The Final Diagnosis

The Final Diagnosis Page 9

"Give me the details."

Hunched over the binocular microscope, Dr. Joseph Pearson half grunted the words to Roger McNeil.

The pathology resident looked at his folder of notes. "Case was a forty-year-old man, admitted for appendicitis." McNeil was seated opposite Pearson at the desk of the pathology office.

Pearson took out the slide he had been studying and substituted another. He asked, "What did the tissue look like at gross?"

McNeil, who had made the gross examination when the removed appendix came down from the operating room, said, "Grossly it looked normal enough to me."

"Hm." Pearson moved the slide around. Then he said, "Wait a minute; here's something." After a pause he slipped the second slide out and selected a third. Now he said, "Here it is - an acute appendicitis. It was just beginning in this section. Who was the surgeon?"

McNeil answered, "Dr. Bartlett."

Pearson nodded. "He got it good and early. Take a look." He made way at the microscope for McNeil.

Working with the resident, as the hospital's teaching program required him to, Pearson was endeavoring to catch up on the pathology department's surgical reports.

Despite his best efforts, though, both men knew they were seriously in arrears with work. The slides being studied now had been sectioned from a patient's appendix removed several weeks earlier. The patient had long since been discharged, and in this case the report would merely confirm or deny the surgeon's original diagnosis. In this instance Gil Bartlett had been entirely right, in fact, creditably so, since he had caught the disease in its early stages and before the patient could have had much distress.

"Next." Pearson moved back to the microscope as McNeil returned to the other side of the desk.

The resident pushed over a slide folder and, as Pearson opened it, McNeil consulted a fresh set of notes. As they worked Bannister entered the room quietly. With a glance at the other two he passed behind them and began to file papers into a cabinet.

"This is a current one," McNeil said. "It came down five days ago. They're waiting to hear what we say."

"You'd better give me any like this first," Pearson said sourly, "otherwise there'll be more bleating from upstairs."

McNeil was on the point of saying that several weeks ago he had suggested changing their procedure in just that way, but Pearson had insisted on reviewing all specimens in the order they came into the department. However, the resident checked himself. Why bother? he thought. He told Pearson, "It's a fifty-six-year-old woman. The specimen is a skin lesion - superficially a mole. Question is: Is it a malignant melanoma?"

Pearson put in the first slide and moved it around. Then he nipped over the highest-powered lens and adjusted the binocular eyepiece. "It could be." He took the second slide, then two more. After that he sat back thoughtfully. "On the other hand it could be a blue nevus. Let's see what you think."

McNeil moved in. This one, he knew, was important. A malignant melanoma was a tumor that was viciously malignant. Its cells could spread rapidly and murderously in the body. If diagnosed as such from the small portion already removed, it would mean immediate major surgery for the woman patient. But a blue nevus tumor was entirely harmless. It could stay where it was in the body, doing no harm, for the rest of the woman's life.

From his own studies McNeil knew that a malignant melanoma was not common, but he also knew that a blue nevus was extremely rare. Mathematically the odds were on this being malignant. But this was not mathematics. It was pathology at its purest.

As he had learned to do, McNeil ran over in his mind the comparative features of the two types of tumor. They were distressingly similar. Both were partly scarred, partly cellular, with a good deal of pigmentation in them. Again, in both, the cellular structure was very pronounced. Something else McNeil had been taught was to be honest. After looking at all the slides he said to Pearson, "I don't know." He added, "What about previous cases? Could we get any out? To compare them."

"It'd take us a year to find any. I don't remember when I last had a blue nevus." Pearson was frowning. He said heavily, "One of these days we've got to set up a cross file. Then when a doubtful case like this comes up we can go back and compare it."

"You've been saying that for five years." Bannister's dry voice came from behind, and Pearson wheeled. "What are you doing here?"

"Filing." The senior lab technician answered laconically. "Something the clerks should be doing if we had some proper help."

