3 Mrs Languid

	The late Lord Dawson used to say that a woman always harbours resentment 	against a doctor who takes away her womb.
	Hypochromic Anaemia by L J Witts

My appointment with "The Consultant Gynaecologist" was on 9 April 1992 four days after I started taking iron tablets. I was very nervous and my sister, a nurse, said she would take me in her car. When she had not arrived at the house half an hour before my appointment was due I took the bus. She met me at the hospital. She had been busy at her daughter's school - too busy even to phone and tell me she would be cutting it fine. This did nothing for my nerves.
The consultant, Mrs Languid, was a newly appointed, young woman. She had an older female assistant. The assistant took my medical history and they both examined me.
I was told that I had a large mass which could be fibroids or an ovarian cyst. Mrs Languid could do a hysterectomy or remove the ovary, or, if it was malignant, everything. I burst into tears. Mrs Languid made sympathetic noises. Maybe I would just have to lose an ovary.
Like Dr Craft-Tort, Mrs Languid's assistant never asked about the amount of sanitary protection I used or tried to assess how heavy my menstrual losses were. Mrs Languid recorded "very unhappy re hysterectomy" in the clinic notes.
The assistant wrote to my new GP mentioning that I was clinically anaemic (though not anaemic enough for Craft-Tort to be bothered to actively inform me of the fact).
She continued:-

In the abdomen there is a large hard mass arising from the pelvis. On vaginal examination the cervix appears healthy, there is a watery discharge and the uterus was felt posteriorly and possibly separately from the mass. We have arranged an urgent ultrasound scan, FBC (full blood count) and an HVS (higher vaginal swab) was taken. She will need a laparotomy, but professed herself to be very unhappy about having a hysterectomy. We will see her again in the clinic in a week's time,

Yours sincerely
A H Minion
CLINICAL ASSISTANT IN GYNAECOLOGY

The blood test showed a haemoglobin level of 8.8.
The following Monday I came on time for my ultrasound scan having drunk nearly a litre of orange squash to ensure that I had a full bladder as requested. After waiting half an hour I told the receptionist that I HAD to pee. She said not to completely empty the bladder and I drank more water. A quarter of an hour later I was scanned by a very non-committal radiographer.
Later that week I went to the university library and read up on myomectomy - the removal of fibroids. Victor Bonney, the pioneer of myomectomy surgery, had removed forty fibroids, weighing twenty one pounds from a single patient. His oldest patient was forty seven. He retired in 1937. I returned home somewhat reassured by my research.

On Thursday I arrived early for my extra early appointment which had been marked "permission for time". Mrs Languid arrived some ten minutes after the appointment time and another woman was called in to see her. Some twenty minutes later I was called by a nurse into a room and confronted by an asian man I had never seen before. I found later that he was Mrs Languid's registrar. If he gave his name I didn't remember it and I subsequently named him "Jack Ketch".
The nurse took up residence in a corner. Jack looked at my file and said "You're going for an ultrasound scan". I told him I'd been. He sent the nurse off to find the scan report and sat in utter silence until she returned. I had a fibroid uterus, he declared, and should have a total abdominal hysterectomy, that is have my entire womb removed.
I had read the Woman's Health leaflet on fibroids which advises you to find out as much as you can about your fibroids - how many fibroids there are, how big and where they are. Jack lied his head off. The womb was full of fibroids. They were all jammed together. It was just a large fibrous mass. Individual fibroids couldn't be made out.
I found later that the radiologist had been asked for a diagnosis only and in ten years of ultrasound experience had NEVER been asked for detailed information, such as fibroid number. There was no point in counting fibroids when you were determined only to amputate the whole womb. "Why would you want a fibroid womb?", sneered male, chauvinist pig Jack. I tried to explain. I wanted to asked him if he'd want his fibrous balls lopping off but unfortunately was far too inhibited.
I asked about myomectomy. "It was no good", lied Jack, "the fibroids only come back". Jack went on about fibroid complications. They could cause the womb to prolapse - extremely uncommon. They could undergo degeneration and become infected - though of infection and abcess formation Symonds writes in Essential Obstetrics and Gynaecology, "these are rare complications which are particularly likely to affect sub mucous fibroids following septic abortions", hardly likely to apply to me. They could turn cancerous - with a probability rate of less than one in a thousand, according to Buttram and Reiter, a very unlikely event.
Jack mentioned none of the hazards associated with hysterectomy.
In his book Operation: a Handbook for surgical patients Dr Robin A J Youngson says, "Any procedure, such as an operation...should only be performed with the patient's explicit  consent. The doctor has a duty to inform the patient of the effects and possible hazards of an operation. These may have greatly differing implications for the patients depending on their life-style and personal values. Whether or not an operation is in the interests of a patient is therefore a decision that can only be made by the patient and not by the doctor. This is the very important principle of informed consent".

