Diagnosis 2: The Postman Always Rings Twice
Posted October 12, 2017, Revised January 2, 2018
Irony and Absurdity and the Return to Good Health
All stories lead to other stories and, as I used to say to my students when we began a new story, “let’s review where we’ve been so far”. The story told in the previous postings is straightforward and even rather common. A man in reasonably good health becomes ill suddenly, seeks treatment for the illness, receives it, recovers, and then continues his life. While it may not be a normal life (and who can say what constitutes a normal life?), it is the life familiar to him, the life into which he now comfortably fits. It’s his life. In contrast to many of the stories of this type, however, the man in this story doesn’t feel that his illness, as serious as it was, has made an important impact on him, and he’s unsure of what to keep as a part of the story and what to discard.
After I was discharged from the hospital in June, 2014, I felt cured — more than cured, I felt renewed in many ways — and I was looking forward to a future of reasonably good, if not excellent, health. Therefore, my story is a sea-monster story of the most common kind: the shark story. The shark had been caught, and it was now safe to go back in the water.
After I’d fully “recovered” that summer, I returned to my volunteer position as the assistant coach for my older daughters’ soccer team. I’d been the assistant coach for the previous two years and, once you agree to do it one year, it’s hard to refuse to do so in subsequent years, regardless of any intervening illnesses. The team did well, no thanks to me and to the regular hazards of rural house-league soccer (such as pigs from nearby houses strolling onto the playing field during practice). On the other hand, I was coming to the realization that whatever changes had taken place in my brain back in May, they were still affecting me and I couldn’t think fast enough to keep up with the games. Every time I tried to yell some barely coherent instructions to one of my players, I’d go through my mental rolodex, trying out all of the wrong names before I got to the correct one. I couldn’t even keep my daughters’ names straight, and sometimes called each of them Jewel, our dog’s name. Still, thanks to the superb compensatory actions of the head coach and of the players themselves, the team did well in the championship that season, losing out only in the semi-finals; a testament to the irrelevance of the quality of assistant coaching of 16 year-old girls in house-league soccer.
Girls from my soccer team try to remove a pig from the soccer field during our practice.
My wife had always wanted to go on a cruise and she became much more insistent after what she liked to call my “health scare”. She often receives offers of special deals for cruises and resorts and showed me one for a Vancouver-to-Alaska-and-return cruise that suited our purposes well, and so we bought tickets for our whole family as well as for a friend who would stay with out older daughters (according to the cruise line’s rules, our daughters were too young to sleep in a room without an adult present, so my wife and I decided that paying for an extra adult was a small price to pay for my wife and I to be able to share a room together). We had a very nice time, the cruise being far less boring than I’d always assumed cruises would be. I especially liked the “beverage package” we purchased, which kept me well-medicated most days from lunch time until well after midnight. Often, my wife and our friend would sign up for the organized activities while I read in one of the many lounges or, if the weather was clear, would just stand at the rail and look down at the water, thinking about the world that extended beyond any possibility of my engagement with the odd whales or dolphins that came near and put on a show for us. When we returned to Vancouver, we spent a couple of days exploring the city and then rented a van for the drive through the interior of BC to Calgary and had a nice leisurely trip, stopping often to enjoy the roadside attractions and the stunning views, etc. Every day, we would find a place that deserved more than a cursory stop and we would say “let’s come back some time and spend a few days here”.
In other words, the principles of absurdism dictated that the Summer of 2014 was an experience most primed for an ironic turn of fate.
Health and the Ironic Turn of Fate
An ironic turn of fate is often described as an event that leads to results opposite to those most expected. For instance, as everyone exposed to the modern popular culture has known since the 70s, the shark that is caught or killed is not the shark that was threatening the swimmers at the beach. Therefore, in contrast to what people expected, it was NOT safe to go back in the water. In fact, for someone whose universe is schemed in absurdity and irony, it should NEVER be safe to go back in the water.
