8—
Some Lessons from the Cancer Ward
Case History
By the time Mrs. C, age forty-seven, was admitted to the hospital in early December, I had been a medical intern for five months. But in all my time on the wards, I had never met anyone like her Here is her history.
Ten years before, after a diagnosis of breast cancel, Mrs. C had had a mastectomy. She had done well for about eight years, until her cancer had recurred. At that point, she had been given radiation therapy and chemotherapy and had done reasonably well for two more years. About one week prior to this admission she had begun to experience shortness of breath. X rays revealed a pleural effusion. She was therefore hospitalized for two reasons: because of her severe shortness of breath and because her doctor wanted to find out why there was so much fluid in her lung. He suspected that it was due to her metastatic disease.
I was the intern who admitted her. Generally, most patients do not affect an intern very much. But this woman was different. What struck me most about Mrs. C was that although she knew that she had metastatic disease, she had obviously not spent the past two years in self-pity I learned that she was a deeply religious woman. what impressed me more, however, was that she clearly loved her family (she had a husband and children) and life itself. Her desire to continue living was so strong that she refused to let her cancer interfere with what she wanted to do.
In the days following her admission, I became attached to Mrs. C, as did some of the other doctors and the nurses. Although often tired when we went in to see her, we soon found that she would cheer us up and make us feel good.
How did she do it? With a combination of humor, spirit, and friendliness—all those "trite" human virtues that are not trite at all. Mrs. C always seemed grateful for whatever we did, no matter how small. Perhaps her faith helped her. She told us that she had one more goal in life: to spend Christmas with her family. To me that goal epitomized her She knew she was dying, but she could focus on what was important while she was alive.
After we had withdrawn some fluid from Mrs. C's lung, we documented that, as we had suspected, the effusion was due to her breast cancer. We then called in a thoracic surgeon to put a chest tube into her lung. The tube was hooked up to a suction device that continued to draw out fluid. After some time we planned to instill a sclerosing agent in the lining of her lung. The procedure is supposed to help prevent fluid from reaccumulating after the chest tube is withdrawn. It is successful only about 50 percent of the time, but we felt it was worth a try
The chest tube had been in Mrs. C's lung for about twelve hours when something obviously went wrong because I was suddenly summoned to her room at around 2:00 a.m. She was having trouble breathing, even while at rest in bed. We took another chest X-ray, which revealed that the fluid had reaccumulated. Mrs. C was starting to go into respiratory distress, a situation that is generally life threatening. Soon she would become exhausted just by the act of breathing.
I rushed to a telephone to consult with her attending physician. We decided that I should call the thoracic surgeon who had
put the tube into her lung and ask him to come in and replace the tube. However, when I reached him at home (it was by then around 3:00 a.m.), he refused to come to the hospital. Instead, he told me to draw off the fluid myself. I was terrified. Although I had seen this procedure done before (it is called a thorocentesis), I had never done it. It involves inserting a large needle into the lung cavity and withdrawing the fluid with a syringe.
I hurried back to Mrs. C's room. In the thirty or forty minutes it had taken me to make the calls and discuss her case, she had deteriorated markedly. She was gasping for every breath now. Without some sort of intervention, she would probably die. I set up the thorocentesis kit as quickly as possible. While I was doing that, I heard Mrs. C say in between gasps for air, "Well, 1 guess . . . I won't . . . be seeing . . . Christmas." At that point, I did not think that she would even see the next morning.
When I got the needle into her, I began to draw off the fluid. I took off a total of about a half gallon. Within minutes, she started to improve, and the next day she was fine. The fluid did not reaccumulate.
After that night the bond between Mrs. C and me was very strong. Because she had been so close to death and because I had withdrawn the fluid, she attributed her life, rightly or wrongly, to my intervention.
Mrs. C seemed to stabilize over the next few days. Her chest tube was removed, and although some fluid gradually reappeared, she was able to breathe almost normally.
The day she was discharged several doctors and nurses who had taken care of her made a point of going in to say good-bye. In her usual way, she touched us with her way of saying thank you.
After she went home, I did not think about her much until Christmas, when I was on duty all day and night. There I was in the middle of the ten thousand odd things an intern always has to do—and the eleven thousand extra things he has to do on a holiday when the staff is shorthanded—when one of the nurses offered me some Christmas cookies from a huge box. They were from Mrs. C. Her note read, "With thanks to all the doctors and nurses who took care of me."
I interpreted her gift to mean that she had lived to see Christmas and spend it with her family I also understood that this
woman possessed the rare ability to reach out to other people. By means of those cookies she was telling us that the most important thing that had remained to her in life had been achieved. And by her gift she was making us a part of it
As we sat in the nurses' room for a while and munched on those cookies, there was silence instead of the banter we usually exchanged. We were thinking about this woman who had touched us all.
