The last autopsy – mystery of Roberta Hansen’s death
n the winter of 1983 1 performed my last autopsy. It had then been 45 years since the day Dr. Lewis Beals Bates guided me through my first fumbling encounter with a corpse at the Gorgas Hospital morgue in Panama. In the interim, I had performed hundreds of postmortems. But this last autopsy was utterly unique in my experience-because I did it without ever having seen the patient or the body. It all started one morning when an attorney named Robert Hammond telephoned me from his office in Grand Rapids, Michigan. His firm, Hammond explained, was representing a group of doctors and their hospitals, the defendants in a $50 million malpractice suit. The case was being brought by the parents of a three-year-old girl who had died of a brain abscess after a bizarre set of medical circumstances. The suit charged-unfairly, Hammond thought-that the doctors had repeatedly misdiagnosed, misunderstood, and mistreated the little girl’s illness and, in the process, caused a delay in proper treatment that was ultimately responsible for her death. A former student of mine, Jonathan Hopkins, a neurosurgeon who was familiar with the case, thought I might be able to help. Would I fly out to Michigan and review the facts?
I told Hammond I was sorry, but I would have to decline. I felt obliged to stay put in New York while I worked on a new book. Besides, I was no specialist in abscess of the brain. Why had Dr. Hopkins thought to call me in the first place, I wondered out loud. It was then that Hammond pulled a nasty trick.
“Well, you see, there’s a parasite involved,” he said nonchalantly. I swallowed hard and thought I could feel the hook being gently inserted into my throat.
Yes,” the lawyer continued, “Dr. Hopkins told me to tell you that, during the early stages of her hospitalization, the child passed roundworms in her stool. He thought this might have a bearing on the case, and that you might tell us how.”
I was hooked! Boxes containing medical records, pretrial testimony, and the written opinions of various experts soon arrived at my Cornell office. My secretary, who had been putting up with nonsense like this for 20 years, stacked the documents on my desk, quietly shut the door, and without asking, canceled all appointments for the next three days while I began to burrow into the medical record. The first thing that caught my eye was the testimony of two leading experts on infectious diseases of the brain. Each man-Robert S. Chabon, director of the Department of Pediatrics, Penn Health Group, Pittsburgh; and Stanford T. Shulman, chairman of the Department of Pediatrics, Northwestem University Medical School–argued persuasively and with the force of specialized knowledge that early, accurate diagnosis and swift, efficient treatment would have saved the child’s life. I knew both men personally and respected their learning and honesty. Chabon’s deposition ran to 182 pages, with footnotes, and Shulman’s to 149. Only a fool would try to contradict their conclusions.
Because it appeared that I was dealing with a classic open-and-shut case, I was angry at Hammond for trying to involve me in a hopeless legal battle. However, my anger slowly turned first to fascination, then to indignation of a different sort, because, as I read on, it became increasingly clear that everybody had overlooked the key medical clues, and as a result, several young doctors were about to have their careers needlessly ruined and three hospitals would be plunged into financial hot water.
It was a tragic case, to be sure. On Sunday morning, August 9, 1981, Brenda Hansen, holding her daughter Roberta in her arms, had rushed into the emergency services section of Lee Memorial Hospital in Dowagiac, Michigan, a small farming community 40 miles southwest of Kalamazoo. Distraught, Brenda Hansen told her story to the emergency room physician, a young resident. For the past week or so Roberta had become progressively more ill. Her fever, slight at the beginning, had crept steadily higher, and she now seemed lethargic and irritable most of the time. She had been vomiting periodically. To the doctor, the symptoms, while troubling, didn’t seem out of the ordinary. He thought Roberta was probably suffering from any one of a number of routine childhood diseases-a viral infection, an earache, a mild case of pneumonia, or a communicable disease like chickenpox in which the rash had been overlooked. He did what most doctors would do under the circumstances; after carefully examining Roberta, he recommended that she be hospitalized and kept under observation while the symptoms sorted themselves into a clearer pattern. Ten days passed, however, and the doctors at Lee Memorial were still no closer to a definitive diagnosis. They seemed to be doing something right, though; they had treated Roberta for an infection of undetermined origin with ampicillin, and her condition had improved. Her fever disappeared. She began eating regular meals again. As far as the doctors were concerned, the patient was on the mend. On the morning of August 18, they sent Roberta home with her mother. Three days later, on August 21, Roberta Hansen and her mother were back in the emergency room, this time at a larger hospital, the Borgess Medical Center in Kalamazoo. Roberta’s symptoms had returned in force. In addition, she now complained of muscle aches and soreness in her joints. The examining physician, another young resident, noticed that her heartbeat was rapid and slightly irregular.
