Polite Dissent

Continuing my series of medical annotations of Naoki Urawawa’s excellent manga Monster.

There is barely any medicine in Monster Volume 5, but it’s my favorite volume of the series so far because of the well-realized characters within it. There is Dr. Rudi Gellen, a former classmate — really a former competitor – of Tenma during medical school. He is now a respected clinical psychologist and when Tenma ends up on his doorstep, will he help him or turn him over to the police? (He should really be a criminal psychiatrist and not a psychologist, so I wonder if that’s a translation mistake or just another appearance of a common error — confusing psychiatrists and psychologists).

Nina Fortner appears again, chasing Michael, one of the ex-cops who murdered her foster parents. Johann, Nina’s brother and the monster of the title, doesn’t appear in the book directly but does influence most of the action and underlying conspiracies. Finally, Inspector Lunge arrives and sets a trap for Tenma, but in the end he is the one who is injured.

In the first chapter of Monster Volume 6, it is up to Tenma to repair Inspector Lunge’s injuries despite the inspector’s distrust of him, not to mention the fact that he is handcuffed.

While I am usually impressed by Tenma’s medical skills, I don’t agree with his choices here. Inspector Lunge has an open abdominal wound and it would be a very bad idea to introduce contamination into the wound — contamination such as thread taken from an old cloth bag left in an abandoned warehouse. I agree that the bleeding needs to be stopped, but there are better ways Tenma could be going about it (for instance using thread pulled from his or the inspector’s clothes; or even direct pressure while driving the inspector to the hospital).

Subsequent chapters focus on Eva, Tenma’s former fiancé. It seems that she’s had her own run in with Johann and now stumbles across one of his associates while searching for Tenma.

Meanwhile, Tenma is once again operating as an “underground surgeon.” His patient this time is the number two man in a criminal organization who was injured in an assassination attempt. One bullet “grazed his skull.” The other “went clean through the leg, and the anterior tibial artery was undamaged.”

The anterior tibial artery is one of the two main arteries of the lower leg (the other, naturally, is the posterior tibial artery). It sounds like the bullet went through the front aspect of the calf. It must have done a fair amount of damage for Tenma’s surgical skills to be required, but since the bullet missed the important artery the patient should recover fully.

The final chapters concern students at the University of Munich and a mystery surrounding a wealthy recluse. It’s probably not much of a spoiler to mention that one of the students is Johann…

Previous Monster Medical Annotations:
Volume 1 (Chapter 1 – part 1, Chapter 1 – part 2, Chapter 2, Chapter 3, Chapter 4, Chapter 5, Chapter 6)
Volume 2
Volume 3 (part 1, part 2)
Volume 4

Tags: comics medicine naoki urasawa monster manga

Speaking of annotations, there really aren’t any medical scenes in volume 4 of Naoki Urasawa’s Monster so thre’s no sense in me posting a medical annotation of this volume. The series remains a thrilling read so I suggest you pick it up if you haven’t already. Medical annotations will return as the medical content warrants.

All previous Monster medical annotations.

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I will soon be taking a look at the manga Ray by Akihito Yoshitomi and published by ADV Press. According to the back cover copy, Ray is “a dark thriller of an underground surgeon out for revenge.” That really says it all, doesn’t it?

Finishing up the medical annotation of Volume 3 of Naoki Urasawa’s excellent manga Monster. In these chapters, Dr. Tenma and Dieter are hiding out in a small village in the German countryside. True to form, Tenma cannot resist helping others and before long is assisting the local physician, Dr. Schumann.

I. The Drunk (pp. 133-137)
A drunk patient has been hit by a car. There are two main medical concerns with this situation: First, the injuries inflicted by the accident itself. Second, the patient is so drunk that he could choke on his own vomitus or suck it into his lungs, leading to a fatal aspiration pneumonia. To prevent this, Dr. Tenma has suctioned the patient’s airway and then intubated him in case he vomits again. He has also set his injured leg as well as placed a band-aid or two. (Personally, I’m just impressed that such a small clinic has its own ventilator — not to mention it’s own operating room).

