Ministry of Public Health of Ukraine Ukrainian Medical Stomatological Academy

"Approved" at the meeting of the Department of Human Anatomy «29» 08 2020 Minutes № Head of the Department Professor O.O. Sherstjuk ______

METHODICAL GUIDANCE for the lecture

Academic subject Human Anatomy Module No 3 "The heart. Vessels and nerves of the head, the , the trunk, extremities" Lecture No 15 Review of the autonomic , its central departments. The principles of the autonomic innervation of the organs Year of study ІI Faculty Foreign students' training faculty, specialty «Medicine» Number of 2 academic hours

Poltava – 2020 1. Educational basis of the topic The autonomic division of peripheral nervous system regulates physiological processes of the human organism like blood circulation, respiration, , excretion and general metabolism; also, it regulates tissue trophic processes. The autonomic division acts relatively independently from the cerebral cortex and the organs supplied act involuntarily as well. It is quite clear that that distinguishing of the somatic and the autonomic compartments is conditional and exact delimitation is not possible. Such impossibility appears due to common regulatory centers for both divisions and tight morphological and functional associations featured by them. The somatic and the of PNS like those of CNS feature topographical and synaptic associations so a reflex arc may comprise both somatic (e.g. afferent) and autonomic neurons. Summarizing the aforesaid, the term ’’ will be applied to a specific compartment of PNS but not for a separate nervous system.

2. Learning objectives of the lecture: . to familiarize students with the autonomic division of CNS; . to specify classification and functional significance, evolutional features of the autonomic division of CNS; . to provide theoretical information on parts of the autonomic division of CNS; . discuss the chief function of the parasympathetic part of the autonomic division of CNS.

3. Objectives of developing the future specialist’s personality (educational aims and objectives): familiarization with axiological, ethical and deontological principles of medical profession.

4. Interdisciplinary integration The preceding The acquired knowledge subjects Biology What are the main functions of the nervous system. The reflex arc and its variations. Phylogeny of cranial nerves. Classification of the . Histology Structure of nerve fibers. Topography of the cranial nerves. Physics Describe the mechanism of nerve impulse. Anatomy Types of receptors. Projection of the nuclei of the cranial nerve 5. The plan and organization of lecture structure No The main stages of the lecture and Type of lecture. Time their content Means of motivation. allocation Teaching materials The preparatory stage 5% 1. Determining the relevance of the pp. 1-2 topic, learning objectives and motivation. The main stage Introductory lecture 85% 2. Delivering the lecture material according to the plan: Feedback and questions 1. Where do the centers of the to students sympathetic part of autonomic division of CNS reside? What are PPT presentation with they represented with? diagrams and tables. 2. What are the compartments of the ? 3. Name the chief function of the parasympathetic part of the autonomic division of CNS. 4. What branches of the vagus nerve supply the viscera? The final stage Human Anatomy. In three 10% 3. General conclusions to the lecture. volumes. Volume 3: Answers to possible questions. textbook / Edited by V.G. Tasks for students’ self-directed Koveshnikov. - Lugansk: work. LTD «Virtualnaya realnost», 2009. – 384p.