Then a new fact emerged. While in the bathroom at the hospital, Roberta passed a roundworm about the size of a lead pencil-a beast not uncommon to the bowels of children in the South, though a little more rare up north in Michigan.
Like his colleagues at Lee Memorial Hospital, the ER doctor had been somewhat perplexed by the wide range of symptoms Roberta presented. He now reached the not-unreasonable conclusion that she suffered from a common worm infection of the intestinal tract. Brenda Hansen was handed a prescription for the standard anti-helminthic drug and told to bring Roberta into the pediatric clinic in a few days for a followup examination.
Five days later, on August 26, Brenda Hansen entered the Bronson Methodist Hospital, in Kalamazoo, in a state of panic. Again Roberta was cradled in Brenda’s arms, but now the little girl was drifting fitfully between consciousness and coma as she gasped for air. Every few minutes, her body shuddered through a minor convulsion. A CAT scan of the child’s head revealed a huge brain abscess.
Roberta was operated on immediately. By this time, however, the abscess had grown to lethal proportions, so large, in fact, that when the neurosurgeon made his drainage incision, a large, pressurized stream of pus shot over his shoulder. Complications required a second operation and then a third. The patient, now deep in coma, was kept alive on a respirator for the next ten months. Finally, on August 3, 1982, Roberta died, a full agonizing year after the onset of her symptoms. At autopsy, no brain as such was found; disease had reduced the organ to a gelatinous mass on the floor of the skull. To all appearances, it was a case of coldhearted incompetence by six doctors at three separate hospitals, each of whom had ignored a blatantly lethal condition and mistreated the patient. Incredible! That was the story emphasized again and again in the formidable testimonies of Drs. Chabon and Shulman. The press, meanwhile, dramatized the image of a young mother shuttling from one hospital to another, unheeded and intimidated, in the fruitless attempt to save her child’s life. Powerful stuff. No wonder the parents and their neighbors-and the high-powered attorneys from Grand Rapids-had absolutely no doubts about who had killed little Roberta.
Emotionally, the response was perfectly understandable. But factually speaking, was it justified? Were the doctors really to blame for Roberta Hansen’s death? Could they indeed have saved her?
Pushing myself away from my paper-strewn desk, I leaned back in my chair and tried to piece things together. What I needed was a common denominator, a starting point. That was relatively easy. The handle was obviously the brain abscess. How did Roberta get it? How long had she had it? Was it the cause of all her symptoms? Should the doctors have recognized it earlier than they did?
The most common cause of brain abscess in children is the spread from the middle ear of a bacterial infection called otitis media. But Roberta’s medical history was puzzling on this point. The doctors at both Lee Memorial and Borgess had examined her and found no evidence of the disease. Nonetheless, she had responded favorably to ampicillin, a standard remedy for otitis media! Why?
The first surgeon had removed large amounts of infected fluid from the child’s brain. This he turned over to a bacteriologist, who, he hoped, could identify the offending organism and recommend the most effective antibiotic to use against it. Two of the organisms thus cultured could indeed be linked to an infection of the ear or the upper respiratory tract. This bit of evidence supported the standard scenario: the doctors had missed Roberta’s ear infection, and the oversight had allowed the pathogens to multiply and to travel the short distance from the ear to the brain.
That scenario didn’t explain the presence of the other five types of bacteria that emerged from the culture dish, however; these were all essentially “good” organisms, ones that help digest food in the intestinal tract. In the brain, however, they were a long, long way from home-and highly toxic. How, I thought, did they get all the way up there?
Then I recalled something Jonathan Hopkins, my former student, had noted in his surgical report. It was Hopkins who performed the second and third operations on Roberta. Coming late to the case, he wasn’t named in the suit, but he was familiar enough with it to provide an important clue. While recounting how he had drained pus from the abscess, he remembered but unmistakable odor of fecal matter-not exactly typical of the normally odorless environment of the brain.
