Twenty-First Century Primary Care

Herbert W. Collins, M.D. F.A.A.F.P.

Preserving Survival Potential Herbert W. Collins, M.D. F.A.A.F.P.

Nothingfulfillsthepromiseofdiagnosticandtherapeuticbenefitsofunmatched

quality as that offered through the exploitation of the anatomical fidelity of the

distributions of neurological labyrinths of spinal nerves and the variables of the

integratedphysiologyoftheperipheralandcentralnervoussystem.Thesebenefits

areavailablewithlittleeffort,time,orexpense,andareobtainedwithouttroublesome

untowardconsequences.Thesebenefitsmakesitpossibletoplacevisceralinsultsto

bewithinthespecificvisceraldistributionsofspecificspinalnervesinrealtimeand

duringthissamemomentsonemayfulfillthepromiseofconvalescencesthatarenot

onlysaferbutarealsoonesthataremorecomfortable,areofashorterduration,

andareassociatedwithalesserdegreeofdisability.

In 1970 Epstein published articles recommending sublesional infiltration of a

corticosteroidforthetreatmentofHerpeszoster.Observationsduringthistreatment

indicated that the benefitswere due to the cutaneous impulses generatedby the

skin pricks of the treatment rather than that of the corticosteroid. The cutaneous

impulses generated by these skin pricks provided instantaneous pain relief. Also

somepatientsalluded to the reliefofdeep seateddiscomfort thatwasobtained

throughtheneurophysiologyofasinglenerve.Thisdeepseatedreliefhintedofthe

presenceofspecificvisceraldistributions.Itwasalsonotedthattherewasamarked

increaseinthesensitivityofthecutaneousdistributionsofthenervethatharboredthe

herpeticlesions.Theseobservationsfurnishedtheimpetusfortwentyyearsofefforts

directedatevaluatinganddefiningtheperipheraldistributionsandphysiologyofthe

neurologicallabyrinthsofindividualspinalnerves.Theseobservationswereconclude

onmyretirementfromasolofamilypracticein1990.

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hypotheses / theory Insults alter local neurological impulses and theymayalso create structuralcompromises. Unless structural compromises represent significant disabilities theycontributelittletotheclinicalpicture.Thisleavestheclinicalpicturetobeprimarilytheexpressionsofneurophysiology.Theseexpressionsaregeneratedbythebrainfromvaluesprocessedandassignedtoalteredneurologicalimpulsesatthespinalnervelevel.Collectivelytheseexpressionsformthebulkofclinicalpicturesandaretermedtobethatofautogenicpathology. DuringWW11aRussianphysiciandemonstratedthatpatientseventhosewithsurvivalpotentialmayberenderedtobewithoutpulseorbreathbytheperpetuatingnature of autogenic pathology. That after the patient is without pulse or breathautogenicpathologyisstillbeingexpressedandsurvivalpotentialmightstillexist.Iftheensuinganoxemiadepressesthefunctionofthebraininasufficientandtimelymannerthenthebraincannolongergeneratethepreviousexpressionsofautogenicpathology.Thisinterruptionoftheexpressionsofautogenicpathologyallowedpulse,breath,andsurvivalpotentialtoberestored. Under theguiseofdefibrillating the heart theelectrodesof theequipmentpreviouslyusedforelectricshocktherapyarenowplacedonthechestinsteadofthehead.Thecurrentjustasreadilyreachedthebrainasdemonstratedbytheresultinggeneralizedconvulsion.Thisdepressedthebrainmoreacutelythanthatofanoxemiaalonetoimprovetherateofsuccess.Thissuccessmadeelectricshocktherapytobethemainstayofresuscitativeefforts. Allwhosurvivearesuscitativeeffortwillhavevaryingdegreesofbraindamage.Somedamagewillbesoseverethatindependentlivingisimpossible.Thosealsowithsurvivalpotentialandyetwhosufferterminalbraindamagecannotbeidentified.Ifthecarnageassociatedwiththeneedforresuscitativeeffortsistobecircumventedthentheexpressionsofautogenicpathologyshouldbe interruptedat theonsetoftherapyandatthesaferspinalnervelevel.Theearlyinterruptionmaydomoretopreserve survival potential then the other efforts of coronary and intensive care.Otherwisesomepatientsmayberequiredtoprovethepresenceofsurvivalpotentialbysurvivingoneormoreresuscitativeefforts. Evenwhensurvivalisnotinquestiontheinterruptionofautogenicpathologyprovidesconvalescencesthataremorecomfortable,areofashorterdurationandareassociatedwithalesserdegreeofdisability.

