History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1928 Vancouver Medical Association Nov 30, 1928

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 Vol. V.
NOVEMBER, 1928
No. 2
The Bulled
ofthe^
Vancouver Medical Association
Qenital Trolapse
technique of 'Version
toxoid
"Published monthly atrUancouver, "33.(2; by
McBEATH-CAMPBELL LIMITED
^Trices $1.50 per yeav^  THE   VANCOUVER   MEDICAL   ASSOCIATION
B U L L EJT I N
Published Monthly under the Auspices of the Vancouver Medical Association in the
Interests of the Medical Profession.
Offices:
529-30-31 Birks Building, 718  Granville St., 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.  V. NOVEMBER,  1928 No.   2
OFFICERS, 1928 - 29
Dr. T. H. Lennie Dr. W. S. Turnbull Dr. A. B. Schinbein
Vice-President President Past President
Dr. G. F. Strong Dr. J. W. Arbuckle
Secretary Treasurer
Additional members of Executive:—Dr. A. C Frost and Dr. F. N. Robertson
TRUSTEES
Dr. W. F. Coy Dr. W. B. Burnett Dr. J. M. Pearson
Auditors:    Messrs. Price, Waterhouse & Co.
SECTIONS
Clinical Section
Dr.  L.  H.   Appleby   Chairman
Dr.  J.  R.  Davies  Secretary
Physiological and Pathological Section
Dr.  C  E.  Brown    Chairman
Dr.  R. E. Coleman  Secretary
Bye, Ear, Nose and Throat
Dr. W. E. Ainley  Chairman
Dr. F. W. Brydone-Jack  Secretary
Physiotherapy Section
Dr. H. R. Ross  : Chairman
Dr. J.  W.  Welch  —Secretary
Pediatric Section
Dr.  E.   D.   Carder   Chairman
Dr.  G.  A.  Lamont   Secretary
STANDING COMMITTEES
Library                                        Orchestra Summer School
Dr. D. F. Busteed Dr. A. M. Warner j)R   g. j). Gillies
Dr. C. H. Bastin Dr. W. L. Pedlow £>r_ jj jj. Appleby
- Dr. W. A. Bagnall Dr. J. A. Smith tjr# w. t. Ewing
Dr. Lyall Hodgins Dr. L. Macmillan dR- j. Christie
Dr. S. Paulin                                        Publications dr. ^. £, Graham
Dr. W. A. Wilson Dr. J. M. Pearson dR- r. p. Kinsman    •
Dinner •"-'R- J# H. McDermot
Dr. E. M. Blair ®r- ^ ^" **• Cleveland Hospitals
Dr. L. Leeson                                        Credentials Dr. H. H. Milburn
Dr. H. H. Pitts Dr. J. T. Wall Dr. A. S. Monro
Rep. to B. C. Med. Assn.   Dr. D. D. Freeze Dr. F. P. Patterson
Dr. Stanley Paulin Dr. W. A. Dobson Dr. H. A. Spohn
Sickness and Benevolent Fund   —   The President   —   The Trustees VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906
PROGRAMME OF THE 31st ANNUAL SESSION
GENERAL MEETINGS will be held on the first Tuesday and
CLINICAL MEETINGS on the third Tuesday of the month at 8 p.m.
from October to April inclusive. Place of meeting will appear on the
Agenda.
1928
November   6th—General Meeting:
Paper—Dr. John Minor Blackford of Seattle:  "The
Clinical Side of Gall Bladder Disease."
November 20th—Clinical Meeting.
December    4th—General Meeting:
Papers—Dr. B. D. Gillies; Dr. G. E. Gillies: "Peptic
Ulcer, its Medical and Surgical Aspect."
December 18 th—Clinical Meeting.
1929
January
January
February
February
March
8th—General Meeting:
Paper—Dr.   Ralph   C.   Matson,   Portland,   Oregon:
"Surgical Treatment of Pulmonary Tuberculosis."
22nd—Clinical Meeting.
5th—General Meeting:
Paper—Dr. R. P. Kinsman: "Focal Infections in Infancy and Childhood."
X-ray films to be shown by Dr. H. A. Rawlings.
19th—Clinical Meeting.
5 th—General Meeting.
The OSLER LECTURE—Dr. H. M. Cunningham.
19th—Clinical Meeting.
2nd—General Meeting.
Paper—-Dr. F. P. Patterson: Subject to be announced.
16 th—Clinical Meeting.
23 rd—Annual Meeting. Jo quote an eminent authority
on ultraviolet therapy:
••TT 7TXH regard to apparatus, there
VV is no lamp which emits heat,
light, and ultra-violet rays of every
wave length. Different lamps give
different selections of all three.
"The lamp which I recommend is
the mercury vapor lamp. Its output
is rich in ultra-violet rays but poor in
heat rays. It gives off no fumes. It is
a clean, cold lamp. It works automatically, needing very little attention.
Patients feel no warmth when under
it, and they may complain of chilliness
during treatment, especially in the
winter months, unless the room is adequately warmed. A lamp of full
size should be chosen. Small lamps are
not of much use."
 E. P. CUMBERBATCH
M.B., D.M.R.E., M.R.C.P.
From a paper read before the Southport Division
of the British. Medical Association, Mar. 30,1928
(British Medical Journal, July 14,1028)
Reprint No. $8j of the above article in full will be sent on request.
THE Uviarc burner, as
used in all Victor
QuartzLamps.is the result
of long and intensive research. It produces a large
quantity of ultraviolet radiations in proportion to
attention for hours at a
time.No special wiring required—simply plug in on
the lighting circuit. That
is why the installation of a
Victor Quartz Lamp represents real economy in
the electrical input, with a consequently low cost   the longrun,and gives the utmost satisfaction to thou-
of oper ation. It operates consistently and without   sands of physicians and institutions the world over.
The scientific advances in ultraviolet therapy, and its widespread adoption in the leading
clinics in recent years, are coincident with the availability of the mercury-vapor arc in quartz.
Vancouver Branch:   Motor Transportation Bldg.   570 Dunsmuir Street
VICTOR X-RAY CORPORATION
Manufacturers of the Coolidge Tube
and complete line of X'Ray Apparatus
PhysicalTherapy Apparatus, Electro,
cardiographs, and other Specialties
2012 Jackson Boulevard Branches in all Principal Cities Chicago, 111., U. S. A*
A GENERAL. ELECTRIC
ORGAN I ZATION The PRICELESS
Ingredient
The priceless ingredient in any prescription is the personal integrity of those responsible for its preparation.
As prescription specialists, we recognize our
duty to the doctor, to the public and to our
own reputation.
Nine
Graduate
Pharmacists
Qeorgia
Pharmacy
Granville at QeortCia^
¥
Open
All
Night
Say it with Flowers
Cut Flowers, Potted Plants, Bulbs, Trees, Shrubs,
Roots, Wedding Bouquets.
Florists' Supplies and Funeral Designs a Specialty
Three Stores to Serve You:
48 Hastings St. E.
665 Granville St.
151 Hastings St. W.
One Phone:
Seymour 8033
Connecting all three stores.
Brown Bros. & Co. Ltd.
