The Final Diagnosis

Boston, Mass.

August 7

Mr. H. N. Tomaselli,

Administrator,

Three Counties Hospital

Burlington, Pa.

Dear Mr. Tomaselli:

Since my visit to Burlington a week ago I have thought a great deal about the appointment in pathology at Three Counties Hospital.

This letter is to advise you that, subject, of course, to your still feeling the same way about me, I have decided to accept the appointment on the terms we discussed.

You mentioned that you were anxious for whoever accepted the post to begin work as soon as possible. There is really nothing to delay me here, and after clearing up a few minor things I could be in Burlington ready to begin on August 15 - that is, in just over a week from now. I trust this will be a convenient arrangement.

In talking with Dr. O'Donnell he mentioned knowing of some bachelor apartments which will be completed soon and are quite near the hospital. I wonder if you have any more information on this subject and, if so, I would be interested to know of it. Meanwhile, perhaps you would be good enough to make a reservation for me at one of the local hotels for arrival August 14.

On the subject of the work I shall be doing at the hospital, there is one point which I felt we did not clear up entirely, and I am mentioning it now in the hope that perhaps you may be able to discuss it with Dr. Pearson sometime before my arrival.

It is my feeling that it would be advantageous, both for the hospital and myself, if there were some clearly defined areas of responsibility where I could have a reasonably free hand, both in general supervision of the day-to-day work and also the carrying-out of any changes of organization and technique which, of course, are always necessary from time to time.

My own wishes in this regard would be to have direct responsibility, within the pathology department, for Serology, Hematology, and Biochemistry, though, of course, assisting Dr. Pearson in pathological anatomy and other matters at any time he might see fit.

As I say, I have raised this point now in the hope that it may be possible for you and Dr. Pearson to consider it before August 15. But please be assured that at all times I will seek to co-operate fully with Dr. Pearson and to serve Three Counties Hospital to the best of my ability.

Yours very truly,

David Coleman, M.D.

Coleman read through the neatly typed letter once more, put it in an envelope, and sealed it. Then, going back to his portable typewriter, he tapped out a similar but slightly shorter note to Dr. Joseph Pearson.

David Coleman left the furnished apartment which he had rented on a short lease for the few months he had been in Boston and walked to a mailbox with both letters. Thinking over what he had written, he still was not sure why he had chosen Three Counties in preference to the seven other posts he had been offered within recent weeks. Certainly it was not the most remunerative. Thought of in financial terms, it was more than halfway down the list. Nor was it a "name" hospital. Two of the other medical centers in which he had been offered employment had names that were internationally renowned. But Three Counties was scarcely known outside the immediate area it served.

Why then? Was it because he was afraid of being lost, swallowed up, in a bigger center? Scarcely, because his own record already showed he could hold his own in that kind of environment. Was it because he felt he would be freer for research in a small place? He certainly hoped to do some research, but if that were what he wanted most he could have chosen a research institute - there had been one on his list - and done nothing else. Was it because of the challenge that he had made his choice? Maybe. There were certainly a lot of things wrong in pathology at Three Counties Hospital. He had seen that just in the two brief days he had spent there last week, following the phone call from the administrator inviting him to visit the hospital and look the situation over. And working with Dr. Pearson was not going to be easy. He had sensed resentment in the older man when they had met, and the administrator had admitted under Coleman's questioning that Pearson had a reputation for being hard to get along with.

So was it because of the challenge? Was that why he had picked Three Counties? Was it? Or was it something else, something quite different? Was it . . . self-mortification? Was it that still - the old specter that had haunted him so long?

Of all his traits of character David Coleman had long suspected pride to be the strongest, and it was a defect he feared and hated most. In his own opinion he had never been able to conquer pride; he spurned it, rejected it, yet always it came back - seemingly strong and indestructible.

Mostly his pride stemmed from an awareness of his own superior intellect. In the company of others he frequently felt himself to be mentally far out front, usually because he was. And, intellectually, everything he had done so far in his life proved this to be true.

