Vegetative Imbalance in Disease: Anatomic and Physiologic Consideration

Vegetative imbalance is a condition in which the normal physiologic control of visceral activity throughout the body or in some certain organ or organs is so unstable that a comparatively mild stimulus, when applied to the particular system of unstable cells, is sufficient to produce marked effect and often to overcome all antagonistic forces and produce a pathologic state. Patients possessed of such unbalance show reaction beyond what is natural for the stimulus applied.

Vegetative System–A brief review of the essential facts of the vegetative system is necessary to an understanding of this subject. 

The vegetative system comprises the striated muscle of the heart, the smooth muscle system, and all glandular structures of the body. The structures and organs of the body which are essential to life and the propagation of the species, such as the respiratory, circulatory, digestive and reproductive, are all parts of this system; in fact, all activities which are essential to maintain man as an individual and to perpetuate the species occur at the vegetative level. Such being a fact, it seems strange that the vegetative system up to the present time has received so little attention from the medical profession. The chief reason that it has been so long neglected is because of the difficulties connected with its investigation. It is the one system in the body which has had to be studied from the functional standpoint, which is much more difficult and uncertain than the structural approach. 

The somatic system, on the other hand, which comprises the system of voluntary muscles and the central nervous system which supplies them, has been carefully studied, even though its importance in human physiology seems to be not only secondary, but even subsidiary, to that of the vegetative system. 

The vegetative nervous system as one of the important controls and the chief integrating and correlating system of the visceral structures is ancient in comparison with the central nervous system. In fact, the somatic structures appeared late in development and may be looked upon as a necessity only because the organism grew in complexity and required an external system to keep it in favorable contact with its environment, and to protect it from harm. 

Voluntary Versus Vegetative Nervous System–In order to understand the importance of the vegetative nervous system and its part in disease, it is essential to know its relationship to the voluntary nervous system, and its relationship to other forces which are responsible for physiologic control. 

The vegetative nervous system is a peripheral system. The ganglia which contain the cells from which the true vegetative fibers arise are found without the central nervous system. They are arranged either along the spinal column as the gangliated cord, or more peripherally at convenient places for sending out nerve fibers to supply the various viscera, as the superior cervical, celiac and mesenteric ganglia; or they may lie in the walls of the viscera themselves, as in case of the plexuses of Auerbach and Meisner. They are connected with the central nervous system, however, by connector nerves which arise from cells which lie in the lateral gray matter of certain segments of the spinal cord and in a similar position in the medulla and midbrain. Certain ganglia, too, have been placed in the brain and cord, which serve as central stations for receiving and distributing impulses which are to result in the correlation and integration of acts of a complicated nature, affecting widely separated structures. These stations distribute impulses to both visceral and skeletal structures, thus bringing the body as a whole into a unity of action, as is often necessary when the organism is faced with grave danger. The cervical segments of the cord and the lower lumbar and upper sacral segments are not connected with vegetative ganglia by efferent connector fibers, but are left, as far as their nervous outflow is concerned, to supply innervation to the arms and legs. 

Action in the vegetative system of nerves is slow when compared with that in the voluntary system. The will has no power to call on the vegetative nerves for visceral effects, as it has in case of the skeletal nerves. There are certain structures, however, in which voluntary and vegetative nerves supplement each other, as in deglutition, respiration, defecation and urination. The vegetative functions must be carried on, no matter whether the patient is awake or asleep, for they are essential to life; so it is necessary that they be autonomous. 

Stimuli which act upon muscle or secreting cells produce an effect of either activation or inhibition. 

In skeletal structures, a nerve supplying a flexor muscle carries a stimulus which also inhibits the opposing extensor, and vice versa. Action and inhibition are produced by opposing musculature, innervated by different nerves of the same voluntary system. In the vegetative structures, on the other hand, the nerves themselves are either activating or inhibiting in their function to the same muscle or secreting cell. The vegetative nerves, therefore, are the opposing systems. The sympathetic, which arises from the thoracic and upper lumbar segments of the cord, opposes the activity of the parasympathetics, which arise in the midbrain, medulla and lower sacral segments of the cord whenever they supply the same organ or structures. There are a few structures which are supplied by one of these systems only, but most visceral structures are supplied by both. Whenever they meet in the same structure, one produces activity and the other inhibits activity. As a second effect, however, stimuli are supplied which aid in the production of any given effect by directly antagonizing the opposing nerve, thus, an excitement which causes the sympathetics to speed up the action of the heart, simultaneously produces inhibition in the cardiac vagus. The distribution of the vegetative nerves is shown in Plate I.

It will be seen by the effects produced by these two components of the vegetative system that the parasympathetics are most intimately bound up with the organism’s intimate functions. The chief function of the parasympathetics is the digestion of food and storing of energy, and the maintaining of the organism as a functioning unit. For this reason it is spoken of as the anabolic system. The sympathetics, on the other hand, are more intimately connected with the expenditure of energy, protection of the organism and influencing its relationship to its environment. It, therefore, is the catabolic system. 

The following is the action of these two systems in the principal visceral tissues of the body: 

Sympathetics–The sympathetics are widespread in their distribution. Through their innervation of blood vessels, sympathetic fibers reach every tissue of the body. They control the constriction of all blood-vessels; activate the subdermal structures, pilomotor muscles and sweat glands and musculature of same; the heart; the sphincter system of the gut and urinary apparatus; the trigone of the bladder and the genitalia, including the uterus, musculature of the penis, prostate, seminal vesicles and vas deferens. They inhibit action in the head structures, such as the eye, the lachrymal glands, the mucous glands of nasopharynx, and the salivary glands; the muscles and glands of the bronchial structures; the muscles and glands of the enteral system; and the muscles of the body of the bladder. 

Parasympathetics–The parasympathetics activate the intrinsic eye muscles, the lachrymal, salivary and mucous glands of nasopharynx; the muscles and glands of the bronchi, and the entire enteral system and the body of the bladder. They inhibit action in the heart and furnish vasodilatation in many structures, but particularly the structures of the head and penis. 

So that it may be readily comprehended what effect stimulation of each of these components of the vegetative system means, the following table, which has been constructed by Meyer and Gottlieb and Biedl, is reproduced: 

 

Effect of Stimulation of Sympathetics and Parasympathetics on Important Viscera, Indicating Their Antagonistic Action 

	Sympathetics	Parasympathetics
Pilomotor muscles	Stimulate	No effect
Musculature of sweat glands	Contract muscle, and force out sweat from glands	No effect
Sweat glands	Stimulate	Possibly stimulate
Vaso motor system	Contract throughout  Dilate in trunk and limbs	Dilate in structures of head and genital organs No effect in trunk and extremities
Heart	Increase rapidity	Slow
Eye	Dilated pupil  Contract Müllerian muscle  No effect	Contract pupil  No effect  Contract and relax muscle of accommodation
Lacrimal glands	Decrease secretion	Increase secretion
Mucous membrane of nose  and throat	Decrease secretion	Increase secretion
Salivary glands	Decrease watery component of secretion	Stimulate watery component of secretion
Respiratory tract	Relax musculature and decrease secretion	Contract musculature and increase secretion
Stomach	Decrease motility and secretion, including hydrochloric acid.  Controls blood-vessels	Increase motility and secretions, including hydrochloric acid
Intestinal tract	Relax musculature and decrease secretion and  control blood vessels	Stimulate musculature and increase secretion
Sphincters	Contract	Relax
Ureter	Contract	No effect
Uterus	Contract	No effect
Bladder	Contract muscles of trigone and sphincters, relax musculature of body	Relax musculature of trigone  and sphincters, stimulate  musculature of body

 

As the voluntary nervous system was developed later than the vegetative, it would seem that its main, probably its sole purpose, being built up around the vegetative structures as it is, is for their protection, to defend them from harm, to aid them in securing necessary nutrition, and to insure the propagation of the species. The voluntary and vegetaive nervous systems are very intimately connected, and are brought into reflex connection in such a way that visceral stimulation has skeletal or somatic expression and skeletal impulses are expressed in visceral tissues.