VANCOUVER, B. C. EDITOR'S PAGE
We notice with pleasure that at the last General Meeting of the
Medical Association the subject of increased accommodation for the
Library was again discussed and negotiations looking towards its realization decided upon. It has long been evident to those in touch with the
constantly increasing work of the Association that the present quarters
have become inadequate for the demand made upon them. In the matter
of shelving alone for books and journals, much is immediately required.
Reading rooms of increased capacity are necessary. The provision of
accommodation where Executive or Committee meetings may be held
without interfering with readers, has become important. The business
office is crowded out and the work of the Librarian rendered unnecessarily difficult.
This of course is not to be surprised at, is indeed to be expected and
a matter for congratulation. Such evidences of growth, signs of expansion, are inconvenient no doubt but they are indications of healthy life
and coincide with the continued advance which we see around us in civic
and commercial affairs. With Vancouver destined, as we are assured on
every side and as we ourselves are convinced, to be one of the three or
four outstanding cities of the Dominion, it is well that those in charge
of the destinies of our Association should realize the necessity of living
up to that high probability. About every ten years it becomes necessary
to make some radical readjustment of the Society's affairs if it is going
to keep abreast of the times, and we presume that condition will hold for
many decades to come. The history of the housing of the Association
is a chequered one; earnest, but unfortunately abortive, attempts have
been made from time to time to provide permanent quarters owned and
operated by the Association itself. Looking backwards it is easy enough
to see what we ought and ought not to have done. Difficulties of location, difficulties in fixing the type of structure required, difficulties of
finance, lack of interest, lack of unanimity have each in turn played a
part in retarding or defeating the object in view.
It would appear as if for the present and for the next few years the
best solution is to remain in one of the down town office buildings, renting as much increased space as the Association funds will permit.
If and when such a change is made, doubtless the also often discussed question of joint offices with the B. C. Medical Association will be
considered.
The general sense of the members of the Vancouver Association is,
we take it, that some such arrangement is desirable as leading to a reduction in the fees which are now paid by our members to the Provincial
Society.
To what extent anything like an amalgamation of the interests and
work of the two societies is desirable will depend upon the terms on which
such merger is based.
The present status of the older society is the result of more than
thirty years of continuous activity, careful management and judicious
Page 33 foresight, the results of which cannot be lightly delegated to any other
organization.
To paraphrase a famous saying, not even for the larger need can
we afford to risk the disruption of the smaller but older society.
The time will also, we think, be opportune for providing the long
overdue additional help. Twenty years ago, with less than a quarter of
our present membership, the services of a librarian were considered necessary. Today we still carry on without any addition to our staff. The
inference is obvious, either then we did not need so much or now we
need (or ought to need) more.
We decline to see any risk in this expansion or to doubt the ability
of the Association to see it through. Always when there are signs of
life, of growth, of activity, financial help will be forthcoming. Only
in stagnation, debility and decay, do wise men refuse to invest their
funds.
ANNUAL DINNER
The Annual Dinner of the Association will be held this year at the
Hotel Vancouver, on Thursday, November 29th. Tickets will be Five
dollars each*    Guests will use the Howe Street entrance only.
CORRESPONDENCE
Cleveland,
Oct. 9th, 1928.
Editor,
Bulletin, Vancouver Medical Association,
Vancouver.
Dear Sir:
I have spent the past week at the Cleveland Clinic. Dr. E. P.
McCullagh, previously at the Vancouver General Hospital, is now a
member of the permanent staff of the Clinic and takes every care to see
that a visitor from Vancouver has entry to all departments.
A new eight-storey Research Building will house the laboratories and
experimental sections of the Clinic in the future. Dr. Crile has almost
completely recovered from his recent accident and in spite of a fractured
clavicle and a bad shake-up, has been operating and lecturing already.
He and his assistants have some very interesting work under way on the
electro-chemical potential of cells.
Dr. Phillips, who visited Vancouver last summer and delivered a
course of lectures, has almost completed his monograph on the liver. It
is to be a book of 350 pages and is to be published by the Oxford University Press.    He has promised a copy for the library.
The Surgery of the Thyroid is still a very live question here. During the past six months it has been the practice to attack the lobes from
Page 34 within outwards and to disturb the lateral aspect of the lobes as little
as possible on account of the relation of the nerves of the larynx and
the position of the parathyroids. This has lessened the incidence of
post-operative vocal cord paralysis and parathyroid deficiency. Iodine
therapy is about as before. Recently upwards of 500 operations on
thyroid cases were performed before a fatality occurred. The number
of thyroidectomies done in one stage is much greater than on a previous
visit.
All departments of the Clinic are very active. Visitors receive a
very courteous welcome and on the whole it is a very pleasant and instructive place to visit.
Yours very sincerely,
Clarence E. Brown.
MEETINGS
The opening meeting of the 1928-9 session of the Vancouver Medical Association was held on the night of October 2nd. The speakers
for the evening, and their subjects, were of themselves such as to bring
out a good attendance, and in addition the agenda contained business of
general interest for discussion.
Letters from the Staff and Board respectively of the Vancouver General Hospital concerning staff appointments were read, and on account
of their bearing upon reorganization, which the Vancouver Medical
Association has had under consideration, it was decided to bring up the
subjects of these letters at a special meeting to be called shortly.
In connection with the start which has been made upon the new
Medical and Dental Building, of which the Vancouver Medical Association was advised in a letter from the architects, it was decided that the
Executive should be authorized to make arrangements for space for
office and library accommodation.
The report of the Summer School Committee presented by Dr.
Storrs, showed that the attendance at the last session had been a record
one, and the financial situation was satisfactory.
Discussion arising upon the reading of communications which had
passed between the Executive of the Vancouver Medical Association and
the Secretary of the Canadian Medical Association resulted in authorization of the Executive to extend a formal invitation to the Canadian
Medical Association to hold the 1931 Annual Meeting in Vancouver.
In connection with the petition, endorsed by the Executive, for obtaining facilities for special anatomical study, Dr. W. D. Brydone Jack
stated that material was readily available, but drew attention to the necessity of complying with the regulations in obtaining licences to dissect.
Eight candidates for membership in the Association were duly
elected.
Page 35 Dr. Mason's paper on Genital Prolapse followed, and his able presentation of the subject, which appears on another page of this issue of
the Bulletin, was received with much interest and enthusiasm.
Dr. Burnett's exposition of the Technique of Version was excellently
illustrated by lantern slides. The speaker's style was enlivened with his
characteristic dry wit, and that he was thoroughly at home with his topic
was very evident.
Following a brief discussion of the papers, a vote of thanks was
tendered the speakers.
The October Clinical meeting of the Association was held in the
Board Room of the Vancouver General Hospital on the 16th. The
number which turned out, considering the inclemency of the weather
was very inspiring. The total attendance was 87. Dr. Appleby, Chairman, presided.
The first case presented was one of anaemia by Dr. G. F. Strong.
Dr. Strong pointed out that as it was a common type of case it was
therefore of special interest. It is generally felt that more benefit is to
be derived from the exhibition of the type of case which everyone is
constantly encountering, than from a discussion of the rarer types.
Discussion was opened by Dr. J. M. Pearson who was followed by Drs.
Keith, Coleman, Hodgins and Cleveland.
