radio transmission, with im
planted electrodes, to the animals
that sympathectomy produced long
legs on the corresponding side. 2 2
Among the most exciting funda
mental studies are those showing the
influence of the sympathetics on sen
sory mechani sms themsel ves . 2 3
Stimulating will increase the sensitivi
ty of cutaneous reception and muscle
spindles and even cause them to fire
spontaneously, falsely report stretch
ing or contact, and cause exagger
ated responses. In other words, the
sympathetic stimulation produces
chaotic feedback, yielding garbled in
formation which is fed into the ner
vous system from the tissues and
which, of course, can do nothing but
create more and more chaos and
cause the disturbance to persist longer
and longer.
There are many studies showing
that the sympathetic nervous system
is an important participant in the
maintenance of splinting. In painful
visceral pathology, for example, sym
pathectomy on a given side will relax
the abdominal musculature on that
side. 2425
At Cornell 'University, Loring
Chapman, Stewart Wolff, Harold
Wolff and Helen Goodell have done
many beautiful studies on the in
fluence of the sympathetics, both plus
and minus, on various allergic and in
flammatory infectious processes .
They show the critical importance of
the sympathetic distribution to such
manifestations as edema, urticaria,
erythema, itching, etc. 2
Perhaps the most dramatic ex
amples are those which represent a
tremendous variety of post-traumatic
syndromes that began with Mitchell' s
description of causalgia. Today all
kinds of complex nomenclature have
been developed to describe those phe
nomena according to the special in
terests of the investigator, such as
causalgia-like syndromes, the minor
causalgias, the sympathalgias, the
sympathetic dystrophies, the reflex
dystrophies, the shoulder-hand syn
drome, pseudoangina, the tropho
neuroses, etc. Studies by Livingston,
Shumacker, Mayfield, Steinbrocker,
Russek, Casten, and many others, all
testify to the tremendous importance
of facilitation of the sympathetic
pathways. This literature has been
reviewed in part by Appenzeller. 2
7
On the basis of our studies, there
fore, we see that in the area of seg
mental facilitation - where the
"gain," in effect, in the sympathetic
nervous system has been turned up -
the areas or segments are vulnerable.
The tissues innervated therefrom are
especially vulnerable, especially sus
ceptible to injury, for a variety of
reasons, and are resistent to recovery.
That is why therapy directed to the
quieting of the sympathetics, especial
ly when aimed at specific segment
is important. Although we accept tfe
efficacy of sympathetic blockade by
our skilled anesthesiologists, in my
opinion there is still nothing more ef-
fective than skilled osteopathic
manipulative therapy applied to the
segment in which facilitation exists.
References

I . Denslow, 1.S. and Hassett, C.C. The central ex

citatory state associated with postural abnormalities.
J. Neurophysiol. J( 1 942), 39342.
2. Denslow, 1. S. An analysis of the variability of
spinal reflex thresholds. J. Neurophysiol. 7 ( 1 94),
207216.
3. Denslow, 1. S., Korr, I.M. and Krems, A.D.
Quantitative studies of chronic facilitation in human
motoneuron pools. Am. J. Physiol. 0 ( 197),
229238.
4. Korr, I . M. Th
e
neural basis of the osteopathic le
sion. J. A. O. A. 4Z(1947), 191 198.
5. The Postgraduate Institute of Osteopathic
Medicine and Surgery. Symposium on the
Physiological Basis of Osteopathic Medicine. New
York, 1970.
6. Korr, I . M. , Thomas, P. E. and Wright, H. M.
Patterns of electrical skin resistance i n man. Acta
Neuroveg. XIU: 12 (1958), 7796.
7. Wright, H. M. and Korr, I . M. Neural and spinal
components of disease: Progress in the application of
thermography. J. A. O. A. M( 1 965), 91 8921 .
8. Wright, H. M. , Korr, I . M. and Thomas, P.E.
Local and regional variations in cutaneous vasomotor
tone of the human trunk. Acta Neuroveg. XXU
( 1 96), 3352.
9. Wright, H. M. Measurement of the cutaneous cir
culation. J. Applied Physiol. 20 (1965), 696-702.
10. Korr, I . M. , Wright, H.M. and Thomas, P. E.
Effects of experimental myofascial insults on
cutaneous patterns of sympathetic activity in man.
Acta Neuroveg 2J(1962), 329355.
18
1 1 . Kr, I. M. , Wright, H. M. and Chac, J. A.
Cutaneous patterns of sppathetic activity i n clinical
abnormalitie on the musculoskeletal system. Acta
Neuroveg. XXV (1 96), 5986.
12. Korr, I. M. , Thomas, P.E. and Wright, H. M.
Symposium on the functional implications of segmen
tal facilitation. J.A. O.A. 54 ( 1955). 265-282.
13. Bardina, R.A. Effect of injury of the CNS on
collateral circulation. Arkh. A nat. Gitol Embriol.
33: I ( 1 956), 5558.
14. Fowler. E. P. , Jr. Capillary circulation with
changes in sympathetic activity. I. Blood sludge from
sympathetic stimulation. Proc. Soc. forExper. Bioi . .
Me. 72 (1949), 592594.
1 5. Cruickshank, A.H. and Harris, R. Accelerated
wound healing in rabbits' ears after cervical sympa
thetomy. Jour. Path. and Bact. 73: I (1 957), 177 1 81 .
1 6. Brena, S. and Bocca, M. Clinical evaluation of
the sympathetic nerve block in the management of
severe burns of the hand. Abstract i n Secnd World
Congres of Anethesiologits. Abstract 158 (Sept
4-10, 19) Toronto. Canada.
1 7. Palou, J. Lumbar sympathetomy in the treat
ment of hypertensive ischemic ulcrs of the leg (Mar
toreU's Syndrome). Circulation XI: 2 (1 955), 239-241 .
1 8. Quijano Mendez, H. Vasocutaneous syndrome
of the leg (nonspecific ulcer). Angiolog 8:4 (1 957),
341-344.
19. Baker, G.S. and Gottlieb, C. M. The prevention
of corneal ulceration in the denervated eye by cervical
sympathectomy: An experimental study in cats. PrO.
Slaf Met. Mayo Clinic 34: 2 ( 1 959), 474-487.
20. Herfort, R. A. Extended sympathectomy in the
treatment of chronic athritis. J. Amer. Gerit. Soc. 5
( 1 957). 9-91 5.
21 . Kotte. F. J. , Gullickson, G. Jr. and Olson, M.E.
Studies on the disturbance of longitudinal bone
growth: II. Effect of the sympathetic nervous system
on longitudinal bone growth after acute anterior
poliomyelitis. Arch. ofPhys. Med. and Rehab. 39: 1 2
( 1958). 770-779.
22. Gullickson, G. Jr. , Kubicek. W.G. and Kottke,
F.J. Effects of stimulation of lumbar sympathetic
nerves on longitudinal bone growth in dgs. Fed.
PrO. 10: I ( 195 I). 56.
23. Chernetski. K.E. Sympathetic enhancement of
peripheral sensory input in the frog. J. Neurophysioi.
XXVI: 3 (1964), 493-51 5.
2. Galitskaya, N . A. How the exclusion of various
components of innervation acts on the functional
properties of the skeletal muscle. Fiziol. Zhur. SSSR
39:6 (1 953), 710-71 8.
25. Galitskaya, N . A. Role of the sympathetic nef
vous system in the development of contractures arising
in the preence of spinal cord traumas. Fj;ol. Zh
SSSR 1M1MSeheno1 51. 4 ( 1 965). 50-51 2.
26. Chapman, L. R. The participation of the ner
vous system in the inflammatory reaction. Annals
N. Y. Academy ofSciences 116 (1 964), 747-1084.
27. AppenzeUer. O. The Autonomic Nervous
System. New York: Elsevier, 1 970.
Reprinted by permission from Osteopathic Annals 1 :
10-12, 17-18. 1973.
19
Andrew Taylor Still memorial lecture:
Research and practice - a century later
(1974)
On June 22, 1 874, Andrew Taylor
Still "flung to the breeze the banner
of Osteopathy. " * One hundred years
later we can say. as he did in his auto
biography, that "it has withstood the
storms, cyclones, and blizzards of op
position. "* The osteopathic profes
sion has conducted a long, relentless,
uphill struggle for recognition, recog
nition of itself as a healing-arts pro
fession and of its members as quali
fied physicians and surgeons. This
struggle has culminated in a rapid
succession of triumphs - of recogni
tion, acceptance, rights, respon
sibilities, and opportunities - which
have added up to a complete victory,
recently marked by the granting of
full practice rights in the last holdout
state.
This has been a great victory, won
at great cost and great odds, and the
profession and those it serves have
every reason to be proud. We must,
however, emphasize a fundamental
distinction: It is one thing to gain
recognition of the competence of the
osteopathic physician to practice
medicine in accordance with estab
lished standards. It is quite another
thing to gain recognition of the
soundness of osteopathic principles
and the value, to total health care, of
distinctively osteopathic methods.
That victory has yet to be won.
The first victory is but prelude to
the second, which extends in impor
tance beyond the profession and
those it directly serves, to all of
mankind. Unfortunately, the osteo
pathic profession seems not to have
appreciated how essential this distinc
tion is. It seems to have assumed
either that the first victory was the
final one or that, in and by itself, it
included the second. It does not, and
if allowed to, may even preclude the
second. In the course of its long
struggle for recognition, the osteo
pathic profssion appears to have
forgotten why it sought recognition:
to enable it to deliver and demon
strate, as widely and fully as possible,
'Still, A.T. : Autobiography of Andrew T. Still. The
author, Kirksville, Mo o 198.
the benefits of osteopathic principles
and methods. In forgetting, the pro
fession has permitted osteopathic
manipulation to slip from its place as
a key element
i
n osteopathic practice.
I propose to show: ( 1 ) that, con
trary to a myth that has been allowed
to impede their wider application, os
teopathic principles and methods
have a solid basis in biomedical
research and biologic mechanism; (2)
that osteopathic palpatory diagnosis
and manipulation, by virtue of the
mechanisms through which they op
erate, as well as their demonstrated
efficacy, represent, potentially, a tru
ly great and urgently needed con
tribution to total health care; (3) that
osteopathic principles and methods
not only are invaluable in the care of
the individual, but that they offer
reliable guidelines to the reformula
tion of the objectives, priorities, and
premises of clinical practice generally
and to the needed restructuring of
health care delivery in the nation as a
whole; and (4) that the osteopathic
profession must now decide whether
to seek the fullest development of the
distinctive contributions for which its
hard-won rights and recognitions
have prepared it, or whether to accept
those rights and recognitions as the
ultimate fulfillment of its purpose.
The pose of scientific detachment
Had the profession maintained the
distinction between itself as an instru
ment, and the unique/unction of that
instrument, it might have seen the
need to be as diligent in learning and
displaying the evidence for the validi
ty of osteopathic principles and osteo
pathic manipulation as it has been in
demonstrating general clinical com
petence. Instead, it has been easy, for
those who wish, to discount and to
restrict the benefits of osteopathic
manipulative medicine on the premise
that there has been no scientific dem
onstration of a mechanism through
which osteopathic manipulation
could significantly improve the
clinical status of a person or influence
the course of an illness.
It is time to expose the falsity of
Interpretation of research
.
this premise. Ordinarily, this posture
of scientific detachment - of waiting
for the evidence to come in before
making such an important judgment
- is admirable. It becomes anti-sci
entific, however, when used as an ex
cuse not to look at the evidence that is
in, and it borders on irresponsibility
when its effect is to limit the availabil
ity of a demonstrably valuable form
of diagnosis and therapy. It is even
more regrettable, I believe, when the
osteopathic physician himself denies
his patients the benefits of that
diagnosis and therapy, justifying his
neglect with an ostensibly scientific
pose.
ls this scientific detachment, which
denies clincial benefits to millions of
persons, the same scientific detach
ment which, year after year, sweeps
into widespread use therapeutic
agents that are soon, though often
not soon enough, swept right out
again?
The absurdity of the pose of scien
tific caution was also demonstrated
recently in connection with acupunc
ture. Though known and practiced
for centuries in China and Japan,
acupuncture has been regarded as an
oriental curiosity outside the realm of
scientific medicine. The physician
who dared investigate acupuncture
and apply it in practice faced scorn
and even ostracism by his colleagues.
Almost overnight the situation has
changed. Acupuncture is in. It is be
ing practiced, taught, and investi
gated on an increasing scale and
under the most respected of medical,
academic, and governmental aus
pices. Physicians who were previ
ously regarded with suspicion are
suddenly in demand as teachers of
acupuncture, as are, even, their
recent pupils.
Was there a sudden breakthrough
in our knowledge of the mechanisms
underlying the practice of acupunc
ture? Did last year see the publication
of a large-scale double-blind study
demonstrating the efficacy of acu
puncture on thousands of patients
and in dozens of diseases and clinical
situations? No. A practice long re
jected as unproved, unscientific and
unorthodox suddenly became accept
able because a few distinguished
figures in American medicine visited
the People' s Republic of China, made
some frst-hand observations of acu
puncture in practice, and returned to
report, "We have seen acupuncture
and it works! " In short, the
wholesale change in attitude is based,
not on confidence generated by re
search, but on good feelings which
had been generated by some interna
tional Ping-Pong matches.
One has reason to wonder, then,
why a system of diagnosis and thera
peutics indigenous to this country,
and easily observed, with a long dis
tinguished record of clinical success
and ever widening public acceptance,
has not excited the same eager recep
tivity or willing inquiry. Some of the
reasons are, of course, the product,
not of scientific judgment, but of
organizational, political, and eco
nomic attitudes. They are the product,
not of the laboratory, but of the
market place. Their falsity is exposed
by facts that come from the labora
tory.
In recent decades, research which
has been well conducted in osteo
pathic institutions and responsibly
reported in scientific journals has
demonstrated a sound biologic basis,
especially in neural and reflex
mechanisms, for the application of
osteopathic manipulation. I welcome
this lecture as an opportunity to sum
marize, at least in part, what this
research has established. Our limited
time makes the utmost brevity neces
sary, but full documentation will be
found in the publications from which
these conclusions emerge. I hope that
the profession will use this informa
tion to shatter the myth that for so
long has been allowed to stand in the
way . Following this brief considera
tion of some neurobiologic mech
anisms involved in osteopathic ma
nipulative medicine, I would like
to review with you a few of their
clinical implicatitms, and then a few
of the obligations and opportunities
that those implications present to you
as a profession.
Summary of neurobiologic
mechanismst
!. Facilitation (lowered thresholds)
t J , S. Denslow, D. O., around 1940, launched the
modern era in laboratory research under osteopathic
auspices, starting a continuing tradition. at the
Kirksville College of Osteopathic Medicine, of
investigation into the neurophysiologic mechanisms
underlying osteopathic practice. This research has
been generously supported by the American Osteo
pathic Association, by the National Institutes of
Health, and by the Kirksville College and its alumni.
ofmolor pathways in lesioned
segments
In those segments of the spinal cord
which supply innervation to "le
sioned": components of the musculo
skeletel system, the anterior horn cells
(and probably interneurons which
synapse upon them) are maintained in
a state of facilitation. In this state,
these nerve cells have lowered reflex
thresholds. That is, they are hyperre
sponsive to impulses reaching them
from any part of the body or from
any part of the brain. It requires
relatively few impulses, from any
source, to initiate and sustain activity
in these neurons, and their responses
are exaggerated.
As a result, the muscles which are
innervated from these facilitated
motoneuron pools are in contraction
when their counterparts in other seg
ments are at rest; they are in strong
contraction when only postural tone
is called for, and they continue to
contract long after the physiologic de
mand has passed. Their metabolic
and circulatory requirements are cor
respondingly increased and sustained.
In daily life, therefore, these muscles
"take a beating" which is reflected.
over a period of time, in physiopath
ologic changes that, in turn, elicit
secondary reflex responses elsewhere.
2. Disturbed sensory inputs to
lesioned segments
Chronic segmental facilitation is ap
parently maintained by disturbed pat
terns of afferent input to the cord
from receptors and sensory endings
either in musculoskeletal structures or
visceral structures, or both, trans
mitted through corresponding dorsal
roots.
J. Facilitation ofsympathetic
pathways
The segmental facilitation not only
affects anterior horn cells, but ex
tends to the other category of efferent
neurons of the spinal cord, the lateral
horn cells, which represent the out
flow of the sympathetic nervous sys
tem. Facilitation of these neurons
results in increased impulse traffic to
viscera and to blood vessels of virtu
ally all tissues.
jWhile not useful in designating an area of basic
research, the term "osteopathic lesion" u useful in
communication among osteopathic physicians, to
whom it represents an area of shared clinical
experience, however differently they may perceive it.
11
Sustained, exaggerated, sympathetic
stimulation may, .over a period of
time, lead to chronic circulatory
changes in target tissues and visceral
organs which can, of course, pro
foundly impair their function and
even threaten their survival. High
sympathetic tone can also lead to
other changes, in structure, function,
and functional capacities. High sym
pathetic tone may alter organ and
tissue responses to hormones, infec
tious agents, and blood components.
It alters cellular metabolism and may
eventually lead to serious pathologic
changes.
4. Experimental induction oj
jacilitated segments
Similar and relatively enduring
changes i n motor and autonomic pat
terns can b eperimentally induced
in selected segments by appropriate
myofascial irritations and musculo
skeletal stresses.
J. Learing and memory in the
spinal cord
Spinal refexes and response patterns
mediated and organized by the spinal
cord are not as stereotyped and im
mutable as has been thought. The
spinal cord can "learn" and "remem
ber" new behavior patterns. Experi
mentally, the spinal cord can be
"taught" new patterns by appropri
ately manipulating the afferent input
to the portions of the cord being
tested. Indeed, chronic segmental
facilitation may be viewed as the
retention of a new "habit" of local
hyperreactivity.
As the result of disturbed afferent
input, segments of the spinal cord re
lated to osteopathic lesions may be
said to have acquired aberrant be
havior patterns which adversely af
fect the organs and tissues "that carry
out the aberrant behavior. They af
fect the person as a whole by disrupt
ing the larger patterns in which the af
fected segments participate.
. Trophic inuences ojnerves and
their bais
The trophic influence of nerves on the
organs and tissues that they supply
has long been a recognized but mys
terious phenomenon in osteopathic
theory and practice. We are now
rapidly approaching an understand
ing of how nerves exert these long
term influences which cannot be
19
ascribed to impulse conduction. Our
research clearly implicates certain
proteins and possibly other highly
specifc substances of large, complex
molecular structure, which are syn
thesized in the peripheral nerve cells.
These neuronal components are
transported down the length of the
axon and, as we have shown, then
cross the junctional barriers into the
tissue cells.
This basic mechanism seems to be
involved in a variety of neurotrophic
influences, the best known of which is
the maintenance of structural, func
tional, and biochemical integrity of
muscles, certain sensory organs, and
other tissues. Interruption of this
mechanism leads to atrophy and de
generation. It seems to be involved,
also, in the regulation of growth,
prenatal and postnatal development,
regeneration, and healing; and in the
regulation of the ability to respond to
hormones and other circulating sub
stances. Of special scientific and clin
ical import is the fact that the same
kind of mechanism seems to be re
sponsible for the neural regulation of
the activity and expression of the
genes in skeletal muscle and possibly
other tissues.
Hence, any factor which for a pro
tracted time alters the metabolism
and protein synthesis of the neuron or
which impedes axonal transport
could block the neural influence on
the innervated structures or cause it
to become adverse and detrimental,
thereby contributing to disease.
Among the most probable factors are
the compressive forces and mechani
cal stresses occurring in the myofas
cial tissues and channels through
which the nerves pass, the accompa
nying chemical cha
q
ges in these
tissues, and their aberrant sensory
input.
7. Changes in somatic tissues as
basis jor pa/patory diagnosis
The mechanisms discussed in sections
1 to 6 result, therefore, in two main
kinds of aberrant neural influences
on tissues and organs innervated
from the affected segments of the
spinal cord: (a) exaggerated efferent
impulse traffc (motor and sym
pathetic); and (b) alteration of
neurotrophic support and condition
ing.
These altered neural and refex in
fuences produce changes in texture,
resiliency, mobility, and other physi
cal qualities of superficial tissues
which are subject to detection and
evaluation by skilled, discerning
palpation, and sometimes by visual
inspection. They provide much of the
basis for osteopathic diagnosis. It is
these localized, palpable changes in
the accessible somatic tissues that
signal to the osteopathic physician
that something is amiss. The osteo
pathic physician knows that the dis
turbance may not be limited to those
somatic tissues, but that it may ex
tend, at the time of examination or at
sometime in the future, to other,
neurologically related tissues or
organs.
The skilled palpator can be remark
ably accurate even in his quantitative
evaluation of the severity of the dis
turbance as shown by correlation be
tween the degree of facilitation (low
ering of reflex thresholds) and the
degree of palpable abnormality and
of hyperalgesia. Through the pal
pable changes in the somatic tissues
the physician can monitor the effi
cacy of his treatment and the re
sponse and progress of the patient.
It is important to emphasize that
the pathologic changes in the somatic
tissues are frequently asymptomatic;
the patient may have been unaware of
an impairment or discomfort, until
areas of tenderness are demonstrated
to him during the course of palpatory
examination.
In these seven items I have sum
marized our understanding, based on
research, of the neurologic mech
anisms (a) through which somatic
dysfunction may impair health and
impede recovery from illness; (b)
through which the clinical status and
progress of a patient may be reflected
in his somatic tissues; and (c) through
which osteopathic manipulation may
favorably influence
"
the total health
and clinical progress of a patient.
These are by no means all the
neurologic mechanisms about which
there is firm knowledge from re
search. Nor are the neurologic mech
anisms the only ones involved.
Blood flow, lymphatic drainage, and
other hydrodynamic factors, along
with their functional and metabolic
corollaries, are also subject to im
pairment by forces and impediments
imposed by musculoskeletal tissues,
and to amelioration by manually ap
plied corrective forces. I have deliber-
Interpretation of research
ately chosen, however, to limit my
summary to those mechanisms with
which, for many years, I have had
first-hand experience; and they will
suffice for the purpose of this lecture.
Incomplete a summary as this is of
the available research-based knowl
edge, it still represents a substantial
basis in biologic mechanism for the
practice of osteopathic manipulative
medicine. There has never been a
valid scientific excuse for not examin
ing and assessing the efficacy of clini
cal methods that have, over many de
cades, been eagerly accepted and
sought by a substantial segment of
the population. And, now that the
mechanisms through which those
methods operate are better under
stood, there can be no rational bar
riers to exploring, and applying, their
implications and potential as broadly
as possible.
Clinical implications
What are the clinical implications of
those mechanisms, and how do they
relate to the total health care of the
individual?
Because of the special demands
made by gravitational forces on the
human body, muscul oskel etal
stresses, particularly in the axial
weightbearing portions of the muscu
loskeletal system, have a peculiarly
high incidence in man. The resultant
musculoskeletal strains tend to be
come self-sustaining because of the
nature of the tissues involved and
their adaptations to these postural
and locomotor stresses, because of
proprioceptive and reflex mecha
nisms, and because of the abuses of
daily life. They may become pro
gressively more severe and more ex
tensive with time. They may persist
and progress long after the initial
facilitating factors have passed.
Because of the uniqueness of the
individual and of his life and, hence,
uniqueness of the demands which he
places on his musculoskeletal system,
the severity and patterns of distribu
tion of these areas of musculoskeletal
dysfunction (palpable osteopathic le
sions) may vary from person to per
son, as do their influences on health.
Through the communication chan
nels provided by the circulatory and
nervous systems, a disturbed portion
of the musculoskeletal system impairs
to some extent the function of other
tissues and organs, especially those
with which it is neurologically most
closely related. Conversely, musculo
skeletal disturbances may, for the
same reason, reflect disturbances
elsewhere, for example, in visceral
organs. But such secondary (reflex)
musculoskeletal disturbances are not
merely maniestations of the visceral
disorder; through afferent feedback,
the somatic tissues become partici
pants in, and contributors to, the
pathologic process. Hence, whether
of primary or secondary origin,
the musculoskeletal dysfunction
threatens homeostasis to some extent
in the healthy person and tends to
promote and sustain ongoing patho
logic processes in the patient.
The segmental facilitation associ
ated with osteopathic lesions causes
the affected segments of the cord to
behave like neurologic lenses which
focus impulse traffc and channel it
through the efferent pathways, both
motor and sympathetic, to the tissues
innervated from those segments.
Those tissues are thus exposed to the
hazards of exaggerated motor activity
and hypersympatheticotonia, both of
which are commonly implicated in
many disease states. To these refex
factors can now be added the aber
rant trophic factors related to altera
tions in axonal transport. Hence, in a
person already ill, these mechanisms
impair the natural capacities and
resources for resistance, repair, and
recovery and tend to prolong and to
exacerbate the illness.
In a healthy person the lesioned
segment represents a site, a channel,
of increased vulnerability. Whether
or not disease develops depends upon
the other factors in that person and in
his life - inherited, developmental,
environmental, emotional, social, nu
tritional, traumatic, microbial, and
others. The more demanding they
are, the more critical is the facili
tating, predisposing infuence of the
osteopathic lesion, and the more the
balance is tipped toward illness. The
mechanisms involved in the lesion
process increase the probability of
disease (and the severity of existing
disease) by focusing, magnifying, and
unfavorably modifying the impact of
other factors.
What determines which organs and
tissues take the greatest daily abuse,
and which diseases develop, or are
more likely to develop? This depends
on which segments are involved and,
therefore, which organs and tissues
are in the line of fire. To reduce the
facilitation and the trophic impair
ment is to reduce the firing and the
vulnerability of the targets - and of
the person himself.
The strategy of osteopathic diagno
sis and manipulative therapy lies,
therefore, in the recognition of the
somatic component of disease and in
the appreciation of its predisposing,
exacerbating, and sustaining in
fluence in the total man. The strategy
lies in the ready accessibility of the
somatic component to detection and
evaluation and its responsiveness to
appropriate treatment.
Regardless of the real or apparent
relationship of the somatic compo
nent to symptoms or identifiable dis
ease in a given patient, amelioration
(or, when possible, "silencing") of
this component interrupts a vicious
circle of detrimental infuences and
liberates the natural mechanisms for
resistance, repair, and recovery.
Recognition and treatment of so
matic dysfunction in the healthy per
son increases his insulation against
the unfavorable factors in his life, in
his environment, and in himself, ren
dering them less deleterious to his bi
ologic capacities and resources and
him less vulnerable. In the healthy
person osteopathic lesions represent
early, slight, and reversible depar
tures from health be/ore they can be
assigned labels as syndromes or
diseases, and even before they can be
detected by usual methods.
Hence, osteopathic medicine, in
corporating manipulative therapy
and other approaches such as nutri
tional, behavioral, and environmen
tal, which also support and disen
cumber inherent biologic capacities
and resources, represents a compre
hensive, strategic, and systematic ap
proach, not merely to therapy, but to
the maintenance of health, which is,
after all, the most comprehensive
form of preventive medicine.
Osteopathic manipulation in
perspective
It has been shown, I hope, that osteo
pathic methods have a solid basis in
biologic mechanism, and that the im
plications of advances in our under
standing of those mechanisms are im
mensely rich in clinical promise.
Clearly, the osteopathic "contribu
tion" could be a truly great contribu-
1J
tion to the health of the nation. No
valid, rational excuse remains, if it
ever existed, for agencies and in
dividuals charged with the responsi
bility of guarding and promoting
health for not exploring the possible
value of including that contribution
in medical education and medical
practice, generally.
As I have already indicated, how
ever, the osteopathic profession has
yet to document its own conviction
about the value of osteopathic prin
ciples and methods in total health
care, and to demonstrate its commit
ment to teach, develop, and apply
those principles and methods as
brQadly and effectively as possible.
When it has done so, through its phy
sicians, its organizations, and its in
stitutions, the osteopathic profession
will have won a new right: the right -
indeed, the obligation -to insist that
these principles and methods are too
important not to be carefully con
sidered for incorporation in what
purports to be scientific, comprehen
sive medicine.
A very fundamental point must be
made in this connection, one that has
been overlooked for a long time. The
value of the osteopathic contribution
to total health care can be correctly
assessed only within the conceptual
contet in which it arose and in which
it operates. Disregard of this point
has hampered the development of the
contribution and its utilization in
practice.
Continued efforts to squeeze osteo
pathic manipulative medicine into an
incompatible (actually, inimical) con
ceptual framework can only continue
to distort and obscure the significance
and value of the osteopathic contri
bution to health care, and to nullify
its impact on the directions of medi
cal development as a whole.
Would it not be absurd to apply the
"rules" for playing
a
nd scoring base
ball to basketball, on the premise
that, after all, basketball differs from
baseball only in the additional two
letters, k and t? It is no less absurd to
force strictly allopathic principles on
osteopathic medicine on the premise
that the latter is "distinctive" by vir
tue only of two additional techniques:
palpatory diagnosis and manipulative
therapy. Let me illustrate.
Osteopathic manipulation (includ
ing its diagnostic components) is not
merely another therapeutic modality
194
or technique in a long and ever
growing catalogue of modalities and
techniques. It cannot be applied and
evaluated as though it were a medi
cation or physical agent, designed for
the "average case, " and "indicated"
or "contraindicated" in wholesale
manner for this or that disease or
condition, for alleviating this or that
symptom, or for combatting this or
that etiologic agent. Nor can it be
viewed and evaluated as though it
were a single, discrete, uniform entity
i ndependent of the parti cul ar
understanding and skills of the in
dividual physician, of the individ
uality of the patient, and of the
unique circumstances of their inter
action.
Osteopathic manipulation is a
whole system of diagnosis, appraisal,
therapy, and prophylaxis. Even when
bein
g
applied primarily for the relief
of symptoms, such as backache and
headache, or for the treatment of dis
eases, manipulative therapy places
the individual as a whole on a more
nearly optimal physiologic path. That
path, unique for each individual,
leads the well person toward greater
well-being and a lowered susceptibil
ity to illness in general, and the ill per
son toward recovery and toward the
cure which, if it comes, must come
from within.
I have found it reasonable to visu
alize an osteopathic treatment as an
inevitably complex transaction be
tween two human beings. In the
course of each treatment two persons
are physically, physiologically, and
even psychologically linked in a
cybernetic loop in which each re
sponds continually to the other's
responses to his own changing input.
As in less physical forms of therapy,
the physician seeks to guide the pa
tient to behavior patterns that are less
costly and more favorable to his
health.
Unlike prescribed therapeutic tech
niques or agents, manipulative
therapy, as a system, as a whole
approach, depends for its efficacy on
an infinite variety of adaptations to
the unique and continually changing
requirements of the individual. It
depends on the physician' s ability to
assess and to meet those require
ments. It can only be as effective as
the physician's art and science make
it. Obviously, the accurate assessment
of the potential value of osteopathic
manipUlative therapy in total health
care requires the maximum develop
ment of the physician' s knowledge.
acuity, judgment, and skills.
This is not to say, however, that
anything less than superb is without
clinical value. It is a reflection of the
merits of the osteopathic approach
that manipulation administered by
osteopathic physicians of moderate
skills has, throughout the years,
produced remarkable results for
which millions of persons have been
grateful. Indeed, what seems most
strongly to motivate students to
develop their manipulative skills are
the frequently astonishing clinical
results even they obtain with their
own as yet inexpert efforts.
I hope I am making it clear that
I view osteopathic diagnosis and
manipulative therapy as an area of
medicine so vast, so deep, so per
vasive in its pathophysiologic rela
tionships that it is as exacting and
demanding of persistent study, long
and meticulous practice, and arduous
endeavor as any other area of medi
cine. Physicians who are accom
plished in this area merit their
profession's highest esteem. I believe
this area of medicine to be of such
great value to human health that to
limit or to withhold its benefits, for
whatever reasons, is ethically, mor
ally, and humanely indefensible.
In the course of the profession's
victorious struggle for recognition O
its competence to practice medicine,
osteopathic manipulation has fallen
from the comprehensive man-ori
ented strategy in which it arose, and
of which it is an essential part, into
a fragmented , di sease-oriented
framework in which its use and
development are seriously impeded,
and in which it cannot possibly be
properly evaluated. In such an in
compatible conceptual framework,
the use of osteopathic manipulative
therapy has tended more and more
toward the palliative, adjunctive,
optional periphery of clinical practice
as another in the long list of physical
techniques.
Toward a total strategy of medicine
The osteopathic profession is now
called on, it seems to me, to restore -
no, to elevate - osteopathic manipu
lation to its key position in a total
strategy of medicine, and to seek its
accelerated development and refine-
Interpretation of research
ment toward the fullest implementa
tion of that strategy. Not to do so,
whether by default or by decision,
would be to renounce a commitment
and an opportunity of immense and
historic magnitude. While such a
total strategy - applicable at any
stage of technologic development -
has long existed as a concept and as
the basis for design of health care,
it does not yet exist in practice, except
possibly in small, local experimental
models. The structural and functional
redesign of health care delivery sys
tems according to such a strategy
has a special, even urgent, relevance
today.
It is becoming more and more
wi del y appreci ated t hat t he
prevailing health care delivery system
is a monstrous anachronism. Techno
logically advanced as medicine is, its
practice, with its social, political and
economic aspects, is geared to an era
that has long passed. The acute infec
tious diseases and the quick killers,
especially of the young, that prevailed
a half-century and longer ago, have
largely been replaced by long-term
illnesses, of the adult, the aging, and
the aged, that cripple and that kill
gradually. A system which continues
to be based on episodic treatment is
absurdly and tragically inappropriate
at a time when the need is for a shift
from periodic individual visits to
extended continuous care, from sick
care to well care, from emergency,
finger-in-the-dike care to preventive
"flood control, " from the palliation
of disease to the maintenance of
health.
It is no coincidence that the con
ceptual framework which for so
many years has offered such valuable
guidelines to the care of the indi
vidual patient also provides valuable
guidelines to the design of health care
delivery systems so urgently needed
today. It is no coincidence that out
of that framework have emerged
methods that would implement the
prognostic, preventive, health-main
taining, health-recovering, whole
man approaches that are essential
components of those needed systems.
These values have always been im
plicit in osteopathic principles and
practice. The new element is in easily
demonstrable timeliness.
Se, for example: Glazier, W. H. : Task of medicine.
Scient Am 228: 137, Apr 73.
Hence, in urging the responsible
agencies in our society to undertake
thorough evaluation of the potential
contribution of osteopathic manip
ulative therapy to total health care,
and in insisting that this be done in
the correct practice framework, the
profession would at the same time be
giving unique leadersip in the ren
ovation of our archaic system of
practice. Now strengthened by its
complete acceptance as a profession
of physicians, by broader and deeper
scientific foundations, and by almost
a century of demonstrated effcacy,
the osteopathic profession, as it
prepares for its second century,
is in a most auspicious position
for giving that crucial leadership
to the reformation movement in
medicine. This could be the pro
fession's greatest triumph, and the
ultimate living memorial to its
founder.
References
Listed here are mainly those publications which are
readily available to physicians and in which the
original research, published elsewhere, had been
reviewed and clinical implications drawn. Only those
primary research publications are included which may
be of special historic interest. References to the
original works and to related research by others can,
however, mfound in the review publications that are
cited herein. Publications ae in chronological order to
show historical progession.
Denslow, J.S., and Clough, G. H. : Reflex activity in
spinal extensors. J. Neurophysiol 4:430-7, Sep 41
Denslow, J. S. : Analysis of variability of spinal
refex thresholds. J Neurophysiol 7:207-1 5, Jul 4
Denslow, J.S.: An analysis of the irritability of
spinal reflex arcs. JAOA 44:35762, Apr 45
Denslow, J .S. : The place of the osteopathic concept
in the healing arts. JAOA 46:617, Aug. 47
Denslow, J.S., Korr, I. M. , and Krems, A. D. :
Quantitative studies of chronic facilitation in human
motorneuron pools. Am J Physiol 150: 22938, Aug 47
Korr, I . M. : The neural basis of the osteopathic
lesion. JAOA 47: 1918, Dec 47
Korr, I . M. : The emerging concept of the osteo
pathic lesion. JAOA 48: 1 2738, Nov 48
Symposium: Denslow, J.S.: An approach to skele
tal components in health and disease, JAOA
50:399403, Apr 51
Thomas, Price E. : An approach t o the analysis of
spinal stress through its physiological manifestations.
JAOA 50:4037, Apr 5 1
Korr, l . M. : The three fundamental problems in
osteopathic research. JAOA 50:40716, Apr 51
Denslow, J. S. : The somatic component. JAOA
52:25861, Jan 5J
Symposium: Korr. I. M = Thomas, P. E . . and
Wright, H. M. : Symposium on the functional im
plications of segmental facilitation. JAOA 54:26582,
Jan 55
Korr, I.M. : The concept of facilitation and its origins.
JAOA 54:26568, Jan 55
""Northup, G. W. : Osteopathic medicine: An
American reformation. AOA, Chicago, 1966.
Thomas, P . E. : Sympathetic activity in facilitate se
ments: Sudomotor studies. JAOA 54:26972, Jan 55
Wright, H. M. : Sympathetic activity in facilitate
segments: Vasomotor studies. JAOA 54:27376,
Jan 55
Korr, I. M. : Clinical significance of t he facilitated
state. JAOA 54:27782, Jan 55
Wright, H. M. : The origins and manifestations of
local vasomotor disturbances and their clinical
significance. JAOA 56:21724, Dec 56
Korr, I. M. : Osteopathic research: Why, what,
.hither? JAOA 56:27585, Jan 57
Thomas, P .E.: Neurovascular factor m disease.
JAOA 56:33944, Feb 57
Denslow, J. S. iet at.: Certain characteristics of the
normal single motor unit. JAOA 57:25761 , Dec 57
Hix, E. L. : Ureterorenal refex facilitating renal
vasoconstrictor responses to emotional stress. Am J
Physiol 192: 1 91 7, 1958
Tilley, R.M., Young, G.S., and Eble, J. N. :
Practical aspects of viscerosomatic reflex interchange
with special reference to surgery. Yearbook. Academy
of Applied Osteopathy, Carmel, Calif., 1959
Eble, J . N. : Patterns of response of the
paravertebral musculature O visceral stimuli. Am J
Physiol 198:42933. Feb 6
Eble. J. N. : Reflex relationships of paravertebral
muscles. Am J Physiol 20:939-43, May 61
Wright, H. M. : Progress i n osteopathic research: A
review of investigations in the Division of
Physiological Sciences, Kirksville College of
Osteopathy and Surgery, JAOA 61 : 34752, Jan 62
Denslow, J. S. , and Chace, J. A. : Mechanical
stresses in the human lumbar spine and pelvis. JAOA
61 :70512, May 62
Wright. H. M. : New perspectives in medicine: The
role of the nervous system in disease. JAOA
62: 1 05763, Aug 63
Denslow, J. S. : Palpation of the musculoskeletal
system. JAOA 63: 1 107-1 5, Aug. 6
Korr, I . M. , Wilkinson, P.N. , and Chornock, F.W.:
Axonal delivery of neuroplasmic components to
muscle cells. Science 155: 3425, 20 Jan 67
Korr, I. M.: The nature and basis of the trophic
function of nerves: Outline of a research program.
JAOA 66:74-8, May 67
MacFarlane, M.D.: A renorenal vasoconstrictor
reflex. Am J Physiol 21 8: 8516, Mar 70
Symposium: Korr, l . M. , Buzzell, K. A. , and Hix,
E. L.: The physiological basis of osteopathic medicine,
moderated by G. W. Northup. Postgraduate Institute
of Osteopathic Medicine and Surgery, New York,
1 970.
Symposium: Denslow, J. S. , Patterson, M. M. , and
Korr, l . M. : Louisa Bums, Memorial Symposium.
JAOA 72: 149-71 , Oct 72
Denslow, J. S. : Neural basis of the somatic component
in health and disease and its clinical management.
AOA 72: 149-56. Oct 7 ,
Patterson, M. M. : Spinal responses: Static or
dynamic? JAOA 72: 1 56-63, Oct. 72
Korr, l .M. : The trophic functions of nerves and their
mechanisms. JASOA 72: 16371 , Oct 72
+eprinted by permission from JAOA 73: 362370,
1 974.
15
Neurochemical and neurotrophic
consequences of nerve deformation:
Clinical implications in relation
to spinal manipulation* (1975)
The purpose of this paper i s to relate
findings on the subjects of axonal
transport, trophic functions, and
neural chemistry and metabolism to
the subject of spinal manipulation.
The ways in which these functions,
processes, and mechanisms might be
affected by nerve-trunk deformations
of musculoskeletal origins, which in
turn are amenable

