TheCollected Papersof IrvinM.Korr PresentedbytheAmericanAcademyof Osteopathy inhonorofDr.Korr'sseventiethbirthday EditorfortheAcademy:BarbaraPeterson AmericanAcademyofOsteopathy 2630AirportRoad ColoradoSprings,Colorado8091 0 Copyright1979,AmericanAcldemyofOsteopathy Publishedforthe membersof theAmericanAcademy ofOsteopathy TableofContents I.Introductorypapers 5Editor' sforeword:BarbaraPeterson 6Acknowledgments 7Preface:IrvinM.Korr,Ph. D. ,Sc.D. 9Biographicalnotesand appreciation:JudyAlter,Ph.D. 1 1ScientificcontributionsofI. M. Korr:MichaelM.Patterson,Ph. D. 1 3Clinicalcontributionsof I.M. Korr:EdwardG.Stiles,D.O. ,FAAO II.Primaryresearchreports:Studiesonelectromyography,sympatheticnervoussystem,reflexes,andrelatedtopics 1 8Quantitativestudiesofchronicfacilitationinhumanmotoneuronpools (1 947)(withJ .S. DenslowandA. D. Krems) 22Dermatomalautonomicactivityinrelationtosegmentalmotorrefex threshold ( 1 948)(withMartinJ.Goldstein) 23Skinresistancepatternsassociatedwithvisceraldisease(1 949) 23The automatic recording of electrical skin resistance patterns on the human trunk(1 951 )(withPriceE.Thomas) 29Relationshipbetweensweatglandactivityandelectricalresistanceofthe skin(1957)(withPriceE.Thomas) 33Patternsof electricalskinresistance in man(1958)(withPriceE.Thomas andHarryM.Wright) 41Amobile instrumentfor recording electricalskin resistance patternsof the humantrunk(1958)(withPriceE.ThomasandHarryM.Wright) 45Localandregionalvariationsincutaneousvasomotortoneof thehuman trunk(1 960)(withH. M. WrightandP. E.Thomas) 54Effectsof experimentalmyofascialinsultsoncutaneouspatternsof sympatheticactivityinman(1 962)(withH. M. WrightandP.E. Thomas) 66Cutaneouspatternsof sympatheticactivityinclinicalabnormalitiesof the musculoskeletalsystem(1964) (withHarryM.Wrightand John A. Chace) 73Neuralandspinalcomponentsofdisease:Progressintheapplicationof "thermography"(1 965)(withH. M. Wright) 75Whatismanipulative therapy?(1 978) 77Sustainedsympathicotoniaasafactor indisease( 1 978) III.Axonaltransport,trophicfunctionsof nerves 92Studiesin neurotrophic mechanisms (1 966) (with P. N.Wilkinson and F.W. Chornock) 93Axonaldeliveryof neuroplasmiccomponentstomusclecells(1 967)(with P. N. WilkinsonandF.W.Chornock) 96Thenatureandbasisofthetrophicfunctionofnerves:Outlineofaresearchprogram(1 967) 99Studiesintrophicmechanisms:Doeschangingitsnerve changeamuscle? (1 967)(withF.W. Chornock,W.V.Cole,andP. N. Wilkinson) 1 00Continuedstudiesontheaxonaltransportofnerveproteinstomuscle (1 970)(withG. S. L.Appeltauer) 1 02The time-courseof axonal transportof neuronalproteinstomuscle (1 974) (withGustavoS. L. Appeltauer) 1 07Axonaldeliveryofsoluble,insolubleandelectrophoreticfractionsof neuronalproteinstomuscle (1 975)(with Gustavo S. L.Appeltauer) 1 1 2Electrophoreticcharacterizationofneuronalbasicproteinsinskeletal muscle(1 976)(withG.Appeltauer) 1 1 3Furtherelectrophoreticstudiesonproteinsofneuronaloriginsinskeletal muscle(1 977)(withGustavoS. L.Appeltauer) 1 1 8Axonal migration of some particle-bound proteins in thehypoglossal nerve andtheirfailuretoenterthestyloglossusmuscle(1 978)(withGustavo Appletauer) IV.Interprtationofresearchfindings 120Theneuralbasisoftheosteopathiclesion( 1947) 128Theemergingconceptof theosteopathiclesion( 1948) Thethreefundamentalproblemsin osteopathicresearch(195 1) 14The concept of facilitationand itsorigins( 1955) 1Clinicalsignificance ofthelacilitatedstate (1955) 158Osteopathicresearch:Why, what.whither?(1957) 169What"osteopathy"and"the osteopathicconcept"meantome(1962) 170Thesympatheticnervoussystemasmediatorbetweenthesomaticand supportive process(1970) 75Vulnerability ofthesegmentalnervoussystemtosomaticinsults( 1970) 178Thesegmentalnervoussystemasamediatorandorganizerofdisease processes( 1970) Thetrophicfunctionsofnervesandtheirmechanisms( 1972) 188The facilitated segment:Afactorininjury tothebodyframework ( 1973) 19Andrew TaylorStillMemorialLecture:Researchand practice-a century later(1974) 196Neurochemicalandneurotrophicconsequencesofnervedeformation: Clinical implicationsinrelationto spinalmanipulation( 1975) 20Proprioceptorsandsomatic dysfunction( 1975) 0Thespinalcordasorganizerofdiseaseprocesses;Somepreliminary perspectives( 1976) 214The spinal cord as organizer of disease processes:The peripheral autonomic nervoussystem( 1979) V.Osteopathicprinciples,practiceandprofession 224Thesomaticapproachto thediseaseprocess ( 1951) 228The function oftheosteopathic profession:Amatterfor decision ( 1959) 2Anallegory:AforgottenepisodeinAmericantransportationhistory ( 1961) 244Osteopathy and medicalevolution( 1962) 254Somethoughtson anosteopathic curriculum ( 1975) Editor'sforeword Thisis1 979,andthisyearDr.Irvin M.Korrcelebrateshisseventieth birthday.Itwould havebeeneasyto findpeopleto contributetheirworks toaFestschrit(orDr.Korr;his influenceandfriendshipsarewide, bothinsideandoutsidetheosteopathicprofession.However,the publicationscommitteeoftheAmerican AcademyofOsteopathyhasdonea wiser thing:It has proposed collecting Dr.Korr'swidelyscatteredwritings intoasinglevolume,foruseand study by everyone, limiting the birthdaytributestothreeshortintroductoryessays. EventhechoiceofwhoshQuld writethebirthdayessayscouldhave been aproblem;but again the Academywasfortunate.AtTexasCollege ofOsteopathicMedicine,whereDr. Korrisprofessorofmedicaleducation, a projectwasunderway toproduceakindof"tributeandinterpretation"bookletinhishonor. When the TCOM editors heard about the Academy project,theygraciously agreedtomergetheirwritingswith ours.So,thehardchoiceswerealreadymade. Asitappears,thisisathickbook, butitcouldhavebeenthicker.Dr. Korrspeaksself-deprecatinglyabout howhehas"cluttereduptheliterature,"and he calls the task of reading some of his earlier works "an exercise inosteopathicarchaeology. "Nevertheless,whenthepublicationscommitteediscussedwhatmightbeleft out,theyfoundthemselvespraising the older papers as ofen as the newer ones.In the end it wasDr.Korr himselfwhoproposedloppingoffthe first21itemsofhisbibliography, representing the workdone before he joinedthefacultyofKirksville CollegeofOsteopathicMedicinein 1 945.Severalotheritemscouldbe deletedbecausetheyduplicatedin somemannermaterialalreadyincludedunderanotherheading. Sectionsareincludedfromthree publishedbooks,allof whicharei n print as of this date;the readermight behelpedintheseinstancesbylookingatthecontextin whichthe essays originallywereset.Everythingelse comeseitherfromperiodicalliterature or unpublished sources.The first twopapersinanewseries,underthe generaltitleof"TheSpinalCordas OrganizerofDiseaseProcesses," appearinthisvolume,thesecond almostatthesametimeasitis publishedinJAOA.Itwouldhave been ideal to have the complete series, but the two dostand alone -and the othersarenotyetwritten,Dr.Korr's literaryworkisverymuchaliveand well. OnewholeaspectofDr.Korr's personalityhadtobeomittedfor sheerlackofspace.Thisisrepresentedbywritingshecallswhimsey, and theyincludesuchsobertopics as nephrotrichosis,fetal suicide, and the directconversionofplantprotein intoanimalprotein.The lattertopic, whichweareassuredisfitonlyfor the Joural of Irreproducible Results. evidentlyhasneurotrophicaspects; thereisasubtitlerelatingtotheimplantationand innervationof an ear ofcorn.Onesuspects,knowingDr. Korr, thatoneshouldnot pursuethe mechanismofthisscientifcprocess tooclosely,atleastinmixedcompany. Letusinsteaddealwithmoreseriousscientificmatters.Afterthe introductorypapers,thematerial dividesneatlyintoprimaryresearch reports,the interpretation of research findings,andpapersonosteopathic practiceandtheosteopathicprQfession.Papersineachsectionare arrangedchronologically,withthe researchreportsdividedintotwo parts.Thefirstcontainsstudieson electromyography,thesympathetic nervoussystem,reflexes,andrelated topics.The second includes studies on axonaltransportandthetrophic functionsofnerves. Dr.Korr,from hisearliest associationwiththeprofession,hataken painstointerprethisstudiesina clinicalcontext,whichdoubtlessis one of the reasonsforhis broad and lasting influenceinapatient-oriented profession.Inthisconnection,Dr. Korrhasprovidedforthisbookan introductiontohisownwritings, placingthemincontextwithhis carer.It would be superfuous to say more aboutthem here. Whatshouldbesaid.however,i s that the Academy counts it a privilege tohonorDr.Korron theoccasionof hisseventiethbirthday.Theeditoris bothprofessionallyandpersonally gratefultohimfortheeffortand cooperationthatmadethisvolume possible. BAPETERN 5 Acknowledgments ParticularthanksaredueDr.Korr. forprovidinmaterialsandcommentsthatprovedinvaluableinthe choiceandarragementofmaterias forthisvolume. Appreciationalsoisexpressedto MarthaI.Drew,Ph.D.,directorof theAmericanAcademyofOsteopathy,andtoBarbaraJ.Wood, assistanttothedirector,whoparticipate heavilyinthe productionof thisbook. MembersofthepublicationscommitteeoftheAmericanAcademy ofOsteopathywhoparticipated directlyintheplanningofthis bookincluded:SaraE.Sutton, D.O.,FAAO,chairman;ViolaM. Frymann,D.O.,FAAU;JohnP. Goodridge,D.O.,FAAO;William L.Johnston,D.O.,FAAO;DavidA. Patriquin,D.O.,FAAO;andDonald Siehl,D.O.,FAAO. Specialthanksgotothosewho contributedintroductoryessaysand whosenamesappearinconnection withthem,andtothe co-authorsand publishersofmaterialsincludedin thisbook.Individualreferencesat theendofeachpaperidentifyexact sources.Followingisalistofjournals,institutionsandorganizations whosematerialshavebeenincluded herein. ActaNeurovegetativa AmericanAssociationfortheAdvancementofScience(Science) AmericanOsteopathicAssociation (JAOA,THED.O.TheForumoj Osteopathy.Health.Osteopathic Magazine) AmericanPhysiologicalSociety (TheAmericnJouralojPhysiolog,JouralojAppliedPhysiolog) ElectroencephalographyandClnicalNeurophysiolog.Elsevier-North HollandBiomedicalPress Epermental Neurology FederationofAmericanSocieties for Exprimental Biology(Federation Pocedings) KirksvilleCollegeofOsteopathic Medicine(Journaloj Osteopathy) OsteopthicAnnal,InsightPublishingCompany PlenumPublishingCorporation ThePostgraduateInstituteof OsteopathicMedicineandSurgery (ThePhysiologicalBaiojOsteopathicMedicine) 6Introductoryessays Preface My"osteopathic"careerbeganwith myappointmenttotheKirksville facultyinDecember1945.Ata na tionalconventionoftheAmerican OsteopathicAssociationsevenor eightyearslater,Iwasintroduced to adelegatewho,onrecognizingmy name,said(Ithinkwithasmile), "Oh yes, you're the fellow who keeps clutteringupourliterature."The littertowhichhereferredhascon tinuedtoaccumulateinthequartercenturythatfollowed,tothepoint thatitnowseemspartoftheosteopathiclandscape.Thoughblownand kicked around,it does not seem to get lost,only morescattered.I am deeply grateful,therefore,totheAmerican AcademyofOsteopathyforundertaking to tidy up the mess and to tie it upinoneneat,disposablebundle -andespeciallyforthinkingthejob worthdoing.Specialappreciationis dueBarbaraPetersonforwielding theeditorialbroomanddustpanso skillfully. Howdidanon-D.O. ,aPh.D.in physiology,cometofillthe pagesof the osteopathic journals with so many words- quiteasidefromthosehe senttoresearchjournals?