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11/14/2005: "I Don't Like Mondays"
Mondays are usually bad because I'm the lead for Gynaecology pathology in Gloucestershire and Mondays are when we hold the weekly gynaecology multidisciplinary team meeting (MDTM); this is the meeting at which all new cases of gynae malignancy are discussed - the history is given, the X-rays are reviewed, the histology (pathology) is reviewed (by me) and then decisions are made about treatment, follow up, diagnosis and prognosis. The meeting lasts at least an hour and a half and the preparation beforehand at least another hour, which is a big chunk out of the working day. Today, though I was on for autopsies as well.
There are approximately 1100-1200 autopsies performed in Gloucestershire every year, and there are 8 of us to do them; on any given day two us are on (one in Cheltenham, the other in Gloucester). Today, in Cheltenham, there were 3, all Coroner's cases.
The first was straightforward - an elderly gentleman with a history of heart disease who suddenly collapsed whilst out with his dogs. His heart weight was twice the normal size and the muscle surrounding the scar of the old infarct (dead tissue) was scarred, liable to go into an arrhythmia at any time.
The second, though, was more problematic. Another elderly gentleman who had come into hospital for resection of a rectal cancer. Following the operation he had developed an acute abdomen and imaging showed free gas and fluid in it. The assumption was that the anastomosis (the join) had leaked. He died from this despite everyone's best efforts. When he was opened up, there was, indeed, established and generalised peritonitis (which stank). Interestingly, though, the anastomosis looked good; even more interestingly, he had a small but deep ulcer in his duodenum, one which had burrowed down into the pancreas. It is entirely possible that this was the source of his peritonitis, but until I look at samples under the microscope, I won't know.
The third was the most troublesome of all. A middle aged woman who 'enjoyed a drink.' Her husband went out; when he came back she was on the floor with her head in a pool of blood. Murder? Well, the police didn't think so. Nothing was missing, there was no sign of a struggle and the blood seemed to be coming from a cut on the side of her head (which was by the corner of a cabinet unit). When I first encountered her, the most obvious thing was the overwhelming smell of alcohol (you can actually get to feel quite light-headed sometimes - a sort of 'passive drinking' effect). There was indeed a cut on the lefthand side of her head and beneath it there was some bruising in the temporalis muscle...but that was it. No skull fracture, no obvious trauma to the brain, no intracranial bleed.
The rest of the post mortem was equally uninformative. No obvious heart disease, no pneumonia, no abdominal catastrophe.
Which is a problem.
All you can do then is take samples to examine under the microscope, take blood and urine for toxicological analysis and, in this case, suspend the brain in formalin for fixation and later expert neurpathological opinion - just in case she was an epileptic or suffering from alcohol-related brain disease. Then I ring the Coroner's office and give them the news that they hate to hear - cause of death is as yet 'unascertained.'
And when I know what she died from, I'll let you know.
If you would like to discuss any of this, please contact me through my website - www.keithmccarthy.co.uk.
Keith McCarthy on Monday, November 14th 2005 @ 08:09 PM GMT [link]