Rosalie's first encounter at my office was on February 8, 1983. Although she was a stranger to me, she was not a stranger to the practice site, having been treated in young adulthood by my predecessor, Dr William Seiler. As a token of gratitude to Dr. Seiler Rosalie had produced two mixed-media works that were remaining in the waiting room. The works depicted sailboats in a somewhat abstract form, sand commingled with acrylic to offer added texture and dimension. Although they no longer hang in the waiting room as they were in turn gifted to the long-term office nurse, Ann Schaeffer, on her retirement, the images remain clear. No doubt the theme and use of the elements was meant to reflect in part the closeness of our practice to the Pacific Ocean (one-half block to be somewhat exact). I was naturally introduced to Rosalie by Ann as the artist of the "sand paintings."

From the onset, Rosalie's medical problems were complex. Dysfunctional bleeding from the uterus manifested as irregular periods served as the harbinger for much more significant disease in the form of Systemic Lupus Erythematosis. Circulating anticoagulants in the blood stream had caused a deficiency in blood clotting that was predisposing to continued bleeding from fibroid tumors of the uterus. On admission to our regional university affiliated medical center transfusion predated a therapeutic D and C. Necessary treatment with high doses of prednisone, a corticosteroid, unmasked psychosis. After thorough specialist evaluation, it was discerned that multiple organs were affected by Rosalie's lupus. Her brain was involved with lupus cerebritis, her heart had been injured by a pancarditis causing leaky valves, the kidneys were injured and what was previously diagnosed as a sun sensitivity of the skin proved to be an inflammatory response caused by a lupus vasculitis.

While all of the aforementioned problems smoldered, each of which could have proved fatal, Rosalie preserved a strong will to survive which ultimately proved to be the major factor allowing her to be ultimately discharged from the hospital. On her return to my office I can recollect her focus succinctly. Rosalie was concerned about her children who were then residing in Australia, specifically that they be relieved of worry and secondly that they each be given some reasonable degree of reassurance that they would not become similarily affected with lupus. I'm sure that they both recall their initial meeting with me wherein HLA-B27 serologic testing (Rosalie was HLA-B27 positive) was pretty much mandated by their mother in spite of the lack of predictive value of a positive test, she hoped for the relative reassurance that a negative result would provide.

Throughout the remaining years of our professional relationship, Rosalie's lupus remained in a relatively quiescent state without the sustained use of steroids. Residual disease processes included seizure disorder and aortic valve stenosis with associated congestive heart failure ultimately requiring aortic valve replacement in 1995. Through this 12 year period in our relationship, I was impressed by Rosalie's pragmatic approach to the decision making process when faced with treatment alternatives. Her main focus was to maintain functionality; in the garden, in helping to keep up her parents home, and in her artistic endeavors.

Rosalie clearly persevered in the face of physical adversity and won my respect for her paucity of complaints. She used the tools that were gifted to her to make every day a productive one, focusing on what she could do, not on what she could not. Ana has written of the disability in the use of her left arm caused by injury to her brachial plexus suffered at the time of radiation as adjunctive treatment for breast cancer. I can honestly say that until she made me aware of a tingling sensation of her left hand in 1990, I was not aware of the level of impairment that had in fact been present for 20 years. On drafting this piece, I counted the number of encounters that Rosalie had in our fifteen year relationship. The total was an even sixty, averaging just four visits per year in a person with significant health problems. Rosalie clearly lived her life in spite of her illness and made every effort to not allow her illness become her life.

The final months of Rosalie's life were again a study in medical complexity and perplexity. An initial presentation in April of 1998 of presumed pneumonia proved in time to be metastatic cancer, with an unknown primary. Throughout the ordeal of diagnostic evaluation and physical disability, Rosalie's primary interests remained her garden and her family, the nurturer extraordinaire. When ultimately diagnosed with cancer on September 21,1998 in spite of dramatic symptomatology, Rosalie wished to be at home. Her last breath occurred on October 2, 1998 culminating a very rapid demise. I know, however, that the presence of her children at her bedside was felt and an infusion of energy occurred that has served as fuel for Ana, Otto and Andrew to preserve this fascinating story.

Dr. Thomas Cummings M.D.
Pacific Beach Family Medical Center San Diego California