House — Episode 17 (Season 5): “The Social Contract”
A good episode of House with a fascinating premise and some good soap opera and social moments. The medicine was average, but didn’t hurt the episode much.
Nick Greenwald is a successful book editor who, while at a party launching his star author’s latest book, finds himself blurting out truth after uncomfortable truth to those around him. He then develops a nosebleed and collapses.
Nick is admitted to House’s service where the team notes that he reminds them of the classic case of Phineas Gage (a railroad worker who suffered personality changes after a spike was driven through his brain). Nick is showing signs of frontal lobe disinhibition, but there is no sign of a frontal lobe tumor as his head MRI is negative. Thirteen suggests that there may be a tumor hidden in the nasal cavity, but a nasopharyngoscope shows nothing. Next, an fMRI (functional MRI — an MRI that looks at blood flow within the brain) is obtained and reveals an abnormal area in the cingulate gyrus. Thirteen remarks that it’s too near the brainstem to biopsy, then Foreman mentions that it might be neurosarcoidosis (sarcoidosis which affects the central nervous system). Steroids are started to treat the presumed sarcoidosis.
Nick suddenly becomes very short of breath. Foreman states that it’s not his heart because the EKG is normal, so it must be kidney failure, and starts him on dialysis.
The differential now includes systemic sclerosis and chronic lymphocytic leukemia (both of which are quickly dismissed), as well as diabetes, and some sort of “congenital genetic disorder.” Foreman points out that there are too many genetic disorders to test for them all. House has Taub run a glucose tolerance test to check for diabetes, and has Kutner check Nick’s daughter for peripheral nerve damage because she suffers from some ill-defined neurological disorder and he thinks the condition might be inherited. The peripheral nerve test is normal, and Taub reports that the glucose tolerance test was completely normal and never above 120 for the entire night. House now wants to check the thyroid, but before the test can be ordered, Nick develops a fever, coughing, and pulmonary edema. Kutner orders 200MG of furosemide (a diuretic) and 2MG of morphine (primarily a pain killer, it also helps with pulmonary edema).
With Nick’s temperature at 103° (39C), the team now considers infection as the likely cause of his symptoms. Foreman mentions Staph aureus, tuberculosis, and strongyloides (threadworm). Kutner determines that a stray dog is living with Nick’s family and he and House suspect that Nick has developed Weil’s Disease (leptospirosis — an infection caused by the Leptospira genus of bacteria). He is started on doxycycline (an antibiotic) and his condition improves. Kutner and Foreman tell him that while the infection is cured, his brain damage and disinhibition are going to be permanent. Nick wants surgery to remove the damaged area, but they tell him it is too risky. He talks to House, who apparently sees some of himself in Nick, and talks Chase into getting his boss — a neurosurgeon — to perform the surgery. Initially, the surgery seems successful, but then it quickly becomes clear that Nick still blurts out whatever crosses his mind. That’s not all though, as his temperature starts falling dangerously low and he develops unstable ventricular tachycardia (and this is the right time to use the paddles). The arrhythmia is corrected and an echocardiogram is obtained, but shows no structural heart damage. Nick continues to have an abnormal temperature. The differential diagnosis now leans toward cancer, but Foreman rather cavalierly dismisses the idea. He orders a full body scan. This shows a small abdominal aneurysm (dismissed as an incidental finding), a cyst in the pleura (the membrane surrounding the lungs — also dismissed as an incidental finding), and a density in the liver. Foreman suspects this density represnts an ateriovenous malformation (AVM) and that multiple AVMs would explain the patient’s condition. He wants to go forward with angiography with embolization (a test to find and then block off the AVMs).
House is in New York with Wilson, but the team is texting him to keep in touch. In the middle of a conversation about Wilson’s guilt over his schizophrenic brother, House has his Eureka! moment. The glucose tolerance test that was normal should not have been normal because Nick was on steroids, which raise a person’s blood sugar. The fact that it did not rise, combined with the cyst — which is really a fibroma — in the pleura means that Nick has Doege-Potter Syndrome (a fibrous tumor that secretes insulin-like compounds and causes low blood sugar; Kutner mentions human growth hormone, but other similar chemicals can also be secreted). Nick has also developed an autoimmune reaction to the tumor, and his immune system has gone into overdrive and attacked his own body (brain, kidney, heart in this case). Removing the tumor should solve his problems — the medical ones at least.
They’re really weren’t any huge medical errors this week, just the usual hodge-podge of symptoms and diagnoses that really don’t fit. The worst was Foreman’s clueless statement about cancer, so that gets the prize this week. Well, there was also that one scene, but I’ve already spent enough space talking about it.
