Case 1

The first thing that struck me was the room. Tiled in aquamarine, with a latticework design of grout, the procedure room struck me more as a YMCA shower than a site for finely tuned medical activity. Shelves lined the walls, crowded with individually packaged sterile equipment. A black portable surgical bed stood in the middle of the room, self important, if not proud. Next to it lay a sterile tray of surgical tools, a rack of dully shining medieval metal and sharp edges. The OR team (as it were) consisted of myself, the attending surgeon, and a single circulating nurse, as this establishment was only for minor surgery. This unassuming room was to be home to my first case on my first day of surgery.

Minor surgery or not, VA policy dictates full sterile procedure, and given the lack of personnel, it was my responsibility to scrub, gown, and glove myself, using the half remembered, half heard instructions from a 3 hour OR orientation. The patient was already in the room, lying on the surgical bed having his arm prepped methodically. A 50 year old vet with a stunning mustache and a slightly bored look on his face, he apathetically took in my relentlessly self-conscious efforts to lacerate my hands into sterility as the nurse lathered his arm in betadyne. He enjoyed my inexperienced efforts to don the uniform of a surgeon, laughing out loud as the nurse patiently helped walk me through the final steps, amused by the gyrations that kept my lanky frame sterile in the cramped space.

The attending finished his note and in moments was scrubbed and fully wrapped. In the meantime, the patient had been fully prepped and draped, and the attending stepped up to the tray, grabbed a syringe of lidocaine/epi, and announced that we were ready to start. The patient was here for a triple lipoma removal from his left arm, and in moments the attending had anesthetized, incised, and dissected the largest fat tumor. In a whirlwind of motion we were left holding a fatty sac and suturing, with my main experience being some supremely impressive retracting (if I do say so myself). I wasn’t really sure what I had learned, except that I don’t faint at the sight of blood. I looked up at the patient, who had been chattering away through the whole thing, looking on in fascination at the bloody mess we were making of his arm.

“Here” the doctor said, handing me a syringe, “you do the next two.”

He plopped the syringe down on my palm. I reflexively grasped it and stared it down, plastic clasped far too firmly in my sterile and double latex clad hand. The patient’s arm remained outstretched, visible bumps calling out for minor medical attention. My own inexperience shouted back that this was almost certainly a bad idea, my entire surgical career to this point having consisted of a single afternoon of suture clinic. As I tried to recall how to sew (no…the surgeons like to call it suture), I tentatively stabbed him, working the needle tip under the skin and injected the sodium channel blocking delight that would keep him blissfully uncaring when I sliced him.

“Minor burn here” I said, willing cheery competence into my voice with every ounce of my frame. I pushed on his arm, poked his skin to see if I had successfully applied the local anesthetic.

“Can’t feel a thing doc,” he said, as I mumbled something almost under my breath about being a medical student, and not a doctor. The attending handed me the scalpel, and for the first time in my life I was seriously about to cut someone. I put the knife to the skin, drawing downward across the protuberant lump I was about to remove. The skin split apart almost eagerly, tiny rivers of blood sliding out as it parted like the skin of a ripe orange.

“OWWWW” yelled the mustachioed man with his arm now wide open. I froze, scalpel in hand, agonized with the knowledge that I must have failed with the anesthesia. I looked up, saw the patient smile, and heard him say “Naw, just fucking with you kid.”

The attending laughed. I didn’t.

Hair of the Dog

Not all alcohol's are created equal. Defined by the telltale -OH group, alcohol ranges from deadly toxin to delightful intoxicant, all dependent on the number of carbon atoms it carries. Ethanol, the friendly molecule in vodka, cause of merriment and only a modicum of increased cancer risk and cirrhotic liver damage, is the safest of all these. But we have not always restricted ourselves to consumption of this only moderately toxic iteration. Prohibition carried with it an epidemic of blindness, a side effect of cheap bootleggers using woodchips in their fermentation process. Methanol, you see, that solitary carbon alcohol, is acutely toxic, both in the pleasant warming nervous system depressant way, and in the terrible formaldehyde producing metabolism kind of way.