II. The Old Lady (pp. 150-168)
Petra has an aneurysm (a bulging weak spot) in the middle cerebral artery, a major blood vessel in the brain. This aneurysm is leaking blood which has collected in the tissue surrounding the brain (the subarachnoid space) and caused a subarachnoid hemorrhage. Blood is very irritating to the tissues around the brain and spinal cord, and this irritation makes it extremely painful to bend the neck. That’s why Tenma is paying attention to Petra’s neck — he’s seeing how much she can move it. She can barely move it and that scares him. If this aneurysm is not treated it can burst, causing a massive stroke which can lethal. Even if patients survive the aneurysm, there can be complications afterward — this is actually one of Dr. Tenma’s specialties as suggested in the first volume of the series.

Read more…

Continuing the medical annotation of Naoki Urasawa’s Monster. This time, I’ll take a look at the first half of the recently released Volume 3, chapters one through four.

Nothing medical happens in the first chapter, so the annotation begins with:

Chapter Two
Tenma is taken to treat a terrorist injured in a gunfight with the police. He realizes that the man was shot through his axillary artery and is bleeding to death.

The axillary artery is an important artery. It starts off as the subclavian artery, coming off the aorta. As it dives under the shoulder it is known as the axillary artery. It then becomes the brachial artery (the main artery of the arm) as it leaves the shoulder. It’s a large enough artery that an injury to it could lead to death from blood loss, and fairly quickly.

Tenma apparently* stops the arterial bleeding with direct pressure, a valid approach, but he succeeds conveniently quickly. Next he announces that he needs to close the injury to the skin which he proceeds to due with a handy stapler. This makes little sense. I have no problem with the use of the stapler — it’s nearby and it works — I’m just not clear on why he closed the wound in the first place. Tenma knows the patient will require a surgical repair of the artery, so the doctors will just have to open the wound up again. The closed skin may provide a little pressure which will help keep the artery from bleeding, but a simple pressure dressing would do the job much better.

After closing the wound, Tenma places the injured arm in a sling, picks the man up fairly roughly (especially considering he is nearly dead already) and moves him outside for the police to find.

Read more…

There is only one medical scene in Monster, Volume 2. It occurs roughly three-quarters of the way through the book, at the beginning of Chapter 7.

In this particular scene, Dr. Tenma is surgically removing the patient’s cerebral arteriovenous malformation (AVM).

Operating Room conversation:
Cutting all arteries.
There are many vessels in this arteriovenous malformation.
Nidus extraction complete.
Now the veins.

The arteries that carry blood from the heart and the veins that return blood to the heart are connected by capillary beds. Arteries branch off into smaller and smaller arteries that eventually connect to capillaries which in turn connect to small veins which join together to make larger veins which join together to make larger veins…and so on. The capillaries are key because they are where the exchange of nutrients and chemicals between the blood and body tissue (such as muscles, lungs, intestines, etc.) takes place. They are also important because they allow a safe connection between the high-pressure arteries and the lower pressure veins.

In addition to the normally capillary beds, some people have one or more arteriovenous malformations. These can be thought of as a short circuit between the arteries and veins, bypassing the capillaries. They appear as a tangle of blood vessels, known as a nidus. Because they are bypassing the capillaries and connecting the high pressure arteries to the low pressure veins, they have a tendency to leak or bleed. If one of these AVMs is in the brain, it can lead to a stroke.

There are several treatment options for AVMs of the brain. Radiation therapy can often resolve small lesions. Larger lesions require surgical removal. A more recent technique is the embolization of the AVM — a tiny catheter is advanced through the body until it reaches the tangle, and then the AVM is clotted off using metal coils, miniature balloons or a special glue. This can be done in addition to surgery or as the primary treatment in certain cases.

In the scene from Monster, Dr. Tenma is surgically removing the AVM by clipping off the arteries, removing the tangle, and then clipping off the veins.

Previous Monster Annotions: Chapter 1 (part 1), Chapter 1 (part 2), Chapter 2, Chapter 3, Chapter 4, Chapter 5, and Chapter 6.
Coming later this week, Volume 3, so pick yours up and get ready…

Tags: comics medicine arteriovenous malformation avm stroke naoki urasawa monster

Continuing the medical annotations of Naoki Urawawa’s Monster. We’re now up to Chapter 6.

