The Final Diagnosis

At this moment, her big bulk overflowing a chair in the administrator’s office, she was fighting hard.

“I wonder if you realize, Mr. T., how serious this is.” Mrs. Straughan invariably used the surname initial when addressing people she knew; she had a habit of referring to her own husband as “Mr. S.”

“I think so,” Harry Tomaselli said.

“The dishwashers I have now were obsolete at least five years ago. Every year since I’ve been here I’ve been told: Next year we’ll give you your new ones. And when next year comes, where are my dishwashers? I find they’re put off for another twelve months. It won’t do, Mr. T. It just won’t do.”

Mrs. Straughan always used the personal pronoun “my” when referring to equipment in her charge. Tomaselli had no objection to this. What he did object to was Hilda Straughan’s unwillingness to consider any problems other than her own. He prepared to cover, once more, the ground they had gone over just a week or two before.

“There’s no question, Mrs. Straughan, that the dishwashers are going to be replaced eventually. I know the problem you have down there in the kitchens, but those are big, expensive machines. If you remember, the last estimate we had ran a little under eleven thousand dollars, allowing for changes in the hot-water system.”

Mrs. Straughan leaned over the desk, her massive bosom brushing a file tray aside. “And the longer you leave it the more the cost will go up.”

“Unfortunately I’m aware of that too.” The rising cost of everything the hospital bought was a problem Tomaselli lived with daily. He added, “But right at this moment hospital money for capital expenditures is extremely tight. The building extension, of course, is partly responsible. It’s simply a question of allocating priorities, and some of the medical equipment has had to come first.”

“What good is medical equipment if your patients don’t have clean plates to eat their food from?”

“Mrs. Straughan,” he said firmly, “the situation is not as bad as that, and both of us know it.”

“It’s not very far removed from it.” The chief dietitian leaned forward and the file tray took another shove; Harry Tomaselli found himself wishing she would keep her breasts off his desk. She went on, “Several times lately whole loads of dishes going through my machines have still been dirty when they came out. We try to check as much as we can, but when there’s a rush it isn’t always possible.”

“Yes,” he said. “I can understand that.”

“It’s the danger of infection I’m worried about, Mr. T. There’s been a lot of intestinal flu among the hospital staff lately. Of course, when that happens everyone blames the food. But it wouldn’t surprise me if this was the cause of it.”

“We’d need considerably more evidence to be sure of that.” Harry Tomaselli’s patience was beginning to wear thin. Mrs. Straughan had come to him on an exceptionally busy morning. There was a board meeting this afternoon, and right now he had several pressing problems to consider in advance of it. Hoping to wind up the interview, he asked, “When did Pathology last run a bacteria test on the dishwashers?”

Hilda Straughan considered. “I could check, but I think it’s about six months ago.”

“We’d better have them do another. Then we’ll know exactly where we stand.”

“Very well, Mr. T.” Mrs. Straughan resigned herself to accomplishing nothing more today. “Shall I speak to Dr. Pearson?”

“No, I’ll do it.” The administrator made a penciled note. At least, he thought, I can save Joe Pearson a similar session to this.

“Thank you, Mr. T.” The chief dietitian eased herself upward and out of the chair. He waited until she had gone, then carefully moved the file tray back to its original position.

David Coleman was returning to Pathology from lunch in the cafeteria. Making his way through the corridors and down the basement stairway, he pondered over the time he had spent so far with Dr. Joseph Pearson. Up to this moment, he decided, it had been unsatisfactory and inconclusive.

Pearson had been cordial enough—later, if not at the beginning. On finding Coleman waiting in his office his first remark had been, “So you really meant what you said about starting right away.”

“There didn’t seem much point in waiting.” He had added politely, “I’ve been looking around the labs. I hope you don’t mind.”

“That’s your privilege.” Pearson had said it with a half-growl, as if it were an invasion he did not like but had to put up with. Then, as if realizing his own ungraciousness, he had added, “Well, I guess I should welcome you.”

When they had shaken hands the older man had said, “First thing I have to do is get some of this work cleared away.” He gestured at the untidy pile of slide folders, dockets, and loose memoranda on his desk. “After that maybe we can figure out what you’ll be doing around here.”

