Polite Dissent

Volume Four of Apothecarius Argentum moves the action from Beazol to the neighboring kingdom of Navara, a poor and starving country with a widespread wasting disease brought on by overuse of a toxic pesticide. Princess Primula and her companions, including friend/love-interest/Royal apothecary Argent and his rival, Lorca, third Prince of Navara.

There’s probably a spoiler or two in the annotations, so consider yourself warned.

Belladonna
The young prince has been suffering from seizures and was given belladonna to treat them.

Belladonna is a plant that has a long history of use in traditional medicine and continues to be used, to some extent, in modern medicine as well. The plant is very potent and must be used sparingly because of the high potential of adverse events, especially death. This is especially true for children (especially sickly malnourished ones like the prince). Let me put it this way: the more common name for belladonna is Deadly Nightshade.

Historically, while belladonna has been used to treat a variety of different ailments, it has not been used to treat seizures. The only mention I’ve even seen of the use of belladonna for seizures comes from homeopathy, which is not traditional medicine — or really any sort of medicine at all (despite what its practitioners would like you to think); homeopathy can best be described as a delusion combining sympathetic magic, wishful thinking, and an early-19th century understanding of science.

Belladonna contains several potent chemicals, most notably atropine, scopolamine, and hyoscyamine — all drugs that are used today. Belladonna extract itself is still used in a few modern medicines, Donnatal (a stomach medication) is probably the best known.

Dandelion
The prince has been given an overdose of belladonna, and Argent gives him dandelion extract to correct it.

Argent is correct that belladonna is excreted almost entirely through the kidney, so increasing kidney function should get rid of the medicine faster. Diuretics (drugs that increase urine output) are one way of doing this. Dandelion has long been used as a diuretic. While I have seen no recent studies or reports that confirm its benefits in this regard, I’m willing to give the plant the benefit of the doubt because the effects of a diuretic are hard to miss (if you pee a lot, it’s a diuretic).

Activated Charcoal
Activated charcoal is used again to treat the chronic wasting disease that is common in Navara. I covered this in depth in the Volume 3 annotations.

Cochineal
The cochineal is a tiny insect (Dactylopius coccus) that grows on cacti in Central and South America. When the females of the species are collected, dried, and crushed they produce the brilliant red dye carmine which is used for coloring fabrics, cosmetics, and food.

It takes 70,000 insects, all collected by hand, to make a pound of dye, which is worth about $36 in today’s market.

Prince Lorca mentions several times that the insects grow on citrus, but they don’t — they can only live on certain species of cactus. I wonder if this might be a translation error, either in the translation of the manga, or from the author’s original sources. (There is a similar insect known as “Polish Cochineal,” and while it doesn’t grow on cacti, it doesn’t grow on citrus either.)

Marijuana
The story mentions a link between marijuana use and psychiatric disease. There haves been several studies that have looked at this very subject, but the results have been unclear. Can marijuana use lead to psychiatric illness, or do people with pre-existing psychiatric disease tend to use marijuana more? Studies have suggested both results, so just leave this one as “undecided.”

Is it possible to die from a marijuana overdose? Again, sources vary, but almost all seem to agree that it would take an incredibly high level of exposure to be fatal, and many experts suggest that it would be physically impossible to achieve this high a dose. (On the other hand, with incense burning in a sealed room with heavy curtains, I suspect the king suffocated to death when the incense used up all the oxygen).

Bunches of high scores this episode, thanks to this year’s ubiquitous diagnoses: paraneoplastic syndrome and “lymphoma.” TRad led this week with 18 points.

Overall, TRad and Noether increase their dominance, with 77 and 75 points, respectively. Theta Sigma stays in third with 57 points, and Corien retains fourth with 54 points. The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

The team in this week’s episode of House followed a more logical approach to the patient, but they were still hampered by bad medicine. But hey, an opossum!

Daryl is a 22 year-old college football player hoping to be spotted by pro scouts. In the middle of practice, he suddenly becomes uncontrollably violent. He grabs his opponent and drags him around by his helmet until it finally comes loose, and then he bashes himself in the face repeatedly with the helmet until he starts bleeding.

He is admitted to the hospital for evaluation, but has no memory of the incident. A head CT scan and a psychiatric evaluation — both obtained in the Emergency Room — were negative. House suspects Daryl’s symptoms are due to steroids, even though he tested clean in the Emergency Room. He believes he is on the “good stuff,” i.e. steroids that don’t show up on tests. The rest of the team suspects a pituitary adenoma (a tumor in the pituitary gland) caused by repeated head trauma. Tests for GnRH (gonadotropin releasing hormone, which controls the gonadotropins, which control the production of testosterone in men) are high, but a pituitary MRI is negative, which lends credence to House’s theory of steroid abuse. He tells the team to start Daryl on a somatostatin-analog (a medication which inhibits the pituitary gland) to block the effects of the elevated GnRH.

