History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1932 Vancouver Medical Association Jan 31, 1932

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  IjOe extend
^he S^asoris (greetings
and
Qood Wishes for the
HB J^[ew year
CHAS. H. ANDERS, Chemist
GORDON M. CLAY, Associate Chemist
70OT THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
Published Monthly under the Auspices of  the Vancouver Medical  Association in  the
Interests of the Medical Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. M. Pearson
Dr. J. H. MacDermot Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. VIII. JANUARY, 1932 No. 4
OFFICERS 1929-30
Dr. C. W. Prowd Dr. E. Murray Blair Dr. G. F. Strong
President Vice-President Past President
Dr. L. H. Appleby Dr. "W. T. Lockhart
Hon.  Secretary Hon. Treasurer
Additional Members of Executive:—Dr. A. C. Frost; Dr. W. L. Pedlow
TRUSTEES
Dr. "W. D. Brydone-Jack. Dr. J. A. Gillespie Dr. J. M. Pearson
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. J. E. Harrison :   Chairman
Dr.  A.  M.  Agnew Secretary
Eye, Ear, Nose and Throat
Dr. J. A. Smith Chairman
Dr. A. O. Brown 1 Secretary
Pediatric Section
Dr.  C.  A. Eggert . Chairman
Dr. S. S. Murray Secretary
STANDING COMMITTEES
Library Orchestra Summer School
Dr. D. M. Meekison Dr. J. R. Davies Dr-  c- e- Brown
Dr. W. H. Hatfield Dr. F. N. Robertson Dr- T- l- Butters
Dr. C. H. Bastin Dr. J. A. Smith Dr- c- h- Vrooman
Dr. C. H. Vrooman Dr.  J. E. Harrison Dr. J. W. Arbuckle
Dr.  C. E.  Brown Dr- H- A- Spohn
Dr. H. A. Spohn Dr- H- R- Mustard
Publications Hospitals
Dinner Dr- J- M- Pearson Dr.  W.  q Walsh
Dr. J. H. MacDermot Dr   F   W  Lees
Dr. J. E. Harrison Dr. D. E. H. Cleveland      Dr. a. W. Bagnall
nR'£'M"™ Dr. F. J. Buller
Dr. N. McNeill
Credentials V.O.N. Advisory Board
„  .    ,    „   „   ,,  ,    . Dr. A. J. MacLachlan        Dr. Isabel Day
Rep. to B. C. Med. Assn.     ,,     ,   v   h \i t-vtuu-/-.,.
y Dr. A. Y. McNair Dr. H. H. Caple
Dr. H. H. Milburn Dr. T. L. Butters Dr. G. O. Matthews
Sickness and Benevolent Fund — The President — The Trustees VANCOUVER HEALTH DEPARTMENT
STATISTICS, NOVEMBER,
Total  Population—Census,   1931   	
Asiatic  Population—(Estimated)    ;	
1931
244,900
  15,000
Rate per 1,000 Population
167
16
147
279
S.J
13.0
7.3
13.9
Total   Deaths |	
Asiatic   Deaths   	
Deaths—Residents only 	
Birth   Registrations   	
Female  129
Male       150
INFANTILE MORTALITY—
Deaths under one year of age	
Death   Rate—Per   1,000   births	
Stillbirths   (not  included in above)   —
CASESE OF CONTAGIOUS DISEASES REPORTED IN CITY
December 1st
October, 1931
Cases      Deaths
0
6
21.5
6
November, 1931
Cases     Deaths
-Smallpox     0
Scarlet  Fever    24
Diphtheria     6
Chicken-pox  18
Measles     14
Mumps     20
Whooping-cough    _•  14
Typhoid   Fever   	
Paratyphoid    	
Tuberculosis   	
Poliomyelitis   	
Meningitis    (Epidemic)
Erysipelas	
Encephalitis   Lethargica
2
0
68
1
0
0
0
0
i
0
0
0
0
0
0
17
0
0
0
0
2
24
15
55
68
24
17
4
0
97
1
5
0
0
0
0
0
0
0
1
0
0
10
0
0
0
0
to 15th, 1931
Cases Deaths
0
11
6
23
130
13
8
1
0
16
0
0
0
0
ridium in tablet form affords a
of obtaining urinary antisepsis
other chronic or acute genito-
uickiy penetrates denuded sur-
nd is rapidly eliminated through
c doses Pyridium is neither toxic
ilable in four convenient forms:
r ointment. Write for literature.
ACCEPTED
MERCK & CO. Ltd.,
412 St. Sulpice Street, MONTREAL
Sole Distributors in Canada
B7C9
Page 63 Paratyphoid Fever Spread by
Raw Milk
The following account of a paratyphoid fever epidemic
is taken from "Health News," of the New York State
Department of Health, for June 29, 1931:
"An outbreak of 17 cases of paratyphoid fever affecting
14 families in the city of Glens Falls -was reported recently to the State Department of Health. The dates of
onset ranged from May 29 th to ]une 7.
Vergil D. Selleck, M.D., Health Officer, immediately
on receipt of the first report of a case, made an investigation and found that all of the cases xvere on one dairy
route. The milk sold by the dairy company was at once
ordered to be pasteurized. Further investigation led to the
discovery of a carrier of B. PARATYPHOSUS B on the
farm furnishing milk to this firm and the supply from
the  farm   was   immediately   excluded,   upon   finding   the
This is merely the repetition of the old story of an
epidemic traced to raw milk which had been infected by
a carrier on the farm. As usual, pasteurization was
promptly ordered and the epidemic stopped spreading.
Pasteurization of the milk is the best and cheapest
protection, supplemented by all other practicable efforts
to provide a safe milk. .
ASSOCIATED DAIRIES
Limited
Distributing
PROPERLY PASTEURIZED
SAFE — CLEAN — MILK
Phones:
Fairmont 1000—North 122—New Westminster 1445 This is an expression of appreciation for your
business and courtesies of the past year.
In the spirit of true friendship, we ask
you to accept our sincere wishes for a
prosperous New Year; and may that
light which illumines the road to
Health, Prosperity and Happiness burn steadily for you
always.
Seymour
1050
Geovgva
Pharmacy
Granville at Ceort^ifcs.
W
Open
All Night
REST HAVEN SANITARIUM
On Marine Drive, near Victoria, B. C.
Practicing Physicians and Surgeons are invited to send
their chronic or convalescent patients to Resthaven. High
Blood Pressure and Diabetic Diets prepared and administered by competent Dietitian. Your instructions carefully
carried   out.     Qualified   physician   and   nursing   staff   in
attendance.
Write,  Telephone or Wire
Manager, Rest Haven, Sidney, B.  C.
Telephone Sidney 61L or 95
— Rates are no higher than Hospital Rates •— VANCOUVER MEDICAL ASSOCIATION
Founded 1898 Incorporated 1906
PROGRAMME OF THE 34th ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday of the
month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the
month at 8 p.m.
Place of meetings will appear on Agenda.
General Meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Paper of Evening.
1931.
November 3rd—GENERAL MEETING.
Papers:
Dr. H. A. DesBrisay: "Syphilis in Medical Practice."
Dr. W. T. Lockhart: "Treatment of Syphilis."
D.  A.  L.  CREASE of  Essondale will discuss  the treatment of
Degenerative Types of Neurosyphilis.
Discussion: Dr. J. E. Campbell; Dr. W. L. C. Middleton.
November 17th—CLINICAL MEETING.