Coleman had sat, with nothing else to do but read a medical journal, while Pearson had plowed through some of the papers. Then a girl had come in to take dictation, and after that he had accompanied Pearson to a gross conference in the autopsy-room annex. Sitting beside Pearson with two residents—McNeil and Seddons—on the opposite side of the dissecting table, he had felt very much like a junior resident himself. There had been almost nothing for him to contribute; Pearson had conducted the gross conference with Coleman merely a spectator. Nor had the older man made any acknowledgment of Coleman’s status as the new assistant director of the entire department.

Later he and Pearson had gone to lunch together and, in the course of it, Pearson had introduced him to a few people on the medical staff. Then the older pathologist had excused himself and left the table, saying there was some urgent work he had to attend to. Now Coleman was returning to Pathology alone, weighing in his mind the problem which seemed to face him.

He had anticipated some slight resistance from Dr. Pearson, of course. From odd pieces of information which had come to him he had pieced together the fact that Pearson had not wanted a second pathologist, but he had certainly not expected anything quite like this.

He had assumed, at the very least, that there would be an office ready for him on arrival and a few clearly defined duties. Certainly David Coleman had not expected to take over a great number of major responsibilities at once. He had no objection to the senior pathologist checking on him for a while; in fact, in Pearson’s position, he himself would take the same precaution with a newcomer. But this situation went far beyond that. Apparently, despite his letter, no thought whatever had been given to what Coleman’s duties were to include. The idea seemed to be that he should sit around until Dr. Pearson could take enough time away from his mail and various other chores to hand out a few tasks. Well, if that were the case, some of the thinking would have to be changed—and soon.

David Coleman had long been aware of defects in his own character, but he was equally aware of a number of important qualities. Among the most significant was his own record and ability as physician and pathologist. Kent O’Donnell had stated nothing more than truth when he had referred to Coleman as highly qualified. Despite his youthfulness he already had qualifications and experience which many practicing pathologists would find it hard to match. Certainly there was no reason for him to stand in awe of Dr. Joseph Pearson and, while he was prepared to defer a little to the other man’s age and seniority, he had no intention of being treated, himself, like a raw and inexperienced hand.

There was another strength, too: a feeling which overrode all other considerations, whether of character, attempts at tolerance, or anything else. It was a determination to practice medicine uncompromisingly, cleanly, honestly—even exactly, as far as exactness was possible in medical affairs. For any who did less—and even in his own few years he had seen and known them—the compromisers, the politicians, the lazy, the at-any-cost ambitious—David Coleman had only anger and disgust.

If he had been asked from whence this feeling sprang, he would have found it hard to answer. Certainly he was no sentimentalist; nor had he entered medicine because of some overt urge to aid humanity. The influence of his own father might have had some effect but, David Coleman suspected, not too much. His father, he realized now, had been an averagely good physician, within the limits of general practice, but there had always been a striking difference between their two natures. The elder Coleman had been a warm, outgoing personality with many friends; his son was cool, hard to know, often aloof. The father had joked with his patients and casually given them his best. The son—as an intern, before pathology cut him off from patients—had never joked but carefully, exactly, skillfully, had given a little better than the best of many others. And even though, as a pathologist, his relationship with patients had changed, this attitude had not.

Sometimes, in his moments of honest self-examination, David Coleman suspected his approach would have been the same, whether his occupation had been medicine or something else. Basically, he supposed, it was a quality of exactitude combined with intolerance of mistake or failure—the feeling, too, that whoever and whatever you set out to serve was entitled, by right, to the utmost you had to give. In a way, perhaps, the two feelings were contradictory. Or possibly they had been summed up accurately by a medical classmate who had once drunk an ironic toast to “David Coleman—the guy with the antiseptic heart.”

Passing now through the basement corridor, his mind returned to the present and instinct told him that conflict lay very close ahead.

He entered the pathology office to find Pearson hunched over a microscope, a slide folder open in front of him. The older man looked up. “Come and take a look at these. See what you make of them.” He moved away from the microscope, waving Coleman toward it.

“What’s the clinical story?” Coleman slipped the first slide under the retaining clips and adjusted the binocular eyepiece.

