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Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

TABLE OF CONTENTS ................................................................................................................................................. 1
ORGAN AND DIGESTIVE PHYSIOLOGY ................................................................................................................. 1

NEUROHORMONAL CONTROLSYSTEM ...................................................................................................... 6
CEPHALIC - & MOUTHPHASE................................................................................................................................ 28

ADDENDUM NEURO-HORMONAL CONTROL..................................................................................................... 33

ESOPHAGAL PHASE OF DIGESTION ....................................................................................................................... 36

GASTRIC PHASE ............................................................................................................................................. 47

ADDENDUM II .............................................................................................................................................................. 66

DUODENTAL PHASE ............................................................................................................................................. 73
SMALLE INTESTINAL PHASE ............................................................................................................................... 107
COLLON PHASE ............................................................................................................................................ 119

ADDENDUM III ........................................................................................................................................................... 135

LIVER & GAL (BILLARY PHASE) ..................................................................................................................... 146
KIDNEYS ........................................................................................................................................................ 160

ADDENDUM IV ........................................................................................................................................................... 169
ADDENDUM V............................................................................................................................................................. 213

PANCREAS & SPLEEN PHASE ............................................................................................................................. 222

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Descriptions of: course concept and the form of the
Tractus Gastro-Intestinalis
We consider the tractus gastro-intestinalis as a tube “external environment” that twists through
a part of our body, from our mouth to our anus. (The red tube) All secretions that play their
part in the decomplexification process, which is digestion, is considered as digestive
physiology. Generally the other functions like the endocrine and vegetative are discussed in
separate chapters or even separate books; I do not agree with that system for Osteopathic
students, because when you lay your hands and minds on people, you have the whole in your
hands, not fascias, or circulatory parts or nerves, or a liver or a duodenum, and the endocrine
parts are somewhere else… No! You have all in one, when you touch the form with your
hands or minds you have the attention of the whole complexity, not just some parts of it.
(Even when you sometimes wished it was.)
Touch an abdomen or thorax and you are dealing with all of its systems, organs and
tissues, cells, fluids and molecules, even more think about biophotons and coherent light,
that is the way we are going to approach it:
-the organ within its system
-the organ with its form
-the tissues
-the cells
-the neuro-hormonal control mechanisms
-the vascularization
All what you have learned until now will fall in place; all of it was just theory
and basics, now comes the living application.
Use your knowledge,
use your embryology,
your histology, physiology and all of the living images we gave you and that you made
make it to what it is:

one story 1
The story in many dimensions and level layers of organization and form; the
story of the complexity of life; Do it and be welcome to join in, in the life of an
Osteopath. (A lifelong student as the old Doctor used to say)
This is my motivation to make a combination of digestive physiology and the organ physiology in one.

The main form of the TGI is a tube with some strange twists and turns, this form in all its dimensions, permits it to
decomplexify substances until their building blocks, and absorb them; but in the same time it will help the organism to
get rid of many waste products. In other words the course from a biochemical point of view will now ask from you to
turn around everything we have been building up until now and to tear it apart again to its basic building blocks. (The
ones we started with from the beginning) Because that is what digestion is.


(before it was didactically thorn apart)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

The term, gastro-intestinal transit, is thus well chosen, because that is exactly what the gut does, breaking the stuff down
while it transits from your mouth to your anus, and increases its content of waste and decreases its content of nutrients
and water.
The most important processes to have a normal transit function are:
- the intrinsic motility of the organs (peristaltic).
- the secretions of the organs (cells, tissue, glands and organs) of the TGI
- the excretion of their products in the lumen of the TGI
- the digestive reactions (decomplexification)
- the absorption of nutrients
- the excretion of disposed waste in the TGI
- the massive amount of colonists in our gut that are synergetic (gut flora)

In big lines the hierarchy is simple but and watch out carefully now:
The way we are looking at it, is the chronology from evolutional, phylogentical, and even ontogenetical or
embryological point of view.
This chronology defines the hierarchy because as you’ll see in detail; every new system is based upon the older
ones and uses them to function, in other words is dependant on it although apparently the new younger one is the
Thus the hierarchy runs from simple too complex in reality and not the other way round as it is usually
described! Osteopathically we are interested in good function, healthy form and not in who is chief over who,
thus where is the basis where does health start, why can’t it express in one level layer or in one dimension; where
lies the cause?
And the answer to that my friends often lies in the hierarchy, the real one not the perception one that is distorted
by our society’s way of thinking.
So let’s start:
In general you can define 4 big control systems categories in the TGI:
* Autocrine control system
* Paracrine control system
* Endocrine control system
* Neural control system
Certainly the last one has many subdivisions, and we’ll come to it, but for now look at the principles.
(Still wrote: “it is my object to teach you principles and not techniques as of how to pull a muscle or bone…”)




and The autocrine system:
Is the oldest system, as old as the cell concept itself (3.8 billion years) see prokaryotes.
The first thing that you would see when approaching a cell would be the brush of receptors fixed on the membrane and
all turned towards the outside. Logic the cell feeds on her environment thus she must sense what her environmental
condition is like. There is another fact, the cell can only sense what is happening in her inside through these receptors,
because they will bind the products she excretes and so inform her on her own physiology. This ancient system is what
we call autocrine control or autocrine communication. A cell reacts on changes in her environment (electrochemical
potential differences) by the reaction, which can be metabolic or form adaptation she will also influence the close
environment. To which she reacts etc. This is what Blechschmidt called an “early metabolic biodynamic field”.
Biodynamic means on the edge of chaos, diversified and interactive.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

There where dynamics and evolution are, on the border of complete chaos,
but away from complete order that is rigid, crystallized you could say or
It is through this way that complexification of interaction between system
and environment started and developed into a massive complex organism
like mammals. And in the end, ven us, humans still function through
autocrine communication. Stronger even, actually all the other forms of
communication, information and control that we will discuss in a moment
are just elaborate forms of autocrine communication in a more complex
environment. Once a communication system comes to its frontier for the
size and complexity of the organism, it is the whole situation of growth and
complexification that will make that the autocrine system in some regions
take an apparently completely new development and looks different and thus we gave it another name, but in the
principle there is only autocrine communication. See also development from prokaryotic cells to eukaryotic cells
(endosymbiosis indications of mitochondria from de Duve, or the Heath Shock Prot. 70 (chaperonines 2) investigations
that proved that even the nucleus is an ancient prokaryotic cell: Gupta & Golding 1996)
On the basis of observation, about 5000 years ago there were therapies developed that make us think of autocrine
communication: in the ancient Ayur Vedic medicine on of the treatments for allergies, skin problems, fungi infections
and other chronic infections is to drink in the morning on an empty stomach a little bit your own urine. Reinform the
system, crazy? No it is not for many people this functions. Although, I would personally, at first start with a little diet to
cleanse before starting to reinform my gut (GALT system) with my waste. (Urine is not toxic, all people that survived
longer than a week when they were buried after a cataclysm did, because they drank their urine. And in Africa, in the
bush we use it to clean the wounds, fresh urine from the source is sterile, and the nutrients and minerals in it speed up
the healing). One should consider that the environment changed since 5000 years, there where not so much additives in
their food and drinks, they did not take all kinds of pills etc; urine is also an evacuation pathway for toxic exogenous
molecules. Read this about endocrine disruptors, it applies to the autocrine system and to the paracrine also.
Endocrine disruptors are exogenous substances that interfere with the endocrine system and disrupt the physiologic
function of hormones. Studies have linked endocrine disruptors to adverse biological effects in animals, giving rise to
concerns that low-level exposure might cause similar effects in human beings. Disruption of the endocrine system can
occur in various ways. Some chemicals mimic a natural hormone, fooling the body into over-responding to the stimulus,
or responding at inappropriate times. Other endocrine disruptors block the effects of a hormone from certain receptors
by blocking the receptor site on a cell. Still others directly stimulate or inhibit the endocrine system and cause
overproduction or underproduction of hormones. Medical interventions commonly manipulate the endocrine system for
the betterment of a patient, and side effects of such therapy can be interpreted as due to endocrine disruption. Substances
in question are also known as Endocrine Disrupting Chemicals (EDCs) or Hormone Disrupting Chemicals (HDCs), and
belong to the group of xenobiotics, foreign chemicals that affect a biological system.
Some of the most well-known examples of EDCs are 17-alpha ethinylestradiol (the contraceptive pill), Dioxins, PCBs,
PAHs, furans, phenols and several pesticides (most prominent DDT and its derivatives). Substances with estrogenic side
effects include the xenoestrogens. There is a long list of substances which may disrupt the endocrine system but have not
yet been scientifically proven to do so.
In recent years, some scientists have proposed that chemicals might inadvertently be disrupting the endocrine system of
humans and wildlife. A variety of chemicals have been found to disrupt the endocrine systems of animals in laboratory
studies, and there is strong evidence that chemical exposure has been associated with adverse developmental and
reproductive effects on fish and wildlife in particular locations. The relationship of human diseases of the endocrine
system and exposure to environmental contaminants, however, is poorly understood and scientifically controversial
(Kavlock et al., 1996, EPA, 1997).
One example of the devastating consequences of the exposure of developing animals, including humans, to endocrine
disruptors is the case of the potent drug diethylstilbestrol (DES), a synthetic estrogen. Prior to its ban in the early 1970s,

Heat shock proteins are generally responsible for preventing damage to proteins in response to high levels of heat. Heat shock
proteins are classified into six major families based on their molecular mass: small HSPs, HSP40, HSP60, HSP70, HSP90, and
HSP110. Heat shock protein 60 (HSP60) is a mitochondrial chaperonin that is typically held responsible for the transportation and
refolding of proteins from the cytoplasm into the mitochondrial matrix. In addition to its role as a heat shock protein, HSP60
functions as a chaperonin to fold linear amino acid chains into their respective three-dimensional structure. Through the extensive
study of groEL, HSP60’s prokayotic homolog, HSP60 has been deemed essential in the synthesis and transportation of essential
mitochondrial proteins from the cell's cytoplasm into the mitochondrial matrix.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

