Sunday, September 22, 2013

Implanting a Magnet III: Procedural Walkthrough

The Father of Hand Surgery
(Step by step video available at the bottom of this blog)

During WWII, the Surgeon General was an orthopedic surgeon who had experienced treating those disabled in the first world war. Many otherwise healthy WWI veterans had been rendered incapable due to poorly treated hand wounds which resulted in a loss of function. Prior to this, hand surgeries required three specialists, but war doesn't allow for such extravagance. In many cases hand injury were being treated by the most inexperienced of junior surgeons. The Surgeon General asked the respected Dr. Sterling Bunnell to open hand centers around the country to assist the injured in the hope they might regain function and return to previous occupations.

Dr. Bunnell wrote the book on hand surgeries. Literally, as in his work was the first text specifically aimed at instruction in treatment of hand injuries. This book remained a fixture in medical schools for over forty years. His hobby was research in comparative anatomy. Colleagues asked about Bunnel were just as likely to talk about the baby rattlesnakes he'd allow to bite him in his basement, and the Black Widows he raised in his attic as they were his many accomplishments in orthopedics.This certainly wasn't his only unusual attribute.

Students of Bunnell were easily recognizable, not simply due to their skill, but also from the many quirks they internalized from working with Bunnell. Foremost amongst these were the so-called Bunnell-isms. An entire generation of hand surgeons would dutifully recite,“Shoot the plaster to me faster, pass the alabaster.
Serve your master; avoid disaster“ as they dressed wounds and casted broken bones. Exactly as taught by Bunnell, they'd admonish assistants holding a limb, “Steady like the Rock of Gilbraltar.” Each step of a procedure had its own mantra.

As we progress through each step performed in a magnet implantation, you understand the value of these Bunnell-isms. Of course even the greatest surgeons find at times injuries even they are incapable of repairing. At the time, many such cases were the result of inexperienced practitioners. Any surgery, especially one performed under sub-optimal conditions by an entirely inexperienced party comes with risks. Bunnell had a special phrase just for such a situation:
A good stump is a joy forever.

S. Bunnell

- My First Magnet Implant Using Poor Technique -

This blog discusses subdermal implants. The procedure discussed is a body modification being performed by various non-medical artists as well as some fool-hardy Do-It-Yourself-ers. Don't misinterpret this work as advocating for people to perform such a procedure at home. DIY surgery of any kind can definitely have disastrous results; furthermore, short of internal organs the hands are likely the worst place to perform such a half-assed surgery. Before WWII hand injuries were treated by three different specialists. Bone injuries were treated by an orthopaedist, a plastic surgeon was responsible for skin healing, and a neurosurgeon would care for the nervous system aspects. I am not an orthopaedist, a plastic surgeon, or a neurosurgeon. It's not my intent to pretend the experience or education of one, much less all three. In fact, I'm not even surgeon at all. The intent of this blog is as follows: If you have already chosen that you are going to perform surgery upon yourself and implant a magnet, then I hope this work improves your chances of avoiding the many possible bad outcomes.

If you perform any of the discussed procedures in this Blog, it's quite possible that you'll end up with an infection which will then spread throughout your hand and into the bones. The treatment for osteomylitis is amputation. So the bottom line is... I don't advise you do this, bub. If you do, it's at your own risk and if something goes wrong whether during the procedure or after, seek the attention of a physician. 

Preoperative Stage: Site Selection and Marking

1. Identify the Mid-lateral Line

Using a permanent marker, begin by marking the most lateral point 
  of the creases created when the finger is fully contracted. 

Extend the finger and connect these dots with a line towards the 
  distal tip.

This is the midlateral line and it isn't just an arbitrary marker. If a person pokes around with a sharp implement, they'll find that the midlateral line divides the highly sensitive palmar surface from the relatively insensitive dorsal surface of the finger. 