to manipulative
therapy, will be identified and, where
possible, characterized. Discussion
will be limited to those circumstances
in which axons survive, disabled
though they may be. Therefore, em
phasis will not be on degeneration
and regeneration, but on first degree
injury, as described by Sunderland. l
While this may be a useful effort,
other than a few clues, the only
products are more unanswered ques
tions.
Questions that arise are: How
many compression, stretching, an
gulation, or other deformations of
nerves and nerve roots by surround
i ng structures i nfluence neural
chemistry and metabolism and the
synthesis and axonal transport of
macromolecules and subcellular
structures? How do these neural
effects in turn influence the tissues,
organs, and processes under neural
control and regulation?
A nerve or nerve root is far more
complex than a mere aggregate of
axons and their myelin sheaths. A
nerve may even be viewed as an in
tegrated organ consisting of many
different kinds of cells, tissues, and
their products. Nevertheless, and for
obvious reasons, the prevailing em
phasis of studies on neural mecha
nisms and their impairment has been
on the axons.
The study of axons, however, does
not answer the central questions
Ba on the author's discussion of presentations by
Sidney Ochs' and David E. Pleasure' at the
Workshop, "The Reearch Status of Spinal Manipula
tive Therapy," Feb. 2-, 1975, at the National In
stitutes of Health. See NINCDS Monograph No. 1 5.
U.S. Dment of Health, Education and Welfare.
19
regarding the neurochemical and
neurotrophic consequences of neural
deformation. We need to know how
the nonaxonal components of nerve
trunks, especially those that serve
nutritive functions and that provide
or control the environment of the
axons, are affected by deformation,
and how these in turn affect neuronal
chemistry, metabolism, synthesis ,
axonal transport, and trophic rela
tions. These nonaxonal components
include the Schwann cells and myelin,
the vascular elements, the various
mesenchymal components, and the
endoneurial fluids and their flow
channels.
Unfortunately, little is known
about how some of these various
components contribute to neural
economy under normal circum
s tances, much less under cir
cumstances arising from mechanical
insult. The following may suggest
how these various components of the
nerve may be affect ed by
deformation.
Axons
Axopiasmic transport.
Proximodistal (cellulifugal)
transport.
Attenuation of the axon by compres
sion or deformation impedes axo
plasmic transport beyond the com
pression. The axon becomes swollen
with dammed-up axoplasm immedi
ately proximal to the compressed
segment, while distally the axon may
become reduced in diameter. A
smaller swelling on the distal side of
the compression reflects dammed-up
axoplasmic components moving
toward the cell. As long as sufficient
axoplasmic passage through the
stenotic segment i s permitted, axo
plasmic continuity is preserved and
the trophic relations between the
perikaryon and its long cytoplasmic
process continue, though probably
with some impairment. The axon
distal to the lesion survives and
wallerian degeneration is forestalled.
Moreover, trophic maintenance of
the axon ensures continued trophic
support of innervated structures. As
long as connection is maintained be
tween nerve cell and, for example,
muscle cells, whether or not impulses
are being or even can be transmitted,
the muscle cells remain intact and
functional. Acetylcholine sensitivity
remains, as in the completely normal
motor unit, limited to the j unctional
area and no fasciculation is seen.
We do not yet know, however, the
effects either on the axon (other than
attenuation) or on the innervated tis
sues of the slowing of the axoplasmic
supplies, or indeed whether the
change in axoplasmic transport i s
purely quantitative. The motoneuron,
for example, is essential not only for
the maintenance of muscle, but it also
exerts a variety of trophic influences
on its structure, excitability, con
tractile properties, enzyme activity,
metabolism, et cetera, indeed on its
genic expression.2,3 These influences,
as Ochs4 has indicated, seem to be
based on axoplasmic transport and
on the actual transsynaptic delivery
of neuronal proteins and other sub
stances to the muscle cells.5-7 How
does the slowing, and possible quali
tative alteration, of this delivery
affect the functions and properties of
the muscle (or other innervated struc
ture)? Such questions are of immense
clinical as well as theoretical interest.
We do know that under such condi
tions of axonal continuity, the axon
distal to the lesion, though thinner,
remains capable of excitation and
conduction. Whether or not the
neuron as a whole is functional, that
is, whether it can conduct impulses
from one end to the other, depends
on the state of the injured segment.
At that site the axon may transmit
impulses normally, or cpnduction
may be blocked, or it may be hyper
excitable and, in the living, breathing,
moving animal or human, it may
oscillate back and forth from one
state to the other. Conduction block
may, however, be persistent, and
recovery may be delayed for hours,
days, or months, even after a mo
mentary deformation, as in concus
sion. The affected fibers suddenly
reawaken to activity, as Sunderland!
describes. The chemical and struc
tural basis for the functional states -
normal, conduction block, hyperex
citability - is unknown. We can only
Interpretation of research
assume that they are somehow related
to the degree of polarization of the
resting membrane, although PleasureS
has also drawn our attention to the
state of paranodal myelin.
Hence, excitatory function and
trophic function are completely
dissociated in this sublethal degree
of axonal deformation. Similar dis
sociation may be produced experi
mentally (or therapeutically) by
chemical or physical agents applied to
the nerve which block conduction
even for long periods of time (for
example, local anesthetics, cold,
pressure, et cetera) without interrupt
ing the axon. 9 It is of historic interest
that only recently was it possible to
produce, experimentally, the reverse
dissociation, in which a trophic
influence was blocked by pharma
col ogi c i nt erference wi t h fast
axoplasmic transport, while the nerve
remained functional as a transmitter
of impulses. Of course, when
axoplasmic transport is reduced to
the point that it is no longer adequate
for axonal maintenance, conduction
soon fails and wallerian degeneration
ensues. Up to this point, removal of
the compressing force permits redis
tribution of dammed-up axoplasm
and the recovery of the neuron.
Retrograde (cellulipetal) transport.
As reviewed by Ochs, ' axonal
transport toward the cell body has
also been demonstrated and studied.
It has been shown that proteins in
muscle may enter the nerve and be
conveyed to the cell body. This
transport, too, may be expected to be
retarded by axonal compression.
Insofar as this serves a feedback
function that chemically "informs"
the neuron about circumstances in
the periphery and thereby regulates
perikaryal morphology, metabolism,
protein synthesis, synaptogenesis,
and possibly even gene expression,
this retardation may be expected to
have deleterious effects. This is
another important area for investiga
tion, not only for obvious theonitical
reasons, but because it relates to the
clinical impact of axonal impinge
ment and the value of spinal manip
ulation.
Schwann cells and myelin sheaths
Aside from the role of the Schwann
cells in the formation of myelin
sheaths, which are important in im-
pulse conduction, there is evidence of
their role in axonal nutrition and
energy exchange also. Though not yet
well understood, it appears that these
cells may supply essential substances,
possibly through the Schmidt-Lanter
mann clefts, that are not supplied by
the neuron or via blood and tissue
fluids. Deformation of a nerve
almost invariably involves deforma
tion, and even disruption of Schwann
cell and myelin layers. As the work of
Denny-Brown and Brenner1 2 1 3 among
others has shown, these structures,
especially in the vicinity of the nodes
of Ranvier. may undergo consider
able disruption in injured segments of
nerve. The axons, though they remain
intact, undergo conspicuous chemical
changes, reflected in altered staining
properties at the affected nodes.
However, little is known about the
effects of such changes on axonal
chemistry, metabolism, transport, or
trophic function, in contrast with the
more substantial understanding of
the role of myelin in excitation and
conduction. However, in view of the
demonstration by Ochs and cowork
ers that fast axoplasmic transport is
energized by metabolic processes
within the axon, reduced access of
Schwann-supplied metabolites may
be expected to impede or even block
such transport. Since the substances,
such as glycoproteins, which are
rapidly transported, seem to be
especially important to the axonal
endings and synaptic and myoneural
t ransmi ssi on, even local di sor
ganization of the Schwann cell an(
myelin layers may have seriou
consequences.
Blood vessels
Deformation of a nerve or spinal root
almost inevitably produces deforma
tion and even occlusion of the vessels
supplying the nerve. Because of the
rich anastomosis and diffusion of ox
ygen from surrounding tissues and
adjacent nerve segments, occlusion of
the blood vessels supplying a periph
eral nerve over even a considerable
stretch of nerve does not necessarily
result in ischemia, much less anoxia.
The effects of experimental ischemia,
with the use of blood-pressure cuffs
or tourniquets, on neural function in
humans and animals, as refected in
sensation and in motor and autonom
ic function, have been studied by
many investigators with varying and
even conflicting results. Interpreta
tions of the results are even more am
biguous because with these methods it
is not possible to distinguish between
the effects of ischemia and those of
neural compressi on. However ,
studies of the effects of local defor
mation or of anoxia on exposed or
isolated nerves clearly indicate that
the respective mechanisms leading to
conduction block are quite different,
as reflected, for example, in different
orders of susceptibility among fiber
types, and in very different dynamics
of induction and recovery from
block.
Of course, ischemia of sufficient
intensity and duration does cause
degeneration of the ischemic and
distal portions. Less severe or briefer
ischemia produces conduction block
without degeneration. Hyperexcit
ability occurs during the induction
and post-ischemic periods. When the
perfusion rate chronically is reduced,
but not to the point of complete
ischemia, different fbers in the same
nerve may at the same time be in
various functional states ranging
from normal conduction to hyperex
citability (ectopic. supernumerary im
pulses) to conduction block, to de
generation. The degree of ischemia
and neural dysfunction may fluctuate
with motion, blood pressure, and
other variables. The functional state,
whether normal, nonconducting, or
hyperexcitalle, of the hypoxis
(ischemic) nerve fibers is related to
the resting membrane potential ,
which also is energized by oxidations
in the axon. IS,11
Mechanical insults or relatively
moderate pressure that selectively oc
cludes the veins draining the nerve in
troduce disturbances other than, or in
addition to, ischemia. As in other tis
sues, venous obstruction produces
hyperemia, increased transudation,
and edema. Accumulation of interfi
brillar fluids almost certainly retards
the exchange of substances between
the axons and other elements in the
nerve, with detriment to axonal me
tabolism and to the processes that
depend on axonal metabolism for
energy and for specific substances.
Alterations in spatial relationships
within the edematous nerve and in
osmotic relations also may have ef
fects on excitation and conduction.
Another factor to be considered as a
complication of the increased transu-
1T
dation is the accumulation of protein
in the extra-axonal fuids, and the
resultant tendency toward fibrosis.
This occurs also in chronically
ischemic nerves.
` .
The consequences of CIrculatory
embarrassment in the spinal roots
may be expected to be the same as for
peripheral nerves. There are several
factors, however, that render the
roots much more vulnerable in this
regard:
1 . Location of the spinal roots
within the intervertebral foramen is i n
itself a great hazard.
2. Spinal roots lack the protection
of epineurium and perineurium.
3. Since each root is dependent on a
single radicular artery entering via the
foramen, the margin of safety provid
ed by collateral pathways is minimal.
4. Venous congestion may be more
common in the roots because the
radicular veins probably would be
compressed immediately by any re
duction of foraminal diameter. There
is also the possibility of refux from
the segmental veins through pressure
damaged valves; and venous conges
tion would have additional con
sequences because the swelling, being
within the foramen, would contribute
to compression of the other in
traforaminal structures.
5. Circulation to the dorsal root
ganglion especially is vulnerable for
anatomic reasons shown by Berg
mann and Alexander.
I t i s interesting t o speculate to what
degree ischemia (or venous conges
tion) of the dorsal root ganglion af
fects its protein metabolism or the
"routing" mechanism discussed by
Ochs, 4 which apparently controls the
relative rates of exportation of
neuronal proteins toward the spinal
cord as compared to-that toward the
periphery. In this connection it is im
portant to remember that sensory
neurons are no less potent trophically
than motor neurons. Also, it should
be noted that because the radicular
arteries contribute substantially to the
blood flow of the spinal cord, re
duced radicular flow over several seg
ments also could affect central
neurons and intraspinal axons.
Interstitial fluids in the nerve
The foregoing discussion of edema
draws attention to the existence of
fuid spaces within the nerve, provid
ed by, or enclosed by, endoneurium
198
(and possibly perineurium) and to
the evidence for circulation of the
endoneurial fluids i n both direc
tions. I8-
2
3
Little or nothing is known of the
origins or fate of the endoneurial
fluid, the channels of fow, or the
propulsive mechanisms. Indeed, if
the observations of Weiss and co
workers 18 are correct, that proximo
distal flow continues in the living
nerve after arrest of circulation and
even in completely excised nerves,
then we are presented with still
another mystery regarding the source
and site of the motor power.
There appears to be good evidence
for connections of endoneurial spaces
with other fuid compartments, direct
or indirect or across selectively per
meable membranes, with subarach
noid space, I 9 and subdural space24
central l y, and wi th l ymphati cs
distally25 and in the epineurium.
Brierly, 19 for example, proposes that
the periradicular cul-de-sac of the
subarachnoid space is a subsidiary
site for the excretin of cerebrospinal
fluid (in which the roots are bathed)
which may pass into the spinal nerve
as well as into segmental lymph chan
nels.
What is the role of the endoneurial
fluid in the nutrition, ionic and
osmotic balance and metabolism of
the neuron, and i n the processes that
depend upon them, including excita
tion, conduction, axonal transport,
and trophic functions? Unfortunate
ly, we know as little about the func
tion of the endoneurial flow as we do
about its mechanisms. We can as
sume that at the very least it serves the
same function as interstitial fluids in
other tissues, for example, as medium
of exchange between the tissue cells
and the blood. We also can assume,
however, that the longitudinal
arrangement, the apparently chan
nelized fow, and the interchange
with fluid compartments of the cen
tral nervous system underlie some ad
ditional functions specific to nerve.
Whatever they are, they also may be
expected to be highly vulnerable to
mechanical insult to the nerve.
The connective tissues
The structure and relatively obvious
functions of the epineurium, peri
neurium, and endoneurium are rea
sonably well understood, and have
been summarized concisely by Sun-
derland. The familiar functions,
especially of the epineurium, include
imparting compactness and cohesive
ness to the nerve; support; compart
mentalization, with the perineurium
binding together and encompassing
the funiculi and the endoneurium en
sheathing the individual fibers with
their Schwann and mycmn layers;
guiding regenerating axons back to
their appropriate terminals; pro
viding and supporting channels for
flow of interstitial fuids, blood, and
lymph; acting as diffusion barriers;
and defending against mechanical,
chemical, and microbial insult.
In connection with neural chemis
try, metabolism, and axoplasmic
transport, it is likely that in the nerve
the mesenchymal components may
play an unusual, perhaps unique, role
in the regulation of fluid volume and
composition and of osmotic equilibri
um. In the normal nerve the dynamic
balance between hydrostatic and
oncotic pressures seems to be between
the radial pressure exerted by the
epineurium and water absorption
by endoneurial and interstitial col
lagen, so abundant in nerve, as
Pleasure8 has emphasized. Lorente de
N626 has shown that when the
epineurium is mechanically breached
or weakened, the nerve swells enor
mously, with progressive thickening
of the endoneurium and enlargement
of the interfibrillar spaces. Under
these conditions, one may expect
disturbances in exchange between
blood and axons, in neural chemistry,
metabolism, transport, and electrical
properties. This is another area for
study with modern methods, for its
neurophysiologic interest and relation
to spinal manipulation.
The neuron
.Having examined the role of axonal
and non axonal components of nerves
and roots with a view to their involve
ment in the effects of deformation, it
is now time to return to the neuron. It
is important to remember that neural
chemistry. metabolism, and axonal
transport are subject to alteration not
only by neural and radicular defor
mation but by the activity of the cor
responding nerve-cell bodies. Almost
any factor that more or less enduring
ly exaggerates the rate of impulse
discharge by neurons also affects the
energy requirements, metabolism,
and, almost inevitably, protein syn-
Interpretation of research
thesis and turnover.
As Denslow27 has shown, interver
tebral and other musculoskeletal
strains, designated as osteopathic
lesions and responsive to manipula
tive therapy, are associated with
facilitated segments of the spinal
cord. In those segments, motoneu
rons and neurons of the sympathetic
nervous system are maintained in a
hyperirritable state, presumably by
disturbed patterns of afferent input
from propri oceptors and ot her
endings i n the stressed tissues. 2 8 In
this state, and under conditions of
daily life, the affected neurons tend
to be in constant or relatively high ac
tivity when corresponding neurons in
nei ghbori ng and cont ral ateral
segments are quiescent or only mildly
active. The effects of such chronic ac
tivity, provoked and sustained by
musculoskeletal disturbances, on
neural chemistry, metabolism, axonal
transport, and trophic infuence and
on the retrograde influences from the
target tissues hardly have been ex
plored, yet they are of great impor
tance to the subject of spinal
manipulation.
Finally, it is important to re
emphasi ze t he evi dence t hat
peripheral nerves not only conduct
impulses to or from the cells, tissues,
and organs that they supply, but that
they also deliver to them substances
synthesized in the cell body, most
notably proteins, that are essential
for their development, maintenance,
and repair, that influence their
various characteristics and functional
capacities, and that condition their
responses to various factors, both
physiologic and noxious.
Any factor that for a protracted
period alters the quality or quantity
of the axonaUy transported sub
stances not only might affect impulse
transmission, but could cause the
trophic influences to become adverse
and detrimental, thereby contributing
to disease. In considering the neuro
logic impact on human health of pos
tural and biomechanical defects in the
body framework that are amenable
to manipulative therapy, we no longer
can limit ourselves to disturbances
in impulse traffic. Conspicuous and
distressing as are the resultant pain
and the motor, sensory, and auto
nomic dysfunction, the more subtle
and insidious trophic consequences
of disturbances in axoplasmic com-
position and transport are no less
important. It seems likely that much
of the efficacy of manipulative ther
apy is related to the amelioration of
these trophic factors.29
J
References
1 . Sunderland, S. : Nerves and nerve injuries.
Williams and Wilkins Co., Baltimore, 1968.
2. Guth, L.: "Trophic" infuences of nerve on mus
cle. Physiol Rev 48:65-87, Oct 6.
3. Drachman, D. B. . ed.: Symposium: Trophic
functions of the neuron. Ann NY Acad Sci 228: 1-423,
22 Mar 74.
4. Ochs, S.: Factors influencing axoplasmic flow
and neural trophic effects. Presented at Workshop on
Research Status of Spinal Manipulative Therapy,
Bethesda, Maryland, Feb 75.
5. Korr, I. M. , Wilkinson. P. N. , and Chornock,
F. W. : Axonal delivery of neuroplasmic components
to muscle cells. Science 1 55: 342-5. 20 Jan 67.
6. Korr. I.M., and Appeltauer. a. S.L: The time
course of axonal transport of neuronal proteins to
muscle. Exp Neurol 43:452-63, May 74.
7. Appeltauer, a. S. L, and Korr, I . M. : Axonal
delivery of soluble, insoluble and electrophoretic frac
tions of neuronal proteins to muscle. Exp Neurol
46: 1 3246. Jan 75.
8. Pleasure, D.E.: Nerve root compression; effects
on neural chemistry and metabolism. Presented at
Workshop on Research Status of Spinal Manipulative
Therapy, Bethesda, Maryland, Feb 75.
9. Robert. E. D . . and Oester, Y.T.: Electrodiagnosis
f nerve-impulse deprived skeletal muscle. J Appl.
Physiol 28:439-43. Apr 70.
10. Albuquerque, E. X. , et al. : Effects of vinblastine
and colchicine on neural regulation of the fast and
slow skeletal muscles of the rat. Exp Neurol
37:6734, 1972.
1 1 . Singer. M. , and Salpeter. M. M. : The transport
of 3H I -histidine through the Schwann and myelin
sheath into the axon, including a reevaluation of
myelin function. J Morph 120:281 -31 5, Nov 66.
1 2. Denny-Brown, D. E. , and Brenner, C. : Paralysis
of nerve induced by direct pressure and by tourniquet.
Arch Neurol Psychiat 5 1 : 1-26, Jan 4.
13. Denny-Brown, D.E., and Brenner. c.: I esion in
peripheral nerve resulting from compression by spring
clip. Arch Neurol Psychiat 52: 1-19, Jul 4.
14. Ochs. S.: Energy metabolism and supply of -
P to the fast axoplamic transport mechanism in
nerve. Fed Proc 33: 1049-58. Apr 74.
1 5. Gerard. R. W. : Metabolism and function in the
nervous system. In Neurochemistry: the chemical
dynamics of brain and nerve. Edited by K. A.C.
Elliott, I. H. Page. and J. H. Quastel. Charles C.
Thomas, Springfield. 1955.
16. Brink, F.: Nerve metabolism. In Metabolism of
the nervous system. Edited by D. Richter. Pergamon
Press. New York, 1957.
17. Bergmann, L, and Alexander. L.: Vascular
supply of spinal ganglia. Arch Neurol Psychiat
46:761-82, Nov 41 .
1 8. Weiss. P et al. : Proximodistal fluid convec
tion in endoneurial spaces of peripheral nerves,
demonstrated by colored and radioactive (isotope)
tracers. Am J Physiol 143:521-40, Apr 45.
19. Brierly, J . B. : Sensory ganglia: recent
anatomical, physiological and pathological contribu
tions. Acta Psychiat et Neurol Scandinav 30:55376,
1955.
2. Appeltauer, G.S.L.. and Sai. E.E.: Incor
poration of C-14 lysine into spinal roots, spinal
ganglia and peripheral nerves of the rat. Exp Neurol
1 4:484-95, Apr 6.
21 . Brierly, J. B. , and Field, J. : Fate of intraneural
injetion as demonstrated by use of radioactive phos
phorus. J Neurol Neurosurg Psychiat 1 2:86-99, May
49.
22. Bodian, D. : Some physiologic aspects of polio
virus infections. Harvey Lect 52:23-56, 1958.
23. Bakin, Y. I . , Dolgachev, I . P. , and Kiselev, P. N. :
Possibility of movement of substances along a nerve.
Herald Roentgenol Radiol (Trans!.) 1 : 3-6, 1953.
24. Dorang. L. A. , and Matzke, H. A. : The fate of a
radio-opaque medium injected into the sciatic nerve. J
Neuropath Exp Neurol 19:25-32, Jan 6.
25. Kurdiumov, N. A. : On the structure of perineu.
ral spaces and efferent lymphatic pathways from the
cerebrospinal nerves. Arkh Anat 44: 1 21 6. Mar 63.
26. Lorente de No, R.: Observations on the proper
ties of the epineurium of frog nerve. Symp Quant Bioi
1 7:299-3 1 5, 1952.
27. Denslow. J.S.: Pathophysiologic evidence for
the osteopathic lesion: The known, unknown, and
controversia. JAOA 7S: Dc 75.
28. Korr, I . M. : Proprioceptors and somatic
dysfunction. JAOA 74:638-50, Ma 75.
29. Korr, I . M. : The nature and basis of the trophic
function of nerves: outline of a research ;rogram.
JAOA 6:984-8, May 67.
30. Korr, I . M. : The trophic functions of nerves and
their mechanisms. JAOA 72: 1 63-71 . Oct 72.
Reprinted by permission from JAOA 75: 40-414,
1975.
19
Proprioceptors and somatic dysfunction*
(1975)
The musculoskeletal system is the
most massive system of the body. yet
in the performance of its infinite
repertoire of motions and postures, it
is the most delicately controlled and
coordinated. Accordingly, the mus
culoskeletal system is the recipient of
most of the efferent outflow from the
central nervous system (CNS), with
the largest portion by far going via
the ventral roots of the spinal cord to
the muscles, which carry out the
motor commands of the CNS.
It is less well appreciated, however,
that for related reasons the musculo
skeletal system is also the source of
the preponderant sensory input to the
CNS, an input that is also the most
widespread. the most continuous,
and the most variable. This sensory
feedback, from countless thousands
of reporting stations in myofascial
and articular components, entering
the cord via the dorsal roots, is essen
tial to the moment-to-moment con
trol and fine adjustment of posture
and locomotion.
In addition to this influence on the
motor pathways, the sensory report
ing is selectively routed to various
other centers throughout the nervous
system, including, of course, the
cerebral cortex, where it enters into
consciousness and the ordering of
volitional motor activity. Relevant
portions of the reports also reach and
are utilized by the autonomic nervous
sy
s
tem in the tuning of visceral, cir
culatory, and metabolic activity to
musculoskeletal demand. Indeed, the
sensory input from the musculo
skeletal system is so extensive, inten
sive, and unceasing as to be a domi
nant influence on the CNS and there
fore the person as a whole.
It may be expected, therefore, that
disturbances in the sensory input
from the musculoskeletal system,
whether generally or locally, would
significantly impair not only motor
function, but also other functions -
and that of the person himself. For
B on a leture given at the 71st Clinical Con
ferene of the New York Academy of Osteopathy. in
conjunction with the Postgraduate Institute of
Osteopathic Medicine and Surgery, January 26. 1 974.
An ealier version appared in Ostepthic Annal' in
August 1974.
20
those engaged in the study of the
neural and reflex mechanisms, that
premise is at the heart of the clinical
significance of the osteopathic lesion
- now modishly and euphemisti
cally designated as "somatic dys
function. " One of the first prod
ucts of experimental research into
those mechanisms, pioneered by Den
slow,2-4 was the concept of chronic
segmental facilitation. In 1 947, the
hypothesis was stated5 as follows:
(An) osteopathic lesion represents a facilitiated
segment of the spinal cord maintained in that
state by impulses of endogenous origin entering
the corresponding dorsal root. All structures
receiving efferent nerve fibers from that seg
ment are, therefore. potentially exposed to ex
cessive excitation or inhibition.
In speculating further about the
site of the "endogenous origin, " the
author suggested that the propriocep
tors, particularly the muscle spindles,
were the most likely candidates be
cause: 1) they would be sensitive to
musculoskeletal stresses; 2) they are
nonadapting receptors, sustaining
streams of impulses for as long as
they are mechanically stimulated; and
3) their influence is highly specific to
the muscles acting on the affected
joints and the corresponding spinal
segments.
In the intervening 28 years, re
search in many neurophysiologic lab
oratories has immensely increased
our understanding of the propriocep
tors. Concurrently, research under
osteopathic auspices (reviewed by
various authors
S
- I I ) has substantially
increased our understanding of the
mechanisms involved in somatic dys
function. This paper is an effort to
determine what importance may still
be ascribed to the proprioceptors in
the origin of segmental facilitation
(the clinical significance of which has
also been explored
S
-
1 1
) . It is shown
that there is now even stronger reason
to view the proprioceptors, and most
particularly muscle spindles, as key
elements in the " neural basis of the
osteopathic lesion. " A new theory is
offered about the neural mechanisms
operating in the osteopathic lesion
and about their relation to osteo
pathic manipUlative therapy.
The palpatory criteria for identify-
ing and evaluating the musculo
skeletal disorders that are designated
"osteopathic lesions" have been
described and taught in many dif
ferent ways. Physicians differ in the
ways that they use these criteria i n
diagnosis and as guides to therapy.
However, there seems to be general
agreement on the importance of at
least one feature, decreased mobility
- reduced range or ease of j oint mo
tion in one or more planes - and on
the importance of restoring mobility.
It also seems to be generally assumed
that the resistance to motion is within
the joint itself, ascribable to articular
friction or to the visco-elastic proper
ties of ligamentous structures. This
assumption needs to be reexamined.
It has, however, been so deeply im
plicit in osteopathic th
i
nking that it i s
seldom verbalized, much less ques-
tioned, for several reasons. First,
the view of the osteopathic lesion
as a "bony, " "structural, " inter
vertebral, or articular derangement
has such venerated origins as to
border on dogma. This traditional
vi ew is rei nforced dai l y by
anatomically-worded descriptions
that imply displacements and altered
interosseous relationships, even when
such descriptions are accompanied by
protestations that the osteopathic le
sion is, of course, afunctional distur
bance, and not a "bone out of
place. " Second, the resistance to mo
tion and reduced range of motiOlf,
whatever their origin, are manifest in
reduced j oint mobility. Third, i n
manipulation the vertebrae or other
bones are commonly the levers to
which the manual forces are applied,
and effectiveness of treatment is
refected in their improved mobility.
The braing power of muscle
To a physiologist, it seems much
more reasonable that the limitation
and resistance to motion of a joint
that characterize an osteopathic le
sion do not ordinarily arise within the
joint, but are imposed by one or more
of the muscles that traverse and move
the j oint. Of all the somatic tissues
(for example, vertebral and paraver
tebral), muscle is the only active one,
the one capable of self-energized, in
dependent motion and of developing
great, widely variable, and rapidly
changing forces. The other tissues are
passively moved, immobilized, pushed,
pulled, compressed, and altered in
Interpretation of research
shape by forces external to themselves
- those of muscular origin and those
external to the body, such as gravity.
While usually thinking of muscles
as the motors of the body, producing
motion by their contraction, it is im
portant to remember that the same
contractile forces are also utilized to
oppose motion. By the application of
controlled counteracting forces, con
tracting muscle absorbs momentum
(for example, of a swinging limb) and
regulates, resists, retards, and arrests
motion. Indeed, the energy-absorbing
function of skeletal muscle is no less
important to the control of motion
than its energy-imparting function.
Both are based on the same cellular
mechanisms - those involved in con
traction.
Valuable and quaDtitative insights
into this aspect of muscular function,
as it relates to the " behavior" of le
sioned segments, have come from ob
servations reported by osteopathic
physicians who are skilled in so-called
"functional technique. " While, as in
other manipulative approaches, mo
bility is to them an important criter
ion, the emphasis in this approach is
not on range of externally imposed
("passive") motion, but on ease of
initiation of active, patient-engen
dered motion. In this form of manip
ulation, the fingers of the palpating
hand are placed on tissues of the seg
ment under examination, . while the
other hand signals and guides the pa
tient through various motions in
which that vertebral segment par
ticipates.
Using finger-tip criteria of "ease"
and "bind, " the physicians describe
what seems like exponentially chang
ing resistance (bind) to motion
around one axis or another in the le
sioned segment. That is, on initiation
of motion, there is a rapid rise in re
sistance in one direction and accel
erating collapse along the opposite.
In contrast, the nonlesioned segment
moves relatively freely in all direc
tions anatomically appropriate to the
joint or joints, offering only linearly
changing resi stance. Hoover,
\ 2
Bowles, 1 3 and 10hnstonl4-16 have de
veloped cybernetic approaches to os
teopathic palpatory diagnosis and
mani pUlative therapy that have
opened new lines of inquiry, in
cluding the present one. I am grateful
to them for their many provocative
"personal communications. "
Al t hough these authors have
cautiously avoided ascribing the
changing resistance in the lesioned
segments to any particular tissue, I
am convinced that their reports are
consistent with the hypothesis that
"bind" is the active opposition or
physiologic "protest" of muscle to
the motion in a particular direction,
and "ease" is increased cooperation
and compliance in the other. Indeed,
the development of resistance is ac
companied by a sensation of "bunch
ing-up" under the palpating fingers
similar to that when muscles in the ex
tremities are voluntarily contracted.
It is therefore proposed as a
premise for this paper that it is in its
capicity as a brake that a muscle may
become the major, and highly vari
able, impediment to mobility of the
lesioned "joint, " whether the motion
is produced by external forces or by
other muscles. Muscular resistance is
not based on inextensibility, as might
be expected of tough connective
tissues, but on changes in the degree
of activation and deactivation of the
contractile mechanism.
What would cause a muscle to be
have in that manner - increasing or
decreasing its contraction (and brak
ing power) according to direction of
motion of the joint? First, the
amount of contraction from moment
to moment is controlled by variations
in impulse traffic along the motor ax
ons supplying the muscle. Second, the
impulse traffic varies with changing
levels of excitation of the anterior
horn cells, which, third, are in accor
dance with changing afferent input
during the joint motion. What are the
sources of the changing afferent bom
bardment during the joint motion?
Proprioceptors
The proprioceptors are the sensory
end organs to look to for an answer
to this question, since it is they that
signal physical changes in the muscu
loskeletal tissues. The three main
categories of proprioceptors are those
related to joint position and motion,
to tendon tension, and to muscle
length.
Joint receptors
Endings located in and around joints
(for example, in capsules and liga
ments) report joint motion, position,
and, possibly, force. The Ruffini
endings, especially strategically
distributed in the capsules, report
direction and velocity of motion and
position very accurately. There is lit
tle or no evidence, however, that
these joint receptors have any direct
influence on motor activity through
segmental pathways. They certainly
do not exert a dominant, selective in
fluence on individual muscles. Their
collective influence is on postural and
locomotor patterns through the
higher centers, including the cerebel
lum and the cerebral cortex.
Attention is directed, therefore, to
receptors more directly related to
muscular contraction: those in the
tendons reporting changes in tension
and those in muscle itself reporting
changes in length. Our current knowl
edge of the structure and function of
these receptors has been admirably
reviewed by Houk and Henneman.
1,l
Golgi tendon receptors
The Golgi endings are located in ten
dons close to the musculotendinous
j unction (Fig. 1 , tendon and afferent
pathway T). Pulling on the tendon
distorts these endings , causing
discharge of impulses into the spinal
cord via afferent fibers. The tension
to which these endings are sensitive is
under physiologic conditions usually
exerted by active contraction of the
muscle itself. Lying in tough tendon,
which is in series with muscle and
relatively unyielding, the tendon end
ings are responsive, not to 'hanges
in length but to changes in force.
Change in length occurs mainly in the
much more compliant and actively
shortening muscle. The tendon end
ings remain silent or nearly silent
when a muscle shortens without de
veloping much tension, but when the
muscle contracts against a load or
fixed object or against the contraction
of antagonistic muscles, the discharge
of the tendon endings is in proportion
to the tension that is developed. That
is, the afferent input varies with the
tension exerted by the muscle on the
tendon, regardless of the muscle
length.
The discharges of the tendon end
ings are conveyed to the spinal cord
by dorsal root fibers (Fig. 1 , T),
where they excite inhibitory inter
neurons that synapse with moto
neurons controlling the same muscle.
The effect of their discharge therefore
is inhibitory, tending to oppose the
further development of tension by the
Z01
"fllf.tW
yMTO
PHLb
QOtlI)11lI
rw
---
--==
=
_ -~c =m FLCLW c
Fig. 1. Innervation of skeletal muscle.
Motor: a -alpha motoneuron to main (e
trafusa/ muscle fibers; g - gamma
motoneuron to intra/usal muscle fibers.
Sensory: T - neuron conveying impule
from Golgi endings in tendon; As - neuron
conveying impulses from annulospiral
(primar) ending in spindle; Fs -neuron con
veying impules from !lowr-spray (secondary)
endings in spindle.
(Adapted from Buzzell. ' )
Fig. 2. Sensory function ofthe spindle. A t left, in muscle at resting length; center, in stretched muscle; at right, in contracting muscle. Relative impulse
frequency i shown in the uppr right-hand corer of each diagram. (From Buzzell. ' )
muscle, that is, to produce relaxation.
This is quite opposite to the
"behavior" at the lesioned segment
described above.
Muscle spindle
Muscle spindle are much more com
plex than the tendon receptors. Each
spindle has two kinds of sensory end
ings, each with different central con
nections and refex influences, and
a muscular component with its own
motor innervation. Spindles are
scattered throughout each muscle in
numbers that vary with the function
of the muscle and the delicacy of its
control. The greater the spindle densi
ty, the fner the control.
Only those details of structure and
function that are essential to the pur
pose of this essay will be reviewed.
The reader is referred to other sources
for further details, such as Houk and
Hennemanl718 or recent editions of
other textbooks in medical physi
ology.
Structure-function of the muscle
spindle
Unlike the tendon endings, spindles
are within the muscle itself and sur
rounded by muscle fibers, arranged in
parallel with them and attached to
them at both ends. The essential
features are diagrammed in Fig. 1 .
Clearly, stretching the muscle also
102
stretches the spindle. and shortening
of the muscle slackens the spindle.
Each spindle, enclosed in a connec
tive tissue sheath, and about 3 mm.
long, has several thin muscle fibers.
They are identified as intrafusal
fibers to distinguish them from the
much larger and more powerful (ex
trafusal) fibers that comprise the bulk
of the muscle. The intrafusal fibers
are attached to the sheath at each
end. They pass through an expanded
lymph space in the middle of the spin
dle. This portion of each fiber is
rather densely nucleated and is only
feebly contractile, if at all.
The intrafusal muscle fibers are in
nervated by gamma
m
otor fibers
originating in the ventral horn and
passing through the ventral root (Fig.
1 ,g). In contrast to the alpha motor
neurons supplying the extrafusal
muscle fibers (Fig. 1 ,a), the gamma,
also known as "fusimotor," neurons
are small in size and their axons quite
thin. The importance of the fusimotor
innervation is indicated by the fact
that the gamma fibers comprise one
third of the ventral root outflow.
The sensory endings of the spindle
are in close relation to the equatorial
(nucleated, noncontractile) portion of
the intrafusal fibers. The so-called
primary ending is wound around the
fbers and is described as the an
nulospiral ending (Fig. I ,As). Sec-
ondary, flower-spray endings occur
on either side of the primary ending
and are connected to thinner myelin
ated axons (Fig. I ,Fs). Both are sen
sitive to stretch of the central portion
of the spindle.
Sensory endings
Figs. 2 A-C illustrate diagrammatical
ly how the primary endings respond
to change in muscle length. When the
muscle is stretched (Fig. 2B) beyond
its resting length (2A), the spindle is
also stretched, causing the primary
and secondary endings to fire at in
creased frequencies in proportion to
the degree of stretch. Shortening of
the muscle (Fig. 2C), whether by its
own contraction or by passive ap
proximation of its attachments, slows
the discharge proportionately, and
may even silence it. For the purpose
of this paper. discussion will be
limited to the primary ending, about
which much more is known than
about the secondary ending. T
tOne distinction may be worth mentioning. Although
discharge of both types of endings are more or less
proportional to length. the primary (annulospiral)
ending has the additional feature Ihat i1s frequency of
firing during a stretch is in proportion to the OE of
change. That is, the secondary ending apparently
reports length at any moment, but the primary ending
reports both velocity of stretch (and hence of joint
motion) and length (hence joint position). The
primary ending, thereby. provides a predictive or an
ticipatory input to the nerous system. This refine
ment will nOl, however, b included in the discussion.
Interpretation of research
.

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 of each spindle is
conveyed by dorsal root fiber di
rectly, that is, monosynaptically, to
the motoneurons of the same muscle.
There is considerable evidence that
the feedback may be even more pre
cisely localized than that - to the
motoneurons controlling the muscle
fibers in the immediate vicinity of the
spindle. This would provide for a
high degree of precision and specific
ity of reflex regulation.
The influence of the afferent dis
charge of the spindle on the moto
neurons of the same muscle is ex
citatory. 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 afferent discharge, reduces the
excitation of the motoneurons, thus
favoring relaxation (that is, length
ening) of the muscle. The infuence of
the muscle spindle, therefore, is to
cause the muscle to resist change in
length in either direction.
The spindle is thus the sensory
component of the familiar stretch, or
myotatic, refex. It is an extremely
important mechanism in the mainte
nance of posture, since it causes the
extensor and elevator muscles, which
tend to be stretched under gravita
tional infuence, to contract against
the force of gravity in a smoothly
regulated manner. The same mech
anism operates in the misnamed
"tendon reflexes " of cl i ni cal
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 spindles also influence the
activity of muscles other than those in
which they are located, such as an
tagonists and synergists, but these
influences and the polyneuronal path
ways that are involved are not essen
tial to this discussion.
Intra/usal muscle fbers
How do the intrafusal muscle fibers
influence spindle discharge? Since
their ends are firmly anchored, con
traction of these fibers stretches the
middle portion in which the sensory
endings are situated, increasing their
discharge. The effect of intrafusal
contraction on the endings - and
their response - is indistinguishable
from that produced by stretch of the
extrafusal fibers, and the two effects
are additive. That is, at any muscle
length, intrafusal contraction would
increase the spindle discharge, as
would an increase in muscle length;
stretch of the muscle while the intra
fusal fibers are contracted produces a
more intense spindle discharge than
when the intrafusal fibers are at rest
or less contracted.
Gamma motoneurons
The function of the gamma neurons,
in turn, is to control contraction of
the intrafusal fibers, and, through
them, the frequency of the spindle
discharge at a given muscle length,
and the change in that frequency per
millimeter change in length (sensi
tivity). The higher t he gamma
activity, the larger the spindle
response. Fig. 3 shows the relation
ship of afferent impulse frequency to
muscle length at different levels of
gamma neuron activity. Thus, the
higher the gamma neuron activity,
the higher the spindle discharge at a
given muscle length (vertical dashed
line) and the shorter the length of
muscle at which a given impulse
frequency is generated (horizontal
dashed line).
Relation 0/alpha-to-gamma
and extra/usal-to-intra/usal
The importance of the foregoing in
formation, at least for 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
depends on the other forces acting
on the joints crossed by that muscle.
But, as a generalization, the greater
the contraction, the more the muscle
tends to shorten and move the joint,
and the more it resists being stretched
by movement of the j oint in the op
posite direction.
Under normal resting conditions,
the gamma activity is apparently such
as to sustain a tonic afferent dis
charge from the spindle. This main
tains the alpha motoneurons in a
moderately facilitated state - a state
Fig. 3. Inluence of muscle length on spindle
impule frequency at two different levels of
gamma motoneuron activity. See text.
of readiness - and the muscles in
low-grade 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 influence on the excita
tory spindle discharge, the more
forceful the muscle's contraction and
the greater its resistance to being
lengthened. During high gamma ac
tivity, the spindle may, in effect,
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 ac
tivity in still another way. Since the
sensory endings of the spindle are
stimulated by mechanical distortion,
whether caused by contraction of the
intrafusal fibers or by stretch of the
main muscle (or both), the spindle in
effect reports not absolute length of
extrafusal fibers, but length relative
to that of the intrafusal fibers. The
greater the disparity, however it is
produced, the greater the discharge
and the greater the contraction of the
muscle. In other words, the very
small intrafusal fibers, inside the scat
tered spindles, seem to serve as
variable standards of comparison
against which the main muscle is
continually measured and adjusted;
variations of the standard are under
gamma control.
An increase in intrafusal-extrafusal
disparity increases the afferent
discharge, which elicits a contractile
response of 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 spindle is turned back down to
tonic, resting discharge. Thus, the
CNS can elicit, and precisely control,
203
M
t I l I I i |
o 0 10 1 ro 2 30 3 0
5 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1111 1 11 11 1
T
1 11 11111 1 1 1 1 1 1
Fig. 4. Change in spindle dischare (5) and
tendon ending dicharge (T during a brief con
traction ofthe mucle (M).
h L HL*Xm .L*Zm
I ) | I ! l I | III III11111111I1 1I llllll!!I!!II! NQ

