It was so unlike her to admit that she needed help that we sat for several moments in silence. “I don’t want to go down to the city and make a big fuss of this,” she said, holding her vodka tonic, but she sounded less sure of herself than usual. I recalled that she had recently had her yearly physical, but there had been nothing remarkable about her results. Her cholesterol level was a concern, which is common for someone her age, she took Pravachol for that, and her blood pressure was a little high—it always rose sharply when she was in a doctor’s office, a reflection of her anxiety at the sight of any kind of medical apparatus, even a stethoscope. Otherwise Margaret’s results were those of a person remarkably healthy for her age.
Could there be a problem with her medications, I wondered, her “pills,” as she always referred to them? Ever since I had known her, almost forty years, Margaret had taken pills to help her sleep (currently Lorazepam and Clonazepam before bedtime), to calm her anxiety and control her depression (currently Effexor and Abilify at breakfast time). Over the decades the medications had been changed from time to time, as well as the dosage, but making sure that she had enough of her pills and that she had them with her if we were away from home was a first priority. She only took exactly what was prescribed, but they were an important part of her life, perhaps by now as much a matter of routine and habit as of need.
There was no mystery about Margaret’s level of anxiety. On the contrary—she was a perfectionist, hard on herself, she worried about aging, losing her looks, what she would do with herself if she had to give up riding. Abilify was a fairly recent replacement for whatever she had been taking before, and might have been a mistake. People change, and so does their reaction to a new medication. “It could be a problem with your pills,” I suggested.
Margaret shook her head. She looked on her pills as a lifeline, they were the last thing she would want to blame. She took a deep breath. “Do you think I could have had a small stroke?” she asked in a small voice.
The expression on her face was briefly one of terror. People who had strokes often become helpless, and if there was one thing Margaret feared, it was helplessness.
I said I didn’t think so, surely she would have felt something, but the truth was that I didn’t know. My maternal grandfather Octavius Musgrove had suffered a stroke at about the same age Margaret was now, but I remembered it as a full-scale medical emergency. He had been rushed to a hospital by ambulance, and when I visited him later on in the nursing home where he was sent to recuperate, which he never did, Ockie could not speak at all, his face was twisted to one side like that of a Picasso portrait, and he looked like a different person from the one I had known and loved.
“I need to know right away,” Margaret said. “The sooner, the better.”
“Let me call Dr. Tom, then, he’ll know what to do.” She nodded, clutching her untouched drink in her hand.
“Dr. Tom,” as we always called Dr. Thomas Murray, a recently retired local ob-gyn doctor, had been a convivial friend of ours over many years, a man with whom we dined once or twice a month, if not more often.
Tall, ruddy-faced, and handsome, Tom Murray is not only a good doctor, but a boon companion who adored and admired Margaret, and therefore brought out the best in her. He has a sharp, boisterous sense of humor, very much like Margaret’s, is a gifted storyteller and an instinctive flirt, and like her he loves horses, although his interest is horse racing rather than riding them. Like her, Dr. Tom loves British TV crime series and is a passionate reader of crime fiction—the two of them were constantly exchanging bags of books. Like me, he reads a lot of history, and is undaunted by long books with many footnotes. He is a connoisseur of good food, extra-dry vodka martinis, and beautiful women. In Tom’s company Margaret could tease, laugh, gossip about the horse world, and enjoy herself to the point at which people sitting at the table next to ours sometimes asked to be moved to a quieter one. The mere mention of his name calmed her down at once. “Go ahead,” she said, taking a sip of her drink. “Talk to Tom.” Perhaps because he was not her doctor, Margaret had perfect faith in him.
I called Tom and he answered right away. After a little friendly chitchat I described Margaret’s concern, trying to keep things as low-key as possible. Tom’s voice dropped from its usual cheerful tone to the slightly more cautious one that any doctor uses when asked to give a diagnosis over the telephone about something that isn’t his specialty for somebody who isn’t his patient. He had seen Margaret less than a week ago at dinner, she hadn’t shown any sign then of a stroke, a problem with her medications was certainly a possibility, what she needed was to see a neurologist, he knew an excellent one and would ask him if he could fit us in tomorrow. Margaret might think the neurologist looked a little odd, he added, but he was first-rate.
By the time we reached the neurologist’s office the next morning we were both in a state of nervous anxiety, alleviated in my case by a certain curiosity to see what he looked like, and what Dr. Tom meant by “odd.” But the doctor, once he introduced himself, did not seem particularly odd, except for his clothes—sandals worn with socks, and clothes that looked as if they had been collected from a Salvation Army bin. His manner was diffident but professional. He asked Margaret to move her finger from her nose to his finger, he tested her reflexes, he told her to squeeze his fingers with her hands, none of which she appeared to have any difficulty in doing; indeed, she squeezed his fingers so hard that he winced. He did not think there was any reason to suppose that she had had a stroke. He raised an eyebrow at the list of medications she was taking—he too thought it was possible that the interaction of her medications might be causing the problems she described, and would talk to her internist about it. In the meantime, he said, it might be a sensible precaution for her to have a brain scan just to rule out any other possibility. He did not seem concerned, but since his office was close to where the scan could be done we might just as well go over there and do it. He would call and arrange everything, it wouldn’t take long. His manner—relaxed and reassuring—did not set off any alarm, even for somebody whose alarm bells were so easily set off in a medical setting as Margaret. He was as good as his word, and when we got there we hardly had to wait at all. We attributed this to the neurologist’s clout, rather than to any concern on his part about the possible severity of her case.
