The Final Diagnosis

Generally speaking, there’s a rising fever, chills, and a slow pulse. There’s also a low blood count and, naturally, the characteristic rose spots. In addition to all that a patient will probably complain of a dull headache, no appetite, and general aching. Some patients may say they’re drowsy in the daytime and that they’re restless at night. One thing to look out for also is bronchitis; that’s quite common with typhoid, and you may encounter nosebleed too. And, of course, a tender, swollen spleen.”

The chief of medicine sat down. O’Donnell asked, “Any questions?”

Lucy Grainger asked, “I take it that typhoid shots are being arranged.”

“Yes,” Chandler said, “for all employees and staff, also patients who are well enough to have them.”

“What about kitchen arrangements?” The question was from Bill Rufus.

O’Donnell said, “If you don’t mind, we’ll come to that shortly. At this point is there anything more medically?” He looked around; there was a shaking of heads, “Very well, then. We’ll hear from Pathology.” He announced quietly, “Dr. Pearson.”

Until this moment there had been background noises in the room—fidgeting, the movement of chairs, murmurs of conversation aside from the main discussion. But now there was a hush as eyes turned curiously to where, halfway down the long table, Joe Pearson sat. Since entering he had not spoken but had remained quite still, his eyes fixed directly ahead. For once he had no cigar lighted, and the effect was like the absence of a familiar trade-mark. Even now, as his name was called, he made no move.

O’Donnell waited. He was about to repeat the announcement when Pearson stirred. As his chair went back the old pathologist rose to his feet.

Slowly his eyes swept the board room. They went the length of the table, then returned to its head. Looking directly at O’Donnell, Pearson said, “This epidemic should not have happened. Nor would it, if Pathology had been alert to a breakdown in hygiene precautions. It is the responsibility of my department, and therefore my own responsibility, that this neglect occurred.”

Again a silence. It was as if history had been made. In this room so many times Joe Pearson had charged others with error and misjudgment. Now he stood himself—accuser and accused.

O’Donnell wondered if he should interrupt. He decided not. Again Pearson looked around him. Then he said slowly, “Having allocated some of the blame, we must now prevent the outbreak going further.” He glanced across the table at Harry Tomaselli. “The administrator, the heads of departments, and I have formulated certain procedures to be carried out at once. I will tell you what they are.”

Now Pearson paused, and when he resumed there was a stronger note to his voice. It was almost, O’Donnell thought, as if in this single moment the old man were throwing off some of his years, as if providing a glimpse of what he had been like long ago as a younger practitioner—intense, earnest, and competent. The old sardonic humor, the air of borderline contempt, which all of them in this room had come to know so well, were gone. In their place were authority and know-how and the forthright frankness of one who accepts without question the fact that he is speaking with equals.

“The immediate problem,” Pearson said, “is to locate the source of infection. Because of the failure to check food handlers properly over the past six months it is logical that we should suspect food as a means of contamination and should begin our search there. For this reason there must be a medical inspection of all food handlers before the next hospital meal is served.” From his frayed woolen vest he extracted a watch and placed it on the table. “The time is now 2:15 p.m. That gives us two and three-quarter hours. In that time every employee who has any part in the preparation and serving of hospital food is to be given a thorough physical check. Facilities are being set up now in the outpatient clinics. I understand that all the internists and house staff were notified before this meeting.” He glanced around and there was a nodding of heads. “Very well. As soon as we are finished here Dr. Coleman”—Pearson glanced down at David Coleman beside him—“will give you your assignment to a specific room.”

Gesturing toward the chief dietitian, Pearson said, “Mrs. Straughan is arranging to assemble all the people concerned, and they will be reporting to Outpatients in batches of twelve. That means ninety-five people to be examined within the time we have.

“When you make these examinations, by the way, remember that the typhoid carrier—and we are assuming there is a carrier—probably has none of the symptoms Dr. Chandler described. What you should look for particularly is any lack of personal cleanliness. And anyone you have doubts about should be suspended from duty for the time being.”

