Pain is usually such a late sign of cancer, he had often thought, that a foul mouth, infected with bacteria, may actually have a salutary value. The spirochetes, aspirated into the lung, may cause an infection, such as pneumonitis. The patient coughs and produces sputum and goes to his doctor. The X-rays show the pneumonia patch, but if he also happens to have cancer it reveals that, too, and he can thank his foul mouth for an early detection.
"All right," he said, withdrawing the wooden depressor and snapping off the flashlight. "How's your sense of smell?"
He was starting, with the olfactory, or first cranial, nerve, to check out the rest of them, looking for any possible invasion of them by the spread of cancer. In medical school they had used one of the few socially acceptable mnemonics to memorize them—"On Old Olympus' Towering Tops, A Finn and German Viewed Some Hops"—but he had long ago forgotten it. He had also forgotten the one, concerned with Oscar's love life, that they had used for the eight branches of the external carotid artery, and another, involving one of Tillie's undergarments, that was the key to the eight carpal, or wrist, bones.
"My sense of smell?" Mr. Ocheller said. "I guess it's all right."
I'll bet he can't smell turpentine, he was thinking, any more than I can smell ether after all these years, but I'll bet he says he can.
"You can smell turpentine, can you?"
"Not that so much," Mr. Scheller said. "I've been working with it so much all my life that I don't notice it much any more. Besides, we don't use it like we used to."
That was honest enough, he thought. Maybe he's relaxing a little.
"How about when you come into the house and your wife's cooking dinner? Can you detect that?"
"Sure. Especially if we've got something like pot roast."
Good, he thought. He's not faking that and his olfactory nerve is all right.
"Your wife cooks it with a little vinegar?"
"That's right. How do you know that, Doctor?"
"I enjoy German cooking myself. Now I just want to take a look at your front teeth. Just show them to me, as if you were smiling for a photographer."
He was no longer interested in Mr. Scheller's teeth but he was still looking for any possible metastasis, or spread, of the cancer to the brain. One of the evidences of it is a drooping eyelid and another is in the way a patient smiles or frowns, but Mr. Scheller had done neither. Now, as his face pulled back symmetrically as he bared his front teeth, it was apparent that the facial, or seventh cranial, nerve was intact.
"You've got good teeth," he said.
"They never give me much trouble," Mr. Scheller said.
"Now just follow my hand, will you?"
He was standing about two feet from Mr. Scheller, and he moved his hand slowly back and forth. Seeing that Mr. Scheller's eyes tracked evenly, he knew that, in all probability, the oculomotor, the trochlear, and the abducent, or third, fourth, and sixth cranial, nerves were unimpaired.
"Fine," he said. "Now I just want to take a closer look at your eyes. Just hold your head back slightly, so you can look right at me."
With the ophthalmoscope, and squinting through the lens hole, he looked into the retina of each eye. He saw that there was no edema, or swelling, at the head of the optic, or second cranial, nerve, and he could see that the dimple at the end had not filled and that the small arteries and veins, pulsating normally, were not obscured.
"Good," he said. "Your eyes look all right."
"They don't give me any trouble," Mr. Scheller said.
"Tell me this," he said, wanting to check out the vagus, or tenth cranial, nerve. "Do you experience any thickness in your voice, any hoarseness?"
"No," Mr. Scheller said. "I don't think so."
"How about when you stay up too late and maybe drink too much and smoke too much?"
"I know what you mean," Mr. Scheller said. "Occasionally I'll be a little husky the next day, but I don't do that very often."
Well, he's honest about that, he thought, but hoarseness, come to think of it, probably wouldn't have any bearing on his case anyway. On the right side, where his tumor is, the branch of the vagus nerve to the vocal cord barely reaches the chest and isn't near the tumor site on his X-ray.
"How about your face and your scalp?" he said, thinking of the trigeminal, or fifth cranial, nerve. "Do you ever get any sensations of pain in the face or up here in your scalp?"
"Nope. Never that I've noticed."
"Have you noticed any swelling in your neck? I mean, have your shirt collars been getting tight?"
"Nope," Mr. Scheller said. "There's no swelling there that I know of."
As a matter of fact, he thought, his shirt collars are probably a little loose on him. Rob said he's lost about ten pounds, but he is not mentioning that.
"How about your hands?" he said, taking Mr. Scheller's right hand and examining the joints. "Have you had any bursitis or arthritis or any pains there?"
"No. My hands are all right."
"How about your legs? Any stiffness in the joints?"
"None. I work on my feet, so my legs are in pretty good shape."
