Finally some doctor orders the right test and discovers the patient’s blood has more iron in it than the Lusitania. The diagnosis will be hemochromatosis, a poisoning of the body by iron overload. It is inherited, but it can be in your family and you might not know it.
Untreated, hemochromatosis can affect virtually every organ in the body. Your knees freeze up with arthritis. Your hips can get deformed, so you walk like a penguin. You get so tired you fall asleep anywhere, in the middle of anything. Your testicles atrophy and you become impotent. Your body softens and loses hair, and you start to look like a woman.4 Your heart palpitates wildly. You get easily out of breath. Your skin erupts in terrifying spidery bruises. You eventually die of liver cancer, or of painful, suppurating peritonitis, or you bleed to death from ruptured esophageal ulcers.
That’s horrible!
No, this is horrible: Hemochromatosis is completely treatable if it is caught early enough. Every week or so you get some of your blood drained away, and it eliminates the problem. But it is sometimes not caught early enough. Too many doctors wasting too much time.
Fortunately, in the 1980s general practitioners started wising up and catching hemochromatosis because they began ordering iron tests as part of routine blood workups. Unfortunately, in the 1990s some HMOs and other superstingy medical insurers have stopped paying for this test.
In short, look for a spike in the number of cases of runaway hemochromatosis. It will be a sharp spike. It will be made of iron.
1 This is exactly like kissing. If you keep your eyes open when kissing, it means there is something wrong with you. I learned that as a teenager, when I violated the rule and got nailed by my date. She chewed me out. Kissing with one’s eyes open, she informed me, was an unmistakable sign of sexual predation; I was a rapist in training. Years passed before I realized that one can be caught at this transgression only by someone who is also kissing with her eyes open. By then my date had become a lawyer. I let it slide.
2 Another is the “pump fake” in football.
3 Not that he is infallible. Used to be, if you had a stomach ulcer, doctors disdainfully concluded you were the “ulcer type,” the sort of feeb who alphabetizes his bookcase and wears tie tacks and makes his bed with hospital corners. You were gently steered toward psychotherapy, and maybe encouraged to find a less stressful job. Now it turns out that more than half of all stomach ulcers are caused by a microbe, H. pylori. Your ulcer is probably no more your fault than is an earache, and just as curable. You feel pretty good about this, sort of exonerated, except you have left your job as an investment banker for a career in large-appliance repair.
4 As distinguished from an arrhenoblastoma, which is a rare ovarian tumor that turns a woman into a man. She gets a deep voice, thick facial hair, flattened breasts, and a rather unnervingly large clitoris.
Are You Too Fat? Yes. (I Mean, Look at You.)
Usually, medical science is guilty of overcomplicating the simple. But sometimes it oversimplifies the complicated. A case in point is weight control. Medical books and popular health magazines inform us that if you are overweight, it is better to be an pear than an apple—that people who are large of chest and belly have greater incidence of heart disease and diabetes than people built like teardrops.
* * *
To find out whether you are apple shaped or pear shaped, take the circumference of your waist one inch above the navel and divide it by the circumference of your hips at the widest point. A normal reading is from 0.7 to 0.85. A higher figure indicates apple obesity; a lower figure indicates pear obesity.
* * *
The apple—pear distinction may be true, but it is woefully incomplete, and discriminatory against the differently bodied. What if you are neither an apple nor a pear? Here is an updated list that recognizes and celebrates diversity.
But by and large, proper body morphology remains a function of weight.
A few months ago, the medical establishment released a new Optimal Weight Chart, replacing the old system of height and weight with a more complex computation of body mass. This chart appears to have been drawn up by pissed-off feminists. Under these new criteria, perfectly healthy, normal men with slightly stocky bodies—say, your average major-league catcher—are computed to be overweight. Meanwhile, short women get a break. Madeleine Albright is not defined as fat even though she is built—and I do not mean this unkindly—exactly like a scoop of mashed potatoes.
