ALKALOSIS AND EPILEPSY
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428 ensure 11-1111tL1’y Uti).LPII ui Mit? wutjuiujs, auu wiuiiuuu z primary union of the skin tendon suture has little or no chance of success. As Mr. H. C. EDWARDS said in the opening paper 4 of the discussion just mentioned, the operation should be performed under ideal conditions, after routine preparation of the skin. It would be well, therefore, if the primary operation, when carried out in a casualty department, were confined to thorough cleansing of the wound and arrest of haemorrhage, the skin edges being trimmed where necessary, and sutured. Even for cases admitted straight to the wards it is probably good policy to concentrate on the asepsis and primary healing of the wound, and postpone more radical measures till the risk of sepsis is over. Immediate suture of nerves and tendons is not essential for the return of satisfactory function ; asepsis and primary union, on the other hand, are all-important. S. L. Keen and M. L. MASON,5 of Boston, who have made a special study of this branch of surgery, refer to the frequency with which severe lesions, even division of the median or ulnar nerve, are missed at the first examination ; and on several occasions they have found one end of the median nerve sutured to a cut end of tendon. More often than not the degree of injury found at operation has been greater than was expected ; for example, in cases where spontaneous recovery of a partially divided nerve was being hopefully anticipated there was complete division with separation of the nerve ends. The points on which KocH and MASON lay emphasis are careful examination to determine the extent of the injury before trying to repair the damaged tendons and nerves ; thoroughness in aseptic technique ; primary union of the skin, especially where there is injury to tendons with sheaths ; and the utmost gentleness in handling the tissues, so as to avoid further trauma. Sponging of the wound during operation is one cause of trauma, and to avoid it they recommend the use of a tourniquet to secure a bloodless field. Local anaesthesia is condemned as likely to increase the damage to the tissues ; moreover, it is difficult to apply a tourniquet for long if the patient is con- scious, and adrenaline, which is almost essential as an adjuvant in prolonged local anaesthesia, should not be injected if the tissues are extensively damaged. Another useful piece of advice given by KocH and MASON is that the incision should be planned so that a flap of skin will he over the site of the tendon suture ; troublesome adhesions between the tendon and cutaneous scars are thus avoided. In the finger, they remark, adhesions are too often encouraged by suturing both flexor tendons, when suture of the profundus alone would give good function and would not leave a mass of scar which obstructs flexion. In the British Orthopaedic Association’s discussion, Mr. R. WATSON JONES recommended that the sublimis tendon should be completely cut away. When dealing with lesions of the group tendons on the front of the wrist, it is useful to know that KocH and MASON have obtained almost as good results 4 Ibid., 1933, i., 65. 5 Surg., Gyn., and Obst., 1933, lvi., 1. by suture of the tendons en masse as by painstaking union of individual tendons. Grafts from the ten- dons of the foot have proved satisfactory, but the same cannot be said for nerve grafting. There are a few scattered reports of successful attempts, but when accurate end-to-end suture of the epineurium is impossible, the result of any measures will be uncertain, and failure is probable. That the treatment of these injuries deserves very special attention, no one who has had to attend compensation cases will question. Even such an apparently simple injury as subcutaneous rupture of the extensor communis tendon opposite the distal interphalangeal joint seems as often as not to leave a permanent and disabling deformity. There is no consensus of opinion about the right form of treatment ; many surgeons would not agree with MASON’S view that the rupture should always be repaired by open operation. The more extensive tendon and nerve injuries incidental to industrial life often mean the loss of livelihood to the wage-earner of the family, and involve large sums of money in compensation. It is not irrelevant to recall the experience of a Liverpool insurance company which now finances the treatment of cases of Colles’s fracture among its clients, and finds that this saves nearly 1400 per patient. ALKALOSIS AND EPILEPSY THE baneful effect of alkalosis and the beneficial effect of acidosis on the incidence of epileptic fits raised hopes some years ago that epilepsy might prove to be simply an expression of disordered acid-base balance. So far, however, no convincing evidence of such a change has been obtained. One of the main difficulties in research on epilepsy is that, apart from the brief aura, the onset of the convulsion can rarely be foreshadowed and biochemical observations in the all-important preconvulsive phrase are accordingly sparse. Once the fit has begun numerous metabolic changes can be demonstrated, but it does not seem permissible to regard these as anything more than direct consequences of violent muscular effort. Dr. F. L. McLaughlin and Dr. R. H. Hurst have recently examined the hydrogen-ion concentration, alkali reserve, and lactic acid content of the blood in a series of cases of epilepsy during and between fits. During the convulsion, and for a short while afterwards, the pH and alkali reserve were found to be abnormally low-this agrees with the observations of other workers-while the lactic acid content was considerably raised. But as similar changes can be provoked in normal subjects by violent exercise it is evident that this acidosis is due partly to respiratory embarrassment in the tonic stage and partly to excessive production of lactic acid by the muscles in the clonic stage of the fit. In the intervals between convulsions, the alkali reserve and lactic acid content of the blood did not fall outside the normal limits, although the pH tended to be rather high. The investigators were fortunate enough to obtain several specimens of blood a few minutes before convulsions began, and in none of these was the acid-base balance or lactic acid content abnormal. These findings are therefore essentially negative; but in confirming the current opinion that alkalosis plays no significant part in the aetiology of epilepsy they help to clear the ground for future research. 1 Quart. Jour. Med., July, 1933, p. 419.
