Regardless of the differing views of physiologists concerning the mechanism of the reduction of ocular tension, based on experiments made on the lower animals, there can be no difference of opinion concerning the effect of excision of the superior cervical ganglion in the human subject. The operations made by Jonnesco and others on the Continent, and by myself in America, prove that removal of the superior cervical ganglion causes a marked reduction of intra-ocular tension in glaucomatous cases. That the same effect occurs in eyes with normal tension is evident from my third operation—that done for optic-nerve atrophy.
EXTENT OF SYMPATHECTOMY IN DIFFERENT DISEASES.
Up to the present time excision of the cervical sympathetic has been performed for the following diseases: epilepsy, exophthalmic goiter, glaucoma, and optic-nerve atrophy. The question naturally arises: How extensive an operation is necessary in these affections? This I will attempt to answer:
In epilepsy it is necessary to excise the entire cervical chain on both sides for the reason that, according to Jonnesco’s theory, it is necessary to convert a state of cerebral anæmia—which he assumes is the condition in epilepsy—into one of cerebral hyperæmia. Since the carotid plexus is formed by branches from the superior ganglion, and the vertebral plexus arises from branches which have their origin in the inferior cervical ganglion, it is evident that the entire cervical sympathetic must be removed.
In exophthalmic goiter, although Jonnesco in his first operation excised only the superior and middle ganglia, he now believes it necessary to remove the inferior as well, for this reason: from the superior ganglion the ocular fibers arise; from the inferior the vasodilator, cardiac-accelerator, and, probably, the secretory nerves of the thyroid gland. If eye, thyroid, and cardiac symptoms are to be relieved the entire chain must be excised.
In glaucoma removal of the superior ganglion alone is necessary. All of the sympathetic fibers of the eye, with the exception of those which pass directly from the cerebrum by way of the trigeminus, are connected with the superior ganglion.
In optic-nerve atrophy, if it should be proved that noninflammatory atrophy of the optic nerve can be improved by sympathectomy, removal of the superior ganglion alone will be necessary, for reasons already given.
If the glaucoma is unilateral, it is necessary to remove only the corresponding ganglion.
HISTORY OF SYMPATHECTOMY.
In 1889 Alexander of Edinburgh resected the superior ganglion on both sides. In 1892 Jacksh resected the vertebral plexus and cut the cord connecting the middle and inferior ganglion. The third operator was Kummel, who excised the superior ganglion on one side only. In 1893 Bojdanik made a bilateral resection of the middle ganglion. In 1896 Jaboulay made a bilateral section of the sympathetic cord, above and below the middle ganglion. These operations were all made for epilepsy.