6.The lecture material. The autonomic nervous system The nervous system is divided into two great subgroups: the cerebrospinal system, made up of the brain, and the peripheral cranial and spinal nerves, and the autonomic system (also termed the vegetative, visceral or involuntary system), comprising the autonomic ganglia and nerves. Broadly speaking, the cerebrospinal system is concerned with the responses of the body to the external environment. In contrast, the autonomic system is concerned with the control of the internal environment, exercised through the innervation of the non-skeletal muscle of the heart, blood vessels, bronchial tree, gut and the pupils and the secretomotor supply of many glands, including those of the alimentary tract and its outgrowths, the sweat glands, and, as a rather special example, the suprarenal medulla. The two systems should not be regarded as being independent of each other, for they are linked anatomically and functionally. Anatomically, autonomic nerve fibres are transmitted in all of the peripheral and some of the cranial nerves; moreover, the higher connections of the autonomic system are situated within the spinal cord and brain. Functionally, the two systems are closely linked within the brain and cord. The characteristic feature of the autonomic system is that its efferent nerves emerge as medullated fibres from the brain and spinal cord, are interrupted in their course by a in a peripheral and are then relayed for distribution as fine non-medullated fibres. In this respect they differ from the cerebrospinal efferent nerves, which pass without interruption to their terminations. The autonomic system is subdivided into the sympathetic and parasympathetic systems on anatomical, functional, and to a considerable extent, pharmacological grounds. Anatomically, the sympathetic nervous system has its motor cell stations in the lateral of the thoracic and upper two segments of the spinal cord. The parasympathetic system is less neatly defined anatomically since it is divided into a cranial outflow, which passes along the cranial nerves III, VII, IX and X, and a sacral outflow, with cell stations in the 2nd, 3rd and sometimes 4th sacral segments of the cord. Functionally, the sympathetic system is concerned principally with stress reactions of the body. When this system is stimulated, the pupils dilate, peripheral blood vessels constrict, the force, rate and oxygen consumption of the heart increase, the bronchial tree dilates, visceral activity is diminished by inhibition of peristalsis and increase of sphincter tone, glycogenolysis takes place in the , the supradrenal medulla is stimulated to secrete, and there is cutaneous sweating and pilo-erection. The sympathetic pelvic nerves inhibit bladder contraction and are motor to the internal vesical sphincter. Coronary blood flow is increased, partly by a direct sympathetic effect and partly produced by indirect factors, which include more vigorous cardiac contraction, reduced systole, relatively increased diastole and an increased concentration of vasodilator metabolites. The parasympathetic system tends to be antagonistic to the sympathetic system. Its stimulation results in constriction of the pupils, diminution in the rate, conduction and excitability of the heart, an increase in gut peristalisis with sphincter relaxation and enhanced alimentary glandular secretion. In addition, the pelvic parasympathetic nerves inhibit the vesical internal sphincter and are motor to the detrusor muscle of the bladder. Table. Summary of effects of sympathetic and parasympathetic stimulation. Sympathetic stimulation Parasympathetic stimulation Eye Pupil dilates Pupil constricts; accommodation of lens Lacrimal Vasoconstrictor Secretomotor gland Heart Increase in force, rate, Decrease in force, rate, conduction conduction and excitability and excitability Lung Bronchi dilate Bronchi constrict; secretomotor to mucous glands Skin Vasoconstrictor Pilo-erection — Secretomotor to sweat glands Salivary Vasoconstrictor Secretomotor glands Musculature Peristalsis inhibited Peristalsis activated; sphincters of relax alimentary canal Acid Secretomotor secretion of stomach Pancreas Secretomotor Liver Glycogenolysis Suprarenal Secretomotor Bladder Detrusor inhibited Detrusor stimulated Sphincter stimulated Sphincter inhibited Uterus Uterine contraction Vasodilatation The sympathetic system tends to have a ‘mass action’ effect; stimulation of any part of it results in a widespread response. In contrast, parasympathetic activity is usually discrete and localized. This difference can be explained, at least in part, by differences in anatomical peripheral connections of the two systems, as will be shown below. It is useful to think of the two systems as acting synergistically. For example, reflex slowing of the heart is effected partly from increased vagal and partly from decreased sympathetic stimulation. In addition, some organs receive their autonomic innervation from one system only; for example, the suprarenal medulla and the cutaneous arterioles receive only sympathetic fibres, whereas neurogenic gastric secretion is entirely under parasympathetic control via the vagus nerve. Pharmacologically, the sympathetic postganglionic terminals release and noradrenaline, with the single exception of the terminals to the sweat glands which, in common with all the parasympathetic postganglionicterminations, release . Fig. The essential difference between the cerebrospinal and autonomic outflows: (a) the cerebrospinal system has its lowest efferent nerve cell stations within the c.n.s.; (b) the autonomic system has its lowest efferent cell stations in a peripheral ganglion (here illustrated by a typica sympathetic nerve ganglion). Red, afferent pathway; yellow, efferent pathway. Visceral afferents. As well as the efferent system, there are afferent visceral fibres which are concerned with the afferent arc of autonomic reflexes and with the conduction of visceral pain stimuli. These nerves have their cell stations in the dorsal root ganglia of the spinal nerves or of the ganglia of the cranial nerves concerned with the autonomic system. The fibres from the viscera ascend in the autonomic plexuses; those from the body wall are conveyed in the peripheral spinal nerves. The afferent course from any structure is therefore along the same pathway as the efferent autonomic fibres which supply the part. The afferent fibres ascend centrally to the and thence to the orbital and frontal gyri of the cerebral cortex along as yet indeterminate pathways. Normally, we are unaware of the afferent impulses from the viscera unless they become sufficiently great to exceed the pain threshold when they are perceived as visceral pain, e.g. the pain of coronary ischaemia or intestinal colic. The parasympathetic system. As already stated, this system has a cranial and a sacral component. Its medullated preganglionic fibres synapse with ganglion cells which lie close to, or actually in the walls of, the viscera supplied. Postganglionic fibres therefore have only a short and direct course to their effector cells and there is thus the anatomical pathway of a local discrete response to parasympathetic stimulation. Cranial outflow. The cranial component of the parasympathetic system is conveyed in cranial nerves III, VII, IX and X, of which X (the vagus) is the most important and the most widely distributed. The functions of this group of nerves can be summarized as follows: 1) pupils — constrictor to pupil, motor to ciliary muscle (accommodation); 2) salivary glands — secretomotor; 3) lacrimal glands — secretomotor; 4) heart — inhibitor of cardiac conduction, contraction, excitability and impulse formation (with consequent slowing of the heart and diminution of its contraction force); 5) lungs — bronchoconstrictor, secretomotor to mucous glands; 6) alimentary canal — motor to gut muscles as far as the region of the ascending colon; inhibitor to the pyloric sphincter; secretomotor to the glands and adnexae of the stomach and intestine. The parasympathetic distribution of III, VII and IX is carried out via four ganglia from which postganglionic fibres relay. These ganglia also transmit (without synapse and therefore without functional connection) sympathetic and sensory fibres which have similar peripheral distribution. These ganglia are the ciliary, pterygopalatine, submandibular and otic. The 10th (vagal) distribution conveys by far the most important and largest contributions of the parasympathetic system. It is responsible for all the functions of the parasympathetic cranial outflow enumerated above, apart from the innervation of the eye and the secretomotor supply to the salivary and lacrimal glands. The efferent fibres are derived from the dorsal nucleus of X and are distributed widely in the cardiac, pulmonary and alimentary plexuses. Postganglionic fibres are relayed from tiny ganglia which lie in the walls of the viscera concerned; in the gut these constitute the submucosal plexus of Meissner and the myenteric plexus of Auerbach. The sacral outflow. The anterior primary rami of S2, 3 and occasionally 4 give off nerve fibres termed the pelvic or nervi erigentes, which join the sympathetic pelvic plexus for distribution to the pelvic organs. Tiny ganglia in the walls of the viscera then relay postganglionic fibres. The sacral parasympathetic system has been termed by Cannon ‘the mechanism for emptying’. It supplies visceromotor fibres to the muscles of the rectum and inhibitor fibres to the internal anal sphincter, motor fibres to the bladder wall and inhibitor fibres to the internal vesical sphincter. In addition, vasodilator fibres supply the erectile cavernous sinuses of the penis and the clitoris. Afferent parasympathetic fibres. Visceral afferent fibres from the heart, lung and the alimentary tract are conveyed in the vagus nerve. Sacral afferents are conveyed in the pelvic splanchnic nerves and are responsible for visceral pain experienced in the bladder, prostate, rectum and uterus. The reference of pain from these structures to the sacral area, buttocks and posterior aspect of the thighs is explained by the similar segmental supply of the sacral dermatomes. Note that although afferent fibres are conveyed in both sympathetic and parasympathetic nerves, they are completely independent of the autonomic system. They do not relay in the autonomic ganglia and have their cell stations, just like somatic sensory fibres, in the dorsal ganglia of the spinal and cranial nerves. They simply use the autonomic nerves as a convenient anatomical conveyor system from the periphery to the brain.