We still see methanol induced blindness. We see it mostly in suicide attempts, but the acute (drinking methanol to end it all), and the long form (alcoholics who are too broke for regular booze). The toxin starts off like regular alcohol, inducing inhibitory effects throughout our brain, slowing our breathing, making everything just a bit distant and complicated. The issue arises when we try to get rid of it, our cellular machinery breaking it down into component parts. The components, with methanol, are worse than the whole, and formaldehyde courses through us, blocking our energy metabolism at every step. The damage to our cellular resources can be staggering, and deadly.

We can help though. We can decrease the metabolism of methanol, forcing it into a slower elimination with less acute toxicity. We do this with alcohol. Ethanol, to be precise, straight into your veins. You will be drunk as a skunk, and the ethanol will block the metabolism of methanol, using up all the available alcohol dehydrogenase.

How is that for hair of the dog that bit you?

Better Know Your Hermaphrodites

We all began this world as girls. The male genome differs from the female in the key fact of extra genetic material (well, extra expressed, less overall). A tiny Y chromosome, with a tinier gene known as SRY, informs the masculine fetus that the uterus and vagina they were developing are of no use, instead growing a second set of tubes (our former embryonic kidney), into a new, more standing up to urinate appropriate set of equipment. This duct, known in medical circles as the appropriately manly "wolffian duct," is activated by Testosterone, the overproduction of which is the definitive physiological trait of manhood. The external genitalia, the organ on which we of the far less fair sex place so much importance, is derived from signals using dihydroxytestosterone (DHT), otherwise known as the hormone that makes you go bald and get a swollen prostate (about 40-60 years down the road). At the same time, mullerian inhibiting factors are obliterating your once promising female genital tract, obliterating the paramesonephros.

But remove these signals, and we develop along the baseline, into someone that is almost a women. You see, we still express baseline levels of estrogen, so in the absence The signals can be broken in several different places, causing several different outcomes.

One breakage can be in the production of testosterone. A 17-alpha hydroxylase deficiency we can't manufacture the copious testosterone needed to inform our bodies what to do, and without the testosterone, there is no DHT. Depending on the damage, the XY fetus would develop as either a partial hermaphrodite (small penis, blind vaginal pouch), or as a women. This all depends on the degree of insufficiency, a sliding scale of gender.

A 5-alpha reductase deficiency will block the production of DHT, leading to an entirely male form, except for that ego and gender defining locus, the genitalia. Ambiguous at best, these infants force the doctor to say "I'm not sure" when announcing the sex. They are male, of course, but will need hormone shots, and possibly a bit of surgery, to function normally.

Androgen insensitivity implies a child whose cells blithely ignore the flood of testosterone, developing quitely into almost female. These children are sterile, presenting with complete lack of internal genitalia. The testicles do develop marginally, and have a distinct tendency to get stuck in the inguinal canal (the site of the hernia), where they also need to be removed to prevent any cancerous development. They are the simplest, because genome aside, they are essentially girls. Typically tall, slender girls, with symmetrical bodies, larger than average breasts, and no body hair. (think about that next time you look at a model)

The true hermaphrodite, the fully formed penis and vagina, is the rarest of breeds. In class, one day, discussing this phenomenon, we heard a professor utter the most odd of screeds: "Its easier to dig a hole then build a pole." These children are almost always forced into feminity, regardless of their intention, because thats the way our society directs the outcome.

Masculinity is a narrow thing. Perhaps we shouldn't take it so seriously?

Mythomania

They want your blood. The beasts of our unruly imaginations, the vampires and werewolves of our gothic past, they want that vital stuff that drives you. The myths have existed for centuries, these dark companions of humanity. Our shadow siblings have survived ages in the comfortable dark, serving as the stuff of nightmares for all of us who have ever started at an unknown shape in the night. These creatures represent our collective fear of the black, the unknown. But these creatures, oddly enough, are based on reality. In fact, they are based on biochemistry.

It all comes down to the blood. Uroporphyrinogen decarboxylase, a simple (well, not so simple) enzyme, designed to help break down you assemble your hemoglobin. Hemoglobin, of course, is the wonderful material that serves your blood so ably as a sherpa of oxygen. Oxygen, however, is the hazardous trade of biochemistry. We need it to drive the reactors that keep our cells flush with energy, but like any source of energy, it comes with risks. As a substance, it loves to attack us for our electrons, to damage the infinitely delicate material that makes up cells and DNA, our molecular identity. To tame this unruly resource we have harnessed equally dangerous materials, locking reactive intermediates into a closed ring, our own tamed beast: hemoglobin.