 

Factors Which May Be Responsible For Vegetative Imbalance

Activity in the Vegetative System–Physiologic activity and control in the vegetative system is a complex affair, carried out by: (1) the cells themselves; (2) the electrolytes which are essential to the activity of the cells; and (3) two correlating systems: (a) chemical, as exemplified in various hormones, and (b) nervous, through the sympathetics and parasympathetics. The action of all these systems is interdependent and can be understood only when considered together. Imbalance in one may mean imbalance in all. 

Imbalance in functional activity may have as its primary cause a disturbance in any one or more of these systems. The cells may be at fault, or the electrolytes, which have an integral part in cellular activity, may not be present in proper proportions, or the chemical and nervous regulators may cause too great or too little stimulation. No matter where the cause lies, deviation from normal physiologic activity may result. 

Body Cells–The body cells present a colloid chemical system which is in a constant state of change during life. Normal activity consists of alterations in the phases of the colloidal systems and in free exchange of electrolytes. The basis of cells is protein molecules and lipoids. They are in a fluid state and surrounded by a different fluid medium. The protein of the cell and that of the fluid medium surrounding it differs in that the protein in the cell is a nucleoprotein, while that in the body fluids consists of albumins and globulins. This difference facilitates action. 

Activity in the cells is produced readily by electrolytes. Cells are stimulated by such substances as sugars, amino acids and salts. Whether or not a circulating substance will cause action, depends on whether or not it is able to penetrate the cell. The cell is surrounded by a semipermeable membrane which goes through phases of greater and lesser permeability, according to the action of certain electrolytes upon it, and activity consists in taking on and giving off electrolytes, whether autonomously or through hormones or nerve stimulation. 

Action of Electrolytes on Cells–The body cells are acted upon differently by different substances which come in contact with or penetrate their limiting membrane. 

The semipermeable membrane is influenced largely by the electrolytes of sodium, potassium and calcium. In fact, its form and permeability seem to be largely determined by the preponderance of Ca or K, which comes to the cell. Calcium causes the membrane to assume more definite form and become less permeable while potassium causes it to become less stable and more permeable. Sodium acts much the same as potassium. Iron, phosphorus, manganese and copper are also elements of great importance to the organism. 

Influence of Acid-Alkali Balance on Cells–The action of cells differs, too, according to the acid-alkali balance of the tissues. It has been shown that a preponderance of K over Ca and alkalinity of the tissues seem to bear a close relationship to stimulation of the parasympathetic nerves, while a preponderance of Ca over K, and acidity of the tissues have a close relationship to sympathetic stimulation.

Part Played by Vegetative Nerves in Body Activity–The fact of the autonomous action on the part of the body cells does not signify that the nerves are not important in their relationship to the vegetative functions. They have a higher function than that of causing simple action in structures. When stimulated, they produce action or inhibition, but they also correlate action in various structures of both the skeletal and vegetative systems, as is so well shown in increased respiratory effort when, because of a failure to completely oxygenate the blood, an excess of CO2 remains. The CO2 comes in contact with the respiratory center which sends out stimuli to all of the muscles of respiration, contracting those which are actively engaged in the respiratory function and inhibiting those which oppose it. Nerve action causes the cell stimulated to either take on or give off some substance into the medium surrounding it. 

Part of Endocrine Glands in Body Activity–Hormones also produce stimulation of cells, calling them into action. They, too, produce a certain amount of correlation, causing structures widely separated in various parts of the body to react at the same time, as in case of adrenalin. All structures which respond to sympathetic stimulation are known to respond to adrenalin except the sweat glands. The thyroid hormone affects tissues widely scattered and is largely sympatheticotropic in action. Other hormones are more limited and selective in their action, as secretin, which seems to confine its action to the gastric glands, and insulin, which confines its action to burning and storing of sugar. 

Tonus and Rhythm–Vegetative structures maintain a constant phase of activity which is spoken of as tonus and rhythm. This differs from that found in the skeletal muscles in that it is a function of the muscles independent of the nerves. If a nerve to a skeletal muscle is cut, the muscle at once degenerates and remains degenerated as long as the nerve is divided. On the other hand, the nerves going to smooth or visceral muscle, or to secreting glands, may be cut and after a temporary disturbance in function tonus is regained and rhythmic action is resumed. The cells have within themselves the power of autonomous action as long as a free circulation is present which carries the necessary nutrition and the electrolytes necessary to maintain action.

 

Physiologic Vegetative Balance

It can be seen, then, that normal physiologic action may be maintained if proper nutrition is supplied the cells and their colloidal phases are usual for the structure under consideration, provided, however, that the necessary electrolytes are supplied in the right proportions, and the hormones from the various endocrine glands are supplied in normal amounts, and the activating and inhibiting impulses which are carried to the cells by nerves balance each other, or at least fail to overbalance each other. The reverse is also true. A deviation from the normal in any of these systems may be the basis for an imbalance.

 

Vegetative Imbalance

This term has been used to describe deviations from the normal physiologic workings of the vegetative structures. Probably the most discussed deviation is the condition of vagotonia as described by Eppinger and Hess. They discussed vagotonia as a general condition indicating excessive action in the parasympathetics in the tissues and structures of the body. Sympathicotonia, its opposite, has received considerable attention, too. These effects may be general or limited to certain organs and systems, as will be illustrated later in this discussion.

No matter whether the cells themselves are primarily at fault, or the electrolytes are out of balance, or some hormone or hormones are deficient or present in excess, or the sympathetic or parasympathetic nerves are unevenly balanced, there can be but one result in any tissue–a disturbance in physiologic activity–either an increase in action beyond that which is normal for the structure or a relative decrease or inhibition. With an understanding of visceral neurology, it will readily be seen that there is a great advantage in classifying these effects in terms of sympathetic and parasympathetic action. Sympathicotonia and parasympathicotonia (vagotonia), both general and limited or local, are, therefore, spoken of not as necessarily indicating that the nervous system is primarily at fault, but rather that the resulting effect falls in line with a preponderance of sympathetic or parasympathetic action, as may be illustrated by the widespread parasympathetic effect produced by the destruction of the adrenal gland. 

In certain groups of the population, the exact percentage of which is not known, there seems to be such a marked tendency to respond unduly to stimuli which act on one or the other component of the vegetative system that it amounts to a disease. It is to this group that sympathicotonia and parasympathicotonia (vagotonia of Eppinger and Ness) particularly apply. 

Those who suffer from sympathicotonia are such as respond with undue sympathetic action when stimulated by adrenalin or by other sympathicotropic substances or stimuli, or when the parasympathetics are inhibited by atropine. They react more markedly than normal to such sympathicotonic stimuli as cold, toxins and emotions. They also respond readily in the production of reflexes in which the sympathetics are involved. 

