Rotten

…L’Absinthe, Edgar Degas, 1876…

“Oh, I’ve been doing just the same, just the same, quite well, no complaints.”

“That’s good.  Anything you’d like to discuss with Dr. Gray today?”

The slight man’s face remains blank as he stares past me at nothing in particular before he shakes his head and gives a faint smile.

“Not that I can say, no ma’am.”

A drop of saliva falls silently from his stiff lower lip onto his freshly pressed slacks.  The fine tremor in his hand disappears as he reaches up to wipe his mouth.

I scroll through Dr. Gray’s last note from a routine visit over two years ago and find no issues, no clinical reminders, no findings on physical exam.  I continue to make small talk, running through a truncated review of systems – negative, of course – as I search the chart.  I finally find an entry with the information I’m looking for, an old intake note from a decade prior.

Family History: No cardiovascular disease known.  Breast cancer – mother, diagnosed at 72, deceased 74.  Type 2 Diabetes, Hypothyroid – sister, alive at 41.  Prostate Cancer – father diagnosed at 57.  Parkinson’s disease – father diagnosed at 68, deceased 73, brother diagnosed at 61 yo.

“Mr. Smith, have you noticed a tremor in your hands?”

Mr. Smith looks at me, his face blank, his eyes hard.

“My hands don’t tremor.”

“When you sit still with your hands in you lap, I noticed you have a slight tremor.”

Mr. Smith looks away, folds his arms across his chest and hugs himself close.

“I don’t have a tremor.”

“I also noticed that sometimes when you speak, your lips have a hard time keeping control of your saliva.  Have you noticed that?”

His face remains blank, eyes averted.

“No, I have not.”

Although his expression is not revealing, his inflection is; he has, indeed, noticed.  He does, indeed, understand the symptoms and their potential cause.  But, having little recourse and limited time, I move on to the physical exam.

When he cannot easily initiate those movements necessary to rise from the chair and walk to the exam table, Mr. Smith seethes, “Gol darn arthritis.”  When he has trouble with specific portions of the neurological exam, he says simply, dismissively “It’s hell to get old.”  When I mark large bruises on his knees, arms, and back, he quietly, but forcefully denies falls.  And whenever his arms are at rest, they exhibit a fine, characteristic tremor, in between those times he must dab his lower lip, frozen like the rest of his face in a blank, masked expression.

In the physician work room, Dr. Gray nods slowly as I present my findings, sighs when I suggest that Mr. Smith has likely developed the same disease his father and brother before him suffered, agrees that Mr. Smith is most certainly well aware of that fact.

“Let’s go see him,” Dr. Gray punches the alcohol gel dispenser on the wall and pauses.  “Parkinson’s is a rotten disease…  Denial is even more rotten.”

He takes a deep breath as he prepares to knock on the exam room door.