"I'll bet."
"Anyway," Rob said, "that's what he says now. He says he feels fine, but his wife says his appetite is poor. He's lost almost ten pounds, and she says he's also short of breath."
"He's here now?"
"Yes. I started him because you were tied up, but Carrie says you're clear now so I thought you should look him over and talk with him. He's pretty nervous."
"They all are."
"This guy's really scared. His wife's upset, too, and I judge they came here expecting to see you."
"How far have you gotten with him?"
"I've got all his history. Everything seems all right except for the chief complaint. His pulse is strong and a little fast, probably because of the nervousness, but his temperature is normal and his blood pressure is okay."
Mr. Scheller, stripped to his shorts, was sitting on the examining table. He was about five feet eleven, pale and lean, his graying, straight, light brown hair receding at the temples and thinning on top.
"Mr. Scheller," Bob Robinson said, "this is Dr. Carter."
"Oh," Mr. Scheller said, getting off the table and putting out his hand. "Hello, Doctor."
"Hello," he said, taking Mr. Scheller's hand. "How are you?"
"Oh, I don't know," Mr. Scheller said. "I don't feel too bad."
"Good," he said. "Then I wouldn't worry too much. Too many of us worry about nothing."
He's nervous all right, he was thinking. His hand wasn't damp and cold like most of them but he can't look at me.
"Excuse me," Bob Robinson said. "I'll go out and talk with Mrs. Scheller for a few minutes."
"Fine," he said, and then to Mr. Scheller: "Just stand here relaxed. I just want to turn you around a little and look you over."
He was starting the search now, the systemic review. It would not end until six days later, when he opened Mr. Scheller on the operating table, but he was looking now for every clue to that shadow in the X-rays, for any indication of its spread and for any sign that might identify Mr. Scheller as an operative risk.
"You've got a pretty good build," he said, trying to relax Mr. Scheller. "You've kept yourself in pretty good shape."
"Well, I work hard," Mr. Scheller said.
Rob said he's a house painter, he was thinking, and that's why his flexors and extensors in his right forearm are more developed than in the left. That goes for his biceps and triceps and for the whole shoulder girdle on the right side, too.
"What business are you in?" he said.
He was feeling the trapezius, the shrugging muscle in the shoulder. He was searching for any metastasis, or spread, of a cancer to the spinal accessory nerve. The spinal accessory, or eleventh cranial, nerve is affixed to, and motivates, the trapezius muscle, and when the nerve is affected the muscle atrophies. Now the trapezius, on the right side as well as the left, felt solid but still supple under his fingers.
"I'm a painter," Mr. Scheller was saying.
He is perspiring at that, he was thinking, but more on that left side than the right. He's actually sweating plenty under the left arm but not much under the right and I'll bet the sympathetic nerve chain on the right is invaded by cancer. That's why his right palm was dry when we shook hands before, and if that's it, if the cancer is not only in the lung but has spread up there far enough to knock out his sympathetic nerve chain there isn't anything I can do to help this poor man.
"So you're a painter?" he said, feeling now for verification in the lymph nodes over the sympathetic chain low on the right side of Mr. Scheller's neck. "How long have you been in the business?"
When he was a younger surgeon, and before the neurosurgeons took over the management of high blood pressure, he occasionally operated for it. When portions of the sympathetic nervous system are removed the blood vessels open and reduce the pressure and it so happened that a couple of his patients were salesmen who were delighted with the unexpected bonus. They had been embarrassed, and had felt handicapped, by their cold-clammy handshakes when they met customers and now, although they overperspired on the left side, their right hands were dry.
"In the painting business?" Mr. Scheller said now. "Too many years. Since I'm eighteen."
On the basis of this experience he had once won a bottle of brandy from another young surgeon named Pete Vilella at the state tuberculosis sanitarium. The patient's X-rays had shown a shadow high in the apex of the right lung and, because the sputum studies had been negative for tuberculosis and there was no significant pain, Vilella had diagnosed it as an old, healed TB scar, while he had held out for cancer.
"You know what you're doing, don't you?" Vilella had said, while they were scrubbing in for the operation. "You're operating for an old, healed TB scar."
"I'll make you a bet," he had said.
"Okay," Vilella had said. "A bottle of Martell."
"That's a bet," he had said.
He had not told Vilella that, two days before, he had sat the patient down in a warm room and had played an infra-red lamp on his face. After fifteen minutes, when the patient was sweating only on the left side of his face and not on the right, he had known for sure that it was cancer that had invaded the right sympathetic nerve chain. He didn't tell Vilella, in fact, until after they had opened the patient and found the cancer, and Vilella had delivered the Martell and they were having a drink together. Considering how he had been trapped, Vilella had taken it quite well.