In parasympathicotonics, on the other hand, it requires doses of atropine larger than usual to cause inhibition in parasympathetically innervated tissues; nor is such activity readily overcome by adrenalin. They respond with increased vigor to pilocarpine. They also show clinical parasympathetic responses more readily than should take place in an evenly balanced opposing system of nerves. They are particularly susceptible to allergic excitants. 

Sympathetic and parasympathetic syndromes may be caused by stimuli which act either centrally or peripherally. For example, toxins act centrally and cause widespread sympathetic effects, while an inflammation in some organ may act upon nerve endings contained therein and produce reflex sympathetic or parasympathetic effects in only the limited number of organs or tissues whose nerves receive the reflex stimulation. 

 

Conception of Vagotonia and Sympathicotonia of Eppinger and Hess

It is to Eppinger and Hess particularly that credit is due for calling attention to vagotonia and sympathicotonia as entities. They were the first to give a conception of these conditions that could be utilized as a basis for understanding unbalanced vegetative neurological effects in clinical disease.

They drew the line of classification roughly according to the way the patient reacted to various pharmacological remedies. Their discussion, too, was directed far more to vagotonia than sympathicotonia.

Starting with the basis that atropine inhibits the parasympathetic nerves and pilocarpine stimulates them, they found that there was a group of people the members of which responded so markedly to the injection of pilocarpine that they could not be looked upon in any other light than as being abnormal. 

They found that these individuals were inclined to suffer from a particular group of diseases which represent increased parasympathetic effects. Inasmuch as most of these effects were connected with the vagus nerve, as must be evident from the fact that the heart and the enteral system consisting of the upper gastrointestinal tract at least as far as the colon and all organs derived from it embryologically, such as the lungs, pancreas, liver, gall-bladder and the body of the bladder, are innervated by it, he called all conditions marked by a hyperirritable vagus “vagotonia.” In order to include all other parasympathetic nerve effects, such as those produced through the third, seventh and ninth cranial and the pelvic nerve, he grouped all of these nerves together and called the system as a whole the “greater vagus.” This was unfortunate and has served to confuse the study somewhat rather than clarify it, as was hoped. 

These authors found that patients who react with sweating and salivation to the hypodermic injection of 0.01 Gm. (⅙ grain) of pilocarpine hydrochloride will also as a class show symptoms indicative of increased parasympathetic action in other organs, such as lachrymation, salivation, bradycardia, increased motility in the gastrointestinal tract, and hypersecretion, low blood sugar, eosinophilia, asthma, hay-fever, or other allergic phenomena. 

It was also found that many of these symptoms or syndromes which were classified as indicative of vagotonia could be relieved by atropine which acts by inhibiting vagus activity. The effect of this remedy in hay-fever, salivation, asthma, spastic colon, bradycardia, urticaria, anaphylaxis and other definitely parasympathetic phenomena is well known. Atropine often fails in these cases because of an inability to use doses sufficiently large without making the patient uncomfortable by the dryness of the mouth and throat and the effects on the pupil and accommodation; nevertheless, its use is indicated. Adrenalin was also used by them in the same cases as atropine, because of its indirect effect in inhibiting the parasympathetics by stimulating the antagonistic sympathetics to marked action. In some structures, such as the bronchial musculature and the heart, adrenalin produces the desired effect more readily; while in others, such as the nasopharyngeal structures, salivary glands, gastrointestinal musculature and glands, and sweat glands, the action of atropine is superior. 

Some clinicians have based their opinions of the existence or nonexistence of parasympathicotonia (“vagotonia’) and sympathicotonia too much on these tests, and not finding the response as ready and as strong as expected, have been inclined to discredit the conception. This is unfortunate, for any student of the clinical aspects of visceral neurology will soon see that those individuals whom they have long recognized as being hypersensitive to stimuli of this or that character will fall into groups which represent a ready response to stimuli of either an activating or of an inhibiting nature in the structure or structures involved. Those who react most markedly are the ones with vegetative nervous systems most unstable (the so-called neurotics). They are the ones who fall into the class of sympathicotonics or parasympathicotonics (vagotonics). Others belong to a class with more stahle nervous systems and are classified as normals. 

The individual does not need to be sympathicotonic or parasympathicotonic throughout the vegetative structures. He may have a sympathicotonic or vagotonic heart, while the rest of the body structures are usual; or a hyperchlorhydria or spastic colon which are evidences of parasympathicotonia in these structures and be normal otherwise; and so on. The important thing from the clinical standpoint is to learn to be able to assign these phenomena when they arise to the components of the vegetative nervous system to which they belong. One confusing fact noted in these vegetative syndromes is that effects of a sympathetic imbalance may be present in one organ and of parasympathetic imbalance in another, as illustrated in exophthalmic goiter. 

 

Sympathicotonia and Certain Tests for Its Determination

The following are some of the more prominent effects which characterize sympathetic dominance or sympathicotonia: dilatation of pupil; protrusion of eyeball; widening of palpebral slits; lessened lachrymal secretions; lessened mucous secretion in nasopharyngeal structures; lessening of watery elements of salivary secretion; decrease in bronchial secretion; dilatation and lengthening of bronchial tree; increased frequency of heart action; vasoconstriction; increase in blood-pressure; increase of blood sugar; increase in secretion of adrenalin; decrease in motility and relaxation of gastric and intestinal musculature except the sphincters; contraction of gastric and intestinal sphincters except the cardia; decrease in gastric and intestinal secretion; relaxation of the body of the bladder with contraction of the trigone and sphincter; contraction of seminal vesicles, vas deferens, prostate, urethra and subdermal musculature of penis; contraction of uterus; erection of hairs, sweating, and stimulation of bone-marrow causing leukocytosis. 

The following tests have been suggested for determining those whose sympathetic system in whole or in part is hypersensitive. 

Adrenalin Test–One-tenth mg. (1/600 grain) of adrenaline intravenously, or 1.0 Gm. (15 grains), injected subcutaneously, may be used to differentiate sympathicotonics from individuals with normal balance, or from those who belong to the parasympathicotonic group If the pulse rate increases more than one-third above its usual rate, and if there is an increase in systolic pressure of from 30 to 40 mg., it is evidence of a sympathicotonia effect unusually strong throughout the cardiovascular system, and may usually be taken as meaning that the patient has a general hyperactive sympathetic system. There is likely to be a doubling of the amount of urine voided, too, during the 24 hours following the test in those who are sympathicotonic. In those who are markedly sympathicotonic, noticeable pallor may appear, with muscular tremors and feelings of fatigability and anxiety. 

Ergotamine Test–Ergotamine, when injected, produces an effect the opposite of adrenalin, bearing somewhat the same inhibiting effect to the sympathetics as is borne by atropine to the parasympathetics. If the patient is markedly sympathicotonic, the effect may be slight. 

Ergotoxine exercises an action on the sympathetic system alone, in small doses stimulating and in large doses paralyzing the activating fibers. No effect on the inhibiting fibers is recognized. Ergotoxine, in paralyzing doses, produces dilatation of the blood-vessels and inhibition of the heart, without effect upon the respiratory and gastrointestinal system. 

Löwi’s Pupillary Reflex–Löwi noted that a few drops of 1:1000 solution of adrenalin, instilled into the conjunctival sac, produces mydriasis in those who belong to the sympathicotonic group, with less effect on the vagotonic. 

