Dissection: A Novel

By R. Peter Mogielnicki

This first novel by a retired professor of medicine is a must read for anyone interested in medical crime and their own bodies. The tale follows a second year medical resident who stumbles on an overly cozy relationship between a medical device manufacturer and one of her husband’s surgical training program mentors while she is researching a talk to her fellow residents. With help from a tech-literate immigrant hospital librarian, an eccentric morgue deiner and the bird-loving chief of the supply department she gradually untangles the mischief only to be confronted by the perpetrator as she discovers crucial evidence. The tale’s ironic denouement surprises even its heroine.

Just as readers of historical novels come to better understand a previous era, readers of Dissection come to understand some of the miraculous workings of their own anatomy and physiology. A detailed illustration from the 100th edition of Gray’s Textbook of Anatomy serves as a frontispiece map to which the reader can return as the story proceeds and each of the novel’s chapters begins with a brief quote from Gray’s describing in eloquent yet precise terms a portion of human anatomy relevant to the subsequent chapter.

Robert Peter Mogielnicki, M.D. is a Dartmouth (now Geisel) Medical School Professor of Medicine emeritus who was drawn away from New Hampshire to Portland Oregon by the pull of his children and grandchildren. Most of his previous publications have been in the professional medical literature with a recent foray into personal essays on his blog at Cereflections. Dissection is his first attempt at fiction and has been in the works for the past 5 years.

• Language: English
• Publisher: R. Peter Mogielnicki
• Release date: Nov 22, 2017
• ISBN: 9781370662548

R. Peter Mogielnicki

Robert Peter Mogielnicki, M.D. is a Dartmouth (now Geisel) Medical School Professor of Medicine emeritus who was drawn away from rural New Hampshire to Portland’s Beaumont Wilshire neighborhood by the pull of his children and grandchildren. As an English major at Cornell University in the 60’s, he vacillated between a career as a writer or physician and eventually chose the safer route. Most of his previous publications have been in the professional medical literature but since retirement he has changed to more creative genres.In 2017 he was honored to have his submission, Dissection: A Novel, selected among entries in the Library’s Writer’s Project for inclusion in Multnomah Library’s ebook collection. Since then he has been working on a collection of essays published in 2023 as Second Thoughts: Reflections on Us and the Natural World. He and his life partner and sometimes editor, Nancy, are fortunate to have a summer home on the Rhode Island shore. That environment has inspired several of the essays in Second Thoughts.When not writing, or doing home maintenance he spends his time building Legos with his grandchildren, gardening, fly fishing in both fresh and salt water and working on a variety of environmental causes.

Book preview

Preface

"The best thing for being sad, replied Merlin, beginning to puff and blow, is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder in your veins, you may miss your only love, you may see the world about you devastated by evil lunatics or know your honor trampled in the sewers of baser minds. There’s only one thing then, to learn.

T.H.White

The Once and Future King

G.P. Putnam and Sons, 1939 p. 185

Merlin was right. Almost everyone carries some degree of sadness. I have written this story in hopes of alleviating a bit of it. If it succeeds, readers will come away entertained to some degree but also more knowledgeable about the miraculous workings of their own bodies.

After attending to patients’ trembling anatomies for over 40 years I decided to retire from the practice of medicine before someone else told me it was time. Restless, the obvious question arose: what to do now? Anticipating sadness at the loss of professional identity and the rich personal contact with others which is one of the great gifts of the practice of medicine, I decided to follow Merlin’s advice. I had majored in English at Cornell. During my junior year I had agonized over what to do next. The two major contenders were creative writing or medicine. I have no regrets that I chose the safer route. Still, one wonders. Why not give the loser a second chance late in life?

In medical school in the ‘60’s there was an oft-quoted adage: See one, do one, teach one. Mercifully, this is no longer the case in medicine, but having read more than one novel I felt prepared to move on to the second level of that three step rule.

In parallel fashion, Write what you know caroms around writing blogs and workshops. I knew something about the workings of the human body and doctoring and how they both sometimes go astray. And I had also been privileged to share the intimate details of a variety of people. I could combine those themes.

