The Final Diagnosis

Outside the main entrance to Three Counties Hospital Dr. David Coleman paused to look around him. It was a few minutes after eight on a warm, mid-August morning, with promise already of a hot and sultry day ahead. At this moment there was little activity outside the hospital. Beside himself, the only other people in sight were a janitor, hosing some of yesterday's dust from a section of the forecourt, and a middle-aged nurse who had just alighted from a bus on the opposite side of the street. The main stream of hospital business, he supposed, would not begin to flow for another hour or so.

David Coleman surveyed the block of buildings which comprised Three Counties. Certainly, he decided, the hospital's builders could never be accused of having wasted money on aesthetic frills. The architecture was strictly utilitarian, the facings of plain brick unadorned by any other masonry. The effect was a succession of conventional rectangles: walls, doors, and windows. Only near the main doorway did the pattern vary, and here a single foundation stone announced, "Laid by His Honor Mayor Hugo Stouting, April 1918." As he walked up the entry steps David Coleman found himself wondering what kind of a man that long-forgotten dignitary had been.

Carl Bannister was sorting papers on Dr. Pearson's desk when Coleman knocked and entered the pathologist's office.

"Good morning."

Surprised, the senior lab technician looked up. It was unusual to have visitors this early. Most people around the hospital knew that Joe Pearson seldom arrived before ten o'clock, sometimes later.

"Good morning." He returned the greeting, not too affably. Bannister was never at his best in the early morning. He asked, "Are you looking for Dr. Pearson?"

"In a way, yes. I'm starting work here today." Seeing the other start, he added, "I'm Dr. Coleman."

The effect, Coleman thought, was somewhat like letting off firecrackers under a hen. Bannister put down his papers hurriedly and came around the desk, almost at a run, his bald head gleaming. "Oh, excuse me, Doctor. I didn't realize. I'd heard you were coming, but we had no idea it would be this soon."

Coleman said calmly, "Dr. Pearson is expecting me. Is he in, by the way?"

Bannister seemed shocked. "You're too early for him. He won't be here for another two hours." His face creased in a confidential man-to-man smile. It seemed to say: I expect you'll keep the same kind of hours yourself as soon as the newness wears off.

"I see."

As Coleman glanced around him Bannister remembered an omission. He said, "Oh, by the way, Doctor, I'm Carl Bannister - senior lab technician." With careful geniality he added, "I expect we'll be seeing a lot of each other." Bannister made a habit of taking no chances with anybody senior to himself.

"Yes, I expect we will." Coleman was not sure how much the idea appealed to him. But he shook hands with Bannister, then looked around for a place to hang the light raincoat he had brought; the morning forecast predicted thunder showers later in the day. Once again Bannister was alert to serve and please.

"Let me take your coat." He found a wire hanger and carefully put coat and hanger on a rack near the door.

"Thank you," Coleman said.

"That's perfectly all right, Doctor. Now, would you like me to show you around the labs?"

Coleman hesitated. Perhaps he ought to wait for Dr. Pearson. On the other hand, two hours was a long time to sit around and he might as well be doing something in the meantime. The labs would be his domain anyway. What was the difference? He said, "I saw part of the labs with Dr. Pearson when I was here a few weeks ago. But I'll take another look if you're not too busy."

"Well, of course, we're always busy around here, Doctor. But I'll be glad to take the time for you. In fact, it'll be a pleasure." The working of Bannister's mind was incredibly transparent.

"This way, please." Bannister had opened the door of the serology lab and stood back for Coleman to enter. John Alexander, who had not seen Bannister since their argument the night before, looked up from the centrifuge in which he had just placed a blood sample.

"Doctor, this is John Alexander. He just started work here." Carl Bannister was warming to his role of showman. He added facetiously, "Still wet behind the ears from technology school, eh, John?"

"If you say so." Alexander answered uncomfortably, resenting the condescension but not wanting to be rude.

Coleman moved forward, offering his hand. "I'm Dr. Coleman."