I preferred the old-fashioned weight chart, and urge readers to stick with it:
MEN
Height Ideal Weight
SMALL-BONED MEDIUM-BONED LARGE-BONED
5′7″ 125-190 135-220 140-250
5′8″ 130-200 140-240 150-270
5′9″ 135-220 145-260 160-290
over 5′9″ 140-300 150-280 170-390
WOMEN
Height Ideal Weight
SMALL-BONED MEDIUM-BONED LARGE-BONED
5′2″ 95 96 97
5′3″ 97 98 99
5′4″ 99 100 101
over 5′4″ 100 102 104
To determine your bone structure, empty a twenty-four-ounce jar of Hellmann’s mayonnaise and attempt to place your left hand inside. If it fits easily, you are small-boned. If it does not fit, you are large-boned. If it fits but you cannot remove your hand, you are medium-boned. To remove jar, strike crisply on the edge of a sturdy piece of furniture. If necessary, treat cuts and abrasions with a mild antiseptic to avoid clostridial myonecrosis, also known as “gas gangrene.” This is a sudden, sullen, raging infection that attacks open wounds. It causes intense pain, fever, and swelling. The skin turns white and stinks. It oozes brown liquid. If it is untreated, stupor and delirium follow, rapidly progressing to coma.
The coroner will note you were “medium-boned.”
Snap, Crackle, and Plop (Minor Aches and Pains That Can Kill You)
The other day I was speaking to a colleague of mine, a talented and vastly accomplished professional who, in less enlightened times, might have been described as having excellent hooters. She is one of those women who make it necessary for decent men in the workplace to learn an unnatural method of communication, in which one focuses the entirety of one’s apparent attention on the eyes and chin, as though the person to whom you are speaking were a severed head attached to life-sustaining devices.1
Like all old, plug-ugly guys, I was using what few meager tools I had to hold her attention—my wisdom, my urbanity, my ability to send this woman on an assignment to Paris if I chose. Things were going swell. Then I made a monstrous error in judgment. To emphasize a point, I stood up.
At the last minute I sensed what was about to happen, but it was too late to stop.
As my behind lifted from the seat, my knee bones began popping like Rice Krispies in seltzer, like bubble wrap being stomped by an epileptic giraffe. I was halfway to my feet, committed. Suddenly aware that I needed to support my ascent with my forearm or risked collapsing back into my seat, I pushed down on the armrest of my chair, causing my elbow to lock, as it sometimes does. This required me to slowly rotate it outward, as though I were performing the disco duck at the bottom of a swimming pool. In so doing, I accidentally knocked off the bookcase and onto the floor a paperweight that is a realistic rubber replica of a prostate gland.2 Smiling gamely, I bent to retrieve it. Because I am no longer supple enough to bend from the waist, I assumed the junior high school squat-thrust position. Thus situated, I found myself at my colleagues feet, looking up. I said something I hoped was erudite. It might as well have been “ribbit.” We would never have Paris.
Medical science has a term for the popping and snapping of aging bone and cartilage. It is called “crepitus.” (“Crepitus” also happens to be the official medical term for expulsion of gas from the anus. Medical science can be cruel to the elderly.)
Orthopedics offers mostly discouraging news for the aging, but it is the one area of medicine where I did not expect to have bad news for hypochondriacs. Hypochondriacs
thrive on ambiguity. In orthopedics, the problems tend to be straightforward. My friend Steve, for example, is an orthopedic surgeon whose practice is in Colorado, not far from the ski slopes. There is not a huge amount of subtlety in his line of work: People walk in with bones sticking straight out of their stomachs. Even non-ski-related injuries tend to be easily diagnosed. Recently, a guy arrived at Steve’s office with an arm problem. The arm arrived separately, in a garbage bag.
Orthopedists anticipate simple, obvious explanations, but sometimes even they are surprised. A pain in the shoulder or above the knee usually is nothing terribly serious. But every once in a while it turns out to be an osteosarcoma, which is a virulent tumor of the bone.