Margaret was instructed to change into a hospital gown and taken away to be given an IV—the procedure would take about three-quarters of an hour. I settled down to read the New York Times, and by the time I had finished it Margaret reappeared, looking none the worse for wear. It had not been difficult or in any way painful, she said, and she was glad to have it over with.
But it was not “over with.” The wait for the results was interminable and inexplicable—we had yet to learn that the longer it takes to review a scan, the more likely it is bad news. No matter how many times I got up and went over to the desk to ask how much longer it would take, I could find out nothing. Margaret, usually the impatient one, was totally occupied in playing solitaire on her cell phone, despite her complaints about how small the buttons were. I recognized this as her own way of blocking out the reality of what was going on. Solitaire was her way of dealing with a delayed flight or a missed connection, or the many interminable waits at the U.S. Citizenship and Immigration Services office in New York City when we were applying for American citizenship.
The lady behind the desk was soon as fed up with me as I was with her. The radiologists were examining the scan, they were badly backed up, we would be called as soon as it was ready, I should sit down and wait until Margaret’s name was called. I am normally an unnaturally patient person, but as the afternoon wore on I became testy, never a productive attitude in a medical setting. When would we have the disk of Margaret’s MRI scan? The radiologists would get to it as soon as they could. Would they discuss it with us? No, they would give us a copy to take to the neurosurgeon, who would then talk to us. Why him? Because that’s the way it is.
>
I placed a call on my cell phone to the office of the neurologist who had sent us here, and asked his secretary why we were being sent to another doctor instead of him. I had thought that we were supposed to bring the disk back to him? No, she said, the neurosurgeon was the one who would review it with us, it would also be scanned to her boss, I had misunderstood him, this was the normal routine, nothing to worry about. Finally, after what seemed like a lifetime, Margaret’s name was called, and we were given a copy of the disk and sent to see the neurosurgeon.
Here, there were no crowds of patients, in fact the large, airy, empty white waiting room was eerily quiet. After what seemed like a long time, I went over to the sliding glass window behind which his secretary sat and asked when we might expect to see the doctor. He was just finishing a procedure, she said, he would be here as soon as it was done, and clacked her window shut firmly. I told Margaret. She sighed, and went back to her solitaire game. I thought she might get up and go home at any minute, but something kept her sitting there, and after a game or two more, at just the point when I began to fear she might get up and leave, the door opened and the secretary took us into the neurosurgeon’s office.
He had a certain remote politeness, and seated us so that we were facing his computer screen, rather than himself. The only decoration on the walls was a huge late nineteenth century German colored print of a human brain, sliced about halfway through the skull, with every part neatly identified in German. His remoteness I understood. Margaret was not yet his patient, his job was merely to tell us about her scan. He was part of the medical equivalent of the military chain of command—the neurologist sends you to have a scan, the radiologist examines the scan, and sends it, together with his or her analysis, to the neurosurgeon, who then tells you what the scan shows. The system effectively prevents the radiologist from interacting with patients, which is perhaps exactly what it is intended to do, and why people become radiologists in the first place. We chatted briefly about Margaret’s symptoms, her difficulty with finding the right words, and so on, and I handed him the disk I had been carrying like an offering. He waved it away; it had already been scanned to his computer. I saw now why we were sitting the way we were, the computer screen facing us, as if we were about to watch CNN together. He gestured toward it as if he were an impresario. “It’s a large malignant brain tumor,” he said, with the triumphant look of someone who has just dropped a bombshell into a conversation and brought it to a screeching halt.
Margaret stared at the screen silently, too shocked perhaps to say anything, then shut her eyes. I had no difficulty in guessing what she was thinking, that this was the end of the life she knew, that whatever was to come would consist of everything she hated, doctors, hospitals, surgery, physical disability, being indoors, that her life would henceforth be divided into two parts, before the diagnosis and after. As for me, it was déjà vu—when I was sixteen I had read John Gunther’s Death Be Not Proud, a best-selling account of his sixteen-year-old son’s doomed battle with brain cancer that was so vivid I read it twice. Gunther was a famous journalist, the author of Inside U.S.A. and a whole series of “Inside” books, and his descriptions of brain cancer—he was a brilliant reporter—etched themselves in my mind. I could still remember whole passages from the book, including the distinction between “encapsulated” tumors that can sometimes be removed easily “like a marble stuck in jelly,” and “others . . . of an infiltrating spidery type that creep and burrow along the minute crevasses of the brain,” as well the fact that any brain tumor the name of which begins with the prefix glio (from the Latin for “glue”), like glioblastoma, was “invariably fatal.” Of course, much had no doubt changed in brain surgery in the sixty-five years since I had read the book, but I nevertheless managed to ask whether Margaret’s tumor was encapsulated and how the doctor knew it was malignant. Could it be a glioblastoma? These were exactly the questions Gunther had asked.
