Dr. H. Austin first case

Even though most physicians are completely unaware of the existence of back mice nowadays, they have been studied throughout history by many physicians that were intrigued by them sometimes BY CHANCE.

This is the story about how Dr. H. Austin (one of our collaborators) operated on his first patient back in 1963.

The First Case of Painful Lipoma of the Low Back, 1963

Jerry was 35 years old and was in such back pain he hadn’t been able to get out of his bed at the VA Hospital for a month.

I was a first-year resident in surgery, having just completed a surgical internship, only a year out of medical school.  This was my first three-month surgical rotation, July through September, 1963 — in the neurosurgery department at the VA Hospital in Albany, NY.   All 25 patients in the three open wards were mine to look after, under the auspices of several local neurosurgeons who made frequent supervisorial visits and performed any neurosurgical procedures a veteran might require.  All the patients were over the age of 60.   Most of were either stroke victims or being treated for brain tumors.   Except Jerry.

As I performed the required chart reviews and physical exams on each man, I got to Jerry’s bed on the sunlit afternoon of the third day.   I had brought his chart, but decided to talk with him and examine him before reading it.

He told me that he had had back pain for years and that he “had a disk” and that he had been in the hospital for a month and that he was in great pain.

“When are they going to operate?”

“They already did.  A month ago. They did a four-hole exploration—both sides of L4-5 and L5-S1.”  He was surprisingly clear.

“What did they find?”

“I’m not sure, but I think they what they meant was …  nothing.”

“Did the operation help?”

“Not a bit.”

That’s weird, I thought.   Once a surgeon frees up the pinched nerve, the pain goes away. Simple. That’s what I had been taught.

“Well, I have to examine you”.

He moved in bed with great difficulty, trying to help.   Clearly in pain.

“I’m sorry but I need you to stand up.”

“Hey, I can’t. I haven’t been out of bed since the surgery a month ago.”

Even with my help, he was barely able to stand by bracing himself with both hands on the mattress.  He winced with pain.

There was, of course the expected vertical midline scar, well-healing.  But, something else.  As he turned, the sun shone on his back obliquely, revealing a tennis-ball diameter mound, maybe half an inch high, just below the right posterior iliac crest.  A lipoma, I thought and, to confirm, pressed it.  He screamed.

“That’s it!  That’s it!  That’s what hurts!”

I then said the stupidest thing I can remember having spoken in my entire medical career.

“It’s just a lipoma.  Lipomas don’t hurt.”

He yelled at me.   “That one does!!!”

Then I said he second stupidest thing.

“You should have told the neurosurgeon that.”

“I did. Of course, I did.  He said the same thing you just did.”

I was so embarrassed I wanted to make it up to him.

“How about I put you on the surgical schedule for tomorrow and I’ll take it out?”

“Yes!   Yes!”   He was adamant.  I must have been his last hope.

The next day, the patient asleep, prepped and draped, the surgical tech across from me ready, I incised the skin and began to remove the lipoma, distinct from its surrounding fatty tissue.  Lipomas, a benign tumor of fat, are easily removed intact, a lump of fat the same size one would guess at.

Not this one.

It just kept coming and coming as I pulled on it.  It came mostly as a single lump, then as a fat strand through a hole in the underlying fascia.   As I pulled the strand, it expanded, first double the size I expected, then, as more and more came, it tripled in size.   I was surprised, never having heard my professors mentioning such a thing. It just seemed to have no end.  I found myself imagining I would be pulling a piece of bowel out, havaing no idea what that  fat-strand might be attached to.  Finally, I simply cut it off and the cut end, not bleeding, retracted back in.

I was left with a huge handful of fat, four times the size I would have expected, and an open wound.

We closed without incident and sent Jerry to recovery.

The next day I made my morning rounds to find him standing by his bed, completely dressed with suitcase by his side.  I was dumbfounded.   “Where are you going?”   “Home”, he said.   “But….but… aren’t you in pain?  “Nope, not bit.   Thanks, Doc.”   And he walked out with a head nod and a wave.

I felt like my universe had been turned upside down.   I had cured a man that a trained and experienced neurosurgeon, my senior in every way, had not been able to.  A medical newbie, I had seen, thanks to the sun shining exactly right, what he had missed.   I had stumbled upon something I had known nothing about and my instincts, not my training, had guided me to do the right thing.  I felt a little frightened. Didn’t know how to talk about it.

I stumbled my way to the medical library and used every key word I could think of to try to make sense of what had happened – back pain, lipoma, subfascial lipoma, fatty lumps… and others.  Nothing. Then I stumbled upon one single article in a journal from 1935 —Surgery, Gynecology and Obstetrics, commonly known as “S,G, and O” — entitled something like  “Anecdotal Case of Lumbosacral Pannicular Hernia.”  Awkward name, but it felt technically correct.  Well, at least now I knew that yesterday had not been an illusion.  There really was such an entity.  Yet, one so obscure I could not find another case reported in a major surgical journal in the intervening thirty years.

I was proud of myself.  I had found a rarity!  And cured a guy!   Looking back, that was an important moment in my life.  At that point, juvenile hubris aside, I considered myself a real surgeon, confident and competent, ready to take on the world.

Dr. Harvey Austin