Medical School 2020, Year 1, Week 17


From our anonymous insider…

“We live every second on the edge between bleeding to death and death by heart attack,” exclaimed the young hematologist attending.  She introduced us to the coagulation pathway and the lucrative and life-sustaining hematological drugs. Numerous clotting factors (proteins) are produced in the liver and released into the bloodstream. My favorites were the actions of fibrin and plasmin. Vascular damage initiates a cascade of clotting factors to cleave the precursor fibrinogen into fibrin. Fibrin acts as a sticky filament that forms an intricate spider web, binding platelets together, creating a thrombus (blood clot). This nanoscopic mesh traps everything from red and white blood cells to the numerous clotting factors such as plasmin to plug the vessel breach. Vascular remodeling and wound repair signals activate the entrapped plasmin which degrade the fibrin web through fibrinolysis.

Simply resting one’s arm on a table creates cuts in the microcirculation. Our finely-tuned coagulation system is able to plug these cuts to prevent severe bleeding, while not creating too many blood clots that would obstruct flow to tissues. The hematologist explained that mutations in clotting proteins lead to uncontrolled bleeding disorders such as hemophilia (factor VI, IX or XI) and von Willibrand Disease or uncontrolled thrombosis formation such as in Leiden Factor V. She finished by explaining that vitamin K is essential for the activity of a liver enzyme that is used in the production of several important clotting factors (Factors II, VII, IX, X, numbers that become ingrained into any medical student’s mind for Step I). Drugs such as warfarin target the enzyme that catalyzes the reduction of oxidized vitamin K. Without this reduction process, fewer functioning clotting factors are synthesized. This results in decreased clotting function for a given signal, the costs and benefits of which were presented in this week’s patient case.

“Gerry” is an eighty year old black male who suffers from congestive heart failure after three heart attacks. “I did not treat my body well for many years.” Gerry became an alcoholic in his twenties, and smoked two packs a day from his late teens through his 60s. Vodka was his drink of choice.

Gerry grew up fatherless in a crime-ridden neighborhood. “Ma did her best to raise my two brothers and me. She would whip us if we did anything wrong. She’d grab us by a leg, hold us upside down and smack away. If none of my brothers would turn the culprit in, she would whip us all to ensure the guilty got punished,” Gerry reflected. “Much of my neighborhood’s problem was from the destruction of the family. No one has respect for authority. When I grew up, the cops were the good guys, Ma the bad one. We grew up wanting to be cops.”

Gerry described the low point in his life as returning home to see his wife and children conducting an alcohol search. “They missed the bottle that I hid in the toilet cover.” He claimed that he was able to “drink a bottle of vodka before work and no one would notice.” His wife divorced him after catching him driving drunk with their two girls and then his unmanaged health conditions continued to deteriorate.

Gerry began to have congestive heart failure from combined systemic hypertension (high blood pressure everywhere) and pulmonary hypertension (high blood pressure in the lungs). His second heart attack in his sixties was a wake-up call. “My doctor said, ‘If you do not make drastic changes, I do not expect you will live another year.’ I went completely cold turkey. I moved back home at sixty and quit cigarettes and alcohol.” Gerry now lives in a retirement home. “I was very anxious about death, so much so I would be afraid to sleep in my bed. I would try to stay awake in my recliner. Eventually I realized when I go, going in my sleep is the best way. Now I sleep like an angel.”

Gerry’s cardiologist explained that Gerry owes his life to advances in pacemakers and fibrinolytic pharmaceutical drugs. His weakened heart, after three separate heart attacks, has less contractility. Certain areas of the his heart, such as the atrial appendages and ventricular apexes, do not fully contract. This causes “pooling” of blood or hemostasis. Still blood is more likely to form a thrombus (or blood clot). These clots, unless broken down, can travel and obstruct vessels to vital organs causing a thromboembolism. A thromboembolism lodging in a coronary artery is the most common type of heart attack; a thromboembolism lodging in a vessel supplying the brain is called a stroke. Gerry is also at increased risk of Deep Vein Thrombosis, or DVT, due to sedentary lifestyle in advanced age and poor circulation from decreased cardiac output . If a DVT in a femoral vein gets dislodged it can lead to rapid death from a pulmonary embolism, blocking blood flow to the lungs (the cause of death in at least one of our cadaver).