2. Identify Potentially Damaging Incision Sites

One potentially damaging incision is a cut which runs longitudinal across a joint. Cutting along longitudinal lines can interrupt the joints range of motion and cause pain whenever the joint is moved.

Anterolateral incisions should be avoid as well. The anterolateral line is found ½ way between the Midlateral line and the Longitudinal line and it cutting here can damage the neurovascular bundles. 

The two remaining inadvisable incision sites are those along the palmar pulp and a fishmouth incision. Both of these area are undertension which acts to pull incisions open which can slow or prevent wound healing.

3. Identify the Outline of Littler's Diamond

Range of motion problems  related to scarring can be avoided by identifying the border of Littler's Diamonds. Contracting the finger again, mark the the ventral end of the crease of the finger. 

 Connect this dot to the lateral point of the crease.
Don't make any incisions proximal to this line.

4.Mark the Incisional Borders

Identifying the damaging areas leave us with a relatively small area along the mid-axial line appropriate for a magnet implant. Place your first mark just distal to the border of Littner's Diamond and ventral to the mid-lateral line. A person requires at least an extra millimeter of space on either side of where the magnet will be inserted. Assuming a 3mm magnet, measure a 5mm line running distal from the first mark. This is the appropriate site for incision. Before concluding that this location is way too far off to the side of the finger, consider that a pouch will be created in the direction of the longitudinal line, bring the final resting place for the magnet far closer to center and nearest to the neurovascular bundles.

Cleaning and Disinfection of the Surgical Area

First, consider air flow in the room chosen for the procedure. It doesn't do much good to disinfect a room and then run the AC, effectively re-coating every surface in the room with dust and bacteria. Choose a room where airflow can be blocked. Close any vents and turn off heating or air conditioning. Furthermore, the room chosen should have a non-carpeted hard floor and minimal or no fabric furnishings such as couches or drapes. This is to facilitate effective cleaning.

Second, perform a preliminary cleaning of the room. This entails damp dusting all furniture surfaces with particular attention to horizontal surfaces. After this wet mop the floor. The liquid used for wet dusting and mopping can be made of a Quats solution, a Chlorhexidine solution or even diluted bleach.

Third, the area on which the sterile field will be prepared is to be cleaned specifically with a Quats disinfectant. Pay attention to the products instructions; often it will give specific instructions for the amount of time needed for the surface to be relatively sterile.

Sterilization of Instruments

All instruments used in the procedure must of course be sterile. Many of these can be purchased as prepackaged sterile instruments; however, reusable implements such as scalpel handles, clamps, and scissors may require sterilization. The optimal method is steam sterilization which can be performed using either an autoclave or a pressure cooker. 
Autoclaves can be purchased for around 260 dollars, but unless you intend to be doing this pretty often I'd go with a 50$ pressure cooker. Instruments are placed in Self Sealing Sterilization pouch. Many of these pouches incorporate a sterilization indicator, but if not, indicator tape can be applied to the pouch. If your using pressure cooker, keep in mind that all the implements must be above the water in order to achieve sterility. Steaming implements at the highest temperature and pressure possible (usually around 15 Psi) for twenty minutes is adequate to kill that majority of organisms.

Another method is chemical sterilization which must be used as Neodymium magnets are notorious for losing strength when heated. High Alcohol content Quats wipes such as supersanicloths kill the vast majority of microorganisms in under 3 minutes. Some organisms such as enveloped viruses take longer. Chemical sterilization is simple. First clean tools and magnet of any obvious material such as hand oils, dirt, dried blood using soap and water. When dry of water, rub the magnet or instrument over with a quats pad and then place the item in the fold of another quats pad. 20 minutes of wet time is sufficient to kill just about any pathogen. Tools and magnet can then be placed in either a sterilized metal bowl or in the fold of sterile gauze dampened with sterile saline. The dampened gauze must be placed on a layer of dry gauze in order to prevent the wicking up of contaminates. 

