A Little Medical Afflictionary (Martin Winckler)

Background: La Maladie de Sachs, Martin Winckler’s second novel, found a huge public when it was published in France in 1998. It turned on the brilliantly simple expedient of having patients describe what goes on in the four walls of the consulting room rather than the person with the white coat. Winckler is a man with a mission, and he makes no bones about his dislike of the French medical establishment: “doctors,” he roundly declares, “are cowards.” His amusing “afflictionary” is revealing of the intense French preoccupation with reading the body personal – the more readings the better.

AIDS: in the western world, historical successor to the plague, TB and cancer at the top of the hit-parade (or Top 50) of sacred diseases. It may be noted that this distinction has nothing to do with the real number of affected individuals. In Africa, for example, malaria, TB and AIDS are so frequent that they are considered not so much as threats, but as aspects of civilisation.

Alternative medicine(s): medical practices based on principles radically opposed to those of conventional medicine. While the latter is founded on respect for the symptom (see Pain), terror and ignorance, the bases of alternative medicine(s) tend to be enhancement of the symptom (see Homeopathy), anxiety and credulity.

Antibiotics: medications for lowering fever. Always a source of tiredness, they should never be taken with milk (it makes them curdle). Very common cause of allergy.

Appendicitis: benign childhood disease which is invariably diagnosed by mothers. Becomes serious when it occurs in an adult (and is then referred to as “peritonitis/septicaemia complicating atypical gangrenous perforated appendicitis”)

Auscultation:

  1. (outdated) technique involving listening to the internal sounds of the body using the ear (immediate auscultation) or with a stethoscope (mediate auscultation) placed on the patient’s body.
  2. (modern) examination of the patient by the doctor. Ex.: “I was really afraid of having cancer of the testicles but he auscultated me all over and it’s just a fungal infection of the privates.” (See Consult.)

Blood pressure (measurement of): objective reflection of the doctor-patient relationship (e.g.: “He didn’t even take my blood pressure!”) but differently assessed depending on the observer:

  1. for the physician, “normal” blood pressure is greater than 155-the figure above which the occasional patient becomes a “patient on permanent treatment”-or less than 80-the figure below which hospitalisation becomes a must. Between these two values, French doctors say that the patient has “no tension” (i.e. normal blood pressure).
  2. for the patient, the blood pressure is “normal” if, and only if, the figures obtained are strictly identical to those previously measured, even if the reading was three years beforehand. (Ex.: “How can that be, 120 on 80? Last year, I measured 130 on 90. It’s not normal!”)

Cholesterol: modern equivalent of the ancient gods. When it climbs, sacrifices have to be made (no more butter, meat, sugar); when it falls, one indulges (no more medication).

Clinical examination: mystical ritual (not to be confused with auscultation) during which the doctor examines a patient. The crowning act of the clinical examination is measurement of the blood pressure.

Consult, to: this term may be applied equally to patient or physician depending on whether:

  1. the first asks the second to explain a complex problem, or;
  2. the second examines the first (see Auscultation) and;
  3. flicks through the telephone directory to find the number of a specialist (who is then referred to as a “consultant”).

Consultation: friendly visit paid by the patient to the doctor. By extension: time of the day during which the doctor sees people he doesn’t know drop in between two appointments.

Death: irremediable breakdown between a patient and doctor. Contrary to a received idea, death is not, as the physician sees it, an end in itself. It is only a stage–often inevitable–in the doctor-patient relationship which ought to be delayed as long as possible in order for it to be fully receipted.

Diagnosis 1: complex mental process at the end of which:

(a) the doctor names the disease or
(b) the patient dies without anyone understanding why. (These two propositions are not incompatible.)

This intellectual process is the product and conjunction of knowledge, intuition, hunches and sometimes amazing revelations, and may be compared to the resolution of a crossword puzzle in which symptoms are the horizontal definitions and signs the vertical definitions. The doctor is able to call upon three diagnostic tools: blood tests, appeals to specialists and hospitalisation.