Each stage of hemoglobin assembly has an intermediate flush with potential destructive capability. It is this chain of manufacture, this biochemical supply line, that gives us our favorite myths. The vampire involves a form of porphyria (a breakdown in the enzymes for hemoglobin assembly) in which a byproduct forms that is extremely reactive to sunshine. This leads to someone who is constantly anemic (and thus hungry for the salty iron of blood), and prone to immediate and dramatic burns upon exposure to sunlight.

The werewolf suffers from hypertrichosis, hair growing from every surface. These poor individuals might suffer from a slightly different porphyria, that of cutanea tarda. They also burn, but the more dramatic side effect of failed synthesis is an overgrown thatch of hair. everywhere.

These deep dark myths, these reflections of the lost soul of humanity, are merely the deranged impressions the sick leave on the uninformed. This extends to our other monsters in human form, the zombie (most likely suffering from hansen's leprosy), the cyclops (holoprosencephaly), and the mermaid (sirenomelia).

Funny how understanding makes it less mysterious, but more disturbing. These creatures aren't the stuff of legend. They are the sad reality of disease.

Make Room for Dinner

One of the most disturbing and odd facets of masculine culture is the reflection and embrace of our digestive systems, particularly the strange communion many men have with the porcelain throne. Beyond the establishment of gaseous expulsions as a hilarious form of art, men commonly seem to want to discuss the quality, quantity, and enjoyment of eliminating solid waste.

Descendants of this fascination include numerous euphemisms and contexts for when one really has to take a shit. Dropping the kids off at the pool, the deuce, and a myriad of others have become commonplace, if unpleasant, phrases. One of the more common concepts of this milieu is the idea of "making room for dinner." The concept underlying this is that if one was to use the facilities, dinner would be better received, as one would have "made room."

It always bugged me when people said this. In general, I never really enjoy hearing about folks fecal fun. It bugs me only slightly less now that I know that this mythos of masculine misanthropy is actually a legitimate fact.

The gastroileal reflex is a system by which distension of the stomach actually triggers increased movement in the ileum (part of your small intestine), and dilates a sphincter allowing food to pass from the small intestine (where it is absorbed into the body as nutrients) to the large (where it is prepared to be expelled). A natural peptide called gastrin, released to increase stomach acidity and break down the various products you consumed, teams up with your autonomic nervous system to literally "make room for dinner."

Which doesn't actually make saying it any less tacky.

Party Trick

The patient perched on the corner of the exam table. He stood up gingerly, a snap and crackle underlying his every move. An younger man, his delicacy was premature, the cautious movements of a man twice his age. His eyes could have used a good cleaning, the whites anything but. Grey orbs with a brown center, he looked at us nonchalantly, a cup of fresh urine in his hand.

The doctor takes the cup, places it on the table, and tells me to keep an eye on it. Nonplussed, I examine the urine, looking for the typical marks of illness. It wasn't cloudy, or discolored. It didn't smell sweet, or musty. I saw no crystals, no blood. So I looked away, taking in the interview, wondering what the doctor thought was going to happen.

After the final reflex hammer falls, the doctor looks up at me, asking for a diagnosis. The only thing I noticed was arthritis, the reason for his care in movement. Gambling, I toss out rheumatoid arthritis, and receive for my trouble a slow shake of the head, and an extended arm pointed at the cup of urine, now sitting there rather dark shade of black.

The patient had alkaptonuria, a fairly benign metabolic disease, a failure of tyrosine metabolism. His buildup of homogentisic acid has stained his connective tissue, darkening his eyes and causing pain in his joints. He eliminates it in the urine, and on exposure to air, it turns itself black.

As diseases go, its a fairly innocuous one to be stuck with. Unless you are the guy at the urinal next to him.

French Pox

Kurt Vonnegut used to discuss the lurching old men of his youth, ambulating irregularly about downtown Indianapolis. His wandering examination of the terrifyingly possessed men, mumbling and bumbling in their confusion and discordance, paints a fairly terrifying picture of the disease once known by names varying from the French Pox to the scourge of royalty: Syphilis.