Fig. The anatomical basis of widespread sympathetic and local parasympathetic response. (a) The widespread distribution of postganglionic fibres from a single sympathetic white ramus. (b) The localized distribution of postganglionic parasympathetic fibres. The sympathetic trunk The sympathetic trunk on each side is a ganglionated nerve chain which extends from the base of the skull to the coccyx in close relationship to the , maintaining a distance of about 1 inch (2.5 cm) from the midline throughout its course. Commencing in the superior cervical ganglion beneath the skull base, the chain descends closely behind the posterior wall of the carotid sheath, enters the anterior to the neck of the first rib, descends over the heads of the upper ribs and then on the sides of the bodies of the last three or four . The chain then passes into the abdomen behind the medial arcuate ligament of the diaphragm and descends in a groove between psoas major and the sides of the lumbar vertebral bodies, overlapped by the abdominal aorta on the left and the inferior vena cava on the right. The chain then passes behind the common iliac vessels to enter the pelvis anterior to the ala of the and then descends medial to the anterior sacral foramina. The sympathetic trunks end below by meeting each other at the ganglion impar on the anterior face of the coccyx. The sympathetic trunk bears a series of ganglia along its course which contain motor cells with which preganglionic medullated fibres enter into synapse and from which non-medullated postganglionic originate. Developmentally, there was originally one ganglion for each peripheral nerve, but by a process of fusion these have been reduced in man to three cervical, twelve or less thoracic, two to four lumbar and four sacral ganglia. Only the ganglia of T1 to L2 receive white rami directly; the higher and lower ganglia must receive their preganglionic supply from medullated nerves which travel through their corresponding ganglia without relay and which then ascend or descend in the sympathetic chain. Still other preganglionic fibres pass intact through the ganglia to peripheral visceral ganglia for relay. There are thus three fates which may befall white rami. 1. To enter into synapse from the corresponding sympathetic ganglion (this applies only to the T1 to L2 segments).

