Pathologists at odds over stroke death
April 25, 2002
Disagree on chiropractic role in woman's demise
It is one hot potato of an inquest that is taking shape at the coroner's court in central Toronto.
It frankly has everything -- immense stakes; duelling pathologists; a dollop of intrigue; powerful interest groups and a veritable rack of suits, which is to say lawyers -- but at its heart, of course, is Lana Dale Lewis.
Ms. Lewis is the woman whose Sept. 12, 1996, death the inquest is examining. She turned 45 on Sept. 8 that year, two days after she had been discharged from hospital after suffering a stroke and two days before she was back there in the grips of the one that killed her.
The inquest began only this week and thus far has heard little about Ms. Lewis the person, but a glimpse came yesterday, when the neurologist who was then treating her, Dr. Al-Noor Dhanini, was explaining some of the symptoms she had experienced.
Ms. Lewis was unsteady on her feet; she had headaches and a sore neck; she was a little confused, and when Dr. Dhanini held up his fingers and asked her to count them, she couldn't. There were certain quadrants missing from her field of vision.
She put it to him like this: ''It feels like I'm looking at a Picasso.'' Given the alarming nature of her symptoms and the panic that must have been gnawing at her edges, the description reveals a woman of rather magnificent, and literate, stuff.
That she died of a stroke is not the issue here. The question is what, if anything, precipitated it? Was it, as one pathologist who will testify later is expected to say, a stroke that arose naturally -- in other words, one that happened ''spontaneously,'' which in this context means it cannot be attributed to a particular trauma?
Or as Dr. John Deck, the pathologist currently in the witness stand, said bluntly yesterday, is it a virtual certainty that Ms. Lewis's death was ''a complication of chiropractic manipulation''?
That is the rub, or crack, as such an adjustment to one's neck is colloquially known. Indeed, the two words to which almost everyone at the inquest is acutely sensitized, even unto horror, are ''chiropractic manipulation.'' The preferred term is ''spinal manipulation,'' because it is apparently practised by other medical practitioners as well as chiropractors.
The two schools of thought appear to go as follows.
One, to which the chiropractors subscribe, holds that Ms. Lewis may have been predisposed to stroke by a number of risk factors -- she smoked, had a family history of heart disease, and suffered from hypertension, migraines and atherosclerotic disease that saw her vertebral arteries, the two that run alongside the spine before turning sharply as they enter the brain, build up with plaque such that they ''threw'' a blood clot -- or she may have been one of those cursed sorts who, in the course of merely gazing at the sky or just turning her neck or engaging in some trivial movement, may have injured one of the same arteries to fatal effect.
The second school traces Ms. Lewis's stroke to a visit, 17 days before her death, she paid to her Toronto chiropractor, where she received an adjustment or had her neck cracked, and which shortly afterwards, the coroner's counsel Tom Schneider said yesterday, had Ms. Lewis on the phone to her sister Judy, in tears from the pain in her neck.
Certainly, it is Dr. Deck's view that this latter is to a ''90%'' certainty the cause of Ms. Lewis's death, and it was also Dr. Dhanini's operating hypothesis while he was treating her.
The location of her first stroke, he said yesterday, was not typical of the sort of stroke caused by long-term, chronic high blood pressure; on a CT scan of her brain, he explained, the injured area is shown in ''big black areas at the back of the brain,'' and not the ''little tiny holes'' that are seen with hypertensive strokes.
Neither, Dr. Dhanini said, did it resemble the sort of stroke caused when a blood clot develops in the heart. Such clots, he said, usually move gaily along the straightaway of the vertebral artery into the brain; they don't lodge in the artery, as Ms. Lewis's clot did, and block it. And there was also the neck pain of which she was persistently complaining, and which, according to nursing notes from the hospital, saw Ms. Lewis ''rubbing her left posterior neck.''
So suspicious was Dr. Dhanini that there was a link between Ms. Lewis's visit to her chiropractor and the arterial dissection -- this is a break in the wall of the artery that allows blood to flow between the layers of the wall, separating or dissecting them -- that after she died, he notified the coroner's office.
Interestingly, the two pathologists -- Dr. Deck and Dr. Michael Pollanen -- originally were in agreement that there was ''a strong likelihood'' Ms. Lewis's death ''came about as a result of chiropractic manipulation of the neck and spine.'' They jointly authored a report in April of 1997 to this effect.
But over the months and years that followed, as they each revisited the tricky subject, Dr. Deck became more strongly convinced of the rightness of that first opinion, while Dr. Pollanen backed away from it, early last year determining there was no definite cause of death, and then, late in 2001, coming to the view that Ms. Lewis had died of a natural disease process.
Dr. Deck is also expected to testify today that he felt pressured -- by the so-called chiropractic community and even allegedly by officials from the coroner's office -- to soften his findings.
To help the jurors, laymen after all, prepare to digest this complicated medical evidence and weigh the testimony of the pathologists whose field is as much art as science, Mr. Schneider yesterday called a University of Toronto anatomy professor to deliver a short, sharp lecture.
Dr. Patricia Stewart came armed with a Power Point presentation and even a bag of bones, among them a perfect, museum-quality cervical spine in a little airtight box, a human skull and a real human brain, from which the water had been slowly removed and replaced with plastic fill.
As she showed the jurors the little brain, she explained that the outer layer covering it, the dura mater, is so tough that in 23 years of teaching, though she always asks the brawniest medical student to give it a whirl, none of them has been able to tear it.
That's how durable one part of the human body is. Yet another, those arteries at the back of the neck, are so fragile that if you're just painting a ceiling, you may inadvertently injure them such that you suffer a stroke.
The trick for these jurors is to find where, along a spectrum almost as vast as that, is the truth of what happened to the woman who briefly saw the world as a Picasso.
Christie Blatchford can be contacted at firstname.lastname@example.org
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