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Nurse”) Each year. approximately 1,400 men and women from all over Canada and the USA congregate in one of Toronto's largest hotels to enjoy a ban- quet and floor show. The only unusual aspect about this get- together is that the meal is pre- ceded by a physical examination for each guest. Moreover, the 1.400 persons have at least one thing in common: they are all tax-patients of the world-famous Shouldice Surgery. A Modest Beginning (Reprinted from “The Canadian This particular hospital had a modest beginning. In 1945. the late Dr. Earle Shouldice. a grad- uate of'rtihe University of Toron- to. opened his own hospital on Church Street. Toronto. It con- tained vsix beds and one operat- ing room. , Shouldice Surgery specializes an elective hernia repair. Nine- ty,-eight percent of its operaâ€" tions are hemiorrhaphles and two percent involve associated conditions. such as hydrocele and‘ cysts of the epididymis. The technique at Shouldice em- phasizes local infiltration anes- thesia. early ambulation. and modified exercises postopera- tively. Many Provinces " THE LIBERAL, Richmond Hill, Untan Treatment Of Hentié ’At Sh‘ouldce Fottows Regular Routine many I luvunocu -Since most of the surgery at Shouldice is elective. many pa- tients come from provinces other than Ontario: in addition. approximately 15 percent of all patients are from the United States. Among the “patient alumni" is a Russian professor who, while on a tour of Canadian hospitals. visited Shouldice Surgery one morning to ob- serve the operative techniques. He was so impressed that he asked the chief surgeon to oper- ate again after lunch -â€" this time on himself â€"- for repair of at twice recurrent inguinal her- nia. The professor is still high- 137 pleased with the results! Types of Hernia Men. women and children may be afflicted with any of the following types of hernia that rhuuire repair: for local infiltration. -r-__. r , Nembutal and Demerol are used preoperatively for seda- tion. Two percent Novocain without adrenalin is employed The latâ€" ter, provides a safe anesthetic for the elderly‘ as well as for young and middle-aged persons, and is particularly valuable for patients with severe heart and chest conditions. Since it is difficult to obtain complete re- laxation with a local anesthetic in young children, a general an- esthetic. usually Fluothane. is administered to children up to 14 years of age. In children up to seven years of age. chromic catgut 00 or 000 is used for all ligatures and re- pair sutures: in children aged seven to twelve. monofilament surgical steel wire, 34 gauge. is used for repair, and catgut for all ligavtures. cor or clir far list an: get coâ€" \ve‘ bee be( pm uni th; c0] cox «on Among the “patient alumni" is a Russian professor who. while on a tour of Canadian hospitals. visited Shouldice Surgery one morning to ob- serve the operative techniques. He was so impressed that he asked the chief surgeon to oper- ate again after lunch â€"- this time on himself â€"- for repair of a~ twice recurrent inguinal her- nia. The professor is still high- 137 pleased with the results! _.,er , Men. women and children may be afflicted with any of the following types of hernia that r‘equire repair: _,j_,, Indirect Inguinal: This type is associated with the spermatic cord. extending from the in- ternal ring. and may be con- tinuous with the tunica vagin- alis of the testicle. It usually consists of a peritoneal sac. but may consist almost entirely of lipomatous fat. Direct Inguinal: This type presents through part. or all of the canal floor. It consists of avperitoneal sac or extra-peri- toneal fat covered by the thin- ned out and stretched transver- salis fascia. run... __. 7 7 , Direct 1118’!“le This time For incisional hernias, monoâ€" presents through part. or all of filament surgical steel wire 30 the canal floor. It consists of or 32 gauge is used for the re. v peritoneal sac or extra-peri- pair satures, except that muscle toneal fat covered by the thin- is sometimes approximinated ned out and stretched transver- with 34 gauge wire. Umbilical salis fascia. and epigastric hernias are usu- 2Slidinz: This refers to the ally repaired with 32 gauge type of 'hernia in which some wire. Scarred tissues and tis- porlion of retroperitoneal viscus sues under tension require the slides downward to form part heavier gauge wire. or all of the hernia mass. The Michel skin clips are used in viscera usually involved are the all patients for approximation ascending and decending colon of the skin edges; these are re- Mrs. William Urquhart, only daughter of the Shouldice Hos- pital’s founder, serves as a di- rector and secretary of the Shouldice organization. Founder's Only Daughter Serves As