393

SPECIAL ARTICLES

THE TREATMENT OF FRACTURES

REPORT OF THE B.M.A. COMMITTEE1

IN the supplement to the current issue of theBriti8h J[edit’(/l Journal will be fouwl the report ofthe committee appointed by the council of theBritish Medical Association in July, 1U33, to considerthe existing arrangements for the treatment offractures and other injuries of the limbs. The com-mittee was seleotecl on a wide basis, including generaland orthopedic, surgeons from hospitals in differentcentres and medical officers to transport firms employ-ing large numbers of men in callings where accidentsare frequent, and their report covers a wide field.In the introductory section an attempt is made to

estimate the dimensions of the fracture problemthroughout the country. No exact data are available eon the point, but an examination of the returns forthe Workmen’s Compensation and Employers’Liability Acts. the statistics for road accidents, andthe figures of aelectecl hospitals, suggests that thetotal number is very large. The accident figuresfor industries do not refer to some of the more

important groups-for instance, building, road trans-port, and agriculture ; on the other hand theyinclude injuries of every sort, a great number of whichare probably trivial, and the proportion of fracturesto total injuries varies from 1-5 per cent. in the caseof mines to 10 per cent. in some of the more dangeroustrades. -Alore light is possibly obtained by examiningthe experience of the hospitals, to which all classesof fracture, wherever sustained, pass for treatment.Here, again, there is the difficulty that the numberstreated at any hospital must vary with its situation,but on a conservative estimate it appears that thetotal number treated in one vear in the voluntary

or hospitals alone must exceed l0U,U00, and this figuretakes no account of cases treated privately or in

municipal hospitals.The Period of Disability

Estimation of the disability resultant from thesefractures is equally dinicult, the time of incapacitydepending upon many factors, some of which are non-medical. In this report, which is largely concernedwith the investigation of fractures as an economic

problem, the injuries of patients under 20 have beenexcluded. Two series, both concerned only with

patients over 20, submitted independently to thecommittee by Mr. H. Platt, of Manchester, andMr. R. Watson Jones, of Liverpool, were found to beclosely comparable ; they are combined in thefollowing Table.These statistics represent patients in a variety of

occupations, a fair number being engaged in sedentary

1 The personnel of the committee was as follows: Mr. H. S.SOUTTAR (chairman), Sir HENRY BRACKENBURY, Dr. E. KAYELE FLEMING, and Mr. N. BISHOP HARMAN, officers of the B.M.A.;Mr. W. ROWLEY BRISTOW, orthopædic surgeon, St. Thomas’sHospital; Mr. E. ROCK CARLING, surgeon, WestminsterHospital; Mr. W. McADAM ECCLES, consulting surgeon,St. Bartholomew’s Hospital; Mr. G. R. GIRDLESTONE, surgeon,Wingfield-Morris Orthopaedic Hospital, Oxford; Prof. E. W.HEY GROVES, consulting orthopædic surgeon. Municipal Hospital,Southmead (vice-chairman) Mr. R. WATSON JONES, orthopædicsurgeon, Liverpool Royal Infirmary; Dr. T. GWYNNE MAITLAND,medical superintendent, Cunard Steamship Company; Mr.S. ALAN S. MALKIN, surgeon-in-charge, Harlow Wood OrthopædicHospital (honorary secretary); Dr. J. B. MENNELL, medicalofficer, physico-therapeutic department, St. Thomas’s Hospital;Mr. H. E. MOORE, medical officer-in-charge, London, Midlandand Scottish Railway Hospital, Crewe; Mr. W. H. OGILVIE,surgeon, Guy’s Hospital; Mr. G. II. STEVENSON, assistantsurgeon, Glasgow Royal Infirmary; and Mr. P. JENNER VERRALL,orthopædic surgeon, Royal Free Hospital.

work allowing an early return to duty. Mr. N.Roberts, however, submitted an account of a series(Series A) of 108 cases of Pott’s fracture in manuallabourers, followed up to determine when theyactually did recommence full heavy work, or go onto full unemployment pay. All these 108 patientsbecame capable of heavy work, and the average

period of incapacity was 12 weeks. These figuresare derived from highly organised fracture clinicsand are considerably better than those usually quoted.They are contrasted with a series (Series B) sent to aconsulting orthopudic surgeon from all sources formedical examination and report. Whereas incapacityremains permanently in only 1 per cent. of thepatients in series 11, in Series B no less than 37 percent. were permanently disabled. Moreover in thelatter the duration of incapacity was more thanthree times as great as it need have been.

