Myxamatosis

In their interminable effort to eradicate the rabbit infestation, the Australians at one point stooped to biowarfare. The rabbits had caused incalculable damage to the ecosystem, and at a population that may number in the billions, the Aussies were running out of bullets, and were markedly tired of rabbit stew.

Their attempt at a solution was to translocate a recent species jumping virus, the myxovirus of a Brazilian rabbit-like creature, to their own outback. Myxovirus had symbiotically adapted to its rainforest host, causing no symptoms, and no mortality. But in european rabbits, the adorable bunnies we know and love, the disease is one of the most infectious, invasive, and destructive diseases we have ever seen. In virology and infectious disease terms, the virus is hotter than hot.

At first glance, the effort was incredibly successful. A massive area of Australia was virtually depopulated of bunnies. But soon enough, nature ran its course, and the .1% of immune rabbits soon exploded again. But the effort had born some fruit. The research into myxovirus, a poxvirus variant, had shown quite a bit about the virus, which had intrigued researchers worldwide with its recent species jump.

We don't understand much of why viruses infect the species they infect. They pick and chose in live animals, infecting some and not others. When they jump species, it is almost always an extremely potent infection. But while studying the virus, a remarkable lab happenstance led to a researcher noting that myxovirus's selectivity was based less on animal type, and more on the presence or absence of a single immunoresponse pathway. A pathway coincidentally absent in virtually all human cancer.

One day, this accidental discovery could be on par with the discovery of penicillin. These viruses preferentially attack solely cancer cells. Mouse studies have shown 90% efficacy in eliminating gangliomas, some of the most resilient and cantankerous brain cancers we generate. This virus, this rabbit plague, kills cancer cells, and only cancer cells.

Myxamatosis. fantastic.

The Egg Lobby Wins Again

The unlikely culprit behind H1N1 shortages is out there, hiding in a chicken coop. Oddly enough, the reason behind the production bottleneck of vaccine has been a shortage in fresh fertilized eggs. This bizarre happenstance occurs due to the bizarre nature of the orthomyxidae (flu) virus that is the source of pandemic flu. Influenza A, the culprit behind the spanish flu epidemic of 1918, is the only human flu variant with the capability to cross-infect multiple species. This cross infection is the root culprit behind the potential of flu to break out of the normal seasonal infectious boundaries, and run rampant.

Viruses aren't like other organisms. In fact, its debatable if they are even alive. Once a virus infects your cells, it rips itself apart, reproducing its component pieces. Reassembly is random, just components bouncing into each other, making up for inefficiency with copious volume. These fractions include the RNA that makes up the flu's genetic blueprint. The problem is that if two viruses infect the same cell, say a pig cell, there is nothing stopping genetic fragments from pig-only flu from integrating into the genome of a human-infectious flu. This is where the danger arises. Humanity has seen just about every variant of flu that is human-infectious. Our bodies know how to fight these. They make us sick, but we beat them, and a good fraction of us are just immune to each variant. When a pig or bird virus integrates into one that can attack us, it become a type that we have never seen before. (a phenomenon known as antigenic shift)

This cross-species infectious pattern is why we are facing a shortage. The vaccine you receive, whether nasally or intramuscularly, was brewed up fresh by infecting the membrane of an unborn chicken. We do this in order to generate the same swapping effect that generates pandemic flu, but with the opposite effect. Growing the virus in the egg allows for less infective genomic fragments to integrate in, creating a flu virus with the same immune system ID as the pandemic variety, but with none of the infectious capabilities. This inactivated virus serves as our vaccine, driving an immune response without a risk of infection.

This process is arduous and difficult. Not only that, but the recombination is random, and ineffective. Imagine trying to produce the volume of vaccine necessary by farming eggs that may not even make the product you need. Now imagine doing this with a shortage of eggs.

Incredible Edible Infected Eggs. I suppose they ARE good for us.

Conduction

His face a mask of confusion, the older man sat down, easing his bulky upper torso carefully into the seat. He had walked in tentatively, shuffling in sandals, his feet and lower legs marked with accidental scuffs. Intimidated and alone, he looked around at us, apprehensive and not entirely sure what to do in this new situation.

The interview began slowly, the questions non-specific and general. He was in the hospital for memory loss, he self-reports, and we nod encouragingly. He told us he had trouble thinking. He would lose his thoughts. Each question came back with its own short answer, or merely a quiet request to hear it again, because he had forgotten.

We all looked at him, assessing his frame for signs of what had caused his problem. His barrel chest indicated potential emphysema. His swollen abdomen told us liver failure. It could be alcoholic damage, either direct or from hepatic emphysema. It could be alpha-1-anti-trypsin deficiency liver disease. We all sat there, thinking the mechanics through in our fact-sodden minds. Until someone asked him his children's age. For five long minutes he couldn't remember. For five long minutes we held our breath. He finally answered, his mind able to dig out the autobiographical information that should have resided right on the surface of his thoughts.

His dementia is conductive, the information of his life not gone, but inaccessible, blocked off behind a decaying network. He knows this, he can sense the absence of thought, the lack of interplay between his current situation and his wealth of acquired experience. He terrifies me, his condition a mirror to my worst fears. He lives in my nightmare, lost in his mind and completely aware of it. We have seen so many things, so much pain, and so much triumph. But this slow degeneration, this quicksand of conductive impotence, it cuts through the defenses. It makes me scared.

Airborne!

The ads used to be everpresent. The air traveler, locked in an aluminum trap with hosts of shockingly ill fellow travelers, a host of infectious disaster waiting to happen. The wary traveler wisely reaches into his or her bag, pulling out the the cure-all: airborne.

This generation's snake oil, the vitamin C megadose is widely held to bolster the immune system, helping your loyal host of T Cells to resist the onslaught of the barbarian hordes of bacterial and viral invaders. This, like the theory that anti-oxidants prevent cancer, is one of those unfortunate pop science ideas that has permeated society, the benefit of which is neglible to non-existent (unless you are the school-teacher who came up with "airborne").