Pearson stopped as if thinking. So far he had consulted no notes. Now he went on again. “Of course, we are all aware that physical checkups will not give us the whole story. We may be lucky and find the individual we’re looking for that way, but the chances are we won’t. Most likely the major work will come in the labs as soon as the medicals are completed. All the people you examine are to be told that stool cultures are required and stool samples must be in the hospital by tomorrow morning.” There was the ghost of a smile. “Constipation will not be taken as an excuse; and if anyone can come through with a sample today we will, of course, accept it gratefully.

“The labs are being set up now to cope with all the cultures we shall be doing. Of course, it will take us a few days—two or three at least—to handle all those stool samples.”

A voice—O’Donnell thought it was Gil Bartlett’s—said quietly, “Ninety-five people! That’s a lot of shit.” A ripple of laughter ran around the table.

Pearson turned. “Yes,” he said, “it is a lot. But we shall do our best.”

With that he sat down.

Lucy signaled with her hand, and O’Donnell nodded for her to speak. She asked, “If the source of infection is not found immediately, will we continue to use the hospital kitchens—to serve food here?”

“For the moment—yes,” O’Donnell answered.

The administrator added, “My office is checking now to see if there’s any outside caterer who could handle food supply if that were felt necessary. I doubt, though, if there’s anyone in town who has facilities—at short notice like this—to do it.”

Bill Rufus asked, “What’s our policy to be on admissions?”

“I’m sorry,” O’Donnell said. “I should have mentioned that. As of this moment we’ve stopped admissions. The admitting department has already been notified. But, of course, we’re hoping pathology can track down the source of infection quickly, and then we’ll review our admissions policy again. Anything else?”

There were no more questions. Looking down the table, O’Donnell asked, “Dr. Coleman, do you have anything to add?”

David Coleman shook his head. “No.”

O’Donnell closed the file which had been open in front of him. “Very well, ladies and gentlemen, I suggest we get started.” Then, as chairs scraped back and conversation began, he asked Pearson, “Joe, could I have a word with you?”

Together they crossed to a window, away from the others who were filing out through the door. O’Donnell said quietly, making sure his voice did not carry, “Joe, naturally you’ll remain in charge of Pathology during this outbreak. But I think I must make clear to you that, concerning other things, nothing has changed.”

Pearson nodded slowly. “Yes,” he said, “I’d already figured that.”

Twenty-two

Like a general appraising his forces ahead of battle, Dr. Joseph Pearson surveyed the pathology lab.

With him were David Coleman, the pathology resident Dr. McNeil, Carl Bannister, and John Alexander. Pearson, Coleman, and McNeil had come directly from the emergency staff meeting in the board room. The other two, acting on earlier instructions, had cleared the lab of all but immediate, essential work.

When Pearson had completed his inspection he addressed the other four. “Our problem,” he announced, “is one of detection. Out of a field of approximately ninety-five people—the food handlers—it is our business to track down a single individual whom we believe to be spreading typhoid germs within this hospital. It is also a problem of speed; the longer we take, the worse the epidemic will be. Our means of detection will be the stool specimens which will start coming in today, with the bulk of them arriving tomorrow.”

He addressed Roger McNeil. “Dr. McNeil, your job for the next few days will be to keep the lab clear of non-essential work. Check all routine requisitions coming in and decide how many of them should have priority and which can be postponed, at least for a day or two. The lab items which in your opinion are urgent can be handled by Carl Bannister. Work with him as much as you can, but don’t load him with any more than is essential; the rest of the time we’ll use him on our major project.” Pearson continued as McNeil nodded. “You yourself will have to take care of all surgical reports. Process those which appear urgent and accumulate anything that can wait. If there’s any diagnosis about which you’re not absolutely sure, call Dr. Coleman or myself.”

“Right. I’ll check with the office now.” McNeil went out.

To the others Pearson said, “We shall use a separate plate for each single stool culture. I don’t want to take the risk of putting several cultures together, then having one overgrow the others; it would mean we’d lose time and have to start again.” He asked Alexander, “Do we have sufficient MacConkey’s medium ready to handle close to a hundred cultures?”

John Alexander was pale and his eyes red-rimmed. He had returned from Elizabeth only a half-hour before. Nevertheless he responded promptly, “No,” he said, “I doubt if we’ve more than a couple of dozen. Normally that’s several days’ supply.”