As usual, major complaints are in red, minor in blue, nit-picking in green:
A normal PSA, normal colonoscopy, and normal blood count absolutely do not rule out cancer. Admittedly, colon cancer and prostate cancer are the most common cancers in a man Nick’s age, but there are plenty of other cancers out there (plus there are concerns about how reliable the PSA test actually is).
Diabetes doesn’t really fit his symptoms at all — other than the kidney disease. Of course, it was just an excuse to run the glucose tolerance test.
Speaking of the glucose tolerance test, the patient needs to be fasting, and it doesn’t take 12 hours to run.
It’s true that the steroids should have raised Nick’s sugars, but even a normal patient whose blood sugar didn’t rise above 120 after a hefty glucose load would be unusual.
Brain damage and peripheral nerve damage are two different things. It’s more common to have one without the other than both together.
If Nick’s kidneys are shot and he requires dialysis (a very important fact that was never mentioned again in the show; the dialysis that is, not the kidneys), then even 200MG of Lasix is not going to have any effect.
An MRI of the brain should have shown any nasal cavity tumor, especially one that was eroding into the brain.
Too many genetic disorders to test for them all? But they tested for them all in at least two previous episodes.
House doesn’t like full body scans? Then why does the team order them so regularly.
A cyst is hollow, a fibroma is solid. A scan should be able to tell the difference.
I thought the medical mystery was good this week, it was interesting not only from a medical perspective, but also fascinating from a social perspective. It made me wonder what horrible secrets I might spill. I give it an A. The solution was fairly logical, even if it did require two diagnoses (Doege-Potter + autoimmune). It earns a B+. The medicine was average for the show and I give it a C; it might have scored higher had that one scene been clearer. The soap opera was the best part of the episode. There were good House/Wilson and House/Taub interactions (the squash racket was great), and the patient’s social interactions were like a car crash: painful, but impossible to look away. The soap opera earns a solid A.
Last week’s House review
A list of all prior House reviews
March 9th, 2009 at 9:53 pm
Best awful moment: At the end, when hubby is smilingly supportive about his wife’s promotion, and the look on her face tells us she can’t trust his sincerity anymore. (Does this marriage have a snowball’s chance in you-know-where of continuing?)
March 9th, 2009 at 9:53 pm
Good review. Scott, do you answer your Polite Dissent email?
March 9th, 2009 at 10:04 pm
Official Comment
Yes, but the speed I get around to it depends on how busy I am at the clinic, ehich lately has gone from “overbooked” to “overwhelmed.”
March 9th, 2009 at 10:21 pm
Love these posts…makes watching stuff on online MUCH better then TV. This was a quick update
March 9th, 2009 at 10:42 pm
Now, IANAN (I am not a neurologist; to borrow Scott’s disclaimer) but I do think that this episode misrepresented the Phineas Gage case/frontal lobe disinhibition.
As I understand it, Gage’s injury essentially resulted in emotional dysregulation. So, it wasn’t that he couldn’t help but say what was on his mind, it’s that he wasn’t feeling, or responding to, the emotional cues that govern social behavior. Thus, it is rather absurd that Nick Greenwald would say what was on him mind and then immediately express embarrassment or remorse over what he said, as lack of that kind of emotional response is what caused him to say it in the first place. This bugged me all episode.
March 9th, 2009 at 10:44 pm
Yes, the underlying theme of not saying what you think was well woven into both the medicine and the drama of this episode, from Wilson’s confession of always needing to be the nice guy to House arranging to have the patient tell Cuddy how hot she is (and her lying to House about her reaction.) I thought the writers got this one just right.
March 10th, 2009 at 12:38 am
As always, thanks for a good review!
March 10th, 2009 at 12:49 am
Thanks for the great review. I really enjoyed this episode, but one big thing about the ending bugged me:
Why didn’t his condition improve after he began taking steroids for the suspected sarcoidosis at the very beginning? Usually, when it’s a two part diagnosis, the patient gets better after the first correct treatment. Then, he gets worse, and House realizes it’s two diseases. This time, the patient only got better after they gave him the wrong treatment: The antibiotic for the suspected bacterial infection.
March 10th, 2009 at 12:51 am
To finish my previous post:
….The patient’s condition didn’t improve after steroids given at the beginning of the episode (which should have helped with the autoimmune reaction to the tumor), but his condition did improve after antibiotics (which should not have helped with the tumor or the resulting autoimmune reaction).
March 10th, 2009 at 1:20 am
Did anyone see the daughter’s burn coming when Kuttner told her “the better you do, the better your daddy will be?” I knew the poor little girl would end up seeing the test as one of endurance and not of nerve function. I thought this was meant to tie in with the episode’s overall theme of dysfunctional communication but it’s an interesting comment on doctor-patient relations as well as being careful what we say to kids. Also, I knew that was no racquetball racquet Taub picked up. He may not be that athletic but hasn’t he ever even SEEN one? Even on TV? Really?
