Consumption (54 page)

My niece is insanely allergic to peanuts; even a glancing contact with a peanut shell will raise red welts on her skin. Her parents live in terror of the ill-considered spring roll. She has asthma too; both these diseases are increasing in prevalence and severity in American cities in a time when other serious medical problems are in decline, as we all grow richer and better doctored.

The problem is that our bodies are meant to struggle as much as our brains are; children’s immune systems expect to have to beat off infections.

When the immune system is never called upon, it behaves the way underworked soldiers do and makes trouble. If it’s not finding infections, then it must not be looking hard enough. So it looks harder, and starts to detect infections that aren’t there: thus the terrible toll of autoimmune disease rises steadily in our era of antiseptic floors and single-child families.

But the real trouble is what people’s minds become when they are never called upon to fight off a predator. Gelatinous grey goo. Middle-aged fat man looking out his window at people walking in the snow, dressed in his underwear at two on a Sunday afternoon, teeth unbrushed since Friday morning, a litter of alcohol swabs on the floor and empty pudding cups stretching to the walls.

I made a deal with myself that I would never do it on weekdays or more often than once a month. And although stealing the morphine was itself a transgression, I was able to limit that transgression to these bounds. I wondered about that often, even at the time: if I was able to control it all, why didn’t I just stop? And if I couldn’t stop, why didn’t I become a daily user, with the attendant ongoing catastrophes for my patients and my eventual firing?

The answer, I think, is twofold. First, either would have been too decisive a course of action for a man of my nature. All my life I have equivocated, puzzled most of all about what it was I wanted, what I should be striving for. I came to the Arctic for a summer to pass the time and make a small bit of money after my exams. But this is where I ended up spending my professional life, out of habit and out of what became an increasingly narrow range of options. I didn’t actually choose the place until I had spent half my life there.

And, too, there was my overfondness for secrets. I was pleased that there was something unapparent about me, something not evident at a cursory glance. The people who divined my secrets—Isabelle, Bernard—and chose not to reveal them, they were bound even closer to me as a result. So my loneliness was assuaged in two ways: by the drug sliding up my arm and by the complicity of my friends. Potent thing, loneliness.

fingernails

The first thing they tell you is how sick someone is. If they are vital, pink, and smooth, their possessor is either well or only recently unwell. Chronic illness of any sort causes them to whiten steadily with the diminution of vitality: this is leukonychia, or simply, white nails. It always bodes ill.

But they reveal more than that. Lung cancer, for instance, induces a gecko-oid swelling of the ends of the fingers. The nails heap up in compound curves, as if some better instinct within the body was seeking to escape the coming disorder, but got lodged in these, the terminus ends. Chronic hepatitis produces the same effect, as do holes in the heart that leave their possessors blue and breathless. This is called clubbing, and when it is caused by trouble, the trouble is serious. Confusingly, however, sometimes it just exists, without any reason except perhaps to temper young doctors’ certainty.

When Victoria returned to Rankin Inlet, her file did not accompany her and did not get sent north for almost a year. I had no details about her medical treatment in the sanatorium. Clearly she had had a thoracoplasty—I knew that much from looking at her. And she had been gone long enough to have completed the year and a half of antibiotic therapy and was now only a little underweight. She didn’t cough.

I was among the first to notice her friendship with the Hudson’s Bay man.

At the time there were a total of seven of us from elsewhere living in the town: me, the priest, the Mountie, the three Bay Boys, and her.

She lived in a kind of internal exile in the community. She could be seen most days in summer and winter walking alone along the edge of the bay perfectly erect—the nuns, and their preoccupation with posture—loneliness rising off her like scent.

As a doctor one can keep out of trouble most of the time by being cautious. It is not necessary to make precise diagnoses with any great facility so long as one is able to recognize the presence and the severity of trouble. Rashes in people who feel well, for instance, will tolerate leisurely investigation and treatment; rashes in people with fevers are an entirely different story. So long as one knows this, there will be no conversations with local licensing authorities.

Victoria used to spend a lot of time down by the bay, a distance from town. We could all see her. We all watched her. I was supposed to follow up on the returnees from the sanatorium, make sure that the treatment held. She came to my little office whenever I asked her to, and she was healthy, she said, but not with the relief I might have expected. She looked at the books on my shelves at length. She asked me if I had anything she could read. At the time I had only textbooks, but I wrote to a friend and asked for some novels.

When they arrived I went looking for her, and of course she was sitting on the beach. I watched her for a time to make certain she was alone and not waiting for anyone. Then I watched her watching me approach.

“I have something for you.” And she looked up at me with disappointment.

“Catcher in the Rye
, it’s about growing up in the city. And
A Passage to India
and
The Magic Mountain.”
I handed them to her. She hadn’t seen these before. She was pleased then.

“Is there anything else?” she asked.

“No, that’s all there was in the package,” I said. “Maybe when you’re done these, if you want, I could get you more.”

She seemed to be waiting for me to say something. I was embarrassed, of course. I couldn’t think of anything else to say, and I walked away. From then on, whenever the forms from the TB people came, I wrote down
unremarkable recovery
and didn’t bother her about them.

Short black streaks running parallel with the finger and lodged at the terminal ends of the fingernails are called splinter haemorrhages, appearing like mahogany slivers lodged under the nails. They look painful, though they are not, and indicate infection in the heart, especially on the valves. The communication between the centre of the body and its extremities is striking: this is the idea of this book, after all—that the edges reveal the centre. It as is true in anatomy as it is in geography.

Splinter haemorrhages occur when small aggregates of bacteria and fibrin break free of the infected heart valves and flow out into the arterial tree, lodging at the ends of the fingernails where they streak out into lesions. Clumps appear also in the retinae, where they are called Roth’s spots, and on the palms of the hands—Janeway’s lesions. And on the finger pads—Osler’s nodes. They enlarge the spleen and cause micro-infarctions in the kidneys, the brain, the bones. But the fingernails are almost as revelatory as the eye, a place where we may observe the havoc that is otherwise concealed.

When the thyroid is deranged and running unchecked, the body’s thermostat cranked too high, the nails peel away from the nail bed. This is called onycholysis: splitting of the nails. They lift up and yellow, and it is unappealing to look at, though in the mania of hyperthyroidism, the afflicted may be unconcerned or, alternatively, preoccupied by them.

When pits appear all over the nails, like divots out of a driving range, it can be the only sign of psoriasis, or the only sign except for active and erosive arthritis. When someone comes to you with a throbbing knee, and you
dwell upon scarcely visible irregularities in his fingernails, it takes some work to persuade him he is not in the presence of an idiot. But the information is useful, and reveals the nature of the arthritis. The edges, again, in their revelatory mode.