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The human body under normal conditions has a perfect physiologic balance. One part or organ is in a state of perfect, balanced relationship with every other part or organ. A disarrangement of this equilibrium produces pathologic conditions and dysfunction. These derangements are indicated by symptoms and signs, which, when grouped, give us a picture of a definite disease. The explanation of well-known symptoms is often wanting, the practitioner being compelled to learn them as a part of the syndrome belonging to a certain disease instead of being able to point out the exact force operating to produce them. An etiologic classification of symptoms leads us to a better understanding of the disease in question and facilitates diagnosis. In analyzing the symptoms and physical signs in pulmonary tuberculosis, I found that they could all be classified etiologically in three groups: 1, those due to toxemia; 2, those due to reflex action; and, 3, those due to the tuberculous process per se, as in the table.
Etiologic Classification of Symptoms and Physical Signs in Tuberculosis
|Group 1: Toxemia||Group 2: Reflex Action||Group 3: Tuberculous Involvement per se|
Lack of endurance
Loss of strength
Lack of appetite
Loss of weight
Tickling in larynx
Loss of weight
Chest and shoulder pains
Flushing of face
|Frequent and protracted colds
Spitting of blood
In this manner we classify some twenty-five or thirty symptoms which belong to tuberculosis in three groups so that each symptom in the individual group is due to a common etiologic factor. Such a classification simplifies diagnosis. It offers an explanation for the fact, which has long been observed, that symptoms are variable, in that the same ones are not always present, and when present, are not always equally prominent.
When studying these three groups of symptoms I was impressed with the fact that there is nothing distinctive of tuberculosis in that group which is due to toxemia. The same symptoms could be due, as well, to an infection of the tonsil, the prostate, the fallopian tube, a toxemia from intestinal stasis or an acute infectious disease. They are, in short, a part of the syndrome of infections in general. I was further impressed with the fact that the second group, those of reflex origin, all point to organs other than the lung, but that they belong to organs which are supplied by the vagus and sympathetic nervous systems, both of which supply the lung. A further analysis of the group which is due to toxemia shows that these symptoms are identical in distribution and effect with a general discharge of nervous impulses through the sympathetic nervous system.
To make this clearer it is necessary to recall that the autonomic nervous system supplies impulses to structures which are not controlled by the will. These are the organs supplied by smooth muscle such as the stomach, intestines, blood vessels, ducts of glands; and also certain organs possessing striated muscle fibers such as the heart, the beginning and terminal portions of the alimentary canal, and the generative organs.
The autonomic system is divided into three groups: 1, the cranial and bulbar, which are spoken of as the vagus system; 2, the thoracic and upper lumbar, known as the sympathetic system; and, 3, the lower lumbar and sacral, known as the sacral system.
The vagus system is the system which conserves life. It contracts the pupil, increases salivary secretion, slows the heart beat, causes an increase of gastric and intestinal juices, and furnishes motor power for the gastrointestinal tract. The sacral system controls the emptying of the lower bowel and bladder and presides over the generative functions. The sympathetic sends branches to all organs supplied by the vagus and sacral systems; and where the fibers from these different systems meet there is an antagonistic action between the sympathetic and other two systems. If the sympathetic stimulation is sufficiently strong, it overcomes the vagus and sacral tonus. If this control is only momentary or of short duration, as it is in fear and anger, as shown by Cannon1, the general strength of the individual is increased. He possesses for the time being a power greater than normal. On the other hand, if this sympathetic control continues, a general inhibition of function in the organs supplied by the sympathetic system takes place and the individual’s powers suffer a diminution; thus, the dry mouth, lack of desire for food, stoppage of digestion and rapid heart’s action, which are temporary in the presence of the major emotions, are emphasized and prolonged during toxemia and are expressed as a more or less continuous absence of appetite, coated tongue, retarded digestion, constipation, rapid heart action and tendency to perspiration.
While impulses may be carried directly from the brain and cord to the skeletal muscles, insuring immediate and selective response, and through the vagus and sacral systems through the intervention of a single ganglion, causing response limited to a certain organ, in the case of the sympathetic nervous system numerous ganglia are interposed and the response is shown in widely distributed parts. These ganglia act as modifiers or transformers of the impulse and make its distribution general, which accounts for the fact that so many organs and parts are involved in sympathetic irritation.
Whether a toxemia acts wholly, centrally, on the sympathetic nervous system is open to some question. While the expression is that of general sympathetic discharge, yet we must bear in mind that it is possible that this may be partly due to, or at least partly prolonged by, certain internal secretions which are engendered by, the same stimulation as that which produces the general sympathetic stimulation. Cannon has shown that the emotional states such as anger and fear, while being an expression of general sympathetic discharge, may be kept up by adrenin in the blood. The adrenal glands are supplied through the splanchnics; and impulses which cause a general sympathetic stimulation stimulate these glands also. A minute amount of adrenin poured into the blood stream has the effect of producing a prolongation of the condition which is brought about by direct sympathetic stimulation; thus adrenin will cause a dry mouth, impaired digestion, intestinal stasis and a rapid heart. That toxemia, like the emotional states, acts by stimulating the sympathetics and by prolonging the action through the stimulation of the adrenals seems quite certain. It may also be found on further study that disturbances in other internal secretions may have a part in this general picture; but, even should this prove true, it will not alter the fact that the syndrome of toxemia is an expression of general sympathetic discharge.
- Cannon, W. B.: “Bodily Changes in Pain, Hunger, Fear and Rage,” Appleton, New York, 1915.