March 10th, 2009 at 4:07 am
This isn’t a medical comment, but…
House’s claiming that Taub couldn’t compete with Wilson at racquetball because he’s Jewish is wrong for so many reasons, but one especially. Wilson is Jewish too!
March 10th, 2009 at 5:24 am
The “normal the whole time” glucose tolerance test struck me as odd. Having taken both 1-hour and 3-hour ones with both of my pregnancies, I recall that the “normal” range for each timepoint is different. Then I figured it was just the writers getting the medicine wrong. :) But then as part of the solution (or, at least, the eureka), I have a different question – if there was insulin plus “acting like insulin” circulating around, shouldn’t the glucose level have just crashed precipitously over the duration of the test?
And, after the teaser for next week, I can’t resist asking: will there be a “cat scan”? ;)
March 10th, 2009 at 5:38 am
I don’t have the faintest idea what a racquetball racqet looks like, either.
never seen one, not even on tv.
March 10th, 2009 at 5:58 am
It was a nice episode, and ironic to see House seeing himself on that patient.
And yes, I don’t think that the guy could ever have his life back again, his wife would always wonder whether he was being honest or not.
I also caught myself thinking what I would do if I was in his place. I would make my life miserable, who wouldnt? I always wonder how we sometimes keep things that just make us miserable in order to not make our lives even more miserable!
You sometimes just can’t understand how the team can stand House being demanding and trying to rule their lives. And yet, they do that cos they gotta pay their bills.
I liked the episode, good food for thought.
March 10th, 2009 at 7:46 am
Didn’t Gage get a rod through his head, not a spike?
Like a 2 inch wide rod.
March 10th, 2009 at 7:54 am
A great moment: Kuttner’s huge, fake smile as he tells the little girl “The better you do, the better your daddy will do!” or something like that. He gave a big, clumsy gesture, too. (Great acting from Kal Penn.)
The camera was at the child’s eye level, and he looked strange, not to say clownish.
I remember adults talking to me that way, and I think it was brilliant that someone had the imagination and understanding to give us that moment from the child’s point of view.
Kuttner meant no harm, but he obviously was out of his depth and didn’t know what to say. I also thought the patient nailing him on his poor bedside manner was a good development. Usually, all the baby doctors are overwhelmingly sincere and humane; it was good to see one of them being fallible and screwing up with a kid.
March 10th, 2009 at 9:31 am
GH only has insulin-like effects in people that are GH-deficient. In otherwise normal patients it raises blood glucose. Please see Table 5-5 in Greenspan’s Basic and Clinical Endocrinology.
March 10th, 2009 at 9:45 am
Sure, it was cruel, but it absolutely cracked me up when the patient started in with “Your mother’s not the smartest crayon in the box” and so forth, possibly because I found the wife so damn irritating. If you know your husband’s going to say everything on his mind, maybe that’s not the time for you and the daughter to hover over him, eh?
March 10th, 2009 at 12:21 pm
As faithfully as I follow these posts, I’ve almost come to dread them. Whenever I’ve seen an episode I really like, I come here the morning after and 1) Scott rips the medicine to shreds and 2) Scott’s posse tears into the remains until they resemble an anatomy class cadaver at spring exam time. Imagine my relief and delight when I found that Scott et. al. liked this episode almost as much as I did. This was not only believable medicine, but a wonderful opportunity for the writers to let it all hang out and be their snarkiest. My only disappointment was that I kept hoping for a direct face to face truth-off between House and Nick that never happened. Everybody took their licks except Sir Gregory. The self-examination of Wilson was especially good. I did wonder how Nick could indulge in anti-semitic jabs when he was so obviously Jewish himself. Self-hatred writ large? Nazi collaborator genes kicking in? One serious question: Is everyone’s inner truth always destructive, critical, and antisocial? Can genuine admiration and affection also blurt out if they are there all along? Have any published studies of this syndrome dealt with this?
March 10th, 2009 at 12:53 pm
This episode was great on so many levels I do not know where to start! The truth telling was without a doubt the best idea the writers had for this whole season! It led to all those great fun/truth moments – like Cuddy being angry that somebody actually found her hotter than a 25 years old bisexual chick, than smiling secretly because she is happy about it (and happy that it was House’s way of saying it too!) then right after that Foreteen unraveling – Foreman is actually just in it because she is hot and has a great ass and 13 angry for that same reason (while flattered!). I will stop before I recount the whole episode – I didn’t actually LOLed even once but I kept smiling the whole time. OK on to medicine:
1. D-r Scott could you please, please explain to everybody what exactly this Doege-Potter Syndrome is? Never heard of it in my life AND never studied it in any of my classes! Didn’t find it in any of my books either – I’m actually ashamed of being a doctor.