doctors mistakenly prescribed DES to as many as five million pregnant women to block spontaneous abortion and
promote fetal growth. It was discovered after the children went through puberty that DES affected the development of
the reproductive system and caused vaginal cancer.
In addition to disruption of reproductive endocrinology, modulation of adrenal, thyroid and growth hormone function
have also been described for various compounds in both humans and some animals, although the significance of these
effects have not yet been fully determined. The paracrine system
This system is as well phylogenetically as ontogenetically the second oldest communication system. It is the inevitable
consequence when organisms made the step to multicellularity. Not only do you have autocrine communication, but as
there are other cells which are close neighbors the autocrine will affect the environment of other cells thus paracrine.
(complexity grows)
From the moent that eukaryotic cells were developped, we see a specialization happening within the cell, each organelle
has its own speciality which contributes for the greater good of the whole. Whole? We are talking about one cell I
hear you think. Technically yes, in reality this is perception, an eukaryotic cell is a delimited community of exprokaryotes that functions together in a society, so we can talk about the greater good of the whole. We are used to talk
about cells as being the smallest organized part of our organism, this made us make an image mistake: when we talk
about a cell we are talking like an anthropologist talks about the Belgians or the French or people from one region,
despite all when you live in that region you think as an individual, no? With th eukaryote it is the same, it is a
community that lives with one delimited area like Brussels. (Keep that image in mind, you will study your physiology
differently and start to see a glimpse of what complexity is) I would even bet that when you are through with this
physiology course you will want to read more about complexity to see the mechanism in action on a broader
scale. When the eukaryotic cells make the next step in evolution and they did, the situation changes completely. The
way how is probably because at some point a mutation happened that made a change in a membrane bound protein
which kept two daughter cells linked instead of living their own life. (These proteins are called CAM’s or cell adhesion
molecules3) Apparently this mutation and multicellularity must have had some advantages because see what an
explosion of multicellular creatures came once the model existed. Thus paracrine communication came with the fact that
more cells stayed anchored together, and the dynamics increased because on one side the environment changed more
rapidly (all the cells secreting and reacting on it), but once the organism had chemically tuned in on the new situation,
the paracrine communication permitted to know how the other end of the organism was. An example of human paracrine
mediaton = histamine in the acid production of the stomach.
ERGO: the paracrine communication is long distance autocrine, or short distance endocrine communication and
it is as vital in our tissues, as is autocrine communication for the individual cell.
Paracrine signaling is a form of cell signaling in which the target cell is close to ("para" = alongside of or next to, but
this strict prefix definition is not meticulously followed here) the signal releasing cell. The signal chemical is called the
paracrine agent. The distinction is sometimes made between paracrine and autocrine signaling. In both types of
signaling, the signal is limited to other cells in the local area. However, paracrine signaling affects cells of a different
type than the cell performing the secretion, while autocrine signaling affects cells of the same type.
Sometimes, the reason that the effects are limited to a local area is because the signal chemical is broken down too
quickly to be carried to other parts of the body. Alternatively, the signal may only reach nearby cells for one of the
following reasons:
(1) the nearby cells take up the signal at a very high rate, leaving little signal free to travel further.
(2) the signal gets stuck in the extracellular-matrix, or structure surrounding the signal releasing cell, and thus the signal
is unable to travel far from the signal releasing cell.
Examples of paracrine signaling agents include growth factor and clotting factors. Growth factor signaling plays an
important role in many aspects of development. In mature organisms paracrine signaling functions include responses to

Cell Adhesion Molecules (CAMs) are proteins located on the cell surface involved with the binding with other cells or with the
extracellular matrix (ECM) in the process called cell adhesion.
These proteins are typically transmembraneous receptors and are composed of three domains: an intracellular domain that interacts
with the cytoskeleton, a transmembrane domain and an extracellular domain that interacts either with other CAMs of the same kind
(homophilic binding) or with other CAMs or the extracellular matrix (heterophilic binding).
Most of the CAMs belong to 4 protein families: Ig (immunoglobulin) superfamily (IgSF CAMs), the integrins, the cadherins and the


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

allergens, repairs to damaged tissue, formation of scar tissue, and clotting. Overproduction of some paracrine growth
factors has been linked to the development of cancer. Other examples of paracrine agents are somatostatin and
histamine. Some paracrine agents also have autocrine, intracrine or endocrine actions as well. For example, testosterone
secreted from the testes acts in an endocrine manner to stimulate peripheral events (e.g. muscle growth), and in a
paracrine manner to stimulate spermatogenesis in the adjacent seminiferous tubules.
Figure 1: autocrine and paracrine communication

In priciple the system does not change but now, there is a fluidic structured circulatory system present in the organism,
thus as a cell excretes it will not be just autocrine or paracrine but the cells close to the circulatory system will have their
excretion transported all over the organism, how each cell reacts on it is different but the message will come everywhere.
Now we call that endocrine.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Now this is really different than autocrine? Nope. Nerves are nothing else than: cells that are anchored and than
extended and elongated while a part of the organism grows at an incredible rate. They are extended that much that their
cytoplasm and cell membrane collapses in the cell body, therefore the comical star like shape with long extensions. In
the end it is one cell that excretes as reaction on a change of her environment, just like the autocrine. What is really new
is the incredible length of the extended cells. What is important here is to know that there is a local nervous system of
the gut that functions independently from the rest, what suggests that it is a very old system, in fact the first model of
neural communication (ENS = Enteric nervous system). Later as the organism complexifies and increases its mass,
newer neural systems will arise and shortcut on the older ENS, accordingly modulate its actions. I n chronological order
it is:
The NANC system (non adrenergic non cholinergic)
The parasympathic nervous system
The orthosympathic nervous system
Later it will even get some indirect connections with the motor and sensory or CNS.

Remember that all frontier tissue cells are polarized? They take their food from the inner tissue and lamina basalis side,
and they produce or secrete towards the outside. That is what the main part of the mucous membrane does, but between
these epithelial cells there are some other epithelial, cells that secrete in the direction of the inner tissue and lamina
basalis and these are the paracrine and endocrine communicating cells. They are spread out all over the mucous
membrane of the TGI. Thus they form microglands of one or some cells, but not clumps of cells like in epithelial glands.
These cells transmit different transmitters or hormones such as: gastrin, cholecystokinine, secretin, gastric inhibiting
polypeptide, motilin, neurotensine and somatostatine among others.

Thus in your minds, please transform your old images into a new one: the neuro-hormonal control system of the TGI,
it is indivisible, it is one system that goes up to the brain.
Usually the secretory granules are found in the cell basis close to the lamina basalis, as well for the para as for the
endocrine cells. Let us look at the transmitters and what for behavior they initiate:

The limbic system (Latin limbus: "border" or "edge") includes the putative structures in the human brain involved in emotion,
motivation, and emotional association with memory. The limbic system influences the formation of memory by integrating emotional
states with stored memories of physical sensations.. It is also claimed that a second evolutionary process also exists that regulates the
evolution of innate behaviours, instincts and emotions in multicellular animals which can be explained by teem theory. Briefly, 'teem
theory' argues that in multicellular animals, powerful, traumatic emotions generated by stressful environmental circumstances (like
predatory attacks, sexual encounters, accidents, etc.) can be genetically encoded into an area of an organism's DNA called 'noncoding
DNA' (ncDNA). Once encrypted in ncDNA, these traumatic emotions can be inherited to offspring, providing them with an
emotional memory of the traumatic event. Each Trauma Encoded Emotional Memory (or 'teem') has the potential to transfer adaptive
information (in the form of an emotional memory) from one generation to the next, thus building up a repository of emotional
memories of the ancestral environment. These emotions form the basis of all instincts and innate behaviour in multicellular animals.
This theory is not proven, it is a model.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015 GASTRIN
Gastrin (polypeptide of 17 up to 34 AA’s, several types of gastrins) are synthesized and stored in the epithelial Gastrin
cells  G. cells; topographically they are mainly found back in the mucous membrane of the glands of the gastric
antrum and in the mucous membrane of the duodenum and jejunum.
Gastrin will be released by the following triggers:
luminal triggers :
- small peptides & AA’s
- Ca
wall trigger over neural pathway:
- wall distention  stretch reflex of the ENS, gives a facilitation on the neural trigger.
neural triggers :
- direct vagal stimuli (cephalic intyervention via X)
- catecholamines
- G.R.P. (gastrine releasing peptide)
- wall stretch reflex activates the vagal afferences: via CNS and vago-vagal reflexes will stimulate the gastrin
release. (GRP as neurotransmitter)
Inhibiting and modulating factors:
- PH less than 3 in the lumen of the stomach
- somatostatin (somatostatin as paracrine transmitter, probably triggered by PH. (Yamada T, local regulatory
actions of gastro-intestinal peptides, 1987)
As you see with this first example, the auto-para-endo and neurocrine sytems are indivisible; the hierarchy will become
clear when we see the organs individually.
Gastrin is certainly a regulator of the gastric acid secretion (HCI), at the same time it stimulates the growth of the cells
that secrete the HCl in the oxyntic glands of the stomach.
Gastrin is probably also the mediator for the intrinsic factor, pepsinogene secretion and a regulator of the stomach
peristaltic and tonus.
Welcome in the world of detail complexity and detail incertitude, but where principles are clear.  CHOLECYSTOKININE - PANCREOZYMINE (CCK - PZ)
The epithelial cells that secrete CCK-PZ are found back in the mucous membrane of the duodenum and jejunum. CCK
and PZ were two groups of hormones: CCK acting on the bile system and PZ acting on the pancreas. CCK is composed
of varying numbers of amino acids (e.g., CCK58, CCK33, CCK8) depending on post-translational modification of the
CCK gene product, pre-procholecystokinin. CCK is very similar in structure to gastrin, another of the gastrointestinal
hormones, so much so that the last five C-terminal amino acids are same as those of gastrin. CCK58 comprises a helixturn-helix configuration.
Pancreozymines is a group of hormones that stimulate the release of the pancreas enzymes in the gut; nowadays
pancrezymine as term is not used anymore(2007) they are all called CCK and a number today 60 different forms are


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

luminal triggers :
- Fatty acid chains of 9 or more C atoms and according monoglycerids.
- Polypeptide chains & AA’s
- Glucose in lesser way
neural triggers :
- GRP was suggested but not proven
CCK’s are certainly: stimulators or facilitators for:
- release of the pancreatic enzymes
- contraction of the gallbladder
- relaxation of the sphincters of both systems and Oddi
They also stimulate the gastric and intestinal (duodenum, jejunum) peristaltic.
CCK’s also have atrophic effect on the pancreas epithelium, for certain in tumor conditions. SECRETIN
Secretin secreting cells (S cells) are found back in the duodenum and jejunum. Secretin is a peptide hormone, comprised
of 27 amino acids, of which 14 amino acids are homologous to the sequence of glucagon,VIP, STH etc.
luminal triggers :
- H+ concentration in the gut (PH) (when the PH gets lower than 4,5)
- presence of fatty acid chains
Secretin certainly:
- stimulates the pancreas secretion (Alkalic secretion with high bicarbonate concentration)
- stimulates the gallbladder secretion by stimulating CCK release
- Pepsinogen release in the stomach (pro-enzymes)
- inhibition of the HCL secretion (not certain to be physiologic, observed in tumors) SOMATOSTATIN
Somatostatin (also known as growth hormone inhibiting hormone (GHIH) or somatotropin release-inhibiting hormone
(SRIF)) is a peptide hormone that regulates the endocrine system and affects neurotransmission and cell proliferation via
interaction with G-protein-coupled somatostatin receptors and inhibition of the release of numerous secondary
Somatostatin has two active forms produced by alternative cleavage of a single polypeptide: one of 14 amino acids, the
other of 28 amino acids with several SS bridges.
Somatostatin is produced and secreted by the D-cells of the islets of Langerhans in the pancreas, and the D-cells that are
spread all over the TGI.
Somatostatin is also found back in in some neurons of the ENS and CNS.
luminal triggers :
- Lipid presence in large amounts
- Polypeptides and proteins in high amounts
- PH increase in the gastric antrum and duodenum. (relative)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Somatostain certainly:
- inhibits the release of:
- glucagon & insulin from the pancreas
- STH from the adenohypofyse
- gastrine from the G-cells
- HCI in the stomach
- CCK-PZ from the TGI
- secretine from the TGI
- inhibits the uptake from AA out of the TGI
- inhibits the gastro-intestinal motility (peristaltic)
- varierd effects on the water-electrolyte uptake from the TGI
Somatostatine is clearly a phylogenetically younger controlling hormone that holds the others within a dynamic
balance with boundaries. In order to prevent a destructive rat race of the one hormone against the other. GASTRISC INHIBITORY PEPTIDE (GIP)
Is a polypeptide from the family of the glucagon-secretin polypeptides, GIP is derived from a 153-amino acid
polypeptide encoded by the GIP gene and circulates as a biologically active 42-amino acid peptide. GIP is found in high
concentrations in the endocrine-paracrine cells of the duodenum and jejunum, in lower concentrations in the gastric
antrum and ileum. (In the mean time GIP is considered as on of the enterogastrones.) Enterogastrone is any substance in
the lower gastrointestinal tract which opposes the caudad (or "forward, analward") motion of the contents of chyme
when exposed to lipids.
luminal triggers :
- glucose
- duodenal ph increase
This polypeptide got its name because of the capacity to inhibit the peristaltic and release of gastric content by closing
the pylorus of the stomach, in the same time it helps the release of insulin.
It was thus proposed to change the name in: glucose-dependent insulinotropic peptide, which permits to keep the
abbreviation GIP. MOTILIN
Is a polypeptide that is found back in the first part of the duodenum.
Motilin is released during the fasting and initiates the MMC’s.
Migrating motor complexes (or migrating myoelectric complex) are waves of activity which sweep through the
intestines in a regular cycle during fasting state.
These motor complexes help trigger peristaltic waves which facilitate transportation of indigestible substances such as
bone, fiber and foreign bodies from the stomach, through the small intestine past the ileocecal sphincter into the colon.
The MMC originates in the stomach roughly every 75-90 minutes during the interdigestive phase (between meals) and is
responsible for the rumbling experienced when hungry.
It also serves to transport bacteria from the small intestine to the large, and to inhibit the migration of colonic bacteria
into the terminal ileum.
The MMC is thought to be partially regulated by motilin which is initiated in the stomach as a response to vagal
stimulation, and does not depend on extrinsic nerves directly. PANCREAS POLYPEPTIDE (PP) (See D.O. thesis B.Janssen 1992 - IWGS Antwerpen)
Is a polypeptide that is found back in the isles of Langerhans.