(And perhapsevenmoreperplexing,why were so many of them read?) In retrospect,itseemsthatapatternbecame setwithmyveryfirstosteopathic publication.Thearticlewas-pretentiouslyandnaively- entitled, "The Neural Basis of the Osteopathic Lesion,"asthoughitwereafinal statement I That paper beganasapersonal exerciseinverbalizingtomyselthe exciting new insights that came out of myreadingofStedDenslow'searlier researchreportsintheJouraloj Neurophysiologyandelsewhereon segmentalmotorreflexthresholds, outofourfirstjointresearcheffort (reported inthe American Joural oJ Physiologin1947,actuallymyfirst ventureintothefieldofneurophysiology)andoutofmybeginning studiesofsegmentalvariationsin sympatheticactivityinhumans. It was, originally,only my intent to summarizeformyselfmyunderstandingof themeaningandpossible implications of the concept of chronic segmentalfacilitation.Thisconcept hadalreadyemerged fromSted'searlierstudiesandwasreinforcedand furtherelaborated by our subsequent investigations.However,oninvitationfromoneofthesessionchairmen,Ihesitantlypresentedmy summaryandspeculationsatthe annualconventionoftheAmerican Osteopathic Association in July1947. The cordial responseof thosepresent movedmetoconsidermakingmy thoughtsavailabletoallD.O.'swho mightfindsomethingofinterestin them.Thepaperwaspreparedfor publicationandsubmittedtoTe Jouraloj the AmericanOsteopathic Association,whereitappearedin December1947. Theresponsewasamazing,andit continued foryears.Practicing D.O.s apparentlyfoundinitaratiomizationoftheirclinicalobservations andaplausibleexplanationofthe waysinwhichthe"osteopathic lesion"washazardoustoone's health.Itseemedtoreinforcetheir convictionsaboutthevalueofosteopathicmanipulation.Asamatterof fact,Iamtoldthatthearticleisstill requiredorrecommendedreadingin atleastsomecollegesofosteopathic medicine,apracticeIaminclinedto viewasanexerciseinosteopathic archeology(muchasit pleasesme). Withthisencouragement(Ididn't seemtoneedmuch)itbecamemy practice,from time to time,to report inpublicationstotheosteopathic professiononourresearch,summarizing ourobjectives, our findings, ourviewsonpossibleclinicalsignificance,togetherwithadditional questions for furtherexploration and testinginthe laboratory orin clinical practice.These papers are grouped in SectionIV," Interpretationofresearchfindings."Theyhavebeen basedonresearchreportspreviously or subsequentlypublishedin research journalsandpresentedatscientific meetings.These,the"Primaryresearchreports,"areassembledin SectionsIIandIII. Withmygrowinggraspofthe meaningofLheosteopathicprinciples,thankstomycolleaguesatthe collegeandthemanyfriendsIwas findingintheprofession,itbeganto becomeevidenttomethatphysiologicalprocessesandtheirdisturbances intheindividual human could befullyunderstoodonlyinthecontext,notonlyofhumanlife,butin thespecificcontextofthatperson's totallifeandhisorhertotalphysical andsocioculturalenvironment,past and present.Theabstractgeneralizations usually taught in the classroom, expressedinsuchtermsasthe heart. therenalcirculation,thedigestive system.etc..wereindeedabstractions,andtheynolongersuffced. AsIcametounderstand more and morethatallphysiologicalprocesses were conditioned by the circumstances oftheindividuallifeofwhichthey werecomponents,thescienceof physiologybegan,forme,toburst out of itstraditional boundaries inall directions.Mystudies,outside ofthe laboratory.tookme into the contiguousareasofthebehavioralsciences, socialsciences,anthropology.epidemiology.comparativehealthcare systems,economicsandeventhe arts.Ibegantodiscernunfortunate trendsandemergingcriticalneeds andproblemsinAmericanhealth whichAmericanmedicine(including osteopathicmedicine)wasnot,generallyspeaking,recognizing,confrontingorpreparing for. This led me totryto"teach"theosteopathic professionitsbusinessbypresuming topointoutwhatIregardedashistoricopportunitiesforwhichitsf philosophyandmethodsuniquely preparedit.The1951paper,"The somaticapproachtothedisease process," was perhaps the first of this genre.Withsucceedingpapers,the tone became more urgent,exhortative andstrident,culminatinginthe period1959-62(theperiodofthe "Californiacrisis"), inpolemic ("Thefunctionoftheosteopathic profession"[ 195 1]and"Osteopathy andmedicalevolution,"[ 1962J)and evenacerbicsatire("AnAllegory," [ 1961] ). Following the Californiadebacle,I withdrew,defeated.fromthisarena, and abandoned (for awhile) my selfappointedroleaspointerofdirectionsandshouterof"Excelsior." Returningtotheivorytower,I turnedtothecompletionofreports onearlierresearchwithmylate colleagues,PriceE.Thomasand HarryM.Wright,andthentonew areasofresearchonthetrophic functionsofnerveswithPaulN. WilkinsonandGustavoAppeltauer, bothof whomarealsodeceased. In1973cametheinvitationto returntothe"arena"throughthe annualA.T.StillMemorialLecture at the annualconvention ofthe AOA 7 inNewOrleans.Bythistime,however,somematuring hadtaken place, andIhadbeomeconvincedthata quietdisplayoftheevidenceona bedofswetreasoningwasinorder, ratherthan raucous effortsatpersuasion.Ithinkthechangeoftoneis evidentinthelecture(thoughit disappointedmany whopreferredmy ferventevangelism).Ihadbecome convinc,also,thatanyeffortsto influencediretionsofosteopathic developmentwouldbestbeexerted through the education ofour doctorsto-be.Thisconvictionisreflectedin ashortarticleoncurriculumpublishein1975(andinmycontinued effortsas professorofmedical educationattheTexaCollegeofOsteopathicMedicine).Thisheterogeneous groupofarticlesthroughwhichI sought,toputitbriefy, todivert osteopathicpractice,policyandeducationfromthepursuitofdiseaseto theputsuitofhealth,comprisesSectionV,"Osteopathicprinciples, practiceandprofession."Thissectionisrelatedtoapersonalstatement ofwhattheosteopathicconcept means tome, written in1962 and previouslyunpublished,whichappears on page169.(Incidentally,I continue tothinkthattheosteopathicprofessionisstillpassingupanhistoric opportunitytofulfllitsroleasan urgentlyneededreformmovementin AmericanMeicine). Impossibletoincludeinthiscollection,exceptforexcerptsinSection II,isthebook"TheNeurobioiogic MechanismsinManipulativeTherapy"whichIeditedwiththeexpert assistanceofMrs.EthelHuntwork, publishedin1978byPlenumPublishingCorporation(andavailable throughtheAmericanAcademyof Osteopathy).Thatvolumewasthe productofaninternationalworkshop,sponsoredbyMichiganState UniversityCollegeofOsteopathic Medicine, duringmytenurethere asprofessorintheDepartmentof Biomechanics,andfundedbythe NationalInstituteofNeurological andCommunicativeDisordersand Stroke.Itwasmyprivilegetochair theplanningcommitteeandtheconferenceitself.Fromtheviewpointof theosteopathicprofession, perhaps itsmainachievementhasbeento establishmanipulativetherapyasa valid and fertileareafor fundamental scientificinvestigation. 8 Theperiodsince1945has,forme, beenagreatadventurewhichstill continues.Ishallalwaysbegrateful tomyfriends,J.S.Denslow, then professorofosteopathictechnique anddirectorof the StillMemorialResearchTrust,andMorrisThompson, thenexecutivevice-president(and soon-ta-be president) of the Kirksville college,forhavingattractedmeto that adventure,asIstood,uncertain, atapost-warforkintheroad,and forthemanyyearsoftheirsupport and encouragementas myfriends and colleagues. Therearenumerousothersto whomI amindebtedfor havingmade thelongadventuresorewarding: PrinceE.Thomas,D.O.,and. HarryM.Wright, D.O., wholef theirpracticesin1949and1950,respectively,tojoinmeinresearch and inteaching,andwho, throughtheir academicachievements,eventually establishedthemselvesasprofessionallyqualifiedphysiologists.Tragically,theircareerswerecutshortby deathduetocancer. ElliottLeeHix, Ph.D., who, in 1953,joinedtheDepartmentof Pharmacology(thenundermyadministration),whoalsosoonfound excitementinthenewkindsofresearchquestionsthatcameoutof osteopathictheoryandpractice,and whomadefundamental contributions tothepathophysiologyofvisceral organs.Heremainsaclosefriend. ThelatePaulN.Wilkinson.B.A . whoseskillsinradioisotopetechnologyenabledusin1966-67to demonstrateforthefirsttimethe deliveryofnerve-cellproteinsto musclecellsviatheaxons,asa possiblemechanisminthetrophic functionsofnerves. GustavoS.L.Appeltauer.M.S., whocamefromUruguayin1967to joinmeinthatresearch,andwhose skillsmadepossiblequantitative analysisofthedynamicsofaxonal deliveryofproteintomuscleandthe demonstrationoffour"wlwes"of delivery,eachcarryingdifferent proteins.Hispromisingcareeralso wasinterruptedbyprematuredeath. EmilD.Blackorby,whocameto theCollegein1951,whosesuperb skills and inventiveness inelectronics, metal-workingandvirtuallyall aspectsofresearch-and-teaching instrumentationwereofinestimable value.Withoutthem, manyofour achievementsbothinteachingand in researchwouldnothavebeenpossible.Thereseemedtobenothing "Blacky"couldnotfix,andnodevice he could not design and construct tosolveatechnicalproblem. GertrudeKrueger,mysecretary and colleague for morethan21 years. andadministrativeassistant,librarian, accountant, grant-managerand friendtoall ofusintheconglomerate knownastheDivisionofPhysiologicalSciences,andespeciallythe DepartmentofPhysiology,whereshe stillcontinuesherskilledandloyal service. Allthetechnicians,studentassistantsandFellowswho joineduswith suchdedicationandskillsinour teachingandresearchprograms. Allthestudentswhorespondedso magnificentlytothelearningopportunitiesIofferedthem,andtothe manyotherswhohadgoodreasonto resentmyexactingstandards,but who,eventually, founditintheir heartstoforgiveme.Itistheirprofessionalachievementsthathave mademylifeasateachersucha rewardingone. Especiallynoteworthyaretwo formerstudents, RalphL.Willard, D.O.,andJamesR.Stookey,D.O., who(amongothers)achievedtheexaltedstateofDeanship,andunder whomIwaspleasedtoserve,frstat KCOMandcurrentlyatTeOM. All themembersoftheosteopathic professionwhohavereadmyarticles withinterestandwho.further,have takenthetimetoconveytheircommentsandcriticismsandto share theirinsightsandexperience.Their responsestomyeffortsandtheir contributionstomy"osteopathic"educationaredeeplyappreciated. Theosteopathicphysicianswho, throughtheyears,andatthreecolleges, havegivensogenerouslyof their skillsandtimetohelpmaintain myhealthandvigorthroughregular manipulativecare:J.S. Denslow,the lateJohnA.Chace,GeorgeA. Laughlin,WilliamL.Johnstonand MarionE.Coy.Iamconvincedthat theircarehasbeenacritical factor in mycontinuedgoodhealth. Finally,alltheosteopathiceditors andtheirassociateswho,throughthe pagestheyprovided, sogenerously metmyneedforself-expression. IRVINM.KORR,PH. D. ,Sc.D. Introductoryessays Biographicalnotesand appreciation IrvinM.Korr,Ph.D.,beganhis association with osteopathic medicine inscientificresearch,and,througha longanddistinguishedcareer,hehas becomeknownasamajorcontributortothemodernscientificunderstandingoftheprofession'sdistinctivecontributiontothefieldof medicine.The impact ofhisworkhas beenfeltinbasicresearchareasand inclinicalmedicine.ButtheimportanceofDr.Korr'scareerandhis writingsgoesbeyondscientificresearchtoembracebothteachingand philosophy. Both in theclassroomandin areas suchascurriculumplanning,hehas becomerenownedforhisknowledge andinsightintothespecialproblems of osteopathiceducation. Further,he hasestablishedhimself,inwriting andatthelectern,asone of the most articulateexponents'oftheprofession,thephilosopherwhobringsto theosteopathicconceptablendof