Sargent’s White Line–Sargent’s white line, produced by a high stroke drawn in the median line from above downward over the abdominal wall, is taken as being indicative of increased sympathetic tonus, or hyperadrenia. 

Pende’s Pilomotor Refer–Pende has shown that in patients who are distinctly sympathicotonic, stroking of the skin may produce a goose flesh. 

Ruggeri’s Test–This consists of an acceleration of the pulse, following convergence of the eyeballs, produced by fixing the attention upon an object which is brought very close to the eyes. This is less marked in the vagotonics.

 

Parasympathicotonia (Vagotonia) and Certain Tests for Its Determination

Contraction of pupil; reaction to accommodation and convergence by narrowing pupil; increased lachrymation; increased secretion of nasal, oral and pharyngeal mucous glands; increased salivary secretion; contraction of laryngeal muscles, as met in laryngospasm; increased bronchial secretions, as in bronchitis; spasm of bronchial muscles, as in asthma; shortening of bronchi, as in pneumonia and massive collapse of lung; bradycardia; vasodilatation; decrease in blood-pressure; hypermotility of gastric musculature causing hunger and increased peristaltic effects; hypersecretion of gastric glands, particularly the glands of the fundus; control of cardiac sphincter and esophagus; hypermotility and hypersecretion throughout the intestinal tract; increased secretion of insulin with reduction of blood sugar; increased secretion of pancreatic, hepatic and other intestinal ferments and hormones; contraction of biliary ducts and gall-bladder with inhibitory effect on sphincter; inhibition of intestinal sphincters; contraction of body of bladder; inhibition of trigone and sphincter; dilatation of blood-vessels of head and pelvic organs and possibly of others; erection of the penis; and eosinophilia are caused by a relatively increased parasympathetic stimulation. 

Pilocarpine Test–One centigram (⅙ grain) of pilocarpine hydrochloride, subcutaneously, provides varying degrees of salivation, perspiration, lachrymation, vomiting, diarrhea, reddening of the skin, asthmatic type of breathing and a rectal and vesical tenesmus. The more marked these symptoms appear, the higher the degree of parasympathicotonia. (Vagotonia, as shown by Eppinger and Hess.)

Eserine Test–Eserine hydrobromide, subcutaneously, is also used as a test for parasympathicotonia. It produces the same group of symptoms as those produced by pilocarpine, only more marked. 

Histamine Test–When histamine is injected subcutaneously in doses of 2 to 3 mg. (1/32 to 1/20 grain), it produces vasodilatation and decreases blood-pressure, even as much as 50 mm. having been noted. The degree of vasodilation and hypotension increases in proportion to the degree of parasympathicotonia present. 

Insulin Test–Inasmuch as parasympathicotonics often show hypoglycemia, it has been found that insulin is more active in this group of cases than in the sympathicotonic type. If, therefore, marked hypoglycemia follows injections of small doses of insulin after from 50 to 100 Gm. (1 ⅖ to 3 ⅓ ounces) of glucose have been administered by mouth, this fact may be taken as indicative of parasympathicotonia. 

Atropine Test–Atropine has much the same effect as the administration of adrenalin, but instead of producing its effect by stimulating the sympathetics as adrenalin does, it produces it by inhibition, paralyzing the parasympathetics. As a result, it produces acceleration of the pulse, with rapid dilatation of the pupil and dryness of the mouth, the character of the effect depending upon the degree of sympathicotonia or parasympathicotonia present. In people who are already distinctly sympathicotonic the effect is much greater than in those who are paiasympathicotonic. In this way the marked effects of atropine in certain individuals is understood. 

Acetylcholine–Acetylcholine, when injected in the blood in minute doses, even in dilutions of 1 to 100,000 (in the frog), produces marked parasympathicotonic effects, slowing of the heart, vasodilatation and lowering of blood pressure. It acts through both the cranial and sacral parasympathetic nerves, producing general parasympathetic action throughout the entire gastrointestinal tract. 

Oculocardiac Reflex–Compression of the eyeballs for about 30 seconds, without producing pain, while the patient is in the recumbent position, may produce slowing of the heart. In people who are distinctly parasympathicotonic (vagotonic) it has been found that this slowing may amount to 10 or 12 beats. Under conditions of excessive pressure, in marked parasympathicotonics, the heart has often been temporarily inhibited. In people of stable nerve balance, neither inclined to sympathicotonia or parasympathicotonia, the slowing is usually less than 12 beats; in fact, in those who are markedly sympathicotonic no slowing may occur. The reflex is caused by stimulating the ocular fibers of the trigeminus, through which the impulse is transmitted to the cardiac inhibitory fibers of the vagus. In individuals who are distinctly parasyrpathicotonic the reflex may show itself in the gastrointestinal tract, as well as in the heart.

Erben’s Reflex–This consists of a slowing of the pulse when the head is bent strongly forward. It is most marked in those who are distinctly parasympathicotonic.

 

General Sympathetic Syndromes

Emotions–The usually accepted theory of emotions is that they arise in the brain but have visceral and somatic expression. Sherrington and Cannon have done much experimental work which they interpret as making this position evident. Kemp has recently discussed the vegetative or autonomic system in its relation to personality and interprets the order of reaction differently. He believes that emotions arise in the vegetative system and cause their peculiar emotional effects in the sensorimotor or voluntary system, thus giving the patterns of fear, anger and rage, as they are recognized in the somatic structures. 

Such emotions as fear, anger, rage and pain, as so well described by Cannon, all call for certain attitudes of expression and certain measures of relief by escape or action. The visible expression as well as the actual escape or protection is a matter which belongs to the somatic structures, but the conditions preparatory to it are brought about largely by and through the sympathetic nervous system, aided, however, by the adrenals and the thyroid.

Fear probably lies at the basis of all emotional expression, whether due to the major emotions or to a continued action of such minor emotions as are caused by chronic fatigue, worry, discouragement, unhappiness, disappointment, discontent and the depressing effect of overwork, and ill health. The major emotions are accompanied by a dilatation of the pupil, dry throat, peripheral vasoconstriction, heightened blood-pressure, increased adrenal secretion, increased sugar content in the blood, erection of hairs, increased heat production, sweating, increased heart beat, increased respiratory rate and a slowing down of the digestive processes so that all of the energy of the body may be massed in the peripheral system for the relief of the body from the agency which caused the fear. No matter whether the fear be followed by an attempt to escape or to assail the antagonist, or by anger and rage, the sympathetic system is called into action in its major distribution, and energy is brought into condition for ready release and easy utilization by the somatic system. 

In the minor emotions, the effects are less severe but more prolonged and the physiologic disturbances are less acute but more lasting. A chronic nerve instability takes the place of the marked overtopping of the vegetative balance. The tone of the skin is impaired, active sweating is not regularly noticed, vasoconstriction of the superficial vessels is often present to some degree in interfering with heat dissipation, the heart beat is often quickened, appetite is usually lessened and digestion is usually slowed, constipation is common and some degree of impotence or other interference with sexual disturbance is often present.

Pain, too, causes the same general action in the body. It stimulates fear and is met by the same body reaction as fear from other causes. 

The treatment of the chronic minor emotions consists in creating for the patient a proper psychology. While this is being done, the process may be hastened by relieving the patient’s tension by such sedatives as bromide, luminal and bromural. 

