CHRISTMAS ROSE | Carol Scott-Conner

 

            At her Christmas visit, my daughter comes to me with the handkerchief.

            “Mother,” Freya says, “What the hell? What IS this?”

            “It is one of Sven’s old hankies. That is all.”

            “It’s got blood on it.”

            So it had. Lots of little tiny blood spots, each the shape and size of the raw area that recently spread like small rose petals on my left breast. Blossomed just in time for Christmas. My Christmas rose.

            Sven has been dead for a decade now. After he died, I gave most of his clothes away to the Salvation Army, all but his hankies and his long underwear. He had these really soft old hankies, they don’t make them anymore. And his long underwear was pure silk. I could not give it away. Nice and warm. I turned up the cuffs with those little stitches, just like Nana taught me when I was a girl.

            “Mom?”
            “It is just a little blood. I was going to wash it. Give it to me. A little cold water, you soak the hankie, the blood comes out. Not hot water – that sets the stain. Always cold water.” I take the hankie back and start off for the back porch, to set it to soak in my wash basin. Beautiful day today, I would hang it out back to dry in the sun. The cold wind would freeze it solid and it would become even softer.

            Lately, I had taken to putting one of Sven’s old hankies in my bra, to catch the little bits of blood. So the bra wouldn’t stain. Freya didn’t need to fret. I wouldn’t let the bra get stained.

            There was really nothing to worry about. Hadn’t I seen Doctor Chen just two months ago? Such a nice young doctor. Always feels my pulse, listens to my heart and lungs. He never makes me take off my blouse, just loosens the top a little. Keeps me decent. Keeps me warm. He said I was as healthy as a woman half my age. If there was something wrong, he would have found it. He is a good young doctor.

            I hear Freya on the kitchen telephone. “Doctor Chen? This is Freya Helversen. My mother is your patient. I just came home for Christmas and she has this bizarre growth on her breast. Like an ulcer or a dog bite or something. Or a… cancer? She won’t tell me how it started and…it’s bleeding. Yes. I know it’s the holidays, but please, can I bring her to your office?”

            My Freya – my strong, strong Freya – sounds like she might cry. I go make her a cup of tea, sit her down. She just looks down at the tea cup.

            Well, the second day after the New Year, I found myself in this cancer clinic at the University. Freya is talking a mile a minute to this woman in a white coat. A lady doctor. Good for her, I think. This lady doctor must be strong, like my Freya. She must be smart, to be a doctor.

            “She has this growth on her breast,” Freya says. “I don’t know how long it’s been there. She never showed it to Doctor Chen. She never showed it to me. Mom – what were you thinking?”

            Well, I know when to keep quiet. So, I just look at her. The doctor smiles at me. She seems young, but she has some gray hair. That is good.

            Freya turns back to the doctor. “I live in San Francisco now. I only get home on holidays. If I hadn’t seen the blood stains…” She spreads the fingers of both hands, like she is asking the doctor to forgive her.

            Freya, I want to say, this is not your problem.

****

            The last patient of the day was listed simply as “Helversen, 89-year-old woman, breast cancer.” The note from her family practitioner had said that her daughter came home from a long absence and accidentally caught a glimpse of a strange growth on her mother’s breast. The mother denied any problem, but finally agreed to go see her doctor. The doctor confirmed a fungating mass on the upper surface of Mrs. Helversen’s left breast. Mammograms and a biopsy revealed an underlying breast cancer, a diagnosis which Mrs. Helversen had chosen to ignore. Daughter and doctor then strong-armed Mrs. Helversen to come in to see me. It was up to me to persuade her to undergo care for her cancer. Mrs. Helversen was alert, oriented, and competent. Nothing could be done without her consent.

            I see a couple of these cases every year, often around Christmas. Cancer of neglect, we call it. Typically, these tumors have been growing slowly for a very long time. And we generally see them in older women. No one knows exactly why these women choose not to seek medical attention. I’ve conjectured that they’ve considered the alternatives, and that they figure they will just drop dead of old age before the cancer ever gives them much trouble. I suspect that often the tumor grows so slowly, so insidiously, that they are seduced into believing that they will get away with it. Often the pivotal event is bleeding, as the center of the tumor outgrows its blood supply and dies. Sometimes it is the odor. Having concealed the problem for so long, they become even more secretive. Then someone, usually a daughter, comes home for a visit and they are (as one daughter said to me) “busted.” Brought to medical attention.

            When I was a young girl, I was a rock hound. There weren’t very many interesting rocks in the New Jersey neighborhood where I grew up, so I slowly acquired a few very special specimens as gifts, from my parents and their kind friends. One of these was a barite crystal formation called a “desert rose.” Its reddish crystals had formed among hot sands or an evaporating salt basin, slowly taking the shape of a rose with flat petals. The illusion was pretty realistic until you touched a petal. Flat, sharp, crystalline edges covered with a light crystal dust, rather than soft coolness. These tumors, red and firm against the pale softness of a breast, sometimes reminded me of that old barite rose.

