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 foot 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, peroneus brevis 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 Achilles tendon 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 peroneus longus. 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 v7 ^ -s- CD] 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, peroneus tertius 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 fibula 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.