was loss of accommodation, and visual accuity was reduced to 20-200. The condition slightly improved under myotics, but on June 25th the condition was much worse. For about a week prior to July 9th vision in the right eye was reduced to little more than perception of light.

On July 9th sympathectomy was done on the right side. The wound healed nicely and the ocular conditions improved rapidly. At the present time the condition of this patient is eminently satisfactory. Her vision, with correcting lenses, is 20-20 in each eye. She reads. Jaeger No. 2 at eight inches with her distance glass, which shows that her accommodation is almost normal, and best of all, she has no pain whatever connected with her eyes. Her field of vision is slightly restricted on the temporal sides and slightly from above, the latter probably due to the ptosis.

When I compare the histories of these three operations with the history of the case of Dr. Emil Javal as described by himself, where he made use of the best ophthalmic talent in Europe, where in spite of operation after operation his condition became steadily worse; of his years of torment, ending first in absolute blindness in one eye and finally of a condition in the other but slightly better, with only perception of light during his good days, I cannot help believing that we have in sympathectomy a much better and more reliable operation than iridectomy, sclerotomy, or any other operation upon the ball of the eye.

With incomplete access to the medical literature on the subject of this operation, the statistics which I will now give are perhaps not quite accurate, but they are very nearly so. In all 110 cases have been reported. In one case death resulted from the operation. In this operation, however, there was an attempt to remove all three cervical ganglia. In twelve cases no effect was noticed upon the tension of the eye or upon the vision. In fifteen cases tension became normal or much reduced and the eye remained free from pain, but the vision continued steadily to decline. In seventy-two cases the disease seemed to have been checked and there was entire relief from pain up until the time the cases had been reported.

Only about a dozen cases have been reported in which the operation was performed during the first stages of the disease, and all these cases show favorable results as to vision and comfort, and this in my opinion is the crux of the whole question. In order

to get a thoroughly satisfactory result from this operation I believe it is necessary that the operation be performed early, as soon as a diagnosis of glaucoma can be certainly made. There is no question but that the leaders in ophthalmic surgery have been and still are bitterly opposed to this operation, but if this operation results in the relief of pain in 75 per cent. of cases, if it restores to sight and happiness even so small a percentage as ten or twelve, it seems to me this operation does not need the indorsement of even men best known in ophthalmology.

THE REMOVAL OF THE SUPERIOR CERVICAL SYMPATHETIC GANGLOIN FOR GLAUCOMA, WITH REPORT OF A CASE.*

By A. A. KERR, M.D.,

Salt Lake City, Utah.

The scarcity of literature on this interesting subject and the comparatively few cases that have been reported justifies the writer in reporting his case; believing that it will be of interest.

Removal of the superior cervical sympathetic ganglion causes contraction of the pupil; this in cases of increased intra-ocular pressure, facilitates drainage and alleviates the glaucomatous condition.

The cervical portion of the gangliated cord consists of three ganglia on each side, called the superior, middle and inferior cervical.

The superior cervical ganglion (the one removed on each side in the case reported), the largest of the three, is located opposite the second and third cervical vertebrae and sometimes as low as the fourth or fifth. It is usually fusiform in shape, of a reddish gray color sometimes broad, and occasionally contracted at intervals so as to give rise to the opinion that it consists of the coalescence of several smaller ganglia; and it is usually believed that it is formed by the coalescence of the four ganglia cor

*Read before the Rocky Mountain Interstate Medical Society, Cheyenne, Wyo., Sept

9th, 1902.

responding to the four upper cervical nerves. It is in relation in front with the sheath of the internal carotid artery and internal jugular vein; behind it lies on the rectus capitis anticus major muscle.

The connection of the ganglion with the aris may be briefly stated: The ganglion gives off a branch to the cavernous plexus which gives off a slender filament to the ophthalmic ganglion (situated at the back part of the orbit between the optic nerve and the external rectus muscle, lying generally on the outer side of the ophthalmic artery). Branches of distribution run forward with the ciliary arteries in a wavy course, above and below the optic nerve. They penetrate the sclerotic at the back part of the globe, pass forward in delicate grooves on the inner surface, and are distributed to the ciliary muscle and iris.

The effect of the sympathetic nerve in causing dilatation of the pupil, which in certain neurotic subjects may be extreme, is well known and was well exemplified in this case.

HISTORY OF CASE.

Mrs. V., aged 36 years, widow, occupation nurse (formerly house work.) Father died at 70 years of age of rheumatism of the heart; mother living, in fair health, aged 66 years. Two brothers and one sister; all living and well as far as known.