Preparing the Sterile Field

Having made ourselves a nice clean surface in the previous step, we can now create our sterile field or work space. Within an operating room, this would entail the opening of a sterile drape to cover the field. Because of the nature of the procedure we are performing this isn't as essential. Your going to be using both hands when
performing the implant and there isn't any way you can keep the operative hand anchored to the work system anyhow. Treat the table as dirty regardless of how well if was cleaned and never allow a tool or open wound to contact the table directly.

We still need to create a small sterile field area as a place on which to hold our supplies. This field can created using the inside of the packaging from one of the supplies used. Surgical gloves for example tend to come in a big sterile container which can be everted and used as the surface on which the tools are placed. In the video, I am using a surgical drape but as long as your working on a well cleaned non-porous surface, and you keep your equipment stored on a sterile field, you'll be just fine. 

Preparing the Surgical Site

Site preparation should begin three hours prior to the procedure occurring. The hands are scrubbed and washed with a Chlorhexidine based cleanser. Pay particular attention to the nail bed as this area tends to harbor the most bacteria. After hands are dried using a clean towel, don a pair of examination gloves and then go about disinfecting the table surface and preparing the sterile field. 20 minutes prior to procedure the hands should be washed and scrubbed again. Immediately before the operative don sterile gloves. Cut the glove finger away from the glove and cut a slit running towards the palm to reveal the areas of injection for a nerve block. Perform nerve block as demonstrated in this previous blog: Magnet II

Operative Stage

A jeweler does not repair a watch in an inkwell – Bunnell

Once adequate anesthesia has been achieved, loop the hair band tourniquet around the finger a few times. This band will prevent excessive bleeding while creating the incision and undermining the tissue. 

There isn't a way to gauge whether the band is tight enough until the incision has been made. If its not tight enough blood will flow freely and the second hair band should be looped around the base of the finger at a tightness that will stem blood flow. In most surgeries, there are two primary considerations when it comes to tourniquet use: time and pressure. We don't have to worry about pressure because the fingers are small and the hair bands aren't really capable of pressure to the point of tissue damage. In regards to time, a tourniquet should be used for as short a time as possible. The Association of Surgical Technologists recommends that a tourniquet not be used on the upper arms for more than sixty minutes at a time. I'm going to suggest that a person go for no more than twenty minutes. After twenty minutes, remove the tourniquet and apply pressure and some gauze at the incision site for a minute or so and then reapply the hair band. 

Making the incision
No one counts fingers - Bunnell

In the video, note that I'm going to break one of the rules of surgery: only use a blade when it's attached to a handle. I thought that the major reason for the this was to prevent the risk of blood borne pathogen exposure. If surgeon doesn't use a handle, they are far more likely to cut themselves and either become infected from a pathogen in the patients blood or infect the patient. I thought that since I'm working on myself, that perhaps not using a handle would result in increased dexterity. The reality? No. It doesn't. I've always used a handle before and I will always use a handle in the future.

Use a pair of clamps to pick up the scalpel blade and attach it to the scalpel handle. Hold the scalpel as if you were using a writing instrument about 4 centimeters away from where the blade meets the handle. If possible, use the fingers on either side of the target finger to pull the skin taught. Make your incision using the flat edge of the knife rather than the very tip. Remember that you don't have to achieve full depth with the first cut and that it's much better to make multiple small cuts than to go too deep and hit nerve or tendon. The final length of the incision should give at least an extra millimeter on each side, so for a 3mm magnet, go for a 5mm long incision.

