Viscerosomatic reflexes: A reviewMYRON C. BEAL, rico., FAA()East Lansing, Michigan

The concept of viscerosomaticreflexes is presented and supportingdocumentation from the basic andclinical sciences is reviewed. Thesomatic manifestations of visceraldisease, including their autonomicsegmental reference sites, aredescribed. Also discussed are thepalpatory findings that are consistentwith diagnosis of a viscerosomaticreflex, as well as their predictivevalue. In addition, the principles andresults of manipulative treatment forvisceral disease, as well as the effectof surgery on viscerosomaticfindings, are reviewed.

The osteopathic profession has held certain basictenets to be true— that altered or impaired func-tion frequently occurs in the somatic system, thatthese somatic components may be manifest as pre-symptomatic signs of disease, and that they maybe expressed as local or remote effects of dysfunc-tion as somatovisceral or viscerosomatic reflexes.

Although these concepts have been accepted asbasic statements of osteopathic philosophy, thereis little formal evidence other than anecdotal clini-cal experience to support them. The incidence ofsomatic dysfunction in a normal population hasnot been established. However, several studies'-5have reported the incidence of palpatory findingsfor certain patient populations. There is limitedevidence to support the theory that dysfunctionalsomatic components act as presymptomatic signsof disease. 6 The local and remote effects of somaticdysfunction have been described, and experimen-tal studies have confirmed the existence of somato-visceral and viscerosomatic reflexes.' The majoremphasis in this paper is the exploration of the re-lationship of somatic dysfunction to visceral dis-ease.

A viscerosomatic reflex is the resultant of the ef-fect of afferent stimuli arising from a visceral dis-

order on the somatic tissues. The reflex is initiatedby afferent impulses from visceral receptors; theseimpulses are transmitted to the dorsal horn of thespinal cord, where they synapse with interconnect-ing neurons. These, in turn, convey the stimulus tosympathetic and peripheral motor efferents, thusresulting in sensory and motor changes in somatictissues of skeletal muscle, viscera, blood vessels,and skin (Fig. 1.).

Visceral afferents play an important part in themaintenance of internal equilibrium and the re-lated mutual adjustments of visceral function.They are also responsible for the conduction ofpain impulses that may be caused by distention ofa viscus, anoxia (particularly of muscle), irritatingmetabolites, stretching or crushing of blood ves-sels, irritation of the peritoneum, contraction ofmuscular walls, and distention of the capsule of asolid organ." Because pain-sensitive nerve end-ings are not numerous in viscera, pain sensation ora visceral reflex response may result from the com-bined input of several different types of receptorsrather than as a specific response to a particularreceptor. A variety of visceral receptors have been

mucosal and epithelial receptors,which respond to mechanical and epithelial stim-uli; tension receptors in the visceral muscle layers,which respond to mechanical distention, such asthe degree of filling; serosal receptors, which areslow adapting mechanoreceptors in mesentery orserosa and which monitor visceral fullness; pacin-ian corpuscles in mesentery and pain receptors;and free nerve endings in viscera and blood ves-sels.

Impulses from visceral receptors travel along af-ferent nerve fibers that parallel sympathetic effer-ent nerve fibers arising from the same spinal cordsegment and that have a similar distribution tothe region or viscus. Visceral afferent nerves arepreponderant in respect to efferent nerve fibers;the ratio of afferent to efferent fibers is 9:1 for thevagus and 3:1 for splanchnic nerves, while it de-creases to 1:1 for pelvic nerves.10

Visceral reflex arcs are polysynaptic. Althoughknowledge about the central ending of visceral af-ferent nerves is insufficient, it is assumed thatthey synapse with cells in the dorsal horn of thespinal cord and join interneurons, some ascending

Viscerosomatic reflexes 786/53

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in the anterolateral funiculus of the cord to highercenters and others connecting with autonomic andperipheral efferent nerve fibers.

Stimuli from viscera, somatic structures, andhigher centers all converge at the T-cells of lamina5 of the dorsal horn of the spinal cord.' The prox-imity of the sensory input provides a theoreticalopportunity for interrelationship between the so-matic and visceral systems and the higher centers.This may be expressed in terms of facilitation, sup-pression, or recruitment.

An abnormal stimulus of the visceral efferentneurons may result in hyperesthesia of the skinand associated vasomotor, pilomotor, and sudomo-tor changes. A similar stimulus of the ventral horncells may result in reflex rigidity of the somaticmusculature. 8 A direct motor connection betweenthe visceral afferent system and the skeletal mus-cles has not been identified. Animal studies12'13have shown evidence of a viscerosomatic reflexthat results in localized muscle contraction. Skel-etal muscle spasm resulting from nociceptive vis-ceral stimuli has been observed clinically in pa-

tients. These spasms may be manifest asgeneralized muscle contractions or as localizedparavertebral muscle splinting.

Higher centers of the central nervous systemacting through the extrapyramidal system on themuscle spindle through the gamma system couldaccount for the muscle splinting reaction observedwith visceral disease. Muscle spindles have a sym-pathetic fiber innervation. 7 ' 4 Repetitive stimula-tion of these nerves increases the afferent dis-charge of receptors and could lead to an increase ingamma activity setting the spindle at a more ac-tive level, increasing the tone of the extrafusal fi-bers and resulting in an increased tonic muscle ac-tivity.

Reflex activities of the autonomic nervous sys-tem are characterized by spinal components of thereflex response originating from afferent stimuliof various viscera, which results in a confined orsegmental reflex response. This is in contrast to asupraspinal response, which is mediated throughhigher centers and results in a more generalizedbody reaction. The spinal reflex response is elicited

787/54 Dec. 1985/Journal of ADA/vol. 85/no. 12

by a small part of the spinal autonomic neuronpool, as compared to the larger number of neuronsin the sympathetic pool that are activated by thesupraspinal pathway. In certain situations all ele-ments of the sympathetic outflow are involved,whereas in others there is a degree of specificity inthe pattern of reflex response. Depending upon theafferent nerve stimulated, stimulation of visceralafferents results in different effector organ re-sponses. The autonomic system plays a role in to-tal body functions, and somatic and autonomic re-sponses are component parts of all behaviorreactions. They are best described as a dual motoroutflow from a common central nervous system.The nature of the afferent signal, the integrativeaction of the spinal cord or higher center, and thepast stimulus experience of the organism are allinvolved in the determination of the quality andcomponents of the reaction.'

Experimental researchExperimental research's-2o that was designed toelicit a somatic response to stimulation of visceraor visceral afferent nerves has demonstrated re-flex responses in the lower extremities and ab-dominal musculature. Eb1e 12 reported that stimu-lation of the renal pelvis, ureter, fallopian tube,small intestine, or colon in rabbits resulted in re-flex muscle contraction of the paravertebral mus-cles. The location of the muscular response variedwith the organ stimulated.

Hix21 provided further evidence of the localizedeffect of visceral stimulation on somatic structuresby showing that a unilateral ureterorenal reflexcan produce a significant enlargement of the uni-lateral cutaneous receptive field, while Schoenand Finn 13 demonstrated a localized muscle re-sponse in the upper thoracic spine of cats that wasassociated with acute periods of coronary isch-emia.

The latter experiments show a localized somaticsegmental effect—both cutaneous and muscular—resulting from visceral stimulation. These compo-nents of the somatic response to visceral stimula-tion have been of particular interest to members ofthe osteopathic profession.

Somatic manifestations of visceral diseaseThe existence of viscerosomatic reflexes and theirdetection by palpatory examination has been ac-knowledged. Grainger22 states that the somaticmanifestations of visceral disease are an integralpart of the disease process, rather than just phys-ical signs and symptoms. Although multiple fac-tors have been suggested as causative agents forthe development of viscerosomatic reflexes, the de-finitive etiologic factors and the characteristic re-

sponse of the individual are still unknown. Pain iscommonly associated with the development of a so-matic manifestation of visceral dysfunction; it is afrequent presenting symptom in acute conditionsthat are related to the heart and gastrointestinalsystem.

The strength and duration of the visceral affer-ent stimulus necessary to effect a somatic responseis not known. It is recognized that visceral affer-ents may be reinforced by somatic stimuli fromskin and muscle, as well as by impulses from high-er centers, which may lower the threshold for vis-ceral afferents or facilitate their action at a specif-ic spinal cord level. Prior facilitation of a cordsegment or cord learning may enable a weaker vis-ceral afferent stimulus to effect a somatic re-sponse. The answer to the question of what is an-adequate stimulus is dependent upon theinteractions of the strength of the afferent stimu-lus, the state of the spinal cord, the response ofhigher centers, and the prior experience of the sub-ject.

