Mrs. Fink
  
When Love is the Only Medicine
By Robert A. Fink, M. D.
(Appeared in Medical Economics, April 17, 1989)

"With cancer imperiling their lifelong romance, the author and his wife looked for solace where they'd always found it; in each other"

Doris and I grew up together, falling deeply and permanently in love when we were both 16. We married the week after I graduated from medical school, and began shouldering the burdens and satisfactions of the medical life. First came internship and residency, followed in no exact order by a cross-country move, a research fellowship, military service, establishment of a private practice, and a family of three daughters. Finally, when we were both 46, we seemed to have reached a point of success and comfort: The children were loving and delightful, Doris was an accomplished artist and mother, and I had a flourishing neurosurgical practice.

As the babies came and grew, there were the usual nocturnal disturbances - nightmares, earaches, the implacable demands for Mommy and Daddy that could only be soothed by ferrying baby into our bed and nestling her between the two of us. After a while, the little one would sufficiently calm down and could be gently carried back to her own bed. Very early, the children learned the importance of the word "middle", and that a few moments "in the middle" were far more comforting than any medicine.

From before the birth of the first child, Doris had known that she had large uterine fibroids, benign growths that usually don't appear until a woman's 40s. Periodically, her gynecologist would urge her to have them removed, but she always resisted. Finally, by 1984, the fibroids had swollen her uterus to the size of a three-month gestation, and we both realized that the operation shouldn't be postponed any longer. In mid-December, just after watching our eldest daughter in her high-school musical, Doris was admitted to my primary hospital in Berkeley for a "routine hysterectomy".

I knew that such operations usually took about two hours. I waiting in the lounge, anxiously sipping coffee and smoking cigarettes. As two hours came and went I grew increasingly anxious, until the surgeon - an old friend - came out, and, with a somber face, asked me to join him in the operating room to see what he'd found.

Both of Doris' ovaries were overrun by cystic, irregular masses of cancerous tissue, and the serosal surfaces of her peritoneal cavity were also studded with many small implants of the tissue. Her uterus, which was indeed full of numerous leiomyomata, clung densely to the ovarian masses. The diagnosis was "serous cystadenocarcinoma of the ovaries, Grade I". The disease had progressed to Stage III.

I watched while, following the protocol of treatment for the disease, a major surgical resection of all gross tumor was carried out, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and a removal of all residual malignant tissue measuring more than one centimeter in diameter.

At the time I was chief of surgery for that hospital. But, as the surgeons worked on my wife, all I could do was sit mutely by, staring into space. In my frustration I thought that the surgeon had been callous to call me in. But afterward, I grew more and more grateful that I had full understanding of my wife's condition from the first.

When Doris went to the recovery room, I called Deborah, our oldest daughter and told her to come to the hospital. As the reality of the situation sank in, we were there to hold each other. Doris, along with our middle daughter, learned of the findings later that evening.

I turned to my old medical textbooks from medical school. I found that the disease typically progresses by spreading all through the abdominal cavity, by grabbing hold of and obstructing the bowel. Most often, the patient dies of inanition. The five year survival rate for ovarian cancer is 20 percent.

These facts burned in my mind as I went shopping for the best oncologist I could find. As a neurosurgeon, I was accustomed to dealing with terminal diseases, and understood how essential it was that a doctor be honest with a patient. I wanted one who would be frank with us if Doris' life became unbearable or no longer worthwhile.

"What's the worst that could happen?" I asked the oncologist we eventually chose. "The worst is that she wouldn't get relief from the chemotherapy", he replied. "So what would that mean?" "Oh," he said, "two more years."

Doris recovered rapidly from her operation, and less than a week after leaving the hospital she began a regimen of chemotherapy, consisting of cyclophosphamide, doxorubicin, and cisplatin. The treatments were at 28 day intervals, and required that Doris enter the hospital because of the renal toxicity of the cisplatin.

Each cycle of chemotherapy was accompanied by severe nausea and vomiting. Three weeks after the first treatment, Doris' long, curly, coal-black hair - her loveliest physical feature - suddenly fell out. For days after each cycle, she'd be exhausted. Then there was the tension surrounding the blood counts, which determined if she could continue with the debilitating but most effective levels of the crucial chemotherapy.

Still, for two weeks of every month, Doris felt reasonably well, and our family carried on with considerable normalcy. She and I quickly learned to appreciate each day. In March, between treatments, we managed to steal two weeks for a second honeymoon on Kauai.

It was an idyllic trip, unencumbered by the children, but sobered by the realization that this might be our last extended time alone together. We shared our deepest fears. Doris' was not of death, but of leaving me alone to raise the children (the youngest was only 7 at the time).

