Polite Dissent

Polio was once so common that ads were placed in comic books warning against it (this particular ad is from the 1950s). The development of the polio vaccine was seen as an answer to parents’ prayers. Today, we’ve become complacent in large part because few remember how devastating a disease polio was and if we’re not careful, we stand to lose everything we’ve gained against the disease.

Today’s cover features Richie Rich, the “poor little rich boy.” What exactly is so poor about Richie? He has loving parents, good friends, and more money than Scrooge McDuck. What is “poor” about all that? Maybe he hides a soul crushing depression (though he’s always smiling), or possibly some horrible fatal disease (which would explain the abnormally large head and swollen ankles)?

Richie Rich and His Girlfriends #13
(Harvey Comics, 1981)

Click on the cover for larger view

13 Days until Christmas!

This year’s Comic Book Cover Advent Calendar (so far).
One year ago, the cover was Oni Double Feature #13.
Two year ago, the cover was Howdy Doody #13.
Three years ago, the cover was Comic Cavalcade #13.
Four years ago, the cover was Captain Atom #13.
Five years ago, the cover was Teen Titans #13
Don’t miss Yet Another Comic Blog’s annual advent calendar

scene from Black Panther #17 (by Reginald Hudlin and Scott Eaton)

Storm seems to be suggesting that the mutant gene is x-linked. This actually fits with what the Beast said in Astonishing X-Men #25 when he mentioned that the x-gene is found on the 23rd chromosome — the sex chromosome. Storm’s statement confirms this, but also tells us that there is no corresponding gene on the Y-chromosome. For you non-biologists, at the simplest level, this means that mutant fathers cannot pass on the x-gene to their sons, only their daughters.

1. Assuming what Beast and Storm said is true, the next question is whether the mutant gene is x-linked dominant or x-linked recessive. There are character histories that support both ideas:

2. Then there are the cases where neither dominant nor recessive genes fit:

3. It would also make sense that the x-gene has a high rate of spontaneous mutation, which would explain all the mutant children born to normal parents (Beast, Iceman, Kitty Pryde, Jean Grey, etc. etc.).

4. Then there’s the more advanced possibilities:

Of course, I’m well aware that attempting to tie 45+ years of mutant continuity — written by dozens of creators of vastly different scientific knowledge — into coherent biology is an impossible task. But damn, sometimes it’s fun to try.

Because you demanded it, I’m going to end the summer’s public service ads with two weeks of PSAs featuring Binky’s younger brother Allergy, in all his huge bow-tied glory. And not just any Allergy PSAs, but two ads concerning Allergy and his pet dog (though, ironically, allergies to dogs is never mentioned).

This week, Binky and Allergy reveal that they are completely clueless about pets, which makes you wonder why their parents let them have one in the first place. They probably should have started them out with fish, a hamster, or a turtle. For example, based on the sixth panel, I’m wondering if they ever fed the dog before they had that chat with their neighbor. No wonder Sport doesn’t like them!

Click on the image for the full ad

This PSA is found in DC comics from October 1953. Like nearly all DC PSAs, it was written by Jack Schiff. Art was handled by Win Mortimer, who did most of the Binky PSAs. This copy was scanned in from Adventure Comics #193.

More PSAs

Tags: comics psa binky allergy pets dog jack schiff win mortimer

It can be challenging enough to diagnose a patient’s problem in the real world — just imagine how difficult how much more difficult it would be in a comic book world where magic, psychic powers, aliens, advanced technology, and Grant Morrison all exist. Here are a handful of actual comic book medical cases — are your diagnostic skills up to the task?

‘Remember how I mentioned that there were two New Teen Titans anti-drug PSA comics from the ’80s? It turns out I was wrong: there were three.

Jesse, trying to emulate his older brother Dave, has started to use drugs. After he shares some angel dust-laced marijuana with his friends, he heads off to an anti-drug rally his parents are making him attend. The Teen Titans (minus Robin, who is once again replaced by generic hero “The Protector”) are speaking at the rally — no, not Speedy, he’s probably back at Titan’s Tower getting high.

When the Teen Titans tell the audience that drugs are bad, and his parents chime in to support the Titans, Jesse throws a tantrum and runs out of the meeting in a huff. Beast Boy tails him, just to make sure he doesn’t get into any trouble and — wouldn’t you know it — there’s a tall cliff in the middle of town that Jesse almost tumbles over. Beast Boy turns into a rhinoceros and stops him from falling off the edge. At just that moment, the drugs Jesse’s been taking cause severe stomach pains, and Jesse falls off the cliff despite the presence of a green pachyderm. Luckily, Raven’s soul-self swoops by and saves him, but not before her empathic powers absorb the hallucinatory effects of the drugs and Raven begins to Freak Out. The other Titans are able to subdue her and they cart her off to the hospital. Seeing the effects of the drugs on Raven, Jesse swears never to use drugs again.

The Teen Titans now turn their attention to Jesse’s supplier: his older brother Dave. They track him down to an old abandoned shack at the end of town (where despite begging his supplier for a hit the page before, he’s now handing out drugs to half a dozen kids – for free). A brief skirmish ensues and Dave escapes , but that was really the plan all along. The Titans now follow him to his supplier. A bigger skirmish follows and the Teen Titans are able to capture the entire drug dealing gang. Furthermore, both Jesse and Dave have sworn off drugs for good.

Like the previous Teen Titan anti-drug comics, this one starts with a letter from Nancy Reagan. Several pages of confidence building and decision making exercises are included at the end of the comic. Unlike previous comics, this one is sponsored by IBM, so I’m not clear why Robin was replaced by the Protector, as I understood that was due to Nabisco/Keebler rivalries. The story is by Marv Wolfman and Joey Cavalieri with capable pencils by Adrian Gonzales.

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Tags: comics medicine psa teen titans

Reviewing last month’s comics today, that’s our motto here at Polite Dissent
Oracle: The Cure #1 Home Again, Home Again
Kevin Vanhook, writer
Julian Lopez and Fernando Pasarin, pencilers

First off, Zolpidem is better known as the sleep aid Ambien.

That brings up an obvious question: why would the doctors give a sleeping pill to a patient who’s already unresponsive?

There’s actually a logical reason for that: evidence has been accumulating that zolpidem improves the state of people in comas, and may actually wake some patients from their comas. It only seems to work for certain types of coma, plus most of this evidence is anecdotal — and it’s always wise to take that kind of evidence with a grain of salt — but the idea is certainly intriguing.

Good job by Vanhook for including this appropriate yet fairly obscure medical research in the story.

Finally, a few words about the art:
There’s a very good attention to detail. IVs are in the right place (though the right IV doesn’t seem to be attached to anything), pulse oximeter is on the finger, and she’s wearing a hospital bracelet. There may be a few too many monitors, but she’s in the ICU, so who can tell?

However, a common error does surface here: patients on ventilators (breathing machines) who are drawn wearing oxygen masks. The bottom line: masks don’t work for patients on ventilators because there’s too much resistance for the air to get to the lungs. Patients on ventilators need to be intubated (a breathing tube down the throat) — or for long term patients, have the ventilator hooked up to a tracheostomy.

There were two interlocking stories on tonight’s episode of Fringe. One of which contained a serial killer, and one of which contained Fringe science (if by “fringe” you mean “in no way connected to the actual laws of science”).

The Plot:A demolition crew is ready to implode an old building when one of them gets a strange feeling and runs back inside. He and his co-workers find a hidden basement that appears to have been sealed off for years, and in it, huddled in the corner, they find a naked, pale, bald ten year-old child.

Meanwhile, the serial killer known as “The Artist” has reappeared after a three year absence and sent a taunting note to the FBI.

Olivia and her team interview the strange child (hereafter called “Lex Jr”) in the hospital. He is having some shortness of breath and the doctor wants to put him on supplemental oxygen. Walter stops her and lets her know that Lex Jr is from a low oxygen environment and needs less oxygen, not more. Sure enough, Walter’s right and Lex Jr starts to breathe better. He seems to form an emotional bond with Olivia. He grabs her pen and writes a name upside down — and it turns out to be the name of the serial killer’s latest victim.

Olivia visits Lex Jr again, hoping for more clues about the killer. This time, he writes an address down for her. She goes to the address, but can’t find anything. It isn’t Lex’s fault though, it was Olivia’s: the murderer’s van was parked at that address and she missed it. While in the hospital, she meets a social worker who remarks that Lex Jr will likely be leaving the hospital soon.

Walter thinks he can provide a way for Lex Jr to talk. Olivia brings him to the lab where Walter hooks him up to the neural stimulator (remember that from episode five?). About this time, the social worker appears in the lab, only he’s not a social worker — he’s a CIA agent and wants the boy. He agrees to give Olivia and team one day to find the killer before he returns for Lex. With Lex’s help, and an assist by Peter, Olivia manages to track down and capture, if not kill outright, the Aritist. In the end, Olivia finds she can’t hand Lex over to the CIA and has the friendly doctor from the hospital set him up in a good foster home instead.

1. When is More Less?
The “Lex lived in a low-oxygen environment” concept bugged me. For one thing, if the hidden basement was that oxygen poor, the demolition crew would not have been able to breathe down there.
And later, when Walter tells the doctor to put Lex on 5% oxygen, what was the other 95%? Hospitals don’t keep tanks of less than 100% oxygen sitting around. If a little oxygen is needed, the flow setting is low. If more is needed, a higher flow (and fancier masks) are used. Remember, room air has 21% oxygen and if the team wants to go less than that, they’d need an air-tight room and would somehow have to remove the oxygen from it. You can’t just use a near-empty oxygen tank because all you’ll get from that are a few minutes of extra oxygen and then back to room air.

2. If a Bone Shatters, and No One is Around ti Hear It, Does It Still Hurt?
If he lived his entire life in the dark, he would not just be low in Vitamin D, he’d have rickets, a bone disease caused by long term Vitamin D deficiency.

3. Oxygen or Cautery
The machine they made a show of turning on before placing Lex on his “low oxygen” nasal canula had nothing at all to do with oxygen or air flow. It was the control panel for a electrocautery machine — which uses an electrical current to cut through tissue and/or cauterize wounds. It is a common piece of surgical equipment. You’ll notice the buttons were labeled monopolar, bipolar, and coagulate.

4. The Future’s So Bright, I Gotta Wear Shades
For someone with an extreme sensitivity to light, he was sure kept in a brightly lit room. How about some sunglasses at least.

5. Call the Amazing Randi
Let me get this straight: Lex can not only read the mind of the serial killer — oh sorry “empathize” with him — but he can miraculously express it in English, a language he cannot speak and isn’t even sure which way is up when he writes it (but he fixes that one fast). I could almost accept it if he drew a vague picture of what the killer was seeing, but for him to give a specific name or address when it’s likely the killer wasn’t even aware of them…

6. When Being Cheap Costs
The meat packing company sold used bloody drop cloths? And they didn’t find this strange? And The Artist didn’t have the common sense to spend a few bucks extra to buy clean ones?

7. Code
Ars Technica has a couple of nice articles (especially the second one) on “The Fringe Code.”

Because of the nonsensical psychic powers, the complete misunderstanding of basic science, and pretending an electrocautery machine is an oxygen machine, I have no choice but to resume the Fringe Doomsday Clock countdown, and the hands move up a minute to 11:56.

ad from Action Comics #166 (March 1952)

Despite the barely above average medicine, I enjoyed this episode of House. Probably because it focused more on House himself than on Foreteen.

Jackson is a teenager born with genetic mosaicism whose parents have chosen to raise him as a male. He is playing on the school’s basketball team and he has just made the winning basket when he collapses to the ground with severe abdominal pain. He is later admitted to House’s service for treatment of this “chronic pelvic pain”. An issue is that his parents have never told him about his underlying genetic condition and have been giving him testosterone shots under the fiction that they are vitamins. They don’t want House or his team to tell him the truth, a situation that doesn’t sit well with some of the team, particularly Thirteen.

The team’s initial differential includes dehydration, congenital adrenal hyperplasia, PMDS (Persistent Mullerian Duct Syndrome), a blind uterus, or problems from the surgical reconstruction of his penis. House wants to perform a urethroscopy, but the parents want an MRI to look for a blind uterus. House gives into their suggestion and an MRI is ordered. The results are negative, so Jackson is prepared for the urethroscopy. As they start the procedure he starts to complain of chest pain and shortness of breath. Thirteen only hears muffled heart sounds on exam and notices jugular venous distention. He appears to be in cardiac tamponade so she jabs a syringe blindly into his chest to remove the extra fluid from around the heart.

The team’s second attempt at a differential diagnosis only yields the generalities of “drugs, toxins or infection.” Then autoimmune disease related to the testosterone injections is mentioned, especially polyarteritis or SLE (lupus). House has the team start Jackson on corticosteroids for the suspected autoimmune condition and finasteride to block the effects of the testosterone. (It’s not made clear at this point, but the testosterone injections are stopped as well). As Thirteen is administering the medicine, she notices red palms on Jackson. She takes this to mean that 1) he has does not have an autoimmune disease, and 2) his liver and kidneys are failing. Blood tests back this up (her second point, at least).

The third version of a differential diagnosis contains amyloidosis or drug/alcohol abuse due to depression. A search of his room yields some dismal and morbid poetry that Thirteen takes as proof that Jackson is depressed. She feels this depression is related to his sexual identity issues and wants his parents to tell him the truth, but his mother refuses. Meanwhile, Taub finds evidence of toxoplasmosis on Jackson’s water bottle, so infection is a possibility as well. He is started on pyrimethamine to treat the suspected toxoplasmosis. His parents ask that his testosterone be restarted as well. When Thirteen is injecting the medicine into Jackson, she confesses that it isn’t a vitamin shot like he’d been told — though she doesn’t tell him what it is, just tells him to ask his parents. This triggers a showdown with her and the parents in Cuddy’s office. Cuddy backs Thirteen, but lets her know it is for Jackson’s sake, not her own. When told the truth, Jackson understandably becomes angry and refuses to speak with his parents anymore. Thirteen comes back in to talk with him and lets him know about finding the poem. He tells her it was for a class assignment (”write a poem in the style of Sylvia Plath”), and was not about his feeling at all. He tells her that he doesn’t feel depressed — or at least he didn’t until his parents told him the truth about his genetics. He becomes suddenly nauseated and begins to vomit blood.

Jackson is found to have a gastric fistula due to necrotizing pancreatitis. Thirteen suggests Zollinger-Ellison Syndrome, but Taub believes it is systemic scleroderma. Foreman decides to treat the possible Zollinger-Ellison first and if that doesn’t work, then to treat the scleroderma. He and the rest of the team know that sclerodema is more likely, but also has a worse outcome, so they are treating the Zollinger Ellison and hoping for the best. It doesn’t work, so Jackson is started on anti-inflammatory medication to treat the scleroderma. The next morning, Foreman tells Thirteen that it is having some effect as Jackson’s liver enzymes are improving. Through some convoluted logic, they deduce that this means it cannot be sclerodema since he is getting better too fast. About this time, House reappears on the scene, hears about the case and instantly makes the diagnosis: it all started with dehydration; that’s what caused the collapse. The ER gave him some IV fluids, but because of his use if energy drinks (which apparently also caused his abdominal pain), his kidneys were slow to respond. When Jackson was then given the contrast for the MRI, the already dehydration/energy drink-strained kidneys could not filter the contrast fast enough so it cycled throughout the body, causing problems wherever it went. It was this contrast that caused the heart disease, the liver failure, the kidney failure, and the pancreatitis.

Methadone is a potent narcotic, and has more respiratory depression than more common narcotics, but it’s not that life threatening. Particularly in a patient with such a heavy previous use of narcotics.

I did like House’s realization that he can’t be the brilliant diagnostician he wants to be if he’s not in pain.

Mosaicism occurs when one person has two genetically distinct lines of cells. Some of their cells have one set of genes, and the other cells have a different set. Mosaicism generally occurs early in development, often from a mutation or nondisjunction. In Jackson’s case, one cell line is genotypically male (XY) and the other female (XX). This is a known, but rare, cause of intersexuality.

As usual, minor complaints are in blue, and nit-picking in green. My main complaint this week, the red one, I’d characterize as a “moderate” complaints — more than minor, but less than major. It’s theoretically possible, but extremely unlikely.

Intravenous contrast can certainly cause renal problems, my kidneys are proof of that. Contrast material can cause acute renal failure (contrast-induced nephropathy). There have also been isolated cases of pancreatitis and pericardial effusion thought to be linked to contrast material, but the patients involved all had significant other co-morbidities (such as AIDS). For Jackson to have had such problems with contrast, his kidneys must have been in bad shape, which should have shown up on simple blood tests — blood tests which radiologists are maniacal about ordering and avoiding the use of contrast if they looks even a little off.
I guess this sort of complication is what happens when you act as your own radiologist.
And seriously, how many energy drinks was this kid downing to cause these problems?

Notice how vague the writers were being when treating the scleroderma: repeatedly using the term “anti-inflammatories” instead of naming a specific drug. This is usually a sign that they’re trying to skirt around a known plot inconsistency.
Such as the fact the anti-inflammatory that they’d use would likely be a corticosteroid, the same type of drug they gave Jackson for a suspected autoimmune condition in the first half of the show. In fact, scleroderma is an autoimmune condition.

I like how psychic the team can be. Thirteen automatically knows it’s an exudate causing Jackson’s tamponade instead of the more common (and seen just two episodes ago) blood.
That’s incredibly fast for an exudate to form.
Blindly jamming a needle in the chest is still not a good idea. It wouldn’t take that much longer the properly position it, and just a little more time to attach it to a cardiac monitor.

Finasteride is not approved for use in children. It blocks the breakdown of testosterone into dihydrotestosterone (DHT), which I guess might help if it is the DHT causing the lupus reaction and not the testosterone itself. Otherwise, you’ve just made things worse by increasing the levels of testosterone.

Toxoplasmosis is a common parasitic disease, but does not typically cause problems in people with healthy immune systems. It is a worry in patients with compromised immune systems and in pregnant patients, because it is one of the diseases that can be passed from mother to fetus.
Symptoms don’t match at all.
Pyrimethamine is not used alone to treat toxoplasmosis. It is given with a sulfonamide.

I suspect a pelvic U/S would be a better choice than MRI when looking for a blind uterus, but then you’d avoid that whole contrast material concept.

Several hours of pelvic pain is not chronic.

The medical mystery was good. The mosaicism was a red herring in terms of the mystery itself — though it did add to the family dynamics issues. I give the mystery a B+. The final diagnosis was logical, but would have required a perfect storm of events to occur. I give it a B. The medicine overall remained haphazard, but at least it was more focused than previous weeks (except for the toxoplasmosis, that came out of left field), and earns a C+. The soap opera was fairly good, both the “House is happy” and “Mother avoids the issue” aspects. I give it a B.

Last week’s House review
A list of all prior House reviews

Another week, another episode of Fringe with painfully bad medicine — only this time with bad computer science as well!

The Plot: A teen age boy is on the computer when he open an anonymously sent program. Strange images begin flickering on the computer screen and he stares, transfixed. His parent find him later, dead, his brain liquefied and oozing from his ears and nose.

Agent Dunham and her team arrive on the scene. They interview parents and friends, but can find nothing incriminating. The grab his computer and take it back to the lab. Astrid tries to look at the hard drive — after all, she has a minor in “computer science” — but announces that she cannot because its platters are fused.

A second body is found, just like the first. This time, it’s a car salesman across town. The computer hard drive shows the same damage, but this time Astrid is able to determine that he had downloaded a shortly before he died. Peter takes both computer hard drives to one of his friends who is not able to track down the sender of the file, but is able to discover that it has been sent to a new location — Agent Dunham’s home. Dunham and Peter rush to her apartment and find her young niece transfixed by the screen. They are able to bring her out of the trance and she appears fine. Dunham does notice that the webcam light is on, suggesting that someone has been watching her.

Another victim is found, this time a day trader in Evanston, Illinois. The killer has gotten sloppy and there is enough information for even Agent Dunham to discover a pattern to the killings. This victim was the new husband of the mother of Luke Dempsey. Luke was the first victim’s best friend. Dunham discovers that Luke’s father is something of an incredible computer genius. She suspects he is the one behind the murders. She brings Luke in, but he won’t tell her where his father is. She lets him go, and follows him to his father’s hideout. She confronts the killer, but in the end he takes his own life.

1. Brain Fondue
Dr. Bishop: A complex combination of visual and subsonic aural stimuli, ingeniously designed to amplify the electrical impulses of the brain, trapping it in an endless loop.
That sure sounds like Dr. Bishop is describing a seizure, or actually a type of potentially fatal seizure known as “status epilepticus“.
People can die from status epilepticus, but their brain doesn’t liquefy.
Speaking of that, how exactly did this seizure-like activity cause the brain to liquefy? Was it supposed to raise the temperature so much the brain melted? That’s really too stupid for words.
And even if the brain did liquefy, why would it leak out the nose and ears? The brain is essentially in a tightly sealed container; it won’t leak out unless the container is broken (a skull fracture, for instance).
Flashing lights can certainly cause seizures in certain people; it’s called a photosensitive seizure and was the reason that one episode of Pokemon was never shown on television in the U.S. But it doesn’t cause seizures in people who aren’t already susceptible.

2. The Brown Note
My speakers can barely play real sounds, let alone “subsonic aural stimuli.”

3. Damn Viruses
Astrid: A computer virus that infects people.
I thought this idea was ridiculous when I first ran across it several years ago in the Cable/Deadpool comic book. Plus, I don’t think this was an actual computer virus. It was malware, certainly, but it didn’t have the self propagating characterstic of true computer viruses.
Yet another reason not to click on spam pop-ups.

4. The American Medical Association
There is no such thing as the “AMA Database.” The AMA is essentially a lobbying organization, it has little to do with the actual practice of medicine.

5. It Didn’t Even Start Well
That is an absolutely horrible episode title.

6. All Your Base Are Belong To Us
I know just enough about computers to realize that most of the “computer science” on this week’s episode was on par with the medicine. I leave it up to all you computer experts to do the critiquing here.

I’m afraid Fringe is rapidly reaching the point where it has gotten so ridiculous that it’s not worth an hour of my time to watch, let alone write about afterward. To this end, I have created the Fringe Doomsday Clock, patterned after the famous nuclear doomsday clock.

When the clock reaches midnight, my patience will be up and I will stop watching Fringe. After the last two episodes, the clock has been moved ahead to 11:57.

Threshold is one of those great villains that you love to hate. From his initial appearance in Gen13 through his time in DV8 and later, he didn’t have a single redeeming bone is his body. Sure, you could make excuses: he saw his parents murdered before him, his sister tried to seduce him, his cyborg boss fed him drugs and used him as a sexual plaything…but his malignant personality was too deep to be explained away that easily. He was pure malignant evil.

In this scene, Threshold is fleeing as fast as he can after trying to kill all the other members of DV8 (by blowing up their helicopter over the middle of the ocean) and then attacking I.O. headquarters.

DV8 by Mike Heisler and Al Rio

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed threshold dv8 gen13 wildstorm

Back to the Golden Age for this next comic. Only fifteen days to go until Christmas!

Calling All Kids #15 (Parents Magazine Institute, December 1947)

Click on the cover for larger view

15 Days until Christmas!

This year’s Comic Book Cover Advent Calendar (so far).
One year ago, the cover was Funny Pages #15.
Two years ago, the cover was Looney Tunes and Merrie Melodies #15.
Three years ago, the cover was The Ren & Stimpy Show #15.
Four years ago, the cover was Classics Illustrated #15: The Gift of the Magi
Don’t miss Yet Another Comic Blog’s annual advent calendar

Two good episodes of House in a row, what are the odds? Sure, the medicine was a little sketchy, but overall it was pretty well done.

Natalie is a sixteen year-old overweight high school student and the victim of frequent bullying. At the school Christmas show, she develops visual hallucinations and vomiting. After admission to the hospital, she is found to have liver failure as well. The initial differential diagnosis is Wilson’s Disease, alcohol abuse, or something the other kids slipped her. Sure enough, some of the kids in the choir do admit secretly giving her a hallucinogenic mushroom. Additionally, a search of Natalie’s locker reveals a large bottle of acetaminophen (Tylenol) — an over-the-counter painkiller than can cause liver failure — raising the possibility of a suicide attempt. Natalie denies any suicidal thoughts or intentions, but Cuddy wants to go ahead and start her on acetylcysteine, the antidote for acetaminophen poisoning.

Next, Natalie develops a rapid heart rate and increased blood pressure, along with pulmonary edema (fluid filling up in the lungs). The differential now a toxic exposure (glue sniffing is mentioned), or infection. When House discovers she has been volunteering at a homeless shelter, he sends Taub to check it out. He returns suspicious that Natalie might have TB (tuberculosis) because one of the residents there has a severe case of it. About this time, Natalie has a seizure. Cuddy remarks that Natalie’s liver functions are very bad; she suspects hepatic fibrosis. Other possibilities mentioned include a severe mold allergy or a fungal infection. House has the team test for the allergy (the prick test) and start her on antifungal medication. The allergy test is negative. One of her “friends” from school visits and drops off some homework for her. He mentions that she used to be a heavy drinker, but stopped a few months ago. This again raises the specter of alcohol abuse, or possibly even alcohol withdrawal as it can cause seizures. Cuddy wants to start benzodiazepines (“benzos”) because they help with alcohol withdrawal, but her parents refuse. House decides to go ahead and start them, but not for alcohol abuse, but for her seizures (“wink, wink” — though they are used to treat seizures as well).

Natalie now passes out and is found to have a dangerously low heart rate. The differential shifts to multiple endocrine neoplasia, a hypothalalmic brain tumor, or leukemia. Wilson and Cuddy want to start treatment for the suspected leukemia, but House wants to wait for a bone marrow biopsy to confirm the diagnosis. Cuddy remains concerned that they may be missing something. She mentions autoimmune disease, particularly microangiopathic vasculitis (inflammation of tiny blood vessels such as capillaries and arterioles). When House tells her about a clinic patient of his, she has her own Eureka! moment and realizes that Natalie has eclampsia (toxemia of pregnancy). It was not caught initially because Natalie gave birth prematurely several weeks before her symptoms appeared and eclampsia has been known to occur several weeks postpartum. Unfortunately, the damage to her liver and heart are permanent and it is likely that Natalie will die in the next few days, particularly when the transplant committee turns down her case. On the bright side, Natalie’s daughter has miraculously survived — she was found by a homeless couple — and now Cuddy wants to adopt her.

