When the Air Hits Your Brain: Tales from Neurosurgery

12. The Wheel of Life

Get up. Shower. Make the coffee. Our lives cycle like planets trapped in their orbits. Each day brings minor variations which cause our individual orbits to wobble a bit—the car breaks down, the school bus is late—but the grand pattern rarely changes. The sun rises and sets. We get up, go to work, retire to bed. The ponderous wheel of life turns inexorably down the road to our uncertain futures.

For some people the stability of life is drudgery. For them, the daily routine carves an intolerable rut, the fixed patterns growing predictable, boring. I, too, once dreaded the ordinary cycles of life. A major motivation for enduring surgical residencies lies in the avoidance of a nine-to-five existence. But as a physician, I learned to pray that my todays will be like my yesterdays, that my orbit remains stable and my wheel of life stays a true course. I pray that I will go home as I have gone home a hundred times in the past, to find my wife and children safe, my parents alive, my house in one piece, my paycheck forthcoming.

I have seen too many patients whose ordinary lives detonated in an instant because of the unexpected: auto accidents, brain hemorrhages, heart attacks. People who awakened to face just one more boring day, and instead found the wheels of their lives careening into the darkness.

There was such a day for Sarah Clarke, age twenty-eight, homemaker, wife of a successful black businessman, and expectant mother of her first child. While preparing dinner in her elegant suburban home, she was startled by an abrupt twitching in her right hand. Her spatula jerked rhythmically out of control. Before she could even become alarmed or cry out, her vision blurred and the room spun violently. She dropped to her knees, then collapsed to the floor in a generalized seizure. The convulsions soon stopped, leaving her stuporous on the floor amid the spilled cake batter and broken cookware. An hour passed before her husband discovered her and had her rushed to the local obstetrical hospital.

At first, no one was sure what had happened. “She just passed out, I think…maybe from the heat in the kitchen,” came the reassuring words of the obstetrician, who further declared the pregnancy in no jeopardy. Such fainting is not uncommon in the first trimester, he observed. Before Sarah could be discharged, however, the seizures returned, first in her right hand and then spreading like a wave to involve her entire body, twisting her trunk in grotesque, violent paroxysms. But this time, the convulsions did not stop until Valium and phenobarbital were given intravenously. The obstetrician, now as alarmed and bewildered as her husband, ordered Sarah transported to the university center—to our neurosurgery service.

As next in line to become chief, I was summoned from my laboratory year to sub for the current chief resident, who had broken his wrist. My first day back on the clinical service, the junior resident paged me to the neuroradiology reading room to help him review a scan on a young black woman. I joined him in the darkened room and we gazed together at the images on the view boxes.

A dark blotch stained her left frontal lobe, an oval hole punched out of the brain tissue. On the enhanced scan, taken after the infusion of intravenous iodine dye, a few areas of white showed up within the ebony hole. Dye cannot enter normal brain tissue, unable to penetrate the chemical shield which protects the delicate brain from all but the most essential nutrients. Portions of the brain where the barrier is destroyed, due to infection, trauma, or tumor, “enhance” by turning white on the CT images.

“Uh-oh,” I said, noting the enhancing areas, “looks like trouble for this lady.”

“Where? Show me,” the junior peered closer.

“There”—I pointed to the small lesion with my reflex hammer—”in the left frontal area. It isn’t big, maybe two centimeters, but with some areas of enhancement. Definitely a glial tumor, either astrocytoma or oligo. Could be low-grade, but that enhancement is worrisome. Malignant degeneration may be occurring…Let me guess, she came in with a focal seizure, her hand twitched for a minute and stopped. Am I right? This lesion is too small to give her headaches or weakness, but it’s smack in the center of her hand region.”

“Close. The seizure did start in the hand, but became generalized. She was found down in her kitchen, woke up, and was taken to Women’s Hospital, where they…”

“Women’s Hospital?”

“Yeah, she’s pregnant. First trimester…Anyway, to continue, they thought she just fainted, since there were no witnesses, until she started flopping again. Needless to say, the OB guys shit their pants and shipped her here.”

“Pregnant. Wonderful. Simply wonderful.”

“What do we do now, O mighty acting chief?”

“Put her on Sakren’s service.”

“He’s not on call.”

