difficulties from and was fearing adhesions, agreeably THE WHITMAN LOOP OPERATION FOR surprised to find that the second operation was as free from technical difficulties as the first. EQUINOVALGUS It would seem as the for though major operation SAMUEL M.D. had reached a of KLEINBERG, trigeminal neuralgia stage perfection NEW YORK that left nothing to be desired. Yet so many advances in have been made surgery and are being made, that It is common knowledge that the tibialis anticus one cannot tell what the future hold. may Satisfactory muscle is frequently irreparably damaged by an attack as the technic now is, satisfactory results will follow of infantile Thus a dorsal in paralysis. very important only when proper discrimination has been exercised flexor and adductor is lost, and the cannot be the selection of cases. The should reserved operation be dorsiflexed to the normal degree or adducted when for call or what we major trigeminal neuralgias, if you at a right to the the disease. When mistakes in angle leg. Frequently, too, choose, Fothergill's diag¬ tibialis posticus muscle is paralyzed or weak, and nosis are it is if not that made, quite possible, probable, there is no power of adduction of the foot even in the will afford little if relief. Our operation any equinus. In a limb in which the tibialis anticus is of the treatment of mastery major trigeminal neuralgia paralyzed and the tibialis posticus is or clears the field for study of those other forms of paralyzed neuralgia, which, while in the trigeminal zone, do not originate in any lesion of the nervus trigeminus, and are not relieved by any operation on it. Our thoughts are now directed to the sympathetic system. What part the sphenopalatine ganglion may play in the etiology of these atypical forms is a question deserving thoughtful consideration. Accumulating evidence in my clinic has at least aroused our suspicion. It may be that the next advance in the surgery of neuralgias will deal with the resection of the sphenopalatine ganglion. The technic for its removal is now engaging our atten¬ tion. A decade hence it may be included among the conventional surgical procedures. 1724 Spruce Street.

ABSTRACT OF DISCUSSION Dr. Gilbert Horrax, Boston : Even at the present time a great many members of the profession regard the operation as one of extreme danger. The best proof for this is the fact that a large number of patients suffering from trigem¬ inal neuralgia are referred by other patients to the surgeon rather than being referred by their physicians. The operation is almost free from mortality. It is a very arduous, tiresome and sometimes a painstaking procedure. At the Brigham Hos¬ pital there have been 345 consecutive cases without a death. As to the subtotal resection of the sensory root for the gan¬ glion, I think I would differ from Dr. Frazier a little. So far as we know all the evidence goes to show that true tic douloureux is absolutely a progressive disease ; it progresses from one division to another. We have found that it always progresses in time over all three divisions. It will be inter¬ Fig. 1.—Technic of loop to see how Dr. Frazier's return opera¬ Fig. 2.—A, ten¬ esting long patients go without tion: A, peroneus brevis tendon; don; , C, distal part of tibialis of pain in the ophthalmic division. However, eye complica¬ A', distal part of peroneus brevis; anticus tendon. direction of of tions are very 10 per at the most. There are four B, transplantation slight, cent., peroneus brevis; C, median inci¬ or five distinct types of neuralgia which are increasingly draw¬ sion for exposure of dorsiflexor ing our attention and in which operations have been done tendons. without any benefit at all. That brings up the question of weak, the foot is in an attitude of equinovalgus. The alcoholic are sometimes of use in differ¬ injections. They is the more element of the entiating the types of neuralgia. Alcohol injection gives com¬ valgus usually prominent plete relief that will differentiate trigeminal from other deformity. If the attitudeof equinovalgus is permitted neuralgias perfectly. The only other point about the injection to persist, the and the peroneus tendons is sometimes when you are in doubt as to whether to do become contracted and a resistant deformity results. complete sensory root avulsion or not, an alcoholic injection With an equinovalgus the individual walks will give a temporary anesthesia over the area involved and deformity and with a marked In the thus get the patient used to what he will necessarily have to badly limp. analyzing of we go through—the entire numbness of the face after sensory deformity equinovalgus find, in addition to the root avulsion. contraction of the heel cord and peroneus tendons, two important factors: (1) During dorsal flexion the The Fundamental Physiologic Requirements of Muscular foot invariably goes into valgus, the dorsal flexors Performance.—O. Riesser discusses, from the therapeutic are to the outer side of the various factors influence displaced the foot, and the standpoint, that muscular per¬ tendon of the tertius such as diet above peroneus is very prominent. (2) formance, drugs, and, all, physical exercise. The dorsal In the multiplicity of its forms, its capacity for exact dosage flexor tendons are frequently unable to and graduation of its effect, physical exercise is one of the raise the foot to a right angle. The correction of most potent weapons for bringing a general systematic influ¬ Read ence to bear on the organism as a whole.—Therapeutische before the Section on Orthopedic Surgery at the Seventy- Second Annual Session of the American Medical Association, Boston, ¡lalhmonatshefte 34: 589, 1920. June, 1921.

Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/26/2015 this deformity therefore involves two problems: (1) reasonable to assume that in this position it will have, To place the dorsal flexor tendons so that when they by virtue of its direction and location, the best oppor¬ function they will hold the foot in a normal or neutral tunity to duplicate the function of the tibialis anticus. position in relation to the leg. (2) To reinforce the dorsal flexors by transplantation of other tendons. TECHNIC OF THE LOOP OPERATION The loop operation was devised by Dr. Royal Whit¬ A vertical incision is made over the lower half of man to meet these problems. the external surface of the leg down to a point The loop operation consists of the following essential behind the external malleolus. The sheath of the steps: (1) The displacement of the dorsal flexor peroneus muscles is incised and the peroneus brevis tendons to the inner side of the foot. The displace¬ separated from the . An inch incision ment is assured by looping the distal part of the is then made over the proximal part of the fifth tendon of the tibialis anticus about the dorsal flexors metatarsal bone and parallel to the external border and implanting it into the tibia. (2) The transplanta¬ of the foot. The tendon of the peroneus brevis is tion of the peroneus brevis to the inner side of identified and is cut from its attachment. This tendon the foot, preferably through the sheath of the tibialis is inserted over an area of about three-fourths inch, anticus, whose function it is to perform. As the and its attachment must be thoroughly separated. The

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Fig, 3.—Peroneus brevis tendon pulled Fig. 4.—A, peroneus brevis tendon; B, tibialis Fig. 5.—A, peroneus brevis tendon, D, pero¬ through sheath of tibialis anticus; B, distal anticus tendon; C, sheath of tibialis anticus neus tertius tendon, and E, extensor proprius free portion of tibialis anticus tendon; C, sheath tendon ; D, tendon ; E, F, hallucis tendon, sutured at site of attachment of tibialis anticus; D, peroneus tertius tendon; proximal and distal parts of extensor proprius of tibialis anticus tendon; B, tibialis anticus E, F, proximal and distal parts of extensor pro- hallucis tendon; G, G', annular ligament. tendon looped about dorsal flexors and im¬ prius hallucis tendon; G, C, annular ligament. planted into tibia; F, distal part of extensor proprius hallucis sewed to neighboring dorsal flexor tendon to prevent toe drop. peroneus brevis is not as strong as the tibialis anticus, tendon in the upper incision is elevated with a dull it is reinforced by transplantation of the peroneus instrument and pulled out from its sheath. It is then tertius and extensor proprius hallucis to the inner separated from the for about 3 or 4 inches above side of the foot. The transplantation of the peroneus the malleolus. In this procedure some of the muscle tertius is a very important part of the loop operation fibers have to be torn away from the fibula. and has a dual advantage. First, this muscle helps An incision is then made over the middle of the to dorsiflex the foot in an improved attitude. Sec¬ ankle, extending from several inches above the ankle ondly, by being displaced from its normal position, joint down to about the middle of the metatarsal the muscle is removed as a factor in the causation of region. The skin and subcutaneous tissue on both the valgus. The peroneus tertius has always been sides of the incision are elevated so as to expose all considered small in size and of little consequence. Dr. of the tendons on the front of the ankle. In order Whitman and I have, however, in a number of cases to avoid subsequent sloughing of the skin, the sub¬ found this muscle to be surprisingly large. At times its cutaneous tissue should be elevated together with the mustie belly was three-fourths inch in diameter. Clini¬ skin. On account of the thinness of the skin and cally it appears of primary importance in maintaining the scant amount of fatty and areolar tissue, it is valgus. The peroneus brevis is transplanted through important to avoid rough manipulation or tearing with the sheath of the tibialis anticus because it seems sharp instruments. A small transverse incision is

Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/26/2015 then made in the sheath of the tibialis anticus about fourth inch on the inner side. An important point 21/L. inches above the ankle, and the tendon of the in the after-care is the retention of the foot continu¬ tibialis anticus is cut. The tendon of the peroneus ously in the median line or in slight varus and at about brevis is then brought over to the front of the leg a right angle to the leg. To this end a posterior through a subcutaneous tunnel, and sewed with a splint is advised for the night. When the original single suture to the distal part of the tendon of the plaster bandage is removed, there is only slight volun¬ tibialis anticus. The distal part of the tibialis anticus tary motion in the foot. Within a few days this motion tendon is then pulled out of its sheath, and at the same increases and can be further increased by massage, time the peroneous brevis is pulled into it. When manipulation and muscle training, always bearing in the tendon of the peroneus brevis emerges through the mind to instruct the patient to hold his foot in the lower pole of the sheath of the tibialis anticus, the median line. The favorable range of motion for the suture holding it to the tibialis anticus tendon is cut. foot in which the loop operation has been performed is A strand of No. 2 or 3 catgut is then attached securely from 80 degrees dorsal flexion to 120 degrees plantar to the tendon of the peroneus brevis. The distal part flexion. It is well, therefore, that the foot be manipu¬ of the tendon of the tibialis anticus is now loose in lated to retain this range of mobility. To make this the wound. possible, the tibialis anticus tendon must not be too The annular ligament of the ankle is now cut just short. In cases in which it was triced up too much, below and in front of the external malleolus. The a moderate degree of calcaneus resulted. tertius is cut at its attachment it is freed peroneus ; RESULTS OF THE LOOP OPERATION from the tissues to a a little above surrounding point The was times the ankle so that it can be inward. It is loop operation performed thirty-two displaced of the then passed in front of the other dorsal fiexors arid on thirty patients, two patients requiring the on both feet. The of the varied into contact with the tendon of the' peroneus operation ages patients brought from to 28 The duration of the brevis. Recently we have been transplanting this 414 years. paralysis muscle through the sheath of the tibialis anticus ranged from three to twenty-six years ; in twenty-three cases the had existed from three to four together with the peroneus brevis. The tendon of paralysis The muscle was active the extensor hallucis is then cut near years. transplanted peroneus proprius the in the corresponding its distal end in seventeen cases, inactive in three cases, and metatarsophalangeal joint, others there was no note its function. is sewed to one of the common dorsal flexor tendons, regarding In our excellent was and its end is over and sutured to classifying results, applied proximal brought when the was corrected and the peroneus brevis and peroneus tertius tendons. With deformity entirely remained so under and the function a dull instrument the dorsal flexor tendons are raised weight bearing, of the foot was normal. If the up and displaced inward. The tendon of the tibialis practically deformity anticus is then behind all the dorsal flexors was corrected but the mobility of the foot restricted, passed the If was from within and then in front of them from result was considered good. the deformity outward, corrected and dorsal and flexion without inward to be attached later to only partly plantar the tibia. This than of the tendon of the tibialis anticus about restricted but the patient evidently walked better looping before the the result was considered an the dorsal flexors assures the inward of operation, displacement to the classifica¬ these tendons and the its name. improvement. According foregoing gives operation fourteen of our cases showed an excellent result. The foot is then to a If this tion, brought right angle. In ten cases the result was Five cases were is not the heel cord is cut good. possible, subcutaneously. and one was a failure. Two cases were not The tendons of the peroneus brevis, extensor improved proprius classified because there was no final note. Four of hallucis and peroneus tertius are then sewed to one the cases here considered had been another and a slit in the tibialis anticus good originally passed through classified as excellent. This was made because tendon and attached with sutures to the change kangaroo the function had decreased. In two of these bone