2. Doesn’t the glucose tolerance test involve eating instead of starving?
3. How on earth did Foreman jump from shortness of breath to kidney failure so fast? It made my head hurt. Lets for a sec assume that he had some bizarre logic behind that – shouldn’t he deal with the fact that the guy can’t breath before putting him on dialysis? If there is fluid in his lungs that is the big issue not the supposed kidney malfunction. His EKG may be normal but than how about pleural infusion/effusion? Both are possible (and most likely!) causes for shortness of breath. Never saw Foreman actually check if the jugular veins are distended OR his throat for obstruction either.
4. I suppose the infection mentioned was actually irrelevant for the major problem – however how on earth could he have an infection without any of the symptoms for infection? Fever, elevated white count (I recall Foreman saying it clearly “normal white count”.), increased hematocrit the whole enchilada? Sure he had that after the steroids but he should of had it before as well…
5. I suppose there is no point mentioning that Lepto needs more than a day on Doxiciclin to be completely cured…if only antibiotics worked in real life so fast as they do on TV.
6. The main complaint here was a frontal lobe dysfunction right? Why on earth do they think that a neurosurgery performed on a completely different part of the brain would help the frontal lobe problems? Shouldn’t Foreman THE NEUROLOGIST say something like “Hey that anomaly is in a different area of the brain?”
7. They always treat before they actually diagnose I know that, but hey he wasn’t dying at the beginning of the episode. When Foreman said “sarcoidosys” why didn’t he run an ANA? It a fairly common test for autoimmune problems (boy they sure like autoimmune in HOUSE!). Steroids are not so safe and they tend to give them left, right and middle here.
I’ll take a sidestep to explain to Khalil that the patient had both an infection (which didn’t cause the “truth” problem) AND an autoimmune syndrome (which apparently did though I still can’t figure out how…)
Apart for the nitpicks in medicine it was a great episode and I enjoyed immensely the whole action. They are recreating the magic from previous seasons and spicing it too! Well done.
March 10th, 2009 at 1:01 pm
@Ledasmom
But the wife wanted to stay with her husband _exactly_ to find out what he thinks about her, about their child etc. Wouldn’t _you_ like to plug your partner into 100% correct truth machine?
March 10th, 2009 at 1:03 pm
Official Comment
Doege-Potter Syndrome occurs when a fibrous tumor, usually in the pleura, causes hypoglycemia (low blood sugar) because it secretes an insulin-like chemical. It is considered a type of paraneoplastic syndrome.
For a glucose tolerance test, the patient needs to be fasting for 8-12 hours before, then they are given a set amount of glucose (usually 75gm) and the blood sugar is measured a set intervals afterwards.
March 10th, 2009 at 1:17 pm
I too wondered if everyone forgot that racketball-playing Wilson was also Jewish.
If the Patient had brain surgery – especially that deeply into the brain – why did he still have hair? Wouldn’t they have shaved his head? Or would they have used a very small probe?
They almost seemed to imply at the end that House left Wilson with his brother at Mercy Hospital and just took off – otherwise that conversation at Princeton-Plainsboro was a little odd, because they would have talked about it on the ride home, or in the waiting room at Mercy when Wilson rejoined House, not waiting until the next day.
—Kimberley
March 10th, 2009 at 1:40 pm
I thought the scene with Cuddy was very near the top of the heap!
March 10th, 2009 at 1:40 pm
Im a Neurobiology doctoral student in their first year and completing the second half of my neuroanatomy intro classes.
One of my big problems in this episode was the misrepresentation that operating on the cingulate gyrus is dangerous. It’s actually relatively easy since it’s a clear anatomical landmark. It would have to be a terribly sloppy surgeon using a lawn dart and hammer in order for them to get near the brainstem. That’s after he’s destroyed about 50 or more key nuclei or fiber tracts. The bigger concern would be hitting the anterior cerebral artery.
Secondly, the anterior cingulate gyrus is involved in the regulation of emotional and executive functions, INCLUDING the suppression of unconscious priming.
March 10th, 2009 at 3:11 pm
10x for the info on the syndrome and the glucose tolerance test! Completely missed the not shaved head part – good one Kimberly!
March 10th, 2009 at 4:13 pm
To joebeets,
Thats an interesting question. Is your inner truth anti-social and destructive? Personally, I think your inner truth is whatever you need it to be. Nick’s inner truth was hateful and impatient because displaying these emotions on the outside would have most likely resulted in divorce and unemployment.
