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TREATMENT OF WAR INJURIES AT SPECIAL SURGICAL CLINICS.
SPECIAL SURGICAL CLINICS AND WAR INJURIIAS.
records by adding his own notes, and incorporating the case-sheet and any pathological reports or X ray films, &c., in the treatment dossier, for the information of medical officers who may have to deal with the case in future. Before proceeding to describe the more professional aspect of the work at these clinics it may be remarked, in illustration of the encouragement to pensioners to avail themselves of such treatment as may be considered to be necessary, that the pensioner’s travelling expenses between his home and the clinic are paid by the Ministry, whether in respect of a single attendance for the purpose of medical examination, or the more frequent attendances which are involved in a course of treatment. In addition, if the man’s attendance will necessitate his absenting himself from work on one or more occasions during the week, he is paid an allowance in respect of loss of remunerative time. Further, if the circumstances of his course of treatment are such as to necessitate his absenting himself from work entirely, either because of the frequency of his attendances or because it is an essential part of his treatment that he should not work, he is granted, in lieu of any pension which he may be drawing, an allowance in respect of himself at a rate equivalent to pension for total disablement, together with allowances at corresponding rates in respect of his wife and children. No pensioner need therefore be deterred from accepting a course of treatment on account of financial considerations, and pensioners more favourably placed in are consequently muchthe this connexion than is average civilian.
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 ORTHOPÆDIC CLINICS, MINISTRY OF PENSIONS :
AND
D. DENHAIM PINNOCK, F.R.C.S.
563
ENG.,
ASSISTANT SURGEON, TEMPERANCE HOSPITAL ; MEDICAL OFFICER IN CHARGE ORTHOPÆDIC CLINICS, MINISTRY OF PENSIONS.
AMONG the many forms of disability which were incurred by all ranks through service in the late war, of which the disabling effects continued in a more or less high degree after leaving the Sarvice, a larger proportion falls within the purview of the surgeon rather than of the physician. The number of such
great that the Ministry of Pensions found it necessary to make special arrangements for dealing with them. The establishment of Special Surgical Clinics was an important part of these arrangements. A Special Surgical Clinic is in essentials an outpatient orthopaedic treatment centre. It consists of treatment rooms, surgeon’s examination room, waiting room for patients, and suitable accommodation for In establishing Special Surgical massage staff. Types of Case Treated. Clinics every endeavour was made to utilise the facilities at existing civil institutions, these facilities The treatment provided at a clinic is necessarily being in many instances expanded to meet the special somewhat limited in scope, but is of considerable need. Even with this expansion, however, the civil variety. Such remedial agents as surgical dressings, hospital facilities fell short of requirements, and further massage, electricity, heat, passive and active movefacilities were rendered available through the agency ments, Swedish exercises of remedial character, and of the British Red Cross Society, who acquired exercises for muscle re-education are extensively suitable premises and opened clinics under the employed. The types of case in which clinic treatadministration of a commandant. Over and above ment is undertaken fall into the following classes :these, the Ministry itself established a number of (1) Nerve Injuries.—Mainly those cases which have had clinics staffed and administered by the department. nerve suture performed at a comparatively recent date, or These Surgical Clinics have two main functions : other nerve injuries which are slowly recovering, and require {1) The examination of pensioners suffering from war treatment by massage, electricity, and muscle re-education. Old Joint Injuries with varying degrees of limitation injury for the purpose of determining the need of (2) movement. for treatment, surgical appliances, &c.: and (2) the (3) Extensive Wound Scarrings with considerable muscle provision of such treatment as can suitably be under- weakness and wasting of limbs. taken at the clinic. Old Bone Injuries with recent or old sinuses requirIn the general scheme of the Ministry for dealing ing(4) dressing and supervision, also recent bone grafts. with surgical cases, the Special Surgical Clinics are (5) Organic Injuries of various kinds, with functional linked up with the surgical hospitals, and with the paralysis of varying degree super-added, and requiring both centres for the provision of surgical appliances and physical and psychical re-education. (6) Amputation Stumps requiring dressings or treatartificial limbs. They may refer cases to hospitals for for pain, &c. in-patient treatment, or to the Appliances and Limb ment (7) Various forms of arthritis. Centres to be provided with appliances or