and other structures at the site of attachment of patients the reduction in function was due to weak dorsal the tibialis anticus. This attachment must be made flexors ; in one the flexion was reduced because secure and covered up with a of subcutaneous plantar layer the tibialis anticus was too and tissue so that there will be no chance of The pulled up tightly, slipping. in the other case the in function was tibialis anticus is then into the tibia. In change attributed implanted to lack of after-care. In the cases in which this tendon it is that the foot there was implanting important an the that one or be in about 100 degrees of flexion. If the foot only improvement, records show plantar more of the calf or dorsal flexors were is at a or less than a the result muscles, peronei right angle right angle, weak before the thus a satisfac¬ will not be because will be awkward operation, precluding good walking ; result and the of and, if the calf muscles are weak, a resistant calcaneus tory snowing importance selecting will appropriate cases for operation. In one case there was develop. failure. In this it was found at the The wounds are then closed with several complete patient layers time of operation that the peroneus brevis was very of catgut sutures and the limb is put up in a plaster pale and evidently paralyzed or almost so. Hence the foot bandage with the foot adducted and forming an angle of 100 degrees with the leg. peroneus longus was transplanted instead. The calf muscles were only weakly active. The result was, as POSTOPERATIVE CARE we might have expected, a resistant varus and a As soon as the sensitiveness of the foot has disap¬ failure. peared, the patient may be permitted to walk. This The loop operation is intended for the permanent usually takes a week or ten days. The plaster-of-Paris correction of paralytic equinovalgus in a foot in which bandage should be removed at the end of about four all of the muscles about the ankle except one or both of weeks. The patient is then provided with a flat foot the tibiales are strongly active. If the muscles are brace and the shoe is raised from one-eighth to one- only weakly active and the condition is one of prac-

Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/26/2015 tically a dangle foot, the result will not be satisfactory the treatment of empyemas, and though the number for, on account of the muscle weakness, the implanta¬ of such cases we have had occasion to treat in this tion of the tendon of the tibialis anticus may produce way is not large, the results obtained are quite as defi- a resistant varus or calcaneus. In a foot in which the nite as those previously reported. calf muscle is weak and atrophied and the dorsal flex¬ The use of negative pressure in pythorax is well ors very active, this operation is distinctly contraindi- established, though its value is usually attributed to cated because with the foot suspended and plantar the fact that it encourages expansion of the lung, little flexion restricted by the implanted tibialis anticus the stress being laid on its power to cause hyperemia and weakly active calf muscle loses its function and a cal¬ the elimination of bacteria and pus cells over the caneus will be the result. It is also important to be whole extent of a thickened and infected pleura. The sure that the untransplanted peroneus longus is strong fact that an empyema may be cured despite failure of and remains as a strong abductor. For if it is weak a the lung to reexpand was strikingly illustrated by the resistant varus will develop. It is equally important following case: that this operation should not be performed on a foot REPORT OF CASE in which the dorsal flexors are very weak. The trans¬ S., a Canadian soldier, aged 23, gassed in France, Aug. 1, planted peroneus brevis is intended to supplement and 1918, developed left-sided pleurisy and had 40 ounces of clear not replace the dorsal flexors. If these muscles are fluid withdrawn twelve days afterward. During the fall of he was a number of times. In dorsal flexion will be and an 1918, aspirated January, 1919, weak, impossible equinus was admitted to Sanatorium with a definite will result. Thus it is evident that the results of the he Speedwell tubercular focus in the right lung. On admission he was thin, loop operation depend entirely on the proper selection had a poor color and was short of breath. The heart impulse of the cases. This operation should be performed only was felt outside the right nipple line, and a roentgen-ray when the dorsal flexors, peronei and calf muscles are examination revealed the left pleural space filled with fluid. was at intervals and strongly active. In such cases the result when the Thereafter he aspirated frequent large quantities of thick yellow fluid, containing numerous pus proper technic has been will be excellent. employed cells but free from organisms, were withdrawn. Jan. 14, 1 West Eighty-Fifth Street. 