Handbook of Clinical Neurology, Vol.

117 (3rd series)

Autonomic Nervous System
R.M. Buijs and D.F. Swaab, Editors
© 2013 Elsevier B.V. All rights reserved

Chapter 1

The autonomic nervous system: a balancing act

RUUD M. BUIJS*
Department of Cell Biology and Physiology, Institute for Biomedical Research, Universidad Nacional Autnoma de Mxico,
Mexico City, Mexico

INTRODUCTION AND OVERVIEW OF
THE AUTONOMIC NERVOUS SYSTEM
The purpose of the present chapter is to give a brief over-
view of the autonomic nervous system (ANS) and to pay
special attention to those parts subject to controversy or
uncertainties. For well-established areas of knowledge
the reader is referred to the chapter by Goldstein
(Chapter 2) and to reviews such as that of Janig and
Habler (2000).
Since the discovery of Otto Loewi (Loewi, 1921) that
stimulation of the vagus branch slowed down the heart-
beat by means of the release of a “vagusstoff” (vagus
substance), and Henry Dale’s discovery (1934) that the
active substance in this process is acetylcholine, we
accept that the parasympathetic branch of the ANS,
which originates from the dorsal motor nucleus of the
vagus (DMV) or from the nucleus ambiguus, uses ace-
tylcholine (ACh) as a transmitter. Consequently, the
transmitter of the parasympathetic nervous system is
thought to be ACh. However, in several targets of these
parasympathetic nuclei of the ANS the final neurotrans-
mitter has not been established. This could be due to the
fact that for some organs, such as the liver, no
ganglion has been described that provides it with para-
sympathetic input; this has even led to the suggestion
that parasympathetic innervation to the liver is absent.
Several models of the autonomic nervous system
therefore do not even indicate the innervation of the liver
by the vagus, in spite of clear macroscopic evidence.
Similar doubts are present for the parasympathetic
innervation of the spleen, adipose tissue, and lymphoid
tissue. Other aspects that demand attention are the
structures in the central nervous system (CNS) that have
the capacity to control or influence the output of the ANS,
and thus provide input to the sympathetic and parasympa-
thetic autonomic motor nuclei. Transneuronal tracing in
the last 20 years has revealed the main brain centers in
terms of the capacity to influence its autonomic
outflow (Card et al., 1990; Nadelhaft et al., 1992; Buijs
et al., 1999, 2003a).
Another important point is that the ANS should not
only be seen as a system merely carrying out the com-
mands of the brain; it also functions as a reflex circuit,
using the sensory feedback of the organs, to change
and precisely adapt the output of the ANS in order to
adjust the physiological state of the body. Clearly these
reflexes are also immediately modulated by input from
higher neural centers located in many different areas in
the brainstem, hypothalamus, and even prefrontal cortex,
which contain preautonomic neurons, i.e., neurons that
provide input to autonomic motor neurons. This is also
evident when analyzing structures that provide input to
the nucleus of the tractus solitarius (NTS), one of the main
centers where sensory information from the body is inte-
grated (Fig. 1.1) (Ruggiero et al., 1996). This sensory input
leads to an immediate change in autonomic output that is
immediately modulated by the input the NTS receives
from many structures higher in the CNS, from the brain-
stem and hypothalamus up to the prefrontal cortex, but
also from ascending sensory information from the spinal
cord (Luiten et al., 1985; al Maskati and Zbrozyna, 1989;
Powell et al., 1994; Van Eden and Buijs, 2000; Craig,
2003). Here, the general consensus is that descending
CNS information is able to influence the reflex arc that
exists between the NTS, and the dorsal motor nucleus
of the vagus (DMV). Interestingly, since the NTS also pro-
vides this sensory information to many areas in the hind
and forebrain, the descending input the NTS receives
may, to a large extent, determine how that information
is transmitted, i.e., the brain is modulating its own input.