understanding,wisdomandenthusiasm for hissubject. Dr.Korrwasgraduatedfromthe UniversityofPennsylvaniawitha Bachelor of Arts degree in the biologicalsciencesin1930.andhewas awardedtheMasterofArtsdegree from that university in 1931.The winnerofafellowshipinthebiological sciencesatPrincetonUniversity.he spentthreeyearsingraduatestudy thereandwasgrantedthePh.D. degreein1935.Anadditionalyearat Princetonwasdevotedtoapostdoctoralfellowshipwithspecialresearchin cellularphysiology. Inthefallof 1936,Dr.Korr joined thefacultyoftheDepartmentof PhysiologyattheNewYorkUniversityCollegeofMedicine.Inaddition toteaching,hecontinuedhisinvestigations in the areas of cellular metabolismand renal physiology and,with membersoftheDepartmentofPsychiatry,conductedresearchinthe fieldofinsulincoma.Thesestudies weresupportedbytheAmerican PhilosophicSociety,thePletz Foundation,theAmericanAcademy ofArtsandSciences,andWarner InstituteforTherapeuticResearch. From1942to1945,Dr.Korrwas engagedinresearchundertheauspicesoftheWarDepartmentandthe OfficeofScientificResearchand Development.Hisinvestigationsin aviationmedicine,woundballistics andclimaticphysiologyduringthis periodwereconductedatColumbia UniversityCollegeofPhysiciansand SurgeonsandatPrincetonUniversity.Alsoduringthistime,hewasappointedseniorphysiologistatthe FortMonmouthSignalCorps,where hedirectedtheMetabolicandBiochemicalLaboratoryoftheClimatic ResearchUnit. Dr. Korr joined members of the osteopathicprofessioninDecember 1945whenheacceptedanappointmenttothefacultyoftheKirksville College of Osteopathic Medicine. The appointmentwasforoneyear,and, inhisownwords,Dr.Korr fullyexpected to return to university teaching aftertheyear.Oneyearlengthened intothirty."Onethingledto another,"hehassaid,"andIjust couldn'tleave.I'mgladIstayed.I wouldn'thavemisseditforthe world." Duringthosethirtyyears,Dr.Korr servedasteacher,departmentaland divisionaladministrator,researchinvestigator,advisorandcounselorto students,interns,residents,faculty and staff. In 1945, he was named professorandchairmanoftheDepartmentofPhysiology.From19S2to 1968,healsoservedaschairmanof theDivisionofPhysiologicalSciences, and in1968 he was named DistinguishedProfessorofPhysiology. From1968to1975,heservedasdirectoroftheprograminneurobiology. In1975,Dr.KorrendedhisthirtyyearassociationwiththeKirksville collegetoaccept a long-standinginvitation to join the faculty of Michigan StateUniversityCollegeofOsteopathicMedicineasprofessorofbiomechanics.Forthenexttwoyears, hisenergiesweremainlydirected towardtheplanningofaninterational research workshop on HNeurobiologic MechanismsinManipulative Therapy,"which was held in October 1977.Theproceedingsofthisworkshop,editedandwithaprefaceby Dr.Korr,werepublishedbyPlenum PublishingCorporationin1978. Inthe fall of 1978,lured bytheopportunitytoparticipateinthedevelopmentofanewcollege,Dr.Korr leftMichigantojointhefacultyof NorthTexasStateUniversityHealth SciencesCenter/TexasCollegeof OsteopathicMedicine.Inadditiontoa chancetoworkwithacollegewhich hedescribesasstillexperimentaland stillwillingtomakemistakesam learnfromthem,theappointmentas professorofmedicaleducationat NTSU/TCOMofferedDr.Korran opportunitytobesurroundedby formerstudents.Somefortyofhis formerstudentsandassociatesserve onthefacultyandadministrationof theTexascollege. Dr. Korr is a member of the American Physiological Society,theSociety forExperimentalBiologyandMedicine,theAmericanAssociationof UniversityProfessors,SigmaXi,the AmericanInstituteofBiologicalSciences,theSocietyofNeurosciences, and theAmericanSocietyforNeurochemistry.HeisaFellowinthe AmericanAssociationfortheAdvancement of Science,aLifeMember intheHarveySociety,anHonorary LifeMemberoftheAmericanAcademyofOsteopathyandanHonoraryMemberofPsiSigmaAlphaand SigmaSigmaPhi,honoraryscholasticfraternities.Heislistedin American Men 0/ Science andWorldWho's WhoinScienc,andistherecipient ofanhonoraryDoctorofScience degreeandaLivingEndowment awardfromtheKirksvilleCollegeof OsteopathicMedicine. Thefactthathismostrecentappointmentisinthefeldofmedical eucationratherthanbasicscience researchissignifcantofhisreputationasateacher.Dr.Korrisnoted forhisperceptionoftheinteraction between student and teacher and for a recognition oftheburden of responsibility on faculty.Formerstudents cite hiscommitmenttostudentsandhis abilitytodefneanddescribeclearly theholisticosteopathicconceptin termsofmodernscientificknowledge.Inpublishedwritingson education,Dr.Korremphasizeshiscommitmenttomaintainingtheosteopathicprincipleandideabystressing theimportanceofintegratingthe holisticconceptintoallareasof teaching. The sameenthusiasmfortheosteopathicconceptthatcharacterizeshis approachto teaching isevidentinDr. Korr'sextensivecareerasalecturer. Hehasspokenbeforesuchscientific societiesastheAmericanPhysiologicalSocietyandtheSocietyfor 10 Neuroscience,beforeamajorityof theosteopathicdivisionalsocieties, and atseminarsat variousuniversities acrossthecountry.LectureinvitationshavetakenhimtwicetoEngland,whereheconductedpostgraduatecoursesattheBritishSchoolof Osteopathy. ,andtoAustralia,where hespokeattheLincolnInstituteof HealthSciencesinMelbourne,In 1948andagainin1959,hewasthe keynotespeakerattheAnnualConventionandScientificSeminarofthe AmericanOsteopathicAssociation. In1967hewasasked to give the Scott MemorialLectureattheKirksville College of Osteopathic Medicine,and in1973hewashonoredbybeingask-. edtodelivertheAndrewTaylorStill Memorial Lecture at the Annual ConventionoftheAmericanOsteopathic Association.In1975,hepresented theLouisaBurnsMemorialLecture atthe19thAnnualResearchConferenceoftheAmericanOsteopathic Association. Dr.Korr'spublishedwritingsincludenearly10articlesinscientifc journalsandabroad.and. theyrange fromreportsofresearchtoessays onthephilosophyofmedicine. Unknowntosome,hiswritinghas branchedouttoincludesuchphilosophicalpiecesasanallegorywhich comparesosteopathicmedicinetoa railroadtransportationsystem.His shortpiece,"What'Osteopathy'and 'TheOsteopathicConcept'MeanTo Me"hasbecomeaclassic. WiththepublicationofthiscollectionofDr.Korr'sworks,notonly willhisscientificresearchbereadily availabletotheosteopathicprofessionandthescientificcommunity, butequally thewitand wisdom ofhis educationalandphilosophicalwritings on medicine willbeeasiy accessibletothemanywhoarehisfriends. colleaguesandformerstudents. JUYATER,PH.D. Introductoryessays Scientificcontributions ofI.M.Korr Theevolutionofanydisciplinedepends upon both the accumulation of knowledgeandtheinterpretationof that knowledge within the framework ofthediscipline.Withoutthesetwo elementsprovidingimpetusforboth growthandredefnitionofitsstructure,anareaofendeavorsoonbecomesobsolete.Medicalhistoryis repletewithexamplesofschoolsof thought which have passed from existenceduetostagnationofthought, leadingtononcompetitivenesswith moredynamicandgrowing areas. TheworksofI.M.Korrreprinted in this book represent efforts over the span of almost35yearsboth to accumulate knowledgeandtointerpretit in the context of osteopathic thought. Insodoing,Korrhasalsoinevitably alteredtheveryframeworkofthat thought.Theamountandeffectof thesealterationscanneverbe measuredaccurately,althoughtheir resultswillbe feltfortheforeseeable future. In thisbriefoverview and introduction,Iwouldliketo putKorr'sbasic writingsintohistoricalcontext,then providesomeevaluationofthedata andinterpretationsin lightof current researchandtheory.Thistaskisat once humbling and necessarily impossibletocomplete:humblingbecause Korrisfirstapersonalmentorand second a colleague;andimpossible to completebecauseheisstillactivein both gathering data and providing interpretations.However,itishoped thatthe perspectiveswillbehelpful. "Kim" Korr frst joined the faculty attheKirksvilleCollegeofOsteopathyandSurgeryin1 945,having alreadyestablishedhimselfasawellknownscholarinvariousareasof physiology.Atthattime,J.S.Denslow'sworkonelectromyographic correlatesofpalpatoryfindingsand the"osteopathiclesion"waswell under way.Fascinated by both the osteopathictheoryofstructure-functionrelationshipsandintegrationof function,andby the pioneering work inDenslow'slaboratory,Korrbegan aninterestwhichhasabsorbedmuch of hissubsequent career:the relationshipsbetweenvisceralandskeletal componentsofthebody. CollaboratingcloselywithDenslow,Korrofferedinterpretationsof thedatabeingaccumulated.Theresearch group was soon expanded with theadditionofPriceE.Thomas, D.O.,in1 949,HarryM.Wright, D.O. ,in1 950,andElliottL.Hix, Ph.D., in1 953.This group comprised thenucleusofresearchpersonnel whichremainedactiveformany years,asthepapersreprintedhere show.Otherswerealsoessentialto theresearch,includingEmilBlackorby.or"Blackie"as he is still affectionatelyknowntohundredsofstudentsandfaculty,whoseskillin equipmentdesignandconstruction enabledtheresearchtocontinpe,as wellastheChornocks,Eble,Chace andmanyothers.Importantinthis perspectiveisthefactthatKorrwas heavilyinvolvedinenticingmostof thisinnovativeanddedicatedgroup toKirksvilleduringtheformative stagesofmodernosteopathicresearchandtheorybuilding. Withthepassingofyears,this groupmademanycontributionsto currentosteopathicthought,and,as thepaperspresentedheretestify, Korr'sleadershipwasevidentand pervasive.Theresearchthrustof the grouplostmomentumint he mid-1 960s,andKorrturnedt o what wastobehismajorresearchcontributiontomodernneurophysiology: investigationsofthemechanisms underlyingtrophicfunctionsof nerves.GustavoAppeltauerjoined Korrin1 967forthismajorresearch endeavor.In1 974,KorrlefKirksville for the Michigan State College of Osteopathic Medicine and at the same timeleftactivelaboratoryresearch. He has since been involved in redefining some of hisearlierinterpretations andinpursuingtheimplicationsof one of hismajor interests,the role of the autonomic nervous system in total physiologicalfunction.Thisactivity has continued withhis recent move to theTexasCollegeofOsteopathic Medicine. Thedirectionand weightof Korr's contributionstoosteopathictheory and research were manifest soon after hisarrivalatKirksville.Twopapers in1 947,onewithDenslowand Krems,werebothgerminalcontributionssettingthestageforthenext1 5yearsofwork. The fi r s t paper cont i nued Denslow'sclassicresearchonelec-tromyographiccorrelatesofpalpatory findingsand extendedthe results toprovidecleardefinitionsofthe characteristicsofabnormalskeletal muscleactivitywhichwasoften foundinareasof osteopathiclesion. Therewerealsospeculationsabout possiblecausesandmaintaininginfluencesfortheobjectivelyobserved abnormalactivity. Thesecondpaper,"Theneural basisoftheosteopathiclesion,"is oneofthemostimportantofKorr's worksinthe profession.Here,he put forththeideasofthe"neurological lens"andthe"facilitatedsegment." Thismajortheoryof regionalexcitationofthespinalcordservingasan abnormalareaofoveractivity.being drivenbybothexternalandinteral sourcesofstimulationandfocusing thisactivity into abnormal patterns of skeletalandvisceralactivity,wasa conceptualbreakthrough.Research inmanyareasofcentralnervous systemactivitytodayisreporting mechanismswhichcouldserveas activating andmaintaining forcesfor theeffectsobservedandspeculated on intheseearly papers.It isnowevidentthatlocalizedhyperactivityin thespinalcordmaybeaprimitive