A REFINEMENT IN THE RADICAL OPERATION FOR TRIGEMINAL NEURALGIA

1921 Journal of the American Medical Association (JAMA)  
distress in the left upper abdominal quadrant. No definite points of tenderness were found except over the operative abdominal scars. Gastric analysis was : free hydrochloric acid, absent; total acidity, IS; lactic acid, absent. A roentgenogram of the stomach and duodenum revealed the stomach empty in six hours; peristalsis, active; the greater curve 1% inches below the umbilicus, and no evidence of ulcer or car¬ cinoma. Food was passing through the pylorus and the gastro-enterostomy opening,
more » ... erostomy opening, more through the pylorus. A specimen of stool still contained larvae of Strongyloides intcstinalis. COMMENT This case has several points of interest. What relation had Taenia saginata to the pyloric ulcer? Evidently, since the worm was vomited it had taken up its position near the pylorus, and was at least partially the cause of the first pyloric spasm. The fact that there was improvement after the expulsion of the worms, and then again a pyloric spasm would seem to indicate that the worms were an exciting factor of the ulcer. After a short latent period the ulcer irritation began again, this time being the result of increased feedings. Vomiting of Taenia is as rare as is a double infestation of the worm. In every respect the results of the radical operation for trigeminal neuralgia are most satisfactory. Since Spiller, in 1901, first proposed section of the sensory root as a substitute for excision of the gasserian ganglion, his operation has grad¬ ually become the accepted procedure. One of the advantages claimed for his operation-a reduction in the mortality-has also been realized. In 189S the mortality as recorded in Tiffany's tables was 22.5 per cent. ; in 1909, in a series of 200 cases that I compiled from four surgeons with the largest experience in trigeminal operations, the mortality rate was 3.5 per cent. Today the mortality is approaching the zero mark. With the exception of one death from apoplexy of a patient in the convalescent stage, there have been none in my clinic in the last 157 operations (0.6 per cent.). The risk of the operation may be said to be a negligible factor, and the complete relief from pain may be offered in full justification of the sensory root operation. These are the major considerations. Of minor considera¬ tion is the "cosmetics." In times past the motor root has been sacrificed with the sensory root, and there followed inevitably atrophy of the temporal, masseter and pterygoid muscles. So far as it affected movements of the jaw it was a matter of inconvenience; but the atrophy of the temporal muscle left a depression above the zygoma that was quite noticeable and prevented what otherwise might have been regarded as a per¬ fect cosmetic result, since the incision was well concealed within the hair line. To meet this objection some surgeons went so far as to resect the zygoma. A year ago I took up this motor root problem and found a solution.1 In the past the motor root was often sacrificed because the surgeon was afraid he might be leaving a fascic¬ ulus of the sensory root with all its unforunate possibilities. But with the use of the electrode the motor root when exposed can positively be identified as motor by observing the tem¬ poral muscle contact. When the sensory root is adequately exposed, in the course of the operation, it is elevated from its bed with a blunt instrument. Usually the motor root may be seen in contact with the skull, traversing the space behind the root and dis¬ appearing behind the ganglion. If recognized or suspected, the electrode is applied ; and should it prove to be the motor root, the fibers of the temporal muscle, exposed to view in the wound, will contract. Sometimes at this preliminary inspec¬ tion the motor root will not be seen because, cleaving to the sensory root, it has been lifted up by the instrument with the sensory root. Under these circumstances I make segmental sections of the sensory root, beginning with the outer fasciculi,
doi:10.1001/jama.1921.92630020028010a fatcat:ewnnyw7cqvhzrp5vt2j2vyhrku