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Duringthedevelopmentoftheembryoasthelabyrinthsofspinalnervesbranchandgrowtheycaptureanddifferentiatestemcellstogrowspecificsegmentsoftissueandtheorganstheycontain.Theselabyrinthsmaintaintheirsegmentsbycapturingandifferentiatingthenecessarystemcells.Theselabyrinthsdefinetissuesegmentsthatarebothanatomicalandneurological. The neurological labyrinths of these segments function as a completeand independent neurological entity. Neurological impulses that are altered bydistribution specific insults are first assigned relative processed values within itsrespective neurological labyrinth. These valuegeneratedat the spinal nerve levelarethentransferredtothecentralnervoussystemwheretheyareprocessedintotheexpressionsofautogenicpathology. The relativity of values first processed and assigned to distribution specificaltered neurological impulses is inversely related to the magnitude of cutaneousimpulsesthataregeneratedthroughtheskinscontactwiththeexternalenvironment.Thereforevaluesbecomerelativityinsignificantwhenalteredimpulsesareprocessedwithin an equation containing an excess of cutaneous impulses. Once alteredneurologicalimpulsesreceivearelativelyinsignificantprocessedvaluethentheyarenolongerprocessed.Robbedofthenecessaryvaluesstreamingfromtherespectivespinalnerveornervesthecentralnervoussystemcannolongergeneratethepreviousexpressionsofautogenicpathology. GoinginacaudaldirectionandstartingwithC-3visceraldistributionsbecomeassociatedwiththemid-gut.Visceraldistributionsarethendraggedbilaterallyinanintermingledmanneras themid-gutexpands.Consequently startingwithC-3andgoinginacaudaldirectionvisceraldistributionsarecontributedbybilateralpairsof spinalnerves. These intermingledbilateralvisceraldistributions share the sameanatomybuttheirphysiologyremainsasindependentasthatofthelocationoftheirbilateralcutaneousdistributions. Theunusualsensitivityofitscutaneousdistributionidentifiesthelabyrinthofaspinalnervemonitoringdistributionspecificanatomicalinsults.Consequentlyaspinalnerveharboringanatomical insultscanbeidentifiedbythepatientsexaggeratedresponse to distribution specific exploratory skin pricks. Placing exploratory skinpricksadjacenttothespinesimplifiesthecorrelationofcutaneousdistributionswiththeidentifyingvertebrae.Evenwhendocumentedvisceralinsultsarecorrelatedwiththeincreasedsensitivityofthecutaneousdistributionofaspecificorbilateralpairsofspinalnervestherearenopatientvariations.Thisnotonlyestablishesthepresenceof specific visceral distributions but alsomakes their mapping possible.Once thismappingiscompletedthenvisceralinsultsmaybelocatedtotheanatomicalsitesofspecificvisceraldistributionsinrealtime.

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Theautogenicpathologyofmultiplesitesofabdominalvisceralinsultsisanallornothingexpression.Thatismultiplevisceralinsultsintheabdomencreateperceptionandphysiologicalchangesthatareofthesameintensitywhetherthesitesinvolveasingleormultiplelabyrinths.Thereforewhentheexpressionofautogenicpathologyis interruptedat only oneofmultiple visceral sites thepatientwill experience nosymptomatic relief. That is symptomatic relief will occur only when the autogenicpathologyisinterruptedatallofthemultipleabdominalvisceralinsultsites.Thisisafailsafemechanismthatpreventsmultiplesitesofabdominalvisceralinsultsfrombeingoverlooked. Undoubtedly some readers are of the opinion that peripheral distributionsmaybedeterminedbydissectionandifspecificvisceraldistributionswerepresentthen they would have already been plotted. Nothing is further from the truth asterminalperipheraldistributionscannotbedeterminedbydissection.ThelesionsofmultiplecasesofHerpeszosterwereusedtoplotthecutaneousdistributionswhilethe observable results of interrupting their continuity were used to plot somaticdistributions. Anotherwayofdefiningautogenicpathology is to say it is thatportionofclinicalpictureswhoseexpressionsaredeterredbyanesthesia.Regardlessoftherouteanesthesiaisdeliveredallanestheticroutesaredirectedatpreventingtheexpressionof processed values that areassigned toaltered impulseswithin the neurologicallabyrinthsofindividualspinalnerves. Generalanesthesiadepressesthefunctionofthebraininamannersufficienttopreventtheprocessingofthevaluestransferredfromspinalnerves.Localandspinalanesthesiablocksthetransferofneurologicalvalues. During surgery ongoing skin pricks of acupuncture generate a continuousstreamofanexcessofcutaneousimpulses.Theongoingsurgeryalsocreatesastringofalteredimpulses.Whenthestreamofalteredneurologicalimpulsesofsurgeryareprocessedwithinanequationcontainingastreamofanexcessofcutaneousimpulsesthentherelativityofprocessedvaluesisdestroyed.Withoutreceivingthenecessaryprocessed values the brain can no longer generate the autogenic pathology thatotherwisewouldhavebeenexpressedduringsurgery. Acupuncture provides satisfactory anesthesia for a variety of surgicalproceduresincludingopenchestsurgery.Thesealertandactivepatientareabletoverballyprotestifthedegreeofanesthesiaisinadequate.Unlikegeneralandspinalanesthesiaanexcessofthesebenignskinpricksdoesnotposearisktothepatient.Thismakestheanesthesiaofacupuncturetobesaferthangeneralandspinalanesthesia,anditalsocircumventsthebraindamageassociatedwithgeneralanesthesia.