My family enjoying the sights in Alaska. You can’t see the shark swimming behind us
but it’s there. It’s there and it’s watching ... and it’s waiting, it’s waiting ... waiting ...
Like most stories, the nature of a shark story differs between the perspective of the protagonist and that of the reader. For instance, the reader of this blog (you) likely considers the summer of 2014 to be, for me at least, an abnormal summer masquerading as a normal one while the protagonists in the story (me and, likely to a lesser extent, my wife) considered the summer to be a normal one, albeit one with an abnormal beginning. If you continue to read this posting, you’ll see that this difference between the two perspectives — the role of the reader in the nature of the story — is a hallmark of the ironic mode in literature. I don’t mean to say that there were no ironic events in literature until there was an ironic mode of literature. Obviously, the ironic turn of fate as a plot device is likely as old as literature itself. However, the ironic mode has been recognized as the dominant mode of literature only beginning in the mid-to-late 19th century and continuing to this day. According to Northrop Frye, the occurrence of a particular mode represented a natural development in the human imagination, just as alternating cooling and warming periods are natural developments in the earth’s geological history. Frye proposed that the predominance of the various modes of literature ran in a predictable order correlated with the literary hero’s decreasing “power of action” over his or her life, the lives of others, and over his or her environment. For example, earlier modes included the mythological in that the protagonists exhibited superhuman powers over both others and their environment. Furthermore, the mode also depended upon the relationship between the protagonist and the reader. In some modes, such as myth and romance, the reader recognized that the protagonist had greater powers that those of the reader while, in the low mimetic and ironic modes, the reader perceives the protagonist to have powers equal to or less than the reader’s, respectively. However, what’s important here is the evolution of the power of the protagonist as the reader, over the centuries, goes through the various modes, and the powers of the protagonist decrease until the ironic mode has become dominant. In this mode, you, the reader, generally feel that you are looking down upon a protagonist inhabiting “... a scene of bondage, frustration, or absurdity ...”
As any astute reader would conclude at this point, the notion of the role of absurdity caught my attention the first time I read it and it suggested to me that Frye must be on to something, since much of the literature that young people like myself were reading in the 1960’s through to today seemed to fit that description. (Also, I can’t help but notice the rise of movies based upon mythological characters with superhuman powers, and I recall that Frye also felt that, as the ironic mode ran it’s course, modes of fiction had run full circle and the ironic mode would be followed by a resurgence of the mythological mode. In a way then, Frye predicted the series of Marvel characters flooding our cinemas today; decades after his death).
But how does the predominance of a particular mode come about? Frye and others suggested that the ironic mode became predominant in the middle of the last century as a result of the development of major shifts in thinking leading to the increased secularization of the relevant aspects of our culture. By the mid-19th century, literary protagonists had become all too human figures who understood their station in life less than did you, the reader, and therefore were bound to evolve further into characters who may have wrongly believed that they held power over their “fates”. In the present example you, as my readers, would then see the folly in my actions, be it my belief that I could avoid carrying a zero gravity chair through downtown Ottawa at night or my belief that there was plenty of time to explore the sights of BC and Alberta over the coming years.
I must diverge yet again in this part of the story. I first read about (and struggled to understand, as I still do) Frye’s Theory of Modes in the 1980’s, when I was working on my Ph.D. and was starting to think a lot about the history of human health or, more specifically, the way we think of the history of human health. I couldn’t help but notice that what Frye said about the shift to the ironic mode in the mid-19th century paralleled another major shift in thinking and understanding that culminated, at around the same time, in the beginning of what we in health research call the “Epidemiologic Transition” in the history of human health and mortality. Although the precise nature of this transition is still the subject of debate, the term refers to the dramatic shifts in the causes of human illness and mortality that began in the mid-19th century. Almost everything in the way we thought of health and disease began to change by the time the ironic mode was in ascendance. Changes in thinking brought about during, or at least accelerated by, the European enlightenment, combined with demographic changes associated with the onset of the industrial age, led to developments such as universal, mandatory childhood education, the germ theory of disease and pro-active public health movements, and these developments led to political, social, organizational and scientific changes that in turn led to great reductions in human mortality — especially that of infants and children — although with little effect on maximum life expectancy. The view is an admittedly Eurocentric one and at least one of the cornerstones – vaccination – was practiced by Islamic physicians in the Middle East before being adopted by European countries, while many medical practices in East Asia have been almost completely ignored by the West.
