10 The Medical Expert

	That any sane nation, having observed that you could provide for the 	supply of bread by giving bakers a pecuniary interest baking for you, 	should go on to give a surgeon a pecuniary interest in cutting off your 	leg, is enough to make one despair of political humanity. But that is 	precisely what we have done. And the more appalling the mutilation, the 	more the mutilator is paid. We also make the surgeon the judge of whether 	the operation is necessary, making it certain that "we shall be 	dismembered unnecessarily in all directions by surgeons who believe the 	operation to be necessary solely because they want to perform them."
	Preface: The Doctor's Dilemma by Bernard Shaw

One of the things that I felt highly suspicious about was the "laparotomy" that was mentioned so often.
On 9/4/92  Dr Languid's assistant Dr Minion had written to Dr Amicable, "She will need a laparotomy."
In his report to my solicitor Professor Tinker had written that when I went to Helton hospital, "It was also thought that a laparotomy would probably be needed. At this stage I think "probably" was too definite a word to use, because there were two likely diagnoses - fibroids for which a variety of treatments might be proposed but which would not need treatment as a life saving measure, or a solid ovarian tumour which would have justified laparotomy because the danger of malignancy would have been moderately high."
But the ultrasound scan on 13/4/92 showed that the mass was fibroids and my ovaries were normal - a conclusion Mrs Languid accepted in her letter to Miss Godly on 30/7/92. Yet she still wrote, "We tried to persuade her that she needed a laparotomy."
If the fibroid diagnosis was accepted I certainly didn't need a laparotomy, according to Professor Tinker, so what did Mrs Languid mean? 
Laparotomy refers to cutting open the belly. The professor seems to have used the term to refer to the opening of the belly done when emergency surgery is necessary or when investigations have been inconclusive and the only way to diagnose a problem with any certainty is to actually cut the patient open and take a look. In these cases the operation is usually referred to as an "exploratory laparotomy". Today though it is more usual to take a look inside by putting a camera in through a small cut in the belly (laparoscopy), a much less traumatic or disfiguring way of viewing the internal organs. However laparotomy could also be used just to refer to cutting open the belly, such as "hysterectomy by laparotomy", meaning open abdominal surgery rather than vaginal hysterectomy (removing the womb through the vagina) or hysterectomy by laparoscopy (keyhole surgery). On this reading Mrs Languid's statement means "she will need some sort of abdominal surgery".
But this was the woman who had written of myomectomy, "I would not feel very happy carrying this out." And whose "capable and caring" registrar had written "Mrs Nomark refuses hysterectomy". At least the male chauvinist was honest about just what surgery was contemplated. So what was it that "we" had tried to persuade me to have? Was it "we tried to persuade her to have a convenient hysterectomy"?

Godly and Co took a different approach. They not only denied that the diagnosis of the Helton radiologist was certain but even said that ultrasound could not provide a definite diagnosis.
Professor Tinker wrote of Dr Curry, "He felt, very reasonably, that he wanted to reassure himself as far as possible that there was not an ovarian tumour in association with the fibroids that he could not palpate clinically and wrote for more detailed information about what had been found at Helton Hospital. This information was available when Miss Nomark eventually saw Miss Godly on 17/8/92.
She explained that while what could be felt clinically and seen on ultrasound was probably a mass that was entirely uterine, it was not possible to be 100% sure that there was not an ovarian tumour as well."
This I regard as a professional cover-up. Dr Curry had only externally felt the mass - he had not even attempted a pelvic examination. And he wrote on 17/7/92, "Discussed the need for laparotomy to diagnose true nature of the mass." Not the possibility of masses in both the womb and ovaries. On 20/7/92 he wrote to Dr Amicable, "I have explained ... that my concern is that if no operation is performed it is impossible to be certain as to the diagnosis of this abdominal pelvic mass. It is most likely a benign fibroid or multiple fibroids. However, a ovarian neoplasm cannot be completely excluded even despite the ultrasound report." And on 17/8/92 Miss Godly wrote to Dr Amicable, "We could not be certain without doing a laparotomy whether the mass was ovarian or uterine... that it was probably uterine but one couldn't be 100% certain just by going on ultrasound reports."
"Ovarian or uterine", not both. And "IT was probably" not there may also be ovarian masses (not that common) as well as with (very common) uterine masses. The mass was very compact and rounded in shape. It felt, even to me, just like what it was eventually shown to be, a solitary, solid lump.
Both Drs Curry and Godly stated that they would not believe an ultrasound scan even though the radiologist was quite certain about her diagnosis. And her ability to discriminate normal ovaries. She even lectured on radiodiagnosis. What was the point of her taking a diploma course with the Royal College of Obstetricians and Gynaecologists if their members were just going to totally ignore her conclusions? 
And why did Professor Tizzy believe that the mass was uterine and my ovaries were normal "just by going on ultrasound reports"? Was the second ultrasound scan, with its detailed description of my organs and the distinctly whorled, fibroid appearance of the mass, a complete fiction since Miss Godly had declared that you couldn't be sure of the origin of a mass without doing a "laparotomy"? Or was she just determined to get in there and take it all out without wasting any effort on unnecessary investigations?

