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THE DISCUSSION AT THE MEDICAL SOCIETYON THE OPERATIVE TREATMENT OFCHRONIC DISEASE OF THE UTERINEAPPENDAGES.

To the Editors of THE LANCET.

SIRS,—Having unavoidably been prevented from attend-ing the above adjourned discussion on Monday evening last,I would like, with your permission, to briefly remark on one-or two points in connexion with Dr. W. Duncan’s paper on,the subject in question.

In the first place, with regard to Dr. Duncan’s tabulatedseries of cases, I think it a matter for regret that no indica-tion whatever was therein afforded as to the dates on whichthe operations thus recorded were performed. Dr. Duncan,’in reply to an inquiry by the President as to whether the,cases-numbered consecutively from one to thirty-com-prised all those of the kind which had been thus treated byhim, stated at the meeting on Jan. 12thl that "his earlierresults in all cases of abdominal section had been so awfulthat he would not like to publish them." In other respects’the cases were said to be consecutive up to the date ofwriting his paper. While giving Dr. Duncan full crediu forthe frankness of his avowal on this point, I venture to thinkthat his omission was an unfortunate one, since statisticsthus compiled cannot be of much scientific value as to thecomparative risks and advantages of the operation to whichthey refer. If we turn back to the history of ovariotomyin this country thirty years ago we learn that what chieflytended to establish the operation upon a firm basis as a well-recognised surgical procedure in the eyes of the professiona.t large was the fact that each case in the practice of Mr.Spencer Wells, whether successful or unsuccessful, was’<duly and faithfully recorded by him from the commence-ment of his work in this field; and, so far as I know,the good rule then initiated has up till now been followedby his successors when bringing forward statisticalresults of their work in any special branch of abdo-minal surgery. It seems to me that any departurefrom such a rule must inevitably destroy the value ofstatistics in any given instance, and it is therefore to behoped that the plan here adopted by Dr. Duncan may notbe followed by other operators. The remaining subject towhich I would allude in connexion with this paper is thecomparatively large number of operations which appear tohave been found necessary in Dr. Duncan’s practice for therelief of suffering presumably connected with the state ofthe uterine appendages The absence already noted of anyindication as to the period covered by the work recordedmakes it impossible to judge as to the relative proportionwhich these operations might bear to the total number ofDr. Duncan’s abdominal sections during the same period,or from the date when he first began to operate. On neitherof these latter points, however, does his paper afford us anyinformation.

In order to estimate the comparative frequency of theseoperations in other hands than those of the author of,this paper I have examined the register of the SamaritanFree Hospital, with a view to ascertaining some definiteinformation on this subject. I find that in 1890, out of a’total of 141 abdominal sections, the number of operationsfor removal of diseased uterine appendages (one or both)was exactly fourteen-a proportionate rate of as nearly as,possible 10 per cent. on the total. These figures, consideredin relation to the twenty-three hospital operations recordedby Dr. Duncan&mdash;which comprise seventeen cases of completeand three of incomplete removal of the uterine appendages,to the exclusion of two cases of ovarian cyst (Nos. 5 and 17)-and one exploratory operation (No. 21)-would apparentlyindicate one or other of two things : either that the surgicalstaff of the Samaritan Hospital do not frequently enoughresort to operative treatment for the cure of the diseasesin question, or else that the number of urgent casesof such nature, unrelievable by rest and medical treat-ment, who apply at the Middlesex and Waterloo-roadHospitals, is greatly in excess of those to be met with at the-Samaritan Free Hospital. In my own belief neither ofthese interpretations can be considered correct. The trueexplanation lies in the spirit of restless surgery now soprevalent that, unless restrained, it will, I fear, bring into

1 See Brit. Med. Journ., Jan. 17th, 1891, p. 118.

disrepute an operation which, when judiciously undertakenin properly selected instances, may prove a most valuablemeans of restoration to health.

I am, Sirs, yours faithfully,Queen Anne-street, W., Jan. 28th, 1891. W. A. MEREDITH.W. A. MEREDITH.

ILEOSTOMY AND INTUSSUSCEPTION.To the Editors of THE LANCET.