Diagnosis 2: (by extension) capacity possessed by a physician to resolve crossword puzzles more or less reliably, i.e. to provide an explanation for everything including an inexplicable death (Ex.: “He has a good nose for diagnosis”).

Diagnostic complex: this is applied to rare or poorly understood diseases (in other words, the most interesting) and calls upon a number of means which, depending on the rarity of the disease in question, enable the physician:

  1. to prepare an article for publication in specialised periodicals;
  2. to list the characteristics enabling him to spot, identify, detect or to drive out of hiding (for ethical purposes) patients suffering from the same disease entity;
  3. to come up with possibilities for research and human vivisection with an aim to trying out new treatments, gruelling but promising;
  4. to advance if not scientific knowledge then at least his own reputation.

Doctor: has a degree from the medical faculty or is just about to get one. Before 1945, his main function was to make diagnoses. From 1945 to1975, spent most of his time prescribing antibiotics and measuring blood pressure. Since 1975, he has been wavering between the war against cholesterol and looking for more financially attractive gaps in the market. (See Alternative medicine.)

Euthanasia:

  1. taboo subject (in hospitals).
  2. hot topic (in the media).
  3. method enabling a family to lose one of its members without risking legal pursuit, and enabling the family to arrange for burial or cremation at a set date.
  4. last resort when a hospitalised patient, in spite of the (good or bad) care provided by the doctor(s), goes on filling a bed and getting up everybody’s nose.

Family: universal pathogenic medium, resistant to antibiotics, vaccinations and to all therapeutic methods invented in the last six thousand years. (See Family Doctor.)

Family doctor: species currently disappearing. After rapid mutation in the last fifty years, the supposed focus of the family doctor’s attentions has acquired a heightened resistance which makes it sometimes insensitive to this category of care provider. Today, it is not uncommon for a family to require multiple therapy involving GP + specialist + psychoanalyst + homeopathic doctor, which at least stabilises the general condition. Some authentic family doctors still subsist in remote regions, but it would seem that urbanization and the spread of parabolic antennae will soon have put paid to these last pockets of susceptibility. (See also Family.)

Fever: symptom which justifies:

  1. wrapping babies in three pullovers and twin covers (to avoid them catching cold);
  2. calling the doctor at night (in order to be sure of finding him at home);
  3. prescribing antibiotics (in order to avoid a complication);
  4. issuing a sick note for the mother (in order to ensure that baby doesn’t develop an allergy to antibiotics).

History-taking: rambling conversation between the doctor and patient, sometimes in the presence of other participants. For the doctor, the point of history-taking is to transform the reason for consultation into an intelligible symptom (at least) or into a classified disease (at best). The patient sees it as an opportunity to ask the doctor all those questions his colleagues have so far refused to answer.

Homeopathy: method consisting of mixing undetectable amounts of various products in sweeties readily absorbed by children of all ages in order to treat numberless disorders of an indefinable nature. Homeopathic medication is defined by how it is manufactured and not by its effects on symptoms. It is therefore perfectly possible (and undoubtedly wise) to treat “life-buoys” with granules of “pneu 5CH.” In any event, even if it doesn’t help it won’t harm.

Moreover, a fundamental concept distinguishes homeopathy from allopathy: “the principle of similitude” or like with like. This involves administering to a patient a toxic substance causing the same symptoms as the disease (but more pronounced), in order to convince him that the remedy is often worse than the disease. This is then referred to as “symptom enhancement.” (Ex.: “With the trots these granules gave me just before I left, it’s not surprising I didn’t catch anything in Thailand!”)

Home visit:

  1. change of location imposed on the physician by a bedbound patient (urgent visit), patient with car problems (comfort visit), or very generous patient (courtesy visit).
  2. in some circumstances, equivalent of a “gynaecological examination”. (Ex.: “The doctor came for a long visit but he was unable to find why my fibroma hurts when Jules does his business.”)

Hunting stories:

  1. (outdated) salacious, juicy, extraordinary or unlikely stories told by doctors to their colleagues to convince them that theirs are the more outstanding patients.
  2. (modern) waiting room conversations during which patients tell each other about the diagnostic errors made by their former physician(s).