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Mostofallof theabove is summarizedby the followinghypothetical case.Thepatientsunmistakeableexaggeratedresponsetoexploratoryskinpricksplacedadjacent tobilateral T3-4will confirm the suspicionofamyocardial infarctionasaccuratelyasanyothersinglediagnostictest.Extendingtheseskinpricksinacephalicandcaudaldirectionuntilthepatientsresponseismutedwillinterrupttheprocessingoftherespectivealteredneurologicalimpulses.Thisinterruptionoftheexpressionofautogenicpathologywilldomoretopreservesurvivalpotentialthantheothereffortsofevenmostofthecoronaryorintensivecareunits.Theabilitytoconductanaccuratetriagewithinamatterofoneor twominutesandat the same time toeffectivelypreservesurvivalpotentialisinvaluablewhendealingwithanemergencysituationssuchasthatofamyocardialinfarction. ThesimilarobservationsmadeduringthetreatmentofHerpeszosterwerenotlostonshamaninItaly.EvenasearlyasthreethousandBCtheseshamanusedtheskinpricksofadryrunofthetattooinstrumenttolocatethesitewherethepatientexhibitedanexaggeratedresponse.Thesiteof thisexaggeratedresponsewouldidentifythatsmallareaofskinwheretheskinpricksoftattooswouldbeaccompaniedbyprofoundandoftenpermanentsymptomaticrelief.Onceasiteofanexaggeratedresponsewasfoundthenpigmentwasappliedtotheskinandthentheresultingtattoowas extended in a cephalic and caudaldirection until thepatients responsewasmuted.TheItalianIcemansskinsportsthreeshortlinesoftattoosthataretotheleft,adjacent,andparallel to the lumbarspine.Fromwhat isnowknown these tattoosprovided the Icemanwith relief of left lower extremity discomfort probably duetolumbardiscdisease.Morethanlikelythesethreelinesoftattoosrecordedthreedifferent treatment sessions. If repeated treatmentbecamenecessary theexistingtattooswouldeliminatethenecessityofrepeatingthedryrunofthetattooinstrumentandalsowouldpermanentlyrecordprevioustreatment. Bymakingabilateraldryrunof thetattoo instrumentandtheextensionoftattoosfromthesiteswherethepatientexhibitedanexaggeratedresponseswouldhaveexpandedtheseshamansability.Thiswouldhavegiventheseshamanstheabilitytoprovidetherapeuticandsymptomaticbenefitstopatientssufferingfromvisceralinsults.Thesecouldhaveincludedmyocardialinfarctions,asthma,gastricandduodenalulcersandothers. Inessenceshamans treatmentofanacutemyocardial infarctionmighthavedonemoretopreservesurvivalpotentialthenthatoftheothereffortsofmostcoronaryand intensivecareunits.Without theprior interruptionofautogenicpathologytoooftenapatientincoronaryorintensivecaremayberequiredtoprovethepresenceofsurvivalpotentialbysurvivingoneormoreavoidableresuscitativeefforts.

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ItcanbedemonstratedthattheherpeticlesionsoftheophthalmicbranchofthetrigeminalnervearetheinflammatoryresponseresultingfromthealterationoftheneurologicalimpulsesofC2andareindependentofthedirectconsequenceoftheherpeticvirus.InthisincidencetheincreasedsensitivityofthecutaneousdistributionofunilateralC-2maybedemonstratedbythepatientsexaggeratedresponsetoexploratoryskinpricks.Extendingtheseskinpricksinacephalicandcaudaldirectionwillresultinasymptomatichealingcompletedinafewdayswithoutscarringorpostherpeticpain.Thiscasedemonstratesthetherapeuticbenefitsthatmaybeexpectedbyjustterminatingtheexpressionofautogenicpathologyincludingtheinflammatoryprocess. The interruptionofautogenicpathologymayoffer significant therapeuticbenefitsevenwhennoothereffectivetherapeuticmeasuresareavailable. Inflammatory responses are so uniquely specific that the origin of someviral infections may be diagnosed by the distribution and characteristics of theirinflammatoryresponse.Inasimilarfashionuniqueperceptionsofclinicalpicturesmaybeused todetermine theoriginof insults.Asanexample the specificperceptionsresultingfromaburnwillbedifferentthanthatofacut.Acaseinpointisthatofcompromisedglucoseoxidation.Compromisedglucoseoxidationgenerates similarperceptions whether oxidation is compromised from the lack of circulation as thecompressionfromincreasedhydrocephalicpressure,thelackofoxygenasinaltitudesicknessorfromthelackofintracellularglucoseavailableforoxidation. Recurrentheadachesarethemostcommonsymptomsofcompromisedglucoseoxidationduetothelackofintracellularglucoseavailableforoxidation.This lackofavailableglucoseresultsfromthephysiologicalstressofaglucoseoverload.Thisoverloadisduetotheexcessiveingestionofsimplecarbohydrates.Localvariationsmaymakeanaspectofonecerebralhemispheremorevulnerableandthusthetermmigraine.SinceunilateralhemispheresofthebrainisgrownandmonitoredbyunilateralC-1thegenerationofanexcess of cutaneous impulsesadjacent to unilateralC-1willprovideinstantaneoussymptomaticreliefofmigraineheadaches.Theoriginoftheseheadacheshasbeenmaskedassymptomsmaynotoccurupuntiltwentyfourhoursor more after the last simple carbohydrate ingestion. Migraine headaches maybe prevented by the dietary restriction of simple carbohydrates. These recurrentheadachesfail tomaterializewhensusceptible individualsdevelopsub-clinicalorovertdiabetes.