As they shook hands Alexander said interestedly, "You mean you're the new pathologist, Doctor?"

"That's right." Coleman glanced around him. As he had on the previous visit, he could see that a lot of changes would need to be made in here.

Bannister said expansively, "You just look around, Doctor - at anything you want."

"Thank you." Turning back to Alexander, Coleman asked, "What are you working on now?"

"It's a blood sensitization." He indicated the centrifuge. "This specimen happens to be from my wife."

"Really." Coleman found himself thinking this young lab assistant was a good deal more impressive than Bannister. In appearance anyway. "When is your wife having her child?" he asked.

"In just over four months, Doctor." Alexander balanced the centrifuge and switched it on, then reached over to set a timing dial. Coleman noticed that all the movements were economical and quick. There was a sense of fluidity in the way this man used his hands. Politely Alexander asked, "Are you married, Doctor?"

"No." Coleman shook his head.

Alexander seemed on the point of asking another question, then appeared to change his mind.

"Did you want to ask me something?"

For a moment there was a pause. Then John Alexander made up his mind. "Yes, Doctor," he said. "I do."

Whether this meant trouble or not, Alexander thought, at least he would bring his doubts out into the open. Last night, after the dispute with Bannister, he had been tempted to drop the whole subject of the extra test on blood samples coming to the lab. He remembered only too clearly the dressing down he had received from Dr. Pearson on the last occasion he had chosen to make a suggestion. This new doctor, though, certainly seemed easier to deal with. And even if he considered Alexander wrong, it didn't seem likely there would be any big scene. He took the plunge. "It's about the blood tests we're doing - for sensitization."

As they had been speaking he had become aware of Banister in the background, the older technician moving his bald head from side to side, intent on missing nothing that was said. Now he moved forward, annoyed and aggressive, to put Alexander in his place. "Now listen! If that's what you were talking about last night, you leave it alone!"

Coleman asked curiously, "What was it you were talking about last night?"

Ignoring the question, Bannister continued to lecture Alexander. "I don't want Dr. Coleman bothered with stuff like that five minutes after he gets here. Forget it! Understand?" He turned to Coleman, the automatic smile switched on. "It's just some bee he's got in his bonnet, Doctor. Now, if you'll come with me, I'll show you our histology setup." He put a hand on Coleman's arm to steer him away.

For the space of several seconds Coleman did nothing. Then, deliberately, he reached down and removed the hand from his sleeve. "Just a moment," he said quietly. Then to Alexander, "Is this something medical? To do with the laboratory?"

Deliberately avoiding Bannister's scowl, Alexander answered, "Yes, it is."

"All right, let's hear it."

"It came up, really, because of this blood-sensitization test - the one for my wife," Alexander said. "She's Rh negative; I'm Rh positive."

Coleman smiled. "Well, that applies to plenty of people. There's no problem - that is, as long as the sensitization test shows a negative result."

"But that's the point, Doctor - the test."

"What about it?" Coleman was puzzled. He was not at all clear about what this young lab assistant was getting at.

Alexander said, "I think we should be doing an indirect Coombs test on all these samples, after the tests in saline and high protein."

"Of course."

There was a silence which Alexander broke. "Would you mind saying that again, Doctor?"

"I said 'of course.' Naturally there should be an indirect Coombs." Coleman still could see no point in this discussion. For a serology lab this sort of thing was elementary, basic.

"But we're not doing an indirect Coombs." Alexander shot a triumphal glance at Bannister. "Doctor, the Rh-sensitivity tests here are all being done just in a saline solution and in high protein. There's no Coombs serum being used at all."

At first Coleman was sure Alexander must be wrong. Apparently the young technologist had been working here only a short time; no doubt he had become confused. Then Coleman remembered the tone of conviction in which the statement had been made. He asked Bannister, "Is this true?"

"The way we do all our tests are according to Dr. Pearson's instructions." The elderly technician made it plain that in his opinion the entire discussion was a waste of time.

