The Final Diagnosis (24 page)

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.