December 1st—GENERAL MEETING.
Papers:
Symposium on Fractures to be arranged by Dr. A. B. Schinbein
and Dr. D. M. Meekison.
Discussion: Dr. F. P. Patterson; Dr. J. A. West.
December 15th—CLINICAL MEETING.
1932.
January 5th—GENERAL MEETING.
Papers:
Dr. C. S. McKee: "The Interpretation of Blood Pictures."
Dr.  Murray  McC.  Baird:  "The  Clinical Aspect of  Some  Blood
Diseases."
Discussion: Dr. W. H. Hatfield; Dr. A. Y. McNair.
January 19th—CLINICAL MEETING.
February 2nd—GENERAL MEETING.
Papers:
Dr. H. Dyer: "Tracheotomy in Children."
Dr.  C.  Graham:  "Inflammation of the Accessory  Nasal Sinuses
in Children."
Dr. E. E. Day: "Indications for Endoscopy."
Discussion: Dr. J. A. Smith; Dr. H. R. Mustard.
February 16th—CLINICAL MEETING.
March 1st—GENERAL MEETING.
The Osier Lecture: Dr. F. P. Patterson.
March 15th—CLINICAL MEETING.
April 5th—GENERAL MEETING
Papers:
Dr. J. W. Thomson: "Emergencies in Abdominal Surgery."
Dr. A. W. Hunter: "Diagnosis and Treatment of Some Urological
Emergencies."
Discussion: Dr. G. E. Gillies; Dr. Lee Smith.
April 19th—CLINICAL MEETING.
April 26th—ANNUAL MEETING.
Page 64 EDITOR'S PAGE
It is with all sincerity and' goodwill that we wish our readers a very
Happy and Prosperous New Year. It may be a little harder than usual,
in these trying times, to respond to this sentiment—the Pollyanna attitude towards life is becoming more and more difficult to maintain—
but there are signs of returning prosperity and we welcome them warmly.
The New Year is traditionally a time for good resolutions—and
while many of these may ultimately prove to be nothing but road-
material for the Acherontean contractors, some of them may stick. "What
are our new resolves to be for the New Year?
This modest journal tries to be an organ or mouthpiece for the
whole of the medical profession, primarily in Vancouver, it is true—
but also throughout our province. Its concern is for the well-being
and continued progress of this profession—and we should like to point
a moral or two, in this, the first number of the New Year.
It is not entirely a bright and shining face that this new year turns
to us—it is a somewhat lowering and threatening visage. The next
twelve months may contain much that is good for us—they may contain
much potentiality of trouble and difficulty.
One need only think for a moment, to see that the present time is
a momentous one for us. Legislation of a revolutionary and far-reaching
kind is in the near future—our whole status as a profession is, we need
not say threatened, but gravely concerned. Are we quite sure that we
are able so to deal with these problems, that we can safeguard and maintain our just rights? We know, or think we know, what these rights
are—can we shew that our claims are unselfish, that our interests are
the interests of those we serve, and that the one is inseparable from the
other?
Can we speak with a united voice? In all our battles hitherto, as
a profession, our greatest danger has been, not from our opponents, but
from our own ranks—from our own lack of unity; we cannot deny it.
How can any organized body fight, with hope of success, unless its ranks
are solid?
Is our organization such that we can secure this unity; and if not,
can we strengthen and remould it?
These are questions that we must answer, and we must answer them
soon.
In this, we may learn a valuable lesson from the French medical
profession. Read in the current number of the Can. Mied. Journal, on
page 739, the extract dealing with "The New System of Health Insurance in France." Read and ponder on these sentences:
"The French doctors have shown that, placing the moral and
material welfare of the patient first, they are irresistible to the onslaughts
of any political party. They did not employ the threat of a strike, but
simply that of a combined front. Solidarity of the profession with the
threat of non-co-operation with any political party which opposed their
just and necessary claims."
Again: "Tribute should be rendered, also, to their insistence on the
control of medical matters and discipline by the medical profession."
What about it, my masters?   Have we the same capacity for union,
Page 65 with its resulting strength, as the French doctors? Or are we like our
brothers in Great Britain, going to let ourselves be "bluffed," to quote
this article again? Are we going to allow ourselves to be exploited and
used, to the advantage of every person but ourselves?
We must examine into our organization more carefully, and if
necessary, recast it, and make it stronger and more comprehensive. And
we must do it at once. If we do not, let us make no mistake about it,
we shall lose much of what we hold most precious, and we shall deserve
to lose it.
ANNUAL DUES
Members who have not yet paid their annual dues are reminded that
their names must be posted in the Library on January 1st, 1932.
NEWS AND NOTES
In view of the fact that many enquiries are being received from
medical men with regard to the Canadian Medical Indemnity and Health
Insurance Co., the Industrial Service Committee of the B. C. Medical
Association deems it necessary to emphasize the following facts. This
Association is a private venture and has no endorsement in any way
from either the B. C. or the Vancouver Medical Association, though
the Company has approached both these bodies and has shown an
anxiety to carry on its business in a way that would be acceptable to
the medical profession. The officers of the Company say that they
intend to allow free choice of doctor, complete medical treatment up
to a certain sum and payment according to a schedule of fees similar to
that of the Workmen's Compensation Board. As these principles are
accepted in the main by our provincial organization, there would seem
to be no objection to members working on these terms, but it must be
understood that it is their own private arrangement with this Company.
Under present conditions the B. C. Medical Association does not feel
that it can in any way sponsor this scheme. It may-be pointed out that,
in view of the possible introduction of Health Insurance in British Columbia, all such plans as this may be terminated at any moment.
The Library Committee wishes to take this opportunity of drawing
the attention of the profession to the fact that the nucleus of a Museum
has arrived, in the donation by Drs. G. E. Gillies and P. W. Barker, of a
mahogany cabinet (said to date from the days of Good Queen Anne)
which the doctor of those days presumably carried around with him
instead of a bag, or in addition to a bag, may-be. If any other member
of the profession has anything, or knows or hears of anything which
he thinks would be of interest, let him generously procure or purchase
it and send it along, and our collection will soon amount to something
worth talking about.
Once more the Library Committee feels it necessary to draw attention to the fact that out of town practitioners can only obtain material
from the Library by becoming Associate members of the Vancouver
Medical Association.    The B. C. Medical Association office is constantly
Page  66 receiving requests for periodicals which can only be obtained from our
Library, as the Provincial Association has no library facilities. Out of
Town men please note.
Drs. F. P. Patterson and H. W. Riggs were the two local members
contributing to the programme of the North Pacific Surgical Association
which met in Vancouver on December 4 th and 5 th under the presidency
of Dr. P. A. MacLennan. The average attendance at the sessions was
forty. The annual Banquet was, as usual, a great success. The 1932
meeting will be held in Spokane.
A portrait of the late Dr. R. Eden Walker, of New Westminster,
for many years a member of the Council of the College of Physicians
and Surgeons of B. C, and for some years its Treasurer, has been presented to the Library by Dr. W. A. Clarke. We should like to get
portraits of all the men who in times past have worked for our profession in the Province.    In years to come they will be of great interest.
As we go to press we learn with deep regret of the death of Dr.
G. L. Campbell, of Kelowna, which occurred quite suddenly on December 16th, and of the accident to Dr. T. J. McPhee, of Nanaimo, which
resulted in his death on Sunday, December 20th. We extend our sincere
sympathy to Mrs. Campbell and Mrs. McPhee and families in their
bereavement.
