Dr. Galen's Little Black Bag

by R. A. Comunale M. D.

  “For the most part, the best tools you have will be your fingers,” Gable added.

  Quit lickin’ yer chops, Berto.

  I couldn’t help it; I let out a snorting laugh, which drew a glare from Gravel Gertie.

  Later we found out that her hoarse voice was the result of a rare condition affecting her vocal cords. It would ultimately take her life.

  “Blunt dissection is always your best bet. You won’t damage structures that way.”

  While we looked on, Hedley’s hands reached like ice-cream scoops on either side of Harry’s brain, his gloved fingers gently loosening the tissues from the boney case we call the skull. He motioned for me to cut underneath where the telephone cables of the brain—what ultimately becomes the spinal cord—exit through the base of the skull.

  The entire class watched Hedley triumphantly holding that tan-gray object above his head like a proud father.

  All that Harry had once been, all that he had once felt and experienced—love, hate, happiness, despair, ecstasy—vibrated as electrical and chemical impulses through that amazingly compact, organic computer.

  Where was Harry now?

  Ya don’ wanna know, kid.

  Days, weeks, months passed. Gradually we got to know Harry more intimately than any partner he had had in life. We spent extra time on weekends and evenings studying him, often bringing snacks and sandwiches to munch on. We’d quiz one another on the various structures such as Harry’s cigarette-smoke-stained lungs, his enlarged heart surrounded by fat, his coronary arteries already almost completely occluded. If the stroke hadn’t killed him Harry would have died almost as quickly from a massive heart attack. And if that hadn’t done him in, the aneurysm in his aorta, a balloon-like weakness in the artery wall, would have sparked a fatal hemorrhage if someone had punched him in the gut—or even if he had sneezed too hard.

  Harry’s other internal organs were no better. His liver was also enlarged, and his pancreas was scarred from too much alcohol. His gallbladder was filled with stones; his kidneys shrunken, the effect of the prolonged, high blood pressure.

  This man had felt pain and ignored it for most of his adult life.

  No doubt about it, Harry had lived hard and died young. The scarring from gonorrhea and syphilis, and the premature enlargement of his prostate, betrayed his penchant for the ladies.

  The only organs that seemed intact were his stomach and intestines—until Gable pointed out the ulcers, a result of his alcohol intake.

  We examined Harry’s muscles, separating each one out and noting how it created a particular motion. It was a difficult study; the preservative fluids had made the muscle fibers brittle, and the evaporation and drying out made them less comprehensible.

  We spent time on another cadaver as well—a necessity for learning the distaff anatomy. During our first trade, we learned that the other group had named her “Shirley.”

  Reminds me of the gal that was with me when I got whacked. Remember her, Berto?

  The old nursery rhyme is wrong; women aren’t made of sugar and spice, and not everything is nice. They, too, can live hard lives and suffer the consequences, often more severely than their male counterparts.

  Sometimes I dream of Harry and Shirley.

  Did they ever meet in life?

  By early spring our cadaver was now in pieces. We had been tested many times on him and the other bodies in grimoire-march practical exams.

  We had suffered routines like this throughout college, moving in single file past various stations of the biologic cross, given twenty seconds to identify ambiguous structures in sea creatures, plants, frogs, cats, and dogs.

  Now the human counterpart challenged us: dried-out pieces of humanity with pins stuck through them and a question scribbled alongside that taxed our brains:

  One: What the hell was that small dried-out macaroni-like tube that bore no resemblance to its real-life appearance?

  Two: What did it do?

  Three: What other action did it work against?

  And so on.

  Our first year was coming to an end. We had studied the normal aspects of the human body: its chemistries, its physiology, and its large, small and microscopic structures. We had attended physical-diagnosis sessions, seeing and talking to live patients. At first clumsy and uncertain, then with more and more self-assurance, we examined them in front of our professors.

  Each time we attended, we carried our little black bags like talismans, self-consciously removing the tools of our trade, as we performed for grades.