Illness: the sum total of unpleasant phenomena which brutalise the body and mind of a patient, and whose cause, development and nature are codified, described and indexed in all good medical treatises. An illness is often a hydra with several heads. Whether it affects the body (physical diseases), psyche (psychiatric diseases), both (a real mess) or neither (psychosomatic diseases), its origin is either external (measles, dysentery, malaria, chemical pollution, radioactivity, family conflict), internal (resentment, guilt, frustration, cancer) or mixed (that’s life … ).

III person: a patient with an illness (the doctor says so). Not all patients have diseases but in order to justify his standing and salary, the doctor prefers that they should. And he hates it if he gets word of the solution to the crossword puzzle before even seeing the grid. (See Diagnosis 1.)

Medical act: comedietta of variable length played out by at least two persons, at least one of whom is a physician.

Medical rep: person who gallantly camps in the waiting rooms in order to throw some light on the doctor’s consultation and leaves him freebies to be used for treating his mother, wife and children. It is rare for reps to be patients, but is it not unheard of for reps to be completely sick. There are two types: the rep (male variety) generally sports a three-piece suit, an attaché case and a frosty smile. The rep (female variety) can be recognised by her portfolio, tailored suit, flat pumps and the gold chain (bearing her employer’s arms) around her ankle. The characteristic common to both is frank hypocrisy. (“What! You haven’t heard of my product yet?”) and a tendency to treat physicians like imbeciles (they’re only wrong about one in ten).

Medication:

  1. object of profit.
  2. instrument of power.
  3. source of allergies. (Ex.: “I’m allergic to all drugs but especially to antibiotics. “)

Morphine: illegal drug consumed solely by hopelessly dependent junkies and patients in terminal phase. Morphine is the doctor’s worst enemy since, by denying the patient’s sense of just how painful reality is, it makes him less dependent on the therapist.

My patients: term used by a doctor to suggest that a large number of patients are unable to suffer without him.

My doctor: outmoded term. Today, it has been replaced by various expressions: “my acupuncturist-iridologist,” “my adolescent psychiatrist,” “my plastic surgeon,” etc.

Nurse:

  1. person with the task of performing injections, blood tests and/or enemas ordered by the doctor (in hospital) or demanded by the patient (outside hospital).
  2. senior registrar’s mistress (in hospital); GP’s skivvy (outside hospital).
  3. sadistic torturer (in hospital); powerless confidante (outside hospital).
  4. undervalued professional (in the media).

Orders: together with the diagnosis, which they may precede, follow or completely replace, doctors’ orders are the other high point of the medical act; they are expressed as a written formalisation of the doctor’s deep thinking, which is unintelligible to the patient. The purpose of doctors’ orders may be diagnostic (ordering of further tests), therapeutic (prescription of several medications), administrative (completion of a certificate or work stoppage) or exorcal (request for a specialist consultation, hospitalisation or seclusion in a padded room). Orders are by convention handwritten, and thereafter remain legible only to a pharmacist (provided he’s long in the tooth and the medications actually exist).

Pain: method of audiovisual communication used since the dawn of time by patients (of whom there are a great many) to draw the attention of doctors (of whom there are far fewer) to their person. It required several thousand years before doctors understood that pain is a very common symptom which is found in very many diseases. Between 1880 and 1995, the reasonable attitude was to “respect the pain”, i.e. to allow it to express itself freely in such a way as “not to mask the symptoms”. (Otherwise how would one know the patient was suffering?) Presently (since about 1995), pain is held to be a symptom which is absolutely unacceptable in a civilized society. As a result, the current attitude is pretty much to treat it with disdain.

Patient: an individual who consults a doctor. The word “patient” comes from the Latin pati, to put up with. The patient puts up with waiting, in the room of the same name, because he doesn’t enjoy putting up with suffering. It may be deduced from the foregoing that a patient is usually (but not always) someone who suffers. At least, he is the one saying so. As a result, the doctor has to put up with-cost what it may!-listening to the patient suffer. (That is called “respecting the symptom”.)