It has been a tenet of the osteopathic professionthat presymptomatic signs of visceral disease maybe evident in the somatic system. Korr 6 reported acharacteristic electrical skin resistance pattern ina subject 3 weeks prior to the development of coro-nary occlusion. The prognosis of somatic dysfunc-tion observed in a cardiac reflex site in an asymp-tomatic patient raised critical questions forWilson. 23 Did the somatic dysfunction indicate apotential for coronary occlusion, and would manip-ulative treatment of the somatic dysfunction re-duce the likelihood of a coronary accident? Bealand Kleiber24 noted viscerosomatic reflex changesin patients with subclinical coronary artery dis-ease (as determined by cardiac catheterization).

Early signs of most disease states are manifest-ed as symptoms and signs that are part of a com-mon reaction pattern to injury or stress. Palpatorycues of transient muscle hypertonicity and irrita-bility or subcutaneous edema may be accompani-ments of ill-defined subclinical states. It is onlywith the continued activity of a particular stressorthat the body response is characterized by specificchanges that are associated with a particular dis-ease state. Transient palpatory cues may be sig-nificant when they are observed to be part of a re-curring disease pattern in a particular patient. Inmany functional disturbances of visceral disease(for example, gastritis), a somatic reflex patternmay be evident, but it disappears as the conditionsubsides, only to recur if the organ dysfunction re-turns. In some individuals, the somatic dysfunc-tion may remain as a latent image manifested bysubtle changes in tissue texture and joint mobility,

Viseerosomatic reflexes 788/55

which are identified only by critical palpatoryevaluation.

The early signs of acute reflex activity are simi-lar to those observed by Larson 25 in cardiac pa-tients in the intensive care unit. These reactionsinclude: vasomotor reaction, with an increase inskin temperature; sudomotor effect as evidencedby an increase in moisture on the skin, which is re-flected by an increase in skin drag; skin texturalchanges, such as thickening; increased subcutane-ous fluid; and increased muscle contraction. Thesechanges are localized to the autonomic spinal ref-erence site for the particular viscus involved. Theygradually decrease as the acute phase subsides;the subcutaneous edema lessens, and the patiententers the healing phase and the stage of chroni-city.

In some patients, the reaction in the acute phaseof an organic disease may be that of a typical so-matic stress reaction pattern for that particularpatient. As the condition progresses, the somaticstress pattern subsides, and the typical visceral re-flex pattern is seen.4.26

The chronic phase of reflex activity is character-ized by trophic changes in the skin, increasedthickening of the skin and subcutaneous tissues,and localized muscle contraction. The muscles arehard and tense, and they may be hypersensitive to

palpation.27 The superficial muscles are usuallyless involved than the deep musculature, which ischaracterized by a deep confluent splinting con-traction that involves two or more adjacent spinalsegments and that is associated with a restrictionin segmental spinal motion. 26 The deep tissue re-sponse may be more evident in the region of thecostotransverse articulation.

Patterns of the somatic response to visceral dis-ease are unique for each individual in terms of lo-cation, the number of spinal segments involved,and whether there is unilateral or bilateral in-volvement. The intensity of the tissue response dif-fers among individuals and among disease states.In general, the reactivity of the tissue response isgreater in patients with pain from serious organicdisease. Preliminary observations 26,28 suggestthat the intensity of the somatic dysfunction isgreater in patients with cardiac and gastrointesti-nal problems who present with symptoms of severepain than in patients with pulmonary disease, whoare more apt to present with symptoms of dyspnea.A viscerosomatic reflex is seen in a high percent-age of patients with coronary artery disease,whereas it may not be apparent in patients withcertain cardiac arrhythmias, such as supraven-tricular tachycardia. Ischemia, pain, and life-threatening conditions may include a psychic rein-

TABLE 1. SEGMENTAL SYMPATHETIC NERVE SUPPLY."

LargeLarge intestine

Small

intestine (splenic flexureAuthor(s) Heart Lungs Esophagus Stomach intestine (splenic flexure) to rectum) Appendix Liver Gallbladder

Gray" Tl-T5 T2-T4 T5-T6 T6-T10 T9-T10

T11-L1 L1-L2 T7-T9 T7-T9House and

Pansky33 TI-T5 T2-T5 T6-T10 T6-T10

T6-T10 T6-T10 T5-T6Crosby and TI-T5 T3-T4 T5-T6 T7-T9 T9-T12

T9-T12 T7-T8 T9-T10

associates34 (T6) (T5)

(R)Bhagat and

associates35 Tl-T5 T2-T7 T5-T6 T6-T9 T9-T10

T11-L1 L1-L2 T10-T12 T9-T10 T9-T10Pottenger35 T2-T8 T4-T9 T7-T9 T9-T12

T7-T10 T8-T9

C3,C4 C3,C4Brodar TI-T4 T2-T7 T6-T10 T6-T10

Ll-L2 T10-T12 1'7-T9 T7-T9

(T5) (T2-T4)

(T5-T11) (T5-T11)

(R) (R)(T5-T9L)

White37 T1-T3 (T6) T9,T10

(T11) S2-S4 (T6) (T6)(afferent) T7,T8 (T11)

T12-L1 T7,T8 T7,T8

(T9)

(1'9) (T9)Bonica" Tl-T4 T2-T7 Upper T6-T9 T6-T8

T12-L1 Ll-L2 T10-T12 T5-T9 T5-T9

(afferent) (T5) T2-T'7 (T10)(T8) duodenum

T9-T11jejunem

ileumBonica35 Tl-T4 T2-T7 Upper T6-T9 T6-T11

(TI I) LI-L2 T10-T12 T6-T9 T5-T9

(efferent) (T5) T2-T4 (T10)

T12-L1 (T10) (T10)LowerT5-T7

* The segments shown in parentheses indicate less frequent findings. L = left; R = right.

789/56 Dec. 1985/Journal of AOA/vol. 85/no. 12

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forcing component, which will produce a moreintense reflex response.

The factors that initiate viscerosomatic reflexesand maintain them are not known. Subthresholdsegmental facilitation can be observed in some pa-tients for many years after an operation for gall-bladder surgery.' It has been suggested that high-er centers may play an important role in theproduction and maintenance of visceral reflexes. Itis not known whether the continuation of the re-flex somatic dysfunction is related to the initialimpact of the visceral disease, or whether it is a re-sult of long-term segmental facilitation.

Spinal segmental sites for somatic dysfunctionassociated with visceral disease are related to theautonomic nervous system supply for various or-gans. The site location has been plotted on the ba-sis of animal experimentation and observations onhumans from regional nerve blocks used to definepain pathways.' Somatic reference areas, whichwere first identified by Head, 31 have been modifiedby other observers"0 '32-37 (Table 1). Bonica 30 haslisted the autonomic afferent and efferent innerva-tion for the various organs, while White' lists theafferent innervation; the specificity of nerve sup-ply is lacking in the other sources. When the auton-omic reference sites in Table I are plotted (Fig. 2),3 distinct groups of viscera are seen, as follows: T1-

Fig. 2. Site location of segmental sympathetic nerve supply.

Adrenal Adrenal Testes, Urinary Prostate Ureterine

Spleen Pancreas Kidney Ureter cortex medulla Ovaries Epididymis bladder gland Uterus tube

T6-T10 T6-T10 T10-L1 T11-L2 T8-L1 T10-T11 T11-T12 T11-L2 T12-L1 T12-L1 T10-L1

T5-T6 T10-T11 T11-L2T7-T9 T11, T11, T9-T10 T11, Ll-L2 T10-L2

T12-L1 T12-L2 T12-L1(L2) (L3)

T6-T10 T6-T10 T11-1,1 L1-L2 T10-T11 T11-L2 T10-L1

T11-L1 T10 T12-L1

T6-T10 T6-T10 T12-L1 Ll-L2 T11-L1 Ll-L2(T5-T11) (T5-T11) (T11-L2) (T11-T12) (T10-L2) (T11-L2)

(T11) L1-L2 S2-S4 T11-L1

T12-L1 S2-S4

T6-T10 T11, T11-L2 T10-1,1 T11-L1 T10-L1 T10-T12

T12-L1 (L1)

T6-T10

(T10) T11-L2 T6-L2

T6-L1 T11-L2 T6-L1 T6-L1T11-L1(L2)

Viscerosomatic reflexes 790/57

TABLE 2. VISCERAL SOMATIC REFERENCE SITES (ADAPTED FROMHANSEN AND SCHLIAC108).

Organ

Spinal reflex site

Cervical Thoracic

Heart C3,C4 C8,T1-T8Lung C3,C4 T3-T9Pleura C3,C4 T2-T12Stomach C3,C4 T5-T9Duodenum C3,C4 T6-T10Jejunum C3,C4 T8-T11Large bowel C3,C4 T9-L1Appendix C3,C4 T9-L1Liver C3,C4 T6-T11Gallbladder C3,C4 T6-T11Spleen C3,C4 T7-T10Pancreas C3,C4 T7-T9Kidney C3,C4 T9-L2Ureter C3,C4 T9-L2

T5—heart and lungs; T5-T10—esophagus, stom-ach, small intestine, liver, gallbladder, spleen,pancreas, and adrenal cortex; and T10-L2—largebowel, appendix, kidney, ureter, adrenal medulla,testes, ovaries, urinary bladder, prostate gland,and uterus.