Fig. The three fates of sympathetic white rami. These may (A) relay in their corresponding ganglion and pass to their corresponding for distribution, (B) ascend or descend in the sympathetic chain and relay in higher or lower ganglia, or (C) pass without synapse to a peripheral ganglion for relay. 2. To ascend or descend in the sympathetic chain with relay in higher or lower ganglia. 3. To traverse the ganglia intact and relay in peripheral ganglia. Pharmacologically, the sympathetic postganglionic terminals release adrenaline and noradrenaline, with a single exception of the sweat glands, which, in common with all the parasympathetic postganglionic terminations, release acetylcholine. Distribution. The branches of the sympathetic ganglionic chain have somatic and visceral distribution. Somatic distribution. Each spinal nerve receives one or more grey rami from a sympathetic ganglion which distributes postganglionic non-medullated sympathetic fibres to the segmental skin area supplied by the spinal nerve. These fibres are vasoconstrictor to the skin arterioles, sudomotor to sweat glands and pilomotor to the cutaneous hairs. Visceral distribution. Postganglionic fibres to the head and neck and to the thoracic viscera arise from the ganglion cells of the sympathetic chain. Those to the head ascend along the internal carotid and vertebral arteries, whereas those to the thoracic organs are distributed by the cardiac, pulmonary and oesophageal plexuses. The abdominal and pelvic viscera, however, are supplied by postganglionic fibres which have their cell stations in more peripherally placed prevertebral ganglia—the coeliac, hypogastric and pelvic plexuses — which receive their preganglionic fibres from the splanchnic nerves. The suprarenal medulla has a unique nerve supply comprising a rich plexus of preganglionic fibres which pass without relay from the coeliac ganglion to the gland. These fibres end in direct contact with the chromaffin medullary cells, and liberate acetylcholine (as in all autonomic ganglia) which stimulates the secretion of adrenaline and noradrenaline by the suprarenal medulla. The chromaffin cells of the suprarenal medulla may thus be regarded as sympathetic cells which have not developed postganglionic fibres; indeed, embryologically both the medulla and the sympathetic nerves have a common origin from the neural crest. The sympathetic chain continues upwards from the thorax by crossing the neck of the first rib, then ascends embedded in the posterior wall of the carotid sheath to the base of the skull. It bears three ganglia: 1) the superior cervical ganglion (the largest) lies opposite C2 and 3 vertebrae and sends grey rami communicantes to C1–4 spinal nerves; 2) the middle ganglion lies level with C6 and sends grey rami to C5 and 6 nerves; 3) the inferior ganglion lies level with C7 and is tucked behind the vertebral artery. Frequently, it fuses with the first thoracic ganglion to form the stellate ganglion at the neck of the first rib. Grey rami pass from it to C7 and 8 nerves. Note that these ganglia receive no white rami from the cervical nerves; their preganglionic fibres originate from the upper thoracic white rami and then ascend in the sympathetic chain. As well as somatic branches transmitted with the cervical nerves, the cervical chain gives off cardiac branches from each of its ganglia and also vascular plexuses along the carotid, subclavian and vertebral vessels. The sympathetic fibres to the dilator pupillae muscle travel in this plexus along the internal carotid artery. Grey rami pass from the superior ganglion to cranial nerves VII, IX, X and XII.