“I know that. But he does the stereotactic biopsies, remember? The only safe approach to this thing is with a needle. An open approach would go right through Broca’s area. She’d end up without her speech. No lullabies for junior that way. If there is a junior.” The speech area of the left frontal lobe is named for Pierre Broca, the nineteenth-century French clinician who first associated left frontal-lobe tumors and aphasia.

“Do you think she’ll lose the pregnancy?”

“I don’t know…probably. While there is nothing about these tumors directly that prevents a normal pregnancy, she may not live six or seven more months without treatment. And I doubt that we could give treatment to a woman who’s in her first trimester. She’ll need radiotherapy, at least six thousand rads, and you can’t shield the fetus from that. At least I don’t think so; we’d have to ask the physicists—this problem has never come up before. Chemo might help, but you aren’t going to give that to a pregnant woman, either. They don’t even let them drink coffee anymore, for Christ’s sake. How are we going to blast her with nitrosourea or platinum? She may have to choose between not surviving until her due date and having a therapeutic abortion. There are your choices, ma’am. Have a nice day! I’ll go and talk to her. Just think, I gave up dealing with laboratory rats for this.”

Sarah was a stunningly beautiful woman, endowed with soft hazel eyes that rode the crests of her high cheekbones. She sat upright in her hospital bed as I entered. Her dapper, well-manicured husband, James, sat in a chair at her side. Although still groggy from the anti-seizure drugs, she managed a smile. The seizure had passed.

“Well, Doctor,” she began in a soft, almost apologetic tone, “I guess I’m an epileptic now.”

“I prefer to think of it as ‘seizure disorder,’ and, yes, you do officially have a seizure disorder.”

“Why? What’s happening to me?”

“Mrs. Clarke, anyone can have a seizure. Some people just have a lower threshold for seizures, that’s all. The threshold can be lowered by sleep deprivation, drugs, overexertion…or, in your case, a blemish on the brain.”

“Blemish? Is that a diplomatic way of saying that I have a brain tumor?”

The comment surprised me. Many patients won’t utter the word “tumor,” even months after their diagnosis.

“Well, you see…” I began to flounder, my carefully planned buildup derailed by the patient’s abruptness.

“It’s all right.” She forced a smile again, sensing my shock. “I heard the technicians mumbling something about a brain tumor…they thought I was asleep, but I just had my eyes closed.”

I gathered myself. “Yes, you may have a brain tumor, but a scan is not diagnostic of anything. It simply suggests what might be there. We will need to obtain a sample of the abnormal tissue and have the pathologists analyze it…It could be an abscess, or…or something else altogether.” I didn’t sound very convincing.

“What else could it be?” The husband’s deep baritone pierced the room.

He had outmaneuvered me. I had to tell them the truth. I sat down and pulled my chair closer. “In all honesty, it is almost certainly some form of tumor. Yes, I guess benign infection or some weird stroke are still possibilities, but they would be long shots. Despite that, we still need tissue samples. There are several different types of tumor that occur in the brains of adults, ranging from pretty good to really, really bad.”

“So,” James continued, “we’re talking brain surgery.”

“Yes, but a small brain operation. We won’t shave very much hair, and it’s done under local anesthesia using a special metal frame that is placed on your head. It takes about an hour and is very safe, although all brain surgery carries some risk.”

Sarah spoke up. “Why don’t you just cut the whole thing out, get rid of it? Won’t that make the seizures stop?”

“Mrs. Clarke, your tumor is right here.” I pointed to her left temple. “Are you right-handed?” She nodded. “Then your speech center lies just over this ‘blemish,’ and cutting into that area and trying to remove it all would carry too great a risk to your speech.”

They sat in stunned silence for a few minutes, holding each other’s hands in a kneading grip that reflected their internalized anxiety. Sarah broke the interlude with her frail voice.

“You do know that I’m pregnant?”

“Thirteen weeks, according to the ER sheet,” I replied.

“Will the surgery affect my baby? Or the tumor, or the seizures?”

“The surgery should not affect your child, especially since it will be done without general anesthetic drugs. The seizures likewise should have little effect, as long as you remain controlled on drugs like phenobarbital that are reasonably safe for the fetus. The tumor…well, the tumor is another matter. It all depends upon what it is and what treatments you may need. Some treatments are just not possible in a pregnant woman. I can see no reason why the tumor would harm the fetus, but our therapies most definitely will. You may need a therapeutic abortion.”