The medicine was not particularly deep this week, but there was nothing I’d consider a big error. Minor complaints in blue, nit-picks in green.

Giving antifungal medications — which are universally hard on the liver — to a patient in liver failure is not a good idea.

You don’t give chemotherapy for leukemia without first determining what type of leukemia it is.
Surely the leukemia showed up on an ealier blood count. They did check a blood count, right?

Acetylcysteine is used for treating acute acetaminophen poisoning, not for treatment well after the fact.
Checking an acetaminophen level first would be a good idea — it’s an easy test.

Magnesium sulfate is the treatment of choice for seizures due to eclampsia (of course, it helps to know that you are treating eclampsia). Benzodiazepines are not as effective, though they do work.

What shot was Cuddy giving Natalie in the leg when she was having the rapid heart rate and high blood pressure? Any “code” medication should have gone in the IV (faster action).

Yes, eclampsia can occur after delivery — I was taught that it could occur up to six weeks later (and you’ll notice it was one of my original predictions for the show). The β-HCG (the hormone checked for in a pregnancy test) drops after delivery, and within a few weeks it generally is back to normal, so it is entirely possible to have eclampsia without a positive pregnancy test.

The medical mystery was modestly interesting this week and deserves an B. The final solution was good and earns an A. The medicine was shallow (lots of jumping to diagnoses that make little sense, no good testing), but not terrible. I’ll give it a weak B. The soap opera was well done — Wilson yanking the team’s chain and Cuddy’s happy ending were both high point, though I don’t buy Foreman/Thirteen — so I’ll give it an A-.

Last week’s House review
A list of all prior House reviews

The 2008 Comic Book Cover Advent Calendar Countdown continues. With 23 days remaining until Christmas, today’s cover is Polly Pigtails #23. I don’t know much about Polly Pigtails, other than it was published in the mid-40s and was billed as “The Magazine for Girls.”

Polly Pigtails #23 (Parents’ Magazine Institute, December 1947 )

Click on the cover for larger view

23 Days until Christmas!

This year’s Comic Book Cover Advent Calendar (so far).
One year ago, the cover was Dennis the Menace Bonus Magazine Series #23.
Two years ago, the cover was Wendy Witch World #23.
Three years ago, the cover was The ‘Nam #23.
Four years ago, the cover was Card Captor Sakura #23
Don’t miss Yet Another Comic Blog’s annual advent calendar

An above average episode of House. The medicine was better than recent episodes, though the soap opera was turned way down.

Sophia is a 16 year old emancipated minor working as a factory foreman. She sought emancipation after both of her parents were killed. While talking with a floor worker, she begins to have chest pain and shortness of breath, and then collapses, red frothy sputum flowing from her mouth.

She is admitted to the hospital for evaluation of her pulmonary edema. The initial differential diagnosis consists of parasite infection, gastrointestinal problem, pregnancy, or damage to the heart from drug use. House has Kutner perform an echocardiogram while Taub and Thirteen search Sophia’s apartment. The echo shows no structural heart disease, but the apartment search shows that she likes to build her own furniture, but it also turns up a bong. When confronted with this, Sophia claims that it is her ex’s bong, and it’s the reason that he’s an ex.

The team now considers that she may have intermittent tachycardia (occasional episodes of an abnormally fast heartbeat) due to drugs, though Kutner favors a diagnosis of vasculitis. He wants to giver Sophia steroids, but House turns him down, stating that a steroid could make an arrhythmia worse. House wants to start her on beta-blockers (a drug that lowers the heart rate) to control the suspected arrhythmia. Kutner decides to go ahead with his original plan and gives her steroids instead. A short time later, Sophia is violently yelling at the staff and having paranoid delusions. She is given Haldol (haloperidol — a potent antipsychotic) to control her outbursts. Kutner reports that labs show that her psychotic break is not due to any metabolic problem, and it was too soon to be related to the steroids.

Given the symptoms of lung problems and delirium, Foreman suggests Prinzmetal’s angina (heart pain caused by spasms of the coronary arteries) — only he suggests it involves arteries in her brain, not the heart. House thinks the idea shows promise, so has the team place her on ergonavine )a drug which can trigger blood vessel spasms) and check an fMRI (functional MRI – an MRI that looks at blood flow). Medically, this part makes little — if any — sense, but is really just used to set up the subsequent revelation. The fMRI shows no arterial spasms, but it suggests that she is lying when she talks about her dead parents. Kutner confronts Sophia and she admits that she lied about the death of her parents, and the truth is that she ran away from home because her father raped her.

The team now adds sexually transmitted disease (especially gonococcal endocarditis) and stress to her differential. House feels it is the latter and suggests that Sophia be put on diazepam (Valium) to help with the stress. As Thirteen is about to give her the medication, Foreman notes that she has reddish-brown urine which wouldn’t be caused by stress. A microscopic examination of the urine reveals “shredded red blood cells.” E.coli, Shigella, and Legionnaires Disease are all suspected, but House believes her symptoms are caused by arsenic poisoning from building furniture with treated lumber. The tests apparently support this and she is started on chelation therapy for the arsenic. After the therapy, when Sophia is ready to be discharged (which is always dangerous in House’s world), she suffers a seizure. A repeat MRI shows brain lesions that were not there just a few days before. Infection (syphilis in particular) and cancer are suggested, but shot down. Then Thirteen suggests acute promyelocytic leukemia (APL). A brain biopsy confirms the diagnosis. Arsenic is used to treat APL, so removing it from her system allowed the leukemia to spread. Giving her more arsenic may slow down the cancer, but according to House, bone marrow transplant is needed for the cure. A family donor would be best, but Sophia refuses to let them tell her parents. Disregarding her wishes, Thirteen visits Sophia’s family only to discover that Sophia has been lying and using a stolen identity. Told of this, House believes her responses are too rational and confronts her. She admits that she ran away from home because she killed her younger brother. House convinces her to contact her parents, and in the end we witness a tearful family reunion.

Meanwhile, Foreman is treating his own patient: Jonah, a four year old boy with several days of unexplained lethargy, diarrhea, and bloody vomiting. The standard tests are all normal, so Foreman proceeds with a capsule endoscopy (a swallowed wireless camera to transmit pictures of the inside of the gastrointestinal tract). As he swallows the camera, Jonah starts giggling uncontrollably with no provocation.

Foreman asks Cameron and Chase for help, and they consider meningitis, thyroid, stomach cancer, and porphyria, but all tests are negative. As they are wondering whether they should involve House, Jonah has a cardiac arrest, but is successfully revived.

Foreman does finally go to House and ask for help, but House turns him down. Commiserating with Cameron and Chase he has his own Eureka! moment when he realizes that Jonah is suffering from iron toxicity from all the extra vitamins his brother had been feeding him to make him stronger.

Major complaints are in red, minor in blue, nit-picking in green:

Once again, you do not shock a flatline.

I mentioned this above, but “Prinzmetal in the brain” to be diagnosed with ergonovine and fMRI is nonsense — and dangerous if it worked. If it did cause a spasm, then they just caused a stroke (or at least a TIA) in sixteen year old. How were they planning on correcting that?

fMRI has been studied as a lie-detector – Mythbusters featured it in one of their episodes. It doesn’t work quite as neatly as it did on the show. For one thing, small movements — like talking — will throw it off. Also, while the limbic region of the brain may house “imagination,” it is also important in emotions and long term memories — so it lighting up while talking about dead parents would be expected.

From my reading on APL, it is treated primarily with specialized chemotherapy (including arsenic trioxide) and has a very good response rate. Bone marrow transplant is not considered unless there is a recurrence.

Valium is overkill for an anxiety disorder. That class of drug (benzodiazepines) is not a bad choice for acute anxiety, but there are better choices than Valium, particularly in a sixteen year old.

I don’t know what procedure Wilson was going to perform, but it’s best to put on your surgical mask and eyewear before scrubbing.

Interesting how they immediately ruled out cancer as a cause of the brain lesions…and then ended up diagnosing APL, a type of cancer.

Neither medical mystery featured dramatic symptoms, but both were solid puzzles and earn a B+. The solutions were both logical and fit fairly well so deserve an A-. The medicine was better than the past several episodes but still had some large holes. Foreman’s case was handled better, but he was still stumbling around more than he should. Still, it was better than average (especially this season), so earns a strong B-. The soap opera aspects were minimal, though it was nice to see House interacting directly with the patient. I give this aspect another B-.

Last week’s House review
A list of all prior House reviews

Continuing my medical annotations of Volume 1 of Black Jack, by Osamu Tezuka, and published by Vertical. This post looks at the six stories that make up the second half of the volume, plus the story “The Two Jans” which is found in the hardcover edition only.

Several of my favorite stories in this volume will be covered in this post. I was particularly fond of “Star, Magnitude Six,” “The Legs Of An Ant,” and “Two Loves.”

There are mild spoiler warnings for this post, but not as significant as part one of the annotations. Click on “Read More” to view the rest of the post.

Read more…

An interesting mystery and clever solution weakened by a diagnosis that requires way too much coincidence and overlooking more obvious answers.

Nicole is a 25 year old Chinese woman raised in New Jersey who was given up for adoption as a young infant. She is back in China trying to find her birth parents. While in a temple there, she suffered a sudden attack of excruciating abdominal pain and started to vomit blood. By the time she has returned to the US and been admitted to Princeton Plainsboro, the Chinese surgeons have removed a foot of bowel.

The team’s initial suspicion is a Meckel’s diverticulum (a defect in the small intestine), so House performs an ultrasound which is negative. Nicole’s biological adoptive parents arrive with her medications from her apartment and tell House that they are saddened to discover Nicole has been drinking “again.” Looking though her medications, House finds the licorice root prescribed by the Chinese doctors and deduces that they suspected she had SARS (Severe Acute Respiratory Syndrome. Some researchers suspect that glycyrrhizin, a chemical found in licorice root, shows benefits in the treatment of SARS). She is placed in isolation and started on ribavirin and interferon (other medications that some research suggests may treat SARS). House is then is kidnapped by Wilson, with help from Cuddy, to guarantee that he will be present at his father’s funeral.

While Kutner is examining Nicole, she develops abdominal pain again and he notices that she is becoming tachycardic (has a faster than normal heart rate) and has signs of liver failure, meaning that SARS is the wrong diagnosis. She is scanned and a clot is found in her hepatic vein which Chase is able to remove surgically. The team discusses what caused her to clot. Thirteen suspects she has a genetic disorder that, when combined with her heavy smoking, makes her more likely to clot. The team decides to run further tests to determine which part of the clotting cascade is malfunctioning. When Kutner goes to draw her blood, he discovers Nicole is not in her room; he finds her outside the hospital, smoking. He draws the blood for the tests, but is unable to get her to stop bleeding afterward. Ultimately it takes 6 units of FFP (fresh frozen plasma — derived from human blood, it contains a high concentration of clotting factors) to get her to stop bleeding. This combination of clotting and bleeding causes the team to suspect that Nicole has DIC (disseminated intravascular coagulation), “which means cancer,” according to Kutner.

A CT scan is obtained and shows a large fluid filled cyst in the pancreas. The team is able to get House on the phone briefly, and he mentions something about a steamroller. Trying to understand his cryptic comment, they consider pancreatic cancer, scleroderma, lupus, gallstones, and a pancreatic divisum (a fairly common anatomical abnormality, it can sometimes cause chronic abdominal pain or pancreatitis). They decide that she has gallstones, which are confirmed on CT. They call in Chase to remove her gallbladder, but when he is talking to her about the planned surgery, he notices that her urine is dark brown (a sign of possible kidney failure). Thirteen recommends running a “bubble test” and injecting small bubbles of air into the pancreatic cyst to see if they travel anywhere else. House agrees; however, when they try to run the test, Nicole has delirium tremens (”the DTs”) so bad she cannot stop shaking. The team places her in a Phenobarbital coma to run the test and help her through DTs. The bubble test is negative, but Nicole is found to have dilated cardiomyopathy and a mass in her right atrium. The team suspects a myxoma (a benign tumor of the heart), but House believes it is iron overload (he suspects one or both of her parents have hemochromatosis). He wants to check an MRI, but he has a sudden revelation and stops Taub from running the test just in time. A simple x-ray of the head shows Nicole’s problem — nails in her brain. It seems her birth parents did not want her as a child and pushed iron nails into her brain through the fontanelles (the “soft spots”) in an attempt to kill her. When that didn’t work, her father secretly gave her up for adoption. She encountered a hidden magnet in the Chinese temple where her symptoms began — a magnet that moved a nail onto a section of the brain that stimulated abdominal pain. House stopped the MRI because the magnet in the machine would have ripped the nails through the brain. Though it’s not explicitly stated, the rest of her symptoms (basically everything but the abdominal pain) were caused by the iron overload (from the iron nails in her brain), which apparently hit full force at the precise moment the nail shifted. What a coincidence!

Major complaints are in red, minor in blue, nit-picking in green:

A diagnosis of DIC does not equal a diagnosis of cancer. There are many other causes of DIC including infection, trauma, major surgery, burns, obstetrical complications, liver disease, and heatstroke.
DIC causes clots in small blood vessels, not large ones like the hepatic vein.

Nicole had abdominal pain and was vomiting blood. Other than an occasional cough, what lung symptoms was she showing that caused the Chinese to treat her for SARS and House to mention the lungs as a source of her symptoms?

I’m suspicious of Thirteen’s “bubble test.” While there is a bubble test that can be used to find heart defects, it is only used on a relatively small single organ. Thirteen’s idea of trying to track microscopic bubbles wherever they may go over the entire body seems fruitless, especially when the overlying gastrointestinal tract is likely to have gas bubbles of its own. Plus this would only work if the cysts were connected.

Delirium tremens was only addressed superficially in the storyline. It is a life threatening condition, and tremors are only a small part of it. Nicole had the rapid heart rate and the tremors, but none of the other symptoms, so the diagnosis seems premature.
Phenobarbital is not the recommended treatment for delirium tremens; Benzodiazepines are. But then, House has made this mistake before.

Nicole’s symptoms didn’t really match Meckel’s, but then it’s a tricky diagnosis and hard to make. Usually it presents with rectal bleeding, and then a technetium scan is the best choice. In cases where there’s no bleeding, an Ultrasound is the best test.

What a pleasantly convenient finding that Nicole has a nail in the “addiction center” of the brain which explains away all of her bad habits.

CT scanners don’t beep when something weird shows up.

The medical mystery was fairly interesting, so earns a B. The final solution of the nails was clever and unexpected and is awarded a B. The medicine, while better than the past several weeks, relied way too heavily on coincidental timing — even for House – and only earns a B-. The non-medical soap opera aspects of this story were by far the best part, from Cuddy tranquilizing House, to the House/Wilson moments, to Hanson, and earns a solid A.

Last week’s House review
A list of all prior House reviews

After gaining infamy for its lurid horror comics, EC Comics tried to rehabilitate its image by releasing its “New Direction” of wholesome comics. These included titles such as Valor, Aces High, and Impact as well as the medical comics M.D. and Psychoanalysis. As the name suggests, in Psychoanalysis the reader follows an unnamed pipe-smoking psychiatrist as he attempts to analyze and cure his patients.

Previous “analysis” of Psychoanalysis issues one, two, and three

For his first appointment, the psychiatrist sees Freddy Carter. Freddy is a fifteen year old who was initially brought for counseling after being caught stealing. The doctor deduced that the theft, along with Freddy’s asthma and poor grades, are really just desperate cries for attention. His parents are constantly sparring with each other — figuratively at least — with Freddy as the battleground.

The subject of this particular session is Freddy’s recent report card. Freddy is failing math and science — the classes important to his father — but doing well in English and history — classes important to his mother. In retaliation, Freddy’s father has grounded him and cut off his allowance. In addition, he has stopped giving any money to his wife other than for groceries, and he fired the maid. After talking with Freddy for several minutes, the doctor goes out to talk to Freddy’s parents who are upset that Freddy isn’t cured yet. The doctor points out that as long as the two of them are fighting, Freddy will never be cured because they each desire a different outcome. The doctor convinces the two of them that they each need psychiatric counseling for the good of their marriage and for Freddy’s sake. They both agree, and the doctor trades a single paying patient for two.

The last portion of the comic shows two sessions with Mark Stone, an unhappy screen writer. Mark has many difficulties, including problems with women, resentment towards his own success, and longstanding issues with his parents. This time, he is angry the psychiatrist because feels that he has become overly dependent on him. The doctor is able to get Mark to calm down, and then has him describe a recent dream. After hearing the dream, the doctor tells Mark that he is not mad at him, the psychiatrist, per se, but instead angry at authority figures in general — which goes back to his anger towards his father. The doctor is also able to deduce that Mark has a deep-seated fear of being abandoned, which brings out his feelings towards his mother. This has come to the surface because of the doctor’s upcoming vacation.

At a later session, Mark has once again started to experience the severe panic attacks and anxiety symptoms that brought him to the doctor in the first place. They started just a few days after Mark and the psychiatrist agreed that Mark had made remarkable progress and could cut back on his sessions. It doesn’t take a genius — or a board certified psychiatrist — to realize that this is nothing more than a subconscious reaction on Mark’s part. He is uncomfortable with the idea of cutting back on the counseling, so he recreates the symptoms that necessitated the visits in the first place. The psychiatrist is able to get Mark to realize the root of the problem, and once again Mark agrees that he doesn’t need many more sessions. This is probably a good thing as this was the final issue of Psychoanalysis.

Previous Flashback Weeks

I have nothing to add to this, other than to report that the Boys Town National Hotline is still going strong and is a good resource for troubles teens and their parents. The number remains 1-800-448-3000.

This image was scanned from New Warriors #33 (March, 1993)

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The Differential Diagnosis is one of the key aspects of good medicine. To make a differential diagnosis, the physician takes the patient’s chief complaint and comes up with a list of the possible causes of that problem. This list is then narrowed down by considering the patient’s other symptoms, physical exam findings and lab and radiology results. Eventually, the correct diagnosis is uncovered.

When House and his team try to determine what their patient has by looking at the whiteboard with all the symptoms listed, they are performing a differential diagnosis (a bastardized version actually, since they seem to focus on rare conditions — “zebras” — rather than more likely causes).

For a real world example, if a patient presents complaining of a sore throat, there are at least fifty to sixty possible diagnoses, the most common of which (in my practice, anyway) would be viral infection, allergies, Strep throat, or sinusitis. If the patient also complains of a fever, this makes it likely to be an infection. A cough would make Strep less likely and allergies and sinusitis more likely. Headaches are common with Strep and sinusitis. Chronic symptoms are more likely to be allergies. Symptoms presenting in the dead of winter are more likely infectious. Taking all the symptoms into account, along with a good patient history and a thorough physical exam, would allow the physician to come up with the likely cause of the sore throat (this time of year in the Midwest, probably allergies).

Differential diagnosis can be very challenging in the real world, but imagine how incredibly difficult it must be in a fantasy world where literally anything is possible. Take one of my favorite examples: a nosebleed. In the real world, this probably represents an irritated nose (from an infection or allergies), trauma (including “finger trauma”), or a bleeding problem. In the super-hero world, you also need to add psychic powers, magic powers, possession, and alien abduction, just to name a few. How do you test for those?

Another example comes from this week’s JSA Classified. Wildcat visits one of his old-time boxing opponents and finds him slumped in a wheelchair, virtually comatose. The family tells him that this happened suddenly, on a recent trip to New York. If this were my patient, I would be worried about a stroke, aneurysm, encephalitis, or dementia pugilistica. But not Wildcat, he immediately deduces that his friend was the victim of memory draining villains. That would never cross my mind, but it was the first thing he thought of.

As boring and conventional as it may sometimes be, I think I prefer the practice of medicine in the real world.

I’ve discussed commotio cordis a couple of times, most recently in relation to Batman #672-674.

Commotio cordis is a rare and frequently fatal condition. It occurs when an individual receives a direct blow (blunt trauma) to the chest at precisely the right time in the cardiac cycle to stop the heart and cause a cardiac arrest. Children are more susceptible to the condition than adults.

Sports injuries are a common cause of commotio cordis, particularly thrown baseballs and softballs. Other causes include physical blows to the chest during a fight, steering wheel impact in motor vehicle accidents, and even the blunt force of bullets stopped by body armor.

The best, and really only, treatment for commotio cordis is immediate cardiopulmonay resuscitation, usually requiring defibrillation and cardiac medications.

Wikipedia has a good write up on commotio cordis

Commotio cordis has been in the news recently because of a lawsuit filed by a New Jersey family against several groups: a maker of aluminum baseball bats, the Sports Authority*, and Little League Baseball**. It’s an unfortunate story on many levels: Twelve year-old Steven was pitching in a baseball game when a line drive hit by the batter caught him square in the chest, causing his heart to stop beating. He was eventually revived, but remained in a coma for several weeks, and now has severe brain damage.

It’s a sad story and an unfortunate case, but personally I think it’s a stretch to treat it as cause for a lawsuit. I know that we Americans always like to blame someone when something goes wrong, but there are times that it’s not appropriate. This is one of those times.
There is no hard evidence that aluminum bats are any more dangerous than wooden ones, particularly in cases of commutio cordis (remember, it’s an issue of timing, not an issue of force).
There is an inherent risk of injury in playing any sport. Proper safety precautions will minimize this, but never eliminate it entirely. I am well aware of this whenever I go for a bike ride on the back country roads near me. Who knows what drunk-driving redneck may be out there weaving across the center line?***
And suing Little League because they endorsed the bat? Give me a break.

*The store where the bat was purchased
**Not because it was a Little League game — it was not — but because they “endorsed” the bat as safe.
***It would be like me, after getting hit by a reckless driver, suing Ford because the person was driving a Mustang and those can go faster than other cars. It may be true (arguably), but it really has nothing to do with the accident and injury.

Tonight features the first of four new House episodes. It was a decently mediocre episode — not bad, but not particularly outstanding, either. Kind of “House Lite.” An episode recap, medical discussion, and spoilers follow!

Jeff, a carpet cleaner by trade, is spending his lunch hour with his wife, a nurse on the picket line in front of the hospital. While there, he starts to have nystagmus (twitching eyes) and then collapses. He is admitted to the hospital Emergency Room for evaluation, but — thanks to the chaos from the nursing strike — is given a low priority and basically sits there waiting for several hours. House, who is in the Emergency Room avoiding Cuddy, is perplexed by Jeff’s constant cheerfulness and niceness. He decides that something must wrong with him and admits him to his service for evaluation.

Jeff’s initial complaints are syncope (fainting), dysgeusia (altered sense of taste), and “niceness.” The altered taste (everything tastes like lemon meringue pie) and happiness have been present for eleven years. House suggests that Jeff may have a metabolic disorder, toxic exposure, carcinoma of the tongue which has spread to the brain, epilepsy, or multiple sclerosis. Taub suggests he just has the flu. House disagrees and orders Foreman and Kutner to search Jeff’s house for toxins, and tells Thirteen and Taub to check an MRI and EEG. The tests are normal, but the team searching the house finds carpet cleaning chemicals including hydrofluoric acid, which is known to affect calcium. From this, House deduces that Jeff has Williams Syndrome. Taub disagrees, pointing out that Jeff is missing some of the necessary symptoms to make the diagnosis including the characteristic facial appearance, lower than normal intelligence, and musical ability. While the team is arguing, Jeff suffers a stroke.

Thirteen suspects that Jeff has a heart defect (a patent foramen ovale) and this is what is causing his symptoms, but never gets the chance to run the test because the patient’s VDRL — a test for syphilis — has come back positive. The team now suspects that Jeff has neurosyphilis. He is started on penicillin to treat the syphilis, and a short time later he begins to vomit blood (”hematemesis”). According to the team, this could be from the syphilis, or it could be due to a reaction to the penicillin, carpet cleaners, or even alcohol. More tests are run and the patient is determined to have “hepatitis” — not viral hepatitis, but some other non-specified kind. House orders a test for sarcoid, and starts Jeff on steroids to treat the hepatitis.

Jeff’s wife returns to visit him, and he is uncharacteristically mean and angry. He then suffers a heart attack (which actually seems more like a cardiac arrest). The team considers the situation: is the rage due to the steroids (too soon; not as common on glucocorticoids as anabolic steroids), a penicillin allergy, a heart defect, or maybe his real personality finally re-emerging? In the middle of an echocardiogram to look for a heart defect, Kutner has an epiphany. The patient doesn’t have syphilis — he has another condition which gives a false positive VDRL result. Jeff has Chagas Disease, a rare parasitic condition (rare in the U.S., at least) which he picked up while in the Peace Corps. He has had a low-level encephalitis since then, and the immune suppression from the steroids caused it to flare up and his symptoms — the anger — worsen. He is started on the appropriate treatment and House assures him that he will be cured in a month — but what personality is the real personality?

I don’t have too much to comment about this one, medically. In this episode, the medicine was clearly secondary to the personality issues (What is Jeff’s real personality? and House vs. Amber). House and the team skipped over a bunch of more common causes of Jeff’s symptoms, going straight for the obscure. They then focused on these obscure causes, when some simple — and frankly standard of care — follow-up tests would have shown them their error from the beginning.

Syphilis antibody tests such as the VDRL are notorious for their false positives. That’s why you always run a confirmatory test such as the FTA-ABS, which was never done. For neurosyphilis, you should test the spinal fluid and not just the blood. Many different things can cause a false positive VDRL, not just Chagas Disease. The list includes HIV, Lupus and other autoimmune diseases, Lyme disease, mycoplasma, hepatitis, mononucleosis, and certain drugs.

Despite what House implies, cure rates for chronic Chagas Disease are dismally low. Treatment is not recommended for those who have been infected for over 10 years due to the low success rates (less than 25%). By this late in the disease, the damage to the heart and other organs has been done — this damage cannot be reversed, but can be fixed with appropriate medications, and in some cases, surgery.

I give the medical mystery a B+ because it brought up some interesting points — is being too happy a bad sign? And if so, is being too curmudgeonly equally bad? The final solution was moderately clever, but even more an out-of-the-blue answer than usual, earning a C. The medicine was weak and sloppy throughout and could have been handled better by a second year medical student; it deserves only a measly D. The House/Amber/Wilson/Cuddy soap opera was good, the House-has-syphilis not as good. Still, I give the soap opera aspect a generous A-.

(And as an aside, why would House and Amber submit to Cuddy’s punishment? When has House ever done anything Cuddy has said, and what power does she have over Amber?)

