LAI ION 
 
 OF THE 
 
 ERVICAL SYMPATHETIC 
 
 DE SCKWEINITZ 
 
 WILDER 
 
 BALL
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 Mrs. Clifford B. Walker
 
 He Iat ton of tfye (Ecrmcal 
 Sympathetic to tfye (Eye :: :: 
 
 Papers rcab before tfye Section on 
 Ophthalmology of tfye American 
 IHebical Association, at tfye Annual 
 Session, Hero Orleans, TTtatj, ItyQZ 
 
 'The Physiology of the Sympathetic in Relation to the 
 Eye." 
 
 G. E. DE SCHWEINITZ, A.M., M.D.. Philadelphia. 
 
 'The Influence of Resection of the Cervical Sympathetic 
 Ganglia in Glaucoma." 
 
 WILLIAM H. WILDER, M.D.. Chicago. 
 
 'Influence of Resection of the Cervical Sympathetic in 
 Optic-Nerve Atrophy. Hydrophthalmos and Exoph- 
 thalmic Goiter.'" 
 
 JAMES MOOEES BALL, M.D., St. Louis. 
 
 Pathology of the Cervical Sympathetic." 
 
 JOHN E. WEEKS, M.D.. New York. 
 
 CHICAGO : 
 
 TRESS OF AMERICAN MEDICAL ASSOCIATION 
 ONE HUNDRED AND THREE DEARBORN AVENUE 
 1904
 
 ttawdkgi 
 Ubraij 
 
 THE PHYSIOLOGY OP THE SYMPATHETIC 
 RELATION TO THE EYE. 
 
 G. E. DE SCHWEINITZ, A.M., M.D. 
 
 PHILADELPHIA. 
 
 The object of this paper is to present a resume of our 
 knowledge of the physiology of the sympathetic in so far 
 as it relates to the eye, and is based on a study of the 
 extant literature. This literature has assumed large 
 proportions, and it must be evident that in the limited 
 time at my disposal it would be impossible to review it 
 elaborately. The endeavor, therefore, has been to bring 
 into prominence such physiologic problems, and the 
 subjects related to them, and to a minor degree some 
 subjects suggested by them, which are of particular in- 
 terest to us as ophthalmic surgeons. 
 
 i. INTRODUCTORY REMARKS ON THE ANATOMY AND 
 
 PHYSIOLOGY OF THE SYMPATHETIC. 
 
 To introduce the subject it seems proper to say a 
 word or two in regard to the general anatomy and phys- 
 iology of the sympathetic. Following Professor Thane's 
 classification, 1 which has also been adopted and elab- 
 orated by Onuf and Joseph Collins, 2 it may be said 
 that the sympathetic nerve is composed of a collection 
 of ganglia, cords and plexuses, or, more specifically, of 
 two great gangliated cords, intermediate and peripheral 
 plexuses and terminal ganglia. The great gangliated 
 cords lie partly in front and partly on the side of the 
 vertebral column, extending from the base of the skull 
 to the coccyx. The number of ganglia in general terms 
 corresponds to the .vertebra? against which they arc 
 placed, except in the neck, where there are only three 
 
 1. Quain's Anatomy, vol. ili, part 2, 1895. p. 357. 
 
 2. Arch, of Xeurol. and Psycho-Pathol., vol. ill, Nos. 1 and 2, 
 1900, p. 6. 
 
 635941
 
 ganglia. The connection between the gangliated cords 
 and the cerebrospinal system is brought about by short 
 filaments called communicating rami, which are of two 
 kinds, one consisting chiefly of medullated fibers and 
 the other of pale fibers. The medullated fibers of the 
 white communicating rami proceed from both roots of 
 the spinal nerves, but to a great extent from the an- 
 terior, and pass to the sympathetic cord. Not all of 
 the spinal nerves, however, furnish these rami. In man 
 it is believed that they exist from the first dorsal to 
 the first or second lumbar nerves, and perhaps also to the 
 third. The gray communicating rami pass between all 
 of the spinal nerves and the sympathetic cord. The 
 fibers arise in the nerve cells of the ganglia of the sym- 
 pathetic cord, and enter the primary anterior division 
 of a spinal nerve. 
 
 As not specially germane to the present topic, the in- 
 terfunicular rami, the efferent rami, the great pre- 
 vertebral plexuses, the peripheral plexuses, and finally, 
 the monocellular ganglia, need not be discussed. 
 
 The general plan of arrangement of the sympathetic 
 supplied to the head, quoting Langley, 3 is as follows : 
 
 The upper part of the thoracic spinal cord sends out fibers by 
 the anterior roots of the spinal nerves of this region. These 
 fibers make no halt at the ganglia until they reach the superior 
 cervical ganglion. This is a relay station for the sympathetic 
 nerve supply for the whole of the head. In it all the nerve 
 fibers form nerve endings, synapses, as they are called by 
 Foster. Each nerve cell sends off a nerve fiber which runs to 
 the periphery, where it branches and supplies a group of un- 
 striped muscle or gland cells. On the course of a nerve impulse 
 from the spinal cord to the periphery, there are, then, two 
 nerve cells, one with cell body in the spinal cord, the other 
 with cell body in the local sympathetic ganglion. 
 
 The centrifugal fiber of the first nerve cell is called 
 by Langley the preganglionic fiber, by Kb'lliker the 
 fiber of Lhe first order; that of the second nerve cell 
 the post-ganglionic fiber (Langley), or motor fiber of 
 the second order (Kolliker). The majority of post- 
 ganglionic fibers of- the superior cervical ganglion pass 
 to the fifth cranial nerve and are distributed with its 
 sensory fibers; for example, the pupillodilator fibers 
 and other fibers destined to the eye pass to the oph- 
 thalmic branch of the fifth and the long ciliary nerves. 
 
 3. Text-Book of Physiology, edited by E. A. Schafer, vol. ii, 1900.
 
 Vasoconstrictor fibers to the iris run in the interna, 
 carotid plexus, and not, according to Francois-Franck, 
 in the cervicogasserian strand. There are also post- 
 ganglionic fibers for the superior cervical ganglion 
 which proceed to the third and to the sixth cranial 
 nerves, which might be supposed, as Langiey suggests, 
 to convey vasomotor fibers of the vessels of the ocular 
 muscles, but thus far experiments have failed to prove 
 that they have this function. 4 In other words, we come 
 to study that part of a system of efferent ganglionated 
 nerves which relates to the eye, a system, to quote from 
 Gaskell, which is characterized by the fineness of its 
 fibers, which are always medullated when they leave 
 the central nervous system ; by . the presence on each 
 of these fine, medullated fibers, in some part of its 
 course, of a ganglion cell, from which fibers of the 
 same physiologic character pass to the end-organ, and 
 we remember in this study that this system includes not 
 only the cells of the sympathetic, but also vagrant motor 
 cells, such as are found in the course of the accessory 
 vagus, in the ganglion trunci vagi, and in the course of 
 the third nerve in the ciliary gariglion. 
 
 II. DISTRIBUTION OF THE SYMPATHETIC TO THE EYE. 
 
 The sets of sympathetic fibers which pass to the eye 
 and its adnexa, following Thane's classification, may be 
 described as follows : 
 
 1. The Pupillodilator Fibers. These arise from 
 the first, second and third dorsal nerves, which are con- 
 nected with the superior cervical ganglion by means of 
 slender cords which belong to the group of the gray 
 communicating rami. They pass upward in the ascend- 
 ing or carotid branch of the first cervical ganglion and 
 arrive at the plexus around the internal carotid artery 
 and the gasserian ganglion. They reach the eyeball 
 through the nasal branch of the ophthalmic nerve, or 
 the first division of the fifth, by means of its long 
 ciliary nerves, which perforate the sclerotic and are dis- 
 
 4. Jendrassik divides the sympathetic into two systems, namely, 
 the spinal system and the vagus system. He describes a third 
 connection between the central nervous system and the organs, 
 which is called the dilator system. The duty of this system is to 
 maintain a tonus acting antagonistically to the sympathetic system, 
 that is. to Jendrassik's motor system. It contains the dilator 
 fibers of the iris and of the blood vessels. For a re'sume' of Jen- 
 drassik's views, see Arch, of Neurol. and Psycho-Pathol.. vol. ill, 
 1900, pp. 9-13.
 
 tributed to the ciliary muscle, the iris and the cornea. 
 Jt is believed by some observers that pupillodilator 
 fibers are also contained in the seventh and eighth cer- 
 vical nerves. A minute filament passes with the central 
 artery of the retina into the eyeball. 
 
 2. Motor Fibers to the Involuntary Muscles of the 
 Orbit and Eyelids. These, according to Langley, pro- 
 ceed from the highest fourth or fifth dorsal nerves and 
 their communicating rami. The involuntary muscle of 
 the orbit which receives this sympathetic supply was 
 originally described in 1858 by H. Miiller. It is a 
 rudimentary layer of unstriped muscle which bridges 
 over the sphenomaxillary fissure and infraorbital 
 groove, and corresponds to a more largely developed 
 layer which is found in the extensive aponeurotic part 
 of the orbital wall in various mammalia. This muscle, 
 usually called Midler's orbital muscle, and sometimes the 
 sphenomaxillary muscle, when it contracts, causes the 
 globe of the eye to start forward, that is, to project 
 more from the orbit. 
 
 The involuntary muscle of the eyelids consists of a 
 layer of unstriped muscular tissue in each eyelid, which 
 was also originally described by Miiller. The layer of the 
 upper eyelid arises from the under surface of the leva- 
 tor palpebrae, while that of the lower springs from 
 the neighborhood of the inferior oblique muscle. Each 
 of these layers is inserted near the attached margin of 
 the tarsus. According to Henle, some of these fibers 
 also have a transverse course. The collection of invol- 
 untary fibers in the lower lid is much less produced 
 than that in the upper. According to Dwight, the func- 
 tion of Miiller's muscle in the upper lid is to draw the 
 skin to the fold above the tarsus when the lids are open. 
 
 3. The Vasomotor Fibers. In so far as the head is 
 concerned, according to Langley, these vasoconstrictor 
 fibers are given off in the dog and cat chiefly by the 
 second, third and fourth dorsal nerves. It is probable 
 that vasodilator fibers also exist. 5 
 
 5. Onuf (see Note 2) has prepared a functional topography 
 of the sympathetic nerves and their correlations in the cat, as 
 established on the ground of physiologic experiment. As he him- 
 self points out, an important drawback to this topography is that 
 it does not relate to man, but predominately to the cat. It may 
 be interesting to quote from this the following : According to 
 Budge, Salkowski and other observers, the pupil-dilating fibers of 
 the cervical sympathetic are derived in part from the seventh 
 and eighth cervical nerves through their communicating raml.
 
 4. Secretory Fibers. These are derived, in so far as 
 the submaxillary gland is concerned, from the third, 
 fourth and fifth dorsal, and are interesting to us because, 
 according to Langley, the results of physiologic inves- 
 tigations on the salivary glands may be applied with 
 little change to the lachrymal glands, which in their 
 histologic and physiologic characters resemble albu- 
 minous salivary glands. Their cranial secretory fibers 
 come through the lachrymal branch of the fifth nerve. 
 Their sympathetic fibers are derived from the cervical 
 sympathetic and the blood vessels of the gland. 
 
 III. THE RELATION OF THE SYMPATHETIC TO THE LACH- 
 . RYMAL SECRETION. 
 
 Eeasoning from analogy, one would expect that stim- 
 ulation of the cervical sympathetic, which causes secre- 
 tion from the salivary glands, would also give rise to 
 secretion from the lachrymal glands, and this, in fact, 
 is usually stated to be one of its well-established effects. 
 Authors, however, are not in accord on this point. 
 Campos 7 thus reviews the contradictory evidence : Her- 
 zenstein, although he failed to obtain any result by sec- 
 tion of the sympathetic cord below the superior cervical 
 ganglion, or by excitation of its upper end, neverthe- 
 less believes that the sympathetic determines a secre- 
 tion of tears different from that which is produced by the 
 trigerninus. Wolferz and Demtschenko 8 have provoked 
 lachrymal secretion by excitation of the sympathetic, 
 while Eeich observed a similar result in only a few cases. 
 Arloing, experimenting on the bullock and goat, failed 
 to obtain any result by exciting the upper end of the 
 vagosympathetic cord, while its section was imme- 
 diately followed by hypersecretion. Tepliachine, on the 
 other hand, arrived at exactly opposite conclusions. 
 Campos' own experiments have led him to believe that 
 
 Langley, however, denies that any of the pupil-dilating fibers are 
 derived from the cervical nerves. He also denies that the latter give 
 origin to the vasoconstrictor and vasodilator fibers for the head. 
 The chief nerve for dilatation of the pupil for the nictitating 
 membrane and for Miiller's muscle arises from the first dorsal. 
 Dilator fibers for the pupil, motor fibers for the nictitating mem- 
 brane and Miiller's muscle are also derived from the second and 
 third dorsal, and a few motor fibers for the nictitating membrane 
 from the fourth dorsal, perhaps, also, from the fifth dorsal. 
 
 6. Text-Book of Physiology, edited by E. A. Schafer, vol. i : 
 The Salivary Glands, by J. N. Langley. p. 475. 
 
 7. Archiv d'Ophthalmologie, vol. xvii, p. 529. 
 
 8. Archiv f. Physiologic, Bd. vi, 1872, p. 191.
 
 stimulation of the upper end of the cervical sympathetic 
 does not cause lachrymal secretion, and that its sec- 
 tion in man is without influence on the normal hu- 
 midity of the eyes and on lachrymation. Levinsolm/' 
 after section of the cervical sympathetic, or removal of 
 the superior ganglion in monkeys, noted lachrymation 
 on the operated side, which was most noticeable im- 
 mediately after the operation, and had disappeared on 
 the following day. This lachrymation, he concludes, i- 
 due to the vascular hyperemia which follows the section 
 and therefore the sympathetic should not be considered 
 the nerve of secretion for the lachrymal gland. 10 
 
 IV. THE INFLUENCE OF THE SYMPATHETIC ON TIIK 
 MOVEMENTS OF THE IRIS THE CILIOSPINAL CEN- 
 TER AND THE MYDRIATIC TRACT OF THE PUPIL. 
 
 The mechanism of the dilatation of the pupil, and 
 whether the presence of a distinct muscular structure. 
 to which the name dilatator pupillse has been given. 
 should be admitted, have occasioned 'much discussion. 11 
 Langley and Anderson 6 have summarized the matter as 
 follows : 
 
 1. Dilatation of the pupil may be due to the action 
 of the sympathetic vasoconstrictor fibers, stimulation of 
 which causes either a decrease in the quantity of blood 
 in the iris, so that it shrinks, or a longitudinal con- 
 traction of the radial arteries of the iris, which cans*-- 
 dragging of the sphincter outward. 
 
 2. Dilatation may be caused by contraction of ra- 
 
 9. Arcbiv f. Ophthalmologie, Bd. Iv, 1902. p. 144. 
 
 10. In this connection it is interesting to note that section of 
 the cervical sympathetic has no observable permanent effect on 
 the salivary gland, and it causes no paralytic secretion : the primary 
 dilatation of the blood vessels soon disappears. Excision of the 
 superior cervical ganglion is not followed by any certain effect on 
 the salivary gland (Langley). 
 
 11. This, subject Is too extensive to admit of much elabora- 
 tion in the present paper. Those who are interested in the litera- 
 ture of the subject and in the controversies which have arisen 
 concerning the presence or absence of a dilatator pupilla? may, with 
 advantage, consult : Frank Baker, the Anatomy of the Eyeball. 
 System of Diseases of the Eye. edited by Norris and Oliver, vol. i. 
 p. 186 ; George A. Piersol, The Microscopical Examination of the 
 Eyeball, Ibid., p. 279: Heese. Ueber den Einfluss des Sympatheticns 
 auf das Auge. insbesondere auf die Irisbewegung. Archiv f. d. ges. 
 Physiolog., Bd. lii, 1893 : Gaskell, Innervation of the Sympathetic 
 Nerves in Relation to the Dilator of the Eye ; J. N. Langley and 
 II. K. Anderson, The Mechanism of the Movements of the Iris. 
 Journal of Physiology, vol. xiii, 1892.
 
 9 
 
 dially arranged muscular fibers, a view maintained by 
 Henle, Budge, Sappey, Kolliker, and many others. 
 
 3. The dilatation may be due to inhibition of the 
 sphincter muscle, that is, as Griinhagen expressed it, 
 the sympathetic may be regarded as an "erschlaffungs- 
 nerv" of the sphincter, or, as Francois-Frank expressed 
 it, the sympathetic dilator nerves of the iris may act 
 in the same manner as the dilator nerves of the vessel, 
 and suspend the activity of the constrictor nerves. Gas- 
 kell, referring to Griinhagen's contention that the ra- 
 dial fibers in the posterior limiting membrane of the 
 iris are not true muscular fibers, agrees with him and 
 does not see the necessity of assuming the presence of a 
 dilator of the pupil, because one may assume that 
 the nerves which dilate the pupil act on the sphincter 
 muscle ; in other words, that they are inhibitory nerves, 
 or dilator nerves of that muscle. According to him. 
 the sphincter muscle of the iris represents an example 
 of a muscular structure which is supplied by two nerves 
 of opposite character, one a motor and the other an in- 
 hibitory nerve. 
 
 4. Dilatation may be due to relaxation of the elas- 
 ticity of part of the ciliary region and the anterior part 
 of the choroid, which pulls backwards the iris. 
 
 5. Dilatation may be caused by the simultaneous ac- 
 tion of more than one of the above-mentioned causes. 
 
 Both Frank Baker and George A. Piersol 11 think that 
 the combined anatomic and physiologic evidence of 
 the existence of a radially arranged dilator muscle 
 is conclusive; while Jessop 12 maintains that he has 
 never seen any fibers that could be compared in thick- 
 ness with the sphincter of the pupil, or capable, physic- 
 ally, of overcoming the sphincter fibers and producing 
 dilatation of the pupil. Whichever of these two, in 
 some respects diametrically opposed views, is accepted, 
 there is no question that the dilating impulse trans- 
 mitted to the iris passes through the cervical sympa- 
 thetic, and, in general terms, along what is called the 
 mydriatic tract of the pupil, which may now be briefly 
 outlined, as follows: It proceeds from a center in the 
 medulla as far as the second dorsal nerve. It then 
 follows the communicating branch of this nerve to the 
 cervical sympathetic, and reaches the plexus around the 
 internal carotid artery. From this point it passes to 
 
 12. Ophthalmic Surgery and Medicine. London. 1898.
 
 10 
 
 the nasocilian- branch of the nasal nerve, which as the 
 long ciliary nerves supply the muscular tissue of the iris. 
 
 Collins and Onuf, after comparing the results of 
 various investigators, find that the pupillodilating 
 fibers occur with the greatest constancy in the first 
 dorsal and almost as constantly in the second dorsal, 
 to less extent and less constantly in the third dorsal 
 and the eighth cervical, and least constantly in the 
 seventh cervical and fourth dorsal. This distribution 
 varies, not only with the species of the animal, but also 
 individually in the same species. 
 
 Experimenting in 1841, Budge and Waller 13 deter- 
 mined the origin of the pupil-dilating fibers of the 
 cervical sympathetic to be in the spinal cord in a re- 
 gion situated between the exits of the sixth cervical 
 and fourth dorsal or thoracic nerves. Since that time 
 this center has been called Budge's center, or the cilio- 
 spinal center.' Budge's conclusions have been both con- 
 firmed and denied, confirmed by Dastre and Morat, and 
 denied by Salkowski and Knoll, the former placing the 
 origin of the pupil-dilating fibers in the medulla, the 
 latter in the anterior corpora quadrigemina. Referring 
 to these contradictory statements, Collins and Onuf 
 declare that although experimental as well as clinical 
 evidence is in favor of the existence of a ciliospinal 
 center, it has not been definitely proven. 
 
 Several observers, notably Francois-Franck, . main- 
 tain that not all the pupil-dilating fibers are derived 
 from the cervical sympathetic, but that some of them 
 reach the gasserian ganglion by way of the roots of 
 the trigeminal nerve, and this view, according to Onuf 
 and Collins, 14 is confirmed by the results of their experi- 
 ments. The possibilit} r that the sympathetic may also 
 contain pupil-contracting fibers is a subject to which 
 reference will be made in another portion of this paper. 
 
 V. CONCERNING THE NATURE OF THE CILIARY GAN- 
 GLK)N, WITH SPECIAL REFERENCE TO ITS RELA- 
 TION TO THE SYMPATHETIC SYSTEM AND A 
 CONSIDERATION OF THE EFFECTS ON THE 
 EYE OF LESIONS OF THIS STRUCTURE. 
 
 The ciliary, 'ophthalmic, or lenticular ganglion, as it 
 is variously called, is a center for the supply of nerves, 
 
 13. Vierordfs Archiv f. Physiolog. Heilkunde, 1852. 
 
 14. See Footnotes 2 and 5, pp. 91, 92, for experiments which 
 these authors think demonstrate their belief.
 
 11 
 
 motor, sensory and sympathetic, to the eyeball. This 
 small, reddish body, composed of cells of the multipolar 
 variety, is placed between the external rectus muscle 
 and the optic nerve at the back of the orbit, and is 
 joined from behind by branches from the trigeminus, 
 the oculomotor and the sympathetic nerves. A slender 
 filament derived from the nasal branch of the ophthal- 
 mic constitutes its long or sensory root, a twig from 
 the branch of the third nerve going to the inferior 
 oblique muscle, its short or motor root, and a small 
 nerve from the cavernous plexus of the sympathetic, its 
 middle or sympathetic root. Much difference of opin- 
 ion has existed and still exists concerning the nature 
 of this ganglion, i. e., whether it should be considered 
 as a spinal, sympathetic, or mixed sensitivo-motor gan- 
 "glion. 
 
 Schwalbe 13 believes that the ciliary ganglion is a 
 spinal ganglion and belongs entirely to the oculo- 
 motor, a view which has also been maintained by Anto- 
 nelli, and confirmed, in so far as its spinal nature is 
 concerned, by Goldberg 16 in his researches on the em- 
 bryo of chickens. Hess, Bemak and Phisalix main- 
 tain the spinal nature of the ganglion and that it be- 
 longs % to the trigeminus. Van Gehuchten, who, like 
 Betzius and von Michel, has employed the Golgi method 
 in his investigations, is inclined to a belief contrary 
 to that of the authors just named, and thinks that the 
 ciliary ganglion is to be reckoned with the spinal gan- 
 glia. " 
 
 Peschel 17 found a diminutive ganglion, which is sit- 
 uated on the oculomotor of the rabbit, to be composed 
 of cerebrospinal ganglion cells. In addition to this, 
 however, he observed a well-developed system of sym- 
 pathetic ganglion elements in the orbit which was sub- 
 ject to a great many variations, but was always demon- 
 strable. 
 
 Holzmann 18 has histologically examined the ciliary 
 ganglion in a number of animals, and found it of va- 
 rious composition in frogs of spinal cells, in birds of 
 -cerebrospinal elements, in rabbits of the same struc- 
 ture, but also the widespread sympathetic elements in 
 the orbit previously described by Peschel ; in dogs great 
 
 15. Jenaische Zeitschr., Bd. xiii, 1879. 
 
 16. Archiv f. Mikroskopie, Bd. xxxvii. 
 
 17. Graefe's Archiv f. Ophth., Bd. xxxix. 2. 
 
 18. Morphologische Arbelten. Bd. vi.
 
 12 
 
 individual variations, as well in the position as in the 
 structure of the ganglion, but with the sympathetic ele- 
 ments prevailing; and in cats practically entirely sym- 
 pathetic cells, spinal elements being at most in the form 
 of under-developed or pigmy cells. 
 
 Michel's 19 researches show that the ganglion in man 
 and calves is a sympathetic structure. An interesting 
 fact observed by Holzmann and Schmiedeberg is on the 
 action of atropin on the different animals in corres- 
 pondence with the different histologic structure of the 
 ganglion. In those species of animal, namely, in which 
 the ganglion is mainly or entirely composed of sym- 
 pathetic cells, atropin produces the most marked par- 
 alysis of the iris and ciliary bod}', while in birds, in 
 which the ganglion cells partake of the nature of 
 cerebrospinal cells, there is practically no atropin ac- 
 tion. Kolliker believes entirely in the sympathetic na- 
 ture of the ciliary ganglion, and rests his belief on his- 
 tologic studies, especially such as have been made by 
 Rauber, Retzius and von Michel, according to which 
 the ciliary ganglion is composed only of multipolar 
 sympathetic cells, and, on the other hand, on the ex- 
 periments of Langley and Anderson, 20 and Langen- 
 dorff, 21 who believe it is a sympathetic ganglion. 
 
 Lodato, 22 who has experimented with dogs, affirms 
 that the ganglion is composed partly of sympathetic 
 elements and partly of cerebrospinal elements. This, 
 according to him, is true for the dog and very probably 
 for other mammalia, and consequently for man. In 
 short, he believes it is a mixed ganglion, sensitivo- 
 motor in nature, in which the motor part naturally de- 
 pends on the sympathetic and the sensitive part on the 
 trigeminus. The double nature of the ganglion has 
 also been maintained by Krause. 
 
 Bernheimer, 23 whose observations were made on the 
 ganglia of apes and monkeys, and who gives a good 
 summary of the previous literature on this subject, 
 from which several quotations have been made, is un- 
 willing to commit himself entirely, but doubts the pure 
 
 19. Trans. Eighth Intern. Ophth. Congress, Edinburgh, 1894. 
 p. 195. 
 
 20. Journal of Physiology, vol. xil, 1894. 
 
 21. Pflueger's Archiv f. Physiologic, Bd. Ivi. 
 
 22. Archivio di Ottalmologia, vol. vii, 1900 ; Abstract Annale& 
 d'Oculistique, T. cxxvi. 1901, p. 230. 
 
 23. Archiv f. Ophth., Bd. xlix, 1897.
 
 13 
 
 sympathetic nature of the ganglion, Avhile Bach's 24 re- 
 searches indicate that the ciliary ganglion in all prob- 
 ability is of a sympathetic nature. Marina, 25 who has 
 elaborately studied the neuron of the ciliary ganglion, 
 concludes that the ciliary ganglion in apes very prob- 
 ably possesses few spinal and numerous sympathetic 
 cells. Jegerow considered the ciliary ganglion homol- 
 ogous to a posterior root ganglion. 
 
 Bach 26 finds that injections of nicotin into the orbit 
 of the cat cause paralysis of the sphincter of the pupii 
 very quickly. Xow, inasmuch as nicotin paralyzes only 
 sympathetic nerve cells, this indicates the presence of 
 such cells in the orbit, and naturally suggests the sym- 
 pathetic nature of the ciliary ganglion, although it does 
 not disprove the possibility of its being of a mixed na- 
 ture. 
 
 Langendorff 27 formerly advocated the spinal nature 
 of the ciliary ganglion, but as the result of recent 
 investigations he has changed his opinion and now 
 believes it to be a sympathetic ganglion. 
 
 It will therefore be seen from this imperfect resume 
 that the nature of this nervous structure has not been 
 positively determined in any one species of animal, 
 and that it differs greatly in different species. All 
 things considered, however, the weight of evidence is 
 in favor of the ganglion belonging to the sympathetic 
 system, at least in so far as man is concerned. As- 
 suming, therefore, the probable sympathetic nature of 
 this structure, a few words may be said on its 
 relation to the pupil movements. As is well 
 known, Langley and Anderson have noticed that 
 the erectores pilorum of the cat are under the 
 influence of certain communicating rami of the an- 
 terior spinal roots, but that this influence is exerted not 
 directly, but with the help of nerve fibers which arise 
 in the ganglion of the sympathetic cord. In the same 
 manner, according to the observation of these authors 
 and according to the researches of Langendorflv the 
 oculomotor nerve acts not directly on the sphincter of 
 the pupil, but in association with the ciliary ganglion. 
 According to Langendorff, electrical stimulation of the 
 
 24. Ibid., xlvii, 1899, p. 68. 
 
 25. Deutsch. Zeitschr. f. Nervenheilkunde, xiv, 1899. p. 356. 
 
 26. Bericht iiber die XXX Versammlung Ophthal. Gesellschaft. 
 Heidelberg. 1902. p. 16. 
 
 27. Klin. Monatsbl. f. Augenheilk., xxxviii, 1900, p. 307.
 
 14 
 
 trunk of the oculomotor of the cat in the cranial cavity 
 never produces contraction of the pupil. Only when 
 quite quickly after death it is stimulated, a distinct con- 
 traction proceeding from the oculomotor trunk can be 
 observed. After a short space of time this result ceases 
 to exist. If, instead of the oculomotor branch, the 
 short ciliary nerves of the orbit are stimulated some 
 time after death, it is still possible to obtain a pupil 
 contraction. Langendorff concludes, therefore, that the 
 myotic fibers of the oculomotor nerve do not traverse 
 the ganglion uncombined, but that ganglion cells 
 are inserted in the pupil-contracting path, early death 
 of which is responsible for the failure of the irritation 
 effect, which ought to follow the proximal stimulation 
 of the nerve trunk. 
 
 Apolant, 28 writing concerning the nature of the 
 ciliary ganglion, maintains that after section of the ocu- 
 lomotor in the skull, the degeneration of the entire oculo- 
 motor fibers in the ganglion can be traced only to the 
 cells of the ganglion and not further on. This result 
 he explains on the supposition that those root-fibers 
 \vhich belong to the oculomotor end in the ganglion, as 
 von Michel has shown in Golgi preparations, and that 
 with the cells of the ciliary ganglion a new neuron be- 
 gins for the fibers which pass to the ciliary muscle and 
 the sphincter of the pupil. 
 
 To put this matter in another form and using the 
 words of Sherrington, the smaller root-cells of the oculo- 
 motor send their nerve fibers to the ciliary ganglion, 
 whence, as from a sympathetic ganglion, fresh nerve 
 cells emit fibers to the ciliary muscle and constrictor- 
 pupillae. 
 
 Marina, 25 after pointing out that there is much dif- 
 ference of opinion as to the exact position of the center 
 of the pupil movements, for example, that Voelker 
 and Hensen place the center in the anterior 
 portion of the oculomotor nucleus, von Bechterew 
 in the central gray matter of the third ven- 
 tricle, Mendel in the ganglion habenula, and 
 that in man the Westphal-Edinger and later the 
 Darkschewitsch nucleus have been claimed as the center, 
 although Bernheimer thinks that the last-named nu- 
 cleus does not belong to the oculomotor group at all, 
 and has nothing to do with pupil-reaction, maintains 
 
 28. Archiv f. Anat. u. Physiol., Physiologische Abth.. 1896. p. 344.
 
 15 
 
 that the ciliary ganglion is the center for pupil-move- 
 ment. He agrees with Bernheimer that five-sixths of 
 the cells of the ciliary ganglion degenerate after cau- 
 terization of the cornea, and that therefore five-sixths 
 of these cells are of sensory nature and are active in 
 the sensibility of the cornea. Xicotin experiments in- 
 dicate that the sensory cells of the ciliary ganglion are 
 of spinal nature. Opticociliary neurotomy and exen- 
 teration of the bulb, or, in other words, injury to those 
 nerves which supply the intraocular muscles, cause all 
 of the cells of the ganglion to be more or less de- 
 generated. It follows, therefore, that the greatest part 
 of the ganglion cells possesses a motor function, namely, 
 the innervation of the sphincter of the iris, and he con- 
 cludes, as before stated, that the ciliary ganglion, in 
 apes at least, very probably contains few spinal and 
 numerous sympathetic cells, and returns to his contention 
 that the ganglion is really the center for pupil move- 
 ments. Now Bernheimer, 23 also experimenting with apes, 
 finds that there are roots of nerve fibers which supply 
 not alone the ganglion cells but also the cornea, hence 
 lesion of the ganglion, for this structure is alike in 
 apes and man, ought to produce a corneal destruction 
 as well as fixation of the pupil, if it really is, as Marina 
 maintains, the center for pupil movement, an associa- 
 tion which has not been observed. Otherwise it would 
 be necessary to assume an elective primary disease of 
 those cells which supply nerves to the iris and ciliary 
 body, and this is exactly what Marina does, although 
 Bernheimer is unwilling to agree with him. In this 
 connection it is interesting to revert to the fact that 
 many years ago ophthalmoplegia interna, that is, par- 
 alysis of the intraocular muscles, the iris and ciliary 
 body, was ascribed by Jonathan Hutchinson to disease 
 of the lenticular ganglion, and although it is customary 
 to say at the present time that he was mistaken in this 
 view of the pathology of these cases, if Marina's re- 
 sults are to be considered trustworthy, and his assump- 
 tion of an elective primary disease of those cells which 
 supply the iris and ciliary body be accepted, he was 
 exactly right. 
 