When he had spoken, realizing that his reaction to a question about the lab had sprung from habit, John Alexander wondered what his own feelings were toward Dr. Pearson. He found he could not define them. He supposed he should hate this old man whose negligence had caused his own son’s death, and perhaps later on he would. But for now there was only a dull, deep aching and a sense of melancholy. Maybe it was as well for the time being that a great deal of work appeared to be facing them all. At least he could try to lose himself in some of it.

“I understand,” Pearson said. “Well, then, will you work in the media kitchen and stay with it until all the plates are ready for use? We must have them all by the end of today.”

“I’ll get started.” Alexander followed McNeil out.

Now Pearson was thinking aloud. “We shall have ninety-five cultures, say a hundred. Assume that 50 per cent will be lactose positive, leaving the other 50 per cent to be investigated further; it shouldn’t be more than that.” He glanced at Coleman for confirmation.

“I’d agree.” Coleman nodded.

“All right then; we shall need ten sugar tubes to a culture. Fifty cultures—that means five hundred subcultures.” Turning to Bannister, Pearson asked, “How many sugar tubes are ready—clean and sterilized?”

Bannister considered. “Probably two hundred.”

“Are you sure?” Pearson looked at him searchingly.

Bannister colored. Then he said, “A hundred and fifty anyway.”

“Then order three hundred and fifty more. Call the supply house and say we want them delivered today, and no excuses. Tell them we’ll take care of the paper work later.” Pearson went on. “When you’ve done that, begin preparing the tubes in sets of ten. Use those on hand first, then the others when they come. Check your sugar supplies too. Remember you’ll need glucose, lactose, dulcitol, sucrose, mannitol, maltose, xylose, arabinose, rhamnose, and one tube for indole production.”

Pearson had rattled off the names without hesitation. With the ghost of a smile he said to Bannister, “You’ll find the list and table of reactions for Salmonella typhi on page sixty-six of laboratory standing orders. All right, get moving.”

Hastily Bannister scurried to the telephone.

Turning to David Coleman, Pearson asked, “Can you think of anything I’ve forgotten?”

Coleman shook his head. The old man’s grasp of the situation, as well as his celerity and thoroughness, had left Coleman both surprised and impressed. “No,” he said, “I can’t think of a thing.”

For a moment Pearson regarded the younger man. Then he said, “In that case, let’s go and have coffee. It may be the last chance we’ll have for quite a few days.”

Now that Mike Seddons had gone, it came to Vivian just how big a gap his absence left behind and how long-drawn-out the next few days were going to seem without him. She believed, though, she had been right in asking Mike to remain away for a time. It would give them both a chance to adjust and to think clearly about the future. Not that Vivian needed any time to think herself; she was quite sure of her own feelings, but it was faker to Mike this way. Or was it? For the first time it occurred to her that by acting as she had perhaps she was asking Mike to prove his love for her, while accepting her own without question.

But that was not what she had intended. Vivian wondered uneasily, though, if Mike had taken it that way—if she had appeared to him untrusting and unwilling to accept his devotion at face value. He hadn’t seemed to, it was true; but perhaps after thinking things over, as she herself was doing at this moment, he might decide that was the way it was. She speculated on whether she should call him or send a note explaining what she had really intended—that is, if she were sure herself. Was she sure though—even now? At times it was so difficult to think clearly; you started out doing what you thought was right, then you wondered if someone else might misinterpret, might look for hidden meanings that you had never considered yourself. How could you be really sure what was the best thing to do about anything . . . anywhere . . . ever . . . ?

There was a light tap on the door and Mrs. Loburton came in. Seeing her, suddenly Vivian forgot that she was all of nineteen, adult, able to decide things for herself. She held out her arms. “Oh, Mother,” she said, “I’m so terribly mixed up.”

The physical checkups on food handlers were proceeding briskly. In a small consulting room—the first of a row of similar rooms in the outpatients’ department—Dr. Harvey Chandler was concluding his examination of one of the male cooks. “All right,” he said, “you may get dressed.”

At first the chief of medicine had not been sure whether it would be dignified for him to handle some of the physicals himself or not. But eventually he had decided to, his attitude being somewhat that of a commanding officer who feels morally bound to position himself at the head of his troops during a beach-head assault.