“It’s a patient of Lucy Grainger’s. Lucy is one of the surgeons here; you’ll meet her.” Pearson consulted some notes. “The case is a nineteen-year-old girl, Vivian Loburton—one of our own student nurses. Got a lump below her left knee. Persistent pain. X-rays show some bone irregularity. These slides are from the biopsy.”

There were eight slides, and Coleman studied each in turn. He knew at once why Pearson had asked him for an opinion. This was a hairline case, as difficult as any came. At the end he said, “My opinion is ‘benign.’ ”

“I think it’s malignant,” Pearson said quietly. “Osteogenic sarcoma.”

Without speaking Coleman took the first slide again. He went over it once more, patiently and carefully, then repeated the process with the other seven. The first time around he had considered the possibility of osteogenic sarcoma; now he did so again. Studying the red— and blue-stained transparencies which could reveal so much to the trained pathologist, his mind ticked off the pros and cons . . . All the slides showed a good deal of new bone formation—osteoblastic activity with islands of cartilage within them . . . Trauma had to be considered. Had trauma caused a fracture? Was the new bone formation a result of regeneration—the body’s own attempt to heal? If so, the growth was certainly benign. . . . Was there evidence of osteomyelitis? Under a microscope it was easy to mistake it for the more deadly osteogenic sarcoma. But no, there were no polymorphonuclear leukocytes, characteristically found in the marrow spaces between the bone spicules . . . There was no blood-vessel invasion . . . So it came back basically to examination of the osteoblasts—the new bone formation. It was the perennial question which all pathologists had to face: was a lesion proliferating, as a natural process to fill a gap in the body’s defenses? Or was it proliferating because it was a neoplasm and therefore malignant? Malignant or benign? It was so easy to be wrong, but all one could do was to weigh the evidence and judge accordingly.

“I’m afraid I disagree with you,” he told Pearson politely. “I’d still say this tissue was benign.”

The older pathologist stood silent and thoughtful, plainly assessing his own opinion against that of the younger man. After a moment he said, “You’d agree there’s room for doubt, I suppose. Both ways.”

“Yes, there is.” Coleman knew there was often room for doubt in situations like this. Pathology was no exact science; there were no mathematical formulas by which you could prove your answer right or wrong. All you could give sometimes was a considered estimate; some might call it just an educated guess. He could understand Pearson’s hesitation; the old man had the responsibility of making a final decision. But decisions like this were part of a pathologist’s job—something you had to face up to and accept. Now Coleman added, “Of course, if you’re right and it is osteogenic sarcoma, it means amputation.”

“I know that!” It was said vehemently but without antagonism. Coleman sensed that however slipshod other things might be in the department, Pearson was too experienced a pathologist to object to an honest difference of opinion. Besides, both of them knew how delicate were the premises in any diagnosis. Now Pearson had crossed the room. Turning, he said fiercely, “Blast these borderline cases! I hate them every time they come up! You have to make a decision, and yet you know you may be wrong.”

Coleman said quietly, “Isn’t that true of a lot of pathology?”

“But who else knows it? That’s the point!” The response was forceful, almost passionate, as if the younger man had touched a sensitive nerve. “The public doesn’t know—nothing’s surer than that! They see a pathologist in the movies, on television! He’s the man of science in the white coat. He steps up to a microscope, looks once, and then says ‘benign’ or ‘malignant’—just like that. People think when you look in there”—he gestured to the microscope they had both been using—“there’s some sort of pattern that falls into place like building bricks. What they don’t know is that some of the time we’re not even close to being sure.”

David Coleman had often thought much the same thing himself, though without expressing it as strongly. The thought occurred to him that perhaps this outburst was something the old man had bottled up for a long time. After all, it was a point of view that only another pathologist could really understand. He interjected mildly, “Wouldn’t you say that most of the time we’re right?”

“All right, so we are.” Pearson had been moving around the room as he talked; now they were close together. “But what about the times we’re not right? What about this case, eh? If I say it’s malignant, Lucy Grainger will amputate; she won’t have any choice. And if I’m wrong, a nineteen-year-old girl has lost a leg for nothing. And yet if it is malignant, and there’s no amputation, she’ll probably die within two years.” He paused, then added bitterly, “Maybe she’ll die anyway. Amputation doesn’t always save them.”