How spinal sensory systems may contribute to visceral
information passing to higher centers in the brain is
still largely uncharted territory (Craig, 2003), but the

*Correspondence to: Ruud M. Buijs, Department of Cell Biology and Physiology, Institute for Biomedical Research, Universidad
Nacional Autónoma de México, Av. Universidad 3000, Mexico City, DF, 04510, Mexico. E-mail: ruudbuijs@gmail.com
2 R.M. BUIJS
Fig. 1.1. Illustrates the sympathetic and parasympathetic
reflex. The relationship between the cell groups that may influ-
ence the vagal output is indicated in green and the influence to
the sympathetic output in pink. Both vagal and sympathetic
outputs are influenced by each other. AP, area postrema;
NTS, nucleus tractus solitarius; DMV, dorsal motor nucleus
of the vagus; IML, intermediolateral column. (Modified from
Buijs et al., 2001.)
conclusion that they do seems logical in view of the reflex
circuitry. In the spinal cord, a similar reflex circuit is in
place between the sensory neurons in the dorsal horn
and the sympathetic motor neurons in the intermediolat-
eral column (IML). Also, this circuit can be modulated by
descending information. Finally, in addition to input from
these sensory areas, the DMV and IML, two major output
stations of the ANS, also receive direct input from higher
centers. Interestingly, this gives the higher centers of the
brain a powerful control, not only over the modulation of
the sensory reflex but also directly, over the outgoing
information from the ANS.
THE SYMPATHETIC NERVOUS SYSTEM
In principle, the central control of the outflow of sympa-
thetic nervous information is tactically organized as a long
chain of motor neurons in the intermediolateral column
of the spinal cord (IML). Tactically, because due to this
segmental organization, the ACh-producing motor neu-
rons reach different and multiple ganglions along the
spinal cord. Neurons in these ganglions have the capacity
to produce different neurotransmitters, of which
noradrenaline/norepinephrine (NA) is the main one, often
together with cotransmitters such as neuropeptide Y
(NPY) (Lundberg et al., 1983). Interestingly, the target
structures of the ANS, although as diverse as the brain
and the kidney, are very often the smooth muscles around
the blood vessels within these organs. This allows the ANS,
by vasoconstriction and vasodilatation, to control the
blood supply, for example, not only to the kidney and
the lungs but also to itself (Zhu et al., 1997).
Differentiation of function
The segmental organization of the sympathetic nervous
system allows topographical signal distribution, albeit
in a very general sense: i.e., the superior cervical ganglion
not only serves to provide the head with sympathetic inner-
vation, it also supplies part of the sympathetic innervation
to the heart. Consequently, even with a segmental distribu-
tion, one cannot conclude that one segment or one gan-
glion provides only one outgoing signal. For example, a
strong sympathetic signal only goes out to the pineal dur-
ing the hours of darkness, when NA releases melatonin
(Klein et al., 1971). At the same time, the heart, receiving
input from the same ganglion, should (at least in humans)
receive a sympathetic signal of lower strength. The sympa-
thetic signal to the heart increases again early in the morn-
ing, when the autonomic signals need to support the
activity of the individual (Massin et al., 2000). If
this autonomic balance is disturbed, as evidenced by a
higher sympathetic tone to the heart, hypertension or dia-
betes may ensue (Nielsen et al., 1999; Nakano et al., 2001).
Interestingly, in coronary heart disease with enhanced
sympathetic signaling to the heart (Lee et al., 2005) the mel-
atonin secretion is lower (Brugger et al., 1995), indicating
lower sympathetic output to the pineal and supporting the
idea of a diversity of sympathetic functions.
Normally, both liver and adrenal receive a higher
sympathetic signal at the beginning of the activity
period, resulting in enhanced glucose production and
(nor)adrenaline and cortisol secretion, respectively, just
before the activity period (Buijs et al., 2003b, 2006). This
differentiation of sympathetic output to liver and
adrenal on the one hand and the pineal on the other is
coordinated by the suprachiasmatic nucleus (SCN),
the biological clock (see Chapter 15 Buijs et al.), and
illustrates the capacity of higher centers in the brain to
differentiate their output (Fig. 1.2A). Finally, differenti-
ation of function within the sympathetic system is prob-
ably best illustrated by the example of sympathetic
output that is essential for heat production, i.e., the
sympathetic output to brown adipose tissue, compared
with the sympathetic output that is essential for heat loss,
i.e., the output to the sweat glands (Schotzinger and
Landis, 1988). The sympathetic projections to brown
adipose tissue will become active just before activity
onset early in the morning in order to generate heat by
burning fat (Ootsuka et al., 2009; Blessing et al.,
2013). This contrasts with the sympathetic tone to the
sweat glands, which is at its highest when the core
temperature is at its lowest, resulting in lower thresholds
for sweating during exercise in the early part of the night
(Waterhouse et al., 2007). This complexity is further
illustrated by studies showing that women susceptible
to hot flashes experience a peak in these unwelcome
events around 3 o’clock in the afternoon, in both hot
and temperate environments, also indicating a different
reaction of the sympathetic system under basal condi-
tions (Freedman et al., 1995; Sievert et al., 2010).