Previous Annotions: Chapter 1 (part 1), Chapter 1 (part 2), Chapter 2, Chapter 3, Chapter 4 and Chapter 5.

The narrative picks up nine years later. Not much has changed for Dr. Tenma. He remains Chief of Surgery at Eisler Memorial Hospital in Düsseldorf and still doesn’t have much of a social life because he always puts his patients and medical practice first. As the chapter starts, Tenma is operating on a complicated patient with a parasellar meningioma¹. Meanwhile, a brutal murder has taken place across Germany in Kõln. The police have their eye on a suspect, but he is hit by a car trying to flee. He suffers a skull fracture and an epidureal hematoma². Dr. Tenma is brought in to operate on the suspect to save his life. While in Kõln, Tenma runs into Inspector Lunge, who all but accuses him of murdering the other physicians at Eisler nine years before.

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Notes:
¹A meningioma is a very slow growing tumor of the meninges, the thin membrane that covers the brain. “Parasellar” refers to a tumor near the sella turcica, a protusion of bone on the inside base of the skull. It is located several inches behind the eyes. To remove this tumor, Dr. Tenma is going to use a pterional approach — this means that he will be going through the pterion, an area at the side of the skull where several of the bones join together. It is one of the thinner areas of the skull and it makes since to use it as an entry point. Once the brain is revealed, Tenma retracts the Sylvian fissure and proceeds to the deeper portions of the brain to remove the tumor. Finally, “extirpation” refers to a surgical removal.

²The injured suspect has suffered a skull fracture. This has torn one of the blood vessels supplying the brain and led to an epidural hematoma (a blood clot between the brain and its thick outer covering). This hematoma is so large that it has increased the pressure on the brain enough to cause the brain to herniate — in other words, the increased pressure is forcing the brain down through the posterior of the skull toward the spinal column. This has damaged the third cranial nerve on the right side of the brain and caused a dilated right pupil (better known as a “blown pupil”). If untreated, a brain herniation can rapidly lead to death.

Tenma performs a craniotomy (basically, he drills a hole in the skull) to drain the hematoma and take the pressure off the brain. It is a successful operation though the patient continues to have some paralysis on the left side and a dilated right pupil afterwards. The left-sided paralysis is residual damage from the hematoma, which caused damage to the right side of the brain (remember the right side of the brain controls the left side of the body, and vice versa). Cranial nerves are different, and damage to one side is reflected on that same side, hence the right-sided herniation leading to a right dilated pupil. Both the paralysis and papillary dilation should improve as the brain recovers, but may never recover 100%.

A final note: while the medicine remains sound, there are several misspellings in this chapter. It’s not really a surprise as these are complex medical terms and spelling them correctly is never easy. Furthermore, remember that the book is translating from Japanese to English a story about a surgeon in Germany, so it’s frankly impressive that this hasn’t been a problem before now. Anyway, Terional should be Pterional and Optic Chasm should be Optic Chiasm.

NOTE: Chapters 7 and 8 of Monster have no medical scenes, so this post is effectively the final Medical Annotations of Volume 1. Stay tuned for annotations of Volume 2 soon.

Tags: comics medicine meningioma epidural hemorrhage herniation naoki urasawa monster

This is the a look at the medicine in the fifth chapter of Naoki Urawawa’s Monster. Annotations for chapter one can be found here and here, chapter two here, chapter three here, and chapter four here.

There are three major plot events in this chapter: the police look into the murders of the three senior physicians at Eisler Memorial Hospital, the twin children escape from the hospital, and Dr. Tenma finds himself promoted to Head of the Surgery Department.

Medically, it was fairly uneventful except for these two (unrelated) items:
1. A patient was noted to have suffered a brain contusion¹.
2. The police revealed that the dead physicians had all been poisoned with nitrate².

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Notes:
¹ A brain contusion is essentially a bruise of the brain. It can be caused by either a direct (coup) or indirect (contrecoup) injury (which I discussed when taking a look at Jack Cross). Brain contusions are associated with swelling of the brain and a subsequent increase in intracranial pressure. If the pressure goes high enough, it can cause coma or death. About one fifth of patients with a brain contusion also suffer a hemorrhage, such as a subdural hemorrhage (this is what killed the Turkish construction worker in chapter one).