MEETINGS
The December general meeting was held in the Medical-Dental
Auditorium on the first of the month, with an excellent attendance,
probably due to the fact that the papers of the evening were on fractures, ever a popular subject. The speakers were Dr. A. B. Schinbein,
on "General Principles in Treatment of Fractures," and Dr. Murray
Meekison, on the "Treatment of some Common Fractures." The discussion was opened by Dr. F. P. Patterson who was followed by Dr. J. A.
West.   Both papers are printed in this issue of the Bulletin.
The Chairman referred to a joint meeting of the B. C. Loggers'
Association with the Executive and a Committee of the B. C. Medical
Association at which the Loggers' Association had presented certain
cases in which they felt they had a grievance. Dr. Prowd emphasized
the importance to the profession of this question, and after discussion he
was authorized by the meeting to appoint a special committee to act
with the Committee of the provincial association to deal with the situation as occasion arose.
The December meeting of the Clinical Section was held at St.
Paul's Hospital, on the fifteenth, with an attendance of fifty.
The Staff of Shaughnessy Hospital extended ah invitation to the
Cancer Investigation Committee to hold this month's meeting at their
Hospital on the 17th. Interesting cases were shown and discussed and at
the close of the programme refreshments were served by Miss Mathieson
and her staff.
i
Page 67 THE SURGICAL TREATMENT OF PULMONARY
TUBERCULOSIS
By Dr. J. S. Burris
Surgery is not a substitute for the older forms of treatment in
pulmonary tuberculosis, but is a supplement, when the older forms
have failed to arrest the disease, or are likely to prove ineffective in reestablishing a resistance balance against the disease. We know the advantage of operating on a case of appendicitis in the interval; of the
multiple stage operation of prostatectomy; of the advantage of operating
on a toxic thyroid, after the crisis is over, and the patient is building
up a reserve balance. We know, too, the advantage of early operations
in cases of carcinoma. The same surgical principles must be applied in
cases of pulmonary tuberculosis. To obtain the best results there must
be the closest co-operation between the attending physician who knows
the limitation of his therapy and the surgeon who recognizes the poor
character of these surgical risks.
The surgical procedures are:
1. Artificial  pneumothorax.    This is done by the physician and
has some dangers and many disadvantages.
The dangers are air embolism and pleural complications. At
the Loomis Sanatorium over a period of fourteen years the
mortality was 5% from pleural complications alone. A lung
that is "collapsed" by artificial pneumothorax over a long
period of time has as much disability as that caused by phrenic
avulsion, and when the lung re-expands the chest is drawn in,
the ribs immobilised and the mediastinum displaced, the pleural
cavity being narrowed to accommodate the lung. It is the
consensus of opinion amongst authorities that the lung should
not be allowed to re-expand until a phrenic avulsion has been
done.
2. Intra and extra pleural pneumolysis.    I have had no practical
experience with this form of compression.
3. Phrenic avulsion.
4. Extra pleural paravertebral thoracoplasty.
It is of the third and fourth procedures that I wish to speak and
more particularly of phrenic avulsion.
Phrenic avulsion is the resection of the intra-thoracic portion of
the phrenic nerve, which supplies the corresponding half of the diaphragm. The effects of this operation are two. The diaphragm is
paralysed, causing it to rise in the thorax where, in the course of a few
months, it is converted into a thin fibrous band. The height to which
it may rise varies. In one of our cases (done in Feb., 1931) it rose to
the fourth rib, a distance of several inches and according to Matson
the rise may not be complete for two years. The forces causing this
rise are the pressure of the abdominal contents on the paralysed dome of
Delivered before  Vancouver  Medical  Association,   October,   1931.
Page 68 —■
the diaphragm, the retraction of the elastic tissue in the lung and the
contraction of the abnormal fibrous tissue. The effects produced on the
lung are the most important. The extent of the lung tissue affected
varies and there is considerable disagreement amongst authorities on this
point.
The success of the operation depends not so much on the localization
of the lesion as on some property inherent in the operation itself. (Alexander) . The upward unimpeded force of the abdominal muscles makes
coughing easier and more productive, therefore, less frequent. The
amount of sputum at first increases, later diminishes, and changes in
character as the lesions improve. There is stasis of the blood and lymph
in the lung, and because of this the absorption of gases from the pleural
cavity is restricted, so the necessity for refills is less frequent. The
diminished gaseous interchange within the lung on the paralyzed side
throws more work on the lung, so we have a valuable index regarding
the advisability of doing a paravertebral thoracoplasty. It is a supplementary measure to a pneumothorax and a substitute when a pneumothorax is too long drawn out and expensive.
Mrs. A.—Age 52 had been ill with cough and expectoration for
many years. For a few months prior to January of this year she had
afternoon rise of temperature.
X-Ray taken on January 9th, 1931, showed two cavities in the right
upper lobe, below the clavicle. The larger, one inch in diameter, the
smaller 1/5—2/3 inches in diameter. In the left lung there was some
infiltration.
Phrenic avulsion was done on January 24th, 1931. X-Ray examination some months after, shows collapse of the smaller cavity. The
larger, which was thick walled, shows little or no change. The right
diaphragm has retracted fully 3J4 inches.
She is now eighteen pounds heavier than before operation, is able
to do most of her housework, the cough has lessened although the sputum
is still positive.
This patient has returned to her home in the East, but writes to
say that she is very definitely improved. This was a case outside the
Sanatorium and had neither the time nor the money to have artificial
pneumothorax done.
If the operation serves no good purpose, pneumothorax can be
continued. Wirth says avulsion is not so effective when employed after
a course of "pneumos," because of secondary indurations and loss of elasticity in the lung and diaphragm. In cases that are at a standstill it
gives more rest to the lung: soft-walled cavities are more benefitted
than the fibrotic ones.
The results may be a striking improvement in the general condition
of the patient, and of X-Ray appearances of the lung, or the operation
may hasten the exit of the patient. It seldom cures the disease. It is
too soon for anyone to be very dogmatic about the effects of collapse
therapy produced by this operation, but I am approaching a point where
Page 69 I am willing to advocate the operation in all cases of unilateral pulmonary
tuberculosis where artificial pneumothorax is indicated.
The operation is safe, simple, and can be done under a local anaesthetic. The dangers are more theoretical than practical. The reduction
in the vital capacity does not inconvenience the patient (Matson) and
they are no worse off for having had the operation. Artificial pneumothorax can be carried on, if thought advisable, or a thoracoplasty can
be done, if the opposite lung is good and there is no tuberculosis in the
other organs.
The older practitioners will recall the uphill fight surgeons have
had in the past to persuade physicians to have an acutely inflamed appendix removed early. The surgeon's wares meet with a stubborn sales-
resistance, and in the past he has had to break this down by performing
miracles on dying patients, before he was allowed to practice his art on
those who might pull through.
Thoracoplasty is a much more serious procedure. The ideal operation is one that is done in one stage, but the fact that these cases are
poor surgical risks prevents this.    It is better done in two or three stages.
It is indicated only in those cases that show a reparative tendency,
that is, in the fibrotic cases and not in the exudative ones. In the cases
in which pneumothorax and phrenic avulsion are insufficient or fail,
there must be good general resistance on the part of the patient. The
other lung must be free from active disease, and in cases with intestinal
or renal tuberculosis, diabetics, or cardiac cases, which have a tendency
to decompensation, it is contraindicated.
