Abstract:
A method, apparatus, and surgical technique for the modulation of autonomic function, for the purpose of treating any of several conditions and diseases, including obesity, metabolic disorders, endocrine disorders, diabetes, respiratory disease, asthma, inflammatory disease, immunological disease, infection, cancer, cardiac disease, cardiovascular disease, cerebrovascular disease, stroke, vasospasm, vascular disease, psychiatric disease, depression, affective disorders, anxiety disorders, and other conditions. This includes neural and tissue modulators, including implanted devices, used to modulate efferent and afferent autonomic neurons to influence or control autonomic or other neural function, including modulation of sympathetic and parasympathetic nervous system components as well as their combination.

Description:
RELATED APPLICATIONS 
       [0001]    This application is a division of and incorporates by reference copending U.S. patent application Ser. No. 11/317,099 (GISTIM 02.02), entitled “Method, Apparatus, And Surgical Technique For Autonomic Neuromodulation For The Treatment Of Obesity”, filed on Dec. 22, 2005. In response to restriction requirement dated Nov. 24, 2008, this divisional comprises claims in species II, drawn to an apparatus for modulating the autonomic index. 
         [0002]    U.S. patent application Ser. No. 11/317,099 (GISTIM 02.02) is a continuation in Part of and incorporates by reference U.S. patent application Ser. No. 10/198,871 (GISTIM 01.01), now U.S. Pat. No. 7,599,736, entitled METHOD AND APPARATUS FOR NEUROMODULATION AND PHSYIOLOGIC MODULATION FOR THE TREATMENT OF METABOLIC AND NEUROPSYCHIATRIC DISEASE, filed Jul. 19, 2002, and naming as inventor Daniel John DiLorenzo, which claims the benefit of U.S. Provisional Patent Application Ser. No. 60/307,124, entitled PHYSIOLOGIC MODULATION FOR THE CONTROL OF OBESITY, DEPRESSION, EPILEPSY, AND DIABETES, filed Jul. 19, 2001, and naming as inventor Daniel John DiLorenzo. 
         [0003]    U.S. patent application Ser. No. 11/317,099 (GISTIM 02.02) is a continuation in Part of and incorporates by reference U.S. patent application Ser. No. 10/872,549 (GISTIM 01.02), now U.S. Pat. No. 7,529,582, entitled METHOD AND APPARATUS FOR NEUROMODULATION AND PHSYIOLOGIC MODULATION FOR THE TREATMENT OF METABOLIC AND NEUROPSYCHIATRIC DISEASE, filed Jun. 21, 2004, and naming as inventor Daniel John DiLorenzo. U.S. patent application Ser. No. 10/872,549 is a continuation of U.S. patent application Ser. No. 10/198,871, which claims the benefit of U.S. Provisional Patent Application Ser. No. 60/307,124, entitled PHYSIOLOGIC MODULATION FOR THE CONTROL OF OBESITY, DEPRESSION, EPILEPSY, AND DIABETES, filed Jul. 19, 2001, and naming as inventor Daniel John DiLorenzo, all of which are incorporated by reference. U.S. patent application Ser. No. 10/872,549 also claims the benefit of U.S. Provisional Patent Application No. 60/500,911, filed Sep. 5, 2003 and naming as inventor Daniel John DiLorenzo, all of which are incorporated by reference. U.S. patent application Ser. No. 10/872,549 also claims the benefit of U.S. Provisional Patent Application No. 60/579,074, filed Jun. 10, 2004 and naming as inventor Daniel John DiLorenzo, all of which are incorporated by reference. 
         [0004]    This application incorporates by reference U.S. patent application Ser. No. 11/187,315, entitled CLOSED-LOOP AUTONOMIC NEUROMODULATION FOR OPTIMAL CONTROL OF NEUROLOGICAL AND METABOLIC DISEASE, filed Jul. 23, 2005. 
         [0005]    This application incorporates by reference U.S. patent application Ser. No. 11/333,979, entitled CLOSED-LOOP FEEDBACK-DRIVEN SYMPATHETIC NEUROMODULATION FOR AFFECT CONTROL, filed Jan. 17, 2006. 
     
    
     BACKGROUND OF THE INVENTION 
       [0006]    1. Field of the Invention 
         [0007]    The present invention relates generally to metabolic disease, systemic disease, and neuropsychiatric disease and, more particularly, to modulation of autonomic neural structures including sympathetic and parasympathetic neural structures for the treatment of a spectrum of conditions including but not limited to obesity, weight loss, eating disorders, psychiatric condition, depression, anxiety, agoraphobia, social anxiety, panic attacks, and other neurological and psychiatric conditions, epilepsy, metabolic disease, diabetes, gastrointestinal modulation, inflammatory conditions and diseases, inflammatory bowel disease, immunomodulation, immune disease, infection, cancer, autoimmune disease, autoimmune immunodeficiency syndrome (AIDS), human immunodeficiency virus) infection (HIV), severe combined immunodeficiency (SCID), other causes of immunodeficiency, other causes of immunosuppression, mitigation of effects of iatrogenic immunosuppression (including that used with organ transplantation or for treating autoimmune disorders), and other causes of decreased immune system activity, multiple sclerosis, reflex sympathetic dystrophy (RSD), type I diabetes (the pathophysiology of which may include an autoimmune component), rheumatoid arthritis, graft versus host disease, psoriasis, allergic reactions, dermatitis, other allergic conditions, some complications from infection, including but not limited to lyme disease, streptococcal pharyngitis (strep throat), rheumatic heart disease, fungal infections, parasitic infections, bacterial infections, viral infections, other infections, and other exposures to infectious or allergenic agents, organ transplantation, asthma, including exercise induced asthma and other forms of asthma, bronchoconstrictive processes, bronchoconstriction, bronchospasm, laryngospasm, cardiac disease, including heart failure and bradycardia, decreased myocardial contractility found in cardiac disease, including congestive heart failure, post myocardial infarction sequelae, and other cardiac disorders, bradycardia and heart block, hypotension, neurogenic shock, diastolic disease, hypertension, congestive heart failure, tachycardia, other cardiac rhythm abnormalities, cerebral vasospasm, ischemic stroke, peripheral vascular disease, low blood pressure, low vascular tone, hypertension, including essential hypertension, renally mediated hypertension, atherosclerosis mediated hypertension, other forms of systemic hypertension, and pulmonary hypertension, coronary artery disease, peripheral vascular disease, cerebral vascular disease, myocardial infarction, and stroke, enhanced circulation and drug delivery in the treatment of infections and as an adjuvant to accelerate healing processes, such as ulcers, postoperative wounds, trauma, headaches, applications for effecting cerebral vasodilation, smoking cessation, drug withdrawal, hyperhidrosis, reflex sympathetic dystrophy, pain, as well as any other condition or disease including those which affect or are affected by dysfunction in the autonomic nervous system, and other conditions. 
         [0008]    2. Related Art 
         [0009]    Physiologic studies have demonstrated the presence of a sympathetic nervous system afferent pathway transmitting gastric distention information to the hypothalamus. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38:239-51.] However, prior techniques have generally not addressed the problems associated with satiety, morbidity, mortality of intracranial modulation and the risk of ulcers. Unlike prior techniques, by specifically targeting sympathetic afferent fibers, the present invention effects the sensation of satiety and avoids the substantial risks of morbidity and mortality of intracranial modulation, particularly dangerous in the vicinity of the hypothalamus. Furthermore, this invention avoids the risk of ulcers inherent in vagus nerve stimulation. 
         [0010]    A. Satiety. Stimulation of intracranial structures has been proposed and described for the treatment of obesity (U.S. Pat. No. 5,782,798). Stimulation of the left ventromedial hypothalamic (VMH) nucleus resulted in delayed eating by dogs who had been food deprived. Following 24 hours of food deprivation, dogs with VMH stimulation waited between 1 and 18 hours after food presentation before consuming a meal. Sham control dogs ate immediately upon food presentation. Dogs that received 1 hour of stimulation every 12 hours for 3 consecutive days maintained an average daily food intake of 35% of normal baseline levels. [Brown, Fessler et al. (1984). Changes in food intake with electrical stimulation of the ventromedial hypothalamus in dogs. Journal of Neurosurgery. 60:1253-7.] 
         [0011]    B. Candidate Peripheral Nerve Pathways for Modulating Satiety. 
         [0012]    B1. Sympathetic Afferents. The effect of gastric distension on activity in the lateral hypothalamus-lateral preoptic area-medial forebrain bundle (LPA-LH-MFB) was studied to determine the pathways for this gastric afferent input to the hypothalamus. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38:239-51.] The periaqueductal gray matter (PAG) was found to be a relay station for this information. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38: 239-51.] This modulation of the hypothalamus was attenuated but not permanently eliminated by bilateral transection of the vagus nerve. This modulation was, however, significantly reduced or eliminated by bilateral transection of the cervical sympathetic chain or spinal transection at the first cervical level. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38: 239-51.] These signals containing gastric distension and temperature stimulation are mediated to a large degree by sympathetic afferents, and the PAG is a relay station for this gastric afferent input to the hypothalamus. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38:239-51.] For example, in the LPA-LH-MFB study, 26.1% of the 245 neurons studied were affected by gastric stimulation, with 17.6% increasing in firing frequency and 8.6% decreasing during gastric distension. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38:239-51.] The response of 8 of 8 neurons sensitive to gastric distension were maintained, though attenuated after bilateral vagus nerves were cut. In 2 of these 8 cells, the effect was transiently eliminated for 2-4 minutes after left vagus transection, and then activity recovered. In 3 LH-MFB cells, two increased and the other decreased firing rate with gastric distension. Following bilateral sympathetic ganglion transection, the response of two were eliminated, and the third (which increased firing with distension) had a significantly attenuated response. [Barone, Zarco de Coronado et al. (1995). Gastric distension modulates hypothalamic neurons via a sympathetic afferent path through the mesencephalic periaqueductal gray. Brain Research Bulletin. 38:239-51.] Vagus stimulation resulted in opposite or similar responses as gastric distension on the mesencephalic cells. 
         [0013]    B2. Vagus Nerve Afferents. Gastric vagal input to neurons throughout the hypothalamus has been characterized. [Yuan and Barber (1992). Hypothalamic unitary responses to gastric vagal input from the proximal stomach. American Journal of Physiology. 262:G74-80.] Nonselective epineural vagus nerve stimulation (VNS) has been described for the treatment of Obesity (U.S. Pat. No. 5,188,104). This suffers from several significant limitations that are overcome by the present invention. 
         [0014]    The vagus nerve is well known to mediate gastric hydrochloric acid secretion. Dissection of the vagus nerve off the stomach is often performed as part of major gastric surgery for ulcers. Stimulation of the vagus nerve may pose risks for ulcers in patients, of particular concern, as obese patients often have gastroesophageal reflux disease (GERD); further augmentation of gastric acid secretion would only exacerbate this condition. 
         [0015]    C. Assessment of Sympathetic and Vagus Stimulation. The present invention teaches a significantly more advanced neuroelectric interface technology to stimulate the vagus nerve and avoid the efferent vagus side effects, including speech and cardiac side effects common in with existing VNS technology as well as the potential ulcerogenic side effects. However, since sympathetic afferent activity appears more responsive to gastric distension, this may represent a stronger channel for modulating satiety. Furthermore, by pacing stimulating modulators on the greater curvature of the stomach, one may stimulate the majority of the circular layer of gastric musculature, thereby diffusely increasing gastric tone. 
         [0016]    D. Neuromuscular Stimulation. The muscular layer of the stomach is comprised of 3 layers: (1) an outer longitudinal layer, (2) a circular layer in between, and (3) a deeper oblique layer. [Gray (1974). Gray&#39;s Anatomy. T. Pick and R. Howden. Philadelphia, Running Press.]The circular fibers, which lie deep to the superficial longitudinal fibers, would appear to be the layer of choice for creating uniform and consistent gastric contraction with elevated wall tension and luminal pressure. Therefore, modulators should have the ability to deliver stimulation through the longitudinal layer. If the modulator is in the form of an electrode, then the electrodes should have the ability to deliver current through the longitudinal layer. 
         [0017]    Gray&#39;s Anatomy describes innervation as including the right and left pneumogastric nerves (not the vagus nerves), being distributed on the back and front of the stomach, respectively. A great number of branches from the sympathetic nervous system also supply the stomach. [Gray (1974). Gray&#39;s Anatomy. T. Pick and R. Howden. Philadelphia, Running Press.] 
         [0018]    E. Metabolic Modulation (Efferent). Electrical stimulation of the VMH enhances lipogenesis in the brown adipose tissue (BAT), preferentially over the white adipose tissue (WAT) and liver, probably through a mechanism involving activation of the sympathetic innervation of the BAT. [Takahashi and Shimazu (1982). Hypothalamic regulation of lipid metabolism in the rat: effect of hypothalamic stimulation on lipogenesis. Journal of the Autonomic Nervous System. 6:225-35.] The VMH is a hypothalamic component of the sympathetic nervous system. [Ban (1975). Fiber connections in the hypothalamus and some autonomic functions. Pharmacology, Biochemistry &amp; Behavior. 3:3-13.] A thermogenic response in BAT was observed with direct sympathetic nerve stimulation. [Flaim, Horwitz et al. (1977). Coupling of signals to brown fat: a- and b-adrenergic responses in intact rats. Amer. J. Physiol. 232:R101-R109.] The BAT had abundant sympathetic innervation with adrenergic fibers that form nest-like networks around every fat cell, [Derry, Schonabum et al. (1969). Two sympathetic nerve supplies to brown adipose tissue of the rat. Canad. J. Physiol. Pharmacol. 47:57-63.] whereas WAT has no adrenergic fibers in direct contact with fat cells except those related to the blood vessels. [Daniel and Derry (1969). Criteria for differentiation of brown and white fat in the rat. Canad. J. Physiol. Pharmacol. 47:941-945.] 