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Methodology Therelativeneurophysiologicactivityofaselectedspinalnerveornervesmaybeaccessed,evaluatedandmodifiedbycreatinganexcessofexploratorydistributionspecific cutaneous impulses. The patients unmistakeable exaggerated responsetoexploratory skinpricks is thehallmarkofa spinalnervemonitoringdistributionspecificanatomicalinsults.Theidentificationoftherespectivelabyrinthisenhancedwhen exploratory skin pricks are placed adjacent to the spine and consequentlyto the identifying vertebrae.Once the site of an exaggerated response is foundthenskinpricksareextendedinacephalicandcaudaldirectionuntilamoremutedpatientresponseisencountered.Thisextensionassuresthattheprocessingequationcontainsaneffectiveexcessofcutaneousimpulses.Theprofoundusuallypermanentsymptomaticreliefthataccompaniestheextensionoftheseskinpricksisconsideredto herald the terminationof theprocessingof the respectivealteredneurologicalimpulses. Robbedof valuespreviously streaming from the respective spinal nerveornerves thebraincanno longergenerate thepreviousexpressionsofautogenicpathology. In spite of the above hyped hypotheses and theory the current level ofknowledgeprecludestheabilitytoadequatelyjustifyneitherthecomplexityoftheneurophysiologyexpressedinclinicalpicturesnortheprinciplesoftheneurophysiologythroughwhichtheseexpressionsmaybeinterrupted.Consequentlythesecasestudiesareregimentedbyhowratherthanwhy.Howeversomewhyhadtobeconjuredtojustifyamoreplausibleexplanationofhow.

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case report Takingaleapoffaithbyprogressingfromtheorytoutility,apatientwithalocalizedburnwasthefirsttobeselectedfortreatment.Alocalizedburnsimplifiedthecorrelationof the insultwith thecutaneousdistributionof the respective spinalnerves.Alsoanytherapeuticbenefits,ifany,couldbeobserveddirectly.Thispatienthappenedtobearobustyoungservicestationattendantwhosufferedasecond-degreeburnofhishandwhileremovingthecapofahotradiator. After explaining that this was not a currently acceptable procedure buthopefullyaneffectivetreatmentthepatientconsented.Anexaggeratedburstofpaininresponsetothegenerationoftherespectivecutaneousimpulseswasaccompaniedbythesuddenonsetofprofoundsymptomaticrelief.Thisrapidsymptomaticreliefresultedintheonsetofatransitshocklikestatethatwasrelievedbyelevatingthepatientsfeet.Afterproperdressingoftheburnhewasabletosafelyreturntohis

workplaceasnoanalgesicswererequired.

discussion This case confirmed the fact that thegeneration of an excess of cutaneousimpulsesallowedaccessto,evaluationof,andmodificationofthephysiologyoftheneurologicallabyrinthsoftherespectivespinalnerves.Profoundpermanentpainrelief,withminimaledemaandbullaformationandrapidhealingnotonlydemonstratedsymptomaticrelief,butalsodemonstratedthetherapeuticbenefitsobtainedthroughterminatingtheassociatedinflammatoryprocess.

case report Duetoeconomicnecessity,acollegestudentdeferredmedicalcareas longaspossible.A sore throat that hadprevented the swallowing of even saliva hadlefthimdehydrated.Thepatientsexaggeratedresponsetoexploratoryskinpricksidentified the neurological labyrinth harboring the initiating insult to liewithin thevisceraldistributionsofbilateralC-3.Profoundsymptomaticreliefaccompaniedthegenerationofanexcessoftherespectivecutaneousimpulses.Thismadeitpossiblefor thepatient to immediatelyandeagerlydrinkwaterwithoutpain ordifficultyinswallowing.Antibioticswereprescribedtocoverpossiblebacterial infection.Hisrecoverywasrapidwithoutfurtherdiscomfortordifficultyinswallowing.Laboratoryresultsreceivedatalatertimeconfirmedthesuspicionofinfectiousmononucleosis.

discussion This casedemonstrates again that terminating the expressions of autogenicpathology evenwithout altering the status of the infectious agent often producesan outpatient convalescence that may be superior to that available from current

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hospitalization.Notonlywastheconvalescencemorecomfortable,butitalsowasofamuchshorterduration.Themonetarysavingswerealsosubstantialasthecostsofhospitalizationwascircumvented.Thiscasealsohintsofpotentialbenefitsthatmightbeobtainedfromtreatinginfectionswhereeffectivetherapiesmaynotbeavailable.

case report Tendaysafter the over sewing of a rupturedduodenal ulcer, a housewifewasstilltakingmaximumdosesofanalgesics.Inspiteoftheanalgesicsthelingeringpersistent severe discomfort made it difficult for the patient to eat or to sleep.The generation of exploratory cutaneous impulses at bilateral L3-4 produced anexaggeratedresponse.Extendingtheseskinprickswasaccompaniedbyprofoundsymptomatic reliefand improvement of herpreviously haggardappearance. Thenextday,herhusbandcalledtoreportthatallshehaddoneinthelast24hourswastoeatandtosleep.