We have done 32 cases, 25 of which have been reported. 21 cases
are cured and living moderately healthy lives.    10 cases have died.
One case is in hospital now, the final stage having been completed
last week.
We have done twenty-four operations of phrenic exairesis for pulmonary tuberculosis and two for bronchiectasis, in addition to those done
as a preliminary to the more severe operation of thoracoplasty, and nine
cases last month too recent to be considered at this time. The twenty-
four cases all shewed advanced tuberculosis with cavities. The duration
of the disease was from six months to fifteen years. The ages were from
twenty to fifty-two years of age.    Eighteen had positive sputum.
In seven cases pneumothorax had failed.
In five cases pneumothorax was not tried.
In four cases pneumothorax was not done again because of inability
to find the space.
In eight cases pneumothorax was done more than once.
(The two cases of bronchiectasis showed marked improvement. They
felt better, coughed less, and there was no gastric disturbance.)
Page 70 The twenty-four cases showed elevation of the diaphragm, and in
one case the diaphragm could not be seen because of a pyopneumothorax.
Of the twenty-four cases, three showed the cavity closed (12^6%).
In one of these pneumothorax failed, in one it was not tried, and in one
pneumothorax was continued.
Five of the cases showed improvement, in that the cavities were
diminished in size (about 21%.)
Twelve of the cases remained unchanged.
Three of the cases became worse.
One of the cases died.
In the three cases which become worse, pneumo thorax had failed.
Four cases had gastric disturbance as a result of phrenic avulsion
and in these the left phrenic nerve was avulsed.
The patient that died had a tuberculosis enteritis. The lung condition
improved, but the patient died of perforation of the bowel.
Closed Cases
No. 1—Mr. W., age 44. This is a far advanced case with multiple
small cavities on the left side to the 2nd rib. His sputum was positive.
Pneumothorax was never tried. Phrenic avulsion was done in October,
1930. After the operation the cavities closed and the infiltration was
contracted into a smaller space.   He is well and working.
No. 2—Mrs. Y., age 40. This was a far advanced case with a
cavity y^ inch in diameter in the upper lobe, sputum negative, pneumothorax failed. Phrenic avulsion was done in September, 1930. The
diaphragm rose three inches. She improved at once and continued to do
so.    The cavity is apparently closed.
No. 3—Miss H., age 22. Far advanced. Positive sputum. Films
showed a cavity in the left apex fully one inch in diameter. The operation of phrenic avulsion was done in February, 1931. The cavity closed
and apparently has remained so.
Improved Cases
Miss F., age 29. Far advanced, sputum negative. The cavity in
her left upper lobe was closed with artificial pneumothorax. At the time
of operation in March, 1931, she had fluid in the pleural cavity. This
has cleared up and she is apparently well.
Mr. McC.—Before operation cavity in his left upper lobe showed to
the extent of probably slightly over one inch in diameter. After operation
cavity was reduced to about one quarter the size.
We hope, at a later date, to report more fully our thoracoplasty cases
and this paper is given with the hope that there will be a discussion on
this recent but important form of therapy.
Page 71 PRINCIPLES IN THE TREATMENT OF FRACTURES
Dr. A. B. Schinbein
With the development of industrial machinery, rapid transportation, the growth of traffic, the increasing number taking part in sport,
there is a yearly increase in the accidents to life and limb. As a consequence the treatment of injuries assumes an ever-growing importance.
Fractures and joint injuries are the commonest accidental causes
of permanent disability and invalidism. Associated with this, of course,
are great economic loss, physical and mental suffering. This economic
loss is felt by the individual, industry and the state.
"Crippling due to Fractures" is the subject of m.any articles by
orthopaedic surgeons, surgeons paying special attention to fractures,
committees on fractures and Workmen's Compensation Boards.
Many of these are very critical of the initial treatment, neglected
or inadequate as it sometimes is. All make a plea to our profession and
hospitals to take a greater interest in the study and treatment of fractures,
and stress the fact that every fracture is a potential cause of disability
and deformity.
The majority of fractures are first seen and treated by the general
practitioner and the general surgeon. On him a heavy responsibility
rests, i.e. on his judgment in deciding what cases he can efficiently treat
himself and those (bad and difficult cases) he should, in the best interests
of the patient and himself, refer for special study and treatment. All
branches of medicine are of necessity concerned with the treatment of
fractures and their complications.
In this paper I intend to confine my remarks to general principles.
There is no branch of surgery where teamwork is more essential
than in the treatment of fractures. The hospital executives (providing
facilities and equipment), the surgeons, X-ray specialist, nursing staff,
make up its personnel.
For the successful treating of fractures sound underlying principles
are absolutely necessary, and bearing these in mind one must adapt his
treatment to the conditions that present themselves.
A fracture may be defined as a break in the continuity of a bone
brought about by some form of violence. In the great majority of cases
the force is suddenly applied and comes from without, but muscular
energy may be the exciting cause.
Bones are the internal support of the body and limbs, and when one
breaks, the associate tissues lose this support, and cannot function until
this support is re-established.
A fracture being a wound of bone, repair, as is natural, takes place
in the same way as the healing of wounds elsewhere, i.e. by granulation
tissue. In the case of bone, however, in the granulation tissue calcium
is deposited which progressively becomes denser until it becomes hard
bone. After a period of months this bone arranges itself in lines and
Delivered before  the  Vancouver  Medical  Association,   November,   1931.
Page 72 1
channels to form the normal histological picture of bone. The actual
mechanism in the deposition of calcium in the granulation tissue is not
known. The origin and function of the so-called osteoblastic cells is not
definite. It is probable that they have to do with this mechanism. The
chemical form of the calcium in bone is unknown.
The pressure of the end of one fragment against the other (end
thrust) is probably nature's strongest call for the depositing of calcium
in the connective tissue between the fractured ends. Where displacement
of fragments is slight only a very small amount of callus will be laid
down (analogous to incised wounds). Where there is marked displacement
the amount of callus will be proportionately large (analogous to lacerated
wounds).
With respect to diagnosis only one point is offered, every suspected
or doubtful case should be considered as a fracttire until examination by
X-ray has decided the presence or absence of a fracture.
Treatment
The object of treatment must be the restoration of complete function.
Treatment commences with first aid. When a bone is broken the
adjacent soft parts are usually injured as well. Temporary immobilization
with provisional traction, if possible, avoiding all unnecessary manipulation, prevents further damage to the soft parts, reduces pain, lessens shock
and if the fracture is compound, ensures that infective agents will not
be further rubbed into the tissues.
When the patient has been transported to a place where suitable
treatment can be carried out (nearly all fractures today need some period
of hospitalization) as complete an examination as possible of the patient
should be made. A search for additional injuries should be carried out.
If shock is present this should be treated and recovered from before
anything further is done.
If shock is not present or is recovered from, then a thorough examination of the injury should be carried out. Complications should be noted
at this time.
An X-ray before reduction is advisable, as we gain thereby information with regard to the position of the fragments, line of fracture, comminution, and any pathological condition of the surrounding bone.
To restore that support I mentioned all treatment of fractures
require:-
(1) Exact apposition of the fractured parts in good alignment,
i.e. reduction.
(2) Prolonged fixation of the opposed parts in good position until
they are re-united.
Each fracture should be considered as an individual problem.
If there is no displacement then, of course, only fixation is necessary.