Based upon clinical studies of patients with var-ious types of visceral disease, tabulation of viscero-somatic reference sites has been presented by Han-son and Schliack38 (Table 2). They identified reflexsites for different organs by palpatory examina-tion of tissue texture change, vasomotor change,and hyperalgesia. Tables for each organ studiedlist a number of patient diagnoses and clinicalfindings. In addition, there are individual casestudies to illustrate different organic conditions;each includes a diagnosis, examination findings,diagrams of pain reference zones, and laboratorytest results.

Areas of somatic dysfunction associated withvisceral disease have been identified by palpatoryexamination by a number of physicians. Membersof the osteopathic profession have shown a particu-lar interest in the identification of somatic dys-function related to organic disease. Observationsof various investigators3,6,23-26,39-130 are presentedin Table 3 and are charted in Figure 3. For themost part, these findings are similar to the chartedautonomic nerve supply data in Table 1 and Fig-ure 2.

Although there is considerable correspondencein the data presented, it is noteworthy that a des-ignation of sidedness is made in certain unpaired.organs. Findings of left sidedness are recorded indisease of the heart and small intestine, and right:sided findings are reported in gallbladder diseaseand appendicitis. Both right- and left-sided find-ings were observed in disorders of the stomach.

Variability in observations of the reflex referencearea for different viscera may be accounted for bythe potential individuality of the autonomic ner-vous system innervation in different persons, aswell as varying degrees of accuracy of the observ-ers in recording spinal findings.

Referred painPain of visceral disease that is referred to a somat-ic area that is supplied by the same or adjacent spi-nal nerve segments has been the object of consider-able study.31,131-134 The terms "referred pain" and"viscerosomatic reflex" have been used inter-changeably for a phenomenon that includes cutan-eous hyperesthesia, vasomotor changes, and con-traction of skeletal muscle. Early investigatorsstudied the cutaneous distribution of pain referredfrom various organs. Visceral pain perceived in asomatic area was called a viscerosensory reflex,and skeletal muscle contraction resulting fromvisceral afferent stimulus was called a visceromo-tor reflex.133

The concept of a central excitatory state of thespinal cord is basic to the hypothesis of referredpain. Visceral afferents initiate the central excita-tory state, and their action may be facilitated bysomatic afferents from skin and muscle or by su-praspinal stimuli. Once the excitatory state hasbeen created, its activity may be increased ormaintained by further visceral stimuli, as well asby afferent stimuli from somatic structures andhigher centers. A cyclical pattern of neuronal ac-tivity in the inner connector neurons of the spinalcord is postulated. This would maintain a lowerthreshold of sensitivity or facilitation to stimuliacting on the segment. The excitatory state may bemaintained by stimuli unrelated to the initiatingevent, and it is thought that the excitation may bemaintained for long periods of time after the initi-ating stimuli have ceased, thus resulting in con-tinued cutaneous hyperesthesia and skeletal mus-cle contraction.

Clinical studiesClinical research studies of visceral disease and itssomatic components have been directed to theidentification of somatic manifestations of visceraldisease and the effectiveness of manipulativetreatment of somatic dysfunction on the diseaseprocess. Early studies described the location andsome characteristics of the identified somatic dys-function, but authors failed to describe the testsused to determine the somatic components.

Wilson 117 presented data on an early study ofpalpatory examination of a group of patientswhose diagnosis was not known to the examiner.Somatic dysfunction was localized in the region of

791/58 Dec. 1985/Journal of ADA/vol. 86/no. 12

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Fig. 3. Graphic representation of viscerosomatic reference sites reported in the osteopathic literature.

C3 and T8 in 19 cases of gallbladder disease in con-trast to patients with other diagnoses. Long andDeming" 2 and Deming and Kruener 3 reported theresults of palpatory findings in patients with disor-ders of the gastrointestinal tract, heart, lungs, andfemale genital tract. Limited statistical verifica-tion was obtained for the characteristics of somaticdysfunction that were tested. Lindberg and associ-ates94 found that somatic dysfunction of T7, T8,T10, and L5 were significant in a study of patients

with colitis. The criteria for the palpatory findingswere listed, but the testing methods were notspecified. Woods96 reported that presurgical palpa-tory findings of a viscerosomatic reflex correlatedwith the diagnosis in 10 of 13 patients who hadacute abdominal disorders.

A 5-year, double-blind study of 5,000 hospital-ized patients who were examined for evidence ofsomatic dysfunction and its relationship to diagno-sis was reported by Kelso.4 Details of the examina-

Viscerosomatic reflexes 792/59

HEARTT3-T5,upper ribs

leftC2,T1-T5 leftRibs 1-2 leftTI-T6,ribs 3-5 leftTI-T4T3,T4C2,C4,C5,T3,T4,

ribs 3-6 leftC3,T4,T5

A single case

T3,T4

T2-T6Tl-T4

C2 left,T2-T5

Low skinresistance areas

Left sidepredominance

TI-T10C 1-C2,T2-T5T1-T4,ribs 1-4 leftT3,T4TI-T3,ribs 1,2,5Tl-T4,T5

occasionally, ribs alsoC6-T5,upper ribs left MyocarditisT3,T4

TABLE 3. VISCEROSOMATIC REFERENCE SITES FROM THEOSTEOPATHIC LITERATURE.

T1,T6T1-T4 leftT1-T5,ribs left

LUNGC3-C4,T4-T9

C7-T5, mostprominent Tl-T3

Rib 2 leftTl-T4

T8-T11

T6-T10

Tl-T3T3-T5T2-T7

Barstow (inPatriquin39)

Bea124."Beasley'Becker'Burchett42Burns'Champlin and

Champlin"Cox and

associates'sGlascock (in

Northup46)Hart"

Johnson48Kelso and

associates'Koch'Korr6

Larson"

Lone°MacBain"Patriquin39Robuck52Singleton'sSnyder"

Steunenberg55A.T. Still

symposium"Waitley"Walton58Wilson"

Bolton's

Burns's."

Bush'sCrane"Deming and

Kruener3

Facto"Goode"Grainger"Gravett67

Hoag"

Howell andassociates's."

Chronic pulmonarydisease

Asthma27 cases asthmaNervous control of

lungsTuberculosis19 cases laryngeal

tuberculosis15 cases upper lobe

tuberculosis38 cases middle

and lower lobetuberculosis

AsthmaLobar pneumonia183 cases disorder

of the respiratorytract

1 case bronchitisAsthmaLobar pneumoniaAcute and chronic

bronchitisChronic lung

disease

Chronic obstructivelung disease

1 case pulmonarydisease

Keene71

Kline"

Koch"

Magoun74McWilliams75

Northup79

A.T. Stillsymposium56

Burns'

Brigham"

Conley52-5"

Gibson"Glascock (in

Northup46)

Halladay"Kranz"Mattem"

Magoun"

Meyers"'Muttart"Waitley57

Brigham'

Gibson'

Kranz"

Magoun"

Martin"