One of the more common complaints an orthopedist fields is lower back pain, and usually this is caused by a muscle strain or a damaged disk in the lumbar portion of the spine. This would be relatively good news. Other causes of lower back pain are tumors of the pancreas or kidney. Those would be worse news. But the worst thing, and it happens from time to time, is metastatic cancer: a malignancy that has spread from another organ, usually the lung or prostate gland or breast. Sometimes you don’t know you have these other tumors until they ride the blood to the bone in your spine. The bone grows amok. It starts strangling the spinal cord. By the time you experience the first twinge in your back, it is often too late.
Occasionally, orthopedists will deal with a persistent pain in the lower back or pelvis that is not a simple strain, and not a disk problem, and not a fracture, and not a tumor. It turns out to be the first sign of Paget’s disease, an infection that causes abnormal bone growth. It can be particularly evident in the head and face. Your hat size increases. Your features coarsen. You scare young children. You limp. Your bones snap like those oily wonton-soup crackers that, to my knowledge, have no official name.3 Paget’s disease squeezes important nerves. It can make you deaf. It can make you dizzy. It can sometimes make you dead.
Mostly, though, orthopedic surgeons do not make complicated diagnoses. They take pride in the homely tools of their craft. They work with drills and saws and screwdrivers. They are humble carpenters who happen to own vacation chalets in Zurich.
Diagnosis of musculoskeletal problems often falls to the noble, harried general practitioner, the only doctor who typically gets to know his patient over months and years.4 This familiarity is important in diagnosing problems like arthritis or rheumatism because these conditions often develop slowly, over time, and people tend to accommodate them by slightly altering their habits. It is like having the brakes in your car slowly fail. You compensate. You start braking a little early. Then you learn to tromp down with both feet. Pretty soon you are veering into shrubbery to slow yourself, and still nothing seems awry. Eventually, you lend your car to your cousin Margaret and she drives off an escarpment.
It is that way with musculoskeletal problems. They tend to sneak up on you.
And so doctors look for subtle behavioral signs of deterioration. They listen for grunts and moans the patient may inadvertently make when performing routine physical activities. Textbooks on physical diagnosis devote pages to recognizing the warning signals in patients who are getting older and may be contracting arthritis or other connective-tissue disease. The list below is adapted from several medical-text sources. It is a scary list, not because it contains terrifying signs but because it doesn’t. Everything seems so … ordinary.
Action Normal Activity Danger Sign Weakness Indicated
Getting up from dinner table Push away while sliding chair Standing first, then pushing chair back with legs or torso Upper arms
Putting on shirt or cardigan Reaching behind your back Putting sleeve on bad arm first, then swinging other sleeve to good arm Shoulder rotation
Putting on trousers Standing Sitting Shoulder, upper arm
Picking up item from floor Bending at waist, squatting Leaning on furniture for support; use of one hand on thigh to assist raising or lowering torso; resting knee on floor Knees, pelvis, lower back
Tying shoes Sitting, resting foot on floor Use of footstool to decrease spinal flexion Lower spine
Rising from lying to sitting Bending at waist, rising straight up Rolling to one side and pushing with arms to raise to elbows; using furniture to rise to sitting position Abdominal muscles, lower back
Combing or brushing hair Head faces forward; brush or comb is maneuvered. Head is turned to accommodate brush or comb. Shoulder rotation
Rising from chair Vertical motion Upper torso thrusts forward before body rises. Feet spread wide to provide broad base of support. Lower back, pelvis, knees
After finishing this list, I spent several hours putting on sweaters, getting up from tables, tying and retying my shoes, taking off my pants, forgetting to put them on and alarming the Federal Express man, etc.
Once you know what to look for, if you are inclined toward worry, every motion you make becomes suspect. There are relatively few reliable tests that can help the diagnostician.
* * *
If your doctor suspects hip fracture or dislocation, he may ask you to take your underpants off and stand on one leg. Assuming he is not just having fun at your expense, he is checking for Trendelenburg’s sign: With a healthy pelvis, the buttock above the raised leg should be held higher than the other buttock. Persons with breaks or pelvic bone disease cannot do this.