discussion

On the completion of surgery permanently eliminating the expression ofautogenicpathologywouldhaveprovidedaconvalescencethatwasnotonlymorecomfortablebutalsoonewithamuchshorterperiodofdisability.

case report Apatientincoronarycarewaswithoutappreciablereliefevenafterreceivingmaximumdosesofintravenousmorphinefor24hours.Thegenerationofanexcessof cutaneous impulses at bilateral T3-4 provided immediate symptomatic relief.Recoverywasuneventfulwithoutfurtherdiscomfortortheneedforanyanalgesics.

discussion Thiscaseisanotherillustrationofasituationinwhichmaximumdosesofanalgesics,evenafteranappropriateperiodoftime,failedtoprovideasatisfactorylevelofsymptomaticrelief.Theterminationoftheexpressionsofautogenicpathologymayhavepreemptedthispatientspotentialneedforresuscitation.Sincethisinterruptiondoesnotcompromisethecontinuedfunctionofthenervoussystem,extensionoftheinfarctwouldhavepromptedthe immediateresurgenceofsymptoms.At theonsetof therapy the patients unmistaken exaggerated response to the generation ofexploratorycutaneousimpulsesatbilateralT3-4wouldhaveconfirmedthesuspicionofamyocardial infarctionasaccuratelyasanyother single test. Interrupting theexpressionofautogenicpathologyprobablydidmoretopreservesurvivalpotential

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thanalloftheotherbenefitsofferedbycoronarycare.Hisrapidrecoverywithlittlecomplicationsmayhavehadsomethingtodowiththeeliminationoftheaccompanyinginflammatoryprocess.

case report Anelderlywidowwithpersistentabdominalpain,andanormalhematologicalpicture found relief from abdominal discomfort only after the completion of thegenerationofanexcessofcutaneousimpulsesatbothbilateralT6-7andL3-4levels.Her pain continued to recur at approximately weekly intervals. She stated thatrecurrenceofsymptomswouldprogressfromanasymptomaticstatetounbearablediscomfortinamatterofonehour.Shealsostatedthatshefeltlikeshewouldratherdiethantosufferthepainoftherequiredtreatmentbutshecouldnotlivewiththepersistent abdominal discomfort. After a negative colon evaluation and her thirdconsultationwithasurgeonandagastroenterologist,anendoscoperevealedbothaduodenalandagastriculcer.Appropriatetherapyprovidedanuneventfulrecovery.

discussion This case presented at the earlier part of this study when efforts wereconcentratedmoreonsymptomaticreliefratherthanthediagnosticpotential.IfatthattimeithadbeenknownthatbilateralT6-7monitoredthegastricareaandthatL3-4monitoredtheduodenalarea,perhapsendoscopywouldhavebeenperformedduring her first hospitalization. Evenwithout a reputable hint of the origin of hersymptomstheincreasedsensitivityofthecutaneousdistributionsconsistentlytracedtheoriginatinginsultstoliewithinthesametwospecificbilateralvisceraldistributions.There were no appreciable changes in the patients symptoms until autogenicpathologyhadbeeninterruptedatallfouroftherespectivesites.Thisisafailsafeprocessthatpreventsmultipleabdominalvisceralinsultsfrombeingoverlooked.Also,therequirementforthegenerationofanexcessofcutaneousimpulsesatallofthedifferentsitesandtheinstantaneousresultseliminatesanynotionthatthissymptomaticreliefistheresultofhormonalactionsasiscommonlybelieved.Therecurrenceofhersymptomsinthepresenceofongoingulcersinmoreorlessonaweeklybasisisincontrast to thepermanent symptomatic reliefexpectedwhen the respective insultsarehealing.Beingabletocorrelatethespecificanatomicallocationofdocumentedvisceralinsultstotheneurophysiologyanddistributionsofspecificpairsofbilateralspinalnervesforecaststhecompletionofthemappingofthemostlyunknownthoughspecificvisceraldistributions.Oncemappingiscompleted,thenvisceralinsultsmaybeaccuratelylocatedtospecificanatomicalsitesinrealtime.Thisabilityshouldmaketheaccurateselectionofdefinitivediagnosticstudiesmorelikelyorevenunnecessary.

