PALATE CLEANSER 1: Zorro and Ankle Fracture

BELIEVABILITY IS WHAT COUNTS

I never thought I'd be able to write a post that mentions Terminator Salvation and Zorro, The Gay Blade in the same sentence, but here we are. What could these two movies possibly have in common? Ankle fracture, sort of.

As was discussed in a previous post, in Terminator Salvation, giant robots are manually dumping humans into "transport vehicles" (who talks like that?). Once released from the grip of the robot, those people are falling from a height significant enough(1) to cause one of two types of fracture-dislocation of the foot; either Pott's fracture, Dupuytren's fracture, or any variation thereof.

Here's an x-ray of Dupuytren's fracture a.k.a Paratrooper's fracture. You can see the way the foot bones have been driven up, between the two bones of the lower leg. As a point of interest, any dislocation is also going to involve sprain because ligaments will be torn.

Terminator Salvation's relationship to ankle fracture is that of missed opportunity. A little hobbling and deformity on the part of a minor character would have given this film about machines and cybernetic organisms taking over the world a lot more credibility. Too bad. It's really the little things in explosive, apocalyptic, science fiction movies that can make or break them.

How does this relate to Zorro, the Gay Blade? Here's the quick plot synopsis from Anonymous at the IMDb site: "In 1840's Mexico, wealthy landowner Don Diego Vega adopts the persona of his late father's secret identity as Zorro, the masked folk hero. But when Vega is incapacitated by an injury, he asks Ramon, his very gay, long lost twin brother (now calling himself 'Bunny'), to replace him as the caped hero, who makes some drastic changes his Zorro persona." That Anonymous sure can write. For a more complete story, see Wikipedia.

The key phrase here is "incapacitated by an injury." Diego(George Hamilton), disguised as Zorro, attends a costume ball, flirts with the ladies, angers the bad guy, gets in a fight and (through a little slapstick comedy) stumbles backward off of a balcony, to land on his feet, at the edge of a fountain, injuring his ankle. He hops to his horse and rides home.

Zorro, before the fall.

At home, Diego accurately cares for his acute injury with R.I.C.E. therapy(2). We see a shot of his foot. It is puffy and bruised. Now I'm no doctor (I watch one on TV), but for that amount of swelling and ecchymosis, I'm willing to bet Diego has at least a 2nd degree ankle sprain(3), or possible 3rd degree sprain, perhaps with fracture of the fibula or medial malleolus (lateral and medial ankle bones).

I couldn't find an image from the film of Diego's injured foot, but it looked quite like this.

In one of his finest acting moments, George Hamilton, who has been hobbling about and wincing in a most convincing way, is confronted Captain Esteban (Ron Leibman) who suspects his identity. Esteban tells Diego that Zorro escaped, but his ankle is "sprained, possibly fractured." Diego, to prove that he is not Zorro, dances and hops about on his injured foot, trying to disguise his acute pain from Diego. The ruse works and Diego leaves. It's actually funny if you think about the additional damage he would be doing to an injury like that. He would probably pass out from the pain.

I don't know if it was Hal Dresner, Johnston McCulley, or one of the other writers who decided to use this device, but it works well. Orthopedists watching the film probably pee their pants with laughter.

ONWARD

I am putting together cyborg research. If anyone would like to suggest any films featuring cyborgs (not androids, clones, or robots) beyond the usual suspects of the Terminator series, Robocop (a misnamed film if ever there was one), Star Trek: First Contact, Cyborg, Universal Soldier, or I, Robot(4), please do.

1. In the movie it seems that they are being dropped into these cages from a height of 12-15 feet onto a solid floor.

2. Rest, Ice, Compression, Elevation.

3. A sprain is the over-stretching, or tearing of a ligament. In a 2nd degree sprain, as much as 99% of a ligaments fibers can be torn. For more on sprains and R.I.C.E. therapy visit the Merck Manual Online.

4. Will Smith's character qualifies as a cyborg because of his prosthetic arm and its capabilities.

THE ELEPHANT MAN part 3- Pain

J. HURT AS J. MERRICK

This will be the last entry about Proteus syndrome and The Elephant Man. Brace yourself: the entry is a little long and complicated because I'm still working through the diagnostic criteria chart from the Leslie Biesecker article from The European Journal of Human Genetics, mentioned in my April 2 post. Yes, I know that some people may be ready to go on to other things, like antiseptic practices in the late 1800s, or a description of how Spiderman could grow web-squirting organs in his palms. To them I say, "All In Good Time." I assume that most of you are willing to go the distance with David Lynch and J. Merrick. So here we go...

WHAT WOULD IT FEEL LIKE TO LIVE WITH PROTEUS SYNDROME?