"Perhaps Dr. Pearson doesn't know you're doing the Rh tests that way."

"He knows all right." This time Bannister let his surliness come through. It was always the same with new people. They weren't inside a place five minutes before they started making trouble. He had tried to be pleasant with this new doctor, and look what you got for it. Well, one thing was for sure - Joe Pearson would soon put this fellow in his place. Bannister just hoped he was around to see it happen.

Coleman decided to ignore the senior technician's tone. Whether he liked it or not he was going to have to work with this man for a while. All the same, this thing had to be cleared up now. He said, "I'm afraid I don't quite understand. Surely you know that some antibodies in the blood of pregnant women will get past a saline test and a high-protein test, whereas they won't if you go on and do a further test in Coombs serum."

Alexander interjected, "That's what I've been saying."

Bannister made no answer. Coleman went on, "Anyway, I'll mention it to Dr. Pearson sometime. I'm sure he wasn't aware of it."

"What shall we do about this test?" Alexander asked. "And the others from here on?"

Coleman answered, "Do them in all three mediums, of course - saline, high protein, and Coombs serum."

"We haven't any Coombs serum in the lab, Doctor." Alexander was very glad now that he had brought this up. He liked the look of this new pathologist. Maybe he'd change some other things around the place. Goodness knows, he thought, there's plenty that can stand it.

"Then let's get some." Coleman was deliberately brisk. "There's no shortage anywhere."

"We can't just go out and get lab supplies," Bannister said. "There has to be a purchase requisition." He wore a superior smile. There were some things, after all, these Johnny-come-latelys didn't know.

Coleman carefully kept his feelings in check. Sometime soon it might be necessary to have a showdown with this man Bannister; he certainly had no intention of taking this kind of behavior permanently. But the first day of arrival was obviously not the time. He said pleasantly enough, but firmly, "Let me have the form then. I imagine I can sign it. That's one of the reasons I'm here."

Briefly the older technician hesitated. Then he opened a drawer and produced a pad of forms which he handed to Coleman.

"A pencil, please?"

With the same reluctance Bannister produced one. Handing it over, he said pettishly, "Dr. Pearson likes to order all lab supplies himself."

Coleman scribbled the order and signed it. With a tight, cool smile, "I expect to have a good deal more responsibility here than just ordering fifteen dollars' worth of rabbit serum," he said. "There you are." As he handed back the pad and pencil the phone rang on the other side of the lab.

It was an excuse for Bannister to turn his back. His face red with anger and frustration, he crossed to the wall phone to answer it. After listening briefly he gave a curt answer and replaced the instrument. "Gotta go down to Outpatients." The words, almost mumbled, were addressed to Coleman.

He answered icily, "You can go ahead."

With the incident closed Coleman found himself more angry than he had realized. What kind of discipline existed which allowed insolence like this from a lab technician? The inadequate procedure was serious enough. But having to correct it over the objections of someone like this man Bannister was intolerable. If this were the general order of things, it seemed probable that the entire pathology department was even more run-down than he had believed at first.

With Bannister gone he began to take a more careful look at the rest of the lab. The worn equipment, some of it inadequate, had already been evident. Now he saw how deplorably sloppy and disorganized the whole place was. The tables and benches were cluttered untidily with an assortment of apparatus and supplies. He noticed a heap of dirty glassware, a pile of yellowed papers. Moving across the lab, he observed a section of a worktable with fungus growing from it. From the other side of the room Alexander was uncomfortably watching the inspection.

"Is this the way the lab is usually kept?" Coleman asked.

"It isn't very tidy, is it?" Alexander felt a surge of shame that anyone should see this place the way it was. What he could not say was that he had already offered to reorganize it but Bannister had emphatically told him to leave things the way they were.

