Post 18 A pregnant pig helps me make a stunning diagnosis!

One definition of serendipity is ‘Looking for a needle in a haystack and finding the farmer’s daughter’.   Perhaps that’s a bit ‘Non PC’ these days, a bit sexist but no matter!    For me, serendipity was having a pregnant pig help me make a stunning diagnosis – let me tell you more.....

I had taken the written papers and my bedside competence in matters medical had been assessed by an evil physician, who had derived great pleasure from laying bare the paucity of my knowledge  (described in Post 10).   The final part of the examination to determine whether I was fit to become a doctor was a test of my knowledge of surgical matters.

My examiner was Sir William Warrender, the most senior surgeon at the City General Hospital, for whom I had a great deal of respect.   I had undertaken part of my training on his 'firm' and found him to be a ‘fatherly figure of the old school’.   He was patient with students, a good teacher with the wisdom of long experience;   I had every confidence that his assessment of me would be entirely fair.

He took me to the far side of the examination hall and introduced me to a generously proportioned West Indian lady of about 50 years of age. 

“I would like you to have a look at the swelling on the front of this lady’s right shoulder,” he said. 

I said a polite “Good morning” to the patient and asked her permission to examine her shoulder.    Sir William was the perfect English gentleman and I knew this was what he would expect. 

There were a number of rolls of fat around the shoulder but in addition there was a lobular, rather ill-defined swelling perhaps three inches in diameter.   It was difficult to be sure whether this was a definite abnormality or merely a part of her general adiposity.   The lump appeared to be slightly firmer than the surrounding fat and had a vaguely nodular feel to it.   I thought it was a simple lipoma, a common fatty swelling of little consequence.   I was just about to say so, when I detected a slight prominence of the skin overlying the apex of the swelling.   Looking carefully at it, it seemed that the skin in this area seemed perhaps to be even darker than that of the surrounding Negroid skin.

In a fortuitous moment of true inspiration, a picture appeared in my mind of an artist’s drawing that I had seen in an early edition of Bailey & Love’s classic ‘Textbook of Surgery’.   This depicted a lady sitting in a chair feeding two infants simultaneously.  One was suckling from her left breast whilst the other infant was suckling from a second breast situated in the groin on the same side.  Just as a sow has a string of breasts on each side of her belly (the ‘milk line’), so humans may occasionally have an additional nipple along a similar line and even more rarely, have some breast tissue underlying the extra nipple. 

Wondering whether this might be such a case, I asked whether she had a family and if so, had she noticed any change in the lump during pregnancy.

“Oh yes, Doctor,” she said, (not understanding that I was still a medical student), “the lump got very much larger and became quite painful.”

“In that case,” I said to Sir William, “although this swelling has the appearance of a lipoma, because it has this little nodule on the summit and since the  swelling is situated on the ‘milk line’, it could be an accessory breast with a rudimentary nipple.

“My, my,” said Sir William, “and that would explain why the swelling got larger in pregnancy.   I’m always telling my students that ‘common things occur commonly’ and that it’s dangerous to diagnose rarities but I do believe that you are right.  I must confess that we presented this lady today as an example of a simple lipoma but I agree with you; it almost certainly is an accessory breast.  Congratulations, young man!”

I left with my head held high, delighted with the way the examination had gone. I had successfully diagnosed a rare condition and had undoubtedly impressed my examiner.

The results of the final medical examination would not be known for another week.   For me it meant an anxious wait.  This surgical viva had undoubtedly gone well, but my concern was my embarrassingly poor performance in the medical assessment.  Would one good performance cancel out the poor one?

 The answer to this question will be the subject of a future Blog!

Comment  

Some of the patients who participated in these exams were in-patients with acute problems; others were ‘chronics’ who attended year after year.   Few patients when asked to fulfil this role declined; most seemed to enjoy the experience.

This story is adapted from ‘THE FIRST CUT’ which is available from Amazon as a paperback or ebook.

Quotation of the Day

‘In reality, serendipity accounts for one per cent of the blessings we receive in love, life and work. The other ninety nine percent is due to our efforts.’                                                

 Peter McWilliams 1949- 2001

Extract from a doctor’s letter: Both breasts are equal and reactive to light and accomodation