The relation of general practitioner to specialists.

NZMJ, 1923 (To the Editor.)

Sir,—I saw a patient a few weeks ago, who gave the following history which I think may be of interest to members of the Association generally:—

Mrs X.Y. was confined of a ten-pound baby in a town in the North Island some four years ago. She was attended by a “surgeon.” The baby was unfortunately born dead, as very large babies are always liable to be at a first labour. In consequence of its loss, her mental condition was very much upset, and she could not pass a baby in the street without wanting to run away with it. She was calmed down somewhat by being told that she would soon become pregnant again and have a living baby next time. However, a year or so went by and there was no pregnancy. She again became somewhat upset, and, on the adviice of some friends in England, she expressed a wish to consult me. She was, however, told by her medical adviser that he had examined her, that she was perfectly normal, and that it was quite unnecessary to consult me. Every subsequent effort on her part to come to me was met by the same statement. Another year or so went by, and, as she still did not become pregnant, she expressed a wish to adopt a child. This wish was met with a somewhat similar statement, namely that she would soon become pregnant again, as she was perfectly normal. At last, some three years or so after the first confinement she left the particular town in which she had up to this lived, every effort on her part to obtain the opinion of a specialist, or to adopt a child, having been squashed by the formula that she was capable of becoming pregnant at any moment.

Eventually, after another interval, she got to Christchurch, and came to see me. The following are the physical signs which I wrote down after a first examination without an anæsthetic:—“Patient difficult to examine, uterus retroverted, possibly adherent, wide bi-lateral tear of cervix.” Cervical tears have been recognised as definite causes of sterility from the time of Marion Sims, or Emmet, and so it was obvious that this tear should be cured. Further, an adherent retroversion in all probability means closed tubes and absolute sterility, so that a further examination under an anæsthetic was necessary. The physical signs noted at this further examination were as follows:—“Uterus retroverted, fundus can be brought partially forward but falls back at once owing to adhesions, whole uterus retroposed, broad ligaments shortened and thickened, no cystic condition of tubes or ovaries, deep tear of cervix on one side only.”

As the patient had stated that she did not wish any abdominal operation to be done at the time, the uterus was curetted and a trachelorrhaphy performed. So far, I have not as yet discussed the question of further operation, but there is little doubt that she is, at the moment, in a condition of absolute sterility due to closure of the tubes, due in turn to some very mild infection at or subsequent to labour. Even if my diagnosis is incorrect, and the inflammation extra- rather than intra-peritoneal, it makes no material difference so far as the present indications for treatment are concerned. The physical signs of the patient are so definite as to render an exploratory operation essential in the case of a woman who is complaining of sterility.

Now, as I understand medical ethics, a medical man has two duties. His first and chief duty is to his patient—and it is the predominant one. His second duty is to himself. I cannot believe that the medical adviser (of whose identity I am in ignorance) of Mrs. X.Y. has discharged either of his duties. In regard to his patient he has failed very egregiously, because, for some reason, or reasons, he has prevented her from consulting a specialist, and has trusted to assume powers of diagnosis which actually he does not possess. In the case of himself, he has, for no benefit that should have been allowed to weigh with him, exposed himself to loss of reputation. It is impossible for me to hide from the patient or her husband that everything her previous adviser told her, so far as her pelvic organs are concerned, is wrong. Who benefits by this kind of thing? I know three people who do not—the patient, the previous medical adviser, and the specialist who should see the patient. Yet the same thing happens at regular intervals, when patients come to me and say, “Do not tell my doctor. He would be furious at my consulting you.” All of which is rather strange hearing to me who know that “her doctor” is probably just as incapable of diagnosing the condition of pelvic organs as I am of undertaking the treatment of a Colles’ fracture, and who am not accustomed to this professional antagonism.

Everybody, be he specialist or general practitioner, makes errors of diagnosis. In the case of Mrs X.Y., I should no more expect a general practitioner to diagnose her condition than I should expect myself to diagnose the locality of intra-cranial lesions. The changes in the pelvic organs are far too slight. Even now, knowing them to be there, it is impossible to tell their extent, and if the patient had been somewhat fatter, they would probably have escaped notice altogether. It is not with mistakes in diagnosis that I quarrel, it is with the attitude of mind which enables a man to think that he is entitled to refuse to a patient the advantages which she can get from the opinions of other advisers, and which tries to compel her to limit her opportunities to what can be given by “her doctor.”

When I had the honour of addressing the Wellington Conference on “Maternal Mortality,” I said : “To imagine that a busy general practitioner can keep himself competent and skilled in all the special branches of modern medicine, is absurd. To deprive the patient, public or private, of the assistance of these special departments helps the quack, discredits the medical profession, wrongs the patient, and, even from a purely selfish point of view, eventually is bound to cause loss rather than gain.” Is this a mere truism which every one recognises and acts on, or am I right in thinking that the case of Mrs. X.Y. is only one amongst many?

Yours, etc.,

HENRY JELLETT.