HE IS LYING in the hospital bed, his frail hand with the strange yellow cast to the skin toying with the cranking apparatus to elevate his head the better, or at least the easier, to watch the preposterous animated bunny on TV peddle the latest in waterfront condos. White mums, pink tea rose buds, a brilliant potted geranium bring some needed color to the room's institutional beige drabness.
The window blinds are up, and outside, beyond the spacious lawns and sodden palms, a furious rain creates a million tin craters on the gloomy gray expense of Biscayne Bay. He is in Mount Sinai Hospital in Miami Beach and along with the flowers and get-well cards and other mementos of a long confinement are the folded wheelchair, the tubes, the needles, the dreaded chart, the quiet comings and goings of the vastly solicitious staff, all the appurtenances and unmistakable atmosphere of death.
The patient's name is Julian Kirchick. Though he has gone to Florida for the winter, his home is in Old Westbury, N.Y. He is himself a medical doctor. And on this cruel and sunless day in Miami Beach he is, as he and all about him know, quite plainly dying. It is his wish to ponder death at length and to share the unique sensations of dying with others. This account, accordingly, becomes at times something very close to an exercise in self-mutilation, for Dr. Kirchick has gone to considerable lengths to record the emotional disarray of terminal illness and to convey the exquisite nuances at each critical turn of his disintegration, from the moment another physician diagnosed the particularly savage strain of cancer tyrannizing Kirchick's body to the final days when the last of his lucidity has fled.
It is also an account of Kirchick's courage in the dwindling days of his life and of the special dignity of the dying sometimes manage to summon to comfort the hale who stand helplessly by, guilt-ridden at their more durable mortality. Kirchick appreciates the ironies in his illness: the role reversal in which healer becomes grievous sufferer and, more poignantly, the physician who has told others of their impending death now hearing with fearful astonishment that mournful message himself. It is an experience, he says, that made him weep. But Kirchick is also be able to laugh at his own sad fortunes and, at times, at death itself.
The principal documentation of Kirchick's long struggle with multiple myeloma, the virulent cancer that first struck him four summers ago, is his own journal, a loose compendium of moments remembered, philosophical wanderings, apothegms of hope, scribbled conversations, literary allusions and the wisdom with which 64 years on earth had equipped him to face his final hours. The rest of his story emerges from several conversations with this writer in Mount Sinai Hospital.
His first intimation that death was arranging an appointment with him, he is saying now in his hospital bed, was metaphorical and came to him on a summer day as he was sunning himself in the backyard of his Old Westbury home. "It was an apparition, a frightening thing." he says. "Scared me witless." He takes several deep breaths, for talking is an effort for him, and he continues. "I don't know whether it was real or not." He again pauses for breath. "But I knew it was death." His hand waves feebly toward the manuscript of the journal I am holding. "It's all down there," he says. "Read it." In prose sometimes as florid as the garden surrounding him, Kirchick has written:
I was sitting at my picturesque backyard pool, which was surrounded by beautiful rose bushes, groups of multihued azaleas and the delicate ballet-like cleomes. The sun was just setting, with its rays filtering through the surrounding trees, scattering patches of light and faint shadows on my patio. This scene, and the stillness broken only by an occasional bird chirping, put me in a restful, semitrance-like state. I was startled by a rustling in the bushes about 20 feet away. I rose from my chaise lounge to investigate. After taking about two steps I suddenly stopped short. For there was a ghostly intruder, the face of death. He was, dressed in a monk-like robe with a large hood and large sleeves, which hung low. The tissue-like skin was drawn tautly against the skull. Eyes which were absent from the sunken hollow eye sockets seemed to pierce my very soul. Strangely, the teeth were parted in what appeared in a friendly smile. His bony hand beckoned to me in a benign gesture. "Come to me," he seemed to say. My feet froze in my tracks. I was immobilized by a chilling fright which ran down my spine.
"To this day," Kirchick is saying in his hospital room, "I don't know if it was a mirage or my imagination or what. It was death, though."
His hands flutter to help emphasize a point he never musters the strength to make. He shakes his head. An attempted smile becomes instead a rictus of pain. Finally he says, "But he can't have me yet."
Some weeks earlier, Kirchich had sent his journal to Newsday with the understanding that the newspaper's editors would read it and publish whatever they found of value in his introspections, particularly his insights, both as a physician and a cancer patient, into the special and peculiar estate of terminal illness. In early February, he and his wife, Jean, had moved to their vacation home in Key Biocayne, Fla., for the winter, but Kirchick would be happy to meet with a reporter for an interview on his return to Old Westbury, probably around April 1. But his cancer began to take a severe turn for the worse, and on March 26 Kirchick entered Mount Sinai Hospital for an indefinite stay.