“Even ten years ago, the general consensus was to avoid excess bleeding,” explained the cardiologist. “This has shifted to prevention of clots. You can recover from excess bleeding by getting a transfusion or IV fluids. You will not recover from brain damage from a stroke, sudden death from a PE or heart damage from a MI.” Gerry and the cardiologist discussed how warfarin and coumadin are difficult to take and to prescribe because their effect varies with vitamin K input. “If my patient eats a lot of spinach one meal, it could throw the whole clotting system out of whack with drastic consequences.” A new age of fibrinolytic drugs are coming that are vitamin K-independent (see eliquis ads on TV). However, this new age would not alleviate a common concern for Gerry and other elderly people: “I sometimes have trouble remembering if I took my medications in the morning if I do not put them in the pillbox. If I took my meds again at night, could this kill me? This is something that gives me so much anxiety.” The cardiologist added that one occasional double dose would not kill him, but emphasized these are powerful drugs.

Jane recounted a “Women in Surgery” interest meeting she attended with other interested female medical students. A young trauma surgeon who has been an attending for three years led the discussion on the life of surgery. “Go into something else if you could be happy there. Surgery is only for people for whom nothing else would satisfy.” Jane recounted the surgeon’s main point: “There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction.  Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.” The surgeon recounted a story of informing the parents their 17-year old child is dead. “Women cry a lot more than men. Men are usually silent. I woke up at 3:00 am for weeks thinking about that case, of what I could have done differently. Surgery never leaves you.” The trauma surgeon said to wait for the surgery rotation (third or fourth year) before seeking to go into her specialty: “Most of you will be pulling your hair out on the first 24-hour shift, but a few of you will become captivated. Don’t force it.”

Our medical school requires students to do community service projects in six-person groups. My group chose to work with opioid addicts. The program was started by the local police department to try to fight the rise in opioid overdoses in the area. As long as there is no outstanding warrant, opioid users can bring in drugs and paraphernalia to the local police station, or a recently added clinic, and receive counseling and access to rehab programs. We met with the director, a middle-aged woman whose college son overdosed on heroin laced with fentanyl, and a nurse.

I asked how many addicts would willingly give up their drugs? The answer turned out to be three or four individuals per day. The nurse explained that based on an interview, a “program ambassador” customizes a recovery plan tapping into local, state, and federal programs: “The resources are there, just it is impossible for a non-expert to navigate them. One common complication is addicts having children. They are afraid of losing custody if they ask for help from healthcare professionals.” Our group will able to serve as ambassadors once we complete an 8-hour training program.

Tuition is due this week. I have a Graduate Plus loan at 6.31 percent. There is no federal subsidy for this loan and the interest begins accruing immediately, but payments are deferred until after graduation. If I work in a non-profit health care system, i.e., most American hospitals, monthly payments are capped at a percentage of my salary. After ten years, the principal will be forgiven (paid by taxpayers!) if it hasn’t been paid off. The program was designed for people who joined the Peace Corps, not for radiologists earning $350,000 per year, so there is some talk about the new Congress closing “the Doctor’s Loophole.”.

Statistics for the week… Study: 25 hours. With exams next week, I wish I was at this stage two weeks ago. Sleep: 7 hours/night; Fun: 1 night. Example fun: Evening watching Netflix’s The Crown followed by Sunday brunch.

The Whole Book:

Medical School 2020, Year 1, Week 16


From our anonymous insider…

A brilliant energetic attending, straight-out of fellowship and with bright red hair to go along with both her specialty and patient (see below), led the introduction to hematology. Blood plasma is almost all water with an amalgam of solutes such as protein, glucose, amino acids, hormones, cytokines and clotting factors. The cellular components suspended in this plasma include red blood cells (erythrocytes), white blood cells (lymphocytes), and platelets (thrombocytes). All of these cellular components are made in mesh-like inner bone structures, bone marrow, home to hematopoietic stem cells which can become any of the cell constituents of blood in response to growth and differentiation signals. For example, if oxygen content is low or an individual has been bleeding, the kidney secretes the hormone erythropoietin (EPO) into the bloodstream to increase differentiation towards the erythrocyte (red) lineage.

Red blood cells are an engineering marvel and a story of sacrifice for a single purpose: transporting oxygen and carbon dioxide through the vascular network.  Hematopoietic stem cells undergo a stunning transformation. The cell rearranges its membrane so the mature erythrocyte can survive intense deformations squeezing through capillary beds. The cell simultaneously begins to synthesize gobs of hemoglobin, which eventually will take up the entire intracellular volume of the cell. Hemoglobin is a marvelous contraption comprised of four oxygen-binding heme rings surrounded by four globin protein chains. Each of the four heme rings contains a reduced iron molecule at its center where oxygen binds. The globin chains are encoded in DNA and translated into an amino acid (protein) sequence. The protein scaffold modulates the oxygen-binding affinity to unload oxygen in metabolically active tissues. Genetic defects in globin genes can lead to hematological disorders such as sickle cell anemia. Lastly, red blood cells expel their nucleus and other internal organelles, such as mitochondria.  Once completed, the 7-9 micrometer biconcave cell has sacrificed its ability to replicate in exchange for a slow but inevitable death. The average circulating red blood cell lasts no more than 120 days.