Is this relationship between the ascendance of the ironic mode in literature and the change in thinking about health just a coincidence, or are these two shifts related in some way. Where does irony come into the picture of the “epidemiologic transition”? One aspect of the ironic mode that should be recognized is the emphasis on hubris: the arrogant display of pride that goeth before the Fall when humans tinker with their meager powers. In terms of health, the history of human intervention is rich with failure at both the individual level and at the institutional level. For example, no one who knows anything about the history of health and medicine would ever feel nostalgic for “the good old days”. There is no fondness for going back to any glorious time before the germ theory took hold or when ether was the predominant anesthetic, or before the use of anesthetics of any kind beyond strong drink. Still, as Roy Porter said in one of his many histories of medicine, we are healthier today than ever before but seem to live in greater anxiety about our health. We live longer and healthier but can’t help but feel that we slipped from a golden era of human health and should attempt to return to that Eden, whatever it may have been (and it is often portrayed as occurring during Paleolithic times, as if a hunter-gatherer lifestyle is the optimal one for us). At least part of this anxiety is reinforced rather that alleviated by pronouncements, from highly fallible humans, that we are about to enter a new golden age of health, even though every previous announcement seemed to have been premature.
In my opinion, such a view is truly ironic, but it’s not the only irony. We also fall into the predictably modern behaviour of assuming that we’ll live, if not forever, then at least a very long time, and we, in the West at least, often find ourselves completely taken by surprise when those we care about have been diagnosed with a major illness or, worse yet, died from an “age-related” cause. I’ve been to funerals of people in their 80s who had received, prior to their deaths, diagnoses of serious chronic health problems, but still their family members described their deaths as “unexpected”. Contrast this with the earlier view of death held by humans for thousands of years, at least until the end of the 19th century, a view Roy Porter termed “the constant presence of death”. For most of human history– almost all of it, in fact – death was never far from human experience as people often died at home, surrounded by family members and friends, and died at rates unacceptable in today’s world. Until only the past 120 years or so, even in the “west”, up to half of all children who made it past birth — itself a remarkable achievement — died before adulthood. In fact, human population growth rates, dependent as they are on a combination of birth and survival rates versus death rates, were just enough to maintain small increases in population during much of human history. Therefore, we see ironies of ironies in our views of health: simultaneously entertaining a view of ill health both as a natural outcome of our “fall from grace” and as an unexpected outcome due to the fact that we are no longer surrounded by “the constant presence of death.
You, the poor readers of this blog, no doubt have realized that you are an accomplice in my tale of irony and woe, “... looking down from above ...” as Frye would put it. My story truly is a sea monster story and, although the reader is aware of the presence of the monster, the protagonist of the story, me, is not. In an earlier entry, I said that the story of my illness was a story with a false ending, and that the true ending was to come later. In fact, it arrived almost exactly three months later.
The Shark Returns
A week after we got back from our vacation, on the Friday evening of the Labour Day weekend, my wife and I sat down to watch the original 1989 miniseries Lonesome Dove with Tommy Lee Jones and Robert Duvall. I watched it when it first came out in 1989 and I’d found a copy in a used DVD store and was curious as to how dated the show would seem after 25 years and how faithful the series was to the book, which I'd read since the first time I'd seen the series.
