Michael LaCombe
Cell 2 Soul. 2005 Autumn; 1(3):a8
There is, in the old section of the city, a fabulous restaurant unique for its culinary eclecticism. The owners are Polish, the food Hungarian, the wine strictly French, and the music is whatever Vera might happen to be humming that day. The place is simply called Stash's.
Not long ago, a group of us were there entertaining a visiting dignitary from Sweden, a hematologist from the Karolinska, all of us letting down from the pressures of the job, feeling important, on the 'cutting edge', that sort of thing. We had the side room for ourselves and Vera herself had looked in on us several times, supervising a quality evening. We were deep into leukotriene chemistry — great stuff if you like that sort of thing — when a song from the main dining room stopped me cold. At first, I could barely hear the music; a note, a chord here and there was all that filtered through. But suddenly the music became everything. I couldn't let it alone. It tore at me, driving me back the way music can do. Feelings struck me first — a vague sense of unrest, of misgiving, of profound mistake. How did I get here, at this table, with these people, I wondered? Why did I feel I had missed a path meant for me so long ago? Had I lost a part of myself with the passage of time? Who, or what, caused this ache that grew within me like the ache for some long, lost love? What was it about this music? Why the regret of having traveled a hundred years in the wrong direction, knowing you could never go back, never could correct the course, never could do it over? And then, on the heels of the emotions came memories.
It was thirty years ago. Our hospital was, in those early years, as it remains even today, primarily a place of research where every mind pursued The Cure and patient care was subordinated to that higher cause. Back then, successful treatment was rare, and patient care too often meant terminal care. In those days, the burden of treating dying patients at our institution was relegated to one man. His name was Arthur. He was a fire-plug of a man, with the face of a boxer and the charging stride of a middle-linebacker. Where whole clutches of academicians could be seen flowing down a corridor, laboratory coats buttoned, as though dancing a stately chorovod, Arthur charged the other way, white coat flailing behind him, off to fight disease.
Art, he would introduce himself in his gruff cop's voice, offering his meaty hand, disarming you with a broad grin and a look that seemed to search your very soul. Arthur, the academicians called him, with gracious condescension. As students, we caught the nuances. Even Arthur might have something to offer here, they would say, or, Where is Arthur now, they would ask impatiently, as another of their research conferences was about to begin. It was in this way that we were to learn what was important, and what ambitions to pursue.
Arthur hardly noticed the condescension. Patients, and helping them, were all that he lived for. Rushing down the halls with his festinating swoop, he attacked his patients' cancers with a vengeance. A young girl, fine-featured, with her sculpted patrician neck deformed like a lumpy minefield, lay swollen with Hodgkin's Disease. He would stand before the parents, reassuring, consoling, exuding his mysterious power, and then before one word of thanks, before one smile of relief could soften a face, he would be off to the next patient, striding like a quarter-miler to the leukemia ward. There, bed after bed of pale ecchymotic children lay listless, tethered by the intravenous lines, unamused by the ubiquitous television, doomed. Blowing in like the March wind, grinning broadly from his stevedore's face, demanding their smiles in return, he lit up the ward like Christmas. Those children who could would sit up, waiting for that moment they knew he would give them. He would move from bed to bed, like a pug checking his pups. Here a tickle, there a caress, now a clownish face for the little boy, "it's growing back" he would say as he stroked the fuzzy skull of a little girl, adding, "you've got to be the prettiest patient I've ever seen!"
The nurses watched him in wonder, marveling at how a man like this could ever live alone — as he made his rounds alone — for only rarely were there students with him, and residents seldom if at all. In the corridors outside, the academicians would glide down the halls, transported from laboratory to conference room and back again, trailing in their wake the residents and students who followed like acolytes, their chins also held high, their laboratory coats meticulously buttoned.
It was at this fork in the road, thirty years ago, that I found myself: would I remain in the security of the university, engaging a life of science or would I charge the faceless enemy with Arthur? With the intention to inform myself, or so I believed at the time, I decided to spend some time on the wards with Arthur, the better to know what path to choose. Swiftly I found myself caught up in his swirling day, with hardly a moment for reflection, barely noticing the smirks of my contemporaries who tolerated this temporary distraction of mine.