"How did you get to be a painter?" he said to Mr. Scheller now. He had instinctively, as he felt for the nodes, let his gaze over Mr. Scheller's shoulder drift to infinity so that he would not be distracted by visual impulses and could better concentrate with his fingers, and yet he was unable, probing, to feel them, cancerous and hard and like peanuts under the skin.
"My father was a painter," Mr. Scheller said. "I learned it from him."
"Good," he said. "will you just turn and look toward that light over there?"
The pupil in the right eye is smaller than the left, he was thinking now, so it's got to be the sympathetic chain. It's strange that I couldn't feel those nodes.
"Then I guess you really know the painting business," he said.
"I know the business all right," Mr. Scheller said.
"I just want to take a closer look at you here now," he said.
He was examining the skin on the neck just above the right collar bone now, and he saw it. It was an old, small, hairline scar, not more than a half-inch in length and hidden right in a natural skin fold.
"You've got a little scar in yom neck," he said, thinking: So that's it; so a stabbing knocked out that chain and the nodes are clean. "Where did you get that?"
"Oh, that?" Mr. Scheller said. "I got that when I was a kid."
"How?"
"Oh, you know. Fooling around. I was fooling around with a pen knife with another kid and I fell on it. A doctor sewed it up in his office."
He's luckier than he knows, he was thinking. He hasn't any idea how lucky he is.
"But surely you must have noticed that you don't perspire on the right side, under the arm and in the hand, like you do on the left."
"That's right," Mr. Scheller said, "but I don't even think of it. I mean, that must have been forty years ago, and I don't ever think of it any more."
"Good, We get accustomed to little things like that."
He was moving his left hand, flat, over Mr. Scheller's left chest, tapping the middle phalanx between the first two joints of his middle finger with the tip of the middle finger of his right hand. When, in medical school, he had first learned to percuss, to distinguish the different shadings of sound, he used to lie in bed at night and tap out the borders of his own heart.
"I never even think of it," Mr. Scheller said.
When he worked under Pete Church they used to percuss a patient before they looked at the X-rays. Then they would compare their separate findings and their diagnoses before they checked them against the pictures for verification.
"Just take a deep breath,"
he said, "and then let the air out and hold it a second before breathing in again."
He was sounding out the lower border of Mr. Scheller's left lung with the lung deflated. He could hear the resonant sound as he tapped over the lung, and then the flatter, duller sound where the lung stopped opposite the ninth rib.
"Good," he said. "Now take a deep breath again, but this time don't let it out. Just hold it a few seconds."
He was testing the respiratory capacity of Mr. Scheller's left lung, the lung on which Mr. Scheller would have to survive if he had to remove the right. As he sounded now, moving his left hand down and tapping, he could hear the resonance down to the eleventh rib, and so he knew the expansion of two intercostal spaces was adequate.
"Good," he said. "Now you can breathe normally again. All right? Now take a deep breath again, and hold it just once more."
He had moved to the right side. He was sounding out the level of the diaphragm below Mr. Scheller's right lung.
"You can breathe out again now," he said, thinking: It's involving his phrenic nerve, though. The right diaphragm is normally a little higher than the left but this one is two inter-spaces too high and doesn't move like the left and it's his phrenic nerve.
He put on his stethoscope and he started to move the bell of it over Mr. Scheller's left back and then left chest. The heart rhythm was good and the left lung was clear, but he wanted to re-establish in his ears and his mind the sounds of normality as, away back in medical school, they had stethoscoped themselves and one another on and off for days, learning the normal sounds before they went into the wards.
"All right," he said. "Now put your right arm up over your head, like you're painting a ceiling."
"I've painted many a ceiling," Mr. Scheller said, putting his arm up.
"That's why you've got good muscles in the arm and up here in the shoulder."
He listened, the bell of the stethoscope at the axI'lla, or armpit, and then he told Mr. Scheller to put his arm down. At the back he placed the bell over the right shoulder blade, to listen to the right upper lobe of the lung, then down between the shoulder blades. He listened over the auscultatory triangle, formed where the muscles, the trapezius and the latissimus dorsi, meet in back of the apex of the lower lobe. Then he moved around to the front and placed the bell over the pectoral muscle, at the level of the second rib and again opposite the upper lobe.
He's got it all right, he was thinking. There's no doubt about it and those X-rays, fuzzy as they are, aren't lying and it's in the upper lobe. He's got it and we'll be taking that lobe and probably the whole lung if it hasn't gone too far already.