            Unyielding stone against frail flesh, as if a cosmic game of scissors-paper-rock were being played out. How would you score it? Flesh wields scissors, flesh folds paper, but rock bruises flesh. Or is it – scissors cut flesh, paper wraps flesh, but flesh holds rock in the hand? No matter how you played it, the perfect Escher-like symmetry of the original game was lost. And yet…well, my patient was waiting.

            I knocked on the exam room door, records in hand.

            Mrs. Helversen was a small, slender white-haired woman with powerful gnarled hands, a broad gold wedding band, and an erect posture. Her blue eyes were milky with age, but her steady gaze reminded me uncomfortably of my high school principal. I resolved to ask her what she had done in younger years. Her daughter was large, angry, fierce, protective, scared.

            I had barely introduced myself when the daughter started in. I logged into the computer, and maintained eye contact with her as I touch-typed the history into the electronic medical record. I’d fix the typos later. It was an efficient system, almost a direct conduit from my ears to the record, and her story was familiar. But then Freya said something that caught my attention.

            “And at one point, she said it was her rose. I asked her what she meant, and she just repeated it – it is my rose. I asked Doctor Chen if this was… you know… and he said not a chance, she’s mentally sharper than I am.”

            “Your rose?” I said, looking straight at Mrs. Helversen. Was it my imagination, or did a slight smile broaden those sun-splotched lips? She stayed silent. Well, I’m used to that. Often these women just clam up. We call it playing possum. The instinct to give away as little as possible.

            The rest of the history was easily filled in. Mrs. Helversen was basically quite active and healthy, and might easily live for another five or even ten years. All bets were off in her age group.

            I wanted to hear Mrs. Helversen’s side of the story, so I asked the daughter to step outside while I did my examination. Reluctantly, she agreed.

            “May I check your breasts?”

            “Of course. That is why I am here.”

            I gently exposed one breast – normal – and then the second, taking care to keep her covered with drapes and the faded lilac-colored clinic poncho as best I could. The tumor growing through the skin of Mrs. Helversen’s left breast had raised red edges. It was maybe the size of the last digit of my right thumb. I carefully measured it, and ascertained that it was not fixed to her chest muscles and that there were no palpable lymph nodes. Good.

            She had plenty of skin. I looked at the breast, and sized it up. What would the easiest surgical approach be? Her breasts were small and only very loosely attached to the chest wall. A mastectomy would be easy, quick, and maybe even less traumatic than a lumpectomy. I could maybe even do it under regional or local anesthesia. It might even be possible to do it as an outpatient procedure.

            She called it her rose. It did look like a rose. More like a rosebud, by size. Maybe she thought it was a flower, miraculously blossoming there. Wasn’t there a saint who, caught carrying bread to the poor against her husband’s prohibition, said she had roses in her apron – and, behold, her apron was full of roses?

            So here was her rose. She had kept it covered with a clean white handkerchief under her bra. The handkerchief was stained with some oily substance and spotted with small crescents of blood, but the tumor itself was clean.

            “I have been putting vitamin E on it,” she said proudly. I nodded.

            “It’s nice and clean. The problem is, it’s a tumor,” I said.

            “When did you notice this?” As soon as I asked the question, I regretted it. Typically women say it just popped up. I usually don’t even ask. But Mrs. Helversen was different.

            “I noticed a little prickling, almost like a thistle, and then last Christmas, this rose came. A little bud, and then it bloomed. It did not hurt after that. I have kept it clean.”

            I finished my examination.

            “Do you know what it is?”

            “I know that it is cancer. Dr. Chen told me. He took a piece off this edge here. It bled for a while. I put more vitamin E on it and it healed right up.”

            “We need to treat it.”

            Mrs. Helversen just shook her head.

            “It is a cancer. You doctors always want to treat cancer. I have known that it was a cancer for a year, before Dr. Chen and his biopsy. My younger sister died from breast cancer. She was only 30. That was so many years ago. They cut off her breast and she died. So now it comes to me. I am 89 and Sven is gone from me for ten years now. Do you want to cut off my breast?”

            It had certainly crossed my mind. In fact, I had been sizing up the breast like a butcher assessing a prime cut of meat. Again, I felt like a small child, caught passing a note in class. I temporized by following her into her world, asking the questions that I never ask. “Why do you call it your rose?”

            “Sven would bring me a rose when he came courting. Always a red rose. From his mother’s garden. He grew up on the farm next door. His mother grew these wonderful wild climbing roses, all around her kitchen window. He always brought me a rose. And now I have a rose again.”

            “But you know this is a cancer.”

            “Yes. But it does not hurt me. It is small, it is clean, and I do not let it stain my bra. I am careful. I use Sven’s hankies. He left me plenty of them.”