mobility, mostpronounced atT4-T5

T2-T5, ribs 1,2depressed

T4-T5 right, ribs4,5 depressedright

T2 right, T6-T7left, rib 2

T2-T8

Cervical and upperthoracic spine

T2-T4C6,C7,T3,T4,

sacrumT4,T5Occiput,T4,T5,ribs

4-5 bilaterallyRib 5 left

STOMACHT5

T5

T5-T10C6,C7,T2-T4

C1,C2,T2,T6,T12

T9,10,ribs involvedT5-T7 left

1 case tuberculosis

1 case tuberculosis

1 case tuberculosis

Respiratoryinfections

Asthma

Bronchi and lungsAsthma

20 cases asthmaAsthma

1 case asthma

1 case chronicgastritis

Acute gastritis1 case chronic

gastritis1 case chronic

gastritis1 caseUlcer,

inflammation ofstomach

Peptic ulcer

Acute indigestion

Gastric ulcerGastritis

1 case gastric ulcerGastric ulcer

Pyloric ulcerPylorus,

inflammation ofDuodenum, areas

of referred painDuodenum,

inflanunation of

Duodenum,functionalconditions of

Duodenal ulcerwith cholecystitis

Observer Findings Remarks

Ribs 5-8 rightT3-T4C2-C4, Tl-T6

C2,C3,T3,T6Rib 5T3-T4C5,C6,rib 1,

clavicleUpper thoracic

area, especiallyTl-T6

T3, rightcostotransversearticulation,T2left

Thoracic spine-extremerestricted

T7-T10T8-T10

T8,T9T5-T7 leftT8-T10 left

T6-T9 left

T5-T7

T5-T12,particularlyT8,T9

T5-T7 right

T6,T7 left

T5-T9,inflammation ofT5-T7

T5-T9, particularlyT5,T6

T9-T12T5-T9 leftT3 rightT1,T3 rightT6-T8, ribs right18T5-T7T6,T7,upper

cervical area,and T5-T10

T5,T6 rightT6-T8 leftT5-T7 leftT5, spastic neckT6-T10T5-T9, most

importantlyT5-T7

SMALL INTEST

Peptic ulcer

INE

793/60

Dee. 198541ournal of AOAAnd. 85/no. 12

T5-T10 leftOcciput,T7,T10 Diabetes

KIDNEYT12-L1T11

T12

Renal tuberculosisNephritis

T8-T10

C2,C3,T9-T1 1

L5 left innominateL4-S2

Sacrococcygealjunction

Ll

T8-T12,L1-L2,S3,S4

SacroiliacC1,C2,ribs 1,2

rightLl spastic muscles

of lower thoracicand lumbarareas

12 rib right, LlLumbar areaT12,L1,L2

T9-T12,L1

L3-L5,sacroiliac

T10,11 right

T10-L1,L4,L5

Tuberculosis of theuterine tubes

1 case ofdysmenorrhea

Ovarian and tubaldisease

Uterus

Menstruation

Primarydysmenorrhea

1 case fibroids1 case cystic right

ovaryRetroverted uterus

Pelvic organs1 case

dysmenorrheaOvaries,

dysfunction ofUterus,

dysfunction of1 case left ovarian

and tubal disease1 case ruptured left

ectopicpregnancy, rightovarian cyst

Magoun"Wilson129

Strachan126URINARY

Gibson"

Wilson127

Gibson"

Glascock (inNorthup")

Wilson'

Burns'

Detwiler125

Gibson"

Glascock (inNorthup")

Hitchcock129

Laughlin99

Burns'Barstow (in

Conn')Blackslee (in

Conn')Ellis122

Smith/25

L5 1 case prostate andbladder disease

UTERUS AND OVARIES

Lower thoracicarea, upperlumbar region, 3lower ribs,frequently rib 12

T9-T11T11-T12T10-L1T10-T12T5-L3, principal

areaT9-T11, most

specifically T10T7-L3, flat,

extreme rigidityT10-T12BLADDER AND URETERLumbar and Bladder

sacral areasbilaterally

Lumbar and Uretersacral areas

L5PROSTATE GLAND

Sacrococcygealarea bilaterally

L3,L4

11 cases

Magoun74Northup79

Simmons/39

Woods"

Gibson"Magoun74".92

NelSOn123.124

Lindberg"Northup95

Waitley"Woods"

Gutensohn"9

LARGE BOWELT7,T8,T10,L5 ColitisLower dorsal or Colitis

lumbar areaT5,L3T12-L2 1 case strangulated

inguinal hernia,left indirect

APPENDIXT9,T10T9-T11 rightS1 right

T11Rib 10 right 1 case appendicitisT9-T11 rightT10-L2,tender spot

T11 rightLowest thoracic

and lumbar areasT9-T12 1 case appendicitisGroup curve right,

apex at T10T11-L1 bilaterally

LIVERT6-T8 rightT5-T7 rightT8, midthoracic region rightT9±2 segments (T7-T11)T5-T9T10 right 1 case

GALLBLADDERRibs,T5-T12 Vertebral lesion

(flexion type)T6-T8 1 case gallstonesT5-T7 rightT9-T1 0, vertebral

and costal lesions,frequently rib of T10

Rib 9, T12,T5-T9,T7 mostfrequent location

T7, pain to right ofT8-T11 spinousprocess

T8, L4-L5, left 1 case cholecystitissacroiliac joint and colitis

T8-T10, includingribs, especiallycostovertebraljoint right

T6-T8 rightT7 rightT5-T7 rightT6-T8 rightT5-T8, ribs bilaterallyT7,T8 midthoracic

region rightRib 8 right 1 case cholecystitisT8-T10 rigidity and

immobility,including ribs

T10

T5-T10 and ribsT5-T9T6-T9, ribs right C3,T8

SPLEENT8-T11 left

PANCREAST6-T11 Paravertebral

tenderness

Brigham97Gibson"Glascock (in

Northup")Kani"Laughlin99Magoun744."

Millardlol

Smithl"Wilsonl o3

Woods"

Magoun74.92

Peckham'Waitley57

Beckeri"

Brigham'Burns'

Conley""9.11°

Denslow111

Downing/12

Gibson"Magoun74.59"

Malone113McWilliams75

Northup".114Starks115

A.T., Stillsymposium"

Townsend116Waitley"Wilson117.115

Gibson"

Viscerosomatic reflexes 794/61

tion method, the tests used, and the results werepresented. He concluded that most visceral dis-eases appeared to have more than one region withan increased frequency of segmental findings, thatunpaired viscera have an increased frequency offindings on one side, and that the number of spinalsegments involved appears to be related to the du-ration of the disease. In a second report, Kelso andassociates5 observed an increased incidence of pal-patory findings in the cervical spine in patientswith sinusitis, tonsillitis, disease of the esophagus,or liver ailments. Upper thoracic involvement wasseen in patients with bronchitis, coronary arterydisease, or chronic heart disease. Somatic dysfunc-tion was significant at T5-T12 in patients withgastritis, duodenal ulcer, pyelonephritis, chronicappendicitis, and cholecystitis.

Larson' examined patients in the intensivecare unit who had proved or suspected acute myo-cardial disease. Details of the palpatory tests and adescription of the findings are contained in his re-port. He found a moderate dominance of left-sidedfindings at C2, T3, T4, and T5.

A pilot study using students in a blind format toidentify somatic dysfunction in patients with vis-ceral disease was presented by Nicholas. 135 No de-tails of the tests or criteria for somatic dysfunctionwere given.

Cox 136 reported the results of a double-blindstudy of the significance of palpatory findings incoronary artery disease. He found a high correla-tion between palpatory findings at T4 and thepresence of coronary artery disease as determinedby cardiac catheterization. Nicholas 137 reportedsignificant palpatory findings in the upper thorac-ic spine in a blind study of patients who had a diag-nosis of myocardial infarction.

Bea126 used a compression test to examine softtissue texture changes and resistance to segmen-tal joint motion. Somatic dysfunction at Tl-T5 as-sociated with cardiac disease and somatic dysfunc-tion at T5-T12 associated with gastrointestinaldisease were observed. In a blind study of 25 pa-tients, he was able to differentiate patients withcardiac or gastrointestinal disease with an accura-cy rate of 76 percent.

In a study by Beal and Dvorak, 138 the same test-ing procedure was used to examine 50 patients in aphysician-blind format who had diagnosis of car-diovascular disease, pulmonary disease, gastroin-testinal disease, or disorders of the musculoskele-tal system. Significant signs of somaticdysfunction were found in the appropriate reflexsite for the patient's diagnosis. Beal and Morlock28reported that 40 patients who had a diagnosis ofpulmonary disease and were examined for evi-

dence of somatic dysfunction had a predominanceof spinal findings in the area T2-T7.

A study in which 99 patients were examined pri-or to a scheduled cardiac catheterization test wasconducted by Beal and Kleiber. 24 A palpatory ex-amination that utilized a compression test to as-sess tissue texture and joint mobility was carriedout without knowledge of the patient's history orhealth status. The presence or absence of somaticdysfunction correlated with the cardiologist's diag-nosis in 79 percent of the cases.

Johnston and coauthors 133 reported a physi-cian-blind study of palpatory findings of vertebraland costal motion dysfunction and tissue texturechange. Results revealed a statistically significantincreased incidence of palpatory findings at T7-T12 in patients with renal disease as comparedwith patients with hypertension or normal bloodpressure. The palpatory findings were associatedwith independent observations of increased skintemperature measurement.

Clinical studies of the effectiveness of the use ofosteopathic manipulative treatment in visceraldisease are limited. Two early studies in which thepatient was used as his/her own control were pre-sented by Wilson. In the first, 76 he reported the re-sults of manipulative treatment in a series of 20patients with a diagnosis of asthmatic bronchitiswho were treated at the clinic of Peter BentBrigham Hospital. He identified somatic dysfunc-tion at T4 on the right, to which he applied specifictreatment. All 20 patients had had prior vaccinetreatment before the use of manipulation. Treat-ment resulted in at least temporary relief for 15patients (50 percent improvement in 10 patients,and 4 of whom the attacks had practically ceased)and no relief in 5 cases.