  And Harry? By the end of the term we had reduced him to skeletal bone and dried-out gristle. The lab assistants had removed his dissected body parts, and we were told they would be cremated in a non-denominational, religious ceremony.

  We could not participate.

  Once more I envy the present generation.

  Hedley and Gable were more animated than usual that second-to-last day in the gross-anatomy lab.

  “Ladies and gentlemen, we have a rare treat for you,” Gable trilled.

  Uh-oh, she’s getting another…

  Shut up, Sal! She’s one of the nicest people you could ever meet.

  “Dr. Hedley has been experimenting with new and improved preservative fluids. These allow the body tissues to appear more normal, more … uh … lifelike in their flexibility.”

  In a flourish more appropriate to a Cordon Bleu Parisian chef, Hedley pulled the cover off of a small, wheeled table, and we stared at disembodied arms, legs and heads that looked as though they had just fallen off someone walking by. He proudly picked up an arm-forearm-hand combination and pulled on the exposed tendons.

  Those of you who are old enough to remember a TV show called “The Addams Family” may understand why some in our class began to laugh and clap, as Hedley the puppeteer manipulated that limb to move across the table. Then each of us experienced the frisson of shaking hands with it.

  What about those heads?

  If you are squeamish, skip the next paragraph.

  Hedley took a flexible tube and inserted it into the stump of the trachea—the windpipe. He held the mouth of the disembodied head open and blew into the plastic pipe. An eerie “ahhhhhhh” resulted, as Hedley’s breath activated the vocal cords of a dead man.

  Congrats, kid. You didn’t even flinch.

  Thanks, Sal.

  Time for me to go, Berto. You’re gonna do just fine now.

  Don’t you want to see me make a fool of myself?

  Nah, I know you won’t. ’Sides, Corrado and I … we’re gonna have a gab fest with Harry and Shirley.

  Good-bye, Sal.

  Nope, it’s arrivederci or ciao. See ya in … oops—not supposed ta tell.

  Sal … Sal?

  On the last lab day, Hedley and Gable congratulated us all for making it through the course. Gable had lost a considerable amount of weight over the year, and Hedley stood more and more at her side to steady her.

  Gable, looking very tired, sat at her desk and smiled, as we all came forward to shake her hand and Hedley’s. Then she gave her valedictory.

  “You are my last class, ladies and gentlemen. I am, as the more astute of you already know, dying of a particular form of cancer. I want to let you know that I am donating my body upon death to this very lab. I know that John,” she turned toward Hedley, “I know John has also made arrangements for himself.

  “God bless you all.”

  Our first year was over … right?

  Guess again.

  Now we faced the dreaded week of comprehensives.

  Our little black bags sat on the shelves in our dorm rooms. We sweated in Richmond’s oppressive heat and humidity, as we pored over all of the notes we had taken during the past year.

  Pass them and move on to second year; flunk and you were either out or—the greater ignominy—forced to repeat year one.

  You know the sensation from hearing finger nails scraping a blackboard? (Do they still use blackboards?) By day seven of the comps
we would have torn the head off a chicken if it looked at us sideways.

  “You’re breathing too loudly, City Boy.”

  “Do you know how annoying your nasal whistle is, Country Boy?”

  It actually helped. After we wrestled each other to the floor, we sat there laughing. Then we hit the books again.

  That final day of comps, we turned in our last exam booklets and headed out.

  Dave was going to spend two week at his family’s farm before returning to his summer job at the school. I had a job lined up as well. It would be two whole weeks of doing nothing, hearing nothing.

  “Wanna come home with me, City Boy?”

  We left together.

  On schedule two weeks later we were back in the anatomy building. Dave and I worked as gofers for several graduate students, doing the scut work and bone articulations of skeletons for teaching assistants.

  “Galen, Nash, would you guys wheel this over to the ENT lab in West Hospital?”