Vitamin C megadoses don't improve your immune system. You may feel slightly better, since the chemical is a slight antihistamine, but if anything, the giant dose may prove slightly toxic. Vitamin C can cause urinary problems, not to mention the tendency to push your system to retain iron. In fact, habitual use of heavy Vitamin C dosages can drive you to develop hemochromatosis, a disease of iron overload that causes major liver damage (and makes eating raw oysters extremely dangerous).

So next time you fly, if you are so exceedingly terrified of the bugs, I strongly suggest a facemask.

Halvsies

The cadaver looked different today. The body shape was off, discontinuous, more lumpy than usual under the concealing shroud. The revelatory moment was a bit beyond surreal, a sheet pulled balk to reveal a dismembered body that had been, at some point in the day before, cut nearly precisely in half. A separated pair of legs stared longingly up at the trunk and upper body, intestines and spinal cords split asunder by a gap they had never known.

We hadn't performed the cut, a rare usurpation of our anatomists rights. We had left a body mostly intact, organs separated here and there, but with everything in its right place. We returned to find our work rudely ripped apart, the neat lines of our abdominal dissection shredded by the work of a gigantic saw. It was abrupt for us, a surprise.

Snake's final remaining touch of humanity had been taken, leaving only a disparate leg and torso combo, a value pack from the world's most disturbing store. It was done so we could study the legs and the pelvic girdle more completely, so we could understand the inside of our own hips. Someone had come into the lab, wielding the scientific equivalent of a chain-saw on fifty dead bodies. Someone does this every year.

It was far too hot...

He sits across from us, genial and jovial despite his general aura of defeat. He is in the inpatient psych ward for the fourth time this year, brought in to protect him from himself. Covered in a shiny spider web tracery of burn marks and skin graft repair, he relaxes on his chair, nonchalantly eating a bag of chips.

His hands are stubby and shortened, the final bone of both pinkies far too explicably missing. He talks about his life, his kids. He talks briefly about the war, but it is far too strong a memory for him. He is on a new mixture of drugs. He hopes out loud that this will be the batch that keeps him from the darker places of his mind.

He has grandkids. A new wife. Friends. How terrible is it that this neurochemical abnormality constantly tries to take that from him. He locked himself in a car once. Covered in gasoline, he lit a match. The heat snapped him out of it, he reports. Deciding that it was far too hot in there, he got out. He won that fight, as he has won all of them. But just barely.

The Plumbing Problem

Cleanliness is next to godliness. A principle high amongst the canonical statements of modern medicine. Handwashing, clean clothes, sterile environments. These things save lives, preventing transmission of the great beasts of the hospital, the resistant nosocomial infection. When we wash our hands, clean our coats, spray down the keyboards we protect everyone we interact with from the hybridized super-strep that plagues the old and the infirm in hospitals worldwide.

It is good that we do this, as we do see a myriad of folks whose immune systems and bodies are poorly equipped to handle a new round of infections. But, oddly enough, it seems counter-productive for this obsession with clean to spread to the general population. Hundreds of years ago, Polio was endemic, but not problematic. Everyone had it, everyone had been exposed in their early childhood, when the maternal gift of a temporary immune system had served as a gold plated shield. It spread through the unappealingly named fecal-oral route (as do a number of diseases that we have ALL had...disturbing as that thought may be), and in the days before modern plumbing, everyone was heavily exposed.

It was with the advent of modern plumbing that polio emerged as the disease we know today, the paralytic invader leaving crippled children in its wake. Without constant exposure, people were not encountering polio until after the maternal antibodies had worn off, leaving them a virgin field, just waiting for polio to colonize. Oddly enough, it was the widespread improvement of sanitation, then end of defecating in a hole in the ground, that sparked an epidemic of crippling disease.

They call this the hygiene hypothesis now, the concern that our over-hygenic society may be protecting infants from disease precisely when they should be encountering it the most, at the peak of their childhood immune potency. We are born with a surfeit of antibodies, a gift from our mothers, but they fade, leaving an undeveloped system behind. Polio is only one example of the viruses that once went ignored, and now cause epidemics. Perhaps, this theory posits, we should let our children wallow in the muck.

Proteus

A seven year old sits at the table, eyes down, playing half heartedly with the years old toys populating the clinic room. His father sits to his side, less nervous than confused, knowing only that something weird was happening. His son had been born with some physical alterations, a misformation here, a port-wine stain there. He had surgery to correct the damage as an infant, and the doctors had assured him that these things just happen. No reason to read into it.

As he grew, the port wine stain expanded. Beyond that, they started to notice his right arm was becoming substantially larger than his left. He began to overbalance, a seven year old with popeye's right hook, the difference unexpected enough to require a double take.

Before we walked in the door, the doctor had been worried about Proteus syndrome. A disease of widespread physical remodeling and tumor formation, Proteus syndrome drives your bones and soft tissue to grow in bizarre, abnormal fashions. They can be as simple as massive lumps, or enlargements, or as complicated as actually forming new structures, new and functionless appendages. We theorize this was the disease the Elephant Man had. She had been worried about that, out in the hall. A disfiguring and fatal disease, and one we can do nothing about.

When we walked in the door, her face brightened subtly. This boy had problems, but they weren't big problems. The enlarged arm and vascular port wine stains over his body read more of Klippel-Trenaunay-Weber syndrome (KTS), a disease of vascular malformations leading to the development of stains and unilateral limb enlargement. We run through the physical just to make sure, feeling for tumors and growths. He is unremarkable, save for the arm. I assemble a literature packet about KTS to hand to them, all the while wondering if I would ever actually see a case of Proteus, and wondering about my sanity for wanting to.

Wicked Shank

Improbably enough, the page listed the main risk factor as "poor golf play." This astounding co-factor of infection relates to the rare disease of Ehrlichiosis, a syndrome named for its own infectious agent. The disease is of the family Rickettsia, a constellation of bugs including such luminaries as the bugs behind Typhus and Rocky Mountain spotted fever (a disease much more common in the eastern seaboard). It presents much like the spotted fever, but without the rash.