! ! l I ! I I lI I ! 11111 W B I N Ngm
III\I I I I I I ! 1 1 1 II 11U!III1I1 I!D' __ ydmm
Fig. 5. Individual and combined inluences of
muscle length (reting length [R.L.l and two
degre of stretch), gamma neuron activity,
and muscle contraction on spindle dicharge.
the contraction and relaxation of
(alpha-innervated) muscle through its
gamma-mediated control of the sev
eral muscle fibers in each spindle.
That is, the gamma neurons, in con
trolling the milligram forces and
micron contractions of a few minute
fibers, indirectly regulate the kilo
gram forces and centimeter contrac
tions of massive . skeletal muscle.
From this viewpoint it becomes clear
why the "gamma loop" is often
viewed a a high-gain servomech
anism, and the gamma neurons as the
gain-control components of the
system.
The gamma system in normal life
It is convenient to begin discussion of
the role of the gamma system in loco
motion and posture by describing
what happens when a muscle sup
porting a moderate load is stimulated
to contract briefly. As described
earlier, the spindle is slackened dur
ing the shortening of the muscle, and
the spindle discharge is reduced -
even silenced. This is diagram
matically represented in Fig. 4 (M and
S). For contrast, the simultaneous
change in the (inhibitory) feedback
from the tendon (T), reporting the
tension developed by the muscle dur
ing its shortening, is also shown. The
combined reports from these two
sources keep the CNS continually ap-
20
prised of tension-length, that is, load
motion changes.
When the spindle is silent, the CNS
is of course deprived of important
information. This may not be a seri
ous loss for a brief twitch, such as
that indicated in Fig. 4. When, how
ever, the muscle is called on to carry
out well-controlled motion while it
remains in a shortened state (as, for
example, the biceps brachialis with
the elbow sharply bent), then the loss
of that information could be a serious
one, and could even be disabling. As
a matter of fact, there would be a
serious impairment in the course of
shortening, since spindle sensitivity to
length-change would progressively
decrease as the spindle slackens.
What device does the CNS have for
ensuring that the spindle remains
reliably operative throughout all
length changes of the muscle? A clue
is offered by Fig. 5, which shows, in a
hypothetical experiment , spindle
discharge in several sets of circum
stances: at resting length and at two
degrees of stretch (X and 2X), at rest
and during a twitch of the muscle,
and each of these with and without
gamma discharge. The discharge is
increased by stretch and by gamma
activity; it is reduced by shortening of
the muscle, for which compensation
can be made by appropriate intra
fusal contraction under gamma
control.
This is precisely the mechanism
that the CNS uses: It calls for adjus
tive tightening and slackening of the
spindle by changing the gamma dis
charges to the intrafusal fibers.
Evidently, as a muscle shortens in
response to impulses in the alpha
motoneurons, parallel volleys of
impulses may be dispatched through
the gamma neurons to stimulate the
intrafusal fibers to contract and take
up the slack as it develops. Con
versely, the intrafusal fibers are per
mitted to lengthen as the extrafusal
muscle fibers relax and lengthen
under alpha direction. In this way, by
appropriately varying the intrafusal
length-standard, the response of the
spindle to each millimeter change in
length, and, therefore, the "gain"of
the entire mechanism, can be kept
relatively constant as a muscle
lengthens and shortens.
Through the same mechanism, the
CNS retains the option, however, to
vary spindle sensitivity and gain in
accordance with the kinds of motion
that are being called for, and i n
accordance with other circumstances.
Gamma activity, and hence gain, may
even be preset according to the length
changes that are called for or antici
pated in a given motion. Through its
control of gamma activity, the CNS
can set the limits - the maximum
lengthening that will be acceptable
and the degree of shortening at which
the spindle would, so to speak, be
unloaded and its discharge turned
back to basal tone.
This continual setting, resetting,
and presetting of intrafusal fiber
length through the gamma neurons
may be viewed as "automatic gain
control" of the length-regulating
mechanism for each muscle. Gain is
continually being adjusted in accor
dance with the motions and the posi
tions that are being volitionally and
refexly called for. For example,
when a tennis player prepares to re
turn a ball with a fast forehand
stroke, the gamma activity is turned
down (low gain), thus permitting
large changes in muscle length during
the preparatory backswing and the
forward swing. On the other hand,
when the player is at the net and
wishes minimum motion of his racket
for a short volley shot, the gamma
activity would be turned up (high
gain) to narrow the range of length
changes that would be reflexly per
mitted. Similarly with the violinist;
who uses the full length of the bow i n
a legato passage, and then uses but a
half-inch of so for a staccato passage.
Or the golfer trying for a long drive,
and then a short chip-shot. Of course,
gain-settings are subject to continual
changes in the course of each motion.
Also, gain control is individually
exercised for each participating
muscle according to its role from
moment to moment.
The cerebral influences illustrated
above in various voluntary activities
may, however, also be maladaptive,
setting the spindle sensitivity and gain
inappropriately for regulation of
muscular activity. In tension and
anxiety states or in situations that are
(or are perceived to be) threatening,
gamma activity may be set too high
for efficient, smoothly coordinated
motion. In these states the muscles
are tense, stiff, resistant to change i n
length. The individual is said to be
"jumpy" and "spastic, " and he
Interpretation of research
tends to move in a staccato manner.
His "tendon" reflexes are propor
tionately exaggerated. Grainger19 has
ingeniously shown how incorrect an
ticipation of the muscular effort
required, for example, to lift an
object, may cause the gain to be set
too high, with serious and painful
consequences. His illustrated article
offers many valuable insights into the
origin of back problems, and to the
mechanisms of their manipulative
amelioration.
The spindle and somatic dysfunction
How may this information relate to
musculoskeletal disturbances desig
nated as osteopathic lesions? I pro
pose as a hypothesis that in the
lesioned area the "gain" has been
turned up in the spindles of one or
more of the muscles. In other words,
according to this concept the dis
charges of the gamma motoneurons
of the related spinal segments are
sustained at high frequencies, keeping
the intrafusal fibers in a chronically
shortened state in which the discharge
frequencies of the spindles, and in
which their frequency change per
millimeter, are exaggerated.
How could this have been brought
about? The concurrence of the fol
lowing two circumstances could, I
believe, instigate the high-frequency
gamma firing: 1 ) strong centrally
ordered contraction during a moment
2) when the muscular attachments
(for example, on two vertebrae) have
been closely and abruptly approxi
mated by forces or factors that have
not been centrally ordered. The
abrupt approximation of the attach
ments, with equally abrupt and un
anticipated slackening of the muscle,
. could be brought about either by an
external force or impact or by un
anticipated yielding of a load or force
opposing a strong isometric contrac
tion. In the suddenly slackened state
the spindles would be silenced equally
suddenly. In calling (or continuing to
call) on the slackened, silent muscle
for strong contraction via the alpha
motoneurons, the eNS, receiving no
feedback, would also greatly increase
the gamma discharges to the intra
fusal fibers until the spindles resumed
their reporting.
On recoil (or refex recovery) of the
body from the forced motion, return
of the attachments (for example, the
vertebrae) to their resting relationship
would be opposed - but not neces
sarily prevented - by the now (re
flexly) resistant muscle. Under the
influence of gravitational forces,
antagonists, and postural refexes,
which would be tending to stretch the
muscle back toward resting length,
the spindle would be continually
discharging and, through the eNS,
ordering the muscle to resist. The
more the stretch, the much more the
resistance. It should be remembered
that the more the resistance, that is,
contractile tension, the more the j oint
surfaces would be pressed together
and their frictional resistance in
creased.
There would be little value, at this
stage of development of the hypoth
esis, in cataloging the many kinds
of circumstances, minor "accidents,"
and microtraumas of daily life in
which these two factors - strong
contraction and slack-produced
spindle-silence - could conspire
to turn up the spindle gain. The
thoughtful reader can doubtless en
visage or reconstruct, from personal
and clinical experience, many such
circumstances. The hypothesis that is
proposed about the osteopathic lesion
is primarily concerned with the high
spindle gain. Further speculation as
to how it may come about is therefore
deferred until the primary hypothesis
has proved viable.
I turn, therefore, to a few illus
trations of the manner in which high
gain spindle function may help ex
plain: a) some functional charac
teristics of osteopathic lesions and b)
the efficacy of certain manipulative
procedures. These illustrations are
offered as guidelines for testing the
theory in practice.
a) How the spindle may be related
to certain lesion characteristics.
1 . The high-gain hypothesis is
consistent with, and offers an ex
planation for, the steeply rising
resistance to motion ("bind") in one
direction and the equally precipitous
collapse of resistance (increasing
"ease") in the opposite direction. 12-1
6
Since, for reasons given above, the
affected muscles would even in rest
ing posture be under some degree of
stretch, they would be on the tense
side of "easy neutral," that is, in
continual active contraction and
palpably hard and unyielding. They
would also be provoked into stronger
and stronger contraction by the ex-
aggerated s pi ndl e discharges as
motions that tend to lengthen the
affected muscles occur.
2. To the degree that spindles re
flexly regulate the contraction of
muscle fibers i n their immediate
vicinity, the hypothesis would also
explain the "ropiness" often found in
muscles in stressed areas. High sensi
tivity of selected spindles in a muscle
would produce spasm in correspond
ingly selected fascicles, which would
feel like tight cords in the muscle.
3. Since the j oints that are crossed
by the affected muscle are com
pressed, with their surfaces tightly ap
posed, they too would appear "stiff"
and diffcult to " gap. " It would be
expected that such j oints would be
much more likely to "pop" when
forcefully gapped than those not
compressed by muscular forces.
4. The high-gain spindle may also
contribute to the "catch" that is
sometimes encountered when muscles
have been caused (or permitted) to
shorten far below their natural resting
length. However, in the markedly
shortened state, the sensory and
refex mechanism may be compli
cated by a change in the contractile
state - one in which the muscle may
have lost the ability to relax, as in
contracture.
5. BaileylO has suggested in re
sponse to this hypothesis that failure
by the eNS to turn up the gamma dis
charges when the spindle has been
silenced by marked shortening of the
muscle may result in nonreporting
spindles. This, she suggests, may ac
count for "dead" segments in which
muscles have become markedly un
responsive to changes in length.
b) Is spindle-gain reset by efective
manipulative procedure?
Since, according to the hypothesis
that has been proposed, certain
functional aberrations of lesJoned
segments, notably impairment of mo
bility, may be ascribable to gamma
induced intrafusal contraction, it is
proposed as a corollary that reduc
tion of gamma discharge may be a
key element in the restoration of
mobility and therefore in the efficacy
of manipulative therapy. Following
are a few "tests" of this suggestion.
1 . According to the hypothesis,
motions that in functionally oriented
manipulative technic tend to favor
"ease"are those that approximate the
attachments of the affected muscles,
205
reducing their tension and permitting
them to shorten. As the motion con
tinues in the direction of ease, intra
fusal-extrafusal disparity narrows.
That is, the relative length of the
muscle once again begins to cor
respond more closely to that of the
intrafusal fibers. The shortened spin
dle nevertheless continues to fire,
despite the slackening of the main
muscle, and the eNS is gradually
enabled to turn down the gamma
discharge, and, in turn, enables the
muscle to return to "easy neutral" at
its resting length. In effect, the
physician has led the patient through
a repetition of the lesioning process;
with, however, two essential differ
ences: first, it is done in slow motion
with gentle muscular forces, and, sec
ond, there have been no "surprises"
for the eNS; the spindle has con
tinued to report throughout.
Presum
a
bly, the compression of
the affeted joints would also be
relieved by such procedures.
2. A variety of manipulative pro
cedures involve, or seem to have
as one of their implicit objectives,
the stretching of the hypertonic
muscles in the lesioned segments. It
is proposed that two mechanisms,
operating either individually or con
jointly in these procedures, may
contribute to the return of the
spindles to more normal gain-set
tings, with resultant relaxation of
the muscles: i) Stretch of the intra
fusal fibers. Forceful stretch of the
muscle against its spindle-maintained
resistance is, of course, mechanically
transmitted to the spindle. This
would produce a barrage of afferent
impulses of such high frequency as,
conceivably, to signal the eNS to
turn down the gama discharge. ii)
Forced stretch of the muscle would,
of course, also be transmitted to its
tendon, causing intense discharge by
the Golgi endings. It is thought that
the inhibitory intluence of this affer
ent input extends to the gamma, a
well as the alpha, motoneurons, con
tributing to relaxation of both the
intrafusal and extrafusal fibers.
These mechanisms would seem to
operate in such muscle-stretching
procedures as "taking joints through
their full range of motion" i n
"springing," and in slowly applying,
slowly releasing manual pressure
transversely to the long axis of
a muscle, for example, the spinal
20
extensors. They may also be impli
cated in the manipulative procedures
involving high-velocity, short-ampli
tude forces. In these procedures, the
affected muscles are stretched against
their resistance, by appropriate posi
tioning of the patient, before the
thrust is applied (often accompanied
by a popping sound as the seal of the
compressed joint is broken). The
gapping of the joint has probably
added a further increment of length
to the already stretched muscle (and
contained spindles) and of tension to
the tendon. "Release" may also be
obtained, without abruptly applied
forces, by maintaining tension on the
hypertonic muscles while they "let
go, " presumably in response to sub
siding spindle bombardment.
3 . The same mechanisms (stretch
of the intrafusal fibers and Golgi
discharge) seem to be operating in
those manipulative technics in which,
under the physician's guidance, the
patient applies the " corrective force"
by active muscle contraction. For ex
ample, the patient may be instructed
to push or pull against opposing force
applied by the physician. In this
procedure, the patient is in effect
contracting the tense muscles iso
metrically, the procedure being
repeated at progressively increasing
lengths. With each isometric contrac
tion, high tension is developed in the
tendons, and at each new muscle
length the spindle is also stretched,
both factors contributing to resetting
of spindle-gain to normal levels.
Apparently similar results may be
obtained by eliciting isometric
contractions, not of the hypertonic
muscles, but of their antagonists. In
this procedure, the physician is, of
course, utilizing the principle of
reciprocal innervation. The inhibitory
influence of this mechanism, like that
of the tendon receptors, may also be
expected to affect the gamma as well
as the alpha motoneurons.
Concluding comment
In proposing this rather large place
for the muscle spindle in the "neural
basis of the osteopathic lesion, "
there is no intention of excluding or
underemphasizing the roles of other
sensory inputs or reflex mechanisms.
Reciprocal innervation and the Golgi
tendon endings have already been im
plicated i n conjunction with the spin
dle. Almost certainly involved under
various circumstances are impulses
from a variety of receptors and pain
endings in and around joint struc
tures, ligaments, tendons, fascia,
skin, and viscera; muscle receptors
other than the spindle may also be in
volved. It should be pointed out that,
whatever their other influences, any
of these may directly or indirectly, ex
cite or inhibit gamma motoneuron ac
tivity,
Nor is it intended to imply that the
spindle is the source of facilitation of
segments of the spinal cord associated
with osteopathic lesions. On the con
trary, it is becoming increasingly evi
dent that the spinal cord does not in
dividually "read" and respond to
discrete reports from this or that set
of receptors. The cord seems, rather,
to deal with total patters collectively
presented to it by inputs from many
reporting stations.
The spinal cord seems to become
agitated (facilitated?) when the
reports from two or more stations are
confl i cti ng and t he patterns ,
therefore, unintelligible (as also hap
pens to the higher centers, with dis
tressing effects, in motion sickness).
Spindles to which gamma discharges
have been increased may signifcantly
contribute to "j amming" and
"garbling" of the input patterns. The
high-gain spindles would, for exam
ple, falsely report to the spinal cord
that their muscle, actually in a short
ened contracted state, was stretched
to nearly its maximum length. This
would signify to the cord that the
muscle's vertebral attachments were
widely separated, when actually, as
correctly reported by the joint recep
tors, they are closely approximated.
There obviously can be no ap
propriate reflex response to irrecon
cilable reports signifying that the
joint is, say, simultaneously flexed
and extended. Segmental "facilita
tion" is beginning to appear more
like a state of segmental "consterna
tion. " A ,segment in such a state is to
some degree disruptive to every total
activity pattern in which it par
ticipates. Effective manipulation i s
that which restores i t to concordant
function - to "tracking" with its
neighbors.
2
1
Mention should be made of a fac
tor that would contribute to sustain
ing the exaggerated spindle discharges
in muscles of the lesioned segments.
One feature of somatic dysfunction
Interpretation of research
that has received emphasis in recent
years, as a result of research in the
Kirksville laboratories, is local sym
pathetic hyperactivity (summarized
by Korr6 and Korr, Buzzell, and
Hix7). One of the effects of sympa
thetic hyperactivity is increased af
ferent discharge from the spindles.
22
Insofar spindle input influences
sympathetic preganglionic neurons in
the spinal cord, a self-sustaining
vicious circle may be envisaged.
The hypothesis says only that the
"lesioned" segment behaves as
though gamma motoneuron activity
("gain") in that segment has been
turned up. In presenting this hypoth
esis, I hope, whether or not it turns
out to be valid, that it stimulates
testing and inquiry in clinical practice
and in the laboratory, leading to new
insights, sounder theory, and more
efficacious practice.
References
I. Korr, I.M.: Proprioceptors and the behavior of
lesioned segments. Osteopathic Annals 2: 1 2-32, Aug
74.
2. Denslow, J .S.: An analysis of the variability of
spinal refex thresholds. J. NeurophysioI 7:207-15. Jul
44.
3. Denslow, J.S.: An analysis of the irritability of
spinal reflex arcs. JAOA 44:35762, Apr 45.
4. Denslow, J.S., Korr, I.M. , and Krems, A.D. :
Quantitative studies of chronic facilitation i n human
motoneuron pools. Amer J Physiol 1 50:229-38, Aug
47.
5. Korr. I.M. : The neural basis of the osteopat hic
lesion, JAOA 47: 1 91 -8, Dec 47.
6. Korr, I.M Thomas, P. E. , and Wright, H.M.:
Symposium on the functional implications of segmen
tal facilitation. JAOA 54: 26582, Jan 55,
7. Korr, I.M .. Buzzell. K.A. , and Hix. E.L. : Sym
posium on the physiological basis of osteopathic
medicine. G. W. Northup. Moderator. Postgraduate
Institute of Osteopathic Medicine and Surgery. New
York. 1 970.
8. Denslow, J. S.: Neural basis of t he somatic com
ponent in health and disease and its clinical manage
ment. JAOA 72: 1495 6, Oct. 12.
9. Patterson, M. M. : Spinal responses: Static or
dynamic? JAOA 72: 1 5 663, Oct 12-
1 0. Korr, I.M.: The t rophic functions of nerves and
their mechanisms. JAOA 72:1 6371 , Oct 72.
I I . Korr, I.M. : Andrew Taylor Still memorial lec
t ure: Research and practive - a century later. JAOA
73:36270, Jan 74.
1 2. Hoover, H.V.: A hopeful road ahead for
osteopathy. Parts I and I I. JAOA 62:48598. Feb. 63;
Part III. JAOA 62:68 1 6, Mar 63.
1 3. Bowles. C, H. A functional orientation for
The spinal cord as organizer of disease
processes: Some preliminary perspectives
(1976)
The purpose of this article is to iden
tify and to characterize briefly the
ways in which the spinal cord may
contribute to illness through the in
fluences it exerts on the tissues and
organs of the body. Subsequent ar
ticles will examine each of these ways
and the underlying mechanisms, with
appropriate documentation from the
research literature.
The concept of the spinal cord as
an organizer of disease processes is
based on two well-establ i shed
premises: ( 1 ) The spinal cord is a
highly complex organizer of normal
adaptive activity; and (2) all disease,
whatever its nature and whatever the
role of the cord, is the highly orga
nized response or adaptation of the
total organism to disturbing factors in
and around it . In the presence of dis
turbing factors, the spinal cord and
its peripheral extensions continue to
behave according to their nature. Un
fortunately, the responses that are
thereby organized under these cir-
cumstances are frequently maladap
tive and deleterious.
It is appropriate, therefore, to
begin with a summary of the ways in
which the spinal cord functions as
organizer of normal adaptive activity.
Before then proceeding to discussion
of pathogenic cord dysfunction, it is
necessary to examine the meaning of
spinal cord "segments" (not to be
confused with vertebral segments) in
normal and clinical situations.
Spinal cord: Information and
command center
The spinal cord is the origin of most
of the innervation of the body. It is
that portion of the central nervous
system where, by far, most of the
nerves originate. Indeed, every tissue
and organ of the body receives some
kind of innervation from the spinal
cord. The spinal cord is the site of en
try, via the dorsal roots, of most of
the "information" about the body
itself. It is in the cord that impulses
technic. Academy of Applied Osteopathy Year Book.
Part I: 1 7791 . 1 955; Part II: 1 07 14, 1 9S6; Part III:
538, 1 957.
14. Johnston, W.L.: Manipulative specifics.
JAOA 61 : 535-9, Mar 62.
1 5. J ohnston, W.L.: Manipulative skills, JAOA
66:389-407. Dec 6.
1 6. Johnston, W.L.: Segmental behavior during
motion: I. A palpatory study of somatice relations.
JAOA 72:352- 61 , Dec 72; II. Somatic dysfunction
the clinical distortion. JAOA 72:36173. De 72; 111 .
Extending behavioral boundaries. JAOA 72:46275,
Jan 73.
1 7. Houk, J. and Henneman, E.: Feedback control
of muscle: Introductory concepts. In Medical
physiology. Edited by v, Mountcastle. Ed. 1 3. C.V.
Mosby. St. Louis, 1 974.
1 8. Henneman. E.: Peripheral mechanisms involved
in the control of muscle. In Medical physiology.
Edited by V. Mount castle. Ed. 1 3. C.V_ Mosby, St.
Louis. 1 974.
1 9, Grainger, H.G.: Basic mechanism of t he com
mon "crick." THE D.O. 928, Jun 69.
2 Bailey, H.W.: Personal communication.
21 . Bowles, C.H. Personal communication.
22. Koizumi. K = and Brooks, C. : The autonomic
nervous system and its role in controlling visceral ac
t ivities. In Medical physiology. Edited by V. Mount
castle. Ed. 1 3. C.V. Mosby, St. Louis, 1 974, p. N.
Reprinted by permission from JAOA 74: 638-650,
1 975.
from most of the tissues of the body
receive their first screening, gating,
arranging, and routing for transmis
sion elsewhere, including the brain.
As the site of origin of the "fnal
common path, " the spinal cord is
also the final command center.
Orders that are issued, consciously or
unconsciously, in the higher centers,
for most of the motor activity of the
body, are issued to the spinal cord,
which recodes them, so to speak, and
then composes and dispatches the ac
tual orders to the muscles, innervated
by motoneurons, and to other tissues
and organs, innervated by the
autonomic nervous system. The latter
includes blood vessels, viscera, sweat
glands, et cetera, innervated by the
sympathetic nervous system, which
has its entire origin in the spinal cord.
as well as those visceral structures
that receive their innervation from
the sacral portion of the parasym
pathetic division of the autonomic
nervous system. For the moment, our
concern will be with the activity of the
skeletal musculature.
In a sense, therefore, the spinal
cord is the keyboard on which the
brain plays when it calls for activity
or for change in activity. But each
"key" in the console sounds, not an
I0T
individual " tone," such as the con
traction of a particular group of mus
cle fibers, but a whole "melody" of
activity, even a "symphony" of mo
tion. In other words, built into the
cord is a large repertoire of patters
of activity, each involving the com
plex, harmonious, delicately balanced
orchestration of the contractions and
relaxations of many muscles. The
brain "thinks" in terms of whole mo
tions, not individual muscles. It calls,
selectively, for the preprogrammed
patterns in the cord and brainstem,
modifying them in countless ways
and combining them in an infinite
variety of still more complex pat
terns. Each activity is also subj ect to
further modulation, refinement, and
adjustment by the afferent feedback
continually streaming in from the
participating muscles, tendons, and
joints.
Spinal cord as trophic center
Before further examining the mean
ing of "patterns" (which, of course,
are based on controlled impulse traf
fic), it is important to emphasize that
impulses (and the neurotransmitters
released at neuroeffector j unctions)
are not the sole means by which
spinal neurons infuence innervated
tissues. Impulses are the means by
which moment-to-moment activity is
regulated through excitation and in
hibition. In addition, there are the
long-term influences on the struc
tural, functional, chemical, and
metabolic properties which are sub
sumed under "trophic functions of
nerves. " For some tissues, most
notably striated muscle, neurotrophic
support is even essential for survival .
The trophic functions appear to be
related to the delivery of neuronally
synthesized macromolecules, rather
than to the conduction of impulses. It
may be assumed, however, that the
trophic conditioning of various
muscles and other tissues is related to
the functional roles of those tissues,
that is, the parts they play in the
various cord-organized activity pat
terns. Since the overwhelming ma
j ority of peripheral neurons and
nerves are cord-derived and cord
connected, the spinal cord may be
said to be responsible through its
organization for patterning trophic
influences also.
208
Spinal patterns
The patterns of activity to which I
have referred are essent i al l y
equivalent to the familiar, named
motor reflexes, such as the (ip
silateral) flexor reflex, crossed
extensor reflex, stretch refex, et
cetera. The reflexes, however, are
commonly viewed as the relatively
stereotyped responses, each based on
an anatomically definable "arc," to
specific stimuli. These stimuli, which
are usually artificial, in contradistinc
tion to those encountered in daily life,
are experimentally or diagnostically
applied to selected areas or struc
tures, for example, electrical stimula
tion of an afferent nerve or area of
skin, a tendon tap, a pinprick.
I prefer to view these reflexes not as
stereotyped mechanisms ever ready to
be sprung into action from ap
propriate push-buttons, but as the
physiologist's way of demonstrating
the built-in, highly plastic patterns of
motion that are available to be com
bined and synthesized into total ac
tivities, such as walking, dancing,
swimming. These modifiable, assem
blable, highly organized reflex
"modules" collectively compose the
massive, automatic reflex substrate
on which the consciously designed
volitional actions are based.
The volitional part of every activity
is the small, conspicuous tip of a
massive, largely subconscious, and
invisible iceberg. That reflex "mass,"
which from moment to moment
automatically adjusts the muscular
forces around each joint, the parts of
the body to each other and to the
body as a whole, and of the body to
the forces of gravity, et cetera,
relieves the cortex of responsibility
for attention to these countless details
and enables it to concentrate on the
objectives, design, and execution of
the learned, skilled, volitional com
ponents of each motion. The reflexes
built into the spinal cord and
brainstem are the largest portion of
the iceberg.
As has already been mentioned, the
spi nal refl exes, descri bed as
"plastic," are subject to continual
modulation and adjustment in force,
velocity. amplitude, trajectory, final
configuration, and so forth. Part of
the modifying influences, of course,
are conveyed over descending path
ways from the higher centers, such as
the motor cortex and vestibular
nuclei. Much of the adjustment and
refinement are due, however, to the
ceaseless feedback, conveyed to the
cord through the dorsal roots, from
the participating and affected parts of
the musculoskeletal system. Unlike
the experimental situation in which a
nerve or its endings are stimulated,
these segmental sensory pathways are
not ordinarily responsible for ini
tiating motor activity, that is, for
eliciting reflexes, but for regulating
them according to volitional demand,
the total motion in process, and the
circumstances i n the i nvolved
muscles, j oints, ligaments, and ten
dons.
Our concern until now has been
with muscles and motor activity, but
it is important to recall that the spinal
cord is the site of origin also of the
sympathetic nervous system (SNS).
This anatomic intimacy between the
sympathetic division of the auto
nomic nervous system and the
somatic nervous system is most ap
propriate, since it is one of the main
functions of the SNS continually to
tune visceral, metabolic, and cir
culatory activity to the rapidly chang
ing requirements of the skeletal
musculature. Every motor activity,
organized via the somatic innervation
originating in the spinal cord, also in
volves the simultaneous, coordinated
activity of the SNS and the tissues
and processes regulated by it. "Spinal
patterns, " therefore, must be viewed
not merely as motor reflex patterns
but as somatosympathetic patterns.
I n order for the SNS to meet its
supportive "responsibilities" to the
musculoskeletal system, it must be
continually apprised of the activities
and requirements of that system.
Hence, soma to autonomic integration
is possible only with simultaneous af
ferent input both to the motoneurons
and to the sympathetic preganglionic
neurons in the cord, from the higher
centers via descending pathways, and
from countless musculoskeletal
reporting stations, via the dorsal
roots.
The question of segments
It is evident that the execution of even
a very simple motion such as the flex
ion of the elbow involves immensely
complex, delicately controlled, and
rapidly changing impulse traffic in
thousands of motoneurons (and sym
pathetic neurons) innervating not on-
Interpretation of research

ly the muscles traversing the elbow

joint, but those arranging and fixing
the shoulder and wrist. Impulse fre
quency in each axon is continually ad
justed, by presynaptic neurons, ac
cording to the contribution that the
muscle fibers that it innervates are to
make at a given moment. The com
plexity related to the elbow joint
alone is immense; that related to the
rest of the extremity is even much
more so. If one adds to this that
massive portion of the ' ' iceberg" con
cerned with adjustment of the posture
of the rest of the body in accordance
with the motion of the arm - and
with autonomic support, for exam- _
pie, for appropriate distribution of
blood fow - the complexity is
almost beyond imagining.
In the execution of a given motion
and its autonomic support, what are
the criteria according to which ef
ferent neurons are called into play
from moment to moment? The
neurons are brought into action ac
cording to what effector (for exam
ple, which muscle or group of arte
rioles) lies at the peripheral end, and
not according to segmental levels. In
deed, the participating neurons may
be distributed throughout the spinal
cord. The corresponding sensory in
puts are also widely and nonsegmen
tally disposed.
In other words, the neuronal basis
for even a simple reflex pattern, such
as a fexor reflex, has a vertical
(multisegmental) distribution, rather
than the horizontal (unisegmental) ar
rangement implied by the usual repre
sentation of a "reflex arc. " Indeed, it
can be safely said that no total mo
tion is carried out through a single
spinal segment. Efferent neurons that
are collectively involved in a given
motion are collaborators not because
they are neighbors - in fact, they
may be widely scattered - but
because cofunction of their effectors
is required.
Hence, " segmental relations"
(functional coordination of organs
and tissues innervated from the same
segments) are not the basis for nor
mal function and behavior, impor
tant a they may be in clinical situa
tions. The participation of individual
segments is not apparent in total pat
terns of activity. In cord-organized
patterns, the anonymity of individual
segments is similar to that of in
dividual rows in a column of well-
drilled marching men: All that one
sees is the flow of motion in the total
parade. But let one of the rows be
disarrayed by missteps of one or two
of the marchers and that row is im
mediately conspicuous . What is
more, as rows in front and behind
seek to compensate, the entire parade
is soon in disarray. So it is with the
spinal patterns. Segments are in
evidence only in dysfunction; they are
"out of step" with the rest of the
"parade. " A segment in view is a seg
ment in trouble, as are all the patterns
in which it participates.
Where, then, is the segmentation?
What are the segments implied by
"segmental relationships, " "segmen
tal nervous system, " "segmental
pathway?" Segmentation is certainly
not inherent in the spinal cord it
self, in which segmented structure
is no more evident than segmented
function.
The segmentation appears to be en
tirely in the "stringing of lines" of
communication between the cord and
the periphery. Segmentation is the
bunching of nerve fibers into the
compact "cables" that we identify as
the spinal roots and spinal nerves ex
tending bilaterally from CI to S5. It is
they that are segmentally arrayed and
not the spinal cord, to which and
from which they transmit impulses.
To what is the segmental arrange
ment of the roots and nerves related?
The segmental grouping of nerve
fibers was not, apparently, in evolu
tionary adaptation to some func
tional demand. Segmentation seems
to have been imposed, in the course
of evolution, by the segmented struc
ture of the bony armor that sur
round the spinal cord, but it is not i n
the cord. That i s, it i s the segmented
spinal column, rather than the cord,
that dictates the segmental arrange
ment of peripheral nerve fibers: The
axons are bunched and compacted
for passage through more or less
regularly spaced holes in the armor -
the intervertebral foramina. The
compacting of a particular group of
axons (emerging in rootlets from the
cord) into a particular "cable" is
purely a matter of location, without
regard to the patterns in which those
axons normally cofunction.
In short, neurons are, as previously
stated, recruited according to what
they innervate and what activity is be
ing called for, and not according to
which intervertebral foramen they
pass through. It is for these reasons
that segmental relationships, having
no basis in normal neurophysiology,
are irrelevant to normal behavior,
prominent though they may be in
clinical practice.
Segments in view
Before we examine how segments,
normally anonymous and invisible,
are made to come into view in clinical
situations, let us review the manner in
which they are in view, clinically.
Segmental relationships perhaps are
most familiarly evident in the
phenomenon of referred pain. Pain
arising in a visceral organ, due, for
example, to chemical irritation,
spasm, or distention, often is fel t in
stead (or also) in somatic structures
that receive their innervation from
the same segments as the viscus. The
pain is said to be referred to cor
responding dermatomes, myotomes,
and sclerotomes, which make up the
"reference zone. " The reference zone
may be quite remote from the site of
instigation, as when an organ or
tissue has migrated in the course of
embryonic development, taking its in
nervation with it (for example, the
diaphragm).
Too often overlooked is the fact
that the phenomenon of referred
pain is not solely. if at all, a matter
of faulty perception or sensory lo
calization by the patient. Objective
pathophysiologic changes can be
found in the reference zone, for ex
ample, vasomotor and sudomotor ac
tivity, muscle spasm. Over a period of
time these may lead to chronic
"organic" changes in the affected
tissues. At various stages the tissues
in the reference zone may become
secondary sources of afferent bom
bardment, with the establishment of
self-sustaining vicious circles of im
pulses and reflexes.
As shown many years ago,
reference is not solely from viscus to
soma. Pain in a muscle, bone, or
joint may be referred to other
segmentally related somatic struc
tures, also with accompanying objec
tive changes in the reference lone.
Much of the practice of osteopathic
medicine, of course, is based on
segmental relationships similar, and
possibly identical, to those ex
emplified by referred pain and
associated phenomena. By palpatory
and other means, the osteopathic
physician detects and evaluates the
pathophysiologic changes in the
somatic tissues segmentally related to
a disordered viscus. The palpatory
fi ndi ngs may even contri bute
substantially to the diagnosis of
visceral pathologic disturbance.
The os t eopat hi c phys i ci an
recognizes, however, that segmental
relationships are two-way mutual
relationships; that the somatic
changes in the reference zone
(whether or not pain is present) not
only reect pathologic processes in
the visceral structure, but also in
fuence them, usually unfavorably.
Osteopathic manipulative therapy is
designed to exert favorable infuences
on this exchange, possibly by silenc
ing or otherwise altering the afferent
impulse traffic coming from the
somatic components so that the
"vicious circle" can come to a halt
and permit healing processes to
operate under more favorable cir
cumstances.
The osteopathic physician rec
ognizes 'also that the spread of
pathophysiologic influences along
segmental pathways may begin with
somatic dysfunction and involve
autonomic as well as somatic
pathways, with consequences to
visceral and somatic tissues and func
tions. Manipulative therapy is
directed toward amelioration of
somatic dysfunction, regardless of
whether it is primary or secondary,
with the expectation that this will
benefit structures on the same
segmental circuit. The widely ac
cepted concept of segmental facilita
tion a it relates to somatic dysfunc
tion presumes only that through some
infuence that selectively affects a
given segment or group of segments
and that is probably conveyed over
their dorsal roots, neurons located in
that portion of the spinal cord are
maintained in a hyperexcitable state,
producing sensory, motor, and auto
nomic manifestations.
The purpose in this section has not
been to examine segmental relation
ships in detail, but only to char
acterize them by illustration, to con
trast clinical and normal cir
cumstances sufficiently. Thus, an
ulcer in the duodenum may, through
pain afferents synapsing in the cord,
provoke circulatory disturbances, ex
cessive sweating, paraspinal and ab-
20
dominal muscular contraction, pain
and tenderness in joints, muscles, and
areas of skin that, like the duodenum,
are innervated from midthoracic
segment s . Conversely, somati c
dysfunction in these segments may,
through segmental pathways involv
ing the splanchnic outflow, produce
functional changes in the duodenum
that predispose it to autodigestion.
In normal life, however, there is no
"meaningful dialogue" between the
duodenum and segmentally related
tissues or organs, at least none that is
essential to their functional regula
tion or integration, their functions
being quite independent of each
other. The midthoracic paravertebral
musculature, for example. makes no
contribution to duodenal function,
just as the duodenum is not involved
in locomotion or maintenance of
posture. There is no reason, in nor
mal Ufe, therefore, for them to com
municate with each other, even
though both duodenum and muscula
ture are, so to speak, hooked up to
the same portion of the spinal cord
through a shared "cable," passing
through a particular hole in the bony
armor.
However, shoul d either the
duodenum (to continue the illustra
tion) or the segmentally related por
tion of the vertebral column become
suffciently and appropriately in
jured, the activities and problems of
one soon become the business of the
other, through a newly established
"party line" that provokes both into
continual, inappropriate, nonadap
tive, deleterious responses. The dis
ruptive entanglements that are thus
created by segmental facilitation are
deleterious not only to the unintended
partners, but also to the total patterns
in which they participate, hence, to
. the total person. In effect, a segment
has gone out of step, messing up the
entire parade. The question before us
now is, how do segments get out of
step'?
How segments come into view
How do tissues and organs that or
dinarily have little direct functional
interaction or interdependence, such
as the duodenum and midthoracic
dermatomes and myotomes, become
entangled with and disturbed by each
other, through the nerves and cord
levels that they share' In seeking to
identify the mechanisms I shall not
consider such factors as direct trauma
to the spinal cord itself. The most
common disturbing factors seem
to fall into two main categories:
( 1 ) disturbances in afferent input;
and (2) physicochemical disturbances
in neuronal excitation and conduc
tion. Each of these will be described
briefly. As will be seen, the second
category contributes to the first. It
may also occur under circumstances
that induce the first. In other words,
though different in mechanism, they
may be present together and in
distinguishable in their impact.
1. Disturbed afferent input
a. From the musculoskeletal
system. As previously mentioned,
streams of impulses continually enter
the cord, via the dorsal roots, from
specialized receptors (proprioceptors)
in muscles, j oints, tendons, and
ligaments. They are, in effect,
transducers which convert changes in
shape (mainly length) of the struc- .
tures in which they are situated, or in
the forces (tension, pressure) acting
upon them, into variations in impulse
frequency in the sensory fbers that
end in them. These afferent fibers
have central connections that are ap
propriate to their peripheral endings.
Collectively, these endings are the
sources of information about cir
cumstances in the periphery con
tinually fed back into the central ner
vous system. Although, as has been
said, the receptors are each respon
sive mainly to changes in force or
shape of the tissue in which they are
embedded, the variety of their sen
sitivities, responses, and locations
(for example, a Ruffni ending in a
specific portion of a particular j oint
capsule, a spindle in. a particular
fascicle of muscle fibers, a Golgi end
ing in a particular portion of a ten
don) and the variety of their central
connections are such that, collective
ly, they report on the direction,
velocity, and amplitude of motion of
each part, and on position, load,
resistance, et cetera.
This continuous feedback, subject
to rapid change in accordance with
activity and posture, is continually
used by the CNS to adjust efferent
discharges (motor and autonomic) in
accordance with the activity called for
and with the circumstances in the par
ticipating and affected parts of the
body. Although the spinal cord is
capable of making discrete responses
Interpretation of research
to experimental stimulation of this or
that proprioceptor, it ordinarily does
not "read" individual reports from
the innumerable reporting stations.
Rather, it seems to watch the chang
ing patterns of their collective
reports. These patterns present to the
cord a continual motion picture of
"what is going on out there, " which
it utilizes in formulating its com
mands to all the tissues "out there. "
As has already been emphasized,
this patterned feedback reaches the
cord via the dorsal roots along the en
tire length of the spinal cord. The
central influence of a given volley of
impulses in a given sensory fiber is
determined by its central connections
(which postsynaptic neurons?) and
the frequency of the impulses, and
not by the foramen and root through
which it reaches the cord.
When, whatever the reason, there
is a disturbance in the movement
of a particular intervertebral, costo
vertebral, or other joint, involving
such functional disturbances as
muscle spasm (and hence persistent
changes in length and tension), tor
sion or other deformation of the cap
sule, or persistent asymmetric
ligamentous tension, then the af
fected proprioceptors will fre equally
persistent and discordant barrages of
impulses. These enter the cord via the
one or two dorsal roots in which the
corresponding sensory fibers lie.
In other words, instead of con
tributing to the fluctuating "hum" of
feedback on which the cord relies for
refinement and adj ustment of its
motor autonomic patterns, they
transmit a steady "roar" into the
cord over those selected roots. That
portion of the cord becomes
dominated by this noisy input, and in
that portion of the cord the "picture"
of the periphery which the eNS
steadily watches is garbled and
distorted by the high noise-to-signal
ratio. Reports from the various pro
prioceptors may be so conflicting that
the cord is presented with "pictures"
of impossible situations. Its responses
to such unintelligible reporting can
not possibly be adaptive, any more
tha nausea and vomiting can be said
to be adaptive to the confused sen
sory reporting in motion sickness and
vertigo.
The central excitatory state at the
corresponding level (and side) of the
cord is exaggerated, leading to the
establishment of an "i rritable
focus, " described in recent years in
terms of facilitated segments. In the
portions of the cord that are receiving
the noisy, garbled input, all kinds of
neurons become susceptible t o
"facilitation, " making exaggerated
responses to incoming impulses from
any source. Unintended partners,
such as the duodenum and spinal
muscles, find themselves on the same
"party l i ne, " and responding
together and to each other in ways
that make no functional sense. These
portions of the cord, therefore, can
not participate appropriately in the
vertical patterns in which they are or
dinarily involved, resulting in faulty,
disarrayed patterns.
I f the fring of pain endings is
added to this segmented input, then
the "roaring" input and the domina
tion of the affected portion of the
cord is even more severe and the
noise-to-signal ratio even higher.
How much the disruptive influence of
activity of pain fibers on spinal pat
terns is ascribable to imbalance be
tween small-fiber and large-fiber
activity and how much to other fac
tors, such as subjective responses, has
yet to be determined.
b. From the viscera. Similarly
"roaring, " segmentally dominating
inputs may develop as a reult of
visceral disturbances that activate
pain endings. Visceral pain fbers are
mainly associated with sympathetic
nerves (for example, the splanchnic),
traversing the ganglia without
synapse and entering the cord
through the dorsal roots along with
somatic sensory fibers. The facilita
tion thus produced extends to the
neurons supplying the somatic struc
tures, producing muscular spasm,
vasomotor and sudomotor changes,
"referred" pain and tenderness .
There is apparently no fundamental
difference in mechanism or response
whether the disturbing input arises in
visceral or in somatic structures. Both
are disruptive to spinal patterns, and
each soon invokes into the distur
bance other structures, the inner
vation of which courses in the same
spinal roots and enters through the
same foramina.
2. Physicochemical disturbances
of excitation and conduction
a. The kinds and origins of in
sults to nerves and neurons. The con
cern in this section is with the effects
of various types of direct bio
mechanical insult to nerves, axons,
and nerve cells, and of the secondary
metabolic disturbances. These insults
have a high incidence in man because
of the compressive forces associated
with the upright stance, and because
of some of the motor and postural
demands of various occupations,
athletic activities, habitual postural
faults, muscular tensions, et cetera.
But nerves, in general, are vulnerable
to deformation, with structural and
functional consequences, along their
entire length, especially where they
pass over bone, through bony canals,
across tissue interfaces, and so forth.
As a result, nerves may be subject to
stretch, constriction, compression,
torsion, angulation, and ischemia.
In man, the spinal roots, spinal
nerves, and the primary divisions are
especially vulnerable not only because
of the hazards associated with the in
tervertebral foramina, but because of
the hazards associated with structures
on which segmentation has also been
imposed by the spinal column, name
ly, the meninges (dural pouches, root
sleeves) and blood vessels (spinal and
radicular arteries and veins).
Detailed examination of the
specific kinds of mechanical hazards
common to each structure is not ap
propriate to this preliminary article.
One need only mention such factors
as the following: compression by nar
owing of the foramen; adhesions
between roots and sleeves, causing
angulation, shearing and constric
tion; shearing forces acting upon
nerves passing through fascia; com
pression (for example, of posterior
rami of spinal nerves) by sustained
contraction of the paravertebral
muscles through which the nerves
pass; constriction at duro arachnoid
j unctions of root pouches; compres
sion within foramina secondary to
venous congestion (compression of
spinal and radicular veins). Hypoxia,
pH shifts, and other chemical
changes in the environments of the
nerves due to ischemia (compression
of spinal arteries, sustained contrac
tion of muscles through which nerves
pass, et cetera) are also important
factors in the alteration of axonal ex
citation and conduction .
Separate consideration must be
given to the paravertebral sym
pathetic ganglia. The cervical ganglia
are subject to frequent micro trauma
211
because of their location in a highly
mobile part of the body and their
proximity to powerful muscles. The
thoracic and lumbar ganglia are
vulnerable because of their close rela
tion to bony structures (vertebrae,
ribs) and compression by, and
possibly adhesion to, parietal pleura
or peritoneum. Compression, as has
been demonstrated, may block lym
phatic drainage of parts of the
ganglionic chain, with severe edema
and swelling of the affected ganglia.
The ganglia, of course, contain the
cell bodies of postganglionic neurons
that innervate various vascular, glan
dular, and visceral structures.
b. The changes in neuronal func
tion resulting from direct insult. In
considering the effects of deforma
tion of musculoskeletal origin on
nerves and nerve cell bodies, it is im
portant to emphasize that our con
cern is not with catastrophic situa
tions in which whole nerves or roots
are crushed or even in which conduc
tion has been blocked in all or most
of the axons. In the extreme case, of
course, involving wholesale interrup
tion of axoplasmic continuity, there
would be a total loss of neural func
tion, with wallerian degeneration
distal to the insult. In the more
moderate situation of conduction
block in some of the fbers in a nerve,
there would be corresponding loss of
sensory and motor function, which
might be transient or fluctuating. In
such cases, the sensory or motor
deficits would not even be percepti
ble. However. since some types of
fibers are more susceptible to defor
mation block than others, garbled
sensory input and incomplete and un
coordinated efferent output may be
the clinically more significant conse
quences.
The predominant consequence of
the more common and more subtle
deforming forces which were the
subject of the foregoing section is
quite different. They cause not the
loss of excitability, but, on the
contrary, hyperexcitability and the
hyperirritability syndromes that it
engenders. The hyperexcitability, lo
calized at the sites of deformation, is
manifested i n several ways, which
have been studied in nerves and roots
during surgical exposure and which
can be simulated experimentally. I n
reviewing these manifestations, i t i s
important to remember that, ordi-
212
narily, nerve impulses are launched
at the end of nerve fbers - at
the central or cellular ends in effer
ent fibers and at the peripheral ends
in sensory fibers - and that im
pulses pass in only one direction,
either toward the CNS or toward the
periphery. The following are the
manifestations of hyperirritability at
sites of deformation:
1 . Impulses are generated at the de
formation site, for example, at a con
striction or angulation or at the edge
of a longer compressed area, and they
are propagated in both directions.
These, of course, are "super
numerary" impulses superimposed
on those being generated in the usual
way, centrally or at the peripheral
ending.
2. Trains of impulses are triggered
by "normal" impulses as they pass
through the deformed locus. Each
normally generated impulse, there
fore, has a grossly amplified and pro
longed effect centrally or peripheral
ly.
3. Cross-talk between fbers may
take place. Under normal cir
cumstances each fiber is, in effect, a
private line, effectively "insulated"
from its neighbors in the nerve or
root, and only end-to-end (synaptic)
transmission occurs. At the hyperir
ritable foci, however, the small elec
trical fields that accompany each im
pulse as it moves along a fiber may be
sufficient to trigger impulses in
neighboring fibers. This lateral, side
to-side (ephaptic) transmission is
usually from large fibers to small
fbers.
4. Pain and possibly other endings
in the epineurium may be additional
sources of impulses provoked by
some types of deformation, especially
stretching or swelling of nerves. They
may be responsible for the pain and
tenderness along the course of a nerve
in some peripheral neuropathies.
5. Cells in the paravertebral sym
pathetic ganglia. which are ordinarily
excited only by presynaptic impulses
delivered by preganglionic fibers, fire
spontaneously under conditions of
ganglionic deformation, edema, or
other, secondary changes in their en
vironment.
6. A significant degree of narrow
ing of axons by constriction or
compression is known to impede the
axonal transport of nerve cell cyto
plasm. Considerable swelling, due to
--- - .. -
the damming of axoplasm, occurs
proximal to the obstruction, while
distally the axon becomes quite atten
uated. Since various proteins and
other complex substances in a given
axon are transported at two or more
rates varying from approximately 1
mm. per day to approximately 40
mm. per day, and by different
mechanisms, changes in composition
of the axon distal to the obstruction
and in the mixture of substances
reaching the terminals are almost cer
tain. If attenuation surpasses a
critical degree, axoplasmic continuity
is interrupted and the distal axon
undergoes waller ian degeneration.
The behavior of "segments in view"
How do the disturbances in afferent
input and in neuronal excitation and
conduction alter the function of the
affected segments? Since disturbed
excitation and conduction inevitably
disturb afferent input, it is not possi
ble to examine their respective im
pacts on cord function entirely
separately. Only the first four items
in the following sample of impacts
are strictly related to aberrant
neuronal excitation and conduction;
the others represent inseparably com
bined impacts .
1 . Ectopic impulses in afferent
fibers, arising as they do somewhere
along the axons rather than at the
endings, present false sensory infor
mation to the cord - situations that
have no basis in the peripheral tissues
in which the affected fbers end. The
total afferent input pattern, there
fore, is deceptively intensified, im
balanced, garbled. If the nerve defor
mation has simultaneously produced
conduction block in large, fast
myelinated fibers (which convey
signals fom skin receptors and pro
prioceptors) causing small- fiber
dominance, then the sensory chaos in
that part of the cord would be even
worse. Only nonsensical responses
can be made to nonsensical informa
tion, and all total-body patterns i n
which the dysfunctional segments
participate would be in disarray to
some extent.
2. Similarly, ectopic impulses in ef
ferent fibers are meaningless com
mands which "jam" the real, central
ly issued commands, convert them to
gibberish, and result in uncoor
dinated motor and autonomic
responses.
I nterpretation of research