            I stalled for time by moving to another part of the physical exam. Carefully felt under her arms and over her clavicles and in her neck. I couldn’t feel any lymph nodes, and that was a very good sign. I was hopeful that she had one of those tumors that is content to grow where it started, slow to metastasize and spread. Possibly just doing a lumpectomy would be enough.

            “We need to treat this tumor, so that it doesn’t grow larger and bother you.” I resisted calling it her rose. I hoped that by focusing her attention on this as a problem that we needed to treat, rather than a gift from her childhood sweetheart, we could move forward together. I knew, as Mrs. Helversen probably did not, where this was all heading. She was basically healthy and might live for another ten years. During that time, the tumor, untreated, would continue to grow. As it grew, the center would become necrotic, would die and grow black and ulcerated. Bacteria would grow on the surface. It would smell, despite her best efforts. It would become impossible for her to “keep it clean.” All of Sven’s old handkerchiefs would no longer be enough. And it would probably become painful. All of this could happen before next Christmas came around. Maybe she did know this at some level. After all, roses droop, fade, and die too.

            I finished my exam, reassured Mrs. Helversen that everything else was normal, and told her to go ahead and get dressed.

            “May I have your daughter join us?”

            “Yes. Freya may come in.” I thought I heard both uncertainty and resolve in her voice.

            “I’m going to tell her that it is up to you,” I said. “You have some options here, and I want both of you to hear them. But ultimately, it is up to you.”

            She nodded.

            Freya was lurking right outside the exam room door. I had anticipated this, so I left the room with a lot of forward momentum, said, “She’s getting dressed. I’ll be back in a few moments to speak with both of you,” and kept moving down the hallway before she could respond and try to corner me for a private conversation. It helps to pretend to be both very busy and slightly deaf at this point. I’d had practice.

            I’m old enough that I can remember the old paternalistic days when the family and the physician would confer separately, as if their collective wisdom was more important than the patient’s own judgment. Now patient autonomy is respected, and the family is involved only to the extent that the patient empowers us to involve them. Unless, of course, the patient is not competent to make medical decisions and has designated someone else to do this.

            The work room that we all use between patients is cavernous and noisy. Small carrels with computers are fiercely fought over. Medical students, having despaired of getting a chair, stand uneasily waiting for the resident or attending surgeon to recognize their presence. I had staked out my carrel early. I always used the same one, and one of the nurses had put a sign with my name on it over the computer. As usual, no one had usurped my seat. I opened our electronic medical record and added the physical findings to Mrs. Helversen’s note. I added a paragraph summarizing our discussion. I did all the necessary “busy work” of creating a complete note – pulled in the review of symptoms form she had completed in the waiting room, and so on. It didn’t add much to what I already knew. It took all of 5 minutes. Time to bring this visit to some sort of closure.

            As I worked on her chart, I’d begun to formulate a plan. Sometimes all you can do is keep things moving forward. I doubted we would be able to reach a decision today. In fact, if I forced the issue, Mrs. Helversen would simply say no. So the trick was to delay that decision point.

            Back in the room, I summarized the findings from her chart and my exam for both of them. Speaking directly to Mrs. Helversen, I concluded, “Thus, although the cancer is growing through the skin of your breast, it is still small and there is no clinical evidence of spread to the lymph nodes. I’d like to send you for an ultrasound examination of your lymph nodes. If that is negative, it provides additional evidence that the tumor is not trying to spread.

            “I want you to see one of my colleagues in Medical Oncology, to see what alternatives she might be able to offer you. She may want you to have some additional x-rays or scans.” I paused, turning back to the computer screen to give Freya and Mrs. Helversen an opportunity to absorb what I had said. Not too long a pause, however; I heard Freya’s indrawn breath as she prepared to launch into her questions and I forged ahead. Experience had told me that this whole discussion usually worked best if I kept my focus on the patient, spoke directly to her.

            I looked at Mrs. Helversen and said, “When your sister was treated, mastectomy was our only option. Sometimes a mastectomy is the quickest and easiest way for us to treat the cancer and let you get back to your life at home. This may be what you choose. Sometimes we just do a lumpectomy. Some women are treated with radiation. And some women just take a pill, like Tamoxifen – have you heard of that?” I figured that was a safe question – I wasn’t going to put her on the spot, force her to decide right this minute.

            I don’t fish, but this part of the process always feels to me a bit like playing a fish on the line. They say you have to feed the line out and reel it back in carefully; if you pull too hard, too early, the line will snap and the fish will swim off with the hook in its jaw, never to be seen again.

            Mrs. Helversen nodded in response to my last question.

            “Do you have questions?” I asked her. Mrs. Helversen just looked back at me. Her gaze was clear-eyed and steady. It gave nothing away. She had gone back into “possum” mode. Had she noticed that “Let’s just do nothing” was not on my list? I felt certain that she had.

