Thursday, February 24, 2005

Death Comes for the Grasshopper

The woods decay, the woods decay and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.
Me only cruel immortality
Consumes: I wither slowly in thine arms,

Alfred, Lord Tennyson, Tithonus, 1860

I grabbed the chart from the plastic holder and paused, one hand on the door knob, quickly reviewing the latest information on the man waiting for me in the exam room. A date in the upper corner of the folder caught my eye. I glided into the room with a big grin and he looked up as I greeted him.

"Do you realize that this is the seventh anniversary of the day you were diagnosed?" I asked. "You have lived a long time - much longer than the average patient."

He bowed his head slightly before answering me and as we exchanged our congratulations I noticed his clavicles bulged from his tee shirt like two tent poles. I helped him to the table and recorded the findings of my examination with perfunctory precision - hard cervical lymph nodes, persistent left pleural effusion, colostomy in place. After shaking his hand I said I'd see him next month.

"Let me know if you run low on pain meds." He nodded to me as I opened the waiting room door for him. I then went back to my office to dictate my note. Outside my window a chickadee caroled me from a nearby branch: see-bee-see-bay. I put down the telephone and listened to its melody, and before I could regain my train of thought lines from a poem learned long ago rose into consciousness.

And though they could not end me, left me maimed
To dwell in presence of immortal youth,
Immortal age beside immortal youth,
And all I was, in ashes.

When oncologists evaluate the benefits of an anti-cancer medicine one of the most important statistics they consider is whether the treatment prolongs survival. Helping patients to live as long as they can is one of the great goals of modern cancer therapy. Those who are cured of cancer obviously receive the greatest reward, just as those who are cursed with tumor progression are fated to see their life end before the "half-opening buds / Of April" push through the earth next spring. What then becomes of those whose disease neither grows nor disappears? What does it mean to be given the gift of survival without remission? The image of my gaunt patient floated in the air as I considered the parallel between him and the title character of Tennyson's poem. According to the myth, Tithonus, the beloved of Aurora, goddess of the dawn, was granted eternal life but not eternal youth, and therefore becomes a withered skeleton, "a white-haired shadow roaming like a dream / The ever-silent spaces of the East." He comes to envy "happy men that have the power to die" and begs the goddess:

Let me go: take back thy gift:
Why should a man desire in any way
To vary from the kindly race of men,

It is this kind of irony that drives physicians mad - to work so hard to lengthen the lives of patients by turning cancer into a chronic disease, only to see them slowly decay.

But thy strong Hours indignant worked their wills,
And beat me down and marred and wasted me,

Some cancers like chronic lymphocytic leukemia can be tolerated for many years without consuming the patient's vitality, but this is simply because of the natural history of the disease. Oncologists continue to search for treatments that will blunt the progression of horrid tumors such as melanoma or lung cancer. If researchers someday announce that a new medicine can stop the growth of cancer but not eradicate it, will this be a blessing or a bane? Are patients who experience a long life living with cancer lucky or unlucky? What would one choose if offered the gift from the goddess of the "rosy shadows", knowing that one's vigor would be sacrificed?

The song outside my window stopped and a gray bank of clouds drifted into view, darkening the office walls. I finished my dictation and stood to leave. Before turning, I peered briefly at the trees by the parking lot. Like a priest who held high the cup, their limbs were hanging in the late winter air, stippled with buds promising new life, a renewal repeated since the dawn of time.

Tithonus was eventually released from his living imprisonment, for the myth ends when Zeus, taking pity upon the aged lover, transforms him into a grasshopper. We who are mere mortals have nothing to fear, for no matter how long we live or how much we suffer we will never end up inside of a glass jar furiously rubbing our hind legs together. Our fate is the fate that Tithonus pleaded for yet was denied. One can imagine he sits outside our window even now, chirping his cry long into the night until the first light of his former lover bathes the distant hills:

Release me, and restore me to the ground;
Thou seest all things, thou wilt see my grave:
Thou wilt renew thy beauty morn by morn;
I earth in earth forget these empty courts,
And thee returning on thy silver wheels.


At 4:43 PM, Anonymous Anonymous said...

that was a beautiful entry.


At 5:05 PM, Blogger Saint Nate said...

It really is a gift to see the classic beauty in what you confront every day. But then, your writing is a true gift unto itself.

At 5:08 PM, Blogger poopie said...

I figure there's a plan for all of it and the oncologist is just another player in the drama...doing good and no harm. And reflecting on the meaning of all of it.

Thanks for your reflections. ^j^

At 7:18 PM, Blogger Jodie said...

We discussed this issue in tumor board today, although (alas) neither so lyrically nor so well.

At 12:07 AM, Blogger JasonC said...

This reminded me of an apropos quote from Dostoyevsky:

"where was it I read about a man who's been sentenced to die, saying or thinking, the hour before his death, that even if he had to live somewhere high up on a rock, and in such a tiny area that he could only stand on it, with all around precipices, an ocean, an endless murk, endless solitude and endless storms--and had to stand there, on those two feet of space, all his life, for a thousand years, eternity--that it would be better to live like that,than to die so very soon! If only he could live, live, and live! Never mind what that life was like! As long as he could live!...What truth there is in that! Lord, what truth!"

At 10:10 PM, Blogger onc_rn said...

There are many days I wonder if prolonging (what we may feel is) marginal existance in these patients is the right thing to do, but for many of these folks another six months or year means another wedding or graduation; the birth of another grandchild or just the joy of seeing another sunrise. Part of our job is to make sure we keep them properly informed and as comfortable as possible and they will let us know when it is time. Thanks again for the lovely reflection.

At 1:07 PM, Blogger jon said...

I was looking at your posts about cancer lung symptom and found a good article about the same cancer lung symptom info too...

God luck with it : )

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