Immediately after Dr. Strong's case the meeting had the pleasure of
hearing Dr. Ross Miller, Medical Director of the Dominion Department
of Pensions and National Health. Dr. Miller explained that his Department has charge of all Federal medical services, except the care of sick
Indians. Referring to the Narcotic Act he pointed out that it orginated
in Geneva and not, as popularly supposed, in Ottawa. Great Britain signed
the convention on behalf of Canada. The United States was also signatory although not a member of the League of Nations. It was to be
understood that the narcotic squad did not exist for the purpose of
persecuting the medical profession. The law specifically is against prescribing narcotics for addicts unless suffering from some painful irremediable disease. The Department keeps close observation upon the
amount of narcotics sold by wholesale and retail drug houses and so can
check up the amount prescribed by any physician when it appears to
exceed the demands made by a normal practice. Dr. Miller outlined the
steps taken by the Department in dealing with such cases. Provincial
Acts are now in force in some provinces under which addicts can be
properly dealt with in hospitals and similar institutions with a view to
cure. Dr. Miller pointed out the desirability of having such an Act in
British Columbia.
Dr. Miller referred briefly to the question of certificates from medical practitioners given to returned soldiers. He explained the proper
use of B. P. C. form 819. If this furnished evidence that the man's disability attributable to service was greater than was recognised by the
Page 3 6 pension awarded, this could be adjusted and the man paid $3.00 by the
Pensions Department to pay the doctor's fee.
Dr. Schinbein presented a case of traumatic fracture of the skull
with loss of bone and brain substance in a boy of 12. The patient was
shown on the twenty-first day following the accident. Dr. Schinbein
pointed out that among the chief lessons learned from military surgery
were those whose application was exemplified in the present case. They
were the importance of thorough mechanical cleansing, removal of
devitalized tissue and closure of the wound. No operative procedure of
any sort should be undertaken before shock, if present, had been dealt
with and recovered from. This case was discussed by Drs. Meekison and
Coleman.
Two cases were shown by Dr. Cleveland. The first was a late
cutaneous syphilide showing atrophic and pigmentary changes clinically
characteristic in a Chinese aged 25. The second case was one of dermatitis herpetiformis (Duhring's disease) complicated by Raynaud's disease
in which the symptoms of Raynaud's disease had apparently entirely
subsided. A brief discussion followed by Drs. Coleman, Schinbein and
Pearson.
Dr. Prowd presented a most interesting series of X-ray films demonstrating bone metastases in carcinoma. These films were most spectacular especially when the history was related accompanying the various
films, and it was brought out that in some instances radical excision of
the breast, or other cancer-bearing structure, had been performed over
five years previously. It is also noteworthy that several of the cases
reported complaining of symptoms which were comparatively trivial
and not arousing suspicion at once of malignancy. This series of films
was very well discussed by Drs. Pitts and Mcintosh.
The Special meeting to discuss matters connected with the staff of
the.Vancouver General Hospital, authorised by a resolution passed at the
General meeting on October 2nd, was held on Tuesday, Octboer 23rd in
the Auditorium, with the President in the chair. Letters from the Secretary of the staff and from the Board of Directors of the Hospital
were read to the meeting by the Secretary and after a prolonged and full
discussion the following motion carried:
"Moved that a Committee of this Association be appointed by the
Executive immediately to meet the Board of Directors of the Vancouver General Hospital to bring before them the reasons why this
Association thinks reorganization of the staff of the Hospital is
necessary and to present to them the reorganization scheme passed
by the Association and that nominations be not received to-night
but that this Committee report back to the Association at the
earliest possible date and that then nominations for the staff be proceeded with if the report is satisfactory."
A strong Committee has been appointed by the Executive to meet
the Board of Directors at an early date.
Page 37 NEWS AND NOTES
Dr. Dowling of Seattle was a visitor to the city early in October.
Dr. Howard Willis was married on September 29 th to Miss Mary B.
Miller. The bride has been a resident of Vancouver for some years,
but came here from Peachland. We habitually refrain from making
facetious compliments, hence will make no further comment upon Dr.
Willis' evident good taste in selecting his mate from an appropriate
locality.
Dr. W. J. Gunn and Dr. Wilfrid Graham have each assumed new
responsibilities since last month.    A boy in each case.
It is reported that Dr. Greaves is away on a holiday trip in the interior of the province. It is understood ajso that there are complications in the form of three ladies and a motor-car. Further details may
be available upon his return—or again they may not.
Drs. C. H. Bastin and Wilfrid Graham were recently appointed to
act in local editorial capacity for the Canadian Medical Association Journal.
Dr. E. H. Funk, who has been superintending a hospital at Leavenworth, Washington, for the Great Northern Railway, in connection with
the Cascade Tunnel, for the last seven months, has returned to Vancouver.    He has re-opened offices in the Birks Building.
The Eye, Ear, Nose and Throat section held a luncheon at the Hudson's Bay on October 12th, where they discussed their programme for the
coming year.
The Pediatric section held their opening meeting at the home of the
chairman, Dr. E. D. Carder on Balfour Avenue. A paper by Dr. E. J.
Curtis on "Pyuria" was read, and appreciated by the members present.
Dr. W. C. Walsh is spending two months in the east, visiting his old
home, and also attending clinics in New York and other large cities.
The first meeting of the Osier Reading Club was held on September
26th at the Georgia Hotel. Papers were presented and read by Drs.
D. M. Meekison and J. R. Davies.
Dr. A. W. Bagnall has gone to New York to attend the Post-Graduate Fortnight of the New York Academy of Medicine.
Dr. E. P. McCullagh, formerly of the Vancouver General Hospital
resident staff, is at present a member of the permanent staff of the Cleveland Clinic, Cleveland, Ohio. He has also been distinguished recently by
being made the father of a son and heir. Mrs. McCullagh was formerly
Miss Mae Gibson, a graduate of the Vancouver General Hospital Training School.
Dr. P. Patterson has returned from the East and resumed practice.
Page 3 8 Dr. H. P. Swann, of Duncan, B. C, has recently been appointed
M. H. O. to the City of Duncan, to the North Cowichan Municipality
and to the schools of the Duncan Consolidated School Board.
Dr. S. B. Peele has just returned from a trip to Chicago and other
Eastern cities.
Dr. W. D. Brydone Jack is at present a patient in the Vancouver
General Hospital. We trust he will soon be well again and able to resume practice.
Dr. C. E. Brown has returned from his Eastern trip and resumed
practice at 736 Granville Street.
VERSION
Notes of an address delivered by Dr. W. B. Burnett, before the
Vancouver Medical Association, October 2nd, 1928.
At the opening meeting of the Thirty-first Annual Session of the
Association held on October 2nd, the second paper of the evening was
given by Dr. W. B. Burnett on "The Technique of Version." At the
outset Dr. Burnett stated that the technique he would describe was in all
essentials that practised by Dr. Irving Potter, of Chicago, with a few
modifications and little points not described by him and not mentioned
in the text books, which were yet exceedingly valuable in practice.. The
actual version of the child was described by Dr. Burnett, step by step
by means of numerous lantern slides, the speaker stating that only by
means of such illustrations was it possible to clearly explain the procedure.
In America among women from 15 to 45 years of age tuberculosis
is the commonest cause of death and next in order comes childbirth.