form of pattern learning inthe spinal reflexarcs.Itisperhapsunfortunate thattheterm"facilitatedsegment" wasused,asitimpliedacircumscribedareaofabnormalactivity associatedwithvertebralstructure, aninterpretationnotstrictlyintended intheoriginalformulations. Fromthesefirstpapersflowedresearchandtheoriesoverthenext1 7 years,from1 948through1 96'.The major impact of this work was the explicitdemonstration,through various meansoftheexistenceofabnormal activitypatternswithintheautonomicnervoussysteminapparently normalaswellasdiseasedhumans, and the correlation of some abnormal autonomicpatternswithmusculoskeletalabnormalities.Throughout thisperiod,Korrwroteontheinteractionswhichtohimwereevident betweentheautonomicandskeletal portionsofthenervoussystem,the implicationsofabnormalautonomic activityforhealthanddisease,and thelongtermeffectsofoveractivationofanyportionofthenervous systemoninnervatedstructures.Unfortunately,theconceptofcloseinteractionbetweenskeletalandauto-11 nomic nervous systems was not generallyacceptedin neurophysiologyand certainlynot in medicine, and is only nowbeginningtoberecognized. Thus,whiletheconcept.ofspinal "facilitation"wasevidentinthe studieshedidandsupervised,the basicneurophysiologicaldatashowingtheactualexistenceofreflex pathwayssubservingKorr'sargumentswaslacking.Morerecently. work in various laboratories (see, e.g. Satol)isdemonstratingtheneural pathsthroughwhichtheinteractions seenbyKorrclinicallyandexperimentally between skeletal and visceral structuresaremediated.Itshouldbe noted that some of Hix's work (e.g.l) demonstratedinanimalsverytight skeletal-autonomicinteractionsmuch earlier.However,whileevidencefor the interactions long stressedbyKorr andhiscolleaguesismounting,itis stilltoosoontoseeageneralacceptancebyeitherthemedicalorscientificcommunityofthewidespread importanceofsuchinteractionsfor healthanddisease. Early inthe1960s,the researchactivityoftheoriginalgroupKorrhad recruited began to diminishandKorr bgantoactivelyfollowhislongstandinginterestinthequestionof special effects of nerveson innervated organs.Long standinginthefieldof neurophysiologywasthebeliefthat the onlyeffectofnerveson theirtargetorganswasthereleaseoftransmittersubstancetoexcitetheorgan to activity.However,muchevidence, suchas the completedegenerationof musclefollowingdenervationasopposedtotheatrophyofdisuse ifonly nerve impulse tramc was interrupted, arguesforsomeother"trophic"effet,orsustaininginfuence,of nervesupontheirtargetorgans. Usingspeciallydevelopedtechniques indprocedures,Korrfoundstrong evidenceforthedeliveryofprotein substances trans synaptically fromthe hypoglossalnervetotonguemuscle fbers.Thiswork,publishedin Scienc in1967, was the first evidence thatnervescontinuouslyprovide substancesotherthantransmittersto theorganstheyinnervate.While practicallyheretical,thenotionof transsynapticproteintransferopened newvistasofthoughtaboutneural regulationofphysiologicprocessand ofdiseasemechanisms.Inseveral paperssince,KorrandAppeltauer 12 provi dedotherdataonthe phenomenonandbegan characterizationoftheproteinsinvolved.Appeltauer'srecentuntimelydeathleft theresearchincomplete.However, therenowexistsagrowingbodyof evidencenotonlyforthepassageof proteinsfromnervetoinnervated organ,butalsointhereversedirection(e.g.3).Investigatorsinother laboratoriesareclosetocharacterizing someof theactual proteins which are passedto musclebyits nerve supply(e.g. 4). Whilethestudiesandtheoretical argumentswhichledtoKorr'sfinding of transsynaptic protein transport areonlynowbeginningtobeac-.. cepted,thisfindingiscertainlythe mostdramaticandimportantofhis career. The implications of such slow, two-waycommunicationbetweenthe nervoussystemandinnervatedorgansarebothvastandseemhardto overestimate,literallyopeningthe way for a revolution in thought about neuralcontrolandfeedbacksystems of physiological process. It is still not known whether the transsynaptic protein delivery isa general phenomenon inthebody,orwhatalltheeffects are, but certainly the pioneering work donebyKorrintheareawillberecognizedasleadingthewaytooneof thegreatadvancesinourknowledgeof physiologicalcontrol.. Over the past severalyearssince he hasleftactivelaboratoryresearch, Korrhasbeenformulatingconcepts ofthefunctionandcontrolofthe autonomicnervoussystem.Hisrecentpaper,"SustainedSympathicotoniaasaFactorin Disease" lwhich appeared in 1978,is an attempttointegrateavastamountofdataabout the effectsoftheautonomicnervous systemontotalphysiologicalfunction.Thiswork,togetherwiththe proprioceptivetheorieshehasrecentlypropoundedinanattemptto explain some of the effectsofmanipulativetherapy,characterizesKorr's ongoing interpretationofdatawithin the frameworkof osteopathy. Theperspectivesandevaluations givenhereindicatethebreadthof Korr'sefforts.Viewedfromthevantage pointoftoday'sscience,it isapparent that much of his data up to the mid-l960shasyettobecritically evaluated and replicated,but stanq as a guide forfutureresearch.The interpretationsandtheoriesflowing pfrom thatworkhavemarkedlyinfuenced osteopathicthoughtandarerichin materialforfurtherwork.aswell as ripeforreevaluationinthelightof newfindingsandinterpretationsof physiologicprocess.Theworkon trophicfunctionisonlybeginningto be recognized and will stand as classic inbothconceptandimportance. Whetherthebulkofhisearlierwork remainsacceptableastheoryorexplanationafterreexaminationis, however,not the important point. Of paramountimportanceisthatKorr hasprovidedtheprofessionandthe scientificcommunitywithabasisfor discussion anda forumfor continued interpretationofthetenetsofosteopathicphilosophy.Tocontinueto reexamineandbuilduponwhathe hasprovidedistheonlyfittingand propermethodofutilizingthisrich legacy. References 1.Sato,A.,Thesomatosympatheticrefexes:Their physiologcalandclinicalsignificance.InThe ReserchStatuojSpinalManipulativeMeicie. Goldstein,M.(Ed.)NationalInstitutesof CommunicativeDisordersandStrokeMonographIS,163-172, 1975. 2.Hix,E.L.Refexcommunictionbetweenskin andkidneyainfuencedbyanactiveviscera-renal refex.FedertionPe ings,18,69,1959. 3.Thonen,H.,Schwab,M.andBarde.Y-A., Transfer of information from effetor orgnsto innervatingneuronsbyretrogradeaonaltransportof .nacromolecules.InTheNeurbiologicMelnims in ManiulativeThertp).Korr,l.M.(Ed.),Plenum; NewYork,311-332,1978. 4.Markelonis,G.J.andOh,T.H.Aproteinfraclionfrompripheralnervehavingneurotrophiceffectsonskeletalmusclecellsinculture.Exrimental Nerbiolog,58.285-289,1978. S.Korr,l.M.Sustainedsympatheticotoniaasafac torindisese.InTieNeurobiologicMelnimin ManipulativeTlerpy.Korr,10M.(Ed.),Plenum; NewYork,229-26,1978. MICHAELM. PATERSN,PH.D. Introductory essays Clinicalcontributionsof I.M.Korr Whenonecontemplatestheimpact I.M.Korrhashadonosteopathic thinkingintheclinicalrealm,one mustbeamazedandrealizehow manyskillsand talents were required. Toappreciatehisclinicalcontribution,we musthavesomeappreciation oftheman. Duringtheearly1 940s,Dr.Korr wasencouragedtojointheresearch groupatKirksvilleCollegeof OsteopathyandSurgeryasitdevelopedundertheguidanceofJ.S. Denslow,D.O.Inlate1944,aftera promisingcareerintheacademic arenaandinmilitaryresearchduring WorldWarI I , Dr.Korrwasagain approachedbyDr.Denslowandby MorrisThompson,thenpresidentof theKirksvillecollege.Ontheencouragementofofficialsofthe RockefellerFoundation,Dr.Korr consideredthechallengeanddecided tojointheKirksvillegroup. Inamannerconsistentwithhis reputationasaqualityscientistwith anuninhibitedmind,Dr.Korrdedicatedhimselftoapursuitofneurophysiologyandanall-outeffortto assistthedevelopingresearchprogram atKirksville. In1947,Dr.Korrwasaskedto addresstheteachinggroupofosteopathicprinciples,diagnosis, and therapeuticsattheAOAconvention inChicago.Histopicwastheneural basisoftheosteopathiclesion,and hispurposewasto"attemptacharacterizationoftheostopathiclesion intermsofbasicneuralmechanisms. "Thushestartedaprocesshe continuedthroughouthiscareer,that of trying tomake clinical applications for the professioninrelationtowhat hewaslearninginhisresearchendeavors. Asa result of that presentation,the professionstartedtocontemplatethe conceptsof afferent bombardmentof thecentralnervoussystem,facilitation,andtherolethatthecerebral cortex,posturalequilibriumcenters, bulbarcenters,cutaneousreceptors, andotherscanhaveonthedevelopmentandmaintenanceofahyperirritablestateofthecentralnervous system.Dr.Korrspeculated,atthat time,abouttherolethefacilitated statecouldhavenotonlyonseg-mentallyrelatedorgans,butalsoon theautonomicnervoussystem.Thus theconceptoftheneurologicallens began to be discussed and appreciated bytheprofession.The role whichthe proprioceptorsmightplayinthe developmentof thefacilitatedregion was also postulatedat thatearly stage of hiscareer. Inthat1 947lectureKorralso warnedthat"thearticularderangementortheosteopathiclesioncannot beconceivedasthe cause of disease; ratheritisoneofmanyfactors simultaneouslyoperating. "Hewent ontodescribethephenomenonas"a sensitizingfactor,apredisposing factor, alocalizi ngfactor, a channelizingfactor. . . . Totreat onlythestructuralsourceof bombardmentisonlytohalf-treat andtoneglectamostimportantpart of thelesionmechanism,andtotake thelesionoutofcontext.Thisdoes notmean,ofcourse,thateveryosteopathicphysicianshouldbecomea psychiatrist,buthecertainlymust takeintoconsiderationthehome factors,environmentalfactors,familyrelations,emotionaladjustments, tensions,etc."Thus at that early date boththepreventiveandholisticpotentialswereenvisioned. Ayearlater,Korrexpressedto anothergrouphisconvictionthat "Theattainmentsoftheosteopathic professionhavebeenpossibleonly becausetheprofessionisfounded uponthesolidrockofbasictruth." Inthatsamespeechhealsosaid, "Whether- andhow- theprofessionmeets[its]challengewill determinethefutureoftheosteopathicprofession,butnotthe survivaloftheosteopathicconcept; thatseemsdetermined.Goodideas neverdie;societyeventuallymakes placesofhonorforthem." During theyears1948to1 950,the Kirksvillegroup. investigatedthe impactwhichfacilitationhasonthe autonomicnervoussystemandon organsinnervated and affectedby the areasoffacilitation.In195 1 Korr wrote,"Wehavecometorecognize thattheosteopathiclesionasa phenomenonofcentralfacilitationis amostimportantpredisposing,localizing,andprobability-increasing factorindisease. " Thenextyearhedescribedosteopathyas"notmerelyaformof therapybutratherabroadphiloso-13 phy,aguideforthinkingandacting in relationto questions of healthand disease."Hecontinued,"Fromthe diagnosticviewpointthesomatic componenthasgreatstrategicsignificancebecauseitmakespossible thedetectionandevaluationofH diseaseprocessfarinadvanceofthe emergenceofsymptoms." Thusin a few short years,the profession had gained a dynamic spokesmanwhohadadeepunderstanding andappreciationofosteopathicconcepts and avision oftheprofession's potential.Atthistimeinhiscareer, Korrunderstoodthatwehavethe potentialtorecognize,byskilled osteopathicevaluation,thelossof healthwhichoccursfarearlierthan early diseasedetection. One must rememberthat asthe politicalcomponentoftheprofession wastrying toprove to society that we werelikeM.D.s,Korr'swasavoice cryinginthewildernessandencouragingtheprofessiontorealizeits potentialandnotstopatthelevelof allopathicacceptanceandcare. At the1956 AOA convention,Korr called for aserious research effort by the profession,and said"through the collaborationofosteopathicphysiciansandscientists,theprinciples whichguideosteopathicpractice mustbetransformedintoabodyof workinghypothesestoguideosteopathicresearch."Thusagainwesee adesiretodevelopaclinicallysignificantosteopathicresearchprogram. Inoneoftheyearsimmediately precedingtheM.D.