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Luminal triggers :
- proteïn rich meals
- Sham feeding
Vascular trigger :
- hypoglycemia
Neurological triggers :
- vago-vagal reflexes when the stomach wall is stretched
The certain effects of PP are: inhibition of bile secretion via relaxation of the gallbladder and contraction or tonus
increase of the sphincter of Oddi.
By the sphincter action, the exocrine pancreas secretion is inhibited also PEPTIDE YY
Is a polypeptide that resembles PP, but it is found back in the mucous membrane endocrine and paracrine cells in the
ileum and colon.
The strongest luminal trigger is the presence of lipids. Peptide YY will also modulate the inhibition of the exocrine
pancreas secretion and gastric acid secretion. HISTAMINE
Is a nonpeptide, paracrine mediator that stimulates the gastric HCI secretion. See stomach.


Enterogastrone is any substance in the lower gastrointestinal tract
which opposes the caudad (or "forward, analward") motion of the
contents of chyme when exposed to lipids.
Examples include:
gastric inhibitory peptide

What they have in common is:
They are released as long as free lipids are
present in the duodenum
They increase the tonus of the pylorus and thus
prevent the further release of gastric content in
the duodenum.
They decrease the gastric motility and even
tonus, when there is a slow fat digestion they are
responsible for the distention of the stomach and
thereby disappearance of the valve of Gubaroff.
(Which leads directly towards GERD.)
Gastroesophageal Reflux Disease (GERD; or GORD when
spelling œsophageal, the BrE form) is defined as chronic
symptoms or mucosal damage produced by the abnormal reflux of
gastric contents into the esophagus.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can
be due to incompetence of the lower esophageal sphincter (LES), transient LES relaxation, impaired expulsion of gastric
reflux from the esophagus, or a hiatal hernia.
Heartburn is the major symptom of acid in the esophagus, characterized by burning discomfort behind the breastbone
(sternum). Findings in GERD include esophagitis (reflux esophagitis) — inflammatory changes in the esophageal lining
(mucosa) — strictures, difficulty swallowing (dysphagia), and chronic chest pain. Patients may have only one of those
findings. Typical GERD symptoms include cough, hoarseness, voice changes, chronic ear ache, burning chest pains,
nausea or sinusitis. GERD complications include stricture formation, Barrett's esophagus, esophageal ulcers, and
possibly even lead to esophageal cancer, especially in adults over 60 years old or when GERD exists since 10 years in a
Occasional heartburn is common but does not necessarily mean one has GERD. Patients with heartburn symptoms more
than once a week are at risk of developing GERD. A hiatal hernia is usually asymptomatic, but the presence of a hiatal
hernia is a risk factor for developing GERD.
GERD may be difficult to detect in infants and children. Symptoms may vary from typical adult symptoms. GERD in
children may cause repeated vomiting, effortless spitting up, coughing, and other respiratory problems. Inconsolable
crying, failure to gain adequate weight, refusing food, bad breath, and belching or burping are also common. Children
may have one symptom or many — no single symptom is universal in all children with GERD.
It is estimated that of the approximately 8 million babies born in the U.S. each year, up to 35% of them may have
difficulties with reflux in the first few months of their life. Most of those children will outgrow their reflux by their first
birthday. However, a small but significant number of them will not outgrow the condition.
Babies' immature digestive systems and milk intolerance are usually the cause, and most infants stop having acid reflux
by the time they reach their first birthday. Some children do not outgrow acid reflux, however, and continue to have it
into their teen years.

We will divide it into CNS and ENS, but bas said before this is madness, just look at the principles for the sake of
understanding and remember that in the reality of the function they are inseparable.
The ENS is an independent integrative system, that is in fact the old original concept on which the rest of the NS is
based so to say. The ENS gets its sensory information directly out of the TGI through sensors that are disposed in the
connective tissue immediately beneath the mucous membrane, all along the TGI.
These sensors are:
- Osmolarity receptors: reacts on strong osmotic fields or trajectories in the matrix
- Thermo-receptors: reacts on thermic changes
- Mechano-receptors: reacts on mechanic distention of the wall, adaptative receptors
- Chemo-receptors: react on concentration of substances, chemical analysis
- PH receptors: react on pH changes in the environment
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal
cord. (Phylogenetically it was for some species the only NS they had).The enteric nervous system, along with the
sympathetic and parasympathetic nervous systems, constitute the autonomic nervous system.
The principal components of the enteric nervous system are two networks or plexuses of neurons, both of which are
embedded in the wall of the digestive tract and extend from esophagus to anus:
The myenteric plexus is located between the longitudinal and circular layers of muscle in the tunica muscularis and,
appropriately, exerts control primarily over digestive tract motility and tonus.
The submucous plexus, as its name implies, is buried in the submucosa. Its principal role is in sensing the environment
within the lumen, regulating gastrointestinal blood flow and controlling epithelial cell function. In regions where these
functions are minimal, such as the esophagus, the submucous plexus is sparse and may actually be missing in sections.

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

In addition to the two major enteric nerve plexuses, there are minor plexuses beneath the serosa, within the circular
smooth muscle and in the mucosa.
Within enteric plexuses are three types of neurons, most of which are multipolar:
Sensory neurons receive information from sensory receptors in the mucosa and muscle. At least five different sensory
receptors have been identified in the mucosa, which respond to mechanical, thermal, osmotic and chemical stimuli.
Chemo-receptors sensitive to acid, glucose and amino acids have been demonstrated which, in essence, allows "tasting"
of luminal contents (See glycocalix in cytology). Sensory receptors in muscle respond to stretch and tension.
Collectively, enteric sensory neurons compile a comprehensive battery of information on gut contents and the state of
the gastrointestinal wall.
Motor neurons within the enteric plexuses control gastrointestinal motility and secretion, and possibly absorption. In
performing these functions, motor neurons act directly on a large number of effector’s cells, including smooth muscle,
secretory cells (chief, parietal, mucous, enterocytes, pancreatic exocrine cells) and gastrointestinal endocrine cells.
Interneuron’s are largely responsible for integrating information from sensory neurons and providing it to
("programming") enteric motor neurons.
Enteric neurons secrete an intimidating array of neurotransmitters. One major neurotransmitter produced by enteric
neurons is acetylcholine. In general, neurons that secrete acetylcholine are excitatory, stimulating smooth muscle
contraction, increases in intestinal secretions, release of enteric hormones and dilation of blood vessels. Norepinephrine
is also used extensively for neurotransmission in the gastrointestinal tract, but it derives from extrinsic sympathetic
neurons; the effect of norepinephrine is almost always inhibitory and opposite that of acetylcholine. There is a third
system that is called Nanc (more about this later)
These efferent neurons react by the means of modulation:
- TGI muscles tonus
- endo- & paracrine cells
- secretory epithelium & absorbing epithelium
- circulatory reactions
The integration and ensuing coordination that are make the ENS programs provide for automatic control of repetitive
cyclic motor responses or stereotype sequences of motor patterns as peristaltic and segmentation.
The ENS thus has the capacity to respond with a complex coordinated motor pattern on the basis of sensory
information, without any intervention of the CNS.
This lead some, to call the ENS “the brain of the gut”.
(See the motility experiments at the university of Lund in 1985 when I was there as Belgian representative for the IPSA
foundation beginning and exchange students program (Sweden))
In 1985 we were lucky to follow during a month this and some other projects in the University of Lund.
This particular project was about gut motility regulation: they took pieces of living gut of dogs and experimented on the
ENS neurotransmitters and the peristaltic motility. Seeing this with my own eyes really was an eye-opener that started
my interest in the ENS and physiology of the TGI.
-a piece of living gut was placed in a solution and kept on temperature, so that it went on with its peristaltic for three
days! (loose from vascularization and CNS control.)
-the peristaltic keeps it ^pattern under these circumstances (intensity, frequency, and direction of contraction)!
-even when inversing a part of the gut, the patterns are kept. (see figure 2)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Figure 2 Peristaltic experiments from the University of Lund 1985

Despite my fascination it set
me to think about the ethics
of animal experimenting.
This was accentuiated when
I saw the pain experiments
on rats at my University
VUB in the laboratory of
neurophysiology. EVOLUTION
- Species with an ENS but no CNS. (protochordata)
Lancet fish
- Species with an ENS and an primitive start of the CNS. (cephalopoda)
Calamar, octopus (the most developed5)


Octopuses are more intelligent than any other order of invertebrates. The exact extent of their intelligence and learning capability is
much debated among biologists, but maze and problem-solving experiments have shown that they do have both short- and long-term
memory. Their short lifespans limit the amount they can ultimately learn. There has been much speculation to the effect that almost
all octopus behaviors are independently learned rather than instinct-based, although this remains largely unproven. They learn almost
no behaviors from their parents, with whom young octopuses have very little contact. An octopus has a highly complex nervous
system (not in comparison to mammals of course), only part of which is localized in its brain. In cephalopods, the brain has two
regions: the supraesophageal mass and the subesophageal mass, separated by the esophagus. The supra- and subesophageal masses
are connected to each other on either side of the esophagus by the basal lobes and the dorsal magnocellular lobes. The large optic
lobes are sometimes not considered to be part of the brain, as they are anatomically separate and are joined to the brain by the optic
stalks. However, the optic lobes perform much visual processing, and so functionally are part of the brain. Two-thirds of an octopus's
neurons are found in the nerve cords of its arms, which have a remarkable amount of autonomy. Octopus arms show a wide variety of
complex reflex actions arising on at least three different levels of the nervous system. Some octopuses, such as the Mimic Octopus,
will move their arms in ways that emulate the movements of other sea creatures.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

- Species with a ENS,  S, and CNS (Limbic.S.) (actinopterygii)
Tuna and other real fish (cartilaginous fish like sharks are between the two)
- Species that have all types of NS. All reptiles
crocodile, snake
- Species that have the same as reptiles but elaborated higher parts of the brain neocortex example) Mammals
and man
The ENS is the oldest form of neural communication, is elaborated and permits some level of integration. It is a
differentiation or specialization of epithelial tissue, the protochordates and cephalopods are the most
demonstrative examples of this.
If this is not sufficient to make it clear to you than think about this: in mammals and thus also the homo sapiens
the nervus vagus (X) consists of10 % efferent fibers and 90 % afferent fibers, that is not a command but an
information and modulation system to work with the ENS, that does the necessary jobs.


