The Final Diagnosis

In an annex to the autopsy room Roger McNeil, the pathology resident, was almost ready for gross conference. All that was necessary to begin was the presence of Dr. Joseph Pearson.

At Three Counties, as at many hospitals, a gross conference was the second stage after autopsy. Half an hour ago George Rinne, diener of the morgue, had brought in the organs removed at three autopsies earlier in the week. Two sets of organs now stood neatly arrayed in white enameled pails, and alongside them, in glass jars, were three brains. Centerpiece of the gross-conference room was a stone table with a large sink let into it and with a water tap above. At present the tap was turned on and beneath it was the third pail of organs, the water washing out the formalin in which the organs had been preserved, as well as some of the more objectionable odor.

McNeil looked around, making a final check. Pearson was always irascible if everything was not ready at hand. McNeil reflected that the room in which they did their work was appropriately macabre - particularly when the organs were laid out, as they would be in a few minutes, making the place look somewhat like a butcher's shop. He had been in hospital dissecting rooms where everything was gleaming stainless steel; but that was the modern way which had not touched Three Counties' pathology department yet. Now he heard the familiar, half-shuffling footsteps, and Pearson came in, the inevitable cloud of cigar smoke with him.

"Can't waste any time." Pearson seldom bothered with preliminaries. "It's a week and a half since I had that set-to with O'Donnell, and we're still behind." The cigar bobbed up and down. "When this is through I want a check on all surgicals outstanding. What's the first case?" While he had been talking he had put on a black rubber apron and rubber gloves. Now he came to the center table and sat down at it. McNeil perched himself on a stool opposite and looked over the case notes.

"Fifty-five-year-old woman. Physician's cause of death, carcinoma of the breast."

"Let me see." Pearson reached for the file. Sometimes he would sit patiently while the resident described a case; at other times he would want to read everything himself. In this, as in all things, he was unpredictable.

"Hm." He put down the papers and turned off the running water. Then he reached into the pail and groped around until he found the heart. He opened it, using both hands.

"Did you cut this?"

The resident shook his head.

"I didn't think so." Pearson peered at the heart again. "Seddons?"

McNeil nodded a little reluctantly. He had noticed himself that the heart was badly cut.

"He left the mark of Zorro." Pearson grinned. "Looks like he was dueling with it. By the way, where is Seddons?"

"I believe there was something in surgery. A procedure he wanted to see."

"Tell him from me that while any resident is assigned to Pathology I expect him at all gross conferences. All right, let's get on with it."

McNeil balanced a clip board on his knee and prepared to write. Pearson dictated: "Heart shows a slight thickening and rolling of the mitral valve. See it there?" He held it out.

Leaning across, McNeil answered, "Yes, I do."

Pearson continued, "The chordae tendineae are fused, shortened and thickened." He added casually, "Looks as if she had an old rheumatic fever. It was not a cause of death though."

He cut away a small portion of tissue and put it into a labeled jar about the size of an ink bottle. This was for microscopic examination later. Then with the ease of long practice he tossed the remainder of the heart accurately into a hole lower down the table. Beneath the hole was a metal bin. Later in the day this would be cleared and cleaned, the contents being burned to fine ash in a special incinerator.

Now Pearson had the lungs. He opened the first lung like the two big leaves of a book, then dictated to McNeil, "Lungs show multiple metastatic nodules." Again he held out the tissue for the resident to see.

He had turned his attention to the second lung when a door behind him opened.

"You busy, Dr. Pearson?"

Pearson turned around irritably. The voice was that of Carl Bannister, senior lab technician in the pathology department. Bannister had his head around the door tentatively, and there was another figure behind him in the corridor.

"Of course I'm busy. What do you want?" It was the tone, half snarling, half bantering, Pearson habitually used to Bannister. Over the years the two of them had become accustomed to it; anything more cordial would probably have confused both.

Bannister was unperturbed. He beckoned to the figure behind him. "Come inside." Then to Pearson he said, "This is John Alexander. You remember - our new lab technician. You hired him a week ago. He starts work today."

"Oh yes. I'd forgotten this was the day. Come in." Pearson sounded more cordial than he had been with Bannister. McNeil thought: Maybe he doesn't want to scare a new employee first day out.