2. Dr. Tenma identifies nitrate as a muscle relaxant, but that’s not quite true. There are two types* of muscle in our bodies. First, there is skeletal muscle (also known as striated muscle). This is what most of us think about when we hear the word muscle. These are the muscles that we voluntarily control, and they are the muscles that help us move our arms, legs, mouth, etc.

The second type of muscle is smooth muscle. We have no conscious control over these muscles, and that’s why they’re also known as involuntary muscles. Smooth muscles are important for the inner workings of our body. For instance, they surround blood vessels and the gastrointestinal tract. They are controlled by the autonomic nervous system.

The class of drugs known as nitrates relaxes smooth muscles. By relaxing the smooth muscles surrounding the blood vessels, nitrates cause vasodilatation — the drug relaxes the blood vessels and allows them to open wider and carry more blood. This lowers the blood pressure, and in fact nitrates were some of the first effective medications for high blood pressure. In addition, this relaxation of the blood vessels allows more blood to get to the heart muscle itself, and that’s why nitrates are used to treat heart attacks and angina. However, too high a dose of nitrates can drop the blood pressure too low. This can lead to loss of consciousness and even death if the dose is high enough. Common nitrate medications include nitroglycerin, isosorbide mononitrate, isosorbide dinitrate, and nitroprusside.

*technically cardiac muscle is considered a third type of muscle as it shares characteristics of both the smooth and skeletal muscles.

Tags: comics medicine brain contusion subdrual hemorrhage nitrate naoki urasawa monster

Chapter Four of Naoki Urasawa’s Monster only has two brief medical scenes in it, but it is a key chapter with a murder (or two, or three).

In the previous chapter, Dr. Tenma found himself demoted from Head of Neurosurgery for choosing to operate on a young boy rather than the mayor. In this chapter, the police try to question Anna, the boy’s twin sister, but with no results. Meanwhile, the Hospital Director, his crony, and the recently promoted Head of Neurosurgery decide to milk the situation for all the PR they can, and decide to stage a photo-op with the two siblings, even though disturbing the boy is contrary to what his physician — Dr. Tenma — has ordered. The boy wakes up, the sister screams and collapses, and Tenma is forced off the case. This combined with seeing his ex-fiancee Eva going out with one of his colleagues drives Tenma to a long night of drinking. That same night, three of his superiors are found dead.

• Medical annotations of the previous chapters of Monster

I disagree with the doctors here: dissociative hysteria is an incorrect diagnosis. First, it is an out-of-date (and somewhat sexist) term. Second,it applies to people with dissociative identity disorder (formerly called multiple personality disorder). Anna simply has none of the symptoms of identity disorder.

I agree that she is suffering from some form of dissociation. In dissociation, a person who has suffered some form of trauma mentally distances themselves from their own body and personality. The Mayo Clinic describes it well: “People with dissociative disorders chronically escape their reality in involuntary, unhealthy ways ranging from suppressing memories to assuming alternate identities. These dissociative patterns usually develop as a reaction to trauma and function to keep difficult memories at bay.”

Anna is suffering from dissociative amnesia and what appears to be a dissociative catatonia (a state of limited — if any — motor activity and no response to external stimuli)

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Anticonvulsives (more commonly called anticonvulsants) are medications used to prevent seizures. They are given to people who have a history of seizures (as in epilepsy), but are also sometimes given to people who do not any prior history of seizures but are at risk of developing them in the near future. Brain trauma, brain tumors, and other brain injuries can cause seizures, so these patients are sometimes placed on medication to prevent them, just in case. Some neurosurgeons place their patients on anticonvulsants after brain surgery for six to twelve months because seizures are more likely while these people are healing from their surgery (though still rare).

Hypotensive is another term for blood pressure medicine (“hypo” = low, “tensive” = pressure). Dr. Tenma wants to keep Ms. Hankel’s blood pressure low. This will put less strain on the blood vessels in her brain. He is most likely concerned about a stroke or aneurysm. I suspect Mrs. Hankel had an aneurysm that bled. He managed to repair it, but wants to keep her blood pressure low so it is unlikely to bleed again, and wants to keep her on seizure medications while her brain heals, just in case.