Toxemia–This is also an expression of general sympathetic effects. The lessening of the secretions of the upper respiratory tract is noticeable. Even the eyes at times become dry. The heartbeat quickens. Peripheral vasoconstriction is present, and often goose flesh, which is caused by pilomotor stimulation, is evident. The adrenals and thyroid are stimulated, and metabolism is increased. Peripheral vasoconstriction interferes with heat elimination, and the heat being produced in excess, elevation of temperature ensues. Sweating follows in some instances of toxemia, as in malaria and tuberculosis. The appetite lags and the gastrointestinal tract shows general lessening of motility and secretion, and constipation supervenes. The blood sugar rises. The reaction of the tissues shifts toward the acid side. Leukocytosis in which the polymorphonuclear leukocytes predominate also occurs. If the toxemia is severe and prolonged, the effects may be alleviated by the free use of water and alkalis, particularly bicarbonate of soda, aspirin, phenacetin, pyramidon, or some other such remedy may be used to relieve the aching. 

Horner’s Syndrome–This is interesting because it is produced artificially in operations which remove or destroy the cervical ganglia. Sympathetic innervation to the head is interrupted and the parasympathetics are left unopposed. The result is a certain syndrome of parasympathetic effects which is more or less constant. The pupil contracts; the lid slit narrows; the eyeball sinks in; the vessels to the affected side of the face and head dilate; sweating is absent; there may or may not be an increase in secretion of tears, saliva and nasal and pharyngeal mucus; atrophy of the skin and subcutaneous tissue takes place, and an increased pigmentation of the iris may occur. 

 

General Parasympathetic Syndromes

Allergic Reaction–Allergic reaction is characterized by widespread stimulation of the parasympathetics, together with a tendency to more marked local expression in certain structures. Vasodilation marks allergy, whether local or widely distributed; whether in the nasal tissues, bronchi, skin or gastrointestinal structures. Its expression takes the effect of edema and stimulation of the local tissues to increased activity. A tendency to allergic reaction seems to be inherited and manifests itself as a state of parasympathicotonia. Allergic individuals usually react strongly to pilocarpine. 

As was previously mentioned, it is not necessary that the cause of a parasympathetic syndrome be primarily in the parasympathetic nerves. It may be in the cell or in the Ca : K balance of the cell; in fact, the increased permeability of tissues, the exudative phenomena which are commonly found in allergic diseases, and the shift of the tissue reaction toward the alkali side are all conditions which are recognized as being a part of the picture caused when the ratio of Ca to K in the cells is lessened. 

Allergy may show itself in various tissues, but the bronchial musculature, the nasopharyngeal structures, the intestinal tract, and the dermal tissues are most commonly affected. Allergy is a condition of alkalosis accompanied by increased vessel permeability and exudation. Its pathologic-physiologic basis is such that it would be expected that the underlying condition would be received partially or wholly by the use of some combination of the following: ionized calcium, ammonium chloride, a ketogenic diet, the acidity produced by starvation, adrenaline and atropine. The precipitating causes, whether pollens, other allergens, foods or mechanical, chemical and reflex irritants, should all be removed by every means at the physician’s command. 

Hay-fever shows vasodilatation and increased permeability of the vessels of the nasal mucous membrane and often of the conjunctiva with edema and increased lachrymation and secretion of nasal mucus, all of which are expressions of increased activity of the vegetative fibers of the seventh cranial nerve. This may at times be relieved by atropine, which inhibits the action of the seventh nerve, or by adrenalin, which stimulates the antagonistic sympathetic fibers and causes vasoconstrictor effects, reducing vessel permeability and relieving edema and lessening the secretion. Theoretically, too, calcium is of value, in that it reduces cell permeability and lowers cell irritability. It further reduces edema and facilitates the action of the sympathetic nerves. Desensitization to the offending protein produces a state of balance by removing the cause of vasodilatation, and increased vessel permeability and hypersensitivity of the local nerves. The fifth nerve is also connected with hay-fever. It furnishes the sensory filaments which pick up the stimuli in the nasal tissues and cause sneezing, lachrymation and other reflex effects. 

Asthma is a common allergic disease. Individuals who suffer from asthma are prone to have other conditions which are expressive of increased parasympathetic action such as hay-fever, urticaria and such visceral reactions as are due to hyperirritability of the vagus and pelvic nerves. Eosinophilia is usually present. 

Asthma has several aspects, i.e., muscular, glandular and vascular. The bronchial muscles in asthma are contracted, lessening the bronchial lumen. The glandular apparatus is stimulated to an increased secretory activity. On account of the reduced size of the lumen, it is difficult to force either air or secretion through the constricted bronchi. The vascular element consists of an increased permeability of the vessel walls, which permits of exudation into the tissues, and which acts with the constricted bronchi as a deterrent to the ready passage of air and secretion. The same therapeutic measures as mentioned in connection with hay-fever are indicated, i.e., atropine, to inhibit the action of the vagus; adrenalin, to stimulate the sympathetics to antagonize the vagal action; calcium, to make the sympathetics act stronger, to reduce cell permeability and to reduce the edema; ammonium chloride, ketogenic diet or starvation, to render the tissues acid; and some form of iodine, sodium (iodide intravenously during the spasm) to fluidify the secretion and aid in its expulsion. For continuous relief, desensitization in those cases which are found to be sensitive to substances which enter the body either by the respiratory or digestive tract is the most valuable method; and shielding the patient from such substances as foods, feathers and powders to which he may prove sensitive, is all important and followed by success in many instances. Reflex causes should also be eliminated. 

Urticaria is another parasympathetic effect. It represents an allergic reaction with a local dilatation of the vessels with usually a rapidly forming edema. It may be brought on by many substances. It can usually be taken as a local effect of some protein which passed the intestinal mucosa in an undigested state. Finding the specific protein is all important. This may be withheld when found or desensitization may be carried out by adrenalin and often by calcium chloride intravenously. 

Angioneurotic edema is similar to urticaria in its causation and treatment. It is a parasympathetic effect usually produced by some food protein which gains entrance to the tissues in undigested form. The treatment is the same as that of urticaria. 

Intestinal allergies are not uncommon. They may be caused by any protein which enters the tissues undigested. A state of sensitization, with increased permeability and edema follows and a stimulation of the musculature causing some form of hyperactivity, spasm, spasticity of the musculature or diarrhea. The blood-pressure is low. 

Withholding the offending foods from the dietary, if they may be determined, is advisable, and then a systematic desensitization should be attempted. Calcium may be given either per os or intravenously. The latter is better. Atropine is also of value. Adrenalin, while theoretically indicated, has not proved so valuable in practice. 

Addison’s Disease–This is an excellent illustration of a parasympathetic disease. The injury or destruction of the adrenal gland removes from the patient the source of a vital secretion. While it is believed that there is a parasympathicotropic product which is produced in the adrenal cortex, which is lost to the patient, yet its loss in no way balances the loss of the sympathicotropic substances, and so a general parasympathicotonia results. 

As the adrenal structures become destroyed, parasympathetic effects come to the fore. Digestion becomes impaired, the patient emaciates, his blood-pressure falls, his blood sugar becomes low, diarrhea supervenes, and pigmentation of the skin takes place. Treatment by adrenalin and the raw suprarenal gland has been of value but the hormones recently described by Swingle and Hartman furnish much more promise for the relief of this otherwise fatal malady.