"Do you like to paint ceilings?" he said. "I've often thought that would be the toughest part of the job."
He had heard it clearly. A healthy lung gives out the sound of leaves rustling in a tree. The bronchial breath sounds in Mr. Scheller's right lung were like those of a door squeaking or of a broken reed on a saxophone.
"Oh, I don't know," Mr. Scheller said. "Ceilings have to be done, so you get used to it."
"But you'd rather paint walls?" he said, trying again to relax him.
"It doesn't much matter," Mr. Scheller said. "I've got a painter works for me who'd rather do ceilings."
"He sounds like a good man to have around," he said. "will you step up on that little platform there and sit down on the table again?"
"I don't know," Mr. Scheller said, getting up on the table. "I'd like to be able to do just ceilings, if I had to, for a few more years."
"Why not?" he said. "You're not an old man. You'll do a lot of ceilings yet."
"I don't know," Mr. Scheller said.
"As a matter of fact," he said, "I was thinking, while I was listening to your chest, that in a year or two we've got to have some more painting done around here. I was thinking that you might be interested in doing the job."
It was a variation of an old device that he had used many times. When they are frightened, afraid that they are incurably I'll and may not have long to live, you try to project them into the next day, the next week, or the next year.
"Believe me," Mr. Scheller said, "I'll be glad to do it, if I'm still around."
"Are you planning on moving away?"
"No," Mr. Scheller said. "It's not that."
"Look," he said, looking right at Mr. Scheller. "Are you scared?"
"Well, I'm a little nervous."
"Why? What do you think your trouble is?"
"I don't know."
"Then why are you so worried?"
"Well, I've never been in a hospital in my life. I've never had anything wrong with my chest. I never had pneumonia. I never even had a cough before."
"I want to tell you something," he said, still looking right at him. "If there's any worrying to be done you should let me do it. You know I'm an expert at my business."
"I know that."
"So you don't think for a minute that I'd have anything to do with you if I didn't think I could help you. Do you?"
"I guess not," Mr. Scheller said, looking at the floor.
"Of course not. You have to remember that I'm pretty well thought of, and I have a reputation to consider. Just to protect my reputation I have to get you well."
"I understand."
It is something you have to do with so many of them, he had often thought. Although most of them never even mention it, they come in with a pretty good idea of their trouble and they're scared. All that publicity on cancer gets some of them in earlier than they would come in otherwise, but it also scares them and you have to get them away from themselves. You have to get them believing in you, so that they don't quit on you when you need them.
"How's your appetite?" he said, although he knew Bob Robinson had been through this. He was examining Mr. Scheller's scalp, finding that the hair, although thinning, was not dry and stiff as is often true in cases of vitamin deficiency.
"I eat pretty good," Mr. Scheller said.
Rob said his wife reported a decrease in appetite, he was thinking. His skin color isn't too good, but part of that is due to his nervousness.
"How's your digestion? Your bowels?"
"All right."
"Do you have much gas?"
"Nope."
"How about heartburn?"
"Nope."
"Do you get up at night?"
"Sometimes. Not always."
"Do you feel a burning sensation when you urinate?"
"Nope."
"What color is the urine, yellow or white?"
"Yellow usually. Isn't that all right?"
"That's good. Do you have any headaches?"
"Nope."
"You don't wear glasses?"
"Just when I read or watch television."
"You haven't had to have your glasses changed lately?"
"About a year ago I did."
"And you still see all right with them?"
"That's right."
"How's your hearing?"
"It's all right."
"Your wife doesn't complain that you're turning up the television set too loud?"
"No. She likes it louder than I do."
"I just want to look in your ears," he said.
He turned Mr. Scheller's head with his left hand and, with his right, he lighted the otoscope and shone the light from the black plastic right-angle nozzle into first one ear and then the other. Peering through the small magnifying lens he saw that there was no perforation on the drum and no drainage and that the waxing was no more than normal. The drum was flat and not convex as it would be if there were pressure in the middle ear.
"Good," he said. "Now I want to look down your throat. will you stick out your tongue?"
He watched the tongue, normally moist, come out evenly. When it comes out to one side or the other it is a sign that the hypoglossal, or twelfth cranial, nerve is affected, and he held it down now with the wooden depressor.
He says he's never been in a hospital, he was thinking, shining the flashlight int
o the mouth and then down into the throat. He's still got his tonsils but there's no inflammation except for some irritation of the pharynx and that's probably from too much smoking. His teeth are good, just one gold inlay and a few silver fillings, and this is one of those cases where, ironically, good oral hygiene may have delayed the detection of his disease.
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