The bad golfer spends a lot of time traipsing about in the woods. They search in the high grass for their wayward shots, presenting a wonderful target for unfriendly ticks. The bite infects you, delivering these pathogens into your system where they infiltrate your cells, reproducing behind the protective barriers of your cell membrane. The infection is quick and unnoticeable, colonizing you while you eke out a double bogey.

I am quietly excited about this, relishing the day when I can make an esoteric diagnosis on a middle aged white man in pseudo-cleats and an argyle sweater. Until then, to all of you who dally on the links, I strongly suggest bug spray. An infection like this says a number of things about your golf game. None of them good.

Scalded

An infant on a page, captured indelibly as a literal textbook example. His eyes are closed, his hand clenched in a miniature paroxysm of agony. His skin is peeling off every part of his body, shedding in waves as if the poor child had been placed at the center of an oven. It is just a picture to me, a representation of dry symptom and associated syndrome.

He has an infection of Staphylococcus Aureus, most likely acquired in birth, caused by a bacterial flora his mother carried harmlessly. It has colonized his skin, and is producing a myriad of toxins, most notably (in this case) the two variants of exfolatin, a toxin that does exactly what it sounds like. He is burning up and shedding skin, immortalized forever in print, a case study image of "Ritter's Syndrome," the scalded skin syndrome of infants. This bacteria is destroying him, ripping apart his body in an attempt to create a large pool of defenseless nutrients, an infectious strip mining.

He must have been in agony. New to the world, confused by every element, he was born into pain, and most likely expired the same way. He lives on, in a fashion, immortalized as an educational tool. I can't decide if it is important to remember his pain, to note it. You see so many pictures, so much agony and shame. Can I really feel for each one?

Idiopathic

Med school is said to expand your vocabulary by hundreds of thousands of new terms. A liturgy of pentasyllabic words of exact or debatable meaning infest your mind, rolling off the tongue nearly effortlessly. Half utility, half status symbol, medical jargon allows us to communicate efficiently and above the heads of our patients, allowing clear categorization in a language limited to those of the elite set.

For the most part, this lingual expansion is actually far more useful than it sounds. The ability to distinguish between an adenocarcinoma and a small cell carcinoma (both two common lung cancers) exists in years of life expectancy. The concepts that we so interestingly name provide us with a way to communicate paragraphs of detail in one sentence, a must for the hectic and high information density world of medical practice.

However this expanded lexicon has its breakdowns. The worst of these is the catch-all word we use to indicate our ignorance. Idiopathic. The word literally means unknown cause. We define a myriad of disease this way, lumping together symptoms whose cause we cannot discern into common pools of generic identity. We have this dominant need to categorize, a need to diagnose even when we have nothing specific to claim. It is the great psychosis of modern medicine, this idea that we have to figure everything out. Idiopathic is the safety blanket, the margin that allows us to maintain our sanity in the face of a world in which there are still innumerable diseases we can only identify by symptoms, if even that.

It is a striking thing to learn, a gaping hole in the midst of a torrent of hard factual data. We are so focused on finding truth, finding answers, that we created a word defined by being undefinable.

Hippocrates

I haven't taken my oath yet. It exists far off in the future, a goal equated squarely with the finish line. It is the glorious finale, the shining moment when the transformation is to occur, moving me from just a normal person to an avatar in a white coat, a person capable of saving lives, of being good enough to be a Doctor. The oath might be seen by some as superfluous to the process, a ribbon to break when the shiny new me is unveiled. Beyond this, my school does not even use the traditional oath.

It is half bizarre antiquity, a product of the strange mindset and times of ancient Greece. I have no inherent allegiance to the god Apollo, and I feel no need to share my money with any of my professors (any more than I have already). Neither do I feel that I need to make any oaths about the proper use of slaves (apparently it has to be specifically spelled out that we should not be having sexual relations with our patients or slaves in the oath of the profession). The oath that has been in place for thousands of years proscribes surgery, abortion, and of payment for medical care.

But the oath already means something to me. The modern oath, the promise that I will lead my life and practice my art in uprightness and honor, that I will exercise my art solely for the cure of my patients and the prevention of disease. It is still far away, but with each disease I learn, each concept I learn, it looms closer. It is remarkable the significance it holds, a transformative event that in a way recreates us as physicians. I believe in the oath, and I believe in what it stands for. It is a sign of common purpose, a promise that encapsulates the higher standard to which we are, and should be held. A whole profession has built its ethics around the concepts established three thousand years ago, and because of it, people can trust us with their most important commodity.

Cervical Security

For the eighty percent of sexually active Americans who already have a latent case of HPV, the emergent practice of vaccination has already come to late. The virus is already at large in our bodies, although localized almost exclusively to the surfaces (both internal and external). For the men out there, this news comes with a resounding shrug. It barely effects our gender, restricted to the occasional awkward lump. We face no real threat from it, a virus so weak that it is actually not detectable unless there is an actual wart.

For women, on the other hand, the complications are far more extensive than an awkward moment between yourself, your partner, and later your doctor. Human Papilloma Virus is a cancer inducing bugger, a particle capable of initiating chemical reactions that will drastically reduce your body's capability to defend itself from the host of offensive insults trying to redefine your DNA. With how common infection is, perhaps it is appropriate that HPV affects the ubiquitin system, a series of proteins serving as a cellular trash disposal. An overstimulation drives a system into overdrive, and it starts attacking and removing the P53 cancer sentinels of your cells. Without these P53 sentinels, your cells have no way to initiate cell suicide if the worst happens, and the cell goes bad.

With this, the cells are left open to environmental attack, and the next mutation will trigger expansion and growth, invasion and metastasis. The cells of the cervix are laid open to their detractors, and the risk of cervical cancer has skyrocketed.

This is an intriguing phenomenon. A communicable cancer (albeit one that can, in another one of the universe's cruel gestures, only affect women), spread by a virus. A cancer that we can effectively immunize everyone against, with just one shot.

Delightful.

Border Security

We are under attack. They drum this into us with each lecture, terrifying us with the commonality of disease both internal and external. Our bodies are large and complicated, and a remarkable amount of energy and time is devoted to beating back the waves of invaders trying to capitalize on the resources we have so carefully hoarded in our own flesh.