 

Instances of Mixed Sympathetic and Parasympathetic Effects

Blood Sugar–Variations in blood sugar represent one of the most beautiful interplays between the sympathetic and parasympathetic systems that take place in the body. Cannon has discussed this most interestingly. Under normal conditions, with average diet and a state of normal pancreatic function, there are about 100 mg. of sugar to the 100 c.c. of circulating blood. In case much sugar is ingested, by the aid of insulin, it is either burned up or stored for emergency, largely in the liver; but the average of 100 mg. of sugar to the 100 c.c. of blood is closely maintained.

In case the amount of sugar rises to 180 mg., it escapes through the kidney and appears in the urine. If it falls to 45 mg., convulsions are apt to appear. When insulin is not produced in normal amounts, sugar is not properly burned or stored in the liver and the amount in the blood rises. It may go to 200 or 300 mg. per cent. If insulin is then used in proper amounts, the sugar is both burned and stored and the blood volume may be reduced to normal. 

If the pancreas is normal, when an undue amount of sugar is ingested, the increased volume in the blood stimulates the vagus and through it causes an increase in insulin. In case of diabetes, where the pancreas is not functionally able to respond, when the sugar volume goes high, insulin must be given or coma may supervene. 

In case of artificial hypoglycemia produced under the use of insulin, the low sugar, and the shock stimulate the sympathetic system, and if the liver contains sufficient sugar, it is forced out into the circulation and may be able to restore the volume sufficiently to save the patient’s life. If the stores in the liver and muscles are already depleted, then sugar must be furnished at once to restore the blood volume or death will ensue. 

Exophthalmic Goiter–Exophthalmic goiter shows many symptoms which are predominantly sympathetic. Now and then, however, it produces certain parasympathetic effects as well. 

As a rule, the effects in the head structures are predominantly sympathicotonic, the opposite of those expressed in Horner’s syndrome. The pupil is dilated, the lid slits are widened and exophthalmos is present instead of enophthalmos. Sweating is present not only in the head structures but the entire body may be moist. General symptoms include such sympathetic effects as elevation of temperature, speeding up of metabolism with loss of weight, increased rapidity of the heart beat and tremor. 

In certain other cases, such parasympathetic effects as hypersecretion and hypermotility of the gastrointestinal canal may be present, showing as increased peristalsis, diarrhea, and even incontinence of feces. There also may be an increase in the function of the lachrymal glands. These parasympathetic effects appear most commonly in patients in whom parasympathetic action normally predominates (the vagotonics). Lugol solution may be given to prepare the patient for operation, but the removal of the gland is the proper treatment. 

Nausea and Vomiting–Vomiting is closely associated with nausea, although either may occur without the other. Nausea may be produced through sight, sound, smell or touch, or through various stimuli from the vegetative organs. Vomiting may follow increased intracranial pressure, concussion of the brain, pain and certain emotional discharges. 

Vomiting is an antiperistaltic act. When analyzed, the gastric effects prove to be due to a preponderance of sympathetic action as follows: the pylorus closes; the antrum contracts; the fundus, the cardia and the lower esophagus relax. The act of ejecting the gastric contents depends upon the contraction of the diaphragm and abdominal muscles. 

These effects are apparently released from a center in the medulla. The centrifugal impulse must pass down the cord, (1) to the sympathetics supplying the stomach and pylorus, and (2) to the nerves of the diaphragm and abdominal muscles; and (3) must be transferred in the medulla to the efferent gastric fibers of the vagus to relax the fundus, cardiac sphincter and lower esophagus. Pallor, sweating, increased heart beat and increased peristalsis with diarrhea often accompany vomiting. The first three effects are distinctly sympathicotonic and the latter two are parasympathicotonic, possibly due to paralysis of the sympathetics as in great fright. 

Anorexia Nervosa–This condition is a vegetative imbalance in which sympathetic action preponderates. Appetite is lessened or absent and sometimes the thought or sight of food causes nausea. Vomiting is not a necessary part of the syndrome, but sometimes occurs. It is apt to be associated with emotional strain and is sometimes acutely precipitated by an emotional crises. It is a common accompaniment of discontent, unhappiness, loneliness, domestic infelicity, disappointment, chronic fatigue, physical strain especially in those who are below par; in fact, it may accompany any condition of nervous or emotional instability. 

It may be relieved by changing the condition which is responsible for it. As a temporary measure, while transforming the life and eliminating the underlying cause or causes bromide, luminal or bromural may be of great value. 

Anorexia nervosa is met often in pampered children whose mothers and nurses sit by and keep prodding them about eating. The child develops an emotional state associated with feelings of resentment accompanied by a lack of appetite and disgust for food.

 

Instances of Local Vegetative Imbalance

Local vegetative imbalance may appear in any organ. Sometimes this may be due to a reflex stimulation of one of the systems of visceral nerves, while the other remains in a state of normal or lesser excitation; at other times it may be due to a constitutional effect which causes a continuous imbalance in one or the other direction; and, again, it may be due to the action of some substance which is preponderantly sympathicotonic or parasympathicotonic.

Every alteration of secretion, internal or external, every alteration in the normal products which follow the wear and tear of the body, changes in acidity and alkalinity of tissues, emotional reactions, and changes in the temperature of the body environment produce visceral effects which are distributed through visceral nerves from centers in the brain and cord. Likewise, abnormal products which result from disease effect changes through the same centers. Every inflammatory reaction in the tissues of the body produces visceral effects through stimulation of afferent nerves found in those tissues, and which mediate in the central nervous system with other nerves in the formation of reflexes. 

Many of these reflexes are expressed through sympathetic nerves; others through the parasympathetics, and still others through the cranial and spinal nerves of the somatic system. An inflammation in an important organ commonly disturbs the vegetative balance in other organs. 

Pathologic Physiology of Gallbladder and Biliary Duct Disease–The gall-bladder has come in for much discussion in recent years because of the advances that have been made in surgery and also because of a better understanding of its physiologic working. This has been greatly stimulated by the work of Lyons. 

The innervation of the gall-bladder theoretically and according to reliable experiment follows the rule of contrary innervation (Meltzer), which postulates that the efficiency of action of any closed sac innervated by two antagonistic sets of nerves requires that the neck of the sac and the body of the sac should show opposite effects under stimulation of either of the sets of nerves supplying it as follows: Stimulation of the nerve closing the neck of the sac must not at the same time cause contraction of the sac itself, nor must stimulation of the nerve which relaxes the opening of the sac relax the body of the sac at the same time.

In case of the gall-bladder, clinical evidence points not only to its following this law, but further indicates that the innervation of this organ and its duct and sphincter follows the same innervation as other parts of the enteral system. The sphincter and ducts are activated by stimulation of the sympathetics and inhibited by stimulation of the vagus, while the body of the bladder, as well as the gall ducts, is activated by stimulation of the vagus and inhibited by stimulation of the sympathetics. In this the innervation of the biliary system is the same as that of the stomach, small intestine, colon, rectum and urinary bladder, and the sphincter systems belonging to them. 

The effect of magnesium sulphate on the biliary system is to stimulate the vagal action and oppose the sympathetic action. Thus, it has a tendency to open the sphincter and at the same time to contract the gall-bladder and the gall ducts. 

