562 MISPLACEMENTS OF THE UTERUS.-THE BATEMAN APPEAL.

instructed as to three points : (1) the regularemptying of the bladder ; (2) the prevention of con-stipation ; and (3) the efficacy of lying on the facefor a time every day. At the end of three months thepessary is removed and in a fair number of casesno further symptom develops.

In cases of longer standing in which the symptomscall for treatment, the effect of replacement and apessary should also be tried, and operation reservedfor those cases in which the uterus cannot be replacedor in which the pessary and the replacement havebeen followed by a definite relief of symptoms.When operation has been decided upon an essentialpoint is to leave the uterus in an approximatelynormal position, and in my opinion a curettage doesnot fulfil the conditions for a cure. The relief experi-enced after dilatation and curettage does not lasb,and many patients suffer a return of their symptom.3after a shorter or longer interval. ’

As to the operation to be practised for the perma-nent replacement of a retroverted or flexed uterusit is difficult to be dogmatic. Numberless varietiesof operative technique have been devised, fallinginto groups : (a) Suspending the uterus from theparietal peritoneum; (b) fixing the lower part of theanterior wall of the uterus to the anterior abdominalwall : or (c) sing the round ligaments as a means

of slinging the uterus in its normal position. Thesecond and third varieties alone have claims toserious consideration, the second in spite of M.Dartigues’ recent dictum that it should be eliminatedfrom the operative methods. It is so simple, so effec-tive, and o free from danger should pregnancy super-vene that it seems worthy of continued use. Thethird group of operations has almost an infinity ofmodifications according to the predilections of theoperator, and within the limits of a short article itis impossible even to enumerate them. A reflectionborn of experience is, that before using the roundligaments to keep the uterus in position, it werewell to investigate the condition of those ligamentsin the particular case. It is no uncommon experienceto find such thin, ill-developed ligaments that to trustto them for maintaining a proper uterine positionwould be unwarrantable optimism. A second maybe added-namely, that care should be taken to avoidstrangulating the round ligament during the operation,as persistent pain has often been noticed over thearea where the ligament has been drawn throughthe fascia.My personal experiences of the after-results of

both direct fixation and of various methods ofshortening the round ligaments have been uniformlygood, but of the two there have been fewer complica-tions after the plain fixation.

Simpk Prolapse of the l7tervs.

The treatment of this condition when causingsymptoms resolves itself into either supporting theuterus by some form of pessary, or devising suchreparative operative procedures as will permanentlymaintain the uterus in its proper position. It is agrowing conviction of the writer that the symptomsof prolapse are less dependent upon the actual positionof the uterus than they are upon the concomitantprolapse of the vaginal walls. Early stages of pro-lapse may undoubtedly be cured by careful attentionsoon after childbirth by the insertion for a fewmonths of a suitable pessary and by the institutionof regular muscular exercises, not the least impor-tant being those which have for their object there-education of the vaginal muscles themselves.In more advanced cases the question arises as towhether the condition is to be palliated or cured.Comfort can be secured by pessaries, but at the costof several minor troubles and with the need of con-stant supervision. In some cases the general health,age, or considered choice of the patient may precludeany other method of treatment, or she may be at atime of life where repeated pregnancies are to be

1 La Chirurgie Illustré " Pauchet." Paris, 1924.

anticipated. In any of these instances the palliativetreatment must be considered, but, in general, cura-tive treatment by operation is the method of choice.In any given case the operation must be most care-fully considered and so planned in its scope anddetails as to restore the cervix and vaginal walls asnearly as possible to their original condition. Theorthopaedic rule that it is wise to over-correct adeformity is equally true in carrying out operationsfor the cure of prolapse. In a simple case of prolapseit is hardly ever necessary to open the abdomen.while, however advanced the condition is, the uterusshould on no account be removed unless there besome other condition making the course imperative.

In patients past the menopause, with markedcystocele and prolapse, the operation of interposingthe uterus between the bladder and the vaginal wallhas a certain though limited usefulness. My ownexperiences of it have been uniformly good. Lastly,.in appropriate cases Le Fort’s operation (unitinganterior and posterior vaginal walls along themiddle line) is easy of accomplishment and givesvery good results.

