102 THE GAMES

Tendon Reconstruction in the Hand" HERE is something wrong. Excise it ! " So runs

one of the earliest principles of surgery, and in thedevelopment of this attitude the surgery of excisionhas attained a. high level of competence and safety.The stage is now being reached beyond which sub-traction from the human frame ceases to be profitable." We think too much," said Sir JAMES WALTON

recently, " of the preservation of life, without con-sidering the quality of the life that is preserved." Anencouraging trend of surgery is towards operationsthat modify function or restore a function that isabsent or has been lost. The hand has longremained outside the surgeon’s serious interest; andthis is not surprising, for the results of interventionhave mostly been disappointing. It is strange,nevertheless, that the primary importance of the handto the patient has not been insisted on, and that theattitude of mind still prevails which will provide animmediate hospital bed and senior surgical attentionfor an elderly patient with an advanced carcinoma yetrequires a young working man with an injury to thehand to be treated by the newly qualified in thecasualty department. Such an attitude is no longerpermissible, for the results of reconstructive surgeryin the hand are now among the most beneficent in

surgery. This advance is largely due to two causes-an improved knowledge of the reactions of tissues toinjury, and perfections in technique. The atraumaticmethods of the plastic surgeon and neurosurgeon areof great value in hand surgery, and it is largely theadvances in these two specialties during the last

thirty years that have made reconstructive surgeryof the hand practicable and effective. Among thosewho have shared in this advance are CUSHING,JEFFERSON, and GILLIES and his colleagues BLAIR andBROWN, but it is to BUNNELL that we look as the

pioneer of the atraumatic method in the hand. Byhis practice and teaching BUNNELL has shown thesurgical world that loss of skin, nerve, tendon, ortendon-sheath in the hand can be repaired and areconstruction achieved restoring movement and

sensibility to man’s most important. workinginstrument.

At King’s College, Newcastle-upon-Tyne, on

June 25, Mr. GUY PULVERTAFT, himself a leadingexponent’ of modern hand surgery, explained theconditions that govern successful tendon reconstruc-tion in the digits, palm, and wrist. He urged theimportance of primary wound closure so as to reducescar-tissue to a minimum ; the necessity for earlytendon repair, whether at the first operation, as inthe palm or at the wrist, or as soon as the wound isunited, as in the finger ; the need to -select the correct

procedure for each repair, PULVERTAFT preferring touse a tendon graft to replace a tendon injured in thethecal canal and to suture tendons divided more

proximally ; the significance of early nerve regenera-tion in the restoration of function to an injured digit ;and the necessity for an exact, atraumatic, and

specialist technique. The conditions that make primarytendon reconstruction inadvisable include inade-

quate operation conditions, crushing of the tissues,and wounds heavily contaminated or with much skinloss or some days old. The operation technique is

the basis of success, but as soon as the wound is

united active movements are essential, assisted byevery art and force of character of the surgeon and

physiotherapist. If the tendon unites but movementremains restricted, the tendon may be freed from itsadhesions at a later operation and full movement stillregained. The results -of these procedures are mostsatisfactory. Full or almost full restoration of move-ment is the rule when reconstruction is done underideal conditions by a specialist team.

For the present this work will inevitably developin surgical centres where the conditions for operationand postoperative arrangements are suitably orga-nised, and where the surgical team has the necessaryqualifications for the job. These include an aptitudefor minute and scrupulous technique and a soundtraining in general surgery with extra experience inplastic, nerve, and orthopaedic surgery. Such a

training and special experience are necessary for anysurgeon who aspires to be a master of his craft, and itis better for the surgeon to combine these experiencesin himself than that they should be divided betweenthe several members of a team. In the United Stateshand surgery is now an accepted specialty, to whichimpetus will be given by the recent formation of theAmerican Society of Surgeons of the Hand. It is

unlikely that such a confinement of interest will gainfavour in this country. The value to hand surgery ofa wide experience in the principles from which itderives is not less than the value of the refinementsof hand surgery to general surgical practice. Manysurgical units, including several of the new professorialunits, have concerned themselves with the problemsof the hand as. part of their more general work. In

every area there should be at least one unit developingthe facilities and techniques necessary for reconstruc-tive hand surgery, and ready to disseminate its

knowledge and example throughout .the area. Onlyin this way will hands receive everywhere the surgicalattention that their importance demands.

The GamesIT is safe to predict that the London Olympic

Games will see a large number -of previous recordsbroken ; for several of the athletes competing havealready recorded times or distances better than the1936 figures, and in any case Olympic performanceshave improved at every meeting since 1896. Of the22 major track, field, and swimming events, 16 of thepresent records were set up in 1936, and the remaining6 in 1932. The reasons for this trend are both bio-

logical and sociological. There have been improve-ments in the conditions the athlete competes under;in athletic technique, in the population sampling ofeach country, and perhaps in the general or averagephysique throughout the world. Of these four,better technique and better sampling must have hadmost effect. Weather conditions vary from one

Games to another, and the excellence of the Berlintrack cannot have accounted for more than a fractionof the new records made there, though a downrightpoor track can seriously slow a runner.