Pharmacist: medical auxiliary whose main field of competence, acquired through long experience, is to know how to decipher and translate prescriptions, and whose main function is to sell shampoos, toothpastes and slimming creams. In tubes.

Physiotherapist: a thug in hospital; a strongman outside. More often considered a masseur by patients than a colleague by doctors.

Prescription: sheet of headed paper on which the doctor writes-usually illegibly-the name of the medications he has been thinking of since the last medical rep visited, or recopies those which he manages to read on the out-of-date prescription presented to him by the patient on coming. Now and again, the doctor may use these same sheets to write to a colleague, to certify the good health of a mother of four who is about to do a course in bungee jumping, or to ask the tax authorities to stagger the obligatory payments for the coming year.

Rara avis (rare bird): figurative term used by doctors to describe a patient lacking the decency to die of an identifiable disease.

Reason for consulting: pretext elegantly provided by the patient in order to allow the doctor to prostitute himself without having to tout for business.

Reimbursement: complex system for racketeering, laundering and recycling money between a producer (pharmaceutical laboratory), wholesaler (pharmacist), dealer (physician) and drug consumer (the insured person) under the supervision of two nationwide criminal organisations (the French State and pharmaceutical industry).

Sexuality:

  1. taboo subject (in consultation).
  2. conversational topic (on TV).
  3. main nutritive element of the pathogenic family milieu.

Sign: objective phenomenon which the doctor observes. (coldly) on the body (still warm), in the behaviour or after further testing of a patient, whether ill or not. A sign is not necessarily pathognomic of a disease, but may often make the doctor worried and give rise to the extra-thorough diagnostic work-up. For doctors, the signs which are most exact, most trustworthy and which lend themselves best to teaching are of course best observed at autopsy.

Specialist: doctor who doesn’t do home visits, and who looks after only a bit of the anatomy (eyes OR breasts OR haemorrhoids, but never all three at once).

Symptom: unpleasant sensation perceived by the patient and sometimes (but not always) observable by the physician. Not to be confused with sign. The symptom most frequently experienced by patients is pain. Many factors (physiological, psychological and cultural) are responsible for the fact that pain is described, acknowledged or expressed differently by each patient. Some weep and cry, others pull discreet faces beneath pillows. The problem is complex because pain-unlike other physiological characteristics-is neither measurable nor comparable. Naturally, when patients openly give voice to their pain(s), doctors tend to think they’re overdoing it a little. It’s quite true that when this happens it’s much more difficult to stay cool: the rooms are badly lagged.

Treatment:

  1. fees paid to their physician by patients who come to consult him regularly: every five years for the tetanus booster; every year for the fitness certificate, vaccination or smear; every six months for allergies; every three months for the pill; every two months for hypertension (you just never know when it might go up again); every month for infants; every fortnight for “normal” pregnancies (the others have to be hospitalised); every ten days for alcohol withdrawal support sessions; every eight days for leg ulcers; every week for morphine; every third day for fevers that won’t go down; every second day for pains in the neck; twice daily for the dying.
  2. attitude of most doctors with reference to their former patients. (Ex.: “Personally, I couldn’t put up any longer with the way he treats us. “)
  3. drug-based or surgical methods sometimes used by doctors to put an end to their patient’s sufferings.

(See also: Antibiotics. Pain. Euthanasia. Morphine.)

White coat: distinctive sign of the caring profession, the white coat is an article of clothing whose significance is as polymorphous as a military uniform. Curiously, it is less the shape of the white coat which counts than what it carries or encloses. Under their white coat, auxiliary nurses wear a vest (especially in summer), nurses a skirt, departmental heads a bow-tie, house officers are clad in operating greens, physiotherapists sport shirt-sleeves and the crash team sweat. And if it happens that the men in white have the blues, it’s always the patient they get shirty at.

 

Discussion Questions

  1. Which of these definitions stand out to you as most surprising/striking? Which do you most sympathize with? Why?
  2. Why do you think Winckler frames his critique of the French medical system using this rather humorous format?
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