Daryl denies any use of steroids and begins to suffer a racing heart rate and chest pain. He has an episode of paroxysmal tachycardia (sudden onset of an abnormally fast heart rate) that requires cardioversion to return it to a normal rhythm (by definition “cardioversion” means returning the patient to a normal heart rhythm. This can be done chemically, such as with adenosine, or electrically). Taub reports that the cardiac symptoms do not fit the diagnosis of steroid abuse, so the team gives Daryl’s heart a further work-up including EKG and sestamibi scan (a test that looks at perfusion of the heart itself), but they are completely normal. The differential diagnosis now consists of a PFO (patent foramen ovale, a hole between the two sides of the heart) or hypertrophic cardiomyopathy (muscular thickening of the heart). House favors the latter and has the team put Daryl on a treadmill to stress him until he develops cardiac symptoms. Unfortunately (or fortunately, really), Daryl is in good enough shape that his heart rate never rises high enough to cause a problem. Going for “plan B”, House decides to chemically induce heart stress by injecting Daryl with a vasodilator (such as adenosine or dipyridamole — they mimic the effects of exercise on the heart). Before he injects the medication, however, he notices that the palms of Daryl’s hands are unusually white.

This new symptom causes the team to reassess their diagnosis. Taub thinks Daryl’s pale hands are due to Raynaud’s phenomenom (spasm of the smooth muscles around the small arteries of the fingers), which he thinks is caused by rheumatoid arthritis. Thirteen suspects that Daryl has plaques in his arteries, and these are breaking off and sending tiny clots blocking the arteries in his hands. Chase believes Daryl has Takayasu arteritis (inflammation of the aorta and other large arteries), and Foreman, ever the optimist, blames lymphoma. House likes the last two ideas the best, and tells Foreman to put Daryl on an ethanol drip. If he develops itchiness, it’s a sign of lymphoma, and if he loses his radial pulses, it’s a sign of Takayasu. Daryl develops itchiness while on the drip, so Foreman’s suspicion of lymphoma appears to be correct. Daryl is taken to surgery for a splenectomy, but during surgery Chase notices that his spleen is fine but his liver is inflamed.

Biopsies reveal no lymphoma and a non-specific liver inflammation. The new differential diagnosis includes polymyositis (a chronic inflammation of the muscles), Felty syndrome (rheumatoid arthritis + splenomegaly, which doesn’t fit at all), and viral hepatitis. Blood is drawn for further testing, but Foreman reports that the blood clotted almost immediately after being drawn. This suggests that Daryl has cryoglobulinemia (abnormal proteins in the blood that thicken with cold temperatures), brought on by football practice on cold days, and needs to be started on anticoagulants (blood thinners). This isn’t good enough for Daryl; he doesn’t want to miss his shot at the pros, so he leaves the hospital, promising to come back the next day. At the exhortation of Daryl’s mother, Foreman tags along to look after him — it was a good thing he did, too, as Daryl starts to experience shortness of breath and blurry vision. He is admitted back to the hospital. As the team begins to evaluate the new symptoms, Foreman admits that their really aren’t any new symptoms. He had dosed Daryl with nitrates (a class of blood pressure medication) to drop his blood pressure so he’d feel bad enough to want to come back to the hospital.

Looking over the chart, House notices that Daryl has only lost one pound during his stay in the hospital and he should have lost more. This lack-of-weight-loss could be due to steroid abuse, or paraneoplastic syndrome — only there’s been no evidence of cancer. The team performs blood test after blood test, and scan after scan, but can find no cancer. House then realizes that the cancer they are looking for is not inside the body, but outside. It turns out that Daryl has melanoma, a skin cancer hard to spot on African-Americans, and this cancer (or course) is causing paraneoplastic syndrome, which explains his symptoms.

(Here’s my take on what’s going on: you may have noticed during the episode that the team gave two different definitions of paraneoplastic syndrome. First, they described a situation where a cancer produces a hormone which can cause systemic effects: in this case, the melanoma is apparently producing GnRH which increased Daryl’s testosterone and gave the appearance and symptoms of steroid abuse including “roid rage,” weight gain, and probably the heart symptoms. Second, House describes paraneoplastic syndrome as a situation where the body is making antibodies against the cancer, and this produces the systemic effects. This would explain the kidney failure and liver inflammation. The apparent cryoglobulinemia may be an effect of the extra paraneoplastic antibodies, or cryoglobulinemia can occur with certain cancers. Both definitions of paraneoplastic syndrome are correct, but I’m not certain if a patient would ever experience both situations.)

I admit that I’m somewhat confused by House’s take on steroids. If Daryl was taking steroids, his GnRH should be suppressed — lower — not higher. Or is House suggesting that Daryl was receiving GnRH itself, or a synthetic substitute — and if that’s the case, the body generally downregulates GnRH receptors when GnRH levels are unusually high, actually leading to hypogonadism and less testosterone.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

The clotting in cryoglobulinemia resolves at normal temperatures, so why would Daryl be clotting in the presumably warm hospital room. Did Princeton-Plainsboro not pay the electric bill?
Why didn’t he show abnormal clotting during surgery as most operating rooms are kept PDC (pretty damn cold).
Surely they drew blood before surgery, at least a blood type/transfusion panel, and should have notoiced the clotting then.
Blood thinners are not the recommended treatment for cryoglobulinemia.

