ON THE OPERATIVE TREATMENT OF DISEASE OF THE UTERINE APPENDAGES.

513 conscious, there is be

roughly handled.

no

why

reason was

There

the

one

clothing

should

tear in the outer

skirt. We have never used the argument which you attribute to us-that the injuries to the vagina were greater than could have been inflicted had there been consent to intercourse with a drunken man, and there is no foundation for such a statement in the depositions. What we did say was that if the woman had been conscious the injuries must have caused great pain, and there would have been evidence of a struggle, even if she had been a consenting party. Apart from the

ON THE OPERATIVE TREATMENT OF DISEASE OF THE UTERINE APPENDAGES. To the Editors of THE LANCET. SIRS,—I am really grateful to Dr. Herman for the way in which he refers to the "courage and candour"with which

I reported the result of a case of removal of the "ovaries’’ for cardiac dyspnœa.—meaning, I suppose, that the result was so bad that no one would again attempt the like. I feel, however, that I hardly merit his praises, as the case, a miserable fiasco, was a brilliant success. utter improbability of a sober, respectable woman consenting instead of to lie down on a muddy, miry bank, we may just allude Moreover, only one ovary was removed. I read this case? to some other evidence against the consent theory. There before the Obstetrical Society of London on April 5th, 1882. She had not The chairman, the late Dr. Matthews Duncan, completely was the smearing of blood on the cheek. me. The drift of his denunciatory speech was placed that there herself, as her hands were clean. There extinguished A severe to the effect that it is better for a woman to have pain or any was the bruise on the head already alluded to. blow or fall would cause such a bruise. In our opinion it amount of suffering, such as my patient had, rather than have This was echoed by most of one diseased ovary removed. was caused by a blow, as there was no evidence on the clothing or bonnet of a fall. The actual mode of death the members, with the noteworthy exception of Dr. Barnes. might be cited as evidence against consent. inasmuch as a They declined to publish my case in the Transactions, woman, conscious and unrestrained, would instinctively and it never was published. It is so unique and interesting:’ make some effort to save herself from suffocation by turning that I venture now to give a brief account of it. L. R-, aged thirty years, multipara, applied as an on her face or side. Kerr himself said, when arrested, " I at the Women and Children’s Hospital, t() no woman, and know nothing about her." He adhered to out-patient saw which I was then one of the surgeons in April, 1881. She this denial after his conviction. II. Did Kerr commit the crime ? The jury have stated that she had been under the care of numerous medical men, of whom she could give the names of eight or in answered this the and no material affirmative, already facts have come out since the trial. You have already nine, but she had never succeeded in getting relief from mentioned some of the presumptive evidence against attacks of dyspno3a. These attacks came on from any Kerr. We do not propose to enter into detail as to ordinary work or exertion, and had for five years rendered the general evidence, but shall confine ourselves mainly to her unable to do her own housework except to a very that for which we are responsible. It has been suggested limited extent. On admission I observed one of these that the vomit on his coat came from himself. We attacks, and it was clearly cardiac, the heart being excited made our first examination of his clothing eight hours and beating violently. The patient could lie upon her after his arrest, when the vomit was still fresh and moist, stomach or on either side in bed, but not upon her back, as and it had no smell of beer, of which he had been par- the " shortness of breath " was at once induced. During out that she could relieve the attack taking freely. Some of it was on the back of his coat, the day she found stool a and bending the body forward so that where he could not have put it himself. As to the blood- sitting upon stains on the vest, we do not think he can have caused the forehead rested upon another stool; also by lying down them by blood-spitting; they probably came from his "curled up" on one side. There was a marked mitral’ The lungs were sound. Behind the uterus, and face; but the smears of blood, epithelial scales, and murmur. almost in Douglas’s pouch, was a prolapsed ovary, exquimud on the fly of his trousers clearly came from another source. They resembled closely the stains on the sitely sensitive to pressure, and pain and discomfort conwoman’s thighs and person. As to the red woollen hairs tinued for some time afterwards. My colleague, Mr. found in the mud on the trousers, it has been suggested Scattergood, agreed with me that it was worth while trying removal of this ovary would relieve her, and we they may have come from his sister’s flannel petticoat. It is whether ourselves thought justified in doing this by the great length not to remember the hairs were important simply adherent, of the case, and the absence of any hope of relief by any but were found embedded in the mud. Probably the other mode of treatment. The curious effect of certain of in first examinatheir overlooked the explanation being tion is due to the fact that only a minute portion of mud positions in relieving her and in bringing on the attacks also led us to this opinion. was placed under the microscope, and it was in conse- ’, I removed this one ovary through a small incision in the quence of the discovery of hairs on the plaster cast that a further examination was made. There is one other point roof of the vagina, the other ovary being left. It was which has been commented upon, and that is the absence of examined, and found to the touch normal. The first result any distinct impression of the prisoner’s knees or toes at of the operation was spontaneously mentioned by the the place where the body was found. It should be stated patient-namely, that she could lie upon her back with that there was a good deal of water in the muddy ditch comfort. The result was to nearly, but not absolutely, cure On Sept. 27th her husband reported that she across which the woman’s legs were stretched, and there the dyspnœa. were many depressions in the ditch filled with water at the had up to then been able to 10 her own housework, and time of our visit. There were several footmarks about. especially to knead the dough, which she never could do for her to resort to the Only two casts of impressions near the edge of the ditch before. It had not been necessary peculiar positions again. Of course I could come to no were taken by direction of the police, but it is a mistake to other conclusion than that the dyspncea, although cardiac, say there were no other impressions. In conclusion, it must be remembered that the evidence was excited in some way by the state and position of the in a case of this kind must be treated as a whole. Nothing ovary. Dr. Galabin kindly made a microscopic examinais more easy than to pick out sundry details from their sur- tion of the ovary, which was cystic. He says : " The tissuegreatly infiltrated with inflamroundings, and to show that these may possibly be ex- near the cysts was in parts nuclei, especially between the cysts, and the surface plained on some other theory (or even on contradictory matory and dilated vessels containing blood were heretheories) than that of the commission of a crime, or of the of the ovary I am content to leave this case to the judgguilt of a prisoner. But we think that few will read the seen." ment of the profession, and to ask if they see any story as a whole without coming to the conclusion which reason why this removal of a diseased and useless ovary we hold, that in no other way can the whole facts be exshould not have been done, and if, as the result showed, than that old the woman was outplained poor grossly relief was given, why I should have been "put down " raged, that in consequence she died, and that Kerr was the great man who did it. The deed was done in darkness, no wit- and " sat upon " by the President, who called the treatment a "wild proceeding." Dr. Barnes, however, said he ness can testify to what actually occurred, and on some small surgeons, points inferences may be wrong. But even if this is so, the " regretted that the attitude assumed by London main facts on which the verdict was given remain unalter- seriously obstructed the progress of this branch of surgery. All great improvements in surgery were largely due to a spirit able evidences of guilt. research." I of enterprise, it might be said of We are, Sirs, yours faithfully, think I have shown that Dr. Herman’s memory has played HENRY BARNES, M.D. him falsely in his reference to this case; perhaps it also has RODERICK MACLAREN, M.D. Carlisle, Feb. 24th, 1891. in reference to the five cases he mentions in which the