       SUMMARY OF THE INVENTION 
       [0019]    The present invention teaches apparatus and methods for treating a multiplicity of diseases, including obesity, depression, epilepsy, diabetes, and other diseases. The invention taught herein employs a variety of energy modalities to modulate central nervous system structures, peripheral nervous system structures, and peripheral tissues and to modulate physiology of neural structures and other organs, including gastrointestinal, adipose, pancreatic, and other tissues. The methods for performing this modulation, including the sites of stimulation and the modulator configurations are described. The apparatus for performing the stimulation are also described. This invention teaches a combination of novel anatomic approaches and apparatus designs for direct and indirect modulation of the autonomic nervous system, which is comprised of the sympathetic nervous system and the parasympathetic nervous system. 
         [0020]    For the purposes of this description the term GastroPace should be interpreted to mean the devices constituting the system of the present embodiment of this invention, including the obesity application as well as others described, implied, enabled, facilitated, and derived from those taught in the present invention. 
         [0021]    A. Obesity and Eating Disorders. The present invention teaches several mechanisms, including neural modulation and direct contraction of the gastric musculature, to effect the perception of satiety. This modulation is useful in the treatment of obesity and eating disorders, including anorexia nervosa and bulemia. 
         [0022]    Direct stimulation of the gastric musculature increases the intraluminal pressure within the stomach; and this simulates the physiologic condition of having a full stomach, sensed by stretch receptors in the muscle tissue and transmitted via neural afferent pathways to the hypothalamus and other central nervous system structures, where the neural activity is perceived as satiety. 
         [0023]    This may be accomplished with the several alternative devices and methods taught in the present invention. Stimulation of any of the gastric fundus, greater curvature of stomach, pyloric antrum, or lesser curvature of stomach, or other region of the stomach or gastrointestinal tract, increases the intraluminal pressure. Increase of intraluminal pressure physiologically resembles fullness of the respective organ, and satiety is perceived. 
         [0024]    The present invention also includes the restriction of the flow of food to effect satiety. This is accomplished by stimulation of the pylorus. The pylorus is the sphincter-like muscle at the distal juncture of the stomach with the duodenum, and it regulates food outflow from the stomach into the duodenum. By stimulating contraction of the pylorus, food outflow from the stomach is slowed or delayed. The presence of a volume of food in the stomach distends the gastric musculature and causes the person to experience satiety. 
         [0025]    B. Depression and Anxiety. An association has been made between depression and overeating, particularly with the craving of carbohydrates; and is believed to be an association between the sense of satiety and relief of depression. Stimulation of the gastric tissues, in a manner that resembles or is perceived as satiety, as described above, provides relief from this craving and thereby relief from some depressive symptoms. There are several mechanisms, including those taught above for the treatment of obesity that are applicable to the treatment of depression, anxiety, agoraphobia, social anxiety, panic attacks, and other neurological and psychiatric conditions. 
         [0026]    An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of limbic physiology, which has efficacy in the treatment of depression, anxiety and other psychiatric conditions. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), the level of activity n the locus ceruleus, solitary nucleus, cingulate nucleus, the limbic system, the supraorbital cortex, and other regions may be modulated, thereby influencing affect or mood as well as level of anxiety. Furthermore, the reduction of systemic sympathetic activity may be used to alleviate the symptoms of anxiety, which is employed in both the treatment of anxiety and in the conditioning of patients to control anxiety. 
         [0027]    C. Epilepsy. The present invention includes electrical stimulation of peripheral nervous system and other structures and tissues to modulate the activity in the central nervous system to control seizure activity. 
         [0028]    This modulation takes the form of peripheral nervous system stimulation using a multiplicity of novel techniques and apparatus. Direct stimulation of peripheral nerves is taught; this includes stimulation of the vagus, trigeminal, accessory, and sympathetic nerves. Indiscriminate stimulation of the vagus nerves has been described for some disorders, but the limitations in this technique are substantial, including cardiac rhythm disruptions, speech difficulties, and gastric and duodenal ulcers. The present invention overcomes these persistent limitations by teaching a method and apparatus for the selective stimulation of structures, including the vagus nerve as well as other peripheral nerves, and other neural, neuromuscular, and other tissues. 
         [0029]    The present invention further includes noninvasive techniques for neural modulation. This includes the use of tactile stimulation to activate peripheral or cranial nerves. This noninvasive stimulation includes the use of tactile stimulation, including light touch, pressure, vibration, and other modalities that may be used to activate the peripheral or cranial nerves. Temperature stimulation, including hot and cold, as well as constant or variable temperatures, are included in the present invention. 
         [0030]    D. Diabetes. The response of the gastrointestinal system, including the pancreas, to a meal includes several phases. The first phase, the anticipatory stage, is neurally mediated. Prior to the actual consumption of a meal, saliva production increases and the gastrointestinal system prepares for the digestion of the food to be ingested. Innervation of the pancreas, in an analogous manner, controls production of insulin. 
         [0031]    Modulation of pancreatic production of insulin may be performed by modulation of at least one of afferent or efferent neural structures. Afferent modulation of at least one of the vagus nerve, the sympathetic structures innervating the gastrointestinal tissue, the sympathetic trunk, and the gastrointestinal tissues themselves is used as an input signal to influence central and peripheral nervous system control of insulin secretion. 
         [0032]    E. Irritable bowel Syndrome. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of gastrointestinal physiology, which has efficacy in the treatment of irritable bowel syndrome. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), the level of gastrointestinal motility and absorption may be modulated. 
         [0033]    Modulation including down-regulation of the activity of the gastrointestinal tract, through autonomic modulation, as taught in the parent case has application to the treatment of irritable bowel syndrome. Said autonomic modulation includes but is not limited to inhibition or blocking of sympathetic nervous system activity and to enhancement or stimulation of parasympathetic nervous system activity. 
         [0034]    The response of the gastrointestinal system to sympathetic stimulation, such as that induced by stress or sympathomimetic agents including caffeine, may include symptoms such as elevated motility and altered absorption. Modulation of gastrointestinal physiology is taught for applications including but not limited to the maintenance of baseline levels of gastrointestinal motility, secretion, absorption, and hormone release. Modulation of gastrointestinal physiology is also taught for applications including but not limited to the real-time control of levels of gastrointestinal motility, secretion, absorption, and hormone release, in response to physiological needs as well as in response to perturbations. Such external perturbation that can induce symptoms that are alleviated by the present invention include but are not limited to stress, consumption of caffeine, alcohol, or other substance, consumption of allergenic substance, or consumption of infectious or toxic agent. By intervening with the application of autonomic modulation to counter these undesirable autonomic responses to external agents, these side effects are reduced or prevented. 
         [0035]    F. Immunomodulation. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of immune system physiology. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), the level of activity of the immune system may be modulated. Both polarities of modulation have efficacy in the treatment of disease as well as in prophylactic applications. 
         [0036]    Modulation, including up-regulation of the immune system, through autonomic modulation, as taught in the parent case invention has application to the treatment of infection, cancer, autoimmune immunodeficiency syndrome (AIDS), human immunodeficiency virus) infection (HIV), severe combined immunodeficiency (SCID), other causes of immunodeficiency, other causes of immunosuppression, mitigation of effects of iatrogenic immunosupppression (including that used with organ transplantation or for treating autoimmune disorders), and other causes of decreased immune system activity. 
         [0037]    Modulation, including down-regulation, of the immune system, through autonomic modulation, as taught in the parent case invention has application to the treatment of autoimmune disease, including but not limited to multiple sclerosis, reflex sympathetic dystrophy (RSD), type I diabetes (the pathophysiology of which may include an autoimmune component), rheumatoid arthritis, graft versus host disease, psoriasis, allergic reactions, dermatitis, other allergic conditions, other diseases involving signs or symptoms due to an autoimmune or other immune pathology, and other diseases with untoward effects arising from excessive or detrimental immune responses. 
         [0038]    Modulation, including down-regulation, of the immune system, through autonomic modulation, as taught in the parent case invention has application to the treatment of some complications from infection, including but not limited to lyme disease, streptococcal pharyngitis (strep throat), rheumatic heart disease, fungal infections, parasitic infections, bacterial infections, viral infections, other infections, and other exposures to infectious or allergenic agents. 
         [0039]    Modulation, including down-regulation, of the immune system, through autonomic modulation, as taught in the parent case invention has application to the augmentation of other therapies, and may be used to suppress immune function in patients with organ transplantation. 
         [0040]    G. Asthma. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of pulmonary physiology. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), the level of activity of the immune system may be modulated. Both polarities of modulation have efficacy in the treatment of disease as well as in prophylactic applications. 
         [0041]    Modulation, including stimulation of the sympathetic nervous system, as taught in the parent case invention has application to the treatment of asthma, including exercise induced asthma and other forms of asthma. Through stimulation of the sympathetic nervous system, the beta-2 efferent pathways of the sympathetic nervous system are activated, effecting bronchodilation, providing a therapeutic action opposing the bronchoconstrictive process that underlies the increased airway resistance which results in the potentially life-threatening signs and symptoms of this disease. This same therapy is also applied to the treatment of bronchospasm and laryngospasm, in which elevated sympathetic efferent activity mitigates the constrictive effects on the airway. 
         [0042]    Modulation, including stimulation of the sympathetic nervous system and stimulation of the parasympathetic nervous system, as taught in the parent case invention has application to the treatment of asthma, including exercise induced asthma through an additional mechanism. Through inhibition of the sympathetic nervous system, the activity of the immune system may be down-regulated, reducing the sensitivity of the pulmonary mast cells to allergens, thereby reducing the susceptibility to and the severity of asthma signs and symptoms. 
         [0043]    H. Cardiovascular Disease—Cardiac. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of cardiovascular physiology, including cardiac physiology in particular. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), cardiac parameters may be modulated. Both polarities of modulation have efficacy in the treatment of cardiac disease as well as in prophylactic applications. 
         [0044]    Modulation, including stimulation of the sympathetic nervous system, inhibition of the parasympathetic system, or increase in the autonomic index, as taught in the parent case invention has application to the treatment of cardiac disease, including hear failure and bradycardia. Through stimulation of the sympathetic nervous system, the beta-1 efferent pathways of the sympathetic nervous system are activated, effecting increase inotropic activity, providing a therapeutic action to mitigate decreased myocardial contractility found in cardiac disease, including congestive heart failure, post myocardial infarction sequelae, and other cardiac disorders. Sympathetic stimulation is also used to effect increased chronotropic behavior, thereby elevating heart rate. This has application to numerous cardiac conditions, including bradycardia and heart block. This has further application to the treatment of hypotension and to neurogenic shock, which may be augmented by autonomic neuromodulation directed toward the vascular system, as described below. 
         [0045]    Modulation, including inhibition of the sympathetic nervous system, stimulation of the parasympathetic system, or decrease in the autonomic index, as taught in the parent case invention has application to the treatment of cardiac disease. The negative inotropic effect of such autonomic modulation has application to cardiac disease, including among others, diastolic disease, in which the heart muscle does not fully relax, thereby impairing proper atrial and ventricular filling during the diastolic portion of the cardiac cycle. This additionally has application to the treatment of hypertension, through each of negative inotropic and negative chronotropic effects. This further has application to the prevention and control of the progression of congestive heart failure, through the reduction of the normal sympathetic physiologic response to heart failure, which itself contributes to progression of the disease. The negative chronotropic effect of such modulation also has application to the treatment of tachycardia and other cardiac rhythm abnormalities. 
         [0046]    I. Cardiovascular Disease—Vascular. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of cardiovascular physiology including vascular physiology in particular. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), the level of activity including the muscular tone of the vascular system may be modulated. Both polarities of modulation have efficacy in the treatment of disease as well as in prophylactic applications. 
         [0047]    Modulation, including stimulation of the sympathetic nervous system, inhibition of the parasympathetic nervous system, or increase in the autonomic index, as taught in the parent case invention has application to the treatment of hypotension and neurogenic shock, and other conditions in which vascular tone or blood pressure is below normal. This further has application to therapeutically increase vascular tone or blood pressure, including to levels above normal, such as in the treatment of cerebral vasospasm, ischemic stroke, peripheral vascular disease, or other condition. Through stimulation of the sympathetic nervous system, the alpha-1 efferent pathways of the sympathetic nervous system are activated, effecting vasoconstriction, providing a therapeutic action to correct low blood pressure as well as to provide a normalizing to correct low vascular tone characterizing neurogenic shock as well as to elevate blood pressure to treat the above listed conditions. A particular advantage of this therapy is conveyed by the ability to selectively rather than systemically induce vasoconstriction, thereby elevating systemic blood pressure while avoiding vasoconstriction in selected circulatory regions, as desired in the treatment of cerebral vasospasm. 
         [0048]    Modulation, including inhibition of the sympathetic nervous system, stimulation of the parasympathetic nervous system, or decrease in the autonomic index, as taught in the parent case invention has application to the treatment of hypertension, including essential hypertension, renally mediated hypertension, atherosclerosis mediated hypertension, other forms of systemic hypertension, and pulmonary hypertension. Through this therapy, vasodilation is achieved, which is also used to treat coronary artery disease, peripheral vascular disease, cerebral vascular disease, myocardial infarction, and stroke. This has further use in other therapy in which enhanced circulation is desired, such as for enhanced circulation and drug delivery in the treatment of infections and as an adjuvant to accelerate healing processes, such as ulcers, postoperative wounds, trauma, and other conditions. 
