The effects of removal of this ganglion are immediate and remote: The
immediate are relief of pain, lachrymation and conjunctival injection,
together with a discharge from the corresponding nostril, unilateral
sweating, and contraction of the pupil. Often there is an immediate
reduction in intra-ocular tension. These effects are noted within five
minutes after the excision.
The remote effects are ptosis, which appears on the third or fourth day,
improvement of vision, and in some instances a tardy contraction of the
pupil and a tardy reduction of the intra-ocular tension. To these there
must also be added a slight sinking of the eyeball into the orbit, and a
feeling of heaviness in the head. What I have just written applies
particularly to cases of glaucoma.
In exophthalmic goiter, after the excision of the ganglia, the
exophthalmus and tachycardia are said to improve almost immediately and
a reduction of the goiter soon follows.
Although Jonnesco speaks of the immediate reduction of the intra-ocular
tension, yet this does not always occur. In my second case, at the end
of eight days the tension was + 2. On the sixteenth day the tension was
normal. In my first case reduction of the tension was immediate. The
relief from pain in the first case was immediate and lasting. This
patient had not been free from pain for two months previously. The
slight ptosis following sympathectomy is to be attributed to paralysis
of Müller’s muscle. Sinking of the eyeball is no doubt due to paralysis
of the unstriped peribulbar fibers found in Tenon’s capsule. Contraction
of the pupil is usually an immediate result; it may, however, appear
tardily. Thus in my first case the pupil was unchanged until the fourth
day after the operation; and it did not become at any time as markedly
contracted as in the other two patients. In the third case—that of
optic-nerve atrophy—the pupil was markedly contracted within five
minutes after the excision.
The lachrymation, conjunctival injection, and nasal moisture are
transient symptoms which are usually absent after the first day.
In this connection it is interesting to note that Mr. Jonathan
Hutchinson, as early as 1866, recognized many of the ocular symptoms of
paralysis of the cervical sympathetic, and wrote a paper thereon.
HOW DOES EXCISION OF THE CERVICAL SYMPATHETIC REDUCE INTRA-OCULAR
TENSION?
This is a question difficult to answer—difficult for the reason that we
are not sufficiently acquainted with the physiology of the production of
aqueous humor under normal surroundings. Panas and Duvigneaud have
assumed rightfully that “If the nervous mechanism of intra-ocular
secretion or, to speak without hypothesis, the action of the nervous
system on intra-ocular tension can be known, the pathology of glaucoma
will be cleared up, iridectomy will be explained, and perhaps a new and
scientific basis for the treatment of glaucoma will be established.”
Many observers have sought to solve the problem. Donders attributed the
hypertension to a neuro-secretory cause and believed the trigeminus to
be the agent of excessive secretion. He held that section of the
trigeminus should relieve intra-ocular tension, while section of the
cervical sympathetic could have no particular influence.
His views were overthrown by experiments made by Wegner in 1866, on
rabbits. By means of manometers placed in the anterior chamber, he
sought to record variations in the intraocular tension. He proved to his
own satisfaction that the trigeminus takes no part, while section of the
cervical sympathetic produces hypotonia, and irritation of its upper end
and causes hypertonia. He held that section of the cervical sympathetic
enlarges the blood vessels of the eye; the blood then flows under
reduced pressure, and intra-ocular secretion is lessened. Almost
identical results were obtained by Adamück—1866‒68—who experimented on
cats.
Von Hippel and Gruenhagen believed that the cervical sympathetic
contains vasoconstrictor fibers for the eye. Their experiments were made
on cats and dogs. They found that irritation of the upper end of the
cervical sympathetic causes in the cat hypertonia, while its extirpation
increases intra-ocular tension. While, according to Wegner, the
hypertonic action proceeds from the enlargement of vessels caused by
cutting the cervical sympathetic, and the contraction of the blood
vessels caused by the irritation of the nerve causes a hypertonic
action, the contrary view is held by Adamück, Von Hippel, and
Gruenhagen.
However this may be, there is no doubt that the trigeminus plays no
great part in the production of ocular tension. Furthermore, the
inefficiency of Bedal’s operation—stretching the nasal nerve—is
explained by the fact that it is the cervical sympathetic, and not the
trigeminus, which influences intra-ocular tension.
Jonnesco believes that the ocular sympathetic fibers from the brain and
spinal cord pass through the superior cervical ganglion; permanent or
intermittent irritation of these is accompanied by dilatation of the
pupil, narrowing of the small intra-ocular arteries, contraction of the
peribulbar muscular fibers, and probably an increased action of the
elements which produce the aqueous humor. “As a matter of fact,” says
Jonnesco, “any increase of the blood pressure will produce a permanent
or intermittent narrowing of the arteries and cause the extravasation
and increase in aqueous humor; then it is probable, although not
definitely settled, that a permanent or intermittent irritation of the
excito-secretory fibers is followed by an increase in the secretion of
aqueous humor; the permanent or intermittent dilatation of the pupil
pushes the iris into the iris-angle, closes the canals of the filtration
zone, and hinders or prolongs the exit of aqueous humor from the eye;
the permanent or intermittent contraction of the unstriped peribulbar
muscular fibers closes the efferent veins of the eyeball, and hinders
the venous circulation of the eye—hence the dilatation of the
intra-ocular veins.”
He holds that excision of the superior cervical ganglion destroys all
vasoconstrictor fibers of the eye. The arteries relax, the blood
pressure is lowered, and extravasation is reduced. This operation
destroys the excito-secretory fibers, thus limiting the amount of
aqueous produced. The fibers which dilate the iris are destroyed, hence
the contraction of the pupil reopens the iris-angle and removes the
obstacle to the outflow of aqueous. The nerve-fibers supplying the
unstriped muscular apparatus contained in Tenon’s capsule are destroyed,
hence the pressure on the efferent veins is removed and ocular
circulation is reestablished.
Jonnesco believes that the starting-point of the nervous derangement
producing glaucoma is central: “When one removes the ganglion the point
of origin of the influence will not be removed, but the communication
between this center and the eyeball is destroyed.”
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.