When the small proportion of time given in the medical course to students on the technique of practical obstetrics as compared with other
subjects and compared with the amount of work in obstetrics which the
men will have to do after graduation (for, said the speaker, they are
unable to get away from it) it is a pitiable state of affairs and a reflection on medical men as a whole. Dr. Burnett compared the work of
the average medical man in obstetrics with the work of the Japanese
midwives and believed it was not head and shoulders above their work.
The condition in which the midwives left • their patients afterwards is
said to be very favourable.
For the past fifteen years the speaker has been gradually and steadily
every year doing more versions. In the last hundred cases he has done
sixteen and in the hundred before that fourteen, and he does these versions because he finds it the easiest and the safest way to deliver the
women in these particular cases.
When can you do a version and when should you do a version?
In the opinion of Dr. Burnett no version should be attempted till the
cervix is dilated or so nearly that dilatation can be completed without
Page 39 injury to the patient. The head must be movable, it must be possible
to lift the head out of the true pelvis. It has been asked whether version
should be attempted in a case where the membranes had been ruptured
for hours. The answer to that was "You know what you can do—it is
not a question of the length of time after rupture of the membranes."
Three months ago the speaker did a version in a case where the membranes had been ruptured for two full days. He did not think this was
desirable but it was the safest thing to do in that particular case, the
safest way he could see to save that particular mother and give the
baby any chance at all. The reason why version has been so decried
and frowned on and so much feared by so many practitioners was because they had not been taught a reasonable and proper technique and he
hoped to make that technique so clear to his listeners that they would
be enabled to undertake this procedure in future without fear, should the
necessity for it arise in the course of their practice. Dr. Burnett stated
that he was now getting the courage to undertake it still more often.
In certain cases where the patient had been in the second stage of
labour for two or three hours he sometimes felt mean to think he had
not helped her by means of version. The patients do so well afterwards
that it is a pleasure to watch them.
The preliminary preparations are very important. The bowels and
bladder must be emptied. So often injuries are caused by the bladder
being pinched in labour. Proper long gloves must be worn because in
going into the uterus you do not want to introduce an exposed arm into
the vagina. A towel wound loosely round the arm is a further protection.
A very important point is good relaxation of the uterus. That
means deep anaesthesia. The speaker said he had, probably very foolishly, done a few with gas. That was all right, but gas was not the
anaesthetic of choice for version. Chloroform he believed to be the
anaesthetic of choice if an anaesthetist skilled in the use of chloroform
is available. But in any case the important point is thorough relaxation
of the uterus. This particularly applies where the membranes have ruptured. Version cannot be safely accomplished unless the uterus is thoroughly relaxed.
The question of position of the patient is important. A modified
Walcher position, according to Dr. Burnett, gives a better chance of
saving the perineum. The patient is brought over the end of the table
and two nurses support the legs. If assistants are not available chairs
will serve the purpose quite efficiently, though if the legs are held by
nurses they can be brought to the level of the table or maybe below, if
necessary.
Dr. Burnett said he had the greatest confidence in the use of mercurochrome in the vagina. Everyone had seen the uselessness of pouring in iodine. How often it is found never to have touched the vaginal
walls at all. Mercurochrome does penetrate. Two to three drams of a
2-4% solution of mercurochrome poured into the vagina is a great
help in reducing the risk of carrying infection up into the uterus.
Page 40 Do not start a version until everything is ready on the table.
Forcepts must be at hand for use on the after-coming head. They may
be used very frequently. It is easier to put on forceps on the after-
coming head than on the fore-coming head, the pulling through is much
less likely to do damage in the former than in the latter case. Another
thing to have handy is a loop of gauze or tape to put on a foot if it is
felt to be slipping.
In going into the uterus it is well to get into the habit of using
one hand. Several of the text books advise the use of the hand opposite
the abdomen of the baby. That is no matter, the speaker said he always
preferred to use the left. When everything is ready and the operator
about to start, the first thing to do is to pull on a pair of short gloves
over the long ones while doing the necessary work about the vagina. An
extra pair of short gloves will greatly improve the technique.
At this stage get the perineum out of the way. After the mercurochrome is in the vagina, with the hand well lubricated with an
abundance of green soap, using first two fingers, then three, iron out the
perineum. Within a very few minutes—three to five—the perineum
can be ironed out with your fingers. It is, of course, possible to do
damage by going at it too violently, but if the fingers are kept well
lubricated with soap and sufficient time is taken, there should be no
difficulty and the perineum can be ironed out until almost large enough
for the head.
With the left hand go into the uterus and separate the membranes
all the way round, avoiding the edge of the placenta. The important
thing in rupturing the membranes is not to do as it says in the text
books "go in and rupture the membranes." That is the one thing not
to do. Go in at the side of the head until your hand is opposite the
umbilicus of the child. A quick tap will rip the membranes high up.
Very little water will come away as the bag will be compressed against
the uterine wall and the arm of the operator.
The next step, and perhaps the most important step, to be remembered in doing a version is to fold the child's arms across the chest.
Unless this is done there is very likely to be trouble. Then go for the
knees.
Version is easy if the membranes are unruptured and there is lots of
water.
Dr. Burnett then carefully explained step by step by means of numerous lantern slides his method of changing a vertex into a breech presentation. Without cuts it is almost impossible to clearly describe the
procedure but the important point emphasized again and again by the
speaker was the avoidance of haste. Hurry is the great cause of trouble
when doing a version. Wait—give the uterus a chance to retract. If
you give the uterus a chance to retract it will help you. The reason
children are lost in breech or version cases is because they are killed—
death is due to fractures—not drowning.
Once the knees are down the version is complete and the anaesthetic
may be stopped.    In starting the actual version wait until the uterus is
Page 41  PUBLIC HEALTH
BIOLOGICAL PRODUCTS
Diphtheria Antitoxin
Diphtheria Toxin for Schick Test
Diphtheria Toxoid (Jnatoxine-Ramon)
Scarlet Fever Antitoxin
Scarlet Fever Toxin for Dick Test
Scarlet Fever Toxin
Tetanus Antitoxin
Anti-Meningitis Serum
Anti-Pneumococcic Serum (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine (Semple Method)
INSULIN
Price List   Upon Request
CONNAUGHT LABORATORIES
University of Toronto
TORONTO 5 '     - CANADA
Depot for British Columbia
MACDONALD'S prescriptions limited
618 Georgia Street West - Vancouver relaxed. When the version is completed wait until the uterus has a
chance to retract; wait again, don't get help from above. The last
thing to be done before inverting the child is to confirm the position of
the arms.
The speaker concluded his remarks by saying that he hoped his hearers would not find version a difficult thing to perform. The average case
of persistent occipito-posterior position can be saved many hours of
labour, and the baby can be delivered more safely than in any other
way. It is essential for every obstetrician to be able to do a version.
In a face presentation the only safe way to let the baby be born is by a
version. In his opinion it is impossible for a baby to come through as
a face presentation without serious injury.
If a definite technique is borne in mind and these little tricks are
remembered—getting the head to one side, folding the arms across the
chest, bringing both legs down, having the perineum dilated before
starting, using abundance of soap to make this easy to work through
at the last, Dr. Burnett thought the men would find themselves doing
more and more versions, sometimes simply and solely for the sake of saving a woman unnecessary hours of pain and anguish.