limbs. They The cases which have responded best to treatment may have referred to them cases from hospital for the purpose of carrying on or supplementing the are the severe wounds with extensive scarring, much surgical work which has been done while the man was muscle weakness, wasting of limbs, and joint stiffness. an in-patient. They may have cases referred to them Under treatment with varying applications of from the Appliances or Limb Centres, for an opinion massage, heat, faradic electricity, graduated exeras to the man’s precise needs, or for a report as to cises, much has been done to restore these limbs to a whether an appliance or limb already provided is high degree of usefulness. Partial injuries to nerves entirely suitable. In addition to these sources of and tendon transplantations for drop-wrist have also supply, many cases are referred to the clinics frombeen very successfully dealt with. On the whole, it has the various local offices set up by the Ministry been somewhat disappointing to see the final results of throughout the country for the performance of the many nerve suture operations, especially those on the local work of the department. When a man is sciatic nerve, external popliteal nerve, and median referred to the clinic, there is sent at the same time and ulnar nerves. After months and years of cona dossier containing documents summarising the, tinuous treatment some of these cases show little man’s medical history as known to the Ministry. response in the direction of increased movement or This history consists of medical notes made at the: power in the foot and hand, the foot remaining partially time of previous examinations by medical boards and. inverted and dropped in spite of treatment. Although other medical officers. In addition, it includes the! disappointing from the point of view of return of records as to the results of any previous courses ofmovement, nervesuture with after-treatment has treatment. At the outset, therefore, the surgeon at: probably been of very definite physiological value to the clinic, is not dependent for his knowledge ofthe limb, in preserving a better blood-supply with the case upon what he himself can ascertain by the less liability to trophic disturbances. The most present examination. Where the man is providedL encouraging of these nerve cases have been those of with treatment at the clinic, the surgeon, on the man’s; musculo-spiral suture, and this experience has been discharge from treatment, continues the history common to many observers. In the case of the lower
cases was so
’
,
564
ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.
limbs, operations on the knee-joint have necessitated as rheumatism, myalgia, sciatica, and various forms a large amount of after-treatment. Where the injury of arthritis. These are treated by means of heat, for which the operation has been done has occurred massage, ionisation, and so forth. The chronic cases several years before, the wasting of the thigh, especially of arthritis are necessarily the most obstinate in of the vastus.internus muscle, requires much treatment responding to treatment, and it is often very difficult to bring it up to anything approaching normal. to decide when treatment. should be discontinued, Injuries of the shoulder, either of the joint itself or in especially in the elderly pensioner. In many the neighbourhood of joint, are the cause of severe instances all that can be done is to attempt to relieve disablement. Very often the pensioner comes to the severe pain, and as pain is fa purely subjective clinic unable to abduct and to elevate his arm as far phenomenon, the question as to whether any definite as a right angle. Much improvement may be effected improvement in the condition can be accomplished
in these cases by treating patients in the lying- by treatment requires very careful investigation and down position. By this means the weight of the arm consideration. In conclusion, we beg to express our indebtedness to is taken off the weakened muscles, and after the application of massage and heat the pensioner is the Director-General of Medical Services of the often able to raise his arm much further in this Ministry of Pensions for his kind permission to position than he had previously thought possible. publish this article. Carefully graduated exercise in the lying-down position is essential for the recovery of movement at the PROCEEDINGS OF THE shoulder. By means of pillows the patient can be gradually raised to a sitting-up position, and moveROYAL COMMISSION ON NATIONAL ments which were at first impossible become comHEALTH INSURANCE.