While Series B appears to represent bad, and notaverage treatment, the comparison serves to empha-sise the considerable loss to the communitv whichmay result from such failure to obtain a satisfactoryfunctional result. It is calculated that the avoidable

incapacity period of the 276 men (Series B) representsa wastage of 168 working years, and a loss of 22,000in wages. This disparity between the results of

good and indifferent treatment has already been

appreciated by some of the large employers of labour.One company, whose workers frequently sustainedbackfire fractures of the wrist, arranged for all suchpatients to be treated by an organised service. Afterthe institution of this service the average incapacityperiod for wrist fractures was reduced from 23 to5 weeks, and the cost per case from E117 to JE19.

The Causes of Unduly Prolonged DisabilityThe report classes the causes of unduly prolonged

disability under three main headings : inadequateorganisation of fracture services ; imperfect surgicaltreatment ; and non-medical causes. Tribute is paidto the pioneer work during the war of Sir RobertJones, under whose leadership expert staffs wereorganised and trained in the technical details requiredfor success. As a result, the majority of fractureswere under the continuous observation of experts,and, as far as possible, under the same continuouscontrol throughout. With the close of the war this

organisation disappeared, and any similar service isfound to-day in a few centres only. A questionnairesent to a number of hospitals throughout the countryshowed that in most of them there is no efficient

organisation. Cases are admitted under surgeonswho have at their disposal none of the expert technicalassistance required ; the actual care of the fracturesoften devolves on the house surgeon, who lacks theknowledge and experience necessary for their adequatetreatment, and, as a rule, the patient is referred, onleaving the ward, to a massage department under

394 THE TREATMENT OF FitACTURES

an officer who has taken no share in the earliertreatment.

Many cases of prolonged disability could be attri-buted to a failure in the application of the mainprinciples of fracture treatment-reduction of thedeformity, immobilisation of the fracture till con-

solidation is complete, and mobilisation of uninjuredregions. In a high proportion of cases of delayedrecovery the displacement had never been fullyreduced. This failure had been due not simply toinadequate manipulation (though in some centresthe standard of reduction which is demanded is notsufficiently high), but to neglect to determine whetherthe manipulation was successful or adequate. Failureto use post-reduction X rays was frequently respon-sible. In a smaller proportion prolonged disabilityhad been attributable to the recurrence of deformitywhich had been previously corrected. Failure to usethe best method of immobilisation, failure in super-vision, and failure to maintain immobilisation for asufficiently long period, were the factors responsiblefor this group of cases. Neglect of the promotion offunctional activity accounted for prolonged disabilityin a large number. Too often the uninjured jointshad been allowed to stiffen unnecessarily, whilemassage and passive movements had been reliedupon to cure what should have been prevented byactive exercise.

Classification of Existing Fracture ServicesThe existing organised fracture services are reviewed

at some length, and these services are grouped inthree categories. In the first the routine treatment iscarried out by fracture clinics, which form a part ofeach surgical unit. The in-patient fractures are

treated in the general surgical wards under the careof the surgeons, and, after leaving the wards, thepatient remains under the care of the out-patientfracture clinic attached to that particular unit.This system has been adopted at St. Bartholomew’sHospital, University College Hospital, and theBirmingham General Hospital. In the second cate-

gory are those hospitals where all ambulatory fracturesare treated by the orthopaedic surgeons in specialclinics held in the out-patient department. In-patientswith fractures are admitted under the general surgeonsand remain under their charge while in the hospital,but are afterwards supervised and treated in theorthopaedic department. In the third category comethose hospitals where the whole treatment of fracturesis undertaken by orthopaedic surgeons. The develop-ment and working of four fracture clinics in this lastgroup are given in considerable detail, since thecommittee have come to the conclusion that in

organisation upon similar lines lies the solution ofthe problem of obtaining better results throughoutthe country. The centres chosen are Ancoats

Hospital, Manchester, the Royal Infirmary, Liverpool,St. James’s Hospital, Balham, and Bohler’s Clinic inVienna.