         [0049]    J. Headaches. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system for physiologic modulation, including modulation of cerebral vascular physiology, including intraparenchymal circulation and meningeal circulation. By altering the level of sympathetic nervous system activity, or the level of parasympathetic nervous system activity, or the ratio of sympathetic to parasympathetic nervous system activity (as reflected in metrics such as the autonomic index), the level of activity of the cerebral vascular system may be modulated. Both polarities of modulation have efficacy in the treatment of headaches as well as in prophylactic applications. 
         [0050]    Modulation, including stimulation of the sympathetic nervous system, inhibition of the parasympathetic nervous system, or increase in the autonomic index, as taught in the parent case invention has application to the treatment of headaches, including migraine headaches, cluster headaches, and other headaches. Through stimulation of the sympathetic nervous system, the alpha-1 efferent pathways of the sympathetic nervous system are activated, effecting cerebral vasoconstriction, providing decrease in the blood volume within the intracranial vascular structures as well as the remainder of the intracranial compartment. This acts through additional mechanisms including but not limited to reduction of the mechanical tension on the dura, reduction of the intracranial pressure, and alteration in the blood flow and neural activity within the brain, altering neural and vascular patterns that can progress to generate headaches or other undesirable neural states. 
         [0051]    Modulation, including inhibition of the sympathetic nervous system, stimulation of the parasympathetic nervous system, or decrease in the autonomic index, as taught in the parent case invention has application to the prophylaxis and treatment of headaches, including migraine headaches, cluster headaches, and other headaches. Through inhibition of the sympathetic nervous system, the activity of alpha-1 efferent pathways of the sympathetic nervous system are reduced, effecting cerebral vasodilation, providing variation in the vascular tone as well as altered blood flow and neural activity, which has application to disrupt neural and vascular patterns that can generate headaches or other undesirable neural states. 
         [0052]    K. Smoking Cessation and Drug Withdrawal. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system, which has application to stabilize or oppose the physiologic response to the introduction or withdrawal of pharmacological or other bioactive agents, including nicotine, caffeine, stimulants, depressants, and other medical and recreational drugs. 
         [0053]    When patients cease smoking, the nicotine plasma levels drop, reducing the level of stimulation of the nicotinic receptors in the sympathetic nervous system. This alteration causes a physiologic response characterized by significant levels of anxiety and a withdrawal response in the person. By modulating the sympathetic nervous system activity using the method and apparatus taught in the parent case or using variants thereof, this response can be mitigated. This has application to controlling addiction to nicotine and in the facilitation of smoking cessation. 
         [0054]    When patients cease intake of alcohol, narcotics, sedatives, hypnotics, or other drugs to which they may be addicted, a withdrawal response ensues. This response can be life threatening. In alcohol withdrawal, delirium tremens can be accompanied by dangerous elevations in heart rate. By modulating sympathetic and/or parasympathetic activity to control the autonomic index, this response can be reduced or prevented. 
         [0055]    L. Hyperhidrosis. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system, which has application to prevent or control the symptoms of hyperhidrosis. 
         [0056]    In hyperhidrosis, a abnormally active or responsive sympathetic nervous system results is excessive perspiration, typically most problematic when involving the hands and axillae. Current treatments employ surgical ablation fo the corresponding region of the sympathetic trunk, which results in irreversible cessation of sympathetic activity in the corresponding anatomical region. By modulating the sympathetic nervous system activity using the method and apparatus taught in the parent case or using variants thereof, the symptoms arising from this condition can be prevented or reduced. 
         [0057]    M. Reflex Sympathetic Dystrophy and Pain. An object of the present invention, as taught in the parent case, is the modulation of the autonomic nervous system, which has application to prevent the development or progression of reflex sympathetic dystrophy and to control the symptoms once the condition has developed. 
         [0058]    Reflex sympathetic dystrophy is a potentially debilitating condition that typically develops following trauma to a peripheral nerve, in which a crush or transection injury disrupts the afferent pain fibers and the sympathetic efferent fibers. The most widely accepted theory as to the etiology underlying this condition holds that during the healing phase, sympathetic efferent fibers develop connections with the pain carrying afferent fibbers, resulting in the perception of pain in response to sympathetic activity. Current therapy involves pharmacological agents and is largely ineffective, leaving a population of otherwise often healthy people who are debilitated by severe chronic medication refractory pain. By modulating the sympathetic nervous system activity using the method and apparatus taught in the parent case or using variants thereof, the symptoms arising from reflex sympathetic dystrophy can be prevented or reduced. 
         [0059]    Inhibition of sympathetic system activity is used to reduce the level of neural activity that is pathologically fed back into pain afferent fibers, thereby reducing symptoms. This therapy may be applied preventatively to modulate sympathetic nervous system activity and minimize the degree of neural connection between the sympathetic efferent neurons and the pain carrying afferent neurons. 
         [0060]    N. General—Control and Temporal Modulation. Various forms of temporal modulation may be performed to achieve the desired efficacy in the treatment of these and other diseases, conditions, or augmentation applications. Constant intensity modulation, time varying modulation, cyclical modulation, altering polarity modulation, up-regulation interspersed with down-regulation, intermittent modulation, and other permutations are include in the present invention. The use of a single or multiplicity of these temporal profiles provides resistance of the treatment or enhancement to habituation by the nervous system, thereby preserving or prolonging the effect of the modulation. The use of a multiplicity of modulation sites provides resistance of the treatment or enhancement to habituation by the nervous system, thereby preserving or prolonging the effect of the modulation; by distributing or varying the intensity of the neuromodulation among a plurality of sites enables the delivery of therapy or augmentation that is more resistant to adaptation or habituation by the nervous system. Furthermore, the control of neural state, including level of sympathetic nervous system activity, level of parasympathetic nervous system activity, autonomic index, or other characteristic or metric of neural function in either or both of an open-loop or closed-loop manner is taught herein. The use of open-loop or closed-loop control to maintain at least one neural state at a constant or time varying target level is used to better control physiology, reduce habituation, reduce side effects, apportion side effect to preferable time windows such as while sleeping), and optimize response to therapy. 
       INCORPORATION BY REFERENCE 
       [0061]    All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual reference, publication, patent, or patent application was specifically and individually indicated to be incorporated by reference. 
     
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         [0062]      FIG. 1  depicts GastroPace implanted along the Superior Greater Curvature of the stomach for both Neural Afferent and Neuromuscular Modulation. 
           [0063]      FIG. 2  depicts GastroPace implanted along the Inferior Greater Curvature of the stomach for both Neural Afferent and Neuromuscular Modulation. 
           [0064]      FIG. 3  depicts GastroPace implanted along the Pyloric Antrum of the stomach for both Neural Afferent and Neuromuscular Modulation. 
           [0065]      FIG. 4  depicts GastroPace implanted adjacent to the Gastric Pylorus for modulation of pylorus activity and consequent control of gastric food efflux and intraluminal pressure. 
           [0066]      FIG. 5  depicts GastroPace implanted along the Pyloric Antrum of the stomach with modulators positioned for stimulation of Neural and Neuromuscular structures of the Pylorus and Pyloric Antrum of the Stomach. 
           [0067]      FIG. 6  depicts GastroPace implanted along the Pyloric Antrum of the stomach with modulators positioned for stimulation of Neural and Neuromuscular structures of the Pylorus, Pyloric Antrum, Greater Curvature, and Lesser Curvature of the Stomach. 
           [0068]      FIG. 7  depicts the Nerve Cuff Electrode, comprising the Epineural Electrode Nerve Cuff Design. 
           [0069]      FIG. 8  depicts the Nerve Cuff Electrode, comprising the Axial Electrode Blind End Port Design. 
           [0070]      FIG. 9  depicts the Nerve Cuff Electrode, comprising the Axial Electrode Regeneration Port Design. 
           [0071]      FIG. 10  depicts the Nerve Cuff Electrode, comprising the Axial Regeneration Tube Design. 
           [0072]      FIG. 11  depicts GastroPace implanted along the Pyloric Antrum of the stomach with modulators positioned for stimulation of Afferent Neural Structures, including sympathetic and parasympathetic fibers. 
           [0073]      FIG. 12  depicts GastroPace implanted along the Pyloric Antrum of the stomach with modulators positioned for stimulation of Neural and Neuromuscular structures of the Pylorus, Pyloric Antrum, Greater Curvature, and Lesser Curvature of the Stomach and with modulators positioned for stimulation of Afferent Neural Structures, including sympathetic and parasympathetic fibers. 
           [0074]      FIG. 13  depicts the Normal Thoracoabdominal anatomy as seen via a saggital view of an open dissection. 
           [0075]      FIG. 14  depicts modulators for GastroPace positioned on the sympathetic trunk and on the greater and lesser splanchnic nerves, both supradiaphragmatically and infradiaphragmatically, for afferent and efferent neural modulation. 
           [0076]      FIG. 15  depicts GastroPace configured with multiple pulse generators, their connecting cables, and multiple modulators positioned on the sympathetic trunk and on the greater and lesser splanchnic nerves, both supradiaphragmatically and infradiaphragmatically, for afferent and efferent neural modulation. 
           [0077]      FIG. 16  depicts GastroPace configured with multiple pulse generators, their connecting cables, and multiple modulators positioned on the sympathetic trunk and on the greater and lesser splanchnic nerves, both supradiaphragmatically and infradiaphragmatically, for afferent and efferent neural modulation and with modulators positioned for stimulation of Neural and Neuromuscular structures of the Pylorus, Pyloric Antrum, Greater Curvature, and Lesser Curvature of the Stomach. 
           [0078]      FIG. 17  depicts the Normal Spinal Cord Anatomy, shown in Transverse Section. 
           [0079]      FIG. 18  depicts GastroPace implanted with multiple modulators positioned for modulation of Spinal Cord structures 
           [0080]      FIG. 19  depicts the three muscle layers of the stomach. 
           [0081]      FIG. 20  depicts GastroPace with modulators implanted along the surface of the stomach. 
           [0082]      FIG. 21  depicts GastroPace with an array of modulators implanted along the surface of the stomach. 
           [0083]      FIG. 22  depicts a GastroPace array, with multiple pulse generators implanted. This figure is exemplary, with two pulse generators shown each in the thorax and abdomen, each connected to modulators. 
           [0084]      FIG. 23  depicts GastroPace, with two pulse generators shown in an exemplary configuration in the abdomen, each connected to modulators. 
           [0085]      FIG. 24  depicts GastroPace, in a close up view of modulators implanted in he abdomen. 
           [0086]      FIG. 25  depicts GastroPace, in a close up view of modulators implanted in he abdomen. 
           [0087]      FIG. 26  depicts GastroPace, in a close up view of modulators and modulator arrays implanted in he abdomen. 
           [0088]      FIG. 27  depicts GastroPace, in a close up view of the modulators implanted adjacent to the spinal cord, spinal nerves, dorsal root ganglia, and adjacent structures. 
           [0089]      FIG. 28  depicts GastroPace, in a detailed view of that shown in the parent case in  FIG. 15 , with more detail of the modulators shown. This figure shows exemplary modulators of the design shown in  FIG. 7 . 
           [0090]      FIG. 29  depicts GastroPace, in a detailed view of that shown in the parent case in  FIG. 15 , with more detail of the modulators shown. This figure shows exemplary modulators similar to the catheter design shown in  FIG. 35 . 
           [0091]      FIG. 30  depicts GastroPace, in a detailed view of that shown in the parent case in  FIG. 15 , with more detail of the modulators shown. This figure shows exemplary modulators a wireless catheter design. 
           [0092]      FIG. 31  depicts GastroPace, in a detailed view of that shown in the parent case in  FIG. 15 , with more detail of the modulators shown. This figure shows exemplary modulators a wireless cylindrical or injectable implant design. 
           [0093]      FIG. 32  depicts GastroPace, in a detailed view of that shown in the parent case in  FIG. 15 , with more detail of the modulators shown. This figure shows exemplary modulators similar to the catheter design shown in  FIG. 35 . 
           [0094]      FIG. 33  depicts electrode catheter being implanted with surgical tools. 
           [0095]      FIG. 34  depicts electrode catheter being implanted with surgical tools. 
           [0096]      FIG. 35  depicts neuromodulatory interface array catheter in detailed view. 
           [0097]      FIG. 36  depicts neurophysiological effects of GastroPace functions, with view of time course of response of autonomic index to modulation of at least one of sympathetic and parasympathetic nervous systems. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0098]    The present invention encompasses a multimodality technique, method, and apparatus for the treatment of several diseases, including but not limited to obesity, eating disorders, depression, epilepsy, and diabetes. 
         [0099]    These modalities may be used for diagnostic and therapeutic uses, and these modalities include but are not limited to stimulation of gastric tissue, stimulation of gastric musculature, stimulation of gastric neural tissue, stimulation of sympathetic nervous tissue, stimulation of parasympathetic nervous tissue, stimulation of peripheral nervous tissue, stimulation of central nervous tissue, stimulation of cranial nervous tissue, stimulation of skin receptors, including Pacinian corpuscles, nociceptors, golgi tendons, and other sensory tissues in the skin, subcutaneous tissue, muscles, and joints. 
         [0100]    Stimulation may be accomplished by electrical means, optical means, electromagnetic means, radiofrequency means, electrostatic means, magnetic means, vibrotactile means, pressure means, pharmacologic means, chemical means, electrolytic concentration means, thermal means, or other means for altering tissue activity. 
         [0101]    Already encompassed in the above description are several specific applications of this broad technology. These specific applications include electrical stimulation of gastric tissue, including at least one of muscle and neural, for the control of appetite and satiety, and for the treatment of obesity. Additional specific uses include electrical stimulation of gastric tissue for the treatment of depression. Further uses include electrical stimulation of pancreatic tissue for the treatment of diabetes. 
         [0102]    A. Satiety Modulation. 
