The Final Diagnosis

“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.

Trying to keep the contempt out of his voice, Coleman asked, “What do you propose?”

“There’s one thing I can do.”

Pearson had gone back to his desk and picked up the telephone. He pressed a button labeled “Intercom.” After a pause, “Tell Bannister to come in.”

He replaced the phone, then turned to Coleman. “There are two men who are experts in this field—Chollingham in Boston and Earnhart in New York.”

Coleman nodded. “Yes, I’ve heard of their work.”

Bannister entered. “Do you want me?” He glanced at Coleman, then pointedly ignored him.

“Take these slides.” Pearson closed the folder and passed it across the desk. “Get two sets off tonight—air mail, special delivery, and put on an urgent tag. One set is to go to Dr. Chollingham at Boston, the other to Dr. Earnhart in New York. Get the usual covering notes typed; enclose a copy of the case history, and ask both of them to telegraph their findings as quickly as possible.”

“Okay.” The slide folder under his arm, Bannister went out.

At least, Coleman reflected, the old man had handled that part of it efficiently. Getting the two expert opinions in this case was a good idea, cross file or not.

Pearson said, “We ought to get an answer within two or three days. Meanwhile I’d better talk to Lucy Grainger.” He mused. “I won’t tell her much. Just that there’s a slight doubt and we’re getting”—he looked sharply at Coleman—“some outside confirmation.”

Thirteen

Vivian kept very still—bewildered, uncomprehending. This thing could not be happening to her; it must be someone else Dr. Grainger was speaking about. Her thoughts raced. That was it! Somehow the charts of two patients had become mixed. It had happened before in hospitals. Dr. Grainger was busy; she could easily be confused. Perhaps some other patient was even now being told . . .