Giving a patient enough of a nitrate to intentionally cause hypotension (low blood pressure) is dangerous. How did Foreman know he didn’t give too much? I’d also expect Daryl to develop a severe headache — the most common nitrate side effect – before any other symptoms.
I guess he learned it from House, who was trying to induce a cardiac event in a patient without even having him hooked up to any cardiac monitors.

Stress tests aren’t used to test for hypertophic cardiomyopathy, at least not as a first-, second-, or even third-line test. An EKG has already been obtained. A structural test, such as an echocardiogram or MRI is the next logical step. If needed, cardiac catheterization may also be performed.

Sorry Taub, steroid abuse can cause heart problems, including tachycardia.

Is there really a link between repeated trauma and pituitary adenoma, a type of cancer? I haven’t been able to find one, but then again, I’m not a neurologist or sports medicine specialist.
GnRH is released into the pituitary, not from it, so why would a pituitary cancer lead to “leaking” GnRH?

There is a condition known as the “lymphoma itch” that is a severe itching, primarily of the lower extremities. It is most commonly seen in Hodgkin’s lymphoma, but even then it only occurs in 10-25% of patients.
It is not associated with alcohol. A separate condition (severe aches and pains) can be worsened by alcohol intake in certain patients with lymphoma.

I don’t know it alcohol will really shut off blood flow in the radial arteries in patients with Takayasu’s arteritis, but who in the hell would thank that is a good idea. Personally, I like my hands to have full blood flow, thank you.

Return to full contact football a day after abdominal surgery, even a laparoscopic one? Nonsense.

Blood in the urine is really not a sign of kidney failure. It suggests that there is a problem with something farther along in the urinary system. This is especially true in patients on blood thinners, were urinary bleeding is more common – maybe from inserting the catheter in the first place.

Why would a melanoma secrete GnRH?

It is certainly possible to have rheumatoid disease with a negative rheumatoid factor.
Wasn’t Chase the one who shot down Taub’s suggestion of rheumatoid arthritis? So why would he later suggest Felty’s, which requires rheumatoid arthritis?

Paraneoplastic syndrome has become the lupus of this season.

I found the medical mystery interesting this week. Not great, but better than recent episodes. I give it a B+. The final solution clever (hidden melanoma in a black male), but too much of “Been there, got the T-Shirt” feeling (paraneoplastic, again, and a nearly impossible one at that). I give the solution a C-. Overall, the medicine was more driven this week, and followed a logical progression, but too much of it was questionable or downright wrong. Another C-. The soap opera was decent. I liked the Foreman and Foreman scenes, and the Wilson/House scenes were good, but I figures Lucas was the culprit fairly early on as Mark Michael Weston was listed as a guest star, but nowhere to be seen. I give the soap opera a B.

The review of the previous episode of House
A list of all prior House reviews

Once again, Wolfie learns the hard way not to move in on Buzzy’s girl. Poor Wolfie. Sure, he’s a jerk, but he has some of the worst luck in comics.

Or does he? I think this scenario was really a plot by Buzzy and Susie:

This PSA was found in Adventure Comics #154 as well as the other DC comics from July 1950. The ad was written by Jack Schiff, with art by Bob Oksner.

More PSAs

Tags: comics psa buzzy wolfie jack schiff bob oksner

Supergirl #49 “Death & The Family”
Sterling Gates, writer
Matt Camp, artist

Lana Lang has been found down and bleeding profusely. She is rushed to the emergency room for resuscitation.

First, they’re shocking a flatline. I’m sure I’ve mentioned at least once before that this is not how to treat a flatline.

How should they proceed? Asystole (the fancy, medical word for a flatline) is tough to treat, and the odds are against you from the start, no matter what television tells you. The key to treating asystole is to correct the underlying cause. One concern: Lana’s lost a lot of blood — there’s at least two panels of her laying supine in large puddles of blood and the staff is splattered with blood. As far as the ER staff is aware, this blood loss is a possible cause of her condition, yet they’ve done nothing to treat it. There’s no blood being transfused — in fact, there’s not even a single IV line, which are important in any resuscitation. (As an aside, the defribrillation paddles are also reversed: the upper paddle should be on Lana’s right, and the lower on the left)

Second, as fancy as that face mask is, it’s not going to be any good at getting the air she needs down into her lungs. I appreciate the fact that Cage at least added a breathing tube entering her mouth, but it’s too narrow to be any use (it needs to be about the width of a thumb to work). Plus, if she’s got a breathing tube in place, why does she need a mask?

Third, Lana is bleeding from her mouth, nose, and eyes. If you were the ER staff, what’s one of the first things that would cross your mind? Hemorrhagic fever (Ebola, Marburg, and for the comic-inclined, the Clench). Sure, none of them are endemic to the US, but in this day and age, who’s to say Lana hasn’t been traveling, or exposed to someone who has? The ER staff would be wearing a lot more protective gear.