It is only in the last twenty years that athletictechnique has become stabilised, particularly in thefield events, and it still improves steadily or (as inswimming) by spectacular steps. The most phenom-enal improvements in performance have been inevents where technique is of greatest importance ;

103KING EDWARD’S FUND

such as the hurdles, the high-jump, and the throws.Athletes now use all the apparatus of slow-motioncinematography and time and motion study to controltheir style, and the track and field events are settlingdown into an applied science of human movement,where a painstaking approach to an ideal will replaceintuitive discovery. After one or two more OlympicGames, however, we may have to rely for new recordschiefly on the other sources of improvement. Howcan we find our superman, and how can we improvethe whole population so that our athletic genius alsoreaches new heights ? It was the express intention

- off Baron DE COMBERTIN, the founder of the modernGames, that they should stimulate the spread ofathletics through the population of all countries, andthis they have done. There remain vast differences

.

in the efficiency of selection from one country toanother. Leaving aside the question of pro-fessionalism, which only affects directly some of theminor events, class customs still have a strong restrain-ing influence and are seen in their most anachronisticform in the Pentathlon and other purely military

- events in the Games themselves. The British trackand field team has in the past been drawn mostly fromthe public schools and the Achilles Athletic Club,because outside these the tracks were few and coachesand tradition lacking. The situation is changingslowly, as the tradition of separate class activitiesfades and physical education becomes recognisedas a subject worth studying and worth teaching.Selection is most efficient in some parts of theUnited States, where physical education is an

important item in the curriculum of the ordinaryschool, and where the universities sometimes providescholarships for students more suited to this type ofinstruction than to any other. This, rather thanthe absolute size of the population, largely explainsthe supremacy of the United States in most events.But there is another respect in which America

is favourably placed. A considerable proportion ofAmerican successes have been due to Negro athletes,and in view of the limited opportunities of this groupto take part in athletics, there is a widespread feelingthat they are, either on the average or in the extreme,superior to the white man in athletic skill. This

superiority clearly resides in some aspect of physique.It has been said,1 for example, that the coloured

sprinter under stress shows less tendency than thewhite to bend outward at the knee, presumably becauseof a difference in the knee-joint formation or the wholeleg leverage system. None of the suggested reasonsare very convincing. Some work has been done onthe subject,2 and groups of Olympic athletes havebeen measured, but nothing very systematic has

yet emerged. In general one would expect a sprinterto have powerful legs and a light body, or, in themore precise terminology of SHELDON, a meso-

morphic increase in the leg region over that of therest of the body. Any race requiring not the rapidanaerobic breakdown of large quantities of glycogenbut the continuous utilisation of large quantities ofoxygen by the muscles calls for a highly efficientcardiovascular system, and in particular highlyvascularised muscles. During the brief period of

1. Webster, F. A. M. Science of Athletics.2. See T. K. Cureton, Physical Fitness Guidance and Appraisal.

London, 1947.

relaxation in the runner’s stride enough oxygenmust reach the muscles-to supply his needs for theensuing muscular contraction. This type of efficiencyperhaps depends on the androgyny or masculine-feminine component of body-build. It is knownthat the lactic-acid production of women is greater,and hence the concurrent utilisation of oxygen less,than that of men doing an equivalent amount ofmoderate work ; that the performance times ofmen with high androgyny are worse than those withlow ; and that androgens have an effect both onskeletal muscle and on the cardiovascular system.To suggest that Negro athletes have a lower femininitycomponent than whites is to go beyond presentevidence and to oversimplify the situation, since otherathletic feats than running remain to be explained ;but the whole subject would well repay further

study by the improved means now available.As for the last of our hypothetical reasons for

improvement, in the last fifty years the growthprocess has been speeded up all over the world, sothat adult height and weight are reached earlier thanpreviously ; and it is highly probable that adultsize has really increased. Both are believed primarilyto be nutritional effects, with perhaps further helpfrom the breaking down of genetic isolates. Butwhether there has been a trend towards increasingmuscularity, or towards decreasing androgeny, or

in any other direction, is as yet unknown. Mean-while, putting speculation and explanation behind us,we look forward to a previously unmatched exhibitionof grace, skill, and strength.

King Edward’s FundIN the past King Edward’s Hospital Fund for London

has perhaps been best known for its grants towardsmaintenance costs and capital expenditure ; and some

may ask how its assets, running into several million

pounds, are now to be used. The answer was given lastweek by the Duke of Gloucester, presiding at the annualmeeting of the general council at St. James’s Palace.He pictured the new functions of this body as those lessof a fund than a foundation, on the lines of the RockefellerFoundation. Nevertheless, the new health service hasnot relieved the Fund of all maintenance costs; 117convalescent homes, with 5212 beds, which have notbeen transferred under the Act still look to the Fund for

support. In other fields the groundwork is already laid,covering aspects of the hospital services which will

possibly always be best dealt with by an extragovern-mental body. For example, through propaganda andthe offer of training bursaries, the Fund is trying toraise the standard of hospital administration, catering,and domestic supervision ; it is actively helping in nursingrecruitment ; and it is financing travel grants for thebetterment of several departments of hospital life,including actual construction. Perhaps the activity mostfamiliar to London’s doctors is the Emergency BedService, now enlarged to serve all four metropolitanhospital regions. Last year the service made a surveyof all mechanical respirators in the voluntary hospitalsof Southern England ; and the value of this precautionwas proved in August when each of the many urgentcalls was met. Less successful, through shortage of

supplies, were the efforts to obtain streptomycin treat-ment for cases of tuberculosis meningitis and miliarytuberculosis. " The situation," says the annual report," reached its worst in April, 1948, when 45 people werewaiting for treatment with little or no prospect of

obtaining it." Since then, however, it has improved.