3. Since, under conditions in which
"crosstalk" occurs, the direction of
lateral transmission is from large
fibers to small fibers, excessive activi
ty is provoked in the pain fibers and
in sympathetic fibers. Under these
circumstances, the passing of im
pulses in large A fbers, such as those
mediating touch or proprioception or
those innervating skeletal muscle,
may be expected to produce pain that
has no basis in the periphery, accom
panied or not by paresthesia of
various kinds. It may also produce,
via the sympathetic innervation, such
manifestations as vasoconstriction,
sweating, visceral activity, or visceral
inhibition that was not centrally
ordered.
It is possible, though not estab
lished, that among the small fibers
victimized by cross-talk are the gam
ma fibers controlling the sensitivity of
the muscle spindle. The effect would
be.xaggerated tension in the affected
m
u
scles and resistance to changes in
length.
4. Since impulses that arise ec
topically somewhere along the length
of the axon are propagated in both
directions (ortho- and antidromi
cally), we need also to consider the ef
fects of the antidromic, or wrong-way,
impulses. Those in motor fibers, on
reaching the cell bodies in the ventral
horn, are known to alter the excitabil
ity of those neurons in the inhibito!
diretion. The effect, of course, would
be to confuse the motor activity in
which those neurons participate. A
similar infuence, though not yet
demonstrated, may also be expected in
sympathetic neurons.
Antidromic impulses in sensory
fibers have been shown to produce
profound vasodilation and hyperemia
(at least in skin), somewhat in the
manner of an "axon reflex. "
5. The chaos in afferent input and
efferent output causes the affected
segments and the organs, tissues, pro
cesses, and activities that they control
to be "out of step," with disruption
of the (vertically organized) activity
patterns in which they participate.
6. Somatosympathetic integration,
so essential to musculoskeletal func
tion, would also be disrupted.
7. As has been shown for segmental
somatic dysfunction, the associated
facilitation, for reasons presented
above, extends to the sympathetic
outflow. The effects of the sym-
pathetic hyperactivity depend on
which of the fibers are involved, that
is, on what cells, tissues, and organs
are victimized by the exaggerated
sympathetic bombardment. Each
organ or tissue responds according to
its own inherent nature. The clinical
impact - the syndromes that may be
produced given sufficient time and
other contributory factors in the per
son's life depend, therefore, on the
segmental level, since that determines
which organs and tissues may be in
the line of fire.
Further examination of this most
important aspect of segmental dys
function is far beyond the scope of
this article, but it i s important to
point out that there is a significant
sympathetic component in many,
possibly most, syndromes and
diseases. Therapy directed at silenc
ing or reducing impulse traffic in the
affected sympathetic pathways is
often ameliorative. Furthermore,
many of the most serious manifesta
tions of sustained sympathetic hyper
activity, aside from the vasospastic
ischemia so often present, are so
diverse as not to be explainable by
conventional views of the sympathet
ic nervous system, that is, solely i n
terms of altered contractile (smooth
and cardiac muscle) and secretory ac
tivity. The sympathetic outflow exerts
influences on many other kinds of
cells and cellular processes which, in
sustained sympathetic hyperactivity,
become pathologic and aberrant . The
nature of the changes varies with the
tissue and organ in question. The
sympathetic impulses merely modify
the inherent cellular functions and
processes. In other words, the diversi
ty of clinical manifestations of local
or segmental sympathetic hyperactivi
ty is in the diversity of the cells,
tissues, and organs innervated by the
sympathetic nervous system.
This aspect of segmental dysfunc
tion will be the subject of another ar
ticle.
8. Since at least several organs and
tissues, somatic and visceral, inner
vated from a given segment or group
of segments may be affected by
segmental dysfunction, each be
comes, in turn, a source of afferent
bombardment. Each, therefore, con
tributes to the establishment and
maintenance of a vicious circle of im
pulses, and each is victimized by the
others' inputs.
9. Finally, the effects of somatic in
sult on nerves and nerve cells are not
only on excitation and conduction.
To the extent that deformation of ax
ons impedes axonal transport, the
trophic influence of those neurons
may be profoundly impaired. Also,
to the extent that driving a neuron to
sustained hyperactivity alters its
metabolism, it may be expected that
the synthesis of proteins and other
macromolecules that are axonally
transported may also be altered; with
trophic consequences to the inner
vated cells and tissues.
Relevance to osteopathic
manipulative therapy
On the basis of the foregoing infor
mation and perspectives, osteopathic
manipUlative therapy appears, em
pirically, to be designed: ( 1) to correct
or ameliorate the biomechanical in
sults to nerves and nerve cells that
lead to disturbances in excitation.
conduction, and trophic function; (2)
to alter the proprioceptive and other
discharges from somatic tissues in
such a manner as to restore balanced,
intelligible, reliable patterns of sen
sory feedback to the spinal cord; and
(3) to soften or silence the somatic in
put to the vicious circles initiated
elsewhere, thus contributing to arrest
or retardation of impulse traffic in
the circular party lines.
To a large extent, it may be said
that much of the basis for the' osteo
pathic emphasis on the spinal column
lies in the segmentation that, in
dysfunction, the spinal column im
poses on the function of the spinal
cord, on the patterns that the spinal
cord organizes, and on the neural
structures through which it expresses
that organization. No other system of
therapy appears to address itself ade
quately to the role of the spinal cord
as organizer of disease processes.
Reprinted by permission from JAOA 76: 35-45, 1976.
113
The spinal cord as organizer of disease
processes: The peripheral autonomic
nervous system (1979)
The first article in this series
presented some preliminary perspec
tives about the spinal cord's role in
organizing disease processes. Refer
ence was made to hyperactivity of the
sympathetic innervation of various
tissues 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 entire origin
within the spinal cord, review of this
aspect of pathophysiology seemed ap
propriate for the second article in the
series. However, it has been my ex
perience that understanding in this
area is often impaired by the archaic
and obfuscating myths and miscon
ceptions that 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 this review I shall not be con
cerned with anatomic, physiologic,
and pharmacologic details, those be
ing abundantly available in many
textbooks and monographs. Rather,
my concern is with basic design,
functional organization, and general
role in the total body economy,
perspectives that are often obscured
by the very plethora of details as well
as by hallowed and hoary concepts
that are belied by the facts.
Myths and misconceptions
Among the most persistent myths i s
that the two divisions of the ANS, the
sympathetic and parasympathetic,
are equal and opposite moieties, one
being inhibitory where the other is ex
citatory, one positive, the other neg
ative, one yin, the other yang. The
implication usually conveyed is that
normal life is a nicely balanced tug
of-war between these two divisions,
and that it is the physician' S function
to redress "autonomic imbalance, "
usually with appropriately -lytic or
-mimetic medications.
Although this view is widely held
by physicians (and others), it will be
114
shown that the two divisions are vast
ly different systems. Indeed, only one
of them, the sympathetic, can truly be
called a system. They differ in their
basic design, central origins, periph
eral distribution (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
two kinds of influence on their target
organs: Motor (regulation of con
tractile activity of smooth and cardiac
muscle and secretomotor (control of
secretion by various exocrine glands).
As will be shown, however, the reper
toire of the ANS is a great deal larger
and more diverse than that.
Relation of the ANS to the
musculoskeletal system
I must confess that my own compre
hension of the ANS remained quite
turbid through years of teaching
autonomic physiology despite 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 distinguished 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 history, medicine
has emphasized the internal organs
and their disturbances, and diagnos
tic and therapeutic methods have
largely been directed at the origins
and manifestations of those distur
bances. In the absence of frank
problems of the musculoskeletal
system, that system has implicitly
been regarded only as the vehicle for
carrying the viscera about.
Rewarding as the visceral emphasis
has been through the centuries, it is
important to keep in mind, however,
that human activity - behavior of
the person - is not a composite of
visceral functions, such as peristalsis,
secretion, digestion, vasomotion, and
glomerular filtration. Human activity
is the continually changing composite
of the activities of striated muscles,
most of them pulling on bony levers,
their contractions and relaxations or
chestrated by the central nervous
system, in response to external and
internal stimuli and to volition.
Even those distinguishing features
of the human species, related to intel
lect and affect, that are associated
with unique cerebral development -
ability to accumulate and transmit
knowledge, reason, imagination, cre
ativity, compassion, conceptualiza
tion, inquisitiveness about self, life,
and the universe, et cetera - are im
portant because they result in equally
unique actions - all musculo
skeletally mediated -that have led to
the products (and problems) of
human life, culture, and civilization
as we know them. It is through the
neuromusculoskeletal system that we
act out our humanity and our in
dividual personalities in the infinite
variety of ways of being human. We
are even recognizable by the idiosyn
cratic ways in which we stand and
move; that is, by the ways in which
we use our musculoskeletal systems.
Since even the highest moral,
ethical, philosophical, and religious
principles have value only insofar as
they lead to appropriate behavior,
they, too, must be acted out or com
municated through the contractile ac
tivities of muscles. Similarly, it is
through our musculoskeletal systems
that we act out and communicate our
attitudes, fears, hopes, aspirations,
beliefs, and childhood conditioning.
If, as has been said, education is the
changing of behavior, then education
has its ultimate expression in changed
patterns of muscular activity.
It is for these and related reasons
that I came to view the neuromuscu
loskeletal system as the primary
machinery of life, the instrumentality
through which we behave as human
beings, each in his or her own way.2
What, then, are the functions of
the viscera, with which the practice of
medicine is so much concerned? Their
role, from this perspective, is to
maintain and service the "primary
machinery" and to create the optimal
circumstances for its operation. Such
"service" includes: (1 ) providing and
delivering, as rapidly (more or less) as
they are consumed, the raw products,
Interpretation of research

including oxygen, which serve as

energy-laden fuels and as materials
for cellular self-renewal; (2) removing
the products of metabolism, more or
less a rapidly as they are produced;
(3) dissipating the heat that is pro
duced; (4) otherwise controlling the
composition and physical properties
of the internal environment in which
the component cells live; and (S) pro
tecting against foreign substances and
invading organisms. (In performing
these services "for" the musculo
skeletal system, the viscera are, of
course, also doing the same for each
other, in the course of maintaining
homeostasis.)
By virtue of their mass, and their
high and rapidly changing metabolic
rate, the muscles are, in effect, the
consumers of the body, and the total
body economy is continually adjusted
to meet their varying demands from
moment to moment and in the long
run. The "responsibility" for "tun
ing" visceral, circulatory, and meta
bolic activity to muscular (and envi
ronmental, especially thermoregula
tory) demand rests with the ANS, in
conjunction, of course, with the en
docrine system. From the viewpoint
presented here, the rapid, moment
to-moment adjustments in accor
dance with levels of exertion and
posture (or anticipation, conscious or
unconscious, of exertion) are or
chestrated largely by the SNS. The
parasympathetic division makes the
long-term adjustments, according to
customary muscular activity (and en
vironmental demand), therefore, ac
cording to personality, temperament,
occupation, habits, sports, recreation,
age, climate, season, et cetera. It
maintains and replenishes the stores
of fuels, nutrients, and precursors
from which the largest withdrawals
are made under direction of the SNS.
It is for reasons such as these that
Nobel laureate W. R. Hess used the
term "ergotropic," signifying energy
expenditure and exchange, to de
scribe activity patterns in which the
SNS plays a dominant role, and the
terms "trophotropic" and "endo
phylactic," signifying nourishment,
conservation, and guarding of the in
ternal environment, to characterize
those patterns in which the parasym
pathetic division participates.
From this viewpoint, also, it be
comes evident that illness results from
- or even is - disparity between the

demands of what I have called the

"primary machinery" and the logistic
meeting of those demands by the
maintenance machinery. Indeed, that
is the basis of therapeutic rest: In
such disparity, the musculoskeletal
system is less able to function and,
when the disparity is sufficiently
great, one takes to one's bed, thereby
reducing the demand and the dispari
ty until the basis for the disparity is
corrected.
Traditional medicine has looked to
the visceral part of the equation as the
basis for disparity. Doubtless, this is
frequently the case. However, I be
lieve a more complete and balanced
equation includes the following fac
tors in the viscerosomatic disparity:
1 . Musculoskeletal. Excessive, in
sufficient, or inappropriate musculo
skeletal demand; somatic dysfunc
tion; errors and problems of locomo
tion and posture.
2 . Behavioral. I nappropriate
("neurotic") behavior; hence, misuse
of the musculoskeletal system; "psy
chosomatic" disorders.
3. Communicative. Impaired com
munication between visceral and so
matic components, through nervous
and vascular channels; "noisy, "
"garbled, " incomplete, interrupted.
4. Viceral. Defect, dysfunction, or
other visceral impairment.
S. Multiple. Any one of the pre
vious may be the original or domi
nant factor in the somatovisceral
"disparity, " and therefore in a given
illness. The disparity, however, soon
involves one or more of the other fac
tors, frequently culminating in a self
sustaining vicious cycle.
Functional organization of the ANS
In this section we shall examine,
schematically, the design and struc
ture of the two divisions of the ANS
as related to their respective roles in
the body economy. Figures 1 through
6 show the basic design of the periph
eral ANS and the differences in func
tional organization between the sym
pathetic and parasympathetic divi
sions.
Central origin.
The preganglionic neurons of the
ANS, collectively represented in
Figure 1, are situated within the cen
tral nervous system, where they re
ceive the converging infuences of a
large number of presynaptic neurons.
Fig. 1. Diagrammatic view oj brinstem and
spinal cord. representing origins oj the ANS;
that i, the location oj the cells oj orgin
(preganglionic neurons) in the central nervous
system. Thee neurons are subjet to a vast
variety ojpresynaptic infuences. In this ant all
the diagrams the sympathetic division I in the
center oj the column and the parasympathetic
is at the top and bottom. Roman numeral
represent parasympathetic cranial nuclei.
Arabic numerals indicate crvical. thoracic,
lumbar, and sacral segments ojthe spinal cord.
and the segmental origins (intermediolateral
cell columns) ojthe sympathetic diviion (TJ to
L2), and the sacral portion oj the paraym
pathetic division (S2 to S).
The presynaptic axons convey im
pulses from many neuronal and sen
sory sources. The preganglionic cell
bodies are grouped into neuron pools
known as nuclei and cell columns .
The preganglionic neurons of the
parasympathetic or craniosacral divi
sion occur in two main and widely
separated populations, the cranial
and the sacral. The cranial portion
consists of four pairs of discrete
nuclei, III, VII, IX, and X; the sacral
portion occupies three (usually) sacral
segments of the intermediolateral cell
column of the spinal cord. The sym-
215
Fig. 1. Paravertebral chains 0/ sympathetic
ganglia and the preganglionic fber (leaving
the spinal cord via the ventral roots and white
rami betwe n Tl and L2). Encircled pairs or
groups 0/ ganglia indicate fusions that are
commonly found.
pathetic preganglionic neurons are
grouped into a pair of long, continu
ous "nuclei" - the intermediolateral
cell columns of the cord, extending
from T1 to L2.
Preganglionic outow and the
ganglia.
The axons of the sympathetic pre
ganglionic neurons issue from the
cord via the ventral roots (together
with aons of motoneurons in the
ventral horn) and through the
thoracic and upper lumbar interverte
bral foramina, to synapse with post
ganglionic neurons, the cell bodies of
which are grouped in the ganglia (Fig.
2). In the SNS, most of the synapses
are with neurons in the paravertebral
ganglia, linked in left and right chains
extending over the entire length of the
spinal column. Upon entering the
chain at each level the preganglionic
116
Fig. 3. Viscral structures are rpresented within the human/igure in/our main groupings: those 0/
head and nek; thoracic; abdominal; pelvic and genital. Only the parasympathetic innervation i
shown. In thi and the rmaining ligure solid lines represent preganglionic aons and interrupted
lines represent potganglionic aons.
axons and their collaterals may turn
upward or downward or both to syn
apse not only in ipsisegmental gan
glia, but also in ganglia at higher and
lower levels. Neurons in the cervical
ganglia receive all of their pregangli
onic innervation from the upper
thoracic segments, and those of the
lower lumbar and sacral segments,
from cord level L2 and above.
Other preganglionic axons (T5 and
lower), comprising the splanchnic
nerves, proceed through the chain,
without synapse, to terminate in out
lying or collateral ganglia (for exam
ple, celiac and mesenteric) on left and
right sides. Some of the preganglionic
axons, however, terminate in the ad
renal medulla. (Viscera are grouped
into the four major regions, as shown
in Figures 3-6, the organs of each
region having certain innervational
features in common.) The innerva-
tion of the adrenal medulla is shown
in Figure 4.
The preganglionic axons issuing
from cranial nuclei III, VII, and IX
synapse in cranial ganglia (ciliary ,
sphenopalatine, otic and submandib
ular), whereas those of the vagus
nerve (X) synapse in small scattered
ganglia lying in close relation to the
innervated viscera. (Parasympathetic
ganglia and viscera are not individu
ally identified in the diagrams.) Gan
glia receiving the sacral outfow are
of both the collateral and intrinsic
types, as shown in Figure 4.
Distribution ofpostganglionic
fibers.
The postganglionic axons are, of
course, those that deliver the auto
nomic influences to the end-organs
that they innervate. The respective in
nervation fields of the sympathetic
Interpretation of research
and parasympathetic divisions are,
therefore, related to their respective
roles in the body economy. The para
sympathetic ganglia provide inner
vation to all the viscera (Fig. 3).
Those connected to the upper three
cranial nuclei have a rather limited
distribution to structures in the head,
the impulses from each nucleus being
rather specifically directed to one or
two organs (for example, eye and
lacrimal and salivary glands). The
vagus, however, diverges to a wide in
nervation field including organs in
the neck, thorax, and abdomen. The
sacral outflow has its influence on the
pelvic organs and genitalia. Blood
vessels related to sexual ( erectile)
function also receive sacral parasym
pathetic innervation.
The sympathetic ganglia provide
innervation to all of the organs sup
plied by the parasympathetic (Fig. 4).
(Sympathetic and parasympathetic
distribution to parts of a given organ
may differ, however, as in the case of
the eye and the urinary bladder.) It is
in these dually innervated organs, all
visceral with the exception of the eye,
that sympathetic-parasympathetic
"antagonism" may be expected. But
even in these, it is at least as much a
matter of delicate coordination of
different tonic influences as it is of
antagonism. Often, the sympathetic
and parasympathetic influences are
not so much opposite in direction as
diferent in quality (for example,
in salivary secretion).
Dual innervation does not, how
ever, extend to the vasculature. This
is almost entirely the domain of the
SNS (the major exception being the
dual innervation of vessels in pelvic
organs and genitalia). Through the
control of the contractile activity of
the smooth-muscle elements in arte
rioles, arteries, and veins (and even
larger lymphatic vessels), the SNS can
regulate the peripheral resistance,
distensibility, vascular capacity. and
arterial pressure, and, through these,
the distribution of blood in the vascu
lar tree, effective filtration pressure in
the capillaries, and the apportion
ment of the cardiac output among the
parts of the body, in accordance with
their metabolic requirements or roles
in the body economy. The SNS,
therefore. is truly the vasomotor
component of the nervous system.
Tie sympathetic innervation of the
heart, through its chronotropic
Fig. 4. Sympathetic innervation ojvisceral structurs has been added, showing dual innervation oj
most vicera. Note that sympathetic postganglionic innervation in hed and nek and the thor
originate in parvertebral ganglia. Those ojthe abomen and some plvic organs arise in outlying
ganglia (or eample, celiac and mesenteric). Note also that the adrenal meulla (shown under let
side oj diaphragm) is innervated by sympathetic preganglionic neurons, and that blood ves el
receive their innervation predominately Jrom the sympathetic diviion.
(rhythm) and inotropic (force of con
traction) influence, has a maj or in
fluence on the ventricular pressure
head and on cardiac output. The
vagus profoundly affects the rhythm
of the heart through its cardioinhibi
tory influence, but the degree and sig
nificance of any inotropic influences
are still under debate. The SNS,
therefore. may be said to mediate the
central regulation of the entire
cardiovascular system in accordance
with what is going on in the body as a
whole.
What is the innervation of the most
massive parts of the body, namely.
the musculoskeletal system and other
somatic tissues? As is indicated in
Figure 5 , the autonomic innervation
is exclusively sympathetic, via the
chain ganglia and spinal nerves, the
axons of which terminate in muscles.
bones, articular structures, ligaments,
tendons. other connective tissues,
and skin. It i s to be noted that the
nervous system itself also receives
autonomic innervation, and. as far a
one can tell. this is also exclusively
sympathetic.
As an example of prevailing per
spectives of the ANS, this major out
flow, to integument and neuromuscu
loskeletal system, which I have called
the "primary machinery, " is usually
represented in the typical schema of
the ANS by an inconspicuous little
drawing of a blood vessel, a sweat
gland. and a hair follicle at the outer
edge of the diagram, as can be seen in
one of the most frequently consulted
schemata. In keeping with the main
sphere of medical practice. visceral
innervation is the main subject of the
typical diagram, while the largest part
of the body. the musculoskeletal sys
tem, is scarcely identified.
Figure 6 summarizes the postgan
glionic distribution discussed hereto
fore, as well a the basic design of the
ANS and its divisions. Certain
217
@. _ ... --- .. _-
@._-- - --_.----
g- - - - - - - - - - - -
g- - - - - - - - - - . _ -
@ = = = = = = = = = = = =
+- - - - - - - - - - - - -

f - -
-
- - - - - - - -
-
-

g = = = = = = = = = = = = = =
g = = = = = = = = = = = = = =
g = = = = = = = = = = = = =
g= =e- - - -.. - . =
g = = = = = = = = = = = = = = =
g= = = - = = = = = = = = = =
g = = = = = = = = = = = = = =
g = = = = = = = = = = = = = =
g = = = = = = = = = = = = =
g = = = = = = = = = = = = = &
g = = = = = = = = = = = ==
g = = = = = = = = = = = = = =
g = = = = = = = e = = = = =
gee e e eeeeeee
g = = = = = = = = = = = = = =
gm= = = = = e
Fig. 5. Somatic structur, including the musculoskeletal system (and the nervous system itsel are
repreented on the left side of the diagram. Note that somatic strcturs receive their autonomic
supply excusivelyfrom the sympathetic diviion (via the spinal nerve).
features are immediately evident:
1 . Unlike the parasympathetic divi
sion, whose sphere is almost entirely
visceral, the sympathetic division pro
vides autonomic innervation to every
part of the body, including the ner
vous system itself.
2. Unlike the parasympathetic,
which is really a collection of highly
"private" lines to individual organs
and tissues, divergence is a conspicu
ous feature of the SNS. Note, first of
all, the rather extensive origin in the
spinal cord, then the "fanning-out"
of the preganglionic axons to ganglia
along the entire length of the verte
bral column and to the collateral gan
glia and, from these, the spread of the
postganglionic axons throughout the
body.
3. To be emphasized again is the
general vasomotor role of the SNS,
which is part of its capacity for
mobilizing resources throughout the
body.
4. Finally. a is symbolized in
Figure 6, the SNS is, in effect,
strategically situated between the
visceral and somatic tissues, whereby
218
it can adjust function of the viscera
(right side of the diagram) to the
demands and requirements of the in
tegumentary and neuromusculoskel
etal systems (left side) .
Obviously, unlike the parasympa
thetic division, the organization of
the SNS provides for coordinated,
body-wide broadcasting of sym
pathetic influences, reinforced and
sustained by circulating epinephrine ,
and norepinephrine from the adrenal
medulla. Yet, like the parasympathet
ic, the SNS is also capable of selec
tive, localized activity. Central activa
tion of the entire sympathetic divi
sion, as in exertion, emergency (real
or perceived), or environmental ex
tremes, results in well-orchestrated,
adaptive changes in visceral, circula
tory, and metabolic activity through
out the body. The SNS, therefore,
can be appropriately described as a
system. I n contrast, the unlikely event
(fortunately) of central activation of
the entire parasympathetic outflow,
that is, simultaneous, intense activity
of all four pairs of cranial nuclei and
the sacral nuclei or the circulation of
a (nonexistent) parasympathomimetic
hormone corresponding to the
adrenomedullary hormones, would
result in utter physiologic chaos.
Relation ofperipheral ANS to
somatic innervation .
In accordance with functional rela
tions of the SNS to the musculoskele
tal system, and its responsiveness to
environmental changes (for example,
in thermoregulation), the SNS is also
intimately related anatomically to
musculoskeletal innervation, both
sensory and motor. As Figure 7
shows, SNS outflow and the motor
supply to the skeletal muscles begin
close together in the cord, where they
are subject to many of the same pre
synaptic influences. The axons of the
preganglionic cells and of the moto
neurons then leave the cord together
via the ventral roots, the motor axons
proceeding to termination in skeletal
muscles, the preganglionic axons
proceeding to synapses in the ganglia.
However, the motor axons are again
rejoined by sympathetic fibers, name
ly the postganglionic axons entering
the spinal nerves (via the rami com
municantes) , on their way to tissues
of the neck, trunk, and extremities.
Because motoneurons and sympa
thetic preganglionic neurons are sub
ject to similar presynaptic sensory,
intraspinal, and supraspinal (that is,
higher-center) inputs, they are also
both vulnerable to disturbances via
these inputs. Similarly, since their ax
ons course together in the spinal roots
and in the spinal nerves, which also
include somatosensory fibers, soma
tic and sympathetic fibers are to
gether vulnerable to deformation and
other trauma of bi omechanical
origin. The clinical implications of
these somatosympathetic distur
bances were discussed in the previous
paper, and their mechanisms and
manifestations will be the primary
subject of the next. It is neverthe
less important to emphasize that
every human action involves the si
multaneous, coordinated activity of
the somatic and autonomic nervous
systems, and that dysfunction of one
inevitably leads to dysfunction of the
other.
Like the SNS, the sacral outfow of
the parasympathetic division also has
close functional relations with the
musculoskeletal system, as in elimina
tion, sexual intercourse, and parturi-
Interpretation of research
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4- - ~ - - - - - ~- ~~ ~
0 * - - ~ ~ ~ ~ ~ - ~ -
$ ~ * ~ - ~ ~ ~ ~ - - ~ ~ - ~
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~ ~ ~ ~ ~ ~ ~ ~ ~ - - -
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4
~ ~ - ~ ~ ~ - ~ ~ ~ ~ ~ ~ ~
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4~ ~- * ~ ~*~ ~ ~
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4~ - - - - - - - - -
- - - - - ~ - - - - - - -
- - - - ~ - - - - - - - - -
4 - . - - _ _ - - _ - _ - - -
- - ~ - ~ - - - - - - - - ~
4
~ ~ ~ ~ ~ ~ ~ ~ _ . . . . .
~ - * * - * * - * *
* * * * * * * * * * * * ^ *
*
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
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~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
= ~~ ~ ~ ~
9~ ~ * ~ =
~
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Fig. 6. Schema ofthe peripheral autonomic nervous system, completed. (Reprinted with permision.),
tion, in which coordination of vis
ceral and motor activity is essential.
Accordingly, this part of the para
sympathetic outfow has its origin
and course in close relation to the
motoneurons . In contrast, the entire
cranial outflow has little if any re
lation to motor function, in accor
dance with its remoteness from in
nervation of skeletal muscle.
Afferent pathways in relation to ANS.
The sensory inputs to which they reo
spond also reflect the respective roles
of the two divisions of the ANS. The
responses of the SNS to sensory input
from receptors in skin, muscle,
j oints, et cetera, via segmental and
suprasegmental pathways, in what
have come to be called somatosympa
thetic reflexes, are highly organized
and adaptive. Feedback from pro
prioceptors is important in local and
regional adjustments according to site
and kind of activity. These reflexes
have been the subject of intensive
study and excellent reviews in recent
years .6-8 Disturbances in these reflexes
and their clinical manifestations have
been previously reviewed, 9 and will
be examined in Part I I I of this
series. l I need only emphasize now
that since this continual sensory feed
back from the soma to the SNS is es
sential for normal function, somatic
dysfunction will also be communi
cated to the SNS, with adverse effects
on other sympathetically innervated
structures.
Although both divisions are assem
blages of efferent pathways, numer
ous sensory fibers run in "sympathet
ie" nerves such as the majority of the
splanchnic and in parasympathetic
nerves such as the vagi and pelvic
splanchnic. Those in the sympathetic
trunks are excited by noxious, painful
states in the viscera, such as severe
di stenti on, chemi cal i rri tati on,
spasm, and ischemia. It is of interest
that these "pain" fibers, through
interneurons, not only sti mulate
sympathetic preganglionic neurons in
the cord, thus producing changes in
target organs (for example, viscera,
blood vessels, sweat glands), but they
also excite neighboring motoneurons,
producing the sustained muscular
contractions so often associated with
referred pain of visceral origin.
In contrast, the sensory fibers run
ning within parasympathetic nerves
bring feedback from various report
ing stations in the viscera. In vagal af-
ferent pathways, for example, these
signals serve mainly regulatory roles
in respiration, circulation, digestion
and other visceral functions. In the
sacral circuits, t hey signal such
circumstances as fullness, that i s,
readiness for evacuation, of uri
n
ary
bladder and rectum. In these sacral
examples, muscular activity is in
voked to assist and help to execute
primarily visceral activity. The con
verse is true of the SNS, which ad
justs visceral function to support
muscular activity.
Repertoire ofSNS.
In view of the divergence of the sym
pathetic outflow to virtually every tis
sue in the body, it is important to ask
what effects impulse activity in these
efferent pathways has on all these di
verse tissues and organs. This is a key
question to explore in preparation for
a survey of the clinical effects of sym
pathetic hyper-activity, which is the
subject of the third article in this
series. `
As has already been mentioned,
there seems to be a prevalent miscon
ception in this regard, too. The tradi
tional view is that whatever the ef
fects of sympathetic activity (and,
119
Fig. 7. Cros-section of the spinal cord at thoracic or upper lumbar levels. Sensory (dorsal root
ganglion) neurn and their fibers (black), convey impulse from receptors and endings in somatic
and visceral tis ue. Motoneuron (ventral hor cel/s, lighter) and their aons supply motor
innervation to skeletal musculatur. Sympathetic neurons (lghtet), the preganglionic neurons in
the intermediolateral cll column, whose fbers (sold lines) synapse in ganglia with postganglionic
neurns the aons of which (interrpted lnes) innervate vicera and certain components of somatic
tisue. A sondarysensory neuron (spinothalamic) conves impulses to higher centers and mediate
sensations of pain and temperature. (Reprinted with permis ion.) 2
presumably, hyperactivity), they are
mediated by regulation of contraction
of smooth or cardiac muscle (the
smooth muscle including that of
blood vessels) and of secretion by
exocrine glands, such as sweat glands
and glands of the digestive tracts.
The truth is, however, that the
sympathetic repertoire is a great deal
more diverse than that, as the follow
ing few examples will indicate. (The
experimental and clinical evidence for
the following statements, and the cor
responding bibliographic references,
can be found in an earlier paper.)9
1 . Mucle. Stimulation of the sym
pathetic innervation of skeletal mus
cle increases the force of contraction,
diminishes the fatigue of repetitively
stimulated muscle or delays its onset,
and facilitates neuromuscular trans
mission.
2. Peripheral sensory mechanims.
Sympathetic activity influences the
function of various sensory organs, in
most cases in the direction of in
creased excitability, that is, lowered
thresholds and exaggerated frequency
of discharge. Receptors and sensory
organs in which this effect has been
demonstrated include muscle spin
dles, tactile receptors, taste receptors,
ol factory apparatus, chemo- and
baroreceptors of the carotid sinus,
pacini an corpuscles, retina, and
cochlea.
ZZ0
J. Central nervous system (CNS).
Sympathetic influences, demon
strated by stimulation, ablation, in
terruption, ganglionic blockade, et
cetera, have been shown on various
parts of the eNS, including the cere
bral cortex and subcortical structures,
reticulospinal system, hypothalamus,
cerebellum, and spinal cord. Effects
have been shown on behavior (for ex
ample, alteration of established con
ditioned motor reflexes), electro
encephalographic patterns, responses
to various kinds of stimuli, motor
reflexes, and many others, signifying
a direct influence on neuronal ex
citability and activity.
4. Development ofcolateral circu
lation, following arterial occlusion, is
impeded by sympathetic activity and
is accelerated by sympathectomy.
S . Sympathetic activity exerts an
important influence on activity of
bone cels and on longitudinal bone
growth.
6. Stimulation of the sympathetic
innervation of adipose tissue favors
lipolysis (release of free fatty acids
and glycerol), whereas interruption of
impulse traffic increases fat content,
a result that suggests a tonic influence
on fat metabolism. Indeed, the rapid
lipolysis that takes place during cold
exposure and the slow lipolysis during
starvation do not occur in sympathec
tomized fat pads. These sympathetic
influences on lipid metabolism have
been shown to be quite independent
of sympathetic influences on blood
fow.
7. Reticuloendothelial system.
Since bone marrow has a rich sym
pathetic innervation, it is not surpris
ing to find effects of sympathetic
activity not only on blood flow, but
on erythropoiesis, phagocytic activity
of reticuloendothelial cells, release
and distribution of leukocytes, and
endothelial permeability.
8. Sympathetic influences have
been demonstrated on various en
docrine organs, including thyroid,
adrenal cortex, pancreas, testicle, and
pineal body. The pineal body is of
special interest in this connection. Its
elaboration of melatonin, which in
fluences growth, gonadal develop
ment, and sexual activity, is con
trolled by sympathetic innervation
from the superior cervical ganglion.
The secretion of melatonin follows a
diurnal cycle in that synthesis is in
creased in the dark (inhibiting growth
and sexual development) and de
creased in the light. When the sym
pathetic fibers to the pineal body are
sectioned, the diurnal fluctuation of
melatonin synthesis and the as
sociated diurnal changes in behavior
cease. Under these conditions, the
animal kept in the dark is no longer
subject to the antigonadal and
growth-inhibiting influence of the
pineal body.
9. Many other examples could be
given of sympathetic influences on
enzyme activity, mitosis, synthesis of
nucleoproteins, growth and develop
ment, and on responses of various tis
sues to other factors (for example,
hormones, parasympathetic stimula
tion, toxins).
The variety of the effects of stimu
lating peripheral sympathetic path
ways does not lie in the sympathetic
neurons or their influences, but in
the responses of the organs that are
innervated. These responses are as
diverse as the target tissues and
organs - virtually every tissue in
the body. Sympathetic stimulation,
rather than introducing new qualities,
modifies the inherent physiology and
molecular processes of the compo
nent cells, so that each tissue re
sponds in its own way.
This provides the basis for under
standing the diversity of clinical con
sequences (discussed in a succeeding
Interpretation of research
paper)' of chronically exaggerated
sympathetic influences associated
with somatic dysfunction. IO'ls
Appreciation is expressed to Mr. Robert N.
May, Director, Audiovisual Department,
Kirksville College of Osteopathic Medicine. for
the illustrations in this paper and for teaching
the author the principle of "progressive
disclosure .
.
.
References
I . Korr. I . M. : The spinal cord as organizer of
disease processes: Some preliminary perspectives.
JAOA 76:3545, Sep 76.
2. Korr, I . M. : The sympathetic nervous system as
mediator between the somatic and supportive pro
cesses. I n The physiological basis of osteopathic
medicine. by The Postgraduate I nstitute of Os
teopathic Medicine and Surgery The Institute, New
York, 1970.
3. Hess, W. R. : The diencephalon -autonomic and
extrapyramidal functions. Grune & Stratton, New
York, 1954.
4. Netter, F. H. : The Ciba collection of medical i1.
lustrations. The nervous system. eiba, New York,
192. Vol. I, plate 54, p. 81 .
5 . Korr, I. M. : The spinal cord as organizer of
disease processes: Hyperactivity of sympathetic
innervation as a common factor i n disease. JAOA,
Dec 79, in press.
6. Kolzum!, K. , and Brooks, CM. : The integration
of autonomic system reactions: A discussion of auto
nomic reflexes, their control and their association with
somatic reactions. Ergeb PhysioI 67: 1-68, 1972.
7. Sato, A., Ed.: Central organization of the auto
nomic nervous system (Symposium). Brain Res
(Spcial issue, No. 213) 87: 137448, I I Apr 75.
8. Coote, J. H. : Somatic sources of afferent input as
factors in aberrant autonomic, sensory and motor
function. In The neurobiologic mechanisms in manip
ulative therapy, edited by I.M. Korr. Plenum Press,
New York, 1978.
9. Korr, LM. Sustained sympathicotonia as a factor
in disease. In op. cit, ref. 8.
1 0. Korr, I . M. , Thomas, P. E. , and Wright, H. M. :
Patterns of electrical skin resistance in man. Acta
Neuroveg 1 7:77.96, 1958.
I I . Wright, H. M. , Korr, I . M. , and Thomas, P. E. :
Local and regional variations i n cutaneous vasomotor
tone of the human trunk. Acta Neuroveg 22:3352,
196.
12. Korr, I . M. , Wright, H. M. , and Thomas, P. E. :
Effects of experimental myofascial insults on cutane
ous patterns of sympathetic activity in man. Acta
Neuroveg 23:32955, 1962 .
13. Wright, H. M. : Progress in osteopathic research:
A review of investigations in the Division of Physio
logical Sciences, Kirksville College of Osteopathy and
Surgery. IAOA 61 :34752, Jan 62.
14. Korr, I . M. , Wright, H. M. , and Chace, I. A. :
Cutaneous patterns of sympathetic activity in clinical
abnormalities of the musculoskeletal system. Acta
Neuroveg 25: 5896, 19.
15. Wright, H. M. : Perspectives in osteopathic
medicine. Kirksville College of Osteopathic Medicine,
Kirksville, Mo., 1976.
Reprinted by permission from JAOA 79:82-9, Oct
1979
The third paper in this series, "The spinal cord as
organizer of disease processes: Hyperactivity of
sympathetic innervation as a common factor in disease
process," appeared in JAOA in December 1 979. This
paper is a less technical version of a longer paper in
this collection, "Sustained Sympathicotonia as a
Factor in Disease," which begins on page 77.
111
IIZ
l