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Thoughtentativeandmeager,theknownvisceraldistributionsareasfollows:The unilateral cerebral hemisphere at C-1, the middle ear and the ophthalmicbranch of the trigeminal nerve at unilateral C2. The pharynx including infectiousmononucleosisatbilateralC-3.Thebronchial treeandasthmaatbilateralC7-T2.MyocardialinfarctionsandthecardiacareaatbilateralT3-4.ThegastricareaandgastriculcersatbilateralT6-7.DuodenalulcersandpyelonephritisaremonitoredbybilateralL3-4.

case report Anelderlymalesufferedanacuteonsetofseverediscomfortandcrampsintherightlowerextremity.Thisepisodewasresolvedbybedrest.Monthslateramoresevereattackoccurredwhichwasnotrelievedbybedrestandrequiredtheuseofcrutchesjusttoambulateafewsteps. ThecreationofanexcessofcutaneousimpulsesatunilateralL3-4producedprofound symptomatic relief that allowed this patient to ambulate symptom freefor approximately onemonth before symptoms recurred.A second session of thegenerationofanexcessofcutaneousimpulsesconvertedarecurrentacuteepisodeintoabearablechronicstate.AnMRIperformedafterthefirsttreatmentrevealeda60-percentstenosisofthespinalcordbyaprotrusionatL3-4.

discussion Thiscaserepresentedpressureonanerveratherthannervepathology.Thismayaccountforsymptomaticreliefthatunexpectedlylastedmuchlongerthanthatobtainedbytreatinganeuritisoracaseofcausalgia.Thiscaseagaindemonstratesthatexploitingtherelativityofneurophysiologyatthespinalnervelevelmayprovidesymptomaticreliefofaqualitysuperiortothatoftheusualcurrenttherapy.

case report Afterseveraldaysofintensivecareaboywithaburnedhandfailedtorespondtoresuscitativeefforts.

discussion Thiscaseoccurredbeforethepresentinformationwascurrentoraccepted.Ifsothenhypotheticallyattheonsetoftherapyanexcessofcutaneousimpulseswouldhavebeengeneratedwithunilateral skinpricksplacedadjacent to thevertebraeidentifiedbythecutaneousdistributionoftheburn.Afterproperdressingoftheburnhecouldhavebeenadmittedforobservation.Ifbythenextmorningheremainedsymptomfreeandhisvitalsignswerestablehecouldhavebeendischargedtobefollowedasan outpatient. Thiswith thepotential of a safealmost symptom freerecovery.Thebenefitspromised through terminating theautogenicpathologyofa

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burnedhandmightconvertthedecisiontoamputatetobemoretentative.Amputationfavorssurvivalas itallowsthemorevirulentautogenicpathologyofaburntobetradedforthemorebenignpictureofanamputation.

Summary Byexploitingthevariablesoftheneurophysiologythatformsthebulkofthepathologyexpressedasclinicalpicturesonemayobtainwithinstantaneousefficiencyconvalescencesthatarenotonlysaferbutalsoareonesthataremorecomfortable,areofashorterduration,andareassociatedwithalesserdegreeofdisability.Evenwhensurvival isnot inquestion interruptingtheexpressionofautogenicpathologypromisesconvalescencesthatarenotonlymorecomfortable,butarealsoofashorterduration,withalesserdegreeofdisability.Theabilitytolocateinsultstothespecificvisceral distribution of specificbilateral pairs of spinal nervesand the invariablespecificity of specific visceral distributions creates the potential for being able tolocatevisceralinsultstobeatspecificanatomicalsitesinrealtime.

Reference: Collins H. Facilitating survival and recovery by removing autogenicpathologyfromtheclinicalpicture,MedHypo98,Vol.50,pp.417-419.

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Is Low Dose Pooled IM Gamma Globulin the Treatment of Choice for all Malignancies?

Herbert W Collins MD FAAFP

Therearetwodifferentinterpretationsofwhatisseenduringthemicroscopicviewofaslidepreparedfromamalignantmass.Thecurrentlyacceptedonedatestoatimewhenitwasthoughtcellswerereplacedthroughmitoses.Duringthistimeonesawamalignantmassthatconsistedofnucleirichcellsthatareinvariousstagesofmitoses.Whenoneiscognizantofstemcellreplacementthenoneseesamassofnucleirichstemcellsthatareinprogressivestagesofdifferentiation. Theanswertothequestionoftheoriginofmalignanciesawaitsthedecisionofthatlittlehairlessgeneticallycompromisedmouse.IfovertimetheDNAofasuccessfullytransferredmalignantmasscontinuestobethatofhumancellsthenmalignantmassesareactuallytheresultofthereproductionofahumancellthathasundergonemutation.HoweverifovertimetheDNAisconvertedtothatofthemousethenmalignantmassesareduetoaninfectionthathasembracedtheabilityofnerves.Thatistocaptureandtodifferentiatereplacementstemcellsintoaspecificcelltype.. A malignant mass converted from human cells to that of the mouse is nowasatisfactorymediaforgrowing therespective infection.Thismediapromises themeansforproducingasafeandeffectivevaccine. Anothersourceofananswertothisquestioncomesfromthefactthatpatientsufferingfromany typeofmalignancieswillusually respondfavorably topooledgammaglobulin.Theeffectivenessofgammaglobulinindicatesthattheoriginofallmalignanciesisthatofanendemicinfection. Thephysiologyandembryologicaldevelopmentofallnervesareconsideredto be interchangeable. However in order to simplify this presentation only thelabyrinthsofspinalnervesarediscussed.Duringthedevelopmentoftheembryoasthedistalaspectsofthelabyrinthsofspinalnervesbranchandexpandtheycaptureanddifferentiatestemcellstogrowandthentomaintainbystemcellreplacementspecificsegmentsoftissueandtheorganstheycontain.Thistypeofgrowthassurestheabsoluteanatomicalspecificityofthedistributionoftheneurologicallabyrinthsofeachspinalnerve. The fact that nerves are responsible for capturing and differentiatingreplacement stem cells is demonstrateby the selectedatrophy of tissue segmentsfollowstheinterruptionofthecontinuityofitsrespectivenerve.