 THE AUTONOMIC NERVOUS SYSTEM: A BALANCING ACT 3

Fig. 1.2. (A) and (B) Sagittal schemes of the sites in the rat brain with autonomic neurons that are able to influence organs in the
abdominal cavity with the liver as example. The direct projections to the liver are indicated in red, the second-order in blue, and
third-order in yellow. Comparing the parasympathetic pattern to the sympathetic pattern illustrates that far more second-order cell
groups are in control of the dorsal motor nucleus of the vagus than in control of the sympathetic motor neurons. A5/RVLM, ros-
troventrolateral medulla; Ace, amygdala central part; ARC, arcuate nucleus; BNST, bed nucleus of the stria terminalis; DMH,
dorsomedial nucleus of the hypothalamus; DMV, dorsal motor nucleus of the vagus; IML, intermediolateral column; INS, insular
cortex; LC, locus coeruleus; LH, lateral hypothalamus; MPO, medial preoptic area; NTS, nucleus tractus solitarius; OVLT, orga-
num vasculosum of the lamina terminalis; PFC, prefrontal cortex; RCA, retrochiasmatic area; SCN, suprachiasmatic nucleus; SFO,
subfornical organ; VMH, ventromedial hypothalamus; PVNdv, paraventricular nucleus dorsal ventral; ZI, zona incerta. (Modified
from Buijs et al., 2001.)

Consequently, on the basis of these differences in
activity and control, we cannot generalize and speak
about the sympathetic nervous system; rather, we need
to be specific and indicate which branches of the sympa-
thetic nervous system we are examining.
Central control of different branches
of the sympathetic and parasympathetic
nervous system
After having concluded that a high differentiation
with dissimilar activities exists between the various
parts of the sympathetic nervous system, we need to
consider that the activity of these diverse branches
needs to be controlled somehow by separate auto-
nomic motor neurons and separate systems in the
brain. Animal studies using pseudorabies virus
(PRV) as a transneuronal tracer have shed some light
on this problem (Fig. 1.2A, B). PRV has the capacity to
be taken up by nerve endings and is retrogradely
transported to the cell bodies that innervate an organ,
since the virus multiplies in the cell body and after
lysis will be taken up again by synaptic terminals that
innervate only this cell. PRV is then retrogradely
transported again until the chain of command has
been determined (Card et al., 1990). Initial studies
using these viruses to trace the central preautonomic
neurons showed that, for example, in the hypothala-
mus, the paraventricular nucleus (PVN) and the lateral
hypothalamus (LH) always show PRV labeling, irre-
spective of whether the brain was infected via the
sympathetic motor neurons or via the parasympathetic
motor neurons. This suggested that the same hypotha-
lamic neurons may provide input to the sympathetic
system as well as the parasympathetic system.
Investigating this possibility, it was observed that there
is a complete separation between neurons in all areas
of the brain that give input to the parasympathetic sys-
tem or sympathetic system – this separation extends as
far as the SCN (Fig. 1.3) (Buijs et al., 2003a). Moreover,
the same areas in the brain also show labeled neurons
irrespective of the organ into which the virus was
injected (Strack et al., 1989), showing that these hypotha-
lamic nuclei are involved not only in driving parasympa-
thetic or sympathetic functions but also in the control of
a whole variety of organs.
Different neurons in the CNS control
different organs
This involvement of the same hypothalamic areas in the
control of different organs provoked the question
whether organs are influenced by a general drive from
the hypothalamus, or whether the hypothalamus would
be able to influence these organs separately, by using dis-
similar neurons projecting exclusively to motor neurons
that are involved only in sending signals to a particular
organ. The development of genetically modified viruses
that produce different markers (Kim et al., 1999), allow-
ing the determination of the chain of command of sep-
arate organs, helped to answer this question. It will be
clear that such tracer studies require that survival time
and infection speed are equal for the different tracers
and are very carefully controlled; if one virus infects fas-
ter or has a faster route of infection this could easily lead
to populations of neurons that show the two tracers in
error. Reliable analysis of transneuronal tracing is there-
fore only possible when the different infection stages are
carefully monitored and different survival times are used;
4 R.M. BUIJS

Fig. 1.3. Scheme of interaction between the hypothalamic suprachiasmatic nucleus (SCN) and the paraventricular nucleus (PVN).
