Year : 2022 | Volume
: 20 | Issue : 1 | Page : 1--2
Publications from secondary care: A historic example
Department of Continuing, Christian Medical College, Vellore, Tamil Nadu, India
Dr. Reena George
Department of Continuing, Christian Medical College, Vellore - 632 002, Tamil Nadu
|How to cite this article:|
George R. Publications from secondary care: A historic example.Curr Med Issues 2022;20:1-2
|How to cite this URL:|
George R. Publications from secondary care: A historic example. Curr Med Issues [serial online] 2022 [cited 2022 Aug 9 ];20:1-2
Available from: https://www.cmijournal.org/text.asp?2022/20/1/1/337316
As scientific information explodes, predatory journals proliferate, and randomized trials expand, health care professionals in small hospitals might wonder how they can contribute to medical literature.
In the history of medicine, landmark discoveries have come not only from well-funded, well-staffed research teams but also from individuals who focused on a challenging problem in their area of work. Ida Scudder's paper on the repair of obstetric vesicovaginal fistula (VVF) is a historic example of an impact-making publication from a small hospital.
Introduction: Identifying a Problem
A 100 years ago when women delivered at home, obstructed labor often led to maternal deaths and obstetric fistulae. Child brides of 12 and 13, women with young children, were left incontinent, smelling, ostracized in the prime of their lives.
This distressing problem became a particular area of interest for the young Dr. Ida Scudder who was in charge of Vellore's then 40-bedded Mary Taber Schell Memorial Hospital for women and children. Naturally gifted with courage, dexterity, and empathy, Ida began to take a special interest in obstetric fistulae, the 'leprosy of midwifery.'
“The characteristic odor, the dejection of the patient, speak plainly to those of us familiar with these cases even before one examines the patient…. Our treatment begins by trying to instill hope into our patients…. Happy surroundings…. absolute cleanliness…. and the chance of knowing she will go home, cured, probably can change a patient from a morbid shrinking creature to one full of hope and expectancy.”
Methods: Sharing Techniques
While on furlough in 1908, Ida spent a few months of her sabbatical year training with gynecologists in New York. Three years later, with added insights from her own work (possibly with fistulae far worse than she had learnt to manage in New York), Ida presented her paper to peers at a Missions Conference in Kodaikanal, South India.
“Experience is the best teacher,” Ida writes “Our textbooks give us detailed descriptions of the different fistulae and the various operations, but I shall confine myself to the operation which has been most successful in my hands.”
She acknowledges her source and mentor, “After adopting Mackenrodt's operation suggested to me by Howard Kelly of Baltimore.” Then there is a detailed, stepwise description of the procedure. Crucial points are stressed, “The first suture is taken well before the angle of the opening and should penetrate the muscular coat only. It should be taken in such a way as to turn in the edges of the fistula. to bring raw surface against raw surface. If there is the least tension at any point, further dissection should be done. She points out possible challenges, “When the bladder is adherent to the pubic bone it seems almost impossible, but careful painstaking dissection can and must be done.” She goes on to stress, “If one lacks patience one had best avoid attempting a difficult fistula operation.
Potential causes for failure must be identified and addressed: Sterilized milk is injected into the bladder and any leakage carefully looked for. If there is any leak the sutures on either side should be removed and that portion re-sutured. this is much better than trying to close the tiny opening by suturing over it.
Specific details are given such as how to compound Emmet's Mixture (Acid Benzoic 3jss, Sodii Borat 5ij, Aquae 3viij) to reduce urinary crusts, which needle to use-“the Marcy Vesico-Vaginal needle set in a handle with eye near the point curved on the flat, without cutting edge is best….”
Postoperative care reflects personal attention to detail and teamwork, “Once daily I re-dress the case. the patient is brought to the table and given a hot sponge bath and oil rub. I find this quiets and relieves patients very much, for they get tired of lying so still. I then wash the bladder thoroughly and put in a fresh sterile catheter. A vaginal douche is given, the vagina wiped dry and dusted with boric powder. The stitches are lightly touched with iodine, and then an oleum santali dressing is placed over them and the vagina lightly packed as before…. The bladder is washed out 3 or 4 times a day by a reliable nurse.”
Ida understands the importance of good domiciliary care, and the cultural barriers that might make this difficult in the woman's marital home,“The patient is allowed to sit up on the 12th day and as soon as she is strong she is advised to go to her mother's home for a couple of months.” Even today, despite advances in medical science, poor outcomes can often be traced to failures in patient education and barriers to compliance.
Results and Discussion
In the 1911 paper, Ida describes a spectrum of four illustrative cases, both simple and complicated. The oldest is 21 with two uncomplicated fistulae. The youngest patient is a 12-year old girl who has lived for a year after with a post-childbirth VVF and a complete laceration of the perineum and rectum. Variations of surgical procedure and treatment outcomes are summarized in each case.
Ida also describes what she has learnt through trial and error, “I have tried silk, linen, chromicized catgut and kangaroo tendon, but have gone back to using silkworm gut for the bladder sutures.” She states her limitations. For example, when the urethra is absent, “I must confess to more failures here than anywhere else.”
She continues to think ahead, even if resources are not immediately available. Since chloroform/ether anesthesia is associated with vomiting, “I believe that spinal anesthesia would be the ideal in fistula cases though I have never used it.”
The manuscript was written in 1911 when Ida (with an apothecary) was the only doctor running a high-turnover maternity hospital and its community outreach work. When the paper was presented at the Kodaikanal Mission Conference and published in the Supplement to Medical Missions in India, it is likely to have translated into better fistula care in other mission hospitals in the country. In 1918, the technique was published in the Indian Medical Gazette thus reaching surgeons in government and military service.
Over time, from across the sub-continent, Indian, British and American women and royal families from the Middle East sought out Ida's surgical expertise for the treatment for VVF. In 1936, when the First All India Obstetrics and Gynecological Congress met in Madras, Dr Ida Sophia Scudder was unanimously selected president.
Ida's fistula work was not done to build up a Curriculum Vitae to earn professional plaudits. However, the work done with competence, compassion, and a commitment to learning, brought healing to the patient, knowledge to the profession, and in time, honor to the surgeon.
The Current Medical Issues journal has a mandate to be platform for research from the grassroots, from alumni and affiliated hospitals, who have pioneered innovations amidst great challenges. Thanks to the tireless efforts of Dr. KPP Abhilash and team, Current Medical Issues is now indexed in the Directory of Open Access Journals. Effective protocols and techniques from secondary care, carefully done prospective and retrospective cohort studies, thoughtful case discussions, review articles, and clinical audits from secondary care have much to teach practitioners in our country.
Even in this era of million-dollar research, much human suffering still remains unseen on the blind spot of academic medicine.
|1||George R. One Step at a Time: The Birth of the Christian Medical College, Vellore. New Delhi: Roli Books; 2018.|
|2||Scudder IS. Vesico-Vaginal Fistulae and Perineorrhaphy. Supplement to Medical Missions in India 1908. p. 1-8.|
|3||Scudder IS. Treatment of vesico-vaginal fistulae. Indian Med Gaz 1918;53:372-5.|
|4||Letter from Sir Lakshmanaswamy Mudaliar to Dr. Ida Scudder, 28 September 1935. Ida Sophia Scudder Additional Papers, 1897-1976.MC 775, Box3, Folder7. Schlesinger Library, Radcliffe Institute, Cambridge, Mass.|