Literary Parallels
Had Mrs. C always been such an exceptional person? Perhaps. Probably, in fact. But is is also possible that her cancer had taught her, more deeply and at a younger age than she might have discovered otherwise, the richness of life and of human emotions. Sometimes after a person has been forced to face the prospect of his or her own death, that person grows extraordinarily and discovers—or rediscovers—new meanings in life and in love.
This is what happens toward the end of Solzhenitsyn's monumental novel, Cancer Ward . There, thirty-four-year-old Oleg Filimonovich Kostoglotov, a victim of the labor camps, of exile, and of a cancer that will probably kill him soon, emerges not as a victim of life but as a victor in life. This novel is particularly appropriate for our purposes and particularly poignant, for Solzhenitsyn himself was once diagnosed as having cancer, the kind of cancer, in all likelihood, of which his character Kostoglotov is probably dying. In fact, as Solzhenitsyn's assistant wrote to us in a letter dated August 20, 1982, "Although Mr. Solzhenitsyn does not give personal 'interviews' on his personal life, it is safe to assume that the descriptions of Kostoglotov's symptoms (although not of Kostoglotov's biography) corresponds with the author's symptoms."[1]
Cancer Ward
Before one can emerge an emotional victor over cancer, one at first feels the victim. Appropriately, it is the victim who appears in the opening pages of Cancer Ward . Although the victim's name here is Pavel Nikolayevich Rusanov, at this point in the novel he is, more than an individual, a symbol of the person who has just learned he has cancer. And that person could be Kostoglotov, or Solzhenitsyn, or Mrs. C, or anyone.
Pavel Nikolayevich Rusanov
"It isn't, it isn't cancer, is it, Doctor? I haven't got cancer?" forty-five-year-old Pavel Nikolayevich Rusanov had asked hopefully in the outpatient clinic just a few days before he had to be admitted to the hospital for lymphoma treatments. And lightly he had touched "the malevolent tumor on the right side of his neck."[2]
Here we sympathize and almost emphathize with Rusanov's terror, denial, and pain. Later in the novel, we shall come to know him for a scoundrel, a member of his factory's "special department" (a euphemism for the KGB), and a man who has risen by denouncing others. But as this new cancer patient enters the hospital, he appears like many middle-class or slightly privileged persons who have just been stricken with the disease they dread most. And we suffer with him.
Only a few weeks before, Rusanov had been self-confident and demanding. As he enters the cancer hospital, however, he appears timid, weak, and dependent.
[He] remained standing in the waiting room. Timidly he tilted his head slightly to the right and felt me tumor that jutted out between his collarbone and his jaw. He had the impression that in the half hour since he had last looked in the mirror . . . [his tumor] seemed to have grown even bigger. Pavel Nikolayevich felt weak and wanted to sit down.[3]
His cancer is changing him, even as it is changing the world in which he must live.
The new patient reacts to the hospital with a combination of disgust, anger, and fear. "Beginning with these slovenly dressing gowns, [Rusanov] . . . found everything in the place unpleasant." When he hears a youth screaming, the "screams deafened [him] . . . and hurt him so much that it seemed the boy was screaming not with his own pain but with Rusanov's."[4]
His wife and son had accompanied him to the hospital. When they leave, Rusanov feels orphaned and worse: like a prisoner condemned to be beheaded on the scaffold.
Orphan-like [Rusanov] . . . looked back at his family . . . and, grasping the banister firmly, started to walk upstairs [to the ward]. His heart was beating violently. . . . He went up the stairs as people mount—what do they call it?—a sort of platform where men have their heads cut off.[5]
Within hours on the ward, Rusanov "became haunted with fear."[6] Suddenly the reader becomes me patient as Solzhenitsyn slips from the third person ("him") to the second person ("you"). In the passage below, "you" cannot help but identify with the patient, the victim.
The hard lump of [Rusanov's] . . . tumor . . . had dragged him in like a fish on a hook and flung him onto this iron bed. . . . Having once undressed, said goodbye to the family and come up to the ward, you felt the door to all your past life had been slammed behind you, and the life here was so vile that it frightened you more than the actual tumor.[7]
To Rusanov, the hospital is like a prison. But the wall of this metaphorical prison is not really the hospital wall: it is the wall of his tumor, for it is his tumor that imprisons, terrifies, and condemns him to death. In "the space of a few days all [Rusanov's past life] . . . had been cut off from him. It was now on the other side of his tumor. . . . However much [his family] . . . might worry, fuss or weep, the tumor was
growing like a wall behind him, and on his side of it he was alone."[8]
Solzhenitsyn's depictions of Rusanov's isolation, pain, and fear when he first enters the hospital help us understand—and feel—the anguish of the new cancer patient. Because of this, although we do not see Kostoglotov when he first learns he has cancer (nor did we see Solzhenitsyn or Mrs. C at that trying time), we realize that his (and Solzhenitsyn's and Mrs. C's) emotions on first becoming a cancer patient were probably similar, in some ways, to Rusanov's. There is a terrible sense of being trapped by the tumor, of being imprisoned and condemned to death by it, a terrible feeling, therefore, of being a victim.