"He was becoming paralyzed on his left side," Jean Kirchick explains. "He'd be chewing his food and some of it would fall out the left side of his mouth and he wouldn't be aware of it. And he was losing strength in his arm. They did a brain scan and found a huge plasma cytoma in the right skull. It was pressing against the right side of his brain; that's why his left was getting paralyzed."
Cobalt treatment reduced the tumor in his head, but his cancer was in his bones, effusing his whole body, torturing his right hip and both knees and his chest. There was no part of his body that didn't hurt to some degree. His strength had fled him. On a physical therapist's handgrip, for which a pressure reading of 100 was normal, Kirchick was registering a 3. He was no longer able to walk without first caging himself in an aluminium walker. It was under those circumstances, and with Kirchick's agreement, that I went to Miami Beach to see him.
"I wanted to write down," he is saying now. "Maybe it was to give myself some courage." He pauses to arrange his thoughts. "Get it down on paper and out of my system - the worry. And I thought it was interesting, a doctor facing death." He smiles thinly. "But it's no different, not really. Doctors don't do any better at dying than anybody else."
His journal makes frequent reference to a physician's obligation to his patient, and to the special relationship betweem them. He writes:
Odd, but despite undergoing a great deal of agony, most patients will desperately cling to life. No matter how great their pain they are reluctant to give up their tenuous thread to existence. A doctor has to have empathy, the ability to place himself into the feeling and the character of the patient. Only thus can he understand the patient's dogged desire to hold on life. Without this, his surgical skill would make him a good surgical technician, but not a true surgeon .
Kirchick, an ear, nose and throat surgeon, has several times known that a patient of his was terminal from some disorder, most often cancer. Did he tell the patient? "Sometimes," he says. "Sometimes I fibbed a little. It's never an easy decision what to tell a patient because you're never 100 percent sure you're right. Only God knows the answer, whether someone has a month or a year to live." As for hisown illness, he knew of its murderous nature from the beginning; even so, he constantly allowed himself to hope, for like the patients he writes of in his journal, he too, he says, is reluctant to surrender the tenuous thread to life.
THE FIRST SYMPTOMS of his illness, Kirchick relates in a halting narrative, appeared about four years ago, beginning with a simple cold. Soon other symptoms developed: laryngitis, inflamed nasal membranes, swollen and inflamed vocal cords, a persistent fever. Kirchick sought other medical advice, first from a specialist in his own field of otolaryngology, and later from an internist. (He chooses not to reveal their names in his journal, the otolaryngologist is called "Bob," the internist, "Dr. Bert Sharp.") His colleagues, both friends of his, are concerned but not terribly worried. The internist, however, decides a full examination is called for, and Kirchick puts it all down with breezy good humor in his journal:
"You have a haziness in one lung [Sharp tells him]. Looks like a viral type of pneumonia - the sort of stuff people call walking pnemonia. Fortunately that temperature this morning got you off your butt and got you in to see me. I want you to get into the hospital today - I've already had you admitted."
"Now, Bert," I protested, "why can't I be treated at home? I'll get into bed and . . . "
"Bull -,"" Sharp retorted. "You'll be in and out of bed like a Mexican jumping bean. I want you where I can watch you. Besides, there are tests and lots of workup that you can only get in the hospital. So get your behind over there this afternoon."
I entered the hospital and was no sooner comfortably ensconced in bed when nurses and lab technicians descended upon me like a plague of locusts. A nurse shoved a thermometer into my mouth and took my blood pressure and pulse; one technician shoved a large syringe with a needle that looked like a javelin into a vein, another pricked my finger and drew blood for several slides and capillary tubes. As they were finishing, the nurse came back with a plastic urinal bottle. "I guess you know what that's for, Doc, and don't miss." As I got comfortably settled again and started watching a TV program, a technician wheeled in a large piece of apparatus and proceeded to do an electrocardiogram. I was starting to get an insight as to how patients felt when they entered a hospital. I was also beginning to feel ashamed of myself for those times I seemed brusque when the patient would voice his complaints.
Kirchick is eager to leave the hospital. The fever persists. Various medications and procedures are tried but the fever, though it seems to diminish during the days, intensifies dramatically at nights. More than two weeks go by and Kirchick makes note of his passing thoughts. "I weighed myself on the scale at the nurse's station [he writes] and found that I had put on 2 1/2 pounds; I felt I should go into Guinness' Book of Records as the only patient who gained weight on a hospital diet." A nurse brings a gallon specimen jug. "Holy cow!" kirchick exclaims, "Do I look like a horse?" The nurse informs him it is for a 24-hour sample, but she enjoys the repartee. And Kirchick, settling in, becoming a devoted follower of the daytime soaps, is beginning to enjoy what he calls "my enforced rest."