Reading about writing, and reading some great writers, however, has created some tension. The impression I come away with is that the modern literary scene is very much directed inwards. The modern focus is on one’s thoughts and one’s feelings. Identification with – becoming if you will – an imagined character is paramount. Abstractions trump physical reality and our part in it. In Conversations with Saul Bellow the great novelist intones We live among ideas much more than we live in nature. To me, that’s like saying we need air more than we need water. I prefer Keat’s vision: Beauty is truth; truth beauty. I’ve tried to write a book which blurs the invented distinction between the internal world of self and the external world of nature. That is not to say that emotions, ideas, imagination and inspiration can be reduced to neuronal connections or even whizzing electrons. That is a gross oversimplification. Rather they are all different expressions of the same awe-inspiring miracle.

This effort would not have been possible without the encouragement and support of my life partner, Nancy, and our children and their partners – Katrina and Rania Spade, Juliana and Oren Bernstein and John Mogielnicki and Anna Petry. I am also indebted to many others for their technical and literary guidance including Richard Davidson, Alice Eberhart, Kate Ninzel, Mariah Knight, Betsy Woodman, Dale Gephart, Ellen Tremper, Frank Pindyk. And of courseI I owe a huge debt of gratitude to the people who were willing to entrust me with some of their care and who taught me so much.

Chapter One

The word anatomy was used by the ancient Greeks of more than two thousand years ago to mean a dissection (ανατομή) from tome (τομή), a cutting, such as that performed by a surgeon (Hippocrates 460 B.C.) with the prefix ana (ανα) meaning up........Although the study of anatomy is concerned primarily with morphology, the knowledge of structure and function are kept continually in mind. It is interesting in this regard that the Father of Anatomy, Vesalius, in 1543 gave his great treatise on anatomy the title De humani corporis fabrica, which is translated by some authorities as the works or workings rather than the architecture of the human body.

Gray’s Anatomy 100th Year

As the landscaper stood up after working on the flower bed he noticed a brief episode of lightheadedness. It reminded him of the way he’d felt before the episode of internal bleeding that had resulted in some emergency surgery a few months earlier. After the surgery, the surgeon who had operated on him explained that the biggest artery in his chest had begun to leak and if he’d gotten to the hospital any later he would have been a dead man. Fortunately, it had been caught in time and a portion of his leaky aorta had undergone a very clever repair by one of the country’s most expert vascular surgeons who was known for having discovered a number of new ways to repair just such a problem.

High in the landscaper’s chest a bulge about the size of a softball was now enlarging next to the spot where one end of the aortic prosthesis used in the repair had been attached. Within a matter of minutes the immature internal scar tissue surrounding the bulge gave way and the landscaper collapsed into the impatiens he’d been weeding as pints of fresh blood rapidly filled his chest cavity and displaced his left lung.

* * *

The two surgical residents were sharing a late lunch in the hospital cafeteria after a particularly long case of multiple trauma from a five story fall by a construction worker.

I heard another of the chief’s aortic repairs arrived at the ER DOA a couple of months after his repair.

Oh Jeez! He gets even more bilious whenever that happens and I’m supposed to scrub on a case with him tomorrow. After he’s done cursing out the nurses and throwing instruments around the room he’ll start grilling me on the anatomy of the operative field. It won’t be fun.

* * *

The voice of the secretary to the medical device maker’s CEO came in over the intercom.

Call from the Surgical Office at Memorial, sir.

Fine, put them through.

Later that afternoon websites showing insider trades of the company indicated the sale of a sizeable block of its shares.

Chapter Two

Fertilization takes place when a spermatozoon enters the ovum. Normally only one sperm takes part in the process; its entrance causes the peripheral layer of the ovum to change into the vitelline membrane which prevents the entrance of additional sperm.

Gray’s Anatomy 100th year

The trip had been incredible. Rocking in a comfortable berth one minute, catapulted into the unknown the next, the speck swam as though life depended on it, which, of course, it did.

