He was not in the least frightened of marrying his dying spouse ...

As Sally sat in front of me, I could not help observing that she was constantly twirling the ornament on her left ring finger. To me that was a sign of recent engagement, as was confirmed at subsequent history taking. As if to make sure that I noticed it, she handed her doctor’s letter with her left hand, proudly showing her ring to me.

“Your doctor tells me that you have found enlarged glands in your armpit and are worried that they could be connected with some hidden disease in your breast,” I said after reading her family doctor’s note. The doctor had mentioned cancer but I avoided using the term because of the stigma attached to it in the public mind.

“Yes,” Sally replied. “I attended a breast cancer awareness meeting last October and heard that sometimes, the first sign of cancer breast is a lump in the armpit.”

“Which side are the glands in your armpit and have you felt a lump in the breast?” I asked.

“They are in the right armpit,” replied Sally and added, “and I haven’t felt a lump in the right breast.”

Because breast cancer can travel to the contra-lateral breast, so I inquired, “Any lump in the left breast?”

“No.”

“What age are you?” I started on my history taking.

“Thirty-one.”

“Any previous illness?”

LEGITIMATE INQUIRY

“Nothing except malaria when I go up-country.”

When I reached the point of family history, my first question was “Married?”

“No, but recently engaged,” Sally replied, flaunting her engagement ring.

I completed my history taking and examined Sally and found rubbery glands in the right armpit. There was nothing abnormal in either breast. More significant were the shotty glands in her left neck.

“I don’t think there is any pathology in your breasts to explain the glands in your armpit,” I expressed my opinion immediately to take away the worried expression Sally carried on her face. “To make sure, though, we will do a mammogram.”

“What is the cause of the enlarged glands in my right armpit if it is not my breast?” Sally asked.

I was wondering how to answer this legitimate inquiry, when my secretary announced on the intercom that Sally’s fiance had arrived and wanted to come in. He was delayed because he was parking his car.

“This is Justus,” Sally introduced him.

“You will be glad to know that Sally’s breasts are normal and are not connected with the enlarged glands in her armpit,” I said to Justus as he was making himself comfortable.

“I know,” he replied. Looking at my arched eyebrows, he added with slight embarrassment: “I don’t know why but I didn’t think that the cause of the enlarged glands in her armpit was in her breasts. So where is it?”

“As I told Sally before you came, we need to do a mammogram to rule out any breast disease. If that draws a blank, we will need to do further investigations to find out the cause of her enlarged glands,” I replied and then elaborated: “We have glands in different parts of our body like the neck, armpits, chest, abdomen and groins and they serve as the first line of defence. In infection in the region which they drain, the glands swell and become painful. In cancer, it secondarily spreads to the relevant glands, as in breast cancer, and that is why they are known as secondaries. But lymph glands also suffer from primary diseases like Hodgkin’s and Burkitt’s Lymphoma.”

 As it turned out, a needle biopsy on one of the enlarged glands proved that Sally had Hodgkin’s disease. It is unfortunately one of the most aggressive types of cancer. It is equally deceptive because the glands disappear quickly with chemotherapy but appear as quickly in another part of the body. My examination had shown a spread in the neck already. So when Sally and Justus came to see me for their biopsy result, they were devastated when they heard the microscopic diagnosis and its implications. Their first reaction, as expressed by Sally, was: “I was so relieved when my mammograms were normal proving that my breasts had no cancer, never realising that I could have another type of cancer in my glands.”

“Where do we go from here?” Justus asked.

“The treatment is chemotherapy,” I replied, “but before we start, we must do a chest X-ray and an ultra-sound of the abdomen to see if the glands there are involved.”

At this point Sally broke down and as I saw Justus comforting her, I could see the bond of love the couple had formed already. I felt sorry for this young couple, who had come to see me for enlarged axillary glands and were now lumbered with a shattering diagnosis, requiring many investigations, disruption of their working life, numerous visits to the hospital and enormous drain of their finances. The abdominal scan did not show anything sinister but the chest X-ray showed enlarged glands. “I think we can now start chemotherapy and I will ask my colleague to do it.”

“How effective are they?” Sally asked.

“Very,” I replied truthfully. I did not mention the possibility of recurrence or glands appearing elsewhere.

I remembered the surgical axiom that we must be truthful to our patients but use our judgement in the dose of truth administered at a time and frequency of its administration.

WEDDING BELLS

I rang my chemotherapist colleague and, after discussing the drugs, their dosage, frequency of administration and number of courses, he started the regime. As expected, the glands disappeared like snow on Mount Kenya under the summer sun. But a couple of months after the chemotherapy course ended Sally started coughing which indicated that the glands in her chest had not abated but, worse still, her belly increased in girth.

On my examination, the cause of this was ascites – accumulation of fluid in the abdomen – caused by abdominal glands and possibly her liver succumbing to Hodgkin’s. Unfortunately, the chest X-ray and abdominal scan confirmed all my clinical suspicions. It was then that I decided to ring Justus and asked him to come and see me mara moja and, more importantly, come alone. When he came to see me, he was fully prepared for the sad news I gave him. “I am afraid that though the chemotherapy has subsided glands in Sally’s armpit and neck, they have flared up afresh in her chest and abdomen,” I said.

“So what do we do?” asked Justus.

“We have to give another course of a different chemotherapy.”

“Will they do any good?” he asked.

“I might as well tell you that the natural history of Hodgkin’s disease is that the glands subside quickly with the chemotherapy, but they erupt in other parts of body equally quickly,” I elaborated. “The latest scan of Sally’s abdomen shows that the liver is also affected.”

“So how long do you give her?” As Justus changed the focus of his inquiry, he sounded very despondent.

“Difficult to say,” I replied. “All I can say is that we should count it in days and weeks rather than in months and years.”

“Right,” Justus replied immediately. “I better book the church for our wedding.”

I was flabbergasted at the reaction and the speed with which he made up his mind. Tragedies in life ennoble the soul and here was a young man, a classic example of that rare quality of life. He was not in the least frightened of marrying his dying spouse, but wanted to beat death. While all these thoughts were circulating in my mind, Justus added, emphasising his candid character: “You top our guest list but also Sally might need your professional services at the wedding.”

He was right for, though Sally stood up to the stress of her special day, soon after cutting the cake, because of the strong chemotherapy she was on, she ran out of energy and later, I had to drive her to the hospital in my car. She looked fabulous for the occasion and was only tearful when the couple reached the bittersweet moment of exchanging vows. They whispered “in sickness and in health” in tears, hiding from all who had congregated in the church so as not to adversely affect the happy atmosphere which normally prevails at a wedding. I later learnt that except for their immediate families, nobody was aware of the ordeal the couple was undergoing.

Justus spent the first night of his honeymoon sitting in a chair, tenderly holding his newly wedded wife’s hand in the ward where I had to admit Sally due to her grave medical condition. I made sure that Sally was comfortable, advised Sister not to institute any heroic measures to revive the patient because it would only prolong the agony and postpone the inevitable.

I arrived early in the morning at the hospital to see Sally where I found my intern signing Sally’s death certificate.  “Sorry, I didn’t inform you about her after Sister told me what you had told her before leaving her ward last night. I didn’t want to disturb you at 3 am.” Little did he know that I hadn’t slept a wink.

In his crumpled wedding suit and looking bedraggled, Justus thanked me profusely and, as he was ready to leave, I said to him: “You are a hero to me and I take my hat off to you.” As he looked at me with puzzling wrinkles on his forehead, I added: “You are the only person I know who got married and widowed on the same day.”

A week later, I attended the funeral service for Sally, conducted in the same church in which she was married.