Consumption (55 page)

I began every examination I ever performed on Victoria by examining her fingers. There was always a long minute of silence as she watched me inspect the lunulae of her fingernails, the texture of the nail beds, the angles between the skin and the nails. I held her hands in mine and ignored her quizzical smile. I can assert with quite uncharacteristic certainty that she never displayed any evidence of endocarditis or recent cytotoxic chemotherapy. She will have suspected that I was only looking for an excuse to hold her hand for a moment, a few times a year. She was insightful that way. But she never did say a word.

Plumbism: think of plumb-bobs plumbing the depths and lead-pipe benders and cinches and metalsmiths sickening—the lines of lead deposit themselves in characteristic streaks called Meese’s lines. Argyria is what the silversmiths get; here the lines and the skin itself become blue and, famously, the tip of the nose as well. Chemotherapy shatters the body sys-temically and systematically; it leaves its traces in parallel brown lines.

And here the beautiful art of physical diagnosis runs up on the shoals of artifice. So many lovely signs and tests and names to know: Castell’s technique, the dripping puddle sign, pistol-shot femoral pulses, retro-ocular bruits, Kernig’s sign, Leopold’s manoeuvres—almost all of them important only as arcana, only for the poetry in their names and the history of their evolution. Physicians without CT scanners find a pathology on autopsy and imagine they could have detected it early enough if only they had felt the liver’s lower edge as the patient had exhaled as hard as he could. The alchemists had books of arcana as well, and these books, and all the names and complex theories, made them feel proficient too.

The Journal of the American Medical Association
publishes a series of articles
called “The Rational Clinical Exam.” In them, the various techniques of physical examination are assessed objectively for the sensitivity and specificity of their findings. In almost every instance, whether it is the accuracy of auscultation compared to echocardiograms in sorting out heart murmurs, or the usefulness of feeling the abdomen in an attempt to discern an enlarged spleen, the imaging studies have revealed that these hallowed techniques are dishearteningly unreliable. It would be easy to become cynical about the physical examination, to conclude that the most useful thing for a doctor would be to commence every encounter with a series of scans and proceed from there. As compelling an argument as that might be in the abstract, no patient would want a doctor who behaved in such a fashion, and no doctor would want to be such a clinician. It is necessary to preserve certain rites. Necessary to persist in our faith.

There is information crowded and stuffed into every aspect of the world: arcana and pith, straight goods and counterfeit. When I have been defeated, it has usually been because I failed in the task of prioritizing it, of giving relative weight to contradictory sources of varying reliability. When I have made my worst mistakes, it has been here.

But it remains true that the best way for a doctor to begin a meeting with someone who is sick is to shake their hand and hold it and look them in the eye and feel the texture of the skin between his fingers. And as he studies the opacities in their corneas, feels the tiny xanthomas running along their tendon sheaths, they will settle, will feel less frightened. As will the doctor. When the fear subsides, the truth becomes twice as apparent.

eyes

They are how the world is taken in and so we should not be surprised that the world marks them tellingly.
Arcus senilis
, the old physicians called the opaque grey rings around the pupils that appear in men in their fifties, women in their sixties. Those with high cholesterol are said to develop such rings sooner and more prominently, but this may just fall into that portion of medical “knowledge” that sees diagonal creases in the earlobes as a sign of incipient heart disease: if it’s true, it is only slightly so.

We understand better what to make of brown rings in the corneas of young people with failing livers and psychoses: they are awash in copper—Wilson’s disease. The metal accumulates in their eyes, and in their livers and their brains. When the problem is identified, the copper can be leached out with noxious drugs, but only if someone takes the time to spot the brown ring in the first place and then wonder what it is.