SIRS,-In your issue of last week, page 221, my friendMr. Reeves gives a short description of a case in which hehad performed ileostomy in a man suffering from cancer ofthe csecum, on similar lines to those described by Mr. Bryantin a former number of THE LANCET. By adopting thismethod of treatment a faecal fistula is formed, which ismost distressing to the patient, and, being situated in thesmall intestine, somewhat difficult to manage. To obviatethis I would strongly advocate the operation of ileo-colostomy, either by approximation of the ileum to someportion of the colon below the disease by means of decalcifiedbone plates as suggested and practised by Dr. Senn, or bydividing the ileum some three inches above the ileo-cseealvalve, closing the distal end and implanting the proximalend into the colon below the disease. This latter operationI performed upon a patient some eighteen months ago,details of which will shortly be reported in your columns.By adopting this operation a fseeal fistula is avoided andthe patient placed in as comfortable a position as possiblefor the remainder of his life. In the discussion at theClinical Society on Jan. 9th, which followed Mr. Lockwood’spaper on a case of Acute Intussusception, I was pleased tosee Mr. Barker alluded to a method of treating those cases,when the intussusception could not be reduced, by makinga longitudinal incision through the intussuscepiens andthen cutting away the inner intussuscepted part, theoriginal incision being closed by sutures. This is a plan oftreatment which I have advocated for some time, but, likeMr. Barker, have not had an opportunity of putting it intopractice. In carrying out the operation, however, I wouldsuggest that a few Lembert sutures should be inserted, tounite the intestine at its junction with the intussuscepiens,for fear of the accident of its slipping after the removal ofthe intussuscepted part ; this part, if small, might be with-drawn through the incision made in the intussuscepiens, or,if extensive and extending low down in the colon, might bymanipulation be passed downwards and withdrawn’throughthe rectum.-I am, Sirs, yours faithfully,

FRED. BOWREMAN JESSETT, F.R.C.S.Upper Wimpole-street, W.

FRED. BOWREMAN JESSETT, F. R. C. S.

"THE THROAT AND NOSE AND THEIRDISEASES."

To the Editors of THE LANCET.

SIRS,&mdash;In thanking you for the lengthened and, on thewhole, very favourable notice of my work, I am sorry to beobliged to point out that there are certain numerousinstances of misrepresentation of matters of fact. These aredue probably to the circumstance that your reviewer hasimperfectly read the book, since an entirely different con-struction would have been placed on some of my quotedremarks had he even read the word before or the line follow-ing some of those that are criticised. To cite only twoinstances of a minor character-when he asks why I do nottreat tuberculosis of the nose at length, he does not reco-gnise that I immediately proceed to say that "it is butrarely if ever primary" (p. 580), and he also ignores thecircumstance that I have exhaustively treated the subjectof tubercle as affecting the throat, independently of theconsiderable attention given to lupus both in the throat andnose. Again, in speaking of my modified views with regardto the etiology of diphtheria, he quotes the word " probable"with a parenthetic sic, whereas the words I use are "moreprobable (p. 335).To come, however, to something more serious. Your

reviewer says, "The only instruments for treating bonyor cartilaginous septal excrescences advocated are Curtis’snasal trephines ...... while no mention is made of themotive power;" and that "Bosworth’s saws are not men-tioned." As a matter of fact, after referring to Adams’soperation of refracturing the septum, I commence my re-

marks on treatment by recommending "removal of the

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obstructing part of the septum by means of a nasal saw, orby circular trephine driven by a surgical engine or electro-motor." It is true the nasal saw is not mentioned as thatof Bosworth, and this is intentional, for the right of thatsurgeon to priority of invention is really in dispute;but marked attention is drawn by me to the practiceand opinions of Bosworth on this particular methodof treating nasal spurs, and he is quoted repeatedlyas the authority most worthy of respect on this and allnasal questions, his name occurring no less than fourteentimes in the chapter devoted to n&egrave;J,sal diseases. There arefurther mentioned, described, and illustrated DundasGrant’s nasal splint for straightening deflections of theseptum, especially in young children ; Hewetson’s dilatorfor forcible stretching of a stenosed nostril ; and Hill’s modi-fication of the same instrument (p. 590) ; all of these beingfor the purpose of treating that special condition for whichyour reviewer says I only advocate Curtis’s trephine. As afurther evidence of the carelessness of this criticism, Imust remark that in twenty detailed cases of septaldeformity, each of which is illustrated, thirteen were sub-mitted to operative treatment ; in most of these thenature of the operation is indicated by dotted lineson the portrait figures, and in not one was the trephinealone used; while the trephine and saw combined were em-ployed in eight cases, and the saw alone in three. As amatter of fact, in the ten pages devoted to treatment andrelation of cases use of the trephine is alluded to thirteentimes, whilst that of the saw is mentioned eighteen times.

Finally, your reviewer is of opinion that " the difficultiesin the after treatment of such operations are ignored." In

reply I must say that not only am I careful to give everynecessary detail, but that I conclude my remarks underthis heading as follows: " It is of the utmost importanceto forewarn a patient that he must be prepared to give up

so much time (fourteen days) for rest at home. While it isdifficult to over-estimate the amount of improvement to begained by removal of septal obstruction in suitable cases,nothing is more likely to bring the operation into disreputethan an under-estimation of the mischief which might occurfrom want of care during convalescence " (p. 598).In making this remonstrance I would, with all respect,

point out that your reviewer endeavours to prejudice me inthe opinion of general practitioners by complaining that Ido not give sufficient details of treatment, as instances ofwhich he selects curetting the sphenoid and ethmoid cellsfor rhinitis caseosa, this rare disease and its treatment bothcoming absolutely within the province of a specialist.Lastly, his only allusion to my illustrations, which havegenerally been considered a feature of the book, is a com-plaint that I do not illustrate a trephine or a saw.

