Last Gasp

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1969, A mid-size suburban hospital, Texas 

I answered the phone.  “Doctor McConnell?” a voice inquired.

“Yes.”

“This is Doctor Bettis.  Could you come up to the operating room?  I have a situation to discuss with you.”

Most of the time when a pathologist is summoned to the OR it is to perform a quick microscopic diagnosis on a scrap of tissue to see if it is malignant, a breast biopsy, for example.  If the pathologist says it is clearly malignant, cancer surgery is performed; if not, the surgeon chooses an alternative, often ending the procedure to wait for a definitive diagnosis on permanent slides, which are much clearer and can be studied at leisure.  But Bettis was not a general surgeon, he was an OB-Gyn for whom I’d never done anything.  Maybe it was a lab goof-up on a specimen from one of his patients and he was summoning the pathologist to complain.

I grabbed a copy of the OR schedule and scanned it, trying to get an idea about what might be up, but Bettis had no cases posted.  Furthermore, it was the middle of the afternoon and the daily surgery schedule had finished at about noon.  Still, something important must be afoot—maybe it was the tone of his voice or his use of the word “situation” that set me on edge. In any case, a pathologist’s trip to the OR is always freighted with the expectation of serious business.

I found Bettis in the doctors’ lounge in the otherwise empty OR suite.

“Thank you for coming,” he said.  “I’ve got a very touchy issue on my hands and I need your advice.”  

He then told me of one of his patients, a young woman who was near term. He had admitted her to the hospital earlier in the day.  The pregnancy had been normal at first but in the last couple of months, her uterus had grown much too large.  Ultrasound diagnosis was unknown in those days and he had not done an abdominal X-ray—fetuses are extraordinarily vulnerable to radiation. Now, though, her abdomen had swelled to such size that he was compelled to X-ray her abdomen to have a look.

“The instant I saw those films I knew there was going to be trouble,” he said. 

X-rays showed that the fetus’s head was gargantuan, larger than the rest of the body. The cause was clear—extreme hydrocephalus, literally “waterhead,” a condition caused by blockage of the flow of cerebrospinal fluid (CSF), which normally streams in a closed loop inside and outside of the brain and spinal cord. With internal obstruction CSF accumulates, the normally small interior brain spaces balloon, and increasing pressure flattens to paper thinness the normally robust rind of cerebral cortex, home to consciousness, intellect, memory, speech, and emotion.  In this instance, the only remaining brain tissue was a nubbin of the reptilian brain, home to the most primordial functions, mainly respiration.

“It’s hydrocephalus of the worst kind,” he said.  “She’ll never deliver vaginally, the head’s way too big.” 

He heaved a sigh. “I’m not going to do a Caesarian section on this woman merely to retrieve an infant that will never draw a breath.  She will need a general anesthetic, dangerous enough as it is, and with a condition this odd I worry that something strange could happen.  If anything happened, I’d never be able to live with myself for having opted to do a C-section when I could do something safer. This is her first pregnancy, and if she has more kids, she’ll have to have each one by C-section, “ he continued, referring to the standard practice.  “But there is an alternative and that’s what I want to talk to you about.”

As he was telling me this story, I kept asking myself, what does this have to do with me or with pathology? He’s been in practice for decades; I’m thirty-one years old and just beginning.  But it dawned on me that he was testing test his idea with someone he thought could offer disinterested advice.

He then told me of an instrument that had rested unused for years on an OR storage shelf.  I had seen one before, a ghastly large stainless steel contraption that looked like something from a medieval torture chamber. It featured a triad of long, toothed tongs that could be clamped tight around the infant’s head. In the center was a corkscrew drill for opening a hole in the skull to drain the CSF, after which the tongs could be screwed down, crushing the huge skull to a size that could be easily pulled through the birth canal.   

“This is going to be an all-physician undertaking. The nurses have wind of this and none of them will help,” he explained.  “It’s a very tense situation.  What I need from you is an autopsy that will document the hydrocephalus and anything else you find.  And I’ll need you in the OR to take the infant and carry it to the morgue yourself.  I doubt any hospital staff will do it and even if they would, I wouldn’t allow it. We might find a picture on the front page tomorrow.  I’ve gone over all of this with the mother and father and they are very distressed but agreeable.  So, what do you think?”

I told him I thought his plan was sound, documentable, and ethically correct. I would take possession of the infant and perform the autopsy.

So, the deed was done.  True to Bettis’ prediction, the infant was limp and never took a breath.  I wrapped it in a heavy white cotton surgical drape and took the back stairs down to the basement, where the morgue was located at the end of a long, poorly lit hall, the door illuminated by a single bare bulb.  With every step, my mission seemed more like a B-grade horror movie than real life.

I locked the door with the deadbolt and, thankful to be alone, opened my sad little package and placed the corpse on the big stainless steel autopsy table.  In the autopsy logbook, I entered the baby’s name as “Infant male ___________” and gave it the next available autopsy number.  After a short time, I was gowned and gloved and had the instruments and dictation apparatus ready.  I dictated the usual opening of an autopsy report, introducing myself, the date, time, and place, and the assigned autopsy number.  It was about 45 minutes after the birth.

Adult or infant, every autopsy incision is the same, extending across the chest from the front of each shoulder to the lower end of the breastbone to form a big V. From the tip of the V a midline cut adds a stem to convert the V to a Y. As I held the knife above the little form I took one last look at the corpse—the face was small and angular, not the round face of a healthy infant, and dwarfed by the huge, high forehead.  I made a mental note to describe the facial appearance, which is sometimes a clue to serious internal congenital abnormalities.

I sighed—it’s impossible to maintain complete emotional detachment, especially standing over a dead child—placed the knife on the right shoulder and drew it across the chest.  The infant gasped.  My heart nearly stopped.  In an instant, I realized what had happened.  I’d inadvertently cut into the chest cavity and triggered the collapse of the right lung, which in turn activated a well-known and powerful Herring-Breur reflex, which operates to expand the chest when lung volume is too low.  It operates through the reptilian brain, far below consciousness.  But even so, at least a few cells in the child’s nubbin of brain tissue were alive to relay the nerve impulses.  Every other cell in the body may have been dead—no heartbeat or other motion—but after 45 minutes a flicker of life still burned in a few brain and chest muscle cells.

Never was I more grateful for the solitude.  Explaining the gasp to anyone other than another physician would have been impossible.  And, besides, what was I to do?

I stood frozen.  The body remained perfectly still—no respiratory effort.  No sound but my own breathing and the hum of a motor somewhere.

I turned again to the task, worried that a small part of the heart might be quivering ineffectively, as I’d seen once before in an autopsy on an adult.  To my relief, nothing else unusual occurred and I found a serious congenital heart defect in addition to the hydrocephalus and almost total lack of brain tissue.