Tags: comics medicine amnesia catatonia dissociation seizure blood pressure naoki urasawa monster

Continuing the medical annotations of Naoki Urasawa’s Monster with Chapter Three (the annotations for Chapter One can be found here and here, and Chapter Two can be found here). Chapter Three is when the story really begins to pick up speed. The cocktail party scene is so masterfully written it still gives me chills. Pick up your copy of Monster and follow along.

As the chapter begins, Dr. Kenzo Tenma is struggling to remove the bullet from the boy’s brain.

Dr. Tenma: Make use of the gunshot wound when cutting
Dr. Tenma: Make sure the debridement is done thoroughly.

NOTES: Tenma is starting his incision at the wound site to provides less trauma to the patient. It also makes it easier on him. As I mentioned in the previous installment, it is a dirty wound. Tenma and his team are debriding the wound, removing all the dead tissue and foreign matter from the wound so that it has less chance of infection and a better chance of healing.

It is a delicate operation, but Tenma successfully removes the bullet and repairs the damaged blood vessels.

NOTES: Proline is a brand of suture (the “thread” used in surgical stitches). It is a non-absorbable (permanent) monofilament (single-stranded) suture made of polypropylene. The “8-0″ denotes the size of the suture, which in this case is very small, about a hundred times less than the diameter of a single hair. Wikipedia has a good article on sutures, if you would like more information.

The boy survives, but remains in a coma. The mayor is not so lucky, he dies during the operation and the other neurosurgeons blame Dr. Tenma for not helping them. The Director shares the bad news at a press conference.

NOTES: “Emphraxis,” one of the words the Director uses is just an old fashioned word that means “clot.” The Director is saying that part of the Mayor’s brain did not get enough blood flow because of a clot and died off. Enough of the brain died that the Mayor did too. Basically, the Mayor had a stroke. As the Director points out, the Mayor’s Inner Carotid (we Americans would say “Internal Carotid”) Artery was clotted off. Because this artery supplies most of the blood to the brain, this was a very serious condition and it is likely the Mayor would have died even if Dr. Tenma had been there.

At work Dr. Tenma is distracted. The nurse has to ask him multiple times for some simple orders.

NOTES: Halcyon is the European spelling for the drug Halcion, generic name triazolam. This drug is a type of drug known as a benzodiazapine that works as a relaxant and a sedative. Valium is probably the best known drug in this family.
A book very critical of Halcion was published in the early ’90s, and whether the books complaints were justified or not, the sales of Halcion suffered in American and have never fully recovered. It is used more in other countries.
You’ll notice that Dr. Tenma does not give a dose for the Halcyon — not a good idea. It’s likely that he has an algorithim the nurse will follow, but it’s always a good idea to give a dose when ordering any medicine, let alone a powerful sedative.

Tenma attends the Director’s cocktail party in an attempt to redeem himself, but the damage has been done. While the Director seems friendly at first, Tenma quickly discovers he’s been demoted and is no longer head of the neurosurgery department. The Director also makes sure that he understands that he no longer has any chance of advancement at Eisler Memorial Hospital and that the Director does not intend to make it easy for him to leave to practice medicine elsewhere. On the way out of the party, his fiancée returns the ring and all but laughs in his face. The cocktail party scene is chilling, and the best scene of the book so far.

Tags: comics medicine suture stroke carotid artery naoki urasawa monster

Picking up the medical annotations of Naoki Urasawa’s Monster with Chapter Two (the annotations for chapter one can be found here and here).

Since last we left Dr. Kenzo Tenma, he has been appointed the Head of Neurosurgery at the prestigious Eisler Memorial Hospital. He and Eva, the daughter of the hospital’s director, have become engaged. At tea one night with Eva and her father, Tenma is stunned to learn that the director wants him to give up on his own promising research¹ and instead write a paper for the director to give at an important European medical conference. The director seems to feel that money and prestige come before research and patient care. Tenma disagrees but doesn’t say anything. Thoughts of that conversation flash though Tenma’s mind as he rushes to the hospital to treat an emergency patient.