The previous House review
A list of all prior House reviews

Challenge scores will be posted later, probably tomorrow

The Truth About Scott

Strapped into a parachute and pushed from a burning plane by loving parents, the young Scott landed deep in the forest and was raised by a pack of wolves. At the age of twelve, he stumbled across a hidden Native American village where the medicine man taught him the secrets of native mysticism, herbalism, and how to get crepes to cook just right so the edges are crisp but the middle still soft. Leaving the village, Scott journeyed until he reached modern civilization where he vowed to use his powers only for good. A scourge of villains and cowards everywhere, Scott protects the city nightly from crime and reality television. During the day he sits in an apartment, reading comics and trashy romance novels, watching the History Channel and eating Poptarts.

In reality, I was raised in small towns in Virginia and the Midwest. I attended both college and medical school in St Louis, and obtained my Family Practice internship and residency in Indianapolis.

After residency, I served as a physician in the US Air Force for four years. Most of my military time was spent at Nellis Air Force Base (outside of Las Vegas), though I did see a few overseas deployments. After the Air Force, I spent two years in a small practice in Central Illinois, but last year I moved back to my hometown (or at least where I graduated high school) in Southwestern Illinois and joined a Family Practice clinic there.

The Set-Up: Derek Reese, John Connor’s uncle, has been shot and severely wounded. He needs a transfusion, but since he’s a wanted man Sarah doesn’t want to take him to the hospital and instead elects to perform a transfusion in the kitchen. She offers her blood, but since she is O- and Derek is AB- her ex-fiancé (an EMT) tells her it won’t work; Derek needs an exact match. John offers his blood and it must be a match because we see him a short time later transfusing his blood into Derek.

Though Sarah Connor is blood type O- (known as the “universal donor”) she cannot donate blood to Derek because this is a whole blood transfusion. In a normal transfusion, just the red blood cells are transfused, but in a whole blood transfusion both the blood cells and blood plasma (i.e. the “whole blood”) are used. The blood cells carry the proteins that determine a person’s blood type, but the plasma carries antibodies that react against other blood types. Because a whole blood transfusion deals with both blood cells and plasma (and proteins and antibodies), the donor and recipient blood types need to match exactly or there will be a nasty transfusion reaction.

AB- is the rarest blood type. In the general population of the United States, about 1 person in 167 (roughly 0.7%) are AB-, though blood type distribution can vary greatly by race.

TYPES	DISTRIBUTION	PERCENT
O +	1 person in 3	38.4%
O -	1 person in 15	7.7%
A +	1 person in 3	32.3%
A -	1 person in 16	6.5%
B +	1 person in 12	9.4%
B -	1 person in 67	1.7%
AB +	1 person in 29	3.2%
AB -	1 person in 167	0.7%

The most important aspect of the transfusion seems to have been entirely missed by the writers: since Sarah has blood type O-, that means that she cannot be John’s mother. John gave Derek a transfusion so he must be AB-. That means that he inherited an A gene from one parent and a B gene from the other (A + B =AB). Sarah is blood type O which means that she has neither an A nor a B gene to pass on to John. Blood type O parents can only have A, B, or O children, depending on the blood type of the other parent. They can never have AB children*.

Miscellaneous nit-picks:
That sure was a tiny IV to transfuse 3 units of blood through. It would have taken the better part of a day.
What sort of EMT strolls around carrying a sedative in their bag (and given the small dose needed to work, it must be a controlled substance, such as Ativan or Valium) or has blood typing serum?
A “manual aspirator to drain the lung” — what the heck does that mean? Did he mean a chest tube?

*I guess John could be a spontaneous mutation, or maybe a liver-transplant recipient, but those are both quite a stretch.

♥A previous post on whole blood transfusions

Tags: television medicine terminator blood type transfusion

To mark only 22 days remaining until Christmas, today’s Advent Calendar cover is Calling All Kids #22.

Calling All Kids #22 (Parents’ Magazine Institute, December 1948)
22 Days until Christmas!
click on image for larger view

The 2007 Comic Book Cover Advent Calendar (so far).
One year ago, the cover was The Best of DC #22.
Two years ago, the cover was New Adventure Comics #22.
Three years ago, the cover was Hitman #22
Previous Comic Book Cover Advent Calendars: 2006 2005 2004
David Carter always has another good comic book advent calendar over at Yet Another Comics Blog

Tags: comics advent calendar christmas calling all kids

From the June 1961 issues of assorted DC comics comes this PSA which reminds us — just like the title says — that parents have rights too.

Looking more closely, it’s not that the parents have given up any rights — it’s more that their kids are being brats. So is this a warning PSA for kids, or a cautionary one for parents? You decide (personally, I’m leaning toward the latter).

Click on the Image for the Full-Sized PSA

This PSA was scanned from Action Comics #277 and is written (as always) by Jack Schiff with art by Bernard Baily.

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Tags: comics psa parents jack schiff bernard baily

Episode Title: In Which Sam Receives an Unexpected Visitor

Two significant cases this week: one was medically wrong and ethically murky, and the second was medically correct (if incredibly fast) but ethically wrong. I’m not going to say much about the stripper other than the rash appeared to be a resolving case of shingles (herpes zoster) from what little was shown. As for Violet, well the bicyclist in me was pained by her destruction of such a nice bicycle.

Dr. Cooper Freedman (with assistance from Dr. Addison Montgomery and Dr. Naomi Bennet)
Cooper has a patient, 9-month Emily O’Brien who is has been sick since birth and not growing well. She also has some poorly defined neurological symptoms. He runs some tests on her, including genetic testing, and determines that she is suffering from a severe form of the rare neurological disorder Pelizeaus Merzbacher. He runs tests on her parents and discovers that they are not carriers for the mutation responsible for Pelizeaus Merzbacher, and this makes him realize that Emily cannot be their child.
Looking through the hospital records, the team is eventually discovers that while Emily was in the nursery after birth, her real father switched his sick child with another couple’s healthy baby. Much pathos ensues when this is announced.

• Pelizeaus Merzbacher is an often fatal x-linked gene. This means that it is a disease that shows up in males, not females. Females are carriers for the condition, and can very rarely show mild symptoms, but full Pelizeaus Merzbacher cases (as Emily is said to be) are always males. This is a major mistake — there is no way that Emily can have Pelizeaus Merzbacher in that they’re describing.
• Any real infertility expert would cringe at Naomi’s line: “I didn’t promise you perfection, I promised you a baby.” The first part is true enough with any pregnancy, but no fertility doctor would ever “promise” any couple a baby. Even with all of modern science, the odds of an infertile couple conceiving is roughly 50%, and drops with each subsequent attempt. Promising success is inviting angry bitter couples and lawsuits.

Dr. Sam Bennet
Sam is making a house call on Dave Walker, a patient who is a known alcoholic. Dave is recently divorced and living with his teenage son and elderly mother. Arriving at the house, Sam finds him very sick with nausea and vomiting. An ambulance is called and Dave transported to the hospital. He improves after a short amount of time and is sent home, much to Sam’s dismay, with a diagnosis of viral gastroenteritis (the “stomach flu”).
Later in the same day his teenage son shows up at the clinic with identical symptoms. A check of his blood reveals coprine (scroll down to the bottom of the page), a toxin found is certain mushrooms. Coprine, we are told, works like “Antabuse” and causes a patient who drinks alcohol after ingesting it to become violently ill. Sam is able to determine that the patient’s mother is purposefully spiking his food with coprine-containing mushrooms to get him to stop drinking. Rather than tell Dave the truth about the poisoning, Sam tells him that he is allergic to alcohol.

• It’s amazing this all happens in one day: patient becomes ill and all his lab tests including cultures — which take several days to grow — are negative. The son becomes ill and his fancy and expensive blood tests are run and manage to come back the same day.
• Antabuse (generic name disulfiram) is a drug that interferes with the breakdown of alcohol in the human body. The alcohol is only partially metabolized and becomes acetaldehyde, a noxious chemical. This accumulates in the body and causes nausea, vomiting, and severe abdominal pain. Antabuse is prescribed in certain situations to help patients with alcohol problems stop drinking. It is not widely used because, in my experience, patients still drink when taking it, and now instead of an alcoholic patient, you have a violently ill still alcoholic patient.
  • Flagyl (generic name metronidazole), an antibiotic, has a similar effect on alcohol metabolism and we advise patients not to drink when on the medication, or even for several days after.
  • Pete is right that Coprine has the same effect as Antabuse.
• Never lie to patient. Sure, it’s tempting and seems like an easy way out sometimes, but it’s never a good idea. Sooner or later, they’ll find out and there goes all their trustin you. For another thing, how would you document it? Does Sam write in the medical record what really happened, the lie he told, or both? It’s a medicolegal nightmare. If the patient drops dead of coprine toxicity and the police discover Sam knew all along he was being poisoned, yet didn’t warn him or tell the police, Sam’s days of practicing medicine are long over.

Tags: television medicine private practice pelizeaues merzbacher coprine antabuse

Another of EC’s “New Direction” comic books, Psychoanalysis is just that: a comic book about psychoanalysis. In each issue, a pipe-smoking Freudian psychiatrist has sessions with several patients and helps them work through their problems, primarily by confrontation, dream interpretation, and free association. Miraculously, each session ends with a new revelation and deeper insight into the patient’s mind. In Psychoanalysis #3, we watch as the psychiatrist follows up with the same three patients he has treated since issue #1:

Freddy Carter is the first patient. He is a 15 year-old who was caught stealing a watch from his best friend. The psychiatrist notices Freddy reading the sports page, but Freddy denies it vociferously. It turns out that while Freddy likes sports and is actually quite good at them, he pretends to dislike them and acts clumsy to anger his father, a devoted sportsman. Disliking sports also makes his mother happy as she prefers him to focus on the finer things in life such as music, art, and poetry — endeavors his father considers only for sissies. Delving deeper, the psychiatrist discovers that Freddy is purposefully trying to drive a wedge between his parents so that his mother will give all her love to him, and their definitely seems to be some oedipal aspects to their relationship. Just like last issue, the doctor tells Freddy in no uncertain terms that it is time for him to grow up and stop acting like a child.

The second patient, Ellen Lyman, believes that she is ugly and unlikable despite the fact that she is quite beautiful and friendly. By interpreting her dream of standing before a hallway of full length mirrors in a prom dress, the psychiatrist is able to deduce that the only person who considers Ellen ugly is herself. The reason Ellen is unable to have a meaningful relationship is that she does not like or love herself. This revelation strikes Ellen like a thunderbolt and thanks to the doctor’s insight, Ellen announce that she is ready to love herself and start dating. The doctor pronounces her cured.

The final patient is Mark Stone, a successful television writer. Mark left his wallet in the doctor’s office last session and the doctor tells Mark that it struck him as strange that he has no pictures of anyone in his wallet — no family, no girlfriend. Mark tells the doctor that he hates and dislikes women, though he has no trouble attracting them.

There are four ways to charm a woman! Handsomeness…fame…money…intelligence! I’ve got three of them! The last three! That’s all I need…

Mark always breaks up with a woman as the relationship starts becoming serious. Once more using dream interpretation, the psychiatrist tells Mark that his nightmare of being chased down an alley by a cat-like car that turns into a beat-up jalopy relates to his problems with women. He sees all women as his mother, who used him as a child to get back at his father. It’s not that Mark hates women, he just hates his mother and projects those feeling onto all women. Feeling better, Mark tells the doctor that he does have a picture hidden in his wallet of a certain someone, and he thinks he’ll ask her out that night.

That’s it for issue #3. One patient cured and two more remaining. The title gets canceled after the next issue, so we have to hope the doctor is able to cure Freddy and Mark with one last appointment.

Psychoanalysis #1
Psychoanalysis #2
Previous episodes of Flashback Week.

Tags: comics medicine psychoanalysis psychiatrist flashback week

Armageddon 2001 was the big DC “event comic” of 1991. There were two bookend comics, Armageddon 2001 #1 and #2, at the beginning and end of the summer. In between, all the annuals (back with every series had an annual) tied into the storyline: in the not too distant future of 2001 (remember, this was written in 1991), the villainous Monarch has taken over the entire world and slaughtered all the super-heroes. The kicker is that he used to be a super-hero himself before becoming evil, but no one knows which hero. One of the citizens of the dystopic future uses experimental equipment to gain time-based superpowers. As “Waverider,” he can travel through time. He can also look into a person’s future just by touching them. He resolves to use his powers to travel back to 1991, the year when Monarch first appeared, and discover Monarch’s identity by looking into the future of each hero.

In Hawk & Dove Annual #2, Waverider appears just as Hawk and Dove have broken up a mugging. First he touches Hawk. He sees a future where Hank has become a member of Monarch’s Peacemakers, his powerful Brownshirt-like police force. Hank is unhappy because he realizes that the Peacemakers are no better than thugs and Monarch just a tin-plated despot. His attitude has already gotten him in trouble once when his superiors decided that Hank needs a little “re-education.” Hank takes this as an opportunity to turn into Hawk, for the first time in years, and face Monarch mano a mano. He explains to Monarch that he hasn’t been in hiding, but slowly and carefully building up his powers to become more powerful. Hawk transforms into a more powerful version of Hawk (who looks ridiculous, like a thick-waisted chicken-headed monster) and attacks Monarch. Despite all his added power, Hawk is still losing the fight when Dove rescues him by bringing him over to another dimension where she’s been hiding and building a resistance against Monarch.

Next, Waverider touches Dove — but unlike other heroes, her link to Order allows her to sense him and she realizes what he is doing. She takes control of Waverider’s powers and shows him three futures, which may or may not be linked. First, there is a council of war on a distant planet. Encouraged by an aged Dove, they agree to attack Monarch before he becomes an intergalactic problem. Second, on another planet (which looks to be Gemworld), Dove mourns a dead Hawk. She is also raising her child, who has some sort of magical powers. For the third future, Dove brings Waverider back to his own world of Armageddon 2001. In this future, Hank is married to Ren and Dawn to Captain Arsala. Hank and Dawn have realized that it is time to confront Monarch one last time. They realize that they are likely to die in the battle, and ask Ren and Arsala to raise their child (Hank and Dawn’s — or is it Hawk and Dove’s) in secret.

Finally, Waverider touches both Hawk and Dove together. In this vision of the future, a young, female, first-nameless Dr. Arsala is the top neurosurgeon of the time, good enough to catch the eye of Monarch. She is also a friend of Barter’s, and he gives her two special gifts that he says comes from her “real parents” who died fighting Monarch. He gives her a vial of Chaos (the essence of Kestrel he took from Ren back in Hawk & Dove #17) and a gem of Order (the blue gem Hawk fought in Hawk & Dove #25) and tells her to remember “unity.” Puzzled, Dr. Arsala talks to her father, the former Captain Arsala, who tells her that Barter was right — Hawk and Dove were her parents. He explains a little about her real parents to her, and how they gained powers by speaking a certain word. She remembers what Barter told her and speaks the word “unity” — and she is instantly transformed into Unity, who seems to have the powers of both Hawk and Dove. Her costume reflects both of her parent’s costumes, in color at least (purple instead of red or blue), though the actual design leaves much to be desired. She confronts Monarch and decides that she will use her super-powers combined with her neurosurgical skills to physically and literally change his mind.

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This comic, published shortly after Hawk & Dove #28 (the official “last issue”) is a fitting epilogue to the series. It follows the themes presented in the series, particularly after Hawk and Dove’s return from Druspa Tau, to their logical conclusion. The annual ties nicely into the continuity of the regular series with such things as Barter, the essence of Kestrel, and the Order gem. It also manages to fit into the Armageddon 2001 storyline in a logical fashion, better than any of the other annuals, and as far as I can tell it was the only annual that actually dealt with Monarch.

Sadly, the art was sub-par for most of the issue. The connecting sequences were by Curt Swan, and while better than his work on issue #28, I still don’t care for his take on Hawk and Dove. The Dove sequences were drawn well, but the Hawk and Hawk-and-Dove sequences could have used better pencils. The character designs, particularly of the supposed-to-be-impressive über-Hawk and Unity, were more silly than awe-inspiring.

All Previous Hawk and Dove Reviews

Tags: comics hawk dove armageddon 2001 monarch waverider unity barter

With this, Hank Pym (among all his other problems) joins the list of super-heroes who have multiple personalities, including the Hulk, Thorn, and Crazy Jane.

There’s a few problems though:
1) Schizophrenia and Multiple Personality Disorder (now called Dissociative Identity Disorder) are two entirely different diagnoses. To oversimplify, individuals with schizophrenia have difficulty with reality: they frequently have delusions, experience hallucinations, and have disordered thinking. They only have a single personality, though. This is very different from Dissociative Personality Disorder, which has none of the abnormal thinking and delusions associated with schizophrenia. However, a person with Dissociative Personality Disorder has at least two distinct and separate personalities.
The diagnostic criteria for Schizophrenia
The diagnostic criteria for Dissociative Identity Disorder

2) One current theory is that multiple personalities develop from mentally traumatic experiences. The traumatized person protects themselves by creating an entirely new personality to escape into. The Hulk (at least as written by Peter David) is a close fit to this theory: he saw his father murder his mother, and developed separate personalities to help him cope with what he witnessed. Similarly, Rose saw her parents murdered and this ultimately gave way to her developing two personalities: the quiet and compliant Rose, and the violent and aggressive Thorn.
What about Hank Pym? What trauma did he experience? He had a lab accident. (Technically, it was a lab accident wherein he inhaled some experimental gases which led to his developing the Yellow Jacket persona. This actually rules out Dissociative Identity Disorder, as it cannot be caused by “the direct physiological effects of a substance.” What Hank Pym actually has is a mental disorder brought about by drugs — just what the public wants in an Avenger.)

An earlier post on Harvey Dent,Two-Face, and multiple personalities

Tags: comics medicine schizophrenia dissociative identity disorder avengers hank pym

Dr. Dan Dazzler, everyone’s favorite intern (spelled “interne” here) is back*, and today’s adventure, courtesy of Ben Casey #5 (Dell Comics April 1963), takes Dan to the circus…

Click on any of the images for the full story

Discussion questions:
1. If Dr. Dazzler has been to the circus many times before as the doctor on call, why is he still an intern? Does the circus come to town that often, or has he been an intern for a long time?
2. Does Dan really think he can suck all that poison out through that tiny straw? Personally, I would tie the tourniquet and then just take her to the hospital ASAP.
3. Wouldn’t this story be so much better if it featured the Flying Graysons instead of the Zooming Zamprellis, and Dr. Dazzler just happened to be there the night Dick Grayson’s parents were killed? He could have tried to save them, but to no avail. That would be great!
4. Does John Philip Sousa know that the ringmaster stole his outfit?

*Dr. Dan Dazzler was the four-page back-up comic that ran in Dell’s Ben Casey comic book. Further adventures and information on Dr. Dazzler can be found here.

Tags: comics dell ben casey dazzler circus snake

It’s the most shocking House yet! Not really — I just thought I’d mimic the ads that play every week (at least on the St Louis affiliate). How can every week be the most shocking?

In reality it was just another so-so episode. The mystery was good, but House’s final deductive leap was a little too unbelievable. The medicine was just OK, but the soap opera parts were much better than the past few weeks.

Addie, a nineteen year old college sophomore is sparring in a karate match when she suddenly begins spitting up blood. In the ER, a bronchoscopy was performed (looking down her lungs with a fiber optic scope). An Upper and Lower GI were also performed, as well as multiple blood tests. All were normal.

Chase suggests that Addie might have a hyperdynamic heart — one that’s pushing more blood than it should, causing extra blood to leak into the lungs causing a bloody cough (this is quite a stretch). A stress echocardiogram is performed but is normal. Chase notices that Addie has goosebumps, yet denies feeling cold or scared. Foreman states it might be a hypothalamic injury while House believes it is a sign of infection. He orders blood cultures, a lung biopsy, and starts her on antibiotics. She later develops diarrhea, but this is blamed on the antibiotics and never mentioned again.

Addie suffers respiratory arrest and requires intubation. She has a pleural effusion (a fluid build-up around the lungs) which is drained by thoracentesis. The effusion is transudative (this has to do with how much protein is in the fluid) which usually represents liver failure or heart failure. These seem unlikely since her echocardiogram and liver function tests were normal (though kidney failure can also cause a transudate — just foreshadowing here). House spots a trace amount of blood in the fluid and believes that it confirms his infection hypothesis, while Cameron points out that blood in the fluid could also represent a cancer. House next orders an arteriogram which is also normal. He is now convinced that the patient has Complement H Deficiency, a deficiency he claims is so rare that there’s no way to test for it. And it’s untreatable and fatal. A macular biopsy is performed but is negative (the macula is the most sensitive part of the retina; there seems to be a connection between age-related macular degeneration and certain types of Complement H abnormalities.). This doesn’t confirm House’s diagnosis, but it doesn’t disprove it either, so he considers it a good sign. The rest of the team point out that her symptoms could be caused by a brain clot or tumor. Cameron states that Addie was bleeding, so she can’t have a clotting disorder (Cameron’s never heard of DIC, apparently), so it must be a tumor. House still maintains Addie’s symptoms are due to the Complement H Deficiency and infection. An MRI is obtained, but shows no clots, tumors, or signs of infection. While in the MRI tube, Addie complains of a severe headache. The team pulls her out and discovers that a chunk of her scalp has become necrotic and started to bleed out. House believes this fits with his infection theory, but Chase states that it could be an autoimmune disease. He wants to put her on steroids. House states that if Chase is wrong and House is right, then Addie will likely have a heart attack as soon as the steroids are started and die. He allows Chase can give the steroids, but only with Cameron standing by with defibrillator paddles. The steroids are given and no heart attack results.

Later that night, House is woken by the news that Addie has developed severe kidney failure due to Hemolytic Uremic Syndrome (HUS) and is on dialysis. House points out that HUS is often caused by an infection (and is more common in people with certain Complement H deficiencies), then trots out the false dichotomy of the episode: he states that since Chase was wrong, House must be right and therefore Addie must have Complement H Deficiency. This means that she will soon die of her disease. She slips into ventricular fibrillation, but Foreman is able to revive her. House takes this as the final sign that he’s right and goes to talk to Addie and her parents. Shortly after talking with them he has a conversation with Wilson, and it the middle of it realizes that Addie does not have Complement H deficiency. Instead, Addie is depressed and has a death wish. She tried to kill herself with drain cleaner, but instead of drinking it, she placed it in a gel cap and swallowed it. This way, it didn’t start to dissolve her GI tract until it hit her intestine where it ate a hole (leading to spitting up blood). Scar tissue covered the hole, so the bleeding stopped, but the damage caused an artery and vein to grow together and this mixing of venous and arterial blood is seeding infections throughout her body. By repairing the blood vessel, Addie will be able to recover physically, but still has a ways to go mentally.

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Not that the House writers have ever made it a completely fair mystery, but this week they definitely weren’t playing fair with the clues. Each episode usually makes a big deal of searching the patient’s house, but it wasn’t shown at all this week (though Cameron was ordered to) — and it would have likely turned up some positives (empty gel caps and drain cleaner, for instance). A patient has a likely gastrointestinal bleed, yet no EGD or colonoscopy were performed — because one of them should have showed the healing bleed, or at least the scar tissue (and according to the links in the narrative, the GI series should have shown scar tissue as well). Addie has all these infections, yet her blood cultures are all negative?

Otherwise, I’m not clear on the use of the arteriogram to look for infection, nor am I entirely certain why her “head exploded.” And why would steroids suddenly cause a heart attack? From what I’ve been able to ascertain, it is possible to test for Complement H deficiency (molecularly, functionally, and genetically). It may not be a common test, but since when has that stopped House?

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I give the medical mystery a B+, because it was intriguing. The final solution I give a C. It was clever, but the way House was able to deduce exactly what happened, down to the anatomic level, instantly and without any lead up I found too unbelievable, even for House. Yet again, the medicine was blah. Not completely horrible, but not particularly good either. This is Grey’s Anatomy level medicine — it may be fine for that show, but it earns a weak C here. The soap opera was quite enjoyable this episode, particularly the whole Wilson on speed scene. I give it an A
The previous House review
A list of all prior House reviews

Tags: television medicine house complement h hemolytic uremic syndrome suicide

Another “just average” episode of House. I’ve come to expect more exciting and improbable medicine, and the show is just not delivering lately. To some extent, tonight’s episode was an ethics episode instead of a medical episode, and as such, it was still average.

Matty and Nick are brothers. Nick is fourteen and has leukemia. He has received total body irradiation to kill off his own bone marrow so that he can receive a transplant from his younger brother Matty, who is a perfect match. On the day of the procedure, Matty is found to be sick: he is sneezing and has a fever and an enlarged spleen. House’s team has only a few days to find out what is causing Matty’s infection and get him cured so that he can donate his blood marrow before his brother dies.

The team decides to make him sicker so that it will be easier to find the cause of the infection. They expose Matty to cold, wet condition and they also remove his white cells (the infection-fighting cells of the blood) through leukophoresis. Matty is getting sicker, but no clear causative agent has emerged. In addition to a snotty nose, Matty complains of a sore right shoulder and a swollen testicle. House suspects Matty’s acute scrotum is infectious and has the team runs tests for E. coli, tuberculosis, Brucella, Klebsiella, and entero- and adenoviruses. The tests all turn up negative (which really is no surprise as an acute scrotum in a ten year-old is unlikely to be infectious). Looking over other test results, Chase notes a high CKMB (an enzyme that is often elevated with heart damage or injury). A transesophageal echocardiogram is obtained and shows a thickened mitral valve. The team believes that Matty has bacterial endocarditis and that this is the source of the infection. The normal treatment for endocarditis is several weeks of antibiotics, but House decides to rush things. He wants Matty’s mitral valve to be surgical removed and replaced to eliminate the source of infection. He believes that this will allow Matty’s bone marrow to be ready in time to donate to Nick. Of course, Matty will probably end up on blood thinners for the rest of his life (depends on whether they would use a mechanical valve or a porcine valve).

As the surgery is being performed, Wilson discovers that the mitral valve growth is fibrous and not infectious and the surgery is called off. The team now suspects that Matty’s condition may not be infectious, but instead an autoimmune disease such as Lupus or Behçets Disease. Tests show no evidence of autoimmune disease.

Meanwhile Nick has started to bruise, suggesting that he needs the bone marrow transplant fast. Foreman suggests pressing ahead with a partial match donor, but House and Wilson believe that there is too much of a risk of graft versus host disease.

Matty is now bleeding from his ears and his blood counts are dropping. Whatever infection he has is suppressing his bone marrow — or it could be the medicine he’s on that’s suppressing the marrow.