Art proved eager to teach. He was a vast repository of information on patient care, uncatalogued, and heretofore unnoticed, which he poured forth from every pocket of his brain, not to please or impress, but only to share, as he might share riches from a secret collection. Imagine this: you have heard of an eccentric recluse who, it is rumored in a most disparaging manner, collects bugs — and bugs of only the most loathsome variety: dung beetles, stink bugs, and bloodsucking conenoses. But when you chance upon his collection you find butterflies...and lacewings and damselflies treasured for their color, and civil bluets and violet dancers, green darners and common amberwings — and you begin to sense you have gotten this collector quite wrong.
Art's knowledge was that of the master clinician: how best to treat his children, and at the same time handle their frantic parents. He had already assumed in me the academic's science; he would teach the clinician's art. How does one recruit the family and patient as allies in the fight against disease? Can there be a proper mindset in the fight against leukemia? If so, how can the clinician engrave that attitude upon the mind of a child? How can he hold a frightened family from bolting at chemotherapy's most terrible juncture, fleeing to laetrile or megavitamins or doctors of the Chiropractic? How does the physician earn their trust?
One day I learned the depth of Art's science as well, and that his bedside manner was not mere alchemy. There is in medicine a condition called pulmonary edema, quite common in the elderly where it often complicates a failing heart. The patient's lungs suddenly fill up with fluid insufficiently pumped. Unless treated with speed, the patient drowns. There are several maneuvers involved in the treatment, seven or eight on the list, and all of them assume at least some proper kidney function to rid the body of excess fluid. The doctor gives a drug to facilitate the heart's pumping, another drug to decrease the flow of blood to the overburdened lungs, and a third to encourage the kidney's elimination. He waits the anxious moment, and in a half hour or so, the patient begins to brighten, and the eyes regain their spark. The doctor folds his arms and relaxes, glancing at the urine bag now distended with the offending fluid, gives a courtly nod to the nurse, and is off. The circumstance is so commonly encountered in medicine that treatment becomes rote, the expectation of success quite high, and the magic of medicines dramatically displayed.
Art and I were making rounds on the wards together one day, where there was a boy of fourteen hospitalized for a testicular cancer. This boy was a fighter, a handsome, radiant youth with a quick, glowing smile and the dark eyes of some ancestral thinker. He was very popular with the nurses and doctors in this section of the hospital. They would stop by at any opportunity to chat with him about his one abiding passion: botany. In his weeks of hospitalization they had assembled for him, with his assistance in taxonomy, presses of flowers and beakers of wild asters that crowded a cluster of tray tables scavenged from every corner of the hospital.
"Look! I found some cowslips for Tim," one might say.
"What do you think this is, Tim? Could it be..."
"Yes," he would say, "That's Fireweed...Blooming Sally. It's a kind of evening Primrose," then adding shyly, "Epilobium."
So it was that Art and I came to Tim's room on morning rounds one day, together with the charge nurse, who had snatched some obscure weed from the parking lot as a gift for Tim. We found him gasping for air. What appeared at first to be mere shortness of breath rapidly evolved into a frantic frothing at the mouth. Tim's deep eyes implored us with a wild desperation. He grunted with each breath, turning his head from side to side, searching for one precious pocket of air. Sweat ran from every pore, the foam collected at his mouth, dripping from the sides of his chin, whitish, pink, curiously lethal. This was pulmonary edema I thought, and turned to the nurse with my list of medications. But Art was ahead of me, already at the bedside.
"No time for that," he muttered to me over his shoulder. "No time for drugs now. His kidneys are knocked out by the chemotherapy. He's overloaded with fluid. He can't get rid of it."