A young boy and his twin sister are the only survivors of an attack that killed their parents. The girl is physically fine, but in a state of mental shock. The young boy, on the other hand, is in critical condition with a bullet through his forehead. He is brought to the emergency room where the x-rays and CT scan show the bullet deep in his brain next to the vital left middle cerebral artery². Dr. Tenma chooses to perform a frontal craniotomy to remove the bullet and repair the damaged artery³. As the surgical team begins to prep the patient for surgery⁴, Dr. Tenma is called out of the room.

It seems the mayor has suffered a stroke and is being brought to the hospital for emergency surgery to remove a suspected clot⁵. The hospital director orders Tenma to operate on the mayor and let another team handle the dangerous surgery in the child. He reminds Tenma that the mayor has promised an increase in funding to the hospital. Tenma is conflicted but ultimately decides to go against orders and returns to his original operation; he performs surgery on the injured child instead of the mayor

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Footnotes:
¹Dr. Tenma’s research is on vascular spasms after subarachnoid hemorrhages, a subject we beat to death last time, so I’m going to spare you and not repeat it here.

²The x-ray (though it looks more like an angiogram as x-rays don’t show blood vessels this well) shows that the bullet has gone in straight and lodged resting against the middle cerebral artery on the left, one of the key arteries in the brain.

Now, I haven’t read enough of the story to know who shot the boy, but let’s play forensic scientist for a second. First, note the bullet’s path: it’s at a slight angle, almost straight down. He must have been shot by someone above him. In addition, the bullet is still remarkably intact, providing important ballistics information about the power behind the shot.

³Dr. Tenma has chosen to perform a frontal craniotomy. He is going to go through the frontal bone of the skull to access the brain. He has two concerns with the injury the patient has sustained. The first is the bullet itself. It needs to be removed and any damage it might have caused to the middle cerebral artery repaired. Second there’s the danger of contamination. The area around the wound is filled with small chips of bone and other debris from the gunshot shattering the skull. These can lead to delayed healing and infection. Dr. Tenma is cognizant of these facts andfeels that his first priority is to remove the bullet and check the artery for damage.

⁴The patient is intubated and ready for surgery. Dr. Tenma has marked out his incision. He is utilizing the bullet hole because it makes access easier and provides less additional trauma to the patient.
The patient’s vitals are strong and appropriate for someone his age.

⁵The mayor has suffered a “cerebral blood clot” — in other words: an ischemic stroke. A clot has cut off circulation to part of the brain, and that part is dying from lack of oxygen.

Hospital Flunkie: There’s a possibility that his internal carotid may be blocked.

The internal carotid artery provides most of the blood to the brain, so a clot stopping its flow is very serious. Narrowed carotid arteries are an unfortunately common sign of atherosclerosis (cholesterol deposition and hardening of the arteries), and if they get narrow enough a surgery called a carotid endarterectomy can be performed to clean them out. Sounds like it’s too late for this for the mayor.

Tags: comics gunshot wound medicine stroke carotid artery cerebral artery naoki urasawa monster

Chapter Synopsis (continued)
After another brain surgery², Kenma bumps into Dr. Becker who warns him not to get involved in hospital politics. He talks briefly to a nurse³, and then has an unsettling encounter with the Turkish wife who accuses him of letting her husband die. Apparently, Tenma was originally supposed to operate on her husband, but was shifted at the last minute to the celebrity patient. She blames Tenma for the subsequent death of her husband.

Later, while eating dinner at a fancy restaurant with his girlfriend, Tenma is mulling over what the Turkish woman said. He has read the chart and thinks that he could have saved the man’s life had he been the surgeon⁴. He suspects he was pulled away from the original case because the singer was more famous and would bring more prestige to the hospital. His girlfriend gets upset that he is obsessing about this during their dinner, and pointedly tells him that “not all people are created equal.”

As the chapter ends, there has been a brutal murder of an East German expatriate family. The mother and father are dead. The daughter survives but the son has sustained a bullet to the brain and is in critical condition. Dr. Tenma is paged…

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Footnotes:
^2. Dr. Tenma is performing more brain surgery here, but the exact nature of the surgery is hard to determine. It is safe to assume that it involves the area of the brain known as the cerebellum because that is where the pyramis is.