Transcript of ALKALOSIS AND EPILEPSY
428
ensure 11-1111tL1’y Uti).LPII ui Mit? wutjuiujs, auu wiuiiuuu z
primary union of the skin tendon suture has littleor no chance of success. As Mr. H. C. EDWARDSsaid in the opening paper 4 of the discussion justmentioned, the operation should be performedunder ideal conditions, after routine preparationof the skin. It would be well, therefore, if the
primary operation, when carried out in a casualtydepartment, were confined to thorough cleansingof the wound and arrest of haemorrhage, the skinedges being trimmed where necessary, and sutured.Even for cases admitted straight to the wards itis probably good policy to concentrate on the
asepsis and primary healing of the wound, andpostpone more radical measures till the risk of
sepsis is over. Immediate suture of nerves andtendons is not essential for the return of satisfactoryfunction ; asepsis and primary union, on the otherhand, are all-important.
S. L. Keen and M. L. MASON,5 of Boston, whohave made a special study of this branch of surgery,refer to the frequency with which severe lesions,even division of the median or ulnar nerve, aremissed at the first examination ; and on severaloccasions they have found one end of the mediannerve sutured to a cut end of tendon. More oftenthan not the degree of injury found at operationhas been greater than was expected ; for example,in cases where spontaneous recovery of a partiallydivided nerve was being hopefully anticipatedthere was complete division with separation of thenerve ends. The points on which KocH and MASONlay emphasis are careful examination to determinethe extent of the injury before trying to repairthe damaged tendons and nerves ; thoroughnessin aseptic technique ; primary union of the skin,especially where there is injury to tendons withsheaths ; and the utmost gentleness in handlingthe tissues, so as to avoid further trauma. Spongingof the wound during operation is one cause oftrauma, and to avoid it they recommend the useof a tourniquet to secure a bloodless field. Localanaesthesia is condemned as likely to increase thedamage to the tissues ; moreover, it is difficult to
apply a tourniquet for long if the patient is con-scious, and adrenaline, which is almost essentialas an adjuvant in prolonged local anaesthesia,should not be injected if the tissues are extensivelydamaged. Another useful piece of advice given byKocH and MASON is that the incision should be
planned so that a flap of skin will he over the siteof the tendon suture ; troublesome adhesionsbetween the tendon and cutaneous scars are thusavoided. In the finger, they remark, adhesionsare too often encouraged by suturing both flexortendons, when suture of the profundus alone wouldgive good function and would not leave a massof scar which obstructs flexion. In the BritishOrthopaedic Association’s discussion, Mr. R.WATSON JONES recommended that the sublimistendon should be completely cut away. Whendealing with lesions of the group tendons on thefront of the wrist, it is useful to know that KocHand MASON have obtained almost as good results
4 Ibid., 1933, i., 65.5 Surg., Gyn., and Obst., 1933, lvi., 1.
by suture of the tendons en masse as by painstakingunion of individual tendons. Grafts from the ten-dons of the foot have proved satisfactory, but thesame cannot be said for nerve grafting. There area few scattered reports of successful attempts, butwhen accurate end-to-end suture of the epineuriumis impossible, the result of any measures will beuncertain, and failure is probable.That the treatment of these injuries deserves
very special attention, no one who has had toattend compensation cases will question. Evensuch an apparently simple injury as subcutaneousrupture of the extensor communis tendon oppositethe distal interphalangeal joint seems as often asnot to leave a permanent and disabling deformity.There is no consensus of opinion about the rightform of treatment ; many surgeons would notagree with MASON’S view that the rupture shouldalways be repaired by open operation. The moreextensive tendon and nerve injuries incidental toindustrial life often mean the loss of livelihood tothe wage-earner of the family, and involve largesums of money in compensation. It is not irrelevantto recall the experience of a Liverpool insurancecompany which now finances the treatment ofcases of Colles’s fracture among its clients, andfinds that this saves nearly 1400 per patient.
ALKALOSIS AND EPILEPSY
THE baneful effect of alkalosis and the beneficialeffect of acidosis on the incidence of epileptic fitsraised hopes some years ago that epilepsy mightprove to be simply an expression of disorderedacid-base balance. So far, however, no convincingevidence of such a change has been obtained. Oneof the main difficulties in research on epilepsy isthat, apart from the brief aura, the onset of theconvulsion can rarely be foreshadowed andbiochemical observations in the all-importantpreconvulsive phrase are accordingly sparse. Oncethe fit has begun numerous metabolic changes canbe demonstrated, but it does not seem permissibleto regard these as anything more than direct
consequences of violent muscular effort.Dr. F. L. McLaughlin and Dr. R. H. Hurst have
recently examined the hydrogen-ion concentration,alkali reserve, and lactic acid content of the bloodin a series of cases of epilepsy during and betweenfits. During the convulsion, and for a short whileafterwards, the pH and alkali reserve were found tobe abnormally low-this agrees with the observationsof other workers-while the lactic acid content wasconsiderably raised. But as similar changes can beprovoked in normal subjects by violent exercise itis evident that this acidosis is due partly to respiratoryembarrassment in the tonic stage and partly toexcessive production of lactic acid by the musclesin the clonic stage of the fit. In the intervals betweenconvulsions, the alkali reserve and lactic acid contentof the blood did not fall outside the normallimits, although the pH tended to be rather high.The investigators were fortunate enough to obtainseveral specimens of blood a few minutes beforeconvulsions began, and in none of these was theacid-base balance or lactic acid content abnormal.These findings are therefore essentially negative;but in confirming the current opinion that alkalosisplays no significant part in the aetiology of epilepsythey help to clear the ground for future research.
1 Quart. Jour. Med., July, 1933, p. 419.