-D.O.mergerin California,Korrwasthekeynote speakerattheAOAconvention,and hetooktheprofessiontotask.He chargedtheprofessionwiththe attitudethatapproval hasbecomean endinitself,thatbeingismore importantthanbecoming.Theprofession'sfunctionwasenvisionedby Korrathe"continualexamination andreexaminationofalltheissues andelementsthatdetermineyour obligations to society and the paths to their fulfillment."He wentontosay inthat1959address,"[Osteopathic manipulation]isnotjustanother formoftherapy;itis awholestrategy,awholeapproachinitself.Itis not merely a treatment of 'lesions'; in effect,itistheputtingofinfluences into the whole man through the accessibletissuesofthebody,influences 14 whichdeflecthislifeprocessesto more favorable paths, and which help put the man in better command of his situation,whateveritis,whateverit maybecome,whateverhisillness, and whateveritsetiology."This noncliniciangraspedtheroleosteopathic care could play in enabling patients to realizetheirhealthpotential. Hisdepthofunderstandingofosteopathicconceptsandtheprofession'spoliticalactionssetthestage forKorrtowritehismasterpieceentitled"AnAllegory."It isapiece of literaturewhichshouldbeseriously studied and contemplatedby the profession.Itsmessageisasrelevant today aswhen written in1961 ,inthe midst of theCaliforniamerger. ItwasatthistimewhenIfirstmet Korrasoneofmyteachers.He taughtbystressingprinciplesand conceptsintowhichonecouldorganizethevariousassociatedfacts. As a student,I devoted much of my free time tolearningfunctionaltechnique approachesunder the guidance ofGeorgeAndrewLaughlin,D.O. OnnumerousoccasionsIobserved Dr.LaughlintreatingDr.Korr. ThosesessionsgavemeanappreciationofwhyKorrhadsuchanunderstandingofosteopathicthinking. During his treatments,Korr would be askingquestionssuchas,Whatare youdoing?Whatareyoupalpating? Whatdoyouthinkyouareaccomplishing?How doyou think it works? Korrwastryingtogetinsidethe D.O.'smindtounderstandhisclinicalthoughtprocessesandwhatwas beingperceivedbytheskilled palpatoryhand.Ihave observedthe sameprocessonnumerousoccasions during the last eighteen years and that sameinquiringmindsystematically evaluatingtheyearsofosteopathic experienceofBowles,Johnston, Buzzell,Wilson,Mitchell,and others.Hefunctionedinthesame inquiringmannerwithhisother colleagues. Korrcontinuedtochallengethe professionwithitsuniquepotential andpredictedthatmedicinewould continuetoevolvetowardholistic thinkingandawayfromcrisiscare whichhasbeensoineffectivein improvingthe healthpotentialofthe patientswithchronicdegenerative diseases.Inhisaddresstoa1961 conventiongroupentitled"OsteopathyandMedicalEvolution,"Korr stated"theosteopathicprofessionis still, in my opinion, the logical instrumentforcatalyzingthetransitionto the next higher stage, and for officiatingatthepassingoftheobsolescent system." Hewentontosay:" Iamconvincedfrommymanyyearsofclose observationandsomefamiliarity withthebiologicmechanisms throughwhichthefavorableinfluencesofmanipUlativetherapyare mediated,thatthissystemoftherapy isamonumentalcontributionto humanhealthandwelfarewhichis, nevertheless,still in its infancy."One mustrememberthat duringthissame period,osteopathicschoolswereputtinglessandlessemphasisonosteopathictraining,andmoreand moreemphasisonallopathictype training,andosteopathicmanagementwasbecomingonlyanextra modality.Thisrealizationprompted Korrtosay"Theprofession . . . will havetotakeasearchinglookatthe premiseswhichhavepermittedthe centrifugalmigrationof manipulative therapyfromthekeypositionina totalstrategyofmedicinetoward thepalliative,adjunctive,optional peripheryofclinicalpractice."He continued"society now awaits -has long awaited -the vision andleadershipthatwillguideittoabetter system of medicine,onewhose strategywillmakebetteruseoftheproductsofscienceinservicetohealth. " He said of the osteopathic profession, "because of itsfoundingpurpose,its history.experience,insights,and skills,[it]isqualifiedtoundertaketo providethatvisionandleadership. " Six years of speaking in osteopathic hospitalsthroughoutourprofession hasallowedmemanyopportunities toaddresslaymensittingonhospital boards andmembers of the insurance industry.Icanassureyouthat1 8 yearslater,thepublicisstilllookingforthatvisionandtheleadershipKorrhadenvisioned.Thesame peoplearenowalsorealizingour potentialashospitalsdevelopfunctioningservicesofosteopathic medicine. Outoftotalfrustrationoverthe profession's apparent desire tofollow theallopathictrend,Korrreturnedto hislaboratoryforapproximatelyten years.Duringthatperiod,Korrand hisassociatesmademajorcontributionstoneurophysiologicalunder-Introductory essays standingintheareasof neurotrophic axonalflow.Thisdiscoveryhastremendousimportance,particularlyfor theosteopathicprofession. Alsoduringthisperiodfrom1 962 to1 973,Korrstartedtodiscussa conceptualizationwhichIhavefound tobeofcornerstonesignificanceto osteopathicpractice.Korrbeganto emphasizehowmanisuniquebecauseofhiscentralnervoussystem, butwouldbeunabletowalk,talk, play golf ortennis,performsurgery, etc. ,withoutamusculoskeletalsystemtocarryoutthedemandsand wishesofthecentrat nervoussystem. Therefore,theneuromusculoskeletal systemrepresentstheprimarymachineryoflifeandenablesusto expressourhumancharacteristics anduniquepersonalities.Inthiscontext,the internalviscera represent the secondarymachineryoflifewhich mustincreaseordecreasetheirfunctionsaccording to the demandsof the body'sphysical,emotional,mental, andspiritualstates,andhowthose statesareexpressedand actedoutby theprimarymachineryoflife.Thus thehost'svisceramustconstantly changeandadaptintheirfunctional activitiesinordertomaintainthe internal milieu by utilizing the various homeostaticmechanisms.Onecan then appreciate how somatic dysfunction causes decreased efficiency of the musculoskeletalsystemandsubsequentlyincreasestheenergyand metabolicdemandsandrequiresadaptationstotakeplaceinallorgan systemsof thebody. Clinicallythisconceptualizationis ofutmostimportance.Asanexample,itisnotuncommonforpatients withC. O. P. D. toexperiencemarked symptomaticimprovement,oncelow backandlowerextremitydysfunctionsaretreatedosteopathicallyand the energydemandssecondaryto gait dysfuncti onsarel owered;this subsequentlylowersthefunctional demandsonthecompromisedrespiratorysystem. Alsointhe1 960s,Korrstarted emphasizingtheuniquenessofthe sympatheticnervoussystemasthe soleautonomiccomponentinnervatingthemusculoskeletalsystem.Sensoryimpulsesfromthemusculoskeletalsystemintot heautonomic nervoussystemthereforeareviathe sympathetic nervoussystem.Thus the sympat heticsystemprovidesanave-nuefortheappropriatefeedbackof informationfromtheprimarymachinerytooccurandallowforthe visceratoappropriatelyadaptmoment-by-momentandfinelytunevisceralfunction so the internal milieu is maintained.Sincefacilitationofthe sympathetic system can result secondarilytosomaticdysfunction,Korr gave the professionanunderstanding ofhowmanipulativetherapycould affecttheautonomicnervoussystem andtherelatedviscera. Duringthisperiodofhiscareer, Korrwasemphasizingtheuniqueness ofthesympatheticnervoussystemin vasomotoractivityandhowsomatic dysfunctionmightplayarolein alteringnormalandoptimalarerial supplytotherelatedviscera. Itwasduring the latter1 960s that I tookoverthepracticeofPerrinT. Wilson,D. O. , whowasagreatadmirerof Korrandhiswork.Wilson, like Korr, emphasizedthe importance ofdevelopinganosteopathicap proachtothepatientwithahealth problem.He always contemplated the rolethatsomaticdysfunctionmight beplayinginfacilitation,introphic flow,inarterialsupplytotheoffended organ, and in venous and lymphaticreturn. FredMitchell,Sr. , D.O. ,alsoheld Korrandhisworkinhighregard. LikeKorr,healsoemphasizedthe roleosteopathicmanagementcould playinassistingthepatienttorealizehishealthpotential.Clinically, Mitchellconsideredthepossibilityof facilitation,trophicflow,arterial, venousandlymphaticderangements secondarytosomaticdysfunction, andhow each playedarole i n the patient'sclinicalproblem. WhereasDr. Wilsonenvisionedan osteopathicapproachtothevarious diseasesandexpectedtofindaspe cificlesionpatternforeachspecific disease,Mitchell'sapproachwas characterizedbyhisfrequentstatement:"Idon't treat pain, ulcers, high bloodpressure,etc. , butpeople with structuralopponents. "Hebelieved thatonce thesomaticcomponentwas alleviated,thepatientcouldstartto realizehishealthpotential . Thus,severalpatientsmighthave thesameclinicaldiagnosis,say pepticulcerdisease,etc. ,butMitchell expectedtofindauniquepatternof somaticdysfunctionforeachpatient. Tobackupthisbeliefhefrequently quotedKorr'sstatementto theeffect thatmanyofushavesimilardisease problemsbutweeacharriveatthe samefinaldestinationbydifferent routes;thuseachhasauniquepatternofsomaticdysfunction. BothWilsonandMitchellstarted bymanagingtheirpatientsosteopathicallyandthenutilizedmedicine andsurgeryasindicatedtomanage the signs and symptomsof the disease process.BothWilsonandMitchell,and bothwereclinicalgiantsinthe osteopathicprofession,reliedheavily ontheworkofKorrintheirclinical conceptualizationastheypracticed andverbalizedwhattheyweredoing forbothpatientsandstudents. ItwasunderMitchell'sguidance thatIbegantoappreciateKorr's contributionofchallengingtheprofessiontolookprimarilyatthehost and its homeostatic capabilities rather thantokeepone'sattentionfocused upondiseaseprocess.Themanifestationsofillnesswhichweseedailyare in realitythe inter-reaction of the host andthediseaseprocesses.Thus,10 patientswithatissuediagnosisof acuteappendicitiscaneachreact uniquelyanddi fferentlyclinically. Onethenrealizesosteopathiccare inrealityisdirectedatthehost component,whilethemedicaland surgicalapproachesaredirectedat thediseaseprocess.Viewedinthis way,osteopathicmanagement can be appreciatedasafoundationalform ofcareforallpatientswhenappropriatelyprovidedfortheirspecificallydiagnosedsomaticdysfunction. Medical andsurgical care canthen be utilizedoncethefoundationalcare hasbeenprovided.Directorsofosteopathicmedicinethroughoutthe countryaredailydemonstratingthe effectivenessof this combination,but itonlyrepresentsabeginningfor allowing ourprofessiontorealize the potential Korr discussed in his earliest writings. Korrreemergedi nhisroleasa voicecryinginthewildernessand exhorteroftheprofessionwhenin 1 973hegavetheAndrewTaylorStill MemorialLecture.He said:"It i s one thingto gainrecognitionofthecompetenceoftheosteopathicphysician topracticemedicineinaccordance withestablishedstandards. Itisquite anotherthingtogainrecognitionof thesoundnessof osteopathicprinci-15 piesandthevalue,tototalhealth care,ofdistinctivelyosteopathic methods.Thatvictoryhasyettobe won. "Korrwentontoexposethe mythsomeholdthatosteopathic principleshavenosolidbasisin biomedical research and mechanisms. In1 974,Korrofferedcliniciansa