This was a facet of Pearson’s make-up that Coleman had not suspected—the deep mental involvement in a particular case. There was nothing wrong in it, of course. In Pathology it was a good thing to remind yourself that a lot of the time you were dealing not merely with bits of tissue but with people’s lives which your own decisions could change for good or ill. Remembering that fact kept you on your toes and conscientious; that is—provided you were careful not to allow feelings to affect scientific judgment. Coleman, though so much younger, had already experienced some of the doubts which Pearson was expressing. His own habit was to keep them to himself, but that was not to say they troubled him less. Trying to help the older man’s thinking, he said, “If it is malignant, there isn’t any time to spare.”

“I know.” Again Pearson was thinking deeply.

“May I suggest we check some past cases,” Coleman said, “cases with the same symptoms?”

The old man shook his head. “No good. It would take too long.”

Trying to be discreet, Coleman persisted, “But surely if we checked the cross file . . .” He paused.

“We haven’t got one.” It was said softly, and at first Coleman wondered if he had heard aright. Then, almost as if to anticipate the other’s incredulity, Pearson went on, “It’s something I’ve been meaning to set up for a long time. Just never got around to it.”

Hardly believing what he had heard, “You mean . . . we can’t study any previous cases?”

“It would take a week to find them.” This time there was no mistaking Pearson’s embarrassment. “There aren’t too many just like this. And we haven’t that much time.”

Nothing that Pearson might have said could have shocked David Coleman quite so much as this. To him, and to all pathologists whom he had trained and worked with until now, the cross file was an essential professional tool. It was a source of reference, a means of teaching, a supplement to a pathologist’s own knowledge and experience, a detective which could assimilate clues and offer solutions, a means of reassurance, and a staff to lean on in moments of doubt.

It was all of this and more. It was an indication that a pathology department was doing its work efficiently; that, as well as giving service for the present, it was storing up knowledge for the future. It was a warranty that tomorrow’s hospital patients would benefit from what was learned today. Pathology departments in new hospitals considered establishment of a cross file a priority task. In older, established centers the type of cross file varied. Some were straightforward and simple, others elaborate and complex, providing research and statistical data as well as information for day-to-day work. But, simple or elaborate, all had one thing in common: their usefulness in comparing a present case against others in the past. To David Coleman the absence of a cross file at Three Counties could be described with only one word: criminal.

Until this moment, despite his outward impression that the pathology department of Three Counties was seriously in need of changes, he had tried to withhold any personal opinion on Dr. Joseph Pearson. The old man had, after all, been operating alone for a long time, and the amount of work involved in a hospital this size could not have been easy for one pathologist to handle. That kind of pressure could account for the inadequate procedure which Coleman had already discovered in the lab, and, while the fault was not excusable, at least it was understandable.

It was possible, too, that Pearson might have been strong in other ways. In David Coleman’s opinion good administration and good medicine usually went together. But, of the two, medicine—in this case pathology—was the more important. He knew of too many whited sepulchers where gleaming chrome and efficient paper work ranked first, with medicine coming in a poor second. He had considered it possible that the situation here might be the reverse—with administration poor and pathology good. This was the reason he had curbed his natural tendency to judge the older pathologist on the basis of what had been evident so far. But now he found it impossible to pretend any longer to himself. Dr. Joseph Pearson was a procrastinator and incompetent.

Trying to keep the contempt out of his voice, Coleman asked, “What do you propose?”

“There’s one thing I can do.”

Pearson had gone back to his desk and picked up the telephone. He pressed a button labeled “Intercom.” After a pause, “Tell Bannister to come in.”

He replaced the phone, then turned to Coleman. “There are two men who are experts in this field—Chollingham in Boston and Earnhart in New York.”

Coleman nodded. “Yes, I’ve heard of their work.”

Bannister entered. “Do you want me?” He glanced at Coleman, then pointedly ignored him.

“Take these slides.” Pearson closed the folder and passed it across the desk. “Get two sets off tonight—air mail, special delivery, and put on an urgent tag. One set is to go to Dr. Chollingham at Boston, the other to Dr. Earnhart in New York. Get the usual covering notes typed; enclose a copy of the case history, and ask both of them to telegraph their findings as quickly as possible.”

“Okay.” The slide folder under his arm, Bannister went out.