Sarah turned her eyes toward me and gave me a look of iron conviction. “Jesus is my Savior,” she intoned slowly, “and I believe He will let me keep my child. We’ve been trying for three years to get pregnant. So do your biopsy, but spare me the details of your ‘treatments.’ I will keep this baby. Please, I don’t want to be mean, but leave us alone for a while.”

The husband produced a Bible and read silently as I stole away from the room.

Dr. Sakren served as our “stereotactic” specialist. Stereotaxis is the art of placing biopsy needles and other customized tools precisely into the brain’s depths, using an awkward, expensive device known as a stereotactic frame. Before the widespread use of stereotactic techniques in the 1980s, tumors situated below the brain’s surface were biopsied “freehand,” with the surgeon’s intuition as the only guide to the tumor’s location. The surgeon might cut a large craniotomy flap over the suspected tumor site and take an educated guess as to where the lesion might be, often attempting a dozen or more blind needle aspirates before either achieving a positive diagnosis or abandoning the procedure altogether. “Freehanded” brain-poking carries a high likelihood of missing the tumor completely, and, worse, a significant risk of catastrophic bleeding.

Nowadays, to perform a stereotactic tumor biospy, the surgeon bolts the aluminum stereotactic frame to the patient’s skull under local anesthesia and then takes the patient to the CT scanner. Brain and frame are imaged together so that brain lesions can be cross-referenced with the frame’s centimeter markings. Because the frame is held in place by graphite pins drilled into the skull’s outer layer of bone, the correlation of the frame’s markings with the internal structures of the head remains exact. The position of a brain tumor relative to the metal frame cannot change, even as the patient jostles from operating room to CT scanner and back again. Such accuracy could never be maintained with more civilized means of attaching the frame to the head (with Velcro chin straps, for example).

After the scan, the surgeon chooses a biopsy point on the scanner’s video screen, using a light pen, cursor, or computer mouse. In Sarah’s case, our target would be one of the enhancing areas within her left frontal lobe. The scanner’s onboard computer provides coordinates of the biopsy point relative to the frame’s markings. Back in the operating room, a metal arm guides the biopsy needle to the target designated by the computer-generated coordinates. Because of the precision of this method, the biopsy requires a scalp incision and skull opening just large enough to admit the biopsy needle (less than half an inch). Since only one or two passes of the needle are needed, the chances of injuring the brain with this method approach nil.

As valuable as stereotaxis has proven, their neurosurgical peers view biopsy surgeons as wimps—surgeons who do tiny operations because they lack the skill or stomach for “real” brain surgery. Stereotactic surgeons are the field-goal kickers of our specialty: skilled, well paid, and thoroughly indispensable on select occasions, but not true players in the eyes of the more violent members of the team.

I presented the case of Sarah Clarke to Sakren the day after her first seizures. He looked at her scan with a squint. “So she wants to keep her baby. Fine, we’ll see what happens. But I know the type. ‘God wants me to live, He has a special purpose for me.’ If God wanted you to live He would not deposit a malignant glioma into your dominant frontal lobe. Personally, I think she should just get an abortion preoperatively and be done with it. What do you think?”

“I think I wouldn’t waste my breath asking her to consider an abortion. I can tell you the answer to that question right now.”

I had seen the answer in her eyes and heard it in the tone of her voice. Sarah would keep her baby, no matter what. Jesus, and her own iron will, would see to it.

Cancer patients are told to direct anger at their tumors, to “fight” the disease as they would fight some evil, hateful enemy determined to rob them of all that is precious. A useful technique clinically, perhaps, but the emotional colorations should not be taken literally. Cancer is not evil, not the enemy. Cancer is a biological process which has evolved for a very useful purpose: to kill us.

Although we look at ourselves as organisms, we are really societies comprised of trillions of specialized cells—blood cells, nerve cells, muscle cells, gland cells—cells which behave in accordance with communal laws developed for the good of the society. We are like giant hives and our microscopic cells the bees and wasps within.

In any society, certain individuals choose to ignore the societal constraints and march to their own drummers. Likewise, in our own bodies, rogue cells arise which do not respond to the laws regulating their growth. These aberrant cells divide endlessly, creating dysfunctional masses of tissue which compress other organs and commandeer nutrients. The cells escape their normal habitats and metastasize to other parts of the body. Like human miscreants, misbehaving cells have little regard for the society in which they live and will destroy it if given the chance. Indeed, cancer evolved for precisely this reason—to destroy the host.