This image is to demonstrate the depth of skin. It certainly isn't what your site should look like.
Proper incision depth warrants a paragraph of its own. I'm very leery about giving a number because different people have different skin thicknesses. I've seen elderly patients with skin at thin as perhaps ¼ of a mm that could be stripped away with a piece of tape. I've seen construction working with thick callused skin all that way around the tip of the finger that was likely 2mm thick. The depth of the cut needed is completely dependent upon the skin of the person. It will most likely be between ½ mm and 1mm. A person knows they've achieve adequate depth because the incision can be pulled open revealing the underlying dark red tissue beneath. If the tissue at the base of the incision stays still when the overlying skin is tugged, then your definitely deep enough. Remember that it's essential not to cut any of the underlying structure. There really isn't fat or muscle at this location, so you have no room for error. If you cut too deep, your cutting tendon, vessels or nerves. Damage to any of these can be disastrous. Not cutting deep enough simply means that your magnet will at some point pop out, which isn't really all that big a deal. You can always do the process again later, and most likely with better technique due to experience. 


Undermining the wound edge
Steady, Like the Rock of Gilbraltar - Bunnell

The skin edge must now be undermined in order to create the space where the magnet will rest. Undermining is accomplished by freeing the skin from its deep tissue attachments. A skilled surgeon would accomplish this using a scalpel, but I feel that this is too risky for someone without experience. I advise the use of surgical scissors. The two sides of these scissors can be easily broken apart resulting in a implement that is sharper and more precise than a probe, yet dull enough that it can be used by an inept shaky hand. This tool isn't really used like a cutting implement, but rather more like how a probe would be used. Slip the edge under the skin layer and push it back and forth with pressure to tear apart the connective tissue holding the skin to deeper tissues. It will take some pressure to accomplish this as you are literally tearing the layers of tissue apart. If the prospect sounds terrifying, consider practicing this on a piece of pig skin from the local butcher with the skin intact.

Undermining is performed moving toward the anterior pulp of the finger. It should be large enough that once the magnet is placed, it will not be visible at the base of the incision itself.

Undermining is the most laborious and frustrating part of the procedure. The pouch should extend at least the diameter of your magnet plus 2mm away from the incision site. When performing this, you are creating the final position where the magnet will be located. The magnet should be positioned offset from the mid-line of the finger. Even after healing, most people report that direct pressure causes pain. A good implant shouldn't stop you from being able to do pull-ups. If the pouch created allows the magnet to sit 45 degrees away from the mid-line of the finger, then pressure will simply push the magnet to the side without resulting in pain. This step requires the most attention as the lack of a proper pouch will inevitably lead to rejection, while a poorly made pouch leads to an inconveniently place magnet. 

Placing the magnet
"Better an empty house than a poor tenant," - Bunnell

Placement of the magnet will likely require a person to go back to the previous step a few times in order to enlarge the pouch. When working on yourself, it really is difficult to get it right in one go. Once the pouch is adequate in size, use a non-ferrous implement such as the back of a disposable scalpel to push the magnet into place. While it's true that using pressure to push the magnet and get it to stay in the pouch creates trauma to the surrounding tissue, it also helps to position the magnet so it's not putting pressure on the healing incision from the inside. The magnet is placed correctly when you can pinch the two sides of the incision site together with minimal pressure without the magnet edge protruding. 

Suturing the wound
"Skin is nature's best dressing." - Bunnell

I advise using a 3-0 or 4-0 braided silk suture with a curved needle. Insert the needle 1.5mm away from lateral edge of the wound to a 1mm depth using forceps. Spin your wrist to drive the needle beneath the incision towards where it will exit, 1.5mm away from the medial wound edge. It's important to pause in the middle of this process and use pressure to push the magnet deep into its pouch. If your using a resin coated magnet, you don't really need to worry about scratching it with the needle, but if your using a magnet coated in parylene C alone, scratching the coating with the needle will inevitably lead to rejection later. If using parylene alone, replace the magnet prior to closing the wound. If you end up driving the needle through and its exit point is non-optimal, it's ok to pull it back and reposition.

