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Billy was one of those patients who haunts every practice. Completely self-indulgent and doctor-dependent, he was reliant on every drug that would help blot out reality: alcohol, morphine, amphetamines and (in those days) Relaxa-tabs. His medical records carried the somewhat elitist diagnosis of Munchausen syndrome—an unfortunate label that eventually was to affect his management adversely.

Aged 38, Billy was an almost comical-looking man of short, obese stature, who tended to communicate with a staccato of almost inaudible grunts (Figure 11.1). Nevertheless, there was something appealing about this harmless roly-poly Dickensian character.

He would present with a dramatic episode of abdominal pain (invariably in the evening) at our surgery or the emergency department of the teaching hospital, where he virtually had a mortgage on a surgical bed following an appendicectomy and a cholecystectomy. He appeared to be a world authority on the symptoms and signs of acute pancreatitis.

We were convinced that the strategy of treating his abdominal pain in hospital with a nasogastric milk drip was proving effective because his visits were now infrequent. Billy was, however, seeking comfort from his Relaxa-tabs despite many visits to drug treatment centres.

I will never forget the day when Billy presented in the morning complaining of the eternal abdominal pain: ‘It’s the worst gut-ache I’ve ever had, Doc’. As he sat in front of me, like a melancholy bullfrog, my imagination drifted fiendishly and most unprofessionally to the scenarios of Ian Fleming’s novels in which trapdoors under chairs lead to tanks of sharks, crocodiles or (best of all) piranha fish. Eventually poor Billy was dispatched, unhappily clutching a prescription for an antacid.

I was not exactly overjoyed when he reappeared at 11 pm claiming he had been treated rudely at the hospital emergency department. Yet, for once in his life, Billy looked genuinely ill. Examination of his abdomen revealed more than his usual guarding and tenderness: rebound tenderness was widespread and he had extreme pain on rectal examination. Could Billy have a real organic problem?

He was admitted to hospital where the surgeon, doing yet another laparotomy, was greeted with an intra abdominal ‘sewer’ due to a perforated small bowel. Floating on the faeces were two toothpicks and several pieces of silver (Relaxa-tabs in their foil covering).

The postoperative course was stormy and eventually Billy died. Every time I think of this loyal patient and great character, I feel guilty about those fantasies of dispatching him into a tank of piranha fish.


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