  Charlie Nestor, our boss, was winding up his Ph.D. in human anatomy. His research developed the new preservative fluids for lab specimens. He was pointing at a medium-sized, wheeled table with large, dark-plastic jars on each of its three shelves. It was surprisingly heavy and needed both of us to maneuver it through the streets. We looked like demented hot dog vendors, dressed in foul-smelling, green lab smocks.

  Two blocks and two elevator rides later we reached the lab where the residents specializing in head-and-neck surgery honed their skills on cadaver specimens. The lab master signed our slips and helped us park the table along the wall.

  As we headed out, we heard him laugh.

  “Hey, guys, who’s the joker who played makeup artist?”

  We turned.

  He had opened one of the jars and taken out its contents. It was a human head—hair combed and tied in a ribbon, wearing lipstick and facial makeup.

  Gertrude Gable really did look natural.

  Mother Nature Ain’t Nice

  “Holy shit!”

  Andy Kagill clutched his groin protectively, while the rest of us guys experienced that uniquely male sensation that occurs when we sit in cold water.

  The gals looked on with Mona Lisa smiles.

  “Yes, ladies and gentlemen, this poor woman definitely had a vaginal overbite.”

  Second year medical school had begun on a beautifully balmy August day—definitely not weather conducive to studying. But this was pathology year, the year of the odd, the unusual, and the unexpected. Our previous year had been spent learning the normal, or what was considered normal. Now we got to see in full detail the tricks that Mother Nature could play on her children.

  We stood there in the Pathology Museum, staring at a vast array of organ specimens in thick glass jars. Needless to say, the urology and gynecology sections grabbed our attention.

  “This is a perfect example of a teratoma,” Professor Madden intoned, pointing at a large jar containing the mortal remains of a woman upon whom nature had bestowed the ultimate indignity: Lining her vulva were two complete rows of teeth.

  For you scientifically inclined readers, teratomas are tumors that usually begin when a baby forms inside its mother. Cells that ultimately become different types of organs and tissues locate in the wrong place and develop just as they would in their correct position—hair, eyeballs, limbs, you name it. They can be found anywhere from the base of the tongue to the genitals.

  Our class clown, Andy—yes, medical school has them—leered at his girlfriend, Tanya.

  “You aren’t going to surprise me, are you?”

  The smile on her face could have air-conditioned the room.

  “You’ll never know.”

  Most of us had survived the first year’s comprehensive exams, that critical testing of mind and body, fighting fatigue and knowledge overload. Ten did not. Three would be repeating freshman year, one had shot himself, and six had decided their best interests lay elsewhere.

  Year two meant pairing off, kindred men and women finding each other and beginning the dating/mating ritual full tilt. Dave had fallen head over country-boy heels in love with Connie, whom he called the Teacher. My other friend, Bill, aka Baby Face, had lost his gentleman’s reserve over Peggy, the Southern Belle.

  Me? I wasn’t the passionate type.

  Right.

  Until I met June, aka The Model.

  From that time on the six of us became life-long friends. We survived and thrived in school because of one another.

  I miss you, my friends.

  Sophomore year. We carried our black bags to clinical presentations, ready to jump up and approach a patient staring back at us from a chair, wheelchair, or stretcher when a professor called our name.

  “Mr. Galen.”

  “Yes, sir?”

  “Take a look at our patient. What are your observations?”

  Dr. Stemp was known for pulling surprises.

  The young man, no more than seventeen, smiled at me when I approached him. He sat in gym shorts and tee-shirt, totally unfazed by the two-hundred-or-so eyes staring at him.

  “Hi … uh … Mr.…”

  “I’m Terry.”

  “Okay, Terry … uh … would you please take your shirt off?”

  “Sure.”

  He reached over his shoulder and, in that special guy way pulled the back of the white tee up and over his head and then looked right at me.