At least, Coleman reflected, the old man had handled that part of it efficiently. Getting the two expert opinions in this case was a good idea, cross file or not.

Pearson said, “We ought to get an answer within two or three days. Meanwhile I’d better talk to Lucy Grainger.” He mused. “I won’t tell her much. Just that there’s a slight doubt and we’re getting”—he looked sharply at Coleman—“some outside confirmation.”

Thirteen

Vivian kept very still—bewildered, uncomprehending. This thing could not be happening to her; it must be someone else Dr. Grainger was speaking about. Her thoughts raced. That was it! Somehow the charts of two patients had become mixed. It had happened before in hospitals. Dr. Grainger was busy; she could easily be confused. Perhaps some other patient was even now being told . . .

Abruptly she stopped her thoughts, made them stand still, tried to clear her mind. There was no mistake. She knew it, clearly and definitely, from the expressions of Dr. Grainger and Mike Seddons. They were watching her now, seated on either side of the hospital bed where Vivian half lay, half sat, propped up by pillows behind her.

She turned to Lucy Grainger. “When will you know . . . for sure?”

“In two days. Dr. Pearson will tell us then. One way or the other.”

“And he doesn’t know . . .”

Lucy said, “Not at this moment, Vivian. He doesn’t know. He doesn’t know anything for sure.”

“Oh, Mike!” She reached for his hand.

He took it gently. Then she said, “I’m sorry . . . but I think . . . I’m going to cry.”

As Seddons put his arms around Vivian, Lucy rose to her feet. “I’ll come back later.” She asked Seddons, “You’ll stay for a while?”

“Yes.”

Lucy said, “Make sure that Vivian is quite clear in her mind that nothing is definite. It’s just that I want her to be prepared . . . in case.”

He nodded, the untidy red hair moving slowly. “I understand.”

As she went out into the corridor Lucy thought: Yes, I’m quite sure you do.”

Yesterday afternoon, when Joe Pearson had reported to her by telephone, Lucy had been undecided whether to tell Vivian at this stage what the possibilities were or to wait until later. If she waited, and Pathology’s report on the biopsy was “benign,” all would be well and Vivian would never know of the shadow which, for a while, had drifted darkly over her. But, on the other hand, if, two days from now, the pathology report said “malignant,” amputation would become vitally urgent. In that case, could Vivian be prepared in time, or would the psychological impact be too great? The shock, suddenly thrust upon a young girl who had not suspected that anything serious was wrong, could be tremendous. It might be days before Vivian was ready mentally to accept major surgery—days they could ill afford to lose.

There was something else Lucy had also weighed in balance. The fact that Joe Pearson was seeking outside opinion was significant in itself. If it had been a clear-cut case of benign tissue, he would have said so at once. The fact that he had not, despite his unwillingness to commit himself either way when they had talked, meant that malignancy was at least a strong possibility.

Deliberating all these things, Lucy had decided that Vivian must be told the situation now. If, later, the verdict was “benign,” it was true she would have suffered fear unneedfully. But better that than a sudden explosive impact for which she was completely unprepared.

The immediate problem had also been simplified by the appearance of Dr. Seddons. Last evening the young resident had come to Lucy and told her of his own and Vivian’s plans for marriage. He had admitted that at first his own intention had been to remain in the background, but now he had changed his mind. Lucy was glad he had. At least it meant that Vivian was no longer alone and there was someone whom she could turn to for support and comfort.

Without question, the girl would need plenty of both. Lucy had broken the news that she suspected osteogenic sarcoma—with all its tragic possibilities—as gently as she could. But no matter how one put it, there was no real way of softening the blow. Now Lucy remembered the next thing she had to do: apprise the girl’s parents of the situation as it stood. She glanced down at a slip of paper in her hand. It contained an address in Salem, Oregon, which she had copied earlier from the “next-of-kin” entry on Vivian’s admitting form. She already had the girl’s agreement that her parents could be told. Now Lucy must do the best job she could of breaking the news by long-distance telephone.

Already her mind was anticipating what might happen next. Vivian was a minor. Under state law a parent’s consent was required before any amputation could be performed. If the parents planned to fly here immediately from Oregon, the written consent could be obtained on arrival. If not, she must do her best to persuade them to telegraph the authority, giving Lucy the discretion to use it if necessary.