Our skin is the first and best defense against all of these barbarous microbes, a hard barrier requiring luck, dedication, or a few anti-connective tissue enzymes to break through. In a testament to its efficacy, our skin is literally swimming with opportunistic buggers waiting for their chance to cross our borders. No matter how clean we are, the reality of day to day life is that we will be firmly colonized, bacterial parasites mooching off of the waste products exuded from our pores. This is not limited to our friendly flora, the Escheria Coli and Streptococcus Viridans that only induce disease when our internal social order breaks down. Staphylococcus Epidermis, that spheroid aggregating bastard, swarms all over the skin of the majority of human beings. It sits there waiting patiently, biding its time until a puncture gives it a way inside. The bane of drug addicts and hospital patients (both a population known for being stuck by needles) S. Epidermis rides the needles inside us, where it can negatively impact us in a myriad of ways. The drug user sees a tendency towards endocarditis, an infection of the interior lining of the heart. The hospital patient is equally subject to this, but can also see the formation of biofilms on the inside of catheters or IV lines. These biofilms become toxin factories, dumping anti-social peptides into your system.

This bacteria is so prevalent that we often have to draw blood from two locations to do diagnostic tests for infection, because of the significant likelihood that S. Epidermis shows up on one, drawn in when the needle perforated skin.

We exist in a hostile world, and when we tell you to wash your hands, we mean it.

Recognition

Vision is a bizarre combination of stimulus and interpretation. By itself, the torrent of lights and colors that makes up the sensory input of the second cranial nerve is merely noise, data picked up and mapped geographically onto receiving portions of your brain. This mapping, interpreted by your brain, allows you to interpret what you see. If section X lights up, your brain knows that whatever information you have received there come from the left side.

But you need more than just this somatotopy to interpret everything you see. You need associations, you need memory. Vision without memory is like listening to a foreign language. You hear the quality, tone, and speed of the sounds, but you don't understand the context. What is it to see an object if you don't know what it is? The significance assigned is what gives you interactivity with your world. This can be taken away from you. Neurological damage can remove your ability to tie visual stimuli to concepts, removing your understanding of the world around you.

For instance, damage to the fusiform gyrus can cause facial agnosia, destroying your ability to recognize the faces around you. You see everyones face, you can describe them, draw them. But you don't know them. The association, the connection between this pattern of intensity and color and your memory, is gone. Without it, a face just becomes a face, not someone's face. Imagine how isolating it must be, walking through hallways, down streets, never recognizing anyone. Imagine knowing your own face only through context, knowing yourself only because the face in the mirror must be you.

Overstimulated

The boy seems fine now, in his cancer ward bed. A little sleepy, but responsive, vitals all well inside the normal range. At 16, his mother's hovering by his side is more frustrating than calming, and he tries to ignore her constant attempts at reassurance. She is frustrated and confused, adrift in a world of dying people, bombarded by esoterica beyond her experience. The machines beep quietly at his side, but she can't help staring at them, a post-traumatic worry that they will start up in their cacophony of alarm one more time.

He doesn't have a typical form of cancer. The invading army of malignant growth is not his primary concern, at least not right now. He has pheochromocytoma, a tumor of the adrenal gland or of a sympathetic ganglion, an overgrowth of the cells responsible for deluging your body with epinephrine or nor-epinephrine. His body produces these neurotransmitters in pulsatile waves, spikes of fight or flight driving through his system. A system reserved for bringing your body to its fullest capability in moments of extreme need is being over-stressed, damaging him further each time it happens. Each wave constricts his arteries, raises his blood pressure, drives overreaction of muscles and mind. Each time it is painful and confusing, the physical sensation of terror dropped onto an unsuspecting overlay, incongruous and uncomfortable.

He is hospitalized because any of these pulses could kill him. At any time arterial constriction could become to pronounced, blood pressure too high. Each time his body speeds up it takes time away from his life, the internally generated neurochemical poison improving his bodies performance beyond its tolerance.

We are imaging him. If we can find it, we can hopefully remove it. Hopefully, the tumor is adrenal. A ganglioma can be harder to get to. But until then, he lies in his bed, almost normal.

Testicular Fortitude

My partner holds the testicles out, moving aside the withered penis with the back of her hand. She cuts into the scrotum, dispassionately revealing nothing. We goggled a bit at the empty vessel, not understanding if this was, perhaps, the way the testicles were supposed to look. She tries the other one, again failing to discover anything remotely ball-like inhabiting the folds of skin. Snake was, at some point, the victim of testicular cancer. I finally felt, in that moment, the force of the myriad of postmortem humiliations that snake had experienced to be with us in that lab.

Throughout the entire anatomy lab, there was no region most of the male students were more loath to slice into than the genitals. In a moment of freudian solidarity, the vast majority of us passed on the honor of that dissection to our female classmates, a shared moment of 100 sympathetic pangs in our own equipment, 100 disturbing visions of emasculation. We got over it, as we were made to get over any number of hang ups, but it was a remarkably visceral experience in social psychology. For reasons both genetic and social, a cornerstone of male psyche rests squarely and oddly on the status of our genitals. The idea of emasculation seems the ultimate pain and humiliation, an injury with a scope beyond the biological damage entailed. When we sliced open Snake, revealing the damage done to his sex organs, I finally felt true empathy with the man we had sliced, fairly literally, into pieces.

How powerful is the force of depersonalization, that I, and all students, can literally take knife to flesh with barely the most fleeting of thoughts? We came out of lab each day, reeking of death, and complaining only of the smell. We dispassionately held up the things that made 50 fellow human beings exist, thinking only of the taxonomy. Yet, for myself, and 99 other guys in my class, this one region, this one more cut, one more dissection, was the one that hit home.

That, I must say, is bizarre.

Ideal Question Law

The test question read:

"Your friend shows up to a dinner party late. He is disorganized, with a confused affect, stains on his shirt, and bloodshot eyes. He eats all 50 of the mini pizzas you have laid out, and then apologizes, saying he didn't know why he was so hungry. What substance is your friend most likely on?