"

'
Osteopathic principles,
practice and profession
223

The somatic approach to the disease

process* (1951)
The osteopathic profession was
founded in order to develop and put
into practice a concept of health and
disease which was not incorporated in
the medical practice of the day and
which remained unincorporated after
the promulgation of that concept by
Still. It is important, especially after
more than three-quarters of a cen
tury, for the minority school - the
revolutionary one - periodically t o
re-examine its position and to evalu
ate the justification for its continu
ance as a separate school of practice
of the healing arts. The only j ustifica
tion would be that the concept has
proved sound and still has not been
adopted by the maj ority school.
With this in mind, it is my purpose
in this lecture to compare on a fun
damental basis the two major schools
of healing that exist today. I believe
that at the present time this can best
be done by assaying the approaches
and the potentials of each with re
spect to the most urgent health prob
lems facing mankind. This must be
done, of course, in the light of the
most recent advances brought by re
search on problems of both schools.
and in the light of the experience and
thinking reported by many physi
cians. I wish especially to express my
appreciation for the excellent sum
marization of the two schools by
George W. Northup. your president.
I have borrowed not only his ideas
but some of his formulations.
The comparison of the two schools
can by no means be a simple one for
the reason that only one of the
schools is definable. Allopathic
medicine is not subject to definition
for the reason that it is not guided by
any unifying and pervasive set of
principles. Osteopathy. on the other
hand, is guided by certain broad and
general natural principles; it. alone,
therefore, may be truly designated
and defined as a system.
There are very clear reasons for the
lack of unifying principle in allop
athy. upon which a system could be
based. The main reason is the place of
Based on an address presented at the meeting of the
Academy of Applie Osteopathy. Milwaukee, July 20,
1 95 1 .
114
etiology in its thinking. As Edward J.
Stieglitz, 2 distinguished geriatrist,
stated, "The concept of specific
etiology, so flnely phrased by Koch i n
hi s postulates and blindly followed by
generations of bacteriologists and
clinicians, has retarded progress in
etiologic analysis for many years. " In
the allopathic view disease is equated
with the pathogenic agent; disease is
produced by the action of a given
pathogenic agent and is characteristic
of that agent. In short, there are as
many diseases or kinds of diseases as
there are "etiologies. "
From this viewpoint i t i s natural
that the therapeutic attention of the
physician should be focused on the
etiological agent or its effects. He has
essentially only two therapeutic alter
natives: First, if possible, remove the
pathogenic agent or block its action
ang trust that with the aid of suppor
tive measures, the effects of that
agent will somehow be reversed; se
cond, failing the identifiability or
removability of the pathogenic agent,
they apply other agents or measures
which tend to produce opposite ef
fects. Indeed, the true meaning of the
word "allopathy" is other or op
posite effect or affection. As will be
shown, this viewpoint appears to be a
relic of the bygone days when the
diseases of "exogenous" origi n,
whose "etiologies" could be iden
tified with microbes or other in
vaders, predominated. The function
of the physician with respect to these
diseases is either to prevent access of
the invader to the human or to re
move it and its effects as soon after
invasion as possible.
This approach has two major and
inevitable practical consequences.
The first is preoccupation with the
differences among diseases rather
than with the features that they have
in common. One expression of this
consequence is that one of the most
highly esteemed of the medical arts is
that of differential diagnosis . We
must recognize that, in essence, dif
ferential diagnosis resolves itself in
many cases into a quest for labels to
be attached to the various constella
tions of signs and symptoms - that is
effects - from which the physician
endeavors to reason back to the
etiology. It has been my privilege to
participate in a large number of
clinical conferences in which findings
and histories are reviewed in great
detail with the sole objective of nam
ing the "disease. " The conferees in
many cases find themselves at a com
plete loss therapeutically until a satis
fying label is found, at which point a
great sigh of achievement may be
heard. Unfortunately, as will be
shown, too small a percentage of the
complaints which are brought to a
doctor's office today can be packaged
and labeled as discrete entities.
Unfortunately; also, the general
public has been falsely educated to
believe that the physician is a failure
unless he can assign an impressive
title to "what is wrong with me. "
The second major consequence of
the allopathic approach is the preoc
cupation with end results. This is im
plicit in the statement that the
strategy of allopathic practice is to
produce effects opposite to those of
the etiological agent. Unfortunately,
in the case of most of the diseases to
which I shall refer in this lecture,
when the effects have already become
apparent through symptoms and
signs, the disease process is already
quite advanced and often beyond re
versal . This limits the function of the
allopathic physician to the three R's:
"relieve, repair or remove. "! That is,
relieve the patient' s symptoms; if
possible patch up the debris of the
disease process; if beyond patching,
then remove !he debris.
This is reflected in the allopathic
attitude toward surgery. The patching
or removal of the debris of the disease
process is viewed as repair or removal
of the "offending" organ, rather
than the offended organ, as though
that organ were the "cause" of the
disease, rather than a victim of a con
tinuing process.
Let us now compare the strategy of
osteopathy. From the osteopathic
viewpoint disease is by no means syn
onymous with, characteristic, of, or
even determined by, the precipitating
or pathogenic agent. Also, from the
osteopathic viewpoint, diseases have
a great deal more in common than
not. Indeed, all human diseases have
in common a most important feature
- man himself.
From this viewpoint, therefore,
disease is not the action of a given
Osteopathic principles
pathogenic agent; rather, disease is
the response of the individual to the
stimulus of the pathogenic agent. As
a matter of fact the distinction be
tween the pathogenic and nonpatho
genic agents is not a fixed one, but
may be determined in many cases by
the response of the individual human
organism. A perfectly normal stimu
lus to one individual may elicit a
disease-response in another.
Complex as man is, the fact re
mains that he can respond in only a
limited number of ways, determined
by his nature rather than that of the
"pathogen. " In the osteopathic view,
therefore, it becomes the fun.tion of
the physician to understand the pat
terns of response of humans in gen
eral, his patient in particular, and
through that understanding to alter
the response in a favorable direction
and to prevent the unfavorable re
sponse. If it is true, as Pope stated,
that "The proper study of mankind is
man," then it is equally true that "the
study of disease is man. "
It is to be noted that in characteriz
ing osteopathy, nowhere have I men
tioned manipulative therapy. Manip
ulation happens to be one of the best
therapeutic modalities available to
day for altering man's patterns of
response to noxious and other stimuli
in favorable directions and for
rendering him less vulnerable. It must
be considered as but one component,
however, of osteopathic therapy since
all aspects of man's life condition and
determine his responses. Osteopathy,
therefore, is not merely a form of
therapy but rather a broad philos
ophy. a guide for thinking and acting
in relation to questions of health and
disease.
Let us now proceed to compare the
potentials of these two approaches
with respect to the most urgent health
problems of the times. In the past 4
decades there has been a maj or trans
formation in the disease picture, par
alleled by a change in the age distri
bution of our population. As a result,
largely, of the conquest of the most
important infectious or communi
cable diseases through advances in
public health, preventive medicine,
immunology, antibiotics, et cetera,
there has been a dramatic increase in
average longevity.
It may be said that we have a rapid
ly aging population. For example,
during the past 4 years the number
of persons over the age of 65 has in
creased twice as rapidly as the popu
lation itself. Persons over the age of
65 have quaarupled since the begin
ning of the century while the entire
population has only doubled .. It is
predicted by the United States Bureau
of the Census that by 1 980 approx
imately 40 per cent of our popuiation
will exceed 45 years of age; more than
20 million persons will be over the age
of 65.
This advance, however, "is tainted
by the immense toll of prolonged dis
ability of varying degrees, "z concen
trated mainly in this most rapidly
growing segment of our population.
The healing arts are today presented
with a new batch of cripplers and
killers, the diseases of breaking down
and wearing out, especially, but not
exclusively, associated with maturity.
These are the diseases which one
"gets" rather than "catches. " These
are the "endogenous" diseases,
originating within the patient, rather
than "exogenous" ones brought by
invaders. These are the diseases which
the lay public commonly designates
as the "troubles" - heart trouble,
kidney trouble, stomach trouble, gall
bladder trouble.
r refer, of course, to the chronic de
generative diseases, including the
various kinds of cardiosvascular-renal
diseases, the arthritides, nephritis,
peptic ulcer, diabetes, metabolic and
endocrine disorders, et cetera. The in
cidence of these diseases is so vast and
so appalling in total disability that
they have been designated as the
"major front" by the Surgeon
General of the United States Public
Health Service. It is estimated that
there are 25 million victims in this
country; one person in every six is a
victim of such disease, that nearly
every family in this country is touched
in some degree by chronic disorders.
Although they are especially associ
ated with maturity, these diseases
have many victims among the youth
of our country.
Man is thus being spared early
death by the infectious diseases only
that he may succumb at a later age to
the misery and disablement of
chronic disease. As Stieglitz1 stated,
"The burden of chronic disease is
both individually and collectively far
greater than the social consequence of
high mortality from acute illnesses. A
man quickly dead is .a lesser tragedy
to himself, his family and the com
munity than one disabled for many
years. " As a measure of the inade
quacy of the healing arts with respect
to these diseases is the fact that
although in the past 4 decades the
percentage of persons over 60 years
of age has doubled, the average man
at 6 today has the same life expec
tancy as had a man of 6 in 1 90. It
might be said in summary that the
conquest of the major infectious
diseases due to the advances in the
clinical sciences has presented
humanity with at least equally serious
problems to which there are, as yet,
no certain answers.
What is the approach of allopathic
medicine to this "enormous personal
and national burden of disease in the
adult population, the most produc
tive element of our society?") In
brief, it is precisely the same as that
previously outlined. Medicine and the
research to which it gives direction
continue the quest for nonexistent in
dividual causes upon which to base
the individual cures for the individual
diseases. In the absence of knowledge
regarding specific etiologies which
can be isolated or exorcised from the
body or whose actions can be blocked,
the medical profession must con
t i nue to cont ent i t sel f wi t h
ameliorating end-effects - with
symptomatic or palliative treatment.
Steiglitz1 states in his introduction
to a recent symposium on chronic
disease, ". . . the vitally significant
objective of prevention of long-term
illness is omitted from these collected
papers" because there was little to of
fer but "ever-growing concern. " He
goes on to say, " The treatment of
chronic disease after disablement has
occurred is equivalent to locking the
stable door after the horse is stolen. "
Allopathic medicine, therefore,
fnds itself in the position of dealing
with end-effects of unknown etiol
ogies. Indeed, in its quest for th in
dividual causes it has often confused
effect with cause. Thus, for example
we see diabetes mellitus "caused" by
pancreatic insufficiency when actual
ly that defect is itself a nearly ter
minal link, immediately preceding the
symptoms, in a long chain of pro
cesses. To take a more recent devel
opment, rheumatoid arthritis is now
ascribed to a metabolic defect
associated with adrenocortical insuf
ficiency whereas that insufficiency is
115
itself one of the results of a complex
disease process that, like many other
chronic diseases, may have had its
origin many years before the emer
gence of symptoms.
A practice based on the attempted
reversal of end-effects without access
to etiological factors is indeed a prac
tice based on temporizations. If the
blood pressure is high, give some
thing that will lower it; if the appetite
is poor, stimulate it; if the weight is
excessive, reduce it; if one of the pa
tient's endocrine glands is overactive,
then poison it, remove all or part of
it, or give an antagonist; if the patient
is deficient in some endocrine or
other component, then supply it or
stimulate its source. Failing any of
these, then restrict the patient's life so
that he may live within his limited
physiological means; add years to his
life, but not life to his years. The
function of the (allopathic) physician
with respect to chronic degenerative
disease is well summed up by another
contributor to the aforementioned
symposium. In an article entitled,
"Mastery of Long-Term Illness, "
Jurgen Ruesch' says, "Mastery of
chronic disease thus becomes an
organismic task of physiological and
psychological adaptation. The physi
cian can rehabilitate the patient by
helping him . . . to find a new adjust
ment to a changed internal and exter
nal environment, and to accept his
total or partial invalidism as part oja
new reality. " (Italics supplied.)
Through this approach there can ob
viously be little hope for cure of
chronic disease and much less for
prevention.
Why is allopathic treatment of
chronic diseases "equivalent to lock
ing the door after the horse is
stolen"? The unknown, endogenous
etiologies are certainly a factor, but
Stieglitzl offers another important
factor , " All these disorders begin
asymptomatically and may be well
advanced before subjective com
plaints of suffcient intensity arise to
cause the patient to seek medical
assistance. . The lesson to be
remembered is that we must search
for these silent, insidious, fifth col
umn disorders in apparently well peo
ple and not wait until they become
obvious by overt lesion." But says
Ruesch, ' "In medical school s,
teaching i s still geared t o acute condi
tions while chronic complaints such
226
as headache, backache, fatigue, ten
sion, or pain are rarely presented in
medical rounds, although they com
prise the bulk of the cases in private
practice. " One wonders what manner
of persuasion would be required to
convince these representatives of the
more advanced segment of the medi
cal profession that what they are
seeking unwittingly, and certainly
blindly, is the osteopathic lesion.
In thus characterizing the allo
pathic approach to chronic degener
ative disease there is no intention of
minimizing the value of the tremen
dous contributions of medical
research and medical practice to the
relief of human suffering associated
with these diseases . Millions of suf
ferers have given and will for some
time continue to give thanks for in
sulin, cortisone and ACTH, pain
relieving agents, and hundreds of
other advances. My only purpose is to
stimulate continued awareness that
these modalities, vital as they are, are
not directed at the disease process
itself, certainly not in its asymp
tomatic stages, but at the manifesta
tions or stages of the process after
"the horse has been stolen, " when
some degree of invalidism must be ac
cepted as "part of a new reality. "
The need for an approach t o the
fundamental disease process in each
case remains. As Fischers stated in an
exceUent article directed at the proper
incorporation of certain recent ad
vaces into osteopathic practice: "Sur
gery removes pathology; it does not
cure it. . . . So it is with some drugs;
they relieve the symptoms without cur
ing the disease." He goes on to say,
"There are no outside agencies which
will cure disease. Cure comes from
within; it comes from rearranging
those parts which are out of order."
What is the potential implicit in the
osteopathic concept with respect to
the "major front"? Research in our
laboratories, and of laboratories in
related fields throughout the world,
and your own clinical experience have
led us to the following conclusions:
1 . The osteopathic lesion, as iden
tifed by palpatory and other current
clinical criteria, represents the
somatic components of a basic, gen
eral disease process, organized
primarily (that is, in its early stages at
least) by the central nervous system.
2. The potential or actual pattern
of manifestations of this process, that
is, the "disease, " is determined by its
locus - the level of the nervous sys
tem involved. Obviously, the various
organs and tissues, innervated from
different parts of the nervous system,
will respond in different ways to the
same process or stimulus.
3. As in all natural processes, the
speed of this process and the fullness
of expression of its pattern of mani
festations (that is, the severity) are in
fluenced by many factors -constitu
tional factors, age, environment, past
history, nutrition, emotions, and per
sonality.
4. The same process may be in
itiated in different ways, although in
the osteopathic view it is most com
monly initiated in the somatic (myo
fascioskeletal) structures through
postural stress; that is, the response
(pattern of manifestations) is deter
mined not by the "etiological" agent
or pathogen, but by the site of its
action and the physiological state of
the patient.
A postural stress, therefore, repre
sents a decisive facilitating or
probability-increasing factor in
disease, predisposing the involved
segments, and therefore the in
dividual as a whole, to the action of
noxious stimuli and exaggerating the
responses of those segments to all
stimuli, normal and noxious. By its
presence or absence the lesion may
decisively determine the patient's
vulnerability to noxious influences,
his responses to daily stresses and
stimuli, and even determine whether a
given agent, stimulus or environmen
tal change is to be classified as
pathogenic or not.
As a localizing and channelizing
factor it determines where the process
is initiated, what organs and tissues
are primarily affected and therefore
what the manifestations - the
"disease" - will be if other factors
contribute sufficiently to the rate and
fullness of expression of the process.
As a localizing factor, it may, for ex
ample, determine the site, and there
fore the nature, of the bodily expres
sion of emotional (psychosomatic)
disturbances. Since the distribution
of postural and mechanical myofas
cioskeletal stresses is unquestionably
infuenced by body type or habitus,
they may be the main factor in the
well-recognized relationship between
body type and the incidence of
various chronic diseases.
Osteopathic principles

From the diagnostic viewpoint the
somatic component has great stra
tegic significance because it makes
possible the detection and evaluation
of the disease process far in advance
of the emergence of symptoms, Os
teopathic lesions appear to represent
the "silent, insidious, fifth column
disorders in apparently well people, "
sought by Stieglitz.
Whether the somatic component of
the basic process is primary (as in
postural stress) or of secondary reflex
origin (as in visceral disease), once it
is established it is no longer a mere
manifestation of the process but has
become a contributing, exacerbating,
and perpetuating influence, which
must be given full consideration in
therapy regardless of the "primary
etiology. " As the most accessible, the
most easily recognizable, and (in the
hands of the osteopathic physician)
the most responsive component, it is
the strategic one through which to in
fluence the process itself and inter
rupt the vicious cycle of autogenic im
pulses.6
78
We begin to recognize, therefore,
that a great many diseases which on
the surface are so diverse in character
as to require a highly complex system
of differential diagnosis, differential
therapy, and differential nomencla
ture, are essentially one disease, the
manifestations of an identical process
expressed in different parts of the
body.
When we have learned the intrinsic
nature of the process, we shall know
how to prevent or interrupt it wher
ever it may be, whatever its mode of
initiation, and thereby deal in a
unified system with many diverse
diseases rather than with each one in
a different way. 9 The "i ntrinsic
nature of the process" is the subject
under investigation in the Kirksville
research program.
Today, therefore, the osteopathic
concept offers the only approach -
certainly the only unitary, basic, and
systematic approach - to the treat
ment and prevention of chronic
disease because:
1 . It alone recognizes the common
denominator of the fundamental
disease process.
2. It is aware of a very common
etiological factor in the initiation of
that process - gravity in the face of
man's incomplete adaptation to the
erect stance.
3. Through its somatic component
- the osteopathic lesion - the fun
damental disease process can be
detected and evaluated long before ir
reversible damage has been done -
before the "stable door" has even
been opened.
4. Through its somatic component,
an accessible, specific, responsive,
and effective lever is provided for the
manipulation and interruption of the
disease process itself.
In these four points, I believe, lies
the future of the osteopathic concept
because in that concept are implicit
some of the answers to some of man
kind's most imperative problems.
Advanced as that concept i s ,
however, i t can offer only the "ap
proach" in its present stage of devel
opment; it is not yet ready for that
future, for the following reasons:
1. The nature of the fundamental
disease process - the lesion process
is inadequately understood.
2. Although the importance of
the relationship between gravi ty
and bodily structure is thoroughly
recognized in osteopathic practice,
our knowledge of the interplay
of those relationships is too frag
mentary t o provide a basis for
the prevention of the initiation of
the process, so important to the
prevention of functional and organic
disease.
3. The methods of detection and
evaluation of the process by the pres
ent SUbjective palpatory procedures
are too crude, too subject to error,
too diffcult of standardization.
4. Although manipulative therapy
is today the only modality which is ef
fectively directed at the fundamental
disease process, it is too slow, too
laborious, too difficult of standard
ization.
Furthermore, the current diag
nostic and manipulative procedures,
relatively excellent as they are, are not
keyed to the magnitude of the prob
lem. There are already 25 million
victims of chronic diseases in this
country alone and many millions
more in whom it needs to be pre
vented. Methods must be developed
for the detection, evaluation, preven
tion, and treatment of the disease
process which have mass applicabil
ity. As stated by Surgeon General
Scheele, "It is possible that we
shall not be able clearly to define
healthy maturity until we attempt to
apply in the entire population our
knowledge of these diseases . . . .
These answers to the problem of
the chronic diseases must be devel
oped, and will be developed, because
society is demanding the answers.
They can flow only from a large
reservoir of basic information which
in turn is achievable only through
enlarged programs of fundamental
research. In view of the unhappiness
of the medical profession with its own
temporization and expedients and its
quest for a more basic approach, it
must inevitably arrive at a similar
conclusion. The osteopathic concept,
therefore, in one form or another,
has a certain and brilliant future as
the logical, unitary, systematic basis
for the treatment and prevention of
chronic diseases - as the preventive
medicine of tomorrow. The future of
the osteopathic profession, however,
will be to a decisive degree deter
mined by the contribution it makes
through fundamental and clinical
research, to the further development
of this concept. Through its 75 years
of experience it is the most richly
prepared profession to undertake this
great responsibility to society. Today
fundamental research on a large scale
offers the most direct (perhaps the
only) road to the osteopathic profes
sion's rightful place in society and to
its preparation for that place. IO 1 l
References
I. Northup. G. W. : Osteopathic concept of disease,
a critical evaluation. J. Am. Osteop. A. 50:20-21 1 .
Dec. 1950.
2. Stieglitz. E. J. : Medicine in an agin population.
M. Clin. North America 33:295308. March 1949.
3. Scheele. L. A. : Statement upon induction 8
Surgeon General. Public Health Service. Federal
Security Agency. April 5. 1 948. J. Am. Osteop. A.
47:472-474. May 1948.
4. Ruesch. J.: Mastery of long-term illness. M. Clin.
North America 33:435-446. March 1949.
5. Fischer. R. L. : Osteopathy - fifty years later. J.
Am. Osteop. A. 50:50-514. June 195 1 .
6. Rinzler, S. H a and Travel!. J. : Therapy directed
'
at somatic component of cardiac pain . . Am. Heart J.
35:248-268, Feb. 1948.
7. Korr, t. M. : Neural basis of the osteopathic Ie
sion. J. Am. Osteop. A. 47: 1 91 -198. Dec. 1941.
8. Korr. I . M. : Emerging concept of the osteopathic
lesion. J. Am. Osteop. A. 48: 1 21- 138. Nov. 1948.
9. Korr, l . M. : Three fundamental problems in
osteopathic research. J. Am. Osteop. A. 50:407-416,
April 1 95 1 .
10. Korr, I . M. : Research program for the
osteopathic profession. J. Am. Osteop. A.
47:369-375. March 19.
1 1 . Korr, I . M. : How far on the scientific road? J .
Osteop. 56: 1 3- 1 6, Dec. 1 949.
Reprinted by permission from JAOA 5 1 :201 -205.
1 951 .
227
The function of the osteopathic profession:
A matter for decision* (1959)
The theme of this Convention, "Un
folding Horizons in Osteopathic
Medicine, " is a challenging one. My
assigned task as keynoter was to de
scribe, from my viewpoint as a physi
ologist in m osteopathic college,
some of the horizons that may
reasonably be expected to unfold for
the osteopathic profession. But I
soon discovered that my task was an
impossible one. The horizons we see
at any given moment are determined
by the places where we stand and the
directions in which we face, and the
number of possible horizons is in
fnite. But the only horizon that un
folds is the one toward which we
move and then only as long as we
move toward it. Your profession now
stands on many platforms and faces
in many directions, frustrated and
uncertain about the future because its
available resources cannot support
movement in all of its present direc
tions. From which of the many plat
forms and in which of the many
directions is your profession to seek
its unfolding horizons? One thing is
certain: Unless this decision is made
very soon, the osteopathic profession
may look toward many horizons, but
none that unfolds.
The only possible course - one
that has any hope of success -is one
to which the profession can, with uni
ty and conviction, commit itself, and
in which every segment can find its
role. The decision, therefore, must be
an organized decision.
For obvious reasons, the decision
must be one in which society can feel
a stake and to which it can whole
heartedly and generously commit
itself. You cannot realistically ask
society, as you have tried to do, to
commit itself before you do; and
without society' s commitment, no
course can be long pursued and no
horizons unfolded. Society' s j udg
ment, therefore, must await your
decision.
You have before you, then, a
momentous and urgent decision:
What do you wish your profession's
on the keynote address of 63rd Annual
Convention of the American Osteopathic Association.
juy 13, 1959, Chicago, Illinois.
ZZ8
contribution to society to be? I em
phasize "profession's contribution"
because the profession is far more
than an aggregation of physicians and
institutions, j ust as a human being is
far more than the sum of his body
parts. Its responsibilities are far
greater than the sum of your in
dividual responsibilities, j ust as
human life is more than the function
of organs. I repeat, unless the profes
sion's function is soon established
and the profession committed to it,
all of its present roads are short ones
and the theme of this Convention is
but an idle phrase expressing a vain
hope.
Unfortunately, you are not ready
to make the decision, and some
preparation is necessary. Three steps
are required:
1 . You must become aware of the
need Jor deciion. There is little in the
present course of your affairs that
refects a deep, pervasive awareness
that a deliberate decision on the right
course needs to be made. There is, in
stead, the implied conviction that of
all the present conflicting courses the
right one will somehow eventually
prevail.
2. You must examine and under
stand the nature and scope oj the
deciion. While you make many deci
sions (and many more will be made at
this Convention), none, since the one
that marked your founding, has been
as epochal in character as the one that
now awaits your deliberation.
3. You must organize Jor decision.
While your organizations make many
decisions your profession is not now
organized to make one of thi s
character.
I propose, therefore, to examine
with you ( 1 ) some of the reasons why
this decision needs to be made and
how the need came about; (2) the
character of the decision; and (3) how
it is to be made. Finally, I shall pro
pose a horizon for your unfolding.
Need for decision
Each of the existing professions has
evolved to meet some social need
which is itself the product of social,
cultural, and technologic evolution
and whose essential character is
generally understood by society. In
the course of its evolution each pro
fession has been charged by society
with the meeting of that need, which
becomes its characterizing function.
Society imposes regulation while at
the same time giving protection and
support. In general, therefore, pro
fessions do not need to decide what
their respective functions shall be, but
only how they are to be carried out.
Uniquely, the osteopathic profes
sion did not evolve, nor was the need
one generally understood by society.
Instead, it arose de novo and self
appointed, so to speak, to a task
which the profession itself declared
and defined and which it alone
understood, and to meet a demand
which it alone recognized.
The profession's founding and self
appointment were marked by the
chartering of the first osteopathic col
lege in 1 892. Its self-defned task was
to teach and to put into practice prin
ciples and methods which it believed
would "improve our present system"
of medicine. Having found the ex
isting medical professions unreceptive
to these principles and methods, the
founders decided to establish a pro
fession which would test, develop,
and apply them. It has been, from the
beginning, an uphill stru.gle, in
which you have had minimal support
from society and unrelenting opposi
tion from powerful organizations and
professions. Nevertheless, in the in"
tervening 67 years you have estab
lished yourself as a strong, indepen
dent profession, one of the two
surviving medical professions in this
country - and potentially a most
powerful force for good in society. At
tremendous cost to your own human
and material resources you have
trained and educated yourselves and
each other, built your own educa
tional and clinical institutions, and
established a profession of 1 3,00
physicians serving millions of persons.
You have been awarded the rights to
practice as fully Qualified physicians
and to create many others as you
can, more or less in your own image.
Your profession now has a powerful
voice which is heard with far greater
effect than one would expect from
your numbers. The public increasingly
seeks, and gratefully receives, the ser
vices of osteopathic physicians. Few
recognitions and privileges remain to
be won; indeed, the withholding of
Osteopathic principles
recognition, approval, and privilege
now raises more questions in the
public mind about the objectivity and
the motives of the withholder than
about the competence of osteopathic
physicians. In all, this has been an im
mense achievement - unmatched in
the history of professions.
What, then, is your problem? And
why is it necessary again to decide
and declare the reasons for your pro
fession's existence?
Your major frustration, as you
identify it, is the lack of resources to
do all the things you now feel yourself
able to do, in the quality and on the
scale to which you aspire. In other
words, the right, recognitions, and
privileges you have been awarded are
largely permissive - the removal of
discriminatory obstacles. Society still
gives little of the positive support it
gives to the functions and institutions
of other professions, through taxes,
major philanthropy, substantial en
dowments, and other specifically
designed provisions. While society
gratefully accepts the services offered
by osteopathic physicians, and will
ingly pays for each service, it still
feels little or no obligation to the
osteopathic profession or to the in
stitutions which are its fountainhead.
After 67 years, a vast amount of your
effort continues to be expended in the
quest for their support.
These are formidable obstacles,
more obstructive to your progress,
and even your existence, than ever
before. But they are now far more of
your own creation and perpetuation,
and therefore far more subject to
your removal, than you seem to be
aware. It is beyond debate that you
have established yourself as a profes
sion. But it is dme long past time
- to ask again, "For what?" For
what have you fought this long, hard,
uphill struggle to establish yourself?
For what have you established a new
profession? You find yourself able to
answer only in terms of the services
delivered by individual physicians
and their clinics and hospitals. But
where is the answer that speaks for
the profession? What do you wish to
do together? Because there is no
ready answer to this question, the
osteopathic profession itself debates
whether it has a function of its own
and a reason for separate existence,
yet wonders why society feels no com
pelling sense of responsibility for its
maintenance. Unless you soon decide
what the function of the osteopathic
profession is a decision no other
profession is called on to make - in
dividual physicians may, for a while,
continue to prosper (such is the de
mand for medical service), but the
profession will atrophy and vanish
for want of a function.
Why is there no longer a ready,
clear, unequivocal answer to the
question, "What is the function for
which you have established and main
tained this profession?" Is there no
longer a need for the function it once
"professed"? On the contrary, it
seems to me that you have been so
long and so deeply absorbed in
establishing yourself that you have
forgotten for what, you no longer ask
for what, and, more than you are
aware, rights, recognitions, and ap
proval have become ends in them
selves . Being has become more im
portant than becoming. Unfortu
nately, existence of the profession is
not in itself reason for existence, and
self-preservation is in itself not a func
tion. So deeply have you been engaged
in what began as a struggle for the
rights to practice and teach accord
ing to your own principles, and to
such an extent have you won those
rights by developing and demonstrat
ing proficiency in the implementation
of other principles, that your own
have become a little vague, irrelevant,
and even obstructive to your present
ends. Though now possessed of a
great voice, your profession asks,
"What will win approval from
whom?" more often than "What is
right for us?"; and says those things
which it believes are expected of it. So
preoccupied with meeting the stan
dards of others, it has virtually relin
quished all responsibility for setting
standards for itself. So much have
you been preoccupied with building
your professional engine, and a
magnificent engine it is, that you have
neglected to lay track, and now can
not quite recall where it was to go.
Consequently, your major struggles
today are not so much for society's
approval of the engine, which has
been approved and duly admired, as
for the privilege of running it on the
tracks of other professions, toward
destinations of their choosing.
The grave problems that now beset
you can only grow and multiply until
your profession is committed to its
own course, or until it is abolished.
Indeed, some members of your pro
fession - fortunately, only a few,
but unfortunately a few in high places
- find themselves so overwhelmed
by these problems that they seriously
propound this conclusion: That the
osteopathic profession, at immense
cost and sacrifice, established itself,
won and maintained its identity for
67 years, so that it could, with a
flourish, diestablish itself, surrender
its identity, and return to oblivion! It
is to be expected, of course, that like
other movements in history, this one,
too, has its "summer soldiers and
sunshine patriots. " But it is sad that a
learned profession permits itself, be- .
-ause of its indecision, to counte
nance and even seriously debate such
tragic nonsensel
Let us now examine how your
gravest problems and some of your
greatest obstacles arise from your
own uncertainty regarding the func
tion of your profession.
1 . Having no clear image of the
function of the osteopathic profes
sion, as it has of others, society has
had to define that function in terms
which it does understand and regulate
its performance according to criteria
and standards with which it is
familiar. Not being able, therefore, to
define its stake in that function,
society cannot define its respon:ibili
ty in sharing the cost of the profes
sion's separate maintenance ahd the
cost of educating osteopathic physi
cians. You are reduced, therefore, to
seeking support, in proportion to
your numbers, for this or that service,
this or that project or endeavor, or
this or that institution or department.
But society remains uncommitted to
the profession as a whole.
2. Until the profession is commit
ted to the contribution it proposes to
make to society, it can have no con
sistent, reliable guide to the formula
tion of long-term policy. In effect,
your profession endlessly debates
how to carry out its function without
a clear view of what that function is.
Without such a guide, the only possi
ble "policy" is expediency: That
which will win approval for this or
that activity, from this or that one of
your many publics, at this or that
time. Over a period of years, it was
inevitable that everything, especially
design, should have been sacrificed
for diversification. As a result, the
229
profession and its activities today
refect not so much your design as its
many expedient adaptations to exter
nal, conflicting pressures - as the
shape of a tree may reflect the pre
vailing winds and a rock, the forces
that erode it.
3. The profession neutralizes its
great strength and dissipates its
resources in diverse and conficting
efforts because, without a clear view
of its central functions and its
primary objectives, it can have no
dependable scale of values for assign
ment of priorities and for apportion
ment of its resources. Each area of
professional endeavor competes with
every other area of endeavor for in
vestment and support, one siphoning
off resources needed by the other.
One area momentarily thrives while
another, on which it ultimately
depends, is permitted to starve. In
vestment in each area is made on its
own merits at a given time, without
regard for long-term, balanced devel
opment of all of them. The resulting
imbalances can find only expedient
correction in a zig-zag course.
Let me cite one such imbalance,
rapidly increasing in severity and
hazard. The area of your profession's
largest investment today, far ex
ceeding all others, is in hospitals.
While in themselves, of course, highly
desirable, the mushrooming of hos
pitals has siphoned off so much of
your profession's resources that your
colleges - your very source - go
begging. ' Conversely, the need of
your hospitals for staff members and
interns is rapidly outrunning the
capacity of your colleges to produce
them; even the raiding of the college
faculties has become an accepted
practice. One has an image of jet
planes so fast and powerful that they
continually outrace the tankers which
are to refuel them in flight. Perhaps
even more important than the quan
titative aspects of this imbalance are
the qualitative aspects. It is pro
foundly and adversely affecting the
entire educational system of your
profession, the professional orienta
tion of its recruits and graduates, the
quality of intern training, the geo
graphic distribution of osteopathic
physicians, the ethics of practice, the
medical specialties - and most pro
foundly of all, the very function of
the osteopathic profession. It is com
mitting your profession to a course
I
upon which it has not consciously
decided.
This example of imbalance has
many counterparts. The question, in
each case, is not only what is the
relative importance of the various
areas and endeavors, but what, at a
given stage along your course, is the
correct balance among them? This
cannot be determined until you have,
as a profession, decided upon your
course.
4. Because of its indecision, your
profession has inficted upon its col
leges, a Babel of conflicting ideol
ogies, principles, practices, and ob
jectives, while demanding excellence
in each. Purusit of "completeness"
has produced curricula which grow
by accretion rather than by design. It
has led more and more to diffuseness,
to superficiality, to acquisition of
unorganized masses of knowledge
and technic, to sacrifice of perspec
tive and unifying themes, and to
neglect of essentials. Design of the
central core of osteopathic education
awaits the profession'S commitment
to its own horizons.
5 . Until a commitment to your pro
fession's mission is made, you can
have no realistic basis for attracting
recruits to your profession nor for
describing their qualifications.
6. Just as you now give society little
basis for defining its obligations to
you, so have you insufficient basis for
determining the full scope of your
obligations to society.
7. Because you have not decided
upon the particular contribution of
your profession and made clear to
yourselves and to society their special
qualities, you are reduced to measur
ing your strength in quantitative
terms - the numbers of your physi
cians, the numbers of your annual
graduates, the numbers of hospitals
and hospital beds, the numbers of
specialties and specialists, the
numbers of dollars, the ratio of
D. O. ' s to M. D. ' s and of D. O. ' s to
the population, and so forth. The
growing assumption that to prevail
you must do so by sheer weight of
numbers can only contribute to a
growing sense of futility and the fur
ther expenditure of your meager
resources in unrewarding ventures.
You struggle to compensate for your
minority position when you should be
capitalizing on it.
8. For the same reasons there are
misapprehensions about the source of
your strength. Your profession ap
pears to believe that its strength is to
be found more in stamps of approval
by self-appointed magistrates of
medicine, who in their own minds are
medicine, than in the public your pro
fession serves, which is the ultimate
judge and the source of your support.
As a result, you often act as though
you believed your strength is to be
nurtured by mimicry, by cloaks of
protective coloration, by compromise
of principles, by organized com
pliance, by appeasement, and by
adaptation to what is prescribed for
you by organizations of another pro
fession, rather than what is designed
for you by yourself. Recent events
loudly proclaim the futility of this ap
proach. History reveals that oblivion
is the fate of those who ask only
"What is acceptable?" and not
"What is right?"
These, then, are the real obstacles
that beset you today, as you con
template your past achievements with
justifiable pride and your future
course without certainty. They are
engendered and perpetuated by your
professi on'S noncommitment to a
function of its own design. The com
mitment becomes more urgent with
each passing moment; for the longer
it is postponed, the more diffcult
does it become, and the more do you
surrender the responsibility for mak
ing it.
It may appear that all that is re
quired is a satisfying and resounding
definition of the noun "osteopathy"
and the adjective "osteopathic. " On
the contrary, it is your actions that
give meaning to your terms, and not
vice versa. Osteopathic medicine is
not a celestial body that happened to
come into being, subject to observa
tion and description, but not to in
tervention. It is a product of human
design and human creation. It is.
therefore, continually subject to
human design. Hence, osteopathic
medicine is an item not for definition,
but for decision. The question is not,
"What is it?" but rather, "What do
you propose that it become and that
it do?" This is the decision before
you. Let us now examine the nature
of that decision - the criteria on
which it is to be based.
Nature of the decision
Following are some of the considera-
Osteopathic principles
tions by which your profession must
be guided in its selection of the hori
zons it proposes to unfold for society:
the profession' s long-term contribu
tion. In part, they are suggested by
the foregoing symptoms of inde
cision.
1 . The contribution must fill a
social need, one in the limitless sphere
of human health.
2. The need must be one which is
not met or likely to be met by any
other profession, however large the
areas of overlap and collaboration
with other professions.
3. The contribution must be of
such scope, character, and enduring
value as to justify - indeed, demand
- the existence, growt h, and
development of the profession.
4. It must be of such value as to
merit society' s continuing and
generous support, particularly of the
institutions in which the contribution
is developed, taught, and delivered.
5. It must be one which can unite
the profession, to which the profes
sion can unreservedly commit itself,
and in which every segment can find
its most gratifying role.
6. It must be within your province
and within your realizable power. It
must emerge therefore from your
history, experience, character, and in
sights as a profession, from your own
interpretations of society' s needs and
from your own determination of the
path to their fulfillment.
7. It must provide comprehensive
design for the profession' s total ef
fort, for its development, for the ac
quisition and utilization of its
resources, for the education of its
physicians, and for their practice. It
must provide guidance in the for
mulation of policy and in the defini
t i on and ful fi l l ment o f t he
profession'S obligations t o society.
Organizing for dedsion
Already so well organized for many
kinds of decisions, you may wonder
why it should be necessary to
organize in particular for this one.
For this reason: This is a decision that
you are not now organized to make.
This is not just another political or
organizational decision to be record
ed, proclaimed, or filed as merely
another resolution, a new by-law, a
new code of ethics - or even a new
set of objectives for the Association.
It is a social, scientific, intellectual,
philosophical, technical, and medical
decision of such comprehensive scope
that it would henceforth govern the
making of all other decisions. It is not
one to be assigned to some commit
tee, some department, or some
bureau; it is one to be made by the en
tire profession and its institutions. It
is not an aye-or-nay issue to be re
solved by parliamentary procedure, in
periodic sessions of chambers and
councils, or in smoke-filled caucus
rooms, and to be legislated into ex
istence by majority vote. Rather, it is
one to be continually developed, ac
cording to searching examination and
re-examination of human needs and
of this profession's share in the
meeting of those needs. This is a deci
sion on long-term directions of
development, to guide all your ef
forts, at every level; one which will
give design to your life as a profes-
- sion.
The decision I am proposing is not,
"What will serve the profession
best?" but, "What and how will the
profession serve best?" Organiza
tional decisions made without regard
for the central function of the profes
sion can in the long run settle
nothing, and at best bring only il
lusory and passing advantages to the
profession. In effect, your profes
sional organizations are preoccupied
with secondary procedural issues,
while the primary issues and objec
tives have yet to be identified; with
means to the end before the end has
been decided. AJd yet, it is these
secondary decisions which today
determine the profession's course and
i ts future hi story. Beauti fully
organized for decisions on tactics,
your profession has yet to organize
for decisions on basic strategy.
In considering how to organize for
this decision, two things are clear.
First, those members and segments of
thi profession who are deeply con
cered about its course and its
horizons, and they are very many,
must find the way to exert their in
fluence on the affairs of the profes
sion and on the plotting of its course.
Second, you will need intelectual
leadership no less than political
leadership. Leaders are required who
are qualified to identify and weigh the
clinical, scientific, social, and profes
sional - as well as the political and
economic - elements that are in
volved. It is a matter for your serious
attention that for want of appropriate
forums many of your greatest and
wisest physicians can have little in
fuence on your profession's course.
For such a decision you also need the
active, and perhaps even the domi
nant, participation of your educators,
for it is they, in the long run, who
give meaning to your decisions,
through the qualifications, attitudes,
and perspectives they inculcate in the
physicians they put into society' s ser
vice each year. But even their func
tion is now more determined by
political considerations than it should
be and more than we like to admit.
Educational process must be freed of
political influence.
A strong academic wing of your
profession, centered around but not
limited to your colleges, still needs to
be developed. Its chief function
would be the continual examination
and re-examination of all the issues
and elements that determine your
obligations to society and the paths to
their fulfillment. It is these consider
ations that should guide the affairs of
the profession and determine the tac
tics and the weapons of organiza
tional warfare wi th whi ch t o
strengthen yourself i n society' s
behalf.
The horizons for your unfolding
Design
In the foregoing discussion, the word
"design" has appeared prominently
several times. In considering the func
tion of the profession our concern is
not with the changing instrumen
talities, procedures, and methods of
health care and of professional func
tion. Rather, it is with the total and
enduring design according to which
they are selected, developed, applied,
and replaced. Our concern is with the
total rationale that guides the use of
the physician's skills and of the pro
fession' s resources. While in itself
relieving no pain and curing no
disease, design, rationale, or medical
philosophy is, consciously or not, a
ubiquitous and essential component
in the theory and practice of
medicine, a part of every diagnosis
and every treatment.
While medical system - an expres
sion which conveys my meaning bet
ter than any other - transcends the
individual aspects, agents, agencies,
and even the professions of health
care, it is the total framework that in-
ZJI
corporates and unites them all. It
determines the degree and the quality
of their integration into a functional
whole, the design behind that integra
tion, the purpose of its operation, its
effectiveness, and the direction of its
progress. System can, of course,
never be stronger than the technical
components available to it at a given
time, and yet in its continual un
folding it reshapes those components
and reveals the places, and the speci
fcations, for new ones. Though the
component knowledge and methods
may change, the system they serve
may remain the same system -in the
sense that a river remains the same
river, and a man the same man, while
their substance continually changes.
It connotes, whether or not they are
explicitly stated, the central strategies
of medical practice, the objectives,
the criteria for success, the perspec
tives, the basic premises, the values,
the frames of reference, the ways of
thinking about health and disease,
and the directions taken in the quests
for new knowledge and technic: the
very horizons whose unfolding is
sought. Medical system not only
guides the physician' s daily practice
but molds his professional way of
life; it determines the function of
physicians and of their professions; it
defnes their obligations to individ
uals and to all of society.
Thus system is both the conceptual
matrix around which the total ap
paratus of health care is organized,
and the ideologic environment in
which that apparatus functions.
System is subject to design, but not to
discovery. It is found, not in nature,
but in the minds of men, and i s
demonstrated in their works. Medical
system, therefore, is subject to
redesign, improvement, or replace
ment. The need for a change of
system may remain, whatever the
technical advances, whatever the new
discoveries and the new cures. In
deed, the need for better system may
even be intensified by scientifc,
technical, and social advance.
The adequacy of a particular sys
tem of medicine is measured not so
much by the existing health status as
by the effectiveness with which it uses
available knowledge and technic on
behalf of human health and by the
way it defines its own successes,
failures, uncompleted tasks, and un
solved problems. As a medical scien-
131
tist who is deeply concerned with the
present health needs of society that
can be met but are not, and who is ac
quainted with the osteopathic profes
sion and its history, I am convinced
that the central function of this pro
fession is to bring into being a system
of medicine which will make the most
effective use of the fruits of science
and which will give momentum to in
vestigation and development in need
ed directions. Let us examine the
possibilities.
Throughout its long recorded
history, medicine, like religion and
politics, has been subject to cleavage
into schools of thought and practice.
In retrospect, however, the schools
appear to have fallen into two main
camps. The "golden threads" of both
are traceable into antiquity. Indeed,
as Dubos2 1 10 says, "The myths of
Hygeia and Asclepius symbolize the
never-ending oscillation between two
different points of view in medicine. "
In one form or another they have al
ways existed simultaneously in all civ
ilizations. Both are discernible today,
though as in the past, .. . . . the cult
of Hygeia tends to be neglected and
. . . the skill of Ascelpius looms large
and bright in the mind of man. " 2, 1 1 2
Ascepius
The central theme of the system sym
bolized by Asclepius and dominant
today, has been the concern for the
afflictions to which man is heir and
susceptible. According to this system,
diseases (whatever may be said about
them) are viewed and treated as
"autonomous entiti es" whi ch
threaten man, attack him, annoy
him, temporarily or permanently
disable him, pain him, reduce his
capacities for pleasure and for work,
and shorten his life.
While, according to this concept,
individuals differ in their susceptibili
ty, resistance, and response to the
various diseases, each of the diseases
is nevertheless an entity with a
distinctive natural history, subject to
only minor modifications by the
"host . " Diseases are subject to iden
tification, description, and classifica
tion (nosology, nosography, and dif
ferential diagnosis) according to ( 1 )
their respective causes (etiology); (2)
the organs, functions, and processes
that are affected (pathology); (3) the
nature of the disturbance (physio
pathology); (4) their effects or mani-
festations (symptomatology, clinical
picture); and (5) the therapeutic
measures to which they respond. The
central strategy of this system of
medicine is to identify the disease and
distinguish it from others; to evaluate
its severity; to learn more and more
accurately and minutely the struc
tures and processes involved and their
deviation from the normal; to map
the course of the disease; to identify
its causes; and to find and apply
therapy which will remove, block, or
avoid the cause, which will halt,
retard, or reverse the process, or
which will remove, repair, or relieve
the "effects" of the disease - and
preferably all of them.
In short, according to this theme,
the function of the physician is to in
tervene between the patient and his
disease. He is defender, protector and
knight in shining armor, always seek
ing superior weapons for combating
disease and eagerly exchanging his
slings for arrows, his arrows for
magic bullets, and his bullets for
atomic weapons . According to this
system the key questions in the physi
cian's inquiries are: What has the pa
tient got? In what part of the body?
What caused it? And, finally, What's
good for it? For every disease there is
a cause or combination of causes,
often unknown, but always to be
sought, and for every disease, a cure,
already at hand or awaiting discovery.
According to this system true cure
is predicated on treatment of cause.
Unfortunately, "of the two thousand
afflictions known in human pathol
ogy, we know the etiology of less
than half, these being precisely those
that man has in common with higher
mammals. " Of the several hundred
new pharmaceuticals and biologicals
and the countless new instruments
and methods which are made
available each year, few have
anything to do with the causes of the
diseases towards which they are
directed. The proponents remain
confident, nevertheless, that, given
time and adequate research programs
centered around each disease or
disease category, the causes and cures
will be discovered and man's diseases
will be "picked off" one by one until
health has been won.
The emphasis is, of course, not so
exclusive as I have drawn it, nor does
it characterize any particular profes
sion, though it seems more intrinsic
Osteopathic principles
to medicine in the United States than
elsewhere. We all rej oice, for exam
ple, in the growing recognition that to
approach man's diseases rationally
or, to use the language of this system,
"in order to solve their etiologic
secret" - we must turn to man
himself: the whole man, the in
dividual man. Nevertheless, this
recognition is still a rhetorical
one, evident mainly jn exhortations,
expressions of hope, and avowals of
faith, more clearly expressed in
prefaces of textbooks than in prac
tice. Progress is sti l l sought,
measured, and acclaimed according
to how precisely and minutely man
can be dissected into his component
parts, processes, and molecular
species, how specifically his diseases
can be identified and related to those
components, and how specifically
they can be treated by physicians
especially qualified to deal with them.
This system, unfortunately, encom
passes no reconcilement between the
whole man and his components; it
must, therefore, continually aspire to
or pretend to travel two divergent
paths while, in fact, it strides along
the one it knows best. It holds aloft
the banner of the Whole Man, while
it proceeds, nosologically, diagnos
tically, and therapeutically, to take
him apart.
I have refrained from naming this
system because I have been more con
cerned with presenting an attitude, a
way of thinking, than with arriving at
defnitions. The system I have charac
terized (some will say "caricatured")
has appeared under a number of
labels, euphemisms, and epithets.
Among the more recent ones are allo
pathic, etiologic, specifistic, curative,
remedial, reconstructive, scientific,
and modern medicine.
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 of patho
logic molecular and biologic pro
cesses which intrude upon life. They
are life, life under unfavorable cir
cumstances: those of disparity be
tween the capacities, resources and
responses of the individual, on the
one hand, and the demands and the
circumstances of his life, on the
other. Disease and diseases, there
fore, are understandable, not as en
tities in themselves, but as aspects or
phases of the individual' s natural
history, in terms of hi nature in rela
tion to his total environment.
Since the individual's total history
and total constellation of capacities
and resources, demands and circum
stances -and therefore his responses
and adaptations - are unique for
him, disease is "biography. " Our ill
nesses, our levels of health, our pre
di sposi tions, our resi stance, re
sponses, and adaptations to all the
elements in our environments are,
therefore, as much a record and a
culmination of our individual biog
raphies as are our personalities.
"We are what we are today largely
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 individuals and the classifiabil
ity of diseases are testimony to the
fact that man can respond in only a
limited number of ways to an infinite
variety of provoking factors. His ill
nesses, l i ke hi s other responses,
reflect his nature, rather than the
qualities of all the factors that act
upon him. The illnesses of man can
find expression only through a
limited number of instruments; his
organs and tissues can behave only
according to 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
formula than are the illnesses of the
human being. For these reasons, the
"same diseases" in different in
dividuals may have very different
"causes," and different diseases in
different individuals may have very
similar "causes. " From this view
poi nt, therefore, the concept of
specific etiology i s untenable.
The patient' s true illness, then, is
not the disease, the particular aberra
tion of organ, cell, or process. His ill
ness is in his total being; it involves
and reflects all the factors that make
him a unique individual. The patient
with duodenal ulcer is not ill because
of his ulcer; he has the ulcer because
he is ill . It is a phase, an expression, a
complication of his illness as a human
being; it is the natural extension of
biologic process under the circum-
stances of his life. The question of the
diseased organs and processes is sec
ondary to the nature and origins of
the patient' s illness. While minute
study of his ulcer, and of "peptic
ulcer" as a phenomenon in itself,
with its own natural history, has
revealed a great deal about peptic
ulcer and what to do about it, such
study can reveal nothing about the ill
ness of the man or what to do about
him. It is upon him that this system of
medicine aims its available arsenal of
methods. From this viewpoint it is as
ridiculous to say that peptic ulcer is a
gastroenterologic disease caused by
hyperacidity and hypermotility of the
stomach as to say that a woman' s
tears are an ophthalmologic affliction
caused by hypersecretion of the lacri
mal glands.
Normality and health, and ab
normality and disease, therefore, are
not separate phenomena. Normal
processes and disease processes are
not different kinds of processes; they
are the same processes, structures,
and phenomena operating under dif
ferent circumstances. There is but one
continuous spectrum, of infinite
numbers of hues, one blending with
the other, 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
completely understandable only in
the context of the whole. To be con
cerned exclusively with either end of
the spectrum is to be scientifically or
medically color blind and to restrict
one's understanding even of that end.
It is the concern of this system of
medicine to understand the factors
that deflect life processes toward the
wrong end of the spectrum. It main
tains that studying only the arrival at
that end cannot yield that under
standing.
From this perspective, therefore, it
is not merely the function of the phy
sician to intervene between the pa
tient and his disease, but, in Gregg's6
words, to keep or "to put the patient
in command of the situation. " This
requires the development and libera
tion of his resources and the achieve
ment of his best possible way of life.
This means, first, the identification
of those factors in the human organ
ism, in human life, and in the human
environment which influence his
resources and capacities, and then the
adjustment of those which are critical
ZJJ
and which are subject to control. The
system, therefore, is predicated on
the recognition that it is the patient
who must get well and stay well -
that cure comes from within; it is
based upon the fullest liberation and
development of the "healing forces
of qature. '
,
This systtm by no means scorns
palliative treatment, as is commonly
supposed. It recognizes that pallia
tion - the treatment of diseases,
their manifestations, symptoms, and
processes - is an essential part of
total therapy. But i t insists that pallia
tion is not enough, and that the treat
ment of diseases is only palliation. It
insists, also, that the palliation not be
such, regardless of its immediate ef
fects, as to j eopardize the patients'
own resources and capacities or to
impair and retard their recovery and
their future maintenance and devel
opment.
According to this system, then,
progress lies in the direction of con
tinually increasing knowledge and
understanding of man and his nature,
and of men and their differences; of
the impacts and demands of human
life in general and of human lives in
particular on biologic structure and
function, and of how they, in turn,
meet those demands and influence the
capacity for human life. This, from
the perspective of this system, is the
road to human health. While the pro
motion of health - "raising the
levels of wellness'" - will inevitably
bring increased freedom from dis
ease, the conquest of diseases is not in
itself health.
Like the system symbolized by
Asclepius, this one, too, has had
many labels, among them: ecologic,
holistic, physiologic, constructive,
social, and, in its broadest sense,
psychosomatic medicine.
The role ofthe osteopathic profession
Under the etiologic-remedial system
of medicine, research has, since the
epoch-making investigations of Pas
teur and Koch, produced theoretic
and clinical achievements so immense
that they constitute the bulk of
modern medicine. The "skill of
Asclepius looms" 2 larger and brighter
in the mind of man than ever before.
It seems natural to assume that, pro
jected into the future, this is the royal
road to health and that the vast
disease burden that confronts man to-
134
day will inevitably yield to "crash
programs" employing the same ap
proach. It would seem to be only a
matter of overcoming technical dif
ficulties and discovering the necessary
causes and cures.
However, as I shall show, convic
tion is mounting throughout the
medical world that the prevailing
system does not meet, nor by its very
nature can it meet, the health needs
and the disease problems that
predominate today. A trend, still
slow and unorganized, is increasingly
evident in the direction of ecologic,
physiologic medicine. The trend to
this system of medicine from the
prevailing one, or the achievement of
a proper integration between them, is
the great improvement in medicine
which is now in the process of social,
clinical, and scientific evolution.
What has this to do with your pro
fession? You already know the
answer. This is but the modern ver
sion of the very transition, the very
"i mprovement i n our present
system, " for which your profession
was established. The osteopathic pro
fession came into existence in 1 892 as
a small but vanguard force in this ,
transition and as the only organized
voice for the ecologic-physiologic
system of medicine. It was not the
first voice, nor is it now the only voice
- there are many in medicine, sci
ence, government , and education -
but it was and still is the only orga
nized voice. Furthermore, unlike its
scattered predecessors, it came into ex
istence not only with principles,
philosophy, and "expectant" con
fidence in natural healing forces, but
it brought with it a new awareness,
new strategy, and new skills. It refor
mulated, in the knowledge and the
language of the time, the whole-man
approach, and its central strategy of
support and liberation of the inherent
processes of homeostasis, adaptation,
resistance, and recovery. But it also
identified, if not for the first time,
certainly more frmly than ever
before, certain critically important
factors and some of the most com
mon impediments to these processes
that arise in human life. Even more
important, it developed remarkably
effective clinical methods for detect
ing, evaluating, and infuencing
them.
These factors and impediments
have their origins in the adaptations
and maladaptations to the unique and
unceasing demands that gravity
makes upon the human being. They
are related to the anatomic rear
rangements associated with verticality
and to man's incomplete structural
and functional adaptations to the
erect stance. The demands of gravity
present man with peculiarly difficult
biologic "problems" which are only
now beginning to receive systematic
investigation. t Primarily biomechan
ical in origin, they are problems in
circulation, in distribution of fluids,
in drainage of organs, tissues, and
cavities, in the mechanical aspects of
visceral function, in gestation and
parturition, in the secondary effects
on cellular function and metabolism
and, most particularly, in the massive
motor system of the body through
which we act on our environment and
express our very lives.
Improperly or i nadequatel y
"solved, " these problems become
important and even decisive impedi
ments to these various functions.
While they appear to have only local
and minor significance to one who
searches only for disease, they impair
and impede not only the functions of
the immediately affected organs, but,
through the communication systems
of the body, the functions of others.
They exaggerate and unfavorably
modify the impact of other variables
in human life: environmental, emo
.tional, social, nutritional, traumatic, .
hereditary, congenital, and micro
bial. Their presence thus inevitably
i mpai r s t o s ome ext ent t he
individual' s capacity for adapting to
the circumstances of his life, for
resisting threats to his health, and for
recovery from disease. The impair
ment becomes more critical, the more
unfavorable the other circumstances
in the individual 's life and in himself.
The mitigation of these impediments,
therefore, liberates the forces of
resistance, recovery, and adaptation
and to a significant degree insulates
the individual against unfavorable
factors, rendering them less impor
tant.
These factors are unique in their
high incidence in man, in the scope
and nature of their influences, and in
their amenability to control - by
tWitness the recent establishment, in New York City,
of the Institute to Study Gravitational Strain, under
the direction of Martin Jungmann, M.D.
Osteopathic principles
l
methods devised and developed by
the osteopathic profession. The
superficial tissues and the motor
system of the body, our means of ex
change with, and of action on, the ex
ternal environment, can reveal much
about the adequacy of our individual
adaptations to gravitational demand,
and, to the discerning observer, are
also mirrors of the internal environ
ment. Systematically evaluated by
methods devised and adapted by the
osteopathic profession, they reveal
information about the person as a
whole which as yet is not obtainable
through any other means. The frame
work and integument of the body,
therefore, both reflect and influence
the health of the individual. There
can be no doubt - for those who
have developed the necessary skills,
for those who have benefited from
those skills, and for those who have
some understanding of the biologic
factors and mechanisms which are in
volved - that osteopathic manipula
tive therapy and its associated diag
nostic methods provide values in
health service for which there are as
yet no substitutes.
Important as this contribution was,
however, and much as your profes
sion, in its early history, concentrated
on the development and application
of the new diagnostic and therapeutic
s ki l l s centered ar ound body
mechanics, it was never an exclusive
emphasis for the profession, though
it was for many individual members.
The profession early recognized that
the care of the whole man required
the appropriate integration of all
methods and measures which would
contribute to his well-being, and ex
plicitly stated so in the charter of its
first college.
The profession sought, from the
beginning, to introduce a more com
prehensive, more rational, and more
effective design into the whole of
medicine, one which would guide the
selection, use, and development of
the physician' s entire armamen
tarium. It recognized that the system
could be no better than the total
methodology that served it. However,
the profession insisted, and with good
reason, that no system of medicine
could be comprehensive which did
not give adequate consideration and
iherapeutic attention to biomechan
ical factors. But it never insisted that
these be the sole considerations. It
welcomed consideration of all other
factors and welcomed and used (when
privileged to do so) all other methods
that could help give expression to the
total design. This included any and all
methods in "surgery, obstetrics, and
the treatment of diseases generally"
which would contribute to well-being,
which would promote the patient' s
own resources and help him take
command of his situation, and which
would not treat one illness while
opening doors to others.
This total design, this improvement
in "our present system of medicine,"
together with a most important con
tribution to its implementation, is
what the osteopathic profession, 67
years ago, sought to introduce into
medicine and for which it established
itself. It is undeniable that, small in
magnitude though it was, it was a
magnificent beginning. t It brought
new hope, a new scope, a new prac
tical meaning to the holistic, man
centered system of medicine un
equaled i n i ts entire 2, 300-year
history. This, in my opinion, is the
great mission to which this profession
must once again address itself. This
is the vast horizon which awaits your
unfolding.
Does it satisfy the criteria?
Does it meet the criteria for the cor
rect decision? Time does not permit
the testing of all the criteria posed in
tThe beginning was especially magnificent in view of
the circumstances, The founders of the osteopathic
movement could not have selected a more difficult
time, a time when the medical stream was running
most strongly in the opposite direction. This was
the period of most precipitous ascendancy of the
etiologic-curative-specifistic school due to the epoch
making discoveries of Pasteur, Koch, von Behring and,
later, Ehrlich and many others. Within a very short
period of history, these discoveries brought confident
expectation that, at last, medicine was ready to
identify, one by one, the specific causes of man's
diseases, identify and describe the specific cellular
pathologies associated with them, and to find, con
coct, or provoke the specific chemical or biologic
cures which would checkmate the causes and undo
their effects.
In the period that followed - a period that has
coincided with the entire life of the osteopathic
profession - greater progress was made in medicine
than in all of its previous history, The results have
been magnificent, dramatic, easy to see, simple to
understand. There could hardly have been a less
propitious time in which to seek to convince the
world of the need for another approach, It is
testimony to the great strength of the early osteopathic
movement, to the courage, the determination, and the
skills of the profession, that not only was it not swept
away in this great, swelling stream, but that it was able
to hold on and even, miraculously, to grow.
an earlier section. I shall, therefore,
test only the most decisive criteria -
those which, if met, will guarantee
the meeting of the others.
Does it fill a social need, one of
such importance as to demand the
continued existence of the osteo
pathetic profession and to justiy
society's most generous support?
Is there a real need for a change in
the system? This, it seems to me, is
the most decisive criterion of all and
it therefore merits the most rigorous
testing. Fortunately, much of this
testing has already been done, and
with conclusive results.
As mentioned earlier, more and
more medical leaders and scholars
have concluded that, brilliant and
numerous as have been the successes
of specifistic medicine, it has failed
abysmally to meet existing health
needs. Nor will the failure be turned
to triumph by the overcoming of
technical difficulties and by the
discovery of missing causes and
cures. It will continue to fail because
of its basic inadequacies, whatever
the technical advances. Because of
the nature and scope of the unmet
health needs, this failure can only
conti nue to have i ncreasi ngly
wasteful and tragic consequences to
our society. In seeking answers, at the
basic level, to these overwhelming
problems, these medical leaders have
eloquently demonstrated that satis
factory progress in the solution of
these problems awaits the application
of principles concerned more with the
factors that determi ne man' s
vulnerability than with the cures for
all the diseases to which he is, or
becomes, vulnerable. The basic
soundness of such a physiologic sys
tem now glows more steadily than
ever through the dazzle of specifistic
medicine and reveals more sharply
than ever the intrinsic inadequacies of
practice based largely on doctrines of
specific etiology and cure.
The writings of Sigerist, 9 Gregg,
6
Dubos , 2, l o Stieglitz,S Galdston, I I , 1 2
Sel ye, I J Wolff, 1 4 Jensen , I ' and
Dunn, 7 to name a few, are especially
deserving of your careful study. As a
matter of fact, if this profession is to
give serious attention to its horizons,
the study of these works must in
evitably be a part of that attention. A
summary of these contributions is far
beyond the scope of this paper, and
time permits selected documentation
ZJ5
from only one or two of these
writings. I a convinced that were
this profession to give careful study
to only one, the most recent one, of
these volumes. The Mirage ofHealh,
by Rene Dubos, 2 it would fnd its own
sense of direction renewed and its
confidence in the rightness of its
founding purpose reawakened. It is a
wise, exciting, and beautifully written
book, by one of the world's most
distinguished microbiologists.
A sobering conclusion emerges
from the study of these works that is
well substantiated by the recent Na
tional Health Survey and other
authoritative reports on the state of
the nation's health. Not only is the
state of American health not supe
rior, as we boast, but, properly
measured, it is poor and getting
worse. If one examines, not the
figures for reduced death rates and
for increased life expectancy at birth
(which are usually misinterpreted as
improvements in health and i n lon
gevity 16 ), but the amount and kinds
of illness, it is staggering in magnitude
and steadily increasing. At the pres
ent time 10 per cent of the average
American' s income goes for medical
care, and hospitals cannot be built
fast enough to accommodate the sick.
Forty-one per cent of the population
have one or more chronic disease con
ditions and 17 million persons, about
one-tenth of the population, are par
tially or completely disabled by dis
ease alone. One out of every four citi
zens will have to spend some months
or years in an institution for men
tal disease. One wonders, with
Dubos, " . . . whether the pretense of
superior health is not itself rapidly
becoming a mental aberration. Is it
not a delusion to proclaim the present
state of health as the best in the
history of the world, at a time when
increasing numbers of persons in our
society depend on drugs and on doc
tors for meeting the ordinary prob
lems of everyday life?"
/
P- ~
We seem
to have forgotten the humiliating
shock this country felt not long ago
when the Selective Service program
revealed the immense amount of
disease and disability in "the cream
of our country. " And no statistics
can reveal the low level of vigor which
most of us have come to regard as
normal. It is grimly amusing that
even the word "euphoric." which
used to mean a state of well-being,
has gradually come to designate an
abnormal state!
But surely the "conquest" of the
communicable diseases, proclaimed
as an achievement of scientific
medicine, testifies to the effectiveness
of its methods? It is no problem to
demonstrate that, contrary to the
prevailing impression, not only have
the infectious diseases not been con
quered, but they continue to be a
tremendous burden. As Dubos
shows, the misleading impression is
created by the use of an inadequate
yardstick - mortality - for evalu
ating the importance of a medical
problem and the progress in the solu
tion. Now that the widespread
epidemics and plagues of the past,
with their wholesale mortality, have
been brought under control, the con
tinued use of this index is deceptive
and dangerously comforting. If, in
stead of merely counting the number
of lives ended by disease, one
measures the total amount of "life
spoiled by disease," or the economic
cost in drugs, hospitals, and doctor's
bills and in reduced productivity, the
burden of infectious disease is re
vealed as still tremendous . "Microbial
diseases have not been conquered.
Rather, physicians and scientists have
resigned themselves to the belief that
a relative protection against them can
be bought at the cost of a huge ran
som.
/, . 1J3
By no means i s the great reduction
in mortality to be dismissed as unim
portant. But accuracy and perspective
demand recognition that the great
decrease in epidemic mortality of the
past few decades is much less a prod
uct of scientific medicine than of
humanitarian movements and social
progress leading to improvements in
social patterns, in physical environ
ment, in sanitation, in living stan
dards, and in nutrition. It is a product
also of natural processes of adapta
tion between man and microbe and
even of such factors as the introduc
tion of inexpensive, easy-to-Iaunder
cotton undergarments, shorter work
ing hours, and other incidental and
accidental circumstances.

