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vega will outpace the long option loss and create the potential for pro ts prior to expiration Now let s look at the model for this trade in Figure 86 This model looks exactly like a long butter y spread You have an area of maximum pro t on the at-the-money strike price on the sold option premium and a maximum risk to the outside legs of the spread when either underlying price exceeds the protective option on the outside of the spread This spread is designed for high implied volatility so as to maximize pro t potential and reduce risk on the spread You should be cautious of the cost of these trades You are creating four trades which means four commissions in either equities or options on futures The commissions, in addition to minimal gains over the course of several spreads, can result in a false sense of success One trade at the maximum loss can offset several winning spreads A signi cant spike in implied volatility will also cause the premium on the spread to be out of line until the time value is exhausted and the volatility declines Some traders recommend buying additional call or put

Figure 8-3 Spinal cord showing the segmental arrangement of nerve bers within major tracts On the left side are indicated the sensory modalities that appear to be mediated by the two main ascending pathways C, cervical; L, lumbar; S, sacral; Th, thoracic (Adapted by permission from Brodal A: Neurological Anatomy, 3rd ed New York, Oxford University Press, 1981)

Spinoreticulothalamic (paleospinothalamic) bers project onto the medial intralaminar (primarily parafascicular and centrolateral) thalamic nuclei; ie, they overlap with the terminations of the medially projecting direct spinothalamic pathway Projections from the dorsal column nuclei, which have a modulating in uence on pain transmission, are mainly to the ventrobasal and ventroposterior group of nuclei Each of the four thalamic nuclear groups that receives nociceptive projections from the spinal cord has a distinct cortical projection, and each is thought to play a different role in pain sensation (see below) One practical conclusion to be reached from these anatomic and physiologic studies is that at thalamic levels, bers and cell stations transmitting the nociceptive impulses are not organized into discrete loci In general, neurophysiologic evidence indicates that as one ascends from peripheral nerve to spinal, medullary, mesencephalic, thalamic, and limbic levels, the predictability of neuron responsivity to noxious stimuli diminishes Thus it comes as no surprise that neurosurgical procedures for interrupting afferent pathways become less and less successful at progressively higher levels of the brainstem and thalamus

Of great importance was the discovery of a system of descending bers and way stations that modulate activity in nociceptive pathways The system that has been studied most extensively emanates from the frontal cortex and hypothalamus and projects to cells in the periaqueductal region of the midbrain and then passes to the ventromedial medulla From there it descends in the dorsal part of the lateral fasciculus of the spinal cord to the posterior horns (laminae I, II, and V; see further discussion under Endogenous Pain-Control Mechanisms ) Several other descending pathways, noradrenergic and serotoninergic, arise in the locus ceruleus, dorsal raphe nucleus, and nucleus reticularis gigantocellularis and are also important modi ers of the nociceptive response The signi cance of these pain-modulating pathways is discussed further on

TABLE 6-12

The stimuli that activate pain receptors vary from one tissue to another As pointed out above, the adequate stimulus for skin is one that has the potential to injure tissue, ie, pricking, cutting, crushing, burning, and freezing These stimuli are ineffective when applied to the stomach and intestine, where pain is produced by an engorged or in amed mucosa, distention or spasm of smooth muscle, and traction on the mesenteric attachment In skeletal muscle, pain is caused by ischemia (the basis of intermittent claudication), necrosis, hemorrhage, and injection of irritating solutions as well as by injuries of connective tissue sheaths Prolonged contraction of skeletal muscle evokes an aching type of pain Ischemia is also the most important cause of pain in cardiac muscle Joints are insensitive to pricking, cutting, and cautery, but pain can be produced in the synovial membrane by in ammation and by exposure to hypertonic saline The stretching and tearing of ligaments around a joint can evoke severe pain Injuries to the periosteum give rise to pain but probably not to other sensations Arteries are a source of pain when pierced by a needle or involved in an in ammatory process Distention of arteries, as occurs with thrombotic or embolic occlusion, and excessive arterial pulsation, as is postulated in migraine, may be sources of pain; other mechanisms of headache relate to traction on arteries and the meningeal structures by which they are supported (see Chap 10) Pain due to intraneural lesions probably arises from the sheaths of the nerves Nerve root(s) and sensory ganglia, when compressed (eg, by a ruptured disc), give rise to pain

Reference was made in Chaps 3 and 4 to motor weakness, akinesia, and bradykinesia as cardinal manifestations of corticospinal and extrapyramidal disease Disorders of these parts of the motor system interfere with voluntary or automatic movements, much to the distress of the patient But motility and activity can be impaired for other reasons, one of which is a lack of conation or impulse These terms designate that basic biologic urge, driving force, or purpose by which every organism is motivated to achieve an endless series of objectives Indeed, motor activity is a necessary and satisfying objective in itself, for few individuals can remain still for long ( dgets, doodling), and even the severely retarded obtain

The emotional life of the patient is expressed in a variety of ways In the rst place, rather marked individual differences in basic temperament are observed in the normal population; some persons are throughout their lives cheerful, gregarious, optimistic, and free from worry, whereas others are just the opposite Changes in emo-

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