The partial match bone marrow transplant is carried out, but Nick has developed high grade graft versus host disease and the medication is not controlling it. His prognosis is very poor.

The team stops Matty’s medication, but there was no bone marrow recovery, so it is unlikely to be the medication’s fault (though they only waited a few hours and it can take days for medications to clear the body, particularly in ill patients). Blood cultures are negative. Knowing that Nick’s condition is fatal and he is immune suppressed, House wants to expose him to Matty’s infection so they can get a better chance to identify it. The parents refuse. Wilson and Foreman continue to run tests on Matty, hoping to find the cause of the elusive infection. In the meantime, House talks to Nick and convinces him to save his brother’s life. Nick agrees to play incubator to Matty’s germs. Luckily, at the last moment, Wilson and Foreman have discovered that Matty has contracted histoplasmosis, a fungal infection he developed because his house was built on farmland and he was exposed to soil from an old chicken coop. Matty should be cured with a course of Amphotericin B. The parents ask if he’ll be better in time to donate bone marrow to Nick. Cuddy sadly tells them no, that the infection has weakened Matty’s bone marrow too much. This doesn’t stop Foreman: he straps Matty down and performs a painful bone marrow collection procedure (which seems to contradict what Cuddy just said). It all ends happily, with both brothers recovering and living happily ever after (one presumes).

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The medicine was mediocre, and I expect better from House. The mystery was good and the solution logical, but there seemed to be a great deal of forgotten symptoms (and/or red herrings) this episode: shoulder pain, the increased CKMB, and acute scrotum for starters. At the very least, the team needed to ultrasound his testicle to rule out testicular torsion, a devastating condition. Histoplasmosis generally causes only mild disease in immunocompetent patients; diffuse disease occurs in immunocompromised patients (such as AIDS patients). Of course, Matty’s white cells were removed so that did compromise his immune system — but fungi are slow growing so it would take at least several days to see any response (and similarly it would take at least several days of Amphotericin to treat the infection, not one dose then slap him down and take his bone marrow). Taking his white cells may have seemed a good idea in theory, but really wasn’t a good idea in practice. For one thing, white cells are responsible for many of the signs of infection we look for such as fever. The contradiction between what Cuddy told the parents and what Foreman did right after didn’t help the storyline either. And I hope I don’t need to mention that Foreman’s actions were entirely unethical. He needs informed consent, and a ten year-old is way too young to truly understand the risks and benefits of the procedure. What Foreman did was no better than assault and child abuse. So as not to end on a downer, the show’s portrayal of Nick’s acute graft versus host disease was well done.

There were a bunch of stupid lines that stood out badly in this episode. First was House’s contention that narrow spectrum antibiotics work faster than broad spectrum ones. The spectrum of the antibiotic has nothing to do with its speed, they’re unrelated. Then there was Cameron’s claim that Matty’s blood was “literally turning into water.” Even if there aren’t many blood cells left, there are still plenty of other proteins, enzymes, and chemicals in blood to make it a lot more than water — I sure wouldn’t drink it. Finally, there was Foreman’s statement that Matty was too sick for sedation. That’s simply ridiculous. Collecting bone marrow without analgesia is a hell of a lot harder on the body than anesthesia — or at the very least pain medicine — would be.

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I give the medical mystery and the solution both a B. Like last week, the medicine was haphazard and and just average, which is why it earns a weak C. The House/Wilson/Hector soap opera was good, but the Foreman scenes were too heavy-handed for my taste. I give this aspect of the show a B as well as an N (Needs more Cuddy).

The previous House review
A list of all prior House reviews

Tags: television medicine house leukemia bone marrow transplant histoplasmosis

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

A clever mystery on tonight’s episode of House. The medicine wasn’t as good, but House’s wheelchair bet was at least fun to watch. Spoilers below, so watch the episode before you read.

Stevie, a sixteen year-old boy, is making out with his girlfriend when he suddenly becomes short of breath and starts gasping for air. He’s brought to the hospital and admitted to House’s service. According to Foreman, Stevie has no history of trauma, asthma, or allergies. An EKG and echocardiogram are both normal. He does have a bloody pleural effusion (a pleural effusion is a build up of fluid in the membrane surrounding the lung). An x-ray reveals no tumors or pneumonia. The team’s initial thoughts are cocaine or some other recreation drug, or a venous aneurysm.

House orders a venogram, which is negative. Chase and Cameron inspect Stevie’s house only to discover it isn’t his house. It seems he lied to them. He is Romani (Gypsy) and he was brought up not to trust outsiders.

Foreman suspects Stevie has a deep venous thrombosis (DVT – blood clot in one of the veins of his legs), but House still suspects a venous aneurysm. He thinks the leak is so small it didn’t show up on the first test. He wants to thin Stevie’s blood and then try the venogram again (not a good idea. There are nuclear medicine tests that are used to discover small amounts of bleeding — much safer). Foreman decides to go ahead and perform an arteriogram first to look for a DVT. The study shows that blood is going into the liver but not coming out, which Foreman and Cameron interpret to mean that one of the three hepatic vein is blocked. (Strangely, this arteriogram which showed a venous abnormality is never mentioned again, except incorrectly when Foreman states that he performed two venograms). Meanwhile, Stevie is having severe stomach pain so the test is stopped.

The team now considers cirrhosis, disseminated intravascular coagulopathy (DIC), and leukemia, but House rules them all out. They next suspect diseases which could cause a granuloma in the liver (this granuloma would be obstructing the hepatic vein); considerations include tuberculosis (TB) or sarcoidosis. An obstructing liver tumor is also a possibility. House orders a CT, MRI (to look for granulomas and tumors), sputum culture (for TB), and an ACE level (which is usually high in sarcoidosis).

The MRI shows what appears to be a granuloma in the liver, so the team shifts their focus to Wegener’s Granulomatosis. Foreman wants to perform a liver biopsy, but House tells him to go ahead and start cyclophosphamide to treat the Wegener’s.

In the meantime, Stevie’s parents have arrived and are causing a commotion. They are redecorating his hospital room and serving him traditional Romani herbal soups. In the middle of a scene between Foreman and the parents, Stevie again complains of severe pain. Foreman pulls back the blankets to reveal a large amount of blood in his groin. It turns out that while his liver seems to have improved, his bladder has now started hemorrhaging. House wants to start FT-28, an experimental drug not approved for Wegener’s, but Stevie’s parents refuse the treatment. Foreman tricks them into leaving the room, and then talks Stevie into taking the medication. Before Stevie can take the medication, however, he double over in severe abdominal pain.

Stevie is rushed to surgery where a ruptured spleen is found. Foreman looks at the spleen under the microscope, but can find no evidence of any granulomas. House wants the surgeon to examine the small bowel for granulomas, but he refuses. House enters the operating room himself and examines the bowel, but he can find no granuloma.

The diagnosis of Wegener’s seems less likely now, particularly when the surgeon tells them it wasn’t a granuloma in the liver, but instead some scar tissue. House wants to look at Stevie’s large intestine so the Young Guns sneak in and perform a quick colonoscopy while House distracts the parents. The test reveals the culprit: a toothpick. Stevie swallowed the toothpick at some point in the past. His contortions while making out in the car had driven it into his lung, and then it migrated into his liver, bladder, spleen, and then large intestine. Once the toothpick is removed, Stevie recovers.

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I liked the fact that the answer to the medical mystery this time was not some obscure disease, but instead something as simple as a swallowed toothpick. It does fit the symptoms, and Foreman is right that wood does not usually show up on x-ray (but I’m not sure about MRI).

While the solution was clever, the medicine was just so-so. House’s fixation on Wegener’s Granulomatosis was strange since it seemed to come out of nowhere. Sure Wegener’s can cause granulomas in the liver (so then it should have been on the differential diagnosis), but so can TB and sarcoidosis, the diseases they were looking for in the first place. The team also continued to confuse pleural effusion (fluid in the membrane surrounding the lungs) with pleural edema (fluid within the lung). Stevie had a bloody pleural effusion, but a bleed within the lung would lead to blood inside the lung, not around it.

The surgery scene seemed off as well. Never mind the House-barging-into-the-OR scene, that’s passé now. I have some concern about the use of silk suture to ligate the blood vessels as silk is only slowly absorbed and extremely irritating to the body. However, a quick perusal of the surgical literature suggests that silk is still used at times to tie off blood vessels, so I’ll let House off the hook on this one, unless some surgeon knows better. I will point out that anatomically, the small intestine is tethered to the mesentery and a variety of blood vessels; it’s not just sitting out like a giant sausage.

Ethically everything was ludicrous, but since when has House or his team bothered to get informed consent?

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Tonight’s medical mystery was a solid B, and the solution was logical as well as unexpected, so earns an A. The medicine wasn’t as good, purely average (for House, above average for most other medical shows), and deserves a C. The character interaction/soap opera between the team members was minimal. Most of this week’s non-medical content was reserved for members outside the team. House got in his “wheelchair duel” — and won in his usual Machiavellian way, but this was primarily a Foreman show. What “soap opera” was present was well done though, and earns a B+.

The previous House review
A list of all prior House reviews

Tags: television medicine house wegener’s granulomatosis

I keep seeing these television ads for the upcoming film The Bridge to Terebithia. The ads strongly play up the fantasy aspects of the story, making it seem akin to The Lion, The Witch and The Wardrobe or The Lord of the Rings.

Now, I’ve read The Bridge to Terebithia, and the fantasy aspects make up only a tiny part of the story and aren’t really that integral to the plot.

This means that either:

1. The movie makers totally missed the entire point of the book, or

2. There’s going to be some upset parents and sobbing children who were expecting a light-hearted fantasy romp.

If you’re unfamiliar with the plot, and don’t mind it being spoiled, the wikipedia article sums up the plot well

Hank returns home from an evening of studying to find a mysterious woman in a wheel-chair waiting for him in his apartment. She explains that she is Barbara Gordon and she calmly informs Hank that she wants him to call Dawn because she needs to talk to both Hawk and Dove.

Once Dawn arrives, Barbara explains that she needs their help in taking down Velvet Tiger once and for all. She explains that Velvet Tiger was once one of Batgirl’s enemies, but since Batgirl has “retired,” Hawk and Dove will need to step in and apprehend Velvet Tiger. When asked how she learned their identities, Barbara plays coy at first, telling them that she got it from “an oracle.” Then she quickly explains that Oracle is a top secret government computer expert, but in the next panel she all but admits she is Oracle (”I hacked the Titan’s database”). Clearly this is before Oracle’s identity became the big secret it is now (and it is one of her first appearances outside of Suicide Squad).

Barbara tells the duo that Velvet Tiger is said to be Lani Gilbert, but she finds that hard to believe because records show that Lani is only ten years old. Barbara explains that the Tiger is trying to take out Washington D.C.’s mob bosses one by one so she can take over as top boss in the city. Barbara has been able to pinpoint who Velvet Tiger will attack next and she wants Hawk and Dove to intercept and capture her.

Across town, the Velvet Tiger and her bodyguard/lackey Sudden Death arrive at the hide out of one of the few remaining mob bosses. As the Tiger moves in for the kill, Hawk and Dove arrive. Hawk quickly subdues Sudden Death with the help of a conveniently thrown gas grenade. Dove’s battle with the Velvet Tiger is much more interesting. First, she fools the Tiger into thinking that Batgirl has returned. While Velvet Tiger is focusing on “Batgirl,” Dove tries to grab her and suddenly everything goes topsy-turvy. It turns out that Velvet Tiger has the ability to stop time and enter a special dimension that is “between the seconds.” Due to an unhappy childhood, she has spent years hiding in this dimension and the grown-up Velvet Tiger really is the ten-year-old Lani Gilbert. She now uses her powers for criminal gain and to evade capture. Since she is the only one who can survive in this dimension, her plan is to strand Dove here to slowly starve to death. Unsurprisingly, Dove is not too keen on this plan, and she deliberately strikes Lani’s already injured ribs so that the shock will cause her to bring them both back into normal time. As they suddenly appear in the hideout, Barbara shows up just in time to handcuff Lani to a pipe. She informs Lani that that while Dove may not be able to testify at a trial (because of that whole secret identity thing), Barbara will testify and make sure that the Velvet Tiger is put away for a long time.

As the issue ends, Dawn has a quiet chat with Barbara while Hank receives another message from his dead brother. This one asks him to steal a special sapphire from the Smithsonian Institute that he’ll need to bring Don back to life. Hank is unsure what action to take: he’ll do anything to bring Don back, but stealing would mean that he’d be “no better than a criminal.”

Notes:
The art by Greg Guler continues to be good. The writing by the Kesels is still good — particularly the quiet character moments — but overall the last issues of Hawk & Dove just don’t have the same zing as the earlier issues.
The Unofficial Oracle Chronology
Barbara Gordon makes a reference to the Titans Hunt storyline, the company-wide Titans crossover that was occurring at the time (and went for what, six or seven months?) This is the second reference to Titans Hunt in Hawk & Dove, but the actual crossover doesn’t occur until issue #28 and lasts for all of 2 panels before it is crushed (literally) by another company-wide crossover, War of the Gods. More about this when later.
While their children are off fighting the Velvet Tiger, Hank’s and Dawn’s parents are both attending a fancy soirée for Senator Tommy O’Neil. The parents chat for a bit and are clearly confused about who’s dating whom, but the main reason I mention this is that O’Neil will play a key role in the remaining 4 issues of the series.
I find the idea that Velvet Tiger has actually spent half her life hiding in her special between-seconds dimension and really should only be ten years old is kind of creepy, but handled well. It’s nice to see super-powers that actually have real world consequences.
All Previous Hawk and Dove Reviews

Tags: comics hawk dove batgirl oracle velvet tiger

A strong episode of House with a good medical mystery, some decent medical care, and fascinating soap opera. Stay tuned for a review of this week’s House complete with spoilers.

Jack is an 18 year old who works as a waiter at a Chuck-E-Cheese-like pizza restaurant. He is also acting as a parent to his two younger siblings since their parents died in a car accident. While at work, Jack develops blurry vision and then starts vomiting (giving some poor eight year old a birthday he’ll never forget). He suffers chest pain, an abnormal heart rhythm, and a heart attack.

At the hospital, House and the Young Guns review Jack’s case. Prior to the heart attack, he had been experiencing fatigue, night sweats, and weight loss. He also complained of itchy feet and reported that cigarettes no longer tasted good. Foreman suggests Jack’s symptoms are due to an increased intracranial pressure caused by a brain tumor, while Chase suggests a acute viral gastroenteritis. House tells them they’re both wrong and that he already knows the cause. House proposes a contest: each of the Young Guns can run one test to find the diagnosis. Chase draws blood cultures looking for a bacterial infection, Foreman runs a brain MRI, and Cameron runs a heart test looking for coronary artery vasospasm. All the tests are negative, except for the single test that House ran. Jack has Hepatitis A, which explains the weight loss, fatigue, night sweats, and vomiting. It was the vomiting that led to an electrolyte imbalance, which itself led to an abnormal heart rhythm which caused the heart attack. Jack is given a course of IVIG (intravenous immunoglubulin) for treatment.

The next morning when he is set to be discharged, Jack starts bleeding from his IV site, nose, and ear. His lab tests reveal a coagulopathy which House diagnoses as DIC (Disseminated Intravascular Coagulopathy). The team suggests possible causes for his DIC. Cameron proposes a community acquired or opportunistic infection such as E. coli, Eikenella, or Strep. Chase suggests a food-borne illness, but Foreman is suspicious of a sexually transmitted disease such as syphilis or gonorrhea. Foreman performs a lumbar puncture and when he is rolling Jack over after the test, he accidentally breaks one of Jack’s ribs (a “pathological fracture“). House takes this to mean that Jack has osteomyelitis, an infection of the bone. At this time the other tests come back and all are positive. Jack has Syphilis, Eikenella, and botulism.

Jack now starts to have seizures. His white blood cell count is normal and his HIV test is negative (he does not hav AIDS). A CT scan of the head is normal as are all neurological tests. House wonders if the symptoms might be related to Jack’s past history of drug use. While the initial toxicology tests were negative, House notes that drugs can be absorbed by fat cells and are released with weight loss. He has the team sit in a sauna with Jack and sweat another few pounds out of him. His retested blood and urine are also drug free.

The brain MRI is repeated and now shows multiple lesions throughout the brain. The team suspects tumors while House thinks it is a fungal infection. A biopsy of one of the lesions reveals the fungus Aspergillus. House is now convinced that Jack has a genetic immune deficiency that has been kicked into high gear by the stress of his parents’ death. The differential includes Bruton’s Agammaglobulinemia, complement deficiency, Chronic Granulomatous Disease, and Common Variable Immunodeficiency. Concerned that genetic testing will take too long, House exposes Jack to a mixture of the germs Serratia, meningococcus, cepacia, and rhinovirus. Each of the germs targets a different genetic weakness, and whichever disease Jack ultimately becomes infected with will show the team which genetic condition he has. Jack comes down with Serratia which means that he has Chronic Granulomatous Disease. A bone marrow transplant from his younger brother will likely lead to a cure, but Jack refuses explaining that his brother is too young to decide for himself. Foreman thinks Jack’s decision is noble, but House shows him that the disease allows him to shrug off the responsibility of acting as a parent. As the episode ends, Jack’s brother and sister are heading off the foster care and Foreman tells him that he’ll change his mind one day.

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Medically, I thought it was a good mystery with a not-too-far-fetched answer. Most of the medicine was good, but there were a couple of things that caught my eye. First, and a repeat offender, is that it takes forty-eight hours to determine a blood culture is negative, not just a few hours. Second, intravenous immunoglobulin is not a treatment for Hepatitis A. It can be used for prevention in pwople who have been, or are going to be exposed to Hepatitis A, but it is not used to cure the disease. Third, botulism is caused by toxins produced by a bacteria, not by infection with the bacteria itself. Chase should not have seen a bunch of bacteria in the vomit and call it “botulism.” Finally, the sauna will cause a temporary weight loss by water loss; it doesn’t affect the fat cells.

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In addition to a good medical mystery, this episode is also chock-full of soap opera-y goodness. Wilson finds that his car has been towed and his DEA license suspended so that he can no longer write prescriptions. House loans him Cameron at one point to write prescriptions for him – which leads to another soap opera within a soap opera – but refuses to let Wilson borrow her another time. When he runs out of Vicodin, he asks Chase and then Cameron to write him a prescription, but they both refuse – though Cameron does offer her PMS pills. In the end, Cuddy writes House a Vicodin prescription and Wilson throws House out of his office.

I give this episode an A for the mystery, with a B+ for the solution because it was clever but a bit of stretch. Despite my concerns addressed above, I thought the medicine was above average and deserves a B-. The soap opera/non-medical aspect continues to be good and earns an A.

The previous House review
A list of all prior House reviews

Tags: television medicine house immune deficiency chronic granulomatous disease.

While the ultimate solution was clever, I felt the medicine was poor over all and a step back from last week’s show — medically, at least. Medical explanations and spoilers follow.

A seven year-old boy named Clancy has repeated nightmares that he is being abducted by aliens. One morning, his parents find him unconscious in the yard, his pajamas soiled from rectal bleeding. Clancy is brought to the hospital and placed under the care of House and team. Other than the hallucinations, Clancy’s only medical history is that he was conceived by in vitro fertilization (IVF), wears glasses for poor vision, and broke his arm when he was four. The team’s first thought is sexual abuse and the “alien abduction” story is just his way of coping with it, but no evidence was found on exam of sexual abuse. The team also thinks that he might have a bleeding disorder and that would explain the rectal bleeding. Foreman (as always) suspects a neurological cause while House suspects the alien hallucinations are nothing more than nightmares. Coagulation studies to look for a bleeding disorder are ordered, as are an EGD and a colonoscopy to look for sources of gastrointestinal bleeding.

The EGD and colonoscopy are all normal, as are the coagulation studies including a bleeding time (an old fashioned test rarely used any more) run by Chase. When Foreman repeats the test, it is abnormal and shows a bleeding disorder.

That night, Clancy runs away from his hospital room and Chase finds him in the bathroom, cutting into the back of his own neck to dig out the alien chip that he thinks is there. There is a small piece of titanium there — but Chase also notices that despite the improvised surgery, Clancy is not bleeding abnormally, so maybe Chase’s test was correct after all. The small piece of titanium is thought to come from a surgical pin used to fix Clancy’s broken arm several years before.

Chase returns to draw more blood and Clancy starts to hallucinate the Chase is an alien. He goes into a hypertensive crisis (a dangerously high blood pressure) and develops pulmonary edema (fluid building up in his lungs). Chase starts him on oxygen and sodium nitroprusside, a strong medication to bring the blood pressure down. About this time one of the blood tests shows that Clancy seems to have von Willebrand’s disease, a clotting disorder. To determine why Clancy went into a hypertensive crisis, a transesophageal echocardiogram is obtained (an ultrasound of the heart shot from inside the throat. It gives a better view of the heart valves than a normal echocardiogram) and it looks normal at first. However, when House puts it on a larger screen he notices a small area of the heart that is not beating. These abnormal myocytes (muscle cells) are removed. The Young Guns (for some reason) DNA type these abnormal cells and notice that they have different DNA than Clancy’s normal cells. Different theories are discussed about why parts of Clancy would have abnormal DNA — you’ll notice that the team is mentioning things that can mutate DNA one or two genes at a time, but not cause the wholesale difference in DNA noted here. Cameron concocts a marker for these abnormal cells and injects this marker into Clancy’s body. Hot spots in the thigh bone marrow, heart, and retina appear. The team decides the bone marrow cells are to blame for the bleeding disorder, the heart cells for the hypertensive crisis, and the retinal cells for Clancy’s poor vision. All of the abnormal cells are removed.

A short time later, Clancy suffers a hallucination and seizure. House is convinced that there must be another focus of abnormal cells in Clancy’s brain, but the marker tests didn’t show any hot spots, even when they injected directly into the cerebrospinal fluid. House suggests that the marker must not work on these abnormal brain cells so he decides to perform brain surgery. Once Clancy’s brain is exposed, House will stimulate a hallucination so he can determine which area in the brain is abnormal and then remove those cells. The surgery — despite the fact that House is not a neurosurgeon — is successful. The ultimate diagnosis is that Clancy is a chimera, which means that he is a combination of two cell lines. In other words, when he was just a tiny embryo, he merged with a twin’s embryo and all that remains of his genetically different twin were those few isolated areas of abnormal (and now removed) cells.

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First, the good:

• Chimeras are real. Some experts suspect that they are more common than we realize because only rarely do we test cells for DNA. The in-vitro fertilization aspect seen in this epidose is really just a red herring as chimerism has nothing to do with IVF and chimerism can occur with non-IVF embryos just as easily.
• Chimerism does pop up in the news now and again. American pro cyclist Tyler Hamilton was banned from competitive cycling last year on suspicion of blood doping (blood cells that weren’t his were found in his blood sample). His defense is that he is really a chimera and this is a normal blood test for him.

Now the bad:

• VonWillebrand’s disease is a clotting disorder caused by the lack of a protein known as the von Willebrand factor (or by an abnormal version of this protein). If only one small portion of Clancy’s bone marrow is producing platelets with missing vWF (or with abnormal vWF), it is doubtful that would be enough to affect his bleeding at all. At most, it might extend his bleeding time a few seconds; it certainly wouldn’t cause intermittent clotting problems because the abnormal platelets are always circulating throughout the entire body.
• Human DNA codes for over 25,000 different genes. How is Cameron going to know which of these are producing proteins different from Clancy’s, let alone happen to be proteins conveniently located on the cell wall? Not to mention that she is able to produce this miraculous cell marker overnight.
• That’s a mighty clear echocardiogram. Furthermore, increasing the size of the screen doesn’t increase the resolution — that remains the same — you just get bigger and blockier pixels.
• I know some of you think that I complain too much about the Young Guns performing tests they’re not trained to do (like the transesophageal echo this episode), but even you have to admit that House performing brain surgery was beyond the pale.

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The character interaction and soap opera was better this week and didn’t feel as clumsy as the season premiere. Both Wilson and Foreman were taking their digs against House, though both knew he was right. Cuddy hemmed and hawed and finally told House the truth. Of course, House’s leg pain seems to be coming back – but is it real or all in his mind. (And don’t ask me about the PET scan of the thalamus Cuddy wants to do. The thalamus is involved in pain reception, but the tests aren’t nearly as clear cut as she would like. Plus they’re damned expensive.)

I give the medical mystery a B and the ultimate solution a B+ for being clever and not too uncommon. On the other hand, I give the medicine it took to reach the solution a miserable D. The soap opera earns a B+ this week because it was much better than last week.

The previous House review
A list of all prior House reviews

Tags: television medicine house von willebrands disease chimera

It still amazes me that EC could publish a comic book series on psychoanalysis; it just doesn’t seem like a topic that would lend itself well to the comic format. Part of EC’s “new direction” following the Senate hearing, Psychoanalysis lasted for four issues. The first issue was surprisingly good, if a little unrealistic in the way everyone had their problem solved so neatly in a single session. This second issue is not nearly as good, mainly because the writer did such a good job tying up the plot threads with the first issue, there’s not as much to go on in this issue. The plot revelations seem random and unfocused.

Freddy Carter was seeing the psychiatrist because he had been caught stealing his friend’s watch. In the first issue, we learned that he stole from his friend because he envied his friend’s loving family life and wanted some part of it for himself.

In this issue, psychoanalysis reveals that Freddy wanted to be caught. He knew that the only attention his parents ever paid to him was when he did something bad. His father would yell at him and hit him which led to his mother pampering and coddling him. We also learn that Freddy gets asthma attacks during times of stress. The doctor informs him that this is not real asthma, but instead a psychosomatic affliction to gain him sympathy from his parents. The psychiatrist tells Freddy that he needs to grow up and start acting like a fifteen year old and not a young child.

Ellen Lyman was an anxious young woman who had a recurring dream of a empty garden. The psychiatrist explained that the dream meant that she was jealous of her older sister and wished her harm. In this issue, Ellen comes to the office complaining that her life is hopeless. She knocked over the water cooler at work and her boss yelled at her. This reminded her of her father. Digging deeper, the psychiatrist discovers that her father often yelled at Ellen, and her mother routinely ignored her in favor of her older sister. During childhood, Ellen had a couple of accidents that landed her in the hospital. Much like Freddy’s psychosomatic asthma, the doctor informs Ellen that she caused these accidents herself trying to gain the attention of her parents. Furthermore, her other symptoms are due to the fact that she feels guilty because she blames herself for the fact that her parents always fought. The psychiatrist informs her that this is all nonsense, her parents simply did not love each other and it was never her fault. “Oh doctor!” says Ellen. “I feel as if a great weight has suddenly been lifted from my shoulders!”