hypothesisconcerningthedevelopmentofsomaticdysfunctionproblemsanda conceptualmodelfor why the variousosteopathicmanipulative techniquesareeffectiveinmanaging somatic dysfunction.Inan address to theNewYorkAcademyofOsteopathyentitled"ProprioCeptorsand SomaticDysfunction, "Korrdiscussedthepossiblemechanismconcerningsomaticdysfunction,therole theproprioceptivesystemmightplay inthemaintenanceof theseareasof somaticdysfunction,andhowthe variousmanipulativeprocedures mightspecificallyalleviatethese dysfunctions.Hishypothesiscoincidesbeautifullywithwhatone palpatesintheareaofsomaticdysfunctionaseffectivemanipulative proceduresareutilized. Insummary,Korrhas mademajor contributionstoclinicalosteopathic medicine.Hehasgivenauseful conceptualmodelforevaluatingthe rolethatthehost'ssomaticdysfunctionmayhaveinloweringresistance andraisingsusceptibilitytopathologicalstates.Thisoccursbyincreasingenergyandfunctionaldemands on the secondary machinery of lifeor viscera,by alteringvasomotor statusand secondarilyarteriasupply tothevariousrelatedviscera,by producingfacilitatedstatesand alteringtrophicaxonaltransportand thus altering impulses and trophins to therelatedviscera,byalteringrib cage,thoracicanddiaphragmatic functionandsecondarilyimpairing thehost ' s abilitytoventilate adequatelyand attainnormalvenous andlymphaticreturn.Somaticdysfunctioncanalsoalterafferent impulsesintothecentralnervous system,aswellastheflowofretrogradetrophinstothecord. ThuswecanappreciatewhatKorr saidin1951intheaddressentitled 'TheSomaticApproachtothe DiseaseProcess":"Webeginto recognize,therefore,thatagreat manydiseaseswhichonthesurface aresodiverseincharacterasto requireahighlycomplexsystemof 16 differentialdiagnosis,differential therapy,anddifferentialnomenclature,areessentiallyonedisease,the manifestations of an identical process expressedindifferentpartsofthe body. "Theroleof somaticdysfunctioncanbebetterappreciatedas"a riskfactor"whenoneconsiders Claude Bernard's comment " Systems do not existinnature,but only inthe mindsof men"; thuswhenone componentofthebodyisfunctioning improperly.the restof the body must adaptandcompensateorbecome compromisedandbecomediseased, i.e .anoffendedorganemerges. Korrhaschallengedustolookat thecontinuumrangingfromoptimal. healthtodiseaseanddeath,and considertheroleofdiseaseofthe musculoskeletalsystemasapredisposing,sensitizingandlocalizing factor.Korrrecognizedthatweas D. O. s canaddressboththehostand diseasecomponentsoftheclinical problem.andherecognizedweare theonlyprofessionthatcannow integrate the managementof both the hostanddiseasedcomponentsintoa comprehensivehealthsystem.Others aremanipulating- chiropractors, physicaltherapistsandM. D. s - but theyareutilizingmanipulative therapyasamodalityandfrosting onanallopathiccake,notasleaven permeatingthroughoutaclinical approachaimedatenablingthepatienttorealizehis/herhealthpotential. Itisoneof my deepestdesiresfor theprofessionandallinterestedin comprehensivehealthcafethateach mightstudyandcontemplatethe visionKorrhaspresentedtheosteopathicphysician,thatwemight developauniquehealthcaresystem and develop aunique osteopathic curriculumandeducationalsystem which will educate men and women to be osteopathically oriented G. P. s and specialists.Osteopathicthinkingcan bethemechanismtoenableusto becometheleadersindevelopinga comprehensivehealthcaresystemfor whichthepubliciseagerlysearching. Korrhasprovidedtheclinicianwith manytoolstoenableustoobtaina levelofdistinctionwhichhasnever beenpreviouslyreachedby the health professions. Whattypeofamanwasrequired tomakethecontributionsKorrhas made?Ittooka manof scientific and professionalquality.onenot trapped byconventionalbeliefs.aninquiring mindutilizedtosearchandunderstandwhatgoesoninthe.mindsand handsoftheosteopathicclinician,a manwhocouldverbalizehislaboratorydatainawaytoencouragethe clinicianinits clinicalapplication,an effectiveeducatorandwriter,aman whowaswillingtogiveuphispreviousinterestsandtotallydedicate himselftotheneedsoftheosteopathicprofession. Inhisnewroleasprofessorof medical education at Texas College of Osteopathic Medicine. one must hope thatherealizesthenecessaryprofessionalsupportsothathewillseea new beginning for the contribution he canmaketothepracticeofclinical osteopathicmedicine.Korrisnow dedicatinghimselftothetrainingof youngphysicianswhowillprovide theleadershipandmanpowertoattaintheprofessionalpotentialhe envisionedandpresentedtotheprofessionduringthelast35 years. EDWADG.STILES,D.O . FAAO Introductoryessays Primaryresearchreports: Studiesonelectromyography, sympatheticnervoussystem, reflexes,andrelatedtopics ITQuantitativestudiesofchronicfacilitation inhumanmotoneuronpools*(1947) J.8.DENSLOW,IRVINM.KORR and A.D.KREMS Previousstudies(2,3,4)haveindicatedtheexistence,inman,of pools of spinal extensor motoneurons whichareinastateofenduring excitation,asreflectedinlowrefex thresholds.Thesewerereproducible overperiodsofmonths.Persistent differencesinthresholdwerefound fromsubjecttosubject,among segmentsofthesamesubject,and betweensidesof the samesegment. This paper reports the following: a, thecorrelationofreflexthreshold with other segmentalfeatures,and b, theintersegmentalspreadofexcitation.Previousobservationsof thresholddifferenceswere confirmed with improvedtechnics. Methos Allthesubjectswereyoungmen apparentlyingoodhealth.Each electrode,abare1inch25gauge hypodermicneedle,wasinserted perpendicularly to the skin, through a procaine wheal 3cm.to the left of the tipsofthespinousprocessesT4T6 , T"and Tlo,intothe underlyingerectorspinaemass.Eachmuscleelectrodewascoupledwithanother25 gaugeneedlewhichwasinsertedintradermallythroughthewheal.This typeof electrodepairingpermitteda higher degreeof localization and sensitivitythanthepreviouspractice(2) ofpairing2electrodesinmuscle,1 segmentapart.Action potentials were recordedapreviouslydescribed(2). The refex threshold of a given segmentwasobtainedbydetermining the lowestpressure,appliedoverthe spinousprocessofthatsegment, whichelicitedspikepotentialsfrom thespinalextensorat thesame level. t "Thesestudiesweresupportedbygrantsfromthe ReseacbFundof tbeAmerican Osteopathic Association. t Itisnotintendedtoimplytbatthesensory fibersat the spinous processand motoneuronsof the muscleat thatlevelbotbemergefromthesamesegment of tbe cord, sinc suchan anatomic relationship has not been demonstrate.Itiprobable,bowever,thatagiven spinousproessbearsacloserneuralrelationshipto neighboringmusclesegmentstbanremoteonesand tbat tbere is more or less parallel segmental"spacing" inthecord. 18 Measuredpressurestimuliwereappliedoverthespinousprocessby meansof the pressure meter previouslydescribed(2).Tosimplifytabulation,responsestopressurestimuli weregroupedanddesignatedas follows:1-2 kgm.Low (L);3-5kgm. Medium (M); 6-7 kgm. High (H); and noactivity at the top limit(7kgm.) of the stimulator,None (N.In figure I, however,theactualthresholdsare given. In addition to establishing the local thresholdforeachofthefoursegments,thepressurerequiredateach of the four spinousprocesses to elicit reflexactivity fromeachof the other threerecording siteswas determined. Ineveryexperiment,therefore,the thresholdsof1 6 relatedreflexpathways wereestablished.These furnishedthedataalsofordeterminingthe extent and facility of spread of excitationamongthesegmentsstudied. Results PartI.Threshold differences; segmenttosegment and subjectto subject. Figure1(arrowsaretobedisregarded until a later section) shows the differencesin(local)thresholdthat mayexistam (1949), 693-70. 55.Adams-Ray. J..andB.Pemow.Smnew observationsconcerning the symptom"pallor"inthe infammationsyndrome.Actachir.Scand.9 (1949), 221-229. 56.Denslow,J. So Ananalysisofthe variabilityof spinal reflex thresholds.1.Neurophysio!., Springfield, 7 (1944), 207-216. 57.Nedzel. A. Jo Pathogenesisof nephritisdue to exposuretocold.J.Urol.,Baltimore,31(1934), 685-691 . 58.Delor,P.,and Mme.Leder,Interet de la thermometrie cutanee.PressemCd.6 ( 1952),1056-10. 59.Hansen.K. ,andH.vonStaa,Refektorische undalgetische Krankheitszeichen derinnerenOrgane. Thieme,Leipzig,1938. 6.Konovalov.N. V. .Vasomotordisordersin hepatolenticulardegenerationandinotherliver diseases;problemsofpathogenesisofvascular hypotonia.Z.nevropat.psichiatr. , Moskva,55 (1955),268-281 .61 .Longo.O.F.,C.A.S.Gallardoand A.Ferrri.Lasalteraci6nesvasculo-nerviossen la patogeniade laspancreatitis.Rev.Asoc.mCd.argent.6(1952), 8-16.62. Wernoe.ATh.B Viscero-kutaneanemiske zonerogderestydning.Uskr.Laeger,K'hvn,85(1923),143-147. 63.Wernoe,AfTh.B Smertezone-diagnostik. Uskr.Laeger,K'hvn,85 (1923), 615-617. 6.Weroe,Af Th.B., Aestesiokopia abdominalis. Uskr.Laeger,K'hvn,82 (1920),1415-1421 .65. Wemo.AfTh.Bo Et diagnostisksystem. Kobenhavn,1931 .6. Weroe.AfTh.B..Smertensdiagnostik. Kobenhavn,1935. 67.Dort,J. B= andC.Ferrro.Inegalitedela temperaturecutaneedans I'infarctusdumyocardeet l'anginedepoitrine.Cardiologia19 ( 1951), 80-86. 68.Stilrup,G.Ko Visceralpain:plethysmographic "painreactions",dilationofoesophagus.Ny!.NordiskForlag.A.Busck,Copenhagen,194. Wegratefullyacknowledgethevaluableassistance ofMr.E.Blackorbyinthe designandconstructionof instrumentsandofMrs.TovaBrooksinthepreparationoftheillustrations. Reprintedbypermissionfrom10urnalofNeural Trasmission22:3,34-52,19. 5JEffectsofexperimentalmyofascial insults oncutaneous patterns ofsympathetic activityinman*(1962) I.M.KORR,H.M.WRIGHT,adP.E.THOMAS Inrecentyearsourlaboratorieshave been engaged in the study of regional andsegmentalvariationsinsympatheticactivity,asrevealedby cutaneoussudomotorandvasomotor manifestations.Studiesofelectrical skin resistance (ESR) ,reported in this Journalin19581,revealedpersistent areasoflow electricalskinresistance inmostindividuals.Thetopographical distribution or"pattern"of these lowresistanceareasvariedfromindividualtoindividual;butinagiven individual,thedistribution,with respecttorightandleftsidesand segmentallevels,remainedconstant for weeks,months andsometimes for as long athreeor four years. Studies ofregionalandsegmentalvariations incutaneousvasomotoractivityalso revealedtopographical"patterns" 2 thatremainedsimilarlycharacteristic andconstantfor eachsubject. ThatthesemeasurementsandpatternsofESRasrecordedbyour methodsreflectvariationsinsympatheticactivitywasshownbythe studies ofThomasandKorr 3, 4. 5and KawahataandThomas 6.Although thesestudiesdid not revealthephysiologicongmsorfunctional significanceofthesympathetic hyperactivitymanifestedinthelow resistanceareas,theirdistribution, thatis,thepatterneddifferencesin sympatheticactivity,wereinsome individualsapparentlyrelatedtovisceralormyofascialdisturbances. Reportsofareasofhyperhidrosis78 orlowskinresistance9-13,lowered skintemperaturel4 IS andcutaneous pallorl6--19reflexlyrelatedtopainful myofascialandvisceralconditions also suggest such a possibility. Inviewofthepossible physiologic andclinicalimplicationsof thetopographicalvariations,asymmetries andlocalaberrationsinsympathetic activity, we have attempted to explore factors that might contribute to them. *T_ investigations weresupportedinpart by grants fromtheNationalInstitutesofHealth,PublicHelth Service (H 1632).and from theAmerican Osteopathic Association. 