 The effect of lesion of the sympathetic on the cornea 
 has been given a new significance by Emil von Grosz. 29 ^ 
 If it is true, he argues, as the researches of Bernheimer 
 
 29. Ungarische Beltrage zur Augenheilkunde, Bd. ii. 1900, p. 295.
 
 16 
 
 and others indicate, that fibers from the ciliary gan- 
 glion of apes go to the cornea, and if, further, it is true 
 that the ciliary ganglion, according to its nature, be- 
 longs to the sympathetic, and that only trigeminus 
 libers pass through it, then the degenerated paths which 
 have been demonstrated may be identical with the fibers 
 which influence the nourishment of the cornea. It fol- 
 lows that it is reasonable to ascribe the cause of the 
 neuroparalytic keratitis to disease of the ciliary gan- 
 glion, because only trigeminus fibers pass the ganglion, 
 therefore section of the ganglion of Gasser or of the 
 trigeminus is associated only with anesthesia and could 
 produce no lesions in the ganglion or in the cornea. 
 On the other hand, the sensitiveness of the cornea could 
 be sympathetically affected if the ganglion was dis- 
 eased, and this is actually the case. He believes, in 
 other words, that the suppurative keratitis which occurs 
 in the eyes of animals and men after section of the 
 trigeminus or disease or injury to the gasserian gan- 
 glion is brought about by infection which comes from 
 the conjunctiva, the lachrymal sac, or the external at- 
 mosphere and which is established because the anesthesia 
 and drying of the cornea can not resist injuries, but 
 that the cause of true neuroparalytic keratitis of men, 
 which is identical with keratomalacia and keratone- 
 crosis, is due to a degeneration of the cells of the ciliary 
 ganglion which may occur from cachexia, hemorrhage 
 or from injury. This view, however, is not substantiated 
 from the experimental standpoint, inasmuch as Ander- 
 son, 30 who has extirpated the ciliary ganglion in kit- 
 tens, never observed trophic changes. 
 
 Ordinarily excision of the ciliary ganglion increases 
 dilatation of the pupil, and, as Jegerow 31 has shown, 
 this dilatation is greater than after section of the nerve. 
 
 Anderson was able to obtain in kittens from which 
 he had removed the ciliary ganglion a paradoxical pu- 
 pilloconstriction of the denervated sphincter, just as 
 after extirpation of the superior cervical ganglion in 
 animals slight stimulation produces a paradoxical pu- 
 pillary dilatation which has been attributed to increased 
 tone in denervated unstriped muscle. Anderson, how- 
 ever, has shown that his observations on paradoxical 
 pupilloconstriction were not to be explained by increased 
 
 30. Jour, of Physiol., vol. xxviii, No. 3. 
 
 31. Arch. Slaves de biol.. Paris. 1887. T. iii. p. 322.
 
 17 
 
 tone, hut increased excitability brought about by very 
 slight stimuli. 
 
 Finally, we come to consider what the effect on the 
 tension of the eyeball is when the ciliar}' ganglion is 
 extirpated, as it has been suggested that this operation 
 might replace the one of excision of the cervical sympa- 
 thetic ganglion in glaucoma. 
 
 Rohmer 32 has extirpated the ciliary ganglion in seven 
 cases of absolute glaucoma, and although he claims that 
 pain was ultimately alleviated, in all cases tension was 
 never reduced to normal. In other words, as J. Herbert 
 Parsons, commenting on this paper, has said, the re- 
 sults of Rohmer's work afford little support to the view 
 that the increased intraocular tension of glaucoma is 
 in any way associated with the ciliary ganglion. There 
 is even less experimental evidence, as he further re- 
 marks, for this hypothesis than for that which attrib- 
 utes this function to the superior cervical ganglion. 
 Rohmer believes that the ciliary ganglion controls the 
 vascularization of the anterior segment of the eye, and 
 the superior cervical ganglion that of the posterior seg- 
 ment, and in this manner each influences the intraocular 
 tension. 
 
 VI. THE RELATION OF THE SYMPATHETIC TO ACCOM- 
 MODATION AND REFRACTION. 
 
 Morat and Doyon 33 maintain that after section of the 
 sympathetic there is a diminution in the size of the an- 
 terior crystalline lens images, and after irritation of 
 the sympathetic an enlargement of the same images. 
 Therefore, they conclude that the sympathetic exer- 
 cises an inhibitory influence on accommodation and has 
 an antagonistic action to the third nerve. In other 
 words, according to them, the sympathetic is an in- 
 hibitory nerve for the accommodation and influences 
 its function at the distant point, the oculomotor, of 
 course, adapting the eye for near objects. These ob- 
 - -nations have not been confirmed by Langley and An- 
 derson or by Hess and Heine. 34 The latter observers, 
 for example, found that if the sympathetic is exposed in 
 a dog and a registering needle inserted into the equator 
 of the eye, and the sympathetic irritated the pupil 
 
 32. Annales d'Oculistiqne, July, 1902. 
 
 33. Archiv de Physiol.. vol. iii. 1901. p. 507. 
 .".4. Archiv f. Ophthalmol.. xlvi. 1898. p. 259.
 
 18 
 
 promptly dilates, but the needle remains quiet ; in other 
 words, the sympathetic can dilate the pupil, but does 
 not influence the ciliary muscle. There is under these 
 circumstances, sometimes, a diminution in refraction, 
 which Hess and Heine attribute to the disturbing in- 
 fluence of the more peripheral portions of the cornea 
 and lens, made possible by the dilatation of the pupil. 
 
 These views Avere contested by Dor at the meet- 
 ing of the Thirteenth International Congress in Paris, 
 and therefore Rohmer and Dufour 35 have returned to 
 the subject and made numerous experiments, and en- 
 deavored especially to elucidate two points, namely, the 
 alteration in the refraction which undoubtedly occurs 
 after stimulation of the sympathetic and which may 
 be demonstrated by retinoscopy and the change in the 
 size of the images on the lens which Dor asserts takes 
 place. They find that the alteration in refraction noted 
 in certain instances on dilatation of the pupil is not 
 necessarily due to any actual change in the lens and 
 show that the difficulty of being quite certain of an 
 increase of diminution in the size of the very small 
 images on the surface of the lens is extremely great. 
 Morat and Doyon state that the image may enlarge by 
 as much as a third or even a half of its own diameter : 
 now in man, at all events, an alteration in size of 
 slightly less than half has been shown to correspond 
 to a change in refraction of 7 D., much greater 
 than the alteration in refraction admitted by Hess and 
 Heine. Eohmer and Dufour do not, moreover, find that 
 close relationship to exist betAveen the pupil dilatation 
 and the alteration in the size of the images on Avhich the 
 French observers have laid considerable stress. Indeed, 
 their results are directly contrary to those of Morat 
 and Doyon. In other words, they do not find that the 
 sympathetic has any power of causing negative accom- 
 modation. 
 
 The effect of stimulation of the cervical sympathetic 
 in rabbits on the refraction of the eye has recently been 
 investigated by Terrien and Camus. 30 They found 
 that stimulation of the cervical sympathetic after sec- 
 tion induces in all cases an increase in the refraction of 
 the eye on the same side, this increase varying from 
 
 33. Ibid., liv, Abth. 3 ; see, also, abstract Ophthal. Review. 
 January, 1903. 
 
 36. Ibid., June, 1902.
 
 19 
 
 1 to 2.05 D. This change in refraction does not co^ 
 exist with the dilatation of the pupil, but begins later 
 and is of shorter duration. The authors do not furnish 
 a satisfactory explanation of the phenomena which 
 they observed, although they eliminated the possibility 
 of elongation of the globe or increase of corneal curva- 
 ture being due to muscular action by cutting the ex- 
 ternal ocular muscles. Experiments with Purkinje's 
 images to ascertain whether the refraction of the lens 
 changed, gave no definite results. 
 
 VII. THE RELATION OF THE SYMPATHETIC TO INTRA- 
 OCULAR TENSION. 
 
 As long ago as the times of Pourfour de Petit, that 
 is in 147, it was observed that after section of the sym- 
 pathetic the eye was softer, and this fact was afterwards 
 verified by Claude Bernard and other experimenters, 
 and very early it was suggested that a primary dis- 
 ease of the sympathetic ganglia of the neck might be 
 the basal cause of glaucoma. In 1867, Adamtlk, 37 and 
 about the same time Wegner, 38 discussed the relation- 
 ship between intraocular tension and the cervical sym- 
 pathetic in the neck, and the influence of the latter 
 on the development of glaucoma, although their ex- 
 perimental researches were not entirely in accord. Eul- 
 enberg and Guttman, n9 discussing this matter, have- 
 summarized the results of these observers somewhat 
 as follows : Adamiik found, after cutting the neck 
 sympathetic in chloroformed cats, a diminution of the 
 intraocular tension of 1 to 2 mm. This lessening was 
 of short duration and it was soon followed by a supple- 
 mentary elevation of tension. Irritation of the 
 cut sympathetic with induction currents caused an ele- 
 vation of intraocular tension of 2 to 4 mm., which re- 
 mained for a time and then gradually disappeared. The- 
 diminution of the tension was coincident with the 
 pupil enlargement and the exophthalmos, and was 
 ascribed by Adamiik to lessening of the blood-stream. 
 The early elevation of tension he attributed to the ac- 
 commodative apparatus. According to him, two fac- 
 tors were potent in the production of changes in the 
 
 37. Med. Centralbl., 1866, No. 36; Ibid.. 1867, No. 28; Abstract 
 Annales d'Ocullstique, Ivlii, p. 5. 
 
 38. Archiv f. Ophthalmol., Bd. xii. Abth. 2. 1866, p. 1. 
 
 39. Die Pathologic des Sympathicus auf Physiologischer Griind- 
 lage. Berlin, 1873.
 
 20 
 
 / 
 
 intraocular tension under the influence of irritation of 
 the sympathetic which worked in opposite ways, and ac- 
 cording as one predominated or did not predominate 
 the tension rose or fell, the one factor, that is, the vaso- 
 motor apparatus, causing lessening of the intraocular 
 tension, the other inherent in the internal ocular 
 muscles, probably the ciliary muscle, giving rise to an 
 elevation of intraocular tension. 
 
 Hippel and Griinhagen also observed that in the early 
 stage of sympathetic irritation in cats there is an ele- 
 vation and later a dropping of the intraocular tension. 
 These results were explained by a contraction of the 
 orbital muscles and the vessels of the eye. Elevation 
 of the intraocular tension after irritation of the sym- 
 pathetic was likewise noted by Francois-Franck. 
 
 Adamiik, in disagreement with Hippel and Griin- 
 hagen, after excluding every possible error, satisfied 
 himself that elevation of intraocular tension depended 
 on contraction of the inner muscles of the eye, that is, 
 of Miiller's fibers of the choroid and perhaps a portion 
 of the ciliary muscle. These sympathetically inner- 
 vated muscles caused the bulb to start forward and in 
 that manner an increase in the depth of the anterior 
 chamber was determined. Irritation of the sympathetic 
 in curarized animals, according to this observer, pro- 
 duced narrowing of the arteries and filling of the veins 
 of the retina, and therefore he believed that the chief 
 cause of glaucoma depended, not so much on an eleva- 
 tion of tension as on inhibition of the venous circula- 
 tion which is induced when there is loss of the elasticity 
 of the sclera as the result of inflammatory processes. 
 Wegner also found diminution of intraocular tension, 
 from 4 to 8 mm., after section of the sympathetic, 
 which he attributed to a paralytic widening of the 
 blood vessels. 
 
 Horner, and later his student Xicati, 40 writing con- 
 cerning paralysis of the sympathetic from various path- 
 ologic conditions in the neck, noted a diminution in the 
 tension of the eye which was present in two periods of 
 the paralysis, that is, in the period which was analogous 
 in his phenomena to those observed in animals after 
 section of the cervical sympathetic, and in the period in 
 which the symptoms were modified by secondary 
 atrophies. Therefore it was concluded that this fall in 
 
 40. La Paralysie du Nerf Sympathiqne Cervical, 1873.
 
 tension was independent of any excess of vasculariza- 
 tion. Abadie, believing that the symptoms of glaucoma 
 can be explained by an excitation of the vasodilator 
 fibers of the ocular blood vessels, suggested in 1898 that 
 relief from this disease might be obtained by section of 
 the sympathetic in the neck, and soon afterward the 
 first operation of resection of the cervical sympathetic 
 was performed by Jonnesco. 
 
 In still more recent times numerous experiments have 
 been made on the effect of irritation and section of the 
 sympathetic on the intraocular tension. Thus Neu- 
 scheuler 41 has observed that narcosis itself causes an 
 elevation of the intraocular tension of from 2 to 6 de- 
 grees in Fick's tonometer, while irritation of the sym- 
 pathetic causes an elevation of at least 10 degrees. Sec- 
 tion of the sympathetic reduces the tension on the same 
 side from 3 to 6 degrees, but only after twenty to forty- 
 five minutes. Observations of this character made in 
 rabbits were confirmed in cats, who have a deeper an- 
 terior chamber, and it was further noted that in these 
 animals irritation on one side caused an elevation of 
 tension in the opposite eye. 
 
 Using the method of slow irritation of the cervical 
 sympathetic, produced by inserting a small foreign body 
 into the superior ganglion, Lodato, 42 by means of the 
 Leber apparatus, studied the relations between secre- 
 tion and excretion of the aqueous fluid in the eye on the 
 same side as the irritated sympathetic, and proved that 
 there was a diminution of the flow from the apparatus 
 to the anterior chamber and therefore increased intra- 
 ocular tension. He further demonstrated that this rise 
 of tension is independent of dilatation or constriction 
 of the blood vessels, inasmuch as he was able to note an 
 increase of tension in cases of superficial and deep vaso- 
 dilatation and vasoconstriction. Finally, he demon- 
 strated that the increase of tension is absolutely inde- 
 pendent of the state of the pupil. The increase of ten- 
 sion may last for several months in the dog, with but 
 slight variation. 
 
 The result of excision of the cervical ganglion of the 
 sympathetic on intraocular tension in rabbits has been 
 investigated by Selenkowski and Eosenberg, 43 and while 
 
 41. Nagel's Jahresbericht f. Ophthalmologie, yol. xxx, 1890. 
 p. 120. 
 
 42. Klin. Monatsbl. f. Augenheilk., xli. Bd. i. 1903, p. 329. 
 
 43. Xagel's Jahresb. f. Ophtalraol.. xxxii. 1900. p. 003.
 
 22 
 
 they found a reduction of intraocular tension, it was 
 always exceedingly temporary in its effect, lasting some- 
 times only three to five days and never more than twelve 
 days. They naturally contend, therefore, that Abadie's 
 theory of glaucoma is untenable. 
 
 Hertel, 44 experimenting on young animals (ten to 
 twenty day old rabbits) found a lowering of tension 
 about one hour after excision of the ganglion, as de- 
 termined by manometer and tonometer, but this lasted 
 only five days. He thinks the varying results reported 
 by observers may depend on the difference of time in 
 noting tension, and believes there is a relation between 
 vessel fullness, myosis and lowered tension. When the 
 vessels return to their natural state and myosis lessens, 
 tension returns to normal. 
 
 Levinsohn, 45 who has quite recently reviewed the en- 
 tire subject of the influence of the cervical sympathetic 
 on the eve, experimenting on apes and other animals, 
 has noted that sympathetic section primarily diminishes 
 the intraocular tension, which in a very short time re- 
 turns to normal. A similar result was noted when only 
 the large branches, but not the carotid branches, were 
 cut, a fact which might indicate that the diminution 
 in pressure was not only due to vessel but to muscle 
 changes. 
 
 Joseph Collins 48 believes that the diminution of intra- 
 ocular tension caused by extirpation of the cervical sym- 
 pathetic depends on a reduction of the blood pressure 
 and that this procedure acts on the blood vessels of the 
 eye something as nitroglycerin does. In other words, 
 he suggests that the diminution of intraocular tension 
 must be dependent on the general dilatation that occurs 
 in the carotid system after the ganglion has been ex- 
 tirpated. 
 
 VIII. THE OCULAR PHENOMENA WHICH FOLLOW GALVAN- 
 IZATION AND FARADIZATION OF THE CERVICAL 
 SYMPATHETIC. 
 
 To a certain extent these phenomena have already 
 been discussed, but they may in general terms be re- 
 ferred to again in a summary manner. The effects 
 which electrical currents when applied to the s} r mpa- 
 
 44. Archiv f. Ophtalmol.. Bd. xlix, 1900, p. 432. 
 
 45. Ibid., Iv. 1902, p. 144. 
 
 46. Personal communication. March 19. 190.>.
 
 23 
 
 thetic produce must be studied in their relation to: (a) 
 the pupil of the same side; (b) the contralateral pupil, 
 that is, the pupil of the opposite side; (c) the color of 
 the iris; (d) the position of the nictitating membrane 
 and the globe of the eye and the width of the palpebral 
 fissure; (e) the blood vessels of the conjunctiva, the iris 
 and the fundus oculi; (f) the tension of the eyeball; 
 (g) the secretion of the lachrymal gland. 
 
 1. Electrical stimulation of the cervical sympathetic 
 produces on the side stimulated a dilatation of the pupil 
 as a result of the contraction of the dilatator pupillae. 
 Whether this dilator should be regarded as a muscular 
 structure or only as a contractile substance, or whether 
 the phenomenon depends on inhibition of the sphincter 
 has been thoroughly discussed and need not again be 
 reviewed. 
 
 According to Lodato, if in the superior ganglion a 
 foreign body is inserted, there is produced a slowly- 
 acting state of irritation of the cervical sympathetic. 
 The pupil dilates, but the dilatation is rarely a lasting 
 one. Such a pupil reacts but slightly to the action of 
 light, but if light is flashed into the opposite pupil, 
 there is a reaction of the one on the operated side. In 
 these cases there is a distinct grade of retinal anemia, 
 to which Lodato attributes the pupillary phenomenon. 
 
 2. In 1893, Dogiel made the interesting observation 
 that when the cervical sympathetic was stimulated on 
 one side, there was on the opposite side a contraction of 
 the pupil, and he explained this phenomenon by assum- 
 ing that there was a physiologic connection with the 
 pupil-dilating center of the one and the pupil-contract- 
 ing center of the other side, although such anatomic con- 
 nection had never been demonstrated. 
 
 Schenck and Fuss 47 have confirmed Dogiel's observa- 
 tion, but believe that in dogs and cats this result de- 
 pends on the consensual pupil-reflex, inasmuch as the 
 increased light impulse which enters the eye on the 
 electrically irritated side, owing to the mydriasis which 
 is produced, causes reflex narrowing of the pupil on 
 the opposite side. In rabbits, in which there is no con- 
 sensual pupil-reflex, they could not in opposition to the 
 statement of Dogiel establish a narrowing of the contra- 
 lateral pupil. 
 
 47. Archiv f. die Gesaramte Physiol., Ixxv. 1899. p. 110.
 
 24: 
 
 Tuemianzevv 48 has investigated this subject most elab- 
 orately and believes that Dogiel's reaction is not pro- 
 duced by changes in the eye on the side of the irri- 
 tated sympathetic, that it can not be considered en- 
 tirely as the result of the consensual pupillary reaction, 
 as maintained by Schenck and Fuss, but that it repre- 
 sents a newly discovered reflex, transmitted through the 
 sympathetic fibers, joining the cranial nerves 'in the re- 
 gion of the cavernous sinus. 
 
 There would seem to be some difference in effect fol- 
 lowing galvanization and faradization of the sympa- 
 thetic, if the observations, but so far as I know uncon- 
 firmed, of Katyschew 49 may be credited, Avhich, briefly 
 summarized, are these: Galvanization of the superior 
 triangle of the neck may cause dilatation of the pupiL 
 but also contraction, anodal opening producing a rapid 
 dilatation, while cathodal closing is usually not asso- 
 ciated with constant changes. If this region is fara- 
 dized, the pupil contracts, either immediately or at 
 some later date, contraction occurring on the side of the 
 electrode, on the other side, or on both sides. He be- 
 lieves that through this faradization nerve fibers still 
 unknown are irritated, which act as inhibitory fibers to 
 those sympathetic nerves going to the pupil dilator. 
 It is likely that they come from the spinal cord and 
 pass through the carotid plexus. 
 
 3. The same observer has noted that after faradiza- 
 tion and contraction of the pupil there is a change in the 
 color of the iris, which he attributes to varying displace- 
 ment of the iritic fibers. So far as I know, this observa- 
 tion has not been confirmed. 
 
 4. Electrical stimulation of the cervical sympathetic- 
 causes retraction of the nictitating membrane, which, 
 according to Langley's observations, is much more prom- 
 inently seen in the cat and dog than in the rabbit. In 
 the higher animals, as in man and apes, the nictitating 
 membrane is rudimentary. In addition to this, there 
 is separation of the lids, the movement being greater in 
 the lower than in the upper eyelid. Finally, there is 
 well-marked projection of the eye, or proptosis ; in other 
 words, the direction of its axis being straight forward. 
 Eckhard is of the opinion that this proptosis is more 
 apparent than real, and is manifest chiefly because the 
 1 
 
 48. Ibid.. Ixix. 1897, p. 199. 
 
 49. Archiv f. Psych, u. Nervenkrank., vol. vili, 1877-78, p. G24.
 
 25 
 
 lower eyelid is drawn decidedly backwards and there- 
 fore there is a greater exposure of the bulbus. This 
 appearance is well marked in animals, especially dogs, 
 and has also been observed by Wagner in the head of a 
 decapitated criminal. There is no doubt that such phe- 
 nomena depend on the action of the unstriped muscle 
 in the region already described, in so far as animals 
 are concerned. It is perhaps not so well established in 
 human beings. 50 
 
 Curiously enough, Heese 51 has found that irritation 
 of the sympathetic causes in rabbits, in contrast to the 
 general rule, a retraction of the eyeball into the orbit, 
 and this is due to a contraction of the orbital vessels 
 and the anemia which is thereby caused. In other 
 words, the sympathetic nerve displays its effect on the 
 eyeball in two different ways, that is, by a contraction 
 of the unstriped muscles of the orbit, Miiller's muscle, 
 and by vasomotor influence. If Miiller's muscle con- 
 tracts there is protrusion, but if there is a contraction 
 of the orbital vessels, then there is a sinking in; pre- 
 dominance of the one influence will cause exophthal- 
 mos, predominance of the other, enophthalmos. 
 
 5. Stimulation of the cervical sympathetic is fol- 
 lowed by contraction of the blood vessels of the con- 
 junctiva, of the iris, and perhaps by alteration in the 
 caliber of the vessels of the retina, although it is dif- 
 ficult to get satisfactory evidence with reference to the 
 last-named phenomena. 
 
 Rockwell and Beard 32 investigated the effect of gal- 
 vanization of the sympathetic on the vessels of the .eye- 
 ground, using a current of from 10 to 25 elements. 
 Roosa, who watched the retina under these circum- 
 stances, saw at first a hyperemia and afterward an ane- 
 mia of its vessels, while Loring noted only decided filling 
 of the veins, and another observer only contraction of 
 the arteries. Slow-acting mechanical irritation of the 
 sympathetic, according to Lodato, produces retinal 
 anemia in dogs. 
 
 6. The effect of electrical currents on the tension of 
 the eyeball, when these were applied to the cervical sym- 
 pathetic, as well as their influence in increasing the 
 secretion of the lachrymal gland, have already been de- 
 tailed. 
 
 50. Consult Die Neurol. d. Auges, Wilbrand and Saenger, i, p. 545. 
 
 51. Archiv f. die Gesammte Physiol., Bd. 52, 1892, p. 535. 
 
 52. Medical and Surgical Electricity, 1871.
 
 IX. THE OCULAR PHENOMENA WHICH FOLLOW INJURY 
 
 TO THE SYMPATHETIC IN THE NECK CAUSED BY 
 
 DISEASE OR BY SECTION OF THE SYMPATHETIC 
 
 CORDS, OR BY THE EXTIRPATION OF THE 
 
 SYMPATHETIC CERVICAL GANGLIA. 
 
 In connection with this subdivision of the subject, 
 we have to study: (a) The condition of the pupil; (b) 
 the width of the palpebral fissure; (c) the position of 
 the nictitating membrane; (d) the position of the ocular 
 globe; (e) the state of the conjunctival blood vessels 
 and the secretion of the lachrymal gland; (f) the intra- 
 ocular tension; (g) alterations in the vascular supply 
 of the uveal tract and the retina; (h) trophic changes 
 in the globe; (i) the shape of the cornea, and in gen- 
 eral, the refraction of the eye. 
 
 It is well known that the sympathetic nervous sys- 
 tem exercises a tonic action on certain of the struc- 
 tures which it supplies; for example, in the cervical 
 sympathetic, the vasoconstrictor fibers, the pupillo- 
 dilator fibers and the constrictor fibers to the unstriped 
 muscle of the eye and its appendages, are, to quote the 
 words of Langley, in a state of constant action, broken 
 only by a state of inhibition, occurring in the central 
 nervous system; hence section of the cervical sympa- 
 thetic will cause a paralytic effect in those tissues which 
 are in a state of tonic contraction. 
 
 (1) As long ago as 1727, Pourfour du Petit noted that 
 division of the cervical sympathetic was followed by 
 contraction of the pupil, and this observation was con- 
 firmed particularly by the studies of Claude Bernard in 
 1851, and later by those of Brown-Sequard in 1852. 
 All subsequent experiments, as well as clinical observa- 
 tions, which indicated that the cervical sympathetic 
 had been destroyed by injury or disease, have confirmed 
 these results, and we now know that when the myd- 
 riatiu path in the sympathetic, that is, the path which 
 contains the pupillodilator fibers, is divided, there is 
 necessarily prompt contraction of the pupil on the cor- 
 responding side. 
 
 A matter of some interest is to determine whether 
 the effect on the pupil, as well as the other structures 
 of the eye, is greater after excision of the superior cer- 
 vical ganglion than after section of the sympathetic 
 cord. Claude Bernard noted greater paralytic results 
 from excision than from section, but Schiff, Callenfels
 
 27 
 
 and Pye-Smith failed to find any difference. This ques- 
 tion has been recently investigated from the experi- 
 mental standpoint by Levinsohn, 53 and he has found, 
 experimenting with apes, that if the sympathetic is 
 cut on one side and the ganglion removed in the other, 
 the difference in the pupillary width is not very great, 
 amounting to no more than 1/2 mm., but in cases where, 
 respectively, the sympathetic is cut or the ganglion re- 
 moved, the pupillary difference is demonstrable and the 
 pupil always smaller on the side on which the ganglion 
 is removed. This of itself is not sufficient evidence to 
 declare that the ganglion exercises an individual tonus 
 over the nerve, but when the ganglion is removed, the 
 nerve having previously been resected, additional con- 
 traction takes place, and this, it would seem, indi- 
 cates that the ganglion has a different and, as it were, 
 a stronger action on the eye than the nerve trunk itself. 
 Furthermore, irritation in some animals of the per- 
 ipheral cut ends of the nerve trunk causes no addi- 
 tional change in the pupil, and the same occurs when 
 the lower part of the ganglion is irritated. Excitation 
 of the upper part of the ganglion, however, produces a 
 prompt response, and therefore the indications are that 
 an individual tone is exercised by the ganglion. The 
 tonus remaining in the ganglion is dependent on higher 
 oerebrospinal twigs. Langendorff believes that the su- 
 perior cervical ganglion possesses a distinct tonic ac- 
 tivity. 
 
 A matter of great importance is the permanence of 
 the myosis after section of the sympathetic or extirpa- 
 tion of the ganglion. According to Langley, this varies 
 greatly in different animals. In the frog the develop- 
 ment of paralytic symptoms in the eye after section 
 of the sympathetic is gradual; in the rabbit after 
 twenty-four hours the pupil begins to dilate, and on 
 the third to the fifth day again becomes small and re- 
 mains smaller than normal ; in all animals there is some 
 degree of return to normal after section. In the cat 
 and dog section of the cervical sympathetic causes a 
 permanent diminution in the size of the pupil; in the 
 rabbit this phenomenon is much less marked. Levinsohn 
 has also noticed that the myosis, as well as the other 
 paralytic symptoms, gradually becomes less apparent but 
 
 53. See footnote 45 : also, Bericht iiber die XXX Versammlung 
 der Ophth. Gesellschaft. Heidelbei-g. 1903. p. 238.
 
 28 
 
 does not entirely disappear, and long ago Pye-Smith ob- 
 served that permanent contraction of the pupil was 
 more nearly a result without exception than the other 
 phenomena. 
 
 Langendorff 54 maintains that myosis produced by ex- 
 cision of the cervical sympathetic, as well as the accom- 
 panying narrowing of the palpebral fissure and retrac- 
 tion of the globe,, may persist for } r ears. After extirpa- 
 tion of the superior cervical sympathetic ganglion all 
 the phenomena of paralysis of the sympathetic nerve, 
 especially contraction of the pupil, are at first pro- 
 nounced. These phenomena, however, gradually become 
 less marked, and may disappear or even give place to the 
 opposite condition. This change to the opposite condi- 
 tion always occurs when the animal is anesthetized, 
 several days, or weeks, or months after the operation, 
 or when it is subjected to sensory or emotional stimuli. 
 It is possible that dyspnea also may have the same 
 effect. Putting this in another way, it may be stated, 
 according to Langendorff, that following extirpation of 
 the upper cervical ganglia the phenomena of sympa- 
 thetic paralysis which appear on the corresponding side 
 soon after the operation may after a time disappear and 
 give place to the signs of sympathetic excitation, which, 
 although moderate, become very pronounced under an- 
 esthesia. 
 
 It would seem to make no difference in regard to the 
 age of the animals experimented on, and within the 
 limits already expressed, the species of animal employed. 
 Extreme narrowing of the pupil, for example, has been 
 seen by Hertcl after the removal of the ganglion in 
 young animals (ten to twenty day rabbits), and al- 
 though the other symptoms were more or less transient, 
 the myosis was permanent, but as time went on it also 
 ceased to be as complete as immediately after section. 
 M"ot only is there myosis when the ganglion is removed 
 and tne cord cut, but the same result may be obtained, 
 as Levinsohn has shown, when the main branches are 
 divided, but neither the main trunk or the secondary 
 branches are injured. The myosis, however, is less 
 marked under these circumstances than when the trunk 
 is divided or the ganglion extirpated. 
 
 As has been already mentioned, Francois-Fraiu i. 
 taught that not all pupil-dilating fibers contained in the 
 
 r>4. Kiln. Monatsbl. f. Augenheilk., xxxviii. 1'joo, p. 120..
 
 first branch of the trigeminal nerve are derived from 
 the cervical sympathetic, but that part of them read 1 , 
 the gasserian ganglion by way of the roots of the tri- 
 geminal nerve, and Onuf and Collins are also con- 
 vinced that not all the mydriatic fibers are contained in 
 the cervical sympathetic.'"""' 
 
 Although section of any portion of the mydriatic 
 tract produces myosis, it does not abolish the pupil re- 
 flexes, that is, the pupil on the operated side will re- 
 spond to light stimuli. Xaturally, however, the so- 
 called sympathetic reaction of the pupil, that is, the 
 pain or the skin reflex, is abolished. Heiligenthal, 00 dis- 
 cussing cases in which the sympathetic had been de- 
 stroyed by diseased glaflds in the neck, suggests that in 
 the neck sympathetic fibers exist which produce a widen- 
 ing of the pupil as the result of psychic impressions. 
 
 According to Levinsohn, 53 the myotic pupil caused by 
 sympathetic section or gangiiectomy is not affected by 
 the action of cocain. It is slightly contracted by eserin, 
 but less contracted on the operated side than on the non- 
 operated side. It is dilated by homatropin, the action 
 being slighter on the operated side than on the other, 
 owing to the smaller size of the pupil on the operated 
 side and to the damaged tone of the dilator. He has 
 further shown that not only is the action of these drugs 
 less marked on the operated eye, especially in so far as 
 eserin is concerned, but that it is slower than normal. 
 Furthermore, the diminution in reaction is greater when 
 the ganglion is resected than when the nerve is cut. 
 These facts he thinks prove that the sphincter is weak- 
 ened by the sympathetic operation, although what con- 
 nection the sphincter has with the sympathetic nerve 
 is not as yet known. Chloroformization of animals on 
 whom sympathectomy has been performed causes a 
 greater dilatation of the pupil on the operated than on 
 the normal side. Gangiiectomy produces a narrower 
 pupil than sympathectomy, although the reverse was 
 present before narcosis. Deep narcosis is necessary to 
 bring about these changes. When intense narcosis is 
 induced, this paradoxical pupillary change is more no- 
 ticeable after the animal has somewhat recovered from 
 
 55. See footnote 14 for their experiments and for their -belief 
 that the sympathetic nerve contains not only the dilator but also 
 contracting fibers for the pupil, that is, contracting fibers for. the 
 pupil of the same side. 
 
