The origins of sympathectomy.

BEFoRE severing the cervical sympathetic nerve in the rabbit's neck, Claude Bernard had expected that the result of this operation would be a decrease in the temperature of the affected side of the head. His hypothesis was false, but the observed fact, the increase in temperature, was unmistakable. The full significance of the experiment was, to him, initially concealed. To no less extent did its therapeutic implications evade early appreciation. One ofthe first to draw attention to the usefulness ofinterruption of the sympathetic pathways was Jaboulay2 who, in 1899, gave an account of periarterial stripping of the femoral artery in a man afflicted with trophic lesions of the foot. The artery was exposed and cleaned in Scarpa's triangle, and, over a period of five weeks, healing of the foot lesions occurred. Jaboulay was not unaware that hospital routine might be accused of contributing to this healing, but the purpose of his assault, aimed at releasing vasoconstrictor tone, was sound. Such limitations as beset him were those of technique. We shall see that technique advanced rapidly upon the limitations of unsound theory. Before this period Jonnesco,3 in 1896, working in Bucharest, had resected the inferior, middle, and superior cervical ganglia for epilepsy and exophthalmic goitre. Jaboulay was another who operated on the cervical sympathetic for the latter condition in this same year. Other surgeons followed suit, extending their indications to migraine and glaucoma. The operation found favour for a multitude of affections of the head and neck, and Jonnesco4 himself, following the suggestion of Frangois Franck, performed the operation for angina pectoris in 1916. Ren6 Leriche5 followed the path of his master, Jaboulay, in advocating periarterial sympathectomy for the treatment of vascular conditions. He was, however, troubled by the observation that a unilateral periarterial sympathectomy often had a bilateral effect, indeed to the extent ofvasodilatation of all four limbs. He entertained doubts as to the centrifugal nature of the fibres which he must be cutting about the femoral artery, and suspected that he might, in fact, be severing centripetal sensory fibres taking part in the maintenance of vasomotor tone. Noting the temporary hyperaemia following resection of an obliterated arterial, or even venous, trunk (in Buerger's disease), he remarked in the former, a 'hyperleucocytosis'.6 The histological evidence perturbed him, for no long nerve fibres were to be found about the artery, and, with the exception of the iliac and axillary arteries, the innervation of the vessels came from the adjacent nerves. These two exceptions derived their nerve supply directly from the sympathetic trunk.