The neurosurgeon gave a small sigh. Death Be Not Proud used to be on the curriculum of most high schools, so I may not have been the first layman in his experience to display more knowledge than I really had thanks to Gunther’s book. The necrosis around the tumor, he said, pointing with his forefinger at a dark band around the white blob, makes it clear that the tumor is malignant and growing, the lighter gray band around that shows the brain swelling as the tumor mass expands . . . As for the kind of tumor it is, it was too early to say, that would have to be determined by a biopsy. He warmed ever so slightly to his subject. As we could see, the tumor was on the left side of the brain, since the left side of the brain controls the right side of the body, which explained the problems with Margaret’s right hand, as well as her difficulty in finding words, because the left side of the brain also controls language and speech . . .
A pause. Did we have any questions?
I could see that Margaret was simply numbed by the news, and frozen by the lecture. I leaned over and put my arm around her—I would have to ask the questions for her. Would Margaret need brain surgery? was the first and most obvious one. The surgeon made a steeple of his fingers and stared over my head at the wall as if he were searching for the answer there. He pursed his lips. He could not say for sure until after seeing the results of the biopsy, but we should bear in mind that removing a tumor of this size might have a significant effect on her “quality of life.”
This was a song I had heard before, when I was about to undergo a radical prostatectomy at Johns Hopkins. When a surgeon of any kind talks about quality of life it is time to start worrying about the future. It also occurred to me that Margaret’s definition of quality of life might be very different from that of the neurosurgeon’s—anything that prevented her from riding her horses with the wind in her hair would not seem to her a life with any quality at all.
Did that mean it was inoperable? I asked. He shook his head, no, not necessarily, but the biopsy was the first step, the sooner, the better.
We should have no concern about the biopsy, the neurosurgeon went on, it was a simple procedure that would tell him everything he needed to know. He described the process briefly. There were a couple of spots of concern on the lungs, he added, as he rose to show us out, but we should not think about them now, the main thing was to get the brain tumor biopsied at once, then we could decide how to go forward. I do not think Margaret heard him, she was still in shock, certainly she had no reaction, and in fact he passed over the subject of “spots of concern” so quickly that it hardly registered with me until much later.
Would she have to have her head shaved? Margaret asked.
Just a tiny spot, he replied with some impatience. Her hair should not be her first concern, there were bigger and more serious ones than that. I could see he thought, quite wrongly, that Margaret either didn’t understand the gravity of what he had told her or didn’t take him seriously, but I recognized it as an altogether sensible question from her point of view. She had absorbed the bad news with her usual stoicism—her health, her life were at risk, she understood all that, but still she wanted to be reassured about what it would do to her appearance.
It was not a question of vanity; her long blond hair was part of who she was, something she would think about even in the midst of a disaster. The first thing Margaret asked at any place we went to was where she could plug in her hair dryer—over the years I had filled a black leather zip bag with an assortment of adapters for every imaginable electric outlet and voltage in the world, two-prong, three-prong, you name it, it was an essential part of her travel kit, Margaret’s hair dryer had blown fuses and caused blackouts in hotels, motels, and safari camps on every continent. To me, her question was a healthy sign that she had not been totally knocked out by the news, but the doctor may have taken it as a sign that she was on the verge of hysteria and about to become difficult. He herded us swiftly and efficiently out of his office and passed us on to his secretary, who was waiting with a thick sheaf of paperwork for us to take home with us.
From the rig
idity of Margaret’s face and her body, her back straight as a drill sergeant’s, shoulders squared, mouth set, I could tell that she was holding back tears. Whether of anger, fear, or just plain shock at bad news presented so abruptly was hard to tell.
“Let’s go home,” she said.
2.
ONCE WE WERE home, Margaret went to the barn to see her horses. She derived a kind of comfort from their presence. They could not be cuddled with like cats and don’t project total devotion and loyalty as many dogs do, but Margaret would place her head against the shoulder of one of them and somehow draw from the horse a degree of sympathy that most people would not. Her horses calmed her even at her most anxious moments in a way that nothing else could. I knew better than to intrude, so I went to my office and began to draw up a list of the people I needed to call.
It quickly grew to a daunting length. I put it to one side for the moment and began to go through the thick wad of papers I had brought home, separating the ones that Margaret would need to sign and the forms that would have to be filled out. To my surprise, there was a copy of the radiologist’s report. I began to read it, with the kind of guilty feeling that accompanies reading someone else’s mail. Some of it was above my head, other parts I could tease the meaning out of in layman’s terms. “There is a mass in the left mid parietal lobe . . . This mass has both solid and necrotic components and vasogenic edema as well as evidence of prior hemorrhage . . . This may represent a primary brain neoplasm such as, but not limited to, an astrocytoma or glioblastoma multiforme but a metastasis cannot be excluded based on this exam.”
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