Separate sympathetic (red) or parasympathetic (blue) neurons of the SCN project to preautonomic neurons of the PVN, where a
similar sympathetic–parasympathetic separation can be observed. Preautonomic neurons of the PVN project either to the pregan-
glionic sympathetic neurons in the intermediolateral (IML) column of the spinal cord, or to the preganglionic neurons of the dorsal
motor nucleus of the vagus (DMV). The presympathetic PVN neurons have axon collaterals to preparasympathetic neurons, either
in the PVN itself, or in the nucleus tractus solitarius. (Reproduced from Buijs et al., 2003a.)

under these conditions, infections up to the third order can
be analyzed. Such studies have been done for colon and
bladder (Rouzade-Dominguez et al., 2003), for adrenal
and ovary (Toth et al., 2008), and for subcutaneous and
intra-abdominal fat (Kreier et al., 2002). The general fea-
tures of these findings are that sympathetic motor neurons
in the spinal cord projecting to these organs are completely
separated. The results for the preautonomic neurons in
brainstem and hypothalamus differ to some extent. Two
studies report the presence of hypothalamic neurons con-
taining two viruses, indicating that the neuron can interact
with two organs, while also in the same sections, neurons
are found that only project to one organ (Rouzade-
Dominguez et al., 2003; Toth et al., 2008). In contrast,
structures where only separate neurons are found, inner-
vating either subcutaneous or intra-abdominal fat, range
from the SCN to the prefrontal cortex (Kreier et al.,
2002). Consequently, the various studies showed that
the brain has the capacity to differentiate its output with
respect to its target structure in order to separate its signal,
depending on the functionality of the organ.
THE PARASYMPATHETIC
NERVOUS OUTPUT
Organization of the dorsal motor
nucleus of the vagus
The consensus is that the output of the parasympathetic
nervous system (PNS) is mainly achieved by the release
of acetylcholine (ACh) from its nerve terminals. This is
true when intermediate ganglions are involved that
transmit the message of the parasympathetic motor
nuclei. However, as we will see, for some organs such
ganglia cannot be found, and therefore the origin of
the parasympathetic innervation to the organ is unclear
or controversial. Liver, spleen, and adipose tissue are
examples of such organs. For the transmission of infor-
mation from parasympathetic ganglia, it is the case
that, unlike noradrenaline, ACh exhibits a very short
half-life of 1–2 milliseconds, due to the presence of
acetylcholinesterase, which hydrolyzes ACh at a high
rate. Close contact between cholinergic nerve terminals
and cells expressing ACh receptors is therefore
required for the cholinergic control of these cells.
The dorsal motor nucleus of the vagus (DMV) and
the nucleus ambiguus are the two nuclei in the brain-
stem from which the parasympathetic output to most
organs arises, either directly or via an intermediate
ganglion. Considering the direct input from these two
parasympathetic motor nuclei, it is important to keep
in mind that Ach is the neurotransmitter in just a part
of these neurons, in some of these colocalized with
dopamine (Jones and Beaudet, 1987; Huang et al.,
1993; Tsukamoto et al., 2005). Consequently, when
organs receive direct input from the DMV the para-
sympathetic neurotransmitter can be different from
Ach. Furthermore, there are other parasympathetic
nuclei in the brainstem and in the lower lumbar levels
of the spinal cord that provide parasympathetic inner-
vation to, respectively, areas of the head and the repro-
ductive organs (Janig and Habler, 2000).
 THE AUTONOMIC NERVOUS SYSTEM: A BALANCING ACT
In addition, neurons of the DMV have projections to
postganglionic neurons localized in the intestine (i.e., the
mesenteric plexus). The role of the mesenteric plexus is
to provide the innervation to the intestines and to regu-
late, for example, its contractions. The large intestine
differs in this respect from the rest of the gastrointesti-
nal tract: it receives a parasympathetic innervation from
two distinct sources: the DMV innervates the proximal
colon and the sacral parasympathetic nucleus provides
vagal input to the distal colon. To some extent this agrees
with the segmental somatotopic organization of the sym-
pathetic system. However, the majority of the organs in
the body cavity receive input from the DMV, and there-
fore the question needs to be asked, does the DMV have
a somatotopic organization similar to that of the sympa-
thetic nervous system (SNS) and do its neurons provide
input to certain organs only?