But he is beginning to read certain signs and doesn't like them. He grumps to Sharp about what he believes to be unnecessary electrophoretic tests on his blood. Sharp tells him he is calling in a surgeon to remove a small gland in the left armpit. And Sharp would like yet another internist in for consultation. Kirchick bellows in protest. "What the heck do we need another one for?" he asks. "I've got all the confidence in the world in your ability." But Sharp insists. Later still, Sharp informs Kirchick that he wants to extract "a little punch" of bone marrow from Kirchick's breast bone.
Kirchick smells a rat. "Say, Bert, what the hell is going on?" he demands. "The nurses won't let me look at the chart. They have it hidden and I can't find it in the chart rack. What's the secret?" Kirchick takes what he seems to be hoping is a preposterous guess at his problem. "Do I have leukemia?" he asks.
No, it is not leukemia, but it is not until the following day, after Sharp has asked Mrs. Kirchick to be in the hospital room with her husband, that Kirchick is told what his illness is. Kirchick has recorded the scene. He has been dressed and fidgeting in his room for two hours - "champing at the bit," as he puts it - when Sharp and Mrs. Kirchick enter. Kirchick tries a weak joke: "Well, at last my jailer is releasing me," he says. But Dr. Sharp, in "an unusually sorrowful tone," tells him they need to talk for a few minutes. Then:
I shot a quick look at Jean. I noted a doleful expression on her face, tinged with fear, as she seemed to sense my feeling of apprehension. I slowly sat down and asked at Dr. Sharp, fearfully expectant, as so many of my patients through the years had probably looked at me. How calm I was at those times, not realizing the fears patients then had felt. "Julian, your gland was negative [Dr. Sharp tells him], it was not malignant, but inflammatory." As I was about to heave a sign of relief he continued, "But all your blood, urine and marrow punch biopsy test lead to diagnosis of - multiple myeloma . . . "
I sat rooted to my chair, staring straight ahead. I saw nothing, as my whole world seemed to crumble . . . From far away I heard, "Julian, dear, everything will be all right. Don't worry. Dr. Sharp told me it can be treated successfully," Jean said in an imploring tone. I looked dazedly at Dr. Sharp and his face seemed blur as my eyes became wet. Even Jean's words became an incomprehensible blur in my mind. What happened to the doctor who is supposed to maintain an unmoving exterior, a cold front, the face of iron? Yes - doctors do cry, and I am not ashamed to admit it. I grasped the arms of my chair to keep from screaming.
Dr. Sharp speaks of new drugs that often keep patients symptom-free for years. Kirchick records his reaction:
I immediately thought: Good God! He is giving me the same pep talk I have given some of my patients, only now it's me he is talking to. I am now the one facing death, with that inevitable Reaper being my direct antagonist, my own personal adversary. What an ironic turn of events. I must be dreaming. It can't be me. I'm the doctor. Now I finally realized the significance of the vision I had seen at my pool.
At home, Kirchick looks up multiple myeloma in an edition of the Cecil-Loeb textbook of medicine he had purchased nine years earlier. He reads that it brings on kidney disease, lung deterioration, gastric and other hemorrhages, a dark litany of disastrous disorders. He broods deeply. His wife tells him that many advances in the treatment of multiple myeloma have been made since the edition of Kirchick's textbook was published. She tries to soothe him by repeating Dr. Sharp's assurances that with proper treatment he has years of life ahead of him. But he is bitter. "There is no cure," he laments. He prophesies a physical Armageddon for himself: "Unable to move, vomitting blood, literally wasting away." His bones, he says, "will be eaten away." He will never allow himself to become so debilitated, so helpless a burden, he vows. He will shoot himself first.
BUT LIFE GOES ON and time passes - nearly two years - and during that period it is his wife whose health becomes unexpectedly threatened. She is stricken with cancer of the pelvis and must undergo surgery. A huge ovarian mass is removed and Mrs. Kirchick will thereafter require chemotheraphy, a program of treatment in which poisons are systematically infused into the body to inhibit the spread and suppress the growth of malignant cells.
After the operation, Kirchick enters her hospital room.
She lays deathly still, her face as white as her bed sheets [he notes later]. I felt like screaming in grief. She barely opened her eyes and asked haltingly, "How was it, Julian?" At that instant there flashed through my mind the years of love and devotion she had given selflessly. How devotedly she guided me though my rough time. Now was she to be taken away from me? I felt as if an unknown fist was trying to wrench my heart out of my chest. Tears welled up into my eyes, as her special nurse looked at me. I had to turn away towards the window and with extreme effort muffled my sobs as I replied, "It's all out, Jean, it's okay. You will be just fine. There is nothing left."
