“A fistful of dollars”

Mr. Johnson was a 53-year-old patient with laryngeal cancer admitted for pain control who loved to watch Westerns.

Figure. Photo by: Fred Sebastian

He had mentioned this fact while I percussed his belly. He had elaborated on it while I examined his motor strength. At the time, it had seemed important, and I felt I should remember it along with his medication list and the review of systems. But later, on rounds, where information needed to have a practical purpose, I wondered if this was wrong. A film preference would not change any part of this patient's medical care: not his pain medications, diet or physical therapy.

As we concluded morning rounds, the attending asked me, “Why Westerns? Why not romantic comedies?”

The next morning I asked Mr. Johnson, “Why is it that you like Westerns so much?”

“I don't know,” he answered.

“Did you live out West?”

“No.”

“Ever travel there?”

“Nope,” he said. He twirled his spoon in the butterscotch pudding on the lunch tray. “Have you seen Fistful of Dollars?”

“No, I haven't.”

“You should see it. It's real good.”

I knew he was dying of his cancer; I had learned the history of his disease. It was a hard and mean squamous-cell carcinoma that had arisen under his right mandible, tracked up and down and finally penetrated the surface of his neck. Hospital records told me that the cancer had been diagnosed a little over a year ago, when Mr. Johnson noticed a bulge in his throat when he swallowed. A surgeon had resected it, leaving a deep cleft underneath his chin. Radiation therapy had followed, and nine months later when the disease reappeared, chemotherapy.

His pain had skyrocketed in the last three weeks and he had been admitted for pain control. I remembered well the description of the constant ache in his jaw and the unpredictable shocks that shot up and down the right side of his skull. I knew his vital signs on admission, the ragged contours of his throat and, beneath these, the quick, bounding pulse of his carotid artery. I could picture the raw mucosa of his mouth and the gaps from which teeth had been successively pulled, over several decades.

When I had admitted him, there had seemed to be a reason for every piece of clinical information. I remembered which pain tablets had worked and then failed because I needed to know where to start. I learned which foods were more difficult to swallow because I wanted to make certain he received enough nutrition. I asked him if he smoked or drank alcohol, since understanding risk factors for his cancer seemed important. But I did not ask Mr. Johnson about films. I only knew that he loved to watch Westerns because he had mentioned it in passing. After all, I thought, medicine is driven by the need to explain that which is relevant to patient care. These bits of information gathered from Mr. Johnson's story carried a certain value. In time, they fell together like pieces of a puzzle whose assembly dictated his initial plan of care and possibly his entire stay in hospital. What could be the relevance of this detail about cowboy movies?

On the day after his admission, I wearily walked home from work late in the afternoon. I had not slept in over a day. Someone was handing out flyers for a small rodeo show in a nearby county. I took one and thought of my patient watching television on the third floor of the hospital, being administered intermittent morphine injections.

That weekend, I rented A Fistful of Dollars. Clint Eastwood wears a dirty poncho and smokes cheap cigarillos. He rides a donkey into a small Mexican town where two factions rival for control of the area. Over the course of several weeks, he is hired by each side in turn to fight against the other. He rescues a beautiful girl and her family from capture and imprisonment. He is severely beaten by one faction and slips out of town to heal his wounds, only to return to shoot the leader of his assailants. Then, at last, he leaves town for good.

As the credits rolled, I considered Mr. Johnson. He had never left the Virginia county of his birth. He had never ridden a horse or a donkey, had never fired a gun. Did he identify with Clint Eastwood's character or predicament? Did he fantasize about a life of gunfighting and danger?

Perhaps he saw cancer as a battle of good and evil. Perhaps he longed to live freely like cowboys, to not be pinned down by his disease.

Mr. Johnson died nearly a month after I met him; I read his obituary in the local newspaper. By that time, I had forgotten his vital signs on admission, the list of medications and the details of the course of his disease. I remembered his five favorite Westerns: The Magnificent Seven, High Noon, Stagecoach, Red Sun, and A Fistful of Dollars. I remembered his impression of Clint Eastwood in San Miguel, eyes squinting at an imaginary sun, finger and thumb cocked into the shape of a revolver.