         [0103]    A1. Sympathetic Afferent Stimulation. Selected stimulation of the sympathetic nervous system is an objective of the present invention. A variety of modulator designs and configurations are included in the present invention and other designs and configurations may be apparent to those skilled in the art and these are also included in the present invention. Said modulator may take the form of electrode or electrical source, optical source, electromagnetic source, radiofrequency source, electrostatic source, magnetic source, vibrotactile source, pressure source, pharmacologic source, chemical source, electrolyte source, thermal source, or other energy or stimulus source. 
         [0104]    One objective of the modulator design for selective sympathetic nervous system stimulation is the avoidance of stimulation of the vagus nerve. Stimulation of the vagus nerve poses the risk enhanced propensity for development of gastric or duodenal ulcers. 
         [0105]    Other techniques in which electrical stimulation has been used for the treatment of obesity have included stimulation of central nervous system structures or peripheral nervous system structures. Other techniques have used sequential stimulation of the gastric tissue to interrupt peristalsis; however, this broad stimulation of gastric tissue necessarily overlaps regions heavily innervated by the vagus nerve and consequently poses the same risks of gastric and duodenal ulcers that stimulation of the vagus nerve does. 
         [0106]    One objective of the present invention is the selective stimulation of said afferent neural fibers that innervate gastric tissue. Avoidance of vagus nerve stimulation is an object of this modulator configuration. Other alternative approaches to gastric pacing involving gastric muscle stimulation secondarily cause stimulation of the vagus nerve as well as stimulation of gastric tissues in acid-secreting regions, consequently posing the undesirable side effects of gastric and duodenal ulcers secondary to activation of gastric acid stimulation. 
         [0107]    There are a number of approaches to selective stimulation of the sympathetic nervous system. This invention includes stimulation of the sympathetic fibers at sites including the zones of innervation of the stomach, the gastric innervation zones excluding those innervated by vagus branches, the distal sympathetic branches proximal to the stomach, the sympathetic trunk, the intermediolateral nucleus, the locus ceruleus, the hypothalamus, and other structures comprising or influencing sympathetic afferent activity. 
         [0108]    Stimulation of the sympathetic afferent fibers elicits the perception of satiety, and achievement of chronic, safe, and efficacious modulation of sympathetic afferents is one of the major objectives of the present invention. 
         [0109]    Alternating and augmenting stimulation of the sympathetic nervous system and vagus nerve is included in the present invention. By alternating stimulation of the vagus nerve and the sympathetic afferent fibers, one may induce the sensation of satiety in the implanted patient while minimizing the potential risk for gastric and duodenal ulcers. 
         [0110]    Since vagus and sympathetic afferent fibers carry information that is related to gastric distention, a major objective of the present invention is the optimization stimulation of the biggest fibers, the afferent sympathetic nervous system fibers, and other afferent pathways such that a maximal sensation of satiety is perceived in the implanted individual and such that habituation of this sensation of satiety is minimized. This optimization is performed in any combination of matters including temporal patterning of the individual signals to each neural pathway, including but not limited to the vagus nerve and sympathetic afferents, as well as temporal patterning between a multiplicity of stimulation channels involving the same were neural pathways The present invention teaches a multiplicity of apparatus and method for stimulation of afferent sympathetic fibers, as detailed below. Other techniques and apparatus may become apparent to those skilled in the art, without departing from the present invention. 
         [0111]    A1a. Sympathetic Afferents—Gastric Region.  FIG. 1  through  FIG. 3  demonstrate stimulation of gastric tissue, including at least one of neural and muscular tissue. Anatomical structures include esophagus  15 , lower esophageal sphincter  14 , stomach  8 , cardiac notch of stomach  16 , gastric fundus  9 , greater curvature of stomach  10 , pyloric antrum  11 , lesser curvature of stomach  17 , pylorus  12 , and duodenum  13 . 
         [0112]    Implantable pulse generator  1  is shown with modulator  2  and modulator  3  in contact with the corresponding portion of stomach  8  in the respective figures, detailed below. Implantable pulse generator further comprises attachment fixture  4  and attachment fixture  5 . Additional or fewer attachment fixtures may be included without departing from the present invention. Attachment means  6  and attachment means  7  are used to secure attachment fixture  4  and attachment fixture  5 , respectively to appropriate portion of stomach  8 . Attachment means  6  and attachment means  7  may be comprised from surgical suture material, surgical staples, adhesives, or other means without departing from the present invention. 
         [0113]    FIGS.  1 , 2 , and  3  show implantable pulse generator  1  in several anatomical positions. In  FIG. 1 , implantable pulse generator  1  is shown positioned along the superior region of the greater curvature of stomach  10 , with modulator  2  and modulator  3  in contact with the tissues comprising the greater curvature of stomach  10 . In  FIG. 2 , implantable pulse generator  1  is shown positioned along the inferior region of the greater curvature of stomach  10 , with modulator  2  and modulator  3  in contact with the tissues comprising the greater curvature of stomach  10 . In  FIG. 3 , implantable pulse generator  1  is shown positioned along the pyloric antrum  11 , with modulator  2  and modulator  3  in contact with the tissues comprising the pyloric antrum  11 . 
         [0114]    Modulator  2  and modulator  3  are used to stimulate at least one of gastric longitudinal muscle layer, gastric circular muscle layer, gastric nervous tissue, or other tissue. Modulator  2  and modulator  3  may be fabricated from nonpenetrating material or from penetrating material, including needle tips, arrays of needle tips, wires, conductive sutures, other conductive material, or other material, without departing from the present invention. 
         [0115]    A1b. Sympathetic Afferents—Sympathetic Trunk. The present invention teaches apparatus and method for stimulation of sympathetic afferent fibers using stimulation in the region of the sympathetic trunk. As shown in  FIGS. 14 ,  15 , and  16 , sympathetic trunk neuromodulatory interface  83  and  85 , positioned on right sympathetic trunk  71 , and sympathetic trunk neuromodulatory interface  85 ,  86  positioned on left sympathetic trunk  72 , are used to provide stimulation for afferent as well as for efferent sympathetic nervous system modulation. Modulation of efferent sympathetic nervous system is discussed below, and this is used for metabolic modulation. 
         [0116]    A1c. Sympathetic Afferents—Other. The present invention teaches apparatus and method for stimulation of sympathetic afferent fibers using stimulation of nerves arising from the sympathetic trunk. As shown in  FIGS. 14 ,  15 , and  16 , thoracic splanchnic neuromodulatory interface  87 ,  89 ,  88 , and  90 , positioned on right greater splanchnic nerve  73 , right lesser splanchnic nerve  75 , left greater splanchnic nerve  74 , left lesser splanchnic nerve  76 , respectively, and are used to provide stimulation for afferent as well as for efferent sympathetic nervous system modulation. Modulation of efferent sympathetic nervous system is discussed below, and this is used for metabolic modulation. 
         [0117]    A2. Gastric Musculature Stimulation. A further object of the present invention is the stimulation of the gastric musculature. This may be performed using either or both of closed loop and open loop control. In the present embodiment, a combination of open and closed loop control is employed. The open loop control provides a baseline level of gastric stimulation. This stimulation maintains tone of the gastric musculature. This increases the wall tension the stomach and plays a role in the perception of satiety in the implanted patient. Additionally, stimulation of the gastric musculature causes contraction of the structures, thereby reducing the volume of the stomach. This gastric muscle contraction, and the consequent reduction of stomach volume effectively restricts the amount of food that may be ingested. Surgical techniques have been developed and are known to those practicing in the field of surgical treatment of obesity. Several of these procedures are of the restrictive type, but because of their surgical nature they are fixed in magnitude and difficult if not impossible to reverse. The present invention teaches a technique which employs neural modulation and gastric muscle stimulation which by its nature is the variable and reversible. This offers the advantages postoperative adjustment of magnitude, fine tuning for the individual patient, varying of magnitude to suit the patient&#39;s changing needs and changing anatomy over time, and the potential for reversal or termination of treatment. Furthermore, since the gastric wall tension is generated in a physiological manner by the muscle itself, it does not have the substantial risk of gastric wall necrosis and rupture inherent in externally applied pressure, as is the case with gastric banding. 
         [0118]      FIGS. 1 ,  2 , and  3  depict placements of the implantable pulse generator  1  that may be used to stimulate gastric muscle tissue. Stimulation of both longitudinal and circular muscle layers is included in the present invention. Stimulation of gastric circular muscle layer causes circumferential contraction of the stomach, and stimulation of gastric longitudinal muscle layer causes longitudinal contraction of the stomach. 
         [0119]    This muscle stimulation and contraction accomplishes several objectives: (1) functional reduction in stomach volume, (2) increase in stomach wall tension, (3) reduction in rate of food bolus flow. All of these effects are performed to induce the sensation of satiety. 
         [0120]    A3. Gastric Pylorus Stimulation.  FIG. 4  depicts implantable pulse generator  1  positioned to perform stimulation of the gastric pylorus  12  to induce satiety by restricting outflow of food bolus material from the stomach  8  into the duodenum  13 . Stimulation of the pylorus  12  may be continuous, intermittent, or triggered manually or by sensed event or physiological condition.  FIG. 4  depicts implantable pulse generator  1  positioned adjacent to the gastric pylorus  12 ; this position provides secure modulator positioning while eliminating the risk of modulator and wire breakage inherent in other designs in which implantable pulse generator  1  is positioned remote from the gastric pylorus  12 . 
         [0121]      FIG. 5  depicts implantable pulse generator  1  positioned to perform stimulation of the gastric pylorus  12  to induce satiety by restricting outflow of food bolus material from the stomach  8  into the duodenum  13 . Stimulation of the pylorus  12  may be continuous, intermittent, or triggered manually or by sensed event or physiological condition.  FIG. 5  depicts implantable pulse generator  1  attached to stomach  8 , specifically by the pyloric antrum  11 ; this position facilitates the use of a larger implantable pulse generator  1 . The risk of modulator and wire breakage is minimized by the use of appropriate strain relief and stranded wire designs. 
         [0122]    A4. Parasympathetic Stimulation. The parasympathetic nervous system is complementary to the sympathetic nervous system and plays a substantial role in controlling digestion and cardiac activity. Several routes are described in the present invention to modulate activity of the parasympathetic nervous system. 
         [0123]    A4a. Parasympathetic Stimulation—Vagus Nerve. Others have advocated the use of vagus nerve stimulation for the treatment of a number of disorders including obesity. Zabara and others have described systems in which the vagus nerve in the region of the neck is stimulated. This is plagued with a host of problems, including life-threatening cardiac complications as well as difficulties with speech and discomfort during stimulation. The present invention is a substantial advance over that discussed by Zabara et al, in which unrestricted fiber activation using epineural stimulation is described. That technique results in indiscriminate stimulation of efferent and afferent fibers. With vagus nerve stimulation, efferent fiber activation generates many undesirable side effects, including gastric and duodenal ulcers, cardiac disturbances, and others. 
         [0124]    In the present invention, as depicted in  FIG. 14 , vagus neuromodulatory interface  97  and  98  are implanted adjacent to and in communication with right vagus nerve  95  and left vagus nerve  96 . The neuromodulatory interface  97  and  98  overcomes these limitations that have persisted for over a decade with indiscriminate vagus nerve stimulation, by selectively stimulating afferent fibers of the at least one of the vagus nerve, the sympathetic nerves, and other nerves. The present invention includes the selective stimulation of afferent fibers using a technique in which electrical stimulation is used to block anterograde propagation of action potentials along the efferent fibers. The present invention includes the selective stimulation of afferent fibers using a technique in which stimulation is performed proximal to a nerve transection and in which the viability of the afferent fibers is maintained. One such implementation involves use of at least one of neuromodulatory interface  34  which is of the form shown in at least one of Longitudinal Electrode Neuromodulatory Interface  118 , Longitudinal Electrode Regeneration Port Neuromodulatory Interface  119 , Regeneration Tube Neuromodulatory Interface  120 , neuromodulatory interface array catheter  284  or other design which may become apparent to one skilled in the art, including designs in which a subset of the neuronal population is modulated. 
         [0125]    A.4.a.i. Innovative Stimulation Anatomy.  FIG. 6  depicts multimodal treatment for the generation of satiety, using sympathetic stimulation, gastric muscle stimulation, gastric pylorus stimulation, and vagus nerve stimulation. This is described in more detail below. Modulators  30  and  31  are positioned in the general region of the lesser curvature of stomach  17 . Stimulation in this region results in activation of vagus nerve afferent fibers. Stimulation of other regions may be performed without departing from the present invention. In this manner, selective afferent vagus nerve stimulation may be achieved, without the detrimental effects inherent in efferent vagus nerve stimulation, including cardiac rhythm disruption and induction of gastric ulcers. 
         [0126]    A.4.a.ii. Innovative Stimulation Device. The present invention further includes devices designed specifically for the stimulation of afferent fibers. 
         [0127]      FIG. 7  depicts epineural cuff electrode neuromodulatory interface  117 , one of several designs for neuromodulatory interface  34  included in the present invention. Nerve  35  is shown inserted through nerve cuff  36 . For selective afferent stimulation, the nerve  35  is transected distal to the epineural cuff electrode neuromodulatory interface  117 . This case is depicted here, in which transected nerve end  37  is seen distal to epineural cuff electrode neuromodulatory interface  117 . Epineural electrode  49 ,  50 , and  51  are mounted along the inner surface of nerve cuff  36  and in contact or close proximity to nerve  35 . Epineural electrode connecting wire  52 ,  53 ,  54  are electrically connected on one end to epineural electrode  49 ,  50 , and  51 , respectively, and merge together on the other end to form connecting cable  55 . 