His wife's condition continues to improve but Julian Kirchick's illness deepens as the months go by. There is severe, constant pain in his shoulder, back and rib cage. He is in and out of hospitals. During one hospitalization he experiences delirium for the first time in his life and screams, "They are sucking my blood out! Nurse, please stop them!" He takes daily dosages of an antibiotic, a cough suppressant, a tranquilizer, a narcotic for pain, a liquid antacid, an antispasmodic, a sleeping pill. Yet so ravaging are the pains that all the medications are as ineffective, he says, "as a glass of water." Soon he, too, must begin chemotheraphy treatments.
Gradually he sells of his medical practice, for his hospital stays become too prolong and work is, in any event, far too exhausting for him. His cancer is a constant presence, his Sword of Damocles, as he calls it, debilitating, depressing, painful. Even so, there are happy moments. His son Howard gets married in May 1977, and he is able to attend "this joyous occasion." He goes scuba diving. He takes his 3-year-old grandson (the child of his oldest son, Calvin) to amusement parks.
But the erosion of his body is an ineluctable as death itself and the cancer's fires next burn in Kirchick's neck, forcing him once again into the hospital, this time with such agonizing neck spasms that body movement is all but impossible and he cannot be X-rayed. It is now September 1977, and Kirchick's 17-year-old daughter Wendy is preparing to depart for her final year at the Vershire School, the private high school she attends in Vermont. The day before she is to leave she visits her father in the hospital. His pains are excruciating, and he half-whispers to his wife, "Jean, what's the use - why don't they let me die and you'll be rid of all this aggravation." His daughter overheard the remark and is horrified. That night she writes him a letter. Kirchick recorded it in his journal:
I am writing this letter because I want to discuss something very important to me, and that something is you. I know it's been a long hard struggle this past year or so, but life is a struggle and you must work your way past all its obstacles. You must taste the bitter to appreciate the sweet. If you love life you must fight for it, especially if life means as much to you as yours does to me. You must keep a good attitude, think positive all the time.
So what's this bull I hear, doing away with oneself, what's the use of suffering. That's ridiculous. Can't you see what that does to Mom. It tears her apart to hear you say things like that. You must keep your spirits up to keep hers up. Can't you see that she would rather sit by your bedside for years and years than not sit by you at all. Can't you see that she needs you, that we all need you. You may think that we don't know how you feel, but we are your blood, and what you feel, we feel. You belong to us and we want you. So keep pushing straight ahead. Fight, if not for yourself (which for whom it should be for) then for Mom. For all your loved ones. Do it for Carl and Jennifer, Ross and Lisa: Do it for Mary, William and Karen. And at last, do it for me. Please, Dad, do it for me. Because when I have that high school diploma put in my hands, you are going to be there to see, and to share the joy with me. Thanks. I love you. Wendy.
NOW, LONG AFTERWARDS, in his bed in Miami Beach, Kirchick remembers the letter and says, speaking again with great difficulty, "It gave me new heart. It gave me the courage to keep fighting. I couldn't let her down. She expects me at her graduation in June, and I'm going to be there. That's a promise I made myself." He struggles bravely to complete his physical therapy exercises each morning, dreary, monotonous drills to strengthen his legs and hands and arms. They are occasionally painful. They're always tiring. Yet he persists, because in his vision he will walk at his daughter's graduation. When a visitor who watches one of the therapy sessions tells him inanely that he is doing fine and should be up and about in no time, Kirchick stares at the fool and shakes his head and says nothing. Later, in his room, he recounts a sorrowful incident in which he operated on a man with a spindle cell carcinoma in his nasal passage. Kirchick removed the tumor but the cancer had spread to other parts of the body and the illenss was terminal. "I called him up on the phone to cheer him up, but I lost control of myself. Tears filled my eyes. I tried not to let him know."
Kirchick himself now begins quietly to weep. "I tried to hide the quivers and wavering in my voice," he continues as his own voice breaks. "I thought, he doesn't realize what's going to happen to him. But he's going to die. And that will be the end."
Kirchick can no longer speak. His wife is sitting in a chair close to his bed. He reaches and takes her hand in his. She too, is weeping. A fragile look passed between them, as mournful as the loss of hope itself. It is a sad and unforgettable moment, for they both are plainly crying at the loss of their life together. They both know it and there is nothing to do or say.
On the following day, Dr. Kirchick was taken to the Miami Beach airport, flown to New York and transferred by ambulance to Central General Hospital in Plainview. One week later, he died.