Voila! I was now sure that I had all the major clues I needed to solve the “murder” of Roberta Hansen. I spent another week impatiently gathering corroborating evidence, and then I telephoned Hammond.
I’ve solved the case,” I told him somewhat immodestly-and unwisely, because one never knew how the jury in a personal injury suit might decide, no matter how powerful the arguments presented for the defense. “But I still can’t travel to Michigan.”
“That’s O.K.,” said Hammond. “Michigan will come to you.”
On the morning of Tuesday, January 18, 1983, eight lawyers appeared at the door of my second-floor office at Cornell. Hammond had made arrangements with the judge in Kalamazoo so that my testimony could be taken in New York. Present, in addition to Hammond and his associate, were four lawyers representing, variously, other doctors and hospitals named in the suit, as well as two attorneys for the Hansens. A device combining a video camera and a tape recorder was switched on to capture not only my words but, presumably, any facial tics or mannerisms that might be helpful later in judging whether I was telling the truth.
The Hansens’ attorneys were full of forced joviality. They appeared comfortable in the knowledge that the high-megaton yield of their own expert testimony would easily flatten whatever feeble arguments I was about to muster. After all, as they took pains to point out, what could a professor of tropical medicine know about a case from Michigan? They had obviously been forced to fly all the way to New York on some kind of wild fishing expedition concocted by a desperate defense. Still, they were prepared to be good sports. So they sat back smugly while Hammond, camera rolling, questioned me about my background and qualifications.
No claim was made that I was an expert on the brain or its malfunctions. It was agreed, however, that, as a pathologist, I was no stranger to the cranial abscess. Neither did the Hansens’ men dispute my expertise in the field of parasitic infection, unimportant though that seemed at the moment.
Had I ever given medical testimony in court before? Hammond asked. Yes, I had. As a young pathologist in Panama, I explained, I had appeared in court many times. I told them how, in the days before television, the coroner’s inquest, with its tantalizing mysteries of mortality, was considered big-time entertainment, and entire families would pack the courthouse gallery for the hearings. The Hansen men chuckled in a relaxed fashion. I could see that I was being perceived as a harmless old spinner of yams, even less of a threat than they had anticipated.
“What is your attitude toward malpractice suits?” Hammond asked.
“Pretty neutral,” I said. “I’ve never been sued.”
“Would the fact that several of the defendants are physicians prejudice you in their favor?”
No,” I said. “I propose simply to give testimony based on the facts of the case.” The Hansen men guffawed as though they’d heard this response before and weren’t inclined to believe it now.
“How many times have you testified in malpractice suits?”
Never?” Even Hammond had a hard time believing this one. Many doctors, especially those who have survived 50 years in medicine, have either been sued for malpractice at least once or have been involved as a trial witness.
“Yes, this is my first malpractice suit,” I said, displaying a halo of innocence and honesty. For the first time, the Hansen men shifted uneasily in their seats.
Hammond proceeded to ask me whether I’d had the opportunity to review all relevant records in the Hansen case. I told him I’d looked at every page of the voluminous material and I’d read much of it sentence by sentence.
“And have you reached a conclusion about the cause of death, Dr. Kean?” he asked, a note of confident anticipation rising in his voice.
“I have,” I said.
“And is your conclusion in harmony with the opinions of the medical experts who have previously testified on behalf of the plaintiffs?”
“No, it is not.” The Hansen men hardly seemed surprised. They exchanged knowing smiles.
“Would you please explain?” asked Hammond.
“Well, in my opinion,” I began, “the nature of the disease that killed Roberta has not been understood by anyone who saw the patient, including the physicians in the three emergency clinics, those who took care of her in the hospital, or the experts who reviewed the case.”
“What then, in your opinion, Dr. Kean, caused Roberta Hansen’s death?”
“Involuntary manslaughter,” I declared. I had hoped to get everyone’s undivided attention-and I succeeded. The attorneys for the plaintiffs rose involuntarily as if standing to attention, and then, recovering momentarily, sat back down. Hammond, who hadn’t been expecting me to pronounce a verdict in the case, but only to render a medical opinion, swallowed hard and asked, in a curiously fluty voice, “Involuntary manslaughter by whom?”