Some people may truely enjoy their station in life and have no need to hide any negative emotions. Some may not need ot hide negative emotions because these emotions do not adversly effect their quality of life, House being the primary example coming to mind. But wait, there’s more! Perhaps House’s inner truth is all bunnies and rainbows, but transparently presenting this truth turns him into a second rate physician.
I think the inner truth you’re referring to is simply the pyschological manifestation of things we need to hide, good or bad. Most people probably hide bad anti-social things because displaying these things gets them the finger from those near and dear to them. However, people might hide good things too. I think one important aspect to realize is that just because Nick was hiding these feelings of contempt for everyone around him, doesn’t necessarily mean all of the good stuff was a bunch of lies. Think to the end, he really did love his wife … for what reason only God knows (especially when she stormed off near the end of the episode … yeah lady, your husband might not really love EVERYTHING you do … bear with him for a little bit, he is dieing after all).
In conclusion, I think you’re “inner truth” as represented in this episode is nothing more then the part of you that needs to be hidden for whatever reason. I don’t think everyone is inherently evil. or that their own bucket o’ truth is filled with nothing but nastiness, but it would be interesting to see a study on what exactly people do keep from the world at large … though how you’d go about gathering such information might present a challenge … I say “at gun point” would probably be easiest. People have pretty instinctive aversions to bulllets.
March 10th, 2009 at 4:45 pm
I didn’t like the medicine in this episode, there were a lot of diagnostic mistakes and the solution of the mystery was not a real solution at all.
Quite a mage Forman in this episode, not only can diagnose dyspnea due to acute renal failure, even without touching the patient , without mention anuria and without mention abnormal creatinin levels, but he even starts dialysis without any confirmation . Am I watching “the Mentalist” instead?
Finally why the nose bleeding? Don’t tell me it’s autoimmune disorder because I don’t buy it….
March 10th, 2009 at 5:02 pm
I loved, loved this episode. Definitely the best of the season, possibly the series (that includes the masterpiece Birthmarks). The medical case was truly interesting. And the House/Wilson scenes were perfection. And the ending suggest H/W have always had a social contract. The House/Taub scenes were awesome. I liked the team diagnostic sessions – really good.
March 10th, 2009 at 5:27 pm
Guy starts talking inappropriately, starts bleeding from his nose and then crashes to the floor. Now, as I follow what Scott wrote, the guy, Nick, has a fibrous tumor which leads to an autoimmune reaction and low blood sugar because it secretes insulin. So, the autoimmune causes the brain problem and thus the inappropriate speech. Was the brain problem what caused the nose bleeding? They didn’t see anything when they looked up his nose. Did he crash to the floor because of the low blood sugar or because of another problem with one of his organs being under attack from the auto-immune? Sorry if my question is silly, but I am non-medical.
I really liked this episode a lot. I thought the premise of examining the social contract that everyone follows was fascinating. And haven’t we all had a moment when that self-filter slips a bit because we are tired or sick or distracted. I thought the concept was well woven through the episode. I also liked the way it played in the Wilson-House scenes. I liked that they spent some time on those scenes with the two of them. House may not have the normal social contracts, but he has some. And, I liked the way it turned out that Wilson said he meeting his brother wasn’t either great or awful.
March 10th, 2009 at 6:17 pm
maybe unintentional … but “Potter” came up very early in the show .. when Kuttner compares the Patient with Harry Potter being under the Sorting-Heat.
fMRI-Analysis was very poor demonstrated. They would need to run a few (30+ i guess) experimentally controlled runs to see that relevant neurological activity (after averaging the data and rendering in onto the structural mri ..), in the scene all they would have seen is activity from the guy talking.
March 10th, 2009 at 6:42 pm
I may have missed something, as I was eating while watching the ep, but did they cut something out of his brain simply because he is always talking the truth?
Would removing brain parts not also have other effects? I always thought the brain was something that’s quite delicate. :)
March 10th, 2009 at 9:28 pm
I thought the scene at the very end, where Wilson was confusing himself so he asked whether House thought things would work out between him and his brother, was priceless. Wilson’s little gesture got a genuine LOL out of me, and proved yet again how important Robert Sean Leonard is to the show.
March 10th, 2009 at 10:57 pm
Aint this like the 4th episode in a row with no Cameron?
March 10th, 2009 at 11:30 pm
Thank you so much for a good review. I feel I can always turn here after watching a House episode to compare my thoughts about the episode. I thought this one was particularly good, and smacked of the first two seasons when the writers didn’t cram two weeks of medicine and one unrealistic, tidy, unimaginative plot into a single episode. I truly hope that they continue in this vein and take the soap opera plots slower and more deliberate rather than the gunslinger style, quick, one episode at a time.