Jack wrote to my GP:-

Dear Dr Amicable

I reviewed your patient in the clinic today. Her vaginal swabs did not demonstrate any infection, her haemoglobin count was 8.8 g/dl which means that her anaemia is getting worse, but she only started the Iron treatment last week. Her ultrasound scan demonstrated a very large uterus extending up to the level of the umbilicus. There were no ovarian masses seen on the scan.
Despite discussing at length the complications of fibroids and the likely prognosis, Mrs Nomark still refuses hysterectomy, and therefore she has been discharged back to your care. However we would be grateful if you would follow-up with regard to an increase in size of the uterus or any change in symptoms. We would of course by happy to see her again should she change her mind about the operation.

Yours sincerely
Jack Ketch
REGISTRAR IN GYNAECOLOGY & OBSTETRICS

I sobbed most of the way home even more devastated than after first being told, by Dr Craft-Tort, that I should have a hysterectomy.
Much later, on 5 November, I wrote to Jack.

Dear Jack Ketch

Since you did not introduce yourself when we met at Helton Hospital on the afternoon of 19 April I gave you a suitable moniker. No doubt you will have forgotten me, just another uterus come for slaughter. I, however, will always remember your sneering "Why would you want a fibroid womb?"
What I should like to have said was "Why would you want fibroid balls?" Would you want your reproductive system amputated if it had non malignant growths? No! So why do you think that I would? I have no less a regard for my body and ALL its organs than you have for yours.
As I now know this female mutilation is very common (no doubt you've done a bit yourself). But so is rape and child abuse and I find none of these laudable.
I have also read about the effects of the little operation - pain, scarring, adhesion formation, the residual ovary syndrome, depression, sexual dysfunction, increased risks of osteoporosis, cardiovascular disease and osteoarthritis and probably vaginal prolapse and vaginal cancer. And of course premature ovarian failure.
And with ovarian failure comes hot flushes, insomnia, depression, loss of sexual desire, neurological complaints, increased allergies, rapid aging of the skin, obesity, thyroid dysfunction, memory loss and severe PMT (Hufnagel, not a fan of hysterectomy).
It's got a lot to answer for. And you expect me to be delighted at the prospect of sampling all these goodies! Well I'll tell you, Jack, if I had to be carved I'd rather Dr Hannibal Lecter did the job. At least I'm sure he would appreciate me as a toothsome morsel and not regard me as just another piece of meat for butchering.
Ever considered a career in pathology? Just the right job for someone with your tact and sensitivity. And you can be sure none of your patients will refuse to be chopped.
But don't keep your knife sharpened for me for I am 

Never yours to carve and I mean that most sincerely, Jack
Pamela Nomark

However Jack had moved on by the time I wrote this letter and as it finished up in my file at Helton I don't think he ever saw it.
In July, when asked for a copy of my scan report Mrs Languid wrote to the Royal.