We can schematize the relation of the ENS and CNS best as follows: figure 3
Figure 3: ENS and CNS
Brain & Medulla

Para and ortho-sympatic

TGI sensory receptors

TGI effectors

The para  nerves (X, sacral branches) and the ortho  nerves (splanchnicbranches) contain also sensory branches from
the TGI.
For the anatomy of the autonomic nervous system see “ SYSTEMATISATIE VAN HET NEURO-VEGETATIEF
The importance of the well known neurotransmitters, acetylcholine and norepinephrine, was thought to be the same in
the ENS. Ac.Ch. is the mediator for smooth muscle contraction and excretion of the exocrine glands, and increases the
blood flow in the TGI.
Norepinephrine inhibits the contraction, the exocrine excretion and the blood flow. Although the NANC and or
Purinergic neurotransmitters were known to be active in the TGI, since years there importance was underestimated.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Electron microscopy changed this; it demonstrated the form differences between adrenergic and cholinergic nerve ends.
Since then many types of nerve ends were described and supposed to use potentially one or more other
neurotransmitters; this is still a hot field of research.
These * putative or supposed transmitters can be divided in two classes:
- putative peptide transmitters
- putative nonpeptide transmitters
* putative is regularly used because despite the massive investigations and publications, this domain swims between
two waters: endocrinology and neurology; and this is literal: the synaptic clefts of living active nerves are swimming in
the interstitium which is also the dwelling medium of the hormonal mediators, and it is technically impossible to clean
that up, or get it sterile without changing the nerves reactions, secretions and those of the other neighbor cells. Everyone
agrees about the transmitter roles but the subdivision, the how and why’s are still in investigation.
- Putative non peptide transmitters are for instance:
ATP, adenosine, glycin (purinergic transmitters)
serotonin, prostaglandin, histamine
 amino butyric acid(GABA), dopamine
- Putative peptide transmitters are for instance
substance P  neuropeptide mediator for pain.
Vasoactive Intestinal Polypeptide (VIP)
Enkephalin (endo-morphine group)
Secretin, motilin, neuropeptide Y, gastrine etc.
The neuropeptide oxytocin. Oxytocin is involved in the control of maternal behavior. It is synthesized inside
magnocellular neurosecretory cells as a precursor protein that is processed by proteolysis to its shorter active peptide
form. Specific parts of the brain such as the supraoptic nucleus produce oxytocin which acts on cells in locations such as
the ventral pallidum to produce the behavioral effects of oxytocin. A large amount of oxytocin is made in the
hypothalamus, transported to the posterior lobe of the pituitary and released into the blood stream by which it reaches
target tissues such as the mammary glands (milk letdown). In the diagram inset, oxytocin is shown bound to a carrier
protein, neurophysin.
Other examples of neurochemicals
Glutamate is the most common neurotransmitter. Most neurons secrete with glutamate or GABA. Glutamate is
excitatory, meaning that the release of glutamate by one cell usually causes adjacent cells to fire an action potential.
(Note: Glutamate is chemically identical to the MSG commonly used to flavor Chinese food.)
GABA is an example of an inhibitory neurotransmitter.
Dopamine is another example of a neurotransmitter. It plays a key role in the functioning of the limbic system, which is
involved in emotional function and control.
Serotonin plays a regulatory role in mood, sleep, and other areas.
Nitric oxide functions as a neurotransmitter, despite being a gas. It is not grouped with the other neurotransmitters
because it is not released in the same way. (Actually this is an autocrine mediator that is in use in neurons)
As seen before, most of the actions of these mediators (neuro-endocrine) are known from pathology, endocrine tumors
with massive production of mediator give clear significance to the action of these substances but the question remains is
it physiology or just pathological....
Endorphins are a part of this category: Endorphins are endogenous opioid biochemical compounds. They are
polypeptides produced by the pituitary gland and the hypothalamus in vertebrates, and they resemble the opiates in their
abilities to produce analgesia and a sense of well-being. In other words, they might work as "natural pain killers." Using
drugs may increase the effects of the endorphins.
The term "endorphin" implies a pharmacological activity (analogous to the activity of the corticosteroid category of
biochemicals) as opposed to a specific chemical formulation.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

The term endorphin rush has been adopted in popular speech to refer to feelings of exhilaration brought on by pain,
danger, or other forms of stress, supposedly due to the influence of endorphins. However, this term does not occur in the
medical literature.
Schematisationof the encephalin or enkephaline or enkephaine chain



(C fibers & A δ fibers)

 

β LPH (pro-hormone)
β endorphin

(encephalin, enkefaine)

A short review of the types of peristaltic.
Peristaltic= motility of the TGI = the patterns of movement that are intrinsic to the TGI, produced by the
muscles of the wall of the TGI.
- propulsion of the bolus / axial flow, transit    
- malaxation of the bolus / local flow    
- circular musculature
- longitudinal musculature


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

FIGURE 4 General review histology of the TGI

FIGURE 5 Schema of the neurological relation

The different types like “Slow Wave Activity”, “Spike Burst Activity,” get combined in different patterns and variations
of frequency, intensity and amplitude: the mix of these gives an image of the complex peristaltic of the TGI. Migrating
motor complexes are waves of activity which sweep through the intestines in a regular cycle during fasting state.
These motor complexes help trigger peristaltic waves which facilitate transportation of indigestible substances such as
bone, fiber and foreign bodies from the stomach, through the small intestine past the ileocecal sphincter into the colon.
The MMC originates in the stomach roughly every 75-90 minutes during the interdigestive phase (between meals) and is
responsible for the rumbling experienced when hungry. It also serves to transport bacteria from the small intestine to the
large, and to inhibit the migration of colonic bacteria into the terminal ileum. The MMC is thought to be partially
regulated by motilin which is initiated in the stomach as a response to vagal stimulation, and does not depend on
extrinsic nerves directly.

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

For the practical side we will approach it differently:

Normal peristaltic is not palpable!

The small intestine is so mobile that usually you can stick a sharp object like a needle or even knife in the belly
without puncturing the gut!

The peritoneum is a fine membrane (mesothelium) not a strong mechanical fascia as some idiots pretend!

The abdomen functions with pressure differences induced by the musculoskeletal system mainly, that makes the
organs glide on each other, they are not hanging on their meso’s like old curtains on o bar.

Do a lot of dissection and than when you think you know your anatomy, make a dissection of freshly killed
animal and look at the consistence, and smoothness. ( go with a hunter or butcher)

Disturbed transit or peristaltic means trouble for the whole organism, because it will lack essential nutrients or
keep contact with the waste for too long, but most certainly for the nervous system will it problematic, as most
neurotoxins pass easily through the gut again. DIARRHEA
Diarrhea (in American English) or diarrhoea (in British English) is a condition in which the sufferer has frequent watery,
loose bowel movements (from the Greek word διάρροια; literally meaning "through-flowing"). Acute infectious diarrhea
is a common cause of death in developing countries (particularly among infants), accounting for 5 to 8 million deaths
annually. Much of the incidence of these deaths is due to the lack of adequate safe water and lack of sewage treatment
capacity; the separation of drinking water from contaminated sewage is also a major issue.
This condition can occur as a symptom of infection, allergy, food intolerance, foodborne illness and/or extreme excesses
of Vitamin C and/or magnesium and may be accompanied by abdominal pain, nausea and vomiting. Temporary diarrhea
can also result from the ingestion of laxative medications or large quantities of certain foods like prunes with laxative
properties. There are other conditions which involve some but not all of the symptoms of diarrhea, and so the formal
medical definition of diarrhea involves defecation of more than 200 grams per day (though formal weighing of stools to
determine a diagnosis is never actually carried out).
Diarrhea occurs when insufficient fluid is absorbed by the colon. As part of the digestion process, or due to fluid intake,
food is mixed with large amounts of water. Thus, digested food is essentially liquid prior to reaching the colon. The
colon absorbs water, leaving the remaining material as a semisolid stool. If the colon is damaged or inflamed, however,
absorption is inhibited, and watery stools result.
Diarrhea is most commonly caused by viral infections or bacterial toxins. In sanitary living conditions and with ample
food and water available, an otherwise healthy patient typically recovers from the common viral infections in a few days
and at most a week. However, for ill or malnourished individuals diarrhea can lead to severe dehydration and can
become life-threatening without treatment.
Diarrhea can also be a symptom of more serious diseases, such as dysentery, cholera, or botulism, and can also be
indicative of a chronic syndrome such as Crohn's disease. Though appendicitis patients do not generally have diarrhea, it
is a common symptom of a ruptured appendix. It is also an effect of severe radiation sickness.
Diarrhea can also be caused by dairy intake in those who are lactose intolerant.
Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss,
preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further
treatment is unnecessary.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

On the Bristol Stool chart: types 5,6,7 are diarrhea, or the
precursor signs.
The following types of diarrhea generally indicate
medical supervision is desirable:
Diarrhea in infants;
Moderate or severe diarrhea in young children;
Diarrhea associated with blood;
Diarrhea that continues for more than 2 weeks;
Diarrhea that is associated with more general illness such
as non-cramping abdominal pain, fever, weight loss, etc;
Diarrhea in travelers, since they are more likely to have
exotic infections such as parasites;
Diarrhea in food handlers, because of the potential to
infect others;
Diarrhea in institutions such as hospitals, child care
centers, or geriatric and convalescent homes.
To expel the contents of the lower digestive tract, the
fluidity of the contents of the small and large intestines is
increased. Active transport of Na+ back into the gut
initiates a reverse sodium transport. This causes both Cl–
and HCO3– to follow passively, as well as water. Now in
the intestines, the water dilutes toxins as well as
triggering contractions of the intestine due to increase in
intestinal distension. These contractions push the contents
of the lower GI tract towards and out of the anal canal.
Types of diarrhea
There are at least four types of diarrhea: secretory diarrhea, osmotic diarrhea, motility-related diarrhea, and
inflammatory diarrhea.
Secretory diarrhea
Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is
little to no structural damage. The most common cause of this form of this type of diarrhea is a cholera toxin that
stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium
is carried with it, along with water.
Osmotic diarrhea
Osmotic diarrhea occurs when there is a loss of water due to a heavy osmotic load. This can occur when there is
maldigestion (e.g., pancreatic disease or Coeliac disease), where the nutrients are left in the lumen, which pulls water
into the lumen.
Motility-related diarrhea
Motility-related diarrhea occurs when the motility of the gastrointestinal tract is abnormal. If the food moves too
quickly, there is not enough contact time between the food and the membrane, meaning that there is not enough time for
the nutrients and water to be absorbed. This can follow a vagotomy or diabetic neuropathy.
Inflammatory diarrhea
Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss
of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of
diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic
infections, or autoimmune problems such as inflammatory bowel disease.
Acute diarrhea
This may be defined as diarrhea that lasts less than three and a half weeks, and is also called enteritis.
This can nearly always be presumed to be infective, although only in a minority of cases is this formally proven.
With cases of acute diarrhea, it is often reasonable to reassure a patient, ensure adequate fluid intake, and wait and see.
In more severe cases, or where it is important to find the cause of the illness, stool cultures are instituted.
The most common organisms found are Campylobacter (from animal products), Salmonella (also often from animal
foodstuffs), Cryptosporidium (ditto), and Giardia lamblia (lives in water). Shigella dysentery is less common, and
usually human in origin. Cholera is rare in Western countries. It is more common in travelers and is usually related to

