Clinical manifestations of the sympathetic reflex arc

CLINICAL MANIFESTATIONS OF THE SYMPATHETIC REFLEX ARC ANATOLE KOLODNY, M.D. New York, New York N a paper read in June, 1947, before the American Association for the Surgery of Trauma I presented neurophysioIogic evidence of the presence of a sympathetic reflex arc’ and I then touched briefly upon its cIinica1 significance. During the past severa years we have read of individua1 suggestions by clinicians recommending sympathetic block for the relief of one or another obscure cIinica1 condition. These suggestions, appearing isoIated and totaIIy unconnected, are further demonstrations of the cIinica1 significance of the sympathetic reflex arc. This entire probIem awaits an anaIytic and systematic interpretation in which a11 the IittIe understood conditions would be presented as having a common etioIogy and, therefore, a common therapy. To stimuIate study and thought by the cIinician who, in contrast to the Laboratory investigator, observes at firsthand numerous manifestations of the reAex, I shaI1 discuss brieff y severa cIinica1 conditions in which the sympathetic reflex arc is of supreme etioIogic importance. During London’s 194 I Crush Syndrome. air raids physicians found that victims whose Iegs had been pinned under timbers and masonry for severa hours died mysteriously of kidney failure. This strange condition was caIIed “crush syndrome.” Injuries to the vesseIs of the crushed extremity reflected the bIood vessels of the kidneys into spasm and thus caused anuria. A gradual increase in the bIood pressure followed. This clinica syndrome has been studied intensiveIy during the past few years by pathologists. While pathologists still taIk about the reIease of toxic substances by crushing injuries to

the muscIes of the Iimb and about some unknown muscIe-endocrine mechanism responsibIe for the observed intense vasoconstriction and ischemia of the gIomeruIar tuft, they agree that vasoconstriction of the kidneys is aIways present in the postgIomeruIar arterioles. The steady rise of the bIood pressure is a resuIt of this vasoconstriction. Experimenta data are now avaiIabIe which confirm the earIy appearance of vasoconstriction in crush wounds as seen by Keele and SIome foIIowing reIease of complete ischemia maintained for four hours in an extremity of a cat.2 Of course, one must admit that the vasoconstriction initiated and caused by a crushed or ischemic limb is Iimited not onIy to the kidneys but it is in the kidneys that this itseIf most vasoconstriction manifests aIarmingly. Considering a11 these proven facts it is IogicaI and scientificaIIy sound that repeated sympathetic blocking should take preference over a11 other measures in the treatment of a patient with a crush syndrome. VasodiIatation of the kidney arterioIes and gIomeruIar tufts is the first clear-cut aim of the chnician. Not a11 of us handIing traumatic surgica1 materia1 will see many cases of a we11 expressed crush syndrome but a11 of us have seen many border line cases in which in more or Iess extensive injuries to an extremity the patient shows numerous unexpIained complications of a systemic nature despite good, conventiona care. It shouId be an established ruIe that along with the management of the injured Iimb, a prompt and repeated bIocking of the sympathetic is a condition without which the management is deficient. This is especiaIIy true in patients with a IabiIe sympathetic system,