I paused briefly before saying, “Roberta’s three-year-old cousin–although manslaughter’ may not be entirely appropriate in this case.” The roomful of lawyers sat in stunned silence. The division between opposing sides had dissolved temporarily, because everybody was now equally confused. Even Hammond sounded a little defensive. “Please explain yourself,” he said.
“Gentlemen ‘ I said, “it will take me 45 minutes to explain to you exactly what transpired. I will go through a chronology of events at the end of which the identity of the murderer will be clear to everyone. Please bear with me.”
After a brief recess, during which I assembled slides and diagrams to help illustrate my case, I began to explain to the lawyers the strange anatomy of Roberta Hansen’s disease.
“Roberta Hansen,” I began, “was killed by a biological bullet to the brain. I will explain the nature of that bullet, and then I will tell you who, in all probability, caused it to be fired.”
I pointed to the first important clue -the bacteriological study of the brain abscess. I reminded them of the seven organisms discovered there and explained why at least five of them, the normal inhabitants of the intestinal tract, had no business being inside the skull in the first place. Most intracranial abscesses are caused by one organism, sometimes two. Seven was almost unheard of-and five of the seven belonged in the gut! Bacteria coming all the way from the remote, unsanitary bowel had been responsible for Roberta’s roaring infection. The fecal matter smelled by Dr. Hopkins was further proof of their presence in the brain. So how did they get there?
“The biological bullet,” I said, “was a parasite, gentlemen-a parasite called Ascaris lumbricoides, the common roundworm.” I looked around the small, impromptu courtroom, and I counted eight pairs of knitted brows.
I explained that A. lumbricoides had been vastly underestimated by the medical experts in this case. This was despite the fact that the record clearly showed the parasite in proximity to the scene of the crime. Roberta had passed roundworms several times-at home, in the outpatient clinic, and in the hospital. Indeed, an antihelminthic drug was prescribed. For the most part, however, the phenomenon was considered unrelated to Roberta’s more baffling, more serious symptoms. The worm got lost in the shuffle. A lot of kids have worms-no big deal.
This reaction was not at all unreasonable. In the vast majority of cases involving humans, the roundworm is a fairly benign character. The patient becomes infected by swallowing eggs that have been deposited via another person’s feces, usually in the soil (and raw vegetables, especially lettuce, are not rare vehicles for transmitting the infection). Once inside the stomach gastric juices obligingly bum away the eggs’ tough protective coating and then gently shunt the little bundles along to the duodenum, where the larvae hatch and begin their bizarre trek to adulthood. Burrowing into the blood vessels lining the gut, they hitch a short, turbulent ride to the liver, where they stop long enough to gorge themselves on blood before tunneling on into the air sacs of the lungs.
Three weeks after entering the host, the worms, now in exuberant adolescence, are really ready to show their stuff. Shinnying up the major lung tubes, the bronchi, they slither past the larynx, reach the tip of the epiglottis, and then, using it as a kind of high-dive platform, plunge back into the digestive tract. Six weeks after arrival, the worms, now young adults, are back where they started and ready to get down to the serious business of reproduction. The average mature female is astonishingly prolific, producing nearly 200,000 eggs daily for five to seven years-or approximately a half billion potential parasites! Just what inspires the worms, which will eventually grow to lengths up to ten inches, to undertake their existential journey in the first place only to return to biological square one in the gut remains a mystery. Happily enough, most human victims remain oblivious to the parasites’ comings and goings and, aside from a mild, flulike pneumonia caused by the larvae passing through the lungs, the worms do little actual harm.
“There is one important exception,” I said, as I looked around the room once again to find the lawyers reacting queasily to the mental images produced by my rather graphic explanation. “Sometimes the questing larvae make a wrong turn,” I said. “Instead of completing the circuit via the lungs and arriving back where they started–in the gut-they lose their way and wind up in exile in some remote organ, even the brain, carrying many harmful bacteria from the bowel with them as they go. The host organ reacts by forming first an abscess and then a cyst around the invaders.