Mindlessly flailing its way forward, surfing a tsunami of high octane mucus, the speck was entirely unaware of the throngs of competitors around it or the two hundred fifty million to one odds against its winning the race. In fact, it was entirely unaware – period. It merely flailed on, this self propelled bundle of coiled code – its complexity a far cry conceptually from the homunculus Nicholaass Hartsoeker imagined he saw in 1691 as he peered at somebody’s sperm through one of the microscopes his boss, Antonie van Leeuwenhoek, had invented a few years earlier.

The speck’s purpose, if one could attribute a purpose to such a thing, was to locate and be the very first to penetrate the selective shell of another speck – this one fifty times larger than itself but still barely visible to the human eye. The process would require the assistance of thousands of the speck’s competitors, each doing its share to partially erode the protective coating of the egg’s chemical shell. Once that process reached a critical level, the first speck to contact the inner membrane would, instantaneously, trigger an exclusivity that made it the one and only member of its peer group to dump its cargo of code into the egg’s inner workings. At that moment, their separate identities vanished, and they were, according to some philosophies, a new living person with all the attendant rights and privileges thereof.

Katie pulled herself closer to Chris. Mmmm. That was wonderful. You’re something else. If that doesn’t do it I don’t know what will.

You’re something else yourself. Chris murmured as he dozed off.

Katie’s mind wandered. Getting married in med school had put Chris and her at a disadvantage in the national lottery used to fill post graduate training slots. Chris had applied to training programs in surgery; Katie in medicine. The same hospital had to rank both of them in its list of top applicants. She’d been close to the top of her class but Chris had been more of a middling student. She’d been well aware of the implications even before he’d proposed but she hadn’t had a single second thought about that. They’d ended up at Memorial – not considered one of the top tier training programs but what counted was their being together. At least together in the same place, though spending time together like a normal married couple was another matter.

Since their schedules were entirely independent, one was often on call in the hospital when the other had the night or weekend off. Sunday had been one of those rare days they had off together. And, wonder of wonders, it had happened right in the middle of her menstrual cycle. Katie even thought she’d felt a little twinge of pain in her lower abdomen when she got home on Saturday. Mittelschmerz. She imagined the tiny translucent bump on her walnut sized ovary rupturing like a popped pimple and setting an egg loose to briefly float free in her pelvic liquor, surrounded by the delicate fimbria of her Fallopian tube. The currents set up by the tube’s millions of microscopic hair-like projections beating in unison and sweeping the egg deep into the tube. The process reminded Katie of using the round dusting attachment of her vacuum cleaner to lift lint off the furniture.

Four years of immersion in the flood of biologic knowledge had radically transformed her view of even the most mundane daily activities. Prior to med school, you ate when you were hungry and enjoyed a good meal. You burped and didn’t think twice about what was actually going on. You did the crossword on the toilet and paid no attention to what was happening inside. Now, she thought of these and so many other events – lovemaking included – in such different terms. Not necessarily more romantic, exactly, but much more richly textured.

Maybe it had been a mistake to go to medical school after all. Her mother and both grandmothers had been thrilled at her career trajectory. The male members of both sides of her family had been coal miners for several generations and her father had died of black lung disease. She remembered her grandmother bursting into tears as she hugged Katie after she’d received her medical diploma.

Now her residency was teaching her more about herself – her own mental, emotional and physical limits – than she had ever thought there was to learn. Of course, there were plenty of costs extracted by the process. She wondered if the trouble she was having becoming pregnant was one of them. Her grandmother had been a very religious woman and instructed Katie to pray by visualizing what she wanted to happen and sending the message to God. Now Katie imagined Chris’s chromosomes facing off with hers – her brown iris’s winning out over his handsome blue; his size and muscularity overpowering her slightness. The field of personality genetics was just in its infancy. She imagined a big, blue eyed lusty child who was kind and loving but athletic and driven.

She snuggled closer to Chris and drifted off to sleep thinking about the chemical processes by which the calories of his dinner were now keeping his body at a delightfully warm 98.6 degrees Fahrenheit.