March 11th, 2009 at 12:08 am
If the brain problems were caused by an autoimmune reaction, why didn’t the surgery solve the problem, and why did he get better as soon as the tumor was removed?
It was a good episode from a drama standpoint, but a mystery that is illogical and cannot be solved by viewers is irritating.
They should have removed the brain symptoms after the surgery and just added the ventricular tachycardia instead.
March 11th, 2009 at 3:15 am
Thank you for the explanation, D-r Bulgaria. Your explanation makes sense and occurred to me as well, but I dismissed it because it would mean that this poor man had 3 simultaneous condiitions. Infection caught from the patient’s dog urinating in his drink left on the floor without him noticing (fairly rare) plus tumor (quite rare) plus autoimmune reaction to the tumor (very rare). A perfect storm rare even by House’s standards.
March 11th, 2009 at 4:19 am
It isn’t the first time they implied autoimmune 10x to a tumor. Remember the dwarf episode(forgot the name it was in the Tritter story ark season 3)? May be it isn’t so rare but I am not truly qualified to tell… I’d thought para neo plastic syndrome after the tumor not autoimmune, but then it was a benigne tumor so I guess PNP is not possible. An Khalil you are 100% right – the steroids should have helped with the social inhibition if the autoimmune was the problem. Then may be that is why the infection came along (diversion from the authors?)
March 11th, 2009 at 7:13 am
Second appearance this season for Phineas Gage. His story, or one very like it, was referred to in an episode of Medium on that other network. Maybe he should get royalties.
March 11th, 2009 at 10:04 am
As “House” stands right now, it all went downhill after the brilliant and compelling Det. Tritter angle in Season 3 (with the exception of last year’s Season 4 finale, which was superb). The new team just doesn’t have the chemistry or quirkiness of Cameron, Chase, and Foreman and so week after week I look forward less and less to a show I once obsessed over enough to pre-order each new DVD box set that I may soon stop watching it altogether. Oh, and does anyone notice that Jennifer Morrison and Jesse Spencer have yet to be replaced with the new team in the opening credits? It’s like a slap in the face presenting the cast as we used to know and love them but then have Cameron MIA for about 4 episodes now. Seriously, what has happened to this show? My money is on “House” being cancelled if this continues for another season.
March 11th, 2009 at 12:09 pm
Hi,just wanted to say great review going on here been following your reviews from season 1!
Anyways,in response to one of the questions earlier,I think they didn’t have to shave his head because they were operating on the brain stem not the brain so they cut into the neck not the head(as shown by the bandaged neck).Not too sure cause I’m not a doctor but that’s my take on it anyways…Loved the whole Wilson thing as it kind of elaborates a point from the first season when Wilson first mentions his mysterious brother as a homeless person(correct me if I’m wrong but I think its season 1 Episode 10…)Also there’s been a retcon ’cause in the season 1 episode Wilson says he last saw his brother in an alleyway whereas this time the last time he saw his brother was outside a deli.
March 11th, 2009 at 2:15 pm
Michael:
Oh, and does anyone notice that Jennifer Morrison and Jesse Spencer have yet to be replaced with the new team in the opening credits? It’s like a slap in the face presenting the cast as we used to know and love them but then have Cameron MIA for about 4 episodes now.
I suspect this is purely contractual – once the contracts run out, the “new” regulars may end up with front billing, and Jennifer Morrison and/or Jesse Spencer may be written out for good.
Which, to me, would be a shame. While I’m in the minority here on this point, I rather like the idea of the former young guns turning up from time to time; it’s a reminder of How Things Used to Be and How Things Stand Now. I especially like how Cameron has matured and moved beyond House, even as the old dynamics come into play now and then.
March 11th, 2009 at 3:59 pm
Thanks a lot for the review, as usual.
Great episode
March 11th, 2009 at 4:31 pm
In response to the comments about Camerons absence, I for one have got to chip in- I really couldn’t care less. I love the new team (well, Taub & Kutner) and tbh think that Cameron, Foreman and Chase are completely redundant to the storylines now and should be let go completely. I loved this episode, as I have the last three or four, and can’t wait for next week! Thanks as usual for the medical review Scott, very interesing :D
March 11th, 2009 at 5:19 pm
They’ve said it before that House hates full body scans.
March 11th, 2009 at 5:43 pm
I’m glad the wife and kid played relatively bigger roles. With the exception of a few episodes (like the Gypsy kid), the patients don’t usually seem to have any family/freinds visiting, which I think is unrealistic.
Great episode…great last scene…
March 11th, 2009 at 7:10 pm
love it but here in surinam(sout-america) it hasn’t been shown yet we are at season 2(horrible). but i didn’t see but i think i love it cause all of them are marvelous!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
March 11th, 2009 at 7:13 pm
What on earth did they plan on doing in the brain surgery to correct his frontal lobe? Were they going to use scalpels and macroscopic surgery to fix damage done by antibodies?