On the positive side, fzzCHOOMPH is the best sound effect I’ve seen in quite a while.

Big questions were answered, the science wasn’t that bad, but it still struck me as a surprisingly lifeless outing for the “Winter Finale” of Fringe.

The Plot: At an office building in Manhattan, the workers grouse about a series of small earthquakes the city has been experiencing. Suddenly, there is a larger tremor and one of the workers finds himself caught in the quake. He blacks out for a second and when he comes to, he is pinned by the rubble — and has four arms and four legs.

The Fringe team is called in to examine the office building. So far, no survivors have been found, but many dead bodies. The bodies aren’t normal, however, but each seems to be two separate people fused together. Walter hypothesizes that a “Quantum Tectonic Event” has caused a rip in space that caused the quake and fusion. A survivor is found upstairs: the worker from the opening scene. Walter converses with him while he is slowly dying and learns that the worker is from the alternate universe. Walter has a new theory: an office building from that universe has suddenly merged with the same office building from ours, killing all the inhabitants. Agent Dunham suspects this to be a deliberate act on the part of Newton (the leader of the team from the alternate universe that is trying to destroy ours).

Back at the lab, Walter realizes what has happened — and what will happen. Twenty-five years ago, he and William Bell sent a car to the alternate universe and a short time later, a car of equivalent mass from that universe appeared in ours, merged into a statue. Walter tells the team that a building from our universe will disappear within 35 hours. His only idea how to stop it is to use some of the abilities Dunham gained from Cortexiphan. He drags her and Peter to Jacksonville, where the original Cortexiphan experiments were carried out. He repeats the experiment on Dunham, but it has no effect this time. Belatedly he realizes that her abilities depends on fear, and Dunham no longer experiences fear, but channels it all into anger. Defeated, the three of them return to New York.

While they’ve been in Florida, small earthquakes have started in New York City, signaling that the calamity is impending. The scientists at Massive Dynamic are trying to find a pattern to the quakes, but Walter tells them there is no pattern to find. Instead, he suggests locating the building in New York City of identical mass to the one that appeared from the other universe. They are able to narrow the list down to 147 building, but the thirty-five hours is up. Concern over her failure and the likely loss of life scares Dunham, kick starting her spot-the-things-from-the-other-universe power. She is able to spot a building that weirdly glimmers, a sign that it is the one that is going to disappear. The team is able to identify the building and the authorities evacuate it just in time — with a massive inrush of air the entire building — basement, foundation, and all — disappears.

As the episode ends, Olivia and Peter are heading out for drinks, but when she looks at him, she realizes that he is glimmering too. Walter begs her not to tell Peter the truth.

1. Spellchecker
Manhattan was spelled wrong in the opening scene.

2. Island of Misfit Toys
If the building in Florida has been sealed for 25 years, why did it have toys from the Ice Age movies (’02, ‘06, and ‘09)?

3. Where’s Johnny? He Was Here Just a Minute Ago!
So did a child of identical mass to Peter get transported to the alternate universe when Walter brought Alterna-Peter here?

4. Glimmer Glimmer Glumpkin
If Olivia’s powers detect items from the other universe (that’s what Walter was testing in the classroom after all), why did the building from this universe glimmer?

5. Tick Tock
Why 35 hours? I’m guessing that’s how long it took for the car to appear.

6. Mass Effect
How are they going to be able to find the mass of the alternate universe building when it is merged with ours. Are they assuming it was identical to the one in our universe, just like their Nixon coins and double-decker cars are identical to ours?

7. There’s No Babble Like Good Babble
Quantum tectonic event. That is some grad-A prime of technobabble. It sounds impressive, but notice how none of the words really work together (or at least the two most important: tectonic and quantum. They’re pretty much contradictory — “quantum” suggest atomic or sub-atomic, while “tectonic” is very macro in its implications.)

I so wanted to like this episode with the Peter reveal (that we all knew anyway), but I couldn’t — it was dull. It wasn’t horrible, but an episode this big should be more fulfilling. The Fringe Doomsday Clock stays put.

This week’s Fringe cipher was: REVEAL.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

It’s always nice to find new reprint collections of old pulp stories. I’m a big fan of these stories — sure, many of the characters are rather two-dimensional and the plots paper-thin — but there are enough diamonds in the rough to make it worth the time and effort. In the past year or two, a number of my favorites have managed to work their way back into print:

El Borak, by Robert E. Howard
The White Wolf — a.k.a. El Borak — is my second favorite Howard character (with Solomon Kane being number one). El Borak has swashbuckling adventures in the early part of the twentieth century: think Lawrence of Arabia with a liberal dash of sword and sorcery. His stories have been out of print for decades, but will be available Tuesday in a nice new edition.