The third patient is Mark Stone, a television writer who is having conflicts between writing for money and writing as an art. Last issue, the psychiatrist also realized that Mark’s late father’s frugal ways were also responsible for Mark’s anxiety. This issue, the psychiatrist addresses Mark’s weight”

“Ten pounds overweight is carelessness. Sixty pounds? That’s deliberate self-punishment! Why are you trying to hurt yourself?”

Next come a confusing series of revelations. Mark overeats because he loved his mother. No, he overeats because he was ashamed of her immigrant manners and ate to punish himself. Then Mark suddenly confesses that he thinks he shot a man during hunting season a few years back. The psychiatrist calmly informs him that the “man” he shot was just his memory of his dead father and he too needs to grow up and stop competing with a dead man.

Again, three more conveniently neat endings with all the (new) plot threads tied up. We’ll have to see if the third and fourth issues can refocus the meandering plots or if they scatter them even farther.

Tags: comics medicine psychoanalysis flashback week

“Dallan and Sepsis Preserve Us!”

Those of you who read the Marvel Comics series Micronauts during the ’80s no doubt recognize that sentence, while those of you with less comics knowledge but more medical background are understandably puzzled. It was a common oath muttered (or screamed) by the denizens of Homeworld whenever danger threatened.

A little background: A thousand years ago, King Dallan Rann and Queen Sepsis Rann were the rulers of Homeworld, the lead “planet” in the Microverse. They sent their only son Arcturus Rann out to the far reached of the universe on a thousand-year quest for knowledge¹. Shortly after he left, Dallan and Sepsis were killed by their son’s tutor, Baron Karza², who went on the conquer Homeworld and the rest of the Microverse and set himself up as dictator. Upon returning from his voyage and discovering what had happened in the Micorverse while he had been gone, Arcturus Rann took the name Space Glider and joined the Resistance trying to drive Karza from power. With the other core members of the Resistance (Marionette, Bug, Acroyear, Microtron and Biotron), Rann formed the Micronauts³.

Personally, I think it’s a clever bit of storytelling to have the modern denizens of the Microverse revere Dallan and Sepsis Rann as saints or demi-gods. It ties together the past and present of the Microverse (but for Space Glider, it’s got to be a bit creepy having your girlfriend pray to your dead parents).

Dallan is a good name. According to Wikipedia, in the Christian context it means “blind,” named after the blind Irish poet Saint Dallan Forgaill. It’s also an Arabic word meaning “lost” which can be used in several contexts including a loss of the true religion. It’s not an uncommon name for boys.

Sepsis, on the other hand, is an unfortunate choice for a name. Sepsis is the medical term for an overwhelming infection of the entire body, though the term is also used to refer to the body’s response to this overwhelming infection. Regardless, sepsis is frequently fatal and always represents a tough battle to survive. Not the best name for a beautiful Queen, though I doubt writer Bill Mantlo was aware of the actual meaning of Sepsis when he chose the name⁴. Still, it’s hard not to chuckle whenever I see a character praying to “Sepsis.”

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NOTES:
¹Not the really best plan to insure the continuance of your dynasty.
²If I were undisputed ruler of the Microverse, I would have chosen something better than Baron. King, or Emporer maybe.
³Though I notice the team was now called the Microns when they appeared in Peter David’s Captain Marvel. I suspect it has to due with the rights to name Micronauts.
⁴Though Mantlo also named another beautiful female character Slug, so maybe he used the term on purpose.

Previous fond memories of the Micronauts:Micronauts #26-28 (The Micronauts and S.H.I.E.L.D. fight Karza) Micronauts #29-35 (The quest for the origin of the Microverse).

Tags: comics medicine micronauts sepsis

It’s that time once again to see what searches have brought people across the web to Polite Dissent. Capitalization has been added to make the searches more readable, but the grammar and spelling are untouched otherwise. As usual, my snarky comments are added in green.

Comic Related Searches

• Is Superman’s girlfriend pretty? All that matters is that Superman thinks so.
• Batman parents disappointed Death and the Maidens I think we all were disappointed with that comic.
• Clark Kent’s 8 pack abs Two better than six-pack abs.
• Green Arrow Longbow rape I’m sure we all can guess what this search was in reference to. For the record, I always though she had been.
• Zatanna naked The return of a classic search term.
• Wonder Woman groin I have no idea what they were searching for here, but I hope I answered their question.
• Lana Lang underwear ditto.
• Does Carter Hawkman Hall have a doctorate? Good question.
• John Byrne Vision Scarlet Witch genitalia I blame Chris Arndt for this one.

Medically Related Searches

• Do drug testes screen for Ritalin? I’m going to assume you mean “tests” and not “testes”, but the answer is yes — I suspect someone takingRitalin would test positive for amphetamines.
• Differance between cyst and mass A mass is solid, a cyst is hollow.
• Why is clostridium perfringens likely to grow in gangrenous wounds? You have it backwards, it is the infection with Clostridium that is causing the gangrene.
• Rh negative celebrities I have no idea. I’m A-, do I count?
• Cleaning a wound bleach Please don’t. While it’s true the bleach would probably kill any nasty germs, it would also kill many of your own cells, severely impeding the healing process.
• Rash where butt hits toilet seat Probably because somebody smeared something on the toilet seat.
• Medical term when scrotal organ burst out Painful
• Will the pregnancy test aome out positive when using the IUD? If you’re pregnant it will.

Homework

• Macbeth soliloquy she should have died hereafter. OK, here you go. From Macbeth, Act V, scene v, spoken by Macbeth:

  She should have died hereafter;
  There would have been a time for such a word.
  To-morrow, and to-morrow, and to-morrow,
  Creeps in this petty pace from day to day
  To the last syllable of recorded time,
  And all our yesterdays have lighted fools
  The way to dusty death. Out, out, brief candle!
  Life’s but a walking shadow, a poor player
  That struts and frets his hour upon the stage
  And then is heard no more: it is a tale
  Told by an idiot, full of sound and fury,
  Signifying nothing.

To Each Their Own (presented without comment)

• Kim Possible and Ron Stoppable having sex
• funny sex comics with the Teen Titans and Kim Possible
• Peter Parker adult fanfiction Norman Osborne

Miscellaneous

• Comics of nose Huh?
• Intravenous pumpkins Double huh?
• Obsessive compulsive personality disorder getting married Hope for neat spouse, or failing that, a patient one.
• Homemade defibrillator These two words should not go together.

What’s your UDQ (Über-Doctor Quotient)? Do you have what it takes to be an über-doctor, the classic comic book doctor who can do everything? Take this simple quiz and find out: Several common family situations are described below. How would you, the nascent über-doctor, respond?

1. Your spouse complains that you spend too much time in the lab, and not enough time with them.
A. Buy your spouse flowers and take them out for a night on the town.
B. I have a spouse?
C. Remind them in no uncertain terms that science is your life.
D. Clone yourself, so that you can keep your spouse happy, but still keep up wour work in the lab.

2. Your daughter thinks that Britney Spears is the greatest musician ever, and plays her music loud enough to rattle the windows.
A. Confiscate her stereo.
B. Invent a special radio that substitutes a Patsy Cline song whenever your daughter tries to play a Britney Spears song.
C. Take her to the symphony, repeatedly, until she learns what real music is.
D. Build a time machine, go back in time, and prevent Britney’s parents from ever meeting.

3. Another driver cuts you off in traffic.
A. Ignore him. He is insignificant compared to your genius,
B. Three words: Alien death ray.
C. Tailgate him, honk, and give him the finger.
D. Using spare components found in the glove compartment, build a remote control device that will let you take control of his car. Have him pass a nearby squad car doing 80, in the wrong lane, backwards. That’ll teach him.

4. Your young child’s pet goldfish has unexpectedly died.
A. Flush!
B. Breed a species of long-lived goldfish that will outlive your child, and quite possibly, the human race.
C. Calmly explain the concept of death to them and buy them another goldfish.
D. Secretly replace the dead goldfish with a robot goldfish you built. Not only will this robo-fish never die, but it can teach them the ABCs and math up through trigonometry.

5. You find yourself trapped in a broken elevator with the very pregnant Mrs. Belding, who (of course) goes into labor.
A. Use the elevator’s phone to call 911.
B. Luckily, the credit-card sized first aid kit you keep in your wallet is equipped for any emergency, from childbirth through major surgery.
C. Try to fix the elevator.
D. Deliver the child, circumcise him, baptise him, toilet train him, and have him reading at a thrird third-grade level by the time the elevator is repaired twenty-minutes later.

Part 2 of the UDQ Quiz (including questions #6-10 and scoring) are coming soon, so keep your answers handy.

Tags: comics medicine über-doctor quiz

Tonight’s two repeat episodes of House, the fifth and sixth episodes of the second year, are both very watchable episodes. The first episode, Daddy’s Boy, had a good medical mystery and earned a solid B from me when I initially reviewed it. It is also full of great House/Wilson moments and we get to meet House’s parents, including everyone’s favorite ex-drill instructor, R. Lee Emery Ermey, who plays his father.

The second episode, Spin, has less exciting (and less accurate) medicine, but does give us a House at his absolute bastardliest, so that’s fun to watch. I gave it a B- the first time out.

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Need more good medicine? Grand Rounds is the weekly collection of the best medical blogging on the ‘net. It always features fascinating stories, advice, and insight into the medical field. Check it out this week at Dr. Deborah Serani’s place.

Tags: television medicine house grand rounds.

As this mini-series starts, Lois is feeling low. She has recently bungled a major interview, and her reputation at the Daily Planet has never been worse. In the midst of a dinner date, she notices police cars tearing down the road and she ditches her date (and “borrows” his car) to follow them. She ends up at a crime scene where the body of a murdered little girl is pulled from the harbor. At that moment Lois Lane, prize winning journalist, has an ONISGS (Oh No, I Suddenly Got Stupid) moment and suddenly realizes that there are missing and exploited children out there, and all too often they turn up murdered.

She spends the rest of this comic and the subsequent issue, both double-sized issues mind you, trying to come to terms with the fact that children go missing and are murdered. She antagonizes Clark Kent, Lana Lang, Jimmy Olsen, Perry White and even her sister Lucy. She harasses the police and assorted businessmen. She meets with parents of missing and murdered children and attends their support groups. In the end, nothing changes, except that now Lois — and we, the reader — know of the dangers that children face.

To be fair, it is not the worst story I’ve ever read, nor even the worst PSA comic. The writer mentions that she was inspired to write this comic after watching the TV movie Adam. Missing and exploied children are an important topic, and the comic does present the information fully, both in the storyline and in the accompanying text pages, but it’s just so heavy handed it’s no fun. If anything, the comic tries too hard and takes itself too seriously. To begin with, it’s hardly the most pleasant idea for a story, and then when you add a depressed and obsessive Lois on top of that, it becomes virtually unreadable.
When you forget the First Rule of PSA Comics (”Keep It Brief”), the message just gets lost.

The art by Gray Morrow is very moody and fits the story well. However, considering that one of this comic’s themes is the exploitation of women and children, it’s amazing how often Lois ends up in her lingerie, just her bra, or in the all together.

The big shocker of the book comes near the end of the story, at a police press conference that Lois and Lana are attending. As the police are discussing a dead body that has been found, Lana gets nauseous and bolts from the room. Lois follows her. In the conversation that follows, we learn a little secret: While Lana was in Europe, she got married and had a son. This child was kidnapped by an Italian terrorist group who sent Lana a little memento — her son’s ear — before ultimately killing him. To this day, Lana keeps her son’s ear in her safe deposit box. So not only did Lana have a marriage and child in her past — a family that has never been mentioned before or since — but she keeps her dead son’s ear (which she describes as “a dried piece of skin that looks like an apricot”) at her bank.

Did I mention what an enjoyable comic this was?

Tags: comics psa lois lane lana lang

I’m feeling a bit under the weather this weekend, so I’m going to declare this “PSA Classic Weekend” and I’ll take a look back at some of the better PSA comic posts from the past two years here at Polite Dissent. First up is Spider-Man and Power-Pack, the infamous (and non-canon) story where Peter Parker reveals he was sexually abused by an older boy. Originally posted 14 November 2005.

Spider-Man and Power-Pack was a giveaway comic produced in 1984 by Marvel, the National Committee For Prevention of Child Abuse, and the NEA. Written to educate children about sexual abuse, this comic contains two stories.

The first is a Spider-Man tale written by Jim Salicrup and penciled by Jim Mooney. Peter Parker is in his apartment darkroom developing pictures when he hears something disturbing from the next apartment. Changing into Spider-Man, he swings over and finds that Tony, the son of the couple next door, has been abused by his babysitter Judy. Spider-Man wants Tony to tell his parents what happened but Tony is too scared.

Spider-Man tells Tony the story of a young man about his same age who lived with his aunt and uncle (could it be Peter Parker?). This young bespectacled boy was a bookworm and didn’t have many friends. He was pleased when a slightly older boy named Skip befriended him. Then one day, Skip pulled out some Girlie magazines (no really, that was the name of the magazine) and told Pete that they should “touch each other like the people in that magazine.” The young boy tells his aunt and uncle what happened and in the end everything works out. Spider-Man tells Tony that just like that other young boy, he should let his parents know what happened. Tony’s parents are very supportive and tell Tony that he did the right thing. They thank Spidey, but he tells them that there’s no need for thanks as Tony has already helped him. Web-swinging back to his apartment, Spider-Man realizes that helping Tony face his abuse has allowed Spieder-Man to face a dark chapter of his own past (an incident never mentioned again in any other Spider-Man comic book ever).

The second part of the comic is a Power Pack story by Louise Simonson with pencils by June Brigman and Mary Wilshire. Jane, a young school friend of the Power children, has run away from home because her father sexually abuses her. Jane told her mother what happened, but her mother didn’t believer her. The Power Pack are able to locate the runaway Jane and they bring her back to their house. Jane tells Mrs. Power what happened. After Mrs. Power consoles her, she gives Jane a number to call to get her family some help.

• SpiderFan on the Spider-Man portion of the story.
• Scott Shaw!’s Oddball Comics entry on this comic.
• The Appendix to the Handbook of the Marvel Universe entry on Skip Westcott.

Tags: comics medicine psa spider-man power pack child abuse

Let’s look at what we know about Thomas Wayne:

• Wealthy ¹
• Physician ²
• Philanthropist
• Husband of Martha
• Father of Bruce
• Frequent player in Batman storylines

It’s the last item that I’d like to discuss. Thomas Wayne is used in too many storylines; he’s become a crutch of the bat-writers . I suspect they think it makes them clever — and once that might have been true — but now it just makes them cliché.

Their approaches to Thomas Wayne are contradictory too. In the previous Batman: Legends of the Dark Knight storyline, a reporter published a book on the Gotham City Ripper and claimed that it has been Thomas Wayne. Bruce had no doubt that his father was innocent and set out to find the real killer. However, in the current Batman: Legends of the Dark Knight storyline, a hidden room is discovered at Wayne Manor. Bruce’s first thought: “My father was a junkie.”

Make up your mind DC: did Bruce believe in his father or not (I vote yes). Pick one and stick with it.

I’d like to suggest a moratorium on all stories concerning Thomas Wayne. At least until 2010. Let the poor man rest in peace.

(And what about Martha? You never see her except in visions/dreams/nightmares Bruce has of both his parents. The only time she’s played any sort of role in a story was the Batman Family mini-series from three years ago).

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¹Most of the wealth he inherited, though Thomas is also shown as an extremely succesful doctor, so he undoubtedly made some good money himself.

²Exactly what sort of doctor was Thomas Wayne? It’s frequently suggested that he was a surgeon, though he’s usually shown acting more as a primary care physician.

Tags: comics href=”http://www.politedissent.com/index.php?s=batman&submit=search” rel=”tag”>batman bruce wayne thomas wayne

Dawn e-mailed to ask about an editor’s footnote in the final volume of the manga Marmalade Boy which reads, “In Japan, the normal length of a full-term pregnancy is considered to be 10 months, not 9 months.”

That footnote is correct: Traditionally in Japan, pregnancies are considered ten months long.

Now, it’s not that Japanese women are pregnant a month longer than non-Japanese women, but instead it all comes down to semantics.

Quick medical background information: Pregnancies are dated from the last normal menstrual period and the average normal pregnancy is considered to be forty weeks long. An infant born at 37 to 42 weeks gestation is considered “full term.” An infant of less than 37 weeks gestation is considered “pre-term” (or more commonly “premature”). A pregnancy that lasts longer than 42 weeks is considered “post-dates.”

According to the Gregorian calendar, where months range from 28-31 days, this means the average pregnancy lasts a little over nine months.

On the other hand, if you’re counting the more traditional lunar months of exactly 28 days (i.e. 4 weeks), then 40 weeks = 10 months. The Japanese belief that a pregnancy lasts ten months refers back to their original calendar that used these shorter months.

So:

9 month American pregnancy = 9 calendar months = 10 lunar months = 10 month Japanese pregnancy

(And just to further confuse thing, the classical phrase regarding a pregnancy in Japan is totsuki tooka, which actually refers to a length of ten months plus ten days)

• A piece of Japanese art from 1882 titled “Knowing the blessings of one’s parents.” This is a niece piece from the collection of the University of Kansas Medical Center and shows the ten-months of pregnancy (remember to read form right to left).

Tags: comics medicine pregnancy marmalade boy japan

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

The fourth episode of House in a row that features sex as a selling point. Enough already, please!

Melinda Bardach is 16 year-old girl who is deathly allergic to penicillin, bee stings, and peanuts. Thanks to trauma from an automobile accident, she also needed a heart transplant. She lives in a specially prepared clean room, and is not allowed out except to visit the doctor. When friends come to visit, they have to scrub down and wear a mask. Melinda’s boyfriend visits her and she wants a kiss. As he leans down to kiss her, he notices hives on her skin. Within seconds, she is wheezing and having difficulty breathing. angioedema sets in. Her mother rushes in and gives her a shot of epinephrine to stop the anaphylaxis.

By the time Melinda is admitted to House’s service, she has undergone “4 days of work-ups” which were all negative. Looking around Melinda’s room at home, Cameron and Chase notice that one window is unlocked, does not have and alarm, and is conveniently near a tree. They confront her boyfriend who admits he snuck in the night before her attack and that he and Melinda had sex. They test his semen, but Melinda shows no allergies against it. House questions him more closely and discovers that he took a week’s worth of antibiotics — penicillin, he thinks– before visiting her because he didn’t want to get her sick. The team deduces that just enough penicillin molecules were in his semen to set off an allergic reaction the next day. Just as House is ready to discharge Melinda home with a diagnosis of ‘allergic reaction” she goes into pulmonary edema, with sudden onset of wheezing, crackles in the lungs, white frothy sputum, and jugular venous distention.

Tests show that Melinda has developed congestive heart failure (the heart isn’t beating strong enough and fluid is backing up into the lungs). There is question whether this is a separate event from the allergic reaction, or if the two are connected. Cameron suggests a toxin of some kind, but that is ruled out. Other thoughts include an infection, heart disease, or rejection. A CT (apparently of her entire body) was negative, as were blood tests to rule out infection (though they came back way too soon. Negative blood cultures take forty eight hours) and a heart biopsy to rule out rejection. Meanwhile, Melinda has fled from her room. Foreman finds her on a back staircase, wanting to go outside, but too scared to go. As he escorts her back down to her room, he notices a left foot drop, which he refers to as steppage gait, but that’s a neurologist for you. As she is being examined for the foot drop, he also notes muscle fasciculations in her leg and diagnoses her with an ascending paralysis (a paralysis that starts at the extremities and works its way in, rather than the other way around).

Cameron suggests tick paralysis, but this is discarded when House points out that thorough exams showed no bites or ticks. ALS and MS — the usual suspects — are mentioned, as are Guillain-Barre Syndrome, botulism, and the catch-all viral infection. A spinal tap is obtained but is shows no evidence of viral infection. EMG (electomyography) shows increasing weakness in her lower-extremities and Foreman is convinced she has Guillain-Barre (an overactive immune response that causes paralysis). She is started on plasmapheresis, which filters out the offending proteins, but shows no improvement. Clearly depressed, she once again develops trouble breathing. This time her lungs are clear and there is no evidence of any allergic reaction. She is intubated and Foreman informs her parents that the paralysis has spread to her lungs (though presumably he means her breathing muscles, and not the lungs themselves).

Foreman and House agree that the paralysis has spread too fast for Guillain-Barre. Cuddy has taken over the case and ordered a spinal MRI to look for a possible lesion there. The team discusses but quickly dismissed the possibility of a toxin from glue inhalation or pesticides. House now decides the answer must be botulism and figures that the boyfriend smuggled in some food. He pulls his usual extubate-the-patient-so-I-can-question-them-as-they-are-gasping-for-air stunt, but Melinda is adamant that her boyfriend did not bring her any food. She also mentions that he had not been taking penicillin, but instead clindamycin – an antibiotic that she is not allergic to. The team now realizes that all three conditions (the allergy, the heart failure, and the paralysis) must be related – House belatedly decides that Cameron was right all along about the diagnosis: tick paralysis. He deduces that the boyfriend must have accidentally brought the tick in with him and that the team must have missed the tick on exam. As Melinda is sliding into a fatal heart rhythm, House declares that he must find and remove the tick before anything else. As Foreman pumps her full of atropine, House searches her entire (and I mean entire) body and manages to find the tick, lodged in the most unlikely of places (and during the most ridiculous scene in quite a while).

Let’s look at the diagnosis and the three main complaints:

1. Anaphylaxis: There have been cases of anaphylaxis from tick bites, though the time course seems a little off. Anaphylaxis usually kicks in quickly, or at most four hours after an exposure, not a day later — though it is possible that the tick had been wandering around for a while before it decided to settle down and bite. I’d also like to know that if it was an allergy to the tick bite that caused her anaphylaxis, then why didn’t she continue to have the reaction while in the hospital as the tick was still attached.
2. Heart Failure: I’m assuming that the paralysis is what led to the heart failure, though some animal studies have shown that tick venom has a direct affect against heart muscle. While atropine is used as an antidote to some neurotoxins, and it can speed up the heart rate under certain conditions, I think its use as depicted here is quite a stretch. It is not indicated in the treatment of tick paralysis or the routine treatment of heart failure. Speaking of heart failure, I never saw them do anything to treat the failure, and the CT scan is not a good way to evaluate heart failure (echocardiogram with doppler is much better).
3. Ascending paralysis: Right symptoms, but the time course is wrong. The symptoms of tick paralysis are fairly slow, taking several days to progress once they appear, not just a few hours. It usually occurs in people who have ticks that have been attached for 5-7 days, and that seems to fit this case as Melinda underwent “four days” of tests before coming to see House. I will agree that House is absolutely correct in that removing the tick solves the problem.

The soap opera again centered mostly on House and Wilson being roommates. House was cruel, but Wilson got him back in the end. Foreman is becoming the strongest of the junior doctors, standing up to House on several occasions this episode. Finally, for Hawk, who thought that Cameron wasn’t getting her share of the limelight: not only was she correct about the diagnosis, she also got the best zinger of the show in her little crack about Chase’s “staying power.”

The mystery was good, so I give it a B+, but the solution was quite a stretch so earns a C-. The medicine overall gets a C because there were too many holes. The soap opera was slight, but fun, so earns a B+ as well.

• The previous House review
• A list of all prior House reviews

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Still want more top of the line medical information? This week’s Grand Rounds are being held over at UroStream.

Tags: television medicine house guillain-barre botulism tick paralysis grand rounds.

This medical review of a rather blah House contains a few spoilers, so don’t say I didn’t warn you…

Adam, a 16 year-old boy, is riding an ATV when he loses control and it crashes, catching fire. He is severely burned and brought to the hospital for treatment. House’s team is consulted when the patient demonstrates tachycardia (an elevated heart rate) and low potassium despite standard burn therapy.

Due to a lack of skin on his chest, the team cannot run an electrocardiogram (also known as an EKG or ECG) to check heart rhythm, instead they have to use an old fashioned instrument, a galvanometer. The heart reading appears normal, but the patient suffers a seizure while they are administering the test.

The team is concerned that Adam may have a brain infection or multiple sclerosis. Because of his condition is unstable, they are unable to move him to radiology for a CT scan or MRI (though they seem to have no trouble moving him into a hyperbaric chamber, not to mention flipping him on his side later). Because of concern about infection, a lumbar puncture (also known as a spinal tap) cannot be performed either. The doctors ultimately perform “transcranial Doppler sonography,” in other words they are looking at the blood flow in the patient’s brain by ultrasound (though in real life this doesn’t work nearly as well as it does here). They see no evidence of infection or multiple sclerosis, but they do find a subarachnoid bleed.

Later, while Adam is in the hyperbaric chamber, the team notices that the patient is having an orgasm. There is thought that his brain might be misinterpreting sensations (i.e. feeling pain as pleasure), but there is still concern about infection or vasculitis. Cameron is concerned that the burns may be infected and this is overwhelming is brain, but somehow a single treatment with maggots proves that there is no infection.

House declares that they must perform a lumbar puncture, only they must do it in the neck where there are no burns. Of course, the neck is the cervical spine as opposed to the lumbar spine of the lower back, so this would be a cervical puncture instead of a lumbar puncture and any doctor — especially a neurologist like Foreman — would know this. Anyway, the spinal fluid shows no evidence of infection or multiple sclerosis.

House wakes Adam up, who despite being in tremendous pain (and one would suspect groggy and very confused) is able to tell House precisely that he felt no tingling in his legs before the accident, but did lose bladder control and pass out before the crash. House deduces that the patient had a seizure before the accident and decides that antidepressants must be causing Adam’s seizures.

Adam’s parents deny that their son was depressed, but House doesn’t believe them. He plans on waking up Adam again to ask about antidepressant use when he notices a cigarette burn on his wrist and nicotine stains on his fingers (so much for doing a thorough exam on admission). He realizes that Adam was using antidepressants to help him stop smoking and this caused his seizures (and other symptoms too, presumably).

Meanwhile, House’s nemesis from early in his training is giving a lecture at the hospital on his new treatment for migraine headaches. House injects himself with this doctor’s “miracle cure” and then induces a migraine in himself with nitroglycerin. He is pleased when the other doctor’ cure fails to work, but now he’s stuck with a migraine. In the end, the drug company pulls funding from this doctor after House e-mails them about the failure of the drug.