By the time ill-fated Texas Ranger Jake Spoon showed up at the Lonesome Dove Ranch, I was noticing a pain in my right side; unfortunately it was a pain familiar to me and more than a little worrisome but, since its occurrence was appropriately absurd, I tried to ignore it. By the end of the episode, after one of the O’Brien brothers meets a rather horrible fate (bitten on the face by a water moccasin – can it get any more horrible than that?), I was in severe constant pain. However, it was close to midnight by this time and so I decided to not mention anything about it to my wife, just in case it went away on its own.
I struggled to sleep during the night (I’m not sure I slept at all), twisting and turning to try to find a position that would ease the pain, and I regretted that I didn’t mention anything to my wife before she fell asleep. I was sweating again as well, and I knew from experience that sweating wasn’t a good sign. As the hours passed, my regrets grew until they filled my mind.
Why did I not say what was happening before we went to bed? I could be getting
treatment at Emerg at this very moment instead of writhing in pain while waiting
for dawn, like a soldier waiting to “go over the top”. What if the pain isn’t due to a recurrence of the abscess at all? What if it’s a burst appendix? Actually, a burst
appendix would be preferable. People get burst appendixes (appendices?) all the time,
and no one blames them for not catching the warning signs and getting something
done about it before it became critical. Wait a minute, maybe they do get blamed.
Why did I even think otherwise? I know nothing about burst appendixes or the people
who get them, and I don’t recall ever knowing anyone who had one. Or do I?
What’s wrong with my brain, I can’t remember anything! I think I’ve seen characters
with burst appendixes on TV shows and movies. Wait, were they really burst appendixes?
Is appendicitis the same as a burst appendix, or does it describe the period before the appendix bursts. Does the appendix really burst, or is that a stock phrase, like a heart “attack”. I’m an idiot. I knew all about shark stories, about how I should never believe anyone who says that it’s safe to go back in the water, that the shark that was killed
was not the shark that was wreaking havoc on the poor swimmers like me, and yet
I did go back in the water. All that time I’ve spent reading and thinking about irony,
and I forgot the lessons just when I needed them most. Useless brain! I know nothing!
I’ve never known anything really worth knowing. My life, or at least a life of normal
health, is probably over and I’m as ignorant as I was when I was born ...
Eventually, morning arrived and I told my wife what was happening and asked her to take me to the ER. I put some things I’d need into a bag, preparing for a longer stay this time, and we explained to the girls that I might have to spend a few days in the hospital again.
The drive to town was a quiet one, much quieter than the drive three months earlier, and both my wife and I seemed to be lost in our respective thoughts. We arrived at the ER in mid-morning and spent most of the day waiting but, eventually that evening, I had a CT scan. This time, however, since there was no discussion of encephalitis or meningitis, they sent the scan results to a surgeon even though I had told the ER staff that I’d been previously treated by an infectious disease specialist. This detail was important to me. All things being equal, I preferred the diagnoses that infectious disease specialists made over those of surgeons, who wished to get inside you and probe and dig to find something serious and treatable only via invasive surgery. All things being equal, infectious disease specialists would ignore such possibilities and be more likely to find something fully treatable through IV infusions of antibiotics or antivirals. The choice of whom to seek treatment by seemed obvious to me.
The surgeon came by to speak with me early that evening. He seemed very young although, at my age, everyone I meet seems to look too young for his or her level of responsibilities. He got right to the point and said that the scan had detected a “thickening” in the intestinal wall near the location of the original abscess, and that it could indicate, and likely did indicate, the presence of a tumour. This was the first time I could recall anyone using that term in my visits to the hospital. He’s being overly cautious, I told myself, and is probably just describing a recurrence of the abscess. In fact, I thought once again, why hasn’t the infectious disease specialist been by to examine me? At least twice now I’d asked if he had been informed that I was back in the ER. Why was I still being seen by a surgeon; someone who was probably pre-primed to diagnose me with cancer? Where was the other doctor, the one who would give me the proper diagnosis; the one who would diagnose me with a recurrence of my abscess due to a recurring infection? Worse, the surgeon didn’t stop telling me what might be wrong. He’d moved on to describe some lymphadenopathy near the right colon and was buttressing his argument with additional observations and rational conclusions based upon those observations, as if he was defending some aspect of Darwinian theory. Great, I thought, I’m being logically argued into having cancer by someone who was probably the leader of his high school debating club and, if I don’t see the infectious disease specialist soon, the cancer diagnosis is going to win out, and I’ll end up being treated for colon cancer rather than for a recurrent abscess.