A) Cannibis

B) Phencyclidine

C) Opiates

D) Benzodiazepines

E) Cocaine"

I started for a moment at the question, not grasping for the answer, written as it was in neon lights on a billboard for all to see, but in a brief flash of reverie. Five different dinner parties, with five different friends, and five different chemical additives. In one, this one, a artificially starving friend, brain doused with cannabinoids, triggering a relapse to a more primal state, a drive to satiety the most important thing in his world. In another, a crazed man, immune to pain and with the strength of lunacy, rampages through the house, PCP (phencyclidine) having added to my soiree a jerky psychotic bull to destroy my china. In two, a similar scene, a sleepy addle brained friend, constantly falling face down into his soup, drowning in a sea of tranquil euphoria. Finally, a hyper compatriot, not hungry in the least, but telling us at a fevered clip the story of his life.

These thoughts burst through my brain, the result of days of study of the neurochemistry and behavioral patterns of each of these substances. For a moment, I am frustrated. All that work, all that understanding, and this is the question they ask?

But I accept it, and move on, wishing wryly that all of my cases could present as poorly written stereotypes.

Temporal Mind

Free will becomes a more interesting concept the more you study neurology. How do you differentiate between the biochemical processes and architecture of the mechanics of thought and the spark that gives us life and light? How can you ascribe us complete freedom if any form of brain damage has the capacity to change, at its very root, who you are?

Take the mirror image diseases of Kluver-Bucy and Geschwind syndromes. A normal individual has full control over their engagement with the world. We decide what we think, how we think, and what we do. Or so we suppose. A Kluver-Bucy individual has had their amygdala damaged or removed on each side of the brain. They develop a placid manner, with a tendency towards hypersexuality and an oral fixation. It is bizarre, but this syndrome, typically caused organically by Herpes Simplex Encephalitis, literally domesticates independent human beings. They become disconnected, untied inside their own minds to the world of cause and effect, and willing to be pointed and directed, engaging only in base needs like eating, sleeping, and sex.

Geschwind syndrome is the opposite. Typically induced in epilepsy, Geschwind individuals display one of the most interesting diagnostic traits one might see, "Interpersonal stickiness." They lack the ability to read space in interpersonal relationships, developing theories of interconnectedness and unifying principles that bind them to anyone they meet. A Geschwind sufferer is typically hyposexual, extremely (and rapidly) religious, extremely verbose, and displays a pronounced tendency to write at extreme length about everything. It is a disease of over stimulus, a driven firing of the neurons of the Amygdala leading the individual to draw theories out of connections that only they can see.

This one portion of the brain, if over or understimulated, will drive your personality to opposite extremes. In a world of free will, how do you reconcile the ability of organic damage to make you into a docile sex slave or a hyperactive monk? I can't, at least not comfortably. It seems as though, when we function in that razor thin margin of acceptable, we make our own decisions. But that margin is a conceit we define ourselves. We are only ever a few chemical changes from being someone else, and to me, that is quite terrifying.

Icy Hot

In high school, a friend once took up a bet that he wouldn't slather icy hot over a most delicately indelicate region. He took the bet for money, a move made on the assumption that it wouldn't be that bad. Mere moments after slathering the viscous jelly on himself and he was clearly regretting his decision. His skin absorbed the active ingredients, menthol and methyl salicylate, and it was sending signals his brain interpreted as the damage of rapid freezing. His brain, convinced that he was somehow accidentally dipping his testicles in a vat of frozen water, was screaming at him that something was direly wrong.

The pain and temperature nervous system runs on different wiring than the rest. Temperature transmits more slowly to your brain, allowing a period of accommodation when changing one's climate. The nerves themselves lack the complicated mechanical apparatus of the somatic sensory, ending in uncomplicated open ports that merely change elements of biological function if the temperature becomes excessively high or low. The odd thing is that these sensors can also be triggered chemically.

The menthol and methyl salicylate of the icy hot had been absorbed by his skin, percolating into his system and encountering nerves dedicated to a purpose of discussing the weather. They bind to these nerves, triggering their activity, and sending a veritable tidal wave of information to the brain, all coded to mean the same thing: Cold. It is this mechanism that makes you feel the air cool when you take a cough drop (menthol), or burns the inside of your mouth when you eat a habanero pepper (capsaicin). For some reason we have an evolutionarily designed mechanism to interpret a chemical as hot or cold, to become sweaty when eating a burrito doused in hot sauce, or to feel a cool breeze merely by contacting menthol.

Perhaps it was a far sighted evolutionary attempt to teach my friend to exert better judgement.

Braincase

I've got the chisel and hammer in my gloved hands, fidgeting with each out of boredom. The anatomy lab is sparkling and nauseating as usual, the gleam of light off chrome given the lie by the pervasive smell of preservatives and sanitized death. We've been here so often by now that the disturbing juxtaposition no longer offends or impacts. The brain is a marvelous thing, adjusting us to our surroundings no matter how strange or unpleasant.

One of my partners holds the saw, the miraculous vibrating serrated edge that somehow can only cut tough material. Another is perched over Snake's head, scraping off those last tenacious bits of fascia from the top of the skull. We had removed the skin the day before, the sterile impersonation of a scalping done quickly and imperfectly, a casualty of dull scalpel blades. We have to remove the leftover soft bits so that the miracle saw can do its work, chopping swiftly and precisely through the skull, yet leaving the internal brain and dura intact.

The girl with the saw moves up to Snake's head, and turns it on. A high pitched buzzing fills the room, and as she lowers the saw to the skull, a small burst of bone dust and smoke plumes upward, bits of burning hydroxyapatite creating another odor in a nostril already at standing room only capacity. She moves awkwardly around the dome of the skull, creating a continuous separation. Now its my turn, and I move in with the hammer and chisel. I place the chisel in newly generated space in the bone, and use it to lever the skull upwards. There is a pop, and the bone falls off, a ragged skull cap in the most literal sense.