If there is displacement, the earlier reduction is attempted the more
easily it is accomplished. For reduction, traction and manipulation are the
essentials and the only two methods at our disposal. Traction may be
manual or mechanical.
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Phone: Seymour 1493 Muscular spasm is the greatest impediment to reduction. However,
with relaxation of this by anaesthesia, and flexion of the joints, with
traction and manipulation it is almost always possible to attain good
apposition and alignment but it is a more difficult business to keep the
ends in good position than it is to secure apposition. This is due to the
continuous pull of the muscles and the action of gravity.
Fractures at the end of the bones such as Colles', Pott's, lower end of
the humerus, neck of the femur, having been reduced, can be maintained by splinting, and plaster of Paris is the best of splints.
In fractures of the shafts of the long bones, transverse or V-shaped
(tongue and groove) fractures if reduced can be maintained in position
but must be carefully inspected by frequent X-ray examinations as angulation tends to occur due to the pull of muscles and the action of
gravity. In the oblique and comminuted fractures of the shafts of the
long bones (and probably in all fractures of the shaft of the femur) it
is impossible to maintain good apposition and alignment with splints alone.
The best method is continuous traction. X-ray should be used to prove
the success of the reduction and from time to time its maintenance, the
progress of callus formation and its consolidation.
In the treatment of fractures of the long bones, good alignment
must be effected, not only for aesthetic reasons but for the preservation
of the true axis of the joints above and below, so that the body weight
or pressure will fall accurately upon the joint lines. .The value of extension in obtaining a correct alignment cannot be over-estimated. The
operative exposure, reduction and fixation of fractures carries with it
certain dangers, especially that of infection, and should be avoided as far
as possible. It is imperative, however, (1) in certain fractures such as
fractures of the patella and olecranon, head of the radius, with separation
of fragments. (2) where reduction and maintenance is impossible by other
methods. Fixation should be uninterrupted and maintained until firm
union is secured.
Passive movement of joints, massage and other physical agents can
only be carried out during this period at the risk of disturbing the
immobility of the limb and position of the fragments and should be
reserved for after treatment, that is, after firm union is present. Then
if there is atrophy of the muscles, swelling of the limb, swelling and
limitation of movement of joints, physiotherapy can be of valuable aid.
During the period of fixation elevation of the limb disperses traumatic swelling, and prevents subsequent swelling. Active movements of
those parts not fixed should be systematically carried out, such as the
fingers in fractures of the arm and forearm. This prevents atrophy and
ischaemia of the functioning muscles. Swelling is diminished due to a
better return circulation. It is possible to actively work muscles and cause
them to contract without movement of the joints they control, such as
the quadriceps extensor. This should be encouraged.
The time necessary for complete consolidation of a fracture is much
longer than generally supposed and taught. It is very important to realize
this especially when treating fractures of the lower extremities, and not
allow weight-bearing too early.
Page 74 The period of consolidation differs in different bones, and in individuals. Age is a factor, consolidation taking place rapidly in the young,
slowly in the aged. The calendar should not be the index, but the solidity
of the union. If the ends of the fracture are in contact (in whole or in
part) and in alignment, and are maintained there, non-union should be
very uncommon as under such conditions soft tissue cannot be interposed
between the fragments.
If, with the above conditions, consolidation is slow and delayed, it
pays to be patient and conservative. After many months consolidation
may result. After a long period of inactivity osteogenetic changes often
become active and solid union results.
That syphilis, cachexia, rickets and other constitutional diseases are
a cause of non-union has not been proven, but if present they may delay
union and should be treated. In all fractures one shotdd treat the patient
as well as the fracture.
All drugs heretofore recommended to hasten union have given no
proven positive results (Bohler), This is true, too, of certain minor procedures, such as rubbing ends together, injecting blood between the
fragments, etc.
In the lower extremities the value of "end thrust" mentioned before in healing of fractures can be made use of, allowing weight-bearing
in an ambulatory splint.
Overlapping, wide separation, soft tissue interposition and infection
are the common causes of non-union. Interrupted fixation, over-extension, may cause non-union. True non-union necessitates open operation.
When union is firm then function may be re-instituted. Splints are removed daily for supervised active movements and physiotherapy. Splints
are discarded when solid union is reached. Weight-bearing is gradually
increased. If position and alignment are to be maintained until union
takes place, the very early movement of the immediate joints as taught
by some is not possible.
If union in good position and alignment has been obtained, and during fixation the details previously mentioned have been carried out, then
return of function largely depends upon the patient himself actively
exercising his muscles and joints.
The indications for physiotherapy are stiff and swollen joints,
atrophied muscles and oedema from impaired circulation. These will be
avoided or minor in degree if the principles here outlined have been
possible of attainment.
It is in the treatment of the deformities and disabilities following
fractures that costly and tedious after-treatment becomes necessary.
Compound Fractures
A compound fracture is one in which there has been a communication between the fractured surface and the air.
A fracture may be compounded in one of two ways:-
(1) From within-out by the penetration of the skin or mucotis
membrane by the bone.
Page (2) From without-in. (a) By a foreign body first piercing the skin
and then continuing to break the bone, (b) A tearing of the skin and
soft parts down to a break in the bone.
All compound fractures therefore are potentially infected. It is not
the fracture but the resulting infection which so endangers life and limb.
Every branch of medicine (except possibly obstetrics and gynaecology) has benefited by the teaching of the war, in the application to
civil practice of the things learned, many only by bitter experience and
disappointment. Surgery in the treatment of wounds, (compound fractures, of course, included in this), probably benefitted most.
Hey Groves, in an article on the treatment of open fractures states
"the cardinal facts which emerge from this welter of blood and pus may
be grouped under three headings:- (1) The time factor. (2) Immobilization.    (3) Wound disinfection.
We know what the time factor means in the outcome of a perforated gastric ulcer. The same is true of compound fractures.
The sooner a thorough disinfection of the wound is done the more
lives and limbs will be saved, long, painful, tedious treatment will be
unnecessary and fewer permanent disabilities and deformities will result.
Immediate efficient immobilization is necessary for transport for the
reasons given before.
After wound disinfection has been carried out fixation of the fragments in apposition and alignment as in simple fractures is necessary to
secure healing.
This is best obtained by axial traction with the limb supported on a
Thomas splint. Easy access to the wound is thus provided.
Time does not allow me to describe the stages and methods tried
in the war to secure disinfection of wounds. The one that ultimately gave
the best results and still is universally used is called "mechanical cleans-
ing."
The essentials are: preparation of the field, thorough opening up
of the wound right down to the remotest part which has been injured,
cutting away torn, soiled, devitalized skin, fascia and muscle, removing
gross dirt and foreign bodies and bits of bone which are completely free
from any attachment. Free irrigation of the wound. Lightly packing the
wound with gauze and sutures placed, not tied. Packs removed in 48
hours and sutures tied if no evidence of infection. Should any distinction
be made in treatment between a fracture compounded from within-out
or without-in, or because of the size of the outside wound?
If the wound is small, up to x/z inch in extent and if it has been
caused from within-out, conservative treatment is justifiable, although
some authorities say no. The wound should not be sutured.
Antitetanic serum should be given to every case of compound
fracture.
Page 76 THE MODERN MANAGEMENT OF SOME COMMON
FRACTURES
Dr. Murray Meekison
Introduction.
Dr. Schinbein has given you an excellent outline of the modern
conception of general principles in the treatment of fractures. It now
devolves on me to take up, one by one, some common fractures, dealing
particularly and in some detail, with their treatment.