As far back as David Coleman could remember, the fruits of scholarship had come to him easily. Learning had proved as simple as breathing. In public school, high school, college, medical school, he had soared above others, taking the highest honors almost as a matter of course. He had a mind which was at once absorbent, analytical, understanding. And proud.

He had first learned about pride in his early years of high school. Like anyone who is naturally brilliant, he was regarded initially by his fellow students with some suspicion. Then, as he made no attempt to conceal his feelings of mental superiority, suspicion turned to dislike and finally to hate.

At the time he had sensed this, but he had not consciously cared until one day the school principal, himself a brilliant scholar and an understanding man, had taken him aside. Even now David Coleman remembered what the other man had said.

"I think you're big enough to take this, so I'm going to spell it out. In these four walls, aside from me, you haven't a single friend."

At first he had not believed it. Then because, above all, he was supremely honest, he had admitted to himself that the fact was true.

Then the principal had said, "You're a brilliant scholar. You know it and there's no reason why you shouldn't. As to what's ahead, you can be anything you choose. You have a remarkably superior mind, Coleman - I may say, unique in my experience. But I warn you: if you want to live with others, sometimes you'll have to seem less superior than you are."

It was a daring thing to say to a young, impressionable man. But the master had not underrated his pupil. Coleman went away with the advice, digested it, analyzed it, and finished up despising himself.

From then on he had worked harder than ever - to rehabilitate himself with a planned program almost of self-mortification. He had begun with games. From as far back as he could remember David Coleman had disliked sports of every kind. At school, so far, he had never participated, and he inclined to the opinion that people who went to sports events and cheered were rather stupid juveniles. But now he turned up at practice - football in winter, baseball in summer. Despite his own first feelings he became expert. At college he found himself in the first teams. And when not playing, as a supporter in college and high school he attended every game, cheering as loudly as the rest.

Yet he was never able to play without a feeling of indifference to games, which he carefully concealed. And he never cheered without an inward uneasiness that he was behaving childishly. It was this which made him believe that, though he had humbled pride, he had never banished it.

His relationship with people had gone much the same way. In the old days, on meeting someone whom he considered intellectually inferior, he had never bothered to conceal his boredom or disinterest. But now, as part of his plan, he went out of his way to be cordial to such people. As a result, in college he had taken on the reputation of a friendly sage. It had become a password among those in academic difficulties to say, "Let's have a bull session with David Coleman. He'll straighten us out." And invariably he did.

By all normal thinking the process should have shaped his feelings for people into a kindlier mold. Time and experience should have made him sympathetic to those less gifted than himself. But he was never sure that it had. Within himself Coleman found he still had the old contempt for mental incompetence. He concealed it, fought it with iron discipline and good acting, but, it seemed, it would never go away.

He had gone into medicine partly because his father, now dead, had been a country doctor and partly because it was something he had always wanted to do himself. But in entering a specific field he had chosen pathology because it was generally considered the least glamorous of the specialties. It was part of his own deliberate process of beating down the inevitable pride.

For a while he believed he had succeeded. Pathology is at times a lonely specialty, cut off as it is from the excitements and pressures of direct contact with hospital patients. But later, as interest and knowledge grew, he found the old contempt returning for those who knew less than he of the hidden mysteries a high-powered microscope revealed. Not to the same extent, though, because inevitably in medicine he met minds which were a match for his own. And still later he found he could relax, lowering some of the iron self-discipline with which he had clad himself. He still met those whom he considered fools - even in medicine there were some. But he never showed it and found occasionally that contact with such people disturbed him less. With such relaxation he began to wonder if at last he had beaten down his old enemy.

He was still wary though. A program of deliberate self-adjustment which had lasted fifteen years was not easy to shake off suddenly. And at times he found it hard to decide whether his motives came from pure choice or were from the habit of sackcloth he had worn so patiently and for so long.

Thus the question to himself on his choice of Three Counties Hospital. Had he chosen it because this was what he really wanted - a medium-size, second-line hospital, without reputation or glamor? Or had it been an old subconscious feeling that here was where his pride would suffer most?