"I'd put it a little stronger than that." Coleman ran one of his fingers over a shelf. It came away grimed with dust. He thought disgustedly: All this is something to be changed. On second thought, though, it might have to wait awhile. He knew he was going to have to be cautious in his dealings with people here, and his own experience had already taught him that there were limits to what you could accomplish quickly. All the same, he knew it would be hard to curb his own natural impatience, especially with this sort of mess visible right under his nose.

For the past few moments John Alexander had been watching Coleman closely. Ever since this new doctor had first come in with Bannister there had been something vaguely familiar about him. He was young - probably not much older than Alexander himself. But it was not that alone. Now Alexander said, "Doctor, excuse my mentioning it, but I have a feeling we've met somewhere before."

"It's possible." Coleman was elaborately casual. Because he had supported this man in one incident, he did not want him to get any impression there was some sort of alliance between them. Then it occurred to him that perhaps he had been a little too curt. He added, "I interned at Bellevue, then I was at Walter Reed and Massachusetts General."

"No." Alexander shook his head. "It must have been before then. Have you ever been in Indiana? New Richmond?"

"Yes," Coleman said, startled, "I was born there."

John Alexander beamed. "I should have remembered the name, of course. Your father would be . . . Dr. Byron Coleman?"

"How do you know that?" It had been a long time since someone other than himself had recalled his father's name.

"I'm from New Richmond too," Alexander said. "So is my wife."

"Really?" Coleman asked. "Did I know you there?"

"I don't think so, though I remember seeing you a couple of times." In the social life of New Richmond, John Alexander had been several stages removed from the orbit of the doctor's son. As the thought occurred to him, there was a "ping" from the centrifuge timer. He paused to remove the blood sample which had been spun down, then went on, "My father was a truck farmer. We lived a few miles outside town. You may remember my wife though. Her family had the hardware store. She was Elizabeth Johnson."

Coleman said thoughtfully, "Yes, I believe I do." Memory stirred. "Wasn't there something about her . . . she was in an accident of some sort?"

"That's right; she was," John Alexander said. "Her father was killed in his car at the rail crossing. Elizabeth was with him."

"I remember hearing about it." David Coleman's mind flew back over the years - to the country doctor's office in which his father had healed so many bodies until in the end his own had failed him. He said, "I was away at college at the time, but my father told me afterward."

"Elizabeth almost died. But they gave her blood transfusions and she made it. I think that was the first time I was ever in a hospital. I almost lived there for a week." Alexander paused. Then, still pleased at his discovery, "If you happen to be free one evening, Dr. Coleman, I'm sure my wife would enjoy meeting you. We have a small apartment . . ." He hesitated, sensing the truth: though both had moved on from New Richmond, there was still a social gulf between them.

Coleman was aware of it too. His brain clicked out a warning: be cautious of alliances with subordinates - even one like this. He rationalized: It isn't snobbery; it's just a matter of hospital discipline and common sense. Aloud he said, "Well, I'm going to be working quite hard for a while. Let's leave it, shall we, and see how things go?"

Even as he spoke them the words sounded hollow and false. He thought: You could have let him down more lightly than that. Mentally he added a footnote to himself: You haven't changed, my friend; you haven't changed at all.

Momentarily Harry Tomaselli found himself wishing that Mrs. Straughan would go back to her kitchens and stay there. Then he checked himself: a good chief dietitian was a pearl to be prized. And Mrs. Straughan was good; of that fact the administrator was well aware.

But there were times when he wondered if Hilda Straughan ever thought of Three Counties Hospital as a unified whole. Most times when talking with her he gained the impression that the hospital's heart consisted of kitchens, from which other and less important facilities radiated outward. He reflected, though - Harry Tomaselli was, above all, a fair-minded man - that this sort of attitude was often found in people who took their jobs seriously. And, if it were a failing, he certainly preferred it to slackness and indifference. Another thing: a good department head was always willing to fight and argue for something which he or she believed in, and Mrs. Straughan was a fighter and arguer in every ample cubic inch of her.

At this moment, her big bulk overflowing a chair in the administrator's office, she was fighting hard.