Actually Dr. Chandler had been inclined to resent the dominance of the situation up to this point by Drs. O’Donnell and Pearson. O’Donnell was, of course, the medical-board president and entitled to be concerned with the over-all welfare of the hospital. All the same, Chandler reasoned, he was merely a surgeon and typhoid was essentially a matter for internal medicine.

In a sense the chief of medicine felt deprived of a starring role in the present crisis. In some of his more ultimate thoughts Dr. Chandler sometimes pictured himself as a man of destiny, but opportunities to prove the point were all too rare. Now, with an opportunity at hand, he was being relegated, if not to a minor role, at least to a secondary one. He had to admit, however, that the arrangements made by O’Donnell and Pearson appeared to be working well, and at least they all had the common aim of ending this deplorable outbreak of typhoid. Frowning slightly, he told the cook who had now dressed, “Remember to be especially careful about hygiene. And practice absolute cleanliness when you’re working in the kitchen.”

“Yes, Doctor.”

As the man went out Kent O’Donnell came in. “Hi,” he said. “How’s it going?”

Chandler’s first inclination was to reply huffily. Then, he decided, perhaps there was not really that much to be concerned about. And apart from the minor fault of O’Donnell’s being—in Chandler’s opinion—a little too democratic at times, he was a good man to have at the head of the board and certainly a big improvement over his predecessor. Therefore, amiably enough, he answered, “I lost count some time ago. I suppose we’re getting through them. But there’s nothing to show so far.”

“What’s the news of the typhoid patients?” O’Donnell asked. “And the four suspected cases?”

“You can make it four definite now,” Chandler said, “and scratch two of the suspects.”

“Anyone in danger?”

“I don’t think so. Thank God for antibiotics! Fifteen years ago we’d have been in a lot more trouble than we are.”

“Yes, I suppose so.” O’Donnell knew better than to inquire about isolation procedure. For all his pompousness Chandler could always be relied on to do the correct thing medically.

“Two of the patients are nurses,” Chandler said. “One’s from Psychiatry, the other from Urology. The other two are men—a generator-room worker and a clerk from the records office.”

“All from widely separated parts of the hospital,” O’Donnell said thoughtfully.

“Exactly! There’s no common denominator except hospital food. All four took their meals in the hospital cafeteria. I don’t think there’s any question that we’re on the right track.”

“Then I won’t hold you up,” O’Donnell said. “You’ve two more people waiting outside, but some of the other men have more, and we’re shifting them around.”

“Very well,” Chandler said. “I’ll just keep going until we’re clear; nothing must stop us—no matter how long it takes.” He sat in his chair a little straighter. He had the feeling that there was a touch of derring-do and a ring of Old Glory to his own forthright words.

“Right you are,” O’Donnell said. “I’ll leave you to it.”

A little piqued by the casual reaction, the chief of medicine said stiffly, “You might ask the nurse to send in the next one, will you?”

“Sure.”

O’Donnell went out, and a moment later a girl kitchen worker entered. She was holding a card.

Chandler said, “I’ll take that. Sit down, please.” He put the card in front of him and selected a blank case-history sheet.

“Yes, sir,” the girl said.

“Now, first I want your medical history—yourself and your family—as far back as we can go. Let’s start with your parents.”

With the girl responding to his careful questioning, Chandler’s rapidly written notes began to fill the sheet in front of him. As always, when he was finished the result would be a model of good case-history reporting, suitable for inclusion in any medical textbook. One of the reasons Dr. Chandler was chief of medicine at Three Counties was because he was an extremely precise and conscientious clinician.

Walking away from the commandeered outpatients’ department, Kent O’Donnell permitted himself to think, for the first time with any degree of perspective, of some of the day’s events so far. It was now midafternoon, and since this morning so much had happened that it had been impossible to grasp the implications of it all.

In swift and unexpected succession had come, first, the incident of the mis-diagnosed child and, shortly afterward, its death. Then there had followed: Pearson’s firing, Charlie Dornberger’s retirement, the discovery that an elementary hygiene precaution had been neglected in the hospital for more than six months, and now the occurrence of typhoid, with the threat of an even graver epidemic hanging over Three Counties like an avenging sword.