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

contaminated water (its ultimate source is probably sea water). Escherichia coli is probably a very common cause of
diarrhea, especially in travelers, but it can be difficult to detect using current technology. The types of E. coli vary from
area to area and country to country. Clostridium difficile is considered the most common cause of infectious diarrhea in
hospitalized patients worldwide.
Viruses, particularly rotavirus, are common in children. (Viral diarrhea is probably over-diagnosed by non-doctors).
Norwalk virus can also cause these symptoms.
Toxins and food poisoning can cause diarrhea. These include staphylococcal toxin (often from milk products due to an
infected wound in workers), and Bacillus cereus. Often "food poisoning" is really Salmonella infection. Diarrhea can
also be caused by ingesting foods that contain indigestible material, for instance, escolar and olestra.
Parasites and worms sometimes cause diarrhea but are often accompanied by weight loss, irritability, rashes or anal
itching. The most common is pinworm (mostly a nuisance rather than a severe medical illness). Other worms, such as
hookworm, ascaria, and tapeworm are more medically significant and may cause weight loss, anemia, general
unwellness and allergy problems. Amoebic dysentery due to Entamoeba histolytica is an important cause of bloody
diarrhea in travelers and also sometimes in western countries. It requires appropriate and complete medical treatment.
Infective diarrhea
It is not uncommon for diarrhea to persist. Diarrhea due to some organisms may persist for years without significant
long term illness. More commonly the diarrhea slowly ameliorates but the patient becomes a carrier (harbors the
infection without illness). This is often an indication for treatment, especially in food workers or institution workers.
Parasites (worms and amoeba) should always be treated. Salmonella is the most common persistent bacterial organism in
These tend to be more severe medical illnesses. Malabsorption is the inability to absorb food, mostly in the small bowel
but also due to the pancreas.
Causes include celiac disease (intolerance to gluten, a wheat product), lactose intolerance (Intolerance to milk sugar,
common in non-Europeans), fructose malabsorption, pernicious anemia (impaired bowel function due to the inability to
absorb vitamin B12), loss of pancreatic secretions (may be due to cystic fibrosis or pancreatitis), short bowel syndrome
(surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other drugs such as
Inflammatory bowel disease
The two overlapping types here are of unknown origin:
Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the
small bowel.
Irritable Bowel Syndrome
Another possible cause of diarrhea is Irritable Bowel Syndrome (IBS). Symptoms defining IBS: abdominal discomfort
or pain relieved by defecation and unusual stool (diarrhea or constipation or both) or stool frequency, for at least 3 days
a week over the previous 3 months. IBS symptoms can be present in patients with a variety of conditions including food
allergies, infective diarrhea, celiac, and inflammatory bowel diseases. Treating the underlying condition (celiac disease,
food allergy, bacterial dysbiosis, etc.) usually resolves the diarrhea. IBS can cause visceral hypersensitivity. While there
is no direct treatment for undifferentiated IBS, symptoms, including diarrhea, can sometimes be managed through a
combination of dietary changes, soluble fiber supplements, and/or medications.
Other important causes
Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
Bowel cancer: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the large intestine is most
Hormone-secreting tumors: some hormones (e.g. serotonin) can cause diarrhea if excreted in excess (usually from a
Bile salt diarrhea: excess bile salt entering the colon rather than being absorbed at the end of the small intestine can
cause diarrhea, typically shortly after eating. Bile salt diarrhea is a possible side-effect of gallbladder removal. It is
usually treated with cholestyramine, a bile acid sequestrant.
Chronic diarrhea can be caused by chronic ethanol ingestion. Consumption of alcohol affects the body's capability to
absorb water - this is often a symptom that accompanies a hangover after a heavy drinking session. The alcohol itself is
absorbed in the intestines and as the intestinal cells absorb it, the toxicity causes these cells to lose their ability to absorb
water. This leads to an outpouring of fluid from the intestinal lining, which is in turn poorly absorbed. The diarrhea
usually lasts for several hours until the alcohol is detoxified and removed from the digestive system. Symptoms range
from person to person and are influenced by both the amount consumed as well as physiological differences. Alcohol20

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

induced diarrhea is often accompanied by "the follow through" where a feeling that the patient is going to break wind
(flatulence) instead becomes an uncontrolled episode of diarrhea.
ERGO: Quick or exaggerated motility of the gut has diarrhea as effect and the consequences on short and long
term are:
Usually the origin is irritation of the TGI by:
- non symbiotic micro-organisms (infection)
- exaggerated stress (ortho  over stimulation)
- non physiologic nutrition (too much fibers, too much oils)
Short term consequences :
- dehydration !!!!!++++with small kids and babies!!!!!
- weight loss and exhaustion
- vitamins and minerals shortages
Long term consequences:
- deficiency syndrome with obvious symptoms that worsen rapidly (CNS) VOMITING
Vomiting (also throwing up or emesis) is the forceful expulsion of the contents of one's stomach through the mouth and
sometimes the nose. Vomiting may result from many causes, ranging from gastritis or poisoning to brain tumors, or
elevated intracranial pressure (ICP). The feeling that one is about to vomit is called nausea. It usually precedes, but does
not always lead to vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting, and in severe cases
where dehydration develops, intravenous fluid may need to be administered to replace fluid volume.
The medical branch investigating vomiting, emetics and antiemetics is called emetology.
Vomiting center
Vomiting is coordinated in the vomiting center in the lateral medullary reticular formation in the medulla. Receptors on
the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, stimulation of which can lead to
vomiting. The chemoreceptor zone lies outside the blood-brain barrier, and can therefore be stimulated by blood-borne
drugs that can stimulate vomiting, or inhibit it. There are various sources of input to the vomiting center:
The chemoreceptor trigger zone at the base of the fourth ventricle has numerous dopamine D2 receptors, serotonin 5HT3 receptors, opioid receptors, Acetylcholine receptors, and receptors for substance P. Stimulation of different
receptors are involved in different pathways leading to emesis, in the final common pathway substance P appears to be
The vestibular system which sends information to the brain via cranial nerve VIII (vestibulocochlear nerve). It plays a
major role in motion sickness and is rich in muscarinic receptors and histamine H1 receptors.
Cranial nerve X (vagus nerve), which is activated when the pharynx is irritated, leading to a gag reflex.
Vagal and enteric nervous system inputs that transmit information regarding the state of the gastrointestinal system.
Irritation of the GI mucosa by chemotherapy, radiation, distention or acute infectious gastroenteritis activates the 5-HT3
receptors of these inputs.
The CNS mediates vomiting arising from psychiatric disorders and stress.
Vomiting act
The vomiting act encompasses three types of outputs initiated by the medulla: Motor, parasympathetic nervous system
(PNS) and sympathetic nervous system (SNS). Collectively, they are as follows:
Increased salivation to protect the enamel of teeth from stomach acids (excessive vomiting leads to caries). This is part
of the PNS output.
Retroperistalsis, starting from the middle of the small intestine, sweeping up the contents of the digestive tract into the
stomach, through the relaxed pyloric sphincter.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

A lowering of intrathoracic pressure (by inspiration against a closed glottis), coupled with an increase in abdominal
pressure as the abdominal muscles contract, propels stomach contents into the esophagus without involvement of
retroperistalsis. The lower esophageal sphincter relaxes. This is part of the motor output, and it is also important to note
that the stomach itself does not contract in the process of vomiting.
Vomiting is ordinarily preceded by retching.
Vomiting also initiates a SNS response causing both sweating and increased heart rate.
The neurotransmitters that regulate vomiting are poorly understood, but inhibitors of dopamine, histamine and serotonin
are all used to suppress vomiting, suggesting that these play a role in the initiation or maintenance of a vomiting cycle.
Vasopressin and neurokinin may also participate.
Since the stomach secretes acid, vomit contains a high concentration of hydronium ions and is thus strongly acidic.
Recent food intake will be reflected in the gastric vomit.
The content of the vomitus (vomit) may be of medical interest. Fresh blood in the vomit is termed hematemesis ("blood
vomiting"). Old blood bears resemblance to coffee grounds (as the iron in the blood is oxidized), and when this matter is
identified the term "coffee ground vomiting" is used. Bile can enter the vomit during subsequent heaves due to duodenal
contraction if the vomiting is severe. Fecal vomiting is often a consequence of intestinal obstruction, and is treated as a
warning sign of this potentially serious problem ("signum mali ominis"); such vomiting is sometimes called "miserere".
If food has recently been consumed, then partly digested food may show up in the vomit.
If the vomiting reflex continues for an extended period of time with no appreciable vomitus, the condition is known as
non-productive emesis or dry heaves, which can become both extremely painful and debilitating.
Complications of vomiting
Aspiration of vomit
Vomiting can be very dangerous if the gastric content gets into the respiratory tract. Under normal circumstances the gag
reflex and coughing will prevent this from occurring, however these protective reflexes are compromised in persons
under narcotic influences such as alcohol or anesthesia. The individual may choke and asphyxiate or suffer an aspiration
Dehydration and electrolyte imbalance
Prolonged and excessive vomiting will deplete the body of water (dehydration) and may alter the electrolyte status. The
loss of acids leads to metabolic alkalosis (increased blood pH), and the electrolyte imbalance shows hypokalemia
(potassium depletion) and hypochloremia (chlorine depletion). The hypokalemia is an indirect result of the kidney
compensating for the loss of acid. With the loss of intake of food the individual will become cachectic.
Vomiting may be due to a large number of causes, and protracted vomiting has a long differential diagnosis.
Digestive tract
Causes in the digestive tract:
Gastritis (inflammation of the gastric wall, usually by viruses)
Pyloric stenosis (in babies - this typically causes a very forceful "projectile vomiting" and is an indication for urgent
Bowel obstruction
Acute abdomen and/or peritonitis
Cholecystitis, pancreatitis, appendicitis, hepatitis
In children, it can be caused by an allergic reaction to cow's milk proteins (milk allergy)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Sensory system and brain
Causes in the sensory system:
Movement: motion sickness (which is caused by overstimulation of the labyrinthine canals of the ear)
Ménière's disease
Causes in the brain:
Cerebral hemorrhage
Brain tumors, which can cause the chemoreceptors to malfunction
Benign intracranial hypertension and hydrocephalus
Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting):
Hypercalcemia (high calcium levels)
Uremia (urea accumulation, usually due to renal failure)
Adrenal insufficiency
Hyperemesis, Morning sickness
Drug reaction (vomiting may occur as an acute somatic response to):
alcohol (being sick whilst being drunk or being sick the next morning suffering from the after-effects, i.e. the hangover).
selective serotonin reuptake inhibitors
many chemotherapy drugs
some entheogens (such as peyote or ayahuasca)
Eating disorders (anorexia nervosa or bulimia nervosa)
Sexual fetish (emetophilia)
To remove a poison in case such has been ingested (some poisons should not be vomited as they may be more toxic
when inhaled or aspirated; it is generally considered better to ask for help before inducing vomiting)
Some people who are engaged in binge drinking will induce vomiting in order to make room in their stomachs for
further alcohol consumption. In the United Kingdom, this practice is known as tactical chundering, and as boot and rally
or pulling the trigger in the United States.
After surgery (postoperative nausea and vomiting)
Disagreeable sights, smells or thoughts (such as decayed matter, others' vomit, thinking of vomiting), etc.
Extreme pain, such as intense headache or myocardial infarction (heart attack)
Violent emotions (including laughing)
Cyclic vomiting syndrome (a poorly understood condition with attacks of vomiting)
High doses of ionizing radiation will sometimes trigger a vomit reflex in the victim.
Violent fits of coughing or hiccups
Related medication
An emetic, such as Syrup of Ipecac, is a substance that induces vomiting when administered orally or by injection. An
emetic is used medically where a substance has been ingested and must be expelled from the body immediately.
Inducing vomiting can remove the substance before it is absorbed into the body. Ipecac abuse can lead to detrimental
health effects.
An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion
sickness and the side effects of some opioid analgesics and chemotherapy directed against cancer.
Antiemetics act by inhibiting the receptor sites associated with emesis. Hence, anticholinergics, antihistamines,
dopamine antagonists, serotonin antagonists and cannabinoids are used as anti-emetics.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Social implications
Nausea inducement in groups
It is quite common that when one person vomits, others nearby will become nauseated, particularly when smelling the
vomit of others, often to the point of vomiting themselves. It is believed that this is an evolved trait among primates.
Many primates in the wild will tend to browse for food in small groups. Should one member of the party react adversely
to some ingested food it may be advantageous (in a survival sense) for other members of the party also to vomit. This
tendency in human populations has been observed at drinking parties, where excessive consumption of alcoholic
beverages may result in a number of party members vomiting nearly simultaneously, this being triggered by the initial
vomiting of a single member of the party. This phenomenon has been touched on in popular culture: notorious instances
appear in the films Monty Python's The Meaning of Life (1983), Saving Private Ryan (1998), and Stand By Me (1986),
while in the computer game Theme Hospital, it is referred to as a 'vomit wave' and can spread through the hospital
Intense vomiting in ayahuasca ceremonies is a common phenomenon. However, people who experience "la purga" after
drinking ayahuasca generally regard it as both a physical and spiritual cleanse and often come to welcome it. It has been
suggested that the consistent emetic effects of ayahuasca — in addition to its many other therapeutic properties — was
of medicinal benefit to indigenous peoples of the Amazon, in helping to clear parasites from the gastrointestinal system.
There have also been documented cases of a single ill and vomiting individual inadvertently causing others to do so,
when they are especially fearful of also becoming ill, through a form of mass hysteria.
Most people try to contain their vomit by vomiting into a sink, toilet, or trash can, as both the act and the vomit itself are
widely considered embarrassing; vomit is also difficult to clean. On airplanes and boats, special bags are supplied for
sick passengers to vomit into. Alternatively, a special disposable bag is available containing absorbent material that
solidifies the vomit quickly, making it convenient and safe to keep (leakproof, puncture resistant, odorless) until there is
an opportunity to dispose of it conveniently.
People who vomit chronically (e.g. as part of an eating disorder such as bulimia nervosa) may devise various ways to
hide this disorder.
According to an online study of 30 traditionally bad sounds, the sound of vomiting is the worst sound in the world.
Professor Cox of the University of Salford's Acoustic Research Centre said that "We are pre-programmed to be repulsed
by horrible things such as vomiting, as it is fundamental to staying alive to avoid nasty stuff". It is thought that the
thought of disgust is triggered by the sound of vomiting to protect food from those possibly diseased nearby.
In language
As with other physiological processes involving body wastes, vomiting has taboo aspects. This is shown by the large
number of colourful euphemisms and dysphemisms for vomiting. (see: toilet humour). Reference to vomiting is often
made in speech (e.g. "it makes me sick", "I need a bucket") or by gesturing to signify being disgusted by someone or
Slang terms for the act of vomiting include: "hurling", "throwing up", "upchucking", "booting", "puking", "barfing",
"keeling", "chucking up", "sicking up", "spewing", "spewing chunks", "chundering", "tossing cookies", "a technicolor
yawn", "making street pizza", "
"Puke" and "puking" date from at least the 16th century. In As You Like It, Shakespeare talks of the infant 'Mewling and
puking in the nurse's arms'.
Vomit Phobia
Vomit phobia, or emetophobia, as it is also known, is the sixth most common phobia in the world, according to the
International Emetophobia Society. In addition to the actual phobia, there are many other disorders and phobias that
sufferers may suffer from, such as IBS and agoraphobia. People with emetophobia tend to avoid eating in public,
socialising and going to parties. They may hardly eat at all, and for this reason may be diagnosed as anorexic.
Emetophobes will go to extraordinary lengths to avoid vomiting or seeing someone vomit. Some emetophobics have the