Prolapse Associated with RetroversimProlapse associated with retroversion is commoner

than simple prolapse. The treatment follows closelythe lines indicated for the last-named condition butwith this important difference, that a constant aimin the operative technique should be to leave theuterus in the normal position of anteversion. Thisposition may be obtained during the vaginal pro-cedures, but should it be found on the completion ofthese manipulations that the uterus is still retro-verted or flexed, the abdomen should be opened and aventral fixation done. The round ligaments are notto be relied upon in the operative treatment ofnrn1:!,n<;p with retro version.

J. BRIGHT BANISTER, M.D. Camb., M.R.C.P. Lond.,F.R.C.S. Edin.,

Consulting Obstetric Surgeon, Queen Charlotte’sLying-in Hospital; Assistant Obstetric

Physician, Charing Cross Hospital.

THE BATEMAN APPEAL.

As already explained in THE LANCET, it has beenfelt that material assistance ought to be offered toDr. Bateman to meet the legal expenses of his recentsuccessful appeal against conviction and to makegood the deficiency in his professional income.Accordingly, the Bateman Fund has been openedand a list of contributions appeared in the last issue.We have received additional contributions as

follows :&mdash;

Remittances should be forwarded to the Managerof THE LANCET, 423, Strand, W.C.2, and madepayable to the " Bateman Fund Account."

563SPECIAL SURGICAL CLINICS AND WAR INJURIIAS.

Special Articles.TREATMENT OF WAR INJURIES AT

SPECIAL SURGICAL CLINICS.

BY CHARLES MACKAY, M.D., B.S. MELB.,LATE LIEUT.-COLONEL, R.A.M.C.; MEDICAL OFFICER IN CHARGE

ORTHOP&AElig;DIC CLINICS, MINISTRY OF PENSIONS :

AND

D. DENHAIM PINNOCK, F.R.C.S. ENG.,ASSISTANT SURGEON, TEMPERANCE HOSPITAL ; MEDICAL

OFFICER IN CHARGE ORTHOP&AElig;DIC CLINICS,MINISTRY OF PENSIONS.

AMONG the many forms of disability which wereincurred by all ranks through service in the late war,of which the disabling effects continued in a more orless high degree after leaving the Sarvice, a largerproportion falls within the purview of the surgeonrather than of the physician. The number of suchcases was so great that the Ministry of Pensions foundit necessary to make special arrangements for dealingwith them. The establishment of Special SurgicalClinics was an important part of these arrangements.A Special Surgical Clinic is in essentials an out-

patient orthopaedic treatment centre. It consists oftreatment rooms, surgeon’s examination room, waitingroom for patients, and suitable accommodation formassage staff. In establishing Special SurgicalClinics every endeavour was made to utilise thefacilities at existing civil institutions, these facilitiesbeing in many instances expanded to meet the specialneed. Even with this expansion, however, the civilhospital facilities fell short of requirements, and furtherfacilities were rendered available through the agencyof the British Red Cross Society, who acquiredsuitable premises and opened clinics under theadministration of a commandant. Over and abovethese, the Ministry itself established a number ofclinics staffed and administered by the department.These Surgical Clinics have two main functions :

{1) The examination of pensioners suffering from warinjury for the purpose of determining the need for treatment, surgical appliances, &c.: and (2) theprovision of such treatment as can suitably be under-taken at the clinic.