And probably a lot better, McNeil thought. He knew the department badly needed more clerical staff and the filing methods used now were hopelessly archaic. The reference to a cross file, too, had reminded him of a gaping hole in their administrative system. There were few good hospitals now whose pathology departments did not have one. Some called them organ-lesion files, but, whatever the name, one purpose of the system was to help resolve the kind of problem they were facing at this moment.

Pearson was studying the slides again. He mumbled, as a lot of pathologists did when they were mentally crossing off some factors and confirming others. McNeil heard, "It's a little small . . . absence of hemorrhage . . . no necrosis of the tissue . . . negative but no indication . . . yes, I'm satisfied." Pearson straightened up from the microscope, replaced the last slide, and closed the slide folder. Motioning to the resident to write, he said, "Diagnosis - a blue nevus." Courtesy of Pathology, the woman patient had been reprieved.

Methodically, for McNeil's benefit, Pearson ran over the reasons for his decision again. As he passed the slide folder he added, "You'd better study these. It's a specimen you won't see often."

McNeil had no doubt that the old man's finding was right. This was one place where years of experience paid off, and he had come to respect Pearson's judgment in matters of pathological anatomy. But when you've gone, he thought, looking at the old man, that's when this place will need a cross file - badly.

They studied two more cases, both fairly straightforward, then Pearson slipped in the first slide from the next series. He took one look through the microscope eyepiece, straightened up, and told McNeil explosively, "Get Bannister!"

"I'm still here." It was Bannister, calmly, behind them at the file cabinets.

Pearson wheeled. "Look at this!" He was using his loudest, hectoring voice. "How many times do I have to give instructions about the way I want slides made? What's wrong with the technicians in Histology? Are they deaf or just plain stupid?"

McNeil had heard the same kind of outburst before. He sat back and watched as Bannister asked, "What's the trouble?"

"I'll tell you what's the trouble." Pearson ripped the slide from his microscope and tossed it across the table. "How can I give a proper diagnosis with this kind of tissue section?"

The senior lab technician picked up the slide and held it to the light. "Too thick, eh?"

"Of course it's too thick." Pearson picked out a second slide from the same set. "Look at this one. If I had some bread I could scrape off the meat and make a sandwich."

Bannister grinned. "I'll check the microtome. We've been having trouble with it." He pointed to the slide folder. "Do you want me to take these away?"

"No. I'll have to make do with them." The explosiveness had gone now; the old man was merely growling. "Just do a better job in supervising Histology."

Bannister, disagreeable himself by this time, grumbled on his way to the door. "Maybe if I didn't have so much else . . ."

Pearson shouted after him, "All right. I've heard that record before."

As Bannister reached the door, there was a light tap and Dr. Charles Dornberger appeared. He asked, "May I come in, Joe?"

"Sure." Pearson grinned. "You might even learn something, Charlie."

The obstetrician nodded pleasantly to McNeil, then said casually to Pearson, "This was the morning I arranged to come down. Had you forgotten?"

"Yes, I had." Pearson pushed the slide folder away from him. He asked the resident, "How many more in this batch?"

McNeil counted the slide folders remaining. "Eight."

"We'll finish later."

The resident began to gather up the case papers already completed.

Dornberger took out his pipe and leisurely filled it. Looking around the big drab room, he shivered. He said, "This place feels damp, Joe. Every time I come here I feel like I'm going to get a chill."

Pearson gave a deep chuckle. He said, "We spray flu germs around - every morning. It discourages visitors." He watched McNeil cross the room and go out of the door. Then he asked, "What's on your mind?"

Dornberger wasted no time. He said, "I'm a deputation. I'm supposed to handle you tactfully." He put the pipe in his mouth, his tobacco pouch away.

Pearson looked up. "What is this? More trouble?"

Their eyes met. Dornberger said quietly, "That depends." After a pause he added, "But it looks as if you may get a new assistant pathologist."

Dornberger had expected an outburst, but Pearson was strangely quiet. He said thoughtfully, "Whether I want one or not, eh?"