* * *
But mostly, diagnosis of musculoskeletal problems is hit-and-miss. Blood tests are not definitive, even for arthritis or lupus erythematosus. It is precisely this subtle nature of musculoskeletal disorders that makes them particularly tempting for the hypochondriac. Diagnosis depends on a highly subjective accounting of what hurts. In short, this is the area in which hypochondriacs can be at their most creative.
Every era contains some musculoskeletal ailment that is characterized by diffuse pain, fatigue, and irritability in the absence of any clear diagnostic evidence of disease. Medical science has always given important-sounding names to these conditions. In the 1800s, patients were diagnosed with “neurasthenia.” In the early 1900s, this was upgraded to “neuromyasthenia.” In the 1930s there was “myalgic encephalomyelitis.” Now all of these illnesses are recognized as quaint artifacts from an unsophisticated past. What silly, gullible bozos we were! Now people get “fibromyalgia.”
Fibromyalgia is a trendy disease. It is growing exponentially. Fifteen years ago, it did not exist. In 1990, there were nine hundred thousand reported cases. In 1995, there were 2 million. In many ways, fibromyalgia, like AIDS, is a modern-day pandemic. Perhaps it would be instructive to compare the two ailments.
AIDS. Strikes young, vigorous people in the prime of their lives, sapping them of energy, making them helpless in the face of opportunistic infections, leading to painful skin lesions, malignant sarcomas, neurological impairment, dementia, and death.
Fibromyalgia. Makes you feel icky-doody.
The Fibromyalgia sufferer reports tender, achy muscles and joints. He says he has trouble sleeping. His muscles feel stiff. He is tired. He is irascible. He is depressed. He is nervous. He tends to have other vague anxiety-driven disorders, like “irritable bowel syndrome” and “chronic fatigue syndrome” Fibromyalgia doesn’t get worse; it just hangs around, like a dingleberry. Also, for some blamed reason it doesn’t show up on any chemical tests.
Now, it this sounds like the sufferer of fibromyalgia is a big ol’ sissy, that just shows how insensitive you are. If fibromyalgia weren’t a real disorder, would doctors be accepting millions of dollars in fees to treat it?
Recently I attended a meeting in Rockville, Maryland, of a support group for persons with fibromyalgia and chronic fatigue syndrome. Rather, I attempted to attend the meeting. There were about a dozen people sitting around in chairs, looking tragic. When I said I was writing a book, I was escorted out by a man named Aaron who looked as though he might be a funeral director or possibly a professional airline-crash grief counselor. He informed me that the group was very se
nsitive about negative publicity; they were afraid they would be portrayed as lazy, whining lunatics. Shocked and insulted, I solemnly assured him that I was a scientist engaged in an objective pursuit of the truth, but he didn’t fall for it.
Reputable medical texts tread very, very gingerly around fibromyalgia. Some discount it altogether. Some take it seriously but note delicately that the recommended treatment includes “reassurance” and “frank discussion” and “sympathetic support.” The books do give criteria for diagnosing fibromyalgia, identifying eighteen pressure points on the body that show tenderness when pressed with a finger. Supposedly, you cannot diagnose fibromyalgia unless the patient reports pain in eleven of the eighteen points.
Interestingly, not many medical texts give a diagram of these supposed pressure points, and when they describe them they do so in highly technical language (“the left and right lateral epicondyle, the supraspinatus above the scapular line …”). I suspect this is deliberate. Doctors know where these points are. If the hypochondriacal patient knew also, he would feel pain wherever he was supposed to.
This leads me to an interesting ethical dilemma. I know precisely where the eighteen diagnostic pressure points are. This book is supposed to be a handbook for hypochondriacs; they are my audience. They have paid for this book. I owe them something. Yet, shall I give them information that might exacerbate their affliction? Dare I tell them where they are supposed to feel pain?
The Hypochondriac's Guide to Life. and Death. Page 12