General ConclusionsIn setting out their conclusions, the committee first

discuss in detail the principles which are essentialto the function and successful working of an organisedfracture service, and thereafter give some practicalsuggestions whereby these principles may be giveneffect. The four cardinal principles are : segregationof cases, continuity of treatment, after-care, and

unity of control.Segregation of the cases into one department is

considered to be a first essential of any organisation.Only by segregation can the staff become sufficientlyhighly trained, skilled, and experienced in the technical

application of modern methods, and in the handlingof special appliances. Such segregation would not.exclude from the organisation any member of the-hospital staff who was interested in fracture treatment.If, in any hospital, there were more than one surgeoninterested and experienced in fracture work, thefusion of their activities into one organisation wouldprovide the stimulus of comparison and criticism,and make for closer cooperation and greater efficiency.The teaching of students and post-graduates would be-facilitated and not hindered by such segregation,since the teacher would have at his disposal manyinstances of the same class of fracture.

Continuity of c6?t<.&mdash;Coordination is likewise-essential, since the aim of fracture organisationsmust be the return of patients to maximum func-tional activity, not merely the exact reduction offractures. The fracture unit staff must be responsiblefor the treatment of the patient from beginning toend, from the primary reduction to complete restora-tion of function ; they should be responsible for-

physiotherapy and all remedial measures. The samecontinuous case record should follow the injured manfrom the casualty department to the wards and to-the out-patient department.

After-care.-Excellent primary treatment is oflittle avail in many fractures unless it is followedby a phase of active exercise directed to a completerestoration of function. This remedial treatment,which must be primarily active in nature, and shouldconcentrate on securing the active cooperation ofthe patient, is again the concern of the fracture unitstaff. Moreover, no organisation can be completewithout adequate " follow up

" measures-the collec-tion of accurate records, the establishment of friendlyrelations between the fracture organisation and the-patient, and the maintenance of contact with his

general practitioner.Unity of c&Ko!.&mdash;Segregation, continuity, and

after-care achieve their greatest value only if there is. zunity of control; not merely expert supervision, butsupervision by one expert. When more than one-

surgeon is interested and experienced in fracture-work, cases may be differentiated by coloured indexcards and case sheets, so that several may worktogether in one clinic without destroying the idealof unity of organisation. The necessity for unifiedcontrol develops, not from the patient in whom.someone is particularly interested, but from the-other cases where individual interest is lacking.Some practical suggestions for (a) a model fracture

unit, (b) rehabilitation centres for the provision’of graduated work, and (c) institutional cooperationare appended ; and there is also a most valuableexposition of non-medical factors of prolongeddisability. The report as a whole provides a masterlysummary of the fracture problem as it affects hospitalpractice.

ST. BARTHOLOMEW’S MEDICAL COLLEGE.-The-workof adapting the Charterhouse site of Merchant Taylors’School to meet the needs of the College has beenbegun. The chemistry and physics laboratories of theschool are being altered and a new laboratory to accom-modate 120 students is being built. The main schoolbuilding, with little alteration, and a new one-storiedstructure which is being put up, are to serve as the physio-logy department. It is hoped that these buildings willbe opened on Oct. 1st. Later it is proposed to convertthe headmaster’s house and to provide accommodationfor an anatomy unit at an estimated cost of :E25,00O,.and a students’ residential block.

395VIENNA.&mdash;SCOTLAND

VIENNA

(FRO’BI OUR OWN CORRESPONDENT)

.NEW REGULATIONS FOR THE " SPECIALIST "

(FACHARZT)THE Union of Medical Specialists of Austria has

recently compiled a list of regulations defining theconditions tha,t will entitle a medical man to applyfor recognition as a qualified specialist. Thus adoctor of medicine-i.e., a man who is an Austriansubject and has obtained his medical degree in anAustrian university, or a foreigner whose qualifica-tion is recognised in Austria, after he has passed thenecessary examinations-must work for a certain

period in public clinics, which teach the specialtyhe wishes to take up. As a rule, the surgical specialties,viz., surgery proper of diseases of the eye, ear,nose, and throat, gynaecology and obstetrics, urology,.and orthopaedics, will require five years of post-graduate study which must be spent as assistantto the professor, as senior house surgeon, or as salariedjunior house surgeon. Two of these five years maybe served in other departments, which have a closerelation to the chosen specialty. For non-surgicalspecialties four years is regarded as sufficient, threeof which must be spent in the chosen branch, andone in an

" affiliated " branch, i.e., pathology,neurology, laboratory work, or the like. In all casesthe would-be specialist must spend four (or five)years as a salaried official, and is debarred fromprivate practice during this time. If an instituteor hospital wishes to be recognised as a school forspecialists, it must have at least ten beds allocatedto the specialty concerned. Sanatoria and con-

valescent homes are not eligible for such recognition.After having served the required terms in the