I was not at all impressed with Professor Tinker. He wrote of GnRH-a therapy, "Various procedures to reduce the size of fibroids are available.... they only reduce the size of the fibroids by about 20% at best". However in the medical literature I found that the GnRH agonists he was referring to have been shown to reduce fibroids by amounts varying from 0-100%, with degenerating fibroids usually showing no reduction. Perl et al (1987) reporting on 10 women with 20 fibroids found 3 women showed complete regression of fibroids (1 of which had measured 571 ccs - the size of a grapefruit) and 5 showed a decrease of more than 40% in fibroid volume. Cirkel et al (1992) found that 92% of 114 women treated with leuprorelin showed fibroid shrinkage averaging 56% and a mean womb volume reduction of 67% was observed. West et al (1987) found a womb reduction of between 38-84% (average 55%). These were all a lot better than "20% at best". Were the medical journals lying?
It's possible. 
In "The Diseases of Civilisation" Brian Inglis points out that in 1977 out of 62 consecutive trials reports in the British Medical Journal 32 contained statistical errors, 18 of them fairly serious. Of the randomised double-blind, cross-over trial itself Inglis says, "The project may be flawed in design and inadequately controlled; the statistics may be suspect and the interpretations misguided but "the chances of promotion for any doctor are directly proportional to the volume of science fiction he has vomited", as Maurice Pappworth has sourly noted."
And their "Introduction to Research" Oyster, Hanten and Llorens write, "Most authors do not deliberately set out to fool the public, but unfortunately the literature is full of well-intentioned mistakes."
And the "literature" they are writing about is not English it's that of health science.