As he mailed the two letters he knew these were questions that only time could answer.

On the seventh floor of the Burlington Medical Arts Building, Elizabeth Alexander dressed herself in the examining room adjoining Dr. Dornberger's office. In the last half-hour Charles Dornberger had given her his usual thorough physical examination, and now he had gone back to his desk. Through the partly opened door she heard him say, "Come and sit down when you're ready, Mrs. Alexander."

Pulling a slip over her head, she answered cheerfully, "I'll just be a minute, Doctor."

Seated at his desk, Dornberger smiled. He liked to have patients who were obviously enjoying pregnancy, and Elizabeth Alexander was. She'll be a good no-nonsense mother, he thought. She seemed an attractive girl, not pretty in the conventional sense, but with a lively personality which more than compensated for it. He glanced at the notes he had recorded earlier; she was twenty-three. When he was a younger man he always took the precaution of having a nurse present when he did physicals on women patients. He had heard of physicians failing to do this and later having nasty accusations hurled at them by unbalanced women. Nowadays, though, he seldom bothered. That, at least, was one advantage of being old.

He called out, "Well, I'd say you're going to have a normal, healthy baby. There don't seem to be any complications."

"That's what Dr. Crossan said." Fastening the belt of a summer green-print dress, Elizabeth emerged from the other room. She seated herself in a chair alongside the desk.

Dornberger checked his notes again. "He was your doctor in Chicago. Is that right?"

"Yes."

"Did he deliver your first child?"

"Yes." Elizabeth opened her purse and took out a slip of paper. "I have his address here, Doctor."

"Thank you. I'll write him for your medical history." Dornberger clipped the paper to his notes. He said matter-of-factly, "What did your first baby die of, Mrs. Alexander?"

"Bronchitis. When she was a month old." Elizabeth said it normally. A year ago the words would have been hard to bring out and she would have had to fight back tears. Now, with another baby coming, the loss seemed easier to accept. But this time her baby would live - of that she was determined.

Dr. Dornberger asked, "Was the delivery normal?"

"Yes," she answered.

He returned to his notes. As if to counter any distress the questions might have caused, he said conversationally, "I understand you've just arrived in Burlington."

"That's right," she said brightly, then added, "My husband is working at Three Counties."

"Yes, Dr. Pearson was telling me." Still writing, he asked, "How does he like it there?"

Elizabeth considered. "John hasn't said too much. But I think he likes it. He's very keen on his work."

Dornberger blotted what he had written. "That's a help. Particularly in pathology." He looked up and smiled. "The rest of us depend very much on the work of the laboratories."

There was a pause while the obstetrician reached in a drawer of his desk. Then, extracting a pad of forms, he said, "Talking of the lab, we must send you for a blood test."

As he wrote on the top form Elizabeth said, "I meant to tell you, Doctor. I'm Rh negative and my husband is Rh positive."

He laughed. "I should have remembered you were the wife of a technologist. We'll have to make it a very thorough check." He tore off the form and gave it to her. "You can take this to the outpatients' department at Three Counties any time."

"Thank you, Doctor." She folded the form and put it in her purse.

On the point of ending the interview Dornberger hesitated. He knew, as most physicians did, that patients frequently had incomplete or wrong ideas about medical matters. When that happened with one of his own patients he was usually at pains to set them straight, even if it meant taking time to do so. In this case the girl had lost her first baby; therefore this second pregnancy was doubly important to her. It was Dornberger's business to see that she had no anxieties.

She had mentioned Rh factors, and obviously the subject was on her mind. Yet he doubted if she had any real understanding of what was involved. He decided to take the time to reassure her.

"Mrs. Alexander," he said, "I want you to be quite clear that, even though you and your husband have differing Rh blood types, it doesn't mean there will necessarily be any problem with the baby. You do understand that?"

"I think so, Doctor." He knew he had been right. In her voice there was a trace of doubt.

Patiently he asked, "Do you understand exactly what is meant by the terms Rh positive and Rh negative?"