So much, it seemed, had broken loose at once. Why? How had it happened? Was it a sudden symptom of a malaise that, undetected until now, had gripped the hospital? Was there more to come perhaps? Was this the signal of a general disintegration soon to follow? Had they all been guilty of a sense of complacency—of which O’Donnell himself might be the instigator?

He thought: We were all sure, so sure, that this regime was better than the last. We worked to make it so. We believed we were creating and progressing, building a temple of healing, a place where good medicine would be learned and practiced. But have we failed—ignominiously and blindly—through the very goodness of our own intentions? Have we been stupid and unseeing—our eyes on the cloud tops, uplifted by the glister of ideals, yet ignoring the plain earthy warning of everyday events? What have we built here? O’Donnell searched his mind. Is it, in truth, a place of healing? Or have we raised, in folly, a whited sepulcher—an empty, antiseptic shrine?

Preoccupied, his thoughts burning and intense, O’Donnell had strode through the hospital instinctively, unconscious of his surroundings. Now he came to his office and went inside.

He crossed to the window and stood looking down at the hospital forecourt. As always, there was a movement of people, coming and going. He saw a man limping, a woman holding his arm; they passed beneath and out of sight. A car drew up; a man jumped out and helped a woman into it. A nurse appeared, handing the woman a baby. The doors slammed; the car moved on. A boy on crutches came into view; he moved quickly, swinging his body with the ease of practice. He was stopped by an old man in a raincoat; the old man seemed uncertain where to go. The boy pointed. They moved together toward the hospital doors.

O’Donnell thought: They come to us in supplication, holding faith. Are we worthy of it? Do our successes mitigate our failures? Can we, in time, by devotion atone for error? Shall we ever know?

More practically, he reasoned: After today there must be many changes. They must plug gaps—not only those already exposed, but others they would uncover by diligent searching. They must probe for weaknesses—among themselves and in the hospital fabric. There must be greater self-criticism, more self-examination. Let today, he thought, stand as a bright and shining beacon—a cross of sorrow, a signal for a new beginning.

There was much to do, a great deal of work ahead. They would begin with Pathology—the weak spot where tribulation had begun. After that there must be reorganization elsewhere—there were several departments which he suspected were in need of it. It was definite now that work on the new buildings would begin in the spring, and the two programs could merge together. O’Donnell began to plan, his brain functioning swiftly.

The telephone rang sharply.

The operator announced, “Dr. O’Donnell, long distance is calling.”

It was Denise. Her voice had the same soft huskiness that had attracted him before. When they had exchanged greetings she said, “Kent darling, I want you to come to New York this next weekend. I’ve invited some people for Friday night and I intend to show you off.”

He hesitated only a moment. Then he said, “I’m terribly sorry, Denise—I won’t be able to make it.”

“But you must come.” Her voice was insistent. “I’ve sent out the invitations and I can’t possibly cancel them.”

“I’m afraid you don’t understand.” He felt himself struggling awkwardly to find the right words. “We have an epidemic here. I have to stay until it’s cleared up, then for a while at least there’ll be other things that must be done.”

“But you said you’d come, dearest—whenever I called you.” There was the slightest hint of petulance. He found himself wishing he were with Denise. He was sure then that he could make her understand. Or could he?

He answered, “Unfortunately I didn’t know that this would happen.”

“But you’re in charge of the hospital. Surely, just for a day or two, you can make someone else responsible.” It was obvious that Denise had no intention of understanding.

He said quietly, “I’m afraid not.”

There was a silence at the other end of the line. Then Denise said lightly, “I did warn you, Kent—I’m a very possessive person.”

He started to say, “Denise dear, please—” then stopped.

“Is that really your final answer?” The voice on the phone was still soft, almost caressing.

“It has to be,” he said. “I’m sorry.” He added, “I’ll call you, Denise—just as soon as I can get away.”

“Yes,” she said, “do that, Kent. Good-by.”

“Good-by,” he answered, then thoughtfully replaced the phone.

It was midmorning—the second day of the typhoid outbreak.

As Dr. Pearson had predicted, while a few stool samples had reached the lab yesterday afternoon, the bulk had arrived within the past hour.

The samples, contained in small cardboard cups with lids, were set out in rows on the center table of the pathology lab. Each was identified as to source, and Pearson, seated on a wooden chair at one end of the table, was adding a lab serial number and preparing report sheets on which the culture results would be recorded later.