Merrick's defomities probably threatened his life by crowding and compressing other tissues and structures in his body. It may be possible that his growths invaded other tissues, but that seems unlikely. Cancer is invasive. Benign tumors like fatty lipomas (more on these later) are not invasive, but when these growths and tumors reach a certain size, they can wreak a lot of havoc on the body.

Section of specific criteria for diagnosis of Proteus Syndrome

As we continue to compare David Lynch's J. Merrick to the Specific Criteria(1) for diagnosis of Proteus syndrome, I will also talk about the types of pain that it is likely Merrick was experiencing from his deformities. Because I'm a teacher specializing in pathology for massage therapists and I'm not a doctor (although I watch one on TV)(2), I'll be focussing mainly on pain Merrick may have felt from over-crowding tissues and musculoskeletal complications, although he certainly may have had many other sources of pain and discomfort.

Look at this picture of Merrick’s skeleton.

As we hear in the film, only his left arm and genitals escape deformity. We can see the bony hypertrophy(3) in Merrick’s right femur (thigh bone), upper extremity, and skull. Muscles attach to those bones and rub across them as they shorten and lengthen. Every time a muscle contracts, it presses into the bone beneath it. The pressure and movement generated by the muscle on the bone would be rubbing it "raw" continuously. Man, that's gotta hurt! The degeneration of his joints would make it severely painful to move those limbs and he would have extremely limited range of motion.

J. MERRICK

The deformity in his joints would cause uneven weight distribution, leading to inflammation and a painful arthritis. As if that weren't enough, those skin growths aren't as flexible as regular skin. They would be heavy, and restrict joint movement by not being able to stretch as Merrick lifted his arm or flexed his elbow. Come to think of it, the bulk of those growths could also get compressed as a joint moved, restricting motion. In the film Merrick limps and rarely uses his right arm and hand. When in public, he also covers his right arm and hand entirely, which means the task of make up would be easier.

RUB SOME SALT IN THOSE WOUNDS

In The Elephant Man, Merrick is beaten by the side show manager. Whether this really happened or not, the violence is off screen, but still very disturbing. I study stage combat as a hobby(4) and I appreciate effective violence. I found myself swept up in the scene and although I couldn't see it, I imagined poor Merrick with everything he'd gone through being caned by his manager. Merrick probably had chronic painful muscle spasm and joint pain from arthritis and postural deformity, he's horribly disfiguring by skin and connective tissue growths, and he's beaten! I envisioned that cane pummeling those cerebriform growths, which would have a pretty good blood supply, and the amount of bruising and pain those blows would cause. It makes my neck tense just to think about it.

Since Merrick was beaten in the film, the next logical question is: who would have spent time keeping Merrick's wounds clean if he weren't at the hospital? He couldn't do it himself. Even if those crevices on his back weren't injured, hygiene is extremely important for preventing skin infection and this was a time when hygienic practices weren't that popular.

Crevices in healthy skin are still susceptible to infection. Fungi love dark, warm, creases in the skin and Merrick certainly had a lot of them. Here's a normal armpit with a simple tinea (fungal) infection. ARMPIT

Even if Merrick's skin was intact, regular bathing and clean clothing would be imperative for maintaining skin health. It's not like he could just powder himself with Tinactin whenever there was a problem. Not only do we have pain, but itching with this scenario.

HEADACHE

J. MERRICK

J. HURT AS J. MERRICK

Merrick’s skull and facial deformities could be credited to “hyperostosis of the skull(6),” from Category B, above. The swellings on his forehead could be partially from bony growth but also from Category C's, “Dysregulated adipose tissue.” Adipose is fat and the swellings on the head could very likely be fatty tumors (lipomas).

Other diseases such as osteitis deformans (3), that cause enlargement of the skull often lead to severe headache because of the stress on the connective tissues surrounding the brain and possible pressure on the brain and cerebrospinal fluid. Merrick probably also had strain on his muscles from the weight of the head. This isn’t in the movie, but I would imagine that Merrick would be subject to some raging headaches caused by both his deformity and severe muscle tension.

BACKACHE

MERRICK'S SCOLIOSIS

Look at the curvature of Merrick's vertebral column in the skeleton photo. In the film we can also see this scoliosis(8) in the naked sillouette of Merrick, as Treves presents his case to his peers at the hospital. When we look at the photo of Merrick’s actual skeleton, it’s hard to tell if there is severe bony deformity causing his curvature, or if it’s a functional deformity as his vertebral column tries to compensate for the incredible stresses put on it from other deformed bones, plus the pounds of tumors distributed throughout his body. I would think this kind of condition would cause debilitating back pain.

In the movie, and reported elsewhere, Merrick had to sleep sitting up because the weight of his head was too great. In the film Merrick chooses suicide by sleeping supine as a normal person would(9). Think about the way you felt the last time you slept sitting up, then imagine having to do that every night.

