Oops!

Foreword: Specimens for pathologic diagnosis usually arrive in the lab in jars filled with formaldehyde preservative and accompanied by a paper slip with the patient’s name, sex, age, specimen source (e.g., skin of the nose). Each specimen is given an identifying sequence number, something like “S79-2914” (i.e., surgical pathology specimen 2914 of 1979).

Pathologic diagnosis of tissue has two major parts—the gross examination is an eyeball assessment of the specimen, which may be as small as a tiny skin biopsy or as large as a kidney containing a cancer. The pathologist dictates a description and selects slices of tissue to be processed into slides for microscopic examination the next day. The pathologist examines the slide and renders the final diagnosis.

1982, A pathology laboratory, Dallas

The next specimen was a somewhat fist-size lump of fat with paperwork indicating the patient was a 12 year-old boy with a “lipoma of the groin.”  Nothing unusual: lipomas are harmless fatty tumors of skin, which are usually removed for cosmetic purposes. 

I toed the record switch and began dictating: “Okay, the next specimen is number 2914, Jesus Hernandez.  The specimen is a smooth, ovoid, yellow, fatty mass . . . ,” I twisted it with long forceps to get a view of all sides and held it against a metric ruler, “. . . about 9 by 5 by 5 centimeters.”

Using a surgical blade, I sliced it in half to inspect the interior.  It was uniform, smooth, greasy, yellow fat like the zillion others I’d seen but in the middle was . . . well, I didn’t know what it was. I had cut across a tube of some kind. It was tan, round, firm, about a half inch in diameter, and seemed to have an internal anatomy of its own. A worm?  A congenital abnormality?  The latter popped to mind because tissues in the developing fetus undergo amazing contortions, move from one place to another, and sometimes leave behind little remnants of normal tissue in odd places.

I made a series of bread-loaf cuts, which revealed the thing to be a tube about 3-4 inches long.  I sat staring. Lipomas just don’t have this sort of thing inside.

I’d never seen anything even remotely like it.  I looked at the paperwork again, grasping for a clue.  The boy’s name was Hispanic, and the specimen had been removed at a small hospital in far West Texas by a doctor with an Eastern European name, and a poor grasp of English.  He hadn’t been in town long. I’d met him once on one of my consultation visits to the hospital’s tiny lab—a Federal requirement if the hospital was to receive Medicare payments.  Maybe the boy emigrated from South or Central America—lots of worm infestations down there.  Worms get into a lot of places—the intestines, the heart, the liver, even the brain.  But fat? 

“What’s the matter Doctor McConnell,” the tissue tech asked, alerted by my vacant stare.  “I don’t know,” I said, and continued looking at the strange thing, hoping that if I looked long enough a snap of recognition would occur.  It didn’t. I asked the tech to look. In her career she’d seen more specimens than me; she had no idea. I gave up, consoled with the knowledge that if you practice medicine long enough you’ll see one of everything.

“In the center of the specimen,” I continued dictating, “is a firm, tan, discrete object, about 10 to 12 millimeters in diameter and about 8 to 9 centimeters long, which extends to the cut edge of the specimen.  Representative slices are submitted for microscopic examination.”

I sliced thin pieces from the ends and middle and forked them over to the tissue tech.  Adding a slip of paper with the identifying number, she put them in small, perforated metal containers for the elaborate overnight processing that would soak out the fat and water and replace it with hot paraffin.  When cooled, the paraffin hardened, rendering the tissue suitable for shaving off pieces a few millionths of an inch thick.  These would be stepped through another process to remove the paraffin, and the remaining tissue would be stained with red and blue dyes and mounted on glass slides for microscopic study.

The next morning I’d forgotten about the case when a technician delivered several big white trays lined with neat rows of shiny glass slides, each holding a bright red and blue-stained slice of tissue.  I flipped the switches on my microscope and the dictating apparatus, and began the daily surgical pathology drill: slap a slide on the microscope platform, look at it for a while, decide what was going down there among the cells, dictate a “micro” description to be wedded to the “gross,” and render a diagnosis to complete the report.  If uncertain about the diagnosis I set the case aside and go to the next case.  Slap, look, decide, dictate, diagnosis, next….

“Alright, the next case is 2914.  Microscopic study reveals . . . ,” I stopped, transfixed: staring back at me from the slide was an appendix—this was that strange case.  I can count on the fingers of one hand the times I’ve been surprised by microscopic findings so completely unexpected—one other was a breast cancer in a man who came to the ER for a lump in his chest muscle.

How in God’s name to explain such a thing.  The appendix is in the abdomen, not in the groin.  Maybe the wrong paperwork was submitted and this was Jane Doe’s appendix and Jesus Hernandez’ lipoma was somewhere else with Jane Doe’s paperwork.

I called the tissue lab and asked them to scan our records for another specimen from the hospital involved.  Nope.  This was the only specimen in the last few weeks.  “They don’t do much surgery out there, Dr. McConnell,” the supervisor reminded me.  It was true.  The hospital was in a remote small town that was desperate to lure doctors to keep its doors open.  Physicians came and went, some of whom, as I was beginning to learn, were foreign medical graduates with marginal training and shady pasts.

Then it hit me.  This was the result of a hernia, a protrusion of tissue that works its way through a weak spot or opening into a place it doesn’t belong. The most well-known is the inguinal hernia of males, in which a loop of bowel in the lower abdomen slides into the scrotum by following the path of the spermatic cord, which connects the testis to the internal base of the penis.  A femoral hernia is similar but slides down alongside the big femoral artery, which serves blood to the leg. In this case the appendix, cloaked by a thick layer of fat, led the way, dragging the colon with it. The boy had a lump in his groin. The doctor saw a bulge and cut it out. The doctor didn’t recognize it for what it was. 

But, so what?  This is what: the surgeon had done an accidental appendectomy. The boy had an unsutured one inch hole in his colon. It had not been stitched closed because the surgeon didn’t know he’d done an appendectomy. I was certain the boy was going to develop a severe abdominal infection caused by bacteria leaking from his intestine.

I buzzed the receptionist and asked her to get the doctor on the phone.  In a few minutes she had him on the line.  The conversation went something like this.

“Hello, Doctor Korzhescu, this is Doctor McConnell from Dallas, your pathology consultant.  I’m calling about the specimen you sent us on Jesus Hernandez.”

“Oh, yes,” he said cheerily.  “Very nice.  A good boy.”

“That mass you removed from his groin.”

“Yes. Yes.”

“Well, it turns out to be a sliding femoral hernia that had the appendix in it.”

“Yes.  What about the lipoma?”  He portrayed no surprise.

Trying to give him the benefit of doubt, I replied, “It’s not a lipoma.  It’s the appendix and some fat.  Did you stitch the bowel closed after your appendectomy?”

“No appendectomy. A lipoma.  Thank you.  No worry.  A strong boy.  Very fine.  Very fine. ”

I was getting nowhere.  Rather than dealing further with the doctor, I called the hospital administrator, a sensible woman I had come to admire in the course of my periodic visits.  I explained the problem to her. She said she would inquire of the nurses and the town’s other doctor, a semi-retired general practitioner who had originally seen Jesus.  She called back that afternoon to tell me that that Jesus had spent one night in the hospital and had been sent home. No one had heard of any problems.  

On my consultation visit a few weeks later Dr. Korzhescu was gone.  The hospital administrator wouldn’t tell me much on the advice of the hospital’s lawyer.  Jesus had recovered completely.