She hesitated. "Well, I suppose not. Not exactly anyway."

This was what he had expected. He thought for a moment, then said, "Let me put it as simply as I can. All of us have certain factors in our blood. And when you speak of a 'factor' you might say that it's another name for an 'ingredient.' "

Elizabeth nodded. "I see." She found herself concentrating, adjusting mentally to take in what Dr. Dornberger was saying. For a moment she was reminded, almost nostalgically, of days in class. At school she had always taken pride in her capacity to understand things, to focus on a particular problem - absorbing facts quickly by excluding other things from consciousness. It had made her one of the brighter pupils. She was curious to know if she had retained the ability.

Dornberger continued, "Different human beings have different blood factors. The last time anyone counted there were forty-nine of these factors known to medicine. Most people - you and I, for example - have between fifteen and twenty of them in our own blood stream."

Elizabeth's brain clicked: question one. She asked, "What causes people to be born with different factors?"

"Mostly we inherit them, but that isn't important now. What's important is to remember that some factors are compatible and some are not."

"You mean . . ."

"I mean that when these blood factors are mixed together, some will get along quite happily, but some will fight one another and won't get along at all. That's why we are always careful in blood typing when we give a transfusion. We have to be sure it's the right kind of blood for the person receiving it."

Frowning thoughtfully, Elizabeth said, "And it's the factors that fight each other - the incompatible ones - that cause trouble? When people have babies, I mean." Again her own classroom formula: be clear on each point before going on to the next.

Dornberger answered, "Occasionally they do, but more often they don't. Let's take the case of you and your husband. You say he's Rh positive?"

"That's right."

"Well, that means his blood contains a factor called 'big D.' And because you're Rh negative you don't have any 'big D.' "

Elizabeth nodded slowly. Her mind was registering: Rh negative - no "big D." Using an old memory trick, she quickly made up a mnemonic:

If you haven't got "big D"

Your blood's a minus quantity.

She found Dornberger watching her. "You make it so interesting," she said. "No one's ever explained it like this before."

"Good. Now let's talk about your baby." He pointed to the bulge below her waist. "We don't know yet whether Junior here has Rh-negative blood or Rh-positive. In other words, we don't know if he has any 'big D.' "

For a moment Elizabeth forgot the mental game she was playing. With a trace of anxiety she asked, "What happens if he does? Does it mean that his blood will fight with mine?"

Dornberger said calmly, "There's always that possibility." He told her with a smile, "Now listen very carefully."

She nodded. Her attention was focused again. Briefly, back there, she had let her mind become sidetracked.

He said deliberately, "A baby's blood is always quite separate from the mother's. Nevertheless, in pregnancy, small amounts of the baby's blood often escape into the mother's blood stream. Do you understand that?"

Elizabeth nodded. "Yes."

"Very well then. If the mother is Rh negative and the baby happens to be Rh positive, sometimes that can mean our old friend 'big D' seeps into the mother's blood stream, and he isn't welcome there. Got it?"

Again Elizabeth said, "Yes."

He said slowly, "When that happens, the mother's blood usually creates something we call antibodies, and those antibodies fight the 'big D' and eventually destroy it."

Elizabeth was puzzled. "Then where's the problem?"

"There never is any problem - for the mother. The problem, if there is one, begins when the antibodies - the 'big D' fighters which the mother has created - cross over the placental barrier into the baby's blood stream. You see, although there's no regular movement of blood between mother and baby, the antibodies can, and do, cross over quite freely."

"I see," Elizabeth said slowly. "And you mean the antibodies would start fighting with the baby's blood - and destroying it." She had it now - clearly in her mind.

Dornberger looked at her admiringly. This is one smart girl, he thought. She hadn't missed a thing. Aloud he said, "The antibodies might destroy the baby's blood - or part of it - if we let them. That's a condition we call Erythroblastosis Foetalis."

"But how do you stop it happening?"