Lucy glanced at her watch. She had a full schedule of appointments this morning in her office downtown. Perhaps she had better make the call now, before leaving Three Counties. On the second floor she turned into the tiny hospital office she shared with Gil Bartlett. It was little more than a cubicle—so small that they rarely used it at the same time. Now it was very much occupied—by Bartlett and Kent O’Donnell.

As he saw her O’Donnell said, “Sorry, Lucy. I’ll get out. This place was never built for three.”

“There’s no need.” She squeezed past the two men and sat down at the tiny desk. “I have a couple of things to do, then I’m leaving.”

“You’d be wise to stay.” Gil Bartlett’s beard followed its usual bobbing course. His voice was bantering. “Kent and I are being extremely profound this morning. We’re discussing the entire future of surgery.”

“Some people will tell you it doesn’t have a future.” Lucy’s tone matched Bartlett’s. She had opened a desk drawer and was extracting some clinical notes she needed for one of her downtown appointments. “They say all surgeons are on the way to becoming extinct, that in a few years we’ll be as out-of-date as the dodo and the witch doctor.”

Nothing pleased Bartlett more than this kind of exchange. He said, “And who, I ask you, will do the cutting and plumbing on the bloomin’ bleeding bodies?”

“There won’t be any cutting.” Lucy had found the notes and reached for a brief case. “Everything will be diagnostic. Medicine will employ the forces of nature against nature’s own malfunctioning. Our mental health will have been proven as the root of organic disease. You’ll prevent cancer by psychiatry and gout by applied psychology.” She zippered the brief case, then added lightly, “As you may guess, I’m quoting.”

“I can hardly wait for it to happen.” Kent O’Donnell smiled. As always, nearness to Lucy gave him a feeling of pleasure. Was he being foolish, even ridiculous, in holding back from allowing their relationship to become more intimate? What was he afraid of, after all? Perhaps they should spend another evening together, then let whatever happened take its course. But here and now—with Gil Bartlett present—was obviously no time to make arrangements.

“I doubt if any of us will live that long.” As Lucy spoke the phone on the desk rang softly. She picked it up and answered, then passed the instrument to Gil Bartlett. “It’s for you.”

“Yes?” Bartlett said.

“Dr. Bartlett?” They could hear a woman’s voice at the other end of the line.

“Speaking.”

“This is Miss Rawson in Emergency. I have a message from Dr. Clifford.” Clifford was the hospital’s senior surgical resident.

“Go ahead.”

“He would like you to come down and scrub, if you can. There’s been a traffic accident on the turnpike. We’ve several seriously injured people, including a bad chest case. That’s the one Dr. Clifford would like your help with.”

“Tell him I’ll be right there.” Bartlett replaced the phone. “Sorry, Lucy. Have to finish some other time.” He moved to the doorway, then paused. “I’ll tell you one thing, though—I don’t think I’ll worry about unemployment. As long as they go on building bigger and faster motorcars there’ll always be a place for surgeons.”

He went out and, with a friendly nod to Lucy, O’Donnell followed him. Alone, Lucy paused a moment, then picked up the telephone again. When the operator answered, “I want a long-distance call, please,” she said, reaching for the slip of paper. “It’s person-to-person—Salem, Oregon.”

Threading the corridor traffic with the skill of long practice, Kent O’Donnell headed briskly for his own office in the hospital. He too had a full schedule ahead. In less than half an hour he was due on the operating floor; later there was a meeting of the medical executive committee, and after that he had several patients to see downtown, a program which would take him well into the evening.

As he walked he found himself thinking once more of Lucy Grainger. Seeing her, being as close as they were a few moments ago, had set him wondering again about Lucy and himself. But now the old familiar doubts—the feeling that perhaps their interests had too much in common for any permanent relationship—came crowding back.

He wondered why he had thought so much about Lucy lately—or any woman for that matter. Perhaps it was because the early forties were traditionally a restive time for men. Then he smiled inwardly, recollecting that there had seldom been a period when occasional love affairs—of one kind or another—had not come naturally to him. Nowadays they were merely spaced more widely apart. Also, of necessity, he was obliged to be considerably more discreet than in his younger years.