This may be silly – I am but a lowly pharmacologist – but is it possible to fix damage down by one’s own antibodies in an autoimmune reaction with a scalpel and other surgical equipment? I would have thought that the damage done to his frontal lobe would be at a molecular and microscopic level, and not something that could be fixed with surgery. I mean, on other episodes where someone is affected by paraneoplastic syndrome, they dont fix them via brain surgery.
March 12th, 2009 at 11:25 am
Is there any precedent for an autoimmune disease causing somebody to blurt out whatever is on his mind?
March 12th, 2009 at 6:53 pm
I always check if you liked the episode I did. If you do, it gives me one more reason to like it. And I appreciate your extensive linking, as well as small witty comments.
BTW I just noticed the Disclaimers on the bottom of your site. Nice :-)
“Many suitcases look alike”? Where would that be?
March 12th, 2009 at 7:43 pm
Was Thirteen in this episode? How about Cameron? They are both delightful characters, the episodes they aren’t really involved in are boring. :(
March 12th, 2009 at 11:23 pm
People have been complaining about this season, but some of the soap opera has been as good as anything the show has ever done. The examination of the House/Wilson dynamic was fascinating (these are two of the best written characters on TV). I thought the writers dropped the ball the first few episodes when Wilson dumped House and it was resolved almost immediately, but this episode more than makes up for it.
March 13th, 2009 at 1:06 am
It’s not house but Dr. Cox (Scrubs) who hates full-body scans. The writers from both scrubs and house have copied each other on many occasions, probably not deliberately but it still happens.
March 13th, 2009 at 8:35 am
House does hate full body scans. I remember him saying in season one (I think in “Role Model”) they´re useless cause it´s a good way how to find 5 things that look like cancer.
March 13th, 2009 at 3:11 pm
thanks for the review people, really nice to find so many people interested in House series,anyway… i want to say that doege potter syndrome quite fits in this episode, a fibroma secreting insulin-like growth factors could be the diagnosis (which is infact very rare) IGFs cause decrease in blood glucose but because of steroids, glucose levels were ok when taub tested it, so a fibroma if it is a non-islet cell tumour, it can secrete IGFs causing the condition, but i’m not sure about the autoimmunity thing, besides any part of brain that is destroyed can’t regenerate, so if the blurting-the-truth symptom was a result of brain damage, it can’t be fixed!! that’s what i think :)
March 13th, 2009 at 5:24 pm
I just stumbled on this blog recently and I would like to say how much I am thoroughly enjoying it; both the reviews and the comments.
I would like one little clarification please, if you have time.
I have my First Aid certification from St. John’s Ambulance and am trained in the use of an AED, so I know that the only heart rhythms it can shock are V. Fib and V. Tach, not asystole or PEA. But I notice how in hospitals (or at least in hospitals on medical shows) they always seem shock asystole, and I was wondering what are the differences between an everyday AED and “the paddles” used in hospitals? The only reason I ask now is because it is mentioned in this review. I’m curious.
Thanks!
March 14th, 2009 at 9:22 am
The mistake of “fixing” the brain damage has been made more than once on the show – however in season one House meets an old lady with syphilis who is brain damaged and because of this extra horny and happy. When he prescribes Penicillin she refuses to take it because she states that she like feeling like this. House responds: “The Penicillin will kill the spirohets that are eating you brain but your brain is already damaged. You are doomed to feel happy for the rest of your life.” So the writers got it right in the beginning – you can’t fix brain damage – but then began to get it wrong from there on – for example in the episode with the nice guy (S4E13). However the human brain can rearrange itself – may be with the cause gone the brain can recreate the lost nerve centers, rewire the neurons, create new pathways for the same emotions – the emotions he needs for normal social life. Who knows? If you have brain damage in the brain stem you’re dead – but the part of the brain responsible for social interactions and inhibitions? What about people after severe head trauma that sometimes cannot speak, have retrograde or anterograde amnesia? They “heal” sometime to a degree or even heal completely…
March 16th, 2009 at 6:00 pm
good episode and advice to all of us to try to tell the true little more in every “normal” condition, unless it affect badly someone else. So we wouldn`t have to find (not just literally but methaforic also) in situation when every our word would be lie!
March 16th, 2009 at 11:19 pm
Did somebody else notice that house took a very small amount of vicodin?
Or I wasn’t paying much attention?