 ."i(j. Archiv f. Psych, u. Nervenkrank., 1900, p. 79.
 
 30 
 
 the anesthetic. The normal pupil returns to its normal 
 narrow state; the other remains dilated. Curare pro- 
 duces dilatation of the pupil on the operated side in 
 rabbits, in monkeys less dilatation on the operated than 
 on the normal side, and in cats greater dilatation on the 
 operated side as compared with the non-operated side. 
 This action is due to paralysis of the nerve supplying 
 the sphincter. 
 
 Langendorff/ 4 writing concerning the paradoxical 
 pupillary dilatation, that is to say, that the myosis which 
 follows gangliectomy is greater than that which suc- 
 ceeds sympathectomy, but that this condition is true 
 only for a period immediately succeeding the operation, 
 inasmuch as a few hours later 1;he difference begins to 
 disappear, and after one or two days the pupil on the 
 side on which gangliectomy has been performed may 
 even be larger than that on the side on which sym- 
 pathectomy has been effected, summarizes the various 
 theories which have been advanced to explain this con- 
 dition, as follows: 
 
 (a) The oculomotor nerve meets with less resist- 
 ance than ordinarily in the performance of its func- 
 tions. This reacts on the focus where the nerve force 
 is generated. In other words, the condition represents 
 an example of the truth that power is increased by ex- 
 ercise and diminished by lack of resistance (Budge). 
 
 (b) Direct irritation of the dilator muscle by the 
 drug used for the purpose of demonstration, for ex- 
 ample, an anesthetic or atropin. 
 
 (c) Vasomotor changes. 
 
 Langendorff objects to all of these theories, and for 
 his arguments the reader should consult the original. 
 His own theory is that the explanation of the para- 
 doxical pupillary phenomenon and associated phenom- 
 ena depend on the degenerative processes in the post- 
 cellular nerves of the ganglion. He assumes that in 
 the smooth muscles Avhich, owing to their sluggish con- 
 tractions, are probably not capable of fibrillary twitch- 
 ing, degeneration of their respective nerves may lead to 
 irritative phenomena manifesting themselves in contrac- 
 tions or contractures. If such contraction may lie as- 
 sumed to take place after the removal of the upper cer- 
 vical ganglion in the radial fibers of the iris muscle, 
 which is the dilatator of the iris, and in the remaining 
 unstriped muscles of the eye supplied by the cervical
 
 31 
 
 sympathetic, the phenomena which have been described 
 can be explained. 
 
 A considerable excision of the sympathetic must be 
 made in order to prevent a rapid regeneration,, and it 
 has been shown that this regeneracy is moderately rapid 
 in the cervical sympathetic and doubtless in other pre- 
 ganglionic sympathetic fibers. Langley states that he 
 has found a return, although not to a full extent, of all 
 of the functions of the sympathetic in a cat twenty-four 
 hours after section, and Langendorff 57 has removed the 
 superior cervical sympathetic ganglion from animals, 
 and noticed restoration of function at the end of 105 
 days. The bearing of these facts on operative work on 
 the cervical sympathetic is only too apparent. 
 
 2-4. From the earliest days of experimentation on the 
 sympathetic to the present time, it has been noted that 
 section of the cervical sympathetic, or its destruction 
 by disease or injury, in addition to myosis, will be fol- 
 lowed by narrowing of the palpebral aperture, projec- 
 tion of the nictitating membrane and retraction of the 
 globe of the eye. 
 
 The narrowing of the palpebral fissure has been at- 
 tributed partly to a predominating tonus of the orbic- 
 ularis, partly to individual weight of the upper lid, 
 and partly to a moderate retraction of the bulbus, 
 brought about by a relaxation of Miiller's orbital muscle, 
 or by consecutive atrophy of the orbital fat. Like the 
 myosis, it is more prominent after gangliectomy than 
 after sympathectomy, but is not so permanent a phe- 
 nomenon. The tone of the muscles, according to Levin- 
 sohn, injured by removal of the sympathetic is not com- 
 pletely destroyed, and under certain circumstances these 
 muscles, especially in some animals, may acquire an 
 increased irritability. When cocain is instilled under 
 these circumstances, the same author has demonstrated 
 that although the pupil is unaffected, the palpebral 
 fissure is slightly widened, but after the ganglion is re- 
 moved cocain produces change neither in the pupil nor 
 in the width of the fissure. This narrowing of the 
 lid 'fissure produces in effect a form of ptosis, some- 
 times called ptosis sympathica, first described clin- 
 ically by Horner 58 and attributed by him to paralysis 
 of the unstriped muscular fibers of the lid, the so- 
 
 57. Abstract, Lancet. Oct. 5, 1901. 
 
 58. Klin. Monatsbl. f. Augenheilk., vol. vii, 1869, p. 193.
 
 33 
 
 called palpebral muscles of Miiller, an explanation which 
 has been adopted by many other writers and particu- 
 larly insisted on by Nicati in his well-known mono- 
 graph on paralysis of the sympathetic nerve. The slight 
 ptosis after sympathetic palsy, according to Wildbrand 
 and Saenger, manifests itself particularly after psychic- 
 alterations and physical exertions. 59 
 
 Inasmuch as stimulation of the cervical sympathetic 
 produces retraction of the nictitating membrane, it is 
 natural that its paralysis or division will cause a pro- 
 jection of the same structure, a phenomenon which 
 is interesting in animals, but not particularly note- 
 worthy in men on account of the rudimentary nature 
 of this structure. The retraction of the globe which 
 follows sympathetic section has been attributed to a 
 reduction of the volume of the bulbus, as was originallv 
 maintained by Pourfour du Petit and Claude Bernard, 
 based on observations on animals who had survived some 
 time after sympathectomy ; to atrophy of the fatty tis- 
 sues of the orbit ; and finally, to paralysis of the smooth 
 muscles which stretch across the floor of the orbital 
 cavity. 
 
 Hertel, 44 experimenting on young rabbits, attributes 
 this enophthalmos to atrophy of the orbital fat, and not 
 to a paralysis of Miiller's muscle, which he maintains 
 comes on only at the end of six weeks. He believes 
 that the elastic fibers in Miiller's muscle are sufficient 
 to hold the globe in place. Angelucci and others, like 
 the earlier experimenters, have attributed this enoph- 
 thalmos to a real smallness of the eye, that is, to an 
 atrophy of the ocular globe, a position which later ex- 
 perimenters, notably Hertel and others, have not ad- 
 mitted to be established. 
 
 5-7. The state of the blood vessels of the conjunctiva 
 nud the iris and the secretion of the lachrymal gland 
 under the influence of sympathetic section have been 
 fully described and need not be referred to again. The 
 same may be stated in regard to intraocular tension, to 
 which a special paragraph has been devoted. 
 
 8. Ophthalmoscopic and microscopic lesions in the 
 
 59. Those interested In the clinical study of this question should 
 consult the admirable work of Wildbrand and Saenger (see Note 50). 
 pp. 541-558. It is interesting to remember that the first accurate 
 study of bullet wound of the sympathetic and the classical symp- 
 toms it caused was made during our Civil War by Drs. Weir 
 Mitchell, George Morehouse and \V. W. Keen.
 
 33 
 
 eyegroimd after sympathetic section have received con- 
 siderable study. As long ago as 1871 Sinitzin 60 found, 
 after extirpation of the superior sympathetic ganglion, 
 an increased vascular injection of the eyegroimd on the 
 operated side. He noticed that the choroidal vessels 
 increased in volume, that their anastomoses were more 
 readily seen, and that, in general terms, the redness of 
 the eyegroimd on the operated side was greater than 
 that on the opposite side. 
 
 Angelucci, 01 after extirpation of the stellate ganglion 
 in the new-born dog, described lessening in the devel- 
 opment of the circumference of the cornea and sclera; 
 also atrophy and sclerosis of the texture of the iris and 
 choroid and the formation of sclerotic plaques. He did 
 not, however, discover fundamental changes in the struc- 
 ture of the retina. These dystrophies Angelucci attrib- 
 uted to changes in the blood vessel walls, which had al- 
 ready been described by Vulpian and Giovanni. Obar- 
 rio has reported hemorrhages in the ciliary body and 
 ciliary processes and less frequently in the retina and 
 choroid. These phenomena Hertel, who quotes them, 
 could not substantiate in his experiments. Neuscheuler 
 noted ophthalmoscopically vessel contraction during 
 the period of sympathetic irritation and elevated ten- 
 sion, and the opposite condition during the period of 
 section. After sympathectomy he observed widening of 
 the blood paths of the uveal tract, as well as miliary 
 hemorrhages, and naturally suggests that therapeutic 
 extirpation of the sympathetic ganglion from this stand- 
 point, at least, is not a harmless procedure. 
 
 Doyon, 62 writing concerning trophic disturbances of 
 the eye after section of the great sympathetic in the 
 neck, states that in rabbits this operation causes lesions 
 of the lid and cataract, and points it out as interesting 
 that the development of these trophic changes took 
 place after section of a centrifugal nerve, although the 
 general conception is that a lesion of sensitive nerves 
 should be made responsible for such conditions. 
 
 Lodato 63 has studied the alterations in the retina which 
 occur after excision of the superior cervical ganglion, 
 his investigations being confined to dogs and rabbits, 
 
 60. Med. Centralbl., 1871, Nr. 11. 
 
 61. Boll. d. It. Acad. di Roma, vol. xix, 1892-93, p. 240. 
 
 62. Abst., Zeit. f. Augenheilk., 1899, 1, p. 89. 
 
 63. Abst. Annal. d'Oculist., cxxvi, 1901, p. 229. 
 3
 
 34 
 
 and has found that after ahlatiou of the ganglion 
 changes occur which are localized exclusively in the 
 retinal ganglion cells. These lesions are slight and com- 
 pletely repair themselves in the rabbit; in the dog they 
 are graver and last longer. With regard to the optic 
 nerve, he believes that the degenerated fibers which 
 have been found after extirpation are not really of a 
 sympathetic nature, but are fibers which have been de- 
 generated owing to alterations in the ganglion cells of 
 the retina. 
 
 It will be remembered that Angelucci thought that 
 the enophthalmos was due to an actual smallness of the 
 globe, that is, to an atrophy of it ; indeed, he maintained 
 that after sympathetic section or gangliectomy a form 
 of micro phthalmos developed. This change Hertel in 
 his later experiments on young rabbits was unable to 
 demonstrate. Levinsohn, 53 referring to trophic changes 
 after gangliectomy, found that the weight of the eyes 
 was about the same on the operated and the non-operated 
 sides. Indeed, there were no very constant alterations, 
 the surest one being a greater filling of the choroidal 
 vessels on the operated side, and the anterior part of 
 the eye seemed smaller on this side. The sphincter in 
 all cases where the sympathetic ganglion was removed, 
 or the capital branches cut, was longer and narrower 
 than on the other side; where the sympathetic was re- 
 sected, the sphincter was shortened. Gatti 64 finds that 
 osmosis at the lens does not alter for a time (three to 
 fifteen days) after section of the sympathetic, but fre- 
 quently loss of weight is evident. 
 
 The relation of the ciliary ganglion to trophic changes 
 and the experiments of Bernheimer, Marina and others, 
 and the idea of Grosz on the etiology of neuroparalytic 
 keratitis, have been described. 05 Curiously enough, mam 
 years ago, the relation of the cervical sympathetic to 
 neuroparalytic ophthalmia was studied by Sinitzin, who 
 thought the cornea on the sympathectomized side was 
 more resisting than that on the non-operated side to 
 foreign substances, for example, bits of glass, inasmuch 
 as on the normal side corneal ulceration always occurred 
 under these circumstances, but not in the other eye. If the 
 trigeminus was cut in the cranium, the neuroparalytic 
 
 64. Abst. Jahresb. f. Ophthal.. 1898, p. 272. 
 
 65. Bach thinks that Bernheimer's cauterization of the cornea 
 produced changes in the iris and ciliary body which were responsible 
 for the degeneration set up in the ciliary ganglion.
 
 phenomena did not appear in the eye if not long before 
 this operation,, or shortly afterwards, the upper cervical 
 sympathetic was excised. He believed that the increased 
 filling of the blood vessels caused by the operation, and 
 on that account the elevation of temperature, played 
 the important role of inhibitory agents. 
 
 9. Claude Bernard, Brown- Sequard and others be- 
 lieved that the cervical sympathetic had an influence on 
 the shape of the cornea and described flattening of this 
 structure after sympathectomy. Heese, however, was 
 unable to find any alteration in the cornea and lens 
 under these circumstances, and doubted whether the 
 sympathetic had an inhibitory action on accommodation ; 
 in fact, according to him, it takes no part in the process 
 at all. Eulenberg and Guttman 39 believed that the my- 
 osis was accompanied with myopia, which in its turn 
 was dependent on a spastic state of the accommodation, 
 but Nicati in his cases of palsy of the sympathetic was 
 unable to find any effect which this lesion could have 
 upon visual acuity, nor was he ever able to discover any 
 influence on accommodation, and he disputes the con- 
 tention of Eulenberg and Guttman that myopia ought 
 to be a consequence of paralytic myosis. A detailed 
 reference to the influence of the sympathetic on accom- 
 modation, and therefore on refraction in general, has 
 been given and the subject need not further be discussed. 
 
 Before finally leaving the subject of the ocular phe- 
 nomena which follow section of the cervical sympathetic 
 or extirpation of its ganglia, reference should be made 
 to the interesting observations of Dupm^. 66 This experi- 
 menter found that ptosis, retraction of the globe, ad- 
 vancement of the nictitating membrane and myosis after 
 section of the cervical sympathetic all disappear if the 
 restiform body is punctured on the side corresponding 
 to that on which the lesion in the sympathetic has been 
 established. In other words, puncture of the restiform 
 body produces just the opposite effects of destruction of 
 the sympathetic, and these effects, moreover, can be 
 transmitted in animals from one generation to another, 
 or, as Dupuy expresses it, transmitted through heredity. 
 
 X. EFFECT OF DRUGS AND TOXIC AGENTS ON THE SYM- 
 PATHETIC. 
 
 The scope of the present paper and the time at my 
 disposal do not permit more than a very brief reference 
 
 66. Compt. rend, de la Soc. de Biol., vol. Jubilaire, 1899, p. 246.
 
 3C 
 
 to this very interesting subject. Eeference may first be 
 made to the exceedingly interesting work of Langley on 
 the influence of nicotin on the activity of ganglionic 
 nerve cells. 67 He found that in certain animals, for 
 example, the rabbit, cat and dog, after nicotin injections 
 into a vein, electrical stimulation of the cervical sym- 
 pathetic on the proximal side of the superior cervical 
 ganglion failed to produce any secretion of saliva; nor 
 was he able to induce secretion under these circum- 
 stances if the electrode was applied to the ganglion 
 itself. On the other hand, if the electrical stimulus 
 was applied to the nerve fibers between the ganglion and 
 the gland, active secretion was at once established. The 
 natural inference from this experiment is that the nico- 
 tin interferes with the passage of secretory impulses, 
 and that this interference is in the ganglion cells them- 
 selves. He further established his position by painting 
 the superior cervical sympathetic ganglion with nicotin 
 and again checked the passage of the secretory 
 impulses, but when the nerve coat itself was painted 
 instead of the ganglion, no interference in the stimuli 
 occurred. 
 
 Pursuing, his studies still further, Langley proved 
 that when an animal was under the influence of nicotin, 
 the cells of the ciliary ganglion were so affected that they 
 formed, to use the technical expression, a "fault" in 
 the transmission of the impulses to the sphincter of the 
 iris, and in the same manner a fault in the transmis- 
 sion of the dilator impulses was obtained. In brief, 
 Langley's experiments proved that nerve impulses, 
 whether they be motor to striped or unstriped muscle, 
 secretory, vasomotor or inhibitory, were all arrested in 
 a nicotinized animal, provided these impulses were 
 obliged to traverse ganglion cells. This important ob- 
 servation of Langley has been much used in physio- 
 logic experiments, and it is the custom now of this dis- 
 tinguished experimenter, as well as others who have fol- 
 lowed in his footsteps, to utilize nicotin in the manner 
 already described if they wish to ascertain if impulses 
 pass along nerve fibers directly or only by synapse 
 through the cells of a ganglion. If impulses such as 
 have been described fail to pass in a nicotinized animal, 
 it is quite certain that ganglion cells are in the path, and 
 form, to use the expression previously used, a fault. 
 
 67. Trans. Royal Soc. and Jour, of Physiology.
 
 37 
 
 We are especially indebted to Walter Jessop 08 for inter- 
 esting observations on the action of cocain on 
 the sympathetic. Shortly after the discovery of 
 this alkaloid, he noted the enlargement of the pal- 
 pebral fissure and the apparent prominence of the eye 
 which followed instillation in the conjunctival cul-de- 
 sac of solutions of cocain, and satisfied himself by a 
 series of experiments, which have often since been con- 
 firmed, that this widening of the palpebral aperture 
 was due to a stimulating or irritating action of the 
 drug on the sympathetically-supplied unstriped muscu- 
 lar fiber of the lids, to which reference has so frequently 
 been made in this paper. If cocain in 4 per cent, so- 
 lution is instilled into the conjunctival cul-de-sac, as 
 we all know, the pupil dilates. This dilated pupil will 
 respond to strong light stimulus and to accommodation, 
 is neutralized by eserin or pilocarpin, and still further 
 widens under the influence of atropin. Xumerous ex- 
 perimenters, notably Jessop, Limbourg and others, 
 have shown that this mydriasis can not be due to par- 
 alysis of the peripheral endings of the oculomotor nerve, 
 because the mydriasis is larger than that after section of 
 the third nerve. Moreover, the pupil acts to light and 
 to accommodation, and pilocarpin, which acts alone on 
 the nerve endings of the oculomotor, produces myosis. 
 Neither does the drug paralyze the sphincter of the 
 pupil because the action to light and accommodation 
 is retained, and eserin, which directly stimulates the 
 muscular fibers, causes contraction. Finally, it has been 
 noted that the mydriasis produced by irritation of the 
 sympathetic is exactly like that which follows the in- 
 stillation of cocain, and therefore it has been reasoned, 
 on good grounds, it would seem, that cocain-dilatation 
 of the pupil is due to a stimulant action of the drug on 
 the mydriatic nerve endings, that is to sa}', on the sym- 
 pathetic. 
 
 The physiologic action of the mydriatic alkaloids, es- 
 pecially of those which belong to the series of tropins, 
 is of great interest, but only a brief reference can be 
 made to them in so far as their action on the sympa- 
 thetic nerve is concerned. 69 The dilatation of the 
 
 68. Trans. Ophth. Soc. U. K., vol. v, 1885, p. 240 ; Ibid., vol. vi. 
 1886, p. 123. 
 
 69. Those interested in this subject may consult H. C. Wood. 
 Therapeutics. Its Principles and Practice, eleventh edition, 1900. 
 pp. 175-177 ; H. C. Wood, Jr., The Physiologic Action of the 
 Mydriatic Alkaloids, THE JOURNAL of the A. M. A., Feb. 21, 1903.
 
 38 
 
 pupil caused by atropin is not centric in its origin, 
 but depends on a peripheral action of the drug. 
 Numerous experiments and the character of the myd- 
 riasis have led to the belief that the dilatation is due 
 to palsy of the oculomotor endings and at the same 
 time to a stimulant action of the drug on the sympa- 
 thetic nerve fibers, or perhaps to a general paralysis of 
 the unstriped pupillary muscle. 
 
 Although it is usually stated, and it seems to me 
 with entire accuracy, that the myosis which is produced 
 by the instillation of eserin is due to a stimulant action 
 of this drug on the muscular fiber, some distinguished 
 authorities, notably H. C. Wood, believe that the drug 
 paralyzes the peripheral sympathetic nerve endings in 
 the iris, although we know when there is complete 
 paralysis of these nerve endings after gangliectomy 
 or sympathectomy, eserin still further contracts the 
 pupil, which would at least strongly indicate that this 
 action is not on nerves, but on muscle fiber itself. 
 
 Eecent experiments by S. J. Meltzer and Clara Melt- 
 zer 70 on the relation of the innervation of an organ to 
 the influence of suprarenal extract on it, have developed 
 some interesting facts. It is well known that intraven- 
 ous injections of suprarenal capsule cause dilatation of 
 the pupil, which lasts a very short time less than a 
 minute. Now the Drs. Meltzer have observed that when 
 the sympathetic is cut a subcutaneous injection of 
 adrenalin causes a dilatation of the pupil on the oper- 
 ated side which can last an hour and longer, and still 
 further noted as remarkable that this effect does not 
 take place if the injection is tried on the day of the 
 operation. Ordinarily, instillation of this drug in the 
 conjunctival sac produces no effect on the pupil, but 
 when the sympathetic is cut, its instillation will cause 
 a dilatation of the pupil lasting for some time. In other 
 words, .this substance exerts, ordinarily at least, no ef- 
 fect on a normal organ, in this instance the iris, but does 
 exert a very considerable effect, and of long duration, if 
 this tissue is deprived of some portion of its nervous 
 control. Later experiments by Dr. S. J. Meltzer 71 are 
 interesting as showing a difference in the effect be- 
 tween the removal of the sympathetic ganglion and sim- 
 ple section of the cervical sympathetic nerve. Subcu- 
 
 70. American Medicine, Feb. 7, 1903. 
 
 71. Personal communication. March 16. 1903.
 
 39 
 
 taneous injection of adrenalin, or instillation into the 
 conjunctival sac, causes a dilatation of the pupil on the 
 side where the ganglion is removed, and not on the side 
 where the sympathetic has been cut, the ganglion re- 
 maining intact again an interesting confirmation of 
 work which has several times been referred to in this 
 paper of a difference in the effects of gangliectomy and 
 sympathectomy, differences which may be well taken 
 into consideration when the surgical side of the ques- 
 tion is considered. 
 
 CONCLUSIONS. 
 
 From this review of the literature and the various 
 opinions of the authors which have been quoted, the fol- 
 lowing conclusions may be drawn: 
 
 1. Although lachrymal secretion may be caused by 
 excitation of the sympathetic, and increased lachryma- 
 tion by section of the cervical sympathetic or removal 
 of the superior cervical ganglion, the sympathetic itself 
 should not be considered the nerve of secretion for the 
 lachrymal gland. 
 
 2. Dilatation of the pupil is probably caused by contrac- 
 tion of a set of radially arranged muscular or contractile 
 fibers, the so-called dilatator pupillas, which is supplied by 
 the sympathetic, and by inhibition of the sphincter of the 
 iris. The dilating impulse transmitted to the iris passes 
 through the cervical sympathetic and in general terms 
 along the mydriatic tract of the pupil, which proceeds 
 from a center in the medulla as far as the second 
 dorsal nerve, follows its communicating branch to the 
 cervical sympathetic, and arrives at the internal carotid 
 plexus, from which point it passes to the nasociliary 
 branches of the nasal nerve, which as the long ciliary 
 nerves supply the muscular tissue of the iris. 
 
 3. Although experimental and clinical evidence favors 
 the presence of a center situated between the spinal 
 cord and the exits of the sixth cervical and fourth dor- 
 sal nerves, to which Budge relegated the origin of the 
 pupil-dilating fibers of the sympathetic, its existence 
 has not been definitely proven. 
 
 4. Although the nature of the ciliary ganglion has 
 not been positively determined in any one species of 
 animal, and, although it differs greatly in different 
 species, the weight of evidence is in favor of the gang- 
 lion belonging to the sympathetic system, at least in so 
 far as man is concerned. The root fibers which belong
 
 40 
 
 to the oculomotor end in the ciliary ganglion, where a 
 new neuron begins for the fibers which pass to the 
 ciliary muscle and the sphincter of the pupil, i. e., the 
 oculomotor does not act directly on the sphincter of 
 the pupil, but only in association with the ciliary gang- 
 lion. There is a certain amount of evidence that this 
 ganglion is related to the pupil movements in the form 
 of a center, and it probably contains cells which are 
 active in the sensibility of the cornea, but lesions of the 
 ganglion itself, although they have been considered by 
 Grosz to be the basal cause of true neuroparalytic kera- 
 titis, have not been proved to sustain this position by 
 experiments, inasmuch as trophic changes have not been 
 observed after extirpation of the ganglion. Removal of 
 the ganglion has little or no influence on intraocular 
 tension, and its excision is not a rational procedure for 
 the relief of glaucoma. 
 
 5. There is no satisfying evidence that the sympathetic 
 is related to the function of accommodation, and it has 
 not been proved that the sympathetic has any power in 
 causing negative accommodation, nor has it been demon- 
 strated that alterations in refraction noted after stimu- 
 lation of the sympathetic are due to actual change in 
 the lens. 
 
 6. Electrical stimulation of the cervical sympathetic 
 produces at first an increase and later a decrease of in- 
 traocular tension, the increase being probably due to an 
 effect on the vessels of the eye. Slow-acting, mechanic- 
 ally produced irritation of the sympathetic causes a ris<- 
 of tension, which, according to Lodato, is independent 
 of dilatation or constriction of the blood vessels, and 
 also independent of the state of the pupil. Section of 
 the sympathetic, or extirpation of the sympathetic gang- 
 lion, is followed by a fall of intraocular tension, which 
 probably depends on vascular and, perhaps, muscular 
 changes. The lowering of tension is more decided after 
 excision-of the ganglion than after section of the sym- 
 pathetic cords, but in either case the effect is a tem- 
 porary one, and may not last more than a few days, and 
 sometimes disappears within a few hours. 
 
 7. Electrical stimulation of the cervical sympathetic- 
 produces on the side stimulated a dilatation of the pupil 
 as a result of contraction of the dilatator pupillas, as- 
 sociated, perhaps, with an inhibition of the sphincter. 
 At the same time there may occur on the opposite side
 
 ' 41 
 
 a contraction of the pupil, which either depends on the 
 consensual pupil reflex, or represents a reflex trans- 
 mitted through the sympathetic fibers joining the 
 cranial nerves in the region of the cavernous sinus. 
 
 8. Electrical stimulation of the cervical sympathetic 
 causes retraction of the nictitating membrane and prop- 
 tosis, owing to the action transmitted to the unstriped 
 muscular fiber. In contrast to the general rule, irrita- 
 tion of the sympathetic in rabbits causes a retraction of 
 the eyeball in the orbit, which has been attributed by 
 Heese to a contraction of the orbital vessels and the ane- 
 mia which this causes. 
 
 9. Electrical stimulation of the cervical sympathetic 
 is followed by contraction of the blood vessels of the 
 conjunctiva and of the iris, and perhaps by alteration' in 
 the caliber of the vessels of the retina, although observa- 
 tions on the last-named phenomenon have been ex- 
 tremely contradictory. 
 
 10. Stimulation of certain areas of the brain cortex 
 causes dilatation of the pupil, associated, if the cervica] 
 sympathetics are intact, with all the symptoms of stim- 
 ulation of the cervical sympathetic. Division of the 
 sympathetic stops the other symptoms, but not the di- 
 latation of the pupil which is supposed to be due to in- 
 hibition of the tonic action of the third nerve (Par- 
 sons). 
 
 11. Sympathectomy or gangliectomy causes the fol- 
 lowing effects: Myosis, narrowing of the palpebral 
 aperture, projection of the nictitating membrane, re- 
 traction of the globe of the eye, hyperemia of the vessels 
 of the conjunctiva, increased lachrymal secretion, dim- 
 inished intraocular tension, certain ophthalmoscopic 
 and microscopic lesions in the eyeground, and possibly 
 trophic disturbances. 
 
 12. The symptoms of sympathetic section or paralysis 
 lessen after a time, myosis being the most permanent, 
 lasting sometimes for 'years. The degree of permanence, 
 however, of the paralytic phenomena varies much in dif- 
 ferent animals. 
 
 13. Myosis is greater after excision of the cervical 
 sympathetic ganglion than after section of the sym- 
 pathetic cord, because it is probable that a certain tone 
 is exercised by the ganglion ; that is, that it has a differ- 
 ent, and, as it was, a stronger action on the eye than 
 the nerve trunk itself (Levinsohn). 
 
 14. All the phenomena of paralysis of the sympa-
 
 42 
 
 thetic nerve, especially the contraction of the pupil, 
 which follow extirpation of the superior cervical gang- 
 lion gradually become less marked and may disappear 
 or even give place to the opposite condition, especially if 
 the animal is anesthetized or subjected to sensory or emo- 
 tional stimuli. In other words, extirpation of the upper 
 cervical ganglion causes the symptoms of sympathetic 
 paralysis which may disappear and give place to the 
 signs of sympathetic excitation. Such paradoxical pu- 
 pillary dilatation may depend on degenerative processes 
 in the post-cellular nerves of the ganglion (Langen- 
 dorff). 
 
 15. The my otic pupil, which follows sympathectomy 
 or gangliectomy, responds to light stimulus, is still 
 further contracted by eserin, and may be dilated by 
 atropin. It is uninfluenced by cocain, which, however, 
 may exercise its influence in widening the contracted 
 palpebral fissure. 
 
 16. A considerable excision of the sympathetic must 
 be made in order to prevent a rapid regeneration. 
 
 17. Narrowing of the palpebral fissure, ptosis sympa- 
 thica, and enophthalmos are probably due to relaxation 
 of Miiller's muscle, aided, perhaps, by atrophy of the 
 orbital fat. It has not been proved, although it has 
 been asserted, that there is an actual reduction in the 
 size of the globe, that is, a true microphthalmos, under 
 these circumstances. 
 
 18. Sympathectomy or gangliectomy may cause in- 
 creased vascularization of the eyeground, perhaps hem- 
 orrhages in the ciliary body and ciliary processes, and 
 alteration in the retinal ganglion cells. 
 
 19. Puncture of the restiform body produces just the 
 opposite effects of destruction of the sympathetic 
 (Dupuy). 
 
 20. Nicotin paralyzes the activity of ganglionic nerve 
 cells in the sympathetic. Cocain dilates the pupil by 
 stimukting the mydriatic nerve endings in the iris. 
 Atropin dilates the pupil, partly by a paralytic action on 
 the oculomotor endings of the sphincter, and, perhaps, 
 by a stimulant action on the sympathetic nerve fibers, 
 or more likely, by causing a general paralysis of the 
 unstriped pupillary muscle. Instillations of adrenalin, 
 ordinarily inactive in causing dilatation of the pupil, 
 become exceedingly active when the sympathetic is 
 cut or the ganglion removed, and cause under these 
 circumstances marked dilatation of the pupil.
 
 THE INFLUENCE OF RESECTION OF THE 
 
 CERVICAL SYMPATHETIC GANGLIA 
 
 IN GLAUCOMA. 
 
 WILLIAM H. WILDER, M.D. 
 
 Assistant Professor of Ophthalmology, Rush Medical College, Uni- 
 versity of Chicago ; Professor of Ophthalmology, Chicago 
 Policlinic; Surgeon to the Illinois Charitable 
 Eye and Ear Infirmary. 
 
 CHICAGO. 
 
 This paper does not pretend to be a treatise on the 
 subject mentioned in the title, nor does it assume to 
 give any positive conclusions as to the value of the 
 operation of sympathectomy in glaucoma ; for it may be 
 said at the outset that, despite the study of almost all 
 the literature on the subject in its preparation and the 
 collection of published and unpublished data in this 
 country, I feel that positive conclusions are not yet to 
 be reached, and I can only offer this as a contribution 
 that may possibly aid in future work. 
 
 I wish at first to express my sincere thanks to the 
 ophthalmologists of the country who so generously re- 
 sponded to the letter asking for data concerning cases 
 of excision of the sympathetic ganglia for glaucoma, and 
 for the latest possible reports of the condition of such 
 cases. 
 
 In this way it has been possible to secure records of 
 almost all the cases of glaucoma treated by this means 
 in this country. In several instances the reports seem 
 so favorable that one is tempted to draw general con- 
 clusions, while in others the data are so meager or the 
 time that has elapsed since the operation is so short 
 that positive deductions are unwarrantable. Such re- 
 ports would be more valuable if in every instance care- 
 ful clinical records had been kept, together with charts 
 of the visual fields. Nothing is more important in the
 
 44 
 
 stud}' of chronic glaucoma than the condition of the 
 peripheral vision, and such record in a number of these 
 cases is lacking. 
 