In the general scheme of the Ministry for dealingwith surgical cases, the Special Surgical Clinics arelinked up with the surgical hospitals, and with thecentres for the provision of surgical appliances andartificial limbs. They may refer cases to hospitals forin-patient treatment, or to the Appliances and LimbCentres to be provided with appliances or limbs. Theymay have referred to them cases from hospital forthe purpose of carrying on or supplementing thesurgical work which has been done while the man wasan in-patient. They may have cases referred to themfrom the Appliances or Limb Centres, for an opinionas to the man’s precise needs, or for a report as towhether an appliance or limb already provided isentirely suitable. In addition to these sources ofsupply, many cases are referred to the clinics fromthe various local offices set up by the Ministrythroughout the country for the performance of thelocal work of the department. When a man isreferred to the clinic, there is sent at the same timea dossier containing documents summarising theman’s medical history as known to the Ministry.This history consists of medical notes made at thetime of previous examinations by medical boards andother medical officers. In addition, it includes therecords as to the results of any previous courses oftreatment. At the outset, therefore, the surgeon atthe clinic, is not dependent for his knowledge ofthe case upon what he himself can ascertain by thepresent examination. Where the man is providedwith treatment at the clinic, the surgeon, on the man’sdischarge from treatment, continues the history

records by adding his own notes, and incorporating thecase-sheet and any pathological reports or X ray films,&c., in the treatment dossier, for the information ofmedical officers who may have to deal with the casein future.

Before proceeding to describe the more professionalaspect of the work at these clinics it may be remarked,in illustration of the encouragement to pensioners toavail themselves of such treatment as may be con-sidered to be necessary, that the pensioner’s travellingexpenses between his home and the clinic are paid bythe Ministry, whether in respect of a single attendancefor the purpose of medical examination, or the morefrequent attendances which are involved in a course oftreatment. In addition, if the man’s attendance willnecessitate his absenting himself from work on oneor more occasions during the week, he is paid anallowance in respect of loss of remunerative time.Further, if the circumstances of his course of treatmentare such as to necessitate his absenting himself fromwork entirely, either because of the frequency of hisattendances or because it is an essential part of histreatment that he should not work, he is granted, inlieu of any pension which he may be drawing, anallowance in respect of himself at a rate equivalentto pension for total disablement, together withallowances at corresponding rates in respect of hiswife and children. No pensioner need therefore bedeterred from accepting a course of treatment onaccount of financial considerations, and pensionersare consequently much more favourably placed inthis connexion than is the average civilian.

Types of Case Treated.The treatment provided at a clinic is necessarily

somewhat limited in scope, but is of considerablevariety. Such remedial agents as surgical dressings,massage, electricity, heat, passive and active move-ments, Swedish exercises of remedial character, andexercises for muscle re-education are extensivelyemployed. The types of case in which clinic treat-ment is undertaken fall into the following classes :-

(1) Nerve Injuries.&mdash;Mainly those cases which have hadnerve suture performed at a comparatively recent date, orother nerve injuries which are slowly recovering, and requiretreatment by massage, electricity, and muscle re-education.

(2) Old Joint Injuries with varying degrees of limitationof movement. ’

(3) Extensive Wound Scarrings with considerable muscleweakness and wasting of limbs.

(4) Old Bone Injuries with recent or old sinuses requir-ing dressing and supervision, also recent bone grafts.

(5) Organic Injuries of various kinds, with functionalparalysis of varying degree super-added, and requiring bothphysical and psychical re-education.

(6) Amputation Stumps requiring dressings or treat-ment for pain, &c.

(7) Various forms of arthritis.The cases which have responded best to treatment

are the severe wounds with extensive scarring, muchmuscle weakness, wasting of limbs, and joint stiffness.Under treatment with varying applications ofmassage, heat, faradic electricity, graduated exer-cises, much has been done to restore these limbs to ahigh degree of usefulness. Partial injuries to nervesand tendon transplantations for drop-wrist have also

been very successfully dealt with. On the whole, it hasbeen somewhat disappointing to see the final results ofmany nerve suture operations, especially those on the

, sciatic nerve, external popliteal nerve, and medianand ulnar nerves. After months and years of con-

, tinuous treatment some of these cases show littleresponse in the direction of increased movement or

: power in the foot and hand, the foot remaining partially. inverted and dropped in spite of treatment. Although! disappointing from the point of view of return ofmovement, nerve suture with after-treatment has: probably been of very definite physiological value tothe limb, in preserving a better blood-supply with

less liability to trophic disturbances. The mostL encouraging of these nerve cases have been those of; musculo-spiral suture, and this experience has beencommon to many observers. In the case of the lower