* paratively simple and easy. To begin the attempt to obtain movement in the region of a damaged shoulder(Continued from p. 509.) joint in the standing or sitting-up position is to invite pain and consequent reluctance to attempt movement THE APPROVED SOCIETIES AND THE MONEY BENEFITS. In the lying-down on the part of the pensioner. The Controller’s Evidence. position his confidence is easily obtained, and he adjusts (App. A. 56.) The ordinary benefits of the National his movements to his own feelings. No attempt is made to force the arm above the position at which he Health Insurance Act are four in number-namely, feels pain. The cardinal idea is that the movements medical benefit, sickness benefit, disablement benefit, The official evidence in should be voluntary and supervised. It is well to and maternity benefit. remember that an arm and hand are useless unless the regard to medical benefit has been summarised. thumb can be opposed to the fingers. This is the So far as this benefit is concerned, the only duty devolving upon Approved Societies is that of keeping supremely essential movement to be striven for in the the Insurance Committees informed of the persons upper limb. Function, no matter how obtained, whether by who are entitled to medical benefit, and of those who so-called trick movements or otherwise, is the aim of cease to be so entitled. For all but a relatively treatment at the clinics. With all forms of injury it is small part of the insured population the other three (collectively known as the money or cash recognised that movement is the ultimate goal, and benefits are administered by Approved Societies. that active movement should be encouraged by every benefits) means possible. Rates of Sickness Benefit. Re-education. (App. A. 57-8.) Sickness benefit consists of money The old conception that the more one did for the payments made after the third day of incapacity, patient the better, is gradually being improved into at the following rates: (a) After 104 weeks in that of encouraging and supervising the patient to do insurance and payment of 104 weekly contributions: It is even yet very for men, 15s. ; for women, 12s. (b) After 26 weeks as much as possible for himself. difficult to get masseuses to recognise that what the in insurance and the payment of 26 weekly contribupatient does for himself is of infinitely more value tions, but before completion of the conditions indithan what is done for him. The tendency to take up cated at (a) : for men, 9s. ; for women, 7s. 6d. too great a proportion of the treatment time in, Disablement benefit is a continuation of sickness applying massage and electricity requires to be benefit after 26 weeks of payment have been made counteracted by the surgeon. Muscle re-education, and is at the rate of 7s. 6d. a week for both men and in the sense of getting the pensioner to concentrate women. Conditions Attaching to these Benefts. his attention on his own supervised attempt to recover power in weak or partially paralysed muscles, (App. A. 60-3.) In general, claims to sickness and always working to this end with the aid of gravity, disablement benefits are based upon the medical and in the positions where the muscles can work at the certificates required to be furnished by the insurance best advantage, is regarded as the most important practitioners. The member must send notice of part of the modern treatment of these conditions, and incapacity within three days if he wishes to avoid is extensively used at the clinics. It may be remarked some loss of benefit. The onus of giving notice that experience at these clinics lends strong confirma- of illness is placed upon the member himself, and tion to the opinion that in all forms of physical there is nothing in the Acts to suggest that this duty treatment a certain amount of psychical treatment is devolves upon relatives or friends of the member, also necessary. It has not always been easy to get the or upon the medical attendant, even in cases where individual pensioner into a frame of mind where he the member is obviously incapable of attending to is inclined voluntarily to assist with his own the matter himself-e.g., in cases of mental derangetreatment. The tendency to do little for himself can ment. Mere ignorance of the requirements of the only be counteracted by the surgeon in charge taking Acts or of the society’s rules regarding the prompt a personal interest in the individual, and showing him notification of illness is not accepted by societies as how much to his own future advantage it is to a sufficient ground in itself for delay in giving notice assist in his own treatment. The atmosphere thus * In previous articles the proceedings of the Commission were created is a great help to the individual and to the the following headings: Introductory Note; reported clinic generally. Re-education in walking has formed The Scopeunder of the Insurance Scheme (see THE LANCET, Jan. 31st, an important part of the advanced treatment of many pp. 247-8); The Provision of Medical Benefit (Feb. 7th, 301-3: Feb. 14th, pp. 355-6 ; Feb. 21st, pp. 403-5); As an cases of severe injury of the lower limbs. pp. Financial Provisions of the Act (Feb. 28th, pp. 454-7); Medical essential part of treatment the provision of various Certification and the Regional Medical Staff (March 7th, types of orthopaedic appliance should be mentioned, pp. 508-9). References to the official statement which has been issued as well as that of surgical boots and shoes. an appendix in four sections are given thus: Section A, Apart from purely surgical cases there are also as para. 69, is shown as App. A. 69," and references to the oral treated at these clinics many medical conditions, such evidence thus—Q. 1369. "