Fractures of Metacarpals and Phalanges.
Fractures of the phalanges and metacarpals are serious injuries and
may result in considerable permanent disability. When the fractures are
not adequately reduced the results are bad, and may be poor even with
correct anatomic reposition. In fractures of the middle phalanx the
lumbricales extend the distal fragment, while the interossei flex the proximal fragment, causing the palmar angulation which presses on the flexor
tendon of the finger. In fracture of the metacarpal, the pull of the
interossei causes the dorsal angulation of the fragments. Fortunately, the
majority of fractures of metacarpals and phalanges seen in practice show
no displacement. For these, an admirable and adequate splint consists of
criss-cross strips of adhesive tape, about % inch in width, laid across
the dorsum of the finger or hand, but not surrounding it, and built up
to include the joints above and below the fractured bone. The relief
from pain is marked.
In the case of a metacarpal with little or no displacement, the roller
bandage splint is ideal. Here one places a roller bandage in the palm of
the hand so that the metacarpophalangeal joint may flex about 45 degrees.
The fingers may then be strapped into position or the whole hand, excluding the thumb, may be wrapped in a flannelette bandage for a
period of three weeks.
Where there is displacement, the banjo splint is our best method
of treatment. There are various forms, but the one I like best extends
from the level of the elbow to 2 inches beyond the end of the fingers.
Extension from the end of the finger to the wire is obtained by means
of adhesive strips on the fingers and elastic bands from these to the wire.
They require adjustment every day or so.
Manipulation of the plaster cast under anaethesia has been recommended, but I can assure you that the banjo splint is much less
difficult technically, and much more likely to be productive of a good
result.
Splinting should be discontinued as soon as possible, three weeks is
ample under ordinary conditions. I prefer slightly less, and early movement is absolutely essential.
The results of open reduction of phalangeal fractures are not good.
I will not go into the subject of Bennet's fracture of the thumb
or joint fractures. These are more difficult to handle but the same
principles of treatment may be employed.
These may be summarized as: 1. Extension. 2. Splinting for a
nominal period.    3. Early movement.
Read  before the Vancouver Medical Association,   December,   1931
Page 77 Fractures of the Lower End of the Radius.
One can almost be dogmatic about the treatment of Colles' fracture. This is an extremely common injury and frequently very badly
handled. The main point to be kept in mind is that complete reduction
must be obtained, and this is best obtained under general anaesthesia.
A whiff of gas is really all that is necessary. In certain continental centres
no anaesthesia is used whatever. However, I am still using general. One
always notes in the typical Colles' fracture, the articular surface of the
lower fragment is directed dorsally. The objective is to reduce it to the
point where the articular surface is directed slightly to the palmar side.
Let us take a fracture of the right radius for example. One grasps the
hand with the right hand as one does in shaking hands. The index finger
of the left hand is applied to the ventral aspect of the fracture line and
the thumb to the dorsal with the palm on the arm above the fracture.
Now loosen the fragments by hyperextension of the wrist combined
with ulnar deviation. When this manoeuvre is accomplished, extension is
obtained by a strong pull with the right hand, and keeping up this extension bring the wrist to an acutely flexed position combined with
ulnar deviation. Your fracture is now reduced. For the left wrist one
simply reverses the hands.
For retention I have been in the habit of using one moulded plaster
splint, applied to the dorsal aspect of the bare arm from just below the
bend of the elbow, down over the flexed wrist to the level of the metacarpophalangeal joints and tending to the radial side. As this hardens
it is bound down by a single flannelette" bandage. This is an extremely
comfortable position. After ten days, this splint is removed and the wrist
gently extended to a straight position. I then apply a similar plaster
splint to the flexor surface of the arm extending from near the elbow
to the metacarpophalangeal joints. This leaves the fingers free and aids
in convalescence. After another ten days this splint is removed and
gentle active movements and gentle massage are commenced. I forbid
any effort with the wrist for another ten days but at the end of that time
the patient may do with it as he likes.
This attitude on the treatment of Colles' fracture is almost universal.
Let me quote two Continental writers. Delitala and Marconi in reporting the conclusions of the Italian Congress of orthopaedic surgeons in
"Italian Reformed Medicine" Nov. 1927 say "Bloodless treatment almost
invariably gives satisfactory results. Reduction is done under an anaesthetic. Immobilization is usually in a position of palmar and ulnar
flexion. The duration of immobilization should be fifteen to twenty
days."
Fractures of Both Bones of the Forearm.
Fractures of both bones of the forearm are frequently very difficult
to handle and not infrequently come to open operation. In this case one
usually finds that the radius is the stumbling block and it is usually
a question of interposition of soft tissue structures between the fragments. The fracture is usually in the middle third of the forearm. In
direct violence the fracture line is usually transverse and both bones are
broken at about the same level. In indirect violence the fracture lines
are usually more or less oblique and at slightly different levels. Comminution is common and the displacement is usually an overlapping of
Page 78 at least one bone and the fractured ends tend to be approximated to a
central position. General anaesthesia is again employed and it is desirable
that the surgeon should have two assistants* This fracture, by the way,
is one in which the fluoroscopic table may be used to great advantage.
Our objective here is (1) at least 50% apposition in both bones. I
am perfectly satisfied that this will give 100% functional result and
if I obtain this I leave it alone. (2) Adequate spacing between the
bones to prevent cross union. (3) No. angulation. The position of the
immobilized arm to attain this must be (1) elbow at right angles (2)
Arm fully supinated. (3) Forearm extended. The main difficulty lies in
the maintaining of the reduction until it is immobilized after reduction
has been obtained. A useful procedure, bearing this in mind, is as follows:
with the usual protection of the bony points about the elbow and wrist,
a circular plaster is applied from the axilla down to a point about 2
inches above the fracture with the elbow at right angles and the forearm supinated. A similar plaster is applied from the level of the metacarpophalangeal joints to a point about 2 inches below the fracture with
the wrist straight. These are allowed to firm and then the manipulation
for reduction is done. This means hyperangulation with plenty of extension. If hyperangulation in one direction fails to obtain the desired
result, they should be angulated in the other and this usually meets with
success. One assistant maintains a pull on the plaster enclosing the upper
arm while the other keeps up the extension on the wrist and hand,
allowing the surgeon to bridge the gap between the two plasters, previously applied, with further plaster, the arm still supinated. In the
after treatment, the fiingers must be closely watched for 24 hours for
compression and indeed one usually sleeps more soundly if the plaster
is split from top to bottom after it is firm. The plaster is left on for
six full weeks in the average adult. An important point, however, is to
have another X-ray at the end of two weeks to make sure there has been
no sagging or slipping in the plaster. It may save considerable embarrassment later on. In the normal case at. the end of six weeks, union will
be far enough advanced to permit the removal of the cast, when we
usually apply a flannelette bandage, more or less for psychological reasons.
This is removed daily for gentle massage and active movements, attention being paind to that of the supination and pronation the loss of
which is frequently a prolonged or permanent disability. After the
lapse of another six weeks the arm should be as good as ever. I am not
going into the question of the normal case, cross union, non union or
delayed union or fractures requiring open operation, but I will say
this. I you find that you have little or no union in six weeks, change
the position of the forearm to one midway between supination and pronation as permanently fixed supination is a severe disability.
Supracondylar fractures of the humerus.