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

distinct ability to actually prevent themselves from vomiting, called "vomit continence". They are able to fight the
feeling of nausea before the feeling eventually subsides.
Very fast and brutal TGI motility or not, propulsion provided by contractions of the diaphragm. (Baby, old
people, fecal vomiting!!!!)
- Usually intoxication or brutal irritation of the TGI (irritation of the sensors of the ENS) :
- Is usually a protective reaction (intoxication)
- can be an obstruction but than they have no stool for a longer time: babies & stenosis or ileo-cecal
invagination!!!! medical urgency.
- anorexia nervosa!!!! Hernia hyatalis in time
- problems that block the transit = tumors, varices, or irritation of the nerves = meningitis as example. CONSTIPATION
Constipation or irregularity, is a condition of the digestive system where a person (or animal) experiences hard feces that
are difficult to egest; it may be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel
obstruction. Obstipation refers to severe constipation. Causes of constipation may be dietary, hormonal, anatomical, a
side effect of medications, or an illness or disorder. Treatment is with a change in dietary and exercise habits.
Signs and symptoms
Types 1 and 2 on the Bristol Stool Chart indicate constipation
Constipation is one of the most common digestive complaints. It varies greatly between different people, as each
person’s bowel movements differ. Most cases of constipation are caused by a low fiber diet or dehydration.Constipation
is most common in children and older people, and affects women more than men. One in 200 women have severe,
continuous constipation and it is most common before a period and in pregnancy.
Over 6 million people in the UK at any time find it painful or difficult to pass stools. The pain can be even worse if you
have hemorrhoids or anal fissure. In common constipation, the stool is hard and difficult to pass. Usually, there is an
infrequent urge to void. Straining to pass stool may cause hemorrhoids and anal fissures. In later stages of constipation,
the abdomen may become distended and diffusely tender and
crampy, occasionally with enhanced bowel sounds. In
addition, constipation is a most painful, disturbing, and
somewhat embarrassing experience.
The definition of constipation includes the following:
infrequent bowel movements (typically 3 times per week)
difficulty during defecation (straining during more than 25%
of bowel movements or a subjective sensation of hard stools),
or the sensation of incomplete bowel evacuation.
Medical authorities accept wide variations in toilet frequency
as long as this does not cause any other symptoms. Defecating
depends on dietary habits, exercise, fluid intake, and various
other factors.
Severe cases ("fecal impaction") may feature symptoms of
bowel obstruction (vomiting, very tender abdomen) and
"paradoxical diarrhea", where soft stool from the small
intestine bypasses the impacted matter in the colon.
Constipation in children can lead to soiling (enuresis and
From Osteopathic point of view defecation should be once or
twice a day, the form should according to the Bristol Stool
Chart be type 4, and dark colored.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

The diagnosis is essentially made from the patient's description of the symptoms. Bowel movements that are difficult to
pass, very firm, or made up of small rabbit-like pellets qualify as constipation, even if they occur every day. Other
symptoms related to constipation can include bloating, distention, abdominal pain, or a sense of incomplete emptying.
Inquiring about dietary habits may reveal a low intake of dietary fiber or inadequate amounts of fluids. Constipation as a
result of poor ambulation or immobility should be considered in the elderly. Constipation may arise as a side effect of
medications (especially antidepressants and opiates). Rarely, other symptoms suggestive of hypothyroidism may be
During physical examination, scybala (manually palpable lumps of stool) may be detected when a diagnostician presses
on the abdomen. Rectal examination gives an impression of the anal sphincter tone and whether the lower rectum
contains any feces or not; if so, then suppositories or enemas may be considered. Otherwise, oral medication may be
required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids, and
whether any tumors or abnormalities are present.
X-rays of the abdomen, generally only performed on hospitalized patients, may reveal impacted fecal matter in the
colon, and confirm or rule out other causes of similar symptoms.
Chronic constipation (symptoms present for more than 3 months at least 3 days per month) associated with abdominal
discomfort is often diagnosed as irritable bowel syndrome (IBS) when no obvious cause is found. Physicians caring for
patients with chronic constipation are advised to rule out obvious causes through normal testing.
The main causes of constipation include:
Hardening of the feces
Improper mastication of food
Insufficient intake of dietary fiber
Medication, e.g. dihydrocodeinone, diuretics and those containing iron, calcium, aluminium
Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along
Hypothyroidism (slow-acting thyroid gland)
Injured anal sphincter (patulous anus)
Medications, such as loperamide, opioids (e.g. codeine & morphine) and certain antidepressants
Severe illness due to other causes; occasionally colds or flu
Acute porphyria (a very rare inherited condition)
Lead poisoning
Dyschezia syn(usually the result of suppressing defecation)
Constriction, where part of the intestine or rectum is narrowed or blocked, not allowing feces to pass
Stenosis (Strictures)
Tumors, either of the bowel or surrounding tissues
Retained foreign body
Psychosomatic constipation, based on anxiety or unfamiliarity with surroundings.
Functional constipation
Constipation-predominant irritable bowel syndrome, characterized by a combination of constipation and abdominal
discomfort and/or pain
Smoking cessation, tobacco smoking has a laxative effect.
Abdominal surgery, other types of surgery, childbirth
In people without medical problems, the main intervention is to increase the intake of fluids (preferably water) and
dietary fiber. The latter may be achieved by consuming more vegetables and fruit and whole meal bread, and by adding
linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action
becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation.
Laxatives may be necessary in people in whom dietary intervention is not effective or is inappropriate. Stimulant
laxatives (e.g. senna) are generally avoided, as they may worsen crampy sensations commonly experienced in

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

constipation. In various conditions (such as the use of codeine or morphine), combinations of hydrating (e.g. lactulose or
glycols), bulk-forming (e.g. psyllium) and stimulant agents may be necessary. Many of the products are widely available
over-the-counter. Enemas and clysters are a remedy occasionally used for hospitalized patients in whom the constipation
has proven to be severe, dangerous in other ways, or resistant to laxatives. Sorbitol, glycerin and arachis oil
suppositories can be used. Severe cases may require phosphate solutions introduced as enemas.
Constipation that resists all the above measures requires physical intervention. Manual disimpaction (the physical
removal of impacted stool) is done by patients who have lost control of their bowels secondary to spinal injuries.
Manual disimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction
can occasionally be done under sedation or a general anesthetic—this avoids pain and loosens the anal sphincter.
In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet and herbs are used to treat constipation.
Constipation is usually easier to prevent than to treat. The relief of constipation with osmotic agents, i.e. lactulose,
polyethylene glycol (PEG), or magnesium salts, should immediately be followed with prevention using increased fiber
(fruits and vegetables) and a nightly decreasing dose of osmotic laxative. With continuing narcotic use, for instance,
nightly doses of osmotic agents can be given indefinitely (without harm) to cause a daily bowel movement.
Recent controlled studies have questioned the role of physical exercise in the prevention and management of chronic
constipation, while exercise is often recommended by published materials on the subject.