Our patient case dealt with a form of hereditary spherocytosis that first manifested in a person who had seemed to be a perfectly healthy 18-year-old. “Jessica” was an A-student, high school homecoming queen, and cross-country athlete. Early in her first college semester, a flu put in her bed for several days. After an apparent recovering, she became even more ill, sleeping all day and unable to leave her dorm. She had piercing pain in her left abdomen, her eyes began to turn yellow, and then her whole body. She was stabilized by a hospital Emergency Department and the next day saw her pediatrician back home — like most young adults had yet to find an internist. Her pediatrician referred her to our hematologist.

The mother interjected, “This was the scariest moment for me. [her pediatrician] would not tell us what it was, although he clearly had some idea. I called the referral office, and got put on hold.  I still remember the lady’s recorded voice while on hold:  ‘You have reached the Hematology-Oncology office of ….’  I was speechless!  Oncology!  My 18-year-old has cancer!” Our hematologist instructor continued, “Hematologists treat both cancer patients and benign blood disorders. Cancer patients almost always have hematology issues from the cancer itself, or from the chemotherapy destroying their bone marrow. I wish we could have two offices.”

Jessica recounted the first appointment. “The waiting room was scary. Almost everyone was old. It smelled of chemo and death. When the doctor spoke to us, everything settled down. She said, ‘You most likely have some sort of anemia, not cancer.'” Blood tests showed severe anemia. The left-sided abdominal swelling and pain was caused by splenomegaly, or enlargement of the spleen. The spleen filters the blood where resident macrophages eat old or damaged red blood cells. The macrophages recycle heme rings by releasing iron and bilirubin into the bloodstream. The yellow discoloration of her eyes and skin were from an excess of toxic bilirubin in her blood, or jaundice, a common affliction for newborn babies.

A basic peripheral blood smear showed that Jessica had premature, sometimes even nucleated, red blood cells in circulation. If the signal for erythropoiesis (formation of new red blood cells) such as EPO levels is high enough, the bone marrow will release premature cells such as reticulocytes. Her symptoms immediately improved after supplements of iron and folate, required during red blood cell differentiation for synthesis of functioning hemoglobin. However, doctors and the family were still at a loss regarding the cause of this flare-up after 18 years of perfect health.

Genetic testing showed a defect in a membrane receptor that causes her macrophages to eat up healthy red blood cells prematurely. Her bone marrow, without any iron and folate, could not keep up with the destruction of red blood cells. The hematologist theorized that the flu virus triggered the immune system to increase erythrocyte destruction. Jessica is now a normal college student. She continues to take iron, folate and recombinant EPO supplements. She gets tired easily, especially around exam time. Her school has given her a single room to allow her to get more sleep. She sometimes has mild left-sided abdominal pain. Her two brothers and sister attended. They had both opted out of genetic testing. Jessica said she has two fears: “having my spleen removed and needing transfusions to live. I’ve spoken to a lot of anemic patients in the waiting room who all have had to do this. I fortunately have a less severe form of spherocytosis.” The class laughed as she struggled to pronounce “spherocytosis”! She ended by saying how it is important for doctors to be cheerful and energetic. She jumped out of her seat, long red hair waving, and hugged our young hematologist. “We are best friends, redheads stick together!”

I shadowed my physician for the afternoon seeing six patients: two cases of Chronic Obstructive Pulmonary Disease (COPD, typically from smoking), a pneumonia case, a two-week follow-up after a car accident, a knee injury, and a fainting teenager. The pneumonia patient was a female in her late 60s with severe dementia and under the care of the state. A caretaker brought her in with a complaint of wheezing. She could no longer speak, but could make grunting sounds. While she tried to grab the physician’s genitals, we listened to her lungs and noted pulmonary edema in her right upper lung. We prescribed antibiotics.

