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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.