"I wonder if you realize, Mr. T., how serious this is." Mrs. Straughan invariably used the surname initial when addressing people she knew; she had a habit of referring to her own husband as "Mr. S."

"I think so," Harry Tomaselli said.

"The dishwashers I have now were obsolete at least five years ago. Every year since I've been here I've been told: Next year we'll give you your new ones. And when next year comes, where are my dishwashers? I find they're put off for another twelve months. It won't do, Mr. T. It just won't do."

Mrs. Straughan always used the personal pronoun "my" when referring to equipment in her charge. Tomaselli had no objection to this. What he did object to was Hilda Straughan's unwillingness to consider any problems other than her own. He prepared to cover, once more, the ground they had gone over just a week or two before.

"There's no question, Mrs. Straughan, that the dishwashers are going to be replaced eventually. I know the problem you have down there in the kitchens, but those are big, expensive machines. If you remember, the last estimate we had ran a little under eleven thousand dollars, allowing for changes in the hot-water system."

Mrs. Straughan leaned over the desk, her massive bosom brushing a file tray aside. "And the longer you leave it the more the cost will go up."

"Unfortunately I'm aware of that too." The rising cost of everything the hospital bought was a problem Tomaselli lived with daily. He added, "But right at this moment hospital money for capital expenditures is extremely tight. The building extension, of course, is partly responsible. It's simply a question of allocating priorities, and some of the medical equipment has had to come first."

"What good is medical equipment if your patients don't have clean plates to eat their food from?"

"Mrs. Straughan," he said firmly, "the situation is not as bad as that, and both of us know it."

"It's not very far removed from it." The chief dietitian leaned forward and the file tray took another shove; Harry Tomaselli found himself wishing she would keep her breasts off his desk. She went on, "Several times lately whole loads of dishes going through my machines have still been dirty when they came out. We try to check as much as we can, but when there's a rush it isn't always possible."

"Yes," he said. "I can understand that."

"It's the danger of infection I'm worried about, Mr. T. There's been a lot of intestinal flu among the hospital staff lately. Of course, when that happens everyone blames the food. But it wouldn't surprise me if this was the cause of it."

"We'd need considerably more evidence to be sure of that." Harry Tomaselli's patience was beginning to wear thin. Mrs. Straughan had come to him on an exceptionally busy morning. There was a board meeting this afternoon, and right now he had several pressing problems to consider in advance of it. Hoping to wind up the interview, he asked, "When did Pathology last run a bacteria test on the dishwashers?"

Hilda Straughan considered. "I could check, but I think it's about six months ago."

"We'd better have them do another. Then we'll know exactly where we stand."

"Very well, Mr. T." Mrs. Straughan resigned herself to accomplishing nothing more today. "Shall I speak to Dr. Pearson?"

"No, I'll do it." The administrator made a penciled note. At least, he thought, I can save Joe Pearson a similar session to this.

"Thank you, Mr. T." The chief dietitian eased herself upward and out of the chair. He waited until she had gone, then carefully moved the file tray back to its original position.

David Coleman was returning to Pathology from lunch in the cafeteria. Making his way through the corridors and down the basement stairway, he pondered over the time he had spent so far with Dr. Joseph Pearson. Up to this moment, he decided, it had been unsatisfactory and inconclusive.

Pearson had been cordial enough - later, if not at the beginning. On finding Coleman waiting in his office his first remark had been, "So you really meant what you said about starting right away."

"There didn't seem much point in waiting." He had added politely, "I've been looking around the labs. I hope you don't mind."

"That's your privilege." Pearson had said it with a half-growl, as if it were an invasion he did not like but had to put up with. Then, as if realizing his own ungraciousness, he had added, "Well, I guess I should welcome you."

When they had shaken hands the older man had said, "First thing I have to do is get some of this work cleared away." He gestured at the untidy pile of slide folders, dockets, and loose memoranda on his desk. "After that maybe we can figure out what you'll be doing around here."

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.

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."