Tim's cancer medicines had damaged his kidneys to such a degree that he could no longer eliminate the intravenous fluids he had been given for re-hydration. His heart was perfect; medicines to help it pump were useless here. His kidney function was gone. Diuretics would never work. I froze. Art kicked at the waste basket, sliding it next to Tim's bed. He grabbed a large-bore needle and sat next to Tim, holding his arm. Tim never felt the needle enter the large vein at his left elbow, so transfixed was he by Art's steady gaze.
Such tenderness! This coarse, rough-cut man with the mug of a prize-fighter murmured softly to Tim, calming him, quieting him, holding him, as Tim's blood poured forth unnoticed from the letted vein into the waste basket. Tim searched Art's face for reassurance, relaxing in his trust, eased by his doctor's strength. This was not just a simple compassion for an ailing child. It was this, but more. Nor was it simply a gentle doctor's caring for his patient. More than this. This was love.
Art was like the farmer who, on an October morning, goes about his chores. His Guernseys munch the offered silage, consulting one another, fogging the chill air, shifting contentedly. Pail in either hand, the farmer shoulders through to the milk-room to find the battered body of a swallow, dazed from a night-long attempt at escape, lying on the concrete floor. His chores forgotten, he sets his milk-pails down and scoops her up in his callused hands. Whispering to her softly, he reminds her of her brothers and sisters, of migration, and of winter spent in Mexico. Now he smoothes her primaries, corrects her coverts, cooing to her, chucking the cinnamon-buff of her chin. She straightens herself, adjusts, reassembles. He thanks her for her tenancy, for the summer of her society. Wit-wit, she answers, blinking her mascara-eyes. With raised hand he lifts her forth, offering her to the south. She stands, hesitates, launches, and is gone. The farmer leans against the milk-shed, pausing, watching her go.
"We had to get his fluid off quickly. It was the only way," said Art, breaking the tension. Tim, quiet now, managed a smile. The nurse, with a cool-wet terry cloth, wiped his face, his neck and his shoulders, caught up in the contagion of tenderness.
"I couldn't breathe," said Tim.
Three months' rotation in this art of medicine convinced me to want to be just like my mentor, to practice rather than preach, to walk the wards like him, and with him, and not live in the laboratory. This decision, made with no small residue of discomfiture, I announced to no one. As students are, I was still quite sensitive to the opinion of my peers. I would simply say farewell on the last day of training, and walk away. Nor did I tell Art of my decision, though I supposed he already knew. I began walking like Art, coat open, stooped forward, charging the halls like him. I even attempted his gruff-tender tone of hard-edged affection. I could feel my heart opening to the children, a timid advance at first and tentative at best. But gradually they became for me more than mere cases: at first patients, they then became children, and finally my children, whom I grew to love unreservedly. Art seemed to know better than to address my intention. I was like the renegade wolf entering the fold, sniffing at the periphery with suspicion, ever cautious, always ready to bolt. Art pretended indifference, standing the ridge, scenting the winds, obliquely welcoming me.
There is in academic medicine a time-honored tradition called the attending's dinner. At the end of a rotation on the wards, or in the laboratory — wherever it is the student finds himself — when the professor has finished his round of teaching, he sponsors a get-together for the students and residents on his service. This may be at the professor's club, in a teak-paneled room, where residents address him by his first name, and smoke cigars with acquired importance, while the medical students look on in admiration. There are martinis at the sideboard, and Ronald is ready with the canapés. Or perhaps it will be a well-appointed restaurant, with the linen and sterling just so. The professor, comforted by the familiarity of the staff, samples his favorite chardonnay and talks of university life.
In this tradition Art invited me to his apartment for dinner in celebration of our three months' service on the wards together. Art entertained infrequently if at all, and never before for a potential protégé. His own excitement filled his rooms. He had overdone everything. For the two of us he had laid out a separate bottle of wine for each of the four courses he had planned, and a crusty bottle of old Port for later on. He had more food than six people might have consumed, flowers, candles, and silver resurrected from some attic storage, with spice trays and a mountain of fresh fruit — to complement, he explained self-consciously, a special bottle of Sauternes. Art had an immense collection of jazz , a passion no one at the hospital had ever known about: volume upon volume of Peetie Wheatstraw, Blind Lemon Jefferson, and Sleepy John Estes. He was clearly partial to blues. But what began as a fascinating exploration in harmonics ended hours later on one long note of heavy sadness.