I

86

American

Journal

of Surgery

KoIodny-Manifestations the one with cyanotic, cIammy hands who is subject to instantaneous vasospastic reactions. Another fieId in which Cardiac Trauma. many individual observations have not been fully understood is the field of vasospastic heart disease. It is onIy through observations by the surgeon interested in trauma of the heart that we are Iearning how to anaIyze and systematize our cIinica1 observations. When a traumatised heart is exposed for repair, the most difflcuIt task is to contro1 the irritability of the heart muscIe. It was found that spraying the exposed heart with a soIution of novocain reIieves this irritability. The novocain, by bIocking the sympathetics, aboIishes the spasm of the numerous smaI1 bIood vesseIs of the exposed myocardium. Maguire and FriswoId3 noticed that a seemingIy trivia1 wound piercing the right ventricIe near the atrioventricuIar groove without damage to the Ieft coronary artery wiI1 cause eIectrocardiographic tracings consistent with a diagnosis of anterior infraction in IOO per cent of the cases. These typica tracings disappeared in from seven to ten days. This is an observation which gives credit to the investigative minds of these surgeons in contrast to the average surgeon who usuaIIy is so preoccupied with the mechanica detaiIs of his job that important observations escape him. This observation, which is bafHing to the cardiologist, to my mind is expIained by the distribution of the sympathetic system in the heart. For a study of this subject I refer you to an exceIIent monomuscIe graph by MueIIer. 4 The heart shows an abundant suppIy of nerve fibers in the pectinate muscIes, the trabecuIa carneae and in the papiIIar muscIes. IncomparabIy more abundantIy suppLed is the region of the heart aIong the coronary suIci and the atrioventricuIar groove. There the heart is thickIy covered with widely ramified bundIes of the sympathetic nerves for at Ieast I inch to each side of the groove or SUICUS. Therefore, even a seemingIy trivial wound in the neighborJuly,

1949

of ReA ex Arc

87

hood of the atrioventricuIar groove divides numerous sympathetic bundIes causing an immediate and widespread spasm of the coronary ramifications with the typical eIectrocardiographic tracings. To some degree an anaIogous observation is seen in disease when even a small coronary ischemic area in the myocardium initiates a further spread through the sympathetic of a reflex spasm and Ieads to an aggravation of the disease. It is onIy IogicaI, therefore, to suggest that measures aiming at vasodiIatation through bIocking of the sympathetic arc in the myocardium shouId foIIow immediately after the conventional administration of anaIgesics and oxygen in the treatment of coronary disease. Such a sympathetic bIock is not to be viewed as a pain-relieving measure only as it is at present. It aIso foIIows that whenever time permits, a sympathetic bIock should precede any surgery on the myocardium. Postvagotomy Complicutions. We now come to a fieId in which the roIe of the sympathetic refIex arc may be studied as a scientificaIIy conducted Iaboratory experiment. With the enthusiastic support of Gragstedt, section of the vagus nerves for the cure of peptic uIcer recentIy acquired great pubIicity. This same operation was tried in Germany a quarter of a century ago and was discarded after severa trials. As usua1 the enthusiasm of the proponents of this operation bIinded them to the complications which follow this most drastic of surgica1 operations. GraduaIly reports appeared mentioning some quite unpleasant CompIications of the section of these most important vegetative nerves. But even in Chicago, the headquarters of vagotomy, no compIications are known to the surgeons. In adjoining Minnesota and even among the stoic New EngIand patients many and varied compIications were noticed by .the surgeons. The gastrointestina1 tract is innervated by both the sympathetic and parasympathetic systems. The parasympathetic system consists of the vagus nerves and of the spIenic nerve which is the sacra1 divi-

KoIodny-Manifestations sion of the parasympathetic system. The vagi suppIy the gastrointestinai tract down to the spIenic fIexure of the coIon whiIe the peIvic nerve suppIies the descending coIon. When the vagus nerves are cut in the chest or about their exit from the thorax, the sympathetic system is Ieft without an antagonist from the stomach down to the spIenic ffexure of the coIon. The postvagotomy compIications naturaIIy are the resuIt of sympathetic irritabiIity. In other words we are deaIing with a sympathetic reffex arc which is as unimpeded as the knee jerk in an upper neuron Iesion. Irritations, which under norma conditions wouId become neutraIized by the antagonistic action of the vagus, Iead to serious compIications in the absence of this antagonist. I had aImost no experience with postvagotomy complications unti1 May, 1947, when a vagotomy was done upon myseIf in the course of an esophagectomy, pIaying havoc with my digestion. Of course, I have studied my postvagotomy complications with greater care and interest than is usuahy the case in a foIIow-up cIinic or in cases in which the busy surgeon Ieaves this study to one of his junior assistants. ImmediateIy folIowing the vagotomy a number of compIications appear which confuse the patient. After a few weeks the compIications assert themseIves and crystahize. In my own case they have continued with some brief intermissions for the past tweIve months. These compIications appear in episodes or bouts and are more frequent in coId or damp weather. Exposure or chiIIing of the Iong thoracotomy scar immediateIy rehects in a new bout of eructations, regurgitations, nausea, occasiona vomiting of white, foamy, gastric secretion, abdomina1 distention and pain in the right Iower quadrant and throughout the Iower abdomen. The eructation and regurgitation resuIt from a dilation of the stomach through contraction of the pyIorus by the inhibiting action of the sympathetic system. Inhibition of the movements of the smaI1 gut and the

