1 The Lost Art of Convalescence When I was twelve years old I had a stupid accident. I was cycling home from town with friends when a colossus of a lorry passed too close, causing me to swerve my bicycle. It was over in a moment: I put out my left foot to steady myself, and my heel jarred hard against the curb. The impact tumbled me off the bike and onto the pavement where I lay in the dust, relieved to be alive, but unable to straighten my leg. The lorry didn't stop. My pals pedaled off to get help, and after what seemed an age, but was probably only twenty minutes, my mum turned up to take me to hospital. An X-ray showed that the topmost piece of my shin bone, the "tibial plateau," had splintered, and a fragment had become lodged at the back of my knee joint. And just as a sliver of wood can hold back a heavy door, that tiny fragment wedged my knee in a bent position. I was taken to an operating theater where, under anesthetic, a surgeon wrenched the knee back and forth until that splinter of bone fell into place. A cylinder of plaster was rolled around the leg, I was given some crutches, and told to come back in the autumn. To be immobilized in plaster through the summer holidays would have its challenges for any twelve-year-old, but it was once the plaster was removed that my journey of recovery really began. A metamorphosis had occurred. The knee had become bulbous, and my thigh and calf seemed by comparison stick-like, wasted and malnourished. A fine pelage of hair had sprouted under the protection of the plaster, bizarrely dark against skin that was now as white as bone. When I tried to walk, the knee wobbled and gave way. It took months for my leg to feel like my own again; months of boring, punishing exercises to build up the muscle. Relearning to walk was a process led not by doctors, but by a pair of brisk and cheerful physiotherapists whose department I remember as one of too-bright lights, wipe-clean benches, weights, straps and gym bars on the walls. I can recall the distinctive disinfectant smell of the floor cleaner, and the regular company of a man I'd met previously on the ward who had shattered his leg in a motorbike crash. He was big, with a black mustache and stubble, and with a delicate gold hoop that hung from one of his earlobes. As we groaned and sweated together, lifting weights attached to our ankles, he joked about how I was recovering more quickly than him. When I think of that period of convalescence now I remember afternoons at home reading in the sunshine, and doing my physiotherapy exercises at first tentatively, then with more confidence. The days were busy with sounds: of birds in the garden, cars in the distance, wind moving through the barley of the field behind the house. For twelve years my body had rarely stopped, and it seemed unnatural to have it rendered so motionless, as if with my injury the nature of time itself had warped and transformed. The flow of my life had been stilled, but it was that very stillness that gave me the opportunity to heal. *** It wasn't my first experience of convalescence. A couple of years earlier I had woken one morning with a hammer-blow headache and a churning in my stomach. I suddenly knew the truth of the saying "he couldn't lift his head off the pillow." My general practitioner was called for, a kindly man of the old school who took one look and, suspecting meningitis, sent me urgently to an infectious diseases hospital an hour's drive away, where the diagnosis was confirmed. I spent eight days and nights in that hospital, in a room with large windows that gave on to trees and afternoon sunshine. In the niches of my memory I carry no images of the doctors, only one of a nurse in a sky-blue tunic, her black hair in a bun, her kind face lined with smiles. An iron-framed bedstead, glaring white sheets, and again, that smell of floor disinfectant. A window in an internal wall of the sick room gave on to a nurses' station-even when my parents were away I was kept under surveillance. Though my mum and dad took shifts to be with me for most of the day they also had my brother to attend to, and I spent many hours alone in silence waiting for them to come; waiting for home. With a limb it seemed possible to objectify the part that needed recovery, to look down on the leg and say "that's the problem, right there." Working to build up the leg was effortful but also visual, my progress inscribed in the bulk of my thigh, the color of my skin, the comparison with the healthy leg at its side. My recovery from meningitis was far more difficult to grasp, the edges of what recovery meant were far less clear. A languorous fuzzy-headed exhaustion dominated my days, burnishing the world with the bright haze of a dream or a hallucination. My body was in convalescence, but the process itself felt disembodied, ethereal, as much mental as physical. As I look back on it now, it's clear that it was my first experience of the complexities of convalescence, and how it can and must take very different forms with different illnesses, and between different people. *** Six years after my leg recovered I went to medical school to train to be a doctor. A decade after that I was working in a brain injury unit, as a junior member of a team caring for a relentless flow of broken people-mostly young men who had been injured through reckless driving, falls or fights. I saw how quickly their bones could heal, but how much longer it took for their brains to do the same. Once the initial crisis of injury was