This was a very unimpressive episode of House, and frankly the worst in recent memory. It’s true that that the final solution was correct, but only to a point. Certain antidepressants do raise the risk of seizure. This is particularly true of bupropion (better known as Welbutrin or Zyban), the antidepressant prescribed to help people quit smoking. However, this has nothing to do with ordering shady drugs over the internet; it’s a known risk of a commonly prescribed drug. Also note that this is an entirely different class of antidepressants than those associated with serotonin syndrome (or “serotonin storm”, as they called it in the episode) — which is what Adam’s other symptoms were blamed on. And for the record, antidepressants are not the most common drugs used for smoking cessation; that would be nicotine, as in “nicotine replacement” (patches and gum), particularly because it can be obtained without a prescription.

Overall, the plot was cluttered and the complications contrived. Concepts were advanced that had little to do with the story (Ooo…maggots!), and stupid mistakes were made. The side plot, Dr. House getting revenge on an old rival, could have been fun but ended up being less exciting than the rest of the uninspired storyline (like a pharmaceutical company would stop studying a drug it spent millions of dollars to develop because it didn’t work a single patient? Get real!)

This episode gets a C for the mystery and another C for the solution. The medicine earns a D, because I’m feeling generous. The soap opera aspects earn a C-.

• Previous House reviews

Tags: television medicine house migraine seizure.

Finishing up the Trivia Night questions with rounds seven through ten. These were some of the hardest rounds, particularly rounds eight and ten.

Read more…

I hope everyone had a nice weekend and a pleasant holiday. The Polite-Family officially celebrated Christmas (and all associated or non-associated, non-denominational and pagan holidays) today because we were waiting for my wife to return from visiting her family. As luck would have it, her plane had to make an abrupt change-of-landing due to fog, and she ended up spending most of Christmas evening stranded in the Springfield, Missouri, airport. I finally picked her up at the local airport at 3:30 AM, and she was asleep before we left the airport parking lot.

Today, we had my parents over as well as my sister for our annual bout of eating, gift giving, eating, card games, and eating. As always, there were some truly bizarre gifts (Marvel really needs to pay more attention to where it is licensing its characters) and some spectacular food. It all finished with several hands of the mystery/card game Sleuth which is still going on downstairs as I type this up.

Much of the comic relief is provided by the pets. My sister brings her dog Suman over, and let’s just say that our cats aren’t particularly fond of him…

Regular blogging resumes tomorrow.

Tiny Toys Remain Major Cause of Child Deaths screams the Associated Press headline in an article about the annual toy survey from the United States Public Interest Reseach Group (USPIRG) carried by many local papers, national news outlets and local news stations yesterday. From the article:

The U.S. Public Interest Research Group’s 20th survey noted that the Consumer Product Safety Commission reported the deaths of 16 children in toy-related incidents last year, along with another 210,000 emergency room visits. Choking on small parts, balls and balloons remains a leading cause of death and injury in children younger than 15.

This makes no sense. How can 16 deaths lead to the conclusion that choking on toys is a “leading cause of death and injury” or a “major cause of child deaths”?

Let’s take a minute to look at the actual statistics:

• The 210,300 toy-related injuries estimated by the Consumer Product Safety Commission (CPSC) is for all ages. 77% of these injuries (161,100) were to children under 15.
• Riding toys were the leading cause of toy-related injuries (34%), and most of these were due to unpowered scooters.
• The NEISS database estimates that there were 12,206 aspiration injuries to children under 15 in 2004. Note that this number includes all aspiration injuries, not just those related to toys. (In contrast, children had 2.3 million falls, three-hundred-thousand bite and stings, and two-hundred-thirty-thousand motor vehicle accidents requiring emergency room visits in 2004).

The CPSC reports 16 toy-related deaths in 2004.

• Choking made up 44% of these injuries (7)
• Riding toys made up 38% (6)

The main causes of death in children depends greatly on age. For children under 15, the leading causes of death include accidents, congenital malformations, assault, cancer, heart disease, influenza and pneumonia. If you have time to kill, the National Vital Statistics Report can be found here (warning, it is a 90 page pdf file).

Here’s a list I compiled of deaths in children under 15 in the US in 2004 due to various causes. This list contains some — but not all — of the leading causes of death and also lists some less common causes. These numbers are presented to contrast to the 16 toy-related deaths in 2004:
Motor vehicle accidents, 2505; Malignant Cancer, 1548; Assault, 1082; Heart Disease, 920; Drowning, 838; Suicide, 273; Falls, 95; Medical or Surgical Complications, 69; HIV, 37.

The following charts do an excellent job presenting the leading causes of deaths and non-fatal injuries in children. You’ll notice that “toy aspiration” is not listed as one of the leading causes. It probably falls under the heading “Unintentional Foreign Body,” but that category includes all foreign body injuries, not just choking, and not just toys.

Conclusion: The statistics simply do not support the claim that “choking on small parts, balls and balloons remains a leading cause of death and injury in children younger than 15.” Nor do the statistics support the headline that small toys are a leading cause of children’s deaths.

Where did these ridiculous claims come from?

• NOT from the CPSC. Their Toy-Related Deaths and Injuries, Calendar Year 2004 makes no such claims (pdf file).
• NOT from the USPIRG. Both their press release and annual Toy-Report are generally level headed and full of good advice. The press release does state “choking on small parts, small balls and balloons remains a leading cause of toy-related deaths and injuries,” which is a much more reasonable claim (the death part anyway, I see no statistics to support choking being a leading cause of toy-related injury).
• Since these are the only sources the Associated Press names, the only reasonable conclusion is that the AP themselves must have come up the misleading statements. Their reporters either misunderstood and misreported the data, or went for the eye-catching headline and sound bite without bothering to accurately report the actual evidence.

Toy-related deaths are tragic and preventable, but they are not the epidemic the Associated Press article claims. The USPIRG Toy Report has good information and I recommend it to parents, grandparents and physicians.

UPDATE:
Apparently the headline I quoted above is just CNN only, other media sources have less salacious headlines. The rest of the article remains the same however.

Spider-Man and Power-Pack was a giveaway comic produced in 1984 by Marvel, the National Committee For Prevention of Child Abuse, and the NEA. Written to educate children about sexual abuse, this comic contains two stories.

The first is a Spider-Man tale written by Jim Salicrup and penciled by Jim Mooney. Peter Parker is in his apartment darkroom developing pictures when he hears something disturbing from the next apartment. Changing into Spider-Man, he swings over and finds that Tony, the son of the couple next door, has been abused by his babysitter Judy. Spider-Man wants Tony to tell his parents what happened but Tony is too scared.

Spider-Man tells Tony the story of a young man about his same age who lived with his aunt and uncle (could it be Peter Parker?). This young bespectacled boy was a bookworm and didn’t have many friends. He was pleased when a slightly older boy named Skip befriended him. Then one day, Skip pulled out some Girlie magazines (no really, that was the name of the magazine) and told Pete that they should “touch each other like the people in that magazine.” The young boy tells his aunt and uncle what happened and in the end everything works out. Spider-Man tells Tony that just like that other young boy, he should let his parents know what happened. Tony’s parents are very supportive and tell Tony that he did the right thing. They thank Spidey, but he tells them that there’s no need for thanks as Tony has already helped him. Web-swinging back to his apartment, Spider-Man realizes that helping Tony face his abuse has allowed Spieder-Man to face a dark chapter of his own past (an incident never mentioned again in any other Spider-Man comic book ever).

The second part of the comic is a Power Pack story by Louise Simonson with pencils by June Brigman and Mary Wilshire. Jane, a young school friend of the Power children, has run away from home because her father sexually abuses her. Jane told her mother what happened, but her mother didn’t believer her. The Power Pack are able to locate the runaway Jane and they bring her back to their house. Jane tells Mrs. Power what happened. After Mrs. Power consoles her, she gives Jane a number to call to get her family some help.

• SpiderFan on the Spider-Man portion of the story.
• Scott Shaw!’s Oddball Comics entry on this comic.
• The Appendix to the Handbook of the Marvel Universe entry on Skip Westcott.

As usual, there are House spoilers below, so I’d suggest you watch the episode before you read (unless you’re one of those people who read the last page of a mystery first).

An interesting and enjoyable episode of House with a good medical mystery.

Cornell, a young black man, is at a party celebrating his graduation from Princeton when he begins to convulse from intermittent and excruciating shock-like pains. Initial work ups are negative except for a low white blood count, and an MRI rules out multiple sclerosis. House thinks the patient might have Type II Neurofibromatosis, but the genetic tests are normal.

Cornell looses control of his bowels. This is a worrisome symptom because it indicates that the central portion of the spinal cord has been compromised. The gang decides that he has transverse myelitis, but they don’t know what caused it. House suspects that it is pesticide exposure, so he starts pralidoxime, an antidote for pesticide poisoning . The medication seems to work at first, but then Cornell starts running a fever of 106°F and his symptoms recur. He develops a perforated bowel from the raging infection and requires immediate surgery.

One of Cornell’s friends from college, who we already knew had a weird rash, starts vomiting blood and is brought to the hospital. House is finally able to put the full story together and realizes that the patients have been exposed to radiation. Cornell’s father runs a scrap yard and gave his son a scrap metal weight as a key chain to remember “where he came from.” Unfortunately, this keychain was radioactive. The father and friend have mild cases of radiation poisoning but Cornell has a much more serious case. The radiation has killed off his white blood cells, leaving him open for infections. It also caused a spinal cord tumor (a cavernous angioma) which explains his neurological symptoms. The surgeons are able to remove the tumor, but as the episode ends it seems unlikely that Cornell will survive his infection.

The medicine was fairly sound in this episode. I have a few nit-picks, but no major complaints. Time course is a concern. It is unlikely that an exposure to a pesticide over spring break would have caused symptoms to appear months later at graduation. Radiation poisoning, especially exposure to long-term low-dose radiation, can take months for symptoms to surface — so the time course there was reasonable. It does seem that the tumor developed awfully fast though. Finally, if Cornell had a white count as low as the story suggests, he should have been in isolation shortly after admission, and his father should have been wearing a mask and gloves (and probably a gown) when he went in to see him at the end.

On the non-medical, soap opera side, the action picks up. House has borrowed $5000 from Wilson to buy a new motorcycle. Of course, it turns out that House didn’t need to borrow that much money — he was just testing Wilson to see how much he’d lend him by asking for increasing amounts over the course of a year. Surprising no one (except maybe House), this annoyed Wilson. Also, House’s parents are in town for a brief layover at the airport and want to go to dinner with him. He is trying to avoid them, but doesn’t want to lie to them. He concocts various schemes to get out of dinner, but ultimately sits down to share a meal with them at the hospital cafeteria. The interactions between House and his father (a bushier-eyebrowed than usual R. Lee Emery) drive home the underlying theme of this episode: fathers and sons, when do they lie to each other, and when do they tell the truth?

I give this episode an A for the mystery with a B+ for the final solution. The medicine overall earns a B and the soap opera also deserves a solid B.

• Previous House reviews

At the end of the previous issue, Lois “Lorne” had decided to stay in Coral City and Superman returned to Metropolis. Now don’t feel sorry for Lois — she’s already engaged to her new boyfriend, “hunky” astronaut Rand Kirby¹.

On the other hand, Clark Kent is having a tough time. He can’t take his mind of Lois. He changes into Superman and decides to go back in time and fix everything that got Lois mad at him in the first place. He fails spectacularly².

Meanwhile, Lois is assisting her boss Dr. Culver with a new experiment. He’s testing a new “mind gas” that is supposed to turn criminals into upstanding citizens. Either that, or it kills the person. The local prison has allowed Dr. Culver to test the drug on four death row criminals³. The death row prisoners escape and hold Lois hostage. Superman arrives and captures the escapees. During the struggle, Lois is exposed to the experimental mind gas.

The gas doesn’t kill Lois⁴, but it does give her a monster headache and she passes out. When she wakes up, she discovers that she’’s gained the ability to read minds. Peeking into Superman’s thoughts, she discovers that he truly loves her. She realizes that she still loves him and resolves to break up with Rand.

Rand’s parents are in town and are taking the couple out for dinner. Lois decides not to break up with him then, because that would just be tacky. At dinner, she discovers that her telepathy has disappeared but now she has gained the ability to predict the future. She receives a vision of Superman trapped in space by a kryptonite-laden satellite. She knows Rand is the only one who can save him, but Rand’s superiors don’t believe Lois’s story. Then their telescope reveals that Superman is indeed trapped by the satellite, so they decide to send Rand into space to rescue him⁵.

Lois sneaks into the space capsule shortly before lift off and takes the place of the robotic co-pilot.

Lois: I’ve learned all about these space ships while covering launchings for the Planet!

As the space capsule nears the satellite, Lois spacewalks out to the satellite and saves Superman. Rand also leaves the capsule to help Superman. Their air hoses get tangled and now Superman has to save the two of them. Once again, Lois passes out⁶. This time when she wakes up, Rand tells her that he know she really loves Superman and sadly lets her return to Metropolis.

This story deserves an award just for its use of tired plot devices. Death row criminals. Holes to China. Experimental medication. Telepathy and precognition that conveniently resolve by the end of the story. A new fiancee and an old boyfriend. They don’t make comics like this anymore (and that may not be a bad thing).

The “medical experiment” aspect is ludicrous. No respectable doctor or scientist would ever attempt such an experiment. First of all, there are strict requirements for any experiment that uses human subjects. The hospital review board would never approve this experiment — the risks are too high and the benefits too low. Second, the test only involved four subjects; that’s not enough to prove anything positive or negative. For very rare diseases and conditions, small experiments may be a necessity –– but this is a test on “criminal thoughts” — an all too common condition.

---

Notes:
¹How many times has Lois been engaged? I’d be interested in seeing a list. I bet she’s had at least a dozen fiancées at one point or another. I doubt any other woman (or character) in comics has had more.

²This is one of the stupidest things Superman has ever done. In the previous issue he missed Lois’s birthday party because he was smashing junked cars and lost track of time.
Now if you or I had the power to travel in time, it would be a no-brainer: go back and attend Lois’s party. Easy, right? Wrong. Superman decides to go back and smash the cars faster this time. Then he smashes too hard and knocks one of the cars clear through the Earth to China. This sets him behind schedule so he misses the party again. (So what happened to the Superman from that time? Why didn’t he make the party? He wasn’’t smashing cars, because that was the Superman-from-the-future.)

³The leader of these criminals is named “Strangler.” Here’s a hint: never trust someone named “Strangler.”

⁴Nor does it cure her criminal tendencies, as Lois is breaking and entering within just a few pages.

⁵So Lois’s precognition didn’t matter at all. Rand went up in the space capsule anyway.

⁶She does this a lot, doesn’t she?

The summer of 1959 was a heady time in Gotham City. Citizens were flocking to the Gotham Theater to see Charlton Heston in Ben Hur and Bobby Darin was rocking the town with Mack the Knife. And in a small periodical known as Detective Comics #267, the hero known as Bat-Mite made his debut.

Originally from a rural farm town in a small backwater dimension, Bat-Mite had always expressed an interest in Earthly super-heroes. When his parents died in a tragic yeti accident, he packed his meager belongings in a suitcase and headed out for the big city: Gotham.

Bat-Mite’s Brother: He always had his head in the clouds, talking about them super-heroes and skyscrapers. He was never any damn good at growing pumpkins, that’s for sure.

His first appearance was a smash success, and Bat-Mite appeared in Detective and Batman and World’s Finest again and again. He hung out and partied with all the big names: Batman, Superman, Batwoman, Robin and even Bat-Girl.

Mr. Mxyzptlk: That Bat-Mite sure knew how to have a good time. I would meet up with him after work and he always had at least 2 or 3 women draped all over him. He also had a fondness for those fruity foo-foo drinks. I think it was the paper umbrellas, really. He could always make me laugh though.

It seemed that the good times would never end. But end they did.

New management took over DC and decided that the comics needed a new direction. The Golden Age was over. The ship had sailed; the jig was up; the soup had scorched. Batman comics would no longer be humorous and extra-dimensional imps were no longer needed. Batman had his new look and only serious comics would be published in Gotham. Bat-Mite found himself out on the street. His money? Wasted on pink ladies, cheap women, and racehorses.

Ex-Girlfriend: I kept telling him he needed to save his money. Stop betting on those damn horses. Buy a better car. And shave. Would shaving at least once a week kill him? And clean up that apartment — jeez, what a pigsty. And then he accused me of being nag, can you believe it?

The late 60’s and early 70’s were tough on Bat-Mite. He kept auditioning for roles at DC, Marvel, Charlton, Atlas, Quality and even Archie — but nobody wanted a washed-up has-been imp. A few editors took pity on him and managed to squeeze Bat-Mite into a story here and there — but paying gigs were few and far between. His Broadway debut as Woodstock in You’re A Good Man Charlie Brown was lambasted by the critics and he was fired after opening night. He soon found himself reduced to performing dinner theater in Lansing.

One night, Bat-Mite had an epiphany after a particularly rousing chorus of “You Gotta Have Heart” as performed by the Southern Michigan Men’s Dinner Theater Glee Club. He realized that if ever wanted to work in a respectable medium — such as comic books — again he would have to clean up his act and get his life together. He joined Alcoholic Anonymous, Gamblers Anonymous and other unnamed organizations and gave up the booze and gambling. He felt better and was able to lose some weight, but he remained unhappy and unemployed. Even with his new outlook he still couldn’t find any good work. He was offered a recurring role on Little House on the Prairie, but even a washed-up cartoon had his pride. Finally, he packed his mask and cape and headed back to the family farm.

Brother: It was good to have him back, and he sure seemed happy — even met and married a local girl — but he still didn’t know the first thing about pumpkins.

Things seemed to be finally settling down for Bat-Mite. His dreams of stardom were over and he was resigned to life as a farmer and husband. Or was he?

In 1977, Hollywood called. Batman and Robin had been given a new Filmation cartoon show and the producers wanted Bat-Mite to be involved. He was ecstatic.

Ex-Wife: He came into the kitchen, stunned, and I asked him what was wrong. He told me to “Pack my bags ’cause we were going to Hollywood!” I had never seen him so happy, even on our wedding day — he was ecstatic. Of course, as we were heading out to California he casually mentioned that the producers wanted a skinny Bat-Mite, so he started popping diet pills. A few with breakfast, some with lunch, a few more with dinner and a handful with every snack. He was eating them like candy.

The New Adventures of Batman was a hit and Bat-Mite was a star again. He didn’t handle the fame well and soon reverted to his old habits. He bought an expensive car and developed a taste for Fuzzy Navels and fast women.

Ex-Wife: I kept telling him that he needed to slow down or he’d kill himself, but he never listened. After I caught him in bed with Betty and Wilma, I’d had enough and I walked out. I told him, “Just you wait. I’ll get my own show.” He just laughed and chugged down a bottle of Grenadine.

The series ended abruptly and Bat-Mite found himself once more out of a job. The cartoon continued to be shown in syndication, but Bat-Mite found his contract was “work-for-hire” and he wasn’t owed any money. In a booze and diet-pill fueled rage, he stormed the offices of DC comics in 1979 and demanded his own comic. He was quickly escorted off the premises and thrown in a back alley dumpster.

A decade of living on the edge followed. Bat-Mite refused to return to the family farm and admit defeat. He was drinking again, peach schnapps, up to a pint a day. He was still hooked on diet pills and had taken to snorting Benadryl in an effort to calm down. He bounced from relationship to relationship, often getting married and divorced the same day.

Ex-Wife #2: It was horrible! Bat-Mite had this two-dollar-a-day Benadryl habit. I was so embarrassed. After one particularly bad argument at a Grateful Dead concert he threw a bong at me. I was so conflicted: I wanted to leave, but I didn’t want to miss the Dead. So I ended up getting a ride home with Shaggy — now he was a quality cartoon character. Too bad he never got over that thing with Velma.

The slope was getting steeper and steeper and Bat-Mite was sliding down like butter on Teflon. Would he ever recover?

After narrowing avoiding a car accident after accepting a ride with Leif Garrett, Bat-Mite took stock of his life. He quit drinking and cut back on the cigarettes. He weaned himself off of diet pills and Benadryl. He swallowed his pride and filmed a few Burger King commercials and a guest shot on Manimal. That gave him enough money to rent a small apartment and hire a personal trainer. He shed pounds, and more importantly, gained confidence. He swallowed his pride and looked up his old partner, Mr. Mxyzptlk.

Mr. Mxyzptlk:I hadn’t seen Bat-Mite for years, and the last time I had seen him it wasn’t pretty. He was high on Schnapps and antihistamines and kept accusing me of selling out. That’s why I was so surprised when he showed up again on my doorstep clean and sober. He apologized for the past and asked if there was any chance I could get him a job.

Mr. Mxyzptlk pulled a few strings and soon DC comics published the critically acclaimed Batman: Mitefall. Bat-Mite was back in print, and on expensive paper, too.

Sadly, the years of hard living had taken their toll. Just two weeks after Mitefall was released, Bat-Mite was found comatose in his Gotham City apartment. The years of booze and pills had been too much for his liver and he never regained consciousness. He was buried in Gotham Heights Cemetary with a simple headstone that reads: Bat-Mite — Cartoon Imp, Visionary, and Hero to Short People Everywhere.

As part of their post-Congressional hearings “New Direction,” EC put out several new comic series including the one titled Psychoanalysis. The comic is exactly what it sounds like: a comic book in the EC style detailing three patients visiting their psychiatrist.

The psychoanalysis in the comic is a fairly basic take on Sigmund Freud’s philosophies. It all boils down to two concepts: First, everything is the parents’ fault. Second, any mental problem can be cured by psychoanalysis. Granted, this is before there were any effective medications for such problems, but several of these patients would benefit from medication..

The first patient is Freddy Carter. His parents bring him to the psychiatrist and are clear that he is a big disappointment to them because he has been caught stealing from his best friend. His father is a successful engineer and is upset that Freddy won’t apply himself in school or at sports. Instead, Freddy prefers the more artistic endeavors such as music and painting. His mother encourages these activities — wanting Freddy to be “refined,” but his father considers them “sissy.”

After some harsh words for Freddy’s parents, the psychiatrist sits down and talks to Freddy. He explains that Freddy is mad at his father for not letting him do what he enjoys. Also, he is mad at his mother for encouraging him in these activities, thus inviting and worsening the anger of his father. Freddy steals things from his friend because he thinks his friend has the perfect parents and perfect family and subconsciously wants to be a part of it.

The second patient is Ellen Lyman. Ellen is clearly a very anxious person. She is also troubled by a recurring dream. This dream, which is incredibly detailed, recounts young Ellen trying to get into a walled garden. A kilted Scotsman bars the way and won’t let her enter until she passes a written exam. She fails the exam, but sneaks into the garden anyway, only to find it is dead and barren.

The psychiatrist explains that the dream is about her sister. The garden represents her parents’ love and it is sealed off and guarded because she believes that they always loved her sister best. The kilted guard represents her sister (kilt = dress). The test represents the fact that her sister always did better in school than Ellen. Finally, the dead garden represents how bereft Ellen’s life would be if her sister wasn’t in it.

The final patient, Mark Stone, is a successful television writer who is having panic attacks. It turns out that the Mark really wants to be a novelist, not a Hollywood writer. The psychiatrist is able to have Mark realize that his stress is from his fear of success and his acceptance of mediocrity. Mark sticks with the television writing because he fears that he may fail as a novelist, and this conflict is causing his stress and panic attacks.

Makes sense? Sure, but it’s not enough for our Freudian psychiatrist. He digs deeper into the patient’s past and is able to discover that true conflict is the patient’s extravagance versus his father’s frugal ways. Thus it is all the father’s fault.

Although every patient is much better by the end of their session, the psychiatrist reminds the reader that they’ll be able to check back in on the patients in the next issue of Psychoanalysis. The series only lasted four issues, so I hope the patients didn’t need long term counseling.

After the infamous 1950s congressional hearings that attempted to link comic books to juvenile delinquency, EC made a dramatic change in its publishing style. Gone were the Tales of the Crypt and other horror and crime comics. Instead, they published their “New Direction” comics. These comics included several topics not usually covered by comic books, including medicine (M.D.) and psychiatry (Psychoanalysis). Unsurprisingly, these New Direction comics weren’t particularly good sellers and lasted less than a year.

M.D. #3 consists of four medical stories and a one-page text piece. The art is in the usual intricate EC style, though the art in the second story does degrade into parody. The lettering is the classic typeface style long used by EC.

The opening story, “What You Need to Know,” warns us of the dangers of sledding and overprotective mothers. After the other boys tease Tad about being a mama’s boy, he grabs his sled and heads to the top of Snake’s Hill. Sledding down the treacherous slope on a dark blizzard night, he crashes into a tree stump. The other boys find him bleeding and unconscious and flag down a passing trooper. Tad is rushed home and Dr. Yates, the local general practitioner, is called.

Dr. Yates examines Tad and diagnoses him with several fractured ribs and a punctured lung. An operation is needed, but the ambulance can’t get through in the blizzard. Dr. Yates decides to operate on the kitchen table. With help from the trooper and Tad’s father, Dr. Yates begins the delicate operation (Tad’s mother, of course, receives a sedative). Due to skill of the doctor, Tad survives. After the operation, does Dr. Yates lecture Tad about taking foolish risks? No, he tells Tad’s mother that it was her fault for being overprotective.

The second story, “The Right Cure,” concerns Appalachian hill folk and their reliance on questionable folk remedies. An older woman has excruciating abdominal pain and her husband has taken her from herbalist to herbalist with no success. Her daughter wants to take her to a doctor, but the father refuses to take her to “a furriner.” When the pain becomes so bad that the old woman begs her husband to shoot her, the daughter sneaks off and finds a doctor. She brings the doctor to their house and then holds a rifle to her father so he can’t interfere while the doctor examines her mother and takes her to the hospital. The patient is diagnosed with an abdominal cyst and successfully treated surgically. Her husband arrives at the hospital with a shotgun and a mad-on for the doctor, but puts down the weapon when he sees how dramatically his wife has recovered. At the end he tearfully promises the doctor that he’ll never go near a folk healer again.

“Shock Treatment” more than any other story highlights the difference between 21st century medicine and the medicine of the 1950s. In this story, a young man attempts suicide and is diagnosed with manic depression. He is admitted to a psychiatric hospital where he is kept heavily sedated for the next ten days in the hopes that he will forget that he’s depressed and suicidal. When that doesn’t work, he is subjected to electoshock therapy, again so that he’ll forget he’s depressed. Meanwhile, the doctor lays the blame for the patient’s depression squarely on the parents and their constant bickering and fighting.