TOXOID
By Harold White, M.D., CM., D.P.H., School Medical Officer,
Vancouver, B. C.
Thanks to the use of antitoxin, the mortality from diphtheria has
been greatly reduced during recent years. Unfortunately the number of
cases of this disease has not decreased to any appreciable extent, but considerable relief in this respect has been afforded by toxin-antitoxin where
this has been systematically used. Toxin-antitoxin however, has certain
disadvantages, firstly that it contains horse serum, which in some cases
sensitizes the patients to this serum, leading to unpleasant results later
when any preparation containing horse serum is used on these patients;
secondly toxin-antitoxin still contains some active toxin although this
is practically all neutralized by antitoxin.
In 1923, Ramon of the Pasteur Institute discovered that diphtheria
toxin may be rendered atoxic by the use of formaldehyde and heat.
This preparation he called '"Anatoxine." In England and America this
same product is named "Toxoid" probably to prevent confusion with the
word "Antitoxin."    Toxoid then contains no serum and is not toxic.
In preparing toxoid, the toxin is developed in the usual manner—
by growing a virulent strain of diphtheria bacillus in veal infusion broth
for six or seven days, and filtering off the bacteria. This toxin broth
must contain at least 400 M.L.D.'s per cc. . Formalin of definite amount
and strength is added, and the mixture, which must have a pH of 8 to
8.3, is kept at a temperature of 37 degrees C. for a period of one to four
weeks, until various strengths and amounts have been found to be atoxic
to a series of guinea pigs.    The mixture is then filtered through Berkefeld
Page 42 candles into sterile containers. The product is again tested for toxicity
and also for sterility and antigenic power. Five cc's of the finished
product are injected into each of five guinea pigs, which are kept under
observation for a month. A final intradermal test is then made from
each lot of filled containers.
As each step in every test is carefully recorded in writing, it will
be seen that every precaution is taken to avoid a mistake in preparation.
It has been found that the product is kept sterile by the formaldehyde used, and is not rendered toxic by freezing nor other physical
changes.
At first, only two injections of 0.5 cc, each with an interval of three
weeks were used; but it was found that only 70 per cent, of the children
were thus immunized. During the past year three doses of 0.5 cc, 0.5 .cc
and 1 cc. respectively have been used, with intervals of three weeks.
Schick tests made four to six weeks after the final doses have shown
that from 80 to 98 per cent, of the persons had been immunized to
diphtheria.
This immunity has already been found to last for some years as
shown by the Schick Test—at least sufficient time to tide the child over
the most susceptible period of life.
Reactions.
Toxoid contains certain proteins derived from the veal broth culture
medium, and from the breaking down of the bacteria themselves; these
are the cause of a local and even a moderate general reaction in some
persons. This occurs chiefly in older children and adults. Children
under eight years of age very seldom, and those under six, practically
never, show any appreciable reaction. Each package of toxoid contains
a vial containing a five per cent, dilution for preliminary skin testing,
when this is considered necessary, 0.1 cc. being injected intradermally.
In immunizing children under eight, and more especially those under six
years of age, this test is seldom used, except in the cases of those with a
history of asthma.
Cases showing skin reaction may easily be desensitized by injecting
minute doses of dilute toxoid.
As more than sixty per cent, of all diphtheria deaths occur in
children under six, and therefore immunization is more urgent in the
earlier years, it is very fortunate that local and general reactions are
practically nil at this period of life.
In cities of the middle west and eastern Canada, toxoid has been
in very general use during the past year, with striking success.
This autumn, fifteen hundred Vancouver children entered school
for the first time, at the age of six, and only an occasional one has been
protected against diphtheria.
The Medical Department of Vancouver schools is urging the parents
of these children to take them and the younger brothers and sisters to
Page 43 the family physician to receive the benefits of immunization. As in
some cases the parents have not received encouragement from the said
family physician, we ask the hearty co-operation of the medical profession in seeing that Vancouver children and especially those of pre-school
age are protected against diphtheria, which, like the poor, is always
with us. Speaking of the poor, reminds the writer that those who are
unable to pay are sent to the Immunization Clinic conducted by the
City Health Department at the Vancouver General Hospital on Saturday mornings.
The Connaught Laboratories have established an agency at 618
Georgia Street West where physicians may obtain toxoid by merely
signing for it, the City Health Department defraying the cost.
References:
Defries—The Public Health Journal Vol. XIX. No. 5, 1928.
Molony and Weld—Trans. Royal Society of Canada, Sec. V.,  1925.
Note: We are informed that the trouble in Australia early in the
present year was due to an error in the preparation of toxin-antitoxin and
not of toxoid.
B. C. MEDICAL ASSOCIATION NEWS
Dr. H. H. Boucher who has been assisting Drs. Knox and Campbell
at Kelowna during the past year, has been appointed medical officer at
Atlin, B. C, succeeding Dr. R. J. Wride who is now at Whitehorse,
Yukon.
Dr. J. T. Steele of Burns Lake is taking over Dr. W. Laishley's
practice at Giscome.    Dr. Laishley is leaving to take post-graduate work.
Dr. A. M. Menzies of Britannia Beach has resigned his position
there and will engage in private practice after taking post-graduate
work. Dr. J. W. Laing will succeed Dr. Menzies at Britannia Beach
with Dr. G. A. Minorgan as his assistant.
The doctors at Nanaimo are very pleased that the new hospital there
is now opened and they no longer have to make long motor trips to see
their patients.
There are a number of members of the B. C. Medical Association
in arrears for membership dues. This is no doubt owing to our Executive-Secretary having been so long away sick. As we are now nearing
the end of the year it will save our office much valuable time if this
appeal brings a cheque by mail.
Page 44 Dr. G. L. Milne, a veteran member of the Victoria Medical Society,
was honored at the annual meeting and dinner of the organization by
being made a life member of the Society in appreciation of his services
to, and continued interest in, the affairs of the profession for nearly fifty
years. He came to Victoria and established a practice in 1880 and has
been an active member of the Society ever since.
Dr. E. M. Casey of Montreal and Dr. J. R. Lingley of Harvard
are now at the Royal Jubilee Hospital, as internes.
*       *       «•       *
Dr. J. A. Stewart, eye, ear, nose and throat specialist of Victoria is
now en route to Vienna where he will do post-graduate study in his
specialty.
Dr. F. M. Bryant of Victoria is now back to practice following a
successful operation.
OBITUARY
Dr. Donald Booth Holden of Victoria, B. C. was a passenger on
the ill-fated plane on which he was crossing to Seattle to meet Mrs.
Holden, who was on a holiday visit with her son Pilot Alec B. Holden,
chief of the Tacoma Air-port Station.
Many passengers had been carried to Vancouver and Seattle and
everyone had enjoyed the safety and riding comfort of this new service,
but August 25th was foggy, and this, combined with the smoke of forest
fires, was apparently the cause of low flying. The plane struck the
water and the impact was severe enough to bring sudden death to the
passengers who had left Victoria a short half-hour before.
Dr. Holden had practised in Victoria almost since his graduation
from McGill in 1891. He was a hard worker, cheery and bright withal.
He was retiring, but to those who knew him best he was possessed of a
kindly heart and a cool calm courage which never failed him or his
patients in emergency. .