            I looked at Freya. She had a list of questions, which I fielded as best I could.

            Back in the clinic work room, I placed orders for the axillary ultrasound and to schedule a consult with Dr. McAdams in Medical Oncology. Finally, I scheduled Mrs. Helversen to return to my own clinic after she saw Dr. McAdams. There was no hurry – the tumor had been there for a while - and I felt that if I tried to rush Mrs. Helversen she would simply refuse to do anything. So I went back into the exam room and outlined the plan to both of them. So far, so good.

            Two weeks later, I had reviewed all of the new material in Mrs. Halversen’s medical record in anticipation of her next clinic visit. I had been relieved to see that there was no evidence that her tumor had spread to the lymph nodes under her arm, or to other parts of her body. Medical Oncology had offered three alternatives: surgery, hormonal treatment with Tamoxifen to suppress the tumor, or radiation treatment. Dr. McAdams’ clear preference was for limited surgery – a lumpectomy – followed, maybe, by radiation and Tamoxifen. It was my own preference. Mastectomy would be a simpler alternative, if Mrs. Halversen agreed.

            The morning of her clinic appointment, I sat at my old wooden desk at home sipping my first cup of coffee. It was still dark outside, and through our library window I could see stars, planets, even – if I craned my neck – the waning crescent moon. Automatically, I named some of them. That would be part of the constellation Orion. There’s Venus.

            I thought about Mrs. Halversen and Freya. The rose-like appearance of her tumor. And then I remembered my desert rose. On an impulse, I rummaged through the small drawers and cubby holes of my old desk. I found a small hoard of rocks and fossils – a geode, a shark’s tooth, some fossil coral, and, finally, deep in the drawer, my old desert rose.

            My desert rose was about the size of a flattened marshmallow. The edges of the crystal were worn smooth, and so it had no value as a geological specimen. Perhaps it had tumbled for centuries in the sand of the desert in which it grew and been altered by the wind and sand. Probably, being so imperfect, it was judged a good gift for a child, and that was how it came into my hands.

            I could not remember the family friend who gave it to me. I had a vague recollection of some kind man visiting our house and pulling this small present out of his pocket. I was probably around eight years old. I had kept it all these years for largely sentimental reasons, a battered reminder of my childhood here in my hand, lovingly preserved down all the decades.

            This was a desert rose that one could carry in the pocket, or carry in a pouch around the neck, like a talisman. I cupped it in my left hand and thought about power; the power of the spoken word, the transfer of power, and the power of small objects. Perhaps it would give me some power – the power to persuade Mrs. Helversen to accept some form of treatment. I slipped it into my briefcase.

***

            So, Freya and I go back to see the lady doctor. The lady doctor spends a lot of time telling me this, telling me that. She wants to cut the cancer out of my breast. Not to cut off the breast, just to cut out the cancer. She says she could just take off the breast and that would be quicker. I want to say, quicker for you, maybe. She keeps saying this operation, that operation, but I know what she means. She wants to take away my rose.

            Freya asks a lot of questions. The doctor and Freya talk for a while. Me, I stay silent.

            Freya turns to me. “Mother, you need to have this done.”

            The lady doctor holds up her hand and stops Freya with a gesture.

            I start to say “No,” but the lady doctor holds up her hand and stops me. She says, “Shhh.” Then she does something very strange. She pulls this rock out of her pocket. She tells me it is a desert rose. She was given it as a child and has kept it safe ever since. Well, I can understand that. I still have the first rose that Sven gave me, safe in my Bible.

            She asks me, “Will you trust me? Could we do a trade, my rose for your rose?” Then she holds out the rock to me. I can see that it is a very special rock. I have never seen a rock like this. I can see why she calls it a rose.

            She keeps talking. She tells me how it formed in the sands of the desert. She thinks maybe someone carried it in a leather pouch around their neck. A healer, like her.

            “A rose for a rose,” she says. “Let me get rid of your cancer.” She holds out the rock to me. I look into her eyes. She is a healer. I can trust her. She waits, holding out the rose to me.

            So I hold out my hand. I take the rose from her, and fold it in my palm. I look at her again. We both smile.


Carol Scott-Conner is Professor Emeritus of Surgery at the University of Iowa Carver College of Medicine, where she is a member of the Humanities Council and serves on the editorial board of ' The Examined Life' literary journal. Her monograph, Medical Writing: Creative Writing for Clinicians, clarifies the distinction between technical writing and creative writing. Her creative work explores the intersection between surgeon and patient, and hopes to illuminate the lives of women in surgery. Her short stories have appeared in numerous small literary journals and she has published two short story collections: A Few Small Moments, and Beachcombings. In “Christmas Rose,” she gives voice to an elderly woman with neglected breast cancer.

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