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Cutaneousandsomaticdistributionsdifferentiatecelltypesthataremoreorlessgenericforallspinalnerves.Howevervisceraldistributionsdifferentiatecelltypesthatarenotonlyspecificforthevisceraldistributionofanindividualspinalnervebutareevenuniqueforspecificterminalendingsofaspecificvisceraldistribution. Ifaninfectionisresponsibleformalignanciesthenfulfillmentoftherespectiveclinicalpicturenecessitatesthattheinfectionincorporatestheabilityoftheterminalaspectofanerveslabyrinththatitinfects.Thatisitembracesthenervesabilitytocaptureandtodifferentiatestemcellsintospecificcelltypes.Toproduceamalignantcellthenthisinfectionintheorynotonlyembracestheseabilitiesbutalsoreplicatesandtransmittheseabilitiestothenewstemcellsitcapturesandinfects. Thefriabilityofmalignantmassesandtheseembracedandtransferredabilitiesgivesevenasinglemigratorymalignantcelltheabilitytorapidlycreateamassofcellsdestinedtobedifferentiatedintothesamecelltypeasthoseoftheirorigin. Evidenceindicatesthatthepotentialinfectiousagentforallmalignanciescouldbeasingleentity.Like theshinglesof theHerpeszostervirus thevariableclinicalcourse and the specific cell type ofmalignancieswould be determined bywhichterminalaspectofwhichnerveisembraced.Consequentlyallthedifferentsitesoforigin,celltype,andclinicalpicturesofanymalignancycouldbetheresultofasingleendemicinfection. BeginningintheearlynineteenfiftiesIMgammaglobulinprovedtobeveryeffectiveintreatingthegeneralrunofendemicbacterialandviralinfections.AsanexamplepatientssufferingfrominfectiousmononucleosisorthefluwouldoftenbemarkedlyimprovedorevencuredovernightafterreceivingonlyonemlofIMpooledgammaglobulin. Withallof theabove inmind in thenineteeneightiesadecisionwasmadetouse lowdosepooled IMgammaglobulin inanattempt to rehabilitatepatientswho hadvoluntarily optedout of seeking the recommendedhospice careorwhoabsolutely refused toaccept the treatment offeredbyanoncologist. Thiswasanimportantrestrictionastherewasnointenttodeprivepatientsofthebenefitsofferedthroughthecareofanoncologist.Noneofthepatientsselectedhadpriorradiationorchemotherapy.Fractionallowdosegammaglobulinwaschoseninordertomagnifythesignificanceofitsobservabletherapeuticbenefits.

case report Apatientinhisearlyseventiessufferedamyocardialinfarction.Overthenextfew years his disability gradually increased until ambulation required the use ofsupplementaloxygen.DuringtheseyearshisdeteriorationwasattributedtothenormalprogressionofheartdiseasewithsomeelementofCOPD.Hebecamehomeboundandeventuallyhissurvivalappearedtobein jeopardy.Hisdaughtersensingthat

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heneededhospitalizationpersuadedherphysiciantoadmithim.Aftercompletionofthenecessarydiagnosticstudieshewastoldthathisliverwasriddledwithmetastaticlesionsfromcarcinomaofhiscolon.Hecontinuedtohaveuncontrollablediarrheaanddiedafewdaysafteradmission.

discussion Amyocardialinfarctionoftenisthefirstindicationofametastaticevent.Sincepatientscourseofcarcinomasometimesparallelsotherchronicillnessesitisdoubtfulifthediagnosisofcarcinomatosiswouldhavebeenmadebutfortheperchanceofachangeofattendants.Thiscasealsodemonstratesthedevastationthatresultswhenmalignantcellsacttocompromisethefunctionofavitalorgan.

case report A housewife witnessed the progress of her sister who diedwhile receivingaggressivetreatmentforcarcinomaofherbreast.Inviewofhersisterscourseshedeferred seekingmedical care for twoyearsandwas steadfast in her refusal tobeseenortreatedbyanoncologist,aradiologist,orasurgeon.Sheagreedtobehospitalizedwiththeconditionthatnoneofthesephysicianswouldbeconsulted. Shehadhundredsof thousands ifnotmillionsofskin lesions,amass inherotherbreast,andherbonemarrowwasinvolved.Askinbiopsywasinterpretedasbeingcompatiblewithmetastaticadenocarcinomaofthebreast.ShewasdischargedaftershereceivedonemlofIMgammaglobulin.Twoweeksafterherfirstdosingherdaughtercalledtoreportthathermotherwasgettingwellandthatalltheplacesinherskinhaddisappeared.Onemonthafterherfirstdosingshewasreadmitted.Herpreviousanemiawascorrected,theskinlesionsnowwerebarelydetectable,themetastaticmassinherotherbreastwasnotevidentonpalpitation,andtheprimarylesionwasreducedinsizeandhadthefeelofabreastthathadbeenaugmentedbystripsofrubber.Arepeatedskinbiopsywasinterpretedasbeingcompatiblewithsclerosedmetastaticadenocarcinomaofthebreast.ShecontinuedtoreceivemonthlyIMinjectionsofonemlofIMgammaglobulin.ApproximatelythirteenmonthsintohertreatmentshewasreadmittedwithanemiathoughttobeduetoGIbleeding.Sherefusedanyandallfurtherdiagnosticproceduresandrefusedapossiblylifesavingtransfusion.