Differentiation of function within the
dorsal motor nucleus of the vagus
The answer to this question is revealing, showing speci-
ficity also within the DMV. A study by Hayakawa et al.
(2003) analyzed the innervation of the stomach and
showed that the neurons projecting to the cardia, antrum,
and pylorus are located throughout the entire DMV, sug-
gesting that the pylorus and the antrum are innervated
not only by the gastric branch, but also by the hepatic
branch of the vagus nerve. In addition, this study indi-
cated that there is no distinctive topographic distribution
in the DMV of gastric motor neurons that innervate dif-
ferent parts of the stomach, suggesting that there is no
topography in the DMV. However, a careful double-
labeling study of the neurons innervating different parts
of the stomach showed that there is a differentiation of
function in the DMV neurons, because distinct neurons
in the DMV contact either the cardiac or the pyloric
sphincter muscles. Additional confirmation of the target
specificity of the DMV neurons can be found in the work
of Cailotto et al., who, after injections of the retrograde
tracer CtB into the proximal and distal part of the ileum,
observed the labeling of separate motor neurons in the
DMV (Cailotto et al., 2012). Consequently, these results
illustrate a high differentiation of function of DMV neu-
rons, which seems to coincide with the distinct tasks of
the targeted tissues.
The question whether this means a complete separa-
tion of function has featured in a study by Kreier et al.,
who demonstrated that possibly not all neurons of the
PNS and SNS target different organs, but that these neu-
rons may be distinguished on the basis of their physiolog-
ical function (Kreier et al., 2005). In this study it was
observed that a large proportion of the DMV neurons
project to the liver, and that a small number of these
5
neurons also project to the pancreas or to intra-
abdominal fat, i.e., targeting the three tissues with the
same neuron. However, neurons that project to intra-
abdominal fat do not project to subcutaneous fat, sug-
gesting a divergent functionality. Not surprisingly in
view of what we have seen before, within the rest of
the brain a similar separation and specialization of neu-
rons was also observed (Kreier et al., 2005). A similar
division in function can be suspected in hypothalamic
neurons that project to DMV neurons projecting to dif-
ferent parts of the stomach and different parts of the
ileum. We would therefore like to propose a specializa-
tion of function within the PNS and SNS, a specialization
not so much in their targets but more in the functions to
be executed. If the function of the ANS is seen as “sup-
porting and executing the physiological functions neces-
sary to support the behavior driven by the brain,” then it
can be hypothesized that the organization of the PNS and
SNS should follow the physiology. Consequently, it is
proposed that the ANS, whose output is controlled by
multiple areas within the brain, directs the body in sepa-
rate compartments and different functions rather than
as a whole. The reflexes will still be specifically aimed
at tuning particular organs, but they will take into
account the functionality of the whole compartment.
Intra-abdominal fat tissue and its
relationship with disease
Considering the specialization in the projections of DMV
neurons to intra-abdominal fat or to subcutaneous fat,
and the association of intra-abdominal fat with diabetes
and hypertension, it has also been proposed that the
body, with respect to the output of the ANS, can be
divided into different compartments: one that drives
the region of the thorax and muscles and one that takes
care of the organs in the abdomen (Kreier et al., 2003).
Anatomical evidence for such compartmentalization is
given above. Since parasympathetic activity is associated
more with the uptake of glucose in the liver (Pocai et al.,
2005) and fat tissue (Kreier et al., 2002), and with the
release of insulin (Luzi et al., 1992), all neurons of the
ANS involved in executing these functions can be con-
sidered as belonging to one compartment. Normally
the output of the ANS to such a compartment is in bal-
ance; however, lifestyle-associated behavior and other
disturbances may shift this balance and result in an
enhanced parasympathetic or sympathetic tone. It is pro-
posed that in the metabolic syndrome resulting from life-
style changes and excessive food intake, this balance is
shifted to a more sympathetic drive to the heart and mus-
cle compartment and a more parasympathetic drive to
the intra-abdominal compartment. This shift in auto-
nomic balance consequently produces the accumulation
6 R.M. BUIJS

Fig. 1.4. Model of the metabolic syndrome caused by desynchronization. The disturbed output of the biological clock affects the
selective balance of the ANS in different parts of the body. In the intra-abdominal compartment, the ANS is shifted in favor of the
parasympathetic branch (blue), resulting in increased insulin secretion and growth of intra-abdominal fat tissue compared with
normal values (gray). Contrarily, in the thorax and movement compartment the sympathetic branch (red) prevails, leading to
high blood pressure and impaired glucose uptake by the muscle compared with normal values. In this model, the symptoms of
the metabolic syndrome are the result and not the cause of the disease. (Reproduced from Kreier et al., 2003.)