Wilson also reported on a series of 12 patients aspart of a research study23 on the diagnosis andtreatment of cardiac disease. Patients were exam-ined by 3 osteopathic physicians independentlyand without knowledge of the history or medicalrecord. A diagnosis based upon the evidence of so-matic dysfunction in the area Tl-T5 was found tocorrelate with the diagnosis of the cardiologist in10 of 12 cases. Patients were given specific manip-ulative treatment on a weekly basis in addition totheir medical management. Although there wereno objective tests of clinical improvement report-ed, the patients in the series were symptomaticallybetter.

Based upon palpatory and x-ray examinations,Koch49 found evidence of somatic dysfunction in100 cases of functional heart disease and 50 casesof organic heart disease. Somatic dysfunction wasobserved at T2-T6. Each patient served as his/her

795/62 Dec. 1985/Journal of AOA/vol. 85/no. 12

own control and showed symptomatic improve-ment with manipulative treatment.

Miller14° reported a controlled study of chronicobstructive lung disease in which patients wererandomly assigned either to a group receivingstandard medical care (control group) or to a groupreceiving both medical care and osteopathic treat-ment. Palpatory examination for somatic dysfunc-tion was carried out by 2 osteopathic physicianswho were blinded as to whether a subject was inthe treatment or control group. A significant in-crease in somatic dysfunction was noted in the tho-racic spine of both groups. Objective measure-ments of changes in tests of lung capacity wereperformed, and significant changes were not ob-served in the treated group as compared with thecontrol group. However, the treated patients ex-hibited a decrease in objective evidence of somaticdysfunction, and they subjectively reported im-provement in the ability to do physical work.

DiagnosisThe diagnosis of viscerosomatic reflex is basedupon a history of visceral disease and the objectivefindings of somatic dysfunction on palpatory ex-amination. Objective palpatory findings of a vis-cerosomatic reflex without an associated diseaseshould lead to a review of the patient's history tosee whether symptoms of a visceral disorder can beelicited. A general structural examination of thepatient should be carried out with the patient inthe standing, seated, and supine positions. A pal-patory examination of the paraspinal tissues toelicit areas of tissue texture changes that are po-tential reflex sites is conducted with the patient inthe seated position. It is important to identify tis-sue texture changes in the various soft tissue lay-ers, as follows: the skin for changes in texture,temperature, and moisture; the subcutaneous tis-sue for changes in consistency and fluid; the super-ficial and deep musculature for tone, irritability,consistency, viscoelastic properties, and fluid con-tent; and the deep fascial layers for texturalchanges. Emphasis is placed upon the palpation oftissue texture, because it is significant for identify-ing visceral effects in the somatic tissues.' Specialattention is given to the examination of tissue tex-ture at the costotransverse area, where it is feltthat autonomic nerve effects are predominant.

Bony landmarks and joint motion tests may con-firm the existence of areas of somatic dysfunction.However, in my experience, tests of the qualityand range of joint movement have not been foundto differentiate between visceral reflexes and so-matic changes.

Palpatory examination of the patient in the su-

pine position has been found to be definitive in theexamination of patients for cardiac reflexes.' Thedeep confluent muscle splinting reflex effect ismore apparent with the relaxation of the superfi-cial muscles. The examiner's fingers are placed onthe skin surface, and after ascertaining its quality,a compressive force is applied by the fingers sothat the examiner may project his/her sensoryawareness in turn to the subcutaneous tissue, su-perficial muscle, deep muscle, fascia, and bone,evaluating the consistency and the viscoelasticproperties of each. Lastly, a compression springingmotion test is effected by contacting the transverseprocess and springing it to elicit its quality of mo-tion. The compression test is used in comparingthe right and left side of an individual vertebra, aswell as the vertebra above and below. The supinecompression test is recommended because the sideof the dominant palpatory pattern observed in theseated position may change when the patient is su-pine. This finding was observed in 25 patients inan examination for cardiac reflexes.24

The findings of a supine compression test aremore difficult to evaluate in the lower thoracicspine because of the patient's weight on the palpat-ing hands. Whether the prone examination posi-tion can be equally discerning for evidence of re-flex change has not been tested, and examinationof acutely ill patients often precludes the use of theprone position. Additional tests may be utilized foradded information or confirmation of findings.These tests may include evaluation of the cervicalspine, ribs, lumbar spine, and pelvis for evidence ofreflex involvement.

The diagnosis of a viscerosomatic reflex is basedupon the following criteria: 2 or more adjacent spi-nal segments that show evidence of somatic dys-function located within the specific autonomic re-flex area; a deep confluent muscle splintingreaction; resistance to segmental joint motion; andskin and subcutaneous tissue changes that areconsistent with the acuteness or chronicity of thereflex.

Palpatory differential diagnosis of the origin ofsomatic dysfunction is difficult. Viscerosomatic re-flexes are characterized by paravertebral deepmuscle contraction at spinal areas that are associ-ated with the autonomic nervous system visceralreference sites. Somatic change may be unilateralwith single-organ or bilateral with paired-organdisease. Somatic change that is resistant to manip-ulative treatment should raise the physician's sus-picion of a potential viscerosomatic reflex.

Psychologic stress often is manifested as a bi-lateral contraction of the superficial paraspinalmusculature in the cervical and upper thoracic

Viscerosomatic reflexes 796/63

spine. In cases of trauma, somatic dysfunction isusually predominant on one side, and the findingsare segmental in nature. Tissue hypertonicity var-ies from segment to segment. There may be agreater viscoelastic effect to palpatory compres-sion; that is, the barrier sense or end point is not asresistant to compression as in the case of the vis-ceral reflex. A transverse process may be promi-nent and tender on palpatory compression, but it issegmental in nature, in contrast to a visceral re-flex that involves 2 or more vertebrae in a conflu-ent pattern. Differentiating a somatic responsefrom a strain or sprain from that of a viscerosoma-tic reflex when 2 or more spinal segments are in-volved is difficult. In general, the strain or sprainis characterized by an individuality of the segmen-tal response or is part of an established spinalcurve.

The predictive value of palpatory findings in thediagnosis of visceral disease has not been estab-lished. As calculated by Cox, 136 the efficiency ofpalpatory tests of range of motion and soft tissuetexture at T4 for correctly identifying patients whohad coronary artery disease and those who did notis 75 percent and 73 percent, respectively. Bea124found a 79 percent efficiency rate for a palpatorycompression test that identified the presence/ab-sence of somatic dysfunction on the left at Tl-T5 asa predictor of the presence/absence of coronary ar-tery disease.

The palpatory diagnosis of viscerosomatic re-flexes assists the physician in the differential diag-nosis of somatic pain. When combined with otherhistoric or physical evidence, a positive visceroso-matic reflex may enhance the predictive value ofthe diagnosis of visceral disease.

TreatmentOsteopathic manipulative treatment of visceroso-matic reflexes has been advocated on the basisthat it is designed to reduce somatic dysfunction,to interrupt the viscerosomatic reflex arcs, to in-fluence the viscus through stimulation of somato-visceral effects, and to reduce the potential precon-ditioning effect of somatic dysfunction to bodystressors.

It has been proposed that manipulative treat-meni administered to the somatic reference areamay effect a change in the viscerosomatic reflexarc, resulting not only in a decrease in the reactionof the paraspinal tissues, but also in a change inthe automaticity of the feedback mechanism to thespinal cord, a reduction in the cyclical internuncialcord behavior, and a reduction in the visceral effer-ent stimulus, thus leading to a decrease in the ad-verse effect that is associated with repetitive vis-

ceral stimulation. The mechanism may be that of asomatic inhibitory stimulus conveyed to lamina 5cells that effects inhibition or blocking of visceralafferents. 141 Treatment is also designed to reducethe residual effects in the somatic structures fol-lowing a visceral disorder. Pain or disability maybe manifest in the somatic reference area of a vis-cus after an acute attack of visceral dysfunctionhas subsided. Residual somatic dysfunction mayalso result from the lowered threshold of sensitiv-ity attributed to facilitation of the segmental in-nervation, and the lowered threshold may permitgeneral stress effects acting on the facilitated seg-ment to replicate the pattern of muscle contractionor referred pain.

Treatment of the acute stage of somatic dysfunc-tion associated with visceral disease is designedprimarily to break into the reflex arc. In cases ofserious illness, the treatment may consist of gentledigital pressure of short duration to effect a localchange in the superficial tissues. 142 When relax-ation has been accomplished in the subcutaneousand superficial paraspinal musculature, the deepmuscle contraction may be addressed. The dura-tion of treatment is dependent upon the patient'scondition and perceived energy level. It is better tocarry out multiple periods of treatment at short in-tervals than a single treatment of longer duration.Acute conditions that are not life threatening,such as asthma, may be addressed in a more ag-gressive manner to effect superficial and deepmuscle relaxation, as well as to attempt to restoresegmental joint mobility. The response to treat-ment of an acute organic dysfunction may be limit-ed, because of the continued afferent stimulationfrom the diseased viscus. A limited response totreatment may continue until there is reduction ofvisceral disease and lessening of the afferent stim-ulation to the somatic tissues.