The cornea is the clear covering over the iris in which the copper deposits collect and in which the senile arcs of age first show themselves. A healthy cornea is perfectly transparent. The particular hue of an iris has given rise to any number of songs and epic ballads, while the much more important cornea is without poetic interest. It is an oddity—uniquely sequestered from the rest of the body, almost inaccessible to the immune system. Tissue typing is not required prior to corneal transplant and the cornea is the only part of the body in which cancer never arises. Think about the aloof Swiss, insulated from centuries of carnage all around them simply because they chose not to participate.

But when the cornea becomes diseased, the loss of function is a catastrophe. Corneal opacification is one of the commonest causes of blindness among children, especially where medical care is unavailable; it is usually caused by
Chlamydia trachomatis
infection, acquired in the headlong slide through the birth canal. The swollen milky eyes that result are called trachoma, found anywhere chlamydia infection is—that is, anywhere men and women make love to one another. When the nurse dabs erythromycin ointment in your daughter’s wee folded eyes as you catch your breath after she is born, the nurse is impugning your virtue
and
she is doing the thing that reduces childhood blindness by 90 per cent. A single squirt of eye ointment and the child sees.

Between the cornea and the iris lies the aqueous humour: transparent, watery, the substrate against which the fibrils and interwoven multicoloured tendrils of irises dazzle. Iridologists believe that the complex patterns woven into the brightest parts of our eyes possess meaning in proportion to their complexity. They may be right; the lingering question is whether we can interpret that meaning usefully. Snowflakes are infinitely and fractally varied too, and their variations reflect the atomic structure of water and the van der Waals forces acting on the hydrogen molecules. Great lessons about the structure of matter, or, at least, of water, can be taught using the range of variation within snowflakes, but—though it would make a good story—it wasn’t simply by peering at mittens in snowstorms that molecular theory was sorted out.

Behind the iris, the lens bulges forward, another transparent sac surrounding clear jelly. Within this translucent gel form crystals and scars from hundreds of thousands of hours of work focusing light and gathering insight. These scars cause opacities called cataracts, which possess the same potential for catastrophe as their homonyms. The repair of these is the best work doctors do. The Inuit became old when they could no longer see well enough to sew or shoot—sight was lost long before will, or knowledge. The Arctic, when men move upon it, is awash in light; all that the black dirt absorbs in the south the snow sends back skyward here. The air is lit from below and above and the light simply dazzles. Within the squinting eye, taking it in, the lens is cooked incrementally.

A cataract may be cured with surgery that lasts fifteen minutes and requires no expensive regimen of pills and intensive care. Old men and women blind ten years go walking on the land a week after the operation, stepping lightly and certainly on the moss and rocks. By comparison, every other therapy offered for every other problem is immeasurably crude.

The crudest of all of these are eyeglasses, of course—condemning the myopes to a lifetime of dependence on the fragile appliances we ask them to strap to their heads. For accountants, perhaps, this is no problem, but for men and women who run and hunt and go to sea, eyeglasses are as incapacitating as a dependence on any other crutch. And consider how common short-sightedness is now among southern children and young Inuit. A generation or two ago it was so rare as to be worth reporting; when Victoria needed such strong lenses, the doctor on the
C.D. Howe
checked her refractive error three times.

Consider the debility that such a condition poses for anyone who does not have access to an optometrist. It would be not much less troublesome than a missing leg. Maybe even more—with a missing leg you could still hobble to a ridgeline and shoot straight.

And yet we have no idea what causes this most common of all of the diseases of affluence. If it was near work, then more women should have had myopia than men and yet they did not. And now that ophthalmologists buy themselves large houses with the proceeds of refractive surgery, one wonders how acute the interest in understanding and interrupting the pathogenesis of myopia can really be.

I enjoy the journals I receive here for their own sake.
The Journal of the American Medical Association, The New England Journal of Medicine, Lancet, The British Medical Journal, The Annals of Internal Medicine:
these are like jewels, with writing about all corporal aspects of humanity rigorously prepared, as precise as a gamma knife. There is a kind of poetry in that precision. Any expectation that the writing within them is dry and unemotional is defeated upon contemplating the case histories—anecdotes of children and adults with malignancies and plagues defeating initial diagnosis: lymphomas and tropical fevers, unapparent self-injury, and malabsorption disorders. In the
accounts as they are printed, the uncommonly clever and usually Bostonian doctor plucks the answer out of the clues in the data and the patient is saved. How can one not applaud?