The patient has never been strong since childhood; had whooping cough, diphtheria and scarlet fever when a child; began to menstruate at eleven years of age. After two months this ceased and did not return till age of thirteen. Menstruations irregular and sometimes quite painful up to marriage at age of twenty-five. Patient has had two children, but no miscarriages.

On September 4th, 1899, her husband being delirious from typhoid fever, shot their two children and himself; this caused the patient a severe nervous shock, which was followed by a protracted neurasthenic condition. She also suffered from a small cyst of the left ovary, which was removed July 19, 1900. About six months ago patient was troubled for about two months with swelling of the feet, which I diagnosed as angiorneurotic oedema.

Patient's eye trouble dates back to time of the death of her husband. She then had some pain in left eye-ball and could not see objects close at hand. In January, 1900, patient then residing in California, consulted a lady oculist and had glasses fitted. She

wore them for three months; her eyes seemed to be better for about a year. About this time, patient then being in a hospital in Rock Springs, learning nursing, had an attack of severe pain in her eyes, when vision became indistinct and pupils persistently dilated. After one month her sight again gradually improved. In October 1901, patient had another similar attack, which troubled her for about two weeks.

In March, 1902, the patient then complaining of impairment of vision, presbyopia and pain in eyes, I referred her to Dr. Henry LaMotte for a re-examination of her eyes. He diagnosed glaucoma; used the ordinary methods of medical treatment, including the use of eserine very carefully, but the patient's condition continuing to grow progressively worse, he strongly recommended operation.

On May 1st, Dr. H. D. Niles and I, assisted by Dr. H. LaMotte operated, removing the superior cervical sympathetic ganglion on the left side. The incision was made parallel with and near the posterior border of the sterno-cleido-mastoid muscle; the internal jugular is avoided. In deepening the incision to expose the sheath of the common carotid and internal jugular vein, it is best to get below the exit through the muscles of the auricularis magnus and superficial cervical nerves, which emerge to near the surface about opposite and slightly back of the middle of the sterno-cleido-mastoid muscle and anterior to splenius capitus muscle. The occipitalis minor nerve which emerges a little higher should also be avoided. By carefully deepening the incision and retracting the wound, the common carotid artery may be recognized by its pulsations. Externally will be felt the internal jugular vein and between the two vessels lies the pneumogastric nerve. The descendens noni nerve lies in front of the common carotid artery. Having located each of these structures, the superior sympathetic gangloin may be recognized by its location posterior, as it lies on the rectus capitus anticus major muscle, opposite the third and fourth cervical vertebrae. It is a small fusiform structure of a grayish color, about one-sixteenth (1-16) of an inch in diameter. Exsection of this ganglion produced in each case an immediate contraction of the pupil, which was quite distinct.

The wound was sutured with a continuous horse hair stitch, which was removed on the fourth day to minimize scar formation.

The wound healed by primary intention and the patient left the hospital in twelve days.

On July 9, 1902, a similar operation was performed on the right side. The patient made a good recovery and left the hospital in one wek after the second operation.

The effects of the operation in each case were: Contraction of the pupil, some ptosis of the upper eyelid, improvement of vision, lessening of the intra-ocular tension and cessation of the ocular pain. On the left side there has been some slight loss of sensation on the part of the neck supplied by the auricularis magnus nerve, which was probably injured. This condition has gradually improved. On the right side the sensation is normal.

DISCUSSION.

DR. JACKSON-The cases reported by Dr. LaMotte are of especial interest on this account: Of the 110 cases of this operation for glaucoma (there are probably more than that which have now been reported), over a hundred were cases that were practically hopeless for any known method of treatment. They were cases, many of them, that had been submitted to iridectomy and had failed, and many others that had reached a stage when iridectomy was excluded as practically or entirely hopeless. By those cases no operation should be judged. The case reported by Dr. Black last year and the cases reported by Dr. LaMotte are of a different character. They are cases in which we would have hoped much from iridectomy, although in one of Dr. La Motte's cases sclerotomy had failed to give relief. They were still in a stage where something might be hoped from earlier methods of treatment. Tried on these cases the operation has certainly made a very much more favorable showing than the general statistics will indicate. For a certain class of cases we have in iridectomy a well recognized remedy, one that cures most cases. The cases of acute glaucoma, and subacute glaucoma that have not advanced beyond a certain stage, iridectomy will mostly cure. I think if we restrict it to this class of cases over ninety per cent. would be cured by iridectomy. For that class of cases sympathectomy must demonstrate its value pretty conclusively before it can be adopted as the superior method of treatment. But there are certain cases which are not hopeless and in which we would very much hesitate to do an iridectomy, and to those I want to call especial attention.