'
l
These
factors have "contributed more to
the control of infection than did all
drugs and medical practices. "
2. P
:
//
"The toll of human lives exacted by
i nfection had begun t o decrease
several decades before control
measures inspired by the germ theory
were put into effect and almost a cen
tury before the introduction of an
ti mi crobi al drugs . "
~:
6
3
The
"monster of infection" had become a
mere shadow of itself before medicine
could provide rational and scientific
methods for its control. The effect of
the antibacterial drugs has been but a
"ripple" on the long-established
decline in mortality, a decline largely
attributable to widespread improve
ment in human factors.
This is not to deny, of course, the
great effectiveness of drugs and
medical practices in interrupting and
preventing many infectious processes,
even many which would be fatal, but
it is to put them in proper - and
urgently needed - perspective.
Moreover, this is not merely a matter
of historical perspective, for it has
critical bearing on our present prob
lem.
Etiologic-curative medicine, so
preoccupied with disease and death
and with their, microbial "causes, "
finds little of interest in the human
factors which permit them to become
causes. Overlooked is the simple but
vital everyday observation that while,
certainly by defnition, microbes are
essential elements in the production
of infectious diseases, the fact re
mains that infection usually occurs,
and even exists for whole lifetimes,
without production of disease.
Disease i s the exception. It is the con
sequence, not of infection, but of a '
breakdown of the mechanisms of ad
aptation and resistance . . . In man the
provocative cause of microbial dis
ease may be a disturbance in any of
the factors of his external or internal
environment. . . ."
/
'
P
:
7
9
As Pasteur
himself said, unrestricted multiplica
tion of germs is no less a consequence
of illness than its cause. For this
reason, "drugs cannot be effective in
the long run until steps have been
taken to correct the physiological and
social conditions originally responsi
ble for the disease . . . . "
2
.