 I desire, first, to present a detailed report of seven 
 cases of sympathectomy for glaucoma in my own prac- 
 tice which are still under observation, two of which are 
 rather recent. I shall then give an abstract of the 
 records of cases of sympathectomy for glaucoma that 
 have been done in this country, as they were furnished to 
 me by the observers in answer to the circular letter sent 
 out this spring. Many of these cases have already been 
 published, but the observers have kindly sent me the 
 latest possible report on the condition : 
 
 CASE 1. Chronic inflammatory glaucoma right eye. Sym- 
 pathectomy (no benefit). Iridectomy (improvement). 
 
 Felix H., aged 40 years. Entered Illinois Eye and Ear In- 
 firmary April 29, 1901. Family history negative, and no 
 previous history of eye trouble until April, 1898, when he 
 lost the sight of the left eye by having it struck with a piece 
 of hot brass. He could see shadoAvs with it until one year 
 before admission. Some three weeks after the injury to the 
 left eye, the right became inflamed, and he states that he was 
 unable to see with it for two or three weeks, and then lie 
 recovered vision. In the last two months he has noticed 
 failure of vision, with occasional pain in the right eye. Halos 
 have been noticed around a light. On admission R. E. V. 
 20/50 with Cyl.+l.oO, 180, slight improvement. Conjunctiva 
 of right eye injected and there is engorgement of the ciliary 
 vessels. Pupil moderately dilated and vertically oblong. Re- 
 sponds to light. T.+. Optic disc distinctly excavated, but no- 
 pulsation of the vessels. L. E. V.=0. Conjunctiva injected; 
 pupil dilated, cataract. T.-j-L ^o perception of light. Fun- 
 dus not visible. Eserin, grains ii-j$i, was used three times 
 daily, and the pupil became somewhat smaller and the ten- 
 sion less. For visual fields see Figure 1, which shows marked 
 contraction in all meridians. 
 
 May 16, 1901, R. V.=20/70 with Cyl.+1.50, 180, through 
 stenopf.ic slit 20/50. Severe pain last night. A. c. shallow. T. 
 + 1. Pupil dilated 5 mm. In the afternoon of this day, under 
 chloroform narcosis, Dr. F. C. Schaefer removed the right 
 superior cervical sympathetic ganglion. Contraction of the 
 pupil immediately followed, but tension was not lowered until 
 several hours after the operation. At the time of the opera- 
 tion there was neither pallor nor flushing of the face, nor wa- 
 there an increase of lachrymal secretion. Ptosis of right side 
 was noticed after recovery of consciousness. 
 
 May 17, 1901. Patient comfortable, right pupil contracted. 
 T. lower than before, but still +.
 
 Figure 1, Case 1. Felix H., aged 40. Before sympathectomy. 
 Chronic inflammatory glaucoma. April 29, 1901. Rt. eye 
 V=20/50. T.-K Good ilium, obj. 1 cm. sq. 
 
 Figure 2, Case 1. Three weeks after sympathectomy. Chronic 
 inflammatory glaucoma. June 17, 1901. Rt. eye V 20/40. T.+ 
 Good ilium, obj. 1 cm. sq.
 
 46 
 
 May 18, 1901. Considerable headache. Pupil contracted. 
 T.+. 
 
 May 20, 1901. Considerable pain in wound anil head. T. 
 slightly +. R. V. 20/40. 
 
 There was some infection of the wound, but by June 7 it 
 had completely healed and patient had no more pain and also 
 no headache. The slight improvement in central vision con- 
 tinued at 20/40 and the tension was only slightly increased. 
 The fields, however, showed no improvement. (Fig. 2.) 
 
 June 13, 1901. Vision fell to 20/70, with an increase of ten- 
 sion. This was not controlled by eserin. 
 
 June 20, 1901. Tension has been elevated for one week and 
 there has been occasional pain in the eye. Large iridectomy 
 done upward. 
 
 June 22, 1901. Very slight reaction from iridectomy. 
 
 July 2, 1901. R. V.=20/100. Tension normal. No pain. 
 Central vision began to improve, but occasionally there was 
 slight pain in the eye and slightly increased tension. 
 
 From Aug. 2, 1901, to date of his discharge, Aug. 29, 1901, 
 the tension remained normal and the eye was quiet. R. V. 
 with Cyl.+l.OO. Ax. 20=20/30+. Visual fields were un- 
 changed. See Figure 3. 
 
 CASE 2. Chronic inflammatory glaucoma. Both eyes. Rt., 
 sympathectomy (marked temporary improvement). Tridec- 
 tomy. 
 
 Edw. L. V., aged 62 years, entered Illinois Eye and Ear 
 Infirmary June 29, 1901. No history of previous eye disease. 
 History of rheumatism. Father became blind at the age of 
 70 years. Examination of urine shows nothing abnormal. 
 About five years before patient noticed he would occasionally 
 see rings of color around a light, but it was not until six 
 months before admission that he commenced to have pain in 
 his eyes, which he describes as dull, persistent and centering 
 over the left eye. He has noticed a gradual failure of vision, 
 and at different times a complete loss of vision in different 
 fields. There is a history of an acute exacerbation three weeks 
 ago, since which time he has had more trouble. Patient hy- 
 peropic. R. E. V. with Sph.+5. 00=20/1 00+1. 
 
 Cornea clear, not anesthetic. A. c. shallow. Some circum- 
 corneaj. injection. Pupil not dilated, responds feebly to light. 
 T.+. Lens slightly cloudy. Disc deeply cupped with glau- 
 coma halo. 
 
 L. E. V. with Sph.+5.00 = Fingers at 5 feet in temporal field. 
 Pupil normal in size. T.+. Some opacity of crystalline lens. 
 Disc deeply cupped. For fields of right eye see Figure 4. It 
 was impossible to chart the field of vision of the left eye. 
 Eserin, grains ii-3i, t. i. d., was used in each eye. 
 
 Operation July 12, 1901. Under ether narcosis the right 
 superior cervical sympathetic ganglion was removed by Dr. F.
 
 Figure 3, Case 1. Five weeks after iridectomy. Chronic in- 
 flammatory glaucoma. Aug. L'9, 1901. Kt. eye V=20/30-K T. n. 
 
 Hiyllt. 
 
 Figure 4, Case 2. Edw. V., aged 62. Chronic inflammatory 
 glaucoma. June 29, 1901. Rt. eye V=20/100. T.+. Obj. 1 cm. sq.
 
 Figure 5, Case 2. Eighteen days after sympathectomy. Chronic 
 inflammatory glaucoma. July 30, 1901. Rt. eye V=20/40+. T. n. 
 Obj. 1 cm. sq. 
 
 Figure 6, Case 2. One month after sympathectomy. Chronic 
 Inflammatory glaucoma. Aug. 8, 1901. Rt. eye V=20/30. T. n. 
 Obj. 1 cm. sq.
 
 49 
 
 C. Schaefer. The operation was successfully and easily per- 
 formed and the patient bore it well. Soon after the opera- 
 tion it was noticed that the right pupil was contracted, there 
 was ptosis and the tension was about normal. 
 
 July 10, 1901. R. V. with Sph. +5.00=20/50. Pupil small. 
 T.+. " 
 
 July 17, 1901. R. V. with Sph. +5=20/70. Pupil small. 
 T.+. Wound in the neck healed by first intention and pa- 
 tient experienced no ill effects from it. Vision began to im- 
 prove, although tension remained slightly increased. 
 
 July 30, 1901. R. V. with Sph.+5.00=20/40+. Fields in- 
 creased (Fig. 5). Tension is also nearer normal. 
 
 Aug. 8. 1901. R.V. with Sph.+5.00=20/30. Tension 
 normal. Field (Fig. 6). 
 
 Aug. 31, 1901. He left the hospital against my advice. 
 T. n. R. V.=20/30. Field as above. 
 
 Oct. 26, 1901. Readmitted to the hospital. R.V. with glass 
 =20/70. L. V. with glass=Fingers 6 in. Tension of right 
 eye decidedly plus. The impairment of central vision is prob- 
 ably due to increasing cloudiness of the central portion of lens. 
 The left lens was much more opaque than when he left the 
 house in August. The visual fields of the right eye had be- 
 come markedly contracted, as seen in Figure 7. As the ten- 
 sion remained high I did an iridectomy on the right eye 
 Nov. 14, 1901, followed one week later by an iridectomy of the 
 left eye. Although the operation was easily performed and 
 without accident or complication, it had the effect of causing 
 the opacity of the lens to increase more rapidly. The tension 
 returned to normal and patient left the hospital Dec. 6, 1901. 
 R. V.=l 5/200. L. V.=shadows. He promised to return as 
 soon as the cataract in the right eye made him helpless, but 
 although I have endeavored to find him, I have not seen him 
 since. 
 
 CASE 3. Simple glaucoma, both eyes. Left sympathectomy, 
 without benefit. Left iridectomy, with questionable benefit. 
 
 Dr. John H., aged 46 years, consulted me Nov. 15, 1901, re- 
 ferred by Dr. A. E. Prince, Springfield, 111. General health 
 good. At the age of 20 he had granulated eyelids, from which 
 he suffered for two years, recovering completely. No trouble 
 of eyes since that time until January, 1901, when his eyesight 
 began to grow dim, and he would occasionally see halos around 
 a light with the left eye. These attacks of dimness of vision, 
 during which he seemed to be looking through a "fog or haze," 
 came on at intervals of five or six days, and lasted several 
 hours. There was no pain, redness of tenderness of the eyes 
 during these attacks or during the intervals. He noticed that 
 his sight was usually clearer in the morning than in the 
 afternoon. Four weeks before coming to me he consulted Dr. 
 Thompson of Indianapolis, who pronounced his case glau- 
 4
 
 Figure 7, Case 2. Fourteen weeks after sympathectomy. Chronic 
 inflammatory glaucoma. Oct. 26, 1901. Rt. eye V=20/70. T.+l. 
 Obj. 1 cm. sq. 
 
 '.' ' \ 
 
 Figure 8, Case 3. Dr. J. H., aged 46. Simple glaucoma. NOT. 
 16, 1901. Rt. eye V 20/200. T.+l. Obj. 1 cm. sq.
 
 51 
 
 coma and prescribed cserin, which he was using at the time. 
 Condition at time of first examination, Nov. 15, 1901: R. V. 
 with Sph.+2.00~Cyl. 3.50, 180:=20/200. L. V. with Sph. 
 +4.003Cyl.+3.00 75 20/200. He was wearing such lenses 
 constantly. Both pupils small and somewhat irregular and do 
 not respond to light. Tension of each +1. 
 
 On discontinuing the use of the eserin for one day the pupils 
 dilated moderately so that the fundus could be seen clearly. 
 There was a deep glaucomatous excavation in each disc. The 
 fields (Figs. 8 and 9), taken Nov. 1C, 1901, showed marked 
 contraction in the nasal region, that of the right noticeably 
 so. The anterior chamber was about of normal depth. After 
 discussing the question of operation with the patient it was 
 decided to do a sympathcctomy on the left side. Nov. 20 r 
 1001, the left superior cervical sympathetic ganglion was ex- 
 cised by Dr. Schaefer at the Post-Graduate Hospital under 
 chloroform narcosis. The operation was successfully per- 
 formed. Immediately after the operation the left pupil, 
 which had been without eserin for two days and was mod- 
 erately dilated, contracted, and the tension became normal. 
 The patient recovered nicely from the operation, but had some 
 sensitiveness of the left side of the neck and face and inabil- 
 ity to raise the left arm and shoulder. He was also quite- 
 hoarse, and this symptom persisted. 
 
 Dec. 1, 1901. L. V. with Sph.+4.00~Cyl.+3.00 75=20/200. 
 T. n., pupil small, ptosis of left. Fields show no increase. 
 R. V. with Sph.+2.00~Cyl. 3.50, 180=r20/200. Pupil small, 
 from pilocarpin. T. n., sometimes +. 
 
 Dec. 30, 1901. Condition same as on December 1. Color 
 fields slightly enlarged (Fig. 10). He left the city Avith in-, 
 structions to continue the miotic and to report at once if his- 
 sight began to get worse. 
 
 Feb. 12, 1902. Patient returned with the statement that 
 his sight was failing. R. V. with glass=10/200. L. V. with 
 glass=8/200. Pupils moderately contracted. T.+. Fields- 
 of left contracted, as shown in Figure 11. 
 
 Feb. 14, 1902. Broad iridectomy upward in left eye. The 
 eye made a good recovery from the operation. 
 
 Feb. 24, 1902. R. V. with glass=15/200. T. n. L. V. with 
 glass=6/200. T. . Patient is somewhat hoarse and has im- 
 perfect power of the left shoulder. He left Chicago for hi* 
 home in southern Illinois. He continued the use of pilocarpin^ 
 grs. ii-5i. 
 
 A letter from him written April 19, 1903, tells me that he 
 has R. V. with glass=13/200. L. V. with glass=9/200. The 
 left vision, however, seems to be somewhat brighter than the 
 right. He says the fields are limited upward and downward, 
 but fairly good to the temporal side. The tension in ea< li eye- 
 is plus, that of the right being a little higher than the Mt.
 
 Figure 9, Case 3. Before sympathectomy. Simple glaucoma. 
 Nov. 16, 1901. Left eye V=20/200. T.+l. Obj. 1 cm. sq. 
 
 Figure 10, Case 3. Five weeks after sympathectomy. Simple 
 glaucoma. Dec. 30, 1901. Left eye V==20/200. T. n. Obj. 1 
 cm. sq.
 
 Figure 11, Case 3. Three months after sympathectomy. Simple 
 glaucoma. Feb. 12, 1002. Left eye V=8/200. T.+. Obj. 1 cm. sq. 
 
 Figure 12, Case 4. Christian K., aged 74. Simple glaucoma. 
 Oct. 7, 1902. Rt. eye V=20/70. T.+. Obj. 1 cm. sq.
 
 54 
 
 He says he never has the least pain or trouble in any way in 
 the eyes and his condition is such that he "can get around 
 with comparative comfort," and attend to his duties as post- 
 master, a position he obtained after giving up his practice. 
 His voice is hoarse and weak, and his neck in front of the scar 
 is sensitive. 
 
 CASE 4. Right, simple glaucoma. Left, absolute glaucoma. 
 Right, sympathectomy (improvement). 
 
 Christian K., aged 74, admitted to Illinois Eye and Ear In- 
 firmary Oct. 3, 1902. One year before, he had severe pain in 
 the left eye, which lasted two weeks, and which was pro- 
 nounced neuralgia by one physician who saw him, and another 
 said his impaired vision was due to a developing cataract. 
 Halos were noticed around a light and the eye was consid- 
 erably reddened. The sight was very imperfect after this 
 period of painfulness, but the eye quieted down. Eight months 
 later he had a most severe attack of pain in the left eye, 
 which lasted two or three hours, after which he discovered 
 that the eye was completely blind. This attack was pro- 
 nounced neuralgia by the physician who saw him after it was 
 over. Soon after this experience he noticed a fogginess of the 
 vision of the right eye, more marked at times than at others. 
 Halos were occasional!} 7 seen around lights, but he had very 
 little or no pain in the eye. He is a strong, healthy man with 
 110 history of previous disease. Urine normal. 
 
 On admission R. V.=20/70. Emmetropia. L. V.=0. Right 
 ye T.+ (?). A. c. of normal depth, pupil not dilated, and 
 responds to light and ace. Optic disc not markedly cupped, 
 but of a grayish unhealthy appearance with indistinct margin, 
 sucn as is seen in incipient glaucoma. 
 
 Left eye, T.+3. Marked pericorneal injection. Pupil mod- 
 erately dilated and shows a greenish reflex. Fundus invisible. 
 Diagnosis: right, simple glaucoma; left, absolute glaucoma. 
 Eserin, grain i-^i, twice daily for each eye. The first chart 
 of visual fields taken a few days after his admission is seen 
 in Figure 12. This was not taken by myself, and may be 
 somewhat inaccurate, for the next field, Figure 13, taken on 
 Oct. 15. 1902, after several days' use of eserin, shows a con- 
 siderably increased field : but as the central vision had im- 
 proved to 20/40 from 20/70, and the tension had become 
 normal after the use of the miotic, the improvement in the 
 fields may probably be ascribed to the treatment. All the 
 other fields w r ere taken carefully by myself. 
 
 Oct. 20, 1902. Excision of the right superior cervical sym- 
 pathetic ganglion was made by Dr. F. C. Schaefer, without any 
 difficulty. Pupil became small immediately after the opera- 
 tion and tension became reduced. Ptosis followed, but there 
 was no pain about the face or neck and no congestion of the 
 conjunctiva or skin. Patient made an excellent recovery
 
 ftiff/it 
 
 Figure 13. C'ase 4. After 1 week of eserin. Simple glaucoma. 
 Oct. 15. 1902. Rt. eye V= 20/40. T. n. Obj. 1 cm. sq. 
 
 Figure 14, Case 4. Two weeks after sympathectomy. Simple 
 glaucoma. Nov. 5, 1902. Rt. eye V=20/40. T. n. Obj. 1 cm. sq.
 
 Riglu. 
 
 Eye 
 
 Figure 13, Case 4. Eight weeks after sympathectomy. Simple 
 glaucoma. Dec. 17, 1902. Rt. eye V=20/40+2. T. n. Obj. 1 
 cm. sq. 
 
 H,glit 
 
 Eye 
 
 Figure 16, Case 4. Six months after sympathectomy. Simple 
 glaucoma. April 20, 1903. Rt. eye V=20/40+. T. n. Obj. 1 cm. sq.
 
 from the operation with no unfavorable symptoms. Slight 
 ptosis of the right eye was noticed. 
 
 Oct. 28, 1902. Pupil contracted. T. n. R. V.=20, 40. 
 
 Nov. 5, 1902. Fields show a remarkable improvement. fSee 
 Fig. 14.) R. V. 20/40. T. n. 
 
 Dec. 17, 1902. Improvement continues. Fields almost 
 normal (Fig. 15). R. V.=20/40+2. Patient still has some 
 pain in right side of face and jaw, as well as the right auricle. 
 
 Jan. 14, 1903. Left the hospital to-day. R. V. 20/40+2. 
 T. n. Pupil contracted. Field same as above. 
 
 April 18, 1903. Readmitted. In left eye there has been 
 severe inflammation and ulceration of the cornea, which be- 
 gan two or three weeks ago. R. V.=20/40+. Pupil still con- 
 tracted and T. n. Fields normal (Fig. 16). It will probably 
 be necessary to enucleate the left eye. 
 
 CASE 5. Simple glaucoma left eye. Sympathectomy. Dis- 
 ease stationary. 
 
 J. S., aged 76 years. First consulted me Nov. 12, 1902, com- 
 plaining that for weeks previously he had the sensation of a 
 fog being over the left eye. He had also noticed halos around 
 a light at night. This phenomenon of colored rings he had 
 noticed at times for years, but he remembered that at such 
 times there was usually a slight secretion from the lids. He 
 also experienced at times a dull pain in the left eye, and the 
 same but less frequently in the right. He -stated that at one 
 time he had severe neuralgic pains extending from the bridge 
 of the nose backward around the left orbit to the ear. General 
 health good, except that he had at times indistinct rheumatic 
 pains and suffered from a bladder disturbance, probably on ac- 
 count of prostatic enlargement. He wears glasses. R. Sph. + 1.50 
 with Cyl.+l.OO, Ax. 15. L. Sph.+1.75 for distance, and R. 
 Sph.+5.00~Cyl.+1.00, Ax. 15. L. Sph.+o.OO for reading 
 prescribed by an ophthalmologist a year or so before. R. V. 
 =20/100 with glass, 20/30+. L. V.=25/70 with glass, 20/30. 
 Right tension normal. Left tension slightly plus, pupil con- 
 tracted with miotic, anterior chamber of normal depth, optic 
 disc shows glaueomatous excavation, that of the right is 
 normal. The chart of the right fields (Fig. 17) shows slightly 
 contracted color fields. That of the left (Fig. 18) shows a 
 scotoma in the upper nasal quadrant. Pilocarpin, grs. ii-^i, 
 t. i. d., was ordered. 
 
 Dec. 1, 1902. Tension has remained about the same as be- 
 fore under the use of pilocarpin. Pupil remains small and 
 anterior chamber of good depth. L. V. with glass=20'30. 
 Left fields show somewhat more contraction in the upper nasal 
 quadrant. (Fig. 19.) 
 
 Dec. 2, 1902. At a consultation with Dr. Hotz it was de- 
 cided to advise an operation. As the anterior chamber was of 
 normal depth, and the fields have not improved under the con-
 
 Figure 17. Case 5. J. S., aged 76. Simple glaucoma. Nov 12 
 1902. Rt. eye V=20/30+. T. n. Obj. lem. sq. 
 
 Figure 18. Case 5. Simple Glaucoma. Nov. 13. 1902. Left 
 eye V=20/30. T.+. Obj. 1 cm. sq.
 
 Figure 19. Case 5. Simple glaucoma. Dec. 1, 1902. Left eye 
 V=20/30. T.+. Obj. 1 cm. sq. 
 
 Figure 20, Case 5. Twelve days after sympathectomy. Simple 
 glaucoma. Dec. 18, 1902. Left eye V=20/20 2. T. n. Good ilium. 
 Obj. 1 cm. sq.
 
 GO 
 
 tinued use of a miotic, although the pupil was markedly con- 
 tracted, it was thought that sympathectomy offered as good a 
 chance of checking the glaucoma as iridectomy. The subject 
 was thoroughly discussed with the patient and his family, and 
 it was finally decided to try first the operation on the neck. 
 
 Dec. 6, 1902. Under chloroform narcosis the left superior 
 cervical sympathetic ganglion was excised by Dr. Schaefer in 
 the usual manner. The pupil, which for the last few days had 
 recovered from the influence of the miotic, contracted promptly 
 after the removal of the ganglion. There were no accidents 
 or difficulties accompanying the operation and the patient 
 recovered well from the anesthetic. He had complete 
 aphonia, and marked hoarseness continued for more than a 
 week. There was suffusion of the left eye and some conges- 
 tion of the conjunctiva, mucous membrane of the left side of 
 the nose and skin of left side of the face lasting for a couple 
 of days. Ptosis of the left side was also noted. The patient 
 was also confused mentally and at times had mild hallucina- 
 tions and did not remember where he was. This rather alarm- 
 ing symptom continued for about one week, and gradually dis- 
 appeared. There was tendei-ness about the angle of the jaw 
 and some pain in masticating. Tension remained normal with- 
 out miotic. Wound healed by first intention. 
 
 Dec. 18, 1902. Hoarseness has disappeared. Ptosis. Gen- 
 eral condition good. L. V. Avith glass=20/20 2. T. n. Field 
 not markedly changed except that it seemed slightly incrai-cii 
 in the upper nasal quadrant for white, and slightly decreased 
 for green in the lower temporal area (Fig. 20). 
 
 The patient went to his home in an adjoining state soon 
 after this date, with instructions to use pilocarpin regularly. 
 
 Jan. 21, 1903. Reported to me again on this date. Refrac- 
 tion has changed somewhat, for now he sees best with Sph.-f- 
 1.25 Cyl.+0.50, 180, which gives him L. V.=20/30. Pupil small. 
 Tension slightly plus. Field was taken in a poor light as com- 
 pared with the others, and shows more contraction, especially 
 for colors, and a notch appears in the upper temporal field 
 (Fig. 21). He still has some pain at corner of left jaw when 
 he eats. Slight ptosis. 
 
 CASE C^ Simple glaucoma, left. Absolute glaucoma, right. 
 Sympathectomy, left (improvement). 
 
 Margaret T., aged 78, entered the service of Dr. Beard in 
 Illinois Eye and Ear Infirmary Jan. 25, 1903, and was kindly 
 referred to me. Strong, well-preserved woman, who has 
 usually had good health, except that since childhood she has 
 had frequent attacks of sick headache, which continued up to 
 two years ago, when the sight of her right eye began to fail, 
 followed soon after by failing vision of the left. Early in the 
 course of the disease she noticed halos around a light. On 
 admission, R. V.=perception of light in temporal field. T.+.
 
 Figure 21, Case 5. Six weeks after sympathectomy. Simple 
 glaucoma. Jan. 21, 1903. Left eye V=20/30. T.+ ( ?) . Poor 
 ilium. Obj. 1 cm. sq. 
 
 Figure 22, Case 6. Margaret T., aged 78. Before sympathec- 
 tomy. Simple glaucoma. Jan. 30, 1903. Left eye V=8/200. 
 T.-K Obj. 1 cm. sq.
 
 A. c. of normal depth, pupil slightly dilated, spicules of 
 opacity in the periphery of the lens. Optic disc sharply 
 cupped, with atrophy and glaucomatous halo. L. V.=8/200 
 with Sph.+3.50, slight improvement. T.+. A. c. of normal 
 depth, pupil slightly dilated, faint spicules of opacity in 
 periphery of lens; well marked, but rather shallow excavation 
 of optic disc with halo. Eetinal veins somewhat engorged. 
 Disc rather pale. No pulsation of arteries or veins. Patient 
 is hyperopic and has been wearing Sph.+3.25 for distance. 
 She has marked arteriosclerosis, the superficial arteries being 
 very hard. Urinalysis shows specific gravity 1024 albumin 
 and no casts. The visual fields of the left eye (Fig. 22) are 
 markedly contracted, especially the color fields, and the nasal 
 side is almost obliterated. Fields of right eye could not be 
 charted. Under eserin and pilocarpin the tension was reduced 
 to nearly normal and the pupils contracted. 
 
 Feb. 14, 1903. Left pupil considerably dilated 5 mm. T.+. 
 
 Feb. 16, 1903. Excision of left superior cervical sympa- 
 thetic ganglion by Dr. A. E. Halstead under morphia and 
 chloroform narcosis. The operation was uneventful and im- 
 mediately after the removal of the ganglion the left pupil con- 
 tracted. 
 
 Feb. 17, 1903. T. n., slight ptosis left, pupil contracted. 
 Has headache and is hoarse. 
 
 Feb. 19, 1903. Pupil again somewhat dilated, but not so 
 much as before the operation. It was suspected that two days 
 before the operation some atropin had been put into the eye 
 accidentally by the use of an atropin dropper when the eserin 
 was being instilled and that this accounted for the sudden 
 mydriasis. Immediately after the operation the pupil con- 
 tracted for 24 hours, then dilated for a few days, and then 
 again contracted and remained so. Headache persists and 
 there is anesthesia of the left auricle. 
 
 Feb. 26, 1903. Ptosis of left. Pupil y 2 mm. smaller than 
 the right. T. n. L. V.=13/200. 
 
 March 10, 1903. L. V.=13/200 with Sph.+3.50=20/200. 
 T. n. Pupil remains smaller than right. Hoarseness and 
 headache have disappeared and sensation has returned to left 
 ear. 
 
 March 30, 1903. L. V.=18/200 with Sph.+ 3.50=207 120. 
 T. n. Tvight pupil 3% mm., left pupil 3 mm. Ptosis persists. 
 Fields improved (Fig. 23). 
 
 April 15, 1903. Left hospital with instructions to use pil- 
 ocarpin and to return at once if vision begins to fail. 
 
 June 1, 1903. Readmitted to hospital. L. V. with Sph. 
 +3.50=20/200. T. n. Left pupil smaller than right. Fields 
 about the same as in Figure 23. 
 
 CASE 7. Simple glaucoma, left; simple absolute glaucoma, 
 right. Left sympathectomy ( without benefit ) . Left iridec-
 
 v- 
 
 Figure 23, Case 6. Six weeks after sympathectomy. Simple 
 glaucoma. March 30, 1903. Left eye V=20/200. T. n. Obj. 
 1 cm. sq. 
 
 Figure 24, Case 7. Chas. D.. aged 57. Before sympatbectomy. 
 Simple glaucoma. Feb. 10, 1903. Left eye V=r20/40. T.+ Obj. 
 1 cm. sq.
 
 tomy, complicated with intraocular hemorrhage. Loss of 
 sight. 
 
 Chas. F. D., aged 57, was admitted to the Illinois Eye and 
 Ear Infirmary Feb. 10, 1903, where he was assigned to the 
 service of Dr. Chas. H. Beard, who kindly transferred him to 
 my service. Patient usually had good health and excellent 
 sight until two years before, when he first noticed that the 
 vision of the right eye was foggy at times, and he would see 
 halos around a light. The right vision continued to fail, but 
 he had no pain or inflammation in it. Three months before 
 his admission the same trouble began in his left eye, so that 
 
 Kl/K 
 
 Figure 25, Case 7. One month after sympathectomy. Simple 
 glaucoma. March 13, 1903. Left eye V=20/40. T.+l. Obj. 1 
 cm. sq. 
 
 he cd*uld no longer see well to do the fine work that his occu- 
 pation, that of bronze sculpture work, required. Three weeks 
 before entrance to the hospital he first noticed halos about a 
 light with the left eye. He states that he has had occasional 
 attacks of temporary blindness in both eyes, lasting a few 
 minutes. Urine normal. Arterial tension rather high. R. V. 
 perception of light. T.+. No fields. Media somewhat hazy. 
 Optic disc deeply cupped. L.V.=20/100 with Sph.+1.50= 
 20/40, pupil responsive to light and moderately dilated, a. c.
 
 Go 
 
 normal in depth. T.+- Glaucomatous excavation of optic 
 disc. Fields markedly. contracted, only a small temporal field 
 remaining (Fig. 24). 
 
 Feb. 16, 1903. Removal of left superior cervical sympathetic 
 ganglion under morphia-chloroform narcosis by Dr. A. E. 
 Halstead. The operation was somewhat difficult on account 
 of the patient's thick neck. The ganglion was very small, but 
 
 Figure 26. Section of ganglion from Case 4. Pigmented, 
 irregular cells with excentric nuclei. 
 
 was removed with about 3 cm. of the nerve. Spinal accessory 
 nerve was cut and was afterward united with catgut suture. 
 
 Feb. 17, 1903. Patient recovered well from the operation. 
 Pupil is contracted, ptosis marked. Partial anesthesia of left 
 side of face and neck. T.+ as before. 
 
 Feb. 26, 1903. L. upper lid droops about 2 mm. more than 
 5
 
 66 
 
 right. Right pupil 4 mm. L. pupil 2 1 X> mm. L. V. with 
 Sph.+ 1.50=20/40. T.+. Pain in left side of face and jaw, 
 slight hoarseness and some loss of power in left shoulder. 
 The hyperesthesia of the left side of the face about the jaw 
 and ear was intense, so that he could not bear the slightest 
 touch. Eserin was used regularly. 
 
 March 13, 1003. L. V. with Sph.+ 1.50=20/40. T.+l. 
 
 S?*ft4M 
 
 m 
 
 j 
 
 
 Figure 27. Section of ganglion from Case 5, showing marked 
 vascularity. 
 
 Ptosis and miosis persist. Hyperesthesia of the face gradu- 
 ally getting less. Fields much contracted, being reduced to a 
 narrow slit (Fig. 25). 
 
 March 17, 1903. Anterior sclerotomy. Slight reduction of 
 tension.
 
 March 21, 1903. Tension again as high as before. Under 
 cocain and holocain anesthesia an iridectomy Avas done up- 
 ward. Immediately after completing the corneal incision the 
 wound gaped widely and after a portion of the iris had been 
 excised vitreous began to present in the wound and the patient 
 complained of intolerable pain. After cutting off the portion 
 of extruding vitreous the lens was forced into the wound and 
 
 Figure 28. Section of ganglion from Case G, showing pigmenta- 
 tion of the cells and apparent increase of connective tissue. 
 
 had to be removed. Then followed more vitreous and a 
 copious hemorrhage, the patient all the time experiencing great 
 suffering. The bleeding was finally checked and the eye 
 bandaged. The patient was given an opiate and put to bed, 
 and immediately had a severe chill. 
 
 March 22, 1903. Patient was fairly well and not suffering 
 much. In the gaping corneal wound was seen a clot of blood
 
 and a tissue resembling iris or choroid. There was compara- 
 tively little reaction after the operation. The wound became 
 smooth by the separation of the protruding mass and the blood 
 in the anterior chamber was absorbed. At the present time, 
 April 20, 1903, the wound has healed. Eye sensitive to 
 touch. T. 2. V.=0. Sensitiveness of the side of the face 
 
 Figure 29. Section from ganglion of Case 7, showing irregularly 
 shaped, deeply pigmented cells. 
 
 has disappeared and the patient has completely regained the 
 power of the arm and shoulder. 
 
 The excised ganglia in the last four cases were pre- 
 pared by Dr. E. V. L. Brown, the pathologist of the 
 Illinois Eye and Ear Infirmary, and were examined by
 
 69 
 
 him and also by Dr. Sydney Kuh, professor of diseases 
 of the nervous system at the Post-Graduate Medical 
 School. To these gentlemen I am indebted for the notes 
 on the histologic appearances of the specimens. All the 
 specimens were hardened in 5 per cent, formalin and 
 corrosive acetic solution and stained with toluidin blue 
 and with hematoxylin and eosin. 
 