Cells which grow beyond their normally defined limits are neoplastic; neoplastic cells which invade and destroy tissue, or which detach and spread to other parts of the body, are cancerous. While all cancers are neoplasia, not all neoplasias are cancerous. For example, common warts are neoplastic, but not cancerous.

Most of the scourges of aging arise from neoplasia. In addition to cancers, male prostatism, eye cataracts, degenerative arthritis, and atherosclerosis (hardening of the arteries) result from unchecked proliferation of normal tissues. Even dementing brain illnesses, such as Alzheimer’s disease, stem from neoplastic overgrowth of brain cells called astrocytes. As our cellular society grows senescent, neoplastic behavior becomes rampant until our bodies fall, like ancient Rome, into anarchy and ruin. Ubiquitous in the elderly, neoplasia is more a form of planned obsolescence than a disease.

To understand cancer’s role in evolution, we must remember that we are built to die. Just as automobiles roll off the assembly line with a predetermined lifespan, the fertilized ovum programs us to decay and perish in an immutable sequence.

The long-term viability of multicellular creatures on this planet demands that each generation enjoy its finite day in the sun and then be thrown from life’s stage to make way for a new cast of players. A continuous turnover of organisms, with mixing and mutations of genes occurring in each new generation, gives life flexibility to survive a wide range of climate shifts. There is no biological reason why we could not be immortal. Indeed, we form the tail end of an unbroken chain of protoplasm, five billion years long. However, immortal species would have to stop replicating, else they would smother themselves.

Nature chose not to populate the earth with static, immortal species. To do so would place all of life’s genetic eggs in one basket, running the very real risk that some drastic geological event could wipe out all life on earth. To prevent this, the gene pool must be in constant flux, changing at a rate fast enough to keep pace with any environmental perturbations that might arise. Thus, all things must die. Death is not a flaw, a failure of biology, but an essential design feature for constant existence on an inconstant earth. Our downward spiral from youth to old age, like the upward spiral from fertilized ovum to developed infant, is stamped into our genetic code.

The wheel of life: one generation rises like summer wheat, then withers and falls to seed. The wheel turns—birth, youth, adulthood, parenthood, senescence, death—driven by genetic machinery set in motion so many eons ago. For all its subtleties and infinite beauty, life has but one purpose: to keep the wheel turning. Turning without the least regard for individuals, species, or ecosystems. The destination of the living wheel as it travels through geological time is unknown, perhaps not even important to us. Yes, each generation grows infinitesimally better than the one before it, but better at just a single thing: keeping the wheel moving. The vibrant colors of a bird’s plumage, the complexity of a spider’s web, the grace of a hunting lioness—all are variations on the single theme of birth, procreation, and death. Adapt, be ready, survive.

For those lucky enough to escape death by predators or accidents, neoplasia in one of its many forms—cancer, dementia, heart attack—will come, a message that all individuals, no matter how worthy they may seem, must give way to the next generation. Regardless of how cautiously we live, our arteries will eventually clog with hardened tissue, our minds grow weak from excessive brain astrocytes, our eyes dim from corneal overgrowths, our organs fill with malignant growths. This is as it should be. Biology doesn’t consider these diseases enemies, just as General Motors does not consider rust a flaw. Decay is a necessary process for any business dealing in renewable goods.

We cannot accept our personal dispensability in this scheme. Cancer may be a threat to us individually, but poses no threat to our species. The vast majority of those afflicted by neoplasia are far beyond child-bearing, or even child-rearing, age. Moreover, cancer is a uniquely human affliction. Animals in the wild rarely survive long enough to suffer the neoplastic illnesses of senescence. The same was true of homo sapiens prior to the advent of civilization. A death at eighty from colon cancer would have been a worthy goal for cavemen daily pitted against mammoths and saber-toothed tigers.

Scientists and spiritualists who insist that our bodies harbor some hidden potential to conquer all cancers ignore the trivial effect cancer exerts on our species. Nature does not care if I get cancer, since the wheel of humanity will turn just fine without me. Biology could have easily endowed me with a foolproof method of defeating cancer. And a tire company could make a tire that lasts for a million miles. The awful truth is that neither nature nor a tire company has any motivation to provide unreasonable longevity.