  I don’t know if my classmates in the amphitheater saw it, but I had one of those pit-of-the-stomach reactions when I spied the glistening, red-black, one-inch spot on Terry’s right shoulder. I moved closer to him, palpated it and then felt under his arms and around his neck. The enlarged lymph nodes were unmistakable.

  “Terry, would you lie down?”

  He stretched himself out on the cart, and I ran my fingers over the place in his abdomen where the liver would be. It wasn’t hard to find. It was twice normal size.

  I helped him sit back up and turned to the professor.

  “Terry has melanoma, and it’s spread to his lymph nodes and liver.”

  The room went silent. Even as sophomores we knew what it meant. We had just completed a section on malignancies of the skin. This young man’s fate was sealed.

  It is fairly easy to read a textbook and study photos and descriptions of different medical problems. It’s another story when the subject is alive, alert, and damned nice.

  “Didn’t you forget something, Mr. Galen?”

  Dr. Stemp raised his right eyebrow.

  Terry whispered softly, so I think I was the only one to hear him.

  “Listen to my chest, Doc.”

  I quickly opened my bag, took out my stethoscope, and self-consciously strained my ears. The classical machine-shop rumble of a hole in the heart wall separating the two main chambers roared back at me.

  “Terry has a VSD, Dr. Stemp, a ventricular septal defect.”

  Stemp nodded, and I sat down.

  In small groups, the rest of the class approached, examined the devil on Terry’s shoulder, and listened to the demon in his chest. After we finished we applauded the young man as an attendant wheeled him out of the room. When they reached the door, Terry sat up, forming the two fingers of his right hand in a V and yelling, “I’m going to lick this, guys!”

  Stemp stared at the floor; the rest of us tried our best not to cry.

  Other memories of those days march through my mind: more practical exams with microscope slides, unlabeled organs in jars, and fresh specimens delivered straight from the operating room or the morgue. Each bore the cryptic questions designed to tease and distract us. We didn’t just identify, we had to extrapolate: What would you expect this patient’s blood tests to show? What symptoms did he or she experience because this organ was not doing its job? And so on.

  We learned something else: vigilance. At conferences we saw doctors called on the carpet and made to look like fools for missing what were obvious diagnoses to the pathologists once they had sliced open a dece
ased’s body. We witnessed even high and mighty specialists knocked down like bowling pins by the pathology reports. And indirectly we learned that cherished beliefs often have no basis in fact.

  “Class, Mrs. Dayten was kind enough to share her problem with you today before her surgery.”

  The general surgeon smiled benignly at the middle-aged woman sitting in the wheel chair. We had just studied breast tissue and the various tumors that could occur.

  “Miss Sabo, would you do the honors?”

  My classmate Judy hesitated then rose from her seat and approached the woman.

  “Hello, Mrs. Dayten, I’m Judy. What seems to be your problem?”

  She jumped back reflexively when the woman abruptly pulled open the top of her gown. Even from the back row we could see the corrugated surface on her left breast.

  Paget’s disease of the breast. Insidious and misleading, it often appears as a skin rash like eczema and lulls the unaware into ignoring it until it becomes untreatable. Today’s health-savvy women are trained not to ignore even the slightest changes. Back then, neither the patient nor the medical professional were as enlightened.

  Once more we stood in small groups around our patient and saw and felt the peau d’orange (orange-peel) roughness of the skin over the tumor.

  Mrs. Dayten was to undergo a radical mastectomy in several hours. The women in the class held her hand.

  We knew what would happen to her. Surgeons would remove not only the entire breast but also the lymph nodes under her arm and even some of the muscle tissue. That side of her chest would become a living skeleton.

  Now, decades later, I shake my head in dismay. The procedure maimed those who underwent it and did little to prolong their survival.

  What present-day treatments will become anathema under the scrutiny of future knowledge?

  The year progressed and we marched through the various disciplines of the human body, studying each organ system with its unique chemistries, physiology, and anatomy, both visible and microscopic. And as we did so, we were introduced to the living personifications of what could go wrong.