I reminded the surgeon that I’d had a colonoscopy just a few years before, and the results had been negative. Typically, the surgeon didn’t think this was much of an obstacle to his theory and had already decided to do his own colonoscopy on me as soon as possible and so, almost 12 hours after we’d arrived in the ER, I was admitted to the hospital as a case of suspected colon cancer.
Awaiting Diagnostic Confirmation
Cancer is a disease for which the diagnosis often evolves over a period of time. Confirmation of a mass of altered cells is usually the first step, and is often obtained by one of the senses, mainly through the tactile or visual senses (i.e., finding a “lump” or seeing one through some sort of imaging technology). Once the presence of a mass is confirmed, the actual nature of the mass must be investigated since there are all sorts of masses in the normal healthy human body and most of them are not an example of cancer. In my case, a colonoscopy was scheduled so that the surgeon could both evaluate the mass visually and then biopsy a tissue sample from the mass. First, however, I needed to be “prepped”. I began a diet of “clear fluids” to cleanse the colon. Also, I required treatment for the infection brought about by the abscess since colonoscopies are invasive procedures associated with a small but real risk of bowel perforation.
Since my original visit, my wife had purchased supplemental health insurance and so, this time, I found myself in a semi-private room instead of in the ward. My room-mate, for the first week or so, was a very pleasant and considerate young man in his early 20s. He was always asking if he and his girlfriend, who climbed into his bed every night to watch TV shows and movies on his laptop with him, were making too much noise or disturbing me in any way (they weren’t). He was recovering after having been stabbed in the chest in a street brawl and, although he’d described the whole event in detail to me early on, I was too affected by the painkillers I was on to keep all the characters and events straight (I regret that I didn’t pay closer attention, as I recall that it was a good story with clear distinctions between the protagonists — he and his friends and brothers who were simply minding their own business — and the antagonists — other unidentifiable young men and their brothers and friends who were bothering people who were just minding their own business). Fortunately, he made a full recovery and was discharged about a week after I arrived.
The day of the colonoscopy was, by coincidence, the day that my family had planned to see Miranda Lambert in concert in Toronto. Since the colonoscopy was in the morning, we decided that there would be plenty of time for my family (minus me, of course) to get to the concert after the results had been determined and, if the news was terrible (i.e., large numerous malignant tumours throughout large segments of my colon and white spots visible throughout my abdomen) my wife insisted that they would stay with me rather than go to the concert. I told them, stoically, that there would be nothing to be gained by their cancelling their evening out, but my wife was insistent.
Diagnostic Confirmation: The Shark Lives!
The surgeon came by in the mid-afternoon and began to describe the findings. Sometimes, in such situations, small details stand out most and so what I recall was that he’d brought his bicycle helmet with him and he twirled it around his index finger while he spoke. He’d found the mass and x-rays had confirmed that the regional lymph nodes were also affected (he seemed justifiably pleased to have been correct in this matter), but to an extent that would have to be determined when they surgically removed the primary colon tumour later. I listened carefully and thought that he described the secondary masses as restricted to the local lymph nodes (i.e., that they were not found to have spread to the liver or any other organs). In other words, the findings were not an automatic death sentence.
“Good,” I said to my wife. “You guys can still go to the concert tonight.”
“What are you talking about,” she responded. “There’re white spots all over your liver. We’re not going to the concert.”
I don’t recall just how long a delay it was, but the room seemed very quiet all of a sudden. I’d misunderstood the surgeon and, in fact, I had just received the death sentence. A numbness began to settle over me.
It seemed like a long time but it was probably only a few seconds before the surgeon spoke up. “No, I didn’t say that. I said that we didn’t find any white spots in the liver or in any other organs.”