AND HE’S A NICE GUY

Throughout the film, Merrick is a pure soul. He is grateful for Treve’s support, treats everyone with courtesy and kindness, and never complains about physical discomfort. Is that possible in a person? As a massage therapist, I’ve worked with clients in chronic, incurable, debilitating pain who had to live most of their lives tanked on pain killers and hooked up to TENS (transcutaneous electric nerve stimuation) machines(10). Some of them were complainers, and frankly, who could possibly blame them? Some of them were the most pleasant, giving, non-complaining people you’d ever hope to meet.

Could Joseph Merrick, a grossly deformed person, probably in constant chronic pain, living in a world without Tylenol or other effective non-addictive pain-killers really be that type of person? If I had to cope with his incurable condition, I’d probably get super drunk all the time, then eventually go on a killing spree and throw myself out a window.

WHAT COULD I, CLAUDIUS POSSIBLY HAVE TO DO WITH THE ELEPHANT MAN?

Merrick has a speech impediment from his facial deformities. Did he have the “parotid monomorphic adenoma(11)” from Category B, number 3b? John Hurt

does a rather wet and drippy sounding voice for Merrick, which I would normally find admirable. But as I was watching the movie, I kept thinking of Derek Jacobi in I, Claudius. I couldn’t figure out why Hurt would sound so much like Jacobi until my husband pointed out that Hurt played Caligula in the same BBC production from 1978. Hurt's version of Jacobi's version of the Emperor Claudius' speech impediment was a little distracting. If encourage you to watch The Elephant Man then watch a later episode of I, Claudius and you will know what I'm talking about.

HURT AS CALIGULA (left)

JACOBI AS CLAUDIUS (right)

If you made it through this entire post in one sitting, you have some highly developed attention endurance skills! This one got away from me. But that’s it for Merrick and Proteus syndrome. Next time I’ll do a little Elephant Man mop up (ha!) about the surgery scene at the top of the film and antiseptic practices in the days of surgeon Fredrick Treves.

1. See post for April 2.

2. Yes, this is the second time I've used that joke, but it's good to keep reminding people that I'm not a doctor and can't do what they do.

3. Over-growth of bone

4. For great information about stage combat classes go to www.safd.org, or if you're in New York, try Joe Travers and Swordplay workshops.

5. Tinea is a common type fungus that is responsible for athletes foot, ringworm, nail fungal infections, etc.

6. Increased bone growth.

7. Osteitis deformans is a chronic condition usually affecting men in middle/late age in which the bones of the head, trunk, and legs become enlarged. The bone will also weaken as it grows, leading to deformities, pain, arthritis, and fractures. The condition is occasionally called "Tight Hat Disease," because your hat would get tighter as your skull got larger. Another popular name for this condition is Paget's disease, named after Sir James Paget.

8. Scoliosis is a lateral curvature of the spine, often accompanied by a rotation. The condition can vary greatly, and can be caused by lots and lots of things including having a head that weighs three times what it should.

9. I have read two different descriptions of how Merrick's supine position killed him. Wikipedia currently says that he dislocated his neck this way. Other sources say that he crushed his trachea, or if he didn't crush it, compressed it to the point which he couldn't breathe. The film doesn't get into the details here.

10. The TENS machine is an apparatus that applies an electrical current through the skin of a patient. This current helps to control pain. Here's a link to Wikipedia, if you're curious. Be warned that the article still needs some work.

11. A parotid monomorphic adenoma is a type of tumor of a salivary gland.

Face/Off part 2 - new anti-inflammatories

NEW ANTI-INFLAMMATORIES

Walsh and Miller pitch the face transplant idea to Archer.  While trying to convince him that this cosmetic/transplantation procedure will be a snap, Walsh tells Archer, "with the new anti-inflammatories, healing takes days, not weeks."

Inflammation gets a bad reputation, but actually helps to stimulate acute wound healing.  The problem is that inflammatory reactions can get out of hand and secondary tissue death and/or delayed healing can be the result.  I'm curious what "new anti-inflammatory" might make it possible to heal from major surgery in "days, not weeks."  One interesting anti-inflammatory mediator I cam across is called Activated Protein C, or APC for short.  This stuff is great at healing rat skin(1) and seems like a very promising therapeutic agent for the healing of chronic wounds.  Even though the research I found dates from 2005 instead of 1997, kudos to screenwriters Mike Werb and Michael Colleary for hopping on the research train.

Image from Regrowhair.com

OTHER PROCEDURES

Walsh also tells Archer that they'll use "laser sheers" and micro plugs to alter his head and body hair.  Did you know that about 80% of all transplanted hair falls out within three weeks, then starts growing again(2)?  I love the idea of John Travolta and Nicholas Cage going about this movie with many looking bald patches on their heads and torsos.  Did they transplant leg hair too?  How many hours would that take?  A head can take hours.