. I am, Sirs, yours faithfully,Weymouth-street, W., Jan. 27th, 1891. LENNOX BROWNE.

On referring to the passages in his book to whichMr. Browne draws our attention, we cannot see, in the firstplace, thau his omission to discuss tuberculosis of the noseis justified by his having written on the same disease asobserved in the throat. Nor do we perceive that his re-tractation of his theory that diphtheria was propagated byptomaines is affected by the criticism. He would apparentlyhave us indicate precisely that he does not quite considerit probable "that germs are the true element of con-

tagion" ; but that he holds this "more probable" (sic)than that the ptomaine spreads the disease, as he formerlymaintained. But, so far as the treatment of septal ex-

crescences is concerned, we willingly admit a slightinaccuracy in the critique. For we find that, as Mr.Browne indicates, mention of the saw is made, thoughwe fail to discover either description of the instrument ordirections for its use. No reference was made in the reviewto simple deviations of the septum, and hence the author’sapparent complaint that several instruments for this

purpose were overlooked is uncalled for. We also con-

cede that Mr. Browne has not altogether omittedthe mention of after-treatment in such operations. Wecan only account for our reviewer’s inaccuracy by thefact that the subject is separated from the discussion ofthe treatment by four pages of cases. We disclaim onthe part of our reviewer any desire to prejudice the author

in the opinion of general practitioners ; yet we cannot butthink that when the curetting of such regions as the.ethmoidal and sphenoidal cells is recommended some refer-ence should be made to the hazardous nature of the pro-cedure, although such a line of treatment be declared to fall.’"absolutely within the province of a specialist."-ED. L.

THE MIDWIVES’ REGISTRATION BILL.To the Editors of THE LANCET.

SIRS,&mdash;I will refer Dr. Aveling to my letter in a con.temporary of last week, and further explain that thefigures and facts which I alluded to as erroneous were thosewhich he brought forward at the British GynaecologicalSociety, and were those he was unable to substantiate in,his reply at the close of the debate. If he had been able to>do so he would not have voted for the resolution, "That-this association, while recognising the necessity for suchlegislation as shall prevent incompetent women acting asmidwives, does not approve of the proposed MidwivesBill." Since my letter was written he has published otherfigures. It appears that the present Bill is intended to servetwo purposes&mdash;(1) To advantage the training schools of mid-wives and to make midwives competitors for practice with the:registered medical practitioner. (2) To curtail the practice ofuntrained midwives. As it stands it would accomplish theformer, but not the latter, which it is the object of everyone ta2effect. It seems a pity that the medical promoters of the Billshould have allied themselves with the Midwives’ Institute,for it is evidently their influence which has ruined the Bill.Now I cannot believe that the eminent authorities men-tioned by Mr. Nichol have been so disloyal to their pro-fession as to countenance anything which would favoux theformer, though they may have approved of some scheme to,effect the latter object. I should like to ask Mr. Nichol at.what t;me and in what manner has the profession advisedhis Institute to take up the matter? I am very muchobliged to Mr. Nichol for his piece of ancient history, tolerably well known as it is, but I would point out to him that.he should have said the Council of the Obstetrical Society.The matter has never been discussed at a meeting of theSociety. We are now practically asked to sanction a com-plete revolution in the practice of midwifery because thedeath-rate-the general death-rate-is slightly in excess ofthat in the out-door departments of some lying-in charities-in London. It seems to be quite as reasonable to demanda complete revolution in the management of such institu-tions as the General Lying-in Hospital because the death-rate there was twice as high as that of Queen Charlotte’E)Hospital in 1889. It is a matter of great regret that thissubject had not the advantage of free and open discussion.before the introduction of a Bill on the subject into Par-liament. The result has been that many members of ourprofession have been misled as to the scope of the presentBill, and that many outsiders have been led to believe thatthe death-rate in childbed is excessive, though it willcompare favourably with that in any other county.

I remain, Sirs, yours faithfully,Hatfield, Jan. 20th, 1891. LOVELL DRAGE.LOVELL DRAGE.

INSURANCES ON THE LIVES OF PHYSICIANS.To the Editors of THE LANCET.

SlRS,&mdash;In reply to your editorial comments on my letterin last week’s issue, I have to explain that in ascertainingthe expected deaths I did not take the average of the death-rates in the table you refer to, but employed the ratio of thesums of the numbers dying to the numbers living in eachgroup of ages, which allows for the age distribution. This.assumes that the physicians are a stationary class; but theerror involved in this assumption must be extremely small,as the numbers living at all ages at the census of 1861was 14,415, while in 1871 it was 14,684. I would remindyou too that before publishing the results I obtainedI tested them by taking out the figures for otherclasses, such as the clergy and the publicans; and I foundthat the method I adopted yielded results which agreedsubstantially with what had been brought out by other in-vestigators with better materials and more exact methods.There is no reason to believe that the age distribution in

the case of physicians differs materially from that in other