“The specific symptoms these lost patrols of parasites produce, which can be very serious in nature, depend on where they get trapped. The boil formed around them is usually in a silent area of the body where it gets walled off and absorbed. Occasionally, however, the immune system fails to fight off the infection, and the boil, instead of shrinking, gets bigger and bigger. The brain is a particularly poor resister.
“In the case of the child in question,” I continued, “one or more of these maverick larvae entered her brain, carrying piggyback a collection of lethally infective organisms from the intestinal tract. So you see, gentlemen, Roberta did not succumb to complications arising from an ear infection that was overlooked by her doctors. The source of the abscess is clear. Roberta died of a tropical disease in northern Michigan.”
One of the Hansens’ lawyers stood up. Forgetting the video camera and the fact that, technically, the floor still belonged to Hammond, the lawyer blurted out, “But what about the cousin? You said the cousin was guilty of manslaughter.”
I must confess to having made that statement mainly as a ploy to get everyone’s attention. O.K., it was a shallow ruse-but it had worked. Furthermore, it pointed to a possible explanation for what was perhaps the most baffling question of all: How had Roberta Hansen acquired a tropical disease in chilly northern Michigan?
I explained: “Roundworms do exist in Michigan, even in northern Michigan, although the disease is much more common in the South. Many, many schoolchildren in Mississippi and Georgia become infected with roundworms. The incidence of the disease in Michigan, on the other hand, is very low. So it is quite likely that, in this particular case, the source of infection was of a long-distance nature. Had Roberta ever traveled outside Michigan? No. Then the disease must have come to her. But how?
“We know that Roberta must have become infected sometime in May of 1981, since it would have taken that long for the roundworm wriggler to hatch, work its way to the brain, and produce the symptoms of severe infection the patient exhibited when she appeared at the emergency room of Lee Memorial in early August. The rest of my answer is to be found in the pretrial testimony of Brenda Hansen, Roberta’s mother.
“Mrs. Hansen reported,” I went on, “that, in the fall of 1980, her sister arrived on a visit from her home in North Carolina. She was accompanied by her three-year-old son, Roberta’s cousin, who had a history of roundworm infection. For a period of several days, the children played in a sandbox in the Hansen backyard before the visitors returned to the warmer-semitropical-Southern climate.
I paused for a moment before presenting my final theme. The Hansen men had lost their earlier shine and sat there looking a little crestfallen.
“We can never be entirely sure,” I said, “but my guess is that Roberta’s cousin, in the informal toilet habits young children often display, deposited the eggs in the backyard during one of the play sessions. The child went back to North Carolina with his mother, but the eggs stayed behind.
“The eggs are tough. They have a hard coating that allows them to withstand vast swings in temperature-even a Michigan winter. So there the eggs remained, buried in the sand, buried under several feet of snow. Come spring, Roberta was allowed out into the yard to play in the sandbox. The eggs were lying in wait. They stuck to her hands, the hands went into her mouth, and she managed to infect herself. Her cousin was the accomplice-.”
“Are you saying, Dr. Kean,” Hammond interrupted, “that, no matter what might have been done for the child, she would have died?”
“That’s precisely it,” I replied. “Up against that agglomeration of organisms, no antibiotic regimen could have been successful. The child was biologically doomed before she set foot in the first emergency room or was examined by a single doctor. Unfortunately, the result would have been the same in any institution around the world, New York, Nairobi, or Kalamazoo. She was killed by a roundworm-not by a doctor.”
The Hansens’ attorneys were beaten men. When Hammond offered them a chance to go at me, they simply said, “No questions.” They seemed eager to return to Grand Rapids. The following da , wrote later, the Hansens agreed to drop their suit. Their lawyers, who had turned down repeated offers to settle out of court, were now willing to talk. A deal was eventually struck under which the hospitals helped defray the Hansens’ medical bills. In return, the doctors were cleared of all charges.
I was happy at the outcome but couldn’t help feeling a twinge of sadness too. As autopsies go, I knew the Hansen case would be a very hard act to follow. It had taken a lifetime of experience as a clinician, pathologist, and parasitologist to produce a satisfactory answer to a unique problem. I’d also been very lucky in stumbling across the right clues. So I vowed to myself to make this the last “autopsy” of my 50 years in medicine. That’s the good thing about your average clinical patho-parasitologist-he usually knows enough to quit when he is ahead.
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