“Oh, sorry,” my wife replied. “My mistake.” She did a dramatic wipe of the back of her hand across her brow. “Never mind.” I’m still not sure whether she was demonstrating her relief that I wasn’t going to die just yet, or her relief that she and my daughters could still go to the Miranda Lambert concert that night, or some combination of both. My wife claims that it was some combination of both.
The surgeon then spoke about treatment options and recommended that we treat it “aggressively”. I agreed without knowing the details, but I knew what he meant in general. I and my cancer were, in a way, a single entity, but did that mean that we had different identities? Was any action taken against my cancer also going to be action against me? He’d used the phrase “recommend to the tumour board” which sounded appropriately ... well ... organized. Furthermore, I'd been a member of enough organizations and boards in my life to know that they are, by nature, conservative in their actions, and I didn't want brave, decisive actions: only cautious ones, at least at this point in time.
There would be a tumour board; a group of people to make decisions, ensuring that the decisions would take into account the views and expertise of various individuals. Would I be a member of the tumour board, I wondered, or was I the tumour the board would be discussing? I started to ponder this as he arranged — rather boastfully, in my opinion — to send some photos he’d taken from the colonoscopy to my wife’s and my cell phones.
Pictures taken during the colonscopy. Pics 1A and 2A are taken from the beginning of the
ascending colon while pics 1B and 2B are taken with the ileocecal valve turned over slightly to
expose the underside, thereby making the lesion visible. The black arrows point to colon polyps.
The blue arrows point to the cell mass that became a cancer tumour over a period of years.
As it was difficult to see in its location beneath the ileocecal valve, the less differentiated
version of it was likely missed by the earlier colonoscopy.
He then left so that my wife and I could discuss things between the two of us and we sat and pondered this new information for a while. I recall apologizing to my wife for ignoring the obvious risk factors of alcohol, processed food, a sedentary lifestyle, etc. I couldn’t claim ignorance, of course, as I’d lectured for years to my students the effects of such risk factors in colon cancer incidence and mortality rates. My wife said little, other than to mention that she would have to make sure that the girls knew what was going on. And then there was my family, including my sister and mother who lived in Thunder Bay. The news wasn’t as bleak as it could have been, in that the cancer didn’t seem to have spread to the extent that there could be no reasonable hope of a full remission. Still, my wife wanted to inoculate the girls against the inappropriate comments their friends and schoolmates might make (for example, how do you protect them against someone who is likely to say “that’s what my uncle died from. He only lasted 4 months after they diagnosed it”. They’d have to be given the information about my diagnosis tempered with an optimistic, but not unrealistic, outlook). We discussed some approaches but, for the most part, I left those decisions to my wife. She’d know what to say when the time came.
My family went to the concert after all and I spent much of the evening sitting in the patient lounge so that my roommate and his girlfriend could have some privacy. I wasn’t the least bit sleepy so I read (or continued to read) Richard Russo’s wonderfully titled Empire Falls. A little after midnight, my wife texted me to tell me that they’d returned safely from the concert, but I still wasn’t tired enough to go back to my room even though I knew that my roommate’s girlfriend had left long before. I sat for a while longer and, when I finally went back to my room, I stayed awake for a while to ponder things. I pondered the decisions I made when I was young and seemed to have the whole magnitude of cosmic time ahead of me, just to find myself facing middle age weighed down by the burdens of these very decisions. I also pondered the mysteries of my family history and just how difficult it can be to really know what drove the decisions my parents made when I was young, and how deciding to stay in or leave my hometown could have seemed like a decision at the time but, later on, could be seen as nothing more than avoidance of making such decisions. Finally, I pondered my stalled career and wondered if it was a mistake to choose such a career in the first place. Did I choose my career or did I simply follow the path of least resistance for most of my life.
Yes, I thought as sleep finally began to overtake me, reading a good book will leave you with more questions than answers.