"Do your feet get cold, say at night when you're in bed?"
"Nope."
Now for the pain symptom, he was thinking. If I'm right about the phrenic nerve being involved, and if I can get him to confess he'll admit it's up there high in the right shoulder. One of the roots of origin of the phrenic nerve is the fifth cervical nerve in the neck and it has a sensory branch in the shoulder, and I'd like to get the truth out of him on this.
"Now tell me about any pain you've been having," he said. "Tell me where it is, and describe it to me."
"Well, I haven't really had any pain, to speak of," Mr. Scheller said. "I don't feel anything now and I've felt pretty good for the last couple of days."
"But what was it that got you to go to your doctor who had your X-rays taken and sent to me?"
"Well, early last summer I got a kind of a cold in my chest. That was the beginning of it."
"Do you usually get colds in the summer?"
"No. That was the first one I ever had in the summer."
"Were you sneezing with it?"
"No. Maybe it was just a cigarette cough."
"How much do you smoke?"
"Oh, I don't know. Maybe a pack and a half a day."
"How long have you been smoking?"
"Oh, more than thirty years, I guess. Since I was about nineteen. Maybe thirty-five years."
"Have you ever thought of cutting down on the cigarettes?"
"Once in a while. Sometimes I try to cut down for a while, but I've been smoking so many years it's hard."
"When you had that difficulty last summer did you spit up any phlegm?"
"Some."
"Was it white or greenish-yellow and kind of thick?"
"Kind of thick, and like you say."
"Did you detect any blood in it?"
"A little, but then I didn't see any more so I figured it was maybe just from the cigarettes."
"And then, a couple of months ago, you began to get some blood again?"
"That's right. I figured maybe I tore something in there, coughing, but my wife wanted me to go to our doctor, so I went and he had some X-rays taken."
"And then, about a week later, you began to have some pain and more blood, and last week you went back?"
"That's right. Like my wife and I told Dr. Robinson."
So now he admits to pain, he was thinking. It's a shame to trap them like this, but their fear turns them into children and you have to do it.
"Do you notice any shortness of breath?" he said, diverting him but preparing to lead him around to it again.
"A little, maybe, but I'm not as young as I used to be."
"You probably notice it when you're climbing stairs, especially if you're carrying some of your equipment."
"That's right. I get a little winded."
"Oh, I forgot to ask you," he said. "Is the pain worse during the day or in
bed at night?"
"At night," Mr. Scheller said.
He had known that, if he could get him to admit it, he would say that. During the day the field of consciousness in the brain is assaulted by sight, taste, smell, and touch, but in the quiet darkness of the sleep hours the pain sensation is without competition and dominates.
"When you feel it at night," he said, "is it down here?"
He was diverting him again. He had placed his hand low, on the ribs on the left side.
"No," Mr. Scheller said. "I don't feel anything there."
"How about higher up? How about here?"
"Nope."
"How about over here?" he said, placing his hand low on the right side.
"Nope."
"Up here a little higher?"
"Nope."
"You do a lot of work with your right arm," he said, putting his hand up on the right shoulder. "What you probably feel is a pain up here."
"That's right," Mr. Scheller said. "That's where I feel it."
"Is it a sharp, pulsating pain," he said, knowing that it would not be, "or is it one of those slow, steady aches we get once in a while as we get older?"
"That's it," he heard Mr. Scheller, walking into the trap, say. "It's a kind of steady ache. I put heat on it and rubbed some stuff in, but it doesn't help much."
"All right," he said. "I haven't got any more questions, so you can get dressed now."
"What do you think, Doctor?" Mr. Scheller said. "I mean, what are you going to do?"
I'll wait until he's dressed and we're with his wife, he was thinking.
"Well, we know we're going to help you," he said. "You remember I have to cure that cough and that pain just to protect my own reputation. Right?"
"I guess so," Mr. Scheller said, starting to dress.
"Tell me something," he said. "If you paint an office like this, where we've got patients in here every afternoon, can you work weekends?"
"Oh yes," Mr. Scheller said. "That's when we have to work in business places and offices like this."
He kept Mr. Scheller talking about the painting while Mr. Scheller dressed and he mentioned again that he wouldn't want it done for a year or two. Then they went out and he met Mrs. Scheller in Bob Robinson's office and they sat down.
"Are you really worried about this husband of yours?" he said to Mrs. Scheller, trying to ease their nervousness first.
"I am, Doctor," she said, looking at her husband, "and he is, too."
"But that's just jumping at conclusions," he said. "Why should you be so worried?"