Chapter Three

The ovaries are homologous with the testes in the male. They are two nodular bodies, situated one on either side of the uterus........The exact position of the ovary has been the subject of considerable difference of opinion, and the description here given applies to the ovary of the nulliparous woman. The ovary becomes displaced during the first pregnancy, and probably never again returns to its original position.

Gray’s Anatomy 100th year

They awoke to Public Radio’s early morning news. Chris got up first and headed to the shower. Katie half listened. Economic woes, suicide bombings, escalating healthcare costs, some new medical breakthrough. She reflected on how often medical news turned out to be too good to be true when the drugs or devices which had been developed and tested in rigidly controlled scientific studies were eventually put into general practice nationwide.

She and Chris had been trying to get pregnant for five years now. Her younger sister already had a daughter and the onset of every menstrual cycle reminded Katie of the emotional surge she’d experienced when she had first held her new niece. She’d mentioned the possibility of a fertility workup to Chris several times but he’d been unenthusiastic. She wondered if he was concerned that the problem might lie with him. The last time the subject came up Chris had said that if the baby wasn’t his he’d probably not be fully committed to fatherhood. This had prompted one of the worst arguments of their marriage and Katie had avoided the subject from then on.

The two had worked for a while before going to medical school and she was more aware than ever of her biologic clock ticking away. The physical and emotional demands on her now, in her second year of medical residency, wouldn’t improve things. She’d always been small statured and could eat whatever she wanted without fear of gaining weight. When she learned in a class on reproductive biology that being underweight decreased a woman’s chance of conceiving she had made a special effort to increase her caloric consumption to no avail. During her internship she had gone three months without having a period. After two negative home pregnancy tests she’d rationalized that they were probably false negatives; then spent several tearful nights when her periods eventually returned.

Her mind drifted to the millions – probably billions – of women of childbearing age who were spending money they could ill afford or taking all sorts of risks in order to avoid having a baby. Birth control pills were now so much safer than they had been when first introduced in the 60’s. Back then hundreds of women had died because of the tendency of the early formulations of estrogens and progestins to upset the delicate chemical balance which kept blood in liquid form when it was circulating inside arteries or veins but turned it to a gel when exposed to a variety of changes in its microenvironment. As a result, women had developed blood clots in the veins of their legs – so called thrombophlebitis. For some, the clots broke loose, floated upstream to the woman’s lungs and caused major, often fatal, breathing problems.

And that was only the women taking birth control pills. How about all those – especially the ones in third world countries – who had to rely on abortions. Done illegally, the morbidity and mortality of those was staggering.

She thought about the pro-life movement. Pro-death really. So much evidence that making abortion illegal just meant they were done out of sight and often under dreadful conditions.

And the religious pontifications prohibiting both abortions and artificial birth control and forcing women to rely on the rhythm method. What a joke. The fact was that this resulted in by far more fetal death than condoms. With a condom, sperm never reached an egg. With the rhythm method, eggs could be fertilized on their way through the Fallopian tube but when they reached the uterus, its lining, which days earlier was a microenvironment ideally suited to nurture a newly fertilized egg, was now too old to allow it to implant. As a result the embryo drifted homeless until it used up what little nutrition had been present in the egg and its remnants went south to be washed away with the normal vaginal secretions. Technically, an early abortion.

Chris’s voice from the bathroom You awake, Hon?

Sort of.

Gotta get there early today. I’m scrubbed in on a vascular case with Dr. Fravitz and that SOB always starts early. What’s your day like?

Pretty much the usual. Rounds. Admission conference. Drop-ins starting at 9. Noon conference on renal failure and then primary care clinic all afternoon. I’m on call in the hospital tonight. I guess you are too.

Silence for a while. Then Chris:

Yesterday was beautiful. Doesn’t happen near enough.