Treponema Palladium, a gram negative spirochete, has brought down rulers and vagabonds, and remains today one of the most prevalent (if slow moving) sexually transmitted disease around. It's readily treatable (simple penicillin does the trick), but if you let it go, it begins to run amok in your cerebellum, corkscrewing its way through the all important cognitive matter. Over years, you slowly go crazy, lose your ability to sense your arms and legs (except for pain and temperature), and develop a series of unsavory skin conditions.

The trick with syphilis is that it spends so much time with no clinically apparent symptoms. (although also decreased chance of catching it). The diagnosis can be tricky because the little spirals are adept at avoiding tests, and the symptoms are erratic and transitory. Perhaps the best (not most effective, just most hilariously named) diagnostic technique for the final stages of syphilis is the the eye exam. A person with late stage syphilis will have normal eye constriction with general eye use (known as accommodation), but not respond to light. This is known as the "prostitute's pupil," although in deference to modern terminology, it has recently been rebranded the Argyll Roberston pupil. Which honestly just makes me associate syphilis with sweaters for some reason (perhaps its because the human race most likely got syphilis in the first place by having inappropriate relations with sheep?)

Recruitment

At some point, something threw a wrench in your machinery. Cosmic rays, bad food, invading microbes, or piss poor protoplasm, but somewhere along the way, something in you got knocked out of place. Your roadmap, your building blocks, got altered. DNA alkylation, cross-linking, deletion.

It had happened before, but this one, this one was different. That single mistake happened to be in just the right place. It amplified, expanding in flawed protein designs, processes erroneously instantiated or failed. The mistake prospered, through luck and tenacity. It defeated or ignored your internal defenders, hiding behind a protective mask of your own flesh. It made a place for itself, even as it made more of itself, reinforcements in its desperate effort to expand.

You have a tumor. Reproductive drive incarnate, an invasive expanding riot of your constituent cells, demanding that the rest of you be more like them. These renegade cells, in their zeal to expand, have lost what defined them. Increasingly ill-shaped and deformed, the multiplying cells have lost their function, their irreplaceable role in the community that is your body. They swarm, they hustle, and dedicate resources in one vast effort to outcompete everything around with sheer numbers.

I’m here to stop them. I have an arsenal of methods, from futuristic rays to simple reinforcements for your beleaguered immune system. But this mistake, it is crafty. It hides itself behind the hostages of your healthy cells, component human shields staying my hand. Its hustle is it’s weakness, its sheer drive to reproduce differentiating it from your more sedate and helpful cellular citizens. Its growth makes it a target for my toxins, my rays. Some cells hide, biding their time, hoping I will accept the elimination of their more eager brethren as total.

I pump you full of poison, indiscriminate and wild. But I have been careful. My agent won’t kill you or your unruly cellular mob, but it will hurt. The tumor shrinks under the onslaught, even as your hair wilts and your immune system surrenders, casualties of friendly fire. When I withdraw my horsemen of alkylation, my carmustine, my mechlorethamine, the tumor will spring forth, hustling to reproduce and replenish, secure in the belief that it has resisted modern medicine. It doesn’t see me, waiting in the wings, an army of specific anti-neoplastics chomping at the bit. It was a trick you see, a con, a bamboozlement.

Your tumor got hustled.

Honeymoon

At the heart of medicine lies the proposition "everything in moderation." A core premise of every aspect of practice, from pharmacology to preventative medicine, homeostasis (our fancy word for balance) is what keeps you going.

Excess is the enemy, a destabilizing force that introduces openings for all of our natural enemies. Even natural acts like sex can be intrinsically damaging (beyond the potential for spread of disease). Honeymoon cystitis is a bladder infection induced by bruising damage to the bladder from repeated or forceful sex. Yes. We named it honeymoon cystitis.

These days, the honeymoon isn't actually the main source of this cystitis. As times changed, and the honeymoon and loss of virginity have diverged, a more experienced population has managed to avoid the pratfalls of their elders. But the name has stuck, an institutionalized giggle at the expense of a population that is enjoying themselves far too much.