Jirel of Joiry and Northwest Smith, by C. L. Moore
Moore was one of the first female adventure pulp writers — she wrote as “C. L.” instead of Catherine to disguise her gender. Most of her stories were published in Weird Tales and have a slight Lovecraftian feel to them.
Jirel is the ruler of a small medieval kingdom and her lands always seem to be under threat from natural, and supernatural, enemies. Her stories tend towards the darker aspect of fantasy.
Northwest Smith is a smuggler and anti-hero in the distant future. His stories have a darker edge to them as well.
The Science Fiction Book Club has inexpensive hardbound collections of Jirel and Northwest Smith. Paizo, under their Planet Stories imprint, also offers a Jirel as well as a Northwest Smith collection. (Paizo also offers several collections of Moore’s husband and fellow writer, Henry Kuttner. Sadly, I haven’t seen any recent reissues of stories by Lewis Padgett, which was the name Moore and Kuttner used when they collaborated together on a story).

Speaking of Paizo, they also are offering what look to be great collections of the Eric John Stark series by Leigh Brackett.

An atypical episode of House as it focused on a day in Dr. Cuddy’s life, moving every other character to the background. A change of pace, but a solid and enjoyable show nonetheless.

Cuddy gets up at five AM and starts the day with some yoga. Her daughter Rachel wakes up a little while later, sick, and Cuddy comforts her while getting ready for work. The nanny arrives, and then Lucas, who’d been up all night on a stakeout. He talks her into a quickie before work, but unfortunately he was a little premature in his efforts and she heads off to work unsatisfied.

Cuddy arrives at the hospital at eight and things are already going crazy.

House strolls up to discuss his patient he thought had resistant Staph, and who he wanted to treat by infecting him with malaria.

Cuddy walks off, telling House that she has to finish a proposal before an important 8:30 meeting and there’s a crisis in the pharmacy where some paperwork, and some ephedrine, is missing. Next, there’s a problem in surgery, where one of the surgeons is complaining because House has turned on the air conditioning. She gets the heat turned back on and heads to her meeting.

Meeting Cuddy in the hallway, House informs her that his patient now has boils and a large abscess.

Cuddy hears from the nanny that Rachel is still sick, only now she’s running a fever and vomiting. She finally makes it to her 8:30 appointment with the contract negotiator from AtlanticNet Insurance, the largest insurance company in the area. He and Cuddy have been arguing about a contract for eight months, and today Cuddy lays it all on the line. She agrees to capitated care, but wants a 12% increase in rates. He refuses. She tells him that this is the hospital’s final offer and he has until 3PM to agree, or she will make a public announcement that they are no longer accepting AtlanticNet, and why.

Thirteen and Taub report to House that their patient is now hallucinating and has a falling blood pressure and rising heart rate. They suspect congestive heart failure, but House disagrees, telling them that the patient has [elevator door shuts before we hear the answer].

On the way to the hospital board meeting, Cuddy has a run in with Dr. Thomas, the hospital’s Chief of Surgery. He is seething about House — upset primarily about the fact that he stole Chase back from the surgery department. She heads into the board meeting where the board makes it clear that Cuddy’s job is on the line if she can’t pull off the contract with AtlanticNet.

House skipped clinic again, so Cuddy fills in for him. The patient is an older man with metastatic cancer who wants a prescription for breast milk. He has heard that breast milk can help with his cancer, and wants a prescription so the insurance company will pay for it. She refuses, pointing out that even with a prescription the insurance company won’t pay for it. He accuses her of being in the pocket of the insurance company before insulting her and storming out.

Back at her office, Cuddy finds a lawyer waiting for her. He is representing Martin Acevedo, a man who had his thumb reattached after cutting it off with a saw. He is suing because he didn’t want the thumb reattached — he is poor and that was too expensive — but Chase went ahead and did the surgery anyway. When confronted Chase admits that he did sew the thumb back on even though that was not what the patient wanted because he felt that the reattachment was the best option for the patient medically.

A little while later, Cuddy meets with Gail, the pharmacy tech who stole the ephedrine. She tells Cuddy that it was to help her lose weight and asks Cuddy not to fire her. Cuddy takes a little pity on her and tells Gail that she has to fire her, but she won’t report her to the DEA. She grabs a quick unhealthy lunch from the cafeteria.

House is sitting in Cuddy’s office – in her chair – waiting for her. He tells her that his patient has renal cell cancer (kidney cancer) and he wants to treat with malaria in addition to chemotherapy.

Lucas swings by the office, bringing Cuddy a real lunch. He tells her that Rachel seems to be doing better — she is no longer running a fever — but she has developed a rash. Unfortunately, Lucas accidentally grabbed the nanny’s phone, and turned the ringer off on Cuddy’s phone at home, so there is no way to reach the nanny.

With Lucas’s help, Cuddy tracks down the CEO of AtlanticNet at lunch and confronts him about the contract. He blows her off, telling her he doesn’t care if her PR campaign makes him out to be a rich bastard, as long as he stays rich.

Back at the hospital she meets with the head of the pharmacy and discovers that a lot more ephedrine is missing from the hospital than previously suspected — $50,000 dollars worth — and the thefts have been going on for at least three years. She realizes that Gail has been lying to her and has been stealing the ephedrine to sell to a meth dealer (ephedrine can be used to make methamphetamine)

The negotiator from AtlanticNet returns and offers an 8% increase as their final offer. Cuddy declines, wanting the full 12%.

