House Watcher was sick last week (final diagnosis: common cold), but I’m all better now, so let’s get right into the best procedural episode of the season, “Recession Proof,” which is about a central theme of the series: why and how people (especially patients) lie, even when it comes to life-and-death matters.
First, though, the standard spoiler alert: If you were at a differential-diagnosis meeting last night, be sure to watch “Recession Proof” before reading on. As usual, all diagnoses are in bold.
The episode opens with a man named Bert scrubbing a floor drenched in blood. His wife calls, and he tells the show’s first lie. Bert says he’s in a contracts meeting that’s running late. “You know Matheson; guy loves to hear himself,” Bert says. Which is almost certainly true — as House knows, every good lie has elements of truth.
Bert changes into a suit and meets his wife at a Japanese restaurant for their third-anniversary dinner, complete with sparkling wine and seafood so fresh it is literally still moving. I expected the fish to be a hallucination — they were moving too uniformly — but instead the fish were just animated poorly. Anyway, Bert eats the fish and then, moments later, seems to choke or seize. He also shows a severe tremor in his hand.
Cut to titles, when I assume we are supposed to think he’s having an allergic reaction.
At Princeton-Plainsboro, the episode’s non-medical story line is set up when House hides from Cuddy. He really, really doesn’t want to attend a charity event where she will receive an award — although he tells her he will go. Which, of course, turns out to be a lie. He also says the hiding was foreplay — which, because all lies must have an element of truth — is probably not a lie.
The DDX opens with House wondering “how someone can have an allergic reaction when all of their tests were negative for known allergens.”
Chase says the problem could be environmental. Bert’s father reported that his son is a real-estate developer, and Chase reasons Bert could have picked up some kind of infection at a construction site.
But Masters pipes up that Bert is lying — and now we really know the episode is about deception, because Masters always assumes the best in people. She says she saw calluses on Bert’s hands. House gives her a hug — as usual, sexual-harassment laws don’t apply here — and says, “Our little girl is finally growing up.” And then a nice punchline for Hugh Laurie: “So what did Mr. Meathook say when you called him a liar?”
Turns out Masters isn’t that grown-up: she hasn’t confronted Bert. House orders her to do so.
Chase goes with her, but Bert’s wife is there. To get her to leave, Chase lies that they need to ask Bert how his bowel movements smell. Once they are alone, Bert admits to the doctors that he lost his entire real-estate company in the recession. He’s now making money by cleaning up the places he used to sell.
“Industrial jobs, crime-scene cleanup, septic tank repair, mold removal — it’s physically killing me,” he says.
At another DDX, Masters calls his environmental exposure “the holy grail of potential diseases: caustic cleaning chemicals, raw sewage, mold spores, fungal infections.” Chase adds that Bert was up to his elbows in blood and other bodily fluids at a crime scene the day before.
House orders antibiotics and a search of wherever Bert spends his time when he’s not working.
The House-Wilson comedic relief begins with House stealing a sandwich from a food cart. “Well, at least the Alzheimer’s patient in room 202 won’t remember she got only half a ham sandwich,” Wilson says. (I sometimes half-expect a laugh track to come on during House-Wilson scenes.)
At Bert’s real-estate office, Foreman and Taub find old food and a bottle of Vicodin in a desk drawer — along with an enormous closet full of chemicals and cleaning supplies. That leads the team to believe Bert has boric acid poisoning, which would explain his rash, convulsions, and collapse.
Just then Bert passes out again, which would confirm borax poisoning — except that he now has a fever, which suggests pathogen infection. At another DDX, we learn that no boric acid was found on Bert’s skin and that an autopsy has shown that the man whose blood Bert was scrubbing had no communicable pathogens. Then Taub mentions the Vicodin, setting up the best scene in the show.
House demands Foreman give him the bottle, but Foreman hesitates. The way House used to pop Vikes like M&Ms, we all expect that, if given the bottle, he might toss a couple in his mouth.
House says evenly, “Might look like Vicodin but be something else.” Foreman throws him the bottle, which House opens. Like the connoisseur he used to be, he smells the aroma of the Vicodins and runs one across his tongue.