 In all of the specimens there was increased pigmenta- 
 tion of the ganglion cells. In Cases 4 and 5, mast cells 
 were seen. In Cases 4, 5 and 7 it was noted that the 
 cells were not round, but of irregular shapes (Figs. 
 26, 27, 29). 
 
 In one case, No. 6, cells slightly vacuolated were ob- 
 served. In two cases, Nos. 4 and 5, it was noted that the 
 cells showed excentric nuclei, and in the same cases 
 marked vascularity was present (Figs. 26-27.) Some of 
 these features, especially the pigmentation and the vascu- 
 larity, are shown in the accompanying photomicro- 
 graphs. None of the specimens shows conspicuous in- 
 crease of connective tissue, as has been noted by some 
 other observers, although Figure 28 at the place where 
 the picture was taken apparently shows it. The his- 
 tologic examination lacks completeness, as, unfortun- 
 ately, there was not available for control study normal 
 ganglia from individuals of the same age as the pa- 
 tients. As the pigment in the ganglion cells is normally 
 increased in advancing age, it can not be said that these 
 present an abnormality. 
 
 REPORT OF 61 ADDITIONAL OPERATIONS OF EXCISION OF 
 
 SUPERIOR CERVICAL SYMPATHETIC GANGLION 
 
 FOR GLAUCOMA. 
 
 JAMES MOORES BALL. THREE CASES 1 OF GLAUCOMA. FOUR 
 OPERATIONS. 
 
 No. 8. Glaucoma absolutum rt. Rt. sympathectomy. Im- 
 provement. 
 
 Man, aged 36. R. V.=P.l. L. V.=20/70. Pain in right eye 
 for two months. Chronic irritative glaucoma. Optic disc 
 cupped. T.+3. 
 
 Operation. May 15, 1899. Excision rt. sup. cerv. sympth. 
 ganglion. Tension fell to +1, ptosis. Vision increased to 
 fingers at 3 ft. Report April 4, 1903, pain was relieved for 
 one year. T. +1. 
 
 1. X. Y. Med. .Jour.. 1890.
 
 70 
 
 Nos. 9 AND 10. Simple glaucoma. Both. Bilateral sym- 
 pathectomy, slight improvement. 
 
 Woman, aged 43. R.V.=0. T.+3. L. V.=P.l. T.+3. Dur- 
 ation, two years. No pain. Optic disc cupped. No fields 
 taken. 
 
 Operation. Left sympathectomy, June 15, 1899. Lachryma- 
 tion, Ocular congestion and contracted pupil of same side fol- 
 lowed. Ptosis. Eighth day counted fingers 4 ft. June 30, 
 loth day, F. 5 ft. in temporal field. T. n. 
 
 Operation. July 16, 1899. Right sympathectomy. Four days 
 later, R. V. hand movements. L. V.=F. 7 ft. R. T. +1. 
 L. T. +1. Report April 4, 1903. Patient became blind in 
 November, 1899, from an acute attack of glaucoma, left. 
 
 No. 11. Hemorrhagic glaucoma. Sympathectomy. Tem- 
 porary improvement. Report of author April 4, 1903, that he 
 once removed the sup. cervical sympathetic ganglion in a man 
 26 years old for relief of pain in hemorrhagic glaucoma. Re- 
 lief of pain was immediate and lasted ten months. One year 
 after operation the man had his eye removed. No further de- 
 tails were given. 
 
 MELVILLE BLACK. ONE CASE. SUBACUTE GLAUCOMA. 1 
 
 No. 12. Sympathectomy. Cure. First reported October, 
 1901, Ophth. Rec. M., aged 35. Colored. Left eye. Duration 
 -2 mos. R. V.=5/5. L. V.=F. 1 ft. after eserin =5/20. Left 
 cornea steamy and no view of fundus obtainable. After 
 eserin pupil was so small that fundus could not be seen. Left 
 T.+2, pupil dilated. Fields normal after eserin. 
 
 Operation. Dec. 24, 1900. Excision of left superior and 
 middle cervical sympathetic ganglia, followed by immediate 
 return to normal vision, normal tension, contracted pupil 1% 
 mm. and normal fields. Ptosis, congestion of conjunctiva, in- 
 creased lacrymation were noted. 
 
 Report April 7, 1903. L. V.=5/6 with Sph.+ l.OO. R. 
 pupil 4 mm. L. pupil 3 mm. T. n. Fields normal. No symp- 
 toms of return of glaucoma nor any other symptoms of incon- 
 venience. Ptosis scarcely noticeable and the conjunctival in- 
 jection had disappeared. Slightly myopic before operation. 
 Now hyperopic 1 D. No complications or accidents attending 
 operation. 
 
 CALLAN. ONE CASE. BUPHTHALMUS. SECONDABY GLAUCOMA. 
 
 No. 13. Sympathectomy. No improvement. M., aged 25 
 years. Highly myopic. R. V. with Sph. 20 Cyl. 1.00, 
 105=20/200. L. V. with Sph. 22.00=20/200. History of 
 gradually failing sight. Nystagmus. Tension plus 1 in each. 
 Marked excavation of optic discs. 
 
 Operation. May 26, 1902. Excision of rt. sup. cerv. sym- 
 
 2. Ophthalmic Record, October, 1901.
 
 71 
 
 pathetic ganglion. After op. R. E. T. 1. L. E. T.+l. Both 
 pupils contracted. No ptosis, congestion of face or other 
 phenomena. Xo accidents or complications. 
 
 Report March 27, 1903 (by letter). "Tension at present 
 time + 1. The only improvement is that the operated eye is 
 not so prominent and possibly the nystagmus not so marked. 
 Tension, pupil and vision remain the same as before the opera- 
 tion. The cosmetic effect is an improvement." 
 
 D. II. COOVER. ONE CASE. 3 
 
 Xo. 14. Simple glaucoma. Both. Rt. sympathectomy; 
 temporary improvement. 
 
 M., aged 65 years. Failing vision for one year. R. V.=P.l 
 in temporal field. T. +3. Optic disc cupped. L. V.=20/200. 
 T.+2. Disc cupped. Fields contracted. Miotics useless. 
 
 Operation. March 31, 1900. Excision of right sup. cerv. 
 sympath. ganglion. A few days later tension somewhat lower. 
 R. V.=5 ft. Four months later R. V. again reduced to P.I. 
 T. +3. L. V. had fallen from 20/200 to 5/200. 
 
 COLEMAN W. CUTLER. ONE CASE. RIGHT CHRONIC IRRITATIVE 
 GLAUCOMA. LEFT, ABSOLUTE GLAUCOMA. RIGHT, SYMPA- 
 THECTOMY, GREAT IMPROVEMENT. PREVIOUS IRIDECTOMY. 4 
 
 Xo. 15. M., aged 56. Duration of disease 8 years. History 
 of attacks of pain, cloudy vision, halos and failing sight. 
 Sclerotomy in 1897. Iridectomy in right in 1898. June 2, 1901, 
 R. E. F. 3 ft. T. +V 2 to 1. L. E. V. 0. T. +2. After eserin 
 R. V .=20/200+. Pain in both eyes. Fields contracted. 
 
 Operation. June 10, 1901. Excision of rt. sup. cerv. 
 sympath. ganglion. One day after T. %. V.=20/30. Slight 
 ptosis, some dysphagia, pain in right side of head and face 
 and impaired phonation. Improvement continued. Fields in- 
 creased. May, 1902, one year after, R. V.=20/30. Fields in- 
 creased. Xo signs of nerve lesions except some paresthesia 
 of side of face and neck and occasional sharp pain in temporo- 
 maxillary articulation. 
 
 Last report, March 27, 1903, by letter. Cutler has not seen 
 patient since Aug. 25, 1902, but thinks if results had not been 
 favorable he would have called. 
 
 W. A. FISHER. ONE CASE. CHRONIC GLAUCOMA. RIGHT SYM- 
 PATHECTOMY. NO IMPROVEMENT. 
 
 Xo. 16. F., aged 62. Both eyes affected for two years. 
 R. V.=12/200. T. n. Pupil somewhat dilated. Excavation 
 of optic disc. Fields contracted. 
 
 Operation. June 8, 1899. Excision of rt. sup. cerv. sympath. 
 ganglion. Xo accidents or complications. Operation negative 
 
 3. Phila. Med. Jour., March 16, 1900. 
 
 4. Annals of Surgery. Phila.. September. 1902.
 
 72 
 
 as to effect on lid, conjunctiva, tears, respiratory passages 
 and skin of face. Negative as to effect on vision. Last report 
 April 4, 1900, ten months after operation, R. V.=4/200. L. V. 
 =0. No effect on pupil or vision. Fields unchanged. 
 
 HENRY CRADLE. ONE CASE. CHRONIC GLAUCOMA. PREVIOUS 
 IRIDECTOMY. SYMPATHECTOMY. (STATIONARY). 
 
 No. 17. F., aged 33 years. Both eyes affected, left for a 
 period of three years. Both optic discs cupped. R. V.= 
 20/40+. Fields normal on temporal side, contracted above 
 10, down 10, inward 15. Pupil moderately dilated on ac- 
 count of large coloboma. T. +. Two iridectomies had been 
 done, one 30 months, the other 15 months before, both having 
 apparently delayed the course of the disease, but not stopping 
 it entirely. L. V.=0. No report of this eye. 
 
 Operation. March 13, 1900. Excision of sup. cerv. sympth. 
 ganglion of rt. side. No accidents or complications. After 
 operation T. and is normal after two and a half years. 
 Pupil distinctly contracted for two or three months, and two 
 and a half years after operation it is as it was before. Cen- 
 tral vision unchanged, 20/40+. Doubtful enlargement of 
 fields at first, but practically stationary during two and a 
 half .years. After operation there was ptosis, slight conges- 
 tion of conjunctiva and skin of face. These all receded in a 
 few months. 
 
 E. GBUENING. TWO CASES. ONE CHRONIC GLAUCOMA (BOTH). 
 ONE OPTIC ATROPHY (BOTH). CASE 1, PREVIOUS IRIDEC- 
 TOMY. SYMPATHECTOMY. SLIGHT IMPROVEMENT. 5 
 
 No. 18. M., aged 60 years. Both eyes affected with 
 chronic glaucoma for three years. R. V.=F. in upper tem- 
 poral quadrant at 2 ft. T. +1. Field in upper temporal 
 quadrant. Disc deeply cupped. Coloboma from previous iri- 
 dectomy. L. V.=0. T.+l. Disc deeply cupped. 
 
 Operation. In 1901. Removal of rt. sup. cerv. sympath. 
 ganglion. There was no change in pupil. T. n. and remained 
 so for one year after operation. Patient retained same central 
 and peripheral vision at time of last report, one year after 
 operation. Ptosis. Paralysis of recurrent laryngeal causing 
 dysphonia that lasted nine months and then disappeared. 
 
 No. Isfc X/eft sympathectomy. No improvement. 
 
 M., aged 35. Atrophy of both optic discs of two years' stand- 
 ing. Both optic discs white. R. V.=0. L. V.=20/30. Fields 
 of left contracted to 10 in every direction. Tension normal 
 in each. 
 
 Operation. 1902. Removal of left sup. cerv. sympath. 
 ganglion. As a result of the operation there was some sinking 
 of the eyeball, and also paralysis of left recurrent laryngeal 
 
 5. Ophth. Sec. N. Y. Academy of Medicine. November, 1901.
 
 73 
 
 nerve. Dysphonia lasted about six months, although the 
 paralysis of the recurrent laryngeal persisted. Tension ro 
 mained normal. Left vision was completely lost two months 
 after the operation. 
 
 A. B. HALE. ONE CASE. THREATENED GLAUCOMA, LEFT. ABSO- 
 LUTE GLAUCOMA, RIGHT. LEFT SYMPATHECTOMY. 
 
 No. 20. F., aged 48. Total loss of vision of right eye 
 after two iridectomies had been done. R. V.=0. T.+. Deep 
 excavation of optic disc. L. V. with Sph.+ 1.00=6/5. T.+ ( ? ; 
 Optic disc normal. Pupil normal. Fields contracted and 
 wavering. 
 
 Operation. Dec. 15, 1902. Excision of left sup. cerv. 
 sympath. ganglion. After operation L. V. with Sph.+ 1.00= 
 6/5. T. . Pupil small. No effect on lid, conjunctiva, lachry- 
 mation, skin. Loss of sensation on lower half of ear. Last 
 report March 1, 1903. Condition as above. Fields normal. 
 T. n. Operation was done to ward off an impending attack 
 of glaucoma. This operation was preferred because the right 
 eye had been lost after two iridectomies. 
 
 J. G. HUIZINGA. TWO CASES. 1, CHRONIC SIMPLE GLAUCOMA, 
 BOTH EYES. DOUBLE SYMPATHECTOMY. NO IMPROVE- 
 MENT. 2, CHRONIC INFLAMMATORY GLAUCOMA, 
 BOTH EYES. LEFT SYMPATHECTOMY. 
 NO IMPROVEMENT. 
 
 Nos. 21 AND 22. M., aged 57. Both eyes affected for 17 
 years. R. V.=P.l. T.+l. Fields greatly contracted. L. V. 
 6/20. T. n. Field for white contracted, being almost oblit- 
 erated on the nasal side; 65 temporal side, 10 above, 40 
 below. Color fields about 10. 
 
 Operation. Oct. 14, 1898. Excision of both sup. cerv. 
 sympath, ganglia. Immediate effects, conjunctiva injected, 
 slight increase of lachrymation. Inspiration difficult from 
 slight edema of glottis. Patient quite hoarse for several weeks, 
 but fully recovered. No material change in vision of either 
 eye. T. n. and remaining so one year afterward. Pupils that 
 were about 4 mm. before operation contracted slightly after- 
 ward, and then returned to the usual size. One year after- 
 ward there was no change. 
 
 No. 23. M., aged 36. Chronic inflammatory glaucoma of 
 both eyes of several years' duration, with recurring attacks. 
 R. V.=F. 3 ft. T.+3. Pupil widely dilated because of atropin 
 used by patient's physician. Fields could not be taken. Optic 
 discs could not be clearly seen. L. V.=F. 3 ft. T. 3. Pupil 
 same as right. Fields could not be taken. Disc could not be 
 seen. 
 
 Operation. January, 1902. Excision of left sup. cerv. 
 ganglion and at the same time iridectomy on each eye. Re- 
 sult: Vision became worse and worse, until there was com-
 
 74 
 
 plete blindness. Considerable lachrymation for several weeks 
 after operation. One year after, R. V. T.+l. L. T.+2. No 
 accidents or complications from the sympathectomy. 
 
 ARNOLD KNAPP. ONE CASE. CHRONIC GLAUCOMA WITH ATROPHY, 
 
 BOTH EYES. BILATERAL SYMPATHECTOMY AFTER 
 
 RIGHT IRIDECTOMY. 
 
 Xos. 24 AND 25. M., aged 20. No history as to duration. 
 R. V.=16/200 after successful iridectomy. Optic disc deeply 
 cupped and atrophic. L. V.=12/200. T.+2. Disc cupped and 
 atrophic. Fields contracted to 10 of center. 
 
 Operation. June 10, 1902. Excision of both sup. cerv. sympath. 
 ganglia. Slight drooping of both upper lids followed. Hoarse- 
 ness that lasted several weeks. V. improved to 20/200 each. 
 R. T. n. L.,T.+ (?). Fields did not change. 
 
 Last report March 18, 1903, ten months after operation. 
 R. V 20/200. T. n. L. V.=12/200. T.+. Fields same as 
 before. 
 
 HARRY LAMOTTE. FOUR CASES. ACUTE INFLAM. GLAUCOMA 
 ( BOTH ) . IRIDECTOMY, RIGHT, RECOVERY. SYM- 
 PATHECTOMY, LEFT, RECOVERY. 6 
 
 No. 2G. M., aged 27. Duration of disease three months. 
 Acute attacks of glaucoma relieved by eserin. Cupping of 
 discs. R. Y.=F. 6 ft. Iridectomy. Vision improved in six 
 weeks to 20/50. L. V.=P.l. T.+L Field not taken. 
 
 Operation. March 25, 1901. Excision of left sup. serv. 
 sympath. ganglion and connections. Ptosis, increased lachry- 
 mation and injection of conjunctiva followed. Pupil before 
 operation was dilated. After operation it contracted. T. 
 became normal. 
 
 Last report July 10, 1902. R. V.=20/40. T. n. Field some- 
 what contracted. Pupil contracted. L. V.=20/20. T. n. 
 Field normal. Pupil normal. 
 
 CHRONIC INFLAM. GLAUCOMA' (BOTH). DOUBLE SYMPATHEC- 
 TOMY. RECOVERY. 
 
 Nos. 27 AND 28. F., aged 38. Duration of two and a half 
 years during which time she had occasional attacks of severe 
 pain, increased tension, impaired vision. In the intervals be- 
 tween attacks vision approached nearly to normal. R. V.= 
 20/30. L. V .=20/40. Slight cupping of optic discs. Visual 
 fields were not taken. 
 
 Operation. May 1, 1901. Excision of left sup. cerv. sympath. 
 ganglion. Pupil contracted afterward and has remained so. 
 Slight ptosis occurred, but no other manifestation except an- 
 
 6. Ophthalmic Record, Chicago, October. 1902 ; Denver Medical 
 Times. March. 1903.
 
 esthe-jia of side of face and neck, which disappeared after 
 several months. L. V. before operation 20/200. Vision re- 
 turned to 20/20. T. n. 
 
 Operation. July 9, 1901. Excision of rt. sup. cerv. sympath. 
 ganglion. For about one week before R. V. had been much re- 
 duced and there was considerable pain. R. V.=P.l. T.+l. 
 Optic disc cupped. After operation vision soon returned to 
 normal. T. n. Slight ptosis, increased lachrymation, pupil 
 contracted, pain and discomfort disappeared. 
 
 Last report Sept. 1, 1902. R. V 20/20. T. n. Some con- 
 traction of fields. L. V.=20/20. T. n. Contraction of fields 
 to 40 2 . 
 
 SIMPLE GLAUCOMA, RIGHT. BIGHT SYMPATHECTOMY. IMPROVE- 
 MENT. 
 
 Xo. 29. M., aged 43. Duration of disease six months. 
 Had been treated by some quack doctor who had been giving 
 atropin for iritis. L. V.=20/20. Eye normal. R. V.=F. 3 ft. 
 T.+2. Pupil dilated. Visual fields could not be taken. 
 
 Operation. Jan. 24, 1902. Excision of rt. sup. cerv. sympath. 
 ganglion. Xo unfavorable signs. Xo ptosis, conjunctiva in- 
 jected, lachrymation increased. T. remained +2, pupil con- 
 tracted. Central vision improved. 
 
 Last report March 23, 1903, fourteen months after. R. V. 
 =20/70. T.+l. Pupil contracted. Fields concentrically con- 
 tracted. Degree not given. 
 
 SIMPLE GLAUCOMA, RIGHT. RIGHT SYMPATHECTOMY. DEATH 
 FROM SEPSIS. 
 
 Xo. 30. M., aged 40, large, healthy soldier. History of 
 impairment of vision of right eye for one year. R. V.=20/30. 
 T.+l. Pupil dilated, concentric contraction of fields, slight 
 excavation of right disc. L. V.=20/20. T. n. Pupil normal, 
 slight contraction of fields. 
 
 Operation. Feb. 17, 1903. Excision of rt. sup. cerv. sympath. 
 ganglion. Patient took ether badly and chloroform was substi- 
 tuted. Just before the nerve was excised he vomited suddenly 
 and expulsively and some of the vomit fell into the wound. This 
 was cleansed with the utmost care, but in spite of all precau- 
 tion infection extended to the deep structures of the neck, 
 and he died of septic pneumonia on the fifteenth day after the 
 operation. After operation T.+l. Pupil contracted. Slight 
 aphonia, increased lachrymation and injection of conjunctiva. 
 Fields were not taken. 
 
 JOSEPH MULLEN. ONE CASE. CHRONIC 1NFLAM. GLAUCOMA 
 (BOTH). PREVIOUS IRIDECTOMY. RT. SYMPATHEC- 
 TOMY. TEMPORARY IMPROVEMENT. 7 
 
 Xo. 31. F., aged 48. History of bilateral iridectomy 23 
 years previously for acute glaucoma. Gradual decrease in 
 
 7. Amer. Med., June, 1901.
 
 7G 
 
 vision since that time with occasional acute pains in eyes aud 
 head. Severe attack at the time she was first seen by the 
 operator. R. V.=F. 5 ft. T.+2. L. V.==5/200. T.+2. 'Both 
 optic discs cupped. Right field irregularly contracted to 20 
 above, 30 temporal, 20 nasal, 15 below. Left field concen- 
 trically contracted to about 30. 
 
 Operation. March 18, 1900. Excision of right sup. cerv. 
 sympath. ganglion. Increased lachrymation. Congestion of 
 conjunctiva and face. Coloboma prevented accurate state- 
 ment as to pupils. Tension in both eyes normal. Pain was 
 relieved. Fields in both eyes were increased by as much as 10 
 to 20 degrees all around, the improvement being more marked 
 in the right. Central vision improved. Degree not stated. 
 Three months after operation improvement was lost and in- 
 creased tension and pain returned. 
 
 Nine months later R. V.=15/20. L. V.=20/200. Chart* 
 showed decrease of fields nearly to same degree as before 
 operation, with left field very irregular. Last report April 
 8, 1903. R. V.=20/100. Field as before operation. L. V. 
 =20/70. Field larger than it was Dec. 18, 1900. 
 
 W. B. MARPLE. ONE CASE. CHRONIC GLAUCOMA. SYMPATHEC- 
 TOMY. NO IMPROVEMENT. 8 
 
 No. 32. Patient who had ribbon-shaped keratitis. V.= 
 10-15/200. T.+l. Pupil partly dilated. 
 
 Operation. August, 1902. Excision of sup. cerv. sympath. 
 ganglion. After operation T. became normal and pupil dimin- 
 ished in size. Vision unchanged. Patient has been under ob- 
 servation six months. 
 
 H. R. PRICE. TWO CASES. SIMPLE CHRONIC GLAUCOMA (BOTH) 
 WITH IIEMORRHAGIC RETINITIS AND CHRONIC NEPHRITIS. 
 RIGHT SYMPATHECTOMY. IMPROVEMENT. 
 
 No. 33. M., aged 70. Duration of disease one year. 
 R. V.=P.l. Improved under eserin to 20/200. Pupil dilated. 
 Tension variable from T. n. to T.+3. Fields contracted, espe- 
 cially on nasal side. Numerous hemorrhages in the macular 
 region. Deep excavation of disc. L. V.=20/100. T. n. Pupil 
 normal. Hemorrhages as in the right, typical glaucoma cup- 
 ping. Before operation R. V. =P.l. 
 
 Operation. May 26, 1902. Excision of right sup. cerv. 
 sympath. ganglion. Pupil contracted, slight hyperemia of 
 conjunctiva and skin of face same side, increased lachryma- 
 tion slight, and slight ptosis. Seven days after operation R. V. 
 =20/200 with Sph. 1D.=20/100. Field considerably en- 
 larged. 
 
 Last report Oct. 3, 1902. Five months after operation 
 
 8. N. Y. Medical Record, May 10, 1902.
 
 77 
 
 R. V .=20/100. T. n., pupil contracted. Patient not seen later. 
 Result considered favorable in view of the hemorrhagic condi- 
 tion. 
 
 SIMPLE GLAUCOMA. EIGHT SYMPATHECTOMY. HISTORY INCOM- 
 PLETE. PREVIOUS IRIDECTOMY MARCH, 1902. 
 
 Xo. 34. M., aged 55. Duration of disease one year. Had 
 iridectomy done March, 1902. V. B.=20/40, declining to 
 20/70 with rapid loss of field. Persistent plus tension. Deep 
 glaucoma cupping. 
 
 Operation. Aug. 1, 1902. Excision of right sup. cerv. 
 sympath. ganglion. Tension became minus and ptosis, hyper- 
 emia of conjunctiva and face were noticed, as well as slightly 
 increased lachrymation. Xo other phenomena and no acci- 
 dents. Patient left hospital 15 days after operation and 
 subsequent history was not obtained. 
 
 R. C. REESE. ONE CASE. CHROMIC SIMPLE GLAUCOMA (BOTH). 
 IRIDECTOMY FIVE YEARS BEFORE. RIGHT SYMPATHEC- 
 TOMY. IMPROVEMENT. 
 
 Xo. 35. F., aged 58. Duration of disease six years. 
 R. V.=F. 10 ft., not. improved with lens. T.+. Pupil shows 
 coloboma. Fields contracted considerably at nasal side. Deep 
 glaucoma cupping of disc. L. V.=0. Pupil and disc as in rt. 
 Double iridectomy had been done five years before, and ever 
 since that time she had used eserin occasionally to keep the 
 tension down. 
 
 Operation. May 28, 1902. Excision of rt. sup. cerv. 
 sympath. ganglion. T. . No increase of central vision. 
 Slight ptosis and neuralgic pains in the left side of face and 
 neck that lasted for two months. 
 
 Last report April 20, 1903, nearly one year after operation. 
 R. V.:=F. 10 ft. Fields unchanged. T. . Does not have to 
 use a miotic. 
 
 E. C. RENAUD. SIX CASES (FIVE BILATERAL). CHRONIC IRRI- 
 TATIVE GLAUCOMA, RIGHT. RIGHT SYMPATHEC- 
 TOMY. IMPROVEMENT. 
 
 Xo. 36. F., aged 48. Duration ten months. R. V.=: 
 20/200. T.+3. Pupil dilated and immovable. Media hazy, 
 disc cupped. Fields not taken. L. V.=20/20. T. n. Pupil 
 and fundus normal. Attacks of pain in right eye. 
 
 Operation. Xov. 29, 1899. Excision of rt. sup. cerv. 
 sympath. ganglion. Ptosis of rt. lasted 18 days. Hyperemia 
 of conjunctiva and lachrymation lasted three days. No acci- 
 dents or complications. R..V. improved to 20/50 and pupil 
 contracted. T. n., later became slightly plus. Pain disap- 
 peared within 24 hours. 
 
 9. St. Louis Med. Review, Feb. 1, 1902.
 
 78 
 
 Last report April, 1903. R. V.=20/50. L. V. 20/20. Xo 
 ptosis. Good condition continues. 
 
 CHRONIC SIMPLE GLAUCOMA, BOTH. BILATERAL SYMPATHECTOMY. 
 SLIGHT IMPROVEMENT. 
 
 Nos. 37 AND 38. M., aged 52. Double simple glaucoma. 
 Duration 18 months. R. V. quantitative. L. V.=Lai'ge ob- 
 jects at 6 ft. In both eyes T.+2. Pupils dilated, discs mark- 
 edly cupped. Fields not taken. 
 
 Operation. March 11, 1901. Bilateral excision of sup. 
 cerv. ganglia. Ptosis lasting two weeks. Hyperernia of con- 
 junctiva and some lachrymation for several days. Pupils 
 contracted. T.+l. Vision improved to 6/100 in each. 
 
 Last report two years after operation shows that improve- 
 ment has been retained, although tension is still plus. 
 
 CHRONIC SIMPLE GLAUCOMA, LEFT. BILATERAL SYMPATHECTOMY. 
 SLIGHT IMPROVEMENT. 
 
 Nos. 39 AND 40. F., aged 40. Simple glaucoma of left 
 eye of 7 months' duration. R. V.=20/20. T. n. Normal in 
 every way. L. V.=F. 3 ft. T.+3. Pupil dilated and fixed. 
 Disc markedly cupped. Fields not taken. 
 
 Operation. Sept. 9, 1901. Bilateral excision of sup. cerv. 
 sympath. ganglia. Bilateral ptosis for 16 days. Hypereinia 
 of conjunctiva and increased lachrymation for 3 days. Hys- 
 terical manifestations. T. n., pupils contracted and L. V.=F. 
 14 ft. No fields. 
 
 Last report April, 1903. Same condition. 
 
 CHRONIC IRRITATIVE GLAUCOMA, RIGHT. BILATERAL SYMPATHEU- 
 TOMY. IMPROVEMENT. 
 
 Nos. 41 AND 42. M., aged 39. Duration of disease in viulit 
 eye 15 months. Attacks of pain at times. R. V.=P.l. T.-j-2. 
 Pupil dilated, media hazy, disc sharply cupped. L. V .=20/20. 
 T. n. Media and fundus normal. Eye normal in every way. 
 No fields were taken. 
 
 Operation. Feb. 12, 1902. Bilateral excision of sup. cerv. 
 sympath. ganglia. Bilateral ptosis for 2 weeks. Some injec- 
 tion of conjunctiva and increased lachrymation for several 
 days. P,ain relieved. R. V.=F. 12 ft. T. n., pupil contracted. 
 
 April, 1903. Last report. Same improved condition. 
 
 ACUTE GLAUCOMA, RIGHT. BILATERAL SYMPATHECTOMY. IM- 
 PROVEMENT. 
 
 Nos. 43 AND 44. M., aged 57., History of acute glaucoma 
 in right eye for 3 weeks. Severe 'pain. R. V.=20/100. T.+3. 
 Pupil dilated and fixed. Very slight cupping of disc. L. V. 
 20/20. Eye in every way normal. No fields taken. 
 
 Operation. June 22, 1902. Bilateral excision of sup. cerv.
 
 79 
 
 sympath. ganglia. Pain in eye disappeared. Ptosis, bilateral, 
 for 13 days. Conjuuctival hyperemia and lachryraation. Pupil 
 contracted. R. V.=20/40. 
 
 In April, 1903, at time of last report, no return of the 
 trouble. 
 
 CHRONIC IRRITATIVE GLAUCOMA, RIGHT. BILATERAL SYMPATHEC- 
 TOMY. SLIGHT IMPROVEMENT. 
 
 Xos. 45 AND 46. M., aged 46. Duration 11 months. His- 
 tory of attacks of pain in right eye. R. V .=20, 200. T.+2. 
 Pupil dilated. Disc cupped. L. V.=20/20. Eye normal in 
 every way. No fields taken. 
 
 Operation. Nov. 16, 1902. Bilateral excision of sup. cerv. 
 sympath. ganglia. Ptosis for 12 days, pronounced hyper- 
 en:ia of conjunctiva and moderate increase of lachrymation. 
 Pupils contracted and tension in rt. eye reduced. R. V.= 
 20/100. L. Y.=20/20. 
 
 Favorable result continues at time of last report, April, 
 1003. 
 
 No recurrence in any of these cases up to date of report, 
 April, 1903. In the irritative cases the pain was relieved in 
 every instance. Xo difference was noted in the anterior cham- 
 ber in any case. In the last four cases the ganglion was torn 
 from its attachment with a strong forceps instead of being cut. 
 
 G. E. DE SCHWEINITZ. ONE CASE. CHRONIC CONGESTIVE GLAU- 
 COMA, BOTH. BILATERAL SYMPATHECTOMY. UN- 
 CERTAIN RESULTS. 
 
 Xos. 47 AND 48. M., aged 23. Duration 7 months. R. V. 
 =shadows on temporal side. T.+2. Pupil dilated 5 to 6 mm. 
 Light field on temporal side only. L. V.=shadows imperfectly. 
 T.+2. Pupil dilated 8 mm. Fields contracted so that there 
 was only light perception on temporal side. Green, atrophic, 
 completely cupped discs on each side with typical halo. 
 
 Operation. Dec. 14, 1901. Excision of rt. sup. cerv. 
 sympath. ganglion and a considerable piece of the nerve. 
 Slight ptosis followed and congestion of conjunctiva. T. 
 slightly diminished. Pupil contracted 3 mm., but this lasted 
 only 3 days. R. V.=uncertain counting of fingers in temporal 
 field. 
 
 Operation. Jan. 31, 1902. Excision of left ganglion. Xo 
 improvement in vision. Xo change in tension, pupil or field. 
 After first operation decided dysphagia lasting 48 hours. Pa- 
 tient remained free from congestive attacks of glaucoma for 
 two months, then they returned. 
 
 JOHN R. SHANNON. ONE CASE. CHRONIC SIMPLE GLAUCOMA, 
 BOTH. LEFT SYMPATHECTOMT. NO IMPROVEMENT. 
 
 No. 49. F., aged 32. Disease existed for 10 years in 
 both eyes. R. V .=15/200. T. (?). Pupil large, irregular.
 
 80 
 
 a. c. deep. No peripheral vision except in lower temporal 
 quadrant. L. V.=hand movements centrally, F. 3 ft. ex- 
 centrically. T.+l. Coloboma from iridectomy upwards. 
 Both discs slightly cupped. 
 
