You know, when I started working almost exclusively at SMACHEAD I thought that I would see "less medicine": that I would see only a fraction of the active medical problems that I was accustomed to seeing at Florey, and that my clinical skills, like unused muscles, would rapidly whither away.
But this has not actually been the case. I spoke last week with a muscular-looking man: stocky, red-headed, swollen calves and forearms like popeye... who was until recently a brickies labourer. He has a mild form of muscular dystrophy. By all accounts he should be in a wheelchair by now, and most people with what he has would be dead before his chidren (both girls, and therefore safe) grow up.
"I don't look like I've got muscular dystrophy, do I?" he grinned, flexing a fist, and I sort-of nodded. Weakness in the muscles closer to the trunk means that forearms and calves are often hypertrophied, excessively large. Like the elevated mood of a bipolar patient, or the absence of wheezing in an asthmatic who is about to die, these are not true signs of health but symptoms of a terrible disease. Once you knew what to look for, he looked sick. But he didn't want to hear that he looked like a sick man.
He smokes twenty cigarettes a day. He's not going to die of a heart attack or lung cancer. We are meant to be handing out cheap nicotine patches to our clients, I haven't pressed him on this.
And another patient. A very unfortunate man with, again, bipolar disorder (seems to be a lot of it about...) who came to us for methadone treatment. His problems are twofold - the way his mania manifests and the way his blood responds to the treatment.
Mania affects different people in different ways. Poor sleep, feelings of limitless energy, disinhibition in various ways, that kind of thing.
I get this weird ego thing - I talk all the time, fast and loose, I exercise lots, and form the conviction that I am sexually irresistable, remarkably artistically talented and full of untapped physical and intellectual potential.
A friend of mine buys expensive but useless stuff. In small amounts none of these are problems, and a mild hypomania is actually a damn fine thing: it's glorious. When you have to deal with the consequences of some of the embarrassingly stupid decisions you've made, then the problem arises.
Anyway - this guy tended to get more of the irritability and impaired judgement side of things, and I suspect this had been partly to blame for the crimes which had put him in prison. Stealing cars, robbing video shops, that kind of thing. Since getting diagnosed in prison and then getting out a few months ago he had been a model citizen - one big purple tablet in the morning, two at night, and for the first time in his life he felt calm.
Until the next GP visit. Blood tests showed that the valproate was affecting his body, causing his bone marrow to stop producing white blood cells. If he didn't stop taking it he would die.
"My arse" he said to the doctor. "I've never felt better."
"This is serious" she said. "You could get very sick. I can't prescribe this any more."
Things deteriorated and she sent him to our service. By this time he had resumed taking his valproate (he had quite a few weeks worth in stock) and felt much better. I tried the same thing.
"If I get sick, I can go to hospital. That's what they're for" he said.
"Mate, they will be able to do piss all for you." I said. "Trust me, I work there. You need white blood cells, you'll die without them. First time you get a cold or something you'll crash. If you get sick, nothing works - no antibiotics, no transfusion. They'll have to put you in intensive care if you get a bloody cold."
He shook his head. "Gotta go sometime."
"If you don't stop taking the valproate" I said, "I reckon you'll be dead within the year."
The preceding was a bit dramatic, but not grossly inaccurate. No white blood cells means essentially no immune response - like AIDS but quicker. He was the kind of man who responded to difficulty with anger, and he was looking pretty angy now.
"There are alternatives" I said. "Lithium, topiramate... look, I'll write them down. Work just as well, better in some cases. As long as you don't get pregnant." And I sent him urgently off to a specialist, because this wasn't one I was going to deal with alone.
Anyway. Apparently Diderot said poverty and disease were the "two great exorcists": they drove out what else inhabited the body and left only the true person, the "true self". We do not see a person's true worth, says Diderot, when they are lying on a bed eating mussels and drinking merlot, we see their true worth when they are weakened, sick or poor.
I don't know about that. Leaving aside the possiblity that you can tell quite a lot about people from looking at what makes them comfortable, from watching what they do with the wealth and health they have,
the idea that we see people truly in sickness does not automatically convince me.
The muscular dystrophy guy - the guy living a relatively normal life, until recently hosting bricks, watching the telly and smoking ciggies down the pub. He has a weak form of muscular dystrophy - a protein that is subtly malformed, not enough to be completely useless, but not good enough to be strong.
He is in between the sick and the well, someone who has a foot in both camps. You can close your eyes and imagine the person he would have been had one codon been different, one gene subtly altered - as if he stands before you flanked on the right by a strong and vigorous man who will die in his seventies, on the left by a withered figure in a wheelchair, wearing an oxygen mask, maybe days away from death.
I don't know that the sick man is any more true, that the sick man's life shows any more of what this man was really like than does the well man. It makes just as much sense to say that this man's true nature was as we saw it - checked shirt, packet of White Ox tobacco in the breast pocket, suntanned and grinning - and that it was the unhealthy man who was the illusion.
And the man on valproate. Was he any more himself when unmedicated, when his blood was vigorous and healthy but his mind was full of racing thoughts, plans and ideas and scams that almost seemed too good to be true, holding up a service station, shaking with wild ideas? Or was he "really" the quiet man with the thin blood and the intelligent, calm look?
I don't know. I don't know that I believe in "true selves". A field grows a flower, that kind of thing. There isn't a true self, any more than there is a "true path" that a leaf can take as it falls to earth: things happen to you, you ride them out, you do the best you can. Diderot died at seventy one of emphysema and the beautifully named dropsy - I don't know that he was any more his true self as he breathed his uncomfortable last.
Anyway, this is starting to sound like something that should have a moral at the end of it, and I've never been particularly good at morals. I suppose in the end I'm just grateful: grateful that I can load bricks and make plans, that I can look at but not leap upon dark-haired and dark-eyed girls I see, and that my proteins were twisted just enough, but no further, than necessary.
Thanks for listening,