"If it happens we can't stop it. But we can combat it. In the first place, as soon as there are any antibodies in the mother's blood we get a warning through a blood-sensitization test. That test will be done on your blood - now and later during your pregnancy."

"How is it done?" Elizabeth asked.

"You're quite a girl with the questions." The obstetrician smiled. "I couldn't tell you the lab procedure. Your husband will know more about that than I do."

"But what else is done? For the baby, I mean."

He said patiently, "The most important thing is to give the baby an exchange transfusion of the right kind of blood immediately after birth. It's usually successful." He deliberately avoided mention of the strong danger of an erythroblastotic child being born dead or that physicians often induced labor several weeks early to give the child a better chance of life. In any case he felt the discussion had gone far enough. He decided to sum it up.

"I've told you all this, Mrs. Alexander, because I thought you had something on your mind about Rh. Also, you're an intelligent girl, and I always believe it's better for someone to know all the truth than just a part of it."

She smiled at that. She guessed she really was intelligent. After all, she had proved she still possessed her old classroom ability to understand and memorize. Then she told herself: Don't be smug; besides, it's a baby you're having, not an end-of-semester exam.

Dr. Dornberger was talking again. "But just let me remind you of the important things." He was serious now, leaning toward her. "Point one: you may never have an Rh-positive baby, either now or later. In that case there can't be any problem. Point two: even if your baby happens to be Rh positive, you may not become sensitized. Point three: even if your baby were to have erythroblastosis, the chances of treatment and recovery are favorable." He looked at her directly. "Now - how do you feel about it all?"

Elizabeth was beaming. She had been treated like an adult and it felt good. "Dr. Dornberger," she said, "I think you're wonderful."

Amusedly Dornberger reached for his pipe and began to fill it. "Yes," he said, "sometimes I feel that way too."

"Joe, can I talk to you?"

Lucy Grainger had been on her way to Pathology when Pearson's bulky figure loomed ahead in the main-floor corridor. As she called to him he stopped.

"Got a problem, Lucy?" It was his usual catarrhal, rumbling voice, but she was glad to notice there was no unfriendliness. She hoped she was still immune from his bad temper.

"Yes, Joe. I'd like you to see a patient of mine."

He was busy lighting one of the inevitable cigars. When he had it going he surveyed the red tip. "What's the trouble?"

"It's one of our own student nurses. A girl named Vivian Loburton. She's nineteen. Do you know her?"

Pearson shook his head. Lucy went on. "The case is worrying me a little. I suspect a bone tumor and I've a biopsy scheduled for the day after tomorrow. The tissue will be coming down to you, of course, but I thought perhaps you'd like to take a look at the girl."

"All right. Where is she?"

"I've had her admitted for observation," Lucy said. "She's on the second floor. Could you see her now?"

Pearson nodded. "Might as well." They moved toward the main vestibule and the passenger elevators.

Lucy's request to Pearson was not unusual. In a case like this, where malignancy was a possibility, it was the pathologist who would give a final opinion on the patient's condition. In the diagnosis of any tumor there were many factors - sometimes conflicting - for a pathologist to weigh in balance. But determination of bone tumors was even more difficult, something of which Lucy was aware. Consequently it was an advantage for the pathologist to be involved with a case at the beginning. In that way he could know the patient, discuss symptoms, and hear the radiologist's opinion, all of which added to his knowledge and aided diagnosis.

As they moved into the elevator Pearson paused and winced. He put a hand to his back.

Lucy pressed the button for the second floor. As the automatic doors slid closed she asked, "Is your back bothering you?"

"Sometimes it does." With an effort he straightened up. "Probably too much hunching over a microscope."

She looked at him concernedly. "Why don't you come to my office? I'll take a look at it."

He puffed his cigar, then grinned. "I'll tell you, Lucy. I can't afford your fees."

The doors opened and they went out on the second floor. Walking down the corridor, she said, "It'll be complimentary. I don't believe in charging my colleagues."

He gave her an amused glance. "You're not like the psychiatrists then?"

"No, I'm not." She laughed. "I hear they send you a bill, even if you work in the same office."