We will omit fractures of the head of the radius and of the
olecranon, both of which will usually be treated by open operation if
there is any displacement, and dwell for a minute on supracondylar
fracture of the humerus. Much has been written on this particularly
worrisome fracture, and in the hands of those with the greatest skill
and widest  experience  all  over the world it  not uncommonly has  an
Page 79 unhappy outcome. Here is a fracture where it is wise to divide the
responsibility with a confrere, preferably one experienced in these lines,
as this and fractures of the os calcis damage more reputations than they
enhance. Here our deformity is caused by a backward displacement of the
lower fragment on the main upper fragment, and frequently this
lower fragment is carried upward by the triceps. The important factor
to be kept in mind is that the damage is done, not only to bone, but to
nerves and blood vessels as well, and our ever present fear is that a
Volkmann's ischaemia will develop. This may be due to obstruction
from without i.e. splints, bandages, or a too acutely flexed elbow, or
from within, i.e. unreduced displacement of bones or subfascial haema-
toma. However, Sir Robert Jones in the B.M.J, for October 13, 1928
states that its chief causative factor is venous obstruction. Many cases
are on record which have developed in the absence of any retentive
apparatus. I myself watched one come on. In any event, the poor
surgeon is not always to blame. At the same time we must be extraordinary careful that we may not take any part in its causation.
With this dread complication in mind we cannot do better than quote
Sir Robert Jones, in his description of his methods, deliberately adopted
to avoid ischaemia.
1. The displaced fragments should be reduced as soon as possible.
He does not advocate leaving a supracondylar fracture unreduced for
several days. His method of reduction he describes as follows: "I first
extend the arm, pulling it and supinating it at the same time. While the
thumb is placed on the upper fragment, the extended and stretched
elbow should be flexed. This usually and without difficulty gives a
complete reduction." (Allison says, "avoid pump handle manipulation.")
2. Use no force in flexing the elbow.
3. Avoid  circular  compression.
4. Avoid all splints. The wrist is slung in a collar and cuff sling
under the chin. It is a mistake to bandage the arm to the forearm or the
elbow to the side.
5. For the first few days critical observation of all fractures about
the  elbow.
Jones describes the usual and effective method of reduction. The
method of retention varies. One man uses the usual circular plaster,
bivalved, another uses some form of traction apparatus (Cornwell,
Southern M. J. Aug. 1927), still another uses adhesive. Personally I have
always used plaster. Someday I will get up my courage and sling the
wrist to the neck as the master, Sir Robert Jones, does. Be that as it may
the next important thing is early movement. This means active motion
at the end of two weeks and not later than three weeks. If these
fractures are kept immobilized for as long as a month it means a long
after-treatment and incomplete return of function. Massage and passive
motion are not indicated. It is active motion and it must be carried
out every two or three hours, short of pain. In spite of the greatest
care both in reduction and after treatment, about ten per cent of
fractures about the elbow will yield poor end results. This aspect is
thoroughly reviewed by Hansson and Birwell in the American Journal
of Surgery for July 1927.
Page SO Fractures of the Neck of the Humerus.
We will now consider for a moment or two fractures of the upper
end of the humerus, usually the surgical neck. Fractures of the shaft
are not nearly as common and would entail a great deal more description
so we will omit them. The cause is usually a fall on the shoulder, and
the usual displacement is that the upper end of the lower fragment
is drawn upward and inward, while the upper fragment remains in
place, or is externally rotated as much as 90 degrees. Here again we make
use of the two-stage plaster, as being easy to carry out, and giving excellent results. General anaesthesia is again employed, and when the
patient is well under, we place the arm in plaster with the elbow at
right angles, the forearm midway between supination and pronation
and the wrist straight. The plaster is carried up to a point midway
between elbow and shoulder. Next, while an assistant holds the affected
arm and the other is kept out of the way, the chest portion of the
plaster is applied to the point where it is sufficiently thick to stand manipulation. When this is accomplished the reduction is made. Taking the
right arm for example, the surgeon grasps the arm encased in plaster
with the right arm and hand, and levers the lower fragment over his
closed left fist in the axilla while an assistant presses inward on the
upper fragment. With the addition of a little extension, crepitus will
usually be obtained. Palpation will usually determine efficiency of reduction, and the arm is carried out to an abducted position of about
90 degrees with the forearm slightly upward. An auxiliary splint of
moulded plaster is then applied to the side of the chest and upper arm,
and the two plasters joined in the usual manner. This procedure will
adequately handle the majority of fractures of the neck. Of course a
checkup with X-ray is made in 24 hours. The usual precautions with regard to compression of the chest are observed, and the patient is allowed
to get up and go home. We usually keep the spica on for nearly four
weeks but rarely longer. It is then removed, and active movements short
of pain are commenced immediately. Massage is very useful in these cases
to restore the deltoid, but active movements are of great importance.
If desired an aeroplane splint may be employed to rest the arm for a week
or so between the periods of exercise. If this procedure is faithfully
followed, we can usually be assured of complete restoration of function
in three or four months, so that we may sum up the treatment of
fracture of the neck of the humerus in five words.
1.    Reduction.    2.    Abduction.     3.    Early active movements.
Fractures of the Clavicle.
Now we turn to a very common fracture which may give us a great
deal of trouble, and yet rarely goes wrong. I refer to fractures of the
clavicle. Here we are treating a patient primarily and a fracture secondarily. Bed treatment is extremely irksome. Sayre's treatment is a messy
thing at best and if we put a cross or a board across the neck, the
confounded things constantly need adjustment and the shoulder straps
are invariably too tight. In the end we usually have good position and
always good union. Occasionally there is some bony prominence at the
site of fracture. It is interesting here to quote a series of Lester's cases
as quoted in Annals of Surgery for  1929. He reviewed the treatment
Page 81 of 422 patients- of both sexes, adults and children, and concluded that
with any type of ambulatory treatment, the functional results were
uniformly good. He advised a simple, comfortable dressing (sling, swathe
or binder) rather than intricate apparatus to hold the fragments in place.
The displacement is fairly constant in adults. The inner fragment is pulled
up by the sterno-mastoid, and since the anterior prop of the shoulder
girdle is broken, the shoulder falls downward, forward and inward being
further assisted by the pectoralis major. Hence all treatment is designed
to raise the arm and carry the shoulder backward. This is more or less
satisfactorily accomplished by one of many methods in common use.
In young children, certainly in those below the age of five, nothing
more need be done than to sling the wrist beneath the chin with a
Thomas halter. In these cases one must treat the mother and the
grandmother but invariably the result as far as the child is concerned
is perfect. In adults, we have various procedures. In women, particularly
young ones, recumbency without a pillow for ten days is probably the
best treatment. Reduction is accomplished, usually, by raising the elbow
on the injured side and pressing the shoulders back over a sandbag
placed between the scapulae while the patient is recumbent. As a rule
no anaesthetic is necessary. If bed treatment is not necessary, then one of
several ambulatory treatments is used. We all know the Sayre's method,
time-honoured and always taught. If it is efficient the patient will not
tolerate it. More satisfactory is the use of the clavicular cross, wherein
the shoulders are fastened back to a form of Latin cross (suitably
padded to conform to the contour of the back), by means of adhesive and
flannelette bandages. As a rule it is fairly comfortable but requires constant observation and adjustments unless, as George Wilson suggests, a
few turns of plaster bandage are added for better immobilization. I need
hardly describe the cross method of treatment as it must be thoroughly
familiar to all of you, but I recommend it as good.