discussion Thiscase isnotableas the timedelay in treatmentallowedotherwiseoccultmicroscopicmetastaticskinlesionstobecomedetectable.Thiscasealsodemonstratesthatevenwhenmetastatic lesionsdonot involvetheskinoneshouldbemindfulof

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thepossibilityofnumerousoccultsitesofmicroscopicsecondarylesions.Onecannotexplainthecauseoftherapiddemiseofmalignantcellsasdemonstratedbyhowquicklylesionsbecomesclerosedoncetheeffectofgammaglobulincomesintoplay.

case report After being evaluated by an oncologist an RN was told that her gastriccarcinomawas inoperableand untreatableand she had voluntarily deferred therecommendedhospicecare.ShereceivedonemlofIMgammaglobulin.Shereturnedinapproximatelytendaysafterherfirstdosingwiththeright lobeofher liversoenlargedthat itwaspalpableall thewaydownandintoherpelvis.Theleft lobehad the feeland sizeofa half ofa soccerball. Shedenieddiscomfortandherliverenzymeswerenormal.Shewasrecheckedapproximatelyfourweeksintohertreatmentwiththelivernowbacktoitsnormalsize.Becauseofthedramaticchangesfromthisfirstdosingandthelackofsimilarpreviousexperiencethepatient,hersister,andIagreedtodiscontinuehertreatmentwithgammaglobulinandshediedafewmonthslater.

discussion Discontinuingtreatmentwasabigmistakeasmostofthetumormasshadbeendepletedanditisdoubtfulifcontinuedtreatmentwouldhaveproducedanyunusualor untowardconsequences. If treatment hadbeen continued it ispossible that shemighthavelivedtodevelopaneffectiveimmuneresponseandconsequentlyacure.Thiscasealsodemonstratesthefactthatthatasinglelowdoseofpooledgammaglobulinisnotacure.

case report Aninetytwoyearoldgrandmotherhadafourplusprolapseduterus.Onareturnvisitthepreviousprolapseduteruswasnowcorrectedandshehadanewmassin her right ovary. Evaluation by consultants resulted in the decision that becauseofheragetreatmentwouldnotbeinherbestinterest.ShewasgivenonemlofIMgammaglobulin.Whenshereturnedonemonthlaterherprolapseduteruswasbackandthesizeofthemassinherrightovarywasreduced.VisitingnursesweregivenanordertocontinuetheadministrationofonemlofIMgammaglobulinonaonceamonthschedule.Ihadnofurthercontinuingcontactwiththepatient.Abouttwoyearsintoher treatmentherdaughter indicatedthathermotherwishedthat thegammaglobulinbediscontinuedashermotherwishedtodie.ThisrequestwasgrantedandIhadnofurthercontactwiththepatientorherfamily.

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case report AWW11navyveteranhadanincompleteresectionofatumorinthearchofhisaorta.Abiopsyoftheresectedtumorprovedtobethatofamesothelioma.AfterthepatienthadvoluntarilydeferredtherecommendedhospicecareHewasplacedonmonthlydosesofonemlofIMpooledgammaglobulin.EighteenmonthsintohistreatmenthedevelopedaslightcoughandchestX-raysshowedthattheremnantsoftheoriginaltumorwerenowbeginningtogrowforthefirsttime.Thedoseofgammaglobulinwas increasedbutwithout improvement.He survivedand recovered fromsurgeryforrepairofafractureofhiship.Afewmonthslaterandduringhisterminalweekhefracturedhisupperarm.

discussion Increasingthedoseofanineffectivebatchofgammaglobulinwasamistake.Instead this ineffectivebatchofgammaglobulin should havebeen replacedwithanotherhopefullyeffectiveone.Fracturesoflongbonesarefrequentlyaconsequenceofterminalcarcinoma.

Conclusions Clinicalobservationsdemonstratetheuniversaltherapeuticbenefitsofpooledgamma globulin and suggests that all malignancies may be the result of even asingleendemicinfection.Liketheshinglesoftheherpeticvirusthecelltype,siteoforigin,andclinicalpicturesofmalignanciesseemstobedependentonwhichterminalaspectofwhichnerveisembracedbytheresponsibleinfectiousagent.Ifthatlittlehairlessmousesucceedsinconvertingthehumancellsofatransferredmalignantmassintothatofthemousethenmalignanciesareduetoaninfection.Ifsothenthissameconvertedmassofnonhumancellsbecomesthegrowthmediafortheinfectionandconsequentlythesourcefortheproductionofasafeandeffectivevaccine.

Reference: Collins H. facilitating survival and recovery by removing autogenicpathologyfromtheclinicalpicturemedhypo98vol50pp417-19.

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