 Operation. June 18, 1902. Excision of left sup. cerv. 
 sympath. ganglion. No change in pupil and tension remained 
 increased as before. Slight ptosis. 
 
 Fields remained the same April 14, 1903. 
 
 J. H. SHORTER. ONE CASE. SECONDARY GLAUCOMA AFTER SYM- 
 PATHETIC INFLAMMATION. LEFT SYMPATHECTOMY. 
 SLIGHT IMPROVEMENT. 10 
 
 No. 50. M., aged 20. Lost right eye from trauma. Glau- 
 coma in left eye for six years following sympathetic oph- 
 thalmia. L. V.=F. 3 ft. T.+2. Pupil fixed from posterior 
 synechise. Disc not visible on account of central cataract. 
 Large defect on nasal side of field. 
 
 Operation. 1901. Excision of left sup. cerv. sympath. 
 ganglion. After operation profuse lachrymation and mucous 
 discharge from left nostril. Conjunctiva and skin of face were 
 injected. Left ptosis. L. V.=F. 6 ft. T. n. one month after 
 operation. 
 
 Final examination showed less contraction of visual fields. 
 Anesthesia of left auricle. Transitory hoarseness. 
 
 ELMER G. STARR. ONE CASE. SIMPLE GLAUCOMA, BOTH. POS- 
 TERIOR SCLEROTOMY. BILATERAL SYMPATHECTOMY. 
 MARKED IMPROVEMENT. 
 
 Nos. 51 AND 52. F., aged 63. Duration one year. Dis- 
 ease had been held in check for nine months with eserin, until 
 by mistake patient used atropin, which caused reduction of 
 vision to F. 4 ft. and increase of tension to +3. Sclerotomy 
 of right eye increased vision to F. 18 ft. Marked cupping of 
 both discs with some atrophy. Immediately before sympathec- 
 tomy R. V.=F. 18 ft. T.+2. Pupil moderately dilated. 
 L. V.=F. 4 ft. T. n. Pupil moderately dilated. Fields of 
 both eyes typically contracted. 
 
 Operation. Oct. 16 3 1902. Bilateral excision of sup. cerv. 
 sympath. ganglia. Result on lid, conjunctiva, etc., nil. R. V. 
 =20/50. T.+ l. Pupil normal. L. V.=20/50. T. n. Pupil 
 normal. 
 
 Last report April 15, 1903, states that above condition per- 
 sists, but that visual fields have decreased somewhat. For 
 two or three weeks after operation inability to raise the arms. 
 This disappeared. Painful sensation at times in the neck. 
 
 10. Medical News, April 6, 1901.
 
 81 
 
 GEO. F. SURER. FOUR CASES. FIVE OPERATIONS. SIMPLE 
 
 CHRONIC GLAUCOMA. BOTH. ABSOLUTE GLAUCOMA, RIGHT. 
 
 RIGHT SYMPATHECTOMY. NO IMPROVEMENT. 11 
 
 No. 53. M., aged 70. Duration about two years. R. V. 
 =0. T.+3. Pupil dilated, a. c. shallow. Fields could not be 
 taken. L. V.=20/200. T. n. Nasal field contracted. Optic 
 discs in both cupped. Iridectomy on left eye in 1898. 
 
 Operation. August, 1899. Excision rt. sup. cerv. sympath. 
 ganglion. Hyperemia of conjunctiva, flushing of side of face 
 and increased lachrymation. No other accidents. Pupil con- 
 tracted and remained so for three years. No change in fields, 
 tension or vision. 
 
 Last observation June, 1902. 
 
 SIMPLE CHRONIC GLAUCOMA, BOTH. BILATERAL SYMPATHECTOMY. 
 NO IMPROVEMENT. 
 
 No. 54 AND 55. M., aged 65. Duration between one and 
 two years. R. V.=F. 8 ft. T.+2. Pupil dilated and a. c. 
 rather deep. Pupil concentrically contracted. Glaucoma cup- 
 ping of disc. L. V.=F. 10 ft. T.+. Pupil and fields as above. 
 Disc not distinctly seen on account of cataractous lens. 
 
 Operation. November, 1899. Bilateral excision of sup. cerv. 
 sympath. ganglion. Hyperemia of conjunctiva followed. 
 Pupils contracted and central vision improved slightly. Fields 
 enlarged somewhat and then contracted to less than before the 
 operation. 
 
 Last observation April, 1903. Sees enough to get about. 
 
 CHRONIC INFLAM. GLAUCOMA, LEFT. LEFT SYMPATHECTOMY. 
 SLIGHT IMPROVEMENT. 
 
 No. 56. F., aged 67. Disease of two or three years' dura- 
 tion in left eye. R. V.=20/40. T. n. Pupil normal. Fields 
 normal. L. V.=20/100. T.+2. Pupil dilated. Disc shows 
 considerable cupping. Fields contracted on nasal side. 
 
 Operation. September, 1899. Excision of left sup. cerv. 
 sympath. ganglion. Slight ptosis. Increased lachrymation. 
 T. n. Pupil contracted. Fields enlarged considerably. L. V. 
 20/100. 
 
 Last observation April, 1902. Fields slightly enlarged as 
 compared with those before operation. L. V.=20/100. Patient 
 died in 1902. 
 
 ABSOLUTE GLAUCOMA, RIGHT. CHRONIC INFLAM. GLAUCOMA, LEFT. 
 
 PREVIOUS IRIDECTOMY ON LEFT. RIGHT SYMPATHEp- 
 
 TOMY. NO IMPROVEMENT. 
 
 No. 57. M., aged 58. History of painful attacks of glau- 
 coma for over one year in both eyes. R. V.=0. T.+3. Pupil 
 
 11. THE JOURNAL A. M. A., 1901. 
 6
 
 82 
 
 dilated, a. c. shallow. Xo fields. L. V.=20/80. T. n. Fields 
 normal. Iridectomy had been done sometime before. 
 
 Operation. January, 1900. Excision of rt. sup. cerv. 
 sympath. ganglion. No effect on lid, tension, etc. Pupil con- 
 tracted. T.+l. Xo change in central vision or fields. 
 
 In two of these four cases there was dysphagia lasting sev- 
 eral days. 
 
 DAVID WEBSTER. ONE CASE. RIGHT, SIMPLE GLAUCOMA. LEFT, 
 ABSOLUTE GLAUCOMA. RIGHT SYMPATHECTOMY, TEMPOR- 
 ARY IMPROVEMENT. DISEASE STATIONARY. 
 
 No. 58. M., aged 49. Disease for one year in left eye 
 and a few months in the right. R. V.=20/50. T.+. Pupil 
 slightly dilated and sluggish. Field up 40, down 50, nasal 
 50, temporal 85. White disc with shallow excavation. L. V. 
 =0. T.+3. Pupil widely dilated, deep glaucoma cupping. 
 
 Operation. Feb. 5, 1902. Excision of rt. sup. cerv. sympath. 
 ganglion. Ptosis followed. Numbness of right side of tonkin- 
 and hoarseness. T. . Contracted pupil. R. V.=2o "><>. 
 Fields improved. 
 
 Last report Jan. 22, 1903, one year later. R. V.=2d .*>u. 
 Fields about the same as before the operation. T. n. Miosis, 
 slight ptosis. 
 
 JOHN E. WEEKS. FIVE CASES. SEVEN OPERATIONS. SI.Ml'I.K 
 CHRONIC GLAUCOMA, RIGHT. RIGHT SYMPATHECTOMY, TEM- 
 PORARY IMPROVEMENT. ACUTE ATTACK. IRIDECTOMY." 
 
 No. 59. F., aged 56. Duration of disease two years. R. V. 
 =F. 1 ft. T.+2. Pupil dilated, a. c. shallow. Cupping of 
 optic disc. Field for white small, color field abolished. L. V. 
 =20/20. T.+l- Fields not much contracted. 
 
 Operation. March 11, 1902. Excision of rt. sup. cerv. 
 sympath. ganglion. Vision began to steadily improve and she 
 could see colors. Fields increased markedly. Tension re- 
 mained plus. April 20, 1902, R. V.=r 20/70. T.+l. June 8, 
 1902, attack of acute glaucoma in right. V.=P.l. June 20, 
 1902. Iridectomy of right eye. July 18, 1902, R. V.=F. 7 ft. 
 L. V. 20/20. 
 
 SIMPLE GLAUCOMA (ABSOLUTE). RIGHT. SUBACUTE GLAUCOMA. 
 
 LFT. LEFT SYMPATHECTOMY, IMPROVEMENT. RIGHT. 
 
 SYMPATHECTOMY. 
 
 Nos. 60 AND 61. M., aged 70. History of 6 months' dura- 
 tion. R. V.=P.l. T.+2. Nerve white and deeply cupped. 
 L. V.=20/40. T.+2. Fields contracted. 
 
 Operation. April 1, 1902. Excision of left sup. cerv. 
 sympath. ganglion. T. . No untoward symptom. 
 
 Operation April 15. 1902, on right side. No untoward re- 
 
 12. Trans. Amer. Ophth. Soc.. 1902.
 
 83 
 
 suits. July 5, 1902, R. V.=P.l. No change in fields. L. V, 
 =20/20. Fields markedly improved. 
 
 SIMPLE CHRONIC GLAUCOMA, LEFT. ABSOLUTE GLAUCOMA, RIGHT, 
 LEFT SYMPATHECTOMY, IMPROVEMENT. 
 
 No. 62. R.V.=0. T.+3. L. V.=20/70. T.+. Duration 
 of disease seven years, during which time he had used eserin. 
 Fields greatly contracted. 
 
 Operation. April 15, 1902. Excision of left sup. cerv. 
 sympath. ganglion. T. n. Pupil small. Suffusion of eye, 
 lachrymation increased. Ten days later L. V.=20/30+. 
 
 July 10, 1902, severe pain in left side of head. L. E. T.+. 
 L. V.=20/20. Fields increased. No later report. 
 
 SIMPLE GLAUCOMA, BOTH. BILATERAL SYMPATHECTOMY, TEM- 
 PORARY IMPROVEMENT. LATER IRIDECTOMY NECESSARY. 
 
 Nos. 63 AND 64. M., aged 30. History of failing vision 
 and increased tension in both eyes for three years. R. V.= 
 20/40+. T.+1.5. Pupil dilated, optic disc cupped, fields con- 
 tracted. 
 
 Operation. April 29, 1902. Excision of rt. sup. cerv, 
 sympath. ganglion. Pupil contracted. T. n. Acute attack 
 of glaucoma was excited in left eye. L. V.=l/200. 
 
 Operation. May 6, 1902. Excision of left ganglion. Pupil 
 contracted. T.+l- Improvement in vision. T. of right eye- 
 remained normal. T. of left remained high and iridectomy was 
 done. July 12, 1902, R. V.=20/20. L. V.=9/200. 
 
 Last report March 1, 1903. Iridectomy was done on right 
 eye because of periodic increase of tension and diminution of 
 vision and visual fields. April 11, 1903, R. V 20/40. T. n. 
 L.V.=F. 17 ft. 
 
 SIMPLE CHRONIC GLAUCOMA, BOTH. LEFT IRIDECTOMY, FOLLOWED' 
 LATER BY LEFT SYMPATHECTOMY, IMPROVEMENT. 
 
 No. 65. M., aged 40. Duration of disease unknown. 
 R. V.=0. Absolute glaucoma. T.+3. Deep cupping of disc. 
 L. V.=F. 5 ft. T.+. Pupil shows coloboma after iridectomy. 
 Cupping of optic disc. 
 
 Operation. Dec. 2, 1902. Excision of left sup. cerv. sympath. 
 ganglion. Ptosis, suffusion of conjunctiva, increased lachryma- 
 tion and nasal mucus and free perspiration on side of face 
 opposite to side of operation occurred. Improvement in ten- 
 sion and vision occurred, and at time of last report, three 
 months after operation, T. n., L. V.=20/200. 
 
 The ganglion was small, not much larger than trunk of 
 the nerve. It was very pale in color. 
 
 MEYER WIENER. TWO CASES. CHRONIC INFLAM. GLAUCOMA, 
 RIGHT. RIGHT SYMPATHECTOMY. NO IMPROVEMENT. 
 
 No. 66. F., aged 50. R. V.=F. 12 ft. T.+2. Dilated
 
 84 
 
 pupil. Cupped disc. L. V.=0. Phthisis bulbi. Field of right 
 contracted. 
 
 Operation. Winter of 1900. Excision of rt. sup. cerv. 
 sympath. ganglion. No change in vision or tension and pa- 
 tient was lost sight of in four weeks after operation. 
 
 CHRONIC SIMPLE GLAUCOMA, RIGHT. RIGHT SYMPATHECTOMY. 
 NO IMPROVEMENT EXCEPT IN PUPIL. 
 
 No. 67. F., aged 45. Duration of disease in right eye 4 
 years. T.+ l. Pupil dilated. Field slightly contracted on 
 inner side. R. V.=6/200. L. V.=6/6. T. n. Eye normal. 
 
 Operation. 1900. Excision of rt. sup. cerv. sympath. gang- 
 lion. No change in tension or pupil. Vision remained the 
 same. Patient disappeared three weeks after the operation 
 and no further report was made. 
 
 H. W. WOODRUFF. ONE CASE. SIMPLE GLAUCOMA, LEFT. LEFT 
 
 SYMPATHECTOMY WITH TEMPORARY IMPROVEMENT. 
 
 LATER IRIDECTOMY. 13 
 
 No. 68. M., aged 29. Failure of right eye for 7 years after 
 an injury. Duration in the left eye three years. R. V.=0. 
 Absolute glaucoma. T.+. Deep cupping of disc. L. V.= 
 20/40. T.+. Pupil dilated. Fields contracted, cupping of 
 optic disc. 
 
 Operation. April 29, 1901. Excision of left sup. cerv. 
 sympath. ganglion. Six days later ptosis. T. n., contracted 
 pupil, improved vision. White fields that were contracted to 
 10 increased to 30 up, 30 nasal, 15 below and 50 tem- 
 poral with irregular outline. Later central vision=20/20. 
 Six months later he had return of all symptoms and failing 
 central vision. He refused iridectomy, but later consented to 
 it, and on Feb. 10, 1902, iridectomy of the left eye was done. 
 Central vision improved to 20/30. 
 
 Last report March 10, 1903, L. V.=20/70. T. n. Field 
 greatly contracted. Above 5, temporal 2, below 5, nasal 10. 
 
 We have here records of 68 operations done on 54 
 cases, i. e., 14 were bilateral. Of these operations. 38 
 were for simple glaucoma; 16 for chronic inflammatory 
 glaucoma; 4 for subacute glaucoma; 3 for acute glau- 
 coma; 4 for absolute glaucoma; 2 for hemorrhagic 
 glaucoma; 1 for buphthalmus. 
 
 Of these five operations were preventive, one by Hale 
 (20), four by Eenaud (40, 42, 44, 46) . No glaucoma up 
 to time of reports. One death occurred (30). Of the 38 
 operations for simple glaucoma, 14 gave no improve- 
 ment whatsoever. Five were temporarily improved 
 
 13. Chicago Med. Recorder, July, 1901.
 
 85 
 
 for periods ranging from fifteen days to eight months, 
 but had recurrent attacks that necessitated iridectomy 
 or caused loss of the eye. Fifteen were improved as 
 long as they were under observation, for periods of from 
 two months to two years. Of these three were sta- 
 tionary (5, 17, 58) ; one died (30) ; six remained un- 
 improved after iridectomy, but improved after sympa- 
 thectomy (17, 18, 24, 34, 35, 65). 
 
 Concerning the 15 that were improved, No. 9 showed 
 slight improvement; No. 18 improvement as to tension; 
 previous iridectomy had been done; observation, one 
 year; No. 24, improvement as to central vision and 
 tension; No. 29, marked improvement; observation, 
 fourteen months; No. 34, previous iridectomy had been 
 done; improvement after sympathectomy, but patient 
 was only under observation for fifteen days; No. 35, 
 previous iridectomy, after the sympathectomy the ten- 
 sion remained minus; Nos. 37 and 38, slight improve- 
 ment as to vision, but tension is still plus; time of ob- 
 servation, two years ; No. 40, improvement as to tension, 
 slight improvement as to vision; time of observation, 
 twenty months; Nos. 51 and 52, marked improvement 
 in tension and vision; posterior sclerotomy had been 
 done without effect ; time of observation, six months ; 
 Nos. 62 and 65, previous iridectomy; marked improve- 
 ment intension and vision; time of observation, four 
 months ; Nos. 4 and 6 showed marked improvement, and 
 have been under observation for nine months and four 
 months, respectively. 
 
 Of the 16 operations for chronic inflammatory, 6 
 showed no improvement; 3 showed improvement for 
 periods from two to three months (2, 31, 50) ; 4 were 
 improved as long as they were under observation; 1 (45) 
 five months, 1 (15) eighteen months, 1 (41) one year, 
 1 (36) three years. 
 
 Of these 1 (15) had not been benefited by iridce- 
 tomy, but greatly improved by sympathectomy; eight- 
 een months under observation; 3 (20, 42, 46) were 
 preventive, and disease had not appeared at three 
 months, eight months and one year after operation. 
 
 Of the four that showed improvement, No. 15 is 
 the most interesting, because an iridectomy failed to 
 check the disease, but sympathectomy produced marked 
 results in central and peripheral vision. Time of ob- 
 servation, eighteen months.
 
 86 
 
 In Xo. 36, improvement in central vision continued 
 after three years, tension slightly plus; in No. 41, im- 
 provement continues after one year; in No. 45, vision 
 and tension were improved and pain was relieved ; time 
 of observation, five months. 
 
 No. 20 is interesting in that the operation was done 
 for threatened glaucoma. 
 
 In Xos. 42 and 46 it is not stated whether the bi- 
 lateral operation was done to influence more profoundly 
 the diseased eye or to prevent the occurrence of the 
 disease in the perfectly sound eye. The same may be 
 said concerning Cases 39 and 44, in which one eye 
 was normal in every respect. 
 
 Of the 4 operations for subacute glaucoma, 1 (12) 
 cured at the end of two and a half years (Black) ; 2 
 (27, 28) remained well at end of fifteen months (La- 
 Motte) ; 1 (60) remained improved after observation 
 of four months (Weeks). 
 
 Of the three operations for acute glaucoma, 1 (26) 
 recovered: observation, fifteen months (LaMotte) ; 1 
 (43) improved; remained so after nine months (Re- 
 naud) ; 1 (44) preventive; no attack occurred. 
 
 Of the four operations for absolute glaucoma, 1 (8) 
 improved as to pain; 3, no improvement and no change. 
 
 Of the two operations for hemorrhagic glaucoma, 1 
 (11) improved as to pain; 1 (33), improved vision 
 during time of observation, five months. 
 
 One operation for buphthalmus had no effect. 
 
 SUMMARY. 
 
 Xo. of Temporarily Sta- Unim 
 
 Form of Glaucoma. Cases. Improved. Improved, tlonary. proved. 
 
 Simple chronic 38 15 5 3 15 
 
 Chronic inflammatory ..16 4 3 3 6 
 
 Subacute 4 3 1 
 
 Acute 3 1 1 1 
 
 Absolute 4 1 .. .. 3 
 
 Hemorrhagic 2 2 
 
 Buphthalmus 1 ; ." . . . . 1 
 
 68 26 10 7 25 
 
 After these 68 operations miosis is mentioned as oc- 
 curring 40 times, and this condition remained for 
 periods ranging from two days to three years. In most 
 cases it seems to be permanent. It is mentioned that 
 in 34 cases the tension was reduced to normal, and in 
 9 others it was much lower than it was before the opera- 
 tion. As to the effect of the operation on the lid, con- 
 junctiva, face, etc., ptosis occurred in 36 cases and lasted
 
 87 
 
 for periods ranging from thirteen days to one year. 
 This, like miosis, is one of the most constant phenom- 
 ena. Conjuiictival congestion was noted in 19 cases, 
 lasting fox a variable time, usually not longer than a 
 few days. One case persisted for three months. In- 
 creased lachrymation was observed in 18 of the cases. 
 This was of short duration, but in one case lasted three 
 weeks. Congestion of the face on the side operated on 
 was observed six times, in one case lasting three months. 
 
 Xeuralgia and hyperesthesia of the side of the face 
 operated on was noted in six cases> lasting in one case 
 for one year. Anesthesia of the face or neck on the 
 operated side was mentioned in only two cases; in one 
 of them it lasted three months. Hoarseness or aphonia 
 occurred in 8 cases, lasting for a variable time, from one 
 week to three weeks. In two of the cases dysphonia was 
 the result of paralysis of the recurrent laryngeal, and 
 lasted in one for nine months and in the other for two 
 years. Dysphagia was observed in 5 cases as a result 
 of the operation. This symptom lasted only two or 
 three days, except in one case, in which it persisted for 
 six months. In one case (5), for a period of several 
 days after the operation, the patient had mild hal- 
 lucinations. 
 
 The results exhibited in this series of cases, at first 
 glance, do not seem as favorable as those presented by 
 Rohmer, 14 who drew conclusions from a study of 74 
 cases collected by Bichat, to which he added 20 of his 
 own. On these 94 cases, 114 operations were done. The 
 following table gives a summary of the results of their 
 analysis of these cases : 
 
 No. of Cases 
 Form of Glaucoma. Operated on. Improved. Negative. Worse. 
 
 Simple chronic 43 36 5 2 
 
 Chronic inflammatory 34 23 10 1 
 
 Subacute 14 6 6 2 
 
 Acute 9 4 5 
 
 Absolute 3 1 2 
 
 Hemorrhagic 5 5 
 
 Hydrophthalmus 6 4 1 1 
 
 114 79 29 6 
 
 The statistics of Ziehe and Axenfeld, 15 who studied 
 the results in 55 cases, agree with this in the main, for 
 many of the cases in each series are the same. Un- 
 
 14. Annales d'Oculistique, May, 1902. 
 
 15. Ziehe and Axenfeld : Sympathicus Resection beim Glaukom. 
 Rostock. 1901.
 
 88 
 
 fortunately, many of these cases, as in the present series, 
 either do not give the final result, or were under ob- 
 servation such a short time as to make any statement 
 as to the final outcome impossible. Again, in studying 
 them, it is seen that the records of many of them are 
 far from exact. 
 
 However, to quote Axenfeld: "There is obtained by 
 this operation in a certain proportion of cases of simple 
 glaucoma, a definite and important result, and, in some 
 instances, there has been a decided improvement, even 
 where a previous iridectomy had failed." Such cases 
 as those reported by Grunert, 16 Demicheri, 17 Cutler, 
 Starr 18 and Weeks, 18 in which sclerotonw and iridec- 
 tomy had been unsuccessfully performed, and sympathec- 
 tomy accomplished not only reduction in tension but 
 improvement in both central and peripheral vision, 
 speak strongly in favor of the operation in certain 
 cases. 
 
 As was said in the beginning, I feel that positive con- 
 clusions are not yet to be reached, and will not be until 
 more carefully selected cases can be studied for longer 
 periods of time. 
 
 The operation in itself, while a major one, is not to 
 be considered one of unusual danger, and with modern 
 technic should show a very trifling mortality. The death 
 recorded in our present series was purely accidental, 
 and might have occurred in any other operation on the 
 neck. With such brilliant results before us as are 
 presented in certain cases on record, we must agree 
 that sympathectom)' is not an operation to be con- 
 demned too hastily. It certainly is not fair to condemn 
 it when it fails to restore sight to an eye that has suf- 
 fered so long from glaucoma that it is blind from 
 atrophy of the nerve, or when it fails to check pain in 
 an eye that is hopelessly lost from absolute glaucoma. 
 
 If it is to be compared with iridectomy at all, it 
 should be given an early trial in any form of the disease 
 in which it is applicable. 
 
 The statistics up to date seem to indicate that the 
 simple chronic form is the one most suited for it, next 
 to the hemorrhagic form, if that can be determined. As 
 
 16. Archiv. f. Augenheilk., 1900, vol. xlii. 
 
 17. Annales d'Oculistique, T cxxi, 1899. 
 18 Loc. cit. 
 
 19. Loc. cit.
 
 89 
 
 a guide for my own practice, I should feel very much 
 like following Abadie- when he says : "In acute forms 
 of glaucoma and in subacute with intermissions, prac- 
 tice first iridectomy, and if it fails do sympathectomy. 
 In simple glaucoma use miotics twice a day ; if they 
 suffice, continue them. If, in spite of their systematic 
 employment the vision fails, do sympathectomy." 
 
 BIBLIOGRAPHY. 
 
 Doyon : Bulletin de Lyons, June, 1897. 
 
 Jonnesco : Sympathectomy for Exoph. Goiter and Epilepsy. 
 Internat. Med. Congress. Moscow, 1897 ; Wiener Klin. Woch., May 
 4. 1899 ; Resection of Cervical Sympathetic Ganglion, International 
 Clinics, 1902, 11. 
 
 Jonnesco and Floresco : Sur les phe'nomenes consecutif a la 
 resection du sympathetique cervical chez 1'homme, Bulletin Acad. de 
 Med., Paris, July 1-8, 1902. : '" 
 
 Abadie : Annales d'Oculistique. T. 119, p. Il4, l'898 ; Archives 
 d'Ophthalmologie, July, 1898 : La Clinique Ophth., Feb, 25. 1901 ; 
 Internat. Med. Congress, Paris, 1900 ; Zeitschrift f. Augenheilkunde, 
 iv, s. 255 ; Archives d'Ophthalmologie, May, 1901. 
 
 Panas : Archives d'Ophthalmologie' July 6, 1898. 
 
 Ball, J. M. : New York Med. Jour., 1899, vol. Ixx ; THE JOUEXAL 
 Amer. Med. Assn., June 2, 1900. 
 
 Coover, D. H. : Removal of Cerv. Sympath. Ganglion for Relief 
 of Glaucoma, Phila. Med. Jour., March 16, 1901 ; also, Ophthalmic 
 Record, March, 1001. 
 
 Dodd, H. Work : Resection of Superior Cerv. Sympath. Ganglion 
 for Glaucoma, Lancet, 1900, vol. xi, p. 1071, and Lancet, March 23, 
 1901. 
 
 Galowin : Optico-ciliary Neurectomy in Absolute Glaucoma, Zeit- 
 schrift f. Augenheilkunde, Berlin, July, 1901. 
 
 Whitehead, A. L. : Treatment of Glaucoma by Excision of Sup. 
 Cerv. Ganglion of Sympathetic, Lancet, London, July 6, 1901. 
 
 Ziehe and Axenfeld : Sympathicus Resection beim Glaukom, 1901 ; 
 Aus der Augenklinik in Rostock. 
 
 Axenfeld : Klin. Monatsbl. f. Augenheilkunde, Bd. xxxviii. August, 
 September. 
 
 Dunn, John : Glaucoma, Va. Med. Semi-Monthly, Oct. 11, 1901. 
 
 Black : Melville : Resection of Superior and Middle Cervical 
 Ganglion of the Sympathetic for Glaucoma, Ophthalmic Record, 
 October, 1901. 
 
 Kipp, N. J. : Discussion of Glaucoma, Trans. Amer. Ophthal. 
 Soc., 1901, p. 309. 
 
 Levinson : Ueber den Einfluss des Hals sympathicus auf das 
 Auge, Graefe's Archiv, Bd. Iv,. Heft 1. 
 
 Chipault : Resec. of Cerv. Sympathetic. Internat. Med. Congress, 
 Paris, 1900. 
 
 Mullen : Amer. Medicine. June 22, 1901. 
 
 Williams and Shorter : Med. News, April 6, 1901. 
 
 Gruening : Discussion in N. Y. Acad. of Med., Ophthal. Sec., 
 Nov. 18, 1901. 
 
 Altland : Exstirpation des gang. cerv. sup. nerv. sympath. bei 
 glaukom, Klin. Monatsbl. f. Augenheilkunde, February, 1902. 
 
 Renaud : Sympathectomy in Simple Optic Nerve Atrophy : a 
 clinical report, St. Louis Med. Review, Feb. 1, 1902. 
 
 20. Archives d'Ophthalmogie, May, 1901.
 
 90 
 
 Cutler and Gibson : Removal of Superior Cervical Ganglion for 
 Relief of Glaucoma, case, Annals of Surgery, Phila., Sept., 1902. 
 
 Floor : Fall von Syinpathicus Resection gegen Glaukom, Wiener 
 Klin. Woch.. No. 36. 1902. 
 
 LaMotte : New Surgical Treatment of Glaucoma, Ophthalmic 
 Record. Chicago. October. 1902 : Denver Medical Times, March, 
 1903. 
 
 Griinert : Die Behandlung des Glaucoms durch Entfernung des 
 oberen Sympath. Hals Ganglion, Archiv f. Augenheilkunde, 1900, 
 vol. xlii ; Klin. Monatsbl. f. Augenheilk., October, 1900. 
 
 Cattaneo : La simpatectomia cervicale nella cura del glaucoma, 
 Bulletin d. Soc. Med. di Bologna, 1900, 75, xl, 526. 
 
 Dor : Glaucome hemorrhag.-gueri par la sympathectomie, Lyon 
 Medicale, 1900 : Revue generate d'Ophthalmologie, July, 1901 ; 
 Archives d'Ophthalmologie, May, 1901. 
 
 Marple : Resection of the Cervical Sympathetic Ganglion In 
 Glaucoma, N. Y. Medical Record, May 10, 1902. 
 
 Lanphear : Operation on Cerv. Ganglia of Sympath. for Epilepsy, 
 Glaucoma, etc.. New England Med. Monthly, 1900, xix, 178. 
 
 -tfuker : THE JOURNAL Amer. Med. Assn.. 1901, p. 1588. 
 
 Burghard : Three Cases of Removal of Sup. Cerv. Sympath. 
 Ganglion. British Med. Jour.. Oct. 20, 1900, p. 1175. 
 
 DeWecker : Valeur de 1'Iridectomie dans le Glaucome, Archives 
 d'Ophthalmologie. May, 1901. 
 
 Jayal : Auto-Observation de Glaucome, Annales d'Oculistique, 
 September. 1901. 
 
 Neuschiiber : Le sympathique et la tension de 1'oeil, Annali 
 d'Ottalmologia. xxv;ii, 1899. 
 
 Mohr : Beitrag. zu Exstirpation des ganglion cerv. sup. bei 
 Glaukom, Klin. Monatsbl. f. Augenh., 1900, s. 159. 
 
 Schimanowski : Excision of Sup. Cerv. Ganglion in Glaukom. 
 AVestnik Ophthalmologi, May- June, 1900. (Translation.) 
 
 Albertotti : Annali di Ottalmologia, xxix, 123. 
 
 Angelucci : La riforma medica, No. 214. 
 
 Rohmer : Quelques observations sur Sympathectomie dans Glau- 
 come, Annales d'Oculistique, May, 1902. p. 328. 
 
 Campos : Sur la th6orie sympathique du Glaucome, Archives 
 d'Ophthalmologie, T. xviii. 1898. 
 
 Demicherie : Sympathectomie dans les cas de Glaucome, Annal. 
 d'Oculistique. T. cxxi, 1899, p. 188. 
 
 Hertel : Archiv. f. Ophthalmologie, Bd. xlix, Abt. 2. 
 
 Langendorff : Klin. Monatsbl. f. Augenh., xxxviii, 1899, March, 
 1900. 
 
 Nicati : Archives d'Ophthalmologie. T. xx. 
 
 Zimmermann : Ophthalmolog. Klinik, iii, No. 14, 1899. 
 
 Weeks : Cases of Simple Chronic Glaucoma Treated by Resection 
 of the Superior Ganglion of the Cervical Sympathetic, Transactions 
 of the American Ophthalmological Society, 1902. 
 
 Woodruff, H. W. : Report of a Case of the Removal of the 
 Superior Cerv. Sympathetic Ganglion for Glaucoma, Chicago Medical 
 Recorder. July. 1901.
 
 IXFLUEXCE OF KESECTIOX OF THE CEK- 
 VICAL SYMPATHETIC 
 
 JX OPTIC-XEUVE ATROPHY, HYDROPHTHALMOS AND EX- 
 OPHTHALMIC GOITER. 
 
 JAMES MOORES BALL, M.D. 
 
 f'rofessor of Ophthalmology in the St. Louis College of Physicians 
 and Surgeons. 
 
 ST. LOUIS. 
 
 I. SYMPATHETICECTOMY IX OPTIC-NERVE ATROPHY. 
 
 History. Excision of the cervical portion of the sym- 
 pathetic nerve for the relief of optic-nerve atrophy was 
 proposed and executed by the writer in 1899. (The 
 date of the first operation was June 24.) 
 
