CORONER'S INQUEST: SERIOUS CHARGE AGAINST A SURGEON

Thames Advertiser, Volume XII, Issue 3352, 27 June 1879, Page 3

CORONER'S INQUEST: SERIOUS CHARGE AGAINST A SURGEON

A coboneb's inquiry into the cause of the death of Mrs Elizabeth Annie Craig, of the Hape Creek, took place at Grannaty's Hotel, Hape Creek, yesterday, at 2 p.m., before G, N, Brassey, Esq, Coroner, and tho following jury .'—Messrs William Deeble (foreman), W, Hearn, John Newson, 11. Thomas, Wm. Newman, W. Graham, R. Bateman, Alfred Edlington, W. P. Danby, Wm. Plant, James Wilson, John Nodder, James Cocks.

The body having been viowed, the following evidence was taken :—

Robert £irkwood Andrews deposed that he was a duly qualified medical practitioner. On Monday last, about 12 o'clock, ho was callod to see Mrs Craig at hor residence. He found her lying in bed deluged with blood, the sheets, blankets, &a,, being saturated. Ho romaincd in the house for about two hours, aud gavo hor some medicino, which stoppod the flow of blood. Ho returned about four o'clock in tho afternoon ; she was thon doing as well could ho oxpected. Ho left about five o'clock, but returned at seven, and remained all night in hopes of tho confinement coming olf. He made an internal examination, and found that she was not then going to bo oonfined. He requsted tho attendant to make hor comfortablo by romoving the linen, &c. He held Mrs Craig in his lap

whilo this request was being attended to, He then put her down on the bed, when all at once she collapsed and died in two minutes. He had not examined the body sinco the post-mortem examination. Death would not have been caused had a medical man been called in in time. As a rule "flooding"indicated premature confinement. She became so week that it was impossible to use surgical instruments. When he returned the third time he sent

for Dr Kilgour, but somehow he got a wrong message, and did not come. Ho took instruments with him, but could not uso them, as the mouth of the womb was so small that ho could not get the forceps in. There was not much danger after the blood was staunched. Deceased was not bleeding when he sat her on his knee. It was judicious to take her bed. No blood ensued after she was placed by kim on tho bed. He had a practice of 24 years in midwifery. He had had four similar cases since ho had been hero, all of which had turned out right. He

would swear that it was utterly, impossible to remove the child by any surgical operation. When he first went to see the woman the child lay favourable for confinement. All hor organs were sound, as far as lie could see, When " flooding" commenced, if it was premature, the bosfc thing to do was to get the child away as quickly as possible. He would swear that it would bo impossible to bring the child into the world alive. Ho had not takon anything in the shape of alcoholic liquors before he went to see the woman.

By tho Foreman-When he first saw

the woman he considered her case dangerous, but not after ho had stopped the blood. He had used internal medicinos, and did not think as they had succeeded that external appliances were necessary. Ho was in hopci that tho woman Would be confined whon ho went there tho third

time; but when ho knew that it was not coming off ho gave orders to have tho bed cleaned. He advised thosa in attendance to call in another medical man. Ho thought Dr Kilgour would be the best. Had he not had the bed pleanod, secondary fever would have set in, killing the woman in no time. The nerse Baid she thought the woman was 6 or 7 months gone, but the husband told him sho had arrived at her full time. He asked Mrs Craig when sho expected her confinement, but she could not speak. So far as he saw the conduct of the nurse was good.