J7
Thus, constructive a force as the
doctrine of specific etiology has been
in medical research, it cannot provide
a satisfactory account of the causa
tion of even the microbial diseases, in
which specific etiologic factors are
known. A system of medicine which
bases itself on such a doctrine, which
directs its skills so much against infec
tious agents and so little for the man;
which relies so much on bullets and
Osteopathic principles
shotguns aimed at the infinite variety
of infectious agents, while neglecting
to identify and influence the factors
which determine man' s vulnerability
and resistance to all of them; a system
which disregards and upsets the
natural processes of mutual adapta
tion between man and microbe -
such a system can only continue to
fail to meet even the problems of in
fectious disease, which it proclaims as
its area of greatest success. Even
worse, it creates new problems, some
times worse in the long run than those
that are "sol ved. " The current
"staph problem" which is plaguing
American hospitals is but one exam
ple.
Great as has been this general fail
ure with respect to the infectious
diseases, how much greater is the
failure - etiologically, therapeutical
ly, and preventively -with respect to
those diseases which cannot even
remotely be ascribed to invading
agents and which today are even a far
greater burden than the infectious
diseases. They, the chronic killers and
cripplers - the heart and cardiovas
cular diseases, the metabolic diseases,
the collagen diseases, cancer, peptic
ulcer, and many other long-term
diseases - are, even more than the
infectious diseases, the products of
whole constellations of human fac
tors. These now present a burden of
incalculably immense proportions,
already overwhelming even the
palliative resources of medicine and
growing at an increasingly rapid
rate.417 A system which continues in a
hopeless quest for the causes of each
and the cures for each, while neglect
ing the human factors from which
they do arise, can only be regarded,
basically, as a fai l ure, however
brilliant, effective, and welcome the
expedient measures with which it tem
porizes.
Unlike the i nfectious diseases,
which man shares with other animals,
the degenerative diseases are almost
peculiar to man. It is a challenge to
the experimenter to produce even
thei r most palli d facsi mi l es i n
ani mal s. The natural , bui l t-i n
defenses, w
h
ich man shares with
other animals, ag
a
inst the microbial
pathogens - fever, inflammation,
immune reactions, phagocytosis, and
so forth - are the adaptive products
of evolut i on. The degenerati ve
diseases are quite another problem.
As t he expression of pecul i arl y
human frailties, "natural" and self
inflicted, they, and not the defenses,
are the products of human evolution.
Indeed, there can be few if any adap
tive biologic defenses against the
rapidly changing stresses peculiar to
human l i fe, many of them man
created, and certainly not against
man's own inadequate or misdirected
responses to those stresses. In most
circumstances the biologic responses
and "adaptations" are worse than
the provoking factors and are in
themselves disease. Not only are they
not self-limiting, but they become
sustaining and exacerbating factors,
initiating and propelling vicious cir
cular processes which continually ex
act larger and larger tolls of the in
dividual as he ages, and as the dis
parity widens between his biologic
resources and the demands upon
them. In effect, the patient writes
larger and larger checks on a shrink
ing account.
For the most part, the chronic
degenerative diseases are not the "ef
fects" of specifc "causes" which can
be identifed, exorcised, combated,
and abolished with magic bullets.
They are the products of whole lives.
Their origins and their basic manage
ment (in contradistinction to their
palliation) are to be found in the
unique nature of man, of his life and
of his environment, in the differences
among men that cause them to em
bark on separate and divergent physi
ologic paths, in the fact that man is
required to live a human life with
biologic apparatus which he inherited
from lower animals. Hopes lies in the
creation of those circumstances which
will permit each individual to stay on
hi s most favorable physiologic paths
and defect him from unfavorable
paths. To speak of causes, cures, and
reversal is to reveal ignorance of the
basic character of chronic degenera
tive disease.
A study recently completed at Cor
nell University Medical College by
Hinkle and W 0lffl 8 magnificently
epitomizes the primacy of human fac
tors in all disease. The illness pat
terns, during 20-year periods in
young adulthood, of approximately
3, 50 people drawn from the ambula
tory populati on, revealed t hat
episodes of illness were most uneven
ly distributed. One fourth of the in
dividuals experienced a majority of
all the episodes of illness that had oc
curred among all of the people, while
another fourth had only 5 to 1 0 per
cent of the illnesses.
Even more startling than the wide
differences in susceptibility was the
comprehensiveness, the non-selectiv
ity, of the susceptibility. The authors
state:
These differences in susceptibility to illness
were not simply the result of differences in
susceptibility to one or another specific syn
drome. In every group the members displayed a
difference in their susceptibility to illnes in
general, regardless 0/its type, or 0/the causal
agents involved. Thus, as the number of
episodes of illness experienced by an individual
increased, the number of different types of
disease syndromes that he exhibited increased
also. Although a great many of these syn
dromes might involve one or two organ sys
tems, episodes of illness were not limited to a
few systems; instead, as the number of episodes
of illness experienced by an individual in
creased, the number of his organ systems
involved in disease increased also. Likewise, as
the number of episodes he experienced in
creased, he exhibited illness of an increasing
variety of etiologies. He was likely to have
more 'major' , irreversible and life-endangering
illnesses, as well as more 'minor', reversible
and transient illnesses. [Italics supplied.]
In the opinion of the authors, these
findings are most reasonably ex
plained by assuming that they are
dependent upon "factors operating
within the individual, " influencing
his responses to the "great variety of
other factors known to be capable of
causing disease. " Consistently high
illness rates in susceptible individuals
refect continuing inability of th
e
in
dividual to make adequate adapta
tions to his total milieu.
One of the most significant results
of the study was the remarkable con
stancy of individual illness patterns.
for it indicates "that the illnes pat
terns of these people were relatively
little infuenced by the therapeutic ef
forts of the physicians who treated
them. (Italics supplied.) It may be
assumed that these "therapeutic ef
forts" were reasonably representative
of specifistic-etiologic medicine and
included a representative sampling of
the several hundred new pharmaceu
tical products and miracle drugs pro
duced each year, I 9 selected for their
effectiveness in each illness. Perhaps
nothing more clearly dramatizes the
basic inadequacy of a system of
medicine which, in the name of
sc
i
ence. concentrates so hard on in
dividual diseases, their "causes" and
their "cures, " while, in its contempt
for what it regards as armchair
IJT
philosophy, it so tragically disregards
the man and the factors in him which
determine his vulnerability to illness
in general. As Hinkle and W olffl 8
conclude:
Ultimately medicine will have to take account
of this in treatment of illness. It is very prob
able that an increasing proportion of the
therapeutic effort will have to be directed at the
patient's relation to his environment i we wih
to make any signicant improvement in hi
health . . . . The problem stands before us as a
stern challenge to medicine, and not as an easy
opportunity. [Italics supplied.]
Obviously, it is becoming more
widely recognized that disease, and
most particularly the rapidly rising
tide of degenerative disease, can be
stemmed only through identification
and control -especially prophylactic
identification and control - of the
variables in the human organism and
in his life situations which determine
the physiologic path he travels.28
This recognition, however, has had
little impact on medical practice. The
basic strategy remains essentially un
changed, though a transformation in
medical knowledge and technic has
taken place. Society' s urgent need for
the holistic-ecologic-physiologic ap
proach is now far greater than ever.
That approach now offers the only
hope. But, unfortunately, this move
ment still awaits organized, dedicated
leadership and implementation. This
is the movement, the great improve
ment in the design of health care, that
this profession, as its only organized
voice set out to lead 67 years ago. 1 6
Seldom i n history has an organized
group of men and women perceived,
grasped, and then seemingly relin
quished, a greater opportunity.
Presented, by its history and now by
society, with an immense opportuni
ty, your professi on still debates
whether it has a function of its own
and a reason for existence, and
wonders where the resources would
come from if it had.
Fortunately, there is still time - a
little time - for a second chance.
Were this profession to proclaim to
the world, again and again, factually,
clearly, courageously, that this is the
movement it seeks to propel, and
why; and were it to demonstrate that,
given the means, it is qualified to do
so, it woule be given the means.
There is no doubt that the frst
criterion, "Is there need for a change
of system?" is amply satisfied.
Is thi function appropriate to, and
238
within the power of the osteopathic
profession?
Not only was thi s movement
toward holistic medicine your found
ing purpose; it is a rich part of your
total experience as a profession. It is
more deeply a part of your insights
than of any other profession, more
than you apparently recognize and
certainly more than now finds expres
sion in your function as a profession.
Your profession is still the greatest
reservoir of physicians oriented in its
principles and skilled in their applica
tion. You are now stronger, better
organized, better armed, more ac
cepted than ever before. Though you
are now preoccupied with numbers,
some of your greatest assets are those
provided by your small size: mobility,
maneuverability, flexibility. You
have the independence that imparts
power to every minority movement.
You lack only the commitment, the
conviction, the objectives to put that
power into motion and to give it
direction.
Does it offer comprehensive design
for your total effort and for the
mobilization and utilization ofyour
resources?
The answer to this question also is
a resounding affirmative, as you
would discover. Long absorbed in
catching up and keeping up with all
the advances in modern medicine and
with meeting standards in all the in
strumentalities and technics of
medicine, you would now be able to
give leadership and to set new stan
dards in the integration of those in
strumentalities and of the available
knowledge on behalf of human
health. It would become possible for
every segment of the profession,
every specialty, every physician, and
every organization to define their
own best roles and for the profession
as a whole to achieve balance among
all of its many, often conflicting,
areas of endeavor. It would offer
design for new and needed forms of
professional organization and of
clinical practice.
Similarly, the profession has long
operated on the apparent premise
that osteopathic education consists of
a more or less conventional medical
curriculum to which simply another
element has been added, like the
cherry on an ice cream sundae. The
profession would recognize that an
improved system of medicine de-
mands an improved system for the
education of physicians. A truly
osteopathic curriculum still awaits
development. The profession and its
educators would discover that the
horizon that is proposed for your un
folding provides the basis for total
design of the curriculum, of its com
ponents, and of its faculties. De
manding, as the system does, new
forms of medical practice, it would
also prescribe the new forms and in
strumentalities of medical education.
Does it define your tasks and your
obligations?
Let me identify but two, which are
of such vast significance that they
alone would demand the existence of
your profession.
The first is the continued develop
ment of one of your most important
and certainly your most conspicuous
ly distinctive contribution to medi
cine. Were you fully to commit your
self to the function which has been
proposed, you would discover that
osteopathic manipulative therapy,
with its ancillary diagnostic methods,
is not merely another form of therapy
in your total arsenal. It is not one
which may be arbitrarily withheld
from the patient just because its
mechanisms are not understood, be
cause the physician has not taken the
trouble to develop the necessary
skills, because he fnds it incon
venient, or because it is politically
inexpedient. You would discover that
you have no greater moral right to
withhold manipulative therapy than
any other therapy.
But it is not just another form of
therapy; it is a whole strategy, a
whole approach in itself. It is not
merely a treatment of "lesions"; in
effect, it is the putting of influences
into the whole man through the acces
sible tissues of the body, influences
which deflect his life processes to
more favorable paths, and which help
put the man in better command of his
situation, whatever it is, whatever
it may become, whatever his illness,
whatever its etiology. To speak and to
think of manipUlative therapy as
though it were a discrete, uniform
entity independent of the unique
understanding and skills of the in
dividual physician, one which can be
designed for a mythical "average
man," as something which can, in
wholesale manner, be declared "indi
cated" or "contraindicated" for this
Osteopathic principles
or that "condition, " or to regard it as
an aspect of physical medicine, is to
miss the strategic significance of
osteopathic manipulative therapy and
to limit its great potential.
As a physiologist who has studied
deeply in this area I am firmly con
vinced that this is an area of medicine
of such vastness, of such depth, of
such endless ramifications and inter
connections, and of such import to
human health that it is as demanding,
as exacting, as honorable a life work
as any other. Its potential has hardly
been explored. Commitment to the
proposed horizon will help you recog
nize your obligation to give manipu
lative therapy and its cognate arts and
sciences their appropriate status and
full expression in your educational
system and, through that, in practice.
Above all, it will guide you in the
recognition and the fulfillment of
your obligations in the development
of this contribution.
I mconvinced that commitment
to the total design of which I have
spoken will in itself give great impetus
to that development, not only within
your profession and its institutions
but throughout the world. For ex
ample, there can be no doubt that the
unfavorable influences of musculo
skeletal stress and the favorable
influences of osteopathic manipula
tive therapy are mediated to a large
extent by the peripheral and seg
mental nervous system.
2
0,
2
1
In the past
quarter-century there has been an
immense increase in laboratory and
clinical investigation in every civilized
country demonstrating (l ) the deci
sive influence of the innervation of
tissues, not only on their moment-to
moment activities, but on their total
condition and on their responses to
all other factors; (2) the subversive
"organizer" role of the spinal cord,
brain stem, and peripheral nerves in
virtually every disease process; and
(3) the common origins of the unfa
vorable influences in the musculo
skeletal and other somatic tissues of
the body. The literature is now so
vast, extending into every function,
every organ, every disease, every area
of health and disease, as to constitute
a massive new movement in medicine.
This is a movement to which the
osteopathic profession should long
ago have given leadership. Not only
has it not given that leadership, but it
seems not even aware that the move-
ment is under way. Unfortunately,
because there has been no conceptual
framework to unite them, t hese
countl ess contri buti ons remai n
scattered fragments which fnd no
place in prevailing frameworks. The
erecting of the needed framework by
this profession would have tremen
dous impact on this and many other
areas of investigation and would give
needed direction to its own investiga
tions. 2 2
The second obligation with which I
would illustrate may be designated as
medical statesmanship. The function
of physicians, and particularly of
their professions, is far more than the
practice and advancement of their
art. They must be deeply concerned
with all factors in society which
have a significant bearing on human
health. They must seek, with the
cooperation of all social agencies,
the best possible environments for
human life. Among the factors that
deeply affect the public health and
the effectiveness of medical service
are the forms and structure of medi
cal service itself and the social,
economic, and political framework in
which medicine is practiced.
There is much that is good, of
course, in the present framework of
medical practice. But there is also
much that is inimical to the health
needs of society; much that prevents
the best use of clinical talent; much
that needlessly and severely limits its
availability and exaggerates its cost;
much that prevents the most effective
utilization of available knowledge
and technic; much that degralies the
physician and the profession of medi
cine; much that is evil. And much,
therefore, that the public finds in
creasingly intolerable. It is not a
coincidence that these same features
are completely inimical to the great
contributions the osteopathic pro
fession set out to make. Indeed, they
are incompatible with - and indefi
nitely postpone - the practice of any
system of comprehensive, construc
tive, prophylactic, ecologic medicine.
Such a system of medicine not only
demands a change in the structure of
medical service, but provides the
design.
The strong voice of this profession
has yet to be heard on these issues.
It has been remarkably willing to
acquiesce to the present framework
and to demonstrate its ability to
adapt to it. Its silence on these
issues contrasts sharply with the vigor
with which this same profession bat
tles for rights and privileges for itself.
To give support, even by silence, to
those parts of the framework and
those forms and aspects of medical
practice which, for society's sake,
need changing is to lend your strength
to the prevention of the unfolding of
your own brightest horizons.
Now is the time for medical criti
cism2l and medical statesmanship of
the highest order. Now is the time to
utilize your organized strength fear
lessly, creatively, imaginatively, and
unselfishly in the promotion of the
needed changes. This is not only your
obligation as a profession. It is the
only way, along with development
and dissemination of your own clini
cal, scientific, and humanistic con
tributions, to win the strength and
the support from society that you so
desperately need.
Conclusions
You have before you, then, a mo
mentous decision: the function you
propose to perform for society. I do
not know whether you will make a
decision or what decision you would
make. I do know that to make the
wrong decision or to delay much
longer (which is the same thing) is to
miss your second and last chance, to
abdicate the right to existence as a
profession and to make of your illus
trious history a shameful fiasco. Far,
far worse, it would delay for many
decades a great forward step in hu
man health and therefore contribute
to untold waste of human life in
needless suffering. In effect, the
decision is between becoming, as you
set out to be, the head of a new move
ment in medicine or the withering
appendage of a declining one. Ac
cording to its decision, the os
teopathic profession either will
always loom bright in the mind of
man or be recorded as a passing
footnote in the history of medicine.
What horizon, then, do you pro
pose to unfold? What contribution to
society do you wish to make? That is
the decision before the osteopathic
profession. It will either merit so
ciety' s nurturing or it will not. Society
will be the judge of that. Society' s
judgment awaits your decision.
IJ
References
I. Thompson, M. ; Continuing growth of pro
fession keyed to continuing college growth. J.
Osteopathy 6: 15-20, April, 1959.
2. Dubos, R.; Mirage of health; utopias, progress,
and biological change. Harper &Brothers, New York,
1959.
3. Marti-Ibafez, F. ; Disease as biography. M. D.
2: 1 1 , Oct. 1958.
4. Scheele, L. A.; Medcal research - unfinished
business. J. Am. Osteop. A. 58:653-655, June 1959.
5. Stieglitz, E. J.; Future for preventive medicine.
Harvard University Press, Cambridge, 1945.
6. Gregg, A.; Challenges to contemporary medi
cine. Columbia University Press, New York, 1956.
7. Dunn, J. H.; Points of attack for raising level of
wellness. J. Nat . " M.A. 49:225-235, July 1957;
reprinted Forum of Osteopathy. 32:32-38, March
1958.
8. Galdston, I.; Psychosomatic medicine; past,
present, and future. A.M.A. Arch. Neurol. &
Psychiat. 74:41-450, Oct. 1955.
9. Sigerist, H. E. ; Civilization and disease. Cornell
University Press, Ithaca, 1943.
10. Dubos, R.; Biochemical determinants of
microbial diseases. Harvard University Press,
Cambridge, 1954.
I I . Galdston, I . ; Meaning of social medicine.
Harvard University Press, Cambridge, 1954.
12. Galdston, I.; Homines ad deos: or Clinical bull
in ecological china shop. Bull. Hist. Med. 28:51 5-524,
Nov.-Dec. 1954.
1 3. Selye, H. ; Stress and disease. Science
122:625-631 , Oct. 7, 1955.
14. Wolff, H. G.; Stress and disease. Charles C.
Thomas, Springfield, Ill., 1953.
IS. Jensen, J.; Modern concepts in medicine. C. V.
Mosby Co., St. Louis, 1953.
16. Ogilvie, C. D., et al. : Symposium: Degenerative
disease: engima? challenge. opportunity! J. Am.
Osteop. A. 58: 151-157, Nov. 1958.
17. Commission on Chronic Illness: Prevention of
chronic illness. Chronic illness in United States, vol. I .
Harvard University Press, Cambridge, 1957.
18. Hinkle, L. E., Jr., and Wolff, H. G.; Ecologic
investigations of relationship between illness, life
experiences and social environment. Ann. Int. Med.
49: 1 373-1388, Dec. 1958.
19. Kramer, L. M.; Drugs and medicines. Pub.
Health Rep. 73: 929-939, Oct. 1958; reprinted J. Am.
Osteop. A. 58: 155-A-I6, Feb. 1959.
20. Korr, I. M., Thomas, P. E., and Wright, H. M. ;
Symposium on functional implications of segmental
facilitation; research report. J. Am. Osteop. A.
54:265-282, Jan. 1955.
21. Korr, I. M.; Monograph in preparation.
22. Korr, I. M. ; Osteopathic research: why, what,
whither? examination of its content, direction, and
relation to function of osteopathic medicine. J. Am.
Osteop. A. 56:275-285, Jan. 1957.
23. Bean, W. B.; Critique of criticism in medicine
and biological sciences in 1958. Perspectives in BioI. &
Med. 1 : 224-232, Winter, 1958.
Reprinted by permission from JAOA 59: 77-9, 1959.
An allegory: A forgotten episode in
American transportation history
From Breeder's Digest, April 20
This story came to light a few years
ago while foundations were being dug
for a new fission power plant in Kan
souri. The cornerstone of what had
apparently been a school or a library
was uncovered and found to contain
several books, in which were recorded
the facts from which this summary
has been drawn.
More than 20 years ago, in the late
1 850s, when mechanized transporta
tion in this country was still very
young and
q
uite primitive, there was
a young railroader named Taylor An
drews, who worked on the only ex
isting line of the time. Young Taylor
was the sort of person who was in
clined to doubt that the way things
were being done was necessarily the
best way, and who was always look
ing for better ways of doing things.
He began to become convinced, as he
rode up and down the railroad line,
loading and unloading freight at one
depot after another, and continually
firing the engine as it went back and
fort h bet ween s t at i ons , t hat
something was wrong with the basic
principles.
How foolish it is, he thought, to
make the same stops at the same com
munities to deliver the many little
things they needed and used up day
after day. Why not, he mused,
deliver, instead, the raw materials,
tools, and machinery with which they
could manufacture and raise the
things they needed? By delivering
means-of-production instead of con
sumer goods, the railroad could help
each community develop its own
economy, allowing it to become more
self-sufficient and less dependent on
frequent deliveries. He recognized, of
course, that such a system would re
quire different kinds of equipment
than were then in existence or even on
the drawing boards.
Equipment would be needed, he
reasoned, which could make occa
sional mass deliveries - rather than
many small ones -to each communi
ty of machinery, tools and raw pro
ducts. The cars would have to be
lower and wider to carry the massive
freight and the engines would have to
be a great deal more powerful. How
wasteful, he though, that engines
must use so much of their power just
to move their own weight and to carry
such immense stocks of their own fuel
over hundreds and thousands of
miles. There must be some way of
reducing engine and fuel mass, or
perhaps even of designing an engine
which somehow draws its fuel as it
runs.
Taylor studied these problems over
a period of years and by the early
1 870s, he had become convinced that
such an engine was possible and,
therefore, that the kind of economy
building railroad system he en
visioned was feasible. By 1 874 he had
drawn his preliminary plans and
specifications for the engines, the
strong, capacious cars, and the wide
gauge tracks and a sketch of the
system as a whole, and proudly began
showing them to other railroad men.
He tried to show them to fellow
workers on the line - engineers,
firemen, brakemen, section hands,
foremen, district managers, station
masters, the vice president in charge
o(promotion, development, advertis
ing, design, etc. , and even to the
president and the chairman of the
board.
Meets Opposition. Everywhere the
response was essentially the same.
"Nonsense. Humbug. We don't need
a new system. This is the way
railroading has a/ways been done.
Our present system is the only possi
ble system. If a better way were possi
ble, we' s have found it ourselves -
long ago. " The leaders in the railroad
said, "We don't know what crazy
thing you've drawn up there, but it's
wrong and it's un-Railroad and
subversive, and we wouldn't touch it
with a t o-foot camshaft. And who
are you, anyway, to tell the experts
how to run their business?" Hardly
anybody in the railroading world
would even look at his sketches.
But Taylor Andrews was not one to
be easily discouraged. So sure was he
that his general plans were sound,
that for 18 more years he continued
to refine and develop them and to
take them from railroader to
Osteopathic principles
railroader, from shop to shop, and
station to station, asking only that his
plans at least be tested, that at least a
little pilot model be set up; at least
think about it. But more and more
doors were shut in his face until it
became evident even to him that there
was no hope in bucking the existing
system, and that there were only two
alternatives: either forget the whole
thing or get started on it himself.
Transecon is Bor. By 1 892 his
mind was made up. "The only thing
to do, " he said, "is to set up my
own model railroad system and
show that it works -and better than
the one we now have. " With a few
nonrailroaders and one or two
refugee railroaders from other coun
tries, he organized and incorporated a
small company with the express pur
pose of establishing "an improved
system of railroading. " They named
t hei r company " Transec on , "
representing "transportation for
stronger economies. " They managed
to interest some investors, set up a
little shop, secured some right of way,
and began accumulating parts and
scrap metal with which to start con
struction. The first thing they did was
to lay a mile or two of broad track in
the direction they wanted their system
eventually to go, and began assem
bling their locomotive right on the
tracks.
As their work progressed, others
joined them; still others brought
scrap or old tools and even money;
some came just to help or to run er
rands. In the course of a few years,
Andrews and his little band had
become quite a large and determined
group. They completed their first
engine and one or two flatcars and
ran them back and forth on their
short length of tracks, endlessly
testing, improving, refining, revising,
replacing, and "ironing out the
bugs. " (We presume this quaint
phrase refers to some sort of metal
grill for excluding the many insects
which would have been drawn in
from the atmosphere together with
the fuel. How this was accomplished
and precisely how the engine
operated, we shall never know, since
the technical language used to
describe the working of the engine
and other equipment is now utterly
unintelligible.)
Some time after the turn of the
twentieth century, they and many
others who had ridden back and forth
on the short tracks were convinced
that the time had come to complete
their pilot system. All that remained
was to complete the laying of their
first line of tracks and open up for
business - to demonstrate to the en
tire railroad industry and the world in
general that, with the right kind of
equipment, there could be a better
system of railroading, which would
liberate communities from their
growi ng dependence on dai l y
deliveries of consumer goods.
Presents Plan. Ard so a few of the
more presentable and articulate
members of the group doffed their
overalls, put on their Sunday suits,
and set out for the state capitol to
seek permission to extend their tracks
to a few communities in the chosen
direction and to license Transecon for
carryi ng means - of- product i on.
(Taylor Andrews, now aging, stayed
home to keep the engine wiped and in
functioning order.)
"Very well, " said the Railroad
Commission and other official Guard
ians of the Public Welfare, "we
can't see any need for all this tom
foolery, but there's no law against it.
So, we'll approve you for a license to
operate your two-bit spur - pro
viding you can prove to our satisfac
tion that you know how to operate a
locomotive and a freight line and can
give the kind of service people have
come to expect of railroads. "
"But, " the delegates objected,
"our proposed system is not j ust
another railroad; it's Transecon. It
should be judged by its own stan
dards, and not by those we're trying
to improve. "
"Poppycock, " the Official Guard
ians responded, "it may be a Fan
cycon or whatever-you-call-it to you,
but sure sounds like a railroad line to
us. We'll have to inspect you. "
Gets Once-Over. Several hundred
application forms and a thousand let
ters later, the Commission made a
visitation to Kansouri to inspect the
engine and other equipment. They
were accompanied, of course, by ex
pert advisers from Big Railroad. One
look was enough.
"This will never do, " they ex
claimed. "No train has ever run on
such ridiculously wide tracks . Con-
trary to all established standards.
And what's the matter with your
locomotive? That is a locomotive,
isn't it? Looks like nothing we've ever
seen - and we've seen them all. Ob
viously too small to be powerful
enough. And where's the tender?
What? Nonsense! Every engine must
carry a certain minimum of fuel at all
times. Also, we don't see any fender
skirts or hubcaps. Absolutely essen
tial. And only one cowcatcher! You
know the law requires one in front
and in back, in case you have to
reverse. And no smokestac k!
Hogwash; smoke or no, no engine is
complete without a smokestack. And
you're going to have to put on some
chrome trim, all around - lots of
it. "
After the inspection, the crestfallen
Transeconners sat around debating
and shaking their heads for many
days. Quite a few were in favor of
chucking the whole thing and return
ing to their farms and shops. And
some of them did. But the stalwarts
said, "No, we must go on. This is
bigger than all of us. Sure, the nar
rower gauge defeats some of our pur
pose. Sure, the unnecessary fuel car,
and all the chrome, the hubcaps,
fender skirts, extra cowcatcher, and
dummy smokestack will waste half of
our power, but at least we can make a
start. And when we've proved how
good our system can be, even under
all those handicaps, then we . can
gradually widen the tracks again and
take off the superfluous load. " As a
matter of fact, some of them even
thought the engine would look pretty
with the trim and extra attachments.
Conforms, Then Accepted. It was
decided to make the required
changes. The men worked hard and
long, narrowing the track and
wheelbases on the engine and cars,
putting on outriggers to keep them
from toppling over, and putting on
tons of trim and other paraphernalia.
And the Commission was invited for
another inspection.
"Strangest looking equipment
we've ever seen, " they said, "but it
seems to meet minimum railroad
standards. In fact, we rather like
those outriggers. Equipment ap
proved. Now - what are you going
to carry?"
-When they were told. they said
"No, that won't do. Oh, all right, go
1
ahead and carry that means-of
production stuff if you insist, but
you're also going to have to carry the
things that people need and want and
have come to expect railroads to
bring them - bread, milk, eggs,
ketchup, cravats , stereopticons,
zithers and mandolin picks. gum
drops, curtains, hair oil, antima
cassars, footstools, rocking chairs,
and the like. And Sears Roebuck
catalogs - so they can order more. "
After much debate, the Transecon
ners reluctantly agreed to carry an
assortment of consumer goods in ad
dition to such means-of-prOduction
as they could also carry. And they
proceeded to finish laying the tracks
to a few of the many communities
they hoped eventually to serve.
Everyone Prospers. Transecon
began to prosper in its small way and
the communities it served also pros
pered - especially those they could
persuade to accept deliveries of
means-of-production for the develop
ment of their own industry and agri
culture. Oradually, Transecon was
able to add a few more engines -all
well-trimmed with chrome and
equipped with tenders, fenders,
smokestacks, and cowcatchers. Many
more people came to work for the
line, and new communities grew up
along the right of way, demanding its
services.
As the years went on, Transecon
grew in equipment, staff, and
resources, and won approval after ap
proval and recognition after recogni
tion. However, it found itself more
and more absorbed 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
" improved system of railroading. "
Life, for Transecon, had become a
continual race to keep up with the
changing standards prescribed by
Big Railroad. It became so involved
in continually changing the width
of the tracks to meet "advancing
standards" and adding new im
provements such as tailfins, power
stering, and even calliopes to replace
outmoded whistles and bells that
there was little opportunity to lay new
track.
Equal Rights. To be sure, these
problems were diffcult enough. But,
in its quest for "equal rights, " which
141
gradual l y became i t s sl ogan,
Transecon' s greatest problem was the
freight it was required to carry. To
prove the full diversity of its
qualifications, Transecon had con
tinually to demonstrate its willingness
and its ability to carry the countless
new consumer goods which endlessly
rolled off the assembly . lines and
floOded the market in response to ad
vancing standards and to meet the
demands of the populace for "the
very latest. "
Among the items for which
Transecon sought and proudly won
approval were automobiles, washing
machines, hair curlers, pens for
writing under water, refrigerators,
electric guitars, devices for shaving
peaches, mix-masters, cameras, lip
sticks, phonographs, radios, movie
films, comic books, hula hoops, and
many others totally unfamiliar to us
now. It even won the right to carry
products that were known to dull the
senses, cripple the intellect, and
destroy the will to work: television
(apparently a primitive form of
telesense), tobacco (a noxious weed
which was somehow burned in the
mouth and its fumes inhaled) , and
liquor (as far as we can tell, a kind of
beverage containing high concentra
tions of an alkyl hydroxide known as
ethyl alcohol).
Inevitably, it became more and
more of a problem to find space for
the means-of-production freight.
More and more it was left until last
on the loading platform, until it
became the practice " i there was
enough power and i the space was
not required for consumer goods -
to load it in the caboose. Transecon
ners became very proud of their abili
ty to meet the advancing Big Railroad
standards and to carry the things that
were in demand, in fashion, and ex
pected of them.
A Loaded Caboose. "See," they
boasted, "we may be small and we
may be poor, but we can carry the
same kinds of things Big Railroad
carries, but in addition, please note,
we also have a loaded caboose."
Gradually, the previous deliveries of
means-of-production deteriorated
faster than it was replaced, and the
communities served by Transecon
became more and more dependent on
daily deliveries of consumer goods.
This troubled the few old members
of the Board who still remembered
Taylor Andrews, now deceased, and
said, when they were given permis
sion to speak, "Oentlemen, aren't we
forgetting that our basic concept was
to help our communities to develop
independent economies? Haven' t
things gotten kind of turned around?
Isn't it the consumer goods that
should be in the caboose?"
.
The young progressive leaders tried
to be very patient with the aging
veterans and said, "Now, grandpop,
we're not forgetting. Just putting first
things first. Railroading has come a
long way since Transecon Railroad
began and we have to meet advancing
standards. As a complete railroad
we're going to have to prove our com
petence in every possible area of
railroading. You do agree, don't you,
that we have to be complete? Now,
you go back to your checkers. Don't
worry, when we're fully recognized,
that will be time enough to give some
thought to means-of-production and,
like you say, to ' developing econ
omies. ' We might even put on some
more cabooses. "
As more and more cars had to be
added to carry the growing variety
and volume of consumer goods -
and since there wasn't time or money
to develop more powerful engines -
the caboose was, with increasing
frequency, left standing on a siding.
"Pick it up the next trip," the
engineers said, "or maybe the one
after . " Duri ng vi si tati ons of
di sti ngui shed Rai l roaders and
Commissioners the idle cabooses
were occasionally pointed to as the
" Transeconic Contribution to Com
prehensive Full-Scope 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.
Fully Approved. Finally, one day
(no precise date was given, but it
seems to have been in the late 1950
or early 1 96s), the great news burst
upon the land: "Transecon is fully
and unreservedly approved as a fully
qualified and complete railroad,
equal in rights and privileges to Big
Railroad. " (The Big Railroaders, of
course, still crossed their arms and
said, "They're still nothing but un
Railroad cultists; it is unethical for us
to work with them." )
Osteopathic principles
After due celebration of their vic
tory, the Transeconners turned to ex
panding their line, saying, Now
we'll show them what a railroad
system can be like. But the old men
who remembered had died off.
Nobody could recall in what direction
they had set out to lay the tracks, how
to build self-fueling engines, and the
purpose of all the heavy freight
rusting in the camouflaged cabooses
on the sidings.
For a year or so, therefore,
Transecon laid track beside the track
of Big Railroad and made deliveries
at the same stations. It soon became
obvious to everyone that it was
foolish to lay duplicate track and give
duplicate service. Besides, Transecon
was rapidly running out of money for
expansion and for replacement of
deteriorating equipment. Besides, the
Commissioners kept saying, "We
don't need two of you. One of you
must go. "
We'll Join You. Finally, the Great
Decision was made. Again, as many
years earlier, the more presentable
and articulate of the Transeconners
(none of whom, of course, now
owned overalls and all of whom wore
Sunday suits every day) went to call
upon the Big Railroaders, saying,
"We've always been very nice to you
and lately you've been real nice to us,
and besides, as everybody knows, we
both want what's best for Humanity.
So, why don't we become one big
happy company? We'd be willing to
run our equipment on your tracks,
and we won't charge you for the
equipment if you won't charge us for
the use of the tracks. "
After a brief caucus, the Big
Railroaders said, "Well, all right; we
could use a few more engines and
cars. But yours are in pretty poor
shape, so if you want to come in with
us, you'll have to fx them up our way
and we'll run them together -
according to our policies. "
After suitable objections, the
Transeconners agreed, holding frm
ly, however, to one stipulation: that
their joining with the Big Railroad be
publicized, not as an absorption,
which some ignoramuses called it, but
as the amalgamation of two equal,
complete systems. and that a name
be agreed on which would appropri
ately memorialize for posterity the
Transeconic part of the amalgama-
tion. Accordingly, they proposed the
name 'Transeconic Railroad' . This,
of course, was rejected and after a
short debate and a series of com
promises, a name was agreed on
which properly recognized the
Transeconic Contribution to More
Comprehensive Fuller-Scope Rail
roading: 'Big Railroad' was changed
to ' Bigger Railroad' .
And that is how Transecon came to
pass. The yellow pages from which
this story was obtained, record that
after the amalgamation there was
great celebration in the homes and
shops of the former Transeconners
who were now Big Railroaders, and
the last page concludes with the
words, "Mission accomplished. "
* * *
Postscript. One century after the
close of the Transeconic episode, it is
diffcult - even for professional
historians - to understand what it
was they were celebrating and what
mission they considered accom
plished. From present perspectives it
would seem that if their objectives
had been to wOfk for Big Railroad,
they could have done so at the very
outset and avoided an exhausting
7S-year struggle. If, on the other
hand, their objective had been to
launch, as they said, an "improved
system of railroading, " one wonders
how they could have celebrated, as
the crowning triumph of their 7S-year
struggle, the placing of their equip
ment at the service of the old system.
Certainly, the opportunity to develop
the improved system remained before
them until that time. One wonders
how acceptance by Big Railroad
became for them the higher goal and
how abject surrender was interpreted
as victory.
These questions are all the more
perplexing in the middle of the
twenty-first century, when we
remember that that old system has
long been replaced and that our entire
transportation system and the
economies it supports, though now
technically more advanced, are based
on the same principle as those of the
original Transecon movement. As
far as we can now tell, however,
Transecon's only surviving contribu
tions to civilization are the yellow
pages from which this story has been
taken.
Reprinted by prmision from THE 0 I (8): 162.
April l9L
Osteopathy and medical evolution (1962)
Organized medicine has consistently
opposed the existence of the osteo
pathic profession and vigorously
resisted its growth. That the profes
sion has survived such powerful op
position, and prospered and grown in
spite of it, is testimony to its vitality.
However, while the osteopathic pro
fession was prospering and growing,
the opposition of political medicine
was also growing in intensity and
vigor, and the contest is now at the
decisive stage. For the frst time
organized medicine has succeeded in
gaining substantial organized support
for these efforts from within the
osteopathi c professi on i t sel f.
Encouraged by its triumph i n
Cal i fornia, organi zed political
medicine has declared its intention*
of carrying this strategy to its logical
"conclusion" - the piecemeal elimi
nation of the ostopathic profession.
The survival of the osteopathic pro
fession is now more gravely threat
ened than ever before, for while its
defenses against external attack are
strong, they provide no immunity
against interal collapse.
Organized osteopathyt responded
to these new threats to survival by
strongly reaffirming its intention to
maintain its separate and independent
existence, and demonstrated its de
termination by creating a sizable war
chest through dues increases and
assessments, "to promote the public
health by preserving and extending
the availability of osteopathic health
care in all states.
t t
Essential as is the will to survive
and to resist absorption and destruc
tion, survival of the profession de
mands that its function a a profes
sion have survival value. It demands,
also, that its members understand
Base on an address by the same title given at the
annual meeing of the Michign Association of
Osteopathic Physicians and Surgeons, Grand Rapids,
October 3, 191 . Dr. Korr is chairman of the Division
of Physiological Sciences. Kirksville College of
Ostepathy and Surgery.
In a statement unanimously adopted by the House of
Delegates, American Medical Association, June 28,
1 91 .
tAt the Annual Convention of the American Osteo
pahic Association, July 191.
24
that function and its value to society
in order that, individually and in
organized aggregate, they may dedi
cate themselves to its performance
and improvement. That function,
motivated by clear understanding of
its value, and well performed, is the
source of the profession's strength;
and it would seem to be the primary
responsibility of the profession's
organizations to ensure and promote
the exercise and development of that
strength.
Nowhere is this more lucidly illus
trated than in the very catastrophe
to which the profession's organiza
tions are now making their response.
Can we really regard it only as a
coincidence that California was the
osteopathic profession's largest,
"most powerful, " and "strongest"
segment? Can we really avoid the
conclusion that, having been the first
to succumb to the blandishments of
organized medicine, it was, in fact,
the weakest? Do we not have com
pelling reason to question the validity
of the criteria by which the profession
has measured strength and power? I s
i t not a possibility that the pursuit
of what passes for strength and power
may be the very source of weakness,
and that it has been bought, and may
again be bought, at suicidal prices?
Can we avoid the conclusion that pre
serving and extending the availability
of "osteopathic health care, " osten
sibly most amply available in Cali
fornia, does not necessarily "pre
serve" the profession and may even
hasten its demise? Can we not be con
cered that in its preoccupation with
quantity as a measure of strength,
the profession may have forgotten
that its true strength is in the quality
-perhaps the special quality -of its
function? Can we, in short, disregard
the paradox that truly osteopathic
health care was, in fact, feeblest
where the profession was "stron
gest"?
I f it asks questions which are
sufficiently incisive and searching,
the osteopathic profession can learn
some extremely valuable lessons from
its experience in California, and its
course henceforth will be decisively
determined by the lessons it does
learn. Although the California pro
fession was the largest blossom on
the osteopathic vine, it was, in fact,
and had long been, a dying part of the
vine, because it chose to "emanci
pate" itself from its roots. At this
point, in my opinion, the remainder
of the profession would do well to
look to its roots, and to turn all
possible resources to nourishing
them; else its other ministrations,
whatever they may be and however
well done, will, as in California, be
to a hollow, dying structure. The pro
fession now more than ever needs to
return to and develop the sources of
its vitality.
The Calforna profession had
obviously decided there was not
sufficient reason, if any, for the
continued existence of the osteopathic
profession. The remainder of the pro
fession has. in response, reaffirmed
its conviction that there are good
reasons for its continued independent
existence. It is now challenged, there
fore, to make clear what those reasons
are. What, other than survival, are its
purposes and objectives? What is its
function in society? What is, should
be, or could be. its value to society?
What is the profession for? These
same questions have been asked be
fore! but now they must receive
answers, lest the answer from Cali
fornia stand, with finality, as the
right one.
The myth of monolithic medicine, or,
Why not two schools of medicine?
It might be well, in the quest for clari
ty on these issues, to begin with a sim
ple question: Why should there be
more than one profession of medi
cine? As so often happens, a question
begins to answer itself when it is in
verted: "Why shouldn't there? Why
should there not be two. three, or
even more professions of medicine?"
In asking the question that way we
begin, immediately, to destroy a myth
with which most people of this coun
try have lived so long that they have
forgotten its origins in human conceit
and human design, and have accepted
it as though it were as inherent a part
of our environment as the atmo
sphere and as natural as the wetness
of the water. Even those -
osteopathic physicians, for example
- who might be expected to recog
nize it as artifact are often its chief
victims. In fact, the osteopathic pro-
Osteopathic principles
fession does appear entrapped in the
myth, and by its acquiescence, as well
as by act and word, the profession
helps perpetuate the myth and
deepens its own entrapment.
This is the myth: That there can be
but one true profession of medicine
-the one, of course, that dominates,
and has long dominated, the scene;
that only its members, holders of
a certain degree from certain "ap
proved" institutions, are the bona
fide, rightful, and exclusive inher
itors, custodians, proprietors, practi
tioners, and judges of medicine; that
only they are, and only they can be,
physicians; that they, and they alone,
have the divine right to control all
aspects of medical practice; indeed,
that this is so inexorably a fact of life
that they and their organizations and
institutions are medicine.
This myth has so much conditioned
our thinking that any other profes
sion, would-be profession, or group
of men and women that presumes to
speak and practice in the name of
medicine is, by its very separateness,
automatically suspect, and must, for
the protection of science and society,
submit to judgment - the judgment,
of course, of the medical profession,
the only "valid" profession, the ony
acceptable standard, and, by self
appointment, the only arbiter of stan
dard.
Because, however, any other pro
fession, would-be profession, or
group of practitioners is outside the
only "valid" profession and departs
from the only acceptable standard, it
is, ipso Jacto, unacceptable; it is a
cult of impostors, charlatans, or
upstarts whose practice and principles
- even without benefit of scrutiny -
are inherently wrong and even dan
gerous. Its adherents must be denied
the title of physician and the right to
practice "medicine. "
We have accepted this myth so long
that any new profession, regardless of
the soundness of its principles and the
efficacy of its practice, has, at best,
only the most tentative, the most pro
bationary right to existence, which it
must continually defend, by justify
ing and explaining why, and in what
way, it presumes to be "different
from medicine. " Osteopathic physi
cians and their spokesmen give
substance and credence to this myth
every time they accept as reasonable,
and set out to answer, the question,
"How does osteopathy differ from
medicine?" - or one of its many
variants. The question is as absurd as
"How do robins differ from birds?"
or "How does sculpture differ from
art?" Even worse, both the questioner
and the answerer have, by implica
tion, accepted the premise that the
dominant profession is the standard
against which all others must be
measured.
We have lived with this myth so
long that we no longer see the
ludicrous paradox of a system by
which a new profession of medicine
can win the right to existence only by
qualifying for acceptance by the
dominant school of medicine, thereby
ending its existence! We shruggingly
accept a system in which the only
possible seal of approval is the kiss of
death.
This is the great myth with which
the American public has lived, and by
which it has been victimized, for
many decades. This is the great myth
to which the osteopathic profession
has tried to adapt (California having,
thus far, been the most successful) in
stead of ruthlessly searching out and
exposing its basic falseness for all to
see.
To whom, then, does medicine
belong, if not to the medical profes
sion? Who are its judges, custodians,
guardians, proprietors, standard
bearers? Medicine is certainly not the
exclusive province or private property
of any particular profession, organi
zation, or association of institutions,
any more than education belongs to
the teachers, or religion to the clergy,
music to performing artists, and the
theater to stagehands and actors.
Medi ci ne i s a vast body of
knowledge, skills, understandings,
experience, facilities, services, agen
cies, and institutions related to health
and belonging to all of society.
Medicine has evolved through the
cumulative experience of the entire
history of the entire human race. In
modern society it is the product of the
activities of dozens of professions,
vocations, industries, arts, and
sciences. Physicians, regardless of
academic degree or particular profes
sion, are those charged with the
responsibility of delivering medical
service, with wielding some of the in
struments and applying some of the
methods of clinical medicine. They
practice it, they "perform" it, they
apply instruments and methods i n
health care. They do not own medi
cine; they are not its personifcation.
They do not design it, create it, or,
with relatively few exceptions, even
nurture it or plot the course of its
progress. The practice of medicine is
a great enough calling in itself,
without the arrogation of others.
The evolution of medicine
Medicine, therefore, is a pervasive
part and product of human culture.
Like all other major endeavors and
sociocultural phenomena - indeed,
like human culture itself - medicine
always has been and, for as long as
the human race survives, always will
be, in a continual process of evolu
tion. This evolution is not merely the
accumulation and turnover of bio
logic and clinical facts and the
multiplication and refinement of
methods and instruments. It is also
the evolution of ways of looking at
the facts, ways of arranging them and
interpreting their confgurations, and
of understanding them - and facts
accumulate much more rapidly than
understanding.
It is the evolution of scales ojvalue
and oj emphasis, the evolution of
strategies and systems for utilizing the
facts and applying the methods and
instruments. It is also the unfolding
of perspectives about human health
and disease. It is the evolution of the
objectives of medicine and medical
practice and of the concepts regard
ing the obligations and qualiications
ojphysicians. It includes the evolu
tion of concepts regarding the social
contexts of medical practice. In short,
the evolution of medicine is as much
the evolution of ideas behind
medicine and its practice as it is of the
knowledge and technique that nur
ture, and are nurtured by, those
ideas. Indeed, it is primarily these
ideas, comprising the philosophy of
medicine, that determine the direc
tions of the quest for new medical
knowledge and technique. It is these
ideas that determine the discoveries
for which the mind is prepared and
for which it goes seeking, and the
meanings it ascribes to them. Per
ceived or not, the prevailing philos
ophy of medicine is 'the little leaven
[that] leaveneth the whole lump" of
medical practice and research.
Because technique is easy to see
and experience, easy to describe and
document, and because its change is
dramatically rapid, we overlook the
pervasive presence of the perspec
tives, strategies, motivations, and
ideas that underlie the use of the
technique and their design and that
guide the quest for new ones. We also
overlook, therefore, their slower, less
dramatic change. Nevertheless,
throughout the recorded history of
medicine, the numerous "schools,"
cults, professions, and systems of
medicine that have had a place in that
history have been formed not only
around methods and instruments, but
around the much subtler, yet power
fully motivating concepts and
strategies.
Some of the schools, cults, sys
tems, and professions of medicine
have been soundly based, others not.
Some have had very brief lives, either
because they did not have significant
answers to human health needs and
better ways of interpreting and utiliz
ing available knowledge, or because
they could not convince enough peo
ple that they had. Others survived for
long periods either because they did
offer better ways of utilizing available
knowlege in the struggle against
disease or because of the persuasive
nes of their proponents and the will to
believe of the human species. Each has
had some impact on human health and
some impact on the course of medical
history - some favorable, some un
favorable. Some have speeded
progress, and some have retarded it.
The coexistence of two or more
schools, systems, or professions i n
the same era has been the rule. Their
lifetimes were usually overlapping,
rather than coextensive. A dominant,
enduring school was often flanked or
surrounded by others coming in or
going out, striving for ascendancy or
resisting decline. All learned from the
past, some better or more willingly
than others; each learned from the
others and each selected, rejected,
and adapted the available methods
and knowledge to its own perspec
tives, some with good success, others
with less success. But for each,
however brief or prolonged its life
and however simple or elaborate its
biography, rise and decline was the
inevitable theme. The rise and decline
of various schools or systems of
meicine, especially of those which
held sway for long periods and had
many followers, may be regarded as
landmarks or stages in the evolution
of medicine.
The history of medicine in this
country, though relatively brief, also
reflects -perhaps even with unusual
clarity - the evolution of medicine
and the struggle for survival and
dominance among schools of medi
cine. A rather large series of schools
and cults is to be found in our
history: thomsonianism, naturop
athy, chiropractic, homeopathy,
allopathy, eclecticism, osteopathy.
Most powerful, most enduring, and
most "successful" of all, of course,
has been allopathic medicine.
The allopathic era of medical
evolution
Since the passing of homeopathy, the
terms "allopathy" and "allopathic
medicine" have fallen into disuse.
Allopathy has worn many guises
. designated by many euphemisms.
Most medical leaders and educators
disown this identity and call for other
approaches. Nevertheless, the over
whelming bulk of medical practice is
still guided by allopathic concepts.
They are now so deeply ingrained, so
much a part of our environment and
pattern of thinking, that we are no
longer aware of their existence. As a
matter of fact, as a demonstration of
freedom from dogma and fixed prin
ciple, it has become fashionable to
deny adherence to any medical
philosophy.
The origins of the allpathic ap
proach are lost in antiquity. It is
perhaps the most direct, the most ob
vious, and the simplest approach:
Undo or reverse the affliction and its
manifestations, counteract the action
of the agents or factors presumed to
cause it; the mor specific the attack
on the disease and its cause, the bet
ter. Allopathy received its greatest
impetus from the epoch-making
scientifc advances that came in the
latter part of the nineteenth and the
early part of the twentieth century.
when the discoveries of Pasteur,
Koch, Virchow, Ehrlich, and others
gave good reason to hope that medi
cine was now well on the way to
characterizing and differentiating
man's diseases, identifying their
causes, and developing the means to
combat them, and that in time, man's
diseases would be conquered one by
one until health had been won for
humanity.
Although the experience and sci
ence of succeeding years have dis
pelled the basis for that hope, it has
nevertheless persisted as a kind of in
sidious faith which guides much of
our research and which provides the
framework for the organization and
financing of research, for medical '
education and practice, and for the
forms of practice. That faith, often
piously expressed by such admoni
tions as "treat the disease by
eliminating the cause" is renewed
from time to time by a discovery or
development that permits some tri
umph over one or another of our dis
eases, one that can be ascribed to a
specific "cause" - usually one of
many contributing or essential fac
tors.
The decline and fall of allopathic
medicine
While the great mass of clinical prac
tice in the existing schools of practice,
including the osteopathic, is largely
allopathic in orientation, and while
the dominant medical profession,
more purely allopathic than any, is
magnificently organized and speaks
with such a loud voice that it is
regarded, not as a particular school
of medicine, but as medicine itself,
the fact remains that it is not
medicine. Allopathy is but another
stage in the evolution of medicine,
and, like the others, it too will pass.
Why will it pass? It will pass for the
same reasons that other traditions, in
stitutions, institutional forms, agen
cies, and governments pass. It will
pass because it does not adequately
meet the needs of society, because the
defects in its basic strategy preclude
the full use of available resources and
knowledge in the war against disease
and for health. What is more, the
failure becomes deeper and deeper as
time goes on. This is true in spite of
the great advances that the allopathic
approach has fostered and the vast
research that it has inspired. A
basically unsound or archaic strategy
cannot possibly make sound use even
of the best of the improvements in
tactics and technique that it may itself
inspire, and it leaves idle or
undeveloped others that are no less,
and often more, effcacious. The
basic fact of strategic failure has for a
long time, however, been concealed
by dazzling displays of tactical
bravura and technical virtuosity, by
Osteopathic principles