Shouldice Secretary Director Mrs. William Urquhart, only daughter of the Shouldice Hos- pital's founder, serves as a di- rector and secretary of the Shouldice organization. She has taken an active part in the hospital's affairs for the past 20 years. Ten years ago. at her father’s request. she started putting out the staff publication “The Bulletin", which contains hospital news and staff suggest- tions. Her interest in education caus- ed Mrs. Urquhart to direct the board of the hospital to estab- lish an educational bursary for‘ children of employees as a fit- ting memorial to her mother and father. She is also a great believer in the independent school sys- tem. and serves on committees of the board of St. Clements School and Lakefield College School. "It keeps the staff in touch and gives us all an opportunity to express ourselvesjflshe _sa,\:s. Mrs. Urquhart took her Bach- elor of Arts Degree at the Uni- versity of Toronto. Later she returned to the university to take her Masters Degree in Psychology. and did research at: the Institute of Child Study. Her children have all attended the institute. All of Mrs. Urquhart’s child- ren were born in the old Church Street division of the Shouldice Hospital, where she experienced first hand her fa- ther‘s practice of early ambula- tiori. Her first child was born at 9 am and Dr. Shouldice drove his daughter and new grand- child home at 8 pm the same day. She has five children and a foster son. Her husband is a prominent corporation lawyer. and serves as a director and vice-president of the hospital. Mrs. Urquhart says that when her father died, both she and her brother felt it was import ant to keep the hospital going. It was then she began taking a very active interest. and they started planning the new hos- pital. \\\\MRS. WILLIAM URQUHART THE LIBERAL, Richmond Hill, Ontario, Thursday and bladder. The peritoneal sac. if present, is usually found on the medial side of the hemia mass. Early recognition and special care in dissection are necessary to prevent damage to the blood supply to these organs. Femoral: This presents below Poupart‘s ligament through the femoral sheath. and lies in close proximity to the femoral vesâ€" sels. This hernia is often and easily overlooked. Umbilical: This protrudes through a defect beneath the umbilicus and may consist of fat or a peritoneal sac. On the medial Blue U]. in: ucuuu mass. Early recognition and special care in dissection are necessary to prevent damage to the blood supply to these organs. Femoral: This presents below Poupart's ligament through the femoral sheath. and lies in close proximity to the femoral ves- sels. This hernia is often and easily overlooked. Umbilical: This protrudes through a defect beneath the umbilicus and may consist of fat or a peritoneal sac. Epigastric: This type protrudâ€" es through a defect in the mid- line between the umbilicus and the sternum. Diastasis of the recti may give the appearance of a hernia without an actual defect. Prior to admission, each pa- tient receives a complete physi- cal examination. Full particu- llars are recorded about age. sex. height, weight. waist measure- ment, type of work, religion, past medical history, present medication and treatment, if any. Hospitalization benefits, insurance. and the cost of surg- ery are discussed. It the patient‘s condition is 'satisfactory. a definite operative date is arranged: if, however, an outstanding health problem re- quires attention. the examining doctor will at the patient‘s re- quest, make an appointment with a corresponding specialist or refer the patient to his own doctor for treatment. uth n... natipnt 1: consider- Incisional: This may follow any abdominal operation if a defect develops in the muscle layers of the incision. Lug»-.. ._.- _, Recurrent: A hernia is des- cribed as recurrent if there has been a previous surgical repair at the same site. Recurrence may result from inadequate disâ€" section and repair. failure to re- move a peritoneal sac, or from postoperative wound infection with breakdown of tissues. Operative Procedure For adults and children over the age of 12. monofilament surgical steel wire 34 gauge is used throughout for ligatures and repair sutures in the ab- dominal wall; chromic catgut 00 is used for suturing the periton- 79731 sac and for an& ligatures in the peritoneal gayity._ of the board of St. Clements School and Lakefield College School. 