Katie loved Chris’s predictability and the way she could tell exactly where he was in the arousal cycle. Even looking at her stepping out of the shower made his feelings apparent. She imagined some cluster of neurons in Chris’s brain reacting to her classic hourglass shape and crackling with electrical sparks that sent microcurrents along their minute living telegraph wires which, packed together with billions of others, made up the brain’s white matter. After lots of instantaneous switching, the signals found their way into the autonomic nervous system – the portion of the brain that does stuff below conscious radar – makes blood pressure go up or down, increases stomach acidity, regulates heart rate......even controls genital blood flow. When that bump grew under Chris’s bathrobe the autonomic nerves which end at the circular muscles surrounding branches of his venous pudendal plexus were releasing minuscule amounts of potent chemicals. In response, the tiny muscles around the outgoing blood vessels constricted, damming up the outflow of blood from his corpus cavernosum. Meanwhile other parts of the system were opening the incoming stopcocks of the pudendal artery while still others pushed his systemic blood pressure to levels that would get him on medication if he had been in a doctor’s office. But he wasn’t and instead the hydraulic miracle grew his bathrobe bump and told Katie he liked what he saw.

With her it was different. Sometimes even she couldn’t tell exactly where she was. She knew where she was now, though. Comfortable in bed but about to get up, get dressed, have some coffee and head into the hospital for another twenty-four hour stint.

* * *

One good thing about their commute was that they usually preceded rush hour on the way in and missed most of it on the way home. Even so, the drive in took 45 minutes. They knew it was going to be a long one when they’d bought their house but they both were dead-set on being able to spend what free time they had in the countryside rather than in an apartment close to the hospital or in some sterile suburb. And it had worked out really well. The town they’d settled in had a nice mix of farmers whose families had lived in the area for generations and newcomers who, like themselves, commuted into town to work. When they had time off together they could work in their little garden or take a walk in the woods. Even cross country ski out their back door in winter. And they’d lucked into really wonderful neighbors. One had turned out to be a patient of Katie’s. Lovely guy who’d spent his whole life in town. Went to work as a hired hand on the farm down the road when he was twelve. Salt of the earth person. Really smart but didn’t know it. Could fix anything. Built his own tractor. Built his own house too. Knew every hill and hollow in the county.

Katie loved seeing him in clinic. He seemed to enjoy seeing her as well. His wife had finally gotten him to see a doctor when he reached 75. They lived on social security and his veteran’s pension. When he went to the VA to sign up for a primary care provider he’d been assigned by chance to the clinic Katie had there every Wednesday afternoon. They were both surprised but delighted to see each other in the exam room. Orv loved telling his cronies that his doctor was the little girl up the road I pulled out of the ditch last winter after that ice storm.

Orv never complained about anything. His standard line whenever she asked him how he felt was If I felt any better I’d scare myself. He’d smoked for as long as he could remember and when she had first examined him it was clear that he had emphysema but it turned out to be only moderately severe when she did formal pulmonary function tests and he never complained about his breathing. She’d considered it a personal compliment when after his first visit with her he’d quit smoking.

* * *

When they reached the hospital Chris went straight to the OR. Katie headed to the library. Since the surgical teams started their day a full hour before the medicine day began she often took advantage of the extra time to catch up on the new journals. She scanned the rack. Two-toned gray-green modern-looking Annals of Internal Medicine; formal, dignified black and white New England Journal of Medicine; bright red in-your-face Archives of Internal Medicine; splashy Journal of the American Medical Association – each week’s cover sporting a reproduction of a well known painting – presumably to remind doctors that medicine was both an art and a science.

Katie heard the library door open. Here she is, da famous Dr. Madame Curie, grinding avay, voerking on her next Nobel prize.

It was Stefan, the librarian, one of her favorite people in the hospital. She found his Eastern European accent amusing with it’s inappropriately stressed early vowels, hard th’s, softly guttural h’s and fricative w’s which came out sounding like a cross between an f and a v.

Katie saw librarians as falling into one of two categories – hoarders, who viewed their job as protecting their collections, and disseminators who saw their job as getting information out to people who could use it. Stefan was an excellent disseminator. He’d grown up on a Polish farm but turned out to be a natural student and got a scholarship to attend the University of Krakow where he’d been a philosophy major and fallen in love