The brain is not yet exposed, still wrapped in a covering of thick fibrous tissue. In a live person, the skull would be full of fluid, a protective cushioning and gravity negating layer designed to protect an organ nearly devoid of strong structural components from its own weight. With Snake, there is barely any drainage as we section the dura, revealing at last the former seat of his personality. I take my chisel and i move it down the front of the skull, moving it in a lazy arc to rupture all the attachment points, where his cranial nerves used to tell his face who it was. I use the chisel to sever the brainstem, and with another liquid pop, the brain comes loose.

I reach a hand into a human skull, ignoring the unreal implications of my action, and pull out his brain, a cacophony of most unseemly squishing noises serving in lieu of a drumroll. I am holding the seat of a man's being in my hands, inspecting it incredulously, wondering how this situation just came to pass. The contents of my hand seem such a small thing to loom so large. I remove the falx cerebri from between the cerebral hemispheres, and toss it aside into the debris bin. We set the brain aside, leaving it afloat in its own bath of chemicals, waiting patiently for a neurology lab months away. Turning back to the empty skull, a dissected face staring at us with an empty grin, we dive right back in, searching for the cranial nerves in a space that once held a man's soul.

All the World's a Stage

He sits slumped in his chair, hair streaked with a gray that is almost dirty, a rime of age showing on a weathered head. His movements are erratic, jerky, as if he can't quite decide what he his telling himself to do. He is still wearing his sunglasses, but seems to have forgotten that, constantly reaching up to rub his eyes and starting in quick surprise. The red bulb of his nose gives away his alcoholism, an unfortunate beacon of failure and difficulty.

We ask him his name once, and after a brief pause, he informs us that he goes by the handle of Woody. He tells us a story then, about how he got the nickname because he used to love woodworking when he was younger, he used to make wooden chairs. We ask what brought him to the hospital, but all he will say is that he is sick. We ask him about his youth, his interestingly offbeat habit of carpentry, but he looks at us blankly, slight confusion in his eyes. We ask him his name again, and he looks directly at my badge before responding: "Tom."

He came in two weeks ago, having been picked up by the police for a drunk and disorderly. He was confused, and walking erratically even after the drunk wore off, so they brought him into the hospital. They hoped it was just Wernicke's Encephalopathy, a temporary condition brought on by an alcoholics tendency to substitute beer for bread, so they hooked him into a supply of vitamin B12. It didn't help. He has Korsakoff's Psychosis, a permanent damage to the titillatingly named mamillary bodies of the hypothalamus, the two round protuberances of the bottom of his brain. The damage is done by a long term lack of B12, a crucial compound for biological functions from energy metabolism to oxidative damage protection. He must have spent years trading his daily bread for booze, depleting his bodies stores of this crucial resource.

His disease has robbed him of himself, and of his future self. He has amnesia, anterograde and retrograde, forwards and backwards. Its a bad case. He doesn't know who he was, what he was. He wont remember this interview for long. It comes with confabulation, the remarkable ability to develop a semi-coherent story based on minimal cues. He became Woody based on the wooden chairs in the office (actually a molded wood-stain plastic, but who wanted to argue). He developed a whole story about his youth, based only on one visual cue. His life is bound eternally in the now, constantly redefined as he sees fit, according to a logic that no one will ever know.

We tell him his real name, and he responds like he has known that all along, glossing over the stories of the past few minutes as if they had never been uttered. Of course, to him, they hadn't.

Sweet Pee

The truck slams into the wall over and over again, grasped firmly in the hyperactive hands of an overly energetic six year old boy. His declarations of a monster in the room have driven the putative occupants of the truck mad with fear, and his attempts to lead them into safety end only in repetitive disaster. His mother brought him in years ago, referred by a pediatrician after an offhanded comment. It's how most of them come to the genetics clinic, always for the subtle things. The major things get caught at birth, as they are usually sort of hard to miss.

She had remarked that her infant's urine smelled sweet. Smelled like maple syrup. Thats not normal, she probably asked, assuming, like most new mothers, that the Doctor would reassure her. But they didn't reassure her. They sent her here. Her son has Maple Syrup Urine Disease, the aptly named syndrome describing an enzymatic failure leading the urine to reek of a thousand McGriddles. Her child is missing a functional copy of the less fortuitously (but equally aptly) named branched chain alpha keto-acid dehydrogenase complex, the enzyme allowing us to break down the amino acids leucine, isoleucine, and valine. Her son can't clear these compounds (readily found in most protein) from his body, so they build up, increasing quantities generating neurotoxicity, neurotoxicity causing brain damage. Unmonitored, a healthy diet will leave her son mentally damaged, a slowly developing crescendo of diminished function.

It is one of the classic metabolic disorders, trailing only phenylketonuria in commonality. We don't know how it was missed in the neonatal screen, but its a great development that they caught it as soon as they did. Her son will be normal, so long as he watches his diet, staying away from milk, meat, and eggs. We have to test his blood frequently, monitoring the buildup of these normally crucial building blocks. Its a wonder, at age six, that he doesn't hate these visits more, the cruel men and women in the white coats, controlling his life and sticking him with needles. His mother, on the other hand, looks to us for quiet reassurance. She is doing her job well, we tell her. She is giving her son the chances he needs.

It most be odd, I think, to dread the smell of pancakes.

Two Point Discrimination

We live in a bubble of interpretation, building a world around us piecemeal from the myriad of detective devices built into our frames. Information is recorded via physical or electrical media, interpreting pressure, chemicals, or light into coded patterns, messages which our brain instinctively interprets.

We feel the outside world via a series of pressure sensors. These sensors read vibrations and force, interpreting the combination into an understanding of texture and position. They combine with internal architecture, stretch receptors reporting the position of your joints. The brain synthesizes the feeling of pressure against your fingertips with the position of your muscles and bones, painting a picture by numbers of what it is you hold.