Treatment of depression has improved by leaps and bounds since this story was written. For one thing, there are very effective antidepressant medications available. It’s true that in some situations electroshock therapy (better known as ECT: electroconvulsant therapy) is still used, but not to the extent it once was. We also know a lot more about the causes of depression, and while family life may complicate the situation, it’s not the root cause. Finally, I should point out that the patient was diagnosed with manic depression (i.e. bipolar disorder) despite the fact that he has never been shown to have experienced a manic episode; major depression is probably a better diagnosis.

The last story, “The Lesson,” concerns a young man who was speeding on a wet road and lost control of his car. He has a few bruises, but his girlfriend suffers multiple broken limbs and a closed head injury. The local doctor arrives at the scene and takes everyone to the hospital. The young man is very apologetic but the doctor drags the him into the operating room so that he can watch as his girlfriend’s broken legs are set and a hole is drilled into her skull to relieve the pressure and remove the clot. At the end we learn the reason the doctor insisted the young man witness the operation: his girlfriend was the doctor’s daughter.

There is a single page text piece about Dr. Ignaz Philipp Semmelweiss. Back in the 18th century, Semmelweiss was the first physician to realize that washing hands between patients saves lives, particularly in the maternity ward. Semmelweiss is an interesting character and deserves a post of his own at a later date.

M.D.s are entertaining to read but are clearly a product of their time. As best illustrated by the first story, a not-so-subtle sexism exists in many of the stories. The practice of medicine has changed a great deal in the past fifty years. While some rural general practitioners still perform emergency surgeries, most have long abandoned this practice. House calls are also a thing of the past, mostly for monetary and time-related reasons. Medication and surgeries are much more reliable and effective now. There are reasons to look back fondly on this era, but I much prefer the current state of medical care.

A villain takes the penultimate spot on the list of Comic Book Doctors Who Actually Practice Medicine:

#2 – Hush

I have no love for the character Hush. He’s the boy-band of Batman’s villains. Determined to make a hit, DC pre-packaged Hush and delivered him to the public without any thought to actual ability or talent. His powers? The awesome power of neurosurgery! His outfit? Cribbed from the Unknown Soldier. His origin? Decide for yourself:

Thomas Elliot was a childhood friend of Bruce Wayne. They lost touch after Elliot’s parents were killed in a car accident. Along the way, Elliot attended medical school and finished a neurosurgery resident, becoming The Best Neurosurgeon in the World!* Sadly, the money, wine and women that every neurosurgeon has (let alone The Best Neurosurgeon in the World!) were not enough…he wanted revenge! It seems that Elliot blamed Thomas Wayne for the death of his parents. Not because Wayne killed them, but because he couldn’t save them. Thus he decided to come to Gotham City and get his revenge on Bruce Wayne and Batman.

Still, for all my dislike of Hush as a villain, I have to admit that he’s an effective doctor. He uses potent anesthetics to kidnap Alfred, he heals Poison Ivy, and he performs delicate life-saving surgery on Prometheus in a hotel room.

As a villain, he leaves a lot to be desired, but as a doctor? He’s The Best Neurosurgeon in the World!

*The phrase “The Best Neurosurgeon in the World” is ™ and © PoliteDissent.

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Tags: comics medicine hush thomas elliot batman neurosurgeon

The final issue of the Hawk & Dove mini-series starts with the origin of the new Dove. Dawn Granger was in London during the time of the “red skies” (i.e. the Crisis on Infinite Earths). Her mother was held hostage by a group of terrorists who had taken over the American Embassy. Desperate for a way to save her, Dawn hears voices that promise her the power to restore order (or should that be Order?) when she says the word “Dove.” Changing into Dove, she captures the terrorists and rescues the hostages. She then decides to return to America to find Hawk. Ultimately, Dawn is able to link Hawk and Hank Hall and enrolls at Georgetown to track him down.

As Dawn and Hank are sitting in Hank’s apartment talking, his parents let themselves in. They of course immediately assume that their little Hank has found himself a girlfriend. Despite the protestations to the contrary, the Halls invite Hank – and Dawn – to dinner at their house the following evening.

It turns out that the Halls weren’t the only one who barged in on Hank and Dawn; one of Kestrel’s demons was listening and threatens Hank’s parents if Hawk and Dove don’t show up at the same warehouse where they first met.

The pair arrives at the warehouse but find it empty. Hawk discovers a mysterious door in the wall that Dove can’t see at all. They enter the doorway and find themselves in the Chaos realm. Dove’s order-based powers are weaker there and she is having problems concentrating. Hawk, on the other hand, finds himself strengthened. They’re not alone in the Chaos realm — Kestrel is there as well. He taunts both Hawk and Dove, but finds particular delight in harassing Dove. She manages to lead Kestrel directly into Hawk’s path, but the chaos has so enraged Hawk that he is as willing to fight Dove as Kestrel. Trying to convince Hawk that he’d be better off without Dove, Kestrel tells him that he and Hawk would make better partners; that they’d be “blood brothers.” This reference to “brothers” reminds Hawk of his brother Don and this immediately calms him down. Finally realizing and admitting that Dove is his partner, Hawk and Dove agree to take down Kestrel once and for all. At this point, the Lords of Chaos realize that Kestrel has failed – he was unable to tempt Hawk to Chaos. The Chaos realm collapses around Hawk and Dove and they find themselves back at Hank’s apartment.

That evening at the Hall’s house as she is talking to Hank’s mother, Dawn realizes that she received her powers before Don died, and she begins to wonder if he died because she was given his powers. She wonders if maybe there was some truth to the “experiment” Kestrel had been ranting about. On the walk home, Hank does his best to reassure her. They encounter Ren, who finally gets Hank to agree to take her out on a date. The series ends as Hawk and Dove chase after a mugger with Ren exhorting them to be careful and make sure they’re back by Friday.

This issue is a fitting end to the mini-series. It establishes the new Hawk and Dove status quo but leaves questions open for exploration later. The Order/Chaos dichotomy is handled well. Dove is weaker in the Chaos realm and is unable even to see the door that leads to it. Hawk becomes stronger when exposed to Chaos – a point that will be revisited in the second year of the subsequent series when the definitive origins of both Hawk and Dove are given (and Kestrel returns).

There are other nice touches as well. The interactions with the parents are handled perfectly, and this continues into the following Hawk & Dove regular series. Crisis on Infinite Earths is referenced, but never explicitly mentioned. This allows new readers to enjoy the story without missing a beat, but allows us old time DC readers a smile. I like the fact that Kestrel remembers how Dove fights and tries to use that against her. Dove, however, anticipates his anticipation and leads him into a trap. For all the time the same heroes and villains fight in comics, you think you’d see more of this recognition of style.

The second issue starts with Hawk confronting a gang of crooks, as well as the new Dove, in a warehouse. Refusing to accept that there’s a new Dove, Hawk attacks her — or at least he tries to. She manages to elude him and along the way they manage to K.O. every criminal. She leaves reminding him that while Don may be dead, Dove isn’t.

The next morning, Hank meets up with Kyle, Donna, Ren and Dawn. He figures one of the girls must be the new Dove, so he starts questioning them, trying to discover who it is. Unfortunately, his questioning is along the lines of “So, Donna – is that your real hair?” and his results are about as dismal as you’d expect.

That evening, Hank joins his parents for dinner at the French restaurant Le Parc (where he orders “A cheeseburger and fries. American Cheese.”) A commotion develops in the restaurant when Dove starts fighting a team of small time thugs across the street. Hawk intervenes and then accuses Dove of following him. She just looks away and refuses to answer. “Get out of Washington,” he tells her. “If you know what’s good for you.”

Hank runs into Kyle and Donna at a local diner the next morning. Dawn and Ren join them a few minutes later. Ren tells them she had been photographing the massacre that had occurred at Le Parc restaurant the previous night. Looking at her photos, Hank realizes that the massacre is somehow connected to the gang he had fought at the warehouse. He excuses himself and runs over to the warehouse. Kestrel, however, has arrived there first and quickly captures him.

The third issue opens with a full-scale battle between Hawk and Kestrel that rages through the Smithsonian Air & Space Museum. Hawk finds Kestrel his toughest opponent ever. He’s quickly battered and bruised and even breaks his hand while punching Kestrel. Hank drops an airplane on Kestrel then hides in a closet, waiting to change back to Hank so he can escape. A good idea, but Kestrel finds him first and decides to finish the fight once and for all. Luckily, Dove chooses that moment to intervene. She grabs Kestrel’s arm and flips him away. Kestrel chases after her, but she’s always manages to stay one step ahead of him. Too late, Kestrel realizes that Dove has led him far enough away from Hawk so that he can change back to Hank.

Kestrel hasn’t given up. He breaks into the police station and releases Shadowblade, the leader of the thugs Hawk and Dove defeated the night before. In a Faustian bargain, Kestrel promises the young thug power. The next morning, the new and improved Shadowblade leads a team of gunmen in an attack on the Georgetown campus designed to flush out Hawk and Dove.

These two issues continue the theme of introducing the new Dove. It’s understandable that Hawk doesn’t want a new Dove because he doesn’t want anything to tarnish his brother’s memory. Clues are given to the new Dove’s identity, but plenty of red herrings are strewn about as well. Kestrel finally meets the pair, and it is clear that he shares some connection to them and their origin. The terms Order and Chaos are bandied about and a mystic “experiment” of some kind is mentioned. Some of this is explained in the mini-series, but the true nature of Hawk and Dove won’t be fully explained until the second year of the subsequent Hawk & Dove series.

The Kesels remember that Hawk and Dove can only be in costume when danger is present, a fact many previous writers had ignored. They actually use this as a plot point. Hank is shown to be a good fighter, but also clever enough to know when to escape. Unlike the first Dove, these issues make clear that the new Dove won’t avoid a fight, but she tries to end it quickly as possible by using her brains. She also sees the big picture: she doesn’t have to defeat Kestrel in combat, just lead him away from Hawk.

The pencils by Liefeld continue to be quite good overall. Still, some of the “quirks” that will dominate his later art can be seen starting here. He was drawing excellent backgrounds in the first issue, but by issue three, fewer and fewer panels have drawn backgrounds. He also starts using more stock poses in these issues (like the Art Adams “girl standing with one hip thrust out”).

In 1988, Hawk and Dove got a new lease on life following with a mini-series and a subsequent regular series from the Kesels (Karl and Barbara). The mini-series introduced a new Dove — a female Dove — into the DC Universe. For better or worse, this mini-series also introduced Rob Liefeld. Today I’ll take a look at the first issue of the mini-series, with subsequent posts covering the later issues.

In the twenty years since the first appearance of Hawk and Dove in Showcase #75, a great deal had changed about the country. The Viet Nam war was long over. Watergate had come and gone. Mobile phones weighed fifteen pounds and Ronald Reagan was just finishing his second term of office. The original pro-war/anti-war stances of the characters were just a quaint reminder of times past. Various writers had tried to update the characters with varying levels of success. To one writer they represented violence versus pacifism and to another they were conservative versus liberal. None of these concepts translated particularly well to the comic book medium however.

In 1988, a new Hawk and Dove mini-series was released that took a new approach to the characters. This time Hawk represented Chaos while Dove represented Order. There was some underlying connection between the characters, but that was just hinted at during the mini-series. This concept of the characters was an entirely new approach, yet tied into established DC history, particularly the ongoing war between Order and Chaos. This approach also allowed more flexibility to the duo: Hawk could reason and Dove could fight without acting out of character.

In this mini-series, Hawk and Dove also got something they’d never had before: an arch-villain. In their own title, Hawk and Dove only fought a costumed villain once, and then he was just a cat burglar dressed up as, well, a cat. In the new series they got Kestrel. He had abilities suspiciously similar to theirs and a very similar costume. Where Hawk’s outfit was red and Dove’s was blue, Kestrel wore purple (red + blue = purple). Kestrel showed up to bedevil the duo on several occasions and it’s been hinted that he’s in the Injustice Society, though I don’t think he’s actually been in there¹.

Hawk & Dove #1 takes place shortly after The Doom Patrol and Suicide Squad Special #1 where Hawk was held prisoner in Nicaragua. Now back in the United States, Hank is chagrinned to discovers that his parents² have enrolled him in Georgetown³ to “get him back on track”.

Most of the first issue is spent introducing the main characters. Hank – and Hawk – are reintroduced and the origin of Hawk and Dove told in flashback. Readers are also introduced to “Georgetown’s Olympic marathoner hopeful” Kyle Spencer and his girlfriend Donna Cabot⁴. Donna’s photographer roommate Ren Takamori shows up and takes a quick shine to Hank. Finally Dawn Granger literally stumbles into the group one night. These five characters make up the basis of both this mini-series and the regular series that followed.

There is plenty of action in this issue as well. Kestrel shows his skill at vivisection as he works his way up from Nicaragua searching for Hawk. Speaking of Hawk, he manages to foil a robbery as well as a mugging. As the issue ends, Hawk again encounters the first group of robbers, but is stunned when the new Dove also appears.

Karl and Barb Kesel did a good job creating memorable characters. Each individual is unique, yet no one is stereotyped. While remaining true to the spirit of Hawk and Dove⁵, they manage to set up an effective mystery that plays out over the following four issues: who is the new Dove?⁶

The art by Rob Liefeld is actually quite good. True, his characters all seem to have that weird angled smile, but the outrageous anatomy and lack of continuity that have come to characterize his current art is all missing. It also helps to have the accomplished inks of Kesel overlying his pencils.

This series can be found inexpensively on eBay, and there was a trade paperback⁷ out at one point too.

---

Notes:
¹ Kestrel was shown as a member of the Injustice Society in one of the Secret Files and the recent DC Encyclopedia.

² Why Judge Hall — a small town judge last seen in Eldon, Oregon – is now serving as a judge in Washington D.C. is never explained. Maybe he’s a Justice on the Supreme Court. If the DC Universe can have Luthor as President, and Talia and Sgt. Rock on the Cabinet, then Hall can be on the Supreme Court as far as I’m concerned.

³ How Hank, always described as a mediocre student at best is accepted into Georgetown remains a mystery. Maybe his dad’s an alum, or maybe having a father who is a Supreme Court Justice carries a lot of weight.

⁴ If there’s one noticeable flaw in the Kesels’ characters is that sometimes they just seem too perfect. Kyle is an Olympic hopeful, Donna is a pro tennis player and so on. It’s just a small issue, but it becomes a little distracting at certain points in the regular series.

⁵ About halfway through the issue, there is a nice scene where Hank meets Linda on the campus. Don’t remember her? She was the girl Don was trying to hit on in The Hawk and the Dove #3, but who actually went home with Hank. Here she reminisces about how great Don was (apparently forgetting that she chose his brother over him) and then accuses Hank of missing his brother’s funeral. I’m pretty sure Hank is at the funeral (that’s why I scanned in that panel all those months ago, just to make this point) – I think the Kesel’s are just trying to tighten up the timing a little. And what’s Linda doing in D.C. anyway? Did the entire town of Eldon move out there?
(Finally, for all you complete continuity buffs, Linda is Hank’s wife in the non-canon appearance in The Brave and the Bold #181)

⁶ Now we all know who Dove is, but it was a well done mystery with good clues and some clever red herrings when the book came out. As for who Dove is: Princess Projectra⁸.

⁷ I noticed that they fixed the tennis error when printing the trade paperback (Wimbledon is now correctly identified as having grass courts), but a few coloring errors were left in, as was a panel where the word balloon are mis-assigned (but I’ll get to that at a later date).

⁸ Oops. That’s the solution to the mystery of who Sensor Girl was. The new Dove is Kara Zor-El.

This week’s Justice League Unlimited episode, the Gail Simone penned “Double Date”, was a fun half-hour featuring returning favorites Green Arrow, Black Canary and Question plus new favorite the Huntress.

The first scene where two mob enforcers are discussing the proper way to cook scones let’s the viewer know that Simone’s trademark humor would be in this episode, and there were several laugh out loud moments (plus a great deal of action) throughout the show.

The Huntress is after Mandragora, the mobster who killed her parents. Mandragora, however, in is federal custody (King Faraday’s, to be precise) because he claims he’s turning State’s evidence. In addition to the federal agents, Black Canary and Green Arrow are also assigned to guard him. Meanwhile, the Huntress cons the Question into helping her find Mandragora so she can kill him. Arrow and Canary intercept the Huntress and Question and stop them from killing Mandragora. During the battle, he manages to escape from custody and both sets of heroes track him down, and both manage to find him at the same time. I can’t say more without spoiling the ending.

Amy “Fred” Acker provided the voice for the Huntress, making this episode an all Joss Whedon episode for the female voice actors (Morena “Inara” Baccarin provides the voice of the Black Canary).

I didn’t get a chance to say anything about last week’s episode, the Hawkgirl-Wonder Woman buddy flick “The Balance.” It was an enjoyable half-hour, but it’s clear Faust isn’t much of a tactical thinker when he sends his second worst enemy to the place where his worst enemy is chained up, apparently never considering the fact that his enemies will join forces and he’ll be facing his two worst most powerful enemies together. No great loss to villainy there.

No medical review in this week’s Lois Lane Friday. Instead, I’m going to take a look at Superman’s Girlfriend Lois Lane #121 and the debut of the “new look” Lois.

Superman’s Girlfriend Lois Lane #121 “Everything You Wanted to Know About Lois Lane * But Were Afraid to Ask!”
Cary Bates, writer
Werner Roth, penciler

The cover is wonderful, but unfortunately there is no scene even remotely resembling that cover in the comic. Sigh.

Distraught over the death of her sister Lucy¹, Lois Lane wanders the streets of Metropolis for days on end. At one point, a young woman named Julie saves her from muggers. Only when Julie’s life is threatened by these muggers does Lois finally wake up out of her funk.

Later, as Julie and Lois are talking in her parent’s apartment, the landlord comes by and tells them that unless Julie can pay the rent, her parents will lose their apartment. It seems that her parents and all the other elderly couples in the apartment building received brochures from a retirement village called “Paradise Haven.” A bus from Paradise Haven was sent to pick up the retirees, but they never returned. The police have no leads².

At this point Lois decides that she needs to rededicate her career as a journalist to helping others. She quits the Daily Planet and starts work as a freelance reporter. She shows up at the Planet office in her new hairstyle and hip-70s outfit to tell Perry, Clark and Jimmy she quits. On the way out, she tearfully breaks up with Superman, telling him she’s no longer “the girl he comes back to between missions.”

Her first job as a freelancer is to discover what happened to Julie’s parents. She digs through old papers and finds out that their landlord is a former con artist. She dresses as an old lady and threatens to blackmail him unless he cuts her in on the deal. He flies her out in his helicopter to Paradise Haven, which is really just a row of shacks in the desert. He then revels that he knows that she’s an imposter and not an old lady because she’s wearing sexy fake eyelashes. “Oops! This is the kind of mistake that can get a girl killed!” thinks Lois as she is pushed out of the helicopter.

Superman arrives just in the nick of time to save Lois. He rips the blades of the helicopter and knocks out the landlord. Just then an earthquake hits Paradise Acres and he flies down to help. In my favorite scene, he tells Lois to take control of the helicopter – that’s right, the helicopter he just ripped the blades off of.

Superman is able to rescue the elderly couples and makes an astonishing discovery, the land Shady Acres is built on is loaded with uranium – they’re rich³!

Lois returns to Metropolis and decides that since she’s no longer a star reporter, she needs to take in some roommates. Julie moves in with her, along with the mysterious Kristin Cutler and the Rubenesque Marsha Mallow⁴. These roommates remain characters in the comic until it is finally cancelled with issue #137.

¹ Lucy disappeared over a waterfall while in a canoe in South America. Superman could find the ruined canoe, but no sign of Lucy. He believes her dead, but I believe to be in The Land of the Lost.
²Exactly how hard is it to find a large bus full of retirees?
³I wonder how this uranium find made the older couples rich. They had never actually bought into Paradise Haven, they were just touring it. The crooked con man still own the land — so he’s the rich one.
⁴I think some people are just doomed to be chunky from the day they were born. With a name like “Marsha Mallow” what chance did she have? She sould changer her name or at least sue her parents.

Superman #362 “The Last Days of Lois and Lana!”
Superman #363 “The Dying Day of Lois and Lana!”
Cary Bates, writer
Curt Swan, penciler

While at a museum preparing for an interview, Lana Lang accidentally drops an ancient Venetian glass vial. Unbeknownst to her, this vial contained a deadly microbe and now Clark Kent, Lois Lane and Lana have all been exposed. The germ is strong enough to get through Clark’s invulnerable skin, but he notices it in time and manages to burn it away with his heat vision. He also destroys all the remaining microbes so no one else can be affected.

Looking closer at the microbe, Clark realizes that it is the same tropical plague that Ma and Pa Kent contracted on vacation one year.

Doctor #1: Your parents are exhibiting symptoms of a rare tropical fever plague that hasn’t claimed any victims in well over a century.
Doctor #2: It’s contagious…but only to adults!

The doctors and Clark a tried everything they could to save the Kents, including a transfusion from Superboy. Nothing worked and the disease killed Ma and Pa Kent (clearly this was before the Byrne reboot).

At his Fortress of Solitude, Superman performs a computer search with his computer, but there is no known cure for the disease. There are no answers in the medical records of other planets either. He talks to Luthor in prison who assures Superman that he can concoct a cure, but he refuses just to watch him suffer. Superman decides to send the girls into the Phantom Zone until he can find a cure, but once again the criminals there manage to block his access to the zone. Finally, he travels far into the future figuring that they will have cured the disease by then. They do have the cure, but they also refuse to share it with him because it may upset the time stream.

Traveling back to the 20th century, Superman has a revelation. The reason his blood didn’t help his parents was because he had not been infected by the germ and therefore made no antibodies against it. Now, he has been exposed to the microbes and his blood has made super antibodies against it. He transfuses his blood into both Lois and Lana and they are almost instantly better (though not super powered this time).

Not a bad story, but it does raise some questions. I can accept the fact that a germ can lay quiescent for many years, but what was a tropical fever germ doing in a Venetian glass vial? Also, if the plague is so deadly and contagious, why doesn’t Superman quarantine Lois and Lana when he realizes they’re infected with the disease? How many other people were infected because he chose to wait until they showed symptoms? Why does the disease affect – and infect – only adults? Sure, some common diseases are worse in adults than children (Chicken Pox, for example), but it’s contagious to all ages – children just seem to handle it better.

I will admit that Bates is clever in his writing this time, using the generic “microbe” or “germ” and never identifying the plague as a bacteria or virus.

Finally, by 1981 when this story was published Superman had been in print for 42 years – surely somewhere in that time the Clarks Kents had a more dignified death than this.

This week’s Lois Lane Friday story is full-length tale from Superman’s Girlfriend Lois Lane #90: “Lois Lane’s Future Husband.” As is common with these Lois Lane stories no writer is credited, but the art is by Irv Novick and Mike Esposito.

Experiencing some strange dizzy spells, Lois decides to take a few days vacation at her parents’ house in the country. While there, she has another dizzy spell and is rescued by a local doctor named Rick Darnell. He takes her back to his house and shows her around. Lois is smitten with the handsome doctor and they agree to meet up the next afternoon for a date.

While on their picnic date, Rick and Lois encounter a rockslide. An injured woman tells them that her husband is still trapped by the slide. Lois climbs the hill and finds the man complaining of chest pain and shortness of breath. She radios back to Rick.

Lois: I’ve found him…but he looks to bad off to be moved! I think he’s having a heart attack! Rick — this man could be dying!
Rick: There’s one chance to save him. Listen closely and follow my instructions! There’s a secret technique I’ve developed…first find the hollow at the base of the patient’s neck…then search for the hidden nerve behind…
Rick: You’ve located the ganglionic center? Good! Now massage the area firmly — to stimulate a feedback reaction through the neural junctions…
Man: The pain – it’s gone! I can breathe freely now! And my strength is coming back!”
Lois: It’s a miracle! A medical miracle!

After a brief kiss, Lois confronts Rick about his secret lifesaving technique. He admits to Lois that he is really from another planet, one much more advanced than Earth. He shows Lois some of his machines, including the Plastimold that would transform Lois in the infamous Superman’s Girlfriend Lois Lane #106. When she asks Rick which planet he’s from, he tells her that he’s from Krypton and his real name is Dahr-Nel.

It turns out that Dahr-Nel’s father was a brilliant scientist who had invented a time scanner and a time machine. Using the scanner one day, Dahr-Nel saw an image of Lois Lane and fell instantly in love with her. When his father discovered that Krypton was doomed, he convinced Dahr-Nel to use his time machine to travel to Earth. Trying to steer the time machine, Dar-Nell zoomed in several times on Lois Lane (which explains her dizzy spells) and finally landed and set up shop by her parents. With the truth out, he asks Lois to marry him and together they can travel to the future to start a new life. Lois tells him to give her one last date with Superman to decide which man she wants to marry.

Unfortunately for Superman, his date with Lois is a disaster. He pretends to marry Lois in order to trick a crime boss into making an attempt on her life. A brilliant plan, except that he forgot to tell Lois that the wedding was fake. Furious, she runs back to Dahr-Nel and agrees to marry him. They climb in the time machine, which Dahr-Nel discovers was damaged when it landed on Earth. Dahr-Nel proposes to use a special sleeping gas to put them in suspended animation for two hundred years. Lois falls asleep instantly, but Dahr-Nel seems unaffected. He reasons that it must be his Kryptonian invulnerability, so he flies to Superman’s Fortress of Solitude, breaks in and steals some Kryptonite. Returning, he is relieved to discover that the sleeping gas works while his is in close proximity to the Kryptonite.

Superman trails the person who broke into his Fortress and stumbles across Lois and Dahr-Nel. Believing that he has lost her forever, he punches the hill side. The sound of his punch rouses Lois from her slumber: “Superman…weeping…for me! I must go to him!” After a moment of indecision she decides to return to sleep alongside Dahr-Nel, but Superman refuses to let her return. She rushes past him into the machine and discovers what Superman saw with his x-ray vision: Dahr-Nel is dead. A reaction between the Kryptonite and gas turned his body to crystal and killed him. Superman builds a tomb for Dahr-Nel and then flies back to Metropolis, Lois in his arms.

Superman: I’ll try to make it up to you, Lois! Someday you’ll really be Mrs. Superman!