Now House’s patient has liver failure and needs a transplant.

Three o’clock arrives, and as there have been no new offers from AtlanticNet, Cuddy calls a staff meeting and informs the physicians that the hospital has terminated the contract with the insurer. This causes widespread disbelief and dismay among the staff, as many of them made much of their money from AtlanticNet patients.

Foreman arrives, telling Cuddy that they’ve found a liver, but now there’s another conflict. House wants Chase to do the surgery, but Thomas refuses to put him on the schedule. Foreman needs someone who outranks both House and Thomas to schedule the surgery.

Cuddy meets with Acevedo and his lawyer. She tells them that not only will the hospital fight the lawsuit tooth and nail, but that she wants Acevedo to pay the remaining bill for his care.

Next, Cuddy arrives at the surgical suite and breaks up a brawl between Drs. Chase and Thomas. She then returns to her office and confronts Gail, the recently fired pharmacy tech, about lying to her. Gail freely admits the theft and tells Cuddy she can’t do anything about it because she’ll lie to the DEA, telling them that she did it on House’s orders, and that House and Cuddy were having an affair. Frustrated, Cuddy walks out of her office, telling the staff that she quits. She sits quietly in her car for a few minutes until House arrives. He cheers her up, as only House can, by insulting her, but this is enough to get her to head back into the hospital.

Cuddy confronts Gail again, who once again brags of her theft and her plan to lie to the DEA. Luckily, Cuddy captured it all on one of Lucas’s hidden recording devices. The nanny calls and tells her that Rachel is doing fine. To complete the hat trick, the negotiator from Atlantic Net arrives and tells Cuddy that the insurer has agreed to her 12% proposal. Ecstatic, she informs the board and staff, who share her enthusiasm. Finally, she heads home to Lucas and Rachel after a long, exhausting day at work.

Though I know nothing of its use in Staph infections or cancer patients, before the advent of penicillin, malaria was used a treatment for syphilis. The malaria gave the patients a high fever — high enough to kill off the syphilis germs — and malaria was curable with quinine.

On one hand, you could argue that Cuddy should have acceded to the patient’s wishes and given him a prescription for breast milk, since, as House said, “it might work.” However, I have to side with Cuddy on this one. First, she’s right: the insurance company will not pay for it, even with a prescription — they’ll consider it an experimental treatment. Second, it’s her signature on the prescription, and she should not write any prescription she is not comfortable signing. Finally, and she should have pushed this part harder, the breast milk is at best a shot in the dark — it’s wishful thinking — and by writing the prescription she would be confirming the patient’s false hope. She handled it well: she was upfront and truthful and told the patient she would not write the prescription. He didn’t like what she said, but he’s free to find a new physician.

Though it was mentioned briefly at the beginning, both Cuddy and the lawyer are glossing over the key fact that the treatment Mr. Acevedo received was not covered by the informed consent he signed. Chase may have done what he thought was best for the patient, but he did it through lying and dishonesty. Sure, Mr. Acevedo kept his thumb, and this will probably restrain the jury’s and judge’s enthusiasm for a large payout, but there is clear written evidence that Chase was deceitful in his treatment of the patient. The hospital’s insurance company will pay this off long before it sees a courtroom. And as for Chase, skipping informed consent or lying on it is a good way to lose a medical license.

Every place I’ve ever worked has a two people count the controlled substances in the pharmacy, just so situations like Gail’s can’t happen. And why does the hospital have so much ephedrine? It’s not that common a drug.

Anyone know what the rules in New Jersey are for surreptitiously recording a conversation? I know in Illinois it needs the consent of both parties involved, but I believe this is the exception, rather than the rule.

The review of the previous episode of House
A list of all prior House reviews

William Tenn passed away this weekend. He was one of the last of the great Golden Age science fiction writers. He was also the first writer I ever saw at a convention. I was about twelve and had convinced my father to take me to Rovacon, a small science-fiction convention in the neighboring town of Roanoke, Virginia, where William Tenn was the guest of honor. I was having fun exploring the con and I only made it to the last ten or fifteen minutes of his talk, but immediately wished I had heard the whole speech. In the portion I heard, he was talking about the difficulties of time traveling. Not the scientific or technological hurdles, but the social ones. He mentioned how a man from just one hundred years ago would find it extremely hard to function in today’s society, and vice versa. Think of all the differences between now and 1910: Technology, certainly. Health and sanitation, too. But think of societal attitudes and how they’ve changed: Women’s lib. Civil rights. The U.N. Non-isolationist policies. A person traveling back to 1910 could quickly find themselves in trouble just mentioning some commonly accepted modern beliefs. At the age of twelve, I found this fascinating, and I still do. Now more than ever I wish I had made it the entire talk.

