A new concept of the sympathetic pathways to the eye.

The sympathetic pupillociliary pathways controlling the dilatation of the pupil in man have been recorded by many authorities as passing via the first and/or second thoracic (dorsal) rami to the lower part of the stellate (first thoracic) ganglion. It has been stated by these and other authorities that the removal of the lower part of the stellate ganglion and/or resection of the first and/or second thoracic rami would produce a Horner's syndrome. This currently accepted concept of the sympathetic pathways to the eye we believe to be incorrect. Our entire clinical experience has consistently contradicted the findings and reports of other investigators. It is suggested that the ability afforded by a new surgical approach to reach, dissect, and exactly control the line of resection without undue trauma to the stellate ganglion has made possible for the first time a definitive statement concerning the entry of the pupillociliary pathways into the sympathetic chain. It is, therefore, postulated that the preganglionic neurons controlling the pupil enter the upper portion of the stellate ganglion by a separate paravertebral route leaving the ventral roots of the eighth cervical, first and/or second thoracic nerves. Our entire clinical experience refutes the concept that these pathways pass via the first ramus communicans to the first thoracic ganglion. This thesis is based on and supported by the results of new surgical approach originally designed to permit a more direct exposure and to overcome many of the deficiencies of current surgical approaches. The anterior transthoracic, transpleural wound employed allows a more direct approach and a more accurate and complete dissection of this segment of the sympathetic supply to the head, neck, upper extremity, heart, and coronary vessels without incurring the undesirable sequela of a Horner's syndrome in 93% of patients.

Distal antrectomy with vagectomy for duodenal ulcer: results in 611 cases.

Distal antrectomy (25% or less) resection of the distal stomach with bilateral vagectomy, Billroth II, antecolic, Polya or Hofmeister gastrojejunostomy, continues to be our operation of choice for chronic duodenal ulcer. This is based upon our experience in 611 operations and as a result of careful complete repeat in-patient followup studies conducted since our original operation which was devised and performed in July 1953. This procedure controls or eliminates the two major gastric acid stimulatory phases responsible in the pathogenesis and chronicity of a duodenal ulcer: neurogenic (cephalic phase) via the vagel gastric pathways, and the humoral (gastrin) phase via antral stimulation. Even though part of the antrum may remain in the gastric remnant in some patients, antral control is maintained because the antrum remains in the gastric acid stream, there is no stasis, and it is vagectomized. The ulcer diathesis is controlled with a minimal disturbance in gastric physiology, in function, and in gastric reservoir capacity; the procedure will almost eliminate all of the undesirable postoperative gastrointestinal sequelase associated with other operations for duodenal ulcer. It insures the least chance for marginal, gastric, or recurrent ulcer formation, and a low morbidity rate.