Once the suture needle is visibly protruding from an optimal exit point, use forceps to grasp the tip and pull it through completely. Pull a good 8 inches or more of suture thread through the wound and then perform a one handed surgical knot. This looks cool, but that's not really the point. A well tied surgical knot does not loosen under pressure or easily become untied. The first knot determines the quality of the stitch. It should be just tight enough that the wound edge touch. Tying it too tightly will pull the edges of the incision to where they overlap, which increases the likelihood of infection, dehiscence, and scarring. Tie the knot just tightly enough that the edges snug together like the incision never happened. Tie a second surgical knot, and then the type of knot from there on is irrelevant. Just make sure to make lots of them. No matter how much attention you pay to taking care of your suture, you will at some point pick something up or doing something without thinking that will put pressure on the wound, so a good suture is damn near essential.

I very strongly feel a suture is necessary in order to achieve a clean well approximated site without  scarring. For some strange reason though, I read all the time about people who have no trouble cutting themselves open and creating the pouch... but are too afraid of needles to suture themselves. Seriously, you cut yourself wide open so the fear of needles thing doesn't make sense! But, I'll remind you that the point of this blog isn't to advocate for people perform this procedure, but rather to help those doing it anyhow to do it safely and with good result.
Dermabond Adhesive
 If you choose not to use a suture, then you can use a medical grade super-glue called Dermabond. Dermabond does a pretty good job at preventing infection as you can form a serious little glue cap right over the incision site. It isn't all that mechanically strong though, so if you use Dermabond, then you should also be using Benzoin tincture and steri-strips. The benzoin tincture is a sticky coating that smells good and really helps the steri-strips stay where you want them. I advise using two steri-strips over the incision site after application of dermabond. Something to keep in mind is that if you cap the wound in Dermabond, it functions not only to keep pathogens out... it also keeps them in. A nice sutured incision naturally has a bit of seeping that acts to clean the wound from anything that might have been introduced during the procedure. Dermabond traps anything introduced and may increase the likelihood of infection. 

 Removal of Tourniquet

"The tourniquet is not off unless it is across the room."-bunnell

Use a pair of scissors to snip off the hair band and observe the finger as it re-perfuses. A little bleeding is normal although it should be relatively scant. If the site continues to bleed, apply enough pressure with a piece of sterile gauze to staunch the flow. Hold pressure for a minute or two and then check to see if the bleeding has stopped. The surgical stage is complete. Congratulations. The wound is ready to be dressed as described below.

Postoperative Stage
Scar begets scar.”

Dressing the wound
To dress the site, begin by irrigating the incision with sterile saline. Although large wounds are usually irrigated with pressure, such as with a 10ml syringe, it's unnecessary in this case. Simply pour the sterile saline over the wound and then wipe it away with a piece of sterile gauze. The gauze shouldn't be used directly on the wound, but rather around the edges and always wiped in a direction moving away from the incision. The point of the first irrigation is primarily to remove any blood from the surrounding area. After irrigation apply triple antibiotic ointment directly to the site. Cover with a piece of clean gauze and then wrap tape loosely around the circumference of the finger.

Wound Care
For the first week it's important to keep the site dry with the exception of saline irrigation. The one disadvantage of a stitch is that it can wick fluid under your skin along with bacteria leading to infection. Put a plastic bag over the finger and wrap it in tape for showering. Repeat the procedure of dressing the wound daily and as needed in order to keep your finger clean. The gauze that covers the wound should be dry so make sure the finger isn't wet from the saline when the gauze is applied. Carry extra triple antibiotic, gauze, and tape with you throughout the day so that you can dress your wound again should it get wet or become soiled. 
Assessing for Complications
Expect full wound healing to take as long a month. Little healing will occur for the first 2-3 days. By day 3, proliferation will begin. Proliferation begins with revascularization of the tissue. All of the capillaries that were damaged are being repaired or replaced so its normal for the site to look very red. This isn't necessarily indicative of infection. Around the same time, fibroblast cells move into the area and begin laying down the collagen matrix to bind the incision back together.