of Reff ex Arc proxima1 two-thirds of the coIon by the sympathetic Ieads to stasis. The overfiIIed, smaI1 gut causes pain typica of an intestina1 obstruction with Ioud borbory.gmus. This may persist for days unti1 a whrstIing sound of escape of intestina1 gas through the spIenic hexure of the coIon gives fuI1 reIief. This terminates the episode but not for Iong. An exposure to coId of my frostbitten finger or even an arduous argument or outburst of temper again reffects in a new bout of sympathetic crises. During the bout, turning from my back to my side and the consequent faIIing of the intestines to the dependent side, immediateIy exacerbates the pain. This is then accompanied by profuse perspiration (a sympathetic reaction), chiI1 and tingIing of the skin. Even Ioud talk and noises of various kinds increase the coIicky abdomina1 pain. From studying my own case I wish to state most emphaticaIIy that vagotomy is a highIy expensive surgica1 procedure. The price the patients pay is entirely out of a11 proportion to the disability caused by the peptic uIcer. I believe that even in esophagectomy the surgeon shouId make a rea1 effort to save the vagus nerves. SUMMARY

AND

CONCLUSIONS

I have spoken here about the role of the sympathetic refIex arc in a number of important IittIe understood conditions. As we have seen, the underIying disturbance of the crush syndrome is renaI vasospasm and subsequent anuria. RecentIy cIinicians have reported rapid contro1 of ecIampsia by means of sympathetic bIock achieved by spinal or high cauda1 anesthesia. This observation supports the suggestion that the pathoIogic physioIogy of ecIampsia is mainIy sympathetic vasoof the kidneys. Another recent spasm observation is that paravertebra1 sympathetic bIock reIieves the swoIIen hands and feet, muscIe spasm and tenderness of poho victims. WhiIe we know that spasm is not the most damaging effect of the it is IogicaI to beIieve that a disease, sympathetic bIock wiI1 accompIish more American

Journal

of Surgery

KoIodny-Manifestations with less in reIieving this spasm than the time and effort-consuming Kenny method. In my paper before the American Association for the Surgery of Trauma Iast year I expressed the view that the presupposed decussation in the pons cerebri of all post-ganghonic sympathetic fibers destined for the bIood vesseIs is not borne out cIinicaIIy. RecentIy Gilbert and de Takats, in treating cerebra1 vascuIar insuIt (another manifestation of vasopasm) with Necking of the sympathetic in the SteIIate ganglion, insist upon bIocking the ipsoIateraI gangIion. 5 This observation is in direct support of my view on decussation of the sympathetic fibers. Thus cIinica1 observations are again at variance with the views expressed by neuro-anatomists and physioIogists.

July,

1949

of Reff ex Arc

89

I have tried to give a few high spots of the field of pathoIogic physiology centering about the sympathetic reflex arc. It is an enormous fieId which requires intensive study, analysis, correlation and systematization. REFERENCES I. KOLODNY, ANATOLE. The sympathetic

its chnical

significance.

Am.

reflex arc and J. Surg., 73: 517.

1947. 2. KEELE, C. A. and SLOME, D. Rena1

blood How in experimentaL “crush syndrome.” Brii. J. Esper. Path., 26: 151, 1945. 3. MACUIKE, C. H. and GRISWOLD, R. A. Further observations on penetration wounds of the heart and pericardium. Am. J. Surg., 74: 721, 1947. 4. ~LuELLER, L. R. Die Lebensnerven. Berlin, 1924. Springer Verlag. 5. GILBERT, N. C. and DE TAKATS, GEZA. Emergency treatment of apoplexy. J. A. M. A., 136: 659, 1948,