         [0128]      FIG. 8  depicts longitudinal electrode neuromodulatory interface  118 , one of several designs for neuromodulatory interface  34  included in the present invention. Nerve  35  is shown inserted into nerve cuff  36 . For selective afferent stimulation, the nerve  35  is transected prior to surgical insertion into nerve cuff  36 . Longitudinal electrode array  38  is mounted within nerve cuff  36  and in contact or close proximity to nerve  35 . Connecting wire array  40  provides electrical connection from each element of longitudinal electrode array  38  to connecting cable  55 . Nerve cuff end plate  41  is attached to the distal end of nerve cuff  36 . Nerve  35  may be advanced sufficiently far into longitudinal electrode array  38  such that elements of longitudinal electrode array  38  penetrate into nerve  35 . Alternatively, nerve  35  may be placed with a gap between transected nerve end  37  and longitudinal electrode array  38  such that neural regeneration occurs from transected nerve end  37  toward and in close proximity to elements of longitudinal electrode array  38 . 
         [0129]      FIG. 9  depicts longitudinal electrode regeneration port neuromodulatory interface  119 , an improved design for neuromodulatory interface  34  included in the present invention. Nerve  35  is shown inserted into nerve cuff  36 . For selective afferent stimulation, the nerve  35  is transected prior to surgical insertion into nerve cuff  36 . Longitudinal electrode array  38  is mounted within nerve cuff  36  and in contact or close proximity to nerve  35 . Connecting wire array  40 . provides electrical connection from each element of longitudinal electrode array  38  to connecting cable  55 . Nerve cuff end plate  41  is attached to the distal end of nerve cuff  36 . Nerve  35  may be advanced sufficiently far into longitudinal electrode array  38  such that elements of longitudinal electrode array  38  penetrate into nerve  35 . Alternatively, nerve  35  may be placed with a gap between transected nerve end  37  and longitudinal electrode array  38  such that neural regeneration occurs from transected nerve end  37  toward and in close proximity to elements of longitudinal electrode array  38 . At least one of nerve cuff  36  and nerve cuff end plate  41  are perforated with one or a multiplicity of regeneration port  39  to facilitate and enhance regeneration of nerve fibers from transected nerve end  37 . 
         [0130]      FIG. 10  depicts regeneration tube neuromodulatory interface  120 , an advanced design for neuromodulatory interface  34  included in the present invention. Nerve  35  is shown inserted into nerve cuff  36 . For selective afferent stimulation, the nerve  35  is transected prior to surgical insertion into nerve cuff  36 . Regeneration electrode array  44  is mounted within regeneration tube array  42 , which is contained within nerve cuff  36 . Each regeneration tube  43  contains at least one element of regeneration electrode array  44 . Each element of regeneration electrode array  44  is electrically connected by at least one element of connecting wire array  40  to connecting cable  55 . Nerve  35  may be surgically inserted into nerve cuff  36  sufficiently far to be adjacent to regeneration tube array  42  or may be placed with a gap between transected nerve end  37  and regeneration tube array  42 . Neural regeneration occurs from transected nerve end  37  toward and through regeneration tube  43  elements regeneration tube array  42 . 
         [0131]    The present invention further includes stimulation of other tissues that influence vagus nerve activity. These include tissues of the esophagus, stomach, small and large intestine, pancreas, liver, gallbladder, kidney, mesentery, appendix, bladder, uterus, and other intraabdominal tissues. Stimulation of one or a multiplicity of these tissues modulates activity of the vagus nerve afferent fibers without significantly altering activity of efferent fibers. This method and the associated apparatus facilitates the stimulation of vagus nerve afferent fibers without activating vagus nerve efferent fibers, thereby overcoming the ulcerogenic and cardiac side effects of nonselective vagus nerve stimulation. This represents a major advance in vagus nerve modulation and overcomes the potentially life-threatening complications of nonselective stimulation of the vagus nerve. 
         [0132]    A4b. Parasympathetic Stimulation—Other. The present invention teaches stimulation of the cervical nerves or their roots or branches for modulation of the parasympathetic nervous system. Additionally, the present invention teaches stimulation of the sacral nerves or their roots or branches for modulation of the parasympathetic nervous system. 
         [0133]    A5. Multichannel Satiety Modulation.  FIG. 6  depicts apparatus and method for performing multichannel modulation of satiety. Implantable pulse generator  1  is attached to stomach  8 , via attachment means  6  and  7  connected from stomach  8  to attachment fixture  4  and  5 , respectively. Implantable pulse generator  1  is electrically connected via modulator cable  32  to modulators  24 ,  25 ,  26 ,  27 ,  28 , and  29 , which are affixed to the stomach  8  preferably along the region of the greater curvature of stomach  10 . Implantable pulse generator  1  is additionally electrically connected via modulator cable  33  to modulators  30  and  31 , which are affixed to the stomach  8  preferably along the region of the lesser curvature of stomach  17 . Implantable pulse generator  1  is furthermore electrically connected via modulator cable  18  and  19  to modulators  2  and  3 , respectively, which are affixed to the gastric pylorus  12 . Modulator  2  is affixed to gastric pylorus via modulator attachment fixture  22  and  23 , and modulator  3  is affixed to gastric pylorus via modulator attachment fixture  20  and  21 . 
         [0134]    Using the apparatus depicted in  FIG. 6 , satiety modulation is achieved through multiple modalities. A multiplicity of modulators, including modulator  30  and  31  facilitate stimulation of vagus and sympathetic afferent fibers directly, as well as through stimulation of tissues, including gastric muscle, that in turn influence activity of the sympathetic and vagus afferent fibers. A multiplicity of modulators, including modulator  24 ,  25 ,  26 ,  27 ,  28 , and  29  facilitate stimulation of sympathetic afferent fibers directly, as well as through stimulation of tissues, including gastric muscle, that in turn influence activity of the sympathetic fibers. Any of these modulators may be used to modulate vagus nerve activity; however, one advancement taught in the present invention is the selective stimulation of sympathetic nerve fiber activation, and this is facilitated by modulators  24 ,  25 ,  26 ,  27 ,  28 , and  29 , by virtue of their design for and anatomical placement in regions of the stomach  8  that are not innervated by the vagus nerve or its branches. 
         [0135]    In addition to the apparatus and methods depicted in  FIG. 6  for satiety modulation, the present invention further includes satiety modulation performed with the apparatus depicted in  FIG. 16 , and described previously, using stimulation of right sympathetic trunk  71 , left sympathetic trunk  72 , right greater splanchnic nerve  73 , left greater splanchnic nerve  74 , right lesser splanchnic nerve  75 , left lesser splanchnic nerve  76  or other branch or the sympathetic nervous system. 
         [0136]    B. Metabolic Modulation 
         [0137]    B.1. Sympathetic Efferent Stimulation. One objective of the modulator configuration employed in the present invention is the selected stimulation of sympathetic efferent nerve fibers. The present invention includes a multiplicity of potential modulator configurations and combinations of thereof. The present embodiment includes modulators placed at a combination of sites to interface with the sympathetic efferent fibers. These sites include the musculature of the stomach, the distal sympathetic branches penetrating into the stomach, postganglionic axons and cell bodies, preganglionic axons and cell bodies, the sympathetic chain and portions thereof, the intermediolateral nucleus, the locus ceruleus, the hypothalamus, and other structures comprising or influencing activity of the sympathetic nervous system. 
         [0138]    Stimulation of the sympathetic efferents is performed to elevate the metabolic rate and lipolysis in the adipose tissue, thereby enhancing breakdown of fat and weight loss in the patient. 
         [0139]    B.1.a. Sympathetic Efferent Stimulation Sympathetic Trunk.  FIGS. 14 ,  15 , and  16  depict apparatus for stimulation of the sympathetic nervous system.  FIG. 14  depicts a subset of anatomical locations for placement of neuromodulatory interfaces for modulation of the sympathetic nervous system.  FIG. 15  depicts the same apparatus with the further addition of a set of implantable pulse generator  1  and connecting cables.  FIG. 16  depicts the apparatus shown in  FIG. 15  with the further addition of gastric modulation apparatus also depicted in  FIG. 6 . 
         [0140]      FIG. 13  reveals the normal anatomy of the thoracic region. Trachea  63  is seen posterior to aortic arch  57 . Brachiocephalic artery  59 , left common carotid artery  60  arise from aortic arch  57 , and left subclavian artery  61  arises from the left common carotid artery  60 . Right mainstem bronchus  64  and left mainstem bronchus  65  arise from trachea  63 . Thoracic descending aorta  58  extends from aortic arch  57  and is continuous with abdominal aorta  62 . Right vagus nerve  95  and left vagus nerve  96  are shown. Intercostal nerve  69  and  70  are shown between respective pairs of ribs, of which rib  67  and rib  68  are labeled. 
         [0141]    Right sympathetic trunk  71  and left sympathetic trunk are lateral to mediastinum  82 . Right greater splanchnic nerve  73  and right lesser splanchnic nerve  75  arise from right sympathetic trunk  71 . Left greater splanchnic nerve  74  and left lesser splanchnic nerve  76  arise from left sympathetic trunk  72 . Right subdiaphragmatic greater splanchnic nerve  78 , left subdiaphragmatic greater splanchnic nerve  79 , right subdiaphragmatic lesser splanchnic nerve  80 , and left subdiaphragmatic lesser splanchnic nerve  81  are extensions below the diaphragm  77  of the right greater splanchnic nerve  73 , left greater splanchnic nerve  74 , right lesser splanchnic nerve  75 , and left lesser splanchnic nerve  76 , respectively. 
         [0142]    B.1.b. Sympathetic Efferent Stimulation—Splanchnics.  FIG. 14  depicts multichannel sympathetic modulation implanted with relevant anatomical structures. Sympathetic trunk neuromodulatory interface  83  and  85  are implanted adjacent to and in communication with right sympathetic trunk  71 . Sympathetic trunk neuromodulatory interface  84  and  86  are implanted adjacent to and in communication with left sympathetic trunk  72 . Sympathetic trunk neuromodulatory interface  83 ,  84 ,  85 , and  86  are implanted superior to their respective sympathetic trunk levels at which the right greater splanchnic nerve  73 , left greater splanchnic nerve  74 , right lesser splanchnic nerve  75 , and left lesser splanchnic nerve  76 , arise, respectively. 
         [0143]    Thoracic splanchnic nerve interface  87 ,  88 ,  89 ,  90  are implanted adjacent to and in communication with the right greater splanchnic nerve  73 , left greater splanchnic nerve  74 , right lesser splanchnic nerve  75 , and left lesser splanchnic nerve  76 , arise, respectively. Abdominal splanchnic nerve interface  91 ,  92 ,  93 , and  94  are implanted adjacent to and in communication with the right subdiaphragmatic greater splanchnic nerve  78 , left subdiaphragmatic greater splanchnic nerve  79 , right subdiaphragmatic lesser splanchnic nerve  80 , and left subdiaphragmatic lesser splanchnic nerve  81 , respectively. 
         [0144]    Stimulation of at least one of right sympathetic trunk  71 , left sympathetic trunk  72 , right greater splanchnic nerve  73 , left greater splanchnic nerve  74 , right lesser splanchnic nerve  75 , and left lesser splanchnic nerve  76 , right subdiaphragmatic greater splanchnic nerve  78 , left subdiaphragmatic greater splanchnic nerve  79 , right subdiaphragmatic lesser splanchnic nerve  80 , and left subdiaphragmatic lesser splanchnic nerve  81  enhances metabolism of adipose tissue. Stimulation of these structures may be performed using at least one of electrical energy, electrical fields, optical energy, mechanical energy, magnetic energy, chemical compounds, pharmacological compounds, thermal energy, vibratory energy, or other means for modulating neural activity. 
         [0145]      FIG. 15  depicts the implanted neuromodulatory interfaces as in  FIG. 14 , with the addition of the implanted pulse generators. Implantable pulse generator  99  is connected via connecting cable  103 ,  105 ,  107 ,  109 ,  115 , to sympathetic trunk neuromodulatory interface  83  and  85 , and thoracic splanchnic neuromodulatory interface  87  and  89 , and vagus neuromodulatory interface  97 , respectively. Implantable pulse generator  100  is connected via connecting cable  104 ,  106 ,  108 ,  110 ,  116 , to sympathetic trunk neuromodulatory interface  83  and  85 , and thoracic splanchnic neuromodulatory interface  88  and  90 , and vagus neuromodulatory interface  98 , respectively. Implantable pulse generator  101  is connected via connecting cable  111  and  113  to abdominal splanchnic neuromodulatory interface  91  and  93 , respectively. Implantable pulse generator  102  is connected via connecting cable  112  and  114  to abdominal splanchnic neuromodulatory interface  92  and  94 , respectively. 
         [0146]    B.1.c. Sympathetic Efferent Stimulation - Spinal Cord.  FIGS. 17 and 18  depicts the normal cross sectional anatomy of the spinal cord  151  and anatomy with implanted neuromodulatory interfaces, respectively. 
         [0147]      FIG. 17  depicts the normal anatomical structures of the spinal cord  151 , including several of its component structures such as the intermediolateral nucleus  121 , ventral horn of spinal gray matter  141 , dorsal horn of spinal gray matter  142 , spinal cord white matter  122 , anterior median fissure  123 . Other structures adjacent to or surrounding spinal cord  151  include ventral spinal root  124 , dorsal spinal root  125 , spinal ganglion  126 , spinal nerve  127 , spinal nerve anterior ramus  128 , spinal nerve posterior ramus  129 , gray ramus communicantes  130 , white ramus communicantes  131 , sympathetic trunk  132 , pia mater  133 , subarachnoid space  134 , arachnoid  135 , meningeal layer of dura mater  136 , epidural space  137 , periosteal layer of dura mater  138 , and vertebral spinous process  139 , and vertebral facet  140 . 