of intra-abdominal fat, since the uptake of fat is driven
by the parasympathetic output. Lastly, this shifted bal-
ance of the ANS may also result in diabetes type 2
(enhanced parasympathetic drive to abdominal compart-
ment) or hypertension (enhanced sympathetic drive to
thoracic compartment). (For more details and discussion
on this topic see Kreier et al., 2003; Buijs and Kreier,
2006, and Fig. 1.4.)
THE BLANK SPOTS
Interestingly, although all organs receive input from the
SNS, PNS input seems to be absent in some organs. Since
it is difficult to prove the absence of something, the
absence of PNS innervation is mainly based on inability
to detect ACh and on the inability of some tracers to be
taken up sufficiently to be detected in parasympathetic
motor nuclei. Relevant organs in this respect are the
spleen and white adipose tissue, while for organs such
as kidney and adrenal it is generally accepted that they
will not receive parasympathetic innervation, mainly
due to the lack of macroscopic evidence for such input
and the lack of retrograde tracing in the DMV. In spite of
the fact that there is no evidence for the presence of ACh
innervation of the liver (Schafer et al., 1998), tracing
studies have for many years shown the presence of input
arising from the DMV (e.g., Magni and Carobi, 1983;
Kohno et al., 1987). The presence of retrograde labeled
neurons in the DMV after tracer injection despite the
absence of ACh in the liver indicates two important
points, first that the DMV projects directly to the liver
without the mediation of a ganglion and second, that
the DMV might use neurotransmitters other than ACh
to signal to the liver, for example, dopamine, just as
has been shown for the stomach (Tsukamoto et al.,
2005). This might be true also for the other organs where
the manner of innervation by parasympathetic nerves is
more controversial.
The spleen
Tracey’s group has demonstrated the inhibition of
inflammation by stimulation of the vagus nerve, via an
action on the Ach receptor in the spleen (Borovikova
et al., 2000). The confirmation of this result of vagal
stimulation came later for intestinal inflammation (de
Jonge et al., 2005). Following this, several studies have
tried to investigate in more detail the importance of vagal
input and Ach receptors in the spleen. As early as 1929,
Henry Dale demonstrated the presence of acetylcholine
in the spleen (Dale and Dudley, 1929). However, ACh is
now suggested to be present mainly in a specific memory
 THE AUTONOMIC NERVOUS SYSTEM: A BALANCING ACT
T cell population producing ACh, as these cells express
choline acetyltransferase (Rosas-Ballina et al., 2011).
Interestingly, in spite of neuroanatomical and physiolog-
ical evidence for the presence of parasympathetic input
to the spleen, as shown by means of retrograde tracing
and the differential effect of parasympathetic denerva-
tion or sympathetic denervation on the adaptive immune
response (Buijs et al., 2008), it has been suggested that the
vagal control of the spleen relies on vagal innervation of
splenic postganglionic sympathetic neurons (Rosas-
Ballina et al., 2008). This last suggestion was recently
challenged by a study showing the absence of neuronal
contacts between vagus nerve fibers and ganglion neu-
rons projecting to the spleen (Bratton et al., 2012). Future
studies will be necessary to determine how the vagus may
influence the functioning of the spleen and which neuro-
transmitters may be used for this. With respect to the
vagal inflammatory pathway, all these studies taken
together suggest that, at least, the brain plays an impor-
tant role in modifying the immune response by changing
the autonomic outflow of the vagus. This was confirmed
in a study by de Jonge et al. (2005), who used vagal stim-
ulation and observed an amelioration of surgery-induced
inflammation and postoperative ileus. The question
whether the vagus may indeed serve as a reflex arc
was recently answered by Cailotto et al. (2012), who dem-
onstrated that, after manipulation of the rat intestine,
which normally leads to postoperative ileus, a vagovagal
reflex was indeed initiated, with a selective activation of
neurons in the NTS and DMV whereby nearly 50% of the
activated DMV neurons project to the zone of inflamma-
tion. Since the majority of the descending projections of
the hypothalamus terminate in the NTS (Fig. 1.3), this con-
struction allows the brain an excellent opportunity to
modify this vagal reflex.