So Sakren, in essence, was right. Whatever entity, divine or earthly, deposits malignant brain tumors into our heads does so not to test our resolve, to challenge our faith, or to prove our strength, but to make us die. This does not mean that we should not use our intellects to prevent this fate when we can. Such is the very business of the medical arts. Nature discards individuals; surgeons do not. Let nature worry about the species; we must care for individuals one at a time.

At this moment, the individual in question (individual plus one-quarter?) was Sarah Clarke. Her biopsy confirmed the presence of a malignant mixed glioma, a small lump of cancerous cells that were to become grains of sand binding up the gears of Sarah’s reason. Over time, her mind’s clockwork would slowly grind to a halt. Would she let us throw our backs into her wheel of life and push it further along? Would she let us try to extend her life?

“No way.” Linda, the university’s chief radiation physicist, shook her head vehemently. We were discussing Sarah. “I’ve done some preliminary calculations and, even with the most coned-down fields and maximal shielding, the scattered dose to the fetus is unacceptable. Third trimester, maybe, but even then there is the liability issue. There is no way we can deliver any meaningful amount of radiotherapy to this tumor unless the pregnancy is terminated. Period.”

“What liability problem is there in treating her in the third trimester?” I asked. “I would think that a fully formed child should be able to tolerate the small amount of radiation that would leak through the abdominal shielding.”

“Medically, none. There really isn’t even that substantial a risk in the first trimester, either, but try and tell that to a jury. There have been some goofy cases which have produced milliondollar malpractice awards. In Texas, a child is born without a leg and the mother’s lawyer successfully argues that an inadvertent occupational exposure to radiation in the ninth month was responsible. You don’t have to be too sophisticated in embryology to know that the legs are fully formed in the ninth month of pregnancy and that whatever caused this child to be born with only one leg must have occurred in the first trimester or in the fertilized ovum itself. Yet they bring this little crippled child into the courtroom, sit her in the arms of her crying mother while some expert waves his arms and says that magic word ‘radiation,’ and the jury gives the kid seven million dollars. Add in the fact that the statute of limitations in children doesn’t run out until they are over eighteen, and our department will assume responsibility for the baby Clarke forever if we treat this woman. If the baby doesn’t get accepted into the college of its choice, it can come back and sue us for brain damage. No thanks. If the patient aborts, we’ll do it. Otherwise, forget it.”

Sakren ran his fingers through his thinning hair. “Goddamned lawyers.” A phrase repeated almost daily by neurosurgeons across the country. Lawyers have pretty much determined when we should scan people, when we should operate upon them, and how much better we should make them. To believe that legal issues don’t alter the practice of medicine is to know nothing about the practice of medicine in the late twentieth century.

The radiation risk to Sarah’s fetus derived as much from the fear of litigation as from tumor biology. Because a fetus is a blank slate, almost any jury award can be conjured up for a pregnancy gone bad. Sarah’s unborn child represented a financial burden that no one wished to bear.

Sakren approached the Clarkes about the refusal of the radiation oncologists to give Sarah radiotherapy. “With radiation therapy, you have maybe a one in ten chance of living five years or longer. Not great, but people waste hundreds of dollars a year on much longer odds in the state lottery. Without it, on the other hand, the median survival is only about three to five months, which means you have a ‘50 percent or greater chance of not carrying the baby to term. I recommend a therapeutic abortion be performed and radiation therapy commenced immediately thereafter.”

Sarah’s face became serene granite. “I am not a statistic, doctor. I’m not interested in odds. I will not abort my baby.”

Sakren’s irritation grew. The surgeon turned to her husband. “For God’s sake, man, talk to her. If she was my wife, I know what decision I would urge her to make. I wouldn’t want to lose her.”

James Clarke was unmoved. “Don’t talk to us about what we should do or not do ‘for God’s sake.’ My wife has made her decision. She’s in the Savior’s hands, not yours.”

“The Savior’s hands didn’t do this”—Sakren laid his finger on the small wound on Sarah’s left temple—“mine did. And I’m telling you that she needs to have some therapy if she is to have any chance at all of surviving the next six months! I’ve been in this business for twelve years, and I haven’t seen Jesus come and lift one of these things out of a head yet.”

“Doctor,” Sarah said calmly, “we’re telling you that I will not have an abortion. What Jesus does to my head is not important, but what I do to my child is. So you might as well send me home now. I’ll have no further therapy.”