Your brain portrays the illusion of continuity, of a physical understanding of what you touch, and what is touching you. The distribution of nerves controls how precisely you can feel, allowing your fingers to read braille, while your legs can barely report more than contact. The phenomenon of sensory acuity is described by the phrase "two point discrimination." In the finger tips, you can feel two different points of contact at minute distances. In the back, the distance goes up to centimeters. I can hold two pens in my hand, touch them to your back at the same time, and your brain will report only one touch. The astonishing nature of this is not in your inability to discriminate, its in your brain's absolute conviction that there is only one pen. Even knowing full well that someone is holding two pens to your back, the only result is a cognitive dissonance between known and observed reality.

I marvel at this, the fact that your body and perception can so convincingly lie to you. It is very mystical in its implications, the idea that the physical, the body, cannot be trusted.

Snake

You spend a lot of time with your cadaver that first year of school. Which is weird, when you think about it. You build your day around anatomy lab, hours spent in a brightly lit room, reeking of formaldehyde. You huddle around this guy, a generous man who donated his body to the advancement of your knowledge, marveling at the structures inside, and tsk-tsking at his imperfections.

We named him (most groups do). It only seems right. You spend so much time with them, refer to them in so many ways. You explore their bodies in ways that nobody ever does, (or can without significant jail time) and a partner in that kind of intimacy deserves an appellation. His salient feature, his key identifier, was the giant chinese dragon tattoo on his right arm. Bright and colorful, the tattoo had survived the chemical fading of the rest of his skin, the forced de-vivification necessary to prevent decay. It stood there, immediately jumping out to us as we began the process of opening up the arms. He must have had it for years, we assumed, as it had sagged a bit from what must have been a once glorious presentation.

That first week we named him Snake. And when the time came, we kept the tattoo intact, keeping it with him in the the chrome case of preservatives. It would have been a shame to do anything else.

A Growing Boy

She is holding her baby on her lap, straining to handle the size and weight of him. He smiles brightly, staring around the room with the expansive credulity of the very young. Seeing the light shine of my badge, he reaches for it, drool spilling from his lip. It is a sight both icky and delightful, the adorable inattentiveness of infants. He is far to large for his age, six months old and nearly 3 ft tall, with a healthy pudge besides. We are in the genetics clinic, and his mother is clearly worried.

I have been in this room so many times, seen Dr. T deliver so much bad news. I have seen the light die in the eyes of parents as they discover that their child, their almost normal, slightly off child, is afflicted with a disease of developmental delay. Their child will never be normal, never go to college, and never live a completely independent life. It is worse than the fatal diagnoses. The dreams inherent in the birth of a child die in this room, and in their place grows a child that they will struggle to care for, for whom their burden as parents never ends.

This is not one of those days. Her child, the giant, jolly rapscallion currently attempting to masticate my ID, is going to be fine. He has Beckwith-Weidemann syndrome, a genetic disorder of Chromosome 11, causing him to grow vastly faster than his peers. He will reach his full pre-pubertal height by age eight, but as time goes, his curve will approach normal. We will monitor him for heart disease, but once he clears that eight year mark, he will be just as happy and healthy as the next kid.

Her face collapses in relief, her arms tightening reflexively around the overgrown ball of exuberance in her lap. Thank you, she says, as she reaches to shake our hands. Dr. T smiles, the light dancing in her eyes, the weight of thousands of diagnoses removed for a moment. No problem, she says. Its our pleasure.

You Two

Epileptics suffer from storms of neural activity. From start loci, waves of energetic chaos criss cross the white matter, triggering uncontrollable tics and movements. We treat this with drugs, with pills designed to prevent these mental typhoons. For some unfortunates, this doesn't work. Their only option is a corpus callosum sectioning, a slice down the middle of their brain, isolating each hemisphere in its own universe.

This can work, breaking the communication lines used to spread the energetic disorder. Oddly enough, the complete isolation of a hemisphere doesn't really lead to much. Our brains are redundant, and one cerebral hemisphere is typically completely dominant. One side (typically the left) handles the speaking, the thinking, the general interaction with society. The other half contributes, but more subtly, and the dominant half can assume its responsibilities.

But the isolated half does not shrivel and die. Each hemisphere has the capacity to support a personality on its own. In the event of a hemisection, both often do. The right brain, marooned and isolated develops its own thoughts and activities, and can interact with the body without your conscious awareness. The right brain sees things you dont, interprets things on its own. It has first crack at sensory awareness from the left side, and its perceptions are subtly altered from yours. It is you, but split off, the moment of conception marked with the downward stroke of the surgeon's knife. It will draw things you cannot see, think things you don't think, and exist as an involuntary passenger in your body.

Our conception of self is a pillar of how we see the world. We are the individual, the observer, the center of our own universe How do we understand it then, when a simple surgical procedure can split us into cerebral siamese twins, two passengers stuck in the same body?

How to Give Bad News

Turn off your cell phone (#1). We all do, ostentatiously hitting power buttons before striding into the conference room, med students playing doctor. We enter, pseudo-sad faces plastered over sheepish grins, learning how to deliver the news that our classmate's imaginary husband or wife had died from an imaginary coronary. Our partners sit at the table, five med students playing actor, knowing full well the "news" that is coming.

I sit down (#2), match eyes and keep an open posture (#3), and ask Frank if there is anyone he would like to join him to hear this (#4). I fire a warning shot (#5), informing him that I have some bad news. I tell Frank his wife has died (#6) We aren't supposed to use the words "passed away," apparently they sound too soft. Frank hams it up, histrionically shouting at me, before breaking apart into snickering. I struggle to keep a straight face. I explain what happened, and Frank regains composure, and starts playing along. An apt expression, "playing along," because we are playing, miming through one of the worst parts of life, and the discomfort of the moment expresses itself most handily as hilarious. Through that I try to remain empathetic (#7) to Frank's false misery, and answer any questions (#8) that Frank doesn't really have. I avoid medical jargon (#9), ask if he would like to see a chaplain (#10), and make arrangements for a follow up meeting that in real life (and our imaginary one) would never happen (#11). Finally I offer to take him to see the body (#12).