71-.. _...l.... ‘nIvA‘IV-MAH‘ In 6-11.: Her major involvement in the new building has been in sel- ecting the furnishings and de- cor. The home-like atmosphere was preserved through the careâ€" ful and painstaking selection of beds, desks. bed tables, drap- eries, and rugs. etc. Canadian prints are planned for the walls of all the hospital rooms. she says. Forty-five rooms and other} hospital areas had to be furn-i ished and decorated. There were drapes to choose for all, the patient's rooms. It took months to select uniforms that 'would be pleasing to the staff and patients alike. Every item of furniture was personally selected. Fifty dif- ferent models of a single type of chair were actually tested by the patients before one was ordered. The same kind of care was lavished on the other items. “My job has been to provide the woman‘s touch and the lay- man's touch. Doctor's some- times forget t he ordinary things." says Mrs‘ Urquhart. “This kind of think takes an awful lot of time. especially when you have to learn as you go along. Even then. it may not be too immediately noticeable," she said. Hickeson-Langs Supply Co. We Salute... SHOULDICE HOSPITAL Institutional Food Distributors 103 ORFUS RD. â€" TORONTO 390, ONT. 7750 BAYVIEW AVE., THORNHILL On The Official Opening Of Their New Extension It Is Our Pleasure To Be A Supplier uni-"N. a-. _ when the patient is consider- ed overweight, he is given a date for operation. along with instructions on how to lose weight.\ Usually he is asked tol lose only 5 to 20 pounds. but occasionally it may be 50 or even 100 pounds. depending on his build and the type of hernia. One of several diet sheets is given to the patient when weight loss is required, and extra daily vitamins are! prescribed. Weight loss is re- corded weekly. either by letter or attendance at the weight clinic. It has been found that moved in most cases on the and postoperative day. Patient Care far better surgery is accomp- lished when the tissues are lax and the patient is in ‘as good general health as possible. o___, Patients are generally very co-operative a b out losing weight. One lady who had been refused surgery elsewhere because her health made her a poor surgical risk, lost approxi- mately 100 pounds in one year under careful supervision. thereby making operation feas- Since so many patients from out-of-tovm asked how arrange- ments could "be made for friends or relatives to come for hernia surgery. a questionnaire that could be sent on request was complied. The questionnaire is completed and returned by the prospective patient, preferably with the help of his family doc- tor, and an appointment is made *by telephone or return mail. Information about the proposed surgery and instructions regard- ing any outstanding health problems. such as heart or chest conditions are included with the questionnaire. Admission ible The patient is admitted be-‘ tween 1 and 6 pm on the day prior to operation. Blood pres- sure, temperature, urine, heart and chest. are checked careful- ly. He is then shown to his private or semi-private room and instructed about such things as valuables, insurance forms. visiting hours (2 to 4 pm. 1 v. u. ._.__ 7 to 9 pm) and the length of stay in hospital (four days are required for a single hernia; six for a double hernia, and eight in triple cases, eg, bilat- eral inguinal and an umbilical or epigastric hernia). The patient is asked to change into lounging wear and dressing‘ gown and then 'is given the op-‘ portunity to rest or to retire to the commbn room. In the com- mon room he will meet other “new” patients, as well as pa- tients recovering from surgery, 1and will find for his amuse- ment television, playing cards, jigsaws, books, and daily pap- ers. The presence of this room encourages early ambulation be- cause without it the patient would be inclined to stay in bed. Operative Day Inaâ€""m- _,., Patients are asked to shavei the operative area prior to ad- imission. On the morning of op- eration the area is thoroughly washed with pHisoHex. A mouth wash (Zinchloris) is pro- ivided and instructions are given ifor care of the teeth. Patients are allowed to keep any rings they might be wearing on their fingers. Operative gown and trousers are provided and the patient is asked to wear his isocks. Nembutal. the preoperative} sedative previously ordered by‘ the admitting doctor. is given orally one and one-half hours prior to operation. and Demerol is administered intramuscularly 20 minutes before surgery. The patient is then walked to the operating room, with the help of two doctors, and asked to lie down on the operating room table. A blood pressure cuff is placed on his arm and blood pressure pulse and respiration are recorded. The operative area is then rechecked and painted three times with zephiran prior to the infiltration of Novacain two percent. More anesthetic is injected into specific tiSSue planes during the operation: also. extra Demerol may be ad- ministered. and occasionally Sparine is used intramuscularly or intravenously. May 28, 1970 On completion of the opera-ftray service in bed. wmcn tion the patient is carefully would discourage mobility. All Walked back to bed and, follow- patients are transferred to ing a few hours rest, is given a ground floor bedrooms on the bed bath and his own lounging first postoperative morning un- attire to put on. After this he less they are scheduled for is encouraged to walk to the further surgery. washroom. On his return to After breakfast the patients __..