McNeil looked curiously at the newcomer. Twenty-two, he figured; later he was to learn he was exactly right. He knew from what he had heard that Alexander was fresh from college with a degree in medical technology. Well, they could do with someone like that around the place. Bannister, for sure, wasn't any Louis Pasteur.

McNeil turned his eyes to the senior technician. As usual, Bannister's appearance made him something of a minor league Pearson. His short, paunchy body was partially covered by a stained lab coat. The coat was not buttoned and the clothes beneath it appeared shabby and unpressed. Bannister was mostly bald, and such hair as was left looked as if it were permanently ignored.

McNeil knew something of Bannister's history. He had come to Three Counties a year or two after Pearson's arrival. He had a high-school education, and Pearson had hired him for odd jobs - stock clerk, messenger, washing glassware. Gradually, as the years passed, Bannister had learned a lot of practical things around the lab, becoming more and more a right hand to Pearson.

Officially Bannister's work was in serology and biochemistry. But he had been in the department so long that he could fill La if necessary, and often did, for technicians in other sections of the lab. Because of this Pearson had pushed a good deal of administrative lab work onto Bannister, leaving him, in effect, in charge of all pathology technicians.

McNeil thought it likely that in Bannister's heyday he had been a good technician who, with more education, might have risen to better things. As it was now, McNeil considered Bannister long on experience and short on theory. From observation the resident knew that much of Bannister's work in the lab was from rote rather than reasoning. He could do serologic and chemical tests but without any real understanding of the science behind them. McNeil had often thought that one day this might prove dangerous.

Alexander, of course, was a different proposition. He had come the way of most lab technicians nowadays, with three years of college behind him, the last year in an approved school for medical technologists. The word "technologist" was sometimes a sore point with people like Bannister who only rated the styling "technician."

Pearson waved his cigar at the remaining stool around the table. "Sit down, John."

"Thank you, Doctor," Alexander answered politely. In his spotless lab coat, with a recent crew cut, pressed pants, and shined shoes, he presented a contrast to Pearson as well as Bannister.

"Do you think you'll like it here?" Pearson looked down at the lungs he was holding, continuing the examination while he talked.

"I'm sure I will, Doctor."

Nice kid, this, McNeil thought. He sounds as if he means it.

"Well, John," Pearson was saying, "you'll discover we have certain ways of doing things. They may not always be the ways you've been used to, but we find they work pretty well for us."

"I understand, Doctor."

Do you? McNeil thought Do you understand what the old man is really telling you? - that he doesn't want any changes around the place, that there's to be no nonsense with ideas you may have picked up in school, that nothing in the department - no matter how trifling - is to be amended without his blessing.

"Some people might say we're old-fashioned," Pearson continued. He was being friendly enough in his way. "But we believe in tried and tested methods. Eh, Carl?"

Called on for endorsement, Bannister was quick to answer. "That's right, Doctor."

Pearson had finished with the lungs now and, dipping into the pail, somewhat like drawing a lottery, had come up with a stomach. He grunted, then held out an open section to McNeil. "See that?"

The resident nodded. "I saw it before. We have it listed."

"All right." Pearson motioned to the clip board, then he dictated, "There is a peptic ulcer lying just below the pyloric ring in the duodenum."

Alexander had shifted slightly to get a better look. Pearson saw his movement and slid the organ across. "Are you interested in dissection, John?"

Alexander answered respectfully, "I've always been interested in anatomy, Doctor."

"As well as lab work, eh?" McNeil sensed that Pearson was pleased. Pathological anatomy was the old man's first love.

"Yes, sir."

"Well, these are the organs of a fifty-five-year-old woman." Pearson turned over the case-history pages in front of him. Alexander was raptly attentive. "Interesting history, this case. The patient was a widow, and the immediate cause of death was cancer of the breast. For two years before she died her children knew she had trouble but they couldn't persuade her to see a physician. It seems she had a prejudice against them."

"Some people do." It was Bannister. He gave a high-pitched giggle which dried up as he caught Pearson's eye.

"Just cut out the snide remarks. I'm giving John here some information. Might not do you any harm either." Anyone but Bannister would have been crushed by Pearson's rejoinder. As it was, the technician merely grinned.

"What happened, Doctor?" Alexander asked.