How can someone who feels himself (or herself) a victim of cancer ever feel—and be —a victor in life? We turn to Kostoglotov.
Oleg Filimonovich Kostoglotov
Kostoglotov, age thirty-four, has had a very hard life. For seven years he was a sergeant in World War II. For seven more years he was a prisoner in the labor camps. Now he is exiled "in perpetuity" to Ush-Terek, a remote region of the U.S.S.R. He also has cancer, probably a seminoma.[9]
By the time Kostoglotov arrived at the cancer hospital, he was almost dead. His body was "tormented and twitching with pain" and his "sharp, emaciated face already registered the indifference of death."[10] Here we see and feel—almost viscerally—Kostoglotov as the victim.
After two weeks of radiation therapy in the hospital, however, Oleg Kostoglotov improves dramatically. When he does, he exults in his refound life.
Oleg had come out for a stroll on the hospital grounds, . . . his leg, with each step and stretch, rejoicing at being able to walk firmly, at being the living leg of a man who had not died. . . .
He was seized and enveloped by a feeling that life had suddenly returned. . . . Though this life promised him nothing
that the people of this great town called good and struggled to acquire: neither apartment, property, social success nor money, there were other joys, sufficient in themselves, which he had not forgotten how to value: the right to move about without waiting for an order; the right to be alone; the right to gaze at stars that were not blinded by prison camp searchlights.[11]
Kostoglotov's joy is all the more profound because he does not prize the superficial things, including possessions and status, that people so often crave. Instead, he values life itself—life free from constant oppression, either by other people or by pain.
But now that Kostoglotov is doing well, he must begin the treatments that Dr. Dontsova (who later discovers that she herself also has cancer) had told him were necessary. "Your tumor is one of the most dangerous kinds of cancer. It is very rapid to develop and acutely malignant, which means secondaries appear very quickly too. Not long ago its mortality rate was reckoned at 95 per cent," Dr. Dontsova had said.[12] She had convinced him that the additional therapy, "a treatment highly recommended for this particular type of cancer by the most up-to-date authorities," would help combat his tumor.[13] Dr. Dontsova had not been completely open with her patient, however, for she had not told him that this up-to-date treatment, hormone therapy, would make him sexually impotent. Only toward the end of his two-month hospitalization does Dr. Dontsova tell him, "speaking softly so that the other patients could not hear . . . [,] "You shouldn't hope to achieve the happiness of a normal family life.'"[14]
During his hospitalization, another female doctor becomes very important to Kostoglotov: Vera Kornilyevna Gangart. "Vega," as Kostoglotov likes to think of her (Vega was a pet name she had once had), is sensitive, lonely, and about Kostoglotov's age. She has never married or made love. An emotional bond develops between them. Shortly before Kostoglotov is discharged, she tells him that on the
day he leaves the hospital he may spend the night at her apartment.
It is very early one March morning when Kostoglotov finally steps out of the hospital. He is not cured of his cancer, but he is no longer at death's door. As he walks through the hospital gates, he thinks, "It's just like leaving prison."[15]
Inhaling the spring air, Kostoglotov feels as though he and the entire world were born anew Time expands. It appears to him to be "the first day of creation."
[He] looked out at the world—it was new and turning green. . . .
It was the morning of creation. The world had been created anew for one reason only, to be given back to Oleg. "Go out and live!" it seemed to say. . . .
His face radiated happiness. . . .
The first morning of creation—who can act rationally on such a day? Oleg discarded all his plans. Instead, he conceived the mad scheme of going to the Old Town immediately, while it was still early morning, to look at a flowering apricot tree.[16]
With feelings of wonder and excitement, Kostoglotov takes a trolley to the Old Town, walks around, and stops for tea in a teahouse, where he is suddenly exhilarated by the sight of the flowering tree. The vision appears to him no less than a miracle: at once sensuous and pure, fiery and flowering, fragile and yet transcendent. Although the tree is enclosed in a courtyard—imprisoned symbolically—it stretches toward the sky. It might be a symbol of himself.
[From] the teahouse balcony he saw above the walled courtyard next door something pink and transparent. It looked like a puff dandelion, only it was six meters in diameter. . . .
Could it be the apricot tree?
Oleg had learned a lesson. This was his reward for not hurrying. The lesson was—never rush on without looking about first.
He walked up to the railings and . . . gazed and gazed through this pink miracle. . . .
It was like a fire tree decorated with candles in a room in a northern home. The flowering apricot was the only tree in this courtyard enclosed by clay walls and open only to the sky. . . .