I, on the other hand, kept brooding about the devastating complications of ovarian carcinoma. It would hurt to see my wife suffer. To my prayers for a cure I added a provisional plea for a quick and dignified end. In fact, as a neurosurgeon, I knew that brain tumors were a relatively peaceful and painless cause of death. But, by the same token, I knew that ovarian cancer metastasized to the brain in only 1 percent of cases. My prayers that spring took on an anguished precision and complexity.

But, in all, the nine months between discovering the carcinoma and the scheduled second-look operation were a time when our relationship, always close, took on new dimensions of intimacy. And, aside from the chemotherapy reactions, Doris felt progressively better and stronger. Perhaps our most optimistic moment came when another oncologist told us that Doris seemed to be improving without complication, and that a new chemotherapy might be even better. And, always, there was the solace of the first oncologist's prognosis that at worst we still had two years.

Two weeks after the final chemotherapy and three weeks before the scheduled second-look operation to determine if the disease had been eradicated, Doris complained of pain in her right shoulder. Her doctor believed it was a delayed reaction from the drug s and said he'd order routine studies at her preoperative screening the following week.

When I came home the next Monday, I noted a slight slur in Doris' speech. She said she'd taken analgesics that afternoon for her shoulder, but to a neurosurgeon, that didn't explain the speech problem. For the moment, however, trying to be a husband instead of a doctor, I conceded that the medication might have caused the slur. A good night's sleep, with no more drugs, would tell the story.

The following morning the slur was still there. I phoned the oncologist and requested a CT scan of the brain. It confirmed our worst fears and answered my most desperate prayers. Doris' ovarian carcinoma had developed large cerebral metastases on both sides of the brain, one in the center of Wernicke's speech area in the left temporal lobe, the other in the contralateral parietal lobe.

A chest x-ray, moreover, showed miliary pulmonary metastases, while a pelvic exam revealed massive intra-abdominal disease. So, God had heard my plea; against very big odds, my wife's spreading cancer had indeed found its way to her brain. But suddenly our worst case minimum had evaporated.

We did what we could. Doris was admitted to the hospital where she received several units of blood (the chemo had made her anemic), and medications to reduce swelling of the brain and to prevent convulsive seizures. But surgery was impossible with both hemispheres diseased. Radiation was offered, but the best that could do was delay the inevitable. Doris and I had discounted it long before. I asked only that she be made as comfortable as possible.

She came home Friday, September 13, 1985. She walked up the steps of our hillside home overlooking San Francisco Bay, entered the house, and asked for a bath to be drawn (we'd always delighted in the luxury of bathing in an old-fashioned tub). I helped her in, and we sat together for almost an hour. By this point Doris' speech was growing more and more muddy, but we went over our long marriage and agreed that we'd hidden or held back nothing from each other; ours had been a wonderful life together. Then we looked to what remained.

"I'm sorry I'm leaving you the kids," Doris said. "Can you handle it?" "I guess I can." "Are you going to be able to let go of me?" It was the most difficult question I'd ever been asked. "Are you ready?" I asked in return. "Yes, I'm ready". "Then so am I."

That night we fell asleep in each other's arms. At 3 AM, I was awakened by a loud thump and saw that Doris, her right side now paralyzed, had fallen while getting out of bed. I called for Deborah, then 18, and we lifted Doris back into bed. By now she couldn't speak at all.

We placed her in the center of the mattress and then, in a spontaneous re-creation of all the nights when a sick or frightened child came to her parents' bed to rest in the comforting "middle", my daughter and I lay down on either side of Doris, and in that way she passed her final night.

Doris was coming to the end of her life, and to her God, "as a little child". As she slipped into a coma, her last perceptions were of being enclosed in a nest, flanked by her loved ones whom, in years past, she'd nurtured in the same way.

Some 16 hours later, when her body let go of life, Doris was nestled in my arms. She passed from the loving middle to the infinite beyond, spared the anguish of a protracted dying. She left this world in the embrace of her family, which was reflecting the love she'd so long given it.

Now, four years later, the family is together and prospering. I've remarried (to Doris' best friend), and we've welcomed yet another daughter. Our ache hasn't healed yet, but our grief and depression have been eased by the manner in which Doris lived, suffered her illness, and died.
(End of article)


(Continued)
Postscript, December, 1995:

I wish that I could conclude this re-printing with a "happy ending". Sadly, I cannot, as the remarriage mentioned above has not worked out and is in the process of being terminated. The experiences described in the above article, however, are still fresh in my heart and mind, and guide me as I continue to care for my patients, many of whom face serious and potentially fatal illness. As a man who was married to Doris for just short of 25 years, I count myself as being most blessed to have experienced this kind of relationship during my lifetime; and whatever the future will bring, I am grateful for having had this experience.
Robert A. Fink, M. D.
Berkeley, California
December 16, 1995

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