Polite Dissent

Due to some unavoidable work and family obligations, my medical annotations of Vertical’s collections of Osamu Tezuka’s Black Jack were delayed, but now they should be back on track. Here are the annotations for the first seven stories from Black Jack, Volume 2. My medical annotations of Black Jack, Volume 1 (part one, part two) are still available.

For those of you unfamiliar with the character, Black Jack is a famous — or infamous — maverick surgeon. He is unlicensed, a fact which gets him into trouble frequently, but he is always able to avoid sanction due to his unsurpassed surgical skills.

The writer of Black Jack, Osamu Tezuka, attended medical school, but chose to become a mangaka rather than a practicing physician. Because of his training, his stories are quite accurate. Most of the medical discrepancies are due either to the advance of medicine in the three decades since the stories were written or to differences between Eastern and the Western medicine. Black Jack, like all of Tezuka’s manga, is phenomenal, so if you have any interest in manga or medicine, you should take the time to track down and read them if you haven’t already.

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. Needle (1975)
The tip of a needle breaks off in a patient’s vein and Black Jack wants to retrieve before it causes damage.
The anatomy is accurate and nicely drawn.
The venae cavae, made up of the superior and inferior vena cava, are the largest veins in the body. All the other veins feed into the venae cavae and they in turn feed into the heart. Black Jack is working with the superior vena cava, which carries blood from the arms, neck, and head.
The subclavian vein drains blood from the arm. It feeds into the superior vena cava.
Hemostatic forceps, also known as “hemostats“, are common surgical instruments. They look like a little like a pair of scissors, but instead of cutting, they are designed for grasping. They are designed so that they can be locked closed.
The “radar” Black Jack uses to find the needle is reminiscent of the set up for Fantastic Voyage, and more than a little unrealistic.

2. Granny (1975)
Every week, an curmudgeonly old lady takes all the money she has been able to scrape up, and pays a visit the widow of the widow of the doctor who saved her son’s life.
I was confused by parts of this story. The son has Neimann-Pick disease, an inherited disease of abnormal lipid metabolism. It is not something that is curable or amenable to surgery, so it’s not clear how Dr Jindai could have treated him.
The mother suffers a cerebral hemorrhage, a stroke caused by bleeding within the brain.
Black Jack gives her steroids to reduce the swelling in the brain caused by the stroke.

3. The Ballad of the Killer Whale (1975)
Black Jack treats an injured killer whale.
The medicine is accurate, at least from my point of view. I’m not completely sure that a marine veterinarian would agree, but I don’t think they’d have any major complaints.

4. To Each His Own (1977)
Black Jack operates on a construction worked badly injured in a gas explosion.
Black Jack is vastly overstating the risk of an air embolism (an air bubble that gets in the blood vessels and blocks blood flow). They can be caused by traumatic injuries, but generally the pressure and direction of the blood flow keeps the air out. Penetrating chest trauma and injuries to the blood vessels in the head and neck are the most common injuries that lead to air emboli; only rarely have they ever been caused by an abdominal injury like this patient suffered. Frankly, if this patient does have an air embolus, it’s from the explosion itself and moving him wouldn’t make any difference.
“We will first correct and inosculate organs in the abdominal cavity” — the patient suffered severe damage to his abdomen, so Black Jack is going to repair the damaged organs, put them back where they belong, and the reconnect them to each other.
“Size 2 suture thread” — this refers to the diameter of the thread in the suture. Assuming Black Jack is referring to metric size, this would be a diameter of about 0.2mm, a middle sized suture.
Shock is a medical emergency caused by a dangerously low blood flow. There can be a variety of causes of shock, but two of the most common are cardiogenic (heart related) and hypovolemic (too little blood, usually due to blood loss). Black Jack’s treatment of shock is focuses on these two causes: cardiac massage, vasopressors (for cardiogenic), and blood transfusions and Vitamin K (for vitamin K).
Vitamin K is important for blood clotting. Black Jack is giving it because he is afraid the patient is hemorrhaging (bleeding out), and this is what is causing the shock.
Cardiac massage — a technique to physically causing the heart to contract. This can be external (better known as CPR), or internal, where the surgeon actually has his hand on the heart. It’s not clear which one is referred to in this scene, I’m guessing external massage as there’s no indication Black Jack has opened the chest, but then again, this is maverick surgeon Black Jack we’re talking about.

Medical Terms in this Story:
ileum = the third, and longest, part of the small intestine.
Schmieden’s Suture = a surgical technique used to repair the intestine.
intestinal forceps = surgical instruments designed to hold and/or block the intestine
Müller fixators = used for repairing broken bones.
Vasopressor = a drug used to raise the blood pressure.
Oscillograph = an older method used to determine blood flow during vascular surgery.
Cyanosis = a blue tint to the skin caused by poor oxygenation.

5. Emergency Shelter (1975)
Black Jack and a group of businessmen are trapped in an escape-proof underground bunker.
Percussion is a technique where the doctor gently taps the patient’s body, like a musician playing a drum. The sound generated tells the doctor if the area in question is hollow (like the lungs), or solid (like the liver). You can use it to find the size of organs, like the liver, or find consolidations in the lungs. I’ve also found that it works well at home when hanging pictures because it allows me to easily find the wall studs. Black Jack is doing the same thing here.
Surgical scalpels are sharp, but because they are so thin, not very sturdy. I doubt three could make any more than a scratch in that heavy steel wall.

6. Dirtjacked (1974)
Black Jack and a bus full of school children are trapped in a collapsed tunnel.
Once again, Black Jack is reluctant to move the victims because of bleeding or clotting. I agree that moving them is not a good idea, but I’m more worried about spinal injury from the trauma.
Steam sterilization is an effective and fairly easy method of sterilizing medical equipment. There is some concern that the high temperatures required for steam sterilization can damage some modern plastic-based medical equipment, but this wouldn’t be an issue when this story was written.

7. Where Art Thou, Friend? (1975)
Black Jack reminisces about and searches for Takashi, the friend who donated skin to him when he was an injured child.
The Krause Method is a full-thickness skin graft. Full-thickness grafts have a higher rate of failure rate than split-thickness grafts, but generally have a better aesthetic appearance. (As described, the surgery actually sounds more like a split-thickness graft.)