records by adding his own notes, and incorporating the case-sheet and any pathological reports or X ray films, &c., in the treatment dossier, for the information of medical officers who may have to deal with the case in future. Before proceeding to describe the more professional aspect of the work at these clinics it may be remarked, in illustration of the encouragement to pensioners to avail themselves of such treatment as may be considered to be necessary, that the pensioner’s travelling expenses between his home and the clinic are paid by the Ministry, whether in respect of a single attendance for the purpose of medical examination, or the more frequent attendances which are involved in a course of treatment. In addition, if the man’s attendance will necessitate his absenting himself from work on one or more occasions during the week, he is paid an allowance in respect of loss of remunerative time. Further, if the circumstances of his course of treatment are such as to necessitate his absenting himself from work entirely, either because of the frequency of his attendances or because it is an essential part of his treatment that he should not work, he is granted, in lieu of any pension which he may be drawing, an allowance in respect of himself at a rate equivalent to pension for total disablement, together with allowances at corresponding rates in respect of his wife and children. No pensioner need therefore be deterred from accepting a course of treatment on account of financial considerations, and pensioners more favourably placed in are consequently muchthe this connexion than is average civilian.
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 ORTHOPÆDIC CLINICS, MINISTRY OF PENSIONS :
AND
D. DENHAIM PINNOCK, F.R.C.S.
563
ENG.,
ASSISTANT SURGEON, TEMPERANCE HOSPITAL ; MEDICAL OFFICER IN CHARGE ORTHOPÆDIC CLINICS, MINISTRY OF PENSIONS.
AMONG the many forms of disability which were incurred by all ranks through service in the late war, of which the disabling effects continued in a more or less high degree after leaving the Sarvice, a larger proportion falls within the purview of the surgeon rather than of the physician. The number of such
great that the Ministry of Pensions found it necessary to make special arrangements for dealing with them. The establishment of Special Surgical Clinics was an important part of these arrangements. A Special Surgical Clinic is in essentials an outpatient orthopaedic treatment centre. It consists of treatment rooms, surgeon’s examination room, waiting room for patients, and suitable accommodation for In establishing Special Surgical massage staff. Types of Case Treated. Clinics every endeavour was made to utilise the facilities at existing civil institutions, these facilities The treatment provided at a clinic is necessarily being in many instances expanded to meet the special somewhat limited in scope, but is of considerable need. Even with this expansion, however, the civil variety. Such remedial agents as surgical dressings, hospital facilities fell short of requirements, and further massage, electricity, heat, passive and active movefacilities were rendered available through the agency ments, Swedish exercises of remedial character, and of the British Red Cross Society, who acquired exercises for muscle re-education are extensively suitable premises and opened clinics under the employed. The types of case in which clinic treatadministration of a commandant. Over and above ment is undertaken fall into the following classes :these, the Ministry itself established a number of (1) Nerve Injuries.—Mainly those cases which have had clinics staffed and administered by the department. nerve suture performed at a comparatively recent date, or These Surgical Clinics have two main functions : other nerve injuries which are slowly recovering, and require {1) The examination of pensioners suffering from war treatment by massage, electricity, and muscle re-education. Old Joint Injuries with varying degrees of limitation injury for the purpose of determining the need of (2) movement. for treatment, surgical appliances, &c.: and (2) the (3) Extensive Wound Scarrings with considerable muscle provision of such treatment as can suitably be under- weakness and wasting of limbs. taken at the clinic. Old Bone Injuries with recent or old sinuses requirIn the general scheme of the Ministry for dealing ing(4) dressing and supervision, also recent bone grafts. with surgical cases, the Special Surgical Clinics are (5) Organic Injuries of various kinds, with functional linked up with the surgical hospitals, and with the paralysis of varying degree super-added, and requiring both centres for the provision of surgical appliances and physical and psychical re-education. (6) Amputation Stumps requiring dressings or treatartificial limbs. They may refer cases to hospitals for for pain, &c. in-patient treatment, or to the Appliances and Limb ment (7) Various forms of arthritis. Centres to be provided with appliances or limbs. They The cases which have responded best to treatment may have