"It says here: 'Daughter states that for the past two years the family has been noticing drainage from the mother's left breast area. Fourteen months before admission bleeding was noticed from the same area. Otherwise she appeared in normal health.' "

Pearson turned a page. "It seems this woman went to a faith healer." He chuckled grimly. "Guess she didn't have enough faith, though, because she finally collapsed and they brought her to this hospital."

"By then, I suppose, it was too late."

This isn't politeness, McNeil thought. This guy Alexander is really interested.

"Yeah," Pearson answered. "But if she had gone to a doctor at the beginning she could have had a radical mastectomy - that's removal of the breast."

"Yes, sir. I know."

"If she'd had that she might still be alive." Pearson tossed the stomach neatly through the hole.

Something was troubling Alexander. He asked, "Didn't you just say, though, she had a peptic ulcer?"

Good for you, McNeil thought. Pearson, it seemed, had the same reaction, for he turned to Bannister. "There you are, Carl. Here's a boy who keeps his ears open. You watch out or he'll be showing you up."

Bannister was grinning, but McNeil suspected a little sourness. What had been said might prove uncomfortably true. "Well, John" - Pearson was really expansive now - "she might have had trouble with that. Then again she might not."

"You mean she'd never have known about it?"

McNeil thought it was time he said something himself. "It's surprising," he told Alexander, "what people have wrong with them besides the things they die of. Things they never know about. You see a lot of that here."

"That's right." Pearson nodded agreement. "You know, John, the remarkable thing about the human body is not what kills us but what we can have wrong inside and still go on living." He paused, then abruptly changed the subject. "Are you married?"

"Yes, sir. I am."

"Your wife here with you?"

"Not yet. She's coming next week. I thought I'd find us a place to live first."

McNeil remembered that Alexander had been one of the out-of-town applicants for the job at Three Counties. He seemed to recall that Chicago had been mentioned.

Alexander hesitated, then he added, "There was something I wanted to ask you, Dr. Pearson."

"What's that?" The old man sounded wary.

"My wife is pregnant, Doctor, and coming into a new town, we don't know anyone." Alexander paused. "This baby is pretty important to us. You see, we lost our first child. A month after she was born."

"I see." Pearson had stopped work now and was listening carefully.

"I was wondering, Doctor, if you could recommend an obstetrician my wife could go to."

"That's easy." Pearson sounded relieved. Plainly he had wondered what was coming. "Dr. Dornberger's a good man. He has an office right here in the hospital. Would you like me to call him?"

"If it's not too much trouble."

Pearson motioned to Bannister. "See if he's in."

Bannister picked up the telephone behind them and asked for an extension. After a pause he said, "He's in," and offered the instrument to Pearson.

With both hands gloved and wet, the old man motioned his head irritably. "Hold it! Hold it!"

Bannister moved in closer and held the receiver against Pearson's ear.

"That you, Charlie?" The pathologist boomed into the mouthpiece. "I've got a patient for you."

In his office three floors above Dr. Charles Dornberger smiled and moved the telephone slightly away from his ear. He asked, "What can obstetrics do for your kind of patients?" At the same time he reflected that this call was convenient. Since the meeting which O'Donnell had called yesterday, Charles Dornberger had speculated on the best method of approach to Joe Pearson. Now, it seemed, an opportunity was presenting itself.

Down in Pathology Pearson maneuvered the cigar to a corner of his mouth. He always enjoyed exchanges with Dornberger.

"This isn't a dead patient, you old fool. It's a live one. Wife of one of my lab boys here - Mrs. John Alexander. They're new in town. Don't know anybody."

As Pearson mentioned the name Dornberger opened a file drawer and selected a blank card.

"Just a minute." He cradled the phone in his shoulder and, using his left hand to hold the card, wrote in a fine script with the right, "Alexander, Mrs. John." It was typical of Dornberger's organized approach to his practice that this was the first thing he did. Now he said, "Be glad to oblige, Joe. Will you have them call me for an appointment?"

"All right. Be some time next week. Mrs. Alexander won't be in town till then." He grinned at Alexander, then added, still almost shouting, "And if they want twins, Charlie, it's up to you to see they get them."

