Chapter XXXVII (3)

The operation described below is practically that advised by Jonnesco, more or less modified by other operators, and may be varied to some extent to meet the exigencies of particular cases. Thus whether it shall be done through one or two incisions will depend on the will of the operator. It is made about as follows: A long incision is made along the posterior border of the sternomastoid. The latter may be either retracted forward or its fibers separated, in order that the fascia on its inner side may be reached and separated from the deeper muscles. This fascia should be divided as high as the base of the skull. The upper ganglion of the cervical sympathetic lies on the inner side of the anterior tubercle of the transverse process of the second and third vertebral processes, resting upon the muscles covered by this fascia. The ganglion, being recognized by its shape, and the sympathetic trunk being thus identified, the nerve should be divided and made free, as high as possible and just beneath the base of the skull. (See Fig. 408.)

Diagram to illustrate the relations of the cervical sympathetic and the mechanism of the various disturbances following lesions of its trunk. (Stewart.)]

The lower end is to be exposed by continuation of the first incision, or by another beginning 1 Cm. above the clavicle and extending along the posterior border of the sternomastoid for 4 or 5 Cm. The platysma should be entered and the tissues separated upward until the fingers can meet in a channel thus made by connection with the upper incision. The tissues should also be loosened downward until a point has been reached behind the clavicle. They then should be widely retracted and the inferior thyroid artery sought. The middle cervical ganglion is found inside of its curve. Occasionally this ganglion is replaced by a plexus, or the main trunk may pass behind the artery. At this level it is to be seized and its upper divided end pulled down and out through this opening. The nerve trunk should then be followed downward. The artery should be freed from any plexus of sympathetic fibers around it, all of which should be destroyed, and especially those fibers which constitute the middle cardiac nerve, which pass to the inner side. The main trunk is to be drawn down beneath the artery and then followed downward and outward to the lower ganglion, where it lies behind the clavicle, on the neck of the first rib, between the scalenus anticus and the longus colli. The ganglion and the trunk should be separated from the efferent and afferent branches which connect with it, as well as from the vertebral artery; being thus made free it is again drawn outward. Here one should divide especially the cardiac branches which form the lower cardiac nerve, as well as the vertebral branches which have so much to do with controlling the supply through the vertebral artery. The ganglion, after being identified, should be finally removed. The nerve should be traced still farther down to the first thoracic ganglion, which has much to do with supplying the heart, and this also should be separated and destroyed (Fig. 409).

Sympathectomy. Exposure and removal of middle and upper ganglia. (Marion.)]

Sympathectomy. Seizure and removal of inferior ganglion. (Marion.)]

It is rarely necessary to provide for drainage after the operation, unless the retraction and laceration of tissues have been very great. My own preference is to make one long incision along the posterior border of the sternomastoid, by which the dissection is facilitated and the operation made less complicated and difficult. When done for glaucoma on one side it will be sufficient to attack one nerve, but when for epilepsy or for exophthalmic goitre the operation should be bilateral. When for epilepsy or glaucoma it is not so necessary to remove the lower cervical ganglion; this is indicated rather in those cases where it is desirable to control the accelerator nerves to the heart. The operation has given good results in all three affections named, yet it is one of considerable difficulty. It would be made extremely difficult by the presence of a large goitre, and in such case it would probably be better to extirpate the thyroid rather than to attack the nerve. (See Glaucoma, Epilepsy, and Exophthalmic Goitre.)