Dear Dr Curry

Thank you for your letter regarding this patient.
She is a rather difficult lady, as you have probably gathered. She indeed has a large fibroid uterus which, on ultrasound scan on 14 April showed a very large fibroid uterus extending to above the level of the umbilicus. Both ovaries appeared normal. She suffers from menorrhagia and has been quite anaemic with this. We tried to persuade her that she needed a laparotomy. As my understanding of trying to shrink down fibroids, is on the whole fairly unproductive, it may well be that a myomectomy would be considered, but I would not  feel very happy carrying this out. I had planned to review her in the clinic when she returned, but unfortunately I did not, and she saw my registrar and informed him that she did not wish to pursue surgery, and did not wish to come back to the clinic.
I hope this information is of help to you.

Yours sincerely
J Languid, Mrs
CONSULTANT GYNAECOLOGIST & OBSTETRICIAN

I found it interesting that Mrs Languid was apparently unfamiliar with the shrinkage produced in fibroids by GnRH-a therapy which is extremely variable but averages 40-50%.
Mrs Languid was well aware of my feelings about hysterectomy as both her clinic notes and Dr Minion's letter to my GP show. I had been told by Jack Ketch that I should have a hysterectomy, not "surgery", and I had said that I was not having it. I had said nothing about either wishing or not wishing to come back to the clinic. As Jack Ketch's letter makes crystal clear I was to have a hysterectomy and if I didn't want it I should go away and not come back until I agreed to it.
At this time I had not read of the many unpleasant effects of hysterectomy, nor had I read Weingold's statement about fibroids being almost always removable regardless of their situation, number or size. I was very upset at even the thought of mutilation but I think that if she had seen me herself and assured me that the fibroids were just too many, too large and too awkwardly placed to remove I would have believed her lies and accepted a hysterectomy.
She had passed me in the open plan waiting area on her way to the offices and had seen me only one week previously. I now believe that, as she was apparently unskilled in conservative surgery, she had decided that her hatchet man should browbeat me into hysterectomy. Destructive surgery was the only thing she could do but she was not going to pass a patient on to a more qualified operator merely because this particular customer did not relish being mutilated. Besides all of the medical profession, except for a few heretics like Mendelsohn and Hufnagel, knows that the amputation of their generative organs is the best thing that can happened to a female. Though for males it is, naturally, a dreadful catastrophe.
Possibly she didn't want to lie herself so that's why she sent Jack to do her lying for her. But I wasn't going to be told by a male chauvinist that my womb was a piece of trash that should be excised without a second thought.
I saw Mrs Languid in February 1993 when getting my records from the hospital. In June I wrote to her.

Dear Mrs Languid

When I saw your registrar last year he sneered "Myomectomy was no good. They (fibroids) only come back." He also went on about a few rare or insignificant consequences of fibroids - uterine prolapse, degenerative changes and sarcoma. He did not mention any of the many unpleasant, and far more common, aftereffects of hysterectomy.
In the latest edition of Bonney's Gynaecology Monaghan describes the results of myomectomy as "excellent".
Sir Norman Jeffcoate's book says of fibroids:-
"Most recurrence occur after myomectomy in young women - those less than 35 years old."
He also says:-
"Myomectomy is said to be more dangerous than hysterectomy but this is not true for present day surgery."
Dr Goldfarb in "The No-Hysterectomy Option" states:-
"However, if a woman is 40, the chances are overwhelming that she's not going to have problems after myomectomy because the menopause will intercede"
Are these authors writing crap or was your registrar spouting it? Is he still misleading women into mutilation? Is your present assistant promulgating similar lies?
I should like an answer to these questions. I should like to know why women's organs are so frequently despatched for slaughter when they can be conserved. Why women regularly and unnecessarily suffer the many effects of miserable mutilation when their organs could be preserved with a little effort.
On the subject of this effort Dr Goldfarb says:-
"It is true that hysterectomy is a technically less difficult operation (though not to the doctor who is accustomed to performing myomectomy)."
I should like to finish with another quote from Dr Goldfarb.
"The number one job of the gynaecologist is to address the patient's needs and desires, and put into perspective for her within the context of those needs and desires what her chances of success will be when availing herself of any particular plan of care. Today, when so many alternatives are available and so much is known about the consequences of hysterectomy, if a gynaecologist just says, "you don't need your uterus, let's take it out," his statements are both unwarranted and uncaring."
So where's the caring NHS? 