.approved institutes, the doctor can apply to theunion of specialists for recognition as a duly qualifiedspecialist. It must be emphasised that this unionis a private association ; any medical man in this

country may style himself " specialist," but member-ship of the union alone gives him the privilege ofthe title " facharzt," which indicates that its holderrestricts his work to a certain branch of medicine.In practice, by arrangement with all the Kranken-kassen and medical relief societies and the sick clubsthat only the facharzt shall be allowed to hold

specialistic appointments, the union has acquiredconsiderable standing. Indeed, the monopoly heldby its members has already met with opposition insome quarters, and in the provinces certain othermedical bodies wish to exercise their own discretionin conferring the title. Another objection made isthat the new regulations which stipulate work in asalaried appointment as a condition for admissionare detrimental to any would-be specialist whohappens to be a Jew. At the moment no Jewishstudent or doctor can hope to obtain a salariedposition in any public hospital. This implies thatin a few years not a single Jewish doctor will be ableto ask for recognition by the union. It is expectedthat some modification of these rules will be made.At present there are about 4000 medical men inVienna alone, of whom about 30 per cent. are ofJewish faith, and another 3500 in the provinces, notmore than 5 per cent. being Jews. There are some1250 specialists (facharzt) in Vienna, 35 per cent.of whom are Jews, and only 300 specialists in theprovinces, nearly all Gentile.

RADIUM THERAPY IN VIENNA

At the last meeting of the Vienna Gesellschaftder Aerzte, Prof. Dr. Schonbauer reported on the

results obtained in the radiotherapy department ofthe municipal hospital, which possesses 5 grammes ofradium. Since the department was only founded in1930 there can be no evidence of cure of malignantdisease. Prof. Schiinbauer only speaks of " freedomfrom symptoms " and absence of recurrence. Theradium is used in combination with operation andelectrocoagulation. It is applied either by meansof a surface plaque or in the form of radium needlesinserted in the substance of the tumour or in neigh-bouring cavities. A review of the results obtainedin the institute shows the following figures: out of258 irradiated cases of primary malignant diseaseof the alimentary tract, 97 have remained free fromsymptoms ; the analogous figures for the upperrespiratory tract are: 92 and 25, for the lower

respiratory tract 50 and 15, the skin 248 and 191,the female genital organs 323 and 137. The so-calledradium cannon, which uses 3 grammes of radium asa massive dose in a special applicator, was used in100 cases of cavity of the cervix with good successin 54.

SCOTLAND

(FROM OUR OWN CORRESPONDENT)

NEW PATHOLOGICAL DEPARTMENT AT GLASGOW

AT the opening of the Margaret Macgregor memorialextension to the pathological department of theWestern Infirmary on Feb. 5th, Sir Robert Muir saidthat his first thought on this occasion was wonderthat mankind should only so recently have taken upthe serious study by scientific methods of that which sointimately concerned its welfare, the nature and causa-tion of disease. The second thought was how rapidhad been the increase of knowledge since that inquirywas seriously undertaken, how beneficial had beenits results, and how greatly had hospital equipmentbeeninfluenced accordingly. Research, increase of know-ledge, new and improved methods arising therefrom,additional equipment and means for utilising them-such had been and always would be the sequence inmedical history. With regard to research, the stimulusto individuals and institutions alike should not be somuch the possibility of making some importantdiscovery as simply the opportunity of taking partin the movement of progress. Investigators werelike soldiers in an army who could do little by them.selves ; together they attained much. In these dayswhen scientific research in one domain had brought themeans of practically unlimited destruction, it was acomfort to look at the other side and see its incalculableresults in the prevention and alleviation of humansuffering.

GLASGOW ROYAL INFIRMARY

In their report for the year ended Dec. 31st, 1934,the managers state that the ordinary revenue ofthe Royal Infirmary has fallen short of the ordinaryexpenditure by 25,538. Extraordinary receipts,including legacies and large donations, amounted to36,746, but all of this sum except f:1978 was requiredfor new X ray apparatus and for balancing thedeficit on ordinary revenue accounts. During theyear 17,263 patients were treated in the wards ofthe hospital, and 119,962 patients were treated inthe out-patient departments. In order to increasethe accommodation available for out-patient treat-ment the adjacent premises of the Blind Asylumhave been acquired and will be reconstructed forthis purpose. The managers deplore the fact thatthe operations of the Scottish Milk Marketing Board