         [0148]      FIG. 17  depicts the normal anatomy of the spinal cord seen in transverse section. Spinal cord and related neural structures structures include intermediolateral nucleus  121 , spinal cord white matter  122 , anterior median fissure  123 , ventral spinal root  124 , dorsal spinal root  125 , spinal ganglion  126 , spinal nerve  127 , spinal nerve anterior ramus  128 , spinal nerve posterior ramus  129 , grey ramus communicantes  130 , white ramus communicantes  131 , sympathetic trunk  132 , pia mater  133 , subarachnoid space  134 , arachnoid  135 , meningeal layer of dura  136 , epidural space  137 , periostial layer of dura mater  138 , vertebral spinous process  139 , vertebral facet  140 , ventral horn of spinal gray matter  141 , and dorsal horn of spinal gray matter  142 . 
         [0149]      FIG. 18  depicts the spinal neuromodulatory interfaces positioned in the vicinity of spinal cord  151 . Neuromodulatory interfaces positioned anterior to spinal cord  151  include anterior central spinal neuromodulatory interface  143 , anterior right lateral spinal neuromodulatory interface  144 , and anterior left lateral spinal neuromodulatory interface  145 . Neuromodulatory interfaces positioned posterior to spinal cord  151  include posterior central spinal neuromodulatory interface  146 , posterior right lateral spinal neuromodulatory interface  147 , and posterior left lateral spinal neuromodulatory interface  148 . Neuromodulatory interfaces positioned lateral to spinal cord  151  include right lateral spinal neuromodulatory interface  149  and left lateral spinal neuromodulatory interface  150 . Neuromodulatory interfaces positioned within the spinal cord  151  include intermediolateral nucleus neuromodulatory interface  152 . 
         [0150]    Stimulation, inhibition, or other modulation of the spinal cord  151  is used to modulate fibers of the sympathetic nervous system, including those in the intermediolateral nucleus  121  and efferent and efferent fibers connected to the intermediolateral nucleus  121 . Modulation of at least one of portions of the spinal cord  151 , intermediolateral nucleus  121 , ventral spinal root  124 , dorsal spinal root  125 , spinal ganglion  126 , spinal nerve  127 , gray ramus communicantes  130 , white ramus communicantes  131  and other structures facilitates modulation of activity of the sympathetic trunk  132 . Modulation of activity of the sympathetic trunk  132 , in turn, is used to modulate at least one of metabolic activity, satiety, and appetite. This may be achieved using intermediolateral nucleus neuromodulatory interface  152 , placed in or adjacent to the intermediolateral nucleus  121 . The less invasive design employing neuromodulatory interfaces ( 144 ,  145 ,  146 ,  147 ,  148 ,  149 ,  150 ) shown positioned in the in epidural space  137  is taught in the present invention. 
         [0151]      FIG. 19  depicts a cut away view of the stomach, revealing the four coats: serous, muscular, aerolar, and mucous. The gastric muscular coat  311  is comprised of  3  layers, the gastric longitudinal fibers  311 , gastric circular fibers  312 , and gastric oblique fibers  313 . Gastric longitudinal fibers  311  are most superficial; they are continuous with the longitudinal fibers of the esophagus  15 , radiating in a stellate manner from the cardiac orifice. They are most distinct along the curvatures, especially the lesser, but are very thinly distributed over the surfaces. At the pyloric end, they are more thickly distributed and are continuous with the longitudinal fibers of the small intestine. Gastric circular fibers  313  form a uniform layer over the whole extent of the stomach beneath the gastric longitudinal fibers  311 . At the gastric pylorus  12  they are most abundant and are aggregated into a circular ring, which projects into the lumen and forms, with the fold of mucous membrane covering its surface, the pyloric valve. They are continuous with the circular layers of the esophagus  15 . The gastric oblique fibers  314  are beneath the gastric circular fibers  313 . Stimulation of afferent neural fibers innervating stretch receptors in these muscle layers is taught in the parent case. This figure merely depicts anatomical detail. 
         [0152]    B.1.d. Sympathetic Efferent Stimulation—Other. The present invention further includes modulation of all sympathetic efferent nerves, nerve fibers, and neural structures. These sympathetic efferent neural structures include but are not limited to distal sympathetic nerve branches, mesenteric nerves, sympathetic efferent fibers at all spinal levels, rami communicantes at all spinal levels, paravertebral nuclei, prevertebral nuclei, and other sympathetic structures. 
         [0153]    B.2. Noninvasive Stimulation. The present invention teaches a device for metabolic control using tactile stimulation. Tactile stimulation of afferent neurons causes alterations in activity of sympathetic neurons which influence metabolic activity of adipose tissue. The present invention teaches tactile stimulation of skin, dermal and epidermal sensory structures, subcutaneous tissues and structures, and deeper tissues to modulate activity of afferent neurons. 
         [0154]    This device for metabolic control employs vibratory actuators. Alternatively, electrical stimulation, mechanical stimulation, optical stimulation, acoustic stimulation, pressure stimulation, and other forms of energy that modulate afferent neural activity, are used. 
         [0155]    C. Multimodal Metabolic Modulation. To maximize efficacy while tailoring treatment to minimize side effects, the preferred embodiment includes a multiplicity of treatment modalities, including afferent, efferent, and neuromuscular modulation. 
         [0156]    Afferent signals are generated to simulate satiety. This is accomplished through neural, neuromuscular, and hydrostatic mechanisms. Electrical stimulation of the vagus via vagus nerve interface  45  afferents provides one such channel to transmit information to the central nervous system for the purpose of eliciting satiety. Electrical stimulation of the sympathetic afferents via sympathetic nerve interface  46  provides another such channel to transmit information to the central nervous system for the purpose of eliciting satiety. Electrical stimulation of gastric circular muscle layerin  FIG. 11 , multimodal stimulation is depicted, including stimulation of gastric musculature using modulators  2  and  3 , as well as stimulation of afferent fibers of the proximal stump of vagus nerve  47  using vagus nerve modulator  45  and stimulation of afferent fibers of sympathetic nerve branch  48 . 
         [0157]    In  FIG. 12 , expanded multimodal stimulation is depicted, including those modalities shown in  FIG. 11 , including stimulation of gastric musculature using modulators  2  and  3 , as well as stimulation of afferent fibers of the proximal stump of vagus nerve  47  using vagus nerve modulator  45  and stimulation of afferent fibers of sympathetic nerve branch  48 , in addition to those modalities shown in  FIG. 6 , explained in detail above, including modulation of gastric muscular fibers, sympathetic afferent fibers innervating gastric tissues, and vagus afferent fibers innervating gastric tissues. 
         [0158]    In  FIG. 16 , further expanded multimodal modulation is depicted, including modalities encompassed and described above and depicted in  FIG. 15  and  FIG. 12 . This includes modulation of gastric muscle fibers, fibers of the sympathetic nerve branch  48  and vagus nerve  47  that innervate gastric tissues, and a multiplicity of structures in the sympathetic nervous system and vagus nerve  47 . 
         [0159]    E. System/Pulse Generator Design. Neuromodulatory interfaces that use electrical energy to modulate neural activity may deliver a broad spectrum of electrical waveforms. One preferred set of neural stimulation parameter sets includes pulse frequencies ranging from 0.1 Hertz to 1000 Hertz, pulse widths from 1 microsecond to 500 milliseconds. Pulses are charge balanced to insure no net direct current charge delivery. The preferred waveform is bipolar pulse pair, with an interpulse interval of 1 microsecond to 1000 milliseconds. Current regulated stimulation is preferred and includes pulse current amplitudes ranging from 1 microamp to 1000 milliamps. Alternatively, voltage regulation may be used, and pulse voltage amplitudes ranging from 1 microamp to 1000 milliamps. These parameters are provided as exemplary of some of the ranges included in the present invention; variations from these parameter sets are included in the present invention. 
         [0160]      FIG. 22  shows the same invention taught in the parent case. In this figure, the distal portion of the sympathetic nervous system is shown in more detail. In the parent case, modulation of the sympathetic nervous system was taught for the treatment of disease. When a portion of the nervous system is modulated, connected neural structures are likewise modulated. Neural structures proximal and distal to the location of the modulator are modulated by the action of the modulator. A multiplicity of locations for neuromodulators are presented in the parent case, and other locations may be selected without departing from the parent case invention. The addition of more detail of the nervous system renders obvious to the reader of the parent application additional locations for placement of neural modulators. 
         [0161]    In  FIG. 22 , additional anatomical structures shown include celiac plexus  154 , celiac ganglion  155 , superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , iliac plexus  161 , right lumbar sympathetic ganglia  162 , left lumbar sympathetic ganglia  163 , right sacral sympathetic ganglia  164 , and left sacral sympathetic ganglia  165 . 
         [0162]    It is obvious to the reader that modulation of the right greater splanchnic nerve  73 , the performance of which is exemplified by Abdominal Splanchnic Neuromodulatory Interface  91 , will in turn effect modulation of connected structures, including proximal and distal portions of Right Subdiaphragmatic Greater Splanchnic Nerve  78 . Proximal or retrograde conduction of neural signals will effect modulation of Right Greater Splanchnic Nerve  73  and more proximal structures. Distal or anterograde conduction of neural signals will effect modulation of distal structures including but not limited to celiac plexus  154 , celiac ganglion  155 , superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , iliac plexus  161 , and other structures connected by neural pathways. 
         [0163]    It is obvious to the reader that modulation of the left greater splanchnic nerve  74 , the performance of which is exemplified by Abdominal Splanchnic Neuromodulatory Interface  92 , will in turn effect modulation of connected structures, including proximal and distal portions of Left Subdiaphragmatic Greater Splanchnic Nerve  79 . Proximal or retrograde conduction of neural signals will effect modulation of Left Greater Splanchnic Nerve  74  and more proximal structures. Distal or anterograde conduction of neural signals will effect modulation of distal structures including but not limited to celiac plexus  154 , celiac ganglion  155 , superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , iliac plexus  161 , and other structures connected by neural pathways. 
         [0164]      FIG. 23  and  FIG. 24  show Abdominal Splanchnic Neuromodulatory Interface  91 , Abdominal Splanchnic Neuromodulatory Interface  92 , Abdominal Splanchnic Neuromodulatory Interface  93 , Abdominal Splanchnic Neuromodulatory Interface  94  and surrounding anatomical structures, as described above, at larger magnification. 
         [0165]      FIG. 25  shows Abdominal Splanchnic Neuromodulatory Interface  166 , Abdominal Splanchnic Neuromodulatory Interface  167 , Abdominal Splanchnic Neuromodulatory Interface  170 , and Abdominal Splanchnic Neuromodulatory Interface  171  in proximity to neural structures distal to and in neural communication with each of the right greater splanchnic nerve  73  and left greater splanchnic nerve  73 . 
         [0166]    Pulse generator  101  generates neuromodulatory signal which is transmitted by connecting cable  168  to abdominal splanchnic neuromodulatory interface  166 , which modulates at least one of celiac plexus  154  and celiac ganglion  155 . Implantable Pulse generator  102  generates neuromodulatory signal which is transmitted by connecting cable  169  to abdominal splanchnic neuromodulatory interface  167 , which modulates at least one of celiac plexus  154  and celiac ganglion  155 . 
         [0167]    Pulse generator  101  generates neuromodulatory signal which is transmitted by connecting cable  172  to abdominal splanchnic neuromodulatory interface  170 , which modulates at least one of superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , and iliac plexus  161 . Pulse generator  102  generates neuromodulatory signal which is transmitted by connecting cable  173  to abdominal splanchnic neuromodulatory interface  171 , which modulates at least one of superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , and iliac plexus  161 . 
         [0168]      FIG. 26  shows neuromodulator array  174  and neuromodulator array  175  in proximity to neural structures distal to and in neural communication with each of the right greater splanchnic nerve  73  and left greater splanchnic nerve  73 . 
         [0169]    Pulse generator  101  generates neuromodulatory signal which is transmitted by connecting cable  176  to neuromodulator array  174 , which modulates at least one of celiac plexus  154 , celiac ganglion  155 , superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , and iliac plexus  161 . 
         [0170]    Pulse generator  102  generates neuromodulatory signal which is transmitted by connecting cable  177  to neuromodulator array  175 , which modulates at least one of celiac plexus  154 , celiac ganglion  155 , superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , and iliac plexus  161 . 
         [0171]      FIG. 27  shows a transverse section through the spinal canal, vertebral columns, and adjacent structures in the lumbar region. The components described may be positioned at a higher level, including cervical and thoracic, or a lover level including sacral and coccygeal, without departing from the present invention. Perispinal neuromodulatory interfaces are described in the description for  FIG. 18 . Abdominal aorta  62  is shown. 
         [0172]    Abdominal Splanchnic Neuromodulatory Interface  178  modulate at least one of sympathetic trunk,  132 , Right Lumbar Sympathetic Ganglia  162 , and Right Sacral Sympathetic Ganglia  164 . Abdominal Splanchnic Neuromodulatory Interface  179  modulates at least one of sympathetic trunk,  132 , Left Lumbar Sympathetic Ganglia  163 , and Left Sacral Sympathetic Ganglia  165   
         [0173]    Abdominal Splanchnic Neuromodulatory Interface  180  modulates at least one neural structure in neural connection to sympathetic trunk  132 , including but not limited to right greater splanchnic nerve  73 , right lesser splanchnic nerve  75 , right least splanchnic nerve, or other structure. Abdominal Splanchnic Neuromodulatory Interface  181  modulates at least one neural structure in neural connection to sympathetic trunk  132 , including but not limited to left greater splanchnic nerve  74 , left lesser splanchnic nerve  76 , left least splanchnic nerve, or other structure. 
