File: consent.txt Cont: (pre)venting one's spleen : fine art of consent and legal obfuscation Date: 18 Nov 2003 If you take your top off and feel your belly below the left lower margin of your rib cage, you won't feel anything much, but that's because you're probably normal. I can, and I'm a bit curious about it. I normally sleep face down with a forearm across my abdomen, and of late, stuff has been moving about inside my guts when I do this, to accommodate a change. This is 'cos my spleen has become large and relatively rigid, taking up more room than is normally allocated to it, a condition known by a word which rolls delightfully off the tongue - splenomegaly. I knew that's what it was called, 'cos when, years ago, I did honours and (deliberately) became acquainted with cytomegalovirus III (which is present in about 90% of the human city dwelling population, and has called me home for about 20 years) splenomegaly was one of the listed symptoms of active CMV infection. CMV usually does fuck-all as long as you're not immunosuppressed or a neonate, in which case it raises all kinds of hell. I sure as shit don't feel immunosuppressed and am exhibiting none of the signs associated with that state (like, being sick all the time). So what's going on? Spleens (a few people have more than one, some are born without them) are the centrepiece of your lymphoid system, wherein is trained an astoundingly complex army of highly specific, molecular recognition capable, cellular attack dogs. Spleens are connected to the lymph nodes (most people call 'em glands, such as the ones in your neck, armpits and groin which swell up when you're sick) via specialised lymphatic plumbing wherein these attack dogs (lymphocytes) roam in search of specific things to kill. You can live without a spleen but you tend to be an easier target for massive bacterial infection if you lack one. I waddled off to retrieve me ol' Merck Manual (any time you're feeling hypochondriacal, DO NOT READ THIS BOOK) and had a gawk at the shitlist of conditions associated with splenomegaly. The 'Manual is best read when you're in perfect health, since it's pretty depressing if you're not. The list is extensive and distasteful. It includes EBV (gives you glandular fever, close viral rello of CMV). CMV (hello old friend, hope it's you). Polycythemia Vera (broken erythropoiesis leading to too many red cells in the blood, the spleen has to expand to provide sufficient resources to destroy 'em). HTLV-3 (which is what they used to call HIV before they realised HIV was an RNA retrovirus). Wilson's disease (inherited disorder of copper metabolism). Lymphoma (malignant cancer of the lymph system, ooh, yummie). Spleens also enlarge for other reasons... sarcoidosis (nobody really knows what causes this), chronic parasitisation, spherocytosis, sickle cell anemia, kinks in their associated vasculature. Various bone marrow fibroses which, on account of their preventing erythrocyte synthesis, can also provoke the spleen to start making these cells instead, but spleens aren't very good at it and tend to release erythrocytes before they're really ready to do their job. With the exception of CMV, all of these things are probably far too exciting to apply to me. So... what's doing it? I arranged to go and have a full blood count, electrolyte analysis, and hepatic function test. The analytical processing used in haematology is heir to knowledge won by humans struggling to understand chemistry and biochemistry over a period of centuries, but nowadays is mostly automated, so it's pretty simple, you just pop along, give 'em a few mL of venous claret (it's always encourgaging that they send it off to the lab in a bag prominently labelled `Biohazard') and wait for the results to come back. Inbetweentimes, machines separate your blood into several different components, humans peer intently at the nature of the isolates, and ponder upon wether or not your metabolism is broken in some significant way. I got the sheet back a couple of days later and according to it I am, haematologically speaking, very reassuringly boring, within expected range for pretty much everything. For a guy who does little exercise, I am stuffed full of haemoglobin. The things I wanted to know are all there - specifically, lymphocyte and erythrocyte counts and morphology are goodish. I'm not gonna turn into a life support system for a load of tumors just yet (that'll happen later when the mesothelioma starts). This test ruled out a lot of things, but still doesn't tell me anything about why this is