A WOMAN’S DEATH

Southland Times, Issue 18939, 12 May 1923, Page 5

A WOMAN’S DEATH

COMMENT BY CORONER SURGEON TAKEN TO TASK (Per United Press Association). CHRISTCHURCH, May 11. A most unusual cause of death was disclosed during the hearing of evidence respecting the death of an elderly woman who died under an anaesthetic, which was being given her for the purpose of having an operation performed. The respiratory organs became flooded with liquid and the patient was practically drowned. The inquest was on the body of Mrs Anita Gundersen, a widow aged 64, who had died under an anaesthetic at Lewisham Hospital last week. Dr H. T. D. Acland said that with Dr Marks he had seen deceased at Lewisham Hospital on May 1. She gave a history of having been seriously ill with symptoms of gall stones. Vomiting had ceased and she was apparently improving. On Thursday, May 3. the patient was again seen and her condition had improved. When he saw deceased on Friday morning she was not so well, and was vomiting slightly. An operation was decided on then, as her condition was serious. Dr Lester administered an anaesthetic which was taken satisfactorily. The operation was begun and he found that there was mischief in the gall bladder region. Dr Acland said he thought he detected a stone there. At that time her breathing was shallow and an effort at vomiting occurred. The anaesthetic was stopped and attention was given to the clearing of the throat. A large quantity of fluid had come from the stomach and as it was impossible to clear the air passages, respiration was not restored and artificial respiration was carried out, but the heart had failed. “When it was obvious that no more could be done for the patient I investigated the abdomen further,” stated Dr Acland. He found a large gall stone about two inches in length and one inch in diameter occupying the small bowel. The stone could be moved. He removed the segment of the bowel in which the stone lay, and this was handed to the pathologist. The stone had ulcerated from the gall bladder through to the intestine and had caused a partial stoppage. The Coroner: Do you think it was a right thing to do? The witness: I do not. The Coroner: I think it was a most improper thing to do in the circumstances. The witness: I realise that. “The proper way was to satisfy yourself from a surgeon’s point of view that life was extinct,” said the Coroner to Dr Acland. The Coroner continued that any interference with a dead patient’s body was wrong and was to be strongly deprecated. Dr Acland: I know that. Asked by the Coroner as to whether he continued, so as to satisfy himself from the technical view. Dr Acland replied in the affirmative. Dr J. M. L. Lester said that he administered the anaesthetic (ether) at the operation. The patient took the anaesthetic fairly well. He had previously sounded her heart and for her age and conditions there was nothing alarming. Shortly after the operation commenced the patient vomited. All efforts were made to clear the respiratory passages, but the flow of the liquid was so continuous and so large in volume that the efforts were unavailing and she was “drowned.” It could not have been anticipated. Vomiting on the operation table under the present anaesthetics was very rare. It occurred perhaps once in every 400 or 500 cases, and could be met by keeping the air passages clear. “In every case where patients die under anaesthetics I think it is desirable, as we have had in this instance, a full investigation of the circumstances,” stated the Coroner. “I think it is desirable in the interests of the medical profession and in the interests of the public. The Coroner added that Mrs Gundersen had put off the operation till her condition had become serious. An enormous gall stone had apparently ulcerated right through into the intestines and had caused a stoppage of a large collection of fluid and the fluid was vomited when Mrs Gundersen was under the anaesthetic, and she had choked herself. The surgeon and doctor were unable to ascertain the collection of fluid, and could not reasonably anticipate the unusual form of vomiting. He returned a verdict in accordance with the medical evidence.