Dr. Holden had taken a keen interest in his profession and had upheld the best traditions of practice in his relations with his colleagues
and patients. He was a member of the Victoria and B. C. and Canadian
Medical Associations. A member of the Union Club, and Yacht Club
and the Colwood Golf and Country Club. His beautiful home and
gardens at "Beresford" provided pleasurable relaxation during the past
few years.
A memorial service was held on September 26th, at Christ Church
Cathedral, which was attended by the members of the Victoria Medical
Society, graduate nurses and the pupil nurses from both the St. Joseph's
and the Jubilee Hospitals. Following cremation the ashes were spread on
the garden at "Beresford."
To Mrs. Holden and family the sympathy of the whole profession
is extended and we trust that the esteem in which her late husband was
held will be a comfort in this hour.
Page 45 GENITAL PROLAPSE
Address delivered by Dr. J. J. Mason before the Vancouver Medical
Association, October 2nd, 1928.
Genital prolapse is an inclusive term embracing cystocele, rectocele,
prolapsed uterus, retroverted uterus and relaxed vaginal outlet. Pure
retroversion of the uterus without prolapse we shall consider separately.
To a proper understanding of genital prolapse it is necessary to have
a clear idea of the anatomy and mechanics of the pelvis and abdomen
and particularly the outlet of the pelvis. The outlet consists anteriorly
of the symphysis pubis, laterally of the rami of the pubes and ischium,
the tuberosities of the ischium and the tense ligamentous structures between the tuberosities of the ischium and lower end of the sacrum and
coccyx, posteriorly of the lower end of the sacrum and coccyx. From
the lower end of the sacrum and coccyx the levatores ani arise, two
companion muscles extending across the floor of the pelvis to be inserted
into the back of the pubes. The anterior part, the insertion is tendinous
and narrow, the posterior part, the origin, is wide and more muscular.
These two muscles starting from the sacrum and coccyx and stretching
across the floor of the pelvis would form a complete hammock for the
pelvic contents were it not that nature required outlet for the urethra,
vagina and rectum. The fibres from these two muscles decussate behind
the rectum, between the vagina and rectum and possibly to some extent
in the tissues between the urethra and vagina and urethra and pubes.
These muscles are in reality the sphincters of the rectum and vagina, for
the sphincter ani is a very delicate structure and can be completely cut
through without resulting rectal incontinence if the levator muscles be
intact. There are cases where the patient has suffered a complete tear
in the median line into and up the rectum with the sphincter ani completely torn through but with surprisingly little genital prolapse or rectal
incontinence if the levator muscles have not been injured. The pelvic
fascia, the bete noire of our student days, is of very secondary importance.
It is not fair to compare the pelvic fascia to the fascia covering the rectus
abdominis, any more than it is to compare it to the fascia over the bipecps
muscle.
There is much difference in the strength of the levators in different
women. In some the levators are atrophic and in rare instances we
see complete prolapse in a nulliparous woman. Often these atrophic
cases are associated with spina bifida of minor degree. Again, the levators in some women do not come close together in their passage way
across the floor of the pelvis and there is a separation in front of the
rectum of 1 inch or more. The fascial and connective tissue at the sides
of the cervix uteri, the so-called cardinal ligaments of the uterus, and the
fascial plane under the anterior vaginal wall is of definite importance as
a means of support. The fascial plane between the rectum and vagina,
the rectovaginal fascia, is less tense and more yielding. The usual position of the uterus, fundus forward and cervix back, almost horizontal,
parallel to the axis of the vagina in the erect position, helps to maintain
the pelvic organs in position. With any increase in intra-abdominal
pressure the fundus uteri is forced downwards and forwards, the cervix
Page 46 upwards and backwards, because the intact levators prevent the cervix
from slipping down.
AEtiology
An occasional woman, as before stated, has markedly atrophic levators and is predestined to have prolapse whether she bears children or not.
I have seen half a dozen or so of these cases. In examining these women
I have been struck with the apparent absence of any levator muscle, or
muscles so atrophic as to be useless. These are the cases that require a
different technique for repair from the standard technique later described.
Admittedly the interposition operation with the cervix high up on the
posterior vaginal wall is the operation of choice. Another type predisposed to prolapse after child-bearing is the woman with a very wide
transverse outlet, four inches or more. In this type labour is often precipitate with no apparent injury to the muscles, and still, in later years,
we find a prolapse. On examining these patients one will find frequently
a wide natural separation of the levators. The other extreme, the narrow
transverse outlet, is a predisposing factor in prolapse after child-bearing
because the narrow outlet forces the foetus so far posteriorly that the
levator muscles are more easily torn or separated from their pubic attachment, and also because this type of pelvis makes resort to forceps more
frequent.
Too early application of forceps or too strenuous dosage with pituitrin is often the cause of levator injury, but to say that all cases of prolapse are due to faulty obstetrical care is not true. We have all been
chagrined to find on examination after a normal case, where no injury
has been done, or if done well repaired, to see, if not prolapse, a marked
tendency to prolapse. We should therefore never tell such a woman that
she was badly torn when her last baby was born. Her inference is that
she was badly treated, when it is probable that no matter who was the
attendant the result would have been the same. A very common cause
of injury to the pelvic floor is a persistent posterior position of the foetal
head preventing flexion.
Symptoms and Signs
If the sagging takes place chiefly in the anterior wall, bladder symptoms are prominent. The patient has difficulty in emptying the bladder
until she pushes up the cystocele. If the sagging be mostly in the posterior wall, the rectum never feels empty. There is often congestion of
the vaginal mucosa with resulting discharges. There is pelvic discomfort, dragging and backache. An occasional mistake is to confuse a
thickening of the vaginal wall with a cystocele. A sound in the bladder
will easily prevent this mistake. Frequently one may think the whole
uterus is lying outside the vulva, when, on further investigation, it is
found that the cervix uteri is only elongated, the fundus still remaining
in its normal position.
Treatment
(a) Prophylactic. Apart from the cases of congenital atrophic
levator muscles much can be done to prevent prolapse. The second stage
of labour should not be hurried.    Pituitrin should be used sparingly and
Page 47 only with definite indications. The bag of waters should be preserved
as long as possible. The vagina with the lateral levators should be carefully ironed out before the head comes down. The bladder should be
emptied. A median episiotomy in a primipara where indicated is a conservative procedure and will prevent tearing of the lower fibres of the
levator muscles. Not all primiparae, by any means, require episiotomy,
the finger will judge during the second stage as to whether the decussating levator fibres are so numerous or so thick that if an episiotomy be
not done there will be lateral vaginal tears comprising the levators. I
say median episiotomy because the median line has less blood supply and
the incision separates the levator fibres rather than incises them. Forceps should not be used until the levator muscles have been thoroughly
stretched and ironed out and then only with an urgent indication. It
is the sharp edge of the forceps blade that frequently cuts through the
levator muscle near its pubic attachment.
All wounds in the vagina and perineum should be immediately
sutured, taking special care to repair deep lateral vaginal wounds and
wounds at the side of the urethra. If the patient's condition or surroundings be such that good work cannot be done, wait for twenty-four
hours or more and repair the injury then. If deep injuries have taken
place a longer convalescence should be urged on the patient.
