812 PERIPHERAL-NERVE REPAIR DURING the 1939-45 war, publications by the British and American Governments led to a resurgence of interest in peripheral-nerve repair.I,2 Approximation of the outer sheath of the nerve, the epineurium, was the technique favoured; it enabled surgeons to cope with the vast numbers of casualties, but there were soon reports of poor results.3,4 Nerve tissue occupies only a small fraction of the cross-sectional area of a peripheral nerve, and repair of the fibrous envelope masks fascicular gaps, buckling, and malrotation; therefore, few patients regained useful function. With the advent of the operating microscope fasciculus can now be sewn to fasciculus, for maximal neuronal coaptation, and experienced rnicrosurgeons declare that this technique is mandatory.5-s The outcome does not, however, depend entirely on the method of repair; it is influenced also by the patient’s age, the peripheral nerve involved, the type and site of nerve laceration, the time between injury and repair, and the skill of the surgeon.s The Medical Research Council’s motory and sensory grading system is the best clinical method of assessment, but to this can be added electrophysiological assessment, which is valuable in the early phase of motor regeneration though unhelpful in estimating the degree of sensory return.9 Donoso and colleagues1o have lately presented their clinical and electrophysiological experience with human peripheral-nerve repair. Unfortunately, few inferences of value can be drawn from a single postoperative assessment. If anomalous innervation is to be identified, serial observations from an early baseline are essential. Donoso and co-workers employed standard electrophysiological techniques but studied only a limited repertoire of muscles. The abductor digiti minimi is not sufficient on its own to reflect the behaviour of the ulnar nerve and the first dorsal interosseous and flexor carpi ulnaris should be included. Only two digits were assessed in terms of sensory potentials and most electrophysiological laboratories would require three and a half digits for median-nerve function, one and a half digits for ulnar-nerve function, and an assessment of the radial nerve for control purposes.9 In addition needle electromyography is very important because it can indicate the number of motor units engendered by voluntary effort or electrical stimulation and these are proportional to the number of motor-nerve fibres passing through the anastomosis or graft. Measurement of conduction velocity reflects only the number of regenerating fibres.9 These questions apart, the patients of Donoso et al. were heterogeneous, so it would be unsafe to draw conclusions about methods of repair, and particularly about the best time for re-exploration. What we need is a detailed electrophysiological study, combined with a J. Medical Research Council Report no. 282, H.M. Stationery Office, 1954. 2. Woodhall, M. B., Beebe, G. W. Veterans Administration Medical Monograph. U.S. Government Printing Office, Washington, D.C., 1956. 3. Sanders, F. K., Young, J. Z. J. Anat. 1942, 76, 143. 4. Seddon, H. J. J. Bone Jt Surg, 1963, 45B, 447. 5. Owen, E. ibid. 1976, 58B, 397. 6. Millessi, H. Orthop Clins N. Am. 1977, 8, 387. 7. O’Brien, B. M. Microvascular Reconstructive Surgery; p. 306. Edinburgh,
1. Seddon, H.
1977. 8. Dickson, R. A. Br J. Hosp. Med 1978, 20, 295. 9. Rushworth, G. Unpublished. 10. Donoso, R. S., Ballantyne, J. P., Hansen, S J.
1979, 42, 97.
prospective clinical assessment, of a sample of patients randomised in terms of the many factors which can influence the success of nerve repair.
careful
Neurol Neurosurg. Psychiat.