As Pearson completed the preliminary paper work, he passed each specimen behind him to where David Coleman and John Alexander, working side by side, were preparing the culture plates.

Bannister, alone at a side table, was handling other orders on the lab which McNeil—now enthroned in the pathology office—had decided could not be delayed.

The lab stank.

With the exception of David Coleman all in the room were smoking, Pearson sending forth great clouds of cigar smoke to combat the odor as lids were lifted from the stool-specimen cups. Earlier Pearson had silently offered Coleman a cigar and the younger pathologist had lighted it for a while. But he had found the cigar almost as unpleasant as the undiluted air and had allowed it to go out.

The youthful hospital messenger who was Bannister’s avowed enemy had derived great satisfaction from bringing the specimens in, and with each new batch he had a fresh line of banter to accompany it. On his first trip he had looked at Bannister and announced, “They certainly found the right place to send this stuff.” Later he had told Coleman, “Got six new flavors for you, Doctor.” Now, setting a series of cartons in front of Pearson, he had asked, “You like cream and sugar in yours, sir?” Pearson grunted and went on writing.

John Alexander was working methodically, his mind concentrated on the work in hand. With the same fluidity of movement which David Coleman had noted at their first meeting he reached for a specimen cup and removed the cardboard lid. He pulled a petri dish toward him and, using a crayon pencil, copied the number from the lid onto the dish. Now he took a small platinum loop fixed to the end of a wooden handle and sterilized it in a burner flame. Next he passed the loop through the stool specimen, transferring a small portion of it to a tube of sterile saline. He repeated the process, then, using the platinum loop again, planted some of the solution on the culture plate, moving the loop in even, steady strokes.

Now he labeled the saline tube and placed it in a rack. The petri dish, with its culture plate, he carried across the lab to an incubator. There it would remain until the following day when subcultures, if necessary, could be begun. The process was one which could not be hurried.

He turned away to find David Coleman close behind him. On impulse Alexander said quietly, conscious of Pearson across the room, “Doctor, there’s something I wanted to tell you.”

“What is it?” Coleman added a petri dish himself to the incubator and closed the door.

“I . . . that is, we . . . have decided to take your advice. I’m going to apply for medical school.”

“I’m glad.” Coleman spoke with genuine feeling. “I’m sure it will turn out well.”

“What will turn out well?” It was Pearson, his head lifted, watching.

Coleman went back to his work position, seated himself, and opened a new specimen. He said matter-of-factly, “John’s just told me he’s decided to apply for medical school. I advised him some time ago that he should.”

“Oh.” Pearson looked at Alexander sharply. He asked, “How will you afford it?”

“My wife can work, for one thing, Doctor. And then I thought I might get some lab work out of school hours; a lot of medical students do.” Alexander paused, then, glancing at Coleman, he added, “I don’t imagine it will be easy. But we think it will be worth it.”

“I see.” Pearson had blown out smoke; now he put down his cigar. He seemed about to say something else, then hesitated. Finally he asked, “How is your wife?”

Quietly Alexander answered, “She’ll be all right. Thank you.”

For a moment there was silence. Then Pearson said slowly, “I wish there was something I could say to you.” He paused. “But I don’t suppose words would do very much good.”

Alexander met the old man’s eyes. “No, Dr. Pearson,” he said, “I don’t believe they would.”

Alone in her hospital room, Vivian had been trying to read a novel which her mother had brought, but her mind would not register the words. She sighed and put the book down. At this moment she wished desperately that she had not forced Mike into promising to stay away. She wondered: should she send for him? Her eyes went to the telephone; if she called he would come, probably within minutes. Did it really matter—this silly idea of hers of a few days’ separation for them both to think things over? After all, they were in love; wasn’t that enough? Should she call? Her hand wavered. She was on the point of picking up the receiver when her sense of purpose won out. No! She would wait. This was already the second day. The other three would go quickly, then she would have Mike to herself—for good and all.

In the house-staff common room, off duty for half an hour, Mike Seddons lay back in one of the deep leather armchairs. He was doing exactly what Vivian had told him—thinking of what it would be like living with a wife who had only one leg.