 Report of Cases. A report of this case was included 
 in a paper 1 which was read before the Ninth Interna- 
 tional Ophthalmologic Congress, in 1899. From that 
 paper I now quote : 
 
 T. J.. aged 46, 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. Xo 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 sev- 
 eral years ago. The patient has been a moderate drinker of 
 alcoholic beverages. In appearance he was robust, and he com- 
 plained only of loss of vision, which in the left eye had been 
 failing for eleven months, in the right for seventeen weeks ac- 
 cording to his statement. Until seventeen weeks before this time 
 lie could see enough with the right eye to get around. Since 
 then vision had steadily declined until he had light perception 
 only and this apparent only when light was concentrated on 
 the eye by the ophthalmoscopic mirror. Vision of left eye =0. 
 
 1. Ball : On Removal of the Cervical Sympathetic in Certain 
 Ocular Diseases Glaucoma and Optic Nerve Atrophy, NeuviSme 
 ?ongrs International d'Ophtalmologie d'Utrecht. 1899, p. 551.
 
 92 
 
 The pupils were widely dilated. The ophthalmoscope showed 
 in the right eye a white disc, particularly on the temporal 
 side; the arteries were 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 disc of a dead white color throughout 
 the whole area, arteries very small, atrophic excavation pro- 
 nounced, A'eins 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 \va- 
 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 gang- 
 lion of the sympathetic was done. The operation was followed 
 by conjunctival congestion, lachrymation and contraction of 
 the pupil, slight ptosis and hypotonia. 
 
 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 disc had doubled 
 in caliber. 
 
 I was led to make this experimental operation for several 
 reasons: 1. The use of glonoin is often followed by an im- 
 provement 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 ques- 
 tion that in glaucoma simplex a disease in which there is an 
 atrophy of the optic nerve improvement in vision follow? 
 sympatheticectomy. 4. Excision of the cervical sympathetic is 
 followed by an increase in the blood supply of the orbital 
 contents. 
 
 My second case of sympatheticectomy for optic nerve 
 atrophy occurred in the summer of 1900. It has not 
 been reported, for the reason that an assistant lost the 
 case history. The result, however, was all that could 
 be expected. 
 
 The patient was an Irishman, a bartender by occupation. 
 He was about 40 years of age. For several months the visior 
 of both eyes had steadily declined. Several oculists had given 
 him medical treatment for simple optic-nerve atrophy without 
 result. The poorer eye had vision equal to the counting of 
 fingers at two feet. I excised the superior cervical ganglion 
 of the sympathetic nerve on the corresponding side. Vision 
 steadily increased to 20/100. The patient was lost sight of. 
 but one year later he sent word ^hat his vision was excellent 
 and that he was following his vocation.
 
 93 
 
 I regret that this case can not be more fully described. 
 My third case of atrophy treated by sympatheticectomy 
 occurred in 1901. 
 
 J. H., aged 64 years, a native of New York City, for 18 
 years had been a sailor. For many years he was excessively 
 addicted to the use of alcohol and tobacco. In 1888 he con-, 
 tracted syphilis, for which he was treated for two months 
 Vision in R. E. began to fail in 1898; in L. E. in 1900. He 
 was admitted to the St. Louis City Hospital on Jan. 29, 1901. 
 The hospital record shows that he was in good general health. 
 He was given large doses of mercury and iodids. 
 
 Patient came under my care on March 1, 1901. His gen- 
 eral condition was good. Vision of R. E. =0; of L. E. = 
 fingers at 6 inches. The ophthalmoscope showed a typical 
 picture of simple atrophy of the optic nerves. Strychnia in 
 increasing doses was ordered and was continued for five weeks 
 without benefit. 
 
 On April 11, 1901, assisted by Dr. R. F. Amyx, I excised the 
 left superior cervical ganglion of the sympathetic nerve. At 
 this time the right eye was absolutely blind; with the left 
 eye fingers could be counted at 6 inches. Tw6 days after the 
 operation he counted fingers at 15 feet. On April 27 he counted 
 fingers at 12 feet. There was a gradual loss of vision, until at 
 the end of a few weeks the patient was in the same condition 
 as before operation. 
 
 Cases Reported by Other Surgeons. Suker 2 per- 
 formed a bilateral sympatheticectomy in a case of bi- 
 lateral simple atrophy of the optic nerve. Before opera- 
 tion the visual acuity was reduced to form perception 
 at two feet. After operation the hand could be recog- 
 nized at six feet. Two years later the acuity was re- 
 tained. 
 
 Renaud 3 has reported one of my cases and two of his 
 own. In January, 1900, he made a bilateral sympa- 
 theticectomy for a unilateral optic-nerve atrophy which 
 followed an attack of optic neuritis existing four months 
 previously. Vision was reduced to the counting of fin- 
 gers at six feet. Four and one-half months later the 
 patient could count fingers at eighteen feet (V. 
 20/100). Renaud's other case, which was one of simple 
 atrophy, showed in two months an improvement in 
 vision from 10/200 to 20/50. Renaud 4 has operated on 
 another case without success. 
 
 2. Snker : New York Medical Journal, Feb. 24, 1900. 
 
 3. Renaud : St. Louis Medical Review, Feb. 1, 1902. 
 
 4. Renaud : Personal communication, April 30, 1903.
 
 94 
 
 E. Gruening 3 of Xe\v York has had one case which 
 is best described in his own words : 
 
 My experience with the excision of the superior cervical 
 sympathetic ganglion in atrophy of the optic nerve is limited 
 to one case. It concerned a man, 33 years of age, who had 
 contracted syphilis fifteen years previously. When I saw 
 him in 1902 he was entirely blind as regards his left eye, but 
 saw well centrally with his right. Here the field was tele 
 scopic, measuring tn degrees in diameter. Vision was ^0/30. 
 He read J. 1. Pupils small. Argyll-Robertson reaction 
 knee reflexes lost entirely a case of post-syphilitic tabes with 
 atrophy of the nerves. The ganglion was removed on the right 
 side. Vision became worse and three months later the man 
 was totally blind. 
 
 Thus, of 8 cases in which sympatheticectomy was per- 
 formed by optic-nerve atrophy, there were 4 failures and 
 4 improvements. 
 
 Should Bilateral Resection be Done for Unilateral 
 Atrophy? At -the present time it is impossible to an- 
 swer this question ex cathedra. Renaud states that "the 
 superior cervical ganglion should be removed on both 
 sides in all cases, whether the affection be unilateral or 
 bilateral." It is possible that the unexcised ganglion 
 exerts an influence on the opposite eye, the anatomic- 
 path probably being through anastomosis of fibers in 
 the carotid plexus. 
 
 II. TREATMENT OF HYDBOPITTHALMOS BY OPERATIONS OX 
 
 THE SYMPATHETIC NERVE. 
 
 Pew cases of congenital hydrophthalmos have been 
 treated by operations made on the cervical sympathetic. 
 Palmtag and Kolle removed the superior ganglion, while 
 Schwilke and Mader performed sympatneticotomy. 
 These four patients were 8, 2~y 2 , 4y 2 and 9 years of age. 
 respectively. The tension was uninfluenced, and the 
 vision, so far as could be determined in such young sub- 
 jects, was unchanged. The operations, consequently, 
 were valueless. Grunert 6 states that the general health 
 of these children was not influenced by these procedures. 
 
 III. OPERATIONS ON THE SYMPATHETIC NERVE FOR THE 
 
 RELIEF OF EXOPHTHALMIC GOITER. 
 
 Exophthalmic goiter is a disease belonging to the 
 
 5. Gruening : Personal communication. March 23, 1003. 
 
 6. Grunert : Die Behandlung des Glaucoms durch Sympatheticus- 
 resection, Bericht xxviii. Versammlung der Ophthalmologischen 
 Gesellschaft (Heidelberg, 1900), Wiesbaden. 1901. p. 19.
 
 domains of the ophthalmologist, neurologist, surgeon 
 and general practitioner. 
 
 Without desiring to enter into a resume of the litera- 
 ture of the last ten years or to excite a discussion on the 
 nature of the disease, I will remark that there are good 
 reasons for dividing cases of exophthalmic goiter into 
 three groups, as advocated by Lanphear : 7 
 
 1. Those dependent on changes in the central nerv- 
 ous system, in which no operative measures can be of 
 benefit. 
 
 2. Those due to disease of the cervical sympathetic, 
 in which excision of the ganglia may give relief. 
 
 3. Those arising from excessive thyroid secretion, in 
 which thyroidectomy may cure. 
 
 Granting that a certain percentage of cases will re- 
 cover spontaneously; that some will show great im- 
 provement without treatment; that others will recover 
 under the rest cure, or by change of climate, or by the 
 influence of pregnancy; and that some will recover un- 
 der the use of such diverse measures as cauterization of 
 hypertrophied inferior turbinatecl bodies, the removal 
 of nasal polypi, the painting of the thyroid region with 
 collodion, the use of the galvanic current, or of the 
 faradic current the administration of iron, quinin. bella- 
 donna, digitalis, strophanthus, hydroiodic acid, ergot,, 
 spartein, salicylate of soda, corbolozate of ammonia, 
 thyroid extract, etc., there will still remain a not incon- 
 siderable number of cases in which surgical intervention 
 will be required. 
 
 Before resorting to any form of operation it is well 
 to remember ( 1 ) that no surgical procedure will cure all 
 cases, and (2) that sudden death has not infrequently fol- 
 lowed carefully planned and skilfully executed opera- 
 tions made on this class of patients. Harris 8 has re- 
 ported the death of a lady who, having exophthalmic 
 goiter, was operated on for the removal of a non-ma- 
 lignant mammary tumor and died suddenly. Lance- 
 reaux 9 has called attention to the danger of sudden death 
 after goiter operations, and has commented on the great 
 value of morphin in such patients. Warren 10 has ad- 
 
 7. Lanphear : St. Louis Medical and Surgical Journal. Majv 
 1900. 
 
 8. Harris : British Medical Journal, May 4, 1901. 
 
 9. Lancereaux : La Semaine Medicale, Paris, January. 1894. 
 10. Warren : American Year-book of Medicine and Surgery. Phila- 
 delphia, 1896, p. 289.
 
 96 
 
 vanced the idea that during the operation a toxic sub- 
 stance from the thyroid may gain admission to the cir- 
 culation and cause death. Booth 11 states that, owing to 
 the care which is now exercised in the removal of the 
 diseased gland, this theory is no longer tenable. 
 
 Patients with simple goiter often do badly under gen- 
 eral anesthetics. In addition to the dangers pertaining 
 to such cases, the patients with exophthalmic goiter 
 must face other dangers. The chance of death from 
 chloroform, according to Halstead, 12 is much increased 
 by the degenerated heart muscle and the increased ir- 
 ritability of the heart centers; and in the retrosternal 
 and retroclavicular forms of goiter ether anesthesia is 
 equally dangerous. Fiitterer has shown that collapse of 
 the trachea, which may occur after operation for any 
 form of goiter, is due to mucoid degeneration of the 
 cartilaginous tracheal rings. The patient makes a vio- 
 lent inspiratory effort, collapse of the trachea results and 
 death occurs by asphyxia. Because of these dangers, 
 not a few surgeons, including Kocher, 13 believe that 
 goiter operations should be performed under local anes- 
 thesia. 
 
 CLASSIFICATION OF OPERATIONS ON THE CERVICAL POR- 
 TION OF THE SYMPATHETIC NERVE. 
 
 These procedures, which have been tried in the treat- 
 ment of exophthalmic goiter, are: 
 
 1. Simple division of the cervical sympathetic (first 
 suggested by Edmunds 14 in cases in which perforation of 
 the cornea is threatened, and first performed by Ja- 
 boulay) . 
 
 2. Ablation of the cervical sympathetic, consisting in 
 the torsion and ablation of the nerve by means of artery 
 forceps passed through a small incision (Jaboulay's 
 procedure). 
 
 3. Simple stretching of the cervical sympathetic 
 (first practiced by Jaboulay). 
 
 4. Partial resection of the cervical sympathetic (first 
 performed by Alexander of Edinburgh, in 1889, for the 
 
 11. Booth : Radical Cure of Exophthalmic Goiter, Journal of 
 Nervous and Mental Diseases, September, 1902, p. 521. 
 
 12. Halstead : Pathogenesis and Surgical Treatment of Exophthal- 
 mic Goiter, Medicine, September, 1902. 
 
 13. Kocher : Sixty-fourth Annual Meeting of the British Medical 
 Association, Aug. 6, 1898. 
 
 14. Edmunds : Lancet, May 25, 1895.
 
 97 
 
 cure of epilepsy, and limited by him to the removal 
 of the superior ganglion) . 
 
 5. Partial and extensive resection (excision of the 
 upper and middle ganglia with the intervening strand). 
 
 6. Total resection of the cervical sympathetic (re- 
 moval of all three ganglia and the nerve strand). This 
 was first performed by Jonnesco. 
 
 7. Thyroidectomy with partial and extensive resec- 
 tion of the cervical sympathetic, was suggested by the 
 writer in 1901, in a case under the care of Dr. F. Eob- 
 ert Boyd, and was practiced by Dr. J. W. Smith of St. 
 Louis. 
 
 The comparative value and mortality of exophthalmic 
 goiter operations can not be definitely determined, be- 
 cause (1) many cases ending in death have not been 
 reported, and (2) not all of the published statistics are 
 reliable, there being in some of the published reports an 
 absence of differentiation between the various procedures 
 practiced on the sympathetic nerve. 
 
 1. Thyroidectomy. The general mortality of this 
 operation is 7 per cent. (Booth 15 ), while the percentage 
 of death in cases of exophthalmic goiter is much higher. 
 Rehn 16 of Frankfurt, who collected 177 cases, places it 
 at 13.6 per cent. Tricomini 17 (72 cases) places the 
 mortality at 15 per cent., and Sorgo 18 (172 cases) at 
 14 per cent. Jonnesco 19 claims that the mortality is 
 over 17 per cent., and rejects the operation because of 
 the high death rate. Kocher's 20 recent statistics are 
 very favorable. He made 59 operations: 45 cases (76 
 per cent.) were cured; 8 (14 per cent.) were improved; 
 2 (3.3 per cent.) were slightly improved, and 4 (6.7 
 per cent.) died. When we remember that many of the 
 unsuccessful cases have not been reported, it seems rea- 
 sonable to place the mortality of thyroidectomy for ex- 
 ophthalmic goiter at 20 per cent. Rehn 21 claims 57.6 
 per cent, of cures for thyroidectomy. Jonnesco 
 claims that the reported successes of this operation have 
 been largely among those atypical cases in which the 
 goiter long preceded the ocular and cardiac symptoms. 
 
 15. Booth: Medical Record. Aug. 13, 1898. 
 
 16. Rehn: Munchener Medizinische Wochenschrift, Oct. 10, 1899. 
 
 17. Tricomini : II Policlinico, Roma, 1896. 
 
 18. Sorgo : Centralblatt fur Grenzgeb. der Medicin, No. 1, p. 329. 
 
 19. Jonnesco : Revue Chirurgicale, November, 1897, supplement. 
 
 20. Keener: Mittheilungen aus dem Grenzgebieten der Medicin 
 und Chirurgie, 1902. 
 
 21. Rehn : Munchener Medizinische Wochenschrift, Oct. 10, 1899. 
 7
 
 98 
 
 Doyon, is a strong advocate of thyroidectomy, and would 
 resect the sympathetic only after failure of the former 
 operation. 
 
 The danger of sudden death after thyroidectomy is 
 emphasized by Starr's report. Of 190 cases, not less 
 than 23 died suddenly. Surrel, 22 who has recently dis- 
 cussed this subject, attributes these accidents to either 
 an acute thyroidin intoxication, or to a sudden stoppage 
 of the heart's action. The latter is supposed to be 
 caused by the traction which, during the operation, is 
 exerted on the nerves of the thyroid gland, which are 
 intimately associated with the vagus nerve. 23 After 
 thyroidectomy a number of complications have been ob- 
 served, such as a rise of temperature, which is accom- 
 panied by a sensation of heaviness, dyspnea, tachycar- 
 dia and vomiting. Hemorrhages, tetany and vocal dis- 
 turbances, dysphagia and bronchopneumonia have also 
 been observed. 
 
 2. Ligation of the thyroid arteries, according to 
 Rehn, 24 gives a mortality of 28.6 per cent. ; 2.4 per cent. 
 were cured, and 50 per cent, were improved. Regard- 
 ing this, Balacesu 25 says : "The method of ligaturing 
 the thyroid arteries has been the first to be abandoned 
 (among operations attacking the thyroid gland), be- 
 cause in nearly all cases the disease recurred in a few 
 months after operation. Secondly, the execution of this 
 operation was difficult where the thyroid was very large, 
 especially in cases in which its relations to surrounding- 
 tissues were altered; or it predisposed to secondary 
 hemorrhages on account of the fragility of the vessels." 
 Kocher, Kopp and Rehn have recorded cases in which 
 this operation was followed by tetany. 
 
 3. Exotliyropexy, which was first done by Poncet and 
 Jaboulay, consists in exposing the thyroid gland, and 
 suturing it in the wound, where it is left exposed, in the 
 hop^ that atrophy will occur. This operation has been 
 abandoned by Poncet, because of the high mortality 
 (23 per cent.) and the frequent recurrence of Basedow's 
 disease after this procedure. 
 
 Simple Section of the Sympathetic Nerve. Jabou- 
 
 22. Surrel : Des accidents qui peuvent compliquer 1'intervention 
 chirurgicale dans le goitre exophtalmique, Thesfe de Paris, 1897. 
 
 23. De Cyon : Acad. des Sciences, 1897, Juin. 
 
 24. Rehn : Miinchener Medizinische Wochenschrift, Oct. 10, 1899. 
 
 25. Balacesu : Archiv fiir Klinische Chirurgie, vol. Ixvii, 1902.
 
 99 
 
 lay 26 performed bilateral section in 6 cases and the uni- 
 lateral operation in 2 cases. He records 2 cures, 5 im- 
 proved cases and 1 death, which occurred 18 months 
 after operation a mortality of 12.5 per cent. In all of 
 these patients the exophthalmos was influenced favora- 
 bly after the first day; the thyroid enlargement dis- 
 appeared slowly, while the tachycardia was scarcely 
 influenced by the operation. He proposes that in cases 
 in which the tachycardia is pronounced the inferior 
 cervical ganglion shall be excised. Balacesu 27 claims 
 that simple section influences the exophthalmos and 
 thyroid enlargement but little, and the tachycardia not 
 at all. Pean 28 pronounces the operation resultless and 
 unnecessary. He advocates thyroidectomy. Gayet 29 has 
 stated that simple section powerfully influences the triad 
 of symptoms, and this effect is permanent. It must be 
 remembered that Gayet's article appeared in 1896, while 
 that of Balacesu was published in 1902. 
 
 5. Stretching of the Cervical Sympathetic. In the 
 only ( Jaboulay's) case in which this operation was per- 
 formed the tachycardia was markedly increased, the 
 pulse ranging from 110 to 130 two weeks after the oper- 
 ation. The exophthalmos and tlryroid enlargement 
 were uninfluenced. 
 
 6. Stretching of the pneumogastric nerve has been 
 tried by Jaboulay 30 in cases of exophthalmic goiter with 
 severe cough. It is said to arrest the laryngeal spasms. 
 This procedure must be regarded as dangerous and with- 
 out curative value. 
 
 7. Ablation of the cervical sympathetic has been 
 abandoned. 
 
 8. Partial Resection (Kemoval of the Superior Gang- 
 lion) and Partial and Extensive Resection (Removal of 
 the Superior and Middle Ganglia with the Intervening 
 Strand. These procedures have gained an established 
 position among exophthalmic goiter operations. Bal- 
 acesu 31 reports 27 cases which were treated by partial re- 
 section, and were observed for periods varying from 
 1 to 4 years. In all of these cases there was rapid and 
 
 26. Jaboulay : Chirurgie du Grand Sympathetique et du Corps 
 Thyroide, p. 79, 1900. 
 
 27. Balacesu : Archiv fur Klinische Chirurgie. vol. Ixvii, 1902. 
 
 28. Pean : Bull. Acad. de Med., Tome iii, p. 31, 1897. 
 
 29. Gayet: Lyon MSdicale, No. 30, 1896. 
 
 30. Jaboulay: Lyon M6dicale, April, 1898. 
 
 31. Balacesu : Archiv fur Klinische Chirurgie, vol. Ixvii, 1902.
 
 100 
 
 pronounced improvement. The exophthalmos disap- 
 peared within the first few days, the thyroid diminished 
 in the first 8 days, but the tachycardia persisted, the 
 pulse ranging from 110 to 120. The palpitation did 
 not return, and the facial expression was much changed 
 for the better. After a time, the tachycardia showed a 
 tendency to decrease, but never was as pronouncedly 
 influenced as were the other Basedow symptoms. In this 
 series of 27 cases there were 9 cures, 11 improvements, 
 2 uncured cases and 5 deaths, none of which could be 
 attributed to the operation. The mortality of these pro- 
 cedures is small, probably less than 5 per cent. Sudden 
 death, however, has occurred after partial resection. 
 One such case, which was operated bilaterally by Ber- 
 nays and Simpson 32 of St. Louis, died of heart failure 
 on the llth day. That partial resection is not always 
 curative is shown by a case recorded by Chauffaud and 
 Quenu, 33 who removed the superior ganglia without in- 
 fluencing the exophthalmos and goiter. It seems rea- 
 sonable to concede (1) that partial resection is the oper- 
 ation of choice in those cases of exophthalmic goiter in 
 which the ocular and thyroid are more prominent than 
 the cardiac symptoms; (2) that the bilateral resection 
 should be made, but not at the same sitting, an interval 
 of 2 or 3 weeks being advisable; (3) that the mortality 
 is low. 
 
 9. Total bilateral resection is the procedure of choice 
 among the sympathetic operations. Of 19 cases which 
 are reported by Balacesu 34 as occurring in the practice of 
 Jonnesco, Soulie, Faure, Peugnecz and Depage, 35 in 14, 
 after the second day after operation, the Basedow symp- 
 toms disappeared one after another. This improvement 
 continued daily until cure was complete. This report 
 is verified by the experience of Halstead 36 and Wither- 
 spoon. 37 Halstead, writing four weeks after total bi- 
 lateral resection, says: "The patient's exophthalmos 
 has gieatly improved; the pulse is better, the tremor and 
 general nervous condition are improved/' Witherspoon, 
 in 1899, was consulted by a woman aged 59 years, who 
 
 32. Bernays and Simpson : Personal communication, April 15, 
 1903. 
 
 33. Chauffaud et Qunu : Presse Medicale, July 3, 1897. 
 
 34. Balacesu : Archiv fur Klinische Chirurgie, 1902. 
 
 35. DSpage : Societe Royale des Sciences Medicates et Naturelles 
 Bruxelles. 1898. 
 
 36. Halstead : Personal communication, April 14, 1903. 
 
 37. Witherspoon : Personal communication, April 15, 1903.
 
 101 
 
 showed moderate exophthalmos, marked enlargement of 
 the right thyroid lobe, and a pulse rate varying from 
 130 to 150. She heard strange noises and had ideas of 
 persecution; the skin was moist, and the urine showed 
 casts and albumin. The diagnosis was chronic intersti- 
 tial nephritis, associated with Graves' disease. Believing 
 that in her general condition thyroidectomy was con- 
 traindicated, Witherspoon advised sympatheticectomy. 
 On September 10 the operation was made on the right 
 side. Eleven days later the left side was operated on. 
 After the second operation the pulse showed improve- 
 ment in quality and rate, the exophthalmos and enlarge- 
 ment of the thyroid almost completely disappeared, and 
 her mental condition improved. In December she went 
 on a visit to the countr} r . In the following February, 
 while riding, she became chilled and died two hours 
 afterward. Up to the present time no deaths have been 
 directly attributed to the total excision of the cervical 
 sympathetic. The results are 63.8 per cent, of cures; 
 18.1 per cent, of improvements; 18.1 per cent, of fail- 
 ures, and no deaths. 
 
 10. Thyroidectomy with partial resection of the cer- 
 vical sympathetic was performed on a patient of Dr. F. 
 Eobert Boyd by Dr. J. W. Smith and myself. The pa- 
 tient nearly died on the table from hemorrhage following 
 the slipping of a ligature. She expired suddenly on the 
 third day. The temperature rose suddenly and the 
 pulse became too frequent to be counted. 
 
 The failure of thyroidectomy to relieve the exophthal- 
 mos of Basedow's disease was remarked on by Stevenson 
 and Shears. 38 In the case of a woman, aged 25 years, 
 from whom the right lobe of the thyroid had been re- 
 moved 4 years previously, while the general symptoms 
 were improved greatly, the exophthalmos had steadily 
 increased. It is possible that cases presenting marked 
 exophthalmos and thyroid enlargement without much 
 tachycardia may be cured by thyroidectomy, combined 
 with resection of the superior cervical ganglion. 
 
 CONCLUSIONS. 
 
 1. Excision of the superior cervical ganglion of the 
 sympathetic nerve is worthy of a trial in those cases of 
 simple atrophy of the optic nerve which resist measures 
 less heroic. 
 
 38. British Medical Journal, Jan. 25. 1902.
 
 102 
 
 2. It is yet impossible to say whether the bilateral 
 operation is advisable in unilateral optic-nerve atrophy. 
 
 3. The value of sympathetieectomy in congenital 
 hydrophthalmos has not been demonstrated. 
 
 4. In exophthalmic goiter,, complete excision of the 
 cervical sympathetic is followed by a larger percentage 
 of cures than is any other procedure. Thus far no deaths 
 have been recorded. The number of operations, how- 
 ever, is small and final conclusions can be announced 
 only after a large number of cases shall have been treated 
 by this method. 
 
 3509 Franklin Avenue.
 
 PATHOLOGY OF THE CEEVICAL SYMPA- 
 THETIC. 
 
 JOHN E. WEEKS, M.D. 
 
 IS T EW YORK. 
 
 The departure from the normal in the cervical sym- 
 pathetic may be classed under two heads, namely, irri- 
 tation and paralysis. 
 
 1. The symptoms of irritation are: (a) mydriasis, due 
 to spasm of the dilator pupilke; (b) exophthalmus, said 
 to be due to contraction of the smooth muscular fibers 
 of the orbit (Miiller's) ; (c) widening of the palpebral 
 fissure by tonic contraction of Miiller's muscle; (d) 
 contraction of the walls of the vessels of the head, face 
 and neck, including pallor of the skin, frequently with 
 an increase in the amount of perspiration; (e) accelera- 
 tion of the heart beat. 
 
 According to Xicati, 1 paralysis of the cervical 
 sympathetic may be divided into two stages : 
 
 First Stage. (a) Contraction of the pupil, (b) nar- 
 rowing of the palpebral fissure (ptosis), (c) decrease 
 of the tension of the globe, (d) increased lachrymation, 
 (e) injection of the ocular conjunctiva, and, in many 
 cases, (f) slight exophthalmus. There is also conges- 
 tion of the corresponding side of the face, anidrosis in 
 the greater number of cases, sometimes hyperidrosis ; 
 also acceleration of the heart action in a minority of the 
 cases. 
 
 Second Stage. The ptosis remains. The miosis per- 
 sists for some months. The miosis, consequent on re- 
 moving the stellate ganglion in animals, is recovered 
 from in two to three months. 2 The tension of the eye- 
 ball becomes normal after some weeks or months, grad- 
 
 1. Nicati, La paralysie du nerf sympathetique cervical, Lau- 
 sanne, 1873. 
 
 2. Onuf and Collins, Arch, of Neur. and Psych., vol. iii, Nos. 
 1 and 2.
 
 104 
 
 ually becoming less pronounced. What may be termed 
 the vasomotor disturbances disappear in a relatively 
 short time. In exceptional cases, atrophy of the tissues 
 of the corresponding side of the face follows. 
 
 Cases of irritation of the cervical sympathetic are not 
 common. They have been observed as being due to 
 abscess in the neck; 3 pressure of tumors, as malignant 
 growths, cystic goiter, 4 with exophthalmus ; thoracic 
 aneurism; 5 injuries to the neck; 6 injuries to the spinal 
 cord, between the fifth cervical and third dorsal verte- 
 brae. 7 
 
 Irritation symptoms may pass over to symptoms of 
 paralysis and again return to those of irritation, due to 
 irregular pressure. Cystic growths are most apt to pro- 
 duce these phenomena. In consulting the literature on 
 affections of the cervical sympathetic, the writer has 
 studied the reported cases of irritation of this portion 
 of the sympathetic nervous system for the purpose of 
 ascertaining if any of the patients suffered from glau- 
 coma. Quite a full list of the reported cases of this na- 
 ture is given by Lloyd. 8 In none of the histories of such 
 cases is mention made of glaucoma as a complication. 
 
 Paralysis of the cervical sympathetic may be due to 
 the pressure of tumors, glandular swellings, 9 malignant 
 neoplasms, 10 cicatrices in the neck, aneurism, 11 abscess, 12 
 wounds of the neck, 13 injuries to the brachial plexus in- 
 volving the sympathetic, diseases and injuries affecting 
 the spinal cord, spinal caries, various pulmonary af- 
 fections; paralysis of the cervical sympathetic also ap- 
 parently occurs idiopathically. 
 
 Tumors originating in the sympathetic and interfer- 
 ing with its function are extremely rare. A case of 
 fibrosarcoma of the cervical sympathetic is reported by 
 Abbe/ 4 and he refers to cases reported by Paget, Prud"- 
 
 3. Althaus, Med. Chir. Trans., vol. xli, p. 398. 
 
 4. Bemere, Wurtzburger med. Zeitschr., 1862, bd. iii, S. 262. 
 
 5. Flint, "Clinical Medicine" ; Walshe, "Diseases of the Heart." 
 
 6. Seeligmuiler, Arch. . Psych., bd. v., S. 835. 
 
 7. Rosenthal. "Diseases of the Nervous System," p. 216. 
 
 8. "Twentieth Century Practice of Medicine," vol. xi., p. 457. 
 
 9. Frankel, Berl. klin. Woch., 1875, No. 3. 
 
 10. Verneuil, Gaz. des hSpitaux, April 1, 1864. 
 
 11. Gairdner, Edinburgh Med. Jour., 1855, p. 143. 
 
 12. Jewell, Chi. Jour, of Mental Dis., 1874. p. 15. 
 
 13. Weir Mitchell, "Gunshot Wounds and Other Injuries of 
 Nerves," Phila.. 1864. 
 
 14. Annals of Surgery, April, 1898.
 
 105 
 
 den., Virchow, Satterthwaite and Reynolds of neuro- 
 fibromata affecting the sympathetic. 
 
 Of the symptoms said to be due to abnormal condi- 
 tions of the cervical sympathetic and the consequent in- 
 fluence on the vessels, migraine may be mentioned. This 
 may be preceded or accompanied by disturbances of 
 vision, (a) periodic hemianopsia, (b) scintillating 
 scotoma, (c) monolateral transient amaurosis, and (d) 
 monolateral photophobia. Accompanying migraine we 
 may also have flushing of one side of the face, anidrosis 
 or hyperidrosis, with narrowing of the palpebral fissures 
 and moderate miosis. 
 
 The affections of the eye, supposed to be caused in 
 greater part by abnormal conditions of the cervical sym- 
 pathetic, are glaucoma and exophthalmic goiter. It is 
 not the province of this article to enter into a discussion 
 of the relation of the cervical sympathetic to these dis- 
 eases further than to inquire into the changes, if any, 
 that have been observed in the tissues of the cervical 
 sympathetic occurring in individuals affected by these 
 diseases. 
 
 THE GANGLIA OF THE CERVICAL SYMPATHETIC. 
 
 The ganglia are surrounded by a thin, firm, adherent 
 covering of connective tissue which sends prolongations 
 into the ganglia, dividing them into compartments of 
 various sizes and serving as a supporting structure. A 
 delicate capsule, composed of a single layer of cells bear- 
 ing nuclei, surrounds each ganglion cell. The ganglion 
 cells have an average diameter of 20 microns, but vary 
 from 13 to 40 microns: The ganglion cells possess one to 
 three processes, one of which is an axon. The cells are 
 made up of a protoplasmic body containing a nucleus and 
 nucleolus. Many of the cells contain a greater or less 
 number of pigment granules. The ganglia contain 
 numerous nerve fibers, only a few of which are medul- 
 lated. The blood vessels are small and not numerous. 
 
 The nerve-trunk resembles the ganglia, except that it 
 contains no ganglion cells, and apparently contains a 
 greater proportion of medullated nerve-fibers. 
 
 PATHOLOGIC CHANGES. 
 
 The writer has little doubt that the ganglia of the 
 cervical sympathetic in the aged undergo degenerative 
 changes to some degree. It is certain that these ganglia
 
 10G 
 
 as examined in the dead-house vary much in size and 
 appearance. 
 