By day five, if you've kept your incision clean and dry and haven't put any pressure on your wound, you could probably get away with removing the suture. My advice is to actually wait ten days if possible. Keep a close eye on the site. After day 5, tug on the suture a bit after irrigating it to make sure that the insertion sites are free of infection. If the suture sites begin to get red or if you see any exudate it's better to take the suture out. To remove the suture, clip it as close to the skin as possible on one side and then tug on the other length to pull the suture through. After removing the suture, it's a good idea to apply steri-strips and benzoin tincture. They aren't as strong as a suture, but will help if you accidentally use your hand. Keep the the dressed for one day after removing the sutures, unless you notice a portion of the incision remaining open. In this case keep it closed with steri-strips and continue to clean and dress it. It's good to keep the triple antibiotic on the site for at least ten days as it will prevent the tissue from drying out which increases the likely-hood of scarring.

By day 5, there shouldn't be an increase in redness. Any redness or swelling, increasing sensation of warmth or pain may indicate that you have an infection or that your body is mounting an immunological response to the implant.

If you see swelling and redness I advise you give yourself one last shot at saving the implant: drain it. You can use a lancet and poke into the wound after cleaning the site well. Assess the drainage closely. If it's just a little cream colored pus, then you have a good chance of having the site heal nicely after draining. If its a copious amount of drainage, or if the drainage is bloody or any other color I advise you to remove the implant, or see your physician. Most of the time a little infection such as this is not a major problem but there is always the chance of something very bad such as gangrene or necrotizing faciitis. Another very bad sign is if you see stripes of color running down your finger or hand. Cellulitis is always a bad thing, and because the hand is such a delicate mechanism a bad infection can easily lead to loss of function or even amputation. Feel free to shoot me an email if you are concerned about the healing of your magnet, but if you have any major indication that something isn't right, consider going to the ER. You will most certainly get chided and overcharged, but it's always better to be safe then sorry. 
30 Days to 6 Months Post Procedure
Barring complications or too much playing with your magnet, the tissue should have regained between 50% and 80% of its tensile strength by the end of the first month. Picking up other magnets, particular large strong magnets can still lead to problems as this can occlude blood flow and cause crush injury. Ferrous objects like staples, nails, and metal filings are just fine though. At this point,  Wooly Willy is your bitch. Don't be disappointed however if your not getting much sensation. In fact, a decrease in initial sensitivity is likely. You might have experienced a bit of sensation within the first few days after the procedure, but full sensitivity is regained generally over a 3 to 6 month period.

Initial wound healing entails a rapid linking by collagen fibers in a rather disorganized haphazard arrangement. As maturation of the site progresses, the initially disorganized fibers are replaced with well organized ones and the area surrounding the implant will contract rather than looking visibly swollen. After the first 30 days the tissue will begin to soften around the implant. Many of the capillaries and small vessels formed during revascularization will be broken down and the redness of the site will begin to resolve. Nerves will regrow and you'll gradually develop the ability to sense electromagnetic fields.

Another item worth mentioning is the so-called “training” of your magnet. I've read articles where those with magnets “practice” with other magnets in order to increase their sensitivity. Some rationalize it as “forming new connections in brain.” I haven't really found any support for this idea. Perhaps the more one plays with their magnet the more sensitive they will become to the electromagnetic fields around them. Alternatively, perhaps they are just experiencing the subtle increase in sensitivity that naturally occurs as the site heals, matures, and re-innervates. Either way, you won't be able to help yourself; it's a very fun toy, but if you need to justify play you can always tell yourself and others, “I'm training.” 