My favorite of Tenn’s stories is Time in Advance. In the future, criminals are shipped out to harsh frontier worlds to serve out their sentences performing the back-breaking work of terraforming the planets. Few survive more than a few years, let alone their entire sentence. There is also the option of serving time in advance. In this case, you haven’t committed any crime yet, but you are planning to. By serving your sentence first, with a hefty fifty-percent reduction in length, you are entirely free to commit your crime upon your return to Earth — if you happen to survive. As the story begins, two convicts have just returned after serving their time in advance for murder. This is a big story for the media — only rarely does a single time-in-advancer survive, let alone two arriving on the same day. However, the two convicts find that having the freedom to commit a murder of their choice open up doors and exposes secrets they weren’t expecting. It’s a great story, with a nice undercurrent of dark comedy.

Time in Advance, along with 32 other stories can be found in Immodest Proposals: The Complete Science Fiction of William Tenn, Volume 1. If you haven’t the story before, or Tenn at all, I recommend picking up the book, or (more economically) at least encouraging your library to do so.

Yesterday marked the 100th Anniversary of the Boy Scouts of America and to commemorate the occasion, here’s a Boy Scouts of America public service ad from Worlds Finest #46 (June/July 1950).

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Tags: comics psa superman batman boy scouts

Back in 1736, concerned that certain medical practitioners were overcharging patients, the legislature of the Colony of Virginia passed a law setting mandatory prices for services. The prices, and the philosophy behind them, make for an entertaining and enlightening read:

Surgeons and apothecaries, who have served an apprenticeship to those trades, shall be allowed,
For every visit, and prescription, in town, or within 5 miles	5 shillings
For every mile, above five, and under ten	1 shilling
For a visit, of ten miles	10 shillings
And for every mile, above ten	sixpence
To Surgeons,
For a simple fracture, and the cure thereof	2 pounds
For a compound fracture, and the cure thereof	4 pounds
But those persons who have studies phisic in any university, and taken any degree therein, shall be allowed,
For every visit,and prescription, in town, or within 5 miles	10 shillings
For every mile, above five, and under ten	1 shilling
For a visit, of ten miles	1 pound
And for every mile, above ten	1 shilling

A couple of things should be obvious looking at this table. First, housecalls were common in the colonial era, and the practitioners charged accordingly. Second, there were two classes of medical practitioners: those who learned the trade by serving an apprenticeship (the surgeons and the apothecaries), and those who learned the trade through years of schooling (the phisic, or physician). Which was better? It varied, and probably depended a lot on both the practitioner and the patient. (Today’s system of medical training combines both methods: multiple years of college and medical school followed by a residency — which is really nothing more than an apprenticeship.) Back in the colonial times, you’ll also notice the surgeons seem to be the only ones who really got their hands dirty.

With the Vancouver Winter Olympics in full swing, I thought now was a good time for “sportmanship” public service ad, courtesy of Batman, Robin and Action Comics #141.

Though this PSA is ostensibly about sportsmanship, the main focus is actually on prejudice, with a little patriotism thrown in for good measure. Still, it’s a good PSA, even if the title is somewhat misleading.

For some good reading on good sportsmanship and the Olympics, check out this article on the Pierre de Coubertin medal (the “True Spirit of Sportmaship” medal).

This PSA was found in DC comics from February 1950. Written, as always, by Jack Schiff, with art by frequent PSA collaborator Win Mortimer.

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Tags: comics psa batman robin sportsmanship olympics jack schiff win mortimer

Back when I was in residency, I had the opportunity on several occasions to serve as the in-house doctor for the local symphony orchestra. There was no pay per se, but I got two tickets to the show (cheap date!) and the chance to hear some great performances. It was easy: I just showed up on my assigned night and introduced myself to the head usher. I was given a pair of seats in the back of the theater and the staff would come and get me if there were any sort of medical emergency. I attended a little over a dozen symphony performances during my residency and never had any real medical emergency — however, every show without fail, at some point I would be called to examine a little old lady who had tripped on the theater steps. It was never a serious injury, just some bruising or maybe a sprain (and for the record: it was a different lady each time; those were some tricky steps).

All of the residents took turns attending the symphony, and no one else was ever called away for any sort of medical problem — except for Gerry. He was summoned once, only it wasn’t for a little old lady, but for the visiting marquee-name soloist. He later told me it was for a very minor issue and he got to hang out after the show with the star.

As I become bitter in my old age, I like to pretend his experience was more like Dr Landon’s in this back-up story from Nurse Betsy Crane #20:

Click on any of the images for the full story

Dr. Landon went on to co-star in his own brief comic book series, The Young Doctors. In past years, I have looked at issues The Young Doctors #4 and The Young Doctors #5.

You know you’re reading an old comic when the doctors are all sitting around smoking:

scene from Doctor Tom Brent, Young Intern #1 (Charlton, 1963)

To be fair, the comic was published a year before the Surgeon General’s report first condemning cigarettes came out, and three years before warning labels were added to cigarette packs.

Of course, it wasn’t just comic books that depicted doctors smoking, cigarette ads did too:

click on the image for the full-sized ad

For those of you wondering how many doctors smoked in the past compared to how many smoke now, I don’t have a good answer for you. The best I have is a short paper that takes a look at smoking rates among Rhode Island physicians from 1963-1983. It is over twenty years out of date, so I suspect the numbers have fallen even more, but I think it gives a good idea of the trend. Here’s one of the charts from that paper.