Like Craft-Tort the professor also played "blame the victim" and insulted my eating habits, ascribing my anaemia to lack of iron in my diet. He wrote, "There are several reasons for doubting whether Miss Nomark's fibroids have made the most important contribution to her anaemia. One is that her periods do not seem to have been heavy enough for her to have sought specific advice until early in 1992. If her haemoglobin had fallen rapidly she would have had symptoms that were clearly due to anaemia - tiredness, breathlessness, dizziness and oedema. These are not easy to assess in an asthmatic of course, but I would have expected them to have been noticeable if the problem had happened acutely. Perhaps the most important reason for thinking that her anaemia was chronic was the incredible speed with which her haemoglobin level was made good once she began to take iron tablets...
Further, I assume that her periods were unaltered during the months of iron therapy and it would have been impossible to achieve such a recovery if the menstrual loss was a major contributor to the anaemia. It would be like trying to fill a bath by turning the taps on but not putting in the plug."
I found his bath analogy both inappropriate and insulting. Heavy bleeding rarely appears suddenly. Some women suddenly experience sudden and extremely heavy blood losses but heavy bleeding associated with fibroids frequently takes years to develop. And anaemia develops slowly with it. The professor said that he himself was "observing" at least a dozen fibroid patients, some of whom needed to be on oral iron for several months a year. Did these women have slow draining "baths" or did they all have bad diets?
Dr Craft-Tort recorded my heavier bleeding on 25/3/1988 when he wrote, "Light-headed x 1 week ? since onset of menstruation, which are regular, but getting heavy.  O/E - CNS NAD> Tm's tick, await events. Weight 11 stone, advice."
When iron deficiency is adequately treated blood haemoglobin levels rise by an average of 0.17/100 g a day, as mine did. It was a small shortfall between my normal iron intake and my excessive monthly loss which caused the gradual loss. If my monthly losses had been so severe that even high iron therapy (600 mg of ferrous sulphate a day) made little impression I could not have been bleeding for years - I would have bled to death, or at least profound invalidity, within months.
As I have stated previously I gave blood on 10 occasions between 23/2/1978 and 2/5/1984. If I had been anaemic the Blood Transfusion Service would have noticed. If I had been iron deficient the stress of regular blood donations would have made me developed anaemia. The fact that I did not shows my iron intake was more than enough to maintain my iron levels, in spite of fairly regular losses to the Blood Transfusion Service. Shortly after I had stopped giving blood I started bleeding really heavily and my monthly blood loss exceeded that of my normal periods and the donations to the Blood Transfusion Service combined. My diet was in no way altered. The shortfall made me gradually anaemic as Professor Tinker himself noted when he wrote, "Miss Nomark's haemoglobin level was 8.8 g/dl which, given the possibility of a 10% error in the laboratory method of measurement suggested that there may have been little change in the 6 months since September 1991 when her haemoglobin had been first estimated." So I would not have noticed sudden symptoms of rapidly developing anaemia since the anaemia developed slowly. But it was due to iron loss associated with heavy periods, not lack of iron in my diet.
The tiredness and breathlessness which I developed happened so slowly that it was not until 2 weeks after starting iron therapy that I realised how much more energy I had, and how tired I had been. I had also noticed that salbutamol did not seem to be relieving my breathless spells as it used to (because they were due to low iron levels and not to constricted lung space) and I had been worrying that my asthma was deteriorating. 
And, as I have related, I DID seek "specific advice" concerning heavy bleeding in 1990. As Dr Craft-Tort chose not to record the consultation nobody, and certainly no member of the medical profession, would even consider that it had ever taken place.

I later estimated my menstrual blood loss at between 200 and 300 g, well within the heavy loss zone. Medics usually do not bother to even attempt to get an idea of how much blood is lost and very rarely do they scientifically assess menstrual flow. They accept a woman's assertion that her flow is heavy and then declare that it is not, without any investigation of the facts, if it is convenient for them to say so.
Dr Curry had actually tried to get an idea of how heavy my menstrual losses were and had written in the medical notes that tampons were lasting only half to one hour, and I was using pads at the same time, and flooding and passing clots. But it pleased Professor Tinker to think that I was not bleeding heavily, so I wasn't.

Of the iron deficiency symptom that had prompted me to ask for an iron test the professor declared, "I am not impressed with the symptom of "ice craving" as an indication of iron deficiency and I do not think that she really did so herself because she did have a form signed to have blood test on 3/3/91 but did not have it carried out until 13/9/91."
He may not be impressed by pica as a symptom of iron deficiency anaemia but Peter M Hartmann MD in his "Guide to Hematologic Disorders" states that, "An interesting associated feature seen in iron deficiency is pica, the ingestion of materials that lack any nutritive value, such as clay, ice, starch, dirt etc. Although pica is usually believed to be a habit induced by the deficiency state, some of the ingestates have the capability of complexing with iron and thereby rendering it non absorbable." He also noted that, "It is of interest to note that if specific attention is focused upon pica in iron-deficient subjects its incidence may be as high as 30-40%. Evidence supporting pica as both cause and effect of iron deficiency is available."
Ice however cannot complex with iron and the facts remain that I WAS anaemic and pica WAS a sign of my iron deficient state and it was present as early as 1989. Moreover my ice pica vanished with increased iron levels. However both the professor and Craft-Tort scorned pica as a symptom, in spite of the fact that the condition it indicated was clearly proved to be present and that its association with anaemia was so well known as to be found in the popular literature.