Fig. The cervical sympathetic chain. Clinical features 1. ‘Cervical sympathectomy’ is a misnomer; it is an upper thoracic sympathectomy carried out through a cervical incision. The sympathetic chain is divided below the 3rd thoracic ganglion and the grey and white rami to the 2nd and 3rd ganglia are also cut. In this way the sudomotor and vasoconstrictor pathways to the head and upper limb (from segments T2, 3 and 4) are divided, preserving the T1 connection and the stellate ganglion, which are the sympathetic connections to the eyelid and pupil. The upper thoracic chain can also be removed via a transthoracic transpleural approach through the second intercostal space, or by fibre-optic endoscopy. The lung is allowed to collapse and the chain identified as it lies on the heads of the upper ribs. Resection of the T2–4 segment results in a warm, dry hand. 2. Horner’s syndrome results from interruption of the sympathetic fibres to the eyelids and pupil. The pupil is constricted (myosis, due to unopposed parasympathetic innervation via the oculomotor nerve), there is ptosis (partial paralysis of levator palpebrae) and the face on the affected side is dry and flushed (sudomotor and vasoconstrictor denervation). Enophthalmos is said to occur, but this is not confirmed by exophthalmometry. The syndrome may follow spinal cord lesions at the T1 segment (tumour or syringomyelia), closed, penetrating or operative injuries to the stellate ganglion or the cervical sympathetic chain, or pressure on the chain or stellate ganglion produced by enlarged cervical lymph nodes, an upper mediastinal tumour, a carotid aneurysm or a malignant mass in the neck.