March 18th, 2009 at 11:18 pm
the soap opera part of this episode was brilliant. we have been overdue for some serious wilson/house exploration time and this was great, although there was one scene that left me wondering a bit- it’s when house is with wilson in the room before they go see his brother and house takes the call from the team. does he not notice wilson leave? why does he choose to pick up the phone then? and why show a scene like that?
either way, i loved the piece added to wilson’s character. he’s by far one of my favorites on this show.
March 21st, 2009 at 10:54 pm
Okay, but frontal lobe disinhibition is present in ADHD and a host of other mental disorders. I know someone who is compelled to say all kinds of disturbing things, and has the ability to figure out just what thing will upset just what person, even if he’s only known them for a matter of hours or days.
There is a whole list of psychoactive medication that they could have tried first. In ADHD there are parts of the frontal lobe that are abnormally small. Folks with ADHD do all kinds of things that they shouldn’t.
April 8th, 2009 at 8:46 am
It’s funny that Chase said he’s not a neurosurgeon. He sure was in the season 4 :)
April 10th, 2009 at 7:33 pm
I was surprised that the little girl did not have speech problems as is common with APD.
May 4th, 2009 at 3:38 pm
Scott, thanks again for you review.
I was just wondering how to link the symptom (blurting out whatever comes to ones mind) to the fibroma?
I was secretly hoping to find the answer in the comments, but I think I haven’t.
Could you shed some light?
Thanks,
Peter
August 10th, 2009 at 5:04 pm
Somewhat relevant to this–they recently uncovered the first picture of Phineas Gage–check it out at
http://brightbytes.com/phineasgage/index.html
also the characterization of disinhibition syndrome is a little overblown–i see patients like this everyday and they are very verbose and say outrageous things but probably not to the level that is portrayed here–also they have very blunted emotions so they prob wouldn’t give a crap if their wife/kid was mad at them–also surgery near brainstem?–ummm…nope…not even close.
August 17th, 2009 at 6:56 pm
What is racquetball? I’ve never heard of it myself (i’m British). I assume its another one of those sports only the Americans play.
September 20th, 2009 at 2:27 pm
Joe, racquetball is an American pursuit (good guess), a little like squash. Public courts are popular, as it’s a simpler arrangement, and more forgiving ball, than squash. The advantage (over tennis or most other ball games) is no ‘equipment’ is needed to furnish the court, other than the area itself.
http://en.wikipedia.org/wiki/Racquetball
On a ‘House’ front, I had never watched a single episode until about 5 weeks ago. Then decided to buy seasons 1-4 in a box-set, and have gotten through them all. Now catching up on season 5. And improving my differential diagnosis skills as well(!)
November 10th, 2009 at 7:06 pm
Apart from the great sexual compliments to Thirteen and Cuddy, best dialogues in my opinion were:
[13 x Foreman]
- He didn’t call me attractive. He cast me in his mental porno.
- That’s what attractive means. “I’m attracted to you, sexually.”
- Attracted can also mean “I’m attracted to the whole package. To who you are.”
- It could. It never does. It’s what women choose to hear, not what men say.
- Actually, it’s exactly what men say if they have any brains.
* * *
[Patient]
- I think people who publicize important things are people who can’t do important things themselves.
* * *
[House x Wilson]
- So you made your one effort to live a normal, selfish life and the universe immediately smacked you down. And because we’re wired to find meaning in semi-random events, you decided never to be that careless again.
- You don’t think that’s a little facile?
- Actually, I don’t. I think you did it consciously. You developed your… people-pleasing talents the way an olympic athlete develops his muscles. Talk about an overreaction to a single event.
- It was a pretty big event.
- Hanging up the phone? That’s what you’re blaming all this on. That’s the behavior you’ve been trying to correct. As though nothing else went wrong in your brother’s life.Of course, he overreacted too, but…
* * *
[House x Wilson]
- Does it bother you that we have no social contract?
- My whole life is one big compromise. I tiptoe around everyone like they’re made of china. I spend all my time analyzing: what
will the effect be if I say this? Then there’s you. You’re a reality junkie. If I offered you a comforting lie, you’d smack me over the head with it.Let’s not change that.
- Ok
- No, see, this… If you were implementing the social contract, you’d say that, but only because… It makes me feel better…
- It is kind of fun watching you torture yourself.
- Do you think things will work out with my brother?
- No. But when it does go wrong, it won’t be your fault.
- Thanks, House.
- You do actually like monster trucks.
- Absolutely.
June 12th, 2010 at 9:45 am
Taub puts on his master cardiology stethoscope the wrong way near the end of the show.
June 12th, 2010 at 3:48 pm
Thanks alot for the review, Dr.Scott. I almost read them all and I just wanted to thank you for the great effort :)
July 10th, 2010 at 6:39 pm
why didnt anyone explain to his wife that she would be just as bad in his condition and to get off of her high horse
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