         [0174]    Abdominal Splanchnic Neuromodulatory Interface  182 , Abdominal Splanchnic Neuromodulatory Interface  183 , Abdominal Splanchnic Neuromodulatory Interface  184 , Abdominal Splanchnic Neuromodulatory Interface  185 , and Abdominal Splanchnic Neuromodulatory Interface  186  each modulate abdominal structures including but not limited to celiac plexus  154 , celiac ganglion  155 , superior mesenteric plexus  156 , superior mesenteric ganglion  157 , renal plexus  158 , renal ganglion  159 , inferior mesenteric plexus  160 , and iliac plexus  161 . 
         [0175]    Modulation is performed to modulate metabolic rate, satiety, blood pressure, heart rate, peristalsis, insulin release, CCK release, and other gastrointestinal functions. Modulation using the system and method taught, as well as equivalent modifications and variations thereof, allows the treatment of disease including obesity, bulimia, anorexia, diabetes, hypoglycemia, hyperglycemia, irritable bowel syndrome, hypertension, hypotension, shock, gastroparesis, and other disorders. Modulation includes at least one of stimulatory and inhibitory effect on neural structures. 
         [0176]      FIG. 28  shows the same invention taught in the parent case and shown in  FIG. 16 , with detail shown for the nerve cuff electrode implementation for the neuromodulatory interfaces. In this figure, the distal portion of the sympathetic nervous system is shown in more detail. In the parent case, modulation of the sympathetic nervous system was taught for the treatment of disease, and several nerve cuff electrode designs were presented in  FIGS. 7 ,  8 ,  9 , and  10  as a subset of many possible implementations of a neuromodulator or neuromodulatory interface. This  FIG. 28  shows one of many potential arrangements of these components shown in the parent case; numerous other arrangements will be apparent to one skilled in the art upon reading the parent patent specification and figures. 
         [0177]      FIG. 29  shows the same invention taught in the parent case and shown in  FIG. 16 , with detail shown for an electrode catheter, a linear catheter based electrode implementation for the neuromodulatory interfaces. In this figure, the distal portion of the sympathetic nervous system is shown in more detail. In the parent case, modulation of the sympathetic nervous system was taught for the treatment of disease. This  FIG. 29  shows another potential arrangement of electrodes that become apparent to one skilled in the art upon reading the parent patent specification and figures. 
         [0178]    Implantable pulse generator  99  is connected via connecting cable  213 ,  215 ,  217 ,  219 ,  221 , and  235  to Right Cervical Plexus Neuromodulator Array  193 , Right Intercostal Neuromodulator Array  195 , Right Intercostal Neuromodulator Array  197 , Right Intercostal Neuromodulator Array  199 , Right Intercostal Neuromodulator Array  201 , and Right Vagal Neuromodulator Array  233 , respectively. 
         [0179]    Implantable pulse generator  100  is connected via connecting cable  214 ,  216 ,  218 ,  220 ,  222 , and  236  to Left Cervical Plexus Neuromodulator Array  194 , Left Intercostal Neuromodulator Array  196 , Left Intercostal Neuromodulator Array  198 , Left Intercostal Neuromodulator Array  200 , and Left Intercostal Neuromodulator Array  202 , and Left Vagal Neuromodulator Array  234 , respectively. 
         [0180]    Implantable pulse generator  101  is connected via connecting cable  223 ,  225 ,  227 ,  229 , and  231  to Right Abdominal Para Plexus Neuromodulator Array  203 , Right Abdominal Greater Splanchnic Neuromodulator Array  205 , Right Abdominal Lesser Splanchnic Neuromodulator Array  207 , Right Abdominal Sympathetic Trunk Neuromodulator Array  209 , and Right Abdominal Sympathetic Trunk Neuromodulator Array  211 , respectively 
         [0181]    Implantable pulse generator  102  is connected via connecting cable  224 ,  226 ,  228 ,  230 , and  232  to Left Abdominal Para Plexus Neuromodulator Array  204 , Left Abdominal Greater Splanchnic Neuromodulator Array  206 , Left Abdominal Lesser Splanchnic Neuromodulator Array  208 , Left Abdominal Sympathetic Trunk Neuromodulator Array  210 , and Left Abdominal Sympathetic Trunk Neuromodulator Array  212 , respectively 
         [0182]    Right Cervical Plexus Neuromodulator Array  193  modulates neural activity in Right Cervical Plexus  237 . Right Intercostal Neuromodulator Array  195 , Right Intercostal Neuromodulator Array  197 , Right Intercostal Neuromodulator Array  199 , and Right Intercostal Neuromodulator Array  201  each modulate neural activity in at least one of Right Sympathetic Trunk  71 , Right Greater Splanchnic Nerve  73 , and Right Lesser Splanchnic Nerve  75 . Right Vagal Neuromodulator Array  233  modulates neural activity in Right Vagus Nerve  95 . 
         [0183]    Left Cervical Plexus Neuromodulator Array  194  modulates neural activity in Left Cervical Plexus  238 . Left Intercostal Neuromodulator Array  196 , Left Intercostal Neuromodulator Array  198 , Left Intercostal Neuromodulator Array  200 , and Left Intercostal Neuromodulator Array  202  each modulate neural activity in at least one of Left Sympathetic Trunk  72 , Left Greater Splanchnic Nerve  74 , and Left Lesser Splanchnic Nerve  76 . Left Vagal Neuromodulator Array  234  modulates neural activity in Left Vagus Nerve  96 . 
         [0184]    Right Abdominal Para Plexus Neuromodulator Array  203  modulates at least one of Celiac Plexus  154 , Celiac Ganglion  155 , Superior Mesenteric Plexus  156 , Superior Mesenteric Ganglion  157 , Renal Plexus  158 , Renal Ganglion  159 , Inferior Mesenteric Plexus  160 , and Iliac Plexus  161 . Right Abdominal Greater Splanchnic Neuromodulator Array  205  modulates Right Subdiaphragmatic Greater Splanchnic Nerve  78 . Right Abdominal Lesser Splanchnic Neuromodulator Array  207  modulates Right Subdiaphragmatic Lesser Splanchnic Nerve  80 . Right Abdominal Sympathetic Trunk Neuromodulator Array  209  and Right Abdominal Sympathetic Trunk Neuromodulator Array  211  each modulate at least one of Right Lumbar Sympathetic Ganglia  162 , Right Sacral Sympathetic Ganglia  164 , and Right Sympathetic Trunk  71 . 
         [0185]    Left Abdominal Para Plexus Neuromodulator Array  204  modulates at least one of Celiac Plexus  154 , Celiac Ganglion  155 , Superior Mesenteric Plexus  156 , Superior Mesenteric Ganglion  157 , Renal Plexus  158 , Renal Ganglion  159 , Inferior Mesenteric Plexus  160 , and Iliac Plexus  161 . Left Abdominal Greater Splanchnic Neuromodulator Array  206  modulates Left Subdiaphragmatic Greater Splanchnic Nerve  79 . Left Abdominal Lesser Splanchnic Neuromodulator Array  208  modulates Left Subdiaphragmatic Lesser Splanchnic Nerve  81 . Left Abdominal Sympathetic Trunk Neuromodulator Array  210  and Left Abdominal Sympathetic Trunk Neuromodulator Array  212  each modulate at least one of Left Lumbar Sympathetic Ganglia  163 , Left Sacral Sympathetic Ganglia  165 , and Left Sympathetic Trunk  72 . 
         [0186]    Elements comprising neuromodulators and neuromodulator arrays provide at least one of activating or inhibiting influence on neural activity of respective neurological target structures. Additional or fewer connecting cables and neuromodulator arrays may be employed without departing from the present invention. 
         [0187]    These connections provided by connecting cables may facilitate communication and/or power transmission via electrical energy, ultrasound energy, optical energy, radiofrequency energy, electromagnetic energy, thermal energy, mechanical energy, chemical agent, pharmacological agent, or other signal or power means without departing from the parent or present invention. 
         [0188]    Neuromodulator and neuromodulatory interface may be used interchangeably in this specification. Neuromodulator is a subset of modulator and modulates neural tissue. 
         [0189]      FIG. 30  shows the same invention taught in the parent case and shown in  FIG. 16 , with detail shown for a telemetrically powered linear catheter based electrode implementation for the neuromodulatory interfaces. In this  FIG. 30 , the distal portion of the sympathetic nervous system is shown in more detail. In the parent case, modulation of the sympathetic nervous system was taught for the treatment of disease. This  FIG. 30  shows the same neuromodulator configuration shown in  FIG. 29 , which is a potential arrangement of electrodes that becomes apparent to one skilled in the art upon reading the parent patent specification and figures. Each of the neuromodulator arrays includes a means for bidirectional transmission of information and power to and from at least one of an implantable pulse generator  99 .  100 ,  101 , and  102 , and an External Transmitting and Receiving Unit  239 . Each of the neuromodulator arrays includes a telemetry module, which serves as a means for bidirectional transmission of information and power to and from at least one of an implantable pulse generator  99 .  100 ,  101 , and  102  and External Transmitting and Receiving Unit  239 . Each of the neuromodulator arrays includes a means for bidirectional transmission of information and power to and from at least one of an External Transmitting and Receiving Unit  239 . Each of the implantable pulse generator  99 .  100 ,  101 , and  102  includes a means for bidirectional transmission of information and power to and from at least one of an External Transmitting and Receiving Unit  239 . 
         [0190]    External Transmitting and Receiving Unit  239  comprises modules including Controller  240 , Memory  241 , Bidirectional Transceiver  242 , and User Interface  243 . Additional or fewer modules may be included without departing from the present invention. 
         [0191]      FIG. 31  shows the same invention taught in the parent case and shown in  FIG. 16 , with detail shown for a telemetrically powered miniature enclosure based electrode implementation for the neuromodulatory interfaces. In one preferred embodiment, the neuromodulatory interfaces are implemented as injectable cylinders. These may have other cross sectional shapes, including flat meshes, paddles, or grid arrays, without departing from this invention. These may have other longitudinal profiles, including rectangular, tapered, serrated, convex, biconcave, or disk shapes, without departing from this invention. In this  FIG. 31 , the distal portion of the sympathetic nervous system is shown in more detail. In the parent case, modulation of the sympathetic nervous system was taught for the treatment of disease. This  FIG. 31  shows the same neuromodulator configuration shown in  FIG. 29 , which is a potential arrangement of electrodes that becomes apparent to one skilled in the art upon reading the parent patent specification and figures. Each of the neuromodulator arrays includes a means for bidirectional transmission of information and power to and from at least one of an implantable pulse generator  99 .  100 ,  101 , and  102 , and an External Transmitting and Receiving Unit  239 . The cylindrical enclosure based electrode implementation for the neuromodulatory interfaces may further be injectable or implantable via laparoscopic procedure, to facilitate minimally invasive implantation. 
         [0192]    Neuromodulatory interfaces include an energy storage element, such as capacitor, battery, or inductor, for storage of power for delivery to at least one of tissue and on board electronic components. 
         [0193]    External Transmitting and Receiving Unit  239  comprises modules including Controller  240 , Memory  241 , Bidirectional Transceiver  242 , and User Interface  243 . Additional or fewer modules and additional or fewer neuromodulatory interfaces may be included without departing from the present invention. 
         [0194]      FIG. 32 : shows the same invention taught in the parent case and shown in  FIG. 16 , with more anatomic detail shown for the autonomic nervous system and with placement of neuromodulatory interfaces for modulation of these structures. 
         [0195]    In addition to the thoracic anatomical structures shown on  FIG. 29 , the superficial cardiac plexus  244 , deep cardiac plexus  245 , right anterior pulmonary nerve  246 , and left anterior pulmonary nerve  247  are depicted in  FIG. 32 . 
         [0196]    In addition to the abdominal anatomical structures shown on  FIG. 29 , the renal plexus  158  and renal ganglion  159  are shown with more branches, including the right renal nerve branch  248 , and left renal nerve branch  249 . 
         [0197]    The activity of these structures are modulated by corresponding neuromodulatory interfaces. Any of the previously described neuromodulatory interfaces in the parent case and the present case may be positioned to modulate these neural structures. Additional or alternate designs for neuromodulatory interfaces may be employed without departing from the present or parent invention. 
         [0198]    Implantable pulse generator  99  is connected via connecting cable  213 ,  215 ,  217 ,  219 ,  221 ,  235 ,  258 ,  260 , and  268  to Right Cervical Plexus Neuromodulator Array  193 , Right Intercostal Neuromodulator Array  195 , Right Intercostal Neuromodulator Array  197 , Right Intercostal Neuromodulator Array  199 , Right Intercostal Neuromodulator Array  201 , and Right Vagal Neuromodulator Array  233 , Right Superficial Cardiac Plexus Neuromodulator Array  250 , Right Deep Cardiac Plexus Neuromodulator Array  252 , Right Anterior Pulmonary Nerve Neuromodulator Array  266 , respectively. 
         [0199]    Implantable pulse generator  100  is connected via connecting cable  214 ,  216 ,  218 ,  220 ,  222 ,  236 ,  259 ,  261 , and  269  to Left Cervical Plexus Neuromodulator Array  194 , Left Intercostal Neuromodulator Array  196 , Left Intercostal Neuromodulator Array  198 , Left Intercostal Neuromodulator Array  200 , and Left Intercostal Neuromodulator Array  202 , and Left Vagal Neuromodulator Array  234 , Left Superficial Cardiac Plexus Neuromodulator Array  251 , Left Deep Cardiac Plexus Neuromodulator Array  253 , Left Anterior Pulmonary Nerve Neuromodulator Array  267 , respectively. 