over-blood clots removed, pressure relieved, skulls plated and wired-they would be moved to a "rehab ward" where they might stay for months at a time, gradually relearning what were known as ADLs-"activities of daily living": bathing, dressing, cooking and so on. For some, those "ADLs" would include relearning to walk or to talk. The word rehabilitation comes from the Latin habilis, "to make fit," and carries the sense of restoration: "to stand, make, or be firm again." The aim of rehabilitation, then, was to make someone as fit as they can be, to be able to stand firmly on their own two feet. And though recovery was the clinicians' ultimate aim, it's curious that the words "recovery" and "convalescence" are generally absent from the index of medical textbooks. As long ago as the 1920s, in her essay "On Being Ill," Virginia Woolf wrote that we lack a mode of writing about illness, that it is "strange indeed that illness has not taken its place with love, battle, and jealousy among the prime themes of literature." A century on, her assertion no longer holds true: we do have a literature of illness. But I'd argue that we still lack a literature of recovery. The medicine I was trained in often assumes that once a crisis has passed, the body and mind find ways to heal themselves-there's almost nothing more to be said on the matter. But after nearly twenty years as a general practitioner, I've often found that the reverse is true: guidance and encouragement through the process of recovery can be indispensable. Odd as it seems, my patients often need to be granted permission to take the time to recover that they need. Illness is not simply a matter of biology, but one of psychology and sociology. We fall ill in ways that are profoundly influenced by our past experiences and expectations, and the same can be said of our paths to recovery. I have learned much from those other clinicians-the nurses, physiotherapists and occupational therapists-who have most helped my patients, and am always being reminded of how much there is still to learn. The therapists in the brain injury unit knew that convalescence is anything but a passive process. Though its rhythms and its tempo are often slow and gentle, it's an act, and actions need us to be present, to engage, to give of ourselves. Whether it's our knees or skulls that need to heal from an injury, or lungs from a viral infection, or brains from a concussion or minds from a crisis of depression or anxiety, I often remind my patients that it's worth giving adequate time, energy and respect to the process of healing. We need to take care over the environment in which we're attempting to heal, celebrating the importance of nature and the natural world and recognizing the part it can play in hastening recovery. Many patients I've known over the years have found a way to make sense of even a very difficult illness journey. When an illness or disability is incurable it can still be possible to "recover" in the sense of building toward a life of greater dignity and autonomy. There is no hierarchy to suffering, and it's not possible to say of one group of conditions that they deserve sympathy while another group deserves to be dismissed. I've known patients whose lives have been dominated, for years, by the grief of a failed love affair, and others who have taken the most disabling injuries, pain, indignity and loss of independence in their stride. Though it can be tempting to resent someone whose illness appears to be less serious than our own, or to judge ourselves harshly when others seem to be coping with more challenging circumstances than we are, comparisons are rarely helpful. Neither should we be anxious to set out a timetable of recovery: it's more important to set achievable goals. As a doctor, sometimes all I can do is reassure my patients that I believe improvement of some kind is possible. The recovery I'm reassuring them of might not be biological in nature, in terms of a resolution of their condition, but rather an improvement in their circumstances. What follows is a series of reflections on recovery and convalescence gleaned from my own experience of illness, and of thirty years in training and in practicing medicine, mostly in the UK, but also around the world. It contains much that I wish I'd known when I set out on my career, while acknowledging that there is always more to know. Every illness is unique, which means that all recoveries must also be in some sense unique, but I have tried to set out some principles and waypoints that have proven helpful over the years to guide me, and my patients, through the many landscapes of illness. It's a place that all of us must visit, sooner or later; from time to time we all need to learn the art of convalescence. Wisdom for Recovery Try to remember that recovery isn't a purely passive process, it's an act and like all actions it can be done well or badly. Convalescence can be an opportunity as well as an imposition-to rest, and to reconsider your priorities. Recovery takes different forms with different conditions and people, but there are some general principles that will help. Illness isn't purely biological, it is also social and psychological-and so is recovery. Recovery happens best if we give it time and respect. Modern medicine is wonderful but still limited in what it can cure. Sometimes drugs are the least of healing. Excerpted from Recovery: The Lost Art of Convalescence by Gavin Francis All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