Oddly Physical

The medical student white coat is too small for me. Tight across the shoulders, short at the wrist, It manages to hang yet cling, simultaneously wrinkled yet tight. It exists as a sartorial metaphor, a reminder that, as of now, the role of the physician doesn't quite fit.

In this capacity it works perfectly, as I only wear my white coat when pretending to be a physician for the purposes of my higher education. Each time I see a patient (even our pretend patients), I gird myself in the uniform of a pseudophysician. I walk into a room, alone, expected to comport myself in a manner suitable to my profession. I walk into a room, ill fitting coat a palpable reminder of my inadequacy, and try, against all common sense, to act as a physician should act.

I perform physicals for training. Real patients, real physicals, fake doctors. It is a surreal moment, running through the physical on the other side of the examination table. 25 years of experience as a patient, 25 years of reflex hammers and the ubiquitous "turn your head and cough." We give our doctor a trust, an understanding that they can violate the extensive rules governing touching in modern society. We do so because they have training, they have impartiality. They have professional dignity that they worked obscene hours and years to obtain. They have done all of this before, and seen all of it before.

I have none of these things. My training is, as of now, mostly scientific, not practical. But every doctor had to learn these things, had to do it and see it the first time. These patients volunteer me a trust I have yet to earn, a right to perform the tasks of a true physician. I take them up on this trust, poking and prodding their bodies, focusing on the science, wrapping myself up in an ill-fitting aura of professionalism. I do the work of a physician, learning and improving, until the day I can get a better white coat.

Special Swimmers

Rogaine, better known in medical circles as Minoxidil, was discovered as part of the search for better anti-hypertensives. A vasodilator, Rogaine causes your blood vessels to loosen up, inducing a drop in your blood pressure. Coincidentally, it also makes hair grow. Some lucky biochemist noted this, instantly transforming the humdrum vasodilatory results of Minoxidil into the volcanic eruption of cash that is Rogaine. This is the bizarre magic of pharmacology, a world in which side effects and desired effects often switch roles, and transforms a drug from a middling vasodilator to the salvation for those wishing for a more hirsute image.

The world of drugs is astonishingly replete with these stories. Viagra was an attempt at combating high blood pressure, Dramamine was (and still is) an anti-histamine. Bimatoprost was designed to combat glaucoma, but is better known today as "Latisse," as a mechanism to grow longer and stronger eyelashes. These are the good surprises, the marketable variations that keep pharmacological research into orphan diseases and concepts viable.

But this doesn't explain some of the strange products. The substances where you know someone, somewhere, just decided to start playing with it on a whim. A classic example of this is Protamine sulfate, a counter-agent to Heparin which we use to address the bleeding that can be a side effect of administration. Protamine sulfate is an interesting little molecule, small, positively charged, and derived from fish sperm. Yes, I said fish sperm. The swimmer's swimmers.

Someone somewhere decided to see what fish sperm could do in the context of anti-coagulative poisoning. Someone somewhere cut out the testes of a fish, isolated chemicals, and derived a use. Someone somewhere STILL does this, in order to provide us with a source of Protamine Sulfate.

And this, my friends, is science.

Post Mortem

There are four of them, cold on their metal carts. They await our inspection like a receiving line, welcoming us to their one last public appearance. They are a palette of unpleasant shades, skin ranging from sickly bronze to dark black, with mottled variations in between. Four bodies, four men clad as they were in their final moments of life. We hear each of their stories, a grand rounds of thanatophelia. A portly white man in a tracksuit, inflated further by bacteria, was found in a rooming house. A black man, naked and covered in cuts and blood, found sprawled outside a bathroom. A middle aged caucasian, colored a sickening shade of tan by what can only have been long-running liver failure, brought in from the streets. An elderly widower, rope still around his neck, a victim of his own hand.

We are here in the medical examiner's lab to find the rest of their story, to explain the nature of their passing. We are here to make sure these men left us on their own terms, that no plot twist of assault or poison embellished lives their unassuming lives. We wheel the portly man to a station, and the examiner's strip his clothes. He has been dead at least four days, and in that time his natural bacterial fauna has energetically gone to work, decaying and fermenting his tissues and fluids. Even without this assistance, failures of self-repair have already started a process that, for lack of a better term, can only be described as melting.