         [0200]    Implantable pulse generator  101  is connected via connecting cable  223 ,  225 ,  227 ,  229 ,  231 ,  262 , and  264  to Right Abdominal Para Plexus Neuromodulator Array  203 , Right Abdominal Greater Splanchnic Neuromodulator Array  205 , Right Abdominal Lesser Splanchnic Neuromodulator Array  207 , Right Abdominal Sympathetic Trunk Neuromodulator Array  209 , and Right Abdominal Sympathetic Trunk Neuromodulator Array  211 , Right Renal Plexus Neuromodulator Array  254 , and Right Renal Nerve Branch Neuromodulator Array  256 , respectively. 
         [0201]    Implantable pulse generator  102  is connected via connecting cable  224 ,  226 ,  228 ,  230 ,  232 .  263 , and  265  to Left Abdominal Para Plexus Neuromodulator Array  204 , Left Abdominal Greater Splanchnic Neuromodulator Array  206 , Left Abdominal Lesser Splanchnic Neuromodulator Array  208 , Left Abdominal Sympathetic Trunk Neuromodulator Array  210 , and Left Abdominal Sympathetic Trunk Neuromodulator Array  212 , Left Renal Plexus Neuromodulator Array  255 , and Left Renal Nerve Branch Neuromodulator Array  257 , respectively 
         [0202]    Right Cervical Plexus Neuromodulator Array  193  modulates neural activity in Right Cervical Plexus  237 . Right Intercostal Neuromodulator Array  195 , Right Intercostal Neuromodulator Array  197 , Right Intercostal Neuromodulator Array  199 , and Right Intercostal Neuromodulator Array  201  each modulate neural activity in at least one of Right Sympathetic Trunk  71 , Right Greater Splanchnic Nerve  73 , and Right Lesser Splanchnic Nerve  75 . Right Vagal Neuromodulator Array  233  modulates neural activity in Right Vagus Nerve  95 . 
         [0203]    Right Superficial Cardiac Plexus Neuromodulator Array  250  modulates neural activity in at least one of Superficial Cardiac Plexus  244  and other structures. Right Deep Cardiac Plexus Neuromodulator Array  252  modulates neural activity in at least one of Deep Cardiac Plexus  245  and other structures. Right Anterior Pulmonary Nerve Neuromodulator Array  266  modulates neural activity in at least one of Right Anterior Pulmonary Nerve  246  and other structures. 
         [0204]    Left Cervical Plexus Neuromodulator Array  194  modulates neural activity in Left Cervical Plexus  238 . Left Intercostal Neuromodulator Array  196 , Left Intercostal Neuromodulator Array  198 , Left Intercostal Neuromodulator Array  200 , and Left Intercostal Neuromodulator Array  202  each modulate neural activity in at least one of Left Sympathetic Trunk  72 , Left Greater Splanchnic Nerve  74 , and Left Lesser Splanchnic Nerve  76 . Left Vagal Neuromodulator Array  234  modulates neural activity in Left Vagus Nerve  96 . 
         [0205]    Left Superficial Cardiac Plexus Neuromodulator Array  251  modulates neural activity in at least one of Superficial Cardiac Plexus  244  and other structures. Left Deep Cardiac Plexus Neuromodulator Array  253  modulates neural activity in at least one of Deep Cardiac Plexus  245  and other structures. Left Anterior Pulmonary Nerve Neuromodulator Array  267  modulates neural activity in at least one of Left Anterior Pulmonary Nerve  247  and other structures. 
         [0206]    Right Abdominal Para Plexus Neuromodulator Array  203  modulates neural activity in at least one of Celiac Plexus  154 , Celiac Ganglion  155 , Superior Mesenteric Plexus  156 , Superior Mesenteric Ganglion  157 , Renal Plexus  158 , Renal Ganglion  159 , Inferior Mesenteric Plexus  160 , and Iliac Plexus  161 . Right Abdominal Greater Splanchnic Neuromodulator Array  205  modulates neural activity in Right Subdiaphragmatic Greater Splanchnic Nerve  78 . Right Abdominal Lesser Splanchnic Neuromodulator Array  207  modulates neural activity in Right Subdiaphragmatic Lesser Splanchnic Nerve  80 . Right Abdominal Sympathetic Trunk Neuromodulator Array  209  and Right Abdominal Sympathetic Trunk Neuromodulator Array  211  each modulate neural activity in at least one of Right Lumbar Sympathetic Ganglia  162 , Right Sacral Sympathetic Ganglia  164 , and Right Sympathetic Trunk  71 . 
         [0207]    Right Renal Plexus Neuromodulator Array  254  modulates neural activity in at least one of Right Renal Nerve Branch  248 , Renal Plexus  158 , Renal Ganglion  159 , and other structures. Right Renal Nerve Branch Neuromodulator Array  256  modulates neural activity in at least one of Right Renal Nerve Branch  248 , Renal Plexus  158 , Renal Ganglion  159 , and other structures. 
         [0208]    Left Abdominal Para Plexus Neuromodulator Array  204  modulates neural activity in at least one of Celiac Plexus  154 , Celiac Ganglion  155 , Superior Mesenteric Plexus  156 , Superior Mesenteric Ganglion  157 , Renal Plexus  158 , Renal Ganglion  159 , Inferior Mesenteric Plexus  160 , and Iliac Plexus  161 . Left Abdominal Greater Splanchnic Neuromodulator Array  206  modulates neural activity in Left Subdiaphragmatic Greater Splanchnic Nerve  79 . Left Abdominal Lesser Splanchnic Neuromodulator Array  208  modulates neural activity in Left Subdiaphragmatic Lesser Splanchnic Nerve  81 . Left Abdominal Sympathetic Trunk Neuromodulator Array  210  and Left Abdominal Sympathetic Trunk Neuromodulator Array  212  each modulate neural activity in at least one of Left Lumbar Sympathetic Ganglia  163 , Left Sacral Sympathetic Ganglia  165 , and Left Sympathetic Trunk  72 . 
         [0209]    Left Renal Plexus Neuromodulator Array  255  modulates neural activity in at least one of Left Renal Nerve Branch  249 , Renal Plexus  158 , Renal Ganglion  159 , and other structures. Left Renal Nerve Branch Neuromodulator Array  257  modulates neural activity in at least one of Left Renal Nerve Branch  249 , Renal Plexus  158 , Renal Ganglion  159 , and other structures. 
         [0210]    Elements comprising neuromodulators and neuromodulator arrays provide at least one of activating or inhibiting influence on neural activity of respective neurological target structures. Additional or fewer connecting cables and neuromodulator arrays may be employed without departing from the present invention. 
         [0211]    These connections provided by connecting cables may facilitate communication and/or power transmission via electrical energy, ultrasound energy, optical energy, radiofrequency energy, electromagnetic energy, thermal energy, mechanical energy, chemical agent, pharmacological agent, or other signal or power means without departing from the parent or present invention. 
         [0212]    Neuromodulators and neuromodulatory interfaces may be used interchangeably in this specification. 
         [0213]      FIGS. 33 and 34 : show the catheter insertion trocar  270  during intraoperative use for placement of neuromodulatory interface array catheter  284 . Surgeon or assistant makes incision in skin  280 , at entry point  285  in the cervical, thoracic, lumbar, or sacral region.  FIGS. 33 and 34  depict a skin incision at an entry point  285 , which is shown in a representative site in the thoracic or lumbar region. Surgeon grasps catheter insertion trocar handle  273  and applies force which is transmitted through catheter insertion trocar shaft  274  to advance catheter insertion trocar bulb tip  275  through skin  280  and parietal pleura  282  into the potential space labeled pleural space  286  which is expanded by this procedure. Entry point  285  and exit point  287  are shown adjacent to but not directly overlying any of rib  281 ; however, either or both of entry point  285  and exit point  287  may overly any of rib  281 , in which case tunneling under skin or through rib may be performed. 
         [0214]    Care is taken to avoid perforating visceral pleura  283 . Skin incision is made at entry point  285  through the majority of the thickness of skin  280  close to parietal pleura  282  to assist in minimizing the amount of force required to enter pleural space  286 , thereby minimizing the velocity and acceleration of catheter insertion trocar bulb tip  275  during this procedure and reducing the risk of perforation of visceral pleura  283 . A novelty of the present invention, shown in  FIG. 33 , is the shape of catheter insertion trocar bulb tip  275 , which is curved to further reduce the risk of perforation of visceral pleura  283 . 
         [0215]    Catheter insertion retriever  271  is inserted through an incision in skin  280  at the site of exit point  287 . Surgeon or assistant grasps catheter insertion retriever handle  277 , and with catheter insertion retriever shaft  286  penetrating skin  280 , positions catheter insertion retriever grasper  279  to grasp catheter insertion trocar bulb tip  275  and to pull or guide attached catheter  272  through incision in skin  280  at exit point  287 . 
         [0216]    As shown in  FIG. 33 , catheter insertion trocar bulb tip  275  may be part of catheter  272 . Tensile and shear force applied through catheter insertion retriever grasper  279  is applied to pull and guide, respectively, catheter  272  in its advancement through pleural space  286  and through parietal pleura  282  and skin  280  at the site of exit point  287 . Catheter attachment means  288  at the trailing end of catheter  272  enables neuromodulatory interface array catheter  284  to be pulled through skin  280  and parietal pleura  282  at entry point  285 , through pleural space  286 , and through parietal pleura  282  and skin  280  at exit point  287 . Depending on the design, catheter insertion trocar  270  may be withdrawn prior to attachment of catheter  272  to neuromodulatory interface array catheter  284 . Alternately, if said catheter attachment means  288  is sufficiently small relative to the internal diameter of catheter insertion trocar shaft  274 , catheter insertion trocar  270  may be withdrawn after attachment of catheter  272  to neuromodulatory interface array catheter  284  and advancement of neuromodulatory interface array catheter  284  through skin  280  at exit point  287 . 
         [0217]      FIG. 34  depicts a pointed design which facilitates advancement of catheter insertion trocar  270  into pleural space  286  and back through parietal pleura  282  and skin  280  at the site of exit point  287 . As shown in this figure, pointed tip  276  is attached to or part of catheter  272 . Alternatively, pointed tip  276  may be attached to or part of catheter insertion trocar shaft  274 , without departing from the present invention. 
         [0218]    In both  FIG. 33  and  FIG. 34 , catheter  272  may serve as a guide to facilitate advancement of neuromodulatory interface array catheter  284  into position, as described above. Alternately, to save time and to reduce procedural complexity, catheter  272  may be replaced with neuromodulatory interface array catheter  284 , without departing form the present invention. In this latter configuration, neuromodulatory interface array catheter  284  is advanced into position by catheter insertion trocar  270  in either of the two methods described and shown in  FIG. 33  and  FIG. 34 . 
         [0219]      FIG. 35  shows the neuromodulatory interface array catheter  284  which represent another implementation of the neuromodulatory interface  34  taught in the parent case and shown in multiple forms in  FIG. 16 . In this embodiment, at least one neuromodulatory interface  34  is implemented as a single or plurality of neuromodulatory interface array catheter  284 . 
         [0220]    Neuromodulatory interface array catheter  284  comprises a connector contact array  300  located near connector end  289 , a neuromodulatory interface array  301  located near neuromodulatory interface end  290 , and catheter body  291 , which provides mechanical connection and signal transmission between connector contact array  300  and neuromodulatory interface array  301 . Said signal transmission may be in the form of electrical fields or energy, electrical voltage, electrical current, optical energy, magnetic fields or energy, electromagnetic fields or energy, mechanical force or energy, vibratory force or energy, chemical agent or activation, pharmacological agent or activation, or other signal transmission means. 
         [0221]    Neuromodulatory interface array  301  is comprised of at least one of neuromodulatory interface  296 ,  297 ,  298 , and  299 . Additional or fewer numbers of neuromodulatory interface may comprise neuromodulatory interface array  301  without departing from the present invention. Neuromodulator interface  296 ,  297 ,  298 ,  299  modulate activity of neural structures using at least one of electrical fields or energy, electrical voltage, electrical current, optical energy, magnetic fields or energy, electromagnetic fields or energy, mechanical force or energy, vibratory force or energy, chemical agent or activation, pharmacological agent or activation, or other neural modulation means. 
         [0222]    Connector contact array  300  is comprised of at least one of connector element  292 ,  293 ,  294 , and  295 . Additional or fewer numbers of connector element may comprise connector contact array  300  without departing from the present invention. 
         [0223]      FIG. 36  shows the effects of modulation of the autonomic nervous system, including periods of sympathetic modulation  309  and parasympathetic modulation  310 . Sympathetic modulation  309  may be performed by stimulating or inhibiting activity in a portion of the sympathetic nervous system. Parasympathetic modulation  310  may be performed by stimulating or inhibiting activity in a portion of the parasympathetic nervous system. 
         [0224]    Tracings showing the level of sympathetic stimulation  305  and sympathetic inhibition  306  are shown. During the time window in which sympathetic stimulation  305  is active, the sympathetic index  303  is seen to be increased and the autonomic index  302  is increased. During the time window in which sympathetic inhibition  306  is active, the sympathetic index  303  is seen to be decreased and the autonomic index  302  is decreased. 
         [0225]    Tracings showing the level of parasympathetic stimulation  307  and parasympathetic inhibition  308  are shown. During the time window in which parasympathetic stimulation  307  is active, the parasympathetic index  304  is seen to be increased and the autonomic index  302  is decreased. During the time window in which parasympathetic inhibition  308  is active, the parasympathetic index  304  is seen to be decreased and the autonomic index  302  is increased. 
         [0226]    Sympathetic and parasympathetic inhibition is accomplished by blockage of neural fibers. This is be performed using high frequency stimulation, with a best mode involving biphasic charge balanced waveforms delivered at frequencies over 100 Hz, though significantly higher as well as lower frequencies may be employed without departing form the present invention.