The Final Diagnosis

“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.