The physician and I read the car accident patient’s chart. He said, “I do not know how this patient is alive.” Crashing his Ford Fusion into a stopped car at 50 miles per hour did not result in a single broken bone. He had a neck brace and terrible lacerations over his face, chest and arm, a rare success story for airbag technology given that this 65-year-old gentleman had not been wearing a seatbelt. The chart showed a history of drug and alcohol abuse, but no evidence that either was involved in the accident.

The next patient was a mid-60s grandfather who hurt his knee while playing basketball with his grandson. “Little Johnny has gotten really good. I was defending with one leg planted, and twisted. I heard a snap. I cannot put any weight on it.” I performed a knee exam and noted anterior displacement of the tibia (lower leg) with the femur (upper leg) under stress. X-rays showed no bones broken. Diagnosis: torn ACL, which unfortunately cannot heal once separated. We referred him to orthopedics for an MRI and refrained from making any Vito Corleone references.

A mature and articulate 13-year old teenager presented with recurrent episodes of fainting and dizziness. She has had these episodes for over a year, but got much worse last week and had to be taken home from school twice. I walked in first and conducted an interview and brief cardiopulmonary physical. I did not note any abnormal heart sounds upon auscultation. The mother explained her theory that the fainting was caused by beginning menstruation. During the family history, we learned that four of the mother’s eleven uncles/aunts had a heart defect requiring open-heart surgery. The doctor joined me. He did not hear any abnormal heart sounds but was clearly concerned by the family history. He ordered several tests and sent the child home with a visibly upset mother. I’m impatient for a diagnosis but will have to follow up via email.

“Geriatricians are a dying breed,” said our lecturer the next day. “No young doctors want to treat old people.” Our class supports his theory; nobody has expressed a desire to become a geriatrician. The most challenging part of interviewing the elderly for him is breaking through their fear of losing independence. Many elderly individuals will not admit if they are struggling to perform certain instrumental activities, such as driving, cooking, taking medications and even walking. Our mid-40s geriatrician stressed, “This information is the most important. Frequently, I am able to prolong their independence but I cannot help them if they do not tell me.” For example, simply using a walker could prevent an all-too-common fall resulting in a hip fracture: “A third of all patients with hip fractures die within one year.”

The class segued into a discussion. Classmates opened up with memories of the last days of their grandparents. One classmate’s grandparents committed joint suicide shortly after being admitted to a nursing home. The geriatrician offered, “I will tell you one thing: You never want to see another horrible death once you see one. I was in the army and saw a parachuter fall. That same feeling comes over me when I see patients suffer through decisions whose consequences they do not fully understand.” He concluded, “Whatever speciality you go into, you need to define what the patient wants. Physicians too often conclude clinical decisions based upon their beliefs. Some of my patients may want to live to see their grandchildren graduate school. Some just want to be able to keep walking for another year. These desires change how I care for my patient.”

Several of Jane’s college girlfriends descended into town for her birthday weekend, arriving around 9:00 pm. At dinner we somehow got on the topic of unions. Jane’s friend was passionate on the subject of the evils of right-to-work legislation and the need to force every worker to pay union dues. It turned out that she was an intern at the American Federation of Teachers (AFT). I’ll probably share her passion for unionization once I work my first 100-hour week as a resident. Jane interjected, “Shut up… today is all about me!”

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Movie night with Harry Potter fans to see Fantastic Beasts and Where to Find Them; Jane dragged me along.

The Whole Book:

Window into how people think about pensions


“The End of the World? In Brazil, It’s Already Here” (nytimes) is interesting for revealing how people think about pensions:

In addition to the spending cap, Mr. Temer has introduced a proposal to revamp Brazil’s pension system. His proposal will set a minimum retirement age of 65, in a country where the average person retires at 54. The law will also require at least 25 years of contributions to the social security system by both men and women.

There are good reasons Brazil hasn’t passed laws like this before. Although the average life expectancy in Brazil is 74, we’re one of the most unequal countries in the world. For example, in 37 percent of the neighborhoods of the city of São Paulo, people have a life expectancy of less than 65 years. It’s even shorter for the rural poor.

It doesn’t sound so bad, right? People retire at 54 and then drop dead around 65, so they are getting paid for 11 years, on average. Could the writer and editors have found a source for why this might not work? How about the New York Times itself! About a year ago they ran “An Exploding Pension Crisis Feeds Brazil’s Political Turmoil”:

When Rosângela Araújo turned 44, she decided that she had worked long enough.

So Ms. Araújo, a public school supervisor, did what millions of others in their 40s and 50s have done in this country: She retired, with a full pension.

“I had to take advantage of the benefit that was available to me,” said Ms. Araújo, now 65. Her government pension stands at about $1,000 a month, five times the minimum wage.