1920, rib resection was performed, 70 ounces of greenish yellow pus evacuated, and a drainage tube inserted. A week tidal with a 5 cent, solution of sodium ABSTRACT OF DISCUSSION later, irrigation per chlorid was commenced. At first we used 1 foot of negative Dr. Walter G. Stern, Cleveland : I have performed this pressure, later increasing this to 3 feet, which is equivalent operation several times, splicing all the tendons together; to 70 mm. of mercury. The cap was removed each evening but with a little knowledge picked up while touring the (being replaced by a sterile pad) and reapplied each follow¬ country with a committee to investigate operations on para¬ ing day, early in the afternoon. During the first ten days, lyzed feet, I came to the conclusion that the thing to do here pus in enormous quantities was discharged, and thereafter the was not to sacrifice the tendon of the great toe, but to per¬ amount diminished until February 25, when it was practically form one or more arthrodeses on the joints of the astragalus. nil. Operative closure of the sinus at this time would prob¬ If one does an arthrodesis of one or more of the astragalar ably have succeeded. The drainage tube was removed, March joints and then does the simple looping operation of Whit¬ 18, and the sinus closed spontaneously, March 20. Roentgen- man, wrapping the tendon of the tibialis anticus around the ray examination revealed a lung collapsed to the hilum, common toe extensors and caring for the peroneus tertius as which appeared only as a narrow strip beside the medias¬ described, one will get the same results without sacrificing tinum, the remainder of the pleural cavity containing air. the function of the great toe. When last seen, in the fall of 1920, the patient had gained in weight and seemed in perfect health, although the size of his pneumothorax was not appreciably reduced.

TIDAL IRRIGATION OF WOUNDS BY COMMENT MEANS OF LIQUID-TIGHT The points of interest in this case are: (a) the prob¬ CLOSURE able tuberculous nature of this empyema; (b) the remarkable of the thoracic SPECIAL REFERENCE TO THE TREATMENT displacement viscera; (c) WITH the unusual size of the which OF EMPYEMA OF THE THORAX pneumothorax closed spontaneously, and (d) the fact that no secondary W. H. TAYLOR, M.D. infection developed even though treatment was main¬ AND tained for less than one third of the time. N. B. TAYLOR, F.R.C.S. (Edin.) Of a series of eight cases of chronic empyema TORONTO treated by this method, the remainder were definitely Tidal irrigation is the alternation of positive with pyogenic in character and had been running from one in the wound. The is to two years prior to the commencement of treatment. negative pressure irrigation closure of the sinus occurred in from means of our which has Spontaneous conducted by liquid-tight cap, six already been described.1 The residue of fluid which four to weeks. No attempt was made to hasten lies in the wound during the incidence of closure by operative interference, and hypertonic solu¬ negative tion of sodium chlorid was the fluid used. pressure is diluted with fresh fluid each time the only wound is flooded, and each time the wound is drained TIDAL IRRIGATION again the resultant mixture is siphoned off into a waste The features of tidal vessel. distinguishing irrigation as compared with other negative pressure methods of From our with this measure in infected experience treating empyema are : wounds we were as war naturally optimistic regards 1. Owing to the nonemployment of adhesive pastes, Read before the Section on Surgery, General and Abdominal, at the apparatus may be removed and replaced as easily the Seventy-Second Annual Session of the American Medical Associa- as a tion, Boston, June, 1921. compress. 1. Taylor, W. H.; Taylor, N. B., and Gallie, W. E.: Tidal Irriga- 2. It may be either rib resection tion of Wounds by Means of Liquid-Tight Closure, J. A. M. A. 74: employed following 1700 (June 19) 1920. or intercostal puncture.

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