Too slow or lack of TGI motility has constipation as effect with its consequences in
Often nutritional problem, lymphatic behavior and mental emotional conditions.
Often a shortage in neutral fluids in the TGI (not enough still water)
- mega-rectum or mega-sigmoid
- mega-colon
- hemorrhoids
long term:
- Carcinoma of the gut: 85 % are sigmoidal or rectal !!!! SPASM
A spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden
contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after
a few minutes. Spasmodic muscle contraction may also be due to a large number of medical conditions, however,
including the dystonias.
By extension, a spasm is also a sudden and temporary burst of energy, activity, or emotion.
A subtype of spasms is colic, an episodic pain due to spasms of smooth muscle in a particular organ (e.g. the bile duct).
A characteristic of colic is the sensation of having to move about, and the pain may induce nausea or vomiting if severe.
Series of spasms or permanent spasms are called a spasmism.
Localized exaggerated motility (mix and segmentation) gives spasm or colic and pain eventually stool like a rabbit
(nuts) Bristol stool chart type 1 STEATORRHEA
Steatorrhoea is the formation of bulky, grey or pale faeces. Stools may also float (due to excess gas from carbohydrate
malabsorption), have an oily appearance or be foul smelling. There is increased fat excretion, which can be measured by
determining the faecal fat level. While definitions have not been standardised, fat excretion in faeces in excess of 0.3
(g/kg)/day is considered indicative of steatorrhoea. Possible causes can be lack of bile acids (due to liver damage or
hypolipidemic drugs), defects in pancreatic juices (enzymes) and defective mucosal cells.
Seen in:
malabsorption, e.g. in inflammatory bowel disease, coeliac disease, and abetalipoproteinaemia
exocrine pancreatic insufficiency
chronic pancreatitis
choledocholithiasis (obstruction of the bile duct by a gallstone)
pancreatic cancer (if it obstructs biliary outflow)
primary sclerosing cholangitis

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

bacterial overgrowth
short bowel syndrome (after surgery)
cystic fibrosis
Zollinger-Ellison syndrome (pancreas neo that provokes GERD)
Giardia infections




- Objectivity in and through all systems, layers and dimensions
- Totality of the contextual situation of the organism and its environment
- Transparency with parietal, cranial and other osteopathic diagnosis
- Priorities classical medical and after that osteopathic
- Diagnostic:
- Visual
- Palpatory general (systems and regions)
- Palpatory specific
Honesty and self criticism!

This phase encloses a series of organs, senses & systems and behavioral characteristics among which trends,
consciousness, and willingness to be part of the group... etc all play their role; all these in interaction will mark which
nutrition you choose and how you like to feed with it. The marketing and publicity plays in on these mechanisms to sell
their products. Martini as drink has nothing to do with beautiful exotic women, or Bounty has nothing to do with
Brazilian beauties on a white beach with palm trees: none of these is included in the package, but the image works in on
the limbic system and makes it sell.
One is what he eats, the basis is biochemistry!!! Ask your patient about it, it will tell you a lot about him or her: what he
needs, how conscious he is, what kind of dysbalance may be induced, and most important do we have to intervene on the
cephalic phase or not?. Often the key lies there and not in the twisting malaxation of the abdomen and its contents. PSYCHIC PHASE (LIMBIC)
Before even touching food, our CNS (limbic system) gets stimulated in positive or negative sense by the information
delivered through the cranial nerves. After that consciousness and knowledge may play their final role in the decision
making. The cranial nerve information is gathered in the limbic system, where it will be colored by scanning and
information comparison, through the circuit of Papez 6with our memory and all it involves. By positive coloration or by

Described by James Papez in 1937, the Papez circuit of the brain is one of the major pathways of the limbic system and is chiefly
involved in the cortical control of emotion. The Papez circuit plays a role in storing memory. Papez discovered the circuit after
injecting rabies virus into a cat's hippocampus and monitoring its progression through the brain. The initial pathway was described as
Hippocampus → fornix → mammillary bodies
Mammillary bodies → mammillothalamic tract → anterior thalamic nucleus
Anterior thalamic nucleus → genu of the internal capsule → cingulate gyrus
Cingulate gyrus → cingulum → parahippocampal gyrus
Parahippocampal gyrus → entorhinal cortex → perforant pathway → hippocampus
Since then, new findings in neuroanatomy and brain function have elucidated a larger circuit that also includes the prefrontal cortex
(PFC), amygdala, and septum among other areas. The PFC and amygdala are key components in this larger loop.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

hunger, it will make us decide positively (what we think of as conscious choice) and inform the ENS that will start up
the digestive machinery and prepare it for the coming food. (These reactions are conditioned and as such very
individual: depending on personal motivation and experience see Pavlov’s experiments)
Pavlov contributed to many areas of physiology, neurology and psychology. Most of his work involved research in
temperament, conditioning and involuntary reflex actions.
Pavlov performed and directed experiments on digestion which earned him the 1904 Nobel Prize in Physiology and
Medicine Experiments included surgically extracting portions of the digestive system from animals, severing nerve
bundles to determine the effects, and implanting fistulas between digestive organs and an external pouch to examine the
organ's contents. This research served as a base for broad research on the digestive system.
Further work on reflex actions involved involuntary reactions to stress and pain. Pavlov extended the definitions of the
four temperament types under study at the time: phlegmatic, choleric, sanguine, and melancholic. Pavlov and his
researchers observed and began the study of transmarginal inhibition (TMI), the body's natural response of shutting
down when exposed to overwhelming stress or pain. This research showed how all temperament types responded to the
stimuli the same way, but different temperaments move through the responses at different times. He commented "that the
most basic inherited difference was how soon they reached this shutdown point and that the quick-to-shut-down have a
fundamentally different type of nervous system."

The second step, which is synergetic with the described system, is the manipulation of the food and put it in the mouth,
from this point on even more cranial nerves play along in the process.
- First step =
- Nervus Opticus & how the food looks
- Nervus Olfactorius & how it smells
- Limbic system and Papez & earlier experience with this food in all its aspects
- Second step =
- Nervus Olfactorius & taste which is for99% smell in the oral cavity.
- Nervus Trigeminus & taste and feeling (consistence) of the nutrition
- Nervus Glossopharyngeus & taste and feeling (consistence) of the nutrition
This complete package of information is continuously brought in feedback with the cephalic phase before swallowing.
To demonstrate the importance: Imagine a crispy toast and when you bite in it it feels like slime, repulsive? Yes you
would probably spit it out directly thanks to these systems and their continuous feedback. Or imagine a little stone in
your food you would probably not swallow it because the system warns you.
All of these packages of information lead also to the active secretion of the salivation glands:
Ortho  stimulation of the producing cells
Para  vascular dynamization through the release of bradykinin7. (Strong vasodilatation in the glands) FUNCTIONAL ANATOMY OF THE SALIVATION GLANDS
There are three pair’s salivation glands, in chronologic order of size: the parotids, the sublingual and the submandibular
glands. All have a typical tubulo-alveolar epithelial gland structure. In other words they consist of groups of mucous and
or serous epithelial cells, which all end in one big secretory duct. The parotid is a pure serous gland; it is mainly under
neurological control of the IX (parasympatic) via the GG. Oticum; and orthosympatic via the GG. Cervicalis superior.
The serous fluid has mainly the function of:
- liquefy the bolus (solve it)
- make the bolus smooth and slippery
- liberate the food remnants between the teeth
- clean the teeth and gums to evince carries
- keep the epithelium membranes of the mouth and throat wet.

Bradykinin is a potent endothelium-dependent vasodilator, causes contraction of non-vascular smooth muscle, increases
vascular permeability and also is involved in the mechanism of pain. In some aspects, it has similar actions to that of
histamine, and like histamine is released from venules rather than arterioles.

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

In the tubules of the glands Na+ ions are recuperated and HCO3- (carbonate) secreted to make the environment Alkalic
(for the enzyme activity and suppress the acid bacteria that provoke carries).
The sublingual is mainly mucoid and controlled by the VII, para  via the GG. Submandibulare, and ortho  via the GG.
Cervicalis superior.
The mucus consists of glycoproteins, mucins8 and the enzyme  amylase or ptyalin.
The mucus has mainly the function of:
- make the bolus stick together and slippery
- keep the wet covering on the epithelial membranes. (Typical smell of kindergarten)
- the enzyme starts the digestion of the D-polysacharids in D-disacharids.
The submandibular gland is a mixed gland, neurologically identical to the sublingual gland.
The most important role of the mouth for the digestion is the macroscopic destruction and malaxation of the food in
order to make the nutrients accessible to enzymatic activity and start it up for the sugars with ptyalin.
Instruments :
Teeth for cutting and grinding the macro-structure and malaxation with the saliva
Tongue for malaxation, taste, move around in the mouth while testing on “strange particles” and prepare the
bolus to swallow.
The functional importance of these actions is primordial for the efficiency and speed of the further digestion.
The more the food is reduced in small particles, the faster the chemical and enzymatic actions can access the molecular
structure of the food. The better the grinding and malaxation the better the chemical next step is prepared. As you have
already understood the digestion is a progressive biochemical process wherein each step prepares or facilitates the next
one. If one step is not being done right, all the rest in line will have to try to compensate it but this will at least slow
down the process often it cannot really be compensated and than it becomes a surcharge for the next organ or step in the
process. Thus the chronology is also hierarchic, if your patient has problems with his stool (not type 4 of the Bristol
Stool Chart) you must start the check in the begin of the process:
 The food constitution
 The food preparation
 The cephalic process (cranial nerves, psychology etc)
 The mouth process (flora, teeth, glands, time taken etc)
 The esophagus
 The stomach and so on…
 This is why we will continue from now on in the anatomical chronology of the bolus, and of your check
pathway if there are problems. These first steps are crucial for the rest of the process and very often
overlooked by Osteopaths who tend to dive immediately into the abdominal investigations!
Please do not forget that the epithelium of the mouth, gums, tongue and throat is covered by mucus that is rich in Ig a
and thus together with the MALT system under the form of the RING OF WALDEYER our first protection barrier
against bacterial hyper contamination, and information source of the immune system.
Waldeyer's tonsillar ring is an anatomical term describing the lymphoid tissue ring located in the nasopharynx.


Mucins are a family of large, heavily glycosylated proteins. Although some mucins are membrane-bound due to the
presence of a hydrophobic membrane-spanning domain that favors retention in the plasma membrane, the concentration
here is on those mucins that are secreted on mucosal surfaces and saliva.

Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

It was named after the nineteenth century German
anatomist Heinrich Wilhelm Gottfried von WaldeyerHartz.
The ring consists of:
Adenoids (also termed pharyngeal tonsils)
Tubal tonsils
Palatine tonsils (more commonly termed "the tonsils")
Lingual tonsils
The mucosa-associated lymphoid tissue (MALT)
(also called mucosa-associated lymphatic tissue) is
the diffuse system of small concentrations of
lymphoid tissue found in various sites of the body
such as the gastrointestinal tract, thyroid, breast, lung,
salivary glands, eye, and skin.
Populated by T cells, which are well-situated to
encounter antigens that enter through the intestinal
mucous epithelium. Contain B cells, plasma cells,
activated TH cells and macrophages in loose clusters.
The components of MALT are sometimes subdivided
into the following:
 GALT (gut-associated lymphoid tissue.
Peyer's patches are a component of GALT
found in the lining of the small intestines.)
 BALT (bronchus-associated lymphoid tissue)
 NALT (nose-associated lymphoid tissue)
 LALT (larynx-associated lymphoid tissue)
 SALT (skin-associated lymphoid tissue)
 VALT (vascular-associated lymphoid tissue. A newly recognized entity that exists inside arteries; its role in the
immune response is unknown. )
 CALT (conjunctiva-associated lymphoid tissue in the human eye)
Swallowing activity is complex and functions with high precision neurological reflex coordination, because the first
part is common to the respiratory pathway and failure in the coordination can be lethal.
Swallowing, known scientifically as deglutition, is the reflex in the human body that makes something pass from the
mouth, to the pharynx, into the esophagus, with the shutting of the epiglottis. If this fails and the object goes through the
trachea, then choking or pulmonary aspiration can occur.
Coordination and control
The mechanism for swallowing is co-ordinated by the swallowing centre in the medulla oblongata and pons. The reflex
is initiated by touch receptors in the pharynx as a bolus of food is pushed to the back of the mouth by the tongue.
Swallowing is a complex mechanism using both skeletal muscle (tongue) and smooth muscles of the pharynx and
esophagus. The autonomic nervous system (ANS) coordinates this process in the
pharyngeal and esophgeal phases.
Normal swallowing consists of four phases: oral preparatory, oral, pharyngeal, and
esophageal (not all sources consider oral preparatory a distinct phase).
Oral preparatory phase
In this phase, the food is processed by mastication, combined with the movement of the
tongue form a bolus to an appropriate size to pass through the pharynx and esophagus.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Oral (or "buccal") phase
When the bolus is ready to enter the oral stage, it is first moved to the back of the tongue. Next, the anterior tongue lifts
to the hard palate and retracts in a posterior direction to force the bolus to the oropharynx. Then, the posterior tongue is
lifted by the mylohyoid muscles, which also elevates the soft palate and seals the nasopharynx to prevent nasal
aspiration. This phase is voluntary and involves important cranial nerves: V (trigeminal), VII (facial), and XII
Pharyngeal phase
In this phase, the bolus is advanced from the pharynx to the esophagus through peristalsis. The soft palate is elevated to
the posterior nasopharyngeal wall, through the action of the levator veli palatini. The palatopharyngeal folds on each
side of the pharynx are brought close together through the superior constrictor muscles, so that
only a small bolus can pass. Then the larynx and hyoid are elevated and pulled forward to the
epiglottis to relax the cricopharyngeus muscle. This passively shuts off its entrance and the vocal
cords are pulled close together, narrowing the passageway between them. This phase is passively
controlled reflexively and involves cranial nerves V, X (vagus), XI (accessory), and XII.
The respiratory centre of the medulla is directly inhibited by the swallowing centre for the very
brief time that it takes to swallow. This is known as deglutition apnoea.
Esophageal phase
The upper oesophageal sphincter relaxes to let food past, after which various striated constrictor
muscles of the pharynx as well as peristalsis and relaxation of the lower esophageal sphincter
sequentially push the bolus of food through the esophagus into the stomach.
In terminally ill patients, a failure of the reflex to swallow leads to a buildup of mucous or saliva
in the throat and airways, producing a noise known as a death rattle, or agonal respiration.
The same with babies, certainly under the age of two (myelinisation not finished) were next
too choking the danger exists that when gastric reflux occurs, the acid stomach content can enter
the lungs and burn the airways or lungs.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Addendum neuro-hormonal CONTROL

Motivation and introduction
The real importance of chronology and chronicity are understood by most students when they study for the final
examination, and some do not even get it there; although in my opinion at least, it is of elemental importance
within the Osteopathic concept.
In this addendum I will try to correct this a little, focus on it, think it over and learn from the missteps of your
predecessors. Evolution is also standing on the shoulders of your ancestors (predecessors) and see further than
they did when they were in your position.
During the lessons about concept and philosophy, the first days of the first seminar, we talked to you about this; later
each teacher in his or her lectures came back to it and used this terminology:

chronology and


Chronology and hierarchy
These two terms get the same meaning when they are applied into biology or the knowledge of living organisms and
their mechanisms.
Osteopathy is no more than a PHILOSOPHY, which can be applied in the science of biology and all of its
subdivisions, or in your daily life. Osteopathy is not techniques or treatments of patients, it can be applied for these
purposes but it is fundamentally a philosophy of life’s complexity.
In the Osteopathic education we are pedagogically and didactically obliged to subdivide and split the whole into pieces
that are called branches or fields. Although these fields overlap each other in so many domains that you should see them
as inseparable, if you did not until now, than it is time to start to see instead of just looking. I know it is a difficult task
for the students to glue this splintering back into a whole what LIFE and biology is in the reality of the organism. But if
your goal is to become Osteopaths and not just be another therapist that does some osteopathy, this heavy task is
exactly what you are up to.
Welcome in the world of growing up minds in the philosophy of Osteopathy.
The term chronology returns in every field, although it often gets another name behind which it seems to be hidden:
-in Biomechanics and dysfunction mechanisms: Chronology will be hidden in terms as: primary – secondary
dysfunction, compensation and compensation loss or decompensation.
-in Neuro-anatomy: chronology will be divided and hidden behind terms as: hierarchy, prosencephalon, mesencephalon,
rhombencephalon, or arche, paleo and neo (which are time bound)
-in Embryology: chronology will be divided in time periods and hidden behind terms as: time frames or phases, per day,
per week or per month, per layer or simply embryological and fetal ...
-in Sutherlands Cranial field and PRM: Chronology will be hidden in terms as: the five elements of the PRM and this
chronology is as important as all the others do not invert parts of it as some do (Busquet, Upledger etc): fluctuation of
the liquor cerebrospinalis (Potency of the Tide), mobility of the reciprocal tension membranes, Nervous system motility,
mobility of the cranial bones and involuntary mobility of the sacrum between the ilia.
-in Biology: Chronology will be stated in terms of Hierarchy: or Phylogeny or complexity: prokaryotes, eukaryotes,
multicellulars, bilayered organisms, trilayered organisms, yolk sac species, amnion cavity species and placental species.
Comparisons between ontogenesis and phylogenesis are plenty in this field and they are all about chronology.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

We could expand this list into infinity, but I think that it becomes clear to you that chronology and intrinsic hierarchy are
the red threads that return throughout your whole Osteopathy course in all fields.
To examine a patient, understand the way his system functions or tries at least, and thus KNOW how you can
eventually be of assistance to this bunch of cells with a common goal in distress, the understanding of chronology and
chronicity turn out to be of primordial importance.
The hierarchy of, how his health maintenance tries to go on, with all what is functioning on half proficiency or even less,
is already a nightmare for most students; but than how to help the system instead of making things worse, that is really
There is no easy standard procedure as in allopathic medicine is probably what you think as an Osteopathy student. And
at this point from your point of view you are right it may seem so but there is one...
Follow the hierarchic line of chronology or complexity that Nature furnished us; it lays before your nose, use
Complexity of Life self organized in steps or levels, like the peels of an onion; each new layer supporting his
form (structure-function in one) on the older deeper ones. The health maintenance mechanism developed or
evolved accordingly with the growing complexity of the organisms.
If the health maintenance mechanism gets into troubles to maintain her integrity, go and start from the core,
the oldest deepest part of the onion and check your way upwards, that is namely the chronology and
hierarchy. Remember what the old Doctor said to his students:
Health has no pattern,
if you have a pattern you have a problem.
and about problems he used to say:
Find it, Fix it and forget it the body will do the rest…


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

What may help you on the way of Finding it is the understanding and knowing of chronology and chronicity, because
that will lead you in the testing of specific relation tests between systems.
The Fixing it is simple if the potency of the patient still has enough of it.
The worst part is the Forget it when you see what the mechanism can and does when you can help it by giving it the
opportunity to express itself fully.

Chronicity is the second, very important part that is: the refined reproduction of how old is / are the problem(s) that
hindered the health maintenance?
The understanding and knowing of “How long” is in itself a huge feedback for the hierarchy and chronology of the
Chronicity is a phenomenon that will demonstrate itself in the type of tissue reactions. Epithelial, connective,
vascularization and innervation...
To recognize chronicity you have to know healthy Form and for this you need observation and know: (knowing not in
the sense of gathering information but in the sense of knowing)
 structure: anatomy, micro anatomy, histology and embryology
 function: P.R.M., physiology and haemodynamics
 Understand what complexity involves
Every time you sense something new in a patient ask them for how long… hear what he says and memorize: that is how
feels… start your own compendium of feeling no one can do it but yourself.


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

For the histology and micro-anatomy of the esophagus, look earlier in this course!
When we restrict ourselves to the organ and digestive physiology most of what has to be said is already said: the
esophagus is the link between throat and stomach where from digestion point of view few things happen because the
transit is rapid a few seconds. But from holistic and thus Osteopathic point of view the esophagus is a very important
organ that is often put aside in the visceral courses, it is important not by itself but by its relations with its
The esophagus is so often overlooked because of its rapid transit function in physiology and as it seems quite
inaccessible for spectacular visceral manipulations. Apparently the esophagus is not a success formula for visceral
courses. Sometimes it is mentioned in a quickie for its lesions with GERD (Gastro Esophageal Reflux Disease), or
for its tumor degeneration after years of GERD, sometimes even for its embryological defects like esophageal
diverticle ...
Physiologically it generates with itsMigrating Myoelectrical Motor Complex the transit from the bolus from throat
to stomach...BUT
Its topography and trajectory touches some of the most vital functions of our organism, and influences them, a short
- cervical
Vertebral column., X, heart innervation, vascularization of the head and brain, innervation of the thyroid,
vascularization of the thyroid, innervation of the larynx, glandulae parathyroideae, trachea, musculus longus
colli, and of course all the neck fascias. (cervically our esophagus starts from ± C5-C6).
- mediastinal
aorta & aortic arch, heart, lungs, pericardium, orthosympatic plexi, azygos & hemiazygos system, ductus
thorachicus lymfaticus, X etc…
Getting interested by the esophagus?


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

FASCIAL RELATIONS ON THE LEVEL OF C6 (After Bouchet et Cuilleret, SIMEP, 1983)

ANATOMIC RELATIONS ON THE LEVEL OF C7 (After Bouchet et Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015



Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

SPIRAL OF THE ESOPHAGUS (After Bouchet et Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015



Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015


RELATIONS ON THE LEVEL OF TH 3 (After Bouchet et Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

LEFT VIEW OF THE MEDIASTINUM (After Bouchet et Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

RIGHT VIEW OF THE MEDIASTINUM (After Bouchet et Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

REAR VIEW OF THE ESOPHAGUS & RELATIONS (After Bouchet et Cuilleret, SIMEP, 1983)


Physiology: Introduction
M.Girardin D.O., Evost Fellow, Pro-sector
1995, reeditions 2007, 2014, 2015

- The connective tissue is the only medium between circulation and epithelial cells, glands, and membranes.
- It is in the connective tissue that all lymphatics and blood vessels arise, as their function
- The fascial system is the distribution and storage system of mechanical strains and chemical compounds of the body.
- The connective tissue is the only one that protects itself and its environment by an inflammatory reaction followed by a
fibrosis and retraction.
- Exaggerated mechanical strain or biochemical stress will lower the inflammation trigger level, think chronicity!
- Connective tissue can compensate enormously by changing its form: the type, proportion and amount of fibers,
viscosity of the matrix and inversely permeability, and if that is not enough to cope with the strains: it can differentiate
its undifferentiated mesenchymal cells into adipocytes, chondroblasts or even osteoblasts if necessary.
- Alternated “normal stress” is necessary for the quality and quantity of the form of connective tissue.
- Epithelium and its physiologic proficiency are directly dependant on the form and behavior of the connective tissue.
- Neural and vascular-lymphatic structures are intimately and closely embedded within the connective tissue.
- Muscle and neural tissue are evolutionary specialized and derived forms of epithelial tissue and its particular
- Embryologically and functionally the venous system is the eldest, think chronology!!!
- The development of the different communication systems runs parallel with the genesis & development of the
connective tissue.
Philosophize with these facts when looking at the esophagus drawings and the relations of the esophagus with the
connective, neural and vascular system, see and know… make a step further towards Osteopathy, become a philosopher!


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