Sakren frowned. “Frank, get a serum phenobarbital level on Mrs. Clarke today and discharge her on a Decadron taper. If she’s forgoing therapy and wants to save her baby, we might as well get her off the steroids, too. Have her come back in one week to have her sutures removed. To residents’ clinic.”

“Residents’ clinic?” I asked.

“Yes, residents’ clinic. There is nothing more I can offer her now.” Residents’ clinic was the dumping ground of patients the staff surgeons no longer wished to follow in their private offices. Although technically overseen by the attendings, the care was relegated to residents.


“Residents’ clinic is fine with us,” James said.

Sakren hustled from the room. I cast an embarrassed look at the Clarkes. “He’s a little high-strung, I guess.”

“Don’t make excuses for the man, son,” James admonished me. “He has his views, we have ours.”

“Do you want to die, Mrs. Clarke?”

“No, I want to have this child.” The tears welled in her eyes, the first I had seen. “When you first came in,” she continued after a pause, “you said these tumors could be either pretty good or very, very bad. Where does a malignant mixed glioma fit in?”

“Somewhere in between.”

“How much in between?”

“Well…drop one ‘very’ in the ‘very, very bad’ category.”

“Fair enough. Fair enough.”

Two days after her biopsy, Sarah went home. The race was on. Which would grow faster, fetus or glioma?

Cancers and embryos are kindred spirits, both composed of highly mobile cells dividing at full throttle. A fertilized ovum changes from a single cell to a miniature human body in a matter of weeks. During this period of high-speed construction, cells migrate freely from one region of the embryo to another as complex organs are assembled from amorphous cell clusters. The ability of cancerous cells to metastasize to distant sites is a throwback to the migratory properties of embryonic cells.

The similarity of cancer cells to embryonic cells goes deeper than a simple capacity to migrate. Proteins and hormones produced in fetal tissues suddenly reappear in cancerous tissues of adults. Carcinoembryonic antigen, a protein normally present only in fetal colons, resurfaces in adult colon cancers; a serum test for this protein allows early detection of the disease. Mechanistically, cancer results not from the degeneration of adult tissues into decrepit forms but from their regression into juvenile forms.

Cancer cells relive the heyday of their fetal youths, chucking the staid responsibilities of mature tissues and reverting to the time when they could grow and travel as they pleased. In this way, cancer reflects a symmetry of life. From dust we came and to dust we shall return. The cancer patient ends life as she began it: an amorphous mass of nomadic cells.

While adult tumors arise from differentiated cells lapsing retrograde into prenatal behavior, pediatric tumors arise from islands of embryonic tissue which never matured in the first place. These ‘“Peter Pan” cells won’t grow up, acting like embryonic tissue even after birth. Rebecca’s PNET was one example of a Peter Pan tumor. Composed of refractory fetal-nerve cells, the PNET endlessly tries to build a new cerebellum—ignorant of the fact that the job has already been completed. The child with a PNET is literally born with brain cancer. The fetal nature of these tumors explains why they are so refractory to treatment. Fetal cells have a mission: to create a child. Their drive to complete this mission is so strong that only killing the patient will stop them. The wheel must turn.

Because of their similarities, cancerous and fetal tissues are both susceptible to anticancer treatments directed against dividing cells. As such, a cancer patient’s decision to abort her child lies beyond the scope of ethical debates about pregnancy termination. No one would have blamed Sarah for aborting her child—no one, perhaps, but herself. Whether she based her decision on her religious views regarding abortion or on her desire to see her child before she died, I didn’t know.

As her clinic visits progressed, a terrible thing became apparent: the tumor was winning the battle.

• • •

I continued to follow Sarah; even residents in the lab have to go to residents’ clinic. Two months after her biospy, a follow-up scan revealed a larger, angrier mass in Sarah’s left brain. She grew clumsy with her right hand and made frequent mistakes with her speech and handwriting. Her arithmetic deteriorated to the point where James took over the family finances. Although he had an M.B.A., she had managed the home budget during their five years of marriage and the forced abdication of this job depressed her immensely.

“James won’t let me…write…the gardens,” she said haltingly.

“The gardens, Mrs. Clarke?” I asked.

“Yes.” She produced a checkbook from her purse. “The gardens…these, he won’t let me…write on them, the gardens, again.” The checks were imprinted with a floral pattern.