Failure of action now and then may be due to an alteration in the normal alkali-acid base of the cells which is produced by the inflammatory process. This interferes with and sometimes even reverses the effect of a nerve impulse. It is assumed that a reversal of action occurs now and then in many structures. It has been noted in the heart and also in the treatment of asthma and hayfever in a few instances in which adrenalin has been reported to have made the attacks worse. 

The Pupil–The pupil may be dilated by a pleurisy involving the apex of the lung or by the inflammation (tuberculosis) in the lung itself. The impulse is carried by the afferent system of the sympathetics to the upper thoracic segments of the cord, where it is transferred to Budge’s center which lies in the segments, eighth cervical to third dorsal, and from which sympathetic stimuli are carried upward through the cervical and ciliary ganglia to the pupil. Dilater effects are carried from the lung at the same time over the vagus which, on reaching the medulla, are transferred to the third cranial nerve. In this same manner imbalance in the muscle of accommodation may be produced through other fibers in the third nerve. 

Bradycardia–May be produced reflexly from pressure on the eyeball, through the sensory fibers of the fifth and the motor fibers of the tenth or vagus; now and then, by inflammation in the lung or other portions of the enteral system, such as the appendix, gallbladder, stomach and intestine when ulcerated. In this reflex both afferent and efferent fibers belong to the vagus. 

Intestinal Block–This is now and then found as a reflex from the gallbladder, the sympathetics probably furnishing both arms of the reflex. 

Pylorospasm–This may be caused by reflexes, the stimuli for which arise in the lung, intestinal tract, liver and gall-bladder, urinary bladder or other important organs. The afferent fibers in this case probably course central ward over the sympathetics to join with other sympathetic nerves in causing the sphincter contraction, for it has been shown that the chief activating system of nerves for the pylorus is the sympathetics. However, the possibility of vagal control too, cannot as yet be denied. 

Impotence–Impotence is often a condition of imbalance in the vegetative nervous system, independent of any organic lesion. 

The centers which govern the sexual act in man are centered in the upper lumbar and lower sacral segments of the cord. The center for erection is situated in the sacral segments of the cord. This center, when irritated, sends out impulses over the pelvic nerve (nervus erigens) to the plexus cavernosus which causes vasodilatation and erection. The stimulus for erection may have many sources: the local sensory nerves, nervus pudendi communis or nervus dorsalis penis; stimuli which come from sight, smell, sound or touch, or through thoughts and sexual emotions. 

The mechanism of erection is an excellent example of the integration of impulses by the nervous system. The impulse may arise in any of the nerves of special sense or as a product of thought, but no matter at what level it enters the central nervous system, it must travel to the sacral segments before it can be transferred into action. 

The mechanism of erection is opposed by the sympathetic system, which causes vasoconstriction and contraction of the musculature of the penis. The center for inhibition is in the upper lumbar segments. Inhibition is brought about quickly through all of those major emotions such as fear, anger, hatred and pain. It is also inhibited by toxemia and the lesser harmful emotions such as prolonged worry, discontent and unhappiness, debilitating sickness, overwork and chronic fatigue. All of these forces act upon the sympathetic nerves and may interfere with erection. These factors lie at the bottom of much of the impotence in man and can be relieved often by eliminating the cause. 

Pollutions are associated with that part of the sexual act which is presided over by the sympathetic nerves which take their origin from and are controlled by a center in the upper lumbar segments. This center becomes very active at the time of and following puberty, and while the normal stimulation for ejaculation comes through the nervus pudendi communis and the nervus dorsalis penis, this center is often influenced by waking thoughts and dreams of a libidinous nature. It is also stimulated by impulses which arise because of pressure in the seminal vesicles and by warmth applied to the lumbar segments, as by sleeping on the back. The result of these thoughts and dreams, pressure and warmth of the bed, especially when acting together, is a contraction of the musculature of the seminal vesicles, the vas deferens and prostate, and an ejaculation of semen. 

Pollutions thus are often due to vegetative imbalance brought about by the new stimuli of sexually efficient organs and their domination of the life and thoughts of the developing boy. 

Hypertonia in Pelvic Nerve–There are a number of other instances of imbalance in the pelvic and its opposing sympathetic nerves which cause troublesome symptoms. 

Enuresis in the child and dribbling urine in the adult may both be considered from the standpoint of a preponderance of action in the pelvic nerve (parasympathetic). The stimuli for maintaining this parasympathetic preponderance commonly arise in the bladder itself or in the urethra. The dribbling which is found particularly in women suffering from tuberculosis, and which accompanies coughing, may be due partly to reflex effects which are transmitted from the lung by way of intracentral paths, and partly, as is usually stated, to a weakened sphincter together with increased pressure on the body of the bladder engendered by the increased intraabdominal tension exerted by the cough impulse. The dribbling due to brain and cord lesions may be caused either by sympathetic inhibition or by overstimulation of the pelvic nerve. Sometimes incontinence may be relieved by inhibiting the action of the pelvic nerve which antagonizes the sympathetics and prevents the closure of the sphincter. Atropine and hyoscyamine are remedies frequently used for this purpose. 

The incontinence of feces and urine caused by fear is probably due to paralysis of the sympathetics which activate the sphincters and oppose the action of the pelvic nerve in the musculature of the bowel and bladder, thus allowing the parasympathetics unopposed, to exert their full dilating effect on the sphincters, and at the same time to increase the muscular contraction of the bowel and bladder. 

Labor pains have been found to cease when the parturient woman was overcome with grief. 

Vegetative Imbalance in Dermal Structures–There are a number of phenomena which are associated with pathologic reactions in the subdermal vegetative structures. Vasomotor, pilomotor and sweat reactions are each presided over by its own particular system of nerve fibers and each reaction possesses its own center or centers in the central nervous system. 

Vasoconstriction, activation of pilomotor muscles and stimulation of sweat secretion are all produced by stimulation of the sympathetics, and so the connector neurons which supply the ganglia from which activating fibers for these structures emerge arise in the thoracic and upper lumbar segments only. For this reason it must be evident that the distribution of nerves for these functions cannot follow the sensory zones of the skin accurately, but must depart widely from them, except over the trunk. The nerves for vasoconstriction, pilomotor and sweat activation course in the anterior root nerves. 

The cervical ganglia give origin to the sympathetic nerves for vasoconstriction, pilomotor reaction and sweat production for the head and face. These nerves are opposed in these structures by the vasodilators, pilomotor and sweat inhibitory fibers of the parasympathetics. 

Vasodilatation and sweat inhibitory fibers for the trunk and extremities are of sympathetic origin, and course with the dorsal instead of the anterior root nerves. 

Stimuli which arise on the surface of the trunk and limbs and cause reflexes in the dermal structures are carried central ward over the sensory spinal nerves to the posterior root ganglia, thence to the cells in the posterior horns, and from these to the vegetative centers in the lateral horn. If vasoconstriction and activation of the pilomotor and sweat glands is to be the result, the efferent impulse passes over fibers which course in the motor nerve; if, on the other hand, vasodilator and sweat inhibiting effects are to result, the impulse passes over fibers which course with the sensory nerve. 

There is one symptom which is commonly found in vagotonia that is difficult to explain on the basis of the usually accepted sympathetic control of the sweat glands, i.e., sweating of the hands and feet. 

Vasomotor Imbalance–Imbalance in the vasomotor system is not at all uncommon. The reaction of the skin to mechanical and chemical stimuli, such as stroking, heat, light, cold and irritants, as has been so carefully studied by Lewis and his coworkers, is very important in leading the way to a better understanding of these phenomena. 