Professor Tinker said of my blood test "I think that it was quite wrong for the result of this test to have been filed without it being noted and an attempt made to contact her and discuss further investigations and treatment. There is no point in carrying out tests and ignoring the results."
However had he been aware that the test was only carried out because I had requested it the professor would no doubt have agreed with Craft-Tort and the Service Committee that it was the patients responsibility to follow these things through. But as Craft-Tort was only a GP, and the professor was being paid for his opinion, he allowed himself to be slightly critical of one of the lower members of the medical profession. Especially as he knew that hysterectomy was the usual treatment, in fact in spite of what he had written, the only treatment, doled out to fibroid females. And an earlier diagnosis would only have meant an earlier posting to the hysterectomy table. Thus he could quite honestly write, "With regard to the standard of care that Miss Nomark received, I think that it was less satisfactory than she might have received but I do not believe that it has affected her condition." because, "If the fibroids had been discovered 3-4 years earlier they would have been smaller but unless causing symptoms, the appropriate treatment would have been observation. There is nothing that can be done to stop them growing, except to stop the ovaries functioning and although myomectomy would have been easier, the length of time available for them to grow again before the menopause would have been greater. A myomectomy for symptomless fibroids is a foolish operation."
So what were the "variety" of treatments which he had earlier noted "might be proposed" for fibroids?
As Symonds says in Essential Obstetrics and Gynaecology, 1987, "There is no medical treatment of fibroids."
In the end the medical profession ignores them until they become troublesome and then rips out your womb, unless you go to a medic who is actually competent at, and willing to do, conservative surgery. 
I would agree with Professor Tinker that myomectomy for symptomless fibroids is a foolish operation. In the absence of symptoms the mutilation of hysterectomy which brings the risks of sexual dysfunction, psychological trauma and ovarian failure with associated heart disease and osteoporosis, is an even more foolish operation. Yet every gynaecological textbook printed states that women with symptomless fibroids greater than 12 weeks size should suffer this mutilation. And many thousands of women do so every week, in every well-heeled country in the world.

The professor concluded, "In summary, I think Miss Nomark has probably had anaemia, due largely to a dietary deficiency of iron over many years, aggravated by slightly heavier periods than normal. In the sense that a hysterectomy would have stopped the loss it would have allowed her to continue with her usual diet without iron tablets. It was never a necessity however, and I do not think that it was presented to her as such. No one can operated on a patient without their consent."
Jack Ketch wrote, "Despite discussing at length the complications of fibroids and the likely prognosis, Mrs Nomark still refuses hysterectomy ...However we would of course be happy to see her again should she change her mind about the operation."
But I was not to think from this that hysterectomy was a necessity! And it was not presented to me as such! 
Dr Minion, "She will need a laparotomy."
Mrs Languid, "We tried to persuade her that she needed a laparotomy."
Dr Curry, "Discussed the need for laparotomy.." and "if no operation is performed..".
And Miss Godly, "We could not be certain without doing a laparotomy..".
They all wanted me cut open. They don't say that the "laparotomy" they're pushing is hysterectomy, but that is exactly what they have in mind. As is  quite obvious from the fact that Mrs Languid was "not happy" at the idea of even attempting a myomectomy and the entry in my medical notes stating quite baldly that "myomectomy not suitable in view of age". And Miss Godly's professional opinion that it would not be "ethical" for her to even think of performing a myomectomy.
Yet the professor says of hysterectomy "It was never a necessity however, and I do not think that it was presented to her as such."
Oh really!
And for this piece of fiction the professor was no doubt well paid.
He should write for Mills and Boon.
I later found that research into 673 medical negligence cases found that experts' fees averaged 15% of the total bill while in commercial cases the average was only 4%.
I wonder how the professor would have treated a patient with a melon sized lump if hysterectomy is never a necessity and myomectomy is not suitable in view of age and nothing can be done to stop fibroids growing.

Finally the case of Caroline Richmond, who went to hospital to have her womb lining removed and woke up with a gutted reproductive system, shows that some women ARE given hysterectomy without their consent.
And many more suffer the operation without giving INFORMED consent to what is about to happen to them.