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Respiratory system
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S2 S3 S4 Urinary system Reproductive system Preganglionic neuron Postganglionic neuron
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Figure 26-2 The parasympathetic (craniosacral) division of the autonomic nervous system Preganglionic bers extend from nuclei of the brainstem and sacral segments of the spinal cord to peripheral ganglia Short postganglionic bers extend from the ganglia to the effector organs The lateral-posterior hypothalamus is part of the supranuclear mechanism for the regulation of parasympathetic activities The frontal and limbic parts of the supranuclear regulatory apparatus are not indicated in the diagram (see text) (Reproduced by permission from Noback CL, Demarest R: The Human Nervous System, 3rd ed New York, McGraw-Hill, 1981)
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DISORDERS OF THE AUTONOMIC NERVOUS SYSTEM, RESPIRATION, AND SWALLOWING 455
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Hypothalamus Descending autonomic pathways
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Eye Blood vessels of head Glands associated with eye, nasal cavity and oral cavity
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Superior cervical ganglion Gray ramus
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Respiratory system
Hair follicle muscle (pilomotor)
Sweat glands (sudomotor)
Circulatory system
Celiac ganglion Digestive system
Superior mesenteric ganglion To perip[heral blood vessels (vasomotor) T12
Adrenal
Kidney
Inferior mesenteric ganglion
S1 Vasomotor fibers to lower extremity CX Preganglionic neuron Postganglionic neuron Sympathetic trunk
Urinary system Reproductive system
Figure 26-3 The sympathetic (thoracolumbar) division of the autonomic nervous system Preganglionic bers extend from the intermediolateral nucleus of the spinal cord to the peripheral autonomic ganglia, and postganglionic bers extend from the peripheral ganglia to the effector organs, according to the scheme in Fig 26-1 (Reproduced by permission from Noback CL, Demarest R: The Human Nervous System, 3rd ed New York, McGraw-Hill, 1981)
via gray communicating rami to spinal nerves of T5 to L2; they supply blood vessels, sweat glands, and hair follicles and also form plexuses that supply the heart, bronchi, kidneys, intestines, pancreas, bladder, and sex organs The postganglionic bers of the prevertebral ganglia (located in the posterior abdomen rather than
paravertebrally) form the hypogastric, splanchnic, and mesenteric plexuses, which innervate the glands, smooth muscle, and blood vessels of the abdominal and pelvic viscera (Figs 26-1 and 26-4) The sympathetic innervation of the adrenal medulla is unique in that its secretory cells receive preganglionic bers directly, via
PART 2
CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
Paravertebral ganglion Internodal segment Splanchnic nerve
Prevertebral ganglion
Figure 26-4 The principle of the sympathetic preganglionic innervation of ganglia that are placed beyond the limits of the usual preganglionic paravetebral sympathetic out ow from the spinal cord Preganglionic bers (heavy lines) emerging from a spinal segment do not synapse exclusively in the corresponding paravertebral ganglion Some pass as splanchnic nerves to prevertebral (posterior abdominal) ganglia; some bers also enter the sympathetic trunk, in which they pass up or down for a variable number of segments (Reproduced by permission from Pick)
the splanchnic nerves This is an exception to the rule that organs innervated by the autonomic nervous system receive only postganglionic bers This special arrangement can be explained by the fact that cells of the adrenal medulla are the morphologic homologues of the postganglionic sympathetic neurons and secrete epinephrine and norepinephrine (the postganglionic transmitters) directly into the bloodstream In this way, the sympathetic nervous system and the adrenal medulla act in unison to produce diffuse effects as one would expect from their role in emergency reactions By contrast, the parasympathetic effects, as in the pupil and urinary bladder, are more discrete There are three cervical (superior, middle, and inferior, or stellate), eleven thoracic, and four to six lumbar sympathetic ganglia The head receives its sympathetic innervation from the eighth cervical and rst two thoracic cord segments, the bers of which pass through the inferior to the middle and superior cervical ganglia Postganglionic bers from cells of the superior cervical ganglion follow the internal and external carotid arteries and innervate the blood vessels