Adipose tissue
Based mainly on the absence of the presence of acetylcho-
line (ACh) (Bryant et al., 1983), adipose tissue was also
assumed not to receive parasympathetic input, until its
presence was detected in brown adipose tissue (BAT)
around the heart (Schafer et al., 1998), in the form of the
vesicular acetylcholine transporter. White adipose tissue
(WAT) also fails to show the presence of ACh or its trans-
porter. Even so, just as in the spleen, injections of PRV
revealed the presence of retrogradely labeled neurons in
the dorsal motor nucleus of the vagus. Interestingly, just
as with the spleen, injections of the retrograde monosynap-
tic retrograde tracers CtB or fluorogold revealed retro-
gradely labeled neurons in the DMV, and the proof of
the specificity of this tracing was that it was undetectable
after parasympathetic denervation of the organ (Kreier
et al., 2002; Buijs et al., 2008; Cailotto et al., 2012). Not
7
surprisingly, these findings met with severe criticism from
those claiming that such DMV labeling is caused by leak-
age of the tracers into the peritoneal cavity, thus causing
nonspecific uptake and labeling of the DMV (Berthoud
et al., 2006). However, these arguments do not explain
the difference between DMV neurons specifically project-
ing only to intra-abdominal fat tissue next to neurons only
projecting to subcutaneous tissue, and the disappearance
of this labeling after vagal denervation (Kreier and
Buijs, 2007). In addition, earlier studies have shown evi-
dence of the labeling of DMV neurons after PRV injection
into BAT tissue not receiving Ach innervation (Bamshad
et al., 1999 – see Figures 2 and 3 in that paper). Recently,
in fact, support for a vagal influence for the growth of
intra-abdominal fat tissue was provided by a surgical inter-
vention in humans. Since bodyweight loss is a common
problem in patients after gastrectomy, it was hypothesized
that selective vagotomy in gastrectomy would result in
preferential reduction of visceral fat; indeed, sparing the
vagus nerve largely prevented this weight loss (Miyato
et al., 2012).
In view of the direct labeling of DMV neurons after
injection of the conventional tracer CtB into the spleen,
liver and adipose tissue, the most likely explanation is
that these organs receive direct input from the DMV
without the ganglion functioning as a go-between. This
would explain both the retrograde labeling after injection
of nonviral retrograde tracers that cannot pass a synapse
and the absence of acetylcholine in liver, adipose tissue,
and spleen nerve fibers. Research aimed at identifying
the transmitters used by the DMV to transmit its
message should clarify this.
Feedback
Although much is known about the organization of the
output of the ANS to our organs, there is relatively little
knowledge about the feedback of our organs to the
brain. It is safe to assume that every organ has the capac-
ity to reach the brain via the release of hormones and thus
to provide feedback to the control center of the ANS.
Examples of this are the secretion of cortisol and aldo-
sterone by the adrenal, leptin and adiponectin by adipose
tissue, renin by the kidney, angiotensinogen and fibro-
blast growth factors by the liver, and so on. Most of these
substances also target at least the CNS, where, if they are
unable to pass the blood–brain barrier, they act in areas
where the blood–brain barrier is absent, such as the cir-
cumventricular organs (Smith and Ferguson, 2010).
