A recent article in the New York Times had me thinking about surprise diagnoses I had made in my career. Most were made via an unexpected finding on a biopsy examination, but the first was undoubtedly during my Pathology residency, spending manyy hours in the morgue on the hospital autopsy rotation.
Mr. Jones was an older gentleman, in his 80's but still spry! Why, according to my review of his hospital chart (paper, not electronic back in in 1979), he had been active enough to be running for a bus a month or two earlier. He had taken a tumble and missed the bus, but he was certainly an active fellow.
Further reading of the chart revealed that about a month before his death he began experiencing bleeding from his mouth. Various studies were done, and it was determined that the bleeding was arising in his esophagus. X-ray studies showed a mass about midway between his mouth and his stomach, and a tentative diagnosis of esophageal cancer was made. A specialist performed an esophagoscopy, passing a viewing tube into Mr. Jones's esophagus, and performed a biopsy of the growth he saw.
The biopsy result from that procedure was inconclusive. Degenerating cells were seen, but no clearly malignant cells were identified. The pros and cons of performing extensive surgery on a man of Mr. Jones's age, especially without a definite diagnosis, were discussed by his medical team. Unfortunately, Mr. Jones's condition was not waiting around for a decision. He experienced severe chest pain, began bleeding heavily from his mouth, and was transferred to our hospital, where he succumbed that evening. The family, at the behest of the Doctor Will, who had been the last doc to see him before he died, consented to an autopsy.
Mr. Jones was my first autopsy of the morning, during a three month period in which I performed about 100 post-mortem exams. There are two philosophies about the best way to go about doing an autopsy. Some pathologists will read the chart, decide where the main findings will be, and make that the first thing they examine. Others take a more methodical approach, following the same dissection order with every case. I have always followed the latter, going organ system to organ system in a prescribed plan. The gastrointestinal tract, the probable site of Mr. Jones's pathology, had to wait until I was done with cardiovascular, renal, and respiratory systems. I could feel Doctor Will's impatient foot taps as he waited for me to "show him the money."
Finally, I grabbed a pair of scissors and openned the esophagus and stomach. Surprise number one, although the esophagus revealed three long gashes through its internal lining, there was no tumor! Surprise number two was a triangular piece of firm pink plastic laying within the stomach. The points of the triangle precisely matched the esophageal damage. We speculated that the triangle had lain in the esophagus for weeks, causing bleeding and appearing to be a mass on the x-ray studies. On his final day, the plastic had moved from the esophagus to the stomach, causing pain and the massive, fatal, bleeding. Doctor Will was satisfied, we had our cause of death.
But what was that piece of plastic? Remember that run for the bus a few months back? It turns out Mr. Jones had done a bit of a face plant while falling and broken his upper dentures. He had grabbed the fragments, but no one had ever tried to reconstruct the dental plate. If only they had!
We recovered the fragments from his family, and sure enough, the deadly triangle had once been part of that upper plate. We published our findings in the Southern Medical Journal. Perhaps the first recorded case of death by denture.
I don't do autopsies anymore. In fact not that many are done, in part because of the belief that with all of our advanced technology, not much can be learned from them. But you never know when there is going to be a surprise!
On a separate medical note, my acquaintance Howard Wolinsky writes for the online journal MedWebPage Today. Here's a link to his article about our discussion about the pathologists role in prostate cancer. Give it a read!
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