Brazilians retire at an average age of 54, and some public servants, military officials and politicians manage to collect multiple pensions totaling well over $100,000 year. Then, once they die, loopholes enable their spouses or daughters to go on collecting the pensions for the rest of their lives, too.

The phenomenon is so common in Brazil’s vast public bureaucracy that some scholars call it the “Viagra effect” — retired civil servants, many in their 60s or 70s, wed to much younger women who are entitled to the full pensions for decades after their spouses are gone.

… economists warn that the pension crisis will grow more acute regardless of whether Ms. Rousseff stays in office, ranking it among Brazil’s most vexing structural binds. Officials had expected a major shortfall in 2030, but they now say that could happen as soon as next year.

Both articles cite life expectancy at birth. Neither article mentions that life expectancy at age 54 in Brazil is about 26 additional years (source).


Map showing how to get rich off global warming


MIT’s alumni magazine, Technology Review, has published a helpful map for where to invest if you think that global warming will be more faster and more dramatic than others expect. Set it up for 2050, for example, and Canada gets a 35 percent GDP boost compared to the “no warming” case. Russia is up 47 percent. A U.S. investment strategy doesn’t need to change; our GDP will supposedly be reduced by 5 percent in 2050 compared to if a magic wand were waved and the climate stayed the same.

[Lending support to those who are skeptical of statements by scientists, the prediction for 2099 is that Russia will be up by 419 percent compared to the “stable climate” scenario. Canada is up by 247 percent.]

Readers: What’s your best long-term climate change investment idea?

Article on rising housing costs that does not mention population growth


“The Year in Housing: The Middle Class Can’t Afford to Live in Cities Anymore” (WIRED) is interesting to me because it demonstrates an apparent blind spot for Americans. Here was my comment on the piece:

The word “population” doesn’t appear in the article. Why isn’t this what we expect as the U.S. population has grown from about 150 million post-World War II to 320 million today? Also, demographers predict immigration-driven growth to about 441 million by 2065 (see Pew Research). Wouldn’t the real estate market also reflect expected future demand based on this growth? (Note that I’m not arguing for or against population growth, merely pointing out that if we have it we will also have a rising cost for housing.)

What do readers think? We do have a lot of land in the U.S. so in theory we could build some more vibrant cities. On the other hand, we don’t seem to excel at building efficiently, so that leaves us with the same cities that we had 100 years ago (plus a lot of exurban sprawl).

The rich bastards leading us around by the nose


“Betsy DeVos, Trump’s Education Pick, Wields Wealth Like a Koch” (nytimes) talks about a rich family that is controlling American voters’ minds with their wealth:

In the 2016 cycle alone, according to the Michigan Campaign Finance Network, the family spent roughly $14 million on political contributions to state and national candidates, parties, PACs and super PACs.

According to the Times, some of the $14 million goes to “education activism, which favors alternatives to traditional public schools”.

Perhaps as much as $5 million then goes to advocating for changes to education policy. Can we put that number in context?

The Department of Education says that, in 2012-13, American taxpayers spent $620 billion on public schools. This analysis suggests roughly 850 hours of actual instruction per year for California schools, which are presumably representative.  Schools are thus spending 0.73 billion tax dollars per hour or $202,614 per second.

The rich bastards are purportedly significantly influencing the national debate about public schools with 25 seconds of spending.

Queen Victoria in the domestic sphere


This will be the first of a few posts about Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire (Julia Baird 2016). What does the biographer have to work with?

It has been conservatively estimated that Victoria [1819-1901] wrote an average of two and a half thousand words per day during her reign, a total of approximately sixty million words.

19th century fathers weren’t waiting outside with cigars…

Queen Victoria was born, roaring, at 4:15 A.M., in the hour before dawn on May 24, 1819. As the duchess lay writhing and breathing through contractions, His Majesty’s ministers waited in an adjoining room. The duke had forewarned them that he would not entertain them, as he planned to stay next to his wife, urging her on. As tradition dictated, these high-ranking men listened to the cries of the duchess during the six-hour labor, then crowded the room once the baby arrived, to attest that it was in fact the mother’s child.