54 Thisreportdealswiththeeffectsof experimentallyinducedirritations and stresses in musculoskeletal tissues onthepatternsofcutaneous sudomotor activity. Methods Sincethemethodswehaveusedfor thestudyofsudomotoractivity-have beenpreviouslydescribedl, 2, 21,they are onlybriefly characterized here. ESR Explorations. Theexperimentsreportedinthis paperweredoneoveraperiodof severalyears.Duringthistimethree methodsforrecordingESRwere used, each yielding a different type of record.However,allthreemethods arebasedonconventionalprinciples of skin resistancemeasurement. Essentially,eachmethodconsists ofmeasuringorrecording,incorrect spatialrelationshiptotheexplored area,themomentarycurrentfow throughtheskinincontactwitha constantlymovingexploringelectrode,atknownvoltages.Thevoltagesweretappedstepwisefroma seriesofdrycellsandappliedtoan electrodefixedtoanearlobeandan exploring electrode.Resistanceofthe skinof theearlobewas minimized by meansofelectrodepaste.Area-toareadifferencesincurrentflowata givenvoltage,therefore,weredueto differencesinthe"resistance"of the skinunderthe exploringelectrode. 1.Explorationswithhand-held electrode. Inourearlierstudiesweusedaninstrumentsimilartothatdescribedby Jasperll.Current flowwasread from amicroammeterastheelectrodewas movedoverthesubject'sskin. Figures1to6and16to18show chartsobtainedwiththismethod. 2.Automatic Explorations. Inlaterstudiesamobileautomatic dermometerwasdeveloped 21.With thisinstrumentskinresistancepatternsonlargeareasofthedorsal trunkwere recorded directly onpaper byrecordinggalvanometerwhose amplitudeofoscillationsisrelated, through anamplifier,tothe skin current.Thepositionofthegalvanometerwriting-pointonthechartwas relatedtothepositionoftheexploring electrode on the subjectbymeans ofapantograph.Recordsobtained with this instrument appear in Figures 8,9, 11,12,14, 15.Recordsobtained with an earlierautomaticdermometer (Thomas and Korr20)are not included inthisreport. ExplorationConditions. Theexplorationswere conducted ina quietroommaintainedbetween230 and250C.Thebodywasunclothed abovethelevelofthesacrum.The tipsofthespinousprocesseswere locatedbypalpationandmarkedon theskin.Inthesestudies,"segmental"levelreferstothetopographical levelon thetrunkasidentifiedbythe correspondingspinousprocess, rather than the dermatomes. There is, however,closecorrespondencebetweentopographicalandsegmental levelsforparavertebralskin,except attheuppermostthoracicsegments. The experimental irritations used in these studieswere produced by the injectionofhypertonicNaClsolution intoparavertebralstructures.The posturalstressesincludedtheartificiallengtheningorshorteningofone lower extrcmity by the insertion or removalofheellifts,andtheinclinationotthepelvisbyseatingsubjects intilt-chairs.In some of the tilt-chair experimentsthechangesinskeletal configurationweremonitoredwith roentgenograms. Results Myojascial Irritations. Forthepurposeofstudying sudomotorresponsestolocalmyofascialirritationweadoptedthe methoddescribed by Kellgren in connectionwithinvestigationsofreferredpainofsomaticorigin23-26As LewiandKellgren26reported,when smallvolumes(0.1to0. 3ml)of hypertonicsaline(61oNaCl)wereinjectedintosuperficialtissues(e.g., skin,periosteumofthetibia,sheath oftheachillestendon)onlyasharp, localizedpainwasproduced.When, however,the irritant was injected into deeper tissues,especially those on the trunkandmostparticularlyaround EMG,SNS,refexes,etc. thespinalcolumn(e. g. , interspinous ligaments,paravertebralmuscles), thelocaltransientpainwassoon followedby a crescendoof deep pain feltinareasoftenquite remote from thesiteofinjection,butapparently innervatedfromthesamesegment andside of thespinalcord.Thepain was usually accompanied by deep and cutaneoustendernessandmuscular rigidityinthecorrespondingdermatomesandmyotomes.Themanifestationssubsidedwithinafewminutes after a peak often of great intensity.Itwasour purpose todetermine what changes inESR were associated with these phenomena. In our experience with a total of 1 5 subjects,some of whom received two ormoreinjections,asignificant changeintheESRpatternwasobtained only when we were succesful in producingreferredpain.Injection of superficialstructures,such as the interspinousligamentsorperiosteumof spinousprocessesorinjectionofa deeperstructure,whichforsome reason,producedonlylocalpain,if any,wasfollowedeitherbylocal decreasesinESRintheimmediate vicinityof theinjectionsite orbyno evidentchange.Somesubjects,however,showedatransient,generalized dropinresistance,withquickreturn topre-existingpatterns. Such responses might, i n apprehensive subjects,evenprecedetheinsertionof the hypodermicneedle.The injection oftheperiosteumofspinousprocesses was, in some cases, immediately followed by considerable distress to thesubject,withdiffuseandpoorly localizedpain,nauseaandfaintness, andpallor,coldnessandclamminess of theskin.Two subjects (injected in mid-thoracicspinousprocesses)sufferedwithvomitinganddiarrhea several hours after the experiment. Theappearanceof ESR changes in thereferenceareaswasespecially clear following injection of the hypertonicsalineintotheerectorspinae andintercostalmuscles.Figures1,2 and3illustratetheresultsoffour suchinjections. Figure1represents theresultsoftwoinjections,35 minutesapart,intwosites,inthe samesubject.The areas of lowresistancewhichappearedfollowingthe injectionsarerepresentedbythetwo rowsofencircledblackspots.The otherareas,mainlyinthemidline, were present before the injectionand Inall figuresdark areas rprsent low-resistance areas (LRA) of skin. Darknes of shading In handdrawn charts (Fig. 1to 6, 16to 18) is in proportion to currentfowat explorationvoltage; the darker theareathelowertheresistance.Whiteareas:/ paorless;(rsistance.inohms,atleast1million timesthenumberoj volts),'blackareas: 20 p or more;i.e.,lessthan 1120oj basicresistance , 'gray areas:intermediatevalues.(Reproductionoj the hand-drawn charts ha darkened the gray areas and thedarkershadehavebecomeinditinguishableJromtheblackaras.) Fig. 1.Subject D.H.12 2048: Area of lowskin reistance (circled black dots) elicited bythe inection oj 0.3 mi.of 600NaCI into the erector spinaemass to the left of the spinousprocesoj T. and intotheeighthintercostalspaceintherightaxillary,midline(bothsitesmarkedbyx). FilS. Fig.2.SubjectL.L.12 2148:Areasof lowskinresistance(circledblack dots)elcitedbythe injectionoj 0.3mi.oj 6%NaC1intotheerectorspinaemastotheleJtoj thespinouprocessofT,. Fig.3. SubjectL.L. 12 649:Areaoj lowskin resistance (Ts_II' right) present 24hours ater the injection of 0.3 mi. oJ 6% NaCl intotheerector spinae mass totheright of the spinous proces oj T,. 55Fig. 4 I Fig.6 . f I 1 .\, I 'J Fig.4.ESR patternsofSubject L.L.I222 49:a)seated horizontally,'b)6 minute 4ter pelviwas tited totheleft. Fig.5.ESR patternsofSubjet J.R.12 2349:a)seated horizontally; b)6 minutes after pelvis was tilted tothelet;c)30minute following returtothehorizontal position. Fig.6.ESR ptterns of Subject J.D.13 50:a)seated horizontaly,'b)120minutes after pelviwa tilted to the left.Ti subject showed very little change in hi ESR patter incontrsttothe subjects showninFigs. 4 and 5. 5 wererepresentativeoftheESR"pattern"(Korr,ThomasandWright!) repeatedlyobservedinpreviousexolorationsofthissubject. Immediatelyfollowingthecompletionofthecontrolexploration,0.3 mlof611 0NaClwasinjected2.5cm. deepintotheerectorspinaemassto theleftofthespinousprocessofthe 8ththoracicvertebra.Thesubject almostimmediatelyreportedpainin theanteriorchestwallintheregion below theleft nipple.In approximately30secondsseverepainhadalso developedintheback.overthe transverseprocessesandrib-headsof theregionT,toTloontheleftside. The new areas of low resistancebegan toappearduringthesecondminute afterinjectionand,after5minutes, appearedasshowninFigure1,by the encircledspotsontheleftside,at whichtimethepainhadvanished. Thirty-fiveminutesafterthefrst injectionasecondinjectionofhypertonicsalinewasmade,thistimeinto the8thintercostalspaceintheright mid-axillaryline.Thepainwhich developed wasrealtively mild and was feltmainlyintheanteriorchestwall, inthemammaryregion.Nevertheless,newareasoflowresistanceappeared,asshownontherightsidein Figure1.moreconspicuouslyonthe dorsalthanventralsurface. Whenthesubjectwasre-explored sixhoursafterthesecondinjection. thelow-resistanceareaswerestillevidentinthesamedistribution,but theyhadbecomelesspunctateand nearlycontinuous.Theexploration ofthechestwasconductedatavoltagewhichpermittednomorethan lJofcurrentthroughmostofthe skin.Nevertheless.thecurrentflow throughtheareasshownwassuffcienttocausethetwostripsoflowresistanceskintobecomesharply delineated astwo erythematous bands inthecourseoftheexploration.Resistance had returnedto controllevels beforethenextexploration18hours later. Theencircledblackspotsshownin Figure2representthenewareasof low resistance which appeared, and remained,overaperiodof5minutes followingtheinjectionof0.3mlof 600NaClintotheerectorspinaeat thelevelofthefifththoracicspinous process in another subject.Numerous spots,notshown,alsoappearedon theventralaspectofthecorrespond-EMG,SNS,refexes,etc. " F ig.7.Roentgenogram tracingsofthe spineofSubjectS.P .: H) seated hori z ontally;L) seated withpelvistiltedtotheleft; R)seatedwith pelvistiltedtotheright. Inthe pantographi c records(F igs.8,9, 1 1,12 , }4,1 5),amplitude ofoscil l ations ofthe recordinggalvanom eterisrelatedtocurrentflow throughtheskin.Th ethinverticallines(no oscillation)representareasperm itting0-1p a atexplorationvoltage;widestoscillations representcurrentf owsof 30 paor m ore.In thesecharts,therefore,the darkestareasrepresent/ /30thebasicresistanceorless.Notethe calibration"stris" showingrelationbetween currentandampli tudeof osci ll ationsinsteps of5pa. L ." '''_J r,'"' m > / J ,, .. = =

j-. /

/

* " = : '-. ;1r $L -'_l .. "! H F ig./0.Roentgenogramtracingsof thespine of Subj ectH.K.H)seatedhori z ontally;L) seatedwithpelvistiltedtotheleft;R)seated withpelvistiltedtotheright. I ' ".|l.\'

'I " F ig.8ESRpattersofSubj ectS. P.6 17 55:a) seated hori z ontally;b)4 m inutesafter pelviswas tiltedtotheleft;c)14 m inutes followingreturtothehori z ontal position. I F ig.9.ESR patterns ofSubj ectS.P.616 55:a) seated hori z ontall y;b)9 m inutesafter pelvi Swas tiltedtotheright;c) 8 m inutes followingreturntothehori z ontal position. F ig.II.ESR patterns ofSubj ect H.K. 7 1955: a) seated horiz onlally;b)/8m inutes after pelvis was tilledtotheleft;c)/ / m inutes fol lowingreturntoI hehoriz ontal position. 57c mi

. F ig.12.ESR po l/ ems of Subj ect H.K.7 25 55: a) seated hori z ontall y; b)18m inutesafter pelviswas tiltedtotheright;c)I I m inutes followingreturtothehori z ontal position. f' 58F ig./3.Roentgenogramtracingsofthespine ofSubj ectC.B.:H)seatedhori z ontall y;L) seatedwithpelvistiltedtotheleft;R)seated withpelvistiltedtotheright. F ig.14.ESR po l/ ems of S ubj ect C.B. 62 455:a)seated hori z ontall y; b) 15m inutesafter p elviswas ,t illedtotheleft;c)14 m inutes followingreturntothehori z ontal position. F ig.15 .ESR patters of Subj ectC. B. 62 855: a) seated hori z ontall y; b)1 7m inutesafter pelviswas tiltedtotheright;c)14 m inutes followingreturtothehori z ontal position. EMG,SNS,refexes,etc.