Fig. The coeliac plexus. 7. Materials for activating students during the lecture: Tables. Slides of scientists-anatomists. Theoretical questions 1. What the autonomic division of CNS is responsible for? 2. What are the evolutional features of the autonomic division of CNS? 3. Name the parts of the autonomic division of CNS. 4. Name the chief function of the parasympathetic part of the autonomic division of CNS. 5. Name the chief function of the sympathetic part of the autonomic division of CNS. 6. Where do the centers of the sympathetic part of autonomic division of CNS reside? What are they represented with? 7. Where do the superior autonomic centers reside? 8. Give definition of the preganglionic nerve fibers. 9. Give definition of the postganglionic nerve fibers. 10. Name the groups of the autonomic ganglia. 11. Give definition of the sympathetic trunk. 12. What are the compartments of the sympathetic trunk? 13. Describe the route of the preganglionic fibers from the accessory nucleus of oculomotor nerve. 14. Describe the route of the postganglionic fibers from the ciliary ganglion. 15. Describe the route of the preganglionic fibers from the superior salivatory nucleus. 16. Describe the route of the preganglionic fibers from the inferior salivatory nucleus. 17. Describe the route of the postganglionic fibers from the pterygopalatine ganglion. 18. What branches of the vagus nerve supply the viscera? 19. Describe the route of the preganglionic fibers from the sacral parasympathetic nuclei. 20. Name the autonomic plexuses of the pelvic viscera. Situational problems 1. In the patient has been found the tumor process. This morbid condition has involved in process the superior cervical ganglion of sympathetic trunk on the right side. Which of the following symptoms were observed? A. Disturbance of the accommodation′s processes of on the right B. Paralysis of the medial rectus muscle of the right eye C. Sustained expansion of the pupil on the right. D. Violation of lacrimation on the right *E. Strong narrowing of the right pupil 2. In patients with pulmonary tuberculosis has been found the increasing of the tracheobronchial lymph nodes which are located between the aortic arch and the bifurcation of the trachea. This morbid condition was leading to changes in .What nerves has been compressed by this pathologic process? A. The internal carotid nerve B. The inferior thyroid nerve C. The vertebral nerve *D. The vagus nerve E. The greater splanchnic nerve 3. After subcutaneous entering of adrenaline the patient has been investigated over 10 minutes. In the patient there were the blanching of the skin, the trembling of the hands, the rise of the blood pressure, the increasing of the blood sugar. Excitability which part nerves system lead to these symptoms? A. The vegetative division of the nervous system B. The *C. The sympathetic part of the autonomic nervous system D. The parasympathetic part of the autonomic nervous system E. The 4. You must do the novocaine blockade in the neck by the penetrating wound of the chest cavity to prevent shock. This solution of novocaine has been injected into the space between the superficial and prevertabral layers of the cervical fascia. What nerve formation while that has been blocked? A. The internal carotid nerve *B. The vagus nerve and cervical part of sympathetic trunk. C. The vertebral nerve D. The jugular nerve E. The greater splanchnic nerve 5. After entering into the skin 1 mg of atropine the patient has been investigated after 5-10 min. In the patient there were the dry mouth, the dilated pupils, the accelerated pulse. Excitability which part nerves system lead to these symptoms? *A. Sympathetic fibers B. Parasympathetic centers in the brain C. Sympathetic centers in the spinal cord D. Parasympathetic fibers E. Celiac plexus 6. Sympathetic nerves form a plexus mainly on the way: А. Somatic nerves В. Bones С. Veins D. Cranial nerves *Е. Arteries 7. The muscle dilating a pupil are innervated by: A. Parasympathetic fibers B. The vagus nerve C. Sympathetic fibers from the inferior cervical ganglion *D. Sympathetic fibers from the superior cervical ganglion E. The facial nerve 8. The central (cortical) part of the sympathetic nervous system is in: А. The cerebellum В. The *С. The spinal cord D. The midbrain Е. The cortex of a limbic brain 9. The unpaired knot of the sympathetic trunk is called: А. Ganglion spinale *B. Ganglion impar C. Ganglion opticum D. Ganglion ciliare E. Ganglion pterigopalatinum 9. References: The basic 1. Human Anatomy. In three volumes. Volume 3: textbook / Edited by V.G. Koveshnikov. - Lugansk: LTD «Virtualnaya realnost», 2009. – 384p. 2. Gray′s anatomy for students / Richard L. Drake, A. Wayne Vogl, and Adam W. M. Mitchell; illustrations by Richard M. Tibbitts and Paul E. Richardson; photographs by Ansell Horn. – 2nd ed. 2012 – 1103p. 3. Sobotta Atlas of Human Anatomy / Edited by R. Putz and R. Pabst, 14th ed. – Elsevier GmbH, Munich, 2008 . – 895p. 4. Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2003. 5. Grant′s atlas of anatomy ∕ Anne M.R., Arthur F. Dalley II, 12th ed. - Baltimore: Wiliams & Wolters, 2009. – 864 p. 6. Martini Frederic H. Martini′s atlas of the human body, 8th ed. – Pearson Education, 2009. – 250p. 7. Atlas of Human Anatomy / Frank H. Netter, M.D. Arthur F. Dalley; 2nd ed. // ILS, Medimedia USA Company, 1997. – 548p. Additional 1. Clinical Anatomy. Applied anatomy for clinical students and junior doctors: eleventh edition / Harold Ellis // Oxford, UK: Blackwell publishing. – 2006. – 455p. 2. Pocket atlas of Human Anatomy / Heinz Feneis, Wolfgang Dauber // Thieme, Stuttgart. – 2000. – 510p. 3. https://human.biodigital.com/ 4. http://anatom.ua/nomina-anatomica/ The methodical guidance has been compiled by N.L. Svinthythka, Associate Professor at the Department of Human Anatomy, PhD in Medicine, Associate Professor