Demonstration Videos

 Welcome Grinder!
(Saal once accused me of hyperbole. To this I say, you aint seen nothin. ) 
 We live in undeniably exciting times. The wealthy bathe in champagne while children go blind from malnutrition. The great infrastructure projects of our times are aging, failing. A new Hoover Damn is as unthinkable as recreating the glorious pyramids of Giza. But, we build excellent death machines with which to solve our disagreements. 
We've tried polytheism and monotheism. We've played at worship to concrete man-gods we pretend hear our prayers and smile down at animal sacrifice. We've dealt in abstraction and patterns, and admonishment for detachment. The oh wells of promised karmic next times, and patience for the  promises of theophany or savior are wearing thin. More religion, a better religion, a better adherence to religion... this is not what we need. 
We've had our fill of Monarchs and Dictators. Some pushed for advancement. Roman Aqueducts and Chinese Walls weren't built under the direction of a senate. Others were content with luxury, buggery, and incest. Some suggest that we should select our rulers through merit, blind to the iron law of oligarchy: Meritocracy is merely despotism lead by those who masturbate to a mirror. Senates and Republic merely guarantee mediocrity, as the very stupid and the very smart are overruled by the average. More government, a better government, a better adherence to government... this is not what we need. 
What we need is better humans. We need to raise the bar for all of mankind. We should expect more out ourselves and our species. This isn't a self-violent endeavor for type-a personas. We needn't tear ourselves apart for minor flaws as beauty magazine advocate. No, we can be kind to ourselves and to others while remaining committed to bettering ourselves through any means possible. And those means are available here and now. Exercise, and not because you want to look at the way your told to look, but because it will make you smarter and healthier and happier. When you hear badness, transcend a sense of justice. We don't need vindication or justice; as the world isn't a scale and it never was. For some it's a staircase, for others a ladder or even a nearly insurmountable precipice. Any step back is a step down. Perhaps there is a top to this tower of babel, but it isn't in sight yet, and the gods and kings will only stop you if they can. 
Learn. Learn not because it will get you a good job and a fancy life. Not to impress others with word games and trivia. Learn so that you can refine your understanding as to what better means. Learn so that you can pursue this better with competence as well as diligence. 
Remember, a scapular isn't a mere indicator of a persons affiliation, but rather serves to remind a person of the promises they've made to their god, and the promises their god has made to them. A magnet implant fulfills a similar role. It's a reminder promise to oneself to pursue self-improvement via any means possible even through modification of the flesh. It's a reminder of the promise of advancements to cure hunger, to cure suffering and the inequities of the world. And you wear it closer that any mere necklace could ever be. 
Alternatively... perhaps it's just a parlor trick to impress people at the bar. Perhaps it means nothing more than any other piece of jewelry, but admit it. If you just went through the process of performing DIY surgery to get it, you deserve the epic hyperbolic manifesto above. A magnet implant is definitely an augment worthy of consideration. 





  1. Aww yeah, I got a plug ;)

    All in all, a damn good write up Cassox. Chock full of medical information, intriguing historical tidbits, and inspirational anti-establishment content as always; I can dig it. Tell me, are we ready to take over the world yet?

    -The one and only true narcissist

  2. I have yet to find an article that I didn't enjoy and find intellectual nourishment.

  3. great F#$%ng write up! i've already emailed you :)

  4. This is a spectacular write up… One of those write ups that terrify you because you thought you were informed and ready to go prior to reading it, and now recognize how abysmally wrong you had been. THANK YOU.

    If only all practitioners of all modifications were so forthcoming with such important knowledge instead of leaving the rest of us fumbling in the dark… I've always been willing to put in the leg work to ensure that I do things as safely and correctly as I can, but with no one to confirm/disconfirm my leg work, how could I know if I'd reached acceptable conclusions?

    Thank you, thank you, thank you! I will owe my second vision to you!

  5. Howdy,

    If you see the magnet through the skin, then that is not deep enough right?

    1. Hello,

      Thought I would update you, don't want to waste your time by replying to my old comment.

      The magnet was clear as day, a gold disc, I expected it would fall out. So I have moved it, it is still somewhat visible, but only as a blueish spot, hopefully this is ok.