"Yes, Joe." Dornberger made it definite; there was no point in holding back. He had thought a good deal about this since the meeting of several days ago.

"I suppose O'Donnell is back of this." Pearson said it with a touch of bitterness but still quietly. As always, he was being unpredictable.

Dornberger answered, "Partly but not entirely."

Again surprisingly, "What do you think I should do?" It was a question asked by one friend of another.

Dornberger laid his pipe, unlighted, in an ash tray on Pearson's desk. He was thinking: I'm glad he's taking it this way. It means I was right. I can help him accept this, adjust to it. Aloud he said, "I don't believe you've much choice, Joe. You are behind with surgical reports, aren't you? And a few other things?"

For a moment he thought he had gone too far. This was a sensitive area. He saw the other man brace up and waited for the storm to break. But again it did not. Instead, more strongly than before, but reasonably, Pearson said, "Sure, a few things need straightening out. I'll admit that to you. But there's nothing I can't handle myself - if I can just get the time to do it."

He has accepted it, Dornberger thought. He's sounding off now. But he has accepted it just the same. He said casually, "Well, maybe you'll get the time - with another pathologist." With equal casualness he pulled from his inside pocket the paper which the administrator had given him.

Pearson asked, "What's that?"

"There's nothing definite about this, Joe. It's a name that Harry Tomaselli had - apparently some young fellow who might be interested in coming here."

Pearson took the single sheet. He said, "They sure didn't waste any time."

Dornberger said lightly, "Our administrator is a man of action."

Pearson was scanning the paper. He read aloud, "Dr. David Coleman." There was a pause. Then with bitterness, frustration, and envy the old man added, "Age thirty-one."

It was twenty minutes after midday, and the hospital cafeteria was at its busiest. Most of the doctors, nurses, and hospital employees usually took their lunch about this time, and a line-up was beginning to form at the point where newcomers collected trays before passing counters and steam tables where the food was served.

Mrs. Straughan, as usual at this period, had her eye on proceedings, ensuring that as fast as one batch of food was used up another was brought from the kitchens to keep the line out front moving briskly. Today there was a choice of Irish stew, lamb chops, and broiled halibut. The chief dietitian noticed that the lamb chops were moving slowly. She decided to try some herself in a few minutes to see if there were any reason. Perhaps the meat was not as succulent as it might be; word of something like that was often passed to those arriving in the cafeteria by others who were leaving. Mrs. Straughan noticed a dish at the top of a pile on the servery that appeared to have a mark on it. She stepped forward and removed it quickly; sure enough, it still bore traces of an earlier meal. The dishwashing machines again! she thought. Their inadequacy was a recurring problem, and she decided to broach the subject with the administrator again very soon.

Over at the tables reserved for the medical staff there was the sound of noisy laughter. It came from a group of which Dr. Ralph Bell, the radiologist, was the center.

Gil Bartlett, who had come from the serving counter with a tray, put it down and went over with extended hand. "Congratulations, Ding Dong," he said. "I just heard."

"Heard what?" It was Lewis Toynbee, the internist, also with a tray, behind him. Then as Bell, beaming, passed a cigar to Bartlett, Toynbee exclaimed, "My God! Not again?"

"Certainly again. Why not?" The radiologist held out another cigar. "Join us, Lewis. It's exactly eight Bells."

"Eight! When was this?"

Bell said calmly, "This morning. Another boy for the ball team."

Bill Rufus put in, "Don't sound critical, Lewis. He's doing his best. After all, he's only been married eight years."

Lewis Toynbee offered his hand. "Don't squeeze it too tight, Ding Dong. I'm afraid some of that fertility might rub off."

"I'm impervious to jealousy," Bell said good-naturedly. He had been through all this before.

Lucy Grainger asked, "How is your wife?"

Bell answered, "She's fine, thanks."

"How does it feel to be a sex fiend?" The question was from Harvey Chandler, the chief of medicine, lower down the table.