Acute disease states of a limited or functionalnature, such as gastritis, may require treatment ofthe localized area of viscerosomatic reference, aswell as treatment of contiguous areas of muscletension that are either related to the visceral dis-order or to the general stress response by the pa-tient. In these patients, treatment to effect generalrelaxation may be as important as treatment ofthe specific viscerosomatic reference area.

In cases of limited visceral dysfunction, manipu-lative treatment is designed to reduce somatic dys-function to a minimum. Treatment of a functionaldisorder such as a gastritis may result in a com-plete resolution of the somatic dysfunction. Im-provement in the tissue response may parallel orprecede the improvement in the patient's symptomprofile. However, recurring episodes will usually

797/64 Dec. 1985/Journal of ADA/vol. 85/no. 12

elicit a similar pattern of somatic response. The in-tensity of the reaction will vary with the intensityof the organ dysfunction. In chronic organic dis-ease, somatic dysfunction may be evident as chron-ic myofascial change or as a latent image of theacute reflex pattern.

The effectiveness of manipulative treatment forthe somatic manifestations of chronic organic dis-ease has not been established. It has been proposedthat long-term management programs result in adecreased incidence of recurrence of acute mani-festations of disease, less somatic pain, less dis-ability, and a decrease in the potential stress ef-fects mediated through segmental facilitation.However, comparative studies of the results of ma-nipulative management have not been made.

Osteopathic physicians 110,142-145 have advocatedmanipulative treatment as a part of the treatmentregime for organic problems of the heart, stomach,and gallbladder, as well as for preoperative andpostoperative management of patients with organ-ic disease. Postoperative manipulative treatmenthas been commended as promoting a shorter,smoother convalescence from the effects of visceraldisease, and, in some instances, as essential for theultimate recovery of the patient's well-be-ing.110,145

There is little information about the effect ofsurgery on viscerosomatic reflexes. Martin 93 re-ported a spinal reflex at T6-T7 on the left in a caseof duodenal ulcer complicated by cholecystitis; thereflex had disappeared by the time of examination2 weeks after surgery. Drew145 observed that spi-nal reflexes in cases of acute appendicitis usuallyreturn to normal a few days postoperatively, butthey may remain for several weeks after surgery.Kelso' found that segmentally related findings didnot change in serial examinations of hospital pa-tients who had undergone cholecystectomy, appen-dectomy, or hysterectomy. Chronic somatic dys-function was noted by Denslow 29 in patientsfollowing gallbladder surgery.

Manipulative treatment has been used to treatsomatic dysfunction associated with a variety oforganic diseases. Downing112 discussed the non-surgical treatment of gallbladder disease and Mat-tern" the treatment of gastroduodenal ulcer.Denslow" presented a case history of acute chole-cystitis and colitis, Meyers99 reported on gastriculcer, and Wilson195 discussed liver disease. Thelong-term management of specific visceral condi-tions has been discussed by Wilson 23 '76 (heart dis-ease and asthma), Koch 49 (heart disease), andFacto" (bronchitis).

There is a definite need for further data on theincidence of viscerosomatic reflexes and the re-

sults of both surgical and manipulative interven-tion.

CommentThe role of the musculoskeletal system in healthand disease is still ill defined. Although we havebasic science confirmation of the existence of so-matovisceral and viscerosomatic effects, the inter-relationships of the somatic and visceral systemsand the determinants of their manifold interactionsis not clear. Are viscerosomatic manifestations theearly signs of visceral disease, or do somatic affer-ents sensitize certain spinal cord segments and therelated viscera, creating a predisposition to func-tional or organic disease? It is highly probable thatthe initiation of organic disease is a complex processof interrelationships involving visceral and somaticafferents, as well as stimuli from higher centers thatis manifested by a highly individualistic selectivitybased on prior experience and learning. The effect ofhigher centers on local somatic dysfunction relatedto visceral disease is not known. It is of interest thatorganic disease may be manifest in both a massivebody reaction and/or a selectivity to a local segmen-tal area.

We lack knowledge of the excitation causes ofvisceral afferent stimuli, the degree and localiza-tion of somatic response, the maintenance of bothvisceral and somatic irritability, and the short-and long-term effects of somatic dysfunction on thespinal cord and viscera. Studies have alluded tothe possibility that visceral disease may havemore widespread manifestations than the localautonomic related segmental component. Para-sympathetic manifestations of visceral diseasehave received minimal documentation.

There is a need for the development of specificpalpatory tests that are easily applied and that arehighly reliable to aid the differential diagnosis ofvisceral disease. Researchers also require specificpalpatory tests to assess the visceral manifesta-tions of somatic dysfunction and the effectivenessof the use of manipulative treatment. Valuable in-formation could be obtained from observing theshort- and long-term effects of surgery on viscero-somatic reflexes. For example, how soon does thesomatic component resolve following surgery? Theprognostic value of palpatory tests will be substan-tially improved by studies of the long-term man-agement of patients undergoing surgery or medi-cal treatment for visceral disease.

The concept of viscerosomatic reflexes reflectsthe strong interest of the osteopathic profession inthe relationship of the musculoskeletal system inhealth and disease. It was apparent to early practi-tioners in the profession that somatic dysfunction

Viscerosomatic reflexes 798/65

was the result of multiple factors—somatic, viscer-al, and psychologic. The identification of visceroso-matic reflexes characterizes the early interest inthe differential diagnosis of somatic dysfunction.It is hoped that continued efforts to explore theetiologic mechanisms of somatic dysfunction andthe interrelationships of the nervous system willlead to further refinements in palpatory diagnosisand manipulative treatment.

Appreciation is extended to William L. Johnston, D.O.,for critical review of the paper, Wolfgang Gilliar for helpwith German translation, Bruce Miles, Ph.D., for assis-tance with the illustrations, and Barbara Scarborough,for preparation of the manuscript.

1. Long, F.A., and Deming, G.S.: Study of the segmental incidence ofcertain spinal palpatory findings in disorders of the gastrointestinaltract. JAOA 41:363-73, May 422. Long, F.A., and Deming, G.S.: Study of the segmental incidence of in-dividual spinal palpatory findings in disorders of certain thoracic andpelvic organs. JAOA 41:453-6, Jul 423. Deming, G.S., and Kruener, V.C.: Study of the segmental incidence ofcertain spinal palpatory findings in disorders of the respiratory tract.JAOA 43:264-7, Feb 434. Kelso, A.F.: A double-blind clinical study of osteopathic findings inhospital patients. Progress report. JAOA 70:570-92, Feb 715. Kelso, A.F., Larson, N.J., and Kappler, R.E.: A clinical investigationof the osteopathic examination. JAOA 79:460-7, Mar 806. Korr, I.M.: Skin resistance patterns associated with visceral disease.Fed Proc 8:87-8, Mar 497. Koizumi, K., and Brooks, McC.C.: The integration of autonomic sys-tem reactions. A discussion of autonomic reflexes, their control and theirassociation with somatic reactions. In Ergebnisse der Physiologie,Springer-Verlag, Berlin, 19728. Brodal, A.: Neurological anatomy in relation to clinical medicine. Ed.3. Oxford University Press, New York, 19819. Appenzeller, 0.: The autonomic nervous system. Ed. 3. Elsevier Bio-medical Press, Amsterdam, 198210. Leek, B.F.: Abdominal and pelvic visceral receptors. Br Med Bull33:163-8, May 7711. Melzack, R.: The puzzle of pain. Revolution in theory and treatment.Basic Books, Inc., New York, 197312. Eble, J.N.: Patterns of response of the paravertebral musculature tovisceral stimuli. Am J Physiol 198:429-33, Feb 6013. Schoen, R.E., and Finn, W.E.: A model for studying a viscerosomaticreflex induced by myocardial infarction in the cat. JAOA 78:62-3, Sep 7814. Hunt, C.C.: The effect of sympathetic stimulation on mammalianmuscle spindles. J Physiol 151:332-41, Nov 5915. Miller, F.: Visceromotor reflexes, II. Am J Physiol 71:84-9, 192416. Miller, F., and Waud, R.A.: Visceromotor reflexes, IV. Am J Physiol73:329-40, 192517. Von Euler, C., and SjOstrand, T.: The elicitation of visceromotor re-flexes. Acta Physiol 14:363-72, 194718. Downman, C.B., and McSwiney, B.A.: Reflexes elicited by visceralstimulation in the acute spinal animal. J Physiol 105:80-94, Jul 4619. Downman, C.B.: Skeletal muscle reflexes of splanchnic and inter-costal nerve origin in acute spinal and decerebrate cats. J Neurophysiol18:217-35, May 5520. Alderson, A.M., and Downman, C.B.: Reflex activation of intercostalnerves and trunk muscles by non-myelinated fibres of the splanchnicnerve in rabbits. J Physiol 150:463-77, Feb 6021. Hix, E.L.: A visceral influence on the cutaneorenal receptive field.JAOA 72:58, Sep 7222. Grainger, H.G.: The somatic component in visceral disease. In Acad-emy of Applied Osteopathy 1958 Year Book. American Academy of Oste-opathy, Newark, Ohio, 195823. Wilson, P.T.: Osteopathic cardiology. In Academy of Applied Oste-opathy 1956 Year Book. American Academy of Osteopathy, Newark,Ohio, 1956