TOO PROFESSIONAL TO CARE? ALMOST before the ink was dry on the statute of Health Service reorganisation, the Royal College of Physicians of Edinburgh launched a debate on the "integration of patient care" which, it was hoped, might follow the administrative upheaval. The first kind of integration to be explored was that of the three branches of the medical profession-hospital specialists, general practitioners, and community-medicine specialistsland the next was cooperation between the health professions.2 At the latest meeting, in Edinburgh last month, a heterogeneous gathering discussed barriers to cooperation between doctors, nurses, and social workers. It is ironic that, since 1974, by far the strongest growth of shared identity and common purpose has been within professions rather than between them. Thus, although the traditional role of doctors as team leaders had been challenged long before that, the conflicts of authority are now between structures and unions rather than between individuals. Even those who want to work together are defeated by the impersonal but far from inanimate cross-currents which are pulling them apart. It seems unlikely that there will be any substantial change until the tensions between professional structures have been relieved. The working groups were less than optimistic that such change was imminent. The second main conclusion was that "mutual respect" between professions will emerge only if their separate philosophies as well as their contributions to care are understood. One straw clutched at frequently is shared education and training; but, since everyone has different jobs to do at the end of it, a small part can realistically be shared without adding to already overcrowded curricula. Even within a profession, specialisation tends to increase the number of things each of us can know nothing about. Acquiring understanding of other people’s philosophies is more daunting still; our values are ingrained long before formal training and are little influenced by it. Perhaps we should be less ambitious; it would be a major step towards understanding if we even
only
in matters of health, one person can all answers. know the seldom So what hope integration? Despite some utopian recommendations, the participants in the symposium seemed only too aware of the practical difficulties. And yet, only by trying will we find out whether they can be overcome or whether professionalism will remain the problem of the 1990s. For those who can sustain the action, the message was again that the next best thing to a team of one is a team of several with a single, common problem and purpose. Common goals are possible, even with different philosophies. There is the story of an Ayrshire Yeomanry troop commander who, at the outset of the Second World War, asked his newly-recruited collection of farmers’ sons what they were really fighting for and was met with a blank reception. "You’re fighting to preserve fox-huntin’ melads" he said "and don’t ever forget it!"
acknowledged that,
1. Integration of Patient Care. Annual Community Medicine Conference Greater Glasgow Health Board, 1975. 2. Crofton, J. Hlth Bull. 1977, 35, 186.
1. Seddon, H.
1977. 8. Dickson, R. A. Br J. Hosp. Med 1978, 20, 295. 9. Rushworth, G. Unpublished. 10. Donoso, R. S., Ballantyne, J. P., Hansen, S J.
1979, 42, 97.
prospective clinical assessment, of a sample of patients randomised in terms of the many factors which can influence the success of nerve repair.
careful
Neurol Neurosurg. Psychiat.
TOO PROFESSIONAL TO CARE? ALMOST before the ink was dry on the statute of Health Service reorganisation, the Royal College of Physicians of Edinburgh launched a debate on the "integration of patient care" which, it was hoped, might follow the administrative upheaval. The first kind of integration to be explored was that of the three branches of the medical profession-hospital specialists, general practitioners, and community-medicine specialistsland the next was cooperation between the health professions.2 At the latest meeting, in Edinburgh last month, a heterogeneous gathering discussed barriers to cooperation between doctors, nurses, and social workers. It is ironic that, since 1974, by far the strongest growth of shared identity and common purpose has been within professions rather than between them. Thus, although the traditional role of doctors as team leaders had been challenged long before that, the conflicts of authority are now between structures and unions rather than between individuals. Even those who want to work together are defeated by the impersonal but far from inanimate cross-currents which are pulling them apart. It seems unlikely that there will be any substantial change until the tensions between professional structures have been relieved. The working groups were less than optimistic that such change was imminent. The second main conclusion was that "mutual respect" between professions will emerge only if their separate philosophies as well as their contributions to care are understood. One straw clutched at frequently is shared education and training; but, since everyone has different jobs to do at the end of it, a small part can realistically be shared without adding to already overcrowded curricula. Even within a profession, specialisation tends to increase the number of things each of us can know nothing about. Acquiring understanding of other people’s philosophies is more daunting still; our values are ingrained long before formal training and are little influenced by it. Perhaps we should be less ambitious; it would be a major step towards understanding if we even
only
in matters of health, one person can all answers. know the seldom So what hope integration? Despite some utopian recommendations, the participants in the symposium seemed only too aware of the practical difficulties. And yet, only by trying will we find out whether they can be overcome or whether professionalism will remain the problem of the 1990s. For those who can sustain the action, the message was again that the next best thing to a team of one is a team of several with a single, common problem and purpose. Common goals are possible, even with different philosophies. There is the story of an Ayrshire Yeomanry troop commander who, at the outset of the Second World War, asked his newly-recruited collection of farmers’ sons what they were really fighting for and was met with a blank reception. "You’re fighting to preserve fox-huntin’ melads" he said "and don’t ever forget it!"
acknowledged that,
1. Integration of Patient Care. Annual Community Medicine Conference Greater Glasgow Health Board, 1975. 2. Crofton, J. Hlth Bull. 1977, 35, 186.
