CASE II.—DOUBLE SYMPATHECTOMY FOR GLAUCOMA SIMPLEX.
Miss M. E., a German, aged forty-three, was sent to me on June 14, 1899. For two years sight had been failing, until at this time vision was as follows: R. E. = 0; L. E = light perception. Tension was + 3. Both optic nerves showed marked cupping of the disk; the vessels were pushed to the nasal side. She stated that she had never had pain in the eyes, and had not consulted an ophthalmic surgeon.
I advised her to submit to an excision of the left superior cervical ganglion; she consented, and on June 15 the operation was performed by myself, assisted by Dr. E. C. Renaud, at St. Joseph’s Sanatorium, in the presence of Drs. J. C. Murphy, A. R. Kieffer, and S. A. Grantham. The operation was difficult, owing to the abnormal position of the vagus nerve. This was outside of and external to the carotid sheath, and was much smaller than normal; it was not larger in diameter than the head of a pin. It was identified by irritating it and watching the effect on the heart. The superior cervical ganglion was removed and one-half inch of the trunk of the sympathetic below. Shortly after the operation there were lachrymation, ocular congestion, and contraction of the pupil on the corresponding side. On the second day she counted fingers at 2½, and on the third at 3½ feet. Slight ptosis was present.
She left the hospital on the eighth day. At this time she counted fingers at four feet. There was only slight, if any, reduction of tension during the eight days she was in the hospital. In counting fingers she saw with the nasal side of the retina—temporal field. I did not see her again until June 30, and she was then counting fingers at five feet. Tension on that day was normal. She had light perception in the right eye.
On July 16 I excised the right superior cervical ganglion without difficulty, and on July 7 she counted fingers at seven feet with the left eye, and could see the hand at four inches with the right. I examined her on July 20, when vision remained the same, the tension of the right eye was + 1, and of the left + 2. She was well pleased to have the small amount of vision she possessed.
CASE III.—SYMPATHECTOMY FOR OPTIC-NERVE ATROPHY.
T. J., aged forty-six, an inmate of the St. Louis City Hospital, a laborer, was admitted on account of blindness. There was no history of syphilis, rheumatism, nor any systemic disease. The patient was of limited mentality. No history of his family could be obtained. He claimed to have had good health all his life, with the exception of an attack of malarial fever several years ago. The patient had been a moderate drinker of alcoholic beverages. In appearance he was robust, and he complained only of loss of vision which, in the left eye, had been failing for eleven months, in the right for seventeen weeks, according to his statement. Until seventeen weeks before this he could see enough with the right eye to get around. Since then vision had steadily declined until he had light perception only—and this only apparent when light was concentrated on the eye by the ophthalmoscopic mirror. Vision of the left eye = 0.
The pupils were widely dilated. The ophthalmoscope showed, in the right eye, a white disk, particularly on the temporal side; the arteries slightly reduced in caliber, veins normal. There was shallow, atrophic cupping of the nerve head. The retina and choroid were normal, the vitreous and lens clear. The left eye showed a disk of a dead white color throughout the whole area, arteries very small, atrophic excavation pronounced, veins reduced in caliber, and choroid normal. The macula was not visible in this eye, owing to the much-reduced blood-supply. The vitreous and lens were clear. Vision was as follows: R. E. = perception of concentrated light. L. E. = 0.
Diagnosis.—R. E. = optic-nerve atrophy. L. E. = complete atrophy of optic nerve and retina.
Treatment: Resection of the right superior cervical ganglion of the sympathetic was done. The operation was followed by conjunctival congestion, lachrymation and contraction of the pupil, slight ptosis and hypotonia.