I’m assuming everybody already knows this, but Rick’s so-called secret techinque is nonsense. While there are some key nerves in the back of the neck, none of them have anything to do with the heart. A heart attack (which we doctors like to call a “myocardial infarction” – mostly to sound cool and impress the women) is caused by a sudden lack of blood flow to part of the heart. To treat a heart attack, blood flow to the damaged part of the heart needs to be restored quickly. No amount of nerve stimulation is going to do this.

Admittedly, stimulation of the parasympathetic nervous system could slow down the heart, reducing its need for oxygen and slowing the heart attack – but this still wouldn’t result in the miraculous recovery experienced by the patient (plus the parasympathetic system is located deep in the body, not in the superficial neck).

My only conclusion is there must be some secret nervous system that we humans have not discovered yet, but the Kryptonians have. This would explain not only Dahr-Nel’s miraculous heart technique, but also explain how Superman could so conveniently render Lois unconscious through his secret nerve pinch — as he did so often in his earliest adventures.

When you think about it, the whole concept of a “secret technique” to save someone’s life is ludicrous. If this technique will save lives, why keep it a secret? What’s Rick going to do, make the patient sign a non-disclosure agreement before he saves their life? Tattoo a copyright sign on their neck? I’d be seriously concerned about his ethics if I were Lois.

Speaking of Lois, good lord is she fickle! I’ve chased Superman for thirty years, but because he pulls a trick on me (like he’s never done that before), I’m going to marry someone I’ve just met. Oh well, that person’s dead, I guess I’ll start chasing Superman again.

I’m down to St. Louis for the weekend, visiting my parents in the land-of-not-even-dial-up. In the meantime, remember that while the NHL may have canceled it’s season, minor league hockey lives on!

Also, tomorrow afternoon is the Daytona 500, the first race of the NASCAR season (and oneof my least favorites, actually. While I like the history of the race, I’ve never enjoyed restrictor-plate racing — and that goes double for Talladega)

Back tomorrow night!

I know I’ve mentioned it before, but rashes have always intrigued me. How can the skin behave is so many peculiar ways? It’s fascinating stuff.

I’m always pleased when there is a patient with the chief complaint of “rash” on my schedule, and today was no exception. I knew the patient well; he was a fun two-and-a-half year-old with good parents.

The medical assistant checked the family in and then brought me the chart.
“What’s the rash look like?” I asked.
“It looks like worms,” she said.
“It looks like he has worms under his skin?” I said, wondering were a Midwest toddler would contract cutaneous leismaniasis.
“No,” she hurriedly corrected. “It’s a flat red rash on his arms and legs that’s all twisty and turny like a worm.”

I entered the exam room. The patient was sitting in his mom’s lap, flipping through one of the comics I keep in the room. He was playful and happy (always a good sign) and seemed to have a slight runny nose. The back of his forearms and the front of his legs showed a prominent lacelike deep red rash. It had a definite serpiginous quality to it, and I could see why my medical assistant would think of worms. There was no evidence of scratching, and other than the rash and the runny nose, the patient looked good.

“It started about four days ago,” his mother said. “At first his cheeks looked bright red, like they were wind-chapped. That faded and now this rash appeared on his arms and legs/”

There was no doubt about this rash: it was a classic presentation of the common viral illness Erythema Infectiosum, better known as Fifth Disease or Slapped Cheek Disease. Caused by Parvovirus B19, it is generally a very mild illness that doesn’t require any treatment. A child infected with Fifth disease usually develops bright red cheeks early in the course of the infection. These fade and an unmistakable lacelike rash shows up on the limbs and trunk several days later. Minor cold-like symptoms are common. The only real risk occurs if a pregnant woman is exposed to the disease, because the virus can cross the placenta to the fetus.

The derivation of the name Fifth disease is interesting. Back in the old days (the old old days — when germ theory was just being formulated), many physicians had noticed that while rashes sometimes appeared on their own, they were often associated with sickness. These illness associated rashes occurred in two broad categories. The first was the pox diseases — chickenpox, smallpox and cowpox. The second category was “everything else.” Not knowing what else to do, they took this group of diseases and numbered them, one through six. Over time, the number designations have given way to more common names, except for erythema infectiosum, which is still better known as Fifth disease.

First Disease — Measles Second Disease — Scarlet fever Third Disease — Rubella (German Measles) Fourth Disease — Duke’s disease (we’re not really sure what this was. Maybe a staph infection or an enteroviral infection) Fifth disease — Erythema Infectiosum Sixth Disease — Roseola

images scrounged from the web and do not show my patient

I hope everyone had a good Christmas! I’m down in St. Louis with my not-even-dial-up-access parents, so this will probably be it today in terms of posting.

I’m just going to relax, read some good books and comics, eats lots of rich food, and watch hours of bad TV. Here’s wishing you the same!

Some Christmas Social Tips, and other Holiday Hints, from Polite Dissent:

• If you plan on wearing a tie, a half windsor knot looks classier than a four in hand.
• A well designed Christmas display should cause neither seizures nor migraines.
• Vodka and tonics should be served with a twist of lemon, not lime.
• Real eggnog does not come in cartons.
• I stilll don’t think the whole Rudolph story is true. Sure, a lighted nose would be helpful when flying at night — with good weather. But in the “worst storm of the century” not even the most powerful halogen lamp is going to allow Santa to see any better in a raging blizzard, let alone a small red nose. I’m skeptical.
• Speaking of Rudolph, please do not sing those ridiculous “between-the-line” lines in Rudolph the Red-Nosed Reindeer. You may have thought that they were hilarious in kindergarten and first-grade, but they weren’t…not then and not now.
• Despite what your teacher and parents told you, poinsettias are not particulalry poisonous. On the other hand, mistletoe is.
• Bourbon is never an appropriate gift for a three year-old.
• I’m glad you remember that the fifth day of Christmas is “Five Golden Rings,” but when singing, please remember that it’s a Christmas carol, not a college fight song.
• If your power bill doubles during December, then you probably have too many Christmas lights.
• Bumbles bounce.

Short answer:

• I am opposed to labeling comic books.

Longer answer:

• Labels make it too easy to treat comics (or movies or music) as stereotypes, not as individual works. This is a “violent comic,” this is an “erotic comic” or this is a “foreign comic featuring characters with unnaturally large eyes.” People see the label and think they know they all need to about a book. This tendency to label creeps into medicine too, but I had it beat out of me at an early stage in my career.
• Labels are uninformative. Wanted and Watchmen both contain violence and sex and would undoubtedly be labeled as such, but they are as different as night and day.
• Labels are arbitrary. For example, the movie Angel Heart was originally given an X rating. The producers appeased the MPAA board and earned an R rating by cutting 10 seconds of a female backside during a sex scene. Ten seconds! How much did that matter — and it was her back, not even the most interesting part! I could see this quickly degenerating into a number scenario: two acts of violence earns this rating, three to eight violent acts earns this label, and anything over nine — look out!
• Labels serve as a crutch. Too many parents blindly decide that all works with or without certain labels are fine for their children. This is a breach of their parental responsibilities. It is imperative that parents should decide what works are right or wrong for their children. Labels, or some anonymous “label board” should not decide for them. It amazes me that any parent would purchase (or allow their child to purchase) a comic named Deadshot and be surprised that it features violence. These are probably the same parents who are shocked — shocked, I tell you! — that a game titled “Grand Theft Auto” showcases criminal activity.
  Not just parents use labels as a crutch, but businesses as well. Some stores won’t carry titles with a certain label, regardless of the actual content of the work and whether or not the label is actually deserved.
• Labels rarely work. How many news stories have been aired about kids being able to buy games and music rated “mature” without any age check or parents present?
• Labels are aesthetically unpleasing. Where would labels be placed on comic books ? The front is already crowded enough. The back is advertiser territory. The inside? There might be violence or sex on that first page! Who’s going to look inside to find a label, anyway?
• Labels are decided by someone who is not me. I am the most important arbiter of what is right, or not right, for me and my children. Not other people. My views are what count, not theirs.

It’s been a mostly quiet day today at the 90% House. While we made time to watch the dinal NASCAR race of the season, we have spend most of the day cleaning and getting ready for the arrival of both sets of parents for the Thanksgiving holiday.

It seemed like a good idea at one point.

Sunday Blog-o-Bits:

• I picked up issues 1 and 2 of Dorothy (ordered them from the company, actually). The comic has a distinct look to it and presents an interesting twist on the Oz story. I’ve definitely enjoyed it so far. The Polite Wife enjoyed it too, and she’s very picky in her comics reading.
• The International Comics Art Association is having a contest to a limited edition hardcover of Visual Storytelling: The Art and Technique.
• Ian over at the Brill Building has a clever idea. Pre-packaged pull quotes and cover blurbs. Just what today’s busy comic publishing executive needs! (I also just realized I had him listed under Medical Blogs, not Comics Blogs. Nice try Ian, but you can’t win a Medblog award that easily!)
• For all of those who enjoy Dorian’s stories of customers gone mad, make sure you check out Acts of Gord. It’s a very funny website authored by a guy who once ran a video game store up in Canada and what he had to deal with on a daily basis.

Time travel stories are one of the staples of comic books. Characters travel up and down the time stream from the distant past to the far future. Almost every character or team seems to have traveled in time: the Flash, JSA, Birds of Prey, Avengers, JLA, X-Men and even the New Warriors.

Stories set in the near future are almost always an interesting read because they show a glimpse of how a character’s life might turn out. This is the reason almost all DC’s Armageddon 2001 Annuals were good — unlike the mini-series itself, and unlike most other themed annuals. Stories set farther in the future are not always as good becuuse the writer needs to establish a frame of reference so the readers can relate to the new setting. Sometimes this is done well (almost all Legion of Super-Heroes stories); sometimes it’s not (the DC One-Million stories). Most comic book futures seem to be portrayed as dark and grim, and the heroes must work to prevent that particular future from occurring (a la Days of Future Past). Rarely have there been any particularly happy futures.

Time traveling to the past presents its own complications. That whole concept of whether changes made in the past will affect the future is always a stumbling block. The trouble with most of these time travel stories is that they don’t change the status quo. Admittedly, sometimes the entire story is set up so the heroes have to fight to maintain the status quo (the “Must Shoot Abe Lincoln” issues of Plastic Man are probably the best recent example.) Have there been any comic stories where characters have traveled into the past and actually significantly changed things in the present? Like Marty McFly did in Back to the Future — he ended up with cool parents and a new truck. Has that ever happened in comics?

Manhunter #3 “Dark Shadows”
Marc Andreyko, writer
Jesus Saiz, artist

At the end of the previous issue, Kate Spencer’s son Ramsey injured himself while playing around with her crime fighting equipment. In the beginning of this issue, he’s rushed to the hospital by ambulance.

Paramedic #1: What’s his status?
Paramedic #2: Boy, age 6, suffered severe force trauma in an explosion. B.P. is 60 over 80 and falling. Possible internal bleeding and…

This is an impossible blood pressure. The top number in the blood pressure is the systolic blood pressure. This is the blood pressure when the heart is beating. It is the maximum arterial pressure. The bottom number is the diastolic blood pressure –the blood pressure when the heart is relaxed. It is the minimum arterial pressure. An average blood pressure is 120/80. For an adult, anything over 140 systolic or 90 diastolic is considered high blood pressure (though we call it hypertension because it sounds cooler). Looking at the scene from Manhunter, Ramsey’s blood pressure is 60/80. In other words, his maximum blood pressure is lower than his minimum blood pressure. The paramedics probably just switched the numbers around, but it’s an impossible blood pressure as it’s written.

Doctor: Ramsey has suffered a severe concussion.
Kate: Meaning what exactly?
Doctor: Meaning that he is experiencing some severe brain swelling. The drugs we’re giving him did not slow it down, so we had to perform brain surgery to relieve the pressure in his skull.

A concussion is also known as a mild traumatic brain injury. There are a variety of definitions for concussion, but the simplest is a post-traumatic alteration of mental status, with or without the loss of consciousness. Over the past several years, the medical field has realized that concussions are not as minor as originally thought and can have lasting effects. The most dangerous situation is when a person suffers a second concussion while still recovering from their first. This is known as Second Injury Syndrome and can be fatal.

That being said, as injured as Ramsey is, he clearly suffered something more than a mere concussion. It sounds like he most likely suffered a brain contusion (a bruise of the brain itself) in addition to a concussion. Brain swelling is common with such contusions. Despite what the doctor implies, neurosurgical intervention is commonly used as an early treatment in such brain injuries before stronger (and riskier) medications are used. The doctor probably just called Ramsey’s injury a concussion to make it easier for the parents to understand. He still shouldn’t have made “brain surgery” sound as dramatic as he did.

Doctor: I can’t say for certain, but his age is a plus. Children tend to bounce back from serious injuries more quickly than adults. These first 24 hours will be the barometer for his recovery.

The doctor is absolutely right here. Children have a tremendous recuperative ability. The first twenty-four hours after a severe injury — especially a brain injury — are very important and are a good indicator of how recovery will proceed.

I need to add that Siaz’s art was excellent, including his depiction of the ambulance, hospital and all the assorted medical paraphernalia.

As a final thought, the nurse who called the reporter is not only due to be fired for violating patient confidentiality, but is also due for a hefty federal fine and jail time for violating HIPAA. I wouldn’t be so smug and open about accepting money from that reporter if I were her.

More Information:
1. Medical Dictionary definition of systolic and diastolic.
2. My comments about Manhunter #1 (legal concerns, not medical this time).
3. More on comic book head injuries (from my post on the Justice League)
4. The full text of the Health Inurance Portability and Accountability Act of 1996 (for those of you with insomnia or lots of time to kill)

I spent the day with my partner and our nurse and office manager at the Peoria Women’s Lifestyle Show. To keep me sane, I dragged the poor Polite-Wife along. I also did something I rarely do: I wore a tie. Not just any tie, but a great one that shows the gameboard from Operation. If I have to wear a tie, it’s that one.

I think we did well and it looks like we interested quite a number of patients in our small-town practice. Many of the people in Pekin work in Peoria, and I don’t think that it ever occurred to them that Pekin actually has doctors and they don’t need to drive to Peoria for medical care.

We offered information on women’s health, plus handouts on pregnancy and pediatric wellness. We also offered blood pressure screenings and I offered a quick depression screen (I used a slightly modified version of the Zung screening form, an online version can be found here).

UPDATE: I forgot to mention that the booth directly behind us was for the Peoria Civic Center’s “Broadway Series.” They played the soundtrack to Mama Mia over and over and over. If I never hear another Abba song, I’ll die a happy man.

Afterwards, the Polite-Wife and I went to Kelleher’s, a nice Irish Pub on the Peoria riverfront, and had an excellent meal. I was ecstatic to discover they carried my favorite beer Paulaner. I know it’s German and not Irish, but it’s simply the best hefeweizen available. Sadly, it’s hard to find in America. (Yes, Jon, I know you can get it in Indy.)

Warning. Soapbox begins here.
There were quite a number of people at the show who, unasked, came up and gave us their views on vaccinations. Personally, I think vaccines are one of the greatest medical advances of all time. I am fully behind all rigorously tested and approved vaccines. If they’re on the “required” vaccination list, I urge my patients to get them.
I understand that there are people who do not share this belief in vaccinations. In some cases, this is due to a religious objection. I can understand that. What worries me is the growing number of parents who do not vaccinate their children because they are misled or deceived by bad information and unscientific fear mongering.
Ironically, much of this can be blamed on our own success. Most people in this country have never seen a case of polio, or even measles or mumps. Iron lungs and a wheelchair-bound President are things of the past. Deaths from measles, birth defects caused by rubella, and post-mumps sterility are unknown to today’s parents. Sadly, as vaccination rates drop, the incidence of these diseases sky-rockets. Just ask Great Britain, which has seen a dramatic rise in the number of measles cases — and deaths — because of a decline in the number of vaccinated children. Thankfully, America is not to that point…yet.

Soapbox #2.
There was a group at the show selling the “nutritional supplement” Juice Plus. I was content to leave them well enough alone until one of them spotted my physician’s name badge and walked up to me. She asked: “Are you familiar with Juice Plus?”
“Yes, I am,” I replied.
“Then certainly, Doctor,” she said loudly. “You recommend Juice Plus in order to give your patients all the important vitamins and nutrients they need.”
“I do not recommend Juice Plus at all,” I responded calmly. “It is simply an overpriced supplement offering what can be more simply and cheaply obtained by eating a healthy diet. It offers misleading and unscientific evidence as so-called proof, and is really no more than a fancy pyramid scheme.”
I don’t think she liked my answer.
Hint: Don’t puts words in mouth, you won’t like the results.
</soapbox>

Aquaman #21 continues the tale of the people of Sub Diego. It’s a fascinating premise, and one of the better Aquaman stories in recent memory. I’ve addressed certain issues of the storyline a few times before, but this latest issues brings up a few more questions.

The Delivery – A baby delivered to water-breathing parents is discovered to be an air-breather and has to be rushed to the surface to survive.

• Why is the doctor wearing gloves when he’s delivering the baby? Any contaminants are just going to float around in the water (and in fact a later panel shows floating blood).
• In some ways, it makes sense that the parents would not know their child was not a water breather until the delivery. Fetal circulation bypasses the lungs, so the baby’s lungs aren’t used until after delivery and there would be no telltale signs beforehand. However, you’d think they would have checked an ultrasound to look for gills.
• Did they cut the umbilical cord before racing the baby to the surface?

Pressure – Has it ever been established how deep Sub Diego is under the water? I’m just wondering about water pressure. For every 33 feet of depth, there is an additional atmosphere of pressure (additional to the regular one atmosphere at sea level). Thus if Sub Diego is at 100 feet, the water pressure is equal to four atmospheres, or four-times normal pressure.

Bends – I have seen some readers speculating that Atlanteans and the citizens of Sub Diego should be suffering from the Bends. Decompression sickness, better known as the Bends, is the result of nitrogen bubbles precipitating out of the blood. At high pressures, air bubbles easily dissolve in liquid (think of a closed 2-liter bottle of soda). As the pressure is reduced, these bubbles rapidly enlarge (open that 2-liter bottle). These enlarging nitrogen bubbles in the blood and organs are responsible for the symptoms of the Bends. The nitrogen gets into the blood by breathing air at high pressures. Since the citizens of Sub Diego have gills and not lungs, they are not breathing air but instead filtering oxygen out of the water. Nitrogen should not be an issue.

Light – There is not much light available underwater. Humans require sunlight to correctly make use of vitamin D. Rickets will be a concern.

Air bubbles – Since everyone in Sub Diego uses gills to get oxygen, why are they all breathing out air bubbles? Where did the air to make these bubbles come from? Similarly, how do the residents of Sub Diego talk? Air passing over the vocal cords causes gives rise to the sounds of speech. I guess water traveling over the cords could work in a similar way, but the carrying distance would be shorter and the tone changed. And in this panel it sure like like one of those gangsters is trying to smoke.

Hair – Here’s an interesting article regarding the hair of Atlanteans, looking at the subject from a physics and anthropology point of view. Good reading, though I think he’s wrong about the Bends.

A quiet holiday weekend so far. My parents came up from St. Louis Friday night and we had a nice dinner at 2 Chez on the north side of Peoria (mmm…crab cakes). Saturday afternoon we traveled down the road (State Road 9, to be exact) to Mackinaw Valley Vineyard, a local winery. They had some excellent wines, and the Polite-Wife and I ended up buying a bottle of Eric’s Red and Edleweiss. Just going to take it easy the rest of the weekend: read some comics, watch NASCAR, and play Looneyland (I don’t know whether to thank Jog or strangle him for suggesting this game).

Sunday Blog-o-Bits:

• I missed Justice League Unlimited last night, but was able to catch it on repeat this afternoon. It was another good episode, this time starring Supergirl, Green Arrow, and the Question. Mike at Progressive Ruin sums it up best. I agree with him that “Tea” seems to be the JLU’s Powergirl, though the name threw me (but I guess they couldn’t exactly call her “Kara”, could they? Karen would have worked though); the scene with the injured Tea at the very end reminded me of JLE #9.
  There were some great lines, such as when the Question tells Supergirl “Don’t be ridiculous. I go through everyone’s trash” and when Green Arrow describes the Tea as more “mature.” And I do think that was Wildcat.
  (And I had to explain to the Polite-Wife who Powergirl was…that’s a long, laborious and mostly non-sensical history. And that’s before Crisis.)
• Johanna and Jon debate Defender Bear, a combination blog/web-comic. It’s worth a look even if most of the humor is subtle (at best) and the message is very un-subtle. (I did like the trout talking about “the Main Stream” though).
• We traveled to Best Buy this morning to find two DVDs: Hellboy and Batman the Animated Series. Of course, they were out of both (sigh). I did find the last disc I need of Big O, and the Polite-Wife picked up the latest episode of Last Exile. And we finally bought the “All in One” scanner/printer/copier/fax we’ve been talking about for a while as both our scanner and printer are terminal and not expected to survive.
• I’ve been having a problem with deer eating the plants in my butterfly garden, so when we were out this morning, I picked up some deer repellant spray. It’s active ingredients? Putrescent egg solids, capsicum (i.e. cayenne pepper oil), and garlic. Sounds like a classic Caesar salad dressing; all it’s missing are the anchovies. (Smells like Frank’s Red Hot Sauce when I was spraying it on)
• Also picked up Tales of a Librarian, a Tori Amos collection while at Best Buy. Appropriately, the songs are arranged according to the Dewey Decimal System. For instance, “Bliss” is listed under 120 Epistemology and 129 Origin and Destiny of Individual Souls. “Pretty Good Year” is listed under 520 Astronomy and 529.32 Calendars.

Family Matters collects issues #1-4 of Invincible, published by Image Comics. Invincible is an unapologetic super-hero tale. It doesn’t aim to take the genre in a new direction. It makes no pretenses of deeper meaning. It simply aims to tell an exciting and compelling super-hero tale, and in that it succeeds brilliantly.

Invincible takes place in an already populated super-hero universe. The world is protected by several groups of heroes such as the multi-national Guardians of the Globe. The most powerful single superhero is Omni-Man, who just happens to be the father of Mark Grayson, the protagonist of Invincible. Mark is a high school senior; he does well academically and flips burgers after school because his father tells him that it builds character. Then one afternoon his super-powers kick in unexpectedly while taking out the trash at work. This is no real surprise to him as his father talked with him years before about this (in a hilarious scene where his father explains not only super-powers but also puberty to a young Mark).

Mark takes to the streets and breaks up a robbery. Chuckling at his son’s costume, his father takes him to a special tailor to get a better costume made (a costume that he wants to be “iconic”). Soon after, he encounters the Teen Team and helps them break-up a robbery (in another good scene where he’s wearing only his pajamas).

Teaming up with his father, he defeats an alien invasion. Later, working with Teen Team members Atom Eve and Robot, he succeeds in discovering who has kidnapped students from his high school and turned then into living bombs.

Writer Robert Kirkman understands the conventions of the genre and uses them to his advantage. While his story will appeal to all readers, it is tailored to the experienced super-hero readers as they will get the most from the unspoken aspects of the story.

There are no unnecessary long explanations or expositions. When Mark’s father realizes he has to write a book for his publisher during the weekend, he tells his wife to pick up some extra keyboards. The reason is never explicitly stated; it is left up for the reader to understand why. (Imagine if Claremont had written that bit of dialogue: “Given that my typing my best-selling novels at super-speeds wears out and breaks ordinary computer keyboards, I will need you to journey to Best Buy and purchase a dozen keyboards that can withstand the blazing speeds of my powerful fingers!”)

Kirkman writes excellent dialogue. Each character speaks in a unique voice. He captures the voice of teen-agers without coming off as an adult trying to sound hip. Mark’s parents speak like parents when talking to each other as well as when speaking to Mark. My favorite is the high school principle at the student assembly who sounds just like my high school principle as he explicitly enumerates where everyone is to go after the assembly.

The art is simple, clean and bright and complements the story perfectly. Cory Walker’s pencils are accented by the bright colors of Bill Crabtree. Watch for character cameos in the background, including Charlie Brown and Bill (from Bill & Ted’s Excellent Adventure).

The extras included in the trade paperback are nice. There are pages and pages of preliminary sketches, all nicely annotated by Kirkman.

Eight is Enough, the second volume of Invincible, continues with some story threads started in the first volume (and has another title based on an old TV show). In the first story, Mark heads to space to defeat a menacing alien as his father is tied up with another mission. In succeeding, Mark shows that his brains are at least as good as his brawn.

Next, after a round-the-world game of catch with his father, Mark and his friend William visit a nearby college they are considering attending. At the Teen Team headquarters, Robot has been invited to try out for a bigger team, and Atom Eve makes an uncomfortable discovery about her boyfriend, Rex Splode. We are introduced briefly to the Guardians of the Globe, a transparent copy of the Justice League. My favorite is Aquarus, the fish-headed hero of Atlantis.

The art changes in the third issue of the collection. It is noticeable, but fits in well as a different artist draws the pages for each member of the Guardians of the Globe. A new penciler takes over in the final issue, but the transition is smooth.

Like the previous volume, Kirkman’s strengths as a writer of dialogue and master of understated action are apparent here. The only major weakness of this collection is that it is “all middle.” There is no underlying storyline connecting these issues, in fact most of them are clearly setting up events to come later. Even with that flaw (readily acknowledged by the writer), this is remains good book to read. I look forward to Book 3: Perfect Strangers.

And remember, everyone tell Robert Kirkman: Brother Voodoo in Marvel Team-Up!

Daredevil #1-8 “Guardian Devil”
Kevin Smith, writer
Joe Quesada, penciler

In a brilliant post over at Peiratikos, Rose does an excellent job of summarizing “Guardian Devil” and highlighting all that she finds wrong with the storyline. Her points are all excellent and she sums up the flaws in the story better than I could. What I remember most about the storyline was the senseless death of Karen Page and the worst d鮯uement in comics history. Rose’s post did remind me of all the questionable medical aspects of the story that I had blocked out…well, until now:

1. Foggy’s new client is seeking a divorce because her husband had her sterilized without her knowledge and she didn’t know it until her last gynecological exam. This is ridiculous. Sterilization requires surgery, and you’d think someone would know if they suddenly developed a scar and a sore abdomen. It sounds like the patient had a hysterectomy, which is a significant surgery with a good sized scar and at least a week of recovery. It turns out later the client was lying, but they should have been suspicious from the start.

2. Matt Murdock can hear a pair of heartbeats, so he knows the young mother and baby are nearby. It’s nice that Quesada’s art correctly shows the baby’s heartbeat as significantly faster than her mother’s, but why is he showing EKG waves? EKG waves are purely electrical in na