{To be continued)
Apparatus for Blood Analysis, Urinalysis
and Bio-Chemistry.
Phone Seymour 1161 To Have Representative Call.
CAVE & COMPANY LIMITED
567 Hornby Street Vancouver, B. C.
Seymour 3334
I    MRS. E. M. PARR
C.S.M.M.G., Eng.
C.A.M.R.G.,  Canada
announces that she has moved from 430 to
906 Birks Building.
Page  82 Bay. 4234 L
MRS. KATE PEGRAM
C.A.M.R.G.
Medical and  Surgical  Massage
Electricity                     Remedial  Exercises
1645  11th AVENUE WEST
Vancouver,   B.   C.
Medical
Practitioners!
A   suggested   New   Year's
Resolution    for    the    busy
Doctors   of   Vancouver:—
"Resolved to become 100%
physically   fit   and   so   increase my efficiency in like
proportion."
n. s. Mcdonald
"Physical Culture"
804 Pender St. W.
Phone Trinity 1550
Office  Sey.  2855          Res. Doug. 46S2Y
MISS BEATRICE GALLOP
C.  A.   M.   R.   G.
Graduate
McGill   University   School   of   Massage
and Remedial Exercises
419 VANCOUVER BLOCK
Vancouver,  B.   C.
Office Doug. 908             Res. Doug. 908
MISS A. E. MARKHAM
Chartered Masseuse, England
Canadian   Association   of   Massage   and
Remedial  Gymnastics
924 BIRKS BUILDING
Vancouver, B.  C.
Telephone   Seymour   8683
Residence  Seymour  1222L
MRS. ETHLA FABER
D.A.D.M.F.    Copenhagen
C.A.M.R.G.   Montreal
PHYSIOTHERAPY
Certified   by  the   General   Danish
Association   of   Physicians
125-6 Vancouver Bk.    Vancouver, B. C.
Nu-Kor Belt
cM%
one
Complete line of
surgical belts, fitted by expert
Corsetieres
For further
information call
Sey. 7258
Office
445   Granville   St.
Vancouver,  B. C. "If one wishes to fortify cod liver oil, it is far more
reasonable and efficacious to increase its potency
by adding a small amount of viostero 1, which is a
specific in the prevention and cure of rickets, as it
brings about calcification not only of the bone but
of the proliferating cartilage as well." (Hess,
Alfred F., Am. J. Dis. Child. 41:1081; May, 1931.)
MEAD'S 10 D Cod Liver Oil with Viosterol is the choice
of many discriminating physicians because it represents
the long pioneer experience of Mead Johnson & Company in
the fields of both cod liver oil and viosterol.
Mead's 10 D Cod Liver Oil is the only brand that combines
all of the following features:
1. Council-accepted. 2. Made of Newfoundland oil (reported
by Profs. Drummond and Hilditch to be higher in vitamins A
and D than Norwegian, Scottish and Icelandic oils). 3. Supplied in brown bottles and light-proof cartons (these authorities have also demonstrated that vitamin A deteriorates rapidly
when stored in white bottles).
In addition, Mead's 10 D Cod Liver Oil is ethically marketed
without public advertising or dosage directions or clinical information. With Mead's,—you control the progress of the case.
Mead's 10 D Cod Liver Oil is therefore worthy of your -personal and unfailing specification.    This product is supplied
in 3-o%. and 16-o%. brown bottles and light-proof cartons.
The patient appreciates the economy of the large si%e.
Mead Johnson & Co. of Canada, Ltd., Belleville, Ont.
t*   Vitamin Research GASTRIC
FABLES
The sad but interesting Case of Mme. de Sable
The Marquise de Sable loved good]
things, was something of a gour-
mande, and enjoyed a reputation all
af Veritable gastronomic authority."
La Rochefoucauld praised highly i
her potage with  carrots, capon
stuffed with prunes, and rated her
truffles above his own "Maximes."
But Madame de Sable suffered
from the venerable disease of
hypochondria. Her morbid anxiety to safeguard her health, which
finally became the ruling passion of her life, began innocently
enough in a healthy appetite. But careful as the Marquise was to
avoid disease, she let her appetite rule and her stomach suffer.
The ideas of Madame de Sable have found many imitators since
the 17th century. The gastric neurasthenic is with us and his
phobias with him. There is nothing better for his overworked
stomach than CAL-BIS-MA because it neutralizes gastric hyperacidity quickly, soothes the irritated mucous membrance, and
relieves the discomfort of gas formation.
Cal-Bis-Ma is a combination of calcium and magnesium carbonates, sodium bicarbonate, bismuth and
colloidal kaolin, blended into a palatable powder...
We will gladly explain the therapeutic merits of
Cal-Bis-Ma and send a professional trial package
for the asking. . . Send for it.
| IN GASTRIC HYPERACIDITY—CAL-BIS-MA
WILLIAM R. WARNER & CO., Inc., 113 WEST 18th STREET, NEW YORK CITY Happy $eui Heat
will result if we help others who in turn will help us.
Prescribing
B. C. Pharmacal Co. Products
keeps money in the city and gives employment to workers
who are your patients. And our soluble elastic capsules may
be equalled but cannot be excelled.
At All Drug Stores.
THE
Bismuth Therapy of Syphilis
LABORATORY POULENC FRERES   U
OF CANADA LIMITED
offers these two  preparations  of Bismuth that have been
carefully selected as the best tolerated and most efficacious.
Both are intended for intramuscular use and are practically
painless to injection.
NEO-LUATOL—Box of 12 ampoules of 2 cc.
An oily suspension of Bismuth Hydroxyde, noted for
its  high  contents  in  metallic  Bismuth with a correspondingly increased therapeutical  activity.
RUBENE—Box of 12 ampoules of 3 cc.
A suspension in  Oil of  Quinine and  Bismuth  Iodide.
In this preparation, the beneficial effect of Quinine is
added to the specific action of the Bismuth.
Write  us  for  literature.
Canadian Distributors:
ROUGIER FRERES,  350  Le Moyne St.,  MONTREAL (Hatter & Ibtrata, J&tk
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.
Powell River, B. C.
DIGIFOLINE "CIBA"
Digitalisid100% of it
Contains   all  the   therapeutically   desirable   constituents   of
digitalis leaves—
Free from irritant substances of the saponin group—
Promptly and  uniformly absorbed from  the gastrointestinal tract—
Liquid
Ampoules     —     Tablets
CIBA COMPANY LIMITED
MONTREAL
Messrs.   Macdonalds   Prescriptions,   Ltd.       -       Vancouver,   B.   C.
Messrs.  McGill &  Orme, Ltd.      -      Victoria,  B.  C.
keep a full range of "CIBA" specialties. mi
536 13th Avenue West - Fairmont 80
Exclusive Ambulance Service
FAIRMONT 80
ALL ATTENDANTS QUALIFIED IN FIRST AID
"St. John's Ambulance Association"
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
R. J.  Campbell J.  H.  Crellin W.  L.  Bertrand
STEVENS'
SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity
for the bag or the office.
Supplied in one yard, five yards and
twenty-five yard packages.
ESTABLISHED  NEARLY A
~   .CENTURY*     ^
B. C. STEVENS CO.
Phone 730 Richards Street
Seymour 698 Vancouver, B. C. NEW WING
Hollywood Sanitarium
LIMITED
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288

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