“It’s real — unfortunately,” he reports. “Because Vicodin doesn’t cause rash, fever, and joint pain.”
House thinks Bert has meningococcemia, a serious bacterial infection that would explain the fever, the rash (which might really be bleeding under the skin), and the passing out.
But Foreman finds an elevated lymphocyte count in Bert’s cerebrospinal fluid, which means it can’t be a runaway bacterial infection but might be a viral infection.
When all their pagers fire simultaneously, the team members converge on Bert’s room to find that he can’t move his feet, which are swollen and discolored.
House now thinks the odd constellation of symptoms indicates Bert is reacting to all the medications he’s been given. This would mean the team has practiced a kind of deceit on Bert’s body: in trying to get him well, they have made him sick. The specific diagnosis: serum sickness, an immune-system reaction (like an allergy) to certain meds. House orders steroids.
Then Bert experiences another symptom: a paranoid hallucination in which he sees blood in his eyes. Screaming, he hits his wife and locks the team out of his room. We learn at the next DDX that his rash is gone. Masters believes whatever was causing it has moved to his brain.
They knock around some other ideas — for example, systemic fungal infection, which is often acquired in hospitals. But he turns out negative for spores and fungus.
Chase shows off by suggesting tumor necrosis factor syndrome, a rare disease in which the body’s defense mechanism causes extreme inflammation. Masters, who is turning toward the dark side in this episode, sarcastically retorts: “Except it’s never been known to cause hearing loss. Ever.”
House, who is like Darth Sidious corrupting Anakin, smiles at her growing bitterness.
Chase thinks the Vicodin caused the deafness, since “extreme abusers can experience hearing loss.” He nods toward House, who is tone-deaf to any emotion. But House goes with Taub’s suggestion that it’s a brain tumor — until the team learns later that both of Bert’s kidneys are fried. He’s on dialysis and near death.
House has few choices: “If it’s a tumor,” he says, “we start chemotherapy—bombard his head with radiation.” Foreman points out that this will probably kill him, but House falls back on one of his standard arguments: “He’s definitely dead if we do nothing.”
Masters is called upon to imply Bert’s wife, incorrectly, that chemo has a strong chance of saving her husband. But Masters lies poorly. The wife is torn about what to do and says she has a secret of her own: she’s pregnant.
But when Bert’s rash returns, the team is back to square one. House still believes Bert’s problem is hospital-induced. He asks if Bert said anything when was getting MRId, and Masters says Bert mentioned it was cold. She tells House what she told Bert: it’s always cold in there.
But that’s enough for House to flicker onto the final diagnosis: Familial Cold Autoinflammatory Syndrome (FCAS), which would explain the rash, the fever, the joint pain, and the eye redness. (That means the show lied to its viewers — a perfect full circle of deception — when it was implied that Bert’s eye redness was a hallucination.) FCAS is caused by a mutation in a gene called the cold-induced auto-inflammatory syndrome 1 (CIAS1 gene).
It’s a very rare and very House M.D. diagnosis. There’s also a treatment that will allow Bert “to live a long and healthy life filled with lies to his wife and future child,” as House puts it.
But Bert dies. What’s interesting about his death is House’s reaction. Previously, when another patient died (in the finale of season 6), he nearly relapsed into his Vicodin addiction. But now he doesn’t seem so bothered.
What’s changed? While drinking at a bar where Wilson finds him, House diagnoses himself with love and happiness. “The only thing my relationship with Cuddy has done for me is make me a worse doctor,” he says. “My happiness is being paid for with other people’s lives.”
But House is sanguine about this personal shortcoming, if you can call it that. Drunk, he tells Cuddy that she’s made him a crappy doctor. You expect him to leave her because of this, but he tells her she’s “totally worth it … If I had to choose between saving everyone and loving you and being happy, I’d choose you. I will always choose you.” Which is almost certainly a lie.
My diagnosis: excellent story-telling in this episode. And a wonderful use of the procedural House M.D. structure to address the show’s central question. Finally, a good way to begin setting up a season finale that, I predict, will see the end of the House-Cuddy ’ship business.
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