endless series of startling discoveries

that feed the vain hope that what are
defects in basic premises and strategy
will somehow be eradicated by dis
coveries as yet unmade - or that
these defects will be accepted as in
herent in medicine itself.
Welcome and momentous as these
technical and clinical advances are,
they can no longer conceal the fact
that a basic failure remains, and that
it will continue to deepen, whatever
the refinements in technique and the
extensions in knowledge. Although
the basic premise of cause-and-cure
has always been biologically un
sound, however "scientific" and
precise it may be made to appear, that
unsoundness is today revealed much
more sharply and at much greater
cost to humanity than ever before.
The gap between human need and the
capacity of the allopathic strategy to
meet that need widens daily. That is
why allopathic medicine is a passing
stage in the evolution of medicine.
Seldom aware even of the existence
of these basic premises of practice,
and even less aware of its inadequacy,
physicians and their professions and
institutions continue to be so preoc
cupied with diseases in their great
variety, and with disease-oriented
technique, that they overlook the
essence of human disease and its
human origins.
Nowhere, in my opinion, has this
been more sharply and more succinct
ly documented than in a study con
ducted at one of the leading universi
ty medical schools and published
about 3 years ago. In this study, 2 the
patterns of health and illness over
periods of at least 20 years in adult
life were studied in approximately
3 ,50 individuals. The following
points, briefy summarized, emerged
from this monumental study:
1 . In all groups (according to na
tional origin, occupation, sex, et
cetera) the illness patterns revealed
that there were wide differences in
susceptibility to illness. Thus, one
fourth of the individuals had a ma
jority of all the episodes of illness,
while, at the other extreme, another
fourth had only 5 to 1 0 per cent of the
illnesses.
2. The differences in susceptibility
was to illness in general, rather than
to specific syndromes. Indeed, as the
number of episodes of illness ex
prienced by an individual increased,
there was a parallel increase in the
variety of syndromes and in the
number of organ systems involved.
He was likely to have more major,
even life-endangering, illnesses as
well as more minor illnesses.
3. These persistent differences in
susceptibility to illness in general are
most reasonably explained by
"assuming that they are dependent
upon factors operating within the in
dividual, influencing the ease, the fre
quency and the degree to which he
responds to the great variety of other
factors known to be capable of caus
ing disease. "
4. The relative constancy of in
dividual illness patterns not only sup
ports this hypothesis, but "inciden
tally, indicates that the illness pat
terns of these people were relatively
little infuenced by the therapeutic ef
forts of the physicians who treated
them. "
Point 4, emerging so "inciden
tally" from this splendid investiga
tion,2 is an incisive indictment of
the allopathic approach and a clear
identification of its inherent defect.
Allopathic medicine is so preoccupied
with "the natural history of dis
eases, " with "the identification of
specific diseases and of correlation
with related disorders, " with "the
biological basis of their manifesta
tions and the amelioration of disease
or symptoms by medical agents, "
with unrewarding attempts "to eluci
date the ultimate causes" that it over
looks the roots (and potential for
control) of human disease in the
factors in the human organism, in
human life, and in the human en
vironment that contribute to de
partures from health - whatever
forms they may take.t It so proudly
displays, in individual "episodes of
illness, " i ts array of skills in dis
tinguishing between diseases in their
vast variety and in ameliorating their
more or less characteristic patterns of
manifestation that it overlooks the
obvious fact that much - possibly
even the decisive part - of the con
trol of illness in its kaleidoscopic
variety lies in the control of "sus
ceptibility to illness in general. "z
This inherent defect has long been
a serious one. But its consequences
;Quotations are from an article3 on mical rearch
by J. A. Shannon, Director of the National Institutes
of Health. Public Health Servic.
are now far more grave than ever. It
becomes increasingly tragic and in
creasingly costly with time. The
burden of illness is so vast (according
to a recent National Health Survey,
41 per cent of the population have
one or more chronic disease condi
tions and lT million persons are, to
some degree, disabled by disease
alone) that it has outrun the capacity
of available medical resources to deal
with it even palliatively. Even worse,
the gap becomes wider and wider with
time; for while there are already tens
of millions in need of care, tens of
millions more, from embryonic life
onward, are continually starting on
the physiologic paths that lead to the
same kinds of denouement and are,
with increasing rapidity, swelling the
ranks of the chronically ill.
Grateful as we have every reason to
be for refinement and multiplication
of techniques, skills, instruments and
agents for the identification of ill
nesses, for diagnosis, amelioration,
compensation, palliation, repair, ad
prolongation of life that modern
medical science has provided, the fact
is now more obvious than ever that
however far this multiplication and
refnement are carried, and however
much we increase the quantity of
medical resources and personnel (es
sential as that is), they cannot cope
with the mounting tide of illness,
much less slow it. In speaking previ
ously of the great preoccupation with
diseases, I concluded that "a system
which continues in a hopeless quest
for the causes of each and the cures
for each, while neglecting the human
factors from which they do arise, can
only be regarded, basically, as a
failure, however brilliant, effective
and welcome the expedient measures
with which it temporizes. "
The dominant medical profession
is, of course, becoming acutely aware
of the inadequacy of the present sys
tem of practice in the face of the
growing burden of illness. Most of its
intellectual, scientific, educational,
and public health leaders are, of
course, dedicated to the improvement
of medical service, some even to the
extent of seeking ways of developing
and extending the availability of the
osteopathic contribution. The inter
professional seminars sponsored by
the Foundation for Research of the
New York Academy of Osteopathy,
and made possible by grants from the
T
Rockefeller Brothers Fund, are a
splendid example of such efforts. '
The political arm of the medical
profession, however -the most pow
erful and most lavishly supported
lobby group in the nation - seeks,
with increasing desperation, to pre
serve the status quo, to reinforce its
domination of the medical scene, and
to extend its life. It seeks to do so
by concealing the inadequacy of the
present system from an increasingly
impatient public, by crying diverting
alarms about cultism, socialized med
icine, and third parties, and by
repeating the hackneyed shibboleths
of the sacredness of the patient-doc
tor relationship, freedom Of choice,
the sanctity of private enterprise and
fee-for-service. From such cynical,
self-centered viewpoints it is impos
sible for organized medicine to regard
osteopathic service, whatever its real
value, as anything other than a threat
to its preponderant authority.
The most dramatic and self-contra
dictory act of desperation by political
medicine is now being consummated
in the state of California. There, the
medical profession is preparing to
absorb into its own ranks, after
appropriate quarantine, the very
"cult" which it has publicly despised
for so long - destroying it as a
menace to its continued hegemony.
Having encouraged and witnessed the
completion of this pilot model of
destruction-by-absorption in one
state, the House of Delegates of the
American Medical Association can
didly and confidently, in its con
vention last June, delcared its inten
tion to complete the demolition, state
by state.
It is difficult to characterize it as
anything other than an act of as
tounding and gigantic stupidity that
the victims could seek and welcome
their own destruction as their crown
ing achievement - as the ultimate in
prestige and recognition! Even more
astounding is the fact that there
continue to be others in the osteo
pathic professi on, also willing
victims, who would like the entire
profession to enjoy the same "rec
ognition. " If they have their way, the
osteopathic profession will soon be
accepted, recognized, and approved
to death.
Whatever the machinations of the
deal-makers in both professions,
whatever desperate and illUSOry mea-
sures of self-protection they may
resort to, and whatever cnical acts
may be engendered by "association
attitudes, " they reveal aU the more
clearly that the old medical order is
passing, that it is passing because it
is failing and must pass, and that
a new order - a superior system of
medicine - is on the way.
The next higher stage of medicine
The next stage of medicine will be one
that better meets the health needs of
the day and that better anticipates the
rapidly changing needs of modern so
ciety. It will not be concerned only
with recognizing, preventing, and
treating individual episodes and types
of illness. It will direct its primary
efforts at the fullest exploitation,
liberation, and development of man's
natural biologic resources for pro
ductive life. It will be engaged much
less in intervening in the in
conceivably complex biologic pro
cesses of the human organism than in
creating circumstances in and around
the individual that will permit their
optimal operation and in eliminating
impediments to their operation.
This emerging, higher stage of
medicine will be concerned with the
identification and control of those
factors and variables in the indi
vidual, in the human organism as a
species, in human life, in society, and
in the environment that significantly
and decisively influence the ability to
stay on optimal physiologic paths, to
resist deflection from those paths,
and to return to them. Its efforts will
be directed not so much at the so
called specific "causes" of disease as
at the factors that permit them to
become causes. Its concern will be
more with elimination and control of
factors contributing to susceptibility
to illness in general than with the
cataloging of diseases and their
treatment in their endless variety. It
will combat disease not so much by
fragmented and expedient attacks on
diseases as by concerted programs
for maintenance and improvement of
health - for "raising levels of
wellness. 6
The practitioners of the emerging
school of medicine will turn their
maj or attention, therefore, to the
A euphemism that James A. Shannon, M.D.,
Diretor of National Institutes of Health, offered a a
substitute for "professional jealousies".'
control of those factors which have
been recognized for many years, even
centuries - the inheritable, the de
velopmental, the nutritional, the psy
chologic, the social, occupational,
recreational, environmental, and so
forth - because they are central to
this strategy. However, in addition,
these practitioners will particularly
recognize the need to help man and
the individual patient to make his best
possible adaptation, throughout life,
to an environmental factor that has
never received adequate attention,
one that makes more exacting de
mands on the human than on any
other mammalian species - gravity.
The emerging school of medicine
will almost certainly, therefore, find
it necessary to place special emphasis
on the musculoskeletal system. For
this is the system which bears the
main brunt of gravitational stress. It
is the main instrument of active life in
the external environment and, as the
most massive system of the body and
the largest consumer of material and
energy in the total body economy, it
places proportionate demands on all
other tissues of the body, being in
tegrally linked to them through the
circulatory and nervous systems, and
intimately influencing them and being
influenced by them. The newer prac
titioners, therefore, will learn to
evaluate, in individuals, the adequacy
of resources, margins of reserve, bio
logic defects, incipient and advanced
pathologic processes, and functional
inadequacies, through their inevitable
reflection in the somatic tissues of the
body. They will learn to introduce
favorable influences, prophylactic
and therapeutic, through those
tissues.
Through such an approach, physi
cias will, in the course ofministering
to the ill, and during "episodes of
illness, " reduce "susceptibility to
illness in general. " I am convinced,
from many years of observation, that
this is precisely what happens in the
course of discerning and skillful os
teopathic practice, whatever the
"presenting complaint. " The patient
is placed on a better "physiologic
path. "
In short, I am deeply convinced
that the next higher stage ofmedicine
- long on the way and now desper
ately needed - wil be guided by
those principle which, in their con
tinually evolving form, constitute
Osteopathic principles
"the osteopathic concept . Indeed, I
have long felt that the osteopathic
profession should be regarded -
should regard itself - not only as a
profession, but as a movement for the
continual reorientation of medicine in
the needed direction, and for leading
the transition to the next higher stage
of medical evolution. The profession
itself, like its concepts, has from the
time of its founding been in continual
evolution. It has been maturing and
preparing for this eventual role even
while society neither understood that
role nor saw the need for it. The
osteopathic profession is at last being
invited to assume that role.
The osteopathic profession and the
transition to the next stage
This transition has been coming a
long time; it has been possible for a
long time. It has been "delayed" not
so much for want of adequate knowl
edge and technique (never enough,
though adequate for a good start),
but for want of appropriate strategy.
More accurately, the delay has been
for want of understanding the need
for a new strategy. One has long been
in readiness, but recognition of its
soundness and appropriateness has
ben delayed by medical tradition,
orthodoxy. and "authority. " Most
regrettably, it has been, and is being,
delayed because the osteopathic pro
fession has been diverted from its
path by submissive deference to that
orthodoxy.
Whether the next higher stage will
be Fecognized as "osteopathic, "
whether the osteopathic profession
provides the stimulus that brings it
into existence, and whether it be
comes the nucleus for the new profes
sion depend almost entirely on the
osteopathic profession itself: its
decisions and course of action in the
immediate future. Though small in
numbers and limited in resources,
though vacillating and uncertain as to
its direction, and though beset with
internal problems, the osteopathic
profession is still, in my opinion, the
logical instrument for catalyzing the
transition to the next higher stage and
for officiating at the passing of the
obsolescent system. I believe this to
be true because this profession is still
the world's largest reservoir of physi
cians and institutions with the neces
sary insights and skills who do - or
could - apply the needed strategies
in their daily practice and teaching. It
is still the only organized voice,
among numerous individual voices,
espousing the new strategy.
Either the osteopathic profession
will very soon rededicate itself to the
unfolding of new horizons in medi
cine, and forever "loom bright in the
mind of man, " or it will vanish from
the scene and be recorded, if at all,
"as a passing footnote in the history
of medicine. Either the osteopathic
profession will emancipate itself -
resolutely and irreversibly - from
the great medical myth discussed
earlier, or it will become increasingly
enmeshed in it and hopelessly seduced
by it, whatever protestations to the
contrary its associations may pro
claim. The longer the delay, the more
diffcult - and the less likely - the
emancipation.
Which course the osteopathic pro
fession chooses depends to a very
large degree on the lessons it chooses
to learn from the California experi
ence. In effect, it must choose be
tween two alternatives: ( 1 ) A qufck
end by fashionable suicide, by being
accepted and approved into oblivion.
This is the alternative chosen by the
California Osteopathic Association.
(2) A long, hard life on the medical
frontiers. This is the opportunity
opened to the profession by the
course of history. There seem to be
no "safe" intermediate positions,
and certainly no stable ones. The first
alternative is easy; the road has al
ready been pointed and traveled part
of the way. The other is a great deal
more difficult, and the course
from where the profession is now -
has yet to be plotted.
In order to be able to plot the
course, the profession must meet a
number of prerequisites:
1 . It must recognize that a course
needs to be plotted.
2. A destination - or goal or
objective - must be established.
3 . The profession must determine
where it is now and in what
direction(s) ! it is facing, with respect
to the goals it sets.
4. It must then plot the course, in
terms of the policy, program, organi
zation, education, and so forth, that
will move the profession as rapidly as
possible from its present situation
toward its ultimate objectives.
5 . In order to take action on the
foregoing prerequisites, it must first
establish the necessary mechanisms.
Meeting the prerequisites
After 16 years of serving and observ
ing the osteopathic profession, I must
conclude that none of these prereq
uisites is presently satisfied. I must
conclude, moreover, that they canot
begin to be satisfed before the pro
fession is appropriately organized for
continual and profession-wide ex
ploration of such basic issues as are
implied by the first four items above.
It is significant, and ironic, that al
though the profession is well orga
nized for almost every procedural and
policy decision, it has no effective
forums and councils for the explora
tion of such fundamental questions as
these. It is for these reasons that I
have previously presumed, l and now
do again, to bring to the profession's
attention the urgent need for the ac
celerated development of intellectual,
as well as political, leadership and for
the establishment of forums and
councils - an "academic wing, " re
gional in distribution yet centrally
coordinated - that would lead the
entire profession, at the grass roots,
in the continual study of the issues
and elements that determine the pro
fession's obligations to society and
the paths to their fulfillment.
As I have indicated here and else
where, I find it difficult to believe
that the profession can claim its right
to existence as an independenn school
of medicine with any objective less
than that of introducing a new and
needed design or strategy into the
practice of medicine: that of piloting,
by example, the transition to a
superior system of medical practice.
This is precisely what, according to
the charter of the frst school. ** it set
out to do, what history now invites it
to do and what it ca now, having
won the right at immense cost, pre
pare itself to do. The question is no
longer, "What is osteopathy'" or
"What are the distinctive features of
osteopathic medicine'" The question
now is, "In what direction does the
osteopathic profession, on the basis
of its philosophy, principles. and
experience, believe that all of
medicine should move, and i s ready
to lead the way by setting an exam
ple'" The profession cannot seek or
. . . the design of which is to improve our prsent
system v n
29
.
expect society's long-term investment
in it with any more confidence than
that with which it can answer this
question. This is the question which
the profession must prepare itself to
answer.
Doe the osteopathic profession
have a program for the improvement
of the national health? Can the
osteopathic profession offer a better
strategy for the care of the currently
and episodically ill, for reducing the
staggering backlog of illness that has
already accumulated, and for reduc
ing the rate of its accumulation? Can
it offer new tactics for the imple
mentation of this strategy? Can it
offer designs for the practice of
medicine which will be more effica
cious, more economi cal , more
broadly available, and more pre
ventative? Will medicine practiced
according to these designs make full
er, prompter use of the fruits of sci
ence? Are the special features of
"osteopathic health care" such or, if
it becomes the mode, will they be
such as to raise the levels of individu
al and public health and reduce the
incidence, severity, and duration of
illness?
It seems to me that it is the answers
to questions such as these that mea
sure the profession's value, in the long
run, to society, that weigh the reasons
for its existence, and that will decide
society's investment in the profes
sion. They are much more reliable
criteria for appraisal of an aspiring
school of medicine than whether it
satisfies the standards of another
school of medicine while still dis
playing enough "distinctiveness" to
justify its independence. It is issues
such as these that should guide the
services of the profession, the prac
tice of its members, the programs and
policies of its organizations, and the
educational and clinical and scientific
activities of its institutions. It is
therefore for the study and resolution
of issues such as these that the profes
sion should be organizing itself. This
is the indispensable first step - yet
to btaken.
Perhaps the most difficult pre
requisite of all to fulfill is the third:
determining where the profession is
now and in what directions it faces.
This means a merciless self-examina
tion, a penetrating scrutiny of recent
and current policies, and objective in
terpretation of recent events. Of all
the "events, " those in California
have been the most distressing and
should, therefore, be the most mean
ingful. The meaning that the profes
sion extracts in the course of its self
scrutiny will determine whether those
events represent the end of one era
and the beginning of another in os
teopathic history or merely the end of
that history; that i s. whether osteo
pathic history continues as the rising
phase of a higher stage of medicine or
whether it becomes the declining
phase of an ephemeral cult.
The tragedy of California. I be
lieve, is not so much in the loss to the
profession of its largest segment. its
largest hospital, one of its colleges,
financial support, and so forth, grave
as these losses are. The tragedy is that
the mass defection is an objective and
unequivocal measure of the profes
sion's own doubt as to whether its
function has enough value to justify
its continued existence. The impact of
California can be counteracted only
by an equally objective and unequivo
cal demonstration that the profession
does have a function, that that
function is of such critical importance
as to demand society's support, and
that, given the means, the osteopathic
profession is prepared to perform
that function.
In this process of self-examination,
the profession will have to determine
to what extent its policies have con
tributed to the California situation
and to what extent they invite other
"Californias. " I believe it can be
shown that the collapse of the profes
sion in California did not happen in
spite of the profession'S policies; that
it was not a departure from its course,
but an extension of its course; that it
was an entirely logical and even high
ly probable culmination of the pro
fession's accelerating drive, during
the past two or three decades, for
"acceptance": acceptance, not of its
principles, but of the rofession itself
as a school of medicine, "complete"
and adequate according to orthodox
criteria. Indeed, the California Osteo
pathic Association achieved the ulti
mate in "acceptance. " Acceptance
and approval by the public are, of
course, essential for survival. Unfor
tunately, in acquiescing and seeking
to adapt to the myth that it must be
j udged according to the standards
of the only fully "accepted" school
of medicine, the osteopathic profes-
sion has conducted its struggle for
acceptance and approval under terms
inimical to independent survival.
California has merely made the most
"successful" adaptation in osteo
pathic history.
Accommodation to this myth has
committed the osteopathic profession
to a course of such precarious "brink
manship" as has never been known.
even in international affairs. Here is
my image of "where it is now. " The
profession tenaciously trudges higher
and higher along a narrow ledge
around the medical mountain. The
ledge is bounded on the brink side by
"sameness, " which favors accep
tance and approval, and, on the rock
side, by "distinctiveness. " The width
between them gives the profession its
ledge of independent "separateness"
to stand on. Unfortunately, for
various reasons the ledge has been
getting narrower and narrower, until
its vanishing point is almost in sight.
California, perhaps slightly in the
vanguard on this trail, looked ahead
and saw the vanishing point, and
leaped over the brink while one
remained to leap over.
Saddened and alarmed, the re
mainder of the profession signals its
resolute determination to continue its
march - evidently along the same
vanishing (ath. The survivors, now
more firmly united by their bereave
ment, tie themselves together like
mountain climbers in the hope that
there will be no further falls -
leaving open the possibility that any
fall (or leap) is more likely to mean
disaster for the entire safari. It
would, however, only be disaster
somewhat earlier than the inescapable
one at the end of the trail.
One obvious lesson is this: If it
truly wants continued and inde
pendent existence, the osteopathic
profession must get off the myth
engendered ledge of distinctiveness
before it is forced off, and onto its
own independent course one that is
as broad and unlimited and as solid as
osteopathic philosophy demands, one
that goes where osteopathic objec
tives indicate, one that has the design
that osteopathic strategy dictates, and
one that al of medicine should travel .
Another lesson is obvious: Policies,
practices, organizational forms. edu
cational programs, and short-term
objectives that are, for the remaining
time, appropriate for keeping the
Osteopathic principles
profession trudging along the vanish
ing trail are absurdly inappropriate
for getting the profession off that
trail and onto the one that has no
end.
The self-scrtiny
It seems, therefore, that i f the profes
sion really wishes to survive as an
independent profession, it must plot a
new course and prepare to travel it. It
cannot plot the course, as we have
shown, without undertaking a search
ing and ruthless examination of each
of its own features that the profession
itself has designed or permitted to
develop. Which of the profession's
policies, programs, and forms of or
ganization, which educational pro
grams, activities, and objectives keep
the profession committed to the van
ishing trail? Which of them have been
put on like protective garments, as
part of the adaptation to the myth
that keeps the profession on the pre
carious, narrowing lane between
sameness and distinctiveness, and
prevents it from proceeding in self
determined directions? Which of the
heavy accoutrements it now carries,
and buys at great cost, are useful, if
at all, only for travel on the pres
ent path? Which of the navigational
guides that it has adopted keep it
"homing" on this suicidal course?
Let us only identify a few for
example.
. The complete reprtoire
As has been previously said, the
things that physicians do are much
more evident to the senses than what
they think " that is, the principles,
objectives, and strategies that guide
the doing. The osteopathic profes
sion, born of idea and of approaches
to the fulfillment of the idea, has
conceded to this, too, in its adapta
tion to the myth of a standard medi
cine. It has permitted itself to be
compared to the "standard, " it has
compared itself to the standard, and it
has even measured its own progress
by comparing catalogs of the meth
ods and procedures in which accept
able competence is to be found
among its members and by compar
ing the inventories of instruments and
agents that are utilized in their prac
tice.
Having adopted this rapidly shift
ing criterion of its qualifications as a
profession - apparently without de-
liberate decision arrived at by orga
nized, profession-wide study - it
could do no less than dedicate itself,
through its undergraduate and post
graduate teaching programs, through
supporting policies and through its
practice, to the development and
maintenance of maximum versatility
in the clinical arts. "Comprehensive"
and "full-scope" became slogans in
osteopathic education. The collective
D. O. , according to this premise, had
to be a jack of al medical trades.
Having adopted this standard, the
profession dared not be less complete
than the dominant school, since a
repertoire less than complete might
imply practice below standard.
According to this premise, the pro
fession' s value to society, and there
fore its viability, is assumed to be
proportional to the size and variety of
its repertoire. Under this premise, the
profession has made huge and vastly
disproportionate investments, from
its limited human and material re
sources, in seeking to match com
petence with the medical profession
in almost every field and technique of
practice - at the cost of developing
the idea behind its practice and
furthering its own contributions to
practice. It has cultivated diffuseness
of service and diversity of technique
at the cost of clarity of purpose and
incisiveness of strategy. TT
Since new and additional methods
and instruments are continually being
developed, the already huge reper
toires of the medical and osteopathic
professions are steadily growing. The
measure of "distinctiveness, " ac
cording to thee criteria, therefore
becomes narrower by the day. The
differential in the catalog of things
that doctors do and in the inventory
of instruments and agents with which
they do them is a vanishing one. For
ttThis is another image that comes to mind. The pro
fession's situation in this regard is reminiscent of a
device intended to dramatize the Swiss instrument
maker's art and often to b found in cutlery displays.
It purports to b an assembly of instruments that is as
compact as a pocket knife, yet as versatile as a whole
chest of tools or even a machine shop. Unfortunately.
it bristles with so many blades, file, chisels. scissors.
bottle-openers, can-openers, screwdrivers, pliers, and
other instruments, and has so many posible uses, that
it i too unwieldly for alY purpose. It is a prfect
symbol of the exchange of utility-to-purpose for dis-
play of diversity, of growth by accretion rather than
by desigrt.
this reason the "edge of distinctive
ness" along which the profession
proceeds is also a vanishing one.
The profession, therefore, needs
to examine very carefully the im
plied premise that in order to claim its
right to independent existence as a
school of medicine, it must be "com
plete" or nothing. It needs to seek,
through clarification of . objectives
and sharpening of strategy, a more
discriminating guide to the selec
tion and development of its clinical
methodology, to the design of its
educational programs, and to the
development and deployment of its
resources.
2. Osteopathic manipulative
therapy
Osteopathic manipulative therapy
began as a central and indispensable
part of a total strategy. In its count
less forms it is designed to eliminate
critical impediments to the optimal
operation of adaptive, homeostatic,
defensive, restorative, and reparative
processes, thereby helping and per
mitting the individual to move to a
physiological path more favorable to
the best use and development of his
biologic resources. It is not a
therapeutic technique or agency for
intervening in the biologic process,
for the treatment of this or that dis
ease, or the alleviation of this or that
symptom, or the elimination of this
or that etiologic agent. On the con
trary, it is C whole system of
diagnosis, appraisal, therapy, and
prophylaxis, subject to infinite
variety of adaptations to individual
requi' 'lents, whereby favorable in
fluences "are introduced to the human
organism through the manually ac
cessible tissues of the body. Those
infuences cause the biologic - and
therefore human - potential to be
more fully released, more appropri
ately utilized and more fully ex
pressed, in health or in recovery from
ill health, in the cure that must come,
if it comes at all, from within.
Osteopathic manipulative therapy
is a system which purports not to
make the patient well, but to help
the patient get well. It is, indeed,
designed to help "put the patient in
command of the situation. ' ' ' I a
convinced, from many years of close
observation and some familiarity with
the biologic ' mechanisms through
which the favorable influences of
11
manipulative therapy are mediated,
that this system of therapy is a
monumental contribution to human
health and welfare which is, neverthe
less, still in its infancy. It can grow to
healthy maturity only in the sort of
medical environment that will be
provided by the next higher stage of
medicine, as part of a total strategy
that will put it into maximal service.
Unfortunately, in the prevailing
purview, it has become - or certainly
is in danger of becoming - only one
of the long and growing inventory of
therapeutic "modalities" or tech
niques. Not being commonly used in
medical practice, it has become the
differential, the symbol of distinc
tiveness, the "plus" in the naive
"M. D.-plus" concept. It has been
torn from the comprehensive man
oriented strategy in which it arose,
and of which it is an essential part,
and has been set in a allopathic,
disease-oriented framework in which
its use and development are seriously
impeded, and in which it can not
possibly be properly evaluated.
As an entire system of clinical ap
praisal and therapeutics which, ac
cording to the skills and judgment of
the physician, has to be precisely
"custom-made" to the patient and to
his continually changing circum
stances, it cannot be regarded and
revaluated as though it were a single,
discrete entity, a particula drug or
physical agent - any more than one
could, for example, generalize about
the effectiveness of "psychiatry" or
"physical medicine" or "pharmaco
therapy" in the treatment of a par
ticular disease entity. To no small
degree, its effectiveness, however it is
measured, is determined by who does
the administering.
As a whole system which must
from moment to moment be adapted
to the unique needs of the individual,
its effectiveness can be only as great
a the judgment, knowledge, and
skills of the physician permit it to be.
The system is of such vastness and
depth and is such a totally unique
combination of art and science that
the necessary skills are inevitably
predicated on innate ability, under
standing of the system's purpose and
potential, knowledge of its biologic
basis and principles, continual and
persistent study, and long and metic
ulous practice. Too often, therefore,
the effectiveness of osteopathic
252
manipUlative practice is judged by the
indifferent results obtained by those
who do not have the requisite skills.
To measure the value of the system by
such criteria is very much like con
demning Beethoven for every bad
performance of his music. However,
the more we are willing to accept bad
performance, the more Beethoven' s
music may as wel be banished!
The profession, therefore, will
have to take a searching look at the
premises which have permitted the
centrifugal migration of manipulative
therapy from the key position in a
total strategy of medicine toward the
palliative , adj unctive, optional
periphery of clinical practice. The
profession will, if it is committed to
independent existence, have to take
the steps to ensure the continued de
velopment of the necessary perspec
tives and skills among its members by
appropriately designed programs of
education, and to ensure continual
improvement of understanding and
method by appropriately designed
programs of research.
J. Osteopathic education
Curricular designs and educational
media and methods, whatever their
individually good features, which are
designed to prepare succeeding gen
erations of physicians to follow along
the narrow. prescribed lane between
sameness and distinctiveness, will
obviously not prepare physicians for
pioneering on the medical frontiers.
While our colleges unquestionably
train able and acceptably versatile
physicians according to the " ac
cepted" standards, an unknown per
centage of whom also display some
distinctive features of osteopathic
medicine, curricula must be especially
designed to produce, in larger num
bers, physicians who understand the
mission of the osteopathic profession
and the reorientation in the practice
of medicine it has the opportunity to
lead.
It is in the colleges that the re
orientation of the profession as a
whole is to be achieved over a period
of time. One cannot expect that such
orientation can be led by physicians
who themselves are inextricably com
mitted to the present course. Obvi
ously, if our young physicians are to
be prepared for the pioneering that
continued independent existence de
mands, our faculties must be led by
those who understand the need for
plotting new courses and who are pre
pared, by precept and by skillful
example, to do so. It is foolish to
expect that succeeding generations
of D. O. ' s can be prepared to meet
the historic opportunity of leading
the reorientation in medicine by es
sentially orthodox curricula in which
"the osteopathic contribution" is
unadherent frosting on the cake in
stead of the "leaven" throughout the
loaf. But curricular redesign can
become possible only as the profes
sion undertakes the searching ex
amination of its basic premises, ob
jectives, and strategies. Otherwise,
like all other aspects of professional
function, it can only be another im
provisation on a dying theme.
For similar reasons, the profession
will have to examine to what extent its
programs of postgraduate education
are designed to orient physicians in
the required direction and to sharpen
the skills necessary for moving in
those directions, as compared with
the degree to which they are designed
to continue movement along the es
tablished path.
4. The profession's investments
The larger the investment one makes
in a given venture or endeavor, the
more one becomes committed to it. If
the profession is truly determined, as
it proclaims, to continue its indepen
dent existence and to extend the avail.
ability of osteopathic health care,
then it cannot avoid a relentless
examination of the degree to which its
past, current, and contemplated in
vestments keep it committed to paths
and circumstances that militate
against its continued existence. We
might take but one example, the most
obvious one. Overwhelmingly. the
profession' s largest single investment
in terms of money. materiel, and
manpower is in the construction and
operation of hospitals. While the in
creased "availability of osteopathic
health care" made possible by these
hospitals is of unquestionable value
to community health, the profession
- if it is serious about continued
independent existence - will have to
determine the degree to which this
huge investment in hospitals, and in
education for practice in hospitals,
deters the profession from giving
leadership in the development of a
system whose main objective is, as far
Osteopathic principles
as possible, to keep people out of
hospitals.
J. Public education,' conclusion
This, my fifth example of areas
needing re-examination, seems an ap
propriate way to recapitulate some
points and, at last, to conclude this
paper. It seems unarguable that the
osteopathic profession will survive, as
it wishes to, and, as a profession,
prosper, only as long and as well as
society understands the profession's
contribution to its welfare, appreci
ates its stake in the profession's
survival and success, and is willing to
invest in it accordingly.
This, in turn, depends on what the
profession seeks, by word and by
practice, to convey to society about
its role and how successfully it con
veys it. Finally, this in turn is
determined by the profession's own
view of its purpose and function a an
independent profession, and by the
courage, clarity, conviction, and
quality with which it adheres to its
purpose and seeks to perform that
function. Obviously, the confidence
with which the profession seeks pub
lic understanding and support can be
no greater than the confidence it has
in its own function and in its ability,
given the opportunity and the means,
to carry it out.
At present, as a result of the widely
publicized action recently taken by
the osteopathic profession's largest
divisional society, the public has,
unfortunately, rather convincing evi
dence that the profession itself is not
very sure that its function, whatever it
is, is sufficiently important to war
rant its continued independent exis
tence. The elected representatives of
the remainder of the profession
responded with a ringing declaration
to the contrary. That avowal can have
meaning, however, only insofar as
the profession can, rather quickly and
unequivocally, demonstrate that it
has a function, that this profession is
the best qualified to perform it, that it
i s of such importance a to demand
its continued existence and as to
j ustify all necessary support and
encouragement by society.
What function? I have tried to
show that society now awaits - has
long awaited -the vision and leader
ship that will guide it to a better
system of medicine, one whose strate
gy will make better use of the prod-
ucts of science in service to health. I
have tried to show that the osteopath
ic profession, because of its founding
purpose, its history, experience, in
sights, and skills, is qualified to
undertake to provide that vision and
leadership. The profession has the
opportunity, therefore, to make clear
that such a superior system of medi
cine is entirely feasible, to explain, to
demonstrate in its own practice what
its features and advantages are and
could be, to prove that the profes
sion, given the means, is qualified to
lead the way, and to prescribe and
recommend what kinds of public and
governmental actions, policies, and
programs are required in order to
hasten the transition.
From this viewpoint, therefore, it
will no longer suffice for the profes
sion, in public education programs,
to tell what osteopathy is and how it
"differs. " It is now required to tell in
what direction it proposes that all of
medicine move and what it will take
to move it in that direction. It will
no longer suffice for the profession
to seek equitable, non-discriminatory
"inclusion, " along with other health
professions, in public and govern
ment-sponsored programs, in legisla
tion, and in the awarding of privi
leges, opportunities, grants, and
subsidies. Demanded now is special
-discriminatory -consideration, in
recognition of the special and unique
function of the osteopathic profes
sion and of its unique requirements.
-In order to do this, as we have said,
the profession must first set up the
mechanisms - the forums, the
media, the "academic wing" -
which will make possible the defini
tion of that function, the setting of
objectives, the ruthless self-scrutiny
and assessment of its present situa
tion, the searching review, revision.
and replacement of the inappropriate
policies and programs by which it i s
encumbered, and the plotting of its
own independent course, unfettered
by the myth of a "standard" medi
cine. This is an immense task, but i f
the profession is t o survive. it is one
that must be undertaken very soon.
There is no doubt that it will require
great courage, great vision, new kinds
of leadership, and prodigious effort.
The stakes are huge. The rewards are
as great as man has ever known.
References
1. Korr, l. M. : Function of osteopathic profession;
matter for decision. J. Am. Osteop. A. 59:779, Ot.
1959.
2. Hinkle, L. E .. Jr . . and Wolff, H. G.: Ecologic
investigations of relationship between illness, life
experiences and social environment. Ann. Int. Med.
49: 13731 388, Dec. 1958.
3. Shannon, J. A.: Symposium on world medicine;
neglected avenue to knowledge. Public Health Rep.
76:803-805, Sept. 1961 .
4. Proceedings of Fourth Seminar of the Founda
tion for Research of the New York Academy of
Osteopathy, New York, N. Y. , February 17-18. 191.
stenographic transcript. unpublished.
S. Shannon. J. A.: Testimony before Intergover
mental Relations Subcommitte of Committee on
Government Operations of House of Repreentatives.
on "Health Research and Training," August 12.
1961 . U.S. Goverment Printing Office, Wahingon.
D.C., 1961.
6. Dunn. H. L. : Points of attack for raising levels
of wellness. J. Nat. M. A. 49:225-235, July 1957.
7. Gregg, A. : Challenges to contemporary
medicine. Columbia University Press, New York,
1 956.
Reprinted by permission from JAOA 61 : 51 5526,
192.
23
Some thoughts on an osteopathic
curriculum (1975)
There seems to be a widely shared,
though unvoiced, conviction among
educators that curricular design
consists of arranging and rearranging
hundreds of hours, each of them ap
propriately labeled with the name of a
"course" (an "ology," an organ
system, or disease-category) and with
the nature of the teacher-student en
counter (lecture, laboratory, clinic,
et cetera). This academic game of
checkers i s continued in the hope that
out of it will emerge that magical
arrangement which embodies effi
ciency. "integration, " and educa
tional excellence. Hundreds of cur
riculum committees all over the
country are engaged in this kind of
exercise. Yet, everybody knows that
no matter how cleverly arranged, a
bunch of weeds remains a bunch of
weeds, and that they never get to look
or smell like roses. What I'm saying is
that it matters much less how the
hours are arranged than what goes on
in those hours, individually and
collectively. I wish to identify but two
factors that determine how worth
while those hours are.
First, it is important to remember
that professional education is a pro
cess, a transaction, that goes on
between two groups of people -
teachers and students. The quality of
the process can be no better than the
quality of the persons who j oin in the
process. Since you cannot choose the
students until you have assembled at
least a minimal faculty, and since it is
the faculty who, in effect, will be
choosing the students, the choice of
the faculty is the most critical factor
in determining the curriculum and its
quality. Therefore, choose the faculty
with the utmost care.
In choosing your faculty members
look carefully at their qualifications.
But look with special care to the per
son who has the qualifications; for,
like the person, qualifications either
grow or they stagnate. It is the person
who determines in what way, how
well, and to what ends the qualifica
tions are used; whether they are dy
namic or static, creative or imitative,
searching or satisfied, impelling or
impeding to institutional progress.
Choose men and women who will
serve well as models of the kinds of
persons and physicians you wish your
students to become.
The second essential factor is that
the faculty share objectives and
principles to which they can whole
heartedly commit themselves, to
guide them in their concerted efforts,
however diverse the approaches to the
objectives and the interpretations of
the principles. Given these two essen
tials, the well-chosen faculty and the
shared objectives and guidelines, a
curriculum suited to both wilevolve,
and continue to evolve. It should not
0prescribed.
In my opinion, the osteopathic
philosophy sets forth objectives and
principles for osteopathic education
so clearly that it never ceases to
amaze me how little they have been
used by our colleges in the design of
faculties, curricula, and educational
programs. Instead, the philosophy,
with its derivative objectives, prin
ciples and methods, has usually been
relegated to an individual department
which, according to its composition,
is either an island or a raft awash in a
turbulent sea.
Let me illustrate in two or three
ways how the osteopathic philosophy
can serve in curricular design. I shall
begin with the principle that " the
body is a unit, " or however one
chooses to express that concept.
To me, this means that the osteo
pathic curriculum must, throughout,
focus on the total person. By all
means, minutely study the compo
nent cells, tissues, organs, systems,
and processes, and the kinds of things
that can go wrong in them and with
them. But always do so in the context
of the total and particular life in
which they participate. In his com
ponent parts and processes, man
differs hardly at all from other
mammals; and, as a matter of fact,
most of. our knowledge about the
parts has come from study of other
animals. Nevertheless, man is a
totally different kind of organism,
and the parts operate in a totally dif
ferent kind of life. It is upon those
unique human features that the osteo-
pathic curriculum should concen
trate. It is in that context that the
parts should be studied, for it is out
of those unique features that man's
health problems arise. Man uses his
biological machinery, so similar
to that of other animals, to live a
totally different kind of life, in man
made and man-transformed environ
ments. (We call them culture and
civilization.) He uses those parts in
different ways and makes different
kinds of demands upon them, too
frequently deleterious. Man's ill
nesses are the products of human life,
and are derivatives of his nature as a
total person. The study of human
health and disease is totally unreal
istic apart from this principle, for
man is more than a collection of
organs and tissues.
There is another corollary of "the
body is a unit" that is of equal
significance, yet which only acci
dentally, if at all, finds its way into
the medical curriculum. And that is
that there is an infinite variety of
ways of being human. This is an enor
mous elaboration on the theme dis
cussed in the foregoing paragraph.
Although all of us have essentially the
same kinds of cells, tissues and
organs, they differ not only according
to our hereditary endowments, but
according to the total personal, and
utterly unique, contexts in which they
operate and have operated through
out our lives. They have been further
differentiated according to our indi
vidual biographies, conditioning,
behavior, attitudes, postures, per
sonalities, beliefs, uses and abuses of
the biological apparatus, and all the
different kinds of lives we live.
Out of these human differences
have come the wide range of differ
ences among humans, even within a
given community, with respect to
levels of vigor, susceptibility to illness
in general and to diseases in particu
lar, frequency and kinds of illness,
the length and quality of the life,
and the causes and manner of dying.
Viewed in this way, diseases would be
seen, not as the "effects" of adventi
tious "causes, " but as the results of
living, under less than favorable
circumstances. To teach about the
heart, the stomach, the thyroid gland,
et cetera, as though they were uni
form in all of us and uninfluenced by
personal context and individual
biography, is absurdly naive and sim-
Osteopathic principles

plistic. For these reasons and others,

the biology of human difference, in
relation to health and disease, must
also be a central theme in osteopathic
education.
Emphasis on health rather than
disease has long been an important
feature of osteopathic thought. The
careful study of human differences as
part of the physician's training would
give new power and substance to this
emphasis. In our centuries-old preoc
cupation with disease and diseases,
and their respective "causes, " and,
more recently, with the one out of
four who contract disease X, the 3.42
out of 10 who succumb to disease Y,
and 273.82 per 10 who die of dis
ease Z, we completely overlook the
lessons to be learned from those who
don't, and especially from those who
don't contract any of these diseases,
and who live healthy lives.
In short, we need to learn the
"causes" of health, as a "phenome
non" in itself - and it i a phe
nomenon. As an old physiologist, I
have a fairly good grasp of the deli
cacy of the countless homeostatic
balances, of the complexities that
enter into the regulation of growth
and cell division, or of arterial blood
pressure, or of renal function, or di
gestion, or hematopoiesis, or what
ever. And it is, therefore, unceasingly
astonishing to me that things don't go
wrong a lot more often - even uni
versally; that everybody doesn't get
cancer, hypertension, blood dyscra
sias, and the other diseases. We need
to look for the causes of "not-cancer"
and "not-hypertension," et cetera.
The answers are to be found in the
study of health and healthy people,
and the many ways of being and re
maining healthy - a by-product of
the study of human difference.
Let me offer a third corollary of
the principle of body unity. It deals
with the most conspicuously "dis
tinctive" feature of osteopathic medi
cine, and it is usually subsumed under
the principle of structure-function
relationship. But, for me, it has most
meaning within the unity context. I
refer to the primacy of the musculo
skeletal system in the total body
unity. This is not only the most
massive and the most energy-con
suming portion of the body, but it is
the system, under the direction of the
nervous system, with which we carry
out human activity, act in and on our
environments and on each other, act
out our individualities, hopes, fears,
beliefs, and our education. All else -
the viscera, circulation, metabolism
- is supportive.
For health, the total body economy
must be continually and accurately
tuned, from moment to moment and
in the long run, to the rapidly chang
ing and long-term requirements o the
musculoskeletal system. This must be
accomplished in each of us, according
to the kind of musculoskeletal system
we have and the ways that we use it;
that is, according to the kind of life
we a.ct out with it. The musculo
skeletal system is the recipient of
most of the output of the central
nervous system, and the source of
most of the input to the central
nervous system. Through its nervous
and vascular connections, the muscu
loskeletal system both reflects and
influences what goes on elsewhere in
the body. This, it seems to me, is at
the very basis for palpatory diagnosis
and manipulative therapy. Therefore,
this corollary - the special place of
the musculoskeletal system in the
organismic, human scheme of things
- must also enter prominently into
the design of an osteopathic cur
riculum.
As another exarple of how osteo
pathic philosophy can enter into
curricular design, let me take another
of the avowed (but neglected) princi
ples. It is the ancient principle of vis
medicatri naturae, reworded by Still
in terms of the body manufacturing
its own medicines. More recently (and
more verbosely) it has been amplified
to state that the body has inherent
capacities for such things as resis
tance to and recovery from injury,
noxious influences, stress, invasion
and infection; for maintenance of,
and return to homeostatic equilibri
um; for healing and repair; for com
pensation for irreparable damage; in
short, the capacities to stay well and
get well.
It seems inescapable to me that an
osteopathic curriculum must, to a
very large extent, be concerned with
the minute study of these capacities
and their mechanisms; with the many
factors in and around the person
which sustain, strengthen and de
velop them; and with the many other
factors that impede and impair them.
Only in this way can the physician
be prepared to support, reinforce, lib-
erate and disencumber the develop
ment and operation of these intrinsic
mechanisms. Only in this way is he
enabled to perform the highest func
tion of the physician, the main
tenance and restoration of health,
which actually is the most compre
hensive form of preventive medicine
(to which we all pay such pious, but
vain, lip-service). It is, of course,
in the context of favorably influenc
ing these self-preserving and self
restorative mechanisms that osteo
pathic manipulative therapy has (or
should have) its core role in clinical
practice.
I could go on to illustrate with
other of the osteopathic principles
and with other corollaries, but my
purpose was only to illustrate, from
my personal viewpoint. Your faculty
will of course have to do this for
itself, from its collective viewpoints.
And they wildo it if they are chosen
well and if they can be helped to see
its importance.
Let me conclude with a few
thoughts that may have some rele
vance to the great task before you and
your colleagues.
1 . It should be obvious that a
curriculum based on osteopathic
principles in the manner that I suggest
crosses all the familiar departmental
boundaries. and has to be organized
on a framework which is indifferent
to those man-made barriers ..It has
always (well, since 1 936, when I first
began teaching physicians-to-be)
seemed absurd to me that instead of
planning the teaching of the physician
in accordance with hi or her needs
and with the way he or she will work,
we plan it for the convenience of the
faculty and in accordance with the
way that scientists (and other special
ists) are classified and catalogued.
By all means, have departments, et
cetera, for administrative or other
purposes, but the teaching must be
designed in accordance with the de
clared objectives and guiding prin
ciples, and not according to the con
ventional "pigeon holes. " To put it
another way, the curriculum should
be designed according to man's
nature, rather than according to the
contrived nature of an institution.
2. Above all, in this connection,
don't have a separate department
(with corresponding courses) of
osteopathic theory and practice (prin
ciples and technique, or whatever the
255
designation). This would be an open
confession that you have not known
how to make this body of philosophy,
art, and science a pervasive element,
much less the "golden thread" that
guides and ties together the entire
curriculum. You would, in effect, be
saying to all other departments,
"This is none of your business; you
are relieved of all responsibility in this
area. "
3. This i s a small point, perhaps,
but an important one, and one that
has "always" troubled me. There is
probably no calling which is more
concerned with life and living than
that of the physician. How ironic to
begin his training by surrounding him
with death and the stinking residues
of life | This is not to question the
importance of anatomy, but only the
timing and manner of its teaching. (It
has been my observation, however,
that in the structure-function rela
tionship in osteopathic education,
function often does come off a poor
second. ) It is no less a mistake, I
believe, to send students for their frst
clinical experience, to a nursing home
or home for the aged, to care for
those at the end of the line, utterly
without hope, and waiting to die.
How much better it would be to begin
the physician's training with the be
ginning of life, when the twig is as yet
unbent or easily straightened.
4. This is a very controversial
point, but one which must be con
fronted. Don't lock in your educa
tional program to a system of health
care delivery which is obsolescent,
and which should have been replaced
decades ago. It is no secret that the
present system is not even remotely
adequate, or appropriately designed,
to meet today's needs, in today's
society. It is so archaic, so anti
quated, so fossilized that it has to be
maintained with all kinds of artificial
infusions and crutches and prostheses
which, in turn, have to be propped
up. And the frantic. enormously
costly, governmental efforts to save
the system with all sorts of artificial
supports and frequently abhorrent,
dehumanizing, disruptive devices for
regulation, supervision, surveillance,
distribution, and intervention, are
only succeeding in overloading an
already overloaded and inefficient
system. It is bound to collapse of its
own dead weight.
As I have repeatedly pointed out,
ZM
the present system makes impossible
the delivery of the best in medicine,
what osteopathic medicine has to
offer - care of the total person and
the maintenance and restoration of
health. I think it is the responsibility
of the osteopathic institutions - and
your proposed college has the best
opportunity of all - to design, pro
pose, and demonstrate forms of prac
tice which are conducive to the
delivery of the best in medicine,
instead of permitting themselves
(inviting themselves! ) to be more and
more enmeshed in a dying system.
. My final point is a derivative
of the previous one. For reasons re
lated to the state of the whole health
care delivery system, the management
of the modern hospital (whatever
may be said about its role in that
system) is a horrendously complex,
highly specialized, high-pressure
business. It is a totally different kind
of operation from that of running an
academic institution, and requires
totally different kinds of people,
minds, interests, and skills. I have no
idea what is contemplated about a
college- hospital affiliation, and
hospital-based training, but whatever
it is, the college must not be permitted
to be caught up in, much less ab
sorbed in, the management of the
hospital, for it is certain to be at the
cost of educational, scientific, and
osteopathic progress.
I am afraid that all of the foregoing
may be of little help to you, there is so
little of a practical nature in it. How
ever, I reemphasize that it is essential
for the faculty and administration to
declare their shared objectives and
principles and be guided by them in
the development and operation of the
college. Otherwise, you live by ex
pediency and by response to daily
crisis, and there is nothing more
deadly to an academic institution.
Reprinted by permission from JAOA 74: 685-688,
1975.

Osteopathic principles