“He won’t let you write checks?”

She nodded vigorously. James stood in the background and never intervened to correct his wife’s speech. This may have been denial, or the refusal to embarrass her by publicly acknowledging her obvious decline. Perhaps by living with her he was able to understand her perfectly, and so perceived no need for making translations.

“Do you have headaches?”

“A little time, small…knocks,” she answered, “my head…uh…knocks…a little time at the morning once…only.”

“Uh-huh. How’s the baby?”

She smiled, the right corner of her full mouth lagging slightly. “Yes!” The single word spoke volumes.

“Then everything’s all right as far as the baby’s concerned?”

James spoke.’ ‘We were at the obstetrician’s last week. Everything’s on schedule.” I thought of the progressing scan; some things were ahead of schedule.

“The scan shows some worsening edema, Mrs. Clarke. I think we’re going to have to put you on some steroids again.”

Her smile evaporated.

“How gone worse my head?”

“I think steroids will help. They will help your speech, too.”

I prescribed a low dose of Decadron. During the next week, her speech came back to normal, her right arm became fully functional, and her headaches eased. Sarah and James hailed me as a miracle worker. But in my mind, I knew I was dealing with Mephistopheles again. Just as I had bargained with epinephrine to keep B.G with a Teflon heart alive years earlier, I now sold my soul to Decadron. Like epinephrine, steroids are miracle drugs with a price. They give you the result you want now, exacting their pound of flesh later. With epinephrine, the pound of flesh is taken in kidneys and limbs rendered dead from lack of blood. With steroids, the long-term toll is obesity, diabetes, poor wound healing, muscle wasting, and osteoporosis.

Like B.G. McKenna, Sarah left me with no choice. Decadron was the only agent that could be used safely. Whether it could carry her all the way to her due date in four months remained to be seen.

Months passed. Each week Sarah’s speech and headaches worsened, prompting me to go up on her Decadron. The combined effects of her pregnancy and escalating Decadron turned her once lithe body into an obese pear. She became an insulindependent diabetic. Her face became bloated and round, her chiseled features obscured. An acne-like rash covered her cheeks and back; her hair became sparse and brittle. The skin on her hands and forearms became thin and bruised, peeling away to form chronic ulcers. She came to her office visits in a wheelchair, her steroid-sapped legs unable to support her expanding girth. I found it difficult to think of her as the person she once was. The complications of her steroid use were profound, more profound than I would have expected from the doses I’d prescribed.

Despite their terrible side effects, the steroids grew less and less effective. Her stuttering speech gave way to “word salads,” and, finally, to incomprehensible gibberish. The weakness in her right arm became paralysis. Her pregnant belly grew large as her steroid-atrophied limbs withered. Her body was now being devoured from both ends by two parasites—a cancer and a fetus—each with a mandate to pick her bones clean for their own survival. Obstetricians instruct expectant mothers to take vitamins, but for themselves, not for their unborn children. The fetus will take what it needs and the mother’s metabolism will gladly yield it all. Cancer is equally voracious. Sarah was fighting a war on two fronts, and the battle would soon be lost.

I had hoped that the tumor would grow as a spherical mass and that we would be able to give Sarah radiotherapy once she was into her third trimester. Or that we would be able to extend her survival by surgical resecting the tumor once her speech had become so impaired that surgery could not worsen it further. Unfortunately, the cancer refused to cooperate. True to its name, the crab crawled sideways into her cerebral ventricles and spilled into her CSF. Once in her spinal fluid, malignant cells floated to her brain stem and spinal cord.

She presented one evening to Women’s Hospital with intractable vomiting. The obstetricians contacted me immediately, since, at almost eight months of gestation, she was too far along in her pregnancy for her impending motherhood to be the likely cause. The OB/GYN resident in the ER gave me an ominous bit of history over the phone: “Her husband says she just throws up without warning, without any nausea at all.” I recognized this as “brain stem” vomiting due to the tumor’s invading an area of the brain stem known as the area postrema—the vomit center. Brain stem vomiting, unaccompanied as it is by nausea, causes considerable embarrassment for the patient. She may be feeling fine one minute and abruptly spewing vomit onto an unsuspecting victim the next. Brain stem vomiting is horrific in two other respects: It is often impossible to relieve, and the patient rarely survives for more than a few weeks after its onset.

