Tiny toothpick does much damage

Dr. Shahar Madjar

Dr. Novick’s love for mathematics had started years before he saw Steve, the young athlete who became suddenly, severely ill. Novick didn’t find interest in the quadratic equation, nor in mathematic expressions of physical phenomena of energy and mass.

Instead, he searched for meaning in shapes. He lived alone in a small, one-bedroom apartment next to the hospital. His living room was bare besides a drawing by Escher showing the gradual transformation of rectangular fields into migrating birds. On a small table at the head of his sofa, he piled medical journals and copies of the Journal of Topology–a magazine dedicated to the mathematical study of shapes.

Novick saw the human body as matter fixed in space and time, no different than other shapes dispersed throughout the universe. What is the human body, he thought to himself, if not a mere convoluted pipe, a hollow flute?

In his mind, he could see himself discussing his theories with Dr. Jane, the curious, fifth-year resident:

“Are you saying I am a bagel?” She would ask.

“More like a donut, because you are so sweet,” he could imagine himself replying jokingly, then adding: “The truth is, Jane, that we are all shaped like a donut–a structure with a hole that runs through it, stretched like a long tube–on one end is a mouth, on the other a butt, and in between those two openings lies our digestive system: esophagus, stomach, small and large intestine–one long conduit that runs across us like air in a flute.”

“So what do you think is happening with Steve, the guy in room 6?” Jane asked Novick.

Novick asked her to summarize the case.

“He is an 18-year-old man, an athlete who was completely healthy until he suddenly developed abdominal pain and bloody diarrhea, and finally high fever and chills–a severe, potentially deadly infection. Yet,” she added, “there is nothing in his urine tests, nor on his CT scan to indicate the cause of his severe symptoms, of his devastating disease.”

“Look at Steve’s CT scan once more,” Novick said, pointing at the computer screen. “Do you see this area here? What do you think of it?”

Jane looked at the CT scan again. She, too, could identify a small collection of fluid mixed with gas just next to the colon and close to a blood vessel that supplies the sigmoid colon. “So what is it?” she asked.

“I guess it could be a lot of things,” Novick said, adding cryptically: “The body is a mysterious matter arranged around a hollow conduit we call the gastrointestinal tract. What comes in through one end of this channel, may change its form, may give away every molecule of nourishment, but eventually, it must leave through the other end, or else, disaster awaits. I think,” he added, “that we are dealing with a foreign body inside Steve’s intestines.

Could Dr. Novick arrive at the same conclusion had he not known topology? The answer is probably yes. I told you about Professor Weissberg, my mentor during a general surgery rotation, who had, in his office, a collection I called “Objects of Unknown Origin.” I am almost certain that the practical Professor Weissberg didn’t consult his knowledge of topology when he extracted these foreign bodies from his patients–objects that had been swallowed, or inserted into the rectum, that found their way into the intestinal tract by mistake or on purpose, as a result of an unfathomable urge or a pure mistake–objects that couldn’t find their way out: a coin, a small avocado pit, a fish bone, a set of dentures, a miniature bottle of wine, several sex-toys of different shapes and colors and a razor blade. Professor Weissberg had to remove these by using a scope, or by opening his patients’ belly.

Steve was taken to the OR. The doctors inserted a colonoscope through his anus and into his colon. The doctors saw a large amount of blood in Steve’s colon, and a two-inch long, thin, foreign body piercing the wall of the colon. They grasped the foreign body, but once they pulled it out, blood started gushing out of the penetration site. Several attempts were made to stop the bleeding, but eventually there was no choice but to perform surgery and remove the diseased segment of colon and the injured blood vessel that supplied it. The surgery was complex and complicated.

It took Steve several months of intensive rehabilitation before he could return to play professional hockey.

The doctors examined the foreign body they retrieved from Steve’s body. It was a toothpick made of wood and therefore not easily detectable on X-rays. It was a toothpick like those used to hold together an extra-tall sandwich served with a cold beer at a bar. Ingestion of a toothpick is associated with high rates of complications, and, in ten percent of patients, even death.

Editor’s note: Dr. Shahar Madjar is a urologist at Aspirus and the author of “Is Life Too Long? Essays about Life, Death and Other Trivial Matters.” Contact him at smadjar@yahoo.com.