^3. Dr. Tenma tells the nurse to increase the patient’s Inovan 3 gammas. Inovan is one of the brand names for the drug Dopamine. Dopamine is a class of drugs known as a pressor and it is used in critically ill patients to keep their blood pressure high. It is given by an intravenous drip in tiny amounts. A “gamma” is a term some doctors use for a microgram. In the United States, Tenma would have told the nurse to increase the Dopamine drip by 3 “mikes.”

^4. The Turkish construction worker suffered a blow to the head during a construction accident. This tore open one of the blood vessels in the head leading to a large subdural hemorrhage (a subdural hemorrhage occurs outside the membranes surrounding the brain, while a subarachnoid hemorrhage occurs between these membranes and the brain). The pressure from this large hemorrhage herniates the brain, pushing it down toward the spinal column. This injures the brainstem, which is unfortunate as the brainstem controls many of the basic functions of life including breathing and heart beats. A severe injury to this area of the brain is fatal.

Tenma feels that if he had been the surgeon, he would have been faster at drilling a hole in the skull (craniotomy) to relieve the pressure and would have been able stop the brain from herniating.

Tags: comics medicine herniation dopamine naoki urasawa monster

Get your copies of Naoki Urasawa’s Monster out because this is the first of a series of medical annotations of the manga. This first post addresses chapter one of volume one — well, chapter one actually has a great deal of medicine in it, so I’m splitting it into two posts. The second part will be posted later tonight.

I’ll start with a brief synopsis of the plot, and then provide the medical footnotes. As always, questions are welcome

Chapter Synopsis:
Dr. Kenzo Tenma is the star neurosurgeon at the Eisler Memorial Hospital in Germany. He is a brilliant young doctor, who emigrated to Germany from Japan to benefit from working in a larger hospital with better equipment and staff.

As the chapter opens, Tenma is congratulated by his team upon a successful surgery. As he walks into the hospital corridor, he sees the wife and children of a Turkish man who was brought in at the same time as his patient. Unfortunately, the Turkish patient was operated on by the less skilled Dr. Becker and died.

Tenma is catching up on sleep at his apartment when his girlfriend — the daughter of the hospital’s director — stops by. While there, they watch a press conference by the director explaining the surgery that Tenma just performed on a famous singer¹. Of course, the director takes full credit for the operation and doesn’t even mention Tenma. Later on, it comes out that the director is even publishing Tenma’s papers under his own name.

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Footnotes:
^1. A cerebral aneurysm occurs when there is a weak spot in one of the arteries that supplies the brain with blood. Arterial pressure causes this weak spot to bulge out like a balloon, forming an aneurysm. Some aneurysms are so small that nobody knows that they even exist. Sometimes they can become large enough that they press against a nerve or a vital part of the brain and cause symptoms such as pain, numbness, or weakness. Aneurysms can also leak or burst, sending blood into the area surrounding the brain (the subarachnoid space, hence this is known as a subarachnoid hemorrhage).

This is precisely what has happened in the case presented: the patient’s aneurysm burst causing a subarachnoid hemorrhage.

This is where a neurosurgeon like Dr. Tenma comes in. He and his team remove part of the skull and retract the tissue layers surrounding the brain. The hematoma is drained and a small metal clip is placed on the base of the aneurysm to stop it from bleeding.

Even with quick surgical treatment, complications can follow a subarachnoid hemorrhage. Vasospasm (“cerebrovascular spasm”) is a common complication. In this situation, one or more of the large arteries at the base of the brain narrow and reduce the blood flow to the brain. This restricts the supply of oxygen (“cerebral ischemia”) to the brain and — despite maximum therapy — leads to stroke or death in about 15-20% of patients. The exact cause of the vasospasm is unknown. It generally starts 3 days out, peaks around day 10, and resolves in 2-4 weeks.

The ventricles of the brain produce and recycle the cerebrospinal fluid. When the ventricles become blocked (or otherwise stop working), they swell leading to a condition known as hydrocephalus. When this follows an injury (such as a subarachnoid hemorrhage) it is known as secondary hydrocephalus.

Compare the sizes of the ventricles

Tags: comics medicine aneurysm subarachnoid hemorrhage hydrocephalus naoki urasawa monster