24. Beal, MC., and Kleiber, G.E.: Somatic dysfunction as a predictor ofcoronary artery disease. JAOA 85:302-7, May 8525. Larson, N.J.: Summary of site and occurence of paraspinal soft tis-sue changes of patients in the intensive care unit. JAOA 75:840-2, May7626. Beal, M.C.: Palpatory testing for somatic dysfunction in patientswith cardiovascular disease. JAOA 82:822-31, Jul 8327. Burns, L.: Qualities distinguishing muscles affected by primary ver-tebral lesions from those affected by viscerosomatic nerve reflexes.JAOA 27:542-5, Mar 2828. Beal, M.C., and Morlock, J.S.: Somatic dysfunction associated withpulmonary disease. JAOA 84:179-83, Oct 8429. Denslow, J.S.: Neural basis of the somatic component in health anddisease and its clinical management. JAOA 72:149-56, Oct 7230. Bonica, J.J.: Autonomic innervation of the viscera in relation tonerve block. Anesthesiol 29:793-813, Jul-Aug 6831. Head, H.: On disturbances of sensation with special reference to thepain of visceral disease. Brain 16:1-133, 189332. Gray, H.: Gray's anatomy. Ed. 35 (Brit.) Edited by R. Warwick andP.L. Williams. W.B. Saunders Co., Philadelphia, 197333. House, E.L., and Pansky, B.: A functional approach to neuroanat-omy. Ed. 2. McGraw-Hill, New York, 196734. Crosby, E.C., Humphry, T., and Lauer, E.W.: Correlative anatomyof the nervous system. MacMillan Co., New York, 196235. Bhagat, B.D., Young, P.A., and Biggerstaff, D.E.: Fundamentals ofvisceral innervation. Charles C. Thomas, Springfield, Illinois, 197736. Pottenger, F.M.: Symptoms of visceral disease. Ed. 5. C.V. MosbyCo., St. Louis, 193837. White, J.C., Smithwick, R.H., and Simeone, F.A.: The autonomicnervous system. Ed. 3. MacMillan Co., New York, 195238. Hansen, K., and Schliack, H.: Segmental innervation. G. Thieme,Stuttgart, 196239. Patriquin, D.A.: Osteopathic management of coronary disease. InAcademy of Applied Osteopathy 1957 Year Book. American Academy ofOsteopathy, Newark, Ohio, 195740. Beasley, RE.: Osteopathic factors in cause and treatment of heartdisease. JAOA 44:134-7, Nov 4441. Becker, A.D.: Mainpulative osteopathy in cardiac therapy. JAOA38:317-9, Mar 3942. Burchett, G.D.: Somatic manifestations of ischemic heart disease.Osteo Ann 4:373-5, Sep 7643. Burns, L.: Principles governing the treatment of cardiac conditions.JAOA 43:231-4, Jan 4444. Champlin, C.A., and Champlin, E.E.: True anginal pectoris. OsteoProf 2:52-4, Oct 3445. Cox, J.M., et al.: Palpatory musculoskeletal findings in coronary ar-tery disease. Results of a double-blind study (abstract). JAOA 80:750,Jul 8146. Northup, T.L.: Relief of pain by manipulative therapy. In Academyof Applied Osteopathy 1940 Year Book. American Academy of Osteop-athy, Newark, Ohio, 194047. Hart, R.C.: Angina pectoris. An osteopathic consideration of a com-mon and serious heart malady. J Osteopathy 44:21-5, May 3748. Johnson, F.E.: Some observations on the use of osteopathic therapyin the care of patients with cardiac disease. JAOA 71:799-804, May 7249. Koch, R.S.: A somatic component in heart disease. JAOA 60:735-40,May 6150. Long, F.A.: Some observations on spinal motion. JAOA 39:405-15,May 4051. MacBain, R.N.: Technic for treatment of cardiac conditions. JAOA33:69, Oct 3352. Robuck, S.V.: Body mechanics in relation to cardiac conditions.JAOA 35:1-4, Sep 3553. Singleton, R.H.: Angina pectoris and its manipulative treatment.JAOA 34:73-7, Oct 3454. Snyder, C.P.: Heart conditions commonly found in practice. JAOA23:399-401, Feb 2455. Steunenberg, G.A.: Palliative treatment in cardiac pain. In Acade-my of Applied Osteopathy 1941 Year Book. American Academy of Oste-opathy, Newark, Ohio, 194156. A.T. Still Research Institute: Symposium on A.T. Still Research In-stitute. JAOA 29:433-7, Jun 3057. Waitley, D.D.: Autonomic nervous system in osteopathic therapy.JAOA 47:447, May 4858. Walton, W.J.: Textbook of osteopathic diagnosis and technique pro-cedures. Ed. 2. Matthews Book Co., Dist., St. Louis, 1972

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59. Bolton, E.B., Jr.: Rehabilitation of patients with chronic pulmonarydisease. JAOA 80:883-6, Aug 8160. Burns, L.: Clinical reports from the Pacific College of Osteopathy.JAOA 11:1054-6, Apr 1261. Burns, L.: Osteopathic case reports of pulmonary disease. A review.JAOA 33:1-5, Sep 3362. Bush, L.M.: How the old doctor treated nose and throat conditions.In Academy of Applied Osteopathy 1942 Year Book. American Academyof Osteopathy, Newark, Ohio, 194263. Crane, R.M.: The osteopathic management of lobar pneumonia.Western Osteopath 26:11-15, Nov 3164. Facto, L.L.: Chronic bronchitis. JAOA 35:262-3, Jan 3665. Goode, G.W.: The fifth rib. JAOA 22:265, Jan 2366. Grainger, H.G.: Lobar pneumonia and "the segmental plane."JAOA 50:255-63, Jan 3167. Gravett, H.H.: A letter. In Academy of Applied Osteopathy 1941Year Book. American Academy of Osteopathy, Newark, Ohio, 194168. Hoag, J.M.: Musculoskeletal involvement in chronic lung disease.JAOA 71:698-706, Apr 7269. Howell, R.K., T.W., and Kappler, R.E.: The influence of osteo-pathic manipulative therapy in the management of patients with chron-ic obstructive lung disease. JAOA 74:757-60, Apr 7570. Howell, R.K., and Kappler, R.E.: The influence of osteopathic ma-nipulative therapy on a patient with advanced cardiopulmonary disease.JAOA 73:322-7, Dec 7371. Keene, W.B.: Some possibilities in the treatment and prevention oftuberculosis from an osteopathic standpoint. JAOA 4:147-54, Dec 0472. Kline, C.A.: Osteopathic manipulative therapy, antibiotics and sup-portive therapy in respiratory infections in children. A comparativestudy. JAOA 65:278-81, Nov 6573. Koch, R.S.: Structural patterns and principles of treatment in theasthmatic patient. In Academy of Applied Osteopathy 1957 Year Book.American Academy of Osteopathy, Newark, Ohio, 195774. Magoun, HI.: Diagnosis in acute conditions. JAOA 28:105-6, Oct 2875. McWilliams, A.F.: Low backs. In Academy of Applied Osteopathy1941 Year Book. American Academy of Osteopathy, Newark, Ohio, 194176. Wilson, P.T.: Experimental work in asthma at the Peter BentBrigham Hospital. JAOA 25:212-4, Nov 2577. Wilson, P.T.: The osteopathic treatment of asthma. In Academy ofApplied Osteopathy 1948 Year Book. American Academy of Osteopathy,Newark, Ohio, 194978. Wilson, P.T.: Case history and discussion. JAOA 33:450-1, Jun 3479. Northup, T.L.: Miscellaneous case reports. In Academy of AppliedOsteopathy 1943-44 Year Book. American Academy of Osteopathy,Newark, Ohio, 1943-4480. Burns, L.: Stomach diseases. JAOA 14:393-6, Apr 1581. Brigham, W.C.: Symposium on osteopathic diagnosis and prognosis.Diagnostic evidence from viscerogenic reflexes. JAOA 27:249-50, Dec 2782. Conley, G.J.: The osteopathic lesion, the etiological factor in somecommon surgical disorders. JAOA 34:79-82, Oct 3483. Conley, G.J.: Osteopathic lesion, etiological factor in some commonsurgical disorders. JAOA 47:513-6, Jun 4884. Conley, G.J.: Diagnosis of abdominal diseases. JAOA 44:274-8, Feb4585. Gibson, J.W.: The significance of spinal reflexes due to visceral dis-turbance. Western Osteopath 20:11-12, Aug 2586. Halladay, H.V.: Symposium on osteopathic technic. Spinal centers.JAOA 28:44-5, Sep 2887. Kranz, M.A.: Symposium on stomach and duodenum. Manipulativetreatment for diseases of stomach and duodenum. JAOA 29:158-60, Dec2988. Mattern, A.V.: Gastro-duodenal ulcer and its non-surgical treat-ment. JAOA 33:188-91, Jan 3489. Magoun, H.I.: Osteopathic diagnosis and therapy for the generalpractitioner. JAOA 48:169-72, Dec 4890. Meyers, T.J.: Gastric ulcer. Case histories. JAOA 30:474, Jul 3191. Muttart, C.J.: Diagnosis and treatment of gastric ulcer. JAOA20:485-9, May 2192. Magoun, H.I.: Role of soft tissues in diagnosis and treatment of os-teopathic pathology. In Academy of Applied Osteopathy 1942 YearBook. American Academy of Osteopathy, Newark, Ohio, 194293. Martin, O.F.: Duodenal ulcer complicated by cholecystitis. JAOA27:282, Dec 2794. Lindberg, R.F., Strachan, W.F., and Koehnlein, W.O.: The relationof structural disturbances to irritable colon ("colitis"). JAOA 40:253-7,Feb 41

