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THE INQUEST UPON MRS. PIERCY.
1366
president of the association, stated briefly the reasons why sponges were counted as a matter of routine both before and deputation approached the London County Council in after the operation but that the instruments were only hope of inducing that authority to graft upon the Fire counted before the operation, and this statement puzzled Brigade an efficient ambulance service. Sir William Church, them, as, indeed, it puzzled us. An examination, however, who next spoke, drew especial attention to the great of all the circumstances puts the matter in a much more saving of cost that would ensue if the advantageous favourable light for the hospital. We have now received method of combining the Fire Brigade and ambulance statements from the two nursing sisters who have been in services was adopted. It was stated that the Poplar Hospital charge practically of the operating theatre at the West London Hospital for the last six years and it is clear was estimated to receive four cases of accident or sudden illness every hour day and night throughout the year. The that the "system"which has been blamed does not exist. representatives of the St. John Ambulance Association also The independent statements of these two sisters show stated how anxious their association was to help the pro- that there is no defect in the system of checking posed plan in every way. A large portion of the time instruments at the hospital, although, to the profound was occupied in answering the many questions asked by the regret of everyone concerned, the routine at the West members of the general purposes committee ; these were London Hospital-the counting and checking which prevail, mostly responded to by Dr. James who explained that of course, everywhere else-was not observed on this occasion. the proposed ambulance service would not put more Each sister says that upon taking charge of the operating work on the Fire Brigade as at present constituted. theatre she was enjoined to count the instruments, sponges, It was estimated that every year 15,000 casualties had and swabs before and after every operation and to hold to be removed to hospitals and the association suggested herself responsible for having done so. On the lamentable that a sufficient number of men, horses, and ambulances occasion in question the nursing sister, following instruc. should be added to the Fire Brigade to deal efficiently with tions, detected that a sponge was missing and it was found the the
the task. It would appear that out of the 90 fire stations only 30 would have to be furnished with ambulances. Dealing with the question as to whether calls for ambulances would not interfere with the alarms for fire Dr. James explained how such calls nowadays were carried out by means of telephones and in this way no inconvenience would arise as might possibly have been the case if the old plan of simply using a bell were still in use. Some confusion seemed to exist as to what should be expected from the police but Dr. James was able to clear up the difficulty entirely by pointing out that the police would help in the ambulance service in exactly the same way as they helped in cases of fire. The council has appointed a subcommittee to consider the question.
in the
but it does not seem to have occurred to an instrument might also be concealed in a similar manner. A reason for this oversight has been communicated to us by the senior surgeon of the hospital who writes :-
abdomen,
anyone concerned that
Changes in methods occur in a progressive art like surgery and following most important change must be remembered. Whereas years ago it was the custom to stop haemorrhage inside the abdomen by applying small artery forceps to numerous points and afterwards tying those points one by one, many surgeons have almost entirely discarded this plan. I do not think that I myself have put out of sight a single small pair of forceps in the last 300 abdominal operations performed by me. I remember well the prethe
mind it caused me on the last occasion when I did such So it happens that while within the last few months I have on various occasions reminded the sister about counting swabs placed in the abdomen, I have never had to ask her about counting the
occupation of a
thing.
at the West London
instruments. As no instruments were put out of sight, it was unnecessary to do so. Some, if not all, of my colleagues have, I know, acted much in the same way. Thus, the house surgeon, the sister, and all concerned have had constantly held up before their eyes the importance of counting the sponges, while actual recent experience has tended to minimise the ancient and necessary rule that instruments should be counted too.