Yours sincerely
P Nomark

Mrs Languid replied a month later.

Dear Mrs Nomark

Thank you for your letter dated 21 June 1993.
When I last saw you in the clinic I felt I had made every effort to explain the situation regarding your fibroids. You were obviously unhappy with my advice and were planning to be seen by another gynaecologist.
I read your quotes with interest, but I would like to point out that not every gynaecology textbook says the same things regarding myomectomy and hysterectomy and we obviously develop our own clinical ideas about how to manage patients and present that to the patient. Every patient is entitled to a second opinion and you have exercised that right which is fair enough. Dr Ketch was a competent Registrar who was very capable and caring.
I am no longer responsible for your care as you have decided to dismiss our advice and I feel I can therefore be of no further assistance to you.

Yours sincerely
J Languid, Mrs
CONSULTANT GYNAECOLOGIST & OBSTETRICIAN

I don't know whether Jack cared about his mother, his mistress or his money but from my experience he showed no consideration whatsoever to patients.
I should also like to think that textbooks DO differ in what they say about womb treatment, but they don't. They all agree that myomectomy is nearly always possible and all think it not worth the effort of even attempting to preserve useless female organs.
Also the ideas gynaecologists "develop and present to their patients" seem to be based on what is convenient for the gynaecologist and how low an opinion they have of the patients organs - which is just about as low as it can get. What the patient wants is never considered.
It suddenly occurred to me although I had copies of my medical notes from Helton and my later session at the Royal there were no notes from the appointment when I had been seen by Jack Ketch. I wondered why. Surely every outpatient appointment should be written up, as every appointment with a GP should be recorded. I wrote to Helton hospital on 29 July.

 
Dear Mrs Walker 
 
I received my medical records from Helton Hospital in March this year and have just noticed that although I have clinical notes for my Helton appointment of 9 April I can find no notes for my appointment of the 16 April 1992, when I saw the registrar, Jack Ketch. 
As I have clinical notes for both my Royal appointments I believe that all outpatient consultations should have a written record and I should like to know what was in this one. 
I would appreciate a copy of the notes for this consultation or
an explanation for their absence.

Yours sincerely 
Pamela Nomark
 
The reply, dated 11 August, said:-

Dear Ms Nomark

I refer to your letter dated 29 July 1993, which was addressed to Mrs Walker, in relation to your consultation on 16 April 1992.
I have discussed this matter with Dr Languid who has assured me that the copy case notes you received are complete. Not all doctors routinely make hand written notes and all the relevant information about your consultation on 16 April 1992 is contained in the typed letter from Dr Ketch to Dr Amicable, also dated 16 April 1992.
I trust this clarifies the matter.

Yours sincerely
TREVOR G COOMBS
Director of Nursing

Jack Ketch was so caring that he was not capable of taking any notes of a consultation, though everybody else did, even when they also wrote letters concerning the consultation. I suppose telling another uninteresting woman that she needed another routine mutilation was just too boring for him to record.

Essential Obstetrics and Gynaecology, 1987
E Malcolm Symonds

on pathological change
infection and abcess formation - these are rare complications which are particularly likely to affect sub mucous fibroids following septic abortions.

Essential Obstetrics and Gynaecology, 1987
E Malcolm Symonds

Small uterine fibroids are a common finding in asymptomatic women, but if they exceed 10 cm in size the tumour should be removed because of the difficulty of excluding the diagnosis of an ovarian tumour. There is no medical treatment of fibroids. Where the preservation of reproductive function is not important, the surgical treatment of choice is by hysterectomy. In younger women or where the preservation of reproductive function is important, the removal of th fibroids by surgical excision or myomectomy is indicated.
Myomectomy is associated with greater morbidity than hysterectomy because of the occurence of haematoma formation in the cavity of the excised fibroid and also because of infection. It is also impossible to be certain that all fibroids are removed without causing excessive uterine damage. There is alwalys a possibility that residual seedling fibroids may grow and lead to recurrence of the fibroids.