Tell Me I Didn't Put it There

E

ven after forty-five years, memories of Simon continue to haunt me.  He was a simple man, so it seemed from the initial medical history.  A high school graduate, he opted out of college for earning a living as a salesman in one clothing store after another.  In an era of few working wives the family income was supplemented by his wife’s clerical job. 

Simon had no special interests or skills.  He was not a joiner. Having had no ritual training, he even avoided synagogue life, which further alienated him from potential friends.  He lumbered through his ten-hour workday, arriving home with no more energy than to eat supper, read a newspaper, and listen to the radio news.  (Television had yet to be commonplace.)  Conversation with his wife was sparse and usually concerned money.  He had little to say to his three children.   

 Yet, Simon was a likable soul.  Customers appreciated his gentlemanly behavior: he offered advice without pushing to make a sale.  In my office he was genuinely courteous.  He was embarrassed to admit that he had agreed to come to me only after a mutual friend had reassured him that I would charge a minimum fee.

He a big man who overflowed the sides of my office chair.  His clothes were crumpled, his thinning gray hair was combed but unruly.  Hesitatingly, he offered his reason for coming to me.  “I’ve been bleeding when I go to the toilet. It happens when I move my bowels … for three weeks.” 

He was pale; otherwise his physical examination was normal.  I hoped I would find bleeding hemorrhoids; no such luck.  The next day I performed a proctoscopy, which showed no abnormalities.  Had I missed something?            

At that point Simon asked if he might have cancer.  “What makes you think so?” I asked.

“Well, my father died of it at forty-seven (Simon was sixty-one). My brother died at fifty-five; we never knew his diagnosis but he lost a lot of weight and was in pain for months before he died.  I don’t think I could go through that.”

As he spoke each word I could sense my training being challenged.  My medical mentors, always peering over my shoulder, waited for me to stumble.  If Simon had cancer, would I be able to lie to him?  Of course I must for that was what I was taught only ten years before (in 1946).  Simon wasn’t one of the exceptions listed on the blackboard such as a wealthy corporation executive with an estate to protect.  I temporized.  “It could be colitis or polyps.  Maybe tomorrow’s X-ray of your colon will give the answer.”  He was not cheered but then again, I don’t think I ever saw him smile.

I gave Simon instructions for “cleaning” his bowel in preparation for the X-ray.  I called his wife, Rose to tell her that “the diagnosis might be cancer and if so …”.

Rose interrupted me.  “You mustn’t tell him.  It would kill him.  He’s been talking about nothing else since he finally admitted to me why he was seeing you.  He says he knows he’s going to die like his father and his brother.”  She began to cry. 

“Okay.  We’ll see.  Maybe you should come in with him.  We can talk after I finish the barium enema.”

What I didn’t tell either of them was that, as a resident though I had performed over a hundred X-ray examinations of the bowel, Simon’s would be the first in my new office. I saw no reason to mention my apprehension about the technical aspects of the procedure.  I didn't want to disturb my image as an infallible Harvard specialist.

The next morning my nurse, Pauline, had everything ready.  Simon lay on the X-ray table. A two-liter bag of chalky barium suspended three feet above the table was connected via a tube inserted into Simon's rectum.  I motioned to Pauline.  “Let’s begin.”

  Pauline released the tubing clamp.  As I turned on the fluoroscope to watch the barium enter the rectum, I was chagrined to see barium spreading on the table.  “Stop,” I said to Pauline.  She snapped on the lights. 

“Oops.  The enema tip came out.  Simon, I’ll reinsert it deeper.  Sorry.”  I  couldn’t be sure but I think Pauline was blushing. 

With the lights out again, we resumed.  Barium was entering freely.  All was normal in the rectum and deeper into the sigmoid until “Oh my God!” resounded in my head.  “Look here,” I whispered to Pauline.  The X-ray motor drowned out my voice.  There was a huge mass, which allowed only trickles of barium to advance beyond it.  I took a few X-rays to show to a surgeon.  “Finished,” I said to Pauline and Simon. 

  I returned to my consultation room and sat in my expensive, high-backed chair.  “Look at me.  What a great doctor I am!”  But almost simultaneously I thought, “Oh, my God!  Poor Simon.  Until I found the tumor, it didn’t exist.  Tell me I didn’t put it there!”  Irrational?  I don’t even have to ask.  I guess it was a form of denial; I didn’t want Simon to have cancer and I dreaded handling all that was bound to follow. 

After Simon had dressed, I invited him and Rose into my consultation room.  They could tell from my expression that the news was not good.  “Bad and good,” I started.  “Good in the sense that we’ve localized the problem and good in the sense that there is a large polyp inside the sigmoid."  I drew them a picture to show its location.  "That’s where the bleeding is coming from.  Bad in the sense that you need to have it removed, Simon, to stop the bleeding.”  I didn’t think it was necessary to add the threat of bowel obstruction if he were to procrastinate. 

“Then, it’s not cancer.”  Rose made it a positive statement.

I lied.  “It doesn’t look like cancer but to be honest, only the pathologist will be able to tell us for sure.  If it turns out to be cancer, I'm sure that the surgeon will be able to remove it all.  You’re not your father, Simon.”  He fought back tears.  “You have reason to cry, Simon, but more reason to be optimistic.”  (See the chapter “Down with doubletalk to cancer patients” in my memoir, “By All Means, Resuscitate.”)

Simon wasn’t convinced nor was he wrong.  Within the week he was operated on.  The bowel cancer had spread to his liver.  The huge mass was removed but only to prevent the hideous complication of obstruction.  Since I had nothing good to offer Simon (those were the days before chemotherapy), I told him that he had a "benign (noncancerous) adenoma" and that it had been totally removed.  (With Rose I was truthful.)  Simon felt better after receiving two units of blood but this didn't last long.  His condition rapidly deteriorated as the flesh fell away from his body. 

Simon never returned to work and he never asked questions even as his skin became yellow from progressive liver failure.  He had very little pain.  Oddly, though he had no medical insurance he never expressed concern for the hospital bills that Rose would have to contend with after he was gone.  Two months following surgery and after a three-day coma, Simon died at home.

  So I didn’t kill him, but in my mind he didn’t have cancer till I found it.  That's an ironic way of looking at what happened in Simon's medical story. I was proud of myself for having suspected and proven his true diagnosis but, then again, how could I feel gratified if I was the one who brought out a verdict of death?