Polite Dissent

Black Jack is a famous manga character written by Osamu Tezuka. He is a supremely skilled surgeon, though an unlicensed one. Often he is the only surgeon skilled enough — or even willing to — perform a particular lifesaving operation. He will operate on the rich and the poor alike, and lives by his own code of ethics.

Tezuka was a medical school graduate and did his best to add medical accuracy to his stories, though he never let that stand in the way of a good plot — you’ll notice that many of the stories contain implausible fantasy or science-fiction elements. The stories were published over a ten-year period, from 1973-1983, so it’s also important to remember that they were written 20-30 years ago and medicine has come a long way in that period of time. There is sometimes a difference in the approach to certain patients and conditions between Western and Eastern medicine, and that occasionally shows up in the stories as well.

Vertical has recently started releasing a very nice collection of Black Jack stories. These volumes present the stories chronologically as they occur in Black Jack’s life. (This is different than the order in which the stories were originally published). My copy of Black Jack: Volume 1 is the limited edition hardbound and the pages references below match that edition. Hopefully, the pages numbers are the same in the softcover edition as well.

In my annotations below, I’ve added the year the story was first published. Consider this a strong Spoiler Warning as well. Click “Read More” to read the rest of the post.

1. Is There A Doctor (1973)
The first surgical surgical scene (page 22) shows a midline incision of the abdomen, with a layer of fat directly under the skin. Black Jack is now cutting through the peritoneum (a thin tissue layer that surrounds the abdominal cavity). As a nit-pick, that looks like an uncomfortable and awkward way to hold the scalpel.
The second surgical anatomy scene (page 23) shows Black Jack removing the stomach.

2. The First Storm of Spring (1977)
The description of Leucoma (also “Leukoma”) is correct (“the disease…turns…the cornea white and cloudy”). As Tezuka states, leucoma refers to a scarring of the cornea and can be due to a variety of causes including infection and trauma. In severe cases, a corneal transplant is required. The anatomical picture of the eye on page 38 is also quite good.
The idea that the any part of the eye (especially the cornea) can remember what it has seen is pure fiction.

3. Teratoid Cystoma (1974)
The patient presented before Black Jack has a fetus in fetu. This is a rare condition where a malformed fetus is found growing within a patient. This is not a pregnancy — it can occur in men or women — but instead the discovery of a partially developed fetus that likely has been present for years. Don’t think of it as a complete fetus either, but instead a collection of partially differentiated tissues.

There are currently two theories of how a fetus in fetu forms:

Tezuka refers to both theories in the story. He describes the twin theory, but then refers to the growth as a teratoid cystoma. To me, this seems contradictory, but it may represent the understanding of fetus in fetu when the story was originally published.

No fetus in fetu has ever been found with anything resembling functional brain tissue, let alone a complete brain (not to mention a psychic brain). They also aren’t developed enough to survive outside the host body, even in a special glass or plastic case.

4. The Face Sore (1974)
A story with strong fantasy elements. The medicine is fine.

5. Sometimes Like Pearls (1974)
When the body encounters a foreign object, it will often try to wall it away from the surrounding tissue by encasing it in a type of scar tissue. Over time, this scar tissue can become calcified. That is what happened to the retained scalpel in this case, left in the body for seven years.

Dr. Honma has suffered a cerebral hemorrhage, which is a rupture of one of the blood vessels supplying blood within the brain. This is usually due to a hemorrhagic stroke, but can be caused by trauma as well.

Black Jack has decided to open the skull, drain the blood, and repair any damage. However, you can’t perform surgery like this on a hemorrhagic stroke as the bleeding is within the brain tissue itself. I suspect that Tezuka is instead referring to a bleed from one of the blood vessels surrounding the brain, which leads to a subdural, subarachnoid, or epidural hematoma. These can be repaired surgically, and the panel showing Black Jack suctioning blood from around the brain seems to support this interpretation (page 110).

Unfortunately, Honma suffers a cardiac arrest while on the operating table and dies.

6. Confluence (1974)
Black Jack’s secret love Megumi has been diagnosed with uterine cancer (more specifically it is probably endometrial cancer, an unfortunately common cancer). Black Jack elects to treat her himself and performs a total abdominal hysterectomy and bilateral salpingo-oophorectomy (he removes the uterus, both ovaries, and both fallopian tubes through an abdominal incision. This is shown in a nicely drawn panel on page 132, though the anatomical drawing on page 129 is a little simple for my taste). This is the recommended treatment for endometrial cancer (the most common type of uterine cancer).

What I have a problem with is some of the text that accompanies the art and the strong implication that after surgery she is more man than woman:

It’s true that without a uterus and ovaries Megumi won’t be able to have children, and she won’t be producing estrogen or progesterone (and by the way, sex hormones which are produced in the ovaries, not the uterus). There will certainly be some changes as Megumi is going through an early surgical menopause, but it is nowhere near what Black Jack is saying. Common symptoms include hot flashes, thinning of the skin, weakening of the bones, vaginal dryness, decreased libido, and mood changes. The appearance and severity of symptoms varies widely among women going through menopause (natural or surgical). None of these changes make her “quit being a woman” — unless your definition of woman is based solely upon reproductive ability. Here’s an experiment to try yourself: tell a menopausal woman that she’s no longer a woman or unfeminine and see what happens. I recommend you duck and cover, quick.

Tezuka’s approach could certainly be due to fact that the story was written 20-30 years ago, and our understanding and treatment of menopause has come a long way in that time. There may also be an East/West difference in the approach to her situation. Regardless, it strikes me as a rather misogynistic and paternalistic view.

On the other hand, the fact that Black Jack discussed the diagnosis and treatment directly with Megumi was a very progressive approach. Traditionally, fatal diagnoses are not shared with the patient in Japanese culture, but discussed with the family while the patient is essentially lied to about their condition and treatment. We had several lectures on this particular topic during my medical ethics class in medical school.