Hospital recently has been made the subject, consequent on the publicity of the proceedings before the coroner, of some unjust reflections upon the institution in question. We need not enter into the details of the story as they have been brought to the attention of all the medical profession, but the gist is as follows. A patient was operated upon for a ruptured Fallopian tube in circumstances of great hurry, the need for the hurry being her absolutely desperate condition. The operation proved only partially
We think that the view taken by the senior surgeon is almost certainly right, and confirmation is given to it by the fact that the present theatre sister, for whose care and conscientiousness we are in a position to vouch, had only returned to the position after an absence from work in the operating theatre of over six years. If we further bear in mind that this unfortunate oversight took place in connexion with a case of acute hemorrhage of the most dangerous description, and if we appreciate that the opera-
-
THE INQUEST UPON MRS. PIERCY. A SAD occurrence which took
place
tions of surgery must sometimes be done under cona recurrence of symptoms led to the rethat a ditions of emergency and haste which resemble those found of the It was then discovered abdomen. opening small pair of forceps had been left in the abdomen in the operations of war, it will be recognised by every after the first operation. The patient died and the fair-minded person that even the most careful surgeon, aided coroner’s jury, having heard the evidence of the by the most scrupulous assistants, is liable to be visited by surgeon who performed the first operation, of his housea similar calamity. Just as it is impossible to make any surgeon who assisted him, and of the nursing sisterdelicate mechanical contrivance absolutely I I fool-proof,so in charge of the theatre, brought in the following verdict :it is impossible to invent any system of counting instruments "Death from misadventure due to peritonitis following an and sponges which will entirely do away with human operation, accelerated by the presence of the forceps,"fallibility. We have the deepest sympathy with the husband adding as a rider, we consider the system at the hospitalof the unfortunate woman, and are in no way attempting to is largely at fault and suggest that in future all instru-lessen the catastrophe when we say that it is quite likely ments should be numbered and counted before and after that the overlooked forceps had nothing to do with her each operation." The operating surgeon, a man ofdeath. many years’ experience, was able to bring unimpeachable DISTRIBUTION OF PLAGUE. testimony to his scrupulous care as an operator, while the LORD MILNER in a telegram received at the Colonial possibility of such a deplorable oversight occurring despite Office on 2nd states that since April 23rd 14 fresh was also The May rigorous precaution proved. jury quite cases of been notified in the Transvaal, 11 these but have considered plague appreciated they evidently points, that at the West London Hospital the procedure in being in coloured persons and 3 in white persons. Out regard to such operations was not attended with due care.of the suspected cases 3Z have been found to be not sufferThe evidence of the theatre sister was to the effect that theing from plague, making the total number of suspected
successful and
____
president of the association, stated briefly the reasons why sponges were counted as a matter of routine both before and deputation approached the London County Council in after the operation but that the instruments were only hope of inducing that authority to graft upon the Fire counted before the operation, and this statement puzzled Brigade an efficient ambulance service. Sir William Church, them, as, indeed, it puzzled us. An examination, however, who next spoke, drew especial attention to the great of all the circumstances puts the matter in a much more saving of cost that would ensue if the advantageous favourable light for the hospital. We have now received method of combining the Fire Brigade and ambulance statements from the two nursing sisters who have been in services was adopted. It was stated that the Poplar Hospital charge practically of the operating theatre at the West London Hospital for the last six years and it is clear was estimated to receive four cases of accident or sudden illness every hour day and night throughout the year. The that the "system"which has been blamed does not exist. representatives of the St. John Ambulance Association also The independent statements of these two sisters show stated how anxious their association was to help the pro- that there is no defect in the system of checking posed plan in every way. A large portion of the time instruments at the hospital, although, to the profound was occupied in answering the many questions asked by the regret of everyone concerned, the routine at the West members of the general purposes committee ; these were London Hospital-the counting and checking which prevail, mostly responded to by Dr. James who explained that of course, everywhere else-was not observed on this occasion. the proposed ambulance service would not put more Each sister says that upon taking charge of the operating work on the Fire Brigade as at present constituted. theatre she was enjoined to count the instruments, sponges, It was estimated that every year 15,000 casualties had and swabs before and after every operation and to hold to be removed to hospitals and the association suggested herself responsible for having done so. On the lamentable that a sufficient number of men, horses, and ambulances occasion in question the nursing sister, following instruc. should be added to the Fire Brigade to deal efficiently with tions, detected that a sponge was missing and it was found the the
the task. It would appear that out of the 90 fire stations only 30 would have to be furnished with ambulances. Dealing with the question as to whether calls for ambulances would not interfere with the alarms for fire Dr. James explained how such calls nowadays were carried out by means of telephones and in this way no inconvenience would arise as might possibly have been the case if the old plan of simply using a bell were still in use. Some confusion seemed to exist as to what should be expected from the police but Dr. James was able to clear up the difficulty entirely by pointing out that the police would help in the ambulance service in exactly the same way as they helped in cases of fire. The council has appointed a subcommittee to consider the question.