Since these circumventricular organs have extensive pro-
jections to autonomic targets within the hypothalamus or
in the brainstem and spinal cord, they form an excellent
feedback circuit. For example, it is known that angioten-
sin II acts on the circumventricular organs not only to
8 R.M. BUIJS
stimulate water intake but also to increase blood pres-
sure via the ANS in order to compensate for volume loss
(Hendel and Collister, 2005). In addition, much is known
about visceral feedback that reaches the brainstem in the
area of the NTS via the sensory vagus nerve. This feed-
back innervation has a general somatotopic distribution
whereby even different areas of the alimentary tract
have different terminal fields in the NTS (Altschuler
et al., 1989; Broussard and Altschuler, 2000). In addition,
the brain receives feedback from the organs via spinal
sensory terminals (Khurana and Petras, 1991; Morita
et al., 1991; Qin et al., 2003). Despite the fact that the
functional significance of the messages able to reach
the brain via spinal afferents from the organs is largely
unknown, more and more evidence has been presented
that the sensory feedback via spinal sensory nerves is
also associated with physiological changes perceived
by the organ (de Jonge et al., 2003; Qin et al., 2003;
Schliess and Haussinger, 2006; Reinehr et al., 2010;
Doignon et al., 2011; Lechner et al., 2011). Most of these
signals may be aimed at regulating the function of the
organ in a “reflex” manner, but there is also evidence
that this feedback may influence the function of other
organs, or behavior, via neuronal sensory feedback
(Uno et al., 2006; Warne et al., 2007).
THE BRAIN BALANCES ITS
AUTONOMIC OUTPUT
As will become clear from many chapters in this book,
the organs of our body need a careful balance between
themselves and the brain. The autonomic nervous system
is the main carrier of direct information between all
these parts. If even only one organ is off balance this
may, via sensory and hormonal pathways, influence
the functioning of the whole system. This becomes clear
when behavior is not in line with the message of the brain.
For instance, when our biological clock tells us that it is
time to fast and rest, and we eat or are active instead, as
is the case in shift work, the result is an increased risk of
hypertension, obesity, and diabetes (Gangwisch et al.,
2006, 2007; Nabe-Nielsen et al., 2008; Scheer et al.,
2009). Animal studies have shown that this might be
due to a lack of balance not only in physiological pro-
cesses but also in the molecular machinery of organs
such as the liver, which could lead to liver steatosis
(Salgado-Delgado et al., 2010, 2013). What emphasizes
the importance of maintaining balance in the interaction
between the various organs is that liver steatosis, with or
without associated obesity, is often associated with kid-
ney disease (Targher et al., 2012; Abenavoli et al., 2013).
This suggests that a disbalance in the liver itself may
have repercussions on the functioning of the kidney.
Similarly, it has been demonstrated that inducing
disbalance in the liver by adenovirus expression of
peroxisome proliferator-activated receptor, which leads
to liver steatosis, results in a loss of peripheral adiposity
and an increase in energy expenditure. Tellingly, these
effects were nullified by selective sensory denervation
of the vagus nerve, which underlines the importance
of sensory liver, brain signaling (Uno et al., 2006).
Similarly, but in this case as a reflection of an unbalance
of the autonomic output of the brain, the association
between intra-abdominal fat and the metabolic syn-
drome might originate in a behavior that is not in line
with the physiological demands of the body, but which
eventually leads to symptoms of liver steatosis and/or
glucose unbalance, resulting in the accumulation of
intra-abdominal fat in one case and hypertension in
the other (Kreier et al., 2003; Salgado-Delgado et al.,
2010, 2013). Animal experiments showing a disturbance
in the liver enzymes and glucose levels in the circulation
after an unbalance of the autonomic interaction with the
liver (Cailotto et al., 2007) also support the hypothesis
that lack of balance in the autonomic output to a single
organ may have effects not only on the organ itself but
also on the entire physiology.
CONCLUDING REMARKS
In this chapter, the importance of the interaction
between brain and body in order to maintain homeostasis
has been emphasized. This is not just a matter of a top-
down or reflex regulation, it is also a matter of signals
from the organs influencing the functioning of the brain
while the reflex regulation of blood pressure and heart is
subject to modulation by descending information from
several areas in hypothalamus or cortex. The output of
the CNS to control its autonomic output shows an amaz-
ing differentiation; not only are there different neurons
within, for example, the biological clock or prefrontal
cortex, which may influence selectively the parasympa-
thetic or sympathetic motor neurons, there are also dif-
ferent neurons that project to different body
compartments. Visceral sensory information may reach
higher centers in the CNS via vagal or spinal sensory
pathways, leading to integrated responses taking into
account such factors as time of day, season, reproduc-
tive status, and mood. Based on all that information,
the brain sets the balance of the different parts of the
ANS, changing the emphasis of the ANS output depend-
ing on the situation. If that balance is disturbed, either by
behavior or by disease of the organ, this may lead to
pathology that may affect the functioning of the whole
individual.
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