In this scene from the Gen 13 (current series) #33, Void uses her teleportation powers to dispose of a bomb — only it’s such a powerful bomb, she has to send it high in the atmosphere, resulting in a classic pushing-powers-to-the-max nosebleed.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed gen 13 void bomb

Yet again, I am here to take on the question of Brother Voodoo: psychologist or psychiatrist?

This time, I’m turning to a new source, MU1 – Gamer’s Handbook to the Marvel Universe (Volume 1 – Abomination through Dreadnought). This was the eight volume encyclopedia of Marvel characters published for the Marvel Super Heroes Game, published by TSR in the mid- to late-80s. In the guide, Brother Voodoo gets a page and a half (and for the record, that’s a little less than American Eagle — who at this point had only appeared in one comic).

On his entry, his profession is listed as “Ex-Psychologist (M.D.), now Houngan (voodoo priest).”

This week’s comic book public service ad celebrates the 1956 Winter Olympics in Cortina d’Ampezzo, Italy. With 32 competing nations, it was the largest Winter Olympics to date, as well as the first to be televised.

So what happened to the 1956 Winter Olympic athletes mentioned in this PSA? Most continued in their sport, in one form or another, or went on to bigger, better things:
Anton Sailer Still considered one of the best alpine skiers, ever. Did a little acting and a little politics after retiring from skiing.
Renee Colliard The 1956 Olympics seems to have been her shining moment (at least as far as this non-French speaker can tell).
Boris Shilov Became a renowned skating coach after retiring from competition.
Antti Hyvarinen A broken hip ended his competitive career, became a coach.
Hayes Alan Jenkins After retiring from skating, earned a Harvard law degree
Tenley Emma Albright Earned a medical degree from Harvard and became a famous surgeon

And for comparison, the winning time in this year’s 5000-meter speed skating was 6:14.60.

This PSA was found in DC comics from February 1957 (Action Comics #225 in this case). It was written by Jack Schiff, with art by Ruben Moreira.

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Thanks to his super-powers, Clark could fake being sick better than anyone else in high school. And I mean anyone else.
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Smallville is having a hobby contest with the winner receiving a trip around the world. The contest looks for the person in town who has the largest coin, rarest stamp, most valuable mineral, and most unusual autograph. Spoiled rich kid Orville Orville plans on winning by using his money to buy the best specimens. Superboy decides to help the other kids beat Orville by using his power to find specimens that will beat out Orville’s.

For the most valuable mineral contest, Orville enters an uncut diamond worth a million dollars. To help Teddy beat him, Superboy returns with a large boulder of pitchblende for him to enter.

Pitchblende, or uraninite, is a uranium ore that is also a source of radium.

Uranium and radium? Doesn’t that mean Ted’s boulder in radioactive and potentially dangerous?

Yes.

Exactly how dangerous is the rock Superboy has brought to class?

Small samples of uranium ore are not particularly dangerous if handled with care, but Superboy has a very large sample, and he’s not being careful at all.

Now for some quick and dirty math: assuming the chunk of rock he is holding is about 4 feet (1.2m) in diameter, then it weighs around 21600 pounds (9800 kg — uranium ore is very dense and heavy). Since Superboy is holding it in his hands, he is being exposed to about 19.5 million millirem (mrem) per hour. For Teddy and the teacher, in the few minutes they’re standing a few inches from the ore, they’ve probably received on the order of 406,000 mrem of radiation — the equivalent of 400 abdominal CT scans (or 40,500 chest x-rays) all at the same time. This puts them in the range of “acute radiation poisoning” which has at least a 60% fatality rate. [here's the math, if you're so inclined]

The rest of the class is about four times farther back from the boulder than Teddy is, so they’ve only received 1/16th of the same dose, or about 25,400 mrem (which is equal to 25 CT scans at the same time). A dose of this magnitude usually causes a temporary decrease in white blood cells, but is not fatal — well, except for recent studies which suggest that it increases the person’s lifetime risk of cancer by a several percentage points.

Nice going Superboy. You won the contest, but gave Teddy and the teacher acute radiation poisoning and increased the risk of cancer in the rest of the class. I think I’ll hang out with Lex Luthor instead: it’s safer.

(Seriously, even in 1947 they had to know a boulder of radioactive material was a bad idea)

scene from The Web #6 (Sturges/Robinson)

I’m pretty sure the pictures and words are supposed to agree. For someone who has no heart rate or respiration, the monitors show surprisingly normal readings in both.

Here’s Magneto working hard, oblivious to the rest of the world, trying to save the life of a certain X-Men. I suspect his nose is bleeding from the effort of breaking the laws of physics –more than usual, that is. Magneto is using his power to affect an object so distant in space that his power his is traveling faster than the speed of light — which considering that his power involves generating electromagnetic waves is pretty damn impressive.

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed magneto x-men