Bell said, "I'm not a sex fiend. At our house we have intercourse once a year. I'm just a dead shot."

Lucy Grainger joined in the ensuing laughter, then she said, "Ralph, I'm sending you a patient this afternoon. It's one of our student nurses - Vivian Loburton."

The laughter had simmered down. "What is it you're looking for?" Bell asked.

"I want you to take some films of the left knee," Lucy answered. Then she added, "There's some sort of growth there. I don't like the look of it."

Back in his own office, Dr. Charles Dornberger had telephoned Kent O'Donnell to report the outcome of the talk with Pearson. At the end he had told the chief of surgery, "I've let Joe know about the man you people have been corresponding with."

O'Donnell had asked, "How did he take it?"

"I wouldn't say he was enthusiastic," Dornberger said. "But I think if you want to have this fellow . . . what's his name - Coleman? . . . if you want to have him come here for a talk, Joe won't be difficult. But I'd suggest you keep Joe posted on everything you do from here on in."

"You can be sure of that," O'Donnell had said. Then, "Thanks, Charlie. Thank you very much."

Afterward Dornberger had made another telephone call. It was to Mrs. John Alexander, who had phoned earlier that morning and left a message. Before calling he had looked up his record card and was reminded that this was the wife of the pathology technologist, referred to him by Joe Pearson. Talking with Mrs. Alexander, he learned that she had just arrived in town to join her husband. They made an appointment for her to come to Dornberger's downtown office the following week.

About the same time that Mrs. Alexander was talking with Dornberger her husband was receiving his first tongue-lashing from Dr. Joseph Pearson. It happened this way.

After Pearson's outburst that morning about the poor-quality surgical slides, Bannister had come back to the serology lab where John Alexander was working and had told him the whole story. By this time Bannister was seething, and later he had taken out some of his own bad humor on the two girl technicians and their male helper who worked in the histology lab next door. Alexander had heard what was said through the doorway which Bannister had left open behind him.

Alexander, though, knew that not all the blame for the bad slides lay with the histology technicians. Even in the short time he had been at the hospital he had sensed the real problem, and afterward he had told Bannister, "You know, Carl, I don't believe it's all their fault. I think they have too much to do."

Bannister had answered sourly, "We've all got too much to do." Then with clumsy sarcasm he had added, "Maybe if you know so much about it you can do your own work and part of theirs as well."

Alexander had declined to be provoked. "I don't think so. But I do think they'd be a lot better off with a tissue-processing machine instead of having to do everything by hand - the old-fashioned way."

"Forget it, kid. It isn't your problem." Bannister had been loftily condescending. "And, besides, anything that means spending money around here is a dead duck before it starts."

Alexander had not argued. But he resolved to raise the subject, the first chance he got, with Dr. Pearson.

He had had to go into Pearson's office that afternoon to leave some lab reports for signature, and he had found the pathologist going through a pile of mail with obvious impatience. Glancing up at Alexander, Pearson had motioned him to put the papers on the desk and had gone on with his reading. Alexander had hesitated, and the old man had barked, "What is it? What is it?"

"Dr. Pearson, I was wondering if I could make a suggestion."

"Now?"

A more experienced hand would have known the tone of voice meant: Leave me alone. Alexander answered, "Yes, sir."

Resignedly Pearson said, "Well?"

A little nervously Alexander began, "It's about speeding up the surgical reports, Doctor." As he mentioned surgical reports, Pearson had put down his letter and looked up sharply. Alexander went on, "I was wondering if you'd ever thought of getting a tissue-processing machine."

"What do you know about tissue processors?" There was an ominous note in Pearson's voice. "And anyway, I thought we put you to work in Serology."

Alexander reminded him, "I did a full course in histology at technologists' school, Doctor." There was a pause. Pearson said nothing, so Alexander went on. "I've used a tissue processor and it's a good machine, sir. It would save us at least a day in preparing slides. Instead of processing tissue by hand through all the solutions, you set the machine overnight and automatically by morning - "

Abruptly Pearson cut in. "I know how it works. I've seen them."