(b) Operative. The type of operative treatment depends upon
the degree and character of the prolapse, the age and parity of the
patient and associated condition of the genitals and abdomen. Unless
complicating lesions be present in the abdomen or in the uterus itself,
every case of prolapse can be handled better without removal of the
uterus and without opening the abdominal cavity, except from below,
and that only rarely. In other words, in pure, uncomplicated, genital
prolapse, whether of bladder, uterus or rectum, hysterectomy alone or
so-called ventral fixation alone, has no place. If the uterus be diseased
or tubo-ovarian or intestinal complications be present, of course the
type of operation is changed. I shall describe, as carefully as I can,
the technique of operation for prolapse, and accessory operations that
may be indicated where complicating conditions may be present.
If the prolapse has been of long standing and there is much excoriation of the genitals with discharge, the patient is advised to stay in
bed a week or so at home before operation, using measures to reduce
congestion and abrasions. The operation is planned following a menstrual period and not before, to avoid the softening effect on suture
material of the menstrual discharge and to avoid the congested condition
that predisposes to bleeding.
The patient is prepared vaginally and abdominally. Methylene blue
grs. V. is given on admission to hospital sixteen hours before operation.
It orientates bladder, ureters and bowel during operation. A vaginal
swab of mercurochrome 2-3% is applied on admission and in the morning
before the operation.
The patient is placed in the dorsal position, legs held in stirrups and
final preparation given, painting the vulvar skin and surroundings and
swabbing the vagina thoroughly with half strength tincture of iodine
Page 48 in pure alcohol. The patient is draped, a clip holding the sheet to
fourchette, the bladder is emptied and patient's pelvis again thoroughly
examined and the method of operative procedure decided upon.
In determining the method we note the extent of the cystocele and
rectocele, the condition of the levator muscles and the sphincter ani,
the cervix and fundus uteri and if there are any associated intra-abdominal lesions. A weighted speculum is placed in the vagina and the cervix
is drawn down and the cervical canal swabbed out with an iodine application. If the cystocele requires repair the anterior wall is first operated
on. A fold of the anterior vaginal wall in the centre line about 1 inch
above the cervix is held out by a mouse-toothed forceps and a blunt-
pointed scissors cuts through the vaginal mucosa and underlying fascia.
The boldness or otherwise of this first cut with the scissors depends on
the thickness of the vaginal wall which has been previously estimated.
The left edge of this incision is grasped with Allis forceps, the operator
grasping the right edge with his mouse-toothed forceps, while blunt-
pointed scissors curved on the flat are plunged, closed, between the vaginal
fascia and the bladder, opened, removed, and the vaginal wall incised
bit by bit in the median line up to the external meatus urethrae. Allis
forceps are placed on both edges, and, one side at a time, by holding the
forceps with gauge over it and with a finger covered with gauze, the
vaginal mucosa and fascia are carefully stripped off the bladder to the
full width of the vaginal wall. If we are in the right line of cleavage
stripping is very easy and there is little oozing, except occasionally low
down and laterally where a vein may require ligature. If the cervix
requires removal the cervical end of the vaginal incision is continued only
to the extreme lateral edge of the cervix.
The bladder is next pushed off the uterus. It is necessary usually
to clip a few fibres in the median line close to the cervix before this
peeling off can be done easily. If there be doubt as to how far the bladder comes down on the uterus the insertion in the bladder, through the
urethra, of a bladder sound, will help. There is no need to widely
separate the bladder from the broad ligaments or troublesome oozing will
be encountered.
If it be necessary to open into the peritoneal cavity to remove a
small ovarian cyst, or a myoma from the fundus, it is done at this stage
of the operation. There is little danger of wounding the bladder if
separation of the structures has been well done. A difficulty often encountered is to dissect into the anterior wall of the uterus in an endeavour to keep away from the bladder.
If the patient has had lack of vesical control, exertion incontinence
extreme or otherwise, the vesical sphincter should be repaired at this step
in the operation by plicating with No. 00 chromic gut on a fine curved
round needle the vesical sphincter in a'mattress fashion, turning in about
three suture lines.
If an interposition operation has been decided upon, the peritoneal
incision is sutured to the posterior wall of the uterus and the uterus
fastened to the sub-pubic tissues.    This operation is indicated in older
Page 49 women with large cystoceles and lax supports, with attenuated or torn
levators that will give little support. The uterus, however, must not
be too small or too large and if this operation be done in the child-bearing
period the tubes must be resected.
If the uterus requires removal this is done from above downwards,
ligating and clamping first one side and then the other, or if time is
of great moment, four clamps, two from above on the upper broad
ligaments and two from below—i.e. two on either side, will more quickly
remove the organ. If the uterus be removed it is absolutely necessary
to suture the broad ligaments together especially the round ligaments and
bring the sutured round ligaments up under the bladder to the sub-pubic
tissues.
The vast majority of prolapse cases can be cured, and probably
better cured, without removal of the uterus and without an interposition
operation. It is only when some special complication such as a suspicious
cervix or bleeding metritic uterus is present that hysterectomy is necessary. Usually a better operation can be done by leaving the uterus in
situ. I used the interposition operation more frequently years ago, but
it is still necessary in some cases of very large cystoceles.
In the vast majority of cases that do not require opening up the anterior peritoneal cul-de-sac, we complete the operation as follows. Mattress sutures of No. 2-40 day chromic gut are placed at l/z -inch intervals
starting near the urethra. These sutures are carried from one flap to
the other and back again, being placed well laterally and are not tied
until all are in. The two or three upper ones, those nearer the cervix,
take a bite, going and coming, of the anterior uterine wall in order to
prevent the bladder sliding down on the uterus. The highest mattress
suture is placed so as to take a bite of the lower end of the cardinal
ligament lateral to the cervix, so that when tied the cervix is held back
by the cardinal ligaments which have been drawn across together in front
of the cervix. If the patient is still in the child-bearing age and has been
left potentially so, no vaginal mucosa is resected. If not, a triangular
piece is resected from each flap and the incision closed with No. 2-20 day
chromic gut, interrupted. We use interrupted sutures to close the anterior wall so that the cervix will not be drawn forward towards the
urethra with a consequent tendency to descend and retrovert the fundus.
No operation for genital prolapse is complete without a thorough
approximation of the levators which is now done. A tissue forceps
grasps the centre line of the vagina at the muco-cutaneous edge posteriorly and with a scalpel an incision is made only through the vaginal
mucosa which at this point is often very thin. Blunt-pointed scissors
are carried laterally under the vaginal mucosa and the mucosa incised on
both sides. A Gelpi retractor is of great help at this stage of the operation. The vagina is then separated from the rectum. If a large rectocele
has been present this separation extends up to the cervix and well out laterally. If a rectocele has not been present there is no need to strip the
vagina far up from the rectum as many large veins are encountered.
If the vaginal flap has been thin the levator muscles will easily be seen
and felt about l/2 -% -inch above the perineum.    They are grasped with
Page 50 Allis forceps and if there is any doubt trace them to their pubic attachment. Often scar tissue will be present where the levators have been
torn and sharp dissection may be necessary. If the stripping of the
vaginal mucosa has extended up to the cervix in the case of a rectocele,
mattress sutures are placed as in the anterior wall using 40 day No. 2
ch. gut. The levators are brought together with No. 2-20 day chromic
gut, tying as you go, releasing the Allis forceps after the first suture is
placed, in order not to compromise the muscle by pressure. The levators
are brought together as far forward as decided necessary or expedient and
then posteriorly, lifting up the muscles by the preceding tied suture
which draws them out of their canal. In this way the muscles are
united for from 1-inch to 2-inch. The vaginal wound is then closed
with a running suture of ch. gut, pouching it in to fill the space between
the sutured levator muscles and skin if there be sufficient for the purpose.