95. Northup, T.L.: Manipulative treatment of mucous colitis. In Acade-my of Applied Osteopathy 1940 Year Book. American Academy of Oste-opathy, Newark, Ohio, 194096. Woods, E.R.: The viscerosomatic reflex in acute abdominal disor-ders. JAOA 62:239-42, Nov 6297. Brigham, W.C.: Osteopathic surgical reflexes. JAOA 31:129-30, Dec3198. Kani, A.: Early diagnosis of acute abdominal conditions. JAOA41:162-3, Nov 4199. Laughlin, E.H., Jr.: Brief abstracts of case histories illustrating therole of secondary lesion in surgical practice. JAOA 38:378, Apr 39100. Magoun, H.I.: Symposium on acute abdomen. Differential diagno-sis of acute appendicitis from the practitioner's standpoint. JAOA28:512-5, Mar 29101. Millard, F.P.: Non-surgical treatment of appendicitis. JAOA14:282-3, Feb 15102. Smith, G.B.: Appendicitis. Case report. JAOA 23:332, Jan 24103. Wilson, P.T.: Osteopathic diagnosis. JAOA 30:357, May 31104. Peckham, R.R.: Treatment for liver. In Academ; of Applied Oste-opathy 1965 Year Book. American Academy of Osteopathy, Newark,Ohio, 1965105. Wilson, P.T.: Case history and discussion III. JAOA 33:348, Apr 34106. Becker, A.R.: Conservative treatment of gallbladder disease.JAOA 51:104-7, Oct 51107. Bell, L.J.: Gallstones. Case report. JAOA 21:47, Sep 21108. Burns, L.: Gallstones. JAOA 19:132-4, Dec 19109. Conley, G.J.: A letter, In Academy of Applied Osteopathy 1941Year Book. American Academy of Osteopathy, Newark, Ohio, 1941110. Conley, G.J.: The role of the spinal joint lesion in gallbladder dis-ease. JAOA 44:121-3, Nov 44111. Denslow, J.S.: Acute cholecystitis and colitis. Report of a case.JAOA 32:285, Mar 33112. Downing, W.J.: Osteopathic manipulative treatment of non-surgi-cal gallbladder. JAOA 39:104-7, Oct 39113. Malone, E.P.: Manipulative therapeutics for gallbladder disease.In Academy of Applied Osteopathy 1941 Year Book. American Academyof Osteopathy, Newark, Ohio, 1941114. Northup, T.L.: Manipulative therapy in gastrointestinal condi-tions. In Academy of Applied Osteopathy 1942 Year Book. AmericanAcademy of Osteopathy, Newark, Ohio, 1942115. Starks, C.R.: Diagnosis of gallbladder disease. JAOA 34:315-6,Mar 35116. Townsend, G.A.: Osteopathy and surgery in treatment of gall-stones. JAOA 15:390-2, Apr 16117. Wilson, P.T.: Osteopathic diagnosis. JAOA 30:357.8, May 31118. Wilson, P.T.: Gallbladder disease. In Academy of Applied Osteop-athy 1949 Year Book. American Academy of Osteopathy, Newark, Ohio,1949119. Gutensohn, MT.: Diagnosis of pancreatitis. JAOA 54:375-7, Feb55120. Wilson, P.T.: A case of diabetic acidosis. In Academy of Applied Os-teopathy 1942 Year Book. American Academy of Osteopathy, Newark,Ohio, 1942121. Conn, R.W.: Osteopathic principles supporting manipulative treat-ment in nephritis. JAOA 40:494-6, Jul 41122. Ellis, S.A.: Osteopathic and surgical diagnosis of abdomen. JAOA6:406, Jul 07123. Nelson, C.R.: Symposium: Urologic manifestations of man's consti-tutional inadequacies. Structural diagnosis and treatment. JAOA53:255-7, Jan 54124. Nelson, C.R.: Structural diagnosis and treatment of urologicalproblems. In Academy of Applied Osteopathy 1954 Year Book. AmericanAcademy of Osteopathy, Newark, Ohio, 1954125. Smith, F.H.: Osteopathic treatment of organic kidney lesions.JAOA 11:848-52, Jan 12126. Strachan, W.F.: Manipulative treatment of kidney diseases. JAOA33:176-7, Dec 33127. Wilson, P.T.: Case history and discussion IV. JAOA 33:159, Dec 33128. Detwiler, E.S.: Case reports. Dysmenorrhea. JAOA 21:383, Feb 22129. Hitchcock, ME.: The manipulative approach to the management ofprimary dysmenorrhea. In American Academy of Osteopathy 1976 YearBook. American Academy of Osteopathy, Newark, Ohio, 1976130. Simmons, G.: Osteopathic treatment of pelvic diseases. JAOA21:626-8, Jun 22131. MacKenzie, J.: Some points bearing on the association of sensorydisorders and visceral disease. Brain 16:321-54, 1893

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132. Lewis, T., and Kellgren, J.H.: Observations relating to referredpain, visceromotor reflexes and other associated phenomena. Clin Sci4:47-71, 1939133. Sinclair, D.C., Weddell, G., and Feindel, W.H.: Referred pain andassociated phenomena. Brain 71:184-211, 1948134. Drucker, D.E.: Referred pain and the osteopathic lesion. JAOA47:623-9, Aug 48135. Nicholas, S.N.: Correlation of somatic dysfunction with visceraldisease. JAOA 75:425-8, Dec 75136. Cox, J.M., et al.: Palpable musculoskeletal findings in coronary ar-tery disease. Results of a double-blind study. JAOA 82:832-6, Jul 83137. Nicholas, A., et al.: A somatic component of acute spontaneousmyocardial infarction. JAOA 83:68, Sep 83138. Beal, M.C., and Dvorak, J.: Palpatory examination of the spine. Acomparison of the results of two methods and their relationship to viscer-al disease. Manual Medicine 1:25-32, 1984139. Johnston, W.L., et al.: A clinical research study of somatic mani-festations in renal disease (abstract). JAOA 84:73, Sep 84140. Miller, W.D.: Treatment of visceral disorders by manipulativetherapy. The research status of spinal manipulative therapy. Depart-ment of Health, Education, and Welfare, Bethesda, Maryland, 1975141. Hix, E.L.: Reflex viscerosomatic reference phenomena. Osteo Ann

4:496-503, Dec 76142. Larson, N.J.: Manipulative care before and after surgery. OsteoMed 2:41-9, Jan 77143. Young, G.S.: Pre-op lesion reduction reduces recovery time. ClinTrends Osteo Med 4:2, Mar-Apr 78144. Young, G.S.: Gently applied manipulation eases post-op convales-cence, Clin Trends Osteo Med 4:5 and 7, May-Jun 78145. Drew, E.G.: The role of the secondary lesion from the surgicalstandpoint. JAOA 38:377-8, Apr 39

Accepted for publication in November 1984. Updating, as nec-essary, has been done by the author.

Dr. Beal is professor, Department of Family Medicine, Michi-gan State University College of Osteopathic Medicine, EastLansing, Michigan.

Dr. Beal, 201 West Fee Hall, East Lansing, Michigan 48824-1316.

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