referred to them cases from hospital for the purpose of carrying on or supplementing the are the severe wounds with extensive scarring, much surgical work which has been done while the man was muscle weakness, wasting of limbs, and joint stiffness. an in-patient. They may have cases referred to them Under treatment with varying applications of from the Appliances or Limb Centres, for an opinion massage, heat, faradic electricity, graduated exeras to the man’s precise needs, or for a report as to cises, much has been done to restore these limbs to a whether an appliance or limb already provided is high degree of usefulness. Partial injuries to nerves entirely suitable. In addition to these sources of and tendon transplantations for drop-wrist have also supply, many cases are referred to the clinics frombeen very successfully dealt with. On the whole, it has the various local offices set up by the Ministry been somewhat disappointing to see the final results of throughout the country for the performance of the many nerve suture operations, especially those on the local work of the department. When a man is sciatic nerve, external popliteal nerve, and median referred to the clinic, there is sent at the same time and ulnar nerves. After months and years of cona dossier containing documents summarising the, tinuous treatment some of these cases show little man’s medical history as known to the Ministry. response in the direction of increased movement or This history consists of medical notes made at the: power in the foot and hand, the foot remaining partially time of previous examinations by medical boards and. inverted and dropped in spite of treatment. Although other medical officers. In addition, it includes the! disappointing from the point of view of return of records as to the results of any previous courses ofmovement, nervesuture with after-treatment has treatment. At the outset, therefore, the surgeon at: probably been of very definite physiological value to the clinic, is not dependent for his knowledge ofthe limb, in preserving a better blood-supply with the case upon what he himself can ascertain by the less liability to trophic disturbances. The most present examination. Where the man is providedL encouraging of these nerve cases have been those of with treatment at the clinic, the surgeon, on the man’s; musculo-spiral suture, and this experience has been discharge from treatment, continues the history common to many observers. In the case of the lower
cases was so
’
,
564
ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.
limbs, operations on the knee-joint have necessitated as rheumatism, myalgia, sciatica, and various forms a large amount of after-treatment. Where the injury of arthritis. These are treated by means of heat, for which the operation has been done has occurred massage, ionisation, and so forth. The chronic cases several years before, the wasting of the thigh, especially of arthritis are necessarily the most obstinate in of the vastus.internus muscle, requires much treatment responding to treatment, and it is often very difficult to bring it up to anything approaching normal. to decide when treatment. should be discontinued, Injuries of the shoulder, either of the joint itself or in especially in the elderly pensioner. In many the neighbourhood of joint, are the cause of severe instances all that can be done is to attempt to relieve disablement. Very often the pensioner comes to the severe pain, and as pain is fa purely subjective clinic unable to abduct and to elevate his arm as far phenomenon, the question as to whether any definite as a right angle. Much improvement may be effected improvement in the condition can be accomplished
in these cases by treating patients in the lying- by treatment requires very careful investigation and down position. By this means the weight of the arm consideration. In conclusion, we beg to express our indebtedness to is taken off the weakened muscles, and after the application of massage and heat the pensioner is the Director-General of Medical Services of the often able to raise his arm much further in this Ministry of Pensions for his kind permission to position than he had previously thought possible. publish this article. Carefully graduated exercise in the lying-down position is essential for the recovery of movement at the PROCEEDINGS OF THE shoulder. By means of pillows the patient can be gradually raised to a sitting-up position, and moveROYAL COMMISSION ON NATIONAL ments which were at first impossible become comHEALTH INSURANCE.