Mrs Eliza Jackson, deposed that she lived on Block 27. She knew the deceased Mrs Craig. She last saw her an hour ago. She attended her as nurse up to the time of her doatb. She was first called in at 10 o'clock on Monday morning by deceased's eldest son. When she went in she found her shivering in bed. Witness placed all the clothes she could find on hor, applied jars of hot water to her feet, and gave her hot brandy and water. She then seemed to got better. Witness asked her whether a doctor had better bo called in, and she said no. Witness went put and told Mr Bateman, the butcher, to go for a doctor, which he did, and the doctor arrived about 1250 a.m. About ten minutes before Dr Andrews arrived, btemorrhage set in. When he came he told her to give the woman brandy. He then left, aud returned in an hour with some medicine, which he gave her about a quarter of a teaspoonful in half a tumbler of water. About half an hour afterwards ho gave her another dose, and the rajmorrhage ceased. The doctor remained until fifteen minutes past fivo o'clock, and returned at five minutes to six o'clock and found her much better, and then said we had better change her for the night. Witness called in another person to warm the clothes, so that I would not leave the room. When the things were ready I called Mrs Molloy in to give them to me. The dootor gently drew her on to' bin knee whilst they made the bed. The bed was nearly made when she saw a sudden ohnnge, and the dootor said send for Dr Kilgour. She rushed out to Batoman's and told the servant to go for Dr Eilgour, and on returning found her dead. By tho Coroner-I had nothing strongor than tea during the time I was nursing Mrs Craig. A bottle of brandy was the only liquor brought into the house. Nobody else bad any brandy out [ of that bottlo besides Mrs Craig I will swoar. I have been a midwife since 1856 I did not suggest, and did not consider it neoessary, that the child should be taken from the mother. Mrs Craig was to have been confined on the 15th or 20th of July next. She engaged me _ for those dates. I have seen similar cases in India, where the same course was adopted as in this. It was not dangerous in her judgment to stop flooding in Mrs Craig's cane. Her opinion was that death was caused by syncope of tho heart, The treatment ot the doctor, so far as she could see, was skilful. She considered there was no danger in lifting the patient from the bed at the time. She seomed quito jollyshe was laughing and talking frooly. Sho told me she got up at daybreak, and as she put her foot out of bed she felt the shivers and fell down, and knew not how long sho lay there. Dr Andrews ordered Dr Kilgour to be sent for. Only half a glass of brandy was administered, Sho was perfeotly sober all the time, as wero all who were in, attendance. She saw no sign of spirits on the doctor. All he had while there was a cup of cold tea.

By Mr Deeble: She did not leave tho room through apprehension of imminent danger. She did not think it possible to take away the child, as the os uteri was not dilated, and instruments could not be used. It was not possible for the doctor to do more than he did.

Mrs John Molloy, who lived next door to the deceased, deposed that she was called to see Mrs Craig about 7 or 8 o'clock. She found her shivering, and said to her, "For God's sake, Mrs Craig, what is the matter ?" She was very white in the face, and she asked her if she thought she ought to send for the nurse. I sent, and also went for Mrs Jackson. Mrs Jackson came at once. Mrs Craig was then in great agony. Witucss uudressed her and put her to bed. She afterwards assisted in putting hot-water jars to her feet. She knew nothing whatever of Mrs Jackson, but from what sho saw thought she was a proper nurse. She was in aud out during the day. Sho told the nurse Mrs Craig was dying. Her reply was, "Don't frighten the woman." Mrs Craig's face was contracted, and she was iu great agony. She did not so deceased till she assisted to chango her clothing. When tho Dr lifted her, she said, "Oh, doctor, she's dying/' He replied " Sho is getting weak, but is not dying." The doctor then put her in the .bed, when she gave three moans and died.

By the Coroner: When sho was being changed Mrs Craig was not able to laugh. Bho said "Oh you are cruel, you will kill me if you change me." In her judgment it would hare been much

host to let her lie still. She did think it cruel of the doctor. She was not there all day, but only a few minutes at a time. Tho doctor said there was no fear.

Dr Andrews: I must contradict that statement.

By a Juror—l thought it cruel to raise her out of bed when she said she would be killed by so doing. She thought, of course, that a clean, warm bed was best, but she might have been, shifted to it in other ways. Mrs Craig had labour pains when she first saw her, and again at two p.m.

M. H. Payne, surgeon, deposed that he made a post mortem examination in company with Dr Kilgour, and found all the internal organs perfectly healthy. Bis own opinion was that instruments ought to have been used, and the child delivered. In his belief, if that had been done both mother and child would have been alive. Ho thought the fatal termination was hastened by allowing deceased to assume an erect posture. The child he should take to be a full-term child.

By the Coroner-From what he saw ho thought the child could have been taken away. The decoased had lost so much blood that without instrumental help she had not sufficient strength. He would slop the bleeding by medicine, or twisting the parts. He thought it unwise in the extreme lo move deceased from the bed under tho circumstances. Ho attributed her death to that. He should not have left her from time to time.