°-_ washroom. On his return to bed he is asked to do deep breathing and leg exercises. Fluids are given as tolerated; oral analgesics are administer- ed four-hourly for postoperative discomfort. A light meal usually is well tolerated in the evening. special diet may be ordered. After an incisional hernia re- pair, the routine diet consists of nourishing fluids for 24 hours. followed by a normal diet until discharge. This diet may be used following appendec- tomy or on request by the oper- ating surgeon. First Postoperative Day A l After breakfast the patients are asked to retire to their rooms to allow the physician to1 remove alternate Michel skin clips and to replace the dres- sing. Following this they can go to the bathroom for a com- plete wash. or be given a bed bath by the nurse. All patients are asked to congregate in the sitting room at 10 am for daily ,exercises. accompanied by se- ilected music. under the super- vision of a nursing assistant. ‘Prior to this the registered nurse has given the nursing as- sistant a list of patients whose exercises have been limited be- cause ‘of general health reasons. bed he is asked to do deep breathing and leg exercises. Fluids are given as tolerated; oral analgesics are administer- ed four-hourly for postoperative discomfort. The patient is encouraged to move about and arise early. Coffee is served between 6 and 7 (am for the very early risers. All meals. including breakfast. are served in the dining room: this is considered preferable to Dr. Bymes Shouldice. son of the Shouldice Hospital's found- er, says the recently completed construction of the new hospital has fulfilled a dream his father had. Shouldice Hospital Now Father's Dream Fulfilled “The hospital is a eo-opera- Live effort, with the team spirit the key to the friendly atmos- phere and esprit de corps. We eliminate the anxiety factor for the patients" says the first vice- president and surgeon. "In the new hospital we have tried to preserve the old atmos- phere of Church Street. It‘s casual relaxed, pleasant." he says. "Our first objective. real- ly, is to get people to relax." “The patient operated on in the morning walks away from the operating area and is up and around in a short time. He encourages the new patient coming in during the afternoon. It’s a question of alleviating fear.” he says. The aim of the operating technique is to cause as little damage to tissue as possible. Then patients are kept busy, ‘happy and satisfied. -â€"â€"rru \Yuo \uu -_._ __-.._ Dr. ghouldice believes the Road‘”Toron'£3’ in 192-9:"He at; Wounds Of happy and busy 133' tended Forest Hill School and tients heal faster. The request Upper Canada College. His of a United States researcher, wife is the former Catherine to attempt to evaluate the ef’ Louise G1 on of Toronto Their fects of patient attitude on th' samin inzludes a girl 'Sheuey ‘healing process met with on . operation from Shouldice Hos- égfigrozoys’ Glynn’ James pital. Although the results of " _ _ the project haven’t $t been Dr. Shouldice studied insti- finalized, Dr. Shouldice believes tUtional management (hospitals this is a valid concept. and hotels) at Toronto Univer- » , -u... ~....;h...+.€un 4n 10R1 'T‘l'la "The hospital is an environ- ment. It can be good or bad for.the patient, This depends even more on the actual people and nurses, than on the hos- pital fiacilities. Its atmosphere can be established by them It depends on how the nurses make the patients welcome, and how the patients get the en- couragement they need," says Dr. Shouldice. “The new hospital has creat- ed the environmem in which the staff has been able to de- velop this esprit de corps among the patients. We have 32 acres far away from city air lpollution. The putting green, ‘outdoor shuffleboard and pav- 21 McCAUL ST., TORONTO ZB, ONTARIO on the opening of your new extension SHOULDICE HOSPITAL Congratulations Â¥We're proud to be one of your suppliers FOR FINER FLOOR CARE PRODUCTS & SERVICES Mineral oil. one-half ounce‘ and fruit juice are given three times daily in hospital. Second Postoperative Day The same routine is followed as for the first postoperative day except that half an ounce ed walks give the patients something to do,” he says. Dr. Earle Byrnes Shouldice was born at 461 Dovercourt Road, Toronto, in 1929. He at- tended Forest Hill School and Upper Canada College. His wife is the former Catherine