We remove his clothes, taking with them swathes of sliding skin. The windbreaker is lined with a thick layer of dermis, slimy with the products of decay. Bubbles of blood ooze out of his mouth. Each movement brings more, a slow cascade of filth marring an already distended face. We cut him open, slicing him like a ripe fruit, a rapid parturition of a material between flesh and fluid. We listen to the examiner's mouth running, a non-stop series of puns and humor oddly fitted to the fetid sickly sweet alcoholic stink of decay pouring out of the deceased abdomen. "The report on this one wont be long" he says, shifting intestines out of the way, "but there will be an appendix." With this he pulls out the small vestigial organ, brandishing it at the room. We attempt to smile obligingly.

We drain aqueous humor from his eye for toxicology (it being the most representative body fluid after death). We remove his organs, and weigh them, trying in vain not to lose any bits of the molten instruments of life. We cut out his heart, and at first glance, it is tremendously large. It is the cause of his death, this hypertrophy, a growth of muscle leading to irregular electrical transmission. We cut out the rest of him, opening his skull and draining out the erstwhile center of his being. We find nothing else of interest, bag up his relevant bits, and mark the chart natural causes. We close the last chapter of his sad and lonely life, and consign the body to public burial. We write a report no one will read. We walk out of the lab, and back into the regular world, with it's animate people, it's fresh air.

I drive home, windows down in the cold winter air. The smell is still in my nostrils, coloring everything with sweet reek that is indescribably wrong. I drive home, waiting for the world to stop smelling of death.

City of Bronze

A year ago, scientists working tirelessly in the field of sunless tanning stumbled upon something that is considered, in the world of pharmacological research, the holy grail. Bremelanotide, a melatonin based chemical trigger, does more than impart a subtle bronze glow. It activates the hypothalamus, triggering a chemical cascade of inevitable arousal. Thirty minutes later, your internal Barry White soundtrack turns on, and like young men in springtime, your thoughts inevitably turn to love.

More importantly (at least to these fortunate researchers), is the fact this magic pill has an equal effect on the fairer sex. Despite all the popular legends about tiger horn, oysters, and spanish fly, science has yet to conclusively find a pill to trigger amorous intent in the fairer sex. This is the great untapped marketplace of sexual pharmacology. Female arousal disorder is ubiquitous, affecting more women then erectile dysfunction does men. A pill that induces a mental state of arousal, as well as a physical one, is literally the magic bullet of psychogenic sexual dysfunction.

Plus, it gives you a tan!

Fidelity Booster

Prairie Voles mate for life. Montane Voles screw around.

Two almost identical species, with two almost identical evolutionary niches, and two fundamentally different behaviors. Of course, Scientists being scientists, this contradiction has recently been studied, and the difference comes down to the presence or absence of one single, solitary gene.

Prairie Voles, like Humans, have a specific promotor gene for the proteins oxytocin and vasopressin. Montane voles, like our promiscuous cousin the Chimpanzee, do not. The relevance of this theoretically revolves around the fact that oxytocin is the hormonal equivalent of love, the chemical we secrete when around those we care about, from family to romantic partners. It is the substance that cements bonds varying from the love between mother and child to the mild affection for an erstwhile fling. In the case of the Montane vole, its relevance revolves around the fact that voles modified to express this promoter show monogamous tendencies. To put it simply, we seem to have found the gene for romantic love.

The practical implication of this for human therapy is as a treatment for those unfortunates afflicted with Nymphomania or Don Juan syndrome, two clinically valid syndromes in which lasting affection is an unattainable goal, an illness in which deeper human contact is only a vaguely understood concept. The impractical implication is the possibility of behavioral modification, an inoculation against temptation. Imagine a world where marriage vows came with genetic checks, with shots created to redesign your brain and your heart. Would we be happier, stripped of the evil of temptation and mistrust, but simultaneously robbed of the validation our relationships receive from these tests?

We learn more about the brain every day, the bizarre interplay of electricity and chemistry that reduces somehow into our individual selves. Each day we reduce what was once magical and spiritual down to chemistry. It might be depressing, if it wasn't so fascinating.