in the
but it does not seem to have occurred to an instrument might also be concealed in a similar manner. A reason for this oversight has been communicated to us by the senior surgeon of the hospital who writes :-
abdomen,
anyone concerned that
Changes in methods occur in a progressive art like surgery and following most important change must be remembered. Whereas years ago it was the custom to stop haemorrhage inside the abdomen by applying small artery forceps to numerous points and afterwards tying those points one by one, many surgeons have almost entirely discarded this plan. I do not think that I myself have put out of sight a single small pair of forceps in the last 300 abdominal operations performed by me. I remember well the prethe
mind it caused me on the last occasion when I did such So it happens that while within the last few months I have on various occasions reminded the sister about counting swabs placed in the abdomen, I have never had to ask her about counting the
occupation of a
thing.
at the West London
instruments. As no instruments were put out of sight, it was unnecessary to do so. Some, if not all, of my colleagues have, I know, acted much in the same way. Thus, the house surgeon, the sister, and all concerned have had constantly held up before their eyes the importance of counting the sponges, while actual recent experience has tended to minimise the ancient and necessary rule that instruments should be counted too.
Hospital recently has been made the subject, consequent on the publicity of the proceedings before the coroner, of some unjust reflections upon the institution in question. We need not enter into the details of the story as they have been brought to the attention of all the medical profession, but the gist is as follows. A patient was operated upon for a ruptured Fallopian tube in circumstances of great hurry, the need for the hurry being her absolutely desperate condition. The operation proved only partially
We think that the view taken by the senior surgeon is almost certainly right, and confirmation is given to it by the fact that the present theatre sister, for whose care and conscientiousness we are in a position to vouch, had only returned to the position after an absence from work in the operating theatre of over six years. If we further bear in mind that this unfortunate oversight took place in connexion with a case of acute hemorrhage of the most dangerous description, and if we appreciate that the opera-
-
THE INQUEST UPON MRS. PIERCY. A SAD occurrence which took
place
tions of surgery must sometimes be done under cona recurrence of symptoms led to the rethat a ditions of emergency and haste which resemble those found of the It was then discovered abdomen. opening small pair of forceps had been left in the abdomen in the operations of war, it will be recognised by every after the first operation. The patient died and the fair-minded person that even the most careful surgeon, aided coroner’s jury, having heard the evidence of the by the most scrupulous assistants, is liable to be visited by surgeon who performed the first operation, of his housea similar calamity. Just as it is impossible to make any surgeon who assisted him, and of the nursing sisterdelicate mechanical contrivance absolutely I I fool-proof,so in charge of the theatre, brought in the following verdict :it is impossible to invent any system of counting instruments "Death from misadventure due to peritonitis following an and sponges which will entirely do away with human operation, accelerated by the presence of the forceps,"fallibility. We have the deepest sympathy with the husband adding as a rider, we consider the system at the hospitalof the unfortunate woman, and are in no way attempting to is largely at fault and suggest that in future all instru-lessen the catastrophe when we say that it is quite likely ments should be numbered and counted before and after that the overlooked forceps had nothing to do with her each operation." The operating surgeon, a man ofdeath. many years’ experience, was able to bring unimpeachable DISTRIBUTION OF PLAGUE. testimony to his scrupulous care as an operator, while the LORD MILNER in a telegram received at the Colonial possibility of such a deplorable oversight occurring despite Office on 2nd states that since April 23rd 14 fresh was also The May rigorous precaution proved. jury quite cases of been notified in the Transvaal, 11 these but have considered plague appreciated they evidently points, that at the West London Hospital the procedure in being in coloured persons and 3 in white persons. Out regard to such operations was not attended with due care.of the suspected cases 3Z have been found to be not sufferThe evidence of the theatre sister was to the effect that theing from plague, making the total number of suspected
successful and
____