Dr Andrews: During what time would you use instruments?

Dr Payne: In a bad case of flooding, just as soon as I could; indeed, whenever there was danger. In any case where tho mother's or child's life was endangered by not using them. By the Coroner—There is no danger if the instruments are carefullv used; and even if there were, that should not stand against the mother's life.

Dr Xilgour deposed that at the request of the police ho proceeded to the house of Mrs Craig, in company with Dr Payne, for the purpose of making a post mortem examination of the body of Mrs Craig. We found the body to be that of a healthy, well nourished woman; and we also found the internal organs which we examined, viz., the heart, the lungs, and the liver, along with the intestines, to be perfectly healthy. The heart was almost devoid of blood,, as were also tho lungs and the liver. Wo found a considerable amount of blood and the body of a full term male child. The parts connected showed that they were all healthy. The cause of death in his opinion was the loss of blood sustained by the woman during labour.

By the Coroner-In referenoe to this particular case, as he had not seen the woman, it seemed to him thatDr Andrews did right at the outset; and ijE his evidence was to be relied on — that is, if he were a good observer—and the patient recovered colour and vigour, he did not know that better could have been done. He was correct in administering ergot at the outset, and if bleeding had entirely ceased, and warmth and colour returned, he was justified in hoping for a successful issue.

By the Coroner: He had seen the body only after the result, whea it was proved that deceased had lost a considerable quantity of blood. Judging from appearances, he should have induced labour, but appearances were deceptive.at times even to practised eyes. He thought it would have been better practice to have delivered .the child or attempted it. Having heard the evidence he judged it would have been wiser to have allowed Mrs Crrig to retain the horizontal position, at the same time it was very easy to speak after the event. As to what ho would have done it entirely depended on the view he took. If he thought it necessary to attempt an immediate delivery he should not have left the patient till she was safe. Prom what he saw at the post mortem, there was no anatomical reason to prevent delivery.

By a juror: He could not answer the question as to whether there had been any neglect.

By Dr Andrews: He would certainly not use instruments when all flow of blood had ceased and natural warmth and colour returned, and when there seemed every prospect of natural labour coming

By Mr Ueeble: He would not think it wise to leave a case where labour had extended over many hours and a great deal of blood had been lost.

The Coroner then addressed the jurors, saying that inquisitions of this kind were held in the public interest and for the satisfaction of public justice. They would all admit that in this case there was tho necessity for a post-mortem examination. It would be for them to pronounce an opinion on tho evidence laid before them. The police had taken this matter up, and he fully endorsed the action they had taken. The evidence of tho two modical men pointed to the conclusion that sufficient means had not been adopted. In order to elicit the amovmt of information to guide them it had been the rule in Coroner's Courts to allow considerable latitude in the questions asked. He had done so, If ho had erred it had been on the right side. The evidence in the case was now before them, and it would.bo for them to duly weigh it. It would be for them to say whether the treatment byDr Andrews was skilful or not. If, on the one hand, you consider skilful treatment was used, you will then return a verdict of death from natural causes. On the other hand, should you find that blame attaches to the doctor, he will be placed in a serious position, as the whole onus would lie at his door. Having explained., the 4th section of the liules guiding Coroner's Courts, he said it provided that Dr Andrews might properly have been present had he wished, but could not have taken any active part in it.

The evidence concluded at 7.30, and the jury retired to consider their verdict. After upwards of an hour's deliberation the Coroner was sent for, and informed by the Foreman that the jury could not agree. They wished direction as to the medical evidence. The evidence was read over again, and tho Coroner further directed thorn as to its bearings, and intimated that in the evont of thoir not being able to agree ho would be obliged to lock them up. Tho Jury then desired further time of half an hour, and at the end of that time returned the following verdict:—That the deceased died through hemorrhage, brought on by labour pains, aud from evidence adduced they believe that if ordinary means had been used life would have been preserved.

Free Kirk Minister (to his' Elder').—' John I should "ke you to intimate that, on Monday next, I propose paying pastoral visits in the High and North streets, in which I also hope to embrace all the servant girls of the congregation in that district!' His wife (whom he had lately married from the South).—'You shall do nothing of the kind, sir I Let me ste you dare to—-1" (Goes, into hysterics)..