Dermographia–The vasomotor reaction of the skin to various mechanical irritants is known as dermographism. This reaction varies from a mild transient hyperemia to a wheal or welt which is considerably elevated above the normal skin and which may last for several minutes. Those who show marked dermographism are found among the vagotonics of Eppinger and Hess. They are often spoken of as having vasomotor instability. Vagotonics are more prone to peripheral dilatation than sympathicotonics. Vasodilatation may be caused by the use of the parasympathicotropic drug pilocarpine. 

Should the mechanical irritation be followed by a paling of the surface, and white line of Sargent, it indicates a preponderant sympathetic status. 

Raynaud’s Disease–This disease, which is a peripheral vasoconstriction which may lead to gangrene and death of the extremity, is now recognized as being a distinctly sympathetic affection, which may be more or less successfully treated by relieving the extremity from the central vasoconstrictor impulses by cutting the activating sympathetics. Its localization would suggest that it might be due to some locally produced substance which stimulates the vasoconstrictor of the affected extremity or to some special condition in the nutrient cells of the particular nerves which are involved. Lewis has recently suggested the treatment of this condition by immersion in cold water. 

Angiospastic Conditions probably often occur in various structures of the body, caused by local sympathetic action. This, too, might have an underlying cause similar to that of Raynaud’s disease. Sometimes such conditions are met in the limbs and give intense pain. Attacks of angina are so explained by some clinicians, and temporary paralysis are now and then met which might be due to a momentary vasoconstriction of cranial vessels. 

Erythromelalgia, on the other hand, is a condition of vasodilatation. The clue seems to be the fact that it affects chiefly the arms, hands and feet, and that the sympathetic nerves responsible for vasodilatation in these members course in the sensory spinal nerves. It has, therefore, been thought that the affection may be due to irritation in the posterior nerve roots or in the spinal ganglia of the posterior horn. Periarterial sympathectomy which has been tried in these cases, has apparently been followed by no regular results. 

Trophic Changes in Dermal Tissues–There are trophic changes in the dermal and subdermal tissues which are due to vegetative imbalance. The dry skin of subthyroid conditions, myxedema and cretinism, the dry scaly condition of ichthyosis and chronic indurative eczema, and the dryness which follows long continued toxemia are to be considered in connection with the thyroid gland and the sympathetic nervous system with which it is so closely bound in its physiologic effects in dermal structures. All of these conditions are aided by thyroid therapy and by calcium which is sympathicotropic in its action. 

Reflex Trophic Effects from Viscera–The writer has described many visceral trophic reflexes, particularly from the lungs and pleura, but has also observed them in case of chronic inflammation of the kidney and chronic inflammation of the intestinal tract. He has been at a loss to explain in what part of the reflex arc the injury responsible for this phenomenon takes place.

The writer has observed it in chronic pulmonary lesions as a reflex in which the afferent impulse is carried over the vagus and transmitted to other cranial nerves as follows: 

 

1. Atrophy of the tongue. This might be produced through one or all of the nerves supplying the tongue, the fifth, seventh and twelfth cranial nerves. 
2. Atrophy of the facial muscles through the fifth and seventh cranial nerves. 
3. Atrophy of the soft structures of the nasal, oral, pharyngeal and laryngeal cavities through the seventh and tenth cranial nerves. 

 

The writer has further observed atrophy of the skin, subcutaneous tissues and muscles which are innervated by the mid cervical segments of the spinal cord, as a reflex in chronic pulmonary lesions in which the efferent impulse is carried by nerves which course with the sympathetics as follows: 

 

1. Atrophy of the muscles of the shoulder girdle, particularly the sternocleidomastoideus, scaleni, pectoralis, trapezius, levator anguli scapulae and rhomboidei. 
2. Atrophy of the skin between the second rib and angle of jaw anteriorly, and between the spine of the scapula and base of the skull posteriorly. 
3. Atrophy of the subcutaneous tissue in the same areas as those mentioned in case of the skin. 

 

The trophic reflex from the pleura is expressed over three sets of nerves: (1) the pulmonary sympathetics, and (2) the phrenic, both of which produce degenerative changes in the same areas as the lung and cannot be differentiated from them; (3) the intercostals, which are expressed by atrophy of the soft tissues lying immediately over the area of inflammation.

It is probably justifiable to assume that all other important organs such as the heart, stomach, pancreas, liver, intestine and pelvic organs, when involved in chronic inflammation, produce reflex atrophy in those skeletal structures which are supplied by nerves which mediate the impulses set up by the inflammation. The writer has described such reflex trophic changes which were caused by the pleura, lung, kidney and intestine. 

Reflex Motor Effects from Viscera–Reflex motor phenomena are expressed in other tissues and organs as a result of an imbalance of the particular vegetative nerves which are involved in inflammation of the various viscera. In this way must be explained the spasm of the rectus muscle in ulcer of the stomach, the spasm of the muscles of the lower right quadrant of the abdomen in appendicitis, the upper right quadrant in gall-bladder diseases, the lumbar muscles in inflammation of the kidney, and the muscles of the shoulder girdle in instances of inflammation of the lung (tuberculosis). 

The imbalance in these cases is, as a rule, temporary and ceases when the inflammatory reaction in the organ subsides, but if it continues into a chronic state the spasm is succeeded by atrophy. 

Reflex Sensory Effects from Viscera–The sensory reflex effects which are usually spoken of as referred pain are also due to a temporary imbalance affecting the afferent system of either the sympathetics or the parasympathetics. The cardiac pain in the arm and upper thoracic areas in angina pectoris; the pain in the upper left quadrant of the abdomen in ulcer of the stomach; the pain in the upper right quadrant in biliary and gall-bladder disease; the pain in the lower right quadrant in appendicitis, the altered sensation (not an acute pain) in the skin or any of the muscles supplied by the midcervical segments of the cord in pulmonary tuberculosis; the acute pain in the thoracic areas in acute pleurisy; the pain in the shoulder areas resulting from diaphragmatic pleurisy, are all due to an overstimulation of the afferent system of the sympathetic nerves. As a result of the overstimulation, the impulses are carried to the cord and transmitted to the sensory nerves of the skeletal system, to produce pain in the particular area which shows pain for each given organ. Likewise, the various pains and achings about the face and head which are transmitted from thoracic, abdominal and pelvic viscera, are due to an overstimulation of the parasympathetics, the impulse being carried over the afferent system of the sacral and vagus nerve, to be transmitted to the various branches of the fifth cranial nerve for expression. 

This phase of temporary imbalance, due to inflammatory conditions of the viscera, is of tremendous importance from a diagnostic standpoint, and in some instances of more importance because of the permanent effects produced, and should receive very careful consideration at the hands of clinicians.

 

Importance of Imbalance in Vegetative System to Clinical Medicine

From the discussion here given it will readily be seen that imbalance in the vegetative nerves is capable of producing many symptoms. A recognizable imbalance is produced in all visceral diseases that reach a sufficient magnitude to be recognized by the patient. 

Bearing in mind that the chief purpose of the vegetative nerves is that of correlating and integrating action in the body, and further bearing in mind that they may be subject to the amount of stimulation which is necessary to overbalance their normal function whenever an abnormal irritation arises in any organ, it may readily be seen that an understanding of visceral neurology will greatly aid and is indispensable to the clinician in understanding and explaining many phases of clinical disease.