Pearson listened to Dornberger's answer and chuckled. A thought struck him. "And hey! Another thing! None of your fancy fees for this job. I don't want the boy coming to me for a raise so he can pay his doctor's bill."

Dornberger smiled. He said, "Don't worry." On the card he made a notation, "Hospital employee." It was a signal to himself that this was a patient he would charge no fee. Into the phone he said, "Joe, there's something I want to talk to you about. When would be a convenient time to come and see you?"

"Can't make it today, Charlie," Pearson said. "Got a full schedule. How about tomorrow?"

Dornberger consulted his own appointment list. "I'm crowded tomorrow myself. Let's make it the day after. How about around ten in the morning? I'll come to your office."

"That'll be all right. Unless you want to tell me now - on the phone." Pearson's voice sounded curious.

"No, Joe," Dornberger said, "I'd rather come and see you."

In Pathology Pearson answered, "All right, Charlie. See you then. So long." Impatiently he motioned the telephone away and Bannister replaced it.

To Alexander, Pearson said, "That's all fixed. Your wife can be admitted to this hospital when she comes to term. Because you're an employee you'll get a twenty per cent discount on your bill."

Alexander was beaming. McNeil thought: Yes, go ahead; enjoy it, my friend. This is one of the old man's good moments. But make no mistake - there'll be others, and those you won't enjoy at all.

"I'll only be a moment." In his office Dornberger smiled at the student nurse who had come in while he was talking with Pearson. He motioned her to the chair alongside his desk.

"Thank you, Doctor." Vivian Loburton had brought a patient's chart that Dornberger had asked to see. Ordinarily physicians didn't get this kind of service; they would have to walk to the ward and look at the chart there. But Dornberger was a favorite with the nurses; they were always doing little things for him, and when he had phoned a few minutes ago the staff nurse had sent Vivian off promptly.

"I like to do one thing at a time when I can." Dornberger was writing in pencil now, noting on the card the new facts Joe Pearson had given him. Later, when he had more information from the patient, he would erase the pencil notes and complete the card in ink. Still writing, he asked the girl, "You're new here, aren't you?"

"Fairly new, Doctor," Vivian said. "This is my fourth month in nursing school."

He noticed she had a soft voice with a lilt. Pretty too. He wondered if she had slept yet with any of the interns or residents. Or had things changed since his own student years? He occasionally suspected that interns and residents nowadays were getting more conservative than they used to be. A pity. If true, they were missing a good deal. Aloud he said, "That was Dr. Pearson, our pathologist. Have you met him yet?"

"Yes," Vivian said. "Our class went to an autopsy."

"Oh dear. How did you . . ." He was going to say "like it" but changed it to, "How did you find it?"

Vivian considered. "At first it was rather a shock. Afterward I didn't mind too much though."

He nodded sympathetically. He had finished writing now and put the card away. This had been a quieter day than usual; it was a luxury to be able to clean up one piece of work before going on to another. He held out his hand for the chart. "Thank you." He added, "I'll only be a moment with this, if you'd like to wait."

"All right, Doctor." Vivian decided a few more minutes' respite from the rush of ward work would be welcome. She settled back in the chair. It was cool in here with the air conditioning. There was no such luxury in the nurses' home.

Vivian watched Dr. Dornberger as he studied the chart. He was probably about the same age as Dr. Pearson, she thought, but certainly a lot different to look at. While the pathologist was round-faced and heavy-jowled, Dr. Dornberger was lean and angular. In other ways, too, his appearance was a contrast, with the thatch of white hair carefully combed and parted. She noticed his hands were manicured, his white hospital jacket pressed and spotless.

Dornberger handed back the chart. "Thank you," he said. "It was good of you to bring it." He has a sparkle to him, Vivian thought. She had heard he was much beloved by his women patients. There was little need to wonder why.

"We'll be seeing each other, I expect." Dornberger had risen and opened the door courteously. "Good luck in your studies."

"Good-by, Doctor." She went out, leaving a trace of fragrance behind her, Dornberger thought. Not for the first time the contact with someone youthful left him wondering about himself. He returned to the swivel chair and leaned back meditatively. Almost absently he took out his pipe and began to fill it.

He had been in medicine now for almost thirty-two years; in a week or two he would being his thirty-third. They had been full years and rewarding ones. Financially he had no problems. His own four children were married, and he and his wife could live comfortably on the careful investments he had made. But would he be content to retire and rusticate? That was the rub.