Kids didn’t have to wait to grow up to get their OxyContin:

It was, after all, a dangerous thing to be born in the nineteenth century. Of every thousand infants, about 150 died at birth. Even then, the prevalence of measles, whooping cough, scarlet fever, and cholera meant that the likelihood that a child would survive to the age of five was little more than 70 percent. Children from poor, urban families who were not breastfed or were weaned too early had even slimmer chances. It was also a common practice to give infants opium to stop their crying, and many babies lost their appetite and starved as a result. Predictably, the mothers were blamed for working long days in factories and leaving their children with strangers. A piece published in 1850 in Household Words, the journal edited by Charles Dickens, attributed this practice to “ignorant hireling nurse(s)” who managed eight or nine babies at a time by keeping them drugged. Concoctions called “Soothing Syrup,” “Mother’s Quietness,” and a laudanum-based potion called “Godfrey’s Cordial” meant “the quiet homes of the poor reek[ed] with narcotics.” Karl Marx, writing in Das Kapital in 1867, described the “disguised infanticide and stupefaction of children with opiates,” adding that their parents were developing addictions of their own. Infant deaths were so common that parents insured their newborns, and were typically paid £5 if they died, a practice that was thought to encourage infanticide. By 1900, 80 percent of babies were insured.

Unrestrained by the father, who died in 1820, Victoria’s mother was inattentive when the future queen was young and then exploitative as the teenager grew close to ascending the throne:

Victoria trusted only one person: her governess. Baroness Lehzen, the daughter of a Lutheran pastor from Coburg, was an eccentric, single-minded, clever woman who dedicated her life to ensuring that Victoria would be a forceful, intelligent queen. … she was the only person who had solely Victoria’s interests at heart. … When Victoria was ill, Lehzen stayed by her side, quietly stitching doll clothes, as Victoria’s mother continued to visit friends and travel.

She knew ambition was curdling her mother’s heart, just as apprehension was gripping hers. It was now, when still a child who played with dolls, that Victoria’s seven-year battle with her mother began, one that would deeply scar her. But her prayers would change once she realized her mother was seeking to snatch away her crown before it could be placed on her head.

Her mother openly chastised Victoria, reminding her of her youth and telling her that she owed all her success to her mother’s good reputation. The woman who had insisted on breastfeeding her child and delighted in her fat cheeks had grown hard with anxious hunger for power, seduced by her own victim narrative of the long-suffering mother. She pointed out repeatedly that she had given up her life in another country to devote herself to raising a girl into a queen. Victoria soon stopped speaking to her.

[see also the 19th century parental altruism paper referenced in this chapter]

The 4’11” queen struggled with her weight:

Walking, she said, made her feel sick. Melbourne also told her to stop drinking beer, which she loved. By December, a “cross and low” Victoria found to her distress that she weighed 125 pounds—an “incredible weight for my size.”

But she set wedding dress fashion for centuries to come…

Victoria’s clothes had been carefully chosen to display her patriotism. The fabric of her dress was from the Spitalfields, the historic center of the silk industry in London, and two hundred lace makers from Devon had labored on it for months. The pattern was destroyed afterward so that no one could copy it. Her gloves were stitched in London and made of English kid. Victoria had commissioned a huge swath of handmade Honiton lace for her dress, in an attempt to revive the flagging lace industry (machine-made copies had been harming the trade).

The queen had asked that no one else wear white to the wedding. Some have wrongly interpreted her choice of color as a signal of sexual purity—as Agnes Strickland later gushed, she had chosen to dress “not as a queen in her glittering trappings, but in spotless white, like a pure virgin, to meet her bridegroom.” Victoria had chosen to wear white mostly because it was the perfect color to highlight the delicate lace—it was not then a conventional color for brides. Before bleaching techniques were mastered, white was a rare and expensive color, more a symbol of wealth than purity. Victoria was not the first to wear it, but she made it popular by example. Lace makers across England were thrilled by the sudden surge in the popularity of their handiwork.

She spent a lot of time being pregnant:

In giving Albert free rein to work alongside her as she carried nine children, Victoria was soon to discover that the clever, intellectually restless Albert was a great asset. She spent roughly eighty months pregnant in the 1840s and 1850s—more than six years in total—and even longer recovering from childbirth.

Unusually for the era, Albert was with her during her labor [with the first-born], along with the doctor and nurse.

Victoria spent two weeks in bed after giving birth, as was then customary. Her baby was brought to her twice a day when she was in her dressing room, and she watched her being bathed once every few weeks.

On Christmas Day 1840, Victoria marveled at her great luck: “This day last year I was an unmarried girl, and this year I have an angelic husband, and a dear little girl five weeks old.” When Vicky was eighteen months old, Victoria wrote she had become “quite a little toy for us & a great pet, always smiling so sweetly when we play with her.” The queen spent more time with Pussy, as she nicknamed her daughter, than was expected of her.