The ER resident at Women’s asked if we wanted her transferred to our service. I said no. The time was approaching when Sarah’s baby would have to be removed, ready or not. Sarah was already where she needed to be, where she would have asked to be if she could still speak. Not the best place for her, perhaps, but the best place for her child.

I went to see Sarah on the obstetrics ward. She was awake, but mute. Her right-side paralysis was now complete; it involved the face and leg as well as the arm. A feeding nasogastric tube jutted from her nose. She looked down, slowing rubbing her large abdomen with her left arm as I walked into the room. I approached the bed and she looked up at me with a blank face, then looked down again. Her husband stood up from his chair and motioned me to exit the room with him.

“They are feeding her by tube, but she still vomits a lot,” James began. “They tried antinausea drugs, but nothing works. The doctors say that if she keeps vomiting, they will take the baby by C-section this week. She’s now about thirty-six weeks and they think it’s safer to deliver now than to let the pregnancy go with the persistent vomiting. She’s also having a lot of problems with her blood pressure and blood sugars, too. And she may have a phlebitis in her right leg, and they can’t treat that. She could have a clot go to her lung at any time and we could lose them both…” He bit his lip and tears filled his eyes.

Inanely, I tried to steer the conversation away from death. “She certainly developed a lot of steroid problems.”

James’s sullen expression turned sheepish. “Well…I have a confession to make. For a few months we doubled the dose of Decadron without telling anyone.”

“How could you do that? The prescriptions were for a set number of pills.”

“We got more from our family doctor and from the obstetricians. We told them that we lost your prescriptions and couldn’t reach you or Dr. Sakren.”


“Sarah wanted to make a series of videotapes for the baby. She taped twenty-one messages—one for each birthday until age eighteen, and special ones for when he graduates from high school and college and for when he gets married.”


“An ultrasound showed that it was a boy…Anyway, to do this, to make all of the tapes, she wanted her speech to be as clear as possible for a month or two until she finished. She wouldn’t let me see any of the tapes, so I couldn’t help her in any way. She would take fistfuls of pills at a time just so that she could get a few sentences out. Sometimes she would vomit them up. Once we drove to Ohio and went to an ER pretending we were on a trip and needed a refill of steroids, just to get more. Who was going to question us? The tapes are done and in our lawyer’s possession. He has instructions to release them at the appropriate times.”

“She’s a strong lady.”

“Too damned strong. I lie awake at night and wonder if we have done the right thing. Lord Jesus, what am I going to do with a baby and without her? What am I going to do? After the baby is delivered, isn’t there anything you can do for her? Can’t we go ahead with the radiation therapy then?”

“We’ve discussed this already, Mr. Clarke. The tumor is lining the ventricles and wrapping around the lower brain stem. It may even be in her spine…in fact, I would be surprised if it wasn’t. Radiotherapy would be cruel at this point.”

He nodded, wiping away the few tears that escaped his brimming eyes.

The following day, Sarah had a seizure which lasted for an hour before it could be controlled. That evening, she was taken to the OR.

I saw Sarah one last time, four days after her Cesarean section. She subsisted now on intravenous fluids, and her consciousness waned. As I stood beside her bed, a nurse brought in the five-pound, seven-ounce James Junior, who was the picture of newborn health. The squirming bundle rested in her good arm. Sarah gazed down upon the infant with wide eyes, her mute stare betraying no emotion. After a minute or so, she turned her head away and closed her eyes. I could almost see her will to live exit her body, and I half expected to hear her voice return for one last, Christ-like phrase: “It is finished.”

There, in a small room, in a small hospital, in a small city, I witnessed the great wheel of life grind through another revolution of renewal. Parent and offspring had fulfilled their destinies; the tumor would soon fulfill its own.

Did Sarah have enough of her cognition left to appreciate her child during the few days that she had remaining? I didn’t know. I hoped that the ultimate irony was not true, that deep within she rejoiced over her victory in the race of a lifetime.

One week after the birth of her son, social services performed a transfer that they hoped never to make again. They moved Sarah from the maternity ward to a cancer hospice. The steroids—the drugs which she had sought like a heroin addict looking for a fix, the drugs which had bought her enough time to make a video legacy for the son who would not remember her otherwise—were withdrawn.

Years have passed since Sarah’s death. I visited her grave to read the epitaph one last time:




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