and smooth muscle as well as the sweat, lacrimal, and salivary glands of the head Included among these postganglionic bers, issuing mainly from T1, are the pupillodilator bers and those innervating Muller s muscle of the upper eyelid The arm receives its postganglionic innervation from the inferior cervical ganglion and uppermost thoracic ganglia (the two are fused to form the stellate ganglion) The cardiac plexus and other thoracic sympathetic nerves are derived from the upper thoracic ganglion and the abdominal visceral plexuses, from the fth to the ninth or tenth thoracic ganglia The lowermost thoracic ganglia have no abdominal visceral connections; the upper lumbar ganglia supply the descending colon, pelvic organs, and legs The terminals of autonomic nerves and their junctions with smooth muscle and glands have been more dif cult to visualize
and study than the motor end plates of striated muscle As the postganglionic axons enter an organ, usually via the vasculature, they ramify into many smaller branches and disperse, without a Schwann cell covering, to innervate the smooth muscle bers, the glands, and, in largest number, the small arteries, arterioles, and precapillary sphincters (see Burnstock) Some of these terminals penetrate the smooth muscle of the arterioles; others remain in the adventitia At the ends of the postganglionic bers and in part along their course there are swellings that lie in close proximity to the sarcolemma or gland cell membrane; often the muscle ber is grooved to accommodate these swellings The axonal swellings contain synaptic vesicles, some clear and others with a dense granular core The clear vesicles contain acetylcholine, and those with a dense core contain catecholamines, particularly norepinephrine (Falck) This is well illustrated in the iris, where nerves to the dilator muscle (sympathetic) contain dense-core vesicles and those to the constrictor (parasympathetic), clear vesicles A single nerve ber innervates multiple smooth muscle and gland cells Visceral Afferents Somewhat arbitrarily, anatomists have declared the autonomic nervous system to be purely efferent motor and secretory in function However, most autonomic nerves are mixed, also containing afferent bers that convey sensory impulses from the viscera and blood vessels The cell bodies of these sensory neurons lie in the posterior root sensory ganglia; some central axons of these ganglionic cells synapse with lateral horn cells of the spinal cord and subserve visceral re exes; others synapse in the dorsal horn and convey or modulate impulses for conscious sensation Secondary afferents carry sensory impulses to certain brainstem nuclei, particularly the nucleus tractus solitarius, as described below, and the thalamus via the lateral spinothalamic and polysynaptic pathways The Central Regulation of Visceral Function Integration of autonomic function takes place at two levels, the brainstem and the cerebrum In the brainstem, the main visceral afferent nucleus is the nucleus tractus solitarius (NTS) Cardiovascular, respiratory, and gastrointestinal afferents, carried in cranial nerves X and IX via the nodose and petrose ganglia, terminate on speci c subnuclei of the NTS The caudal subnuclei are the primary receiving site for viscerosensory bers; other less well de ned areas receive baroreceptor and chemoreceptor information The caudal NTS integrates these signals and projects to a number of critical areas in the hypothalamus, amygdala, and insular cortex, involved primarily in cardiovascular control, as well as to the pontine and medullary nuclei controlling respiratory rhythms The NTS therefore serves a critical integratory function for both circulation and respiration, as described further on An important advance in our understanding of the autonomic nervous system occurred with the discovery of autonomic regulating functions of the hypothalamus Small, insigni cant-appearing nuclei in the walls of the third ventricle and in buried parts of the limbic cortex, formerly judged to have purely olfactory functions, are now known to have rich bidirectional connections with autonomic centers in various parts of the nervous system In fact, the hypothalamus serves as the integrating mechanism of the autonomic nervous system and limbic system, as indicated in Chap 25 The regulatory activity of the hypothalamus is accomplished in two ways through direct pathways that descend to particular groups of cells in the brainstem and spinal cord and through the pituitary and thence to other endocrine glands The supranuclear regulatory apparatus of the hypothalamus includes three main cerebral struc-
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