Why nine kids?

And so, when she found herself pregnant again just three months after giving birth, Victoria wept and raged. She did not have the aid of the natural—if imperfect—contraceptive of breastfeeding, as she refused to nurse her children as her own mother had done, and birth control was widely considered sinful. Some women tried to coat their vaginas with cedar oil, lead, frankincense, or olive oil, in the belief that this might prevent the “seed” from implanting. In 1838, many aristocrats used sponges “as large as can be pleasantly introduced, having previously attached a bobbin or bit of narrow riband to withdraw it.” But there is no evidence Victoria was even aware of such a thing. Women were also advised to have sex around the time of ovulation if they wanted to avoid pregnancy, which we now know to be precisely the time that most conceive.

Were medical professionals better informed regarding pediatrics?

Pussy became weak and unsettled when she was just a few months old, and neither Lehzen nor the wet nurse was able to soothe or fatten her. The queen wrote: “ ’Til the end of August she was such a magnificent, strong fat child, that it is a great grief to see her so thin, pale and changed.” Dr. Clark gave her ass’s milk and chicken broth with cream, which she was unable to keep down, as well as mercury-laced calomel, and the appetite-suppressing laudanum. The birth of a little brother, the boy her parents had longed for, only made little Pussy worse. The day after he was born, Victoria wrote: “Saw both children, Pussy terrified and not at all pleased with her little brother.

What about the basics?

Victoria had a “totally unsurmountable disgust” for breastfeeding. She was incensed when her daughter Alice decided to nurse her children herself, later in life, and a heifer in the Balmoral dairy was soon named Princess Alice. Victoria viewed it as vulgar, and inappropriate for upper-class women. She also believed it was incompatible with performing public duties, perhaps a persuasive argument in the days before breast pumps existed. Until commercial baby foods became widespread in the 1860s, most women in the Victorian middle class, and even aristocrats, combined breastfeeding with animal milk or mashed foods until the baby was a few months old. Wet nurses were expensive and frequently suspected of somehow corrupting their charges with dubious morals. But Victoria did not hesitate to employ them, believing it better for the child if a woman who was less refined and “more like an animal” suckled them.

Victoria’s take-away on being a mom?

Victoria was now the most famous working mother in the world. In England at the time, women who had jobs were pitied, but the 1851 census found one in four wives and two in three widows worked.

She told her daughter that childbearing was “a complete violence to all one’s feelings of propriety (which God knows receive a shock enough in marriage alone).”

She also warned her daughter against neglecting her husband or duties because of too much love for her babies. “No lady, and less still a Princess,” she said, would be fit for her husband or her position if she “overdid the passion for the nursery.” Victoria insisted that she saw her youngest children being bathed and put to bed only about four times a year.

For seven excruciating months in 1884, there had been glacial silence at the royal table. From May to November, Beatrice and her mother refused to talk to each other, instead pushing notes across the table to communicate, while their knives and forks clinked against china. The large block of ice Victoria regularly had placed on the dining tables to cool the summertime air was barely needed. It was bitterly awkward, especially given their usual closeness. Victoria’s youngest child had, to this point, shown only obedience. But now she had fallen in love with the handsome Prince Henry of Battenberg, right under Victoria’s nose.*1 When the dutiful, shy twenty-seven-year-old Beatrice confessed that Prince Henry had snatched her heart, Victoria was predictably selfish and melodramatic: “Pleasure has for ever died out of my life.” Victoria had long dreaded this moment. She had tried to prevent the word “wedding” from being uttered in front of Beatrice. She had ensured her daughter was never left alone in a room with a man and never danced with anyone but her brothers. She had delayed her confirmation. She wanted to protect her beloved youngest daughter from an institution she viewed with skepticism; after all, Victoria now claimed to hate marriage. She had adored her own, of course, but thought that incessant pregnancies were traumatic and painful, the loss of a child was an unbearable wrench, and most marriages were miserable. Her own family bore this out. Vicky was miserable in Prussia, bullied by disapproving and controlling parents-in-law; Louise had married a man suspected to be gay and had taken on a series of lovers; Alice had died in a far-off land; only the introverted Helena lived contentedly with her husband nearby. Victoria said glumly, “The longer I live the more I think marriages only rarely are a real happiness. The most are convenience—not real happiness—though of course when it is, it is greatly valued but how rarely it lasts.

To modern eyes, Victoria’s control of Beatrice seems stifling and selfish, and in many ways it was. But it was also common practice in the nineteenth century for youngest daughters to devote themselves to their surviving parents.