being

by

experimental

514

patients had been advised to have the uterine appendages editorial article suggests that I wish to form a low order of removed, and got ultimately perfectly well without the practitioners educated in medicine, surgery, and midwifery. ’operation. We all know how much patients’ accounts of shall only answer this by calling attention to the notice of opinions of their cases may be trusted. Probably in motion put down by me for the Jast meeting of the British several the operation had been merely mentioned as Medical Association, which, I trust, shows that I am as .possibly required at some time. I am mvself not in sym- opposed to the recognition of midwives as to the recognition pathy with the manifesto of Dr. John Williams and Dr. of a barber surgeon, or any itinerant bone-setter, herbalist, Champneys; it breathes too much the same spirit with and quack specialist, holding, as I do, that the midwife which I was met. The real secret of this matter is that the must give place to the woman doctor, just as the barber London obstetric physicians are as a body not surgeons, surgeon has been displaced by the modern surgeon. The whereas gynæcology has been becoming more and more sur- following is the notice of motion :Registration of Midwines.—Dr. Rentoul also gives notice that lie gical ; and it is a question whether the appointments should willThemove: that no new order or class "It is the of this

I

rather than medical. I am, Sirs, yours faithfully, JAMES BRAITHWAITE, President of the North of England Gynæcological Society. Leeds, Feb. 21st, 1891.

not be

surgical ones.

MIDWIVES’ REGISTRATION BILL. To the Editors of THE LANCET. SIRS,—I had hoped that I bad made my position quite ’clear in connexion with the Bill. It is evident from your leading article that I have not. My contention has been from the first that it is for the promoters of the Bill to justify its introduction. This they have not done. Neither during the debate at the Obstetrical Society nor in their did the Council furnish, or attempt to furnish, any facts to demonstrate the basis on which they rest their position. All that is said in the circular is : "From year to year successive Councils since 1872 carefully discussed every aspect of the question, and through a system of examinations gained practical experience as to the value of examination." Sarely after nearly twenty years’ labour they might have incontestably proved the justness of their views by facts, if facts existed. In the next place, I have taken my stand against the present Bill on the ground that it reverses the principle of all recent medical legislation, and that it creates a new race of inferior female practitioners in midwifery. You, Sirs, protest against the same clas", if - educated in medicine and surgery as well, so I do not think there is much between us on that point. You talk of reasonable legislation to stop incompetent midwives from practising. I have from the first stated that I believe that is exactly what is required. But before such legislation could be passed, surely the grounds for its necessity must be clearly stated, and the sufficiency of the means adopted to secure the end demonstrated. With regard to the satisfaction you say I expressed to the Lord President, I must remind you that you have omitted a very material part of my statement-I mean that relating to the paucity of women attended by any but doctors in my own district, and also the inquiry as to how it was that of all the women who receive the diplomas year after year from different bodies so few of them were found attending the poor and destitute. It is a tolerably well known fact that these trained women as a rule prefer monthly nursing at high fees, and small blame to them. I very much regret the tone that some have introduced into the discussion-Dr. Holman’s accusation, for instance, that an appeal has been made to the cupidity of the profession ; and Dr. Grigg’s charges against his own profession, contained in his address to the British Gynaecological Society. It seems a pity that he did not make them during his speech in the debate on the Bill, when there were present those who could answer him. Verily, discretion is the better part of valour. In answer to him I will ask him who is responsible if doctors are turned out with insufficient knowledge of their subject? Surely, I say, those men in the position of Dr. Grigg whose ’establishments are advertised as training medical students and monthly nursing. What has Queen Charlotte’s Hospital done in the cause of education in midwifery ? In my time in London the men who went there, as a rule, were those who were not anxious to do more than the indispensable minimum, and that comfortably. I am, Sirs, yours faithfully, LOVELL LOVELL DRAGE. Hatfield, Feb. 21st, 1891.