"I don't know," she said, still looking at her husband. "Next month we'll be married thirty years."
"Well, congratulations," he said. "You're going to have a fine anniversary."
"I don't know, Doctor," Mrs. Scheller said. "What do you think his trouble is?"
"What did your family doctor tell you when he sent you here?"
"Not very much. He just said he wanted you to look at the X-rays and make your own examination."
Here we go, he thought. I've got to tell them and this is the moment.
"Well," he said, turning to Mr. Scheller, "you've got something in your right lung, and we've got to take a look at it and get it out of there."
"Oh, no," Mr. Scheller said, shaking his head. "I don't want any operation."
"Are you sure, Doctor?" Mrs. Scheller said, looking at him.
"Yes," he said, "but there's no reason to be so upset."
"I was afraid of this when I came here," Mr. Scheller said.
"Please just listen to the doctor," his wife said.
"I feel pretty good," Mr. Scheller said. "I've never been in any hospital and I don't want to go in any now."
"He tells you he feels pretty good, Doctor," his wife said, 'Taut he's awake every night with the pain now. He doesn't tell you that."
"Yes, he said he has some pain."
"More than he says," she said. "He doesn't think I know it, but I hear him get up and walk around the house and cough."
"You make it sound worse than it is," Mr. Scheller said.
"I don't," she said, and the tears were starting to come into her eyes. "Believe me, Doctor, I don't."
"I know you don't," he said, "and I want you both to listen to me. There's something in that lung that absolutely has to come out, but there's no cause for all this worry. I do operations like this every day in the week. I've done thousands of them."
"I know," Mrs. Scheller said, looking over at Bob Robinson, sitting behind his desk. "Dr. Robinson told me."
"Then why are you both so upset?"
"Well, I'm not used to being sick," Mr. Scheller said.
"We all have to get used to it as we get older," he said.
"But when would he have to go into the hospital?" Mrs. Scheller said.
"Today's Thursday, so he should go in next Monday. Miss McKeen can call and find out if they can take him then."
"Next Monday?" Mr. Scheller said. "So soon?"
"Waiting isn't going to help you," he said. "The sooner you go in the sooner we'll have you out and you'll be back to work."
"You're finishing a job this week," his wife said. "You could go in Monday."
"How long will I have to be in there?"
"Oh, a couple of weeks. Then, when you get home, you'll have to take it easy for a couple of weeks more."
"I'll lose an awful lot of time."
"Harry can look after things," his wife said. "For heaven's sake, he's old enough now."
"They have a son," Bob Robinson said. "He's in business with Mr. Scheller."
"Oh?" he said. "Then you haven't got any worries there and you've both got to stop being so worried about this, too. Well stop at Miss McKeen's desk on the way out, and she'll check with the hospital right now. All right?"
"I guess it's the right thing to do," Mrs. Scheller said, looking at her husband.
"It's the only thing to do."
He waited while they shook hands with Bob Robinson and then he walked them out to Carrie McKeen's desk. He shook hands with them there, and when he walked back into his office Bob Robinson was sitting there looking at the X-rays still on the lighted panel.
"Well, what do you think now?" Rob said.
"He's got a cancer all right."
"I presumed so."
"When I put the stethoscope on him I could hear the wind whistling right by that lesion."
"You know what this is like?" Rob said.
"Like?"
"I've been thinking lately," Rob said. "You know, when you have to tell them they've got cancer it's like you've got a loaded forty-five right in your hand."
"I know what you mean," he said, "but we don't have to tell this one for a while."
"Sure," Rob said, "but whether they admit it or not, they've got a pretty strong suspicion of what's wrong when they come in here. Once they eventually learn it was a cancer, you realize that from the moment you told them they had to submit to an operation their lives would never quite be the same again. Even when we cure them it still hangs over them. It's like a forty-five."
"That's true."
"Anyway," Rob said, "what kind of shape is he in otherwise?"
"Fortunately, not bad. As I guess you got in his history, he has no unusual headaches, his vision hasn't changed, and he has no significant pains in his joints. His kidneys and digestive habits are standard and there's no evidence of any metastasis to any of the areas of the brain from which the cranial nerves originate."
"It hasn't spread much then?"
"Well, it's probably spread into the mediastinum," he said, meaning the space between the lungs and containing the heart and the major blood vessels. "There's no swelling of his neck veins, but it's involving his phrenic nerve, because his right diaphragm is a couple of spaces too high, and I got him to confess to the pain high in the right shoulder."
"How come it doesn't show on these pictures?"
"They're poor, and if he didn't breath in hard enough it might not b
e obvious."
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