No appreciable change in the patient’s vision followed, and ophthalmoscopic examination made two weeks after operation showed no change in the appearance of the fundus, except that a cilioretinal artery in the upper part of the disk had doubled in caliber.
So far as I know, Case III. is the first instance in the history of medicine of an excision of the superior cervical ganglion, or of any part of the sympathetic system, for the relief of optic-nerve atrophy. Although the operation was not of benefit in this particular instance, yet I am not willing to concede that it will prove valueless in cases of non-inflammatory atrophy in which vision is not entirely lost. In truth, I expect it to prove beneficial in such cases, sufficiently often to justify the procedure.
I was led to make this experimental operation for several reasons: 1. The use of glonoin is often followed by an improvement in vision in cases of simple atrophy of the optic nerve. 2. Glonoin enlarges the retinal vessels, as has been proved by ophthalmoscopic examination. 3. There is no question that in glaucoma simplex—a disease in which there is an atrophy of the optic nerve—improvement in vision follows sympathectomy. 4. Excision of the cervical sympathetic is followed by an increase in the blood-supply of the orbital contents.
PATHOLOGIC CHANGES IN THE EXCISED GANGLIA.
The microscopic examination of three of the excised ganglia was made by my friend, Dr. Carl Fisch, of St. Louis. The specimens were those from Cases I., II., and III. Of the two ganglia removed from Case II. only the first one—the left—was examined.
Transverse and longitudinal sections of the three specimens were studied microscopically, by means of a great number of different staining methods. Owing to the method by which the ganglia had been preserved—weak formalin solution—the employment of the Golgi—Marchi—and the more delicate Nissl stains was rendered impossible. In general it may be said that the pathologic changes found were the same in the three cases, although a little less pronounced in No. 2 than in 1 and 3.
Most striking of all was a very marked hyperplasia of the connective tissue, which in some places resulted in dividing up the ganglion into small groups of nervous elements separated by broad bands of fibrous elements. The walls of the vascular structures showed decided sclerosis; the connective-tissue sheaths of the ganglionic cells were much increased in thickness. In Case I. small foci of round-cell infiltration were seen in this hyperplastic growth, of an inflammatory character. No plasma nor mast cells could be demonstrated.
The ganglionic cells were markedly pigmented. Together with a number of cells normal to all appearance there were great numbers showing different stages of degeneration. As a rule the nucleus, besides having lost part of its peculiar staining property, had assumed the parietal position; the nucleus was reduced in size or even missing in a large percentage of the cells. While in some cells the chromatic elements were well preserved, in others the process of chromatorhexis and chromatolysis could be followed up through all of its stages. Only comparatively few cells were seen showing the normal dendriform processes; very often the processes were short, ending bluntly, or they had even disappeared altogether. The general peripheral network of processes was much reduced in volume and compressed by the pressure of the connective-tissue formation. Only very few medullated fibers were seen. Unfortunately it was impossible to study their structure with the Marchi method.
The general pathologic aspect was that of a decided sclerosis, originating in inflammatory processes going on in, and starting out from, the walls of the vascular structures. The changes of the nervous elements were most likely not idiopathic, but due to pressure and inhibited nutrition.
The plates accompanying this paper have been made from drawings of sections of superior cervical ganglia.