I've been on the other side of that table. I have heard doctors run through their checklist, the procedure of "giving bad news." In retrospect, I wonder if it has an ICD-9 code, so as to get reimbursed. But even with my perspective it was awkwardly funny, five fake tragic discourses at the same table. Awkwardly funny, until the moment walking out, when you realize that taking part in the worst moments of people's lives is now part of your job description.

Pancreatic Punch

Type I Diabetes is usually a juvenile onset. You don't produce enough insulin, you see, so your body reacts poorly, overreacting with a burst of signals to the delinquent cells, leading to further complications. Your cells starve in a sea of plenty, unable to absorb the sugars from your blood, like a starving man paralyzed in a bakery store room. As you can imagine, this is frustrating to your internal chemistry.

My friend developed Type I after a punch in the back ruptured his pancreas. The damage to his pancreas resulted in a leak of pancreatic lipase. His organ dissolved itself, bubbling with disintegrating fat, ultimately calcifying into a saponified white chalk. His islets of langerhans, the most scenic cell pattern extant, failed in their function, and production of insulin dropped off.

We fix Type I with injections of insulin. This used to be costly, the insulin harvested from humans or pigs, until we learned how to convince bacteria to make it for us. You inject the insulin with meals, or twice a day. The insulin opens the door, lets the sugar in, and your body stops its frenetic response. My friend had his insulin stolen once. In Las Vegas, the capitol city of excess, he was pickpocketed. He didn't notice until reaching for his shot. He stumbled into the hotel that night, disheveled and sweaty, reeking with the sickly sweet stench of ketones. His liver was breaking apart fat to feed his starving cells. His cells, starving in the midst of overabundance.

We didn't appreciate the metaphor.

He Can Read Your Mind

The twelve of us sit there, hovering on the edge of our seats, wondering what the soft spoken man in the purple silk pajamas will do next. Vitiligo emblazons his eyes with a burning white, mirroring the discordant energy vibrating through his frontal cortex. He has schizophrenia, a bad case. But he is vibrant, and happy. He is a 3.5 billion year old supercomputer. 3.6 billion actually, he declares, having had a birthday last week.

Between admonishments to increase our daily quotient of vitamin C, we learn that he can also read our minds. Pointing at each of us, he declares our true names. Mine was Chad. In between fevered typing on an a keyboard only he can see, he exhorts us to stop thinking at him. His hands blur in fevered incantations, and he starts to laugh, happily.

His root problem is based on misbalanced brain chemistry. A neurotransmitter extra here, less there, and his perceptions have altered fundamentally. We can fix this, to an extent. It comes at the cost of a forced personality leveling, a demolition of the peaks of inconsistency. He is paranoid, but ecstatic. He is delusional, and delightful. He is sick, but should we fix him?

The First Cut

The strangest thing about walking into a room of 50 dead people is how completely not strange it was. A bustling crowd of twenty-somethings enters the room, gathering four or five to a corpse and staring at the bulging sheets with a curiosity that can only be described (with a cringe) as morbid. We had heard talks, hours of talks. This is our first patient, they told us. Treat them with respect. We had listened seriously, reveled in the concept of receiving such a gift.

We remove the sheets, exposing the skin of the chest to our prying eyes. It was grey, with the consistency of cold wax, wrinkled and molded into sharp creases by the processing these donor's had endured in order to be with us on this bright and sunny day. We sit there, clinically eying the rubberized flesh of one of our former compatriots on this earth, wondering who was going to open up the newly purchased dissection kit and take the first whack at our patient.

I'll do it, I think, and as I open my mouth a small girl grabs the scalpel, and tentatively slices the congealed flesh under the nipple. She is trying to expose the pectoralis major, and with the imperfect confidence of a newly minted anatomist, she is being defeated by her care for the integrity of the structures. She sits there, delicately peeling back layers of fascia and fat, engrossed in the act of perfect invasion we have all conspired to create.

A proctor walks by, and laughs. At this rate, she says, we will be here all day. She grabs the knife, and slices deep. Reaching in with her tools, she roughly separates the skin and fascia from the chest muscles, and slices off the insertion point of the pec major. She holds up her prize, greasy and covered in bits of what had once been, as Mr. Heston said, People. She holds up the muscle from our first patient, for all the world to see.

Start skinning the arm, she says. So we do.

Agnoscosis

There is a disease to learning about disease. A creeping sickness of the mind, a pathological invasion of your connection to normality, health, wellness. It is unavoidable. They tell us in medical school, we will lose our empathy. With 100% infection rate, this disease creeps into you with every deconstructive factoid you memorize about how the living, breathing, working thing you call your body is actually just a massive cooperative machine running on the knife edge of failure.

The disease is spread by books. You carry these books with you. These books full of stories of pain and suffering. Demographics of disease, people like you, like your parents, and incidence statistics that add up to well over 100% (everyone has, or will get, something...). These books are full of pictures of things that are so obviously wrong. Pictures of organs, once functioning vital parts of a person, of a life, now sectioned, exposed, isolated diseased and alone. The heart, the lungs, expanded, lesioned, granulated, fibroid, decayed, enlarged, or necrotic. These things happen you learn. They happen to everyone. All the time. Every part of your body can, and will, go defunct, fail, and disintegrate.

I traveled this weekend. I flew to visit my girlfriend, to reconnect with my humanity, with the happy parts of life, the hubbub below the skin diminished in importance. But I carried my books with me, and I saw my disease reflected in the revulsion of the flight attendant and the woman sitting next to me. As I studied, as I intently focused on learning the precise etiology and cell patterns of usual interstitial pneumonia, these poor women avoided glancing at the pictures. The disincarnated lungs idly waiting on the page, blackened from coal, crystallized with silicon. Silicosis, Anthracosis, the dry names and concepts associated with death by dust of quartz or coal. I can identify them from their pictures now. But this exposure, a memetic equivalent of coal or quartz dust, flying through and calcifying the pathways of the mind, comes with its own risk. This disease of knowledge is shown in its disconnection, its clinical obsession, and its reduction of the human condition. This disease presents macroscopically in the eyes of others. In the eyes of my fellow passengers I saw disease. Agnoscosis, the sickness of knowing.