circular

opinion

meeting

of midwifery practitioners is required, and that any Act passed by Parliament which provided that any man or woman may practise midwifery, either as a registered midwife or registered medical practitioner, unless such have undergone a period of four years’ study at a recognised school of medicine, and possess a degree or diploma recognised at present by the General Medical Council, would be injurious to the lives of lying-in women and infants, and prejudicial to the best interests of the medical profession. Also, that the Local Government Board be requested to put into force in each Union the General Order of the Poor-law Commis. sioners of 1847, Acts 182 and 183, empowering guardians to pay certain fees to their medical officers, in cases of childbirth and puerperal maladies. TtM.t a copy of this resolution be forwarded by the General Secretary of the Association to the General MedICal Council, both Houses of Parliament, the President of the Local Government Board, to the daily press, and to the medical journals."

Secondly, you question my statement regardipg 7s. 6d. midwifery fees. In a late number of THE LANCET the Derby Friendly Societies’ Medical Association advertised for a doctor, offering 5s. 3d. per confinement. Is it not a fact that some Poor-law medical officers get less than 10s. ? Personally, I may say that the fee paid to me for attendance on the confinement itself frequently

does not exceed 6d Take a case of a 30s. confinement fee. The woman comes to engage me and is certain to want twenty minutes’ consultation and a prescription. Then I have to go out at night to her confinement perhaps twice. Next I have to visit her again on the night of the confinement. She will expect to be visited during the fourteen days following the labour. It is 50 to 1 she will also ask that her baby be vaccinated free-i.e,, included in the confinement fee. That latter means for me-writing to London for calf lymph and paying Is. 2d. for it, seeing the child to see that it is fit, vaccinating it, inspecting the arm, and filling up the certificate. I do not think any reader will consider the above an exaggerated picture of general practice. I regret the above conditions ; but the competition of medical charities, midwives, doctors who keep unqualified assistants, State vaccinators, and younger practitioners all tend, by an unhealthy competition, to keep the fees down. I know very well that those who pay me my lowest confinement fee of 30s. can readily pay me 50s, but thus they can get Dr. So-and-So to attend for 20s., 25s, or 30s. !! I do not in the above estimate include bad debts. Now, Sirs, taking the above 30s. confinement fee, and counting that I must give at least ten visits, this gives me 3s. 6d. per visit, and practically nothing for the confinement. I do not include the vaccination and its usual three visits. Indeed, most general practitioners own that the fee paid nontinally for the confinernent gives them on an average 2s. 6d., 3s. 6d., to 5s. per visit, and leaves nothing for attendance on the confinement itself. I wish that general practitioners would honestly speak out, and let you know the real state of affairs. At present I know good men who are going out for a fee of Is., and to confinements for less than 10s. I have no ends to gain by exaggeration, and no one has yet shown my statements to be wrong. I am, Sirs, yours faithfullv, ROBERT REID ROBERT REID RENTOUL, M.D. Liverpool Feb. 23rd, 1891. *** We gladly give Dr. Rentoul, as we have freely given before, room to expound his views-in our opinion extreme views, which do not place the profession in a good light before the public and Parliament. His statement before Lord Cranbrook that "many medical men were willing to attend midwifery fori’s. 6d. " still appears to us one of the most astounding assertions which any medical man assuming to represent the profession could have made, To tlze Editors of THE LANCET. when considered in connexion with a proposal especially SIRS,—I trust, as you have made some very grave state- of his to ask Parliament to prohibit midwives attendments regarding my action in opposing the Midwives’ ing a case under 15s. And, in our judgment, his attempt Registration Bill, that .v --oii will give me room for reply. In THE LANCET of Feb. 21st, p. 444, the wiiter of the to justify it fails completely. The offer of a Friendly