Image from Wikipedia

This is a great line: "Your blood types won't match, but Pollux won't know that." But Pollux might get suspicious when Archer's face, which would actually be Troy's face, started turning black and sliding around.  The problem here is that blood typing is really important to transplanting.  Tissue rejection can happen within minutes to hours (acute rejection) from blood coagulation, if the donor and recipient don't have compatible blood types.  Tissue typing would also be a good idea if you were doing a transplant.  More on this in later posts.

Walsh also explains to Archer that abdominoplasty can be performed for his "love handles."  Abdominoplasy is often called a "tummy tuck."  The procedure involves "tightening" the abdominal musculature and fascia with sutures, repositioning the navel, cutting away redundant skin, and a little liposuction to get those extra areas of fat.  Does Troy get Archer's fat squirted into his abdominal fascia when he takes Archer's place?  Ew!  He might need some of that cut away skin to accommodate the extra fat.  Ick!  If he's on prednisone (an immune suppressive drug to prevent tissue refection) for long enough, he may develop a layer of abdominal fat caused by the drug, and not have to get Archer's fat squirted in there after all.

"REAL" SCIENCE

Walsh has been taking Archer around his facility, showing him the great strides he's made in surgery, tissue regeneration, and transplantation.  After talking about anti-inflammatory drugs and love handles, Walsh says "but here's the real science."

Face/Off

To give Archer Troy's face, Walsh is going to use a "state of the art Morphogenetic Template" which looks like a clear hard plastic facemask with blobs of putty inside it.  The inside is modeled on Archer's skull, the outside on Troy's skull, although the external surface is shaped like soft tissue and not bone.  The morpho plate (my nickname for it) doesn't have a separate jaw hinge, which should make speaking difficult, but we don't notice any speech impediments or inability to chew, post operation, so what do I know?

That the template is "morphogenetic" implies all sorts of things, and nothing at all.  Morphogenesis means the formation of an organism.  It can refer to cell formation, tissue formation, and also the organization of cells and tissues in a larger structure or organism.

So if I was the writer trying to justify the science, I might say that the morpho plate was impregnated (by lasers, of course) with some type of, I don't know... polymer?.... enzyme?... protein?... I'm trying to recall substance that previous movies have relied on for this kind of thing.  Ultimately the plate would be impregnated with something that promotes organized cell growth, as dictated by the DNA(3) of the cells in the donor tissue that has been laid over it.

Image from Wikipedia

Now, this part is unclear to me:  The remove Archer's skin, put the mask on him, and put Troy's skin over the mask to "fit the face on top."  Walsh will "simply connect the muscles, tear ducts, and nerve endings" and voila!  My confusion arises because some facial muscle run from bone to bone(4), some run from skin to skin(5), and some from bone to skin(6).  If they want to attach zygomaticus minor, how do they get the muscle from Archer's face through the mask to Troy's mouth-skin?  Or, how do they get Troy's muscle through the mask to the bone below?  Apparently they can do this because both men smile after their transplants.  Of course Archer (as Troy) is smiling ironically at the cruelty of his position, but it's still a smile.

Even with the "new anti-inflammatories," it takes time to build movement skills with parts that have undergone major surgery, or parts that were moved from one area to another, or parts that aren't originally yours.  As an example of the time it takes for this type of recovery, the woman who received the first face transplant in the United States in December of 2008 has a good prognosis.  she should have feeling return to her face in six months, and with physical therapy to retrain her muscles, she should be able to smile and have most function (speaking, eating, expression) return in about a year(7).  Archer has six days to have transplant surgery, recover full function, fool Pollux into revealing the location of the bomb, find it, and neutralize it.  That's a lot of pressure for his physical therapist.

One of my favorite things about this film is that everyone keeps saying, "this procedure is completely reversible."

Next time, the surgery!

1.  Jackson, Christopher J., et al. "Activated Protein C Prevents Inflammation Yet Stimulates Angiogenesis to Promote Cutaneous Wound Healing." Wound Repair & Regeneration 13.3 (2005): 284-94.

2.  "Hair Today, More Hair Tomorrow?" Harvard Health Letter 33.10 (2008): 1-3

3.  Yes, I know DNA is so 90s but this is a 90s film, so it would fit if they'd used it.

4.  E.g., the masseter which closes the jaw, attaches at the cheekbone and onto the jawbone.

5.  Obicularis oculi makes a sphincter around teh eye, just under the skin.  It is a blinker and a squinter.

6.  Zygomaticus minor runs fromt he cheekbone to tissue of the upper lip.  This muscle contributes to smiling and sneering derisively.

7.  Altman, Lawrence K.  "First U.S. Face Transplant Described."  The New York Times, December 18, 2008.