Originally published in JAMA (A Piece of My Mind) on 16 November 1994 by John F. Stamler, MD, PhD, Iowa City, IA
My father had always been a quiet man, but I remember two weeks when he did not speak at all. I had arrived at his office shortly before lunch one morning in the spring of my sophomore year in medical school. He had a small office in the old medical laboratories building that housed the pathology department. A sign on the door read Knock and Enter.
The door only opened halfway before it hit his large oak desk in the center of the small room. He sat in the middle of the room surrounded by desk in front, bookcases covering the walls behind and to his left, and a double-headed microscope on his right. Taped to the wall were a couple of 20-year-old finger paintings that bore my fingerprints.
His large frame was wrapped in a white lab coat and topped by a shock of white hair. With his glasses perched on his nose or balanced on his forehead, he gave the impression of a scholarly polar bear. I sat at the double-headed microscope. This seat was one of my favorite places.
His desk was, as always, buried under journals, papers, and books. On the corner next to the microscope sat a stack of wooden trays filled with microscope slides. These trays contained the current cases that were waiting to be examined and given a diagnosis. I would look through one side of the scope while he looked through the other. Case after case would pass before us. We never knew what we would see next. There were autopsies and biopsies, tumors–benign or malignant, infections, inflammations, traumas, and degenerations.
The format would be the same each time. He would ask questions and I would answer. If I hesitated he would move the slide around and zoom in the focus to the part of the specimen that would give me the best clue. When I would start to go down the wrong path he would not criticize or contradict me, but he wouldn’t go on. He would hesitate, ask me if I was sure, or perhaps clear his throat. Then I knew to retrace my steps until I was heading in the right direction again. When I eventually stumbled onto the correct diagnosis, we would pretend that I had figured it out myself. Some cases were straightforward while others were ambiguous. From that vantage we explored together the universe of disease and health, life and death, male and female, from head to toe. We watched together the intricate dance of cells as they played out their stories in front of us. I came to understand the joy, fascination, and mystery of disease and medicine that were so much a part of his life and becoming part of mine. I saw how much knowledge and wisdom he had learned and that he still, after six decades, loved learning something new every day.
I sat at my usual place that day, but I did not get my usual greeting. My father handed me a piece of paper explaining that he had been placed on voice rest. He had become progressively hoarse over the last few weeks and a growth had been found on his vocal cord. I tried to remember the risk factors for laryngeal carcinoma. He did have a short smoking history. He smoked cigarettes for a couple of years, but that was 15 to 20 years ago. The lesion could be reactive tissue, a benign tumor, or cancer. If the lesion did not resolve after two weeks of voice rest, it would be biopsied.
I was just a sophomore medical student, but I had seen the ENT ward at the VA. I knew what laryngeal cancer could do. The best that we could hope for would be a hole in the front of his throat and loss of speech except for perhaps the strange belching speech from the esophagus. More likely was death.
The next two weeks crept along. Our family tied to ignore it, but my father’s strangely silent presence was a constant reminder that cancer and death were lurking nearby, unseen but not far away. We were reminded when he wouldn’t answer the telephone or we would forgetfully ask him a question and get a raised eyebrow in reply. None of us believed that voice rest would make any difference. Few people exercised their voice less than my father.
After two weeks he went in for a biopsy. The next day, I found myself hanging around my parents’ home, waiting with them for the telephone call with the verdict.
I felt the ropes of the hammock press against my back as I lay with a heavy pathology textbook on my abdomen, looking up through the old oak branches to the sky. The blue of the sky was sprinkled among the greens of the leaves–dark green where the leaves were in shadows and bright, almost glowing green in the sunlight. The breeze pushed the branches gently back and forth creating a kaleidoscope of blue and green shapes. The only sound was the rustle of the leaves and the occasional call from a hidden bird. That ancient oak had a trunk so big a tall man like my father could reach only halfway around it with both arms. The branches spread in a canopy over half the width of our yard and stretched over into the neighbors’ yard.
I heard the back door slam and saw my mother coming toward me with some iced tea. She handed me the glass, put one hand on her hip, and looked up into the tree. “There are some big dead branches up there,” she said. “I called the tree trimmers last week, but they haven’t come yet. I read in the paper a couple of weeks ago that a branch fell out of a tree onto a baby in a playpen.” She turned and walked back into the house.
I looked up into the tree again and noticed that it had changed. I could now see a few bare limbs scattered throughout the canopy–crooked, lifeless limbs that were shedding shaggy pieces of black bark. I felt an urge to go sit in the sun.
As I moved to a lawn chair, my father came out to the yard. He stood straight and tall, silently staring into the flower garden. He had an apple in his hands that he was rubbing and turning like a pitcher rubs a baseball as he gets the signs from the catcher. He had grown up on a farm in the days when the work was done by hand and horse. Standing there in the sun that day he looked strong enough to walk out into a field and go right to work. However, there was something different about him: a certain dullness to his eyes that I had never seen before.
As he raised the apple to his teeth the phone rang from inside the house. The ringing stopped. There was a moment of silence. Then my mother came through the back door and let it slam behind her.
“That was Earl. He said they passed the slides around to the whole department and they all agree.” Her face was flushed as she rushed from the shade of the house over to us in the sunshine. She took a deep breath and then expelled the verdict. “It was benign.”
I felt my heart soar to my throat. My mother beamed at my father while she stood there on the grass shivering like the leaves above us in the gentle breeze. Dad said nothing. He looked at the apple and brought it to his mouth. He cracked off a large piece and stood there chewing while we waited. Finally, he swallowed, cleared his throat, and spoke his first words in two weeks.
He looked at my mother with no apparent emotion, nodded, and calmly said, “I got a look at it as it came out. It looked benign to me, too.” He didn’t say anything else, but I saw the spark of life return to his eyes that is still there 20 years later.
John F. Stamler, MD, PhD
Iowa City, Iowa
Copyright 1994 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610.