* paratively simple and easy. To begin the attempt to obtain movement in the region of a damaged shoulder(Continued from p. 509.) joint in the standing or sitting-up position is to invite pain and consequent reluctance to attempt movement THE APPROVED SOCIETIES AND THE MONEY BENEFITS. In the lying-down on the part of the pensioner. The Controller’s Evidence. position his confidence is easily obtained, and he adjusts (App. A. 56.) The ordinary benefits of the National his movements to his own feelings. No attempt is made to force the arm above the position at which he Health Insurance Act are four in number-namely, feels pain. The cardinal idea is that the movements medical benefit, sickness benefit, disablement benefit, The official evidence in should be voluntary and supervised. It is well to and maternity benefit. remember that an arm and hand are useless unless the regard to medical benefit has been summarised. thumb can be opposed to the fingers. This is the So far as this benefit is concerned, the only duty devolving upon Approved Societies is that of keeping supremely essential movement to be striven for in the the Insurance Committees informed of the persons upper limb. Function, no matter how obtained, whether by who are entitled to medical benefit, and of those who so-called trick movements or otherwise, is the aim of cease to be so entitled. For all but a relatively treatment at the clinics. With all forms of injury it is small part of the insured population the other three (collectively known as the money or cash recognised that movement is the ultimate goal, and benefits are administered by Approved Societies. that active movement should be encouraged by every benefits) means possible. Rates of Sickness Benefit. Re-education. (App. A. 57-8.) Sickness benefit consists of money The old conception that the more one did for the payments made after the third day of incapacity, patient the better, is gradually being improved into at the following rates: (a) After 104 weeks in that of encouraging and supervising the patient to do insurance and payment of 104 weekly contributions: It is even yet very for men, 15s. ; for women, 12s. (b) After 26 weeks as much as possible for himself. difficult to get masseuses to recognise that what the in insurance and the payment of 26 weekly contribupatient does for himself is of infinitely more value tions, but before completion of the conditions indithan what is done for him. The tendency to take up cated at (a) : for men, 9s. ; for women, 7s. 6d. too great a proportion of the treatment time in, Disablement benefit is a continuation of sickness applying massage and electricity requires to be benefit after 26 weeks of payment have been made counteracted by the surgeon. Muscle re-education, and is at the rate of 7s. 6d. a week for both men and in the sense of getting the pensioner to concentrate women. Conditions Attaching to these Benefts. his attention on his own supervised attempt to recover power in weak or partially paralysed muscles, (App. A. 60-3.) In general, claims to sickness and always working to this end with the aid of gravity, disablement benefits are based upon the medical and in the positions where the muscles can work at the certificates required to be furnished by the insurance best advantage, is regarded as the most important practitioners. The member must send notice of part of the modern treatment of these conditions, and incapacity within three days if he wishes to avoid is extensively used at the clinics. It may be remarked some loss of benefit. The onus of giving notice that experience at these clinics lends strong confirma- of illness is placed upon the member himself, and tion to the opinion that in all forms of physical there is nothing in the Acts to suggest that this duty treatment a certain amount of psychical treatment is devolves upon relatives or friends of the member, also necessary. It has not always been easy to get the or upon the medical attendant, even in cases where individual pensioner into a frame of mind where he the member is obviously incapable of attending to is inclined voluntarily to assist with his own the matter himself-e.g., in cases of mental derangetreatment. The tendency to do little for himself can ment. Mere ignorance of the requirements of the only be counteracted by the surgeon in charge taking Acts or of the society’s rules regarding the prompt a personal interest in the individual, and showing him notification of illness is not accepted by societies as how much to his own future advantage it is to a sufficient ground in itself for delay in giving notice assist in his own treatment. The atmosphere thus * In previous articles the proceedings of the Commission were created is a great help to the individual and to the the following headings: Introductory Note; reported clinic generally. Re-education in walking has formed The Scopeunder of the Insurance Scheme (see THE LANCET, Jan. 31st, an important part of the advanced treatment of many pp. 247-8); The Provision of Medical Benefit (Feb. 7th, 301-3: Feb. 14th, pp. 355-6 ; Feb. 21st, pp. 403-5); As an cases of severe injury of the lower limbs. pp. Financial Provisions of the Act (Feb. 28th, pp. 454-7); Medical essential part of treatment the provision of various Certification and the Regional Medical Staff (March 7th, types of orthopaedic appliance should be mentioned, pp. 508-9). References to the official statement which has been issued as well as that of surgical boots and shoes. an appendix in four sections are given thus: Section A, Apart from purely surgical cases there are also as para. 69, is shown as App. A. 69," and references to the oral treated at these clinics many medical conditions, such evidence thus—Q. 1369. "