Louise Glynn of Toronto. Their Dr. Shouldice studied insti- tutional management (hospitals and hotels) at Toronto Univer- sity, graduating in 1951. The same year he took an army commission in the Irish Regi- ment of Canada. Then he spent some two years involved in the administration of the Shouldice ;Hospital. In 1954 Dr. Shouldice started new studies at the University of Western Ontario, graduating with his Bachelor of Arts De- gree in 1957. He then entered medicine at the university, graduating in 1961. He returned to work at the Shouldice Hospital in 1962 to iake over his present medical responsibilities. fifs interests are skiing, curl- ing. golf and sailing. DR. BYRNES SHOULDICE bed. which 0f milk of magnesia is given be- Antibiotic Polybactrln powder, 10bility. Alllfore breakfast. All remaining sprayed directly into the wound, isferred to'Michel skin clips are removed, is preferred for use during dif- .oms on thelalong with the dressing. Gly- ficult and lengthy surgery. morning un-gcerine suppositories are given Postoperative complications are neduled for for relief of gas pains and ab-lvery rare. but occasionally chest ldominal distension if necessarywconditions or wound infections the patients a Dulcolax suppository is some- may require the use of antibiot- re to their times ordered if the patient is ics. , physician to unduly worried about not hav- Not one case of pulmonary Michel skin ing a bowel movement. embolism has occurred at rBe the dres' Third Postoperative Day Shouldice Surgery, probably be- The patient is examined In the morning. Temperature heart. lungs and operative area are all checked before he is dis- charged home. He is instruct-1 ed to return within 10 days. or before if worried. so that the physician can examine the oper- ‘ative area. Advice is given about resuming work: sedentary workers may return to Work immediately if they wish, but persons engaged in heavy physi- cal labor may require three to four weeks off before resuming work. ‘ Sometimes after bilateral in- guinal hernia repairs. there is swelling, combined with ecchy- mosis. of the scrotum. The pa- tient may need extra reassur- ance that this is natural and will recede within a few days. Complications Rare With this highly advanced technique and psychological ap- proach, many procedures have been simplified. It rarely is necessary to administer intra- venous fluid of any type; when it is necessary. it is usually for some other medical reason. such ‘as perforated peptic or duoden- lal ulcer. abdominal obstruction, etc. Only one ‘blood transfusion has had to be administered in many operations. Because of rthe type of anes- thesia, early ambulation. and the giving of copious amounts of fluid after return from the operating room, catheterization is rarely necessary. Enemata are nearly obsolete. being need- ed only once or twice a year; ‘mostly theyare given because ‘the patient normally uses them. Early ambulation. exercise. daily mineral oil. and normal diet are the reasons why ene- mas are seldom required. Occasionally. antibiotics are used prophylactically where there has been previous wound infection, or for difficult inci- sional and recurrent hernias; also. they may be administered to the patient who has a history ‘of being prone to infection. SHOULDIBE HHSPITAL 768 WARDEN AVE. We Extend Good Wishes We Have Been Entrusted With The Designing And Installation 0f Aluminum Siding |n Buildings And Institutions Of Every Type And Size Over The Past Many Years Therefore We Are Happy And Proud To Add The Shouldice Hospital To Our Latest Completed Projects. ALCAN BUILDING PRODUCTS And Compliment Them On Their Foresight And Planning Of T he New Extension Not one case of pulmonary embolism has occurred at Shouldice Surgery, probably be- cause of early ambulation. Des- pite the large numbers of oper- ations on persons who were considered to be poor surgical risks because of general health, there have been only 11 deaths out of 50.000 operations in 21 Xyears. During the years the post-‘ operative wound infection rate1 has fallen from two percent to‘y one percent. The recurrencel rate of hernia is very low; it is; approximately 1 in 200 for all operations. and about 1 in 500 ‘for inguinal repairs. A 15-year followup plan is in force which helps greatly with research in hernia knowledge and surgery. The oldest patient to 'be operab . ed on was 100 years old and was still living at the age of 103: the youngest was four weeks. JACKSON, YPES 8. ASSOCIATES ARCHITECTS AND ENGINEERS THORNHILL To The LIMITED SCARBOROUGH, ONT. 2S4 YONGE ST. We Extend Our Sincere C ongra tu/a tions Shouldice Hospital ON THEIR NEW EXTENSION FROM A FRIEND Shouldice Hospital In Supplying the Uniforms We Are Proud To Be Associated UNIFORM WORLD with 751-6200 TORONTO