Oleg was trying to absorb it all into his eyes. He wanted to remember it for a long time and to tell the Kadmins [fellow exiles in Ush-Terek] about it.[17]
Along with his joy and wonder, two things are striking here. Above all, there is the lesson "never rush on without looking about first." He has learned to appreciate and savor each moment. Then, he wants to share this "miracle" with his friends in Ush-Terek. And so, despite—or perhaps just because of—his past sufferings, he is able to feel for, and to want to communicate with, others who have also suffered. It is a lesson in living and in loving.
After Kostoglotov has tried to absorb—to drink in and incorporate within himself—this miracle, he walks about the town, absorbing in the same way, sensuously and spiritually, the wonders of the world and of life: sights, sounds, smells, tastes, and impressions. Although he may not live to see another spring, he is able to rejoice in this one because it is "a spring he had not reckoned on living to see. . . . [It] was like a surprise gift, and he was grateful."[18]
The ecstasy does not last. Still, even as his joy wanes and his suffering returns, his new suffering is tempered by the lessons he has just learned. Kostoglotov had wandered about for a long time before finally going to Vera Gangart's apartment. By the time he had gotten there, she had already gone out. (She had told him that she would be in until 4:00 p.m.) He had then left and decided to return later. And he had tried to return, but on his trip back to Vera's, he had had a painful revelation. Riding on the crowded trolley, he had been pressed up close against a young girl and suddenly realized the full—and devastating—effects of his hormone therapy. Through the young girl's
worn old clothes he was absorbing her warmth, her softness and her youth. . . .
This sensation—he hadn't felt it, he hadn't had it confirmed for . . . [years]. It was all the more powerful for that, all die stronger.
It was a happiness, and it was a sorrow There was in the sensation a threshold he could not cross whatever his power of self-suggestion.
They had warned him, hadn't they? The libido remains, the libido but nothing else. . . .
And as he straightened his bent, weakened knees Oleg realized his journey to see Vega would end as a torture and a deceit.
It would mean his demanding more from her than he could ask from himself.[19]
Kostoglotov had gotten off the trolley and had gone to the railroad station where he could board the train that would take him back to Ush-Terek and his exile. It might seem that he is defeated here, that he has lost his joy in, and love of, life. But has he really?
From the railroad station, Kostoglotov sends Vera a note that, by apparently renouncing love, is, in fact, a profound expression of love and kindness. "Darling Vega," it begins. It goes on to explain why he did not return to her apartment that day:
You see, Vega, if I'd found you in, something false and forced might have started between us. . . . What was about to begin between us was something we could never have confessed to anyone. You and I, and between us this thing: this sort of gray, decrepit yet ever-growing snake. . . .
You may disagree, but I have a prediction to make: even before you drift into the indifference of old age you will come to bless this day, the day you did not commit yourself to share my life. (I'm not just talking about my exile.) . . .
Now that I'm going away . . . , I can tell you quite frankly: even when we were having the most intellectual conversa-
tions . . . , I still wanted all the time, all the time , to pick you up and kiss you on the lips. . . .
And now, without your permission, I kiss them.[20]
Thus, although impotent and probably dying of his disease, Kostoglotov is not a victim of cancer but a victor in life. He is able to shun sham and pretense and love life and another person unselfishly. Although he probably does not have much time left to live, during the time remaining he will live life generously, caringly, and feelingly. What more can any of us do during the time—however long or short—we have left?
Some Lessons from the Cancer Ward
In a sense, Rusanov, Kostoglotov, and Mrs. C are all victims. We see and feel their suffering. But, we come to appreciate, a victim is not necessarily someone who is dying.
Throughout his novel, Solzhenitsyn uses the prison metaphor to describe the cancer ward and, beyond it, life itself. Frequently, the patient is depicted as a victim, a prisoner of cancer. Cut off from ordinary life, imprisoned in a hospital, walled in by his tumor, the patient feels condemned to death. In Cancer Ward , however, Solzhenitsyn uses his metaphor to describe not only the experience of facing cancer but also the experience of facing life, for facing life also implies, eventually, facing death. "We die daily; . . . while we are growing, our life decreases; every moment that passes takes away part of it; . . . nay, we divide with death the very instant that we live."[21] A victim, therefore, is not merely someone who is going to die. We are all going to die. A victim is someone who does not know how to live. And knowing how to live, we intuit from Kostoglotov and Mrs. C, means knowing how to love life and other people.
A person may be a victor, then. even though he or she may be dying of cancer. "You do not die of being sick, you die of being alive. Death kills you well enough without the
help of illness."[22] Even though we are all dying, we need not consider ourselves victims, for the cancer ward has illustrated how a person who has learned to savor life and to care for others can be a victor in life and in the lives of those he or she touches, as long as he or she lives and afterward.