It started with the third bottle of wine. The two of us had fairly split the first bottle, a heavily perfumed Alsatian. Feeling the effects of the alcohol, I had only sipped at the second, while Art consumed most of it. He was well into the third bottle, some obscure Italian red, when he began his diatribe.
"This isn't an easy job, you know," he confessed. "There will be hard moments. You just can't know. It's when you think you have the battle won, that He takes it all away from you. I'll tell you about a case," he said, pointing at me with the wine cork.
"I had a young man with Hodgkin's Disease on Q-3. He was about twenty-eight...had a pretty wife, no kids yet, up-town parents. He had come to me early in his disease. I sent him for radiotherapy. They toasted him, but within a year he was back to me with advanced disease...very advanced. I gave him the standard protocols and he remitted for a few months, only to recur. I gave him stronger stuff, made him sick as hell, but apparently he became disease-free. I was congratulating myself and his family was happy, ecstatic. You get the idea.
"A few months later he was back to me with some cervical nodes which I should have biopsied but didn't and which I figured was recurrent lymphoma. I treated him with an experimental protocol, and killed him with it. At autopsy he had no evidence of Hodgkin's disease anywhere. Just a simple infection. He had been a cure and I killed him with drugs when I should have treated him for a simple goddamn infection. That's what's diabolical about this business. Di-a-BOL-i-cal."
Art went back to his wine, quietly reflecting upon his wounds. I was ready with all sorts of excuses, with the academic's rationalizations about the intricacies of the case and its unusual evolution. But Art had grabbed his wine glass and was already up and pacing the length of the room. I became apprehensive, aware of the creeping anxiety one might feel when about to violate some cabalistic tract on The Forbidden Secrets of Mankind. I was suddenly sober.
"I had a young woman with sarcoma. Sarcoma is as common as hell in our business, boy," (he had begun calling me boy when he had sensed that I had become his disciple) "but this girl couldn't have any ordinary sarcoma. No! She was twenty-two, beautiful as hell and newly married. She came to me with her husband. He was obviously crazy about her, couldn't get close enough to her or stop looking at her, and she told me about the lump in her vagina. Could I tell her what it was, she asked me. Her doctor had sent her to me, believing that I could. That type of thing. She had a sarcoma of the pelvic floor, nine centimeters wide. What we were feeling in her vagina was just the tip of the iceberg. So instead of her lying under some apple tree with the sun in her face, looking up at that handsome buck of hers, she was in a hospital bed retching her guts out from my medicine, her hair in clumps in the trash can. Why couldn't it have been some old lady who had had a full life with plenty of kids and enough of her husband — why couldn't she have gotten this sarcoma? Why did it have to be this young girl just at the beginning? Do you see my point? That's where the torment is, you see. That's what makes it diabolical." The word grated in his teeth. "Don't you see how He was laughing at me?"
I looked around the apartment as if to find some convenient route of escape. These were problems I didn't want to hear about, questions I didn't have answers for. Art, sensing my impatience, renewed his arguments as though finally to convince me.
"I had a patient, an opera singer, a baritone, who was sent to me with what were assumed to be singer's nodules. Singer's nodules...sure. It was cancer of the larynx, that's what he had. Here's a guy who could make men weep with his arias, who had graced the air at Carnegie Hall, whose voice was his very essence. Sure we could cure him. But the timbre of his voice was irretrievably lost. Now he's teaching music somewhere. Tell me that's random. Tell me that's a simple act of Nature."
Art peeled the foil from the neck of his bottle of Sauternes. He aligned the corkscrew with his shaking hands, and drove the screw down. Popping the cork he turned back to me, pointing the corkscrew, waving it, and then let it fall to his side.
"I used to pray, you know," he said. "I used to pray for every goddamn one of them. But He just mocked me."