In all his years in medicine Charles Dornberger had prided himself in keeping up to date. He had made up his mind long ago that no young newcomer was going to surpass him, either in technique or knowledge. As a result he had read avidly and still continued to do so. He subscribed to many of the medical journals which he read thoroughly and occasionally contributed articles himself. He was a regular attender at medical conventions and conscientiously took in most of the business sessions. Early in his career, long before the present boundary lines were drawn in medicine, he had foreseen the need for specialization. His own choice had been obstetrics and gynecology. It was a choice he had never regretted, and he often felt it had helped him to keep young in mind.

Because of this by the mid-thirties, when American specialty boards were coming into being, Dornberger was already established in his own field. As a result, under the so-called "grandfather" clause, he had been given Board certification without examination. It was something he had always been proud of. If anything, it had made him keener still to remain up to date.

And yet he had never resented younger men. When he had felt them to be good and conscientious, he had gone out of his way to offer help and advice. He admired and respected O'Donnell. He considered the youthful chief of surgery one of the best things that had ever happened to Three Counties. His own morale had risen with O'Donnell's changes and progress in the hospital.

He had made many friends, some among his own immediate colleagues, others in unlikely places. Joe Pearson might be called one of the unlikely ones. Professionally the two men looked at a lot of things in different ways. Dornberger knew, for example, that Joe did not read much these days. He suspected that in a few areas of knowledge the elderly pathologist had slipped behind the times, and, administratively, there was the problem which yesterday's meeting had revealed. And yet, over the years, the bond between the two men had grown strong. To his own surprise sometimes he had found himself siding with Pearson at medical conferences and defending him occasionally when Pathology was criticized in private.

Dornberger's interjection ten days ago at the mortality conference had been much like that. He supposed other people recognized the alliance between himself and Joe. What was it Gil Bartlett had said? "You're a friend of his; and besides he doesn't have a vendetta with obstetricians." Until this moment he had forgotten the remark, but he realized now it had had an edge of bitterness and he was sorry about that. Bartlett was a good physician, and Dornberger made a mental note to be especially cordial next time they met.

But there was still his own problem. To quit or not to quit? And if he did quit, when? Just lately, despite his carefully guarded physical fitness, he had found himself tiring. And although he had spent a lifetime answering night calls, lately they had seemed harder to take. Yesterday at lunch he had heard Kersh, the dermatologist, telling a new intern, "You should join us in the skin game, son. Haven't been called out at night in fifteen years." Dornberger had laughed with the rest but harbored a little secret envy.

One thing he was sure of though. He would not hang on if he found himself weakening. Right now he knew he was as good as ever. His mind was clear, his hands steady and eyes sharp. He always watched himself carefully because he knew that at the first sign of failing he would not hesitate. He would clear his desk and go. He had seen too many others try to stay the course too long. That would never be for him.

But as for the present, well, maybe he would let things go another three months, then think it over.

By this time he had packed the tobacco tightly in his pipe and now he reached for a folder of matches. He was about to strike one when the telephone rang. Putting down pipe and matches, he answered it. "Dr. Dornberger speaking."

It was one of his patients. She had begun labor pains an hour ago. Now her membranes had ruptured and she had discharged water. She was a young girl in her early twenties, and it would be her first baby. She sounded breathless, as if nervous but trying not to be.

As he had so many times before, Dornberger gave his instructions quietly. "Is your husband at home?"

"Yes, Doctor."

"Then get your things together and have him drive you to the hospital. I'll see you after you've arrived."

"Very well, Doctor."

"Tell your husband to drive carefully and stop at all the red lights. We've plenty of time. You'll see."

He could sense, even over the phone, that he had helped her to relax. It was something he did often, and he considered it as much a part of his job as any course of treatment. Nevertheless he felt his own senses quickening. A new case always had that effect. Logically, he thought, he should have lost the feeling long ago. As you grew older in medicine you were supposed to become impervious, mechanical and unsentimental. It had never worked that way for him, though - perhaps because, even now, he was doing what he loved to do most.

He reached for his pipe, then changed his mind and picked up the telephone again. He must let Obstetrics know that his patient was coming in.