I am moved by these accounts, but the truth is that they do not much help me. I pore over the journals, trying to learn, but when things happen quickly, as bad things generally do in medicine, all that knowledge seems to retreat from me. I delivered Victoria’s son, and both her daughters—the older, eccentric one, Justine, and the intense skinny one, Marie—and in each instance all I did was gape as her babies fell into my hands. And still she remained patient with me. She was even patient with me when her last baby died as I tried to deliver him.

If I had been as clever as those Bostonians, I would have become an ophthalmologist. I wanted to, applied to all the residencies I could find, in America. But as the replies came to me, thin and perfunctory, I realized that among the men I had approached to be references, one at least had seen me clearly. I finished a general internship at a community hospital in Yonkers and then I looked for a job. There was an advertisement by the Canadian government, looking for doctors in the Arctic, where the turnover was rapid. I came up here.

Behind the lens, and the vitreous humour—yet another transparent and particular gel—is the retina, the film of the eye’s camera. Here are the only blood vessels that may be directly witnessed in an unincised body; they sit in a transparent mesh at the back of the eye. All the illnesses of rich people may be glimpsed here. The poor develop river blindness and trachoma and congenital cataracts: all at the front of the eye, and while they are young. Age and rich living seep into the back of the eye. It is here the wealthy grow blind. The banker’s high blood pressure tightens the retinal arteries in stiff wires now coppery, now silvery in appearance. Diabetes prompts new vessels to sprout here and grow across the retina, shading it from the light slowly and then abruptly as the new and ill-formed vessels burst and bleed across the field of vision.

The optic disk is at the back of the eye as well, a visible outpouching of the brain itself. When tumours grow inside the skull the evidence of the pressure
they exert may be seen here, in the bulging of the optic disk. It is a bad day when an unremarkable-sounding headache is being assessed and the optic disks turn out to be swollen and distorted: this is called papilledema and it is usually terrible news. The patient, at that moment, may hear her physician inhale sharply and lean abruptly forward, turning the clicking wheel of his ophthalmoscope—taking in the portent of trouble full in the eye.

The poets talk in their excessive way about eyes as the windows of the soul. And perhaps sometimes they are that. But they reveal things this side of the soul as well. The desperation of the poor marks the fronts of them and the indulgence of the rich marks their backs. The eyes have it, the essence of us and our lives, marked all over them, awaiting the perceptive observer. Shining corneas and reddened sclerae, engorged eyelids and oedematous periorbital tissue: none of us are as placid, or opaque, as we try so hard to seem.

big blues

Anomie. Ennui
. The French have the best names for it, but it was the Americans who invented teenagers and adolescence and it is among the Americans that the phenomenon is the most impressive. People say that change is hardest for the old, but this is unlikely because the old have the simple expedient available to them of just refusing to. New forms of music—swing, rock, hip hop—are not embraced by anyone over forty, except poseurs. New languages are all but unavailable to anyone over thirty. Revolutions in thought are launched by mathematicians before thirty, and physicists before they are thirty-five. Poets: twenty-five. Change is not so difficult for adults because, for the most part, they just don’t.

Deep fundamental change breaks like surf upon children. And it is change that injures us when we become wealthy, not some Calvinist idea that riches corrupt the flesh and soul. Poverty remains the most potent toxin for humans but the next most potent poison is confusion. When we are confused about what and how much we should eat, about how much assistance to receive from our machines, about how much attention to pay to our parents and our aunts and uncles, and, God help us, our children, we become ill, we sicken ourselves. We stop moving and we stop attending to the necessary rituals. We become fat and hubristic, and we lose confidence in our own capacity.