It will be noticed that the levator muscles are attacked from the
vagina, not from the perineum. It is seldom necessary to make an incision in the skin of the perineum unless the sphincter ani needs to be
repaired which is done by the same incision except for an accessory
downward incision at either end to expose the retracted ends of the
sphincter ani. These are brought together with catgut after first
suturing the rectal mucosa, tying the suture line on the rectal side. A
3-inch gauze packing is placed in the vagina to be renewed in 36 hours
and the bladder catheterized.
The patient is placed in the Trendelenberg position for some days.
Morphia is not often required. The bladder is emptied by catheterization frequently enough to ensure that not over 10 ounces urine collect
in the bladder. After the patient begins to void, which she can do as
early as she wishes, we continue catheterization immediately after voiding once daily until only half an ounce or less residual urine is present.
If this is not done where a patient has required catheterization for some
days, residual urine gradually accumulates and cystitis occurs. The
nurse is instructed to instill a medicine dropper full of 1% mercurochrome before she passes the catheter at any time. The patient is kept
in bed 14-18 days and is not allowed too much liberty for another week.
The bowels can be looked after according to indications. The patient is
warned to expect some discomfort in the rectum for ten days or so, due
to the approximation of the levator muscles. A month later when you
examine the patient you may notice a little pouting of the vaginal mucosa
if you have saved it. Explain the reason for this to the patient or she
may think it is a recurrence.
Let me sum up some principles in the treatment of genital prolapse.
1. Of first importance is the repair of the levator muscles.
2. In cystocele repair, be sure wide separation of the bladder from
the vagina and bladder from uterus has been practised and be sure that
the mattress sutures close to the cervix take a bite of the uterine tissue.
3. Never expect to cure genital prolapse, especially of bladder or
rectum, by opening the abdomen and doing a fixation or hysterectomy.
Page 51 It never can and never will. Go back to first causes and strike at the
cause, not the result.
4. There is no class of surgery that requires a more painstaking
ritual and none that will reward the surgeon higher for his care.
I have said nothing about the retroverted uterus alone, uncomplicated. I believe the majority of cases of retroversion of the uterus require no operation, or treatment for that matter. If complications are
present it is a different matter.
"THE AETIOLOGY OF GOITRE"
extracted from a paper by Dr. G. O. Matthews read before the Vaediatric
Section of the Vancouver Medical Association.
It is now generally accepted that the most important factor in the
causation of simple colloid goitre is a deficiency of iodine in the soil and
drinking water. Marine and Kimball proved that administration of iodin
will prevent diffuse colloid goitre. You all know of their work on
Cleveland and Akron school children and many later investigators have
corroborated their results. McClendon and Williams have analyzed the
iodine content of the soil and water in various parts of the United States
and have shown that the amount of available iodine and the distribution
of goitre are in absolute inverse ratio.
However, there must be other factors in the aetiology of goitre.
The great preponderance of colloid goitre in the female would indicate
that the lack of iodine is not all. At puberty and during pregnancy
great changes occur in the breast tissues and pelvic organs. These changes
result in overwork on the part of the thyroid gland and in its attempt
to supply sufficient thyroxin it lays down an incomplete substance.
Undue mental or physical strain imposes a heavy tax on the thyroid.
Now, an increasing demand on the thyroid necessitates an increasing
supply of thyroxin and to secrete thyroxin the thyroid must have iodine.
If the iodine be insufficient the thyroid will have to give to the body an
incomplete substance and this substance is colloid.
Infectious Theory
McGarrison's work would seem to indicate that bacteria play a part
in the causation of goitre. He showed that as one descended a river in
India, the prevalence of goitre steadily increased and he explained this
increased incidence by the fact that as the river flowed down stream it
became steadily more contaminated.
Some investigators believe that focal infection plays a part—e.g.
teeth, tonsils, etc. Crotti is a strong believer in the infectious theory.
He has tabulated his arguments and they are certainly strong evidence.
Namely:
1. The influence of filtration upon the capability of water to produce goitre.
2. The efficacy of three germicides—iodine mercury and arsenic
in treatment.
3. Experimental evidence of its transmissibility.
4. Destruction of causative agent by boiling.
Page 52 Strong as these arguments appear, however, it is now generally
conceded that the work of Marine and Kimball presents the most concrete and illuminating facts in this controversy of the aetiology of
goitre. The infectious theory fails to explain why some families escape
the infection in a goitre district. Neither does the theory of focal infection explain the development of a goitre in the absence of any foci
of infection.
It is generally accepted, therefore, that colloid goitres develop because the thyroid gland is unable to supply the needs of the body for
thyroxin and so lays down an incomplete substance—colloid. This inability of the thyroid is caused by a lack of available iodine for the manufacture of the necessary thyroxin.
Plummer has said that the majority of adenomata of the thyroid
have their inception in colloid goitre. Jackson puts forward this theory,
that adenomatous goitre is the result of a compensatory attempt, that
it represents an effort on the part of the gland to produce more iodine in
order to be able to meet the demands of the body for thyroxin.
There are two main types of adenomata of the thyroid—namely,—
foetal and adult—so called because of their historical resemblance to
normal foetal or adult thyroid tissue. The above theory only applies of
course to the adult type. The foetal type like other tumours probably
originates and grows from embryonal tissue rests. The adult type is the
more common of the two.
Two-thirds of all adenomata of the thyroid give toxic symptoms by
the time the patient is 45. The reason why some adenomata remain
quiescent and others become toxic is not known. Two theories have
been elaborated—
First—that the adenomatous tissue proliferates and gives to the
body an excess of thyroxin.
Second—that in some way the adenomata stimulates the surrounding
thyroid tissue to hyperfunction.
The important fact to remember is that many of the adenomata
undoubtedly have their beginning in colloid goitres and that, if there
were no colloid goitres, there would be a great decrease in adenomata.
We must think of every simple colloid goitre that we see as a potential
adenomatous thyroid which may at a future date become toxic. That
is one reason we must do all in our power to check the prevalence of
endemic goitre. There is, however, another reason. Simple colloid
goitre is classed as a hypothyroid state. Cretinism and deaf-mutism
are known to occur in children of such goiterous indviduals with great
regularity. Of course the incidence of cretinism and deaf-mutism is
much less than that of endemic goitre but as generation after generation
of goitre patients succeed each other this incidence will become more
marked. British Columbia is comparatively a new country and fortunately our incidence of the so-called cretinic degeneration is as yet trifling.
In Europe* and India, however, where endemic goitre has been prevalent
for many centuries, the story is different. In India half a million souls
suffer from the congenital manifestations of goitre. In France in 1873
one per cent, of the total population were goiterous and 0.3 were cretins.
In Switzerland cretinism and deaf-mutism are known to be closely associated with goitre.
Page 53 Vancouver, B. C
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