The pleasures of grandmotherhood?

Victoria criticized Helena for producing “excessively plain” babies, for ill health and pudginess, and for looking older than her twenty-four years.

As grandchildren ran giggling around her palaces, Victoria doted on them—especially the good-looking ones—while simultaneously complaining about how many there were. She experienced diminishing returns when it came to her grandchildren: she was interested in perhaps two to three of them, but “when they come at a rate of three a year,” she told an apologetically maternal Vicky, “it becomes a cause of mere anxiety for my own children and of no great interest.

What about marriage per se?

When looking at suitors for Princess Alice in 1860, Victoria was gloomy: “All marriage is such a lottery—the happiness is always an exchange—though it may be a very happy one—still the poor woman is bodily and morally the husband’s slave. That always sticks in my throat.”

(They had divorce back then, but nothing like our modern no-fault system; see the History chapter of Real World Divorce for how/when it evolved. Also see the International chapter for what a divorce plaintiff can get in the English courts today.)

How does it end?

When she was properly examined for the first time, on her deathbed, her doctor found that Victoria had a prolapsed uterus and a ventral hernia—sources of significant pain and discomfort—both of which were most likely to have been caused by difficult labors and exacerbated by her subsequent weight gain.

Her coffin was draped with white, the horses drawing her coffin were white, and the marble of her grave was white. The drapes everywhere were to be white and gold, and she ordered that no black should be seen anywhere. And in death, the widow became a bride again. She asked to be buried in white silk and cashmere, with a cape and veil over her face. Victoria had lived almost as twice as long as her husband, and had ruled on her own for twice as long as they spent ruling together.

More: read Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire.

Rex Tillerson, jury member


“What I learned about Exxon CEO Rex Tillerson after spending a week on jury duty with him” (Dallas News)  is kind of interesting for those who are curious about our new Secretary of State.

[Separately, the case is a reflection of our times: “A young girl had accused her mom’s boyfriend of sexual assault”. As noted in the Children, Mothers, and Fathers chapter of Real World Divorce, “A sociologist we talked to said that ‘this is the first time in human history where we actually encourage unmarried teenage girls to be in intimate domestic contact with men other than a father or brother.'”]

Wall Street titans and the Trump victory


“George Soros reportedly lost around $1 billion after Trump’s election” is interesting for proving the adage that “nobody knows anything”:

Additionally, most Wall Street analysts believed that a Trump win would sow uncertainty and cause a sell-off.

They could have bought portfolio insurance for almost nothing! (see Wall Street nerds: How much does it cost to hedge against a 20-percent drop in the stock market this week?)

Whole-drive encryption for Dell XPS 13 running Windows 10?



After the Microsoft Surface Book debacle I am ready to dip my toe back into the laptop market (upcoming trip to Hawaii where I need to get a lot of work done!). The new Dell XPS 13 2-in-1 seems to have some potential. I can use it to read a book on an airplane, type a report in a hotel room, set it up to run a slide show (tent mode), etc.

Back in 2011 I wrote “Why isn’t file encryption more popular?” and the question seems to be equally relevant today. Windows 10 Home doesn’t do it. Windows 10 Pro does, but does that even make sense to enable after the operating system has been installed?

What’s the practical consequence of having one’s laptop stolen? The criminals can mount the hard drive in their own computer and read all of the files, right? If you’ve got saved passwords in Google Chrome can they then use those passwords and cookies to shop at Amazon, transfer money in online banking, etc.? (this article says “not unless the criminals crack your Windows password”)

Using an eDrive would seem like the best solution but those don’t seem to be available as factory options from Dell. (And setting one up after the fact is not simple: article.)

Apple fans: How does Apple do this on their laptops? There is a separate OS partition that is never encrypted? And when the purchaser starts up the machine he or she is prompted for a password to use for unlocking the user files, which are subsequently encrypted?

Readers: What is the most sensible practical approach? Use Windows 10 Home and take the risk that someone grabs the laptop? If someone does, change a bunch of passwords using some other PC? Or Windows 10 Pro and Bitlocker and take the performance hit plus the hassle of entering a password all of the time? (though maybe the fingerprint reader on the new Dell eliminates that annoyance)

[All of my previous questions about the PC market remain live as well! Dell seems to be promoting primarily computers, including laptops, with mechanical hard drives. A SanDisk 480 GB SSD retails for $125. How could it ever make business sense for Dell to try to get a consumer to buy a machine that boots from a mechanical hard drive?]

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