"That's right." She had seldom seen him quite so relaxed as this. "They say it's part of the treatment."

"Here we are." She opened a door and Pearson went first. Then she followed him in, closing the door behind her.

It was a small semi-private room with two patients. Lucy greeted a woman in the bed nearest the door, then moved over to the second bed where Vivian looked up from the magazine she had been reading.

"Vivian, this is Dr. Pearson."

"Hullo, Vivian." Pearson said it absently as he took the chart which Lucy offered him.

She answered politely, "Good afternoon, Doctor."

It was still a puzzle to Vivian why she was here at all. Her knee had been paining her again, it was true, but it seemed such a small thing to be put to bed for. However, she didn't mind very much. In a way the break from nursing-school routine was welcome, and it was pleasant to be reading and resting for a change. Mike had just phoned too. He seemed concerned on hearing what had happened and had promised to come in later, as soon as he could.

Lucy drew the overhead curtain between the two beds, and now Pearson said, "Let me see both knees, please."

Vivian turned back the bedclothes and lifted the hem of her nightgown. Pearson put down the chart and bent over for a close inspection.

Lucy watched the pathologist's short stubby fingers move carefully over the limbs. She thought: For someone who can be so rough with people he's surprisingly gentle. Once Vivian winced as a finger probed. Pearson looked up. "Hurt you there, eh?" Vivian nodded.

"I see from Dr. Grainger's report that you hit your knee about five months ago," he said.

"Yes, Doctor." Vivian was being careful to get her facts straight. "I didn't remember it at first - not until I started thinking back. I hit it on the bottom of a swimming pool though. I guess I dived too deeply."

Pearson asked her, "Did it hurt very much at the time?"

"Yes. But then the pain went away and I didn't think any more about it - not until now."

"All right, Vivian." He gestured to Lucy, who pulled the bedclothes back into place.

He asked Lucy, "Have you got the X-rays?"

"I have them here." She produced a large manila envelope. "There are two sets. The first set didn't show anything. Then we softened them up to see the muscles, and that showed an irregularity in the bone."

Vivian listened interestedly to the exchange. She found herself experiencing a sense of importance that all this should be about her.

Now Pearson and Lucy had moved to the window and the pathologist held the X-ray negatives to the light. As he studied the second one Lucy pointed. "There. You see?" They looked at it together.

"I guess so." Pearson grunted and handed back the negatives. His attitude to X-rays was always that of one specialist groping on the unfamiliar territory of another. He said, "Shadows from shadow land. What does Radiology say?"

"Ralph Bell confirms the irregularity," Lucy answered. "But he can't see enough for a diagnosis. He agrees we should have a biopsy."

Pearson turned back to the bed. "Do you know what a biopsy is, Vivian?"

"I have an idea." The girl hesitated. "But I'm not really sure."

"Haven't taken it in your nursing course yet, eh?"

She shook her head.

Pearson said, "Well, what happens is that Dr. Grainger will take out a small piece of tissue from your knee - just where the trouble seems to be. Then it will come down to me and . . . I'll study it."

Vivian asked, "And can you tell from that . . . what's the matter?"

"Most times I can." He started to leave, then hesitated. "Do you play a lot of sports?"

"Oh yes, Doctor. Tennis, swimming, skiing." She added, "I love horse riding too. I used to do a lot in Oregon."

"Oregon, eh?" He said it thoughtfully; then, turning away, "All right, Vivian; that's all for now."

Lucy smiled. "I'll be back later." She gathered up the chart and X-rays and followed Pearson out.

As the door closed, for the first time Vivian felt an uneasy chill of fear.

When they were well down the corridor Lucy asked, "What's your opinion, Joe?"

"It could be a bone tumor." Pearson said it slowly, thinking.

"Malignant?"

"It's possible."

They came to the elevator and stopped. Lucy said, "Of course, if it's malignant, I'll have to amputate the leg."

Pearson nodded slowly. Suddenly he looked very old. "Yes," he said. "I was thinking of that."