ingdermatomes.Thelargeencircled areashownbetweenthevertebral columnandtheleftscapularepresents an area of muscular rigidity first evidentasaconspicuousbulgeand easilydelineablebypalpation.Atreexplorationthreehoursafterinjection,themuscularrigidityhadsubsided,thelowresistanceareashad becomelesspunctateindistribution andthe totalareahadbecomemuch narrower,noreductioninresistance beingevidentbelowthe7thinterspace. Inanother experimenton the same subject,the right erector spinae at the levelofthe8ththoracicspinousprocesswasinjectedwith0. 3ml600 NaCl.Onlyafewsmallareasof moderatelyloweredresistanceappearedduringthesucceedingthirty minutes,overthe8thand9thvertebraeandribs.Atthere-exploration 24hourslater,however,alarge triangular area of low resistance (Fig. 3)was present. Acute PosturalStres. Intheexperimentstobedescribed underthisheadingwestudied changesin ESR patterns that followedacutelyimposedposturalstress. Thestressesappliedwereoftwo general kinds:a) lateral tiltingof the pelvis,relativetothespinalcolumn and b)artificialalterationof relative lengthsoftherightandleftlegs 'by meansofheelliftsinsertedinone shoe. PelvicTilts. Intheseexperimentssubjectswere seatedonaspecialstooltheseatof whichcouldbetiltedtorightor left bymeansofawormgeararrangement.Thesubject'spelviswasfirmly securedwithabeltilsuchamanner as tominimizerotationof thepelvis around the verticalaxis and to render the tilt (andtheresultingscoliosis)as purelylateralaspossible.Thesubject's arms rested on a horizontal surface, thereby reducing the inclination of the shoulders andforcing the compensationmainly on the thoracic and lumbarsegmentsofthespinalcolumn. Explorationswerebegunafterthe subjecthadbeenseated,withtrunk exposed,forasufficientperiodto permitstabilizationof theESRpatterns I.Aftercompletionofthecontrol exploration,the seat was tilted in Fig.16. ESRpatters ofsubject M.O.12 2748 - 123048: a)without heel-lift;b) 24 hours after wearing3/8 inchheel-litinrightshoe;c)24 hoursafterremovalofheel-lit.

t, d Fig.1ESRpatterns of Subject A.M. 12 2748 - 122848: a)without heel-lift;b)afer wearing ! inch heel-litin rightshoe for 5hours;c)patterimmediatelyupon arisingthefol/owingmoring; d)"!hourslater,heel-litstillinplace. 5., Fig.18.E/ects0/removal 0/ heel-litson ESRpatterns 0/subject R. H.who hadwor!inch lit underhis right heel/or more than a yer to compensate/or shortness 0/ that extrmity.oj 12124149: Control ESRpattern (subject wearing hel-lift) in the moring (a 1,9:00 A.M.)and afteroon (a 2, 4:15P.M.).Moringandateroonexplorationswerealsodoneonthreeotherdayswithsimilar reults.b)12128149:Followingthe ESReplorationat 9:30A.M.,(bl)thelitwasremoved.The fgureat 4:05P.M. (b 2) showsthealteredESRpatterwhichdevelopedduringthisinterval. the chosen direction while the subject remainedseated.Hewasthenreexploredatvariousintervalsafter tilting.Insomeexperimentsexplorationswerealsoconductedafterrestorationofthe seattothehorizontal position..Inallexperimentstobe shown theangle of tilt with respect to thehorizontalwas1 5.Inexplorationsdonewithhand-heldelectrodes (Fig.4to6)thechartsrepresenting the experimentalexplorationindicate thepatternsthathaddevelopedby thetimetheexplorationwascomplete. Comparison of Figures 4 a and 4 b indicatesthechangeinpatternwhich 6 developedinsubjectL.L.inthe course of one hour of sitting with the lefthiptilteddownward.Newareas oflowresistancewereespecially markedinthelowercervical,lower thoracicandlumbarareas.Pain developedat thebaseoftheneck on theleftsidewithin1 5to20minutes aftertilting. Fig.5showsanexperimenton another subject (J.R.).A comparison ofchartsaandbrevealsthenew areasoflowresistancewhichappearedwhilethesubjectwasseated foronehourwiththepelvistilted 1 5,lefthipdown.Thenewareasin thethoracicandlumbarregions,es-pecially on the left (convex side of the spinal curve) andtheexaggerationof thelowresistanceareasatthecervicodorsal junction are particularly to benoted.Thesechangeswerealmost entirelyreversedwithin30minutes afterrestorationtothehorizontal position(Fig.5c). Incontrasttotheabovesubjects, subjectJ.D.(Fig.6)showedvery littlechange in ESRpatternafter1 20 minutesofsittinginthetiltedposition.Thissubjectwasatall,slender individualwhofeltremarkablylittle discomfort.Hereported onlyaslight sensationof"strain"inareasover theupperbordersofbothscapulae. Thetopographicallyrelatedareasof slightlyloweredresistancewhichappearedafteraboutonehourare to be noted,althoughtheywereprobably extensionsofthesmallareasevident abovethe scapulaeinthecontrolexploration. Inmorerecentexperiments,ithas been possible, with the automatic dermometer( Thomas.Korrand Wright21),torecordtheprogressive development of new patterns after the assumptionofthetiltedpostureand theirregressionfollowingreturnto thenormalseatedposture.Anteroposteriorroentgenogramsofeach subjectweretakenintheleveland tiltedposturesinordertovisualize the configuration of the vertebral columns.Tracingsshowingthespinal confgurationineachsubjectinnormalandtiltedsitting,weremade fromthesefilmsandaccompanythe ESR patterns in the following figures. SubjectS.P.hadabnormalitiesof the vertebral column evident in Fig.7 H (seated level) as conspicuous lateral curvesinthethoracicspine,with sharpreversalsofdirectionatupper andmid-thoraciclevels.Figures7L andRrevealthepooradaptationof thesubjecttothetiltedpostureand themarkedlackofsymmetryofthe spinalconfguration intherightand lefttilt.Theimpositionofthese posturesonthesubjectprovokedintenseanddiffusesudomotorresponses as revealed by comparison of chart b with a,pre-tilt, and c,post-tilt controlinbothFig.8(lefttilt)and Fig.9(right tilt). Differences in responsetoleft and right tilt are also revealed.The sharp upperboundariesoflow-resistance areas at themid-thoraciclevelinFig. 8 b and the elevation of the boundary EMG.SNS,reflexes,etc. to upperthoraciclevels in the reverse tilt(Fig.9b)areespeciallytobe noted. Subject H.K. had no gross postural orspinalabnormalityevidentinthe roentgenogramstakeninthelevelseatedposition(Fig.10H).Nevertheless,thosetakeninthe tiltedpositions(Fig.10L,R)revealedvarious restrictions and asymmetries in spinal moti on. Accordi ngl y, marked changesinESRpatternsoccurred during tilt-seating inbothdirections, the patterns of the left andright tilts beingquitedifferent.Low-resistance areasatlumbarlevelsontheright side werethe first to appearin tilting bothtotheleftandtotheright. Followingtheappearanceofthese areasof lowresistance,however,the patternsduringrightandlefttilts developedquite differently(compare Fig.1 1 b and1 2b),theadditional areas being in each case on the convex sideoftheinducedspinalcurve. Thus,whilethelowresistanceareas developedduringthetilttotheleft (Fig.1 1b) were quite extensive,there were only scattered small spots of low resistaceintheupperrightquadrant.It is thi area,however, in which resistance was diffusely lowered when thetiltwasinthereversedirection (Fig.1 2) ,the left side being relatively free of lowresistance areas. In contrast with the above subjects, C. B.showed,on X-rayexamination, bothexcellentvertebralalignmentin thelevel-seatpostureandsmoothly rounded,symmetricalspinaladaptationtothetiltofthepelvisinboth directions(Fig.1 3).The new areas of lowresistancethatdevelopedwere small andlimitedmainly to the upper thoracic levels (Figs.14, 1 5). Hel Lits. Theexperimentsreportedunderthis headingillustratetheregionalsympathetic responsesto artifcial change in lengthofoneleg,eitherby insertingaheellift (hard-rubberwedge insertedin one of the shoes)underone heel,or removing one towhich some adaptationhasbeenmade. Inthisseriesofexperimentsthe posturalstresswasnotsogrossas thatimposedbytiltingtheseat1 50,but,on the other hand,the stress was permittedtoactformuchlonger periods of time, and under conditions oflocomotion.Consequently,the discomfortandthechangesinESR patterns have often been more severe. All the subjects used in this series had shownstableESRpatternsover periods of atleast several weeks.The stresswasapplied afteracontrolexploration,andthesubjectwasreexploredatvariousintervalsthereafter. The series of charts comprising Fig. 1 6 shows,on subjectM.O., the effect onESRpatternofwearingaliftone dayandthesubsequenteffectof removingit.Fig.1 6 arepresentsthe pattern repeatedly foundon thissubjectwithonlyminormodifications fromdaytoday.Thisexploration wasbegun30minutesaferthesubjecthadcompleteda1 Y' milewalk from his hometo the laboratory.His only complaint was a continuous ache inthelumbosacralareaontheright side,in which general region was also found an area of moderately lowered resistance.X-rayflmstakeninthe standingpositionindicatedthatthe rightlegof thissubjectwasapproximately7t inchshorterthanthe left. Upon completion of the exploration a 3/8inchliftwasplacedinhisright shoe andhe was instructed to wear it throughout the day and the following morningtoreturnforanexploration thenextmorning,alsoafterwalking (withheel-liftinplace)fromhis home. Fig.16bshowsthepatternobtainedthenextday.Bothacheand low-resistance areas in the lower right quadranthadvanished,butthesubject now complained of discomfort in the midthoracic region in whichthere wasespeciallymarkedextensionof low-resistanceareas.Theliftwas removedat 2:30 P. M. ,aftera"spotcheck"revealedthattherehadbeen furtherloweringofresistanceand some extension of theareas shown in Fig.16b. Fig.1 6 cshowsthepatternfound thenextmorning,againafterthe walkfromthesubject'shome.The ache(andthelow-resistancearea)in the lower right quadrant had returned andthemidthoracicachehadbeen exacerbated.Areasofmarkedly loweredresi stancehadspread throughoutthemidlineoftheback. Atotallynewstripof lowresistance appeared on the right side in the midthoracic region, extending peripherally from the level of vertebra T 8on the right side (Fig.16 c;possibly a lateral extensionoftheparavertebralarea evidentin Fig.1 6 b).It hadnotpreviouslybeen observedon this subject butitcontinuedtobeobservedon everysubsequentexplorationuntil thefinalexplorationonthissubject almost16monthsaftertheexperiment. Anothersubject'sresponsetoartificial increase in lengthof one leg is shown in Fig.1 7.This subject's ESR pattern,repeatedlyrecordedovera periodofthreeweeks,wasremarkablyundistinguishedbyanyconspicuousandpersistentareasoflow resistance,andthecontrolpattern (Fig.1 7a)wastypical.At1 1 :0 A. M.,followingthisexploration,a one-halfinchheel liftwasinsertedin thesubject'srightshoe.Hewasinstructedtogoabouthisusualactivities and to return later the same afternoon for exploration. Fig.1 7 bshows the pattern obtained in an exploration begun at 4:0 P. M. ,at which time the subjectcomplainedofdiscomfortin theregionofthelumbosacraljunction.Theextensivedevelopmentof low-resistanceareasbelowthe thoracolumbarjunctionandinthe vicinity of the cervicodorsalj unction isespeciallytobenoted.Fig.1 7c representsthepatternobtainedon thissubjectthefollowingmorning shortlyafterrising.Ingeneral,a recessionofthelow-resistanceareas ofthepreviousafternoonisevident. However, by early afternoon the subject'sdiscomfort,generalizedinthe lowback,was sufficiently severe that hecametothelaboratorytorequest discontinuationoftheexperiment, andtheheelliftwasremoved.Explorationdoneatthattimedisclosed thepatternshowninFig.1 7 d.In general,thisseemsanexaggeration ofthepatternofthepreviousafternoon(Fig.1 7 b).Unfortunately,the subjectwasnotabletoreturnuntil twodayslater( 1 2/30),atwhichtime low-resistanceareas were stillpresent atthe cervicodorsaljunction,the entiremidlinebelowT sand totheright of thedorsolumbarj unction. TheexperimentshowninFig.1 8 wasalsoconductedt oexaminethe responsetoalterationofrelativeleg length.Inthiscase,however,the stresswasthatofremovingalift wornfortherap