Alexander said, "I see, sir. Then don't you think - "

"I said I've seen these so-called tissue processors and I'm not impressed." Pearson's Voice was harsh and grating. "There's not the quality in the slides that there is with the old hand method. What's more, the machines are expensive. You see these?" He riffled through a stack of typed yellow forms in a tray on his desk.

"Yes, sir."

"They're purchase requisitions. For things I need in this department. And every time I put a bunch through I have a fight with the administrator. He says we're spending too much money."

Alexander had made his first mistake in broaching the suggestion when Pearson had not wanted to hear. Now he made a second error. He mistook Pearson's statement as an invitation to continue the discussion.

He said placatingly, "But surely, if it would save a whole day, maybe two . . ." He became more earnest. "Dr. Pearson, I've seen slides made with a processor and they're good. Perhaps the one you saw wasn't being used properly."

Now the older man had risen from his chair. Whatever the provocation, Alexander had overstepped the bounds between physician and technologist. Head forward, Pearson shouted, "That'll do! I said I'm not interested in a tissue processor, and that's what I meant, and I don't want any argument about it." He came around the desk until he was directly in front of Alexander, his face close to the younger man's. "And there's something else I want you to remember: I'm the pathologist here and I'm running this department. I don't mind suggestions if they're reasonable. But don't get stepping out of line. Understand?"

"Yes, sir. I understand." Crestfallen and miserable, not really understanding at all, John Alexander went back to his work in the lab.

Mike Seddons had been preoccupied all day; several times he had had to check himself and make a conscious effort to pull back his mind to the work he happened to be doing. Once, during an autopsy, McNeil had been forced to warn him, "There's a piece of your hand under that section you're about to slice. We like people to leave here with all the fingers they came with." Seddons had changed his grip hastily; it would not have been the first time that some inexperienced learner had lopped off a gloved finger with one of the razor-edged knives of pathology.

All the same his attention still kept wandering, the question recurring: What was it about Vivian that disturbed him so? She was attractive and desirable, and he was anxious to take her to bed as quickly as possible - Mike Seddons was under no illusions about that. She seemed amenable, too, assuming the pain in her knee the night before had been genuine, and he now believed it was. He hoped she would still feel the same way, though there was no guarantee she would, of course. Some girls were inconsistent like that - you could have the most exotic intimacies with them one day, then the next time round they would reject even the most basic advance, pretending that the earlier incident had never even happened.

But was there something more to Vivian and himself than merely sex? Mike Seddons was beginning to wonder. Certainly none of the earlier episodes - and there had been several - had caused him to do half so much thinking as he was doing right now. A new thought occurred to him: Perhaps if he could get the sex bit out of his system other things might become clearer. He decided to ask Vivian to meet him again; and tonight - assuming she would be free - was as good a time as any.

Vivian had found the note from Mike Seddons when she finished her last class of the day and went back to the student nurses' residence. It had been delivered by hand and was waiting for her in the mail rack under "L." It asked her to be on the hospital's fourth floor near Pediatrics at 9:45 that night. At first she had not intended to go, knowing she would have no reason officially to be in the hospital and she might be in trouble if she ran into any of the nursing supervisors. But she found herself wanting to go, and at 9:40 she crossed the wooden boardwalk between the nurses' home and the main hospital buildings.

Mike was waiting, strolling in the corridor, apparently preoccupied. But as soon as he saw her he motioned to a door and they went inside. It led to an interior stair well, with a metal stairway leading up and down. At this time of night it was quiet and deserted and there would be plenty of warning of anyone's approach. Mike went down half a flight onto the next landing, leading her by the hand. Then he turned, and it seemed the most natural thing in the world that she should go into his arms.