I felt like the timid child who surprises a parent in the secret throes of some private grief, a parent who, face contorted, wracked with sobs, has suddenly assumed some other identity. I didn't want to see Art this way, and yet in some horrible manner I was fascinated by it. Having little religion myself, and even less experience of life, I didn't have any answers for him.
"Maybe God just isn't a part of all of this," I said, shrugging, raising my eyebrows hopefully, playing the optimistic child. Art had overfilled his wineglass, and spilled some of the wine on his shirt-front, gulping down most of what was left.
"Coconut," he said.
"Pardon me?" I asked.
"Mangoes, papayas, and coconuts...botrytis. This wine smells like coconuts. Climens. KLEE-MENS. A-MENDS. Make amends. Rends...rending...heart-rending. It's all heart-rending."
I began to make ready my escape. He stopped me with a look.
"You think it's all random, don't you?," he said to me. "Well it isn't random at all. I have found that out, mister. I have learned that on this job. Why is it the gourmet who gets cancer of the tongue, and the lady with the perfect smile, a squamous cell cancer of the face? Why does the breathtaking model have to have a cancer of the breast, or the scholar dementia? Can you deny the design? The diabolical design?
"Wait, boy, before you go," Art said, trying to catch me as I moved toward the door, mumbling thanks and excuses, "Will you have any of this?" He held out the bottle of Sauternes to me. I refused.
"Listen, boy," Art said again, "I'm sorry about all this. It's been a rough sea. I had to talk about it. It's been eating at me. One more case...please...
"I had another patient, not too long ago. A lovely little girl. She had a double disability — both deaf and blind. She was so sweet...so very, very sweet. Devoted parents. They could communicate with her only by writing in her palm. In the palm of her right hand. She loved to read. She read all the Braille books they could get for her. They brought her to see me. She had widely metastatic bone cancer. She'd sit there on the examining table erect and polite, quiet, waiting for some sign of me. As soon as I touched her, she'd know that I'd come into the room and her face would light up. She'd turn in my general direction, smiling, holding out her palm for me to "talk" to her. The palm of her right hand was her only link to the rest of us. I'd ask her about her puppy, tell her she looked especially pretty that day. That type of thing. It took me a while to get across to her, and I never got very good at it. But her mother would often ask what I had written if I couldn't get through, and then write it again for me. Anna, the little girl, would answer me in her soft, moaning whisper that only her mother could really understand, and could translate for me.
"She had very advanced disease when she came to me, so there wasn't much I could do for her. But the tumor went to her chest and she developed a tremendous swelling of her arms. And then her hands became terribly swollen. We couldn't relieve the swelling with radiation therapy. Her fingers were left "sightless," and her palms became insensitive to touch. She was cut off from all of us completely and forever. And she was forced to die alone."
Art was subdued now, introspective. He held his empty glass, tipped, against his waist, and stared out at the lights of the traffic in the streets down below. His agitation was gone, his anger dissipated. All that was left was a heavy sadness.
Had he been a contemporary, I might have said I understood, even though I didn't, or I might have sympathized with him. I might have reached out to him. I might have tried to love him. But I was so caught up in my own emotion, so shocked by his hidden identity, that the moment of healing passed.
In the months that followed, I became aware that the laboratory was the proper place for me. It would offer a tremendous challenge — that was where it was really happening in medicine, that was where I could do the greatest good for the greatest number. I could teach the residents, spend a month each year caring for patients, presiding at the bedside. I would develop new drugs and new protocols, cross-fertilizing with colleagues at the conferences, always up to date with the literature, training young doctors, and still, on occasion, involve myself with patients.
An occasional nod was all that passed between Art and me any more. The evening of his confession was like a blemish to be hidden away. On his part, Art filled his days with patients, as always. I hardly noticed him as he hurried off to the wards, white coat flailing behind him, charging off to fight his war.
(This article first appeared in Hospital Practice April 15, 1991 in abbreviated form and is reprinted here with permission of that journal.)