 Hale White found in examining 33 semilunar ganglia, 
 taken from persons dying from different causes, that 
 most of them showed degenerative changes (Onuf and 
 Collins). 
 
 Gustav Kicke 15 reports a case presenting symptoms of 
 irritation of the cervical sympathetic. Autopsy showed 
 round-cell infiltration and 1 small hemorrhages in the 
 superior cervical ganglion of the affected side. He 
 thinks that paralysis of the vasomotor fibers and irrita- 
 tion of the oculopupillary fibers occurred. 
 
 Petrow 16 describes changes occurring in the sympa- 
 thetic in constitutional syphilis. In twelve cases which 
 he examined he found distinct alterations in the nerve 
 elements and in the interstitial connective tissue, hyper- 
 plasia of the latter being apparent. There was pigment 
 and colloid degeneration in the nerve-cells, alterations in 
 the cells of the sheaths of the ganglion cells consisting 
 of increase in size and proliferation. The endothelial 
 cells showed secondary fatty degeneration. 
 
 Pio Foa (Suir anatomia del gran simpatico) wrote 
 concerning some changes he had observed in the sym- 
 pathetic in various diseases. These were found 
 chiefly in the cervical and abdominal ganglia, 
 and consisted sometimes of simple or fibrous atrophy, 
 at other times of hyperemia, sclerosis, pigmentary and 
 fatty infiltration, amyloid degeneration, accumulation 
 of colorless blood-corpuscles and the presence of micro- 
 cocci in the blood vessels of the ganglia. These altera- 
 tions are well marked in syphilis, leukemia, pellagra, 
 tuberculosis and infectious diseases. 
 
 Mention should be made of two reports by Koster 17 
 on the state of the cervical sympathetic in persons who 
 had died suddenly from sunstroke. In one case, that 
 of a soldier, the superior ganglion of the right sympa- 
 thetic" was twice the size of the left and was the seat 
 of hemorrhagic effusion; microscopically, the nerve- 
 fibers were seen to be separated and disintegrated. 
 There were small hemorrhages in the upper part of the 
 right sympathetic, while slight effusions of blood were 
 found in and around both vagi and in the sheaths of 
 
 15. Wiener med. Presse. 1884. p. 1077. 
 
 16. Virchow's Arch.. 1873. bd. Ivii. p. 121. 
 
 17. Berliner klin. Woeh.. 1875. 'No. 34.
 
 both phrenic nerves. In the second case, that of a 
 woman 21 years of age, the pathologic phenomena were 
 a hemorrhagic infiltration and enlargement of both su- 
 perior ganglia of the cervical sympathetic, while the 
 microscope revealed the same appearances as in the other 
 case : there were also ecchymoses as large as peas in both 
 Vagi. In the first case, the patient had lived twenty- 
 four hours, having a pulse so rapid that its beats could 
 scarcely be counted; there was, however, no acceleration 
 of the respiration. 
 
 GLAUCOMA. 
 
 The ganglia excised in Ball's cases were examined by 
 Dr. Carl Fisch 18 of St. Louis. A great number of dif- 
 ferent staining methods were employed, but those of 
 Golgi, March! and Xissl were not employed, on account 
 of the method of hardening the specimen. The changes 
 found were approximately the same in all cases. 
 
 The most striking change Avas "a very marked hyper- 
 plasia 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." There was decided sclerosis of the walls of 
 the vessels and the capsules of the ganglion cells were 
 "much increased in thickness." "In Case 1, small foci 
 of round-cell infiltration are seen in this hyperplastic 
 growth of an inflammatory character." No "plasma or 
 mast-cells" could be demonstrated. 
 
 The ganglion cells were "immensely" pigmented; 
 many were in various stages of degeneration. Only a 
 few showed normal dendritiform processes. The net- 
 work of processes was reduced in volume and compressed 
 by the connective tissue new formation. The general 
 aspect Avas that of a general sclerosis, inflammatory and 
 originating in the walls of the vascular structures. The 
 changes in the nerA'ous elements are attributed to pres- 
 sure and inhibited nutrition. 
 
 Ziehe and Axenfeld (Sympatheticus-Resection beim 
 Glaucoma, Halle, 1901) report the examination of fiA-e 
 ganglia removed from three patients at Eostock. The 
 ganglia Avere examined by Dr. Keeker, Privatdocent, 
 working in the Pathologic Institute at Rostock. 
 
 CASE 1. Capsule thick; the connective tissue that accom- 
 panied the blood vessels was also thickened. Connective tis- 
 
 18. Ninth Internat. Ophthal. Congress. Utrecht. 1899, p. 554.
 
 108 
 
 sue poor in nuclei. Often the adventitia was thicker than the 
 remaining portion of the wall of the vessel, plus the lumen 
 of the vessel. A slight increase in the small cells was observed 
 in the vicinity of the vessels. No change in nerve elements. 
 Both ganglia presented the same microscopic appearance. 
 
 CASE 2. Right ganglion; marked diffuse interstitial scle- 
 rosis, most pronounced in the vicinity of the larger blood ves- 
 sels. Nerve elements normal. The left ganglion showed the 
 same changes, but to a less degree. Leucocytes slightly in- 
 creased in number. 
 
 CASE 3. The left ganglion, which was the only one re- 
 moved, showed increase of the connective tissue about the 
 blood vessels; adventitia very much thickened. Diffuse in- 
 terstitial sclerosis absent. 
 
 Lodato 19 examined two ganglia removed from a pa- 
 tient with glaucoma and found hyperplasia and sclerosis 
 of the connective tissue and a peripheral small-cell in- 
 filtration. The sclerosis was more marked in the gang- 
 lion from the older patient, the small-cell infiltration in 
 the ganglion from the younger patient. 
 
 In the first he found a number of small hemorrhages 
 which had destroyed some of the nervous elements. 
 There was some degeneration of a few of the medullated 
 nerve-fibers. No change in the nerve-elements in the 
 second case. 
 
 Lodato questions whether the small-cell infiltration 
 might not have produced an irritation which could have 
 caused a hypersecretion of fluids into the globe, and thus 
 have established the first stage of the glaucoma. There 
 is no report of control examinations. 
 
 Albertotti 20 gives an example of ten superior cer- 
 vical sympathetic ganglia, the cut being reproduced 
 from a photograph, which shows them to be of various 
 sizes and shapes. 
 
 Cutler 21 reports, regarding the microscopic examina- 
 tion of one superior cervical ganglion removed from a 
 patient suffering from glaucoma simplex, as follows: 
 
 Spofimen 5 centimeters long, % centimeter in diameter. 
 At one point for 1% centimeters is a thickening. Section* 
 through whole length of specimen show large ganglion cells. 
 In these cells the chromophilic bodies do not show the normal 
 size and arrangement, and many cells show small granules of 
 pigment. A growth of connective tissue is between the gang 
 lion cells. Nerve fibers are normal. 
 
 19. Arch, di ottalm,, vol. viii, p. 358. 
 
 20. Ann. di ottalm., Naples, xxix, p. 472. 
 
 21. Annals of Surgery, Phila., September, 1902.
 
 109 
 
 When we take into consideration the fact that de- 
 generative changes in the cervical sympathetic occur in 
 the old, whether there is marked evidence of disease or 
 not, it becomes apparent that it is necessary to make 
 control examinations before we can reach any reliable 
 definite conclusion regarding the condition of the cer- 
 vical sympathetic in individuals suffering from glau- 
 coma, or, in fact, in any disease supposed to be due to 
 pathologic changes in the cervical sympathetic. Such 
 control experiments were made by Dr. Ira Van Giesen, 
 in connection with the examination of the ganglia re- 
 moved, in the cases reported by the writer. 22 His report 
 follows : 
 
 Seven ganglia have been examined microscopically, includ 
 ing two bilateral operations, comprising thus five different 
 cases. The work has been paralleled by the examination of 
 control ganglia taken from subjects as near as possible the 
 same age as the operation cases. As the control studies are 
 very important in an examination of this kind, the normal 
 ganglia were subjected to precisely the same steps as in the 
 operation cases, and carried along with them side by, side. 
 Four ganglia of normal subjects were studied as controls and 
 secured in autopsies averaging about twenty-four hours after 
 death. (Thus far, however, but two of the control ganglia 
 have been complete for study.) 
 
 We have endeavored to bring to bear on the question as com- 
 prehensive an examination as possible, and the technic has 
 been directed toward all of the structures of the ganglion in 
 the following order: (1) The detection of any cytologic 
 changes in the neuron cell bodies. (2) A special study of 
 the so-called pigment granules in the neuron cell bodies. (3) 
 An examination of the connective tissue framework of the 
 ganglion. (4) A study of the blood vessels; and (5) the ex- 
 amination of the medullated and non-medullated fibers. 
 
 Special methods, both of fixation and staining, have been 
 used for each of these points in both sets of ganglia the 
 operation cases and the control cases and in all some three 
 hundred sections have been examined. Ten different fixations 
 have been employed, as well as the several varieties of stain- 
 ing methods best adapted for the demonstration of each of the 
 objects of examination. 
 
 1. The Neuron Cell Bodies. Throughout the series of op- 
 erated cases, the neuron cell bodies show the normal arrange- 
 ment and distribution of the chromophilic granules. There 
 are no evidences of degeneration, nor is there any atrophy or 
 signs of disappearance of the neuron cell bodies. In a very 
 
 22. Trans. Amer. Ophth. Soc., 1902, p. 455.
 
 110 
 
 few places, in fact, of quite exceptional occurrence, there are 
 appearances which might be considered as similar to the form 
 of chromatolysis in the centers of the neuron cell bodies seen 
 in the central nervous system. This, however, is also seen 
 in the control cases, and it seems to be of no significance ir 
 relation to the production of the glaucoma. 
 
 2. The Pigment Granules. The capsules of the ganglion 
 cells are also without alteration. The pigment grains are 
 certainly increased in the glaucoma cases as compared with 
 the control cases. A larger number of cells contain pig- 
 ment grains in the glaucoma cases, and the aggregate volume 
 of the pigment grains is greater. While the control cases con 
 tain a considerable amount of pigment particles, this can be 
 reckoned as being only fifty to sixty per cent, of the quantity 
 in the operation cases. 
 
 3. The Connective Tissue. Studied in specimens prepared 
 in Fleming's weak and strong solutions and stained by the 
 picric acid fuschin method, the connective tissue framework 
 shows no signs of proliferation or degeneration in the glau- 
 coma cases. One would not be able to distinguish between the 
 operation cases and the controls, judging by the connective 
 tissue. 
 
 4. The Blood Vessels. These were examined with especial 
 attention, both in the substance of the ganglion and in the 
 loose connective tissue surrounding it. The vessels are normal. 
 
 5. The Fibers. The medullated fibers in the ganglion are 
 so relatively few as compared with the non-medullated fibers 
 that Weigert's method of staining the medullated sheath leaves 
 the section quite decolorized. There are not enough medul 
 lated fibers to take the stain. Under the microscope, however, 
 the bundles of fibers in the ganglion show here and there the 
 darkly-stained medullated fibers among the axons. Compared 
 with the controls there seems to be no differences in the non- 
 medullated fibers. 
 
 Summary. We find, then, that as far as our methods of 
 examination of hardened material go the ganglia seem to be 
 normal with the exception of an excess of pigment in the 
 neuron cell bodies, and as to the significance of this, if it has 
 any, we are entirely as yet in the dark. The result of the 
 examination does not positively preclude the existence of a 
 lesion in the ganglia. (The ganglia were examined at the 
 new pathologic laboratory of the Women's Infirmary of New 
 York.) 
 
 Dr. W. H. Wilder of Chicago has kindly permitted me 
 to refer to the microscopic findings in the ganglia re- 
 moved from patients with glaucoma in his service. The 
 examinations were made by Dr. Sidney Kuh, who re- 
 ports as follows: Excess of pigment in the ganglion
 
 Ill 
 
 cells (age a factor?) ; cells not round, often appear 
 shrunken; eccentric nuclei, occasionally only the nu- 
 cleolus visible ; cells at times vacuolated ; mast cells ; vas- 
 cularity. All of these findings were present in each 
 case except the second finding (that of the cells not be- 
 ing round), as in some of the specimens the cells were 
 perfectly round. 
 
 Onuf and Collins 23 write: 
 
 Concerning the morbid findings in cases of Graves' disease, 
 Moebius has recently written: "All sorts of conditions have 
 been described; the ganglia are too large or too small; the 
 nerve too thick or too thin; there is too much connective 
 tissue or too few nerve cells; the nerve cells are deformed, 
 shrunken, or pigmented; there are small hemorrhages, de- 
 struction of nerve fibers, etc., etc. To all of which we make 
 an affirmative, choosing to disregard the writer's attempt at 
 irony. We have learned in recent years that in individuals 
 dying of long-standing nervous disease, the so-called func- 
 tional as well as organic, there are also invariably, especially 
 if the individual be somewhat advanced in years, retrogres- 
 sive changes in the nervous system. Although Moebius comes 
 to the conclusion that in the majority of cases of Graves' 
 disease nothing characteristic or essential is to be found in 
 the cervical sympathetic to explain the pathogenesis of the 
 disease, it does not seem to us that investigation of the 
 vegetative system of nerves in its peripheral and central 
 distribution has been sufficiently comprehensive to give tena- 
 ability to his position." 
 
 The following report is from the examination of nine 
 ganglia removed from patients suffering from exoph- 
 thalmic goiter. Five of these patients were in the prac- 
 tice of Dr. B. Farquhar Curtis, who has kindly per- 
 mitted me to make use of the report. The examinations 
 were made by Dr. F. C. Wood, pathologist to St. Luke's 
 Hospital, to whom I am indebted. I wish to express 
 my thanks to both these gentlemen for their courtesy. 
 This report is of practical value because of the control 
 examinations, which were made in connection with the 
 examination of the ganglia removed from patients suf- 
 fering from exophthalmic goiter. 
 
 1. There is no definite increase in the connective tissue of 
 the ganglia. 
 
 2. Pigmentation of the ganglion cells is quite constant and 
 abundant, though not present in all cells. 
 
 23. B. Onuf and Joseph Collins : "Experimental Researches on 
 the Cervical Sympathetic," etc., Archives of Neurology and Psycho- 
 pathology, vol. iii, Nos. 1 and 2, p. 217.
 
 112 
 
 3. A small proportion, always less than half, of the gang- 
 lion cells shows a central chromatolysis when stained by 
 Nissl's method. In some cells the change was advanced and 
 no chomophilic bodies could be seen; in others they were clus- 
 tered about the periphery of the cell. The nuclei were often 
 eccentric in the degenerated cells. 
 
 4. No fiber degeneration could be demonstrated. All the 
 ganglia showed about the same changes. 
 
 Control ganglia from autopsy cases dying from a variety 
 of diseases did not show marked chron*atolysis, though an 
 occasional cell with degeneration could be seen. The amount 
 of pigment formed was variable in these controls. It was 
 more abundant in the aged than in adults, but a certain 
 amount seems to be present in some of the ganglion cells of 
 the sympathetic, at least in cases which I have been able 
 to examine. 
 
 Keports of changes in the cervical sympathetic ob- 
 served in different pathologic conditions affecting the 
 system locally and generally, make it evident that as 
 yet no change has been found that is peculiar to glau- 
 coma. The findings in the cases of Ball, Ziehe and 
 Axenfeld, Lodato and Cutler, are uniform in regard to 
 the hyperplasia of connective tissue. This was also found 
 by Petrow in cases of constitutional syphilis, and by 
 Pio Foa in patients with various diseases. Slight in- 
 filtration of small cells does not appear to be peculiar 
 to glaucoma. 
 
 Changes in the nervous elements are reported by Ball, 
 by Cutler and by Kuh. These were not observed by 
 Ziehe and Axenfeld, nor by Lodato, except in the presence 
 of pigment granules. Changes in the ganglion cells were 
 observed by Petrow in individuals suffering from con- 
 stitutional syphilis. The validity of the statements re- 
 garding the uniform increase of connective tissue is 
 somewhat shaken by the results of Van Giesen's ex- 
 aminations, as no such increase could be demonstrated 
 in the seven ganglia which he examined. Kuh also fails 
 to irtention an increase of connective tissue. 
 
 The testimony in our possession is not sufficiently 
 conclusive to enable us to say that there is any constant 
 change in the cervical sympathetic peculiar to glaucoma. 
 Nor is it sufficiently conclusive to exclude the possi- 
 bility of such constant change. Farther and more care- 
 ful research is necessary; first, probably along the lines, 
 suggested by Dr. Van G-iesen, viz., by means of the Ehr- 
 lich methylene blue method with fresh ganglia or by
 
 113 
 
 other equally delicate methods for the purpose of de- 
 termining the conditions of the processes of the neu- 
 rons and the cell structure, and, second, a study of the 
 pigmentation of the neurons, which must be made in 
 comparison with control studies. 
 
 DISCUSSION 
 
 ON THE PAPERS OF DUS. DE SCHWEINITZ, WILDER, BALL AND 
 WEEKS, 
 
 DR. MELVILLE BLACK, Denver It has been a great privilege 
 to listen to these papers, and I am sure we must all feel that 
 we know more about the subject now than we did before. It 
 is a particularly interesting subject to me, and I believe that 
 we can feel from the statistics presented so far that the opera- 
 tion is one of value. It is an operation, however, that is to 
 be properly considered. My own personal feelings are that it 
 should not be performed as a last resort, but really as a first 
 one. The statistics of the operation will be vitiated, and have 
 been up to the present time, by attempting it as a procedure 
 where nothing could possibly be of any benefit. If sympathec- 
 tomy is to be of any service it must be before the filtration 
 angle is blocked or closed. If this angle has been occluded it 
 is a question if the operation can be of any permanent benefit. 
 It would seem to me that where eserin has a prompt action in 
 relieving tension and pain and in improving vision and bring- 
 ing up the field, that the action of sympathectomy should be 
 correspondingly good and more permanent; that is, we can 
 liken somewhat the after-effects of sympathectomy to the 
 effects we obtain from the use of eserin. Of course, we can not 
 continue the use of eserin indefinitely, and if we have in this 
 procedure something permanent, it is certainly of great value. 
 
 I am inclined to believe that the results will not be as 
 permanent as we would wish. With watching this one case 
 of mine it has seemed to me that the eye is getting from some 
 source more and more sympathetic nerve power. The ptosis 
 is subsiding; the eye is no longer congested; the pupil is be- 
 coming more nearly the size of its fellow; at one time we had 
 .50 diopter of myopia we now have .50 diopter of hyper- 
 metropia. Therefore it would seem to me that this eye is 
 gradually regaining its sympathetic nerve supply. 
 
 It would seem to me that where this operation is done a 
 sufficiently extensive procedure should be adopted to insure 
 as much cutting off as possible of the sympathetic nerve 
 supply; and that therefore it would seem well to excise the 
 middle ganglion with the superior. Any one who has watched 
 the operation will have noticed how associated these two 
 ganglia are and how easy it would be in removing the 
 superior alone to have a supply from the middle. Dr. Free- 
 8
 
 114 
 
 man, Denver, has operated on ten cases, removing both gan- 
 glia. Only one of these operations, however, was done for glau- 
 coma. He has seen in his practice no undesirable results 
 following this procedure, and his opinion was, as I obtained it, 
 that the operation was a comparatively easy one unless the 
 subject were an enormous, bull-necked individual. The scar 
 resulting is slight, provided a buried suture is placed, and in 
 the course of three or four months it is scarcely possible to 
 find a scar. The only thing of serious consequence that may 
 follow is. neuralgia, and that seems to be due to rather un- 
 necessary bruising of some of the nerves that come off through 
 the vertebrae. 
 
 I think that this operation is one that we should all con- 
 sider, so far as our statistical results present, as being one 
 of value, and while we should not embrace it with too much 
 enthusiasm, yet at the same time we should give it the benefit 
 of the doubt as being of some service, and we should not depend 
 on the operation only where iridectomy has failed and all other 
 known procedures have failed. It should be tried first, not last. 
 Several cases have been reported where the operation has been 
 of value even after iridectomy has failed. This might lead 
 us to think that in certain cases ganglion excitation existed 
 and that the removal of the ganglia relieved that irritation, 
 which might have been the beginning cause of the glaucoma. 
 
 DR. G. C. SAVAGE, Nashville, Tenn. I believe we have some 
 reasons for holding the opinion that the sympathetic nervous 
 system is the source of power that Nature has given us for 
 the correction of astigmatism. That in early life every astig- 
 matic eye has the power of correcting a considerable portion of 
 its defect, if not all, is now universally believed. One must 
 certainly be convinced that Nature has furnished some power 
 by which this defect is remedied. It is not in Mueller's muscle, 
 nor in the third nerve. In my own case atropin and homa- 
 tropin were used to uncover my error of refraction, but both 
 failed. I am to-day wearing a lens four times as strong as 
 that with which I commenced. Each time the increase was 
 made I got additional relief, until finally the full strength lens 
 was given. I happened to be in Dr. Burnett's office in 1889 
 and my corneal astigmatism was the same then as it is to-day. 
 A coasiderable portion of my astigmatism was corrected by 
 some means within the eye in spite of a mydriatic. 
 
 Only two meridians of any cornea that is astigmatic have a 
 focus the two principal meridians. One is the meridian of 
 greatest curvature, and the other of least curvature. When 
 Mueller's muscle, supplied by the third nerve, contracts, the 
 lens is made more convex, and the two foci are brought into 
 definite relation with the retina, but not closer to each other, 
 hence they are not made to fuse. The other muscle in the 
 ciliary body is that of Bowman, which I believe is controlled
 
 115 
 
 by the superior cervical sympathetic. If under the influence 
 of the sympathetic some fibers of Bowman's muscle can be 
 thrown into contraction while others are not, it would result 
 in tilting of the lens. When the lens is tilted on an axis in 
 the plane of the meridian of greatest curvature the two foci 
 are made to approach each other, and if the tilting be far 
 enough they are fused into one. The power given vis by Nature 
 for the correction of astigmatism is in Bowman's muscle, and 
 I believe it acts under the influence of the superior cervical 
 sympathetic ganglion. 
 
 UK. GEOHGE F. SUKER, Chicago I maintain that the relation 
 between any form of glaucoma and the sympathetic nervous 
 system, including the cervical, is still open for considerable 
 debate. We do not to a certainty know the physiologic tracts 
 of the cranial sympathetic fibers in all instances; nor do we 
 know whether or not these sympathetic fibers decussate in all 
 individuals as do the cranial nerves proper. The ganglion of 
 Ribes, situated on the anterior communicating artery, is not 
 present in every instance according to some anatomists. Yet, 
 if it is present, it is here where the cephalic extremities of the 
 ascending branches of the cervical sympathetic fibers join and 
 cross. This point may explain why, in some cases, a unilateral 
 excision of the ganglion is of only temporary benefit. For, if 
 this communication does exist, it is not unreasonable to sup- 
 pose that the opposite side is furnishing the abnormal stim- 
 ulus through the intact cephalic ends of the excised side. 
 Just as the other corresponding nerve centers take up the 
 function of its fellow when it is destroyed, so may the sym- 
 pathetic system, by means of its ganglia, do the same. This 
 fact may and does explain why in Dr. Black's case there was 
 a return of the function of the sympathetic with its detri- 
 mental effects on the side operated on. 
 
 There is no justification in excising the middle cervical 
 ganglion as well as the superior for glaucoma. However, it 
 is very necessary to cut the connecting cord and excise that 
 ascending branch of the middle ganglion which connects with 
 the ascending fibers of the superior ganglion high up in the 
 neck. It is only the cavernous and carotid plexuses of the 
 superior ganglion which hav.e any relation to the eye. For 
 reasons already stated it is necessary to completely destroy 
 the connections between these two ganglia. 
 
 The ciliary or lenticular ganglion must also be considered 
 if we expect to explain the relation of the sympathetic fibers 
 to glaucoma. For, it is the upper two-thirds which contain 
 sympathetic filaments supplying the anterior segment of the 
 eye. The lower third of this ganglion receives a branch of the 
 third nerve. Furthermore, the sympathetic fibers in the rami 
 communicantes, which are closely associated with the fifth 
 nerve and enter the eye along with the optic nerve, must be
 
 116 
 
 seriously considered. These branches also supply the segment 
 of the eye around which centers the pathology of glaucoma. 
 The experiments of Anderson, 1 Delens- and Rohmer 3 with the 
 sympathetic supply of the eye are to be considered in solving 
 its relation to glaucoma. Especially are these various sym- 
 pathetic fibers and ganglia to be surgically thought of in glau- 
 coma, for we know that the superior cervical is frequently, if 
 not invariably, histologically changed. What is true for this 
 ganglion may hold true for the others also. 
 
 In no case of glaucoma have all the sympathetic fibers and 
 ganglia, on one or both sides, supplying that eye ever been 
 severed. Experimentally they have, then tension was reduced 
 and the iris remained contracted, both permanently. 
 
 It is questionable, as Dr. de Schweinitz has stated, whether 
 any trophic actions can be ascribed to the sympathetic nerves. 
 As yet we are not in a position to attribute any trophic func- 
 tions to certain kind of nerves. The untoward effects which 
 follow the extirpation of the superior sympathetic ganglion 
 are trivial and not permanent. The only one to receive any 
 consideration is the enophthalmus; this, however, is only 
 slight and does not supervene in every case. 
 
 The statistics here given by Drs. Wilder and Ball show that 
 the operation was undertaken in such cases as might well be 
 called desperate. Therefore, the operation has not been 
 awarded a fair trial. There is no doubt that in well- 
 selected cases it will accomplish what an iridectomy will not. 
 In my hands the operation has been successful in a few in- 
 stances, as the reports of the cases show. What good the ex- 
 cision of the ganglion will do in optic atrophy is yet de- 
 batable. In the case on which I operated I did obtain a de- 
 cided benefit, though temporary. Dana of New York tried it 
 in a case of tabetic atrophy, though with what success I could 
 not ascertain. 
 
 Several years ago I was quite enthusiastic concerning the 
 future of sympathectomy; but of late I have become very 
 conservative, as my paper before this Section in 1901 clearly 
 demonstrated. 
 
 DR. EDWARD JACKSON, Denver The trend of the papers 
 would seem to indicate that we are not in a position to decide 
 man> . questions in reference to the use of excision of the 
 sympathetic ganglia in glaucoma. Yet in going over the 
 literature one point seemed pretty clear to me, and that is 
 confirmed this morning. Dr. Black broached it when he said 
 that the case in which excision does good is the case favorably 
 influenced by eserin. I think there is enough evidence now, 
 although it lies in a very small minority of the published 
 
 l.i Jour. Phys.. vol. xxviii. No. 3. 
 
 2. Bull, de la Soc. de Chlrnrgle. April, 1902, 
 
 3. Annals d'OcuUstlque, July, 1902.
 
 117 
 
 cases, to indicate that sympathectomy, or excision of the 
 ganglia, will do good in the cases that would be benefited by 
 iridectomy. If we consider apart those cases in which iridec- 
 tomy would have been a hopeful operation, I think the record 
 for sympathetic excision is very promising. That might ap- 
 pear to be saying that operations on the sympathetic had no 
 place where iridectomy is an established operation, but such 
 is not the case. I think sympathectomy may be of value in 
 an important class of cases ; as where one eye has been lost and 
 it is difficult to get the patient to consent to an operation on 
 the other eye at the stage where the operation is most hopeful, 
 where iridectomy can not be done, or the patient can not be 
 induced to have it done, and yet where if it were done the 
 probabilities would be in favor of it, we are now justified in 
 urging operation on the sympathetic. The cases where iridec- 
 tomy is reported to have been done and no good accom- 
 plished, and then sympathectomy has been efficient, might seem 
 to lead in another direction. I have seen one case where iridec- 
 tomy did no good and sympathectomy afterwards restored 
 vision. But it may be that in some of these cases where 
 iridectomy is said to have been done it has not been a broad, 
 complete excision of the iris, which I believe necessary to give 
 iridectomy its best effect. 
 
 DR. G. E. DE SCHWEINITZ, Philadelphia The members of the 
 Section must have realized that it has been impossible in pre- 
 senting a resume of the physiologic side of this question to 
 read in detail the experiments and observations on which the 
 conclusions were based. For example, I did not have time to 
 discuss the question of the pupil-dilating fibers which do not 
 run in the sympathetic system, although in the extended paper 
 I have made reference to them. I confess that I am distinctly 
 skeptical as to the permanent value of sympathectomy in the 
 treatment of glaucoma, although I realize that a certain num- 
 ber of brilliant results have followed this operation, and also 
 realize that at present our statistical information is to a cer- 
 tain extent misleading, because the operation has in most in- 
 stances been utilized as a last resource, and therefore the re- 
 sults of prompt interference according to this method are not 
 at our disposal, or, at least, at our disposal in a most limited 
 degree. Dr. Black's idea that if the effect of eserin on a 
 glaucomatous eye is good, we may reason that sympathectomy 
 would likewise be followed by good results, does not seem to 
 me to be an entirely safe guiding principle. Eserin accom- 
 plishes its good in those cases in which it is able to release the 
 filtration angle from blockade by contracting the pupil and 
 drawing the periphery of the iris away from the danger of 
 adhesive inflammation to the structures in the filtration angle. 
 Now, in a certain number of cases, perhaps in the majority of 
 cases in which sympathectomy has been performed, the process
 
 118 
 
 has been a chronic one in which pronounced blockade in the 
 filtration angle was lacking, cases in which it is possible that 
 there may have been a hypersecretion of the intra-ocular 
 fluids, or an increased serosity. Cases of acute glaucoma are 
 just the ones in which strong solutions of the myotics give 
 frequently the best temporary relief, and they are certainly 
 not the ones in which the sympathectomy is advisable, at least, 
 as far as our present knowledge goes. I entirely agree with 
 Dr. Suker, and all physiologic investigation is on his side, 
 that it is not necessary to excise the middle ganglion. Ex- 
 cision of the superior ganglion, which is the relay station for 
 the sympathetic nerve supply for the whole of the head, ac- 
 complishes everything that can be accomplished by this opera- 
 tion in so far as the relief of glaucoma is concerned. EC 
 ferring to Dr. Savage's interesting observations on his own 
 eyes, I may say that in the extended paper I have reviewed 
 at some length the action of the sympathetic on the eye in its 
 relation to accommodation and refraction. The evidence is 
 exceedingly contradictory, and the whole subject is an invit- 
 ing one for further research. 
 
 DR. WM. H. WILDER, Chicago The report of the histologic 
 appearance of the ganglia that were excised was not read, but 
 if any of you are interested in seeing the specimens they are 
 on exhibition in the next room. The ganglia do not show, as 
 was stated by Dr. Weeks, any increase in connective tissue, 
 but one can see in the specimens that there is an increase in 
 the adventitia of the coats of the vessels and that there is con- 
 siderable pigment in the cells. 
 
 One important question comes up in connection with the 
 statement made by Dr. Black, that he considers that where 
 there is good contraction of the pupil with eserin sympathec- 
 tomy would be indicated; one case I have reported, Case 7, 
 makes me doubt seriously whether we should resort to sym- 
 pathectomy or to iridectomy first in these cases of simple 
 glaucoma, I am skeptical about the value of iridectomy in true 
 simple glaucoma, particularly where the anterior chamber is of 
 normal depth, and it is in such cases that sympathectomy 
 should do good. We can not place much reliance on either 
 procedure, but perhaps we can rely as much on sympathectomy 
 as on* iridectomy. The unpleasant experience in Case 7 sug- 
 gests that possibly it might be safer to do the iridectomy first. 
 In spite of the sympathectomy in this case, the tension and 
 the central vision remained the same; the peripheral vision 
 continued to contract until it was as though the patient were 
 looking through a narrow gun barrel. I did an iridectomy 
 and there was hemorrhage from the choroid and the eye was 
 lost. A similar case has been reported by Mohr. However, in 
 such a case the same accident might happen if sympathectoiny 
 had not been done.
 
 119 
 
 It is not fair to condemn the operation when it fails to 
 restore an eye that has atrophy of the optic nerve, or when it 
 fails to relieve pain in an eye lost from glaucoma. It should 
 be given an early trial. The statistics indicate that the simple 
 chronic form is the most suited for the operation, with the 
 hemorrhagic form next. 
 
 DR. J. M. BALL, St. Louis As to the pathologic changes 
 found in the ganglia, we have found in exophthalmic goiter 
 that the same pathologic condition exists. It is" the same in 
 each of these conditions an overgrowth of connective tissue, 
 a separation of the nerve elements and the presence of pig- 
 ment. I have been told by Dr. Fish of St. Louis that the 
 same changes are found in multiple sclerosis and in tabes.
 
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