WRONG DIAGNOSIS

New Zealand Times, Volume XLIX, Issue 11194, 27 April 1922, Page 3

WRONG DIAGNOSIS

BEATH AFTER OPERATION INQUEST ON BODY OF RETURNED - SOLDIER. PATIENT’S HEART UNSOUND. PEE PEESS ASSOCIATION. CHRISTCHURCH, April 26. The inquest on the death of Wilfred Moore, a returned soldier, 24 years of age, who died at the Christchurch Hospital on April 21st, was resumed (to-night before '.the District Coroner (Mr Wyvern Wilson, S.M.). The evidence given at the previoushearing showed that Mooro was admitted to the hospital to undergo an operation for an internal complaint, and he died when the operation was practically completed. Dr. A. B. Pearson, who conducted the post-mortem examination, gave evidence showing that death was primarily due to valvular disease of the he<yt j and secondly, to heart failure, resulting from the anaesthetic. Replying to the coroner, Dr. Pearson said he did not think deceased was in a. fit condition to he placed under an operation, and he wae rather surprised to learn that the nnaethetist thought the heart was regular in rythm. Witness could not understand the anaethetist hearing a systolic murmer. Dr. J. S. Guthrie, honorary surgeon at the hospital, who conducted the operation, said he decided to operate to confirm the supposition he held as to the cause of the man’s condition, and' to relieve the patient’s trouble. Prior to his admission. Mbore had suffered attacks of violent pain and jaundice. Witness said he. had no knowledge of the man’s heart beyond that an examination had been made by the house surgeon. Dr. Reay, the anaesthetist, 6aid ho had made the usual examination in the laboratory. The house surgeon" reported that the heart waa sound. The result of Dr. Reay’s examination was not communicated to witness. When the anaesthetist’s report indicated that the symptoms were contrary to an operation the praotioe was for it to be communicated -to the operating surgeon. A systolic murmur in itself was not an indication that a patient was unfit to undergo an operation. If the house' surgeon had reported the patient’s heart as unsound, witness would probably have called in a physician to decide whether the risk of performing an operation was greater than that of leaving the patient in his then condition.

Dr Guthrie said lie was surprised, after hearing Dr. Pearson’s evidence, that the patient’s heart had been reported to him as sound. However, the presence of a murmur was not necessarily an indication of watvular disease and there could be a murmur from a heart that was not diseased arising perhaps from the heart being enlarged. The coroner said that when a person died under an anaesthetic, whether in a public or in a private institution, more particularly in a public hospital, it was necessary to hold the fullest inquiry in the interests of the public, the interests of the medical profession generally, and in the interests of rathe medical men, surgeons, anaesthetics, nitd physicians who acted in the case. In this instance the impression left on his mind was that Moore,- a young manj Who'had" bad health ‘fbr' some: time, and that although he had had sharp pains over the heart quite recently he did not attach very much importance to them because he never told the doctor, the anaesthetic, or the house surgeons.. The house surgeon examined him and made the report that the heart was sound. After hearing Dr. Guthrie, said the coroner, he thought that in view of the history of the case, given by the pati. ..t, and the fact that under examination only a murmur was heard, the anaesthetist was justified—he would not say the anaesthetist was not justified—under the circumstances in reporting that the heart was sound. The events proved that the anaesthetist had not detected that the heart was unsound, but he (the coroner) would not say he was negligent in doing so. The murmur was not sufficient to satisfy the house surgeon that the heart was unsound. The heart was, in fact, unsound, and the patient had suffered a relapse' after an operation. As to the conduct of the operation, everything seemed to have been as it should have been, and this doctors could not realise his condition without an operation. The coroner returned a verdict that death was due to valvular disease of the heart and anaesthesia.