idiopathic splenic bloat is happening. The final bit of interrogation will be an abdominal CT scan, in a day or two. These use X-rays, so in order to make oneself more radiopaque, one is required to selectively stuff oneself with heavy atoms in advance of the scan. One gobbles down a load of barium sulfate the night before (I know all about that stuff from my Merck Index - same publisher as the Merck Manual, different topic) to make one's intestines less transparent to the incoming electromagnetic rays. On the morning of the scan, though, they inject you with ... well ... something. The consent form doesn't say exactly what it is with which one is going to be injected. It mentions that the stuff which will be injected into you is a radiopaquing agent, implying it's a vasculature contrast medium, and alludes that the material contains iodine (makes sense, iodine's a heavy atom, the sort x-rays cannot penetrate) and is non-ionic (exists in an uncharged state... so what?). Nowhere, however, is the molecule or mix of molecules actually specified. Iodine in its native aqueous diatomic state would kill you stone dead if you were injected with it, so it obviously isn't that. But what is it, exactly? They give an associated death rate when using this stuff intravenously as less 1 per 180,000. But which stuff? How can I give them informed consent to shoot me up with some or other crap if they won't tell me what it is? If they tell me what it is, I can investigate its metabolic half-life, LD50 and eventual fate perfectly well in the existing literature, and make a decision. I'd normally go looking in my Martindales 38th pharmacopoea, but opaquing agents are not, strictly, pharmaceuticals, so they don't list any, as far as I can see. The mention of iodine, lower down in the form, is an important giveaway... one can whiz off to the Merck Index and directly observe structures of any molecules whose names start with io- or iodo-, and grep immediately at the bottom of these entries looking for the words `opaquing agent'. This won't get all of them (I mean, there's a heap of different ways to iodinate any of a squillion different molecules for this purpose) but one can at least acquire something like a clue about their probable natures. It appears most of the ones in this section of the Merck are variations on, or oligomers of, 1,3,5-triiodobenzene. Don't get the idea there's anything spooky about iodine, one needs it for thyroxine synthesis, and one gets goitred without it, among other things. I think I'm going to be shot up with any of iobenguane, iobenzamic acid, iocarmic acid, iocetamic acid, iodamide, iodipamide, iodixanol, iodoalphionic acid, iodopyracet, ioglycamic acid, iohexol, iomeglamic acid, iopamidol, iopanioic acid, iopentol, iophenydylate, iophenoxic acid, metrizamide, metrizoic acid, iopromide, iopronic acid, iothalamic acid, iotrolan, ioversol, ioxilan, or ipodate. I could sieve these entries by their water and lipid solubility to narrow it down to ones likely to stay in the blood rather than be incorporated into my cell walls for the next few years. None of these are radioactive (of course, they just scatter the x-rays, they don't emit anything themselves) and I think I excluded all the ionic ones from the list (and who in hell invents these names?!) But which one? I got LD50's for mice, rabbits, and just about everything else that moves there in the Merck, some of these things are actually moderately poisonous (especially if you're an experimental mouse or rabbit) though you'd have to shoot a lot more of them up your arm than the equivalent mass of diacetylated morpine required to kill a heroin user. I wonder what percentage of the population in general knows what is meant by non-ionic contrast agent anyway? I know what it means, but don't know why non-ionisation matters to the procedure. By signing this form I effectively say to these people, I don't care what you're gonna shoot me full of, go right ahead. This is, actually, an _uninformed_ consent document, wherein you put your signature on a chunk of paper that says that you neither know or care what is going to happen in this procedure. If, subsequent to some mishap in the scan, you wanted to get up MayneHealth for compensation, and had made the mistake of signing this thing, they'd piss their pants laughing you out of court. And, interestingly, they're right. I actually don't care. So shoot 'em up and pass the bremsstrahlung, I wanna know what's goin on in my guts. (the next .txt in this series is conway.cat.org.au/~predator/gutful.txt)