As they kissed she felt Mike's arms tightening and the magic of the night before came sweeping back. At this moment she knew why she had wanted so much to come here. This man with the wild red hair had suddenly become indispensable to her. She wanted him in every way - to be close to him, talk with him, make love with him. It was an electric, exciting feeling she had never known before. He was kissing her cheeks now, her eyes, her ears. His face in her hair, he whispered, "Vivian darling, I've been thinking about you all day. I haven't been able to stop." With both hands he took her face and looked into it. "Do you know what you're doing?" She shook her head. "You're undermining me."

She reached out for him again. "Oh, Mike darling!"

It was hot on the stairway. Vivian felt the warmth of his body against the fire of her own. Now his hands were questing, seeking. She whispered, trembling, "Mike, isn't there somewhere else?"

She felt his hands pause and knew he was considering. He said, "I share a room with Frank Worth. But he's out tonight, won't be back till late. Do you want to take a chance and come to the residents' quarters?"

She hesitated. "What would happen? If we got caught."

"We'd both get thrown out of the hospital." He kissed her again. "At this moment I couldn't care." He took her hand. "Come on."

They went down one flight of stairs and along a corridor. They passed another resident who grinned as he saw them but made no comment. Then more stairs, another corridor. This time a white figure turned out of a doorway just ahead. Vivian's heart leaped as she recognized the night nursing supervisor. But the supervisor did not turn around and went in another doorway before they passed. Then they were in a narrower, quieter corridor with closed doors on each side. There were lights beneath some of the doors, and from one she could hear music. She recognized it as Chopin's Prelude in E Minor; the Burlington Symphony had played it a month or two before.

"In here." Mike had opened a door, and quickly they moved inside. It was dark, but she could make out the shape of bunk beds and an armchair. Behind her she heard the lock click as Mike fastened the catch.

They reached for each other demandingly, urgently. His fingers were at the buttons of her uniform. When they hesitated she helped him. Now she was standing in her slip. For a moment he held her tightly, together savoring the torture of delay. Then, his hands moving gently, tenderly, and with exquisite promise, he lifted the slip over her head. As she moved to the bed she kicked off her shoes. There was a swift movement and then he was with her, his hands helping her again. "Vivian, darling Vivian!"

She scarcely heard him. "Mike, don't wait! Please don't wait!" She felt the contours of his body pressing madly, abandonedly, into her. She responded wildly, fought fiercely to bring him tighter, nearer, deeper. Then suddenly there was nothing else in the world, nothing but a peak of tempestuous ecstasy, now sweeping, searing, surging . . . coming closer, closer, closer.

As they lay quietly together afterward, Vivian could hear the music again, coming faintly from down the hall. It was still Chopin, this time the Etude in E Major. It seemed strange, at this moment, to be identifying a musical composition, but the liquid, haunting melody, heard softly in the darkness, fitted her mood of completion.

Mike reached over and kissed her gently. Then he said, "Vivian dearest, I want to marry you."

She asked him softly, "Mike darling, are you sure?"

The impetuousness of his own words had surprised even himself. Mike had spoken them on impulse, hut suddenly, deeply, he knew them to be true. His objective in avoiding entanglements seemed pointless and shallow; this was an entanglement he wanted, to the exclusion of all others. He knew now what had troubled him today and earlier; at this moment it troubled him no more. Characteristically he answered Vivian's questions with a touch of humor. "Sure I'm sure. Aren't you?"

As her arms went around him Vivian murmured, "I've never been more sure of anything."

"Hey!" Mike broke away and he propped himself on an elbow, facing her. "All this put it out of my mind. What about your knee?"

Vivian smiled mischievously. "It wasn't any trouble tonight, was it?"

After he had kissed her again he asked, "Tell me what Lucy Grainger said."

"She didn't. She had Dr. Bell take some X-rays this afternoon. She said she'd send for me in a couple of days."

Mike said, "I'll be glad when it's cleared up."

Vivian said, "Don't be silly, darling. How could a little bump like that be anything serious?"